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Plan for your best health

2018 Aetna Pharmacy Drug Guide Aetna Value Small Group Plan: IA, NE

aetna.com 05.02.378.1 N (12/18)

How to use this guide

Your guide includes a list of commonly used drugs covered on your pharmacy plan. The amount you pay depends on the drug your doctor prescribes. It’s either a flat fee or a percentage of the prescription’s price after you meet your deductible, if applicable. Preferred generic drugs cost less. Preferred brand drugs will have a higher cost.

Your plan includes

• Brand and generic drugs that are hand-picked for their quality and effectiveness

• Aetna Specialty Pharmacy® fills specialty drug prescriptions (ones that are injected, infused or taken by mouth) — and provides services that include personal support, helpful resources and training, and free secure home delivery

• Aetna Rx Home Delivery® pharmacy that delivers maintenance drugs to your home or wherever you choose (for drugs that are taken regularly to treat conditions like arthritis, diabetes or asthma)

What you can expect to pay

With your pharmacy plan, the amount you pay depends on the drug your doctor prescribes. It’s either a flat fee or a percentage of the drug’s/medicine’s price.

Each drug is grouped as a generic, a brand or a specialty drug. The preferred drugs within these groups will generally save you money compared to a non-preferred drug. Generic drugs are less expensive than brands.

Specialty prescription drugs typically include higher-cost drugs that require special handling, special storage or monitoring. These types of drugs may include, but are not limited to, drugs that are injected, infused, inhaled or taken by mouth.

You’re covered for all types of medicine — some more expensive, and some less.

• Generic: the lowest cost

• Preferred brand: a slightly higher cost

• Non-preferred brand: a higher cost

• Preferred Specialty: lower cost for specialty drugs

• Non-preferred specialty: higher cost for non-preferred specialty drugs

Your pharmacy plan may not have all the coverage levels listed above so check your plan documents to see how much you will pay.

For your exact coverage and cost, and to learn more about your plan

Visit the website that’s on your member ID card. Then log in to your account, where you can:

• Find out the coverage and estimate of cost for specific drugs

• View your deductibles and plan limits

• Order medications

• Check your pharmacy order status

• Get a member ID card

• View your claims, Explanation of Benefits and more

Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, including Aetna Life Insurance Company and its affiliates (Aetna). Aetna Pharmacy Management refers to an internal business unit of Aetna Health Management, LLC. Aetna Pharmacy Management administers, but does not offer, insure or otherwise underwrite the prescription drug benefits portion of your health plan and has no financial responsibility therefor. Aetna Specialty Pharmacy refers to Aetna Specialty Pharmacy, LLC, a subsidiary of Aetna Inc., which is a licensed pharmacy that operates through specialty pharmacy prescription fulfillment.

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Have more questions about your pharmacy benefits?

We’re here to help. There are several ways you can learn more about your benefits:

• Check your Plan Design and Benefits Summary in your enrollment kit.

• Call the toll-free number on your member ID card.

• Review our pharmacy frequently asked questions (FAQs) and answers. Just visit the website that’s on your member ID card to search for the “Pharmacy FAQ.”

Aetna Specialty Pharmacy

Aetna Specialty Pharmacy® medicine and support services is our in-house specialty pharmacy that can fill your prescriptions for specialty drugs. These are the types of drugs that may be injected, infused or taken by mouth. They often need special storage and handling. And they need to be delivered quickly. A nurse or pharmacist may monitor you during your treatment, if needed. With Aetna Specialty Pharmacy, you can get this medicine sent right to your mailbox.

How to get started with Aetna Specialty Pharmacy

Ordering your prescription through Aetna Specialty Pharmacy is easy. And we typically offer a 30-day medicine supply.

• To transfer your prescription, just call us toll-free at 1-866-353-1892.

• For a new prescription, your doctor can send it to us in one of four ways:

1. Electronically: Through e-prescribe

2. Fax: 1-866-FAX-ASRX (1-866-329-2779)

3. Mail: Aetna Specialty Pharmacy 503 Sunport Lane Orlando, FL 32809

4. Phone: 1-866-782-ASRX (1-866-782-2779), option 2

If you mail in your own prescription, please send it with a completed Patient Profile Form. To find this form, just visit the website that’s on your member ID card, to search for the “Patient Profile Form.”

Aetna Rx Home Delivery

You can have maintenance drugs sent right to your home or anywhere else you choose with Aetna Rx Home Delivery® pharmacy. These are drugs that are taken regularly for chronic conditions like arthritis, diabetes or asthma. Depending on your plan, you can get up to a 90-day supply of medicine for less cost. It’s fast and convenient, and standard shipping is always free.

Get started right away

You can submit your order using one of these options:

1. Online — Visit your secure member website and sign in to your account. There you can add or remove your prescriptions.

2. Phone — Call us toll-free, 24/7 at 1-888-792-3862. If you need the help of a telephone device for the deaf, call 1-877-833-2779.

3. Mail — Get a new prescription from your doctor. Then mail it to us with a completed order form. You can find the form on your secure member website. The mailing address is on the form.

Your doctor can submit your order using one of these options:

1. Online — They can submit your prescriptions using the e-prescribe services on our provider website.

2. Fax — They can fax your prescription to 1-877-270-3317. Make sure they include your member ID number, date of birth and mailing address on the fax cover sheet. Only a doctor may fax a prescription.

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Frequently asked questions

How can I save on prescriptions?

Here are some tips to pay less out of pocket for your prescription drugs:

• Ask your doctor to consider prescribing drugs that are on the Pharmacy Drug Guide (formulary).

• Ask your doctor to consider prescribing generic drugs instead of brand-name drugs.

• Check to see if your plan includes our home delivery pharmacy service. Depending upon your plan, our home delivery service may save you money. For more information, visit the website on your member ID card and log in to your account.

• Remind your doctor to check your plan to make sure you get maximum coverage.

What are generic drugs?

Generic drugs are proven to be just as safe and effective as brand-name drugs. They contain the same active ingredients in the same amounts as the brand-name drugs and work the same way. So they have the same risks and benefits as brand-name drugs. However, they typically cost less.

When appropriate, your doctor may decide to prescribe a generic drug or allow the pharmacist to substitute a generic drug.

What is precertification?

Precertification is one way that we can help you and your doctor find safe, appropriate drugs and keep costs down. Precertification means that you or your doctor need to get approval from the plan before certain drugs will be covered. Generally, precertification applies to drugs that:

• Are often taken in the wrong way

• Should only be used for certain conditions

• Often cost more than other drugs that are proven to be just as effective

Keep in mind that your doctor must contact us to request approval of coverage for these drugs.

What is step therapy?

Some drugs require step therapy. This means that you must try one or more prerequisite drug(s) before a step therapy drug is covered.

The prerequisite drugs are equally effective, have U.S. Food and Drug Administration (FDA) approval and may cost less. They treat the same condition as the step therapy drug.

If you don’t try the appropriate alternative drug first, you may need to pay full cost for the brand-name version.

What are quantity limits?

Quantity limits help your doctor and pharmacist make sure that you use your drug correctly and safely. We use medical guidelines and FDA-approved recommendations from drug makers to set these coverage limits. The quantity limit program includes:

• Dose efficiency edits — Limits prescription coverage to one dose per day for drugs that have approval for once-daily dosing

• Maximum daily dose — If a prescription is lower than the minimum or higher than the maximum allowed dose, a message is sent to the pharmacy

• Quantity limits over time — Limits prescription coverage to a specific number of units over a specific amount of time

What if I need a drug that requires an exception to the precertification, step therapy or quantity limits requirements? Or what if I need a drug that’s not covered under my plan?

In certain cases, you or your prescriber can request a medical exception to the precertification, step therapy or quantity limits requirements. And also for a drug that’s not covered in your plan. If you ask for your request to be expedited, a coverage determination will be made within 24 hours of receiving it.

We’ll then contact you or your prescriber with our decision. All medically necessary outpatient prescription drugs will be covered. If a medical exception is approved, you only need to pay the copay after the deductible. This amount is based on your pharmacy plan design.

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How can your provider request a medical exception?

• Submit their request through our secure provider website on NaviNet®.

• Call the Aetna Pharmacy Precertification Unit at 1-855-240-0535.

• Fax the completed request form to 1-877-269-9916.

• Mail the completed request form to: Aetna Pharmacy Management 1300 East Campbell Road Richardson, TX 75081

How is the formulary (drug list) developed?

Our Pharmacy and Therapeutics Committee meets regularly to review new drugs and new information about current drugs. We review them for their safety, effectiveness and current use in therapy.

This committee includes licensed pharmacists and doctors. They are currently in practice or are Aetna employees.

Once we complete our clinical review, we also consider overall value before adding or removing a drug from the formulary. We may recommend moving a drug to a different coverage level. Or that it be placed on our Formulary Exclusions List and no longer be covered.

Can the formulary change during the year?

The formulary can change throughout the year. Some reasons why they can change include:

• New drugs are approved.

• Existing drugs are removed from the market.

• Prescription drugs may become available over the counter (without a prescription). Over-the-counter drugs are not generally covered in a formulary.

• Brand-name drugs lose patent protection and generic versions become available. When this happens, the brand-name drug is likely to be covered at a higher cost. And the generic versions cost less. See the “What are generic drugs?” section above for more information.

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Commercial 1557 Nondiscrimination Notice

Aetna complies with applicable Federal civil rights laws and does not discriminate, exclude or treat people differently based on their race, color, national origin, sex, age, or disability.

Aetna provides free aids/services to people with disabilities and to people who need language assistance.

If you need a qualified interpreter, written information in other formats, translation or other services, call the number on your ID card.

If you believe we have failed to provide these services or otherwise discriminated based on a protected class noted above, you can also file a grievance with the Civil Rights Coordinator by contacting:

Civil Rights Coordinator, P.O. Box 14462, Lexington, KY 40512 (CA HMO customers: PO Box 24030 Fresno, CA 93779), 1-800-648-7817, TTY: 711, Fax: 859-425-3379 (CA HMO customers: 860-262-7705), [email protected].

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or at:

U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, or at 1-800-368-1019, 800-537-7697 (TDD).

Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, including Aetna Life Insurance Company, Coventry Health Care plans and their affiliates (Aetna).

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Remember to visit the website on your member ID card. Then sign in to your account for the most up-to-date information.

Please note that if your prescription drug benefits plan changes, the information here may no longer apply. A copayment is a flat fee. Coinsurance is a percentage of the rate that Aetna negotiates with the plan sponsor for covered prescriptions except as required by law to be otherwise. Some drugs on the Preferred Drug List are subject to manufacturer rebates. Coinsurance is calculated before any rebates are subtracted. That means it may be possible for your cost of a preferred drug to be higher than your cost of a non-preferred drug. Louisiana members: depending on your specific plan and the prescription medication in question, you may in some instances be subject to an excess consumer cost burden for prescription drugs as defined by your state. Not all health services are covered. See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan features and availability may vary by location and are subject to change. Aetna receives rebates from drug manufacturers that may be taken into account in determining Aetna’s Pharmacy Drug (formulary) Guide. Rebates do not reduce the amount a member pays the pharmacy for covered prescriptions. Information is subject to change. The drugs on the Pharmacy Drug (formulary) Guide, Formulary Exclusions, Precertification, and Quantity Limit Lists are subject to change. The quantity limits and drug coverage review programs are not available in all service areas. In accordance with state law, commercial fully insured members in Louisiana and Texas (except Federal Employee Health Benefit Plan members) who are receiving coverage for medications that are added or removed from the Pharmacy Drug (formulary) Guide, Precertification, Quantity Limits or Step-Therapy Lists during the plan year will continue to have those medications covered at the same benefit level until their plan’s renewal date. In Texas, precertification approval is known as “pre-service utilization review.” It is not “verification” as defined by Texas law. In accordance with state law, fully insured Commercial California health maintenance organization (HMO) members (except Federal Employee Health Benefit Plan members) who are receiving coverage for medications that are added to the Precertification or Step-Therapy Lists will continue to have those medications covered, for as long as the treating physician continues prescribing them, provided that the drug is appropriately prescribed and is considered safe and effective for treating the enrollee’s medical condition. In accordance with state law, fully insured Commercial Connecticut preferred provider organization (PPO) members (except Federal Employee Health Benefit Plan members) who are receiving coverage for medications that are added to the Precertification or Step-Therapy Lists will continue to have those medications covered for as long as the treating physician prescribes them, provided the drug is medically necessary and more medically beneficial than other covered drugs. Nothing in this section shall preclude the prescribing provider from prescribing another drug covered by the plan that is medically appropriate for the enrollee, nor shall anything in this section be construed to prohibit generic drug substitutions. This material is for information only. It contains only a partial, general description of plan benefits or programs and does not constitute a contract. See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan features and availability may vary by location and are subject to change. Providers are independent contractors and are not agents of Aetna. Provider participation may change without notice. Aetna does not provide care or guarantee access to health services. Information is subject to change.

aetna.com ©2018 Aetna Inc. 05.02.378.1 N (12/18)

2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE

Table of Contents

*ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS*....................................................17*AGENTS FOR NARCOTIC WITHDRAWAL***.................................................................................19*AGENTS FOR OPIOID WITHDRAWAL***........................................................................................19*AMEBICIDES*........................................................................................................................................19*AMINO ACIDS***..................................................................................................................................19*AMINOGLYCOSIDES*..........................................................................................................................19*ANALGESICS - ANTI-INFLAMMATORY*........................................................................................ 20*ANALGESICS - NONNARCOTIC*.......................................................................................................22*ANALGESICS - OPIOID*.......................................................................................................................23*ANDROGENS-ANABOLIC*................................................................................................................. 27*ANORECTAL AGENTS*....................................................................................................................... 28*ANTHELMINTICS*............................................................................................................................... 29*ANTIANGINAL AGENTS*................................................................................................................... 29*ANTIANXIETY AGENTS*....................................................................................................................30*ANTIARRHYTHMICS*.........................................................................................................................30*ANTIASTHMATIC AND BRONCHODILATOR AGENTS*.............................................................. 31*ANTICOAGULANTS*........................................................................................................................... 33*ANTICONVULSANTS*......................................................................................................................... 34*ANTIDEMENTIA AGENT COMBINATIONS***............................................................................... 37*ANTIDEPRESSANTS*........................................................................................................................... 37*ANTIDIABETICS*..................................................................................................................................39*ANTIDIARRHEAL/PROBIOTIC AGENTS*........................................................................................43*ANTIDIARRHEALS*.............................................................................................................................43*ANTIDOTES AND SPECIFIC ANTAGONISTS*.................................................................................44*ANTIDOTES*..........................................................................................................................................44*ANTIEMETICS*..................................................................................................................................... 44*ANTIFUNGALS*....................................................................................................................................45*ANTIHEMOPHILIC PRODUCTS - MONOCLONAL ANTIBODIES***...........................................46*ANTIHISTAMINES*.............................................................................................................................. 46*ANTIHYPERLIPIDEMICS*.................................................................................................................. 47*ANTIHYPERTENSIVES*.......................................................................................................................49*ANTI-INFECTIVE AGENTS - MISC.*..................................................................................................52*ANTIMALARIALS*............................................................................................................................... 53*ANTIMYASTHENIC AGENTS*........................................................................................................... 54*ANTIMYASTHENIC/CHOLINERGIC AGENTS*.............................................................................. 54*ANTIMYCOBACTERIAL AGENTS*................................................................................................... 54*ANTINEOPLASTIC - BCL-2 INHIBITORS***.....................................................................................55*ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES*................................................................. 55*ANTIPARKINSON AGENTS*.............................................................................................................. 59*ANTIPSYCHOTICS/ANTIMANIC AGENTS*..................................................................................... 60*ANTIRETROVIRALS ADJUVANTS***...............................................................................................62*ANTISEPTICS & DISINFECTANTS*................................................................................................... 62*ANTIVIRALS*........................................................................................................................................ 62*ASSORTED CLASSES*.......................................................................................................................... 66*ATOPIC DERMATITIS - MONOCLONAL ANTIBODIES***............................................................67*BETA BLOCKER & ANGIOTENSIN II RECEPTOR ANTAGONIST COMB***............................. 68*BETA BLOCKERS*................................................................................................................................ 68

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*BILE ACID SYNTHESIS DISORDER AGENTS***............................................................................ 69*BIOLOGICALS MISC*........................................................................................................................... 69*BULK CHEMICALS - NY***.................................................................................................................69*CALCITONIN GENE-RELATED PEPTIDE (CGRP) RECEPTOR ANTAG***................................69*CALCIUM CHANNEL BLOCKERS*................................................................................................... 69*CARDIOTONICS*.................................................................................................................................. 71*CARDIOVASCULAR AGENTS - MISC.*.............................................................................................71*CEPHALOSPORINS*............................................................................................................................. 72*CHEMICALS*......................................................................................................................................... 73*CIC AGENTS - GUANYLATE CYCLASE-C (GC-C) AGONISTS***.................................................73*CONTRACEPTIVES*............................................................................................................................. 73*CORTICOSTEROIDS*........................................................................................................................... 78*COUGH/COLD/ALLERGY*..................................................................................................................79*CYCLIN-DEPENDENT KINASES (CDK) INHIBITORS***.............................................................. 80*CYSTIC FIBROSIS AGENT - COMBINATIONS***............................................................................80*DERMATOLOGICALS*........................................................................................................................ 81*DIAGNOSTIC PRODUCTS*................................................................................................................. 93*DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS*.................................................98*DIGESTIVE AIDS*............................................................................................................................... 102*DIRECT-ACTING P2Y12 INHIBITORS***........................................................................................102*DIURETICS*......................................................................................................................................... 102*ENDOCRINE AND METABOLIC AGENTS - MISC.*...................................................................... 103*ESTROGENS*....................................................................................................................................... 108*ESTROGEN-SELECTIVE ESTROGEN RECEPTOR MODULATOR COMB***............................ 109*FARNESOID X RECEPTOR (FXR) AGONISTS***.......................................................................... 109*FLUOROQUINOLONES*.................................................................................................................... 109*GASTROINTESTINAL AGENTS - MISC.*........................................................................................ 110*GENITOURINARY AGENTS - MISCELLANEOUS*....................................................................... 111*GLYCOPEPTIDES***...........................................................................................................................112*GOUT AGENTS*.................................................................................................................................. 112*HEMATOLOGICAL AGENTS - MISC.*.............................................................................................113*HEMATOPOIETIC AGENTS*.............................................................................................................115*HEMOSTATICS*...................................................................................................................................118*HEPATITIS C AGENT - COMBINATIONS***.................................................................................. 118*HEREDITARY OROTIC ACIDURIA TREATMENT - AGENTS**.................................................119*HYPNOTICS*........................................................................................................................................119*HYPOPHOSPHATASIA (HPP) AGENTS***...................................................................................... 120*IBS AGENT - MU-OPIOID RECEPTOR AGONISTS***................................................................... 120*INSULIN-INCRETIN MIMETIC COMBINATIONS***................................................................... 120*INTEGRIN RECEPTOR ANTAGONISTS***.................................................................................... 120*INTERLEUKIN ANTAGONISTS***.................................................................................................. 120*INTERLEUKIN-5 ANTAGONISTS (IGG1 KAPPA)***.................................................................... 120*INTERLEUKIN-5 ANTAGONISTS (IGG4 KAPPA)***.................................................................... 120*ISOCITRATE DEHYDROGENASE-1 (IDH1) INHIBITORS***.......................................................120*ISOCITRATE DEHYDROGENASE-2 (IDH2) INHIBITORS***.......................................................120*LAXATIVES*........................................................................................................................................ 120*LEPTIN ANALOGUES***................................................................................................................... 122*LHRH/GNRH AGONIST ANALOG COMBINATIONS***.............................................................. 122*LOCAL ANESTHETICS-PARENTERAL*..........................................................................................122*LYMPHOCYTE FUNCTION-ASSOCIATED ANTIGEN-1 (LFA-1) ANTAG***............................122

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*LYSOSOMAL ACID LIPASE (LAL) DEFICIENCY - AGENTS***.................................................. 122*MACROLIDES*.................................................................................................................................... 123*MEDICAL DEVICES*.......................................................................................................................... 123*MIGRAINE PRODUCTS*....................................................................................................................127*MINERALS & ELECTROLYTES*.......................................................................................................129*MONOBACTAMS***........................................................................................................................... 130*MOUTH/THROAT/DENTAL AGENTS*............................................................................................130*MUCOPOLYSACCHARIDOSIS IV (MPS IV) - AGENTS***............................................................ 131*MULTIVITAMINS*..............................................................................................................................131*MUSCULOSKELETAL THERAPY AGENTS*.................................................................................. 133*NASAL AGENTS - SYSTEMIC AND TOPICAL*.............................................................................. 134*NEPRILYSIN INHIB (ARNI)-ANGIOTENSIN II RECEPT ANTAG COMB***.............................135*NEUROGENIC ORTHOSTATIC HYPOTENSION (NOH) - AGENTS***.......................................135*NEUROMUSCULAR AGENTS*.........................................................................................................135*OPHTHALMIC AGENTS*................................................................................................................... 135*OPHTHALMIC RHO KINASE INHIBITORS***...............................................................................140*OREXIN RECEPTOR ANTAGONISTS***.........................................................................................140*OTIC AGENTS*.................................................................................................................................... 140*OXABOROLE-RELATED ANTIFUNGALS - TOPICAL***............................................................. 141*OXYTOCICS*........................................................................................................................................141*PASSIVE IMMUNIZING AGENTS - COMBINATIONS***............................................................. 141*PASSIVE IMMUNIZING AGENTS*...................................................................................................141*PCSK9 INHIBITORS***....................................................................................................................... 142*PENICILLINS*......................................................................................................................................142*PHARMACEUTICAL ADJUVANTS*.................................................................................................143*PHOSPHATIDYLINOSITOL 3-KINASE (PI3K) INHIBITORS***................................................... 143*PHOSPHODIESTERASE 4 (PDE4) INHIBITORS - TOPICAL***.....................................................143*PHOSPHODIESTERASE 4 (PDE4) INHIBITORS***.........................................................................143*PLASMA KALLIKREIN INHIBITORS - MONOCLONAL ANTIBODIES***................................ 143*POLY (ADP-RIBOSE) POLYMERASE (PARP) INHIBITORS**......................................................143*POLY (ADP-RIBOSE) POLYMERASE (PARP) INHIBITORS***.....................................................144*POSTHERPETIC NEURALGIA (PHN)/NEUROPATHIC PAIN AGENTS***................................144*POTASSIUM REMOVING AGENTS***.............................................................................................144*PROGESTINS*...................................................................................................................................... 144*PROTEASE-ACTIVATED RECEPTOR-1 (PAR-1) ANTAGONISTS***.......................................... 144*PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.*..........................................144*PULMONARY FIBROSIS AGENTS - KINASE INHIBITORS***....................................................148*PULMONARY FIBROSIS AGENTS***..............................................................................................148*PULMONARY HYPERTENSION - PROSTACYCLIN RECEPTOR AGONIST***........................148*RESPIRATORY AGENTS - MISC.*.................................................................................................... 148*SEROTONIN MODULATORS***.......................................................................................................148*SGLT2 INHIBITOR - DPP-4 INHIBITOR COMBINATIONS***......................................................148*SINUS NODE INHIBITORS**.............................................................................................................148*SODIUM-GLUCOSE CO-TRANSPORTER 2 INHIBITOR-BIGUANIDE COMB***..................... 149*SPLEEN TYROSINE KINASE (SYK) INHIBITORS***.................................................................... 149*SULFONAMIDES*............................................................................................................................... 149*TETRACYCLINES*..............................................................................................................................149*THYROID AGENTS*........................................................................................................................... 150*TOPICAL ANESTHETIC GASES***...................................................................................................151*TOXOIDS*............................................................................................................................................. 151

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*TRYPTOPHAN HYDROXYLASE INHIBITORS***......................................................................... 151*ULCER DRUGS*.................................................................................................................................. 151*URINARY ANTI-INFECTIVES*.........................................................................................................154*URINARY ANTISPASMODICS*........................................................................................................ 154*VAGINAL PRODUCTS*...................................................................................................................... 155*VASOPRESSORS*.................................................................................................................................155*VITAMINS*........................................................................................................................................... 156

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lowercase = Brand name drugslowercase italics = Generic drugs

Drug StatusCE = Copay Exception: Available to some members at no cost with a prescription from your provider when obtained at an in-network pharmacy. Certain limitations may apply.G = Preferred GenericLGC = Lowest Generic Copay AppliesM = Coverage where required by state lawNC = Not Covered NP = Non-Preferred BrandPB = Preferred BrandSP = Specialty

Drug Details# = Brand-name drug expected to become available generically in the near future. After the generic drug becomes available, the brand-name drug may be covered at a higher non-preferred copay and/or added to the Formulary Exclusion List. The brand-name drug may also be subject to precertification and/or step-therapy.AL = Age LimitLGC = Lowest Generic Copay AppliesMPG = PG tier applies to members residing in MassachusettsMST = Step Therapy does not apply to members residing in Massachusetts.N1 = Refer to member plan documents for Erectile Dysfuncition use/coverageN5 = Drug may be covered by some plansPA = Prior Authorization PPA = Prior Authorization does not apply to members residing in Pennsylvania. QL = Quantity LimitSelect OTC = Select OTC Program if your pharmacy plan includes this program you may have coverage for products noted with a doctors prescription. Please see your plan benefit information for specific coverage details.


The formulary is updated the first week of each month.

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SP = You may pay higher out of pocket costs and may be required to get these products at an Aetna Specialty Pharmacy network provider, such as Aetna Specialty Pharmacy. Specialty products are limited to a 30 day supply.ST = Step Therapy

Drug Name Drug Status Drug Details

*ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS*

adderall NC N5

adderall xr NC N5

adzenys er NP PA; ST; QL

adzenys xr-odt NP PA; ST; QL

amphetamine sulfate G QL

amphetamine-dextroamphet er G QL

amphetamine-dextroamphetamine G QL

aptensio xr NP PA; ST; #; QL

armodafinil G PA; QL

atomoxetine hcl G QL

benzphetamine hcl oral tablet 50 mg MOnly covered in states: DC and excluded elsewhere; TIER 3

caffeine citrate oral solution 20 mg/ml G

clonidine hcl er G PA; QL

concerta NC N5

cotempla xr-odt NP PA; ST; QL

daytrana NP PA; ST; #; QL

desoxyn NC N5

dexedrine oral capsule extended release 24 hour

NC N5

dexmethylphenidate hcl G QL

dexmethylphenidate hcl er G QL

dextroamphetamine sulfate er G QL

dextroamphetamine sulfate oral solution G PA; QL

dextroamphetamine sulfate oral tablet G QL

diethylpropion hcl er MOnly covered in states: DC and excluded elsewhere; TIER 3



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diethylpropion hcl oral MOnly covered in states: DC and excluded elsewhere; TIER 3

dyanavel xr NP PA; ST; QL

evekeo NP PA; ST; QL

focalin NC N5

focalin xr oral capsule extended release 24 hour 10 mg, 15 mg, 30 mg, 40 mg, 5 mg

NC N5

focalin xr oral capsule extended release 24 hour 20 mg, 25 mg, 35 mg

NP ST; QL

guanfacine hcl er G PA; QL

intuniv NC N5

kapvay oral tablet extended release 12 hour NC N5

metadate er oral tablet extended release 20 mg G QL

methamphetamine hcl G PA; QL

methylin oral solution NC N5

methylphenidate hcl er G QL

methylphenidate hcl er (cd) G QL

methylphenidate hcl er (la) G QL

methylphenidate hcl oral G QL

modafinil G PA; QL

mydayis NP PA; ST; QL

nuvigil NP PA; QL

phendimetrazine tartrate MOnly covered in states: DC and excluded elsewhere; TIER 3

phendimetrazine tartrate er MOnly covered in states: DC and excluded elsewhere; TIER 3

phentermine hcl oral MOnly covered in states: DC and excluded elsewhere; TIER 3

procentra NC N5

provigil NC N5

quillichew er NP PA; ST; QL

quillivant xr NP PA; ST; #; QL

regimex MOnly covered in states: DC and excluded elsewhere; TIER 3

relexxii G QL

ritalin NC N5



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ritalin la oral capsule extended release 24 hour 10 mg, 20 mg, 30 mg, 40 mg

NC N5

strattera NP ST; QL

vyvanse PB QL

xenical MOnly covered in states: DC and excluded elsewhere; TIER 3

zenzedi oral tablet 10 mg, 5 mg G QL

zenzedi oral tablet 15 mg, 2.5 mg, 20 mg, 30 mg, 7.5 mg

NC N5

*AGENTS FOR NARCOTIC WITHDRAWAL***

lucemyra NP QL

*AGENTS FOR OPIOID WITHDRAWAL***

lucemyra NP QL

*AMEBICIDES*

solosec NC

*AMINO ACIDS***

endari NP PA; ST; QL

*AMINOGLYCOSIDES*

amikacin sulfate injection solution 1 gm/4ml, 500 mg/2ml

G

arikayce SP PA; ST; SP

bethkis SP SP; QL

gentamicin in saline intravenous solution 0.8-0.9 mg/ml-%, 1-0.9 mg/ml-%, 1.2-0.9 mg/ml-%, 1.6-0.9 mg/ml-%, 2-0.9 mg/ml-%

G

gentamicin sulfate injection SP

kitabis pak NC N5

neomycin sulfate oral G

paromomycin sulfate oral G

streptomycin sulfate intramuscular SP

tobi NC N5; SP

tobi podhaler SP SP; QL

tobramycin inhalation SP SP; QL

tobramycin sulfate injection SP



12/01/201819


*ANALGESICS - ANTI-INFLAMMATORY*

actemra intravenous SP PA; ST; SP

actemra subcutaneous SP PA; ST; SP; QL

anaprox ds NC N5

arava NC N5

arcalyst SP PA; SP

arthrotec oral tablet delayed release NC N5

celebrex NC N5

celecoxib oral G QL

daypro NC N5

diclofenac potassium G

diclofenac sodium er G

diclofenac sodium oral G

diclofenac-misoprostol oral tablet delayed release

G

duexis NC N5

ec-naprosyn NC N5

enbrel mini SP PA; ST; SP; QL

enbrel subcutaneous solution prefilled syringe SP PA; ST; SP; QL

enbrel subcutaneous solution reconstituted SP PA; ST; QL

enbrel sureclick subcutaneous solution auto-injector

SP PA; ST; SP; QL

etodolac er G

etodolac oral G

feldene NC N5

fenoprofen calcium oral G

flurbiprofen oral G

humira pediatric crohns start subcutaneous prefilled syringe kit 40 mg/0.8ml, 80 mg/0.8ml, 80 mg/0.8ml & 40mg/0.4ml

SP PA; ST; SP; QL

humira pen subcutaneous pen-injector kit SP PA; ST; SP; QL

humira pen-cd/uc/hs starter SP PA; ST; SP; QL

humira pen-ps/uv starter SP PA; ST; SP; QL

humira subcutaneous prefilled syringe kit SP PA; ST; SP; QL

ibuprofen comfort pac NC N5

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



12/01/201820


ic 400 NC N5

ic 800 NC N5

ilaris subcutaneous solution SP PA; SP

indocin oral NP

indocin rectal NP

indomethacin er G

indomethacin oral G QL

ketoprofen er G

ketorolac tromethamine injection solution 15 mg/ml

G

ketorolac tromethamine intramuscular solution60 mg/2ml

G

ketorolac tromethamine oral G QL

kevzara SP PA; ST; SP; QL

kineret subcutaneous solution prefilled syringe SP PA; ST; SP; QL

leflunomide oral G QL

meclofenamate sodium oral G

mefenamic acid oral G QL

meloxicam oral tablet G

mobic oral tablet NC N5

nabumetone oral G

nalfon oral capsule 400 mg NP

naprelan oral tablet extended release 24 hour 375 mg, 500 mg, 750 mg

NC N5

naprosyn oral tablet 250 mg, 500 mg NC N5

naproxen dr G

naproxen oral G

naproxen sodium er NC N5

naproxen sodium oral tablet 275 mg, 550 mg G

olumiant SP PA; ST; SP; QL

orencia clickject SP PA; ST; SP; QL

orencia intravenous SP PA; ST; SP

orencia subcutaneous solution prefilled syringe SP PA; ST; SP; QL

otrexup subcutaneous solution auto-injector 10 mg/0.4ml, 15 mg/0.4ml, 17.5 mg/0.4ml, 20 mg/0.4ml, 22.5 mg/0.4ml, 25 mg/0.4ml

SP ST; SP



12/01/201821


otrexup subcutaneous solution auto-injector 12.5 mg/0.4ml

SP ST

oxaprozin G

piroxicam oral G

ponstel NC N5

rasuvo subcutaneous solution auto-injector 10 mg/0.2ml, 12.5 mg/0.25ml, 15 mg/0.3ml, 17.5 mg/0.35ml, 20 mg/0.4ml, 22.5 mg/0.45ml, 25 mg/0.5ml, 30 mg/0.6ml, 7.5 mg/0.15ml

SP ST; SP

ridaura NP

simponi aria SP PA; ST; SP

simponi subcutaneous solution auto-injector SP PA; ST; SP; QL

simponi subcutaneous solution prefilled syringe

SP PA; ST; SP; QL

sprix NC LGC; N5; #

sulindac oral G

tivorbex NC N5

tolmetin sodium G

vimovo NC N5

vivlodex NC N5; #

xeljanz SP PA; ST; SP; QL

xeljanz xr SP PA; ST; SP; QL

zipsor NC N5

zorvolex NC N5

*ANALGESICS - NONNARCOTIC*

allzital NC

aspir-81 CE

aspir-low CE

bayer aspirin ec low dose CE

bayer low dose oral tablet chewable CE

bupap oral tablet 50-300 mg NC

butalbital-acetaminophen oral capsule NC

butalbital-acetaminophen oral tablet 50-300 mg NC

butalbital-acetaminophen oral tablet 50-325 mg G

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

G



12/01/201822


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

G

butalbital-aspirin-caffeine oral capsule G

childrens aspirin CE

diflunisal oral G

ec-81 aspirin CE

ecotrin CE

ecotrin low strength CE

ecpirin CE

esgic oral capsule G

esgic oral tablet NC N5

fiorinal NC N5

miniprin low dose CE

prialt SP SP

qc aspirin low dose oral tablet delayed release CE

st joseph aspirin oral tablet delayed release CE

tgt aspirin oral tablet delayed release CE

vanatol lq NC N5

*ANALGESICS - OPIOID*

abstral NP PA; ST; #; QL

acetaminophen-codeine G PA; QL

acetaminophen-codeine #2 G PA; QL



actiq NC N5

apap-caff-dihydrocodeine oral capsule G PA; QL

apap-caff-dihydrocodeine oral tablet 325-30-16 mg

NC N5

arymo er NP PA; ST; MPG; QL

ascomp-codeine G PA; QL

belbuca NP PA; QL

bunavail NP ST; MST; QL

buprenorphine G PA; QL

buprenorphine hcl injection solution 0.3 mg/ml G

buprenorphine hcl sublingual G QL



12/01/201823


buprenorphine hcl-naloxone hcl sublingual tablet sublingual

G QL

butalbital-apap-caff-cod G PA; QL

butalbital-asa-caff-codeine G PA; QL

butorphanol tartrate injection G

butorphanol tartrate nasal G PA; QL

butrans NP PA; QL

codeine sulfate oral tablet G PA; QL

conzip NC N5

demerol injection solution 75 mg/1.5ml NP

demerol injection solution 75 mg/ml NC

dilaudid injection solution 2 mg/ml NP

dilaudid oral NC N5

dolophine oral tablet 10 mg NP PA; PPA; QL

dolophine oral tablet 5 mg NC N5; PPA

duragesic-100 NC N5

duragesic-12 NC N5

duragesic-25 NC N5

duragesic-50 NC N5

duragesic-75 NC N5

duramorph G

embeda PB PA; MPG; QL

endocet oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg

G PA; QL

endocet oral tablet 2.5-325 mg G PA; QL

exalgo oral tablet er 24 hour abuse-deterrent 12 mg, 16 mg, 8 mg

NC N5

exalgo oral tablet er 24 hour abuse-deterrent 32 mg

NP PA; ST; QL

fentanyl G PA; QL

fentanyl citrate buccal G PA; ST; QL

fentora buccal tablet 100 mcg, 200 mcg, 400 mcg, 600 mcg, 800 mcg

NP PA; ST; #; QL

fioricet/codeine oral capsule 50-300-40-30 mg NP PA; QL

fiorinal/codeine #3 NC N5



12/01/201824


hydrocodone-acetaminophen oral solution 2.5-108 mg/5ml, 5-217 mg/10ml, 7.5-325 mg/15ml

