Your 2019 Formulary - Health Alliance

Your 2019 Formulary Effective January 1, 2019

Updated December 1, 2019

For the most current list of covered medications or if you have questions, call the Customer Service number on the back of your ID card or visit YourHealthAlliance.org.

On YourHealthAlliance.org, you can also: • Locate a participating retail pharmacy by ZIP code. • Look up possible lower-cost medication alternatives. • Compare medication pricing and options.

Understanding your formulary

What is a formulary? A formulary is a list of prescribed medications chosen About this formulary by your plan for their safety, cost and effectiveness. Where differences exist between Medications are listed by categories or classes and this formulary and your benefit plan are placed into cost levels known as tiers. The formulary documents, the benefit plan documents includes both brand-name and generic prescription rule. This may not be a complete list of medications approved by the U.S. Food and Drug medications, and not all medications Administration (FDA). listed may be covered by your plan.

Please look at the benefit planHow do I use my formulary? documents provided by your employerYou and your doctor can consult the formulary to or plan sponsor for full details.help you select the most cost-effective prescription medications. This guide tells you if a medication is generic or brand name, and if special rules apply. Bring this list with you when you see your doctor. If you have questions on how your medication is covered, call the Customer Service number on the back of your ID card or visit YourHealthAlliance.org.

What are tiers? Tiers are the different cost levels you pay for a medication. Generally, the higher your medication’s tier, the more you’ll pay out of pocket for it.

When does the formulary change? • Medications may move to a lower tier at any time.

• Medications may move to a higher tier when a generic equivalent becomes available.

• Medications may move to a higher tier or be excluded from coverage during the year as other formulary alternatives become available.

When a medication changes tiers, you may have to pay a different amount for that medication.

Why are some medications excluded from coverage? A medication may be excluded from coverage under your pharmacy benefit when it works the same as or similar to another prescription or over-the-counter (OTC) medication.

What if I don’t agree with a decision about an excluded medication? You (or your authorized representative) and your doctor can ask for a coverage request by calling the Customer Service number on the back of your ID card.

2

Medication tips

What is the difference between brand-name and generic medications? Generic medications contain the same active ingredients (what makes the medication work) as brand-name medications, but they often cost less. Once the patent for a brand-name medication ends, the FDA can approve a generic version with the same active ingredients. If you choose a brand-name medication after a generic version is available, you may pay the brand-name copayment plus the cost difference between the brand-name and generic medication. These medications will have a comment saying “Brand penalty applies” in the notes section.

What if my doctor writes a brand-name prescription?

Over-the-counter (OTC) medications An OTC medication may be the right treatment option for some conditions. Talk to your doctor about available OTC options. Even though these medications may not be covered by your pharmacy benefit, they may cost less than a prescription medication.

If your doctor gives you a prescription for a brand-name medication, ask if a generic equivalent or lower-cost option is available and could be right for you. Generic medications are usually your lowest-cost option.

3

Reading your formulary

The formulary gives you choices so you and your doctor can determine your best course of treatment. In this formulary, brand-name medications are shown in UPPERCASE (for example, CLOBEX) and generic medications in lowercase (for example, clobetasol).

Tier Information Using lower tier or preferred medications can help you pay your lowest out-of-pocket cost. Please note: If you have a high-deductible plan, the tier cost levels will apply once you hit your deductible.

Drug Tier Includes Helpful Tips

Tier 1

Tier 2

Tier 3

Tier 4

Tier 5

Tier 6

General Medical (GM)

Preventive and preferred generic

Non-preferred generic (most generics)

Preferred brand name

Non-preferred brand name

Preferred specialty pharmacy and medical

Non-preferred specialty pharmacy and medical

Medications covered under the medical benefit

Preventive care medications and preferred generic medications are available at no out-of-pocket cost.

Use Tier 2 medications for the lowest out-of-pocket costs. Alternatives may be found in Tier 1.

Use Tier 3 medications, instead of Tier 4, to help reduce your out-of-pocket costs.

Many Tier 4 medications may have lower-cost options in Tier 1, 2 and 3. Ask your doctor or pharmacist if they could work for you.

Specialty medications may be limited to a specialty pharmacy.

Specialty medications may be limited to a specialty pharmacy.

These medications are not covered under your pharmacy benefit. They are provided and managed in a doctor’s office or hospital.

Drug list Information In this drug list, some medications are noted with letters next to them to help you see which ones may have coverage requirements or limits. Your benefit plan determines how these medications may be covered for you.

AL Age Limit – Based on government or manufacturer guidelines, these medications are only covered for certain age groups.

PA Prior Authorization – Your doctor is required to provide additional information to determine coverage.

PV Preventive – These medications are covered at $0 under preventive benefit.

PV* Preventive* – These medications may be covered as preventive care if you meet the guidelines based on your plan.

QL Quantity Limit – Medication may be limited to a certain quantity.

ST Step Therapy – Trial of lower-cost medication(s) is required before a higher-cost medication can be covered.

4

Table of Contents

Analgesics - Drugs for Pain ...........................9Analgesics - Drugs for Pain and

Inflammation .................................................6Anesthetics ................................................... 18Anti-Addiction / Substance Abuse

Treatment Agents .......................................23Antibacterials ................................................24Anticoagulants ..............................................37Anticonvulsants - Drugs for Seizures ........ 41Antidementia Agents - Drugs for

Alzheimer's Disease and Dementia .......... 46Antidepressants ........................................... 47Antiemetics - Drugs for Nausea and

Vomiting ......................................................50Antifungals ....................................................51Antigout Agents ............................................55Anti-inflammatory Agents ............................55Antimigraine Agents .................................... 55Antimyasthenic Agents ................................57Antimycobacterials ...................................... 57Antineoplastics - Drugs for Cancer ............ 58Antiparasitics ................................................71Antiparkinson Agents .................................. 72Antiplatelets ..................................................74Antipsychotics - Drugs for Mood

Disorders .....................................................75Antivirals ....................................................... 78Anxiolytics - Drugs for Anxiety ................... 83Bipolar Agents - Drugs for Mood

Disorders .....................................................85Blood Products / Modifiers / Volume

Expanders - Drugs for Bleeding Disorders 85

Cardiovascular Agents - Drugs for Heart and Circulation Conditions ....................... 91

Central Nervous System Agents - Drugs for Attention Deficit Disorder .................109

Central Nervous System Agents - Drugs for Multiple Sclerosis ...............................111

Central Nervous System Agents - Miscellaneous ...........................................113

Dental and Oral Agents - Drugs for Mouth and Throat Conditions .............................114

Dermatological Agents - Drugs for Skin Conditions .................................................116

Diabetes - Antidiabetic Agents ..................125Diabetes - Glucose Monitoring ..................129Diabetes - Glycemic Agents ...................... 129Diabetes - Insulins ......................................129Electrolytes / Minerals / Metals / Vitamins132

Gastrointestinal Agents - Drugs for Acid Reflux and Ulcer .......................................151

Gastrointestinal Agents - Drugs for Bowel, Intestine and Stomach Conditions

......................................................................152Genetic or Enzyme Disorder - Drugs for

Replacement, Modification, Treatment .. 156Genitourinary Agents - Drugs for Bladder,

Genital and Kidney Conditions ...............158Genitourinary Agents - Drugs for Prostate

Conditions .................................................161Hormonal Agents - Adrenal ....................... 162Hormonal Agents - Men's Health .............. 164Hormonal Agents - Osteoporosis ............. 166Hormonal Agents - Parathyroid ................ 166Hormonal Agents - Pituitary ...................... 166Hormonal Agents - Prostaglandins .......... 170Hormonal Agents - Sex Hormones and

Birth Control ............................................. 170Hormonal Agents - Thyroid ....................... 180Immunological Agents - Drugs for

Immune System Stimulation or Suppression ..............................................182

Immunological Agents - Drugs for Vaccination ............................................... 189

Inflammatory Bowel Disease Agents ........192Metabolic Bone Disease Agents - Drugs

for Osteoporosis ...................................... 193Metabolic Bone Disease Agents - Other .. 195Miscellaneous Therapeutic Agents .......... 195Ophthalmic Agents - Drugs for Eye

Allergy, Infection and Inflammation ....... 210Ophthalmic Agents - Drugs for Glaucoma......................................................................213Ophthalmic Agents - Drugs for

Miscellaneous Eye Conditions ................215Otic Agents - Drugs for Ear Conditions ... 219Respiratory Tract / Pulmonary Agents -

Drugs for Allergies, Cough, Cold ............220Respiratory Tract / Pulmonary Agents -

Drugs for Asthma and Other Lung Conditions .................................................223

Respiratory Tract / Pulmonary Agents - Drugs for Cystic Fibrosis ........................ 228

Respiratory Tract / Pulmonary Agents - Drugs for Pulmonary Hypertension ........228

Skeletal Muscle Relaxants - Drugs for Muscle Pain and Spasm .......................... 229

Sleep Disorder Agents ............................... 231Index of Drugs.............................................. 232

5

Drug NameDrug Tier

Notes

Analgesics - Drugs for Pain and Inflammation

ACTIVE-KETOPROFEN EXTERNAL CREAM 5 %

4

ANAPROX DS ORAL TABLET 550 MG

4

ARTHROTEC ORAL TABLET DELAYED RELEASE 50-0.2 MG, 75-0.2 MG

4

aspirin adult low strength oral tablet delayed release 81 mg

PV

aspirin childrens oral tablet chewable 81 mg

PV

aspirin ec low dose oral tablet delayed release 81 mg

PV

aspirin ec low strength oral tablet delayed release 81 mg

PV

aspirin low dose oral tablet chewable 81 mg

PV

aspirin low dose oral tablet delayed release 81 mg

PV

bayer aspirin ec low dose oral tablet delayed release 81 mg

PV

CALDOLOR INTRAVENOUS SOLUTION 800 MG/8ML

GM

CAMBIA ORAL PACKET 50 MG

4

CELEBREX ORAL CAPSULE 100 MG, 200 MG, 400 MG, 50 MG

4

celecoxib oral capsule 100 mg, 200 mg, 400 mg, 50 mg

2

choline-mag trisalicylate oral liquid 500 mg/5ml

2

Drug NameDrug Tier

Notes

DAYPRO ORAL TABLET 600 MG

4

DICLOFENAC EPOLAMINE TRANSDERMAL PATCH 1.3 %

4 ST

diclofenac potassium oral tablet 50 mg

2

diclofenac sodium er oral tablet extended release 24 hour 100 mg

2

diclofenac sodium oral tablet delayed release 25 mg

2

diclofenac sodium oral tablet delayed release 50 mg, 75 mg

1

diclofenac sodium transdermal gel 1 %

2

diclofenac-misoprostol oral tablet delayed release 50-0.2 mg, 75-0.2 mg

2

DICLOSTREAM EXTERNAL THERAPY PACK 1.5-10 %

4

diflunisal oral tablet 500 mg

2

DIMENTHO EXTERNAL THERAPY PACK 1.5 & 10 %

4

DITHOL EXTERNAL THERAPY PACK 1.5-10 %

4

EC-NAPROSYN ORAL TABLET DELAYED RELEASE 375 MG, 500 MG

4

ec-naproxen oral tablet delayed release 375 mg, 500 mg

2


PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria

6

Drug NameDrug Tier

Notes

ENOVARX-IBUPROFEN EXTERNAL CREAM 10 %

4

EQUAPAX/IBUPROFEN/MINREX ORAL THERAPY PACK 800 MG

4

etodolac er oral tablet extended release 24 hour 400 mg, 500 mg, 600 mg

2

etodolac oral capsule 200 mg, 300 mg

2

etodolac oral tablet 400 mg, 500 mg

2

FBL KIT EXTERNAL CREAM 15-4-5 %

4

FELDENE ORAL CAPSULE 10 MG, 20 MG

4

fenoprofen calcium oral capsule 200 mg, 400 mg

2

fenoprofen calcium oral tablet 600 mg

2

fenortho oral capsule 200 mg

2

FLECTOR TRANSDERMAL PATCH 1.3 %

4 ST

flurbiprofen oral tablet 100 mg, 50 mg

2

ibu oral tablet 400 mg, 600 mg, 800 mg

2

ibuprofen lysine intravenous solution 10 mg/ml

GM

ibuprofen oral suspension 100 mg/5ml

2

ibuprofen oral tablet 400 mg, 600 mg, 800 mg

2

IC 400 ORAL KIT 400 MG

4

Drug NameDrug Tier

Notes

IC 800 ORAL KIT 800 MG

4

INDOCIN ORAL SUSPENSION 25 MG/5ML

4

INDOCIN RECTAL SUPPOSITORY 50 MG

3

indomethacin er oral capsule extended release 75 mg

2

indomethacin oral capsule 25 mg, 50 mg

2

indomethacin sodium intravenous solution reconstituted 1 mg

GM

ketoprofen er oral capsule extended release 24 hour 200 mg

2

ketoprofen oral capsule 25 mg, 50 mg, 75 mg

2

ketorolac tromethamine injection solution 15 mg/ml, 30 mg/ml

2

KETOROLAC TROMETHAMINE INJECTION SOLUTION PREFILLED SYRINGE 60 MG/20ML

GM

ketorolac tromethamine oral tablet 10 mg

2QL (20 EA

per 30 days)

KETOROLAC TROMETHAMINE SOLUTION 60 MG/2ML INTRAMUSCULAR 60 MG/2ML

4

ketorolac tromethamine solution 60 mg/2ml intramuscular 60 mg/2ml

2



7

Drug NameDrug Tier

Notes

KETOROLAC-BUPIV-KETAMINE INJECTION SOLUTION PREFILLED SYRINGE 60-150-60 MG/50ML

GM

KETOROLAC-ROPIV-KETAMINE INJECTION SOLUTION PREFILLED SYRINGE 15-100-30 MG/50ML

GM

LIDOPROFEN EXTERNAL CREAM 5-5-2 %

4

LODINE ORAL TABLET 400 MG

4

meclofenamate sodium oral capsule 100 mg, 50 mg

2

mefenamic acid oral capsule 250 mg

2

meloxicam oral tablet 15 mg, 7.5 mg

1

MOBIC ORAL TABLET 15 MG, 7.5 MG

4

nabumetone oral tablet 500 mg, 750 mg

2

NALFON ORAL CAPSULE 400 MG

4

NALFON ORAL TABLET 600 MG

4

NAPRELAN ORAL TABLET EXTENDED RELEASE 24 HOUR 375 MG, 500 MG, 750 MG

4

NAPROSYN ORAL SUSPENSION 125 MG/5ML

4

NAPROSYN ORAL TABLET 500 MG

4

naproxen dr oral tablet delayed release 375 mg, 500 mg

2

Drug NameDrug Tier

Notes

naproxen oral suspension 125 mg/5ml

2

naproxen oral tablet 250 mg, 375 mg, 500 mg

2

naproxen sodium er oral tablet extended release 24 hour 375 mg, 500 mg

2

naproxen sodium oral tablet 275 mg, 550 mg

2

NEOPROFEN INTRAVENOUS SOLUTION 10 MG/ML

GM

oxaprozin oral tablet 600 mg

2

piroxicam oral capsule 10 mg, 20 mg

2

PONSTEL ORAL CAPSULE 250 MG

4

profeno oral tablet 600 mg

2

qc aspirin low dose oral tablet delayed release 81 mg

PV

salsalate oral tablet 500 mg, 750 mg

2

SPRIX NASAL SOLUTION 15.75 MG/SPRAY

4QL (5 EA

per 30 days)

st joseph low dose oral tablet delayed release 81 mg

PV

sulindac oral tablet 150 mg, 200 mg

2

tolmetin sodium oral capsule 400 mg

2

tolmetin sodium oral tablet 200 mg, 600 mg

2

VOLTAREN TRANSDERMAL GEL 1 %

4

VOPAC KT EXTERNAL CREAM 5-5-2 %

4



8

Drug NameDrug Tier

Notes

Analgesics - Drugs for Pain

7T GUMMY ES ORAL TABLET CHEWABLE 500 MG

4

ABSTRAL SUBLINGUAL TABLET SUBLINGUAL 100 MCG, 200 MCG, 300 MCG, 400 MCG, 600 MCG, 800 MCG

4 PA

acetaminophen-codeine #2 oral tablet 300-15 mg

2


2


2

acetaminophen-codeine oral solution 120-12 mg/5ml

2

acetaminophen-codeine oral tablet 300-15 mg, 300-30 mg, 300-60 mg

2

ACTIQ BUCCAL LOZENGE ON A HANDLE 1200 MCG, 1600 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG

4 PA

alfentanil hcl intravenous solution 1000 mcg/2ml, 2500 mcg/5ml

GM

apap-caff-dihydrocodeine oral capsule 320.5-30-16 mg

2

ARYMO ER ORAL TABLET EXTENDED RELEASE ABUSE-DETERRENT 15 MG, 30 MG, 60 MG

4 ST

ascomp-codeine oral capsule 50-325-40-30 mg

2

Drug NameDrug Tier

Notes

BELBUCA BUCCAL FILM 150 MCG, 300 MCG, 450 MCG, 600 MCG, 75 MCG, 750 MCG, 900 MCG

4PA; QL (60 EA per 30

days)

BUPAP ORAL TABLET 50-300 MG

4

BUPRENEX INJECTION SOLUTION 0.3 MG/ML

GM

buprenorphine hcl injection solution 0.3 mg/ml

GM

buprenorphine transdermal patch weekly 10 mcg/hr, 15 mcg/hr, 20 mcg/hr, 5 mcg/hr

2

BUPRENORPHINE TRANSDERMAL PATCH WEEKLY 7.5 MCG/HR

4

BUTALBITAL-ACETAMINOPHEN ORAL CAPSULE 50-300 MG

2

butalbital-acetaminophen oral tablet 50-300 mg, 50-325 mg

2

butalbital-apap oral tablet 50-325 mg

2

butalbital-apap-caff-cod oral capsule 50-300-40-30 mg, 50-325-40-30 mg

2

butalbital-apap-caffeine oral capsule 50-300-40 mg, 50-325-40 mg

2

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

2

butalbital-asa-caff-codeine oral capsule 50-325-40-30 mg

2

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

2



9

Drug NameDrug Tier

Notes

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

2

butorphanol tartrate injection solution 1 mg/ml, 2 mg/ml

GM

butorphanol tartrate nasal solution 10 mg/ml

2

BUTRANS TRANSDERMAL PATCH WEEKLY 10 MCG/HR, 15 MCG/HR, 20 MCG/HR, 5 MCG/HR, 7.5 MCG/HR

4

capacet oral capsule 50-325-40 mg

2

carisoprodol-aspirin-codeine oral tablet 200-325-16 mg

2

clonidine hcl (analgesia) epidural solution 100 mcg/ml, 500 mcg/ml

6Specialty Medical

codeine sulfate oral tablet 15 mg, 30 mg, 60 mg

2

DEMEROL INJECTION SOLUTION 100 MG/2ML, 100 MG/ML, 25 MG/0.5ML, 25 MG/ML, 50 MG/ML, 75 MG/1.5ML, 75 MG/ML

GM

DEMEROL ORAL TABLET 100 MG

4

DILAUDID INJECTION SOLUTION 1 MG/ML, 2 MG/ML, 4 MG/ML

GM

DILAUDID ORAL LIQUID 1 MG/ML

4

DILAUDID ORAL TABLET 2 MG, 4 MG, 8 MG

4

DOLOPHINE ORAL TABLET 10 MG, 5 MG

4

Drug NameDrug Tier

Notes

DSUVIA SUBLINGUAL TABLET SUBLINGUAL 30 MCG

4

DURACLON EPIDURAL SOLUTION 100 MCG/ML, 500 MCG/ML

6Specialty Medical

DURAGESIC-100 TRANSDERMAL PATCH 72 HOUR 100 MCG/HR

4QL (15 EA

per 30 days)


4QL (15 EA

per 30 days)


4QL (15 EA

per 30 days)


4QL (15 EA

per 30 days)


4QL (15 EA

per 30 days)

duramorph injection solution 0.5 mg/ml, 1 mg/ml

GM

duraxin oral capsule 300-200-20 mg

2

EMBEDA ORAL CAPSULE EXTENDED RELEASE 100-4 MG, 20-0.8 MG, 30-1.2 MG, 50-2 MG, 60-2.4 MG, 80-3.2 MG

4ST; QL (60 EA per 30

days)

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

2

esgic oral capsule 50-325-40 mg

2

ESGIC ORAL TABLET 50-325-40 MG

4

EXALGO ORAL TABLET ER 24 HOUR ABUSE-DETERRENT 12 MG, 16 MG, 32 MG, 8 MG


days)



10

Drug NameDrug Tier

Notes

fentanyl citrate (pf) injection solution 100 mcg/2ml, 1000 mcg/20ml, 250 mcg/5ml, 2500 mcg/50ml, 500 mcg/10ml

GM

fentanyl citrate (pf) injection solution cartridge 100 mcg/2ml

GM

fentanyl citrate buccal lozenge on a handle 1200 mcg, 1600 mcg, 200 mcg, 400 mcg, 600 mcg, 800 mcg

2 PA

FENTANYL CITRATE BUCCAL TABLET 100 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG

4 PA

FENTANYL CITRATE INJECTION SOLUTION 1500 MCG/30ML

GM

FENTANYL CITRATE INJECTION SOLUTION PREFILLED SYRINGE 100 MCG/2ML, 50 MCG/5ML

GM

FENTANYL CITRATE INTRAVENOUS SOLUTION 2500 MCG/50ML, 5000 MCG/100ML

GM

FENTANYL CITRATE INTRAVENOUS SOLUTION PREFILLED SYRINGE 1500 MCG/30ML, 250 MCG/5ML, 2750 MCG/55ML

GM

Drug NameDrug Tier

Notes

FENTANYL CITRATE-NACL INTRAVENOUS SOLUTION 1-0.9 MG/100ML-%, 1.25-0.9 MG/250ML-%, 2-0.9 MG/100ML-%, 2.5-0.9 MG/250ML-%

GM

FENTANYL CITRATE-NACL INTRAVENOUS SOLUTION PREFILLED SYRINGE 10-0.9 MCG/2ML-%, 5-0.9 MCG/ML-%, 550-0.9 MCG/55ML-%

GM

FENTANYL CIT-ROPIVACAINE-NACL EPIDURAL SOLUTION 0.3-0.2-0.9 MG/150ML-%, 0.4-0.15-0.9 MG/200ML-%, 0.4-0.2-0.9 MG/200ML-%, 1.25-0.2-0.9 MG/250ML-%

GM

fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 37.5 mcg/hr, 50 mcg/hr, 62.5 mcg/hr, 75 mcg/hr, 87.5 mcg/hr

2QL (15 EA

per 30 days)



11

Drug NameDrug Tier

Notes

FENTANYL-BUPIVACAINE-NACL EPIDURAL SOLUTION 0.2-0.08-0.9 MG/100ML-%, 0.2-0.1-0.9 MG/100ML-%, 0.2-0.125-0.9 MG/100ML-%, 0.25-0.08-0.9 MG/125ML-%, 0.3-0.125-0.9 MG/100ML-%, 0.4-0.15-0.9 MG/200ML-%, 0.5-0.0625-0.9 MG/100ML-%, 0.5-0.0625-0.9 MG/250ML-%, 0.5-0.1-0.9 MG/100ML-%, 0.5-0.1-0.9 MG/250ML-%, 0.5-0.125-0.9 MG/250ML-%, 0.6-0.125-0.9 MG/200ML-%, 0.75-0.1-0.9 MG/150ML-%, 0.75-0.125-0.9 MG/250ML-%, 1-0.0625-0.9 MG/250ML-%, 1-0.1-0.9 MG/250ML-%, 1-0.125-0.9 MG/250ML-%, 1.25-0.0625-0.9 MG/250ML-%, 1.25-0.075-0.9 MG/250ML-%

GM

FENTORA BUCCAL TABLET 100 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG

4 PA

FIORICET ORAL CAPSULE 50-300-40 MG

4

FIORICET/CODEINE ORAL CAPSULE 50-300-40-30 MG

4

FIORINAL ORAL CAPSULE 50-325-40 MG

4

FIORINAL/CODEINE #3 ORAL CAPSULE 50-325-40-30 MG

4

Drug NameDrug Tier

Notes

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

2

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

2

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

2

hydromorphone hcl er oral tablet er 24 hour abuse-deterrent 12 mg, 16 mg, 32 mg, 8 mg


days)

hydromorphone hcl injection solution 4 mg/ml

GM

hydromorphone hcl oral liquid 1 mg/ml

2

hydromorphone hcl oral tablet 2 mg, 4 mg, 8 mg

2

hydromorphone hcl pf injection solution 1 mg/ml, 10 mg/ml, 2 mg/ml, 4 mg/ml, 50 mg/5ml, 500 mg/50ml

GM

hydromorphone hcl rectal suppository 3 mg

2

HYDROMORPHONE HCL SOLUTION 1 MG/ML INJECTION 1 MG/ML

GM

hydromorphone hcl solution 1 mg/ml injection 1 mg/ml

GM

HYDROMORPHONE HCL SOLUTION 2 MG/ML INJECTION 2 MG/ML

GM



12

Drug NameDrug Tier

Notes

hydromorphone hcl solution 2 mg/ml injection 2 mg/ml

GM

HYDROMORPHONE HCL-NACL INJECTION SOLUTION 20-0.9 MG/100ML-%

GM

HYDROMORPHONE HCL-NACL INTRAVENOUS SOLUTION 10-0.9 MG/100ML-%, 100-0.9 MG/50ML-%, 12-0.9 MG/30ML-%, 15-0.9 MG/30ML-%, 150-0.9 MG/150ML-%, 2-0.9 MG/50ML-%, 20-0.9 MG/100ML-%, 200-0.9 MG/100ML-%, 24-0.9 MG/30ML-%, 25-0.9 MG/250ML-%, 250-0.9 MG/250ML-%, 3-0.9 MG/30ML-%, 30-0.9 MG/150ML-%, 30-0.9 MG/30ML-%, 36-0.9 MG/30ML-%, 40-0.9 MG/200ML-%, 5-0.9 MG/50ML-%, 50-0.9 MG/250ML-%, 60-0.9 MG/30ML-%, 9-0.9 MG/30ML-%

GM

Drug NameDrug Tier

Notes

HYDROMORPHONE HCL-NACL INTRAVENOUS SOLUTION PREFILLED SYRINGE 0.2-0.9 MG/0.2ML-%, 0.4-0.9 MG/2ML-%, 0.5-0.9 MG/0.5ML-%, 0.5-0.9 MG/ML-%, 1-0.9 MG/5ML-%, 1-0.9 MG/ML-%, 10-0.9 MG/25ML-%, 12-0.9 MG/30ML-%, 12.5-0.9 MG/25ML-%, 2-0.9 MG/10ML-%, 2-0.9 MG/ML-%, 2.5-0.9 MG/25ML-%, 20-0.9 MG/50ML-%, 25-0.9 MG/25ML-%, 25-0.9 MG/50ML-%, 3-0.9 MG/30ML-%, 50-0.9 MG/50ML-%, 55-0.9 MG/55ML-%, 6-0.9 MG/30ML-%

GM

HYDROMORPHONE-BUPIVACAINE-NACL EPIDURAL SOLUTION 2.5-0.1-0.9 MG/250ML-%, 4-0.125-0.9 MG/200ML-%

GM

HYDROMORPHONE-ROPIVACAINE-NACL EPIDURAL SOLUTION 2-0.1-0.9 MG/250ML-%

GM

HYSINGLA ER ORAL TABLET ER 24 HOUR ABUSE-DETERRENT 100 MG, 120 MG, 20 MG, 30 MG, 40 MG, 60 MG, 80 MG

4 ST

IBUDONE ORAL TABLET 10-200 MG

4

ibudone oral tablet 5-200 mg

2



13

Drug NameDrug Tier

Notes

INFUMORPH 200 INJECTION SOLUTION 200 MG/20ML (10 MG/ML)

GM

INFUMORPH 500 INJECTION SOLUTION 500 MG/20ML (25 MG/ML)

GM

KADIAN ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG, 100 MG, 20 MG, 200 MG, 30 MG, 40 MG, 50 MG, 60 MG, 80 MG


days)

LAZANDA NASAL SOLUTION 100 MCG/ACT, 300 MCG/ACT, 400 MCG/ACT

4 PA

levorphanol tartrate oral tablet 2 mg, 3 mg

2

lorcet hd oral tablet 10-325 mg

2

lorcet oral tablet 5-325 mg

2

lorcet plus oral tablet 7.5-325 mg

2

LORTAB ORAL ELIXIR 10-300 MG/15ML

4

marten-tab oral tablet 50-325 mg

2

MEDI-DERM-RX EXTERNAL CREAM 0.035-5-20 %

4

MEDROX-RX EXTERNAL OINTMENT 0.05-7-20 %

4

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

GM

meperidine hcl oral solution 50 mg/5ml

2

Drug NameDrug Tier

Notes

meperidine hcl oral tablet 100 mg, 50 mg

2

MEPERIDINE HCL-SODIUM CHLORIDE INTRAVENOUS SOLUTION 300-0.9 MG/30ML-%

GM

methadone hcl injection solution 10 mg/ml

GM

methadone hcl intensol oral concentrate 10 mg/ml

2

methadone hcl oral concentrate 10 mg/ml

2

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

2

methadone hcl oral tablet 10 mg, 5 mg

2

methadone hcl oral tablet soluble 40 mg

2

METHADOSE ORAL CONCENTRATE 10 MG/ML

4

methadose oral tablet soluble 40 mg

2

METHADOSE SUGAR-FREE ORAL CONCENTRATE 10 MG/ML

4

mitigo injection solution 200 mg/20ml (10 mg/ml), 500 mg/20ml (25 mg/ml)

GM

morphine sulfate (concentrate) oral solution 100 mg/5ml, 20 mg/ml

2

morphine sulfate (pf) injection solution 0.5 mg/ml, 1 mg/ml, 10 mg/ml, 2 mg/ml, 4 mg/ml, 5 mg/ml, 8 mg/ml

GM



14

Drug NameDrug Tier

Notes

morphine sulfate (pf) intravenous solution 10 mg/ml, 2 mg/ml, 4 mg/ml, 8 mg/ml

GM

morphine sulfate er beads oral capsule extended release 24 hour 120 mg, 30 mg, 45 mg, 60 mg, 75 mg, 90 mg


days)

morphine sulfate er oral capsule extended release 24 hour 10 mg, 100 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg, 80 mg


days)

morphine sulfate er oral tablet extended release 100 mg, 15 mg, 200 mg, 30 mg, 60 mg

2QL (90 EA

per 30 days)

MORPHINE SULFATE IN DEXTROSE INTRAVENOUS SOLUTION 100-5 MG/100ML-%, 250-5 MG/250ML-%

GM

MORPHINE SULFATE IN DEXTROSE INTRAVENOUS SOLUTION PREFILLED SYRINGE 50-5 MG/25ML-%

GM

MORPHINE SULFATE INJECTION SOLUTION 1 MG/ML

GM

morphine sulfate injection solution 10 mg/ml, 2 mg/ml, 4 mg/ml, 5 mg/ml, 8 mg/ml

GM

morphine sulfate intramuscular device 10 mg/0.7ml

GM

MORPHINE SULFATE INTRAVENOUS SOLUTION 0.5 MG/ML

GM

Drug NameDrug Tier

Notes

morphine sulfate intravenous solution 150 mg/30ml

GM

morphine sulfate oral solution 10 mg/5ml, 20 mg/5ml

2

morphine sulfate oral tablet 15 mg, 30 mg

2

morphine sulfate rectal suppository 10 mg, 20 mg, 30 mg, 5 mg

2

MORPHINE SULFATE SOLUTION 1 MG/ML INTRAVENOUS 1 MG/ML

GM

morphine sulfate solution 1 mg/ml intravenous 1 mg/ml

GM

MORPHINE SULFATE-NACL INJECTION SOLUTION PREFILLED SYRINGE 5-0.9 MG/5ML-%

GM

MORPHINE SULFATE-NACL INTRAVENOUS SOLUTION 100-0.9 MG/100ML-%, 1000-0.9 MG/100ML-%, 150-0.9 MG/150ML-%, 250-0.9 MG/250ML-%, 250-0.9 MG/50ML-%, 500-0.9 MG/100ML-%

GM

MORPHINE SULFATE-NACL INTRAVENOUS SOLUTION PREFILLED SYRINGE 150-0.9 MG/30ML-%, 2-0.9 MG/2ML-%, 2-0.9 MG/ML-%, 275-0.9 MG/55ML-%, 30-0.9 MG/30ML-%, 4-0.9 MG/ML-%, 5-0.9 MG/5ML-%, 55-0.9 MG/55ML-%, 60-0.9 MG/30ML-%

GM



15

Drug NameDrug Tier

Notes

MS CONTIN ORAL TABLET EXTENDED RELEASE 100 MG, 15 MG, 200 MG, 30 MG, 60 MG

4QL (90 EA

per 30 days)

nalbuphine hcl injection solution 10 mg/ml, 20 mg/ml

GM

NALOCET ORAL TABLET 2.5-300 MG

4

NORCO ORAL TABLET 10-325 MG, 5-325 MG, 7.5-325 MG

4

NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HOUR 100 MG, 150 MG, 200 MG, 250 MG, 50 MG


days)

NUCYNTA ORAL TABLET 100 MG, 50 MG, 75 MG

4

ST; QL (120 EA per 30 days)

OPANA ER ORAL TABLET ER 12 HOUR ABUSE-DETERRENT 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 5 MG, 7.5 MG


days)

OPANA ORAL TABLET 10 MG, 5 MG

4

OXAYDO ORAL TABLET ABUSE-DETERRENT 5 MG, 7.5 MG

4 PA

OXYCODONE HCL ER ORAL TABLET ER 12 HOUR ABUSE-DETERRENT 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 60 MG, 80 MG


days)

oxycodone hcl oral capsule 5 mg

2

oxycodone hcl oral concentrate 100 mg/5ml

2

Drug NameDrug Tier

Notes

oxycodone hcl oral solution 5 mg/5ml

2

oxycodone hcl oral tablet 10 mg, 15 mg, 20 mg, 30 mg, 5 mg

2

oxycodone-acetaminophen oral solution 5-325 mg/5ml

2

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

2

oxycodone-aspirin oral tablet 4.8355-325 mg

2

oxycodone-ibuprofen oral tablet 5-400 mg

2

OXYCONTIN ORAL TABLET ER 12 HOUR ABUSE-DETERRENT 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 60 MG, 80 MG


days)

oxymorphone hcl er oral tablet extended release 12 hour 10 mg, 20 mg, 30 mg, 40 mg, 5 mg

2

oxymorphone hcl er oral tablet extended release 12 hour 15 mg, 7.5 mg

2QL (60 EA

per 30 days)

oxymorphone hcl oral tablet 10 mg, 5 mg

2

pentazocine-naloxone hcl oral tablet 50-0.5 mg

2

PERCOCET ORAL TABLET 10-325 MG, 2.5-325 MG, 5-325 MG, 7.5-325 MG

4

phrenilin forte oral capsule 50-300-40 mg

2



16

Drug NameDrug Tier

Notes

PRIALT INTRATHECAL SOLUTION 100 MCG/ML, 500 MCG/20ML, 500 MCG/5ML

GM

PRIMLEV ORAL TABLET 10-300 MG, 5-300 MG, 7.5-300 MG

4

PROBUPHINE IMPLANT KIT SUBCUTANEOUS IMPLANT 74.2 MG

3

remifentanil hcl intravenous solution reconstituted 1 mg, 2 mg, 5 mg

GM

ROXICODONE ORAL TABLET 15 MG, 30 MG, 5 MG

4

SUBSYS SUBLINGUAL LIQUID 100 MCG, 1200 (600 X 2) MCG, 1600 (800 X 2) MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG

4 PA

sufentanil citrate intravenous solution 100 mcg/2ml, 250 mcg/5ml, 50 mcg/ml

GM

SYNALGOS-DC ORAL CAPSULE 356.4-30-16 MG

4

tencon oral tablet 50-325 mg

2

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


days)

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

2

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

2

Drug NameDrug Tier

Notes

tramadol hcl oral tablet 50 mg

2

tramadol-acetaminophen oral tablet 37.5-325 mg

2

TREZIX ORAL CAPSULE 320.5-30-16 MG

4

TYLENOL WITH CODEINE #3 ORAL TABLET 300-30 MG

4

TYLENOL WITH CODEINE #4 ORAL TABLET 300-60 MG

4

ULTIVA INTRAVENOUS SOLUTION RECONSTITUTED 1 MG, 2 MG, 5 MG

GM

ULTRACET ORAL TABLET 37.5-325 MG

4

ULTRAM ORAL TABLET 50 MG

4

VANATOL LQ ORAL SOLUTION 50-325-40 MG/15ML

4

VANATOL S ORAL SOLUTION 50-325-40 MG/15ML

4

vicodin es oral tablet 7.5-300 mg

2

vicodin hp oral tablet 10-300 mg

2

vicodin oral tablet 5-300 mg

2

XODOL ORAL TABLET 10-300 MG, 5-300 MG, 7.5-300 MG

4

XTAMPZA ER ORAL CAPSULE ER 12 HOUR ABUSE-DETERRENT 13.5 MG, 18 MG, 27 MG, 36 MG, 9 MG


days)



17

Drug NameDrug Tier

Notes

xylon oral tablet 10-200 mg

2

zebutal oral capsule 50-325-40 mg

2

ZOHYDRO ER ORAL CAPSULE ER 12 HOUR ABUSE-DETERRENT 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 50 MG


days)

Anesthetics

1ST MEDX-PATCH/ LIDOCAINE EXTERNAL PATCH 4-0.0375-5-20 %

4

7T LIDO EXTERNAL GEL 2 %

4

agoneaze external kit 2.5-2.5 %

2

anodyne lpt external kit 2.5-2.5 %

2

ARTICADENT DENTAL INJECTION SOLUTION CARTRIDGE 4 %-1:100000, 4 %-1:200000

GM

BUFFERED LIDOCAINE INJECTION SOLUTION PREFILLED SYRINGE 0.9-8.4 %

GM

bupivacaine fisiopharma injection solution 2.5 mg/ml, 5 mg/ml

GM

bupivacaine hcl (pf) injection solution 0.25 %, 0.5 %, 0.75 %

GM

bupivacaine hcl injection solution 0.25 %

GM

BUPIVACAINE HCL INJECTION SOLUTION 312.5 MG/10ML

GM

Drug NameDrug Tier

Notes

BUPIVACAINE HCL INJECTION SOLUTION PREFILLED SYRINGE 0.125 % (50 ML), 0.25 % (30 ML), 0.5 % (20 ML), 0.5 % (30 ML), 0.5 % (60 ML)

GM

BUPIVACAINE HCL SOLUTION 0.5 % INJECTION 0.5 %

GM

bupivacaine hcl solution 0.5 % injection 0.5 %

GM

BUPIVACAINE HCL-NACL EPIDURAL SOLUTION 0.0625-0.9 %, 0.1-0.9 %, 0.125-0.9 %, 0.15-0.9 %, 0.2-0.9 %, 0.25-0.9 %

GM

BUPIVACAINE HCL-NACL EPIDURAL SOLUTION PREFILLED SYRINGE 0.1-0.9 %, 0.25-0.9 %, 0.5-0.9 %

GM

BUPIVACAINE HCL-NACL INJECTION SOLUTION 0.03-0.9 %, 0.0625-0.9 %, 0.1-0.9 %, 0.125-0.9 %, 0.2-0.9 %, 0.25-0.9 %, 0.375-0.9 %, 0.5-0.9 %

GM

BUPIVACAINE HCL-NACL INJECTION SOLUTION PREFILLED SYRINGE 0.0625-0.9 % (50 ML), 0.1-0.9 % (50 ML), 0.125-0.9 % (50 ML), 0.25-0.9 %, 0.25-0.9 % (20 ML), 0.25-0.9 % (30 ML), 0.375-0.9 %

GM

bupivacaine in dextrose intrathecal solution 0.75-8.25 %

GM



18

Drug NameDrug Tier

Notes

BUPIVACAINE IN DEXTROSE SOLUTION PREFILLED SYRINGE 0.75-8.25 % (2 ML)

GM

bupivacaine spinal intrathecal solution 0.75-8.25 %

GM

bupivacaine-epinephrine (pf) injection solution 0.25% -1:200000, 0.5% -1:200000

GM

bupivacaine-epinephrine injection solution 0.25% -1:200000, 0.5% -1:200000

GM

BUPIVACAINE-EPINEPHRINE INJECTION SOLUTION PREFILLED SYRINGE 0.75% -1:400000

GM

CARBOCAINE INJECTION SOLUTION 1 %, 2 %

GM

CARBOCAINE PRESERVATIVE-FREE INJECTION SOLUTION 1 %, 1.5 %, 2 %

GM

CETACAINE EXTERNAL AEROSOL 2-2-14 %

GM

chloroprocaine hcl (pf) injection solution 2 %, 3 %

GM

CITANEST FORTE DENTAL INJECTION SOLUTION 4% -1:200000

GM

CITANEST PLAIN DENTAL INJECTION SOLUTION 4 %

GM

CLOROTEKAL INTRATHECAL SOLUTION 50 MG/5ML

GM

Drug NameDrug Tier

Notes

cocaine hcl external solution 4 %

2

COCAINE HCL NASAL SOLUTION 40 MG/ML

GM

dermacinrx empricaine external kit 2.5-2.5 %

2

dermacinrx prizopak external kit 2.5-2.5 %

2

ethyl chloride external aerosol

2

EXPAREL INJECTION SUSPENSION 1.3 %

GM

FLEXIN EXTERNAL PATCH 0.0375-5 %

4

glydo external gel 2 % 2

GOPRELTO NASAL SOLUTION 40 MG/ML

GM

LETS KIT 4

leva set/occlusive dressing external kit 2.5-2.5 %

2

LEVATIO EXTERNAL PATCH 0.03-5 %

4

lidenza external patch 4-1 %

2

lido bdk external kit 2.5-2.5 %

2

lidocaine external ointment 5 %

2QL (50 GM

per 30 days)

lidocaine external patch 5 %

2

lidocaine hcl (cardiac) intravenous solution prefilled syringe 100 mg/5ml, 50 mg/5ml

GM

lidocaine hcl (cardiac) pf intravenous solution 100 mg/5ml

GM



19

Drug NameDrug Tier

Notes

lidocaine hcl (cardiac) pf intravenous solution prefilled syringe 100 mg/5ml, 50 mg/5ml

GM

lidocaine hcl (pf) injection solution 0.5 %, 1 %, 1.5 %, 2 %, 4 %

GM

LIDOCAINE HCL EPIDURAL SOLUTION PREFILLED SYRINGE 400 MG/20ML

GM

lidocaine hcl external cream 3 %

2

lidocaine hcl external gel 2 %

2

lidocaine hcl external lotion 3 %

2

lidocaine hcl external solution 4 %

2

lidocaine hcl injection solution 0.5 %, 1 %, 2 %

GM

LIDOCAINE HCL INJECTION SOLUTION PREFILLED SYRINGE 10 MG/ML, 200 MG/10ML, 400 MG/20ML

GM

LIDOCAINE HCL INTRADERMAL JET-INJECTOR 0.5 MG

4

lidocaine hcl urethral/mucosal external gel 2 %

2

LIDOCAINE HCL-SODIUM CHLORIDE INJECTION SOLUTION 0.25-0.9 %

GM

LIDOCAINE IN D5W INTRAVENOUS SOLUTION 3-5 MG/ML-%

GM

lidocaine in d5w intravenous solution 4-5 mg/ml-%, 8-5 mg/ml-%

GM

Drug NameDrug Tier

Notes

LIDOCAINE IN DEXTROSE SOLUTION 5-7.5 %

GM

lidocaine pak external ointment 5 %

2QL (50 GM

per 30 days)

lidocaine-epinephrine injection solution 0.5 %-1:200000, 1 %-1:100000, 1.5 %-1:200000, 2 %-1:100000, 2 %-1:200000, 2 %-1:50000

GM

lidocaine-prilocaine external cream 2.5-2.5 %

2

lidocaine-prilocaine external kit 2.5-2.5 %

2

LIDOCAINE-TETRACAINE EXTERNAL CREAM 7-7 %

4

LIDODERM EXTERNAL PATCH 5 %

4

LIDO-EPINEPHRINE-TETRACAINE EXTERNAL SOLUTION 4-0.05-0.5 %

GM

lido-k external lotion 3 % 2

lidopin external cream 3 %

2

lidopril external kit 2.5-2.5 %

2

lidopril xr external kit 2.5-2.5 %

2

lido-prilo caine pack external kit 2.5-2.5 %

2

LIDO-SORB EXTERNAL LOTION 3 %

4

LIDOSTREAM EXTERNAL KIT 5 & 10 %

4

LIDOZION EXTERNAL LOTION 3 %

4



20

Drug NameDrug Tier

Notes

liprozonepak external kit 2.5-2.5 %

2

livixil pak external kit 2.5-2.5 %

2

lorenza external patch 4-1 %

2

lp lite pak external kit 2.5-2.5 %

2

MARCAINE INJECTION SOLUTION 0.25 %, 0.5 %, 0.75 %

GM

MARCAINE PRESERVATIVE FREE INJECTION SOLUTION 0.25 %, 0.5 %

GM

MARCAINE SPINAL INTRATHECAL SOLUTION 0.75-8.25 %

GM

MARCAINE/EPINEPHRINE INJECTION SOLUTION 0.25% -1:200000, 0.5% -1:200000

GM

MARCAINE/EPINEPHRINE PF INJECTION SOLUTION 0.25% -1:200000, 0.5% -1:200000

GM

MEDI-DERM/L-RX EXTERNAL CREAM 2-0.035-5-20 %

4

MEDI-PATCH RX EXTERNAL PATCH 0.5-0.035-5-20 %

4

medolor pak external kit 2.5-2.5 %

2

NAROPIN INJECTION SOLUTION 10 MG/ML, 2 MG/ML, 5 MG/ML, 7.5 MG/ML

GM

NESACAINE INJECTION SOLUTION 1 %, 2 %

GM

Drug NameDrug Tier

Notes

NESACAINE-MPF INJECTION SOLUTION 2 %, 3 %

GM

NUVAKAAN EXTERNAL KIT 2.5-2.5 %

4

ORABLOC INJECTION SOLUTION CARTRIDGE 4 %-1:100000, 4 %-1:200000

GM

PAINGO KFT EXTERNAL KIT 2.5-2.5-10-30 %

GM

PLIAGLIS EXTERNAL CREAM 7-7 %

4

polocaine injection solution 1 %, 2 %

GM

polocaine-mpf injection solution 1 %, 1.5 %, 2 %

GM

port-prep external kit 2.5-2.5 %

2

premium lidocaine external ointment 5 %

2QL (50 GM

per 30 days)

prikaan external kit 2.5-2.5 %

2

prikaan lite external kit 2.5-2.5 %

2

PRILO PATCH EXTERNAL KIT 2.5 %

4

prilolid external kit 2.5-2.5 %

2

prilovix external kit 2.5-2.5 %

2

PRILOVIX LITE EXTERNAL KIT 2.5-2.5 %

4

prilovix plus external kit 2.5-2.5 %

2

prilovix ultralite external kit 2.5-2.5 %

2

priloxx lp external kit 2.5-2.5 %

2



21

Drug NameDrug Tier

Notes

RECK SOLUTION PREFILLED SYRINGE 123-0.25-0.04- 15 MG/50ML

GM

relador pak external kit 2.5-2.5 %

2

relador pak plus external kit 2.5-2.5 %

2

RELEEVIA EXTERNAL PATCH 0.0375-5 %

4

RELEEVIA MC EXTERNAL PATCH 0.0375-5 %

4

releevia ml external patch 4-1 %

2

RENOVO EXTERNAL PATCH 0.0375-5 %

4

ROPIVACAINE HCL EPIDURAL SOLUTION PREFILLED SYRINGE 0.5 %

GM

ropivacaine hcl injection solution 10 mg/ml, 7.5 mg/ml

GM

ROPIVACAINE HCL INJECTION SOLUTION 33.4 MG/ML

GM

ROPIVACAINE HCL INJECTION SOLUTION PREFILLED SYRINGE 0.2 %, 0.5 %

GM

ROPIVACAINE HCL SOLUTION 2 MG/ML INJECTION 2 MG/ML

GM

ropivacaine hcl solution 2 mg/ml injection 2 mg/ml

GM

ROPIVACAINE HCL SOLUTION 5 MG/ML INJECTION 5 MG/ML

GM

ropivacaine hcl solution 5 mg/ml injection 5 mg/ml

GM

Drug NameDrug Tier

Notes

ROPIVACAINE HCL-NACL EPIDURAL SOLUTION 0.07-0.9 %, 0.1-0.9 %, 0.125-0.9 %, 0.2-0.9 %

GM

ROPIVACAINE HCL-NACL EPIDURAL SOLUTION PREFILLED SYRINGE 0.2-0.9 %

GM

ROPIVACAINE HCL-NACL INJECTION SOLUTION 0.15-0.9 %, 0.2-0.9 %, 0.25-0.9 %

GM

ROPIVACAINE HCL-NACL INJECTION SOLUTION PREFILLED SYRINGE 0.1-0.9 %, 0.2-0.9 %

GM

ROPIV-CLONIDINE-KETOROLAC SOLUTION PREFILLED SYRINGE 123-0.04-15 MG/50ML

GM

sensorcaine injection solution 0.25 %, 0.5 %

GM

sensorcaine/epinephrine injection solution 0.25% -1:200000, 0.5% -1:200000

GM

sensorcaine-mpf injection solution 0.25 %, 0.5 %, 0.75 %

GM

sensorcaine-mpf spinal intrathecal solution 0.75-8.25 %

GM

sensorcaine-mpf/epinephrine injection solution 0.25% -1:200000, 0.5% -1:200000

GM

SENSORCAINE-MPF/EPINEPHRINE INJECTION SOLUTION 0.75-1:200000 %

GM



22

Drug NameDrug Tier

Notes

soluline external kit 2.5-2.5 %

2

solupicc external kit 2.5-2.5 %

2

SYNERA EXTERNAL PATCH 70-70 MG

GM

synvexia external patch 4-1 %

2

SYNVEXIA TC EXTERNAL CREAM 4-1 %

4

VELTRIX EXTERNAL CREAM 4-1 %

4

vexatrol external kit 2.5-2.5 %

2

XYLOCAINE (CARDIAC) INTRAVENOUS SOLUTION 20 MG/ML

GM

xylocaine dental injection solution 2 %-1:100000, 2 %-1:50000

GM

XYLOCAINE INJECTION SOLUTION 0.5 %, 1 %, 2 %

GM

XYLOCAINE/EPINEPHRINE INJECTION SOLUTION 0.5 %-1:200000, 1 %-1:100000, 2 %-1:100000

GM

XYLOCAINE-MPF INJECTION SOLUTION 0.5 %, 1 %, 1.5 %, 2 %

GM

XYLOCAINE-MPF/EPINEPHRINE INJECTION SOLUTION 1 %-1:200000, 1.5 %-1:200000, 2 %-1:200000

GM

zeruvia external patch 4-1 %

2

ZINGO INTRADERMAL JET-INJECTOR 0.5 MG

4

Drug NameDrug Tier

Notes

Anti-Addiction / Substance Abuse Treatment Agents

acamprosate calcium oral tablet delayed release 333 mg

1

ANTABUSE ORAL TABLET 250 MG, 500 MG

3

BUNAVAIL BUCCAL FILM 2.1-0.3 MG, 4.2-0.7 MG, 6.3-1 MG

3

buprenorphine hcl sublingual tablet sublingual 2 mg, 8 mg

1

buprenorphine hcl-naloxone hcl sublingual film 12-3 mg, 2-0.5 mg, 4-1 mg, 8-2 mg

1

buprenorphine hcl-naloxone hcl sublingual tablet sublingual 2-0.5 mg, 8-2 mg

1

bupropion hcl er (smoking det) oral tablet extended release 12 hour 150 mg

PV

CHANTIX CONTINUING MONTH PAK ORAL TABLET 1 MG

PV

CHANTIX ORAL TABLET 0.5 MG, 1 MG

PV

CHANTIX STARTING MONTH PAK ORAL TABLET 0.5 MG X 11 & 1 MG X 42

PV

disulfiram oral tablet 250 mg, 500 mg

1

LUCEMYRA ORAL TABLET 0.18 MG

3QL (224

EA per 14 days)



23

Drug NameDrug Tier

Notes

naloxone hcl injection solution 0.4 mg/ml, 4 mg/10ml

2

naloxone hcl injection solution cartridge 0.4 mg/ml

2

naloxone hcl injection solution prefilled syringe 2 mg/2ml

2

naltrexone hcl oral tablet 50 mg

1

NALTREXONE SUBCUTANEOUS IMPLANT 200-6.5 MG

3

NARCAN NASAL LIQUID 4 MG/0.1ML

3

NICORETTE MOUTH/THROAT GUM 2 MG

PV

nicotine polacrilex mouth/throat gum 2 mg, 4 mg

PV

nicotine polacrilex mouth/throat lozenge 2 mg, 4 mg

PV

nicotine step 1 transdermal patch 24 hour 21 mg/24hr

PV


PV


PV

NICOTROL INHALATION INHALER 10 MG

PV

NICOTROL NS NASAL SOLUTION 10 MG/ML

PV

Drug NameDrug Tier

Notes

SUBLOCADE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 100 MG/0.5ML, 300 MG/1.5ML

3

SUBOXONE SUBLINGUAL FILM 12-3 MG, 2-0.5 MG, 4-1 MG, 8-2 MG

3

VIVITROL INTRAMUSCULAR SUSPENSION RECONSTITUTED 380 MG

3

ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL 0.7-0.18 MG, 1.4-0.36 MG, 11.4-2.9 MG, 2.9-0.71 MG, 5.7-1.4 MG, 8.6-2.1 MG

3

ZYBAN ORAL TABLET EXTENDED RELEASE 12 HOUR 150 MG

PV

Antibacterials

AEMCOLO ORAL TABLET DELAYED RELEASE 194 MG

4QL (12 EA

per 30 days)

ALTABAX EXTERNAL OINTMENT 1 %

4 ST

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

2

amoxicillin oral capsule 250 mg, 500 mg

2

amoxicillin oral suspension reconstituted 125 mg/5ml, 200 mg/5ml, 250 mg/5ml, 400 mg/5ml

1

amoxicillin oral tablet 500 mg

2

amoxicillin oral tablet 875 mg

1



24

Drug NameDrug Tier

Notes

amoxicillin oral tablet chewable 125 mg, 250 mg

2

amoxicillin-potassium clavulanate er oral tablet extended release 12 hour 1000-62.5 mg

2

amoxicillin-potassium clavulanate oral suspension reconstituted 200-28.5 mg/5ml, 250-62.5 mg/5ml, 400-57 mg/5ml, 600-42.9 mg/5ml

2

amoxicillin-potassium clavulanate oral tablet 250-125 mg, 500-125 mg, 875-125 mg

2

amoxicillin-potassium clavulanate oral tablet chewable 200-28.5 mg, 400-57 mg

2

ampicillin oral capsule 500 mg

1

ampicillin sodium injection solution reconstituted 1 gm, 10 gm, 125 mg, 2 gm, 250 mg, 500 mg

GM

ampicillin sodium intravenous solution reconstituted 1 gm, 10 gm, 2 gm

GM

ampicillin-sulbactam sodium injection solution reconstituted 1.5 (1-0.5) gm, 15 (10-5) gm, 3 (2-1) gm

GM

ampicillin-sulbactam sodium intravenous solution reconstituted 15 (10-5) gm

GM

ARIKAYCE INHALATION SUSPENSION 590 MG/8.4ML

6 PA

Drug NameDrug Tier

Notes

AUGMENTIN ES-600 ORAL SUSPENSION RECONSTITUTED 600-42.9 MG/5ML

4

AUGMENTIN ORAL SUSPENSION RECONSTITUTED 125-31.25 MG/5ML, 250-62.5 MG/5ML

4

AUGMENTIN ORAL TABLET 500-125 MG, 875-125 MG

4

AUGMENTIN XR ORAL TABLET EXTENDED RELEASE 12 HOUR 1000-62.5 MG

4

AVELOX INTRAVENOUS SOLUTION 400 MG/250ML

GM

AVELOX ORAL TABLET 400 MG

4

avidoxy oral tablet 100 mg

2

AVYCAZ INTRAVENOUS SOLUTION RECONSTITUTED 2.5 (2-0.5) GM

GM

AZACTAM IN DEXTROSE INTRAVENOUS SOLUTION 1 GM/50ML, 2 GM/50ML

GM

AZACTAM INJECTION SOLUTION RECONSTITUTED 1 GM, 2 GM

GM

azithromycin intravenous solution reconstituted 500 mg

GM

azithromycin oral packet 1 gm

2



25

Drug NameDrug Tier

Notes

azithromycin oral suspension reconstituted 100 mg/5ml, 200 mg/5ml

2

azithromycin oral tablet 250 mg, 500 mg, 600 mg

2

aztreonam injection solution reconstituted 1 gm, 2 gm

GM

baciim intramuscular solution reconstituted 50000 unit

GM

bacitracin intramuscular solution reconstituted 50000 unit

GM

BACTOCILL IN DEXTROSE INTRAVENOUS SOLUTION 1 GM/50ML, 2 GM/50ML

GM

BACTRIM DS ORAL TABLET 800-160 MG

4

BACTRIM ORAL TABLET 400-80 MG

4

BACTROBAN NASAL NASAL OINTMENT 2 %

4

BAXDELA INTRAVENOUS SOLUTION RECONSTITUTED 300 MG

5Specialty Medical

BAXDELA ORAL TABLET 450 MG

5

benzalkonium chloride external solution , 50 %

2

BICILLIN C-R 900/300 INTRAMUSCULAR SUSPENSION 900000-300000 UNIT/2ML

GM

BICILLIN C-R INTRAMUSCULAR SUSPENSION 1200000 UNIT/2ML

GM

Drug NameDrug Tier

Notes

BICILLIN L-A INTRAMUSCULAR SUSPENSION 1200000 UNIT/2ML, 2400000 UNIT/4ML, 600000 UNIT/ML

GM

BUCALSEP EXTERNAL LIQUID

4

BUCALSEP EXTERNAL SOLUTION

4

CEDAX ORAL CAPSULE 400 MG

4

CEDAX ORAL SUSPENSION RECONSTITUTED 180 MG/5ML

4

cefaclor er oral tablet extended release 12 hour 500 mg

2

cefaclor oral capsule 250 mg, 500 mg

2

cefaclor oral suspension reconstituted 125 mg/5ml, 250 mg/5ml, 375 mg/5ml

2

cefadroxil oral capsule 500 mg

2

cefadroxil oral suspension reconstituted 250 mg/5ml, 500 mg/5ml

2

cefadroxil oral tablet 1 gm

2

CEFAZOLIN IN SODIUM CHLORIDE INTRAVENOUS SOLUTION 2-0.9 GM/100ML-%, 2-0.9 GM/50ML-%, 3-0.9 GM/100ML-%

GM



26

Drug NameDrug Tier

Notes

CEFAZOLIN IN SODIUM CHLORIDE INTRAVENOUS SOLUTION PREFILLED SYRINGE 2-0.9 GM/10ML-%

GM

cefazolin sodium injection solution reconstituted 1 gm, 10 gm, 100 gm, 20 gm, 300 gm, 500 mg

GM

CEFAZOLIN SODIUM INTRAVENOUS SOLUTION PREFILLED SYRINGE 1 GM/10ML, 2 GM/20ML, 3 GM/20ML

GM

cefazolin sodium intravenous solution reconstituted 1 gm

GM

cefazolin sodium-dextrose intravenous solution 1-4 gm/50ml-%, 2-4 gm/100ml-%

GM

CEFAZOLIN SODIUM-DEXTROSE INTRAVENOUS SOLUTION 2-5 GM/100ML-%, 2-5 GM/50ML-%, 3-5 GM/100ML-%

GM

cefazolin sodium-dextrose intravenous solution reconstituted 1-4 gm-%(50ml), 2-3 gm-%(50ml)

GM

CEFAZOLIN SODIUM-NACL INTRAVENOUS SOLUTION PREFILLED SYRINGE 1-0.9 GM/10ML-%

GM

cefdinir oral capsule 300 mg

2

Drug NameDrug Tier

Notes

cefdinir oral suspension reconstituted 125 mg/5ml, 250 mg/5ml

2

cefditoren pivoxil oral tablet 200 mg, 400 mg

2

cefepime hcl injection solution reconstituted 1 gm, 2 gm

GM

cefepime hcl intravenous solution 1 gm/50ml, 2 gm/100ml

GM

cefepime-dextrose intravenous solution reconstituted 1-5 gm-%(50ml), 2-5 gm-%(50ml)

GM

cefixime oral capsule 400 mg

2

cefixime oral suspension reconstituted 100 mg/5ml, 200 mg/5ml

2

CEFOTAN INJECTION SOLUTION RECONSTITUTED 1 GM, 2 GM

GM

cefotaxime sodium injection solution reconstituted 1 gm, 10 gm, 2 gm, 500 mg

GM

cefotetan disodium injection solution reconstituted 1 gm, 10 gm, 2 gm

GM

cefotetan disodium-dextrose intravenous solution reconstituted 1-3.58 gm-%(50ml), 2-2.08 gm-%(50ml)

GM

cefoxitin sodium injection solution reconstituted 10 gm

GM



27

Drug NameDrug Tier

Notes

cefoxitin sodium intravenous solution reconstituted 1 gm, 2 gm

GM

cefoxitin sodium-dextrose intravenous solution reconstituted 1-4 gm-%(50ml), 2-2.2 gm-%(50ml)

GM

cefpodoxime proxetil oral suspension reconstituted 100 mg/5ml, 50 mg/5ml

2

cefpodoxime proxetil oral tablet 100 mg, 200 mg

2

cefprozil oral suspension reconstituted 125 mg/5ml, 250 mg/5ml

2

cefprozil oral tablet 250 mg, 500 mg

2

ceftazidime and dextrose intravenous solution reconstituted 1-5 gm-%(50ml), 2-5 gm-%(50ml)

GM

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

GM

ceftibuten oral capsule 400 mg

2

ceftibuten oral suspension reconstituted 180 mg/5ml

2

CEFTIN ORAL SUSPENSION RECONSTITUTED 125 MG/5ML, 250 MG/5ML

4

ceftriaxone sodium in dextrose intravenous solution 20 mg/ml, 40 mg/ml

GM

Drug NameDrug Tier

Notes

ceftriaxone sodium injection solution reconstituted 1 gm, 100 gm, 2 gm, 250 mg, 500 mg

GM

ceftriaxone sodium intravenous solution reconstituted 1 gm, 10 gm, 2 gm

GM

ceftriaxone sodium-dextrose intravenous solution reconstituted 1-3.74 gm-%(50ml), 2-2.22 gm-%(50ml)

GM

cefuroxime axetil oral tablet 250 mg, 500 mg

2

cefuroxime sodium injection solution reconstituted 7.5 gm, 750 mg

GM

cefuroxime sodium intravenous solution reconstituted 1.5 gm

GM

CENTANY AT EXTERNAL KIT 2 %

3

cephalexin oral capsule 250 mg, 500 mg

1

cephalexin oral capsule 750 mg

2

cephalexin oral suspension reconstituted 125 mg/5ml, 250 mg/5ml

2

cephalexin oral tablet 250 mg, 500 mg

2

chloramphenicol sod succinate intravenous solution reconstituted 1 gm

GM

CIPRO IN D5W INTRAVENOUS SOLUTION 400 MG/200ML

GM



28

Drug NameDrug Tier

Notes

CIPRO ORAL SUSPENSION RECONSTITUTED 250 MG/5ML (5%), 500 MG/5ML (10%)

3

CIPRO ORAL TABLET 250 MG, 500 MG

4

ciprofloxacin hcl oral tablet 100 mg, 750 mg

2

ciprofloxacin hcl oral tablet 250 mg, 500 mg

1

ciprofloxacin in d5w intravenous solution 200 mg/100ml, 400 mg/200ml

GM

ciprofloxacin intravenous solution 200 mg/20ml, 400 mg/40ml

GM

ciprofloxacin oral suspension reconstituted 250 mg/5ml (5%), 500 mg/5ml (10%)

2

ciprofloxacin-ciproflox hcl er oral tablet extended release 24 hour 1000 mg, 500 mg

2

clarithromycin er oral tablet extended release 24 hour 500 mg

2

clarithromycin oral suspension reconstituted 125 mg/5ml, 250 mg/5ml

2

clarithromycin oral tablet 250 mg, 500 mg

2

CLEOCIN IN D5W INTRAVENOUS SOLUTION 300 MG/50ML, 600 MG/50ML, 900 MG/50ML

GM

CLEOCIN ORAL CAPSULE 150 MG, 300 MG

4

CLEOCIN ORAL CAPSULE 75 MG

3

Drug NameDrug Tier

Notes

CLEOCIN ORAL SOLUTION RECONSTITUTED 75 MG/5ML

4

CLEOCIN PHOSPHATE INJECTION SOLUTION 300 MG/2ML, 600 MG/4ML, 9 GM/60ML, 900 MG/6ML

GM

CLEOCIN PHOSPHATE INTRAVENOUS SOLUTION 300 MG/2ML, 600 MG/4ML, 900 MG/6ML

GM

CLEOCIN VAGINAL CREAM 2 %

4

CLEOCIN VAGINAL SUPPOSITORY 100 MG

3

clindamycin hcl oral capsule 150 mg, 300 mg, 75 mg

2

clindamycin palmitate hcl oral solution reconstituted 75 mg/5ml

2

clindamycin phosphate in d5w intravenous solution 300 mg/50ml, 600 mg/50ml, 900 mg/50ml

GM

clindamycin phosphate injection solution 300 mg/2ml, 600 mg/4ml, 9 gm/60ml, 900 mg/6ml, 9000 mg/60ml

GM

clindamycin phosphate intravenous solution 300 mg/2ml, 600 mg/4ml, 900 mg/6ml

GM

clindamycin phosphate vaginal cream 2 %

2

CLINDESSE VAGINAL CREAM 2 %

4



29

Drug NameDrug Tier

Notes

colistimethate sodium (cba) injection solution reconstituted 150 mg

GM

COLY-MYCIN M INJECTION SOLUTION RECONSTITUTED 150 MG

GM

CUBICIN INTRAVENOUS SOLUTION RECONSTITUTED 500 MG

GM

CUBICIN RF INTRAVENOUS SOLUTION RECONSTITUTED 500 MG

GM

DALVANCE INTRAVENOUS SOLUTION RECONSTITUTED 500 MG

6Specialty Medical

daptomycin intravenous solution reconstituted 350 mg, 500 mg

GM

demeclocycline hcl oral tablet 150 mg, 300 mg

2

dicloxacillin sodium oral capsule 250 mg, 500 mg

2

DIFICID ORAL TABLET 200 MG

4 ST

DORIBAX INTRAVENOUS SOLUTION RECONSTITUTED 250 MG, 500 MG

GM

DORIPENEM INTRAVENOUS SOLUTION RECONSTITUTED 250 MG, 500 MG

GM

doxy 100 intravenous solution reconstituted 100 mg

GM

Drug NameDrug Tier

Notes

doxycycline hyclate intravenous solution reconstituted 100 mg

GM

doxycycline hyclate oral capsule 100 mg, 50 mg

2

doxycycline hyclate oral tablet 100 mg, 20 mg

2

doxycycline hyclate oral tablet delayed release 100 mg, 150 mg, 75 mg

2

doxycycline monohydrate oral capsule 100 mg, 150 mg, 50 mg, 75 mg

2

doxycycline monohydrate oral suspension reconstituted 25 mg/5ml

2

doxycycline monohydrate oral tablet 100 mg, 150 mg, 50 mg, 75 mg

2

e.e.s. 400 oral tablet 400 mg

2

E.E.S. GRANULES ORAL SUSPENSION RECONSTITUTED 200 MG/5ML

3

ertapenem sodium injection solution reconstituted 1 gm

2

ERYPED 200 ORAL SUSPENSION RECONSTITUTED 200 MG/5ML

3

ERYPED 400 ORAL SUSPENSION RECONSTITUTED 400 MG/5ML

3

ERY-TAB ORAL TABLET DELAYED RELEASE 250 MG, 333 MG, 500 MG

4



30

Drug NameDrug Tier

Notes

ERYTHROCIN LACTOBIONATE INTRAVENOUS SOLUTION RECONSTITUTED 500 MG

GM

ERYTHROCIN STEARATE ORAL TABLET 250 MG

4

erythromycin base oral capsule delayed release particles 250 mg

2

erythromycin base oral tablet 250 mg, 500 mg

2

erythromycin base oral tablet delayed release 250 mg, 333 mg, 500 mg

2

erythromycin ethylsuccinate oral suspension reconstituted 200 mg/5ml, 400 mg/5ml

2

erythromycin ethylsuccinate oral tablet 400 mg

2

FIRST-VANCOMYCIN ORAL SOLUTION 25 MG/ML, 50 MG/ML

4

FIRVANQ ORAL SOLUTION RECONSTITUTED 25 MG/ML, 50 MG/ML

4

FLAGYL ORAL CAPSULE 375 MG

4

FLAGYL ORAL TABLET 250 MG, 500 MG

4

FURADANTIN ORAL SUSPENSION 25 MG/5ML

4

Drug NameDrug Tier

Notes

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-%

GM

gentamicin sulfate external cream 0.1 %

2

gentamicin sulfate external ointment 0.1 %

2

gentamicin sulfate injection solution 10 mg/ml, 40 mg/ml

GM

HIPREX ORAL TABLET 1 GM

4

hydrogen peroxide solution 30 %

2

imipenem-cilastatin intravenous solution reconstituted 250 mg, 500 mg

GM

INVANZ INJECTION SOLUTION RECONSTITUTED 1 GM

4

INVANZ INTRAVENOUS SOLUTION RECONSTITUTED 1 GM

GM

iodine tincture external tincture 2 %

2

KEFLEX ORAL CAPSULE 250 MG, 500 MG, 750 MG

4

LEVAQUIN ORAL TABLET 250 MG, 500 MG, 750 MG

4

levofloxacin in d5w intravenous solution 250 mg/50ml, 500 mg/100ml, 750 mg/150ml

GM

levofloxacin intravenous solution 25 mg/ml

GM

levofloxacin oral solution 25 mg/ml

2



31

Drug NameDrug Tier

Notes

levofloxacin oral tablet 250 mg, 500 mg, 750 mg

2

LINCOCIN INJECTION SOLUTION 300 MG/ML

GM

lincomycin hcl injection solution 300 mg/ml

GM

linezolid in sodium chloride intravenous solution 600-0.9 mg/300ml-%

5Specialty Medical

linezolid intravenous solution 600 mg/300ml

5Specialty Medical

linezolid oral suspension reconstituted 100 mg/5ml

5QL (900

ML per 30 days)

linezolid oral tablet 600 mg

5QL (60 EA

per 30 days)

lugols external solution 2

MACROBID ORAL CAPSULE 100 MG

4

MACRODANTIN ORAL CAPSULE 100 MG, 50 MG

4

MACRODANTIN ORAL CAPSULE 25 MG

3

mafenide acetate external packet 5 %

2

MAXIPIME INJECTION SOLUTION RECONSTITUTED 1 GM, 2 GM

GM

MAXIPIME INTRAVENOUS SOLUTION RECONSTITUTED 1 GM, 2 GM

GM

meropenem intravenous solution reconstituted 1 gm, 500 mg

GM

Drug NameDrug Tier

Notes

MEROPENEM-SODIUM CHLORIDE INTRAVENOUS SOLUTION RECONSTITUTED 1 GM/50ML, 500-0.9 MG-%

GM

MERREM INTRAVENOUS SOLUTION RECONSTITUTED 1 GM, 500 MG

GM

methenamine hippurate oral tablet 1 gm

2

methenamine mandelate oral tablet 0.5 gm, 1 gm

2

METROGEL-VAGINAL VAGINAL GEL 0.75 %

4

metronidazole in nacl intravenous solution 5-0.79 mg/ml-%, 500-0.74 mg/100ml-%, 500-0.79 mg/100ml-%

GM

METRONIDAZOLE INTRAVENOUS SOLUTION 5 MG/ML

GM

metronidazole oral capsule 375 mg

2

metronidazole oral tablet 250 mg, 500 mg

2

metronidazole vaginal gel 0.75 %

2

MINOCIN INTRAVENOUS SOLUTION RECONSTITUTED 100 MG

GM

MINOCIN ORAL CAPSULE 100 MG, 50 MG

4

minocycline hcl oral capsule 100 mg, 50 mg, 75 mg

2



32

Drug NameDrug Tier

Notes

minocycline hcl oral tablet 100 mg, 50 mg, 75 mg

2

mondoxyne nl oral capsule 100 mg, 50 mg, 75 mg

2

MONODOX ORAL CAPSULE 100 MG, 75 MG

4

MONUROL ORAL PACKET 3 GM

4

morgidox oral capsule 100 mg, 50 mg

2

MOXATAG ORAL TABLET EXTENDED RELEASE 24 HOUR 775 MG

4

moxifloxacin hcl in nacl intravenous solution 400 mg/250ml

GM

MOXIFLOXACIN HCL INTRAVENOUS SOLUTION 400 MG/250ML

GM

moxifloxacin hcl oral tablet 400 mg

2

mupirocin external ointment 2 %

2

NAFCILLIN SODIUM IN DEXTROSE INTRAVENOUS SOLUTION 1 GM/50ML, 2 GM/100ML

GM

nafcillin sodium injection solution reconstituted 1 gm, 2 gm

GM

nafcillin sodium intravenous solution reconstituted 1 gm, 10 gm, 2 gm

GM

neomycin sulfate oral tablet 500 mg

2

Drug NameDrug Tier

Notes

neomycin-polymyxin b gu irrigation solution 40-200000

2

nitrofurantoin macrocrystal oral capsule 100 mg, 25 mg, 50 mg

2

nitrofurantoin monohydrate macrocrystals oral capsule 100 mg

2

nitrofurantoin oral suspension 25 mg/5ml

2

NUTRIDOX ORAL KIT 75 MG

4

NUZYRA INTRAVENOUS SOLUTION RECONSTITUTED 100 MG

6Specialty Medical

NUZYRA ORAL TABLET 150 MG

6QL (30 EA

per 14 days)

ofloxacin oral tablet 300 mg, 400 mg

2

okebo oral capsule 75 mg

2

ORBACTIV INTRAVENOUS SOLUTION RECONSTITUTED 400 MG

5Specialty Medical

oxacillin sodium injection solution reconstituted 1 gm, 10 gm, 2 gm

GM

paromomycin sulfate oral capsule 250 mg

2

PCE ORAL TABLET DELAYED RELEASE 333 MG, 500 MG

4



33

Drug NameDrug Tier

Notes

PENICILLIN G POT IN DEXTROSE INTRAVENOUS SOLUTION 20000 UNIT/ML, 40000 UNIT/ML, 60000 UNIT/ML

GM

penicillin g potassium injection solution reconstituted 20000000 unit, 5000000 unit

GM

penicillin g procaine intramuscular suspension 600000 unit/ml

GM

penicillin g sodium injection solution reconstituted 5000000 unit

GM

penicillin v potassium oral solution reconstituted 125 mg/5ml, 250 mg/5ml

2

penicillin v potassium oral tablet 250 mg, 500 mg

1

PFIZERPEN INJECTION SOLUTION RECONSTITUTED 20000000 UNIT, 5000000 UNIT

GM

piperacillin sod-tazobactam so intravenous solution reconstituted 13.5 (12-1.5) gm, 2.25 (2-0.25) gm, 3.375 (3-0.375) gm, 4.5 (4-0.5) gm, 40.5 (36-4.5) gm

GM

polymyxin b sulfate injection solution reconstituted 500000 unit

GM

Drug NameDrug Tier

Notes

PRIMAXIN IV INTRAVENOUS SOLUTION RECONSTITUTED 250-250 MG, 500-500 MG

GM

PRIMSOL ORAL SOLUTION 50 MG/5ML

4

SILVADENE EXTERNAL CREAM 1 %

4

silver nitrate external ointment 10 %

2

silver nitrate external solution 0.5 %, 10 %, 25 %, 50 %

2

silver sulfadiazine external cream 1 %

2

SIVEXTRO INTRAVENOUS SOLUTION RECONSTITUTED 200 MG

6Specialty Medical

SIVEXTRO ORAL TABLET 200 MG

6QL (6 EA

per 30 days)

soloxide oral tablet delayed release 150 mg

2

SPECTRACEF ORAL TABLET 400 MG

4

ssd external cream 1 % 2

streptomycin sulfate intramuscular solution reconstituted 1 gm

GM

sulfadiazine oral tablet 500 mg

2

sulfamethoxazole-trimethoprim intravenous solution 400-80 mg/5ml

GM

sulfamethoxazole-trimethoprim oral suspension 200-40 mg/5ml

2



34

Drug NameDrug Tier

Notes

sulfamethoxazole-trimethoprim oral tablet 400-80 mg, 800-160 mg

1

SULFAMYLON EXTERNAL CREAM 85 MG/GM

4

SULFAMYLON EXTERNAL PACKET 5 %

4

sulfatrim pediatric oral suspension 200-40 mg/5ml

2

SUPRAX ORAL CAPSULE 400 MG

4

SUPRAX ORAL SUSPENSION RECONSTITUTED 100 MG/5ML, 200 MG/5ML, 500 MG/5ML

4

SUPRAX ORAL TABLET CHEWABLE 100 MG, 200 MG

4

SYNERCID INTRAVENOUS SOLUTION RECONSTITUTED 150-350 MG

GM

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

GM

TAZICEF INTRAVENOUS SOLUTION 1 GM/50ML

GM

TAZICEF SOLUTION RECONSTITUTED 1 GM INTRAVENOUS 1 GM

GM

tazicef solution reconstituted 1 gm intravenous 1 gm

GM

TAZICEF SOLUTION RECONSTITUTED 2 GM INTRAVENOUS 2 GM

GM

Drug NameDrug Tier

Notes

tazicef solution reconstituted 2 gm intravenous 2 gm

GM

TEFLARO INTRAVENOUS SOLUTION RECONSTITUTED 400 MG, 600 MG

GM

tetracycline hcl oral capsule 250 mg, 500 mg

2

tigecycline intravenous solution reconstituted 50 mg

GM

TINDAMAX ORAL TABLET 500 MG

3

tinidazole oral tablet 250 mg, 500 mg

2

tobramycin sulfate injection solution 1.2 gm/30ml, 10 mg/ml, 2 gm/50ml, 80 mg/2ml

GM

tobramycin sulfate injection solution reconstituted 1.2 gm

GM

trimethoprim oral tablet 100 mg

2

TRIMPEX ORAL SOLUTION 50 MG/5ML

4

TYGACIL INTRAVENOUS SOLUTION RECONSTITUTED 50 MG

GM

UNASYN INJECTION SOLUTION RECONSTITUTED 1.5 (1-0.5) GM, 15 (10-5) GM, 3 (2-1) GM

GM

VABOMERE INTRAVENOUS SOLUTION RECONSTITUTED 2 (1-1) GM

GM



35

Drug NameDrug Tier

Notes

VANCOCIN HCL ORAL CAPSULE 125 MG, 250 MG

4

VANCOMYCIN HCL IN DEXTROSE INTRAVENOUS SOLUTION 1-5 GM/100ML-%, 1-5 GM/250ML-%, 1.25-5 GM/250ML-%, 1.5-5 GM/250ML-%, 1.5-5 GM/300ML-%, 1.5-5 GM/500ML-%, 1.75-5 GM/500ML-%, 2-5 GM/500ML-%

GM

vancomycin hcl in dextrose intravenous solution 1-5 gm/200ml-%, 500-5 mg/100ml-%

GM

vancomycin hcl in dextrose solution 750-5 mg/150ml-% intravenous 750-5 mg/150ml-%

GM

VANCOMYCIN HCL IN DEXTROSE SOLUTION 750-5 MG/150ML-% INTRAVENOUS 750-5 MG/150ML-%

GM

VANCOMYCIN HCL IN NACL INTRAVENOUS SOLUTION 1-0.9 GM/150ML-%, 1-0.9 GM/250ML-%, 1.25-0.9 GM/150ML-%, 1.25-0.9 GM/250ML-%, 1.5-0.9 GM/150ML-%, 1.5-0.9 GM/250ML-%, 1.5-0.9 GM/300ML-%, 1.5-0.9 GM/500ML-%, 1.75-0.9 GM/250ML-%, 1.75-0.9 GM/500ML-%, 2-0.9 GM/250ML-%, 2-0.9 GM/500ML-%, 2.5-0.9 GM/500ML-%, 750-0.9 MG/250ML-%

GM

Drug NameDrug Tier

Notes

vancomycin hcl in nacl intravenous solution 1-0.9 gm/200ml-%, 500-0.9 mg/100ml-%

GM

VANCOMYCIN HCL IN NACL SOLUTION 750-0.9 MG/150ML-% INTRAVENOUS 750-0.9 MG/150ML-%

GM

vancomycin hcl in nacl solution 750-0.9 mg/150ml-% intravenous 750-0.9 mg/150ml-%

GM

VANCOMYCIN HCL INTRAVENOUS SOLUTION 1000 MG/10ML, 1250 MG/12.5ML, 1500 MG/15ML, 1750 MG/17.5ML, 2000 MG/20ML, 750 MG/7.5ML

GM

vancomycin hcl intravenous solution 1000 mg/200ml, 1500 mg/300ml, 2000 mg/400ml, 500 mg/100ml

GM

vancomycin hcl intravenous solution reconstituted 1 gm, 1.25 gm, 1.5 gm, 10 gm, 1000 mg, 5 gm, 500 mg, 750 mg

GM

vancomycin hcl oral capsule 125 mg, 250 mg

2

vancomycin hcl oral solution reconstituted 250 mg/5ml

2

VANCOSOL PACK INTRAVENOUS KIT 1-0.9 GM-%

GM

vandazole vaginal gel 0.75 %

2



36

Drug NameDrug Tier

Notes

VIBATIV INTRAVENOUS SOLUTION RECONSTITUTED 750 MG

GM

VIBRAMYCIN ORAL CAPSULE 100 MG

4

VIBRAMYCIN ORAL SUSPENSION RECONSTITUTED 25 MG/5ML

4

VIBRAMYCIN ORAL SYRUP 50 MG/5ML

3

XENLETA INTRAVENOUS SOLUTION 150 MG/15ML

6Specialty Medical

XENLETA ORAL TABLET 600 MG

6 PA

XEPI EXTERNAL CREAM 1 %

4 ST

XERAVA INTRAVENOUS SOLUTION RECONSTITUTED 50 MG

5Specialty Medical

XIFAXAN ORAL TABLET 200 MG, 550 MG

5 PA

ZEMDRI INTRAVENOUS SOLUTION 500 MG/10ML

6Specialty Medical

ZERBAXA INTRAVENOUS SOLUTION RECONSTITUTED 1.5 (1-0.5) GM

GM

ZITHROMAX INTRAVENOUS SOLUTION RECONSTITUTED 500 MG

GM

ZITHROMAX ORAL PACKET 1 GM

4

Drug NameDrug Tier

Notes

ZITHROMAX ORAL SUSPENSION RECONSTITUTED 100 MG/5ML, 200 MG/5ML

4

ZITHROMAX ORAL TABLET 250 MG, 500 MG, 600 MG

4

ZITHROMAX TRI-PAK ORAL TABLET 500 MG

4

ZITHROMAX Z-PAK ORAL TABLET 250 MG

4

ZMAX ORAL SUSPENSION RECONSTITUTED 2 GM

4

ZOSYN INTRAVENOUS SOLUTION 2-0.25 GM/50ML, 3-0.375 GM/50ML, 4-0.5 GM/100ML

GM

ZOSYN 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

GM

ZYVOX INTRAVENOUS SOLUTION 200 MG/100ML, 600 MG/300ML

5Specialty Medical

ZYVOX ORAL SUSPENSION RECONSTITUTED 100 MG/5ML

5QL (900

ML per 30 days)

ZYVOX ORAL TABLET 600 MG

5QL (60 EA

per 30 days)

Anticoagulants

ACD FORMULA A IN VITRO SOLUTION 0.73-2.45-2.2 GM/100ML

4

ACD-A NOCLOT-50 IN VITRO SOLUTION 0.73-2.45-2.2 GM/100ML

4



37

Drug NameDrug Tier

Notes

ACTIVASE INTRAVENOUS SOLUTION RECONSTITUTED 100 MG, 50 MG

GM

ANGIOMAX INTRAVENOUS SOLUTION RECONSTITUTED 250 MG

GM

anticoagulant cit dext soln a in vitro solution 0.8-2.45-2.2 gm/100ml

2

anticoagulant sodium citrate in vitro solution 4 gm/100ml

2

argatroban in sodium chloride intravenous solution 250-0.9 mg/250ml-%, 50 mg/50ml

GM

argatroban intravenous solution 125 mg/125ml, 250 mg/2.5ml, 50 mg/50ml

GM

ARIXTRA SUBCUTANEOUS SOLUTION 10 MG/0.8ML, 2.5 MG/0.5ML, 5 MG/0.4ML, 7.5 MG/0.6ML

4

BEVYXXA ORAL CAPSULE 40 MG, 80 MG

4QL (30 EA

per 30 days)

bivalirudin trifluoroacetate intravenous solution reconstituted 250 mg

GM

BIVALIRUDIN-SODIUM CHLORIDE INTRAVENOUS SOLUTION 250-0.9 MG/50ML-%, 500-0.9 MG/100ML-%

6Specialty Medical

Drug NameDrug Tier

Notes

CATHFLO ACTIVASE INJECTION SOLUTION RECONSTITUTED 2 MG

GM

COUMADIN ORAL TABLET 1 MG, 10 MG, 2 MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG

3

DEFITELIO INTRAVENOUS SOLUTION 200 MG/2.5ML

GM

ELIQUIS ORAL TABLET 2.5 MG, 5 MG

3

ELIQUIS STARTER PACK ORAL TABLET 5 MG

3

enoxaparin sodium injection solution 300 mg/3ml

2

enoxaparin sodium subcutaneous solution 100 mg/ml, 120 mg/0.8ml, 150 mg/ml, 30 mg/0.3ml, 40 mg/0.4ml, 60 mg/0.6ml, 80 mg/0.8ml

2

fondaparinux sodium subcutaneous solution 10 mg/0.8ml, 2.5 mg/0.5ml, 5 mg/0.4ml, 7.5 mg/0.6ml

