KANSAS ACA MEMBER PRESCRIPTION DRUG LIST 2018KANSAS ACA MEMBER . PRESCRIPTION DRUG LIST . 2018 . 2 Table of Contents . ... COARTEM 2 colistin (colistimethate na) 1 COLY-MYCIN M PARENTERAL

HIX BCBSKC-KS 2018 1-1-2018

KANSAS ACA MEMBER PRESCRIPTION DRUG LIST

2018

2

Table of Contents

ANTI - INFECTIVES .......................................................................................................................................... 4

ANTINEOPLASTIC & IMMUNOSUPPRESSANT DRUGS .......................................................................... 12

AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH ........................................................................... 18

CARDIOVASCULAR, HYPERTENSION & LIPIDS ..................................................................................... 34

DERMATOLOGICALS/TOPICAL THERAPY ............................................................................................... 42

DIAGNOSTICS & MISCELLANEOUS AGENTS .......................................................................................... 51

EAR, NOSE & THROAT MEDICATIONS...................................................................................................... 53

ENDOCRINE/DIABETES ................................................................................................................................ 54

GASTROENTEROLOGY ................................................................................................................................. 70

IMMUNOLOGY, VACCINES & BIOTECHNOLOGY .................................................................................. 77

MUSCULOSKELETAL & RHEUMATOLOGY ............................................................................................. 80

OBSTETRICS & GYNECOLOGY ................................................................................................................... 82

OPHTHALMOLOGY ........................................................................................................................................ 88

RESPIRATORY, ALLERGY, COUGH & COLD ............................................................................................ 91

UROLOGICALS ................................................................................................................................................ 96

VITAMINS, HEMATINICS & ELECTROLYTES .......................................................................................... 97

Index ................................................................................................................................................................. 107

3

Please see the benefit schedule in your member certificate for member cost sharing associated with

Generic and Brand (Preferred and Non Preferred) drugs.

List of Abbreviations for Prescription Drugs

Drug Category:

1: Generic Drug and Generic Specialty Drug

2: Preferred Drug and Non Preferred Generic Drug

3: Non Preferred Drug and Preferred Specialty Drug

4: Non Preferred Specialty Drug

5: Zero Cost Share Preventive Drug

6: Medical Service Drugs

7: Infertility Drug

ACA*: Affordable Care Act is a zero cost share preventive drug.

M: Maintenance drug.

MSD: Medical Service Drug. This drug is only covered under the medical benefit.

OTC*: Over the Counter drug.

PA: Prior Authorization. The Plan requires you or your physician to get prior authorization for certain drugs.

This means that you will need to get approval before you fill your prescriptions. If you don’t get approval, we

may not cover the drug.

QL: Quantity Limit. For certain drugs, the Plan limits the amount of the drug that we will cover.

S: Specialty drug.

SLA: Specialty Limited Availability. This prescription may be available only at certain pharmacies.

ST: Step Therapy. In some cases, the Plan requires you to first try certain drugs to treat your medical

condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat

your medical condition, we may not cover Drug B unless you try Drug A first.

*Your plan has tobacco use coverage through the Routine Preventive Care benefit. Tobacco use includes two

tobacco cessation attempts per year (both prescription and over-the-counter medications) for a 90-day

treatment regimen when prescribed by an in-network health care provider without prior authorization.

You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not

affiliated companies.

4

Drug Name Drug

Category

Requirements

/ Limits

ANTI - INFECTIVES

ANTIFUNGAL AGENTS

AMBISOME 6 MSD

amphotericin b 6 MSD

ANCOBON 3

CANCIDAS 6 MSD

CASPOFUNGIN 6 MSD

clotrimazole 1

CRESEMBA

INTRAVENOUS

6 MSD

CRESEMBA ORAL 2

DIFLUCAN ORAL

SUSPENSION FOR

RECONSTITUTIO

N

3

DIFLUCAN ORAL

TABLET 100 MG,

200 MG, 50 MG

3

DIFLUCAN ORAL

TABLET 150 MG

3 QL

ERAXIS(WATER

DILUENT)

6 MSD

fluconazole in

dextrose(iso-o)

6 MSD

fluconazole in nacl

(iso-osm)

6 MSD

fluconazole oral

suspension for

reconstitution

1

fluconazole oral

tablet 100 mg, 200

mg, 50 mg

1

fluconazole oral

tablet 150 mg

1 QL

flucytosine 1

Drug Name Drug

Category

Requirements

/ Limits

griseofulvin

microsize

1

griseofulvin

ultramicrosize

1

GRIS-PEG

(ULTRAMICROSIZ

E)

3

itraconazole 1 QL

ketoconazole 1

LAMISIL 3

NOXAFIL 2

nystatin 1

ONMEL 3 QL

ORAVIG 3

SPORANOX 2

SPORANOX

PULSEPAK

3 QL

terbinafine hcl 1

VFEND 3

VFEND IV 6 MSD

voriconazole

intravenous

6 MSD

voriconazole oral 1

ANTIVIRALS

abacavir 1 S; QL

abacavir-lamivudine 1 S; QL

abacavir-

lamivudine-

zidovudine

1 S; QL

acyclovir 1

adefovir 1

amantadine hcl 1 M

APTIVUS 3 S; QL



5

Drug Name Drug

Category

Requirements

/ Limits

ATRIPLA 3 S; QL

BARACLUDE

ORAL SOLUTION

2

BARACLUDE

ORAL TABLET

3

cidofovir 6 MSD

COMBIVIR 4 S; QL

COMPLERA 3 S; QL

CRIXIVAN 3 S; QL

CYTOVENE 6 MSD

DAKLINZA 4 PA; S; SLA

DESCOVY 3 S

didanosine 1 S; QL

EDURANT 3 S; QL

EMTRIVA 3 S; QL

entecavir 1

EPCLUSA 3 PA; S; SLA

EPIVIR 4 S; QL

EPIVIR HBV

ORAL SOLUTION

2

EPIVIR HBV

ORAL TABLET

3 QL

EPZICOM 4 S; QL

EVOTAZ 4 S; QL

famciclovir 1 QL

FLUMADINE 3

fosamprenavir 1 S; QL

foscarnet 6 MSD

FOSCAVIR 6 MSD

FUZEON 3 S; QL

GANCICLOVIR 6 MSD

ganciclovir sodium 6 MSD

Drug Name Drug

Category

Requirements

/ Limits

GENVOYA 3 S

HARVONI 3 PA; S; SLA;

QL

HEPSERA 3

INTELENCE 3 S; QL

INVIRASE 3 S; QL

ISENTRESS 3 S; QL

ISENTRESS HD 3 S

KALETRA ORAL

SOLUTION

4 S; QL

KALETRA ORAL

TABLET

3 S; QL

lamivudine oral

solution

1 S; QL

lamivudine oral

tablet 100 mg

1 QL

lamivudine oral

tablet 150 mg, 300

mg

1 S; QL

lamivudine-

zidovudine

1 S; QL

LEXIVA 3 S; QL

lopinavir-ritonavir 1 S; QL

MAVYRET 3 S

nevirapine 1 S; QL

NORVIR 3 S; QL

ODEFSEY 3 S

OLYSIO 4 PA; ST; S;

SLA; QL

oseltamivir 1 QL

PREZCOBIX 4 S

PREZISTA 3 S; QL

RELENZA

DISKHALER

2 QL



6

Drug Name Drug

Category

Requirements

/ Limits

RESCRIPTOR 3 S; QL

RETROVIR

INTRAVENOUS

6 MSD

RETROVIR ORAL 4 S; QL

REYATAZ 3 S

ribavirin 1 S; SLA

rimantadine 1

SELZENTRY

ORAL SOLUTION

3 PA; S

SELZENTRY

ORAL TABLET

150 MG, 300 MG

3 PA; S; QL

SELZENTRY

ORAL TABLET 25

MG, 75 MG

3 PA; S

SITAVIG 3 ST; QL

SOVALDI 4 PA; ST; S;

SLA; QL

stavudine 1 S; QL

STRIBILD 3 S; QL

SUSTIVA 3 S; QL

SYNAGIS 6 MSD

TAMIFLU ORAL

CAPSULE

3 QL

TAMIFLU ORAL

SUSPENSION FOR

RECONSTITUTIO

N

2 QL

TECHNIVIE 3 PA; S; SLA

TIVICAY ORAL

TABLET 10 MG, 25

MG

3 S

TIVICAY ORAL

TABLET 50 MG

3 S; QL

TRIUMEQ 3 S; QL

Drug Name Drug

Category

Requirements

/ Limits

TRIZIVIR 4 S; QL

TRUVADA ORAL

TABLET 100-150

MG, 133-200 MG,

167-250 MG

3 S

TRUVADA ORAL

TABLET 200-300

MG

3 S; QL

TYBOST 4 S; QL

valacyclovir 1 QL

VALCYTE 3

valganciclovir 1

VALTREX 3 ST; QL

VEMLIDY 2

VIDEX 2 GRAM

PEDIATRIC

3 S; QL

VIDEX EC 4 S; QL

VIEKIRA PAK 3 PA; S; SLA;

QL

VIEKIRA XR 3 PA; S; SLA

VIRACEPT 3 S; QL

VIRAMUNE 4 S; QL

VIRAMUNE XR 4 S; QL

VIRAZOLE 4 S; SLA

VIREAD 3 S; QL

VOSEVI 3 S; SLA

ZEPATIER 4 PA; S; SLA

ZERIT 4 S; QL

ZIAGEN 4 S; QL

zidovudine 1 S; QL

ZOVIRAX 3

CEPHALOSPORINS

AVYCAZ 6 MSD



7

Drug Name Drug

Category

Requirements

/ Limits

CEDAX 3

cefaclor 1

cefadroxil 1

cefazolin 6 MSD

CEFAZOLIN IN

0.9% SOD

CHLORIDE

6 MSD

cefazolin in dextrose

(iso-os) intravenous

piggyback 1 gram/50

ml, 2 gram/50 ml

6 MSD

CEFAZOLIN IN

DEXTROSE (ISO-

OS)

INTRAVENOUS

PIGGYBACK 2

GRAM/100 ML

6 MSD

CEFAZOLIN IN

DEXTROSE 5 %

6 MSD

CEFAZOLIN IN

STERILE WATER

6 MSD

cefdinir 1

cefditoren pivoxil 1

cefepime 6 MSD

cefepime in

dextrose,iso-osm

6 MSD

cefixime 1

CEFOTAN 6 MSD

cefotaxime 6 MSD

cefotetan 6 MSD

cefoxitin 6 MSD

cefpodoxime 1

cefprozil 1

CEFTIN 3

Drug Name Drug

Category

Requirements

/ Limits

ceftriaxone in

dextrose,iso-os

6 MSD

ceftriaxone injection

recon soln 1 gram,

10 gram, 2 gram,

250 mg, 500 mg

6 MSD

CEFTRIAXONE

INJECTION

RECON SOLN 100

GRAM

6 MSD

cefuroxime axetil 1

cefuroxime sodium 6 MSD

cephalexin 1

CLAFORAN 6 MSD

DAXBIA 3

KEFLEX 3

MAXIPIME 6 MSD

SPECTRACEF 3

SUPRAX 3

TAZICEF 6 MSD

TEFLARO 6 MSD

ZINACEF 6 MSD

ERYTHROMYCINS & OTHER

MACROLIDES

azithromycin

intravenous

6 MSD

azithromycin oral 1

clarithromycin 1

DIFICID 3

e.e.s. 400 1

E.E.S. GRANULES 3

ERYPED 200 3

ERYPED 400 3



8

Drug Name Drug

Category

Requirements

/ Limits

ery-tab oral

tablet,delayed

release (dr/ec) 250

mg, 333 mg

1

ERY-TAB ORAL

TABLET,DELAYE

D RELEASE

(DR/EC) 500 MG

3

erythrocin (as

stearate)

1

erythromycin 1

erythromycin

ethylsuccinate

1

PCE 3

ZITHROMAX

INTRAVENOUS

6 MSD

ZITHROMAX

ORAL

3

ZITHROMAX TRI-

PAK

3

ZITHROMAX Z-

PAK

3

ZMAX 3

MISCELLANEOUS

ANTIINFECTIVES

ALBENZA 2 QL

ALINIA 2 QL

amikacin 6 MSD

atovaquone 1

atovaquone-

proguanil

1

BETHKIS 6 MSD

BILTRICIDE 2

CAPASTAT 6 MSD

CAYSTON 3 S; SLA; QL

Drug Name Drug

Category

Requirements

/ Limits

chloramphenicol sod

succinate

6 MSD

chloroquine

phosphate

1

CLEOCIN HCL 3

CLEOCIN IN 5 %

DEXTROSE

6 MSD

CLEOCIN

INJECTION

6 MSD

cleocin intravenous

solution 300 mg/2 ml

6 MSD

CLEOCIN

INTRAVENOUS

SOLUTION 600

MG/4 ML, 900

MG/6 ML

6 MSD

CLEOCIN

PEDIATRIC

3

CLIN SINGLE USE 6 MSD

clindamycin hcl 1

CLINDAMYCIN IN

0.9 % SOD CHLOR

6 MSD

clindamycin in 5 %

dextrose

6 MSD

clindamycin

palmitate hcl

1

clindamycin

pediatric

1

clindamycin

phosphate

6 MSD

COARTEM 2

colistin

(colistimethate na)

1

COLY-MYCIN M

PARENTERAL

3

CUBICIN 6 MSD



9

Drug Name Drug

Category

Requirements

/ Limits

CUBICIN RF 6 MSD

CYCLOSERINE 3

dapsone 1 M

daptomycin 6 MSD

DARAPRIM 2 PA; SLA

DORIBAX 6 MSD

DORIPENEM 6 MSD

EMVERM 2 QL

ethambutol 1

FLAGYL 3

gentamicin 6 MSD

gentamicin in nacl

(iso-osm)

intravenous

piggyback 100

mg/100 ml, 60 mg/50

ml, 70 mg/50 ml, 80

mg/100 ml, 80 mg/50

ml, 90 mg/100 ml

1

GENTAMICIN IN

NACL (ISO-OSM)

INTRAVENOUS

PIGGYBACK 100

MG/50 ML

2

GENTAMICIN IN

NACL (ISO-OSM)

INTRAVENOUS

PIGGYBACK 120

MG/100 ML

3

gentamicin sulfate

(ped) (pf)

1

gentamicin sulfate

(pf) intravenous

solution 100 mg/10

ml

1

Drug Name Drug

Category

Requirements

/ Limits

GENTAMICIN

SULFATE (PF)

INTRAVENOUS

SOLUTION 60

MG/6 ML

3

hydroxychloroquine 1 M

imipenem-cilastatin 6 MSD

IMPAVIDO 3 S

INVANZ 6 MSD

isoniazid 1

ivermectin 1 QL

KITABIS PAK 3 S; SLA

LINCOCIN 6 MSD

lincomycin 6 MSD

linezolid intravenous 6 MSD

linezolid oral 1 PA

MALARONE 3

MALARONE

PEDIATRIC

3

mefloquine 1

MEPRON 3

meropenem 6 MSD

MEROPENEM-

0.9% SODIUM

CHLORIDE

6 MSD

MERREM 6 MSD

metro i.v. 6 MSD

metronidazole 1

metronidazole in

nacl (iso-os)

6 MSD

MYAMBUTOL 3

MYCOBUTIN 3

NEBUPENT 2 QL

neomycin 1



10

Drug Name Drug

Category

Requirements

/ Limits

paromomycin 1

PASER 3

PLAQUENIL 3 ST; M

polymyxin b sulfate 6 MSD

PRIFTIN 2

PRIMAQUINE 2 M

PRIMAXIN IV 6 MSD

pyrazinamide 1

QUALAQUIN 3

quinine sulfate 1

rifabutin 1

RIFADIN

INTRAVENOUS

6 MSD

RIFADIN ORAL 3

RIFAMATE 3

rifampin intravenous 6 MSD

rifampin oral 1

RIFATER 3

SIRTURO 2 SLA

SIVEXTRO 3 PA

STREPTOMYCIN 6 MSD

STROMECTOL 3 QL

SYNERCID 6 MSD

TIGECYCLINE 6 MSD

TINDAMAX 3 QL

tinidazole oral tablet

250 mg

1

tinidazole oral tablet

500 mg

1 QL

TOBI 3 ST; QL

TOBI PODHALER 2 QL

Drug Name Drug

Category

Requirements

/ Limits

tobramycin in 0.225

% nacl

1 QL

tobramycin sulfate 6 MSD

TOBRAMYCIN

WITH NEBULIZER

4 S

TRECATOR 3

TYGACIL 6 MSD

XIFAXAN 2

ZYVOX

INTRAVENOUS

6 MSD

ZYVOX ORAL 3 PA

PENICILLINS

amoxicillin 1

amoxicillin-pot

clavulanate

1

ampicillin 1

ampicillin sodium 6 MSD

ampicillin-sulbactam 6 MSD

AUGMENTIN ES-

600

3

AUGMENTIN

ORAL

SUSPENSION FOR

RECONSTITUTIO

N 125-31.25 MG/5

ML

2

AUGMENTIN

ORAL

SUSPENSION FOR

RECONSTITUTIO

N 250-62.5 MG/5

ML

3

AUGMENTIN

ORAL TABLET

3

AUGMENTIN XR 3

BICILLIN C-R 6 MSD



11

Drug Name Drug

Category

Requirements

/ Limits

dicloxacillin 1

MOXATAG 3

nafcillin 6 MSD

oxacillin 6 MSD

oxacillin in

dextrose(iso-osm)

6 MSD

penicillin g

potassium

6 MSD

penicillin v

potassium

1

pfizerpen-g 6 MSD

PIPERACILLIN-

TAZOBACTAM

INTRAVENOUS

RECON SOLN 13.5

GRAM

6 MSD

piperacillin-

tazobactam

intravenous recon

soln 2.25 gram,

3.375 gram, 4.5

gram, 40.5 gram

6 MSD

UNASYN 6 MSD

QUINOLONES

AVELOX 3

AVELOX IN NACL

(ISO-OSMOTIC)

6 MSD

CIPRO 3

CIPRO XR 3

ciprofloxacin 1

ciprofloxacin

(mixture)

1

ciprofloxacin hcl 1

FACTIVE 3

LEVAQUIN 3

Drug Name Drug

Category

Requirements

/ Limits

levofloxacin in d5w 6 MSD

levofloxacin

intravenous

6 MSD

levofloxacin oral 1

moxifloxacin 1

ofloxacin 1

SULFA'S & RELATED AGENTS

BACTRIM 3

BACTRIM DS 3

sulfadiazine 1

sulfamethoxazole-

trimethoprim

1

sulfatrim 1

TETRACYCLINES

ACTICLATE 3 ST

avidoxy 1

demeclocycline 1

DORYX 3 ST

DORYX MPC 3 ST

doxycycline hyclate 1

doxycycline

monohydrate oral

capsule

1

DOXYCYCLINE

MONOHYDRATE

ORAL

CAPSULE,IR -

DELAY

REL,BIPHASE

3 ST

doxycycline

monohydrate oral

suspension for

reconstitution

1



12

Drug Name Drug

Category

Requirements

/ Limits

doxycycline

monohydrate oral

tablet

1

MINOCIN 3 ST

minocycline 1

mondoxyne nl 1

MONODOX 3 ST

morgidox 1

ORACEA 2 ST

SOLODYN 2 ST

TARGADOX 3 ST

tetracycline 1

VIBRAMYCIN 3 ST

URINARY TRACT AGENTS

FURADANTIN 3

HIPREX 3

MACROBID 3

MACRODANTIN 3

methenamine

hippurate

1

methenamine

mandelate

1

MONUROL 3

nitrofurantoin 1

nitrofurantoin

macrocrystal

1

nitrofurantoin

monohyd/m-cryst

1

PRIMSOL 3

trimethoprim 1

VANCOMYCIN

VANCOCIN 3

Drug Name Drug

Category

Requirements

/ Limits

VANCOMYCIN IN

0.9% SODIUM CL

6 MSD

VANCOMYCIN IN

DEXTROSE 5 %

6 MSD

VANCOMYCIN

INJECTION

6 MSD

vancomycin

intravenous

6 MSD

vancomycin oral 1

VIBATIV 6 MSD

ANTINEOPLASTIC &

IMMUNOSUPPRESSANT

DRUGS

ADJUNCTIVE AGENTS

amifostine

crystalline

6 MSD

dexrazoxane hcl 6 MSD

ELITEK 6 MSD

ETHYOL 6 MSD

FUSILEV 6 MSD

KEPIVANCE 6 MSD

leucovorin calcium

injection

1 S

leucovorin calcium

oral

1

LEVOLEUCOVORI

N INTRAVENOUS

RECON SOLN 175

MG

6 MSD

levoleucovorin

intravenous recon

soln 50 mg

6 MSD

levoleucovorin

intravenous solution

6 MSD

mesna 6 MSD



13

Drug Name Drug

Category

Requirements

/ Limits

MESNEX

INTRAVENOUS

6 MSD

MESNEX ORAL 2

TOTECT 6 MSD

VISTOGARD 2 SLA

VORAXAZE 6 MSD

XGEVA 6 MSD

ZINECARD (AS

HCL)

6 MSD

ANTINEOPLASTIC &

IMMUNOSUPPRESSANT DRUGS

ABRAXANE 6 MSD

ADCETRIS 6 MSD

adriamycin 6 MSD

adrucil 6 MSD

AFINITOR 3 S; QL

AFINITOR

DISPERZ

3 S; QL

ALECENSA 3 S; SLA

ALIQOPA 3

ALKERAN

INTRAVENOUS

6 MSD

ALKERAN ORAL 3

ALUNBRIG 4 S

anastrozole 1

ARIMIDEX 3

AROMASIN 4 S

ARRANON 6 MSD

ARZERRA 6 MSD

ASTAGRAF XL 3 ST

AVASTIN 6 MSD

azacitidine 6 MSD

Drug Name Drug

Category

Requirements

/ Limits

AZASAN 3

azathioprine 1

BAVENCIO 6 MSD

BELEODAQ 6 MSD

BENDEKA 6 MSD

BESPONSA 2

bexarotene 1 S

bicalutamide 1

BICNU 6 MSD

bleo 15k 6 MSD

bleomycin 6 MSD

BLINCYTO 6 MSD

BOSULIF 3 S; SLA

busulfan 6 MSD

BUSULFEX 6 MSD

CABOMETYX 4 S

CAMPTOSAR 6 MSD

capecitabine 1 S

CAPRELSA 3 S; SLA; QL

carboplatin 6 MSD

CASODEX 3

CELLCEPT 3

CELLCEPT

INTRAVENOUS

6 MSD

cisplatin 6 MSD

cladribine 6 MSD

clofarabine 6 MSD

CLOLAR 6 MSD

COMETRIQ 3 SLA; QL

COSMEGEN 6 MSD

COTELLIC 3 S; SLA



14

Drug Name Drug

Category

Requirements

/ Limits

cyclophosphamide

intravenous

6 MSD

CYCLOPHOSPHA

MIDE ORAL

2

cyclosporine

intravenous

1 S

cyclosporine

modified

1

cyclosporine oral 1

CYRAMZA 6 MSD

cytarabine 6 MSD

cytarabine (pf) 6 MSD

dacarbazine 6 MSD

DACOGEN 6 MSD

DARZALEX 6 MSD

daunorubicin 6 MSD

decitabine 6 MSD

DOCEFREZ 6 MSD

docetaxel


160 mg/16 ml (10

mg/ml), 160 mg/8 ml

(20 mg/ml), 20 mg/2

ml (10 mg/ml), 20

mg/ml (1 ml), 80

mg/4 ml (20 mg/ml),

80 mg/8 ml (10

mg/ml)

6 MSD

DOCETAXEL

INTRAVENOUS

SOLUTION 20

MG/ML

6 MSD

DOXIL 6 MSD

doxorubicin 6 MSD

doxorubicin, peg-

liposomal

6 MSD

Drug Name Drug

Category

Requirements

/ Limits

DROXIA 3 S

ELIGARD 3 S

ELIGARD (3

MONTH)

3 S

ELIGARD (4

MONTH)

3 S

ELIGARD (6

MONTH)

3 S

ELLENCE 6 MSD

EMCYT 3 S

EMPLICITI 6 MSD

ENVARSUS XR 3 ST

epirubicin 6 MSD

ERBITUX 6 MSD

ERIVEDGE 3 S; SLA

ERWINAZE 6 MSD

etoposide

intravenous

6 MSD

etoposide oral 1 S

EVOMELA 6 MSD

exemestane 1 S

FARESTON 3 S

FARYDAK 4 S

FASLODEX 6 MSD

FEMARA 3

FIRMAGON KIT W

DILUENT

SYRINGE

3 S; SLA

floxuridine 6 MSD

fludarabine 6 MSD

fluorouracil 6 MSD

flutamide 1

FOLOTYN 6 MSD



15

Drug Name Drug

Category

Requirements

/ Limits

GAZYVA 6 MSD

gemcitabine 6 MSD

GEMZAR 6 MSD

gengraf 1

GILOTRIF 3 S

GLEEVEC 4 S; QL

GLEOSTINE 3 S

GLIADEL WAFER 3

HALAVEN 6 MSD

HERCEPTIN 6 MSD

HEXALEN 3 S

HYCAMTIN

INTRAVENOUS

6 MSD

HYCAMTIN ORAL 3 S

HYDREA 3

hydroxyurea 1

IBRANCE 3 S

ICLUSIG 2 SLA

IDAMYCIN PFS 6 MSD

idarubicin 6 MSD

IDHIFA 3 S

IFEX 6 MSD

ifosfamide 6 MSD

ifosfamide-mesna 6 MSD

imatinib 1 S; QL

IMBRUVICA 2 SLA

IMFINZI 6 MSD

IMLYGIC 6 MSD

IMURAN 3

INLYTA 3 S; SLA; QL

IRESSA 3 S; SLA

Drug Name Drug

Category

Requirements

/ Limits

irinotecan 6 MSD

ISTODAX 6 MSD

IXEMPRA 6 MSD

JAKAFI 3 S; SLA; QL

JEVTANA 6 MSD

KADCYLA 6 MSD

KISQALI 4 S

KISQALI FEMARA

CO-PACK

4 S

KYMRIAH 3

KYPROLIS 6 MSD

LARTRUVO 6 MSD

LENVIMA 3 S

letrozole 1

LEUKERAN 2

leuprolide 1 S

lipodox 6 MSD

LONSURF 3 S

LUPRON DEPOT

(3 MONTH)

INTRAMUSCULA

R SYRINGE KIT

11.25 MG

3 S

LUPRON DEPOT

(3 MONTH)

INTRAMUSCULA

R SYRINGE KIT

22.5 MG

4 S

LUPRON DEPOT

(4 MONTH)

4 S

LUPRON DEPOT

(6 MONTH)

4 S



16

Drug Name Drug

Category

Requirements

/ Limits

LUPRON DEPOT

INTRAMUSCULA

R SYRINGE KIT

3.75 MG

3 S

LUPRON DEPOT

INTRAMUSCULA

R SYRINGE KIT

7.5 MG

4 S

LUPRON DEPOT-

PED

3 S

LYNPARZA 3 S; SLA

LYSODREN 3 S

MARQIBO 6 MSD

MATULANE 2 SLA

MEGACE ES 3

megestrol oral

suspension

1

megestrol oral tablet 1 S

MEKINIST 3 S

melphalan 1

melphalan hcl 6 MSD

mercaptopurine 1

methotrexate sodium 1

methotrexate sodium

(pf)

1

mitomycin 6 MSD

mitoxantrone 6 MSD

MUSTARGEN 6 MSD

mycophenolate

mofetil

1

mycophenolate

mofetil hcl

6 MSD

mycophenolate

sodium

1

MYFORTIC 3

Drug Name Drug

Category

Requirements

/ Limits

MYLERAN 3 S

MYLOTARG 3

NAVELBINE 6 MSD

NEORAL 3

NERLYNX 3 S

NEXAVAR 3 S; QL

NILANDRON 4 S

nilutamide 1 S

NINLARO 3 S; SLA

NIPENT 6 MSD

NULOJIX 6 MSD

octreotide acetate 1 S; SLA

ODOMZO 4 S

ONCASPAR 6 MSD

ONIVYDE 6 MSD

OPDIVO 6 MSD

oxaliplatin 6 MSD

paclitaxel 6 MSD

PERJETA 6 MSD

PORTRAZZA 6 MSD

PROGRAF 3

PURIXAN 2 SLA

RAPAMUNE

ORAL SOLUTION

2

RAPAMUNE

ORAL TABLET

3

RITUXAN 6 MSD

RITUXAN

HYCELA

2

RUBRACA 2 PA; SLA

RYDAPT 3 S



17

Drug Name Drug

Category

Requirements

/ Limits

SANDIMMUNE

INTRAVENOUS

4 S

SANDIMMUNE

ORAL CAPSULE

3

SANDIMMUNE

ORAL SOLUTION

2

SANDOSTATIN 4 S; SLA

SANDOSTATIN

LAR DEPOT

6 MSD

SIGNIFOR 6 MSD

SIGNIFOR LAR 6 MSD

SIMULECT 6 MSD

sirolimus 1

SOLTAMOX 3

SOMATULINE

DEPOT

3 S; SLA

SPRYCEL 3 S; QL

STIVARGA 3 S

SUPPRELIN LA 6 MSD

SUTENT 3 S; QL

SYLVANT 6 MSD

SYNRIBO 6 MSD

TABLOID 3 S

tacrolimus 1

TAFINLAR 3 S

TAGRISSO 3 S

tamoxifen 1

TARCEVA 3 S; QL

TARGRETIN

ORAL

4 S

TARGRETIN

TOPICAL

2

TASIGNA 3 S; QL

Drug Name Drug

Category

Requirements

/ Limits

TAXOTERE 6 MSD

TECENTRIQ 6 MSD

TEMODAR 4 S

temozolomide 1 S

TENIPOSIDE 6 MSD

TEPADINA 6 MSD

THALOMID 3 S

thiotepa 6 MSD

toposar 6 MSD

topotecan 6 MSD

TORISEL 6 MSD

TREANDA 6 MSD

TRELSTAR 6 MSD

tretinoin

(chemotherapy)

1 S

TREXALL 3

TRIPTODUR 6 MSD

TRISENOX 6 MSD

TYKERB 3 S; QL

UNITUXIN 6 MSD

VANTAS 6 MSD

VECTIBIX 6 MSD

VELCADE 6 MSD

VENCLEXTA 2 SLA

VIDAZA 6 MSD

vinblastine 6 MSD

vincasar pfs 6 MSD

vincristine 6 MSD

vinorelbine 6 MSD

VOTRIENT 3 S; QL

VYXEOS 2



18

Drug Name Drug

Category

Requirements

/ Limits

XALKORI 3 S; QL

XATMEP 4 ST; S

XELODA 4 S

XERMELO 2 PA; SLA

XTANDI 3 S; QL

YERVOY 6 MSD

YONDELIS 6 MSD

ZALTRAP 6 MSD

ZANOSAR 6 MSD

ZEJULA 2 SLA

ZELBORAF 3 S; QL

ZEVALIN (Y-90) 6 MSD

ZOLADEX 6 MSD

ZOLINZA 3 S; QL

ZORTRESS 2

ZYDELIG 2 SLA

ZYKADIA 3 S; SLA

ZYTIGA 3 S; QL

AUTONOMIC & CNS DRUGS,

NEUROLOGY & PSYCH

ANTICONVULSANTS

APTIOM 3

BANZEL 2

BRIVIACT 3 ST

carbamazepine 1

CARBATROL 3

CELONTIN 2

clonazepam 1

DEPACON 6 MSD

DEPAKENE 3 ST

DEPAKOTE 3 ST

Drug Name Drug

Category

Requirements

/ Limits

DEPAKOTE ER 3 ST

DEPAKOTE

SPRINKLES

3 ST

DIASTAT 3

DIASTAT

ACUDIAL

3

diazepam 1

DILANTIN 2

DILANTIN

EXTENDED

3

DILANTIN

INFATABS

3

DILANTIN-125 3

divalproex 1

epitol 1

EQUETRO 3

ethosuximide 1

felbamate 1

FELBATOL 3

fosphenytoin 6 MSD

FYCOMPA 2

gabapentin 1

GABITRIL ORAL

TABLET 12 MG, 16

MG

2

GABITRIL ORAL

TABLET 2 MG, 4

MG

3

GRALISE 2 ST; QL

GRALISE 30-DAY

STARTER PACK

2 ST; QL

KEPPRA

INTRAVENOUS

6 MSD

KEPPRA ORAL 3 ST



19

Drug Name Drug

Category

Requirements

/ Limits

KEPPRA XR 3 ST

KLONOPIN 3

LAMICTAL 3 ST

LAMICTAL ODT 3 ST

LAMICTAL ODT

STARTER (BLUE)

3 ST

LAMICTAL ODT

STARTER

(GREEN)

3 ST

LAMICTAL ODT

STARTER

(ORANGE)

3 ST

LAMICTAL

STARTER (BLUE)

KIT

3 ST

LAMICTAL

STARTER

(GREEN) KIT

3 ST

LAMICTAL

STARTER

(ORANGE) KIT

3 ST

LAMICTAL XR 3 ST

LAMICTAL XR

STARTER (BLUE)

3 ST

LAMICTAL XR

STARTER

(GREEN)

3 ST

LAMICTAL XR

STARTER

(ORANGE)

3 ST

lamotrigine 1

levetiracetam in nacl

(iso-os)

6 MSD

levetiracetam

intravenous

6 MSD

levetiracetam oral 1

LYRICA 2 ST

Drug Name Drug

Category

Requirements

/ Limits

MYSOLINE 3

NEURONTIN 3 ST

ONFI 2

oxcarbazepine 1

OXTELLAR XR 3 ST

PEGANONE 2

phenobarbital 1

PHENYTEK 3

phenytoin 1

phenytoin sodium

extended

1

primidone 1

QUDEXY XR 2 ST

roweepra 1

SABRIL 3 PA; S; SLA

TEGRETOL 3

TEGRETOL XR 3

tiagabine 1

TOPAMAX 3 ST

topiramate oral

capsule, sprinkle

1

TOPIRAMATE

ORAL

CAPSULE,SPRINK

LE,ER 24HR

3 ST

topiramate oral

tablet

1

TRILEPTAL 3 ST

TROKENDI XR 3 ST

valproate sodium 6 MSD

valproic acid 1

valproic acid (as

sodium salt)

1



20

Drug Name Drug

Category

Requirements

/ Limits

vigabatrin 1 PA; S; SLA

VIMPAT 2

ZARONTIN 3

ZONEGRAN 3

zonisamide 1

ANTIPARKINSONISM AGENTS

APOKYN 3 S; SLA

AZILECT 3 M

benztropine 1

bromocriptine 1

carbidopa 1 M

carbidopa-levodopa 1 M

carbidopa-levodopa-

entacapone

1 M

COMTAN 3 M

DUOPA 6 MSD

ELDEPRYL 3 M

entacapone 1 M

GOCOVRI 3

LODOSYN 3 M

MIRAPEX 3 M

MIRAPEX ER 3 M

NEUPRO 3 M

PARLODEL 3

pramipexole 1 M

rasagiline 1 M

REQUIP 3 M

REQUIP XL 3 M

ropinirole 1 M

RYTARY 3 M

selegiline hcl 1 M

Drug Name Drug

Category

Requirements

/ Limits

SINEMET 3 M

SINEMET CR 3 M

STALEVO 100 3 M

STALEVO 125 3 M

STALEVO 150 3 M

STALEVO 200 3 M

STALEVO 50 3 M

STALEVO 75 3 M

TASMAR 3 M

tolcapone 1 M

trihexyphenidyl 1

XADAGO 3 M

ZELAPAR 3 M

MIGRAINE & CLUSTER

HEADACHE THERAPY

almotriptan malate 1 QL

AMERGE 3 ST; QL

AXERT 3 ST; QL

CAFERGOT 3

D.H.E.45 3

dihydroergotamine

injection

1

dihydroergotamine

nasal

1 QL

eletriptan hbr 1 QL

ERGOMAR 3

ergotamine-caffeine 1

frovatriptan 1 QL

IMITREX 3 ST; QL

IMITREX

STATDOSE KIT

REFILL

3 ST; QL



21

Drug Name Drug

Category

Requirements

/ Limits

IMITREX

STATDOSE PEN

3 ST; QL

isometh-dichloral-

acetaminophn

1

isomethepten-caf-

acetaminophen

1

MAXALT 3 ST; QL

MAXALT-MLT 3 ST; QL

migergot 1

MIGRANAL 3 QL

naratriptan 1 QL

nodolor 1

ONZETRA XSAIL 3 QL

PRODRIN 3

RELPAX 3 ST; QL

rizatriptan 1 QL

sumatriptan 1 QL

sumatriptan

succinate

1 QL

SUMAVEL

DOSEPRO

3 ST; QL

TREXIMET 3 ST; QL

ZEMBRACE

SYMTOUCH

3 QL

zolmitriptan 1 QL

ZOMIG NASAL 2 QL

ZOMIG ORAL 3 ST; QL

ZOMIG ZMT 3 ST; QL

MISCELLANEOUS

NEUROLOGICAL THERAPY

AMPYRA 3 PA; S; SLA;

QL

ARICEPT 3 ST; M

Drug Name Drug

Category

Requirements

/ Limits

AUSTEDO 3 PA; SLA

donepezil oral tablet

10 mg, 5 mg

1 M

donepezil oral tablet

23 mg

1 ST; M

donepezil oral

tablet,disintegrating

1 M

EXELON 3 ST; M; QL

EXONDYS 51 6 MSD

galantamine oral

capsule,ext rel.

pellets 24 hr

1 M; QL

galantamine oral

solution

1 M; QL

galantamine oral

tablet 12 mg

1 M

galantamine oral

tablet 4 mg, 8 mg

1 M; QL

HORIZANT 3 ST; QL

INGREZZA 3 PA; SLA

KEVEYIS 3 PA; SLA

memantine oral

solution

1 M

memantine oral

tablet

1 M

MEMANTINE

ORAL

TABLETS,DOSE

PACK

3 M; QL

NAMENDA 3 ST; M

NAMENDA

TITRATION PAK

3 M; QL

NAMENDA XR

ORAL

CAP,SPRINKLE,E

R 24HR DOSE

PACK

2 M; QL



22

Drug Name Drug

Category

Requirements

/ Limits

NAMENDA XR

ORAL

CAPSULE,SPRINK

LE,ER 24HR

2 ST; M; QL

NAMZARIC 2 ST

NUEDEXTA 2 PA

RADICAVA 2

RAZADYNE ER 3 ST; M; QL

RAZADYNE ORAL

TABLET 12 MG

3 ST; M

RAZADYNE ORAL

TABLET 4 MG, 8

MG

3 ST; M; QL

rivastigmine 1 M; QL

rivastigmine tartrate 1 M; QL

tetrabenazine 1 PA

TYSABRI 6 MSD

XENAZINE 3 PA

MUSCLE RELAXANTS &

ANTISPASMODIC THERAPY

AMRIX 3 ST

baclofen 1 M

BRIDION 6 MSD

carisoprodol 1

carisoprodol-asa-

codeine

1

carisoprodol-aspirin 1

chlorzoxazone 1

cyclobenzaprine 1

DANTRIUM 3 M

dantrolene 1 M

FEXMID 3 ST

LORZONE 3 ST

Drug Name Drug

Category

Requirements

/ Limits

meprobamate 1

MESTINON ORAL

SYRUP

2 M

MESTINON ORAL

TABLET

3 M

MESTINON

TIMESPAN

3 M

metaxall 1

metaxalone 1

methocarbamol

injection

6 MSD

methocarbamol oral 1

orphenadrine citrate 1

PARAFON FORTE

DSC

3

pyridostigmine

bromide

1 M

ROBAXIN

INJECTION

6 MSD

ROBAXIN ORAL 3

ROBAXIN-750 3

SKELAXIN 3

SOMA 3

tizanidine 1

ZANAFLEX 3

NARCOTIC ANALGESICS

ABSTRAL 3 ST; QL

acetaminophen-caff-

dihydrocod oral

capsule

1

ACETAMINOPHE

N-CAFF-

DIHYDROCOD

ORAL TABLET

3



23

Drug Name Drug

Category

Requirements

/ Limits

acetaminophen-

codeine

1

ACTIQ 3 ST; QL

ALLZITAL 3 ST

ARYMO ER 3 ST; QL

ascomp with codeine 1

aspirin-caffeine-

dihydrocodein

1

BELBUCA 3 PA

BUPAP 3 ST

BUPRENEX 6 MSD

BUPRENORPHINE 3 ST

buprenorphine hcl

injection

6 MSD

buprenorphine hcl

sublingual

1

butalbital compound

w/codeine

1

butalbital-

acetaminop-caf-cod

1

butalbital-

acetaminophen

1

butalbital-

acetaminophen-caff

1

butalbital-aspirin-

caffeine

1

BUTRANS 3 ST

capacet 1

CAPITAL WITH

CODEINE

3

codeine sulfate 1

DEMEROL 3

DILAUDID

INJECTION

6 MSD

Drug Name Drug

Category

Requirements

/ Limits

DILAUDID ORAL 3

diskets 1

DOLOPHINE 3

DURAGESIC 3

EMBEDA 3 ST; QL

endocet 1

ESGIC 3 ST

EXALGO ER 3 ST; QL

FENTANYL (PF)-

BUPIVACAINE-

NACL

6 MSD

fentanyl citrate 1 ST; QL

fentanyl citrate (pf) 6 MSD

FENTANYL

CITRATE-

0.9%NACL (PF)

INTRAVENOUS

SOLUTION 20

MCG/ML

6 MSD

fentanyl citrate-

0.9%nacl (pf)


5 mcg/ml

6 MSD

fentanyl transdermal

patch 72 hour 100

mcg/hr, 12 mcg/hr,

25 mcg/hr, 50

mcg/hr, 75 mcg/hr

1

FENTANYL

TRANSDERMAL

PATCH 72 HOUR

37.5 MCG/HOUR,

62.5 MCG/HOUR,

87.5 MCG/HOUR

3

FENTANYL-

ROPIVACAINE-

NACL (PF)

6 MSD

FENTORA 3 ST; QL



24

Drug Name Drug

Category

Requirements

/ Limits

FIORICET 3 ST

FIORINAL 3 ST

FIORINAL-

CODEINE #3

3 ST

hydrocodone-

acetaminophen

1

hydrocodone-

ibuprofen

1

HYDROMORPHO

NE IN 0.9 % NACL

INJECTION

6 MSD

HYDROMORPHO

NE IN 0.9 % NACL

INTRAVENOUS

PATIENT

CONTROL.ANALG

ESIA SOLN

6 MSD

HYDROMORPHO

NE IN 0.9 % NACL

INTRAVENOUS

PREFILLED PUMP

RESERVOIR

6 MSD

hydromorphone in

0.9 % nacl

intravenous pt

controlled analgesia

syring 15 mg/30 ml

(0.5 mg/ml)

6 MSD

HYDROMORPHO

NE IN 0.9 % NACL

INTRAVENOUS

PT CONTROLLED

ANALGESIA

SYRING 5 MG/25

ML (0.2 MG/ML), 6

MG/30 ML (0.2

MG/ML)

6 MSD

HYDROMORPHO

NE IN 0.9 % NACL

INTRAVENOUS

SOLUTION

6 MSD

Drug Name Drug

Category

Requirements

/ Limits

HYDROMORPHO

NE IN 0.9 % NACL

INTRAVENOUS

SYRINGE

6 MSD

hydromorphone

injection solution

6 MSD

HYDROMORPHO

NE INJECTION

SYRINGE 0.5

MG/0.5 ML

6 MSD

hydromorphone

injection syringe 1

mg/ml, 2 mg/ml, 4

mg/ml

6 MSD

hydromorphone oral

liquid

1

hydromorphone oral

tablet

1

hydromorphone oral

tablet extended

release 24 hr

1 QL

hydromorphone

rectal

1

HYSINGLA ER 2 ST; QL

IBUDONE 3

ibuprofen-oxycodone 1

KADIAN 3 ST; QL

LAZANDA 3 ST; QL

levorphanol tartrate 1

lorcet (hydrocodone) 1

lorcet hd 1

lorcet plus 1

LORTAB ELIXIR 3

marten-tab 1

meperidine 1

methadone 1



25

Drug Name Drug

Category

Requirements

/ Limits

methadose 1

MORPHABOND

ER

3 ST; QL

morphine (pf) 6 MSD

MORPHINE (PF)