G PA; QL

hydrocodone-acetaminophen oral tablet 10-300 mg, 10-325 mg, 2.5-325 mg, 5-300 mg, 5-325 mg, 7.5-300 mg, 7.5-325 mg

G PA; QL

hydrocodone-ibuprofen oral tablet 10-200 mg, 5-200 mg, 7.5-200 mg

G PA; QL

hydromorphone hcl er G PA; QL

hydromorphone hcl injection solution 1 mg/ml, 2 mg/ml, 4 mg/ml

G

hydromorphone hcl oral G PA; QL

hydromorphone hcl pf injection solution 50 mg/5ml

G

hydromorphone hcl rectal G PA; QL

hysingla er PB PA; #; QL

ibudone oral tablet 10-200 mg NC N5

ibudone oral tablet 5-200 mg G PA; QL

infumorph 200 NP

infumorph 500 NP

kadian oral capsule extended release 24 hour 10 mg, 100 mg, 20 mg, 30 mg, 50 mg, 60 mg, 80 mg

NC N5

kadian oral capsule extended release 24 hour 200 mg, 40 mg

NP PA; ST; QL

lazanda NC

levorphanol tartrate oral G PA; QL

lorcet G PA; QL

lorcet hd G PA; QL

lorcet plus oral tablet 7.5-325 mg G PA; QL

meperidine hcl injection solution 10 mg/ml, 100 mg/ml, 25 mg/ml, 50 mg/ml

G

meperidine hcl oral G PA; QL

methadone hcl intensol G PA; PPA; QL

methadone hcl oral concentrate G PA; PPA; QL

methadone hcl oral solution G PA; PPA; QL

methadone hcl oral tablet G PA; PPA; QL

methadose oral concentrate 10 mg/ml NC N5; PPA



12/01/201825


methadose sugar-free NC N5; PPA

morphabond er NP PA; ST; MPG; QL

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

G PA; QL

morphine sulfate (concentrate) oral solution 20 mg/ml

G QL

morphine sulfate (pf) injection solution 0.5 mg/ml

G

morphine sulfate (pf) intravenous solution 10 mg/ml

G

morphine sulfate er beads G PA; QL

morphine sulfate er oral capsule extended release 24 hour

G PA; QL

morphine sulfate er oral tablet extended release G PA; QL

morphine sulfate injection solution 10 mg/ml, 5 mg/ml, 8 mg/ml

G

morphine sulfate oral G PA; QL

morphine sulfate rectal G PA; QL

ms contin oral tablet extended release NC N5

nalbuphine hcl injection SP

nalocet NC

norco NC N5

nucynta NP PA; ST; QL

nucynta er NP PA; ST; QL

opana oral NC N5

oxaydo PB PA; MPG; QL

oxycodone hcl er oral tablet er 12 hour abuse-deterrent

G PA; QL

oxycodone hcl oral capsule G PA; QL

oxycodone hcl oral concentrate 100 mg/5ml G PA; QL

oxycodone hcl oral solution G PA; QL

oxycodone hcl oral tablet G PA; QL

oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg

G PA; QL

oxycodone-aspirin oral tablet 4.8355-325 mg G PA; QL

oxycodone-ibuprofen G PA; QL



12/01/201826


oxycontin oral tablet er 12 hour abuse-deterrent

PB PA; QL

oxymorphone hcl G PA; QL

oxymorphone hcl er G PA; QL

pentazocine-naloxone hcl G PA; QL

percocet oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg

NC N5

primlev NC

roxicodone oral tablet NC N5

roxybond NP PA; ST; MPG; QL

suboxone sublingual film NP #; QL

subsys NC

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

G PA; QL

tramadol hcl er oral capsule extended release 24 hour

NC N5

tramadol hcl er oral tablet extended release 24 hour

G PA; QL

tramadol hcl oral G PA; QL

tramadol-acetaminophen G PA; QL

trezix oral capsule 320.5-30-16 mg NP PA; QL

tylenol with codeine #3 NC N5

tylenol with codeine #4 NC N5

ultracet NC N5

ultram NC N5

verdrocet NP PA; QL

vicodin es oral tablet 7.5-300 mg G PA; QL

vicodin hp oral tablet 10-300 mg G PA; QL

vicodin oral tablet 5-300 mg G PA; QL

xodol oral tablet 5-300 mg, 7.5-300 mg NC N5

xtampza er NP PA; ST; QL

zohydro er oral capsule er 12 hour abuse-deterrent

NP PA; ST; #; QL

zubsolv NP ST; MST; #; QL

*ANDROGENS-ANABOLIC*

anadrol-50 NP



12/01/201827


androderm transdermal patch 24 hour NC N5

androgel pump transdermal gel 20.25 mg/act (1.62%)

NC #

androgel transdermal gel 20.25 mg/1.25gm (1.62%), 40.5 mg/2.5gm (1.62%)

NC #

androgel transdermal gel 25 mg/2.5gm (1%), 50 mg/5gm (1%)

NC N5

danazol oral G

depo-testosterone intramuscular solution NC N5

fortesta NC N5

methitest NP

methyltestosterone oral G

natesto NC N5

oxandrin oral tablet 10 mg NC N5

oxandrolone oral G

striant NC N5; #

testim NC N5

testosterone cypionate intramuscular solution100 mg/ml, 200 mg/ml

G

testosterone enanthate intramuscular solution G

testosterone transdermal gel 10 mg/act (2%), 12.5 mg/act (1%), 25 mg/2.5gm (1%), 50 mg/5gm (1%)

G PA; QL

testosterone transdermal gel 20.25 mg/1.25gm (1.62%), 20.25 mg/act (1.62%), 40.5 mg/2.5gm (1.62%)

G QL

testosterone transdermal solution NP PA; ST; QL

vogelxo pump NC N5

vogelxo transdermal gel 50 mg/5gm (1%) NC N5

*ANORECTAL AGENTS*

ana-lex NC

analpram-hc rectal cream NC N5

anusol-hc rectal cream NC N5

colocort G

cortenema NC N5

cortifoam NC N5



12/01/201828


hydrocortisone ace-pramoxine rectal cream 1-1 %

G

hydrocortisone rectal enema G

lidocaine-hydrocortisone ace rectal NC

pramcort rectal G

proctocort rectal cream NC N5

proctofoam hc NC N5

procto-pak G

proctosol hc G

proctozone-hc rectal G

rectiv NP QL

uceris rectal NP PA; #; QL

*ANTHELMINTICS*

albendazole oral G QL

albenza NP QL

benznidazole NP PA; QL

biltricide NP

emverm G QL

ivermectin oral G

praziquantel oral G

stromectol NC N5

*ANTIANGINAL AGENTS*

dilatrate-sr NP

gonitro NP

isordil titradose oral tablet 40 mg NP

isordil titradose oral tablet 5 mg NC N5

isosorbide dinitrate er G

isosorbide dinitrate oral G

isosorbide mononitrate G

isosorbide mononitrate er G

minitran G

nitro-bid NP

nitro-dur transdermal patch 24 hour 0.3 mg/hr, 0.8 mg/hr

NP

nitroglycerin in d5w G



12/01/201829


nitroglycerin intravenous G

nitroglycerin sublingual G

nitroglycerin transdermal patch 24 hour G

nitroglycerin translingual solution G

nitrolingual NC N5

nitromist NP

nitrostat NP ST

nitro-time oral capsule extended release 2.5 mg, 6.5 mg

G

ranexa PB #; QL

*ANTIANXIETY AGENTS*

alprazolam er G QL

alprazolam intensol NP

alprazolam oral G

alprazolam xr G QL

ativan oral NC N5

buspirone hcl oral G

chlordiazepoxide hcl G AL

clorazepate dipotassium G AL

diazepam intensol G

diazepam oral concentrate G

diazepam oral tablet G

hydroxyzine hcl intramuscular G

hydroxyzine hcl oral syrup G

hydroxyzine pamoate oral G

lorazepam oral G

meprobamate G

oxazepam G AL

tranxene-t oral tablet 7.5 mg NC N5

valium NC N5

vistaril NC N5

xanax NC N5

xanax xr NC N5

*ANTIARRHYTHMICS*

amiodarone hcl oral tablet 200 mg, 400 mg G



12/01/201830


disopyramide phosphate oral G

dofetilide G

flecainide acetate G

lidocaine hcl (cardiac) intravenous solution 20 mg/ml

G

lidocaine in d5w G

mexiletine hcl oral G

multaq NP QL

nexterone NP

norpace cr NP

pacerone oral tablet 100 mg, 200 mg, 400 mg G

procainamide hcl injection G

propafenone hcl G

propafenone hcl er G SP; QL

quinidine gluconate er G

quinidine gluconate injection G

quinidine sulfate oral G

rythmol sr NC N5

tikosyn NP

*ANTIASTHMATIC AND BRONCHODILATOR AGENTS*

accolate NP QL

advair diskus NP #; QL

advair hfa NP QL

airduo respiclick 113/14 NP PA; ST; QL



albuterol sulfate er G

albuterol sulfate inhalation G

albuterol sulfate oral G

alvesco NP PA; ST; QL

aminophylline intravenous G

anoro ellipta PB QL

arcapta neohaler NP PA; ST; QL

armonair respiclick 113 NP PA; ST; QL



12/01/201831




arnuity ellipta NP QL

asmanex 120 metered doses PB #; QL





asmanex hfa PB QL

atrovent hfa NP QL

bevespi aerosphere NP PA; ST; QL

breo ellipta PB QL

brovana NP PA; ST; QL

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

G PA; QL

budesonide inhalation suspension 1 mg/2ml G PA; QL; AL

combivent respimat PB QL

cromolyn sodium inhalation G

daliresp NP PA; ST; QL

dulera PB QL

elixophyllin NP

flovent diskus NP #; QL

flovent hfa NP #; QL

fluticasone-salmeterol G QL

ipratropium bromide inhalation G

ipratropium-albuterol G

levalbuterol hcl inhalation nebulization solution0.31 mg/3ml, 0.63 mg/3ml, 1.25 mg/3ml

G

lonhala magnair refill kit NP PA; ST; QL

lonhala magnair starter kit NP PA; ST; QL

metaproterenol sulfate oral G

montelukast sodium oral G QL

perforomist NP PA; ST; QL

proair hfa PB #

proventil hfa NP ST; #



12/01/201832


pulmicort NC N5

pulmicort flexhaler NP PA; ST; QL

qvar redihaler PB QL

seebri neohaler NP PA; ST; QL

serevent diskus PB QL

singulair NC N5

spiriva handihaler PB QL

spiriva respimat inhalation aerosol solution 1.25 mcg/act, 2.5 mcg/act

PB QL

stiolto respimat inhalation aerosol solution 2.5-2.5 mcg/act

PB QL

striverdi respimat NP PA; ST; QL

symbicort PB QL

terbutaline sulfate injection G

terbutaline sulfate oral G

theo-24 oral capsule extended release 24 hour 100 mg, 200 mg, 400 mg

PB

theochron oral tablet extended release 12 hour100 mg, 200 mg, 300 mg

G

theophylline G

theophylline er G

trelegy ellipta PB QL

tudorza pressair inhalation aerosol powder breath activated

NP PA; ST; QL

utibron neohaler NP PA; ST; QL

ventolin hfa PB

xolair SP PA; ST; SP

xopenex NC N5

xopenex concentrate NC N5

xopenex hfa NP ST; QL

zafirlukast G QL

zileuton er G QL

zyflo NP QL

zyflo cr NP QL

*ANTICOAGULANTS*

arixtra NC N5



12/01/201833


bevyxxa NP PA; ST; QL

coumadin oral NC N5

eliquis PB QL

eliquis starter pack PB QL

enoxaparin sodium G QL

fondaparinux sodium G QL

fragmin subcutaneous solution 10000 unit/ml, 12500 unit/0.5ml, 15000 unit/0.6ml, 18000 unt/0.72ml, 2500 unit/0.2ml, 5000 unit/0.2ml, 7500 unit/0.3ml, 95000 unit/3.8ml

NP QL

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

G

heparin sodium (porcine) pf G

jantoven G

lovenox NC N5

pradaxa NP ST; QL

savaysa NP ST; QL

warfarin sodium oral G

xarelto PB QL

xarelto starter pack PB QL

*ANTICONVULSANTS*

aptiom NP PA; QL

banzel oral suspension NP PA

banzel oral tablet NP PA; QL

briviact oral NP PA; QL

carbamazepine er G

carbamazepine oral G

carbatrol NC N5

celontin PB

cerebyx SP

clonazepam oral G

depakene oral capsule NC N5

depakene oral solution NC N5

depakote NC N5

depakote er NC N5



12/01/201834


depakote sprinkles oral capsule delayed release sprinkle

NC N5

diastat acudial PB QL

diastat pediatric PB QL

diazepam rectal G QL

dilantin infatabs NC N5

dilantin oral capsule 100 mg NC N5

dilantin oral capsule 30 mg PB

dilantin oral suspension NC N5

divalproex sodium er oral tablet extended release 24 hour

G

divalproex sodium oral capsule delayed release sprinkle

G

divalproex sodium oral tablet delayed release G

epidiolex SP PA; ST; SP; QL

epitol G

ethosuximide oral G

felbamate G

felbatol NC N5

fosphenytoin sodium SP

fycompa oral suspension NP

fycompa oral tablet NP PA; QL

gabapentin oral capsule G QL

gabapentin oral solution 250 mg/5ml G QL

gabapentin oral tablet G QL

gabitril oral tablet 12 mg, 16 mg NP QL

gabitril oral tablet 2 mg, 4 mg NC N5

keppra oral NC N5

keppra xr NC N5

klonopin NC N5

lamictal odt oral kit NP

lamictal odt oral tablet dispersible NC N5

lamictal oral tablet NC N5

lamictal oral tablet chewable 25 mg, 5 mg NC N5

lamictal starter NP



12/01/201835


lamictal xr oral kit NP

lamictal xr oral tablet extended release 24 hour NC N5

lamotrigine er G PA; ST; QL

lamotrigine oral tablet G

lamotrigine oral tablet chewable G

lamotrigine oral tablet dispersible G PA; ST; QL

lamotrigine starter kit-blue G

lamotrigine starter kit-green G

lamotrigine starter kit-orange G

levetiracetam er G QL

levetiracetam in nacl G

levetiracetam oral G

lyrica PB #

mysoline NC N5

neurontin NC N5

onfi oral suspension NP PA; #

onfi oral tablet 10 mg, 20 mg NP PA; #; QL

oxcarbazepine G

oxtellar xr NP ST; QL

peganone NP

phenytek PB

phenytoin infatabs G

phenytoin oral suspension 125 mg/5ml G

phenytoin oral tablet chewable G

phenytoin sodium extended oral capsule 100 mg G

phenytoin sodium injection G

primidone oral G

qudexy xr NP ST; QL

sabril oral packet SP PA; SP; QL

sabril oral tablet SP PA; #; SP; QL

spritam NP ST; QL

tegretol oral suspension NC N5

tegretol oral tablet NC N5

tegretol-xr NC N5

tiagabine hcl G QL



12/01/201836


topamax NC N5

topamax sprinkle NC N5

topiramate oral capsule sprinkle NC

topiramate oral tablet G

trileptal NC N5

trokendi xr NP ST; #; QL

valproate sodium intravenous solution 100 mg/ml G

valproate sodium oral solution G

valproic acid oral capsule G

vigabatrin SP PA; SP; QL

vigadrone SP PA; SP; QL

vimpat intravenous NP

vimpat oral NP #; QL

zarontin NC N5

zonegran NC N5

zonisamide oral G

*ANTIDEMENTIA AGENT COMBINATIONS***

namzaric oral capsule er 24 hour therapy pack PB PA; AL

namzaric oral capsule extended release 24 hour 14-10 mg, 28-10 mg

PB PA; AL

namzaric oral capsule extended release 24 hour 21-10 mg, 7-10 mg

PB PA

*ANTIDEPRESSANTS*

amitriptyline hcl oral G

amoxapine G

anafranil NC N5

aplenzin NC N5

bupropion hcl er (sr) G QL

bupropion hcl er (xl) G QL

bupropion hcl oral G QL

celexa oral tablet NC N5

citalopram hydrobromide oral solution G

citalopram hydrobromide oral tablet G QL

clomipramine hcl oral G



12/01/201837


cymbalta NC N5

desipramine hcl oral G

desvenlafaxine er G PA; ST; QL

desvenlafaxine succinate er G PA; ST; QL

doxepin hcl oral G

duloxetine hcl oral G QL

effexor xr NC N5

emsam NP #; QL

escitalopram oxalate oral solution G

escitalopram oxalate oral tablet G QL

fetzima NP PA; ST; QL

fetzima titration NP PA; ST; QL

fluoxetine hcl oral capsule G QL

fluoxetine hcl oral capsule delayed release G QL

fluoxetine hcl oral solution G

fluoxetine hcl oral tablet G QL

fluvoxamine maleate G QL

fluvoxamine maleate er G QL

forfivo xl NC N5; #

imipramine hcl oral G

imipramine pamoate G

khedezla NP PA; ST; QL

lexapro oral tablet NC N5

maprotiline hcl G QL

marplan NP

mirtazapine oral G QL

nardil NC N5

nefazodone hcl G

norpramin oral tablet 10 mg, 25 mg NC N5

nortriptyline hcl oral G

pamelor oral capsule NC N5

parnate NC N5

paroxetine hcl er G QL

paroxetine hcl oral tablet G QL

paxil cr NC N5



12/01/201838


paxil oral suspension NP QL

paxil oral tablet NC N5

pexeva NC N5

phenelzine sulfate oral G

pristiq NP PA; ST; QL

protriptyline hcl G

prozac oral capsule NC N5

remeron oral tablet 15 mg, 30 mg NC N5

remeron soltab NC N5

sertraline hcl oral concentrate G

sertraline hcl oral tablet G QL

surmontil NP

tranylcypromine sulfate G

trazodone hcl oral G

trimipramine maleate oral G

trintellix NP PA; ST; QL

venlafaxine hcl G QL

venlafaxine hcl er oral capsule extended release 24 hour

G QL

venlafaxine hcl er oral tablet extended release 24 hour 150 mg, 37.5 mg, 75 mg

NC N5

venlafaxine hcl er oral tablet extended release 24 hour 225 mg

G QL

viibryd oral tablet NP PA; ST; QL

viibryd starter pack NP PA

wellbutrin sr NC N5

wellbutrin xl NC N5

zoloft oral tablet NC N5

*ANTIDIABETICS*

acarbose G

actoplus met NC N5

actoplus met xr NP QL

actos NC N5

adlyxin NC N5

adlyxin starter pack NC N5



12/01/201839


admelog NC

admelog solostar NC

afrezza inhalation powder 12 unit, 4 & 8 & 12 unit, 4 (90) & 8 (90) unit, 4 unit, 8 unit

