ELENCO DEI FARMACI COPERTI Community Care Plus FIDA-MMP 2016 1.877.ICS.2525 1.877.ICS.2525 www.icsny.org www.icsny.org H4465_ListofCoveredDrugs_2016_81415_Approved
H4465_ListofCoveredDrugs_2016_81415 ICS Community Care Plus FIDA-MMP Elenco dei farmaci coperti (formulario) per il 2016 Questo è un elenco dei farmaci che i Partecipanti possono ottenere nell ambito del piano ICS Community Care Plus FIDA-MMP. ICS Community Care Plus FIDA-MMP è un piano di cure gestite basato su accordi sia con Medicare che con il New York State Department of Health (Dipartimento della sanità dello stato di New York, Medicaid) per offrire ai Partecipanti i benefici di entrambi i programmi attraverso la dimostrazione FIDA (Fully Integrated Duals Advantage, vantaggio completamente integrato per candidati idonei per entrambi i sistemi). I benefici, l Elenco dei farmaci coperti e le reti di farmacie e fornitori possono cambiare di volta in volta nel corso dell anno e il 1 gennaio di ciascun anno. È possibile controllare l Elenco aggiornato dei farmaci coperti di ICS Community Care Plus FIDA-MMP in qualsiasi momento sul sito Web www.icsny.org/careplus/pharmacy-benefits/ oppure contattando i Servizi per i partecipanti di ICS Community Care Plus FIDA-MMP al numero 1.877.ICS.2525. Possono applicarsi limitazioni. Per ulteriori informazioni contattare il Servizio partecipanti (ICS Community Care Plus FIDA-MMP Participant Services) o leggere il manuale del partecipante (ICS Community Care Plus FIDA-MMP Participant Handbook). Non è previsto alcun ticket (contributo personale) per alcun farmaco convenzionato. Queste informazioni sono disponibili gratuitamente anche in altri formati, quali Braille o stampa a caratteri grandi. Contattare il numero 1.877.ICS.2525. La chiamata è gratuita. È possibile ottenere queste informazioni gratuitamente in altre lingue. Contattare il numero 1.877.ICS.2525 e TTY 711 dal lunedì al venerdì, tra le 8:00 e le 20:00. La Per eventuali domande si prega di contattare ICS Community Care Plus FIDA-MMP al numero 1.877.ICS.2525, TTY: 711 dal lunedì al venerdì, tra le 8:00 e le 20:00. La chiamata è gratuita. Per ulteriori informazioni visiti il sito www.icsny.org/care-plus.? i
chiamata è gratuita. È possibile ottenere queste informazioni gratuitamente in altre lingue. Вы можете бесплатно получить всю эту информацию на других языках. Звоните в ICS по телефону 1.877.ICS.2525 и телетайпу TTY 711 с понедельника по пятницу с 8:00 до 20:00. Звонок бесплатный. 您可免费获得所有这些信息的其他语言版本 请在周一至周五上午 8 点至晚上 8 点致电 ICS, 电话号码为 1.877.ICS.2525, 听障专线 (TTY) 为 711 此为免费电话 Puede obtener toda esta información en otros idiomas de manera gratuita. Llame a ICS al 1.877.ICS.2525 y a la línea TTY 711, entre las 8 a. m. y las 8 p. m., de lunes a viernes. La llamada es gratuita. Ou kapab jwenn tout enfòmasyon sa a gratis nan lòt lang. Rele ICS nan 1.877.ICS.2525 ak TTY 711, ant 8 a.m. ak 8 p.m., lendi jiska vandredi. Apèl la gratis. Lo Stato di New York ha creato un programma di tutela dei partecipanti (Participant Ombudsman Program) per offrire gratuitamente ai Partecipanti assistenza in modo riservato su tutti i servizi offerti da ICS Community Care Plus FIDA-MMP. L Ombudsman può essere contattato tramite il numero verde 1.844.614.8800 oppure attraverso il sito www.icannys.org. Per eventuali domande si prega di contattare ICS Community Care Plus FIDA-MMP al numero 1.877.ICS.2525, TTY: 711 dal lunedì al venerdì, tra le 8:00 e le 20:00. La chiamata è gratuita. Per ulteriori informazioni visitare il sito? ii
Domande più comuni (FAQ) Di seguito sono disponibili risposte a possibili domande in merito a questo Elenco dei farmaci convenzionati. È possibile leggere tutta la sezione delle domande più comuni per apprendere ulteriori informazioni oppure cercare una domanda e una risposta specifiche. 1. Quali farmaci su prescrizione sono contenuti nell Elenco dei farmaci coperti? (Per comodità, l Elenco dei farmaci coperti viene denominato Elenco dei farmaci.) I farmaci contenuti nell Elenco dei farmaci coperti che inizia a pagina 18 sono i farmaci coperti da ICS Community Care Plus FIDA-MMP. Questi farmaci sono disponibili nelle farmacie facenti parte della nostra rete. Una farmacia fa parte della nostra rete se abbiamo stipulato un accordo di collaborazione con essa per fornire servizi ai nostri Partecipanti. Tali farmacie vengono denominate farmacie di rete. ICS Community Care Plus FIDA-MMP coprirà tutti i farmaci contenuti nell Elenco dei farmaci a condizione che: il medico o altro professionista della rete che prescrive il farmaco dichiari che il Partecipante necessita di tale farmaco per guarire o mantenersi in salute; il farmaco sia necessario sotto il profilo medico per la condizione del Partecipante; e il Partecipante presenti la prescrizione presso una farmacia di rete ICS Community Care Plus FIDA-MMP. ICS Community Care Plus FIDA-MMP potrebbe richiedere procedure aggiuntive per accedere a determinati farmaci (vedere la domanda 5 di seguito). In alcuni casi potrebbe essere necessario che il Partecipante faccia qualcosa prima di poter ottenere un determinato farmaco, come per esempio provare innanzitutto un altro farmaco. Per eventuali domande si prega di contattare ICS Community Care Plus FIDA-MMP al numero 1.877.ICS.2525, TTY: 711 dal lunedì al venerdì, tra le 8:00 e le 20:00. La chiamata è gratuita. Per ulteriori informazioni visitare il sito? iii
Un elenco aggiornato dei farmaci che copriamo è inoltre disponibile sul nostro sito www.icsny.org/care-plus/pharmacy-benefits/ oppure telefonicamente contattando il Servizi per i partecipanti al numero 1.877.ICS.2525. 2. L Elenco dei farmaci può essere modificato? Sì. ICS Community Care Plus FIDA-MMP può aggiungere o rimuovere farmaci dall Elenco dei farmaci durante il corso dell anno. In generale, l Elenco dei farmaci viene modificato solo se: diventa disponibile un nuovo farmaco che funziona altrettanto bene di un farmaco attualmente nell Elenco dei farmaci; oppure veniamo informati che un farmaco non è sicuro. Ci riserviamo inoltre di modificare le nostre regole relative ai farmaci. Per esempio, potremmo: decidere di richiedere o meno un'approvazione preventiva per un farmaco. [per Approvazione preventiva (Prior approval) si intende il permesso da parte di ICS Community Care Plus FIDA-MMP o dell Equipe interdisciplinare (Interdisciplinary Team, IDT) prima che il Partecipante possa ottenere un farmaco.] aggiungere o modificare la quantità di farmaco che il Partecipante può ottenere (chiamata limiti di quantità [quantity limits]); aggiungere o modificare le limitazioni a una terapia per fasi relative a un farmaco (Terapia per fasi [Step therapy] significa che il Partecipante deve provare un farmaco prima che un altro farmaco possa essere coperto). (Per ulteriori informazioni su queste regole relative ai farmaci, vedere pagina 5.) Il Partecipante verrà informato quando un farmaco che sta assumendo viene rimosso dall Elenco dei farmaci. Il Partecipante verrà inoltre informato di eventuali cambiamenti alle regole relative alla copertura di un farmaco. Le Domande 3, 4 e 7 di seguito Per eventuali domande si prega di contattare ICS Community Care Plus FIDA-MMP al numero 1.877.ICS.2525, TTY: 711 dal lunedì al venerdì, tra le 8:00 e le 20:00. La chiamata è gratuita. Per ulteriori informazioni visitare il sito? iv
presentano ulteriori informazioni in merito a cosa accade quando l Elenco dei farmaci viene modificato. È possibile controllare l Elenco aggiornato dei farmaci di ICS Community Care Plus FIDA-MMP in qualsiasi momento sul sito www.icsny.org/careplus/pharmacy-benefits/ Potrà inoltre contattare il Servizio partecipanti (Participant Services) per controllare l Elenco dei farmaci attuale al numero 1.877.ICS.2525. 3. Cosa succede se diventa disponibile un farmaco più economico che funziona altrettanto bene di un farmaco attualmente nell Elenco dei farmaci? Se diventa disponibile un farmaco meno costoso che funziona altrettanto bene di un farmaco attualmente nell Elenco dei farmaci: Il farmacista potrà consegnare il farmaco più economico la prossima volta che il Partecipante presenta la prescrizione. Se il Partecipante e il suo fornitore decidono che il farmaco più economico non è idoneo per il Partecipante, il fornitore potrà istruire il farmacista a continuare a consegnare il farmaco che il Partecipante sta assumendo attualmente. ICS Community Care Plus FIDA-MMP potrà decidere di rimuovere il farmaco più costoso dall Elenco dei farmaci. Se il Partecipante sta assumendo un farmaco che viene rimosso dall Elenco dei farmaci perché è diventato disponibile un farmaco più economico che funziona altrettanto bene, il Partecipante verrà informato con almeno 60 giorni di anticipo rispetto alla rimozione di tale farmaco dall Elenco dei farmaci oppure nel momento in cui il Partecipante ripresenta la prescrizione. In tal caso il Partecipante potrà ricevere una fornitura di farmaco per 60 giorni prima che il cambiamento all Elenco dei farmaci venga effettuato. Per eventuali domande si prega di contattare ICS Community Care Plus FIDA-MMP al numero 1.877.ICS.2525, TTY: 711 dal lunedì al venerdì, tra le 8:00 e le 20:00. La chiamata è gratuita. Per ulteriori informazioni visitare il sito? v
ICS Community Care Plus FIDA-MMP informerà i membri di tali cambiamenti tramite posta e includerà informazioni relative a come inoltrare una lagnanza, un ricorso o una richiesta di eccezione. ICS Community Care Plus FIDA-MMP pubblicherà inoltre tali informazioni sul sito Web, disponibile all indirizzo www.icsny.org/care-plus e informerà i membri con decorrenza annuale del formulario aggiornato. Tali informazioni possono essere fornite anche in formati diversi. 4. Cosa succede se veniamo informati che un farmaco non è sicuro? Se l ente statunitense preposto alla vigilanza sugli alimenti e sui farmaci (Food and Drug Administration, FDA) dichiara che un farmaco che il Partecipante sta assumendo non è sicuro, tale farmaco verrà rimosso immediatamente dall Elenco dei farmaci. Il Partecipante sarà informato tramite lettera e riceverà una telefonata per essere informato che il farmaco non sicuro è stato rimosso dall Elenco dei farmaci. Il Partecipante verrà istruito a contattare il medico che ha eseguito la prescrizione non appena possibile per ottenere istruzioni per la sostituzione del farmaco sospeso. Il responsabile delle cure potrà essere contattato per ulteriore assistenza. 5. Vi sono limitazioni relative alla copertura dei farmaci? Oppure è necessario fare qualcosa per ottenere determinati farmaci? Sì, per alcuni farmaci vi sono determinate regole o limitazioni relative alla quantità che può essere ottenuta. In alcuni casi è necessario fare qualcosa prima di poter ottenere il farmaco. Per esempio: Approvazione preventiva o autorizzazione preventiva (Prior approval or prior authorization): Per alcuni farmaci, il Partecipante o il suo medico o altro professionista che effettua la prescrizione deve ottenere l approvazione da parte di ICS Community Care Plus FIDA-MMP o della propria equipe interdisciplinare (Interdisciplinary Team, IDT) prima di presentare la prescrizione. Se non ottiene Per eventuali domande si prega di contattare ICS Community Care Plus FIDA-MMP al numero 1.877.ICS.2525, TTY: 711 dal lunedì al venerdì, tra le 8:00 e le 20:00. La chiamata è gratuita. Per ulteriori informazioni visitare il sito? vi