IN 0.9 % NACL

INTRAVENOUS

SOLUTION

6 MSD

morphine (pf) in 0.9

% nacl intravenous

syringe

6 MSD

morphine

concentrate

1

MORPHINE IN 0.9

% NACL

6 MSD

morphine injection 6 MSD

MORPHINE

INTRAMUSCULA

R

6 MSD

morphine

intravenous

cartridge 10 mg/ml,

2 mg/ml, 4 mg/ml

6 MSD

MORPHINE

INTRAVENOUS

CARTRIDGE 8

MG/ML

6 MSD

morphine

intravenous pt

controlled analgesia

syring

6 MSD

morphine


10 mg/ml, 100 mg/4

ml, 25 mg/ml, 250

mg/10 ml, 50 mg/ml

6 MSD

Drug Name Drug

Category

Requirements

/ Limits

MORPHINE

INTRAVENOUS

SOLUTION 4

MG/ML, 8 MG/ML

6 MSD

MORPHINE

INTRAVENOUS

SYRINGE 10

MG/ML, 8 MG/ML

6 MSD

morphine

intravenous syringe

2 mg/ml, 4 mg/ml

6 MSD

morphine oral

capsule, er

multiphase 24 hr

1 QL

morphine oral

capsule,extend.relea

se pellets

1 QL

morphine oral

solution

1

morphine oral tablet 1

morphine oral tablet

extended release

1 QL

morphine rectal 1

MS CONTIN 3 ST; QL

NORCO 3

OPANA 3

OXAYDO 3

oxycodone oral

capsule

1

oxycodone oral

concentrate

1

oxycodone oral

solution

1

oxycodone oral

tablet

1



26

Drug Name Drug

Category

Requirements

/ Limits

OXYCODONE

ORAL

TABLET,ORAL

ONLY,EXT.REL.12

HR

3 ST; QL

oxycodone-

acetaminophen

1

oxycodone-aspirin 1

OXYCONTIN 2 ST; QL

oxymorphone oral

tablet

1

oxymorphone oral

tablet extended

release 12 hr

1 QL

PERCOCET 3

PRIMLEV 3

PROBUPHINE 6 MSD

ROXICODONE 3

SUBSYS 3 ST; QL

SYNALGOS-DC 3

tencon 1

TREZIX 3

TYLENOL-

CODEINE #3

3

TYLENOL-

CODEINE #4

3

VANATOL LQ 3 ST

VANATOL S 3

verdrocet 1

vicodin 1

vicodin es 1

vicodin hp 1

XODOL 10/300 3

XODOL 5/300 3

Drug Name Drug

Category

Requirements

/ Limits

XODOL 7.5/300 3

XTAMPZA ER 3 ST; QL

xylon 10 1

zamicet 1

zebutal 1

ZOHYDRO ER 3 ST; QL

NON-NARCOTIC ANALGESICS

ANAPROX DS 3 ST; M

ARTHROTEC 50 3 ST; M

ARTHROTEC 75 3 ST; M

aspir-81 5 M; ACA; OTC

aspirin low dose 5 M; ACA; OTC

aspirin oral tablet 5 ACA; OTC

aspirin oral

tablet,chewable

5 M; ACA; OTC

aspirin oral

tablet,delayed

release (dr/ec) 325

mg

5 ACA; OTC

aspirin oral

tablet,delayed

release (dr/ec) 81

mg

5 M; ACA; OTC

aspir-low 5 M; ACA; OTC

aspir-trin 5 ACA; OTC

bayer aspirin 5 ACA; OTC

BUNAVAIL 3 QL

buprenorphine-

naloxone

1 QL

butorphanol tartrate

injection

6 MSD

butorphanol tartrate

nasal

1 QL

CAMBIA 3 ST; QL



27

Drug Name Drug

Category

Requirements

/ Limits

CELEBREX 3 ST; M; QL

celecoxib 1 ST; M; QL

children's aspirin 5 M; ACA; OTC

choline,magnesium

salicylate

1

CONZIP 3 ST; QL

DAYPRO 3 ST; M

DICLO GEL-

XRYLIX SHEET

3 ST; M

diclofenac potassium 1

diclofenac sodium

oral

1 M

diclofenac sodium

topical drops

1 M; QL

diclofenac sodium

topical gel

1 ST; M; QL

diclofenac-

misoprostol

1 M

diflunisal 1 M

DISALCID 3

DUEXIS 3 ST; M; QL

e.c. prin 5 ACA; OTC

EC-NAPROSYN 3 ST; M

ecotrin 5 ACA; OTC

ecotrin low strength 5 M; ACA; OTC

etodolac 1 M

EUFLEXXA 6 MSD

EVZIO INJECTION

AUTO-INJECTOR

0.4 MG/0.4 ML

3 ST; QL

EVZIO INJECTION

AUTO-INJECTOR

2 MG/0.4 ML

3 ST

FELDENE 3 ST; M

Drug Name Drug

Category

Requirements

/ Limits

FENOPROFEN

ORAL CAPSULE

3 ST; M

fenoprofen oral

tablet

1 M

FENORTHO 3 ST; M

FLECTOR 2 ST; QL

flurbiprofen 1 M

FROTEK 3 ST; M

ibuprofen 1 M

INDOCIN 3 ST

indomethacin 1

ketoprofen 1 M

ketorolac injection 6 MSD

ketorolac

intramuscular

6 MSD

ketorolac oral 1 QL

lite coat aspirin 5 ACA; OTC

LODINE 3 ST; M

meclofenamate 1 M

mefenamic acid 1

meloxicam oral

suspension

1 M

meloxicam oral

tablet 15 mg

1 M

meloxicam oral

tablet 7.5 mg

1 M; QL

MOBIC ORAL

TABLET 15 MG

3 ST; M

MOBIC ORAL

TABLET 7.5 MG

3 ST; M; QL

nabumetone 1 M

nalbuphine 6 MSD

NALFON 3 ST; M

naloxone 1



28

Drug Name Drug

Category

Requirements

/ Limits

naltrexone 1

NAPRELAN CR 3 ST; M

NAPROSYN 3 ST; M

naproxen 1 M

naproxen sodium 1 M

NARCAN 2

NUCYNTA 2 QL

NUCYNTA ER 2 ST; QL

oxaprozin 1 M

PENNSAID 3 ST; M; QL

pentazocine-

naloxone

1

piroxicam 1 M

PONSTEL 3 ST

READYSHARP

KETOROLAC

6 MSD

REVIA 3

salsalate 1

SPRIX 3 ST; SLA; QL

SUBOXONE 2 QL

sulindac 1 M

TALWIN 6 MSD

TIVORBEX 3 ST; M

tolmetin 1 M

TORONOVA II

SUIK

6 MSD

TORONOVA SUIK 6 MSD

TRAMADOL

ORAL

CAPSULE,ER

BIPHASE 24 HR

17-83

3 ST; QL

Drug Name Drug

Category

Requirements

/ Limits

TRAMADOL

ORAL

CAPSULE,ER

BIPHASE 24 HR

25-75

3 ST; QL

tramadol oral tablet 1 QL

tramadol oral tablet

extended release 24

hr

1 ST; QL

tramadol oral tablet,

er multiphase 24 hr

1 ST; QL

tramadol-

acetaminophen

1 QL

ULTRACET 3 QL

ULTRAM 3 QL

ULTRAM ER 3 ST; QL

VIMOVO 3 ST; M; QL

VIVITROL 6 MSD

VIVLODEX 3 ST; M

VOLTAREN 3 ST; M; QL

VOLTAREN-XR 3 ST; M

ZIPSOR 3 ST; QL

ZORVOLEX 3 ST; M; QL

ZUBSOLV

SUBLINGUAL

TABLET 0.7-0.18

MG, 11.4-2.9 MG,

2.9-0.71 MG, 8.6-

2.1 MG

2

ZUBSOLV

SUBLINGUAL

TABLET 1.4-0.36

MG, 5.7-1.4 MG

2 QL

PSYCHOTHERAPEUTIC DRUGS

ABILIFY 3 ST; QL



29

Drug Name Drug

Category

Requirements

/ Limits

ABILIFY

MAINTENA

6 MSD

ADASUVE 3

ADDERALL 3 ST; QL

ADDERALL XR 3 ST; QL

ADDYI 3 PA

ADZENYS XR-

ODT

3 ST

alprazolam 1

alprazolam intensol 1

AMBIEN 3 ST; QL

AMBIEN CR 3 ST; QL

amitriptyline 1

amitriptyline-

chlordiazepoxide

1

amoxapine 1

ANAFRANIL 3

APLENZIN 3 ST; M; QL

APTENSIO XR 3 ST

aripiprazole oral

solution

1

aripiprazole oral

tablet

1 QL

aripiprazole oral


1 QL

ARISTADA 6 MSD

armodafinil 1 PA; QL

ATIVAN 3

atomoxetine 1 QL

BELSOMRA 3 ST

BRISDELLE 2 ST; M; QL

bupropion hcl oral

tablet

1 M

Drug Name Drug

Category

Requirements

/ Limits

bupropion hcl oral

tablet extended

release 12 hr

1 M; QL

bupropion hcl oral

tablet extended

release 24 hr 150 mg

1 M

bupropion hcl oral

tablet extended

release 24 hr 300 mg

1 M; QL

buspirone 1 M

BUTISOL 3

CELEXA 3 ST; M; QL

chlordiazepoxide hcl 1

chlorpromazine 1

citalopram 1 M

clomipramine 1

clonidine hcl 1 QL

clorazepate

dipotassium

1

clozapine oral tablet 1

clozapine oral


100 mg, 12.5 mg, 25

mg

1

CLOZAPINE

ORAL

TABLET,DISINTE

GRATING 150 MG,

200 MG

3

CLOZARIL 3

CONCERTA 3 ST; QL

COTEMPLA XR-

ODT

3 ST

CYMBALTA 3 ST; M; QL

DAYTRANA 2 ST; QL

desipramine 1



30

Drug Name Drug

Category

Requirements

/ Limits

DESOXYN 3 QL

DESVENLAFAXIN

E

3 ST; M; QL

DESVENLAFAXIN

E FUMARATE

3 ST; M

desvenlafaxine

succinate oral tablet

extended release 24

hr 100 mg, 50 mg

1 M; QL

desvenlafaxine

succinate oral tablet

extended release 24

hr 25 mg

1 M

DEXEDRINE

SPANSULE

3 ST; QL

dexmethylphenidate 1 QL

dextroamphetamine 1 QL

dextroamphetamine-

amphetamine

1 QL

diazepam injection 6 MSD

diazepam intensol 1

diazepam oral 1

DORAL 3

doxepin 1

duloxetine oral

capsule,delayed

release(dr/ec) 20

mg, 30 mg, 60 mg

1 M; QL

duloxetine oral

capsule,delayed

release(dr/ec) 40 mg

1 M

DYANAVEL XR 3 ST

EDLUAR 3 ST; QL

EFFEXOR XR 3 ST; M; QL

EMSAM 3 M; QL

ergoloid 1 M

Drug Name Drug

Category

Requirements

/ Limits

escitalopram oxalate 1 M

estazolam 1

eszopiclone 1 QL

EVEKEO 2 PA

FANAPT 3 QL

FAZACLO 3

FETZIMA 2 ST; M; QL

flumazenil 6 MSD

fluoxetine oral

capsule 10 mg, 40

mg

1 M; QL

fluoxetine oral

capsule 20 mg

1 M

fluoxetine oral

capsule,delayed

release(dr/ec)

1 M; QL

fluoxetine oral

solution

1 M

fluoxetine oral tablet

10 mg

1 M; QL

fluoxetine oral tablet

20 mg

1 M

FLUOXETINE

ORAL TABLET 60

MG

3 ST

fluphenazine

decanoate

1

fluphenazine hcl 1

flurazepam 1

fluvoxamine 1 M; QL

FOCALIN 3 QL

FOCALIN XR 3 ST; QL

FORFIVO XL 3 ST; M; QL



31

Drug Name Drug

Category

Requirements

/ Limits

GEODON

INTRAMUSCULA

R

6 MSD

GEODON ORAL 3 QL

guanfacine 1 QL

guanidine 1

HALCION 3

HALDOL 3

HALDOL

DECANOATE

3

haloperidol 1

haloperidol

decanoate

1

haloperidol lactate 1

HETLIOZ 4 S; SLA; QL

imipramine hcl 1

imipramine pamoate 1

INTERMEZZO 3 ST; QL

INTUNIV ER 3 ST; QL

INVEGA 3 QL

IRENKA 3 ST; M

KAPVAY 3 ST; QL

KHEDEZLA 3 ST; M; QL

LATUDA 2 QL

LEXAPRO 3 ST; M; QL

lithium carbonate 1

lithium citrate 1

LITHOBID 3

lorazepam 1

lorazepam intensol 1

loxapine succinate 1

LUNESTA 3 ST; QL

Drug Name Drug

Category

Requirements

/ Limits

maprotiline 1

MARPLAN 3 M

metadate er 1

methamphetamine 1 QL

METHYLIN 3 QL

methylphenidate hcl

oral capsule, er

biphasic 30-70

1

methylphenidate hcl

oral capsule,er

biphasic 50-50

1

methylphenidate hcl

oral solution

1 QL

methylphenidate hcl

oral tablet

1 QL

methylphenidate hcl

oral tablet extended

release

1

methylphenidate hcl

oral tablet extended

release 24hr

1 QL

methylphenidate hcl

oral tablet,chewable

1 QL

mirtazapine 1 QL

modafinil 1 PA; QL

MYDAYIS 2 ST

NARDIL 3 M

nefazodone 1 M

NORPRAMIN 3

nortriptyline 1

NUPLAZID 4 S; SLA

NUVIGIL 3 PA; QL

olanzapine

intramuscular

6 MSD



32

Drug Name Drug

Category

Requirements

/ Limits

olanzapine oral

tablet 10 mg, 15 mg,

2.5 mg, 5 mg, 7.5 mg

1 QL

olanzapine oral

tablet 20 mg

1

olanzapine oral


1 QL

olanzapine-

fluoxetine

1

ORAP 3

oxazepam 1

paliperidone 1 QL

PAMELOR 3

PARNATE 3 M

paroxetine hcl 1 M; QL

paroxetine mesylate 1 M; QL

PAXIL CR 3 ST; M; QL

PAXIL ORAL

SUSPENSION

3 ST; M

PAXIL ORAL

TABLET

3 ST; M; QL

perphenazine 1

perphenazine-

amitriptyline

1

PEXEVA 3 ST; M; QL

phenelzine 1 M

pimozide 1

PRISTIQ ORAL

TABLET

EXTENDED

RELEASE 24 HR

100 MG, 50 MG

3 ST; M; QL

Drug Name Drug

Category

Requirements

/ Limits

PRISTIQ ORAL

TABLET

EXTENDED

RELEASE 24 HR

25 MG

3 ST; M

procentra 1 QL

protriptyline 1

PROVIGIL 3 ST; QL

PROZAC ORAL

CAPSULE 10 MG,

40 MG

3 ST; M; QL

PROZAC ORAL

CAPSULE 20 MG

3 ST; M

quazepam 1

quetiapine 1 QL

QUILLICHEW ER 2 ST

QUILLIVANT XR 2 ST; QL

REMERON 3 QL

REMERON

SOLTAB

3 QL

RESTORIL 3

REXULTI 3

RISPERDAL M-

TAB

3 QL

RISPERDAL ORAL

SOLUTION

3

RISPERDAL ORAL

TABLET

3 QL

risperidone oral

solution

1

risperidone oral

tablet

1 QL

risperidone oral


1 QL

RITALIN 3 QL



33

Drug Name Drug

Category

Requirements

/ Limits

RITALIN LA 3 ST

ROZEREM 2 ST; QL

SAPHRIS (BLACK

CHERRY)

SUBLINGUAL

TABLET 10 MG, 5

MG

3 QL

SAPHRIS (BLACK

CHERRY)

SUBLINGUAL

TABLET 2.5 MG

3

SARAFEM ORAL

TABLET 10 MG

3 ST; M; QL

SARAFEM ORAL

TABLET 20 MG

3 ST; M

seconal sodium 1

SEROQUEL 3 ST; QL

SEROQUEL XR 3 ST; QL

sertraline oral

concentrate

1 M

sertraline oral tablet 1 M; QL

SILENOR 3 ST; QL

SONATA 3 ST; QL

STRATTERA 3 ST; QL

SURMONTIL 3

SYMBYAX 3

temazepam 1

thioridazine 1

thiothixene 1

TOFRANIL 3

TRANXENE T-

TAB

3

tranylcypromine 1 M

trazodone 1

Drug Name Drug

Category

Requirements

/ Limits

triazolam 1

trifluoperazine 1

trimipramine 1

TRINTELLIX 3 ST; QL

VALIUM 3 ST

venlafaxine oral

capsule,extended

release 24hr 150 mg

1 M

venlafaxine oral

capsule,extended

release 24hr 37.5

mg, 75 mg

1 M; QL

venlafaxine oral

tablet

1 M; QL

venlafaxine oral

tablet extended

release 24hr

1 ST; M; QL

VERSACLOZ 3

VIIBRYD ORAL

TABLET

2 ST; M; QL

VIIBRYD ORAL

TABLETS,DOSE

PACK

2 ST; QL

VRAYLAR 3

VYVANSE 2 ST; QL

WELLBUTRIN SR 3 ST; M; QL

WELLBUTRIN XL 3 ST; M; QL

XANAX 3 ST

XANAX XR 3 ST

XYREM 3 PA; S; SLA;

QL

zaleplon 1 QL

zenzedi oral tablet

10 mg, 5 mg

1 QL



34

Drug Name Drug

Category

Requirements

/ Limits

ZENZEDI ORAL

TABLET 15 MG

3 QL

ZENZEDI ORAL

TABLET 2.5 MG,

20 MG, 30 MG, 7.5

MG

3

ziprasidone hcl 1 QL

ZOLOFT ORAL

CONCENTRATE

3 ST; M

ZOLOFT ORAL

TABLET

3 ST; M; QL

zolpidem 1 QL

ZOLPIMIST 3 ST

ZYPREXA

INTRAMUSCULA

R

6 MSD

ZYPREXA ORAL

TABLET 10 MG, 15

MG, 2.5 MG, 5 MG,

7.5 MG

3 QL

ZYPREXA ORAL

TABLET 20 MG

3

ZYPREXA ZYDIS 3 QL

CARDIOVASCULAR,

HYPERTENSION & LIPIDS

ANTIARRHYTHMIC AGENTS

amiodarone 1 M

BETAPACE 3 M

BETAPACE AF 3 M

disopyramide

phosphate

1 M

dofetilide 1

flecainide 1 M

mexiletine 1 M

MULTAQ 3 M

Drug Name Drug

Category

Requirements

/ Limits

NORPACE 3 M

NORPACE CR 3 M

pacerone 1 M

procainamide 6 MSD

propafenone 1 M

quinidine gluconate 1 M

quinidine sulfate 1 M

RYTHMOL SR 3 M

sotalol 1 M

sotalol af 1 M

SOTYLIZE 2 M

TIKOSYN 3 ST

ANTIHYPERTENSIVE THERAPY

ACCUPRIL 3 M

ACCURETIC 3 M

acebutolol 1 M

ADALAT CC 3 ST; M

afeditab cr 1 M

ALDACTAZIDE 3 M

ALDACTONE 3 M

ALTACE 3 M

amiloride 1 M

amiloride-

hydrochlorothiazide

1 M

amlodipine 1 M

amlodipine-

benazepril

1 M

amlodipine-

olmesartan

1 M

amlodipine-

valsartan

1 M

amlodipine-

valsartan-hcthiazid

1 M



35

Drug Name Drug

Category

Requirements

/ Limits

ATACAND 3 ST; M

ATACAND HCT 3 ST; M

atenolol 1 M

atenolol-

chlorthalidone

1 M

AVALIDE 3 ST; M

AVAPRO 3 ST; M

AZOR 3 ST; M

benazepril 1 M

benazepril-

hydrochlorothiazide

1 M

BENICAR 3 ST; M

BENICAR HCT 3 ST; M

betaxolol 1 M

BIDIL 3 M

bisoprolol fumarate 1 M

bisoprolol-

hydrochlorothiazide

1 M

BREVIBLOC 6 MSD

BREVIBLOC IN

NACL (ISO-OSM)

6 MSD

bumetanide 1 M

BYSTOLIC 2 ST; M

BYVALSON 2 ST; M

CALAN 3 ST; M

CALAN SR 3 ST; M

candesartan oral

tablet 16 mg

1

candesartan oral

tablet 32 mg, 4 mg, 8

mg

1 M

candesartan-

hydrochlorothiazid

1 M

captopril 1 M

Drug Name Drug

Category

Requirements

/ Limits

captopril-

hydrochlorothiazide

1 M

CARDENE IV 6 MSD

CARDENE IV IN

DEXTROSE

6 MSD

CARDENE IV IN

SODIUM

CHLORIDE

6 MSD

CARDIZEM 3 M

CARDIZEM CD 3 M

CARDIZEM LA 3 M

CARDURA 3 ST; M; QL

CARDURA XL 3 ST; M; QL

cartia xt 1 M

carvedilol 1 M

CATAPRES 3 M

CATAPRES-TTS-1 3 M; QL



chlorothiazide 1 M

chlorothiazide

sodium

6 MSD

chlorthalidone 1 M

CLEVIPREX 6 MSD

clonidine 1 M; QL

clonidine hcl 1 M

clorpres oral tablet

0.1-15 mg, 0.2-15

mg

1 M

CLORPRES ORAL

TABLET 0.3-15

MG

3 M

COREG 3 ST; M

COREG CR 2 ST; M



36

Drug Name Drug

Category

Requirements

/ Limits

CORGARD 3 ST; M

CORZIDE 3 ST; M

COZAAR 3 ST; M

DEMADEX 3 M

DEMSER 2

DIBENZYLINE 3

diltiazem 1 M

DILTIAZEM HCL

IN 0.9% NACL

6 MSD

DILTIAZEM IN

DEXTROSE 5 %

6 MSD

dilt-xr 1 M

DIOVAN 3 ST; M

DIOVAN HCT 3 ST; M

DIURIL 3 M

DIURIL IV 6 MSD

doxazosin 1 M; QL

DUTOPROL 3 ST; M

DYAZIDE 3 M

DYRENIUM 3 M

EDARBI 2 ST; M

EDARBYCLOR 2 ST; M

EDECRIN 3 M

enalapril maleate 1 M

enalaprilat 6 MSD

enalapril-

hydrochlorothiazide

1 M

EPANED 3 M

eplerenone 1 M

epoprostenol

(glycine)

6 MSD

eprosartan 1 M

Drug Name Drug

Category

Requirements

/ Limits

esmolol 6 MSD

ethacrynate sodium 6 MSD

ethacrynic acid 1 M

EXFORGE 3 ST; M

EXFORGE HCT 3 ST; M

felodipine 1 M

FLOLAN 6 MSD

fosinopril 1 M

fosinopril-

hydrochlorothiazide

1 M

furosemide injection 6 MSD

furosemide oral 1 M

guanfacine 1 M

HEMANGEOL 3 SLA

hydralazine injection 6 MSD

hydralazine oral 1 M

hydrochlorothiazide 1 M

HYZAAR 3 ST; M

indapamide 1 M

INDERAL LA 3 ST; M

INDERAL XL 3 ST; M

INNOPRAN XL 3 ST; M

INSPRA 3 M

irbesartan 1 M

irbesartan-

hydrochlorothiazide

1 M

isradipine 1 M

labetalol

intravenous

6 MSD

labetalol oral 1 M

LASIX 3 M

LEVATOL 3 ST; M



37

Drug Name Drug

Category

Requirements

/ Limits

lisinopril 1 M

lisinopril-

hydrochlorothiazide

1 M

LOPRESSOR 3 ST; M

losartan 1 M

losartan-

hydrochlorothiazide

1 M

LOTENSIN 3 M

LOTENSIN HCT 3 M

LOTREL 3 M

matzim la 1 M

MAXZIDE 3 M

MAXZIDE-25MG 3 M

methyclothiazide 1 M

methyldopa 1 M

methyldopa-

hydrochlorothiazide

1 M

methyldopate 6 MSD

metolazone 1 M

metoprolol succinate 1 M

METOPROLOL

SU-

HYDROCHLOROT

HIAZ

3 ST; M

metoprolol ta-

hydrochlorothiaz

1 M

metoprolol tartrate

intravenous

6 MSD

metoprolol tartrate

oral

1 M

MICARDIS 3 ST; M

MICARDIS HCT 3 ST; M

MICROZIDE 3 M

MINIPRESS 3 M

Drug Name Drug

Category

Requirements

/ Limits

minoxidil 1 M

moexipril 1 M

moexipril-

hydrochlorothiazide

1 M

nadolol 1 M

nadolol-

bendroflumethiazide

1 M

nicardipine

intravenous

6 MSD

nicardipine oral 1 M

nifedipine 1 M

nimodipine 1

nisoldipine 1 M

NORVASC 3 ST; M

NYMALIZE 3

olmesartan 1 M

olmesartan-

amlodipin-hcthiazid

1 M

olmesartan-

hydrochlorothiazide

1 M

ORENITRAM 4 PA; S; SLA

perindopril

erbumine

1 M

phenoxybenzamine 1

phentolamine 6 MSD

pindolol 1 M

prazosin 1 M

PRESTALIA 3 ST; M

PRINIVIL 3 M

PROCARDIA 3 ST; M

PROCARDIA XL 3 ST; M

propranolol 1 M



38

Drug Name Drug

Category

Requirements

/ Limits

propranolol-

hydrochlorothiazid

1 M

QBRELIS 3 M

quinapril 1 M

quinapril-

hydrochlorothiazide

1 M

ramipril 1 M

REMODULIN 6 MSD

SODIUM

EDECRIN

6 MSD

spironolactone 1 M

spironolacton-

hydrochlorothiaz

1 M

SULAR 3 ST; M

TARKA 3 M

taztia xt 1 M

TEKTURNA 2 M

TEKTURNA HCT 2 M

telmisartan 1 M

telmisartan-

amlodipine

1 M

telmisartan-

hydrochlorothiazid

1 M

TENORETIC 100 3 ST; M

TENORETIC 50 3 ST; M

TENORMIN 3 ST; M

terazosin 1 M; QL

TIAZAC 3 M

timolol maleate 1 M

TOPROL XL 3 ST; M

torsemide 1 M

trandolapril 1 M

Drug Name Drug

Category

Requirements

/ Limits

trandolapril-

verapamil

1 M

triamterene-

hydrochlorothiazid

1 M

TRIBENZOR 3 ST; M

TWYNSTA 3 ST; M

UPTRAVI 3 PA; S; SLA

valsartan 1 M

valsartan-

hydrochlorothiazide

1 M

VASERETIC 3 M

VASOTEC 3 M

veletri 6 MSD

verapamil

intravenous

6 MSD

verapamil oral 1 M

VERELAN 3 ST; M

VERELAN PM 3 ST; M

ZESTORETIC 3 M

ZESTRIL 3 M

ZIAC 3 ST; M

CARDIAC GLYCOSIDES

digitek 1 M

digox 1 M

digoxin injection 6 MSD

digoxin oral 1 M

LANOXIN

INJECTION

6 MSD

LANOXIN ORAL 3 M

LANOXIN

PEDIATRIC

6 MSD

COAGULATION THERAPY

ADVATE 6 MSD



39

Drug Name Drug

Category

Requirements

/ Limits

ADYNOVATE 6 MSD

AFSTYLA 6 MSD

AGGRENOX 3 M

ALPHANATE 6 MSD

ALPHANINE SD 6 MSD

ALPROLIX 6 MSD

AMICAR 2

ANGIOMAX 6 MSD

ARGATROBAN 6 MSD

ARGATROBAN IN

0.9 % SOD CHLOR

6 MSD

ARGATROBAN IN

NACL (ISO-OS)

6 MSD

ARIXTRA 3

aspirin-dipyridamole 1 M

BEBULIN 6 MSD

BENEFIX 6 MSD

BEVYXXA 3

bivalirudin 6 MSD

BRILINTA 2 M

CEPROTIN (BLUE

BAR)

6 MSD

CEPROTIN

(GREEN BAR)

6 MSD

cilostazol 1 M

clopidogrel oral

tablet 300 mg

1

clopidogrel oral

tablet 75 mg

1 M

COAGADEX 6 MSD

CORIFACT 6 MSD

COUMADIN 3

DEFITELIO 6 MSD

Drug Name Drug

Category

Requirements

/ Limits

dipyridamole 1 M

DURLAZA 3 ST; M

EFFIENT 3 M

ELIQUIS 2 PA

ELOCTATE 6 MSD

enoxaparin

subcutaneous

solution

6 MSD

enoxaparin

subcutaneous

syringe

1

FEIBA NF 6 MSD

fondaparinux 1

FRAGMIN 2

HELIXATE FS 6 MSD

HEMOFIL M HIGH 6 MSD

HEMOFIL M LOW 6 MSD

HEMOFIL M MID 6 MSD

HEMOFIL M

SUPER HIGH

6 MSD

hep flush-10 (pf) 1

heparin (porcine) 1

HEPARIN

(PORCINE) IN

0.9% NACL

6 MSD

heparin (porcine) in

5 % dex

6 MSD

heparin (porcine) in

nacl (pf)

1

heparin

flush(porcine)-

0.9nacl

6 MSD

heparin lock flush 1

heparin lock flush

(porcine)

1



40

Drug Name Drug

Category

Requirements

/ Limits

heparin

lockflush(porcine)(pf

)

1

heparin, porcine (pf) 1

HUMATE-P 6 MSD

IDELVION 6 MSD

IPRIVASK 6 MSD

IXINITY 6 MSD

jantoven 1

KOATE 6 MSD

KOGENATE FS 6 MSD

KOVALTRY 6 MSD

LOVENOX

SUBCUTANEOUS

SOLUTION

6 MSD

LOVENOX

SUBCUTANEOUS

SYRINGE

3 ST

MEPHYTON 2

MONOCLATE-P 6 MSD

MONONINE 6 MSD

NOVOEIGHT 6 MSD

NOVOSEVEN RT 6 MSD

NPLATE 6 MSD

NUWIQ 6 MSD

OBIZUR 6 MSD

pentoxifylline 1 M

PLAVIX ORAL

TABLET 300 MG

3 ST

PLAVIX ORAL

TABLET 75 MG

3 ST; M

PRADAXA 3 PA; M

prasugrel 1 M

PRAXBIND 6 MSD

Drug Name Drug

Category

Requirements

/ Limits

PROFILNINE 6 MSD

PROMACTA 2 PA

RECOMBINATE 6 MSD

RIASTAP 6 MSD

RIXUBIS 6 MSD

SAVAYSA 3 PA

ticlopidine 1 M

tranexamic acid 6 MSD

TRETTEN 6 MSD

VONVENDI 6 MSD

warfarin 1

WILATE 6 MSD

XARELTO 2 PA

XYNTHA 6 MSD

XYNTHA

SOLOFUSE

6 MSD

YOSPRALA 3 ST; M

ZONTIVITY 2 PA; M

LIPID/CHOLESTEROL LOWERING

AGENTS

ALTOPREV 3 ST; M; QL

amlodipine-

atorvastatin

1 M; QL

ANTARA 3 ST; M; QL

atorvastatin 1 M; QL

CADUET 3 ST; M; QL

cholestyramine (with

sugar)

1 M

cholestyramine light 1 M

COLESTID 3 ST; M

COLESTID

FLAVORED

3 ST; M



41

Drug Name Drug

Category

Requirements

/ Limits

colestipol 1 M

CRESTOR 3 ST; M; QL

ezetimibe 1 ST; M

ezetimibe-

simvastatin

1 M; QL

fenofibrate

micronized

1 M; QL

fenofibrate

nanocrystallized

1 M; QL

FENOFIBRATE

ORAL CAPSULE

3 ST; M; QL

fenofibrate oral

tablet

1 M; QL

fenofibric acid 1 M; QL

fenofibric acid

(choline)

1 M; QL

FENOGLIDE 3 ST; M; QL

FIBRICOR 3 ST; M; QL

FLOLIPID 3 ST; M

fluvastatin 1 M; QL

gemfibrozil 1 M; QL

JUXTAPID ORAL

CAPSULE 10 MG,

20 MG, 5 MG

2 PA; SLA; QL

JUXTAPID ORAL

CAPSULE 30 MG,

40 MG, 60 MG

2 PA; SLA

KYNAMRO 4 PA; S; SLA;

QL

LESCOL XL 3 ST; M; QL

LIPITOR 3 ST; M; QL

LIPOFEN 2 ST; M; QL

LIVALO 2 ST; M; QL

LOPID 3 M; QL

Drug Name Drug

Category

Requirements

/ Limits

lovastatin 1 M; QL

LOVAZA 3 PA; M

niacin 1 M

NIACOR 3 M

NIASPAN

EXTENDED-

RELEASE

3 M

omega-3 acid ethyl

esters

1 PA; M

PRALUENT PEN 3 PA; S; SLA

PRAVACHOL 3 ST; M; QL

pravastatin 1 M; QL

prevalite 1 M

QUESTRAN 3 ST; M

QUESTRAN

LIGHT

3 ST; M

REPATHA

PUSHTRONEX

3 PA; S; SLA

REPATHA

SURECLICK

3 PA; S; SLA

REPATHA

SYRINGE

3 PA; S; SLA

rosuvastatin 1 M; QL

simvastatin 1 M; QL

TRICOR 3 ST; M; QL

TRIGLIDE 3 ST; M; QL

triklo 1 PA; M

TRILIPIX 3 ST; M; QL

VASCEPA 2 PA; M

VYTORIN 10-10 3 ST; M; QL






42

Drug Name Drug

Category

Requirements

/ Limits

WELCHOL 2 ST; M

ZETIA 3 ST; M

ZOCOR 3 ST; M; QL

MISCELLANEOUS

CARDIOVASCULAR AGENTS

CORLANOR 2 PA; M

ENTRESTO 2 PA; M

NIPRIDE RTU 6 MSD

RANEXA 2 M

VECAMYL 3 SLA

NITRATES

DILATRATE-SR 2 M

GONITRO 3

ISOCHRON 3 M

ISORDIL 3 M

ISORDIL

TITRADOSE

3 M

isosorbide dinitrate 1 M

isosorbide

mononitrate

1 M

MINITRAN 3 M

nitro-bid 1 M

NITRO-DUR 3 M

nitroglycerin oral 1 M

nitroglycerin

sublingual

1

nitroglycerin

transdermal

1 M

nitroglycerin

translingual

1

NITROLINGUAL 3

NITROMIST 3

NITROSTAT 3

Drug Name Drug

Category

Requirements

/ Limits

nitro-time 1 M

DERMATOLOGICALS/TOPICA

L THERAPY

ANTIPSORIATIC /

ANTISEBORRHEIC

acitretin 1

ANALPRAM-HC 3 ST

calcipotriene 1 QL

calcipotriene-

betamethasone

1 QL

calcitrene 1 QL

calcitriol 1 QL

COAL TAR 2

COSENTYX 3 ST; S; SLA;

QL

COSENTYX (2

SYRINGES)

3 ST; S; SLA;

QL

COSENTYX PEN 3 ST; S; SLA;

QL

COSENTYX PEN

(2 PENS)

3 ST; S; SLA;

QL

DOVONEX 3 QL

drithocreme hp 1

ENSTILAR 2

EPIFOAM 3 ST

hydrocortisone-

pramoxine

1

OVACE 3

OVACE PLUS

SHAMPOO

3

OVACE PLUS

TOPICAL

CLEANSER,EXTE

NDED RELEASE

3



43

Drug Name Drug

Category

Requirements

/ Limits

OVACE PLUS

TOPICAL CREAM

3 ST

OVACE PLUS

TOPICAL FOAM

3

OVACE PLUS

TOPICAL LOTION

3 ST

OVACE PLUS

WASH

3

PRAMOSONE 3 ST

PRAMOSONE E 3 ST

seb-prev 1

selenium sulfide 1

SELRX 3

SILIQ 4 ST; S

SORIATANE 3

SORILUX 3 QL

STELARA 6 MSD

sulfacetamide

sodium

1

TACLONEX

TOPICAL

OINTMENT

3 QL

TACLONEX

TOPICAL

SUSPENSION

2

TALTZ

AUTOINJECTOR

4 ST; S; SLA

TALTZ

AUTOINJECTOR

(2 PACK)

4 ST; S; SLA

TALTZ

AUTOINJECTOR

(3 PACK)

4 ST; S; SLA

TALTZ SYRINGE 4 ST; S; SLA

TALTZ SYRINGE

(2 PACK)

4 ST; S; SLA

Drug Name Drug

Category

Requirements

/ Limits

TALTZ SYRINGE

(3 PACK)

4 ST; S; SLA

TERSI FOAM 3

TREMFYA 4 ST; S

VECTICAL 3 QL

ZITHRANOL 3

BURN THERAPY

SILVADENE 3

silver sulfadiazine 1

ssd 1

thermazene 1

KERATOLYTICS

BENSAL HP 3

INOVA 4-1 3 ST

KERALYT RX 3

PODOCON 3

POTASSIUM

HYDROXIDE

3

SALEX 3

salicylic acid 1

SALKERA 3

salvax 1

SALVAX DUO

PLUS

3

ULTRASAL-ER 3

VIRASAL 3

MISCELLANEOUS

DERMATOLOGICALS

ALEVICYN PLUS 3

AMELUZ 6 MSD

ATOPICLAIR 3

ATRAPRO CP 3



44

Drug Name Drug

Category

Requirements

/ Limits

ATRAPRO

HYDROGEL

3

avo cream 1

BIAFINE

EMULSION

3

bp-50% urea 1

CARAC 2

celacyn 1

CONDYLOX 3

CORTANE-B 3

DEXERYL 3

diclofenac sodium 1 PA

doxepin 1

DUPIXENT 3 PA; S

EFUDEX 3

eletone 1

ELIDEL 2 ST; QL

EPICERAM 3

EUCRISA 3 PA; ST; QL

FLUOROPLEX 3

FLUOROURACIL

TOPICAL CREAM

0.5 %

3 ST

fluorouracil topical

cream 5 %

1

fluorouracil topical

solution

1

GORDONS UREA 3

hpr 1

hpr plus 1

hpr plus hydrogel 1

HPR PLUS-MB

HYDROGEL

3

Drug Name Drug

Category

Requirements

/ Limits

HYDRO 35 3

HYDRO 40 3

HYLATOPIC 3

HYLATOPICPLUS 3

KERAFOAM 3

KERALAC 3

LEVULAN 6 MSD

LOUTREX 3

luxamend 1

methoxsalen 1

NEOSALUS 3

nivatopic plus 1

NUTRASEB 3

OXSORALEN

ULTRA

3

PANRETIN 3

PICATO 2 QL

podofilox 1

PRESERA 3

PROMISEB 3

PROTOPIC 3 ST; QL

pruclair 1

prudoxin 1

prumyx 1

prutect 1

QUTENZA 6 MSD

rea lo 39 1

rea lo 40 1

REGRANEX 2 QL

RESTIZAN 3

silver nitrate 1



45

Drug Name Drug

Category

Requirements

/ Limits

silver nitrate

applicators

1

SOLARAZE 3 PA

sonafine 1

sp antipruritic 1

sp scar management 1

tacrolimus 1 ST; QL

TOLAK 3

umecta 1

urea 1

urea nail stick 1

UTOPIC 3

VALCHLOR 3 S; SLA

VEREGEN 3

XCLAIR 3

ZONALON 3

THERAPY FOR ACNE

ABSORICA 2 QL

ACANYA 2 ST; QL

ACZONE 3 ST

adapalene topical

cream

1 QL

adapalene topical

gel

1 QL

adapalene topical

gel with pump

1 QL

ADAPALENE

TOPICAL LOTION

3 ST; QL

adapalene-benzoyl

peroxide

1 QL

AKTIPAK 3 ST

amnesteem 1 QL

ATRALIN 3 QL

Drug Name Drug

Category

Requirements

/ Limits

AVAR LS 3 ST

avar topical cleanser 1

AVAR TOPICAL

FOAM

3 ST

AVAR TOPICAL

PADS,

MEDICATED

3 ST

AVAR-E GREEN 3 ST

AVAR-E LS 3 ST

avita topical cream 1 QL

AVITA TOPICAL

GEL

3 QL

AZELEX 3 ST; QL

BENZACLIN 3 ST

BENZACLIN

PUMP

3 ST; QL

BENZAMYCIN 3 ST

BENZEFOAM 3 ST

BENZEFOAM

ULTRA

3 ST

benzepro 1

bp 10-1 1

bpo 1

claravis 1 QL

cleansing wash 1

CLEOCIN T 3 ST

CLINDACIN ETZ 3 ST

clindacin p 1

CLINDACIN PAC 3 ST

CLINDAGEL 3 ST

clindamycin

phosphate

1



46

Drug Name Drug

Category

Requirements

/ Limits

clindamycin-benzoyl

peroxide topical gel

1.2 %(1 % base) -5

%

1 QL

clindamycin-benzoyl


1-5 %

1

clindamycin-benzoyl


with pump

1 QL

clindamycin-

tretinoin

1

DIFFERIN 3 ST; QL

DUAC 3 ST; QL

EPIDUO 2 ST; QL

EPIDUO FORTE 2 ST

ery pads 1

erygel 1

erythromycin with

ethanol

1

erythromycin-

benzoyl peroxide

1

EVOCLIN 3 ST

FABIOR 3 PA; QL

FINACEA 2 ST

INOVA 3 ST

METROCREAM 3 ST

METROGEL 3 ST

METROLOTION 3 ST

metronidazole 1

MIRVASO 2

neuac 1 QL

NEUAC KIT 3 ST

NORITATE 3 ST

Drug Name Drug

Category

Requirements

/ Limits

NUOX 3 ST

ONEXTON 2 ST; QL

PLEXION 3 ST

PLEXION

CLEANSING

CLOTHS

3 ST

RETIN-A MICRO 3

RETIN-A MICRO

PUMP

3

RETIN-A TOPICAL

CREAM 0.025 %

3 QL

RETIN-A TOPICAL

CREAM 0.05 %, 0.1

%

3

RETIN-A TOPICAL

GEL 0.01 %

3

RETIN-A TOPICAL

GEL 0.025 %

3 QL

RHOFADE 3

rosadan topical

cream

1

rosadan topical gel 1

ROSADAN

TOPICAL KIT,

CLEANSER AND

GEL

3 ST

ROSADAN

TOPICAL

KIT,CLEANSER

AND CREAM

3 ST

ROSANIL 3 ST

ROSULA 3 ST

rosula cleansing

cloths

1

SOOLANTRA 2 ST

sss 10-5 1



47

Drug Name Drug

Category

Requirements

/ Limits

sulfacetamide

sodium-sulfur

1

sulfacetamide sod-

sulfur-urea

1

sulfacleanse 8-4 1

SUMADAN 3 ST

SUMAXIN 3 ST

SUMAXIN TS 3 ST

tazarotene 1 PA; QL

TAZORAC

TOPICAL CREAM

0.05 %

2 PA; QL

TAZORAC

TOPICAL CREAM

0.1 %

3 PA; QL

TAZORAC

TOPICAL GEL

2 PA; QL

tretinoin

microspheres

1

tretinoin topical

cream 0.025 %

1 QL

tretinoin topical

cream 0.05 %, 0.1 %

1

tretinoin topical gel

0.01 %

1

tretinoin topical gel

0.025 %, 0.05 %

1 QL

TRETIN-X 3

TRETIN-X CREAM

KIT

3

VANOXIDE-HC 3 ST

VELTIN 3 ST

zenatane 1 QL

ZIANA 3 ST

TOPICAL ANESTHETICS

Drug Name Drug

Category

Requirements

/ Limits

AGONEAZE 3

ANASTIA 3

ANODYNE LPT 3

ASTERO 3

BUCALSEP 3

cidaleaze 1

DERMACINRX

EMPRICAINE

3

DOLOTRANZ 3

ethyl chloride 1

glydo 1

LDO PLUS 3

LEVA SET 3

lidocaine (pf) 6 MSD

lidocaine hcl

injection

6 MSD

lidocaine hcl

laryngotracheal

1

lidocaine hcl mucous

membrane

1

lidocaine hcl topical 1

lidocaine hcl-

hydrocortison ac

1

lidocaine topical

adhesive

patch,medicated

1 PA

lidocaine topical

ointment

1

lidocaine viscous 1

lidocaine-prilocaine 1

LIDOCAINE-

TETRACAINE

3 ST

LIDODERM 3 PA

LIDOPAC 3



48

Drug Name Drug

Category

Requirements

/ Limits

lidopin topical

cream 3 %

1

LIDOPIN TOPICAL

CREAM 3.25 %

3

LIDO-PRILO

CAINE PACK

3

LIDORX 3

LIDOTRAL 3

LIDTOPIC MAX 3

LIPROZONEPAK 3

lta pre-attached 1

MEDOLOR PAK 3

NUMBONEX 3

P-CARE X (PF) 6 MSD

PLIAGLIS 3

PRILOLID 3

READYSHARP

LIDOCAINE (PF)

6 MSD

relador pak 1

relador pak plus 1

SYNERA 3

TRANZAREL 3

XYLOCAINE 6 MSD

XYLOCAINE-MPF 6 MSD

ZINGO 6 MSD

TOPICAL ANTIBACTERIALS

ALTABAX 3

BACTROBAN 3

CENTANY 3

CENTANY AT 3

CORTISPORIN 3

gentamicin 1

Drug Name Drug

Category

Requirements

/ Limits

hydrocortisone-

iodoquinol-aloe

1

iodoquinol-hc 1

KLARON 3 ST

lugols 1

mupirocin 1

mupirocin calcium 1

NEO-SYNALAR 3

NEO-SYNALAR

KIT

3

SILVRSTAT 3

sulfacetamide

sodium (acne)

1

SULFAMYLON 2

TOPICAL ANTIFUNGALS

ciclodan 1

CICLODAN KIT

TOPICAL COMBO

PACK

3

CICLODAN KIT

TOPICAL

SOLUTION

3 ST

ciclopirox 1

clotrimazole-

betamethasone

1

econazole 1

ECOZA 3

ERTACZO 3

EXELDERM 3

EXODERM 3

EXTINA 3

JUBLIA 3 ST; QL

KERYDIN 3 ST; QL



49

Drug Name Drug

Category

Requirements

/ Limits

ketoconazole 1

LOPROX 3

LOPROX (AS

OLAMINE)