2

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

3



38

Drug NameDrug Tier

Notes

heparin (porcine) in nacl injection solution 100-0.45 unit/ml-%

2

HEPARIN (PORCINE) IN NACL INTRAVENOUS SOLUTION 100-0.45 UT/100ML-%, 100-0.9 UT/100ML-%, 1000-0.9 UNIT/L-%, 1000-0.9 UT/100ML-%, 1000-0.9 UT/250ML-%, 10000-0.9 UNIT/L-%, 10000-0.9 UT/100ML-%, 10000-0.9 UT/500ML-%, 1250-0.9 UT/250ML-%, 150-0.45 UT/150ML-%, 1500-0.9 UT/150ML-%, 1500-0.9 UT/250ML-%, 15000-0.9 UT/500ML-%, 20000-0.9 UNIT/L-%, 250-0.45 UT/250ML-%, 250-0.9 UT/250ML-%, 2500-0.9 UT/250ML-%, 2500-0.9 UT/500ML-%, 25000-0.9 UT/250ML-%, 25000-0.9 UT/500ML-%, 3000-0.9 UNIT/L-%, 3000-0.9 UT/500ML-%, 4000-0.9 UT/500ML-%, 40000-0.45 UNIT/L-%, 500-0.45 UT/500ML-%, 500-0.9 UT/500ML-%, 5000-0.45 UNIT/L-%, 5000-0.9 UNIT/L-%, 5000-0.9 UT/500ML-%, 6000-0.9 UNIT/L-%, 8000-0.9 UNIT/L-%

GM

heparin (porcine) in nacl intravenous solution 12500-0.45 ut/250ml-%, 25000-0.45 ut/250ml-%

2

Drug NameDrug Tier

Notes

HEPARIN (PORCINE) IN NACL INTRAVENOUS SOLUTION 2000-0.9 UT/500ML-%, 30000-0.9 UNIT/L-%, 4000-0.9 UNIT/L-%, 500-0.45 UT/250ML-%

4

HEPARIN (PORCINE) IN NACL INTRAVENOUS SOLUTION PREFILLED SYRINGE 100-0.9 UNT/50ML-%, 20-0.45 UNT/20ML-%, 4-0.9 UNIT/2ML-%, 50-0.9 UNT/50ML-%

GM

HEPARIN (PORCINE) IN NACL INTRAVENOUS SOLUTION PREFILLED SYRINGE 20-0.9 UNT/20ML-%, 50-0.45 UNT/50ML-%

4

heparin (porcine) in nacl solution 1000-0.9 ut/500ml-% intravenous 1000-0.9 ut/500ml-%

2

HEPARIN (PORCINE) IN NACL SOLUTION 1000-0.9 UT/500ML-% INTRAVENOUS 1000-0.9 UT/500ML-%

4

heparin (porcine) in nacl solution 2000-0.9 unit/l-% intravenous 2000-0.9 unit/l-%

2

HEPARIN (PORCINE) IN NACL SOLUTION 2000-0.9 UNIT/L-% INTRAVENOUS 2000-0.9 UNIT/L-%

4

heparin (porcine) in nacl solution 25000-0.45 ut/500ml-% intravenous 25000-0.45 ut/500ml-%

GM



39

Drug NameDrug Tier

Notes

HEPARIN (PORCINE) IN NACL SOLUTION 25000-0.45 UT/500ML-% INTRAVENOUS 25000-0.45 UT/500ML-%

GM

HEPARIN SOD (PORCINE) IN D5W INTRAVENOUS SOLUTION 10000-5 UT/100ML-%

GM

HEPARIN SOD (PORCINE) IN D5W INTRAVENOUS SOLUTION 12500-5 UT/250ML-%

4

heparin sod (porcine) in d5w intravenous solution 25000-5 ut/500ml-%

2

HEPARIN SOD (PORCINE) IN D5W SOLUTION 100 UNIT/ML INTRAVENOUS 100 UNIT/ML

4

heparin sod (porcine) in d5w solution 100 unit/ml intravenous 100 unit/ml

2

heparin sod (porcine) in d5w solution 40-5 unit/ml-% intravenous 40-5 unit/ml-%

2

HEPARIN SOD (PORCINE) IN D5W SOLUTION 40-5 UNIT/ML-% INTRAVENOUS 40-5 UNIT/ML-%

4

HEPARIN SOD (PORCINE)-D10 INTRAVENOUS SOLUTION PREFILLED SYRINGE 50-10 UNT/50ML-%

GM

Drug NameDrug Tier

Notes

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

2

heparin sodium (porcine) injection solution prefilled syringe 5000 unit/0.5ml

GM

HEPARIN SODIUM (PORCINE) INTRAVENOUS SOLUTION PREFILLED SYRINGE 10000 UNIT/10ML, 3000 UNIT/3ML, 5000 UNIT/5ML

4

HEPARIN SODIUM (PORCINE) INTRAVENOUS SOLUTION PREFILLED SYRINGE 15000 UNIT/3ML, 6000 UNIT/6ML, 7000 UNIT/7ML

GM

heparin sodium (porcine) pf injection solution 5000 unit/0.5ml

2

heparin sodium (porcine) pf injection solution 5000 unit/ml

GM

IPRIVASK SUBCUTANEOUS SOLUTION RECONSTITUTED 15 MG

GM

jantoven oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg

1

LOVENOX INJECTION SOLUTION 300 MG/3ML

3



40

Drug NameDrug Tier

Notes

LOVENOX SUBCUTANEOUS SOLUTION 100 MG/ML, 120 MG/0.8ML, 150 MG/ML, 30 MG/0.3ML, 40 MG/0.4ML, 60 MG/0.6ML, 80 MG/0.8ML

4

PRADAXA ORAL CAPSULE 110 MG, 150 MG, 75 MG

3

SAVAYSA ORAL TABLET 15 MG, 30 MG, 60 MG

4 ST

SODIUM CITRATE IN VITRO SOLUTION PREFILLED SYRINGE 4 %

GM

SODIUM CITRATE LOCK FLUSH INTRAVENOUS SOLUTION PREFILLED SYRINGE 120 MG/3ML

GM

SODIUM CITRATE-GENTAMICIN SULF INTRAVENOUS SOLUTION 4-320 %-MCG/ML

GM

THROMBATE III INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 500 UNIT

GM PA

TNKASE INTRAVENOUS KIT 50 MG

GM

TRICITRASOL IN VITRO CONCENTRATE 46.7 %

4

warfarin sodium oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg

1

XARELTO ORAL TABLET 10 MG, 15 MG, 2.5 MG, 20 MG

3

Drug NameDrug Tier

Notes

XARELTO STARTER PACK ORAL TABLET THERAPY PACK 15 & 20 MG

3

Anticonvulsants - Drugs for Seizures

APTIOM ORAL TABLET 200 MG, 400 MG, 600 MG, 800 MG

4 ST

BANZEL ORAL SUSPENSION 40 MG/ML

4

BANZEL ORAL TABLET 200 MG, 400 MG

4

BRIVIACT INTRAVENOUS SOLUTION 50 MG/5ML

GM ST

BRIVIACT ORAL SOLUTION 10 MG/ML

4 ST

BRIVIACT ORAL TABLET 10 MG, 100 MG, 25 MG, 50 MG, 75 MG

4 ST

carbamazepine er oral capsule extended release 12 hour 100 mg, 200 mg, 300 mg

2

carbamazepine er oral tablet extended release 12 hour 100 mg, 200 mg, 400 mg

2

carbamazepine oral suspension 100 mg/5ml

2

carbamazepine oral tablet 200 mg

2

carbamazepine oral tablet chewable 100 mg

2

CARBATROL ORAL CAPSULE EXTENDED RELEASE 12 HOUR 100 MG, 200 MG, 300 MG

4

CELONTIN ORAL CAPSULE 300 MG

4



41

Drug NameDrug Tier

Notes

CEREBYX INJECTION SOLUTION 100 MG PE/2ML, 500 MG PE/10ML

GM

clobazam oral suspension 2.5 mg/ml

2

clobazam oral tablet 10 mg, 20 mg

2

DEPACON INTRAVENOUS SOLUTION 100 MG/ML

GM

DEPAKENE ORAL CAPSULE 250 MG

4

DEPAKENE ORAL SOLUTION 250 MG/5ML

4

DEPAKOTE ER ORAL TABLET EXTENDED RELEASE 24 HOUR 250 MG, 500 MG

4

DEPAKOTE ORAL TABLET DELAYED RELEASE 125 MG, 250 MG, 500 MG

4

DEPAKOTE SPRINKLES ORAL CAPSULE DELAYED RELEASE SPRINKLE 125 MG

4

DIACOMIT ORAL CAPSULE 250 MG, 500 MG

4

DIACOMIT ORAL PACKET 250 MG, 500 MG

4

DIASTAT ACUDIAL RECTAL GEL 10 MG, 20 MG

4

DIASTAT PEDIATRIC RECTAL GEL 2.5 MG

4

diazepam rectal gel 10 mg, 2.5 mg, 20 mg

2

DILANTIN INFATABS ORAL TABLET CHEWABLE 50 MG

4

Drug NameDrug Tier

Notes

DILANTIN ORAL CAPSULE 100 MG, 30 MG

4

DILANTIN ORAL SUSPENSION 125 MG/5ML

4

divalproex sodium er oral tablet extended release 24 hour 250 mg, 500 mg

2

divalproex sodium oral capsule delayed release sprinkle 125 mg

2

divalproex sodium oral tablet delayed release 125 mg, 250 mg, 500 mg

2

EPIDIOLEX ORAL SOLUTION 100 MG/ML

6 PA

epitol oral tablet 200 mg 2

EQUETRO ORAL CAPSULE EXTENDED RELEASE 12 HOUR 100 MG, 200 MG, 300 MG

4

ethosuximide oral capsule 250 mg

2

ethosuximide oral solution 250 mg/5ml

2

felbamate oral suspension 600 mg/5ml

2

felbamate oral tablet 400 mg, 600 mg

2

FELBATOL ORAL SUSPENSION 600 MG/5ML

3

FELBATOL ORAL TABLET 400 MG, 600 MG

3

fosphenytoin sodium injection solution 100 mg pe/2ml, 500 mg pe/10ml

GM

FYCOMPA ORAL SUSPENSION 0.5 MG/ML

4



42

Drug NameDrug Tier

Notes

FYCOMPA ORAL TABLET 10 MG, 12 MG, 2 MG, 4 MG, 6 MG, 8 MG

4

gabapentin oral capsule 100 mg, 300 mg, 400 mg

2

gabapentin oral solution 250 mg/5ml, 300 mg/6ml

2

gabapentin oral tablet 600 mg, 800 mg

2

GABITRIL ORAL TABLET 12 MG, 16 MG, 2 MG, 4 MG

4

KEPPRA INTRAVENOUS SOLUTION 500 MG/5ML

GM

KEPPRA ORAL SOLUTION 100 MG/ML

4

KEPPRA ORAL TABLET 1000 MG, 250 MG, 500 MG, 750 MG

4

KEPPRA XR ORAL TABLET EXTENDED RELEASE 24 HOUR 500 MG, 750 MG

4

LAMICTAL ODT ORAL KIT 21 X 25 MG & 7 X 50 MG, 25 & 50 & 100 MG, 42 X 50 MG & 14X100 MG

4

LAMICTAL ODT ORAL TABLET DISPERSIBLE 100 MG, 200 MG, 25 MG, 50 MG

4

LAMICTAL ORAL TABLET 100 MG, 150 MG, 200 MG, 25 MG

4

LAMICTAL ORAL TABLET CHEWABLE 25 MG, 5 MG

4

Drug NameDrug Tier

Notes

LAMICTAL STARTER ORAL KIT 35 X 25 MG, 42 X 25 MG & 7 X 100 MG, 84 X 25 MG & 14X100 MG

4

LAMICTAL XR ORAL KIT 21 X 25 MG & 7 X 50 MG, 25 & 50 & 100 MG, 50 & 100 & 200 MG

4

LAMICTAL XR ORAL TABLET EXTENDED RELEASE 24 HOUR 100 MG, 200 MG, 25 MG, 250 MG, 300 MG, 50 MG

4

lamotrigine er oral tablet extended release 24 hour 100 mg, 200 mg, 25 mg, 250 mg, 300 mg, 50 mg

2

lamotrigine oral kit 21 x 25 mg & 7 x 50 mg, 25 & 50 & 100 mg, 42 x 50 mg & 14x100 mg

2

lamotrigine oral tablet 100 mg, 150 mg, 200 mg

1

lamotrigine oral tablet 25 mg

2

lamotrigine oral tablet chewable 25 mg, 5 mg

2

lamotrigine oral tablet dispersible 100 mg, 200 mg, 25 mg, 50 mg

2

lamotrigine starter kit-blue oral kit 35 x 25 mg

2

lamotrigine starter kit-green oral kit 84 x 25 mg & 14x100 mg

2

lamotrigine starter kit-orange oral kit 42 x 25 mg & 7 x 100 mg

2

levetiracetam er oral tablet extended release 24 hour 500 mg, 750 mg

2



43

Drug NameDrug Tier

Notes

levetiracetam in nacl intravenous solution 1000 mg/100ml, 1500 mg/100ml, 500 mg/100ml

GM

levetiracetam intravenous solution 500 mg/5ml

GM

levetiracetam oral solution 100 mg/ml

2

levetiracetam oral tablet 1000 mg, 250 mg, 500 mg, 750 mg

2

MYSOLINE ORAL TABLET 250 MG

3

MYSOLINE ORAL TABLET 50 MG

4

NEMBUTAL INJECTION SOLUTION 50 MG/ML

GM

NEURONTIN ORAL CAPSULE 100 MG, 300 MG, 400 MG

4

NEURONTIN ORAL SOLUTION 250 MG/5ML

4

NEURONTIN ORAL TABLET 600 MG, 800 MG

4

ONFI ORAL SUSPENSION 2.5 MG/ML

4

ONFI ORAL TABLET 10 MG, 20 MG

4

oxcarbazepine oral suspension 300 mg/5ml

2

oxcarbazepine oral tablet 150 mg, 300 mg, 600 mg

2

OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HOUR 150 MG, 300 MG, 600 MG

4

PEGANONE ORAL TABLET 250 MG

4

Drug NameDrug Tier

Notes

pentobarbital sodium injection solution 50 mg/ml

GM

phenobarbital oral elixir 20 mg/5ml

2

phenobarbital oral solution 20 mg/5ml

2

phenobarbital oral tablet 100 mg, 15 mg, 16.2 mg, 30 mg, 32.4 mg, 60 mg, 64.8 mg, 97.2 mg

2

phenobarbital sodium injection solution 130 mg/ml, 65 mg/ml

GM

PHENYTEK ORAL CAPSULE 200 MG, 300 MG

4

phenytoin infatabs oral tablet chewable 50 mg

2

phenytoin oral suspension 125 mg/5ml

2

phenytoin oral tablet chewable 50 mg

2

phenytoin sodium extended oral capsule 100 mg, 200 mg, 300 mg

2

phenytoin sodium injection solution 50 mg/ml

GM

primidone oral tablet 250 mg, 50 mg

2

QUDEXY XR ORAL CAPSULE ER 24 HOUR SPRINKLE 100 MG, 150 MG, 200 MG, 25 MG, 50 MG

4 PA

roweepra oral tablet 1000 mg, 500 mg, 750 mg

2

roweepra xr oral tablet extended release 24 hour 500 mg, 750 mg

2



44

Drug NameDrug Tier

Notes

SABRIL ORAL PACKET 500 MG

6 PA

SABRIL ORAL TABLET 500 MG

6 PA

SPRITAM ORAL TABLET DISINTEGRATING SOLUBLE 1000 MG, 250 MG, 500 MG, 750 MG

4 ST

subvenite oral tablet 100 mg, 150 mg, 200 mg

1

subvenite oral tablet 25 mg

2

subvenite starter kit-blue oral kit 35 x 25 mg

2

subvenite starter kit-green oral kit 84 x 25 mg & 14x100 mg

2

subvenite starter kit-orange oral kit 42 x 25 mg & 7 x 100 mg

2

SYMPAZAN ORAL FILM 10 MG, 20 MG, 5 MG

4

TEGRETOL ORAL SUSPENSION 100 MG/5ML

4

TEGRETOL ORAL TABLET 200 MG

4

TEGRETOL-XR ORAL TABLET EXTENDED RELEASE 12 HOUR 100 MG, 200 MG, 400 MG

4

tiagabine hcl oral tablet 12 mg, 16 mg, 2 mg, 4 mg

2

TOPAMAX ORAL TABLET 100 MG, 200 MG, 25 MG, 50 MG

4

TOPAMAX SPRINKLE ORAL CAPSULE SPRINKLE 15 MG, 25 MG

4

Drug NameDrug Tier

Notes

topiramate er oral capsule er 24 hour sprinkle 100 mg, 150 mg, 200 mg, 25 mg, 50 mg

2 PA

topiramate oral capsule sprinkle 15 mg, 25 mg

2

topiramate oral tablet 100 mg, 200 mg, 25 mg, 50 mg

2

TRILEPTAL ORAL SUSPENSION 300 MG/5ML

4

TRILEPTAL ORAL TABLET 150 MG, 300 MG, 600 MG

4

TROKENDI XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 100 MG, 200 MG, 25 MG, 50 MG

4 PA

valproate sodium intravenous solution 100 mg/ml, 500 mg/5ml

GM

valproate sodium oral solution 250 mg/5ml

2

valproic acid oral capsule 250 mg

2

valproic acid oral solution 250 mg/5ml

2

vigabatrin oral packet 500 mg

5 PA

vigabatrin oral tablet 500 mg

5 PA

vigadrone oral packet 500 mg

5 PA

VIMPAT INTRAVENOUS SOLUTION 200 MG/20ML

GM

VIMPAT ORAL SOLUTION 10 MG/ML

4



45

Drug NameDrug Tier

Notes

VIMPAT ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG

4

ZARONTIN ORAL CAPSULE 250 MG

4

ZARONTIN ORAL SOLUTION 250 MG/5ML

4

ZONEGRAN ORAL CAPSULE 100 MG, 25 MG

4

zonisamide oral capsule 100 mg, 25 mg, 50 mg

2

Antidementia Agents - Drugs for Alzheimer's Disease and Dementia

ARICEPT ORAL TABLET 10 MG, 5 MG

4

ARICEPT ORAL TABLET 23 MG

3

donepezil hcl oral tablet 10 mg, 23 mg, 5 mg

2

donepezil hcl oral tablet dispersible 10 mg, 5 mg

2

EXELON TRANSDERMAL PATCH 24 HOUR 13.3 MG/24HR, 4.6 MG/24HR, 9.5 MG/24HR

3

galantamine hydrobromide er oral capsule extended release 24 hour 16 mg, 24 mg, 8 mg

2

galantamine hydrobromide oral solution 4 mg/ml

2

galantamine hydrobromide oral tablet 12 mg, 4 mg, 8 mg

2

memantine hcl er oral capsule extended release 24 hour 14 mg, 21 mg, 28 mg, 7 mg

2

Drug NameDrug Tier

Notes

memantine hcl oral solution 10 mg/5ml, 2 mg/ml

2

memantine hcl oral tablet 10 mg, 28 x 5 mg & 21 x 10 mg, 5 mg

2

NAMENDA ORAL TABLET 10 MG, 5 MG

4

NAMENDA TITRATION PAK ORAL TABLET 28 X 5 MG & 21 X 10 MG

4

NAMENDA XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 14 MG, 21 MG, 28 MG, 7 MG

4

NAMENDA XR TITRATION PACK ORAL CAPSULE EXTENDED RELEASE 24 HOUR 7 & 14 & 21

4

NAMZARIC ORAL CAPSULE ER 24 HOUR THERAPY PACK 7 & 14 & 21 &28 -10 MG

4

NAMZARIC ORAL CAPSULE EXTENDED RELEASE 24 HOUR 14-10 MG, 21-10 MG, 28-10 MG, 7-10 MG

4

RAZADYNE ER ORAL CAPSULE EXTENDED RELEASE 24 HOUR 16 MG, 24 MG, 8 MG

4

RAZADYNE ORAL TABLET 12 MG, 4 MG, 8 MG

4

rivastigmine tartrate oral capsule 1.5 mg, 3 mg, 4.5 mg, 6 mg

2

rivastigmine transdermal patch 24 hour 13.3 mg/24hr, 4.6 mg/24hr, 9.5 mg/24hr

2



46

Drug NameDrug Tier

Notes

Antidepressants

amitriptyline hcl oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg

2

amoxapine oral tablet 100 mg, 150 mg, 25 mg, 50 mg

2

ANAFRANIL ORAL CAPSULE 25 MG, 50 MG, 75 MG

4

APLENZIN ORAL TABLET EXTENDED RELEASE 24 HOUR 174 MG, 348 MG, 522 MG


days)

bupropion hcl er (sr) oral tablet extended release 12 hour 100 mg, 150 mg, 200 mg

2

bupropion hcl er (xl) oral tablet extended release 24 hour 150 mg, 300 mg

2

bupropion hcl oral tablet 100 mg, 75 mg

2

CELEXA ORAL TABLET 10 MG, 20 MG, 40 MG

4

chlordiazepoxide-amitriptyline oral tablet 10-25 mg, 5-12.5 mg

2

citalopram hydrobromide oral solution 10 mg/5ml

2

citalopram hydrobromide oral tablet 10 mg, 20 mg, 40 mg

1

clomipramine hcl oral capsule 25 mg, 50 mg, 75 mg

2

CYMBALTA ORAL CAPSULE DELAYED RELEASE PARTICLES 20 MG, 30 MG, 60 MG

4

Drug NameDrug Tier

Notes

desipramine hcl oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg

2

DESVENLAFAXINE ER ORAL TABLET EXTENDED RELEASE 24 HOUR 100 MG, 50 MG

4 PA

desvenlafaxine succinate er oral tablet extended release 24 hour 100 mg, 25 mg, 50 mg

2 PA

doxepin hcl oral capsule 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg

2

doxepin hcl oral concentrate 10 mg/ml

2

duloxetine hcl oral capsule delayed release particles 20 mg, 30 mg, 60 mg

2

EFFEXOR XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 150 MG, 37.5 MG, 75 MG

4

ELAVIL ORAL TABLET 25 MG

4

EMSAM TRANSDERMAL PATCH 24 HOUR 12 MG/24HR, 6 MG/24HR, 9 MG/24HR

3

escitalopram oxalate oral solution 5 mg/5ml

2

escitalopram oxalate oral tablet 10 mg, 20 mg, 5 mg

2

FETZIMA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 20 MG, 40 MG, 80 MG

4 PA



47

Drug NameDrug Tier

Notes

FETZIMA TITRATION ORAL CAPSULE ER 24 HOUR THERAPY PACK 20 & 40 MG

4

fluoxetine hcl (pmdd) oral capsule 10 mg, 20 mg

2

fluoxetine hcl oral capsule 10 mg, 20 mg, 40 mg

1

fluoxetine hcl oral capsule delayed release 90 mg

2

fluoxetine hcl oral solution 20 mg/5ml

2

fluoxetine hcl oral tablet 10 mg, 20 mg

2

fluvoxamine maleate er oral capsule extended release 24 hour 100 mg, 150 mg

2

fluvoxamine maleate oral tablet 100 mg, 25 mg, 50 mg

2

imipramine hcl oral tablet 10 mg, 25 mg, 50 mg

2

imipramine pamoate oral capsule 100 mg, 125 mg, 150 mg, 75 mg

2

KHEDEZLA ORAL TABLET EXTENDED RELEASE 24 HOUR 100 MG, 50 MG

4 PA

LEXAPRO ORAL TABLET 10 MG, 20 MG, 5 MG

4

maprotiline hcl oral tablet 25 mg, 50 mg, 75 mg

2

MARPLAN ORAL TABLET 10 MG

4

mirtazapine oral tablet 15 mg, 30 mg, 45 mg, 7.5 mg

2

Drug NameDrug Tier

Notes

mirtazapine oral tablet dispersible 15 mg, 30 mg, 45 mg

2

NARDIL ORAL TABLET 15 MG

4

nefazodone hcl oral tablet 100 mg, 150 mg, 200 mg, 250 mg, 50 mg

2

NORPRAMIN ORAL TABLET 10 MG, 25 MG

4

nortriptyline hcl oral capsule 10 mg, 25 mg, 50 mg, 75 mg

2

nortriptyline hcl oral solution 10 mg/5ml

2

olanzapine-fluoxetine hcl oral capsule 12-25 mg, 12-50 mg, 3-25 mg, 6-25 mg, 6-50 mg

2 PA

PAMELOR ORAL CAPSULE 10 MG, 25 MG, 50 MG, 75 MG

4

PARNATE ORAL TABLET 10 MG

4

paroxetine hcl er oral tablet extended release 24 hour 12.5 mg, 25 mg, 37.5 mg

2

paroxetine hcl oral tablet 10 mg, 20 mg, 30 mg, 40 mg

2

PAXIL CR ORAL TABLET EXTENDED RELEASE 24 HOUR 12.5 MG, 25 MG, 37.5 MG

4

PAXIL ORAL SUSPENSION 10 MG/5ML

3

PAXIL ORAL TABLET 10 MG, 20 MG, 30 MG, 40 MG

4



48

Drug NameDrug Tier

Notes

perphenazine-amitriptyline oral tablet 2-10 mg, 2-25 mg, 4-10 mg, 4-25 mg, 4-50 mg

2

phenelzine sulfate oral tablet 15 mg

2

PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HOUR 100 MG, 25 MG, 50 MG

4 PA

protriptyline hcl oral tablet 10 mg, 5 mg

2

PROZAC ORAL CAPSULE 10 MG, 20 MG, 40 MG

4

REMERON ORAL TABLET 15 MG, 30 MG, 45 MG

4

REMERON SOLTAB ORAL TABLET DISPERSIBLE 15 MG, 30 MG, 45 MG

4

sertraline hcl oral concentrate 20 mg/ml

2

sertraline hcl oral tablet 100 mg, 25 mg, 50 mg

1

SPRAVATO (56 MG DOSE) NASAL SOLUTION THERAPY PACK 28 MG/DEVICE

6PA;

Specialty Medical

SPRAVATO (84 MG DOSE) NASAL SOLUTION THERAPY PACK 28 MG/DEVICE

6PA;

Specialty Medical

SURMONTIL ORAL CAPSULE 100 MG, 25 MG, 50 MG

4

SYMBYAX ORAL CAPSULE 12-25 MG, 12-50 MG, 3-25 MG, 6-25 MG, 6-50 MG

4 PA

Drug NameDrug Tier

Notes

TOFRANIL ORAL TABLET 10 MG, 25 MG, 50 MG

4

tranylcypromine sulfate oral tablet 10 mg

2

trazodone hcl oral tablet 100 mg, 150 mg, 300 mg, 50 mg

2

trimipramine maleate oral capsule 100 mg, 25 mg, 50 mg

2

TRINTELLIX ORAL TABLET 10 MG, 20 MG, 5 MG

4 PA

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

2

venlafaxine hcl oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 75 mg

2

VIIBRYD ORAL TABLET 10 MG, 20 MG, 40 MG

4 PA

VIIBRYD STARTER PACK ORAL KIT 10 & 20 MG

4 PA

WELLBUTRIN SR ORAL TABLET EXTENDED RELEASE 12 HOUR 100 MG, 150 MG, 200 MG

4

WELLBUTRIN XL ORAL TABLET EXTENDED RELEASE 24 HOUR 150 MG, 300 MG

4

ZOLOFT ORAL CONCENTRATE 20 MG/ML

4

ZOLOFT ORAL TABLET 100 MG, 25 MG, 50 MG

4



49

Drug NameDrug Tier

Notes

Antiemetics - Drugs for Nausea and Vomiting

AKYNZEO INTRAVENOUS SOLUTION RECONSTITUTED 235-0.25 MG

GM

AKYNZEO ORAL CAPSULE 300-0.5 MG

4QL (3 EA

per 21 days)

ALOXI INTRAVENOUS SOLUTION 0.25 MG/5ML

GM

ANZEMET ORAL TABLET 100 MG, 50 MG

3

aprepitant oral capsule 125 mg, 40 mg, 80 & 125 mg, 80 mg

2QL (6 EA

per 30 days)

BONJESTA ORAL TABLET EXTENDED RELEASE 20-20 MG

4

CESAMET ORAL CAPSULE 1 MG

4

CINVANTI INTRAVENOUS EMULSION 130 MG/18ML

GMQL (6 ML

per 30 days)

compro rectal suppository 25 mg

2

dimenhydrinate injection solution 50 mg/ml

GM

dronabinol oral capsule 10 mg, 2.5 mg, 5 mg

2

droperidol injection solution 2.5 mg/ml

GM

EMEND INTRAVENOUS SOLUTION RECONSTITUTED 150 MG

GM PA

EMEND ORAL CAPSULE 125 MG, 40 MG, 80 MG

4QL (6 EA

per 30 days)

Drug NameDrug Tier

Notes

EMEND ORAL SUSPENSION RECONSTITUTED 125 MG

3QL (6 EA

per 30 days)

EMEND TRI-PACK ORAL CAPSULE 80 & 125 MG

4QL (6 EA

per 30 days)

fosaprepitant dimeglumine intravenous solution reconstituted 150 mg

GM PA

granisetron hcl intravenous solution 0.1 mg/ml, 1 mg/ml, 4 mg/4ml

GM

granisetron hcl oral tablet 1 mg

2

MARINOL ORAL CAPSULE 10 MG, 2.5 MG, 5 MG

4

meclizine hcl oral tablet 12.5 mg, 25 mg

2

metoclopramide hcl injection solution 5 mg/ml

GM

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

2

metoclopramide hcl oral tablet 10 mg, 5 mg

2

metoclopramide hcl oral tablet dispersible 10 mg, 5 mg

2

ondansetron hcl injection solution 40 mg/20ml

GM

ondansetron hcl oral solution 4 mg/5ml

2

ondansetron hcl oral tablet 24 mg, 4 mg, 8 mg

2

ONDANSETRON HCL SOLUTION 4 MG/2ML INJECTION 4 MG/2ML

GM



50

Drug NameDrug Tier

Notes

ondansetron hcl solution 4 mg/2ml injection 4 mg/2ml

GM

ONDANSETRON HCL-DEXTROSE INTRAVENOUS SOLUTION 8-5 MG/50ML-%

GM

ONDANSETRON HCL-NACL INTRAVENOUS SOLUTION 4-0.9 MG/50ML-%

GM

ondansetron odt oral tablet dispersible 4 mg, 8 mg

2

palonosetron hcl intravenous solution 0.25 mg/2ml, 0.25 mg/5ml

GM

palonosetron hcl intravenous solution prefilled syringe 0.25 mg/5ml

GM

perphenazine oral tablet 16 mg, 2 mg, 4 mg, 8 mg

2

prochlorperazine edisylate injection solution 10 mg/2ml, 50 mg/10ml

GM

prochlorperazine maleate oral tablet 10 mg, 5 mg

2

prochlorperazine rectal suppository 25 mg

2

REGLAN ORAL TABLET 10 MG, 5 MG

4

SANCUSO TRANSDERMAL PATCH 3.1 MG/24HR

3QL (1 EA

per 30 days)

scopolamine transdermal patch 72 hour 1 mg/3days

2

Drug NameDrug Tier

Notes

SUSTOL SUBCUTANEOUS PREFILLED SYRINGE 10 MG/0.4ML

6QL (2 ML

per 30 days)

SYNDROS ORAL SOLUTION 5 MG/ML

4

TIGAN INTRAMUSCULAR SOLUTION 100 MG/ML

GM

TIGAN ORAL CAPSULE 300 MG

4

TRANSDERM SCOP (1.5 MG) TRANSDERMAL PATCH 72 HOUR 1 MG/3DAYS

4

TRANSDERM-SCOP (1.5 MG) TRANSDERMAL PATCH 72 HOUR 1 MG/3DAYS

4

trimethobenzamide hcl oral capsule 300 mg

2

VARUBI INTRAVENOUS EMULSION 166.5 MG/92.5ML

GM

VARUBI ORAL TABLET 90 MG

4QL (2 EA

per 30 days)

ZOFRAN ODT ORAL TABLET DISPERSIBLE 4 MG, 8 MG

4

ZOFRAN ORAL SOLUTION 4 MG/5ML

4

ZOFRAN ORAL TABLET 4 MG, 8 MG

4

ZUPLENZ ORAL FILM 4 MG, 8 MG

4

Antifungals

ABELCET INTRAVENOUS SUSPENSION 5 MG/ML

GM



51

Drug NameDrug Tier

Notes

AMBISOME INTRAVENOUS SUSPENSION RECONSTITUTED 50 MG

GM

amphotericin b intravenous solution reconstituted 50 mg

GM

ANCOBON ORAL CAPSULE 250 MG, 500 MG

4

AVC VAGINAL VAGINAL CREAM 15 %

4

BIO-STATIN ORAL CAPSULE 1000000 UNIT, 500000 UNIT

4

bio-statin oral powder 2

CANCIDAS INTRAVENOUS SOLUTION RECONSTITUTED 50 MG, 70 MG

GM

caspofungin acetate intravenous solution reconstituted 50 mg, 70 mg

GM

CICLODAN CREAM EXTERNAL KIT 0.77 %

4 PA

ciclodan external cream 0.77 %

2

ciclodan external solution 8 %

2QL (13.2

ML per 30 days)

CICLODAN SOLUTION EXTERNAL KIT 8 %

4

ciclopirox external gel 0.77 %

2

ciclopirox external shampoo 1 %

2

ciclopirox external solution 8 %

2QL (13.2

ML per 30 days)

Drug NameDrug Tier

Notes

ciclopirox olamine external cream 0.77 %

2

ciclopirox olamine external suspension 0.77 %

2

ciclopirox treatment external kit 8 %

2

clotrimazole external cream 1 %

2

clotrimazole external solution 1 %

2

clotrimazole mouth/throat lozenge 10 mg

2

clotrimazole mouth/throat troche 10 mg

2

CRESEMBA INTRAVENOUS SOLUTION RECONSTITUTED 372 MG

GM

CRESEMBA ORAL CAPSULE 186 MG

6 PA

DIFLUCAN ORAL SUSPENSION RECONSTITUTED 10 MG/ML, 40 MG/ML

4

DIFLUCAN ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG

4

econazole nitrate external cream 1 %

2

ERAXIS INTRAVENOUS SOLUTION RECONSTITUTED 100 MG, 50 MG

GM

ERTACZO EXTERNAL CREAM 2 %

4 ST

EXELDERM EXTERNAL CREAM 1 %

4 ST

EXELDERM EXTERNAL SOLUTION 1 %

4 ST



52

Drug NameDrug Tier

Notes

EXODERM EXTERNAL LOTION 25-1 %

4

EXTINA EXTERNAL FOAM 2 %

4

fluconazole in dextrose intravenous solution 200 mg/100ml, 400 mg/200ml

GM

fluconazole in sodium chloride intravenous solution 100-0.9 mg/50ml-%, 200-0.9 mg/100ml-%, 400-0.9 mg/200ml-%

GM

fluconazole oral suspension reconstituted 10 mg/ml, 40 mg/ml

2

fluconazole oral tablet 100 mg, 150 mg, 200 mg, 50 mg

2

flucytosine oral capsule 250 mg, 500 mg

2

FUNGIMEZ EXTERNAL SOLUTION

4

griseofulvin microsize oral suspension 125 mg/5ml

2

griseofulvin microsize oral tablet 500 mg

2

griseofulvin ultramicrosize oral tablet 125 mg, 250 mg

2

GRIS-PEG ORAL TABLET 125 MG, 250 MG

3

GYNAZOLE-1 VAGINAL CREAM 2 %

4

HALOTIN EXTERNAL CREAM 1 %

4

itraconazole oral capsule 100 mg

2

itraconazole oral solution 10 mg/ml

2

Drug NameDrug Tier

Notes

JUBLIA EXTERNAL SOLUTION 10 %

4 PA

KERYDIN EXTERNAL SOLUTION 5 %

4 PA

ketoconazole external cream 2 %

2

ketoconazole external foam 2 %

2

ketoconazole external shampoo 2 %

2

ketoconazole oral tablet 200 mg

2

LAMISIL ORAL TABLET 250 MG

4

LOPROX EXTERNAL CREAM 0.77 %

4

LOPROX EXTERNAL KIT 0.77 %

4 PA

LOPROX EXTERNAL SHAMPOO 1 %

4

LOPROX EXTERNAL SUSPENSION 0.77 %

4

LULICONAZOLE EXTERNAL CREAM 1 %

4 ST

LUZU EXTERNAL CREAM 1 %

4 ST

MENTAX EXTERNAL CREAM 1 %

4 ST

miconazole 3 vaginal suppository 200 mg

2

MICONAZOLE-ZINC OXIDE-PETROLAT EXTERNAL OINTMENT 0.25-15-81.35 %

4

MYCAMINE INTRAVENOUS SOLUTION RECONSTITUTED 100 MG, 50 MG

GM

naftifine hcl external cream 1 %, 2 %

2 ST



53

Drug NameDrug Tier

Notes

naftifine hcl external gel 1 %

2 ST

NAFTIN EXTERNAL CREAM 2 %

4 ST

NAFTIN EXTERNAL GEL 1 %, 2 %

4 ST

NIZORAL EXTERNAL SHAMPOO 2 %

4

NOXAFIL INTRAVENOUS SOLUTION 300 MG/16.7ML

6Specialty Medical

NOXAFIL ORAL SUSPENSION 40 MG/ML

6

NOXAFIL ORAL TABLET DELAYED RELEASE 100 MG

6

nyata external powder 100000 unit/gm

2

nystatin external cream 100000 unit/gm

2

nystatin external ointment 100000 unit/gm

2

nystatin external powder 100000 unit/gm

2

nystatin mouth/throat suspension 100000 unit/ml

2

nystatin oral tablet 500000 unit

2

nystatin-triamcinolone external cream 100000-0.1 unit/gm-%

2

nystatin-triamcinolone external ointment 100000-0.1 unit/gm-%

2

nystop external powder 100000 unit/gm

2

ONMEL ORAL TABLET 200 MG

4 PA

Drug NameDrug Tier

Notes

ORAVIG BUCCAL TABLET 50 MG

4

oxiconazole nitrate external cream 1 %

2 ST

OXISTAT EXTERNAL CREAM 1 %

4 ST

OXISTAT EXTERNAL LOTION 1 %

4 ST

PENLAC EXTERNAL SOLUTION 8 %

4QL (13.2

ML per 30 days)

posaconazole oral tablet delayed release 100 mg

6

RECURA EXTERNAL CREAM

4

SPORANOX ORAL CAPSULE 100 MG

4

SPORANOX ORAL SOLUTION 10 MG/ML

4

SPORANOX PULSEPAK ORAL CAPSULE 100 MG

4

TERAZOL 7 VAGINAL CREAM 0.4 %

4

terbinafine hcl oral tablet 250 mg

2

terconazole vaginal cream 0.4 %, 0.8 %

2

terconazole vaginal suppository 80 mg

2

VFEND IV INTRAVENOUS SOLUTION RECONSTITUTED 200 MG

5Specialty Medical

VFEND ORAL SUSPENSION RECONSTITUTED 40 MG/ML

6

VFEND ORAL TABLET 200 MG, 50 MG

6



54

Drug NameDrug Tier

Notes

voriconazole intravenous solution reconstituted 200 mg

5Specialty Medical

voriconazole oral suspension reconstituted 40 mg/ml

5

voriconazole oral tablet 200 mg, 50 mg

5

VUSION EXTERNAL OINTMENT 0.25-15-81.35 %

4

XOLEGEL COREPAK EXTERNAL KIT 2 & 1 %

4

XOLEGEL DUO/HEAD & SHOULDERS EXTERNAL KIT 2 & 1 %

4

XOLEGEL DUO/XOLEX EXTERNAL KIT 2 & 1 %

4

XOLEGEL EXTERNAL GEL 2 %

4

Antigout Agents

allopurinol oral tablet 100 mg, 300 mg

1

allopurinol sodium intravenous solution reconstituted 500 mg

GM

ALOPRIM INTRAVENOUS SOLUTION RECONSTITUTED 500 MG

GM

COLCHICINE ORAL CAPSULE 0.6 MG

4

COLCHICINE ORAL TABLET 0.6 MG

3

colchicine-probenecid oral tablet 0.5-500 mg

2

COLCRYS ORAL TABLET 0.6 MG

3

DUZALLO ORAL TABLET 200-200 MG, 200-300 MG

4 PA

Drug NameDrug Tier

Notes

febuxostat oral tablet 40 mg, 80 mg

2

GLOPERBA ORAL SOLUTION 0.6 MG/5ML

4

KRYSTEXXA INTRAVENOUS SOLUTION 8 MG/ML

6PA;

Specialty Medical

MITIGARE ORAL CAPSULE 0.6 MG

4

probenecid oral tablet 500 mg

2

ULORIC ORAL TABLET 40 MG, 80 MG

4

ZURAMPIC ORAL TABLET 200 MG

4 PA

ZYLOPRIM ORAL TABLET 100 MG, 300 MG

4

Anti-inflammatory Agents

EMFLAZA ORAL SUSPENSION 22.75 MG/ML

6 PA

EMFLAZA ORAL TABLET 18 MG, 30 MG, 36 MG, 6 MG

6 PA

Antimigraine Agents

AIMOVIG SUBCUTANEOUS SOLUTION AUTO-INJECTOR 140 MG/ML, 70 MG/ML

4PA; QL (1 ML per 28

days)

AIMOVIG SUBCUTANEOUS SOLUTION AUTO-INJECTOR 70 MG/ML


days)

AJOVY SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 225 MG/1.5ML

4PA; QL

(1.5 ML per 28 days)



55

Drug NameDrug Tier

Notes

almotriptan malate oral tablet 12.5 mg, 6.25 mg

2QL (9 EA

per 30 days)

AMERGE ORAL TABLET 1 MG, 2.5 MG

4QL (9 EA

per 30 days)

AXERT ORAL TABLET 12.5 MG, 6.25 MG

4QL (9 EA

per 30 days)

CAFERGOT ORAL TABLET 1-100 MG

4

D.H.E. 45 INJECTION SOLUTION 1 MG/ML

GM

dihydroergotamine mesylate injection solution 1 mg/ml

GM

dihydroergotamine mesylate nasal solution 4 mg/ml


days)

eletriptan hydrobromide oral tablet 20 mg, 40 mg

2QL (9 EA

per 30 days)

EMGALITY (300 MG DOSE) SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 100 MG/ML


days)

EMGALITY SUBCUTANEOUS SOLUTION AUTO-INJECTOR 120 MG/ML


days)

EMGALITY SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 120 MG/ML


days)

ERGOMAR SUBLINGUAL TABLET SUBLINGUAL 2 MG

4

ergotamine-caffeine oral tablet 1-100 mg

2

FROVA ORAL TABLET 2.5 MG

4QL (9 EA

per 30 days)

Drug NameDrug Tier

Notes

frovatriptan succinate oral tablet 2.5 mg

2QL (9 EA

per 30 days)

IMITREX NASAL SOLUTION 20 MG/ACT, 5 MG/ACT

3QL (6 EA

per 30 days)

IMITREX ORAL TABLET 100 MG, 25 MG, 50 MG

4QL (9 EA

per 30 days)

IMITREX STATDOSE REFILL SUBCUTANEOUS SOLUTION CARTRIDGE 4 MG/0.5ML, 6 MG/0.5ML

4QL (2 ML

per 30 days)

IMITREX STATDOSE SYSTEM SUBCUTANEOUS SOLUTION AUTO-INJECTOR 4 MG/0.5ML, 6 MG/0.5ML

4QL (2 ML

per 30 days)

IMITREX SUBCUTANEOUS SOLUTION 6 MG/0.5ML

4QL (2 ML

per 30 days)

MAXALT ORAL TABLET 10 MG, 5 MG

4QL (12 EA

per 30 days)

MAXALT-MLT ORAL TABLET DISPERSIBLE 10 MG, 5 MG

4QL (12 EA

per 30 days)

MIGERGOT RECTAL SUPPOSITORY 2-100 MG

4

MIGRANAL NASAL SOLUTION 4 MG/ML


days)

naratriptan hcl oral tablet 1 mg, 2.5 mg

2QL (9 EA

per 30 days)

RELPAX ORAL TABLET 20 MG, 40 MG

4QL (9 EA

per 30 days)



56

Drug NameDrug Tier

Notes

rizatriptan benzoate oral tablet 10 mg, 5 mg

2QL (12 EA

per 30 days)

rizatriptan benzoate oral tablet dispersible 10 mg, 5 mg

2QL (12 EA

per 30 days)

sumatriptan nasal solution 20 mg/act, 5 mg/act

2QL (6 EA

per 30 days)

sumatriptan succinate oral tablet 100 mg, 25 mg, 50 mg

2QL (9 EA

per 30 days)

sumatriptan succinate refill subcutaneous solution cartridge 4 mg/0.5ml, 6 mg/0.5ml

2QL (2 ML

per 30 days)

sumatriptan succinate subcutaneous solution 6 mg/0.5ml

2QL (2 ML

per 30 days)

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

2QL (2 ML

per 30 days)

sumatriptan succinate subcutaneous solution prefilled syringe 6 mg/0.5ml

2QL (2 ML

per 30 days)

zolmitriptan oral tablet 2.5 mg, 5 mg

2QL (9 EA

per 30 days)

zolmitriptan oral tablet dispersible 2.5 mg, 5 mg

2QL (9 EA

per 30 days)

ZOMIG NASAL SOLUTION 2.5 MG, 5 MG

4QL (6 EA

per 30 days)

ZOMIG ORAL TABLET 2.5 MG, 5 MG

4QL (9 EA

per 30 days)

ZOMIG ZMT ORAL TABLET DISPERSIBLE 2.5 MG, 5 MG

4QL (9 EA

per 30 days)

Drug NameDrug Tier

Notes

Antimyasthenic Agents

BLOXIVERZ INTRAVENOUS SOLUTION 10 MG/10ML, 5 MG/10ML

GM

GUANIDINE HCL ORAL TABLET 125 MG

4

MESTINON ORAL SYRUP 60 MG/5ML

3

MESTINON ORAL TABLET 60 MG

4

MESTINON ORAL TABLET EXTENDED RELEASE 180 MG

3

neostigmine methylsulfate intravenous solution 10 mg/10ml, 5 mg/10ml

GM

NEOSTIGMINE METHYLSULFATE INTRAVENOUS SOLUTION 3 MG/3ML, 5 MG/5ML

GM

NEOSTIGMINE METHYLSULFATE INTRAVENOUS SOLUTION PREFILLED SYRINGE 3 MG/3ML, 4 MG/4ML

GM

pyridostigmine bromide er oral tablet extended release 180 mg

2

pyridostigmine bromide oral solution 60 mg/5ml

2

pyridostigmine bromide oral tablet 30 mg, 60 mg

2

REGONOL INTRAVENOUS SOLUTION 10 MG/2ML

GM

Antimycobacterials

CAPASTAT SULFATE INJECTION SOLUTION RECONSTITUTED 1 GM

GM



57

Drug NameDrug Tier

Notes

cycloserine oral capsule 250 mg

2

dapsone oral tablet 100 mg, 25 mg

2

ethambutol hcl oral tablet 100 mg, 400 mg

2

isoniazid injection solution 100 mg/ml

GM

isoniazid oral syrup 50 mg/5ml

2

isoniazid oral tablet 100 mg, 300 mg

2

MYAMBUTOL ORAL TABLET 100 MG, 400 MG

4

MYCOBUTIN ORAL CAPSULE 150 MG

3

PASER ORAL PACKET 4 GM

4

PRETOMANID ORAL TABLET 200 MG

4

PRIFTIN ORAL TABLET 150 MG

4

pyrazinamide oral tablet 500 mg

2

rifabutin oral capsule 150 mg

2

RIFADIN INTRAVENOUS SOLUTION RECONSTITUTED 600 MG

GM

RIFADIN ORAL CAPSULE 150 MG, 300 MG

4

RIFAMATE ORAL CAPSULE 150-300 MG

4

rifampin intravenous solution reconstituted 600 mg

GM

rifampin oral capsule 150 mg, 300 mg

2

Drug NameDrug Tier

Notes

RIFATER ORAL TABLET 50-120-300 MG

4

SIRTURO ORAL TABLET 100 MG

6 PA

TRECATOR ORAL TABLET 250 MG

4

Antineoplastics - Drugs for Cancer

abiraterone acetate oral tablet 250 mg

5 PA

ABRAXANE INTRAVENOUS SUSPENSION RECONSTITUTED 100 MG

6PA;

Specialty Medical

ADCETRIS INTRAVENOUS SOLUTION RECONSTITUTED 50 MG

6PA;

Specialty Medical

adriamycin intravenous solution 2 mg/ml

GM PA

adriamycin intravenous solution reconstituted 10 mg, 50 mg

GM PA

adrucil intravenous solution 2.5 gm/50ml, 5 gm/100ml, 500 mg/10ml

GM PA

AFINITOR DISPERZ ORAL TABLET SOLUBLE 2 MG, 3 MG, 5 MG

6 PA

AFINITOR ORAL TABLET 10 MG, 2.5 MG, 5 MG, 7.5 MG

6 PA

ALECENSA ORAL CAPSULE 150 MG

6 PA

ALIMTA INTRAVENOUS SOLUTION RECONSTITUTED 100 MG, 500 MG

6PA;

Specialty Medical



58

Drug NameDrug Tier

Notes

ALIQOPA INTRAVENOUS SOLUTION RECONSTITUTED 60 MG

6PA;

Specialty Medical

ALKERAN INTRAVENOUS SOLUTION RECONSTITUTED 50 MG

6PA;

Specialty Medical

ALKERAN ORAL TABLET 2 MG

3 PA

ALUNBRIG ORAL TABLET 180 MG, 30 MG, 90 MG

6 PA

ALUNBRIG ORAL TABLET THERAPY PACK 90 & 180 MG

6 PA

anastrozole oral tablet 1 mg

2

ARIMIDEX ORAL TABLET 1 MG

4

AROMASIN ORAL TABLET 25 MG

4

ARRANON INTRAVENOUS SOLUTION 5 MG/ML

6PA;

Specialty Medical

arsenic trioxide intravenous solution 10 mg/10ml

6PA;

Specialty Medical

ARZERRA INTRAVENOUS CONCENTRATE 100 MG/5ML, 1000 MG/50ML

6PA;

Specialty Medical

ASPARLAS INTRAVENOUS SOLUTION 3750 UNIT/5ML

6PA;

Specialty Medical

AVASTIN INTRAVENOUS SOLUTION 100 MG/4ML, 400 MG/16ML

6PA;

Specialty Medical

Drug NameDrug Tier

Notes

azacitidine injection suspension reconstituted 100 mg

6PA;

Specialty Medical

AZEDRA DOSIMETRIC INTRAVENOUS SOLUTION 15 MCI/ML

GM

AZEDRA THERAPEUTIC INTRAVENOUS SOLUTION 15 MCI/ML

GM

BALVERSA ORAL TABLET 3 MG, 4 MG, 5 MG

6 PA

BAVENCIO INTRAVENOUS SOLUTION 200 MG/10ML

GM

BELEODAQ INTRAVENOUS SOLUTION RECONSTITUTED 500 MG

6PA;

Specialty Medical

BELRAPZO INTRAVENOUS SOLUTION 100 MG/4ML

6PA;

Specialty Medical

BENDAMUSTINE HCL INTRAVENOUS SOLUTION 100 MG/4ML

6PA;

Specialty Medical

BENDEKA INTRAVENOUS SOLUTION 100 MG/4ML

6PA;

Specialty Medical

BESPONSA INTRAVENOUS SOLUTION RECONSTITUTED 0.9 MG

6PA;

Specialty Medical

bexarotene oral capsule 75 mg

6 PA

bicalutamide oral tablet 50 mg

2



59

Drug NameDrug Tier

Notes

BICNU INTRAVENOUS SOLUTION RECONSTITUTED 100 MG

6PA;

Specialty Medical

BLEO 15K INJECTION SOLUTION RECONSTITUTED 15 (15000 IU) UNIT

6PA;

Specialty Medical

bleomycin sulfate injection solution reconstituted 15 unit, 30 unit

6PA;

Specialty Medical

BLINCYTO INTRAVENOUS SOLUTION RECONSTITUTED 35 MCG

6PA;

Specialty Medical

BORTEZOMIB INTRAVENOUS SOLUTION RECONSTITUTED 3.5 MG

6PA;

Specialty Medical

BOSULIF ORAL TABLET 100 MG, 400 MG, 500 MG


days)

BRAFTOVI ORAL CAPSULE 50 MG, 75 MG

6 PA

busulfan intravenous solution 6 mg/ml

6PA;

Specialty Medical

BUSULFEX INTRAVENOUS SOLUTION 6 MG/ML

6PA;

Specialty Medical

CABOMETYX ORAL TABLET 20 MG, 40 MG, 60 MG

6 PA

CALQUENCE ORAL CAPSULE 100 MG

6 PA

CAMPATH INTRAVENOUS SOLUTION 30 MG/ML

6PA;

Specialty Medical

Drug NameDrug Tier

Notes

CAMPTOSAR INTRAVENOUS SOLUTION 100 MG/5ML, 300 MG/15ML, 40 MG/2ML

GM PA

capecitabine oral tablet 150 mg, 500 mg

4 PA

CAPRELSA ORAL TABLET 100 MG, 300 MG

6 PA

carboplatin intravenous solution 150 mg/15ml, 450 mg/45ml, 50 mg/5ml, 600 mg/60ml

GM PA

carmustine intravenous solution reconstituted 100 mg

6PA;

Specialty Medical

CASODEX ORAL TABLET 50 MG

4

cisplatin intravenous solution 100 mg/100ml, 200 mg/200ml, 50 mg/50ml

GM PA

cladribine intravenous solution 10 mg/10ml

6PA;

Specialty Medical

clofarabine intravenous solution 1 mg/ml

6PA;

Specialty Medical

CLOLAR INTRAVENOUS SOLUTION 1 MG/ML

6PA;

Specialty Medical

COMETRIQ (100 MG DAILY DOSE) ORAL KIT 1 X 80 & 1 X 20 MG

6 PA

COMETRIQ (140 MG DAILY DOSE) ORAL KIT 1 X 80 & 3 X 20 MG

6 PA

COMETRIQ (60 MG DAILY DOSE) ORAL KIT 20 MG

6 PA



60

Drug NameDrug Tier

Notes

COPIKTRA ORAL CAPSULE 15 MG, 25 MG

6 PA

COSMEGEN INTRAVENOUS SOLUTION RECONSTITUTED 0.5 MG

6PA;

Specialty Medical

COTELLIC ORAL TABLET 20 MG

6 PA

cyclophosphamide injection solution reconstituted 1 gm, 2 gm, 500 mg

6PA;

Specialty Medical

cyclophosphamide oral capsule 25 mg, 50 mg

2 PA

CYRAMZA INTRAVENOUS SOLUTION 100 MG/10ML, 500 MG/50ML

6PA;

Specialty Medical

cytarabine (pf) injection solution 100 mg/ml, 20 mg/ml

6PA;

Specialty Medical

cytarabine injection solution 20 mg/ml

6PA;

Specialty Medical

dacarbazine intravenous solution reconstituted 100 mg, 200 mg

6PA;

Specialty Medical

DACOGEN INTRAVENOUS SOLUTION RECONSTITUTED 50 MG

6PA;

Specialty Medical

dactinomycin intravenous solution reconstituted 0.5 mg

6PA;

Specialty Medical

DARZALEX INTRAVENOUS SOLUTION 100 MG/5ML, 400 MG/20ML

6PA;

Specialty Medical

Drug NameDrug Tier

Notes

daunorubicin hcl intravenous injectable 5 mg/ml

GM PA

daunorubicin hcl intravenous solution 20 mg/4ml, 50 mg/10ml

GM PA

DAURISMO ORAL TABLET 100 MG, 25 MG

6 PA

decitabine intravenous solution reconstituted 50 mg

6PA;

Specialty Medical

dexrazoxane hcl intravenous solution reconstituted 250 mg, 500 mg

GM

dexrazoxane intravenous solution reconstituted 500 mg

GM

docetaxel (non-alcohol) intravenous solution 160 mg/8ml, 20 mg/ml, 80 mg/4ml

6PA;

Specialty Medical

docetaxel intravenous concentrate 160 mg/8ml, 20 mg/0.5ml, 20 mg/ml, 200 mg/10ml, 80 mg/2ml, 80 mg/4ml

6PA;

Specialty Medical

docetaxel intravenous solution 160 mg/16ml, 20 mg/2ml, 80 mg/8ml

6PA;

Specialty Medical

DOXIL INTRAVENOUS INJECTABLE 2 MG/ML

6PA;

Specialty Medical

doxorubicin hcl intravenous solution 2 mg/ml

GM PA

doxorubicin hcl intravenous solution reconstituted 10 mg, 50 mg

GM PA

doxorubicin hcl liposomal intravenous injectable 2 mg/ml

6PA;

Specialty Medical



61

Drug NameDrug Tier

Notes

DROXIA ORAL CAPSULE 200 MG, 300 MG, 400 MG

4

ELITEK INTRAVENOUS SOLUTION RECONSTITUTED 1.5 MG, 7.5 MG

6Specialty Medical

ELLENCE INTRAVENOUS SOLUTION 200 MG/100ML, 50 MG/25ML

6PA;

Specialty Medical

ELZONRIS INTRAVENOUS SOLUTION 1000 MCG/ML

6PA;

Specialty Medical

EMCYT ORAL CAPSULE 140 MG

3 PA

EMPLICITI INTRAVENOUS SOLUTION RECONSTITUTED 300 MG, 400 MG

6PA;

Specialty Medical

epirubicin hcl intravenous solution 200 mg/100ml, 50 mg/25ml

6PA;

Specialty Medical

ERBITUX INTRAVENOUS SOLUTION 100 MG/50ML, 200 MG/100ML

6PA;

Specialty Medical

ERIVEDGE ORAL CAPSULE 150 MG

6 PA

ERLEADA ORAL TABLET 60 MG

6 PA

erlotinib hcl oral tablet 100 mg, 150 mg, 25 mg

5 PA

ERWINAZE INJECTION SOLUTION RECONSTITUTED 10000 UNIT

6PA;

Specialty Medical

Drug NameDrug Tier

Notes

ETOPOPHOS INTRAVENOUS SOLUTION RECONSTITUTED 100 MG

6PA;

Specialty Medical

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

GM PA

etoposide oral capsule 50 mg

2 PA

EVOMELA INTRAVENOUS SOLUTION RECONSTITUTED 50 MG

GM

exemestane oral tablet 25 mg

2

FARESTON ORAL TABLET 60 MG

3 PA

FARYDAK ORAL CAPSULE 10 MG, 15 MG, 20 MG

6 PA

FASLODEX INTRAMUSCULAR SOLUTION 250 MG/5ML

6PA;

Specialty Medical

FEMARA ORAL TABLET 2.5 MG

4

floxuridine injection solution reconstituted 0.5 gm

6PA;

Specialty Medical

fludarabine phosphate intravenous solution 50 mg/2ml

6PA;

Specialty Medical

fludarabine phosphate intravenous solution reconstituted 50 mg

6PA;

Specialty Medical

fluorouracil intravenous solution 1 gm/20ml, 2.5 gm/50ml, 5 gm/100ml, 500 mg/10ml

GM PA

flutamide oral capsule 125 mg

2 PA



62

Drug NameDrug Tier

Notes

FOLOTYN INTRAVENOUS SOLUTION 20 MG/ML, 40 MG/2ML

6PA;

Specialty Medical

fulvestrant intramuscular solution 250 mg/5ml

6PA;

Specialty Medical

FUSILEV INTRAVENOUS SOLUTION RECONSTITUTED 50 MG

6PA;

Specialty Medical

GAZYVA INTRAVENOUS SOLUTION 1000 MG/40ML

6PA;

Specialty Medical

gemcitabine hcl intravenous solution 1 gm/10ml, 1.5 gm/15ml, 2 gm/20ml, 200 mg/2ml

GM

gemcitabine hcl intravenous solution 1 gm/26.3ml, 2 gm/52.6ml, 200 mg/5.26ml

GM PA

gemcitabine hcl intravenous solution reconstituted 1 gm, 2 gm, 200 mg

GM PA

GEMZAR INTRAVENOUS SOLUTION RECONSTITUTED 1 GM, 200 MG

GM PA

GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG

6 PA

GLEEVEC ORAL TABLET 100 MG


days)

GLEEVEC ORAL TABLET 400 MG


days)

Drug NameDrug Tier

Notes

GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG, 5 MG

6 PA

GLIADEL WAFER IMPLANT WAFER 7.7 MG

GM

HALAVEN INTRAVENOUS SOLUTION 1 MG/2ML

6PA;

Specialty Medical

HERCEPTIN HYLECTA SUBCUTANEOUS SOLUTION 600-10000 MG-UNT/5ML

6 PA

HERCEPTIN INTRAVENOUS SOLUTION RECONSTITUTED 150 MG, 440 MG

6PA;

Specialty Medical

HEXALEN ORAL CAPSULE 50 MG

3 PA

HYCAMTIN INTRAVENOUS SOLUTION RECONSTITUTED 4 MG

GM PA

HYCAMTIN ORAL CAPSULE 0.25 MG, 1 MG

4 PA

HYDREA ORAL CAPSULE 500 MG

4

hydroxyurea oral capsule 500 mg

2

IBRANCE ORAL CAPSULE 100 MG, 125 MG, 75 MG

6 PA

ICLUSIG ORAL TABLET 15 MG, 45 MG


days)

IDAMYCIN PFS INTRAVENOUS SOLUTION 10 MG/10ML, 20 MG/20ML, 5 MG/5ML

6PA;

Specialty Medical



63

Drug NameDrug Tier

Notes

idarubicin hcl intravenous solution 10 mg/10ml, 20 mg/20ml, 5 mg/5ml

6PA;

Specialty Medical

IDHIFA ORAL TABLET 100 MG, 50 MG

6 PA

IFEX INTRAVENOUS SOLUTION RECONSTITUTED 1 GM, 3 GM

6PA;

Specialty Medical

ifosfamide intravenous solution 1 gm/20ml, 3 gm/60ml

6PA;

Specialty Medical

ifosfamide intravenous solution reconstituted 1 gm, 3 gm

6PA;

Specialty Medical

imatinib mesylate oral tablet 100 mg


days)

imatinib mesylate oral tablet 400 mg


days)

IMBRUVICA ORAL CAPSULE 140 MG, 70 MG

6 PA

IMBRUVICA ORAL TABLET 140 MG, 280 MG, 420 MG, 560 MG

6 PA

IMLYGIC INTRALESIONAL SUSPENSION 1000000 UNIT/ML, 100000000 UNIT/ML

6PA;

Specialty Medical

Drug NameDrug Tier

Notes

INFUGEM INTRAVENOUS SOLUTION 1200-0.9 MG/120ML-%, 1300-0.9 MG/130ML-%, 1400-0.9 MG/140ML-%, 1500-0.9 MG/150ML-%, 1600-0.9 MG/160ML-%, 1700-0.9 MG/170ML-%, 1800-0.9 MG/180ML-%, 1900-0.9 MG/190ML-%, 2000-0.9 MG/200ML-%, 2200-0.9 MG/220ML-%

6PA;

Specialty Medical

INLYTA ORAL TABLET 1 MG, 5 MG

6 PA

INREBIC ORAL CAPSULE 100 MG

6 PA

IRESSA ORAL TABLET 250 MG

6 PA

irinotecan hcl intravenous solution 100 mg/5ml, 40 mg/2ml, 500 mg/25ml

GM PA

ISTODAX (OVERFILL) INTRAVENOUS SOLUTION RECONSTITUTED 10 MG

6PA;

Specialty Medical

IXEMPRA KIT INTRAVENOUS SOLUTION RECONSTITUTED 15 MG, 45 MG

6PA;

Specialty Medical

JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 25 MG, 5 MG

6 PA

JEVTANA INTRAVENOUS SOLUTION 60 MG/1.5ML

6PA;

Specialty Medical

KADCYLA INTRAVENOUS SOLUTION RECONSTITUTED 100 MG, 160 MG

6PA;

Specialty Medical



64

Drug NameDrug Tier

Notes

KANJINTI INTRAVENOUS SOLUTION RECONSTITUTED 150 MG, 420 MG

6PA;

Specialty Medical

KEYTRUDA INTRAVENOUS SOLUTION 100 MG/4ML

6PA;

Specialty Medical

KHAPZORY INTRAVENOUS SOLUTION RECONSTITUTED 175 MG, 300 MG

6PA;

Specialty Medical

KISQALI (200 MG DOSE) ORAL TABLET THERAPY PACK 200 MG

6 PA


6 PA


6 PA

KYPROLIS INTRAVENOUS SOLUTION RECONSTITUTED 10 MG, 30 MG, 60 MG

6PA;

Specialty Medical

LARTRUVO INTRAVENOUS SOLUTION 190 MG/19ML, 500 MG/50ML

6PA;

Specialty Medical

LENVIMA (10 MG DAILY DOSE) ORAL CAPSULE THERAPY PACK 10 MG

6 PA

LENVIMA (12 MG DAILY DOSE) ORAL CAPSULE THERAPY PACK 3 X 4 MG

6 PA

Drug NameDrug Tier

Notes

LENVIMA (14 MG DAILY DOSE) ORAL CAPSULE THERAPY PACK 10 & 4 MG

6 PA

LENVIMA (18 MG DAILY DOSE) ORAL CAPSULE THERAPY PACK 10 MG & 2 X 4 MG

6 PA


6 PA

LENVIMA (24 MG DAILY DOSE) ORAL CAPSULE THERAPY PACK 2 X 10 MG & 4 MG

6 PA

LENVIMA (4 MG DAILY DOSE) ORAL CAPSULE THERAPY PACK 4 MG

6 PA


6 PA

letrozole oral tablet 2.5 mg

2

leucovorin calcium injection solution 100 mg/10ml, 500 mg/50ml

GM PA

leucovorin calcium injection solution reconstituted 100 mg, 200 mg, 350 mg, 50 mg, 500 mg

GM PA

leucovorin calcium oral tablet 10 mg, 15 mg, 25 mg, 5 mg

2

LEUKERAN ORAL TABLET 2 MG

3 PA

levoleucovorin calcium intravenous solution 175 mg/17.5ml

6PA;

Specialty Medical



65

Drug NameDrug Tier

Notes

LEVOLEUCOVORIN CALCIUM INTRAVENOUS SOLUTION RECONSTITUTED 175 MG

6PA;

Specialty Medical

levoleucovorin calcium intravenous solution reconstituted 50 mg

6PA;

Specialty Medical

levoleucovorin calcium pf intravenous solution 250 mg/25ml

6PA;

Specialty Medical

LIBTAYO INTRAVENOUS SOLUTION 350 MG/7ML

6PA;

Specialty Medical

lipodox 50 intravenous injectable 2 mg/ml

6PA;

Specialty Medical

LONSURF ORAL TABLET 15-6.14 MG, 20-8.19 MG

6 PA

LORBRENA ORAL TABLET 100 MG, 25 MG

6 PA

LUMOXITI INTRAVENOUS SOLUTION RECONSTITUTED 1 MG

6PA;

Specialty Medical

LYNPARZA ORAL CAPSULE 50 MG

6 PA

LYNPARZA ORAL TABLET 100 MG, 150 MG

6 PA

LYSODREN ORAL TABLET 500 MG

3 PA

MARQIBO INTRAVENOUS SUSPENSION 5 MG/31ML

6PA;

Specialty Medical

MATULANE ORAL CAPSULE 50 MG

6 PA

MEKINIST ORAL TABLET 0.5 MG, 2 MG

6 PA

Drug NameDrug Tier

Notes

MEKTOVI ORAL TABLET 15 MG

6 PA

melphalan hcl intravenous solution reconstituted 50 mg

6PA;

Specialty Medical

melphalan oral tablet 2 mg

2 PA

mercaptopurine oral tablet 50 mg

2

mesna intravenous solution 100 mg/ml

6Specialty Medical

MESNEX INTRAVENOUS SOLUTION 100 MG/ML

6Specialty Medical

MESNEX ORAL TABLET 400 MG

3

METASTRON INTRAVENOUS SOLUTION 1 MCI/ML

GM

mitomycin intravenous solution reconstituted 20 mg, 40 mg, 5 mg

GM PA

MITOMYCIN INTRAVESICAL SOLUTION PREFILLED SYRINGE 20 MG/40ML

GM

mitoxantrone hcl intravenous concentrate 20 mg/10ml, 25 mg/12.5ml, 30 mg/15ml

6Specialty Medical

MUSTARGEN INJECTION SOLUTION RECONSTITUTED 10 MG

6PA;

Specialty Medical

mutamycin intravenous solution reconstituted 20 mg, 40 mg, 5 mg

GM PA

MVASI INTRAVENOUS SOLUTION 100 MG/4ML, 400 MG/16ML

6PA;

Specialty Medical

MYLERAN ORAL TABLET 2 MG

3



66

Drug NameDrug Tier

Notes

MYLOTARG INTRAVENOUS SOLUTION RECONSTITUTED 4.5 MG

6PA;

Specialty Medical

NAVELBINE INTRAVENOUS SOLUTION 10 MG/ML, 50 MG/5ML

6PA;

Specialty Medical

NERLYNX ORAL TABLET 40 MG

6 PA

NEXAVAR ORAL TABLET 200 MG

6 PA

NILANDRON ORAL TABLET 150 MG

3

nilutamide oral tablet 150 mg

2

NINLARO ORAL CAPSULE 2.3 MG, 3 MG, 4 MG

6 PA

NIPENT INTRAVENOUS SOLUTION RECONSTITUTED 10 MG

6PA;

Specialty Medical

NUBEQA ORAL TABLET 300 MG

6 PA

ODOMZO ORAL CAPSULE 200 MG

6 PA

OGIVRI INTRAVENOUS SOLUTION RECONSTITUTED 150 MG, 420 MG

6PA;

Specialty Medical

ONCASPAR INJECTION SOLUTION 750 UNIT/ML

6PA;

Specialty Medical

ONIVYDE INTRAVENOUS INJECTABLE 43 MG/10ML

6PA;

Specialty Medical

Drug NameDrug Tier

Notes

OPDIVO INTRAVENOUS SOLUTION 100 MG/10ML, 240 MG/24ML, 40 MG/4ML

6PA;

Specialty Medical

oxaliplatin intravenous solution 100 mg/20ml, 50 mg/10ml

GM PA

oxaliplatin intravenous solution reconstituted 100 mg, 50 mg

GM PA

paclitaxel intravenous concentrate 100 mg/16.7ml, 150 mg/25ml, 30 mg/5ml, 300 mg/50ml

6PA;

Specialty Medical

PANRETIN EXTERNAL GEL 0.1 %

4

PERJETA INTRAVENOUS SOLUTION 420 MG/14ML

6PA;

Specialty Medical

PHOTOFRIN INTRAVENOUS SOLUTION RECONSTITUTED 75 MG

6PA;

Specialty Medical

PIQRAY (200 MG DAILY DOSE) ORAL TABLET THERAPY PACK 200 MG

6 PA

PIQRAY (250 MG DAILY DOSE) ORAL TABLET THERAPY PACK 200 & 50 MG

6 PA

PIQRAY (300 MG DAILY DOSE) ORAL TABLET THERAPY PACK 2 X 150 MG

6 PA

POLIVY INTRAVENOUS SOLUTION RECONSTITUTED 140 MG

6PA;

Specialty Medical



67

Drug NameDrug Tier

Notes

POMALYST ORAL CAPSULE 1 MG, 2 MG, 3 MG, 4 MG

6 PA

PORTRAZZA INTRAVENOUS SOLUTION 800 MG/50ML

6PA;

Specialty Medical

POTELIGEO INTRAVENOUS SOLUTION 20 MG/5ML

6PA;

Specialty Medical

PROLEUKIN INTRAVENOUS SOLUTION RECONSTITUTED 22000000 UNIT

6PA;

Specialty Medical

PURIXAN ORAL SUSPENSION 2000 MG/100ML

4

QUADRAMET INTRAVENOUS SOLUTION 1850 MBQ/ML

6Specialty Medical

REVLIMID ORAL CAPSULE 10 MG, 15 MG, 2.5 MG, 20 MG, 25 MG, 5 MG

6 PA

RITUXAN HYCELA SUBCUTANEOUS SOLUTION 1400-23400 MG -UT/11.7ML, 1600-26800 MG -UT/13.4ML

6PA;

Specialty Medical

RITUXAN INTRAVENOUS SOLUTION 100 MG/10ML, 500 MG/50ML

6PA;

Specialty Medical

ROMIDEPSIN INTRAVENOUS SOLUTION RECONSTITUTED 10 MG

6PA;

Specialty Medical

ROZLYTREK ORAL CAPSULE 100 MG, 200 MG

6 PA

Drug NameDrug Tier

Notes

RUBRACA ORAL TABLET 200 MG, 250 MG, 300 MG

6 PA

RYDAPT ORAL CAPSULE 25 MG

6 PA

SPRYCEL ORAL TABLET 100 MG, 140 MG, 20 MG, 50 MG, 70 MG, 80 MG

6 PA

STIVARGA ORAL TABLET 40 MG

6 PA

SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 37.5 MG, 50 MG

6 PA

SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 MCG, 600 MCG

6PA;

Specialty Medical

SYLVANT INTRAVENOUS SOLUTION RECONSTITUTED 100 MG, 400 MG

6PA;

Specialty Medical

SYNRIBO SUBCUTANEOUS SOLUTION RECONSTITUTED 3.5 MG

6 PA

TABLOID ORAL TABLET 40 MG

3

TAFINLAR ORAL CAPSULE 50 MG, 75 MG

6 PA

TAGRISSO ORAL TABLET 40 MG, 80 MG

6 PA

TALZENNA ORAL CAPSULE 0.25 MG, 1 MG

6 PA

tamoxifen citrate oral tablet 10 mg, 20 mg

PV

TARCEVA ORAL TABLET 100 MG, 150 MG, 25 MG

6 PA



68

Drug NameDrug Tier

Notes

TARGRETIN EXTERNAL GEL 1 %

6 PA

TARGRETIN ORAL CAPSULE 75 MG

6 PA

TASIGNA ORAL CAPSULE 150 MG, 200 MG


days)

TASIGNA ORAL CAPSULE 50 MG

4

TAXOTERE INTRAVENOUS CONCENTRATE 20 MG/ML, 80 MG/4ML

6PA;

Specialty Medical

TECENTRIQ INTRAVENOUS SOLUTION 1200 MG/20ML, 840 MG/14ML

6PA;

Specialty Medical

TEMODAR INTRAVENOUS SOLUTION RECONSTITUTED 100 MG

6PA;

Specialty Medical

TEMODAR ORAL CAPSULE 100 MG, 140 MG, 180 MG, 20 MG, 250 MG, 5 MG

6 PA

temozolomide oral capsule 100 mg, 140 mg, 180 mg, 20 mg, 250 mg, 5 mg

5 PA

teniposide intravenous solution 10 mg/ml

6PA;

Specialty Medical

TEPADINA INJECTION SOLUTION RECONSTITUTED 100 MG, 15 MG

6PA;

Specialty Medical

THALOMID ORAL CAPSULE 100 MG, 150 MG, 200 MG, 50 MG

6 PA

thiotepa injection solution reconstituted 15 mg

6PA;

Specialty Medical

Drug NameDrug Tier

Notes

TIBSOVO ORAL TABLET 250 MG

6 PA

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

GM PA

topotecan hcl intravenous solution 4 mg/4ml

GM PA

topotecan hcl intravenous solution reconstituted 4 mg

GM PA

toremifene citrate oral tablet 60 mg

2 PA

TOTECT INTRAVENOUS SOLUTION RECONSTITUTED 500 MG

GM

TREANDA INTRAVENOUS SOLUTION RECONSTITUTED 100 MG, 25 MG

6PA;

Specialty Medical

tretinoin oral capsule 10 mg

2 PA

TURALIO ORAL CAPSULE 200 MG

6 PA

TYKERB ORAL TABLET 250 MG

6 PA

UNITUXIN INTRAVENOUS SOLUTION 17.5 MG/5ML

6PA;

Specialty Medical

UVADEX INJECTION SOLUTION 20 MCG/ML

GM

VALCHLOR EXTERNAL GEL 0.016 %

6 PA

valrubicin intravesical solution 40 mg/ml

6PA;

Specialty Medical

VALSTAR INTRAVESICAL SOLUTION 40 MG/ML

6PA;

Specialty Medical



69

Drug NameDrug Tier

Notes

VECTIBIX INTRAVENOUS SOLUTION 100 MG/5ML, 400 MG/20ML

6PA;

Specialty Medical

VELCADE INJECTION SOLUTION RECONSTITUTED 3.5 MG

6PA;

Specialty Medical

VENCLEXTA ORAL TABLET 10 MG, 100 MG, 50 MG

6 PA

VENCLEXTA STARTING PACK ORAL TABLET THERAPY PACK 10 & 50 & 100 MG

6 PA

VERZENIO ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG

6 PA

VIDAZA INJECTION SUSPENSION RECONSTITUTED 100 MG

6PA;

Specialty Medical

vinblastine sulfate intravenous solution 1 mg/ml

6PA;

Specialty Medical

vincasar pfs intravenous solution 1 mg/ml

GM PA

vincristine sulfate intravenous solution 1 mg/ml

GM PA

vinorelbine tartrate intravenous solution 10 mg/ml, 50 mg/5ml

6PA;

Specialty Medical

VITRAKVI ORAL CAPSULE 100 MG, 25 MG

6 PA

VITRAKVI ORAL SOLUTION 20 MG/ML

6 PA

VIZIMPRO ORAL TABLET 15 MG, 30 MG, 45 MG

6 PA

Drug NameDrug Tier

Notes

VORAXAZE INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT

GM

VOTRIENT ORAL TABLET 200 MG

6 PA

VYXEOS INTRAVENOUS SUSPENSION RECONSTITUTED 44-100 MG

6PA;

Specialty Medical

XALKORI ORAL CAPSULE 200 MG, 250 MG

6 PA

XELODA ORAL TABLET 150 MG, 500 MG

6 PA

XOFIGO INTRAVENOUS SOLUTION 30 MCCI/ML

6PA;

Specialty Medical

XOSPATA ORAL TABLET 40 MG

6 PA

XPOVIO (100 MG ONCE WEEKLY) ORAL TABLET THERAPY PACK 20 MG

6 PA


6 PA


6 PA

XPOVIO (80 MG TWICE WEEKLY) ORAL TABLET THERAPY PACK 20 MG

6 PA

XTANDI ORAL CAPSULE 40 MG

6 PA



70

Drug NameDrug Tier

Notes

YERVOY INTRAVENOUS SOLUTION 200 MG/40ML, 50 MG/10ML

6PA;

Specialty Medical

YESCARTA INTRAVENOUS SUSPENSION

6PA;

Specialty Medical

YONDELIS INTRAVENOUS SOLUTION RECONSTITUTED 1 MG

6PA;

Specialty Medical

YONSA ORAL TABLET 125 MG

6 PA

ZALTRAP INTRAVENOUS SOLUTION 100 MG/4ML, 200 MG/8ML

6PA;

Specialty Medical

ZANOSAR INTRAVENOUS SOLUTION RECONSTITUTED 1 GM

6PA;

Specialty Medical

ZEJULA ORAL CAPSULE 100 MG

6 PA

ZELBORAF ORAL TABLET 240 MG

6 PA

ZEVALIN Y-90 INTRAVENOUS KIT 3.2 MG/2ML

6Specialty Medical

ZINECARD INTRAVENOUS SOLUTION RECONSTITUTED 250 MG, 500 MG

GM

ZOLINZA ORAL CAPSULE 100 MG

6 PA

ZYDELIG ORAL TABLET 100 MG, 150 MG

6 PA

ZYKADIA ORAL CAPSULE 150 MG

6 PA

ZYKADIA ORAL TABLET 150 MG

6 PA

ZYTIGA ORAL TABLET 250 MG, 500 MG

6 PA

Drug NameDrug Tier

Notes

Antiparasitics

albendazole oral tablet 200 mg

2

ALBENZA ORAL TABLET 200 MG

4

ALINIA ORAL SUSPENSION RECONSTITUTED 100 MG/5ML

4

ALINIA ORAL TABLET 500 MG

4

ARAKODA ORAL TABLET 100 MG

3

atovaquone oral suspension 750 mg/5ml

2

atovaquone-proguanil hcl oral tablet 250-100 mg, 62.5-25 mg

2

BENZNIDAZOLE ORAL TABLET 100 MG, 12.5 MG

4

BILTRICIDE ORAL TABLET 600 MG

4

chloroquine phosphate oral tablet 250 mg, 500 mg

2

COARTEM ORAL TABLET 20-120 MG

3

crotan external lotion 10 %

2 PA

DARAPRIM ORAL TABLET 25 MG

6

ELIMITE EXTERNAL CREAM 5 %

4

EMVERM ORAL TABLET CHEWABLE 100 MG

4

EURAX EXTERNAL CREAM 10 %

3 PA

EURAX EXTERNAL LOTION 10 %

4 PA



71

Drug NameDrug Tier

Notes

hydroxychloroquine sulfate oral tablet 200 mg

2

IMPAVIDO ORAL CAPSULE 50 MG

4

ivermectin oral tablet 3 mg

2

KRINTAFEL ORAL TABLET 150 MG

3QL (2 EA

per 30 days)

lindane external shampoo 1 %

2

MALARONE ORAL TABLET 250-100 MG, 62.5-25 MG

4

malathion external lotion 0.5 %

2

mefloquine hcl oral tablet 250 mg

2

MEPRON ORAL SUSPENSION 750 MG/5ML

3

NATROBA EXTERNAL SUSPENSION 0.9 %

4

NEBUPENT INHALATION SOLUTION RECONSTITUTED 300 MG

4

OVIDE EXTERNAL LOTION 0.5 %

4

PENTAM INJECTION SOLUTION RECONSTITUTED 300 MG

GM

pentamidine isethionate injection solution reconstituted 300 mg

GM

permethrin external cream 5 %

2

PLAQUENIL ORAL TABLET 200 MG

4

Drug NameDrug Tier

Notes

praziquantel oral tablet 600 mg

2

primaquine phosphate oral tablet 26.3 mg

2

QUALAQUIN ORAL CAPSULE 324 MG

4

quinine sulfate oral capsule 324 mg

2

SKLICE EXTERNAL LOTION 0.5 %

4

SOLOSEC ORAL PACKET 2 GM

4

spinosad external suspension 0.9 %

2

STROMECTOL ORAL TABLET 3 MG

4

sulfurated lime external solution

2

ULESFIA EXTERNAL LOTION 5 %

4

Antiparkinson Agents

amantadine hcl oral capsule 100 mg

2

amantadine hcl oral syrup 50 mg/5ml

2

amantadine hcl oral tablet 100 mg

2

APOKYN SUBCUTANEOUS SOLUTION CARTRIDGE 30 MG/3ML

6 PA

AZILECT ORAL TABLET 0.5 MG, 1 MG

4

benztropine mesylate injection solution 1 mg/ml

GM

benztropine mesylate oral tablet 0.5 mg, 1 mg, 2 mg

1

bromocriptine mesylate oral capsule 5 mg

2



72

Drug NameDrug Tier

Notes

bromocriptine mesylate oral tablet 2.5 mg

2

carbidopa oral tablet 25 mg

2

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

2

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

2

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

2

carbidopa-levodopa-entacapone oral tablet 12.5-50-200 mg, 18.75-75-200 mg, 25-100-200 mg, 31.25-125-200 mg, 37.5-150-200 mg, 50-200-200 mg

2

COGENTIN INJECTION SOLUTION 1 MG/ML

GM

COMTAN ORAL TABLET 200 MG

4

ELDEPRYL ORAL CAPSULE 5 MG

4

entacapone oral tablet 200 mg

2

INBRIJA INHALATION CAPSULE 42 MG

6 PA

LODOSYN ORAL TABLET 25 MG

4

MIRAPEX ER ORAL TABLET EXTENDED RELEASE 24 HOUR 0.375 MG, 0.75 MG, 1.5 MG, 2.25 MG, 3 MG, 3.75 MG, 4.5 MG

4

Drug NameDrug Tier

Notes

MIRAPEX ORAL TABLET 0.125 MG, 0.25 MG, 0.5 MG, 0.75 MG, 1 MG, 1.5 MG

4

NEUPRO TRANSDERMAL PATCH 24 HOUR 1 MG/24HR, 2 MG/24HR, 3 MG/24HR, 4 MG/24HR, 6 MG/24HR, 8 MG/24HR

4

NOURIANZ ORAL TABLET 20 MG, 40 MG

6 PA

PARLODEL ORAL CAPSULE 5 MG

4

PARLODEL ORAL TABLET 2.5 MG

4

pramipexole dihydrochloride er oral tablet extended release 24 hour 0.375 mg, 0.75 mg, 1.5 mg, 2.25 mg, 3 mg, 3.75 mg, 4.5 mg

2

pramipexole dihydrochloride oral tablet 0.125 mg, 0.25 mg, 0.5 mg, 0.75 mg, 1 mg, 1.5 mg

2

rasagiline mesylate oral tablet 0.5 mg, 1 mg

2

REQUIP ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG, 3 MG, 4 MG, 5 MG

4

REQUIP XL ORAL TABLET EXTENDED RELEASE 24 HOUR 12 MG, 2 MG, 4 MG, 6 MG, 8 MG

4

ropinirole hcl er oral tablet extended release 24 hour 12 mg, 2 mg, 4 mg, 6 mg, 8 mg

