Formulary - EpiphanyRx · 2021. 5. 12. · © EpiphanyRx, LLC. All Rights Reserved 5/12/2021 Drug Name Route Tier Specialty PA QL Non-EHB DayproOral 3 Diclofenac PotassiumOral 1 Y

Formulary

© EpiphanyRx, LLC. All Rights Reserved 5/12/2021

EpiphanyRx Formulary

Welcome to EpiphanyRx! We are excited to serve you and manage your prescription drug benefits. This drug list,

or formulary, contains important information about drug coverage. Our team of pharmacists, nurses, doctors,

statisticians and healthcare economists review drugs approved by the U.S. Food and Drug Administration (FDA)

to determine coverage for you and your employer. This drug list is regularly updated and subject to change at

any time.

About the list

You can use this list to find information about drug coverage and therapeutic options. You can search for a drug

name by downloading the document and clicking on Edit and then selecting Find/Search or by using the Control

and F keys on your keyboard. After typing in the drug name, click Search to find your drug. It is always an option

to bring this list with you to your next doctor’s appointment. You can use the information from this list to talk

with your doctor about potential lower-cost drug options.

On the list, each drug is identified with a tier value based on the drug’s cost to the plan. Tier 1 drugs are the lowest cost drugs to the plan and Tier 3 are the highest cost drugs to the plan. Your plan may cover specialty drugs in Tier 4. Tiers are important because the amount you pay is based on the drug tier. You can receive up to a 30-day supply of most medications on the formulary. Some drugs, like diabetes and drugs to help with heart conditions, may be covered for up to a 90-day supply. If you are interested in which drugs may qualify, please reference the Maintenance Drug list

located at https://epiphanyrx.com/resources/members/.

While this drug list is a good guide, it is good idea to check your Summary Plan Description to confirm the amount you will pay and what coverage your plan allows.

Some FDA-approved drugs may not be covered by the plan if they have over-the-counter (OTC) equivalents or provide

low-value as compared to other drugs available on the plan’s formulary. Not all FDA-approved indications or uses may

be covered for a drug if multiple uses exist. Your prescription drug benefit plan may not cover certain products or drug

categories regardless of the appearance in this document. Your Summary Plan Document is a good place to go to better

understand exclusions. You can always call us if you have questions, by dialing 844-820-3260.

Under the Affordable Care Act, certain preventative medications may be covered at a $0 copay. Please refer to the

Affordable Care Act Preventative drug list located at https://epiphanyrx.com/resources/members/for these drugs.

https://epiphanyrx.com/resources/members/

https://epiphanyrx.com/resources/members/


Legend

Prior Authorization (PA) – The Plan requires a review to determine if the drug qualifies for coverage under the

benefit. If your physician prescribes a drug that requires a prior authorization, the PBM will work with your

prescriber to complete the prior authorization review. Either you or the pharmacy can ask your doctor to call

844-820-3260 to initiate the prior authorization or appeal process.

Quantity Limits (QL) - For certain drugs, the amount of the drug that will be covered by the plan is limited based on national standards and current scientific literature. These limits ensure the quantity of units supplied for each prescription remain consistent with clinical dosing guidelines and benefit plan design.

Tier (T#)– The value that determines the copayment in which you pay for the medication. Every drug will be given a tier value. Refer to your Summary Plan Design document for the specific copayment.

Specialty Drugs – Specialty medications are drugs that are used to treat complex conditions, such as cancer, growth hormone deficiency, hemophilia, hepatitis C, immune deficiency, multiple sclerosis and rheumatoid arthritis. Specialty drugs must be obtained from a select pharmacy and are limited to 30-day supply.

Non-Essential Health Benefit Drugs - Your plan may cover select Non-Essential Health Benefits (Non-EHB) Drugs at the tiers outlined below. Any amount you pay for Non-Essential Health Benefits Drugs will NOT count toward your deductible and/or out of pocket maximum.