3

LOPROX KIT 3

LOTRISONE 3

LUZU 3 QL

naftifine 1

NAFTIN 3

NIZORAL 3

nyamyc 1

nyata 1

nystatin 1

nystatin-

triamcinolone

1

nystop 1

oxiconazole 1

OXISTAT 3

PENLAC 3 ST

TRIACETIN 2

TRIPLE DYE 3

VUSION 3

XOLEGEL 3

TOPICAL ANTIVIRALS

acyclovir 1 QL

DENAVIR 3

XERESE 3

ZOVIRAX

TOPICAL CREAM

2 QL

ZOVIRAX

TOPICAL

OINTMENT

3 QL

Drug Name Drug

Category

Requirements

/ Limits

TOPICAL CORTICOSTEROIDS

ala-cort 1

ALA-SCALP 3 ST

alclometasone 1

amcinonide 1

apexicon e 1 QL

AQUA GLYCOLIC

HC

3 ST

betamethasone

dipropionate

1

betamethasone

valerate

1

betamethasone,

augmented

1

CAPEX 3 ST; QL

clobetasol 1

clobetasol-emollient 1

CLOBEX 3 ST

CLOCORTOLONE

PIVALATE

3 ST; QL

clodan 1

CLODAN KIT 3 ST

CLODERM 3 ST; QL

CORDRAN 3 ST

CORDRAN TAPE

LARGE ROLL

3 ST

cormax 1

CUTIVATE 3 ST

DERMA-

SMOOTHE/FS

BODY OIL

3 ST; QL

DERMA-

SMOOTHE/FS

SCALP OIL

3 ST; QL



50

Drug Name Drug

Category

Requirements

/ Limits

DERMATOP 3 ST

DESONATE 3 ST

desonide 1 QL

DESOWEN 3 ST; QL

desoximetasone 1 QL

diflorasone 1 QL

DIPROLENE 3 ST

ELLZIA PAK 3

ELOCON 3 ST

fluocinolone 1 QL

fluocinolone and

shower cap

1 QL

fluocinonide 1

fluocinonide-e 1

fluocinonide-

emollient

1

flurandrenolide 1

fluticasone 1

halobetasol

propionate

1 QL

HALOG 3 ST

hydrocortisone 1

hydrocortisone

butyrate

1

hydrocortisone

butyr-emollient

1

hydrocortisone

valerate

1

hydrocortisone-min

oil-wht pet

1

KENALOG 3 ST

LOCOID 3 ST

LOCOID

LIPOCREAM

3 ST

Drug Name Drug

Category

Requirements

/ Limits

LUXIQ 3 ST

mometasone 1

nolix 1

OLUX 3 ST

OLUX-E 3 ST

PANDEL 3 ST

prednicarbate 1

PSORCON 3 ST; QL

scalacort 1

SERNIVO 3 ST

SYNALAR 3 ST; QL

SYNALAR

CREAM KIT

3 ST

SYNALAR

OINTMENT KIT

3 ST

SYNALAR TS 3 ST

TEMOVATE 3 ST

TEXACORT 3 ST

TOPICORT

TOPICAL CREAM

3 ST; QL

TOPICORT

TOPICAL GEL

3 ST; QL

TOPICORT

TOPICAL

OINTMENT

3 ST; QL

TOPICORT

TOPICAL

SPRAY,NON-

AEROSOL

3 ST

triamcinolone

acetonide

1

trianex 1

triderm 1

TRIDESILON 3 ST; QL



51

Drug Name Drug

Category

Requirements

/ Limits

ULTRAVATE

TOPICAL CREAM

3 ST; QL

ULTRAVATE

TOPICAL LOTION

3 ST

ULTRAVATE

TOPICAL

OINTMENT

3 ST; QL

ULTRAVATE X 3 ST

VANOS 3 ST

VERDESO 3 ST

TOPICAL ENZYMES

SANTYL 2

TOPICAL SCABICIDES /

PEDICULICIDES

ELIMITE 3

EURAX 3

lindane 1

malathion 1

NATROBA 3 QL

OVIDE 3

permethrin 1

SKLICE 3

spinosad 1 QL

ULESFIA 3

DIAGNOSTICS &

MISCELLANEOUS AGENTS

IRRIGATING SOLUTIONS

lactated ringers 1

PHYSIOLYTE 3

PHYSIOSOL

IRRIGATION

3

ringer's 1

Drug Name Drug

Category

Requirements

/ Limits

SORBITOL-

MANNITOL

3

tis-u-sol pentalyte 1

VASHE WOUND

THERAPY

3


acamprosate 1

ACTONEL 3 ST; QL

ADAGEN 6 MSD

AGRYLIN 3 M

alendronate 1 M; QL

AMMONUL 6 MSD

AMPHADASE 6 MSD

anagrelide 1 M

ANTABUSE 3

ARALAST NP 6 MSD

BUPHENYL ORAL

POWDER

3

BUPHENYL ORAL

TABLET

2

caffeine citrate 1

CARBAGLU 3 PA; S; SLA

CARNITOR 3 M

CARNITOR

(SUGAR-FREE)

3 M

cevimeline 1 M

CHEMET 2

disulfiram 1

ENDARI 3

etidronate disodium 1 M

EVOXAC 3 M

EXJADE 3 S; SLA

FERRIPROX 3 S; SLA



52

Drug Name Drug

Category

Requirements

/ Limits

FERRLECIT 6 MSD

GLASSIA 6 MSD

ic green 6 MSD

INCRELEX 3 PA; S; SLA

indocyanine green 6 MSD

INFASURF 3

JADENU 3 S

JADENU

SPRINKLE

3 S

KIT PREP OF TC-

99M-

MEBROFENIN

6 MSD

levocarnitine 1 M

levocarnitine (with

sugar)

1 M

LIPOCHOL PLUS 3

LITHOSTAT 3

METOPIRONE 3 SLA

midodrine 1

NITYR 2 SLA

NORTHERA 4 PA; S; SLA

NUTRESTORE 3

ORFADIN 2 SLA

pilocarpine hcl 1

PROLASTIN-C 6 MSD

RADIOGARDASE 6 MSD

RAVICTI 3 S; SLA

RECLAST 6 MSD

RILUTEK 3

riluzole 1

risedronate 1 QL

SALAGEN

(PILOCARPINE)

3

Drug Name Drug

Category

Requirements

/ Limits

sodium benzoate-sod

phenylacet

6 MSD

sodium chlor 0.9%

bacteriostat

6 MSD

sodium chloride 0.9

%

6 MSD

sodium ferric

gluconat-sucrose

6 MSD

sodium

phenylbutyrate

1

SOLIRIS 6 MSD

SURVANTA 6 MSD

SYPRINE 3 PA

THIOLA 3 SLA

water for irrigation,

sterile

1

XURIDEN 2 SLA

ZEMAIRA 6 MSD

zoledronic acid-

mannitol-water

6 MSD

SMOKING DETERRENTS

bupropion hcl

(smoking deter)

5 M; ACA

CHANTIX 2

CHANTIX

CONTINUING

MONTH BOX

2

CHANTIX

STARTING

MONTH BOX

2

NICODERM CQ

TRANSDERMAL

PATCH 24 HOUR

14 MG/24 HR, 7

MG/24 HR

2 OTC



53

Drug Name Drug

Category

Requirements

/ Limits

NICODERM CQ

TRANSDERMAL

PATCH 24 HOUR

21 MG/24 HR

2 M; OTC

nicorelief 5 ACA; OTC

NICORETTE

BUCCAL GUM 2

MG

2 OTC

nicorette buccal gum

4 mg

5 ACA; OTC

NICORETTE

BUCCAL

LOZENGE

2 OTC

NICORETTE

BUCCAL MINI

LOZENGE

2 OTC

nicotine (polacrilex) 5 ACA; OTC

nicotine transdermal

patch 24 hour 14

mg/24 hr, 7 mg/24

hr

5 ACA; OTC


patch 24 hour 21

mg/24 hr

5 M; ACA; OTC


patch, td daily,

sequential

5 ACA; OTC

NICOTROL 5 ACA

NICOTROL NS 5 ACA

nts step 1 5 M; ACA; OTC

quit 2 buccal gum 5 ACA; OTC

QUIT 2 BUCCAL

LOZENGE

2 OTC

quit 4 buccal gum 5 ACA; OTC

QUIT 4 BUCCAL

LOZENGE

2 OTC

stop smoking aid 5 ACA; OTC

Drug Name Drug

Category

Requirements

/ Limits

ZYBAN 5 M; ACA

EAR, NOSE & THROAT

MEDICATIONS


ARESTIN 6 MSD

ASTEPRO 3

azelastine nasal

aerosol,spray

1 QL

azelastine nasal

spray,non-aerosol

1

BACTROBAN

NASAL

3

chlorhexidine

gluconate

1

CLINPRO 5000 3 M

DEBACTEROL 3

denta 5000 plus 1 M

dentagel 1 M

EPISIL 3

fluoride (sodium) 1 M

FLUORIDEX

DAILY DEFENSE

3 M

GELCLAIR 3

ipratropium bromide 1 QL

MUGARD 3

olopatadine 1 QL

oralone 1

ORAMAGICRX 3

paroex oral rinse 1

PATANASE 3 QL

PERIDEX 3

periogard 1

pilocarpine hcl 1



54

Drug Name Drug

Category

Requirements

/ Limits

PREVIDENT 3 M

PREVIDENT 5000

BOOSTER PLUS

3 M

PREVIDENT 5000

DRY MOUTH

3 M

PREVIDENT 5000

ENAMEL

PROTECT

3 M

PREVIDENT 5000

PLUS

3 M

PREVIDENT 5000

SENSITIVE

3 M

Q-CARE RX Q4 3

SALAGEN

(PILOCARPINE)

3

sf 1 M

sf 5000 plus 1 M

triamcinolone

acetonide

1

TYZINE 3

MISCELLANEOUS OTIC

PREPARATIONS

acetic acid 1

CETRAXAL 3 ST

ciprofloxacin hcl 1

DERMOTIC OIL 3

floxin 1

fluocinolone

acetonide oil

1

hydrocortisone-

acetic acid

1

ofloxacin 1

OTIPRIO 3

OTIC STEROID / ANTIBIOTIC

Drug Name Drug

Category

Requirements

/ Limits

CIPRO HC 3

CIPRODEX 2

COLY-MYCIN S 3

neomycin-

polymyxin-hc

1

OTOVEL 2

ENDOCRINE/DIABETES

ADRENAL HORMONES

ACTHAR H.P. 6 MSD

ARZE-JECT-A 6 MSD

betamethasone

acet,sod phos

6 MSD

CELESTONE

SOLUSPAN

6 MSD

CORTEF 3 M

cortisone 1

CORTROSYN 6 MSD

cosyntropin 6 MSD

CUSHINGS

SYNDROME

DIAGNOSTIC

6 MSD

deltasone 1

dexamethasone 1

dexamethasone

intensol

1

dexamethasone

sodium phos (pf)

6 MSD

dexamethasone

sodium phosphate

6 MSD

DEXPAK 10 DAY 3 ST

DEXPAK 13 DAY 3 ST

DEXPAK 6 DAY 3 ST

EMFLAZA 3 PA; SLA



55

Drug Name Drug

Category

Requirements

/ Limits

fludrocortisone 1 M

hydrocortisone 1 M

KENALOG 6 MSD

LOCORT 3 ST

MEDROL 3

MEDROL (PAK) 3

methylprednisolone 1

millipred dp 1

MILLIPRED ORAL

SOLUTION

3

millipred oral tablet 1

ORAPRED ODT 3

P-CARE K40 6 MSD

P-CARE K80 6 MSD

PEDIAPRED 3

POD-CARE 100K 6 MSD

prednisolone 1

prednisolone sodium

phosphate

1

prednisone 1

prednisone intensol 1

PRO-C-DURE 5 6 MSD

PRO-C-DURE 6 6 MSD

RAYOS 3 ST

READYSHARP

DEXAMETHASON

E

6 MSD

READYSHARP

TRIAMCINOLONE

6 MSD

triamcinolone

acetonide

6 MSD

veripred 20 1

ZONACORT 3 ST

Drug Name Drug

Category

Requirements

/ Limits

ANTITHYROID AGENTS

methimazole 1 M

propylthiouracil 1 M

SSKI 3 M

TAPAZOLE 3 M

BLOOD GLUCOSE MONITORING

DEVICES & SUPPLIES

ACCU-CHEK

AVIVA PLUS

TEST STRP

3 ST; OTC

ACCU-CHEK

COMPACT PLUS

TEST

3 ST; OTC

ACCU-CHEK

GUIDE

3 ST; OTC

ACCU-CHEK

SMARTVIEW

TEST STRIP

3 ST; OTC

ACCUTREND

GLUCOSE

3 ST; OTC

ADVANCED

GLUC METER

TEST STRIP

3 ST; OTC

ADVOCATE REDI-

CODE

3 ST; OTC

ADVOCATE TEST

STRIPS

3 ST; OTC

AGAMATRIX

AMP TEST STRIPS

3 ST; OTC

ASSURE 4 STRIPS 3 ST; OTC

ASSURE

PLATINUM

3 ST; OTC

ASSURE PRISM

MULTI STRIP

3 ST; OTC

BIONIME

RIGHTEST TEST

STRIPS

3 ST; OTC



56

Drug Name Drug

Category

Requirements

/ Limits

BLOOD GLUCOSE

TEST

3 ST; OTC

BREEZE 2 TEST

STRIPS

3 ST; OTC

CARESENS N

TEST STRIPS

3 ST; OTC

CLEVER CHOICE

MICRO TEST

STRIP

3 ST; OTC

CLEVER CHOICE

PRO

3 ST; OTC

CLEVER CHOICE

TEST STRIPS

3 ST; OTC

CLEVER CHOICE

VOICE+ TEST

3 ST; OTC

CONTOUR NEXT

STRIPS

3 ST; OTC

CONTOUR TEST

STRIPS

3 ST; OTC

COOL GLUCOSE

TEST STRIP

3 ST; OTC

DIATRUE PLUS

TEST STRIP

3 ST; OTC

EASY PLUS II

TEST

3 ST; OTC

EASY STEP 3 ST; OTC

EASY TALK

GLUCOSE TEST

3 ST; OTC

EASY TOUCH

TEST STRIP

3 ST; OTC

EASY TRAK

GLUCOSE TEST

3 ST; OTC

EASYGLUCO

PLUS

3 ST; OTC

EASYGLUCO

TEST

3 ST; OTC

EASYMAX 3 ST; OTC

Drug Name Drug

Category

Requirements

/ Limits

ELEMENT

COMPACT TEST

STRIPS

3 ST; OTC

ELEMENT TEST

STRIPS

3 ST; OTC

EMBRACE

BLOOD GLUCOSE

SYSTEM

3 ST; OTC

EMBRACE EVO

TEST STRIPS

3 ST; OTC

EMBRACE PRO

TEST STRIPS

3 ST; OTC

EVENCARE G2 3 ST; OTC

EVENCARE G3

TEST

3 ST; OTC

EVENCARE MINI

GLUCOSE TEST

STR

3 ST; OTC

EVOLUTION TEST

STRIPS

3 ST; OTC

EZ SMART PLUS

TEST

3 ST; OTC

EZ SMART TEST 3 ST; OTC

FIFTY50 TEST

STRIP

3 ST; OTC

FORA D15G 3 ST; OTC

FORA D20 3 ST; OTC

FORA D40-G31

TEST STRIPS

3 ST; OTC

FORA G20 3 ST; OTC

FORA G30A 3 ST; OTC

FORA GD50 TEST

STRIPS

3 ST; OTC

FORA TEST STRIP 3 ST; OTC

FORA TN'G VOICE

TEST STRIPS

3 ST; OTC



57

Drug Name Drug

Category

Requirements

/ Limits

FORA V10 3 ST; OTC

FORA V10-V12-

D10-D20 STRIPS

3 ST; OTC

FORA V12

GLUCOSE

3 ST; OTC

FORA V20 3 ST; OTC

FORACARE GD20 3 ST; OTC

FORACARE GD40 3 ST; OTC

FORTISCARE

GLUCOSE TEST

STRIPS

3 ST; OTC

FREESTYLE

INSULINX

3 ST; OTC

FREESTYLE

INSULINX TEST

STRIPS

3 ST; OTC

FREESTYLE LITE

STRIPS

3 ST; OTC

FREESTYLE

PRECISION NEO

STRIPS

3 ST; OTC

FREESTYLE TEST 3 ST; OTC

GE100 BLOOD

GLUCOSE TEST

STRIP

3 ST; OTC

GENSTRIP TEST

STRIP

3 ST; OTC

GLUCO NAVII

TEST STRIP

3 ST; OTC

GLUCOCARD 01

SENSOR PLUS

3 ST; OTC

GLUCOCARD

EXPRESSION

3 ST; OTC

GLUCOCARD

SHINE TEST

STRIPS

3 ST; OTC

Drug Name Drug

Category

Requirements

/ Limits

GLUCOCARD

VITAL SENSOR

3 ST; OTC

GLUCOCARD

VITAL TEST

STRIPS

3 ST; OTC

GLUCOCOM

GLUCOSE

3 ST; OTC

GM100 3 ST; OTC

HEALTHPRO

TEST STRIPS

3 ST; OTC

INFINITY TEST

STRIPS

3 ST; OTC

MICRO BLOOD

GLUCOSE

3 ST; OTC

MICRODOT

BLOOD GLUCOSE

SYSTEM

3 ST; OTC

MYGLUCOHEALT

H

3 ST; OTC

NEUTEK 2TEK

TEST STRIPS

3 ST; OTC

NOVA MAX

GLUCOSE TEST

3 ST; OTC

ON CALL

EXPRESS TEST

STRIP

3 ST; OTC

ON CALL PLUS

TEST STRIP

3 ST; OTC

ON CALL VIVID

TEST STRIP

3 ST; OTC

ONETOUCH

ULTRA TEST

2 ST; OTC

ONETOUCH

VERIO

2 ST; OTC

OPTIUM EZ 3 ST; OTC

OPTIUM TEST 3 ST; OTC

OPTUMRX 3 ST; OTC



58

Drug Name Drug

Category

Requirements

/ Limits

PHARMACIST

CHOICE

3 ST; OTC

PRECISION PCX

PLUS TEST

3 ST; OTC

PRECISION PCX

TEST

3 ST; OTC

PRECISION POINT

OF CARE TEST

3 ST; OTC

PRECISION Q-I-D

TEST

3 ST; OTC

PRECISION XTRA

TEST

3 ST; OTC

PREMIUM V10 3 ST; OTC

PRODIGY NO

CODING

3 ST; OTC

QUINTET AC 3 ST; OTC

REFUAH PLUS 3 ST; OTC

RELION

CONFIRM-MICRO

3 ST; OTC

RELION PRIME

TEST STRIPS

3 ST; OTC

REVEAL TEST

STRIP

3 ST; OTC

RIGHTEST GS550

TEST STRIPS

3 ST; OTC

SMART SENSE

TEST STRIPS

3 ST; OTC

SMARTEST TEST 3 ST; OTC

SOLUS V2 TEST

STRIPS

3 ST; OTC

SURE-TEST

EASYPLUS MINI

3 ST; OTC

TELCARE TEST

STRIPS

3 ST; OTC

TEST N'GO TEST 3 ST; OTC

Drug Name Drug

Category

Requirements

/ Limits

TRUE METRIX

GLUCOSE TEST

STRIP

3 ST; OTC

TRUETEST TEST

STRIPS

3 ST; OTC

TRUETRACK

TEST

3 ST; OTC

ULTIMA TEST

STRIPS

3 ST; OTC

ULTRATRAK 3 ST; OTC

ULTRATRAK

ULTIMATE

3 ST; OTC

UNISTRIP1 TEST

STRIP

3 ST; OTC

WAVESENSE

JAZZ

3 ST; OTC

WAVESENSE

PRESTO

3 ST; OTC

DIABETES, SUPPLIES, & DURABLE

MEDICAL EQUIPMENT

GLUCAGEN

DIAGNOSTIC KIT

2

GLUCAGON HCL 3

INSULIN

SYRINGE-

NEEDLE U-100

2 M

GLUCOSE ELEVATING AGENTS

GLUCAGEN

HYPOKIT

2

GLUCAGON

EMERGENCY KIT

(HUMAN)

2

PROGLYCEM 2 M

INSULIN

SYRINGES/MISCELLANEOUS

DURABLE MEDICAL EQU



59

Drug Name Drug

Category

Requirements

/ Limits

2TEK

GLUCOSE/BLOOD

PRESSURE

3 OTC

ACCU-CHEK

AVIVA CONNECT

METER

3 ST; OTC

ACCU-CHEK

AVIVA PLUS

METER

3 ST; OTC

ACCU-CHEK

COMPACT PLUS

CONTROL

3 OTC

ACCU-CHEK

GUIDE GLUCOSE

METER

3 ST; OTC

ACCU-CHEK

GUIDE L1-L2

CTRL SOL

3 OTC

ACCU-CHEK

NANO

3 ST; OTC

ACCU-CHEK

SMARTVIEW

CONTRL SOL

3 OTC

ACCUTREND

GLUCOSE

CONTROL

3 OTC

ADVANCED

GLUCOSE METER

3 ST; OTC

ADVOCATE

BLOOD GLUCOSE

MONITOR

3 ST; OTC

ADVOCATE DUO 3 ST; OTC

ADVOCATE LOW

CONTROL

3 OTC

ADVOCATE REDI-

CODE DUO

METER

3 ST; OTC

Drug Name Drug

Category

Requirements

/ Limits

ADVOCATE REDI-

CODE GLU

MONITOR

3 ST; OTC

ADVOCATE REDI-

CODE+ CTRL

LOW

3 OTC

AGAMATRIX

AMP GLUC

MONITOR SYS

3 ST; OTC

AGAMATRIX

CONTROL HIGH

3 OTC

ASSURE 4

CONTROL

SOLUTION

3 OTC

ASSURE DOSE

NORMAL

CONTROL

3 OTC

ASSURE

PLATINUM

3 ST; OTC

ASSURE PRISM

CONTROL 1-2

SOLN

3 OTC

ASSURE PRISM

MULTI METER

3 ST; OTC

AUTOJECT 2

INJECTION

DEVICE

2 OTC

AUTOPEN 1 TO 21

UNITS

2 OTC

BIONIME

RIGHTEST GM300

SYSTEM

3 ST; OTC

BLOOD GLUCOSE

CONTROL,

NORMAL

3 OTC

BLOOD-GLUCOSE

METER

3 ST; OTC



60

Drug Name Drug

Category

Requirements

/ Limits

BREEZE 2

CONTROL

SOLUTION,HIGH

3 OTC

CARESENS

CONTROL A

NORMAL

3 OTC

CARESENS N 3 ST; OTC

CARESENS N

VOICE

3 ST; OTC

CLEO 90

INFUSION SET 24"

2

CLEVER CHEK

BLOOD GLUCOSE

3 ST; OTC

CLEVER CHOICE

GLUCOSE

MONITOR

3 ST; OTC

CLEVER CHOICE

LEVEL 2

CONTROL

3 OTC

CLEVER CHOICE

MICRO

3 ST; OTC

CLEVER CHOICE

PRO

3 ST; OTC

COMFORT SHORT

INSULIN PUMP

23"

2

CONTOUR

CONTROL

SOLUTION, NML

3 OTC

CONTOUR LINK 3 ST; OTC

CONTOUR NEXT

EZ METER

3 ST; OTC

CONTOUR NEXT

LEV 2 CONTROL

SOL

3 OTC

CONTOUR NEXT

LINK

3 OTC

Drug Name Drug

Category

Requirements

/ Limits

CONTOUR NEXT

METER

3 ST; OTC

CONTOUR NEXT

ONE METER

3 ST; OTC

CONTROL AST

MONITORING

SYSTEM

3 ST; OTC

COOL BLOOD

GLUCOSE METER

3 ST; OTC

COOL CONTROL

A SOLUTION

3 OTC

DEXCOM G5

RECEIVER

2

DEXCOM

RECEIVER

2

DIATRUE

CONTROL SOLN

NORMAL

3 OTC

DIATRUE PLUS

BLOOD GLUCOSE

MET

3 ST; OTC

EASY PLUS II

BLOOD GLUCOSE

MET

3 ST; OTC

EASY STEP

BLOOD GLUCOSE

METER

3 ST; OTC

EASY TALK

BLOOD GLUCOSE

METER

3 ST; OTC

EASY TOUCH

GLUCOSE

MONITOR

3 ST; OTC

EASY TRAK LOW

CONTROL

3 OTC

EASYGLUCO

MONITORING

SYSTEM

3 ST; OTC



61

Drug Name Drug

Category

Requirements

/ Limits

EASYGLUCO

PLUS

3 ST; OTC

EASYGLUCO

PLUS NORMAL

CONTROL

3 OTC

EASYMAX L

BLOOD GLUCOSE

METER

3 ST; OTC

EASYMAX LOW

CONTROL

3 OTC

EASYMAX NG 3 ST; OTC

EASYMAX

NORMAL

CONTROL

3 OTC

EASYMAX V

SPEAKING

GLUCOSE SYS

3 ST; OTC

EASYMAX V2

BLOOD GLUCOSE

METER

3 ST; OTC

ELEMENT

COMPACT

GLUCOSE METER

3 ST; OTC

ELEMENT

COMPACT

NORMAL

CONTROL

3 OTC

ELEMENT

COMPACT V

GLUCOSE MTR

3 ST; OTC

ELEMENT

NORMAL

CONTROL

3 OTC

ELEMENT PLUS

BLOOD GLUCOSE

KIT

3 ST; OTC

EMBRACE

BLOOD GLUCOSE

SYSTEM

3 ST; OTC

Drug Name Drug

Category

Requirements

/ Limits

EMBRACE EVO

LEVEL 1

3 OTC

EMBRACE

GLUCOSE

CONTROL LOW

3 OTC

EMBRACE PRO

GLUCOSE METER

3 ST; OTC

EVENCARE G2 3 ST; OTC

EVENCARE G3

GLUCOSE METER

3 ST; OTC

EVENCARE MINI

MONITOR

SYSTEM

3 ST; OTC

EVOLUTION

BLOOD GLUCOSE

METER

3 ST; OTC

EVOLUTION

NORMAL

CONTROL

3 OTC

EZ SMART PLUS

SYSTEM

3 ST; OTC

EZ SMART

SYSTEM

3 ST; OTC

FORA D10 3 OTC

FORA D20 3 ST; OTC

FORA G20 3 ST; OTC

FORA G30A 3 ST; OTC

FORA GD50

BLOOD GLUCOSE

SYSTEM

3 ST; OTC

FORA NORMAL

CONTROL

3 OTC

FORA PREMIUM

V10 GLUCOSE

METER

3 ST; OTC

FORA TEST N'GO

VOICE METER

3 ST; OTC



62

Drug Name Drug

Category

Requirements

/ Limits

FORA TN'G VOICE

METER

3 ST; OTC

FORA V10 3 ST; OTC

FORA V12 BLOOD

GLUCOSE

SYSTEM

3 ST; OTC

FORA V20 3 ST; OTC

FORA V30A 3 ST; OTC

FORACARE GD20

GLUCOSE METER

3 ST; OTC

FORACARE

GD40A GLUCOSE

METER

3 ST; OTC

FORACARE

GD40B GLUCOSE

METER

3 ST; OTC

FORACARE GDH

LOW CONTROL

3 OTC

FORTISCARE

BLOOD GLUCOSE

SYST

3 ST; OTC

FORTISCARE

NORMAL

3 OTC

FREESTYLE

CONTROL

3 OTC

FREESTYLE

FLASH SYSTEM

3 ST; OTC

FREESTYLE

FREEDOM

3 ST; OTC

FREESTYLE

FREEDOM LITE

3 ST; OTC

FREESTYLE

INSULINX

3 ST; OTC

FREESTYLE LITE

METER

3 ST; OTC

Drug Name Drug

Category

Requirements

/ Limits

FREESTYLE

PRECISION NEO

METER

3 ST; OTC

FREESTYLE

SIDEKICK II

3 ST; OTC

FREESTYLE

SYSTEM KIT

3 ST; OTC

GE100 BLOOD

GLUCOSE

SYSTEM

3 ST; OTC

GE100 CONTROL

SOLUTION

NORMAL

3 OTC

GLUCO NAVII

GLUCOSE

MONITOR

3 ST; OTC

GLUCOCARD 01

METER

3 ST; OTC

GLUCOCARD 01

NORMAL

CONTROL

3 OTC

GLUCOCARD

EXPRESSION

3 ST; OTC

GLUCOCARD

SHINE METER

3 ST; OTC

GLUCOCARD

VITAL

3 ST; OTC

GLUCOCOM

BLOOD GLUCOSE

3 ST; OTC

GLUCOCOM

CONTROL

NORMAL

3 OTC

GLUCOSE

CONTROL

3 OTC

GM100 3 ST; OTC

HEALTHPRO

GLUCOSE

MONITOR

3 ST; OTC



63

Drug Name Drug

Category

Requirements

/ Limits

HEALTHPRO

HIGH-LOW

CONTROL

3 OTC

HUMAPEN

LUXURA HD

2

INFINITY

CONTROL

SOLUTION NORM

3 OTC

INFINITY

STARTER KIT

3 ST; OTC

INSET 30

INFUSION SET 23"

2

INSET INFUSION

SET 23"

2

JAZZ WIRELESS 2

METER KIT

3 ST; OTC

LANCETS 2 OTC

LANCING DEVICE 2 OTC

MEDISENSE 3 OTC

MEDISENSE

GLUCOSE

KETONE

3 OTC

MICRODOT

BLOOD GLUCOSE

SYSTEM

3 ST; OTC

MYGLUCOHEALT

H

3 ST; OTC

MYGLUCOHEALT

H CONTROL

SOLUTION

3 OTC

NOVA MAX

BLOOD GLUCOSE

METER

3 ST; OTC

NOVA MAX

GLUCOSE

CONTROL

3 OTC

NOVAMAX PLUS

GLU-KET

3 OTC

Drug Name Drug

Category

Requirements

/ Limits

NOVOPEN ECHO 3

ON CALL

EXPRESS

CONTROL

3 OTC

ON CALL

EXPRESS METER

3 ST; OTC

ON CALL PLUS

CONTROL

3 OTC

ON CALL PLUS

METER

3 ST; OTC

ON CALL VIVID

CONTROL

3 OTC

ON CALL VIVID

METER

3 ST; OTC

ON CALL VIVID

PAL METER

3 ST; OTC

ONETOUCH

ULTRA CONTROL

2 OTC

ONETOUCH

ULTRA2

2 ST; OTC

ONETOUCH

ULTRAMINI

2 ST; OTC

ONETOUCH

VERIO FLEX

2 ST; OTC

ONETOUCH

VERIO IQ METER

2 ST; OTC

ONETOUCH

VERIO SYSTEM

2 ST; OTC

OPTUMRX 3 ST; OTC

PEN NEEDLE 2 M; OTC

PHARMACIST

CHOICE

GLUCOSE SYS

3 ST; OTC

PRECISION XTRA

MONITOR

2 ST; OTC



64

Drug Name Drug

Category

Requirements

/ Limits

PREMIUM BLOOD

GLUCOSE

MONITOR

3 ST; OTC

PREMIUM V10 3 ST; OTC

PRESTO PRO

BLOOD GLUCOSE

METER

3 ST; OTC

PRODIGY

AUTOCODE

METER

3 ST; OTC

PRODIGY

AUTOCODE

MONITOR SYST

3 ST; OTC

PRODIGY

CONTROL

SOLUTION, LOW

3 OTC

PRODIGY

CONTROL

SOLUTION,HIGH

3 OTC

PRODIGY

POCKET METER

3 ST; OTC

PRODIGY VOICE

GLUCOSE METER

3 ST; OTC

QUINTET BLOOD

GLUCOSE METER

3 ST; OTC

REFUAH PLUS

GLUCOSE

CONTROL

3 OTC

REFUAH PLUS

GLUCOSE

MONITOR

3 ST; OTC

RELION ALL-IN-

ONE METER

3 ST; OTC

RELION CONFIRM 3 ST; OTC

RELION MICRO

GLUCOSE

MONITOR

3 ST; OTC

Drug Name Drug

Category

Requirements

/ Limits

RELION PRIME

METER

3 ST; OTC

REVEAL BLOOD

GLUCOSE METER

3 ST; OTC

RIGHTEST

CONTROL

SOLUTION HIGH

3 OTC

RIGHTEST GM550

SYSTEM

3 ST; OTC

SMART SENSE

MONITORING

SYSTEM

3 ST; OTC

SMARTEST

CONTROL

3 OTC

SMARTEST EJECT 3 ST; OTC

SMARTEST

PERSONA

STARTER

3 ST; OTC

SMARTEST

PRONTO

STARTER

3 ST; OTC

SMARTEST

PROTEGE

3 ST; OTC

SNAP INSULIN

PUMP

CONTROLLER

2

SOLUS V2

AUDIBLE METER

3 ST; OTC

SOLUS V2

CONTROL

SOLUTION,HIGH

3 OTC

SURE-TEST

EASYPLUS MINI

METER

3 ST; OTC

T:30 INFUSION

SET

2

T:90 INFUSION

SET 23"

2



65

Drug Name Drug

Category

Requirements

/ Limits

T:SLIM 2

T:SLIM G4 2

TELCARE BGM 3 ST; OTC

TELCARE BLOOD

GLUCOSE KIT

3 ST; OTC

TELCARE

CONTROL

3 OTC

TEST N'GO

BLOOD GLUCOSE

SYSTEM

3 ST; OTC

TRUE METRIX

AIR GLUCOSE

METER

3 ST; OTC

TRUE METRIX

GLUCOSE METER

3 ST; OTC

TRUE METRIX GO

GLUCOSE METER

3 ST; OTC

TRUE METRIX

LEVEL 1

3 OTC

TRUE2GO BLOOD

GLUCOSE

SYSTEM

3 ST; OTC

TRUECONTROL

LEVEL 0

3 OTC

TRUERESULT

BLOOD GLUCOSE

SYSTM

3 ST; OTC

TRUETRACK

BLOOD GLUCOSE

SYSTEM

3 ST; OTC

TRUETRACK

SMART SYSTEM

3 ST; OTC

ULTIMA

MONITOR

3 ST; OTC

ULTRATRAK

GLUCOSE METER

3 ST; OTC

Drug Name Drug

Category

Requirements

/ Limits

ULTRATRAK

ULTIMATE

3 ST; OTC

UNISTRIP LOW

CONTROL

3 OTC

VGO 20 6 MSD

VGO 30 6 MSD

VGO 40 6 MSD

WAVESENSE AMP 3 ST; OTC

WAVESENSE

CONTROL

SOLUTION

3 OTC

WAVESENSE

PRESTO

3 ST; OTC

INSULIN THERAPY

AFREZZA

INHALATION

CARTRIDGE

WITH INHALER 12

UNIT, 4 UNIT (90)/

8 UNIT (90), 4

UNIT/8 UNIT/ 12

UNIT (60), 8 UNIT

3 M

AFREZZA

INHALATION

CARTRIDGE

WITH INHALER 4

UNIT, 4 UNIT (30)/

8 UNIT (60), 4

UNIT (60)/ 8 UNIT

(30), 8 UNIT (60)/

12 UNIT (30)

3 M; QL

APIDRA 3 ST; M

APIDRA

SOLOSTAR

3 ST; M

BASAGLAR

KWIKPEN

3 M

HUMALOG 2 M



66

Drug Name Drug

Category

Requirements

/ Limits

HUMALOG

JUNIOR KWIKPEN

2 M

HUMALOG

KWIKPEN

2 M

HUMALOG MIX

50-50

2 M

HUMALOG MIX

50-50 KWIKPEN

2 M

HUMALOG MIX

75-25

2 M

HUMALOG MIX

75-25 KWIKPEN

2 M

HUMULIN 70/30 2 M; QL

HUMULIN 70/30

KWIKPEN

2 M; QL

HUMULIN N 2 M; QL

HUMULIN N

KWIKPEN

2 M

HUMULIN R U-100 2 M; QL

HUMULIN R U-500

(CONC) KWIKPEN

2 M

HUMULIN R U-500

(CONCENTRATED

)

2 M; QL

LANTUS 2 M

LANTUS

SOLOSTAR

2 M

LEVEMIR 2 M

LEVEMIR

FLEXTOUCH

2 M

NOVOLOG 3 ST; M

NOVOLOG

FLEXPEN

3 ST; M

NOVOLOG MIX

70-30

3 ST; M

Drug Name Drug

Category

Requirements

/ Limits

NOVOLOG MIX

70-30 FLEXPEN

3 ST; M

NOVOLOG

PENFILL

3 ST; M

RELION NOVOLIN

70/30

3 ST; M; QL

RELION NOVOLIN

N

3 ST; M; QL

RELION NOVOLIN

R

3 ST; M; QL

SOLIQUA 100/33 2 M

TOUJEO

SOLOSTAR

2 M

TRESIBA

FLEXTOUCH U-

100

2 M

TRESIBA

FLEXTOUCH U-

200

2 M

XULTOPHY

100/3.6

2 ST; M

MISCELLANEOUS HORMONES

ALDURAZYME 6 MSD

ANADROL-50 3

ANDRODERM 2 PA

ANDROGEL

TRANSDERMAL

GEL IN

METERED-DOSE

PUMP

2 PA

ANDROGEL

TRANSDERMAL

GEL IN PACKET 1

% (25

MG/2.5GRAM), 1

% (50 MG/5

GRAM)

3 PA



67

Drug Name Drug

Category

Requirements

/ Limits

ANDROGEL

TRANSDERMAL

GEL IN PACKET

1.62 % (20.25

MG/1.25 GRAM),

1.62 % (40.5

MG/2.5 GRAM)

2 PA

ANDROID 3 ST

AVEED 6 MSD

AXIRON 3 PA

BRAVELLE 7 ST

BRINEURA 2

cabergoline 1 M; QL

calcitonin (salmon) 1 M

calcitriol 1 M

CERDELGA 3 S; SLA

CEREZYME 6 MSD

CETROTIDE 7

CHORIONIC

GONADOTROPIN,

HUMAN

7

clomiphene citrate 7

danazol 1

DDAVP 3 M

DEPO-

TESTOSTERONE

3 PA

desmopressin 1 M

doxercalciferol

intravenous

6 MSD

doxercalciferol oral 1 M

ELAPRASE 6 MSD

ELELYSO 6 MSD

FABRAZYME 6 MSD

FOLLISTIM AQ 7 ST

Drug Name Drug

Category

Requirements

/ Limits

FORTESTA 3 ST

GANIRELIX 7 ST; S

GONAL-F 7

GONAL-F RFF 7

GONAL-F RFF

REDI-JECT

7

HECTOROL

INTRAVENOUS

6 MSD

HECTOROL ORAL 3 M

KANUMA 6 MSD

KORLYM 3 PA; SLA

KUVAN 3 PA; S; SLA

LUMIZYME 6 MSD

MENOPUR 7

METHITEST 2

methyltestosterone 1

MIACALCIN 6 MSD

MYALEPT 3 PA; S; SLA

NAGLAZYME 6 MSD

NATESTO 3 ST

NATPARA 3 PA; S; SLA

NOVAREL 7

OVIDREL 7

OXANDRIN 3

oxandrolone 1

pamidronate 6 MSD

PARICALCITOL

HEMODIALYSIS

PORT INJECTION

6 MSD

paricalcitol

intravenous

6 MSD

paricalcitol oral 1 M

PREGNYL 7



68

Drug Name Drug

Category

Requirements

/ Limits

RAYALDEE 3 M

ROCALTROL 3 M

SAMSCA 2 PA; QL

SENSIPAR 2 PA

serophene 7

SOMAVERT 3 S; SLA

STIMATE 2

STRENSIQ 2 SLA

STRIANT 3 PA

SYNAREL 2

TESTIM 3 ST

testosterone

cypionate

1 PA

testosterone

enanthate

1 PA

TESTOSTERONE

TRANSDERMAL

GEL

3 ST

TESTOSTERONE

TRANSDERMAL

GEL IN

METERED-DOSE

PUMP 10 MG/0.5

GRAM

/ACTUATION

3 ST

testosterone

transdermal gel in

metered-dose pump

12.5 mg/ 1.25 gram

(1 %)

1

testosterone

transdermal gel in

packet

1

testosterone

transdermal solution

in metered pump

w/app

1

Drug Name Drug

Category

Requirements

/ Limits

TESTRED 3 ST

vasopressin in 0.9

% nacl

6 MSD

VASOSTRICT 6 MSD

VIMIZIM 6 MSD

VOGELXO 3 ST

VPRIV 6 MSD

ZAVESCA 2

ZEMPLAR

INTRAVENOUS

6 MSD

ZEMPLAR ORAL 3 M

zoledronic acid 6 MSD

ZOLEDRONIC AC-

MANNITOL-

0.9NACL

6 MSD

ZOMETA 6 MSD

NON-INSULIN HYPOGLYCEMIC

AGENTS

acarbose 1 M

ACTOPLUS MET 3 ST; M; QL

ACTOPLUS MET

XR

3 ST; M; QL

ACTOS 3 ST; M; QL

ADLYXIN 3 ST; M

ALOGLIPTIN 3 ST; M; QL

ALOGLIPTIN-

METFORMIN

3 ST; M; QL

ALOGLIPTIN-

PIOGLITAZONE

3 M; QL

AMARYL 3 M

AVANDIA 3 ST; M; QL

BYDUREON

SUBCUTANEOUS

PEN INJECTOR

2 ST; M



69

Drug Name Drug

Category

Requirements

/ Limits

BYDUREON

SUBCUTANEOUS

SUSPENSION,EXT

ENDED REL

RECON

2 ST; M; QL

BYETTA 2 ST; M; QL

chlorpropamide 1 M

CYCLOSET 3 M; QL

DM2 3 M

DUETACT 3 ST; M; QL

FARXIGA 2 ST; M; QL

FORTAMET 3 ST; M

glimepiride 1 M

glipizide 1 M

glipizide-metformin 1 M

GLUCOPHAGE 3 ST; M

GLUCOPHAGE XR 3 ST; M

GLUCOTROL 3 M

GLUCOTROL XL 3 M

GLUCOVANCE 3 M

GLUMETZA 3 ST; M; QL

glyburide 1 M

glyburide

micronized

1 M

glyburide-metformin 1 M

GLYNASE 3 M

GLYSET 3 M

GLYXAMBI 2 M

INVOKAMET 2 ST; M; QL

INVOKAMET XR 2 ST; M; QL

INVOKANA 2 ST; M; QL

JANUMET 2 ST; M; QL

JANUMET XR 2 ST; M; QL

Drug Name Drug

Category

Requirements

/ Limits

JANUVIA 2 ST; M; QL

JARDIANCE 2 ST; M; QL

JENTADUETO 2 ST; M; QL

JENTADUETO XR 2 ST; M

KAZANO 3 ST; M; QL

KOMBIGLYZE XR 3 ST; M; QL

metformin oral

tablet

1 M

metformin oral

tablet extended

release 24 hr

1 M

metformin oral

tablet extended

release 24hr

1 ST; M

metformin oral

tablet,er

gast.retention 24 hr

1 M; QL

miglitol 1 M

nateglinide 1 M

NESINA 3 ST; M; QL

ONGLYZA 3 ST; M; QL

OSENI 3 M; QL

pioglitazone 1 M; QL

pioglitazone-

glimepiride

1 M; QL

pioglitazone-

metformin

1 M; QL

PRANDIN 3 M

PRECOSE 3 M

repaglinide 1 M

repaglinide-

metformin

1 M; QL

RIOMET 3 ST; M; QL

STARLIX 3 M



70

Drug Name Drug

Category

Requirements

/ Limits

SYMLINPEN 120 2 ST; M; QL

SYMLINPEN 60 2 ST; M; QL

SYNJARDY 2 ST; M

SYNJARDY XR 2 ST; M

TANZEUM 3 ST; M; QL

tolazamide 1 M

tolbutamide 1 M

TRADJENTA 2 ST; QL

TRULICITY 2 ST; M; QL

VICTOZA 2-PAK 3 ST; M; QL

VICTOZA 3-PAK 3 ST; M; QL

XIGDUO XR 2 ST; M; QL

THYROID HORMONES

ARMOUR

THYROID

2 M

CYTOMEL 3 ST; M

LEVO-T 3 M

LEVOTHYROXINE

INTRAVENOUS

RECON SOLN 100

MCG

6 MSD

levothyroxine

intravenous recon

soln 200 mcg, 500

mcg

6 MSD

levothyroxine oral 1 M

levoxyl 1 M

liothyronine 1 M

nature-throid 1 M

np thyroid 1 M

SYNTHROID 3 M

THYROLAR-1 3 M

THYROLAR-1/2 3 M

Drug Name Drug

Category

Requirements

/ Limits

THYROLAR-1/4 3 M

THYROLAR-2 3 M

THYROLAR-3 3 M

TIROSINT 3 M

unithroid 1 M

westhroid 1 M

WP THYROID 3 M

GASTROENTEROLOGY

ANTIDIARRHEALS &

ANTISPASMODICS

anaspaz 1

atropine 6 MSD

belladonna

alkaloids-opium

1

belladonna-opium 1

BENTYL

INTRAMUSCULA

R

6 MSD

BENTYL ORAL 3

chlordiazepoxide-

clidinium

1

CUVPOSA 3

dicyclomine

intramuscular

6 MSD

dicyclomine oral 1

diphenoxylate-

atropine

1

DONNATAL 3

ed-spaz 1

glycopyrrolate

injection

6 MSD

GLYCOPYRROLA

TE

INTRAVENOUS

6 MSD



71

Drug Name Drug

Category

Requirements

/ Limits

glycopyrrolate oral 1

hyoscyamine sulfate 1

hyosyne 1

LEVBID 3

LEVSIN

INJECTION

6 MSD

LEVSIN ORAL 3

LEVSIN/SL 3

LIBRAX (WITH

CLIDINIUM)

3 ST

LOMOTIL 3

methscopolamine 1

MOTOFEN 3

MYTESI 3

NULEV 3

opium tincture 1

oscimin 1

oscimin sl 1

oscimin sr 1

paregoric 1

phenobarb-hyoscy-

atropine-scop

1

phenohytro 1

propantheline 1

ROBINUL FORTE 3

ROBINUL

INJECTION

6 MSD

ROBINUL ORAL 3

SYMAX DUOTAB 3

symax fastabs 1

symax-sl 1

symax-sr 1

Drug Name Drug

Category

Requirements

/ Limits

MISCELLANEOUS

GASTROINTESTINAL AGENTS

ACTIGALL 3 M

AKYNZEO 2 QL

alophen 5 ACA; OTC

alosetron 1

ALOXI 6 MSD

AMITIZA 2

ANALPRAM-HC 3

ANALPRAM-HC

SINGLES

3

anucort-hc 1

ANUSOL-HC 3 ST

ANZEMET 3 QL

aprepitant 1 QL

APRISO 2 M

ASACOL HD 3 ST; M

AURYXIA 3

AZULFIDINE 3 M

AZULFIDINE EN-

TABS

3 M

balsalazide 1

bisacodyl 5 ACA; OTC

bisa-lax 5 ACA; OTC

budesonide 1

calcium acetate 1

CANASA 2

CESAMET 3 QL

CHENODAL 2 PA; SLA

CHOLBAM 2 PA; SLA

CIMZIA 4 PA; ST; S;

SLA



72

Drug Name Drug

Category

Requirements

/ Limits

CIMZIA POWDER

FOR RECONST

4 PA; ST; S;

SLA

citrate of magnesia 5 ACA; OTC

citroma 5 ACA; OTC

clearlax 5 ACA; OTC

COLAZAL 3

colocort 1

COLYTE WITH

FLAVOR PACKS

3

COMPAZINE 3

compro 1

constulose 1

CORTENEMA 3

CORTIFOAM 2

CREON 2

cromolyn 1

CYSTADANE 2 SLA

DELZICOL 3 ST; M

DICLEGIS 3

DIPENTUM 3 ST; M

dronabinol 1

ducodyl 5 ACA; OTC

eliphos 1

EMEND

(FOSAPREPITANT

)