NP PA

alogliptin benzoate G QL

alogliptin-metformin hcl G QL

alogliptin-pioglitazone G QL

amaryl NC N5

apidra NC N5

apidra solostar subcutaneous solution pen-injector

NC N5

avandia oral tablet 2 mg, 4 mg NP QL

basaglar kwikpen PB

bydureon bcise NC N5

bydureon subcutaneous pen-injector NC N5

bydureon subcutaneous suspension reconstituted er

NC N5

byetta 10 mcg pen subcutaneous solution pen-injector

NC N5; #

byetta 5 mcg pen subcutaneous solution pen-injector

NC N5; #

chlorpropamide G

cycloset NP QL

duetact NC N5

farxiga NP QL

fiasp NC N5

fiasp flextouch NC N5

fortamet NC N5

glimepiride G

glipizide oral G

glipizide xl G

glipizide-metformin hcl G

glucagen hypokit PB QL

glucagon emergency PB QL

glucophage oral tablet 1000 mg NC

glucophage oral tablet 500 mg, 850 mg NC N5



12/01/201840


glucophage xr oral tablet extended release 24 hour 500 mg

NP

glucophage xr oral tablet extended release 24 hour 750 mg

NC N5

glucotrol NC N5

glucotrol xl NC N5

glumetza NC N5

glyburide micronized G

glyburide oral G

glyburide-metformin G

glynase NC N5

glyset NP

humalog PB

humalog kwikpen subcutaneous solution pen-injector 100 unit/ml, 200 unit/ml

PB

humalog mix 50/50 PB

humalog mix 50/50 kwikpen subcutaneous suspension pen-injector

PB

humalog mix 75/25 PB

humalog mix 75/25 kwikpen subcutaneous suspension pen-injector

PB

humulin 70/30 PB

humulin 70/30 kwikpen subcutaneous suspension pen-injector

PB

humulin n PB

humulin n kwikpen subcutaneous suspension pen-injector

PB

humulin r PB

humulin r u-500 (concentrated) PB

humulin r u-500 kwikpen subcutaneous solution pen-injector

PB

invokana PB QL

janumet PB QL

janumet xr PB QL

januvia PB QL

jardiance PB QL



12/01/201841


jentadueto PB QL

jentadueto xr PB QL

kazano NC N5

kombiglyze xr NC N5

korlym SP PA; SP; QL

lantus NC N5

lantus solostar subcutaneous solution pen-injector

NC N5

levemir PB

levemir flextouch PB

metformin hcl er (mod) NC N5

metformin hcl er (osm) oral tablet extended release 24 hour 1000 mg, 500 mg

NC N5

metformin hcl er oral tablet extended release 24 hour 500 mg

NC

metformin hcl er oral tablet extended release 24 hour 750 mg

G

metformin hcl oral G

miglitol G

nateglinide G

nesina NC N5

novolin 70/30 NC N5

novolin 70/30 relion NC N5

novolin n NC N5

novolin n relion NC N5

novolin r NC N5

novolin r relion NC N5

novolog NC N5

novolog flexpen subcutaneous solution pen-injector

NC N5

novolog mix 70/30 NC N5

novolog mix 70/30 flexpen subcutaneous suspension pen-injector

NC N5

novolog penfill subcutaneous solution cartridge

NC N5

onglyza NC N5



12/01/201842


oseni NC N5

ozempic NC

pioglitazone hcl G QL

pioglitazone hcl-glimepiride G QL

pioglitazone hcl-metformin hcl G QL

prandin oral tablet 1 mg, 2 mg NC N5

precose NC N5

proglycem NP

repaglinide G

repaglinide-metformin hcl G QL

riomet NC

starlix NC N5

steglatro NC

symlinpen 120 subcutaneous solution pen-injector

NP PA; #; QL

symlinpen 60 subcutaneous solution pen-injector

NP PA; #

tolazamide G

tolbutamide G

toujeo max solostar NC

toujeo solostar NC N5

tradjenta PB QL

tresiba flextouch PB

trulicity PB PA; ST; QL

victoza subcutaneous solution pen-injector PB PA; ST; QL

*ANTIDIARRHEAL/PROBIOTIC AGENTS*

vsl#3 ds NP

*ANTIDIARRHEALS*

diphenoxylate-atropine G

lomotil oral tablet NC N5

motofen NP

mytesi NP PA; ST; QL

opium G

vsl#3 ds NP



12/01/201843


*ANTIDOTES AND SPECIFIC ANTAGONISTS*

deferoxamine mesylate SP SP

desferal injection solution reconstituted 500 mg NC N5; SP

vistogard SP SP; QL

*ANTIDOTES*

chemet NP

deferoxamine mesylate SP SP

desferal injection solution reconstituted 500 mg NC N5; SP

evzio injection solution auto-injector 2 mg/0.4ml

NC N5

exjade SP PA; #; SP

ferriprox oral solution SP PA

ferriprox oral tablet SP PA; #; SP

jadenu SP PA; #; SP

jadenu sprinkle SP PA; #; SP

naloxone hcl injection solution 0.4 mg/ml G

naltrexone hcl oral G

narcan PB #; QL

vistogard SP SP; QL

vivitrol NP

*ANTIEMETICS*

akynzeo oral NP PA; ST; QL

aloxi intravenous solution 0.25 mg/5ml SP SP

anzemet oral NP QL

aprepitant G QL

bonjesta NP PA; ST; QL

cesamet NP QL

diclegis NP PA; #; QL

dronabinol G PA; QL

emend oral capsule 125 mg, 40 mg, 80 mg NP QL

emend oral suspension reconstituted PB #

granisetron hcl intravenous SP

granisetron hcl oral G

marinol NC N5



12/01/201844


meclizine hcl oral tablet G

ondansetron G

ondansetron hcl injection solution 4 mg/2ml G

ondansetron hcl oral G

palonosetron hcl intravenous solution 0.25 mg/5ml

SP SP

sancuso NP QL

syndros NC N5; #

tigan intramuscular NP

tigan oral NC N5

transderm-scop (1.5 mg) NP

trimethobenzamide hcl oral G

varubi oral NP QL

zofran oral solution NP

zofran oral tablet 4 mg NP

zofran oral tablet 8 mg NC N5

zuplenz NC N5

*ANTIFUNGALS*

ambisome NP

ancobon NP

cresemba oral NP

diflucan NC N5

fluconazole in sodium chloride intravenous solution 400-0.9 mg/200ml-%

G

fluconazole oral G

flucytosine oral G

griseofulvin microsize oral G

griseofulvin ultramicrosize G

itraconazole oral capsule G QL

itraconazole oral solution G

ketoconazole oral G QL

lamisil oral tablet NC N5

noxafil intravenous NP

noxafil oral suspension NP

noxafil oral tablet delayed release NP #; QL



12/01/201845


nystatin oral tablet G

sporanox oral capsule NC N5

sporanox oral solution NC

sporanox pulsepak NC N5

terbinafine hcl oral G

vfend NC N5

voriconazole intravenous G

voriconazole oral tablet G

*ANTIHEMOPHILIC PRODUCTS - MONOCLONAL ANTIBODIES***

hemlibra SP PA; SP

*ANTIHISTAMINES*

alavert oral tablet dispersible G Select OTC

allegra allergy G Select OTC

allegra allergy childrens oral suspension G Select OTC

allegra allergy childrens oral tablet dispersible G Select OTC

allergy relief oral tablet dispersible G Select OTC

carbinoxamine maleate oral solution G

carbinoxamine maleate oral tablet 4 mg G

carbinoxamine maleate oral tablet 6 mg NC

cetirizine hcl oral tablet G Select OTC

cetirizine hcl oral tablet chewable G Select OTC

childrens loratadine G Select OTC

clarinex oral syrup NP

clarinex oral tablet NC N5

claritin oral capsule G Select OTC

claritin oral syrup NC N5; Select OTC

claritin oral tablet NC N5; Select OTC

claritin oral tablet chewable G Select OTC

claritin reditabs G Select OTC

cyproheptadine hcl oral G

desloratadine oral tablet G QL

desloratadine oral tablet dispersible 2.5 mg G QL

desloratadine oral tablet dispersible 5 mg G

diphenhydramine hcl injection G



12/01/201846


fexofenadine hcl childrens G Select OTC

fexofenadine hcl oral tablet 180 mg, 60 mg G Select OTC

karbinal er oral suspension extended release NP ST

levocetirizine dihydrochloride oral NC

loratadine childrens oral solution G Select OTC

loratadine childrens oral syrup G Select OTC

loratadine oral capsule G Select OTC

loratadine oral solution G Select OTC

loratadine oral tablet G LGC; Select OTC

loratadine oral tablet chewable G Select OTC

phenadoz rectal suppository 12.5 mg G

promethazine hcl injection G

promethazine hcl oral G

promethazine hcl rectal G

promethegan G

ryvent NC N5

triaminic allerchews G Select OTC

xyzal allergy 24hr G Select OTC

xyzal allergy 24hr childrens G Select OTC

zyrtec allergy oral capsule G Select OTC

zyrtec allergy oral tablet G Select OTC

*ANTIHYPERLIPIDEMICS*

altoprev NP ST; #; QL

antara oral capsule 30 mg, 90 mg NP #; QL

atorvastatin calcium oral tablet 10 mg CE QL

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

G QL

cholestyramine light oral powder G

colesevelam hcl G

colestid NC N5

colestid flavored NC N5

colestipol hcl oral granules G

crestor NP ST; QL

ezetimibe G QL

ezetimibe-simvastatin G QL



12/01/201847


fenofibrate micronized G QL

fenofibrate oral capsule 150 mg, 50 mg G QL

fenofibrate oral tablet 120 mg, 40 mg NC N5

fenofibrate oral tablet 145 mg, 160 mg, 48 mg, 54 mg

G QL

fenofibric acid G QL

fenoglide NC N5

fibricor NP QL

flolipid NC

fluvastatin sodium G QL

fluvastatin sodium er G QL

gemfibrozil oral G

juxtapid SP PA; ST; SP; QL

kynamro subcutaneous solution prefilled syringe

SP PA; ST; SP; QL

lescol oral capsule 20 mg NC N5

lescol xl NC N5

lipitor NC N5

lipofen NP QL

livalo NP ST; QL

lovastatin G QL

lovaza NC N5

mevacor oral tablet 40 mg NC N5

niacin er (antihyperlipidemic) G

niacor NP

niaspan NC N5

omega-3-acid ethyl esters G QL

pravachol oral tablet 20 mg, 40 mg, 80 mg NC N5

pravastatin sodium G QL

prevalite oral packet G

questran light oral powder NC N5

rosuvastatin calcium G QL

simvastatin oral tablet 10 mg, 5 mg CE QL

simvastatin oral tablet 20 mg, 40 mg, 80 mg G QL

tricor NC N5



12/01/201848


triglide oral tablet 160 mg NC N5

trilipix NC N5

vascepa PB QL

vytorin NP ST; QL

welchol NP #

zetia NP ST; QL

zocor NC N5

zypitamag NC

*ANTIHYPERTENSIVES*

accupril oral tablet 10 mg, 20 mg, 5 mg NC N5

accupril oral tablet 40 mg NC

accuretic NC N5

altace oral capsule NC N5

amlodipine besy-benazepril hcl G

amlodipine besylate-valsartan G QL

amlodipine-olmesartan G QL

amlodipine-valsartan-hctz G QL

atacand oral tablet 16 mg, 4 mg, 8 mg NC N5

atacand oral tablet 32 mg NP ST; QL

atenolol-chlorthalidone G

avalide oral tablet 150-12.5 mg, 300-12.5 mg NC N5

avapro NC N5

azor NP ST; QL

benazepril hcl oral G

benazepril-hydrochlorothiazide G

benicar NP ST; QL

benicar hct NP ST; QL

bisoprolol-hydrochlorothiazide G

candesartan cilexetil oral tablet 16 mg, 4 mg, 8 mg

G QL

candesartan cilexetil-hctz G QL

captopril oral G

captopril-hydrochlorothiazide G

cardura NC N5

catapres NC N5



12/01/201849


catapres-tts-1 NC N5



clonidine hcl oral G

corzide NC N5

cozaar NC N5

demser SP ST; SP

dibenzyline NC N5

diovan NC N5

diovan hct NC N5

doxazosin mesylate oral G

dutoprol NC N5

edarbi NP ST; QL

edarbyclor NP ST; QL

enalapril maleate oral NC

enalapril-hydrochlorothiazide G

epaned oral solution NP PA; #; QL

eplerenone G

eprosartan mesylate G QL

exforge NC N5

exforge hct NP ST; QL

fosinopril sodium G

fosinopril sodium-hctz G

guanfacine hcl oral G

hydralazine hcl oral G

hyzaar NC N5

inspra NC N5

irbesartan G QL

irbesartan-hydrochlorothiazide G QL

lisinopril oral G

lisinopril-hydrochlorothiazide G

lopressor hct oral tablet 50-25 mg NC N5

losartan potassium oral tablet 100 mg G

losartan potassium oral tablet 25 mg, 50 mg G QL

losartan potassium-hctz G



12/01/201850


lotensin hct oral tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg

NC N5

lotensin oral tablet 10 mg, 20 mg, 40 mg NC N5

lotrel oral capsule 10-20 mg, 10-40 mg, 5-10 mg, 5-20 mg

NC N5

methyldopa oral G

methyldopa-hydrochlorothiazide G

methyldopate hcl G

metoprolol-hctz er NC N5

metoprolol-hydrochlorothiazide G

micardis NC N5

micardis hct NC N5

minipress NC N5

minoxidil oral G

moexipril hcl G

moexipril-hydrochlorothiazide G

nadolol-bendroflumethiazide oral tablet 40-5 mg G

olmesartan medoxomil oral G QL

olmesartan medoxomil-hctz G QL

olmesartan-amlodipine-hctz G QL

perindopril erbumine G

phenoxybenzamine hcl oral SP QL

prazosin hcl oral G

prestalia NP #

prinivil NC N5

propranolol-hctz G

qbrelis NP PA

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

quinapril-hydrochlorothiazide G

ramipril G

tarka oral tablet extended release 2-180 mg, 2-240 mg, 4-240 mg

NC N5

tekturna NP ST; #; QL

tekturna hct NP ST; QL

telmisartan G QL



12/01/201851


telmisartan-amlodipine G QL

telmisartan-hctz G QL

terazosin hcl oral G

trandolapril G

trandolapril-verapamil hcl er G

tribenzor NP ST; QL

twynsta NC N5

valsartan G QL

valsartan-hydrochlorothiazide G QL

vaseretic NC N5

vasotec NC N5

vecamyl SP PA; ST; SP; QL

zestril oral tablet 10 mg, 20 mg, 5 mg NC N5

ziac NC N5

*ANTI-INFECTIVE AGENTS - MISC.*

alinia NP #; QL

atovaquone oral G

bactrim NC N5

bactrim ds NP

cleocin in d5w intravenous solution 300 mg/50ml

NC

cleocin oral capsule 150 mg, 300 mg NC N5

cleocin oral capsule 75 mg NC

cleocin oral solution reconstituted NC N5

cleocin phosphate injection NC N5

cleocin phosphate intravenous solution 600 mg/4ml, 900 mg/6ml

NC

clindamycin hcl oral G

clindamycin palmitate hcl G

clindamycin phosphate injection SP

clindamycin phosphate intravenous solution 150 mg/ml, 900 mg/6ml

SP

coly-mycin m NC N5; SP

dapsone oral G

flagyl oral capsule NC N5



12/01/201852


flagyl oral tablet 250 mg NC N5

flagyl oral tablet 500 mg NP

impavido NP PA; QL

linezolid oral G QL

mepron NC N5

metronidazole in nacl intravenous solution 500-0.79 mg/100ml-%

G

metronidazole oral capsule G

metronidazole oral tablet 250 mg G

nebupent PB

primsol NP

sivextro oral NP QL

sulfamethoxazole-trimethoprim intravenous G

sulfamethoxazole-trimethoprim oral suspension200-40 mg/5ml

G

sulfamethoxazole-trimethoprim oral tablet 400-80 mg

G

tindamax oral tablet 500 mg NC N5

tinidazole oral G

trimethoprim oral G

trimpex NP

xifaxan oral tablet 200 mg NP QL

xifaxan oral tablet 550 mg PB PA; QL

zyvox oral NC N5

*ANTIMALARIALS*

atovaquone-proguanil hcl G

chloroquine phosphate oral G

coartem NP

daraprim PB

hydroxychloroquine sulfate oral G

malarone NC N5

mefloquine hcl G

plaquenil NC N5

primaquine phosphate oral G

qualaquin NC N5



12/01/201853


quinine sulfate oral G

*ANTIMYASTHENIC AGENTS*

guanidine hcl oral G

mestinon oral syrup NP

mestinon oral tablet NC N5

mestinon oral tablet extended release NC N5

pyridostigmine bromide er G

pyridostigmine bromide oral G

regonol intravenous NP

*ANTIMYASTHENIC/CHOLINERGIC AGENTS*

guanidine hcl oral G

mestinon oral syrup NP

mestinon oral tablet NC N5

mestinon oral tablet extended release NC N5

pyridostigmine bromide er G

pyridostigmine bromide oral G

regonol intravenous NP

*ANTIMYCOBACTERIAL AGENTS*

capastat sulfate SP

cycloserine oral G

ethambutol hcl oral G

isoniazid injection G

isoniazid oral G

myambutol NC N5

mycobutin NC N5

paser NP

priftin NP

pyrazinamide oral G

rifabutin G

rifadin oral NC N5

rifamate NP

rifampin oral G

rifater NP

sirturo SP PA; SP; QL



12/01/201854


trecator NP

*ANTINEOPLASTIC - BCL-2 INHIBITORS***

venclexta SP PA; SP; QL

venclexta starting pack SP PA; SP; QL

*ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES*

actimmune SP PA; SP

adcetris SP

adrucil intravenous solution 5 gm/100ml NP

afinitor SP PA; SP; QL

afinitor disperz SP PA; SP; QL

alecensa SP PA; SP; QL

alferon n SP SP

alkeran intravenous NP

alkeran oral NP ST

alunbrig SP PA; SP; QL

anastrozole oral G

arimidex NC N5

aromasin NC N5

arzerra SP PA

bexarotene SP PA; SP

bicalutamide G QL

bosulif SP PA; ST; SP; QL

braftovi SP PA; SP; QL

busulfex SP

cabometyx SP PA; SP; QL

calquence SP PA; SP; QL

camptosar NC N5

capecitabine G PA; SP

caprelsa SP PA; SP; QL

casodex NC N5

cometriq (100 mg daily dose) SP PA; SP; QL





12/01/201855


cotellic SP PA; SP; QL

cyclophosphamide injection G

cyclophosphamide oral capsule G

depo-provera intramuscular suspension 400 mg/ml

NP

eligard SP PA; SP

emcyt PB

erivedge SP PA; SP; QL

erleada SP PA; SP; QL

ethyol SP

etoposide intravenous solution 1 gm/50ml, 100 mg/5ml, 500 mg/25ml

SP

etoposide oral G

exemestane G

fareston PB

farydak SP PA; SP; QL

faslodex intramuscular solution 250 mg/5ml SP PA; #; SP

femara NC N5

firmagon SP PA; SP

fluorouracil intravenous solution 5 gm/100ml G

flutamide G

gilotrif SP PA; SP; QL

gleevec NC N5; SP

gleostine oral capsule 10 mg, 100 mg, 40 mg NP PA

hycamtin oral SP PA; SP

hydrea NP

hydroxyurea oral G

iclusig SP PA; SP; QL

imatinib mesylate G PA; SP; QL

imbruvica oral capsule 70 mg SP PA; SP; QL

imbruvica oral tablet SP PA; SP; QL

inlyta SP PA; SP; QL

intron a NP PA; SP

iressa SP PA; QL

irinotecan hcl SP



12/01/201856


jakafi SP PA; SP; QL

jevtana SP PA

kepivance SP PA

kisqali femara 200 dose SP PA; SP; QL



lenvima 10 mg daily dose SP PA; SP; QL








letrozole oral G

leucovorin calcium injection solution reconstituted 350 mg, 500 mg

G

leucovorin calcium oral G

leukeran SP

leuprolide acetate injection G PA; SP

lonsurf SP PA; QL

lupron depot (1-month) SP PA; #; SP




lysodren PB

matulane SP

megestrol acetate oral suspension 40 mg/ml, 400 mg/10ml

G

megestrol acetate oral tablet G

mekinist SP PA; SP; QL

mektovi SP PA; SP; QL

melphalan G

melphalan hcl SP

mercaptopurine oral G



12/01/201857


mesnex oral PB

methotrexate oral G

methotrexate sodium (pf) injection solution 1 gm/40ml, 250 mg/10ml, 50 mg/2ml

G

mitoxantrone hcl G

myleran PB

nerlynx SP PA; SP; QL

nexavar SP PA; SP; QL

nilandron PB

nilutamide G

ninlaro SP PA; QL

odomzo SP PA; QL

pomalyst SP PA; SP; QL

purixan SP PA; SP; QL

rituxan intravenous solution SP PA; ST

rydapt SP PA; SP; QL

soltamox NP #

sprycel SP PA; ST; SP; QL

stivarga SP PA; SP; QL

sutent PB PA; SP; QL

sylatron subcutaneous kit 200 mcg, 300 mcg, 600 mcg

SP PA; SP

synribo SP PA; ST

tabloid PB

tafinlar SP PA; SP; QL

tagrisso SP PA; SP; QL

tamoxifen citrate oral CE

tarceva NP PA; #; SP; QL

targretin oral NC N5; SP

tasigna SP PA; ST; SP; QL

temodar oral NC N5

temozolomide G PA; SP

temsirolimus SP SP

toposar intravenous solution 1 gm/50ml, 100 mg/5ml, 500 mg/25ml

SP



12/01/201858


torisel SP #; SP

trelstar mixject SP PA; #; SP

tretinoin oral G SP; AL

trexall NP

tykerb SP PA; SP

vantas SP PA; SP

vizimpro SP PA; SP; QL

voraxaze SP

votrient SP PA; SP; QL

xalkori SP PA; SP; QL

xatmep NP PA

xeloda NC N5; SP

xtandi SP PA; ST; SP; QL

yervoy SP PA

yonsa SP PA; ST; SP; QL

zaltrap SP

zanosar SP

zelboraf SP PA; SP; QL

zoladex SP PA; SP

zolinza SP PA; SP; QL

zykadia SP PA; SP; QL

zytiga PB PA; #; SP; QL

*ANTIPARKINSON AGENTS*

amantadine hcl oral G

azilect NP QL

benztropine mesylate injection SP

benztropine mesylate oral G

bromocriptine mesylate oral G

carbidopa oral G

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

G

carbidopa-levodopa oral tablet G

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

G

comtan NC N5



12/01/201859


duopa enteral SP PA; ST; QL

entacapone G

gocovri NC

lodosyn NC N5

mirapex NC N5

mirapex er NC N5

neupro NP #; QL

osmolex er NC

pramipexole dihydrochloride G

pramipexole dihydrochloride er G QL

rasagiline mesylate oral G QL

requip oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 4 mg, 5 mg

NC N5

requip xl NC N5

ropinirole hcl G

ropinirole hcl er G QL

rytary NP #

selegiline hcl oral G

sinemet NC N5

sinemet cr NC N5

stalevo 100 NP

stalevo 125 NP

stalevo 150 NP

stalevo 200 NP

stalevo 50 NP

stalevo 75 NP

tasmar oral tablet 100 mg NC N5

tolcapone G

trihexyphenidyl hcl G

xadago NP PA; ST; QL

zelapar NC N5

*ANTIPSYCHOTICS/ANTIMANIC AGENTS*

abilify oral tablet NC N5

aripiprazole oral solution G QL



12/01/201860


aripiprazole oral tablet 10 mg, 15 mg, 2 mg G QL

aripiprazole oral tablet dispersible G QL

chlorpromazine hcl injection solution 25 mg/ml G

chlorpromazine hcl oral G

clozapine G QL

clozaril NC N5

compro G

equetro NP

fanapt NP ST; QL

fanapt titration pack NP ST

fazaclo oral tablet dispersible 100 mg, 12.5 mg, 25 mg

NC N5

fazaclo oral tablet dispersible 150 mg, 200 mg NP PA; ST; QL

fluphenazine decanoate injection G

fluphenazine hcl injection G

fluphenazine hcl oral G

geodon oral NC N5

haldol NP

haldol decanoate intramuscular solution 100 mg/ml

NP

haldol decanoate intramuscular solution 50 mg/ml

NC

haloperidol lactate oral G

haloperidol oral G

invega NC N5

latuda oral tablet 120 mg, 20 mg, 40 mg, 80 mg PB ST; #; QL

latuda oral tablet 60 mg PB ST; #

lithium G

lithium carbonate er G

lithium carbonate oral G

lithobid NP

loxapine succinate oral G

nuplazid SP PA; SP; QL

olanzapine oral G QL

paliperidone er G QL



12/01/201861


perphenazine oral G

prochlorperazine G

prochlorperazine maleate oral G

quetiapine fumarate G QL

quetiapine fumarate er G QL

rexulti NP PA; ST; QL

risperdal NC N5

risperidone m-tab oral tablet dispersible 0.5 mg, 1 mg, 2 mg

G QL

risperidone oral solution G

risperidone oral tablet G QL

risperidone oral tablet dispersible 0.25 mg G

risperidone oral tablet dispersible 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg

G QL

saphris NP PA; ST; #; QL

seroquel NC N5

seroquel xr NP ST; QL

thioridazine hcl oral G

thiothixene oral G

trifluoperazine hcl oral G

versacloz NP PA; ST

vraylar oral capsule NP PA; ST; QL

vraylar oral capsule therapy pack NP PA; ST

ziprasidone hcl G QL

zyprexa oral NC N5

zyprexa zydis NC N5

*ANTIRETROVIRALS ADJUVANTS***

tybost NP QL

*ANTISEPTICS & DISINFECTANTS*

formadon NP

formaldehyde external solution 10 % G

iodosorb NP

kerr triple dye swabs NP

*ANTIVIRALS*

abacavir sulfate G



12/01/201862


abacavir sulfate-lamivudine G

abacavir-lamivudine-zidovudine G

acyclovir oral G

adefovir dipivoxil G SP; QL

aptivus PB

atazanavir sulfate G QL

atripla NP QL

baraclude oral solution SP SP

baraclude oral tablet NC N5; SP

biktarvy NP PA

cidofovir intravenous SP SP

cimduo NP QL

combivir NC N5

complera NP QL

crixivan oral capsule 200 mg, 400 mg PB

cytovene NC N5; SP

daklinza SP PA; ST; SP; QL

delstrigo NP PA; QL

descovy NP QL

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

G

edurant PB QL

efavirenz G

emtriva oral capsule PB QL

emtriva oral solution PB

entecavir G SP; QL

epivir NC N5

epivir hbv oral solution NP #; SP

epivir hbv oral tablet NC N5

epzicom NP

evotaz NP

famciclovir oral G QL

flumadine NC N5

fosamprenavir calcium G

fuzeon subcutaneous solution reconstituted SP #; SP



12/01/201863


ganciclovir sodium intravenous solution reconstituted

SP SP

genvoya SP PA; QL

hepsera NC N5; SP

intelence PB QL

invirase NP

isentress hd NP QL

isentress oral packet NP

isentress oral tablet NP QL

isentress oral tablet chewable NP QL

juluca NP ST; QL

kaletra oral solution NC N5

kaletra oral tablet PB #

lamivudine G

lamivudine-zidovudine G

lexiva PB #

lopinavir-ritonavir G

moderiba 1200 dose pack NP SP

moderiba 800 dose pack NP SP

moderiba oral tablet 200 mg G SP

nevirapine er G QL

nevirapine oral tablet G

norvir oral packet PB

norvir oral solution PB #

norvir oral tablet PB

odefsey NP QL

oseltamivir phosphate oral G QL

pegasys proclick PB PA; SP

pegasys subcutaneous solution PB PA; SP

pifeltro NP

prevymis oral SP PA; SP; QL

prezcobix PB

prezista oral suspension PB QL

prezista oral tablet 150 mg, 600 mg, 75 mg, 800 mg

PB QL



12/01/201864


rebetol oral capsule NC N5; SP

rebetol oral solution NP SP; QL

relenza diskhaler NP QL

rescriptor NP

retrovir intravenous NP

retrovir oral capsule NC N5

retrovir oral syrup NC N5

reyataz oral capsule 150 mg, 200 mg, 300 mg NP QL

reyataz oral packet NP #

ribasphere G SP

ribasphere ribapak oral tablet 400 mg, 600 mg G SP

ribavirin oral capsule G SP

ribavirin oral tablet 200 mg G SP

rimantadine hcl G

ritonavir G

selzentry oral solution PB QL

selzentry oral tablet 150 mg, 25 mg, 75 mg PB QL

selzentry oral tablet 300 mg PB

sitavig NC N5

sovaldi SP PA; SP; QL

stavudine oral capsule G

stribild SP PA; QL

sustiva NP

symfi NP

symfi lo NP

symtuza NP PA

tamiflu oral capsule NP QL

tamiflu oral suspension reconstituted 6 mg/ml NP QL

tenofovir disoproxil fumarate G QL

tivicay NP QL

triumeq PB QL

trizivir NC N5

truvada NP

valacyclovir hcl oral G

valcyte oral solution reconstituted SP PA; SP; QL



12/01/201865


valcyte oral tablet NC N5; SP

valganciclovir hcl G PA; SP; QL

valtrex NC N5

vemlidy SP PA; ST; SP; QL

videx PB

videx ec NC N5

viracept oral tablet NP

viramune oral suspension NC

viramune oral tablet NC N5

viramune xr NC N5

viread oral powder NP #

viread oral tablet 150 mg, 200 mg, 250 mg NP #; QL

viread oral tablet 300 mg NP QL

zerit oral capsule NC N5

ziagen NC N5

zidovudine G

zovirax oral NC N5

*ASSORTED CLASSES*

astagraf xl oral capsule extended release 24 hour 0.5 mg, 1 mg

SP #; SP; QL

astagraf xl oral capsule extended release 24 hour 5 mg

SP #; SP

atgam SP SP

azasan NP

azathioprine oral G

benlysta intravenous SP PA; ST; SP

benlysta subcutaneous SP PA; ST; SP; QL

cellcept SP SP

cellcept intravenous SP

cuprimine oral capsule 250 mg SP PA; ST; #

cyclosporine intravenous G SP

cyclosporine modified G

cyclosporine oral capsule G

depen titratabs SP PA

envarsus xr SP



12/01/201866


gengraf oral capsule 100 mg, 25 mg G

gengraf oral solution G

hylafem NC

imuran NC N5

lokelma NP PA

morcin NC

mycophenolate mofetil G SP

myfortic SP SP

neoral oral capsule SP SP

neoral oral solution NP SP

nulojix SP SP

physiolyte G

prograf SP SP

rapamune SP SP

revlimid SP PA; SP; QL

sandimmune SP SP

simulect SP SP

sirolimus oral G SP

sodium polystyrene sulfonate oral powder G

sterile water for irrigation G

syprine SP PA; SP

tacrolimus oral G SP

thalomid PB PA; #; SP

thymoglobulin SP SP

tis-u-sol G

traumeel external ointment NC

trientine hcl SP PA; SP

veltassa NP PA; QL

xiaflex SP SP

zortress oral tablet 0.25 mg, 0.5 mg, 0.75 mg SP #; SP

*ATOPIC DERMATITIS - MONOCLONAL ANTIBODIES***

dupixent subcutaneous solution prefilled syringe 300 mg/2ml

SP PA; SP; QL



12/01/201867


*BETA BLOCKER & ANGIOTENSIN II RECEPTOR ANTAGONIST COMB***

byvalson NP PA; ST; QL

*BETA BLOCKERS*

acebutolol hcl oral G

atenolol oral G

betapace af oral tablet 80 mg NP

betaxolol hcl oral G

bisoprolol fumarate G

bystolic NP PA; ST; QL

carvedilol G

carvedilol phosphate er G QL

coreg NC N5

coreg cr NP QL

corgard NC N5

hemangeol NP PA

inderal la NC N5

inderal xl oral capsule extended release 24 hour 80 mg

NP QL

innopran xl NP QL

kapspargo sprinkle NP

labetalol hcl intravenous solution G

labetalol hcl oral G

lopressor oral NC N5

metoprolol succinate er G QL

metoprolol tartrate intravenous solution 5 mg/5ml

G

metoprolol tartrate oral G

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

pindolol G

propranolol hcl er G

propranolol hcl intravenous G

propranolol hcl oral G

sorine G

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



12/01/201868


sotalol hcl intravenous G

sotalol hcl oral tablet 240 mg, 80 mg G

sotylize NP

timolol maleate oral G

toprol xl NC N5

*BILE ACID SYNTHESIS DISORDER AGENTS***

cholbam SP PA

*BIOLOGICALS MISC*

adagen SP PA; SP

mixed vespid venom protein injection solution reconstituted

G

venomil mixed vespid venom SP

*BULK CHEMICALS - NY***

nystatin G

*CALCITONIN GENE-RELATED PEPTIDE (CGRP) RECEPTOR ANTAG***

aimovig NP PA; ST; QL

aimovig 140 dose NP PA; ST; QL

ajovy NP PA; ST; QL

emgality NP PA; ST; QL

*CALCIUM CHANNEL BLOCKERS*

adalat cc NC N5

afeditab cr G QL

amlodipine besylate oral G

calan sr NC N5

cardene iv intravenous solution 20-4.8 mg/200ml-%

NP

cardizem cd oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 360 mg

NC N5

cardizem la oral tablet extended release 24 hour 120 mg

NP QL

cardizem la oral tablet extended release 24 hour 180 mg, 240 mg, 300 mg, 360 mg, 420 mg

NC N5

cartia xt G QL

diltiazem hcl er beads G QL



12/01/201869


diltiazem hcl er coated beads oral capsule extended release 24 hour

G QL

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

G

diltiazem hcl er oral capsule extended release 12 hour

G

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

G

diltiazem hcl er oral capsule extended release 24 hour 240 mg

G QL

diltiazem hcl intravenous solution 50 mg/10ml G

diltiazem hcl intravenous solution reconstituted G

diltiazem hcl oral G

dilt-xr oral capsule extended release 24 hour 120 mg, 180 mg

G

dilt-xr oral capsule extended release 24 hour 240 mg

G QL

felodipine er G QL

isoptin sr oral tablet extended release 240 mg NC N5

isradipine G

matzim la oral tablet extended release 24 hour180 mg, 240 mg, 300 mg, 360 mg

NP QL

matzim la oral tablet extended release 24 hour420 mg

NP

nicardipine hcl intravenous G

nicardipine hcl oral G

nifedical xl oral tablet extended release 24 hour60 mg

G QL

nifedipine er G QL

nifedipine er osmotic release G QL

nifedipine oral G

nimodipine oral G

nisoldipine er oral tablet extended release 24 hour 17 mg, 20 mg, 30 mg, 34 mg, 40 mg, 8.5 mg

G QL

nisoldipine er oral tablet extended release 24 hour 25.5 mg

G

norvasc NC N5



12/01/201870


nymalize oral solution 60 mg/20ml NP QL

procardia xl NC N5

sular oral tablet extended release 24 hour 17 mg, 34 mg, 8.5 mg

NC N5

taztia xt G QL

tiazac NC N5

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

G QL

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

G

verapamil hcl er oral tablet extended release 120 mg, 180 mg, 240 mg

G

verapamil hcl intravenous G

verapamil hcl oral G

verelan NC N5

*CARDIOTONICS*

digitek G

digox G

digoxin oral G

lanoxin oral tablet 125 mcg, 250 mcg NC N5

*CARDIOVASCULAR AGENTS - MISC.*

adcirca SP PA; ST; #; SP; QL

adempas SP PA; ST; SP; QL

amlodipine-atorvastatin NC N5

bidil NP

caduet oral tablet 10-10 mg, 10-20 mg, 10-40 mg, 10-80 mg, 5-10 mg, 5-20 mg, 5-40 mg, 5-80 mg

NC N5

epoprostenol sodium G PA; SP

flolan SP PA; SP

isoxsuprine hcl oral tablet 10 mg G

letairis SP PA; #; SP

opsumit SP PA; SP; QL

orenitram SP PA; SP

remodulin SP PA; #; SP

revatio intravenous SP PA; SP



12/01/201871


revatio oral suspension reconstituted SP PA; ST; #; SP

revatio oral tablet NC N5; SP

sildenafil citrate oral tablet 20 mg G PA; SP; QL

tadalafil (pah) SP PA; SP; QL

tadalafil oral tablet 2.5 mg, 5 mg G PA

tracleer oral tablet SP PA; #; SP

tracleer oral tablet soluble SP PA; SP

tyvaso SP PA; SP; QL

tyvaso refill SP PA; SP; QL

tyvaso starter SP PA; SP; QL

veletri SP PA; #; SP

ventavis SP PA; SP

*CEPHALOSPORINS*

cefaclor G

cefaclor er G

cefadroxil oral suspension reconstituted G

cefadroxil oral tablet G

cefazolin sodium injection SP

cefazolin sodium intravenous solution reconstituted

SP

cefdinir G

cefditoren pivoxil G

cefepime hcl SP

cefixime G

cefotaxime sodium injection solution reconstituted 1 gm, 500 mg

SP

cefotetan disodium SP

cefoxitin sodium SP

cefpodoxime proxetil G

cefprozil G

ceftazidime injection solution reconstituted 1 gm, 2 gm, 6 gm

SP

ceftriaxone sodium in dextrose G

ceftriaxone sodium injection solution reconstituted 1 gm, 2 gm, 250 mg, 500 mg

SP

ceftriaxone sodium intravenous SP



12/01/201872


cefuroxime axetil oral tablet G

cefuroxime sodium injection solution reconstituted 7.5 gm, 750 mg

SP

cefuroxime sodium intravenous solution reconstituted 1.5 gm

SP

cephalexin oral capsule 250 mg, 500 mg G

cephalexin oral suspension reconstituted G

cephalexin oral tablet G

keflex NC N5

maxipime injection solution reconstituted 1 gm, 2 gm

NC N5

maxipime intravenous NC

spectracef oral tablet 400 mg NP

suprax oral capsule NP #

suprax oral suspension reconstituted NP

suprax oral tablet chewable NP #

tazicef injection SP

tazicef intravenous solution reconstituted SP

teflaro SP

*CHEMICALS*

cholestyramine G

pentylene glycol G

quinidine sulfate dihydrate G

sodium hydroxide pellet G

testosterone cypionate G

testosterone powder G

triacetin G

zinc acetate powder G

*CIC AGENTS - GUANYLATE CYCLASE-C (GC-C) AGONISTS***

trulance PB QL

*CONTRACEPTIVES*

altavera CE

alyacen 1/35 CE

alyacen 7/7/7 CE

amethia CE



12/01/201873


amethia lo CE

apri CE

aranelle CE

aubra eq CE

aviane CE

azurette CE

balcoltra NP

balziva CE

beyaz NP

briellyn CE

camila CE

camrese CE

camrese lo CE

caziant CE

cesia CE

chateal CE

chateal eq CE

cryselle-28 CE

cyclafem 1/35 CE

cyclafem 7/7/7 CE

dasetta 1/35 CE

dasetta 7/7/7 CE

daysee CE

deblitane CE

depo-provera intramuscular suspension 150 mg/ml

NP

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

CE

drospiren-eth estrad-levomefol oral tablet 3-0.02-0.451 mg

CE

drospirenone-ethinyl estradiol oral tablet 3-0.03 mg

CE

elinest CE

ella CE #

emoquette CE

enpresse-28 CE



12/01/201874


enskyce oral tablet 0.15-30 mg-mcg CE

errin CE

estrostep fe NP

falessa oral kit 20-1-0.1 mcg-mg CE

falmina CE

fayosim CE

generess fe NP

gianvi CE

gildess fe 1.5/30 CE

gildess fe 1/20 CE

heather CE

introvale CE

isibloom CE

jolessa CE

jolivette CE

junel 1.5/30 CE

junel 1/20 CE

junel fe 1.5/30 CE

junel fe 1/20 CE

kariva CE

kelnor 1/35 CE

kurvelo CE

kyleena CE

larin fe 1.5/30 CE

leena CE

lessina CE

levonest CE

levonorgest-eth estrad 91-day oral tablet 0.1-0.02 & 0.01 mg, 0.15-0.03 mg

CE

levonorgestrel-ethinyl estrad CE

levora 0.15/30 (28) CE

lo loestrin fe NP

loestrin 1.5/30 (21) NP

loestrin 1/20 (21) NP

loryna CE



12/01/201875


loseasonique NP

low-ogestrel CE

lutera CE

lyza CE

marlissa CE

medroxyprogesterone acetate intramuscular suspension

CE

mibelas 24 fe CE

microgestin 1.5/30 CE

microgestin 1/20 CE

microgestin fe 1.5/30 CE

microgestin fe 1/20 CE

minastrin 24 fe NP

mircette NP N5

mirena (52 mg) CE #

mono-linyah CE

mononessa CE

myzilra CE

natazia NP

necon 0.5/35 (28) CE

necon 1/35 (28) CE

nexplanon CE

next choice one dose CE QL

nikki CE

nora-be CE

norethin ace-eth estrad-fe CE

norethindrone oral CE

norethin-eth estradiol-fe CE

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

CE

norgestim-eth estrad triphasic oral tablet0.18/0.215/0.25 mg-35 mcg

CE

norlyroc CE

nortrel 0.5/35 (28) CE

nortrel 1/35 (21) CE



12/01/201876


nortrel 1/35 (28) CE

nortrel 7/7/7 CE

nuvaring CE #

ocella CE

ogestrel CE

option 2 CE

orsythia CE

ortho micronor NP

ortho tri-cyclen (28) NP

ortho tri-cyclen lo NP

ortho-cyclen (28) NP

ortho-novum 1/35 (28) NP

ortho-novum 7/7/7 (28) NP

paragard intrauterine copper CE

philith CE

plan b one-step NP

portia-28 CE

previfem CE

quartette CE

quasense CE

rajani CE

reclipsen CE

rivelsa CE

safyral NP

seasonique NP N5

sharobel CE

skyla CE

solia CE QL

sprintec 28 CE

sronyx CE

syeda CE

take action CE QL

taytulla NP #

tilia fe CE

tri femynor CE



12/01/201877


tri-legest fe CE

tri-linyah CE

tri-mili CE

trinessa (28) CE

tri-norinyl (28) NP

tri-previfem CE

tri-sprintec CE

trivora (28) CE

tulana CE

tydemy CE

velivet CE

vestura CE

viorele CE

wera CE

wymzya fe CE

xulane CE

yasmin 28 NP

yaz NP

zarah CE

zovia 1/35e (28) CE

*CORTICOSTEROIDS*

budesonide er oral tablet extended release 24 hour

G QL

budesonide oral G

cortef NC N5

depo-medrol NP

dexamethasone intensol NP

dexamethasone oral elixir G

dexamethasone oral tablet G

dexamethasone oral tablet therapy pack G

dexamethasone sod phosphate pf G

dexamethasone sodium phosphate injection solution 10 mg/ml, 100 mg/10ml

G

emflaza NC N5



12/01/201878


entocort ec oral capsule delayed release particles

NC N5

fludrocortisone acetate oral G

hydrocortisone oral G

medrol oral tablet NC N5

methylprednisolone oral G

methylprednisolone sodium succ injection solution reconstituted 40 mg

G

millipred oral solution NP

orapred odt NC N5

prednisolone oral solution G

prednisolone sodium phosphate oral solution 10 mg/5ml, 15 mg/5ml, 20 mg/5ml, 25 mg/5ml, 6.7 (5 base) mg/5ml