l approvazione, ICS Community Care Plus FIDA-MMP potrebbe non coprire tale farmaco. Limiti di quantità (Quantity limits): A volte ICS Community Care Plus FIDA- MMP limita la quantità di farmaco che è possibile ottenere. Terapia per fasi: A volte ICS Community Care Plus FIDA-MMP richiede che il Partecipante si sottoponga a una terapia per fasi. Ciò significa che il Partecipante dovrà provare dei farmaci per la sua condizione medica in un determinato ordine. Potrebbe essere necessario provare un farmaco prima che un altro farmaco venga coperto. Se il medico del Partecipante ritiene che il primo farmaco non funzioni per il Partecipante, allora il secondo farmaco sarà coperto. Per determinare se per il farmaco d interesse sono previsti eventuali requisiti aggiuntivi o limiti, consultare le tabelle a partire da pagina 18. Ulteriori informazioni sono disponibili sul sito Web www.icsny.org/care-plus/pharmacy-benefits. Sul sito sono disponibili documenti che spiegano l autorizzazione preventiva e le limitazioni della terapia per fasi. È inoltre possibile richiedere una copia tramite posta. È possibile richiedere una eccezione per tali limiti. Per ulteriori informazioni sulle eccezioni, vedere la domanda 11. Se il Partecipante si trova in una residenza sanitaria o in altra struttura di cura a lungo termine e necessita di un farmaco che non è incluso nell Elenco dei farmaci, oppure se il farmaco necessario non è facilmente disponibile, è possibile richiedere la nostra assistenza. Copriremo una fornitura di emergenza di 31 giorni del farmaco necessario (a meno che la prescrizione non preveda meno giorni), indipendentemente dal fatto che il Partecipante si sia appena iscritto a ICS Community Care Plus FIDA-MMP. In tal modo avrà tempo di parlare con il proprio medico o altro professionista che effettua la prescrizione. Il medico potrà aiutare il Partecipante a decidere se nell Elenco dei farmaci esiste un farmaco simile che può assumere in alternativa oppure se sia necessario richiedere un eccezione. Per ulteriori informazioni sulle eccezioni, vedere la domanda 11. Per eventuali domande si prega di contattare ICS Community Care Plus FIDA-MMP al numero 1.877.ICS.2525, TTY: 711 dal lunedì al venerdì, tra le 8:00 e le 20:00. La chiamata è gratuita. Per ulteriori informazioni visitare il sito? vii
6. Come si fa a sapere se per il farmaco d interesse sono previste limitazioni oppure se sono previste azioni specifiche per ottenere tale farmaco? L Elenco dei farmaci coperti a pagina 18, presenta una colonna denominata Azioni necessarie, limitazioni o limiti per l uso. 7. Cosa succede se le regole relative alle modalità di copertura per alcuni farmaci vengono modificate? Per esempio, se viene aggiunta l autorizzazione (approvazione) preventiva, un limite di quantità oppure limitazioni tramite terapia per fasi relativa a un farmaco. Il Partecipante verrà informato se aggiungiamo l approvazione preventiva, limiti alla quantità e/o limitazioni tramite terapia per fasi relativa a un farmaco. Il Partecipante verrà informato con almeno 60 giorni di anticipo rispetto alla data di aggiunta della limitazione oppure al momento in cui ripresenterà una prescrizione. In tal caso il Partecipante potrà ricevere una fornitura di farmaco per 60 giorni prima che la modifica all Elenco dei farmaci venga effettuata. In tal modo avrà tempo di discutere la decisione da prendere con il proprio medico o altro professionista che effettua la prescrizione. 8. Come si fa a trovare un farmaco nell Elenco dei farmaci? Vi sono due modi per trovare un farmaco: ricerca alfabetica (se si conosce come scrivere il nome del farmaco); oppure ricerca per condizione medica. Per la ricerca in ordine alfabetico, andare alla sezione Elenco alfabetico a pagina I-1. Quindi cercare il nome del farmaco nell elenco. Per la ricerca per condizione medica, andare alla sezione Elenco dei farmaci per condizione medica a pagina 18. Quindi individuare la condizione medica. Per esempio, Per eventuali domande si prega di contattare ICS Community Care Plus FIDA-MMP al numero 1.877.ICS.2525, TTY: 711 dal lunedì al venerdì, tra le 8:00 e le 20:00. La chiamata è gratuita. Per ulteriori informazioni visitare il sito? viii
se la condizione medica è cardiaca, cercare in tale categoria. In tale categoria saranno inclusi i farmaci per trattare condizioni cardiache. 9. Cosa fare se il farmaco desiderato non è incluso nell Elenco dei farmaci? Se il farmaco d interesse non è incluso nell Elenco dei farmaci, contattare il Servizio partecipanti (Participant Services) al numero 1.877.ICS.2525 per informazioni in merito. Se ICS Community Care Plus FIDA-MMP non copre tale farmaco, procedere in base a una delle opzioni seguenti: Chiedere al Servizio partecipanti (Participant Services) un elenco dei farmaci come quello che si desidera assumere. Quindi mostrare l elenco al proprio medico o altro professionista che effettua la prescrizione, che potrà prescrivere un farmaco incluso nell Elenco dei farmaci simile a quello d interesse. Oppure Chiedere al piano o alla propria equipe interdisciplinare (Interdisciplinary Team, IDT) di fare un eccezione per coprire il farmaco. Per ulteriori informazioni sulle eccezioni, vedere la domanda 11. 10. Cosa fare se il Partecipante si è appena iscritto a ICS Community Care Plus FIDA-MMP e non trova il proprio farmaco nell Elenco dei farmaci oppure ha problemi a ottenere il farmaco? Possiamo fornire il nostro aiuto. Ci impegniamo a coprire fino a 90 giorni di forniture temporanee del farmaco d interesse, secondo necessità, durante i primi 90 giorni di iscrizione come Partecipante di ICS Community Care Plus FIDA-MMP. In tal modo avrà tempo di parlare con il proprio medico o altro professionista che effettua la prescrizione. Il medico potrà aiutare il Partecipante a decidere se nell Elenco dei farmaci esiste un farmaco simile che può assumere in alternativa oppure se sia necessario richiedere un eccezione. Copriremo fino a 90 giorni di forniture temporanee del farmaco d interesse se: Per eventuali domande si prega di contattare ICS Community Care Plus FIDA-MMP al numero 1.877.ICS.2525, TTY: 711 dal lunedì al venerdì, tra le 8:00 e le 20:00. La chiamata è gratuita. Per ulteriori informazioni visitare il sito? ix
il Partecipante sta assumendo un farmaco che non è incluso nell Elenco dei farmaci; oppure le regole del piano sanitario non consentono al Partecipante di ottenere la quantità richiesta dal professionista che effettua la prescrizione; oppure per il farmaco è prevista l approvazione preventiva da parte di ICS Community Care Plus FIDA-MMP o dell equipe interdisciplinare (Interdisciplinary Team, IDT) del Partecipante; oppure il Partecipante sta assumendo un farmaco che fa parte di una limitazione tramite terapia per fasi. Se il Partecipante risiede in una residenza sanitaria o in altra struttura di cura a lungo termine, potrà ripresentare la prescrizione per un massimo di 98 giorni. Potrà ripresentare la prescrizione più volte per 98 giorni. In tal modo il professionista che ha effettuato la prescrizione avrà il tempo di modificare i farmaci per usare quelli che sono inclusi nell Elenco dei farmaci oppure di richiedere un eccezione. Se il Partecipante è interessato da un cambiamento di livello di cura da un tipo di trattamento a un altro, può essere idoneo per una fornitura di farmaco non incluso nell'elenco dei farmaci per un massimo di 90 giorni, in modo che il medico o il professionista che effettua la prescrizione abbia il tempo di individuare un farmaco idoneo in elenco o di richiedere un'eccezione. Il Partecipante potrà essere idoneo per una fornitura di transizione del livello di cura se: fa ingresso in una struttura di cura a lungo termine (Long-Term Care, LTC) da un ospedale o da altra struttura lascia una struttura LTC e fa rientro nella comunità viene dimesso dall'ospedale per recarsi a casa termina una permanenza in un centro di assistenza infermieristica avanzata coperto da Medicare, Parte A (inclusi i costi farmaceutici), e ritorna alla copertura come alla Parte D Per eventuali domande si prega di contattare ICS Community Care Plus FIDA-MMP al numero 1.877.ICS.2525, TTY: 711 dal lunedì al venerdì, tra le 8:00 e le 20:00. La chiamata è gratuita. Per ulteriori informazioni visitare il sito? x
ritorna dallo stato di ricoverato in casa di accoglienza ai benefici standard Medicare come da Parte A e B oppure viene dimesso da un ospedale psichiatrico con regimi farmaceutici altamente individualizzati. 11. È possibile richiedere un eccezione per coprire un farmaco? Sì. È possibile chiedere a ICS Community Care Plus FIDA-MMP o alla propria equipe interdisciplinare (Interdisciplinary Team, IDT) di effettuare un eccezione per coprire un farmaco che non è incluso nell Elenco dei farmaci. È inoltre possibile chiedere a ICS Community Care Plus FIDA-MMP o alla propria IDT di modificare le regole relative al farmaco d interesse. Per esempio, ICS Community Care Plus FIDA-MMP potrebbe limitare la quantità di un farmaco che è coperto. Se per il farmaco d interesse è previsto un limite, è possibile richiedere a noi o alla propria IDT di modificare tale limite e coprire una quantità maggiore. Altri esempi: È possibile richiedere a noi o alla propria IDT di non imporre le limitazioni della terapia per fasi o i requisiti di approvazione preventiva. 12. Quanto tempo è necessario per ottenere un eccezione? Innanzitutto ICS Community Care Plus FIDA-MMP o l equipe interdisciplinare (Interdisciplinary Team, IDT) deve ricevere una dichiarazione da parte del professionista che effettua la prescrizione a supporto della richiesta di eccezione da parte del Partecipante. Una volta ricevuta la dichiarazione, la decisione in merito alla richiesta di eccezione viene presa entro 72 ore. Se il Partecipante o il professionista che effettua la prescrizione ritiene che la salute del Partecipante potrebbe essere compromessa durante l attesa di 72 ore per una decisione, è possibile richiedere un eccezione accelerata. In tal modo la decisione viene presa più rapidamente e, se il professionista che effettua la prescrizione supporta la Per eventuali domande si prega di contattare ICS Community Care Plus FIDA-MMP al numero 1.877.ICS.2525, TTY: 711 dal lunedì al venerdì, tra le 8:00 e le 20:00. La chiamata è gratuita. Per ulteriori informazioni visitare il sito? xi
richiesta da parte del Partecipante, la decisione verrà presa entro 24 ore dal momento in cui viene ricevuta la dichiarazione di supporto. 13. Come si fa a richiedere un eccezione? Per richiedere un eccezione, contattare il proprio Responsabile delle cure (Care Manager). Il Responsabile delle cure collaborerà con il Partecipante e il professionista che effettua la prescrizione per assisterli nella richiesta di un eccezione. 14. Cosa sono i farmaci generici? I farmaci generici sono composti dagli stessi ingredienti dei farmaci di marca. Solitamente costano meno dei farmaci di marca e non hanno nomi conosciuti. I farmaci generici sono approvati dall ente statunitense per la vigilanza sugli alimenti e i farmaci (Food and Drug Administration, FDA). ICS Community Care Plus FIDA-MMP copre sia farmaci di marca che farmaci generici. 15. Che cosa sono i farmaci OTC? OTC significa over-the-counter, ovvero da banco. ICS Community Care Plus FIDA- MMP copre alcuni farmaci OTC se vengono prescritti dal fornitore del Partecipante. Per sapere quali farmaci OTC sono coperti, consultare l Elenco dei farmaci ICS Community Care Plus FIDA-MMP. 16. ICS Community Care Plus FIDA-MMP copre prodotti OTC non farmaceutici? ICS Community Care Plus FIDA-MMP copre alcuni prodotti OTC non farmaceutici, quali garze e bende, tamponi imbevuti d alcool, siringhe e aghi per insulina, ecc. se vengono inclusi nella prescrizione da parte del fornitore del Partecipante. Per eventuali domande si prega di contattare ICS Community Care Plus FIDA-MMP al numero 1.877.ICS.2525, TTY: 711 dal lunedì al venerdì, tra le 8:00 e le 20:00. La chiamata è gratuita. Per ulteriori informazioni visitare il sito? xii