Drug Name Route Tier Specialty PA QL Non-EHB

ADHD/Anti-Narcolepsy /Anti-Obesity/Anorexiant Agents

Adderall XR Oral 2

Adzenys XR-ODT Oral 3

Amphetamine ER Oral 3

Amphetamine Sulfate Oral 1

Amphetamine-Dextroamphet ER Oral 1

Amphetamine-Dextroamphetamine Oral 1

Armodafinil Oral 1

Atomoxetine HCl Oral 1

Caffeine Citrate Intravenous 1

cloNIDine HCl ER Oral 1

Concerta Oral 2

Daytrana Transdermal 3

Dexmethylphenidate HCl Oral 1

Dexmethylphenidate HCl ER Oral 1

Dextroamphetamine Sulfate Oral 1

Dextroamphetamine Sulfate ER Oral 1

Dyanavel XR Oral 3

guanFACINE HCl ER Oral 1

Jornay PM Oral 3 Y

Metadate ER Oral 2

Methylphenidate HCl Oral 1

Methylphenidate HCl ER Oral 1

Methylphenidate HCl ER (CD) Oral 1

Methylphenidate HCl ER (LA) Oral 1

Methylphenidate HCl ER (XR) Oral 1

Modafinil Oral 1

Nuvigil Oral 3

Provigil Oral 3

QuilliChew ER Oral 3

Quillivant XR Oral 3

Sunosi Oral 3 Y Y

Vyvanse Oral 2 Y

Zenzedi Oral 2

Analgesic/Anti-Inflammatory/Migraine/Gout Agents/Anesthetics

Abstral Sublingual 3 Y Y

Acetaminophen-Codeine Oral 1 Y

Acetaminophen-Codeine #2 Oral 1 Y





Actemra Subcutaneous 2 Y Y

Actemra ACTPen Subcutaneous 2 Y Y

Actiq Buccal 3 Y Y

Aimovig Subcutaneous 2 Y

Aimovig (140 MG Dose) Subcutaneous 2 Y

Allopurinol Oral 1

Almotriptan Malate Oral 1 Y

Amerge Oral 3 Y

APAP-Caff-Dihydrocodeine Oral 1 Y

Arava Oral 3

Arcalyst Subcutaneous 3 Y Y

Ascomp-Codeine Oral 1 Y

Aspirin-Caff-Dihydrocodeine Oral 1 Y

Axert Oral 3 Y

Bac Oral 1 Y

Bunavail Buccal 3 Y

Bupap Oral 1

Buprenorphine Transdermal 1 Y

Buprenorphine HCl Sublingual 1 Y

Buprenorphine HCl-Naloxone HCl Sublingual 1 Y

Butalbital-Acetaminophen Oral 1 Y

Butalbital-APAP Oral 1 Y

Butalbital-APAP-Caff-Cod Oral 1 Y

Butalbital-APAP-Caffeine Oral 1 Y

Butalbital-ASA-Caff-Codeine Oral 1 Y

Butalbital-ASA-Caffeine Oral 1

Butalbital-Aspirin-Caffeine Oral 1

Butorphanol Tartrate Nasal 1 Y

Butrans Transdermal 3 Y

Cafergot Oral 3

Capacet Oral 1 Y

Cataflam Oral 1 Y

CeleBREX Oral 3

Celecoxib Oral 1

Codeine Sulfate Oral 1 Y

Colchicine Oral 1

Colchicine-Probenecid Oral 1

Colcrys Oral 2



Daypro Oral 3

Diclofenac Potassium Oral 1 Y

Diclofenac Sodium Oral 1

Diclofenac Sodium ER Oral 1

Diclofenac-miSOPROStol Oral 1

Diflunisal Oral 1

Duragesic-12 Transdermal 3 Y




Duzallo Oral 3

Eletriptan Hydrobromide Oral 1 Y

Embeda Oral 3 Y

Emgality Subcutaneous 2 Y

Emgality (300 MG Dose) Subcutaneous 2 Y

Enbrel Subcutaneous 2 Y Y Y

Enbrel Mini Subcutaneous 2 Y Y

Enbrel SureClick Subcutaneous 2 Y Y Y

Endocet Oral 1 Y

Ergomar Sublingual 3

Ergotamine-Caffeine Oral 1

Esgic Oral 3 Y

Etodolac Oral 1

Etodolac ER Oral 1

Febuxostat Oral 1

Feldene Oral 3

Fenoprofen Calcium Oral 1

Fenortho Oral 3

fentaNYL Transdermal 1 Y

fentaNYL Citrate Buccal 1 Y Y

Fentora Buccal 3 Y Y

Fioricet Oral 3 Y

Fioricet/Codeine Oral 3 Y

Fiorinal/Codeine #3 Oral 3 Y

Flurbiprofen Oral 1 Y

Frova Oral 3 Y

Frovatriptan Succinate Oral 1 Y

Humira Subcutaneous 2 Y Y Y

Humira Pediatric Crohns Start Subcutaneous 2 Y Y Y



Humira Pen Subcutaneous 2 Y Y Y

Humira Pen-CD/UC/HS Starter Subcutaneous 2 Y Y Y

Humira Pen-Ps/UV/Adol HS Start Subcutaneous 2 Y Y Y

Humira Pen-Psor/Uveit Starter Subcutaneous 2 Y Y Y

HYDROcodone Bitartrate ER Oral 1 Y

HYDROcodone-Acetaminophen Oral 1 Y

HYDROcodone-Ibuprofen Oral 1 Y

HYDROmorphone HCl Oral 1 Y

HYDROmorphone HCl ER Oral 1

Hysingla ER Oral 3 Y

IBU Oral 1

Ibudone Oral 3 Y

Ibuprofen Oral 1

Ilaris Subcutaneous 2 Y Y

Imitrex Nasal 3 Y

Imitrex STATdose Refill Subcutaneous 3 Y

Imitrex STATdose System Subcutaneous 3 Y

Indocin Oral 3

Indomethacin Oral 1

Indomethacin ER Oral 1

Isometheptene-Dichloral-APAP Oral 1

Ketoprofen Oral 1 Y

Ketoprofen ER Oral 1 Y

Ketorolac Tromethamine Oral 1

Kevzara Subcutaneous 3 Y Y

Kineret Subcutaneous 3 Y Y Y

Leflunomide Oral 1

Levorphanol Tartrate Oral 1 Y

Lodine Oral 3

Lorcet Oral 1 Y

Lorcet HD Oral 1 Y

Lortab Oral 3 Y

Marten-Tab Oral 1 Y

Maxalt Oral 3 Y

Maxalt-MLT Oral 3 Y

Meclofenamate Sodium Oral 1

Mefenamic Acid Oral 1

Meloxicam Oral 1 Y

Meperidine HCl Oral 1 Y



Methadone HCl Oral 1 Y

Methadone HCl Intensol Oral 1 Y

Methadone HCl-NaCl Intravenous 3

Methadose Oral 1 Y

Methadose Sugar-Free Oral 3 Y

Migergot Rectal 3

Mitigare Oral 3

Mobic Oral 3 Y

MorphaBond ER Oral 3 Y

Morphine Sulfate Oral 1 Y

Morphine Sulfate (Concentrate) Oral 1 Y

Morphine Sulfate ER Oral 1 Y

Morphine Sulfate ER Beads Oral 1 Y

MS Contin Oral 3 Y

Nabumetone Oral 1

Naproxen Oral 1

Naproxen Sodium Oral 1

Naratriptan HCl Oral 1 Y

Nucynta Oral 3 Y

Nucynta ER Oral 3 Y

Olumiant Oral 3 Y Y

Onzetra Xsail Nasal 3 Y Y

Opana Oral 3 Y

Opana ER Oral 3 Y

Orencia Subcutaneous 3 Y Y

Orencia ClickJect Subcutaneous 3 Y Y

Otezla Oral 2 Y Y

Otrexup Subcutaneous 3 Y

Oxaprozin Oral 1

oxyCODONE HCl Oral 1 Y

oxyCODONE HCl ER Oral 1 Y

oxyCODONE-Acetaminophen Oral 1 Y

oxyCODONE-Aspirin Oral 1 Y

oxyCODONE-Ibuprofen Oral 1 Y

OxyCONTIN Oral 3 Y

oxyMORphone HCl Oral 1 Y

oxyMORphone HCl ER Oral 1 Y

Panlor Oral 3 Y

Pentazocine-Naloxone HCl Oral 1 Y



Phrenilin Forte Oral 1 Y

Piroxicam Oral 1

Ponstel Oral 3

Probenecid Oral 1

ProFeno Oral 3

Relpax Oral 2 Y

Ridaura Oral 3

Rinvoq Oral 2 Y Y

Rizatriptan Benzoate Oral 1 Y

Salsalate Oral 1

Simponi Subcutaneous 3 Y Y Y

Suboxone Sublingual 2 Y

Sulindac Oral 1

SUMAtriptan Nasal 1 Y

SUMAtriptan Succinate Oral 1 Y

SUMAtriptan Succinate Refill Subcutaneous 1 Y

Sumavel DosePro Subcutaneous 3 Y Y

Synalgos-DC Oral 3 Y

Tencon Oral 2 Y

Tolmetin Sodium Oral 1

traMADol HCl Oral 1 Y

traMADol HCl ER Oral 1 Y

traMADol HCl ER (Biphasic) Oral 1 Y

traMADol-Acetaminophen Oral 1 Y

Trezix Oral 3 Y

Tylenol with Codeine #3 Oral 3 Y

Tylenol with Codeine #4 Oral 3 Y

Uloric Oral 3

Vanatol S Oral 3

Vicodin HP Oral 1 Y

Vtol LQ Oral 3

Xeljanz Oral 2 Y Y Y

Xeljanz XR Oral 2 Y Y Y

Xodol Oral 3 Y

Xtampza ER Oral 3 Y

Xylon Oral 1 Y

Zamicet Oral 3 Y

Zebutal Oral 1 Y

Zembrace SymTouch Subcutaneous 3 Y



ZOLMitriptan Nasal 3 Y

Zomig Nasal 3 Y

Zomig ZMT Oral 3 Y

Zubsolv Sublingual 3 Y

Zurampic Oral 3

Zyloprim Oral 3

Antihistamines/Nasal Agents/Cough & Cold/Respiratory/Misc

Accolate Oral 3

Acetylcysteine Inhalation 1

Advair Diskus Inhalation 2

Advair HFA Inhalation 2

Aerospan Inhalation 3

AirDuo RespiClick 113/14 Inhalation 3



Albuterol Sulfate Inhalation 1

Albuterol Sulfate ER Oral 1

Albuterol Sulfate HFA Inhalation 2

Alvesco Inhalation 3

Anoro Ellipta Inhalation 2

Arcapta Neohaler Inhalation 3

ArmonAir Digihaler Inhalation 3

ArmonAir RespiClick 113 Inhalation 3



Arnuity Ellipta Inhalation 2

Asmanex (120 Metered Doses) Inhalation 2





Asmanex HFA Inhalation 2

Astepro Nasal 3

Atrovent HFA Inhalation 3

Azelastine HCl Nasal 1

Azelastine-Fluticasone Nasal 1

Bactroban Nasal Nasal 2

Benzonatate Oral 1

Bevespi Aerosphere Inhalation 3



Breo Ellipta Inhalation 2

Bromfed DM Oral 1

Brovana Inhalation 3

Budesonide Inhalation 1

Carbinoxamine Maleate Oral 1

Cetirizine HCl Oral 1

Clemastine Fumarate Oral 1

Cocaine HCl Nasal 3

Combivent Respimat Inhalation 3

Cromolyn Sodium Inhalation 1

Cyproheptadine HCl Oral 1

Daliresp Oral 3

Diphen Oral 1

diphenhydrAMINE HCl Oral 1

Dulera Inhalation 2

Dymista Nasal 3

Elixophyllin Oral 3

Esbriet Oral 3 Y Y Y

Fasenra Subcutaneous 3 Y Y

Fasenra Pen Subcutaneous 3 Y Y

Flovent Diskus Inhalation 2

Flovent HFA Inhalation 2

Fluticasone Propionate Nasal 1

Fluticasone-Salmeterol Inhalation 1

Goprelto Nasal 3

Hycodan Oral 1 Y

Hycofenix Oral 3

HYDROcodone-Homatropine Oral 1 Y

Hydromet Oral 1 Y

HyperSal Inhalation 3

Incruse Ellipta Inhalation 2

Ipratropium Bromide Inhalation 1

Ipratropium-Albuterol Inhalation 1

Kalydeco Oral 2 Y Y Y 3

Levalbuterol HCl Inhalation 1

Levalbuterol Tartrate Inhalation 1

Levocetirizine Dihydrochloride Oral 1

Lonhala Magnair Refill Kit Inhalation 3 Y

Lonhala Magnair Starter Kit Inhalation 3 Y



Metaproterenol Sulfate Oral 1

Mometasone Furoate Nasal 1

Montelukast Sodium Oral 1

Nucala Subcutaneous 3 Y Y

Numbrino Nasal 3

Ofev Oral 3 Y Y Y

Orkambi Oral 3 Y Y Y 3

Patanase Nasal 3

Perforomist Inhalation 3

Phenadoz Rectal 1

Phenergan Rectal 1

ProAir Digihaler Inhalation 3

ProAir HFA Inhalation 3

ProAir RespiClick Inhalation 2

Promethazine HCl Injection 1

Promethazine VC Oral 1

Promethazine VC Plain Oral 1

Promethazine-DM Oral 1

Promethazine-Phenylephrine Oral 1

Promethegan Rectal 1

Proventil HFA Inhalation 3

Pseudoeph-Bromphen-DM Oral 1

Pulmicort Inhalation 3

Pulmicort Flexhaler Inhalation 3

PulmoSal Inhalation 1

Pulmozyme Inhalation 2 Y Y Y

Qvar Inhalation 2

Qvar RediHaler Inhalation 2

RyVent Oral 3

Seebri Neohaler Inhalation 3

Serevent Diskus Inhalation 2

Singulair Oral 3

Sodium Chloride Inhalation 1

Spiriva HandiHaler Inhalation 2

Spiriva Respimat Inhalation 2

SSKI Oral 2

Stiolto Respimat Inhalation 2

Striverdi Respimat Inhalation 3

Symbicort Inhalation 2



Symdeko Oral 3 Y Y Y 3

Terbutaline Sulfate Oral 1

Tessalon Perles Oral 3

Theo-24 Oral 3

Theochron Oral 3

Theophylline Oral 1

Theophylline ER Oral 1

Trelegy Ellipta Inhalation 3

Trikafta Oral 2 Y Y 3

Tudorza Pressair Inhalation 3

Tussigon Oral 1 Y

Utibron Neohaler Inhalation 3

Ventolin HFA Inhalation 2

Vituz Oral 3 Y

VoSpire ER Oral 3

Wixela Inhub Inhalation 1

Xopenex Inhalation 3

Xopenex Concentrate Inhalation 3

Xopenex HFA Inhalation 3

Zafirlukast Oral 1

Zileuton ER Oral 1

Zyflo Oral 3

Zyflo CR Oral 3

Anti-Infective Agents

Abacavir Sulfate Oral 1

Abacavir Sulfate-lamiVUDine Oral 1

Abacavir-lamiVUDine-Zidovudine Oral 1

Acyclovir Oral 1

Adefovir Dipivoxil Oral 1 Y Y Y

Aemcolo Oral 3

Albendazole Oral 1

Albenza Oral 2

Amoxicillin Oral 1

Amoxicillin-Pot Clavulanate Oral 1

Amoxicillin-Pot Clavulanate ER Oral 1

Ampicillin Oral 1

Ancobon Oral 3 Y

Aptivus Oral 3

Arakoda Oral 3



Atazanavir Sulfate Oral 1

Atovaquone Oral 1

Atovaquone-Proguanil HCl Oral 1

Atripla Oral 2

Augmentin Oral 3

Augmentin ES-600 Oral 3

Augmentin XR Oral 3

Avelox Oral 3

Avidoxy Oral 1

Azithromycin Oral 1 Y

Bactrim Oral 3

Bactrim DS Oral 3

Baraclude Oral 3 Y Y Y

Baxdela Oral 3

Benznidazole Oral 1

Biktarvy Oral 2 Y

Biltricide Oral 2

Cayston Inhalation 3 Y Y Y

Cedax Oral 3

Cefaclor Oral 1

Cefaclor ER Oral 1

Cefadroxil Oral 1

Cefdinir Oral 1

Cefditoren Pivoxil Oral 1

Cefixime Oral 1

Cefpodoxime Proxetil Oral 1

Cefprozil Oral 1

Ceftibuten Oral 1

Ceftin Oral 3

Cefuroxime Axetil Oral 1

Cephalexin Oral 1

Chloroquine Phosphate Oral 1 Y

Cimduo Oral 2

Cipro Oral 3

Ciprofloxacin Oral 1

Ciprofloxacin HCl Oral 1

Ciprofloxacin-Ciproflox HCl ER Oral 1

Clarithromycin Oral 1

Clarithromycin ER Oral 1



Cleocin Oral 3

Clindamycin HCl Oral 1

Clindamycin Palmitate HCl Oral 1

Clindamycin Phosphate Injection 1

Coartem Oral 2

Combivir Oral 3

Complera Oral 2

Copegus Oral 3 Y Y

CoreMino Oral 1

Cresemba Oral 3 Y

Crixivan Oral 3

cycloSERINE Oral 1

Daklinza Oral 3 Y Y Y

Dapsone Oral 1

Daxbia Oral 3

Delstrigo Oral 3

Demeclocycline HCl Oral 1

Descovy Oral 3 Y

Dicloxacillin Sodium Oral 1

Didanosine Oral 1

Dificid Oral 3 Y Y

Diflucan Oral 3

Dovato Oral 2

Doxycycline Hyclate Oral 1

Doxycycline Monohydrate Oral 1

E.E.S. 400 Oral 2

E.E.S. Granules Oral 3

Edurant Oral 3

Efavirenz Oral 1

Efavirenz-Emtricitab-Tenofovir Oral 1

Efavirenz-lamiVUDine-Tenofovir Oral 1

Emtricitabine Oral 1

Emverm Oral 3

Entecavir Oral 1 Y Y Y

Epclusa Oral 2 Y Y Y

Epivir Oral 3

Epivir HBV Oral 3 Y

Epzicom Oral 3

EryPed 200 Oral 3



EryPed 400 Oral 3

Ery-Tab Oral 3

Erythrocin Stearate Oral 2

Erythromycin Oral 3

Erythromycin Base Oral 1

Erythromycin Ethylsuccinate Oral 1

Ethambutol HCl Oral 1

Evotaz Oral 2

Factive Oral 3

Famciclovir Oral 1

Firvanq Oral 3

Flagyl Oral 3

Fluconazole Oral 1

Flucytosine Oral 1 Y

Flumadine Oral 3

Fosamprenavir Calcium Oral 1

Fosfomycin Tromethamine Oral 1

Furadantin Oral 3

Fuzeon Subcutaneous 3

Genvoya Oral 2

Griseofulvin Microsize Oral 1

Griseofulvin Ultramicrosize Oral 1

Gris-PEG Oral 3

Harvoni Oral 2 Y Y Y

Hepsera Oral 3 Y Y Y

Hiprex Oral 3

Hydroxychloroquine Sulfate Oral 1 Y

Hyophen Oral 3

Impavido Oral 3 Y

Intelence Oral 2

Invirase Oral 3

Isentress Oral 2

Isentress HD Oral 2

Isoniazid Oral 1

Itraconazole Oral 1

Ivermectin Oral 1

Juluca Oral 2