6 MSD

EMEND ORAL

CAPSULE 125 MG,

40 MG

2 QL

EMEND ORAL

CAPSULE 80 MG

3 QL

EMEND ORAL

CAPSULE,DOSE

PACK

3 QL

Drug Name Drug

Category

Requirements

/ Limits

EMEND ORAL

SUSPENSION FOR

RECONSTITUTIO

N

2

ENTOCORT EC 3

ENTYVIO 6 MSD

enulose 1

fleet laxative 5 ACA; OTC

FOSRENOL 3 ST

GASTROCROM 3

GATTEX 30-VIAL 4 S; SLA

gavilax 5 ACA; OTC

gavilyte-c 5 ACA

gavilyte-g 5 ACA

gavilyte-n 5 ACA

generlac 1

gentle laxative 5 ACA; OTC

gentlelax 5 ACA; OTC

GIALAX 5 ACA

GIAZO 3

glycolax 5 ACA; OTC

GOLYTELY ORAL

POWDER IN

PACKET

5 ACA

GOLYTELY ORAL

RECON SOLN

3

granisetron hcl 1 QL

healthylax 5 ACA; OTC

hemmorex-hc 1

hydrocortisone 1

hydrocortisone

acetate

1

hydrocortisone-

pramoxine

1



73

Drug Name Drug

Category

Requirements

/ Limits

INFLECTRA 6 MSD

kionex 1

kionex (with

sorbitol)

1

KRISTALOSE 3 M

lactulose 1

lanthanum 1

laxaclear 5 ACA; OTC

laxative (bisacodyl) 5 ACA; OTC

laxative feminine 5 ACA; OTC

laxative peg 3350 5 ACA; OTC

LIALDA 3 M

lidocaine hcl-

hydrocortison ac

1

LINZESS 2

LOTRONEX 3

MAGNEBIND 400 3

magnesium citrate 5 ACA; OTC

MARINOL 3

mesalamine oral

tablet,delayed

release (dr/ec) 1.2

gram

1 M

MESALAMINE

ORAL

TABLET,DELAYE

D RELEASE

(DR/EC) 800 MG

3 ST; M

mesalamine rectal 1

mesalamine with

cleansing wipe

1

metoclopramide hcl

injection

6 MSD

metoclopramide hcl

oral

1

Drug Name Drug

Category

Requirements

/ Limits

MICORT-HC 3 ST

milk of magnesia 5 ACA; OTC

milk of magnesia

concentrated

5 ACA; OTC

miralax 5 ACA; OTC

MOVANTIK 2

MOVIPREP 5 ACA

natura-lax 5 ACA; OTC

NULYTELY WITH

FLAVOR PACKS

3

OCALIVA 3 PA; S; SLA

ondansetron 1 QL

ondansetron hcl (pf) 6 MSD

ondansetron hcl

intravenous

6 MSD

ondansetron hcl oral 1 QL

oral saline laxative 5 ACA; OTC

OSMOPREP 5 ACA

PANCREAZE 3 ST

peg 3350-

electrolytes

5 ACA

peg3350 5 ACA; OTC

peg-electrolyte soln 5 ACA

PENTASA 2 M

PERTZYE 3 ST

PHOSLYRA 2

phosphate laxative 5 ACA; OTC

powderlax 5 ACA; OTC

pramcort 1

PREPOPIK 2

prochlorperazine 1

prochlorperazine

edisylate

6 MSD



74

Drug Name Drug

Category

Requirements

/ Limits

prochlorperazine

maleate

1

PROCORT 3

PROCTOCORT 3

PROCTOFOAM HC 3

procto-med hc 1

proctosol hc 1

proctozone-hc 1

purelax 5 ACA; OTC

RECTIV 2

REGLAN 3

RELISTOR ORAL 3

RELISTOR

SUBCUTANEOUS

2

REMICADE 6 MSD

RENAGEL 3 ST

RENFLEXIS 3 PA; ST

RENVELA ORAL

POWDER IN

PACKET

3

RENVELA ORAL

TABLET

2

ROWASA 3

SANCUSO 2 QL

scopolamine base 1

sevelamer carbonate 1

SFROWASA 3

smoothlax 5 ACA; OTC

sodium polystyrene

sulfonate oral

1

sodium polystyrene

sulfonate rectal

enema 30 gram/120

ml

1

Drug Name Drug

Category

Requirements

/ Limits

SODIUM

POLYSTYRENE

SULFONATE

RECTAL ENEMA

50 GRAM/200 ML

3

SOLESTA 6 MSD

sps (with sorbitol) 1

SUCRAID 3 S; SLA

sulfasalazine 1 M

SUPREP BOWEL

PREP KIT

2

SUSTOL 6 MSD

SYNDROS 3

TIGAN

INTRAMUSCULA

R

6 MSD

TIGAN ORAL 3

TRANSDERM-

SCOP

3

trilyte with flavor

packets

5 ACA

trimethobenzamide 1

TRULANCE 3 ST

UCERIS ORAL 2

UCERIS RECTAL 3

URSO 250 3 M

URSO FORTE 3 M

ursodiol 1 M

VARUBI 2

VELPHORO 2

VELTASSA 3 S; SLA

VIBERZI 2

VIOKACE 2

woman's laxative 5 ACA; OTC



75

Drug Name Drug

Category

Requirements

/ Limits

women's gentle

laxative(bisac)

5 ACA; OTC

women's laxative

(bisacodyl)

5 ACA; OTC

ZENPEP 2

ZOFRAN (AS

HYDROCHLORID

E) INTRAVENOUS

6 MSD

ZOFRAN (AS

HYDROCHLORID

E) ORAL

3 QL

ZOFRAN ODT 3 QL

ZUPLENZ 3 QL

ULCER THERAPY

ACIPHEX 3 ST; M

ACIPHEX

SPRINKLE

3 ST; M; QL

amoxicil-

clarithromy-

lansopraz

1

CARAFATE ORAL

SUSPENSION

2 M

CARAFATE ORAL

TABLET

3 M

cimetidine 1 M

cimetidine hcl 1 M

CYTOTEC 3 M

DEXILANT 3 ST; M; QL

esomeprazole

magnesium oral

capsule,delayed


1 M; QL

esomeprazole

magnesium oral

capsule,delayed


1 M

Drug Name Drug

Category

Requirements

/ Limits

esomeprazole

sodium

6 MSD

ESOMEPRAZOLE

STRONTIUM

ORAL

CAPSULE,DELAY

ED

RELEASE(DR/EC)

24.65 MG

3 ST; M; QL

ESOMEPRAZOLE

STRONTIUM

ORAL

CAPSULE,DELAY

ED

RELEASE(DR/EC)

49.3 MG

3 ST; M

famotidine (pf) 6 MSD

famotidine (pf)-nacl

(iso-os)

6 MSD

famotidine

intravenous

6 MSD

famotidine oral 1 M

lansoprazole oral

capsule,delayed


1 M; QL

lansoprazole oral

capsule,delayed


1 M

misoprostol 1 M

NEXIUM IV 6 MSD

NEXIUM ORAL

CAPSULE,DELAY

ED

RELEASE(DR/EC)

20 MG

3 ST; M; QL

NEXIUM ORAL

CAPSULE,DELAY

ED

RELEASE(DR/EC)

40 MG

3 ST; M



76

Drug Name Drug

Category

Requirements

/ Limits

NEXIUM PACKET

ORAL GRANULES

DR FOR SUSP IN

PACKET 10 MG,

2.5 MG, 20 MG, 5

MG

2 ST; M; QL

NEXIUM PACKET

ORAL GRANULES

DR FOR SUSP IN

PACKET 40 MG

2 ST; M

nizatidine 1 M

OMECLAMOX-

PAK

3 QL

omeppi oral capsule

20-1.1 mg-gram

1 ST; M; QL

omeppi oral capsule

40-1.1 mg-gram

1 ST; M

omeprazole oral

capsule,delayed


1 M; QL

omeprazole oral

capsule,delayed

release(dr/ec) 20

mg, 40 mg

1 M

omeprazole-sodium

bicarbonate oral

capsule 20-1.1 mg-

gram

1 ST; M; QL

omeprazole-sodium

bicarbonate oral

capsule 40-1.1 mg-

gram

1 ST; M

omeprazole-sodium

bicarbonate oral

packet 20-1,680 mg

1 ST; QL

omeprazole-sodium

bicarbonate oral

packet 40-1,680 mg

1 ST

Drug Name Drug

Category

Requirements

/ Limits

pantoprazole oral

tablet,delayed

release (dr/ec) 20

mg

1 M; QL

pantoprazole oral

tablet,delayed

release (dr/ec) 40

mg

1 M

PEPCID 3 M

PREVACID ORAL

CAPSULE,DELAY

ED

RELEASE(DR/EC)

15 MG

3 ST; M; QL

PREVACID ORAL

CAPSULE,DELAY

ED

RELEASE(DR/EC)

30 MG

3 ST; M

PREVACID

SOLUTAB ORAL

TABLET,DISINTE

GRAT, DELAY

REL 15 MG

3 ST; M; QL

PREVACID

SOLUTAB ORAL

TABLET,DISINTE

GRAT, DELAY

REL 30 MG

3 ST; M

PREVPAC 3

PRILOSEC 3 ST; M; QL

PROTONIX ORAL

GRANULES DR

FOR SUSP IN

PACKET

3 ST; M

PROTONIX ORAL

TABLET,DELAYE

D RELEASE

(DR/EC) 20 MG

3 ST; M; QL



77

Drug Name Drug

Category

Requirements

/ Limits

PROTONIX ORAL

TABLET,DELAYE

D RELEASE

(DR/EC) 40 MG

3 ST; M

PYLERA 2

rabeprazole 1 M

ranitidine hcl

injection

6 MSD

ranitidine hcl oral 1 M

sucralfate 1 M

ZANTAC

INJECTION

6 MSD

ZANTAC ORAL 3 M

ZEGERID ORAL

CAPSULE 20-1.1

MG-GRAM

3 ST; M; QL

ZEGERID ORAL

CAPSULE 40-1.1

MG-GRAM

3 ST; M

ZEGERID ORAL

PACKET 20-1,680

MG

3 ST; QL

ZEGERID ORAL

PACKET 40-1,680

MG

3 ST

IMMUNOLOGY, VACCINES &

BIOTECHNOLOGY

BIOTECHNOLOGY DRUGS

ARANESP (IN

POLYSORBATE)

6 MSD

EPOGEN 6 MSD

GRANIX 6 MSD

LEUKINE 6 MSD

MIRCERA 6 MSD

MOZOBIL 6 MSD

Drug Name Drug

Category

Requirements

/ Limits

NEULASTA 6 MSD

NEUPOGEN 6 MSD

PROCRIT 6 MSD

ZARXIO 6 MSD

GROWTH HORMONES

EGRIFTA 3 PA; S

GENOTROPIN 3 PA; S

GENOTROPIN

MINIQUICK

3 PA; S

HUMATROPE 3 PA; S

NORDITROPIN

FLEXPRO

3 PA; S

NUTROPIN AQ

NUSPIN

4 PA; S

OMNITROPE 4 PA; S

SAIZEN 4 PA; S

SAIZEN

CLICK.EASY

4 PA; S

SAIZEN

SAIZENPREP

4 PA; S

SEROSTIM 3 PA; S

ZOMACTON 4 PA; S

ZORBTIVE 4 PA; S; SLA

INTERFERONS

AUBAGIO 4 PA; S; SLA;

QL

AVONEX 3 PA; S; QL

AVONEX (WITH

ALBUMIN)

3 PA; S; QL

BETASERON 3 PA; ST; S; QL

COPAXONE

SUBCUTANEOUS

SYRINGE 20

MG/ML

4 ST; S; QL



78

Drug Name Drug

Category

Requirements

/ Limits

COPAXONE

SUBCUTANEOUS

SYRINGE 40

MG/ML

3 PA; S; QL

COPEGUS 4 ST; S; SLA

EXTAVIA 3 PA; S; QL

GILENYA 3 PA; S; SLA

glatopa 1 PA; S; QL

LEMTRADA 6 MSD

moderiba 1 ST; S; SLA

moderiba dose pack 1 ST; S; SLA

OCREVUS 6 MSD

PEGASYS 3 PA; S; SLA;

QL

PEGASYS

PROCLICK

3 PA; S; SLA;

QL

PEGINTRON 4 PA; S; SLA;

QL

PLEGRIDY 3 ST; S; QL

POMALYST 3 S; QL

REBETOL 4 ST; S; SLA

REBIF (WITH

ALBUMIN)

3 PA; S; QL

REBIF REBIDOSE 3 PA; S; QL

REBIF TITRATION

PACK

3 PA; S; QL

REVLIMID 3 S

ribasphere 1 ST; S; SLA

ribasphere ribapak 1 ST; S; SLA

ribavirin 1 S; SLA

SYLATRON 3 PA; S; SLA;

QL

TECFIDERA 3 PA; S; SLA;

QL

Drug Name Drug

Category

Requirements

/ Limits

ZINBRYTA 4 ST; S; SLA

INTERLEUKINS

ACTIMMUNE 3 S; SLA

ALDARA 3 QL

ALFERON N 6 MSD

ARCALYST 3 PA; ST; S;

SLA

ILARIS (PF) 6 MSD

imiquimod 1 QL

INTRON A 3 S; SLA

KINERET 3 PA; ST; SLA;

QL

PROLEUKIN 6 MSD

ZYCLARA 3 ST; QL

VACCINES & MISCELLANEOUS

IMMUNOLOGICALS

ACTHIB (PF) 6 MSD

ADACEL(TDAP

ADOLESN/ADULT

)(PF)

6 MSD

AFLURIA 2017-

2018

2

AFLURIA 2017-

2018 (PF)

2

AFLURIA QUAD

2017-2018

2

AFLURIA QUAD

2017-2018 (PF)

2

ATGAM 6 MSD

BCG VACCINE,

LIVE (PF)

6 MSD

BEXSERO 6 MSD

BIVIGAM 6 MSD

BOOSTRIX TDAP 6 MSD



79

Drug Name Drug

Category

Requirements

/ Limits

BOTOX 6 MSD

CARIMUNE NF

NANOFILTERED

6 MSD

CUVITRU 6 MSD

DAPTACEL (DTAP

PEDIATRIC) (PF)

6 MSD

DYSPORT 6 MSD

ENGERIX-B (PF) 6 MSD

ENGERIX-B

PEDIATRIC (PF)

6 MSD

FLEBOGAMMA

DIF

6 MSD

FLUAD 2017-2018

(65 YR UP)(PF)

2

FLUARIX QUAD

2017-2018 (PF)

2

FLUBLOK 2017-

2018 (PF)

2

FLUBLOK QUAD

2017-2018 (PF)

2

FLUCELVAX

QUAD 2017-2018

2

FLUCELVAX

QUAD 2017-2018

(PF)

2

FLULAVAL QUAD

2017-2018

2

FLULAVAL QUAD

2017-2018 (PF)

2

FLUMIST QUAD

2017-2018

3

FLUVIRIN 2017-

2018

2

FLUVIRIN 2017-

2018 (PF)

2

Drug Name Drug

Category

Requirements

/ Limits

FLUZONE HIGH-

DOSE 2017-18 (PF)

2

FLUZONE

INTRADERM

QUAD 2017-18

2

FLUZONE QUAD

2017-2018

2

FLUZONE QUAD

2017-2018 (PF)

2

FLUZONE QUAD

PEDI 2017-18 (PF)

2

GAMASTAN S/D 6 MSD

GAMMAGARD

LIQUID

6 MSD

GAMMAGARD S-

D (IGA < 1

MCG/ML)

6 MSD

GAMMAKED 6 MSD

GAMMAPLEX 6 MSD

GAMMAPLEX

(WITH SORBITOL)

6 MSD

GAMUNEX-C 6 MSD

GRASTEK 2 PA

HAVRIX (PF) 6 MSD

HEPAGAM B 6 MSD

HIBERIX (PF) 6 MSD

HIZENTRA 6 MSD

HYPERHEP B S/D 6 MSD

HYPERHEP B S-D

NEONATAL

6 MSD

HYPERRAB S/D

(PF)

6 MSD

HYPERTET S/D

(PF)

6 MSD

HYQVIA 6 MSD



80

Drug Name Drug

Category

Requirements

/ Limits

IMOGAM RABIES-

HT (PF)

6 MSD

INFANRIX (DTAP)

(PF)

6 MSD

KINRIX (PF) 6 MSD

MENACTRA (PF) 6 MSD

MENOMUNE -

A/C/Y/W-135

6 MSD

MENOMUNE -

A/C/Y/W-135 (PF)

6 MSD

MENVEO A-C-Y-

W-135-DIP (PF)

6 MSD

M-M-R II (PF) 6 MSD

MYOBLOC 6 MSD

NABI-HB 6 MSD

OCTAGAM 6 MSD

ORALAIR 3 PA; SLA

PEDIARIX (PF) 6 MSD

PENTACEL

ACTHIB

COMPONENT (PF)

6 MSD

PNEUMOVAX 23 6 MSD

PRIVIGEN 6 MSD

PROQUAD (PF) 6 MSD

PROVENGE 6 MSD

QUADRACEL (PF) 6 MSD

RABAVERT (PF) 6 MSD

RAGWITEK 2 PA

RECOMBIVAX HB

(PF)

6 MSD

ROTARIX 6 MSD

ROTATEQ

VACCINE

6 MSD

TENIVAC (PF) 6 MSD

Drug Name Drug

Category

Requirements

/ Limits

TETANUS,DIPHTH

ERIA TOX

PED(PF)

6 MSD

TETANUS-

DIPHTHERIA

TOXOIDS-TD

6 MSD

THYMOGLOBULI

N

6 MSD

TWINRIX (PF) 6 MSD

TYPHIM VI 6 MSD

VAQTA (PF) 6 MSD

VARIZIG 6 MSD

VAXCHORA

VACCINE

6 MSD

VIVOTIF 6 MSD

VIVOTIF BERNA

VACCINE

6 MSD

XEOMIN 6 MSD

YF-VAX (PF) 6 MSD

ZINPLAVA 6 MSD

MUSCULOSKELETAL &

RHEUMATOLOGY

GOUT THERAPY

allopurinol 1 M

COLCHICINE 3 ST

COLCRYS 2

DUZALLO 3

KRYSTEXXA 6 MSD

MITIGARE 2

probenecid 1 M

probenecid-

colchicine

1 M

ULORIC 2 ST; M



81

Drug Name Drug

Category

Requirements

/ Limits

ZURAMPIC 3 ST; M

ZYLOPRIM 3 M

OSTEOPOROSIS THERAPY

ACTONEL 3 ST; M; QL

alendronate 1 M; QL

ATELVIA 3 ST; M; QL

BINOSTO 3 ST; M; QL

BONIVA

INTRAVENOUS

6 MSD

BONIVA ORAL 3 ST; M; QL

EVISTA 3 PA; M

FORTEO 4 PA; S; SLA;

QL

FOSAMAX 3 ST; M; QL

FOSAMAX PLUS

D

3 ST; M; QL

ibandronate

intravenous

6 MSD

ibandronate oral 1 M; QL

PROLIA 6 MSD

raloxifene 1 PA; M

risedronate 1 M; QL

TYMLOS 2

OTHER RHEUMATOLOGICALS

ACTEMRA

INTRAVENOUS

6 MSD

ACTEMRA

SUBCUTANEOUS

3 PA; ST; S;

SLA; QL

ARAVA 3 QL

BENLYSTA

INTRAVENOUS

6 MSD

BENLYSTA

SUBCUTANEOUS

3 S; SLA

Drug Name Drug

Category

Requirements

/ Limits

CUPRIMINE 3 ST; M

DEPEN

TITRATABS

2 M

ENBREL 3 PA; ST; S; QL

ENBREL

SURECLICK

3 PA; ST; S; QL

HUMIRA 3 PA; ST; S; QL

HUMIRA

PEDIATRIC

CROHN'S START

3 PA; ST; S; QL

HUMIRA PEN 3 PA; ST; S; QL

HUMIRA PEN

CROHN'S-UC-HS

START

3 PA; ST; S; QL

KEVZARA 4 ST; S

leflunomide 1 QL

ORENCIA 4 PA; ST; S

ORENCIA (WITH

MALTOSE)

6 MSD

ORENCIA

CLICKJECT

4 PA; ST; S

OTEZLA 3 ST; S; SLA;

QL

OTEZLA

STARTER

3 ST; S; SLA;

QL

OTREXUP (PF) 3 S; QL

RASUVO (PF) 3 S; QL

RIDAURA 2 M

SAVELLA ORAL

TABLET

2 ST; M; QL

SAVELLA ORAL

TABLETS,DOSE

PACK

2 ST; QL

SIMPONI ARIA 6 MSD



82

Drug Name Drug

Category

Requirements

/ Limits

SIMPONI

SUBCUTANEOUS

PEN INJECTOR

100 MG/ML

3 PA; ST; S; QL

SIMPONI

SUBCUTANEOUS

PEN INJECTOR 50

MG/0.5 ML

4 PA; ST; S; QL

SIMPONI

SUBCUTANEOUS

SYRINGE 100

MG/ML

3 PA; ST; S; QL

SIMPONI

SUBCUTANEOUS

SYRINGE 50

MG/0.5 ML

4 PA; ST; S; QL

XELJANZ 3 ST; S; QL

XELJANZ XR 3 ST; S; QL

OBSTETRICS &

GYNECOLOGY

DIAPHRAGMS AND OTHER NON-

ORAL CONTRACEPTIVES

CAYA

CONTOURED

5 ACA

FC2 FEMALE

CONDOM

2 OTC

FEMCAP 2

KYLEENA 6 MSD

LILETTA 6 MSD

MIRENA 6 MSD

PARAGARD T

380A

6 MSD

SKYLA 6 MSD

WIDE-SEAL

DIAPHRAGM

5 ACA

ESTROGENS & PROGESTINS

Drug Name Drug

Category

Requirements

/ Limits

ACTIVELLA 3 M

ALORA 3 M; QL

amabelz 1 M

ANGELIQ 3 M

AYGESTIN 3 M

camila 5 M; ACA

CLIMARA 3 M; QL

CLIMARA PRO 3 M; QL

COMBIPATCH 2 M

covaryx 1

covaryx h.s. 1

CRINONE

VAGINAL GEL 4

%

2

CRINONE

VAGINAL GEL 8

%

7

deblitane 5 M; ACA

DELESTROGEN 3

DEPO-ESTRADIOL 2

DEPO-PROVERA 5 ACA; QL

DEPO-SUBQ

PROVERA 104

5 ACA; QL

DIVIGEL 2 M; QL

DUAVEE 2

eemt 1

eemt hs 1

ELESTRIN 3 M; QL

ENDOMETRIN 7 ST

errin 5 M; ACA

ESTRACE ORAL 3 M

ESTRACE

VAGINAL

2 M



83

Drug Name Drug

Category

Requirements

/ Limits

estradiol oral 1 M

estradiol

transdermal

1 M; QL

estradiol vaginal 1 M

estradiol valerate 1

estradiol-

norethindrone acet

1 M

ESTRING 2 M

ESTROGEL 3 ST; M; QL

estrogens-

methyltestosterone

1

estropipate 1 M

EVAMIST 3 QL

FEMHRT LOW

DOSE

3 M

FEMRING 3 ST; M

fyavolv 1 M

heather 5 M; ACA

hydroxyprogesterone

caproate

6 MSD

jencycla 5 M; ACA

jevantique lo 1 M

jinteli 1 M

jolivette 5 M; ACA

lopreeza 1 M

lyza 5 M; ACA

MAKENA 6 MSD

medroxyprogesteron

e intramuscular

5 ACA; QL

medroxyprogesteron

e oral

1 M

MENEST 3 M

MENOSTAR 3 M; QL

Drug Name Drug

Category

Requirements

/ Limits

mimvey 1 M

mimvey lo 1 M

MINIVELLE 2 M; QL

nora-be 5 M; ACA

norethindrone

(contraceptive)

5 M; ACA

norethindrone

acetate

1 M

norethindrone ac-eth

estradiol

1 M

norlyda 5 M; ACA

norlyroc 5 M; ACA

ORTHO

MICRONOR

5 ST; M; ACA

PREFEST 3 M

PREMARIN 2 M

PREMPHASE 2 M

PREMPRO 2 M

progesterone 7

progesterone

micronized

1 M

PROMETRIUM 3 M

PROVERA 3 M

sharobel 5 M; ACA

VAGIFEM 3 M

VIVELLE-DOT 3 M; QL

yuvafem 1 M

MISCELLANEOUS OB/GYN

AVC VAGINAL 3

CERVIDIL 3

CLEOCIN 3

clindamycin

phosphate

1



84

Drug Name Drug

Category

Requirements

/ Limits

CLINDESSE 3

CONCEPTROL 2 OTC

fem ph 1

GYNAZOLE-1 3

gynol ii 5 ACA; OTC

INTRAROSA 3

isoxsuprine 1 M

LUPANETA PACK

(1 MONTH)

3

LUPANETA PACK

(3 MONTH)

3

LYSTEDA 3

METROGEL

VAGINAL

3

metronidazole 1

MIFEPREX 4 S; SLA

NEXPLANON 6 MSD

NUVARING 2 M

NUVESSA 3

OSPHENA 3

PREPIDIL 3

PROSTIN E2 3

RELAGARD 3

TERAZOL 7 3

terconazole 1

TODAY

CONTRACEPTIVE

SPONGE

2 OTC

tranexamic acid 1

vaginal

contraceptive foam

5 ACA; OTC

vandazole 1

Drug Name Drug

Category

Requirements

/ Limits

VCF

CONTRACEPTIVE

FILM

2 OTC

VCF

CONTRACEPTIVE

GEL

2 OTC

xulane 5 M; ACA

ORAL CONTRACEPTIVES &

RELATED AGENTS

AFTERA 5 ACA; OTC;

QL

altavera (28) 5 M; ACA

alyacen 1/35 (28) 5 M; ACA

alyacen 7/7/7 (28) 5 M; ACA

amethia 5 M; ACA

amethia lo 5 M; ACA

amethyst 5 M; ACA

apri 5 M; ACA

aranelle (28) 5 M; ACA

ashlyna 5 M; ACA

aubra 5 M; ACA

aviane 5 M; ACA

azurette (28) 5 M; ACA

balziva (28) 5 M; ACA

bekyree (28) 5 M; ACA

BEYAZ 5 ST; M; ACA

blisovi 24 fe 5 M; ACA

blisovi fe 1.5/30 (28) 5 M; ACA

blisovi fe 1/20 (28) 5 M; ACA

BREVICON (28) 5 ST; M; ACA

briellyn 5 M; ACA

camrese 5 M; ACA

camrese lo 5 M; ACA



85

Drug Name Drug

Category

Requirements

/ Limits

caziant (28) 5 M; ACA

chateal 5 M; ACA

cryselle (28) 5 M; ACA

cyclafem 1/35 (28) 5 M; ACA

cyclafem 7/7/7 (28) 5 M; ACA

CYCLESSA (28) 5 ST; M; ACA

cyred 5 M; ACA

dasetta 1/35 (28) 5 M; ACA

dasetta 7/7/7 (28) 5 M; ACA

daysee 5 M; ACA

delyla (28) 5 M; ACA

desog-

e.estradiol/e.estradio

l

5 M; ACA

desogestrel-ethinyl

estradiol

5 M; ACA

drospirenone-

e.estradiol-lm.fa

5 M; ACA

drospirenone-ethinyl

estradiol

5 M; ACA

econtra ez 5 ACA; OTC;

QL

elinest 5 M; ACA

ELLA 5 ACA; QL

emoquette 5 M; ACA

enpresse 5 M; ACA

enskyce 5 M; ACA

estarylla 5 M; ACA

ESTROSTEP FE-28 5 ST; M; ACA

ethynodiol diac-eth

estradiol

5 M; ACA

falmina (28) 5 M; ACA

fayosim 5 M; ACA

Drug Name Drug

Category

Requirements

/ Limits

femynor 5 M; ACA

GENERESS FE 5 ST; ACA

gianvi (28) 5 M; ACA

gildagia 5 M; ACA

introvale 5 M; ACA

isibloom 5 M; ACA

jolessa 5 M; ACA

juleber 5 M; ACA

junel 1.5/30 (21) 5 M; ACA

junel 1/20 (21) 5 M; ACA

junel fe 1.5/30 (28) 5 M; ACA

junel fe 1/20 (28) 5 M; ACA

junel fe 24 5 M; ACA

kaitlib fe 5 ACA

kariva (28) 5 M; ACA

kelnor 1/35 (28) 5 M; ACA

kimidess (28) 5 M; ACA

kurvelo 5 M; ACA

l norgest/e.estradiol-

e.estrad

5 M; ACA

larin 1.5/30 (21) 5 M; ACA

larin 1/20 (21) 5 M; ACA

larin 24 fe 5 M; ACA

larin fe 1.5/30 (28) 5 M; ACA

larin fe 1/20 (28) 5 M; ACA

larissia 5 M; ACA

layolis fe 5 ACA

leena 28 5 M; ACA

lessina 5 M; ACA

levonest (28) 5 M; ACA

levonorgestrel-

ethinyl estrad

5 M; ACA



86

Drug Name Drug

Category

Requirements

/ Limits

levonorg-eth estrad

triphasic

5 M; ACA

levora-28 5 M; ACA

lillow 5 M; ACA

LO LOESTRIN FE 2 ST; M

LOESTRIN 1.5/30

(21)

5 ST; M; ACA

LOESTRIN 1/20

(21)

5 ST; M; ACA

LOESTRIN FE

1.5/30 (28-DAY)

5 ST; M; ACA

LOESTRIN FE 1/20

(28-DAY)

5 ST; M; ACA

lomedia 24 fe 5 M; ACA

loryna (28) 5 M; ACA

LOSEASONIQUE 5 ST; M; ACA

low-ogestrel (28) 5 M; ACA

lutera (28) 5 M; ACA

marlissa 5 M; ACA

melodetta 24 fe 5 M; ACA

mibelas 24 fe 5 M; ACA

microgestin 1.5/30

(21)

5 M; ACA

microgestin 1/20

(21)

5 M; ACA

MICROGESTIN 24

FE

5 ST; M; ACA

microgestin fe 1.5/30

(28)

5 M; ACA

microgestin fe 1/20

(28)

5 M; ACA

MINASTRIN 24 FE 5 ST; M; ACA

MIRCETTE (28) 5 ST; M; ACA

mono-linyah 5 M; ACA

Drug Name Drug

Category

Requirements

/ Limits

mononessa (28) 5 M; ACA

my way 5 ACA; OTC;

QL

myzilra 5 M; ACA

NATAZIA 2 ST; M

necon 0.5/35 (28) 5 M; ACA

necon 1/50 (28) 5 M; ACA

necon 7/7/7 (28) 5 M; ACA

next choice one dose 5 ACA; OTC;

QL

nikki (28) 5 M; ACA

noreth-ethinyl

estradiol-iron oral

tablet,chewable

0.4mg-35mcg(21)

and 75 mg (7)

5 M; ACA

noreth-ethinyl

estradiol-iron oral

tablet,chewable

0.8mg-25mcg(24)

and 75 mg (4)

5 ACA

norethindrone ac-eth

estradiol

5 M; ACA

norethindrone-

e.estradiol-iron

5 M; ACA

norgestimate-ethinyl

estradiol

5 M; ACA

nortrel 0.5/35 (28) 5 M; ACA

nortrel 1/35 (21) 5 M; ACA

nortrel 1/35 (28) 5 M; ACA

nortrel 7/7/7 (28) 5 M; ACA

ocella 5 M; ACA

ogestrel (28) 5 M; ACA

opcicon one-step 5 ACA; OTC;

QL



87

Drug Name Drug

Category

Requirements

/ Limits

option-2 5 ACA; OTC;

QL

orsythia 5 M; ACA

ORTHO TRI-

CYCLEN (28)

5 ST; M; ACA

ORTHO TRI-

CYCLEN LO (28)

5 ST; M; ACA

ORTHO-CYCLEN

(28)

5 ST; M; ACA

ORTHO-NOVUM

1/35 (28)

5 ST; M; ACA

ORTHO-NOVUM

7/7/7 (28)

5 ST; M; ACA

philith 5 M; ACA

pimtrea (28) 5 M; ACA

pirmella 5 M; ACA

PLAN B ONE-

STEP

2 OTC; QL

portia 5 M; ACA

previfem 5 M; ACA

QUARTETTE 5 ST; M; ACA

quasense 5 M; ACA

rajani 5 M; ACA

reclipsen (28) 5 M; ACA

rivelsa 5 M; ACA

SAFYRAL 2 ST; M

SEASONIQUE 5 ST; M; ACA

setlakin 5 M; ACA

sprintec (28) 5 M; ACA

sronyx 5 M; ACA

syeda 5 M; ACA

TAKE ACTION 5 ACA; OTC;

QL

tarina fe 1/20 (28) 5 M; ACA

Drug Name Drug

Category

Requirements

/ Limits

TAYTULLA 2 ST; M

tilia fe 5 M; ACA

tri femynor 5 M; ACA

tri-estarylla 5 M; ACA

tri-legest fe 5 M; ACA

tri-linyah 5 M; ACA

tri-lo-estarylla 5 M; ACA

tri-lo-marzia 5 M; ACA

tri-lo-sprintec 5 M; ACA

trinessa (28) 5 M; ACA

trinessa lo 5 M; ACA

TRI-NORINYL (28) 5 ST; M; ACA

tri-previfem (28) 5 M; ACA

tri-sprintec (28) 5 M; ACA

trivora (28) 5 M; ACA

velivet triphasic

regimen (28)

5 M; ACA

vestura (28) 5 M; ACA

vienva 5 M; ACA

viorele (28) 5 M; ACA

vyfemla (28) 5 M; ACA

wera (28) 5 M; ACA

wymzya fe 5 M; ACA

YASMIN (28) 5 ST; M; ACA

YAZ (28) 5 ST; M; ACA

zarah 5 M; ACA

zenchent (28) 5 M; ACA

zovia 1/35e (28) 5 M; ACA

zovia 1/50e (28) 5 M; ACA

OXYTOCICS

methergine 1



88

Drug Name Drug

Category

Requirements

/ Limits

OPHTHALMOLOGY

ANTIBIOTICS

AZASITE 2

bacitracin 1

bacitracin-

polymyxin b

1

BESIVANCE 3

BETADINE

OPHTHALMIC

PREP

3

CEFUROXIME

SODIUM-

0.9%NACL(PF)

6 MSD

CILOXAN 3

ciprofloxacin hcl 1

erythromycin 1

gatifloxacin 1

gentak 1

gentamicin 1

levofloxacin 1

MOXEZA 2

moxifloxacin 1

MOXIFLOXACIN

(PF)-BSS NO.2

6 MSD

NATACYN 2

neomycin-

bacitracin-

polymyxin

1 M

neomycin-

polymyxin-

gramicidin

1

neo-polycin 1 M

OCUFLOX 3

ofloxacin 1

Drug Name Drug

Category

Requirements

/ Limits

polycin 1

polymyxin b sulf-

trimethoprim

1

POLYTRIM 3

tobramycin 1

TOBREX 3

VIGAMOX 3

ZYMAXID 3

ANTIVIRALS

trifluridine 1

VIROPTIC 3

ZIRGAN 3

BETA-BLOCKERS

BETAGAN 3 M

betaxolol 1 M

BETIMOL 3 M

BETOPTIC S 3 M

carteolol 1 M

ISTALOL 3 ST; M

levobunolol 1 M

metipranolol 1 M

timolol maleate 1 M

TIMOPTIC 3 M

TIMOPTIC

OCUDOSE (PF)

3 ST; M

TIMOPTIC-XE 3 M

CHOLINESTERASE INHIBITOR

MIOTICS

PHOSPHOLINE

IODIDE

2 M

CYCLOPLEGIC MYDRIATICS

atropine 1 M



89

Drug Name Drug

Category

Requirements

/ Limits

CYCLOGYL 3 M

cyclopentolate 1 M

homatropaire 1 M

homatropine hbr 1 M

MYDRIACYL 3 M

PAREMYD 3

tropicamide 1 M

DIRECT ACTING MIOTICS

ISOPTO CARPINE 3 M

MIOCHOL-E 3

pilocarpine hcl 1 M

MISCELLANEOUS

OPHTHALMOLOGICS

acuicyn 1

AKTEN (PF) 3

ALOCRIL 3 ST

ALOMIDE 3 ST

altacaine 1

altafluor 1

azelastine 1

BEPREVE 2 ST

cromolyn 1

CYSTARAN 2 PA; SLA

ELESTAT 3 ST

EMADINE 3 ST

epinastine 1

EYLEA 6 MSD

flucaine 1

fluorescein-

proparacaine

1

flurox 1

Drug Name Drug

Category

Requirements

/ Limits

JETREA (PF) 6 MSD

LACRISERT 3

LASTACAFT 3 ST

LUCENTIS 6 MSD

MACUGEN 6 MSD

olopatadine 1

OMIDRIA 6 MSD

PATADAY 3 ST

PATANOL 3 ST

PAZEO 2 ST

PHOTREXA

VISCOUS

6 MSD

proparacaine 1

RESTASIS 2 PA; M; QL

RESTASIS

MULTIDOSE

2 PA; M; QL

tetcaine 1

tetracaine hcl 1

tetracaine hcl (pf) 1

TETRAVISC 3

TETRAVISC

FORTE

3

VISUDYNE 6 MSD

VITRASE 6 MSD

XIIDRA 2 M; QL

NON-STEROIDAL ANTI-

INFLAMMATORY AGENTS

ACULAR 3

ACULAR LS 3

ACUVAIL (PF) 3 ST

bromfenac 1

BROMSITE 3



90

Drug Name Drug

Category

Requirements

/ Limits

diclofenac sodium 1 QL

flurbiprofen sodium 1

ILEVRO 2

ketorolac 1

NEVANAC 3 ST

PROLENSA 2

ORAL DRUGS FOR GLAUCOMA

acetazolamide 1 M

acetazolamide

sodium

6 MSD

DIAMOX

SEQUELS

3 M

methazolamide 1 M

NEPTAZANE 3 M

OTHER GLAUCOMA DRUGS

AZOPT 3 M

bimatoprost 1 ST; M

COMBIGAN 2 M

COSOPT 3 M

COSOPT (PF) 3 M

dorzolamide 1 M

dorzolamide-timolol 1 M

latanoprost 1 ST; M

LUMIGAN 2 ST; M

MITOSOL 3

SIMBRINZA 3 M

TRAVATAN Z 2 ST; M

TRUSOPT 3 M

XALATAN 3 ST; M

ZIOPTAN (PF) 3 ST; M

STEROID-ANTIBIOTIC

COMBINATIONS

Drug Name Drug

Category

Requirements

/ Limits

MAXITROL 3

neomycin-

bacitracin-poly-hc

1

neomycin-polymyxin

b-dexameth

1

neomycin-

polymyxin-hc

1

neo-polycin hc 1

PRED-G 3

PRED-G S.O.P. 3

TOBRADEX

OPHTHALMIC

(EYE)

DROPS,SUSPENSI

ON

3

TOBRADEX

OPHTHALMIC

(EYE) OINTMENT

2

TOBRADEX ST 2

tobramycin-

dexamethasone

1

ZYLET 2

STEROIDS

ALREX 2 ST

dexamethasone

sodium phosphate

1

DUREZOL 3

FLAREX 3

fluorometholone 1

FML FORTE 3

FML LIQUIFILM 3

FML S.O.P. 3

ILUVIEN 6 MSD

LOTEMAX 2



91

Drug Name Drug

Category

Requirements

/ Limits

MAXIDEX 3

OMNIPRED 3

OZURDEX 6 MSD

PRED FORTE 3

PRED MILD 3

prednisolone acetate 1

prednisolone sodium

phosphate

1

RETISERT 6 MSD

STEROID-SULFONAMIDE

COMBINATIONS

BLEPHAMIDE 3

BLEPHAMIDE

S.O.P.