Per sapere quali prodotti OTC non farmaceutici sono coperti, consultare l Elenco dei farmaci ICS Community Care Plus FIDA-MMP. 17. Qual è il contributo addebitato al Partecipante ( ticket )? Il Partecipante non sarà soggetto ad alcun pagamento parziale per farmaci inclusi nell Elenco dei farmaci. 18. Che cosa sono i livelli di farmaci? I livelli sono gruppi di farmaci. Ogni farmaco nell'elenco dei farmaci del piano è incluso in uno di 4 livelli. Il Partecipante non è soggetto ad alcun costo per i farmaci in tutti i livelli. Livello 1: farmaci generici coperti da Medicare Livello 2: farmaci di marca e specialistici coperti da Medicare Livello 3: farmaci generici e di marca non Parte D coperti da Medicaid Livello 4: farmaci OTC (Over-The-Counter, da banco) coperti da Medicaid Per eventuali domande si prega di contattare ICS Community Care Plus FIDA-MMP al numero 1.877.ICS.2525, TTY: 711 dal lunedì al venerdì, tra le 8:00 e le 20:00. La chiamata è gratuita. Per ulteriori informazioni visitare il sito? xiii
Elenco dei farmaci coperti L elenco dei farmaci coperti a pagina 18 fornisce informazioni sui farmaci coperti da ICS Community Care Plus FIDA-MMP. Se l individuazione del farmaco nell elenco risulta problematica, consultare l Indice che inizia a pagina I-1. La prima colonna dell elenco indica il nome del farmaco. I farmaci di marca sono scritti in carattere maiuscolo (per es. AVONEX) e i farmaci generici in minuscolo corsivo (per es. amoxicillina). Le informazioni nella colonna delle azioni, limitazioni o limiti all uso indica se ICS Community Care Plus FIDA-MMP prevede regole per la copertura di tale farmaco. Abbreviazioni e simboli Questo documento può contenere le seguenti abbreviazioni per la gestione dell'utilizzo. ABBREVIAZIONI DELLE NOTE DI COPERTURA ABBREVIAZIONE DESCRIZIONE SPIEGAZIONE PA Limitazioni alla gestione dell utilizzo Prior Authorization Restriction (Autorizzazione preventiva obbligatoria) Il Partecipante o il suo medico devono ottenere l autorizzazione preventiva da parte di ICS Community Care Plus FIDA-MMP prima di presentare la prescrizione per il farmaco d interesse. Senza l approvazione preventiva, ICS Community Care Plus FIDA-MMP potrebbe non coprire il farmaco. Autorizzazione preventiva obbligatoria per determinazione Parte B o Parte D (Prior Authorization Questo farmaco potrebbe essere idoneo per il pagamento in base a Medicare Parte B o Parte D. Il Partecipante (o il suo medico) devono ottenere l autorizzazione preventiva da Per eventuali domande si prega di contattare ICS Community Care Plus FIDA-MMP al numero 1.877.ICS.2525, TTY: 711 dal lunedì al venerdì, tra le 8:00 e le 20:00. La chiamata è gratuita. Per ulteriori informazioni visitare il sito? xiv
ABBREVIAZIONE DESCRIZIONE SPIEGAZIONE Restriction for Part B vs Part D Determination) parte di ICS Community Care Plus FIDA-MMP per determinare che il farmaco è coperto da Medicare Parte D prima di presentare la prescrizione per tale farmaco. Senza l approvazione preventiva, FIDA Care Complete potrebbe non coprire il farmaco. PA NSO QL ST Autorizzazione preventiva solo per i nuovi iscritti (Prior Authorization Restriction for New Starts Only) Limitazione della quantità (Quantity Limit Restriction) Limitazione tramite terapia per fasi (Step Therapy Restriction) Se il Partecipante è un nuovo membro o se non ha mai assunto questo farmaco in precedenza, il Partecipante (o il suo medico) devono ottenere l autorizzazione preventiva da parte di ICS Community Care Plus FIDA-MMP prima di presentare la prescrizione per il farmaco d interesse. Senza l approvazione preventiva, FIDA Care Complete potrebbe non coprire il farmaco. ICS Community Care Plus FIDA-MMP limita la quantità di questo farmaco che viene coperta per ciascuna prescrizione o entro un determinato periodo di tempo. Prima che ICS Community Care Plus FIDA-MMP fornisca la copertura per il farmaco d interesse è necessario che il Partecipante provi uno (o più) altri farmaci per il trattamento della sua condizione medica. Il farmaco d interesse potrà essere coperto solo Per eventuali domande si prega di contattare ICS Community Care Plus FIDA-MMP al numero 1.877.ICS.2525, TTY: 711 dal lunedì al venerdì, tra le 8:00 e le 20:00. La chiamata è gratuita. Per ulteriori informazioni visitare il sito? xv
ABBREVIAZIONE DESCRIZIONE SPIEGAZIONE se uno (o più) altri farmaci non funzionano per il Partecipante. Questo documento potrebbe non contenere le seguenti ulteriori abbreviazioni relative alla copertura. ALTRI REQUISITI SPECIALI PER LA COPERTURA LA Farmaco ad accesso limitato (Limited Access Drug) Questa prescrizione potrebbe essere disponibile solo presso determinate farmacie. Per ulteriori informazioni consultare l'elenco delle farmacie oppure contattare il Servizio per i membri al numero 1.877.ICS.2525, tra le 8:00 e le 20:00, dal lunedì al venerdì. Gli utenti con funzionalità TTY/TDD devono rivolgersi al numero 711. NM * Farmaco non ordinato tramite servizio postale Farmaco non di Parte D (Not a Part D Drug) Il Partecipante potrebbe ricevere oltre 1 mese di fornitura della maggior parte dei farmaci presenti nel formulario tramite ordine postale a una prezzo ridotto. I farmaci non disponibili tramite ordine postale sono annotati con NM nella colonna Requisiti/Limiti del formulario del Partecipante. Il farmaco d interesse non è un farmaco di Parte D coperto da Medicaid. Nota: Il simbolo (*) a fianco di un farmaco indica che il farmaco non è un farmaco di Parte D. Tali farmaci hanno regole diverse per i ricorsi. Un ricorso (appeal) è un modo formale di richiedere la revisione e il cambiamento di una decisione di copertura se si ritiene che sia stato commesso un errore. Per esempio, ICS Community Care Plus FIDA-MMP o l equipe interdisciplinare (Interdisciplinary Team, IDT) potrebbe decidere che un farmaco d interesse per Per eventuali domande si prega di contattare ICS Community Care Plus FIDA-MMP al numero 1.877.ICS.2525, TTY: 711 dal lunedì al venerdì, tra le 8:00 e le 20:00. La chiamata è gratuita. Per ulteriori informazioni visitare il sito? xvi
il Partecipante non è coperto o non è più coperto da Medicare o Medicaid. Se il Partecipante o il suo medico o altro professionista che effettua la prescrizione non è d accordo con la decisione, è possibile fare ricorso. Per istruzioni su come fare ricorso, contattare i Servizi per i partecipanti al numero 1.877.ICS.2525 oppure il Garante dei Partecipanti FIDA (FIDA Participant Ombudsman) al numero 1.877.ICS.2525. Informazioni su come fare ricorso su una decisione sono disponibili anche nel Manuale del Partecipante. Di seguito sono riportati i significati dei codici utilizzati nella colonna Azioni necessarie, limitazioni o limiti per l'uso : (g) = Solo la versione generica di questo farmaco è coperta. La versione con marchio non è coperta. M = La versione con marchio di questo farmaco è nel livello 3. La versione generica è nel livello 1. PA = Autorizzazione preventiva (Prior authorization, approvazione): il Partecipante deve ricevere l'approvazione da parte del piano o dell'equipe Interdisciplinare (IDT) prima di poter ottenere questo farmaco. ST = Terapia per fasi (Step therapy): il Partecipante deve provare un altro farmaco prima di ottenere questo. Per eventuali domande si prega di contattare ICS Community Care Plus FIDA-MMP al numero 1.877.ICS.2525, TTY: 711 dal lunedì al venerdì, tra le 8:00 e le 20:00. La chiamata è gratuita. Per ulteriori informazioni visitare il sito? xvii
Table of Contents Analgesics... 3 Anesthetics... 15 Anti-Addiction/Substance Abuse Treatment Agents... 16 Antianxiety Agents... 17 Antibacterials... 18 Anticancer Agents... 31 Anticholinergic Agents... 42 Anticonvulsants... 42 Antidementia Agents... 47 Antidepressants... 48 Antidiabetic Agents... 52 Antifungals... 56 Antihistamines... 60 Anti-Infectives (Skin And Mucous Membrane)... 66 Antimigraine Agents... 67 Antimycobacterials... 68 Antinausea Agents... 68 Antiparasite Agents... 70 Antiparkinsonian Agents... 71 Antipsychotic Agents... 73 Antivirals (Systemic)... 77 Blood Products/Modifiers/Volume Expanders... 84 Caloric Agents... 88 Formulario ICS Community Care Plus FIDA-MMP per il 2016 ID del formulario:16508.000, Versione: 19 In vigore da: 1 Dicembre 2016 1
Cardiovascular Agents... 94 Central Nervous System Agents... 110 Contraceptives... 113 Cough And Cold Products... 122 Dental And Oral Agents... 134 Dermatological Agents... 134 Devices... 144 Disinfectants (For Non-Dermatologic Use)... 145 Enzyme Replacement/Modifiers... 145 Eye, Ear, Nose, Throat Agents... 147 Gastrointestinal Agents... 156 Genitourinary Agents... 169 Heavy Metal Antagonists... 170 Hormonal Agents, Stimulant/Replacement/Modifying... 171 Immunological Agents... 178 Inflammatory Bowel Disease Agents... 188 Irrigating Solutions... 188 Metabolic Bone Disease Agents... 189 Miscellaneous Therapeutic Agents... 191 Ophthalmic Agents... 197 Replacement Preparations... 199 Respiratory Tract Agents... 209 Skeletal Muscle Relaxants... 213 Sleep Disorder Agents... 214 Vasodilating Agents... 215 Vitamins And Minerals... 217 Formulario ICS Community Care Plus FIDA-MMP per il 2016 ID del formulario:16508.000, Versione: 19 In vigore da: 1 Dicembre 2016 2
Analgesics Analgesics, Miscellaneous acephen 120 mg suppository outer 120 mg * acephen 325 mg suppository outer 325 mg * acephen 650 mg suppository outer 650 mg * acetaminophen 120 mg suppos outer 120 mg * acetaminophen 160 mg rapid tab 160 mg * acetaminophen 160 mg/5 ml elx 160 mg/5 ml * acetaminophen 325 mg liqui-gel 325 mg * acetaminophen 650 mg suppos 650 mg * acetaminophen 80 mg rapid tab children's 80 mg * acetaminophen 80 mg/0.8 ml drp infants 80 mg/0.8 ml * acetaminophen-codeine 120 mg-12 mg/5 ml solution 120-12 mg/5 ml acetaminophen-codeine oral solution 300 mg-30 mg /12.5 ml acetaminophen-codeine oral tablet 300-15 mg, 300-30 mg acetaminophen-codeine oral tablet 300-60 mg ALLZITAL ORAL TABLET 25-325 MG (Acetaminophen) (Acetaminophen) (Acetaminophen) (Acetaminophen) (Acetaminophen) (Acetaminophen) (Acetaminophen) (Acetaminophen) (Acetaminophen) (Acetaminophen) (Acetaminophen with Codeine) (Acetaminophen with Codeine) (Tylenol-Codeine No.3) (Tylenol-Codeine No.3) QL (360 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (240 per 30 days) QL (360 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (2700 per 30 days) QL (2700 per 30 days) QL (360 per 30 days) QL (180 per 30 days) 3