Kaletra Oral 2

Keflex Oral 3



Ketoconazole Oral 1

Kitabis Pak Inhalation 3 Y Y Y

Krintafel Oral 3

LamISIL Oral 3

lamiVUDine Oral 1 Y

lamiVUDine-Zidovudine Oral 1

Ledipasvir-Sofosbuvir Oral 1 Y Y Y

Levaquin Oral 3

levoFLOXacin Oral 1

Lexiva Oral 3

Linezolid Oral 1

Lopinavir-Ritonavir Oral 1

Macrobid Oral 3

Macrodantin Oral 3

Malarone Oral 3

Mavyret Oral 2 Y Y Y

Mefloquine HCl Oral 1

Mepron Oral 3

Methenamine Hippurate Oral 1

Methenamine Mandelate Oral 1

metroNIDAZOLE Oral 1

Minocin Oral 3

Minocycline HCl Oral 1

Minocycline HCl ER Oral 1

Moderiba Oral 3 Y Y

Moderiba (1000 MG Pack) Oral 3 Y

Moderiba (1200 MG Pack) Oral 3 Y Y

Moderiba (600 MG Pack) Oral 3 Y

Moderiba (800 MG Pack) Oral 3 Y Y

Mondoxyne NL Oral 1

Monodox Oral 3

Monurol Oral 3

Morgidox Oral 1

Moxifloxacin HCl Oral 1

Myambutol Oral 3

Mycobutin Oral 3

Nebupent Inhalation 2

Neomycin Sulfate Oral 1

Nevirapine Oral 1



Nevirapine ER Oral 1

Nitazoxanide Oral 1 Y

Nitrofurantoin Oral 1

Nitrofurantoin Macrocrystal Oral 1

Nitrofurantoin Monohyd Macro Oral 1

Norvir Oral 2

Noxafil Oral 3 Y

Nystatin Oral 1

Odefsey Oral 2

Ofloxacin Oral 1

Olysio Oral 3 Y Y Y

Oseltamivir Phosphate Oral 1 Y

Paromomycin Sulfate Oral 1

Paser Oral 3

PCE Oral 3

Pegasys Subcutaneous 2 Y Y Y

Pegasys ProClick Subcutaneous 2 Y Y Y

PegIntron Subcutaneous 3 Y Y

Peg-Intron Redipen Subcutaneous 3 Y Y

Penicillin V Potassium Oral 1

Pentamidine Isethionate Inhalation 1

Phosphasal Oral 1

Pifeltro Oral 3

Plaquenil Oral 3 Y

Posaconazole Oral 2

Praziquantel Oral 1

Prevymis Oral 3 Y Y

Prezcobix Oral 2

Prezista Oral 2

Priftin Oral 2

Primaquine Phosphate Oral 1

Primsol Oral 3

Pyrazinamide Oral 1

Qualaquin Oral 3

quiNINE Sulfate Oral 1

Rebetol Oral 3 Y Y

Relenza Diskhaler Inhalation 3 Y

Rescriptor Oral 3

Retrovir Oral 3



Reyataz Oral 2

Ribasphere Oral 1 Y Y

Ribasphere RibaPak (1000 Pack) Oral 3 Y

Ribasphere Ribapak (1200 Pack) Oral 3 Y



Ribavirin Oral 1 Y Y

Rifabutin Oral 1

Rifadin Oral 3

Rifamate Oral 3

rifAMPin Oral 1

Rifater Oral 3

riMANTAdine HCl Oral 1

Ritonavir Oral 1

Selzentry Oral 3

Sirturo Oral 3

Sivextro Oral 2 Y

Sofosbuvir-Velpatasvir Oral 1 Y Y Y

Sovaldi Oral 2 Y Y Y

Spectracef Oral 3

Sporanox Oral 3

Sporanox Pulsepak Oral 3

Stavudine Oral 1

Stribild Oral 2

Stromectol Oral 3

sulfADIAZINE Oral 1

Sulfamethoxazole-Trimethoprim Oral 1

Sulfatrim Pediatric Oral 1

Suprax Oral 2

Sustiva Oral 2

Symfi Oral 2

Symfi Lo Oral 2

Symtuza Oral 2

Tamiflu Oral 3 Y

Technivie Oral 3 Y Y Y

Temixys Oral 2

Tenofovir Disoproxil Fumarate Oral 1

Terbinafine HCl Oral 1

Tetracycline HCl Oral 1



Tindamax Oral 3

Tinidazole Oral 1

Tivicay Oral 2

Tobi Inhalation 3 Y Y Y

Tobi Podhaler Inhalation 3 Y Y Y

Tobramycin Inhalation 1 Y Y Y

Trecator Oral 3

Trimethoprim Oral 1

Trimpex Oral 3

Triumeq Oral 2

Trizivir Oral 3

Truvada Oral 2 Y

Tybost Oral 3

Uribel Oral 1

Ustell Oral 1

valACYclovir HCl Oral 1

Valcyte Oral 3 Y

valGANciclovir HCl Oral 1 Y

Valtrex Oral 3

Vancocin Oral 3

Vancocin HCl Oral 3

Vancomycin HCl Oral 1

Vemlidy Oral 3 Y Y Y

Vfend Oral 3

Vibramycin Oral 3

Videx Oral 2

Videx EC Oral 3

Viekira Pak Oral 3 Y Y

Viekira XR Oral 3 Y Y

Vilamit MB Oral 1

Vilevev MB Oral 1

Viracept Oral 3

Viramune Oral 3

Viramune XR Oral 3

Viread Oral 2

Voriconazole Oral 1

Vosevi Oral 2 Y Y Y

Xifaxan Oral 2

Xofluza (40 MG Dose) Oral 3 Y



Xofluza (80 MG Dose) Oral 3 Y

Zepatier Oral 3 Y Y

Zerit Oral 3

Ziagen Oral 3

Zidovudine Oral 1

Zithromax Oral 3 Y

Zithromax Tri-Pak Oral 3 Y

Zithromax Z-Pak Oral 3 Y

Zmax Oral 3 Y

Zovirax Oral 3

Zyvox Oral 3

Antineoplastic Agents and Adjunctive Therapies

Abiraterone Acetate Oral 1 Y Y Y

Actimmune Subcutaneous 2 Y Y 3

Afinitor Oral 2 Y Y Y

Afinitor Disperz Oral 2 Y Y Y

Alecensa Oral 2 Y Y Y

Alkeran Oral 3 Y Y

Alunbrig Oral 3 Y Y Y

Anastrozole Oral 1

Arimidex Oral 3

Aromasin Oral 3 Y

Bexarotene Oral 1 Y Y Y

Bicalutamide Oral 1

Bosulif Oral 2 Y Y Y

Braftovi Oral 3 Y Y

Cabometyx Oral 3 Y Y Y

Calquence Oral 3 Y Y Y

Capecitabine Oral 1 Y Y Y

Caprelsa Oral 2 Y Y Y

Casodex Oral 3

Cometriq (100 MG Daily Dose) Oral 2 Y Y Y



Copiktra Oral 3 Y Y

Cotellic Oral 2 Y Y Y

Cyclophosphamide Intravenous 3

Emcyt Oral 2 Y Y

Erivedge Oral 2 Y Y Y



Erleada Oral 3 Y Y Y

Erlotinib HCl Oral 1 Y Y Y

Etoposide Oral 1 Y Y

Everolimus Oral 1 Y Y Y

Exemestane Oral 1 Y

Fareston Oral 3 Y Y

Farydak Oral 2 Y Y Y

Femara Oral 3

Flutamide Oral 1

Gilotrif Oral 2 Y Y Y

Gleevec Oral 3 Y Y Y

Gleostine Oral 3 Y Y

Hexalen Oral 2 Y Y

Hycamtin Oral 2 Y Y

Hydrea Oral 3

Hydroxyurea Oral 1

Ibrance Oral 2 Y Y Y

Iclusig Oral 2 Y Y Y

IDHIFA Oral 3 Y Y Y

Imatinib Mesylate Oral 1 Y Y Y

Imbruvica Oral 2 Y Y Y

Inlyta Oral 2 Y Y Y

Iressa Oral 2 Y Y Y

Jakafi Oral 2 Y Y Y

Kisqali (200 MG Dose) Oral 2 Y Y



Kisqali Femara (400 MG Dose) Oral 3 Y Y

Kisqali Femara (600 MG Dose) Oral 3 Y Y

Kisqali Femara(200 MG Dose) Oral 3 Y Y

Lapatinib Ditosylate Oral 1 Y Y

Lenvima (10 MG Daily Dose) Oral 2 Y Y Y










Letrozole Oral 1

Leucovorin Calcium Oral 1

Leukeran Oral 2 Y Y

Lonsurf Oral 2 Y Y

Lynparza Oral 3 Y Y Y

Lysodren Oral 2 Y Y

Matulane Oral 2 Y Y

Megestrol Acetate Oral 1

Mekinist Oral 2 Y Y Y

Mektovi Oral 3 Y Y

Melphalan Oral 1 Y Y

Mercaptopurine Oral 1

Mesnex Oral 3 Y

Methotrexate Oral 1

Methotrexate Sodium Injection 1

Methotrexate Sodium (PF) Injection 1

Myleran Oral 2

Nerlynx Oral 3 Y Y Y

NexAVAR Oral 2 Y Y Y

Nilandron Oral 3 Y Y Y

Nilutamide Oral 1 Y Y Y

Ninlaro Oral 2 Y Y Y

Odomzo Oral 2 Y Y Y

Piqray (200 MG Daily Dose) Oral 2 Y Y Y



Pomalyst Oral 2 Y Y Y

Purixan Oral 2 Y Y

Rubraca Oral 3 Y Y Y

Rydapt Oral 3 Y Y

Soltamox Oral 2

Sprycel Oral 2 Y Y Y

Stivarga Oral 2 Y Y Y

Sutent Oral 2 Y Y Y

Tabloid Oral 2 Y Y

Tafinlar Oral 2 Y Y Y

Tagrisso Oral 2 Y Y Y

Tamoxifen Citrate Oral 1

Tarceva Oral 2 Y Y Y



Targretin Oral 3 Y Y Y

Tasigna Oral 2 Y Y Y

Temodar Oral 3 Y Y Y

Temozolomide Oral 1 Y Y Y

Tibsovo Oral 3 Y Y

Toremifene Citrate Oral 1 Y Y

Tretinoin Oral 1 Y Y

Trexall Oral 3

Venclexta Oral 3 Y Y Y

Venclexta Starting Pack Oral 3 Y Y Y

Verzenio Oral 3 Y Y Y

Vizimpro Oral 3 Y Y

Votrient Oral 2 Y Y Y

Xalkori Oral 2 Y Y Y

Xatmep Oral 3

Xeloda Oral 3 Y Y Y

Xtandi Oral 2 Y Y Y

Yonsa Oral 3 Y Y

Zejula Oral 3 Y Y

Zelboraf Oral 2 Y Y Y

Zolinza Oral 2 Y Y Y

Zydelig Oral 2 Y Y Y

Zykadia Oral 3 Y Y Y

Cardiovascular Agents

Acebutolol HCl Oral 1

Aceon Oral 3

acetaZOLAMIDE Oral 1

acetaZOLAMIDE ER Oral 1

Adcirca Oral 2 Y Y Y

Adempas Oral 3 Y Y Y

Adrenalin Injection 3 Y

Adyphren Injection 3 Y

Afeditab CR Oral 1

Aliskiren Fumarate Oral 1

Alyq Oral 1 Y Y Y

Ambrisentan Oral 1 Y Y Y

aMILoride HCl Oral 1

aMILoride-hydroCHLOROthiazide Oral 1

Amiodarone HCl Oral 1



amLODIPine Besy-Benazepril HCl Oral 1

amLODIPine Besylate Oral 1

amLODIPine Besylate-Valsartan Oral 1

amLODIPine-Atorvastatin Oral 1

amLODIPine-Olmesartan Oral 1

amLODIPine-Valsartan-HCTZ Oral 1

Atenolol Oral 1

Atenolol-Chlorthalidone Oral 1

Atorvastatin Calcium Oral 1

Benazepril HCl Oral 1

Benazepril-hydroCHLOROthiazide Oral 1

Betaxolol HCl Oral 1

BiDil Oral 3

Bisoprolol Fumarate Oral 1

Bisoprolol-hydroCHLOROthiazide Oral 1

Bosentan Oral 1 Y Y Y

Bumetanide Oral 1

Bystolic Oral 3

Candesartan Cilexetil Oral 1

Captopril Oral 1

Captopril-hydroCHLOROthiazide Oral 1

Cartia XT Oral 1

Carvedilol Oral 1

Carvedilol Phosphate ER Oral 1

Caverject Intracavernosal 3 Y

Caverject Impulse Intracavernosal 3 Y

Chlorothiazide Oral 1

Chlorthalidone Oral 1

Cholestyramine Oral 1

Cholestyramine Light Oral 1

Cialis Oral 3 Y

cloNIDine Transdermal 1

cloNIDine HCl Oral 1

Colesevelam HCl Oral 1

Colestid Oral 3

Colestid Flavored Oral 3

Colestipol HCl Oral 1

Consensi Oral 3

Corlanor Oral 2 Y



Demser Oral 3

Dibenzyline Oral 3 Y

Digitek Oral 1

Digox Oral 1

Digoxin Oral 1

dilTIAZem CD Oral 1

dilTIAZem HCl Oral 1

dilTIAZem HCl ER Oral 1

dilTIAZem HCl ER Beads Oral 1

dilTIAZem HCl ER Coated Beads Oral 1

Dilt-XR Oral 1

Disopyramide Phosphate Oral 1

Diuril Oral 3

Dofetilide Oral 1

Doxazosin Mesylate Oral 1

Dyazide Oral 3

Dyrenium Oral 3

Edex Intracavernosal 3 Y

Enalapril Maleate Oral 1

Enalapril-hydroCHLOROthiazide Oral 1

Entresto Oral 2

Epaned Oral 3

EPINEPHrine Injection 1 Y

EPINEPHrine prefilled syringe Injection 1

Epinephrine Professional Injection 3 Y

EPINEPHrine solution Injection 1

EpinephrineSnap-EMS Injection 3 Y

Epinephrinesnap-v Injection 3 Y

EpiPen 2-Pak Injection 2 Y

EpiPen Jr 2-Pak Injection 2 Y

EPIsnap Injection 3 Y

Eplerenone Oral 1

Eprosartan Mesylate Oral 1

Ezetimibe Oral 1

Ezetimibe-Simvastatin Oral 1

Felodipine ER Oral 1

Fenofibrate Oral 1

Fenofibrate Micronized Oral 1

Fenofibric Acid Oral 1



Flecainide Acetate Oral 1

FloLipid Oral 3

Fluvastatin Sodium ER Oral 1

Fosinopril Sodium Oral 1

Fosinopril Sodium-HCTZ Oral 1

Furosemide Oral 1

Gemfibrozil Oral 1

GoNitro Sublingual 3

guanFACINE HCl Oral 1

Hemangeol Oral 3

hydrALAZINE HCl Oral 1

hydroCHLOROthiazide Oral 1

Indapamide Oral 1

Irbesartan Oral 1

Irbesartan-hydroCHLOROthiazide Oral 1

Isosorbide Dinitrate Oral 1

Isosorbide Dinitrate ER Oral 1

Isosorbide Mononitrate Oral 1

Isosorbide Mononitrate ER Oral 1

Isoxsuprine HCl Oral 1

Isradipine Oral 1

Juxtapid Oral 3 Y Y Y

Kapspargo Sprinkle Oral 3

Keveyis Oral 3 Y Y Y

Kynamro Subcutaneous 3 Y Y

Labetalol HCl Intravenous 3

Lanoxin Injection 3

Letairis Oral 2 Y Y Y

Levitra Oral 3 Y

Lidocaine in D5W Intravenous 3

Lisinopril Oral 1

Lisinopril-hydroCHLOROthiazide Oral 1

Livalo Oral 3

Losartan Potassium Oral 1

Losartan Potassium-HCTZ Oral 1

Lovastatin Oral 1

Matzim LA Oral 1

Maxzide Oral 3

Maxzide-25 Oral 3



methazolAMIDE Oral 1

Methyclothiazide Oral 1

Methyldopa Oral 1

Methyldopa-hydroCHLOROthiazide Oral 1

metOLazone Oral 1

Metoprolol Succinate ER Oral 1

Metoprolol Tartrate Oral 1

Metoprolol-HCTZ ER Oral 1

Metoprolol-hydroCHLOROthiazide Oral 1

metyroSINE Oral 1

Mexiletine HCl Oral 1

Midodrine HCl Oral 1

Minitran Transdermal 1

Minoxidil Oral 1

Moexipril HCl Oral 1

Moexipril-hydroCHLOROthiazide Oral 1

Multaq Oral 2

Muse Urethral 3 Y

Nadolol Oral 1

Nadolol-Bendroflumethiazide Oral 1

Neptazane Oral 3

Niacin (Antihyperlipidemic) Oral 3

Niacin ER (Antihyperlipidemic) Oral 1

Niacor Oral 3

Niaspan Oral 3

niCARdipine HCl Oral 1

NIFEdipine Oral 1

NIFEdipine ER Oral 1

NIFEdipine ER Osmotic Release Oral 1

niMODipine Oral 1

Nisoldipine ER Oral 1

Nitro-Bid Transdermal 2

Nitro-Dur Transdermal 3

Nitroglycerin Sublingual 1

Nitroglycerin ER Oral 1

Nitrolingual Translingual 3

NitroMist Translingual 3

Nitrostat Sublingual 3

Nitro-Time Oral 3



Northera Oral 3 Y Y

Nymalize Oral 3

Olmesartan Medoxomil Oral 1

Olmesartan Medoxomil-HCTZ Oral 1

Olmesartan-amLODIPine-HCTZ Oral 1

Opsumit Oral 2 Y Y Y

Orenitram Oral 3 Y Y 4

Pacerone Oral 1

Perindopril Erbumine Oral 1

Phenoxybenzamine HCl Oral 1

Phenylephrine HCl (Pressors) Intravenous 3

Pindolol Oral 1

Praluent Subcutaneous 2 Y

Pravastatin Sodium Oral 1

Prazosin HCl Oral 1

Prevalite Oral 1

Propafenone HCl Oral 1

Propafenone HCl ER Oral 1

Propranolol HCl Oral 1

Propranolol HCl ER Oral 1

Propranolol-HCTZ Oral 1

Qbrelis Oral 3

Questran Oral 3

Questran Light Oral 3

Quinapril HCl Oral 1

Quinapril-hydroCHLOROthiazide Oral 1

quiNIDine Gluconate Injection 1

quiNIDine Gluconate ER Oral 1

quiNIDine Sulfate Oral 1

Ramipril Oral 1

Ranexa Oral 3

Ranolazine ER Oral 1

Repatha Subcutaneous 2 Y

Repatha Pushtronex System Subcutaneous 2 Y

Repatha SureClick Subcutaneous 2 Y

Revatio Oral 3 Y Y Y

Rosuvastatin Calcium Oral 1

Sildenafil Citrate Oral 1 Y Y

Sildenafil Citrate (Pulmonary Hypertension) Oral 1 Y Y Y



Simvastatin Oral 1

Sorine Oral 1

Sotalol HCl Oral 1

Sotalol HCl (AF) Oral 1

Sotylize Oral 3

Spironolactone Oral 1

Spironolactone-HCTZ Oral 1

Staxyn Oral 3 Y

Stendra Oral 3 Y

Sular Oral 3

Tadalafil Oral 1 Y

Tadalafil (PAH) Oral 1 Y Y Y

Taztia XT Oral 1

Telmisartan Oral 1

Telmisartan-HCTZ Oral 1

Terazosin HCl Oral 1

Tiadylt ER Oral 1

Tikosyn Oral 3

Timolol Maleate Oral 1

Torsemide Oral 1

Tracleer Oral 2 Y Y Y

Trandolapril Oral 1

Trandolapril-Verapamil HCl ER Oral 1

Triamterene Oral 1

Triamterene-HCTZ Oral 1

Tricor Oral 3