3

sulfacetamide-

prednisolone

1

SULFONAMIDES

BLEPH-10 3

sulfacetamide

sodium

1

SYMPATHOMIMETICS

ALPHAGAN P

OPHTHALMIC

(EYE) DROPS 0.1

%

2 M

ALPHAGAN P

OPHTHALMIC

(EYE) DROPS 0.15

%

3 M

apraclonidine 1 M

brimonidine 1 M

IOPIDINE 3 M

VASOCONSTRICTOR

DECONGESTANTS

Drug Name Drug

Category

Requirements

/ Limits

CYCLOMYDRIL 3 M

phenylephrine hcl 1

RESPIRATORY, ALLERGY,

COUGH & COLD

ANTIHISTAMINE &

ANTIALLERGENIC AGENTS

ADYPHREN 3

ADYPHREN AMP 3

ADYPHREN AMP

II

3

ADYPHREN II 3

AUVI-Q 3 ST; QL

carbinoxamine

maleate

1

cetirizine 1

CLARINEX ORAL

SYRUP

3

CLARINEX ORAL

TABLET

3 QL

clemastine 1

cyproheptadine 1

desloratadine 1 QL

diphenhydramine hcl 6 MSD

EPINEPHRINE 3 ST; QL

EPINEPHRINESNA

P-V

3

EPIPEN 2-PAK 2 QL

EPIPEN JR 2-PAK 2 QL

EPISNAP 6 MSD

hydroxyzine hcl 1

hydroxyzine

pamoate

1

KARBINAL ER 3



92

Drug Name Drug

Category

Requirements

/ Limits

phenadoz 1

PHENERGAN

INJECTION

6 MSD

phenergan rectal 1

promethazine

injection

6 MSD

promethazine oral 1

promethazine rectal 1

promethegan 1

RYVENT 3

VISTARIL 3

COUGH & COLD THERAPY

benzonatate 1

BROMFED DM 3

brompheniramine-

pseudoeph-dm

1

CAPCOF 3

centergy 1

cheratussin ac 1

CLARINEX-D 12

HOUR

3 QL

codeine-guaifenesin 1

CODITUSSIN AC 3

CODITUSSIN DAC 3

FLOWTUSS 3 ST

g tussin ac 1

guaiatussin ac 1

guaifenesin ac 1

guaifenesin dac 1

HISTEX-AC 3

HYCOFENIX 3 ST

hydrocodone-

chlorpheniramine

1

Drug Name Drug

Category

Requirements

/ Limits

hydrocodone-cpm-

pseudoephed

1

hydrocodone-

homatropine

1

hydromet 1

lortuss ex 1

MAR-COF BP 3

MAR-COF CG 3

m-clear wc 1

M-END PE 3

NINJACOF-XG 3

OBREDON 3 ST

POLY-TUSSIN AC 3

promethazine vc-

codeine

1

promethazine-

codeine

1

promethazine-dm 1

promethazine-

phenyleph-codeine

1

promethazine-

phenylephrine

1

PRO-RED AC (W/

DEXCHLORPHENI

R)

3

relcof c 1

RESPA-AR 3

rydex 1

SEMPREX-D 3

TESSALON

PERLES

3

tusnel c 1

TUSNEL

PEDIATRIC

3



93

Drug Name Drug

Category

Requirements

/ Limits

TUSSICAPS 3 ST

tussigon 1

TUSSIONEX

PENNKINETIC ER

3

TUZISTRA XR 3 ST

virtussin ac 1

virtussin dac 1

VITUZ 3 ST

ZODRYL AC 25 3

ZODRYL AC 30 3

ZODRYL AC 35 3

ZODRYL AC 40 3

ZODRYL AC 50 3

ZODRYL AC 60 3

ZODRYL AC 80 3

ZODRYL DAC 25 3

ZODRYL DAC 30 3

ZODRYL DAC 35 3

ZODRYL DAC 40 3

ZODRYL DAC 50 3

ZODRYL DAC 60 3

ZODRYL DAC 80 3

ZODRYL DEC 25 3

ZODRYL DEC 30 3

ZODRYL DEC 35 3

ZODRYL DEC 40 3

ZODRYL DEC 50 3

ZODRYL DEC 60 3

ZODRYL DEC 80 3

Z-TUSS AC 3

ZUTRIPRO 3

Drug Name Drug

Category

Requirements

/ Limits

PULMONARY AGENTS

ACCOLATE 3 M; QL

acetylcysteine 1

ADCIRCA 3 PA; ST; S; QL

ADEMPAS 3 PA; S; SLA

ADRENALIN 3

ADVAIR DISKUS 2 ST; M; QL

ADVAIR HFA 2 ST; M; QL

AEROSPAN 3 M

AIRDUO

RESPICLICK

3 ST; M; QL

albuterol sulfate

inhalation

1

albuterol sulfate oral 1 M

ALVESCO 3 ST; M; QL

ANORO ELLIPTA 2 M; QL

ARCAPTA

NEOHALER

2 M; QL

ARMONAIR

RESPICLICK

2 M

ARNUITY

ELLIPTA

2 M

ASMANEX HFA 2 M

ASMANEX

TWISTHALER

2 M; QL

ATROVENT HFA 2 M; QL

BECONASE AQ 3 ST; QL

BERINERT 6 MSD

BEVESPI

AEROSPHERE

2 M

BREO ELLIPTA 2 ST; M; QL

BROVANA 3 M; QL



94

Drug Name Drug

Category

Requirements

/ Limits

budesonide

inhalation

1 M; QL

budesonide nasal 1 QL

CINQAIR 6 MSD

CINRYZE 6 MSD

COMBIVENT

RESPIMAT

2 QL

cromolyn 1 M

CUROSURF 3

DALIRESP 2 PA; QL

DULERA 2 ST; M; QL

DYMISTA 2 ST; QL

ELIXOPHYLLIN 3 M

ESBRIET ORAL

CAPSULE

3 PA; S; SLA;

QL

ESBRIET ORAL

TABLET

3 PA; S; SLA

FIRAZYR 3 PA; S; SLA

FLOVENT DISKUS 2 M; QL

FLOVENT HFA 2 M; QL

flunisolide 1 QL

fluticasone 1 QL

FLUTICASONE-

SALMETEROL

2 ST; M; QL

HAEGARDA 3 PA

HYPER-SAL 3

INCRUSE

ELLIPTA

2 M

ipratropium bromide 1 M

ipratropium-

albuterol

1 QL

KALBITOR 6 MSD

KALYDECO 3 PA; S; SLA

Drug Name Drug

Category

Requirements

/ Limits

LETAIRIS 3 PA; ST; S

levalbuterol hcl 1

LEVALBUTEROL

TARTRATE

3 ST

metaproterenol 1 M

mometasone 1 QL

montelukast oral

granules in packet

1 M

montelukast oral

tablet

1 M; QL

montelukast oral

tablet,chewable

1 M; QL

NASONEX 3 ST; QL

nebusal inhalation

solution for

nebulization 3 %

1

NEBUSAL

INHALATION

SOLUTION FOR

NEBULIZATION 6

%

3

NUCALA 6 MSD

OFEV 3 PA; S; SLA;

QL

OMNARIS 3 ST; QL

OPSUMIT 3 PA; S

ORKAMBI 3 S; SLA

PERFOROMIST 2 M; QL

PROAIR HFA 2 QL

PROAIR

RESPICLICK

2

PROVENTIL HFA 3 ST; QL

PULMICORT 3 ST; M; QL

PULMICORT

FLEXHALER

2 M; QL



95

Drug Name Drug

Category

Requirements

/ Limits

pulmosal 1

PULMOZYME 2

QNASL NASAL

HFA AEROSOL

INHALER 40

MCG/ACTUATION

2 ST

QNASL NASAL

HFA AEROSOL

INHALER 80

MCG/ACTUATION

2 ST; QL

QVAR 2 M; QL

REVATIO

INTRAVENOUS

4 PA; S

REVATIO ORAL 4 PA; ST; S; QL

RUCONEST 6 MSD

SEEBRI

NEOHALER

3 M

SEREVENT

DISKUS

2 M; QL

sildenafil

(antihypertensive)

1 PA; S; QL

SINGULAIR ORAL

GRANULES IN

PACKET

3 ST; M

SINGULAIR ORAL

TABLET

3 ST; M; QL

SINGULAIR ORAL

TABLET,CHEWAB

LE

3 ST; M; QL

sodium chloride 1

SPIRIVA

RESPIMAT

2 M

SPIRIVA WITH

HANDIHALER

2 M; QL

STIOLTO

RESPIMAT

2 M

Drug Name Drug

Category

Requirements

/ Limits

STRIVERDI

RESPIMAT

2 M

SURFAXIN 3

SYMBICORT 2 ST; M; QL

terbutaline oral 1 M

terbutaline

subcutaneous

1

THEO-24 3 M

theochron 1 M

theophylline 1 M

TICALAST 3 ST

TRACLEER 3 PA; S; SLA

TUDORZA

PRESSAIR

2 M; QL

TYVASO 6 MSD

TYVASO REFILL

KIT

6 MSD

TYVASO

STARTER KIT

6 MSD

UTIBRON

NEOHALER

3 M

VENTAVIS 3 ST; S

VENTOLIN HFA 2 QL

XOLAIR 6 MSD

XOPENEX 3

XOPENEX

CONCENTRATE

3

XOPENEX HFA 3 ST

zafirlukast 1 M; QL

ZETONNA 3 ST; QL

zileuton 1 M; QL

ZYFLO 3 ST; M

ZYFLO CR 3 ST; M; QL



96

Drug Name Drug

Category

Requirements

/ Limits

UROLOGICALS

ANTICHOLINERGICS &

ANTISPASMODICS

darifenacin 1 M

DETROL 3 ST; M

DETROL LA 3 ST; M

DITROPAN XL 3 ST; M

ENABLEX 3 ST; M

flavoxate 1 M

GELNIQUE

TRANSDERMAL

GEL IN

METERED-DOSE

PUMP

2 ST

GELNIQUE

TRANSDERMAL

GEL IN PACKET

2 ST; M; QL

MYRBETRIQ 2 ST; M

oxybutynin chloride 1 M

OXYTROL 3 ST; M; QL

tolterodine 1 M

TOVIAZ 2 ST; M

trospium 1 M

VESICARE 2 ST; M

BENIGN PROSTATIC

HYPERPLASIA (BPH) THERAPY

alfuzosin 1 M

AVODART 3 ST; M

CIALIS 2 ST; QL

dutasteride 1 ST; M

dutasteride-

tamsulosin

1 ST; M

finasteride 1 M

Drug Name Drug

Category

Requirements

/ Limits

FLOMAX 3 ST; M

JALYN 3 ST; M

PROSCAR 3 ST; M

RAPAFLO 2 ST; M

tamsulosin 1 M

UROXATRAL 3 ST; M

CHOLINERGIC STIMULANTS

bethanechol chloride 1

URECHOLINE 3

MISCELLANEOUS UROLOGICALS

azuphen mb 1

CYSTAGON 2 PA; SLA

cytra k crystals 1

cytra-2 1

cytra-3 1

cytra-k 1

ELMIRON 2

hyolev mb 1

hyophen 1

INDIOMIN MB 3

K-PHOS NO 2 3

K-PHOS

ORIGINAL

2

methen-sod phos-

meth blue-hyos

1

ORACIT 3

phosphasal 1

pot,sodium citrate-

citric acid

1

potassium citrate 1 M

potassium citrate-

citric acid

1



97

Drug Name Drug

Category

Requirements

/ Limits

PROCYSBI 4 PA; ST; S;

SLA

SHOHL'S

MODIFIED

3

sodium citrate-citric

acid

1

tricitrates 1

ur n-c 1

uramit mb 1

URELLE 3

uretron d-s 1

URIBEL 3

urimar-t 1

urin ds 1

uro-458 1

UROCIT-K 10 3 M

UROCIT-K 15 3 M

UROCIT-K 5 3 M

urogesic-blue 1

uro-mp 1

urophen mb 1

UROQID-ACID

NO.2

3

uryl 1

ustell 1

UTA 3

utira-c 1

virtrate-2 1

virtrate-3 1

virtrate-k 1

URINARY ANESTHETICS

phenazopyridine 1

Drug Name Drug

Category

Requirements

/ Limits

PYRIDIUM 3

VITAMINS, HEMATINICS &

ELECTROLYTES

ELECTROLYTES

calcium 500 + d 5 ACA; OTC

calcium 500 with d 5 ACA; OTC

calcium 600 + d(3) 5 ACA; OTC

calcium 600 with

vitamin d3

5 ACA; OTC

calcium carb and

citrate-vitd3

5 ACA; OTC

calcium carbonate-

vitamin d3

5 ACA; OTC

calcium citrate + d 5 ACA; OTC

calcium citrate-

vitamin d2

5 ACA; OTC

calcium citrate-

vitamin d3

5 ACA; OTC

calcium gluconate in

0.9% nacl


1 gram/100 ml

6 MSD

CALCIUM

GLUCONATE IN

0.9% NACL

INTRAVENOUS

SOLUTION 1

GRAM/50 ML, 2

GRAM/100 ML, 2

GRAM/50 ML, 3

GRAM/100 ML

6 MSD

CALCIUM

GLUCONATE IN

D5W

6 MSD

citrus calcium 5 ACA; OTC



98

Drug Name Drug

Category

Requirements

/ Limits

EFFER-K ORAL

TABLET,

EFFERVESCENT

10 MEQ, 20 MEQ

3 M

effer-k oral tablet,

effervescent 25 meq

1 M

GALZIN 3

hi-cal plus vit d 5 ACA; OTC

k-effervescent 1 M

klor-con 1 M

klor-con 10 1 M

klor-con 8 1 M

klor-con m10 1 M

klor-con m15 1 M

klor-con m20 1 M

klor-con sprinkle 1 M

KLOR-CON/25 3 M

klor-con/ef 1 M

k-phos-neutral 1

K-TAB ORAL

TABLET

EXTENDED

RELEASE 10 MEQ,

20 MEQ

3 M

k-tab oral tablet

extended release 8

meq

1 M

lugols 1

oysco 500/d 5 ACA; OTC

oyster shell + d3 5 ACA; OTC

oyster shell calcium-

vit d3

5 ACA; OTC

oystercal-d 5 ACA; OTC

phospha 250 neutral 1

Drug Name Drug

Category

Requirements

/ Limits

POTABA 3 M

potassium acetate 6 MSD

potassium bicarb

and chloride

1 M

potassium bicarb-

citric acid

1 M

potassium chloride 1 M

potassium chloride

in 0.9%nacl

6 MSD

POTASSIUM CL-

LIDO-0.9 % NACL

6 MSD

POTASSIUM PHOS

IN 0.9 % NACL

6 MSD

sodium chloride 6 MSD

sodium chloride 0.45

%

6 MSD

sodium chloride 3 % 6 MSD

sodium chloride 5 % 6 MSD

SODIUM

PHOSPHATE IN

0.9 % NACL

6 MSD

strong iodine 1

virt-phos 250 neutral 1

MISCELLANEOUS VITAMINS,

HEMATINICS, & ELECTROLYTES

FORTAVIT 3

ISOLYTE-S 6 MSD

VITAMINS & HEMATINICS

ACTIVE FE 3

ANIMI-3 WITH

VITAMIN D

3

ATABEX EC 3

b complex-vitamin

b12

5 ACA; OTC



99

Drug Name Drug

Category

Requirements

/ Limits

b complex-vitamin c-

folic acid

5 ACA; OTC

B-12

COMPLIANCE

6 MSD

BACMIN 3

balanced b-100 5 ACA; OTC

balanced b-100

complex

5 ACA; OTC

balanced b-50 5 ACA; OTC

bal-care dha 1

BAL-CARE DHA

ESSENTIAL

3

b-complex with

vitamin c oral tablet

5 ACA; OTC

b-complex with

vitamin c oral tablet

400-500 mcg-mg

1 OTC

BIFERA RX 3

CADEAU DHA 3

calcium pnv 1

calcium-folic acid-

vitamin d

1

centratex 1

cholecalciferol

(vitamin d3)

5 ACA; OTC

ciferex 1 M

CITRANATAL

(DUAL-IRON)

3

CITRANATAL 90

DHA (ALGAL OIL)

3

CITRANATAL

ASSURE

3

CITRANATAL B-

CALM (FE GLUC)

3

Drug Name Drug

Category

Requirements

/ Limits

CITRANATAL

DHA (ALGAL OIL)

3

CITRANATAL

HARMONY (IRON

FUM)

3

classic prenatal 5 ACA; OTC

c-nate dha 1

complete natal dha 1

completenate 1

complex b-100 1 OTC

CONCEPT DHA 3

CONCEPT OB 3

corvita 1

corvita 150 1

CORVITE 3

CORVITE 150 3

CORVITE FE 3

CORVITE FREE 3

cyanocobalamin

(vitamin b-12)

1

delta d3 5 ACA; OTC

dialyvite 1

DIALYVITE 3000 3

DIALYVITE 5000 3

dialyvite 800 5 ACA; OTC

DIALYVITE 800

WITH IRON

3

DIALYVITE

SUPREME D

3

dothelle dha 1

DUET DHA

BALANCED

3

DUET DHA WITH

OMEGA-3

3



100

Drug Name Drug

Category

Requirements

/ Limits

d-vi-sol 5 ACA; OTC

ENBRACE HR 3

ergocalciferol

(vitamin d2) oral

capsule

1

ergocalciferol

(vitamin d2) oral

tablet

5 ACA; OTC

ESCAVITE 3

ESCAVITE D 3 M

ESCAVITE LQ 3 M

EXTRA-VIRT

PLUS DHA

3

FERIVA 21-7

TABLET

3

ferocon 1

FERRALET 90

DUAL-IRON

DELIVERY

3

ferraplus 90 1

ferrocite plus 1

FLORIVA 3 M

FLORIVA

(FLUORIDE-

VITAMIN D3)

5 M; ACA

FLORIVA PLUS 3 M

FLUORABON 5 M; ACA

FLUOR-A-DAY 5 M; ACA

fluor-a-day (with

xylitol)

1 M

fluoride (sodium)

oral drops

5 M; ACA

Drug Name Drug

Category

Requirements

/ Limits

fluoride (sodium)


0.25 mg(0.55 mg

sod. fluoride), 0.5

mg (1.1 mg sodium

fluorid)

5 M; ACA

fluoride (sodium)


1 mg (2.2 mg sod.

fluoride)

1 M

fluoritab oral

tablet,chewable 0.5

mg (1.1 mg sodium

fluorid)

5 M; ACA

fluoritab oral

tablet,chewable 1

mg (2.2 mg sod.

fluoride)

1 M

FLURA-DROPS 5 M; ACA

focalgin 90 dha 1

focalgin ca 1

focalgin dss 1

folbee 1

folbee plus 1

FOLET ONE 3

FOLGARD OS 3

FOLGARD RX 3

folic acid oral tablet

1 mg

1 M

folic acid oral tablet

400 mcg, 800 mcg

5 M; ACA; OTC

folic acid-vit b6-vit

b12

1

folivane-f 1

folivane-ob 1

folivane-plus 1



101

Drug Name Drug

Category

Requirements

/ Limits

folplex 2.2 1

foltabs 800 1 OTC

FOLTRATE 3

full spectrum b-

vitamin c

5 ACA; OTC

FUSION PLUS 3

FUSION

SPRINKLES

3

hematinic plus

vit/minerals

1

hematinic/folic acid 1

hematogen 1

hematogen fa 1

hematogen forte 1

HEMATRON-AF 3

hemenatal ob 1

hemenatal ob + dha 1

hemetab 1

HEMOCYTE-F 3

HEMOCYTE-PLUS 3

ICAR-C PLUS 3

INFUVITE ADULT 6 MSD

INFUVITE

PEDIATRIC

6 MSD

INJECTAFER 6 MSD

INTEGRA F 3

INTEGRA PLUS 3

IROSPAN 24/6 3

kobee 1 OTC

KOSHER

PRENATAL PLUS

IRON

3

kpn 1 OTC

Drug Name Drug

Category

Requirements

/ Limits

levomefolate dha 1

ludent fluoride oral

tablet,chewable 0.25

mg(0.55 mg sod.

fluoride), 0.5 mg

(1.1 mg sodium

fluorid)

5 M; ACA

ludent fluoride oral

tablet,chewable 1

mg (2.2 mg sod.

fluoride)

1 M

m.v.i. adult 6 MSD

MARNATAL-F 3

MAXFE (FOLATE-

DOCUSATE)

3

multigen folic 1

multigen plus 1

multi-vit with

fluoride-iron

5 ACA

multi-vitamin with

fluoride oral drops

5 ACA

multi-vitamin with

fluoride oral


mg, 0.5 mg

5 ACA

multi-vitamin with

fluoride oral

tablet,chewable 1

mg

1

multivitamins with

fluoride oral


mg, 0.5 mg

5 ACA

multivitamins with

fluoride oral

tablet,chewable 1

mg

1



102

Drug Name Drug

Category

Requirements

/ Limits

mvc-fluoride oral


mg, 0.5 mg

5 ACA

mvc-fluoride oral

tablet,chewable 1

mg

1

mynatal 1

mynatal advance 1

mynatal plus 1

mynatal-z 1

mynate 90 plus 1

mynephrocaps 1

mynephron 1

NASCOBAL 2 M

NATACHEW (FE

BIS-GLYCINATE)

3

NATELLE ONE 3

natural b-100

complex

5 ACA; OTC

NEEVODHA

(WITH ALGAL

OIL)

3

nephplex rx 1

NEPHROCAPS 3

NEPHROCAPS QT 3

NEPHRON FA 3

nephro-vite rx 1

NESTABS 3

NESTABS ABC 3

NESTABS DHA 3

NESTABS ONE 3

NEURIN-SL 3

newgen 1

NEXA PLUS 3

Drug Name Drug

Category

Requirements

/ Limits

NEXAVIR 3

NIVA-PLUS 3

NUTRICAP 3

OB COMPLETE

GOLD

3

OB COMPLETE

ONE

3

OB COMPLETE

PETITE

3

OB COMPLETE

PREMIER

3

OB COMPLETE

WITH DHA

3

obstetrix dha 1

OBSTETRIX EC 3

OBSTETRIX ONE 3

OBTREX DHA 3

O-CAL FA 3

O-CAL

PRENATAL

3

one daily prenatal 5 ACA; OTC

ortho d 1 M

oyster shell calcium-

vit d2

5 ACA; OTC

perry prenatal 5 ACA; OTC

PHYSICIANS EZ

USE B-12

6 MSD

pnv 29-1 1

pnv ob+dha 1

pnv-dha 1

pnv-dha + docusate 1

pnv-ferrous

fumarate-docu-fa

1

pnv-omega 1



103

Drug Name Drug

Category

Requirements

/ Limits

pnv-select 1

pnv-vp-u 1

POLY-VI-FLOR 3

POLY-VI-FLOR

WITH IRON

3

pr natal 400 1

pr natal 400 ec 1

pr natal 430 1

pr natal 430 ec 1

PREFERA-OB 3

PREFERA-OB ONE 3

PREFERA-OB

PLUS DHA

3

prena1 chew 1

prena1 pearl 1

prena1 true 1

prenaissance 1

prenaissance plus 1

PRENATA 3

prenatabs fa 1

prenatabs rx 1

prenatal 5 ACA; OTC

prenatal complete 5 ACA; OTC

prenatal formula 5 ACA; OTC

prenatal multi-dha

(algal oil)

1 OTC

prenatal one daily 5 ACA; OTC

prenatal plus 1

prenatal plus

(calcium carb)

1

PRENATAL PLUS

DHA

3

prenatal vitamin 5 ACA; OTC

Drug Name Drug

Category

Requirements

/ Limits

prenatal vitamin

plus low iron

1

prenatal vitamin

with minerals

5 ACA; OTC

prenatal vits96-iron

fum-folic

5 ACA; OTC

prenatal-u 1

PRENATE AM 3

PRENATE

CHEWABLE

3

PRENATE DHA

(FERR ASP

GLYCIN)

3

PRENATE ELITE

(IRON ASP GLYC)

3

PRENATE

ENHANCE

3

PRENATE

ESSENTIAL(IRON-

ASP-GL)

3

PRENATE MINI

(FERR ASP

GLYCIN)

3

PRENATE PIXIE 3

PRENATE

RESTORE

3

PRENATE STAR 3

preplus 1

pretab 1

PRIMACARE 3

PROFERRIN-

FORTE

3

PROTECT IRON 3

PROVIDA DHA 3

PROVIDA OB 3



104

Drug Name Drug

Category

Requirements

/ Limits

PURALOR CI 3 M

PUREFE OB PLUS 3

PUREFE PLUS 3

purevit dualfe plus 1

QUFLORA FE 3 M

QUFLORA FE

(FERROUS

SULFATE)

5 M; ACA

QUFLORA

PEDIATRIC

3 M

QUFLORA

PEDIATRIC

DROPS

3 M

relnate dha 1

renal caps 1

rena-vite 5 ACA; OTC

rena-vite rx 1

reno caps 1

risacal-d 5 ACA; OTC

R-NATAL OB 3

SELECT-OB 3

SELECT-OB

(FOLIC ACID)

3

SELECT-OB +

DHA

3

se-natal 19 1

se-natal 19 (with

docusate)

1

se-tan plus 1

stress formula 5 ACA; OTC

stress formula with

iron

1 OTC

stress formula with

iron(sulf)

1 OTC

Drug Name Drug

Category

Requirements

/ Limits

STROVITE FORTE 3

STROVITE ONE 3

super b complex-

vitamin c

1 OTC

super b maxi

complex

1 OTC

super b-50 complex

plus

1 OTC

super quints 1 OTC

super quints b-50 5 ACA; OTC

superplex-t 1 OTC

SUPERVITE 3

TANDEM PLUS 3

taron forte 1

taron-c dha 1

taron-prex prenatal-

dha

1

TEXAVITE LQ 3 M

THRIVITE RX 3

thrivite-19 1

tl gard rx 1

tl g-fol os 1

tl icon 1

tl-hem 150 1

total b/c 1 OTC

TRICARE 3

TRICARE

PRENATAL

3

TRICARE

PRENATAL DHA

ONE

3

tricon 1

TRIFERIC 6 MSD



105

Drug Name Drug

Category

Requirements

/ Limits

trigels-f forte 1

trinatal gt 1

trinatal rx 1 1

trinate 1

triphrocaps 1

TRISTART DHA 3

tri-tabs dha 1

triveen-duo dha 1

TRI-VI-FLOR 3

tri-vit with fluoride

and iron

5 ACA

tri-vitamin with

fluoride

5 ACA

trust natal dha 1

UDAMIN SP 3

ultimatecare one 1

ultimatecare one nf 1

ultra b-100 complex 1 OTC

v-c forte 1

vemavite-prx-2 1

VENOFER 6 MSD

vic-forte 1

vinate care 1

VINATE DHA RF 3

vinate ii 1

vinate m 1

vinate one 1

virt-advance 1

virt-c dha 1

VIRT-CAPS 3

virt-gard 1

virt-nate 1

Drug Name Drug

Category

Requirements

/ Limits

virt-nate dha 1

virt-pn 1

virt-pn dha 1

virt-pn plus 1

VIRTPREX 3

virt-select 1

virt-vite 1

virt-vite gt 1

VIRT-VITE PLUS 3 M

vit 3 1

vit b complex-folic

acid

5 ACA; OTC

VITAFOL 3

VITAFOL FE+

(WITH

DOCUSATE)

3

VITAFOL

GUMMIES

3

VITAFOL NANO 3

VITAFOL ULTRA 3

VITAFOL-OB 3

VITAFOL-

OB+DHA

3

VITAFOL-ONE 3

vitajoy daily d 5 ACA; OTC

VITAL-D RX 3

VITAMED MD

ONE RX

3

VITAMEDMD

REDICHEW RX

3

vitamin b complex 5 ACA; OTC

vitamin d3 5 ACA; OTC

vitamins a,c,d and

fluoride

5 ACA



106

Drug Name Drug

Category

Requirements

/ Limits

VITAPEARL 3

VITA-RESPA 3

VITATRUE 3

vol-care rx 1

vol-nate 1

vol-plus 1

vol-tab rx 1

vp-ch plus 1

vp-ch-pnv 1

vp-ggr-b6 1

vp-heme ob 1

vp-heme one 1

VP-PNV-DHA 3

vp-vite rx 1

zatean-ch 1

zatean-pn dha 1

zatean-pn plus 1

zavara 1 M

zingiber 1



107

Index

2 2TEK GLUCOSE/BLOOD

PRESSURE ...................... 58

A abacavir .................................. 3

abacavir-lamivudine ............... 3

abacavir-lamivudine-

zidovudine .......................... 3

ABILIFY .............................. 28

ABILIFY MAINTENA ........ 28

ABRAXANE ........................ 12

ABSORICA .......................... 44

ABSTRAL ............................ 21

acamprosate .......................... 51

ACANYA ............................. 44

acarbose ................................ 68

ACCOLATE......................... 93

ACCU-CHEK AVIVA

CONNECT METER ........ 58

ACCU-CHEK AVIVA PLUS

METER ............................ 58

ACCU-CHEK AVIVA PLUS

TEST STRP ...................... 55

ACCU-CHEK COMPACT

PLUS CONTROL ............ 58

ACCU-CHEK COMPACT

PLUS TEST...................... 55

ACCU-CHEK GUIDE ......... 55

ACCU-CHEK GUIDE

GLUCOSE METER ......... 58

ACCU-CHEK GUIDE L1-L2

CTRL SOL ....................... 58

ACCU-CHEK NANO .......... 58

ACCU-CHEK SMARTVIEW

CONTRL SOL ................. 58

ACCU-CHEK SMARTVIEW

TEST STRIP .................... 55

ACCUPRIL .......................... 33

ACCURETIC ....................... 33

ACCUTREND GLUCOSE .. 55

ACCUTREND GLUCOSE

CONTROL ....................... 58

acebutolol ............................. 33

acetaminophen-caff-

dihydrocod ........................ 22

ACETAMINOPHEN-CAFF-

DIHYDROCOD ............... 22

acetaminophen-codeine ........ 22

acetazolamide ....................... 90

acetazolamide sodium .......... 90

acetic acid ............................. 53

acetylcysteine ....................... 93

ACIPHEX ............................. 74

ACIPHEX SPRINKLE......... 75

acitretin ................................. 41

ACTEMRA .......................... 81

ACTHAR H.P. ..................... 54

ACTHIB (PF) ....................... 78

ACTICLATE ........................ 10

ACTIGALL .......................... 71

ACTIMMUNE ..................... 78

ACTIQ .................................. 22

ACTIVE FE .......................... 98

ACTIVELLA........................ 82

ACTONEL ..................... 51, 80

ACTOPLUS MET ................ 68

ACTOPLUS MET XR ......... 68

ACTOS ................................. 68

acuicyn.................................. 89

ACULAR.............................. 89

ACULAR LS ........................ 89

ACUVAIL (PF) .................... 89

acyclovir ........................... 3, 48

ACZONE .............................. 44

ADACEL(TDAP

ADOLESN/ADULT)(PF) 78

ADAGEN ............................. 51

ADALAT CC ....................... 33

adapalene .............................. 44

ADAPALENE ...................... 44

adapalene-benzoyl peroxide . 44

ADASUVE ........................... 28

ADCETRIS .......................... 12

ADCIRCA ............................ 93

ADDERALL ........................ 28

ADDERALL XR .................. 28

ADDYI ................................. 28

adefovir ................................... 3

ADEMPAS ........................... 93

ADLYXIN ............................ 68

ADRENALIN ....................... 93

adriamycin ............................ 12

adrucil ................................... 12

ADVAIR DISKUS ............... 93

ADVAIR HFA ...................... 93

ADVANCED GLUC METER

TEST STRIP ..................... 55

ADVANCED GLUCOSE

METER ............................. 58

ADVATE .............................. 38

ADVOCATE BLOOD

GLUCOSE MONITOR .... 58

ADVOCATE DUO .............. 59

ADVOCATE LOW

CONTROL ....................... 59

ADVOCATE REDI-CODE .. 55

ADVOCATE REDI-CODE

DUO METER ................... 59

ADVOCATE REDI-CODE

GLU MONITOR .............. 59

ADVOCATE REDI-CODE+

CTRL LOW ...................... 59

ADVOCATE TEST STRIPS 55

ADYNOVATE ..................... 38

ADYPHREN ........................ 91

ADYPHREN AMP ............... 91

ADYPHREN AMP II ........... 91

ADYPHREN II ..................... 91

ADZENYS XR-ODT ........... 28

AEROSPAN ......................... 93

afeditab cr ............................. 33

AFINITOR ........................... 12

AFINITOR DISPERZ .......... 12

AFLURIA 2017-2018 .......... 78

AFLURIA 2017-2018 (PF) .. 78

AFLURIA QUAD 2017-2018

.......................................... 78

AFLURIA QUAD 2017-2018

(PF) ................................... 78

AFREZZA ............................ 65

AFSTYLA ............................ 38

AFTERA ............................... 84

AGAMATRIX AMP GLUC

MONITOR SYS ............... 59

AGAMATRIX AMP TEST

STRIPS ............................. 55



108

AGAMATRIX CONTROL

HIGH ................................ 59

AGGRENOX ....................... 38

AGONEAZE ........................ 46

AGRYLIN ............................ 51

AIRDUO RESPICLICK ...... 93

AKTEN (PF) ........................ 89

AKTIPAK ............................ 44

AKYNZEO........................... 71

ala-cort .................................. 48

ALA-SCALP ........................ 48

ALBENZA ............................. 7

albuterol sulfate .................... 93

alclometasone ....................... 48

ALDACTAZIDE .................. 34

ALDACTONE ..................... 34

ALDARA ............................. 78

ALDURAZYME .................. 66

ALECENSA ......................... 12

alendronate ..................... 51, 80

ALEVICYN PLUS ............... 43

ALFERON N........................ 78

alfuzosin ............................... 96

ALINIA .................................. 7

ALIQOPA ............................ 12

ALKERAN ........................... 12

allopurinol ............................ 80

ALLZITAL........................... 22

almotriptan malate ................ 19

ALOCRIL............................. 89

ALOGLIPTIN ...................... 68

ALOGLIPTIN-METFORMIN

.......................................... 68

ALOGLIPTIN-

PIOGLITAZONE ............. 68

ALOMIDE ........................... 89

alophen ................................. 71

ALORA ................................ 82

alosetron ............................... 71

ALOXI ................................. 71

ALPHAGAN P ..................... 91

ALPHANATE ...................... 38

ALPHANINE SD ................. 38

alprazolam ............................ 28

alprazolam intensol .............. 28

ALPROLIX .......................... 38

ALREX................................. 90

ALTABAX ........................... 47

altacaine ................................ 89

ALTACE .............................. 34

altafluor ................................ 89

altavera (28) .......................... 84

ALTOPREV ......................... 40

ALUNBRIG ......................... 12

ALVESCO............................ 93

alyacen 1/35 (28) .................. 84

alyacen 7/7/7 (28) ................. 84

amabelz ................................. 82

amantadine hcl ........................ 3

AMARYL ............................. 68

AMBIEN .............................. 28

AMBIEN CR ........................ 28

AMBISOME .......................... 3

amcinonide ........................... 48

AMELUZ ............................. 43

AMERGE ............................. 19

amethia ................................. 84

amethia lo ............................. 84

amethyst................................ 84

AMICAR .............................. 38

amifostine crystalline ........... 11

amikacin ................................. 7

amiloride ............................... 34

amiloride-hydrochlorothiazide

.......................................... 34

amiodarone ........................... 33

AMITIZA ............................. 71

amitriptyline ......................... 28

amitriptyline-chlordiazepoxide

.......................................... 28

amlodipine ............................ 34

amlodipine-atorvastatin ........ 40

amlodipine-benazepril .......... 34

amlodipine-olmesartan ......... 34

amlodipine-valsartan ............ 34

amlodipine-valsartan-hcthiazid

.......................................... 34

AMMONUL ......................... 51

amnesteem ............................ 44

amoxapine ............................ 28

amoxicil-clarithromy-lansopraz

.......................................... 75

amoxicillin .............................. 9

amoxicillin-pot clavulanate .... 9

AMPHADASE ..................... 51

amphotericin b ........................ 3

ampicillin ................................ 9

ampicillin sodium ................... 9

ampicillin-sulbactam .............. 9

AMPYRA ............................. 20

AMRIX ................................. 21

ANADROL-50 ..................... 66

ANAFRANIL ....................... 28

anagrelide ............................. 51

ANALPRAM-HC ........... 41, 71

ANALPRAM-HC SINGLES71

ANAPROX DS ..................... 25

anaspaz ................................. 70

ANASTIA ............................. 46

anastrozole ............................ 12

ANCOBON ............................ 3

ANDRODERM .................... 66

ANDROGEL ........................ 66

ANDROID ............................ 66

ANGELIQ ............................ 82

ANGIOMAX ........................ 38

ANIMI-3 WITH VITAMIN D

.......................................... 98

ANODYNE LPT .................. 46

ANORO ELLIPTA ............... 93

ANTABUSE ......................... 51

ANTARA ............................. 40

anucort-hc ............................. 71

ANUSOL-HC ....................... 71

ANZEMET ........................... 71

apexicon e ............................. 49

APIDRA ............................... 65

APIDRA SOLOSTAR .......... 65

APLENZIN ........................... 28

APOKYN ............................. 19

apraclonidine ........................ 91

aprepitant .............................. 71

apri ........................................ 84

APRISO ................................ 71

APTENSIO XR .................... 28

APTIOM ............................... 17

APTIVUS ............................... 3

AQUA GLYCOLIC HC ....... 49

ARALAST NP ...................... 51

aranelle (28) .......................... 84

ARANESP (IN

POLYSORBATE) ............ 77

ARAVA ................................ 81

ARCALYST ......................... 78



109

ARCAPTA NEOHALER ..... 93

ARESTIN ............................. 53

ARGATROBAN .................. 38

ARGATROBAN IN 0.9 %

SOD CHLOR ................... 38

ARGATROBAN IN NACL

(ISO-OS) .......................... 38

ARICEPT ............................. 20

ARIMIDEX .......................... 12

aripiprazole ........................... 28

ARISTADA .......................... 28

ARIXTRA ............................ 38

armodafinil ........................... 28

ARMONAIR RESPICLICK 93

ARMOUR THYROID ......... 69

ARNUITY ELLIPTA ........... 93

AROMASIN......................... 12

ARRANON .......................... 12

ARTHROTEC 50 ................. 25

ARTHROTEC 75 ................. 25

ARYMO ER ......................... 22

ARZE-JECT-A ..................... 54

ARZERRA ........................... 12

ASACOL HD ....................... 71

ascomp with codeine ............ 22

ashlyna .................................. 84

ASMANEX HFA ................. 93

ASMANEX TWISTHALER 93

aspir-81 ................................. 25

aspirin ................................... 25

aspirin low dose .................... 25

aspirin-caffeine-dihydrocodein

.......................................... 22

aspirin-dipyridamole ............ 38

aspir-low ............................... 26

aspir-trin ............................... 26

ASSURE 4 CONTROL

SOLUTION ...................... 59

ASSURE 4 STRIPS ............. 55

ASSURE DOSE NORMAL

CONTROL ....................... 59

ASSURE PLATINUM ... 55, 59

ASSURE PRISM CONTROL

1-2 SOLN ......................... 59

ASSURE PRISM MULTI

METER ............................ 59

ASSURE PRISM MULTI

STRIP ............................... 55

ASTAGRAF XL................... 12

ASTEPRO ............................ 53

ASTERO .............................. 46

ATABEX EC ........................ 98

ATACAND .......................... 34

ATACAND HCT ................. 34

ATELVIA ............................. 80

atenolol ................................. 34

atenolol-chlorthalidone ......... 34

ATGAM ............................... 78

ATIVAN ............................... 28

atomoxetine .......................... 28

ATOPICLAIR ...................... 43

atorvastatin ........................... 40

atovaquone.............................. 7

atovaquone-proguanil ............. 7

ATRALIN ............................ 44

ATRAPRO CP ..................... 43

ATRAPRO HYDROGEL .... 43

ATRIPLA ............................... 4

atropine ........................... 70, 88

ATROVENT HFA ............... 93

AUBAGIO............................ 77

aubra ..................................... 84

AUGMENTIN ........................ 9

AUGMENTIN ES-600 ........... 9

AUGMENTIN XR ................. 9

AURYXIA............................ 71

AUSTEDO ........................... 20

AUTOJECT 2 INJECTION

DEVICE ........................... 59

AUTOPEN 1 TO 21 UNITS 59

AUVI-Q ................................ 91

AVALIDE ............................ 34

AVANDIA ........................... 68

AVAPRO.............................. 34

avar ....................................... 44

AVAR ................................... 44

AVAR LS ............................. 44

AVAR-E GREEN................. 44

AVAR-E LS ......................... 45

AVASTIN ............................ 12

AVC VAGINAL .................. 83

AVEED ................................ 66

AVELOX.............................. 10

AVELOX IN NACL (ISO-

OSMOTIC) ....................... 10

aviane.................................... 84

avidoxy ................................. 10

avita ...................................... 45

AVITA .................................. 45

avo cream .............................. 43

AVODART ........................... 96

AVONEX ............................. 77

AVONEX (WITH ALBUMIN)

.......................................... 77

AVYCAZ ............................... 5

AXERT ................................. 19

AXIRON ............................... 66

AYGESTIN .......................... 82

azacitidine ............................. 12

AZASAN .............................. 12

AZASITE ............................. 87

azathioprine .......................... 12

azelastine ........................ 53, 89

AZELEX ............................... 45

AZILECT ............................. 19

azithromycin ........................... 6

AZOPT ................................. 90

AZOR ................................... 34

AZULFIDINE ...................... 71

AZULFIDINE EN-TABS .... 71

azuphen mb ........................... 96

azurette (28) .......................... 84

B b complex-vitamin b12 ......... 98

b complex-vitamin c-folic acid

.......................................... 99

B-12 COMPLIANCE ........... 99

bacitracin .............................. 87

bacitracin-polymyxin b ......... 88

baclofen ................................ 21

BACMIN .............................. 99

BACTRIM ............................ 10

BACTRIM DS ...................... 10

BACTROBAN ..................... 47

BACTROBAN NASAL ....... 53

balanced b-100 ...................... 99

balanced b-100 complex ....... 99

balanced b-50 ........................ 99

bal-care dha .......................... 99

BAL-CARE DHA

ESSENTIAL ..................... 99

balsalazide ............................ 71

balziva (28) ........................... 84

BANZEL .............................. 17



110

BARACLUDE ....................... 4

BASAGLAR KWIKPEN ..... 65

BAVENCIO ......................... 12

bayer aspirin ......................... 26

BCG VACCINE, LIVE (PF) 78

b-complex with vitamin c ..... 99

BEBULIN............................. 38

BECONASE AQ .................. 93

bekyree (28).......................... 84

BELBUCA ........................... 22

BELEODAQ ........................ 12

belladonna alkaloids-opium . 70

belladonna-opium ................. 70

BELSOMRA ........................ 28

benazepril ............................. 34

benazepril-hydrochlorothiazide

.......................................... 34

BENDEKA ........................... 12

BENEFIX ............................. 38

BENICAR ............................ 34

BENICAR HCT ................... 34

BENLYSTA ......................... 81

BENSAL HP ........................ 43

BENTYL .............................. 70

BENZACLIN ....................... 45

BENZACLIN PUMP ........... 45

BENZAMYCIN ................... 45

BENZEFOAM ..................... 45

BENZEFOAM ULTRA ....... 45

benzepro ............................... 45

benzonatate ........................... 92

benztropine ........................... 19

BEPREVE ............................ 89

BERINERT .......................... 93

BESIVANCE ....................... 88

BESPONSA ......................... 12

BETADINE OPHTHALMIC

PREP ................................ 88

BETAGAN ........................... 88

betamethasone acet,sod phos 54

betamethasone dipropionate . 49

betamethasone valerate ........ 49

betamethasone, augmented... 49

BETAPACE ......................... 33

BETAPACE AF ................... 33

BETASERON ...................... 77

betaxolol ......................... 34, 88

bethanechol chloride ............ 96

BETHKIS ............................... 7

BETIMOL ............................ 88

BETOPTIC S ........................ 88

BEVESPI AEROSPHERE ... 93

BEVYXXA .......................... 38

bexarotene ............................ 12

BEXSERO ............................ 78

BEYAZ ................................. 84

BIAFINE EMULSION......... 43

bicalutamide ......................... 12

BICILLIN C-R ....................... 9

BICNU.................................. 12

BIDIL ................................... 34

BIFERA RX ......................... 99

BILTRICIDE .......................... 7

bimatoprost ........................... 90

BINOSTO ............................. 80

BIONIME RIGHTEST

GM300 SYSTEM ............. 59

BIONIME RIGHTEST TEST

STRIPS ............................. 55

bisacodyl ............................... 71

bisa-lax ................................. 71

bisoprolol fumarate............... 34

bisoprolol-hydrochlorothiazide

.......................................... 34

bivalirudin ............................ 38

BIVIGAM ............................ 78

bleo 15k ................................ 12

bleomycin ............................. 12

BLEPH-10 ............................ 91

BLEPHAMIDE .................... 91

BLEPHAMIDE S.O.P. ......... 91

BLINCYTO .......................... 12

blisovi 24 fe .......................... 84

blisovi fe 1.5/30 (28) ............ 84

blisovi fe 1/20 (28) ............... 84

BLOOD GLUCOSE

CONTROL, NORMAL .... 59

BLOOD GLUCOSE TEST .. 55

BLOOD-GLUCOSE METER

.......................................... 59

BONIVA ........................ 80, 81

BOOSTRIX TDAP............... 78

BOSULIF ............................. 12

BOTOX ................................ 78

bp 10-1 .................................. 45

bp-50% urea ......................... 43

bpo ........................................ 45

BRAVELLE ......................... 66

BREEZE 2 CONTROL

SOLUTION,HIGH ........... 59

BREEZE 2 TEST STRIPS ... 55

BREO ELLIPTA .................. 93

BREVIBLOC ....................... 34

BREVIBLOC IN NACL (ISO-

OSM) ................................ 34

BREVICON (28) .................. 84

BRIDION ............................. 21

briellyn .................................. 84

BRILINTA ........................... 38

brimonidine ........................... 91

BRINEURA .......................... 66

BRISDELLE ......................... 28

BRIVIACT ........................... 17

BROMFED DM ................... 92

bromfenac ............................. 89

bromocriptine ....................... 19

brompheniramine-pseudoeph-

dm ..................................... 92

BROMSITE .......................... 89

BROVANA .......................... 93

BUCALSEP .......................... 46

budesonide ...................... 71, 94

bumetanide ........................... 34

BUNAVAIL ......................... 26

BUPAP ................................. 22

BUPHENYL ......................... 51

BUPRENEX ......................... 22

BUPRENORPHINE ............. 22

buprenorphine hcl ................. 22

buprenorphine-naloxone ....... 26

bupropion hcl ........................ 28

bupropion hcl (smoking deter)

.......................................... 52

buspirone .............................. 28

busulfan ................................ 12

BUSULFEX ......................... 12

butalbital compound w/codeine

.......................................... 22

butalbital-acetaminop-caf-cod

.......................................... 22

butalbital-acetaminophen ..... 22

butalbital-acetaminophen-caff

.......................................... 22

butalbital-aspirin-caffeine ..... 22



111

BUTISOL ............................. 28

butorphanol tartrate .............. 26

BUTRANS ........................... 22

BYDUREON ........................ 68

BYETTA .............................. 68

BYSTOLIC .......................... 34

BYVALSON ........................ 34

C cabergoline ........................... 66

CABOMETYX..................... 12

CADEAU DHA.................... 99

CADUET .............................. 40

CAFERGOT ......................... 19

caffeine citrate ...................... 51

CALAN ................................ 34

CALAN SR .......................... 34

calcipotriene ......................... 41

calcipotriene-betamethasone 41

calcitonin (salmon) ............... 66

calcitrene .............................. 42

calcitriol .......................... 42, 66

calcium 500 + d .................... 97

calcium 500 with d ............... 97

calcium 600 + d(3) ............... 97

calcium 600 with vitamin d3 97

calcium acetate ..................... 71

calcium carb and citrate-vitd3

.......................................... 97

calcium carbonate-vitamin d3

.......................................... 97

calcium citrate + d ................ 97

calcium citrate-vitamin d2 .... 97

calcium citrate-vitamin d3 .... 97

calcium gluconate in 0.9% nacl

.......................................... 97

CALCIUM GLUCONATE IN

0.9% NACL ...................... 97

CALCIUM GLUCONATE IN

D5W ................................. 97

calcium pnv .......................... 99

calcium-folic acid-vitamin d 99

CAMBIA .............................. 26

camila ................................... 82

CAMPTOSAR ..................... 12

camrese ................................. 84

camrese lo ............................. 84

CANASA ............................. 71

CANCIDAS ........................... 3

candesartan ........................... 34

candesartan-hydrochlorothiazid

.......................................... 34

capacet .................................. 22

CAPASTAT ........................... 7

CAPCOF .............................. 92

capecitabine .......................... 12

CAPEX ................................. 49

CAPITAL WITH CODEINE

.......................................... 22

CAPRELSA.......................... 12

captopril ................................ 34

captopril-hydrochlorothiazide

.......................................... 34

CARAC ................................ 43

CARAFATE ......................... 75

CARBAGLU ........................ 51

carbamazepine ...................... 17

CARBATROL ...................... 17

carbidopa .............................. 19

carbidopa-levodopa .............. 19

carbidopa-levodopa-

entacapone ........................ 19

carbinoxamine maleate ......... 91

carboplatin ............................ 12

CARDENE IV ...................... 34

CARDENE IV IN

DEXTROSE ..................... 34

CARDENE IV IN SODIUM

CHLORIDE ...................... 34

CARDIZEM ......................... 34

CARDIZEM CD................... 34

CARDIZEM LA ................... 34

CARDURA .......................... 34

CARDURA XL .................... 34

CARESENS CONTROL A

NORMAL ......................... 59

CARESENS N ...................... 59

CARESENS N TEST STRIPS

.......................................... 55

CARESENS N VOICE ........ 59

CARIMUNE NF

NANOFILTERED............ 78

carisoprodol .......................... 21

carisoprodol-asa-codeine ...... 21

carisoprodol-aspirin .............. 21

CARNITOR.......................... 51

CARNITOR (SUGAR-FREE)