ascomp with codeine oral capsule 30-50-325-40 mg BELBUCA BUCCAL FILM 150 MCG, 300 MCG, 450 MCG, 600 MCG, 75 MCG, 750 MCG, 900 MCG buprenorphine hcl injection syringe 0.3 mg/ml butalbital compound w/codeine oral capsule 30-50-325-40 mg butalbital-acetaminop-caf-cod oral capsule 50-300-40-30 mg, 50-325- 40-30 mg butalbital-acetaminophen oral tablet 50-325 mg butalbital-acetaminophen-caff oral capsule 50-325-40 mg butalbital-acetaminophen-caff oral tablet 50-325-40 mg butalbital-aspirin-caffeine oral capsule 50-325-40 mg BUTRANS TRANSDERMAL PATCH WEEKLY 10 MCG/HOUR, 15 MCG/HOUR, 20 MCG/HOUR, 5 MCG/HOUR, 7.5 MCG/HOUR (Fiorinal with Codeine #3) (Buprenorphine HCl) (Fiorinal with Codeine #3) (Fioricet with Codeine) (Tencon) (Esgic) (Esgic) (Fiorinal) capacet oral capsule 50-325-40 mg (Esgic) PA-HRM; QL (180 per 30 days); AGE (Max 64 Years) ST; QL (60 per 30 days) PA-HRM; QL (180 per 30 days); AGE (Max 64 Years) PA-HRM; QL (180 per 30 days); AGE (Max 64 Years) PA-HRM; QL (180 per 30 days); AGE (Max 64 Years) PA-HRM; QL (180 per 30 days); AGE (Max 64 Years) PA-HRM; QL (180 per 30 days); AGE (Max 64 Years) PA-HRM; QL (180 per 30 days); AGE (Max 64 Years) QL (4 per 28 days) PA-HRM; QL (180 per 30 days); AGE (Max 64 Years) 4
child non-aspirin 160 mg/5 ml QL (240 per 30 days) (Acetaminophen) children's 160 mg/5 ml * child pain-fever 160 mg/5 ml QL (240 per 30 days) (Infants' Tylenol) a/f,gluten/f,cherry 160 mg/5 ml * child tactinal 80 mg tab chw 80 mg QL (30 per 30 days) (Acetaminophen) * children's mapap 80 mg rapid 80 QL (30 per 30 days) (Acetaminophen) mg * codeine sulfate oral tablet 15 mg, 30 QL (180 per 30 days) (Codeine Sulfate) mg, 60 mg cvs child non-asa 80 mg tb chw 80 QL (30 per 30 days) (Acetaminophen) mg * cvs non-aspirin jr tab chew 160 mg QL (30 per 30 days) (Acetaminophen) * cvs pain relief adult liquid 500 (Tylenol Sore QL (120 per 30 days) mg/15 ml * Throat) endocet oral tablet 10-325 mg, 2.5- QL (360 per 30 days) (Xolox) 325 mg, 5-325 mg, 7.5-325 mg endodan oral tablet 4.8355-325 mg (Percodan) QL (360 per 30 days) fentanyl citrate buccal lozenge on a handle 1,200 mcg, 1,600 mcg, 200 (Actiq) PA; QL (120 per 30 days) mcg, 400 mcg, 600 mcg, 800 mcg fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 37.5 mcg/hour, 50 mcg/hr, 62.5 mcg/hour, 75 mcg/hr, 87.5 mcg/hour (Duragesic) QL (10 per 30 days) feverall 120 mg suppository QL (30 per 30 days) (Acetaminophen) children's, outer 120 mg * feverall 325 mg suppository junior QL (30 per 30 days) (Acetaminophen) str, outer 325 mg * feverall 650 mg suppository adult, QL (30 per 30 days) (Acetaminophen) outer 650 mg * 5
hydrocodone-acetaminophen oral solution 10-325 mg/15 ml(15 ml), 2.5-167 mg/5 ml, 7.5-325 mg/15 ml hydrocodone-acetaminophen oral tablet 10-300 mg, 5-300 mg, 7.5-300 mg hydrocodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg hydrocodone-ibuprofen oral tablet 10-200 mg, 2.5-200 mg, 5-200 mg, 7.5-200 mg hydromorphone (pf) injection solution 10 mg/ml hydromorphone injection solution 2 mg/ml, 4 mg/ml hydromorphone injection syringe 2 mg/ml (Hycet) (Norco) (Norco) (Ibudone) (Dilaudid-HP) QL (2700 per 30 days) (includes Vicodin, Vicodin ES and Vicodin HP); QL (390 per 30 days) QL (360 per 30 days) QL (150 per 30 days) (Hydromorphone HCl) (Hydromorphone HCl) hydromorphone oral liquid 1 mg/ml (Dilaudid) QL (1200 per 30 days) hydromorphone oral tablet 2 mg, 4 QL (180 per 30 days) (Dilaudid) mg hydromorphone oral tablet 8 mg (Dilaudid) QL (240 per 30 days) HYSINGLA ER ORAL QL (30 per 30 days) TABLET,ORAL ONLY,EXT.REL.24 HR 100 MG, 120 MG, 20 MG, 30 MG, 40 MG, 60 MG, 80 MG junior mapap 160 mg rapid tab 160 mg * LAZANDA NASAL SPRAY,NON- AEROSOL 100 MCG/SPRAY, 300 MCG/SPRAY, 400 MCG/SPRAY (Acetaminophen) QL (30 per 30 days) PA; QL (30 per 30 days) 6
lorcet (hydrocodone) oral tablet 5- QL (360 per 30 days) (Norco) 325 mg lorcet hd oral tablet 10-325 mg (Norco) QL (360 per 30 days) lorcet plus oral tablet 7.5-325 mg (Norco) QL (360 per 30 days) mapap 160 mg/5 ml elixir 160 mg/5 (Tylenol Sore QL (240 per 30 days) ml * Throat) mapap 160 mg/5 ml suspension 160 QL (240 per 30 days) (Infants' Tylenol) mg/5 ml * mapap 325 mg tablet 325 mg * (Tylenol) QL (360 per 30 days) mapap 500 mg capsule 500 mg * (Acetaminophen) QL (240 per 30 days) mapap 500 mg tablet 500 mg * (Tylenol) QL (240 per 30 days) mapap 500 mg/15 ml liquid 500 (Tylenol Sore QL (120 per 30 days) mg/15 ml * Throat) mapap 80 mg tablet chew 80 mg * (Acetaminophen) QL (30 per 30 days) mapap arthritis er 650 mg cplt 650 QL (180 per 30 days) (Tylenol Arthritis) mg * margesic oral capsule 50-325-40 mg (Esgic) PA-HRM; QL (180 per 30 days); AGE (Max 64 Years) methadone injection solution 10 mg/ml (Methadone HCl) methadone oral solution 10 mg/5 QL (1800 per 30 days) (Methadone HCl) ml, 5 mg/5 ml methadone oral tablet 10 mg, 5 mg (Diskets) QL (360 per 30 days) methadose oral tablet,soluble 40 mg (Diskets) QL (90 per 30 days) morphine (pf) in 0.9 % nacl intravenous pt controlled analgesia (Morphine Sulfate/0.9% syring 50 mg/25 ml (2 mg/ml) Nacl/PF) morphine 10 mg/ml carpuject 10 mg/ml (Morphine Sulfate) morphine 2 mg/ml carpuject outer, latex-f, p/f 2 mg/ml (Morphine Sulfate) morphine 4 mg/ml carpuject outer,latex-free,p/f 4 mg/ml (Morphine Sulfate) 7
morphine 8 mg/ml syringe 8 mg/ml (Morphine Sulfate) morphine concentrate oral solution QL (200 per 30 days) (Morphine Sulfate) 100 mg/5 ml (20 mg/ml) morphine in dextrose 5 % injection pt controlled analgesia syring 100 (Morphine mg/50 ml (2 mg/ml), 50 mg/25 ml (2 Sulfate/D5W) mg/ml) morphine injection solution 15 mg/ml, 8 mg/ml (Morphine Sulfate) morphine injection syringe 10 mg/ml (Morphine Sulfate) morphine intramuscular pen injector 10 mg/0.7 ml (Morphine Sulfate) morphine intravenous cartridge 15 mg/ml (Morphine Sulfate) morphine intravenous solution 25 mg/ml, 50 mg/ml (Morphine Sulfate) morphine intravenous syringe 10 mg/ml, 2 mg/ml, 4 mg/ml, 8 mg/ml (Morphine Sulfate) morphine oral solution 10 mg/5 ml (Morphine Sulfate) QL (700 per 30 days) morphine oral solution 20 mg/5 ml QL (300 per 30 days) (Morphine Sulfate) (4 mg/ml) MORPHINE ORAL TABLET 15 QL (180 per 30 days) MG, 30 MG morphine oral tablet extended QL (120 per 30 days) (MS Contin) release 100 mg, 30 mg, 60 mg morphine oral tablet extended QL (180 per 30 days) (MS Contin) release 15 mg, 200 mg morphine rectal suppository 10 mg, (Morphine Sulfate) 20 mg, 30 mg, 5 mg non-aspirin x-str 167 mg/5 ml 500 mg/15 ml * nortemp 80 mg/0.8 ml drop 80 mg/0.8 ml * (Tylenol Sore Throat) (Acetaminophen) QL (120 per 30 days) QL (30 per 30 days) 8
NUCYNTA ER ORAL TABLET QL (60 per 30 days) EXTENDED RELEASE 12 HR 100 MG, 150 MG, 200 MG, 250 MG, 50 MG NUCYNTA ORAL TABLET 100 QL (181 per 30 days) MG, 50 MG, 75 MG oxycodone oral concentrate 20 QL (180 per 30 days) (Oxycodone HCl) mg/ml oxycodone oral solution 5 mg/5 ml (Oxycodone HCl) QL (1300 per 30 days) oxycodone oral tablet 10 mg, 15 mg, QL (180 per 30 days) (Roxicodone) 20 mg, 30 mg, 5 mg oxycodone oral tablet,oral QL (60 per 30 days) only,ext.rel.12 hr 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 60 mg (Oxycontin) oxycodone oral tablet,oral only,ext.rel.12 hr 80 mg oxycodone-acetaminophen oral solution 5-325 mg/5 ml oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg oxycodone-acetaminophen oral tablet 10-650 mg oxycodone-acetaminophen oral tablet 7.5-500 mg oxycodone-aspirin oral tablet 4.8355-325 mg OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 60 MG (Oxycontin) (Oxycodone HCl/Acetaminophe n) (Xolox) (Xolox) (Xolox) (Percodan) QL (120 per 30 days) QL (1800 per 30 days) QL (360 per 30 days) QL (180 per 30 days) QL (240 per 30 days) QL (360 per 30 days) QL (60 per 30 days) 9
OXYCONTIN ORAL QL (120 per 30 days) TABLET,ORAL ONLY,EXT.REL.12 HR 80 MG oxymorphone oral tablet 10 mg, 5 QL (180 per 30 days) (Opana) mg oxymorphone oral tablet extended QL (60 per 30 days) release 12 hr 10 mg, 15 mg, 20 mg, 5 mg, 7.5 mg (Opana ER) oxymorphone oral tablet extended QL (120 per 30 days) (Opana ER) release 12 hr 30 mg, 40 mg pain relief 500 mg capsule 500 mg * (Acetaminophen) QL (240 per 30 days) pain reliever er 650 mg caplet 8 QL (180 per 30 days) (Tylenol Arthritis) hour, caplet 650 mg * pharbetol 325 mg tablet regular QL (360 per 30 days) (Tylenol) strength 325 mg * pharbetol 500 mg caplet extra-str, QL (240 per 30 days) (Tylenol) caplet 500 mg * pv non-aspirin 500 mg softgel exstr,liq filled 500 mg * QL (240 per 30 days) (Acetaminophen) q-pap 160 mg/5 ml solution a/f, (Tylenol Sore QL (240 per 30 days) cherry 160 mg/5 ml * Throat) q-pap 325 mg tablet 325 mg * (Tylenol) QL (360 per 30 days) q-pap 80 mg/0.8 ml drops 80 mg/0.8 QL (30 per 30 days) (Acetaminophen) ml * q-pap ex-str 500 mg tablet aspirin QL (240 per 30 days) (Tylenol) free 500 mg * ra jr acetaminophen 160 mg tab QL (30 per 30 days) (Acetaminophen) rapid melts 160 mg * reprexain oral tablet 10-200 mg, 2.5-200 mg, 5-200 mg roxicet oral solution 5-325 mg/5 ml (Ibudone) (Oxycodone HCl/Acetaminophe n) QL (150 per 30 days) QL (1800 per 30 days) 10
silapap infant's drops infant 80 QL (30 per 30 days) (Acetaminophen) mg/0.8 ml * sm arthritis pain er 650 mg caplet QL (180 per 30 days) (Tylenol Arthritis) 650 mg * sm pain rel jr str tab chew 160 mg * (Acetaminophen) QL (30 per 30 days) sm pain reliever 80 mg tab QL (30 per 30 days) (Acetaminophen) children's 80 mg * tactinal 325 mg tablet 325 mg * (Tylenol) QL (360 per 30 days) tactinal 500 mg tablet extra-strength QL (240 per 30 days) (Tylenol) 500 mg * PA-HRM; QL (180 per tencon oral tablet 50-325 mg (Tencon) 30 days); AGE (Max 64 Years) tramadol oral tablet 50 mg (Ultram) QL (240 per 30 days) tramadol-acetaminophen oral tablet QL (240 per 30 days) (Ultracet) 37.5-325 mg (includes Vicodin, vicodin es oral tablet 7.5-300 mg (Norco) Vicodin ES and Vicodin HP); QL (390 per 30 days) vicodin hp oral tablet 10-300 mg (Norco) (includes Vicodin, Vicodin ES and Vicodin HP); QL (390 per 30 days) vicodin oral tablet 5-300 mg (Norco) (includes Vicodin, Vicodin ES and Vicodin HP); QL (390 per 30 days) xylon 10 oral tablet 10-200 mg (Ibudone) QL (150 per 30 days) zebutal oral capsule 50-325-40 mg (Esgic) Nonsteroidal Anti- Inflammatory Agents PA-HRM; QL (180 per 30 days); AGE (Max 64 Years) 11
ADVIL 100 MG TABLET JR STRENGTH,COATED 100 MG * ADVIL 200 MG TABLET 200 MG * ADVIL JR STR 100 MG TAB CHEW TB CHEW,8 HOUR,GRAPE 100 MG * aspirin 300 mg suppository 300 mg (Aspirin) * aspirin 325 mg tablet 325 mg * (Ecotrin) aspirin 600 mg suppository 600 mg (Aspirin) * aspirin 81 mg chewable tablet 81 (Bayer Chewable mg * Aspirin) aspirin buffered 325 mg tab 325 mg (Aspirin/Calcium * Carbonate/Mag) aspirin ec 325 mg tablet 325 mg * (Ecotrin) aspirin ec 500 mg tablet 500 mg * (Ecotrin) aspirin ec 81 mg tablet low dose 81 (Ecotrin) mg * aspir-low ec 81 mg tablet 81 mg * (Ecotrin) CALDOLOR INTRAVENOUS RECON SOLN 400 MG/4 ML (100 MG/ML) celecoxib oral capsule 100 mg, 200 (Celebrex) mg, 400 mg, 50 mg CHILDREN'S ADVIL 100 MG/5 ML A/F (OTC) 100 MG/5 ML * cvs ibuprofen 200 mg softgel liquid (Advil) filled,softge 200 mg * bufferin 325 mg tablet coated 325 choline,magnesium salicylate oral (Aspirin/Calcium (Choline Sal/Mag mg * liquid 500 mg/5 ml Carbonate/Mag) Salicylate) QL (60 per 30 days) 12
diclofenac potassium oral tablet 50 (Diclofenac mg Potassium) diclofenac sodium oral tablet extended release 24 hr 100 mg (Voltaren-XR) diclofenac sodium oral (Diclofenac tablet,delayed release (dr/ec) 25 mg, Sodium) 50 mg, 75 mg diclofenac sodium topical gel 3 % (Voltaren) diclofenac-misoprostol oral tablet,ir,delayed rel,biphasic 50-200 (Arthrotec 50) mg-mcg, 75-200 mg-mcg diflunisal oral tablet 500 mg (Diflunisal) ecpirin ec 325 mg tablet 325 mg * (Ecotrin) etodolac oral capsule 200 mg, 300 mg (Etodolac) etodolac oral tablet 400 mg, 500 mg (Lodine) etodolac oral tablet extended release 24 hr 400 mg, 500 mg, 600 (Etodolac) mg fenoprofen oral capsule 200 mg (Nalfon) fenoprofen oral tablet 600 mg (Fenoprofen Calcium) FLECTOR TRANSDERMAL PATCH 12 HOUR 1.3 % flurbiprofen oral tablet 100 mg, 50 mg (Flurbiprofen) gnp ibuprofen jr str 100 mg tb 100 mg * (Advil) ibuprofen 100 mg/5 ml susp children's (otc) 100 mg/5 ml * (Children'S Advil) ibuprofen 200 mg tablet 200 mg * (Advil) ibuprofen oral suspension 100 mg/5 ml (Ibuprofen) PA 13