Triklo Oral 1

Trilipix Oral 3

Tyvaso Inhalation 3 Y Y

Tyvaso Refill Inhalation 3 Y Y

Tyvaso Starter Inhalation 3 Y Y

Uptravi Oral 2 Y Y

Valsartan Oral 1

Valsartan-hydroCHLOROthiazide Oral 1

Vardenafil HCl Oral 1 Y

Vecamyl Oral 3

Ventavis Inhalation 3 Y Y Y 3

Verapamil HCl Oral 1

Verapamil HCl ER Oral 1



Viagra Oral 3 Y

Vyndaqel Oral 2 Y Y Y

Welchol Oral 2

Central Nervous System Agents

Abilify Oral 3

Abilify Maintena Intramuscular 3

Adasuve Inhalation 3

ALPRAZolam Oral 1

ALPRAZolam ER Oral 1

ALPRAZolam Intensol Oral 3

ALPRAZolam XR Oral 1

Ambien Oral 3

Ambien CR Oral 3

Amitriptyline HCl Oral 1

Amoxapine Oral 1

Anafranil Oral 3

ARIPiprazole Oral 1

Aristada Intramuscular 3

Asenapine Maleate Sublingual 1

Ativan Injection 3

buPROPion HCl Oral 1

buPROPion HCl ER (SR) Oral 1

buPROPion HCl ER (XL) Oral 1

busPIRone HCl Oral 1

Butisol Sodium Oral 3

CeleXA Oral 3

chlordiazePOXIDE HCl Oral 1

chlorproMAZINE HCl Injection 1

Citalopram Hydrobromide Oral 1

clomiPRAMINE HCl Oral 1

Clorazepate Dipotassium Oral 1

cloZAPine Oral 1

Clozaril Oral 3

Compro Rectal 1

Cymbalta Oral 3

Desipramine HCl Oral 1

Desvenlafaxine ER Oral 1

Desvenlafaxine Succinate ER Oral 1

diazePAM Injection 1



diazePAM Intensol Oral 1

Doral Oral 3

Doxepin HCl Oral 1

Drizalma Sprinkle Oral 3 Y

DULoxetine HCl Oral 1

Edluar Sublingual 3

Effexor XR Oral 3

Elavil Oral 3

Emsam Transdermal 3

Equetro Oral 3

Escitalopram Oxalate Oral 1

Estazolam Oral 1

Eszopiclone Oral 1

Fanapt Oral 3 Y

Fanapt Titration Pack Oral 3

FazaClo Oral 3

Fetzima Oral 3

Fetzima Titration Oral 3

FLUoxetine HCl Oral 1

fluPHENAZine Decanoate Injection 1

fluPHENAZine HCl Injection 1

Flurazepam HCl Oral 1

fluvoxaMINE Maleate Oral 1

fluvoxaMINE Maleate ER Oral 1

Forfivo XL Oral 3

Geodon Oral 3

Halcion Oral 3

Haloperidol Oral 1

Haloperidol Lactate Oral 1

Hetlioz Oral 3 Y Y Y

hydrOXYzine HCl Oral 1

hydrOXYzine Pamoate Oral 1

Imipramine HCl Oral 1

Imipramine Pamoate Oral 1

Intermezzo Sublingual 3

Invega Oral 3 Y

Invega Sustenna Intramuscular 3

Invega Trinza Intramuscular 3 Y

Khedezla Oral 3



Latuda Oral 3

Lexapro Oral 3

Lithium Oral 1

Lithium Carbonate Oral 1

Lithium Carbonate ER Oral 1

Lithobid Oral 3

LORazepam Injection 1

LORazepam Intensol Oral 1

Loxapine Succinate Oral 1

Lunesta Oral 3

Maprotiline HCl Oral 1

Marplan Oral 3

Meprobamate Oral 1

Mirtazapine Oral 1

Molindone HCl Oral 1

Nardil Oral 3

Nefazodone HCl Oral 1

Norpramin Oral 3

Nortriptyline HCl Oral 1

Nuplazid Oral 3 Y Y

OLANZapine Intramuscular 1

Oxazepam Oral 1

Paliperidone ER Oral 1

Pamelor Oral 3

Parnate Oral 3

PARoxetine HCl Oral 1

PARoxetine HCl ER Oral 1

Paxil Oral 3

Paxil CR Oral 3

Perphenazine Oral 1

Perseris Subcutaneous 3 Y

Pexeva Oral 3

Phenelzine Sulfate Oral 1

PHENobarbital Oral 1

Pristiq Oral 3

Prochlorperazine Rectal 1

Prochlorperazine Maleate Oral 1

Protriptyline HCl Oral 1

Quazepam Oral 1



QUEtiapine Fumarate Oral 1

QUEtiapine Fumarate ER Oral 1

Ramelteon Oral 1

Remeron Oral 3

Remeron SolTab Oral 3

Restoril Oral 3

Rexulti Oral 3 Y

RisperDAL Oral 3

RisperDAL Consta Intramuscular 3

RisperDAL M-TAB Oral 3

risperiDONE Oral 1

risperiDONE M-TAB Oral 1

Rozerem Oral 3

Seconal Oral 3

SEROquel Oral 3

SEROquel XR Oral 2

Sertraline HCl Oral 1

Sonata Oral 3

Surmontil Oral 3

Temazepam Oral 1

Thioridazine HCl Oral 1

Thiothixene Oral 1

Tofranil Oral 3

Tranxene-T Oral 3

Tranylcypromine Sulfate Oral 1

traZODone HCl Oral 1

Triazolam Oral 1

Trifluoperazine HCl Oral 1

Trimipramine Maleate Oral 1

Trintellix Oral 3

Valium Oral 3

Venlafaxine HCl Oral 1

Venlafaxine HCl ER Oral 1

Viibryd Oral 3

Viibryd Starter Pack Oral 3

Vistaril Oral 3

Vraylar Oral 3

Xanax Oral 3

Xanax XR Oral 3



Zaleplon Oral 1

Ziprasidone HCl Oral 1

Ziprasidone Mesylate Intramuscular 1

Zoloft Oral 3

Zolpidem Tartrate Oral 1

Zolpidem Tartrate ER Oral 1

Zolpimist Oral 3

ZyPREXA Intramuscular 3

ZyPREXA Relprevv Intramuscular 3

ZyPREXA Zydis Oral 3

Dermatological/Anorectal/Mouth-Throat/Dental/Ophthalmic/Otic

Acetasol HC Otic 1

Acitretin Oral 1

Acular Ophthalmic 3

Acular LS Ophthalmic 3

Acuvail Ophthalmic 3

Acyclovir External 1

Adapalene External 1

AK-Poly-Bac Ophthalmic 1

Akten Ophthalmic 3

Ala-Cort External 1

Alcaine Ophthalmic 3

Alclometasone Dipropionate External 1

Aldara External 3

Alocril Ophthalmic 3

Alomide Ophthalmic 3

Alphagan P Ophthalmic 2

AlphaTrex External 1

Alrex Ophthalmic 2

Altabax External 3

Altacaine Ophthalmic 1

Amcinonide External 1

Amnesteem Oral 1

Analpram HC External 3

Analpram HC Singles External 3

Analpram-HC External 3

Anusol-HC External 3

Apraclonidine HCl Ophthalmic 1

Atropine Sulfate Ophthalmic 1



Atropine Sulfate-NaCl Ophthalmic 1

Avita External 1

AzaSite Ophthalmic 3

Azelaic Acid External 1

Azelastine HCl Ophthalmic 1

Azopt Ophthalmic 2

Bacitracin Ophthalmic 1

Bacitracin-Polymyxin B Ophthalmic 1

Bacitra-Neomycin-Polymyxin-HC Ophthalmic 1

Bactroban External 3

Benzo-Lidocaine-Tetracaine External 3

Benzoyl Peroxide-Erythromycin External 1

Bepreve Ophthalmic 3

Beser External 1

Besivance Ophthalmic 3

Betadine Ophthalmic Prep Ophthalmic 3

Betagan Ophthalmic 3

Betamethasone Dipropionate External 1

Betamethasone Dipropionate Aug External 1

Betamethasone Valerate External 1

Betaxolol HCl Ophthalmic 1

Betoptic-S Ophthalmic 3

Bimatoprost Ophthalmic 1

Bleph-10 Ophthalmic 3

Blephamide Ophthalmic 3

Blephamide S.O.P. Ophthalmic 3

Brimonidine Tartrate Ophthalmic 1

Brimonidine-Dorzolamide Ophthalmic 1

Bromfenac Sodium Ophthalmic 1

Bromfenac Sodium (Once-Daily) Ophthalmic 1

BromSite Ophthalmic 3

Calcipotriene External 1

Calcipotriene-Betameth Diprop External 1

Calcitrene External 1

Calcitriol External 1

Capex External 3

Carac External 2 Y

Carteolol HCl Ophthalmic 1

Centany External 3



Cerovel External 1

Cetraxal Otic 3

Cevimeline HCl Oral 1

Chlooxia External 3

Chlorhexidine Gluconate Mouth/Throat 1

Ciclodan External 1

Ciclopirox External 1

Ciclopirox Olamine External 1

Ciclopirox-Clobetasol External 1

Ciclopirox-Clobetasol-Sal Acid External 1

Ciclopirox-Salicylic Acid External 1

Ciloxan Ophthalmic 2

Cimetidine-Lido-Salicylic Acid External 3

Cipro HC Otic 2

Ciprodex Otic 2

Ciprofloxacin HCl Ophthalmic 1

Ciprofloxacin-Dexamethasone Otic 1

Ciprofloxacin-Fluocinolone PF Otic 3

Claravis Oral 1

Clindamycin Phos-Benzoyl Perox External 1

Clindamycin Phosphate External 1

Clobetasol Prop Emollient Base External 1

Clobetasol Propionate External 1

Clobetasol Propionate E External 1

Clobetasol Propionate Emulsion External 1

Clobetasol Prop-Levocetirizine External 3

Clobetasol Prop-Niacinamide External 3

Clobex External 3

Clocortolone Pivalate External 1

Clocortolone Pivalate Pump External 1

Clodan External 1

Cloderm External 3

Cloderm Pump External 3

Clotrimazole External 1

Clotrimazole-Betamethasone External 1

Colocort Rectal 1

Coly-Mycin S Otic 3

Combigan Ophthalmic 3

Condylox External 3



Cordran External 3

Cormax Scalp Application External 1

Cortane-B Otic 3

Cortane-B Aqueous Otic 3

Cortenema Rectal 3

Cortic-ND Otic 1

Cortifoam External 2

Cortisporin External 3

Cosentyx Subcutaneous 2 Y Y Y

Cosentyx (300 MG Dose) Subcutaneous 2 Y Y Y

Cosentyx Sensoready (300 MG) Subcutaneous 2 Y Y Y

Cosentyx Sensoready Pen Subcutaneous 2 Y Y Y

Cosopt Ophthalmic 3

Cosopt PF Ophthalmic 3

Cromolyn Sodium Ophthalmic 1

Crotan External 3

Cutivate External 3

Cyclogyl Ophthalmic 3

Cyclomydril Ophthalmic 3

Cyclopentolate HCl Ophthalmic 1

cycloSPORINE in Klarity Ophthalmic 3

Cystadrops Ophthalmic 3 Y Y Y

Cystaran Ophthalmic 3 Y Y Y

Derma-Smoothe/FS Body External 3

Derma-Smoothe/FS Scalp External 3

Dermatop External 3

DermOtic Otic 3

Desonate External 3

Desonide External 1

DesOwen External 3

Desoximetasone External 1

Dexamethasone Sodium Phosphate Ophthalmic 1

Dexamethasone-Moxifloxacin Intraocular 1

Dexameth-Moxiflox-Ketorolac Intraocular 1

Diclofenac Epolamine External 3

Diclofenac Sodium External 1 Y

Differin External 2

Diprolene External 3

Diprolene AF External 3



Dorzolamide HCl Ophthalmic 1

Dorzolamide HCl-Timolol Mal Ophthalmic 1

Dorzolamide HCl-Timolol Mal PF Ophthalmic 1

Double PM Ophthalmic 3

Dovonex External 3

Drysol External 2

Dupixent Subcutaneous 3 Y Y

Durezol Ophthalmic 3

Econasil External 3

Econazole Nitrate External 1

Econazole Nitrate-Niacinamide External 3

Efudex External 3

Elestat Ophthalmic 3

Elidel External 2

Elimite External 3

Elocon External 3

Emadine Ophthalmic 3

Epifoam External 3

Epinastine HCl Ophthalmic 1

Ertaczo External 3

Erythromycin External 1

Eucrisa External 3

Eurax External 3

Evoxac Oral 3

Exotic-HC Otic 1

Eysuvis Ophthalmic 3

Flac Otic 3

Flarex Ophthalmic 3

Flector External 3

Floxin Otic Otic 3

Fluocinolone Acet-Niacinamide External 3

Fluocinolone Acetonide External 1

Fluocinolone Acetonide Body External 1

Fluocinolone Acetonide Scalp External 1

Fluocinonide External 1

Fluocinonide Emulsified Base External 1

Fluorometholone Ophthalmic 1

Fluoroplex External 2

Fluorouracil External 1



Flurandrenolide External 1

Flurbiprofen Sodium Ophthalmic 1

Fluticasone Propionate External 1

FML Ophthalmic 3

FML Forte Ophthalmic 3

FML Liquifilm Ophthalmic 3

Gatifloxacin Ophthalmic 1

Gentak Ophthalmic 1

Gentamicin Sulfate External 1

Halcinonide External 1

Halobetasol Propionate External 1

Halog External 3

Homatropaire Ophthalmic 1

Homatropine HBr Ophthalmic 1

Hyaluronate-Niacin-Tacrolimus External 3

Hydrocortisone External 1

Hydrocortisone (Perianal) External 1

Hydrocortisone Ace-Pramoxine External 1

Hydrocortisone Acetate Rectal 1

Hydrocortisone Butyr Lipo Base External 1

Hydrocortisone Butyrate External 1

Hydrocortisone in Absorbase External 1

Hydrocortisone Valerate External 1

Hydrocortisone-Acetic Acid Otic 1

Hydrocortisone-Iodoquinol External 1

Hydrocort-Pramoxine (Perianal) External 1

Ilevro Ophthalmic 3

Ilumya Subcutaneous 3 Y Y

Imioxia External 3

Imiquimod External 1

Imiquimod Pump External 3 Y

Impoyz External 3

Inveltys Ophthalmic 3

Iodoquinol-HC-Ketoconazole External 3

Iopidine Ophthalmic 3

Isopto Atropine Ophthalmic 2

Isopto Carpine Ophthalmic 3

ISOtretinoin Oral 1

Istalol Ophthalmic 3



Kenalog External 3

Ketoconazole External 1

Ketodan External 1

Ketorolac Tromethamine Ophthalmic 1

Klarity-A Ophthalmic 3

Lacrisert Ophthalmic 3

Lanolin External 3

Lastacaft Ophthalmic 3

Latanoprost Ophthalmic 1

Latanoprost-Timolol Maleate Ophthalmic 1

Levobunolol HCl Ophthalmic 1

levoFLOXacin Ophthalmic 1

Lidocaine External 1 Y

Lidocaine HCl Mouth/Throat 1

Lidocaine HCl Urethral/Mucosal External 1 Y

Lidocaine Viscous HCl Mouth/Throat 1

Lidocort External 1

Lidoderm External 3 Y

Lindane External 1

LoKara External 1

Loprox External 3

Lotemax Ophthalmic 2

Lotemax SM Ophthalmic 3

Loteprednol Etabonate Ophthalmic 1

Lotrisone External 3

Lumigan Ophthalmic 2

Malathion External 1

Maxidex Ophthalmic 3

Maxitrol Ophthalmic 3

Mentax External 3

Methoxsalen Rapid Oral 1

Metipranolol Ophthalmic 1

metroNIDAZOLE External 1

Microvix LP External 3

Miochol-E Intraocular 3

Miostat Intraocular 3

Mometasone Furoate External 1

Moxeza Ophthalmic 3

Moxifloxacin HCl Ophthalmic 1



Moxifloxacin HCl (2X Day) Ophthalmic 1

Mupirocin External 1

Mupirocin Calcium External 1

Myorisan Oral 1

Naftifine HCl External 1

Naftin External 3

Natacyn Ophthalmic 2

Natroba External 3

Neomycin-Bacitracin Zn-Polymyx Ophthalmic 1

Neomycin-Polymyxin-Dexameth Ophthalmic 1

Neomycin-Polymyxin-Gramicidin Ophthalmic 1

Neomycin-Polymyxin-HC Ophthalmic 1

Neo-Polycin Ophthalmic 1

Neo-Polycin HC Ophthalmic 1

Neosporin Ophthalmic 3

Neo-Synalar External 3

Nevanac Ophthalmic 3

Niacinamide-Tacrolimus External 3

Niacinamide-Triamcinolone Acet External 3

Nizoral External 3

Nuvakaan-II External 3

Nyamyc External 1

Nyata External 1

Nystatin External 1

Nystatin-Triamcinolone External 1

Nystop External 1

Ocufen Ophthalmic 3

Ocuflox Ophthalmic 3

Ofloxacin Ophthalmic 1

Omnipred Ophthalmic 3

Onycho-Med External 3

Oralone Mouth/Throat 1

Oticin HC NR Otic 3

Otovel Otic 3

Ovide External 3

Oxervate Ophthalmic 3 Y Y

Oxiconazole Nitrate External 1

Oxistat External 3

Oxsoralen Ultra Oral 3