2



73

Drug NameDrug Tier

Notes

ropinirole hcl oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg, 5 mg

2

RYTARY ORAL CAPSULE EXTENDED RELEASE 23.75-95 MG, 36.25-145 MG, 48.75-195 MG, 61.25-245 MG

4

selegiline hcl oral capsule 5 mg

2

selegiline hcl oral tablet 5 mg

2

SINEMET CR ORAL TABLET EXTENDED RELEASE 25-100 MG, 50-200 MG

4

SINEMET ORAL TABLET 10-100 MG, 25-100 MG, 25-250 MG

4

STALEVO 100 ORAL TABLET 25-100-200 MG

4

STALEVO 125 ORAL TABLET 31.25-125-200 MG

4


4

STALEVO 200 ORAL TABLET 50-200-200 MG

4


4


4

TASMAR ORAL TABLET 100 MG

4

tolcapone oral tablet 100 mg

2

trihexyphenidyl hcl oral elixir 0.4 mg/ml

2

trihexyphenidyl hcl oral tablet 2 mg, 5 mg

2

Drug NameDrug Tier

Notes

XADAGO ORAL TABLET 100 MG, 50 MG

4

ZELAPAR ORAL TABLET DISPERSIBLE 1.25 MG

4

Antiplatelets

AGGRASTAT INTRAVENOUS CONCENTRATE 3.75 MG/15ML

GM

AGGRASTAT INTRAVENOUS SOLUTION 12.5-0.9 MG/250ML-%, 5-0.9 MG/100ML-%

GM

AGGRENOX ORAL CAPSULE EXTENDED RELEASE 12 HOUR 25-200 MG

4

aspirin-dipyridamole er oral capsule extended release 12 hour 25-200 mg

2

BRILINTA ORAL TABLET 60 MG, 90 MG

3

CABLIVI INJECTION KIT 11 MG

6 PA

cilostazol oral tablet 100 mg, 50 mg

2

clopidogrel bisulfate oral tablet 300 mg

2

clopidogrel bisulfate oral tablet 75 mg

1

dipyridamole oral tablet 25 mg, 50 mg, 75 mg

2

EFFIENT ORAL TABLET 10 MG, 5 MG

4 ST

eptifibatide intravenous solution 20 mg/10ml, 200 mg/100ml, 75 mg/100ml

GM



74

Drug NameDrug Tier

Notes

INTEGRILIN INTRAVENOUS SOLUTION 20 MG/10ML, 200 MG/100ML, 75 MG/100ML

GM

KENGREAL INTRAVENOUS SOLUTION RECONSTITUTED 50 MG

GM

PLAVIX ORAL TABLET 300 MG, 75 MG

4

prasugrel hcl oral tablet 10 mg, 5 mg

2 ST

REOPRO INTRAVENOUS SOLUTION 2 MG/ML

GM

ZONTIVITY ORAL TABLET 2.08 MG

4 ST

Antipsychotics - Drugs for Mood Disorders

ABILIFY MAINTENA INTRAMUSCULAR PREFILLED SYRINGE 300 MG, 400 MG

5

ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION RECONSTITUTED ER 300 MG, 400 MG

5

ABILIFY ORAL TABLET 10 MG, 15 MG, 2 MG, 20 MG, 30 MG, 5 MG

4QL (30 EA

per 30 days)

ADASUVE INHALATION AEROSOL POWDER BREATH ACTIVATED 10 MG

GM

aripiprazole oral solution 1 mg/ml

2

aripiprazole oral tablet 10 mg, 15 mg, 2 mg, 20 mg, 30 mg, 5 mg

2QL (30 EA

per 30 days)

Drug NameDrug Tier

Notes

aripiprazole oral tablet dispersible 10 mg, 15 mg

2QL (30 EA

per 30 days)

ARISTADA INITIO INTRAMUSCULAR PREFILLED SYRINGE 675 MG/2.4ML

5

ARISTADA INTRAMUSCULAR PREFILLED SYRINGE 1064 MG/3.9ML, 441 MG/1.6ML, 662 MG/2.4ML, 882 MG/3.2ML

5

chlorpromazine hcl injection solution 25 mg/ml, 50 mg/2ml

GM

chlorpromazine hcl oral tablet 10 mg, 100 mg, 200 mg, 25 mg, 50 mg

2

clozapine oral tablet 100 mg, 200 mg, 25 mg, 50 mg

2

clozapine oral tablet dispersible 100 mg, 12.5 mg, 150 mg, 200 mg, 25 mg

2

CLOZARIL ORAL TABLET 100 MG, 25 MG

4

FANAPT ORAL TABLET 1 MG, 10 MG, 12 MG, 2 MG, 4 MG, 6 MG, 8 MG

4 PA

FANAPT TITRATION PACK ORAL TABLET 1 & 2 & 4 & 6 MG

4 PA

FAZACLO ORAL TABLET DISPERSIBLE 100 MG, 12.5 MG, 150 MG, 200 MG, 25 MG

4

fluphenazine decanoate injection solution 25 mg/ml

GM



75

Drug NameDrug Tier

Notes

fluphenazine hcl injection solution 2.5 mg/ml

GM

fluphenazine hcl oral concentrate 5 mg/ml

2

fluphenazine hcl oral elixir 2.5 mg/5ml

2

fluphenazine hcl oral tablet 1 mg, 10 mg, 2.5 mg, 5 mg

2

GEODON INTRAMUSCULAR SOLUTION RECONSTITUTED 20 MG

GM

GEODON ORAL CAPSULE 20 MG, 40 MG, 60 MG, 80 MG

4

HALDOL DECANOATE INTRAMUSCULAR SOLUTION 100 MG/ML, 50 MG/ML

GM

HALDOL INJECTION SOLUTION 5 MG/ML

GM

haloperidol decanoate intramuscular solution 100 mg/ml, 50 mg/ml

GM

haloperidol lactate injection solution 5 mg/ml

GM

haloperidol lactate oral concentrate 2 mg/ml

2

haloperidol oral tablet 0.5 mg, 1 mg, 2 mg, 5 mg

1

haloperidol oral tablet 10 mg, 20 mg

2

INVEGA ORAL TABLET EXTENDED RELEASE 24 HOUR 1.5 MG, 3 MG, 6 MG, 9 MG

4QL (30 EA

per 30 days)

Drug NameDrug Tier

Notes

INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 117 MG/0.75ML, 156 MG/ML, 234 MG/1.5ML, 39 MG/0.25ML, 78 MG/0.5ML

5

INVEGA TRINZA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 273 MG/0.875ML, 410 MG/1.315ML, 546 MG/1.75ML, 819 MG/2.625ML

5

LATUDA ORAL TABLET 120 MG, 20 MG, 40 MG, 60 MG, 80 MG

4 PA

loxapine succinate oral capsule 10 mg, 25 mg, 5 mg, 50 mg

2

molindone hcl oral tablet 10 mg, 25 mg, 5 mg

2

NUPLAZID ORAL CAPSULE 34 MG

4 PA

NUPLAZID ORAL TABLET 10 MG, 17 MG

4 PA

olanzapine intramuscular solution reconstituted 10 mg

GM

olanzapine oral tablet 10 mg, 15 mg, 2.5 mg, 20 mg, 5 mg, 7.5 mg

2

olanzapine oral tablet dispersible 10 mg, 15 mg, 20 mg, 5 mg

2

ORAP ORAL TABLET 1 MG, 2 MG

4

paliperidone er oral tablet extended release 24 hour 1.5 mg, 3 mg, 6 mg, 9 mg

2QL (30 EA

per 30 days)



76

Drug NameDrug Tier

Notes

PERSERIS SUBCUTANEOUS PREFILLED SYRINGE 120 MG, 90 MG

5

pimozide oral tablet 1 mg, 2 mg

2

quetiapine fumarate er oral tablet extended release 24 hour 150 mg, 200 mg, 300 mg, 400 mg, 50 mg

2QL (30 EA

per 30 days)

quetiapine fumarate oral tablet 100 mg, 200 mg, 25 mg, 300 mg, 400 mg, 50 mg

2

REXULTI ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG, 3 MG, 4 MG

4 PA

RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION RECONSTITUTED 12.5 MG, 25 MG, 37.5 MG, 50 MG

5

RISPERDAL M-TAB ORAL TABLET DISPERSIBLE 0.5 MG, 1 MG, 3 MG, 4 MG

4

RISPERDAL ORAL SOLUTION 1 MG/ML

4

RISPERDAL ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG, 3 MG, 4 MG

4

risperidone m-tab oral tablet dispersible 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg

2

risperidone oral solution 1 mg/ml

2

risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg

1

Drug NameDrug Tier

Notes

risperidone oral tablet dispersible 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg

2

SAPHRIS SUBLINGUAL TABLET SUBLINGUAL 10 MG, 2.5 MG, 5 MG

4 PA

SEROQUEL ORAL TABLET 100 MG, 200 MG, 25 MG, 300 MG, 400 MG, 50 MG

4

SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HOUR 150 MG, 200 MG, 300 MG, 400 MG, 50 MG

4QL (30 EA

per 30 days)

thioridazine hcl oral tablet 10 mg, 100 mg, 25 mg, 50 mg

2

thiothixene oral capsule 1 mg, 10 mg, 2 mg, 5 mg

2

trifluoperazine hcl oral tablet 1 mg, 10 mg, 2 mg, 5 mg

2

VERSACLOZ ORAL SUSPENSION 50 MG/ML

4

VRAYLAR ORAL CAPSULE 1.5 MG, 3 MG, 4.5 MG, 6 MG

4 PA

VRAYLAR ORAL CAPSULE THERAPY PACK 1.5 & 3 MG

4 PA

ziprasidone hcl oral capsule 20 mg, 40 mg, 60 mg, 80 mg

2

ZYPREXA INTRAMUSCULAR SOLUTION RECONSTITUTED 10 MG

GM



77

Drug NameDrug Tier

Notes

ZYPREXA ORAL TABLET 10 MG, 15 MG, 2.5 MG, 20 MG, 5 MG, 7.5 MG

4

ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION RECONSTITUTED 210 MG, 300 MG, 405 MG

5

ZYPREXA ZYDIS ORAL TABLET DISPERSIBLE 10 MG, 15 MG, 20 MG, 5 MG

4

Antivirals

abacavir sulfate oral solution 20 mg/ml

2

abacavir sulfate oral tablet 300 mg

2

abacavir sulfate-lamivudine oral tablet 600-300 mg

2

abacavir-lamivudine-zidovudine oral tablet 300-150-300 mg

2

acyclovir external cream 5 %

2

acyclovir external ointment 5 %

2QL (15 GM

per 30 days)

acyclovir oral capsule 200 mg

2

acyclovir oral suspension 200 mg/5ml

2

acyclovir oral tablet 400 mg, 800 mg

2

acyclovir sodium intravenous solution 50 mg/ml

GM

acyclovir sodium intravenous solution reconstituted 500 mg

GM

Drug NameDrug Tier

Notes

adefovir dipivoxil oral tablet 10 mg

2 PA

APTIVUS ORAL CAPSULE 250 MG

3

APTIVUS ORAL SOLUTION 100 MG/ML

3

atazanavir sulfate oral capsule 150 mg, 200 mg, 300 mg

2

ATRIPLA ORAL TABLET 600-200-300 MG

6

BARACLUDE ORAL SOLUTION 0.05 MG/ML

4 PA

BARACLUDE ORAL TABLET 0.5 MG, 1 MG

4 PA

BIKTARVY ORAL TABLET 50-200-25 MG

4

cidofovir intravenous solution 75 mg/ml

GM

CIMDUO ORAL TABLET 300-300 MG

6

COMBIVIR ORAL TABLET 150-300 MG

4

COMPLERA ORAL TABLET 200-25-300 MG

6

COPEGUS ORAL TABLET 200 MG

5

CRIXIVAN ORAL CAPSULE 200 MG, 400 MG

3

CYTOVENE INTRAVENOUS SOLUTION RECONSTITUTED 500 MG

GM

DAKLINZA ORAL TABLET 30 MG, 60 MG, 90 MG

6 PA

DELSTRIGO ORAL TABLET 100-300-300 MG

6



78

Drug NameDrug Tier

Notes

DENAVIR EXTERNAL CREAM 1 %

4 ST

DESCOVY ORAL TABLET 200-25 MG

6

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

2

DOVATO ORAL TABLET 50-300 MG

6

EDURANT ORAL TABLET 25 MG

4

efavirenz oral capsule 200 mg, 50 mg

2

efavirenz oral tablet 600 mg

2

EMTRIVA ORAL CAPSULE 200 MG

3

EMTRIVA ORAL SOLUTION 10 MG/ML

3

entecavir oral tablet 0.5 mg, 1 mg

2 PA

EPCLUSA ORAL TABLET 400-100 MG

5 PA

EPIVIR HBV ORAL SOLUTION 5 MG/ML

4

EPIVIR HBV ORAL TABLET 100 MG

4

EPIVIR ORAL SOLUTION 10 MG/ML

4

EPIVIR ORAL TABLET 150 MG, 300 MG

4

EPZICOM ORAL TABLET 600-300 MG

4

EVOTAZ ORAL TABLET 300-150 MG

6

famciclovir oral tablet 125 mg, 250 mg, 500 mg

2

FLUMADINE ORAL TABLET 100 MG

4

fosamprenavir calcium oral tablet 700 mg

2

Drug NameDrug Tier

Notes

FOSCAVIR INTRAVENOUS SOLUTION 6000 MG/250ML

GM

FUZEON SUBCUTANEOUS SOLUTION RECONSTITUTED 90 MG

6

GANCICLOVIR INTRAVENOUS SOLUTION 500 MG/250ML

GM

ganciclovir sodium intravenous solution 500 mg/10ml

GM

ganciclovir sodium intravenous solution reconstituted 500 mg

GM

GENVOYA ORAL TABLET 150-150-200-10 MG

6

HARVONI ORAL TABLET 45-200 MG, 90-400 MG

5 PA

HEPSERA ORAL TABLET 10 MG

4 PA

INTELENCE ORAL TABLET 100 MG, 200 MG, 25 MG

4

INTRON A INJECTION SOLUTION 10000000 UNIT/ML, 6000000 UNIT/ML

6PA;

Specialty Medical

INTRON A INJECTION SOLUTION RECONSTITUTED 10000000 UNIT, 18000000 UNIT, 50000000 UNIT

6PA;

Specialty Medical

INVIRASE ORAL CAPSULE 200 MG

3



79

Drug NameDrug Tier

Notes

INVIRASE ORAL TABLET 500 MG

3

ISENTRESS HD ORAL TABLET 600 MG

3

ISENTRESS ORAL PACKET 100 MG

3

ISENTRESS ORAL TABLET 400 MG

3

ISENTRESS ORAL TABLET CHEWABLE 100 MG, 25 MG

3

JULUCA ORAL TABLET 50-25 MG

6

KALETRA ORAL SOLUTION 400-100 MG/5ML

3

KALETRA ORAL TABLET 100-25 MG, 200-50 MG

3

lamivudine oral solution 10 mg/ml

2

lamivudine oral tablet 100 mg, 150 mg, 300 mg

2

lamivudine-zidovudine oral tablet 150-300 mg

2

LEDIPASVIR-SOFOSBUVIR ORAL TABLET 90-400 MG

5 PA

LEXIVA ORAL SUSPENSION 50 MG/ML

4

LEXIVA ORAL TABLET 700 MG

4

lopinavir-ritonavir oral solution 400-100 mg/5ml

2

MAVYRET ORAL TABLET 100-40 MG

5 PA

MODERIBA 1200 DOSE PACK ORAL TABLET 600 MG

6

Drug NameDrug Tier

Notes

MODERIBA 800 DOSE PACK ORAL TABLET 400 MG

6

moderiba oral tablet 200 mg

5

MODERIBA ORAL TABLET THERAPY PACK 200 & 400 MG, 400 & 600 MG

6

nevirapine er oral tablet extended release 24 hour 100 mg, 400 mg

2

nevirapine oral suspension 50 mg/5ml

2

nevirapine oral tablet 200 mg

2

NORVIR ORAL CAPSULE 100 MG

3

NORVIR ORAL PACKET 100 MG

4

NORVIR ORAL SOLUTION 80 MG/ML

3

NORVIR ORAL TABLET 100 MG

3

ODEFSEY ORAL TABLET 200-25-25 MG

6

OLYSIO ORAL CAPSULE 150 MG

6 PA

oseltamivir phosphate oral capsule 30 mg

2QL (20 EA

per 180 days)

oseltamivir phosphate oral capsule 45 mg, 75 mg

2QL (10 EA

per 180 days)

oseltamivir phosphate oral suspension reconstituted 6 mg/ml

2QL (120

ML per 180 days)

PEGASYS PROCLICK SUBCUTANEOUS SOLUTION 135 MCG/0.5ML, 180 MCG/0.5ML

5 PA



80

Drug NameDrug Tier

Notes

PEGASYS SUBCUTANEOUS SOLUTION 180 MCG/0.5ML, 180 MCG/ML

5 PA

PEGINTRON SUBCUTANEOUS KIT 50 MCG/0.5ML

5 PA

PIFELTRO ORAL TABLET 100 MG

4

PREVYMIS INTRAVENOUS SOLUTION 240 MG/12ML, 480 MG/24ML

6PA;

Specialty Medical

PREVYMIS ORAL TABLET 240 MG, 480 MG

6 PA

PREZCOBIX ORAL TABLET 800-150 MG

6

PREZISTA ORAL SUSPENSION 100 MG/ML

4

PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG, 800 MG

4

RAPIVAB INTRAVENOUS SOLUTION 200 MG/20ML

GM

REBETOL ORAL CAPSULE 200 MG

5

REBETOL ORAL SOLUTION 40 MG/ML

6

RELENZA DISKHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 5 MG/BLISTER

4QL (20 EA

per 180 days)

RESCRIPTOR ORAL TABLET 100 MG, 200 MG

3

Drug NameDrug Tier

Notes

RETROVIR INTRAVENOUS SOLUTION 10 MG/ML

GM

RETROVIR ORAL CAPSULE 100 MG

4

RETROVIR ORAL SYRUP 50 MG/5ML

4

REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG

3

REYATAZ ORAL PACKET 50 MG

4

ribasphere oral capsule 200 mg

5

ribasphere oral tablet 200 mg

5

ribasphere oral tablet 400 mg, 600 mg

6

ribasphere ribapak oral tablet 400 mg, 600 mg

6

RIBASPHERE RIBAPAK ORAL TABLET THERAPY PACK 200 & 400 MG

6

ribasphere ribapak oral tablet therapy pack 400 & 600 mg

6

ribavirin inhalation solution reconstituted 6 gm

6PA;

Specialty Medical

ribavirin oral capsule 200 mg

5

ribavirin oral tablet 200 mg

5

rimantadine hcl oral tablet 100 mg

2

ritonavir oral tablet 100 mg

2

SELZENTRY ORAL SOLUTION 20 MG/ML

4



81

Drug NameDrug Tier

Notes

SELZENTRY ORAL TABLET 150 MG, 25 MG, 300 MG, 75 MG

4

SOFOSBUVIR-VELPATASVIR ORAL TABLET 400-100 MG

5 PA

SOVALDI ORAL TABLET 200 MG, 400 MG

6 PA

stavudine oral capsule 15 mg, 20 mg, 30 mg, 40 mg

2

STRIBILD ORAL TABLET 150-150-200-300 MG

6

SUSTIVA ORAL CAPSULE 200 MG, 50 MG

3

SUSTIVA ORAL TABLET 600 MG

3

SYMFI LO ORAL TABLET 400-300-300 MG

6

SYMFI ORAL TABLET 600-300-300 MG

6

SYMTUZA ORAL TABLET 800-150-200-10 MG

6

TAMIFLU ORAL CAPSULE 30 MG

4QL (20 EA

per 180 days)

TAMIFLU ORAL CAPSULE 45 MG, 75 MG

4QL (10 EA

per 180 days)

TAMIFLU ORAL SUSPENSION RECONSTITUTED 6 MG/ML

4QL (120

ML per 180 days)

TECHNIVIE ORAL TABLET 12.5-75-50 MG

6 PA

TEMIXYS ORAL TABLET 300-300 MG

6

Drug NameDrug Tier

Notes

tenofovir disoproxil fumarate oral tablet 300 mg

2

TIVICAY ORAL TABLET 10 MG, 25 MG, 50 MG

6

TRIUMEQ ORAL TABLET 600-50-300 MG

6

TRIZIVIR ORAL TABLET 300-150-300 MG

4

TROGARZO INTRAVENOUS SOLUTION 200 MG/1.33ML

6Specialty Medical

TRUVADA ORAL TABLET 100-150 MG, 133-200 MG, 167-250 MG, 200-300 MG

6

TYBOST ORAL TABLET 150 MG

4 ST

valacyclovir hcl oral tablet 1 gm, 500 mg

2

VALCYTE ORAL SOLUTION RECONSTITUTED 50 MG/ML

6

VALCYTE ORAL TABLET 450 MG

6

valganciclovir hcl oral solution reconstituted 50 mg/ml

5

valganciclovir hcl oral tablet 450 mg

5

VALTREX ORAL TABLET 1 GM, 500 MG

4

VEMLIDY ORAL TABLET 25 MG

5 PA

VIDEX EC ORAL CAPSULE DELAYED RELEASE 125 MG, 200 MG, 250 MG, 400 MG

4



82

Drug NameDrug Tier

Notes

VIDEX ORAL SOLUTION RECONSTITUTED 2 GM, 4 GM

3

VIEKIRA PAK ORAL TABLET THERAPY PACK 12.5-75-50

6 PA

VIEKIRA XR ORAL TABLET EXTENDED RELEASE 24 HOUR 200-8.33-50- 33.33 MG

6 PA

VIRACEPT ORAL TABLET 250 MG, 625 MG

4

VIRAMUNE ORAL SUSPENSION 50 MG/5ML

4

VIRAMUNE ORAL TABLET 200 MG

4

VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 HOUR 100 MG, 400 MG

4

VIRAZOLE INHALATION SOLUTION RECONSTITUTED 6 GM

6PA;

Specialty Medical

VIREAD ORAL POWDER 40 MG/GM

3

VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG, 300 MG

3

VOSEVI ORAL TABLET 400-100-100 MG

6 PA

XOFLUZA ORAL TABLET THERAPY PACK 2 X 20 MG, 2 X 40 MG

4QL (2 EA per 180 days)

ZEPATIER ORAL TABLET 50-100 MG

6 PA

ZERIT ORAL CAPSULE 15 MG, 20 MG, 30 MG, 40 MG

4

Drug NameDrug Tier

Notes

ZERIT ORAL SOLUTION RECONSTITUTED 1 MG/ML

4

ZIAGEN ORAL SOLUTION 20 MG/ML

4

ZIAGEN ORAL TABLET 300 MG

4

zidovudine oral capsule 100 mg

2

zidovudine oral syrup 50 mg/5ml

2

zidovudine oral tablet 300 mg

2

ZOVIRAX EXTERNAL CREAM 5 %

3

ZOVIRAX EXTERNAL OINTMENT 5 %

3QL (15 GM

per 30 days)

ZOVIRAX ORAL CAPSULE 200 MG

4

ZOVIRAX ORAL SUSPENSION 200 MG/5ML

4

ZOVIRAX ORAL TABLET 400 MG, 800 MG

4

Anxiolytics - Drugs for Anxiety

alprazolam er oral tablet extended release 24 hour 0.5 mg, 1 mg, 2 mg, 3 mg

2

ALPRAZOLAM INTENSOL ORAL CONCENTRATE 1 MG/ML

4

alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg

2

alprazolam oral tablet dispersible 0.25 mg, 0.5 mg, 1 mg, 2 mg

2 ST



83

Drug NameDrug Tier

Notes

alprazolam xr oral tablet extended release 24 hour 0.5 mg, 1 mg, 2 mg, 3 mg

2

ATIVAN INJECTION SOLUTION 2 MG/ML, 4 MG/ML

GM

ATIVAN ORAL TABLET 0.5 MG, 1 MG, 2 MG

4

buspirone hcl oral tablet 10 mg, 15 mg, 5 mg

1

buspirone hcl oral tablet 30 mg, 7.5 mg

2

chlordiazepoxide hcl oral capsule 10 mg, 25 mg, 5 mg

2

clonazepam oral tablet 0.5 mg, 1 mg, 2 mg

2

clonazepam oral tablet dispersible 0.125 mg, 0.25 mg, 0.5 mg, 1 mg, 2 mg

2

clorazepate dipotassium oral tablet 15 mg, 3.75 mg, 7.5 mg

2

diazepam intensol oral concentrate 5 mg/ml

2

diazepam oral concentrate 5 mg/ml

2

diazepam oral solution 5 mg/5ml

2

diazepam oral tablet 10 mg, 2 mg, 5 mg

2

diazepam solution 5 mg/ml injection 5 mg/ml

GM

DIAZEPAM SOLUTION 5 MG/ML INJECTION 5 MG/ML

GM

DORAL ORAL TABLET 15 MG

4

estazolam oral tablet 1 mg, 2 mg

2

Drug NameDrug Tier

Notes

HALCION ORAL TABLET 0.25 MG

4

hydroxyzine hcl intramuscular solution 25 mg/ml, 50 mg/ml

GM

hydroxyzine hcl oral syrup 10 mg/5ml

2

hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg

2

hydroxyzine pamoate oral capsule 100 mg, 25 mg, 50 mg

2

KLONOPIN ORAL TABLET 0.5 MG, 1 MG, 2 MG

4

lorazepam injection solution 2 mg/ml, 4 mg/ml

GM

lorazepam intensol oral concentrate 2 mg/ml

2

lorazepam oral concentrate 2 mg/ml

2

lorazepam oral tablet 0.5 mg, 1 mg, 2 mg

2

LORAZEPAM-DEXTROSE INTRAVENOUS SOLUTION 100-5 MG/100ML-%

GM

meprobamate oral tablet 200 mg, 400 mg

2

midazolam hcl injection solution 10 mg/10ml, 10 mg/2ml, 2 mg/2ml, 25 mg/5ml, 5 mg/5ml, 5 mg/ml, 50 mg/10ml

GM

MIDAZOLAM HCL INTRAVENOUS SOLUTION 30 MG/30ML

GM



84

Drug NameDrug Tier

Notes

MIDAZOLAM HCL-DEXTROSE INTRAVENOUS SOLUTION 50-5 MG/50ML-%

GM

MIDAZOLAM HCL-SODIUM CHLORIDE INTRAVENOUS SOLUTION 50-0.9 MG/50ML-%

GM

MIDAZOLAM HCL-SODIUM CHLORIDE INTRAVENOUS SOLUTION PREFILLED SYRINGE 2-0.9 MG/2ML-%, 5-0.9 MG/5ML-%, 55-0.9 MG/55ML-%

GM

MIDAZOLAM-SODIUM CHLORIDE INTRAVENOUS SOLUTION 50-0.9 MG/50ML-%

GM

oxazepam oral capsule 10 mg, 15 mg, 30 mg

2

quazepam oral tablet 15 mg

2

TRANXENE-T ORAL TABLET 7.5 MG

4

triazolam oral tablet 0.125 mg, 0.25 mg

2

VALIUM ORAL TABLET 10 MG, 2 MG, 5 MG

4

VISTARIL ORAL CAPSULE 25 MG, 50 MG

4

XANAX ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG

4

XANAX XR ORAL TABLET EXTENDED RELEASE 24 HOUR 0.5 MG, 1 MG, 2 MG, 3 MG

4

Drug NameDrug Tier

Notes

Bipolar Agents - Drugs for Mood Disorders

lithium carbonate er oral tablet extended release 300 mg, 450 mg

2

lithium carbonate oral capsule 150 mg, 300 mg, 600 mg

1

lithium carbonate oral tablet 300 mg

2

lithium oral solution 8 meq/5ml

2

LITHOBID ORAL TABLET EXTENDED RELEASE 300 MG

4

Blood Products / Modifiers / Volume Expanders - Drugs for Bleeding Disorders

ADVATE INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 4000 UNIT, 500 UNIT

6Specialty Medical

ADYNOVATE INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 2000 UNIT, 250 UNIT, 500 UNIT, 750 UNIT

6Specialty Medical

ADYNOVATE INTRAVENOUS SOLUTION RECONSTITUTED 3000 UNIT

6PA;

Specialty Medical

AFSTYLA INTRAVENOUS KIT 1000 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 UNIT

6Specialty Medical



85

Drug NameDrug Tier

Notes

AGRYLIN ORAL CAPSULE 0.5 MG

4

ALPHANATE/VWF COMPLEX/HUMAN INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 2000 UNIT, 250 UNIT, 500 UNIT

6Specialty Medical

ALPHANINE SD INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 500 UNIT

6Specialty Medical

ALPROLIX INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 4000 UNIT, 500 UNIT

6Specialty Medical

AMICAR ORAL SOLUTION 0.25 GM/ML

4

AMICAR ORAL TABLET 1000 MG, 500 MG

4

aminocaproic acid intravenous solution 250 mg/ml

GM

aminocaproic acid oral solution 0.25 gm/ml

2

aminocaproic acid oral tablet 1000 mg, 500 mg

2

anagrelide hcl oral capsule 0.5 mg, 1 mg

2

ARANESP (ALBUMIN FREE) INJECTION SOLUTION 100 MCG/ML, 200 MCG/ML, 25 MCG/ML, 300 MCG/ML, 40 MCG/ML, 60 MCG/ML

6

Drug NameDrug Tier

Notes

ARANESP (ALBUMIN FREE) INJECTION SOLUTION PREFILLED SYRINGE 10 MCG/0.4ML, 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

6

ASTRINGYN EXTERNAL SOLUTION 259 MG/GM

4

BEBULIN INTRAVENOUS SOLUTION RECONSTITUTED 200-1200 UNIT

6Specialty Medical

BENEFIX INTRAVENOUS KIT 1000 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 UNIT

6Specialty Medical

CEPROTIN INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 500 UNIT

GM

COAGADEX INTRAVENOUS SOLUTION RECONSTITUTED 250 UNIT, 500 UNIT

6Specialty Medical

CORIFACT INTRAVENOUS KIT 1000-1600 UNIT

6Specialty Medical

CYKLOKAPRON INTRAVENOUS SOLUTION 1000 MG/10ML

GM

DOPTELET ORAL TABLET 20 MG

6 PA



86

Drug NameDrug Tier

Notes

ELOCTATE INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 4000 UNIT, 500 UNIT, 5000 UNIT, 6000 UNIT, 750 UNIT

6Specialty Medical

EPOGEN INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML

6

EVITHROM EXTERNAL SOLUTION 800-1200 UNIT/ML

4

FEIBA INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 2500 UNIT, 500 UNIT

6Specialty Medical

FIBRYGA INTRAVENOUS SOLUTION RECONSTITUTED

GM

FULPHILA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 6 MG/0.6ML

5

GRANIX SUBCUTANEOUS SOLUTION 300 MCG/ML, 480 MCG/1.6ML

5

GRANIX SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 300 MCG/0.5ML, 480 MCG/0.8ML

5

Drug NameDrug Tier

Notes

HELIXATE FS INTRAVENOUS KIT 1000 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 UNIT

6Specialty Medical

HEMLIBRA SUBCUTANEOUS SOLUTION 105 MG/0.7ML, 150 MG/ML, 30 MG/ML, 60 MG/0.4ML

GM

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

6Specialty Medical

HEMOFIL M INTRAVENOUS SOLUTION RECONSTITUTED 1700 UNIT

6Specialty Medical

HESPAN INTRAVENOUS SOLUTION 6-0.9 %

GM

hetastarch-nacl intravenous solution 6-0.9 %

GM

HEXTEND INTRAVENOUS SOLUTION 6 %

GM

HUMATE-P INTRAVENOUS SOLUTION RECONSTITUTED 1000-2400 UNIT, 250-600 UNIT, 500-1200 UNIT

6Specialty Medical

IDELVION INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 2000 UNIT, 250 UNIT, 3500 UNIT, 500 UNIT

6Specialty Medical



87

Drug NameDrug Tier

Notes

IXINITY INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 UNIT

6Specialty Medical

JIVI INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 2000 UNIT, 3000 UNIT, 500 UNIT

6Specialty Medical

KCENTRA INTRAVENOUS KIT 1000 UNIT, 500 UNIT

GM

KOATE INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 250 UNIT, 500 UNIT

6Specialty Medical

KOATE-DVI INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 250 UNIT, 500 UNIT

6Specialty Medical

KOGENATE FS BIO-SET INTRAVENOUS KIT 1000 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 UNIT

6Specialty Medical

KOGENATE FS INTRAVENOUS KIT 1000 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 UNIT

6Specialty Medical

KOVALTRY INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 UNIT

6Specialty Medical

Drug NameDrug Tier

Notes

LEUKINE INTRAVENOUS SOLUTION RECONSTITUTED 250 MCG

6Specialty Medical

LMD IN D5W INTRAVENOUS SOLUTION 10-5 %

GM

LMD IN NACL INTRAVENOUS SOLUTION 10-0.9 %

GM

LYSTEDA ORAL TABLET 650 MG

3

MIRCERA INJECTION SOLUTION PREFILLED SYRINGE 100 MCG/0.3ML, 150 MCG/0.3ML, 200 MCG/0.3ML, 30 MCG/0.3ML, 50 MCG/0.3ML, 75 MCG/0.3ML

4

MONOCLATE-P INTRAVENOUS KIT 1000 UNIT, 1500 UNIT

6Specialty Medical

MONONINE INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT

6Specialty Medical

MONSELS FERRIC SUBSULFATE EXTERNAL SOLUTION

4

MOZOBIL SUBCUTANEOUS SOLUTION 24 MG/1.2ML

6PA;

Specialty Medical

MULPLETA ORAL TABLET 3 MG

6 PA

NEULASTA ONPRO SUBCUTANEOUS PREFILLED SYRINGE KIT 6 MG/0.6ML

6



88

Drug NameDrug Tier

Notes

NEULASTA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 6 MG/0.6ML

6

NEUPOGEN INJECTION SOLUTION 300 MCG/ML, 480 MCG/1.6ML

6

NEUPOGEN INJECTION SOLUTION PREFILLED SYRINGE 300 MCG/0.5ML, 480 MCG/0.8ML

6

NIVESTYM INJECTION SOLUTION 300 MCG/ML, 480 MCG/1.6ML

5

NIVESTYM INJECTION SOLUTION PREFILLED SYRINGE 300 MCG/0.5ML, 480 MCG/0.8ML

5

NOVOEIGHT INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 UNIT

6Specialty Medical

NOVOSEVEN RT INTRAVENOUS SOLUTION RECONSTITUTED 1 MG, 2 MG, 5 MG, 8 MG

6Specialty Medical

NPLATE SUBCUTANEOUS SOLUTION RECONSTITUTED 250 MCG, 500 MCG

6PA;

Specialty Medical

NUWIQ INTRAVENOUS KIT 250 UNIT

6Specialty Medical

Drug NameDrug Tier

Notes

NUWIQ INTRAVENOUS SOLUTION RECONSTITUTED 2500 UNIT, 3000 UNIT, 4000 UNIT

6Specialty Medical

OBIZUR INTRAVENOUS SOLUTION RECONSTITUTED 500 UNIT

GM

PANHEMATIN INTRAVENOUS SOLUTION RECONSTITUTED 350 MG

GM

PROCRIT INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML, 40000 UNIT/ML

6

PROFILNINE INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 500 UNIT

6Specialty Medical

PROFILNINE SD INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 500 UNIT

6Specialty Medical

PROMACTA ORAL TABLET 12.5 MG, 25 MG, 50 MG, 75 MG

6 PA

protamine sulfate intravenous solution 10 mg/ml

GM

REBINYN INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 2000 UNIT, 500 UNIT

GM



89

Drug NameDrug Tier

Notes

RECOMBINATE INTRAVENOUS SOLUTION RECONSTITUTED 1241-1800 UNIT, 1801-2400 UNIT, 220-400 UNIT, 401-800 UNIT, 801-1240 UNIT

6Specialty Medical

RECOTHROM EXTERNAL SOLUTION RECONSTITUTED 20000 UNIT, 5000 UNIT

4

RECOTHROM SPRAY KIT EXTERNAL SOLUTION RECONSTITUTED 20000 UNIT

4

RETACRIT INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML, 40000 UNIT/ML

5

RIASTAP INTRAVENOUS SOLUTION RECONSTITUTED

GM

RIXUBIS INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 UNIT

6Specialty Medical

SOLIRIS INTRAVENOUS SOLUTION 300 MG/30ML

6PA;

Specialty Medical

TAVALISSE ORAL TABLET 100 MG, 150 MG

6 PA

THROMBIN-JMI EPISTAXIS EXTERNAL KIT 5000 UNIT

4

Drug NameDrug Tier

Notes

THROMBIN-JMI EXTERNAL KIT 20000 UNIT, 5000 UNIT

4

THROMBIN-JMI EXTERNAL SOLUTION RECONSTITUTED 20000 UNIT, 5000 UNIT

4

THROMBOGEN EXTERNAL KIT 10000 UNIT

4

THROMBOGEN EXTERNAL SOLUTION RECONSTITUTED 1000 UNIT, 10000 UNIT

4

tranexamic acid intravenous solution 1000 mg/10ml

GM

tranexamic acid oral tablet 650 mg

2

TRANEXAMIC ACID-NACL INTRAVENOUS SOLUTION 1000-0.7 MG/100ML-%

GM

TRETTEN INTRAVENOUS SOLUTION RECONSTITUTED 2000-3125 UNIT

6Specialty Medical

UDENYCA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 6 MG/0.6ML

5

ULTOMIRIS INTRAVENOUS SOLUTION 300 MG/30ML

6PA;

Specialty Medical

VOLUVEN INTRAVENOUS SOLUTION 6-0.9 %

GM

VONVENDI INTRAVENOUS SOLUTION RECONSTITUTED 1300 UNIT, 650 UNIT

6Specialty Medical



90

Drug NameDrug Tier

Notes

WILATE INTRAVENOUS KIT 1000-1000 UNIT, 500-500 UNIT

6Specialty Medical

XYNTHA INTRAVENOUS KIT 1000 UNIT, 2000 UNIT, 250 UNIT, 500 UNIT

6Specialty Medical

XYNTHA SOLOFUSE INTRAVENOUS KIT 1000 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 UNIT

6Specialty Medical

ZARXIO INJECTION SOLUTION PREFILLED SYRINGE 300 MCG/0.5ML, 480 MCG/0.8ML

5

Cardiovascular Agents - Drugs for Heart and Circulation Conditions

ACCUPRIL ORAL TABLET 10 MG, 20 MG, 40 MG, 5 MG

4

ACCURETIC ORAL TABLET 10-12.5 MG, 20-12.5 MG, 20-25 MG

4

acebutolol hcl oral capsule 200 mg, 400 mg

2

acetazolamide oral tablet 125 mg

2

acetazolamide sodium injection solution reconstituted 500 mg

GM

ADALAT CC ORAL TABLET EXTENDED RELEASE 24 HOUR 30 MG, 60 MG, 90 MG

4

ADENOCARD INTRAVENOUS SOLUTION 12 MG/4ML, 6 MG/2ML

GM

Drug NameDrug Tier

Notes

adenosine intravenous solution 12 mg/4ml, 6 mg/2ml

GM

ADENOSINE INTRAVENOUS SOLUTION PREFILLED SYRINGE 60 MG/20ML, 90 MG/30ML

GM

afeditab cr oral tablet extended release 24 hour 30 mg, 60 mg

2

AKOVAZ INTRAVENOUS SOLUTION 50 MG/ML

GM

ALDACTAZIDE ORAL TABLET 25-25 MG

4

ALDACTAZIDE ORAL TABLET 50-50 MG

3

ALDACTONE ORAL TABLET 100 MG, 25 MG, 50 MG

4

aliskiren fumarate oral tablet 150 mg, 300 mg

2

alprostadil injection solution 500 mcg/ml

GM

ALTACE ORAL CAPSULE 1.25 MG, 10 MG, 2.5 MG, 5 MG

4

ALTOPREV ORAL TABLET EXTENDED RELEASE 24 HOUR 20 MG, 40 MG, 60 MG

4 PA

amiloride hcl oral tablet 5 mg

2

amiloride-hydrochlorothiazide oral tablet 5-50 mg

2



91

Drug NameDrug Tier

Notes

AMIODARONE HCL IN DEXTROSE INTRAVENOUS SOLUTION 1000-5 MG/500ML-%, 450-5 MG/250ML-%, 750-5 MG/500ML-%

GM

amiodarone hcl intravenous solution 150 mg/3ml, 450 mg/9ml, 900 mg/18ml

GM

amiodarone hcl oral tablet 100 mg, 200 mg, 400 mg

2

amlodipine besylate oral tablet 10 mg, 2.5 mg, 5 mg

1

amlodipine besylate-benazepril hcl oral capsule 10-20 mg, 10-40 mg, 2.5-10 mg, 5-10 mg, 5-20 mg, 5-40 mg

2

amlodipine besylate-valsartan oral tablet 10-160 mg, 10-320 mg, 5-160 mg, 5-320 mg

2

amlodipine-atorvastatin oral tablet 10-10 mg, 10-20 mg, 10-40 mg, 10-80 mg, 2.5-10 mg, 2.5-20 mg, 2.5-40 mg, 5-10 mg, 5-20 mg, 5-40 mg, 5-80 mg

2

amlodipine-olmesartan oral tablet 10-20 mg, 10-40 mg, 5-20 mg, 5-40 mg

2

amlodipine-valsartan-hctz oral tablet 10-160-12.5 mg, 10-160-25 mg, 10-320-25 mg, 5-160-12.5 mg, 5-160-25 mg

2

ANTARA ORAL CAPSULE 30 MG, 90 MG

4

Drug NameDrug Tier

Notes

ASCLERA INTRAVENOUS SOLUTION 0.5 %, 1 %

GM

ATACAND HCT ORAL TABLET 16-12.5 MG, 32-12.5 MG, 32-25 MG

4

ATACAND ORAL TABLET 16 MG, 32 MG, 4 MG, 8 MG

4

atenolol oral tablet 100 mg, 25 mg, 50 mg

2

atenolol-chlorthalidone oral tablet 100-25 mg, 50-25 mg

2

atorvastatin calcium oral tablet 10 mg, 20 mg, 40 mg, 80 mg

2

AVALIDE ORAL TABLET 150-12.5 MG, 300-12.5 MG

4

AVAPRO ORAL TABLET 150 MG, 300 MG, 75 MG

4

AZOR ORAL TABLET 10-20 MG, 10-40 MG, 5-20 MG, 5-40 MG

3

benazepril hcl oral tablet 10 mg, 20 mg, 40 mg, 5 mg

1

benazepril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg, 5-6.25 mg

2

BENICAR HCT ORAL TABLET 20-12.5 MG, 40-12.5 MG, 40-25 MG

3

BENICAR ORAL TABLET 20 MG, 40 MG, 5 MG

3

BETAPACE AF ORAL TABLET 120 MG, 160 MG, 80 MG

4



92

Drug NameDrug Tier

Notes

BETAPACE ORAL TABLET 120 MG, 160 MG, 80 MG

4

betaxolol hcl oral tablet 10 mg, 20 mg

2

BIDIL ORAL TABLET 20-37.5 MG

4

bisoprolol fumarate oral tablet 10 mg, 5 mg

2

bisoprolol-hydrochlorothiazide oral tablet 10-6.25 mg, 2.5-6.25 mg, 5-6.25 mg

1

BREVIBLOC IN NACL INTRAVENOUS SOLUTION 2000 MG/100ML, 2500 MG/250ML

GM

BREVIBLOC INTRAVENOUS SOLUTION 100 MG/10ML

GM

BREVIBLOC PREMIXED DS INTRAVENOUS SOLUTION 2000 MG/100ML

GM

BREVIBLOC PREMIXED INTRAVENOUS SOLUTION 2500 MG/250ML

GM

bumetanide injection solution 0.25 mg/ml

GM

bumetanide oral tablet 0.5 mg, 1 mg, 2 mg

2

BUMEX ORAL TABLET 0.5 MG, 1 MG, 2 MG

4

BYSTOLIC ORAL TABLET 10 MG, 2.5 MG, 20 MG, 5 MG

3

BYVALSON ORAL TABLET 5-80 MG

4

Drug NameDrug Tier

Notes

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

4

CALAN ORAL TABLET 120 MG, 80 MG

4

CALAN SR ORAL TABLET EXTENDED RELEASE 120 MG, 180 MG, 240 MG

4

candesartan cilexetil oral tablet 16 mg, 32 mg, 4 mg, 8 mg

2

candesartan cilexetil-hctz oral tablet 16-12.5 mg, 32-12.5 mg, 32-25 mg

2

captopril oral tablet 100 mg, 12.5 mg, 25 mg, 50 mg

2

captopril-hydrochlorothiazide oral tablet 25-15 mg, 25-25 mg, 50-15 mg, 50-25 mg

2

CARDENE IV INTRAVENOUS SOLUTION 20-0.86 MG/200ML-%, 20-4.8 MG/200ML-%, 40-0.83 MG/200ML-%, 40-5 MG/200ML-%

GM

CARDIZEM CD ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG

4

CARDIZEM CD ORAL CAPSULE EXTENDED RELEASE 24 HOUR 360 MG

3



93

Drug NameDrug Tier

Notes

CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG, 420 MG

4

CARDIZEM ORAL TABLET 120 MG, 30 MG, 60 MG

4

CARDURA ORAL TABLET 1 MG, 2 MG, 4 MG, 8 MG

4

cartia xt oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 300 mg

2

carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg, 6.25 mg

1

carvedilol phosphate er oral capsule extended release 24 hour 10 mg, 20 mg, 40 mg, 80 mg

2

CATAPRES ORAL TABLET 0.1 MG, 0.2 MG, 0.3 MG

4

CATAPRES-TTS-1 TRANSDERMAL PATCH WEEKLY 0.1 MG/24HR

4


4


4

chlorothiazide oral tablet 250 mg, 500 mg

2

chlorothiazide sodium intravenous solution reconstituted 500 mg

GM

chlorthalidone oral tablet 25 mg, 50 mg

2

Drug NameDrug Tier

Notes

cholestyramine light oral packet 4 gm

2

cholestyramine light oral powder 4 gm/dose

2

cholestyramine oral packet 4 gm

2

cholestyramine oral powder 4 gm/dose

2

choline fenofibrate oral capsule delayed release 135 mg

2

CLEVIPREX INTRAVENOUS EMULSION 25 MG/50ML, 50 MG/100ML

GM

clonidine hcl oral tablet 0.1 mg, 0.2 mg, 0.3 mg

2

clonidine transdermal patch weekly 0.1 mg/24hr, 0.2 mg/24hr, 0.3 mg/24hr

2

CLORPRES ORAL TABLET 0.1-15 MG, 0.2-15 MG, 0.3-15 MG

4

colesevelam hcl oral packet 3.75 gm

2

colesevelam hcl oral tablet 625 mg

2

COLESTID FLAVORED ORAL GRANULES 5 GM

4

COLESTID FLAVORED ORAL PACKET 5 GM

4

COLESTID ORAL GRANULES 5 GM

4

COLESTID ORAL PACKET 5 GM

4

COLESTID ORAL TABLET 1 GM

4

colestipol hcl oral granules 5 gm

2

colestipol hcl oral packet 5 gm

2



94

Drug NameDrug Tier

Notes

colestipol hcl oral tablet 1 gm

2

COREG CR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG, 20 MG, 40 MG, 80 MG

4

COREG ORAL TABLET 12.5 MG, 25 MG, 3.125 MG, 6.25 MG

4

CORGARD ORAL TABLET 20 MG, 40 MG, 80 MG

4

CORLANOR ORAL SOLUTION 5 MG/5ML

4 PA

CORLANOR ORAL TABLET 5 MG, 7.5 MG

4 PA

CORLOPAM INTRAVENOUS SOLUTION 10 MG/ML, 20 MG/2ML

GM

CORVERT INTRAVENOUS SOLUTION 1 MG/10ML

GM

CORZIDE ORAL TABLET 40-5 MG, 80-5 MG

4

COZAAR ORAL TABLET 100 MG, 25 MG, 50 MG

4

CRESTOR ORAL TABLET 10 MG, 20 MG, 40 MG, 5 MG

4

DEMADEX ORAL TABLET 10 MG, 20 MG

4

DEMSER ORAL CAPSULE 250 MG

4

DIBENZYLINE ORAL CAPSULE 10 MG


days)

digitek oral tablet 125 mcg, 250 mcg

2

Drug NameDrug Tier

Notes

digox oral tablet 125 mcg, 250 mcg

2

digoxin injection solution 0.25 mg/ml

GM

digoxin oral solution 0.05 mg/ml

2

digoxin oral tablet 125 mcg, 250 mcg

2

DILATRATE-SR ORAL CAPSULE EXTENDED RELEASE 40 MG

3

diltiazem cd oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 300 mg

2

diltiazem hcl er beads oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 300 mg, 360 mg, 420 mg

2

diltiazem hcl er coated beads oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 300 mg, 360 mg

2

diltiazem hcl er coated beads oral tablet extended release 24 hour 180 mg, 240 mg, 300 mg, 360 mg, 420 mg

2

diltiazem hcl er oral capsule extended release 12 hour 120 mg, 60 mg, 90 mg

2

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

2

diltiazem hcl intravenous solution 125 mg/25ml, 25 mg/5ml, 50 mg/10ml

GM



95

Drug NameDrug Tier

Notes

DILTIAZEM HCL INTRAVENOUS SOLUTION PREFILLED SYRINGE 25 MG/5ML

GM

diltiazem hcl intravenous solution reconstituted 100 mg

GM

diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg, 90 mg

2

DILTIAZEM HCL-DEXTROSE INTRAVENOUS SOLUTION 100-5 MG/100ML-%, 250-5 MG/250ML-%

GM

DILTIAZEM HCL-SODIUM CHLORIDE INTRAVENOUS SOLUTION 125-0.7 MG/125ML-%, 125-0.9 MG/125ML-%, 250-0.9 MG/250ML-%

GM

dilt-xr oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg

2

DIOVAN HCT ORAL TABLET 160-12.5 MG, 160-25 MG, 320-12.5 MG, 320-25 MG, 80-12.5 MG

4

DIOVAN ORAL TABLET 160 MG, 320 MG, 40 MG, 80 MG

4

disopyramide phosphate oral capsule 100 mg, 150 mg

2

DIURIL ORAL SUSPENSION 250 MG/5ML

4

dobutamine hcl intravenous solution 250 mg/20ml, 500 mg/40ml

GM

Drug NameDrug Tier

Notes

dobutamine in d5w intravenous solution 1-5 mg/ml-%, 2 mg/ml, 4-5 mg/ml-%

GM

dofetilide oral capsule 125 mcg, 250 mcg, 500 mcg

2

dopamine hcl intravenous solution 160 mg/ml, 40 mg/ml, 80 mg/ml

GM

dopamine in d5w intravenous solution 0.8-5 mg/ml-%, 1.6-5 mg/ml-%, 3.2-5 mg/ml-%

GM

doxazosin mesylate oral tablet 1 mg, 2 mg, 4 mg, 8 mg

2

DUTOPROL ORAL TABLET EXTENDED RELEASE 24 HOUR 100-12.5 MG, 25-12.5 MG, 50-12.5 MG

4

DYAZIDE ORAL CAPSULE 37.5-25 MG

4

DYRENIUM ORAL CAPSULE 100 MG, 50 MG

4

EDARBI ORAL TABLET 40 MG, 80 MG

4

EDARBYCLOR ORAL TABLET 40-12.5 MG, 40-25 MG

4

EDECRIN ORAL TABLET 25 MG

4

enalapril maleate oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg

2

enalaprilat intravenous injectable 1.25 mg/ml

GM



96

Drug NameDrug Tier

Notes

enalapril-hydrochlorothiazide oral tablet 10-25 mg, 5-12.5 mg

2

ENTRESTO ORAL TABLET 24-26 MG, 49-51 MG, 97-103 MG

4 ST

EPANED ORAL SOLUTION 1 MG/ML

4

EPHEDRINE SULFATE (PRESSORS) INJECTION SOLUTION PREFILLED SYRINGE 25 MG/5ML, 50 MG/10ML, 50 MG/5ML

GM

ephedrine sulfate injection solution 50 mg/ml

GM

ephedrine sulfate intravenous solution 50 mg/ml

GM

EPHEDRINE SULFATE INTRAVENOUS SOLUTION PREFILLED SYRINGE 25 MG/5ML

GM

EPHEDRINE SULFATE-NACL INTRAVENOUS SOLUTION PREFILLED SYRINGE 10-0.9 MG/5ML-%

GM

EPINEPHRINE HCL-DEXTROSE INTRAVENOUS SOLUTION 1-5 MG/250ML-%, 16-5 MG/250ML-%, 2-5 MG/100ML-%, 2-5 MG/250ML-%, 4-5 MG/250ML-%, 5-5 MG/250ML-%, 6.25-5 MG/250ML-%, 8-5 MG/250ML-%

GM

Drug NameDrug Tier

Notes

EPINEPHRINE HCL-DEXTROSE INTRAVENOUS SOLUTION PREFILLED SYRINGE 5000-5 MCG/50ML-%, 750-5 MCG/25ML-%

GM

EPINEPHRINE HCL-NACL EPIDURAL SOLUTION PREFILLED SYRINGE 80-0.9 MCG/10ML-%

GM

EPINEPHRINE HCL-NACL INTRAVENOUS SOLUTION 1-0.9 MG/250ML-%, 10-0.9 MG/250ML-%, 16-0.9 MG/250ML-%, 2-0.9 MG/250ML-%, 2.5-0.9 MG/250ML-%, 4-0.9 MG/250ML-%, 5-0.9 MG/250ML-%, 8-0.9 MG/250ML-%

GM

EPINEPHRINE HCL-NACL INTRAVENOUS SOLUTION PREFILLED SYRINGE 10-0.9 MCG/10ML-%, 100-0.9 MCG/10ML-%, 1200-0.9 MCG/50ML-%, 200-0.9 MCG/10ML-%, 3000-0.9 MCG/15ML-%, 40-0.9 MCG/10ML-%, 50-0.9 MCG/5ML-%, 500-0.9 MCG/10ML-%, 500-0.9 MCG/50ML-%, 5000-0.9 MCG/50ML-%, 6000-0.9 MCG/50ML-%

GM

epinephrine injection solution 30 mg/30ml

GM

EPINEPHRINE INJECTION SOLUTION PREFILLED SYRINGE 1 MG/10ML

GM



97

Drug NameDrug Tier

Notes

epinephrine pf injection solution 1 mg/ml

GM

epinephrine pf injection solution prefilled syringe 1 mg/10ml

GM

EPINEPHRINE-DEXTROSE INTRAVENOUS SOLUTION 2-5 MG/250ML-%

GM

EPINEPHRINE-NACL INTRAVENOUS SOLUTION 2-0.9 MG/250ML-%

GM

EPINEPHRINE-NACL INTRAVENOUS SOLUTION PREFILLED SYRINGE 1-0.9 MG/10ML-%

GM

eplerenone oral tablet 25 mg, 50 mg

2

eprosartan mesylate oral tablet 600 mg

2

EQUAPAX/ATORVASTATIN/COQ10 ORAL THERAPY PACK 20 & 100 MG

4

esmolol hcl intravenous solution 100 mg/10ml

GM

ESMOLOL HCL INTRAVENOUS SOLUTION 2000 MG/100ML, 2500 MG/250ML

GM

esmolol hcl-sodium chloride intravenous solution 2000 mg/100ml, 2500 mg/250ml

GM

ethacrynate sodium intravenous solution reconstituted 50 mg

GM

ethacrynic acid oral tablet 25 mg

2

Drug NameDrug Tier

Notes

EXFORGE HCT ORAL TABLET 10-160-12.5 MG, 10-160-25 MG, 10-320-25 MG, 5-160-12.5 MG, 5-160-25 MG

4

EXFORGE ORAL TABLET 10-160 MG, 10-320 MG, 5-160 MG, 5-320 MG

4

ezetimibe oral tablet 10 mg

2

ezetimibe-simvastatin oral tablet 10-10 mg, 10-20 mg, 10-40 mg, 10-80 mg

2

felodipine er oral tablet extended release 24 hour 10 mg, 2.5 mg, 5 mg

2

fenofibrate micronized oral capsule 130 mg, 134 mg, 200 mg, 43 mg, 67 mg

2

fenofibrate oral capsule 134 mg, 150 mg, 200 mg, 50 mg, 67 mg

2

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

2

fenofibric acid oral capsule delayed release 135 mg, 45 mg

2

fenofibric acid oral tablet 105 mg, 35 mg

2

FIBRICOR ORAL TABLET 105 MG, 35 MG

4

flecainide acetate oral tablet 100 mg, 150 mg, 50 mg

2

fluvastatin sodium er oral tablet extended release 24 hour 80 mg

2 PA

fluvastatin sodium oral capsule 20 mg, 40 mg

2



98

Drug NameDrug Tier

Notes

fosinopril sodium oral tablet 10 mg, 20 mg, 40 mg

2

fosinopril sodium-hctz oral tablet 10-12.5 mg, 20-12.5 mg

2

FUROSEMIDE IN SODIUM CHLORIDE INTRAVENOUS SOLUTION 100-0.9 MG/100ML-%

GM

furosemide injection solution 10 mg/ml

GM

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

2

furosemide oral tablet 20 mg, 40 mg, 80 mg

1

gemfibrozil oral tablet 600 mg

2

guanfacine hcl oral tablet 1 mg, 2 mg

1

hydralazine hcl injection solution 20 mg/ml

GM

hydralazine hcl oral tablet 10 mg, 100 mg, 25 mg, 50 mg

2

hydrochlorothiazide oral capsule 12.5 mg

1

hydrochlorothiazide oral tablet 12.5 mg, 25 mg, 50 mg

1

HYZAAR ORAL TABLET 100-12.5 MG, 100-25 MG, 50-12.5 MG

4

ibutilide fumarate intravenous solution 1 mg/10ml

GM

indapamide oral tablet 1.25 mg, 2.5 mg

2

Drug NameDrug Tier

Notes

INDERAL LA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 160 MG, 60 MG, 80 MG

4

INDERAL XL ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 80 MG

4

INNOPRAN XL ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 80 MG

4

INSPRA ORAL TABLET 25 MG, 50 MG

4

irbesartan oral tablet 150 mg, 300 mg, 75 mg

2

irbesartan-hydrochlorothiazide oral tablet 150-12.5 mg, 300-12.5 mg

2

isoproterenol hcl injection solution 0.2 mg/ml

GM

ISORDIL TITRADOSE ORAL TABLET 40 MG

3

ISORDIL TITRADOSE ORAL TABLET 5 MG

4

isosorbide dinitrate er oral tablet extended release 40 mg

2

isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 mg, 5 mg

2

isosorbide mononitrate er oral tablet extended release 24 hour 120 mg, 30 mg, 60 mg

2

isosorbide mononitrate oral tablet 10 mg, 20 mg

2

isradipine oral capsule 2.5 mg, 5 mg

2

ISUPREL INJECTION SOLUTION 0.2 MG/ML

GM



99

Drug NameDrug Tier

Notes

JUXTAPID ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG, 5 MG, 60 MG

6 PA

KYNAMRO SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 200 MG/ML

6 PA

LABETALOL HCL INTRAVENOUS SOLUTION PREFILLED SYRINGE 20 MG/4ML, 25 MG/5ML, 50 MG/10ML

GM

labetalol hcl oral tablet 100 mg, 200 mg, 300 mg

2

labetalol hcl solution 5 mg/ml intravenous 5 mg/ml

GM

LABETALOL HCL SOLUTION 5 MG/ML INTRAVENOUS 5 MG/ML

GM

LABETALOL HCL-DEXTROSE INTRAVENOUS SOLUTION 100-5 MG/100ML-%, 200-5 MG/200ML-%, 250-5 MG/250ML-%, 500-5 MG/250ML-%

GM

LABETALOL HCL-SODIUM CHLORIDE INTRAVENOUS SOLUTION 200-0.9 MG/200ML-%, 500-0.9 MG/500ML-%

GM

LANOXIN INJECTION SOLUTION 0.25 MG/ML

GM

LANOXIN ORAL TABLET 125 MCG, 187.5 MCG, 250 MCG, 62.5 MCG

4

Drug NameDrug Tier

Notes

LANOXIN PEDIATRIC INJECTION SOLUTION 0.1 MG/ML

GM

LASIX ORAL TABLET 20 MG, 40 MG, 80 MG

4

LESCOL XL ORAL TABLET EXTENDED RELEASE 24 HOUR 80 MG

4 PA

LEVOPHED INTRAVENOUS SOLUTION 1 MG/ML

GM

LIPITOR ORAL TABLET 10 MG, 20 MG, 40 MG, 80 MG

4

LIPOFEN ORAL CAPSULE 150 MG, 50 MG

4

lisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 30 mg, 40 mg, 5 mg

1

lisinopril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg

1

LIVALO ORAL TABLET 1 MG, 2 MG, 4 MG

4 PA

LOPID ORAL TABLET 600 MG

4

LOPRESSOR HCT ORAL TABLET 50-25 MG

4

LOPRESSOR ORAL TABLET 100 MG, 50 MG

4

losartan potassium oral tablet 100 mg, 25 mg, 50 mg

1

losartan potassium-hctz oral tablet 100-12.5 mg, 100-25 mg, 50-12.5 mg

1

LOTENSIN HCT ORAL TABLET 10-12.5 MG, 20-12.5 MG, 20-25 MG

4



100

Drug NameDrug Tier

Notes

LOTENSIN ORAL TABLET 10 MG, 20 MG, 40 MG

4

LOTREL ORAL CAPSULE 10-20 MG, 10-40 MG, 5-10 MG, 5-20 MG

4

lovastatin oral tablet 10 mg, 20 mg, 40 mg

2

LOVAZA ORAL CAPSULE 1 GM

4 PA

mannitol intravenous solution 20 %, 25 %

GM

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

2

MAXZIDE ORAL TABLET 75-50 MG

4

MAXZIDE-25 ORAL TABLET 37.5-25 MG

4

methyclothiazide oral tablet 5 mg

2

methyldopa oral tablet 250 mg, 500 mg

2

methyldopa-hydrochlorothiazide oral tablet 250-15 mg, 250-25 mg

2

methyldopate hcl intravenous solution 250 mg/5ml

GM

metolazone oral tablet 10 mg, 2.5 mg, 5 mg

2

metoprolol succinate er oral tablet extended release 24 hour 100 mg, 200 mg, 25 mg, 50 mg

2

metoprolol tartrate intravenous solution 5 mg/5ml

GM

Drug NameDrug Tier

Notes

METOPROLOL TARTRATE INTRAVENOUS SOLUTION PREFILLED SYRINGE 5 MG/5ML

GM

metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg

1

metoprolol tartrate oral tablet 37.5 mg, 75 mg

2

METOPROLOL-HCTZ ER ORAL TABLET EXTENDED RELEASE 24 HOUR 100-12.5 MG, 25-12.5 MG, 50-12.5 MG

4

metoprolol-hydrochlorothiazide oral tablet 100-25 mg, 100-50 mg, 50-25 mg

2

mexiletine hcl oral capsule 150 mg, 200 mg, 250 mg

2

MICARDIS HCT ORAL TABLET 40-12.5 MG, 80-12.5 MG, 80-25 MG

4

MICARDIS ORAL TABLET 20 MG, 40 MG, 80 MG

4

MICROZIDE ORAL CAPSULE 12.5 MG

4

midodrine hcl oral tablet 10 mg, 2.5 mg, 5 mg

2

milrinone lactate in dextrose intravenous solution 20-5 mg/100ml-%, 40-5 mg/200ml-%

GM

milrinone lactate intravenous solution 10 mg/10ml, 20 mg/20ml, 50 mg/50ml

GM

MINIPRESS ORAL CAPSULE 1 MG, 2 MG, 5 MG

4



101

Drug NameDrug Tier

Notes

minitran transdermal patch 24 hour 0.1 mg/hr, 0.2 mg/hr, 0.4 mg/hr, 0.6 mg/hr

2

minoxidil oral tablet 10 mg, 2.5 mg

2

moexipril hcl oral tablet 15 mg, 7.5 mg

2

moexipril-hydrochlorothiazide oral tablet 15-12.5 mg, 15-25 mg, 7.5-12.5 mg

2

MULTAQ ORAL TABLET 400 MG

3

nadolol oral tablet 20 mg, 40 mg, 80 mg

2

nadolol-bendroflumethiazide oral tablet 40-5 mg

2

NATRECOR INTRAVENOUS SOLUTION RECONSTITUTED 1.5 MG

GM

NEXTERONE INTRAVENOUS SOLUTION 150-4.21 MG/100ML-%, 360-4.14 MG/200ML-%

GM

niacin (antihyperlipidemic) oral tablet 500 mg

2

niacin er (antihyperlipidemic) oral tablet extended release 1000 mg, 500 mg, 750 mg

2

NIACOR ORAL TABLET 500 MG

4

NIASPAN ORAL TABLET EXTENDED RELEASE 1000 MG, 500 MG, 750 MG

4

Drug NameDrug Tier

Notes

NICARDIPINE HCL IN DEXTROSE INTRAVENOUS SOLUTION 25-5 MG/250ML-%

GM

NICARDIPINE HCL IN NACL INTRAVENOUS SOLUTION 125-0.9 MG/250ML-%, 25-0.9 MG/250ML-%, 50-0.9 MG/250ML-%

GM

NICARDIPINE HCL IN NACL INTRAVENOUS SOLUTION PREFILLED SYRINGE 10-0.9 MG/50ML-%, 4-0.9 MG/10ML-%

GM

nicardipine hcl intravenous solution 2.5 mg/ml

GM

nicardipine hcl oral capsule 20 mg, 30 mg

2

nifedipine er oral tablet extended release 24 hour 30 mg, 60 mg, 90 mg

2

nifedipine er osmotic release oral tablet extended release 24 hour 30 mg, 60 mg, 90 mg

2

nifedipine oral capsule 10 mg, 20 mg

2

nimodipine oral capsule 30 mg

2

NIPRIDE RTU INTRAVENOUS SOLUTION 20-0.9 MG/100ML-%, 50-0.9 MG/100ML-%

GM

nisoldipine er oral tablet extended release 24 hour 17 mg, 20 mg, 25.5 mg, 30 mg, 34 mg, 40 mg, 8.5 mg

2



102

Drug NameDrug Tier

Notes

NITRO-BID TRANSDERMAL OINTMENT 2 %

3

NITRO-DUR TRANSDERMAL PATCH 24 HOUR 0.1 MG/HR, 0.2 MG/HR, 0.3 MG/HR, 0.4 MG/HR, 0.6 MG/HR, 0.8 MG/HR

3

nitroglycerin in d5w intravenous solution 100-5 mcg/ml-%, 200-5 mcg/ml-%, 400-5 mcg/ml-%

GM

nitroglycerin intravenous solution 5 mg/ml

GM

nitroglycerin sublingual tablet sublingual 0.3 mg, 0.4 mg, 0.6 mg

2

nitroglycerin transdermal patch 24 hour 0.1 mg/hr, 0.2 mg/hr, 0.4 mg/hr, 0.6 mg/hr

2

nitroglycerin translingual solution 0.4 mg/spray

2

NITROLINGUAL TRANSLINGUAL SOLUTION 0.4 MG/SPRAY

4

NITROMIST TRANSLINGUAL AEROSOL SOLUTION 400 MCG/SPRAY

3

NITROPRESS INTRAVENOUS SOLUTION 25 MG/ML

GM

nitroprusside sodium intravenous solution 25 mg/ml

GM

NITROSTAT SUBLINGUAL TABLET SUBLINGUAL 0.3 MG, 0.4 MG, 0.6 MG

3

Drug NameDrug Tier

Notes

nitro-time oral capsule extended release 2.5 mg, 6.5 mg, 9 mg

2

norepinephrine bitartrate intravenous solution 1 mg/ml

GM

NOREPINEPHRINE-DEXTROSE INTRAVENOUS SOLUTION 12.5-5 MG/250ML-%, 16-5 MG/250ML-%, 16-5 MG/500ML-%, 8-5 MG/500ML-%

GM

NOREPINEPHRINE-SODIUM CHLORIDE INTRAVENOUS SOLUTION 12.5-0.9 MG/250ML-%, 15-0.9 MG/250ML-%, 16-0.9 MG/100ML-%, 16-0.9 MG/250ML-%, 16-0.9 MG/500ML-%, 32-0.9 MG/250ML-%, 32-0.9 MG/500ML-%, 4-0.9 MG/500ML-%, 6-0.9 MG/50ML-%, 8-0.9 MG/500ML-%

GM

NOREPINEPHRINE-SODIUM CHLORIDE INTRAVENOUS SOLUTION PREFILLED SYRINGE 0.4-0.9 MG/50ML-%, 2-0.9 MG/50ML-%

GM

NORPACE CR ORAL CAPSULE EXTENDED RELEASE 12 HOUR 100 MG, 150 MG

3

NORPACE ORAL CAPSULE 100 MG, 150 MG

4

NORTHERA ORAL CAPSULE 100 MG, 200 MG, 300 MG

6 PA



103

Drug NameDrug Tier

Notes

NORVASC ORAL TABLET 10 MG, 2.5 MG, 5 MG

4

NYMALIZE ORAL SOLUTION 30 MG/10ML, 60 MG/20ML

4

olmesartan medoxomil oral tablet 20 mg, 40 mg, 5 mg

2

olmesartan medoxomil-hctz oral tablet 20-12.5 mg, 40-12.5 mg, 40-25 mg

2

olmesartan-amlodipine-hctz oral tablet 20-5-12.5 mg, 40-10-12.5 mg, 40-10-25 mg, 40-5-12.5 mg, 40-5-25 mg

2

omega-3-acid ethyl esters oral capsule 1 gm

2 PA

OSMITROL INTRAVENOUS SOLUTION 10 %, 5 %

GM

osmitrol intravenous solution 15 %, 20 %

GM

pacerone oral tablet 100 mg, 200 mg, 400 mg

2

pentoxifylline er oral tablet extended release 400 mg

2

perindopril erbumine oral tablet 2 mg, 4 mg, 8 mg

2

phenoxybenzamine hcl oral capsule 10 mg


days)

phentolamine mesylate injection solution reconstituted 5 mg

GM

Drug NameDrug Tier

Notes

PHENYLEPHRINE HCL (PRESSORS) INTRAVENOUS SOLUTION PREFILLED SYRINGE 0.5 MG/5ML, 1 MG/10ML

GM

phenylephrine hcl injection solution 10 mg/ml

GM

phenylephrine hcl intravenous solution 10 mg/ml

GM

PHENYLEPHRINE HCL INTRAVENOUS SOLUTION PREFILLED SYRINGE 0.4 MG/10ML, 0.8 MG/10ML, 1 MG/10ML

GM

PHENYLEPHRINE HCL-DEXTROSE INTRAVENOUS SOLUTION 10-5 MG/250ML-%, 100-5 MG/250ML-%, 20-5 MG/250ML-%, 20-5 MG/500ML-%, 200-5 MG/250ML-%, 25-5 MG/250ML-%, 30-5 MG/250ML-%, 40-5 MG/250ML-%, 40-5 MG/500ML-%, 50-5 MG/250ML-%, 8-5 MG/100ML-%

GM



104

Drug NameDrug Tier

Notes

PHENYLEPHRINE HCL-NACL INTRAVENOUS SOLUTION 10-0.9 MG/100ML-%, 10-0.9 MG/250ML-%, 100-0.9 MG/100ML-%, 100-0.9 MG/250ML-%, 100-0.9 MG/500ML-%, 160-0.9 MG/500ML-%, 20-0.9 MG/250ML-%, 20-0.9 MG/500ML-%, 200-0.9 MG/250ML-%, 25-0.9 MG/250ML-%, 250-0.9 MG/250ML-%, 30-0.9 MG/100ML-%, 30-0.9 MG/250ML-%, 40-0.9 MG/250ML-%, 40-0.9 MG/500ML-%, 50-0.9 MG/250ML-%, 50-0.9 MG/500ML-%, 60-0.9 MG/250ML-%, 80-0.9 MG/250ML-%, 80-0.9 MG/500ML-%

GM

PHENYLEPHRINE HCL-NACL INTRAVENOUS SOLUTION PREFILLED SYRINGE 0.5-0.9 MG/5ML-%, 1.6-0.9 MG/20ML-%

GM

pindolol oral tablet 10 mg, 5 mg

2

POLIDOCANOL INTRAVENOUS SOLUTION 5 %

GM

PRALUENT SUBCUTANEOUS SOLUTION AUTO-INJECTOR 75 MG/ML

6 PA

PRALUENT SUBCUTANEOUS SOLUTION PEN-INJECTOR 150 MG/ML, 75 MG/ML

6 PA

Drug NameDrug Tier

Notes

PRAVACHOL ORAL TABLET 20 MG, 40 MG, 80 MG

4

pravastatin sodium oral tablet 10 mg, 20 mg, 40 mg, 80 mg

2

prazosin hcl oral capsule 1 mg, 2 mg, 5 mg

2

PRESTALIA ORAL TABLET 14-10 MG, 3.5-2.5 MG, 7-5 MG

4

prevalite oral packet 4 gm

2

prevalite oral powder 4 gm/dose

2

PRINIVIL ORAL TABLET 10 MG, 20 MG, 5 MG

4

procainamide hcl injection solution 100 mg/ml, 500 mg/ml

GM

PROCARDIA ORAL CAPSULE 10 MG

4

PROCARDIA XL ORAL TABLET EXTENDED RELEASE 24 HOUR 30 MG, 60 MG, 90 MG

4

propafenone hcl er oral capsule extended release 12 hour 225 mg, 325 mg, 425 mg

2

propafenone hcl oral tablet 150 mg, 225 mg, 300 mg

2

propranolol hcl er oral capsule extended release 24 hour 120 mg, 160 mg, 60 mg, 80 mg

2

propranolol hcl intravenous solution 1 mg/ml

GM

propranolol hcl oral solution 20 mg/5ml, 40 mg/5ml

2



105

Drug NameDrug Tier

Notes

propranolol hcl oral tablet 10 mg, 20 mg, 40 mg, 60 mg, 80 mg

2

propranolol-hctz oral tablet 40-25 mg, 80-25 mg

2

PROSTIN VR INJECTION SOLUTION 500 MCG/ML

GM

QBRELIS ORAL SOLUTION 1 MG/ML

4

QUESTRAN LIGHT ORAL POWDER 4 GM/DOSE

4

QUESTRAN ORAL PACKET 4 GM

4

QUESTRAN ORAL POWDER 4 GM/DOSE

4

quinapril hcl oral tablet 10 mg, 20 mg, 40 mg, 5 mg

2

quinapril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg

2

quinidine gluconate er oral tablet extended release 324 mg

2

QUINIDINE GLUCONATE INJECTION SOLUTION 80 MG/ML

GM

quinidine sulfate oral tablet 200 mg, 300 mg

2

ramipril oral capsule 1.25 mg, 10 mg, 2.5 mg, 5 mg

2

RANEXA ORAL TABLET EXTENDED RELEASE 12 HOUR 1000 MG, 500 MG

4

ranolazine er oral tablet extended release 12 hour 1000 mg, 500 mg

2

Drug NameDrug Tier

Notes

RECTIV RECTAL OINTMENT 0.4 %

4

REPATHA PUSHTRONEX SYSTEM SUBCUTANEOUS SOLUTION CARTRIDGE 420 MG/3.5ML

6 PA

REPATHA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 140 MG/ML

6 PA

REPATHA SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 140 MG/ML

6 PA

rosuvastatin calcium oral tablet 10 mg, 20 mg, 40 mg, 5 mg

2

RYTHMOL SR ORAL CAPSULE EXTENDED RELEASE 12 HOUR 225 MG, 325 MG, 425 MG

4

simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg, 80 mg

1

SODIUM DIURIL INTRAVENOUS SOLUTION RECONSTITUTED 500 MG

GM

SODIUM EDECRIN INTRAVENOUS SOLUTION RECONSTITUTED 50 MG

GM

sorine oral tablet 120 mg, 160 mg, 240 mg, 80 mg

2

sotalol hcl (af) oral tablet 120 mg, 160 mg, 80 mg

2

SOTALOL HCL INTRAVENOUS SOLUTION 150 MG/10ML

GM



106

Drug NameDrug Tier

Notes

sotalol hcl oral tablet 120 mg, 160 mg, 240 mg, 80 mg

2

SOTRADECOL INTRAVENOUS SOLUTION 1 %, 3 %

GM

SOTYLIZE ORAL SOLUTION 5 MG/ML

4

spironolactone oral tablet 100 mg, 25 mg, 50 mg

2

spironolactone-hctz oral tablet 25-25 mg

2

SULAR ORAL TABLET EXTENDED RELEASE 24 HOUR 17 MG, 34 MG, 8.5 MG

4

TARKA ORAL TABLET EXTENDED RELEASE 2-180 MG, 2-240 MG, 4-240 MG

4

taztia xt oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 300 mg, 360 mg

2

TEKTURNA HCT ORAL TABLET 150-12.5 MG, 150-25 MG, 300-12.5 MG, 300-25 MG

3

TEKTURNA ORAL TABLET 150 MG, 300 MG

3

telmisartan oral tablet 20 mg, 40 mg, 80 mg

2

telmisartan-amlodipine oral tablet 40-10 mg, 40-5 mg, 80-10 mg, 80-5 mg

2

telmisartan-hctz oral tablet 40-12.5 mg, 80-12.5 mg, 80-25 mg

2

TENORETIC 100 ORAL TABLET 100-25 MG

4

TENORETIC 50 ORAL TABLET 50-25 MG

4

Drug NameDrug Tier

Notes

TENORMIN ORAL TABLET 100 MG, 25 MG, 50 MG

4

tiadylt er oral capsule extended release 24 hour 360 mg

2

TIAZAC ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG, 420 MG

4

TIKOSYN ORAL CAPSULE 125 MCG, 250 MCG, 500 MCG

4

timolol maleate oral tablet 10 mg, 20 mg, 5 mg

2

TOPROL XL ORAL TABLET EXTENDED RELEASE 24 HOUR 100 MG, 200 MG, 25 MG, 50 MG

4

torsemide oral tablet 10 mg, 100 mg, 20 mg, 5 mg

2

trandolapril oral tablet 1 mg, 2 mg, 4 mg

2

trandolapril-verapamil hcl er oral tablet extended release 1-240 mg, 2-180 mg, 2-240 mg, 4-240 mg

2

triamterene oral capsule 100 mg, 50 mg

2

triamterene-hctz oral capsule 37.5-25 mg

2

triamterene-hctz oral tablet 37.5-25 mg, 75-50 mg

2



107

Drug NameDrug Tier

Notes

TRIBENZOR ORAL TABLET 20-5-12.5 MG, 40-10-12.5 MG, 40-10-25 MG, 40-5-12.5 MG, 40-5-25 MG

3

TRICOR ORAL TABLET 145 MG, 48 MG

4

TRIGLIDE ORAL TABLET 160 MG

4

triklo oral capsule 1 gm 2 PA

TRILIPIX ORAL CAPSULE DELAYED RELEASE 135 MG, 45 MG

4

TWYNSTA ORAL TABLET 40-10 MG, 40-5 MG, 80-10 MG, 80-5 MG

4

valsartan oral tablet 160 mg, 320 mg, 40 mg, 80 mg

2

valsartan-hydrochlorothiazide oral tablet 160-12.5 mg, 160-25 mg, 320-12.5 mg, 320-25 mg, 80-12.5 mg

2

VARITHENA INTRAVENOUS FOAM 180 MG/18ML

GM

VASCEPA ORAL CAPSULE 0.5 GM, 1 GM

4 PA

VASERETIC ORAL TABLET 10-25 MG

4

VASOTEC ORAL TABLET 10 MG, 2.5 MG, 20 MG, 5 MG

4

VAZCULEP INTRAVENOUS SOLUTION 10 MG/ML

GM

VECAMYL ORAL TABLET 2.5 MG

4

Drug NameDrug Tier

Notes

verapamil hcl er oral capsule extended release 24 hour 100 mg, 120 mg, 180 mg, 200 mg, 240 mg, 300 mg, 360 mg

2

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

2

verapamil hcl intravenous solution 2.5 mg/ml

GM

verapamil hcl oral tablet 120 mg, 40 mg, 80 mg

2

VERELAN ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 360 MG

4

VERELAN PM ORAL CAPSULE EXTENDED RELEASE 24 HOUR 100 MG, 200 MG, 300 MG

4

VYNDAMAX ORAL CAPSULE 61 MG

6 PA

VYNDAQEL ORAL CAPSULE 20 MG

6 PA

VYTORIN ORAL TABLET 10-10 MG, 10-20 MG, 10-40 MG, 10-80 MG

4

WELCHOL ORAL PACKET 3.75 GM

4

WELCHOL ORAL TABLET 625 MG

4

ZESTORETIC ORAL TABLET 10-12.5 MG, 20-12.5 MG, 20-25 MG

4

ZESTRIL ORAL TABLET 10 MG, 2.5 MG, 20 MG, 30 MG, 40 MG, 5 MG

4

ZETIA ORAL TABLET 10 MG

4



108

Drug NameDrug Tier

Notes

ZIAC ORAL TABLET 10-6.25 MG, 2.5-6.25 MG, 5-6.25 MG

4

ZOCOR ORAL TABLET 10 MG, 20 MG, 40 MG, 5 MG, 80 MG

4

ZYPITAMAG ORAL TABLET 1 MG, 2 MG, 4 MG

4 PA

Central Nervous System Agents - Drugs for Attention Deficit Disorder

ADDERALL ORAL TABLET 10 MG, 12.5 MG, 15 MG, 20 MG, 30 MG, 5 MG, 7.5 MG

4QL (90 EA

per 30 days)

ADDERALL XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG, 15 MG, 5 MG

4QL (30 EA

per 30 days)

ADDERALL XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 20 MG, 25 MG, 30 MG

4QL (60 EA

per 30 days)

amphetamine-dextroamphetamine er oral capsule extended release 24 hour 10 mg, 15 mg, 5 mg

2QL (30 EA

per 30 days)

amphetamine-dextroamphetamine er oral capsule extended release 24 hour 20 mg, 25 mg, 30 mg

2QL (60 EA

per 30 days)

amphetamine-dextroamphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 30 mg, 5 mg, 7.5 mg

2QL (90 EA

per 30 days)

Drug NameDrug Tier

Notes

APTENSIO XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG

4

atomoxetine hcl oral capsule 10 mg, 18 mg, 25 mg

2QL (60 EA

per 30 days)

atomoxetine hcl oral capsule 100 mg, 40 mg, 60 mg, 80 mg

2QL (30 EA

per 30 days)

clonidine hcl er oral tablet extended release 12 hour 0.1 mg

2

CONCERTA ORAL TABLET EXTENDED RELEASE 18 MG, 27 MG, 54 MG

4QL (30 EA

per 30 days)

CONCERTA ORAL TABLET EXTENDED RELEASE 36 MG

4QL (60 EA

per 30 days)

DAYTRANA TRANSDERMAL PATCH 10 MG/9HR, 15 MG/9HR, 20 MG/9HR, 30 MG/9HR

4QL (30 EA

per 30 days)

DESOXYN ORAL TABLET 5 MG

4

DEXEDRINE ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG, 15 MG, 5 MG

4QL (150

EA per 30 days)

dexmethylphenidate hcl er oral capsule extended release 24 hour 10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 35 mg, 40 mg, 5 mg

2QL (30 EA

per 30 days)

dexmethylphenidate hcl oral tablet 10 mg, 2.5 mg, 5 mg

2QL (90 EA

per 30 days)



109

Drug NameDrug Tier

Notes

dextroamphetamine sulfate er oral capsule extended release 24 hour 10 mg, 15 mg, 5 mg

2QL (150

EA per 30 days)

dextroamphetamine sulfate oral solution 5 mg/5ml

2

dextroamphetamine sulfate oral tablet 10 mg, 5 mg

2QL (180

EA per 30 days)

DYANAVEL XR ORAL SUSPENSION EXTENDED RELEASE 2.5 MG/ML

4

PA; AL (Min 6

Years and Max 12 Years)

FOCALIN ORAL TABLET 10 MG, 2.5 MG, 5 MG

4QL (90 EA

per 30 days)

FOCALIN XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG, 15 MG, 20 MG, 25 MG, 30 MG, 35 MG, 40 MG, 5 MG

4QL (30 EA

per 30 days)

guanfacine hcl er oral tablet extended release 24 hour 1 mg, 2 mg, 3 mg, 4 mg

2

INTUNIV ORAL TABLET EXTENDED RELEASE 24 HOUR 1 MG, 2 MG, 3 MG, 4 MG

4

KAPVAY ORAL TABLET EXTENDED RELEASE 12 HOUR 0.1 MG

4

metadate er oral tablet extended release 20 mg

2QL (90 EA

per 30 days)

methamphetamine hcl oral tablet 5 mg

2

METHYLIN ORAL SOLUTION 10 MG/5ML, 5 MG/5ML

4QL (900

ML per 30 days)

Drug NameDrug Tier

Notes

methylphenidate hcl er (cd) oral capsule extended release 10 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg

2QL (30 EA

per 30 days)

methylphenidate hcl er (la) oral capsule extended release 24 hour 10 mg, 20 mg, 30 mg, 40 mg, 60 mg

2QL (30 EA

per 30 days)

methylphenidate hcl er oral tablet extended release 10 mg

2

methylphenidate hcl er oral tablet extended release 18 mg, 27 mg, 54 mg

2QL (30 EA

per 30 days)


2QL (90 EA

per 30 days)

methylphenidate hcl er oral tablet extended release 24 hour 18 mg, 27 mg, 36 mg, 54 mg

2


2QL (60 EA

per 30 days)


1QL (1 EA per 1 day)

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

2QL (900

ML per 30 days)

methylphenidate hcl oral tablet 10 mg

2QL (180

EA per 30 days)


2


2QL (90 EA

per 30 days)

methylphenidate hcl oral tablet chewable 10 mg

2



110

Drug NameDrug Tier

Notes

methylphenidate hcl oral tablet chewable 2.5 mg, 5 mg

2QL (90 EA

per 30 days)

PROCENTRA ORAL SOLUTION 5 MG/5ML

4

QUILLICHEW ER ORAL TABLET CHEWABLE EXTENDED RELEASE 20 MG, 30 MG, 40 MG

4

PA; AL (Min 6


QUILLIVANT XR ORAL SUSPENSION RECONSTITUTED 25 MG/5ML

4

PA; QL (180 ML per 30

days); AL (Min 6


relexxii oral tablet extended release 72 mg


RITALIN LA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG, 20 MG, 30 MG, 40 MG

4QL (30 EA

per 30 days)

RITALIN ORAL TABLET 10 MG

4QL (180

EA per 30 days)


4


4QL (90 EA

per 30 days)

STRATTERA ORAL CAPSULE 10 MG, 18 MG, 25 MG

4QL (60 EA

per 30 days)

STRATTERA ORAL CAPSULE 100 MG, 40 MG, 60 MG, 80 MG

4QL (30 EA

per 30 days)

VYVANSE ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG, 70 MG

4QL (30 EA

per 30 days)

Drug NameDrug Tier

Notes

VYVANSE ORAL TABLET CHEWABLE 10 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG

4

PA; QL (30 EA per 30 days); AL

(Min 6 Years and

Max 12 Years)

zenzedi oral tablet 10 mg, 5 mg


ZENZEDI ORAL TABLET 15 MG, 2.5 MG, 20 MG, 30 MG, 7.5 MG

4QL (60 EA

per 30 days)