ibuprofen oral tablet 400 mg, 600 mg, 800 mg (Ibuprofen) indomethacin oral capsule 25 mg (Indomethacin) QL (240 per 30 days) indomethacin oral capsule 50 mg (Indomethacin) QL (120 per 30 days) indomethacin oral capsule, extended QL (60 per 30 days) (Indomethacin) release 75 mg indomethacin sodium intravenous (Indomethacin recon soln 1 mg Sodium) infant ibuprofen 50 mg/1.25 ml d/f,a/f,non-staining 50 mg/1.25 ml * (Infants' Motrin) INFANTS' MOTRIN 50 MG/1.25 ML D/F, BERRY FLAVOR 50 3 $0 MG/1.25 ML * ketoprofen oral capsule 50 mg, 75 mg (Ketoprofen) ketoprofen oral capsule,ext rel. pellets 24 hr 200 mg (Ketoprofen) ketorolac oral tablet 10 mg (Ketorolac QL (20 per 30 days) Tromethamine) mefenamic acid oral capsule 250 mg (Ponstel) meloxicam oral suspension 7.5 mg/5 ml (Mobic) meloxicam oral tablet 15 mg, 7.5 mg (Mobic) nabumetone oral tablet 500 mg, 750 mg (Nabumetone) naproxen oral suspension 125 mg/5 ml (Naprosyn) naproxen oral tablet 250 mg, 375 mg, 500 mg (Naprosyn) naproxen oral tablet,delayed release (Ec-Naprosyn) (dr/ec) 375 mg, 500 mg naproxen sodium oral tablet 275 mg, 550 mg (Anaprox) 14
piroxicam oral capsule 10 mg, 20 mg ra aspirin tri-buffered tb 325 mg * (Feldene) (Aspirin/Calcium Carbonate/Mag) sm ibuprofen ib 100 mg tablet junior (Advil) strength 100 mg * st. joseph aspirin 81 mg chew (Bayer Chewable orange 81 mg * Aspirin) st. joseph aspirin ec 81 mg tb enteric coated 81 mg * (Ecotrin) sulindac oral tablet 150 mg, 200 mg (Sulindac) tolmetin oral capsule 400 mg (Tolmetin Sodium) tolmetin oral tablet 200 mg, 600 mg (Tolmetin Sodium) VOLTAREN TOPICAL GEL 1 % wal-profen 200 mg softgel softgel 200 mg * (Advil) Anesthetics Local Anesthetics glydo mucous membrane jelly in applicator 2 % (Lidocaine HCl) lidocaine (pf) injection solution 15 mg/ml (1.5 %), 40 mg/ml (4 %), 5 (Xylocaine-MPF) mg/ml (0.5 %) lidocaine 2% viscous soln 2 % (Xylocaine) lidocaine hcl injection solution 10 mg/ml (1 %), 20 mg/ml (2 %) (Xylocaine) lidocaine hcl mucous membrane jelly 2 % (Lidocaine HCl) lidocaine hcl mucous membrane solution 2 %, 4 % (40 mg/ml) (Xylocaine) lidocaine topical adhesive patch,medicated 5 % (Lidoderm) lidocaine topical ointment 5 % (Lidocaine) PA 15
lidocaine-prilocaine topical cream 2.5-2.5 % Anti-Addiction/Substance Abuse Treatment Agents Anti-Addiction/Substance Abuse Treatment Agents acamprosate oral tablet,delayed (EMLA) (Acamprosate release (dr/ec) 333 mg Calcium) buprenorphine hcl sublingual tablet (Buprenorphine 2 mg, 8 mg HCl) (Buprenorphine buprenorphine-naloxone sublingual HCl/Naloxone tablet 2-0.5 mg, 8-2 mg HCl) bupropion hcl sr 150 mg tablet f/c 150 mg (Zyban) CHANTIX CONTINUING MONTH BOX ORAL TABLET 1 MG CHANTIX ORAL TABLET 0.5 MG, 1 MG CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK 0.5 MG (11)- 1 MG (42) disulfiram oral tablet 250 mg, 500 mg (Antabuse) naloxone injection solution 0.4 mg/ml (Naloxone HCl) naloxone injection syringe 0.4 mg/ml, 1 mg/ml (Naloxone HCl) naltrexone oral tablet 50 mg (Revia) NARCAN NASAL SPRAY,NON- AEROSOL 4 MG/ACTUATION NICODERM CQ 14 MG/24HR PATCH 14 MG/24 HR * PA; QL (90 per 30 days) PA; QL (90 per 30 days) QL (168 per 84 days) QL (168 per 84 days) QL (53 per 28 days) QL (4 per 30 days) QL (168 per 365 days) 16
NICODERM CQ 21 MG/24HR PATCH 21 MG/24 HR * NICODERM CQ 7 MG/24HR PATCH 7 MG/24 HR * nicorelief 2 mg gum 2 mg * (Nicorette) nicorelief 4 mg gum 4 mg * (Nicorette) nicorette 2 mg chewing gum white ice mint 2 mg * (Nicorette) nicotine 14 mg/24hr patch outer (otc) 14 mg/24 hr * (Nicoderm Cq) nicotine 2 mg chewing gum sugar free 2 mg * (Nicorette) nicotine 2 mg lozenge mint, 3 quittube 2 mg * (Nicorette) nicotine 21 mg/24hr patch step 1 (otc) 21 mg/24 hr * (Nicoderm Cq) nicotine 22 mg/24hr patch 1 week starter kit 22 mg/24 hr * (Nicoderm Cq) nicotine 4 mg chewing gum 4 mg * (Nicorette) nicotine 4 mg lozenge mint, 3 quittube 4 mg * (Nicorette) nicotine 7 mg/24hr patch (otc) 7 mg/24 hr * (Nicoderm Cq) NICOTROL INHALATION CARTRIDGE 10 MG ZUBSOLV SUBLINGUAL TABLET 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 Antianxiety Agents Benzodiazepines alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg (Xanax) QL (168 per 365 days) QL (180 per 365 days) QL (168 per 365 days) QL (168 per 365 days) QL (180 per 365 days) QL (1008 per 90 days) PA; QL (90 per 30 days) QL (120 per 30 days) 17
chlordiazepoxide hcl oral capsule (Chlordiazepoxide QL (120 per 30 days) 10 mg, 25 mg, 5 mg HCl) clonazepam oral tablet 0.5 mg, 1 mg (Klonopin) QL (90 per 30 days) clonazepam oral tablet 2 mg (Klonopin) QL (300 per 30 days) clonazepam oral tablet,disintegrating 0.125 mg, 0.25 mg, 0.5 mg, 1 mg (Clonazepam) QL (90 per 30 days) clonazepam oral QL (300 per 30 days) (Clonazepam) tablet,disintegrating 2 mg clorazepate dipotassium oral tablet QL (120 per 30 days) (Tranxene T-Tab) 15 mg clorazepate dipotassium oral tablet QL (60 per 30 days) (Tranxene T-Tab) 3.75 mg, 7.5 mg diazepam injection syringe 5 mg/ml (Diazepam) QL (10 per 28 days) diazepam intensol oral concentrate QL (1200 per 30 days) (Diazepam) 5 mg/ml diazepam oral solution 5 mg/5 ml (1 QL (1200 per 30 days) (Diazepam) mg/ml) diazepam oral tablet 10 mg, 2 mg, 5 QL (120 per 30 days) (Valium) mg diazepam rectal kit 12.5-15-17.5-20 mg, 2.5 mg, 5-7.5-10 mg (Diastat) lorazepam oral tablet 0.5 mg, 1 mg, QL (90 per 30 days) (Ativan) 2 mg ONFI ORAL SUSPENSION 2.5 PA NSO; QL (480 per MG/ML 30 days) Antibacterials Aminoglycosides BETHKIS INHALATION SOLUTION FOR NEBULIZATION 300 MG/4 ML 18
gentamicin in nacl (iso-osm) intravenous piggyback 100 mg/100 ml, 100 mg/50 ml, 60 mg/50 ml, 70 mg/50 ml, 80 mg/100 ml, 80 mg/50 ml, 90 mg/100 ml gentamicin injection solution 40 mg/ml gentamicin ped 20 mg/2 ml vial latex-free, sdv 20 mg/2 ml gentamicin sulfate (pf) intravenous solution 80 mg/8 ml (Gentamicin In Nacl, Iso-Osm) (Gentamicin Sulfate) (Gentamicin Sulfate/PF) (Gentamicin Sulfate/PF) neomycin oral tablet 500 mg (Neomycin Sulfate) streptomycin intramuscular recon (Streptomycin soln 1 gram Sulfate) TOBI PODHALER INHALATION CAPSULE, W/INHALATION DEVICE 28 MG tobramycin in 0.225 % nacl inhalation solution for nebulization 300 mg/5 ml tobramycin in 0.9 % nacl intravenous piggyback 60 mg/50 ml, 80 mg/100 ml tobramycin sulfate injection solution 10 mg/ml, 40 mg/ml Antibacterials, Miscellaneous bacitracin intramuscular recon soln 50,000 unit chloramphenicol sod succinate intravenous recon soln 1 gram clindamycin 75 mg/5 ml soln 75 mg/5 ml (Tobi) (Tobramycin/Sodiu m Chloride) (Tobramycin Sulfate) (Bacitracin) (Chloramphenicol Sod Succ) (Cleocin Palmitate) QL (224 per 28 days) 19
clindamycin hcl oral capsule 150 mg, 300 mg, 75 mg (Cleocin HCl) clindamycin in 5 % dextrose (Cleocin Phosphate intravenous piggyback 300 mg/50 In D5w) ml, 600 mg/50 ml, 900 mg/50 ml clindamycin pediatric oral recon soln 75 mg/5 ml (Cleocin Palmitate) clindamycin phosphate injection (Cleocin solution 150 mg/ml Phosphate) clindamycin phosphate intravenous (Cleocin solution 600 mg/4 ml Phosphate) colistin (colistimethate na) injection (Coly-Mycin M recon soln 150 mg Parenteral) CUBICIN INTRAVENOUS RECON SOLN 500 MG daptomycin intravenous recon soln 500 mg (Cubicin) linezolid intravenous parenteral solution 600 mg/300 ml (Zyvox) linezolid oral suspension for reconstitution 100 mg/5 ml (Zyvox) linezolid oral tablet 600 mg (Zyvox) methenamine hippurate oral tablet 1 gram (Hiprex) metronidazole in nacl (iso-os) (Metronidazole/So intravenous piggyback 500 mg/100 dium Chloride) ml metronidazole oral capsule 375 mg (Flagyl) metronidazole oral tablet 250 mg, 500 mg (Flagyl) 20
nitrofurantoin macrocrystal oral capsule 100 mg, 25 mg, 50 mg nitrofurantoin monohyd/m-cryst oral capsule 100 mg nitrofurantoin monohyd/m-cryst oral capsule 100 mg (75/25) (Macrodantin) (Macrobid) (Macrobid) polymyxin b sulfate injection recon (Polymyxin B soln 500,000 unit Sulfate) SYNERCID INTRAVENOUS RECON SOLN 500 MG trimethoprim oral tablet 100 mg (Trimethoprim) vancomycin hcl 1g/200 ml bag 1 (Vancomycin Hcl gram/200 ml In Dextrose 5 %) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (120 per 30 days); AGE (Max 64 Years) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (120 per 30 days); AGE (Max 64 Years) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (120 per 30 days); AGE (Max 64 Years) 21
vancomycin in 0.9% sodium cl intravenous solution 1.5 gram/500 ml vancomycin intravenous recon soln 1,000 mg, 10 gram, 750 mg vancomycin intravenous recon soln 500 mg vancomycin oral capsule 125 mg, 250 mg XIFAXAN ORAL TABLET 200 MG XIFAXAN ORAL TABLET 550 MG ZYVOX ORAL SUSPENSION FOR RECONSTITUTION 100 MG/5 ML Cephalosporins cefaclor oral capsule 250 mg, 500 mg cefaclor oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml (Vancomycin/0.9 % Sod Chloride) (Vancomycin HCl) (Vancomycin Hcl In Dextrose 5 %) (Vancocin HCl) (Cefaclor) (Cefaclor) cefadroxil oral capsule 500 mg (Cefadroxil) cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml (Cefadroxil) cefadroxil oral tablet 1 gram (Cefadroxil) cefazolin in dextrose (iso-os) intravenous piggyback 1 gram/50 ml, 2 gram/50 ml (Cefazolin Sodium/Dextrose, Iso) cefazolin injection recon soln 1 gram, 10 gram, 500 mg (Cefazolin Sodium) cefdinir oral capsule 300 mg (Cefdinir) PA; QL (9 per 30 days) PA 22
cefdinir oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml cefditoren pivoxil oral tablet 200 mg, 400 mg CEFEPIME 2 GM INJECTION 2 GRAM/100 ML CEFEPIME IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK 1 GRAM/50 ML, 2 GRAM/50 ML cefepime injection recon soln 1 gram, 2 gram cefotaxime injection recon soln 1 gram, 10 gram, 2 gram, 500 mg cefoxitin in dextrose, iso-osm intravenous piggyback 2 gram/50 ml (Cefdinir) (Spectracef) (Maxipime) (Claforan) (Cefoxitin Sodium/Dextrose, Iso) cefoxitin intravenous recon soln 1 gram, 10 gram, 2 gram (Cefoxitin Sodium) cefpodoxime oral suspension for (Cefpodoxime reconstitution 100 mg/5 ml, 50 mg/5 Proxetil) ml cefpodoxime oral tablet 100 mg, 200 (Cefpodoxime mg Proxetil) cefprozil oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml (Cefprozil) cefprozil oral tablet 250 mg, 500 mg (Cefprozil) ceftazidime injection recon soln 2 gram, 6 gram (Fortaz) ceftibuten oral capsule 400 mg (Cedax) ceftibuten oral suspension for reconstitution 180 mg/5 ml (Cedax) 23
ceftriaxone 1 gm piggyback 50ml galaxycontainer 1 gram/50 ml ceftriaxone 1 gm vial 10's, fliptop,l/f 1 gram ceftriaxone 2 gm piggyback 50ml galaxycontainer 2 gram/50 ml ceftriaxone injection recon soln 10 gram, 250 mg, 500 mg ceftriaxone intravenous recon soln 1 gram, 2 gram cefuroxime axetil oral tablet 250 mg, 500 mg cefuroxime sodium injection recon soln 1.5 gram, 750 mg cefuroxime sodium intravenous recon soln 7.5 gram cephalexin oral capsule 250 mg, 500 mg, 750 mg cephalexin oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml cephalexin oral tablet 250 mg, 500 mg MEFOXIN IN DEXTROSE (ISO- OSM) INTRAVENOUS PIGGYBACK 1 GRAM/50 ML, 2 GRAM/50 ML SUPRAX ORAL TABLET,CHEWABLE 100 MG, 200 MG tazicef injection recon soln 2 gram, 6 gram TEFLARO INTRAVENOUS RECON SOLN 400 MG, 600 MG (Ceftriaxone Na/Dextrose, Iso) (Rocephin) (Ceftriaxone Na/Dextrose, Iso) (Rocephin) (Ceftriaxone Na/Dextrose, Iso) (Ceftin) (Zinacef) (Zinacef) (Keflex) (Cephalexin) (Cephalexin) (Fortaz) 24