Panretin External 3 Y

Paroex Mouth/Throat 1

Patanol Ophthalmic 3

Pazeo Ophthalmic 2

Peridex Mouth/Throat 3

Periogard Mouth/Throat 1

Permethrin External 1

Phenylephrine HCl Ophthalmic 1

Pheodoyo External 3

Phospholine Iodide Ophthalmic 3

Pilocarpine HCl Ophthalmic 1

Pimecrolimus External 1

Podofilox External 1

Polycin Ophthalmic 1

Polymyxin B-Trimethoprim Ophthalmic 1

Polytrim Ophthalmic 3

Povidone-Iodine Ophthalmic 3

Pramosone External 3

Pred Forte Ophthalmic 3

Pred Mild Ophthalmic 3

Pred-G Ophthalmic 3

Pred-G S.O.P. Ophthalmic 3

Prednicarbate External 1

prednisoLONE Acetate Ophthalmic 1

prednisoLONE Acetate P-F Ophthalmic 3

prednisoLONE Sodium Phosphate Ophthalmic 1

prednisoLONE-Bromfenac Ophthalmic 1

prednisoLONE-Gatifloxacin Ophthalmic 1

prednisoLONE-Moxifloxacin Ophthalmic 1

Prednisolon-Gatiflox-Bromfenac Ophthalmic 1

Prednisolon-Moxiflox-Bromfenac Ophthalmic 1

Proctofoam HC External 3

Procto-Med HC External 1

Procto-Pak External 1

Proctosol HC External 1

Proctozone-HC External 1

Prolensa Ophthalmic 3

Proparacaine HCl Ophthalmic 1

Protopic External 3



Rea Lo 40 External 1

Remeven External 1

Rescula Ophthalmic 3

Restasis Ophthalmic 3 Y

Restasis MultiDose Ophthalmic 3 Y

Retin-A External 3

Rhopressa Ophthalmic 3

Rosadan External 1

Salicylic Acid External 1

Selenium Sulfide External 1

Siliq Subcutaneous 3 Y Y

Silvadene External 3

Silver sulfADIAZINE External 1

Simbrinza Ophthalmic 2

Sklice External 3

Skyrizi (150 MG Dose) Subcutaneous 2 Y Y

Sodium Sulfacetamide External 1

Solaravix External 3

Solaraze External 3 Y Y

Soriatane Oral 3 Y

Spinosad External 1

SSD External 1

Stelara Subcutaneous 2 Y Y Y

Sulfacetamide Sodium External 1

Sulfacetamide-prednisoLONE Ophthalmic 1

Sulfamylon External 3

Synalar External 3

Taclonex External 3

Tacrolimus External 1

Taltz Subcutaneous 3 Y Y

Targretin External 3 Y

Tazarotene External 1

Tazorac External 2

Temovate External 3

Tetcaine Ophthalmic 1

TetraVisc Ophthalmic 1

TetraVisc Forte Ophthalmic 1

Texacort External 3

Timolol Maleate Ophthalmic 1



Timolol Maleate PF Ophthalmic 1

Timolol-Brimon-Dorzol-Latanopr Ophthalmic 1

Timolol-Brimonidine-Dorzolamid Ophthalmic 1

Timolol-Dorzolamid-Latanoprost Ophthalmic 1

Timoptic Ophthalmic 3

Timoptic Ocudose Ophthalmic 3

Timoptic-XE Ophthalmic 3

TobraDex Ophthalmic 3

TobraDex ST Ophthalmic 3

Tobramycin Ophthalmic 1

Tobramycin-Dexamethasone Ophthalmic 1

Tobrex Ophthalmic 2

Tolak External 3

Topicort External 3

Topicort Spray External 3

Tovet External 1

Travatan Z Ophthalmic 2

Travoprost (BAK Free) Ophthalmic 1

Tremfya Subcutaneous 2 Y Y Y

Tretinoin External 1

Triamcinolone Acetonide External 1

Triamcinolone-Moxifloxacin Intraocular 1

Trianex External 1

Triderm External 1

Tridesilon External 3

Triesence Intraocular 3

Trifluridine Ophthalmic 1

Triple PMB Ophthalmic 3

Tropicamide Ophthalmic 1

Tropicamide-Cyclopentolate-PE Ophthalmic 1

Tropic-Proparaca-PE-Ketorolac Ophthalmic 1

Trusopt Ophthalmic 3

Ultravate External 3

Umecta Mousse External 1

Urea External 1

Urea-C40 External 1

Valchlor External 2 Y Y

Vanos External 3

Verdeso External 3



Veregen External 3 Y

Vigamox Ophthalmic 2

Viroptic Ophthalmic 3

Vyzulta Ophthalmic 3

Westcort External 3

Xalatan Ophthalmic 3

Xelpros Ophthalmic 3

Xiidra Ophthalmic 3 Y

Xolegel External 3

Xurea External 1

Zenatane Oral 1

Zioptan Ophthalmic 3

Zirgan Ophthalmic 3

Zolpak External 3

Zovirax External 3

Zyclara External 3 Y

Zyclara Pump External 3 Y

Zylet Ophthalmic 2

Zymaxid Ophthalmic 3

Endocrine and Metabolic Agents

Acarbose Oral 1

Acthar Injection 3 Y Y Y

Activella Oral 3

Actonel Oral 3

Actoplus Met Oral 3

Actoplus met XR Oral 3

Actos Oral 3

Adlyxin Subcutaneous 3

Adlyxin Starter Pack Subcutaneous 3

Admelog Subcutaneous 3

Admelog SoloStar Subcutaneous 3

Afirmelle Oral 1

Afrezza Inhalation 3

Alendronate Sodium Oral 1

Alogliptin Benzoate Oral 1

Alogliptin-metFORMIN HCl Oral 1

Alogliptin-Pioglitazone Oral 1

Alora Transdermal 3

Altavera Oral 1



Alyacen 1/35 Oral 1

Alyacen 7/7/7 Oral 1

Amabelz Oral 1

Amaryl Oral 3

Amethia Oral 1

Amethia Lo Oral 1

Amethyst Oral 3

Anadrol-50 Oral 3 Y

Androderm Transdermal 3 Y

AndroGel Transdermal 3 Y

AndroGel Pump Transdermal 2 Y

Android Oral 3 Y

Androxy Oral 2 Y

Angeliq Oral 3

Apidra Injection 3

Apidra SoloStar Subcutaneous 3

Apri Oral 1

Aranelle Oral 1

Armour Thyroid Oral 3

Ashlyna Oral 1

Atelvia Oral 3

Aubra Oral 1

Aubra EQ Oral 1

Aurovela 1.5/30 Oral 1

Aurovela 1/20 Oral 1

Aurovela 24 FE Oral 1

Aurovela Fe 1.5/30 Oral 1

Aurovela FE 1/20 Oral 1

Avandia Oral 3

Aviane Oral 1

Axiron Transdermal 2 Y

Aygestin Oral 3

Ayuna Oral 1

Azurette Oral 1

Balcoltra Oral 3

Balziva Oral 1

Baqsimi One Pack Nasal 2 Y

Basaglar KwikPen Subcutaneous 3

Bekyree Oral 1



Beyaz Oral 3

Biest/Progesterone Transdermal 3

Bijuva Oral 3

Binosto Oral 3

Blisovi 24 Fe Oral 1

Blisovi Fe 1.5/30 Oral 1

Blisovi FE 1/20 Oral 1

Boniva Oral 3

Bravelle Injection 3 Y

Brevicon (28) Oral 3

Briellyn Oral 1

Budesonide Oral 1

Buphenyl Oral 3 Y Y

Bydureon Subcutaneous 3

Bydureon BCise Subcutaneous 3

Byetta 10 MCG Pen Subcutaneous 3

Byetta 5 MCG Pen Subcutaneous 3

Cabergoline Oral 1

Calcitonin (Salmon) Nasal 1

Calcitriol Oral 1

Camila Oral 1

Camrese Oral 1

Camrese Lo Oral 1

Carbaglu Oral 3 Y Y

Carnitor Oral 3

Carnitor SF Oral 3

Caziant Oral 1

Cetrotide Subcutaneous 2 Y

Charlotte 24 Fe Oral 1

Chateal Oral 1

Chateal EQ Oral 1

chlorproPAMIDE Oral 1

Chorionic Gonadotropin Intramuscular 1 Y

Cinacalcet HCl Oral 1 Y Y

Climara Transdermal 3

Climara Pro Transdermal 2

clomiPHENE Citrate Oral 1

CombiPatch Transdermal 3

Cortef Oral 3



Cortisone Acetate Oral 1

Covaryx Oral 1

Covaryx HS Oral 1

Cryselle-28 Oral 1

Crysvita Subcutaneous 3 Y Y

Cyclafem 1/35 Oral 1

Cyclafem 7/7/7 Oral 1

Cyclessa Oral 3

Cycloset Oral 3

Cyred Oral 1

Cyred EQ Oral 1

Cystadane Oral 3 Y Y

Cytomel Oral 3

Danazol Oral 1

Dasetta 1/35 Oral 1

Dasetta 7/7/7 Oral 1

Daysee Oral 1

DDAVP Nasal 3

DDAVP Rhinal Tube Nasal 3

Deblitane Oral 1

Decadron Oral 3

Delestrogen Intramuscular 3

Deltasone Oral 1

Delyla Oral 1

Depo-Estradiol Intramuscular 3

Depo-Provera Intramuscular 3 Y

Depo-SubQ Provera 104 Subcutaneous 3

Depo-Testosterone Intramuscular 3 Y

Desmopressin Ace Spray Refrig Nasal 1

Desmopressin Acetate Injection 1 Y

Desmopressin Acetate Spray Nasal 1

Desogen Oral 3

Desogestrel-Ethinyl Estradiol Oral 1

Dexamethasone Oral 1

Dexamethasone Intensol Oral 2

Dexamethasone Sod Phos-Bupiv Injection 3 Y

Divigel Transdermal 2

Dotti Transdermal 1

Doxercalciferol Oral 1



Drospiren-Eth Estrad-Levomefol Oral 1

Drospirenone-Ethinyl Estradiol Oral 1

Duavee Oral 3

Duetact Oral 3

EEMT Oral 1

EEMT HS Oral 1

Egrifta Subcutaneous 3 Y Y Y

Elestrin Transdermal 3

Elinest Oral 1

Ella Oral 2

EluRyng Vaginal 1

Emflaza Oral 3 Y Y

Emoquette Oral 1

Enpresse-28 Oral 1

Enskyce Oral 1

Errin Oral 1

Est Estrogens-Methyltest Oral 1

Est Estrogens-Methyltest DS Oral 1

Est Estrogens-Methyltest HS Oral 1

Estarylla Oral 1

Estrace Oral 3

Estradiol Oral 1

Estradiol-Norethindrone Acet Oral 1

Estrogel Transdermal 2

Estropipate Oral 1

Estrostep Fe Oral 3

Ethynodiol Diac-Eth Estradiol Oral 1

Etidronate Disodium Oral 1 Y

Etonogestrel-Ethinyl Estradiol Vaginal 1

Euthyrox Oral 1

Evamist Transdermal 3

Evista Oral 3

FaLessa Oral 3

Falmina Oral 1

Farxiga Oral 2

Fayosim Oral 1

Femhrt Low Dose Oral 3

Femynor Oral 1

Fiasp Subcutaneous 2



Fiasp FlexTouch Subcutaneous 2

Fiasp PenFill Subcutaneous 2

Fludrocortisone Acetate Oral 1

Follistim AQ Subcutaneous 2 Y

Forteo Subcutaneous 3 Y Y Y

Fortesta Transdermal 3 Y

Fosamax Oral 3

Fosamax Plus D Oral 3

Fyavolv Oral 1

Galafold Oral 3 Y Y

Ganirelix Acetate Subcutaneous 1 Y

Gemmily Oral 1

Generess FE Oral 3

Gianvi Oral 1

Gildagia Oral 1

Glimepiride Oral 1

glipiZIDE Oral 1

glipiZIDE ER Oral 1

glipiZIDE XL Oral 1

glipiZIDE-metFORMIN HCl Oral 1

GlucaGen HypoKit Injection 3 Y

Glucagon Emergency Injection 1 Y

Glucophage Oral 3

Glucophage XR Oral 3

Glucotrol Oral 3

Glucotrol XL Oral 3

Glucovance Oral 3

glyBURIDE Oral 1

glyBURIDE Micronized Oral 1

glyBURIDE-metFORMIN Oral 1

Glynase Oral 3

Glyset Oral 3

Glyxambi Oral 2

Gonal-f Injection 2 Y

Gonal-f RFF Subcutaneous 2 Y

Gonal-f RFF Rediject Subcutaneous 2 Y

Gvoke HypoPen 1-Pack Subcutaneous 2 Y

Gvoke HypoPen 2-Pack Subcutaneous 2 Y

Gvoke PFS Subcutaneous 2 Y



Hailey 1.5/30 Oral 1

Hailey 24 Fe Oral 1

Hailey FE 1.5/30 Oral 1

Hailey FE 1/20 Oral 1

HCG Injection 3 Y

Heather Oral 1

Hectorol Oral 3

HumuLIN 70/30 Subcutaneous 3

HumuLIN 70/30 KwikPen Subcutaneous 3

HumuLIN N Subcutaneous 3

HumuLIN N KwikPen Subcutaneous 3

HumuLIN R Injection 3

HumuLIN R U-500 (CONCENTRATED) Subcutaneous 2 Y

HumuLIN R U-500 KwikPen Subcutaneous 2 Y

Hydrocortisone Oral 1

Ibandronate Sodium Oral 1

Iclevia Oral 1

Incassia Oral 1

Increlex Subcutaneous 2 Y Y

Insulin Lispro Subcutaneous 3

Insulin Lispro (1 Unit Dial) Subcutaneous 3

Insulin Lispro Junior KwikPen Subcutaneous 3

Insulin Lispro Prot & Lispro Subcutaneous 3

Introvale Oral 1 Y

Invokamet Oral 2

Invokamet XR Oral 2

Invokana Oral 2

Isibloom Oral 1

Jaimiess Oral 1 Y

Janumet Oral 2

Janumet XR Oral 2

Januvia Oral 2

Jardiance Oral 2

Jasmiel Oral 1

Jencycla Oral 1

Jentadueto Oral 3

Jentadueto XR Oral 3

Jevantique Lo Oral 1

Jinteli Oral 1



Jolessa Oral 1 Y

Jolivette Oral 1

Juleber Oral 1

Junel 1.5/30 Oral 1

Junel 1/20 Oral 1

Junel FE 1.5/30 Oral 1

Junel FE 1/20 Oral 1

Junel Fe 24 Oral 1

Jynarque Oral 2 Y Y Y

Kaitlib Fe Oral 1

Kalliga Oral 1

Kariva Oral 1

Kazano Oral 3

Kelnor 1/35 Oral 1

Kelnor 1/50 Oral 1

Kimidess Oral 1

Kombiglyze XR Oral 3

Kurvelo Oral 1

Lantus Subcutaneous 2

Lantus SoloStar Subcutaneous 2

Larin 1.5/30 Oral 1

Larin 1/20 Oral 1

Larin 24 FE Oral 1

Larin Fe 1.5/30 Oral 1

Larin Fe 1/20 Oral 1

Larissia Oral 1

Layolis FE Oral 1

Leena Oral 1

Lessina Oral 1

Levemir Subcutaneous 2

Levemir FlexTouch Subcutaneous 2

levOCARNitine Oral 1

levOCARNitine SF Oral 1

Levonest Oral 1

Levonorgest-Eth Est & Eth Est Oral 1

Levonorgest-Eth Estrad 91-Day Oral 1 Y

Levonorgestrel-Ethinyl Estrad Oral 1

Levonorg-Eth Estrad Triphasic Oral 1

Levora 0.15/30 (28) Oral 1



Levo-T Oral 1

Levothyroxine Sodium Oral 1

Levoxyl Oral 1

Lillow Oral 2

Liothyronine Sodium Oral 1

Lo Loestrin Fe Oral 3

Loestrin 1.5/30 (21) Oral 3

Loestrin 1/20 (21) Oral 3

Loestrin Fe 1.5/30 Oral 3

Loestrin Fe 1/20 Oral 3

LoJaimiess Oral 1 Y

Lomedia 24 FE Oral 1

Lopreeza Oral 1

Loryna Oral 1

LoSeasonique Oral 3

Low-Ogestrel Oral 1

Lo-Zumandimine Oral 1

Lupaneta Pack Combination 3 Y Y

Lutera Oral 1

Lyleq Oral 1

Lyllana Transdermal 1

Lyza Oral 1

Marlissa Oral 1

Medrol Oral 3

medroxyPROGESTERone Acetate Intramuscular 1 Y

Megace ES Oral 3

Megestrol Acetate Oral 1

Melodetta 24 Fe Oral 1

Menest Oral 3

Menopur Subcutaneous 3 Y

Menostar Transdermal 3

Merzee Oral 1

metFORMIN HCl Oral 1

metFORMIN HCl ER Oral 1

metFORMIN HCl ER (MOD) Oral 1

Methergine Oral 2

methIMAzole Oral 1

Methitest Oral 3 Y

Methylergonovine Maleate Oral 1



methylPREDNISolone Oral 1

Mibelas 24 Fe Oral 1

Microgestin 1.5/30 Oral 1

Microgestin 1/20 Oral 1

Microgestin 24 Fe Oral 1

Microgestin FE 1.5/30 Oral 1

Microgestin FE 1/20 Oral 1

Mifeprex Oral 3 Y

miFEPRIStone Oral 1 Y Y

Miglitol Oral 1

Mili Oral 1

Millipred Oral 3

Millipred DP Oral 3

Millipred DP 12-Day Oral 3

Mimvey Oral 1

Mimvey Lo Oral 1

Minastrin 24 Fe Oral 3

Minivelle Transdermal 3

Mircette Oral 3

Mono-Linyah Oral 1

MonoNessa Oral 1

Myalept Subcutaneous 3 Y Y

Myzilra Oral 1

Natazia Oral 3

Nateglinide Oral 1

Nature-Throid Oral 3

Necon 0.5/35 (28) Oral 1

Necon 1/50 (28) Oral 2

Necon 10/11 (28) Oral 2

Necon 7/7/7 Oral 1

Nesina Oral 3

Nikki Oral 1

Nitisinone Oral 3 Y Y

Nityr Oral 3 Y Y

Nocdurna Sublingual 3

Nora-BE Oral 1

Norditropin FlexPro Subcutaneous 2 Y Y

Norethin Ace-Eth Estrad-FE Oral 1

Norethindrone Oral 1



Norethindrone Acet-Ethinyl Est Oral 1

Norethindrone-Eth Estradiol Oral 1

Norethin-Eth Estradiol-Fe Oral 1

Norgestimate-Eth Estradiol Oral 1

Norgestim-Eth Estrad Triphasic Oral 1

Norlyda Oral 1

Norlyroc Oral 1