.......................................... 51

carteolol ................................ 88

cartia xt ................................. 34

carvedilol .............................. 34

CASODEX ........................... 12

CASPOFUNGIN .................... 3

CATAPRES .......................... 34

CATAPRES-TTS-1 .............. 34

CATAPRES-TTS-2 .............. 35

CATAPRES-TTS-3 .............. 35

CAYA CONTOURED ......... 82

CAYSTON ............................. 7

caziant (28) ........................... 84

CEDAX .................................. 6

cefaclor ................................... 6

cefadroxil ................................ 6

cefazolin ................................. 6

CEFAZOLIN IN 0.9% SOD

CHLORIDE ........................ 6

cefazolin in dextrose (iso-os) .. 6

CEFAZOLIN IN DEXTROSE

(ISO-OS) ............................. 6

CEFAZOLIN IN DEXTROSE

5 % ...................................... 6

CEFAZOLIN IN STERILE

WATER .............................. 6

cefdinir .................................... 6

cefditoren pivoxil .................... 6

cefepime ................................. 6

cefepime in dextrose,iso-osm . 6

cefixime .................................. 6

CEFOTAN .............................. 6

cefotaxime .............................. 6

cefotetan ................................. 6

cefoxitin .................................. 6

cefpodoxime ........................... 6

cefprozil .................................. 6

CEFTIN .................................. 6

ceftriaxone .............................. 6

CEFTRIAXONE .................... 6

ceftriaxone in dextrose,iso-os . 6

cefuroxime axetil .................... 6

cefuroxime sodium ................. 6

CEFUROXIME SODIUM-

0.9%NACL(PF) ................ 88

celacyn .................................. 43

CELEBREX ......................... 26



112

celecoxib............................... 26

CELESTONE SOLUSPAN . 54

CELEXA .............................. 28

CELLCEPT .......................... 12

CELLCEPT INTRAVENOUS

.......................................... 12

CELONTIN .......................... 17

CENTANY ........................... 47

CENTANY AT .................... 47

centergy ................................ 92

centratex ............................... 99

cephalexin............................... 6

CEPROTIN (BLUE BAR) ... 38

CEPROTIN (GREEN BAR) 38

CERDELGA......................... 66

CEREZYME ........................ 66

CERVIDIL ........................... 83

CESAMET ........................... 71

cetirizine ............................... 91

CETRAXAL......................... 53

CETROTIDE ........................ 66

cevimeline ............................ 51

CHANTIX ............................ 52

CHANTIX CONTINUING

MONTH BOX .................. 52

CHANTIX STARTING

MONTH BOX .................. 52

chateal................................... 84

CHEMET ............................. 51

CHENODAL ........................ 71

cheratussin ac ....................... 92

children's aspirin ................... 26

chloramphenicol sod succinate

............................................ 7

chlordiazepoxide hcl ............ 28

chlordiazepoxide-clidinium .. 70

chlorhexidine gluconate ....... 53

chloroquine phosphate............ 7

chlorothiazide ....................... 35

chlorothiazide sodium .......... 35

chlorpromazine ..................... 28

chlorpropamide..................... 68

chlorthalidone ....................... 35

chlorzoxazone....................... 21

CHOLBAM .......................... 71

cholecalciferol (vitamin d3) . 99

cholestyramine (with sugar) . 40

cholestyramine light ............. 40

choline,magnesium salicylate

.......................................... 26

CHORIONIC

GONADOTROPIN,

HUMAN ........................... 66

CIALIS ................................. 96

ciclodan ................................ 48

CICLODAN KIT .................. 48

ciclopirox .............................. 48

cidaleaze ............................... 46

cidofovir ................................. 4

ciferex ................................... 99

cilostazol ............................... 38

CILOXAN ............................ 88

cimetidine ............................. 75

cimetidine hcl ....................... 75

CIMZIA ................................ 71

CIMZIA POWDER FOR

RECONST ........................ 71

CINQAIR ............................. 94

CINRYZE ............................. 94

CIPRO .................................. 10

CIPRO HC ............................ 54

CIPRO XR ............................ 10

CIPRODEX .......................... 54

ciprofloxacin ......................... 10

ciprofloxacin (mixture)......... 10

ciprofloxacin hcl ....... 10, 53, 88

cisplatin ................................ 12

citalopram ............................. 28

CITRANATAL (DUAL-

IRON) ............................... 99

CITRANATAL 90 DHA

(ALGAL OIL) .................. 99

CITRANATAL ASSURE .... 99

CITRANATAL B-CALM (FE

GLUC) .............................. 99

CITRANATAL DHA

(ALGAL OIL) .................. 99

CITRANATAL HARMONY

(IRON FUM) .................... 99

citrate of magnesia................ 71

citroma .................................. 71

citrus calcium ....................... 97

cladribine .............................. 12

CLAFORAN .......................... 6

claravis.................................. 45

CLARINEX .......................... 91

CLARINEX-D 12 HOUR .... 92

clarithromycin ......................... 6

classic prenatal ...................... 99

cleansing wash ...................... 45

clearlax ................................. 71

clemastine ............................. 91

CLEO 90 INFUSION SET 24

.......................................... 59

cleocin ..................................... 7

CLEOCIN ......................... 7, 83

CLEOCIN HCL ...................... 7

CLEOCIN IN 5 %

DEXTROSE ....................... 7

CLEOCIN PEDIATRIC ......... 7

CLEOCIN T ......................... 45

CLEVER CHEK BLOOD

GLUCOSE ........................ 59

CLEVER CHOICE


CLEVER CHOICE LEVEL 2

CONTROL ....................... 59

CLEVER CHOICE MICRO . 59

CLEVER CHOICE MICRO

TEST STRIP ..................... 55

CLEVER CHOICE PRO 55, 59

CLEVER CHOICE TEST

STRIPS ............................. 55

CLEVER CHOICE VOICE+

TEST ................................. 55

CLEVIPREX ........................ 35

CLIMARA ............................ 82

CLIMARA PRO ................... 82

CLIN SINGLE USE ............... 7

CLINDACIN ETZ ................ 45

clindacin p ............................ 45

CLINDACIN PAC ............... 45

CLINDAGEL ....................... 45

clindamycin hcl ...................... 7

CLINDAMYCIN IN 0.9 %

SOD CHLOR ...................... 7

clindamycin in 5 % dextrose .. 7

clindamycin palmitate hcl ....... 7

clindamycin pediatric ............. 7

clindamycin phosphate .... 7, 45,

83

clindamycin-benzoyl peroxide

.......................................... 45

clindamycin-tretinoin ........... 45



113

CLINDESSE ........................ 83

CLINPRO 5000 .................... 53

clobetasol .............................. 49

clobetasol-emollient ............. 49

CLOBEX .............................. 49

CLOCORTOLONE

PIVALATE ...................... 49

clodan ................................... 49

CLODAN KIT...................... 49

CLODERM .......................... 49

clofarabine ............................ 12

CLOLAR .............................. 12

clomiphene citrate ................ 66

clomipramine ........................ 28

clonazepam ........................... 17

clonidine ............................... 35

clonidine hcl ................... 28, 35

clopidogrel ............................ 38

clorazepate dipotassium ....... 28

clorpres ................................. 35

CLORPRES .......................... 35

clotrimazole ............................ 3

clotrimazole-betamethasone . 48

clozapine......................... 28, 29

CLOZAPINE ........................ 29

CLOZARIL .......................... 29

c-nate dha ............................. 99

COAGADEX ....................... 38

COAL TAR .......................... 42

COARTEM ............................ 7

codeine sulfate ...................... 22

codeine-guaifenesin .............. 92

CODITUSSIN AC................ 92

CODITUSSIN DAC ............. 92

COLAZAL ........................... 71

COLCHICINE ...................... 80

COLCRYS ........................... 80

COLESTID........................... 40

COLESTID FLAVORED .... 40

colestipol .............................. 40

colistin (colistimethate na) ..... 7

colocort ................................. 71

COLY-MYCIN M

PARENTERAL .................. 7

COLY-MYCIN S ................. 54

COLYTE WITH FLAVOR

PACKS ............................. 71

COMBIGAN ........................ 90

COMBIPATCH .................... 82

COMBIVENT RESPIMAT . 94

COMBIVIR ............................ 4

COMETRIQ ......................... 12

COMFORT SHORT INSULIN

PUMP 23 .......................... 59

COMPAZINE ....................... 71

COMPLERA .......................... 4

complete natal dha ................ 99

completenate ......................... 99

complex b-100 ...................... 99

compro .................................. 71

COMTAN ............................. 19

CONCEPT DHA .................. 99

CONCEPT OB ..................... 99

CONCEPTROL .................... 83

CONCERTA ........................ 29

CONDYLOX........................ 43

constulose ............................. 71

CONTOUR CONTROL

SOLUTION, NML ........... 59

CONTOUR LINK ................ 59

CONTOUR NEXT EZ

METER ............................ 59

CONTOUR NEXT LEV 2

CONTROL SOL............... 60

CONTOUR NEXT LINK .... 60

CONTOUR NEXT METER 60

CONTOUR NEXT ONE

METER ............................ 60

CONTOUR NEXT STRIPS . 55

CONTOUR TEST STRIPS .. 55

CONTROL AST

MONITORING SYSTEM 60

CONZIP................................ 26

COOL BLOOD GLUCOSE

METER ............................ 60

COOL CONTROL A

SOLUTION ...................... 60

COOL GLUCOSE TEST

STRIP ............................... 55

COPAXONE ........................ 77

COPEGUS ............................ 77

CORDRAN .......................... 49

CORDRAN TAPE LARGE

ROLL................................ 49

COREG ................................ 35

COREG CR .......................... 35

CORGARD ........................... 35

CORIFACT .......................... 38

CORLANOR ........................ 41

cormax .................................. 49

CORTANE-B ....................... 43

CORTEF ............................... 54

CORTENEMA ..................... 71

CORTIFOAM ....................... 71

cortisone ............................... 54

CORTISPORIN .................... 47

CORTROSYN ...................... 54

corvita ................................... 99

corvita 150 ............................ 99

CORVITE ............................. 99

CORVITE 150 ...................... 99

CORVITE FE ....................... 99

CORVITE FREE .................. 99

CORZIDE ............................. 35

COSENTYX ......................... 42

COSENTYX (2 SYRINGES)

.......................................... 42

COSENTYX PEN ................ 42

COSENTYX PEN (2 PENS) 42

COSMEGEN ........................ 12

COSOPT ............................... 90

COSOPT (PF) ....................... 90

cosyntropin ........................... 54

COTELLIC ........................... 12

COTEMPLA XR-ODT ........ 29

COUMADIN ........................ 38

covaryx ................................. 82

covaryx h.s. ........................... 82

COZAAR .............................. 35

CREON ................................. 71

CRESEMBA ........................... 3

CRESTOR ............................ 40

CRINONE ............................ 82

CRIXIVAN ............................. 4

cromolyn ................... 71, 89, 94

cryselle (28) .......................... 84

CUBICIN ................................ 7

CUBICIN RF .......................... 8

CUPRIMINE ........................ 81

CUROSURF ......................... 94

CUSHINGS SYNDROME

DIAGNOSTIC .................. 54

CUTIVATE .......................... 49

CUVITRU ............................ 78



114

CUVPOSA ........................... 70

cyanocobalamin (vitamin b-12)

.......................................... 99

cyclafem 1/35 (28) ............... 84

cyclafem 7/7/7 (28) .............. 84

CYCLESSA (28) .................. 84

cyclobenzaprine .................... 21

CYCLOGYL ........................ 88

CYCLOMYDRIL................. 91

cyclopentolate....................... 88

cyclophosphamide ................ 13

CYCLOPHOSPHAMIDE .... 13

CYCLOSERINE .................... 8

CYCLOSET ......................... 68

cyclosporine ......................... 13

cyclosporine modified .......... 13

CYMBALTA ....................... 29

cyproheptadine ..................... 91

CYRAMZA .......................... 13

cyred ..................................... 84

CYSTADANE ...................... 71

CYSTAGON ........................ 96

CYSTARAN ........................ 89

cytarabine ............................. 13

cytarabine (pf) ...................... 13

CYTOMEL........................... 69

CYTOTEC ........................... 75

CYTOVENE .......................... 4

cytra k crystals ...................... 96

cytra-2................................... 96

cytra-3................................... 96

cytra-k................................... 96

D D.H.E.45 ............................... 19

dacarbazine ........................... 13

DACOGEN .......................... 13

DAKLINZA ........................... 4

DALIRESP ........................... 94

danazol ................................. 66

DANTRIUM ........................ 21

dantrolene ............................. 21

dapsone ................................... 8

DAPTACEL (DTAP

PEDIATRIC) (PF)............ 78

daptomycin ............................. 8

DARAPRIM ........................... 8

darifenacin ............................ 96

DARZALEX ........................ 13

dasetta 1/35 (28) ................... 85

dasetta 7/7/7 (28) .................. 85

daunorubicin ......................... 13

DAXBIA ................................ 6

DAYPRO.............................. 26

daysee ................................... 85

DAYTRANA........................ 29

DDAVP ................................ 66

DEBACTEROL.................... 53

deblitane ............................... 82

decitabine.............................. 13

DEFITELIO.......................... 38

DELESTROGEN ................. 82

delta d3 ................................. 99

deltasone ............................... 54

delyla (28)............................. 85

DELZICOL .......................... 71

DEMADEX .......................... 35

demeclocycline ..................... 10

DEMEROL ........................... 22

DEMSER .............................. 35

DENAVIR ............................ 48

denta 5000 plus ..................... 53

dentagel ................................ 53

DEPACON ........................... 17

DEPAKENE ......................... 17

DEPAKOTE ......................... 17

DEPAKOTE ER ................... 17

DEPAKOTE SPRINKLES .. 17

DEPEN TITRATABS .......... 81

DEPO-ESTRADIOL ............ 82

DEPO-PROVERA................ 82

DEPO-SUBQ PROVERA 104

.......................................... 82

DEPO-TESTOSTERONE .... 66

DERMACINRX

EMPRICAINE.................. 47

DERMA-SMOOTHE/FS

BODY OIL ....................... 49

DERMA-SMOOTHE/FS

SCALP OIL ...................... 49

DERMATOP ........................ 49

DERMOTIC OIL ................. 53

DESCOVY ............................. 4

desipramine .......................... 29

desloratadine ......................... 91

desmopressin ........................ 66

desog-e.estradiol/e.estradiol . 85

desogestrel-ethinyl estradiol . 85

DESONATE ......................... 49

desonide ................................ 49

DESOWEN ........................... 49

desoximetasone ..................... 49

DESOXYN ........................... 29

DESVENLAFAXINE .......... 29

DESVENLAFAXINE

FUMARATE .................... 29

desvenlafaxine succinate ...... 29

DETROL .............................. 96

DETROL LA ........................ 96

dexamethasone ..................... 54

dexamethasone intensol ........ 54

dexamethasone sodium phos

(pf) .................................... 54

dexamethasone sodium

phosphate .................... 54, 90

DEXCOM G5 RECEIVER .. 60

DEXCOM RECEIVER ........ 60

DEXEDRINE SPANSULE .. 29

DEXERYL ........................... 43

DEXILANT .......................... 75

dexmethylphenidate .............. 29

DEXPAK 10 DAY ............... 54

DEXPAK 13 DAY ............... 54

DEXPAK 6 DAY ................. 54

dexrazoxane hcl .................... 11

dextroamphetamine .............. 29

dextroamphetamine-

amphetamine ..................... 29

dialyvite ................................ 99

DIALYVITE 3000 ................ 99

DIALYVITE 5000 ................ 99

dialyvite 800 ......................... 99

DIALYVITE 800 WITH IRON

.......................................... 99

DIALYVITE SUPREME D . 99

DIAMOX SEQUELS ........... 90

DIASTAT ............................. 17

DIASTAT ACUDIAL .......... 17

DIATRUE CONTROL SOLN

NORMAL ......................... 60

DIATRUE PLUS BLOOD

GLUCOSE MET .............. 60

DIATRUE PLUS TEST STRIP

.......................................... 55

diazepam ......................... 17, 29



115

diazepam intensol ................. 29

DIBENZYLINE ................... 35

DICLEGIS ............................ 71

DICLO GEL-XRYLIX

SHEET ............................. 26

diclofenac potassium ............ 26

diclofenac sodium .... 26, 43, 89

diclofenac-misoprostol ......... 26

dicloxacillin .......................... 10

dicyclomine .......................... 70

didanosine............................... 4

DIFFERIN ............................ 45

DIFICID ................................. 6

diflorasone ............................ 49

DIFLUCAN ............................ 3

diflunisal ............................... 26

digitek ................................... 38

digox ..................................... 38

digoxin .................................. 38

dihydroergotamine ............... 19

DILANTIN ........................... 17

DILANTIN EXTENDED .... 17

DILANTIN INFATABS ...... 17

DILANTIN-125 ................... 17

DILATRATE-SR ................. 41

DILAUDID .......................... 22

diltiazem ............................... 35

DILTIAZEM HCL IN 0.9%

NACL ............................... 35

DILTIAZEM IN DEXTROSE

5 %.................................... 35

dilt-xr .................................... 35

DIOVAN .............................. 35

DIOVAN HCT ..................... 35

DIPENTUM ......................... 72

diphenhydramine hcl ............ 91

diphenoxylate-atropine ......... 70

DIPROLENE ........................ 49

dipyridamole......................... 38

DISALCID ........................... 26

diskets ................................... 22

disopyramide phosphate ....... 33

disulfiram ............................. 51

DITROPAN XL ................... 96

DIURIL ................................ 35

DIURIL IV ........................... 35

divalproex ............................. 17

DIVIGEL .............................. 82

DM2...................................... 68

DOCEFREZ ......................... 13

docetaxel ............................... 13

DOCETAXEL ...................... 13

dofetilide ............................... 33

DOLOPHINE ....................... 22

DOLOTRANZ...................... 47

donepezil .............................. 20

DONNATAL ........................ 70

DORAL ................................ 29

DORIBAX .............................. 8

DORIPENEM ......................... 8

DORYX ................................ 10

DORYX MPC ...................... 10

dorzolamide .......................... 90

dorzolamide-timolol ............. 90

dothelle dha .......................... 99

DOVONEX .......................... 42

doxazosin .............................. 35

doxepin ........................... 29, 43

doxercalciferol ................ 66, 67

DOXIL.................................. 13

doxorubicin ........................... 13

doxorubicin, peg-liposomal .. 13

doxycycline hyclate .............. 10

doxycycline monohydrate ... 10,

11

DOXYCYCLINE

MONOHYDRATE ........... 10

drithocreme hp ...................... 42

dronabinol ............................. 72

drospirenone-e.estradiol-lm.fa

.......................................... 85

drospirenone-ethinyl estradiol

.......................................... 85

DROXIA .............................. 13

DUAC ................................... 45

DUAVEE.............................. 82

ducodyl ................................. 72

DUET DHA BALANCED ... 99

DUET DHA WITH OMEGA-3

........................................ 100

DUETACT ........................... 68

DUEXIS ............................... 26

DULERA .............................. 94

duloxetine ............................. 29

DUOPA ................................ 19

DUPIXENT .......................... 43

DURAGESIC ....................... 22

DUREZOL ........................... 90

DURLAZA ........................... 38

dutasteride ............................. 96

dutasteride-tamsulosin .......... 96

DUTOPROL ......................... 35

DUZALLO ........................... 80

d-vi-sol ................................ 100

DYANAVEL XR ................. 29

DYAZIDE ............................ 35

DYMISTA ............................ 94

DYRENIUM ......................... 35

DYSPORT ............................ 78

E e.c. prin ................................. 26

e.e.s. 400 ................................. 6

E.E.S. GRANULES ................ 6

EASY PLUS II BLOOD

GLUCOSE MET .............. 60

EASY PLUS II TEST ........... 55

EASY STEP ......................... 55

EASY STEP BLOOD


EASY TALK BLOOD


EASY TALK GLUCOSE

TEST ................................. 55

EASY TOUCH GLUCOSE

MONITOR ....................... 60

EASY TOUCH TEST STRIP

.......................................... 55

EASY TRAK GLUCOSE

TEST ................................. 55

EASY TRAK LOW

CONTROL ....................... 60

EASYGLUCO


EASYGLUCO PLUS ..... 56, 60

EASYGLUCO PLUS

NORMAL CONTROL ..... 60

EASYGLUCO TEST ........... 56

EASYMAX .......................... 56

EASYMAX L BLOOD


EASYMAX LOW CONTROL

.......................................... 60

EASYMAX NG .................... 60



116

EASYMAX NORMAL

CONTROL ....................... 60

EASYMAX V SPEAKING

GLUCOSE SYS ............... 60

EASYMAX V2 BLOOD


EC-NAPROSYN .................. 26

econazole .............................. 48

econtra ez.............................. 85

ecotrin ................................... 26

ecotrin low strength .............. 26

ECOZA................................. 48

EDARBI ............................... 35

EDARBYCLOR ................... 35

EDECRIN............................. 35

EDLUAR .............................. 29

ed-spaz .................................. 70

EDURANT ............................. 4

eemt ...................................... 82

eemt hs.................................. 82

effer-k ................................... 98

EFFER-K .............................. 98

EFFEXOR XR...................... 29

EFFIENT .............................. 38

EFUDEX .............................. 43

EGRIFTA ............................. 77

ELAPRASE .......................... 67

ELDEPRYL ......................... 19

ELELYSO ............................ 67

ELEMENT COMPACT


ELEMENT COMPACT

NORMAL CONTROL ..... 60

ELEMENT COMPACT TEST

STRIPS ............................. 56

ELEMENT COMPACT V

GLUCOSE MTR .............. 60

ELEMENT NORMAL

CONTROL ....................... 60

ELEMENT PLUS BLOOD

GLUCOSE KIT ................ 61

ELEMENT TEST STRIPS... 56

ELESTAT............................. 89

ELESTRIN ........................... 82

eletone .................................. 43

eletriptan hbr ........................ 19

ELIDEL ................................ 43

ELIGARD ............................ 13

ELIGARD (3 MONTH) ....... 13



ELIMITE .............................. 50

elinest.................................... 85

eliphos .................................. 72

ELIQUIS .............................. 38

ELITEK ................................ 11

ELIXOPHYLLIN ................. 94

ELLA .................................... 85

ELLENCE ............................ 13

ELLZIA PAK ....................... 49

ELMIRON ............................ 96

ELOCON .............................. 49

ELOCTATE ......................... 38

EMADINE............................ 89

EMBEDA ............................. 22

EMBRACE BLOOD

GLUCOSE SYSTEM . 56, 61

EMBRACE EVO LEVEL 1 . 61

EMBRACE EVO TEST

STRIPS ............................. 56

EMBRACE GLUCOSE

CONTROL LOW ............. 61

EMBRACE PRO GLUCOSE

METER ............................ 61

EMBRACE PRO TEST

STRIPS ............................. 56

EMCYT ................................ 13

EMEND ................................ 72

EMEND (FOSAPREPITANT)

.......................................... 72

EMFLAZA ........................... 54

emoquette ............................. 85

EMPLICITI .......................... 13

EMSAM ............................... 29

EMTRIVA .............................. 4

EMVERM .............................. 8

ENABLEX ........................... 96

enalapril maleate................... 35

enalaprilat ............................. 35

enalapril-hydrochlorothiazide

.......................................... 35

ENBRACE HR ................... 100

ENBREL .............................. 81

ENBREL SURECLICK ....... 81

ENDARI ............................... 51

endocet.................................. 22

ENDOMETRIN .................... 82

ENGERIX-B (PF) ................ 78

ENGERIX-B PEDIATRIC

(PF) ................................... 78

enoxaparin ............................ 38

enpresse ................................ 85

enskyce ................................. 85

ENSTILAR ........................... 42

entacapone ............................ 19

entecavir ................................. 4

ENTOCORT EC ................... 72

ENTRESTO .......................... 41

ENTYVIO ............................ 72

enulose .................................. 72

ENVARSUS XR .................. 13

EPANED .............................. 35

EPCLUSA .............................. 4

EPICERAM .......................... 43

EPIDUO ............................... 45

EPIDUO FORTE .................. 45

EPIFOAM ............................. 42

epinastine .............................. 89

EPINEPHRINE .................... 91

EPINEPHRINESNAP-V ...... 91

EPIPEN 2-PAK .................... 91

EPIPEN JR 2-PAK ............... 91

epirubicin .............................. 13

EPISIL .................................. 53

EPISNAP .............................. 91

epitol ..................................... 17

EPIVIR ................................... 4

EPIVIR HBV .......................... 4

eplerenone ............................. 35

EPOGEN .............................. 77

epoprostenol (glycine) .......... 35

eprosartan ............................. 35

EPZICOM ............................... 4

EQUETRO ........................... 17

ERAXIS(WATER DILUENT)

............................................ 3

ERBITUX ............................. 13

ergocalciferol (vitamin d2) . 100

ergoloid ................................. 29

ERGOMAR .......................... 19

ergotamine-caffeine .............. 19

ERIVEDGE .......................... 13

errin ....................................... 82

ERTACZO ............................ 48



117

ERWINAZE ......................... 13

ery pads ................................ 45

erygel .................................... 45

ERYPED 200 ......................... 6

ERYPED 400 ......................... 6

ery-tab..................................... 7

ERY-TAB............................... 7

erythrocin (as stearate) ........... 7

erythromycin .................... 7, 88

erythromycin ethylsuccinate .. 7

erythromycin with ethanol ... 45

erythromycin-benzoyl peroxide

.......................................... 45

ESBRIET .............................. 94

ESCAVITE......................... 100

ESCAVITE D ..................... 100

ESCAVITE LQ .................. 100

escitalopram oxalate ............. 29

ESGIC .................................. 22

esmolol ................................. 35

esomeprazole magnesium .... 75

esomeprazole sodium ........... 75

ESOMEPRAZOLE

STRONTIUM................... 75

estarylla ................................ 85

estazolam .............................. 29

ESTRACE ............................ 82

estradiol ................................ 82

estradiol valerate .................. 82

estradiol-norethindrone acet . 82

ESTRING ............................. 82

ESTROGEL ......................... 82

estrogens-methyltestosterone 83

estropipate ............................ 83

ESTROSTEP FE-28 ............. 85

eszopiclone ........................... 29

ethacrynate sodium ............... 35

ethacrynic acid...................... 35

ethambutol .............................. 8

ethosuximide ........................ 17

ethyl chloride ........................ 47

ethynodiol diac-eth estradiol 85

ETHYOL .............................. 11

etidronate disodium .............. 51

etodolac ................................ 26

etoposide............................... 13

EUCRISA ............................. 43

EUFLEXXA ......................... 26

EURAX ................................ 50

EVAMIST ............................ 83

EVEKEO .............................. 29

EVENCARE G2 ............. 56, 61

EVENCARE G3 GLUCOSE

METER ............................ 61

EVENCARE G3 TEST ........ 56

EVENCARE MINI

GLUCOSE TEST STR ..... 56

EVENCARE MINI

MONITOR SYSTEM....... 61

EVISTA ................................ 81

EVOCLIN ............................ 45

EVOLUTION BLOOD


EVOLUTION NORMAL

CONTROL ....................... 61

EVOLUTION TEST STRIPS

.......................................... 56

EVOMELA .......................... 13

EVOTAZ ................................ 4

EVOXAC ............................. 51

EVZIO .................................. 26

EXALGO ER ....................... 22

EXELDERM ........................ 48

EXELON .............................. 20

exemestane ........................... 13

EXFORGE............................ 35

EXFORGE HCT................... 35

EXJADE ............................... 51

EXODERM .......................... 48

EXONDYS 51 ...................... 20

EXTAVIA ............................ 77

EXTINA ............................... 48

EXTRA-VIRT PLUS DHA 100

EYLEA ................................. 89

EZ SMART PLUS SYSTEM

.......................................... 61

EZ SMART PLUS TEST ..... 56

EZ SMART SYSTEM.......... 61

EZ SMART TEST ................ 56

ezetimibe .............................. 40

ezetimibe-simvastatin ........... 40

F FABIOR ............................... 45

FABRAZYME ..................... 67

FACTIVE ............................. 10

falmina (28) .......................... 85

famciclovir .............................. 4

famotidine ............................. 75

famotidine (pf) ...................... 75

famotidine (pf)-nacl (iso-os) 75

FANAPT ............................... 29

FARESTON ......................... 13

FARXIGA ............................ 68

FARYDAK ........................... 13

FASLODEX ......................... 13

fayosim ................................. 85

FAZACLO ............................ 29

FC2 FEMALE CONDOM ... 82

FEIBA NF ............................ 38

felbamate .............................. 17

FELBATOL .......................... 17

FELDENE ............................ 26

felodipine .............................. 35

fem ph ................................... 83

FEMARA ............................. 13

FEMCAP .............................. 82

FEMHRT LOW DOSE ........ 83

FEMRING ............................ 83

femynor ................................. 85

fenofibrate ............................. 40

FENOFIBRATE ................... 40

fenofibrate micronized .......... 40

fenofibrate nanocrystallized . 40

fenofibric acid ....................... 40

fenofibric acid (choline) ....... 40

FENOGLIDE ........................ 40

fenoprofen ............................. 26

FENOPROFEN .................... 26

FENORTHO ......................... 26

fentanyl ................................. 22

FENTANYL ......................... 23

FENTANYL (PF)-

BUPIVACAINE-NACL ... 22

fentanyl citrate ...................... 22

fentanyl citrate (pf) ............... 22

fentanyl citrate-0.9%nacl (pf)

.......................................... 22

FENTANYL CITRATE-

0.9%NACL (PF) ............... 22

FENTANYL-

ROPIVACAINE-NACL

(PF) ................................... 23

FENTORA ............................ 23

FERIVA 21-7 TABLET ..... 100



118

ferocon ................................ 100

FERRALET 90 DUAL-IRON

DELIVERY .................... 100

ferraplus 90 ......................... 100

FERRIPROX ........................ 51

FERRLECIT......................... 51

ferrocite plus ....................... 100

FETZIMA............................. 29

FEXMID............................... 21

FIBRICOR ........................... 40

FIFTY50 TEST STRIP ........ 56

FINACEA............................. 45

finasteride ............................. 96

FIORICET ............................ 23

FIORINAL ........................... 23

FIORINAL-CODEINE #3 ... 23

FIRAZYR ............................. 94

FIRMAGON KIT W

DILUENT SYRINGE ...... 13

FLAGYL ................................ 8

FLAREX .............................. 90

flavoxate ............................... 96

FLEBOGAMMA DIF .......... 79

flecainide .............................. 33

FLECTOR ............................ 26

fleet laxative ......................... 72

FLOLAN .............................. 35

FLOLIPID ............................ 40

FLOMAX ............................. 96

FLORIVA........................... 100

FLORIVA (FLUORIDE-

VITAMIN D3) ............... 100

FLORIVA PLUS ................ 100

FLOVENT DISKUS ............ 94

FLOVENT HFA ................... 94

FLOWTUSS ......................... 92

floxin .................................... 53

floxuridine ............................ 13

FLUAD 2017-2018 (65 YR

UP)(PF) ............................ 79

FLUARIX QUAD 2017-2018

(PF) ................................... 79

FLUBLOK 2017-2018 (PF) . 79

FLUBLOK QUAD 2017-2018

(PF) ................................... 79

flucaine ................................. 89

FLUCELVAX QUAD 2017-

2018 .................................. 79

FLUCELVAX QUAD 2017-

2018 (PF) .......................... 79

fluconazole ............................. 3

fluconazole in dextrose(iso-o) 3

fluconazole in nacl (iso-osm) . 3

flucytosine .............................. 3

fludarabine ............................ 13

fludrocortisone...................... 54

FLULAVAL QUAD 2017-

2018 .................................. 79

FLULAVAL QUAD 2017-

2018 (PF) .......................... 79

FLUMADINE ........................ 4

flumazenil ............................. 29

FLUMIST QUAD 2017-2018

.......................................... 79

flunisolide ............................. 94

fluocinolone .......................... 49

fluocinolone acetonide oil .... 53

fluocinolone and shower cap 49

fluocinonide .......................... 49

fluocinonide-e ....................... 49

fluocinonide-emollient ......... 49

FLUORABON.................... 100

FLUOR-A-DAY ................. 100

fluor-a-day (with xylitol) .... 100

fluorescein-proparacaine ...... 89

fluoride (sodium) .......... 53, 100

FLUORIDEX DAILY

DEFENSE ........................ 53

fluoritab .............................. 100

fluorometholone ................... 90

FLUOROPLEX .................... 43

fluorouracil ..................... 13, 43

FLUOROURACIL ............... 43

fluoxetine ........................ 29, 30

FLUOXETINE ..................... 30

fluphenazine decanoate ........ 30

fluphenazine hcl ................... 30

FLURA-DROPS ................. 100

flurandrenolide ..................... 49

flurazepam ............................ 30

flurbiprofen ........................... 26

flurbiprofen sodium .............. 89

flurox .................................... 89

flutamide ............................... 13

fluticasone ...................... 49, 94

FLUTICASONE-

SALMETEROL ................ 94

fluvastatin ............................. 40

FLUVIRIN 2017-2018 ......... 79

FLUVIRIN 2017-2018 (PF) . 79

fluvoxamine .......................... 30

FLUZONE HIGH-DOSE

2017-18 (PF) ..................... 79

FLUZONE INTRADERM

QUAD 2017-18 ................ 79

FLUZONE QUAD 2017-2018

.......................................... 79

FLUZONE QUAD 2017-2018

(PF) ................................... 79

FLUZONE QUAD PEDI

2017-18 (PF) ..................... 79

FML FORTE ........................ 90

FML LIQUIFILM ................ 90

FML S.O.P. ........................... 90

focalgin 90 dha ................... 100

focalgin ca .......................... 100

focalgin dss ......................... 100

FOCALIN ............................. 30

FOCALIN XR ...................... 30

folbee .................................. 100

folbee plus .......................... 100

FOLET ONE ...................... 100

FOLGARD OS ................... 100

FOLGARD RX ................... 100

folic acid ............................. 100

folic acid-vit b6-vit b12 ...... 100

folivane-f ............................ 100

folivane-ob .......................... 100

folivane-plus ....................... 100

FOLLISTIM AQ .................. 67

FOLOTYN ........................... 14

folplex 2.2 ........................... 101

foltabs 800 .......................... 101

FOLTRATE ........................ 101

fondaparinux ......................... 38

FORA D10 ............................ 61

FORA D15G ......................... 56

FORA D20 ...................... 56, 61

FORA D40-G31 TEST

STRIPS ............................. 56

FORA G20 ...................... 56, 61

FORA G30A ................... 56, 61



119

FORA GD50 BLOOD

GLUCOSE SYSTEM ....... 61

FORA GD50 TEST STRIPS 56

FORA NORMAL CONTROL

.......................................... 61

FORA PREMIUM V10


FORA TEST N'GO VOICE

METER ............................ 61

FORA TEST STRIP ............. 56

FORA TN'G VOICE METER

.......................................... 61

FORA TN'G VOICE TEST

STRIPS ............................. 56

FORA V10 ..................... 56, 61

FORA V10-V12-D10-D20

STRIPS ............................. 56

FORA V12 BLOOD


FORA V12 GLUCOSE ........ 56

FORA V20 ..................... 56, 61

FORA V30A ........................ 61

FORACARE GD20 .............. 56

FORACARE GD20


FORACARE GD40 .............. 56

FORACARE GD40A


FORACARE GD40B


FORACARE GDH LOW

CONTROL ....................... 61

FORFIVO XL ...................... 30

FORTAMET ........................ 68

FORTAVIT .......................... 98

FORTEO .............................. 81

FORTESTA .......................... 67

FORTISCARE BLOOD

GLUCOSE SYST ............. 61

FORTISCARE GLUCOSE

TEST STRIPS .................. 56

FORTISCARE NORMAL ... 61

FOSAMAX .......................... 81

FOSAMAX PLUS D ............ 81

fosamprenavir ......................... 4

foscarnet ................................. 4

FOSCAVIR ............................ 4

fosinopril .............................. 35

fosinopril-hydrochlorothiazide

.......................................... 35

fosphenytoin ......................... 17

FOSRENOL ......................... 72

FRAGMIN............................ 38

FREESTYLE CONTROL .... 61

FREESTYLE FLASH

SYSTEM .......................... 61

FREESTYLE FREEDOM .... 61

FREESTYLE FREEDOM

LITE ................................. 62

FREESTYLE INSULINX ... 56,

62

FREESTYLE INSULINX

TEST STRIPS .................. 56

FREESTYLE LITE METER 62

FREESTYLE LITE STRIPS 56

FREESTYLE PRECISION

NEO METER ................... 62

FREESTYLE PRECISION

NEO STRIPS .................... 56

FREESTYLE SIDEKICK II 62

FREESTYLE SYSTEM KIT 62

FREESTYLE TEST ............. 56

FROTEK .............................. 26

frovatriptan ........................... 19

full spectrum b-vitamin c ... 101

FURADANTIN .................... 11

furosemide ............................ 35

FUSILEV.............................. 11

FUSION PLUS ................... 101

FUSION SPRINKLES ....... 101

FUZEON ................................ 4

fyavolv .................................. 83

FYCOMPA ........................... 17

G g tussin ac ............................. 92

gabapentin ............................ 17

GABITRIL ........................... 17

galantamine .......................... 20

GALZIN ............................... 98

GAMASTAN S/D ................ 79

GAMMAGARD LIQUID .... 79

GAMMAGARD S-D (IGA < 1

MCG/ML) ........................ 79

GAMMAKED ...................... 79

GAMMAPLEX .................... 79

GAMMAPLEX (WITH

SORBITOL) ..................... 79

GAMUNEX-C ...................... 79

GANCICLOVIR ..................... 4

ganciclovir sodium ................. 4

GANIRELIX ........................ 67

GASTROCROM .................. 72

gatifloxacin ........................... 88

GATTEX 30-VIAL .............. 72

gavilax .................................. 72

gavilyte-c .............................. 72

gavilyte-g .............................. 72

gavilyte-n .............................. 72

GAZYVA ............................. 14

GE100 BLOOD GLUCOSE

SYSTEM .......................... 62

GE100 BLOOD GLUCOSE

TEST STRIP ..................... 56

GE100 CONTROL

SOLUTION NORMAL .... 62

GELCLAIR .......................... 53

GELNIQUE .......................... 96

gemcitabine ........................... 14

gemfibrozil ........................... 40

GEMZAR ............................. 14

GENERESS FE .................... 85

generlac ................................. 72

gengraf .................................. 14

GENOTROPIN ..................... 77

GENOTROPIN MINIQUICK

.......................................... 77

GENSTRIP TEST STRIP ..... 56

gentak ................................... 88

gentamicin .................. 8, 47, 88

gentamicin in nacl (iso-osm) .. 8

GENTAMICIN IN NACL

(ISO-OSM) ......................... 8

gentamicin sulfate (ped) (pf) .. 8

gentamicin sulfate (pf) ............ 8

GENTAMICIN SULFATE

(PF) ..................................... 8

gentle laxative ....................... 72

gentlelax ............................... 72

GENVOYA ............................ 4

GEODON ............................. 30

GIALAX ............................... 72

gianvi (28) ............................ 85

GIAZO .................................. 72



120

gildagia ................................. 85

GILENYA ............................ 77

GILOTRIF ............................ 14

GLASSIA ............................. 51

glatopa .................................. 77

GLEEVEC ............................ 14

GLEOSTINE ........................ 14

GLIADEL WAFER.............. 14

glimepiride ........................... 68

glipizide ................................ 68

glipizide-metformin .............. 68

GLUCAGEN DIAGNOSTIC

KIT ................................... 58

GLUCAGEN HYPOKIT ..... 58

GLUCAGON EMERGENCY

KIT (HUMAN) ................ 58

GLUCAGON HCL .............. 58

GLUCO NAVII GLUCOSE

MONITOR ....................... 62

GLUCO NAVII TEST STRIP

.......................................... 56

GLUCOCARD 01 METER . 62

GLUCOCARD 01 NORMAL

CONTROL ....................... 62

GLUCOCARD 01 SENSOR

PLUS ................................ 56

GLUCOCARD EXPRESSION

.................................... 57, 62

GLUCOCARD SHINE

METER ............................ 62

GLUCOCARD SHINE TEST

STRIPS ............................. 57

GLUCOCARD VITAL ........ 62

GLUCOCARD VITAL

SENSOR........................... 57

GLUCOCARD VITAL TEST

STRIPS ............................. 57

GLUCOCOM BLOOD

GLUCOSE ....................... 62

GLUCOCOM CONTROL

NORMAL......................... 62

GLUCOCOM GLUCOSE.... 57

GLUCOPHAGE ................... 68

GLUCOPHAGE XR ............ 68

GLUCOSE CONTROL........ 62

GLUCOTROL ...................... 68

GLUCOTROL XL ............... 68

GLUCOVANCE .................. 68

GLUMETZA ........................ 68

glyburide ............................... 68

glyburide micronized ............ 69

glyburide-metformin ............ 69

glycolax ................................ 72

glycopyrrolate ....................... 70

GLYCOPYRROLATE ......... 70

glydo ..................................... 47

GLYNASE ........................... 69

GLYSET ............................... 69

GLYXAMBI ........................ 69

GM100............................ 57, 62

GOCOVRI ............................ 19

GOLYTELY ......................... 72

GONAL-F ............................ 67

GONAL-F RFF .................... 67

GONAL-F RFF REDI-JECT 67

GONITRO ............................ 41

GORDONS UREA ............... 43

GRALISE ............................. 17

GRALISE 30-DAY STARTER

PACK ............................... 17

granisetron hcl ...................... 72

GRANIX .............................. 77

GRASTEK............................ 79

griseofulvin microsize ............ 3

griseofulvin ultramicrosize ..... 3

GRIS-PEG

(ULTRAMICROSIZE) ...... 3

guaiatussin ac ....................... 92

guaifenesin ac ....................... 92

guaifenesin dac ..................... 92

guanfacine ...................... 30, 35

guanidine .............................. 30

GYNAZOLE-1 ..................... 83

gynol ii .................................. 83

H HAEGARDA........................ 94

HALAVEN ........................... 14

HALCION ............................ 30

HALDOL.............................. 30

HALDOL DECANOATE .... 30

halobetasol propionate .......... 49

HALOG ................................ 49

haloperidol ............................ 30

haloperidol decanoate ........... 30

haloperidol lactate ................ 30

HARVONI.............................. 4

HAVRIX (PF) ...................... 79

HEALTHPRO GLUCOSE

MONITOR ....................... 62

HEALTHPRO HIGH-LOW

CONTROL ....................... 62

HEALTHPRO TEST STRIPS

.......................................... 57

healthylax ............................. 72

heather .................................. 83

HECTOROL ......................... 67

HELIXATE FS ..................... 38

HEMANGEOL ..................... 35

hematinic plus vit/minerals . 101

hematinic/folic acid ............ 101

hematogen ........................... 101

hematogen fa ...................... 101

hematogen forte .................. 101

HEMATRON-AF ............... 101

hemenatal ob ....................... 101

hemenatal ob + dha ............. 101

hemetab ............................... 101

hemmorex-hc ........................ 72

HEMOCYTE-F .................. 101

HEMOCYTE-PLUS ........... 101

HEMOFIL M HIGH ............. 39

HEMOFIL M LOW .............. 39

HEMOFIL M MID ............... 39

HEMOFIL M SUPER HIGH39

hep flush-10 (pf) ................... 39

HEPAGAM B ....................... 79

heparin (porcine) .................. 39

HEPARIN (PORCINE) IN

0.9% NACL ...................... 39

heparin (porcine) in 5 % dex 39

heparin (porcine) in nacl (pf) 39

heparin flush(porcine)-0.9nacl

.......................................... 39

heparin lock flush ................. 39

heparin lock flush (porcine) .. 39

heparin lockflush(porcine)(pf)

.......................................... 39

heparin, porcine (pf) ............. 39

HEPSERA .............................. 4

HERCEPTIN ........................ 14

HETLIOZ ............................. 30

HEXALEN ........................... 14

HIBERIX (PF) ...................... 79

hi-cal plus vit d ..................... 98



121

HIPREX ............................... 11

HISTEX-AC ......................... 92

HIZENTRA .......................... 79

homatropaire......................... 88

homatropine hbr ................... 89

HORIZANT ......................... 20

hpr......................................... 43

hpr plus ................................. 43

hpr plus hydrogel .................. 43

HPR PLUS-MB HYDROGEL

.......................................... 43

HUMALOG ......................... 65

HUMALOG JUNIOR

KWIKPEN ....................... 65

HUMALOG KWIKPEN ...... 65

HUMALOG MIX 50-50 ...... 65

HUMALOG MIX 50-50

KWIKPEN ....................... 65

HUMALOG MIX 75-25 ...... 65

HUMALOG MIX 75-25

KWIKPEN ....................... 65

HUMAPEN LUXURA HD .. 62

HUMATE-P ......................... 39

HUMATROPE ..................... 77

HUMIRA .............................. 81

HUMIRA PEDIATRIC

CROHN'S START ........... 81

HUMIRA PEN ..................... 81

HUMIRA PEN CROHN'S-

UC-HS START ................ 81

HUMULIN 70/30 ................. 65

HUMULIN 70/30 KWIKPEN

.......................................... 65

HUMULIN N ....................... 65

HUMULIN N KWIKPEN .... 65

HUMULIN R U-100 ............ 65

HUMULIN R U-500 (CONC)

KWIKPEN ....................... 65

HUMULIN R U-500

(CONCENTRATED) ....... 65

HYCAMTIN ........................ 14

HYCOFENIX ....................... 92

hydralazine ........................... 35

HYDREA ............................. 14

HYDRO 35 ........................... 43

HYDRO 40 ........................... 43

hydrochlorothiazide .............. 36

hydrocodone-acetaminophen 23

hydrocodone-chlorpheniramine

.......................................... 92

hydrocodone-cpm-

pseudoephed ..................... 92

hydrocodone-homatropine .... 92

hydrocodone-ibuprofen ........ 23

hydrocortisone .......... 49, 54, 72

hydrocortisone acetate .......... 72

hydrocortisone butyrate ........ 49

hydrocortisone butyr-emollient

.......................................... 49

hydrocortisone valerate ........ 49

hydrocortisone-acetic acid .... 53

hydrocortisone-iodoquinol-aloe

.......................................... 47

hydrocortisone-min oil-wht pet

.......................................... 49

hydrocortisone-pramoxine ... 42,

72

hydromet ............................... 92

hydromorphone .................... 23

HYDROMORPHONE ......... 23

hydromorphone in 0.9 % nacl

.......................................... 23

HYDROMORPHONE IN 0.9

% NACL ........................... 23

hydroxychloroquine................ 8

hydroxyprogesterone caproate

.......................................... 83

hydroxyurea .......................... 14

hydroxyzine hcl .................... 91

hydroxyzine pamoate ........... 91

HYLATOPIC ....................... 43

HYLATOPICPLUS.............. 43

hyolev mb ............................. 96

hyophen ................................ 96

hyoscyamine sulfate ............. 70

hyosyne ................................. 70

HYPERHEP B S/D .............. 79

HYPERHEP B S-D

NEONATAL .................... 79

HYPERRAB S/D (PF) ......... 79

HYPER-SAL ........................ 94

HYPERTET S/D (PF) .......... 79

HYQVIA .............................. 79

HYSINGLA ER ................... 23

HYZAAR ............................. 36

I ibandronate ........................... 81

IBRANCE ............................. 14

IBUDONE ............................ 23

ibuprofen ............................... 26

ibuprofen-oxycodone ............ 23

ic green ................................. 51

ICAR-C PLUS .................... 101

ICLUSIG .............................. 14

IDAMYCIN PFS .................. 14

idarubicin .............................. 14

IDELVION ........................... 39

IDHIFA ................................. 14

IFEX ..................................... 14

ifosfamide ............................. 14

ifosfamide-mesna ................. 14

ILARIS (PF) ......................... 78

ILEVRO ............................... 89

ILUVIEN .............................. 90

imatinib ................................. 14

IMBRUVICA ....................... 14

IMFINZI ............................... 14

imipenem-cilastatin ................ 8

imipramine hcl ...................... 30

imipramine pamoate ............. 30

imiquimod ............................. 78

IMITREX ............................. 20

IMITREX STATDOSE KIT

REFILL ............................. 20

IMITREX STATDOSE PEN 20

IMLYGIC ............................. 14

IMOGAM RABIES-HT (PF)