Macrolides azithromycin intravenous recon soln 500 mg (Zithromax) azithromycin oral packet 1 gram (Zithromax) azithromycin oral suspension for reconstitution 100 mg/5 ml, 200 (Zithromax) mg/5 ml azithromycin oral tablet 250 mg, 250 mg (6 pack), 600 mg (Zithromax) azithromycin oral tablet 500 mg (Zithromax) clarithromycin oral suspension for reconstitution 125 mg/5 ml, 250 (Biaxin) mg/5 ml clarithromycin oral tablet 250 mg, 500 mg (Biaxin) clarithromycin oral tablet extended release 24 hr 500 mg (Clarithromycin) DIFICID ORAL TABLET 200 MG QL (20 per 10 days) e.e.s. 400 oral tablet 400 mg (Erythromycin Ethylsuccinate) e.e.s. granules oral suspension for reconstitution 200 mg/5 ml (Eryped 200) ery-tab oral tablet,delayed release (Erythromycin (dr/ec) 250 mg, 500 mg Base) ERY-TAB ORAL TABLET,DELAYED RELEASE (DR/EC) 333 MG erythrocin (as stearate) oral tablet (Erythromycin 250 mg Stearate) ERYTHROCIN INTRAVENOUS RECON SOLN 1,000 MG, 500 MG erythromycin ethylsuccinate oral suspension for reconstitution 200 mg/5 ml (Eryped 200) 25
erythromycin ethylsuccinate oral tablet 400 mg erythromycin oral capsule,delayed release(dr/ec) 250 mg erythromycin oral tablet 250 mg, 500 mg Miscellaneous B-Lactam Antibiotics aztreonam injection recon soln 1 gram CAYSTON INHALATION SOLUTION FOR NEBULIZATION 75 MG/ML imipenem-cilastatin intravenous recon soln 250 mg, 500 mg INVANZ INJECTION RECON SOLN 1 GRAM meropenem intravenous recon soln 500 mg meropenem iv 1 gm vial outer, latexfree 1 gram Penicillins amoxicillin oral capsule 250 mg, 500 mg amoxicillin oral suspension for reconstitution 125 mg/5 ml, 200 mg/5 ml, 250 mg/5 ml, 400 mg/5 ml amoxicillin oral tablet 500 mg, 875 mg amoxicillin oral tablet,chewable 125 mg, 250 mg (Erythromycin Ethylsuccinate) (Erythromycin Base) (Erythromycin Base) (Azactam) (Primaxin) (Merrem) (Merrem) (Amoxicillin) (Amoxicillin) (Amoxicillin) (Amoxicillin) LA 26
amoxicillin-pot clavulanate oral suspension for reconstitution 200-28.5 mg/5 ml, 250-62.5 mg/5 ml, 400-57 mg/5 ml, 600-42.9 mg/5 ml amoxicillin-pot clavulanate oral tablet 250-125 mg, 500-125 mg, 875-125 mg amoxicillin-pot clavulanate oral tablet extended release 12 hr 1,000-62.5 mg amoxicillin-pot clavulanate oral tablet,chewable 200-28.5 mg, 400-57 mg ampicillin 2 gm vial 10's, latex-free 2 gram ampicillin oral capsule 250 mg, 500 mg ampicillin oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml ampicillin sodium injection recon soln 1 gram, 10 gram, 125 mg ampicillin sodium intravenous recon soln 2 gram ampicillin-sulbactam injection recon soln 1.5 gram, 15 gram, 3 gram BICILLIN C-R INTRAMUSCULAR SYRINGE 1,200,000 UNIT/ 2 ML(600K/600K), 1,200,000 UNIT/ 2 ML(900K/300K) (Augmentin) (Augmentin) (Augmentin XR) (Amoxicillin/Potas sium Clav) (Ampicillin Sodium) (Ampicillin Trihydrate) (Ampicillin Trihydrate) (Ampicillin Sodium) (Ampicillin Sodium) (Unasyn) 27
BICILLIN L-A INTRAMUSCULAR SYRINGE 1,200,000 UNIT/2 ML, 2,400,000 UNIT/4 ML, 600,000 UNIT/ML dicloxacillin oral capsule 250 mg, 500 mg nafcillin 2 gm vial sterile, latex-free 2 gram nafcillin injection recon soln 1 gram, 10 gram nafcillin intravenous recon soln 2 gram oxacillin 1 gm add-vantage vl addvantage, inner 1 gram oxacillin in dextrose(iso-osm) intravenous piggyback 1 gram/50 ml, 2 gram/50 ml oxacillin injection recon soln 10 gram oxacillin intravenous recon soln 2 gram penicillin g pot in dextrose intravenous piggyback 1 million unit/50 ml, 2 million unit/50 ml, 3 million unit/50 ml penicillin g potassium injection recon soln 5 million unit penicillin g procaine intramuscular syringe 1.2 million unit/2 ml, 600,000 unit/ml penicillin gk 20 million unit 20 million unit penicillin v potassium oral recon soln 125 mg/5 ml, 250 mg/5 ml (Dicloxacillin Sodium) (Nafcillin Sodium) (Nafcillin Sodium) (Nafcillin Sodium) (Oxacillin Sodium) (Oxacillin Sodium/Dextrose, Iso) (Oxacillin Sodium) (Oxacillin Sodium) (Pen G Pot/Dextrose- Water) (Penicillin G Potassium) (Penicillin G Procaine) (Penicillin G Potassium) (Penicillin V Potassium) 28
penicillin v potassium oral tablet (Penicillin V 250 mg, 500 mg Potassium) pfizerpen-g injection recon soln 20 (Penicillin G million unit Potassium) piperacillin-tazobactam intravenous recon soln 2.25 gram, 3.375 gram, (Zosyn) 4.5 gram piperacil-tazobact 40.5 gram p/f, latex-free 40.5 gram (Zosyn) Quinolones ciprofloxacin hcl oral tablet 100 mg, (Cipro) 250 mg, 500 mg, 750 mg ciprofloxacin in 5 % dextrose intravenous piggyback 200 mg/100 ml (Cipro I.V.) ciprofloxacin lactate intravenous (Ciprofloxacin solution 400 mg/40 ml Lactate) ciprofloxacin oral suspension,microcapsule recon 250 (Cipro) mg/5 ml, 500 mg/5 ml ciprofloxacn-d5w 400 mg/200 ml p/f,latex/f, in d5w 400 mg/200 ml (Cipro I.V.) levofloxacin in d5w intravenous piggyback 500 mg/100 ml, 750 (Levaquin) mg/150 ml levofloxacin intravenous solution 25 mg/ml (Levofloxacin) levofloxacin oral solution 250 mg/10 ml (Levaquin) levofloxacin oral tablet 250 mg, 500 mg, 750 mg (Levaquin) moxifloxacin oral tablet 400 mg (Avelox) ofloxacin oral tablet 300 mg, 400 mg (Ofloxacin) 29
Sulfonamides sulfadiazine oral tablet 500 mg (Sulfadiazine) sulfamethoxazole-trimethoprim intravenous solution 400-80 mg/5 ml (Sulfamethoxazole/ Trimethoprim) sulfamethoxazole-trimethoprim oral (Sulfamethoxazole/ suspension 200-40 mg/5 ml Trimethoprim) sulfamethoxazole-trimethoprim oral tablet 400-80 mg, 800-160 mg (Bactrim) sulfasalazine oral tablet 500 mg (Azulfidine) sulfasalazine oral tablet,delayed release (dr/ec) 500 mg (Azulfidine) sulfatrim oral suspension 200-40 (Sulfamethoxazole/ mg/5 ml Trimethoprim) Tetracyclines doxy-100 intravenous recon soln (Doxycycline 100 mg Hyclate) doxycycline hyclate 100 mg cap 100 mg (Morgidox) doxycycline hyclate 100 mg tab 100 mg (Doryx) doxycycline hyclate intravenous (Doxycycline recon soln 100 mg Hyclate) doxycycline hyclate oral capsule 100 mg (Adoxa) doxycycline hyclate oral capsule 50 mg (Morgidox) doxycycline hyclate oral tablet 100 mg, 50 mg (Avidoxy) doxycycline hyclate oral tablet 20 mg (Doryx) doxycycline mono 100 mg cap 100 mg (Adoxa) 30
doxycycline mono 100 mg tablet f/c 100 mg doxycycline mono 50 mg tablet 50 mg doxycycline monohydrate oral capsule 150 mg, 50 mg, 75 mg doxycycline monohydrate oral suspension for reconstitution 25 mg/5 ml doxycycline monohydrate oral tablet 150 mg, 75 mg minocycline oral capsule 100 mg, 50 mg, 75 mg minocycline oral tablet 100 mg, 50 mg, 75 mg tetracycline oral capsule 250 mg, 500 mg TYGACIL INTRAVENOUS RECON SOLN 50 MG Anticancer Agents Anticancer Agents ABRAXANE INTRAVENOUS SUSPENSION FOR RECONSTITUTION 100 MG ADCETRIS INTRAVENOUS RECON SOLN 50 MG adriamycin intravenous recon soln 10 mg, 20 mg, 50 mg adriamycin intravenous solution 50 mg/25 ml adrucil 2,500 mg/50 ml vial outer, latex-free 2.5 gram/50 ml adrucil intravenous solution 500 mg/10 ml (Avidoxy) (Avidoxy) (Adoxa) (Vibramycin) (Avidoxy) (Minocin) (Minocycline HCl) (Tetracycline HCl) (Doxorubicin HCl) (Doxorubicin HCl) (Fluorouracil) (Fluorouracil) PA NSO; QL (4 per 21 days) 31
AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION 2 MG, 3 MG, 5 MG AFINITOR ORAL TABLET 10 MG AFINITOR ORAL TABLET 2.5 MG, 5 MG, 7.5 MG ALECENSA ORAL CAPSULE 150 MG ALIMTA INTRAVENOUS RECON SOLN 500 MG anastrozole oral tablet 1 mg (Arimidex) AVASTIN INTRAVENOUS SOLUTION 25 MG/ML, 25 MG/ML (16 ML) azacitidine injection recon soln 100 mg (Vidaza) BELEODAQ INTRAVENOUS RECON SOLN 500 MG BENDEKA INTRAVENOUS SOLUTION 25 MG/ML bexarotene oral capsule 75 mg (Targretin) bicalutamide oral tablet 50 mg (Casodex) bleomycin injection recon soln 30 (Bleomycin unit Sulfate) bleomycin sulfate 15 unit vial latexfree 15 unit Sulfate) (Bleomycin BLINCYTO INTRAVENOUS KIT 35 MCG BOSULIF ORAL TABLET 100 MG BOSULIF ORAL TABLET 500 MG PA NSO; QL (112 per 28 days) PA NSO; QL (56 per 28 days) PA NSO; QL (28 per 28 days) PA NSO; QL (240 per 30 days) PA NSO PA NSO PA NSO PA NSO; QL (420 per 30 days) PA NSO; QL (140 per 365 days) PA NSO; QL (120 per 30 days) PA NSO; QL (30 per 30 days) 32
CABOMETYX ORAL TABLET 20 MG, 60 MG CABOMETYX ORAL TABLET 40 MG CAPRELSA ORAL TABLET 100 MG CAPRELSA ORAL TABLET 300 MG COMETRIQ ORAL CAPSULE 100 MG/DAY(80 MG X1-20 MG X1), 140 MG/DAY(80 MG X1-20 MG X3), 60 MG/DAY (20 MG X 3/DAY) COTELLIC ORAL TABLET 20 MG cyclophosphamide intravenous recon soln 1 gram, 2 gram, 500 mg CYCLOPHOSPHAMIDE ORAL CAPSULE 25 MG, 50 MG cyclophosphamide oral tablet 25 mg, 50 mg CYRAMZA INTRAVENOUS SOLUTION 10 MG/ML, 10 MG/ML (50 ML) dactinomycin intravenous recon soln 0.5 mg DARZALEX INTRAVENOUS SOLUTION 20 MG/ML decitabine intravenous recon soln 50 mg doxorubicin, peg-liposomal intravenous suspension 2 mg/ml DROXIA ORAL CAPSULE 200 MG, 300 MG, 400 MG (Cyclophosphamid e) (Cyclophosphamid e) (Dactinomycin) (Dacogen) (Doxil) PA NSO; QL (30 per 30 days) PA NSO; QL (60 per 30 days) PA NSO; QL (60 per 30 days) PA NSO; QL (30 per 30 days) PA NSO; QL (112 per 28 days) PA NSO; LA; QL (63 per 28 days) ; ST ; ST PA NSO PA NSO; LA 33
ELIGARD (3 MONTH) SUBCUTANEOUS SYRINGE 22.5 MG ELIGARD (4 MONTH) SUBCUTANEOUS SYRINGE 30 MG ELIGARD (6 MONTH) SUBCUTANEOUS SYRINGE 45 MG ELIGARD SUBCUTANEOUS SYRINGE 7.5 MG (1 MONTH) EMCYT ORAL CAPSULE 140 MG EMPLICITI INTRAVENOUS RECON SOLN 300 MG, 400 MG ERIVEDGE ORAL CAPSULE 150 MG ETOPOPHOS INTRAVENOUS RECON SOLN 100 MG etoposide intravenous solution 20 mg/ml (Etoposide) exemestane oral tablet 25 mg (Aromasin) FARESTON ORAL TABLET 60 MG FARYDAK ORAL CAPSULE 10 MG, 15 MG, 20 MG FASLODEX INTRAMUSCULAR SYRINGE 250 MG/5 ML floxuridine injection recon soln 0.5 gram (Floxuridine) fluorouracil 5,000 mg/100 ml latexfree 5 gram/100 ml (Fluorouracil) QL (1 per 84 days) QL (1 per 112 days) QL (1 per 168 days) PA NSO PA NSO; QL (30 per 30 days) PA NSO 34
fluorouracil intravenous solution 1 gram/20 ml, 2.5 gram/50 ml, 500 mg/10 ml (Fluorouracil) flutamide oral capsule 125 mg (Flutamide) GAZYVA INTRAVENOUS SOLUTION 1,000 MG/40 ML GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG HERCEPTIN INTRAVENOUS RECON SOLN 440 MG HEXALEN ORAL CAPSULE 50 MG hydroxyurea oral capsule 500 mg (Hydrea) IBRANCE ORAL CAPSULE 100 MG, 125 MG, 75 MG ICLUSIG ORAL TABLET 15 MG ICLUSIG ORAL TABLET 45 MG ifosfamide 1 gm/20 ml vial suv 1 gram/20 ml ifosfamide intravenous recon soln 1 gram ifosfamide-mesna intravenous kit 1-1 gram, 3,000-1,000 mg (Ifex) (Ifex) (Ifosfamide/Mesna ) imatinib oral tablet 100 mg (Gleevec) imatinib oral tablet 400 mg (Gleevec) IMBRUVICA ORAL CAPSULE 140 MG PA NSO PA NSO; QL (30 per 30 days) PA NSO PA NSO; QL (21 per 28 days) PA NSO; QL (60 per 30 days) PA NSO; QL (30 per 30 days) PA NSO; QL (90 per 30 days) PA NSO; QL (60 per 30 days) PA NSO 35
IMLYGIC INJECTION SUSPENSION 10EXP6 (1 MILLION) PFU/ML IMLYGIC INJECTION SUSPENSION 10EXP8 (100 MILLION) PFU/ML INLYTA ORAL TABLET 1 MG INLYTA ORAL TABLET 5 MG IRESSA ORAL TABLET 250 MG IXEMPRA 15 MG KIT WITH DILUENT 15 MG IXEMPRA INTRAVENOUS RECON SOLN 45 MG JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 25 MG, 5 MG KEYTRUDA INTRAVENOUS RECON SOLN 50 MG KEYTRUDA INTRAVENOUS SOLUTION 100 MG/4 ML (25 MG/ML) KYPROLIS INTRAVENOUS RECON SOLN 30 MG KYPROLIS INTRAVENOUS RECON SOLN 60 MG LARTRUVO INTRAVENOUS SOLUTION 10 MG/ML PA NSO; QL (4 per 365 days) PA NSO; QL (8 per 28 days) PA NSO; QL (180 per 30 days) PA NSO; QL (60 per 30 days) PA NSO; QL (60 per 30 days) PA NSO; QL (60 per 30 days) PA NSO PA NSO PA NSO; QL (12 per 28 days) PA NSO; QL (6 per 28 days) PA NSO; LA 36