Nortrel 0.5/35 (28) Oral 1

Nortrel 1/35 (21) Oral 1

Nortrel 1/35 (28) Oral 1

Nortrel 7/7/7 Oral 1

Novarel Intramuscular 2 Y

NovoLIN 70/30 Subcutaneous 2

NovoLIN 70/30 FlexPen Subcutaneous 2

NovoLIN 70/30 FlexPen Relion Subcutaneous 2

NovoLIN 70/30 ReliOn Subcutaneous 2

NovoLIN N Subcutaneous 2

NovoLIN N FlexPen Subcutaneous 2

NovoLIN N FlexPen ReliOn Subcutaneous 2

NovoLIN N ReliOn Subcutaneous 2

NovoLIN R Injection 2

NovoLIN R FlexPen Injection 2 Y

NovoLIN R FlexPen ReliOn Injection 2 Y

NovoLIN R ReliOn Injection 2

NovoLOG Subcutaneous 2

NovoLOG FlexPen Subcutaneous 2

NovoLOG Mix 70/30 Subcutaneous 2

NovoLOG Mix 70/30 FlexPen Subcutaneous 2

NovoLOG PenFill Subcutaneous 2

NP Thyroid Oral 1

NuvaRing Vaginal 2

Nylia 7/7/7 Oral 1

Nymyo Oral 1

Ocella Oral 3

Ogestrel Oral 2

Onglyza Oral 3

Orapred ODT Oral 3

Orfadin Oral 3 Y Y

Orilissa Oral 2 Y



Orsythia Oral 1

Ortho Micronor Oral 3

Ortho Tri-Cyclen (28) Oral 3

Ortho Tri-Cyclen Lo Oral 3

Ortho-Cyclen (28) Oral 3

Ortho-Novum 1/35 (28) Oral 3

Ortho-Novum 7/7/7 (28) Oral 3

Oseni Oral 3

Osphena Oral 3

Ovcon-35 (28) Oral 3

Ovidrel Subcutaneous 2 Y

Oxandrin Oral 3 Y

Oxandrolone Oral 1 Y

Ozempic (0.25 or 0.5 MG/DOSE) Subcutaneous 2

Ozempic (1 MG/DOSE) Subcutaneous 2

Palynziq Subcutaneous 3 Y Y

Paricalcitol Oral 1

Pediapred Oral 3

Philith Oral 1

Pimtrea Oral 1

Pioglitazone HCl Oral 1

Pioglitazone HCl-Glimepiride Oral 1

Pioglitazone HCl-metFORMIN HCl Oral 1

Pirmella 1/35 Oral 1

Pirmella 7/7/7 Oral 1

Portia-28 Oral 1

Prandin Oral 3

Precose Oral 3

prednisoLONE Oral 1

prednisoLONE Sodium Phosphate Oral 1

predniSONE Oral 1

predniSONE Intensol Oral 3

Prefest Oral 3

Pregnyl Intramuscular 2 Y

Premarin Oral 2

Premphase Oral 2

Prempro Oral 2

Previfem Oral 1

Progesterone Intramuscular 1



Progesterone Micronized Oral 1

Prometrium Oral 3

Propylthiouracil Oral 1

Provera Oral 3

Qtern Oral 3

Quartette Oral 3

Quasense Oral 1 Y

Rajani Oral 1

Raloxifene HCl Oral 1

Ravicti Oral 3 Y Y

Reclipsen Oral 1

Repaglinide Oral 1

Repaglinide-metFORMIN HCl Oral 1

Riomet Oral 3

Riomet ER Oral 3

Risedronate Sodium Oral 1

Rivelsa Oral 1

Rocaltrol Oral 3

Rybelsus Oral 2 Y

Safyral Oral 3

Samsca Oral 3 Y Y Y

Sapropterin Dihydrochloride Oral 1 Y Y

Seasonique Oral 3

Segluromet Oral 3

Sensipar Oral 3 Y Y

Setlakin Oral 1 Y

Sharobel Oral 1

Signifor Subcutaneous 3 Y Y Y

Simliya Oral 1

Simpesse Oral 1

Sodium Phenylbutyrate Oral 1 Y Y

Soliqua Subcutaneous 2

Somavert Subcutaneous 3 Y Y Y

Sprintec 28 Oral 1

Sronyx Oral 1

Starlix Oral 3

Steglatro Oral 3

Steglujan Oral 3

Stimate Nasal 3



Strensiq Subcutaneous 2 Y Y 4

Striant Buccal 3 Y

Supprelin LA Subcutaneous 3 Y Y

Syeda Oral 1

SymlinPen 120 Subcutaneous 3

SymlinPen 60 Subcutaneous 3

Synarel Nasal 3 Y Y

Synjardy Oral 2

Synjardy XR Oral 2

Synthroid Oral 3

Tanzeum Subcutaneous 3

Tapazole Oral 3

Tarina 24 Fe Oral 1

Tarina FE 1/20 Oral 1

Tarina FE 1/20 EQ Oral 1

Taytulla Oral 3

Testim Transdermal 3 Y

Testosterone Transdermal 1 Y

Testosterone Cypionate Injection 1

Testosterone Cypionate & Prop Injection 1

Testosterone Enanthate Injection 1

Testosterone Propionate Injection 1

Testred Oral 3 Y

Thyquidity Oral 3

Thyroid Oral 1

Thyrolar-1 Oral 3

Thyrolar-1/2 Oral 3

Thyrolar-1/4 Oral 3

Thyrolar-2 Oral 3

Thyrolar-3 Oral 3

Tilia Fe Oral 1

Tirosint Oral 3

Tirosint-SOL Oral 3

TOLAZamide Oral 1

TOLBUTamide Oral 1

Tolvaptan Oral 1 Y Y Y

Toujeo Max SoloStar Subcutaneous 2

Toujeo SoloStar Subcutaneous 2

Tradjenta Oral 3



Tresiba Subcutaneous 2

Tresiba FlexTouch Subcutaneous 2

Tri Femynor Oral 1

Tri-Estarylla Oral 1

Trijardy XR Oral 2 Y

Tri-Legest Fe Oral 1

Tri-Linyah Oral 1

Tri-Lo-Estarylla Oral 1

Tri-Lo-Marzia Oral 1

Tri-Lo-Mili Oral 1

Tri-Lo-Sprintec Oral 1

Tri-Mili Oral 1

TriNessa (28) Oral 1

TriNessa Lo Oral 1

Tri-Norinyl (28) Oral 3

Tri-Nymyo Oral 1

Tri-Previfem Oral 1

Tri-Sprintec Oral 1

Trivora (28) Oral 1

Tri-VyLibra Oral 1

Tri-VyLibra Lo Oral 1

Trulicity Subcutaneous 2

Tulana Oral 1

Tyblume Oral 1

Tydemy Oral 1

Tymlos Subcutaneous 2 Y Y

Unithroid Oral 1

Unithroid Direct Oral 1

Velivet Oral 1

Vestura Oral 1

Victoza Subcutaneous 2

Vienva Oral 1

Viorele Oral 1

Vivelle-Dot Transdermal 3

Vogelxo Transdermal 3 Y

Vogelxo Pump Transdermal 3 Y

Volnea Oral 1

Vyfemla Oral 1

VyLibra Oral 1



Wera Oral 1

Westhroid Oral 3

WP Thyroid Oral 3

Wymzya Fe Oral 1

Xigduo XR Oral 2

Xulane Transdermal 2

Xultophy Subcutaneous 2

Xuriden Oral 3 Y Y

Yasmin 28 Oral 3

YAZ Oral 3

Zarah Oral 1

Zemplar Oral 3 Y

Zenchent Oral 1

Zenchent FE Oral 1

Zovia 1/35 (28) Oral 1

Zovia 1/35E (28) Oral 1

Zovia 1/50E (28) Oral 1

Zumandimine Oral 1

Gastrointestinal Agents

Actigall Oral 3

Akynzeo Oral 3 Y Y

Alosetron HCl Oral 1

Anaspaz Oral 3

Anzemet Oral 3

Aprepitant Oral 1

Apriso Oral 3

Asacol HD Oral 2

Auryxia Oral 3

Azulfidine Oral 3

Azulfidine EN-tabs Oral 3

Balsalazide Disodium Oral 1

Bentyl Intramuscular 3

Calcium Acetate Oral 1

Calcium Acetate (Phos Binder) Oral 1

Canasa Rectal 2

Carafate Oral 2

Cesamet Oral 3

Chenodal Oral 2 Y Y Y

chlordiazePOXIDE-Clidinium Oral 1



Cholbam Oral 3 Y Y

Cimetidine Oral 1

Cimetidine HCl Oral 1

Cimzia Subcutaneous 2 Y Y Y

Cimzia Prefilled Subcutaneous 2 Y Y Y

Cimzia Starter Kit Subcutaneous 2 Y Y Y

Clenpiq Oral 3

Colazal Oral 3

Colyte with Flavor Packs Oral 3

Constulose Oral 1

Creon Oral 2

Cromolyn Sodium Oral 1

Cuvposa Oral 3 Y

Cytotec Oral 3

Delzicol Oral 2

Dicyclomine HCl Intramuscular 1

Dipentum Oral 3

Diphenoxylate-Atropine Oral 1

Dronabinol Oral 1

Ed-Spaz Oral 1

Eliphos Oral 3

Enulose Oral 1

Famotidine Oral 1

Fosrenol Oral 3

Gastrocrom Oral 3

GaviLyte-C Oral 1

GaviLyte-G Oral 1

GaviLyte-H Oral 1

GaviLyte-N with Flavor Pack Oral 1

Generlac Oral 1

Gialax Oral 3

Giazo Oral 3

Glycopyrrolate Oral 1

Golytely Oral 3

Granisetron HCl Oral 1

Helidac Therapy Oral 3

Hyoscyamine Sulfate Injection 1

Hyoscyamine Sulfate ER Oral 1

Hyoscyamine Sulfate SL Sublingual 1



Hyosyne Oral 1

Kristalose Oral 3

Lactulose Oral 1

Lactulose Encephalopathy Oral 1

Lanthanum Carbonate Oral 1

Levsin Injection 3

Levsin/SL Sublingual 3

Lialda Oral 2

Linzess Oral 3

Lomotil Oral 3

Loperamide HCl Oral 1

Lotronex Oral 3

Lubiprostone Oral 3

Marinol Oral 3

Meclizine HCl Oral 1

Mesalamine Oral 1

Mesalamine ER Oral 1

Methscopolamine Bromide Oral 1

Metoclopramide HCl Oral 1

miSOPROStol Oral 1

Movantik Oral 3 Y

MoviPrep Oral 3

Nizatidine Oral 1

NuLev Oral 1

Nulytely with Flavor Packs Oral 3

Ocaliva Oral 3 Y Y Y

Ondansetron Oral 1

Ondansetron HCl Oral 1

Oscimin Oral 1

OsmoPrep Oral 3

Pancreaze Oral 3

PB-Hyoscy-Atropine-Scopolamine Oral 1

PCP 100 Combination 3

PEG 3350/Electrolytes Oral 1

PEG 3350-KCl-Na Bicarb-NaCl Oral 1

PEG-3350/Electrolytes Oral 1

PEG-3350/Electrolytes/Ascorbat Oral 1

PEG-KCl-NaCl-NaSulf-Na Asc-C Oral 1

PEG-Prep Oral 1



PEGyLAX Oral 1

Pentasa Oral 2

Pepcid Oral 3

Pertzye Oral 3

PHENobarbital-Belladonna Alk Oral 1

Phenohytro Oral 1

Phoslyra Oral 3

Plenvu Oral 3

Polyethylene Glycol 3350 Oral 1

Poly-Prep Combination 3

Propantheline Bromide Oral 1

Pylera Oral 3

QC Natura-LAX Oral 1

raNITIdine HCl Oral 1

Reglan Oral 3

Renagel Oral 3

Robinul Oral 3

Robinul-Forte Oral 3

Sancuso Transdermal 3 Y Y

Scopolamine Transdermal 1

Sevelamer Carbonate Oral 1

Sevelamer HCl Oral 1

SfRowasa Rectal 3

Sucraid Oral 3 Y Y

Sucralfate Oral 1

sulfaSALAzine Oral 1

Suprep Bowel Prep Kit Oral 3

Symax-SL Sublingual 1

Symproic Oral 2 Y

TGT Powderlax Oral 1

Tigan Intramuscular 3

Transderm Scop (1.5 MG) Transdermal 3

Transderm-Scop (1.5 MG) Transdermal 2

TriLyte Oral 1

Trimethobenzamide HCl Oral 1

Trulance Oral 2

Urso 250 Oral 3

Urso Forte Oral 3

Ursodiol Oral 1



Varubi (180 MG Dose) Oral 3 Y Y

Viberzi Oral 3 Y Y

Viokace Oral 3

Xermelo Oral 3 Y Y

Zantac Oral 3

Zenpep Oral 2

Zofran Oral 3

Zofran ODT Oral 3

Zuplenz Oral 3

GU Anti-Infectives/GU Antispasmodics/Vaginal Products/Misc

Alfuzosin HCl ER Oral 1

AVC Vaginal Vaginal 3

Avodart Oral 3

Bethanechol Chloride Oral 1

Cardura XL Oral 3

Cleocin Vaginal 2

Clindamycin Phosphate Vaginal 1

Clindesse Vaginal 3

Crinone Vaginal 3

Cystagon Oral 2 Y Y

Cytra K Crystals Oral 1

Darifenacin Hydrobromide ER Oral 1

Detrol Oral 3

Detrol LA Oral 3

Ditropan XL Oral 3

Dutasteride Oral 1

Dutasteride-Tamsulosin HCl Oral 1

Elmiron Oral 3 Y

Enablex Oral 3

Endometrin Vaginal 3

Estrace Vaginal 2

Estradiol Vaginal 1

Estring Vaginal 3

Femring Vaginal 3

Finasteride Oral 1

flavoxATE HCl Oral 1

Flomax Oral 3

Gelnique Transdermal 3

Gelnique Pump Transdermal 3



Gynazole-1 Vaginal 3

Imvexxy Maintenance Pack Vaginal 3

Imvexxy Starter Pack Vaginal 3

Intrarosa Vaginal 3

Jalyn Oral 3

Lithostat Oral 3

MetroGel-Vaginal Vaginal 3

metroNIDAZOLE Vaginal 1

Miconazole 3 Vaginal 3

Myrbetriq Oral 3

Nuvessa Vaginal 3

Oracit Oral 3

Oxybutynin Chloride Oral 1

Oxybutynin Chloride ER Oral 1

Phenazo Oral 1

Phenazopyridine HCl Oral 1

Pot & Sod Cit-Cit Ac Oral 1

Potassium Citrate ER Oral 1

Potassium Citrate-Citric Acid Oral 1

Premarin Vaginal 3

Proscar Oral 3

Pyridium Oral 3

Rapaflo Oral 3

Shohls Modified Oral 3

Silodosin Oral 1

Sod Citrate-Citric Acid Oral 1

Solifenacin Succinate Oral 1

Tamsulosin HCl Oral 1

Taron-Crystals Oral 1

Terazol 7 Vaginal 3

Terconazole Vaginal 1

Thiola Oral 3 Y Y

Thiola EC Oral 3 Y Y

Tolterodine Tartrate Oral 1

Tolterodine Tartrate ER Oral 1

Toviaz Oral 3

Tricitrates Oral 1

Trospium Chloride Oral 1

Trospium Chloride ER Oral 1



Urecholine Oral 3

Urocit-K 10 Oral 3

Urocit-K 15 Oral 3

Urocit-K 5 Oral 3

Uroxatral Oral 3

Vagifem Vaginal 2

Vandazole Vaginal 1

VESIcare Oral 2

Virtrate-2 Oral 1

Virtrate-3 Oral 1

Virtrate-K Oral 1

Yuvafem Vaginal 1

Zazole Vaginal 1

Hematological Agents

Aggrenox Oral 3

Agrylin Oral 3

Amicar Oral 3

Aminocaproic Acid Oral 1

Anagrelide HCl Oral 1

Arixtra Subcutaneous 3 Y

Aspirin-Dipyridamole ER Oral 1

Bevyxxa Oral 3

Brilinta Oral 2

Cerdelga Oral 3 Y Y Y

Cilostazol Oral 1

Clopidogrel Bisulfate Oral 1

Coumadin Oral 3

Dipyridamole Oral 1

Doptelet Oral 3 Y Y

Droxia Oral 3 Y

Effient Oral 3

Eliquis Oral 2

Eliquis DVT/PE Starter Pack Oral 2

Endari Oral 3 Y Y

Enoxaparin Sodium Injection 1 Y

Firazyr Subcutaneous 2 Y Y Y

Folic Acid Injection 1

Fondaparinux Sodium Subcutaneous 1 Y

Fragmin Subcutaneous 3 Y



Haegarda Subcutaneous 2 Y Y Y 1

Heparin Lock Flush Intravenous 1

Heparin Sodium (Porcine) Injection 1

Heparin Sodium (Porcine) PF Injection 1

Heparin Sodium Lock Flush Intravenous 1

Icatibant Acetate Subcutaneous 1 Y Y Y

Iprivask Subcutaneous 3 Y

Jantoven Oral 1

Kalbitor Subcutaneous 3 Y Y Y

Lovenox Injection 3 Y

Lysteda Oral 3

Methylcobalamin Injection 3

migLUstat Oral 1 Y Y Y

Mulpleta Oral 3 Y Y

Pentoxifylline ER Oral 1

Plavix Oral 3

Pradaxa Oral 3

Prasugrel HCl Oral 1

Promacta Oral 3 Y Y Y

Savaysa Oral 3

Takhzyro Subcutaneous 2 Y Y 3

Tavalisse Oral 3 Y Y

Tranexamic Acid Oral 1

Warfarin Sodium Oral 1

Xarelto Oral 2

Xarelto Starter Pack Oral 2

Zavesca Oral 3 Y Y Y

Zontivity Oral 3

Miscellaneous Products

1st Tier Unifine Pentips Does not apply 1 Y

1st Tier Unifine Pentips Plus Does not apply 1 Y

1st Tier Unilet ComforTouch Does not apply 1

AboutTime Pen Needle Does not apply 3 Y

Accu-Chek FastClix Lancets Does not apply 1

Accu-Chek Multiclix Lancets Does not apply 1

Accu-Chek Safe-T Pro Lancets Does not apply 1

Accu-Chek Soft Touch Lancets Does not apply 1

Accu-Chek Softclix Lancets Does not apply 1

Acti-Lance Lite Lancets 28G Does not apply 1



Acti-Lance Special Lancets 17G Does not apply 1

Acti-Lance Universal 23G Does not apply 1

AgaMatrix Ultra-Thin Lancets Does not apply 1

Aimsco Twist Lancets 32G Does not apply 1

Aimsco Twist Lancets 33G Does not apply 1

Anhydrous Base Does not apply 3

Anti-Stick Insulin Syringe Does not apply 1 Y

AquaLance Lancets 30G Does not apply 1

Assure Comfort Lancets 28G Does not apply 1

Assure Haemolance Plus High Does not apply 1

Assure Haemolance Plus Low Does not apply 1

Assure Haemolance Plus Micro Does not apply 1

Assure Haemolance Plus Normal Does not apply 1

Assure Haemolance Plus Ped Does not apply 1

Assure ID Insulin Safety Syr Does not apply 1 Y