.......................................... 79

IMPAVIDO ............................ 8

IMURAN .............................. 14

INCRELEX .......................... 51

INCRUSE ELLIPTA ............ 94

indapamide ........................... 36

INDERAL LA ...................... 36

INDERAL XL ...................... 36

INDIOMIN MB .................... 96

INDOCIN ............................. 26

indocyanine green ................. 51

indomethacin ........................ 26

INFANRIX (DTAP) (PF) ..... 79

INFASURF ........................... 51

INFINITY CONTROL

SOLUTION NORM ......... 62



122

INFINITY STARTER KIT .. 62

INFINITY TEST STRIPS .... 57

INFLECTRA ........................ 72

INFUVITE ADULT ........... 101

INFUVITE PEDIATRIC.... 101

INGREZZA .......................... 20

INJECTAFER .................... 101

INLYTA ............................... 14

INNOPRAN XL ................... 36

INOVA ................................. 45

INOVA 4-1 ........................... 43

INSET 30 INFUSION SET 23

.......................................... 62

INSET INFUSION SET 23 .. 62

INSPRA ................................ 36

INSULIN SYRINGE-

NEEDLE U-100 ............... 58

INTEGRA F ....................... 101

INTEGRA PLUS................ 101

INTELENCE .......................... 4

INTERMEZZO .................... 30

INTRAROSA ....................... 83

INTRON A ........................... 78

introvale ................................ 85

INTUNIV ER ....................... 30

INVANZ................................. 8

INVEGA............................... 30

INVIRASE ............................. 4

INVOKAMET ...................... 69

INVOKAMET XR ............... 69

INVOKANA ........................ 69

iodoquinol-hc ....................... 47

IOPIDINE............................. 91

ipratropium bromide ....... 53, 94

ipratropium-albuterol ........... 94

IPRIVASK ........................... 39

irbesartan .............................. 36

irbesartan-hydrochlorothiazide

.......................................... 36

IRENKA ............................... 30

IRESSA ................................ 14

irinotecan .............................. 14

IROSPAN 24/6 ................... 101

ISENTRESS ........................... 4

ISENTRESS HD .................... 4

isibloom ................................ 85

ISOCHRON ......................... 41

ISOLYTE-S .......................... 98

isometh-dichloral-

acetaminophn.................... 20

isomethepten-caf-

acetaminophen .................. 20

isoniazid.................................. 8

ISOPTO CARPINE .............. 89

ISORDIL .............................. 41

ISORDIL TITRADOSE ....... 41

isosorbide dinitrate ............... 41

isosorbide mononitrate ......... 41

isoxsuprine............................ 83

isradipine .............................. 36

ISTALOL ............................. 88

ISTODAX ............................ 14

itraconazole ............................ 3

ivermectin ............................... 8

IXEMPRA ............................ 14

IXINITY ............................... 39

J JADENU .............................. 51

JADENU SPRINKLE .......... 51

JAKAFI ................................ 14

JALYN ................................. 96

jantoven ................................ 39

JANUMET ........................... 69

JANUMET XR ..................... 69

JANUVIA ............................. 69

JARDIANCE ........................ 69

JAZZ WIRELESS 2 METER

KIT ................................... 62

jencycla ................................. 83

JENTADUETO .................... 69

JENTADUETO XR .............. 69

JETREA (PF) ....................... 89

jevantique lo ......................... 83

JEVTANA ............................ 14

jinteli ..................................... 83

jolessa ................................... 85

jolivette ................................. 83

JUBLIA ................................ 48

juleber ................................... 85

junel 1.5/30 (21) ................... 85

junel 1/20 (21) ...................... 85

junel fe 1.5/30 (28) ............... 85

junel fe 1/20 (28) .................. 85

junel fe 24 ............................. 85

JUXTAPID ........................... 40

K KADCYLA ........................... 14

KADIAN .............................. 24

kaitlib fe ................................ 85

KALBITOR .......................... 94

KALETRA ............................. 4

KALYDECO ........................ 94

KANUMA ............................ 67

KAPVAY ............................. 30

KARBINAL ER ................... 91

kariva (28) ............................ 85

KAZANO ............................. 69

k-effervescent ....................... 98

KEFLEX ................................. 6

kelnor 1/35 (28) .................... 85

KENALOG ..................... 49, 54

KEPIVANCE ....................... 11

KEPPRA ......................... 17, 18

KEPPRA XR ........................ 18

KERAFOAM ........................ 43

KERALAC ........................... 43

KERALYT RX ..................... 43

KERYDIN ............................ 48

ketoconazole ..................... 3, 48

ketoprofen ............................. 26

ketorolac ......................... 26, 90

KEVEYIS ............................. 20

KEVZARA ........................... 81

KHEDEZLA ......................... 30

kimidess (28) ........................ 85

KINERET ............................. 78

KINRIX (PF) ........................ 79

kionex ................................... 72

kionex (with sorbitol) ........... 72

KISQALI .............................. 14

KISQALI FEMARA CO-

PACK ............................... 14

KIT PREP OF TC-99M-

MEBROFENIN ................ 51

KITABIS PAK ....................... 8

KLARON ............................. 47

KLONOPIN .......................... 18

klor-con ................................. 98

klor-con 10 ............................ 98

klor-con 8 .............................. 98

klor-con m10 ........................ 98

klor-con m15 ........................ 98

klor-con m20 ........................ 98



123

klor-con sprinkle .................. 98

KLOR-CON/25 .................... 98

klor-con/ef ............................ 98

KOATE ................................ 39

kobee .................................. 101

KOGENATE FS ................... 39

KOMBIGLYZE XR ............. 69

KORLYM............................. 67

KOSHER PRENATAL PLUS

IRON .............................. 101

KOVALTRY ........................ 39

K-PHOS NO 2 ...................... 96

K-PHOS ORIGINAL ........... 96

k-phos-neutral....................... 98

kpn ...................................... 101

KRISTALOSE ..................... 72

KRYSTEXXA ...................... 80

k-tab ...................................... 98

K-TAB .................................. 98

kurvelo .................................. 85

KUVAN ............................... 67

KYLEENA ........................... 82

KYMRIAH ........................... 14

KYNAMRO ......................... 40

KYPROLIS .......................... 14

L l norgest/e.estradiol-e.estrad . 85

labetalol ................................ 36

LACRISERT ........................ 89

lactated ringers ..................... 50

lactulose ................................ 72

LAMICTAL ......................... 18

LAMICTAL ODT ................ 18

LAMICTAL ODT STARTER

(BLUE) ............................. 18


(GREEN) .......................... 18


(ORANGE)....................... 18

LAMICTAL STARTER

(BLUE) KIT ..................... 18

LAMICTAL STARTER

(GREEN) KIT .................. 18

LAMICTAL STARTER

(ORANGE) KIT ............... 18

LAMICTAL XR ................... 18

LAMICTAL XR STARTER

(BLUE) ............................. 18

LAMICTAL XR STARTER

(GREEN) .......................... 18

LAMICTAL XR STARTER

(ORANGE) ....................... 18

LAMISIL ................................ 3

lamivudine .............................. 4

lamivudine-zidovudine ........... 4

lamotrigine............................ 18

LANCETS ............................ 62

LANCING DEVICE ............ 62

LANOXIN ............................ 38

LANOXIN PEDIATRIC ...... 38

lansoprazole .......................... 75

lanthanum ............................. 72

LANTUS .............................. 65

LANTUS SOLOSTAR......... 65

larin 1.5/30 (21) .................... 85

larin 1/20 (21) ....................... 85

larin 24 fe.............................. 85

larin fe 1.5/30 (28) ................ 85

larin fe 1/20 (28) ................... 85

larissia ................................... 85

LARTRUVO ........................ 14

LASIX .................................. 36

LASTACAFT ....................... 89

latanoprost ............................ 90

LATUDA.............................. 30

laxaclear................................ 72

laxative (bisacodyl) .............. 72

laxative feminine .................. 72

laxative peg 3350.................. 72

layolis fe ............................... 85

LAZANDA ........................... 24

LDO PLUS ........................... 47

leena 28................................. 85

leflunomide ........................... 81

LEMTRADA ........................ 77

LENVIMA............................ 14

LESCOL XL......................... 40

lessina ................................... 85

LETAIRIS ............................ 94

letrozole ................................ 14

leucovorin calcium ............... 11

LEUKERAN ........................ 14

LEUKINE ............................. 77

leuprolide .............................. 14

LEVA SET ........................... 47

levalbuterol hcl ..................... 94

LEVALBUTEROL

TARTRATE ..................... 94

LEVAQUIN ......................... 10

LEVATOL ............................ 36

LEVBID ............................... 70

LEVEMIR ............................ 65

LEVEMIR FLEXTOUCH .... 65

levetiracetam ......................... 18

levetiracetam in nacl (iso-os) 18

levobunolol ........................... 88

levocarnitine ......................... 51

levocarnitine (with sugar) ..... 51

levofloxacin .................... 10, 88

levofloxacin in d5w .............. 10

levoleucovorin ...................... 11

LEVOLEUCOVORIN ......... 11

levomefolate dha ................ 101

levonest (28) ......................... 85

levonorgestrel-ethinyl estrad 85

levonorg-eth estrad triphasic 85

levora-28 ............................... 85

levorphanol tartrate ............... 24

LEVO-T ................................ 69

levothyroxine ........................ 70

LEVOTHYROXINE ............ 69

levoxyl .................................. 70

LEVSIN ................................ 70

LEVSIN/SL .......................... 70

LEVULAN ........................... 43

LEXAPRO ............................ 30

LEXIVA ................................. 4

LIALDA ............................... 72

LIBRAX (WITH

CLIDINIUM) ................... 70

lidocaine ............................... 47

lidocaine (pf) ........................ 47

lidocaine hcl .......................... 47

lidocaine hcl-hydrocortison ac

.................................... 47, 72

lidocaine viscous .................. 47

lidocaine-prilocaine .............. 47

LIDOCAINE-TETRACAINE

.......................................... 47

LIDODERM ......................... 47

LIDOPAC ............................. 47

lidopin ................................... 47

LIDOPIN .............................. 47



124

LIDO-PRILO CAINE PACK

.......................................... 47

LIDORX ............................... 47

LIDOTRAL .......................... 47

LIDTOPIC MAX ................. 47

LILETTA ............................. 82

lillow..................................... 85

LINCOCIN ............................. 8

lincomycin .............................. 8

lindane .................................. 50

linezolid .................................. 8

LINZESS .............................. 72

liothyronine .......................... 70

LIPITOR............................... 40

LIPOCHOL PLUS ............... 51

lipodox .................................. 14

LIPOFEN ............................. 40

LIPROZONEPAK ................ 47

lisinopril ............................... 36

lisinopril-hydrochlorothiazide

.......................................... 36

lite coat aspirin ..................... 26

lithium carbonate .................. 30

lithium citrate ....................... 30

LITHOBID ........................... 30

LITHOSTAT ........................ 51

LIVALO ............................... 40

LO LOESTRIN FE............... 85

LOCOID ............................... 49

LOCOID LIPOCREAM ....... 49

LOCORT .............................. 54

LODINE ............................... 26

LODOSYN ........................... 19

LOESTRIN 1.5/30 (21) ........ 85

LOESTRIN 1/20 (21) ........... 86

LOESTRIN FE 1.5/30 (28-

DAY) ................................ 86

LOESTRIN FE 1/20 (28-DAY)

.......................................... 86

lomedia 24 fe ........................ 86

LOMOTIL ............................ 70

LONSURF ............................ 14

LOPID .................................. 40

lopinavir-ritonavir .................. 4

lopreeza ................................ 83

LOPRESSOR ....................... 36

LOPROX .............................. 48

LOPROX (AS OLAMINE) .. 48

LOPROX KIT ...................... 48

lorazepam ............................. 30

lorazepam intensol ................ 30

lorcet (hydrocodone) ............ 24

lorcet hd ................................ 24

lorcet plus ............................. 24

LORTAB ELIXIR ................ 24

lortuss ex............................... 92

loryna (28) ............................ 86

LORZONE ........................... 21

losartan ................................. 36

losartan-hydrochlorothiazide 36

LOSEASONIQUE................ 86

LOTEMAX .......................... 90

LOTENSIN .......................... 36

LOTENSIN HCT ................. 36

LOTREL ............................... 36

LOTRISONE ........................ 48

LOTRONEX ........................ 72

LOUTREX ........................... 43

lovastatin .............................. 40

LOVAZA.............................. 40

LOVENOX ........................... 39

low-ogestrel (28) .................. 86

loxapine succinate ................ 30

lta pre-attached ..................... 47

LUCENTIS ........................... 89

ludent fluoride .................... 101

lugols .............................. 47, 98

LUMIGAN ........................... 90

LUMIZYME ........................ 67

LUNESTA ............................ 30

LUPANETA PACK (1

MONTH) .......................... 84

LUPANETA PACK (3

MONTH) .......................... 84

LUPRON DEPOT ................ 15

LUPRON DEPOT (3

MONTH) .......................... 14

LUPRON DEPOT (4

MONTH) .......................... 14

LUPRON DEPOT (6

MONTH) .......................... 14

LUPRON DEPOT-PED ....... 15

lutera (28) ............................. 86

luxamend .............................. 44

LUXIQ.................................. 49

LUZU ................................... 48

LYNPARZA ......................... 15

LYRICA ............................... 18

LYSODREN ......................... 15

LYSTEDA ............................ 84

lyza ....................................... 83

M m.v.i. adult .......................... 101

MACROBID ......................... 11

MACRODANTIN ................ 11

MACUGEN .......................... 89

MAGNEBIND 400 ............... 72

magnesium citrate ................. 72

MAKENA ............................. 83

MALARONE ......................... 8

MALARONE PEDIATRIC .... 8

malathion .............................. 50

maprotiline ............................ 30

MAR-COF BP ...................... 92

MAR-COF CG ..................... 92

MARINOL ........................... 73

marlissa ................................. 86

MARNATAL-F .................. 101

MARPLAN ........................... 30

MARQIBO ........................... 15

marten-tab ............................. 24

MATULANE ........................ 15

matzim la .............................. 36

MAVYRET ............................ 4

MAXALT ............................. 20

MAXALT-MLT ................... 20

MAXFE (FOLATE-

DOCUSATE) ................. 101

MAXIDEX ........................... 90

MAXIPIME ............................ 6

MAXITROL ......................... 90

MAXZIDE ............................ 36

MAXZIDE-25MG ................ 36

m-clear wc ............................ 92

meclofenamate ...................... 26

MEDISENSE ........................ 62

MEDISENSE GLUCOSE

KETONE .......................... 62

MEDOLOR PAK ................. 47

MEDROL ............................. 54

MEDROL (PAK) .................. 54

medroxyprogesterone ........... 83

mefenamic acid ..................... 26

mefloquine .............................. 8



125

MEGACE ES ....................... 15

megestrol .............................. 15

MEKINIST ........................... 15

melodetta 24 fe ..................... 86

meloxicam ............................ 27

melphalan ............................. 15

melphalan hcl ....................... 15

memantine ............................ 20

MEMANTINE ..................... 20

MENACTRA (PF) ............... 79

M-END PE ........................... 92

MENEST .............................. 83

MENOMUNE - A/C/Y/W-135

.......................................... 79

MENOMUNE - A/C/Y/W-135

(PF) ................................... 79

MENOPUR .......................... 67

MENOSTAR ........................ 83

MENVEO A-C-Y-W-135-DIP

(PF) ................................... 80

meperidine ............................ 24

MEPHYTON ........................ 39

meprobamate ........................ 21

MEPRON ............................... 8

mercaptopurine ..................... 15

meropenem ............................. 8

MEROPENEM-0.9%

SODIUM CHLORIDE ....... 8

MERREM............................... 8

mesalamine ........................... 73

MESALAMINE ................... 73

mesalamine with cleansing

wipe .................................. 73

mesna .................................... 11

MESNEX ............................. 12

MESTINON ......................... 21

MESTINON TIMESPAN .... 21

metadate er ........................... 30

metaproterenol ...................... 94

metaxall ................................ 21

metaxalone ........................... 21

metformin ............................. 69

methadone ............................ 24

methadose ............................. 24

methamphetamine ................ 30

methazolamide ..................... 90

methenamine hippurate ........ 11

methenamine mandelate ....... 11

methen-sod phos-meth blue-

hyos .................................. 96

methergine ............................ 87

methimazole ......................... 55

METHITEST ........................ 67

methocarbamol ..................... 21

methotrexate sodium ............ 15

methotrexate sodium (pf) ..... 15

methoxsalen .......................... 44

methscopolamine .................. 70

methyclothiazide .................. 36

methyldopa ........................... 36

methyldopa-

hydrochlorothiazide .......... 36

methyldopate ........................ 36

METHYLIN ......................... 30

methylphenidate hcl ....... 30, 31

methylprednisolone .............. 54

methyltestosterone ................ 67

metipranolol.......................... 88

metoclopramide hcl .............. 73

metolazone............................ 36

METOPIRONE .................... 51

metoprolol succinate............. 36

METOPROLOL SU-

HYDROCHLOROTHIAZ 36

metoprolol ta-hydrochlorothiaz

.......................................... 36

metoprolol tartrate ................ 36

metro i.v.................................. 8

METROCREAM .................. 45

METROGEL ........................ 45

METROGEL VAGINAL ..... 84

METROLOTION ................. 45

metronidazole ............. 8, 45, 84

metronidazole in nacl (iso-os) 8

mexiletine ............................. 33

MIACALCIN ....................... 67

mibelas 24 fe ........................ 86

MICARDIS .......................... 36

MICARDIS HCT ................. 36

MICORT-HC........................ 73

MICRO BLOOD GLUCOSE

.......................................... 57

MICRODOT BLOOD

GLUCOSE SYSTEM . 57, 62

microgestin 1.5/30 (21) ........ 86

microgestin 1/20 (21) ........... 86

MICROGESTIN 24 FE ........ 86

microgestin fe 1.5/30 (28) .... 86

microgestin fe 1/20 (28) ....... 86

MICROZIDE ........................ 36

midodrine .............................. 51

MIFEPREX .......................... 84

migergot ................................ 20

miglitol ................................. 69

MIGRANAL ......................... 20

milk of magnesia .................. 73

milk of magnesia concentrated

.......................................... 73

millipred ............................... 54

MILLIPRED ......................... 54

millipred dp .......................... 54

mimvey ................................. 83

mimvey lo ............................. 83

MINASTRIN 24 FE ............. 86

MINIPRESS ......................... 36

MINITRAN .......................... 41

MINIVELLE ........................ 83

MINOCIN ............................. 11

minocycline .......................... 11

minoxidil ............................... 36

MIOCHOL-E ........................ 89

miralax .................................. 73

MIRAPEX ............................ 19

MIRAPEX ER ...................... 19

MIRCERA ............................ 77

MIRCETTE (28) .................. 86

MIRENA .............................. 82

mirtazapine ........................... 31

MIRVASO ............................ 45

misoprostol ........................... 75

MITIGARE ........................... 80

mitomycin ............................. 15

MITOSOL ............................ 90

mitoxantrone ......................... 15

M-M-R II (PF) ...................... 80

MOBIC ................................. 27

modafinil ............................... 31

moderiba ............................... 77

moderiba dose pack .............. 77

moexipril ............................... 36

moexipril-hydrochlorothiazide

.......................................... 36

mometasone .................... 49, 94

mondoxyne nl ....................... 11



126

MONOCLATE-P ................. 39

MONODOX ......................... 11

mono-linyah ......................... 86

mononessa (28) .................... 86

MONONINE ........................ 39

montelukast .......................... 94

MONUROL .......................... 11

morgidox .............................. 11

MORPHABOND ER ........... 24

morphine............................... 24

MORPHINE ......................... 24

morphine (pf)........................ 24

morphine (pf) in 0.9 % nacl . 24

MORPHINE (PF) IN 0.9 %

NACL ............................... 24

morphine concentrate ........... 24

MORPHINE IN 0.9 % NACL

.......................................... 24

MOTOFEN........................... 70

MOVANTIK ........................ 73

MOVIPREP .......................... 73

MOXATAG ......................... 10

MOXEZA ............................. 88

moxifloxacin................... 10, 88

MOXIFLOXACIN (PF)-BSS

NO.2 ................................. 88

MOZOBIL ............................ 77

MS CONTIN ........................ 24

MUGARD ............................ 53

MULTAQ ............................. 33

multigen folic ..................... 101

multigen plus ...................... 101

multi-vit with fluoride-iron 101

multi-vitamin with fluoride 101

multivitamins with fluoride 101

mupirocin ............................. 48

mupirocin calcium ................ 48

MUSTARGEN ..................... 15

mvc-fluoride ....................... 102

my way ................................. 86

MYALEPT ........................... 67

MYAMBUTOL ...................... 8

MYCOBUTIN ........................ 8

mycophenolate mofetil ......... 15

mycophenolate mofetil hcl ... 15

mycophenolate sodium ......... 15

MYDAYIS ........................... 31

MYDRIACYL ...................... 89

MYFORTIC ......................... 15

MYGLUCOHEALTH .... 57, 62

MYGLUCOHEALTH

CONTROL SOLUTION .. 62

MYLERAN .......................... 15

MYLOTARG ....................... 15

mynatal ............................... 102

mynatal advance ................. 102

mynatal plus ....................... 102

mynatal-z ............................ 102

mynate 90 plus.................... 102

mynephrocaps ..................... 102

mynephron .......................... 102

MYOBLOC .......................... 80

MYRBETRIQ ...................... 96

MYSOLINE ......................... 18

MYTESI ............................... 70

myzilra .................................. 86

N NABI-HB ............................. 80

nabumetone .......................... 27

nadolol .................................. 36

nadolol-bendroflumethiazide 36

nafcillin ................................. 10

naftifine ................................ 48

NAFTIN ............................... 48

NAGLAZYME ..................... 67

nalbuphine ............................ 27

NALFON .............................. 27

naloxone ............................... 27

naltrexone ............................. 27

NAMENDA.......................... 20

NAMENDA TITRATION

PAK .................................. 21

NAMENDA XR ................... 21

NAMZARIC ......................... 21

NAPRELAN CR .................. 27

NAPROSYN ........................ 27

naproxen ............................... 27

naproxen sodium .................. 27

naratriptan ............................. 20

NARCAN ............................. 27

NARDIL ............................... 31

NASCOBAL ...................... 102

NASONEX ........................... 94

NATACHEW (FE BIS-

GLYCINATE) ................ 102

NATACYN .......................... 88

NATAZIA ............................ 86

nateglinide ............................ 69

NATELLE ONE ................. 102

NATESTO ............................ 67

NATPARA ........................... 67

NATROBA ........................... 50

natural b-100 complex ........ 102

natura-lax .............................. 73

nature-throid ......................... 70

NAVELBINE ....................... 15

NEBUPENT ........................... 8

nebusal .................................. 94

NEBUSAL ............................ 94

necon 0.5/35 (28) .................. 86

necon 1/50 (28) ..................... 86

necon 7/7/7 (28) .................... 86

NEEVODHA (WITH ALGAL

OIL) ................................ 102

nefazodone ............................ 31

neomycin ................................ 9

neomycin-bacitracin-poly-hc 90

neomycin-bacitracin-

polymyxin ......................... 88

neomycin-polymyxin b-

dexameth ........................... 90

neomycin-polymyxin-

gramicidin ......................... 88

neomycin-polymyxin-hc . 54, 90

neo-polycin ........................... 88

neo-polycin hc ...................... 90

NEORAL .............................. 15

NEOSALUS ......................... 44

NEO-SYNALAR .................. 48

NEO-SYNALAR KIT .......... 48

nephplex rx ......................... 102

NEPHROCAPS .................. 102

NEPHROCAPS QT ............ 102

NEPHRON FA ................... 102

nephro-vite rx ..................... 102

NEPTAZANE ....................... 90

NERLYNX ........................... 15

NESINA ............................... 69

NESTABS .......................... 102

NESTABS ABC ................. 102

NESTABS DHA ................. 102

NESTABS ONE ................. 102

neuac ..................................... 45

NEUAC KIT ......................... 45



127

NEULASTA ......................... 77

NEUPOGEN ........................ 77

NEUPRO .............................. 19

NEURIN-SL ....................... 102

NEURONTIN....................... 18

NEUTEK 2TEK TEST

STRIPS ............................. 57

NEVANAC .......................... 90

nevirapine ............................... 4

newgen ............................... 102

NEXA PLUS ...................... 102

NEXAVAR .......................... 15

NEXAVIR .......................... 102

NEXIUM .............................. 75

NEXIUM IV ......................... 75

NEXIUM PACKET ............. 75

NEXPLANON ..................... 84

next choice one dose ............ 86

niacin .................................... 40

NIACOR............................... 40

NIASPAN EXTENDED-

RELEASE ........................ 40

nicardipine ............................ 36

NICODERM CQ .................. 52

nicorelief............................... 52

nicorette ................................ 52

NICORETTE ........................ 52

nicotine ................................. 52

nicotine (polacrilex) ............. 52

NICOTROL .......................... 52

NICOTROL NS.................... 52

nifedipine .............................. 36

nikki (28) .............................. 86

NILANDRON ...................... 15

nilutamide ............................. 15

nimodipine ............................ 36

NINJACOF-XG ................... 92

NINLARO ............................ 15

NIPENT ................................ 15

NIPRIDE RTU ..................... 41

nisoldipine ............................ 36

nitro-bid ................................ 41

NITRO-DUR ........................ 41

nitrofurantoin ........................ 11

nitrofurantoin macrocrystal .. 11

nitrofurantoin monohyd/m-

cryst .................................. 11

nitroglycerin ......................... 41

NITROLINGUAL ................ 41

NITROMIST ........................ 41

NITROSTAT ........................ 41

nitro-time .............................. 41

NITYR .................................. 51

NIVA-PLUS ....................... 102

nivatopic plus ....................... 44

nizatidine .............................. 75

NIZORAL ............................ 48

nodolor.................................. 20

nolix ...................................... 49

nora-be .................................. 83

NORCO ................................ 24

NORDITROPIN FLEXPRO 77

noreth-ethinyl estradiol-iron . 86

norethindrone (contraceptive)

.......................................... 83

norethindrone acetate ........... 83

norethindrone ac-eth estradiol

.................................... 83, 86

norethindrone-e.estradiol-iron

.......................................... 86

norgestimate-ethinyl estradiol

.......................................... 86

NORITATE .......................... 45

norlyda .................................. 83

norlyroc ................................ 83

NORPACE ........................... 33

NORPACE CR ..................... 33

NORPRAMIN ...................... 31

NORTHERA ........................ 51

nortrel 0.5/35 (28)................. 86

nortrel 1/35 (21).................... 86

nortrel 1/35 (28).................... 86

nortrel 7/7/7 (28) .................. 86

nortriptyline .......................... 31

NORVASC ........................... 36

NORVIR ................................. 4

NOVA MAX BLOOD


NOVA MAX GLUCOSE

CONTROL ....................... 63

NOVA MAX GLUCOSE

TEST ................................ 57

NOVAMAX PLUS GLU-KET

.......................................... 63

NOVAREL ........................... 67

NOVOEIGHT ...................... 39

NOVOLOG .......................... 66

NOVOLOG FLEXPEN ........ 66

NOVOLOG MIX 70-30 ....... 66

NOVOLOG MIX 70-30

FLEXPEN ......................... 66

NOVOLOG PENFILL ......... 66

NOVOPEN ECHO ............... 63

NOVOSEVEN RT ................ 39

NOXAFIL ............................... 3

np thyroid .............................. 70

NPLATE ............................... 39

nts step 1 ............................... 52

NUCALA ............................. 94

NUCYNTA ........................... 27

NUCYNTA ER .................... 27

NUEDEXTA ........................ 21

NULEV ................................. 70

NULOJIX ............................. 15

NULYTELY WITH FLAVOR

PACKS ............................. 73

NUMBONEX ....................... 47

NUOX ................................... 45

NUPLAZID .......................... 31

NUTRASEB ......................... 44

NUTRESTORE .................... 51

NUTRICAP ........................ 102

NUTROPIN AQ NUSPIN .... 77

NUVARING ......................... 84

NUVESSA ............................ 84

NUVIGIL ............................. 31

NUWIQ ................................ 39

nyamyc ................................. 48

nyata ..................................... 48

NYMALIZE ......................... 36

nystatin ............................. 3, 48

nystatin-triamcinolone .......... 48

nystop ................................... 48

O OB COMPLETE GOLD .... 102

OB COMPLETE ONE ....... 102

OB COMPLETE PETITE .. 102

OB COMPLETE PREMIER

........................................ 102

OB COMPLETE WITH DHA

........................................ 102

OBIZUR ............................... 39

OBREDON ........................... 92

obstetrix dha ....................... 102



128

OBSTETRIX EC ................ 102

OBSTETRIX ONE ............. 102

OBTREX DHA .................. 102

O-CAL FA.......................... 102

O-CAL PRENATAL .......... 102

OCALIVA ............................ 73

ocella .................................... 86

OCREVUS ........................... 77

OCTAGAM .......................... 80

octreotide acetate .................. 15

OCUFLOX ........................... 88

ODEFSEY .............................. 4

ODOMZO ............................ 15

OFEV ................................... 94

ofloxacin ................... 10, 53, 88

ogestrel (28).......................... 86

olanzapine............................. 31

olanzapine-fluoxetine ........... 31

olmesartan ............................ 37

olmesartan-amlodipin-

hcthiazid ........................... 37

olmesartan-

hydrochlorothiazide .......... 37

olopatadine ..................... 53, 89

OLUX ................................... 49

OLUX-E ............................... 50

OLYSIO ................................. 4

OMECLAMOX-PAK .......... 75

omega-3 acid ethyl esters ..... 40

omeppi ............................ 75, 76

omeprazole ........................... 76

omeprazole-sodium

bicarbonate ....................... 76

OMIDRIA ............................ 89

OMNARIS ........................... 94

OMNIPRED ......................... 90

OMNITROPE....................... 77

ON CALL EXPRESS

CONTROL ....................... 63

ON CALL EXPRESS METER

.......................................... 63

ON CALL EXPRESS TEST

STRIP ............................... 57

ON CALL PLUS CONTROL

.......................................... 63

ON CALL PLUS METER ... 63

ON CALL PLUS TEST STRIP

.......................................... 57

ON CALL VIVID CONTROL

.......................................... 63

ON CALL VIVID METER .. 63

ON CALL VIVID PAL

METER ............................ 63

ON CALL VIVID TEST

STRIP ............................... 57

ONCASPAR ......................... 15

ondansetron .......................... 73

ondansetron hcl..................... 73

ondansetron hcl (pf).............. 73

one daily prenatal ............... 102

ONETOUCH ULTRA

CONTROL ....................... 63

ONETOUCH ULTRA TEST

.......................................... 57

ONETOUCH ULTRA2 ........ 63

ONETOUCH ULTRAMINI. 63

ONETOUCH VERIO ........... 57

ONETOUCH VERIO FLEX 63

ONETOUCH VERIO IQ

METER ............................ 63

ONETOUCH VERIO

SYSTEM .......................... 63

ONEXTON ........................... 45

ONFI ..................................... 18

ONGLYZA ........................... 69

ONIVYDE ............................ 15

ONMEL .................................. 3

ONZETRA XSAIL............... 20

OPANA ................................ 25

opcicon one-step ................... 86

OPDIVO ............................... 15

opium tincture....................... 70

OPSUMIT ............................ 94

option-2 ................................ 86

OPTIUM EZ ......................... 57

OPTIUM TEST .................... 57

OPTUMRX .................... 57, 63

ORACEA.............................. 11

ORACIT ............................... 96

oral saline laxative ................ 73

ORALAIR ............................ 80

oralone .................................. 53

ORAMAGICRX ................... 53

ORAP ................................... 31

ORAPRED ODT .................. 54

ORAVIG ................................ 3

ORENCIA ............................ 81

ORENCIA (WITH

MALTOSE) ...................... 81

ORENCIA CLICKJECT ...... 81

ORENITRAM ...................... 37

ORFADIN ............................ 51

ORKAMBI ........................... 94

orphenadrine citrate .............. 21

orsythia ................................. 86

ortho d ................................. 102

ORTHO MICRONOR .......... 83

ORTHO TRI-CYCLEN (28) 86

ORTHO TRI-CYCLEN LO

(28) ................................... 86

ORTHO-CYCLEN (28) ....... 87

ORTHO-NOVUM 1/35 (28) 87

ORTHO-NOVUM 7/7/7 (28)

.......................................... 87

oscimin ................................. 70

oscimin sl .............................. 70

oscimin sr .............................. 70

oseltamivir .............................. 4

OSENI .................................. 69

OSMOPREP ......................... 73

OSPHENA ............................ 84

OTEZLA ............................... 81

OTEZLA STARTER ............ 81

OTIPRIO .............................. 53

OTOVEL .............................. 54

OTREXUP (PF) .................... 81

OVACE ................................ 42

OVACE PLUS ...................... 42

OVACE PLUS SHAMPOO . 42

OVACE PLUS WASH ......... 42

OVIDE .................................. 50

OVIDREL ............................. 67

oxacillin ................................ 10

oxacillin in dextrose(iso-osm)

.......................................... 10

oxaliplatin ............................. 15

OXANDRIN ......................... 67

oxandrolone .......................... 67

oxaprozin .............................. 27

OXAYDO ............................. 25

oxazepam .............................. 31

oxcarbazepine ....................... 18

oxiconazole ........................... 48

OXISTAT ............................. 48



129

OXSORALEN ULTRA ....... 44

OXTELLAR XR .................. 18

oxybutynin chloride.............. 96

oxycodone ............................ 25

OXYCODONE..................... 25

oxycodone-acetaminophen ... 25

oxycodone-aspirin ................ 25

OXYCONTIN ...................... 25

oxymorphone ........................ 25

OXYTROL ........................... 96

oysco 500/d .......................... 98

oyster shell + d3 ................... 98

oyster shell calcium-vit d2 . 102

oyster shell calcium-vit d3 ... 98

oystercal-d ............................ 98

OZURDEX ........................... 90

P pacerone ............................... 33

paclitaxel .............................. 15

paliperidone .......................... 31

PAMELOR ........................... 31

pamidronate .......................... 67

PANCREAZE ...................... 73

PANDEL .............................. 50

PANRETIN .......................... 44

pantoprazole ......................... 76

PARAFON FORTE DSC ..... 21

PARAGARD T 380A........... 82

paregoric ............................... 70

PAREMYD .......................... 89

paricalcitol ............................ 67

PARICALCITOL ................. 67

PARLODEL ......................... 19

PARNATE ........................... 31

paroex oral rinse ................... 53

paromomycin .......................... 9

paroxetine hcl ....................... 31

paroxetine mesylate .............. 31

PASER ................................... 9

PATADAY ........................... 89

PATANASE ......................... 53

PATANOL ........................... 89

PAXIL .................................. 31

PAXIL CR ............................ 31

PAZEO ................................. 89

P-CARE K40 ........................ 54

P-CARE K80 ........................ 54

P-CARE X (PF) .................... 47

PCE ......................................... 7

PEDIAPRED ........................ 54

PEDIARIX (PF) ................... 80

peg 3350-electrolytes ........... 73

peg3350 ................................ 73

PEGANONE ........................ 18

PEGASYS ............................ 78

PEGASYS PROCLICK ....... 78

peg-electrolyte soln .............. 73

PEGINTRON ....................... 78

PEN NEEDLE ...................... 63

penicillin g potassium ........... 10

penicillin v potassium ........... 10

PENLAC .............................. 48

PENNSAID .......................... 27

PENTACEL ACTHIB

COMPONENT (PF) ......... 80

PENTASA ............................ 73

pentazocine-naloxone ........... 27

pentoxifylline........................ 39

PEPCID ................................ 76

PERCOCET.......................... 25

PERFOROMIST .................. 94

PERIDEX ............................. 53

perindopril erbumine ............ 37

periogard ............................... 53

PERJETA ............................. 15

permethrin ............................ 50

perphenazine ......................... 31

perphenazine-amitriptyline ... 31

perry prenatal ...................... 102

PERTZYE ............................ 73

PEXEVA .............................. 31

pfizerpen-g............................ 10

PHARMACIST CHOICE .... 57

PHARMACIST CHOICE

GLUCOSE SYS ............... 63

phenadoz ............................... 91

phenazopyridine ................... 97

phenelzine ............................. 31

phenergan ............................. 92

PHENERGAN ...................... 92

phenobarb-hyoscy-atropine-

scop ................................... 71

phenobarbital ........................ 18

phenohytro ............................ 71

phenoxybenzamine ............... 37

phentolamine ........................ 37

phenylephrine hcl ................. 91

PHENYTEK ......................... 18

phenytoin .............................. 18

phenytoin sodium extended .. 18

philith .................................... 87

PHOSLYRA ......................... 73

phospha 250 neutral .............. 98

phosphasal ............................ 96

phosphate laxative ................ 73

PHOSPHOLINE IODIDE .... 88

PHOTREXA VISCOUS ....... 89

PHYSICIANS EZ USE B-12

........................................ 102

PHYSIOLYTE ..................... 50

PHYSIOSOL IRRIGATION 50

PICATO ................................ 44

pilocarpine hcl .......... 51, 53, 89

pimozide ............................... 31

pimtrea (28) .......................... 87

pindolol ................................. 37

pioglitazone .......................... 69

pioglitazone-glimepiride ....... 69

pioglitazone-metformin ........ 69

piperacillin-tazobactam ........ 10

PIPERACILLIN-

TAZOBACTAM .............. 10

pirmella ................................. 87

piroxicam .............................. 27

PLAN B ONE-STEP ............ 87

PLAQUENIL .......................... 9

PLAVIX ............................... 39

PLEGRIDY .......................... 78

PLEXION ............................. 45

PLEXION CLEANSING

CLOTHS ........................... 45

PLIAGLIS ............................ 47

PNEUMOVAX 23 ................ 80

pnv 29-1 .............................. 102

pnv ob+dha ......................... 102

pnv-dha ............................... 102

pnv-dha + docusate ............. 102

pnv-ferrous fumarate-docu-fa

........................................ 103

pnv-omega .......................... 103

pnv-select ............................ 103

pnv-vp-u ............................. 103

POD-CARE 100K ................ 54

PODOCON ........................... 43



130

podofilox .............................. 44

polycin .................................. 88

polymyxin b sulfate ................ 9

polymyxin b sulf-trimethoprim

.......................................... 88

POLYTRIM ......................... 88

POLY-TUSSIN AC.............. 92

POLY-VI-FLOR ................ 103

POLY-VI-FLOR WITH IRON

........................................ 103

POMALYST ........................ 78

PONSTEL ............................ 27

portia..................................... 87

PORTRAZZA ...................... 15

pot,sodium citrate-citric acid 96

POTABA .............................. 98

potassium acetate.................. 98

potassium bicarb and chloride

.......................................... 98

potassium bicarb-citric acid . 98

potassium chloride................ 98

potassium chloride in 0.9%nacl

.......................................... 98

potassium citrate ................... 96

potassium citrate-citric acid . 96

POTASSIUM CL-LIDO-0.9 %

NACL ............................... 98

POTASSIUM HYDROXIDE

.......................................... 43

POTASSIUM PHOS IN 0.9 %

NACL ............................... 98

powderlax ............................. 73

pr natal 400 ......................... 103

pr natal 400 ec .................... 103

pr natal 430 ......................... 103

pr natal 430 ec .................... 103

PRADAXA........................... 39

PRALUENT PEN ................ 40

pramcort ............................... 73

pramipexole .......................... 19

PRAMOSONE ..................... 42

PRAMOSONE E .................. 42

PRANDIN ............................ 69

prasugrel ............................... 39

PRAVACHOL ..................... 40

pravastatin ............................ 41

PRAXBIND ......................... 39

prazosin ................................ 37

PRECISION PCX PLUS TEST

.......................................... 57

PRECISION PCX TEST ...... 57

PRECISION POINT OF

CARE TEST ..................... 57

PRECISION Q-I-D TEST .... 57

PRECISION XTRA

MONITOR ....................... 63

PRECISION XTRA TEST ... 57

PRECOSE ............................ 69

PRED FORTE ...................... 91

PRED MILD......................... 91

PRED-G................................ 90

PRED-G S.O.P. .................... 90

prednicarbate ........................ 50

prednisolone ......................... 54

prednisolone acetate ............. 91

prednisolone sodium phosphate

.................................... 54, 91

prednisone ............................ 54

prednisone intensol ............... 54

PREFERA-OB.................... 103

PREFERA-OB ONE .......... 103

PREFERA-OB PLUS DHA

........................................ 103

PREFEST ............................. 83

PREGNYL............................ 67

PREMARIN ......................... 83

PREMIUM BLOOD


PREMIUM V10 ............. 57, 63

PREMPHASE ...................... 83

PREMPRO ........................... 83

prena1 chew ........................ 103

prena1 pearl ........................ 103

prena1 true .......................... 103

prenaissance........................ 103

prenaissance plus ................ 103

PRENATA.......................... 103

prenatabs fa......................... 103

prenatabs rx ........................ 103

prenatal ............................... 103

prenatal complete ............... 103

prenatal formula ................. 103

prenatal multi-dha (algal oil)