LENVIMA ORAL CAPSULE 10 MG/DAY (10 MG X 1/DAY), 14 MG/DAY(10 MG X 1-4 MG X 1), 18 MG/DAY (10 MG X 1-4 MG X2), 20 MG/DAY (10 MG X 2), 24 MG/DAY(10 MG X 2-4 MG X 1), 8 MG/DAY (4 MG X 2) letrozole oral tablet 2.5 mg (Femara) LEUKERAN ORAL TABLET 2 MG leuprolide subcutaneous kit 1 mg/0.2 ml lipodox 50 intravenous suspension 2 mg/ml lipodox intravenous suspension 2 mg/ml lomustine oral capsule 10 mg, 100 mg, 40 mg LONSURF ORAL TABLET 15-6.14 MG LONSURF ORAL TABLET 20-8.19 MG LUPRON DEPOT (3 MONTH) INTRAMUSCULAR SYRINGE KIT 11.25 MG, 22.5 MG LUPRON DEPOT (4 MONTH) INTRAMUSCULAR SYRINGE KIT 30 MG LUPRON DEPOT (6 MONTH) INTRAMUSCULAR SYRINGE KIT 45 MG LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 3.75 MG, 7.5 MG (Leuprolide Acetate) (Doxil) (Doxil) (Lomustine) PA NSO PA NSO; QL (100 per 28 days) PA NSO; QL (80 per 28 days) QL (1 per 84 days) QL (1 per 84 days) QL (1 per 168 days) 37
LYNPARZA ORAL CAPSULE 50 MG LYSODREN ORAL TABLET 500 MG MATULANE ORAL CAPSULE 50 MG megestrol oral tablet 20 mg, 40 mg MEKINIST ORAL TABLET 0.5 MG (Megestrol Acetate) MEKINIST ORAL TABLET 2 MG mercaptopurine oral tablet 50 mg (Mercaptopurine) methotrexate 50 mg/2 ml vial latexfree, 5's, mdv 25 mg/ml Sodium) (Methotrexate methotrexate sodium (pf) injection (Methotrexate recon soln 1 gram Sodium/PF) methotrexate sodium (pf) injection (Methotrexate solution 25 mg/ml Sodium) methotrexate sodium oral tablet 2.5 (Methotrexate mg Sodium) mitoxantrone intravenous (Mitoxantrone concentrate 2 mg/ml HCl) NEXAVAR ORAL TABLET 200 MG NILANDRON ORAL TABLET 150 MG nilutamide oral tablet 150 mg (Nilandron) NINLARO ORAL CAPSULE 2.3 MG, 3 MG, 4 MG ODOMZO ORAL CAPSULE 200 MG ONCASPAR INJECTION SOLUTION 750 UNIT/ML PA NSO; QL (480 per 30 days) PA NSO; QL (90 per 30 days) PA NSO; QL (30 per 30 days) ; ST PA NSO; QL (120 per 30 days) PA NSO; QL (3 per 28 days) PA NSO; LA PA NSO 38
OPDIVO INTRAVENOUS SOLUTION 40 MG/4 ML POMALYST ORAL CAPSULE 1 MG, 2 MG, 3 MG, 4 MG PORTRAZZA INTRAVENOUS SOLUTION 800 MG/50 ML (16 MG/ML) PROLEUKIN INTRAVENOUS RECON SOLN 22 MILLION UNIT PURIXAN ORAL SUSPENSION 20 MG/ML REVLIMID ORAL CAPSULE 10 MG, 15 MG, 2.5 MG, 20 MG, 25 MG, 5 MG RITUXAN INTRAVENOUS CONCENTRATE 10 MG/ML SOLTAMOX ORAL SOLUTION 10 MG/5 ML SPRYCEL ORAL TABLET 100 MG, 140 MG, 50 MG, 70 MG, 80 MG SPRYCEL ORAL TABLET 20 MG STIVARGA ORAL TABLET 40 MG SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 37.5 MG, 50 MG SYLVANT INTRAVENOUS RECON SOLN 100 MG, 400 MG SYNRIBO SUBCUTANEOUS RECON SOLN 3.5 MG TABLOID ORAL TABLET 40 MG TAFINLAR ORAL CAPSULE 50 MG, 75 MG PA NSO PA NSO; QL (21 per 28 days) PA NSO; QL (100 per 21 days) PA NSO; LA PA NSO PA NSO; QL (30 per 30 days) PA NSO; QL (60 per 30 days) PA NSO; QL (84 per 28 days) PA NSO; QL (30 per 30 days) PA NSO PA NSO; QL (28 per 28 days) PA NSO; QL (120 per 30 days) 39
TAGRISSO ORAL TABLET 40 MG, 80 MG tamoxifen oral tablet 10 mg, 20 mg TARCEVA ORAL TABLET 100 MG, 25 MG TARCEVA ORAL TABLET 150 MG TARGRETIN ORAL CAPSULE 75 MG (Tamoxifen Citrate) TARGRETIN TOPICAL GEL 1 % TASIGNA ORAL CAPSULE 150 MG, 200 MG TECENTRIQ INTRAVENOUS SOLUTION 1,200 MG/20 ML (60 MG/ML) TEMODAR INTRAVENOUS RECON SOLN 100 MG thiotepa injection recon soln 15 mg (Thiotepa) toposar intravenous solution 20 mg/ml (Etoposide) TREANDA 25 MG VIAL 25 MG TREANDA INTRAVENOUS RECON SOLN 100 MG TREANDA INTRAVENOUS SOLUTION 180 MG/2 ML, 45 MG/0.5 ML TRELSTAR 22.5 MG SYRINGE OUTER, LATEX-FREE 22.5 MG/2 ML TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 22.5 MG PA NSO; LA; QL (30 per 30 days) PA NSO; QL (60 per 30 days) PA NSO; QL (90 per 30 days) PA NSO; QL (420 per 30 days) PA NSO; QL (60 per 28 days) PA NSO; QL (112 per 28 days) PA NSO; QL (20 per 21 days) PA NSO; (vial only) QL (1 per 168 days) QL (1 per 168 days) 40
TRELSTAR INTRAMUSCULAR SYRINGE 11.25 MG/2 ML TRELSTAR INTRAMUSCULAR SYRINGE 3.75 MG/2 ML tretinoin (chemotherapy) oral capsule 10 mg (Tretinoin) TREXALL ORAL TABLET 10 MG, 15 MG, 5 MG, 7.5 MG TYKERB ORAL TABLET 250 MG UNITUXIN INTRAVENOUS SOLUTION 3.5 MG/ML VALSTAR INTRAVESICAL SOLUTION 40 MG/ML VELCADE INJECTION RECON SOLN 3.5 MG VENCLEXTA ORAL TABLET 10 MG, 100 MG, 50 MG VENCLEXTA STARTING PACK ORAL TABLETS,DOSE PACK 10 MG-50 MG- 100 MG vinorelbine intravenous solution 50 mg/5 ml (Navelbine) VOTRIENT ORAL TABLET 200 MG XALKORI ORAL CAPSULE 200 MG, 250 MG XTANDI ORAL CAPSULE 40 MG YERVOY INTRAVENOUS SOLUTION 50 MG/10 ML (5 MG/ML) YONDELIS INTRAVENOUS RECON SOLN 1 MG QL (1 per 84 days) (capsule: 10mg) ; ST PA NSO PA NSO PA NSO; LA PA NSO; LA PA NSO; QL (120 per 30 days) PA NSO; QL (60 per 30 days) PA NSO; QL (120 per 30 days) PA NSO PA NSO 41
ZELBORAF ORAL TABLET 240 MG ZOLADEX SUBCUTANEOUS IMPLANT 10.8 MG ZOLADEX SUBCUTANEOUS IMPLANT 3.6 MG ZOLINZA ORAL CAPSULE 100 MG ZYDELIG ORAL TABLET 100 MG, 150 MG ZYKADIA ORAL CAPSULE 150 MG ZYTIGA ORAL TABLET 250 MG Anticholinergic Agents Antimuscarinics/Antispasm odics atropine injection solution 0.4 mg/ml atropine injection syringe 0.05 mg/ml, 0.1 mg/ml atropine intravenous syringe 0.8 mg/2 ml (0.4 mg/ml) propantheline oral tablet 15 mg STIOLTO RESPIMAT INHALATION MIST 2.5-2.5 MCG/ACTUATION Anticonvulsants Anticonvulsants APTIOM ORAL TABLET 200 MG, 400 MG, 600 MG, 800 MG BANZEL ORAL SUSPENSION 40 MG/ML (Atropine Sulfate) (Atropine Sulfate) (Atropine Sulfate) (Propantheline Bromide) PA NSO; QL (240 per 30 days) QL (1 per 84 days) QL (1 per 28 days) PA NSO; QL (60 per 30 days) PA NSO; QL (140 per 28 days) PA NSO; QL (120 per 30 days) QL (4 per 28 days) ST ST 42
BANZEL ORAL TABLET 200 MG, 400 MG BRIVIACT INTRAVENOUS SOLUTION 50 MG/5 ML BRIVIACT ORAL SOLUTION 10 MG/ML BRIVIACT ORAL TABLET 10 MG, 100 MG, 25 MG, 50 MG, 75 MG carbamazepine oral capsule, er multiphase 12 hr 100 mg, 200 mg, (Carbatrol) 300 mg carbamazepine oral suspension 100 mg/5 ml (Tegretol) carbamazepine oral tablet 200 mg (Tegretol) carbamazepine oral tablet extended release 12 hr 100 mg, 200 mg, 400 (Tegretol XR) mg carbamazepine oral tablet,chewable 100 mg (Carbamazepine) CELONTIN ORAL CAPSULE 300 MG DILANTIN ORAL CAPSULE 30 MG divalproex oral capsule, sprinkle (Depakote 125 mg Sprinkle) divalproex oral tablet extended release 24 hr 250 mg, 500 mg (Depakote ER) divalproex oral tablet,delayed release (dr/ec) 125 mg, 250 mg, 500 (Depakote) mg epitol oral tablet 200 mg (Tegretol) ethosuximide oral capsule 250 mg (Zarontin) ST QL (80 per 30 days) QL (600 per 30 days) QL (60 per 30 days) 43
ethosuximide oral solution 250 mg/5 ml felbamate oral suspension 600 mg/5 ml felbamate oral tablet 400 mg, 600 mg fosphenytoin 500 mg pe/10 ml 10's,sdv,latex-free 500 mg pe/10 ml fosphenytoin injection solution 100 mg pe/2 ml FYCOMPA ORAL SUSPENSION 0.5 MG/ML FYCOMPA ORAL TABLET 10 MG, 12 MG, 2 MG, 4 MG, 6 MG, 8 MG gabapentin oral capsule 100 mg, 300 mg, 400 mg gabapentin oral solution 250 mg/5 ml gabapentin oral tablet 600 mg, 800 mg GABITRIL ORAL TABLET 12 MG, 16 MG LAMICTAL ORAL TABLET, CHEWABLE DISPERSIBLE 2 MG lamotrigine oral tablet 100 mg, 150 mg, 200 mg, 25 mg lamotrigine oral tablet extended release 24hr 100 mg, 200 mg, 25 mg, 250 mg, 300 mg, 50 mg lamotrigine oral tablet, chewable dispersible 25 mg, 5 mg lamotrigine oral tablets,dose pack 25 mg (35) (Zarontin) (Felbatol) (Felbatol) (Cerebyx) (Cerebyx) (Neurontin) (Neurontin) (Neurontin) (Lamictal) (Lamictal XR) (Lamictal) (Lamictal (Blue)) ST ST 44
levetiracetam intravenous solution 500 mg/5 ml (Keppra) levetiracetam oral solution 100 mg/ml (Keppra) levetiracetam oral tablet 1,000 mg, 250 mg, 500 mg, 750 mg (Roweepra) levetiracetam oral tablet extended release 24 hr 500 mg, 750 mg (Keppra XR) LYRICA ORAL CAPSULE 100 QL (90 per 30 days) MG, 150 MG, 200 MG, 225 MG, 25 MG, 300 MG, 50 MG, 75 MG LYRICA ORAL SOLUTION 20 QL (900 per 30 days) MG/ML oxcarbazepine oral suspension 300 mg/5 ml (Trileptal) oxcarbazepine oral tablet 150 mg, 300 mg, 600 mg (Trileptal) OXTELLAR XR ORAL TABLET ST EXTENDED RELEASE 24 HR 150 MG, 300 MG, 600 MG PEGANONE ORAL TABLET 250 MG phenobarbital oral elixir 20 mg/5 ml QL (1500 per 30 days) (Phenobarbital) (4 mg/ml) phenobarbital oral tablet 100 mg, QL (90 per 30 days) 15 mg, 16.2 mg, 32.4 mg, 60 mg, 64.8 mg, 97.2 mg (Phenobarbital) phenobarbital oral tablet 30 mg (Phenobarbital) QL (200 per 30 days) phenobarbital sodium injection (Phenobarbital QL (2 per 30 days) solution 130 mg/ml, 65 mg/ml Sodium) phenytoin oral suspension 125 mg/5 ml (Dilantin-125) phenytoin oral tablet,chewable 50 mg (Dilantin) 45
phenytoin sodium extended oral capsule 100 mg, 200 mg, 300 mg (Dilantin) phenytoin sodium intravenous (Phenytoin solution 50 mg/ml Sodium) phenytoin sodium intravenous (Phenytoin syringe 50 mg/ml Sodium) POTIGA ORAL TABLET 200 MG, QL (90 per 30 days) 300 MG, 400 MG POTIGA ORAL TABLET 50 MG QL (270 per 30 days) primidone oral tablet 250 mg, 50 mg (Mysoline) ROWEEPRA ORAL TABLET 500 MG SABRIL ORAL POWDER IN PACKET 500 MG SABRIL ORAL TABLET 500 MG SPRITAM ORAL TABLET FOR ST; QL (60 per 30 SUSPENSION 1,000 MG days) SPRITAM ORAL TABLET FOR SUSPENSION 250 MG, 500 MG, 750 MG tiagabine oral tablet 2 mg, 4 mg (Gabitril) topiragen oral tablet 100 mg, 200 mg, 25 mg, 50 mg (Topamax) topiramate oral capsule, sprinkle 15 mg, 25 mg (Topamax) topiramate oral capsule,sprinkle,er 24hr 100 mg, 150 mg, 200 mg, 25 (Qudexy XR) mg, 50 mg topiramate oral tablet 100 mg, 200 mg, 25 mg, 50 mg (Topamax) TROKENDI XR ORAL CAPSULE,EXTENDED RELEASE 24HR 100 MG, 200 MG, 25 MG, 50 MG ST; QL (120 per 30 days) ST 46
valproate sodium intravenous solution 500 mg/5 ml (100 mg/ml) (Depacon) valproic acid (as sodium salt) oral solution 250 mg/5 ml (Depakene) valproic acid oral capsule 250 mg (Depakene) VIMPAT INTRAVENOUS SOLUTION 200 MG/20 ML VIMPAT ORAL SOLUTION 10 MG/ML VIMPAT ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG zonisamide oral capsule 100 mg, 25 mg, 50 mg (Zonegran) Antidementia Agents Antidementia Agents donepezil oral tablet 10 mg, 23 mg, QL (200 per 5 days) QL (1200 per 30 days) QL (60 per 30 days) QL (30 per 30 days) (Aricept) 5 mg donepezil oral tablet,disintegrating QL (30 per 30 days) (Donepezil HCl) 10 mg, 5 mg galantamine oral capsule,ext rel. QL (30 per 30 days) (Razadyne ER) pellets 24 hr 16 mg, 24 mg, 8 mg galantamine oral solution 4 mg/ml (Galantamine Hbr) QL (200 per 30 days) galantamine oral tablet 12 mg, 4 QL (60 per 30 days) (Razadyne) mg, 8 mg memantine oral solution 2 mg/ml (Namenda) QL (360 per 30 days) memantine oral tablet 10 mg, 5 mg (Namenda) QL (60 per 30 days) memantine oral tablets,dose pack 5- QL (49 per 28 days) (Namenda) 10 mg NAMENDA XR ORAL QL (28 per 28 days) CAP,SPRINKLE,ER 24HR DOSE PACK 7-14-21-28 MG NAMENDA XR ORAL QL (30 per 30 days) CAPSULE,SPRINKLE,ER 24HR 14 MG, 21 MG, 28 MG, 7 MG 47