Assure Lance Lancets Does not apply 1

Assure Lance Lancets 21G Does not apply 1

Assure Lance Plus Safety 25G Does not apply 1

Assure Lance Plus Safety 30G Does not apply 1

Astagraf XL Oral 3

At Last Lancets Does not apply 1

ATREVIS HYDROGEL External 3

Aurora Lancet Super Thin 30G Does not apply 1

Aurora Lancet Thin 23G Does not apply 1

Aurora Pen Needles Does not apply 1 Y

Aurora Unifine Pentips Does not apply 1 Y

Azasan Oral 3

azaTHIOprine Oral 1

Bayer Breeze 2 System Does not apply 3 Y

Bayer Contour Link 2.4 Does not apply 2 Y Y

Bayer Contour Link Monitor Does not apply 2 Y Y

Bayer Contour Monitor Does not apply 2 Y Y

Bayer Microlet Lancets Does not apply 1

BD AutoShield Does not apply 3 Y

BD AutoShield Duo Does not apply 3 Y

BD Insulin Syr Ultrafine II Does not apply 1 Y

BD Insulin Syringe Does not apply 1 Y

BD Insulin Syringe Half-Unit Does not apply 1 Y

BD Insulin Syringe MicroFine Does not apply 1 Y



BD Insulin Syringe U/F Does not apply 1 Y

BD Insulin Syringe U/F 1/2Unit Does not apply 1 Y

BD Insulin Syringe U-500 Does not apply 1 Y

BD Insulin Syringe Ultrafine Does not apply 1 Y

BD Lancet Ultrafine 30G Does not apply 1

BD Lancet Ultrafine 33G Does not apply 1

BD Microtainer Lancets Does not apply 1

BD Pen Needle Mini U/F Does not apply 3 Y

BD Pen Needle Nano 2nd Gen Does not apply 3 Y

BD Pen Needle Nano U/F Does not apply 3 Y

BD Pen Needle Original U/F Does not apply 3 Y

BD Pen Needle Short U/F Does not apply 3 Y

BD SafetyGlide Insulin Syringe Does not apply 1 Y

BD Safety-Lok Insulin Syringe Does not apply 1 Y

BD Veo Insulin Syr U/F 1/2Unit Does not apply 1 Y

BD Veo Insulin Syringe U/F Does not apply 1 Y

Benlysta Subcutaneous 3 Y Y Y

BraVura All-In-One External 3

Breeze 2 Test In Vitro 2 Y

CareFine Pen Needles Does not apply 1 Y

CareOne Insulin Syringe Does not apply 1 Y

CareOne Lancet Super Thin 30G Does not apply 1

CareOne Lancet Thin 23G Does not apply 1

CareOne Unifine Pentips Does not apply 1 Y

CareOne Unifine Pentips Plus Does not apply 1 Y

CareTouch Insulin Syringe Does not apply 1 Y

CareTouch Pen Needles Does not apply 1 Y

CareTouch Safety Lancets 26G Does not apply 1

CareTouch Twist Lancets 28G Does not apply 1



Caya Vaginal 3

CellCept Oral 3

CeQur Simplicity Inserter Does not apply 3

Cetylev Oral 3

Chemet Oral 2

Clickfine Pen Needles Does not apply 3 Y

Clovique Oral 1 Y Y

CoaguChek Lancets Does not apply 1



Comfort Assist Insulin Syringe Does not apply 1 Y

Comfort EZ Insulin Syringe Does not apply 1 Y

Comfort EZ Micro Pen Needles Does not apply 3 Y

Comfort EZ Pen Needles Does not apply 3 Y

Comfort EZ Short Pen Needles Does not apply 1 Y

Comfort Lancets Does not apply 1

Contour Blood Glucose System Does not apply 2 Y Y

Contour Monitor Does not apply 2 Y Y

Contour Next EZ Does not apply 2 Y Y

Contour Next Link Does not apply 2 Y Y

Contour Next Monitor Does not apply 2 Y Y

Contour Next One Does not apply 2 Y Y

Contour Next Test In Vitro 2 Y

Contour Test In Vitro 2 Y

Cream Base External 3

CVS Lancets Original Does not apply 1

CVS Lancets Thin 26G Does not apply 1

CVS Ultra Thin Lancets Does not apply 1

cycloSPORINE Oral 1

cycloSPORINE Modified Oral 1

Deferasirox Oral 1 Y Y

Deferasirox Granules Oral 1 Y Y

Deferiprone Oral 1 Y Y

Diathrive Lancet Ultra Thin 30 Does not apply 1

Diathrive Lancets Does not apply 1

D-Penamine Oral 3

Droplet Lancets Ultra Thin 30G Does not apply 1

Droplet Micron Does not apply 3 Y

Droplet Pen Needles Does not apply 1 Y

Drug Mart On-The-Go Lancet 30G Does not apply 1

Drug Mart Unifine Pentips Does not apply 1 Y

Drug Mart Unifine Pentips Plus Does not apply 1 Y

Drug Mart Unilet Lancets 28G Does not apply 1

Drug Mart Unilet Lancets 30G Does not apply 1

Durabase External 3

Durabase Advanced External 3

Easy Touch FlipLock Insulin Sy Does not apply 1 Y

Easy Touch Insulin Safety Syr Does not apply 1 Y

Easy Touch Insulin Syringe Does not apply 1 Y



Easy Touch Lancets 21G Does not apply 1




Easy Touch Lancets 28G/Twist Does not apply 1






Easy Touch Pen Needles Does not apply 1 Y

Easy Touch Safety Lancets 21G Does not apply 1




Easy Touch SheathLock Syringe Does not apply 1 Y

EasyTest II Lancets Does not apply 1

EasyTest Lancets Does not apply 1

Elite-Thin Insulin Syringe Does not apply 1 Y

Emollient Base External 3

Envarsus XR Oral 3

Everolimus (Immunosuppressant) Oral 1 Y Y

Exel Comfort Point Insulin Syr Does not apply 1 Y

Exel Comfort Point Pen Needle Does not apply 1 Y

FemCap Vaginal 3

Ferriprox Oral 3 Y Y

Ferriprox Twice-A-Day Oral 3 Y Y

Fifty50 Pen Needles Does not apply 3 Y

Fifty50 Safety Seal Lancets Does not apply 1

Fifty50 Superior Comfort Syr Does not apply 1 Y

Fifty50 Unilet Lancets 33G Does not apply 1

Fine 30 Does not apply 1

Fingerstix Lancets Does not apply 1

Freds Pharmacy Unifine Pentip+ Does not apply 1 Y

Freds Pharmacy Unifine Pentips Does not apply 1 Y

Freds Pharmacy Unilet Lanc 28G Does not apply 1

Freds Pharmacy Unilet Lanc 30G Does not apply 1

FreeStyle Unistick II Lancets Does not apply 1

Gengraf Oral 1



Gentle-Let GP Lancets Does not apply 1

Gentle-Let Lancets Does not apply 1

Global Easy Glide Insulin Syr Does not apply 1 Y

GlucoCom Lancets 28G Does not apply 1



GlucoPro Insulin Syringe Does not apply 1 Y

Glucosource Lancets Does not apply 1

GNP UltiCare Pen Needles Does not apply 1 Y

Gojji Sterile Lancets Does not apply 1

GoodSense Clickfine Pen Needle Does not apply 3 Y

GoodSense Pen Needle Penfine Does not apply 3 Y

Haemolance Does not apply 1

Haemolance Low Flow Lancets Does not apply 1

Haemolance Plus Does not apply 1

Haemolance Plus High Flow Does not apply 1

Haemolance Plus Low Flow Does not apply 1

Haemolance Plus Max Flow Does not apply 1

Haemolance Plus Pediatric Flow Does not apply 1

HealthWise Insulin Syr/Needle Does not apply 1 Y

HealthWise Micron Pen Needles Does not apply 1 Y

HealthWise Mini Pen Needles Does not apply 1 Y

HealthWise Pen Needles Does not apply 1 Y

HealthWise Short Pen Needles Does not apply 1 Y

HealthWise Unifine Pentips Does not apply 1 Y

Healthy Accents Unifine Pentip Does not apply 1 Y

Healthy Accents Unilet Lancets Does not apply 1

H-E-B inControl Lancets 28G Does not apply 1



H-E-B inControl Pen Needles Does not apply 1 Y

H-E-B inControl Unifine Pentip Does not apply 1 Y

HM UltiCare Mini Pen Needles Does not apply 3 Y

HumaPen LUXURA HD Does not apply 3

Imuran Oral 3

InPen 100-Blue-Lilly Does not apply 3

InPen 100-Blue-Novo Does not apply 3

InPen 100-Gray-Lilly Does not apply 3

InPen 100-Grey-Novo Does not apply 3



InPen 100-Pink-Lilly Does not apply 3

InPen 100-Pink-Novo Does not apply 3

Insulin Syringe Does not apply 1 Y

Insulin Syringe/Needle Does not apply 1 Y

Insupen Pen Needles Does not apply 1 Y

Insupen Sensitive Does not apply 1 Y

Insupen Ultrafin Does not apply 1 Y

Kinney Lancets Does not apply 1

Kinney Thin Lancets Does not apply 1

Kinray Insulin Syringe Does not apply 1 Y

Kionex Oral 1

Kroger HealthPro Lancet 26G Does not apply 1

Kroger Pen Needles Does not apply 1 Y

Lancets Does not apply 1

Lancets 28G Does not apply 1



Lancets Micro Thin 33G Does not apply 1

Lancets Thin Does not apply 1

Lancets Ultra Thin Does not apply 1

Lanolin Does not apply 1

Leader Unifine Pentips Does not apply 1 Y

Leader Unifine Pentips Plus Does not apply 1 Y

Liberty Medical Lancets Does not apply 1

LifeScan Unistik 2 Does not apply 1

LifeScan Unistik II Lancets Does not apply 1

Liposomal Heavy External 3

Liposomal Regular External 3

Litetouch Insulin Syringe Does not apply 1 Y

Live Better Lancet Super Thin Does not apply 1

Live Better Lancet Ultra Thin Does not apply 1

Lokelma Oral 3

Magellan Insulin Safety Syr Does not apply 1 Y

Marathon Medical Pentips Does not apply 1 Y

Maxi-Comfort Insulin Syringe Does not apply 1 Y

Maxi-Comfort Safety Pen Needle Does not apply 3 Y

Maxicomfort syr 27G x 1/2" Does not apply 1 Y

Medic Insulin Syringe Does not apply 1 Y

MediChoice Safety Lancet Does not apply 1



MediChoice Safety Lancet Extra Does not apply 1

MediChoice Safety Lancet Norm Does not apply 1

Medicine Shoppe Pen Needles Does not apply 1 Y

MediSense Thin Lancets Does not apply 1

Medlance Extra 21G Does not apply 1

Medlance Lite 25G Does not apply 1

Medlance Plus Extra 21G Does not apply 1

Medlance Plus Lancets Does not apply 1

Medlance Plus Lite 25G Does not apply 1

Medlance Plus Special 0.8mm Does not apply 1

Medlance Plus SuperLite 30G Does not apply 1

Medlance Plus Universal 21G Does not apply 1

Medlance Universal 21G Does not apply 1

Meijer Lancets Universal 21G Does not apply 1

Meijer Lancets Universal 30G Does not apply 1

Meijer Pen Needles Does not apply 1 Y

Microdot Pen Needle Does not apply 3 Y

Microlet Lancets Does not apply 1

Microtainer Safety Flow Lancet Does not apply 1

Monoject Insulin Syringe Does not apply 1 Y

Monoject Ultra Comfort Syringe Does not apply 1 Y

Monolet Lancets Does not apply 1

Monolet OPD Lancets Does not apply 1

Monolettor Safety Lancets Does not apply 1

Moore Mono Insulin Syringe Does not apply 1 Y

MultiBase External 3

Mycophenolate Mofetil Oral 1

Mycophenolate Sodium Oral 1

Myfortic Oral 3

Naltrexone HCl Oral 1 Y

Narcan Nasal 2 Y

Neoral Oral 3

NetGroup Lancets Does not apply 1

Nova Safety Lancets 23G Does not apply 1

Nova Safety Lancets 28G Does not apply 1

Nova Sureflex Lancets Does not apply 1

NovoFine Does not apply 3 Y

NovoFine Autocover Does not apply 3 Y

NovoFine Plus Does not apply 3 Y



NovoPen Echo Does not apply 3

NovoTwist Does not apply 3 Y

Omnibase External 3

Omniflex Diaphragm Vaginal 3

On Call Lancets Does not apply 1

On Call Plus Lancets Does not apply 1

OneTouch Club Lancets Fine Pt Does not apply 1

OneTouch Combo Pack Does not apply 1

OneTouch Delica Lancets 30G Does not apply 1

OneTouch Delica Lancets 33G Does not apply 1

OneTouch Delica Plus Lancet30G Does not apply 1

OneTouch Delica Plus Lancet33G Does not apply 1

OneTouch FinePoint Lancets Does not apply 1

OneTouch UltraSoft Lancets Does not apply 1

Oral Mix Dry Alka SF Oral 3

Oral Mix Dry Alka/Cherry Oral 3

PC Lancets Super Thin 30G Does not apply 1

PC Unifine Pentips Does not apply 1 Y

PCCA Ellage Vaginal Does not apply 3

PEG Ointment Base External 3

Pen Needles Does not apply 1 Y

Pen Needles 1/2" Does not apply 1 Y

Pen Needles 5/16" Does not apply 3 Y

PENcream External 3

penicillAMINE Oral 1 Y Y

PenSomal External 3

PenTips Does not apply 1 Y

Perfect Lancets 28G Does not apply 1

Perfect Lancets 30G Does not apply 1

Performax Salt Supportive Base External 3

Phenol Injection 3

PLO20 Flowable External 3

Precision SureDose Plus Syr Does not apply 1 Y

Precision Sure-Dose Syringe Does not apply 1 Y

Precision Thin Lancets Does not apply 1

Precision Thins GP Lancets Does not apply 1

Precision Ultra Lancet Does not apply 1

Preferred Plus Unifine Pentips Does not apply 1 Y

Pressure Activat Safety Lancet Does not apply 1



Prevent Safety Pen Needles Does not apply 3 Y

Pro Comfort Pen Needles Does not apply 3 Y

Prodigy Insulin Syringe Does not apply 1 Y

Prodigy Lancets 28G Does not apply 1

Prodigy Safety Lancets 26G Does not apply 1

Prodigy Twist Top Lancets 28G Does not apply 1

Prograf Oral 3

PSS Select GP Lancets Does not apply 1

PSS Select Safety Lancets Does not apply 1

Pure Comfort Pen Needle Does not apply 3 Y

Purified Water Oral 3

Push Button Safety Lancets Does not apply 1

PX Lancets Ultra Thin Does not apply 1

PX Lancets Ultra Thin 28G Does not apply 1

PX Mini Pen Needles Does not apply 1 Y

QC Lancets Super Thin 30G Does not apply 1

QC Lancets Ultra Thin Does not apply 1

QC Pen Needles Does not apply 1 Y

QC Unifine Pentips Does not apply 1 Y

QC Unilet Lancets 28G Does not apply 1

QC Unilet Lancets Micro Thin Does not apply 1

RA E-Zject Color Lancets 33G Does not apply 1

RA Insulin Syringe Does not apply 1 Y

RA Pen Needles Does not apply 1 Y

Rapamune Oral 3

ReliOn Insulin Syringe Does not apply 1 Y

ReliOn Lancets Thin 26G Does not apply 1

ReliOn Mini Pen Needles Does not apply 1 Y

ReliOn Pen Needles Does not apply 1 Y

ReliOn Short Pen Needles Does not apply 1 Y

Revlimid Oral 2 Y Y Y

Rightest GL300 Lancets Does not apply 1

SafeSnap Insulin Syringe Does not apply 1 Y

Safe-T-Lance Does not apply 1