G

prednisolone sodium phosphate oral tablet dispersible

G

prednisone intensol NP

prednisone oral G

rayos NP ST

solu-cortef injection solution reconstituted 100 mg, 500 mg

NP

solu-medrol injection solution reconstituted 2 gm, 500 mg

NP

taperdex 12-day NC

taperdex 6-day NC

uceris oral NP ST; #; QL

*COUGH/COLD/ALLERGY*

acetylcysteine inhalation G

alavert allergy/sinus G Select OTC

allegra-d allergy & congestion G Select OTC

benzonatate G

cetirizine-pseudoephedrine er G Select OTC

clarinex-d 12 hour NP QL

claritin-d 12 hour G Select OTC

claritin-d 24 hour NC N5; Select OTC



12/01/201879


fexofenadine-pseudoephed er oral tablet extended release 24 hour

G Select OTC

guaifenesin ac NC

hydrocod polst-cpm polst er oral suspension extended release

G QL

hydromet G

loratadine-d 12hr G Select OTC

loratadine-d 24hr G Select OTC

lortuss ex oral liquid 30-10-100 mg/5ml NP

nebusal inhalation nebulization solution 3 % G

nebusal inhalation nebulization solution 6 % PB

promethazine vc/codeine G

promethazine-dm G

pseudoeph-chlorphen-hydrocod G

semprex-d NP

sodium chloride inhalation nebulization solution10 %, 7 %

G

sski NP

tessalon perles NC N5

tusnel c NC

tussicaps oral capsule extended release 12 hour 10-8 mg

NP QL

tussionex pennkinetic er oral suspension extended release

NP QL

tuzistra xr oral suspension extended release NP

zyrtec-d allergy & congestion NC N5; Select OTC

*CYCLIN-DEPENDENT KINASES (CDK) INHIBITORS***

ibrance SP PA; SP; QL

kisqali 200 dose SP PA; SP; QL



verzenio SP PA; SP; QL

*CYSTIC FIBROSIS AGENT - COMBINATIONS***

orkambi oral packet SP PA; SP; QL



12/01/201880


orkambi oral tablet SP PA; QL

symdeko SP PA; SP; QL

*DERMATOLOGICALS*

abreva G Select OTC

absorica NC N5

acanya NC N5; #

acitretin G QL

acyclovir external G

aczone external gel 5 % NP ST; QL

aczone external gel 7.5 % NP ST; #; QL

adapalene external cream G PA; AL

adapalene external gel 0.1 % NC

adapalene external gel 0.3 % G PA; AL

adapalene external lotion G PA; AL

adapalene external solution NC

adapalene-benzoyl peroxide G PA; AL

aktipak NP

ala scalp NP

ala-quin NC

alclometasone dipropionate G

alcortin a NC

aldara NC N5

altabax NP

altreno NC

amcinonide external cream G ST

amcinonide external lotion G ST

amcinonide external ointment G

ameluz NP #

ammonium lactate external G

amnesteem G PA; QL

apexicon e NP ST

astero NC

atralin NC N5

avage NP

avar cleanser NC



12/01/201881


avar ls cleanser NC N5

avar-e emollient NC

avar-e green NC

avar-e ls NC N5

avita G PA; AL

avo cream NP

azelex NP

bactroban external cream NC N5

bensal hp NC

benzaclin NC N5

benzaclin with pump NC N5

benzoyl peroxide-erythromycin G

betamethasone dipropionate aug external cream G

betamethasone dipropionate aug external gel G QL

betamethasone dipropionate aug external lotion G QL

betamethasone dipropionate aug external ointment

G QL

betamethasone dipropionate external G

betamethasone valerate external cream G ST

betamethasone valerate external foam G

betamethasone valerate external lotion G ST

betamethasone valerate external ointment G ST

biafine NP

bionect external cream NP

bionect external gel NP

botox cosmetic intramuscular solution reconstituted 100 unit

NC N5

bp 10-1 NC

bp cleansing wash NP

calcipotriene external cream G ST

calcipotriene external ointment G ST

calcipotriene external solution G

calcipotriene-betameth diprop NC N5

calcitrene NP ST

calcitriol external G



12/01/201882


cantharidin G

capex NC N5

carac NC N5

cem-urea NC

centany NC N5

centany at NP

ciclodan external solution G PA

ciclodan solution NC N5

ciclopirox external gel G

ciclopirox external shampoo G

ciclopirox external solution G PA

ciclopirox olamine external G

ciclopirox treatment NC N5

claravis G PA; QL

cleocin-t NC N5

clindacin etz external kit NC N5

clindacin pac NC N5

clindagel NC N5

clindamycin phos-benzoyl perox external gel1.2-2.5 %

NC

clindamycin phos-benzoyl perox external gel 1-5 %, 1.2-5 %

NC N5

clindamycin phosphate external foam G

clindamycin phosphate external gel G ST

clindamycin phosphate external lotion G ST

clindamycin phosphate external solution G ST

clindamycin phosphate external swab G

clindamycin-tretinoin G PA; AL

clobetasol propionate e G ST; QL

clobetasol propionate emulsion G QL

clobetasol propionate external cream G ST; QL

clobetasol propionate external foam G QL

clobetasol propionate external gel G ST; QL

clobetasol propionate external liquid G QL

clobetasol propionate external lotion G ST; QL



12/01/201883


clobetasol propionate external ointment G ST; QL

clobetasol propionate external shampoo G QL

clobetasol propionate external solution G ST; QL

clobex NC N5

clobex spray NC N5

clocortolone pivalate G

clodan external shampoo NP QL

cloderm NP

clotrimazole-betamethasone G

coal tar external solution G

collagenase G

condylox external gel NP

cordran external cream 0.05 % NP QL

cordran external lotion NP QL

cordran external ointment NP QL

cordran external tape NP #; QL

cortisporin external PB

cosentyx SP PA; ST; SP

cosentyx sensoready pen subcutaneous solution auto-injector 150 mg/ml

SP PA; ST; SP

crotan G

cutivate external lotion NC N5

dapsone external G QL

denavir NP

derma-smoothe/fs body NC N5

dermasorb ta NP

desonate NP #

desonide external G ST

desowen external cream NC N5

desowen external lotion NC N5

desoximetasone external cream G ST

desoximetasone external gel G ST

desoximetasone external liquid NC

desoximetasone external ointment G ST

diclofenac sodium transdermal gel 1 % G QL



12/01/201884


diclofenac sodium transdermal gel 3 % NC N5

diclofenac sodium transdermal solution NC N5

diclofex dc NC

differin external cream NC N5

differin external gel 0.1 % G PA; Select OTC; AL

differin external gel 0.3 % NC N5

differin external lotion NP PA; ST; AL

diflorasone diacetate external cream G ST

diflorasone diacetate external ointment G

diprolene NC N5

diprolene af NC N5

dovonex external cream NC N5

doxepin hcl external G QL

doxycycline NC N5

dritho-creme hp NP

duac NC N5

econazole nitrate external G QL

ecoza NC N5

efudex external cream NC N5

elidel NP PA; ST; #

elocon external cream NC N5

elocon external ointment NC N5

enstilar NP QL

epiceram NP

epiduo PB PA; AL

epiduo forte PB PA; #; AL

epifoam NP

ertaczo NC N5

ery G

erygel NC N5

erythromycin external G

eurax NP

exelderm NC N5

exoderm external lotion NP

extina NC N5



12/01/201885


fabior NP PA; ST; AL

finacea external foam NP

finacea external gel NP #

finasteride oral tablet 1 mg G

flector NC N5; #

fluocinolone acetonide G

fluocinolone acetonide body G

fluocinolone acetonide external cream G ST

fluocinolone acetonide external ointment G ST

fluocinolone acetonide external solution G

fluocinonide external cream G ST; QL

fluocinonide external gel G ST; QL

fluocinonide external ointment G ST; QL

fluocinonide external solution G QL

fluoroplex NC N5

fluorouracil external cream 0.5 % NC N5

fluorouracil external cream 5 % G

fluorouracil external solution G

flurandrenolide G QL

fluticasone propionate external cream G ST

fluticasone propionate external lotion G

fluticasone propionate external ointment G

gebauers pain ease NP

gebauers spray and stretch NP

genadur external NP

gentamicin sulfate external G

geri-hydrolac 12 external cream NP

halobetasol propionate G ST; QL

halog NP

hydrocortisone ace-pramoxine external cream2.5-1 %

NC

hydrocortisone butyr lipo base G

hydrocortisone butyrate external lotion G

hydrocortisone butyrate external ointment G

hydrocortisone butyrate external solution G



12/01/201886


hydrocortisone external cream 2.5 % G

hydrocortisone external lotion 2.5 % G

hydrocortisone external ointment 2.5 % G

hydrocortisone valerate G

hylatopic plus external cream NP

ilumya SP PA; ST; SP; QL

imiquimod external G QL

imiquimod pump G ST

impoyz NC

inova 4/1 acne control therapy NP

inova 8/2 acne control therapy NP

isotretinoin oral G PA; QL

jublia NP PA; ST

kenalog external NC N5

keralyt scalp NP

ketoconazole external cream G

ketoconazole external foam NC N5

ketoconazole external shampoo G

klaron NC N5

klofensaid ii NC N5

lactic acid e G

lactic acid external lotion G

latisse NP

ldo plus NC

levulan kerastick NP QL

lidocaine external ointment G PA; QL

lidocaine external patch 5 % G PA; ST; QL

lidocaine hcl external solution G

lidocaine pak G PA; QL

lidocaine-prilocaine external cream G PA; QL

lidocaine-tetracaine G QL

lidoderm NC N5

lindane external shampoo G

locoid external cream NC N5

locoid external lotion NC



12/01/201887


locoid lipocream NC N5

loprox external cream NC N5

loprox external kit 0.77 % NC N5

loprox external shampoo NC N5

lotrisone external cream NC N5

luliconazole NC

luxiq NC N5

luzu NC N5

lycelle NP

malathion external G

melpaque hp G

methoxsalen rapid G

metrocream NP

metrogel external gel NC N5

metrolotion NP

metronidazole external gel G

micort-hc NC N5

mirvaso NC N5

mometasone furoate external cream G ST

mometasone furoate external ointment G ST

mometasone furoate external solution G

mupirocin calcium G QL

mupirocin external G QL

myorisan oral capsule 10 mg, 20 mg, 40 mg G PA; QL

myorisan oral capsule 30 mg G PA; QL

naftifine hcl external cream 2 % NC N5

naftin external cream 2 % NC N5

naftin external gel 1 % NC N5

naftin external gel 2 % NC LGC; N5; #

napro external NC N5

natroba NP

neosalus cp NP

neosalus external foam NP

neosalus external lotion NP

neo-synalar external cream NP



12/01/201888


neuac external gel NC N5

nizoral NC N5

nolix external lotion G QL

noritate NP

nucort NC N5

nyamyc G

nystatin external G

nystatin-triamcinolone G

nystop G

olux NC N5

olux-e NC N5

onexton NC N5; #

oracea NC N5

ovace plus external shampoo NC N5

ovace plus wash NC N5

ovace wash NC N5

ovide NC N5

oxiconazole nitrate NC N5

oxistat NC N5

oxsoralen ultra NC N5

pandel NP

panretin PB

penlac NC N5

pennsaid transdermal solution 2 % NC N5

permethrin external cream G

picato PB QL

plexion NC N5

plexion cleanser external liquid NC N5

plexion cleansing cloth external pad NC

plixda NC

podocon G

pramosone external cream 1-1 % NP

pramosone external lotion 1-2.5 % NP

pramosone external ointment 1-2.5 % NP

prednicarbate G



12/01/201889


promiseb NP

propecia NP

protopic NC N5

prudoxin NP QL

prutect NP

psorcon G ST

qbrexza NP PA; ST; QL

radiagel NP

radiaplexrx NP

refissa NP

regenecare NP

regranex NP PA; QL

renova NP

retin-a NC N5

retin-a micro NC N5

retin-a micro pump external gel 0.04 %, 0.1 % NC N5

retin-a micro pump external gel 0.06 % NC

retin-a micro pump external gel 0.08 % NP PA; ST; AL

rhofade NP QL

rosadan external gel G

rosadan external kit NC N5

rosanil cleanser NC

rynoderm NC

salex NP

salicylic acid external cream G

salicylic acid external liquid 26 % G

salicylic acid external lotion G

salicylic acid external shampoo G

salicylic acid wart remover G

santyl NP QL

selenium sulfide external lotion G

selenium sulfide external shampoo 2.25 % NC

selrx NC N5

sernivo NP

siliq SP PA; ST; SP; QL



12/01/201890


silvadene NC N5

silver nitrate external G

silver sulfadiazine external G

sklice NP

sodium sulfacetamide external shampoo G

sonafine NP

soolantra NP ST

soriatane oral capsule 10 mg, 25 mg NC N5

sorilux NC N5

spinosad G

sss 10-5 NC

stelara subcutaneous solution 45 mg/0.5ml SP PA; ST; SP; QL

stelara subcutaneous solution prefilled syringe SP PA; ST; SP; QL

sulfacetamide sodium (acne) G

sulfacetamide sodium external gel G

sulfacetamide sodium external liquid G

sulfacetamide sodium-sulfur external cream NC

sulfacetamide sodium-sulfur external emulsion NC

sulfacetamide sodium-sulfur external liquid 10-2 %, 9.8-4.8 %

NC

sulfacetamide sodium-sulfur external lotion NC

sulfacetamide sodium-sulfur external pad 10-4 % NC

sulfacetamide sodium-sulfur external suspension NC

sulfacetamide sod-sulfur wash external kit NC N5

sulfacleanse 8/4 NC

sulfamylon NP

sumadan NC N5

sumaxin NC

sumaxin cp NC N5

synalar (cream) NC N5

synalar (ointment) NC N5

synalar external cream NP ST

synalar external ointment G ST

synalar ts NC N5

synera NP QL



12/01/201891


taclonex external ointment NC N5

taclonex external suspension NP #; QL

tacrolimus external G PA; ST

taltz SP PA; ST; SP

targretin external SP PA; SP

tazarotene external G PA; AL

tazorac NP PA; ST; AL

temovate external cream NP ST; QL

temovate external ointment NC N5

texacort PB

tolak NC N5; #

topicort external cream NC N5

topicort external gel NC N5

topicort external ointment NC N5

topicort spray NC N5

tremfya SP PA; ST; SP; QL

tretinoin (emollient) G

tretinoin external cream G PA; AL

tretinoin external gel 0.01 %, 0.025 % G PA; AL

tretinoin external gel 0.05 % G PA

tretinoin microsphere G PA; AL

tretinoin microsphere pump G PA; AL

triamcinolone acetonide external aerosol solution

G

triamcinolone acetonide external cream G

triamcinolone acetonide external lotion G

triamcinolone acetonide external ointment 0.025 %

G

triamcinolone acetonide external ointment 0.1 %, 0.5 %

G LGC

triderm external cream 0.1 % LGC LGC

triderm external cream 0.5 % LGC LGC

tridesilon NC N5

tri-luma NP

ulesfia NP #; QL



12/01/201892


ultravate external cream NC N5

ultravate external lotion NP QL

ultravate external ointment NC N5

utopic NC

valchlor SP PA; SP; QL

vaniqa NP

vanos NC N5

vectical NP

veltin NP PA; ST; AL

venipuncture cpi NC

verdeso NC N5

virasal NP

voltaren transdermal PB QL

vusion NP

xelitral NC

xepi NP QL

xerese NP

xolegel NC N5

zenatane oral capsule 10 mg, 20 mg, 40 mg G PA; QL

zenatane oral capsule 30 mg G PA; QL

ziana NP PA; ST; AL

zonalon NP QL

zovirax external ointment NC N5

ztlido NC

zyclara NC N5; #

zyclara pump external cream 2.5 % NC N5

zyclara pump external cream 3.75 % NC N5; #

*DIAGNOSTIC PRODUCTS*

accu-chek aviva plus in vitro NC N5

accu-chek compact plus NC N5

accu-chek smartview NC N5

accutrend glucose NC N5

advance intuition test NC N5

advance micro-draw test NC N5

advocate redi-code in vitro NC N5



12/01/201893


advocate redi-code+ test NC N5

advocate test NC N5

agamatrix amp test NC N5

agamatrix jazz test NC N5

agamatrix keynote test NC N5

agamatrix presto test NC N5

assure 3 test NC N5

assure 4 test NC N5

assure ii NC N5

assure ii check NC N5

assure platinum NC N5

assure prism multi test NC N5

assure pro test NC N5

bayer breeze 2 test NC N5

bayer contour test NC N5

bioscanner glucose test NC N5

blood glucose test NC N5

caresens n glucose test NC N5

chemstrip k NP

clever chek auto-code test NC N5

clever chek auto-code voice in vitro NC N5

clever chek test NC N5

clever choice auto-code test NC N5

clever choice micro test NC N5

cool blood glucose test strips NC N5

cvs advanced glucose test NC N5

diatrue plus test NC N5

duo-care test NC N5

easy plus ii glucose test NC N5

easy step test NC N5

easy talk blood glucose test NC N5

easy touch healthpro test NC N5

easy touch test NC N5

easy trak blood glucose test NC N5

easygluco in vitro NC N5



12/01/201894


easygluco plus in vitro NC N5

easymax 15 test NC N5

easymax test NC N5

easyplus blood glucose test NC N5

easypro blood glucose test NC N5

easypro plus in vitro NC N5

element compact test NC N5

element test NC N5

embrace blood glucose test NC N5

embrace evo blood glucose test NC N5

embrace pro glucose test NC N5

evencare + blood glucose test NC N5

evencare blood glucose test NC N5

evencare g2 test NC N5

evencare g3 test NC N5

evencare mini glucose test NC N5

evolution autocode in vitro NC N5

ez smart blood glucose test NC N5

ez smart plus glucose test NC N5

fifty50 glucose test 2.0 NC N5

fora d15g blood glucose test NC N5

fora d20 blood glucose test NC N5

fora d40/g31 blood glucose NC N5

fora g20 blood glucose test NC N5

fora g30/prem v10 glucose test NC N5

fora gd20 test NC N5

fora gd50 blood glucose test NC N5

fora tn'g/tn'g voice NC N5

fora v10 blood glucose test NC N5



fora v30a blood glucose test NC N5

foracare gd40 test NC N5

foracare premium v10 test NC N5

foracare test n go test NC N5



12/01/201895


fortiscare test NC N5

freestyle insulinx test PB QL

freestyle lite test PB QL

freestyle precision neo test PB QL

freestyle test PB QL

gastrografin NC N5

ge100 blood glucose test NC N5

genstrip 50 NC N5

ght test NC N5

glucagen diagnostic PB QL

gluco perfect 3 test NC N5

glucocard 01 sensor plus NC N5

glucocard expression test NC N5

glucocard shine test NC N5

glucocard vital test NC N5

glucocard x-sensor NC N5

glucocom test NC N5

gluconavii blood glucose test NC N5

in touch blood glucose test NC N5

infinity blood glucose test NC N5

ketocare NP

ketostix NP

kroger blood glucose test NC N5

kroger test NC N5

liberty next generation test NC N5

liberty test NC N5

md-gastroview NP

meijer blood glucose test NC N5

meijer truetest test NC N5

meijer truetrack test NC N5

metopirone NP

microdot test NC N5

myglucohealth test NC N5

neutek 2tek test NC N5

nova max glucose test NC N5



12/01/201896


on call express blood glucose NC N5

on call plus blood glucose NC N5

on call vivid blood glucose NC N5

onetouch ultra blue PB QL

onetouch verio in vitro strip PB QL

optumrx blood glucose test NC N5

pocketchem ez test NC N5

precision pcx PB QL

precision pcx plus test PB QL

precision point of care test PB QL

precision qid test PB QL

precision sof-tact test PB QL

precision xtra blood glucose PB QL

precision xtra ketone NP

prodigy no coding blood gluc NC N5

pts panels glucose test NC N5

quicktek test NC N5

quintet ac blood glucose test NC N5

quintet blood glucose test NC N5

ra truetest test NC N5

refuah plus blood glucose test NC N5

reveal blood glucose test NC N5

rightest gs100 blood glucose NC N5



smart sense value test NC N5

smartest blood glucose test NC N5

solus v2 test NC N5

supreme test NC N5

sure edge test NC N5

surechek blood glucose test NC N5

sure-test easyplus mini test NC N5

telcare blood glucose test NC N5

thyrogen SP SP

true metrix blood glucose test NC N5



12/01/201897


truetest test NC N5

truetrack test NC N5

ultima test NC N5

ultratrak pro test NC N5

ultratrak ultimate test NC N5

unistrip1 generic NC N5

victory agm-4000 test NC N5

vocal point blood glucose test NC N5

wavesense presto NC N5

*DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS*

apptrim MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; TIER 3

apptrim-d MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; TIER 3

availnex MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; TIER 3

axona MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; Tier 3

cardiotek rx oral tablet MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; Tier 3

cerefolin MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; Tier 3

cerefolin nac MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; TIER 3

deplin 15 MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; TIER 3

deplin 7.5 MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; TIER 3



12/01/201898


enlyte MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; Tier 3

enteragam MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; TIER 3

folbic MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; Tier 3

folbic rf MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; TIER 3

foltanx MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; Tier 3

foltanx rf MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; TIER 3

foltx oral tablet 1.13-25-2 mg MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; TIER 3

fosteum MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; TIER 3

fosteum plus MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; TIER 3

fovex MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; TIER 3

gabadone MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; TIER 3

hypertensa MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; TIER 3

limbrel MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; Tier 3



12/01/201899


limbrel250 MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; TIER 3

limbrel500 MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; Tier 3

lipichol 540 MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; TIER 3

lister-v MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; TIER 3

l-methylfolate ca me-cbl nac MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; TIER 3

l-methylfolate forte MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; TIER 3

l-methylfolate-algae-b12-b6 MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; TIER 1

l-methylfolate-b6-b12 oral tablet 3-35-2 mg MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; TIER 1

l-methyl-mc MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; TIER 3

l-methyl-mc nac MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; TIER 3

macutek MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; TIER 3

metafolbic MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; TIER 3

metafolbic plus MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; Tier 3



12/01/2018100


metafolbic plus rf MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; TIER 3

metanx oral capsule MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; TIER 3

percura MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; TIER 3

proteolin ds MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; TIER 3

proteolin oral tablet MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; TIER 3

pulmona MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; TIER 3

sentra am MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; TIER 3

sentra pm MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; TIER 3

theramine MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; Tier 3

theramine plus MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; TIER 3

trepadone MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; TIER 3

vascazen MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; TIER 3

vasculera MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; TIER 3



12/01/2018101


vayacog MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; TIER 3

vayarin MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; TIER 3

vayarol MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; TIER 3

vsl#3 junior MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; TIER 3

vsl#3 oral packet MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; TIER 3

zytaze MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; TIER 3

*DIGESTIVE AIDS*

creon PB

pancreaze NP ST

pertzye NP ST

sucraid SP SP

viokace NP ST

zenpep oral capsule delayed release particles 10000-32000 unit, 15000-47000 unit, 20000-63000 unit, 25000-79000 unit, 3000-14000 unit, 40000-126000 unit, 5000-24000 unit

PB

*DIRECT-ACTING P2Y12 INHIBITORS***

brilinta PB QL

*DIURETICS*

acetazolamide er NC N5

acetazolamide oral G

aldactazide NC N5

aldactone NC N5

amiloride hcl oral G

amiloride-hydrochlorothiazide G

bumetanide injection G



12/01/2018102


bumetanide oral G

carospir NC N5

chlorothiazide oral G

chlorothiazide sodium G

chlorthalidone oral tablet 25 mg, 50 mg G

demadex oral tablet 10 mg, 20 mg NC N5

diuril NP

dyazide NC N5

dyrenium NP

edecrin NP

ethacrynic acid oral G

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

furosemide oral tablet G

hydrochlorothiazide oral tablet G

indapamide oral G

keveyis SP PA; QL

lasix NC N5

maxzide NC N5

maxzide-25 NC N5

methazolamide oral tablet 25 mg G

methyclothiazide oral G

metolazone G

sodium edecrin NP

spironolactone oral G

spironolactone-hctz G

torsemide oral G

triamterene-hctz oral capsule 37.5-25 mg G

triamterene-hctz oral tablet G

*ENDOCRINE AND METABOLIC AGENTS - MISC.*

actonel oral tablet 150 mg, 30 mg, 35 mg, 5 mg NC N5

aldurazyme SP PA; SP

alendronate sodium oral solution G

alendronate sodium oral tablet G QL

ammonul SP SP



12/01/2018103


atelvia NC N5

binosto NC N5

boniva intravenous NC N5; SP

boniva oral tablet 150 mg NC N5

bravelle M

PA; Only covered in states: CT,IL, KS, MD, NC, and WV and excluded elsewhere; Tier 4; SP

buphenyl oral powder 3 gm/tsp NC N5; SP

buphenyl oral tablet NC SP

cabergoline G

calcitonin (salmon) G QL

calcitriol oral G

carbaglu SP PA; #; SP

carnitor oral solution NP

carnitor sf NP

cetrotide subcutaneous kit 0.25 mg M

PA; #; Only covered in states: CT,IL, KS, MD, NC, and WV and excluded elsewhere; TIER 5; SP

chorionic gonadotropin intramuscular G PA; SP

clomiphene citrate oral MOnly covered in states: CT,IL, KS, MD, NC, and WV and excluded elsewhere; TIER 3

cystadane SP SP

ddavp injection solution 4 mcg/ml NC N5

ddavp oral NC N5

ddavp rhinal tube NC N5

desmopressin ace spray refrig G

desmopressin acetate injection G

desmopressin acetate oral G

doxercalciferol intravenous NC

doxercalciferol oral G QL

egrifta subcutaneous solution reconstituted 1 mg

NC N5

elaprase SP PA; SP

etidronate disodium G



12/01/2018104


evista NP

fabrazyme SP PA; SP

follistim aq subcutaneous M

PA; ST; Only covered in states: CT,IL, KS, MD, NC, and WV and excluded elsewhere; Tier 4; SP

forteo subcutaneous solution 600 mcg/2.4ml SP PA; ST; #; SP

fosamax oral tablet 70 mg NC N5

fosamax plus d NP ST; QL

galafold SP SP; QL

ganirelix acetate SP PA; SP

genotropin SP PA; ST; SP

genotropin miniquick SP PA; ST; SP

gonal-f injection solution reconstituted 1050 unit

M


gonal-f injection solution reconstituted 450 unit

M

PA; Only covered in states: CT,IL, KS, MD, NC, and WV and excluded elsewhere; TIER 5; SP

gonal-f rff M


gonal-f rff rediject M


hectorol intravenous solution 2 mcg/ml NC

hectorol intravenous solution 4 mcg/2ml NC N5

hp acthar SP PA; SP

humatrope SP PA; ST; SP

ibandronate sodium intravenous solution 3 mg/3ml

SP ST; SP

ibandronate sodium oral G ST; QL

increlex SP PA; SP

jynarque SP PA; SP



12/01/2018105


kuvan SP PA; SP

levocarnitine oral solution G

lumizyme SP PA; SP

lupron depot-ped (1-month) SP PA; #; SP

lupron depot-ped (3-month) SP PA; #; SP

menopur M

PA; ST; Only covered in states: CT,IL, KS, MD, NC, and WV and excluded elsewhere; TIER 5; SP

miacalcin injection SP PA

miacalcin nasal NC N5

naglazyme SP PA; SP

natpara SP PA; QL

nityr SP PA; SP

nocdurna NP PA; QL

noctiva PB QL; AL

norditropin flexpro SP PA; ST; SP

novarel intramuscular solution reconstituted10000 unit

G


nutropin aq nuspin 10 SP PA; ST; SP



octreotide acetate injection solution 100 mcg/ml, 1000 mcg/ml, 200 mcg/ml, 50 mcg/ml, 500 mcg/ml

G PA; SP

omnitrope SP PA; SP

orfadin oral capsule 10 mg, 2 mg, 5 mg SP PA; SP

orfadin oral capsule 20 mg SP PA

orfadin oral suspension SP PA; SP

orilissa SP PA; SP; QL

osphena NP QL

ovidrel M

PA; Only covered in states: CT,IL, KS, MD, NC, and WV and excluded elsewhere; TIER 5; SP



12/01/2018106


palynziq SP PA; ST; SP; QL

pamidronate disodium SP SP

paricalcitol intravenous NC

paricalcitol oral G QL

pregnyl G


prolia SP PA; ST; SP

raloxifene hcl CE

ravicti SP PA; ST; SP; QL

rayaldee NP PA; ST; QL

reclast NC N5; SP

risedronate sodium oral tablet 150 mg, 30 mg, 35 mg, 5 mg

G ST; QL

risedronate sodium oral tablet delayed release G QL

rocaltrol oral capsule NC N5

saizen SP PA; ST; SP

samsca SP PA; #; SP; QL

sandostatin injection solution 100 mcg/ml, 50 mcg/ml, 500 mcg/ml

NC N5; SP

sandostatin lar depot SP PA; #; SP

sensipar NP PA; #; QL

serostim subcutaneous solution reconstituted 4 mg, 5 mg, 6 mg

SP PA; SP

signifor SP PA; SP; QL

signifor lar intramuscular suspension reconstituted er

SP PA; SP; QL

sod benz-sod phenylacet G

sodium phenylbutyrate oral powder 3 gm/tsp SP PA; SP

sodium phenylbutyrate oral tablet SP PA; SP

somatuline depot SP PA; #; SP

somavert SP PA; #; SP

stimate NP PA

supprelin la SP PA; SP

synarel SP PA; SP



12/01/2018107


triptodur SP PA; SP

tymlos SP PA; ST; SP; QL

xgeva SP PA; ST; SP

zemplar intravenous NC N5

zemplar oral capsule 1 mcg, 2 mcg NC N5

zoledronic acid intravenous concentrate SP SP

zoledronic acid intravenous solution SP SP

zomacton SP PA; ST; SP

zometa intravenous concentrate NC N5; SP

zometa intravenous solution NC SP

zorbtive SP PA; SP

*ESTROGENS*

activella NC N5

alora NC N5

angeliq NP

climara NC N5

climara pro NP #; QL

combipatch NP QL

delestrogen intramuscular oil 10 mg/ml, 40 mg/ml

NP

delestrogen intramuscular oil 20 mg/ml NC N5

depo-estradiol NP

elestrin NP QL

estrace oral NC N5

estradiol oral G

estradiol transdermal G QL

estradiol valerate intramuscular oil 20 mg/ml G

estradiol-norethindrone acet G QL

estrogel NP QL

evamist NP QL

femhrt low dose NP

fyavolv G

jinteli G

menest oral tablet 0.3 mg, 0.625 mg PB

menest oral tablet 1.25 mg NP



12/01/2018108


menostar NP #; QL

mimvey G QL

minivelle NC N5; #

norethindrone-eth estradiol G

prefest NP QL

premarin injection NP

premarin oral PB

premphase PB

prempro PB

vivelle-dot NC N5

*ESTROGEN-SELECTIVE ESTROGEN RECEPTOR MODULATOR COMB***

duavee PB QL

*FARNESOID X RECEPTOR (FXR) AGONISTS***

ocaliva oral tablet 5 mg SP PA; ST; SP; QL

*FLUOROQUINOLONES*

avelox intravenous NP

avelox oral NC N5

baxdela oral NP PA; QL

cipro oral suspension reconstituted NP

cipro oral tablet 250 mg, 500 mg NC N5

cipro xr NC N5

ciprofloxacin hcl oral G

ciprofloxacin in d5w intravenous solution 400 mg/200ml

G

ciprofloxacin oral suspension reconstituted 500 mg/5ml (10%)

G

ciprofloxacin-ciproflox hcl er G

levaquin oral tablet NC N5

levofloxacin in d5w intravenous solution 750 mg/150ml

G

levofloxacin oral G

moxifloxacin hcl oral G

ofloxacin oral tablet 300 mg G QL

ofloxacin oral tablet 400 mg G



12/01/2018109


*GASTROINTESTINAL AGENTS - MISC.*

actigall NC N5

alosetron hcl G PA; ST

amitiza NP ST; QL

apriso NP ST; #; QL

asacol hd NP ST; QL

azulfidine NC N5

azulfidine en-tabs NC N5

balsalazide disodium G QL

canasa PB #; QL

chenodal SP PA

cimzia prefilled SP PA; ST; SP; QL

cimzia starter kit SP PA; ST; SP; QL

cimzia subcutaneous kit 2 x 200 mg SP PA; ST; SP; QL

colazal NC N5

cromolyn sodium oral G

delzicol PB #; QL

dipentum NP ST; QL

enulose G

fosrenol oral packet NP

fosrenol oral tablet chewable 1000 mg, 500 mg, 750 mg

NP

gastrocrom NC N5

gattex SP PA; SP; QL

generlac G

inflectra SP PA; ST; SP

lactulose encephalopathy G

lanthanum carbonate G

lialda PB QL

linzess oral capsule 145 mcg, 290 mcg PB QL

linzess oral capsule 72 mcg PB

lotronex NC N5

mesalamine oral G QL

mesalamine rectal G

mesalamine-cleanser G



12/01/2018110


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

G

metoclopramide hcl oral tablet G

metoclopramide hcl oral tablet dispersible G

movantik PB QL

pentasa PB QL

phoslo NP

phoslyra NP

reglan oral NC N5

relistor oral NP PA; #; QL

relistor subcutaneous solution 12 mg/0.6ml, 8 mg/0.4ml

NP PA; QL

remicade SP PA; ST; SP

renagel oral tablet 800 mg NP #

renflexis SP PA; ST; SP

renvela PB

rowasa rectal NC N5

sevelamer carbonate G

sfrowasa NP

sulfasalazine oral G QL

sulfazine G QL

symproic NP PA; ST; QL

urso 250 NC N5

urso forte NC N5

ursodiol oral G

velphoro NP #

*GENITOURINARY AGENTS - MISCELLANEOUS*

acetic acid irrigation G

alfuzosin hcl er G QL

argyle sterile saline G

avodart NC N5

cardura xl NP QL

cystagon NP PA

cytra-2 NC



12/01/2018111


dutasteride oral G QL

dutasteride-tamsulosin hcl G

elmiron PB QL

finasteride oral tablet 5 mg G PA

flomax NC N5

jalyn NC N5

lithostat PB

neomycin-polymyxin b gu G

phenazopyridine hcl oral tablet 100 mg G

potassium citrate er oral tablet extended release10 meq (1080 mg), 15 meq (1620 mg)

G

potassium citrate-citric acid oral solution G

procysbi SP PA; ST; SP; QL

proscar NC N5

pyridium oral tablet 100 mg NP

rapaflo PB #

renacidin PB

shohls modified NC

sod citrate-citric acid NC

sodium chloride irrigation solution 0.9 % G

tamsulosin hcl G

thiola SP PA; ST

urocit-k 10 NC N5

urocit-k 15 NC N5

urocit-k 5 NC N5

*GLYCOPEPTIDES***

firvanq oral solution reconstituted 25 mg/ml NP

vancomycin hcl oral G

*GOUT AGENTS*

aloprim NP

colchicine oral G QL

colchicine-probenecid G

colcrys NC N5

duzallo NP PA; ST; QL

krystexxa SP PA; ST; SP



12/01/2018112


mitigare PB QL

probenecid oral G

uloric NP ST; QL

zurampic NP PA; ST; QL

zyloprim NP

*HEMATOLOGICAL AGENTS - MISC.*

advate SP PA; SP

adynovate intravenous solution reconstituted 1000 unit, 2000 unit, 250 unit, 500 unit

SP PA

adynovate intravenous solution reconstituted 1500 unit, 3000 unit, 750 unit

SP PA; SP

afstyla SP PA; SP

aggrenox NP

alphanate/vwf complex/human NC N5

alphanine sd NC N5; SP

alprolix NC N5; SP

anagrelide hcl G

aspirin-dipyridamole er G

bebulin NC N5; SP

benefix intravenous kit SP PA; SP

berinert SP PA; ST; SP

brilinta PB QL

cilostazol G

cinryze SP PA; ST; SP; QL

clopidogrel bisulfate oral G QL

coagadex SP PA

corifact NC N5; SP

dipyridamole oral G

durlaza NP

effient NP PA; QL

eloctate intravenous solution reconstituted 1000 unit, 1500 unit, 2000 unit, 250 unit, 3000 unit, 500 unit, 750 unit

NC N5; SP

eloctate intravenous solution reconstituted 4000 unit, 5000 unit, 6000 unit

NC N5

feiba SP PA



12/01/2018113


fibryga NC

firazyr NC N5; #

haegarda SP PA; ST; SP; QL

helixate fs intravenous kit 1000 unit, 2000 unit, 250 unit, 500 unit

NC N5

helixate fs intravenous kit 3000 unit SP PA; SP

hemofil m intravenous solution reconstituted 1000 unit, 1700 unit, 250 unit, 500 unit

NC N5; SP

humate-p intravenous solution reconstituted 1000-2400 unit, 250-600 unit, 500-1200 unit

NC N5; SP

idelvion SP PA; SP

ixinity SP PA

jivi SP PA; SP

kalbitor SP PA; ST; SP

koate NC N5

koate-dvi NC N5; SP

kogenate fs intravenous kit 1000 unit, 2000 unit, 250 unit, 500 unit

NC N5

kogenate fs intravenous kit 3000 unit SP PA; SP

kovaltry NC N5; SP

monoclate-p intravenous kit 1000 unit NC N5; SP

mononine intravenous solution reconstituted 1000 unit

SP PA; SP

novoeight NC N5; SP

novoseven rt NC N5; SP

nuwiq intravenous kit 1000 unit, 2000 unit, 250 unit, 500 unit

NC N5; SP

nuwiq intravenous kit 2500 unit, 3000 unit, 4000 unit

NC N5

nuwiq intravenous solution reconstituted 1000 unit, 2000 unit, 250 unit, 500 unit

NC N5; SP

nuwiq intravenous solution reconstituted 2500 unit, 3000 unit, 4000 unit

NC N5

pentoxifylline er G

plavix NC N5

prasugrel hcl G PA; QL



12/01/2018114


profilnine intravenous solution reconstituted 1000 unit, 500 unit

NC N5; SP

profilnine intravenous solution reconstituted 1500 unit

NC N5

profilnine sd NC N5; SP

rebinyn SP PA; SP

recombinate NC N5; SP

riastap NC N5; SP

rixubis SP PA; SP

ruconest SP PA; SP

tretten NC N5; SP

vonvendi SP PA

wilate intravenous kit NC N5; SP

xyntha intravenous kit 1000 unit, 2000 unit, 250 unit, 500 unit

NC N5; SP

xyntha solofuse NC N5; SP

yosprala NC N5

*HEMATOPOIETIC AGENTS*

abaneu-sl NC

active fe NC

airavite NC

animi-3 NC

animi-3/vitamin d NC

aranesp (albumin free) injection solution 100 mcg/ml, 200 mcg/ml, 25 mcg/ml, 300 mcg/ml, 40 mcg/ml, 60 mcg/ml

SP PA; SP

aranesp (albumin free) injection solution prefilled syringe 100 mcg/0.5ml, 150 mcg/0.3ml, 200 mcg/0.4ml, 25 mcg/0.42ml, 300 mcg/0.6ml, 40 mcg/0.4ml, 500 mcg/ml, 60 mcg/0.3ml

SP PA; SP

av-vite fb NC

b-6 folic acid NC

bp vit 3 NC

cenfol NC

centratex NC

cerdelga PB PA; SP; QL



12/01/2018115


cerezyme intravenous solution reconstituted 400 unit

SP PA; SP

ciferex NC

corvita 150 NC

corvite 150 oral tablet 150-1.25 mg NC

corvite fe G

cyanocobalamin injection G

divista NC

doptelet oral tablet 20 mg SP PA; SP; QL

droxia NP

durachol NC

elelyso SP PA; SP

epogen injection solution 10000 unit/ml, 2000 unit/ml, 20000 unit/ml, 3000 unit/ml, 4000 unit/ml

SP PA; SP

fabb NC

fa-vitamin b-6-vitamin b-12 NC

feriva 21/7 NC

ferocon NC

ferotrinsic NC

ferraplus 90 NC

ferrlecit NC N5; SP

ferrocite plus oral tablet NC

ferro-plex hematinic NC

ferrotrin NC

folbee NC

folgard rx NC N5

folic acid oral tablet 1 mg G

folic acid oral tablet 400 mcg, 800 mcg CE

folivane-f NC

folivane-plus NC

folplex 2.2 NC

foltrin NC

fulphila SP PA; SP

fusion plus NC



12/01/2018116


gnp folic acid CE

granix SP PA; ST; SP

hematinic plus vit/minerals NC

hematinic/folic acid NC

hematogen fa NC

hematogen forte NC

hemetab NC

hemocyte plus NC

hemocyte-f oral tablet NC

hemocyte-plus oral tablet 106-1 mg NC

integra f NC

integra plus NC

irospan 24/6 NC

is 24/6 NC

k-tan plus NC

leukine intravenous SP PA; SP

maxfe oral tablet NC

miglustat SP PA; SP; QL

mircera injection solution prefilled syringe 100 mcg/0.3ml, 200 mcg/0.3ml, 50 mcg/0.3ml, 75 mcg/0.3ml

SP PA

mircera injection solution prefilled syringe 150 mcg/0.3ml, 30 mcg/0.3ml

SP PA; SP

mozobil SP PA

mulpleta SP PA; SP; QL

multigen NC

multigen folic NC

multigen plus NC

na ferric gluc cplx in sucrose G SP

nascobal NC N5

nephron fa NC

neulasta subcutaneous solution prefilled syringe

SP PA

neupogen injection solution 300 mcg/ml, 480 mcg/1.6ml

SP PA; ST; SP

neupogen injection solution prefilled syringe SP PA; ST



12/01/2018117


neurin-sl NC

nivestym SP PA; SP

nplate SP SP

nufol NC

procrit SP PA; SP

proferrin-forte NC

promacta SP PA; SP; QL

protectiron NC

purefe plus NC

purevit dualfe plus NC

retacrit SP PA; SP

revesta NC

se-tan plus NC

siklos NP PA

tandem f NC

tandem plus NC

taron forte NC

tl gard rx NC

tl icon NC

tricon NC

trigels-f forte NC

venofer SP SP

virt-gard NC

vpriv SP PA; SP

zarxio SP PA

zavara NC

zavesca SP PA; #; SP; QL

*HEMOSTATICS*

amicar oral solution NP

amicar oral tablet PB

lysteda NC N5

tranexamic acid oral G QL

*HEPATITIS C AGENT - COMBINATIONS***

epclusa SP PA; #; SP; QL



12/01/2018118


harvoni SP PA; #; SP

mavyret SP PA; ST; SP; QL

technivie SP PA; ST; QL

viekira pak SP PA; ST; SP; QL

viekira xr SP PA; ST; QL

vosevi SP PA; PPA; SP; QL

zepatier SP PA; SP; QL

*HEREDITARY OROTIC ACIDURIA TREATMENT - AGENTS**

xuriden SP PA; SP; QL

*HYPNOTICS*

ambien NC N5

ambien cr NC N5

butisol sodium oral tablet 30 mg NP

doral NP

edluar NC N5

estazolam G

eszopiclone G QL; AL

flurazepam hcl G

halcion NC N5

hetlioz SP PA; SP; QL

intermezzo NC N5

lunesta NC N5

midazolam hcl oral G

phenobarbital oral elixir G

phenobarbital oral tablet G

quazepam G AL

restoril NC N5

rozerem NP ST; #; QL

seconal NP

silenor NC N5; #; SP

temazepam oral capsule 15 mg, 30 mg G

temazepam oral capsule 22.5 mg, 7.5 mg G QL

triazolam G

zaleplon G QL



12/01/2018119


zolpidem tartrate er G ST; QL

zolpidem tartrate oral G QL

zolpidem tartrate sublingual NC N5

zolpimist NC N5; #

*HYPOPHOSPHATASIA (HPP) AGENTS***

strensiq SP PA; SP

*IBS AGENT - MU-OPIOID RECEPTOR AGONISTS***

viberzi PB PA; QL

*INSULIN-INCRETIN MIMETIC COMBINATIONS***

soliqua PB ST; QL

xultophy PB ST; QL

*INTEGRIN RECEPTOR ANTAGONISTS***

entyvio SP PA; ST; SP

*INTERLEUKIN ANTAGONISTS***

stelara intravenous SP PA; ST; SP

*INTERLEUKIN-5 ANTAGONISTS (IGG1 KAPPA)***

nucala SP PA; SP; QL

*INTERLEUKIN-5 ANTAGONISTS (IGG4 KAPPA)***

cinqair SP PA; SP

*ISOCITRATE DEHYDROGENASE-1 (IDH1) INHIBITORS***

tibsovo SP PA; SP; QL

*ISOCITRATE DEHYDROGENASE-2 (IDH2) INHIBITORS***

idhifa SP PA; SP; QL

*LAXATIVES*

clearlax oral powder CE

clenpiq CE

constulose G

cvs purelax CE



12/01/2018120


eq clearlax CE

eql clearlax CE

gavilax CE

gavilyte-c G

gavilyte-g G

gavilyte-h CE

gavilyte-n with flavor pack G

gentlelax oral powder CE

gialax CE

glycolax CE

gnp clearlax oral powder CE

golytely oral solution reconstituted 227.1 gm NP

golytely oral solution reconstituted 236 gm NC N5

healthylax CE

hm clearlax CE

kls laxaclear CE

kristalose NP QL

lactulose oral packet G QL

lactulose oral solution G

miralax oral packet NC N5

miralax oral powder CE

moviprep CE#; Only covered in states: CT,GA,IL,MI,NV,PA,TN,TX and excluded elsewhere

nulytely with flavor packs NC N5

osmoprep CE#; Only covered in states: CT,GA,IL,MI,NV,PA,TN,TX and excluded elsewhere

peg 3350 CE

peg 3350/electrolytes CEOnly covered in states: CT,GA,IL,MI,NV,PA,TN,TX and excluded elsewhere

peg 3350-kcl-na bicarb-nacl GOnly covered in states: CT,GA,IL,MI,NV,PA,TN,TX and excluded elsewhere