Central Nervous System Agents - Drugs for Multiple Sclerosis

AMPYRA ORAL TABLET EXTENDED RELEASE 12 HOUR 10 MG

6 PA

AUBAGIO ORAL TABLET 14 MG, 7 MG

5

AVONEX PEN INTRAMUSCULAR AUTO-INJECTOR KIT 30 MCG/0.5ML

6 PA

AVONEX PREFILLED INTRAMUSCULAR PREFILLED SYRINGE KIT 30 MCG/0.5ML

6 PA

AVONEX VIAL INTRAMUSCULAR KIT INTRAMUSCULAR KIT 30 MCG

5

BETASERON SUBCUTANEOUS KIT 0.3 MG

5

COPAXONE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 20 MG/ML, 40 MG/ML

5

dalfampridine er oral tablet extended release 12 hour 10 mg

6 PA



111

Drug NameDrug Tier

Notes

EXTAVIA SUBCUTANEOUS KIT 0.3 MG

6

GILENYA ORAL CAPSULE 0.25 MG, 0.5 MG

6

glatiramer acetate subcutaneous solution prefilled syringe 20 mg/ml, 40 mg/ml

5

glatopa subcutaneous solution prefilled syringe 20 mg/ml, 40 mg/ml

5

LEMTRADA INTRAVENOUS SOLUTION 12 MG/1.2ML

6PA;

Specialty Medical

MAVENCLAD (10 TABS) ORAL TABLET THERAPY PACK 10 MG

6 PA


6 PA


6 PA


6 PA


6 PA


6 PA


6 PA

MAYZENT ORAL TABLET 0.25 MG, 2 MG

6

Drug NameDrug Tier

Notes

MAYZENT STARTER PACK ORAL TABLET THERAPY PACK 0.25 MG

6

OCREVUS INTRAVENOUS SOLUTION 300 MG/10ML

6PA;

Specialty Medical

PLEGRIDY STARTER PACK SUBCUTANEOUS SOLUTION PEN-INJECTOR 63 & 94 MCG/0.5ML

5

PLEGRIDY SUBCUTANEOUS SOLUTION PEN-INJECTOR 125 MCG/0.5ML

5

REBIF REBIDOSE SUBCUTANEOUS SOLUTION AUTO-INJECTOR 22 MCG/0.5ML, 44 MCG/0.5ML

5

REBIF REBIDOSE TITRATION PACK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 6X8.8 & 6X22 MCG

5

REBIF SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 22 MCG/0.5ML, 44 MCG/0.5ML

5

REBIF TITRATION PACK SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 6X8.8 & 6X22 MCG

5

TECFIDERA ORAL 120 & 240 MG

5



112

Drug NameDrug Tier

Notes

TECFIDERA ORAL CAPSULE DELAYED RELEASE 120 MG, 240 MG

5

TYSABRI INTRAVENOUS CONCENTRATE 300 MG/15ML

6PA;

Specialty Medical

VUMERITY (STARTER) ORAL CAPSULE DELAYED RELEASE 231 MG

4

VUMERITY ORAL CAPSULE DELAYED RELEASE 231 MG

4

ZINBRYTA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 150 MG/ML

6PA;

Specialty Medical

Central Nervous System Agents - Miscellaneous

ANECTINE INJECTION SOLUTION 20 MG/ML

GM

atracurium besylate intravenous solution 100 mg/10ml, 50 mg/5ml

GM

AUSTEDO ORAL TABLET 12 MG, 6 MG, 9 MG

6 PA

CAFCIT INTRAVENOUS SOLUTION 60 MG/3ML

GM

caffeine citrate intravenous solution 60 mg/3ml

GM

caffeine citrate oral solution 20 mg/ml, 60 mg/3ml

2

cisatracurium besylate (pf) intravenous solution 10 mg/5ml, 200 mg/20ml

GM

Drug NameDrug Tier

Notes

cisatracurium besylate intravenous solution 20 mg/10ml

GM

CISATRACURIUM BESYLATE INTRAVENOUS SOLUTION PREFILLED SYRINGE 10 MG/5ML

GM

DOPRAM INTRAVENOUS SOLUTION 20 MG/ML

GM

GRALISE ORAL TABLET 300 MG, 600 MG

4 ST

GRALISE STARTER ORAL 300 & 600 MG

4 ST

HORIZANT ORAL TABLET EXTENDED RELEASE 300 MG, 600 MG

4 ST

INGREZZA ORAL CAPSULE 40 MG, 80 MG

6 PA

INGREZZA ORAL CAPSULE THERAPY PACK 40 & 80 MG

6 PA

LYRICA CR ORAL TABLET EXTENDED RELEASE 24 HOUR 165 MG, 330 MG, 82.5 MG

4

LYRICA ORAL CAPSULE 100 MG, 150 MG, 200 MG, 225 MG, 25 MG, 300 MG, 50 MG, 75 MG

4

LYRICA ORAL SOLUTION 20 MG/ML

4

NIMBEX INTRAVENOUS SOLUTION 10 MG/5ML, 20 MG/10ML, 200 MG/20ML

GM



113

Drug NameDrug Tier

Notes

ONPATTRO INTRAVENOUS SOLUTION 10 MG/5ML

6PA;

Specialty Medical

pancuronium bromide intravenous solution 1 mg/ml

GM

pregabalin oral capsule 100 mg, 150 mg, 200 mg, 225 mg, 25 mg, 300 mg, 50 mg, 75 mg

2

pregabalin oral solution 20 mg/ml

2

QUELICIN INJECTION SOLUTION 20 MG/ML

GM

RADICAVA INTRAVENOUS SOLUTION 30 MG/100ML

6Specialty Medical

RILUTEK ORAL TABLET 50 MG

6

riluzole oral tablet 50 mg 6

rocuronium bromide intravenous solution 100 mg/10ml, 50 mg/5ml

GM

ROCURONIUM BROMIDE INTRAVENOUS SOLUTION PREFILLED SYRINGE 100 MG/10ML, 20 MG/2ML, 75 MG/7.5ML

GM

SAVELLA ORAL TABLET 100 MG, 12.5 MG, 25 MG, 50 MG

4 PA

SAVELLA TITRATION PACK ORAL 12.5 & 25 & 50 MG

4 PA

succinylcholine chloride injection solution 20 mg/ml

GM

Drug NameDrug Tier

Notes

SUCCINYLCHOLINE CHLORIDE INJECTION SOLUTION PREFILLED SYRINGE 100 MG/5ML, 140 MG/7ML, 200 MG/10ML

GM

TEGSEDI SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 284 MG/1.5ML

6 PA

tetrabenazine oral tablet 12.5 mg, 25 mg

5 PA

TIGLUTIK ORAL SUSPENSION 50 MG/10ML

6

vecuronium bromide intravenous solution reconstituted 10 mg, 20 mg

GM

XENAZINE ORAL TABLET 12.5 MG, 25 MG

6 PA

Dental and Oral Agents - Drugs for Mouth and Throat Conditions

ARESTIN DENTAL 1 MG GM

BOCASAL MOUTH/THROAT PACKET

4

cavarest dental gel 1.1 % 2

cevimeline hcl oral capsule 30 mg

2

chlorhexidine gluconate mouth/throat solution 0.12 %

2

clinpro 5000 dental paste 1.1 %

2

DEBACTEROL MOUTH/THROAT SOLUTION 30-50 %

4

denta 5000 plus dental cream 1.1 %

2



114

Drug NameDrug Tier

Notes

dentagel dental gel 1.1 % 2

easygel dental gel 0.4 % 2

EVOXAC ORAL CAPSULE 30 MG

4

FIRST-MOUTHWASH BLM MOUTH/THROAT SUSPENSION

4

fluoridex daily renewal mouth/throat concentrate 0.63 %

2

fluoridex dental paste 1.1 %

2

fluoridex enhanced whitening dental paste 1.1 %

2

fluoridex sensitivity relief dental paste 1.1-5 %

2

KEPIVANCE INTRAVENOUS SOLUTION RECONSTITUTED 6.25 MG

6PA;

Specialty Medical

lidocaine viscous mouth/throat solution 2 %

2

MI PASTE DENTAL PASTE

4

MI PASTE PLUS DENTAL PASTE

4

MUCOSITISRX MOUTH/THROAT PACKET

4

NAFRINSE DAILY ACIDULATED MOUTH/THROAT SOLUTION RECONSTITUTED 1 MG/5ML

4

NAFRINSE DAILY/NEUTRAL MOUTH/THROAT SOLUTION RECONSTITUTED 0.05 %

4

Drug NameDrug Tier

Notes

NAFRINSE WEEKLY MOUTH/THROAT SOLUTION RECONSTITUTED 0.2 %

4

neutragard advanced dental gel 1.1 %

2

neutral sodium fluoride mouth/throat solution 0.2 %

2

NEUTRASAL MOUTH/THROAT PACKET

4

NUMOISYN MOUTH/THROAT LOZENGE

4

oralone mouth/throat paste 0.1 %

2

paroex mouth/throat solution 0.12 %

2

PERIDEX MOUTH/THROAT SOLUTION 0.12 %

4

periogard mouth/throat solution 0.12 %

2

pilocarpine hcl oral tablet 5 mg, 7.5 mg

2

PREVIDENT 5000 BOOSTER PLUS DENTAL PASTE 1.1 %

4

PREVIDENT 5000 DRY MOUTH DENTAL GEL 1.1 %

4

PREVIDENT 5000 ENAMEL PROTECT DENTAL PASTE 1.1-5 %

4

PREVIDENT 5000 ORTHO DEFENSE DENTAL PASTE 1.1 %

4

PREVIDENT 5000 PLUS DENTAL CREAM 1.1 %

4



115

Drug NameDrug Tier

Notes

PREVIDENT 5000 SENSITIVE DENTAL PASTE 1.1-5 %

4

PREVIDENT DENTAL GEL 1.1 %

4

prevident mouth/throat solution 0.2 %

2

REMESENSE DENTAL 3 %

4

SALAGEN ORAL TABLET 5 MG, 7.5 MG

4

SALIVAMAX MOUTH/THROAT PACKET

4

SALIVATE RX MOUTH/THROAT PACKET

4

sf 5000 plus dental cream 1.1 %

2

sf dental gel 1.1 % 2

sodium fluoride 5000 plus dental cream 1.1 %

2

sodium fluoride dental gel 1.1 %

2

sodium fluoride dental paste 1.1 %

2

topex topical anesthetic mouth/throat aerosol 20 %

2

triamcinolone acetonide mouth/throat paste 0.1 %

2

XEROSTOMIA RELIEF SPRAY MOUTH/THROAT SOLUTION

4

Dermatological Agents - Drugs for Skin Conditions

ABSORICA ORAL CAPSULE 10 MG, 20 MG, 25 MG, 30 MG, 35 MG, 40 MG

4 PA

Drug NameDrug Tier

Notes

acitretin oral capsule 10 mg, 17.5 mg, 25 mg

2

ACZONE EXTERNAL GEL 5 %

4

ACZONE EXTERNAL GEL 7.5 %

4 PA

adapalene external cream 0.1 %

2

adapalene external gel 0.1 %, 0.3 %

2

ala-cort external cream 1 %, 2.5 %

2

alclometasone dipropionate external cream 0.05 %

2

alclometasone dipropionate external ointment 0.05 %

2

ALCOHOL PREP PADS EXTERNAL 70 %

4

amcinonide external cream 0.1 %

2

amcinonide external lotion 0.1 %

2

amcinonide external ointment 0.1 %

2

ammonium lactate external cream 12 %

2

ammonium lactate external lotion 12 %

2

amnesteem oral capsule 10 mg, 20 mg, 40 mg


ANACAINE EXTERNAL OINTMENT 10 %

4

AQUACEL AG BURN EXTERNAL PAD 4"X5"

4

arzol silver nit applicators external 75-25 %

2

ATRAPRO DERMAL SPRAY EXTERNAL LIQUID

4



116

Drug NameDrug Tier

Notes

avar cleanser external emulsion 10-5 %

2

avar-e emollient external cream 10-5 %

2

avar-e green external cream 10-5 %

2

avita external cream 0.025 %

2

avita external gel 0.025 %

2

azelaic acid external gel 15 %

2 PA

AZELEX EXTERNAL CREAM 20 %

4 PA

balsam peru-castor oil external ointment

2

BENSAL HP EXTERNAL OINTMENT 3-6 %

4

benzoin compound external tincture

2

benzoin external tincture 2

beser external lotion 0.05 %

2

betamethasone dipropionate aug external cream 0.05 %

2

betamethasone dipropionate aug external gel 0.05 %

2

betamethasone dipropionate aug external lotion 0.05 %

2

betamethasone dipropionate aug external ointment 0.05 %

2

betamethasone dipropionate external cream 0.05 %

2

betamethasone dipropionate external lotion 0.05 %

2

Drug NameDrug Tier

Notes

betamethasone dipropionate external ointment 0.05 %

2

betamethasone valerate external cream 0.1 %

2

betamethasone valerate external lotion 0.1 %

2

betamethasone valerate external ointment 0.1 %

2

bp 10-1 external emulsion 10-1 %

2

BP CLEANSING WASH EXTERNAL EMULSION 10-4 %

4

BPCO EXTERNAL OINTMENT

4

calcipotriene external cream 0.005 %

2

calcipotriene external ointment 0.005 %

2

calcipotriene external solution 0.005 %

2

calcipotriene-betameth diprop external ointment 0.005-0.064 %

2 ST

calcitrene external ointment 0.005 %

2

calcitriol external ointment 3 mcg/gm

2 ST

cem-urea external solution 45 %

2

cerisa wash external emulsion 10-1 %

2

cerovel external lotion 40 %

2

claravis oral capsule 10 mg, 20 mg, 30 mg, 40 mg


CLINDACIN ETZ EXTERNAL KIT 1 %

4



117

Drug NameDrug Tier

Notes

clindacin etz external swab 1 %

2

CLINDACIN PAC EXTERNAL KIT 1 %

4

clindacin-p external swab 1 %

2

clindamycin phosphate external foam 1 %

2

clindamycin phosphate external gel 1 %

2

clindamycin phosphate external lotion 1 %

2

clindamycin phosphate external solution 1 %

2

clindamycin phosphate external swab 1 %

2

CLINOIN EXTERNAL CREAM 1.25-0.025-1 %

4

clobetasol prop emollient base external cream 0.05 %

2

clobetasol propionate e external cream 0.05 %

2

clobetasol propionate emulsion external foam 0.05 %

2

clobetasol propionate external cream 0.05 %

2

clobetasol propionate external foam 0.05 %

2

clobetasol propionate external gel 0.05 %

2

clobetasol propionate external lotion 0.05 %

2

clobetasol propionate external ointment 0.05 %

2

clobetasol propionate external shampoo 0.05 %

2

clobetasol propionate external solution 0.05 %

2

Drug NameDrug Tier

Notes

clocortolone pivalate external cream 0.1 %

2

clocortolone pivalate pump external cream 0.1 %

2

clodan external shampoo 0.05 %

2

CLODERM EXTERNAL CREAM 0.1 %

4

CLODERM PUMP EXTERNAL CREAM 0.1 %

4

clotrimazole-betamethasone external cream 1-0.05 %

2

clotrimazole-betamethasone external lotion 1-0.05 %

2

coal tar external solution 20 %

2

CONDYLOX EXTERNAL GEL 0.5 %

3

CORDRAN EXTERNAL CREAM 0.025 %, 0.05 %

4

CORDRAN EXTERNAL LOTION 0.05 %

4

CORDRAN EXTERNAL TAPE 4 MCG/SQCM

4

cormax scalp application external solution 0.05 %

2

CORTISPORIN EXTERNAL CREAM 3.5-10000-0.5

4

CORTISPORIN EXTERNAL OINTMENT 1 %

4

dapsone external gel 5 % 2

DERMULCERA EXTERNAL OINTMENT

4

desonide external cream 0.05 %

2



118

Drug NameDrug Tier

Notes

desonide external lotion 0.05 %

2

desonide external ointment 0.05 %

2

desoximetasone external cream 0.05 %, 0.25 %

2

desoximetasone external gel 0.05 %

2

desoximetasone external liquid 0.25 %

2 ST

desoximetasone external ointment 0.05 %, 0.25 %

2

diclofenac sodium transdermal gel 3 %

2 PA

diflorasone diacetate external cream 0.05 %

2

diflorasone diacetate external ointment 0.05 %

2

doxepin hcl external cream 5 %

2

DRITHO-CREME HP EXTERNAL CREAM 1 %

3

DRYSOL EXTERNAL SOLUTION 20 %

3

DUPIXENT SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 200 MG/1.14ML, 300 MG/2ML

6 PA

ELIDEL EXTERNAL CREAM 1 %

4

EPIFOAM EXTERNAL FOAM 1-1 %

4

ery external pad 2 % 2

erythromycin external gel 2 %

2

erythromycin external pad 2 %

2

erythromycin external solution 2 %

2

Drug NameDrug Tier

Notes

EUCRISA EXTERNAL OINTMENT 2 %

4 PA

FASENRA PEN SUBCUTANEOUS SOLUTION AUTO-INJECTOR 30 MG/ML

6 PA

FINACEA EXTERNAL FOAM 15 %

4 PA

FINACEA EXTERNAL GEL 15 %

4 PA

fluocinolone acetonide body external oil 0.01 %

2

fluocinolone acetonide external cream 0.01 %, 0.025 %

2

fluocinolone acetonide external ointment 0.025 %

2

fluocinolone acetonide external solution 0.01 %

2

fluocinolone acetonide scalp external oil 0.01 %

2

fluocinonide emulsified base external cream 0.05 %

2

fluocinonide external cream 0.05 %

2

fluocinonide external gel 0.05 %

2

fluocinonide external ointment 0.05 %

2

fluocinonide external solution 0.05 %

2

fluorouracil external cream 5 %

2

fluorouracil external solution 2 %, 5 %

2

flurandrenolide external cream 0.05 %

2

flurandrenolide external lotion 0.05 %

2



119

Drug NameDrug Tier

Notes

flurandrenolide external ointment 0.05 %

2

fluticasone propionate external cream 0.05 %

2

fluticasone propionate external lotion 0.05 %

2

fluticasone propionate external ointment 0.005 %

2

glycolic acid solution 70 %

2

GORDOFILM EXTERNAL SOLUTION 16.7-16.7 %

4

grafco silver nit applicator external 75-25 %

2

halcinonide external cream 0.1 %

2

halobetasol propionate external cream 0.05 %

2

halobetasol propionate external ointment 0.05 %

2

HALOG EXTERNAL CREAM 0.1 %

4

HALOG EXTERNAL OINTMENT 0.1 %

4

HYDRO 35 EXTERNAL FOAM 35 %

4

hydrocortisone butyr lipo base external cream 0.1 %

2

hydrocortisone butyrate external cream 0.1 %

2

hydrocortisone butyrate external lotion 0.1 %

2

hydrocortisone butyrate external ointment 0.1 %

2

hydrocortisone butyrate external solution 0.1 %

2

hydrocortisone external cream 1 %, 2.5 %

2

Drug NameDrug Tier

Notes

hydrocortisone external lotion 2.5 %

2

hydrocortisone external ointment 1 %, 2.5 %

2

hydrocortisone in absorbase external ointment 1 %

2

hydrocortisone valerate external cream 0.2 %

2

hydrocortisone valerate external ointment 0.2 %

2

imiquimod external cream 5 %

2

INOVA 4/1 ACNE CONTROL THERAPY EXTERNAL KIT 4 & 1 & 5 %

4

INOVA 8/2 ACNE CONTROL THERAPY EXTERNAL KIT 8 & 2 & 5 %

4

isotretinoin oral capsule 10 mg, 20 mg, 30 mg, 40 mg


ivermectin external cream 1 %

2 PA

KERALYT EXTERNAL GEL 6 %

4

KERALYT SCALP EXTERNAL KIT 6 %

4

KERAMATRIX REPLICINE 5CMX5CM EXTERNAL SHEET

4

LAC-HYDRIN EXTERNAL CREAM 12 %

4

LAC-HYDRIN EXTERNAL LOTION 12 %

4

lactic acid e external cream 10-3500 %-unt/30gm

2



120

Drug NameDrug Tier

Notes

lactic acid external lotion 10 %

2

latrix external suspension 50 %

2

LATRIX XM EXTERNAL EMULSION 45 %

4

LEVULAN KERASTICK EXTERNAL SOLUTION RECONSTITUTED 20 %

GM

LOTRISONE EXTERNAL CREAM 1-0.05 %

4

LOYON EXTERNAL SOLUTION

4

methoxsalen oral capsule 10 mg

2

methoxsalen rapid oral capsule 10 mg

2

methyl salicylate external liquid

2

metopic external cream 41 %

2

metronidazole external cream 0.75 %

2

metronidazole external gel 0.75 %, 1 %

2

metronidazole external lotion 0.75 %

2

MICROCYN EXTERNAL LIQUID 0.023 %

4

MIRVASO EXTERNAL GEL 0.33 %

4 PA

mometasone furoate external cream 0.1 %

2

mometasone furoate external ointment 0.1 %

2

mometasone furoate external solution 0.1 %

2

myorisan oral capsule 10 mg, 20 mg, 30 mg, 40 mg


Drug NameDrug Tier

Notes

NEO-SYNALAR EXTERNAL CREAM 0.5-0.025 %

4

nolix external cream 0.05 %

2

nolix external lotion 0.05 %

2

NUVAIL EXTERNAL SOLUTION

4

OVACE PLUS EXTERNAL CREAM 10 %

4

OVACE PLUS EXTERNAL SHAMPOO 10 %

4

OVACE PLUS WASH EXTERNAL LIQUID 10 %

4

OVACE WASH EXTERNAL LIQUID 10 %

4

OXSORALEN ULTRA ORAL CAPSULE 10 MG

3

PICATO EXTERNAL GEL 0.015 %, 0.05 %

4 PA

pimecrolimus external cream 1 %

2

podocon external solution 25 %

2

podofilox external solution 0.5 %

2

pramox external gel 1 % 2

PRE & POST SX POUCH EXTERNAL THERAPY PACK 4 & 2 & 5 %

4

prednicarbate external cream 0.1 %

2

prednicarbate external ointment 0.1 %

2

PRUDOXIN EXTERNAL CREAM 5 %

4



121

Drug NameDrug Tier

Notes

PSORCON EXTERNAL CREAM 0.05 %

4

PURAPLY EXTERNAL SHEET 6X9CM

GM

pyrogallic acid external ointment 25-2 %

2

QBREXZA EXTERNAL PAD 2.4 %

4 PA

QUTENZA (2 PATCH) EXTERNAL KIT 8 %

6Specialty Medical

QUTENZA EXTERNAL KIT 8 %

6Specialty Medical

rea lo 39 external cream 39 %

2

rea lo 40 external cream 40 %

2

rea lo 40 external lotion 40 %

2

REGRANEX EXTERNAL GEL 0.01 %

4 PA

remeven external cream 50 %

2

RESORCINOL-SULFUR EXTERNAL LOTION 2-5 %

4

RETIN-A MICRO EXTERNAL GEL 0.1 %

4

RETIN-A MICRO PUMP EXTERNAL GEL 0.1 %

4

RHOFADE EXTERNAL CREAM 1 %

4 PA

rosadan external cream 0.75 %

2

rosadan external gel 0.75 %

2

ROSADAN EXTERNAL KIT 0.75 % (CREAM)

4

ROSADAN EXTERNAL KIT 0.75 % (GEL)

4 PA

rosanil cleanser external emulsion 10-5 %

2

Drug NameDrug Tier

Notes

salacyn external cream 6 %

2

salacyn external lotion 6 %

2

SALEX EXTERNAL KIT 6 % (CREAM), 6 % (LOTION)

4

SALEX EXTERNAL SHAMPOO 6 %

4

salicylic acid external cream 6 %

2

salicylic acid external foam 6 %

2

salicylic acid external gel 6 %

2

salicylic acid external liquid 26 %, 27.5 %

2

salicylic acid external lotion 6 %

2

salicylic acid external shampoo 6 %

2

salicylic acid external solution 26 %

2

salicylic acid wart remover external liquid 27.5 %

2

salicylic acid-cleanser external kit 6 % (cream), 6 % (lotion)

2

salimez external cream 6 %

2

SALIMEZ FORTE EXTERNAL CREAM 10 %

4

salisol forte external solution 26 %

2

salitech forte external lotion 6 %

2

SALVAX DUO PLUS EXTERNAL KIT 6 & 35 %

4



122

Drug NameDrug Tier

Notes

SALVAX EXTERNAL FOAM 6 %

4

SANTYL EXTERNAL OINTMENT 250 UNIT/GM

6

SCALACORT DK EXTERNAL KIT 2 & 2-2 %

4

SCULPTRA INJECTION SUSPENSION RECONSTITUTED 367.5 MG

GM

seb-prev wash external liquid 10 %

2

selenium sulfide external lotion 2.5 %

2

selenium sulfide external shampoo 2.25 %, 2.3 %

2

SELRX EXTERNAL SHAMPOO 2.3 %

4

SILA III EXTERNAL THERAPY PACK 0.1 %

4

sodium sulfacetamide external shampoo 10 %

2

sodium sulfacetamide wash liquid 10 % external 10 %

2

SODIUM SULFACETAMIDE WASH LIQUID 10 % EXTERNAL 10 %

4

SOOLANTRA EXTERNAL CREAM 1 %

4 PA

SORIATANE ORAL CAPSULE 10 MG, 17.5 MG, 25 MG

3

sss 10-5 external cream 10-5 %

2

sulfacetamide sodium (acne) external lotion 10 %

2

Drug NameDrug Tier

Notes

sulfacetamide sodium external liquid 10 %

2

sulfacetamide sodium-sulfur external cream 10-2 %, 10-5 %, 9.8-4.8 %

2

sulfacetamide sodium-sulfur external emulsion 10-5 %

2

sulfacetamide sodium-sulfur external liquid 10-2 %, 9-4 %, 9-4.5 %, 9.8-4.8 %

2

sulfacetamide sodium-sulfur external lotion 10-5 %, 9.8-4.8 %

2

sulfacetamide sodium-sulfur external pad 10-4 %

2

sulfacetamide sodium-sulfur external suspension 10-5 %, 8-4 %

2

sulfacetamide sod-sulfur wash external kit 9-4.5 %

2

sulfacetamide-sulfur in urea external emulsion 10-5 %

2

sulfacleanse 8/4 external suspension 8-4 %

2

sulfamez wash external emulsion 10-1 %

2

SUMADAN EXTERNAL KIT 9-4.5 %

4

SUMAXIN CP EXTERNAL KIT 10-4 %

4

tacrolimus external ointment 0.03 %, 0.1 %

2

tazarotene external cream 0.1 %

2 PA

TAZORAC EXTERNAL CREAM 0.05 %, 0.1 %

4 PA



123

Drug NameDrug Tier

Notes

TAZORAC EXTERNAL GEL 0.05 %, 0.1 %

4 PA

THERAHONEY EXTERNAL SHEET

4

tovet external foam 0.05 %

2

tretinoin external cream 0.025 %, 0.05 %, 0.1 %

2

tretinoin external gel 0.01 %, 0.025 %

2

tretinoin microsphere external gel 0.04 %, 0.1 %

2

tretinoin microsphere pump external gel 0.04 %, 0.1 %

2

triamcinolone acetonide external aerosol solution 0.147 mg/gm

2

triamcinolone acetonide external cream 0.025 %, 0.1 %, 0.5 %

2

triamcinolone acetonide external lotion 0.025 %, 0.1 %

2

triamcinolone acetonide external ointment 0.025 %, 0.1 %, 0.5 %

2

TRI-CHLOR EXTERNAL LIQUID 80 %

4

triderm external cream 0.1 %, 0.5 %

2

turpentine external spirit 2

umecta mousse external foam 40 %

2

URAMAXIN EXTERNAL FOAM 20 %

4

urea external cream 39 %, 40 %, 41 %, 45 %, 50 %

2

urea external lotion 40 %, 45 %

2

Drug NameDrug Tier

Notes

urea external suspension 40 %

2

urea hydrating external foam 35 %

2

urea in zn undecyl-lactic acid external emulsion 50 %

2

urea nail external gel 45 %

2

UREA NAIL EXTERNAL KIT 40 & 0.2 %

4

UREA NAIL EXTERNAL STICK 50 %

4

urea-c40 external lotion 40 %

2

uredeb external cream 39 %

2

ure-k external cream 50 %

2

uremez-40 external cream 40 %

2

VECTICAL EXTERNAL OINTMENT 3 MCG/GM

4 ST

VENELEX EXTERNAL OINTMENT

4

VEREGEN EXTERNAL OINTMENT 15 %

4

VIRASAL EXTERNAL LIQUID 27.5 %

4

XERAC AC EXTERNAL SOLUTION 6.25 %

4

XERFORM OIL EMULSION ROLL EXTERNAL

4

XEROFORM OIL EMULSION 2"X2" EXTERNAL PAD

4

XEROFORM OIL EMULSION GAUZE EXTERNAL PAD

4



124

Drug NameDrug Tier

Notes

XEROFORM OIL EMULSION STRIP EXTERNAL

4

XEROFORM PETROLAT GAUZE 1"X8" EXTERNAL

4

XEROFORM PETROLAT GAUZE 5"X9" EXTERNAL

4

XEROFORM PETROLAT PATCH 2"X2" EXTERNAL PAD

4

XEROFORM PETROLAT PATCH 4"X4" EXTERNAL PAD

4

XEROFORM PETROLATUM ROLL 4"X9' EXTERNAL

4

xurea external cream 39 %

2

zenatane oral capsule 10 mg, 20 mg, 30 mg, 40 mg


zencia external liquid 9-4 %

2

ZITHRANOL EXTERNAL SHAMPOO 1 %

4

ZONALON EXTERNAL CREAM 5 %

4

Diabetes - Antidiabetic Agents

acarbose oral tablet 100 mg, 25 mg, 50 mg

2

ACTOPLUS MET ORAL TABLET 15-500 MG, 15-850 MG

4

ACTOPLUS MET XR ORAL TABLET EXTENDED RELEASE 24 HOUR 15-1000 MG, 30-1000 MG

4

Drug NameDrug Tier

Notes

ACTOS ORAL TABLET 15 MG, 30 MG, 45 MG

4

ADLYXIN STARTER PACK SUBCUTANEOUS PEN-INJECTOR KIT 10 & 20 MCG/0.2ML

4 PA

ADLYXIN SUBCUTANEOUS SOLUTION PEN-INJECTOR 20 MCG/0.2ML

4 PA

ALOGLIPTIN BENZOATE ORAL TABLET 12.5 MG, 25 MG, 6.25 MG


days)

ALOGLIPTIN-METFORMIN HCL ORAL TABLET 12.5-1000 MG, 12.5-500 MG


days)

ALOGLIPTIN-PIOGLITAZONE ORAL TABLET 12.5-15 MG, 12.5-30 MG, 12.5-45 MG, 25-15 MG, 25-30 MG, 25-45 MG


days)

AMARYL ORAL TABLET 1 MG, 2 MG, 4 MG

4

AVANDIA ORAL TABLET 2 MG, 4 MG

4 ST

BYDUREON BCISE AUTOINJECTOR SUBCUTANEOUS AUTO-INJECTOR 2 MG/0.85ML

3PA; QL


BYDUREON SUBCUTANEOUS PEN-INJECTOR 2 MG


days)

BYDUREON SUBCUTANEOUS SUSPENSION RECONSTITUTED ER 2 MG


days)



125

Drug NameDrug Tier

Notes

BYETTA 10 MCG PEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 10 MCG/0.04ML

3PA; QL


BYETTA 5 MCG PEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 5 MCG/0.02ML

3PA; QL


chlorpropamide oral tablet 100 mg, 250 mg

2

CYCLOSET ORAL TABLET 0.8 MG

4

DUETACT ORAL TABLET 30-2 MG, 30-4 MG

3

FARXIGA ORAL TABLET 10 MG, 5 MG


days)

glimepiride oral tablet 1 mg, 2 mg, 4 mg

1

glipizide er oral tablet extended release 24 hour 10 mg, 2.5 mg, 5 mg

2

glipizide oral tablet 10 mg, 5 mg

1

glipizide xl oral tablet extended release 24 hour 10 mg, 2.5 mg, 5 mg

2

glipizide-metformin hcl oral tablet 2.5-250 mg, 2.5-500 mg, 5-500 mg

2

GLUCOPHAGE ORAL TABLET 1000 MG, 500 MG, 850 MG

4

GLUCOPHAGE XR ORAL TABLET EXTENDED RELEASE 24 HOUR 500 MG, 750 MG

4

GLUCOTROL ORAL TABLET 10 MG, 5 MG

4

Drug NameDrug Tier

Notes

GLUCOTROL XL ORAL TABLET EXTENDED RELEASE 24 HOUR 10 MG, 2.5 MG, 5 MG

4

GLUCOVANCE ORAL TABLET 2.5-500 MG, 5-500 MG

4

glyburide micronized oral tablet 1.5 mg, 3 mg, 6 mg

2

glyburide oral tablet 1.25 mg, 2.5 mg, 5 mg

2

glyburide-metformin oral tablet 1.25-250 mg, 2.5-500 mg, 5-500 mg

2

GLYNASE ORAL TABLET 1.5 MG, 3 MG, 6 MG

4

GLYSET ORAL TABLET 100 MG, 25 MG, 50 MG

4

GLYXAMBI ORAL TABLET 10-5 MG, 25-5 MG


days)

INVOKAMET ORAL TABLET 150-1000 MG, 150-500 MG, 50-1000 MG, 50-500 MG


days)

INVOKAMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR 150-1000 MG, 150-500 MG, 50-1000 MG, 50-500 MG


days)

INVOKANA ORAL TABLET 100 MG, 300 MG


days)

JANUMET ORAL TABLET 50-1000 MG, 50-500 MG


days)

JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR 100-1000 MG, 50-500 MG


days)



126

Drug NameDrug Tier

Notes

JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR 50-1000 MG


days)

JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG


days)

JARDIANCE ORAL TABLET 10 MG, 25 MG


days)

JENTADUETO ORAL TABLET 2.5-1000 MG, 2.5-500 MG, 2.5-850 MG


days)

JENTADUETO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 2.5-1000 MG


days)

JENTADUETO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 5-1000 MG


days)

KAZANO ORAL TABLET 12.5-1000 MG, 12.5-500 MG


days)

KOMBIGLYZE XR ORAL TABLET EXTENDED RELEASE 24 HOUR 2.5-1000 MG


days)

KOMBIGLYZE XR ORAL TABLET EXTENDED RELEASE 24 HOUR 5-1000 MG, 5-500 MG


days)

metformin hcl er oral tablet extended release 24 hour 500 mg, 750 mg

1

METFORMIN HCL ORAL SOLUTION 500 MG/5ML

4

metformin hcl oral tablet 1000 mg, 500 mg, 850 mg

1

miglitol oral tablet 100 mg, 25 mg, 50 mg

2

Drug NameDrug Tier

Notes

nateglinide oral tablet 120 mg, 60 mg

2

NESINA ORAL TABLET 12.5 MG, 25 MG, 6.25 MG


days)

ONGLYZA ORAL TABLET 2.5 MG, 5 MG


days)

OSENI ORAL TABLET 12.5-15 MG, 12.5-30 MG, 12.5-45 MG, 25-15 MG, 25-30 MG, 25-45 MG


days)

OZEMPIC SUBCUTANEOUS SOLUTION PEN-INJECTOR 2 MG/1.5ML

3PA; QL


OZEMPIC SUBCUTANEOUS SOLUTION PEN-INJECTOR 2 MG/1.5ML


days)

pioglitazone hcl oral tablet 15 mg, 30 mg, 45 mg

2

pioglitazone hcl-glimepiride oral tablet 30-2 mg, 30-4 mg

2

pioglitazone hcl-metformin hcl oral tablet 15-500 mg, 15-850 mg

2

PRANDIN ORAL TABLET 1 MG, 2 MG

4

PRECOSE ORAL TABLET 100 MG, 25 MG, 50 MG

4

QTERN ORAL TABLET 10-5 MG


days)

QTERN ORAL TABLET 5-5 MG

4PA; QL (1 EA per 1

day)

repaglinide oral tablet 0.5 mg, 1 mg, 2 mg

2



127

Drug NameDrug Tier

Notes

repaglinide-metformin hcl oral tablet 1-500 mg, 2-500 mg

2

RIOMET ORAL SOLUTION 500 MG/5ML

4

SEGLUROMET ORAL TABLET 2.5-1000 MG, 2.5-500 MG, 7.5-1000 MG, 7.5-500 MG


days)

SOLIQUA SUBCUTANEOUS SOLUTION PEN-INJECTOR 100-33 UNT-MCG/ML


days)

STARLIX ORAL TABLET 120 MG, 60 MG

4

STEGLATRO ORAL TABLET 15 MG, 5 MG


days)

STEGLUJAN ORAL TABLET 15-100 MG, 5-100 MG


days)

SYMLINPEN 120 SUBCUTANEOUS SOLUTION PEN-INJECTOR 2700 MCG/2.7ML

4 ST

SYMLINPEN 60 SUBCUTANEOUS SOLUTION PEN-INJECTOR 1500 MCG/1.5ML

4 ST

SYNJARDY ORAL TABLET 12.5-1000 MG, 12.5-500 MG, 5-1000 MG, 5-500 MG


days)

SYNJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR 10-1000 MG, 12.5-1000 MG, 25-1000 MG, 5-1000 MG


days)

Drug NameDrug Tier

Notes

TANZEUM SUBCUTANEOUS PEN-INJECTOR 30 MG, 50 MG


days)

tolazamide oral tablet 250 mg, 500 mg

2

tolbutamide oral tablet 500 mg

2

TRADJENTA ORAL TABLET 5 MG


days)

TRULICITY SUBCUTANEOUS SOLUTION PEN-INJECTOR 0.75 MG/0.5ML, 1.5 MG/0.5ML


days)

VICTOZA SOLUTION PEN-INJECTOR 18 MG/3ML SUBCUTANEOUS 18 MG/3ML


days)

VICTOZA SOLUTION PEN-INJECTOR 18 MG/3ML SUBCUTANEOUS 18 MG/3ML


days)

XIGDUO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 10-1000 MG, 10-500 MG, 5-500 MG


days)

XIGDUO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 2.5-1000 MG

4 PA

XIGDUO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 5-1000 MG


days)



128

Drug NameDrug Tier

Notes

XULTOPHY SUBCUTANEOUS SOLUTION PEN-INJECTOR 100-3.6 UNIT-MG/ML


days)

Diabetes - Glucose Monitoring

FREESTYLE INSULINX TEST IN VITRO STRIP

3QL (150

EA per 30 days)

FREESTYLE LITE TEST IN VITRO STRIP

3QL (150

EA per 30 days)

FREESTYLE PRECISION NEO TEST IN VITRO STRIP


FREESTYLE TEST IN VITRO STRIP

3QL (150

EA per 30 days)

PRECISION PCX PLUS TEST IN VITRO STRIP

3QL (150

EA per 30 days)

PRECISION QID TEST IN VITRO STRIP

3QL (150

EA per 30 days)

PRECISION SOF-TACT TEST IN VITRO STRIP

3QL (150

EA per 30 days)

PRECISION XTRA BLOOD GLUCOSE IN VITRO STRIP

3QL (150

EA per 30 days)

PRECISION XTRA KETONE IN VITRO STRIP

3

Diabetes - Glycemic Agents

BAQSIMI ONE PACK NASAL POWDER 3 MG/DOSE

4

BAQSIMI TWO PACK NASAL POWDER 3 MG/DOSE

4

Drug NameDrug Tier

Notes

GLUCAGEN HYPOKIT INJECTION SOLUTION RECONSTITUTED 1 MG

3

GLUCAGON EMERGENCY INJECTION KIT 1 MG

3

GVOKE PFS SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 0.5 MG/0.1ML, 1 MG/0.2ML

4

PROGLYCEM ORAL SUSPENSION 50 MG/ML

4

Diabetes - Insulins

ADMELOG SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML

4ST; QL (60 ML per 30

days)

ADMELOG SOLUTION 100 UNIT/ML SUBCUTANEOUS 100 UNIT/ML

4QL (60 ML

per 30 days)

ADMELOG SOLUTION 100 UNIT/ML SUBCUTANEOUS 100 UNIT/ML


days)

AFREZZA INHALATION POWDER 12 UNIT, 4 & 8 & 12 UNIT, 8 UNIT, 90 X 4 UNIT & 90X8 UNIT

4QL (60 EA

per 30 days)

AFREZZA INHALATION POWDER 30 X 4 UNIT & 60X8 UNIT, 4 UNIT, 60 X 4 UNIT & 30X8 UNIT, 60 X 8 UNIT & 30X12 UNIT

4QL (180

EA per 30 days)

AFREZZA INHALATION POWDER 90 X 8 UNIT & 90X12 UNIT

4

APIDRA SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML

4QL (60 ML

per 30 days)



129

Drug NameDrug Tier

Notes

APIDRA VIAL INJECTION SOLUTION 100 UNIT/ML

4QL (60 ML

per 30 days)

BASAGLAR KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML

4QL (60 ML

per 30 days)

BD AUTOSHIELD DUO PEN NEEDLES 30G X 5 MM

3

BD ULTRA-FINE INSULIN SYRINGES 27G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G 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 15/64" 0.3 ML, 31G X 15/64" 0.5 ML, 31G X 15/64" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML, 31G X 6MM 0.5 ML

3

BD ULTRA-FINE PEN NEEDLES 29G X 12.7MM , 31G X 5 MM , 31G X 8 MM , 32G X 4 MM , 32G X 6 MM

3

FIASP FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML


days)

FIASP PENFILL SUBCUTANEOUS SOLUTION CARTRIDGE 100 UNIT/ML


days)

FIASP SUBCUTANEOUS SOLUTION 100 UNIT/ML


days)

HUMALOG KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML, 200 UNIT/ML

3QL (60 ML

per 30 days)

Drug NameDrug Tier

Notes

HUMALOG MIX 50/50 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (50-50) 100 UNIT/ML

3QL (60 ML

per 30 days)

HUMALOG MIX 50/50 VIAL SUBCUTANEOUS SUSPENSION (50-50) 100 UNIT/ML

3QL (60 ML

per 30 days)

HUMALOG MIX 75/25 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (75-25) 100 UNIT/ML

3QL (60 ML

per 30 days)

HUMALOG MIX 75/25 VIAL SUBCUTANEOUS SUSPENSION (75-25) 100 UNIT/ML

3QL (60 ML

per 30 days)

HUMALOG U-100 JUNIOR KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML

3QL (60 ML

per 30 days)

HUMALOG U-100 VIAL AND CARTRIDGE SUBCUTANEOUS SOLUTION 100 UNIT/ML

3QL (60 ML

per 30 days)

HUMALOG U-100 VIAL AND CARTRIDGE SUBCUTANEOUS SOLUTION CARTRIDGE 100 UNIT/ML

3QL (60 ML

per 30 days)

HUMULIN 70/30 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML

3QL (60 ML

per 30 days)

HUMULIN 70/30 VIAL SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML

3QL (60 ML

per 30 days)



130

Drug NameDrug Tier

Notes

HUMULIN N KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR 100 UNIT/ML

3QL (60 ML

per 30 days)

HUMULIN N VIAL SUBCUTANEOUS SUSPENSION 100 UNIT/ML

3QL (60 ML

per 30 days)

HUMULIN R U-500 KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 500 UNIT/ML

3QL (60 ML

per 30 days)

HUMULIN R U-500 VIAL (CONCENTRATED) SUBCUTANEOUS SOLUTION 500 UNIT/ML

3QL (60 ML

per 30 days)

HUMULIN R VIAL INJECTION SOLUTION 100 UNIT/ML

3QL (60 ML

per 30 days)

INSULIN PEN NEEDLES 29G X 12.7MM , 29G X 12MM , 29G X 5MM , 29G X 8MM , 30G X 5 MM , 30G X 8 MM , 31G X 5 MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 MM , 32G X 5 MM , 32G X 6 MM , 33G X 4 MM , 33G X 5 MM , 33G X 6 MM

3

Drug NameDrug Tier

Notes

INSULIN SYRINGES 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G 0.3 ML, 29G X 1/2" 0.3 ML, 29G 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, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 15/64" 0.3 ML, 31G X 15/64" 0.5 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML, 32G X 5/16" 0.5 ML, 32G X 5/16" 1 ML

3

LANTUS SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML

3QL (60 ML

per 30 days)

LANTUS U-100 VIAL SUBCUTANEOUS SOLUTION 100 UNIT/ML

3QL (60 ML

per 30 days)

LEVEMIR U-100 FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML

3QL (60 ML

per 30 days)

LEVEMIR U-100 VIAL SUBCUTANEOUS SOLUTION 100 UNIT/ML

3QL (60 ML

per 30 days)

MAXICOMFORT SYR 27G X 1/2" 27G X 1/2" 0.5 ML, 27G X 1/2" 1 ML

3

MYXREDLIN INTRAVENOUS SOLUTION 100-0.9 UT/100ML-%

GM

NOVOFINE AUTOCOVER PEN NEEDLE 30G X 8 MM

3

NOVOFINE PEN NEEDLE 32G X 6 MM

3



131

Drug NameDrug Tier

Notes

NOVOFINE PLUS PEN NEEDLE 32G X 4 MM

3

NOVOLIN 70/30 FLEXPEN RELION SUBCUTANEOUS SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML


days)

NOVOLIN 70/30 FLEXPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML


days)

NOVOLIN 70/30 RELION SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML


days)

NOVOLIN 70/30 VIAL SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML


days)

NOVOLIN N RELION SUBCUTANEOUS SUSPENSION 100 UNIT/ML


days)

NOVOLIN N VIAL SUBCUTANEOUS SUSPENSION 100 UNIT/ML


days)

NOVOLIN R RELION INJECTION SOLUTION 100 UNIT/ML


days)

NOVOLIN R VIAL INJECTION SOLUTION 100 UNIT/ML


days)

NOVOLOG FLEXPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML


days)

Drug NameDrug Tier

Notes

NOVOLOG MIX 70/30 FLEXPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML


days)

NOVOLOG MIX 70/30 VIAL SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML


days)

NOVOLOG PENFILL SUBCUTANEOUS SOLUTION CARTRIDGE 100 UNIT/ML


days)

NOVOLOG U-100 VIAL SUBCUTANEOUS SOLUTION 100 UNIT/ML


days)

NOVOTWIST PEN NEEDLE 32G X 5 MM

3

TOUJEO MAX SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 300 UNIT/ML

3QL (60 ML

per 30 days)

TOUJEO SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 300 UNIT/ML

3QL (60 ML

per 30 days)

TRESIBA FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML, 200 UNIT/ML

4QL (60 ML

per 30 days)

TRESIBA SUBCUTANEOUS SOLUTION 100 UNIT/ML

4QL (60 ML

per 30 days)

Electrolytes / Minerals / Metals / Vitamins

ABANEU-SL SUBLINGUAL TABLET SUBLINGUAL 600-600 MCG

4

ACTIVE FE ORAL TABLET 75-1.25 MG

4



132

Drug NameDrug Tier

Notes

ACTIVITE ORAL TABLET 1 MG

4

adc/f (0.5mg/ml) oral solution 0.5 mg/ml

2

ADRENAL C FORMULA ORAL TABLET

4

ADVANCED AM/PM ORAL

4

AMINO ACID INTRAVENOUS SOLUTION 10 %

GM

aminoamrms oral capsule

2

aminoreliefrms oral capsule

2

AMINOSYN II INTRAVENOUS SOLUTION 10 %, 15 %, 8.5 %

GM

aminosyn ii/electrolytes intravenous solution 8.5 %

GM

AMINOSYN INTRAVENOUS SOLUTION 10 %, 8.5 %

GM

AMINOSYN M INTRAVENOUS SOLUTION 3.5 %

GM

AMINOSYN/ELECTROLYTES INTRAVENOUS SOLUTION 7 %

GM

aminosyn/electrolytes intravenous solution 8.5 %

GM

AMINOSYN-HBC INTRAVENOUS SOLUTION 7 %

GM

AMINOSYN-PF INTRAVENOUS SOLUTION 10 %, 7 %

GM

Drug NameDrug Tier

Notes

AMINOSYN-RF INTRAVENOUS SOLUTION 5.2 %

GM

ANIMI-3 ORAL CAPSULE 1 MG

4

ANIMI-3/VITAMIN D ORAL CAPSULE 1 MG

4

AP-ZEL ORAL TABLET 4

AQUASOL A INTRAMUSCULAR SOLUTION 50000 UNIT/ML

GM

ARGININE HCL INJECTION SOLUTION 6 GM/30ML

GM

argyle sterile saline irrigation solution 0.9 %

2

argyle sterile water irrigation solution

2

ASCOR INTRAVENOUS SOLUTION 25000 MG/50ML

GM

ASCORBIC ACID INTRAVENOUS SOLUTION 15000 MG/30ML

GM

ATABEX OB ORAL TABLET 29-1 MG

4

b-6 folic acid oral capsule 400-1000-50 mcg-mcg-mg

2

BACMIN ORAL TABLET 4

BCAA INJECTION SOLUTION 15-10-40 MG/ML

GM

BCAA INTRAVENOUS SOLUTION 15-10-40 MG/ML

GM

bd posiflush intravenous solution 0.9 %

2



133

Drug NameDrug Tier

Notes

BIFERARX ORAL TABLET 22-6-1-0.025 MG

4

biocel oral tablet 2

bp vit 3 oral capsule 1 mg

2

b-plex oral tablet 2

b-plex plus oral tablet 2

CALCIFOL ORAL WAFER 1342-1.6 MG

4

CALCIUM CHLORIDE SOLUTION 10 % INTRAVENOUS 10 %

GM

calcium chloride solution 10 % intravenous 10 %

GM

CALCIUM GLUCONATE INTRAVENOUS SOLUTION PREFILLED SYRINGE 1000 MG/10ML

GM

CALCIUM GLUCONATE-DEXTROSE INTRAVENOUS SOLUTION 1-5 GM/100ML-%, 1-5 GM/50ML-%, 2-5 GM/100ML-%, 2-5 GM/50ML-%, 4-5 GM/250ML-%

GM

CALCIUM GLUCONATE-NACL INTRAVENOUS SOLUTION 1-0.675 GM/50ML-%, 1-0.9 GM/50ML-%, 2-0.675 GM/100ML-%, 3-0.9 GM/100ML-%, 4-0.9 GM/250ML-%

GM

CALCIUM GLUCONATE-NACL INTRAVENOUS SOLUTION PREFILLED SYRINGE 1-0.9 GM/50ML-%

GM

Drug NameDrug Tier

Notes

CALCIUM-FOLIC ACID PLUS D ORAL WAFER 1342-1 MG

4

CALM INJECTION SOLUTION

GM

CARBAGLU ORAL TABLET 200 MG

6 PA

CARDIOPLEGIC SOLUTION PERFUSION

GM

cardioplegic solution perfusion

GM

CARNITOR INTRAVENOUS SOLUTION 200 MG/ML

GM

CARNITOR ORAL SOLUTION 1 GM/10ML

4

CARNITOR ORAL TABLET 330 MG

4

CARNITOR SF ORAL SOLUTION 1 GM/10ML

4

CENTRATEX ORAL CAPSULE 106-1 MG

4

CHEMET ORAL CAPSULE 100 MG

4

chromagen oral capsule 2

chromic chloride intravenous solution 40 mcg/10ml

GM

CITRANATAL MEDLEY ORAL CAPSULE 27-1-200 MG

4

CLINIMIX E/DEXTROSE (2.75/10) INTRAVENOUS SOLUTION 2.75 %

GM


GM


GM



134

Drug NameDrug Tier

Notes


GM


GM

CLINIMIX E/DEXTROSE (5/15) INTRAVENOUS SOLUTION 5 %

GM


GM


GM

CLINIMIX N9G20E INTRAVENOUS SOLUTION 2.75 %

GM

CLINIMIX/DEXTROSE (2.75/5) INTRAVENOUS SOLUTION 2.75 %

GM


GM


GM


GM


GM

CLINIMIX/DEXTROSE (5/15) INTRAVENOUS SOLUTION 5 %

GM


GM

Drug NameDrug Tier

Notes


GM

clinisol sf intravenous solution 15 %

GM

CLINOLIPID INTRAVENOUS EMULSION 20 %

GM

clovique oral capsule 250 mg

6 PA

cod liver oil oral oil 2

COPPER CHLORIDE INTRAVENOUS SOLUTION 0.4 MG/ML

GM

corvita 150 oral tablet 150-1.25 mg

2

corvita oral tablet 1.25 mg

2

CORVITE 150 ORAL TABLET , 150-1.25 MG

4

CORVITE FE ORAL TABLET

4

corvite free oral tablet 2

CORVITE ORAL TABLET 1.25 MG

4

curity sterile saline irrigation solution 0.9 %

2

cyanocobalamin injection solution 1000 mcg/ml

2

CYANOCOBALAMIN INJECTION SOLUTION 2000 MCG/ML

GM

cytra k crystals oral packet 3300-1002 mg

2

d3 vitamin oral liquid 400 unit/ml

PVAL (Min 65

Years)

decara oral capsule 1.25 mg (50000 ut)

2

deferasirox oral tablet soluble 125 mg, 250 mg, 500 mg

6 PA



135

Drug NameDrug Tier

Notes

DELFLEX-LC/1.5% DEXTROSE INTRAPERITONEAL SOLUTION 344 MOSM/L

4


4


4

delflex-sm/1.5% dextrose intraperitoneal solution 347 mosm/l

2

delflex-sm/2.5% dextrose intraperitoneal solution 398 mosm/l

2

dexifol oral tablet 5 mg 2

DEXTROSE 5%/ELECTROLYTE #48 INTRAVENOUS SOLUTION

GM

dextrose in lactated ringers intravenous solution 5 %

GM

dextrose intravenous solution 10 %, 20 %, 30 %, 40 %, 5 %, 70 %

GM

DEXTROSE SOLUTION 250 MG/ML INTRAVENOUS 250 MG/ML

GM

dextrose solution 250 mg/ml intravenous 250 mg/ml

GM

DEXTROSE SOLUTION 50 % INTRAVENOUS 50 %

GM

dextrose solution 50 % intravenous 50 %

GM

Drug NameDrug Tier

Notes

dextrose-nacl intravenous solution 10-0.2 %, 10-0.45 %, 2.5-0.45 %, 5-0.2 %, 5-0.225 %, 5-0.3 %, 5-0.33 %, 5-0.45 %, 5-0.9 %

GM

dextrose-sodium chloride intravenous solution 5-0.225 %

GM

DIALYVITE 3000 ORAL TABLET 3 MG

4

DIALYVITE 5000 ORAL TABLET 5 MG

4

dialyvite oral tablet 2

DIALYVITE SUPREME D ORAL TABLET 3 MG

4

DIALYVITE/ZINC ORAL TABLET

4

DIANEAL LOW CALCIUM/1.5% DEX INTRAPERITONEAL SOLUTION 344 MOSM/L

4


4


4

DIANEAL PD-2/1.5% DEXTROSE INTRAPERITONEAL SOLUTION 346 MOSM/L

4


4


4



136

Drug NameDrug Tier

Notes

DILUENT FOR LEFAMULIN INTRAVENOUS SOLUTION 0.9 %

GM

DIVISTA ORAL CAPSULE 1 MG

4

DRISDOL ORAL CAPSULE 1.25 MG (50000 UT)

4

EFFER-K ORAL TABLET EFFERVESCENT 10 MEQ, 20 MEQ

4

effer-k oral tablet effervescent 25 meq

2

effervescent pot chloride oral tablet effervescent 25 meq

2

elite-ob oral tablet 50-1.25 mg

2

ELLIOTTS B INTRATHECAL SOLUTION

GM

ENBRACE HR ORAL CAPSULE

4

ergocalciferol oral capsule 1.25 mg (50000 ut)

2

ESCAVITE D ORAL TABLET CHEWABLE 0.25-6 MG

4

escavite lq oral liquid 0.25-6 mg/ml

2

ESCAVITE ORAL TABLET CHEWABLE 0.25-7.5 MG

4

EXJADE ORAL TABLET SOLUBLE 125 MG, 250 MG, 500 MG

6 PA

EXTRANEAL INTRAPERITONEAL SOLUTION 7.5 %

4

Drug NameDrug Tier

Notes

fabb oral tablet 2.2-25-1 mg

2

fa-vitamin b-6-vitamin b-12 oral tablet 2.2-25-0.5 mg

2

FERAHEME INTRAVENOUS SOLUTION 510 MG/17ML

GM

FERIVA ORAL CAPSULE 75-1 MG

4

FERIVAFA ORAL CAPSULE 110-1 MG

4

ferocon oral capsule 2

ferotrinsic oral capsule 2

FERRALET 90 ORAL TABLET 90-1 MG

4

FERRAPLUS 90 ORAL TABLET 90-1 MG

4

FERRIPROX ORAL SOLUTION 100 MG/ML

6 PA

FERRIPROX ORAL TABLET 1000 MG, 500 MG

6 PA

FERRLECIT INTRAVENOUS SOLUTION 12.5 MG/ML

GM

FERRO-PLEX HEMATINIC ORAL TABLET 115-1 MG

4

FERROTRIN ORAL CAPSULE

4

FLORIVA PLUS ORAL SOLUTION 0.25 MG/ML

4

FLUORABON ORAL SOLUTION 0.55 (0.25 F) MG/0.6ML

4

FLUOR-A-DAY ORAL TABLET CHEWABLE 0.25 (F)-236.79 MG, 1 (F)-236.79 MG

4



137

Drug NameDrug Tier

Notes

fluoritab oral solution 0.275 (0.125 f) mg/drop

PV

fluoritab oral tablet chewable 0.55 (0.25 f) mg, 1.1 (0.5 f) mg, 2.2 (1 f) mg

PV

FLURA-DROPS ORAL SOLUTION 0.55 (0.25 F) MG/DROP

4

folbee plus oral tablet 2

FOLGARD OS ORAL TABLET 500-1.1 MG

4

FOLGARD RX ORAL TABLET 2.2-25-1 MG

4

folic acid injection solution 5 mg/ml

GM

folic acid oral tablet 1 mg 2

folic acid oral tablet 400 mcg, 800 mcg

PV

FOLIKA-T ORAL TABLET 1 MG

4

FOLIVANE-F ORAL CAPSULE 125-1 MG

4

FOLIVANE-PLUS ORAL CAPSULE

4

folplex 2.2 oral tablet 2.2-25-0.5 mg

2

FOLTRATE ORAL TABLET 500-1 MCG-MG

4

foltrin oral capsule 2

FORTAVIT ORAL CAPSULE

4

FREAMINE HBC INTRAVENOUS SOLUTION 6.9 %

GM

FREAMINE III INTRAVENOUS SOLUTION 10 %

GM

FUSION PLUS ORAL CAPSULE

4

Drug NameDrug Tier

Notes

GABA INJECTION SOLUTION 1000 MG/10ML

GM

GALZIN ORAL CAPSULE 25 MG, 50 MG

3

GENICIN VITA-S ORAL TABLET 1 MG

4

glucose intravenous solution 5 %

GM

GLUTATHIONE INJECTION SOLUTION 200 MG/ML

GM

GLUTATHIONE INTRAVENOUS SOLUTION 6 GM/30ML

GM

GLYCINE INJECTION SOLUTION 50 MG/ML

GM

gnp folic acid oral tablet 400 mcg

PV

hematinic/folic acid oral tablet 324-1 mg

2

HEMATOGEN FA ORAL CAPSULE 200-250-0.01-1 MG

4

hematogen forte oral capsule 460-60-0.01-1 mg

2

hematogen oral capsule 2

HEMATRON-AF ORAL TABLET 150-1 MG

4

hemenatal ob + dha oral 28-6-1 & 203 mg

2

HEMETAB ORAL TABLET 22-6-1-0.025 MG

4

HEMOCYTE PLUS ORAL CAPSULE 106-1 MG

4

hemocyte-f oral tablet 324-1 mg

2



138

Drug NameDrug Tier

Notes

HEPATAMINE INTRAVENOUS SOLUTION 8 %

GM

hydroxocobalamin acetate intramuscular solution 1000 mcg/ml

GM

HYLAVITE ORAL TABLET

4

ICAR-C PLUS ORAL TABLET 100-250-0.025-1 MG

4

iferex 150 forte oral capsule 150-25-1 mg-mcg-mg

2

INFUVITE ADULT INTRAVENOUS INJECTABLE

GM

INFUVITE PEDIATRIC INTRAVENOUS SOLUTION

GM

INJECTAFER INTRAVENOUS SOLUTION 750 MG/15ML

GM

INTEGRA F ORAL CAPSULE 125-1 MG

4

INTEGRA PLUS ORAL CAPSULE

4

intralipid intravenous emulsion 20 %

GM

INTRALIPID INTRAVENOUS EMULSION 30 %

GM

iodine strong oral solution 5 %

2

IONOSOL-MB IN D5W INTRAVENOUS SOLUTION

GM

IROSPAN 24/6 ORAL 4

IS 24/6 ORAL 4

Drug NameDrug Tier

Notes

ISOLYTE-P IN D5W INTRAVENOUS SOLUTION

GM

ISOLYTE-S INTRAVENOUS SOLUTION

GM

ISOLYTE-S PH 7.4 INTRAVENOUS SOLUTION

GM

JADENU ORAL TABLET 180 MG, 360 MG, 90 MG

6 PA

JADENU SPRINKLE ORAL PACKET 180 MG, 360 MG, 90 MG

6 PA

JYNARQUE ORAL TABLET 15 MG, 30 MG

6 PA

JYNARQUE ORAL TABLET THERAPY PACK 45 & 15 MG, 60 & 30 MG, 90 & 30 MG

6 PA

KABIVEN INTRAVENOUS EMULSION 3.3-9.8-3.9-0.7 %

GM

KCL (IN NACL 0.9%) INTRAVENOUS SOLUTION 10 MEQ/100ML, 10 MEQ/500ML, 20 MEQ/250ML, 30 MEQ/100ML, 40 MEQ/250ML, 40 MEQ/500ML

GM

kcl in d5w lactated ringers intravenous solution 40 meq/l

GM



139

Drug NameDrug Tier

Notes

kcl in dextrose-nacl intravenous solution 10-5-0.45 meq/l-%-%, 20-5-0.2 meq/l-%-%, 20-5-0.225 meq/l-%-%, 20-5-0.33 meq/l-%-%, 20-5-0.45 meq/l-%-%, 20-5-0.9 meq/l-%-%, 30-5-0.45 meq/l-%-%, 40-5-0.45 meq/l-%-%, 40-5-0.9 meq/l-%-%

GM

KCL IN LACTATED RINGERS INTRAVENOUS SOLUTION 20 MEQ/L

GM

kcl-lactated ringers-d5w intravenous solution 20 meq/l

GM

KCL-LIDOCAINE IN NACL INTRAVENOUS SOLUTION 20-10 MEQ-MG /100ML

GM

KCL-LIDOCAINE-NACL INTRAVENOUS SOLUTION 10-10 MEQ-MG /100ML

GM

k-effervescent oral tablet effervescent 25 meq

2

kionex oral powder 2

kionex oral suspension 15 gm/60ml

2

klor-con 10 oral tablet extended release 10 meq

2

klor-con m10 oral tablet extended release 10 meq

2

KLOR-CON M15 ORAL TABLET EXTENDED RELEASE 15 MEQ

4

klor-con m20 oral tablet extended release 20 meq

2

klor-con oral packet 20 meq

2

Drug NameDrug Tier

Notes

klor-con oral tablet extended release 8 meq

2

klor-con sprinkle oral capsule extended release 10 meq, 8 meq

2

klor-con/ef oral tablet effervescent 25 meq

2

K-PHOS NO 2 ORAL TABLET 305-700 MG

4

K-PHOS ORAL TABLET 500 MG

4

K-PHOS-NEUTRAL ORAL TABLET 155-852-130 MG

4

k-prime oral tablet effervescent 25 meq

2

K-TAB ORAL TABLET EXTENDED RELEASE 10 MEQ, 20 MEQ, 8 MEQ

4

k-tan plus oral capsule 162-115.2-1 mg

2

k-vescent oral tablet effervescent 25 meq

2

lactated ringers intravenous solution

GM

lactated ringers irrigation solution

2

LEVOCARNITINE INJECTION SOLUTION 500 MG/ML

GM

levocarnitine oral solution 1 gm/10ml

2

levocarnitine oral tablet 330 mg

2

LIPO INTRAMUSCULAR SOLUTION 50-50-25 MG/ML

GM

LIPO-C INTRAMUSCULAR SOLUTION

GM



140

Drug NameDrug Tier

Notes

LIQUIVIDA HYDRATION INTRAVENOUS KIT 0.9 %

GM

LORID ORAL TABLET 1 MG

4

ludent oral tablet chewable 0.55 (0.25 f) mg, 1.1 (0.5 f) mg, 2.2 (1 f) mg

PV

LYSINE HCL INJECTION SOLUTION 100 MG/ML

GM

lysiplex plus oral tablet 2

M.V.I. ADULT INTRAVENOUS INJECTABLE

GM

M.V.I. PEDIATRIC INTRAVENOUS SOLUTION RECONSTITUTED

GM

M.V.I.-12 (WITHOUT VITAMIN K) INTRAVENOUS INJECTABLE

GM

MAGNEBIND 400 ORAL TABLET 400-200-1 MG

4

magnesium sulfate in d5w intravenous solution 1-5 gm/100ml-%

GM

Drug NameDrug Tier

Notes

MAGNESIUM SULFATE IN D5W INTRAVENOUS SOLUTION 1-5 GM/50ML-%, 10-5 GM/100ML-%, 10-5 GM/250ML-%, 2-5 GM/100ML-%, 2-5 GM/50ML-%, 20-5 GM/250ML-%, 20-5 GM/500ML-%, 20-5 GM/L-%, 25-5 GM/250ML-%, 3-5 GM/50ML-%, 4-5 GM/100ML-%, 4-5 GM/50ML-%, 40-5 GM/500ML-%, 40-5 GM/L-%, 5-5 GM/100ML-%, 50-5 GM/500ML-%, 6-5 GM/100ML-%, 6-5 GM/50ML-%

GM

magnesium sulfate injection solution 50 %

2

MAGNESIUM SULFATE INTRAVENOUS SOLUTION 1000 MG/1.6ML, 2000 MG/3.2ML, 3000 MG/4.8ML, 4000 MG/6.4ML

GM

magnesium sulfate intravenous solution 2 gm/50ml, 20 gm/500ml, 4 gm/100ml, 4 gm/50ml, 40 gm/1000ml

GM

MAGNESIUM SULFATE-LACT RINGERS INTRAVENOUS SOLUTION 10 GM/250ML, 20 GM/250ML, 20 GM/500ML, 25 GM/250ML, 40 GM/1000ML, 40 GM/500ML, 50 GM/500ML

GM



141

Drug NameDrug Tier

Notes

MAGNESIUM SULFATE-NACL INTRAVENOUS SOLUTION 1-0.9 GM/50ML-%, 10-0.9 GM/100ML-%, 2-0.9 GM/100ML-%, 2-0.9 GM/50ML-%, 20-0.9 GM/250ML-%, 3-0.9 GM/150ML-%, 3-0.9 GM/50ML-%, 4-0.9 GM/100ML-%, 4-0.9 GM/50ML-%, 40-0.9 GM/500ML-%, 40-0.9 GM/L-%, 6-0.9 GM/100ML-%, 6-0.9 GM/150ML-%, 6-0.9 GM/50ML-%

GM

MANGANESE CHLORIDE INTRAVENOUS SOLUTION 0.1 MG/ML

GM

MAXFE ORAL TABLET 160-1 MG

4

MEPHYTON ORAL TABLET 5 MG

4

METHYLCOBALAMIN INJECTION SOLUTION RECONSTITUTED 10000 MCG, 50000 MCG

GM

MIFEPREX ORAL TABLET 200 MG

4

mifepristone oral tablet 200 mg

2

M-NATAL PLUS ORAL TABLET 27-1 MG


monoject flush syringe intravenous solution 0.9 %

2

monoject sodium chloride flush intravenous solution 0.9 %

2

MULTIGEN FOLIC ORAL TABLET 70-150-2-1 MG

4

Drug NameDrug Tier

Notes

MULTIGEN ORAL TABLET 70 MG

4

MULTIGEN PLUS ORAL TABLET 50-101-1 MG

4

multi-vit/fluoride oral solution 0.25 mg/ml, 0.5 mg/ml

2

multi-vit/fluoride/iron oral solution 0.25-10 mg/ml

2

multi-vit/iron/fluoride oral solution 0.25-10 mg/ml

2

multivitamin/fluoride oral solution 0.25 mg/ml, 0.5 mg/ml

2

multi-vitamin/fluoride oral solution 0.25 mg/ml, 0.5 mg/ml

2

multivitamin/fluoride oral tablet chewable 0.25 mg, 1 mg

2

multivitamin/fluoride/iron oral solution 0.25-10 mg/ml

2

multi-vitamin/fluoride/iron oral solution 0.25-10 mg/ml

2

mvc-fluoride oral tablet chewable 0.25 mg, 1 mg

2

myferon 150 forte oral capsule 150-25-1 mg-mcg-mg

2

mynephrocaps oral capsule 1 mg

2

mynephron oral capsule 1 mg

2

na ferric gluc cplx in sucrose intravenous solution 12.5 mg/ml

GM

n-acetyl-l-cysteine oral capsule 600 mg

2



142

Drug NameDrug Tier

Notes

nafrinse drops oral solution 0.275 (0.125 f) mg/drop

PV

nafrinse oral tablet chewable 2.2 (1 f) mg

PV

NASCOBAL NASAL SOLUTION 500 MCG/0.1ML

3

NEONATAL COMPLETE ORAL TABLET 27-1 MG


NEONATAL PLUS ORAL TABLET 27-1 MG


NEOVITE ORAL TABLET

4

NEPHPLEX RX ORAL TABLET

4

NEPHRAMINE INTRAVENOUS SOLUTION 5.4 %

GM

NEPHROCAPS ORAL CAPSULE 1 MG

4

NEPHRON FA ORAL TABLET

4

nephronex oral tablet 2

NEPHRO-VITE RX ORAL TABLET 1 MG

4

NESTABS ORAL TABLET 32-1 MG

4

NEURIN-SL SUBLINGUAL TABLET SUBLINGUAL 600-600 MCG

4

NICADAN ORAL TABLET

4

NICAZEL FORTE ORAL TABLET

4

NICAZEL ORAL TABLET 4

NICOMIDE ORAL TABLET 750-25-1.5-0.5 MG, 750-27-2-0.5 MG

4

Drug NameDrug Tier

Notes

NIFEREX ORAL TABLET

4

normal saline flush intravenous solution 0.9 %

2

NORMOSOL-M IN D5W INTRAVENOUS SOLUTION

GM

NORMOSOL-R IN D5W INTRAVENOUS SOLUTION

GM

NORMOSOL-R INTRAVENOUS SOLUTION

GM

NORMOSOL-R PH 7.4 INTRAVENOUS SOLUTION

GM

NUFERA ORAL TABLET 4

NUTRESTORE ORAL PACKET 5 GM

4

NUTRICAP ORAL TABLET

4

nutrifac zx oral tablet 2

nutrilipid intravenous emulsion 20 %

GM

nutrilyte intravenous concentrate

GM

NUTRIVIT ORAL LIQUID 4

OMEGAVEN INTRAVENOUS EMULSION 10 GM/100ML, 5 GM/50ML

6PA;

Specialty Medical

ONEVITE ORAL TABLET 1 MG

4

ORACIT ORAL SOLUTION 490-640 MG/5ML

3

PERIKABIVEN INTRAVENOUS EMULSION 2.4-6.8-3.5-0.5 %

GM



143

Drug NameDrug Tier

Notes

phospha 250 neutral oral tablet 155-852-130 mg

2

phosphorous oral tablet 155-852-130 mg

2

phospho-trin 250 neutral oral tablet 155-852-130 mg

2

PHOXILLUM BK4/2.5 INTRAVENOUS SOLUTION 32-4-2.5-1 MEQ-MMOL/L

GM

physiolyte irrigation solution

2

physiosol irrigation irrigation solution

2

phytonadione injection solution 1 mg/0.5ml, 10 mg/ml

GM

phytonadione oral tablet 5 mg

2

PLASMA-LYTE 148 INTRAVENOUS SOLUTION

GM

PLASMA-LYTE A INTRAVENOUS SOLUTION

GM

PLEGISOL PERFUSION SOLUTION

GM

plenamine intravenous solution 15 %

GM

pnv prenatal plus multivit+dha oral 27-1 & 312 mg

2

poly-iron 150 forte oral capsule 150-25-1 mg-mcg-mg

2

polysaccharide iron forte oral capsule 150-25-1 mg-mcg-mg

2

POLY-VI-FLOR FS ORAL STRIP 0.25 MG, 0.5 MG, 1 MG

4

Drug NameDrug Tier

Notes

POLY-VI-FLOR ORAL SUSPENSION 0.25 MG/ML

4

POLY-VI-FLOR ORAL TABLET CHEWABLE 0.25 MG, 0.5 MG, 1 MG

4

POLY-VI-FLOR/IRON ORAL SUSPENSION 0.25-7 MG/ML

4

POLY-VI-FLOR/IRON ORAL TABLET CHEWABLE 0.5-10 MG

4

pot bicarb-pot chloride oral tablet effervescent 25 meq

2

potassium acetate intravenous solution 2 meq/ml

GM

POTASSIUM ACETATE-NACL INTRAVENOUS SOLUTION 10 MEQ/100ML

GM

potassium bicarbonate oral tablet effervescent 25 meq

2

potassium chloride crys er oral tablet extended release 10 meq, 20 meq

2

potassium chloride er oral capsule extended release 10 meq, 8 meq

2

potassium chloride er oral tablet extended release 10 meq, 20 meq, 8 meq

2

POTASSIUM CHLORIDE IN D5W INTRAVENOUS SOLUTION 10 MEQ/500ML, 20 MEQ/250ML, 40 MEQ/250ML, 40 MEQ/500ML

GM



144

Drug NameDrug Tier

Notes

potassium chloride in dextrose intravenous solution 20-5 meq/l-%, 40-5 meq/l-%

GM

POTASSIUM CHLORIDE IN NACL INTRAVENOUS SOLUTION 10-0.9 MEQ/L-%

GM

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

GM

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

GM

POTASSIUM CHLORIDE INTRAVENOUS SOLUTION PREFILLED SYRINGE 10 MEQ/5ML

GM

potassium chloride oral packet 20 meq

2

potassium chloride oral solution 20 meq/15ml (10%), 40 meq/15ml (20%)

2

potassium chloride proamp intravenous solution 2 meq/ml

GM

POTASSIUM CHLORIDE SOLUTION 2 MEQ/ML INTRAVENOUS 2 MEQ/ML

GM

potassium chloride solution 2 meq/ml intravenous 2 meq/ml

GM

POTASSIUM CHLORIDE SOLUTION 20 MEQ/100ML INTRAVENOUS 20 MEQ/100ML

GM

Drug NameDrug Tier

Notes

potassium chloride solution 20 meq/100ml intravenous 20 meq/100ml

GM

potassium citrate er oral tablet extended release 10 meq (1080 mg), 15 meq (1620 mg), 5 meq (540 mg)

2

potassium citrate-citric acid oral packet 3300-1002 mg

2

potassium citrate-citric acid oral solution 1100-334 mg/5ml

2

POTASSIUM PHOSPHATE-NACL INTRAVENOUS SOLUTION 15 MMOL/100ML

GM

POTASSIUM PHOSPHATES-DEXTROSE INTRAVENOUS SOLUTION 15 MMOL/250ML, 30 MMOL/500ML, 7.5 MMOL/100ML, 9 MMOL/50ML

GM



145

Drug NameDrug Tier

Notes

POTASSIUM PHOSPHATES-NACL INTRAVENOUS SOLUTION 10 MMOL/100ML, 10 MMOL/250ML, 15 MMOL/150ML, 15 MMOL/250ML, 20 MMOL/100ML, 22 MMOL/500ML, 30 MMOL/250ML, 30 MMOL/500ML, 40 MMOL/250ML, 5 MMOL/250ML, 7 MMOL/100ML, 7.5 MMOL/100ML, 9 MMOL/100ML

GM

PREFERAOB +DHA ORAL 28-6-1 & 200 MG

4

PRE-FOLIC ORAL TABLET 1-100 MG

4

PREMASOL INTRAVENOUS SOLUTION 10 %

GM

premasol intravenous solution 6 %

GM

PREMESISRX ORAL TABLET 1 MG

4

PRENAISSANCE ORAL CAPSULE 29-1.25-325 MG

4

PRENATA ORAL TABLET CHEWABLE 29-1 MG

4

prenatal oral tablet 27-1 mg


prenatal plus iron oral tablet 29-1 mg

2

PRISMASOL B22GK 4/0 INTRAVENOUS SOLUTION 22-4 MEQ/L

GM

Drug NameDrug Tier

Notes

PRISMASOL BGK 0/2.5 INTRAVENOUS SOLUTION 32-2.5 MEQ/L

GM

PRISMASOL BGK 2/0 INTRAVENOUS SOLUTION 32-2 MEQ/L

GM

PRISMASOL BGK 2/3.5 INTRAVENOUS SOLUTION 32-2-3.5 MEQ/L

GM

PRISMASOL BGK 4/0/1.2 INTRAVENOUS SOLUTION 32-4-1.2 MEQ/L

GM

PRISMASOL BGK 4/2.5 INTRAVENOUS SOLUTION 32-4-2.5 MEQ/L

GM

PRISMASOL BK 0/0/1.2 INTRAVENOUS SOLUTION 32-1.2 MEQ/L

GM

PROCALAMINE INTRAVENOUS SOLUTION 3 %

GM

PROSOL INTRAVENOUS SOLUTION 20 %

GM

PROTECT PLUS ORAL CAPSULE

4

PUREFE PLUS ORAL CAPSULE 106-1 MG

4

purevit dualfe plus oral capsule 162-115.2-1 mg

2

PYRIDOXINE HCL SOLUTION 100 MG/ML INJECTION 100 MG/ML

GM

pyridoxine hcl solution 100 mg/ml injection 100 mg/ml

GM



146

Drug NameDrug Tier

Notes

quflora pediatric oral solution 0.25 mg/ml, 0.5 mg/ml

2

quflora pediatric oral tablet chewable 0.25 mg, 1 mg

2

RELNATE DHA ORAL CAPSULE 28-1-200 MG

4

renal oral capsule 1 mg 2

RENATABS ORAL TABLET 1 MG

4

RENATABS WITH IRON ORAL 1 & 100 MG

4

REQ 49+ ORAL TABLET 4

ringers intravenous solution

GM

ringers irrigation irrigation solution

2

saline bacteriostatic injection solution 0.9 %

GM

saline flush intravenous solution 0.9 %

2

saline flush zr intravenous solution 0.9 %

2

SALINE-PHENOL INJECTION SOLUTION 0.4-0.9 %

GM

SAMSCA ORAL TABLET 15 MG, 30 MG

6 PA

SELECT-OB ORAL TABLET CHEWABLE 29-1 MG

4

SELENIOUS ACID INTRAVENOUS SOLUTION 60 MCG/ML

GM

se-tan plus oral capsule 162-115.2-1 mg

2

SIDEROL ORAL TABLET

4

Drug NameDrug Tier

Notes

SMOFLIPID INTRAVENOUS EMULSION 20 %

GM

sod citrate-citric acid oral solution 500-334 mg/5ml

2

sodium acetate intravenous solution 2 meq/ml

GM

SODIUM BICARBONATE INJECTION SOLUTION 8.4 %

GM

SODIUM BICARBONATE SOLUTION 8.4 % INTRAVENOUS 8.4 %

GM

sodium bicarbonate solution 8.4 % intravenous 8.4 %

GM

SODIUM BICARBONATE-DEXTROSE INTRAVENOUS SOLUTION 150 MEQ/L

GM

sodium chloride (pf) injection solution 0.9 %

GM

sodium chloride bacteriostatic injection solution 0.9 %

GM

sodium chloride flush intravenous solution 0.9 %

2

sodium chloride injection solution 2.5 meq/ml

GM

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

GM

sodium chloride irrigation solution 0.9 %

2

SODIUM CHLORIDE SOLUTION 0.9 % INJECTION 0.9 %

GM



147

Drug NameDrug Tier

Notes

SODIUM CHLORIDE SOLUTION 0.9 % INTRAVENOUS 0.9 %

GM

sodium chloride solution 0.9 % intravenous 0.9 %

GM

sodium fluoride oral solution 1.1 (0.5 f) mg/ml

PV

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

PV

sodium fluoride oral tablet chewable 0.55 (0.25 f) mg, 1.1 (0.5 f) mg, 2.2 (1 f) mg

PV

sodium lactate intravenous solution 5 meq/ml

GM

SODIUM PHOSPHATE-NACL INTRAVENOUS SOLUTION 10 MMOL/100ML, 15 MMOL/100ML, 15 MMOL/250ML, 30 MMOL/250ML, 40 MMOL/250ML, 7.5 MMOL/100ML, 9 MMOL/50ML

GM

SODIUM PHOSPHATES-DEXTROSE INTRAVENOUS SOLUTION 15 MMOL/100ML, 15 MMOL/250ML

GM

sodium polystyrene sulfonate oral powder

2

sodium polystyrene sulfonate oral suspension 15 gm/60ml

2

sodium polystyrene sulfonate rectal suspension 30 gm/120ml, 50 gm/200ml

2

Drug NameDrug Tier

Notes

sps oral suspension 15 gm/60ml

2

sterile water for irrigation irrigation solution

2

STROVITE FORTE ORAL SYRUP

4

STROVITE FORTE ORAL TABLET

4

STROVITE ONE ORAL TABLET

4

SUPERVITE ORAL LIQUID

4

SUPPORT ORAL LIQUID

4

SUPPORT-500 ORAL CAPSULE

4

swabflush saline flush intravenous solution 0.9 %

2

SYNAGEX ORAL CAPSULE 1.25 MG

4

SYNATEK ORAL CAPSULE 1.25 MG

4

SYNTHAMIN 17 INTRAVENOUS SOLUTION 10 %

GM

SYPRINE ORAL CAPSULE 250 MG

6 PA

TALIVA ORAL CAPSULE 1 MG

4

TANDEM F ORAL CAPSULE 162-115.2-1 MG

4

TANDEM PLUS ORAL CAPSULE 162-115.2-1 MG

4

TARON FORTE ORAL CAPSULE

4

taron-crystals oral packet 3300-1002 mg

2



148

Drug NameDrug Tier

Notes

TAURINE INJECTION SOLUTION 50 MG/ML

GM

thiamine hcl injection solution 100 mg/ml

GM

tis-u-sol irrigation solution 2

tl gard rx oral tablet 2.2-25-1 mg

2

TL G-FOL OS ORAL TABLET 500-1.1 MG

4

tl icon oral capsule 2

TL-FLUORIVITE ORAL TABLET CHEWABLE 0.25-7.5 MG

4

tl-hem 150 oral tablet 150-1 mg

2

tpn electrolytes intravenous solution

GM

TRAVASOL INTRAVENOUS SOLUTION 10 %

GM

TRICARE PRENATAL DHA ONE ORAL CAPSULE 27-1-500 MG

4

tricitrates oral solution 550-500-334 mg/5ml

2

tricon oral capsule 2

trientine hcl oral capsule 250 mg

6 PA

trigels-f forte oral capsule 460-60-0.01-1 mg

2

trinate oral tablet 2

triphrocaps oral capsule 1 mg

2

TRI-VI-FLOR ORAL SUSPENSION 0.25 MG/ML, 0.5 MG/ML

4

TRI-VI-FLORO ORAL SUSPENSION 0.25 MG/ML, 0.5 MG/ML

4

Drug NameDrug Tier

Notes

tri-vit/fluoride oral solution 0.25 mg/ml, 0.5 mg/ml

2

tri-vit/fluoride/iron oral solution 0.25-10 mg/ml

2

tri-vitamin/fluoride oral solution 0.25 mg/ml, 0.5 mg/ml

2

tri-vite/fluoride oral solution 0.25 mg/ml, 0.5 mg/ml

2

TRONVITE ORAL TABLET 1 MG

4

TROPHAMINE INTRAVENOUS SOLUTION 10 %, 6 %

GM

tryptophan oral capsule 500 mg

2

UDAMIN SP ORAL TABLET 1 MG

4

ULTRABAG/DIANEAL PD-2/1.5% DEX INTRAPERITONEAL SOLUTION 346 MOSM/L

4

ULTRABAG/DIANEAL PD-2/2.5% DEX INTRAPERITONEAL SOLUTION 396 MOSM/L

4

ULTRABAG/DIANEAL PD-2/4.25%DEX INTRAPERITONEAL SOLUTION 485 MOSM/L

4

ULTRABAG/DIANEAL/1.5% DEXTROSE INTRAPERITONEAL SOLUTION 344 MOSM/L

4

ULTRABAG/DIANEAL/2.5% DEXTROSE INTRAPERITONEAL SOLUTION 395 MOSM/L

4



149

Drug NameDrug Tier

Notes

ULTRABAG/DIANEAL/4.25% DEX INTRAPERITONEAL SOLUTION 483 MOSM/L

4

UROCIT-K 10 ORAL TABLET EXTENDED RELEASE 10 MEQ (1080 MG)

3


3


3

urosex oral tablet 2

v-c forte oral capsule 2

VELTASSA ORAL PACKET 16.8 GM, 25.2 GM, 8.4 GM

4 PA

VENOFER INTRAVENOUS SOLUTION 20 MG/ML

GM

vic-forte oral capsule 2

virt-caps oral capsule 1 mg

2

VIRT-FEFA PLUS ORAL CAPSULE

4

virt-gard oral tablet 2.2-25-1 mg

2

virt-phos 250 neutral oral tablet 155-852-130 mg

2

virtrate-2 oral solution 500-334 mg/5ml

2

virtrate-3 oral solution 550-500-334 mg/5ml

2

virtrate-k oral solution 1100-334 mg/5ml

2

virt-vite plus oral tablet 5 mg

2

vita s forte oral tablet 2

Drug NameDrug Tier

Notes

vitacel oral tablet 2

VITAFOL ORAL TABLET 4

VITAFOL-OB+DHA ORAL 65-1 & 250 MG

4

VITAL-D RX ORAL TABLET 1 MG

4

vitamax pediatric oral solution

2

VITAMEZ ORAL CAPSULE 1 MG

4

vitamin d (cholecalciferol) oral capsule 10 mcg (400 unit)