Safe-T-Lance Plus Does not apply 1

Safety Lancet 21G/Pressure Act Does not apply 1






Safety Lancets Does not apply 1

Safety Lancets 21G Does not apply 1

Safety Lancets 28G Does not apply 1

Salt Durable Cream External 3

Salt Stable LS Advanced External 3

Saltstable LO External 3

SandIMMUNE Oral 3

SAPS Twist Top Lancets Does not apply 1

SB Insulin Syringe Does not apply 1 Y

Schnucks Insulin Syringe Does not apply 1 Y

Shopko On-the-Go Lancets 30G Does not apply 1

Shopko Unifine Pentips Does not apply 1 Y

Shopko Unifine Pentips Plus Does not apply 1 Y

Shopko Unilet Lancets 28G Does not apply 1

Shopko Unilet Lancets 30G Does not apply 1

Side Button Safety Lancet Does not apply 1

Single-Let Does not apply 1

Sirolimus Oral 1

Skyy Derm External 3

Smartest Lancets 28G Does not apply 1

Sodium Polystyrene Sulfonate Oral 1

Solus V2 Lancets 28G Does not apply 1

Solus V2 Twist Lancets 30G Does not apply 1

SPS Oral 1

SteriLance TL Does not apply 1

SuspendRx w/BitterBloc Sweet Oral 3

SuspendRx w/BitterBloc Unsweet Oral 3

Syprine Oral 3 Y Y

Tacrolimus Oral 1

TechLite AST Lancets Does not apply 1

TechLite Lancets Does not apply 1

TechLite Lancets 30G Does not apply 1

TechLite Pen Needles Does not apply 1 Y

Thalomid Oral 2 Y Y Y

Thinlets GP Lancets Does not apply 1

Thinlets Lancet Does not apply 1

Todays Health Mini Pen Needles Does not apply 1 Y

Todays Health Pen Needles Does not apply 1 Y

Todays Health Short Pen Needle Does not apply 1 Y



Todays Health Thin Lancets 28G Does not apply 1

Todays Health Thin Lancets 30G Does not apply 1

Topco Insulin Syringe Does not apply 1 Y

Travel Lancets Does not apply 1

Trientine HCl Oral 1 Y Y

True Comfort Pro Insulin Syr Does not apply 3 Y

True Comfort Pro Pen Needles Does not apply 3 Y

True Comfort Twist Top Lancets Does not apply 3

TRUEplus 5-Bevel Pen Needles Does not apply 1 Y

TRUEplus Insulin Syringe Does not apply 1 Y

TRUEplus Lancets 26G Does not apply 1




TRUEplus Pen Needles Does not apply 1 Y

TRUEplus Safety Lancets 28G Does not apply 1

UltiCare Insulin Safety Syr Does not apply 1 Y

UltiCare Insulin Syringe Does not apply 1 Y

UltiCare Micro Pen Needles Does not apply 1 Y

UltiCare Mini Pen Needles Does not apply 1 Y

UltiCare Pen Needles Does not apply 1 Y

UltiCare Short Pen Needles Does not apply 1 Y

UltiCare Thin Lancets 30G Does not apply 1

UltiGuard SafePack Pen Needle Does not apply 1 Y

Ultilet Classic Lancets Does not apply 1

Ultilet Insulin Syringe Does not apply 1 Y

Ultilet Insulin Syringe Short Does not apply 1 Y

Ultilet Lancets Does not apply 1

Ultilet Pen Needle Does not apply 1 Y

Ultilet Safety Lancets Does not apply 1

Ultilet Safety Lancets 23G Does not apply 1

Ultra Flo Insulin Pen Needles Does not apply 3 Y

Ultra Flo Insulin Syringe Does not apply 1 Y

Ultra Thin Pen Needles Does not apply 1 Y

Ultra-Comfort Insulin Syringe Does not apply 1 Y

Ultra-Thin II Auto Lancet Does not apply 1

Ultra-Thin II Ins Syr Short Does not apply 1 Y

Ultra-Thin II Insulin Syringe Does not apply 1 Y

Ultra-Thin II Lancets Does not apply 1



Ultra-Thin II Mini Pen Needle Does not apply 1 Y

Ultra-Thin II Pen Needle Short Does not apply 1 Y

Ultra-Thin II Pen Needles Does not apply 1 Y

Unifine Pentips Does not apply 1 Y

Unifine Pentips Plus Does not apply 1 Y

Unifine SafeControl Pen Needle Does not apply 3 Y

Unilet ComforTouch Lancet Does not apply 1

Unilet ExceLite Does not apply 1

Unilet ExceLite II Does not apply 1

Unilet G.P. Lancet Does not apply 1

Unilet G.P. Superlite Lancet Does not apply 1

Unilet GP 28 Ultra Thin Does not apply 1

Unilet Lancet Does not apply 1

Unilet Superlite Lancet Does not apply 1

Unilet Super-Thin 30G Does not apply 1

Unilet Ultra-Thin 28G Does not apply 1

UniSpend Anhydrous Sweetened Oral 3

Unistik 3 Gentle Does not apply 1

Unistik Safety Lancets 28G Does not apply 1

Unistik Safety Lancets 30G Does not apply 1

Unistik Touch Safety Lanc 21G Does not apply 1




Universal Water Does not apply 3

ValuMark Lancet Super Thin 30G Does not apply 1

ValuMark Lancet Ultra Thin 28G Does not apply 1

ValuMark Pen Needles Does not apply 1 Y

Vanishing External 3

Veltassa Oral 3

Vida Mia Unifine Pentips Does not apply 1 Y

Vida Mia Unilet Lancets 28G Does not apply 1

Vida Mia Unilet Lancets 30G Does not apply 1

V-R Mono Insulin Syringe Does not apply 1 Y

W&F Lancets 26G Does not apply 1

W&F Lancets Colored 21G Does not apply 1

Walgreens Adv Travel Lancets Does not apply 1

Wegmans Unifine Pentips Plus Does not apply 1 Y

White Petrolatum External 3



Wide-Seal Diaphragm 60 Vaginal 3








Zortress Oral 3 Y Y

Neuromuscular Agents

Amantadine HCl Oral 1

Apokyn Subcutaneous 3 Y Y Y

Aptiom Oral 3

Azilect Oral 3

Baclofen Oral 1 Y

Banzel Oral 2 Y

Benztropine Mesylate Injection 1

Briviact Oral 3 Y

Bromocriptine Mesylate Oral 1

carBAMazepine Oral 1

carBAMazepine ER Oral 1

Carbatrol Oral 3

Carbidopa Oral 1

Carbidopa-Levodopa Oral 1

Carbidopa-Levodopa ER Oral 1

Carbidopa-Levodopa-Entacapone Oral 1

Carisoprodol Oral 1

Carisoprodol-Aspirin Oral 1

Carisoprodol-Aspirin-Codeine Oral 1

Celontin Oral 2

Cerebyx Injection 3

Chlorzoxazone Oral 1 Y

cloBAZam Oral 1

clonazePAM Oral 1

Cogentin Injection 3

Comtan Oral 3

Cyclobenzaprine HCl Oral 1

Dantrium Oral 3

Dantrolene Sodium Oral 1



Depakene Oral 3

Depakote Oral 3

Depakote ER Oral 3

Depakote Sprinkles Oral 3

Diacomit Oral 3 Y Y

Diastat AcuDial Rectal 2

Diastat Pediatric Rectal 2

diazePAM Rectal 1

Dilantin Oral 2

Dilantin Infatabs Oral 3

Divalproex Sodium Oral 1

Divalproex Sodium ER Oral 1

Duopa Enteral 3

Eldepryl Oral 3

Entacapone Oral 1

Epidiolex Oral 3 Y

Epitol Oral 1

Ethosuximide Oral 1

Fanatrex FusePaq Oral 3 Y

Felbamate Oral 1

Felbatol Oral 3

Fexmid Oral 3

Fycompa Oral 3 Y

Gabapentin Oral 1 Y

Gabitril Oral 3

Guanidine HCl Oral 1

Inbrija Inhalation 3 Y Y

Keppra Oral 3

Keppra XR Oral 3

KlonoPIN Oral 3

LaMICtal Oral 3

LaMICtal ODT Oral 3

LaMICtal Starter Oral 3

LaMICtal XR Oral 3

lamoTRIgine Oral 1

lamoTRIgine ER Oral 1

lamoTRIgine Starter Kit-Blue Oral 1

lamoTRIgine Starter Kit-Green Oral 1

lamoTRIgine Starter Kit-Orange Oral 1



levETIRAcetam Oral 1

levETIRAcetam ER Oral 1

Lodosyn Oral 3

Lyrica Oral 2

Mestinon Oral 3

Metaxall Oral 1

Metaxalone Oral 1

Methocarbamol Oral 1

Mirapex Oral 3

Mirapex ER Oral 3

Mysoline Oral 3

Nayzilam Nasal 3 Y

Neupro Transdermal 3 Y

Neurontin Oral 3 Y

Onfi Oral 3 Y

Orphenadrine Citrate ER Oral 1

Orphengesic Forte Oral 1

OXcarbazepine Oral 1

Oxtellar XR Oral 3 Y

Parafon Forte DSC Oral 3 Y

Parlodel Oral 3

Peganone Oral 3

Phenytek Oral 3

Phenytoin Oral 1

Phenytoin Infatabs Oral 1

Phenytoin Sodium Extended Oral 1

Pramipexole Dihydrochloride Oral 1

Pramipexole Dihydrochloride ER Oral 1

Pregabalin Oral 1

Primidone Oral 1

Pyridostigmine Bromide Oral 1

Pyridostigmine Bromide ER Oral 1

Rasagiline Mesylate Oral 1

Requip Oral 3

Requip XL Oral 3

Rilutek Oral 3 Y

Riluzole Oral 1 Y

Robaxin Oral 3

Robaxin-750 Oral 3



rOPINIRole HCl Oral 1

rOPINIRole HCl ER Oral 1

Roweepra Oral 1

Roweepra XR Oral 3

Sabril Oral 2 Y Y

Selegiline HCl Oral 1

Sinemet Oral 3

Sinemet CR Oral 3

Skelaxin Oral 3

Soma Oral 3

Stalevo 100 Oral 3

Stalevo 125 Oral 3

Stalevo 150 Oral 3

Stalevo 200 Oral 3

Stalevo 50 Oral 3

Stalevo 75 Oral 3

Subvenite Oral 1

Subvenite Starter Kit-Blue Oral 3

Subvenite Starter Kit-Green Oral 3

Subvenite Starter Kit-Orange Oral 3

Sympazan Oral 3

Tasmar Oral 3

TEGretol Oral 3

TEGretol-XR Oral 3

tiaGABine HCl Oral 1

Tiglutik Oral 3 Y

tiZANidine HCl Oral 1 Y

Tolcapone Oral 1

Topamax Oral 3

Topamax Sprinkle Oral 3

Topiramate Oral 1

Topiramate ER Oral 1

Trihexyphenidyl HCl Oral 1

Trileptal Oral 3

Trokendi XR Oral 3 Y

Valproate Sodium Oral 1

Valproic Acid Oral 1

Valtoco 10 MG Dose Nasal 3 Y






Vanadom Oral 1

Vigabatrin Oral 1 Y Y

Vigadrone Oral 1 Y Y

Vimpat Oral 3 Y

Xadago Oral 3

Zanaflex Oral 3 Y

Zarontin Oral 3

Zelapar Oral 3

Zonegran Oral 3

Zonisamide Oral 1

Nutritional Products

Cytotine Oral 3

Effer-K Oral 1

Floriva Oral 3

Fluorabon Oral 3

Fluor-a-day Oral 1

Fluoritab Oral 1

Flura-Drops Oral 1

Galzin Oral 3

Karidium Oral 1

K-Effervescent Oral 1

Klor-Con Oral 1

Klor-Con 10 Oral 1

Klor-Con M10 Oral 1

Klor-Con M15 Oral 3

Klor-Con M20 Oral 1

Klor-Con Sprinkle Oral 1

Klor-Con/EF Oral 1

K-Prime Oral 1

K-Tab Oral 3

K-Vescent Oral 1

Lozi-Flur Mouth/Throat 3

Ludent Oral 1

MIC-L-Carnitine Injection 3

NaFrinse Oral 1

NaFrinse Drops Oral 1

Phospha 250 Neutral Oral 1



Phospho-Trin 250 Neutral Oral 1

Phytonadione Oral 1

Potassium Bicarbonate Oral 1

Potassium Chloride Oral 1

Potassium Chloride Crys ER Oral 1

Potassium Chloride ER Oral 1

Sodium Fluoride Oral 1

Virt-Phos 250 Neutral Oral 1

Wilzin Oral 3

Psychotherapeutic and Neurological Agents - Miscellaneous

Acamprosate Calcium Oral 1

Antabuse Oral 3

Aricept Oral 3

Aubagio Oral 2 Y Y Y

Austedo Oral 3 Y Y

Avonex Intramuscular 2 Y Y Y

Avonex Pen Intramuscular 2 Y Y Y

Avonex Prefilled Intramuscular 2 Y Y Y

Betaseron Subcutaneous 2 Y Y Y

buPROPion HCl ER (Smoking Det) Oral 1

Chantix Oral 2

Chantix Continuing Month Pak Oral 2

Chantix Starting Month Pak Oral 2

chlordiazePOXIDE-Amitriptyline Oral 1

Copaxone Subcutaneous 2 Y Y Y

Dalfampridine ER Oral 1 Y Y Y

Dimethyl Fumarate Oral 1 Y Y Y

Dimethyl Fumarate Starter Pack Oral 1 Y Y Y

Disulfiram Oral 1

Donepezil HCl Oral 1

Ergoloid Mesylates Oral 1

Exelon Transdermal 3

Extavia Subcutaneous 3 Y Y Y

FLUoxetine HCl (PMDD) Oral 1

Gabapal Combination 3

Galantamine Hydrobromide Oral 1

Galantamine Hydrobromide ER Oral 1

Gilenya Oral 2 Y Y Y

Glatiramer Acetate Subcutaneous 1 Y Y Y



Ingrezza Oral 3 Y Y

Lidotin Combination 3

Lipritin Combination 3

Lipritin II Combination 3

Lyrica CR Oral 3 Y

Mavenclad (10 Tabs) Oral 2 Y Y







Mayzent Oral 2 Y Y

Mayzent Starter Pack Oral 2 Y Y

Memantine HCl Oral 1

Memantine HCl ER Oral 1

Namenda Oral 3

Namenda Titration Pak Oral 3

Namenda XR Oral 3

Namenda XR Titration Pack Oral 3

Namzaric Oral 3

Nicotrol Inhalation 2

Nicotrol NS Nasal 2

Nuedexta Oral 2 Y

OLANZapine-FLUoxetine HCl Oral 1

Orap Oral 3

Perphenazine-Amitriptyline Oral 1

Pimozide Oral 1

Plegridy Intramuscular 2 Y Y

Plegridy Starter Pack Subcutaneous 2 Y Y

Prilopentin Combination 3

Razadyne Oral 3

Razadyne ER Oral 3

Rebif Subcutaneous 2 Y Y Y

Rebif Rebidose Subcutaneous 2 Y Y Y

Rebif Rebidose Titration Pack Subcutaneous 2 Y Y Y

Rebif Titration Pack Subcutaneous 2 Y Y Y

Rivastigmine Transdermal 1

Rivastigmine Tartrate Oral 1



Sarafem Oral 3

Savella Oral 3

Savella Titration Pack Oral 3

Symbyax Oral 3

Tetrabenazine Oral 1 Y Y Y

Xenazine Oral 3 Y Y Y

Zinbryta Subcutaneous 3 Y Y

Zyban Oral 3

Vaccines/Toxoids/Passive Immunizing/Allergenic Extracts/Misc

ADHD/Anti-Narcolepsy /Anti-Obesity/Anorexiant Agents

Adderall XR Oral 1.7

Adzenys XR-ODT Oral 1.7

Amphetamine ER Oral 1.7

Amphetamine Sulfate Oral 1.7

Amphetamine-Dextroamphet ER Oral 1.7

Amphetamine-Dextroamphetamine Oral 1.7

Armodafinil Oral 1.7

Atomoxetine HCl Oral 1.7

Caffeine Citrate Intravenous 1.7

cloNIDine HCl ER Oral 1.7

Concerta Oral 1.7

Daytrana Transdermal 1.7

Dexmethylphenidate HCl Oral 1.7

Dexmethylphenidate HCl ER Oral 1.7

Dextroamphetamine Sulfate Oral 1.7

Dextroamphetamine Sulfate ER Oral 1.7

Dyanavel XR Oral 1.7

guanFACINE HCl ER Oral 1.7

Jornay PM Oral 1.7 Y

Metadate ER Oral 1.7

Methylphenidate HCl Oral 1.7

Methylphenidate HCl ER Oral 1.7

Methylphenidate HCl ER (CD) Oral 1.7

Methylphenidate HCl ER (LA) Oral 1.7

Methylphenidate HCl ER (XR) Oral 1.7

Modafinil Oral 1.7

Nuvigil Oral 1.7

Provigil Oral 1.7

QuilliChew ER Oral 1.7



Quillivant XR Oral 1.7

Sunosi Oral 1.7 Y Y

Vyvanse Oral 1.7 Y

Zenzedi Oral 1.7

Analgesic/Anti-Inflammatory/Migraine/Gout Agents/Anesthetics 1.7

Abstral Sublingual 1.7 Y Y

Acetaminophen-Codeine Oral 1.7 Y

Acetaminophen-Codeine #5 Oral 1.7 Y



Actemra Subcutaneous 1.7 Y Y

Actemra ACTPen Subcutaneous 1.7 Y Y

Actiq Buccal 1.7 Y Y

Aimovig Subcutaneous 1.7 Y

Aimovig (140 MG Dose) Subcutaneous 1.7 Y

Documents

Formulary - EpiphanyRx · 2021. 5. 12. · © EpiphanyRx, LLC. All Rights Reserved 5/12/2021 Drug Name Route Tier Specialty PA QL Non-EHB DayproOral 3 Diclofenac PotassiumOral 1 Y