12/01/2018121


peg-3350/electrolytes GOnly covered in states: CT,GA,IL,MI,NV,PA,TN,TX and excluded elsewhere

peg-prep CE

pegylax CE

plenvu CE

polyethylene glycol 3350 oral CE

prepopik CE#; Only covered in states: CT,GA,IL,MI,NV,PA,TN,TX and excluded elsewhere

qc natura-lax CE

ra laxative oral packet CE

ra laxative oral powder CE

sb polyethylene glycol 3350 CE

sm clearlax CE

smooth lax oral powder CE

suprep bowel prep kit CEOnly covered in states: CT,GA,IL,MI,NV,PA,TN,TX and excluded elsewhere

tgt powderlax CE

trilyte CE

*LEPTIN ANALOGUES***

myalept SP PA; SP; QL

*LHRH/GNRH AGONIST ANALOG COMBINATIONS***

lupaneta pack SP PA; SP

*LOCAL ANESTHETICS-PARENTERAL*

lidocaine hcl (pf) injection solution 0.5 %, 1 % G

lidocaine hcl injection solution 0.5 % G

*LYMPHOCYTE FUNCTION-ASSOCIATED ANTIGEN-1 (LFA-1) ANTAG***

xiidra PB

*LYSOSOMAL ACID LIPASE (LAL) DEFICIENCY - AGENTS***

kanuma SP PA; SP



12/01/2018122


*MACROLIDES*

azithromycin intravenous solution reconstituted500 mg

G

azithromycin oral packet G

azithromycin oral suspension reconstituted G

azithromycin oral tablet 250 mg, 500 mg, 600 mg

G

biaxin oral tablet 500 mg NC N5

clarithromycin er G

clarithromycin oral G

dificid NP QL

e.e.s. 400 oral tablet NP

e.e.s. granules NP

eryped 200 NP

eryped 400 NP

ery-tab NP

erythrocin lactobionate intravenous solution reconstituted 500 mg

NP

erythrocin stearate oral tablet 250 mg NP

erythromycin base oral capsule delayed release particles

G

erythromycin base oral tablet G

erythromycin ethylsuccinate oral G

zithromax oral packet NP

zithromax oral suspension reconstituted NC N5

zithromax oral tablet NC N5

zithromax tri-pak NC N5

zithromax z-pak NC N5

*MEDICAL DEVICES*

accu-chek fastclix lancets NP

accu-chek multiclix lancet dev NP QL

accu-chek multiclix lancets NP

accu-chek soft touch lancets NP

accu-chek softclix lancets NP

advocate duo device NP QL

assure lancets NP



12/01/2018123


bayer microlet lancets NP

bd autoshield 29g x 5mm , 29g x 8mm PB

bd insulin syringe 25g x 1" 1 ml, 25g x 5/8" 1 ml, 26g x 1/2" 1 ml, 29g x 1/2" 1 ml, 30g x 1/2" 0.5 ml, 31g x 5/16" 0.3 ml, u-100 1 ml

PB

bd insulin syringe half-unit PB

bd insulin syringe microfine 28g x 1/2" 0.5 ml PB

bd insulin syringe u/f 30g x 1/2" 1 ml PB

bd insulin syringe ultrafine 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 1/2" 0.3 ml

PB

bd lancet ultrafine 30g NP

bd lancet ultrafine 33g NP

bd microtainer lancets NP

bd pen PB

bd pen mini PB

bd pen needle mini u/f PB

bd pen needle nano u/f PB

bd pen needle short u/f PB

bd pen needle ultrafine PB

bd safetyglide insulin syringe 30g x 5/16" 0.5 ml PB

bullseye mini safety lancets NP

bullseye safety lancets NP

clever chek auto-code NP QL

coaguchek lancets NP

comfort assured lancets 28g NP

comfort assured lancets 33g NP

drug mart unifine pentips 31g x 5 mm G

easy comfort insulin syringe 30g x 1/2" 0.5 ml, 30g x 1/2" 1 ml

G

easy touch insulin syringe 31g x 5/16" 1 ml NP

easy touch lancets 21g NP



easy touch lancets 26g/twist NP





12/01/2018124







easy touch lancing device NP

easy touch safety lancets 21g NP




easy twist & cap lancets NP

fc2 female condom CE

fingerstix lancets NP

fora d10 2-in-1 monitor NP QL

fora d15g 2-in-1 monitor NP QL

fora d20 2-in-1 monitor NP QL

freestyle lancets NP

freestyle precision ins syr 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml

NP

freestyle unistick ii lancets NP

global inject ease insulin syr 28g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 1/2" 0.3 ml, 30g x 1/2" 0.5 ml, 30g x 1/2" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml

G

gnp clickfine pen needles 31g x 8 mm G

gnp insulin syringe 28g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 31g x 5/16" 0.5 ml

G

gnp ultra com insulin syringe 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml

G

healthy accents unifine pentip 31g x 5 mm , 31g x 6 mm

G

insulin syringe G

insulin syringe/needle 27g x 1/2" 0.5 ml, 28g x 1/2" 1 ml

G

insulin syringe/needle 28g x 1/2" 0.5 ml G

insulin syringe-needle u-100 31g x 1/4" 0.3 ml, 31g x 1/4" 0.5 ml, 31g x 1/4" 1 ml

G



12/01/2018125


kroger insulin syringe 29g x 1/2" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml

G

lancets G

lancets super thin 28g NP

lancets ultra thin NP

lancets ultra thin 30g NP

lifescan unistik 2 NP

lifescan unistik ii lancets NP

lite touch lancets NP

litetouch lancets NP

magellan insulin safety syr 29g x 1/2" 1 ml NP

microlet lancets NP

microtainer safety flow lancet NP

neutek 2tek glucose/pressure NP QL

novofine 32g x 6 mm NP

novotwist 32g x 5 mm NP

onetouch club lancets fine pt NP

onetouch combo pack NP

onetouch delica lancets 33g NP

onetouch delica lancets fine NP

onetouch delica lancing dev NP

onetouch finepoint lancets NP

onetouch ultrasoft lancets NP

pen needles G

pen needles 1/2" G

pen needles 3/16" G

pen needles 5/16" G

precision suredose plus syr 29g x 1/2" 1 ml NP

precision sure-dose syringe 28g x 1/2" 0.5 ml NP

relion insulin syringe 29g x 1/2" 1 ml NP

reli-on insulin syringe 29g x 1/2" 1 ml NP

relion pen needles 31g x 8 mm NP

safety let lancets NP

sapscare twist top lancets NP



12/01/2018126


simple diagnostics lancing dev NP

super thin lancets NP

trueplus insulin syringe 29g x 1/2" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml

NP

trueplus lancets 26g NP

trueplus lancets 30g NP

trueplus safety lancets 28g NP

ulticare insulin syringe 28g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 1/2" 0.3 ml, 30g x 1/2" 0.5 ml, 30g x 1/2" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml

NP

ulticare short pen needles NP

unifine pentips plus 31g x 5 mm G

vanishpoint insulin syringe 30g x 3/16" 0.5 ml, 30g x 3/16" 1 ml

NP

vida mia unifine pentips 31g x 6 mm NP

wide-seal diaphragm 60 CE








*MIGRAINE PRODUCTS*

almotriptan malate G QL

amerge NC N5

cafergot NP

cambia NC N5

d.h.e. 45 NC N5

dihydroergotamine mesylate injection G

dihydroergotamine mesylate nasal G ST; QL

eletriptan hydrobromide G QL

ergomar NP

frova NP ST; QL



12/01/2018127


frovatriptan succinate G QL

imitrex nasal NP QL

imitrex oral NC N5

imitrex statdose refill subcutaneous solution cartridge 4 mg/0.5ml

NC N5

imitrex statdose refill subcutaneous solution cartridge 6 mg/0.5ml

NP QL

imitrex statdose system subcutaneous solution auto-injector 4 mg/0.5ml

NP N5; QL

imitrex statdose system subcutaneous solution auto-injector 6 mg/0.5ml

NP QL

imitrex subcutaneous NC N5

maxalt oral tablet 10 mg NC N5

maxalt-mlt NC N5

migergot NP

migranal NC N5

naratriptan hcl G QL

onzetra xsail NP ST; QL

relpax NP ST; QL

rizatriptan benzoate G QL

sumatriptan nasal G QL

sumatriptan succinate oral G QL

sumatriptan succinate refill subcutaneous solution cartridge

G QL

sumatriptan succinate subcutaneous solution 6 mg/0.5ml

G QL

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

G QL

sumatriptan-naproxen sodium NC

treximet oral tablet 10-60 mg NC N5; #

treximet oral tablet 85-500 mg NC N5

zembrace symtouch NP ST; QL

zolmitriptan oral G QL

zomig nasal NP ST; QL

zomig oral NC N5

zomig zmt NC N5



12/01/2018128


*MINERALS & ELECTROLYTES*

effer-k oral tablet effervescent 20 meq PB

effer-k oral tablet effervescent 25 meq G

fluorabon CE

fluoritab oral tablet chewable 0.55 (0.25 f) mg G

fluoritab oral tablet chewable 1.1 (0.5 f) mg CE

flura-drops oral solution 0.55 (0.25 f) mg/drop CE

galzin NP

iodine strong oral G

isolyte-s NP

isolyte-s ph 7.4 NP

k-effervescent G

klor-con 10 G

klor-con m10 G

klor-con m20 G

klor-con oral packet 20 meq G QL

k-phos PB

k-phos-neutral NP

k-tab oral tablet extended release 10 meq NC N5

k-vescent oral tablet effervescent G

ludent oral tablet chewable 0.55 (0.25 f) mg G

ludent oral tablet chewable 1.1 (0.5 f) mg, 2.2 (1 f) mg

CE

magnebind 400 NP

magnesium sulfate injection solution 50 % G

micro-k NC N5

monoject sodium chloride flush intravenous G

normosol-r NP

normosol-r ph 7.4 NP

phospha 250 neutral G

plasma-lyte 148 NP

plasma-lyte a NP

pot bicarb-pot chloride G

potassium bicarbonate oral G

potassium chloride crys er G



12/01/2018129


potassium chloride er G

potassium chloride in nacl intravenous solution20-0.45 meq/l-%, 20-0.9 meq/l-%, 40-0.9 meq/l-%

G

potassium chloride intravenous solution 0.4 meq/ml, 10 meq/100ml, 10 meq/50ml, 2 meq/ml, 20 meq/100ml, 20 meq/50ml, 40 meq/100ml

G

potassium chloride oral packet G QL

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

G

sodium chloride injection solution 2.5 meq/ml G

sodium chloride intravenous solution 0.45 %, 0.9 %, 3 %, 5 %

G

sodium fluoride oral solution CE

sodium fluoride oral tablet chewable 0.55 (0.25 f) mg

G

sodium fluoride oral tablet chewable 1.1 (0.5 f) mg, 2.2 (1 f) mg

CE

swabflush saline flush NP

*MONOBACTAMS***

azactam NC N5

aztreonam SP

cayston SP SP; QL

*MOUTH/THROAT/DENTAL AGENTS*

cevimeline hcl G QL

chlorhexidine gluconate mouth/throat G

clotrimazole mouth/throat lozenge G

debacterol NP

denta 5000 plus CE

evoxac NC N5

first-mouthwash blm NP

nystatin mouth/throat G

oralone G

oramagicrx NP

oravig NP QL

paroex G



12/01/2018130


periomed NP

pilocarpine hcl oral G

salagen NC N5

triamcinolone acetonide mouth/throat G

*MUCOPOLYSACCHARIDOSIS IV (MPS IV) - AGENTS***

vimizim SP PA; SP

*MULTIVITAMINS*

citranatal 90 dha oral 90-1 & 300 mg NP

citranatal assure oral 35-1 & 300 mg NP

citranatal b-calm NP

citranatal dha NP

citranatal harmony oral capsule 27-1-260 mg NP

citranatal medley NP

citranatal rx NP

co-natal fa G

concept dha NP

concept ob NP

corvita G

corvite NP

dialyvite 5000 NP

dialyvite supreme d NP

hemenatal ob NP

marnatal-f NP

multivitamin/fluoride oral tablet chewable 0.5 mg, 1 mg

NP

multi-vitamin/fluoride/iron G

multivitamins/fluoride oral tablet chewable 0.5 mg

G

mynatal advance G

mynatal oral tablet G

mynatal plus G

mynatal-z G

nephplex rx NP

nestabs NP



12/01/2018131


nexa plus NP

ob complete gold NP

ob complete premier NP

ob complete/dha NP

o-cal fa NP

o-cal prenatal NP

ocuvel oral capsule 0.5 mg NP

pnv-dha G

pnv-omega NP

pnv-select G

poly-vi-flor PB

poly-vi-flor fs oral strip 1 mg NP

poly-vi-flor/iron oral suspension PB

prenata NP

prenatabs rx G

prenatal 19 oral tablet G

prenatal 19 oral tablet chewable G

prenatal plus iron NP

prenate dha oral capsule 18-0.6-0.4-300 mg NP

quflora fe pediatric NP

se-natal 19 oral tablet chewable G

synagex NC

synatek NC

taron-c dha NP

tricare NP

tricare prenatal dha one oral capsule 27-1-500 mg

NP

triveen-duo dha NP

udamin sp NP

virt-pn NP

virt-pn dha NP

vitafol fe+ NP

vitafol gummies NP

vitafol-ob+dha PB

vitafol-one NP



12/01/2018132


vital-d rx NP

vol-plus PB

vol-tab rx NP

zatean-pn dha NP

zatean-pn plus NP

*MUSCULOSKELETAL THERAPY AGENTS*

amrix NC N5; #

baclofen oral G

carisoprodol oral tablet 250 mg NC

carisoprodol oral tablet 350 mg G

carisoprodol-aspirin G

carisoprodol-aspirin-codeine G

chlorzoxazone oral tablet 250 mg NC N5

chlorzoxazone oral tablet 500 mg G

cyclobenzaprine hcl oral G

dantrolene sodium oral G

durolane intra-articular SP PA; ST; SP

euflexxa intra-articular solution prefilled syringe

SP PA; SP

fexmid NC N5

gablofen intrathecal solution 10000 mcg/20ml, 20000 mcg/20ml, 40000 mcg/20ml

SP

gel-one intra-articular prefilled syringe SP PA; ST; SP

gelsyn-3 SP PA; ST

genvisc 850 SP PA; ST

hyalgan SP PA; ST; SP

hymovis SP PA; ST; SP

lorzone NC N5

metaxalone G

methocarbamol oral G

monovisc SP PA; SP

orphenadrine citrate er G

orthovisc intra-articular solution prefilled syringe

SP PA; SP

robaxin injection solution 1000 mg/10ml NP



12/01/2018133


skelaxin NC N5

soma NC N5

supartz fx SP PA; ST

synvisc intra-articular solution prefilled syringe SP PA; ST; SP

synvisc one intra-articular solution prefilled syringe

SP PA; ST; SP

tizanidine comfort pac NC N5

tizanidine hcl oral capsule NC N5

tizanidine hcl oral tablet G

trivisc SP PA; ST; SP

zanaflex NC N5

*NASAL AGENTS - SYSTEMIC AND TOPICAL*

adrenalin nasal PB

astepro nasal solution 0.15 % NC N5

azelastine hcl nasal solution 0.1 %, 0.15 % G

bactroban nasal PB SP

beconase aq NP ST

budesonide nasal G Select OTC

dymista NC N5

flonase NC

flonase allergy relief G Select OTC

flunisolide nasal solution 25 mcg/act (0.025%) G

fluticasone propionate nasal G Select OTC

ipratropium bromide nasal G QL

mometasone furoate nasal G

nasacort allergy 24hr G Select OTC; QL

nasacort allergy 24hr children G Select OTC; QL

nasal allergy 24 hour G Select OTC; QL

nasonex NP ST

olopatadine hcl nasal G

omnaris NP ST; #

patanase NC N5

qnasl NP ST

qnasl childrens NP ST



12/01/2018134


rhinocort allergy G Select OTC

triamcinolone acetonide nasal aerosol G Select OTC; QL

xhance NC N5

zetonna NP ST

*NEPRILYSIN INHIB (ARNI)-ANGIOTENSIN II RECEPT ANTAG COMB***

entresto PB PA; QL

*NEUROGENIC ORTHOSTATIC HYPOTENSION (NOH) - AGENTS***

northera SP PA; ST; SP; QL

*NEUROMUSCULAR AGENTS*

botox SP PA; ST; SP

dysport SP PA; SP

myobloc intramuscular solution 2500 unit/0.5ml, 5000 unit/ml

SP PA

rilutek NC N5

riluzole G PA

tiglutik NP PA; QL

xeomin SP PA; SP

*OPHTHALMIC AGENTS*

acular NC N5

acular ls NC N5

acuvail NP

akten NC

alaway G Select OTC

alaway childrens allergy G Select OTC

alcaine NC N5

allergy eye drops G Select OTC

alocril NP

alomide NP

alphagan p ophthalmic solution 0.1 % NP

alphagan p ophthalmic solution 0.15 % NC N5

alrex PB

altacaine G

altafluor NP



12/01/2018135


altafrin ophthalmic solution 10 % G

apraclonidine hcl G

atropine sulfate ophthalmic G

azasite NP #

azelastine hcl ophthalmic G

azopt PB

bacitracin ophthalmic G

bacitracin-polymyxin b ophthalmic ointment500-10000 unit/gm

G

bacitra-neomycin-polymyxin-hc G

bepreve NP #

besivance NP

betadine ophthalmic prep NP

betagan NC N5

betaxolol hcl ophthalmic G

betimol NP

betoptic-s NP

bimatoprost ophthalmic G PA; ST

bio glo NP

bleph-10 NC N5

blephamide NP

blephamide s.o.p. NP

brimonidine tartrate ophthalmic G

bromfenac sodium (once-daily) G

bromsite NP

carteolol hcl G

ciloxan ophthalmic ointment NP

ciloxan ophthalmic solution NC N5

ciprofloxacin hcl ophthalmic G

claritin eye G Select OTC

combigan PB

cosopt pf NC #

cromolyn sodium ophthalmic G

cyclogyl ophthalmic solution 0.5 %, 2 % NC N5

cyclogyl ophthalmic solution 1 % NC



12/01/2018136


cyclomydril NP

cyclopentolate hcl ophthalmic solution 0.5 %, 2 %

G

cystaran SP PA; #; SP; QL

dexamethasone sodium phosphate ophthalmic G

diclofenac sodium ophthalmic G

dorzolamide hcl ophthalmic G

dorzolamide hcl-timolol mal G

dorzolamide hcl-timolol mal pf G

durezol PB #

elestat NC N5

emadine NP

epinastine hcl G

eye itch relief G Select OTC

eylea intravitreal SP PA; SP

flarex NP

flucaine NP

fluorescein-benoxinate G

fluor-i-strips a.t. NP

fluorometholone ophthalmic G

flura-safe NP

flurbiprofen sodium G

fml PB

fml forte NP

fml liquifilm NC N5

ful-glo ophthalmic strip 0.6 mg NP

ful-glo ophthalmic strip 1 mg NP

gatifloxacin ophthalmic G

gentak ophthalmic ointment NP

gentamicin sulfate ophthalmic solution G

homatropaire NP

homatropine hbr ophthalmic G

ilevro NP

inveltys NP

iopidine ophthalmic solution 0.5 % NC N5



12/01/2018137


iopidine ophthalmic solution 1 % NP

isopto homatropine ophthalmic solution 5 % NC N5

istalol NP

jetrea intravitreal solution 0.375 mg/0.3ml SP PA; SP

ketorolac tromethamine ophthalmic G

ketotifen fumarate ophthalmic G Select OTC

lacrisert NP

lastacaft NP

latanoprost ophthalmic G

levobunolol hcl ophthalmic solution 0.5 % G

levofloxacin ophthalmic G

lotemax ophthalmic gel PB #

lotemax ophthalmic ointment PB

lotemax ophthalmic suspension PB

lucentis intravitreal solution prefilled syringe SP PA; SP

lumigan ophthalmic solution 0.01 % NP PA; ST

macugen SP PA; SP

maxidex NP

moxeza NP #

moxifloxacin hcl ophthalmic G

mydriacyl NC N5

natacyn NP

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

G

neomycin-polymyxin-dexameth ophthalmic ointment

G

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

G

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

G

neomycin-polymyxin-hc ophthalmic suspension3.5-10000-1

G

nevanac NP

ocuflox NC N5

ofloxacin ophthalmic G

olopatadine hcl ophthalmic G



12/01/2018138


omnipred NC N5

pataday NP

patanol NC N5

pazeo NP

phenylephrine hcl ophthalmic solution 2.5 % G

phospholine iodide PB

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

G

polymyxin b-trimethoprim G

polytrim NC N5

pred forte NC N5

pred mild NP

pred-g NP

pred-g s.o.p. NP

prednisolone acetate ophthalmic G

prednisolone sodium phosphate ophthalmic G

prolensa NP

proparacaine hcl ophthalmic G

proparacaine-fluorescein G

restasis PB #

restasis multidose PB #

simbrinza NP

sulfacetamide sodium ophthalmic G

sulfacetamide-prednisolone ophthalmic solution G

tetcaine G

tetracaine hcl ophthalmic G

tetravisc G

timolol maleate ophthalmic gel forming solution G

timolol maleate ophthalmic solution 0.25 %, 0.5 %

G

timolol maleate ophthalmic solution 0.5 % (daily)

NP

timoptic NC N5

timoptic ocudose NP

timoptic-xe ophthalmic gel forming solution 0.5 %

NC N5



12/01/2018139


tobradex ophthalmic ointment NP

tobradex ophthalmic suspension NC N5

tobradex st NP

tobramycin-dexamethasone G

tobrex ophthalmic ointment NP

travatan z PB #

trifluridine ophthalmic G

tropicamide ophthalmic G

trusopt NC N5

vigamox NP

visionblue NP

visudyne SP PA; #; SP

vyzulta NC N5

xalatan NC N5

zaditor NC N5; Select OTC

zioptan NP PA; ST

zirgan NP #

zylet NP

zymaxid NC N5

*OPHTHALMIC RHO KINASE INHIBITORS***

rhopressa NP ST

*OREXIN RECEPTOR ANTAGONISTS***

belsomra NP ST; QL; AL

*OTIC AGENTS*

acetasol hc G

acetic acid otic G

cetraxal NP

cipro hc NP #

ciprodex PB #

ciprofloxacin hcl otic G

coly-mycin s NP

dermotic NC N5

floxin otic NC

fluocinolone acetonide otic G



12/01/2018140


hydrocortisone-acetic acid G

neomycin-polymyxin-hc otic G

ofloxacin otic G

otovel NP

*OXABOROLE-RELATED ANTIFUNGALS - TOPICAL***

kerydin NP PA; ST

*OXYTOCICS*

methergine oral G QL

*PASSIVE IMMUNIZING AGENTS - COMBINATIONS***

hyqvia SP PA; ST; SP

*PASSIVE IMMUNIZING AGENTS*

bivigam NC N5; SP

carimune nf intravenous solution reconstituted 12 gm, 6 gm

NC N5; SP

cuvitru NC N5

cytogam NC N5; SP

flebogamma dif SP PA; SP

gamastan s/d intramuscular injectable SP SP

gammagard NC N5; SP

gammagard s/d less iga NC N5; SP

gammaked NC N5; SP

gammaplex intravenous solution 10 gm/200ml, 20 gm/400ml, 5 gm/100ml

SP PA; SP

gamunex-c SP PA; SP

hizentra subcutaneous solution 1 gm/5ml, 10 gm/50ml, 2 gm/10ml, 4 gm/20ml

SP PA; SP

hyperhep b s/d NC N5; SP

hyperrab NC

hyperrho s/d intramuscular solution prefilled syringe

NC N5; SP

hypertet s/d NC N5; SP

micrhogam ultra-filtered plus intramuscular solution prefilled syringe

NC N5; SP

nabi-hb NC N5; SP



12/01/2018141


octagam SP PA; SP

panzyga SP PA; ST; SP

privigen NC N5; SP

rhogam ultra-filtered plus intramuscular solution prefilled syringe

NC N5; SP

rhophylac injection solution prefilled syringe NC N5; SP

synagis SP PA; SP

winrho sdf NC N5; SP

*PCSK9 INHIBITORS***

praluent subcutaneous solution pen-injector SP PA; ST; QL

repatha SP PA; ST; QL

repatha pushtronex system SP PA; ST; QL

repatha sureclick SP PA; ST; QL

*PENICILLINS*

amoxicillin oral capsule G

amoxicillin oral suspension reconstituted G

amoxicillin oral tablet G

amoxicillin oral tablet chewable 125 mg, 250 mg G

amoxicillin-pot clavulanate er G

amoxicillin-pot clavulanate oral suspension reconstituted

G

amoxicillin-pot clavulanate oral tablet G

amoxicillin-pot clavulanate oral tablet chewable200-28.5 mg

G

ampicillin oral capsule 500 mg G

ampicillin sodium injection SP

ampicillin sodium intravenous SP

ampicillin-sulbactam sodium injection SP

ampicillin-sulbactam sodium intravenous solution reconstituted 1.5 (1-0.5) gm, 15 (10-5) gm

SP

augmentin oral suspension reconstituted 125-31.25 mg/5ml

PB

augmentin oral suspension reconstituted 250-62.5 mg/5ml

NC N5

augmentin oral tablet 500-125 mg, 875-125 mg NC N5



12/01/2018142


augmentin xr NC N5

bactocill in dextrose NP

dicloxacillin sodium G

moxatag NP

penicillin g pot in dextrose G

penicillin v potassium G

piperacillin sod-tazobactam so intravenous solution reconstituted 2.25 (2-0.25) gm, 3.375 (3-0.375) gm, 4.5 (4-0.5) gm, 40.5 (36-4.5) gm

SP

unasyn injection solution reconstituted 15 (10-5) gm, 3 (2-1) gm

NP

zosyn intravenous solution reconstituted NC N5

*PHARMACEUTICAL ADJUVANTS*

saline bacteriostatic G

saline-benzyl alcohol G

sodium chloride bacteriostatic G

*PHOSPHATIDYLINOSITOL 3-KINASE (PI3K) INHIBITORS***

copiktra SP PA; SP; QL

zydelig SP PA; SP; QL

*PHOSPHODIESTERASE 4 (PDE4) INHIBITORS - TOPICAL***

eucrisa NC N5

*PHOSPHODIESTERASE 4 (PDE4) INHIBITORS***

otezla oral tablet SP PA; ST; SP; QL

otezla oral tablet therapy pack SP PA; ST; SP; QL

*PLASMA KALLIKREIN INHIBITORS - MONOCLONAL ANTIBODIES***

takhzyro SP PA; SP; QL

*POLY (ADP-RIBOSE) POLYMERASE (PARP) INHIBITORS**

lynparza oral tablet SP PA; SP; QL

rubraca oral tablet 200 mg, 300 mg SP PA; QL

rubraca oral tablet 250 mg SP PA; SP; QL

talzenna SP PA; SP; QL



12/01/2018143


zejula SP PA; SP; QL

*POLY (ADP-RIBOSE) POLYMERASE (PARP) INHIBITORS***

lynparza oral tablet SP PA; SP; QL

rubraca oral tablet 200 mg, 300 mg SP PA; QL

rubraca oral tablet 250 mg SP PA; SP; QL

talzenna SP PA; SP; QL

zejula SP PA; SP; QL

*POSTHERPETIC NEURALGIA (PHN)/NEUROPATHIC PAIN AGENTS***

gralise NP ST; QL

gralise starter NP ST; QL

lyrica cr PB QL

*POTASSIUM REMOVING AGENTS***

lokelma NP PA

sodium polystyrene sulfonate oral powder G

veltassa NP PA; QL

*PROGESTINS*

aygestin NC N5

hydroxyprogesterone caproate intramuscular oil SP PA; SP

makena intramuscular NC #

makena subcutaneous SP PA; SP; QL

medroxyprogesterone acetate oral tablet 10 mg, 5 mg

G

megace es NC N5

megestrol acetate oral suspension 625 mg/5ml G

norethindrone acetate oral G

progesterone micronized oral G QL

prometrium NC N5

provera NC N5

*PROTEASE-ACTIVATED RECEPTOR-1 (PAR-1) ANTAGONISTS***

zontivity NP PA; QL

*PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.*

acamprosate calcium G QL



12/01/2018144


ampyra NC #

antabuse NC N5

aricept oral tablet 10 mg, 5 mg NC N5

aricept oral tablet 23 mg NC N5; AL

aubagio SP PA; SP; QL

austedo SP PA; ST; SP; QL

avonex SP PA; SP; QL

avonex pen intramuscular auto-injector kit SP PA; SP; QL

avonex prefilled intramuscular prefilled syringe kit

SP PA; SP; QL

betaseron subcutaneous kit SP PA; SP; QL

brisdelle NP PA; ST; QL

bupropion hcl er (smoking det) CE QL

chantix CE QL

chantix continuing month pak CE QL

chantix starting month pak CE

chlordiazepoxide-amitriptyline G

copaxone subcutaneous solution prefilled syringe 20 mg/ml

NC N5; SP

copaxone subcutaneous solution prefilled syringe 40 mg/ml

SP PA; SP

cvs nicotine polacrilex mouth/throat lozenge 4 mg

G QL

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

CE QL

dalfampridine er SP PA; SP; QL

disulfiram oral G

donepezil hcl oral tablet 10 mg, 23 mg G PA

donepezil hcl oral tablet 5 mg G PA; AL

donepezil hcl oral tablet dispersible G PA

eq nicotine transdermal CE QL

ergoloid mesylates oral G

exelon transdermal NC N5

extavia subcutaneous kit SP PA; ST; SP; QL

fluoxetine hcl (pmdd) G

galantamine hydrobromide G PA; AL



12/01/2018145


galantamine hydrobromide er G PA; AL

gilenya oral capsule 0.25 mg SP PA; SP; QL

gilenya oral capsule 0.5 mg SP PA; #; SP; QL

glatiramer acetate SP PA; SP

glatopa SP PA; SP

gralise NP ST; QL

gralise starter NP ST; QL

hm nicotine CE QL

hm nicotine polacrilex mouth/throat lozenge 2 mg

G QL

horizant oral tablet extended release NP PA; ST; QL

ingrezza oral capsule 40 mg SP PA; SP; QL

ingrezza oral capsule 80 mg SP PA; PPA; QL

lemtrada SP PA; SP; QL

lyrica cr PB QL

memantine hcl er G PA; AL

memantine hcl oral tablet G AL

namenda oral tablet NC N5

namenda titration pak NC N5

namenda xr PB PA; AL

namenda xr titration pack PB PA; #

nicoderm cq CE QL

nicorelief mouth/throat gum NP QL

nicorette mouth/throat gum CE QL

nicorette mouth/throat lozenge CE

nicotine polacrilex mouth/throat gum 4 mg G

nicotine step 1 CE QL



nicotine transdermal patch 24 hour CE QL

nicotrol CE QL

nicotrol ns CE QL

nuedexta PB QL

olanzapine-fluoxetine hcl oral capsule 12-25 mg, 12-50 mg, 6-25 mg, 6-50 mg

G QL



12/01/2018146


olanzapine-fluoxetine hcl oral capsule 3-25 mg G

orap NC N5

paroxetine mesylate G PA; QL

perphenazine-amitriptyline G

pimozide G

plegridy SP PA; SP; QL

plegridy starter pack SP PA; SP; QL

ra nicotine transdermal CE QL

razadyne er NC N5; AL

razadyne oral tablet NC N5

rebif rebidose subcutaneous solution auto-injector

SP PA; SP; QL

rebif rebidose titration pack subcutaneous solution auto-injector

SP PA; SP; QL

rebif subcutaneous solution prefilled syringe SP PA; SP; QL

rebif titration pack subcutaneous solution prefilled syringe

SP PA; SP; QL

rivastigmine G PA

rivastigmine tartrate G PA

sarafem oral tablet 10 mg, 20 mg NP

savella NP PA; ST; QL

savella titration pack NP PA; ST; QL

sm nicotine transdermal CE QL

symbyax NC N5

tecfidera SP PA; SP; QL

tetrabenazine SP PA; QL

tgt nicotine step one CE QL

tgt nicotine step three CE QL

tgt nicotine step two CE QL

thrive mouth/throat gum 2 mg NP QL

tysabri SP PA; ST; SP

xenazine NC N5; SP

xyrem SP PA; SP

zyban CE QL



12/01/2018147


*PULMONARY FIBROSIS AGENTS - KINASE INHIBITORS***

ofev SP PA; SP; QL

*PULMONARY FIBROSIS AGENTS***

esbriet SP PA; SP; QL

*PULMONARY HYPERTENSION - PROSTACYCLIN RECEPTOR AGONIST***

uptravi oral tablet 1000 mcg, 1200 mcg, 1400 mcg, 1600 mcg, 400 mcg, 600 mcg, 800 mcg

SP PA; SP; QL

uptravi oral tablet 200 mcg SP PA; SP

uptravi oral tablet therapy pack SP PA; SP

*RESPIRATORY AGENTS - MISC.*

aralast np intravenous solution reconstituted 1000 mg, 500 mg

SP PA; SP

glassia SP PA; SP

kalydeco SP PA; SP; QL

prolastin-c intravenous solution SP PA; SP

prolastin-c intravenous solution reconstituted 1000 mg

SP PA; SP

pulmozyme SP PA; SP; QL

zemaira SP PA; SP

*SEROTONIN MODULATORS***

nefazodone hcl G

trazodone hcl oral G

trintellix NP PA; ST; QL

viibryd oral tablet NP PA; ST; QL

viibryd starter pack NP PA

*SGLT2 INHIBITOR - DPP-4 INHIBITOR COMBINATIONS***

glyxambi PB QL

qtern NC N5

steglujan NC

*SINUS NODE INHIBITORS**

corlanor NP PA; ST; QL



12/01/2018148


*SODIUM-GLUCOSE CO-TRANSPORTER 2 INHIBITOR-BIGUANIDE COMB***

invokamet PB QL

invokamet xr PB QL

segluromet NC

synjardy PB QL

synjardy xr PB QL

xigduo xr oral tablet extended release 24 hour 10-1000 mg, 10-500 mg, 5-500 mg

NP

xigduo xr oral tablet extended release 24 hour 2.5-1000 mg, 5-1000 mg

NP QL

*SPLEEN TYROSINE KINASE (SYK) INHIBITORS***

tavalisse SP PA; SP; QL

*SULFONAMIDES*

sulfadiazine oral G

*TETRACYCLINES*

acticlate NC N5

avidoxy NC N5

avidoxy dk NC N5

coremino NC

demeclocycline hcl oral G

doryx mpc NC N5

doryx oral tablet delayed release 200 mg, 50 mg NC N5

doxy 100 NP

doxycycline hyclate oral capsule G

doxycycline hyclate oral tablet 100 mg, 20 mg, 50 mg

G

doxycycline hyclate oral tablet 150 mg, 75 mg NC N5

doxycycline hyclate oral tablet delayed release NC N5

doxycycline monohydrate oral capsule 150 mg, 75 mg

NC N5

doxycycline monohydrate oral capsule 50 mg G

doxycycline monohydrate oral tablet NC N5

minocin oral capsule 100 mg, 50 mg NC N5



12/01/2018149


minocycline hcl er oral tablet extended release 24 hour 115 mg, 65 mg

NC

minocycline hcl er oral tablet extended release 24 hour 135 mg, 45 mg, 90 mg

NC N5

minocycline hcl oral capsule G

minocycline hcl oral tablet NC N5

minolira NC

morgidox combination NC N5

morgidox oral capsule 100 mg G

solodyn oral tablet extended release 24 hour 105 mg, 55 mg, 80 mg

NC N5; #

solodyn oral tablet extended release 24 hour 115 mg, 65 mg

NC N5

targadox NC

tetracycline hcl oral G

vibramycin oral capsule NC N5

vibramycin oral suspension reconstituted NP

vibramycin oral syrup NP

ximino NC N5

*THYROID AGENTS*

armour thyroid oral tablet 120 mg G

armour thyroid oral tablet 15 mg, 180 mg, 240 mg, 30 mg, 300 mg, 90 mg

NP

armour thyroid oral tablet 60 mg NC N5

cytomel NC N5

levothyroxine sodium oral G

levoxyl G

liothyronine sodium intravenous G

liothyronine sodium oral G

methimazole oral G

nature-throid NP

np thyroid oral tablet 60 mg G

propylthiouracil oral G

synthroid NC N5

tapazole oral tablet 5 mg NC N5

tirosint NP



12/01/2018150


unithroid direct G

unithroid oral tablet 100 mcg, 112 mcg, 125 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg

G

westhroid oral tablet 130 mg, 195 mg, 32.5 mg, 65 mg, 97.5 mg

NP

wp thyroid NP

*TOPICAL ANESTHETIC GASES***

gebauers pain ease NP

gebauers spray and stretch NP

*TOXOIDS*

adacel intramuscular suspension 5-2-15.5 lf-mcg/0.5

PB

*TRYPTOPHAN HYDROXYLASE INHIBITORS***

xermelo SP PA; QL

*ULCER DRUGS*

acid control maximum strength oral tablet 20 mg

NC

acid controller max st NC

acid reducer maximum strength oral tablet 20 mg

NC

acid reducer oral tablet 150 mg NC

aciphex NC N5

aciphex sprinkle NP PA; ST; #; QL

amoxicill-clarithro-lansopraz G

anaspaz NC N5

belladonna alkaloids-opium G

belladonna-opium G

bentyl intramuscular NP

carafate oral suspension NP

carafate oral tablet NC N5

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

cuvposa NP #

cvs acid controller max st NC

dexilant NP PA; ST; QL



12/01/2018151


dicyclomine hcl oral G

donnatal oral tablet NP

eq acid reducer max st NC

eql heartburn prevention oral tablet 20 mg NC

esomeprazole magnesium oral capsule delayed release 20 mg

G Select OTC; QL

esomeprazole magnesium oral capsule delayed release 40 mg

G QL

esomeprazole strontium oral capsule delayed release 49.3 mg

NC N5

famotidine oral suspension reconstituted G

famotidine oral tablet 20 mg NC

famotidine oral tablet 40 mg G

famotidine premixed G

glycopyrrolate injection solution 4 mg/20ml G

glycopyrrolate oral tablet 1 mg, 2 mg G

gnp acid reducer max st NC

heartburn relief max st oral tablet 20 mg NC

hm famotidine oral tablet 20 mg NC

kls acid controller max st NC

lansoprazole oral capsule delayed release 15 mg G Select OTC; QL

lansoprazole oral capsule delayed release 30 mg NC

lansoprazole oral tablet dispersible G PA; QL

levbid NC N5

levsin oral tablet NC N5

levsin/sl NC N5

librax NC N5

methscopolamine bromide oral G

misoprostol oral G

nexium 24hr G Select OTC; QL

nexium i.v. intravenous solution reconstituted 40 mg

NP

nexium oral capsule delayed release 40 mg NC N5

nexium oral packet NP ST; #; QL

nizatidine G

omeclamox-pak NP



12/01/2018152


omeprazole magnesium G Select OTC

omeprazole oral capsule delayed release 10 mg, 40 mg

G

omeprazole oral capsule delayed release 20 mg NC

omeprazole oral tablet delayed release G Select OTC

omeprazole-sodium bicarbonate oral capsule 20-1100 mg

G Select OTC; QL

omeprazole-sodium bicarbonate oral capsule 40-1100 mg

NC N5

omeprazole-sodium bicarbonate oral packet NC N5

pantoprazole sodium oral G

pepcid ac maximum strength oral tablet NC

pepcid oral suspension reconstituted NC N5

pepcid oral tablet 20 mg NC

prevacid NC

prevacid 24hr NC

prevacid solutab NP PA; ST; QL; AL

prevpac NC N5

prilosec oral packet NC N5; #

prilosec otc G Select OTC

propantheline bromide oral G

protonix intravenous NP

protonix oral packet NP ST

protonix oral tablet delayed release NC N5

px acid reducer max st oral tablet 20 mg NC

pylera NP #

qc acid controller max st NC

ra acid reducer max st oral tablet 20 mg NC

rabeprazole sodium G QL

ranitidine hcl injection solution 50 mg/2ml G

ranitidine hcl oral capsule G

ranitidine hcl oral syrup 75 mg/5ml G

ranitidine hcl oral tablet 300 mg G

sb acid controller max st NC

sm acid reducer max st oral tablet 20 mg NC



12/01/2018153


sucralfate oral tablet G

symax duotab NC

zantac injection solution 1000 mg/40ml NP

zantac oral tablet 300 mg NC N5

zegerid oral capsule 20-1100 mg NC

zegerid oral capsule 40-1100 mg NC N5

zegerid oral packet NC N5

zegerid otc G Select OTC; QL

*URINARY ANTI-INFECTIVES*

furadantin NC N5

hiprex NC N5

macrobid NC N5

macrodantin NC N5

methenamine hippurate G

methenamine mandelate oral tablet 0.5 gm G

nitrofurantoin macrocrystal oral capsule 50 mg G

nitrofurantoin monohyd macro G

nitrofurantoin oral suspension G

*URINARY ANTISPASMODICS*

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

G

darifenacin hydrobromide er G QL

detrol NC N5

detrol la NC N5

ditropan xl oral tablet extended release 24 hour 10 mg, 5 mg

NC N5

enablex NP ST; QL

flavoxate hcl G

gelnique transdermal gel 10 % NP ST

myrbetriq PB ST; QL

oxybutynin chloride er G QL

oxybutynin chloride oral syrup G

oxybutynin chloride oral tablet G QL

oxytrol NC #

oxytrol for women G #; Select OTC; QL



12/01/2018154


tolterodine tartrate G

tolterodine tartrate er G QL

toviaz NP ST; QL

trospium chloride G QL

trospium chloride er G QL

urecholine NC N5

vesicare NP ST; #; QL

*VAGINAL PRODUCTS*

avc vaginal NP

cleocin vaginal cream NC N5

cleocin vaginal suppository NP

clindamycin phosphate vaginal G

crinone NP

endometrin NP #

estrace vaginal NP

estradiol vaginal G

estring NP

fem ph NP

femring NP #; QL

gynazole-1 NP

imvexxy maintenance pack NP ST

imvexxy starter pack NP ST

intrarosa NP QL

metrogel-vaginal NC N5

metronidazole vaginal G

miconazole 3 vaginal suppository G

premarin vaginal PB

relagard NP

terconazole G

vagifem vaginal tablet 10 mcg NP

vandazole G

yuvafem G

*VASOPRESSORS*

adrenalin injection NC

adyphren NP QL



12/01/2018155


adyphren amp ii NP QL

adyphren ii NP QL

auvi-q injection solution auto-injector 0.1 mg/0.1ml

NC

auvi-q injection solution auto-injector 0.15 mg/0.15ml, 0.3 mg/0.3ml

NC N5

epinephrine injection solution auto-injector G QL

epipen 2-pak injection solution auto-injector PB #; QL

epipen jr 2-pak injection solution auto-injector PB #; QL

episnap NP QL

midodrine hcl G SP

*VITAMINS*

aqueous vitamin d CE

calcidol NC

calciferol NC

cvs d3 oral capsule 2000 unit, 5000 unit NC

d 10000 NC

d 5000 oral capsule NC

d-2000 maximum strength NC

d2000 ultra strength NC

d3 dots NC

d3 maximum strength NC

d3 super strength NC

d3-1000 oral capsule CE

d-3-5 NC

d-5000 NC

ddrops oral liquid 2000 unt/0.03ml, 2000 ut/0.028ml

NC

decara oral capsule 25000 unit, 50000 unit NC

delta d3 CE

dialyvite vitamin d 5000 NC

dialyvite vitamin d3 max NC

drisdol oral capsule NC N5

d-vi-sol CE

eql vitamin d3 oral capsule 2000 unit, 5000 unit NC



12/01/2018156


ergocal NP

ergocalciferol oral capsule G

gnp vitamin d maximum strength NC

gnp vitamin d oral tablet 1000 unit CE

gnp vitamin d super strength NC

hm vitamin d3 NC

maximum d3 NC

mephyton PB QL

nat-rul vitamin d oral tablet 2000 unit, 5000 unit NC

natural vitamin d-3 NC

optimal d3 m NC

optimal-d NC

opurity vitamin d NC

pa vitamin d-3 oral capsule 5000 unit NC

phytonadione oral G QL

potaba oral capsule NP

ra vitamin d-3 oral capsule 5000 unit NC

replesta NC

replesta childrens NC

replesta nx NC

sm vitamin d3 oral capsule 2000 unit, 4000 unit NC

super daily d3 oral liquid 2000 ut/0.028ml NC

thera-d 2000 NC

thera-d 4000 NC

thera-d rapid repletion NC

vitamin d (ergocalciferol) oral capsule 50000 unit

G

vitamin d oral capsule 2000 unit NC

vitamin d oral tablet 2000 unit NC

vitamin d2 oral tablet 2000 unit NC

vitamin d3 maximum strength NC

vitamin d3 oral capsule 10000 unit, 5000 unit, 50000 unit

NC

vitamin d3 oral liquid 5000 unit/ml NC



12/01/2018157


vitamin d3 oral tablet 10000 unit, 3000 unit, 5000 unit, 50000 unit

NC

vitamin d3 oral tablet 400 unit CE

vitamin d3 oral tablet chewable 2000 unit, 5000 unit

NC

vitamin d3 super strength oral tablet NC



12/01/2018158



12/01/2018159

Index

abacavir sulfate ........................ 62abacavir sulfate-lamivudine ...... 63abacavir-lamivudine-zidovudine 63abaneu-sl............................... 115abilify...................................... 60abreva......................................81absorica................................... 81abstral..................................... 23acamprosate calcium .............. 144acanya..................................... 81acarbose ...................................39accolate................................... 31accu-chek aviva plus................93accu-chek compact plus...........93accu-chek fastclix lancets.......123accu-chek multiclix lancet dev123accu-chek multiclix lancets.... 123accu-chek smartview................93accu-chek soft touch lancets.. 123accu-chek softclix lancets.......123accupril....................................49accuretic.................................. 49accutrend glucose.................... 93acebutolol hcl ........................... 68acetaminophen-codeine .............23acetaminophen-codeine #2 ........23acetaminophen-codeine #3 ........23acetaminophen-codeine #4 ........23acetasol hc ..............................140acetazolamide .........................102acetazolamide er .....................102acetic acid .......................111, 140acetylcysteine ...........................79acid control maximum strength...............................................151acid controller max st ............. 151acid reducer ............................151acid reducer maximum strength...............................................151aciphex.................................. 151aciphex sprinkle.....................151acitretin ................................... 81actemra....................................20acticlate................................. 149actigall................................... 110actimmune...............................55actiq........................................ 23active fe ..................................115activella................................. 108

actonel................................... 103actoplus met............................ 39actoplus met xr........................ 39actos........................................ 39acular.....................................135acular ls................................. 135acuvail................................... 135acyclovir .............................63, 81aczone..................................... 81adacel.................................... 151adagen..................................... 69adalat cc.................................. 69adapalene .................................81adapalene-benzoyl peroxide ......81adcetris.................................... 55adcirca.....................................71adderall................................... 17adderall xr............................... 17adefovir dipivoxil ......................63adempas.................................. 71adlyxin.....................................39adlyxin starter pack................. 39admelog...................................40admelog solostar..................... 40adrenalin........................ 134, 155adrucil ......................................55advair diskus........................... 31advair hfa................................ 31advance intuition test.............. 93advance micro-draw test..........93advate.................................... 113advocate duo......................... 123advocate redi-code...................93advocate redi-code+ test..........94advocate test............................94adynovate.............................. 113adyphren............................... 155adyphren amp ii.....................156adyphren ii.............................156adzenys er................................17adzenys xr-odt......................... 17afeditab cr ................................69afinitor.................................... 55afinitor disperz........................ 55afrezza..................................... 40afstyla.................................... 113agamatrix amp test.................. 94agamatrix jazz test...................94agamatrix keynote test.............94

agamatrix presto test............... 94aggrenox................................113aimovig....................................69aimovig 140 dose..................... 69airavite...................................115airduo respiclick 113/14........... 31airduo respiclick 232/14........... 31airduo respiclick 55/14.............31ajovy........................................69akten......................................135aktipak.................................... 81akynzeo................................... 44ala scalp...................................81ala-quin................................... 81alavert ......................................46alavert allergy/sinus ..................79alaway ....................................135alaway childrens allergy.........135albendazole .............................. 29albenza.................................... 29albuterol sulfate ....................... 31albuterol sulfate er ................... 31alcaine................................... 135alclometasone dipropionate .......81alcortin a................................. 81aldactazide.............................102aldactone............................... 102aldara...................................... 81aldurazyme............................ 103alecensa................................... 55alendronate sodium .................103alferon n.................................. 55alfuzosin hcl er ....................... 111alinia....................................... 52alkeran.................................... 55allegra allergy.......................... 46allegra allergy childrens........... 46allegra-d allergy & congestion. 79allergy eye drops .................... 135allergy relief .............................46allzital......................................22almotriptan malate ................. 127alocril.................................... 135alogliptin benzoate ................... 40alogliptin-metformin hcl ........... 40alogliptin-pioglitazone .............. 40alomide..................................135aloprim.................................. 112alora...................................... 108

160

alosetron hcl ...........................110aloxi........................................ 44alphagan p.............................135alphanate/vwf complex/human..................... 113alphanine sd...........................113alprazolam ............................... 30alprazolam er ........................... 30alprazolam intensol................. 30alprazolam xr ...........................30alprolix.................................. 113alrex.......................................135altabax.....................................81altacaine .................................135altace....................................... 49altafluor ................................. 135altafrin ................................... 136altavera ....................................73altoprev................................... 47altreno..................................... 81alunbrig................................... 55alvesco.....................................31alyacen 1/35 ............................. 73alyacen 7/7/7 ............................ 73amantadine hcl ......................... 59amaryl..................................... 40ambien...................................119ambien cr...............................119ambisome................................ 45amcinonide ...............................81ameluz..................................... 81amerge................................... 127amethia .................................... 73amethia lo ................................ 74amicar....................................118amikacin sulfate ....................... 19amiloride hcl ...........................102amiloride-hydrochlorothiazide 102aminophylline ...........................31amiodarone hcl .........................30amitiza...................................110amitriptyline hcl ....................... 37amlodipine besy-benazepril hcl ..49amlodipine besylate .................. 69amlodipine besylate-valsartan ...49amlodipine-atorvastatin ............ 71amlodipine-olmesartan ............. 49amlodipine-valsartan-hctz .........49ammonium lactate .................... 81ammonul............................... 103

amnesteem ............................... 81amoxapine ............................... 37amoxicill-clarithro-lansopraz ..151amoxicillin ............................. 142amoxicillin-pot clavulanate ..... 142amoxicillin-pot clavulanate er . 142amphetamine sulfate .................17amphetamine-dextroamphet er . 17amphetamine-dextroamphetamine ..................17ampicillin ............................... 142ampicillin sodium ....................142ampicillin-sulbactam sodium ... 142ampyra.................................. 145amrix..................................... 133anadrol-50............................... 27anafranil.................................. 37anagrelide hcl ......................... 113ana-lex.....................................28analpram-hc............................ 28anaprox ds...............................20anaspaz..................................151anastrozole ...............................55ancobon...................................45androderm...............................28androgel.................................. 28androgel pump........................ 28angeliq................................... 108animi-3.................................. 115animi-3/vitamin d.................. 115anoro ellipta............................ 31antabuse................................ 145antara...................................... 47anusol-hc................................. 28anzemet................................... 44apap-caff-dihydrocodeine ......... 23apexicon e................................81apidra...................................... 40apidra solostar.........................40aplenzin................................... 37apptrim....................................98apptrim-d................................ 98apraclonidine hcl .................... 136aprepitant ................................ 44apri .......................................... 74apriso.....................................110aptensio xr...............................17aptiom..................................... 34aptivus.....................................63aqueous vitamin d ................... 156

aralast np...............................148aranelle .................................... 74aranesp (albumin free)........... 115arava....................................... 20arcalyst.................................... 20arcapta neohaler......................31argyle sterile saline .................111aricept....................................145arikayce................................... 19arimidex.................................. 55aripiprazole ........................ 60, 61arixtra......................................33armodafinil .............................. 17armonair respiclick 113........... 31armonair respiclick 232........... 32armonair respiclick 55............. 32armour thyroid...................... 150arnuity ellipta.......................... 32aromasin..................................55arthrotec..................................20arymo er.................................. 23arzerra..................................... 55asacol hd................................110ascomp-codeine ........................ 23asmanex 120 metered doses..... 32asmanex 14 metered doses....... 32asmanex 30 metered doses....... 32asmanex 60 metered doses....... 32asmanex 7 metered doses.........32asmanex hfa.............................32aspir-81 ....................................22aspirin-dipyridamole er ...........113aspir-low .................................. 22assure 3 test............................. 94assure 4 test............................. 94assure ii....................................94assure ii check..........................94assure lancets.........................123assure platinum....................... 94assure prism multi test............. 94assure pro test..........................94astagraf xl................................66astepro...................................134astero.......................................81atacand....................................49atazanavir sulfate ..................... 63atelvia.................................... 104atenolol .................................... 68atenolol-chlorthalidone ............. 49atgam...................................... 66

161

ativan...................................... 30atomoxetine hcl ........................17atorvastatin calcium ................. 47atovaquone ...............................52atovaquone-proguanil hcl ..........53atralin......................................81atripla......................................63atropine sulfate .......................136atrovent hfa.............................32aubagio..................................145aubra eq.................................. 74augmentin..............................142augmentin xr......................... 143austedo.................................. 145auvi-q.................................... 156avage....................................... 81availnex................................... 98avalide..................................... 49avandia....................................40avapro..................................... 49avar cleanser ............................ 81avar ls cleanser........................ 82avar-e emollient ........................82avar-e green ............................. 82avar-e ls................................... 82avc vaginal.............................155avelox.................................... 109aviane ...................................... 74avidoxy .................................. 149avidoxy dk.............................149avita .........................................82avo cream................................ 82avodart.................................. 111avonex................................... 145avonex pen.............................145avonex prefilled..................... 145av-vite fb ................................ 115axona.......................................98aygestin..................................144azactam................................. 130azasan......................................66azasite....................................136azathioprine ............................. 66azelastine hcl .................. 134, 136azelex.......................................82azilect...................................... 59azithromycin .......................... 123azopt......................................136azor......................................... 49aztreonam .............................. 130

azulfidine............................... 110azulfidine en-tabs...................110azurette ....................................74b-6 folic acid ...........................115bacitracin ............................... 136bacitracin-polymyxin b ........... 136bacitra-neomycin-polymyxin-hc ...........................................136baclofen ..................................133bactocill in dextrose...............143bactrim.................................... 52bactrim ds................................52bactroban................................ 82bactroban nasal..................... 134balcoltra.................................. 74balsalazide disodium ...............110balziva ..................................... 74banzel...................................... 34baraclude.................................63basaglar kwikpen.....................40baxdela.................................. 109bayer aspirin ec low dose .......... 22bayer breeze 2 test................... 94bayer contour test....................94bayer low dose ..........................22bayer microlet lancets............ 124bd autoshield......................... 124bd insulin syringe...................124bd insulin syringe half-unit.... 124bd insulin syringe microfine...124bd insulin syringe u/f..............124bd insulin syringe ultrafine.... 124bd lancet ultrafine 30g........... 124bd lancet ultrafine 33g........... 124bd microtainer lancets........... 124bd pen....................................124bd pen mini............................124bd pen needle mini u/f............124bd pen needle nano u/f...........124bd pen needle short u/f...........124bd pen needle ultrafine.......... 124bd safetyglide insulin syringe. 124bebulin...................................113beconase aq........................... 134belbuca.................................... 23belladonna alkaloids-opium .....151belladonna-opium ................... 151belsomra................................ 140benazepril hcl ........................... 49benazepril-hydrochlorothiazide . 49

benefix................................... 113benicar.....................................49benicar hct...............................49benlysta................................... 66bensal hp................................. 82bentyl.....................................151benzaclin................................. 82benzaclin with pump............... 82benznidazole .............................29benzonatate ..............................79benzoyl peroxide-erythromycin .82benzphetamine hcl .................... 17benztropine mesylate ................ 59bepreve.................................. 136berinert.................................. 113besivance............................... 136betadine ophthalmic prep...... 136betagan..................................136betamethasone dipropionate ..... 82betamethasone dipropionate aug ...........................................82betamethasone valerate ............ 82betapace af.............................. 68betaseron............................... 145betaxolol hcl ..................... 68, 136bethanechol chloride ............... 154bethkis.....................................19betimol.................................. 136betoptic-s...............................136bevespi aerosphere...................32bevyxxa................................... 34bexarotene ............................... 55beyaz....................................... 74biafine..................................... 82biaxin.....................................123bicalutamide .............................55bidil......................................... 71biktarvy................................... 63biltricide.................................. 29bimatoprost ............................ 136binosto...................................104bio glo .................................... 136bionect.....................................82bioscanner glucose test............ 94bisoprolol fumarate .................. 68bisoprolol-hydrochlorothiazide ..49bivigam..................................141bleph-10.................................136blephamide............................ 136blephamide s.o.p....................136

162

blood glucose test ..................... 94boniva....................................104bonjesta................................... 44bosulif..................................... 55botox..................................... 135botox cosmetic.........................82bp 10-1 .....................................82bp cleansing wash....................82bp vit 3...................................115braftovi....................................55bravelle.................................. 104breo ellipta.............................. 32briellyn .....................................74brilinta........................... 102, 113brimonidine tartrate ................136brisdelle................................. 145briviact.................................... 34bromfenac sodium (once-daily)...............................................136bromocriptine mesylate ............ 59bromsite.................................136brovana................................... 32budesonide .................. 32, 78, 134budesonide er ............................78bullseye mini safety lancets ..... 124bullseye safety lancets............ 124bumetanide ..................... 102, 103bunavail...................................23bupap...................................... 22buphenyl................................104buprenorphine .......................... 23buprenorphine hcl ..................... 23buprenorphine hcl-naloxone hcl .24bupropion hcl ........................... 37bupropion hcl er (smoking det)...............................................145bupropion hcl er (sr) ................ 37bupropion hcl er (xl) ................37buspirone hcl ............................ 30busulfex................................... 55butalbital-acetaminophen ......... 22butalbital-apap-caff-cod ........... 24butalbital-apap-caffeine ...... 22, 23butalbital-asa-caff-codeine ....... 24butalbital-aspirin-caffeine .........23butisol sodium....................... 119butorphanol tartrate ................. 24butrans.................................... 24bydureon................................. 40bydureon bcise.........................40

byetta 10 mcg pen....................40byetta 5 mcg pen......................40bystolic.................................... 68byvalson.................................. 68cabergoline .............................104cabometyx............................... 55caduet......................................71cafergot..................................127caffeine citrate ......................... 17calan sr.................................... 69calcidol.................................. 156calciferol................................ 156calcipotriene .............................82calcipotriene-betameth diprop ...82calcitonin (salmon) ................ 104calcitrene ................................. 82calcitriol ........................... 82, 104calquence.................................55cambia................................... 127camila ...................................... 74camptosar................................55camrese ....................................74camrese lo ................................ 74canasa....................................110candesartan cilexetil .................49candesartan cilexetil-hctz ......... 49cantharidin ...............................83capastat sulfate........................54capecitabine ............................. 55capex....................................... 83caprelsa................................... 55captopril ...................................49captopril-hydrochlorothiazide ... 49carac........................................83carafate..................................151carbaglu.................................104carbamazepine ......................... 34carbamazepine er ..................... 34carbatrol..................................34carbidopa ................................. 59carbidopa-levodopa .................. 59carbidopa-levodopa er .............. 59carbinoxamine maleate .............46cardene iv................................ 69cardiotek rx............................. 98cardizem cd............................. 69cardizem la.............................. 69cardura.................................... 49cardura xl.............................. 111caresens n glucose test............. 94

carimune nf............................141carisoprodol ........................... 133carisoprodol-aspirin ................133carisoprodol-aspirin-codeine ... 133carnitor..................................104carnitor sf.............................. 104carospir..................................103carteolol hcl ............................136cartia xt ................................... 69carvedilol ................................. 68carvedilol phosphate er ............. 68casodex....................................55catapres................................... 49catapres-tts-1........................... 50catapres-tts-2........................... 50catapres-tts-3........................... 50cayston.................................. 130caziant ..................................... 74cefaclor .................................... 72cefaclor er ................................ 72cefadroxil .................................72cefazolin sodium .......................72cefdinir .....................................72cefditoren pivoxil ......................72cefepime hcl ............................. 72cefixime ................................... 72cefotaxime sodium ....................72cefotetan disodium ....................72cefoxitin sodium ....................... 72cefpodoxime proxetil ................ 72cefprozil ................................... 72ceftazidime ...............................72ceftriaxone sodium ................... 72ceftriaxone sodium in dextrose . 72cefuroxime axetil ..................... 73cefuroxime sodium ................... 73celebrex................................... 20celecoxib .................................. 20celexa.......................................37cellcept.................................... 66cellcept intravenous................. 66celontin....................................34cem-urea..................................83cenfol.....................................115centany.................................... 83centany at................................ 83centratex................................115cephalexin ................................ 73cerdelga................................. 115cerebyx.................................... 34

163

cerefolin...................................98cerefolin nac............................ 98cerezyme................................ 116cesamet....................................44cesia .........................................74cetirizine hcl .............................46cetirizine-pseudoephedrine er .... 79cetraxal.................................. 140cetrotide.................................104cevimeline hcl ......................... 130chantix...................................145chantix continuing month pak...............................................145chantix starting month pak....145chateal ..................................... 74chateal eq................................ 74chemet..................................... 44chemstrip k..............................94chenodal................................ 110childrens aspirin ....................... 23childrens loratadine .................. 46chlordiazepoxide hcl ................. 30chlordiazepoxide-amitriptyline145chlorhexidine gluconate .......... 130chloroquine phosphate .............. 53chlorothiazide .........................103chlorothiazide sodium ............. 103chlorpromazine hcl ................... 61chlorpropamide ........................ 40chlorthalidone .........................103chlorzoxazone ........................ 133cholbam...................................69cholestyramine ......................... 73cholestyramine light ................. 47chorionic gonadotropin ........... 104ciclodan................................... 83ciclodan solution..................... 83ciclopirox ................................. 83ciclopirox olamine .................... 83ciclopirox treatment ................. 83cidofovir ...................................63ciferex.................................... 116cilostazol ................................ 113ciloxan................................... 136cimduo.................................... 63cimetidine ...............................151cimzia.................................... 110cimzia prefilled...................... 110cimzia starter kit.................... 110cinqair................................... 120

cinryze................................... 113cipro...................................... 109cipro hc..................................140cipro xr.................................. 109ciprodex.................................140ciprofloxacin .......................... 109ciprofloxacin hcl ......109, 136, 140ciprofloxacin in d5w ............... 109ciprofloxacin-ciproflox hcl er ..109citalopram hydrobromide ..........37citranatal 90 dha....................131citranatal assure.....................131citranatal b-calm....................131citranatal dha........................ 131citranatal harmony................ 131citranatal medley................... 131citranatal rx........................... 131claravis .................................... 83clarinex....................................46clarinex-d 12 hour................... 79clarithromycin ........................ 123clarithromycin er .................... 123claritin..................................... 46claritin eye............................. 136claritin reditabs........................46claritin-d 12 hour.....................79claritin-d 24 hour.....................79clearlax .................................. 120clenpiq................................... 120cleocin..............................52, 155cleocin in d5w..........................52cleocin phosphate.................... 52cleocin-t...................................83clever chek auto-code............ 124clever chek auto-code test........94clever chek auto-code voice..... 94clever chek test........................ 94clever choice auto-code test..... 94clever choice micro test............94climara...................................108climara pro............................ 108clindacin etz.............................83clindacin pac............................83clindagel.................................. 83clindamycin hcl .........................52clindamycin palmitate hcl ......... 52clindamycin phos-benzoyl perox ....................................... 83clindamycin phosphate .52, 83, 155clindamycin-tretinoin ................83

clobetasol propionate .......... 83, 84clobetasol propionate e ............. 83clobetasol propionate emulsion . 83clobex...................................... 84clobex spray.............................84clocortolone pivalate .................84clodan ...................................... 84cloderm................................... 84clomiphene citrate .................. 104clomipramine hcl ...................... 37clonazepam .............................. 34clonidine hcl ............................. 50clonidine hcl er ......................... 17clopidogrel bisulfate ................113clorazepate dipotassium ............30clotrimazole ........................... 130clotrimazole-betamethasone ..... 84clozapine .................................. 61clozaril.....................................61coagadex................................113coaguchek lancets.................. 124coal tar .................................... 84coartem................................... 53codeine sulfate ..........................24colazal................................... 110colchicine ............................... 112colchicine-probenecid ..............112colcrys................................... 112colesevelam hcl .........................47colestid.................................... 47colestid flavored...................... 47colestipol hcl ............................ 47collagenase ...............................84colocort ....................................28coly-mycin m........................... 52coly-mycin s...........................140combigan...............................136combipatch............................108combivent respimat................. 32combivir.................................. 63cometriq (100 mg daily dose)...55cometriq (140 mg daily dose)...55cometriq (60 mg daily dose).....55comfort assured lancets 28g .... 124comfort assured lancets 33g .... 124complera..................................63compro .....................................61comtan.................................... 59co-natal fa ..............................131concept dha........................... 131

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concept ob............................. 131concerta...................................17condylox..................................84constulose ...............................120conzip......................................24cool blood glucose test strips... 94copaxone............................... 145copiktra................................. 143cordran....................................84coreg........................................68coreg cr....................................68coremino................................149corgard.................................... 68corifact.................................. 113corlanor................................. 148cortef....................................... 78cortenema................................28cortifoam.................................28cortisporin............................... 84corvita ....................................131corvita 150.............................116corvite....................................131corvite 150............................. 116corvite fe................................116corzide.....................................50cosentyx...................................84cosentyx sensoready pen..........84cosopt pf................................136cotellic..................................... 56cotempla xr-odt....................... 17coumadin.................................34cozaar......................................50creon......................................102cresemba..................................45crestor..................................... 47crinone...................................155crixivan....................................63cromolyn sodium ....... 32, 110, 136crotan...................................... 84cryselle-28 ................................74cuprimine................................ 66cutivate....................................84cuvitru................................... 141cuvposa..................................151cvs acid controller max st ........151cvs advanced glucose test.........94cvs d3 ..................................... 156cvs nicotine .............................145cvs nicotine polacrilex .............145cvs purelax.............................120

cyanocobalamin ......................116cyclafem 1/35 ........................... 74cyclafem 7/7/7 .......................... 74cyclobenzaprine hcl .................133cyclogyl..................................136cyclomydril............................137cyclopentolate hcl ................... 137cyclophosphamide .................... 56cycloserine ............................... 54cycloset....................................40cyclosporine ............................. 66cyclosporine modified ............... 66cymbalta..................................38cyproheptadine hcl ....................46cystadane...............................104cystagon................................ 111cystaran................................. 137cytogam.................................141cytomel.................................. 150cytovene.................................. 63cytra-2 ................................... 111d 10000 .................................. 156d 5000 .................................... 156d.h.e. 45................................. 127d-2000 maximum strength ...... 156d2000 ultra strength ................156d3 dots...................................156d3 maximum strength ............. 156d3 super strength .................... 156d3-1000 .................................. 156d-3-5 ...................................... 156d-5000 ....................................156daklinza...................................63dalfampridine er ..................... 145daliresp....................................32danazol .................................... 28dantrolene sodium ...................133dapsone .............................. 52, 84daraprim..................................53darifenacin hydrobromide er ... 154dasetta 1/35 ..............................74dasetta 7/7/7 .............................74daypro..................................... 20daysee ...................................... 74daytrana.................................. 17ddavp.....................................104ddavp rhinal tube.................. 104ddrops................................... 156debacterol..............................130deblitane..................................74

decara.................................... 156deferoxamine mesylate ............. 44delestrogen............................ 108delstrigo...................................63delta d3 .................................. 156delzicol.................................. 110demadex................................ 103demeclocycline hcl .................. 149demerol................................... 24demser..................................... 50denavir.................................... 84denta 5000 plus .......................130depakene................................. 34depakote..................................34depakote er..............................34depakote sprinkles...................35depen titratabs.........................66deplin 15..................................98deplin 7.5.................................98depo-estradiol........................108depo-medrol............................ 78depo-provera..................... 56, 74depo-testosterone.................... 28derma-smoothe/fs body........... 84dermasorb ta........................... 84dermotic................................ 140descovy....................................63desferal.................................... 44desipramine hcl .........................38desloratadine ............................46desmopressin ace spray refrig . 104desmopressin acetate .............. 104desogestrel-ethinyl estradiol ......74desonate.................................. 84desonide ................................... 84desowen...................................84desoximetasone ........................ 84desoxyn................................... 17desvenlafaxine er ......................38desvenlafaxine succinate er .......38detrol..................................... 154detrol la................................. 154dexamethasone .........................78dexamethasone intensol...........78dexamethasone sod phosphate pf ............................................. 78dexamethasone sodium phosphate ......................... 78, 137dexedrine................................. 17dexilant..................................151

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dexmethylphenidate hcl ............ 17dexmethylphenidate hcl er ........ 17dextroamphetamine sulfate .......17dextroamphetamine sulfate er ...17dialyvite 5000.........................131dialyvite supreme d................131dialyvite vitamin d 5000.........156dialyvite vitamin d3 max........156diastat acudial......................... 35diastat pediatric.......................35diatrue plus test ........................ 94diazepam ............................ 30, 35diazepam intensol ..................... 30dibenzyline.............................. 50diclegis.....................................44diclofenac potassium .................20diclofenac sodium .. 20, 84, 85, 137diclofenac sodium er ................. 20diclofenac-misoprostol ..............20diclofex dc............................... 85dicloxacillin sodium ................ 143dicyclomine hcl .......................152didanosine ................................ 63diethylpropion hcl .....................18diethylpropion hcl er .................17differin.....................................85dificid.................................... 123diflorasone diacetate .................85diflucan................................... 45diflunisal .................................. 23digitek..................................... 71digox ........................................71digoxin .....................................71dihydroergotamine mesylate ... 127dilantin.................................... 35dilantin infatabs...................... 35dilatrate-sr...............................29dilaudid................................... 24diltiazem hcl .............................70diltiazem hcl er .........................70diltiazem hcl er beads ............... 69diltiazem hcl er coated beads .... 70dilt-xr ...................................... 70diovan..................................... 50diovan hct................................50dipentum............................... 110diphenhydramine hcl .................46diphenoxylate-atropine .............43diprolene................................. 85diprolene af............................. 85

dipyridamole .......................... 113disopyramide phosphate ............31disulfiram ...............................145ditropan xl............................. 154diuril......................................103divalproex sodium .................... 35divalproex sodium er ................ 35divista.................................... 116dofetilide .................................. 31dolophine................................ 24donepezil hcl ...........................145donnatal................................ 152doptelet..................................116doral...................................... 119doryx..................................... 149doryx mpc..............................149dorzolamide hcl ...................... 137dorzolamide hcl-timolol mal ....137dorzolamide hcl-timolol mal pf 137dovonex...................................85doxazosin mesylate ...................50doxepin hcl ......................... 38, 85doxercalciferol ....................... 104doxy 100 ................................ 149doxycycline .............................. 85doxycycline hyclate ................ 149doxycycline monohydrate ....... 149drisdol................................... 156dritho-creme hp.......................85dronabinol ................................44drospiren-eth estrad-levomefol ..74drospirenone-ethinyl estradiol ...74droxia.................................... 116drug mart unifine pentips...... 124duac.........................................85duavee................................... 109duetact.....................................40duexis...................................... 20dulera...................................... 32duloxetine hcl ........................... 38duo-care test............................ 94duopa...................................... 60dupixent.................................. 67durachol ................................. 116duragesic-100...........................24duragesic-12............................ 24duragesic-25............................ 24duragesic-50............................ 24duragesic-75............................ 24duramorph ............................... 24

durezol...................................137durlaza...................................113durolane................................ 133dutasteride ............................. 112dutasteride-tamsulosin hcl .......112dutoprol.................................. 50duzallo...................................112d-vi-sol...................................156dyanavel xr.............................. 18dyazide.................................. 103dymista.................................. 134dyrenium............................... 103dysport.................................. 135e.e.s. 400................................ 123e.e.s. granules.........................123easy comfort insulin syringe...124easy plus ii glucose test ............. 94easy step test............................94easy talk blood glucose test .......94easy touch healthpro test......... 94easy touch insulin syringe...... 124easy touch lancets 21g............124easy touch lancets 23g............124easy touch lancets 26g............124easy touch lancets 26g/twist... 124easy touch lancets 28g............124easy touch lancets 28g/twist... 124easy touch lancets 30g............125easy touch lancets 30g/twist... 125easy touch lancets 32g............125easy touch lancets 32g/twist... 125easy touch lancets 33g/twist... 125easy touch lancing device.......125easy touch safety lancets 21g..125easy touch safety lancets 23g..125easy touch safety lancets 26g..125easy touch safety lancets 28g..125easy touch test......................... 94easy trak blood glucose test ...... 94easy twist & cap lancets......... 125easygluco................................. 94easygluco plus..........................95easymax 15 test........................95easymax test............................ 95easyplus blood glucose test ........95easypro blood glucose test....... 95easypro plus.............................95ec-81 aspirin .............................23ec-naprosyn............................. 20econazole nitrate ...................... 85