PVAL (Min 65

Years)

vitamin d (ergocalciferol) oral capsule 1.25 mg (50000 ut)

2

vitamin d3 oral tablet 10 mcg (400 unit)

PVAL (Min 65

Years)

vitamin k1 injection solution 1 mg/0.5ml, 10 mg/ml

GM

vita-min oral capsule 2

vitamins acd-fluoride oral solution 0.25 mg/ml

2

VITAROCA PLUS ORAL TABLET

4

VITA-RX DIABETIC VITAMIN ORAL CAPSULE

4

VITASURE ORAL TABLET 1 MG

4

vol-care rx oral tablet 1 mg

2

vol-tab rx oral tablet 29-1 mg

2

vp-pnv-dha oral capsule 28-1-215.8 mg

2

vp-vite rx oral tablet 1 mg 2

VP-ZEL ORAL TABLET 4

wheat germ oil oral oil 2



150

Drug NameDrug Tier

Notes

XVITE ORAL TABLET 1 MG

4

ZINC TRACE METAL INTRAVENOUS SOLUTION 1 MG/ML

GM

Gastrointestinal Agents - Drugs for Acid Reflux and Ulcer

ACIPHEX ORAL TABLET DELAYED RELEASE 20 MG

4

ACIPHEX SPRINKLE ORAL CAPSULE SPRINKLE 10 MG, 5 MG

4

CARAFATE ORAL SUSPENSION 1 GM/10ML

3

CARAFATE ORAL TABLET 1 GM

4

cimetidine hcl oral solution 300 mg/5ml

2

cimetidine oral tablet 200 mg, 300 mg, 400 mg, 800 mg

2

CYTOTEC ORAL TABLET 100 MCG, 200 MCG

4

DEXILANT ORAL CAPSULE DELAYED RELEASE 60 MG

4 PA

esomeprazole sodium intravenous solution reconstituted 20 mg, 40 mg

GM

famotidine intravenous solution 20 mg/2ml, 200 mg/20ml, 40 mg/4ml

GM

famotidine oral suspension reconstituted 40 mg/5ml

2

famotidine oral tablet 20 mg, 40 mg

2

Drug NameDrug Tier

Notes

famotidine premixed intravenous solution 20-0.9 mg/50ml-%

GM

FIRST-LANSOPRAZOLE ORAL SUSPENSION 3 MG/ML

4

FIRST-OMEPRAZOLE ORAL SUSPENSION 2 MG/ML

2

lansoprazole oral capsule delayed release 15 mg, 30 mg

2

lansoprazole oral tablet dispersible 15 mg, 30 mg

2

misoprostol oral tablet 100 mcg, 200 mcg

2

NEXIUM 24HR ORAL CAPSULE DELAYED RELEASE 20 MG

2QL (120

EA per 30 days)

NEXIUM 24HR ORAL TABLET DELAYED RELEASE 20 MG

2QL (120

EA per 30 days)

NEXIUM I.V. INTRAVENOUS SOLUTION RECONSTITUTED 40 MG

GM

nizatidine oral capsule 150 mg, 300 mg

2

nizatidine oral solution 15 mg/ml

2

omeprazole oral capsule delayed release 10 mg, 20 mg, 40 mg

2

OMEPRAZOLE+SYRSPEND SF ALKA ORAL SUSPENSION 2 MG/ML

2

pantoprazole sodium intravenous solution reconstituted 40 mg

GM

pantoprazole sodium oral tablet delayed release 20 mg, 40 mg

2



151

Drug NameDrug Tier

Notes

PEPCID ORAL SUSPENSION RECONSTITUTED 40 MG/5ML

4

PEPCID ORAL TABLET 20 MG, 40 MG

4

PREVACID ORAL CAPSULE DELAYED RELEASE 15 MG, 30 MG

4

PREVACID SOLUTAB ORAL TABLET DISPERSIBLE 15 MG, 30 MG

4

PRILOSEC ORAL PACKET 10 MG, 2.5 MG

4

PROTONIX INTRAVENOUS SOLUTION RECONSTITUTED 40 MG

GM

PROTONIX ORAL PACKET 40 MG

4

PROTONIX ORAL TABLET DELAYED RELEASE 20 MG, 40 MG

4

RABEPRAZOLE SODIUM ORAL CAPSULE SPRINKLE 10 MG

4

rabeprazole sodium oral tablet delayed release 20 mg

2

ranitidine hcl injection solution 1000 mg/40ml, 150 mg/6ml, 50 mg/2ml

GM

ranitidine hcl oral capsule 150 mg, 300 mg

2

ranitidine hcl oral syrup 15 mg/ml, 150 mg/10ml, 75 mg/5ml

1

Drug NameDrug Tier

Notes

ranitidine hcl oral tablet 150 mg, 300 mg

2

sucralfate oral tablet 1 gm

2

ZANTAC INJECTION SOLUTION 1000 MG/40ML, 150 MG/6ML, 50 MG/2ML

GM

ZANTAC ORAL TABLET 150 MG, 300 MG

4

Gastrointestinal Agents - Drugs for Bowel, Intestine and Stomach Conditions

ACTIGALL ORAL CAPSULE 300 MG

4

alosetron hcl oral tablet 0.5 mg, 1 mg

2

AMITIZA ORAL CAPSULE 24 MCG, 8 MCG

3QL (60 EA

per 30 days)

amoxicill-clarithro-lansopraz oral

2

ANASPAZ ORAL TABLET DISPERSIBLE 0.125 MG

4

ATROPINE SULFATE INTRAVENOUS SOLUTION PREFILLED SYRINGE 1.2 MG/3ML, 2 MG/5ML

GM

belladonna alkaloids-opium rectal suppository 16.2-30 mg, 16.2-60 mg

2

BENTYL INTRAMUSCULAR SOLUTION 10 MG/ML

GM

BENTYL ORAL CAPSULE 10 MG

4

CHENODAL ORAL TABLET 250 MG

6



152

Drug NameDrug Tier

Notes

chlordiazepoxide-clidinium oral capsule 5-2.5 mg

2

CHOLBAM ORAL CAPSULE 250 MG, 50 MG

6 PA

CLENPIQ ORAL SOLUTION 10-3.5-12 MG-GM -GM/160ML

4

COLYTE WITH FLAVOR PACKS ORAL SOLUTION RECONSTITUTED 240 GM

4

QL (1 ML per 365

days); AL (Min 50


constulose oral solution 10 gm/15ml

2

cromolyn sodium oral concentrate 100 mg/5ml

2

CUVPOSA ORAL SOLUTION 1 MG/5ML

4

dicyclomine hcl intramuscular solution 10 mg/ml

GM

dicyclomine hcl oral capsule 10 mg

1

dicyclomine hcl oral solution 10 mg/5ml

2

dicyclomine hcl oral tablet 20 mg

1

diphenoxylate-atropine oral liquid 2.5-0.025 mg/5ml

2

diphenoxylate-atropine oral tablet 2.5-0.025 mg

2

ed-spaz oral tablet dispersible 0.125 mg

2

ENTEREG ORAL CAPSULE 12 MG

4

enulose oral solution 10 gm/15ml

2

Drug NameDrug Tier

Notes

GASTROCROM ORAL CONCENTRATE 100 MG/5ML

4

GATTEX SUBCUTANEOUS KIT 5 MG

6 PA

gavilyte-c oral solution reconstituted 240 gm

2

QL (1 ML per 365

days); AL (Min 50


gavilyte-g oral solution reconstituted 236 gm

2

QL (1 ML per 365

days); AL (Min 50


gavilyte-h oral kit 5-210 mg-gm

2

gavilyte-n with flavor pack oral solution reconstituted 420 gm

2

QL (1 ML per 365

days); AL (Min 50


generlac oral solution 10 gm/15ml

2

glycopyrrolate injection solution 0.2 mg/ml, 0.4 mg/2ml, 1 mg/5ml, 4 mg/20ml

GM

GLYCOPYRROLATE INJECTION SOLUTION PREFILLED SYRINGE 0.6 MG/3ML, 1 MG/5ML

GM

GLYCOPYRROLATE INTRAVENOUS SOLUTION PREFILLED SYRINGE 0.4 MG/2ML

GM



153

Drug NameDrug Tier

Notes

glycopyrrolate oral tablet 1 mg, 2 mg

2

glycopyrrolate pf injection solution prefilled syringe 0.2 mg/ml, 0.4 mg/2ml

GM

GLYRX-PF INJECTION SOLUTION 0.2 MG/ML, 0.4 MG/2ML

GM

GOLYTELY ORAL SOLUTION RECONSTITUTED 227.1 GM

4

QL (1 EA per 365

days); AL (Min 50


GOLYTELY ORAL SOLUTION RECONSTITUTED 236 GM

4

QL (1 ML per 365

days); AL (Min 50


hyoscyamine sulfate er oral tablet extended release 12 hour 0.375 mg

2

hyoscyamine sulfate oral elixir 0.125 mg/5ml

2

hyoscyamine sulfate oral solution 0.125 mg/ml

2

hyoscyamine sulfate oral tablet 0.125 mg

2

hyoscyamine sulfate oral tablet dispersible 0.125 mg

2

hyoscyamine sulfate sl sublingual tablet sublingual 0.125 mg

2

hyoscyamine sulfate sublingual tablet sublingual 0.125 mg

2

KRISTALOSE ORAL PACKET 10 GM, 20 GM

4

Drug NameDrug Tier

Notes

lactulose encephalopathy oral solution 10 gm/15ml

2

lactulose oral packet 10 gm

2

lactulose oral solution 10 gm/15ml, 20 gm/30ml

2

LEVBID ORAL TABLET EXTENDED RELEASE 12 HOUR 0.375 MG

4

LEVSIN ORAL TABLET 0.125 MG

4

LEVSIN/SL SUBLINGUAL TABLET SUBLINGUAL 0.125 MG

4

LIBRAX ORAL CAPSULE 5-2.5 MG

4

LINZESS ORAL CAPSULE 145 MCG, 290 MCG, 72 MCG

3QL (30 EA

per 30 days)

LOMOTIL ORAL TABLET 2.5-0.025 MG

4

loperamide hcl oral capsule 2 mg

2

LOTRONEX ORAL TABLET 0.5 MG, 1 MG

4

methscopolamine bromide oral tablet 2.5 mg, 5 mg

2

mineral oil heavy oral oil 2

MOTEGRITY ORAL TABLET 1 MG, 2 MG

4QL (30 EA

per 30 days)

MOTOFEN ORAL TABLET 1-0.025 MG

4

MOVANTIK ORAL TABLET 12.5 MG, 25 MG

4QL (30 EA

per 30 days)

MOVIPREP ORAL SOLUTION RECONSTITUTED 100 GM

4



154

Drug NameDrug Tier

Notes

nulev oral tablet dispersible 0.125 mg

2

NULYTELY WITH FLAVOR PACKS ORAL SOLUTION RECONSTITUTED 420 GM

4

QL (1 ML per 365

days); AL (Min 50


OMECLAMOX-PAK ORAL 500-500-20 MG

4

opium oral tincture 10 mg/ml (1%)

2

oscimin oral tablet 0.125 mg

2

oscimin oral tablet dispersible 0.125 mg

2

oscimin sr oral tablet extended release 12 hour 0.375 mg

2

oscimin sublingual tablet sublingual 0.125 mg

2

OSMOPREP ORAL TABLET 1.102-0.398 GM

4

paregoric oral tincture 2 mg/5ml

2

peg 3350/electrolytes oral solution reconstituted 240 gm

2

QL (1 ML per 365

days); AL (Min 50


peg 3350-kcl-na bicarb-nacl oral solution reconstituted 420 gm

2

QL (1 ML per 365

days); AL (Min 50


Drug NameDrug Tier

Notes

peg-3350/electrolytes oral solution reconstituted 236 gm

2

QL (1 ML per 365

days); AL (Min 50


peg-prep oral kit 5-210 mg-gm

2

pegylax oral powder 2

phenobarbital-belladonna alk oral elixir 16.2 mg/5ml

2

polyethylene glycol 3350 oral packet

2

polyethylene glycol 3350 oral powder

2

PREPOPIK ORAL PACKET 10-3.5-12 MG-GM-GM

4

PREVPAC ORAL 4

propantheline bromide oral tablet 15 mg

2

PYLERA ORAL CAPSULE 140-125-125 MG

4

RELISTOR ORAL TABLET 150 MG

3 PA

RELISTOR SUBCUTANEOUS SOLUTION 12 MG/0.6ML, 8 MG/0.4ML

3 PA

ROBINUL INJECTION SOLUTION 0.2 MG/ML, 0.4 MG/2ML, 1 MG/5ML, 4 MG/20ML

GM

ROBINUL ORAL TABLET 1 MG

4

ROBINUL-FORTE ORAL TABLET 2 MG

4



155

Drug NameDrug Tier

Notes

SEROSTIM SUBCUTANEOUS SOLUTION RECONSTITUTED 4 MG, 5 MG, 6 MG

6 PA

sodium bicarbonate oral powder

2

SUPREP BOWEL PREP KIT ORAL SOLUTION 17.5-3.13-1.6 GM/177ML

4

SYMAX DUOTAB ORAL TABLET EXTENDED RELEASE 0.375 MG

4

symax-sr oral tablet extended release 12 hour 0.375 mg

2

SYMPROIC ORAL TABLET 0.2 MG

4QL (30 EA

per 30 days)

trilyte oral solution reconstituted 420 gm

2

QL (1 ML per 365

days); AL (Min 50


TRULANCE ORAL TABLET 3 MG

4QL (30 EA

per 30 days)

URSO 250 ORAL TABLET 250 MG

4

URSO FORTE ORAL TABLET 500 MG

4

ursodiol oral capsule 300 mg

2

ursodiol oral tablet 250 mg, 500 mg

2

VIBERZI ORAL TABLET 100 MG, 75 MG

5 PA

XERMELO ORAL TABLET 250 MG

6 PA

Drug NameDrug Tier

Notes

ZORBTIVE SUBCUTANEOUS SOLUTION RECONSTITUTED 8.8 MG

6 PA

Genetic or Enzyme Disorder - Drugs for Replacement, Modification, Treatment

ADAGEN INTRAMUSCULAR SOLUTION 250 UNIT/ML

6PA;

Specialty Medical

ALDURAZYME INTRAVENOUS SOLUTION 2.9 MG/5ML

6PA;

Specialty Medical

AMMONUL INTRAVENOUS SOLUTION 10-10 %

GM

BRINEURA KIT 2 X 150 MG/5ML

6PA;

Specialty Medical

BUPHENYL ORAL POWDER 3 GM/TSP

4

BUPHENYL ORAL TABLET 500 MG

4

CERDELGA ORAL CAPSULE 84 MG

6 PA

CEREZYME INTRAVENOUS SOLUTION RECONSTITUTED 400 UNIT

6PA;

Specialty Medical

CREON ORAL CAPSULE DELAYED RELEASE PARTICLES 12000 UNIT, 24000-76000 UNIT, 3000-9500 UNIT, 36000 UNIT, 6000 UNIT

3

CRYSVITA SUBCUTANEOUS SOLUTION 10 MG/ML, 20 MG/ML, 30 MG/ML

6PA;

Specialty Medical



156

Drug NameDrug Tier

Notes

CYSTADANE ORAL POWDER

4

CYSTAGON ORAL CAPSULE 150 MG, 50 MG

4

ELAPRASE INTRAVENOUS SOLUTION 6 MG/3ML

6PA;

Specialty Medical

ELELYSO INTRAVENOUS SOLUTION RECONSTITUTED 200 UNIT

6PA;

Specialty Medical

ENZADYNE ORAL CAPSULE

4

FABRAZYME INTRAVENOUS SOLUTION RECONSTITUTED 35 MG, 5 MG

6PA;

Specialty Medical

GALAFOLD ORAL CAPSULE 123 MG

6 PA

KANUMA INTRAVENOUS SOLUTION 20 MG/10ML

6PA;

Specialty Medical

KUVAN ORAL PACKET 100 MG, 500 MG

6

KUVAN ORAL TABLET SOLUBLE 100 MG

6 PA

LUMIZYME INTRAVENOUS SOLUTION RECONSTITUTED 50 MG

6PA;

Specialty Medical

MEPSEVII INTRAVENOUS SOLUTION 10 MG/5ML

6PA;

Specialty Medical

miglustat oral capsule 100 mg

6 PA

Drug NameDrug Tier

Notes

MYALEPT SUBCUTANEOUS SOLUTION RECONSTITUTED 11.3 MG

6 PA

NAGLAZYME INTRAVENOUS SOLUTION 1 MG/ML

6PA;

Specialty Medical

nitisinone oral capsule 10 mg, 2 mg, 5 mg

6 PA

NITYR ORAL TABLET 10 MG, 2 MG, 5 MG

6 PA

OCALIVA ORAL TABLET 10 MG, 5 MG

6 PA

ORFADIN ORAL CAPSULE 10 MG, 2 MG, 20 MG, 5 MG

6 PA

ORFADIN ORAL SUSPENSION 4 MG/ML

6 PA

PALYNZIQ SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 10 MG/0.5ML, 2.5 MG/0.5ML, 20 MG/ML

6 PA

PANCREAZE ORAL CAPSULE DELAYED RELEASE PARTICLES 10500 UNIT, 16800 UNIT, 21000 UNIT, 2600 UNIT, 4200 UNIT

4

PERTZYE ORAL CAPSULE DELAYED RELEASE PARTICLES 16000 UNIT, 24000-86250 UNIT, 4000 UNIT, 8000 UNIT

4

PROCYSBI ORAL CAPSULE DELAYED RELEASE 25 MG, 75 MG

6 PA

RAVICTI ORAL LIQUID 1.1 GM/ML

6 PA



157

Drug NameDrug Tier

Notes

REVCOVI INTRAMUSCULAR SOLUTION 2.4 MG/1.5ML

6PA;

Specialty Medical

sod benz-sod phenylacet intravenous solution 10-10 %

GM

sodium phenylbutyrate oral powder 3 gm/tsp

2

sodium phenylbutyrate oral tablet 500 mg

2

STRENSIQ SUBCUTANEOUS SOLUTION 18 MG/0.45ML, 28 MG/0.7ML, 40 MG/ML, 80 MG/0.8ML

6PA;

Specialty Medical

SUCRAID ORAL SOLUTION 8500 UNIT/ML

6 PA

VIMIZIM INTRAVENOUS SOLUTION 5 MG/5ML

6PA;

Specialty Medical

VIOKACE ORAL TABLET 10440 UNIT, 20880 UNIT

4

VPRIV INTRAVENOUS SOLUTION RECONSTITUTED 400 UNIT

6PA;

Specialty Medical

XURIDEN ORAL PACKET 2 GM

6 PA

ZAVESCA ORAL CAPSULE 100 MG

6 PA

Drug NameDrug Tier

Notes

ZENPEP ORAL CAPSULE DELAYED RELEASE PARTICLES 10000 UNIT, 10000-32000 UNIT, 15000-47000 UNIT, 15000-51000 UNIT, 20000-63000 UNIT, 20000-68000 UNIT, 25000 UNIT, 25000-79000 UNIT, 3000-10000 UNIT, 3000-14000 UNIT, 40000-126000 UNIT, 40000-136000 UNIT, 5000 UNIT, 5000-24000 UNIT

3

Genitourinary Agents - Drugs for Bladder, Genital and Kidney Conditions

acetic acid irrigation solution 0.25 %

2

aminoacetic acid irrigation solution 1.5 %

2

AURYXIA ORAL TABLET 1 GM 210 MG(FE)

4

azuphen mb oral capsule 120 mg

2

bethanechol chloride oral tablet 10 mg, 25 mg, 5 mg, 50 mg

2

BI-MIX INTRACAVERNOSAL SOLUTION RECONSTITUTED 150-5 MG

GM

calcium acetate (phos binder) oral capsule 667 mg

2

calcium acetate (phos binder) oral tablet 667 mg

2



158

Drug NameDrug Tier

Notes

CIALIS ORAL TABLET 10 MG, 20 MG

4

PA; QL (4 EA per 30 days); AL (Min 18 Years)

CIALIS ORAL TABLET 2.5 MG, 5 MG

4


darifenacin hydrobromide er oral tablet extended release 24 hour 15 mg, 7.5 mg

2

DEPEN TITRATABS ORAL TABLET 250 MG

5

DETROL LA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 2 MG, 4 MG

4

DETROL ORAL TABLET 1 MG, 2 MG

4

DITROPAN XL ORAL TABLET EXTENDED RELEASE 24 HOUR 10 MG, 15 MG, 5 MG

4

ELMIRON ORAL CAPSULE 100 MG

4

ENABLEX ORAL TABLET EXTENDED RELEASE 24 HOUR 15 MG, 7.5 MG

4

FEM PH VAGINAL GEL 0.9-0.025 %

4

flavoxate hcl oral tablet 100 mg

2

FOSRENOL ORAL TABLET CHEWABLE 1000 MG, 500 MG, 750 MG

4

GELNIQUE PUMP TRANSDERMAL GEL 10 %

4

Drug NameDrug Tier

Notes

GELNIQUE TRANSDERMAL GEL 10 %

4

glycine irrigation solution 1.5 %

2

glycine urologic irrigation solution 1.5 %

2

hyolev mb oral tablet 81 mg

2

hyophen oral tablet 81.6 mg

2

indiomin mb oral capsule 120 mg

2

INTRAROSA VAGINAL INSERT 6.5 MG

4

lanthanum carbonate oral tablet chewable 1000 mg, 500 mg, 750 mg

2

LITHOSTAT ORAL TABLET 250 MG

4

me/naphos/mb/hyo1 oral tablet 81.6 mg

2

MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HOUR 25 MG, 50 MG

3

oxybutynin chloride er oral tablet extended release 24 hour 10 mg, 15 mg, 5 mg

2

oxybutynin chloride oral syrup 5 mg/5ml

2

oxybutynin chloride oral tablet 5 mg

2

phenazo oral tablet 200 mg

2

phenazopyridine hcl oral tablet 100 mg, 200 mg

2

PHENYLEPHRINE HCL INTRACAVERNOSAL SOLUTION 2 MG/2ML

GM



159

Drug NameDrug Tier

Notes

PHOSLYRA ORAL SOLUTION 667 MG/5ML

4

phosphasal oral tablet 81.6 mg

2

PYRIDIUM ORAL TABLET 100 MG, 200 MG

4

QUAD-MIX INTRACAVERNOSAL SOLUTION RECONSTITUTED 150-10-0.1-1 MG

GM

RELAGARD VAGINAL GEL 0.9-0.025 %

4

RENACIDIN IRRIGATION SOLUTION

4

RENAGEL ORAL TABLET 400 MG, 800 MG

4

RENVELA ORAL PACKET 0.8 GM, 2.4 GM

4

RENVELA ORAL TABLET 800 MG

4

RIMSO-50 INTRAVESICAL SOLUTION 50 %

GM

sevelamer carbonate oral packet 0.8 gm, 2.4 gm

2

sevelamer carbonate oral tablet 800 mg

2

sevelamer hcl oral tablet 400 mg, 800 mg

2

sildenafil citrate oral tablet 100 mg, 25 mg, 50 mg


days)

solifenacin succinate oral tablet 10 mg, 5 mg

2

Drug NameDrug Tier

Notes

SUPER BI-MIX INTRACAVERNOSAL SOLUTION RECONSTITUTED 150-10 MG

GM

SUPER QUAD-MIX INTRACAVERNOSAL SOLUTION RECONSTITUTED 150-20-0.2-2 MG

GM

SUPER TRI-MIX INTRACAVERNOSAL SOLUTION RECONSTITUTED 150-10-100 MG-MG-MCG

GM

tadalafil oral tablet 10 mg, 20 mg

2


tadalafil oral tablet 2.5 mg, 5 mg

2


THIOLA EC ORAL TABLET DELAYED RELEASE 100 MG, 300 MG

4 PA

THIOLA ORAL TABLET 100 MG

4 PA

tolterodine tartrate er oral capsule extended release 24 hour 2 mg, 4 mg

2

tolterodine tartrate oral tablet 1 mg, 2 mg

2

TOVIAZ ORAL TABLET EXTENDED RELEASE 24 HOUR 4 MG, 8 MG

4

trospium chloride er oral capsule extended release 24 hour 60 mg

2



160

Drug NameDrug Tier

Notes

trospium chloride oral tablet 20 mg

2

ur n-c oral tablet 81.6 mg 2

uramit mb oral capsule 118 mg

2

URECHOLINE ORAL TABLET 10 MG, 25 MG, 5 MG, 50 MG

4

uretron d/s oral tablet 2

uribel oral capsule 118 mg

2

URIMAR-T ORAL TABLET 120 MG

4

urin ds oral tablet 2

uro-458 oral tablet 81 mg 2

UROGESIC-BLUE ORAL TABLET 81.6 MG

4

uro-mp oral capsule 118 mg

2

urophen mb oral tablet 81.6 mg

2

uryl oral tablet 81.6 mg 2

ustell oral capsule 120 mg

2

UTA ORAL CAPSULE 120 MG

4

uticap oral capsule 120 mg

2

utira-c oral tablet 81.6 mg 2

utrona-c oral tablet 81.6 mg

2

VELPHORO ORAL TABLET CHEWABLE 500 MG

6

VESICARE ORAL TABLET 10 MG, 5 MG

3

VIAGRA ORAL TABLET 100 MG, 25 MG, 50 MG


days)

Drug NameDrug Tier

Notes

vilamit mb oral capsule 118 mg

2

vilevev mb oral tablet 81 mg

2

Genitourinary Agents - Drugs for Prostate Conditions

alfuzosin hcl er oral tablet extended release 24 hour 10 mg

2

AVODART ORAL CAPSULE 0.5 MG

4

CARDURA XL ORAL TABLET EXTENDED RELEASE 24 HOUR 4 MG, 8 MG

3

dutasteride oral capsule 0.5 mg

2

dutasteride-tamsulosin hcl oral capsule 0.5-0.4 mg

2

finasteride oral tablet 5 mg

2

FLOMAX ORAL CAPSULE 0.4 MG

4

JALYN ORAL CAPSULE 0.5-0.4 MG

4

PROSCAR ORAL TABLET 5 MG

4

RAPAFLO ORAL CAPSULE 4 MG, 8 MG

4

silodosin oral capsule 4 mg, 8 mg

2

tamsulosin hcl oral capsule 0.4 mg

2

terazosin hcl oral capsule 1 mg, 10 mg, 2 mg, 5 mg

1

UROXATRAL ORAL TABLET EXTENDED RELEASE 24 HOUR 10 MG

4



161

Drug NameDrug Tier

Notes

Hormonal Agents - Adrenal

BETAMETHASONE COMBO INJECTION SUSPENSION 6 (3-3) MG/ML

GM

BETAMETHASONE SOD PHOS & ACET SUSPENSION 6 (3-3) MG/ML INJECTION 6 (3-3) MG/ML

GM

betamethasone sod phos & acet suspension 6 (3-3) mg/ml injection 6 (3-3) mg/ml

GM

BETAMETHASONE SODIUM PHOSPHATE INJECTION SOLUTION 12 MG/2ML, 6 MG/ML

GM

CELESTONE SOLUSPAN INJECTION SUSPENSION 6 (3-3) MG/ML

GM

CORTEF ORAL TABLET 10 MG, 20 MG, 5 MG

4

cortisone acetate oral tablet 25 mg

2

DECADRON ORAL ELIXIR 0.5 MG/5ML

4

DECADRON ORAL TABLET 0.5 MG, 0.75 MG, 4 MG, 6 MG

4

deltasone oral tablet 20 mg

1

DEPO-MEDROL INJECTION SUSPENSION 20 MG/ML, 40 MG/ML, 80 MG/ML

GM

DEXAMETHASONE INTENSOL ORAL CONCENTRATE 1 MG/ML

3

Drug NameDrug Tier

Notes

dexamethasone oral elixir 0.5 mg/5ml

2

dexamethasone oral solution 0.5 mg/5ml

2

dexamethasone oral tablet 0.5 mg, 0.75 mg, 1 mg, 1.5 mg, 2 mg, 4 mg, 6 mg

1

dexamethasone oral tablet therapy pack 1.5 mg (21), 1.5 mg (35), 1.5 mg (51)

2

DEXAMETHASONE SOD PHOS IN D5W INTRAVENOUS SOLUTION 10-5 MG/50ML-%, 12-5 MG/50ML-%, 20-5 MG/50ML-%, 8-5 MG/50ML-%

GM

DEXAMETHASONE SOD PHOS-BUPIV INJECTION SOLUTION PREFILLED SYRINGE 0.01-0.375 %

GM

DEXAMETHASONE SOD PHOS-NACL INTRAVENOUS SOLUTION 10-0.9 MG/50ML-%, 12-0.9 MG/50ML-%, 20-0.9 MG/50ML-%, 8-0.9 MG/50ML-%

GM

dexamethasone sod phosphate pf injection solution 10 mg/ml

GM

dexamethasone sod phosphate pf injection solution prefilled syringe 10 mg/ml

GM



162

Drug NameDrug Tier

Notes

dexamethasone sodium phosphate injection solution 10 mg/ml, 100 mg/10ml, 120 mg/30ml, 20 mg/5ml, 4 mg/ml

GM

DEXAMETHASONE SODIUM PHOSPHATE INTRAVENOUS SOLUTION PREFILLED SYRINGE 10 MG/2.5ML, 4 MG/ML, 8 MG/2ML

GM

DEXONTO 0.4% IONTOPHORESIS SOLUTION 20 MG/5ML

GM

DEXPAK 10 DAY ORAL TABLET THERAPY PACK 1.5 MG (35)

4


4


4

fludrocortisone acetate oral tablet 0.1 mg

2

HIDEX 6-DAY ORAL TABLET THERAPY PACK 1.5 MG (21)

4

hydrocortisone oral tablet 10 mg, 20 mg, 5 mg

2

KENALOG INJECTION SUSPENSION 10 MG/ML, 40 MG/ML

GM

KENALOG-80 INJECTION SUSPENSION 80 MG/ML

GM

LIDOCIDEX I INJECTION SOLUTION 5-10 MG/1.5ML

GM

MEDROL ORAL TABLET 16 MG, 2 MG, 32 MG, 4 MG, 8 MG

3

Drug NameDrug Tier

Notes

MEDROL ORAL TABLET THERAPY PACK 4 MG

4

METHYLPREDNISOLONE ACETATE INJECTION SUSPENSION 50 MG/ML

GM

METHYLPREDNISOLONE ACETATE SUSPENSION 40 MG/ML INJECTION 40 MG/ML

GM

methylprednisolone acetate suspension 40 mg/ml injection 40 mg/ml

GM

METHYLPREDNISOLONE ACETATE SUSPENSION 80 MG/ML INJECTION 80 MG/ML

GM

methylprednisolone acetate suspension 80 mg/ml injection 80 mg/ml

GM

methylprednisolone oral tablet 16 mg, 32 mg, 4 mg, 8 mg

2

methylprednisolone oral tablet therapy pack 4 mg

2

methylprednisolone sodium succ injection solution reconstituted 1000 mg, 125 mg, 40 mg, 500 mg

GM

METHYLPREDNISOLONE-BUPIVACAINE INJECTION SUSPENSION 40-5 MG/ML, 80-5 MG/ML

GM

MILLIPRED DP 12-DAY ORAL TABLET THERAPY PACK 5 MG (48)

4



163

Drug NameDrug Tier

Notes

MILLIPRED DP ORAL TABLET THERAPY PACK 5 MG (21), 5 MG (48)

4

MILLIPRED ORAL SOLUTION 10 MG/5ML

4

MILLIPRED ORAL TABLET 5 MG

3

ORAPRED ODT ORAL TABLET DISPERSIBLE 10 MG, 15 MG, 30 MG

4

PEDIAPRED ORAL SOLUTION 6.7 (5 BASE) MG/5ML

4

prednisolone oral solution 15 mg/5ml

2

prednisolone oral syrup 15 mg/5ml

2

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

2

prednisolone sodium phosphate oral tablet dispersible 10 mg, 15 mg, 30 mg

2

PREDNISONE INTENSOL ORAL CONCENTRATE 5 MG/ML

3

prednisone oral solution 5 mg/5ml

2

prednisone oral tablet 1 mg, 10 mg, 2.5 mg, 20 mg, 5 mg, 50 mg

1

prednisone oral tablet therapy pack 10 mg (21), 10 mg (48), 5 mg (21), 5 mg (48)

2

Drug NameDrug Tier

Notes

SOLU-CORTEF INJECTION SOLUTION RECONSTITUTED 100 MG, 1000 MG, 250 MG, 500 MG

GM

SOLU-MEDROL INJECTION SOLUTION RECONSTITUTED 1000 MG, 125 MG, 2 GM, 40 MG, 500 MG

GM

TAPERDEX 6-DAY ORAL TABLET THERAPY PACK 1.5 MG (21)

4

triamcinolone acetonide suspension 40 mg/ml injection 40 mg/ml

GM

TRIAMCINOLONE ACETONIDE SUSPENSION 40 MG/ML INJECTION 40 MG/ML

GM

TRIAMCINOLONE-BUPIVACAINE INJECTION SUSPENSION 40-5 MG/ML

GM

VERIPRED 20 ORAL SOLUTION 20 MG/5ML

4

ZILRETTA INTRA-ARTICULAR SUSPENSION RECONSTITUTED ER 32 MG

GM

ZODEX 6-DAY ORAL TABLET THERAPY PACK 1.5 MG (21)

4

Hormonal Agents - Men's Health

ANADROL-50 ORAL TABLET 50 MG

4



164

Drug NameDrug Tier

Notes

ANDRODERM TRANSDERMAL PATCH 24 HOUR 2 MG/24HR, 4 MG/24HR

4 PA

ANDROGEL PUMP TRANSDERMAL GEL 20.25 MG/ACT (1.62%)

3 PA

ANDROGEL TRANSDERMAL GEL 20.25 MG/1.25GM (1.62%), 25 MG/2.5GM (1%), 40.5 MG/2.5GM (1.62%), 50 MG/5GM (1%)

3 PA

ANDROID ORAL CAPSULE 10 MG

4

danazol oral capsule 100 mg, 200 mg, 50 mg

2

DEPO-TESTOSTERONE INTRAMUSCULAR SOLUTION 100 MG/ML, 200 MG/ML

4

FORTESTA TRANSDERMAL GEL 10 MG/ACT (2%)

4 PA

METHITEST ORAL TABLET 10 MG

4

methyltestosterone oral capsule 10 mg

2

NANDROLONE DECANOATE INJECTION OIL 200 MG/ML

GM

NANDROLONE-TESTOSTERONE CYP&EN INJECTION OIL 60-70-70 MG/ML

4

OXANDRIN ORAL TABLET 10 MG, 2.5 MG

4

oxandrolone oral tablet 10 mg, 2.5 mg

2

STRIANT BUCCAL 30 MG

4 PA

Drug NameDrug Tier

Notes

TESTIM TRANSDERMAL GEL 50 MG/5GM (1%)

4 PA

TESTONE CIK INTRAMUSCULAR KIT 200 MG/ML

4

TESTOPEL IMPLANT PELLET 75 MG

GM PA

TESTOSTERONE CYPIONATE & PROP INJECTION SOLUTION 160-40 MG/ML

4

TESTOSTERONE CYPIONATE INJECTION SOLUTION 100 MG/ML, 150 MG/ML, 200 MG/ML, 50 MG/ML

4

testosterone cypionate intramuscular solution 100 mg/ml, 200 mg/ml

2

TESTOSTERONE ENANTHATE INJECTION SOLUTION 200 MG/ML

4

testosterone enanthate intramuscular solution 200 mg/ml

2

TESTOSTERONE PROPIONATE INJECTION SOLUTION 100 MG/ML

4

testosterone transdermal gel 10 mg/act (2%), 12.5 mg/act (1%), 20.25 mg/1.25gm (1.62%), 20.25 mg/act (1.62%), 25 mg/2.5gm (1%), 40.5 mg/2.5gm (1.62%), 50 mg/5gm (1%)

2 PA

testosterone transdermal solution 30 mg/act

2 PA

TESTRED ORAL CAPSULE 10 MG

4



165

Drug NameDrug Tier

Notes

VOGELXO PUMP TRANSDERMAL GEL 12.5 MG/ACT (1%)

4 PA

VOGELXO TRANSDERMAL GEL 50 MG/5GM (1%)

4 PA

Hormonal Agents - Osteoporosis

clomiphene citrate oral tablet 50 mg

2 PA

EVISTA ORAL TABLET 60 MG

4

OSPHENA ORAL TABLET 60 MG

4

raloxifene hcl oral tablet 60 mg

PV

Hormonal Agents - Parathyroid

cinacalcet hcl oral tablet 30 mg, 60 mg, 90 mg

5 PA

SENSIPAR ORAL TABLET 30 MG, 60 MG, 90 MG

6 PA

Hormonal Agents - Pituitary

ACTHAR INJECTION GEL 80 UNIT/ML

6 PA

BRAVELLE INJECTION SOLUTION RECONSTITUTED 75 UNIT

6 PA

cabergoline oral tablet 0.5 mg

2

CETROTIDE SUBCUTANEOUS KIT 0.25 MG

6 PA

chorionic gonadotropin intramuscular solution reconstituted 10000 unit

6 PA

DDAVP INJECTION SOLUTION 4 MCG/ML

GM

Drug NameDrug Tier

Notes

DDAVP NASAL SOLUTION 0.01 %

4

DDAVP ORAL TABLET 0.1 MG, 0.2 MG

4

DDAVP RHINAL TUBE NASAL SOLUTION 0.01 %

4

desmopressin ace spray refrig nasal solution 0.01 %

2

desmopressin acetate injection solution 4 mcg/ml

GM

desmopressin acetate oral tablet 0.1 mg, 0.2 mg

2

desmopressin acetate spray nasal solution 0.01 %

2

EGRIFTA SUBCUTANEOUS SOLUTION RECONSTITUTED 1 MG

6 PA

ELIGARD SUBCUTANEOUS KIT 22.5 MG, 30 MG, 45 MG, 7.5 MG

6PA;

Specialty Medical

FIRMAGON SUBCUTANEOUS SOLUTION RECONSTITUTED 120 MG, 80 MG

6PA;

Specialty Medical

FOLLISTIM AQ SUBCUTANEOUS SOLUTION 300 UNT/0.36ML, 600 UNT/0.72ML, 900 UNT/1.08ML

5 PA

ganirelix acetate subcutaneous solution 250 mcg/0.5ml

6 PA



166

Drug NameDrug Tier

Notes

GENOTROPIN MINIQUICK SUBCUTANEOUS SOLUTION RECONSTITUTED 0.2 MG, 0.4 MG, 0.6 MG, 0.8 MG, 1 MG, 1.2 MG, 1.4 MG, 1.6 MG, 1.8 MG, 2 MG

6 PA

GENOTROPIN SUBCUTANEOUS SOLUTION RECONSTITUTED 12 MG, 5 MG

6 PA

GONAL-F INJECTION SOLUTION RECONSTITUTED 1050 UNIT, 450 UNIT

6 PA

GONAL-F RFF REDIJECT SUBCUTANEOUS SOLUTION 300 UNIT/0.5ML, 450 UNT/0.75ML, 900 UNIT/1.5ML

6 PA

GONAL-F RFF SUBCUTANEOUS SOLUTION RECONSTITUTED 75 UNIT

6 PA

HUMATROPE INJECTION SOLUTION RECONSTITUTED 12 MG, 24 MG, 5 MG, 6 MG

6 PA

INCRELEX SUBCUTANEOUS SOLUTION 40 MG/4ML

6 PA

leuprolide acetate injection kit 1 mg/0.2ml

6 PA

LEUPROLIDE ACETATE-BUPIVACAINE INTRAMUSCULAR SOLUTION 25-5 MG/ML

GM

Drug NameDrug Tier

Notes

LUPANETA PACK COMBINATION KIT 11.25 & 5 MG, 3.75 & 5 MG

6PA;

Specialty Medical

LUPRON DEPOT (1-MONTH) INTRAMUSCULAR KIT 3.75 MG, 7.5 MG

6PA;

Specialty Medical

LUPRON DEPOT (3-MONTH) INTRAMUSCULAR KIT 11.25 MG, 22.5 MG

6PA;

Specialty Medical

LUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT 30MG INTRAMUSCULAR KIT 30 MG

6PA;

Specialty Medical

LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT 45MG INTRAMUSCULAR KIT 45 MG

6PA;

Specialty Medical

LUPRON DEPOT-PED (1-MONTH) INTRAMUSCULAR KIT 11.25 MG, 15 MG, 7.5 MG

6PA;

Specialty Medical

LUPRON DEPOT-PED (3-MONTH) INTRAMUSCULAR KIT 11.25 MG (PED), 30 MG (PED)

6PA;

Specialty Medical

MENOPUR SUBCUTANEOUS SOLUTION RECONSTITUTED 75 UNIT

6 PA

NORDITROPIN FLEXPRO SUBCUTANEOUS SOLUTION 10 MG/1.5ML, 30 MG/3ML, 5 MG/1.5ML

6 PA



167

Drug NameDrug Tier

Notes

novarel intramuscular solution reconstituted 10000 unit

6 PA

NOVAREL INTRAMUSCULAR SOLUTION RECONSTITUTED 5000 UNIT

6 PA

NUTROPIN AQ NUSPIN 10 SUBCUTANEOUS SOLUTION 10 MG/2ML

6 PA


6 PA


6 PA

octreotide acetate solution 100 mcg/ml injection 100 mcg/ml

6 PA


5 PA


6 PA


5 PA


6 PA


5 PA


6 PA


5 PA

Drug NameDrug Tier

Notes


6 PA


5 PA

OMNITROPE SUBCUTANEOUS SOLUTION 10 MG/1.5ML, 5 MG/1.5ML

5 PA

OMNITROPE SUBCUTANEOUS SOLUTION RECONSTITUTED 5.8 MG

5 PA

ORILISSA ORAL TABLET 150 MG, 200 MG

4 PA

OVIDREL SUBCUTANEOUS INJECTABLE 250 MCG/0.5ML

6 PA

oxytocin injection solution 10 unit/ml

GM

OXYTOCIN-DEXTROSE INTRAVENOUS SOLUTION 10-5 UT/500ML-%, 15-5 UT/250ML-%, 20-5 UT/500ML-%, 30-5 UNIT/L-%, 30-5 UT/500ML-%

GM

OXYTOCIN-DEXTROSE-LACT RINGERS INTRAVENOUS SOLUTION 10-5 UNIT/L-%, 10-5 UT/500ML-%, 20-5 UNIT/L-%, 20-5 UT/500ML-%, 30-5 UNIT/L-%, 30-5 UT/500ML-%, 40-5 UNIT/L-%

GM



168

Drug NameDrug Tier

Notes

OXYTOCIN-LACTATED RINGERS INTRAVENOUS SOLUTION 10 UNIT/500ML, 10 UNIT/L, 15 UNIT/250ML, 20 UNIT/500ML, 20 UNIT/L, 30 UNIT/L, 40 UNIT/500ML, 40 UNIT/L

GM

OXYTOCIN-SODIUM CHLORIDE INTRAVENOUS SOLUTION 10-0.9 UNIT/L-%, 10-0.9 UT/500ML-%, 15-0.9 UT/250ML-%, 20-0.45 UNIT/L-%, 20-0.9 UT/500ML-%, 30-0.9 UNIT/L-%, 30-0.9 UT/500ML-%, 40-0.9 UNIT/L-%, 40-0.9 UT/500ML-%, 60-0.9 UNIT/L-%, 80-0.9 UNIT/L-%

GM

PITOCIN INJECTION SOLUTION 10 UNIT/ML

GM

pregnyl intramuscular solution reconstituted 10000 unit

6 PA

SAIZEN CLICK.EASY INJECTION SOLUTION RECONSTITUTED 8.8 MG

6 PA

SAIZEN INJECTION SOLUTION RECONSTITUTED 5 MG, 8.8 MG

6 PA

SAIZENPREP INJECTION SOLUTION RECONSTITUTED 8.8 MG

6 PA

Drug NameDrug Tier

Notes

SANDOSTATIN INJECTION SOLUTION 100 MCG/ML, 1000 MCG/ML, 200 MCG/ML, 50 MCG/ML, 500 MCG/ML

6 PA

SANDOSTATIN LAR DEPOT INTRAMUSCULAR KIT 10 MG, 20 MG, 30 MG

6PA;

Specialty Medical

SIGNIFOR LAR INTRAMUSCULAR SUSPENSION RECONSTITUTED ER 10 MG, 30 MG

6PA;

Specialty Medical

SIGNIFOR SUBCUTANEOUS SOLUTION 0.3 MG/ML, 0.6 MG/ML, 0.9 MG/ML

6 PA

SOMATULINE DEPOT SUBCUTANEOUS SOLUTION 120 MG/0.5ML, 60 MG/0.2ML, 90 MG/0.3ML

6PA;

Specialty Medical

SOMAVERT SUBCUTANEOUS SOLUTION RECONSTITUTED 10 MG, 15 MG, 20 MG, 25 MG, 30 MG

6 PA

STIMATE NASAL SOLUTION 1.5 MG/ML

3

SUPPRELIN LA SUBCUTANEOUS KIT 50 MG

6PA;

Specialty Medical

SYNAREL NASAL SOLUTION 2 MG/ML

3

TRELSTAR MIXJECT INTRAMUSCULAR SUSPENSION RECONSTITUTED 11.25 MG, 22.5 MG, 3.75 MG

6PA;

Specialty Medical



169

Drug NameDrug Tier

Notes

TRIPTODUR INTRAMUSCULAR SUSPENSION RECONSTITUTED ER 22.5 MG

6PA;

Specialty Medical

VANTAS SUBCUTANEOUS KIT 50 MG

6PA;

Specialty Medical

VAPRISOL INTRAVENOUS SOLUTION 20-5 MG/100ML-%

GM

VASOPRESSIN-DEXTROSE INTRAVENOUS SOLUTION 100-5 UT/100ML-%, 20-5 UT/100ML-%, 25-5 UT/250ML-%, 50-5 UT/250ML-%, 60-5 UT/100ML-%

GM

VASOPRESSIN-SODIUM CHLORIDE INTRAVENOUS SOLUTION 100-0.9 UT/100ML-%, 100-0.9 UT/250ML-%, 25-0.9 UT/250ML-%, 40-0.9 UT/100ML-%, 50-0.9 UT/250ML-%, 50-0.9 UT/50ML-%, 60-0.9 UT/100ML-%, 80-0.9 UT/100ML-%

GM

VASOSTRICT INTRAVENOUS SOLUTION 20 UNIT/ML

GM

ZOLADEX SUBCUTANEOUS IMPLANT 10.8 MG, 3.6 MG

6PA;

Specialty Medical

Hormonal Agents - Prostaglandins

carboprost tromethamine intramuscular solution 250 mcg/ml

GM

Drug NameDrug Tier

Notes

CERVIDIL VAGINAL INSERT 10 MG

4

HEMABATE INTRAMUSCULAR SOLUTION 250 MCG/ML

GM

KORLYM ORAL TABLET 300 MG

6 PA

PREPIDIL VAGINAL GEL 0.5 MG/3GM

4

PROSTIN E2 VAGINAL SUPPOSITORY 20 MG

4

Hormonal Agents - Sex Hormones and Birth Control

ACTIVELLA ORAL TABLET 0.5-0.1 MG, 1-0.5 MG

4

afirmelle oral tablet 0.1-20 mg-mcg

PV

ALORA PATCH TWICE WEEKLY 0.025 MG/24HR TRANSDERMAL 0.025 MG/24HR

3


4


3


4


3



170

Drug NameDrug Tier

Notes


4

ALORA TRANSDERMAL PATCH TWICE WEEKLY 0.05 MG/24HR

3

altavera oral tablet 0.15-30 mg-mcg

PV

alyacen 1/35 oral tablet 1-35 mg-mcg

PV

alyacen 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg

PV

amabelz oral tablet 0.5-0.1 mg, 1-0.5 mg

2

amethia lo oral tablet 0.1-0.02 & 0.01 mg

PV

amethia oral tablet 0.15-0.03 &0.01 mg

PV

amethyst oral tablet 90-20 mcg

PV

ANGELIQ ORAL TABLET 0.25-0.5 MG, 0.5-1 MG

4

ANNOVERA VAGINAL RING 0.013-0.15 MG/24HR

4

apri oral tablet 0.15-30 mg-mcg

PV

aranelle oral tablet 0.5/1/0.5-35 mg-mcg

PV

ashlyna oral tablet 0.15-0.03 &0.01 mg

PV

aubra eq oral tablet 0.1-20 mg-mcg

PV

aubra oral tablet 0.1-20 mg-mcg

PV

aurovela 1.5/30 oral tablet 1.5-30 mg-mcg

PV

aurovela 1/20 oral tablet 1-20 mg-mcg

PV

Drug NameDrug Tier

Notes

aurovela 24 fe oral tablet 1-20 mg-mcg(24)

PV

aurovela fe 1.5/30 oral tablet 1.5-30 mg-mcg

PV

aurovela fe 1/20 oral tablet 1-20 mg-mcg

PV

aviane oral tablet 0.1-20 mg-mcg

PV

AYGESTIN ORAL TABLET 5 MG

4

ayuna oral tablet 0.15-30 mg-mcg

PV

azurette oral tablet 0.15-0.02/0.01 mg (21/5)

PV

BALCOLTRA ORAL TABLET 0.1-20 MG-MCG(21)

4

balziva oral tablet 0.4-35 mg-mcg

PV

bekyree oral tablet 0.15-0.02/0.01 mg (21/5)

PV

BEYAZ ORAL TABLET 3-0.02-0.451 MG

4

blisovi 24 fe oral tablet 1-20 mg-mcg(24)

PV

blisovi fe 1.5/30 oral tablet 1.5-30 mg-mcg

PV

blisovi fe 1/20 oral tablet 1-20 mg-mcg

PV

BREVICON (28) ORAL TABLET 0.5-35 MG-MCG

4

briellyn oral tablet 0.4-35 mg-mcg

PV

camila oral tablet 0.35 mg

PV

camrese lo oral tablet 0.1-0.02 & 0.01 mg

PV

camrese oral tablet 0.15-0.03 &0.01 mg

PV



171

Drug NameDrug Tier

Notes

caziant oral tablet 0.1/0.125/0.15 -0.025 mg

PV

chateal eq oral tablet 0.15-30 mg-mcg

PV

chateal oral tablet 0.15-30 mg-mcg

PV

CLIMARA PRO TRANSDERMAL PATCH WEEKLY 0.045-0.015 MG/DAY

4

CLIMARA TRANSDERMAL PATCH WEEKLY 0.025 MG/24HR, 0.0375 MG/24HR, 0.05 MG/24HR, 0.06 MG/24HR, 0.075 MG/24HR, 0.1 MG/24HR

4

COMBIPATCH TRANSDERMAL PATCH TWICE WEEKLY 0.05-0.14 MG/DAY, 0.05-0.25 MG/DAY

4

covaryx hs oral tablet 0.625-1.25 mg

2

covaryx oral tablet 1.25-2.5 mg

2

CRINONE VAGINAL GEL 4 %, 8 %

4

cryselle-28 oral tablet 0.3-30 mg-mcg

PV

cyclafem 1/35 oral tablet 1-35 mg-mcg

PV

cyclafem 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg

PV

CYCLESSA ORAL TABLET 0.1/0.125/0.15 -0.025 MG

4

cyred eq oral tablet 0.15-30 mg-mcg

PV

cyred oral tablet 0.15-30 mg-mcg

PV

Drug NameDrug Tier

Notes

dasetta 1/35 oral tablet 1-35 mg-mcg

PV

dasetta 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg

PV

daysee oral tablet 0.15-0.03 &0.01 mg

PV

deblitane oral tablet 0.35 mg

PV

DELESTROGEN INTRAMUSCULAR OIL 10 MG/ML, 20 MG/ML, 40 MG/ML

4

delyla oral tablet 0.1-20 mg-mcg

PV

DEPO-ESTRADIOL INTRAMUSCULAR OIL 5 MG/ML

GM

DEPO-PROVERA INTRAMUSCULAR SUSPENSION 150 MG/ML

4

DEPO-PROVERA INTRAMUSCULAR SUSPENSION 400 MG/ML

GM

DEPO-PROVERA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 150 MG/ML

4

DEPO-SUBQ PROVERA 104 SUBCUTANEOUS SUSPENSION PREFILLED SYRINGE 104 MG/0.65ML

4

DESOGEN ORAL TABLET 0.15-30 MG-MCG

4

desogestrel-ethinyl estradiol oral tablet 0.15-0.02/0.01 mg (21/5), 0.15-30 mg-mcg

PV



172

Drug NameDrug Tier

Notes

DIVIGEL TRANSDERMAL GEL 0.25 MG/0.25GM, 0.5 MG/0.5GM, 0.75 MG/0.75GM, 1 MG/GM

4

dotti transdermal patch twice weekly 0.025 mg/24hr, 0.0375 mg/24hr, 0.05 mg/24hr, 0.075 mg/24hr, 0.1 mg/24hr

2

drospiren-eth estrad-levomefol oral tablet 3-0.02-0.451 mg, 3-0.03-0.451 mg

PV

drospirenone-ethinyl estradiol oral tablet 3-0.02 mg, 3-0.03 mg

PV

DUAVEE ORAL TABLET 0.45-20 MG

4

EC-RX PROGESTERONE TRANSDERMAL CREAM 10 %

4

eemt hs oral tablet 0.625-1.25 mg

2

eemt oral tablet 1.25-2.5 mg

2

ELESTRIN TRANSDERMAL GEL 0.52 MG/0.87 GM (0.06%)

4

elinest oral tablet 0.3-30 mg-mcg

PV

ELLA ORAL TABLET 30 MG

PV

emoquette oral tablet 0.15-30 mg-mcg

PV

ENDOMETRIN VAGINAL INSERT 100 MG

3

enpresse-28 oral tablet 50-30/75-40/ 125-30 mcg

PV

Drug NameDrug Tier

Notes

enskyce oral tablet 0.15-30 mg-mcg

PV

errin oral tablet 0.35 mg PV

est estrogens-methyltest ds oral tablet 1.25-2.5 mg

2

est estrogens-methyltest hs oral tablet 0.625-1.25 mg

2

est estrogens-methyltest oral tablet 1.25-2.5 mg

2

estarylla oral tablet 0.25-35 mg-mcg

PV

ESTRACE ORAL TABLET 0.5 MG, 1 MG, 2 MG

4

ESTRACE VAGINAL CREAM 0.1 MG/GM

3

estradiol oral tablet 0.5 mg, 1 mg, 2 mg

1

estradiol transdermal patch twice weekly 0.025 mg/24hr, 0.0375 mg/24hr, 0.05 mg/24hr, 0.075 mg/24hr, 0.1 mg/24hr

2

estradiol transdermal patch weekly 0.025 mg/24hr, 0.0375 mg/24hr, 0.05 mg/24hr, 0.06 mg/24hr, 0.075 mg/24hr, 0.1 mg/24hr

2

estradiol vaginal cream 0.1 mg/gm

2

estradiol vaginal tablet 10 mcg

2

estradiol valerate intramuscular oil 20 mg/ml, 40 mg/ml

2

estradiol-norethindrone acet oral tablet 0.5-0.1 mg, 1-0.5 mg

2



173

Drug NameDrug Tier

Notes

ESTRING VAGINAL RING 2 MG

3

ESTROGEL TRANSDERMAL GEL 0.75 MG/1.25 GM (0.06%)

4

estropipate oral tablet 0.75 mg, 1.5 mg, 3 mg

2

ESTROSTEP FE ORAL TABLET 1-20/1-30/1-35 MG-MCG

4

ethynodiol diac-eth estradiol oral tablet 1-35 mg-mcg, 1-50 mg-mcg

PV

EVAMIST TRANSDERMAL SOLUTION 1.53 MG/SPRAY

4

FALESSA ORAL KIT 20-1-0.1 MCG-MG

4

falmina oral tablet 0.1-20 mg-mcg

PV

fayosim oral tablet 42-21-21-7 days

PV

FEMHRT LOW DOSE ORAL TABLET 0.5-2.5 MG-MCG

3

FEMRING VAGINAL RING 0.05 MG/24HR, 0.1 MG/24HR

4

femynor oral tablet 0.25-35 mg-mcg

PV

FIRST-PROGESTERONE VGS VAGINAL SUPPOSITORY 100 MG, 200 MG

4

fyavolv oral tablet 0.5-2.5 mg-mcg, 1-5 mg-mcg

2

GENERESS FE ORAL TABLET CHEWABLE 0.8-25 MG-MCG

4

Drug NameDrug Tier

Notes

gianvi oral tablet 3-0.02 mg

PV

gildagia oral tablet 0.4-35 mg-mcg

PV

hailey 1.5/30 oral tablet 1.5-30 mg-mcg

PV

hailey 24 fe oral tablet 1-20 mg-mcg(24)

PV

heather oral tablet 0.35 mg

PV

hydroxyprogesterone caproate intramuscular oil 250 mg/ml

6PA;

Specialty Medical

hydroxyprogesterone caproate intramuscular solution 1.25 gm/5ml

5 PA

incassia oral tablet 0.35 mg

PV

introvale oral tablet 0.15-0.03 mg

PV

isibloom oral tablet 0.15-30 mg-mcg

PV

jasmiel oral tablet 3-0.02 mg

PV

jencycla oral tablet 0.35 mg

PV

jevantique lo oral tablet 0.5-2.5 mg-mcg

2

jinteli oral tablet 1-5 mg-mcg

2

jolessa oral tablet 0.15-0.03 mg

PV

jolivette oral tablet 0.35 mg

PV

juleber oral tablet 0.15-30 mg-mcg

PV

junel 1.5/30 oral tablet 1.5-30 mg-mcg

PV

junel 1/20 oral tablet 1-20 mg-mcg

PV



174

Drug NameDrug Tier

Notes

junel fe 1.5/30 oral tablet 1.5-30 mg-mcg

PV

junel fe 1/20 oral tablet 1-20 mg-mcg

PV

junel fe 24 oral tablet 1-20 mg-mcg(24)

PV

kaitlib fe oral tablet chewable 0.8-25 mg-mcg

PV

kalliga oral tablet 0.15-30 mg-mcg

PV

kariva oral tablet 0.15-0.02/0.01 mg (21/5)

PV

kelnor 1/35 oral tablet 1-35 mg-mcg

PV

kelnor 1/50 oral tablet 1-50 mg-mcg

PV

kimidess oral tablet 0.15-0.02/0.01 mg (21/5)

PV

kurvelo oral tablet 0.15-30 mg-mcg

PV

KYLEENA INTRAUTERINE INTRAUTERINE DEVICE 19.5 MG

GM

larin 1.5/30 oral tablet 1.5-30 mg-mcg

PV

larin 1/20 oral tablet 1-20 mg-mcg

PV

larin 24 fe oral tablet 1-20 mg-mcg(24)

PV

larin fe 1.5/30 oral tablet 1.5-30 mg-mcg

PV

larin fe 1/20 oral tablet 1-20 mg-mcg

PV

larissia oral tablet 0.1-20 mg-mcg

PV

layolis fe oral tablet chewable 0.8-25 mg-mcg

PV

leena oral tablet 0.5/1/0.5-35 mg-mcg

PV

Drug NameDrug Tier

Notes

lessina oral tablet 0.1-20 mg-mcg

PV

levonest oral tablet 50-30/75-40/ 125-30 mcg

PV

levonorgest-eth est & eth est oral tablet 42-21-21-7 days

PV

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

PV

levonorgestrel oral tablet 1.5 mg

PV

levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg, 0.15-30 mg-mcg, 90-20 mcg

PV

levonorg-eth estrad triphasic oral tablet

PV

levora 0.15/30 (28) oral tablet 0.15-30 mg-mcg

PV

LILETTA (52 MG) INTRAUTERINE INTRAUTERINE DEVICE 19.5 MCG/DAY

GM

lillow oral tablet 0.15-30 mg-mcg

PV

LO LOESTRIN FE ORAL TABLET 1 MG-10 MCG / 10 MCG

4

LOESTRIN 1.5/30 (21) ORAL TABLET 1.5-30 MG-MCG

4

LOESTRIN 1/20 (21) ORAL TABLET 1-20 MG-MCG

4

LOESTRIN FE 1.5/30 ORAL TABLET 1.5-30 MG-MCG

4

LOESTRIN FE 1/20 ORAL TABLET 1-20 MG-MCG

4



175

Drug NameDrug Tier

Notes

lomedia 24 fe oral tablet 1-20 mg-mcg(24)

PV

lopreeza oral tablet 0.5-0.1 mg, 1-0.5 mg

2

loryna oral tablet 3-0.02 mg

PV

LOSEASONIQUE ORAL TABLET 0.1-0.02 & 0.01 MG

4

low-ogestrel oral tablet 0.3-30 mg-mcg

PV

lo-zumandimine oral tablet 3-0.02 mg

PV

lutera oral tablet 0.1-20 mg-mcg

PV

lyza oral tablet 0.35 mg PV

MAKENA INTRAMUSCULAR OIL 250 MG/ML

6PA;

Specialty Medical

MAKENA SUBCUTANEOUS SOLUTION AUTO-INJECTOR 275 MG/1.1ML

6 PA

marlissa oral tablet 0.15-30 mg-mcg

PV

medroxyprogesterone acetate intramuscular suspension 150 mg/ml

PV

medroxyprogesterone acetate intramuscular suspension prefilled syringe 150 mg/ml

PV

medroxyprogesterone acetate oral tablet 10 mg, 2.5 mg, 5 mg

1

MEGACE ES ORAL SUSPENSION 625 MG/5ML

4

Drug NameDrug Tier

Notes

megestrol acetate oral suspension 40 mg/ml, 400 mg/10ml, 625 mg/5ml

2

megestrol acetate oral tablet 20 mg, 40 mg

2

melodetta 24 fe oral tablet chewable 1-20 mg-mcg(24)

PV

MENEST ORAL TABLET 0.3 MG, 0.625 MG, 1.25 MG

3

MENOSTAR TRANSDERMAL PATCH WEEKLY 14 MCG/24HR

3

mibelas 24 fe oral tablet chewable 1-20 mg-mcg(24)

PV

microgestin 1.5/30 oral tablet 1.5-30 mg-mcg

PV

microgestin 1/20 oral tablet 1-20 mg-mcg

PV

microgestin fe 1.5/30 oral tablet 1.5-30 mg-mcg

PV

microgestin fe 1/20 oral tablet 1-20 mg-mcg

PV

mili oral tablet 0.25-35 mg-mcg

PV

mimvey lo oral tablet 0.5-0.1 mg

2

mimvey oral tablet 1-0.5 mg

2

MINASTRIN 24 FE ORAL TABLET CHEWABLE 1-20 MG-MCG(24)

4

MINIVELLE TRANSDERMAL PATCH TWICE WEEKLY 0.025 MG/24HR, 0.0375 MG/24HR, 0.05 MG/24HR, 0.075 MG/24HR, 0.1 MG/24HR

3



176

Drug NameDrug Tier

Notes

MIRCETTE ORAL TABLET 0.15-0.02/0.01 MG (21/5)

4

MIRENA (52 MG) INTRAUTERINE INTRAUTERINE DEVICE 20 MCG/24HR

GM

mono-linyah oral tablet 0.25-35 mg-mcg

PV

mononessa oral tablet 0.25-35 mg-mcg

PV

myzilra oral tablet 50-30/75-40/ 125-30 mcg

PV

NATAZIA ORAL TABLET 3/2-2/2-3/1 MG

PV

necon 0.5/35 (28) oral tablet 0.5-35 mg-mcg

PV

necon 1/50 (28) oral tablet 1-50 mg-mcg

PV

necon 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg

PV

NEXPLANON SUBCUTANEOUS IMPLANT 68 MG

GM

nikki oral tablet 3-0.02 mg

PV

nora-be oral tablet 0.35 mg

PV

norethin ace-eth estrad-fe oral tablet 1-20 mg-mcg, 1-20 mg-mcg(24)

PV

norethin ace-eth estrad-fe oral tablet chewable 1-20 mg-mcg(24)

PV

norethindrone acetate oral tablet 5 mg

2

norethindrone acet-ethinyl est oral tablet 1-20 mg-mcg, 1.5-30 mg-mcg

PV

Drug NameDrug Tier

Notes

norethindrone acet-ethinyl est oral tablet chewable 1-20 mg-mcg(24)

PV

norethindrone oral tablet 0.35 mg

PV

norethindrone-eth estradiol oral tablet 0.5-2.5 mg-mcg, 1-5 mg-mcg

2

norethin-eth estradiol-fe oral tablet chewable 0.4-35 mg-mcg, 0.8-25 mg-mcg

PV

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

PV

norgestimate-ethinyl estradiol triphasic oral tablet 0.18/0.215/0.25 mg-25 mcg, 0.18/0.215/0.25 mg-35 mcg

PV

norlyda oral tablet 0.35 mg

PV

norlyroc oral tablet 0.35 mg

PV

nortrel 0.5/35 (28) oral tablet 0.5-35 mg-mcg

PV

nortrel 1/35 (21) oral tablet 1-35 mg-mcg

PV

nortrel 1/35 (28) oral tablet 1-35 mg-mcg

PV

nortrel 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg

PV

NUVARING VAGINAL RING 0.12-0.015 MG/24HR

PV

ocella oral tablet 3-0.03 mg

PV

ogestrel oral tablet 0.5-50 mg-mcg

PV



177

Drug NameDrug Tier

Notes

orsythia oral tablet 0.1-20 mg-mcg

PV

ORTHO MICRONOR ORAL TABLET 0.35 MG

4

ORTHO TRI-CYCLEN (28) ORAL TABLET 0.18/0.215/0.25 MG-35 MCG

4

ORTHO TRI-CYCLEN LO ORAL TABLET 0.18/0.215/0.25 MG-25 MCG

4

ORTHO-CYCLEN (28) ORAL TABLET 0.25-35 MG-MCG

4

ORTHO-NOVUM 1/35 (28) ORAL TABLET 1-35 MG-MCG

4

ORTHO-NOVUM 7/7/7 (28) ORAL TABLET 0.5/0.75/1-35 MG-MCG

4

PARAGARD INTRAUTERINE COPPER INTRAUTERINE INTRAUTERINE DEVICE

GM

philith oral tablet 0.4-35 mg-mcg

PV

pimtrea oral tablet 0.15-0.02/0.01 mg (21/5)

PV

pirmella 1/35 oral tablet 1-35 mg-mcg

PV

pirmella 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg

PV

PLAN B ONE-STEP ORAL TABLET 1.5 MG

4

portia-28 oral tablet 0.15-30 mg-mcg

PV

PREFEST ORAL TABLET 1/1-0.09 MG (15/15)

4

Drug NameDrug Tier

Notes

PREMARIN INJECTION SOLUTION RECONSTITUTED 25 MG

GM

PREMARIN ORAL TABLET 0.3 MG, 0.45 MG, 0.625 MG, 0.9 MG, 1.25 MG

4

PREMARIN VAGINAL CREAM 0.625 MG/GM

4

PREMPHASE ORAL TABLET 0.625-5 MG

4

PREMPRO ORAL TABLET 0.3-1.5 MG, 0.45-1.5 MG, 0.625-2.5 MG, 0.625-5 MG

4

preventeza oral tablet 1.5 mg

PV

previfem oral tablet 0.25-35 mg-mcg

PV

progesterone intramuscular oil 50 mg/ml

2

progesterone micronized oral capsule 100 mg, 200 mg

2

progesterone micronized transdermal cream 10 %

2

PROMETRIUM ORAL CAPSULE 100 MG, 200 MG

4

PROVERA ORAL TABLET 10 MG, 2.5 MG, 5 MG

4

QUARTETTE ORAL TABLET 42-21-21-7 DAYS

4

quasense oral tablet 0.15-0.03 mg

PV

rajani oral tablet 3-0.02-0.451 mg

PV



178

Drug NameDrug Tier

Notes

reclipsen oral tablet 0.15-30 mg-mcg

PV

rivelsa oral tablet 42-21-21-7 days

PV

SAFYRAL ORAL TABLET 3-0.03-0.451 MG

4

SEASONIQUE ORAL TABLET 0.15-0.03 &0.01 MG

4

setlakin oral tablet 0.15-0.03 mg

PV

sharobel oral tablet 0.35 mg

PV

simliya oral tablet 0.15-0.02/0.01 mg (21/5)

PV

simpesse oral tablet 0.15-0.03 &0.01 mg

PV

SKYLA INTRAUTERINE INTRAUTERINE DEVICE 13.5 MG

GM

SLYND ORAL TABLET 4 MG

4

sprintec 28 oral tablet 0.25-35 mg-mcg

PV

sronyx oral tablet 0.1-20 mg-mcg

PV

syeda oral tablet 3-0.03 mg

PV

tarina 24 fe oral tablet 1-20 mg-mcg(24)

PV

tarina fe 1/20 eq oral tablet 1-20 mg-mcg

PV

tarina fe 1/20 oral tablet 1-20 mg-mcg

PV

TAYTULLA ORAL CAPSULE 1-20 MG-MCG(24)

4

tilia fe oral tablet 1-20/1-30/1-35 mg-mcg

PV

Drug NameDrug Tier

Notes

tri femynor oral tablet 0.18/0.215/0.25 mg-35 mcg

PV

tri-estarylla oral tablet 0.18/0.215/0.25 mg-35 mcg

PV

tri-legest fe oral tablet 1-20/1-30/1-35 mg-mcg

PV

tri-linyah oral tablet 0.18/0.215/0.25 mg-35 mcg

PV

tri-lo-estarylla oral tablet 0.18/0.215/0.25 mg-25 mcg

PV

tri-lo-marzia oral tablet 0.18/0.215/0.25 mg-25 mcg

PV

tri-lo-mili oral tablet 0.18/0.215/0.25 mg-25 mcg

PV

tri-lo-sprintec oral tablet 0.18/0.215/0.25 mg-25 mcg

PV

tri-mili oral tablet 0.18/0.215/0.25 mg-35 mcg

PV

trinessa (28) oral tablet 0.18/0.215/0.25 mg-35 mcg

PV

trinessa lo oral tablet 0.18/0.215/0.25 mg-25 mcg

PV

TRI-NORINYL (28) ORAL TABLET 0.5/1/0.5-35 MG-MCG

4

tri-previfem oral tablet 0.18/0.215/0.25 mg-35 mcg

PV

tri-sprintec oral tablet 0.18/0.215/0.25 mg-35 mcg

PV

trivora (28) oral tablet 50-30/75-40/ 125-30 mcg

PV



179

Drug NameDrug Tier

Notes

tri-vylibra lo oral tablet 0.18/0.215/0.25 mg-25 mcg

PV

tri-vylibra oral tablet 0.18/0.215/0.25 mg-35 mcg

PV

tulana oral tablet 0.35 mg PV

tydemy oral tablet 3-0.03-0.451 mg

PV

VAGIFEM VAGINAL TABLET 10 MCG

4

velivet oral tablet 0.1/0.125/0.15 -0.025 mg

PV

vestura oral tablet 3-0.02 mg

PV

vienva oral tablet 0.1-20 mg-mcg

PV

viorele oral tablet 0.15-0.02/0.01 mg (21/5)

PV

VIVELLE-DOT TRANSDERMAL PATCH TWICE WEEKLY 0.025 MG/24HR, 0.0375 MG/24HR, 0.05 MG/24HR, 0.075 MG/24HR, 0.1 MG/24HR

4

vyfemla oral tablet 0.4-35 mg-mcg

PV

vylibra oral tablet 0.25-35 mg-mcg

PV

wera oral tablet 0.5-35 mg-mcg

PV

wymzya fe oral tablet chewable 0.4-35 mg-mcg

PV

xulane transdermal patch weekly 150-35 mcg/24hr

PV

YASMIN 28 ORAL TABLET 3-0.03 MG

4

YAZ ORAL TABLET 3-0.02 MG

4

yuvafem vaginal tablet 10 mcg

2

Drug NameDrug Tier

Notes

zarah oral tablet 3-0.03 mg

PV

zenchent oral tablet 0.4-35 mg-mcg

PV

zovia 1/35e (28) oral tablet 1-35 mg-mcg

PV

zovia 1/50e (28) oral tablet 1-50 mg-mcg

PV

zumandimine oral tablet 3-0.03 mg

PV

Hormonal Agents - Thyroid

ARMOUR THYROID ORAL TABLET 120 MG, 15 MG, 180 MG, 240 MG, 30 MG, 300 MG, 60 MG, 90 MG

3

CYTOMEL ORAL TABLET 25 MCG, 5 MCG, 50 MCG

4

euthyrox oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg

2

levo-t oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg

2

levothyroxine sodium intravenous solution 100 mcg/5ml, 200 mcg/5ml, 500 mcg/5ml

GM

levothyroxine sodium intravenous solution reconstituted 100 mcg, 200 mcg, 500 mcg

GM



180

Drug NameDrug Tier

Notes

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

2

levothyroxine-liothyronine oral tablet 30 mg, 60 mg, 90 mg

2

levoxyl oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg

2

liothyronine sodium intravenous solution 10 mcg/ml

GM

liothyronine sodium oral tablet 25 mcg, 5 mcg, 50 mcg

2

methimazole oral tablet 10 mg, 5 mg

2

NATURE-THROID ORAL TABLET 113.75 MG, 130 MG, 146.25 MG, 16.25 MG, 162.5 MG, 195 MG, 260 MG, 32.5 MG, 325 MG, 48.75 MG, 65 MG, 81.25 MG, 97.5 MG

4

np thyroid oral tablet 120 mg, 15 mg, 30 mg, 60 mg, 90 mg

2

PARSABIV INTRAVENOUS SOLUTION 10 MG/2ML, 2.5 MG/0.5ML, 5 MG/ML

6Specialty Medical

propylthiouracil oral tablet 50 mg

2

Drug NameDrug Tier

Notes

SYNTHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG

3

TAPAZOLE ORAL TABLET 10 MG, 5 MG

4

thyroid oral tablet 120 mg, 15 mg

2

THYROLAR-1 ORAL TABLET 60 (12.5-50) MG (MCG)

3

THYROLAR-1/2 ORAL TABLET 30 (6.25-25) MG (MCG)

3

THYROLAR-1/4 ORAL TABLET 15 (3.1-12.5) MG (MCG)

3

THYROLAR-2 ORAL TABLET 120 (25-100) MG (MCG)

3

THYROLAR-3 ORAL TABLET 180 (37.5-150) MG (MCG)

3

TIROSINT ORAL CAPSULE 100 MCG, 112 MCG, 125 MCG, 13 MCG, 137 MCG, 150 MCG, 25 MCG, 50 MCG, 75 MCG, 88 MCG

4

TRIOSTAT INTRAVENOUS SOLUTION 10 MCG/ML

GM

unithroid oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg

2



181

Drug NameDrug Tier

Notes

WESTHROID ORAL TABLET 130 MG, 195 MG, 32.5 MG, 65 MG, 97.5 MG

4

WP THYROID ORAL TABLET 113.75 MG, 130 MG, 16.25 MG, 32.5 MG, 48.75 MG, 65 MG, 81.25 MG, 97.5 MG

4

Immunological Agents - Drugs for Immune System Stimulation or Suppression

ACTEMRA ACTPEN SUBCUTANEOUS SOLUTION AUTO-INJECTOR 162 MG/0.9ML

6 PA

ACTEMRA INTRAVENOUS SOLUTION 200 MG/10ML, 400 MG/20ML, 80 MG/4ML

6PA;

Specialty Medical

ACTEMRA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 162 MG/0.9ML

6 PA

ACTIMMUNE SUBCUTANEOUS SOLUTION 2000000 UNIT/0.5ML

6 PA

ALFERON N INJECTION SOLUTION 5000000 UNIT/ML

6PA;

Specialty Medical

ARAVA ORAL TABLET 10 MG, 20 MG

4

ARCALYST SUBCUTANEOUS SOLUTION RECONSTITUTED 220 MG

6 PA

Drug NameDrug Tier

Notes

ASTAGRAF XL ORAL CAPSULE EXTENDED RELEASE 24 HOUR 0.5 MG, 1 MG, 5 MG

4

ATGAM INTRAVENOUS INJECTABLE 50 MG/ML

6PA;

Specialty Medical

AZASAN ORAL TABLET 100 MG, 75 MG

4

azathioprine oral tablet 50 mg

2

azathioprine sodium injection solution reconstituted 100 mg

GM

BENLYSTA INTRAVENOUS SOLUTION RECONSTITUTED 120 MG, 400 MG

6PA;

Specialty Medical

BENLYSTA SUBCUTANEOUS SOLUTION AUTO-INJECTOR 200 MG/ML

6 PA

BENLYSTA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 200 MG/ML

6 PA

BERINERT INTRAVENOUS KIT 500 UNIT

6PA;

Specialty Medical

BIVIGAM INTRAVENOUS SOLUTION 5 GM/50ML

6PA;

Specialty Medical

CARIMUNE NF SOLUTION RECONSTITUTED 12 GM INTRAVENOUS 12 GM

6PA;

Specialty Medical

carimune nf solution reconstituted 12 gm intravenous 12 gm

6PA;

Specialty Medical



182

Drug NameDrug Tier

Notes

CARIMUNE NF SOLUTION RECONSTITUTED 6 GM INTRAVENOUS 6 GM

6PA;

Specialty Medical

carimune nf solution reconstituted 6 gm intravenous 6 gm

6PA;

Specialty Medical

CELLCEPT INTRAVENOUS INTRAVENOUS SOLUTION RECONSTITUTED 500 MG

GM

CELLCEPT ORAL CAPSULE 250 MG

4

CELLCEPT ORAL SUSPENSION RECONSTITUTED 200 MG/ML

4

CELLCEPT ORAL TABLET 500 MG

4

CIMZIA PREFILLED KIT SUBCUTANEOUS KIT 2 X 200 MG/ML

6 PA

CIMZIA STARTER KIT SUBCUTANEOUS KIT 6 X 200 MG/ML

6 PA

CIMZIA SUBCUTANEOUS KIT 2 X 200 MG

6 PA

CINRYZE INTRAVENOUS SOLUTION RECONSTITUTED 500 UNIT

6PA;

Specialty Medical

COSENTYX (300 MG DOSE) SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 150 MG/ML

6 PA

COSENTYX 150 MG/ML SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 150 MG/ML

6 PA

Drug NameDrug Tier

Notes

COSENTYX SENSOREADY (300 MG) SUBCUTANEOUS SOLUTION AUTO-INJECTOR 150 MG/ML

6 PA

COSENTYX SENSOREADY PEN SUBCUTANEOUS SOLUTION AUTO-INJECTOR 150 MG/ML

6 PA

CUTAQUIG SUBCUTANEOUS SOLUTION 1 GM/6ML, 1.65 GM/10ML, 2 GM/12ML, 3.3 GM/20ML, 4 GM/24ML, 8 GM/48ML

6 PA

CUVITRU SUBCUTANEOUS SOLUTION 1 GM/5ML, 10 GM/50ML, 2 GM/10ML, 4 GM/20ML, 8 GM/40ML

6 PA

cyclosporine intravenous solution 50 mg/ml

GM

cyclosporine modified oral capsule 100 mg, 25 mg, 50 mg

2

cyclosporine modified oral solution 100 mg/ml

2

cyclosporine oral capsule 100 mg, 25 mg

2

CYTOGAM INTRAVENOUS INJECTABLE 50 MG/ML

6Specialty Medical

ENBREL MINI SUBCUTANEOUS SOLUTION CARTRIDGE 50 MG/ML

5 PA

ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 25 MG/0.5ML, 50 MG/ML

5 PA



183

Drug NameDrug Tier

Notes

ENBREL SUBCUTANEOUS SOLUTION RECONSTITUTED 25 MG

5 PA

ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 50 MG/ML

5 PA

ENTYVIO INTRAVENOUS SOLUTION RECONSTITUTED 300 MG

6PA;

Specialty Medical

ENVARSUS XR ORAL TABLET EXTENDED RELEASE 24 HOUR 0.75 MG, 1 MG, 4 MG

4

FIRAZYR SUBCUTANEOUS SOLUTION 30 MG/3ML


days)

FLEBOGAMMA DIF INTRAVENOUS SOLUTION 0.5 GM/10ML, 10 GM/100ML, 10 GM/200ML, 2.5 GM/50ML, 20 GM/200ML, 20 GM/400ML, 5 GM/100ML, 5 GM/50ML

6PA;

Specialty Medical

GAMASTAN INTRAMUSCULAR INJECTABLE

6PA;

Specialty Medical

GAMASTAN S/D INTRAMUSCULAR INJECTABLE

6PA;

Specialty Medical

GAMIFANT INTRAVENOUS SOLUTION 10 MG/2ML, 50 MG/10ML

6PA;

Specialty Medical

Drug NameDrug Tier

Notes

GAMMAGARD INJECTION SOLUTION 1 GM/10ML, 10 GM/100ML, 2.5 GM/25ML, 20 GM/200ML, 30 GM/300ML, 5 GM/50ML

6PA;

Specialty Medical

GAMMAGARD S/D LESS IGA INTRAVENOUS SOLUTION RECONSTITUTED 10 GM, 5 GM

6PA;

Specialty Medical

GAMMAKED INJECTION SOLUTION 10 GM/100ML, 20 GM/200ML, 5 GM/50ML

6PA;

Specialty Medical

GAMMAPLEX INTRAVENOUS SOLUTION 10 GM/100ML, 10 GM/200ML, 20 GM/200ML, 20 GM/400ML, 5 GM/100ML, 5 GM/50ML

6PA;

Specialty Medical

GAMUNEX-C INJECTION SOLUTION 1 GM/10ML, 10 GM/100ML, 2.5 GM/25ML, 20 GM/200ML, 40 GM/400ML, 5 GM/50ML

6PA;

Specialty Medical

gengraf oral capsule 100 mg, 25 mg, 50 mg

2

gengraf oral solution 100 mg/ml

2

HAEGARDA SUBCUTANEOUS SOLUTION RECONSTITUTED 2000 UNIT, 3000 UNIT

6 PA

HEPAGAM B INJECTION SOLUTION

GM



184

Drug NameDrug Tier

Notes

HIZENTRA SUBCUTANEOUS SOLUTION 1 GM/5ML, 10 GM/50ML, 2 GM/10ML, 4 GM/20ML

6 PA

HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 40 MG/0.8ML, 80 MG/0.8ML, 80 MG/0.8ML & 40MG/0.4ML

5 PA

HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.4ML, 40 MG/0.8ML

5 PA

HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML, 80 MG/0.8ML

5 PA

HUMIRA PEN-PS/UV/ADOL HS START SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML, 80 MG/0.8ML & 40MG/0.4ML

5 PA

HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 10 MG/0.1ML, 10 MG/0.2ML, 20 MG/0.2ML, 20 MG/0.4ML, 40 MG/0.4ML, 40 MG/0.8ML

5 PA

HYPERHEP B S/D INTRAMUSCULAR SOLUTION

GM

HYPERRAB INJECTION SOLUTION 1500 UNIT/5ML, 300 UNIT/ML

GM

HYPERRAB S/D INJECTION SOLUTION 1500 UNIT/10ML, 300 UNIT/2ML

GM

Drug NameDrug Tier

Notes

HYPERRHO S/D INTRAMUSCULAR SOLUTION PREFILLED SYRINGE 1500 UNIT, 250 UNIT

6Specialty Medical

HYPERTET S/D INTRAMUSCULAR INJECTABLE 250 UNIT/ML

GM

HYQVIA SUBCUTANEOUS KIT 10 GM/100ML, 2.5 GM/25ML, 20 GM/200ML, 30 GM/300ML, 5 GM/50ML

6 PA

icatibant acetate subcutaneous solution 30 mg/3ml


days)

ILARIS (150MG DELIVERED) SUBCUTANEOUS SOLUTION RECONSTITUTED 180 MG

6PA;

Specialty Medical

ILARIS SUBCUTANEOUS SOLUTION 150 MG/ML

6 PA

ILUMYA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 100 MG/ML

6 PA

IMOGAM RABIES-HT INJECTION SOLUTION 1500 UNIT/10ML, 300 UNIT/2ML

GM

IMURAN ORAL TABLET 50 MG

4

INFLECTRA INTRAVENOUS SOLUTION RECONSTITUTED 100 MG

5PA;

Specialty Medical



185

Drug NameDrug Tier

Notes

KEDRAB INJECTION SOLUTION 1500 UNIT/10ML, 300 UNIT/2ML

GM

KEVZARA SUBCUTANEOUS SOLUTION AUTO-INJECTOR 150 MG/1.14ML, 200 MG/1.14ML

6 PA

KEVZARA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 150 MG/1.14ML, 200 MG/1.14ML

6 PA

KINERET SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 100 MG/0.67ML

6 PA

KYMRIAH INTRAVENOUS SUSPENSION

6PA;

Specialty Medical

leflunomide oral tablet 10 mg, 20 mg

2

methotrexate oral tablet 2.5 mg

2

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

2

methotrexate sodium injection solution 250 mg/10ml, 50 mg/2ml

2

methotrexate sodium injection solution reconstituted 1 gm

6Specialty Medical

methotrexate sodium oral tablet 2.5 mg

2

Drug NameDrug Tier

Notes

MICRHOGAM ULTRA-FILTERED PLUS INTRAMUSCULAR SOLUTION PREFILLED SYRINGE 250 UNIT

6Specialty Medical

mycophenolate mofetil hcl intravenous solution reconstituted 500 mg

GM

mycophenolate mofetil oral capsule 250 mg

2

mycophenolate mofetil oral suspension reconstituted 200 mg/ml

2

mycophenolate mofetil oral tablet 500 mg

2

mycophenolate sodium oral tablet delayed release 180 mg, 360 mg

2

MYFORTIC ORAL TABLET DELAYED RELEASE 180 MG, 360 MG

4

NABI-HB INTRAMUSCULAR SOLUTION

GM

NEORAL ORAL CAPSULE 100 MG, 25 MG

3

NEORAL ORAL SOLUTION 100 MG/ML

3

NULOJIX INTRAVENOUS SOLUTION RECONSTITUTED 250 MG

GM

OCTAGAM INTRAVENOUS SOLUTION 1 GM/20ML, 10 GM/100ML, 10 GM/200ML, 2 GM/20ML, 2.5 GM/50ML, 20 GM/200ML, 25 GM/500ML, 5 GM/100ML, 5 GM/50ML

6PA;