........................................ 103

prenatal one daily ............... 103

prenatal plus ....................... 103

prenatal plus (calcium carb)103

PRENATAL PLUS DHA ... 103

prenatal vitamin .................. 103

prenatal vitamin plus low iron

........................................ 103

prenatal vitamin with minerals

........................................ 103

prenatal vits96-iron fum-folic

........................................ 103

prenatal-u ............................ 103

PRENATE AM ................... 103

PRENATE CHEWABLE ... 103

PRENATE DHA (FERR ASP

GLYCIN) ........................ 103

PRENATE ELITE (IRON ASP

GLYC) ............................ 103

PRENATE ENHANCE ...... 103

PRENATE

ESSENTIAL(IRON-ASP-

GL) ................................. 103

PRENATE MINI (FERR ASP

GLYCIN) ........................ 103

PRENATE PIXIE ............... 103

PRENATE RESTORE ....... 103

PRENATE STAR ............... 103

PREPIDIL ............................. 84

preplus ................................ 103

PREPOPIK ........................... 73

PRESERA ............................. 44

PRESTALIA ......................... 37

PRESTO PRO BLOOD


pretab .................................. 103

PREVACID .......................... 76

PREVACID SOLUTAB ....... 76

prevalite ................................ 41

PREVIDENT ........................ 53

PREVIDENT 5000 BOOSTER

PLUS ................................ 53

PREVIDENT 5000 DRY

MOUTH ........................... 53

PREVIDENT 5000 ENAMEL

PROTECT ........................ 53

PREVIDENT 5000 PLUS .... 53

PREVIDENT 5000

SENSITIVE ...................... 53

previfem ................................ 87

PREVPAC ............................ 76



131

PREZCOBIX .......................... 4

PREZISTA ............................. 4

PRIFTIN ................................. 9

PRILOLID ............................ 47

PRILOSEC ........................... 76

PRIMACARE..................... 103

PRIMAQUINE ....................... 9

PRIMAXIN IV ....................... 9

primidone ............................. 18

PRIMLEV ............................ 25

PRIMSOL............................. 11

PRINIVIL ............................. 37

PRISTIQ ............................... 31

PRIVIGEN ........................... 80

PROAIR HFA ...................... 94

PROAIR RESPICLICK ....... 94

probenecid ............................ 80

probenecid-colchicine .......... 80

PROBUPHINE ..................... 25

procainamide ........................ 33

PROCARDIA ....................... 37

PROCARDIA XL ................ 37

PRO-C-DURE 5 ................... 54

PRO-C-DURE 6 ................... 54

procentra ............................... 31

prochlorperazine ................... 73

prochlorperazine edisylate.... 73

prochlorperazine maleate ..... 73

PROCORT ........................... 73

PROCRIT ............................. 77

PROCTOCORT ................... 73

PROCTOFOAM HC ............ 73

procto-med hc ....................... 73

proctosol hc .......................... 73

proctozone-hc ....................... 73

PROCYSBI .......................... 97

PRODIGY AUTOCODE

METER ............................ 63

PRODIGY AUTOCODE

MONITOR SYST ............ 63

PRODIGY CONTROL

SOLUTION, LOW ........... 63

PRODIGY CONTROL


PRODIGY NO CODING ..... 57

PRODIGY POCKET METER

.......................................... 63

PRODIGY VOICE GLUCOSE

METER ............................ 63

PRODRIN ............................ 20

PROFERRIN-FORTE ........ 104

PROFILNINE ....................... 39

progesterone ......................... 83

progesterone micronized ...... 83

PROGLYCEM ..................... 58

PROGRAF............................ 15

PROLASTIN-C .................... 51

PROLENSA ......................... 90

PROLEUKIN ....................... 78

PROLIA................................ 81

PROMACTA ........................ 39

promethazine ........................ 92

promethazine vc-codeine ...... 92

promethazine-codeine .......... 92

promethazine-dm .................. 92

promethazine-phenyleph-

codeine.............................. 92

promethazine-phenylephrine 92

promethegan ......................... 92

PROMETRIUM ................... 83

PROMISEB .......................... 44

propafenone .......................... 33

propantheline ........................ 71

proparacaine ......................... 89

propranolol ........................... 37

propranolol-hydrochlorothiazid

.......................................... 37

propylthiouracil .................... 55

PROQUAD (PF)................... 80

PRO-RED AC (W/

DEXCHLORPHENIR) .... 92

PROSCAR ............................ 96

PROSTIN E2 ........................ 84

PROTECT IRON ............... 104

PROTONIX .......................... 76

PROTOPIC ........................... 44

protriptyline .......................... 31

PROVENGE ......................... 80

PROVENTIL HFA ............... 94

PROVERA ........................... 83

PROVIDA DHA................. 104

PROVIDA OB .................... 104

PROVIGIL ........................... 31

PROZAC .............................. 31

pruclair.................................. 44

prudoxin ................................ 44

prumyx .................................. 44

prutect ................................... 44

PSORCON ............................ 50

PULMICORT ....................... 94

PULMICORT FLEXHALER

.......................................... 94

pulmosal ............................... 95

PULMOZYME ..................... 95

PURALOR CI .................... 104

PUREFE OB PLUS ............ 104

PUREFE PLUS .................. 104

purelax .................................. 73

purevit dualfe plus .............. 104

PURIXAN ............................ 15

PYLERA ............................... 76

pyrazinamide .......................... 9

PYRIDIUM .......................... 97

pyridostigmine bromide ........ 21

Q QBRELIS ............................. 37

Q-CARE RX Q4 ................... 53

QNASL ................................. 95

QUADRACEL (PF) ............. 80

QUALAQUIN ........................ 9

QUARTETTE ....................... 87

quasense ................................ 87

quazepam .............................. 31

QUDEXY XR ....................... 18

QUESTRAN ......................... 41

QUESTRAN LIGHT ............ 41

quetiapine ............................. 31

QUFLORA FE .................... 104

QUFLORA FE (FERROUS

SULFATE) ..................... 104

QUFLORA PEDIATRIC ... 104

QUFLORA PEDIATRIC

DROPS ........................... 104

QUILLICHEW ER ............... 31

QUILLIVANT XR ............... 31

quinapril ................................ 37

quinapril-hydrochlorothiazide

.......................................... 37

quinidine gluconate .............. 33

quinidine sulfate ................... 33

quinine sulfate ........................ 9

QUINTET AC ...................... 57



132

QUINTET BLOOD


quit 2 ..................................... 52

QUIT 2 ................................. 52

quit 4 ..................................... 52

QUIT 4 ................................. 52

QUTENZA ........................... 44

QVAR................................... 95

R RABAVERT (PF) ................ 80

rabeprazole ........................... 76

RADICAVA ......................... 21

RADIOGARDASE .............. 51

RAGWITEK......................... 80

rajani ..................................... 87

raloxifene .............................. 81

ramipril ................................. 37

RANEXA ............................. 41

ranitidine hcl ......................... 76

RAPAFLO ............................ 96

RAPAMUNE ....................... 15

rasagiline .............................. 19

RASUVO (PF) ..................... 81

RAVICTI .............................. 51

RAYALDEE ........................ 67

RAYOS ................................ 54

RAZADYNE ........................ 21

RAZADYNE ER .................. 21

rea lo 39 ................................ 44

rea lo 40 ................................ 44

READYSHARP

DEXAMETHASONE ...... 54

READYSHARP

KETOROLAC .................. 27

READYSHARP LIDOCAINE

(PF) ................................... 47

READYSHARP

TRIAMCINOLONE......... 54

REBETOL ............................ 78

REBIF (WITH ALBUMIN) . 78

REBIF REBIDOSE .............. 78

REBIF TITRATION PACK 78

RECLAST ............................ 51

reclipsen (28) ........................ 87

RECOMBINATE ................. 39

RECOMBIVAX HB (PF) .... 80

RECTIV ............................... 73

REFUAH PLUS ................... 57

REFUAH PLUS GLUCOSE

CONTROL ....................... 63

REFUAH PLUS GLUCOSE

MONITOR ....................... 63

REGLAN .............................. 73

REGRANEX ........................ 44

relador pak ............................ 47

relador pak plus .................... 47

RELAGARD ........................ 84

relcof c .................................. 92

RELENZA DISKHALER ...... 4

RELION ALL-IN-ONE

METER ............................ 64

RELION CONFIRM ............ 64

RELION CONFIRM-MICRO

.......................................... 57

RELION MICRO GLUCOSE

MONITOR ....................... 64

RELION NOVOLIN 70/30 .. 66

RELION NOVOLIN N ........ 66

RELION NOVOLIN R ........ 66

RELION PRIME METER.... 64

RELION PRIME TEST

STRIPS ............................. 57

RELISTOR ........................... 73

relnate dha .......................... 104

RELPAX .............................. 20

REMERON .......................... 31

REMERON SOLTAB .......... 31

REMICADE ......................... 73

REMODULIN ...................... 37

RENAGEL ........................... 73

renal caps ............................ 104

rena-vite .............................. 104

rena-vite rx ......................... 104

RENFLEXIS ........................ 73

reno caps ............................. 104

RENVELA ........................... 74

repaglinide ............................ 69

repaglinide-metformin .......... 69

REPATHA PUSHTRONEX 41

REPATHA SURECLICK .... 41

REPATHA SYRINGE ......... 41

REQUIP................................ 19

REQUIP XL ......................... 19

RESCRIPTOR ........................ 5

RESPA-AR ........................... 92

RESTASIS............................ 89

RESTASIS MULTIDOSE .... 89

RESTIZAN ........................... 44

RESTORIL ........................... 32

RETIN-A .............................. 46

RETIN-A MICRO ................ 45

RETIN-A MICRO PUMP .... 46

RETISERT ........................... 91

RETROVIR ............................ 5

REVATIO ............................. 95

REVEAL BLOOD GLUCOSE

METER ............................. 64

REVEAL TEST STRIP ........ 57

REVIA .................................. 27

REVLIMID ........................... 78

REXULTI ............................. 32

REYATAZ ............................. 5

RHOFADE ........................... 46

RIASTAP ............................. 39

ribasphere ............................. 78

ribasphere ribapak ................ 78

ribavirin ............................ 5, 78

RIDAURA ............................ 81

rifabutin .................................. 9

RIFADIN ................................ 9

RIFAMATE ............................ 9

rifampin .................................. 9

RIFATER ............................... 9

RIGHTEST CONTROL

SOLUTION HIGH ........... 64

RIGHTEST GM550 SYSTEM

.......................................... 64

RIGHTEST GS550 TEST

STRIPS ............................. 57

RILUTEK ............................. 51

riluzole .................................. 51

rimantadine ............................. 5

ringer's .................................. 50

RIOMET ............................... 69

risacal-d .............................. 104

risedronate ...................... 51, 81

RISPERDAL ........................ 32

RISPERDAL M-TAB .......... 32

risperidone ............................ 32

RITALIN .............................. 32

RITALIN LA ........................ 32

RITUXAN ............................ 15

RITUXAN HYCELA ........... 15

rivastigmine .......................... 21



133

rivastigmine tartrate.............. 21

rivelsa ................................... 87

RIXUBIS .............................. 39

rizatriptan ............................. 20

R-NATAL OB .................... 104

ROBAXIN ............................ 21

ROBAXIN-750 .................... 21

ROBINUL ............................ 71

ROBINUL FORTE .............. 71

ROCALTROL ...................... 67

ropinirole .............................. 19

rosadan ................................. 46

ROSADAN........................... 46

ROSANIL............................. 46

ROSULA .............................. 46

rosula cleansing cloths ......... 46

rosuvastatin........................... 41

ROTARIX ............................ 80

ROTATEQ VACCINE ........ 80

ROWASA............................. 74

roweepra ............................... 18

ROXICODONE ................... 25

ROZEREM ........................... 32

RUBRACA........................... 15

RUCONEST ......................... 95

RYDAPT .............................. 15

rydex ..................................... 92

RYTARY ............................. 19

RYTHMOL SR .................... 33

RYVENT .............................. 92

S SABRIL ................................ 18

SAFYRAL ............................ 87

SAIZEN ................................ 77

SAIZEN CLICK.EASY ....... 77

SAIZEN SAIZENPREP ....... 77

SALAGEN (PILOCARPINE)

.................................... 51, 53

SALEX ................................. 43

salicylic acid ......................... 43

SALKERA ........................... 43

salsalate ................................ 27

salvax .................................... 43

SALVAX DUO PLUS ......... 43

SAMSCA ............................. 67

SANCUSO ........................... 74

SANDIMMUNE .................. 16

SANDOSTATIN .................. 16

SANDOSTATIN LAR

DEPOT ............................. 16

SANTYL .............................. 50

SAPHRIS (BLACK

CHERRY) ........................ 32

SARAFEM ........................... 32

SAVAYSA ........................... 39

SAVELLA ............................ 81

scalacort ................................ 50

scopolamine base .................. 74

SEASONIQUE ..................... 87

seb-prev ................................ 42

seconal sodium ..................... 32

SEEBRI NEOHALER .......... 95

SELECT-OB ...................... 104

SELECT-OB (FOLIC ACID)

........................................ 104

SELECT-OB + DHA ......... 104

selegiline hcl ......................... 19

selenium sulfide .................... 42

SELRX ................................. 42

SELZENTRY ......................... 5

SEMPREX-D ....................... 92

se-natal 19........................... 104

se-natal 19 (with docusate) . 104

SENSIPAR ........................... 67

SEREVENT DISKUS .......... 95

SERNIVO ............................. 50

serophene .............................. 67

SEROQUEL ......................... 32

SEROQUEL XR................... 32

SEROSTIM .......................... 77

sertraline ............................... 32

se-tan plus ........................... 104

setlakin.................................. 87

sevelamer carbonate ............. 74

sf 53

sf 5000 plus .......................... 53

SFROWASA ........................ 74

sharobel ................................ 83

SHOHL'S MODIFIED ......... 97

SIGNIFOR............................ 16

SIGNIFOR LAR................... 16

sildenafil (antihypertensive) . 95

SILENOR ............................. 32

SILIQ .................................... 42

SILVADENE........................ 42

silver nitrate .......................... 44

silver nitrate applicators ....... 44

silver sulfadiazine ................. 42

SILVRSTAT ......................... 48

SIMBRINZA ........................ 90

SIMPONI ........................ 81, 82

SIMPONI ARIA ................... 81

SIMULECT .......................... 16

simvastatin ............................ 41

SINEMET ............................. 19

SINEMET CR ...................... 19

SINGULAIR ......................... 95

sirolimus ............................... 16

SIRTURO ............................... 9

SITAVIG ................................ 5

SIVEXTRO ............................ 9

SKELAXIN .......................... 21

SKLICE ................................ 50

SKYLA ................................. 82

SMART SENSE


SMART SENSE TEST

STRIPS ............................. 57

SMARTEST CONTROL ..... 64

SMARTEST EJECT ............. 64

SMARTEST PERSONA

STARTER ........................ 64

SMARTEST PRONTO

STARTER ........................ 64

SMARTEST PROTEGE ...... 64

SMARTEST TEST ............... 57

smoothlax ............................. 74

SNAP INSULIN PUMP

CONTROLLER ................ 64

sodium benzoate-sod

phenylacet ......................... 52

sodium chlor 0.9% bacteriostat

.......................................... 52

sodium chloride .............. 95, 98

sodium chloride 0.45 % ........ 98

sodium chloride 0.9 % .......... 52

sodium chloride 3 % ............. 98

sodium chloride 5 % ............. 98

sodium citrate-citric acid ...... 97

SODIUM EDECRIN ............ 37

sodium ferric gluconat-sucrose

.......................................... 52

sodium phenylbutyrate ......... 52



134

SODIUM PHOSPHATE IN

0.9 % NACL ..................... 98

sodium polystyrene sulfonate

.......................................... 74

SODIUM POLYSTYRENE

SULFONATE................... 74

SOLARAZE ......................... 44

SOLESTA ............................ 74

SOLIQUA 100/33 ................ 66

SOLIRIS ............................... 52

SOLODYN ........................... 11

SOLTAMOX ........................ 16

SOLUS V2 AUDIBLE

METER ............................ 64

SOLUS V2 CONTROL


SOLUS V2 TEST STRIPS ... 57

SOMA .................................. 21

SOMATULINE DEPOT ...... 16

SOMAVERT ........................ 67

sonafine ................................ 44

SONATA .............................. 32

SOOLANTRA ...................... 46

SORBITOL-MANNITOL .... 50

SORIATANE ....................... 42

SORILUX............................. 42

sotalol ................................... 33

sotalol af ............................... 33

SOTYLIZE ........................... 33

SOVALDI .............................. 5

sp antipruritic........................ 44

sp scar management ............. 44

SPECTRACEF ....................... 6

spinosad ................................ 50

SPIRIVA RESPIMAT ......... 95

SPIRIVA WITH

HANDIHALER ................ 95

spironolactone ...................... 37

spironolacton-hydrochlorothiaz

.......................................... 37

SPORANOX .......................... 3

SPORANOX PULSEPAK ..... 3

sprintec (28).......................... 87

SPRIX................................... 27

SPRYCEL ............................ 16

sps (with sorbitol) ................. 74

sronyx ................................... 87

ssd ......................................... 43

SSKI ..................................... 55

sss 10-5 ................................. 46

STALEVO 100 ..................... 19

STALEVO 125 ..................... 19

STALEVO 150 ..................... 19

STALEVO 200 ..................... 19

STALEVO 50 ....................... 19

STALEVO 75 ....................... 19

STARLIX ............................. 69

stavudine ................................. 5

STELARA ............................ 42

STIMATE ............................. 67

STIOLTO RESPIMAT......... 95

STIVARGA .......................... 16

stop smoking aid ................... 52

STRATTERA ....................... 32

STRENSIQ ........................... 67

STREPTOMYCIN ................. 9

stress formula ..................... 104

stress formula with iron ...... 104

stress formula with iron(sulf)

........................................ 104

STRIANT ............................. 67

STRIBILD .............................. 5

STRIVERDI RESPIMAT .... 95

STROMECTOL ..................... 9

strong iodine ......................... 98

STROVITE FORTE ........... 104

STROVITE ONE ............... 104

SUBOXONE ........................ 27

SUBSYS ............................... 25

SUCRAID ............................ 74

sucralfate .............................. 76

SULAR ................................. 37

sulfacetamide sodium ..... 42, 91

sulfacetamide sodium (acne) 48

sulfacetamide sodium-sulfur 46

sulfacetamide sod-sulfur-urea

.......................................... 46

sulfacetamide-prednisolone .. 91

sulfacleanse 8-4 .................... 46

sulfadiazine ........................... 10

sulfamethoxazole-trimethoprim

.......................................... 10

SULFAMYLON ................... 48

sulfasalazine ......................... 74

sulfatrim................................ 10

sulindac ................................. 27

SUMADAN .......................... 46

sumatriptan ........................... 20

sumatriptan succinate ........... 20

SUMAVEL DOSEPRO ........ 20

SUMAXIN ........................... 46

SUMAXIN TS ...................... 46

super b complex-vitamin c . 104

super b maxi complex ......... 104

super b-50 complex plus ..... 104

super quints ......................... 104

super quints b-50 ................ 104

superplex-t .......................... 104

SUPERVITE ....................... 104

SUPPRELIN LA .................. 16

SUPRAX ................................ 6

SUPREP BOWEL PREP KIT

.......................................... 74

SURE-TEST EASYPLUS

MINI ................................. 58

SURE-TEST EASYPLUS

MINI METER .................. 64

SURFAXIN .......................... 95

SURMONTIL ....................... 32

SURVANTA ........................ 52

SUSTIVA ............................... 5

SUSTOL ............................... 74

SUTENT ............................... 16

syeda ..................................... 87

SYLATRON ......................... 78

SYLVANT ........................... 16

SYMAX DUOTAB .............. 71

symax fastabs ........................ 71

symax-sl ................................ 71

symax-sr ............................... 71

SYMBICORT ....................... 95

SYMBYAX .......................... 32

SYMLINPEN 120 ................ 69

SYMLINPEN 60 .................. 69

SYNAGIS ............................... 5

SYNALAR ........................... 50

SYNALAR CREAM KIT .... 50

SYNALAR OINTMENT KIT

.......................................... 50

SYNALAR TS ...................... 50

SYNALGOS-DC .................. 25

SYNAREL ............................ 67

SYNDROS ........................... 74

SYNERA .............................. 47



135

SYNERCID ............................ 9

SYNJARDY ......................... 69

SYNJARDY XR .................. 69

SYNRIBO ............................ 16

SYNTHROID ....................... 70

SYPRINE ............................. 52

T T

30 INFUSION SET .......... 64

90 INFUSION SET 23 ..... 64

SLIM ................................ 64

SLIM G4 .......................... 64

TABLOID ............................ 16

TACLONEX ........................ 42

tacrolimus ....................... 16, 44

TAFINLAR .......................... 16

TAGRISSO .......................... 16

TAKE ACTION ................... 87

TALTZ AUTOINJECTOR .. 42

TALTZ AUTOINJECTOR (2

PACK) .............................. 42

TALTZ AUTOINJECTOR (3

PACK) .............................. 42

TALTZ SYRINGE ............... 42

TALTZ SYRINGE (2 PACK)

.......................................... 42

TALTZ SYRINGE (3 PACK)

.......................................... 42

TALWIN .............................. 27

TAMIFLU .............................. 5

tamoxifen .............................. 16

tamsulosin............................. 96

TANDEM PLUS ................ 104

TANZEUM .......................... 69

TAPAZOLE ......................... 55

TARCEVA ........................... 16

TARGADOX ....................... 11

TARGRETIN ....................... 16

tarina fe 1/20 (28) ................. 87

TARKA ................................ 37

taron forte ........................... 104

taron-c dha .......................... 104

taron-prex prenatal-dha ...... 104

TASIGNA ............................ 16

TASMAR ............................. 19

TAXOTERE ......................... 16

TAYTULLA......................... 87

tazarotene ............................. 46

TAZICEF................................ 6

TAZORAC ........................... 46

taztia xt ................................. 37

TECENTRIQ ........................ 16

TECFIDERA ........................ 78

TECHNIVIE ........................... 5

TEFLARO .............................. 6

TEGRETOL ......................... 18

TEGRETOL XR ................... 18

TEKTURNA ........................ 37

TEKTURNA HCT ............... 37

TELCARE BGM .................. 64

TELCARE BLOOD

GLUCOSE KIT ................ 64

TELCARE CONTROL ........ 64

TELCARE TEST STRIPS ... 58

telmisartan ............................ 37

telmisartan-amlodipine ......... 37

telmisartan-hydrochlorothiazid

.......................................... 37

temazepam ............................ 32

TEMODAR .......................... 16

TEMOVATE ........................ 50

temozolomide ....................... 16

tencon ................................... 25

TENIPOSIDE ....................... 16

TENIVAC (PF) .................... 80

TENORETIC 100 ................. 37

TENORETIC 50 ................... 37

TENORMIN ......................... 37

TEPADINA .......................... 16

TERAZOL 7 ......................... 84

terazosin................................ 37

terbinafine hcl ......................... 3

terbutaline ............................. 95

terconazole............................ 84

TERSI FOAM ...................... 42

TESSALON PERLES .......... 92

TEST N'GO BLOOD


TEST N'GO TEST ............... 58

TESTIM................................ 67

testosterone ........................... 68

TESTOSTERONE................ 67

testosterone cypionate .......... 67

testosterone enanthate........... 67

TESTRED ............................ 68

TETANUS,DIPHTHERIA

TOX PED(PF) .................. 80

TETANUS-DIPHTHERIA

TOXOIDS-TD .................. 80

tetcaine .................................. 89

tetrabenazine ......................... 21

tetracaine hcl ......................... 89

tetracaine hcl (pf) .................. 89

tetracycline ........................... 11

TETRAVISC ........................ 89

TETRAVISC FORTE .......... 89

TEXACORT ......................... 50

TEXAVITE LQ .................. 104

THALOMID ......................... 16

THEO-24 .............................. 95

theochron .............................. 95

theophylline .......................... 95

thermazene ............................ 43

THIOLA ............................... 52

thioridazine ........................... 32

thiotepa ................................. 16

thiothixene ............................ 32

THRIVITE RX ................... 104

thrivite-19 ........................... 104

THYMOGLOBULIN ........... 80

THYROLAR-1 ..................... 70

THYROLAR-1/2 .................. 70

THYROLAR-1/4 .................. 70

THYROLAR-2 ..................... 70

THYROLAR-3 ..................... 70

tiagabine ............................... 18

TIAZAC ............................... 37

TICALAST ........................... 95

ticlopidine ............................. 39

TIGAN .................................. 74

TIGECYCLINE ...................... 9

TIKOSYN ............................. 33

tilia fe .................................... 87

timolol maleate ............... 37, 88

TIMOPTIC ........................... 88

TIMOPTIC OCUDOSE (PF)

.......................................... 88

TIMOPTIC-XE ..................... 88

TINDAMAX .......................... 9

tinidazole ................................ 9

TIROSINT ............................ 70

tis-u-sol pentalyte ................. 50

TIVICAY ................................ 5



136

TIVORBEX .......................... 27

tizanidine .............................. 21

tl gard rx ............................. 104

tl g-fol os ............................ 104

tl icon .................................. 104

tl-hem 150 .......................... 104

TOBI....................................... 9

TOBI PODHALER ................ 9

TOBRADEX ........................ 90

TOBRADEX ST .................. 90

tobramycin ............................ 88

tobramycin in 0.225 % nacl ... 9

tobramycin sulfate .................. 9

TOBRAMYCIN WITH

NEBULIZER ...................... 9

tobramycin-dexamethasone .. 90

TOBREX .............................. 88

TODAY CONTRACEPTIVE

SPONGE .......................... 84

TOFRANIL .......................... 32

TOLAK ................................ 44

tolazamide ............................ 69

tolbutamide ........................... 69

tolcapone .............................. 19

tolmetin................................. 27

tolterodine............................. 96

TOPAMAX .......................... 18

TOPICORT .......................... 50

topiramate ............................. 18

TOPIRAMATE .................... 18

toposar .................................. 16

topotecan .............................. 16

TOPROL XL ........................ 37

TORISEL ............................. 16

TORONOVA II SUIK ......... 27

TORONOVA SUIK ............. 27

torsemide .............................. 37

total b/c ............................... 104

TOTECT............................... 12

TOUJEO SOLOSTAR ......... 66

TOVIAZ ............................... 96

TRACLEER ......................... 95

TRADJENTA ....................... 69

tramadol ................................ 27

TRAMADOL ....................... 27

tramadol-acetaminophen ...... 27

trandolapril ........................... 37

trandolapril-verapamil .......... 37

tranexamic acid............... 39, 84

TRANSDERM-SCOP .......... 74

TRANXENE T-TAB ............ 32

tranylcypromine.................... 32

TRANZAREL ...................... 47

TRAVATAN Z..................... 90

trazodone .............................. 32

TREANDA ........................... 16

TRECATOR ........................... 9

TRELSTAR .......................... 16

TREMFYA ........................... 42

TRESIBA FLEXTOUCH U-

100 .................................... 66

TRESIBA FLEXTOUCH U-

200 .................................... 66

tretinoin ................................ 46

tretinoin (chemotherapy) ...... 16

tretinoin microspheres .......... 46

TRETIN-X............................ 46

TRETIN-X CREAM KIT ..... 46

TRETTEN ............................ 39

TREXALL ............................ 16

TREXIMET .......................... 20

TREZIX ................................ 25

tri femynor ............................ 87

TRIACETIN ......................... 48

triamcinolone acetonide 50, 53,

54

triamterene-hydrochlorothiazid

.......................................... 37

trianex ................................... 50

triazolam ............................... 32

TRIBENZOR........................ 37

TRICARE ........................... 104

TRICARE PRENATAL ..... 105

TRICARE PRENATAL DHA

ONE ................................ 105

tricitrates ............................... 97

tricon ................................... 105

TRICOR ............................... 41

triderm .................................. 50

TRIDESILON ...................... 50

tri-estarylla............................ 87

TRIFERIC .......................... 105

trifluoperazine ...................... 32

trifluridine ............................. 88

trigels-f forte ....................... 105

TRIGLIDE............................ 41

trihexyphenidyl ..................... 19

triklo ..................................... 41

tri-legest fe ............................ 87

TRILEPTAL ......................... 18

tri-linyah ............................... 87

TRILIPIX ............................. 41

tri-lo-estarylla ....................... 87

tri-lo-marzia .......................... 87

tri-lo-sprintec ........................ 87

trilyte with flavor packets ..... 74

trimethobenzamide ............... 74

trimethoprim ......................... 11

trimipramine ......................... 32

trinatal gt ............................. 105

trinatal rx 1 ......................... 105

trinate .................................. 105

trinessa (28) .......................... 87

trinessa lo .............................. 87

TRI-NORINYL (28) ............. 87

TRINTELLIX ....................... 32

triphrocaps .......................... 105

TRIPLE DYE ....................... 48

tri-previfem (28) ................... 87

TRIPTODUR ........................ 16

TRISENOX .......................... 16

tri-sprintec (28) ..................... 87

TRISTART DHA ............... 105

tri-tabs dha .......................... 105

TRIUMEQ .............................. 5

triveen-duo dha ................... 105

TRI-VI-FLOR ..................... 105

tri-vit with fluoride and iron

........................................ 105

tri-vitamin with fluoride ..... 105

trivora (28) ............................ 87

TRIZIVIR ............................... 5

TROKENDI XR ................... 18

tropicamide ........................... 89

trospium ................................ 96

TRUE METRIX AIR


TRUE METRIX GLUCOSE

METER ............................. 64

TRUE METRIX GLUCOSE

TEST STRIP ..................... 58

TRUE METRIX GO


TRUE METRIX LEVEL 1 ... 64



137

TRUE2GO BLOOD


TRUECONTROL LEVEL 0 64

TRUERESULT BLOOD

GLUCOSE SYSTM ......... 64

TRUETEST TEST STRIPS . 58

TRUETRACK BLOOD


TRUETRACK SMART

SYSTEM .......................... 65

TRUETRACK TEST ........... 58

TRULANCE......................... 74

TRULICITY ......................... 69

TRUSOPT ............................ 90

trust natal dha ..................... 105

TRUVADA ............................ 5

TUDORZA PRESSAIR ....... 95

tusnel c.................................. 92

TUSNEL PEDIATRIC ......... 92

TUSSICAPS ......................... 93

tussigon................................. 93

TUSSIONEX PENNKINETIC

ER ..................................... 93

TUZISTRA XR .................... 93

TWINRIX (PF) .................... 80

TWYNSTA .......................... 37

TYBOST ................................ 5

TYGACIL .............................. 9

TYKERB .............................. 16

TYLENOL-CODEINE #3.... 25

TYLENOL-CODEINE #4.... 25

TYMLOS ............................. 81

TYPHIM VI ......................... 80

TYSABRI ............................. 21

TYVASO .............................. 95

TYVASO REFILL KIT ....... 95

TYVASO STARTER KIT ... 95

TYZINE ............................... 53

U UCERIS ................................ 74

UDAMIN SP ...................... 105

ULESFIA ............................. 50

ULORIC ............................... 80

ULTIMA MONITOR ........... 65

ULTIMA TEST STRIPS ...... 58

ultimatecare one ................. 105

ultimatecare one nf ............. 105

ultra b-100 complex ........... 105

ULTRACET ......................... 27

ULTRAM ............................. 27

ULTRAM ER ....................... 27

ULTRASAL-ER ................... 43

ULTRATRAK ...................... 58

ULTRATRAK GLUCOSE

METER ............................ 65

ULTRATRAK ULTIMATE 58,

65

ULTRAVATE ...................... 50

ULTRAVATE X .................. 50

umecta .................................. 44

UNASYN ............................. 10

UNISTRIP LOW CONTROL

.......................................... 65

UNISTRIP1 TEST STRIP ... 58

unithroid ............................... 70

UNITUXIN .......................... 16

UPTRAVI ............................. 37

ur n-c..................................... 97

uramit mb ............................. 97

urea ....................................... 44

urea nail stick........................ 44

URECHOLINE .................... 96

URELLE ............................... 97

uretron d-s............................. 97

URIBEL................................ 97

urimar-t ................................. 97

urin ds ................................... 97

uro-458 ................................. 97

UROCIT-K 10 ...................... 97

UROCIT-K 15 ...................... 97

UROCIT-K 5 ........................ 97

urogesic-blue ........................ 97

uro-mp .................................. 97

urophen mb ........................... 97

UROQID-ACID NO.2.......... 97

UROXATRAL ..................... 96

URSO 250 ............................ 74

URSO FORTE ...................... 74

ursodiol ................................. 74

uryl........................................ 97

ustell ..................................... 97

UTA ...................................... 97

UTIBRON NEOHALER ...... 95

utira-c.................................... 97

UTOPIC................................ 44

V VAGIFEM ............................ 83

vaginal contraceptive foam ... 84

valacyclovir ............................ 5

VALCHLOR ........................ 44

VALCYTE ............................. 5

valganciclovir ......................... 5

VALIUM .............................. 32

valproate sodium .................. 18

valproic acid ......................... 19

valproic acid (as sodium salt)

.......................................... 19

valsartan ................................ 37

valsartan-hydrochlorothiazide

.......................................... 37

VALTREX ............................. 5

VANATOL LQ .................... 25

VANATOL S ........................ 25

VANCOCIN ......................... 11

vancomycin ........................... 11

VANCOMYCIN ................... 11

VANCOMYCIN IN 0.9%

SODIUM CL .................... 11

VANCOMYCIN IN

DEXTROSE 5 % .............. 11

vandazole .............................. 84

VANOS ................................ 50

VANOXIDE-HC .................. 46

VANTAS .............................. 16

VAQTA (PF) ........................ 80

VARIZIG .............................. 80

VARUBI ............................... 74

VASCEPA ............................ 41

VASERETIC ........................ 37

VASHE WOUND THERAPY

.......................................... 51

vasopressin in 0.9 % nacl .... 68

VASOSTRICT ..................... 68

VASOTEC ............................ 37

VAXCHORA VACCINE ..... 80

v-c forte .............................. 105

VCF CONTRACEPTIVE

FILM ................................. 84

VCF CONTRACEPTIVE GEL

.......................................... 84

VECAMYL .......................... 41

VECTIBIX ........................... 16

VECTICAL .......................... 42



138

VELCADE ........................... 16

veletri .................................... 37

velivet triphasic regimen (28)

.......................................... 87

VELPHORO......................... 74

VELTASSA ......................... 74

VELTIN ............................... 46

vemavite-prx-2 ................... 105

VEMLIDY ............................. 5

VENCLEXTA ...................... 16

venlafaxine ........................... 32

VENOFER ......................... 105

VENTAVIS .......................... 95

VENTOLIN HFA ................. 95

verapamil .............................. 37

VERDESO ........................... 50

verdrocet ............................... 25

VEREGEN ........................... 44

VERELAN ........................... 38

VERELAN PM .................... 38

veripred 20............................ 55

VERSACLOZ ...................... 32

VESICARE .......................... 96

vestura (28) ........................... 87

VFEND................................... 3

VFEND IV ............................. 3

VGO 20 ................................ 65

VGO 30 ................................ 65

VGO 40 ................................ 65

VIBATIV ............................. 11

VIBERZI .............................. 74

VIBRAMYCIN .................... 11

vic-forte .............................. 105

vicodin .................................. 25

vicodin es.............................. 25

vicodin hp ............................. 25

VICTOZA 2-PAK ................ 69

VICTOZA 3-PAK ................ 69

VIDAZA............................... 16

VIDEX 2 GRAM PEDIATRIC

............................................ 5

VIDEX EC ............................. 5

VIEKIRA PAK ...................... 5

VIEKIRA XR ......................... 5

vienva ................................... 87

vigabatrin .............................. 19

VIGAMOX........................... 88

VIIBRYD ....................... 32, 33

VIMIZIM.............................. 68

VIMOVO.............................. 27

VIMPAT ............................... 19

vinate care........................... 105

VINATE DHA RF.............. 105

vinate ii ............................... 105

vinate m .............................. 105

vinate one ........................... 105

vinblastine ............................ 16

vincasar pfs ........................... 16

vincristine ............................. 16

vinorelbine ............................ 16

VIOKACE ............................ 74

viorele (28) ........................... 87

VIRACEPT ............................ 5

VIRAMUNE .......................... 5

VIRAMUNE XR .................... 5

VIRASAL ............................. 43

VIRAZOLE ............................ 5

VIREAD ................................. 5

VIROPTIC............................ 88

virt-advance ........................ 105

virt-c dha............................. 105

VIRT-CAPS ....................... 105

virt-gard .............................. 105

virt-nate .............................. 105

virt-nate dha ........................ 105

virt-phos 250 neutral ............ 98

virt-pn ................................. 105

virt-pn dha .......................... 105

virt-pn plus ......................... 105

VIRTPREX ........................ 105

virtrate-2 ............................... 97

virtrate-3 ............................... 97

virtrate-k ............................... 97

virt-select ............................ 105

virtussin ac ............................ 93

virtussin dac .......................... 93

virt-vite ............................... 105

virt-vite gt ........................... 105

VIRT-VITE PLUS ............. 105

VISTARIL ............................ 92

VISTOGARD ....................... 12

VISUDYNE.......................... 89

vit 3 ..................................... 105

vit b complex-folic acid ...... 105

VITAFOL ........................... 105

VITAFOL FE+ (WITH

DOCUSATE) ................. 105

VITAFOL GUMMIES ....... 105

VITAFOL NANO .............. 105

VITAFOL ULTRA ............. 105

VITAFOL-OB .................... 105

VITAFOL-OB+DHA ......... 105

VITAFOL-ONE ................. 105

vitajoy daily d ..................... 105

VITAL-D RX ..................... 106

VITAMED MD ONE RX .. 106

VITAMEDMD REDICHEW

RX ................................... 106

vitamin b complex .............. 106

vitamin d3 ........................... 106

vitamins a,c,d and fluoride . 106

VITAPEARL ...................... 106

VITA-RESPA ..................... 106

VITATRUE ........................ 106

VITRASE ............................. 89

VITUZ .................................. 93

VIVELLE-DOT .................... 83

VIVITROL ........................... 27

VIVLODEX ......................... 27

VIVOTIF .............................. 80

VIVOTIF BERNA VACCINE

.......................................... 80

VOGELXO ........................... 68

vol-care rx ........................... 106

vol-nate ............................... 106

vol-plus ............................... 106

vol-tab rx ............................ 106

VOLTAREN ......................... 27

VOLTAREN-XR .................. 27

VONVENDI ......................... 39

VORAXAZE ........................ 12

voriconazole ........................... 3

VOSEVI ................................. 5

VOTRIENT .......................... 16

vp-ch plus ........................... 106

vp-ch-pnv ............................ 106

vp-ggr-b6 ............................ 106

vp-heme ob ......................... 106

vp-heme one ....................... 106

VP-PNV-DHA .................... 106

VPRIV .................................. 68

vp-vite rx ............................ 106

VRAYLAR ........................... 33



139

VUSION ............................... 48

vyfemla (28) ......................... 87

VYTORIN 10-10.................. 41

VYTORIN 10-20.................. 41

VYTORIN 10-40.................. 41

VYTORIN 10-80.................. 41

VYVANSE ........................... 33

VYXEOS .............................. 16

W warfarin ................................ 40

water for irrigation, sterile .... 52

WAVESENSE AMP ............ 65

WAVESENSE CONTROL

SOLUTION ...................... 65

WAVESENSE JAZZ ........... 58

WAVESENSE PRESTO 58, 65

WELCHOL .......................... 41

WELLBUTRIN SR .............. 33

WELLBUTRIN XL.............. 33

wera (28) .............................. 87

westhroid .............................. 70

WIDE-SEAL DIAPHRAGM

.......................................... 82

WILATE............................... 40

woman's laxative .................. 74

women's gentle laxative(bisac)

.......................................... 74

women's laxative (bisacodyl)74

WP THYROID ..................... 70

wymzya fe ............................ 87

X XADAGO............................. 19

XALATAN........................... 90

XALKORI ............................ 17

XANAX ............................... 33

XANAX XR ......................... 33

XARELTO ........................... 40

XATMEP ............................. 17

XCLAIR ............................... 44

XELJANZ ............................ 82

XELJANZ XR ...................... 82

XELODA ............................. 17

XENAZINE .......................... 21

XEOMIN .............................. 80

XERESE ............................... 48

XERMELO........................... 17

XGEVA ................................ 12

XIFAXAN .............................. 9

XIGDUO XR ........................ 69

XIIDRA ................................ 89

XODOL 10/300 .................... 25

XODOL 5/300 ...................... 25

XODOL 7.5/300 ................... 25

XOLAIR ............................... 95

XOLEGEL............................ 48

XOPENEX ........................... 95

XOPENEX CONCENTRATE

.......................................... 95

XOPENEX HFA .................. 95

XTAMPZA ER..................... 25

XTANDI ............................... 17

xulane ................................... 84

XULTOPHY 100/3.6 ........... 66

XURIDEN ............................ 52

XYLOCAINE ....................... 47

XYLOCAINE-MPF ............. 47

xylon 10 ................................ 25

XYNTHA ............................. 40

XYNTHA SOLOFUSE ........ 40

XYREM................................ 33

Y YASMIN (28)....................... 87

YAZ (28) .............................. 87

YERVOY ............................. 17

YF-VAX (PF) ....................... 80

YONDELIS .......................... 17

YOSPRALA ......................... 40

yuvafem ................................ 83

Z zafirlukast ............................. 95

zaleplon ................................ 33

ZALTRAP ............................ 17

zamicet.................................. 25

ZANAFLEX ......................... 21

ZANOSAR ........................... 17

ZANTAC .............................. 76

zarah ..................................... 87

ZARONTIN.......................... 19

ZARXIO ............................... 77

zatean-ch ............................. 106

zatean-pn dha ...................... 106

zatean-pn plus ..................... 106

zavara.................................. 106

ZAVESCA............................ 68

zebutal .................................. 25

ZEGERID ............................. 77

ZEJULA ............................... 17

ZELAPAR ............................ 19

ZELBORAF ......................... 17

ZEMAIRA ............................ 52

ZEMBRACE SYMTOUCH . 20

ZEMPLAR ........................... 68

zenatane ................................ 46

zenchent (28) ........................ 87

ZENPEP ............................... 74

zenzedi .................................. 33

ZENZEDI ............................. 33

ZEPATIER ............................. 5

ZERIT ..................................... 5

ZESTORETIC ...................... 38

ZESTRIL .............................. 38

ZETIA ................................... 41

ZETONNA ........................... 95

ZEVALIN (Y-90) ................. 17

ZIAC ..................................... 38

ZIAGEN ................................. 5

ZIANA .................................. 46

zidovudine .............................. 5

zileuton ................................. 95

ZINACEF ............................... 6

ZINBRYTA .......................... 78

ZINECARD (AS HCL) ........ 12

zingiber ............................... 106

ZINGO .................................. 47

ZINPLAVA .......................... 80

ZIOPTAN (PF) ..................... 90

ziprasidone hcl ...................... 33

ZIPSOR ................................ 27

ZIRGAN ............................... 88

ZITHRANOL ....................... 42

ZITHROMAX ........................ 7

ZITHROMAX TRI-PAK ....... 7

ZITHROMAX Z-PAK ........... 7

ZMAX .................................... 7

ZOCOR ................................. 41

ZODRYL AC 25 .................. 93

ZODRYL AC 30 .................. 93

ZODRYL AC 35 .................. 93

ZODRYL AC 40 .................. 93

ZODRYL AC 50 .................. 93

ZODRYL AC 60 .................. 93

ZODRYL AC 80 .................. 93

ZODRYL DAC 25 ............... 93

ZODRYL DAC 30 ............... 93



140

ZODRYL DAC 35 ............... 93

ZODRYL DAC 40 ............... 93

ZODRYL DAC 50 ............... 93

ZODRYL DAC 60 ............... 93

ZODRYL DAC 80 ............... 93

ZODRYL DEC 25 ................ 93

ZODRYL DEC 30 ................ 93

ZODRYL DEC 35 ................ 93

ZODRYL DEC 40 ................ 93

ZODRYL DEC 50 ................ 93

ZODRYL DEC 60 ................ 93

ZODRYL DEC 80 ................ 93

ZOFRAN (AS

HYDROCHLORIDE) ...... 74

ZOFRAN ODT ..................... 74

ZOHYDRO ER .................... 25

ZOLADEX ........................... 17

zoledronic acid ..................... 68

zoledronic acid-mannitol-water

.......................................... 52

ZOLEDRONIC AC-

MANNITOL-0.9NACL ... 68

ZOLINZA ............................. 17

zolmitriptan .......................... 20

ZOLOFT ............................... 33

zolpidem ............................... 33

ZOLPIMIST ......................... 33

ZOMACTON ....................... 77

ZOMETA ............................. 68

ZOMIG ................................. 20

ZOMIG ZMT ....................... 20

ZONACORT ........................ 55

ZONALON ........................... 44

ZONEGRAN ........................ 19

zonisamide ............................ 19

ZONTIVITY ........................ 40

ZORBTIVE .......................... 77

ZORTRESS .......................... 17

ZORVOLEX ........................ 28

zovia 1/35e (28) .................... 87

zovia 1/50e (28) .................... 87

ZOVIRAX ........................ 5, 48

Z-TUSS AC .......................... 93

ZUBSOLV ............................ 28

ZUPLENZ ............................ 74

ZURAMPIC ......................... 80

ZUTRIPRO ........................... 93

ZYBAN ................................ 53

ZYCLARA ........................... 78

ZYDELIG ............................. 17

ZYFLO ................................. 95

ZYFLO CR ........................... 95

ZYKADIA ............................ 17

ZYLET ................................. 90

ZYLOPRIM .......................... 80

ZYMAXID ........................... 88

ZYPREXA ............................ 33

ZYPREXA ZYDIS ............... 33

ZYTIGA ............................... 17

ZYVOX .................................. 9

Insured/CP-10.14.2016

Discrimination is Against the Law Blue KC complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Blue KC does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Blue KC:

• Provides free aids and services to people with disabilities to communicate effectively with us, such as:

○ Qualified sign language interpreters ○ Written information in other formats (large print, audio, accessible electronic

formats, other formats) • Provides free language services to people whose primary language is not English, such

as: ○ Qualified interpreters ○ Information written in other languages

If you need these services, contact Customer Service, 844-395-7126 (Toll free), [email protected]. If you believe that Blue KC has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with the Appeals Department, PO Box 419169, Kansas City, MO 64141-6169, 816-395-3537, TTY: 816-842-5607, [email protected]. You can file a grievance in person or by mail, or email. If you need help filing a grievance, the Appeals Department is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019, 800-537-7697 (TDD) Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. If you, or someone you’re helping, has questions about Blue KC, you have the right to get help and information in your language at no cost. To talk to an interpreter, call 1-844-395-7126. Spanish: Si usted, o alguien a quien usted está ayudando, tiene preguntas acerca de Blue KC, tiene derecho a obtener ayuda e información en su idioma sin costo alguno. Para hablar con un intérprete, llame al 1-844-395-7126. Chinese: 如果您，或是您正在協助的對象，有關於 Blue KC方面的問題，您有權利免費以您的母語得到幫

助和訊息。洽詢一位翻譯員，請撥電話1-844-395-7126。 Vietnamese: Nếu quý vị, hay người mà quý vị đang giúp đỡ, có câu hỏi về Blue KC, quý vị sẽ có quyền được giúp và có thêm thông tin bằng ngôn ngữ của mình miễn phí. Để nói chuyện với một thông dịch viên, xin gọi 1-844-395-7126. German: Falls Sie oder jemand, dem Sie helfen, Fragen zum Blue KC haben, haben Sie das Recht, kostenlose Hilfe und Informationen in Ihrer Sprache zu erhalten. Um mit einem Dolmetscher zu sprechen, rufen Sie bitte die Nummer 1-844-395-7126 an.

Insured/CP-10.14.2016

Korean: 만약 귀하 또는 귀하가 돕고 있는 어떤 사람이 [Blue KC]에 관해서 질문이 있다면 귀하는 그러한

도움과 정보를 귀하의 언어로 비용 부담없이 얻을 수 있는 권리가 있습니다. 그렇게 통역사와 얘기하기

위해서는 1-844-395-7126 로 전화하십시오. Serbo-Croatian: Ukoliko Vi ili neko kome Vi pomažete ima pitanje o Blue KC, imate pravo da besplatno dobijete pomoć i informacije na Vašem jeziku. Da biste razgovarali sa prevodiocem, nazovite 1-844-395-7126. Arabic:

الضرورية بلغتك من دون اية تكلفة. ، فلديك الحق في الحصول على المساعدة والمعلومات Blue KC إن كان لديك أو لدى شخص تساعده أسئلة بخصوص .7126-395-844-1. للتحدث مع مترجم اتصل بـ

Russian: Если у вас или лица, которому вы помогаете, имеются вопросы по поводу Blue KC, то вы имеете право на бесплатное получение помощи и информации на вашем языке. Для разговора с переводчиком позвоните по телефону1-844-395-7126. French: Si vous, ou quelqu'un que vous êtes en train d’aider, a des questions à propos de Blue KC, vous avez le droit d'obtenir de l'aide et l'information dans votre langue à aucun coût. Pour parler à un interprète, appelez 1-844-395-7126. Tagalog: Kung ikaw, o ang iyong tinutulangan, ay may mga katanungan tungkol sa Blue KC, may karapatan ka na makakuha ng tulong at impormasyon sa iyong wika ng walang gastos. Upang makausap ang isang tagasalin, tumawag sa1-844-395-7126. Laotian: ຖ້ າທ່ ານ, ຫຼື ຄົນ ◌່ ທທ່ ານກໍ າລັງຊ່ ວຍເຫືຼ ອ, ມ ◌ໍ ຄາຖາມກ່ ຽວກັບ Blue KC, ທ່ ານມ ◌ິ ສດ ◌່ ທຈະໄດ້ຮັບການຊ່ ວຍເຫຼື ອແລະ◌ໍ ຂ້ ມູ ນຂ່ າວສານ ◌່ ທເປັ ນພາສາຂອງທ່ ານໍ ◌່ ບມ ຄ່ າໃຊ້ຈ່ າຍ. ການໂອ້ລົມກັບນາຍພາສາ, ໃຫ້ ໂທຫາ 1-844-395-7126. Pennsylvanian Dutch: Wann du hoscht en Froog, odder ebber, wu du helfscht, hot en Froog baut Blue KC, hoscht du es Recht fer Hilf un Information in deinre eegne Schprooch griege, un die Hilf koschtet nix. Wann du mit me Interpreter schwetze witt, kannscht du 1-844-395-7126 uffrufe. Persian:

زبان خود را به طور ، داشته باشيد حق اين را داريد که کمکو اطالعات به Blue KC اگر شما، يا کسی که شما به او کمک ميکنيد ، سوال در مورد .تماس حاصل نماييد 7126-395-844-1.رايگان دريافت نماييد

Cushite: Isin yookan namni biraa isin deeggartan Blue KC irratti gaaffii yo qabaattan, kaffaltii irraa bilisa haala ta’een afaan keessaniin odeeffannoo argachuu fi deeggarsa argachuuf mirga ni qabdu. Nama isiniif ibsu argachuuf, lakkoofsa bilbilaa 1-844-395-7126 tiin bilbilaa. Portuguese: Se você, ou alguém a quem você está ajudando, tem perguntas sobre o Blue KC, você tem o direito de obter ajuda e informação em seu idioma e sem custos. Para falar com um intérprete, ligue para 1-844-395-7126. For TTY services, please call 1-816-842-5607.

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KANSAS ACA MEMBER PRESCRIPTION DRUG LIST 2018KANSAS ACA MEMBER . PRESCRIPTION DRUG LIST . 2018 . 2 Table of Contents . ... COARTEM 2 colistin (colistimethate na) 1 COLY-MYCIN M PARENTERAL