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ecotrin..................................... 23ecotrin low strength .................. 23ecoza....................................... 85ecpirin ......................................23edarbi...................................... 50edarbyclor............................... 50edecrin................................... 103edluar.................................... 119edurant.................................... 63efavirenz .................................. 63effer-k.................................... 129effer-k .................................... 129effexor xr................................. 38effient.................................... 113efudex......................................85egrifta.................................... 104elaprase..................................104elelyso....................................116element compact test ................ 95element test..............................95elestat.................................... 137elestrin................................... 108eletriptan hydrobromide ..........127elidel........................................ 85eligard..................................... 56elinest ...................................... 74eliquis...................................... 34eliquis starter pack...................34elixophyllin..............................32ella...........................................74elmiron.................................. 112elocon......................................85eloctate.................................. 113emadine................................. 137embeda.................................... 24embrace blood glucose test...... 95embrace evo blood glucose test...........................................95embrace pro glucose test..........95emcyt.......................................56emend......................................44emflaza.................................... 78emgality...................................69emoquette .................................74emsam..................................... 38emtriva.................................... 63emverm....................................29enablex.................................. 154enalapril maleate ......................50enalapril-hydrochlorothiazide ... 50

enbrel...................................... 20enbrel mini.............................. 20enbrel sureclick........................20endari...................................... 19endocet .....................................24endocet.................................... 24endometrin............................ 155enlyte.......................................99enoxaparin sodium ................... 34enpresse-28 .............................. 74enskyce.................................... 75enstilar.....................................85entacapone ............................... 60entecavir .................................. 63enteragam................................99entocort ec...............................79entresto..................................135entyvio...................................120enulose ................................... 110envarsus xr.............................. 66epaned..................................... 50epclusa...................................118epiceram.................................. 85epidiolex.................................. 35epiduo..................................... 85epiduo forte............................. 85epifoam................................... 85epinastine hcl ..........................137epinephrine .............................156epipen 2-pak.......................... 156epipen jr 2-pak.......................156episnap.................................. 156epitol ........................................35epivir....................................... 63epivir hbv................................ 63eplerenone ................................ 50epogen................................... 116epoprostenol sodium ................. 71eprosartan mesylate ..................50epzicom................................... 63eq acid reducer max st ............ 152eq clearlax..............................121eq nicotine .............................. 145eql clearlax.............................121eql heartburn prevention ......... 152eql vitamin d3 ......................... 156equetro.................................... 61ergocal ................................... 157ergocalciferol ......................... 157ergoloid mesylates .................. 145

ergomar................................. 127erivedge................................... 56erleada.....................................56errin .........................................75ertaczo.....................................85ery ........................................... 85erygel.......................................85eryped 200............................. 123eryped 400............................. 123ery-tab................................... 123erythrocin lactobionate..........123erythrocin stearate................. 123erythromycin ............................85erythromycin base .................. 123erythromycin ethylsuccinate ....123esbriet.................................... 148escitalopram oxalate ................ 38esgic .........................................23esgic.........................................23esomeprazole magnesium ........152esomeprazole strontium .......... 152estazolam ............................... 119estrace............................ 108, 155estradiol ..........................108, 155estradiol valerate .................... 108estradiol-norethindrone acet ... 108estring....................................155estrogel.................................. 108estrostep fe.............................. 75eszopiclone ............................. 119ethacrynic acid ....................... 103ethambutol hcl ..........................54ethosuximide ............................ 35ethyol...................................... 56etidronate disodium ................ 104etodolac ................................... 20etodolac er ............................... 20etoposide .................................. 56eucrisa................................... 143euflexxa................................. 133eurax....................................... 85evamist.................................. 108evekeo..................................... 18evencare + blood glucose test.. 95evencare blood glucose test......95evencare g2 test........................95evencare g3 test........................95evencare mini glucose test........95evista..................................... 105evolution autocode.................. 95

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evotaz...................................... 63evoxac....................................130evzio........................................ 44exalgo...................................... 24exelderm.................................. 85exelon.................................... 145exemestane ...............................56exforge.....................................50exforge hct...............................50exjade...................................... 44exoderm...................................85extavia................................... 145extina.......................................85eye itch relief ..........................137eylea...................................... 137ez smart blood glucose test...... 95ez smart plus glucose test.........95ezetimibe ..................................47ezetimibe-simvastatin ............... 47fabb ........................................116fabior.......................................86fabrazyme..............................105falessa......................................75falmina .....................................75famciclovir ............................... 63famotidine .............................. 152famotidine premixed ...............152fanapt...................................... 61fanapt titration pack................61fareston................................... 56farxiga..................................... 40farydak.................................... 56faslodex................................... 56fa-vitamin b-6-vitamin b-12 .....116fayosim....................................75fazaclo..................................... 61fc2 female condom.................125feiba.......................................113felbamate ................................. 35felbatol.................................... 35feldene..................................... 20felodipine er ............................. 70fem ph................................... 155femara..................................... 56femhrt low dose..................... 108femring.................................. 155fenofibrate ............................... 48fenofibrate micronized ..............48fenofibric acid .......................... 48fenoglide..................................48

fenoprofen calcium ................... 20fentanyl ....................................24fentanyl citrate .........................24fentora.....................................24feriva 21/7..............................116ferocon ................................... 116ferotrinsic ...............................116ferraplus 90............................116ferriprox.................................. 44ferrlecit.................................. 116ferrocite plus .......................... 116ferro-plex hematinic...............116ferrotrin................................. 116fetzima.....................................38fetzima titration.......................38fexmid....................................133fexofenadine hcl ....................... 47fexofenadine hcl childrens .........47fexofenadine-pseudoephed er .... 80fiasp.........................................40fiasp flextouch......................... 40fibricor.................................... 48fibryga................................... 114fifty50 glucose test 2.0............. 95finacea..................................... 86finasteride .........................86, 112fingerstix lancets.................... 125fioricet/codeine........................ 24fiorinal.....................................23fiorinal/codeine #3.................. 24firazyr.................................... 114firmagon..................................56first-mouthwash blm..............130firvanq................................... 112flagyl..................................52, 53flarex..................................... 137flavoxate hcl ...........................154flebogamma dif......................141flecainide acetate ......................31flector...................................... 86flolan....................................... 71flolipid ..................................... 48flomax................................... 112flonase................................... 134flonase allergy relief...............134flovent diskus.......................... 32flovent hfa............................... 32floxin otic.............................. 140flucaine .................................. 137fluconazole ...............................45

fluconazole in sodium chloride .. 45flucytosine ................................45fludrocortisone acetate ............. 79flumadine................................ 63flunisolide ...............................134fluocinolone acetonide .......86, 140fluocinolone acetonide body ...... 86fluocinonide ..............................86fluorabon...............................129fluorescein-benoxinate ............ 137fluor-i-strips a.t. ..................... 137fluoritab ................................. 129fluorometholone ..................... 137fluoroplex................................ 86fluorouracil .........................56, 86fluoxetine hcl ............................38fluoxetine hcl (pmdd) .............145fluphenazine decanoate .............61fluphenazine hcl ........................61flura-drops.............................129flurandrenolide ......................... 86flura-safe............................... 137flurazepam hcl ........................119flurbiprofen .............................. 20flurbiprofen sodium .................137flutamide ..................................56fluticasone propionate ....... 86, 134fluticasone-salmeterol ...............32fluvastatin sodium .................... 48fluvastatin sodium er ................ 48fluvoxamine maleate .................38fluvoxamine maleate er .............38fml......................................... 137fml forte.................................137fml liquifilm...........................137focalin..................................... 18focalin xr................................. 18folbee ..................................... 116folbic ........................................99folbic rf....................................99folgard rx...............................116folic acid ................................ 116folivane-f............................... 116folivane-plus.......................... 116follistim aq.............................105folplex 2.2 .............................. 116foltanx..................................... 99foltanx rf................................. 99foltrin .....................................116foltx.........................................99

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fondaparinux sodium ................ 34fora d10 2-in-1 monitor......... 125fora d15g 2-in-1 monitor........125fora d15g blood glucose test.... 95fora d20 2-in-1 monitor......... 125fora d20 blood glucose test...... 95fora d40/g31 blood glucose......95fora g20 blood glucose test...... 95fora g30/prem v10 glucose test.95fora gd20 test...........................95fora gd50 blood glucose test.... 95fora tn'g/tn'g voice................... 95fora v10 blood glucose test...... 95fora v12 blood glucose test...... 95fora v20 blood glucose test...... 95fora v30a blood glucose test.... 95foracare gd40 test.................... 95foracare premium v10 test....... 95foracare test n go test...............95forfivo xl..................................38formadon ................................. 62formaldehyde ........................... 62fortamet...................................40forteo.....................................105fortesta.................................... 28fortiscare test........................... 96fosamax................................. 105fosamax plus d.......................105fosamprenavir calcium ..............63fosinopril sodium ...................... 50fosinopril sodium-hctz ...............50fosphenytoin sodium ................. 35fosrenol..................................110fosteum....................................99fosteum plus............................ 99fovex........................................99fragmin....................................34freestyle insulinx test................96freestyle lancets......................125freestyle lite test....................... 96freestyle precision ins syr....... 125freestyle precision neo test....... 96freestyle test.............................96freestyle unistick ii lancets..... 125frova...................................... 127frovatriptan succinate ............. 128ful-glo.................................... 137ful-glo .................................... 137fulphila.................................. 116furadantin..............................154

furosemide ..............................103fusion plus............................. 116fuzeon......................................63fyavolv...................................108fycompa...................................35gabadone.................................99gabapentin ............................... 35gabitril.....................................35gablofen.................................133galafold..................................105galantamine hydrobromide ..... 145galantamine hydrobromide er ..146galzin..................................... 129gamastan s/d..........................141gammagard............................141gammagard s/d less iga.......... 141gammaked............................. 141gammaplex............................ 141gamunex-c............................. 141ganciclovir sodium ....................64ganirelix acetate .....................105gastrocrom............................ 110gastrografin............................. 96gatifloxacin ............................ 137gattex.....................................110gavilax ................................... 121gavilyte-c ................................121gavilyte-g ............................... 121gavilyte-h...............................121gavilyte-n with flavor pack ......121ge100 blood glucose test ........... 96gebauers pain ease............86, 151gebauers spray and stretch......................................... 86, 151gelnique................................. 154gel-one................................... 133gelsyn-3..................................133gemfibrozil ............................... 48genadur................................... 86generess fe............................... 75generlac ..................................110gengraf .....................................67genotropin............................. 105genotropin miniquick............ 105genstrip 50............................... 96gentak .................................... 137gentamicin in saline .................. 19gentamicin sulfate ....... 19, 86, 137gentlelax ................................ 121genvisc 850.............................133

genvoya................................... 64geodon.....................................61geri-hydrolac 12 ....................... 86ght test .....................................96gialax..................................... 121gianvi ....................................... 75gildess fe 1.5/30 ........................ 75gildess fe 1/20 ...........................75gilenya................................... 146gilotrif..................................... 56glassia.................................... 148glatiramer acetate .................. 146glatopa...................................146gleevec..................................... 56gleostine.................................. 56glimepiride ............................... 40glipizide ................................... 40glipizide xl ............................... 40glipizide-metformin hcl ............. 40global inject ease insulin syr...125glucagen diagnostic................. 96glucagen hypokit..................... 40glucagon emergency................ 40gluco perfect 3 test...................96glucocard 01 sensor plus..........96glucocard expression test......... 96glucocard shine test................. 96glucocard vital test.................. 96glucocard x-sensor...................96glucocom test...........................96gluconavii blood glucose test... 96glucophage.............................. 40glucophage xr.......................... 41glucotrol.................................. 41glucotrol xl.............................. 41glumetza.................................. 41glyburide .................................. 41glyburide micronized ................ 41glyburide-metformin .................41glycolax ................................. 121glycopyrrolate ........................ 152glynase.....................................41glyset....................................... 41glyxambi................................148gnp acid reducer max st .......... 152gnp clearlax........................... 121gnp clickfine pen needles....... 125gnp folic acid .......................... 117gnp insulin syringe.................125gnp ultra com insulin syringe.125

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gnp vitamin d ..........................157gnp vitamin d maximum strength ..................................157gnp vitamin d super strength ... 157gocovri.................................... 60golytely.................................. 121gonal-f................................... 105gonal-f rff.............................. 105gonal-f rff rediject..................105gonitro.....................................29gralise.............................144, 146gralise starter..................144, 146granisetron hcl ......................... 44granix.................................... 117griseofulvin microsize ............... 45griseofulvin ultramicrosize ........45guaifenesin ac ...........................80guanfacine hcl .......................... 50guanfacine hcl er ...................... 18guanidine hcl ............................ 54gynazole-1............................. 155haegarda................................114halcion...................................119haldol...................................... 61haldol decanoate..................... 61halobetasol propionate ..............86halog....................................... 86haloperidol ............................... 61haloperidol lactate ....................61harvoni.................................. 119healthy accents unifine pentip 125healthylax .............................. 121heartburn relief max st ........... 152heather .....................................75hectorol................................. 105helixate fs...............................114hemangeol............................... 68hematinic plus vit/minerals ......117hematinic/folic acid .................117hematogen fa......................... 117hematogen forte ......................117hemenatal ob......................... 131hemetab................................. 117hemlibra.................................. 46hemocyte plus........................117hemocyte-f ............................. 117hemocyte-plus .........................117hemofil m.............................. 114heparin sodium (porcine) ......... 34heparin sodium (porcine) pf ..... 34

hepsera.................................... 64hetlioz....................................119hiprex.................................... 154hizentra..................................141hm clearlax............................ 121hm famotidine ........................ 152hm nicotine .............................146hm nicotine polacrilex .............146hm vitamin d3 .........................157homatropaire ..........................137homatropine hbr ..................... 137horizant................................. 146hp acthar............................... 105humalog.................................. 41humalog kwikpen.................... 41humalog mix 50/50.................. 41humalog mix 50/50 kwikpen....41humalog mix 75/25.................. 41humalog mix 75/25 kwikpen....41humate-p............................... 114humatrope............................. 105humira.....................................20humira pediatric crohns start...20humira pen.............................. 20humira pen-cd/uc/hs starter..... 20humira pen-ps/uv starter..........20humulin 70/30..........................41humulin 70/30 kwikpen........... 41humulin n................................ 41humulin n kwikpen..................41humulin r.................................41humulin r u-500 (concentrated)......................... 41humulin r u-500 kwikpen.........41hyalgan..................................133hycamtin..................................56hydralazine hcl ......................... 50hydrea..................................... 56hydrochlorothiazide ................ 103hydrocod polst-cpm polst er ...... 80hydrocodone-acetaminophen .....25hydrocodone-ibuprofen ............. 25hydrocortisone .............. 29, 79, 87hydrocortisone ace-pramoxine...........................................29, 86hydrocortisone butyr lipo base .. 86hydrocortisone butyrate ............86hydrocortisone valerate ............ 87hydrocortisone-acetic acid ...... 141hydromet ..................................80

hydromorphone hcl ...................25hydromorphone hcl er ............... 25hydromorphone hcl pf ...............25hydroxychloroquine sulfate .......53hydroxyprogesterone caproate 144hydroxyurea .............................56hydroxyzine hcl ........................ 30hydroxyzine pamoate ............... 30hylafem....................................67hylatopic plus.......................... 87hymovis................................. 133hyperhep b s/d....................... 141hyperrab................................ 141hyperrho s/d.......................... 141hypertensa............................... 99hypertet s/d............................141hyqvia....................................141hysingla er............................... 25hyzaar......................................50ibandronate sodium ................ 105ibrance.....................................80ibudone................................... 25ibudone .................................... 25ibuprofen ..................................20ibuprofen comfort pac.............20ic 400....................................... 21ic 800....................................... 21iclusig...................................... 56idelvion..................................114idhifa..................................... 120ilaris.........................................21ilevro..................................... 137ilumya..................................... 87imatinib mesylate ..................... 56imbruvica................................ 56imipramine hcl ..........................38imipramine pamoate ................. 38imiquimod ................................ 87imiquimod pump .......................87imitrex................................... 128imitrex statdose refill ............. 128imitrex statdose system.......... 128impavido................................. 53impoyz.....................................87imuran.....................................67imvexxy maintenance pack.... 155imvexxy starter pack..............155in touch blood glucose test...... 96increlex.................................. 105indapamide .............................103

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inderal la................................. 68inderal xl................................. 68indocin.................................... 21indomethacin ............................21indomethacin er ........................21infinity blood glucose test........96inflectra................................. 110infumorph 200.........................25infumorph 500.........................25ingrezza................................. 146inlyta....................................... 56innopran xl.............................. 68inova 4/1 acne control therapy.87inova 8/2 acne control therapy.87inspra...................................... 50insulin syringe ........................ 125insulin syringe/needle ..............125insulin syringe/needle.............125insulin syringe-needle u-100 .... 125integra f................................. 117integra plus............................ 117intelence.................................. 64intermezzo............................. 119intrarosa................................ 155intron a....................................56introvale ...................................75intuniv..................................... 18invega...................................... 61inveltys.................................. 137invirase.................................... 64invokamet..............................149invokamet xr......................... 149invokana..................................41iodine strong ...........................129iodosorb.................................. 62iopidine.......................... 137, 138ipratropium bromide ......... 32, 134ipratropium-albuterol ............... 32irbesartan .................................50irbesartan-hydrochlorothiazide . 50iressa....................................... 56irinotecan hcl ............................56irospan 24/6........................... 117is 24/6.................................... 117isentress................................... 64isentress hd.............................. 64isibloom...................................75isolyte-s..................................129isolyte-s ph 7.4....................... 129isoniazid ...................................54

isoptin sr..................................70isopto homatropine............... 138isordil titradose........................29isosorbide dinitrate ................... 29isosorbide dinitrate er ............... 29isosorbide mononitrate ............. 29isosorbide mononitrate er ..........29isotretinoin ...............................87isoxsuprine hcl ..........................71isradipine ................................. 70istalol.....................................138itraconazole ............................. 45ivermectin ................................ 29ixinity.................................... 114jadenu......................................44jadenu sprinkle........................ 44jakafi....................................... 57jalyn.......................................112jantoven ................................... 34janumet................................... 41janumet xr............................... 41januvia.....................................41jardiance..................................41jentadueto................................42jentadueto xr........................... 42jetrea......................................138jevtana.....................................57jinteli ......................................108jivi..........................................114jolessa ...................................... 75jolivette .................................... 75jublia....................................... 87juluca.......................................64junel 1.5/30 ...............................75junel 1/20 ................................. 75junel fe 1.5/30 ...........................75junel fe 1/20 ..............................75juxtapid................................... 48jynarque.................................105kadian..................................... 25kalbitor..................................114kaletra..................................... 64kalydeco................................ 148kanuma..................................122kapspargo sprinkle.................. 68kapvay.....................................18karbinal er............................... 47kariva .......................................75kazano.....................................42k-effervescent ......................... 129

keflex.......................................73kelnor 1/35 ............................... 75kenalog....................................87kepivance.................................57keppra..................................... 35keppra xr................................. 35keralyt scalp............................ 87kerr triple dye swabs................62kerydin.................................. 141ketocare...................................96ketoconazole .......................45, 87ketoprofen er ............................21ketorolac tromethamine .... 21, 138ketostix....................................96ketotifen fumarate .................. 138keveyis................................... 103kevzara.................................... 21khedezla.................................. 38kineret..................................... 21kisqali 200 dose....................... 80kisqali 400 dose....................... 80kisqali 600 dose....................... 80kisqali femara 200 dose........... 57kisqali femara 400 dose........... 57kisqali femara 600 dose........... 57kitabis pak...............................19klaron......................................87klofensaid ii............................. 87klonopin.................................. 35klor-con................................. 129klor-con 10 ............................. 129klor-con m10 .......................... 129klor-con m20 .......................... 129kls acid controller max st ........152kls laxaclear ...........................121koate......................................114koate-dvi............................... 114kogenate fs.............................114kombiglyze xr.......................... 42korlym.....................................42kovaltry................................. 114k-phos....................................129k-phos-neutral....................... 129kristalose............................... 121kroger blood glucose test .......... 96kroger insulin syringe............ 126kroger test ................................96krystexxa............................... 112k-tab...................................... 129k-tan plus...............................117

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kurvelo .....................................75kuvan.....................................106k-vescent ................................ 129kyleena.................................... 75kynamro.................................. 48labetalol hcl ..............................68lacrisert..................................138lactic acid .................................87lactic acid e .............................. 87lactulose ................................. 121lactulose encephalopathy ........ 110lamictal....................................35lamictal odt............................. 35lamictal starter.........................35lamictal xr............................... 36lamisil......................................45lamivudine ................................64lamivudine-zidovudine .............. 64lamotrigine ...............................36lamotrigine er ...........................36lamotrigine starter kit-blue ....... 36lamotrigine starter kit-green ..... 36lamotrigine starter kit-orange ...36lancets ....................................126lancets super thin 28g ............. 126lancets ultra thin....................126lancets ultra thin 30g .............. 126lanoxin.................................... 71lansoprazole ........................... 152lanthanum carbonate .............. 110lantus.......................................42lantus solostar......................... 42larin fe 1.5/30...........................75lasix....................................... 103lastacaft................................. 138latanoprost ............................. 138latisse.......................................87latuda...................................... 61lazanda.................................... 25ldo plus....................................87leena ........................................ 75leflunomide ...............................21lemtrada................................ 146lenvima 10 mg daily dose.........57lenvima 12 mg daily dose.........57lenvima 14 mg daily dose.........57lenvima 18 mg daily dose.........57lenvima 20 mg daily dose.........57lenvima 24 mg daily dose.........57lenvima 4 mg daily dose...........57

lenvima 8 mg daily dose...........57lescol........................................48lescol xl....................................48lessina ...................................... 75letairis......................................71letrozole ................................... 57leucovorin calcium ....................57leukeran...................................57leukine................................... 117leuprolide acetate ..................... 57levalbuterol hcl ......................... 32levaquin................................. 109levbid.....................................152levemir.....................................42levemir flextouch..................... 42levetiracetam ............................36levetiracetam er ........................36levetiracetam in nacl .................36levobunolol hcl ........................138levocarnitine ...........................106levocetirizine dihydrochloride ... 47levofloxacin .................... 109, 138levofloxacin in d5w ................. 109levonest .................................... 75levonorgest-eth estrad 91-day ... 75levonorgestrel-ethinyl estrad ..... 75levora 0.15/30 (28) .................. 75levorphanol tartrate ..................25levothyroxine sodium ..............150levoxyl ................................... 150levsin..................................... 152levsin/sl.................................. 152levulan kerastick......................87lexapro.................................... 38lexiva....................................... 64lialda......................................110liberty next generation test...... 96liberty test ................................96librax..................................... 152lidocaine ...................................87lidocaine hcl ......................87, 122lidocaine hcl (cardiac) ............. 31lidocaine hcl (pf) ....................122lidocaine in d5w ........................31lidocaine pak ............................ 87lidocaine-hydrocortisone ace .....29lidocaine-prilocaine .................. 87lidocaine-tetracaine .................. 87lidoderm.................................. 87lifescan unistik 2.................... 126

lifescan unistik ii lancets........ 126limbrel..................................... 99limbrel250..............................100limbrel500..............................100lindane ..................................... 87linezolid ................................... 53linzess.................................... 110liothyronine sodium ................ 150lipichol 540............................ 100lipitor...................................... 48lipofen..................................... 48lisinopril ...................................50lisinopril-hydrochlorothiazide ... 50lister-v....................................100lite touch lancets .....................126litetouch lancets.....................126lithium ..................................... 61lithium carbonate ..................... 61lithium carbonate er ................. 61lithobid....................................61lithostat................................. 112livalo....................................... 48l-methylfolate ca me-cbl nac.. 100l-methylfolate forte................ 100l-methylfolate-algae-b12-b6 .... 100l-methylfolate-b6-b12 ............. 100l-methyl-mc........................... 100l-methyl-mc nac..................... 100lo loestrin fe.............................75locoid...................................... 87locoid lipocream...................... 88lodosyn....................................60loestrin 1.5/30 (21)................... 75loestrin 1/20 (21)......................75lokelma............................ 67, 144lomotil.....................................43lonhala magnair refill kit......... 32lonhala magnair starter kit...... 32lonsurf..................................... 57lopinavir-ritonavir .................... 64lopressor..................................68lopressor hct............................ 50loprox......................................88loratadine .................................47loratadine childrens .................. 47loratadine-d 12hr ......................80loratadine-d 24hr ......................80lorazepam ................................ 30lorcet....................................... 25lorcet hd.................................. 25

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lorcet plus................................25lortuss ex................................. 80loryna ...................................... 75lorzone...................................133losartan potassium ....................50losartan potassium-hctz ............ 50loseasonique............................ 76lotemax..................................138lotensin....................................51lotensin hct.............................. 51lotrel........................................51lotrisone.................................. 88lotronex................................. 110lovastatin ................................. 48lovaza...................................... 48lovenox....................................34low-ogestrel ..............................76loxapine succinate .................... 61lucemyra..................................19lucentis.................................. 138ludent ..................................... 129luliconazole .............................. 88lumigan..................................138lumizyme............................... 106lunesta................................... 119lupaneta pack........................ 122lupron depot (1-month)........... 57lupron depot (3-month)........... 57lupron depot (4-month)........... 57lupron depot (6-month)........... 57lupron depot-ped (1-month).. 106lupron depot-ped (3-month).. 106lutera ....................................... 76luxiq........................................ 88luzu..........................................88lycelle.......................................88lynparza......................... 143, 144lyrica....................................... 36lyrica cr.......................... 144, 146lysodren...................................57lysteda................................... 118lyza..........................................76macrobid............................... 154macrodantin.......................... 154macugen................................ 138macutek................................. 100magellan insulin safety syr..... 126magnebind 400...................... 129magnesium sulfate .................. 129makena.................................. 144

malarone................................. 53malathion .................................88maprotiline hcl ......................... 38marinol....................................44marlissa ................................... 76marnatal-f..............................131marplan................................... 38matulane..................................57matzim la ................................. 70mavyret..................................119maxalt....................................128maxalt-mlt............................. 128maxfe.....................................117maxidex................................. 138maximum d3..........................157maxipime.................................73maxzide................................. 103maxzide-25............................ 103md-gastroview .......................... 96meclizine hcl .............................45meclofenamate sodium ............. 21medrol..................................... 79medroxyprogesterone acetate......................................... 76, 144mefenamic acid .........................21mefloquine hcl .......................... 53megace es...............................144megestrol acetate .............. 57, 144meijer blood glucose test ...........96meijer truetest test................... 96meijer truetrack test.................96mekinist...................................57mektovi................................... 57meloxicam ................................21melpaque hp ............................. 88melphalan .................................57melphalan hcl ........................... 57memantine hcl ........................ 146memantine hcl er .................... 146menest................................... 108menopur................................ 106menostar................................109meperidine hcl .......................... 25mephyton.............................. 157meprobamate ........................... 30mepron.................................... 53mercaptopurine ........................ 57mesalamine ............................ 110mesalamine-cleanser ...............110mesnex.....................................58

mestinon..................................54metadate er..............................18metafolbic..............................100metafolbic plus...................... 100metafolbic plus rf...................101metanx...................................101metaproterenol sulfate ..............32metaxalone .............................133metformin hcl ........................... 42metformin hcl er ....................... 42metformin hcl er (mod) ............42metformin hcl er (osm) ............ 42methadone hcl .......................... 25methadone hcl intensol ..............25methadose............................... 25methadose sugar-free...............26methamphetamine hcl ...............18methazolamide ....................... 103methenamine hippurate ...........154methenamine mandelate ..........154methergine.............................141methimazole ........................... 150methitest..................................28methocarbamol .......................133methotrexate ............................58methotrexate sodium (pf) ........ 58methoxsalen rapid .................... 88methscopolamine bromide .......152methyclothiazide .....................103methyldopa .............................. 51methyldopa-hydrochlorothiazide ..................51methyldopate hcl ...................... 51methylin.................................. 18methylphenidate hcl ..................18methylphenidate hcl er ..............18methylphenidate hcl er (cd) ......18methylphenidate hcl er (la) ...... 18methylprednisolone ...................79methylprednisolone sodium succ ..........................................79methyltestosterone ................... 28metoclopramide hcl .................111metolazone ............................. 103metopirone.............................. 96metoprolol succinate er .............68metoprolol tartrate ................... 68metoprolol-hctz er .................... 51metoprolol-hydrochlorothiazide 51metrocream............................. 88

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metrogel.................................. 88metrogel-vaginal....................155metrolotion..............................88metronidazole ..............53, 88, 155metronidazole in nacl ................53mevacor...................................48mexiletine hcl ........................... 31miacalcin............................... 106mibelas 24 fe............................76micardis...................................51micardis hct............................. 51miconazole 3 ...........................155micort-hc................................. 88micrhogam ultra-filtered plus 141microdot test........................... 96microgestin 1.5/30 .................... 76microgestin 1/20 ....................... 76microgestin fe 1.5/30 ................ 76microgestin fe 1/20 ................... 76micro-k.................................. 129microlet lancets......................126microtainer safety flow lancet 126midazolam hcl ........................ 119midodrine hcl ..........................156migergot................................ 128miglitol .................................... 42miglustat ................................ 117migranal................................ 128millipred.................................. 79mimvey ...................................109minastrin 24 fe.........................76minipress................................. 51miniprin low dose ......................23minitran ................................... 29minivelle................................ 109minocin..................................149minocycline hcl .......................150minocycline hcl er ................... 150minolira................................. 150minoxidil ..................................51miralax.................................. 121mirapex................................... 60mirapex er............................... 60mircera.................................. 117mircette................................... 76mirena (52 mg)........................ 76mirtazapine .............................. 38mirvaso....................................88misoprostol .............................152mitigare................................. 113

mitoxantrone hcl ...................... 58mixed vespid venom protein ...... 69mobic...................................... 21modafinil ..................................18moderiba .................................. 64moderiba 1200 dose pack........ 64moderiba 800 dose pack.......... 64moexipril hcl ............................ 51moexipril-hydrochlorothiazide .. 51mometasone furoate ..........88, 134monoclate-p...........................114monoject sodium chloride flush129mono-linyah ............................. 76mononessa ................................76mononine...............................114monovisc............................... 133montelukast sodium ..................32morcin ......................................67morgidox............................... 150morphabond er........................26morphine sulfate .......................26morphine sulfate (concentrate) .26morphine sulfate (pf) ............... 26morphine sulfate er ...................26morphine sulfate er beads ......... 26motofen................................... 43movantik............................... 111moviprep............................... 121moxatag.................................143moxeza.................................. 138moxifloxacin hcl ............. 109, 138mozobil..................................117ms contin.................................26mulpleta.................................117multaq..................................... 31multigen.................................117multigen folic.........................117multigen plus......................... 117multivitamin/fluoride .............. 131multi-vitamin/fluoride/iron ......131multivitamins/fluoride .............131mupirocin ................................. 88mupirocin calcium .................... 88myalept..................................122myambutol.............................. 54mycobutin............................... 54mycophenolate mofetil ..............67mydayis................................... 18mydriacyl...............................138myfortic...................................67

myglucohealth test...................96myleran................................... 58mynatal..................................131mynatal advance....................131mynatal plus ...........................131mynatal-z ............................... 131myobloc.................................135myorisan .................................. 88myorisan..................................88myrbetriq...............................154mysoline.................................. 36mytesi...................................... 43myzilra .....................................76na ferric gluc cplx in sucrose ... 117nabi-hb.................................. 141nabumetone ..............................21nadolol ..................................... 68nadolol-bendroflumethiazide .....51naftifine hcl .............................. 88naftin.......................................88naglazyme..............................106nalbuphine hcl .......................... 26nalfon...................................... 21nalocet ..................................... 26naloxone hcl ............................. 44naltrexone hcl ...........................44namenda................................146namenda titration pak........... 146namenda xr............................146namenda xr titration pack..... 146namzaric..................................37naprelan.................................. 21napro ....................................... 88naprosyn..................................21naproxen ..................................21naproxen dr ..............................21naproxen sodium ...................... 21naproxen sodium er .................. 21naratriptan hcl ........................128narcan..................................... 44nardil.......................................38nasacort allergy 24hr............. 134nasacort allergy 24hr children 134nasal allergy 24 hour .............. 134nascobal.................................117nasonex..................................134natacyn..................................138natazia.....................................76nateglinide ................................42natesto.....................................28

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natpara.................................. 106natroba....................................88nat-rul vitamin d .....................157natural vitamin d-3 ................. 157nature-throid......................... 150nebupent..................................53nebusal .....................................80nebusal.................................... 80necon 0.5/35 (28) .....................76necon 1/35 (28) ........................76nefazodone hcl .................. 38, 148neomycin sulfate .......................19neomycin-bacitracin zn-polymyx ................................. 138neomycin-polymyxin b gu ....... 112neomycin-polymyxin-dexameth...............................................138neomycin-polymyxin-gramicidin .............................. 138neomycin-polymyxin-hc .. 138, 141neoral...................................... 67neosalus...................................88neosalus cp.............................. 88neo-synalar..............................88nephplex rx............................ 131nephron fa............................. 117nerlynx.................................... 58nesina...................................... 42nestabs...................................131neuac....................................... 89neulasta................................. 117neupogen............................... 117neupro..................................... 60neurin-sl ................................. 118neurontin.................................36neutek 2tek glucose/pressure..126neutek 2tek test........................96nevanac..................................138nevirapine .................................64nevirapine er .............................64nexa plus................................132nexavar....................................58nexium...................................152nexium 24hr...........................152nexium i.v.............................. 152nexplanon................................76next choice one dose ................. 76nexterone.................................31niacin er (antihyperlipidemic) .. 48niacor...................................... 48

niaspan.................................... 48nicardipine hcl .......................... 70nicoderm cq........................... 146nicorelief ................................ 146nicorette.................................146nicotine .................................. 146nicotine polacrilex .................. 146nicotine step 1 .........................146nicotine step 2 .........................146nicotine step 3 .........................146nicotrol.................................. 146nicotrol ns..............................146nifedical xl ............................... 70nifedipine ................................. 70nifedipine er ............................. 70nifedipine er osmotic release ..... 70nikki........................................ 76nilandron.................................58nilutamide ................................ 58nimodipine ................................70ninlaro.....................................58nisoldipine er ............................ 70nitro-bid.................................. 29nitro-dur..................................29nitrofurantoin ......................... 154nitrofurantoin macrocrystal .... 154nitrofurantoin monohyd macro154nitroglycerin .............................30nitroglycerin in d5w ..................29nitrolingual..............................30nitromist..................................30nitrostat...................................30nitro-time ................................. 30nityr.......................................106nivestym................................ 118nizatidine ................................152nizoral..................................... 89nocdurna............................... 106noctiva...................................106nolix........................................ 89nora-be .....................................76norco....................................... 26norditropin flexpro................ 106norethin ace-eth estrad-fe ......... 76norethindrone ........................... 76norethindrone acetate ............. 144norethindrone-eth estradiol ..... 109norethin-eth estradiol-fe ........... 76norgestimate-eth estradiol ........ 76norgestim-eth estrad triphasic ...76

noritate....................................89norlyroc...................................76normosol-r.............................129normosol-r ph 7.4.................. 129norpace cr................................31norpramin............................... 38northera.................................135nortrel 0.5/35 (28) ................... 76nortrel 1/35 (21) ...................... 76nortrel 1/35 (28) ...................... 77nortrel 7/7/7 ............................. 77nortriptyline hcl ........................38norvasc.................................... 70norvir...................................... 64nova max glucose test..............96novarel ................................... 106novoeight...............................114novofine.................................126novolin 70/30...........................42novolin 70/30 relion.................42novolin n................................. 42novolin n relion....................... 42novolin r..................................42novolin r relion........................42novolog................................... 42novolog flexpen....................... 42novolog mix 70/30................... 42novolog mix 70/30 flexpen.......42novolog penfill.........................42novoseven rt.......................... 114novotwist...............................126noxafil..................................... 45np thyroid ...............................150nplate.....................................118nucala.................................... 120nucort......................................89nucynta....................................26nucynta er................................26nuedexta................................ 146nufol...................................... 118nulojix..................................... 67nulytely with flavor packs......121nuplazid...................................61nutropin aq nuspin 10............106nutropin aq nuspin 20............106nutropin aq nuspin 5............. 106nuvaring.................................. 77nuvigil..................................... 18nuwiq.....................................114nyamyc .................................... 89