Specialty Medical



186

Drug NameDrug Tier

Notes

OLUMIANT ORAL TABLET 1 MG, 2 MG

6 PA

ORENCIA CLICKJECT SUBCUTANEOUS SOLUTION AUTO-INJECTOR 125 MG/ML

6 PA

ORENCIA INTRAVENOUS SOLUTION RECONSTITUTED 250 MG

6PA;

Specialty Medical

ORENCIA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 125 MG/ML, 50 MG/0.4ML, 87.5 MG/0.7ML

6 PA

OTEZLA ORAL TABLET 30 MG

6 PA

OTEZLA ORAL TABLET THERAPY PACK 10 & 20 & 30 MG

6 PA

PANZYGA INTRAVENOUS SOLUTION 1 GM/10ML, 10 GM/100ML, 2.5 GM/25ML, 20 GM/200ML, 30 GM/300ML, 5 GM/50ML

6PA;

Specialty Medical

PRIVIGEN INTRAVENOUS SOLUTION 10 GM/100ML, 20 GM/200ML, 40 GM/400ML, 5 GM/50ML

6PA;

Specialty Medical

PROGRAF INTRAVENOUS SOLUTION 5 MG/ML

GM

PROGRAF ORAL CAPSULE 0.5 MG, 1 MG, 5 MG

3

PROVENGE INTRAVENOUS SUSPENSION

6PA;

Specialty Medical

Drug NameDrug Tier

Notes

RAPAMUNE ORAL SOLUTION 1 MG/ML

3

RAPAMUNE ORAL TABLET 0.5 MG, 1 MG, 2 MG

3

REMICADE INTRAVENOUS SOLUTION RECONSTITUTED 100 MG

6PA;

Specialty Medical

RENFLEXIS INTRAVENOUS SOLUTION RECONSTITUTED 100 MG

5PA;

Specialty Medical

RHOGAM ULTRA-FILTERED PLUS INTRAMUSCULAR SOLUTION PREFILLED SYRINGE 1500 UNIT

6Specialty Medical

RHOPHYLAC INJECTION SOLUTION PREFILLED SYRINGE 1500 UNIT/2ML

6Specialty Medical

RIDAURA ORAL CAPSULE 3 MG

3

RINVOQ ORAL TABLET EXTENDED RELEASE 24 HOUR 15 MG

6 PA

RUCONEST INTRAVENOUS SOLUTION RECONSTITUTED 2100 UNIT

6PA;

Specialty Medical

SANDIMMUNE INTRAVENOUS SOLUTION 50 MG/ML

GM

SANDIMMUNE ORAL CAPSULE 100 MG, 25 MG

3

SANDIMMUNE ORAL SOLUTION 100 MG/ML

3



187

Drug NameDrug Tier

Notes

SILIQ SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 210 MG/1.5ML

6 PA

SIMPONI ARIA INTRAVENOUS SOLUTION 50 MG/4ML

6PA;

Specialty Medical

SIMPONI SUBCUTANEOUS SOLUTION AUTO-INJECTOR 100 MG/ML, 50 MG/0.5ML

6 PA

SIMPONI SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 100 MG/ML, 50 MG/0.5ML

6 PA

SIMULECT INTRAVENOUS SOLUTION RECONSTITUTED 10 MG, 20 MG

GM

sirolimus oral solution 1 mg/ml

2

sirolimus oral tablet 0.5 mg, 1 mg, 2 mg

2

SKYRIZI (150 MG DOSE) SUBCUTANEOUS PREFILLED SYRINGE KIT 75 MG/0.83ML

6 PA

STELARA INTRAVENOUS SOLUTION 130 MG/26ML

6PA;

Specialty Medical

STELARA SUBCUTANEOUS SOLUTION 45 MG/0.5ML

6 PA

STELARA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 45 MG/0.5ML, 90 MG/ML

6 PA

Drug NameDrug Tier

Notes

SYNAGIS INTRAMUSCULAR SOLUTION 100 MG/ML, 50 MG/0.5ML

6PA;

Specialty Medical

tacrolimus oral capsule 0.5 mg, 1 mg, 5 mg

2

TALTZ SUBCUTANEOUS SOLUTION AUTO-INJECTOR 80 MG/ML

6 PA

temsirolimus intravenous solution 25 mg/ml

6PA;

Specialty Medical

THYMOGLOBULIN INTRAVENOUS SOLUTION RECONSTITUTED 25 MG

GM

TICE BCG INTRAVESICAL SUSPENSION RECONSTITUTED 50 MG

GM PA

TORISEL INTRAVENOUS SOLUTION 25 MG/ML

6PA;

Specialty Medical

TREMFYA SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 MG/ML

6 PA

TREMFYA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 100 MG/ML

6 PA

TREXALL ORAL TABLET 10 MG, 15 MG, 5 MG, 7.5 MG

3

WINRHO SDF INJECTION SOLUTION 1500 UNIT/1.3ML, 15000 UNIT/13ML, 2500 UNIT/2.2ML, 5000 UNIT/4.4ML

6Specialty Medical



188

Drug NameDrug Tier

Notes

XELJANZ ORAL TABLET 10 MG, 5 MG

6 PA

XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HOUR 11 MG

6 PA

XEMBIFY SUBCUTANEOUS SOLUTION 1 GM/5ML, 10 GM/50ML, 2 GM/10ML, 4 GM/20ML

6 PA

ZINPLAVA INTRAVENOUS SOLUTION 1000 MG/40ML

GM

ZORTRESS ORAL TABLET 0.25 MG, 0.5 MG, 0.75 MG, 1 MG

6

Immunological Agents - Drugs for Vaccination

ACTHIB INTRAMUSCULAR SOLUTION RECONSTITUTED

PVAL (Max 6

Years)

ADACEL INTRAMUSCULAR SUSPENSION 5-2-15.5 LF-MCG/0.5

PV

AFLURIA INTRAMUSCULAR SUSPENSION

PV

AFLURIA PRESERVATIVE FREE INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML

PV

AFLURIA QUADRIVALENT INTRAMUSCULAR SUSPENSION

PV

Drug NameDrug Tier

Notes

AFLURIA QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.25 ML, 0.5 ML

PV

BCG VACCINE INJECTION INJECTABLE

GM

BEXSERO INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE

PV

BIOTHRAX INTRAMUSCULAR SUSPENSION

GM

BOOSTRIX INTRAMUSCULAR SUSPENSION 5-2.5-18.5 LF-MCG/0.5

PV

DAPTACEL INTRAMUSCULAR SUSPENSION 23-15-5

PV

DIPHTHERIA-TETANUS TOXOIDS DT INTRAMUSCULAR SUSPENSION 25-5 LFU/0.5ML

PV

ENGERIX-B INJECTION SUSPENSION 10 MCG/0.5ML, 20 MCG/ML

PV

ENGERIX-B INTRAMUSCULAR INJECTABLE 10 MCG/0.5ML, 20 MCG/ML

PV

EZ FLU SHOT-FLUCELVAX QUAD INTRAMUSCULAR PREFILLED SYRINGE KIT 0.5 ML

PV



189

Drug NameDrug Tier

Notes

FLUAD INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML

PV

FLUARIX QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML

PV

FLUBLOK INTRAMUSCULAR SOLUTION

PV

FLUBLOK QUADRIVALENT INTRAMUSCULAR SOLUTION PREFILLED SYRINGE 0.5 ML

PV

FLUCELVAX QUADRIVALENT INTRAMUSCULAR SUSPENSION

PV

FLUCELVAX QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML

PV

FLULAVAL QUADRIVALENT INTRAMUSCULAR SUSPENSION

PV

FLULAVAL QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML

PV

FLUMIST QUADRIVALENT NASAL SUSPENSION

PV

AL (Min 2 Years and

Max 49 Years)

Drug NameDrug Tier

Notes

FLUVIRIN INTRAMUSCULAR SUSPENSION

PV

FLUVIRIN INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML

PV

FLUZONE HIGH-DOSE INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML

PV

FLUZONE QUADRIVALENT INTRADERMAL SUSPENSION PEN-INJECTOR 9 MCG/STRAIN

PV

FLUZONE QUADRIVALENT INTRAMUSCULAR SUSPENSION , 0.5 ML

PV

FLUZONE QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.25 ML, 0.5 ML

PV

GARDASIL 9 INTRAMUSCULAR SUSPENSION

4

AL (Min 9 Years and

Max 27 Years)

GARDASIL 9 INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE

4

AL (Min 9 Years and

Max 27 Years)

HAVRIX INTRAMUSCULAR SUSPENSION 1440 EL U/ML, 720 EL U/0.5ML

PV



190

Drug NameDrug Tier

Notes

HEPLISAV-B INTRAMUSCULAR SOLUTION 20 MCG/0.5ML

PVAL (Min 18

Years)

HEPLISAV-B INTRAMUSCULAR SOLUTION PREFILLED SYRINGE 20 MCG/0.5ML

PVAL (Min 18

Years)

HIBERIX INJECTION SOLUTION RECONSTITUTED 10 MCG

PVAL (Max 6

Years)

IMOVAX RABIES INTRAMUSCULAR INJECTABLE 2.5 UNIT/ML

GM

INFANRIX INTRAMUSCULAR SUSPENSION 25-58-10

PV

IPOL INJECTION INJECTABLE

PVAL (Max 17

Years)

IXIARO INTRAMUSCULAR SUSPENSION

GM

KINRIX INTRAMUSCULAR SUSPENSION

PV

MENACTRA INTRAMUSCULAR INJECTABLE

PV

MENVEO INTRAMUSCULAR SOLUTION RECONSTITUTED

PV

M-M-R II SUBCUTANEOUS INJECTABLE

PV

PEDIARIX INTRAMUSCULAR SUSPENSION

PV

Drug NameDrug Tier

Notes

PEDVAX HIB INTRAMUSCULAR SUSPENSION 7.5 MCG/0.5ML

PVAL (Max 6

Years)

PENTACEL INTRAMUSCULAR SUSPENSION RECONSTITUTED

PV

PNEUMOVAX 23 INJECTION INJECTABLE 25 MCG/0.5ML

PV

PREVNAR 13 INTRAMUSCULAR SUSPENSION

PV

PROQUAD SUBCUTANEOUS INJECTABLE

PV

PROQUAD SUBCUTANEOUS SUSPENSION RECONSTITUTED

PV

QUADRACEL INTRAMUSCULAR SUSPENSION

PV

RABAVERT INTRAMUSCULAR SUSPENSION RECONSTITUTED

GM

RECOMBIVAX HB INJECTION SUSPENSION 10 MCG/ML, 40 MCG/ML, 5 MCG/0.5ML

PV

ROTARIX ORAL SUSPENSION RECONSTITUTED

PVAL (Max 8 Months)

ROTATEQ ORAL SOLUTION

PVAL (Max 8 Months)

SHINGRIX INTRAMUSCULAR SUSPENSION RECONSTITUTED 50 MCG/0.5ML

PV

QL (2 EA per 30

days); AL (Min 50 Years)



191

Drug NameDrug Tier

Notes

STAMARIL INJECTION SUSPENSION RECONSTITUTED

GM

TDVAX INTRAMUSCULAR SUSPENSION 2-2 LF/0.5ML

PV

TENIVAC INTRAMUSCULAR INJECTABLE 5-2 LFU

PV

TRUMENBA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE

PV

TWINRIX INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 720-20 ELU-MCG/ML

PV

TYPHIM VI INTRAMUSCULAR SOLUTION 25 MCG/0.5ML

GM

VAQTA INTRAMUSCULAR SUSPENSION 25 UNIT/0.5ML, 50 UNIT/ML

PV

VARIVAX SUBCUTANEOUS INJECTABLE 1350 PFU/0.5ML

PV

VIVOTIF ORAL CAPSULE DELAYED RELEASE

4QL (4 EA per 365 days)

YF-VAX SUBCUTANEOUS INJECTABLE

GM

ZOSTAVAX SUBCUTANEOUS SUSPENSION RECONSTITUTED 19400 UNT/0.65ML

PVAL (Min 60

Years)

Drug NameDrug Tier

Notes

Inflammatory Bowel Disease Agents

ana-lex rectal kit 2-2 % 2

ANUSOL-HC RECTAL CREAM 2.5 %

4

APRISO ORAL CAPSULE EXTENDED RELEASE 24 HOUR 0.375 GM

3

ASACOL HD ORAL TABLET DELAYED RELEASE 800 MG

4

AZULFIDINE EN-TABS ORAL TABLET DELAYED RELEASE 500 MG

4

AZULFIDINE ORAL TABLET 500 MG

4

balsalazide disodium oral capsule 750 mg

2

budesonide er oral tablet extended release 24 hour 9 mg

5 PA

budesonide oral capsule delayed release particles 3 mg

5

CANASA RECTAL SUPPOSITORY 1000 MG

3

COLAZAL ORAL CAPSULE 750 MG

4

colocort rectal enema 100 mg/60ml

2

CORTENEMA RECTAL ENEMA 100 MG/60ML

4

CORTIFOAM RECTAL FOAM 10 %

3

DELZICOL ORAL CAPSULE DELAYED RELEASE 400 MG

3

DIPENTUM ORAL CAPSULE 250 MG

3



192

Drug NameDrug Tier

Notes

ENTOCORT EC ORAL CAPSULE DELAYED RELEASE PARTICLES 3 MG

6

GIAZO ORAL TABLET 1.1 GM

4 PA

hydrocortisone ace-pramoxine rectal cream 1-1 %

2

hydrocortisone rectal cream 1 %, 2.5 %

2

hydrocortisone rectal enema 100 mg/60ml

2

LIALDA ORAL TABLET DELAYED RELEASE 1.2 GM

4

lidocaine-hydrocortisone ace rectal cream 3-0.5 %

2

lidocaine-hydrocortisone ace rectal gel 2.8-0.55 %

2

lidocaine-hydrocortisone ace rectal kit 2-2 %, 3-0.5 %, 3-1 %, 3-2.5 %

2

mesalamine oral capsule delayed release 400 mg

2

mesalamine oral tablet delayed release 1.2 gm, 800 mg

2

mesalamine rectal enema 4 gm

2

mesalamine rectal suppository 1000 mg

2

mesalamine-cleanser rectal kit 4 gm

2

PENTASA ORAL CAPSULE EXTENDED RELEASE 250 MG, 500 MG

4

PROCORT RECTAL CREAM 1.85-1.15 %

4

PROCTOCORT RECTAL CREAM 1 %

4

Drug NameDrug Tier

Notes

PROCTOFOAM HC RECTAL FOAM 1-1 %

4

procto-med hc rectal cream 2.5 %

2

procto-pak rectal cream 1 %

2

proctosol hc rectal cream 2.5 %

2

proctozone-hc rectal cream 2.5 %

2

ROWASA RECTAL KIT 4 GM

4

SFROWASA RECTAL ENEMA 4 GM/60ML

4

sulfasalazine oral tablet 500 mg

2

sulfasalazine oral tablet delayed release 500 mg

2

UCERIS ORAL TABLET EXTENDED RELEASE 24 HOUR 9 MG

6 PA

UCERIS RECTAL FOAM 2 MG/ACT

4

Metabolic Bone Disease Agents - Drugs for Osteoporosis

ACTONEL ORAL TABLET 150 MG, 30 MG, 35 MG, 5 MG

4 ST

alendronate sodium oral solution 70 mg/75ml

2

alendronate sodium oral tablet 10 mg

1

alendronate sodium oral tablet 35 mg, 70 mg

1QL (4 EA

per 28 days)

alendronate sodium oral tablet 40 mg, 5 mg

2

ATELVIA ORAL TABLET DELAYED RELEASE 35 MG

4 ST



193

Drug NameDrug Tier

Notes

BINOSTO ORAL TABLET EFFERVESCENT 70 MG

4 ST

BONIVA INTRAVENOUS SOLUTION 3 MG/3ML

GM

BONIVA ORAL TABLET 150 MG

4 ST

calcitonin (salmon) nasal solution 200 unit/act

2

doxercalciferol intravenous solution 4 mcg/2ml

GM

EVENITY SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 105 MG/1.17ML

6 PA

FORTEO SUBCUTANEOUS SOLUTION 600 MCG/2.4ML

6 PA

FOSAMAX ORAL TABLET 70 MG

4QL (4 EA

per 28 days)

FOSAMAX PLUS D ORAL TABLET 70-2800 MG-UNIT, 70-5600 MG-UNIT

4

HECTOROL INTRAVENOUS SOLUTION 2 MCG/ML, 4 MCG/2ML

GM

ibandronate sodium intravenous solution 3 mg/3ml

GM

ibandronate sodium oral tablet 150 mg

2

MIACALCIN INJECTION SOLUTION 200 UNIT/ML

3

pamidronate disodium intravenous solution 30 mg/10ml, 6 mg/ml, 90 mg/10ml

5Specialty Medical

Drug NameDrug Tier

Notes

pamidronate disodium intravenous solution reconstituted 30 mg, 90 mg

5Specialty Medical

paricalcitol intravenous solution 2 mcg/ml, 5 mcg/ml

GM

PROLIA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 60 MG/ML

6Specialty Medical

RAYALDEE ORAL CAPSULE EXTENDED RELEASE 30 MCG

6 PA

RECLAST INTRAVENOUS SOLUTION 5 MG/100ML

6Specialty Medical

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

2 ST

risedronate sodium oral tablet delayed release 35 mg

2 ST

TYMLOS SUBCUTANEOUS SOLUTION PEN-INJECTOR 3120 MCG/1.56ML

6 PA

XGEVA SUBCUTANEOUS SOLUTION 120 MG/1.7ML

6Specialty Medical

ZEMPLAR INTRAVENOUS SOLUTION 2 MCG/ML, 5 MCG/ML

GM

zoledronic acid intravenous concentrate 4 mg/5ml

5Specialty Medical

zoledronic acid intravenous solution 4 mg/100ml, 5 mg/100ml

5Specialty Medical



194

Drug NameDrug Tier

Notes

ZOMETA INTRAVENOUS CONCENTRATE 4 MG/5ML

6Specialty Medical

ZOMETA INTRAVENOUS SOLUTION 4 MG/100ML

5Specialty Medical

Metabolic Bone Disease Agents - Other

calcitriol intravenous solution 1 mcg/ml

GM

calcitriol oral capsule 0.25 mcg, 0.5 mcg

2

calcitriol oral solution 1 mcg/ml

2

doxercalciferol oral capsule 0.5 mcg, 1 mcg, 2.5 mcg

2 PA

etidronate disodium oral tablet 200 mg, 400 mg

2

HECTOROL ORAL CAPSULE 0.5 MCG, 1 MCG, 2.5 MCG

4 PA

NATPARA SUBCUTANEOUS CARTRIDGE 100 MCG, 25 MCG, 50 MCG, 75 MCG

6PA;

Specialty Medical

paricalcitol oral capsule 1 mcg, 2 mcg, 4 mcg

2 ST

ROCALTROL ORAL CAPSULE 0.25 MCG, 0.5 MCG

4

ROCALTROL ORAL SOLUTION 1 MCG/ML

4

ZEMPLAR ORAL CAPSULE 1 MCG, 2 MCG

4 ST

Drug NameDrug Tier

Notes

Miscellaneous Therapeutic Agents

ACACIA SUBCUTANEOUS SOLUTION 1:20

GM

ACETADOTE INTRAVENOUS SOLUTION 200 MG/ML

GM

acetylcysteine intravenous solution 200 mg/ml

GM

ACREMONIUM SUBCUTANEOUS SOLUTION 20000 PNU/ML

GM

ACTHREL INTRAVENOUS SOLUTION RECONSTITUTED 100 MCG

GM

ADENOSCAN INTRAVENOUS SOLUTION 3 MG/ML

GM

adenosine (diagnostic) intravenous solution 3 mg/ml

GM

adenosine intravenous solution 3 mg/ml

GM

ADREVIEW INTRAVENOUS SOLUTION 10 MCI/5ML

GM

ALBUKED 25 INTRAVENOUS SOLUTION 25 %

GM

ALBUKED 5 INTRAVENOUS SOLUTION 5 %

GM

albumin human intravenous solution 25 %, 5 %

GM

ALBUMINAR-25 INTRAVENOUS SOLUTION 25 %

GM



195

Drug NameDrug Tier

Notes

ALBUMINAR-5 INTRAVENOUS SOLUTION 5 %

GM

ALBUMINEX INTRAVENOUS SOLUTION 25 %, 5 %

GM

albumin-zlb intravenous solution 25 %, 5 %

GM

alburx intravenous solution 5 %

GM

ALBUTEIN INTRAVENOUS SOLUTION 25 %, 5 %

GM

ALDER SUBCUTANEOUS SOLUTION 1:20

GM

ALPHA-LIPOIC ACID INJECTION SOLUTION 25 MG/ML

GM

ALTERNARIA SUBCUTANEOUS SOLUTION 20000 PNU/ML

GM

AMD FOAM DRESSING PAD 3-1/2"X3" , 4"X4" , 6"X6"

4

AMD FOAM DRESSING TOPSHEET PAD 4"X4"

4

AMERICAN BEECH SUBCUTANEOUS SOLUTION 1:20

GM

AMERICAN COCKROACH SUBCUTANEOUS SOLUTION 1:20

GM

AMERICAN ELM SUBCUTANEOUS SOLUTION 1:20

GM

AMERICAN SYCAMORE SUBCUTANEOUS SOLUTION 1:20

GM

Drug NameDrug Tier

Notes

AMIDATE INTRAVENOUS SOLUTION 2 MG/ML

GM

AMMONIA N 13 INTRAVENOUS SOLUTION 3.75-37.5 MCI/ML

GM

AMPHADASE INJECTION SOLUTION 150 UNIT/ML

GM

AMYVID INTRAVENOUS SOLUTION 500-1900 MBQ/ML

GM

ANASCORP INTRAVENOUS SOLUTION RECONSTITUTED

GM

ANAVIP INTRAVENOUS SOLUTION RECONSTITUTED

6Specialty Medical

ANDEXXA INTRAVENOUS SOLUTION RECONSTITUTED 100 MG, 200 MG

6Specialty Medical

ANESTHESIA S/I-40 INTRAVENOUS KIT 200 MG/20ML

GM

ANESTHESIA S/I-40A INTRAVENOUS KIT 200 MG/20ML

GM

ANESTHESIA S/I-40H INTRAVENOUS KIT 200 MG/20ML

GM

ANESTHESIA S/I-40S INTRAVENOUS KIT 200 MG/20ML

GM

ANESTHESIA S/I-60 INTRAVENOUS KIT 200 MG/20ML

GM



196

Drug NameDrug Tier

Notes

ANTIVENIN MICRURUS FULVIUS INTRAVENOUS SOLUTION RECONSTITUTED

GM

APP SLIM RMS ORAL CAPSULE

4

ARIZONA CYPRESS SUBCUTANEOUS SOLUTION 1:20

GM

arnica flower tincture 2

ARTISS EXTERNAL SOLUTION

4

ASPERGILLUS FUMIGATUS SUBCUTANEOUS SOLUTION 20000 PNU/ML

GM

AUREOBASIDIUM SUBCUTANEOUS SOLUTION 10000 PNU/ML, 20000 PNU/ML

GM

AUSTRALIAN PINE SUBCUTANEOUS SOLUTION 1:20

GM

AXUMIN INTRAVENOUS SOLUTION 9-221 MCI/ML

GM

bacteriostatic water(benz alc) solution injection

GM

BACTERIOSTATIC WATER(BENZ ALC) SOLUTION INJECTION

GM

BAHIA SUBCUTANEOUS SOLUTION 1:20

GM

bal in oil intramuscular solution 100 mg/ml

GM

BALD CYPRESS SUBCUTANEOUS SOLUTION 1:20

GM

Drug NameDrug Tier

Notes

BAYBERRY (WAX MYRTLE) SUBCUTANEOUS SOLUTION 1:20

GM

BERMUDA GRASS SUBCUTANEOUS SOLUTION 10000 BAU/ML

GM

BIOFREQUENCY INSOLES

4

BIOGUARD GAUZE SPONGES PAD 4"X4"

4

BIOGUARD ISLAND DRESSINGS PAD 4"X10" , 4"X14" , 4"X5"

4

BIOGUARD NON-ADHERENT DRESSING PAD 3"X4" , 3"X8"

4

BLACK WALNUT POLLEN SUBCUTANEOUS SOLUTION 1:20

GM

BLACK WILLOW SUBCUTANEOUS SOLUTION 1:20

GM

BOTOX INJECTION SOLUTION RECONSTITUTED 100 UNIT, 200 UNIT

GM PA

BOTRYTIS SUBCUTANEOUS SOLUTION 20000 PNU/ML

GM

BOX ELDER SUBCUTANEOUS SOLUTION 1:20

GM

BREVITAL SODIUM INJECTION SOLUTION RECONSTITUTED 2.5 GM, 500 MG

GM



197

Drug NameDrug Tier

Notes

BRIDION INTRAVENOUS SOLUTION 200 MG/2ML, 500 MG/5ML

GM

BROME SUBCUTANEOUS SOLUTION 1:20

GM

BUMINATE INTRAVENOUS SOLUTION 25 %, 5 %

GM

CALCIUM DISODIUM VERSENATE INJECTION SOLUTION 1 GM/5ML

GM

CALIFORNIA PEPPER TREE SUBCUTANEOUS SOLUTION 1:20

GM

CANDIDA ALBICANS EXTRACT SUBCUTANEOUS SOLUTION 10000 PNU/ML, 20000 PNU/ML

GM

CARDIOVID PLUS ORAL CAPSULE

4

CAT HAIR EXTRACT SUBCUTANEOUS SOLUTION 10000 BAU/ML

GM

CATTLE EPITHELIUM SUBCUTANEOUS SOLUTION 1:20

GM

CAYA VAGINAL DIAPHRAGM

PV

CEDAR ELM SUBCUTANEOUS SOLUTION 1:20

GM

CERETEC INTRAVENOUS KIT

GM

CHIRHOSTIM INTRAVENOUS SOLUTION RECONSTITUTED 16 MCG

GM

Drug NameDrug Tier

Notes

CHLORHEXIDINE GLUCONATE SOLUTION 20 %

4

CHOLETEC INTRAVENOUS KIT

GM

CLADOSPORIUM CLADOSPORIOIDES SUBCUTANEOUS SOLUTION 10000 PNU/ML, 20000 PNU/ML

GM

CLADOSPORIUM SPHAEROSPERMUM SUBCUTANEOUS SOLUTION 20000 PNU/ML

GM

COCKLEBUR SUBCUTANEOUS SOLUTION 1:20

GM

COENZYME Q-10 INJECTION SOLUTION 20 MG/ML

GM

CORN POLLEN SUBCUTANEOUS SOLUTION 1:20

GM

CORTROSYN INJECTION SOLUTION RECONSTITUTED 0.25 MG

GM

cosyntropin injection solution reconstituted 0.25 mg

GM

CROFAB INTRAVENOUS SOLUTION RECONSTITUTED

GM

CURITY AMD ANTIMICROBIAL SPNGE PAD 4"X4"

4

CURITY AMD ANTIMICROBIAL STRIP

4

CURITY IODOFORM PACKING STRIP

4



198

Drug NameDrug Tier

Notes

CURVULARIA SUBCUTANEOUS SOLUTION 20000 PNU/ML

GM

CYANOKIT INTRAVENOUS SOLUTION RECONSTITUTED 5 GM

GM

CYSTO-CONRAY II URETHRAL SOLUTION 17.2 %

GM

CYSVIEW INTRAVESICAL SOLUTION RECONSTITUTED 100 MG

GM

DANDELION SUBCUTANEOUS SOLUTION 1:20

GM

DATSCAN INTRAVENOUS SOLUTION 185 MBQ/2.5ML

GM

deferoxamine mesylate injection solution reconstituted 2 gm, 500 mg

GM

DEFINITY INTRAVENOUS SUSPENSION 6.52 MG/ML

GM

DEFLUX INJECTION PREFILLED SYRINGE 50-15 MG/ML

GM

DESFERAL INJECTION SOLUTION RECONSTITUTED 500 MG

GM

dexmedetomidine hcl in nacl intravenous solution 200 mcg/50ml, 400 mcg/100ml, 80 mcg/20ml

GM

Drug NameDrug Tier

Notes

DEXMEDETOMIDINE HCL INTRAVENOUS SOLUTION 1000 MCG/10ML, 400 MCG/4ML

GM

dexmedetomidine hcl intravenous solution 200 mcg/2ml

GM

DEXMEDETOMIDINE HCL-DEXTROSE INTRAVENOUS SOLUTION 200MCG/50ML -5%, 400MCG/100ML -5%

GM

DIAGNOSTIC INJECTION KIT

GM

DIGIFAB INTRAVENOUS SOLUTION RECONSTITUTED 40 MG

GM

DILUENT FOR TREPROSTINIL INTRAVENOUS SOLUTION

GM

DIPRIVAN INTRAVENOUS EMULSION 100 MG/10ML, 1000 MG/100ML, 200 MG/20ML, 500 MG/50ML

GM

dipyridamole intravenous solution 5 mg/ml

GM

DOG EPITHELIUM SUBCUTANEOUS SOLUTION 1:10 , 1:20

GM

DOG FENNEL SUBCUTANEOUS SOLUTION 1:20

GM



199

Drug NameDrug Tier

Notes

DOTAREM INTRAVENOUS SOLUTION 2.5 MMOL/5ML, 5 MMOL/10ML, 50 MMOL/100ML

GM

DOTATOC GA 68 INTRAVENOUS SOLUTION 0.5-4 MCI/ML

GM

DRECHSLERA SUBCUTANEOUS SOLUTION 10000 PNU/ML, 20000 PNU/ML

GM

DUODOTE INTRAMUSCULAR SOLUTION AUTO-INJECTOR 2.1-600 MG

GM

DUROLANE INTRA-ARTICULAR PREFILLED SYRINGE 60 MG/3ML

GM

DUST MITE MIXED ALLERGEN EXT SUBCUTANEOUS SOLUTION 10000 AU/ML

GM

DYSPORT INTRAMUSCULAR SOLUTION RECONSTITUTED 300 UNIT, 500 UNIT

GM PA

EASTERN COTTONWOOD SUBCUTANEOUS SOLUTION 1:20

GM

ENDARI ORAL PACKET 5 GM

6

ENGLISH PLANTAIN SUBCUTANEOUS SOLUTION 1:20

GM

ENLON INJECTION SOLUTION 10 MG/ML

GM

Drug NameDrug Tier

Notes

EOVIST INTRAVENOUS SOLUTION 0.25 MOL/L

GM

EPICOCCUM SUBCUTANEOUS SOLUTION 10000 PNU/ML, 20000 PNU/ML

GM

ergoloid mesylates oral tablet 1 mg

2

etomidate intravenous solution 2 mg/ml

GM

EUFLEXXA INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 20 MG/2ML

GM

EVICEL EXTERNAL KIT 2 ML, 5 ML

4

EXCILON AMD DRAIN SPONGES PAD 4"X4"

4

FEMCAP VAGINAL DEVICE 22 MM, 26 MM, 30 MM

PV

FIRDAPSE ORAL TABLET 10 MG

6 PA

FIRE ANT SUBCUTANEOUS SOLUTION 1:10 , 1:20

GM

FLEXBUMIN INTRAVENOUS SOLUTION 25 %, 5 %

GM

FLUDEOXYGLUCOSE F 18 INTRAVENOUS SOLUTION 20-300 MCI/ML

GM

flumazenil intravenous solution 0.5 mg/5ml, 1 mg/10ml

GM

fomepizole intravenous solution 1 gm/ml, 1.5 gm/1.5ml

GM

formadon external solution 10 %

2



200

Drug NameDrug Tier

Notes

formaldehyde external solution 10 %, 37 %

2

FORMA-RAY EXTERNAL SOLUTION 20 %

4

fresenius propoven intravenous emulsion 1000 mg/100ml, 200 mg/20ml, 500 mg/50ml

GM

FUSARIUM SUBCUTANEOUS SOLUTION 10000 PNU/ML, 20000 PNU/ML

GM

GADAVIST INTRAVENOUS SOLUTION 1 MMOL/ML

GM

GELFOAM-JMI SPONGE EXTERNAL KIT

4

GEL-ONE INTRA-ARTICULAR PREFILLED SYRINGE 30 MG/3ML

GM

GELSYN-3 INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 16.8 MG/2ML

GM

GENVISC 850 INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 25 MG/2.5ML

GM

GERMAN COCKROACH SUBCUTANEOUS SOLUTION 1:20

GM

GLEOLAN ORAL SOLUTION RECONSTITUTED 1.5 GM

GM

GLUCAGEN DIAGNOSTIC INJECTION SOLUTION RECONSTITUTED 1 MG

GM

Drug NameDrug Tier

Notes

GLUCAGON HCL (DIAGNOSTIC) INJECTION SOLUTION RECONSTITUTED 1 MG

GM

glutaraldehyde external solution 25 %

2

GOLDENROD SUBCUTANEOUS SOLUTION 1:20

GM

GRASTEK SUBLINGUAL TABLET SUBLINGUAL 2800 BAU

3

HACKBERRY SUBCUTANEOUS SOLUTION 1:20

GM

heparin lock flush intravenous solution 1 unit/ml, 10 unit/ml, 100 unit/ml

2

heparin sodium flush intravenous kit 100-0.9 unit/ml-%

2

heparin sodium lock flush intravenous solution 100 unit/ml

2

HEPATOLITE INTRAVENOUS KIT

GM

HEPMED COMBINATION KIT 100&0.9&2.5-2.5 UT/ML

4

HISTATROL INJECTION SOLUTION 2.75 MG/ML

GM

HONEY BEE VENOM PROTEIN INJECTION SOLUTION RECONSTITUTED 550 MCG

GM

HONEY BEE VENOM SUBCUTANEOUS SOLUTION RECONSTITUTED 1100 MCG, 120 MCG

GM



201

Drug NameDrug Tier

Notes

HORSE EPITHELIUM SUBCUTANEOUS SOLUTION 1:10 , 1:20

GM

HUMAN ALBUMIN GRIFOLS INTRAVENOUS SOLUTION 25 %

GM

HYALGAN INTRA-ARTICULAR SOLUTION 20 MG/2ML

GM

HYALGAN INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 20 MG/2ML

GM

HYLENEX INJECTION SOLUTION 150 UNIT/ML

GM

HYMOVIS INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 24 MG/3ML

GM

IC GREEN INTRAVENOUS SOLUTION RECONSTITUTED 25 MG

GM

INDICLOR INTRAVENOUS SOLUTION

GM

indium in 111 oxyquinoline intravenous solution 1 mci/ml

GM

indocyanine green intravenous solution reconstituted 25 mg

GM

INFED INJECTION SOLUTION 50 MG/ML

GM

isosulfan blue subcutaneous solution 1 %

GM

JOHNSON GRASS SUBCUTANEOUS SOLUTION 1:20

GM

Drug NameDrug Tier

Notes

JUNE GRASS POLLEN STANDARDIZED SUBCUTANEOUS SOLUTION 100000 BAU/ML

GM

KALBITOR SUBCUTANEOUS SOLUTION 10 MG/ML

6PA;

Specialty Medical

KAPOK SUBCUTANEOUS SOLUTION 1:20

GM

kedbumin intravenous solution 25 %

GM

KERLIX AMD ANTIMICROBIAL

4

KERLIX AMD SUPER SPONGES PAD 6"X6-3/4"

4

KETALAR INJECTION SOLUTION 10 MG/ML, 100 MG/ML, 50 MG/ML

GM

KETAMINE HCL INJECTION SOLUTION 0.6 MG/ML

GM

ketamine hcl injection solution 10 mg/ml, 100 mg/ml, 50 mg/ml

GM

KETAMINE HCL INJECTION SOLUTION PREFILLED SYRINGE 100 MG/10ML, 30 MG/3ML, 50 MG/5ML, 50 MG/ML, 60 MG/20ML

GM

KETAMINE HCL-SODIUM CHLORIDE INTRAVENOUS SOLUTION PREFILLED SYRINGE 10-0.9 MG/ML-%, 20-0.9 MG/2ML-%

GM

KINEVAC INJECTION SOLUTION RECONSTITUTED 5 MCG

GM



202

Drug NameDrug Tier

Notes

KOCHIA SUBCUTANEOUS SOLUTION 1:20

GM

LAMBS QUARTERS SUBCUTANEOUS SOLUTION 1:20

GM

LENSCALE SUBCUTANEOUS SOLUTION 1:20

GM

LEXISCAN INTRAVENOUS SOLUTION 0.4 MG/5ML

GM

LUMASON INTRAVENOUS SUSPENSION RECONSTITUTED 60.7-25 MG

GM

LUVIRA ORAL CAPSULE 1.22 GM

4

MACI INTRA-ARTICULAR SHEET

GM

MACRILEN ORAL PACKET 60 MG

6

MAGNEVIST INTRAVENOUS SOLUTION 469.01 MG/ML

GM

MEADOW FESCUE GRASS POLLEN SUBCUTANEOUS SOLUTION 100000 BAU/ML

GM

MELALEUCA SUBCUTANEOUS SOLUTION 1:20

GM

MESQUITE SUBCUTANEOUS SOLUTION 1:20

GM

methergine oral tablet 0.2 mg

2

methylergonovine maleate injection solution 0.2 mg/ml

GM

Drug NameDrug Tier

Notes

methylergonovine maleate oral tablet 0.2 mg

2

MITE (D. FARINAE) SUBCUTANEOUS SOLUTION 10000 AU/ML

GM

MITE (D. PTERONYSSINUS) SUBCUTANEOUS SOLUTION 10000 AU/ML

GM

MIXED ASPERGILLUS SUBCUTANEOUS SOLUTION 20000 PNU/ML

GM

MIXED FEATHERS SUBCUTANEOUS SOLUTION 1:20

GM

MIXED RAGWEED SUBCUTANEOUS SOLUTION 1:20

GM

MIXED VESPID VENOM PROTEIN INJECTION SOLUTION RECONSTITUTED 550-550-550 MCG

GM

MIXED VESPID VENOM PROTEIN SUBCUTANEOUS SOLUTION RECONSTITUTED 1100-1100-1100 MCG, 120-120-120 MCG

GM

MONOVISC INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 88 MG/4ML

GM

MOUNTAIN CEDAR SUBCUTANEOUS SOLUTION 1:20

GM

MOUSE EPITHELIUM SUBCUTANEOUS SOLUTION 1:20

GM



203

Drug NameDrug Tier

Notes

MUCOR SUBCUTANEOUS SOLUTION 10000 PNU/ML, 20000 PNU/ML

GM

MUGWORT SUBCUTANEOUS SOLUTION 1:20

GM

MULTIHANCE INTRAVENOUS SOLUTION 529 MG/ML

GM

MYOBLOC INTRAMUSCULAR SOLUTION 10000 UNIT/2ML, 2500 UNIT/0.5ML, 5000 UNIT/ML

GM PA

MYOVIEW 30ML INTRAVENOUS KIT

GM

NETSPOT INTRAVENOUS KIT

GM

NITHIODOTE INTRAVENOUS KIT 300MG/10ML&12.5 GM/50ML

GM

OCTAPLAS BLOOD GROUP A INTRAVENOUS SOLUTION

GM

OCTAPLAS BLOOD GROUP AB INTRAVENOUS SOLUTION

GM

OCTAPLAS BLOOD GROUP B INTRAVENOUS SOLUTION

GM

OCTAPLAS BLOOD GROUP O INTRAVENOUS SOLUTION

GM

ODACTRA SUBLINGUAL TABLET SUBLINGUAL 12 SQ-HDM

4

Drug NameDrug Tier

Notes

OLIVE TREE SUBCUTANEOUS SOLUTION 1:20

GM

OMNIPAQUE INTRAVENOUS SOLUTION 350 MG/ML

GM

OMNISCAN INJECTION INJECTABLE 287 MG/ML

GM

OMNISCAN INTRAVENOUS SOLUTION 287 MG/ML

GM

OMNISCAN/SODIUM CHLORIDE INTRAVENOUS SOLUTION 287-0.9 MG/ML-%

GM

OPTIMARK INTRAVENOUS SOLUTION 330.9 MG/ML

GM

OPTIONS CONCEPTROL VAGINAL GEL 4 %

PV

OPTIRAY 350 INJECTION SOLUTION 74 %

GM

OPTISON INTRAVENOUS SUSPENSION

GM

ORAFATE MOUTH/THROAT PASTE 10 %

4

ORALAIR ADULT SAMPLE KIT SUBLINGUAL TABLET SUBLINGUAL 300 IR

4

ORALAIR ADULT STARTER PACK SUBLINGUAL TABLET SUBLINGUAL 300 IR

4



204

Drug NameDrug Tier

Notes

ORALAIR CHILDRENS SAMPLE KIT SUBLINGUAL THERAPY PACK 3 X 100 IR & 6 X 300 IR

4

ORALAIR CHILDRENS STARTER PACK SUBLINGUAL TABLET SUBLINGUAL 100 IR

4

ORALAIR SUBLINGUAL TABLET SUBLINGUAL 300 IR

4

ORCHARD GRASS POLLEN SUBCUTANEOUS SOLUTION 100000 BAU/ML

GM

ORTHOVISC INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 30 MG/2ML

GM

PECAN POLLEN SUBCUTANEOUS SOLUTION 1:20

GM

PENICILLIUM NOTATUM SUBCUTANEOUS SOLUTION 10000 PNU/ML, 20000 PNU/ML

GM

PERENNIAL RYE GRASS POLLEN SUBCUTANEOUS SOLUTION 100000 BAU/ML

GM

PHOMA EXIGUA SUBCUTANEOUS SOLUTION 20000 PNU/ML

GM

PHOTREXA VISCOUS OPHTHALMIC SOLUTION PREFILLED SYRINGE 0.146-20 %

6 PA

Drug NameDrug Tier

Notes

PLASBUMIN-25 INTRAVENOUS SOLUTION 25 %

GM

PLASBUMIN-5 INTRAVENOUS SOLUTION 5 %

GM

PLASMANATE INTRAVENOUS SOLUTION 5 %

GM

pralidoxime chloride intramuscular solution auto-injector 600 mg/2ml

GM

PRAXBIND INTRAVENOUS SOLUTION 2.5 GM/50ML

GM

PRECEDEX INTRAVENOUS SOLUTION 200 MCG/2ML, 200 MCG/50ML, 400 MCG/100ML, 80 MCG/20ML

GM

PRIVET SUBCUTANEOUS SOLUTION 1:20

GM

PROHANCE INTRAVENOUS SOLUTION 279.3 MG/ML

GM

propofol intravenous emulsion 1000 mg/100ml, 200 mg/20ml, 500 mg/50ml

GM

PROPOFOL INTRAVENOUS PREFILLED SYRINGE 100 MG/10ML, 150 MG/15ML, 200 MG/20ML, 50 MG/5ML

GM

PROSTASCINT INTRAVENOUS KIT

GM



205

Drug NameDrug Tier

Notes

PROTHELIAL MOUTH/THROAT PASTE 10 %

4

PROTOPAM CHLORIDE INTRAVENOUS SOLUTION RECONSTITUTED 1 GM

GM

PROVAYBLUE INTRAVENOUS SOLUTION 50 MG/10ML

GM

QUEEN PALM SUBCUTANEOUS SOLUTION 1:20

GM

RABBIT EPITHELIUM SUBCUTANEOUS SOLUTION 1:10 , 1:20

GM

RADIOGARDASE ORAL CAPSULE 0.5 GM

6

RAGWITEK SUBLINGUAL TABLET SUBLINGUAL 12 AMB A 1-U

3

RED BIRCH SUBCUTANEOUS SOLUTION 1:20

GM

RED CEDAR SUBCUTANEOUS SOLUTION 1:20

GM

RED MAPLE SUBCUTANEOUS SOLUTION 1:20

GM

RED MULBERRY SUBCUTANEOUS SOLUTION 1:20

GM

RED TOP GRASS POLLEN SUBCUTANEOUS SOLUTION 100000 BAU/ML

GM

red yeast rice oral powder 500 mg/0.5gm

2

Drug NameDrug Tier

Notes

R-GENE 10 INTRAVENOUS SOLUTION 10 %

GM

RHIZOPUS SUBCUTANEOUS SOLUTION 20000 PNU/ML

GM

ROUGH MARSH ELDER SUBCUTANEOUS SOLUTION 1:20

GM

ROUGH PIGWEED SUBCUTANEOUS SOLUTION 1:20

GM

RUSSIAN THISTLE SUBCUTANEOUS SOLUTION 1:20

GM

RUZURGI ORAL TABLET 10 MG

6 PA

SACCHAROMYCES CEREVISIAE SUBCUTANEOUS SOLUTION 20000 PNU/ML

GM

SAGEBRUSH SUBCUTANEOUS SOLUTION 1:20

GM

sash kit intravenous kit 100-0.9 unit/ml-%

2

SERMORELIN ACETATE DIAGNOSTIC INJECTION SOLUTION RECONSTITUTED 15 MG, 6 MG, 9 MG

GM

SHAGBARK HICKORY SUBCUTANEOUS SOLUTION 1:20

GM

SHEEP SORREL SUBCUTANEOUS SOLUTION 1:20

GM

SHORT RAGWEED POLLEN EXT SUBCUTANEOUS SOLUTION 1:20

GM



206

Drug NameDrug Tier

Notes

SODIUM HYALURONATE INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 20 MG/2ML

GM

sodium nitrite intravenous solution 30 mg/ml

GM

sodium saccharin powder 2

SODIUM THIOSULFATE SOLUTION 25 % INTRAVENOUS 25 %

GM

sodium thiosulfate solution 25 % intravenous 25 %

GM

SOLESTA INJECTION GEL 50-15 MG/ML

GM

SOLU-PREF COMBINATION KIT 100&0.9&2.5-2.5 UT/ML

4

SORBITOL IRRIGATION SOLUTION 3 %

4

sorbitol irrigation solution 3.3 %

2

sorbitol-mannitol irrigation solution 2.7-0.54 gm/100ml

2

SORREL/DOCK MIX SUBCUTANEOUS SOLUTION 1:20

GM

SPINRAZA INTRATHECAL SOLUTION 12 MG/5ML

6PA;

Specialty Medical

SPINY PIGWEED SUBCUTANEOUS SOLUTION 1:20

GM

STEMPHYLIUM SUBCUTANEOUS SOLUTION 20000 PNU/ML

GM

Drug NameDrug Tier

Notes

STERILE DILUENT FLOLAN PH 12 INTRAVENOUS SOLUTION

GM

STERILE DILUENT FOR FLOLAN INTRAVENOUS SOLUTION

GM

sterile diluent/epoprostenol intravenous solution

GM

sterile water for injection intravenous solution

GM

STERILE WATER FOR INJECTION SOLUTION INJECTION

GM

sterile water for injection solution injection

GM

SUPARTZ FX INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 25 MG/2.5ML

GM

SWEET GUM SUBCUTANEOUS SOLUTION 1:20

GM

SWEET VERNAL GRASS POLLEN SUBCUTANEOUS SOLUTION 100000 BAU/ML

GM

SYNVISC INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 16 MG/2ML

GM

SYNVISC ONE INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 48 MG/6ML

GM

TAKHZYRO SUBCUTANEOUS SOLUTION 300 MG/2ML


days)



207

Drug NameDrug Tier

Notes

TALL RAGWEED SUBCUTANEOUS SOLUTION 1:20

GM

TECHNET TC 99M SULFUR COLLOID INJECTION KIT

GM

technetium tc 99m mebrofenin intravenous kit

GM

TECHNETIUM TC 99M MEDRONATE INTRAVENOUS KIT

GM

TECHNETIUM TC 99M PYROPHOS INTRAVENOUS KIT

GM

technetium tc 99m sestamibi intravenous kit

GM

TELFA AMD ISLAND DRESSING PAD 4"X5" , 4"X8"

4

TELFA AMD NON-ADHERENT PAD 3"X8"

4

thallous chloride tl 201 intravenous solution 1 mci/ml

GM

THALLOUS CHLORIDE TL 201 INTRAVENOUS SOLUTION 2 MCI/ML

GM

THYROGEN INTRAMUSCULAR SOLUTION RECONSTITUTED 1.1 MG

GM

TIMOTHY GRASS POLLEN ALLERGEN SUBCUTANEOUS SOLUTION 10000 BAU/ML, 100000 BAU/ML

GM

TISSEEL EXTERNAL KIT 10 ML, 2 ML, 4 ML

4

TISSEEL EXTERNAL SOLUTION

4

Drug NameDrug Tier

Notes

TISSEEL VH EXTERNAL KIT 10 ML, 2 ML, 4 ML

4

TISSEEL VHSD EXTERNAL SOLUTION

4

TRICHOPHYTON SUBCUTANEOUS SOLUTION 20000 PNU/ML

GM

TRIVISC INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 25 MG/2.5ML

GM

ULTRAVIST INJECTION SOLUTION 77 %

GM

vcf vaginal contraceptive vaginal gel 4 %

PV

VENOMIL MIXED VESPID VENOM INJECTION SOLUTION RECONSTITUTED 550-550-550 MCG

GM

VIASPAN SOLUTION 4

VIRGINIA LIVE OAK SUBCUTANEOUS SOLUTION 1:20

GM

VISCO-3 INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 25 MG/2.5ML

GM

VISIPAQUE INTRAVENOUS SOLUTION 320 MG/ML

GM

VISTOGARD ORAL PACKET 10 GM

6

VITRASE INJECTION SOLUTION 200 UNIT/ML

GM

VIZAMYL INTRAVENOUS SOLUTION 4.05 MCI/ML

GM

volumex intravenous solution prefilled syringe 25 mcci/ml

GM



208

Drug NameDrug Tier

Notes

WASP VENOM PROTEIN INJECTION SOLUTION RECONSTITUTED 550 MCG

GM

WASP VENOM PROTEIN SUBCUTANEOUS SOLUTION RECONSTITUTED 1100 MCG, 120 MCG

GM

WESTERN JUNIPER SUBCUTANEOUS SOLUTION 1:20

GM

WHITE ASH SUBCUTANEOUS SOLUTION 1:20

GM

WHITE BIRCH SUBCUTANEOUS SOLUTION 1:20

GM

WHITE FACED HORNET VENOM SUBCUTANEOUS SOLUTION RECONSTITUTED 1100 MCG, 120 MCG

GM

WHITE MULBERRY SUBCUTANEOUS SOLUTION 1:20

GM

WHITE OAK SUBCUTANEOUS SOLUTION 1:20

GM

WHITE PINE SUBCUTANEOUS SOLUTION 1:20

GM

WHITE-FACED HORNET VENOM INJECTION SOLUTION RECONSTITUTED 550 MCG

GM

WIDE-SEAL DIAPHRAGM 60 VAGINAL DIAPHRAGM 2 %

PV

Drug NameDrug Tier

Notes

XENON XE 133 INHALATION GAS 20 MCI

GM

XEOMIN INTRAMUSCULAR SOLUTION RECONSTITUTED 100 UNIT, 200 UNIT, 50 UNIT

GM PA

XIAFLEX INJECTION SOLUTION RECONSTITUTED 0.9 MG

6PA;

Specialty Medical

YELLOW DOCK SUBCUTANEOUS SOLUTION 1:20

GM

YELLOW HORNET VENOM PROTEIN INJECTION SOLUTION RECONSTITUTED 550 MCG

GM

YELLOW HORNET VENOM PROTEIN SUBCUTANEOUS SOLUTION RECONSTITUTED 1100 MCG, 120 MCG

GM

YELLOW JACKET VENOM PROTEIN INJECTION SOLUTION RECONSTITUTED 550 MCG

GM

YELLOW JACKET VENOM PROTEIN SUBCUTANEOUS SOLUTION RECONSTITUTED 120 MCG

GM

ZOLGENSMA 10.1-10.5 KG INTRAVENOUS KIT 7X8.3 ML

6PA;

Specialty Medical

ZOLGENSMA 10.6-11.0 KG INTRAVENOUS KIT 2X5.5ML & 6X8.3ML

6PA;

Specialty Medical



209

Drug NameDrug Tier

Notes


6PA;

Specialty Medical


6PA;

Specialty Medical


6PA;

Specialty Medical


6PA;

Specialty Medical


6PA;

Specialty Medical


6PA;

Specialty Medical


6PA;

Specialty Medical


6PA;

Specialty Medical


6PA;

Specialty Medical


6PA;

Specialty Medical


6PA;

Specialty Medical


6PA;

Specialty Medical


6PA;

Specialty Medical


6PA;

Specialty Medical

Drug NameDrug Tier

Notes


6PA;

Specialty Medical


6PA;

Specialty Medical


6PA;

Specialty Medical


6PA;

Specialty Medical


6PA;

Specialty Medical


6PA;

Specialty Medical

Ophthalmic Agents - Drugs for Eye Allergy, Infection and Inflammation

ACULAR LS OPHTHALMIC SOLUTION 0.4 %

4

ACULAR OPHTHALMIC SOLUTION 0.5 %

4

ACUVAIL OPHTHALMIC SOLUTION 0.45 %

4

ALOCRIL OPHTHALMIC SOLUTION 2 %

4

ALOMIDE OPHTHALMIC SOLUTION 0.1 %

3

ALREX OPHTHALMIC SUSPENSION 0.2 %

4

AZASITE OPHTHALMIC SOLUTION 1 %

4

azelastine hcl ophthalmic solution 0.05 %

2

bacitracin ophthalmic ointment 500 unit/gm

2



210

Drug NameDrug Tier

Notes

BEPREVE OPHTHALMIC SOLUTION 1.5 %

4

BESIVANCE OPHTHALMIC SUSPENSION 0.6 %

4

BETADINE OPHTHALMIC PREP OPHTHALMIC SOLUTION 5 %

4

BLEPH-10 OPHTHALMIC SOLUTION 10 %

4

bromfenac sodium (once-daily) ophthalmic solution 0.09 %

2

BROMSITE OPHTHALMIC SOLUTION 0.075 %

4

CEFUROXIME SODIUM-NACL INTRAOCULAR SOLUTION PREFILLED SYRINGE 3-0.9 MG/0.3ML-%

GM

CEFUROXIME SODIUM-NACL INTRAVITREAL SOLUTION 10-0.9 MG/ML-%

4

CILOXAN OPHTHALMIC OINTMENT 0.3 %

4

CILOXAN OPHTHALMIC SOLUTION 0.3 %

4

ciprofloxacin hcl ophthalmic solution 0.3 %

2

cromolyn sodium ophthalmic solution 4 %

1

dexamethasone sodium phosphate ophthalmic solution 0.1 %

2

DEXYCU INTRAOCULAR SUSPENSION 9 %

5

Drug NameDrug Tier

Notes

diclofenac sodium ophthalmic solution 0.1 %

2

DUREZOL OPHTHALMIC EMULSION 0.05 %

4

ELESTAT OPHTHALMIC SOLUTION 0.05 %

4

EMADINE OPHTHALMIC SOLUTION 0.05 %

4

epinastine hcl ophthalmic solution 0.05 %

2

erythromycin ophthalmic ointment 5 mg/gm

2

FLAREX OPHTHALMIC SUSPENSION 0.1 %

3

fluorometholone ophthalmic suspension 0.1 %

2

flurbiprofen sodium ophthalmic solution 0.03 %

2

FML FORTE OPHTHALMIC SUSPENSION 0.25 %

3

FML LIQUIFILM OPHTHALMIC SUSPENSION 0.1 %

4

FML OPHTHALMIC OINTMENT 0.1 %

3

gatifloxacin ophthalmic solution 0.5 %

2

gentak ophthalmic ointment 0.3 %

2

gentamicin sulfate ophthalmic solution 0.3 %

2

ILEVRO OPHTHALMIC SUSPENSION 0.3 %

4

ILUVIEN INTRAVITREAL IMPLANT 0.19 MG

4



211

Drug NameDrug Tier

Notes

INVELTYS OPHTHALMIC SUSPENSION 1 %

4

ketorolac tromethamine ophthalmic solution 0.4 %, 0.5 %

2

KLARITY-A OPHTHALMIC SOLUTION 1 %

4

levofloxacin ophthalmic solution 0.5 %

2

LOTEMAX OPHTHALMIC GEL 0.5 %

4

LOTEMAX OPHTHALMIC OINTMENT 0.5 %

4

LOTEMAX OPHTHALMIC SUSPENSION 0.5 %

4

LOTEMAX SM OPHTHALMIC GEL 0.38 %

4

loteprednol etabonate ophthalmic suspension 0.5 %

2

MAXIDEX OPHTHALMIC SUSPENSION 0.1 %

4

MITOSOL OPHTHALMIC KIT 0.2 MG

GM

MOXEZA OPHTHALMIC SOLUTION 0.5 %

4

MOXIFLOXACIN HCL INTRAOCULAR SOLUTION 1 MG/ML, 5 MG/ML

GM

MOXIFLOXACIN HCL INTRAOCULAR SOLUTION PREFILLED SYRINGE 0.3 MG/0.3ML

GM

moxifloxacin hcl ophthalmic solution 0.5 %

2

Drug NameDrug Tier

Notes

NATACYN OPHTHALMIC SUSPENSION 5 %

4

NEVANAC OPHTHALMIC SUSPENSION 0.1 %

4

OCUFLOX OPHTHALMIC SOLUTION 0.3 %

4

ofloxacin ophthalmic solution 0.3 %

2

olopatadine hcl ophthalmic solution 0.1 %, 0.2 %

2

OMNIPRED OPHTHALMIC SUSPENSION 1 %

4

OZURDEX INTRAVITREAL IMPLANT 0.7 MG

6Specialty Medical

PATADAY OPHTHALMIC SOLUTION 0.2 %

4

PATANOL OPHTHALMIC SOLUTION 0.1 %

4

PAZEO OPHTHALMIC SOLUTION 0.7 %

4

POVIDONE-IODINE OPHTHALMIC SOLUTION 5 %

4

PRED FORTE OPHTHALMIC SUSPENSION 1 %

4

PRED MILD OPHTHALMIC SUSPENSION 0.12 %

3

PREDNISOL ACE-MOXIFLOX-BROMFEN OPHTHALMIC SUSPENSION 1-0.5-0.075 %

4



212

Drug NameDrug Tier

Notes

prednisolone acetate ophthalmic suspension 1 %

2

prednisolone acetate p-f ophthalmic suspension 1 %

2

prednisolone sodium phosphate ophthalmic solution 1 %

2

PROLENSA OPHTHALMIC SOLUTION 0.07 %

4

sulfacetamide sodium ophthalmic ointment 10 %

2

sulfacetamide sodium ophthalmic solution 10 %

2

tobramycin ophthalmic solution 0.3 %

1

TOBREX OPHTHALMIC OINTMENT 0.3 %

3

TOBREX OPHTHALMIC SOLUTION 0.3 %

4

TRIESENCE INTRAOCULAR SUSPENSION 40 MG/ML

4

trifluridine ophthalmic solution 1 %

2

TRIPLE PMB OPHTHALMIC SOLUTION RECONSTITUTED 1-0.5-0.09 %

4

TRIPLE PMK OPHTHALMIC SOLUTION RECONSTITUTED 1-0.5-0.5 %

4

VIGAMOX OPHTHALMIC SOLUTION 0.5 %

4

Drug NameDrug Tier

Notes

VIROPTIC OPHTHALMIC SOLUTION 1 %

4

ZIRGAN OPHTHALMIC GEL 0.15 %

4

ZYMAXID OPHTHALMIC SOLUTION 0.5 %

4

Ophthalmic Agents - Drugs for Glaucoma

acetazolamide er oral capsule extended release 12 hour 500 mg

2

acetazolamide oral tablet 250 mg

2

ALPHAGAN P OPHTHALMIC SOLUTION 0.1 %, 0.15 %

3

apraclonidine hcl ophthalmic solution 0.5 %

2

AZOPT OPHTHALMIC SUSPENSION 1 %

4

BETAGAN OPHTHALMIC SOLUTION 0.5 %

4

betaxolol hcl ophthalmic solution 0.5 %

2

BETIMOL OPHTHALMIC SOLUTION 0.25 %, 0.5 %

4

BETOPTIC-S OPHTHALMIC SUSPENSION 0.25 %

3

bimatoprost ophthalmic solution 0.03 %

2

brimonidine tartrate ophthalmic solution 0.15 %

2

brimonidine tartrate ophthalmic solution 0.2 %

1



213

Drug NameDrug Tier

Notes

BRIMONIDINE-DORZOLAMIDE OPHTHALMIC SOLUTION 0.15-2 %

4

carteolol hcl ophthalmic solution 1 %

2

COMBIGAN OPHTHALMIC SOLUTION 0.2-0.5 %

4

COSOPT OPHTHALMIC SOLUTION 22.3-6.8 MG/ML

4

COSOPT PF OPHTHALMIC SOLUTION 22.3-6.8 MG/ML

4

DIAMOX SEQUELS ORAL CAPSULE EXTENDED RELEASE 12 HOUR 500 MG

4

DORZOLAMIDE HCL SOLUTION 2 % OPHTHALMIC 2 %

4

dorzolamide hcl solution 2 % ophthalmic 2 %

2

dorzolamide hcl-timolol mal ophthalmic solution 22.3-6.8 mg/ml

2

dorzolamide hcl-timolol mal pf ophthalmic solution 22.3-6.8 mg/ml

2

IOPIDINE OPHTHALMIC SOLUTION 0.5 %, 1 %

4

ISOPTO CARPINE OPHTHALMIC SOLUTION 1 %, 2 %, 4 %

4

ISTALOL OPHTHALMIC SOLUTION 0.5 %

4

KEVEYIS ORAL TABLET 50 MG

6 PA

latanoprost ophthalmic solution 0.005 %

2

Drug NameDrug Tier

Notes

LATANOPROST-TIMOLOL MALEATE OPHTHALMIC SOLUTION 0.005-0.5 %

4

levobunolol hcl ophthalmic solution 0.5 %

2

LUMIGAN OPHTHALMIC SOLUTION 0.01 %

3

methazolamide oral tablet 25 mg, 50 mg

2

metipranolol ophthalmic solution 0.3 %

2

NEPTAZANE ORAL TABLET 25 MG, 50 MG

4

PHOSPHOLINE IODIDE OPHTHALMIC SOLUTION RECONSTITUTED 0.125 %

3

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

2

RESCULA OPHTHALMIC SOLUTION 0.15 %

4

RHOPRESSA OPHTHALMIC SOLUTION 0.02 %

4

ROCKLATAN OPHTHALMIC SOLUTION 0.02-0.005 %

4

SIMBRINZA OPHTHALMIC SUSPENSION 1-0.2 %

4

timolol maleate ophthalmic gel forming solution 0.25 %, 0.5 %

2

timolol maleate ophthalmic solution 0.25 %, 0.5 %

1



214

Drug NameDrug Tier

Notes

timolol maleate ophthalmic solution 0.5 % (daily)

2

TIMOLOL-BRIMON-DORZOL-LATANOPR OPHTHALMIC SOLUTION 0.5-0.15-2 -0.005%

4

TIMOLOL-BRIMONIDINE-DORZOLAMID OPHTHALMIC SOLUTION 0.5-0.15-2 %

4

TIMOLOL-DORZOLAMID-LATANOPROST OPHTHALMIC SOLUTION 0.5-0.15-0.005 %

4

TIMOPTIC OCUDOSE OPHTHALMIC SOLUTION 0.25 %, 0.5 %

4

TIMOPTIC OPHTHALMIC SOLUTION 0.25 %, 0.5 %

3

TIMOPTIC-XE OPHTHALMIC GEL FORMING SOLUTION 0.25 %, 0.5 %

4

TRAVATAN Z OPHTHALMIC SOLUTION 0.004 %

3

TRUSOPT OPHTHALMIC SOLUTION 2 %

4

VYZULTA OPHTHALMIC SOLUTION 0.024 %

4

XALATAN OPHTHALMIC SOLUTION 0.005 %

4

ZIOPTAN OPHTHALMIC SOLUTION 0.0015 %

4

Drug NameDrug Tier

Notes

Ophthalmic Agents - Drugs for Miscellaneous Eye Conditions

ak-fluor intravenous solution 10 %, 25 %

GM

ak-poly-bac ophthalmic ointment 500-10000 unit/gm

2

AKTEN OPHTHALMIC GEL 3.5 %

4

ALCAINE OPHTHALMIC SOLUTION 0.5 %

4

altacaine ophthalmic solution 0.5 %

2

altafrin ophthalmic solution 10 %, 2.5 %

2

AMVISC INTRAOCULAR SOLUTION 12 MG/ML

4

AMVISC PLUS INTRAOCULAR SOLUTION 16 MG/ML

4

ATROPINE SULFATE OPHTHALMIC EMULSION 0.01 %

4

atropine sulfate ophthalmic ointment 1 %

2

atropine sulfate ophthalmic solution 1 %

2

ATROPINE SULFATE-NACL OPHTHALMIC SOLUTION 0.01-0.9 %

4

bacitracin-polymyxin b ophthalmic ointment 500-10000 unit/gm

2

bacitra-neomycin-polymyxin-hc ophthalmic ointment 1 %

2

balanced salt intraocular solution

2



215

Drug NameDrug Tier

Notes

BEOVU INTRAVITREAL SOLUTION 6 MG/0.05ML

6PA;

Specialty Medical

BEVACIZUMAB INTRAOCULAR SOLUTION PREFILLED SYRINGE 2.75 MG/0.11ML, 3.75 MG/0.15ML

6PA;

Specialty Medical

BEVACIZUMAB INTRAVITREAL SOLUTION PREFILLED SYRINGE 2.5 MG/0.1ML, 3.25 MG/0.13ML, 3.75 MG/0.15ML

6PA;

Specialty Medical

BIOLON INTRAOCULAR SOLUTION 10 MG/ML

4

BLEPHAMIDE OPHTHALMIC SUSPENSION 10-0.2 %

3

BLEPHAMIDE S.O.P. OPHTHALMIC OINTMENT 10-0.2 %

3

bss intraocular solution 2

bss plus intraocular solution

2

CYCLOGYL OPHTHALMIC SOLUTION 0.5 %, 1 %, 2 %

3

CYCLOMYDRIL OPHTHALMIC SOLUTION 0.2-1 %

3

cyclopentolate hcl ophthalmic solution 0.5 %

2

cyclopentolate hcl ophthalmic solution 1 %, 2 %

1

CYCLOSPORINE IN KLARITY OPHTHALMIC EMULSION 0.1 %

4

Drug NameDrug Tier

Notes

DEXAMETHASONE-MOXIFLOXACIN INTRAOCULAR SOLUTION 1-5 MG/ML

GM

DEXAMETH-MOXIFLOX-KETOROLAC INTRAOCULAR SOLUTION 1-0.5-0.4 MG/ML

GM

EYLEA INTRAVITREAL SOLUTION 2 MG/0.05ML

6Specialty Medical

FLUORESCITE INTRAVENOUS SOLUTION 10 %

GM

GATIFLOXACIN-DEXAMETHASONE OPHTHALMIC SOLUTION 0.5-0.1 %

4

GELFILM OPHTHALMIC FILM

4

HEALON GV INTRAOCULAR SOLUTION 14 MG/ML

4

HEALON INTRAOCULAR SOLUTION 10 MG/ML

4

HEALON5 INTRAOCULAR SOLUTION 23 MG/ML

4

homatropaire ophthalmic solution 5 %

2

homatropine hbr ophthalmic solution 5 %

2

HYALURONIDASE (INTRAOCULAR) INTRAOCULAR SOLUTION 175 UNIT/ML

GM

ISOPTO ATROPINE OPHTHALMIC SOLUTION 1 %

4



216

Drug NameDrug Tier

Notes

JETREA INTRAVITREAL SOLUTION 0.375 MG/0.3ML

6PA;

Specialty Medical

LACRISERT OPHTHALMIC INSERT 5 MG

4

LASTACAFT OPHTHALMIC SOLUTION 0.25 %

4

LIDOCAINE-EPINEPHRINE INTRAOCULAR SOLUTION 7.5-0.25 MG/ML

GM

LIDOCAINE-PHENYLEPHRINE INTRAOCULAR SOLUTION 1-1.5 %

GM

LIDOCAINE-PHENYLEPHRINE-BSS INTRAOCULAR SOLUTION PREFILLED SYRINGE 1-1.5 % (1ML)

GM

LUCENTIS INTRAVITREAL SOLUTION 0.3 MG/0.05ML, 0.5 MG/0.05ML

6Specialty Medical

LUCENTIS INTRAVITREAL SOLUTION PREFILLED SYRINGE 0.3 MG/0.05ML

4

LUCENTIS INTRAVITREAL SOLUTION PREFILLED SYRINGE 0.5 MG/0.05ML

6Specialty Medical

LUXTURNA INTRAOCULAR SUSPENSION 5000000000000 VG/ML

6PA;

Specialty Medical

Drug NameDrug Tier

Notes

MACUGEN INTRAOCULAR SOLUTION 0.3 MG

6Specialty Medical

MAXITROL OPHTHALMIC OINTMENT 3.5-10000-0.1

4

MAXITROL OPHTHALMIC SUSPENSION 3.5-10000-0.1

4

MEMBRANEBLUE OPHTHALMIC SOLUTION 0.15 %

GM

MIOCHOL-E INTRAOCULAR SOLUTION RECONSTITUTED 20 MG

4

MIOSTAT INTRAOCULAR SOLUTION 0.01 %

4

MOXIFLOXACIN HCL-BSS INTRAVITREAL SOLUTION 1 MG/ML

GM

neomycin-bacitracin zn-polymyx ophthalmic ointment 3.5-400-10000 , 5-400-10000

2

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

2

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

2

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

2

neomycin-polymyxin-hc ophthalmic suspension 3.5-10000-1

2



217

Drug NameDrug Tier

Notes

neo-polycin hc ophthalmic ointment 1 %

2

neo-polycin ophthalmic ointment 3.5-400-10000

2

NEOSPORIN OPHTHALMIC SOLUTION 1.75-10000-.025

4

OMIDRIA INTRAOCULAR SOLUTION 1-0.3 %

GM

OXERVATE OPHTHALMIC SOLUTION 0.002 %

6 PA

phenylephrine hcl ophthalmic solution 10 %, 2.5 %

2

polycin ophthalmic ointment 500-10000 unit/gm

2

polymyxin b-trimethoprim ophthalmic solution 10000-0.1 unit/ml-%

2

POLYTRIM OPHTHALMIC SOLUTION 10000-0.1 UNIT/ML-%

4

PRED-G OPHTHALMIC SUSPENSION 0.3-1 %

3

PRED-G S.O.P. OPHTHALMIC OINTMENT 0.3-0.6 %

3

PREDNISOLONE-BROMFENAC OPHTHALMIC SOLUTION 1-0.075 %

4

PREDNISOLONE-BROMFENAC OPHTHALMIC SUSPENSION 1-0.075 %

GM

Drug NameDrug Tier

Notes

PREDNISOLONE-GATIFLOXACIN OPHTHALMIC SOLUTION 1-0.5 %

4

PREDNISOLONE-GATIFLOXACIN OPHTHALMIC SUSPENSION 1-0.5 %

4

PREDNISOLON-GATIFLOX-BROMFENAC OPHTHALMIC SOLUTION 1-0.5-0.075 %

4

PREDNISOLON-GATIFLOX-BROMFENAC OPHTHALMIC SUSPENSION 1-0.5-0.075 %

4

PREDNISOLON-MOXIFLOX-BROMFENAC OPHTHALMIC SOLUTION 1-0.5-0.075 %

4

proparacaine hcl ophthalmic solution 0.5 %

2

PROVISC INTRAOCULAR SOLUTION 10 MG/ML

4

RESTASIS MULTIDOSE OPHTHALMIC EMULSION 0.05 %

3

RESTASIS OPHTHALMIC EMULSION 0.05 %

3

SHELLGEL INTRAOCULAR SOLUTION 12 MG/ML

4

sulfacetamide-prednisolone ophthalmic solution 10-0.23 %

2



218

Drug NameDrug Tier

Notes

tetcaine ophthalmic solution 0.5 %

2

tetracaine hcl ophthalmic solution 0.5 %

2

tetravisc forte ophthalmic solution 0.5 %

2

tetravisc ophthalmic solution 0.5 %

2

TOBRADEX OPHTHALMIC OINTMENT 0.3-0.1 %

3

TOBRADEX OPHTHALMIC SUSPENSION 0.3-0.1 %

3

TOBRADEX ST OPHTHALMIC SUSPENSION 0.3-0.05 %

3

tobramycin-dexamethasone ophthalmic suspension 0.3-0.1 %

2

TRIAMCINOLONE-MOXIFLOXACIN INTRAOCULAR SUSPENSION 15-1 MG/ML

GM

TROPICAMIDE-CYCLOPENTOLATE-PE OPHTHALMIC SOLUTION 1-1-2.5 %

4

TROPICAMIDE-PHENYLEPHRINE OPHTHALMIC SOLUTION 1-2.5 %

4

TROPIC-PROPARACA-PE-KETOROLAC OPHTHALMIC SOLUTION 1-0.5-2.5-0.5 %

4

VISIONBLUE OPHTHALMIC SOLUTION 0.06 %

GM

Drug NameDrug Tier

Notes

VISUDYNE INTRAVENOUS SOLUTION RECONSTITUTED 15 MG

6Specialty Medical

XIIDRA OPHTHALMIC SOLUTION 5 %

4

ZYLET OPHTHALMIC SUSPENSION 0.5-0.3 %

4

Otic Agents - Drugs for Ear Conditions

acetasol hc otic solution 2-1 %

2

acetic acid otic solution 2 %

2

CETRAXAL OTIC SOLUTION 0.2 %

4

CIPRO HC OTIC SUSPENSION 0.2-1 %

4

CIPRODEX OTIC SUSPENSION 0.3-0.1 %

4

ciprofloxacin hcl otic solution 0.2 %

2

CIPROFLOXACIN-FLUOCINOLONE PF OTIC SOLUTION 0.3-0.025 %

4

COLY-MYCIN S OTIC SUSPENSION 3.3-3-10-0.5 MG/ML

4

DERMOTIC OTIC OIL 0.01 %

4

flac otic oil 0.01 % 2

FLOXIN OTIC OTIC SOLUTION 0.3 %

4

fluocinolone acetonide otic oil 0.01 %

2

hydrocortisone-acetic acid otic solution 1-2 %

2

neomycin-polymyxin-hc otic solution 1 %, 3.5-10000-1

2



219

Drug NameDrug Tier

Notes

neomycin-polymyxin-hc otic suspension 3.5-10000-1

2

ofloxacin otic solution 0.3 %

2

OTIPRIO INTRATYMPANIC SUSPENSION 6 %

4

OTOVEL OTIC SOLUTION 0.3-0.025 %

4

PRAMOTIC OTIC LIQUID 1-0.1 %

4

Respiratory Tract / Pulmonary Agents - Drugs for Allergies, Cough, Cold

ADRENALIN NASAL SOLUTION 0.1 %

4

ASTEPRO NASAL SOLUTION 0.15 %

4

azelastine hcl nasal solution 0.1 %, 0.15 %, 137 mcg/spray

2

BECONASE AQ NASAL SUSPENSION 42 MCG/SPRAY

4

benzonatate oral capsule 100 mg, 150 mg, 200 mg

2

biotuss oral liquid 10-15-300 mg/5ml

2

biotuss pediatric oral liquid 2.5-5-50 mg/ml

2

bromfed dm oral syrup 30-2-10 mg/5ml

2

brompheniramine tannate oral tablet chewable 12 mg

2

budesonide nasal suspension 32 mcg/act

2

CARBAPHEN 12 ORAL LIQUID 10-4-27.5 MG/5ML

4

Drug NameDrug Tier

Notes

CARBAPHEN 12 PED ORAL SUSPENSION 2.5-1.25-7.5 MG/ML

4

carbinoxamine maleate oral solution 4 mg/5ml

2

carbinoxamine maleate oral tablet 4 mg

2

CINQAIR INTRAVENOUS SOLUTION 100 MG/10ML

6PA;

Specialty Medical

clemastine fumarate oral tablet 2.68 mg

2

CODAR AR ORAL LIQUID 2-8 MG/5ML

4

CUROSURF INTRATRACHEAL SUSPENSION 120 MG/1.5ML, 240 MG/3ML

4

cyproheptadine hcl oral syrup 2 mg/5ml

2

cyproheptadine hcl oral tablet 4 mg

2

DECON-A ORAL ELIXIR 2-5 MG/5ML

4

desloratadine oral tablet 5 mg

2

desloratadine oral tablet dispersible 2.5 mg, 5 mg

2

dexchlorpheniramine maleate oral solution 2 mg/5ml

2

diphen oral elixir 12.5 mg/5ml

2

diphenhydramine hcl injection solution 50 mg/ml

2

diphenhydramine hcl oral elixir 12.5 mg/5ml

2

EXACTUSS ORAL LIQUID 10-28-388 MG/5ML

4



220

Drug NameDrug Tier

Notes

FASENRA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 30 MG/ML

6PA;

Specialty Medical

flunisolide nasal solution 25 mcg/act (0.025%)

2

fluticasone propionate nasal suspension 50 mcg/act

2

GILPHEX TR ORAL TABLET 10-388 MG

4

GILTUSS ORAL LIQUID 10-28-388 MG/5ML

4

giltuss pediatric oral liquid 2.5-7.5-88 mg/ml

2

GILTUSS TR ORAL TABLET 10-28-388 MG

4

hydrocodone polst-cpm polst er oral suspension extended release 10-8 mg/5ml

2

hydrocodone-homatropine oral syrup 5-1.5 mg/5ml

2

hydrocodone-homatropine oral tablet 5-1.5 mg

2

hydromet oral syrup 5-1.5 mg/5ml

2

HYPERSAL INHALATION NEBULIZATION SOLUTION 3.5 %, 7 %

4

INFASURF INTRATRACHEAL SUSPENSION 35-0.9 MG/ML-%

4

ipratropium bromide nasal solution 0.03 %, 0.06 %

2

Drug NameDrug Tier

Notes

KARBINAL ER ORAL SUSPENSION EXTENDED RELEASE 4 MG/5ML

4

levocetirizine dihydrochloride oral solution 2.5 mg/5ml

2

levocetirizine dihydrochloride oral tablet 5 mg

2

mometasone furoate nasal suspension 50 mcg/act

2

NASONEX NASAL SUSPENSION 50 MCG/ACT

4

nebusal inhalation nebulization solution 3 %

2

NEBUSAL INHALATION NEBULIZATION SOLUTION 6 %

4

NEOTUSS PLUS ORAL LIQUID 7.5-4-30 MG/5ML

4

NORTUSS-EX ORAL LIQUID 20-200 MG/5ML

4

NUCALA SUBCUTANEOUS SOLUTION AUTO-INJECTOR 100 MG/ML

6 PA

NUCALA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 100 MG/ML

6 PA

NUCALA SUBCUTANEOUS SOLUTION RECONSTITUTED 100 MG

6PA;

Specialty Medical

olopatadine hcl nasal solution 0.6 %

2



221

Drug NameDrug Tier

Notes

OMNARIS NASAL SUSPENSION 50 MCG/ACT

4

PATANASE NASAL SOLUTION 0.6 %

4

phenadoz rectal suppository 12.5 mg, 25 mg

2

PHENERGAN INJECTION SOLUTION 25 MG/ML, 50 MG/ML

4

phenergan rectal suppository 12.5 mg, 25 mg, 50 mg

2

phenylephrine-guaifenesin oral liquid 1.5-20 mg/ml

2

promethazine hcl injection solution 25 mg/ml, 50 mg/ml

2

promethazine hcl oral solution 6.25 mg/5ml

2

promethazine hcl oral syrup 6.25 mg/5ml

2

promethazine hcl oral tablet 12.5 mg, 25 mg, 50 mg

2

promethazine hcl rectal suppository 12.5 mg, 25 mg, 50 mg

2

promethazine vc plain oral solution 6.25-5 mg/5ml

2

promethazine vc/codeine oral syrup 6.25-5-10 mg/5ml

2

promethazine-codeine oral solution 6.25-10 mg/5ml

2

promethazine-codeine oral syrup 6.25-10 mg/5ml

2

Drug NameDrug Tier

Notes

promethazine-dm oral solution 6.25-15 mg/5ml

2

promethazine-dm oral syrup 6.25-15 mg/5ml

2

promethazine-phenyleph-codeine oral syrup 6.25-5-10 mg/5ml

2

promethazine-phenylephrine oral syrup 6.25-5 mg/5ml

2

promethegan rectal suppository 12.5 mg, 25 mg, 50 mg

2

pseudoeph-chlorphen-hydrocod oral solution 60-4-5 mg/5ml

2

pseudoephedrine-bromphen-dm oral syrup 30-2-10 mg/5ml

2

pulmosal inhalation nebulization solution 7 %

2

QNASL CHILDRENS NASAL AEROSOL SOLUTION 40 MCG/ACT

4

QNASL NASAL AEROSOL SOLUTION 80 MCG/ACT

4

rhinocort allergy nasal suspension 32 mcg/act

2

RYCLORA ORAL SOLUTION 2 MG/5ML

4

SINUVA NASAL IMPLANT 1350 MCG

5Specialty Medical

sodium chloride inhalation nebulization solution 0.9 %, 10 %, 3 %, 7 %

2

SSKI ORAL SOLUTION 1 GM/ML

4



222

Drug NameDrug Tier

Notes

SURVANTA INTRATRACHEAL SUSPENSION 25-0.9 MG/ML-%

4

TESSALON PERLES ORAL CAPSULE 100 MG

4

triamcinolone acetonide nasal aerosol 55 mcg/act

2

TUSSICAPS ORAL CAPSULE EXTENDED RELEASE 12 HOUR 10-8 MG, 5-4 MG

4

tussigon oral tablet 5-1.5 mg

2

TUSSIONEX PENNKINETIC ER ORAL SUSPENSION EXTENDED RELEASE 10-8 MG/5ML

4

TUXARIN ER ORAL TABLET EXTENDED RELEASE 12 HOUR 54.3-8 MG

4

TUZISTRA XR ORAL SUSPENSION EXTENDED RELEASE 14.7-2.8 MG/5ML

4

XHANCE NASAL EXHALER SUSPENSION 93 MCG/ACT

4

XOLAIR SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 150 MG/ML, 75 MG/0.5ML

6PA;

Specialty Medical

XOLAIR SUBCUTANEOUS SOLUTION RECONSTITUTED 150 MG

6PA;

Specialty Medical

Drug NameDrug Tier

Notes

ZETONNA NASAL AEROSOL SOLUTION 37 MCG/ACT

4

ZUTRIPRO ORAL SOLUTION 60-4-5 MG/5ML

4

Respiratory Tract / Pulmonary Agents - Drugs for Asthma and Other Lung Conditions

ACCOLATE ORAL TABLET 10 MG, 20 MG

4

acetylcysteine inhalation solution 10 %, 20 %

2

ADRENALIN INJECTION SOLUTION 1 MG/ML, 30 MG/30ML

GMQL (4 ML

per 30 days)

ADVAIR DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 100-50 MCG/DOSE, 250-50 MCG/DOSE, 500-50 MCG/DOSE

4 PA

ADVAIR HFA INHALATION AEROSOL 115-21 MCG/ACT, 230-21 MCG/ACT, 45-21 MCG/ACT

4 PA

AEROSPAN INHALATION AEROSOL SOLUTION 80 MCG/ACT

3

albuterol sulfate er oral tablet extended release 12 hour 4 mg, 8 mg

2

albuterol sulfate inhalation nebulization solution (2.5 mg/3ml) 0.083%, (5 mg/ml) 0.5%, 0.63 mg/3ml, 1.25 mg/3ml

2

albuterol sulfate oral syrup 2 mg/5ml

2



223

Drug NameDrug Tier

Notes

albuterol sulfate oral tablet 2 mg

2

albuterol sulfate oral tablet 4 mg

1

ALVESCO INHALATION AEROSOL SOLUTION 160 MCG/ACT, 80 MCG/ACT

4

aminophylline intravenous solution 25 mg/ml

2

ANORO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 62.5-25 MCG/INH

4

ARALAST NP INTRAVENOUS SOLUTION RECONSTITUTED 1000 MG, 500 MG

6PA;

Specialty Medical

ARCAPTA NEOHALER INHALATION CAPSULE 75 MCG

4QL (30 EA

per 30 days)

ARMONAIR RESPICLICK 113 INHALATION AEROSOL POWDER BREATH ACTIVATED 113 MCG/ACT

4 PA


4 PA


4 PA

Drug NameDrug Tier

Notes

ARNUITY ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 100 MCG/ACT, 200 MCG/ACT, 50 MCG/ACT

4 PA

ASMANEX (120 METERED DOSES) INHALATION AEROSOL POWDER BREATH ACTIVATED 220 MCG/INH

3QL (1 EA

per 30 days)


3QL (1 EA

per 30 days)

ASMANEX (30 METERED DOSES) INHALATION AEROSOL POWDER BREATH ACTIVATED 110 MCG/INH, 220 MCG/INH

3QL (1 EA

per 30 days)


3QL (1 EA

per 30 days)


3QL (1 EA

per 30 days)

ASMANEX HFA INHALATION AEROSOL 100 MCG/ACT, 200 MCG/ACT

3

ATROVENT HFA INHALATION AEROSOL SOLUTION 17 MCG/ACT

3



224

Drug NameDrug Tier

Notes

BEVESPI AEROSPHERE INHALATION AEROSOL 9-4.8 MCG/ACT

4

BREO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 100-25 MCG/INH, 200-25 MCG/INH

4 PA

BROVANA INHALATION NEBULIZATION SOLUTION 15 MCG/2ML

4

budesonide inhalation suspension 0.25 mg/2ml, 0.5 mg/2ml, 1 mg/2ml

2

COMBIVENT RESPIMAT INHALATION AEROSOL SOLUTION 20-100 MCG/ACT

3

cromolyn sodium inhalation nebulization solution 20 mg/2ml

2

DALIRESP ORAL TABLET 250 MCG, 500 MCG

4 PA

difil-g forte oral liquid 100-100 mg/5ml

2

DULERA INHALATION AEROSOL 100-5 MCG/ACT, 200-5 MCG/ACT

3

ELIXOPHYLLIN ORAL ELIXIR 80 MG/15ML

4

epinephrine injection solution 0.3 mg/0.3ml

2QL (4 EA

per 30 days)

epinephrine injection solution auto-injector 0.15 mg/0.15ml, 0.15 mg/0.3ml, 0.3 mg/0.3ml

2QL (4 EA

per 30 days)

Drug NameDrug Tier

Notes

EPIPEN 2-PAK INJECTION SOLUTION AUTO-INJECTOR 0.3 MG/0.3ML

4QL (4 EA

per 30 days)

EPIPEN JR 2-PAK INJECTION SOLUTION AUTO-INJECTOR 0.15 MG/0.3ML

4QL (4 EA

per 30 days)

ESBRIET ORAL CAPSULE 267 MG

6 PA

ESBRIET ORAL TABLET 267 MG, 801 MG

6 PA

FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 100 MCG/BLIST, 250 MCG/BLIST, 50 MCG/BLIST

4

FLOVENT HFA INHALATION AEROSOL 110 MCG/ACT, 220 MCG/ACT, 44 MCG/ACT

4QL (24 GM

per 30 days)

fluticasone-salmeterol inhalation aerosol powder breath activated 100-50 mcg/dose, 250-50 mcg/dose, 500-50 mcg/dose

2

FLUTICASONE-SALMETEROL INHALATION AEROSOL POWDER BREATH ACTIVATED 113-14 MCG/ACT, 232-14 MCG/ACT, 55-14 MCG/ACT

2

GLASSIA INTRAVENOUS SOLUTION 1000 MG/50ML

6PA;

Specialty Medical



225

Drug NameDrug Tier

Notes

INCRUSE ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 62.5 MCG/INH

3

ipratropium bromide inhalation solution 0.02 %

2

ipratropium-albuterol inhalation solution 0.5-2.5 (3) mg/3ml

2

levalbuterol hcl inhalation nebulization solution 0.31 mg/3ml, 0.63 mg/3ml, 1.25 mg/0.5ml, 1.25 mg/3ml

2

metaproterenol sulfate oral syrup 10 mg/5ml

2

metaproterenol sulfate oral tablet 10 mg, 20 mg

2

montelukast sodium oral packet 4 mg

2

montelukast sodium oral tablet 10 mg

2

montelukast sodium oral tablet chewable 4 mg, 5 mg

2

OFEV ORAL CAPSULE 100 MG, 150 MG

6 PA

PERFOROMIST INHALATION NEBULIZATION SOLUTION 20 MCG/2ML

4

PROAIR HFA INHALATION AEROSOL SOLUTION 108 (90 BASE) MCG/ACT

2QL (3 GM

per 30 days)

PROAIR RESPICLICK INHALATION AEROSOL POWDER BREATH ACTIVATED 108 (90 BASE) MCG/ACT

2QL (3 EA

per 30 days)

Drug NameDrug Tier

Notes

PROLASTIN-C INTRAVENOUS SOLUTION 1000 MG/20ML

6PA;

Specialty Medical

PROLASTIN-C INTRAVENOUS SOLUTION RECONSTITUTED 1000 MG

6PA;

Specialty Medical

PULMICORT FLEXHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 180 MCG/ACT, 90 MCG/ACT

3

PULMICORT SUSPENSION INHALATION SUSPENSION 0.25 MG/2ML, 0.5 MG/2ML, 1 MG/2ML

4

QVAR INHALATION AEROSOL SOLUTION 40 MCG/ACT, 80 MCG/ACT

3QL (17.4

GM per 30 days)

QVAR REDIHALER INHALATION AEROSOL BREATH ACTIVATED 40 MCG/ACT, 80 MCG/ACT

3

SCLEROSOL INTRAPLEURAL INTRAPLEURAL AEROSOL POWDER 4 GM

4

SEREVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 50 MCG/DOSE

3

SINGULAIR ORAL PACKET 4 MG

4

SINGULAIR ORAL TABLET 10 MG

4



226

Drug NameDrug Tier

Notes

SINGULAIR ORAL TABLET CHEWABLE 4 MG, 5 MG

4

SPIRIVA HANDIHALER INHALATION CAPSULE 18 MCG

3

SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION 1.25 MCG/ACT, 2.5 MCG/ACT

3

STERILE TALC POWDER INTRAPLEURAL SUSPENSION RECONSTITUTED 5 GM

4

STIOLTO RESPIMAT INHALATION AEROSOL SOLUTION 2.5-2.5 MCG/ACT

4

STRIVERDI RESPIMAT INHALATION AEROSOL SOLUTION 2.5 MCG/ACT

3

SYMBICORT INHALATION AEROSOL 160-4.5 MCG/ACT, 80-4.5 MCG/ACT

3

terbutaline sulfate injection solution 1 mg/ml

GM

terbutaline sulfate oral tablet 2.5 mg, 5 mg

2

THEO-24 ORAL CAPSULE EXTENDED RELEASE 24 HOUR 100 MG, 200 MG, 300 MG, 400 MG

4

theochron oral tablet extended release 12 hour 100 mg, 200 mg, 300 mg

2

theophylline er oral tablet extended release 12 hour 100 mg, 200 mg, 300 mg, 450 mg

2

Drug NameDrug Tier

Notes

theophylline er oral tablet extended release 24 hour 400 mg, 600 mg

2

theophylline in d5w intravenous solution 0.8-5 mg/ml-%

GM

theophylline oral solution 80 mg/15ml

2

TRELEGY ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 100-62.5-25 MCG/INH

4

TUDORZA PRESSAIR INHALATION AEROSOL POWDER BREATH ACTIVATED 400 MCG/ACT

3

UTIBRON NEOHALER INHALATION CAPSULE 27.5-15.6 MCG

4

VENTOLIN HFA INHALATION AEROSOL SOLUTION 108 (90 BASE) MCG/ACT

2QL (3 GM

per 30 days)

wixela inhub inhalation aerosol powder breath activated 100-50 mcg/dose, 250-50 mcg/dose, 500-50 mcg/dose

2

XOPENEX CONCENTRATE INHALATION NEBULIZATION SOLUTION 1.25 MG/0.5ML

4

XOPENEX INHALATION NEBULIZATION SOLUTION 0.31 MG/3ML, 0.63 MG/3ML, 1.25 MG/3ML

4



227

Drug NameDrug Tier

Notes

YUPELRI INHALATION SOLUTION 175 MCG/3ML

6 PA

zafirlukast oral tablet 10 mg, 20 mg

2

ZEMAIRA INTRAVENOUS SOLUTION RECONSTITUTED 1000 MG

6PA;

Specialty Medical

zileuton er oral tablet extended release 12 hour 600 mg

5

ZYFLO CR ORAL TABLET EXTENDED RELEASE 12 HOUR 600 MG

5

ZYFLO ORAL TABLET 600 MG

5

Respiratory Tract / Pulmonary Agents - Drugs for Cystic Fibrosis

BETHKIS INHALATION NEBULIZATION SOLUTION 300 MG/4ML

6 PA

CAYSTON INHALATION SOLUTION RECONSTITUTED 75 MG

6 PA

KALYDECO ORAL PACKET 25 MG, 50 MG, 75 MG

6 PA

KALYDECO ORAL TABLET 150 MG

6 PA

KITABIS PAK INHALATION NEBULIZATION SOLUTION 300 MG/5ML

6 PA

ORKAMBI ORAL PACKET 100-125 MG, 150-188 MG

6 PA

Drug NameDrug Tier

Notes

ORKAMBI ORAL TABLET 100-125 MG, 200-125 MG

6 PA

PULMOZYME INHALATION SOLUTION 1 MG/ML

6 PA

SYMDEKO ORAL TABLET THERAPY PACK 100-150 & 150 MG, 50-75 & 75 MG

6 PA

TOBI NEBULIZER INHALATION NEBULIZATION SOLUTION 300 MG/5ML

6 PA

TOBI PODHALER INHALATION CAPSULE 28 MG

6 PA

tobramycin nebulization solution 300 mg/5ml inhalation 300 mg/5ml

5 PA

TOBRAMYCIN NEBULIZATION SOLUTION 300 MG/5ML INHALATION 300 MG/5ML

6 PA

TRIKAFTA ORAL TABLET THERAPY PACK 100-50-75 & 150 MG

6 PA

Respiratory Tract / Pulmonary Agents - Drugs for Pulmonary Hypertension

ADCIRCA ORAL TABLET 20 MG

6 PA

ADEMPAS ORAL TABLET 0.5 MG, 1 MG, 1.5 MG, 2 MG, 2.5 MG

6 PA

alyq oral tablet 20 mg 5 PA

ambrisentan oral tablet 10 mg, 5 mg

5 PA

bosentan oral tablet 125 mg, 62.5 mg

5 PA



228

Drug NameDrug Tier

Notes

epoprostenol sodium intravenous solution reconstituted 0.5 mg, 1.5 mg

5PA;

Specialty Medical

FLOLAN INTRAVENOUS SOLUTION RECONSTITUTED 0.5 MG, 1.5 MG

6PA;

Specialty Medical

LETAIRIS ORAL TABLET 10 MG, 5 MG

6 PA

OPSUMIT ORAL TABLET 10 MG

6 PA

ORENITRAM ORAL TABLET EXTENDED RELEASE 0.125 MG, 0.25 MG, 1 MG, 2.5 MG, 5 MG

6 PA

REMODULIN INJECTION SOLUTION 100 MG/20ML, 20 MG/20ML, 200 MG/20ML, 50 MG/20ML

6PA;

Specialty Medical

REVATIO INTRAVENOUS SOLUTION 10 MG/12.5ML

6PA;

Specialty Medical

REVATIO ORAL SUSPENSION RECONSTITUTED 10 MG/ML

6 PA

REVATIO ORAL TABLET 20 MG

6 PA

sildenafil citrate intravenous solution 10 mg/12.5ml

5PA;

Specialty Medical

sildenafil citrate oral suspension reconstituted 10 mg/ml

6 PA

sildenafil citrate oral tablet 20 mg

5 PA

tadalafil (pah) oral tablet 20 mg

5 PA

Drug NameDrug Tier

Notes

TRACLEER ORAL TABLET 125 MG, 62.5 MG

6 PA

TRACLEER ORAL TABLET SOLUBLE 32 MG

6 PA

treprostinil injection solution 100 mg/20ml, 20 mg/20ml, 200 mg/20ml, 50 mg/20ml

6PA;

Specialty Medical

TYVASO INHALATION SOLUTION 0.6 MG/ML

6 PA

TYVASO REFILL INHALATION SOLUTION 0.6 MG/ML

6 PA

TYVASO STARTER INHALATION SOLUTION 0.6 MG/ML

6 PA

UPTRAVI ORAL TABLET 1000 MCG, 1200 MCG, 1400 MCG, 1600 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG

6 PA

UPTRAVI ORAL TABLET THERAPY PACK 200 & 800 MCG

4

VELETRI INTRAVENOUS SOLUTION RECONSTITUTED 0.5 MG, 1.5 MG

6PA;

Specialty Medical

VENTAVIS INHALATION SOLUTION 10 MCG/ML, 20 MCG/ML

6 PA

Skeletal Muscle Relaxants - Drugs for Muscle Pain and Spasm

baclofen intrathecal solution 10 mg/20ml, 40 mg/20ml

GM



229

Drug NameDrug Tier

Notes

baclofen oral tablet 10 mg, 20 mg, 5 mg

2

carisoprodol oral tablet 250 mg, 350 mg

2

carisoprodol-aspirin oral tablet 200-325 mg

2

chlorzoxazone oral tablet 250 mg, 375 mg, 500 mg, 750 mg

2

cyclobenzaprine hcl oral tablet 10 mg, 5 mg

2

cyclobenzaprine hcl oral tablet 7.5 mg

2 ST

DANTRIUM INTRAVENOUS SOLUTION RECONSTITUTED 20 MG

GM

DANTRIUM ORAL CAPSULE 25 MG, 50 MG

4

dantrolene sodium intravenous solution reconstituted 20 mg

GM

dantrolene sodium oral capsule 100 mg, 25 mg, 50 mg

2

FEXMID ORAL TABLET 7.5 MG

4 ST

GABLOFEN INTRATHECAL SOLUTION 10000 MCG/20ML, 40000 MCG/20ML

GM

LIORESAL INTRATHECAL INTRATHECAL SOLUTION 2000 MCG/ML, 40 MG/20ML, 500 MCG/ML

GM

Drug NameDrug Tier

Notes

LIORESAL INTRATHECAL SOLUTION 0.05 MG/ML, 10 MG/20ML, 10 MG/5ML, 40 MG/20ML

GM

LORZONE ORAL TABLET 375 MG, 750 MG

4

metaxall oral tablet 800 mg

2

metaxalone oral tablet 400 mg, 800 mg

2

methocarbamol injection solution 1000 mg/10ml

GM

methocarbamol oral tablet 500 mg, 750 mg

2

NORGESIC FORTE ORAL TABLET 50-770-60 MG

4

orphenadrine citrate er oral tablet extended release 12 hour 100 mg

2

orphenadrine citrate injection solution 30 mg/ml

GM

orphenadrine-aspirin-caffeine oral tablet 50-770-60 mg

2

ORPHENGESIC FORTE ORAL TABLET 770-60-50 MG

4

revonto intravenous solution reconstituted 20 mg

GM

ROBAXIN INJECTION SOLUTION 1000 MG/10ML

GM

ROBAXIN ORAL TABLET 500 MG

4

ROBAXIN-750 ORAL TABLET 750 MG

4



230

Drug NameDrug Tier

Notes

RYANODEX INTRAVENOUS SUSPENSION RECONSTITUTED 250 MG

GM

SKELAXIN ORAL TABLET 800 MG

4

SOMA ORAL TABLET 250 MG, 350 MG

4

tizanidine hcl oral capsule 2 mg, 4 mg, 6 mg

2

tizanidine hcl oral tablet 2 mg, 4 mg

2

ZANAFLEX ORAL CAPSULE 2 MG, 4 MG, 6 MG

4

ZANAFLEX ORAL TABLET 4 MG

4

Sleep Disorder Agents

AMBIEN CR ORAL TABLET EXTENDED RELEASE 12.5 MG, 6.25 MG

4

AMBIEN ORAL TABLET 10 MG, 5 MG

4

armodafinil oral tablet 150 mg, 200 mg, 250 mg, 50 mg

2

BELSOMRA ORAL TABLET 10 MG, 15 MG, 20 MG, 5 MG

4

BUTISOL SODIUM ORAL TABLET 30 MG

4

eszopiclone oral tablet 1 mg, 2 mg, 3 mg

2

flurazepam hcl oral capsule 15 mg, 30 mg

2

HETLIOZ ORAL CAPSULE 20 MG

6 PA

Drug NameDrug Tier

Notes

LUNESTA ORAL TABLET 1 MG, 2 MG, 3 MG

4

modafinil oral tablet 100 mg, 200 mg

2

NUVIGIL ORAL TABLET 150 MG, 200 MG, 250 MG, 50 MG

4

PROVIGIL ORAL TABLET 100 MG, 200 MG

4

ramelteon oral tablet 8 mg

2

RESTORIL ORAL CAPSULE 15 MG, 22.5 MG, 30 MG, 7.5 MG

4

ROZEREM ORAL TABLET 8 MG

4

SECONAL ORAL CAPSULE 100 MG

4

SILENOR ORAL TABLET 3 MG, 6 MG

4

SONATA ORAL CAPSULE 10 MG, 5 MG

4

SUNOSI ORAL TABLET 150 MG, 75 MG


days)

temazepam oral capsule 15 mg, 22.5 mg, 30 mg, 7.5 mg

2

WAKIX ORAL TABLET 17.8 MG, 4.45 MG

6 PA

XYREM ORAL SOLUTION 500 MG/ML

6 PA

zaleplon oral capsule 10 mg, 5 mg

2

zolpidem tartrate er oral tablet extended release 12.5 mg, 6.25 mg

2

zolpidem tartrate oral tablet 10 mg, 5 mg

2



231

Index of Drugs

1ST MEDX-PATCH/ LIDOCAINE........................ 187T GUMMY ES..................... 97T LIDO.............................. 18abacavir sulfate...................78abacavir sulfate-lamivudine 78abacavir-lamivudine-zidovudine...........................78ABANEU-SL..................... 132ABELCET........................... 51ABILIFY.............................. 75ABILIFY MAINTENA...........75abiraterone acetate.............58ABRAXANE........................ 58ABSORICA....................... 116ABSTRAL............................. 9ACACIA............................ 195acamprosate calcium..........23acarbose........................... 125ACCOLATE...................... 223ACCUPRIL..........................91ACCURETIC.......................91ACD FORMULA A.............. 37ACD-A NOCLOT-50........... 37acebutolol hcl......................91ACETADOTE....................195acetaminophen-codeine....... 9acetaminophen-codeine #2.. 9acetaminophen-codeine #3.. 9acetaminophen-codeine #4.. 9acetasol hc........................219acetazolamide.............91, 213acetazolamide er.............. 213acetazolamide sodium........ 91acetic acid.................158, 219acetylcysteine........... 195, 223ACIPHEX.......................... 151ACIPHEX SPRINKLE....... 151acitretin............................. 116ACREMONIUM.................195ACTEMRA........................ 182ACTEMRA ACTPEN.........182ACTHAR........................... 166ACTHIB.............................189ACTHREL......................... 195ACTIGALL........................ 152ACTIMMUNE.................... 182ACTIQ...................................9ACTIVASE.......................... 38ACTIVE FE....................... 132ACTIVE-KETOPROFEN.......6ACTIVELLA...................... 170ACTIVITE..........................133

ACTONEL.........................193ACTOPLUS MET..............125ACTOPLUS MET XR........125ACTOS............................. 125ACULAR........................... 210ACULAR LS......................210ACUVAIL.......................... 210acyclovir..............................78acyclovir sodium................. 78ACZONE...........................116ADACEL........................... 189ADAGEN...........................156ADALAT CC........................91adapalene......................... 116ADASUVE...........................75adc/f (0.5mg/ml)................133ADCETRIS..........................58ADCIRCA..........................228ADDERALL.......................109ADDERALL XR.................109adefovir dipivoxil ................. 78ADEMPAS........................ 228ADENOCARD.....................91ADENOSCAN................... 195adenosine................... 91, 195ADENOSINE.......................91adenosine (diagnostic)......195ADLYXIN.......................... 125ADLYXIN STARTER PACK................................ 125ADMELOG........................129ADMELOG SOLOSTAR... 129ADRENAL C FORMULA...133ADRENALIN............. 220, 223ADREVIEW.......................195adriamycin.......................... 58adrucil ................................. 58ADVAIR DISKUS.............. 223ADVAIR HFA.................... 223ADVANCED AM/PM......... 133ADVATE............................. 85ADYNOVATE......................85AEMCOLO..........................24AEROSPAN......................223afeditab cr........................... 91AFINITOR........................... 58AFINITOR DISPERZ.......... 58afirmelle............................ 170AFLURIA...........................189AFLURIA PRESERVATIVE FREE....189AFLURIA QUADRIVALENT..............189

AFREZZA......................... 129AFSTYLA............................85AGGRASTAT......................74AGGRENOX....................... 74agoneaze............................ 18AGRYLIN............................ 86AIMOVIG............................ 55AJOVY................................ 55ak-fluor..............................215AKOVAZ............................. 91ak-poly-bac....................... 215AKTEN..............................215AKYNZEO...........................50ala-cort..............................116albendazole........................ 71ALBENZA........................... 71ALBUKED 25.................... 195ALBUKED 5...................... 195albumin human................. 195ALBUMINAR-25................195ALBUMINAR-5..................196ALBUMINEX..................... 196albumin-zlb....................... 196alburx................................ 196ALBUTEIN........................ 196albuterol sulfate........ 223, 224albuterol sulfate er............ 223ALCAINE.......................... 215alclometasone dipropionate...................... 116ALCOHOL PREP PADS... 116ALDACTAZIDE................... 91ALDACTONE......................91ALDER..............................196ALDURAZYME................. 156ALECENSA.........................58alendronate sodium.......... 193alfentanil hcl..........................9ALFERON N..................... 182alfuzosin hcl er..................161ALIMTA...............................58ALINIA................................ 71ALIQOPA............................ 59aliskiren fumarate............... 91ALKERAN........................... 59allopurinol........................... 55allopurinol sodium...............55almotriptan malate.............. 56ALOCRIL.......................... 210ALOGLIPTIN BENZOATE 125ALOGLIPTIN-METFORMIN HCL............125

232

ALOGLIPTIN-PIOGLITAZONE............... 125ALOMIDE..........................210ALOPRIM............................55ALORA......................170, 171alosetron hcl..................... 152ALOXI................................. 50ALPHAGAN P...................213ALPHA-LIPOIC ACID....... 196ALPHANATE/VWF COMPLEX/HUMAN............ 86ALPHANINE SD................. 86alprazolam.......................... 83alprazolam er...................... 83ALPRAZOLAM INTENSOL.83alprazolam xr...................... 84ALPROLIX.......................... 86alprostadil ........................... 91ALREX.............................. 210ALTABAX............................24altacaine........................... 215ALTACE..............................91altafrin............................... 215altavera............................. 171ALTERNARIA................... 196ALTOPREV.........................91ALUNBRIG......................... 59ALVESCO.........................224alyacen 1/35..................... 171alyacen 7/7/7.................... 171alyq................................... 228amabelz............................ 171amantadine hcl................... 72AMARYL........................... 125AMBIEN............................ 231AMBIEN CR......................231AMBISOME........................ 52ambrisentan...................... 228amcinonide....................... 116AMD FOAM DRESSING...196AMD FOAM DRESSING TOPSHEET...................... 196AMERGE............................ 56AMERICAN BEECH......... 196AMERICAN COCKROACH.......................................... 196AMERICAN ELM.............. 196AMERICAN SYCAMORE. 196amethia............................. 171amethia lo......................... 171amethyst........................... 171AMICAR..............................86AMIDATE..........................196

amikacin sulfate.................. 24amiloride hcl........................91amiloride-hydrochlorothiazide.............91AMINO ACID.................... 133aminoacetic acid............... 158aminoamrms..................... 133aminocaproic acid...............86aminophylline....................224aminoreliefrms.................. 133AMINOSYN.......................133AMINOSYN II....................133aminosyn ii/electrolytes.....133AMINOSYN M...................133AMINOSYN/ELECTROLYTES...................................133aminosyn/electrolytes....... 133AMINOSYN-HBC..............133AMINOSYN-PF.................133AMINOSYN-RF.................133amiodarone hcl................... 92AMIODARONE HCL IN DEXTROSE........................ 92AMITIZA............................152amitriptyline hcl................... 47amlodipine besylate............ 92amlodipine besylate-benazepril hcl......................92amlodipine besylate-valsartan............................. 92amlodipine-atorvastatin.......92amlodipine-olmesartan....... 92amlodipine-valsartan-hctz...92AMMONIA N 13................ 196ammonium lactate............ 116AMMONUL....................... 156amnesteem....................... 116amoxapine.......................... 47amoxicill-clarithro-lansopraz.......................... 152amoxicillin..................... 24, 25amoxicillin-potassium clavulanate..........................25amoxicillin-potassium clavulanate er..................... 25AMPHADASE................... 196amphetamine-dextroamphetamine.......... 109amphetamine-dextroamphetamine er......109amphotericin b.................... 52ampicillin............................. 25ampicillin sodium................ 25

ampicillin-sulbactam sodium................................ 25AMPYRA...........................111AMVISC............................ 215AMVISC PLUS..................215AMYVID............................ 196ANACAINE....................... 116ANADROL-50................... 164ANAFRANIL........................47anagrelide hcl..................... 86ana-lex.............................. 192ANAPROX DS...................... 6ANASCORP......................196ANASPAZ......................... 152anastrozole......................... 59ANAVIP.............................196ANCOBON..........................52ANDEXXA.........................196ANDRODERM.................. 165ANDROGEL......................165ANDROGEL PUMP.......... 165ANDROID......................... 165ANECTINE........................113ANESTHESIA S/I-40........ 196ANESTHESIA S/I-40A...... 196ANESTHESIA S/I-40H......196ANESTHESIA S/I-40S...... 196ANESTHESIA S/I-60........ 196ANGELIQ..........................171ANGIOMAX........................ 38ANIMI-3.............................133ANIMI-3/VITAMIN D......... 133ANNOVERA......................171anodyne lpt......................... 18ANORO ELLIPTA............. 224ANTABUSE........................ 23ANTARA............................. 92anticoagulant cit dext soln a..........................................38anticoagulant sodium citrate.................................. 38ANTIVENIN MICRURUS FULVIUS...........................197ANUSOL-HC.....................192ANZEMET...........................50apap-caff-dihydrocodeine..... 9APIDRA SOLOSTAR........129APIDRA VIAL....................130APLENZIN.......................... 47APOKYN.............................72APP SLIM RMS................ 197apraclonidine hcl...............213aprepitant............................50

233

apri....................................171APRISO............................ 192APTENSIO XR..................109APTIOM.............................. 41APTIVUS............................ 78AP-ZEL............................. 133AQUACEL AG BURN....... 116AQUASOL A..................... 133ARAKODA.......................... 71ARALAST NP................... 224aranelle............................. 171ARANESP (ALBUMIN FREE)................................. 86ARAVA..............................182ARCALYST.......................182ARCAPTA NEOHALER.... 224ARESTIN.......................... 114argatroban.......................... 38argatroban in sodium chloride............................... 38ARGININE HCL................ 133argyle sterile saline........... 133argyle sterile water............133ARICEPT............................ 46ARIKAYCE..........................25ARIMIDEX.......................... 59aripiprazole......................... 75ARISTADA..........................75ARISTADA INITIO.............. 75ARIXTRA............................ 38ARIZONA CYPRESS........197armodafinil ........................ 231ARMONAIR RESPICLICK 113....................................224ARMONAIR RESPICLICK 232....................................224ARMONAIR RESPICLICK 55......................................224ARMOUR THYROID.........180arnica flower..................... 197ARNUITY ELLIPTA...........224AROMASIN.........................59ARRANON..........................59arsenic trioxide....................59ARTHROTEC....................... 6ARTICADENT DENTAL......18ARTISS.............................197ARYMO ER...........................9ARZERRA...........................59arzol silver nit applicators. 116ASACOL HD..................... 192ASCLERA........................... 92ascomp-codeine................... 9

ASCOR............................. 133ASCORBIC ACID............. 133ashlyna............................. 171ASMANEX (120 METERED DOSES)......... 224ASMANEX (14 METERED DOSES)............................ 224ASMANEX (30 METERED DOSES)............................ 224ASMANEX (60 METERED DOSES)............................ 224ASMANEX (7 METERED DOSES)............................ 224ASMANEX HFA................ 224ASPARLAS.........................59ASPERGILLUS FUMIGATUS.....................197aspirin adult low strength...... 6aspirin childrens....................6aspirin ec low dose............... 6aspirin ec low strength.......... 6aspirin low dose.................... 6aspirin-dipyridamole er....... 74ASTAGRAF XL................. 182ASTEPRO.........................220ASTRINGYN.......................86ATABEX OB..................... 133ATACAND...........................92ATACAND HCT.................. 92atazanavir sulfate................78ATELVIA........................... 193atenolol............................... 92atenolol-chlorthalidone........92ATGAM............................. 182ATIVAN...............................84atomoxetine hcl.................109atorvastatin calcium............ 92atovaquone......................... 71atovaquone-proguanil hcl... 71atracurium besylate.......... 113ATRAPRO DERMAL SPRAY..............................116ATRIPLA.............................78ATROPINE SULFATE.................................. 152, 215atropine sulfate................. 215ATROPINE SULFATE-NACL................................ 215ATROVENT HFA.............. 224AUBAGIO......................... 111aubra.................................171aubra eq............................171AUGMENTIN...................... 25

AUGMENTIN ES-600......... 25AUGMENTIN XR................ 25AUREOBASIDIUM............197aurovela 1.5/30................. 171aurovela 1/20.................... 171aurovela 24 fe................... 171aurovela fe 1.5/30............. 171aurovela fe 1/20................ 171AURYXIA.......................... 158AUSTEDO........................ 113AUSTRALIAN PINE..........197AVALIDE.............................92AVANDIA.......................... 125AVAPRO.............................92avar cleanser.................... 117avar-e emollient................ 117avar-e green..................... 117AVASTIN............................ 59AVC VAGINAL....................52AVELOX............................. 25aviane............................... 171avidoxy................................25avita.................................. 117AVODART........................ 161AVONEX PEN.................. 111AVONEX PREFILLED...... 111AVONEX VIAL INTRAMUSCULAR KIT... 111AVYCAZ............................. 25AXERT................................56AXUMIN............................197AYGESTIN........................171ayuna................................ 171azacitidine...........................59AZACTAM...........................25AZACTAM IN DEXTROSE. 25AZASAN........................... 182AZASITE...........................210azathioprine...................... 182azathioprine sodium..........182AZEDRA DOSIMETRIC......59AZEDRA THERAPEUTIC...59azelaic acid....................... 117azelastine hcl............ 210, 220AZELEX............................ 117AZILECT............................. 72azithromycin..................25, 26AZOPT..............................213AZOR..................................92aztreonam...........................26AZULFIDINE.....................192AZULFIDINE EN-TABS.... 192azuphen mb...................... 158

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azurette.............................171b-6 folic acid......................133baciim................................. 26bacitracin.................... 26, 210bacitracin-polymyxin b...... 215bacitra-neomycin-polymyxin-hc.....................215baclofen.................... 229, 230BACMIN............................133bacteriostatic water(benz alc).................................... 197BACTERIOSTATIC WATER(BENZ ALC).........197BACTOCILL IN DEXTROSE........................ 26BACTRIM............................26BACTRIM DS......................26BACTROBAN NASAL.........26BAHIA............................... 197bal in oil .............................197balanced salt.....................215BALCOLTRA.................... 171BALD CYPRESS.............. 197balsalazide disodium........ 192balsam peru-castor oil ...... 117BALVERSA.........................59balziva...............................171BANZEL..............................41BAQSIMI ONE PACK....... 129BAQSIMI TWO PACK.......129BARACLUDE......................78BASAGLAR KWIKPEN.....130BAVENCIO......................... 59BAXDELA........................... 26BAYBERRY (WAX MYRTLE).......................... 197bayer aspirin ec low dose..... 6BCAA................................ 133BCG VACCINE................. 189BD AUTOSHIELD DUO PEN NEEDLES.................130bd posiflush.......................133BD ULTRA-FINE INSULIN SYRINGES....................... 130BD ULTRA-FINE PEN NEEDLES......................... 130BEBULIN............................ 86BECONASE AQ................220bekyree............................. 171BELBUCA............................. 9BELEODAQ........................ 59

belladonna alkaloids-opium.......................................... 152BELRAPZO.........................59BELSOMRA......................231benazepril hcl......................92benazepril-hydrochlorothiazide.............92BENDAMUSTINE HCL....... 59BENDEKA...........................59BENEFIX............................ 86BENICAR............................92BENICAR HCT................... 92BENLYSTA....................... 182BENSAL HP......................117BENTYL............................152benzalkonium chloride........ 26BENZNIDAZOLE................ 71benzoin............................. 117benzoin compound........... 117benzonatate...................... 220benztropine mesylate..........72BEOVU............................. 216BEPREVE.........................211BERINERT........................182BERMUDA GRASS.......... 197beser.................................117BESIVANCE..................... 211BESPONSA........................ 59BETADINE OPHTHALMIC PREP................................ 211BETAGAN.........................213BETAMETHASONE COMBO............................ 162betamethasone dipropionate...................... 117betamethasone dipropionate aug............... 117BETAMETHASONE SOD PHOS & ACET..................162betamethasone sod phos & acet................................162BETAMETHASONE SODIUM PHOSPHATE.... 162betamethasone valerate... 117BETAPACE.........................93BETAPACE AF................... 92BETASERON....................111betaxolol hcl................93, 213bethanechol chloride.........158BETHKIS.......................... 228BETIMOL.......................... 213BETOPTIC-S.................... 213BEVACIZUMAB................ 216

BEVESPI AEROSPHERE 225BEVYXXA........................... 38bexarotene..........................59BEXSERO........................ 189BEYAZ.............................. 171bicalutamide........................59BICILLIN C-R......................26BICILLIN C-R 900/300........26BICILLIN L-A.......................26BICNU.................................60BIDIL...................................93BIFERARX........................134BIKTARVY.......................... 78BILTRICIDE........................ 71bimatoprost....................... 213BI-MIX...............................158BINOSTO..........................194biocel................................ 134BIOFREQUENCY INSOLES.......................... 197BIOGUARD GAUZE SPONGES........................ 197BIOGUARD ISLAND DRESSINGS.....................197BIOGUARD NON-ADHERENT DRESSING.. 197BIOLON............................ 216BIO-STATIN........................52bio-statin............................. 52BIOTHRAX....................... 189biotuss.............................. 220biotuss pediatric................220bisoprolol fumarate............. 93bisoprolol-hydrochlorothiazide.............93bivalirudin trifluoroacetate...38BIVALIRUDIN-SODIUM CHLORIDE......................... 38BIVIGAM...........................182BLACK WALNUT POLLEN.......................................... 197BLACK WILLOW.............. 197BLEO 15K...........................60bleomycin sulfate................ 60BLEPH-10.........................211BLEPHAMIDE...................216BLEPHAMIDE S.O.P........ 216BLINCYTO..........................60blisovi 24 fe.......................171blisovi fe 1.5/30.................171blisovi fe 1/20....................171BLOXIVERZ........................57BOCASAL.........................114

235

BONIVA............................ 194BONJESTA.........................50BOOSTRIX....................... 189BORTEZOMIB.................... 60bosentan........................... 228BOSULIF............................ 60BOTOX............................. 197BOTRYTIS........................197BOX ELDER..................... 197bp 10-1..............................117BP CLEANSING WASH... 117bp vit 3.............................. 134BPCO................................117b-plex................................ 134b-plex plus........................ 134BRAFTOVI..........................60BRAVELLE....................... 166BREO ELLIPTA................ 225BREVIBLOC....................... 93BREVIBLOC IN NACL........ 93BREVIBLOC PREMIXED... 93BREVIBLOC PREMIXED DS.......................................93BREVICON (28)................171BREVITAL SODIUM......... 197BRIDION...........................198briellyn.............................. 171BRILINTA............................74brimonidine tartrate...........213BRIMONIDINE-DORZOLAMIDE............... 214BRINEURA....................... 156BRIVIACT........................... 41BROME.............................198bromfed dm.......................220bromfenac sodium (once-daily)................................. 211bromocriptine mesylate.72, 73brompheniramine tannate.220BROMSITE....................... 211BROVANA........................ 225bss.................................... 216bss plus.............................216BUCALSEP.........................26budesonide....... 192, 220, 225budesonide er................... 192BUFFERED LIDOCAINE.... 18bumetanide......................... 93BUMEX............................... 93BUMINATE....................... 198BUNAVAIL.......................... 23BUPAP..................................9BUPHENYL...................... 156

bupivacaine fisiopharma..... 18bupivacaine hcl................... 18BUPIVACAINE HCL........... 18bupivacaine hcl (pf).............18BUPIVACAINE HCL-NACL.18bupivacaine in dextrose...... 18BUPIVACAINE IN DEXTROSE........................ 19bupivacaine spinal.............. 19bupivacaine-epinephrine.....19BUPIVACAINE-EPINEPHRINE................... 19bupivacaine-epinephrine (pf)...................................... 19BUPRENEX.......................... 9buprenorphine.......................9BUPRENORPHINE.............. 9buprenorphine hcl........... 9, 23buprenorphine hcl-naloxone hcl........................23bupropion hcl...................... 47bupropion hcl er (smoking det)......................................23bupropion hcl er (sr)............47bupropion hcl er (xl)............ 47buspirone hcl...................... 84busulfan.............................. 60BUSULFEX.........................60BUTALBITAL-ACETAMINOPHEN.............. 9butalbital-acetaminophen......9butalbital-apap...................... 9butalbital-apap-caff-cod........ 9butalbital-apap-caffeine........ 9butalbital-asa-caff-codeine....9butalbital-aspirin-caffeine 9, 10BUTISOL SODIUM........... 231butorphanol tartrate............ 10BUTRANS...........................10BYDUREON..................... 125BYDUREON BCISE AUTOINJECTOR..............125BYETTA 10 MCG PEN..... 126BYETTA 5 MCG PEN....... 126BYSTOLIC.......................... 93BYVALSON........................ 93cabergoline....................... 166CABLIVI.............................. 74CABOMETYX..................... 60CADUET............................. 93CAFCIT.............................113CAFERGOT........................56caffeine citrate.................. 113

CALAN................................93CALAN SR..........................93CALCIFOL........................ 134calcipotriene......................117calcipotriene-betameth diprop................................117calcitonin (salmon)............194calcitrene.......................... 117calcitriol.....................117, 195calcium acetate (phos binder)...............................158CALCIUM CHLORIDE...... 134calcium chloride................ 134CALCIUM DISODIUM VERSENATE.................... 198CALCIUM GLUCONATE.. 134CALCIUM GLUCONATE-DEXTROSE...................... 134CALCIUM GLUCONATE-NACL................................ 134CALCIUM-FOLIC ACID PLUS D.............................134CALDOLOR.......................... 6CALIFORNIA PEPPER TREE................................ 198CALM................................134CALQUENCE..................... 60CAMBIA................................ 6camila............................... 171CAMPATH.......................... 60CAMPTOSAR..................... 60camrese............................ 171camrese lo........................ 171CANASA........................... 192CANCIDAS......................... 52candesartan cilexetil ........... 93candesartan cilexetil-hctz... 93CANDIDA ALBICANS EXTRACT......................... 198capacet............................... 10CAPASTAT SULFATE........57capecitabine........................60CAPRELSA.........................60captopril .............................. 93captopril-hydrochlorothiazide.............93CARAFATE.......................151CARBAGLU...................... 134carbamazepine................... 41carbamazepine er............... 41CARBAPHEN 12.............. 220CARBAPHEN 12 PED...... 220CARBATROL......................41

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carbidopa............................ 73carbidopa-levodopa............ 73carbidopa-levodopa er........ 73carbidopa-levodopa-entacapone......................... 73carbinoxamine maleate.....220CARBOCAINE.................... 19CARBOCAINE PRESERVATIVE-FREE..... 19carboplatin.......................... 60carboprost tromethamine..170CARDENE IV......................93CARDIOPLEGIC...............134cardioplegic.......................134CARDIOVID PLUS........... 198CARDIZEM......................... 94CARDIZEM CD...................93CARDIZEM LA....................94CARDURA.......................... 94CARDURA XL...................161CARIMUNE NF.........182, 183carimune nf............... 182, 183carisoprodol...................... 230carisoprodol-aspirin.......... 230carisoprodol-aspirin-codeine............................... 10carmustine.......................... 60CARNITOR....................... 134CARNITOR SF................. 134carteolol hcl.......................214cartia xt............................... 94carvedilol.............................94carvedilol phosphate er.......94CASODEX.......................... 60caspofungin acetate............52CAT HAIR EXTRACT....... 198CATAPRES........................ 94CATAPRES-TTS-1............. 94CATAPRES-TTS-2............. 94CATAPRES-TTS-3............. 94CATHFLO ACTIVASE........ 38CATTLE EPITHELIUM..... 198cavarest............................ 114CAYA................................ 198CAYSTON........................ 228caziant.............................. 172CEDAR ELM.....................198CEDAX............................... 26cefaclor............................... 26cefaclor er........................... 26cefadroxil ............................ 26CEFAZOLIN IN SODIUM CHLORIDE................... 26, 27

cefazolin sodium................. 27CEFAZOLIN SODIUM........ 27cefazolin sodium-dextrose.. 27CEFAZOLIN SODIUM-DEXTROSE........................ 27CEFAZOLIN SODIUM-NACL.................................. 27cefdinir................................ 27cefditoren pivoxil ................. 27cefepime hcl........................27cefepime-dextrose.............. 27cefixime...............................27CEFOTAN...........................27cefotaxime sodium..............27cefotetan disodium..............27cefotetan disodium-dextrose.............................. 27cefoxitin sodium............ 27, 28cefoxitin sodium-dextrose... 28cefpodoxime proxetil ...........28cefprozil .............................. 28ceftazidime..........................28ceftazidime and dextrose....28ceftibuten............................ 28CEFTIN...............................28ceftriaxone sodium..............28ceftriaxone sodium in dextrose.............................. 28ceftriaxone sodium-dextrose.............................. 28cefuroxime axetil .................28cefuroxime sodium..............28CEFUROXIME SODIUM-NACL................................ 211CELEBREX...........................6celecoxib...............................6CELESTONE SOLUSPAN162CELEXA..............................47CELLCEPT....................... 183CELLCEPT INTRAVENOUS................183CELONTIN..........................41cem-urea...........................117CENTANY AT..................... 28CENTRATEX.................... 134cephalexin...........................28CEPROTIN......................... 86CERDELGA...................... 156CEREBYX...........................42CERETEC.........................198CEREZYME......................156cerisa wash.......................117cerovel.............................. 117

CERVIDIL......................... 170CESAMET.......................... 50CETACAINE....................... 19CETRAXAL.......................219CETROTIDE..................... 166cevimeline hcl................... 114CHANTIX............................ 23CHANTIX CONTINUING MONTH PAK...................... 23CHANTIX STARTING MONTH PAK...................... 23chateal.............................. 172chateal eq......................... 172CHEMET...........................134CHENODAL......................152CHIRHOSTIM................... 198chloramphenicol sod succinate.............................28chlordiazepoxide hcl........... 84chlordiazepoxide-amitriptyline.........................47chlordiazepoxide-clidinium153chlorhexidine gluconate.... 114CHLORHEXIDINE GLUCONATE................... 198chloroprocaine hcl (pf)........ 19chloroquine phosphate....... 71chlorothiazide......................94chlorothiazide sodium......... 94chlorpromazine hcl..............75chlorpropamide................. 126chlorthalidone..................... 94chlorzoxazone...................230CHOLBAM........................ 153cholestyramine....................94cholestyramine light............ 94CHOLETEC...................... 198choline fenofibrate.............. 94choline-mag trisalicylate....... 6chorionic gonadotropin..... 166chromagen........................134chromic chloride................134CIALIS.............................. 159ciclodan...............................52CICLODAN CREAM........... 52CICLODAN SOLUTION......52ciclopirox.............................52ciclopirox olamine............... 52ciclopirox treatment.............52cidofovir.............................. 78cilostazol............................. 74CILOXAN.......................... 211CIMDUO............................. 78

237

cimetidine..........................151cimetidine hcl.................... 151CIMZIA..............................183CIMZIA PREFILLED KIT.. 183CIMZIA STARTER KIT..... 183cinacalcet hcl.................... 166CINQAIR...........................220CINRYZE.......................... 183CINVANTI........................... 50CIPRO................................ 29CIPRO HC........................ 219CIPRO IN D5W...................28CIPRODEX....................... 219ciprofloxacin........................29ciprofloxacin hcl.. 29, 211, 219ciprofloxacin in d5w............ 29ciprofloxacin-ciproflox hcl er.........................................29CIPROFLOXACIN-FLUOCINOLONE PF........219cisatracurium besylate...... 113CISATRACURIUM BESYLATE....................... 113cisatracurium besylate (pf)113cisplatin...............................60citalopram hydrobromide.... 47CITANEST FORTE DENTAL..............................19CITANEST PLAIN DENTAL..............................19CITRANATAL MEDLEY....134CLADOSPORIUM CLADOSPORIOIDES....... 198CLADOSPORIUM SPHAEROSPERMUM......198cladribine............................ 60claravis..............................117clarithromycin......................29clarithromycin er................. 29clemastine fumarate......... 220CLENPIQ.......................... 153CLEOCIN............................29CLEOCIN IN D5W.............. 29CLEOCIN PHOSPHATE.....29CLEVIPREX........................94CLIMARA..........................172CLIMARA PRO................. 172CLINDACIN ETZ...............117clindacin etz...................... 118CLINDACIN PAC.............. 118clindacin-p.........................118clindamycin hcl................... 29clindamycin palmitate hcl....29

clindamycin phosphate29, 118clindamycin phosphate in d5w..................................... 29CLINDESSE....................... 29CLINIMIX E/DEXTROSE (2.75/10)........................... 134CLINIMIX E/DEXTROSE (2.75/5)............................. 134CLINIMIX E/DEXTROSE (4.25/10)........................... 134CLINIMIX E/DEXTROSE (4.25/25)........................... 135CLINIMIX E/DEXTROSE (4.25/5)............................. 135CLINIMIX E/DEXTROSE (5/15)................................ 135CLINIMIX E/DEXTROSE (5/20)................................ 135CLINIMIX E/DEXTROSE (5/25)................................ 135CLINIMIX N9G20E........... 135CLINIMIX/DEXTROSE (2.75/5)............................. 135CLINIMIX/DEXTROSE (4.25/10)........................... 135CLINIMIX/DEXTROSE (4.25/20)........................... 135CLINIMIX/DEXTROSE (4.25/25)........................... 135CLINIMIX/DEXTROSE (4.25/5)............................. 135CLINIMIX/DEXTROSE (5/15)................................ 135CLINIMIX/DEXTROSE (5/20)................................ 135CLINIMIX/DEXTROSE (5/25)................................ 135clinisol sf........................... 135CLINOIN........................... 118CLINOLIPID......................135clinpro 5000...................... 114clobazam............................ 42clobetasol prop emollient base.................................. 118clobetasol propionate........118clobetasol propionate e.....118clobetasol propionate emulsion........................... 118clocortolone pivalate......... 118clocortolone pivalate pump.......................................... 118clodan............................... 118CLODERM........................118

CLODERM PUMP............ 118clofarabine.......................... 60CLOLAR............................. 60clomiphene citrate.............166clomipramine hcl.................47clonazepam........................ 84clonidine..............................94clonidine hcl........................ 94clonidine hcl (analgesia)..... 10clonidine hcl er..................109clopidogrel bisulfate............ 74clorazepate dipotassium..... 84CLOROTEKAL....................19CLORPRES........................ 94clotrimazole.........................52clotrimazole-betamethasone................. 118clovique.............................135clozapine.............................75CLOZARIL.......................... 75COAGADEX....................... 86coal tar.............................. 118COARTEM..........................71cocaine hcl..........................19COCAINE HCL................... 19COCKLEBUR................... 198cod liver oil ........................135CODAR AR.......................220codeine sulfate....................10COENZYME Q-10............ 198COGENTIN.........................73COLAZAL......................... 192COLCHICINE......................55colchicine-probenecid......... 55COLCRYS.......................... 55colesevelam hcl.................. 94COLESTID..........................94COLESTID FLAVORED..... 94colestipol hcl................. 94, 95colistimethate sodium (cba)....................................30colocort............................. 192COLY-MYCIN M................. 30COLY-MYCIN S................219COLYTE WITH FLAVOR PACKS..............................153COMBIGAN...................... 214COMBIPATCH..................172COMBIVENT RESPIMAT. 225COMBIVIR.......................... 78COMETRIQ (100 MG DAILY DOSE)..................... 60

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COMETRIQ (140 MG DAILY DOSE)..................... 60COMETRIQ (60 MG DAILY DOSE)..................... 60COMPLERA........................78compro................................50COMTAN............................ 73CONCERTA......................109CONDYLOX......................118constulose.........................153COPAXONE..................... 111COPEGUS..........................78COPIKTRA......................... 61COPPER CHLORIDE....... 135CORDRAN........................118COREG...............................95COREG CR........................ 95CORGARD......................... 95CORIFACT......................... 86CORLANOR....................... 95CORLOPAM....................... 95cormax scalp application.. 118CORN POLLEN................ 198CORTEF........................... 162CORTENEMA...................192CORTIFOAM.................... 192cortisone acetate.............. 162CORTISPORIN.................118CORTROSYN...................198CORVERT.......................... 95corvita............................... 135corvita 150........................ 135CORVITE..........................135CORVITE 150...................135CORVITE FE.................... 135corvite free........................ 135CORZIDE............................95COSENTYX (300 MG DOSE).............................. 183COSENTYX 150 MG/ML.. 183COSENTYX SENSOREADY (300 MG).183COSENTYX SENSOREADY PEN........ 183COSMEGEN.......................61COSOPT...........................214COSOPT PF..................... 214cosyntropin....................... 198COTELLIC.......................... 61COUMADIN........................ 38covaryx............................. 172covaryx hs.........................172COZAAR.............................95

CREON.............................156CRESEMBA........................52CRESTOR.......................... 95CRINONE......................... 172CRIXIVAN...........................78CROFAB...........................198cromolyn sodium.......................... 153, 211, 225crotan..................................71cryselle-28........................ 172CRYSVITA........................156CUBICIN............................. 30CUBICIN RF....................... 30CURITY AMD ANTIMICROBIAL SPNGE 198CURITY AMD ANTIMICROBIAL STRIP.. 198CURITY IODOFORM PACKING STRIP.............. 198curity sterile saline............ 135CUROSURF..................... 220CURVULARIA...................199CUTAQUIG.......................183CUVITRU..........................183CUVPOSA........................ 153cyanocobalamin................135CYANOCOBALAMIN........135CYANOKIT....................... 199cyclafem 1/35....................172cyclafem 7/7/7...................172CYCLESSA.......................172cyclobenzaprine hcl.......... 230CYCLOGYL...................... 216CYCLOMYDRIL................216cyclopentolate hcl............. 216cyclophosphamide.............. 61cycloserine..........................58CYCLOSET...................... 126cyclosporine......................183CYCLOSPORINE IN KLARITY...........................216cyclosporine modified....... 183CYKLOKAPRON................ 86CYMBALTA........................ 47cyproheptadine hcl............220CYRAMZA.......................... 61cyred................................. 172cyred eq............................ 172CYSTADANE....................157CYSTAGON......................157CYSTO-CONRAY II..........199CYSVIEW......................... 199cytarabine........................... 61

cytarabine (pf).....................61CYTOGAM........................183CYTOMEL........................ 180CYTOTEC.........................151CYTOVENE........................ 78cytra k crystals.................. 135D.H.E. 45............................ 56d3 vitamin......................... 135dacarbazine........................ 61DACOGEN..........................61dactinomycin.......................61DAKLINZA.......................... 78dalfampridine er................ 111DALIRESP........................ 225DALVANCE........................ 30danazol............................. 165DANDELION.....................199DANTRIUM.......................230dantrolene sodium............ 230dapsone...................... 58, 118DAPTACEL.......................189daptomycin......................... 30DARAPRIM.........................71darifenacin hydrobromide er.......................................159DARZALEX.........................61dasetta 1/35...................... 172dasetta 7/7/7..................... 172DATSCAN.........................199daunorubicin hcl..................61DAURISMO........................ 61DAYPRO...............................6daysee.............................. 172DAYTRANA...................... 109DDAVP............................. 166DDAVP RHINAL TUBE.....166DEBACTEROL................. 114deblitane........................... 172DECADRON..................... 162decara...............................135decitabine........................... 61DECON-A......................... 220deferasirox........................ 135deferoxamine mesylate.....199DEFINITY......................... 199DEFITELIO......................... 38DEFLUX............................199DELESTROGEN...............172DELFLEX-LC/1.5% DEXTROSE...................... 136DELFLEX-LC/2.5% DEXTROSE...................... 136

239

DELFLEX-LC/4.25% DEXTROSE...................... 136delflex-sm/1.5% dextrose. 136delflex-sm/2.5% dextrose. 136DELSTRIGO....................... 78deltasone.......................... 162delyla................................ 172DELZICOL........................ 192DEMADEX.......................... 95demeclocycline hcl..............30DEMEROL.......................... 10DEMSER............................ 95DENAVIR............................79denta 5000 plus................ 114dentagel............................ 115DEPACON.......................... 42DEPAKENE........................ 42DEPAKOTE........................ 42DEPAKOTE ER.................. 42DEPAKOTE SPRINKLES... 42DEPEN TITRATABS.........159DEPO-ESTRADIOL.......... 172DEPO-MEDROL............... 162DEPO-PROVERA.............172DEPO-SUBQ PROVERA 104....................................172DEPO-TESTOSTERONE. 165dermacinrx empricaine....... 19dermacinrx prizopak........... 19DERMOTIC.......................219DERMULCERA.................118DESCOVY.......................... 79DESFERAL.......................199desipramine hcl...................47desloratadine.................... 220desmopressin ace spray refrig..................................166desmopressin acetate.......166desmopressin acetate spray................................. 166DESOGEN........................172desogestrel-ethinyl estradiol............................ 172desonide................... 118, 119desoximetasone................119DESOXYN........................ 109DESVENLAFAXINE ER......47desvenlafaxine succinate er.........................................47DETROL........................... 159DETROL LA......................159dexamethasone................ 162

DEXAMETHASONE INTENSOL........................162DEXAMETHASONE SOD PHOS IN D5W.................. 162DEXAMETHASONE SOD PHOS-BUPIV....................162DEXAMETHASONE SOD PHOS-NACL.....................162dexamethasone sod phosphate pf..................... 162dexamethasone sodium phosphate................. 163, 211DEXAMETHASONE SODIUM PHOSPHATE.... 163DEXAMETHASONE-MOXIFLOXACIN...............216DEXAMETH-MOXIFLOX-KETOROLAC....................216dexchlorpheniramine maleate............................. 220DEXEDRINE.....................109dexifol............................... 136DEXILANT........................ 151DEXMEDETOMIDINE HCL.......................................... 199dexmedetomidine hcl........199dexmedetomidine hcl in nacl................................... 199DEXMEDETOMIDINE HCL-DEXTROSE..............199dexmethylphenidate hcl.... 109dexmethylphenidate hcl er 109DEXONTO 0.4%...............163DEXPAK 10 DAY..............163DEXPAK 13 DAY..............163DEXPAK 6 DAY................163dexrazoxane....................... 61dexrazoxane hcl..................61dextroamphetamine sulfate.......................................... 110dextroamphetamine sulfate er.......................................110dextrose............................ 136DEXTROSE...................... 136DEXTROSE 5%/ELECTROLYTE #48...136dextrose in lactated ringers.......................................... 136dextrose-nacl.................... 136dextrose-sodium chloride..136DEXYCU...........................211DIACOMIT.......................... 42DIAGNOSTIC................... 199

dialyvite.............................136DIALYVITE 3000.............. 136DIALYVITE 5000.............. 136DIALYVITE SUPREME D. 136DIALYVITE/ZINC.............. 136DIAMOX SEQUELS..........214DIANEAL LOW CALCIUM/1.5% DEX........ 136DIANEAL LOW CALCIUM/2.5% DEX........ 136DIANEAL LOW CALCIUM/4.25% DEX...... 136DIANEAL PD-2/1.5% DEXTROSE...................... 136DIANEAL PD-2/2.5% DEXTROSE...................... 136DIANEAL PD-2/4.25% DEXTROSE...................... 136DIASTAT ACUDIAL............ 42DIASTAT PEDIATRIC........ 42diazepam...................... 42, 84DIAZEPAM......................... 84diazepam intensol...............84DIBENZYLINE.................... 95DICLOFENAC EPOLAMINE.........................6diclofenac potassium............ 6diclofenac sodium. 6, 119, 211diclofenac sodium er.............6diclofenac-misoprostol.......... 6DICLOSTREAM....................6dicloxacillin sodium............. 30dicyclomine hcl................. 153didanosine.......................... 79DIFICID...............................30difil-g forte......................... 225diflorasone diacetate.........119DIFLUCAN..........................52diflunisal................................6DIGIFAB........................... 199digitek................................. 95digox................................... 95digoxin................................ 95dihydroergotamine mesylate............................. 56DILANTIN........................... 42DILANTIN INFATABS.........42DILATRATE-SR..................95DILAUDID........................... 10diltiazem cd.........................95diltiazem hcl.................. 95, 96DILTIAZEM HCL.................96diltiazem hcl er....................95

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diltiazem hcl er beads......... 95diltiazem hcl er coated beads.................................. 95DILTIAZEM HCL-DEXTROSE........................ 96DILTIAZEM HCL-SODIUM CHLORIDE......................... 96dilt-xr................................... 96DILUENT FOR LEFAMULIN......................137DILUENT FOR TREPROSTINIL................199dimenhydrinate................... 50DIMENTHO...........................6DIOVAN.............................. 96DIOVAN HCT......................96DIPENTUM....................... 192diphen............................... 220diphenhydramine hcl.........220diphenoxylate-atropine..... 153DIPHTHERIA-TETANUS TOXOIDS DT....................189DIPRIVAN.........................199dipyridamole............... 74, 199disopyramide phosphate.....96disulfiram............................ 23DITHOL.................................6DITROPAN XL..................159DIURIL................................ 96divalproex sodium...............42divalproex sodium er...........42DIVIGEL............................173DIVISTA............................137dobutamine hcl................... 96dobutamine in d5w..............96docetaxel............................ 61docetaxel (non-alcohol)...... 61dofetilide............................. 96DOG EPITHELIUM........... 199DOG FENNEL.................. 199DOLOPHINE.......................10donepezil hcl.......................46dopamine hcl...................... 96dopamine in d5w.................96DOPRAM.......................... 113DOPTELET.........................86DORAL............................... 84DORIBAX............................30DORIPENEM...................... 30DORZOLAMIDE HCL....... 214dorzolamide hcl.................214

dorzolamide hcl-timolol mal.......................................... 214dorzolamide hcl-timolol mal pf.......................................214DOTAREM........................200DOTATOC GA 68............. 200dotti ................................... 173DOVATO.............................79doxazosin mesylate............ 96doxepin hcl..................47, 119doxercalciferol...........194, 195DOXIL................................. 61doxorubicin hcl....................61doxorubicin hcl liposomal....61doxy 100............................. 30doxycycline hyclate.............30doxycycline monohydrate... 30DRECHSLERA................. 200DRISDOL..........................137DRITHO-CREME HP........119dronabinol........................... 50droperidol............................50drospiren-eth estrad-levomefol.......................... 173drospirenone-ethinyl estradiol............................ 173DROXIA.............................. 62DRYSOL........................... 119DSUVIA.............................. 10DUAVEE........................... 173DUETACT.........................126DULERA........................... 225duloxetine hcl......................47DUODOTE........................200DUPIXENT........................119DURACLON........................10DURAGESIC-100............... 10DURAGESIC-12................. 10DURAGESIC-25................. 10DURAGESIC-50................. 10DURAGESIC-75................. 10duramorph.......................... 10duraxin................................ 10DUREZOL.........................211DUROLANE......................200DUST MITE MIXED ALLERGEN EXT...............200dutasteride........................ 161dutasteride-tamsulosin hcl 161DUTOPROL........................96DUZALLO........................... 55DYANAVEL XR.................110DYAZIDE............................ 96

DYRENIUM.........................96DYSPORT........................ 200e.e.s. 400............................ 30E.E.S. GRANULES.............30EASTERN COTTONWOOD............... 200easygel............................. 115EC-NAPROSYN................... 6ec-naproxen..........................6econazole nitrate................ 52EC-RX PROGESTERONE173EDARBI.............................. 96EDARBYCLOR................... 96EDECRIN............................96ed-spaz............................. 153EDURANT.......................... 79eemt..................................173eemt hs............................. 173efavirenz............................. 79EFFER-K.......................... 137effer-k................................137effervescent pot chloride...137EFFEXOR XR.....................47EFFIENT.............................74EGRIFTA.......................... 166ELAPRASE.......................157ELAVIL................................47ELDEPRYL......................... 73ELELYSO......................... 157ELESTAT..........................211ELESTRIN........................ 173eletriptan hydrobromide...... 56ELIDEL............................. 119ELIGARD.......................... 166ELIMITE..............................71elinest............................... 173ELIQUIS..............................38ELIQUIS STARTER PACK. 38ELITEK............................... 62elite-ob.............................. 137ELIXOPHYLLIN................ 225ELLA................................. 173ELLENCE........................... 62ELLIOTTS B..................... 137ELMIRON......................... 159ELOCTATE.........................87ELZONRIS..........................62EMADINE......................... 211EMBEDA.............................10EMCYT............................... 62EMEND...............................50EMEND TRI-PACK............. 50EMFLAZA........................... 55

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EMGALITY..........................56EMGALITY (300 MG DOSE)................................ 56emoquette.........................173EMPLICITI.......................... 62EMSAM...............................47EMTRIVA............................79EMVERM............................ 71ENABLEX......................... 159enalapril maleate................ 96enalaprilat........................... 96enalapril-hydrochlorothiazide.............97ENBRACE HR.................. 137ENBREL................... 183, 184ENBREL MINI...................183ENBREL SURECLICK......184ENDARI............................ 200endocet............................... 10ENDOMETRIN..................173ENGERIX-B...................... 189ENGLISH PLANTAIN....... 200ENLON............................. 200ENOVARX-IBUPROFEN...... 7enoxaparin sodium............. 38enpresse-28......................173enskyce.............................173entacapone......................... 73entecavir............................. 79ENTEREG........................ 153ENTOCORT EC................193ENTRESTO........................ 97ENTYVIO.......................... 184enulose............................. 153ENVARSUS XR................ 184ENZADYNE...................... 157EOVIST.............................200EPANED............................. 97EPCLUSA........................... 79ephedrine sulfate................ 97EPHEDRINE SULFATE......97EPHEDRINE SULFATE (PRESSORS)..................... 97EPHEDRINE SULFATE-NACL.................................. 97EPICOCCUM....................200EPIDIOLEX.........................42EPIFOAM..........................119epinastine hcl....................211epinephrine................. 97, 225EPINEPHRINE................... 97EPINEPHRINE HCL-DEXTROSE........................ 97

EPINEPHRINE HCL-NACL 97epinephrine pf..................... 98EPINEPHRINE-DEXTROSE........................ 98EPINEPHRINE-NACL.........98EPIPEN 2-PAK................. 225EPIPEN JR 2-PAK............225epirubicin hcl.......................62epitol................................... 42EPIVIR................................ 79EPIVIR HBV........................79eplerenone..........................98EPOGEN............................ 87epoprostenol sodium........ 229eprosartan mesylate........... 98eptifibatide.......................... 74EPZICOM........................... 79EQUAPAX/ATORVASTATIN/COQ10............................ 98EQUAPAX/IBUPROFEN/MINREX...................................7EQUETRO.......................... 42ERAXIS...............................52ERBITUX............................ 62ergocalciferol.................... 137ergoloid mesylates............200ERGOMAR......................... 56ergotamine-caffeine............ 56ERIVEDGE......................... 62ERLEADA........................... 62erlotinib hcl..........................62errin...................................173ERTACZO...........................52ertapenem sodium.............. 30ERWINAZE.........................62ery.....................................119ERYPED 200...................... 30ERYPED 400...................... 30ERY-TAB............................ 30ERYTHROCIN LACTOBIONATE................ 31ERYTHROCIN STEARATE.........................31erythromycin............. 119, 211erythromycin base.............. 31erythromycin ethylsuccinate..................... 31ESBRIET.......................... 225ESCAVITE........................ 137ESCAVITE D.................... 137escavite lq.........................137escitalopram oxalate...........47esgic................................... 10

ESGIC.................................10esmolol hcl..........................98ESMOLOL HCL.................. 98esmolol hcl-sodium chloride............................... 98esomeprazole sodium.......151est estrogens-methyltest...173est estrogens-methyltest ds...................................... 173est estrogens-methyltest hs...................................... 173estarylla............................ 173estazolam........................... 84ESTRACE.........................173estradiol............................ 173estradiol valerate.............. 173estradiol-norethindrone acet................................... 173ESTRING..........................174ESTROGEL...................... 174estropipate........................ 174ESTROSTEP FE.............. 174eszopiclone.......................231ethacrynate sodium............ 98ethacrynic acid....................98ethambutol hcl.................... 58ethosuximide.......................42ethyl chloride.......................19ethynodiol diac-eth estradiol............................ 174etidronate disodium.......... 195etodolac................................ 7etodolac er............................ 7etomidate.......................... 200ETOPOPHOS..................... 62etoposide............................ 62EUCRISA..........................119EUFLEXXA....................... 200EURAX............................... 71euthyrox............................ 180EVAMIST.......................... 174EVENITY.......................... 194EVICEL............................. 200EVISTA............................. 166EVITHROM.........................87EVOMELA.......................... 62EVOTAZ............................. 79EVOXAC...........................115EXACTUSS...................... 220EXALGO............................. 10EXCILON AMD DRAIN SPONGES........................ 200EXELDERM........................ 52

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EXELON............................. 46exemestane........................ 62EXFORGE.......................... 98EXFORGE HCT..................98EXJADE............................137EXODERM..........................53EXPAREL........................... 19EXTAVIA...........................112EXTINA...............................53EXTRANEAL.................... 137EYLEA.............................. 216EZ FLU SHOT-FLUCELVAX QUAD......... 189ezetimibe............................ 98ezetimibe-simvastatin......... 98fabb...................................137FABRAZYME....................157FALESSA..........................174falmina.............................. 174famciclovir...........................79famotidine......................... 151famotidine premixed......... 151FANAPT..............................75FANAPT TITRATION PACK.................................. 75FARESTON........................ 62FARXIGA.......................... 126FARYDAK...........................62FASENRA.........................221FASENRA PEN................ 119FASLODEX.........................62fa-vitamin b-6-vitamin b-12137fayosim............................. 174FAZACLO........................... 75FBL KIT.................................7febuxostat........................... 55FEIBA................................. 87felbamate............................ 42FELBATOL......................... 42FELDENE............................. 7felodipine er........................ 98FEM PH............................ 159FEMARA.............................62FEMCAP...........................200FEMHRT LOW DOSE...... 174FEMRING......................... 174femynor.............................174fenofibrate...........................98fenofibrate micronized........ 98fenofibric acid......................98fenoprofen calcium............... 7fenortho.................................7fentanyl............................... 11

fentanyl citrate.................... 11FENTANYL CITRATE.........11fentanyl citrate (pf).............. 11FENTANYL CITRATE-NACL.................................. 11FENTANYL CIT-ROPIVACAINE-NACL........ 11FENTANYL-BUPIVACAINE-NACL.........12FENTORA...........................12FERAHEME......................137FERIVA.............................137FERIVAFA........................ 137ferocon..............................137ferotrinsic.......................... 137FERRALET 90.................. 137FERRAPLUS 90............... 137FERRIPROX.....................137FERRLECIT......................137FERRO-PLEX HEMATINIC...................... 137FERROTRIN.....................137FETZIMA............................ 47FETZIMA TITRATION........ 48FEXMID............................ 230FIASP............................... 130FIASP FLEXTOUCH.........130FIASP PENFILL................130FIBRICOR...........................98FIBRYGA............................ 87FINACEA.......................... 119finasteride......................... 161FIORICET........................... 12FIORICET/CODEINE..........12FIORINAL........................... 12FIORINAL/CODEINE #3.....12FIRAZYR.......................... 184FIRDAPSE........................200FIRE ANT......................... 200FIRMAGON...................... 166FIRST-LANSOPRAZOLE. 151FIRST-MOUTHWASH BLM.................................. 115FIRST-OMEPRAZOLE..... 151FIRST-PROGESTERONE VGS.................................. 174FIRST-VANCOMYCIN........31FIRVANQ............................31flac.................................... 219FLAGYL.............................. 31FLAREX............................211flavoxate hcl......................159FLEBOGAMMA DIF..........184

flecainide acetate................98FLECTOR............................. 7FLEXBUMIN..................... 200FLEXIN............................... 19FLOLAN............................229FLOMAX........................... 161FLORIVA PLUS................ 137FLOVENT DISKUS...........225FLOVENT HFA................. 225FLOXIN OTIC................... 219floxuridine........................... 62FLUAD.............................. 190FLUARIX QUADRIVALENT..............190FLUBLOK......................... 190FLUBLOK QUADRIVALENT..............190FLUCELVAX QUADRIVALENT..............190fluconazole..........................53fluconazole in dextrose....... 53fluconazole in sodium chloride............................... 53flucytosine...........................53fludarabine phosphate........ 62FLUDEOXYGLUCOSE F 18......................................200fludrocortisone acetate..... 163FLULAVAL QUADRIVALENT..............190FLUMADINE....................... 79flumazenil ..........................200FLUMIST QUADRIVALENT..............190flunisolide..........................221fluocinolone acetonide.................................. 119, 219fluocinolone acetonide body.................................. 119fluocinolone acetonide scalp................................. 119fluocinonide.......................119fluocinonide emulsified base.................................. 119FLUORABON................... 137FLUOR-A-DAY................. 137FLUORESCITE.................216fluoridex............................ 115fluoridex daily renewal...... 115fluoridex enhanced whitening...........................115fluoridex sensitivity relief...115fluoritab............................. 138

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fluorometholone................ 211fluorouracil .................. 62, 119fluoxetine hcl.......................48fluoxetine hcl (pmdd).......... 48fluphenazine decanoate......75fluphenazine hcl..................76FLURA-DROPS................ 138flurandrenolide.......... 119, 120flurazepam hcl.................. 231flurbiprofen............................7flurbiprofen sodium........... 211flutamide............................. 62fluticasone propionate.................................. 120, 221fluticasone-salmeterol.......225FLUTICASONE-SALMETEROL..................225fluvastatin sodium............... 98fluvastatin sodium er...........98FLUVIRIN......................... 190fluvoxamine maleate...........48fluvoxamine maleate er.......48FLUZONE HIGH-DOSE....190FLUZONE QUADRIVALENT..............190FML...................................211FML FORTE..................... 211FML LIQUIFILM................ 211FOCALIN.......................... 110FOCALIN XR.................... 110folbee plus........................ 138FOLGARD OS.................. 138FOLGARD RX.................. 138folic acid............................138FOLIKA-T..........................138FOLIVANE-F.....................138FOLIVANE-PLUS............. 138FOLLISTIM AQ................. 166FOLOTYN...........................63folplex 2.2......................... 138FOLTRATE....................... 138foltrin................................. 138fomepizole........................ 200fondaparinux sodium.......... 38formadon...........................200formaldehyde.................... 201FORMA-RAY.................... 201FORTAVIT........................ 138FORTEO...........................194FORTESTA.......................165FOSAMAX........................ 194FOSAMAX PLUS D.......... 194fosamprenavir calcium........79

fosaprepitant dimeglumine..50FOSCAVIR......................... 79fosinopril sodium.................99fosinopril sodium-hctz......... 99fosphenytoin sodium...........42FOSRENOL...................... 159FRAGMIN........................... 38FREAMINE HBC...............138FREAMINE III ................... 138FREESTYLE INSULINX TEST.................................129FREESTYLE LITE TEST.. 129FREESTYLE PRECISION NEO TEST........................129FREESTYLE TEST...........129fresenius propoven........... 201FROVA............................... 56frovatriptan succinate..........56FULPHILA...........................87fulvestrant........................... 63FUNGIMEZ......................... 53FURADANTIN.....................31furosemide.......................... 99FUROSEMIDE IN SODIUM CHLORIDE..........99FUSARIUM....................... 201FUSILEV.............................63FUSION PLUS..................138FUZEON............................. 79fyavolv...............................174FYCOMPA.................... 42, 43GABA................................138gabapentin.......................... 43GABITRIL........................... 43GABLOFEN...................... 230GADAVIST........................201GALAFOLD.......................157galantamine hydrobromide. 46galantamine hydrobromide er.........................................46GALZIN.............................138GAMASTAN......................184GAMASTAN S/D...............184GAMIFANT....................... 184GAMMAGARD..................184GAMMAGARD S/D LESS IGA....................................184GAMMAKED.....................184GAMMAPLEX................... 184GAMUNEX-C....................184GANCICLOVIR................... 79ganciclovir sodium.............. 79ganirelix acetate................166

GARDASIL 9.....................190GASTROCROM................153gatifloxacin........................211GATIFLOXACIN-DEXAMETHASONE......... 216GATTEX........................... 153gavilyte-c...........................153gavilyte-g.......................... 153gavilyte-h.......................... 153gavilyte-n with flavor pack.153GAZYVA............................. 63GELFILM.......................... 216GELFOAM-JMI SPONGE.201GELNIQUE....................... 159GELNIQUE PUMP............159GEL-ONE..........................201GELSYN-3........................ 201gemcitabine hcl...................63gemfibrozil .......................... 99GEMZAR............................ 63GENERESS FE................ 174generlac............................ 153gengraf..............................184GENICIN VITA-S.............. 138GENOTROPIN..................167GENOTROPIN MINIQUICK.......................167gentak............................... 211gentamicin in saline............ 31gentamicin sulfate.......31, 211GENVISC 850...................201GENVOYA.......................... 79GEODON............................76GERMAN COCKROACH..201gianvi................................ 174GIAZO...............................193gildagia............................. 174GILENYA.......................... 112GILOTRIF........................... 63GILPHEX TR.................... 221GILTUSS.......................... 221giltuss pediatric................. 221GILTUSS TR.....................221GLASSIA.......................... 225glatiramer acetate............. 112glatopa.............................. 112GLEEVEC...........................63GLEOLAN.........................201GLEOSTINE....................... 63GLIADEL WAFER...............63glimepiride........................ 126glipizide.............................126glipizide er.........................126

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glipizide xl......................... 126glipizide-metformin hcl...... 126GLOPERBA........................ 55GLUCAGEN DIAGNOSTIC.......................................... 201GLUCAGEN HYPOKIT.....129GLUCAGON EMERGENCY...................129GLUCAGON HCL (DIAGNOSTIC)................. 201GLUCOPHAGE................ 126GLUCOPHAGE XR.......... 126glucose............................. 138GLUCOTROL................... 126GLUCOTROL XL.............. 126GLUCOVANCE.................126glutaraldehyde.................. 201GLUTATHIONE................ 138glyburide........................... 126glyburide micronized.........126glyburide-metformin.......... 126GLYCINE.......................... 138glycine...............................159glycine urologic................. 159glycolic acid...................... 120glycopyrrolate........... 153, 154GLYCOPYRROLATE....... 153glycopyrrolate pf............... 154glydo................................... 19GLYNASE.........................126GLYRX-PF........................154GLYSET............................126GLYXAMBI....................... 126gnp folic acid.....................138GOLDENROD...................201GOLYTELY.......................154GONAL-F..........................167GONAL-F RFF..................167GONAL-F RFF REDIJECT167GOPRELTO........................19GORDOFILM.................... 120grafco silver nit applicator. 120GRALISE.......................... 113GRALISE STARTER........ 113granisetron hcl.................... 50GRANIX.............................. 87GRASTEK.........................201griseofulvin microsize......... 53griseofulvin ultramicrosize.. 53GRIS-PEG.......................... 53guanfacine hcl.....................99guanfacine hcl er.............. 110GUANIDINE HCL................57

GVOKE PFS..................... 129GYNAZOLE-1..................... 53HACKBERRY................... 201HAEGARDA......................184hailey 1.5/30..................... 174hailey 24 fe....................... 174HALAVEN........................... 63halcinonide........................120HALCION............................84HALDOL............................. 76HALDOL DECANOATE...... 76halobetasol propionate..... 120HALOG............................. 120haloperidol.......................... 76haloperidol decanoate........ 76haloperidol lactate...............76HALOTIN............................ 53HARVONI........................... 79HAVRIX............................ 190HEALON........................... 216HEALON GV.....................216HEALON5......................... 216heather..............................174HECTOROL..............194, 195HELIXATE FS.....................87HEMABATE...................... 170hematinic/folic acid........... 138hematogen........................138HEMATOGEN FA............. 138hematogen forte................138HEMATRON-AF............... 138hemenatal ob + dha..........138HEMETAB........................ 138HEMLIBRA......................... 87HEMOCYTE PLUS........... 138hemocyte-f........................ 138hemofil m............................ 87HEMOFIL M........................87HEPAGAM B.................... 184heparin (porcine) in nacl..... 39HEPARIN (PORCINE) IN NACL............................ 39, 40heparin lock flush..............201HEPARIN SOD (PORCINE) IN D5W........... 40heparin sod (porcine) in d5w..................................... 40HEPARIN SOD (PORCINE)-D10................. 40heparin sodium (porcine).... 40HEPARIN SODIUM (PORCINE)......................... 40

heparin sodium (porcine) pf.........................................40heparin sodium flush.........201heparin sodium lock flush. 201HEPATAMINE.................. 139HEPATOLITE................... 201HEPLISAV-B.....................191HEPMED.......................... 201HEPSERA...........................79HERCEPTIN....................... 63HERCEPTIN HYLECTA..... 63HESPAN............................. 87hetastarch-nacl................... 87HETLIOZ...........................231HEXALEN........................... 63HEXTEND...........................87HIBERIX........................... 191HIDEX 6-DAY................... 163HIPREX.............................. 31HISTATROL......................201HIZENTRA........................185homatropaire.....................216homatropine hbr................216HONEY BEE VENOM.......201HONEY BEE VENOM PROTEIN..........................201HORIZANT....................... 113HORSE EPITHELIUM...... 202HUMALOG KWIKPEN...... 130HUMALOG MIX 50/50 KWIKPEN......................... 130HUMALOG MIX 50/50 VIAL.................................. 130HUMALOG MIX 75/25 KWIKPEN......................... 130HUMALOG MIX 75/25 VIAL.................................. 130HUMALOG U-100 JUNIOR KWIKPEN......................... 130HUMALOG U-100 VIAL AND CARTRIDGE............ 130HUMAN ALBUMIN GRIFOLS.......................... 202HUMATE-P......................... 87HUMATROPE...................167HUMIRA............................185HUMIRA PEDIATRIC CROHNS START............. 185HUMIRA PEN................... 185HUMIRA PEN-CD/UC/HS STARTER......................... 185HUMIRA PEN-PS/UV/ADOL HS START. 185

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HUMULIN 70/30 KWIKPEN......................... 130HUMULIN 70/30 VIAL.......130HUMULIN N KWIKPEN.... 131HUMULIN N VIAL............. 131HUMULIN R U-500 KWIKPEN......................... 131HUMULIN R U-500 VIAL (CONCENTRATED)......... 131HUMULIN R VIAL............. 131HYALGAN.........................202HYALURONIDASE (INTRAOCULAR)..............216HYCAMTIN......................... 63hydralazine hcl....................99HYDREA.............................63HYDRO 35........................120hydrochlorothiazide.............99hydrocodone polst-cpm polst er.............................. 221hydrocodone-acetaminophen................... 12hydrocodone-homatropine 221hydrocodone-ibuprofen.......12hydrocortisone.. 120, 163, 193hydrocortisone ace-pramoxine......................... 193hydrocortisone butyr lipo base.................................. 120hydrocortisone butyrate.... 120hydrocortisone in absorbase......................... 120hydrocortisone valerate.... 120hydrocortisone-acetic acid 219hydrogen peroxide.............. 31hydromet...........................221hydromorphone hcl....... 12, 13HYDROMORPHONE HCL. 12hydromorphone hcl er.........12hydromorphone hcl pf......... 12HYDROMORPHONE HCL-NACL.................................. 13HYDROMORPHONE-BUPIVACAINE-NACL.........13HYDROMORPHONE-ROPIVACAINE-NACL........ 13hydroxocobalamin acetate 139hydroxychloroquine sulfate. 72hydroxyprogesterone caproate............................174hydroxyurea........................ 63hydroxyzine hcl................... 84hydroxyzine pamoate..........84

HYLAVITE........................ 139HYLENEX......................... 202HYMOVIS......................... 202hyolev mb......................... 159hyophen............................ 159hyoscyamine sulfate......... 154hyoscyamine sulfate er..... 154hyoscyamine sulfate sl......154HYPERHEP B S/D............185HYPERRAB...................... 185HYPERRAB S/D............... 185HYPERRHO S/D.............. 185HYPERSAL.......................221HYPERTET S/D................185HYQVIA............................ 185HYSINGLA ER....................13HYZAAR............................. 99ibandronate sodium.......... 194IBRANCE............................63ibu......................................... 7IBUDONE........................... 13ibudone............................... 13ibuprofen...............................7ibuprofen lysine.....................7ibutilide fumarate................ 99IC 400................................... 7IC 800................................... 7IC GREEN........................ 202ICAR-C PLUS................... 139icatibant acetate................185ICLUSIG............................. 63IDAMYCIN PFS.................. 63idarubicin hcl.......................64IDELVION........................... 87IDHIFA................................ 64iferex 150 forte..................139IFEX....................................64ifosfamide........................... 64ILARIS.............................. 185ILARIS (150MG DELIVERED).................... 185ILEVRO.............................211ILUMYA............................ 185ILUVIEN............................211imatinib mesylate................ 64IMBRUVICA........................64imipenem-cilastatin............. 31imipramine hcl.....................48imipramine pamoate........... 48imiquimod......................... 120IMITREX............................. 56IMITREX STATDOSE REFILL................................56

IMITREX STATDOSE SYSTEM............................. 56IMLYGIC............................. 64IMOGAM RABIES-HT.......185IMOVAX RABIES..............191IMPAVIDO.......................... 72IMURAN............................185INBRIJA.............................. 73incassia.............................174INCRELEX........................167INCRUSE ELLIPTA.......... 226indapamide......................... 99INDERAL LA.......................99INDERAL XL.......................99INDICLOR.........................202indiomin mb...................... 159indium in 111 oxyquinoline202INDOCIN...............................7indocyanine green............ 202indomethacin........................ 7indomethacin er.................... 7indomethacin sodium............7INFANRIX......................... 191INFASURF........................221INFED............................... 202INFLECTRA......................185INFUGEM........................... 64INFUMORPH 200............... 14INFUMORPH 500............... 14INFUVITE ADULT.............139INFUVITE PEDIATRIC..... 139INGREZZA........................113INJECTAFER....................139INLYTA............................... 64INNOPRAN XL................... 99INOVA 4/1 ACNE CONTROL THERAPY...... 120INOVA 8/2 ACNE CONTROL THERAPY...... 120INREBIC............................. 64INSPRA.............................. 99INSULIN PEN NEEDLES. 131INSULIN SYRINGES........ 131INTEGRA F.......................139INTEGRA PLUS............... 139INTEGRILIN........................75INTELENCE........................79intralipid............................ 139INTRALIPID...................... 139INTRAROSA.....................159INTRON A...........................79introvale............................ 174INTUNIV........................... 110

246

INVANZ...............................31INVEGA.............................. 76INVEGA SUSTENNA..........76INVEGA TRINZA................ 76INVELTYS........................ 212INVIRASE..................... 79, 80INVOKAMET.....................126INVOKAMET XR...............126INVOKANA....................... 126iodine strong..................... 139iodine tincture..................... 31IONOSOL-MB IN D5W..... 139IOPIDINE.......................... 214IPOL..................................191ipratropium bromide..221, 226ipratropium-albuterol.........226IPRIVASK........................... 40irbesartan............................99irbesartan-hydrochlorothiazide.............99IRESSA...............................64irinotecan hcl.......................64IROSPAN 24/6..................139IS 24/6.............................. 139ISENTRESS....................... 80ISENTRESS HD................. 80isibloom.............................174ISOLYTE-P IN D5W......... 139ISOLYTE-S....................... 139ISOLYTE-S PH 7.4........... 139isoniazid..............................58isoproterenol hcl................. 99ISOPTO ATROPINE.........216ISOPTO CARPINE........... 214ISORDIL TITRADOSE........99isosorbide dinitrate..............99isosorbide dinitrate er......... 99isosorbide mononitrate....... 99isosorbide mononitrate er... 99isosulfan blue....................202isotretinoin........................ 120isradipine............................ 99ISTALOL........................... 214ISTODAX (OVERFILL)....... 64ISUPREL............................ 99itraconazole........................ 53ivermectin................... 72, 120IXEMPRA KIT..................... 64IXIARO..............................191IXINITY............................... 88JADENU........................... 139JADENU SPRINKLE.........139JAKAFI................................64

JALYN...............................161jantoven.............................. 40JANUMET.........................126JANUMET XR...........126, 127JANUVIA...........................127JARDIANCE..................... 127jasmiel...............................174jencycla.............................174JENTADUETO..................127JENTADUETO XR............127JETREA............................ 217jevantique lo......................174JEVTANA............................64jinteli ..................................174JIVI......................................88JOHNSON GRASS...........202jolessa...............................174jolivette..............................174JUBLIA................................53juleber............................... 174JULUCA..............................80JUNE GRASS POLLEN STANDARDIZED..............202junel 1.5/30....................... 174junel 1/20.......................... 174junel fe 1.5/30................... 175junel fe 1/20...................... 175junel fe 24......................... 175JUXTAPID........................ 100JYNARQUE...................... 139KABIVEN.......................... 139KADCYLA........................... 64KADIAN.............................. 14kaitlib fe.............................175KALBITOR........................ 202KALETRA........................... 80kalliga................................175KALYDECO...................... 228KANJINTI............................65KANUMA.......................... 157KAPOK............................. 202KAPVAY........................... 110KARBINAL ER.................. 221kariva................................ 175KAZANO........................... 127KCENTRA...........................88KCL (IN NACL 0.9%)........ 139kcl in d5w lactated ringers 139kcl in dextrose-nacl........... 140KCL IN LACTATED RINGERS......................... 140kcl-lactated ringers-d5w....140

KCL-LIDOCAINE IN NACL.......................................... 140KCL-LIDOCAINE-NACL... 140kedbumin.......................... 202KEDRAB........................... 186k-effervescent................... 140KEFLEX.............................. 31kelnor 1/35........................ 175kelnor 1/50........................ 175KENALOG........................ 163KENALOG-80................... 163KENGREAL........................ 75KEPIVANCE..................... 115KEPPRA............................. 43KEPPRA XR....................... 43KERALYT......................... 120KERALYT SCALP.............120KERAMATRIX REPLICINE 5CMX5CM........................ 120KERLIX AMD ANTIMICROBIAL..............202KERLIX AMD SUPER SPONGES........................ 202KERYDIN............................53KETALAR......................... 202KETAMINE HCL............... 202ketamine hcl......................202KETAMINE HCL-SODIUM CHLORIDE....................... 202ketoconazole.......................53ketoprofen.............................7ketoprofen er.........................7ketorolac tromethamine 7, 212KETOROLAC TROMETHAMINE.................7KETOROLAC-BUPIV-KETAMINE........................... 8KETOROLAC-ROPIV-KETAMINE........................... 8KEVEYIS.......................... 214KEVZARA......................... 186KEYTRUDA........................ 65KHAPZORY........................ 65KHEDEZLA.........................48kimidess............................175KINERET.......................... 186KINEVAC.......................... 202KINRIX..............................191kionex............................... 140KISQALI (200 MG DOSE).. 65KISQALI (400 MG DOSE).. 65KISQALI (600 MG DOSE).. 65KITABIS PAK....................228