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nymalize.................................. 71nystatin ................. 46, 69, 89, 130nystatin-triamcinolone ..............89nystop ...................................... 89ob complete gold................... 132ob complete premier.............. 132ob complete/dha.................... 132o-cal fa...................................132o-cal prenatal.........................132ocaliva................................... 109ocella ....................................... 77octagam.................................142octreotide acetate ................... 106ocuflox...................................138ocuvel.................................... 132odefsey.................................... 64odomzo................................... 58ofev........................................148ofloxacin ................. 109, 138, 141ogestrel .................................... 77olanzapine ................................61olanzapine-fluoxetine hcl .146, 147olmesartan medoxomil ............. 51olmesartan medoxomil-hctz ...... 51olmesartan-amlodipine-hctz ......51olopatadine hcl ................134, 138olumiant.................................. 21olux......................................... 89olux-e...................................... 89omeclamox-pak..................... 152omega-3-acid ethyl esters ..........48omeprazole .............................153omeprazole magnesium ...........153omeprazole-sodium bicarbonate ............................ 153omnaris..................................134omnipred............................... 139omnitrope..............................106on call express blood glucose...97on call plus blood glucose........97on call vivid blood glucose.......97ondansetron ..............................45ondansetron hcl ........................ 45onetouch club lancets fine pt. 126onetouch combo pack............126onetouch delica lancets 33g....126onetouch delica lancets fine... 126onetouch delica lancing dev... 126onetouch finepoint lancets.....126onetouch ultra blue................. 97

onetouch ultrasoft lancets......126onetouch verio.........................97onexton................................... 89onfi..........................................36onglyza.................................... 42onzetra xsail...........................128opana...................................... 26opium .......................................43opsumit................................... 71optimal d3 m......................... 157optimal-d...............................157option 2................................... 77optumrx blood glucose test......97opurity vitamin d...................157oracea......................................89oralone ................................... 130oramagicrx............................ 130orap....................................... 147orapred odt..............................79oravig.................................... 130orencia.....................................21orencia clickject....................... 21orenitram.................................71orfadin...................................106orilissa................................... 106orkambi............................. 80, 81orphenadrine citrate er ............133orsythia ....................................77ortho micronor........................77ortho tri-cyclen (28).................77ortho tri-cyclen lo.................... 77ortho-cyclen (28)..................... 77ortho-novum 1/35 (28).............77ortho-novum 7/7/7 (28)............77orthovisc................................133oseltamivir phosphate ............... 64oseni........................................ 43osmolex er............................... 60osmoprep...............................121osphena................................. 106otezla..................................... 143otovel.....................................141otrexup.............................. 21, 22ovace plus................................89ovace plus wash....................... 89ovace wash.............................. 89ovide........................................89ovidrel................................... 106oxandrin.................................. 28oxandrolone ............................. 28

oxaprozin .................................22oxaydo.....................................26oxazepam .................................30oxcarbazepine .......................... 36oxiconazole nitrate ................... 89oxistat......................................89oxsoralen ultra........................ 89oxtellar xr................................ 36oxybutynin chloride ................ 154oxybutynin chloride er ............ 154oxycodone hcl .......................... 26oxycodone hcl er .......................26oxycodone-acetaminophen ........26oxycodone-aspirin .................... 26oxycodone-ibuprofen ................ 26oxycontin.................................27oxymorphone hcl ...................... 27oxymorphone hcl er .................. 27oxytrol................................... 154oxytrol for women................. 154ozempic................................... 43pa vitamin d-3 .........................157pacerone ...................................31paliperidone er ..........................61palonosetron hcl ....................... 45palynziq................................. 107pamelor................................... 38pamidronate disodium .............107pancreaze...............................102pandel......................................89panretin................................... 89pantoprazole sodium ...............153panzyga................................. 142paragard intrauterine copper...77paricalcitol ............................. 107parnate.................................... 38paroex....................................130paromomycin sulfate ................ 19paroxetine hcl ...........................38paroxetine hcl er .......................38paroxetine mesylate ................147paser........................................54pataday..................................139patanase................................ 134patanol.................................. 139paxil........................................ 39paxil cr.....................................38pazeo..................................... 139peg 3350 .................................121peg 3350/electrolytes .............. 121

176

peg 3350-kcl-na bicarb-nacl .... 121peg-3350/electrolytes .............. 122peganone................................. 36pegasys.................................... 64pegasys proclick...................... 64peg-prep.................................122pegylax.................................. 122pen needles ............................. 126pen needles 1/2" ...................... 126pen needles 3/16" .................... 126pen needles 5/16" .................... 126penicillin g pot in dextrose ...... 143penicillin v potassium ..............143penlac...................................... 89pennsaid.................................. 89pentasa.................................. 111pentazocine-naloxone hcl ..........27pentoxifylline er ..................... 114pentylene glycol ........................73pepcid.................................... 153pepcid ac maximum strength. 153percocet................................... 27percura.................................. 101perforomist..............................32perindopril erbumine .................51periomed ................................ 131permethrin ................................89perphenazine ............................ 62perphenazine-amitriptyline ..... 147pertzye................................... 102pexeva..................................... 39phenadoz ..................................47phenazopyridine hcl ................ 112phendimetrazine tartrate .......... 18phendimetrazine tartrate er ...... 18phenelzine sulfate ..................... 39phenobarbital ......................... 119phenoxybenzamine hcl ..............51phentermine hcl ........................ 18phenylephrine hcl ....................139phenytek..................................36phenytoin ................................. 36phenytoin infatabs .................... 36phenytoin sodium ......................36phenytoin sodium extended ....... 36philith ...................................... 77phoslo....................................111phoslyra.................................111phospha 250 neutral ................129phospholine iodide................ 139

physiolyte .................................67phytonadione ..........................157picato...................................... 89pifeltro.....................................64pilocarpine hcl .................131, 139pimozide .................................147pindolol .................................... 68pioglitazone hcl ........................ 43pioglitazone hcl-glimepiride ...... 43pioglitazone hcl-metformin hcl ..43piperacillin sod-tazobactam so 143piroxicam .................................22plan b one-step........................ 77plaquenil..................................53plasma-lyte 148......................129plasma-lyte a......................... 129plavix.....................................114plegridy..................................147plegridy starter pack.............. 147plenvu....................................122plexion.....................................89plexion cleanser....................... 89plexion cleansing cloth............ 89plixda...................................... 89pnv-dha .................................. 132pnv-omega.............................132pnv-select ............................... 132pocketchem ez test...................97podocon.................................. 89polyethylene glycol 3350 .........122polymyxin b-trimethoprim ...... 139polytrim.................................139poly-vi-flor............................ 132poly-vi-flor fs.........................132poly-vi-flor/iron..................... 132pomalyst..................................58ponstel.....................................22portia-28 .................................. 77pot bicarb-pot chloride ............129potaba................................... 157potassium bicarbonate ............ 129potassium chloride .................. 130potassium chloride crys er .......129potassium chloride er .............. 130potassium chloride in nacl ....... 130potassium citrate er ................ 112potassium citrate-citric acid ....112pradaxa................................... 34praluent................................. 142pramcort .................................. 29

pramipexole dihydrochloride .....60pramipexole dihydrochloride er .60pramosone...............................89prandin....................................43prasugrel hcl ...........................114pravachol.................................48pravastatin sodium ................... 48praziquantel ............................. 29prazosin hcl .............................. 51precision pcx............................97precision pcx plus test..............97precision point of care test.......97precision qid test......................97precision sof-tact test...............97precision suredose plus syr.....126precision sure-dose syringe.... 126precision xtra blood glucose.... 97precision xtra ketone............... 97precose.................................... 43pred forte...............................139pred mild............................... 139pred-g.................................... 139pred-g s.o.p............................139prednicarbate ........................... 89prednisolone ............................. 79prednisolone acetate ............... 139prednisolone sodium phosphate......................................... 79, 139prednisone ................................79prednisone intensol..................79prefest....................................109pregnyl ................................... 107premarin........................ 109, 155premphase............................. 109prempro.................................109prenata.................................. 132prenatabs rx ........................... 132prenatal 19 ............................. 132prenatal plus iron...................132prenate dha............................132prepopik................................ 122prestalia...................................51prevacid................................. 153prevacid 24hr.........................153prevacid solutab.................... 153prevalite ................................... 48previfem ................................... 77prevpac.................................. 153prevymis.................................. 64prezcobix................................. 64

177

prezista.................................... 64prialt........................................23priftin...................................... 54prilosec.................................. 153prilosec otc............................ 153primaquine phosphate ...............53primidone ................................. 36primlev.................................... 27primsol.................................... 53prinivil.....................................51pristiq...................................... 39privigen..................................142proair hfa................................ 32probenecid ..............................113procainamide hcl ...................... 31procardia xl............................. 71procentra................................. 18prochlorperazine .......................62prochlorperazine maleate ..........62procrit....................................118proctocort................................29proctofoam hc......................... 29procto-pak ................................29proctosol hc ..............................29proctozone-hc ...........................29procysbi................................. 112prodigy no coding blood gluc.. 97proferrin-forte....................... 118profilnine............................... 115profilnine sd...........................115progesterone micronized ......... 144proglycem................................43prograf.................................... 67prolastin-c............................. 148prolensa................................. 139prolia..................................... 107promacta............................... 118promethazine hcl ...................... 47promethazine vc/codeine ........... 80promethazine-dm ......................80promethegan ............................ 47prometrium........................... 144promiseb..................................90propafenone hcl ........................ 31propafenone hcl er .................... 31propantheline bromide ............ 153proparacaine hcl ..................... 139proparacaine-fluorescein .........139propecia...................................90propranolol hcl ......................... 68

propranolol hcl er ..................... 68propranolol-hctz .......................51propylthiouracil ......................150proscar...................................112protectiron.............................118proteolin................................ 101proteolin ds............................101protonix.................................153protopic...................................90protriptyline hcl ........................39proventil hfa............................ 32provera.................................. 144provigil.................................... 18prozac......................................39prudoxin..................................90prutect..................................... 90pseudoeph-chlorphen-hydrocod . 80psorcon .................................... 90pts panels glucose test..............97pulmicort.................................33pulmicort flexhaler.................. 33pulmona................................ 101pulmozyme............................ 148purefe plus ..............................118purevit dualfe plus .................. 118purixan.................................... 58px acid reducer max st ............153pylera.....................................153pyrazinamide ............................54pyridium................................ 112pyridostigmine bromide ............ 54pyridostigmine bromide er ........ 54qbrelis......................................51qbrexza....................................90qc acid controller max st .........153qc aspirin low dose ....................23qc natura-lax ..........................122qnasl...................................... 134qnasl childrens.......................134qtern...................................... 148qualaquin................................ 53quartette.................................. 77quasense ...................................77quazepam ............................... 119qudexy xr.................................36questran light...........................48quetiapine fumarate ..................62quetiapine fumarate er ..............62quflora fe pediatric................ 132quicktek test............................ 97

quillichew er............................ 18quillivant xr............................. 18quinapril hcl ............................. 51quinapril-hydrochlorothiazide ... 51quinidine gluconate ...................31quinidine gluconate er ...............31quinidine sulfate ....................... 31quinidine sulfate dihydrate ........73quinine sulfate .......................... 54quintet ac blood glucose test....97quintet blood glucose test........ 97qvar redihaler.......................... 33ra acid reducer max st ............ 153ra laxative .............................. 122ra nicotine .............................. 147ra truetest test..........................97ra vitamin d-3 ......................... 157rabeprazole sodium .................153radiagel....................................90radiaplexrx.............................. 90rajani....................................... 77raloxifene hcl ..........................107ramipril ....................................51ranexa......................................30ranitidine hcl .......................... 153rapaflo................................... 112rapamune................................ 67rasagiline mesylate ................... 60rasuvo......................................22ravicti.................................... 107rayaldee................................. 107rayos........................................79razadyne................................ 147razadyne er............................ 147rebetol..................................... 65rebif....................................... 147rebif rebidose......................... 147rebif rebidose titration pack...147rebif titration pack.................147rebinyn.................................. 115reclast.................................... 107reclipsen ...................................77recombinate...........................115rectiv....................................... 29refissa...................................... 90refuah plus blood glucose test..97regenecare................................90regimex....................................18reglan.....................................111regonol.................................... 54

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regranex...................................90relagard................................. 155relenza diskhaler......................65relexxii.....................................18relion insulin syringe..............126reli-on insulin syringe............ 126relion pen needles.................. 126relistor................................... 111relpax.....................................128remeron................................... 39remeron soltab.........................39remicade................................ 111remodulin................................ 71renacidin................................112renagel................................... 111renflexis................................. 111renova..................................... 90renvela................................... 111repaglinide ............................... 43repaglinide-metformin hcl .........43repatha.................................. 142repatha pushtronex system.... 142repatha sureclick....................142replesta.................................. 157replesta childrens................... 157replesta nx............................. 157requip...................................... 60requip xl.................................. 60rescriptor................................. 65restasis................................... 139restasis multidose...................139restoril................................... 119retacrit................................... 118retin-a......................................90retin-a micro............................90retin-a micro pump..................90retrovir.................................... 65revatio................................71, 72reveal blood glucose test..........97revesta................................... 118revlimid................................... 67rexulti...................................... 62reyataz.....................................65rhinocort allergy.................... 135rhofade.................................... 90rhogam ultra-filtered plus......142rhophylac.............................. 142rhopressa............................... 140riastap....................................115ribasphere ................................ 65

ribasphere ribapak ....................65ribavirin ................................... 65ridaura.....................................22rifabutin ................................... 54rifadin......................................54rifamate................................... 54rifampin ................................... 54rifater...................................... 54rightest gs100 blood glucose.... 97rightest gs300 blood glucose.... 97rightest gs550 blood glucose.... 97rilutek.................................... 135riluzole ................................... 135rimantadine hcl ........................ 65riomet......................................43risedronate sodium ..................107risperdal.................................. 62risperidone ............................... 62risperidone m-tab.................... 62ritalin.......................................18ritalin la...................................19ritonavir ................................... 65rituxan.....................................58rivastigmine ............................147rivastigmine tartrate ............... 147rivelsa...................................... 77rixubis....................................115rizatriptan benzoate ................128robaxin.................................. 133rocaltrol.................................107ropinirole hcl ............................ 60ropinirole hcl er ........................ 60rosadan .................................... 90rosadan....................................90rosanil cleanser .........................90rosuvastatin calcium ................. 48rowasa................................... 111roxicodone...............................27roxybond.................................27rozerem..................................119rubraca...........................143, 144ruconest................................. 115rydapt......................................58rynoderm ..................................90rytary.......................................60rythmol sr................................31ryvent...................................... 47sabril....................................... 36safety let lancets.....................126safyral......................................77

saizen.....................................107salagen...................................131salex........................................ 90salicylic acid .............................90salicylic acid wart remover ....... 90saline bacteriostatic ................ 143saline-benzyl alcohol ...............143samsca................................... 107sancuso....................................45sandimmune............................ 67sandostatin............................ 107sandostatin lar depot............. 107santyl.......................................90saphris..................................... 62sapscare twist top lancets ........126sarafem.................................. 147savaysa.................................... 34savella....................................147savella titration pack............. 147sb acid controller max st .........153sb polyethylene glycol 3350 .....122seasonique............................... 77seconal...................................119seebri neohaler.........................33segluromet............................. 149selegiline hcl .............................60selenium sulfide ........................ 90selrx.........................................90selzentry.................................. 65semprex-d................................ 80se-natal 19 ..............................132sensipar..................................107sentra am............................... 101sentra pm...............................101serevent diskus.........................33sernivo.....................................90seroquel................................... 62seroquel xr...............................62serostim................................. 107sertraline hcl ............................ 39se-tan plus .............................. 118sevelamer carbonate ............... 111sfrowasa................................ 111sharobel...................................77shohls modified..................... 112signifor.................................. 107signifor lar............................. 107siklos..................................... 118sildenafil citrate ........................72silenor....................................119

179

siliq..........................................90silvadene..................................91silver nitrate ............................. 91silver sulfadiazine ..................... 91simbrinza............................... 139simple diagnostics lancing dev...............................................127simponi....................................22simponi aria.............................22simulect................................... 67simvastatin ...............................48sinemet.................................... 60sinemet cr................................ 60singulair...................................33sirolimus .................................. 67sirturo......................................54sitavig...................................... 65sivextro....................................53skelaxin..................................134sklice........................................91skyla........................................ 77sm acid reducer max st ........... 153sm clearlax.............................122sm nicotine ............................. 147sm vitamin d3 ......................... 157smart sense value test...............97smartest blood glucose test...... 97smooth lax............................. 122sod benz-sod phenylacet ..........107sod citrate-citric acid .............. 112sodium chloride ......... 80, 112, 130sodium chloride bacteriostatic .143sodium edecrin.......................103sodium fluoride .......................130sodium hydroxide ..................... 73sodium phenylbutyrate ............107sodium polystyrene sulfonate......................................... 67, 144sodium sulfacetamide ................91solia ......................................... 77soliqua................................... 120solodyn.................................. 150solosec..................................... 19soltamox..................................58solu-cortef............................... 79solu-medrol............................. 79solus v2 test............................. 97soma...................................... 134somatuline depot................... 107somavert................................107

sonafine................................... 91soolantra................................. 91soriatane..................................91sorilux..................................... 91sorine ....................................... 68sotalol hcl .................................69sotalol hcl (af) ......................... 68sotylize.................................... 69sovaldi..................................... 65spectracef.................................73spinosad ................................... 91spiriva handihaler....................33spiriva respimat....................... 33spironolactone ........................ 103spironolactone-hctz .................103sporanox..................................46sporanox pulsepak...................46sprintec 28 ................................77spritam.................................... 36sprix........................................ 22sprycel..................................... 58sronyx ......................................77sski.......................................... 80sss 10-5 .................................... 91st joseph aspirin ........................23stalevo 100...............................60stalevo 125...............................60stalevo 150...............................60stalevo 200...............................60stalevo 50.................................60stalevo 75.................................60starlix...................................... 43stavudine .................................. 65steglatro...................................43steglujan................................ 148stelara.............................. 91, 120sterile water for irrigation .........67stimate................................... 107stiolto respimat........................33stivarga....................................58strattera................................... 19strensiq.................................. 120streptomycin sulfate ................. 19striant...................................... 28stribild..................................... 65striverdi respimat.....................33stromectol................................29suboxone................................. 27subsys...................................... 27sucraid................................... 102

sucralfate ............................... 154sular........................................ 71sulfacetamide sodium ........ 91, 139sulfacetamide sodium (acne) .... 91sulfacetamide sodium-sulfur ......91sulfacetamide sod-sulfur wash ...91sulfacetamide-prednisolone ..... 139sulfacleanse 8/4 ........................ 91sulfadiazine ............................ 149sulfamethoxazole-trimethoprim 53sulfamylon...............................91sulfasalazine ...........................111sulfazine ................................. 111sulindac ....................................22sumadan.................................. 91sumatriptan ............................ 128sumatriptan succinate ............. 128sumatriptan succinate refill .....128sumatriptan-naproxen sodium .128sumaxin................................... 91sumaxin cp.............................. 91supartz fx...............................134super daily d3 ......................... 157super thin lancets ....................127supprelin la............................ 107suprax......................................73supreme test.............................97suprep bowel prep kit............ 122sure edge test........................... 97surechek blood glucose test..... 97sure-test easyplus mini test...... 97surmontil................................. 39sustiva..................................... 65sutent.......................................58swabflush saline flush ..............130syeda ........................................77sylatron................................... 58symax duotab........................ 154symbicort.................................33symbyax................................ 147symdeko.................................. 81symfi........................................65symfi lo....................................65symlinpen 120..........................43symlinpen 60............................43symproic................................ 111symtuza................................... 65synagex..................................132synagis................................... 142synalar.....................................91

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synalar (cream)........................91synalar (ointment)................... 91synalar ts................................. 91synarel................................... 107synatek.................................. 132syndros.................................... 45synera...................................... 91synjardy.................................149synjardy xr.............................149synribo.................................... 58synthroid............................... 150synvisc................................... 134synvisc one.............................134syprine.....................................67tabloid..................................... 58taclonex................................... 92tacrolimus ...........................67, 92tadalafil ................................... 72tadalafil (pah) ......................... 72tafinlar.....................................58tagrisso.................................... 58take action ............................... 77takhzyro................................ 143taltz......................................... 92talzenna..........................143, 144tamiflu.....................................65tamoxifen citrate ......................58tamsulosin hcl .........................112tandem f................................ 118tandem plus........................... 118tapazole................................. 150taperdex 12-day....................... 79taperdex 6-day.........................79tarceva.....................................58targadox................................ 150targretin............................. 58, 92tarka........................................51taron forte ..............................118taron-c dha............................ 132tasigna..................................... 58tasmar..................................... 60tavalisse................................. 149taytulla.................................... 77tazarotene ................................ 92tazicef ...................................... 73tazorac.....................................92taztia xt ................................... 71tecfidera.................................147technivie................................ 119teflaro......................................73

tegretol.................................... 36tegretol-xr................................36tekturna...................................51tekturna hct............................. 51telcare blood glucose test.........97telmisartan ...............................51telmisartan-amlodipine ............. 52telmisartan-hctz ....................... 52temazepam ............................. 119temodar................................... 58temovate..................................92temozolomide ........................... 58temsirolimus .............................58tenofovir disoproxil fumarate ....65terazosin hcl ............................. 52terbinafine hcl .......................... 46terbutaline sulfate .....................33terconazole .............................155tessalon perles..........................80testim.......................................28testosterone ........................ 28, 73testosterone cypionate .........28, 73testosterone enanthate .............. 28tetcaine .................................. 139tetrabenazine ..........................147tetracaine hcl ..........................139tetracycline hcl ....................... 150tetravisc ................................. 139texacort................................... 92tgt aspirin .................................23tgt nicotine step one ................147tgt nicotine step three ............. 147tgt nicotine step two ................147tgt powderlax.........................122thalomid.................................. 67theo-24.................................... 33theochron ................................. 33theophylline ..............................33theophylline er ..........................33thera-d 2000...........................157thera-d 4000...........................157thera-d rapid repletion...........157theramine...............................101theramine plus....................... 101thiola..................................... 112thioridazine hcl .........................62thiothixene ............................... 62thrive ......................................147thymoglobulin......................... 67thyrogen.................................. 97

tiagabine hcl .............................36tiazac....................................... 71tibsovo...................................120tigan........................................ 45tiglutik................................... 135tikosyn.....................................31tilia fe ...................................... 77timolol maleate ................. 69, 139timoptic................................. 139timoptic ocudose................... 139timoptic-xe............................ 139tindamax................................. 53tinidazole ................................. 53tirosint................................... 150tis-u-sol .................................... 67tivicay......................................65tivorbex................................... 22tizanidine comfort pac........... 134tizanidine hcl .......................... 134tl gard rx ................................118tl icon .....................................118tobi..........................................19tobi podhaler........................... 19tobradex................................ 140tobradex st.............................140tobramycin ...............................19tobramycin sulfate ....................19tobramycin-dexamethasone .... 140tobrex.................................... 140tolak........................................ 92tolazamide ................................43tolbutamide .............................. 43tolcapone ..................................60tolmetin sodium ........................22tolterodine tartrate ................. 155tolterodine tartrate er ............. 155topamax.................................. 37topamax sprinkle.....................37topicort....................................92topicort spray.......................... 92topiramate ............................... 37toposar .....................................58toprol xl...................................69torisel...................................... 59torsemide ................................103toujeo max solostar................. 43toujeo solostar.........................43toviaz.....................................155tracleer.................................... 72tradjenta.................................. 43

181

tramadol hcl ............................. 27tramadol hcl er ......................... 27tramadol hcl er (biphasic) ........ 27tramadol-acetaminophen .......... 27trandolapril .............................. 52trandolapril-verapamil hcl er .... 52tranexamic acid ......................118transderm-scop (1.5 mg).......... 45tranxene-t................................ 30tranylcypromine sulfate ............ 39traumeel.................................. 67travatan z...............................140trazodone hcl .................... 39, 148trecator....................................55trelegy ellipta........................... 33trelstar mixject.........................59tremfya.................................... 92trepadone.............................. 101tresiba flextouch...................... 43tretinoin ..............................59, 92tretinoin (emollient) .................92tretinoin microsphere ................92tretinoin microsphere pump ...... 92tretten.................................... 115trexall...................................... 59treximet................................. 128trezix....................................... 27tri femynor.............................. 77triacetin ................................... 73triamcinolone acetonide..................................92, 131, 135triaminic allerchews.................47triamterene-hctz ..................... 103triazolam ................................119tribenzor..................................52tricare .................................... 132tricare prenatal dha one.........132tricon ..................................... 118tricor....................................... 48triderm .....................................92triderm.................................... 92tridesilon................................. 92trientine hcl .............................. 67trifluoperazine hcl .................... 62trifluridine ..............................140trigels-f forte .......................... 118triglide..................................... 49trihexyphenidyl hcl ................... 60tri-legest fe ...............................78trileptal....................................37

tri-linyah .................................. 78trilipix......................................49tri-luma................................... 92trilyte ..................................... 122trimethobenzamide hcl ..............45trimethoprim ............................ 53tri-mili..................................... 78trimipramine maleate ............... 39trimpex .................................... 53trinessa (28) ............................ 78tri-norinyl (28).........................78trintellix........................... 39, 148tri-previfem .............................. 78triptodur................................108tri-sprintec ............................... 78triumeq....................................65triveen-duo dha..................... 132trivisc.....................................134trivora (28) ..............................78trizivir......................................65trokendi xr...............................37tropicamide ............................ 140trospium chloride ....................155trospium chloride er ................155true metrix blood glucose test..97trueplus insulin syringe.......... 127trueplus lancets 26g............... 127trueplus lancets 30g............... 127trueplus safety lancets 28g..... 127truetest test.............................. 98truetrack test........................... 98trulance................................... 73trulicity....................................43trusopt................................... 140truvada.................................... 65tudorza pressair.......................33tulana...................................... 78tusnel c.................................... 80tussicaps.................................. 80tussionex pennkinetic er.......... 80tuzistra xr................................ 80twynsta.................................... 52tybost...................................... 62tydemy.....................................78tykerb...................................... 59tylenol with codeine #3........... 27tylenol with codeine #4........... 27tymlos....................................108tysabri....................................147tyvaso...................................... 72

tyvaso refill ..............................72tyvaso starter...........................72uceris................................. 29, 79udamin sp.............................. 132ulesfia...................................... 92uloric..................................... 113ulticare insulin syringe........... 127ulticare short pen needles.......127ultima test................................98ultracet.................................... 27ultram......................................27ultratrak pro test..................... 98ultratrak ultimate test..............98ultravate.................................. 93unasyn................................... 143unifine pentips plus................127unistrip1 generic...................... 98unithroid ................................ 151unithroid direct .......................151uptravi................................... 148urecholine.............................. 155urocit-k 10............................. 112urocit-k 15............................. 112urocit-k 5............................... 112urso 250................................. 111urso forte............................... 111ursodiol .................................. 111utibron neohaler......................33utopic...................................... 93vagifem.................................. 155valacyclovir hcl .........................65valchlor................................... 93valcyte................................65, 66valganciclovir hcl ......................66valium..................................... 30valproate sodium ...................... 37valproic acid .............................37valsartan .................................. 52valsartan-hydrochlorothiazide ...52valtrex..................................... 66vanatol lq................................ 23vancomycin hcl ....................... 112vandazole ............................... 155vaniqa......................................93vanishpoint insulin syringe.... 127vanos....................................... 93vantas...................................... 59varubi...................................... 45vascazen.................................101vascepa.................................... 49

182

vasculera................................101vaseretic...................................52vasotec.....................................52vayacog................................. 102vayarin...................................102vayarol...................................102vecamyl................................... 52vectical.................................... 93veletri...................................... 72velivet .......................................78velphoro................................ 111veltassa.............................67, 144veltin....................................... 93vemlidy....................................66venclexta..................................55venclexta starting pack............ 55venipuncture cpi...................... 93venlafaxine hcl ......................... 39venlafaxine hcl er ..................... 39venofer...................................118venomil mixed vespid venom...69ventavis................................... 72ventolin hfa............................. 33verapamil hcl ............................71verapamil hcl er ........................71verdeso.................................... 93verdrocet................................. 27verelan.....................................71versacloz..................................62verzenio................................... 80vesicare.................................. 155vestura ..................................... 78vfend....................................... 46viberzi....................................120vibramycin.............................150vicodin ..................................... 27vicodin es ................................. 27vicodin hp .................................27victory agm-4000 test...............98victoza..................................... 43vida mia unifine pentips.........127videx........................................66videx ec....................................66viekira pak.............................119viekira xr............................... 119vigabatrin .................................37vigadrone.................................37vigamox.................................140viibryd..............................39, 148viibryd starter pack.......... 39, 148

vimizim..................................131vimovo.................................... 22vimpat..................................... 37viokace.................................. 102viorele ...................................... 78viracept....................................66viramune................................. 66viramune xr............................. 66virasal......................................93viread...................................... 66virt-gard................................ 118virt-pn....................................132virt-pn dha.............................132visionblue.............................. 140vistaril..................................... 30vistogard..................................44visudyne.................................140vitafol fe+.............................. 132vitafol gummies..................... 132vitafol-ob+dha...................... 132vitafol-one............................. 132vital-d rx................................ 133vitamin d ................................ 157vitamin d (ergocalciferol) .......157vitamin d2 .............................. 157vitamin d3 .......................157, 158vitamin d3 maximum strength .157vitamin d3 super strength ........ 158vivelle-dot..............................109vivitrol.....................................44vivlodex................................... 22vizimpro.................................. 59vocal point blood glucose test..98vogelxo.................................... 28vogelxo pump..........................28vol-plus..................................133vol-tab rx............................... 133voltaren................................... 93vonvendi................................115voraxaze.................................. 59voriconazole ............................. 46vosevi.....................................119votrient....................................59vpriv...................................... 118vraylar..................................... 62vsl#3......................................102vsl#3 ds................................... 43vsl#3 junior........................... 102vusion......................................93vytorin.....................................49

vyvanse....................................19vyzulta................................... 140warfarin sodium ....................... 34wavesense presto..................... 98welchol.................................... 49wellbutrin sr............................ 39wellbutrin xl............................ 39wera .........................................78westhroid...............................151wide-seal diaphragm 60......... 127wide-seal diaphragm 65......... 127wide-seal diaphragm 70......... 127wide-seal diaphragm 75......... 127wide-seal diaphragm 80......... 127wide-seal diaphragm 85......... 127wide-seal diaphragm 90......... 127wide-seal diaphragm 95......... 127wilate..................................... 115winrho sdf..............................142wp thyroid............................. 151wymzya fe ................................ 78xadago.....................................60xalatan...................................140xalkori..................................... 59xanax.......................................30xanax xr...................................30xarelto..................................... 34xarelto starter pack..................34xatmep.....................................59xelitral..................................... 93xeljanz..................................... 22xeljanz xr................................. 22xeloda......................................59xenazine.................................147xenical..................................... 19xeomin...................................135xepi..........................................93xerese.......................................93xermelo..................................151xgeva..................................... 108xhance................................... 135xiaflex......................................67xifaxan.....................................53xigduo xr............................... 149xiidra..................................... 122ximino................................... 150xodol....................................... 27xolair....................................... 33xolegel..................................... 93xopenex................................... 33

183

xopenex concentrate................ 33xopenex hfa............................. 33xtampza er...............................27xtandi...................................... 59xulane......................................78xultophy................................ 120xuriden.................................. 119xyntha....................................115xyntha solofuse......................115xyrem.....................................147xyzal allergy 24hr.................... 47xyzal allergy 24hr childrens..... 47yasmin 28................................ 78yaz...........................................78yervoy......................................59yonsa....................................... 59yosprala.................................115yuvafem.................................155zaditor................................... 140zafirlukast ................................33zaleplon ..................................119zaltrap..................................... 59zanaflex................................. 134zanosar.................................... 59zantac.................................... 154zarah ........................................78zarontin................................... 37zarxio.....................................118zatean-pn dha........................ 133zatean-pn plus....................... 133zavara .................................... 118zavesca...................................118zegerid................................... 154zegerid otc............................. 154zejula..................................... 144zelapar.....................................60zelboraf................................... 59zemaira.................................. 148zembrace symtouch............... 128zemplar..................................108zenatane ...................................93zenatane.................................. 93zenpep................................... 102zenzedi.....................................19zepatier.................................. 119zerit......................................... 66zestril.......................................52zetia.........................................49zetonna.................................. 135ziac.......................................... 52

ziagen...................................... 66ziana........................................93zidovudine ................................ 66zileuton er ................................ 33zinc acetate .............................. 73zioptan...................................140ziprasidone hcl ..........................62zipsor.......................................22zirgan.....................................140zithromax.............................. 123zithromax tri-pak...................123zithromax z-pak.....................123zocor....................................... 49zofran...................................... 45zohydro er............................... 27zoladex.................................... 59zoledronic acid ....................... 108zolinza..................................... 59zolmitriptan ............................128zoloft....................................... 39zolpidem tartrate .................... 120zolpidem tartrate er ................ 120zolpimist................................ 120zomacton...............................108zometa................................... 108zomig.....................................128zomig zmt.............................. 128zonalon....................................93zonegran..................................37zonisamide ............................... 37zontivity.................................144zorbtive..................................108zortress.................................... 67zorvolex...................................22zosyn..................................... 143zovia 1/35e (28) .......................78zovirax............................... 66, 93ztlido....................................... 93zubsolv.................................... 27zuplenz.................................... 45zurampic................................113zyban..................................... 147zyclara..................................... 93zyclara pump........................... 93zydelig................................... 143zyflo........................................ 33zyflo cr.....................................33zykadia.................................... 59zylet....................................... 140zyloprim................................ 113

zymaxid................................. 140zypitamag................................49zyprexa.................................... 62zyprexa zydis........................... 62zyrtec allergy........................... 47zyrtec-d allergy & congestion...80zytaze.....................................102zytiga.......................................59zyvox....................................... 53

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Plan for your best healthfm.formularynavigator.com/FBO/41/2018_Aetna_Value_Small...Plan for your best health 2018 Aetna Pharmacy Drug Guide Aetna Value Small Group Plan: IA, NE aetna.com