247

KLARITY-A....................... 212KLONOPIN......................... 84klor-con............................. 140klor-con 10........................ 140klor-con m10..................... 140KLOR-CON M15...............140klor-con m20..................... 140klor-con sprinkle................140klor-con/ef......................... 140KOATE................................88KOATE-DVI........................ 88KOCHIA............................ 203KOGENATE FS.................. 88KOGENATE FS BIO-SET...88KOMBIGLYZE XR............ 127KORLYM...........................170KOVALTRY.........................88K-PHOS............................ 140K-PHOS NO 2...................140K-PHOS-NEUTRAL.......... 140k-prime..............................140KRINTAFEL........................ 72KRISTALOSE................... 154KRYSTEXXA...................... 55K-TAB............................... 140k-tan plus.......................... 140kurvelo.............................. 175KUVAN............................. 157k-vescent.......................... 140KYLEENA......................... 175KYMRIAH......................... 186KYNAMRO........................100KYPROLIS..........................65LABETALOL HCL............. 100labetalol hcl.......................100LABETALOL HCL-DEXTROSE...................... 100LABETALOL HCL-SODIUM CHLORIDE........100LAC-HYDRIN....................120LACRISERT......................217lactated ringers................. 140lactic acid.......................... 121lactic acid e....................... 120lactulose............................154lactulose encephalopathy. 154LAMBS QUARTERS.........203LAMICTAL.......................... 43LAMICTAL ODT..................43LAMICTAL STARTER........ 43LAMICTAL XR.................... 43LAMISIL.............................. 53lamivudine...........................80

lamivudine-zidovudine........ 80lamotrigine.......................... 43lamotrigine er...................... 43lamotrigine starter kit-blue.. 43lamotrigine starter kit-green...................................43lamotrigine starter kit-orange.................................43LANOXIN.......................... 100LANOXIN PEDIATRIC......100lansoprazole..................... 151lanthanum carbonate........ 159LANTUS SOLOSTAR....... 131LANTUS U-100 VIAL........ 131larin 1.5/30........................ 175larin 1/20........................... 175larin 24 fe.......................... 175larin fe 1.5/30.................... 175larin fe 1/20....................... 175larissia...............................175LARTRUVO........................ 65LASIX................................100LASTACAFT..................... 217latanoprost........................ 214LATANOPROST-TIMOLOL MALEATE........ 214latrix.................................. 121LATRIX XM.......................121LATUDA..............................76layolis fe............................175LAZANDA........................... 14LEDIPASVIR-SOFOSBUVIR.................... 80leena................................. 175leflunomide....................... 186LEMTRADA...................... 112LENSCALE....................... 203LENVIMA (10 MG DAILY DOSE)................................ 65LENVIMA (12 MG DAILY DOSE)................................ 65LENVIMA (14 MG DAILY DOSE)................................ 65LENVIMA (18 MG DAILY DOSE)................................ 65LENVIMA (20 MG DAILY DOSE)................................ 65LENVIMA (24 MG DAILY DOSE)................................ 65LENVIMA (4 MG DAILY DOSE)................................ 65LENVIMA (8 MG DAILY DOSE)................................ 65

LESCOL XL...................... 100lessina...............................175LETAIRIS..........................229letrozole.............................. 65LETS...................................19leucovorin calcium.............. 65LEUKERAN........................ 65LEUKINE............................ 88leuprolide acetate............. 167LEUPROLIDE ACETATE-BUPIVACAINE..................167leva set/occlusive dressing. 19levalbuterol hcl..................226LEVAQUIN..........................31LEVATIO.............................19LEVBID............................. 154LEVEMIR U-100 FLEXTOUCH.................... 131LEVEMIR U-100 VIAL...... 131levetiracetam...................... 44levetiracetam er.................. 43levetiracetam in nacl........... 44levobunolol hcl.................. 214LEVOCARNITINE.............140levocarnitine......................140levocetirizine dihydrochloride................. 221levofloxacin........... 31, 32, 212levofloxacin in d5w..............31levoleucovorin calcium..65, 66LEVOLEUCOVORIN CALCIUM............................66levoleucovorin calcium pf....66levonest............................ 175levonorgest-eth est & eth est..................................... 175levonorgest-eth estrad 91-day.................................... 175levonorgestrel................... 175levonorgestrel-ethinyl estrad................................175levonorg-eth estrad triphasic............................ 175LEVOPHED...................... 100levora 0.15/30 (28)............175levorphanol tartrate.............14levo-t................................. 180levothyroxine sodium 180, 181levothyroxine-liothyronine. 181levoxyl...............................181LEVSIN............................. 154LEVSIN/SL........................154LEVULAN KERASTICK.... 121

248

LEXAPRO...........................48LEXISCAN........................ 203LEXIVA............................... 80LIALDA............................. 193LIBRAX............................. 154LIBTAYO.............................66lidenza................................ 19lido bdk............................... 19lidocaine..............................19LIDOCAINE HCL................ 20lidocaine hcl........................ 20lidocaine hcl (cardiac)......... 19lidocaine hcl (cardiac) pf...................................... 19, 20lidocaine hcl (pf)..................20lidocaine hcl urethral/mucosal................. 20LIDOCAINE HCL-SODIUM CHLORIDE......................... 20LIDOCAINE IN D5W...........20lidocaine in d5w.................. 20LIDOCAINE IN DEXTROSE........................ 20lidocaine pak.......................20lidocaine viscous...............115lidocaine-epinephrine..........20LIDOCAINE-EPINEPHRINE................. 217lidocaine-hydrocortisone ace.................................... 193LIDOCAINE-PHENYLEPHRINE........... 217LIDOCAINE-PHENYLEPHRINE-BSS... 217lidocaine-prilocaine............. 20LIDOCAINE-TETRACAINE 20LIDOCIDEX I.................... 163LIDODERM.........................20LIDO-EPINEPHRINE-TETRACAINE..................... 20lido-k................................... 20lidopin................................. 20lidopril ................................. 20lidopril xr............................. 20lido-prilo caine pack............ 20LIDOPROFEN...................... 8LIDO-SORB........................ 20LIDOSTREAM.................... 20LIDOZION...........................20LILETTA (52 MG)............. 175lillow.................................. 175LINCOCIN...........................32lincomycin hcl..................... 32

lindane................................ 72linezolid...............................32linezolid in sodium chloride.32LINZESS...........................154LIORESAL........................ 230LIORESAL INTRATHECAL.......................................... 230liothyronine sodium...........181LIPITOR............................100LIPO..................................140LIPO-C..............................140lipodox 50........................... 66LIPOFEN.......................... 100liprozonepak....................... 21LIQUIVIDA HYDRATION..141lisinopril .............................100lisinopril-hydrochlorothiazide...........100lithium................................. 85lithium carbonate................ 85lithium carbonate er............ 85LITHOBID........................... 85LITHOSTAT...................... 159LIVALO............................. 100livixil pak............................. 21LMD IN D5W.......................88LMD IN NACL..................... 88LO LOESTRIN FE............ 175LODINE................................ 8LODOSYN.......................... 73LOESTRIN 1.5/30 (21)..... 175LOESTRIN 1/20 (21)........ 175LOESTRIN FE 1.5/30....... 175LOESTRIN FE 1/20.......... 175lomedia 24 fe.................... 176LOMOTIL.......................... 154LONSURF...........................66loperamide hcl.................. 154LOPID............................... 100lopinavir-ritonavir................ 80lopreeza............................ 176LOPRESSOR................... 100LOPRESSOR HCT........... 100LOPROX.............................53lorazepam........................... 84lorazepam intensol..............84LORAZEPAM-DEXTROSE.84LORBRENA........................ 66lorcet................................... 14lorcet hd.............................. 14lorcet plus........................... 14lorenza................................ 21LORID...............................141

LORTAB............................. 14loryna................................ 176LORZONE........................ 230losartan potassium............100losartan potassium-hctz....100LOSEASONIQUE............. 176LOTEMAX.........................212LOTEMAX SM.................. 212LOTENSIN........................101LOTENSIN HCT............... 100loteprednol etabonate....... 212LOTREL............................101LOTRISONE..................... 121LOTRONEX...................... 154lovastatin...........................101LOVAZA............................101LOVENOX.................... 40, 41low-ogestrel...................... 176loxapine succinate.............. 76LOYON............................. 121lo-zumandimine................ 176lp lite pak.............................21LUCEMYRA........................23LUCENTIS........................ 217ludent................................ 141lugols.................................. 32LULICONAZOLE................ 53LUMASON........................ 203LUMIGAN......................... 214LUMIZYME....................... 157LUMOXITI...........................66LUNESTA......................... 231LUPANETA PACK............ 167LUPRON DEPOT (1-MONTH)........................... 167LUPRON DEPOT (3-MONTH)........................... 167LUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT 30MG................................ 167LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT 45MG................................ 167LUPRON DEPOT-PED (1-MONTH)........................... 167LUPRON DEPOT-PED (3-MONTH)........................... 167lutera.................................176LUVIRA.............................203LUXTURNA...................... 217LUZU.................................. 53

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LYNPARZA.........................66LYRICA.............................113LYRICA CR.......................113LYSINE HCL.....................141lysiplex plus...................... 141LYSODREN........................ 66LYSTEDA........................... 88lyza................................... 176M.V.I. ADULT....................141M.V.I. PEDIATRIC............ 141M.V.I.-12 (WITHOUT VITAMIN K).......................141MACI.................................203MACRILEN....................... 203MACROBID........................ 32MACRODANTIN................. 32MACUGEN....................... 217mafenide acetate................ 32MAGNEBIND 400............. 141magnesium sulfate............141MAGNESIUM SULFATE.. 141magnesium sulfate in d5w 141MAGNESIUM SULFATE IN D5W............................. 141MAGNESIUM SULFATE-LACT RINGERS............... 141MAGNESIUM SULFATE-NACL................................ 142MAGNEVIST.....................203MAKENA...........................176MALARONE........................72malathion............................ 72MANGANESE CHLORIDE142mannitol............................ 101maprotiline hcl.....................48MARCAINE.........................21MARCAINE PRESERVATIVE FREE......21MARCAINE SPINAL........... 21MARCAINE/EPINEPHRINE......................................... 21MARCAINE/EPINEPHRINE PF....................................21MARINOL........................... 50marlissa............................ 176MARPLAN.......................... 48MARQIBO...........................66marten-tab.......................... 14MATULANE........................ 66matzim la.......................... 101MAVENCLAD (10 TABS)..112MAVENCLAD (4 TABS)....112MAVENCLAD (5 TABS)....112

MAVENCLAD (6 TABS)....112MAVENCLAD (7 TABS)....112MAVENCLAD (8 TABS)....112MAVENCLAD (9 TABS)....112MAVYRET.......................... 80MAXALT............................. 56MAXALT-MLT..................... 56MAXFE............................. 142MAXICOMFORT SYR 27G X 1/2"................................ 131MAXIDEX..........................212MAXIPIME.......................... 32MAXITROL....................... 217MAXZIDE..........................101MAXZIDE-25.....................101MAYZENT.........................112MAYZENT STARTER PACK................................ 112me/naphos/mb/hyo1......... 159MEADOW FESCUE GRASS POLLEN.............. 203meclizine hcl....................... 50meclofenamate sodium.........8MEDI-DERM/L-RX..............21MEDI-DERM-RX.................14MEDI-PATCH RX............... 21medolor pak........................ 21MEDROL.......................... 163MEDROX-RX......................14medroxyprogesterone acetate.............................. 176mefenamic acid.....................8mefloquine hcl.....................72MEGACE ES.................... 176megestrol acetate............. 176MEKINIST...........................66MEKTOVI............................66MELALEUCA.................... 203melodetta 24 fe................. 176meloxicam.............................8melphalan........................... 66melphalan hcl......................66memantine hcl.................... 46memantine hcl er................ 46MEMBRANEBLUE............217MENACTRA......................191MENEST...........................176MENOPUR....................... 167MENOSTAR..................... 176MENTAX.............................53MENVEO.......................... 191meperidine hcl.................... 14

MEPERIDINE HCL-SODIUM CHLORIDE..........14MEPHYTON..................... 142meprobamate......................84MEPRON............................ 72MEPSEVII.........................157mercaptopurine...................66meropenem.........................32MEROPENEM-SODIUM CHLORIDE......................... 32MERREM............................32mesalamine...................... 193mesalamine-cleanser........193mesna................................. 66MESNEX.............................66MESQUITE....................... 203MESTINON.........................57metadate er.......................110metaproterenol sulfate...... 226METASTRON..................... 66metaxall ............................ 230metaxalone....................... 230METFORMIN HCL............127metformin hcl.................... 127metformin hcl er................ 127methadone hcl.................... 14methadone hcl intensol.......14METHADOSE..................... 14methadose.......................... 14METHADOSE SUGAR-FREE.................................. 14methamphetamine hcl...... 110methazolamide................. 214methenamine hippurate...... 32methenamine mandelate.... 32methergine........................203methimazole..................... 181METHITEST..................... 165methocarbamol................. 230methotrexate.....................186methotrexate sodium........ 186methotrexate sodium (pf)..186methoxsalen..................... 121methoxsalen rapid............ 121methscopolamine bromide154methyclothiazide............... 101methyl salicylate............... 121METHYLCOBALAMIN...... 142methyldopa....................... 101methyldopa-hydrochlorothiazide...........101methyldopate hcl...............101methylergonovine maleate203

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METHYLIN........................110methylphenidate hcl..110, 111methylphenidate hcl er......110methylphenidate hcl er (cd).......................................... 110methylphenidate hcl er (la)110methylprednisolone...........163METHYLPREDNISOLONE ACETATE......................... 163methylprednisolone acetate.............................. 163methylprednisolone sodium succ......................163METHYLPREDNISOLONE-BUPIVACAINE................ 163methyltestosterone........... 165metipranolol...................... 214metoclopramide hcl.............50metolazone....................... 101metopic............................. 121metoprolol succinate er.....101metoprolol tartrate.............101METOPROLOL TARTRATE.......................101METOPROLOL-HCTZ ER 101metoprolol-hydrochlorothiazide...........101METROGEL-VAGINAL.......32METRONIDAZOLE.............32metronidazole............. 32, 121metronidazole in nacl..........32mexiletine hcl.................... 101MI PASTE......................... 115MI PASTE PLUS...............115MIACALCIN...................... 194mibelas 24 fe.................... 176MICARDIS........................ 101MICARDIS HCT................101miconazole 3.......................53MICONAZOLE-ZINC OXIDE-PETROLAT............ 53MICRHOGAM ULTRA-FILTERED PLUS.............. 186MICROCYN...................... 121microgestin 1.5/30............ 176microgestin 1/20............... 176microgestin fe 1.5/30........ 176microgestin fe 1/20........... 176MICROZIDE......................101midazolam hcl.....................84MIDAZOLAM HCL.............. 84MIDAZOLAM HCL-DEXTROSE........................ 85

MIDAZOLAM HCL-SODIUM CHLORIDE..........85MIDAZOLAM-SODIUM CHLORIDE......................... 85midodrine hcl.................... 101MIFEPREX....................... 142mifepristone...................... 142MIGERGOT........................ 56miglitol...............................127miglustat........................... 157MIGRANAL......................... 56mili .................................... 176MILLIPRED.......................164MILLIPRED DP.................164MILLIPRED DP 12-DAY... 163milrinone lactate................101milrinone lactate in dextrose............................ 101mimvey............................. 176mimvey lo..........................176MINASTRIN 24 FE........... 176mineral oil heavy...............154MINIPRESS...................... 101minitran............................. 102MINIVELLE....................... 176MINOCIN............................ 32minocycline hcl............. 32, 33minoxidil ............................102MIOCHOL-E..................... 217MIOSTAT..........................217MIRAPEX............................73MIRAPEX ER......................73MIRCERA........................... 88MIRCETTE....................... 177MIRENA (52 MG)..............177mirtazapine......................... 48MIRVASO......................... 121misoprostol....................... 151MITE (D. FARINAE)..........203MITE (D. PTERONYSSINUS)..........203MITIGARE.......................... 55mitigo.................................. 14mitomycin............................66MITOMYCIN....................... 66MITOSOL..........................212mitoxantrone hcl................. 66MIXED ASPERGILLUS.... 203MIXED FEATHERS.......... 203MIXED RAGWEED...........203MIXED VESPID VENOM PROTEIN..........................203M-M-R II............................191

M-NATAL PLUS................142MOBIC.................................. 8modafinil ........................... 231moderiba.............................80MODERIBA.........................80MODERIBA 1200 DOSE PACK.................................. 80MODERIBA 800 DOSE PACK.................................. 80moexipril hcl......................102moexipril-hydrochlorothiazide...........102molindone hcl......................76mometasone furoate.121, 221mondoxyne nl..................... 33MONOCLATE-P................. 88MONODOX.........................33monoject flush syringe...... 142monoject sodium chloride flush.................................. 142mono-linyah...................... 177mononessa....................... 177MONONINE........................ 88MONOVISC...................... 203MONSELS FERRIC SUBSULFATE.................... 88montelukast sodium..........226MONUROL......................... 33morgidox............................. 33MORPHINE SULFATE....... 15morphine sulfate................. 15morphine sulfate (concentrate).......................14morphine sulfate (pf).....14, 15morphine sulfate er............. 15morphine sulfate er beads.. 15MORPHINE SULFATE IN DEXTROSE........................ 15MORPHINE SULFATE-NACL.................................. 15MOTEGRITY.................... 154MOTOFEN........................154MOUNTAIN CEDAR......... 203MOUSE EPITHELIUM...... 203MOVANTIK....................... 154MOVIPREP.......................154MOXATAG..........................33MOXEZA...........................212MOXIFLOXACIN HCL 33, 212moxifloxacin hcl.......... 33, 212moxifloxacin hcl in nacl....... 33MOXIFLOXACIN HCL-BSS...................................217

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MOZOBIL............................88MS CONTIN........................16MUCOR............................ 204MUCOSITISRX.................115MUGWORT...................... 204MULPLETA.........................88MULTAQ...........................102MULTIGEN....................... 142MULTIGEN FOLIC............142MULTIGEN PLUS.............142MULTIHANCE.................. 204multi-vit/fluoride.................142multi-vit/fluoride/iron..........142multi-vit/iron/fluoride..........142multivitamin/fluoride.......... 142multi-vitamin/fluoride.........142multivitamin/fluoride/iron... 142multi-vitamin/fluoride/iron..142mupirocin............................ 33MUSTARGEN.....................66mutamycin.......................... 66MVASI.................................66mvc-fluoride...................... 142MYALEPT......................... 157MYAMBUTOL..................... 58MYCAMINE........................ 53MYCOBUTIN...................... 58mycophenolate mofetil ......186mycophenolate mofetil hcl 186mycophenolate sodium.....186myferon 150 forte..............142MYFORTIC....................... 186MYLERAN.......................... 66MYLOTARG........................67mynephrocaps.................. 142mynephron........................142MYOBLOC........................204myorisan........................... 121MYOVIEW 30ML.............. 204MYRBETRIQ.................... 159MYSOLINE......................... 44MYXREDLIN.....................131myzilra.............................. 177na ferric gluc cplx in sucrose............................. 142NABI-HB........................... 186nabumetone..........................8n-acetyl-l-cysteine.............142nadolol.............................. 102nadolol-bendroflumethiazide......... 102nafcillin sodium................... 33

NAFCILLIN SODIUM IN DEXTROSE........................ 33nafrinse............................. 143NAFRINSE DAILY ACIDULATED................... 115NAFRINSE DAILY/NEUTRAL..............115nafrinse drops................... 143NAFRINSE WEEKLY........115naftifine hcl....................53, 54NAFTIN...............................54NAGLAZYME....................157nalbuphine hcl.....................16NALFON............................... 8NALOCET...........................16naloxone hcl........................24NALTREXONE................... 24naltrexone hcl..................... 24NAMENDA..........................46NAMENDA TITRATION PAK.....................................46NAMENDA XR....................46NAMENDA XR TITRATION PACK.............. 46NAMZARIC......................... 46NANDROLONE DECANOATE................... 165NANDROLONE-TESTOSTERONE CYP........................... 165NAPRELAN.......................... 8NAPROSYN..........................8naproxen...............................8naproxen dr...........................8naproxen sodium.................. 8naproxen sodium er.............. 8naratriptan hcl..................... 56NARCAN.............................24NARDIL...............................48NAROPIN........................... 21NASCOBAL...................... 143NASONEX........................ 221NATACYN.........................212NATAZIA...........................177nateglinide........................ 127NATPARA.........................195NATRECOR......................102NATROBA.......................... 72NATURE-THROID............ 181NAVELBINE........................67NEBUPENT........................ 72nebusal............................. 221NEBUSAL......................... 221necon 0.5/35 (28)..............177

necon 1/50 (28).................177necon 7/7/7....................... 177nefazodone hcl................... 48NEMBUTAL........................ 44neomycin sulfate.................33neomycin-bacitracin zn-polymyx.............................217neomycin-polymyxin b gu... 33neomycin-polymyxin-dexameth.......................... 217neomycin-polymyxin-gramicidin......................... 217neomycin-polymyxin-hc.......................... 217, 219, 220NEONATAL COMPLETE..143NEONATAL PLUS............ 143neo-polycin....................... 218neo-polycin hc...................218NEOPROFEN....................... 8NEORAL........................... 186NEOSPORIN.................... 218neostigmine methylsulfate.. 57NEOSTIGMINE METHYLSULFATE............. 57NEO-SYNALAR................ 121NEOTUSS PLUS.............. 221NEOVITE.......................... 143NEPHPLEX RX.................143NEPHRAMINE..................143NEPHROCAPS.................143NEPHRON FA.................. 143nephronex.........................143NEPHRO-VITE RX........... 143NEPTAZANE.................... 214NERLYNX...........................67NESACAINE....................... 21NESACAINE-MPF.............. 21NESINA............................ 127NESTABS......................... 143NETSPOT.........................204NEULASTA.........................89NEULASTA ONPRO...........88NEUPOGEN....................... 89NEUPRO............................ 73NEURIN-SL...................... 143NEURONTIN...................... 44neutragard advanced........115neutral sodium fluoride..... 115NEUTRASAL.................... 115NEVANAC........................ 212nevirapine........................... 80nevirapine er....................... 80NEXAVAR...........................67

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NEXIUM 24HR..................151NEXIUM I.V...................... 151NEXPLANON....................177NEXTERONE................... 102niacin (antihyperlipidemic) 102niacin er (antihyperlipidemic)...........102NIACOR............................102NIASPAN.......................... 102NICADAN..........................143nicardipine hcl...................102NICARDIPINE HCL IN DEXTROSE...................... 102NICARDIPINE HCL IN NACL................................ 102NICAZEL...........................143NICAZEL FORTE............. 143NICOMIDE........................143NICORETTE....................... 24nicotine polacrilex............... 24nicotine step 1.....................24nicotine step 2.....................24nicotine step 3.....................24NICOTROL......................... 24NICOTROL NS................... 24nifedipine.......................... 102nifedipine er...................... 102nifedipine er osmotic release.............................. 102NIFEREX.......................... 143nikki...................................177NILANDRON.......................67nilutamide........................... 67NIMBEX............................ 113nimodipine........................ 102NINLARO............................67NIPENT...............................67NIPRIDE RTU...................102nisoldipine er.....................102NITHIODOTE....................204nitisinone...........................157NITRO-BID....................... 103NITRO-DUR......................103nitrofurantoin.......................33nitrofurantoin macrocrystal. 33nitrofurantoin monohydrate macrocrystals......................33nitroglycerin...................... 103nitroglycerin in d5w........... 103NITROLINGUAL............... 103NITROMIST...................... 103NITROPRESS.................. 103nitroprusside sodium.........103

NITROSTAT..................... 103nitro-time...........................103NITYR............................... 157NIVESTYM......................... 89nizatidine...........................151NIZORAL............................ 54nolix.................................. 121nora-be............................. 177NORCO.............................. 16NORDITROPIN FLEXPRO.......................................... 167norepinephrine bitartrate...103NOREPINEPHRINE-DEXTROSE...................... 103NOREPINEPHRINE-SODIUM CHLORIDE........103norethin ace-eth estrad-fe.177norethindrone....................177norethindrone acetate.......177norethindrone acet-ethinyl est..................................... 177norethindrone-eth estradiol.......................................... 177norethin-eth estradiol-fe....177NORGESIC FORTE......... 230norgestimate-eth estradiol 177norgestimate-ethinyl estradiol triphasic..............177norlyda.............................. 177norlyroc............................. 177normal saline flush............143NORMOSOL-M IN D5W... 143NORMOSOL-R................. 143NORMOSOL-R IN D5W... 143NORMOSOL-R PH 7.4..... 143NORPACE........................ 103NORPACE CR..................103NORPRAMIN......................48NORTHERA......................103nortrel 0.5/35 (28)............. 177nortrel 1/35 (21)................ 177nortrel 1/35 (28)................ 177nortrel 7/7/7.......................177nortriptyline hcl....................48NORTUSS-EX.................. 221NORVASC........................ 104NORVIR..............................80NOURIANZ......................... 73novarel.............................. 168NOVAREL.........................168NOVOEIGHT...................... 89NOVOFINE AUTOCOVER PEN NEEDLE................... 131

NOVOFINE PEN NEEDLE131NOVOFINE PLUS PEN NEEDLE........................... 132NOVOLIN 70/30 FLEXPEN.......................................... 132NOVOLIN 70/30 FLEXPEN RELION............................ 132NOVOLIN 70/30 RELION. 132NOVOLIN 70/30 VIAL.......132NOVOLIN N RELION........132NOVOLIN N VIAL............. 132NOVOLIN R RELION........132NOVOLIN R VIAL............. 132NOVOLOG FLEXPEN...... 132NOVOLOG MIX 70/30 FLEXPEN......................... 132NOVOLOG MIX 70/30 VIAL.................................. 132NOVOLOG PENFILL........ 132NOVOLOG U-100 VIAL.... 132NOVOSEVEN RT............... 89NOVOTWIST PEN NEEDLE........................... 132NOXAFIL............................ 54np thyroid.......................... 181NPLATE..............................89NUBEQA.............................67NUCALA........................... 221NUCYNTA.......................... 16NUCYNTA ER.................... 16NUFERA........................... 143nulev................................. 155NULOJIX...........................186NULYTELY WITH FLAVOR PACKS.............. 155NUMOISYN...................... 115NUPLAZID.......................... 76NUTRESTORE................. 143NUTRICAP....................... 143NUTRIDOX......................... 33nutrifac zx......................... 143nutrilipid............................ 143nutrilyte............................. 143NUTRIVIT......................... 143NUTROPIN AQ NUSPIN 10......................................168NUTROPIN AQ NUSPIN 20......................................168NUTROPIN AQ NUSPIN 5168NUVAIL.............................121NUVAKAAN........................ 21NUVARING.......................177NUVIGIL........................... 231

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NUWIQ............................... 89NUZYRA............................. 33nyata................................... 54NYMALIZE........................104nystatin............................... 54nystatin-triamcinolone.........54nystop................................. 54OBIZUR.............................. 89OCALIVA.......................... 157ocella................................ 177OCREVUS........................ 112OCTAGAM........................186OCTAPLAS BLOOD GROUP A......................... 204OCTAPLAS BLOOD GROUP AB.......................204OCTAPLAS BLOOD GROUP B......................... 204OCTAPLAS BLOOD GROUP O.........................204octreotide acetate............. 168OCUFLOX........................ 212ODACTRA........................ 204ODEFSEY...........................80ODOMZO............................67OFEV................................ 226ofloxacin..............33, 212, 220ogestrel............................. 177OGIVRI............................... 67okebo.................................. 33olanzapine.......................... 76olanzapine-fluoxetine hcl.... 48OLIVE TREE.....................204olmesartan medoxomil......104olmesartan medoxomil-hctz................................... 104olmesartan-amlodipine-hctz................................... 104olopatadine hcl..........212, 221OLUMIANT....................... 187OLYSIO.............................. 80OMECLAMOX-PAK.......... 155omega-3-acid ethyl esters 104OMEGAVEN..................... 143omeprazole....................... 151OMEPRAZOLE+SYRSPEND SF ALKA.....................151OMIDRIA.......................... 218OMNARIS......................... 222OMNIPAQUE....................204OMNIPRED...................... 212OMNISCAN...................... 204

OMNISCAN/SODIUM CHLORIDE....................... 204OMNITROPE.................... 168ONCASPAR........................67ondansetron hcl............ 50, 51ONDANSETRON HCL........50ONDANSETRON HCL-DEXTROSE........................ 51ONDANSETRON HCL-NACL.................................. 51ondansetron odt..................51ONEVITE.......................... 143ONFI................................... 44ONGLYZA.........................127ONIVYDE............................67ONMEL............................... 54ONPATTRO......................114OPANA............................... 16OPANA ER......................... 16OPDIVO..............................67opium................................ 155OPSUMIT......................... 229OPTIMARK....................... 204OPTIONS CONCEPTROL204OPTIRAY 350................... 204OPTISON..........................204ORABLOC.......................... 21ORACIT............................ 143ORAFATE.........................204ORALAIR.......................... 205ORALAIR ADULT SAMPLE KIT.....................204ORALAIR ADULT STARTER PACK.............. 204ORALAIR CHILDRENS SAMPLE KIT.....................205ORALAIR CHILDRENS STARTER PACK.............. 205oralone..............................115ORAP..................................76ORAPRED ODT............... 164ORAVIG..............................54ORBACTIV......................... 33ORCHARD GRASS POLLEN............................205ORENCIA......................... 187ORENCIA CLICKJECT.....187ORENITRAM.................... 229ORFADIN..........................157ORILISSA......................... 168ORKAMBI......................... 228orphenadrine citrate..........230orphenadrine citrate er......230

orphenadrine-aspirin-caffeine............................. 230ORPHENGESIC FORTE.. 230orsythia............................. 178ORTHO MICRONOR........178ORTHO TRI-CYCLEN (28).......................................... 178ORTHO TRI-CYCLEN LO 178ORTHO-CYCLEN (28)......178ORTHO-NOVUM 1/35 (28).......................................... 178ORTHO-NOVUM 7/7/7 (28)................................... 178ORTHOVISC.................... 205oscimin..............................155oscimin sr..........................155oseltamivir phosphate.........80OSENI...............................127OSMITROL....................... 104osmitrol............................. 104OSMOPREP..................... 155OSPHENA........................ 166OTEZLA............................187OTIPRIO........................... 220OTOVEL........................... 220OVACE PLUS...................121OVACE PLUS WASH....... 121OVACE WASH................. 121OVIDE.................................72OVIDREL.......................... 168oxacillin sodium.................. 33oxaliplatin............................67OXANDRIN.......................165oxandrolone...................... 165oxaprozin.............................. 8OXAYDO............................ 16oxazepam........................... 85oxcarbazepine.................... 44OXERVATE...................... 218oxiconazole nitrate..............54OXISTAT............................ 54OXSORALEN ULTRA.......121OXTELLAR XR................... 44oxybutynin chloride........... 159oxybutynin chloride er.......159oxycodone hcl.....................16OXYCODONE HCL ER...... 16oxycodone-acetaminophen.16oxycodone-aspirin...............16oxycodone-ibuprofen.......... 16OXYCONTIN...................... 16oxymorphone hcl................ 16oxymorphone hcl er............ 16

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oxytocin.............................168OXYTOCIN-DEXTROSE.. 168OXYTOCIN-DEXTROSE-LACT RINGERS............... 168OXYTOCIN-LACTATED RINGERS......................... 169OXYTOCIN-SODIUM CHLORIDE....................... 169OZEMPIC......................... 127OZURDEX........................ 212pacerone...........................104paclitaxel.............................67PAINGO KFT...................... 21paliperidone er.................... 76palonosetron hcl................. 51PALYNZIQ........................ 157PAMELOR.......................... 48pamidronate disodium...... 194PANCREAZE....................157pancuronium bromide....... 114PANHEMATIN.................... 89PANRETIN..........................67pantoprazole sodium........ 151PANZYGA.........................187PARAGARD INTRAUTERINE COPPER.......................................... 178paregoric...........................155paricalcitol.................194, 195PARLODEL.........................73PARNATE...........................48paroex...............................115paromomycin sulfate...........33paroxetine hcl..................... 48paroxetine hcl er................. 48PARSABIV........................181PASER................................58PATADAY......................... 212PATANASE.......................222PATANOL......................... 212PAXIL..................................48PAXIL CR........................... 48PAZEO..............................212PCE.................................... 33PECAN POLLEN.............. 205PEDIAPRED..................... 164PEDIARIX......................... 191PEDVAX HIB.................... 191peg 3350/electrolytes........155peg 3350-kcl-na bicarb-nacl................................... 155peg-3350/electrolytes....... 155PEGANONE....................... 44

PEGASYS...........................81PEGASYS PROCLICK....... 80PEGINTRON...................... 81peg-prep........................... 155pegylax............................. 155PENICILLIN G POT IN DEXTROSE........................ 34penicillin g potassium..........34penicillin g procaine............ 34penicillin g sodium.............. 34penicillin v potassium..........34PENICILLIUM NOTATUM 205PENLAC............................. 54PENTACEL.......................191PENTAM.............................72pentamidine isethionate......72PENTASA......................... 193pentazocine-naloxone hcl... 16pentobarbital sodium.......... 44pentoxifylline er.................104PEPCID............................ 152PERCOCET........................16PERENNIAL RYE GRASS POLLEN............................205PERFOROMIST............... 226PERIDEX.......................... 115PERIKABIVEN..................143perindopril erbumine......... 104periogard...........................115PERJETA............................67permethrin...........................72perphenazine...................... 51perphenazine-amitriptyline..49PERSERIS..........................77PERTZYE......................... 157PFIZERPEN........................34phenadoz.......................... 222phenazo............................ 159phenazopyridine hcl..........159phenelzine sulfate...............49PHENERGAN................... 222phenergan.........................222phenobarbital...................... 44phenobarbital sodium......... 44phenobarbital-belladonna alk..................................... 155phenoxybenzamine hcl..... 104phentolamine mesylate.....104phenylephrine hcl......104, 218PHENYLEPHRINE HCL.................................. 104, 159PHENYLEPHRINE HCL (PRESSORS)................... 104

PHENYLEPHRINE HCL-DEXTROSE...................... 104PHENYLEPHRINE HCL-NACL................................ 105phenylephrine-guaifenesin222PHENYTEK........................ 44phenytoin............................ 44phenytoin infatabs...............44phenytoin sodium................44phenytoin sodium extended............................. 44philith................................ 178PHOMA EXIGUA.............. 205PHOSLYRA...................... 160phospha 250 neutral......... 144phosphasal....................... 160PHOSPHOLINE IODIDE.. 214phosphorous..................... 144phospho-trin 250 neutral...144PHOTOFRIN.......................67PHOTREXA VISCOUS.....205PHOXILLUM BK4/2.5....... 144phrenilin forte...................... 16physiolyte..........................144physiosol irrigation............ 144phytonadione.................... 144PICATO............................ 121PIFELTRO.......................... 81pilocarpine hcl...........115, 214pimecrolimus.....................121pimozide............................. 77pimtrea..............................178pindolol............................. 105pioglitazone hcl................. 127pioglitazone hcl-glimepiride.......................................... 127pioglitazone hcl-metformin hcl..................................... 127piperacillin sod-tazobactam so........................................ 34PIQRAY (200 MG DAILY DOSE)................................ 67PIQRAY (250 MG DAILY DOSE)................................ 67PIQRAY (300 MG DAILY DOSE)................................ 67pirmella 1/35..................... 178pirmella 7/7/7.................... 178piroxicam.............................. 8PITOCIN........................... 169PLAN B ONE-STEP..........178PLAQUENIL........................72PLASBUMIN-25................205

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PLASBUMIN-5..................205PLASMA-LYTE 148.......... 144PLASMA-LYTE A..............144PLASMANATE..................205PLAVIX............................... 75PLEGISOL........................ 144PLEGRIDY........................112PLEGRIDY STARTER PACK................................ 112plenamine......................... 144PLIAGLIS............................21PNEUMOVAX 23..............191pnv prenatal plus multivit+dha.......................144podocon............................ 121podofilox........................... 121POLIDOCANOL................105POLIVY...............................67polocaine............................ 21polocaine-mpf..................... 21polycin...............................218polyethylene glycol 3350.. 155poly-iron 150 forte.............144polymyxin b sulfate............. 34polymyxin b-trimethoprim..218polysaccharide iron forte...144POLYTRIM....................... 218POLY-VI-FLOR.................144POLY-VI-FLOR FS........... 144POLY-VI-FLOR/IRON.......144POMALYST........................ 68PONSTEL............................. 8portia-28............................178port-prep............................. 21PORTRAZZA...................... 68posaconazole......................54pot bicarb-pot chloride...... 144potassium acetate.............144POTASSIUM ACETATE-NACL................................ 144potassium bicarbonate......144potassium chloride............145POTASSIUM CHLORIDE. 145potassium chloride crys er 144potassium chloride er........144POTASSIUM CHLORIDE IN D5W............................. 144potassium chloride in dextrose............................ 145POTASSIUM CHLORIDE IN NACL............................145potassium chloride in nacl 145

potassium chloride proamp.......................................... 145potassium citrate er.......... 145potassium citrate-citric acid.......................................... 145POTASSIUM PHOSPHATE-NACL.........145POTASSIUM PHOSPHATES-DEXTROSE...................... 145POTASSIUM PHOSPHATES-NACL...... 146POTELIGEO....................... 68POVIDONE-IODINE......... 212PRADAXA...........................41pralidoxime chloride..........205PRALUENT.......................105pramipexole dihydrochloride................... 73pramipexole dihydrochloride er............... 73PRAMOTIC.......................220pramox..............................121PRANDIN..........................127prasugrel hcl....................... 75PRAVACHOL....................105pravastatin sodium............105PRAXBIND....................... 205praziquantel........................ 72prazosin hcl.......................105PRE & POST SX POUCH 121PRECEDEX...................... 205PRECISION PCX PLUS TEST.................................129PRECISION QID TEST.... 129PRECISION SOF-TACT TEST.................................129PRECISION XTRA BLOOD GLUCOSE...........129PRECISION XTRA KETONE........................... 129PRECOSE........................ 127PRED FORTE...................212PRED MILD...................... 212PRED-G............................218PRED-G S.O.P................. 218prednicarbate....................121PREDNISOL ACE-MOXIFLOX-BROMFEN.... 212prednisolone..................... 164prednisolone acetate........ 213prednisolone acetate p-f... 213

prednisolone sodium phosphate................. 164, 213PREDNISOLONE-BROMFENAC...................218PREDNISOLONE-GATIFLOXACIN............... 218PREDNISOLON-GATIFLOX-BROMFENAC 218PREDNISOLON-MOXIFLOX-BROMFENAC.......................................... 218prednisone........................ 164PREDNISONE INTENSOL.......................................... 164PREFERAOB +DHA.........146PREFEST......................... 178PRE-FOLIC.......................146pregabalin......................... 114pregnyl.............................. 169PREMARIN.......................178PREMASOL......................146premasol........................... 146PREMESISRX.................. 146premium lidocaine...............21PREMPHASE................... 178PREMPRO........................178PRENAISSANCE..............146PRENATA.........................146prenatal.............................146prenatal plus iron.............. 146PREPIDIL......................... 170PREPOPIK....................... 155PRESTALIA...................... 105PRETOMANID....................58PREVACID....................... 152PREVACID SOLUTAB......152prevalite............................ 105preventeza........................ 178PREVIDENT..................... 116prevident........................... 116PREVIDENT 5000 BOOSTER PLUS..............115PREVIDENT 5000 DRY MOUTH.............................115PREVIDENT 5000 ENAMEL PROTECT.........115PREVIDENT 5000 ORTHO DEFENSE.........................115PREVIDENT 5000 PLUS..115PREVIDENT 5000 SENSITIVE....................... 116previfem............................ 178PREVNAR 13................... 191

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PREVPAC.........................155PREVYMIS......................... 81PREZCOBIX....................... 81PREZISTA.......................... 81PRIALT............................... 17PRIFTIN..............................58prikaan................................ 21prikaan lite.......................... 21PRILO PATCH....................21prilolid................................. 21PRILOSEC........................152prilovix.................................21PRILOVIX LITE...................21prilovix plus......................... 21prilovix ultralite.................... 21priloxx lp..............................21primaquine phosphate........ 72PRIMAXIN IV...................... 34primidone............................ 44PRIMLEV............................ 17PRIMSOL............................34PRINIVIL...........................105PRISMASOL B22GK 4/0.. 146PRISMASOL BGK 0/2.5... 146PRISMASOL BGK 2/0...... 146PRISMASOL BGK 2/3.5... 146PRISMASOL BGK 4/0/1.2 146PRISMASOL BGK 4/2.5... 146PRISMASOL BK 0/0/1.2... 146PRISTIQ............................. 49PRIVET.............................205PRIVIGEN.........................187PROAIR HFA....................226PROAIR RESPICLICK......226probenecid.......................... 55PROBUPHINE IMPLANT KIT...................................... 17procainamide hcl...............105PROCALAMINE................146PROCARDIA.................... 105PROCARDIA XL............... 105PROCENTRA................... 111prochlorperazine................. 51prochlorperazine edisylate..51prochlorperazine maleate... 51PROCORT........................193PROCRIT............................89PROCTOCORT................ 193PROCTOFOAM HC..........193procto-med hc...................193procto-pak.........................193proctosol hc...................... 193proctozone-hc................... 193

PROCYSBI....................... 157profeno..................................8PROFILNINE...................... 89PROFILNINE SD................ 89progesterone.....................178progesterone micronized.. 178PROGLYCEM...................129PROGRAF........................ 187PROHANCE..................... 205PROLASTIN-C..................226PROLENSA...................... 213PROLEUKIN....................... 68PROLIA.............................194PROMACTA....................... 89promethazine hcl.............. 222promethazine vc plain.......222promethazine vc/codeine..222promethazine-codeine...... 222promethazine-dm..............222promethazine-phenyleph-codeine............................. 222promethazine-phenylephrine................... 222promethegan.....................222PROMETRIUM................. 178propafenone hcl................ 105propafenone hcl er............105propantheline bromide...... 155proparacaine hcl............... 218propofol.............................205PROPOFOL......................205propranolol hcl.......... 105, 106propranolol hcl er.............. 105propranolol-hctz................ 106propylthiouracil ..................181PROQUAD........................191PROSCAR........................ 161PROSOL...........................146PROSTASCINT................ 205PROSTIN E2.................... 170PROSTIN VR....................106protamine sulfate................ 89PROTECT PLUS.............. 146PROTHELIAL................... 206PROTONIX....................... 152PROTOPAM CHLORIDE..206protriptyline hcl....................49PROVAYBLUE................. 206PROVENGE..................... 187PROVERA........................ 178PROVIGIL.........................231PROVISC..........................218PROZAC.............................49

PRUDOXIN.......................121pseudoeph-chlorphen-hydrocod........................... 222pseudoephedrine-bromphen-dm................... 222PSORCON........................122PULMICORT FLEXHALER.......................................... 226PULMICORT SUSPENSION.................. 226pulmosal........................... 222PULMOZYME................... 228PURAPLY......................... 122PUREFE PLUS.................146purevit dualfe plus.............146PURIXAN............................68PYLERA............................155pyrazinamide...................... 58PYRIDIUM........................ 160pyridostigmine bromide.......57pyridostigmine bromide er.. 57PYRIDOXINE HCL........... 146pyridoxine hcl....................146pyrogallic acid................... 122QBRELIS.......................... 106QBREXZA.........................122qc aspirin low dose............... 8QNASL..............................222QNASL CHILDRENS........222QTERN............................. 127QUAD-MIX........................160QUADRACEL................... 191QUADRAMET.....................68QUALAQUIN.......................72QUARTETTE.................... 178quasense.......................... 178quazepam........................... 85QUDEXY XR.......................44QUEEN PALM.................. 206QUELICIN.........................114QUESTRAN......................106QUESTRAN LIGHT.......... 106quetiapine fumarate............ 77quetiapine fumarate er........77quflora pediatric................ 147QUILLICHEW ER............. 111QUILLIVANT XR...............111quinapril hcl.......................106quinapril-hydrochlorothiazide...........106QUINIDINE GLUCONATE 106quinidine gluconate er.......106quinidine sulfate................106

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quinine sulfate.....................72QUTENZA.........................122QUTENZA (2 PATCH)...... 122QVAR................................226QVAR REDIHALER.......... 226RABAVERT...................... 191RABBIT EPITHELIUM...... 206RABEPRAZOLE SODIUM 152rabeprazole sodium.......... 152RADICAVA....................... 114RADIOGARDASE.............206RAGWITEK.......................206rajani................................. 178raloxifene hcl.....................166ramelteon..........................231ramipril .............................. 106RANEXA........................... 106ranitidine hcl......................152ranolazine er..................... 106RAPAFLO......................... 161RAPAMUNE..................... 187RAPIVAB............................ 81rasagiline mesylate............. 73RAVICTI............................157RAYALDEE.......................194RAZADYNE........................ 46RAZADYNE ER.................. 46rea lo 39............................122rea lo 40............................122REBETOL........................... 81REBIF............................... 112REBIF REBIDOSE............112REBIF REBIDOSE TITRATION PACK............ 112REBIF TITRATION PACK 112REBINYN............................89RECK..................................22RECLAST......................... 194reclipsen........................... 179RECOMBINATE................. 90RECOMBIVAX HB............191RECOTHROM.................... 90RECOTHROM SPRAY KIT 90RECTIV.............................106RECURA.............................54RED BIRCH...................... 206RED CEDAR.....................206RED MAPLE..................... 206RED MULBERRY............. 206RED TOP GRASS POLLEN............................206red yeast rice.................... 206REGLAN............................. 51

REGONOL..........................57REGRANEX......................122relador pak..........................22relador pak plus.................. 22RELAGARD...................... 160RELEEVIA.......................... 22RELEEVIA MC....................22releevia ml.......................... 22RELENZA DISKHALER......81relexxii ...............................111RELISTOR........................155RELNATE DHA.................147RELPAX..............................56REMERON......................... 49REMERON SOLTAB.......... 49REMESENSE................... 116remeven............................122REMICADE.......................187remifentanil hcl....................17REMODULIN.................... 229RENACIDIN...................... 160RENAGEL.........................160renal..................................147RENATABS...................... 147RENATABS WITH IRON.. 147RENFLEXIS......................187RENOVO............................ 22RENVELA......................... 160REOPRO............................ 75repaglinide........................ 127repaglinide-metformin hcl. 128REPATHA.........................106REPATHA PUSHTRONEX SYSTEM........................... 106REPATHA SURECLICK... 106REQ 49+...........................147REQUIP.............................. 73REQUIP XL.........................73RESCRIPTOR.................... 81RESCULA.........................214RESORCINOL-SULFUR.. 122RESTASIS........................ 218RESTASIS MULTIDOSE.. 218RESTORIL........................231RETACRIT..........................90RETIN-A MICRO.............. 122RETIN-A MICRO PUMP... 122RETROVIR......................... 81REVATIO.......................... 229REVCOVI..........................158REVLIMID...........................68revonto..............................230REXULTI.............................77

REYATAZ........................... 81R-GENE 10.......................206rhinocort allergy................ 222RHIZOPUS....................... 206RHOFADE........................ 122RHOGAM ULTRA-FILTERED PLUS.............. 187RHOPHYLAC................... 187RHOPRESSA................... 214RIASTAP............................ 90ribasphere...........................81ribasphere ribapak.............. 81RIBASPHERE RIBAPAK.... 81ribavirin............................... 81RIDAURA..........................187rifabutin............................... 58RIFADIN............................. 58RIFAMATE..........................58rifampin............................... 58RIFATER............................ 58RILUTEK...........................114riluzole.............................. 114rimantadine hcl................... 81RIMSO-50.........................160ringers...............................147ringers irrigation................ 147RINVOQ............................187RIOMET............................128risedronate sodium........... 194RISPERDAL....................... 77RISPERDAL CONSTA....... 77RISPERDAL M-TAB........... 77risperidone.......................... 77risperidone m-tab................77RITALIN............................ 111RITALIN LA.......................111ritonavir............................... 81RITUXAN............................ 68RITUXAN HYCELA.............68rivastigmine.........................46rivastigmine tartrate............ 46rivelsa............................... 179RIXUBIS............................. 90rizatriptan benzoate............ 57ROBAXIN..........................230ROBAXIN-750.................. 230ROBINUL..........................155ROBINUL-FORTE............ 155ROCALTROL....................195ROCKLATAN....................214rocuronium bromide..........114

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ROCURONIUM BROMIDE.......................................... 114ROMIDEPSIN..................... 68ropinirole hcl....................... 74ropinirole hcl er................... 73ROPIVACAINE HCL........... 22ropivacaine hcl....................22ROPIVACAINE HCL-NACL 22ROPIV-CLONIDINE-KETOROLAC......................22rosadan.............................122ROSADAN........................ 122rosanil cleanser.................122rosuvastatin calcium......... 106ROTARIX..........................191ROTATEQ........................ 191ROUGH MARSH ELDER. 206ROUGH PIGWEED.......... 206ROWASA..........................193roweepra.............................44roweepra xr.........................44ROXICODONE................... 17ROZEREM........................231ROZLYTREK...................... 68RUBRACA.......................... 68RUCONEST......................187RUSSIAN THISTLE.......... 206RUZURGI......................... 206RYANODEX......................231RYCLORA........................ 222RYDAPT............................. 68RYTARY............................. 74RYTHMOL SR.................. 106SABRIL............................... 45SACCHAROMYCES CEREVISIAE.................... 206SAFYRAL......................... 179SAGEBRUSH................... 206SAIZEN.............................169SAIZEN CLICK.EASY.......169SAIZENPREP................... 169salacyn..............................122SALAGEN.........................116SALEX.............................. 122salicylic acid......................122salicylic acid wart remover 122salicylic acid-cleanser....... 122salimez..............................122SALIMEZ FORTE............. 122saline bacteriostatic.......... 147saline flush........................147saline flush zr....................147SALINE-PHENOL............. 147

salisol forte........................122salitech forte..................... 122SALIVAMAX..................... 116SALIVATE RX...................116salsalate................................8SALVAX............................123SALVAX DUO PLUS........ 122SAMSCA...........................147SANCUSO.......................... 51SANDIMMUNE................. 187SANDOSTATIN................ 169SANDOSTATIN LAR DEPOT............................. 169SANTYL............................123SAPHRIS............................ 77sash kit ..............................206SAVAYSA........................... 41SAVELLA..........................114SAVELLA TITRATION PACK................................ 114SCALACORT DK..............123SCLEROSOL INTRAPLEURAL...............226scopolamine........................51SCULPTRA.......................123SEASONIQUE.................. 179seb-prev wash.................. 123SECONAL.........................231SEGLUROMET.................128SELECT-OB..................... 147selegiline hcl....................... 74SELENIOUS ACID............147selenium sulfide................ 123SELRX.............................. 123SELZENTRY.................81, 82SENSIPAR........................166sensorcaine........................ 22sensorcaine/epinephrine.....22sensorcaine-mpf................. 22sensorcaine-mpf spinal.......22sensorcaine-mpf/epinephrine.................. 22SENSORCAINE-MPF/EPINEPHRINE...........22SEREVENT DISKUS........ 226SERMORELIN ACETATE DIAGNOSTIC................... 206SEROQUEL........................77SEROQUEL XR..................77SEROSTIM....................... 156sertraline hcl....................... 49se-tan plus........................ 147setlakin..............................179

sevelamer carbonate........ 160sevelamer hcl....................160sf....................................... 116sf 5000 plus...................... 116SFROWASA..................... 193SHAGBARK HICKORY.... 206sharobel............................ 179SHEEP SORREL..............206SHELLGEL....................... 218SHINGRIX........................ 191SHORT RAGWEED POLLEN EXT....................206SIDEROL.......................... 147SIGNIFOR........................ 169SIGNIFOR LAR................ 169SILA III .............................. 123sildenafil citrate......... 160, 229SILENOR.......................... 231SILIQ.................................188silodosin............................161SILVADENE........................34silver nitrate........................ 34silver sulfadiazine............... 34SIMBRINZA...................... 214simliya...............................179simpesse...........................179SIMPONI...........................188SIMPONI ARIA................. 188SIMULECT........................188simvastatin........................106SINEMET............................74SINEMET CR......................74SINGULAIR.............. 226, 227SINUVA............................ 222sirolimus............................188SIRTURO............................58SIVEXTRO..........................34SKELAXIN........................ 231SKLICE............................... 72SKYLA.............................. 179SKYRIZI (150 MG DOSE) 188SLYND..............................179SMOFLIPID...................... 147sod benz-sod phenylacet..158sod citrate-citric acid......... 147sodium acetate................. 147SODIUM BICARBONATE.147sodium bicarbonate.. 147, 156SODIUM BICARBONATE-DEXTROSE...................... 147sodium chloride.147, 148, 222SODIUM CHLORIDE 147, 148sodium chloride (pf).......... 147

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sodium chloride bacteriostatic.....................147sodium chloride flush........ 147SODIUM CITRATE............. 41SODIUM CITRATE LOCK FLUSH................................ 41SODIUM CITRATE-GENTAMICIN SULF........... 41SODIUM DIURIL...............106SODIUM EDECRIN.......... 106sodium fluoride......... 116, 148sodium fluoride 5000 plus.116SODIUM HYALURONATE207sodium lactate...................148sodium nitrite.................... 207sodium phenylbutyrate......158SODIUM PHOSPHATE-NACL................................ 148SODIUM PHOSPHATES-DEXTROSE...................... 148sodium polystyrene sulfonate........................... 148sodium saccharin..............207sodium sulfacetamide....... 123sodium sulfacetamide wash................................. 123SODIUM SULFACETAMIDE WASH 123SODIUM THIOSULFATE..207sodium thiosulfate.............207SOFOSBUVIR-VELPATASVIR................... 82SOLESTA......................... 207solifenacin succinate.........160SOLIQUA..........................128SOLIRIS..............................90SOLOSEC.......................... 72soloxide...............................34SOLU-CORTEF................ 164soluline................................23SOLU-MEDROL............... 164solupicc...............................23SOLU-PREF..................... 207SOMA............................... 231SOMATULINE DEPOT..... 169SOMAVERT......................169SONATA........................... 231SOOLANTRA....................123SORBITOL........................207sorbitol.............................. 207sorbitol-mannitol............... 207SORIATANE..................... 123sorine................................ 106

SORREL/DOCK MIX........ 207SOTALOL HCL................. 106sotalol hcl..........................107sotalol hcl (af)................... 106SOTRADECOL................. 107SOTYLIZE........................ 107SOVALDI............................ 82SPECTRACEF....................34spinosad............................. 72SPINRAZA........................207SPINY PIGWEED............. 207SPIRIVA HANDIHALER... 227SPIRIVA RESPIMAT........ 227spironolactone.................. 107spironolactone-hctz...........107SPORANOX....................... 54SPORANOX PULSEPAK... 54SPRAVATO (56 MG DOSE)................................ 49SPRAVATO (84 MG DOSE)................................ 49sprintec 28........................ 179SPRITAM............................45SPRIX................................... 8SPRYCEL........................... 68sps.................................... 148sronyx............................... 179ssd...................................... 34SSKI..................................222sss 10-5............................ 123st joseph low dose................ 8STALEVO 100.................... 74STALEVO 125.................... 74STALEVO 150.................... 74STALEVO 200.................... 74STALEVO 50...................... 74STALEVO 75...................... 74STAMARIL........................192STARLIX...........................128stavudine............................ 82STEGLATRO.................... 128STEGLUJAN.....................128STELARA......................... 188STEMPHYLIUM................207STERILE DILUENT FLOLAN PH 12.................207STERILE DILUENT FOR FLOLAN............................207sterile diluent/epoprostenol.......................................... 207STERILE TALC POWDER227sterile water for injection... 207

STERILE WATER FOR INJECTION.......................207sterile water for irrigation.. 148STIMATE.......................... 169STIOLTO RESPIMAT....... 227STIVARGA..........................68STRATTERA.................... 111STRENSIQ....................... 158streptomycin sulfate............34STRIANT.......................... 165STRIBILD............................82STRIVERDI RESPIMAT... 227STROMECTOL...................72STROVITE FORTE...........148STROVITE ONE............... 148SUBLOCADE......................24SUBOXONE....................... 24SUBSYS............................. 17subvenite............................ 45subvenite starter kit-blue.....45subvenite starter kit-green.. 45subvenite starter kit-orange 45succinylcholine chloride.... 114SUCCINYLCHOLINE CHLORIDE....................... 114SUCRAID..........................158sucralfate.......................... 152sufentanil citrate..................17SULAR..............................107sulfacetamide sodium.................................. 123, 213sulfacetamide sodium (acne)................................123sulfacetamide sodium-sulfur................................. 123sulfacetamide sod-sulfur wash................................. 123sulfacetamide-prednisolone..................... 218sulfacetamide-sulfur in urea...................................123sulfacleanse 8/4................123sulfadiazine.........................34sulfamethoxazole-trimethoprim..................34, 35sulfamez wash.................. 123SULFAMYLON................... 35sulfasalazine..................... 193sulfatrim pediatric................35sulfurated lime.................... 72sulindac.................................8SUMADAN........................123sumatriptan......................... 57

260

sumatriptan succinate.........57sumatriptan succinate refill . 57SUMAXIN CP................... 123SUNOSI............................ 231SUPARTZ FX................... 207SUPER BI-MIX................. 160SUPER QUAD-MIX.......... 160SUPER TRI-MIX............... 160SUPERVITE..................... 148SUPPORT........................ 148SUPPORT-500................. 148SUPPRELIN LA................ 169SUPRAX............................. 35SUPREP BOWEL PREP KIT.................................... 156SURMONTIL.......................49SURVANTA...................... 223SUSTIVA............................ 82SUSTOL............................. 51SUTENT............................. 68swabflush saline flush.......148SWEET GUM....................207SWEET VERNAL GRASS POLLEN............................207syeda................................ 179SYLATRON........................ 68SYLVANT........................... 68SYMAX DUOTAB............. 156symax-sr........................... 156SYMBICORT.................... 227SYMBYAX.......................... 49SYMDEKO........................228SYMFI.................................82SYMFI LO........................... 82SYMLINPEN 120.............. 128SYMLINPEN 60................ 128SYMPAZAN........................ 45SYMPROIC.......................156SYMTUZA...........................82SYNAGEX........................ 148SYNAGIS..........................188SYNALGOS-DC..................17SYNAREL......................... 169SYNATEK......................... 148SYNDROS.......................... 51SYNERA............................. 23SYNERCID......................... 35SYNJARDY.......................128SYNJARDY XR.................128SYNRIBO............................68SYNTHAMIN 17................148SYNTHROID.....................181synvexia..............................23

SYNVEXIA TC.................... 23SYNVISC.......................... 207SYNVISC ONE................. 207SYPRINE.......................... 148TABLOID............................ 68tacrolimus................. 123, 188tadalafil ............................. 160tadalafil (pah).................... 229TAFINLAR.......................... 68TAGRISSO......................... 68TAKHZYRO...................... 207TALIVA............................. 148TALL RAGWEED..............208TALTZ...............................188TALZENNA......................... 68TAMIFLU............................ 82tamoxifen citrate................. 68tamsulosin hcl................... 161TANDEM F....................... 148TANDEM PLUS................ 148TANZEUM........................ 128TAPAZOLE....................... 181TAPERDEX 6-DAY...........164TARCEVA...........................68TARGRETIN....................... 69tarina 24 fe........................179tarina fe 1/20.....................179tarina fe 1/20 eq................179TARKA..............................107TARON FORTE................ 148taron-crystals.................... 148TASIGNA............................ 69TASMAR.............................74TAURINE.......................... 149TAVALISSE........................ 90TAXOTERE........................ 69TAYTULLA........................179tazarotene.........................123tazicef................................. 35TAZICEF.............................35TAZORAC.................123, 124taztia xt............................. 107TDVAX..............................192TECENTRIQ....................... 69TECFIDERA............. 112, 113TECHNET TC 99M SULFUR COLLOID...........208technetium tc 99m mebrofenin........................208TECHNETIUM TC 99M MEDRONATE...................208TECHNETIUM TC 99M PYROPHOS..................... 208

technetium tc 99m sestamibi...........................208TECHNIVIE.........................82TEFLARO........................... 35TEGRETOL........................ 45TEGRETOL-XR.................. 45TEGSEDI.......................... 114TEKTURNA...................... 107TEKTURNA HCT.............. 107TELFA AMD ISLAND DRESSING....................... 208TELFA AMD NON-ADHERENT...................... 208telmisartan........................ 107telmisartan-amlodipine......107telmisartan-hctz................ 107temazepam....................... 231TEMIXYS............................ 82TEMODAR..........................69temozolomide..................... 69temsirolimus......................188tencon................................. 17teniposide........................... 69TENIVAC.......................... 192tenofovir disoproxil fumarate..............................82TENORETIC 100.............. 107TENORETIC 50................ 107TENORMIN.......................107TEPADINA..........................69TERAZOL 7........................ 54terazosin hcl......................161terbinafine hcl..................... 54terbutaline sulfate............. 227terconazole......................... 54TESSALON PERLES....... 223TESTIM.............................165TESTONE CIK..................165TESTOPEL....................... 165testosterone...................... 165TESTOSTERONE CYPIONATE..................... 165testosterone cypionate......165TESTOSTERONE CYPIONATE & PROP...... 165TESTOSTERONE ENANTHATE.................... 165testosterone enanthate..... 165TESTOSTERONE PROPIONATE.................. 165TESTRED......................... 165tetcaine............................. 219tetrabenazine.................... 114

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tetracaine hcl.................... 219tetracycline hcl.................... 35tetravisc............................ 219tetravisc forte.................... 219thallous chloride tl 201...... 208THALLOUS CHLORIDE TL 201...............................208THALOMID......................... 69THEO-24...........................227theochron..........................227theophylline.......................227theophylline er.................. 227theophylline in d5w........... 227THERAHONEY.................124thiamine hcl.......................149THIOLA.............................160THIOLA EC.......................160thioridazine hcl....................77thiotepa............................... 69thiothixene.......................... 77THROMBATE III ................. 41THROMBIN-JMI..................90THROMBIN-JMI EPISTAXIS......................... 90THROMBOGEN..................90THYMOGLOBULIN...........188THYROGEN..................... 208thyroid............................... 181THYROLAR-1................... 181THYROLAR-1/2................ 181THYROLAR-1/4................ 181THYROLAR-2................... 181THYROLAR-3................... 181tiadylt er............................ 107tiagabine hcl........................45TIAZAC............................. 107TIBSOVO............................69TICE BCG.........................188TIGAN.................................51tigecycline........................... 35TIGLUTIK..........................114TIKOSYN.......................... 107tilia fe................................ 179timolol maleate..107, 214, 215TIMOLOL-BRIMON-DORZOL-LATANOPR...... 215TIMOLOL-BRIMONIDINE-DORZOLAMID..................215TIMOLOL-DORZOLAMID-LATANOPROST............... 215TIMOPTIC.........................215TIMOPTIC OCUDOSE..... 215TIMOPTIC-XE...................215

TIMOTHY GRASS POLLEN ALLERGEN....... 208TINDAMAX......................... 35tinidazole.............................35TIROSINT......................... 181TISSEEL........................... 208TISSEEL VH..................... 208TISSEEL VHSD................ 208tis-u-sol............................. 149TIVICAY..............................82tizanidine hcl..................... 231tl gard rx............................149TL G-FOL OS................... 149tl icon................................ 149TL-FLUORIVITE............... 149tl-hem 150.........................149TNKASE............................. 41TOBI NEBULIZER............ 228TOBI PODHALER.............228TOBRADEX...................... 219TOBRADEX ST................ 219tobramycin................ 213, 228TOBRAMYCIN..................228tobramycin sulfate...............35tobramycin-dexamethasone................ 219TOBREX........................... 213TOFRANIL.......................... 49tolazamide........................ 128tolbutamide....................... 128tolcapone............................ 74tolmetin sodium.....................8tolterodine tartrate.............160tolterodine tartrate er........ 160TOPAMAX.......................... 45TOPAMAX SPRINKLE....... 45topex topical anesthetic.... 116topiramate...........................45topiramate er.......................45toposar................................69topotecan hcl...................... 69TOPROL XL......................107toremifene citrate................ 69TORISEL.......................... 188torsemide.......................... 107TOTECT............................. 69TOUJEO MAX SOLOSTAR...................... 132TOUJEO SOLOSTAR.......132tovet.................................. 124TOVIAZ.............................160tpn electrolytes..................149TRACLEER.......................229

TRADJENTA.....................128tramadol hcl........................ 17tramadol hcl er.................... 17tramadol hcl er (biphasic)... 17tramadol-acetaminophen.... 17trandolapril ........................ 107trandolapril-verapamil hcl er.......................................107tranexamic acid...................90TRANEXAMIC ACID-NACL.................................. 90TRANSDERM SCOP (1.5 MG).....................................51TRANSDERM-SCOP (1.5 MG).....................................51TRANXENE-T.....................85tranylcypromine sulfate.......49TRAVASOL.......................149TRAVATAN Z................... 215trazodone hcl...................... 49TREANDA...........................69TRECATOR........................ 58TRELEGY ELLIPTA..........227TRELSTAR MIXJECT.......169TREMFYA.........................188treprostinil ......................... 229TRESIBA.......................... 132TRESIBA FLEXTOUCH....132tretinoin....................... 69, 124tretinoin microsphere........ 124tretinoin microsphere pump.......................................... 124TRETTEN........................... 90TREXALL..........................188TREZIX............................... 17tri femynor.........................179triamcinolone acetonide.................. 116, 124, 164, 223TRIAMCINOLONE ACETONIDE.....................164TRIAMCINOLONE-BUPIVACAINE..................164TRIAMCINOLONE-MOXIFLOXACIN...............219triamterene........................107triamterene-hctz................107triazolam............................. 85TRIBENZOR..................... 108TRICARE PRENATAL DHA ONE......................... 149TRI-CHLOR...................... 124TRICHOPHYTON............. 208TRICITRASOL.................... 41

262

tricitrates........................... 149tricon................................. 149TRICOR............................ 108triderm...............................124trientine hcl....................... 149TRIESENCE..................... 213tri-estarylla........................ 179trifluoperazine hcl................77trifluridine.......................... 213trigels-f forte......................149TRIGLIDE......................... 108trihexyphenidyl hcl.............. 74TRIKAFTA........................ 228triklo.................................. 108tri-legest fe........................ 179TRILEPTAL.........................45tri-linyah............................ 179TRILIPIX........................... 108tri-lo-estarylla.................... 179tri-lo-marzia.......................179tri-lo-mili ............................ 179tri-lo-sprintec..................... 179trilyte................................. 156trimethobenzamide hcl........51trimethoprim........................35tri-mili ................................ 179trimipramine maleate.......... 49TRIMPEX............................35trinate................................149trinessa (28)......................179trinessa lo......................... 179TRI-NORINYL (28)........... 179TRINTELLIX....................... 49TRIOSTAT........................ 181triphrocaps........................ 149TRIPLE PMB.................... 213TRIPLE PMK.................... 213tri-previfem........................179TRIPTODUR.....................170tri-sprintec......................... 179TRIUMEQ........................... 82TRI-VI-FLOR.....................149TRI-VI-FLORO..................149TRIVISC............................208tri-vit/fluoride..................... 149tri-vit/fluoride/iron.............. 149tri-vitamin/fluoride............. 149tri-vite/fluoride................... 149trivora (28)........................ 179tri-vylibra........................... 180tri-vylibra lo....................... 180TRIZIVIR.............................82TROGARZO....................... 82

TROKENDI XR................... 45TRONVITE........................149TROPHAMINE..................149TROPICAMIDE-CYCLOPENTOLATE-PE.. 219TROPICAMIDE-PHENYLEPHRINE........... 219TROPIC-PROPARACA-PE-KETOROLAC..............219trospium chloride.............. 161trospium chloride er.......... 160TRULANCE...................... 156TRULICITY....................... 128TRUMENBA......................192TRUSOPT.........................215TRUVADA...........................82tryptophan.........................149TUDORZA PRESSAIR..... 227tulana................................ 180TURALIO............................ 69turpentine..........................124TUSSICAPS..................... 223tussigon............................ 223TUSSIONEX PENNKINETIC ER............223TUXARIN ER.................... 223TUZISTRA XR.................. 223TWINRIX...........................192TWYNSTA........................ 108TYBOST............................. 82tydemy.............................. 180TYGACIL............................ 35TYKERB............................. 69TYLENOL WITH CODEINE #3...................... 17TYLENOL WITH CODEINE #4...................... 17TYMLOS........................... 194TYPHIM VI........................192TYSABRI.......................... 113TYVASO........................... 229TYVASO REFILL.............. 229TYVASO STARTER......... 229UCERIS............................ 193UDAMIN SP......................149UDENYCA.......................... 90ULESFIA.............................72ULORIC.............................. 55ULTIVA............................... 17ULTOMIRIS........................ 90ULTRABAG/DIANEAL PD-2/1.5% DEX...................... 149

ULTRABAG/DIANEAL PD-2/2.5% DEX...................... 149ULTRABAG/DIANEAL PD-2/4.25%DEX..................... 149ULTRABAG/DIANEAL/1.5% DEXTROSE..................149ULTRABAG/DIANEAL/2.5% DEXTROSE..................149ULTRABAG/DIANEAL/4.25% DEX............................ 150ULTRACET.........................17ULTRAM............................. 17ULTRAVIST...................... 208umecta mousse................ 124UNASYN.............................35unithroid............................ 181UNITUXIN...........................69UPTRAVI.......................... 229ur n-c.................................161URAMAXIN.......................124uramit mb..........................161urea...................................124urea hydrating...................124urea in zn undecyl-lactic acid................................... 124urea nail ............................ 124UREA NAIL.......................124urea-c40............................124URECHOLINE.................. 161uredeb...............................124ure-k..................................124uremez-40.........................124uretron d/s.........................161uribel................................. 161URIMAR-T........................ 161urin ds............................... 161uro-458............................. 161UROCIT-K 10................... 150UROCIT-K 15................... 150UROCIT-K 5..................... 150UROGESIC-BLUE............ 161uro-mp.............................. 161urophen mb.......................161urosex............................... 150UROXATRAL....................161URSO 250........................ 156URSO FORTE.................. 156ursodiol............................. 156uryl.................................... 161ustell ................................. 161UTA...................................161UTIBRON NEOHALER.....227uticap................................ 161

263

utira-c................................161utrona-c.............................161UVADEX............................. 69VABOMERE....................... 35VAGIFEM..........................180valacyclovir hcl....................82VALCHLOR........................ 69VALCYTE........................... 82valganciclovir hcl.................82VALIUM.............................. 85valproate sodium................ 45valproic acid........................45valrubicin.............................69valsartan........................... 108valsartan-hydrochlorothiazide...........108VALSTAR........................... 69VALTREX........................... 82VANATOL LQ..................... 17VANATOL S........................17VANCOCIN HCL.................36VANCOMYCIN HCL........... 36vancomycin hcl................... 36VANCOMYCIN HCL IN DEXTROSE........................ 36vancomycin hcl in dextrose.36VANCOMYCIN HCL IN NACL.................................. 36vancomycin hcl in nacl........36VANCOSOL PACK............. 36vandazole........................... 36VANTAS........................... 170VAPRISOL........................170VAQTA..............................192VARITHENA..................... 108VARIVAX.......................... 192VARUBI.............................. 51VASCEPA.........................108VASERETIC..................... 108VASOPRESSIN-DEXTROSE...................... 170VASOPRESSIN-SODIUM CHLORIDE....................... 170VASOSTRICT...................170VASOTEC.........................108VAZCULEP.......................108v-c forte.............................150vcf vaginal contraceptive.. 208VECAMYL.........................108VECTIBIX........................... 70VECTICAL........................ 124vecuronium bromide......... 114VELCADE........................... 70

VELETRI...........................229velivet................................180VELPHORO......................161VELTASSA....................... 150VELTRIX.............................23VEMLIDY............................ 82VENCLEXTA...................... 70VENCLEXTA STARTING PACK.................................. 70VENELEX......................... 124venlafaxine hcl.................... 49venlafaxine hcl er................49VENOFER........................ 150VENOMIL MIXED VESPID VENOM.............................208VENTAVIS........................ 229VENTOLIN HFA................227verapamil hcl.....................108verapamil hcl er................ 108VEREGEN........................ 124VERELAN......................... 108VERELAN PM...................108VERIPRED 20.................. 164VERSACLOZ...................... 77VERZENIO......................... 70VESICARE........................161vestura.............................. 180vexatrol............................... 23VFEND................................54VFEND IV........................... 54VIAGRA............................ 161VIASPAN.......................... 208VIBATIV.............................. 37VIBERZI............................156VIBRAMYCIN..................... 37vic-forte............................. 150vicodin.................................17vicodin es............................17vicodin hp............................17VICTOZA.......................... 128VIDAZA...............................70VIDEX................................. 83VIDEX EC........................... 82VIEKIRA PAK..................... 83VIEKIRA XR........................83vienva............................... 180vigabatrin............................ 45vigadrone............................ 45VIGAMOX......................... 213VIIBRYD............................. 49VIIBRYD STARTER PACK.49vilamit mb..........................161vilevev mb.........................161

VIMIZIM............................ 158VIMPAT........................ 45, 46vinblastine sulfate............... 70vincasar pfs.........................70vincristine sulfate................ 70vinorelbine tartrate.............. 70VIOKACE..........................158viorele............................... 180VIRACEPT..........................83VIRAMUNE.........................83VIRAMUNE XR...................83VIRASAL...........................124VIRAZOLE.......................... 83VIREAD.............................. 83VIRGINIA LIVE OAK.........208VIROPTIC.........................213virt-caps............................ 150VIRT-FEFA PLUS.............150virt-gard.............................150virt-phos 250 neutral......... 150virtrate-2............................150virtrate-3............................150virtrate-k............................150virt-vite plus.......................150VISCO-3........................... 208VISIONBLUE.................... 219VISIPAQUE...................... 208VISTARIL............................85VISTOGARD.....................208VISUDYNE....................... 219vita s forte......................... 150vitacel................................150VITAFOL...........................150VITAFOL-OB+DHA...........150VITAL-D RX...................... 150vitamax pediatric...............150VITAMEZ.......................... 150vita-min............................. 150vitamin d (cholecalciferol). 150vitamin d (ergocalciferol)...150vitamin d3......................... 150vitamin k1..........................150vitamins acd-fluoride.........150VITAROCA PLUS............. 150VITA-RX DIABETIC VITAMIN........................... 150VITASURE........................150VITRAKVI........................... 70VITRASE.......................... 208VIVELLE-DOT.................. 180VIVITROL........................... 24VIVOTIF............................192VIZAMYL.......................... 208

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VIZIMPRO.......................... 70VOGELXO........................ 166VOGELXO PUMP.............166vol-care rx......................... 150vol-tab rx........................... 150VOLTAREN.......................... 8volumex............................ 208VOLUVEN...........................90VONVENDI......................... 90VOPAC KT............................8VORAXAZE........................ 70voriconazole........................55VOSEVI.............................. 83VOTRIENT..........................70vp-pnv-dha........................150VPRIV............................... 158vp-vite rx........................... 150VP-ZEL............................. 150VRAYLAR........................... 77VUMERITY....................... 113VUMERITY (STARTER)... 113VUSION.............................. 55vyfemla............................. 180vylibra............................... 180VYNDAMAX......................108VYNDAQEL...................... 108VYTORIN..........................108VYVANSE.........................111VYXEOS............................. 70VYZULTA..........................215WAKIX.............................. 231warfarin sodium.................. 41WASP VENOM PROTEIN 209WELCHOL........................ 108WELLBUTRIN SR...............49WELLBUTRIN XL............... 49wera.................................. 180WESTERN JUNIPER....... 209WESTHROID....................182wheat germ oil .................. 150WHITE ASH......................209WHITE BIRCH.................. 209WHITE FACED HORNET VENOM.............................209WHITE MULBERRY......... 209WHITE OAK......................209WHITE PINE.....................209WHITE-FACED HORNET VENOM.............................209WIDE-SEAL DIAPHRAGM 60......................................209WILATE.............................. 91WINRHO SDF...................188

wixela inhub...................... 227WP THYROID...................182wymzya fe.........................180XADAGO............................ 74XALATAN......................... 215XALKORI............................ 70XANAX................................85XANAX XR..........................85XARELTO........................... 41XARELTO STARTER PACK.................................. 41XELJANZ.......................... 189XELJANZ XR.................... 189XELODA............................. 70XEMBIFY.......................... 189XENAZINE........................114XENLETA........................... 37XENON XE 133................ 209XEOMIN............................209XEPI....................................37XERAC AC....................... 124XERAVA............................. 37XERFORM OIL EMULSION ROLL.............124XERMELO........................ 156XEROFORM OIL EMULSION 2"X2"............. 124XEROFORM OIL EMULSION GAUZE..........124XEROFORM OIL EMULSION STRIP........... 125XEROFORM PETROLAT GAUZE 1"X8"................... 125XEROFORM PETROLAT GAUZE 5"X9"................... 125XEROFORM PETROLAT PATCH 2"X2"....................125XEROFORM PETROLAT PATCH 4"X4"....................125XEROFORM PETROLATUM ROLL 4"X9'................................. 125XEROSTOMIA RELIEF SPRAY..............................116XGEVA............................. 194XHANCE...........................223XIAFLEX........................... 209XIFAXAN............................ 37XIGDUO XR......................128XIIDRA..............................219XODOL............................... 17XOFIGO..............................70XOFLUZA........................... 83

XOLAIR.............................223XOLEGEL........................... 55XOLEGEL COREPAK........ 55XOLEGEL DUO/HEAD & SHOULDERS..................... 55XOLEGEL DUO/XOLEX..... 55XOPENEX........................ 227XOPENEX CONCENTRATE.............. 227XOSPATA...........................70XPOVIO (100 MG ONCE WEEKLY)............................70XPOVIO (60 MG ONCE WEEKLY)............................70XPOVIO (80 MG ONCE WEEKLY)............................70XPOVIO (80 MG TWICE WEEKLY)............................70XTAMPZA ER.....................17XTANDI...............................70xulane............................... 180XULTOPHY...................... 129xurea.................................125XURIDEN..........................158XVITE............................... 151XYLOCAINE....................... 23XYLOCAINE (CARDIAC)....23xylocaine dental.................. 23XYLOCAINE/EPINEPHRINE......................................... 23XYLOCAINE-MPF.............. 23XYLOCAINE-MPF/EPINEPHRINE...........23xylon................................... 18XYNTHA............................. 91XYNTHA SOLOFUSE.........91XYREM............................. 231YASMIN 28....................... 180YAZ...................................180YELLOW DOCK............... 209YELLOW HORNET VENOM PROTEIN............209YELLOW JACKET VENOM PROTEIN............209YERVOY.............................71YESCARTA........................ 71YF-VAX.............................192YONDELIS..........................71YONSA............................... 71YUPELRI.......................... 228yuvafem............................ 180zafirlukast..........................228zaleplon............................ 231

265

ZALTRAP............................71ZANAFLEX....................... 231ZANOSAR.......................... 71ZANTAC........................... 152zarah.................................180ZARONTIN......................... 46ZARXIO.............................. 91ZAVESCA......................... 158zebutal................................ 18ZEJULA.............................. 71ZELAPAR........................... 74ZELBORAF.........................71ZEMAIRA..........................228ZEMDRI.............................. 37ZEMPLAR.................194, 195zenatane........................... 125zenchent........................... 180zencia............................... 125ZENPEP........................... 158zenzedi............................. 111ZENZEDI.......................... 111ZEPATIER.......................... 83ZERBAXA........................... 37ZERIT................................. 83zeruvia................................ 23ZESTORETIC................... 108ZESTRIL........................... 108ZETIA................................108ZETONNA.........................223ZEVALIN Y-90.................... 71ZIAC..................................109ZIAGEN.............................. 83zidovudine...........................83zileuton er......................... 228ZILRETTA.........................164ZINBRYTA........................ 113ZINC TRACE METAL....... 151ZINECARD......................... 71ZINGO................................ 23ZINPLAVA........................ 189ZIOPTAN.......................... 215ziprasidone hcl....................77ZIRGAN............................ 213ZITHRANOL..................... 125ZITHROMAX.......................37ZITHROMAX TRI-PAK....... 37ZITHROMAX Z-PAK........... 37ZMAX..................................37ZOCOR.............................109ZODEX 6-DAY..................164ZOFRAN............................. 51ZOFRAN ODT.................... 51ZOHYDRO ER....................18

ZOLADEX......................... 170zoledronic acid..................194ZOLGENSMA 10.1-10.5 KG.....................................209ZOLGENSMA 10.6-11.0 KG.....................................209ZOLGENSMA 11.1-11.5 KG.....................................210ZOLGENSMA 11.6-12.0 KG.....................................210ZOLGENSMA 12.1-12.5 KG.....................................210ZOLGENSMA 12.6-13.0 KG.....................................210ZOLGENSMA 13.1-13.5 KG.....................................210ZOLGENSMA 2.6-3.0 KG.210ZOLGENSMA 3.1-3.5 KG.210ZOLGENSMA 3.6-4.0 KG.210ZOLGENSMA 4.1-4.5 KG.210ZOLGENSMA 4.6-5.0 KG.210ZOLGENSMA 5.1-5.5 KG.210ZOLGENSMA 5.6-6.0 KG.210ZOLGENSMA 6.1-6.5 KG.210ZOLGENSMA 6.6-7.0 KG.210ZOLGENSMA 7.1-7.5 KG.210ZOLGENSMA 7.6-8.0 KG.210ZOLGENSMA 8.1-8.5 KG.210ZOLGENSMA 8.6-9.0 KG.210ZOLGENSMA 9.1-9.5 KG.210ZOLGENSMA 9.6-10.0 KG.......................................... 210ZOLINZA.............................71zolmitriptan......................... 57ZOLOFT..............................49zolpidem tartrate............... 231zolpidem tartrate er...........231ZOMETA...........................195ZOMIG................................ 57ZOMIG ZMT........................57ZONALON........................ 125ZONEGRAN....................... 46zonisamide..........................46ZONTIVITY......................... 75ZORBTIVE........................156ZORTRESS...................... 189ZOSTAVAX.......................192ZOSYN............................... 37zovia 1/35e (28)................ 180zovia 1/50e (28)................ 180ZOVIRAX............................ 83ZUBSOLV........................... 24zumandimine.................... 180

ZUPLENZ........................... 51ZURAMPIC......................... 55ZUTRIPRO....................... 223ZYBAN................................24ZYDELIG............................ 71ZYFLO.............................. 228ZYFLO CR........................ 228ZYKADIA............................ 71ZYLET...............................219ZYLOPRIM......................... 55ZYMAXID..........................213ZYPITAMAG..................... 109ZYPREXA..................... 77, 78ZYPREXA RELPREVV.......78ZYPREXA ZYDIS............... 78ZYTIGA...............................71ZYVOX................................37

266

DISCRIMINATION IS AGAINST THE LAW

Health Alliance complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. Health Alliance does not exclude people or treat them differently because of race, color, national origin, age, disability or sex. Health Alliance:

• Provides free aids and services to people with disabilities to communicate effectively with us, such as:o Qualified sign language interpreterso Written information in other formats (large print, audio, accessible electronic formats, other formats)

• Provides free language services to people whose primary language is not English, such as:o Qualified interpreterso Information written in other languages

If you need these services, contact customer service.If you believe that Health Alliance has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Health Alliance Medical Plans, Customer Service, 3310 Fields South Drive, Champaign, IL 61822, telephone: 1-800-851-3379, TTY: 711, fax: 217-902-9705, [email protected]. You can file a grievance in person or by mail, fax or email. If you need help filing a grievance, Customer Service is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW, Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019, TTY: 1-800-537-7697.Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

cmp-nondiscrim15MWCM-0318

DISCRIMINATION IS AGAINST THE LAW

Health Alliance complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. Health Alliance does not exclude people or treat them differently because of race, color, national origin, age, disability or sex. Health Alliance:

• Provides free aids and services to people with disabilities to communicate effectively with us, such as: o Qualified sign language interpreters o Written information in other formats (large print, audio, accessible electronic formats, other

formats) • Provides free language services to people whose primary language is not English, such as:

o Qualified interpreters o Information written in other languages

If you need these services, contact customer service. If you believe that Health Alliance has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Health Alliance Medical Plans, Customer Service, 3310 Fields South Drive, Champaign, IL 61822, telephone: 1-800-851-3379, TTY: 711, fax: 217-902-9705, [email protected]. You can file a grievance in person or by mail, fax or email. If you need help filing a grievance, Customer Service is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW, Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019, TTY: 1-800-537-7697. Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

ATENCIÓN: Si habla Español, servicios de asistencia lingüística, de forma gratuita, están disponibles para usted. Llame 1-800-851-3379 (TTY: 711). 注意：如果你講中文，語言協助服務，免費的，都可以給你。呼叫1-800-851-3379（TTY: 711）。 Polish: UWAGA: Je li mówi Polskie, usługi pomocy j zyka, bezpłatnie, s dost pne dla Ciebie. Zadzwo 1-800-851-3379 (TTY: 711). Chú ý: Nếu bạn nói Tiếng Việt, các dịch vụ hỗ trợ ngôn ngữ, miễn phí, có sẵn cho bạn. Gọi 1-800-851-3379 (TTY: 711). 주의 : 당신이한국어, 무료 언어 지원 서비스를 말하는 경우 사용할 수 있습니다. 1-800-851-3379 전화 (TTY: 711). ВНИМАНИЕ: Если вы говорите русский, вставки услуги языковой помощи, бесплатно, доступны для вас. Вызов 1-800-851-3379 (TTY: 711). Pansin: Kung magsalita ka Tagalog, mga serbisyo ng tulong sa wika, nang walang bayad, ay magagamit sa iyo. Tumawag 1-800-851-3379 (TTY: 711). .(TTY: 711) 3379-851-800-1 تنبيه: إذا كنت تتحدث اللغة العربية ، خدمات المساعدة اللغوية ، مجانا ، تتوفر لك . ستدعاء Wenn Sie Deutsch sprechen, Sprachassistenzdienste sind kostenlos, zur Verfügung. Anruf 1-800-851-3379 (TTY: 711). ATTENTION: Si vous parlez français, les services d'assistance linguistique, gratuitement, sont à votre disposition. Appelez 1-800-851-3379 (TTY: 711).

�યા�: તમે વાત તો �જુરાતી, ભાષા સહાય સેવાઓ, મફત, તમારા માટ� ��લ�� છે. કૉલ 1-800-851-3379 (TTY: 711).

注意：あなたは、日本語、無料で言語支援サービスを、話す場合は、あなたに利用可能です。 1-800-851-3379コール

（TTY: 711）。 LET OP: Als je spreekt pennsylvania nederlandse, taalkundige bijstand diensten, gratis voor u beschikbaar zijn. Bel 1-800-851-3379 (TTY: 711). УВАГА: Якщо ви говорите український, вставки послуги мовної допомоги, безкоштовно, доступні для вас. Виклик 1-800-851-3379 (TTY: 711). ATTENZIONE: Se si parla italiano, servizi di assistenza linguistica, a titolo gratuito, sono a vostra disposizione. Chiamare 1-800-851-3379 (TTY: 711).

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