NAMZARIC ORAL CAP,SPRINKLE,ER 24HR DOSE PACK 7/14/21/28 MG-10 MG NAMZARIC ORAL CAPSULE,SPRINKLE,ER 24HR 14-10 MG, 21-10 MG, 28-10 MG, 7-10 MG rivastigmine tartrate oral capsule 1.5 mg, 3 mg, 4.5 mg, 6 mg rivastigmine transdermal patch 24 hour 13.3 mg/24 hour, 4.6 mg/24 hr, 9.5 mg/24 hr Antidepressants Antidepressants amitriptyline oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg amoxapine oral tablet 100 mg, 150 mg, 25 mg, 50 mg BRINTELLIX ORAL TABLET 10 MG, 20 MG, 5 MG buproban oral tablet extended release 150 mg bupropion hcl (smoking deter) oral tablet extended release 150 mg bupropion hcl oral tablet 100 mg, 75 mg bupropion hcl oral tablet extended release 100 mg, 150 mg, 200 mg bupropion hcl oral tablet extended release 24 hr 150 mg, 300 mg citalopram oral solution 10 mg/5 ml citalopram oral tablet 10 mg, 20 mg, 40 mg (Exelon) (Exelon) (Amitriptyline HCl) (Amoxapine) (Wellbutrin SR) (Wellbutrin SR) (Wellbutrin) (Wellbutrin SR) (Wellbutrin XL) (Citalopram Hydrobromide) (Celexa) QL (56 per 365 days) QL (60 per 30 days) QL (30 per 30 days) PA NSO-HRM ST QL (30 per 30 days) 48
clomipramine oral capsule 25 mg, PA NSO-HRM (Anafranil) 50 mg, 75 mg desipramine oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg (Norpramin) doxepin oral capsule 10 mg, 100 PA NSO-HRM (Doxepin HCl) mg, 150 mg, 25 mg, 50 mg, 75 mg doxepin oral concentrate 10 mg/ml (Doxepin HCl) PA NSO-HRM duloxetine oral capsule,delayed (Cymbalta); QL (60 (Duloxetine) release(dr/ec) 20 mg, 60 mg per 30 days) duloxetine oral capsule,delayed (Cymbalta); QL (30 (Duloxetine) release(dr/ec) 30 mg per 30 days) duloxetine oral capsule,delayed (Irenka); QL (30 per 30 (Duloxetine) release(dr/ec) 40 mg days) EMSAM TRANSDERMAL QL (30 per 30 days) PATCH 24 HOUR 12 MG/24 HR, 6 MG/24 HR, 9 MG/24 HR escitalopram oxalate oral solution 5 mg/5 ml (Lexapro) escitalopram oxalate oral tablet 10 mg, 20 mg, 5 mg (Lexapro) FETZIMA ORAL CAPSULE,EXT ST REL 24HR DOSE PACK 20 MG (2)- 40 MG (26) FETZIMA ORAL ST CAPSULE,EXTENDED RELEASE 24 HR 120 MG, 20 MG, 40 MG, 80 MG fluoxetine oral capsule 10 mg, 20 mg, 40 mg (Prozac) fluoxetine oral capsule,delayed release(dr/ec) 90 mg (Prozac Weekly) fluoxetine oral solution 20 mg/5 ml (4 mg/ml) (Fluoxetine HCl) fluoxetine oral tablet 10 mg, 20 mg (Fluoxetine HCl) 49
fluvoxamine oral capsule,extended release 24hr 100 mg, 150 mg fluvoxamine oral tablet 100 mg, 25 mg, 50 mg imipramine hcl oral tablet 10 mg, 25 mg, 50 mg imipramine pamoate oral capsule 100 mg, 125 mg, 150 mg, 75 mg maprotiline oral tablet 25 mg, 50 mg, 75 mg MARPLAN ORAL TABLET 10 MG mirtazapine oral tablet 15 mg, 30 mg, 45 mg, 7.5 mg mirtazapine oral tablet,disintegrating 15 mg, 30 mg, 45 mg nefazodone oral tablet 100 mg, 150 mg, 200 mg, 250 mg, 50 mg nortriptyline oral capsule 10 mg, 25 mg, 50 mg, 75 mg nortriptyline oral solution 10 mg/5 ml olanzapine-fluoxetine oral capsule 12-25 mg, 12-50 mg, 3-25 mg, 6-25 mg, 6-50 mg paroxetine hcl oral tablet 10 mg, 20 mg, 30 mg, 40 mg paroxetine hcl oral tablet extended release 24 hr 12.5 mg, 25 mg, 37.5 mg PAXIL ORAL SUSPENSION 10 MG/5 ML (Fluvoxamine Maleate) (Fluvoxamine Maleate) (Tofranil) (Tofranil-Pm) (Maprotiline HCl) (Remeron) (Remeron) (Nefazodone HCl) (Pamelor) (Nortriptyline HCl) (Symbyax) (Paxil) (Paxil CR) PA NSO-HRM PA NSO-HRM 50
perphenazine-amitriptyline oral tablet 2-10 mg, 2-25 mg, 4-10 mg, 4-25 mg, 4-50 mg (Perphenazine/Ami triptyline HCl) phenelzine oral tablet 15 mg (Nardil) PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 100 MG, 25 MG, 50 MG protriptyline oral tablet 10 mg, 5 mg (Protriptyline HCl) sertraline oral concentrate 20 mg/ml (Zoloft) sertraline oral tablet 100 mg, 25 mg, 50 mg (Zoloft) SILENOR ORAL TABLET 3 MG, 6 MG SURMONTIL ORAL CAPSULE 100 MG, 25 MG, 50 MG tranylcypromine oral tablet 10 mg (Parnate) trazodone oral tablet 100 mg, 150 mg, 300 mg, 50 mg (Trazodone HCl) trimipramine oral capsule 100 mg, (Trimipramine 25 mg, 50 mg Maleate) TRINTELLIX ORAL TABLET 10 MG, 20 MG, 5 MG venlafaxine oral capsule,extended release 24hr 150 mg, 37.5 mg, 75 (Effexor XR) mg venlafaxine oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 75 mg venlafaxine oral tablet extended release 24hr 150 mg, 37.5 mg, 75 mg VIIBRYD ORAL TABLET 10 MG, 20 MG, 40 MG (Venlafaxine HCl) (Venlafaxine HCl) PA NSO-HRM ST; QL (30 per 30 days) QL (30 per 30 days) PA NSO-HRM PA NSO-HRM ST 51
VIIBRYD ORAL TABLETS,DOSE PACK 10 MG (7)- 20 MG (23), 10 MG (7)-20 MG (7)-40 MG (16) Antidiabetic Agents Antidiabetic Agents, Miscellaneous acarbose oral tablet 100 mg, 25 mg, 50 mg CYCLOSET ORAL TABLET 0.8 MG GLYXAMBI ORAL TABLET 10-5 MG, 25-5 MG INVOKAMET ORAL TABLET 150-1,000 MG, 150-500 MG, 50-1,000 MG, 50-500 MG INVOKAMET XR ORAL TABLET, IR - ER, BIPHASIC 24HR 150-1,000 MG, 150-500 MG, 50-1,000 MG, 50-500 MG INVOKANA ORAL TABLET 100 MG, 300 MG JANUMET ORAL TABLET 50-1,000 MG, 50-500 MG JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 100-1,000 MG, 50-1,000 MG, 50-500 MG JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG JARDIANCE ORAL TABLET 10 MG, 25 MG JENTADUETO ORAL TABLET 2.5-1,000 MG, 2.5-500 MG, 2.5-850 MG (Precose) QL (90 per 30 days) QL (180 per 30 days) ST ST ST ST ST 52
JENTADUETO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 2.5-1,000 MG, 5-1,000 MG KORLYM ORAL TABLET 300 MG PA; QL (112 per 28 days) metformin oral tablet 1,000 mg (Glucophage) QL (75 per 30 days) metformin oral tablet 500 mg (Glucophage) QL (150 per 30 days) metformin oral tablet 850 mg (Glucophage) QL (90 per 30 days) metformin oral tablet extended QL (120 per 30 days) (Glucophage XR) release 24 hr 500 mg metformin oral tablet extended QL (90 per 30 days) (Glucophage XR) release 24 hr 750 mg metformin oral tablet extended QL (60 per 30 days) (Fortamet) release 24hr 1,000 mg metformin oral tablet extended QL (150 per 30 days) (Fortamet) release 24hr 500 mg miglitol oral tablet 100 mg, 25 mg, QL (90 per 30 days) (Glyset) 50 mg nateglinide oral tablet 120 mg, 60 QL (90 per 30 days) (Starlix) mg pioglitazone oral tablet 15 mg, 30 QL (30 per 30 days) (Actos) mg, 45 mg pioglitazone-glimepiride oral tablet QL (30 per 30 days) (Duetact) 30-2 mg, 30-4 mg pioglitazone-metformin oral tablet QL (90 per 30 days) (Actoplus Met) 15-500 mg, 15-850 mg repaglinide oral tablet 0.5 mg, 1 mg, QL (240 per 30 days) (Prandin) 2 mg repaglinide-metformin oral tablet 1- QL (150 per 30 days) (Prandimet) 500 mg, 2-500 mg SYMLINPEN 120 SUBCUTANEOUS PEN INJECTOR 2,700 MCG/2.7 ML PA; QL (10.8 per 28 days) 53
SYMLINPEN 60 SUBCUTANEOUS PEN INJECTOR 1,500 MCG/1.5 ML SYNJARDY ORAL TABLET 12.5-1,000 MG, 12.5-500 MG, 5-1,000 MG, 5-500 MG TRADJENTA ORAL TABLET 5 MG TRULICITY SUBCUTANEOUS PEN INJECTOR 0.75 MG/0.5 ML, 1.5 MG/0.5 ML VICTOZA Insulins HUMULIN R U-500 (CONC) KWIKPEN SUBCUTANEOUS INSULIN PEN 500 UNIT/ML (3 ML) HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS SOLUTION 500 UNIT/ML LANTUS SOLOSTAR SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML) LANTUS SUBCUTANEOUS SOLUTION 100 UNIT/ML NOVOLIN 70/30 SUBCUTANEOUS SUSPENSION 100 UNIT/ML (70-30) NOVOLIN N SUBCUTANEOUS SUSPENSION 100 UNIT/ML NOVOLIN R INJECTION SOLUTION 100 UNIT/ML PA; QL (6 per 28 days) ST QL (24 per 28 days) QL (40 per 28 days) QL (40 per 28 days) QL (40 per 28 days) QL (40 per 28 days) 54
NOVOLOG FLEXPEN QL (30 per 28 days) SUBCUTANEOUS INSULIN PEN 100 UNIT/ML NOVOLOG MIX 70-30 FLEXPEN QL (30 per 28 days) SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (70-30) NOVOLOG MIX 70-30 QL (40 per 28 days) SUBCUTANEOUS SOLUTION 100 UNIT/ML (70-30) NOVOLOG PENFILL QL (30 per 28 days) SUBCUTANEOUS CARTRIDGE 100 UNIT/ML NOVOLOG SUBCUTANEOUS QL (40 per 28 days) SOLUTION 100 UNIT/ML TOUJEO SOLOSTAR SUBCUTANEOUS INSULIN PEN 300 UNIT/ML (1.5 ML) Sulfonylureas glimepiride oral tablet 1 mg, 2 mg (Amaryl) QL (30 per 30 days) glimepiride oral tablet 4 mg (Amaryl) QL (60 per 30 days) glipizide oral tablet 10 mg (Glucotrol) QL (120 per 30 days) glipizide oral tablet 5 mg (Glucotrol) QL (60 per 30 days) glipizide oral tablet extended QL (60 per 30 days) (Glucotrol XL) release 24hr 10 mg glipizide oral tablet extended QL (30 per 30 days) (Glucotrol XL) release 24hr 2.5 mg, 5 mg glipizide-metformin oral tablet 2.5- (Glipizide/Metform QL (240 per 30 days) 250 mg glipizide-metformin oral tablet 2.5-500 mg, 5-500 mg glyburide micronized oral tablet 1.5 mg, 3 mg, 6 mg glyburide oral tablet 1.25 mg, 2.5 mg, 5 mg in HCl) (Glipizide/Metform in HCl) (Glynase) (Glyburide) QL (120 per 30 days) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) 55
glyburide-metformin oral tablet PA-HRM; AGE (Max (Glucovance) 1.25-250 mg, 2.5-500 mg, 5-500 mg 64 Years) tolazamide oral tablet 250 mg (Tolazamide) QL (120 per 30 days) tolazamide oral tablet 500 mg (Tolazamide) QL (60 per 30 days) tolbutamide oral tablet 500 mg (Tolbutamide) QL (180 per 30 days) Antifungals Antifungals ABELCET INTRAVENOUS SUSPENSION 5 MG/ML aloe vesta 2% antifungal oint 2 % * (Miconazole Nitrate) AMBISOME INTRAVENOUS SUSPENSION FOR RECONSTITUTION 50 MG amphotericin b injection recon soln (Amphotericin B) 50 mg anti-fungal 1% powder 1 % * (Tolnaftate) antifungal 2% cream 2 % * (Nuzole) baza antifungal 2% cream 12's 2 % (Nuzole) * blis-to-sol 1% liquid 1 % * (Tolnaftate) CANCIDAS INTRAVENOUS RECON SOLN 50 MG, 70 MG ciclopirox topical cream 0.77 % (Loprox) ciclopirox topical gel 0.77 % (Loprox) ciclopirox topical shampoo 1 % (Loprox) ciclopirox topical solution 8 % (Penlac) ciclopirox topical suspension 0.77 (Ciclopirox % Olamine) ciclopirox-ure-camph-menth-euc (Ciclodan) topical solution 8 % clotrim 1% vaginal cream 1 % * (Gyne-Lotrimin) clotrimazole 1% cream (otc) 1 % * (Lotrimin AF) 56
clotrimazole 1% solution (otc) 1 % * (Clotrimazole) clotrimazole insert 100 mg * (Clotrimazole) clotrimazole mucous membrane troche 10 mg (Clotrimazole) clotrimazole topical cream 1 % (Clotrimazole) clotrimazole topical solution 1 % (Clotrimazole) clotrimazole-7 cream 1 % * (Gyne-Lotrimin) clotrimazole-betamethasone topical cream 1-0.05 % (Lotrisone) clotrimazole-betamethasone topical (Clotrimazole/Beta lotion 1-0.05 % methasone Dip) critic-aid clear af 2% oint 12's, w/ (Miconazole antifungal 2 % * Nitrate) cvs 3-day vaginal cream 2 % * (Gyne-Lotrimin) cvs af 1% spray powder 1 % * (Tinactin) cvs miconazole 3 combo pack 3pref applic w/cream 4 % (200 mg)- 2 % (9 gram) * (Miconazole Nitrate) dermafungal 2% ointment 2 % * (Miconazole Nitrate) econazole topical cream 1 % (Econazole Nitrate) elon dual defense 25% solution 25 % * (Undecylenic Acid) fluconazole in dextrose(iso-o) (Fluconazole In intravenous piggyback 400 mg/200 Nacl,Iso-Osm) ml fluconazole in nacl (iso-osm) intravenous piggyback 100 mg/50 ml, 200 mg/100 ml fluconazole oral suspension for reconstitution 10 mg/ml, 40 mg/ml fluconazole oral tablet 100 mg, 150 mg, 200 mg, 50 mg (Fluconazole In Nacl,Iso-Osm) (Diflucan) (Diflucan) 57
fluconazole-nacl 400 mg/200 ml (Fluconazole In 10's,latex-free, p/f 400 mg/200 ml Nacl,Iso-Osm) flucytosine oral capsule 250 mg, 500 mg (Ancobon) fungi cure intensive 1% spray 1 % * (Clotrimazole) FUNGI-NAIL TINCTURE * fungoid-d 1% cream 1 % * (Tinactin) gnp miconazole 3 combo pack 4 % (Miconazole (200 mg)- 2 % (9 gram) * Nitrate) griseofulvin microsize oral tablet 500 mg (Grifulvin V) inzo antifungal 2% cream 2 % * (Nuzole) itraconazole oral capsule 100 mg (Sporanox) ketoconazole oral tablet 200 mg (Ketoconazole) ketoconazole topical cream 2 % (Ketoconazole) ketoconazole topical shampoo 2 % (Nizoral) lamisil af defens 1% spray pwd 1 % * (Tinactin) lamisil af defense 1% powder 1 % * (Tolnaftate) LAMISIL ANTIFUNGAL 1% SPRAY FOR ATHLETES FOOT 1 % * LAMISIL AT 1% GEL 1 % * micatin 2% antifungal cream 2 % * (Nuzole) miconazole 3 combo pack 3 sup,9gm (Monistat 3) crm w/app 200 mg- 2 % (9 gram) * miconazole 7 100 mg vag supp 100 (Miconazole mg * Nitrate) miconazole nitrate 2% cream 2 % * (Miconazole Nitrate) miconazole-3 vaginal suppository 200 mg (Miconazole Nitrate) 58
MONISTAT 3 COMBO PACK 3 SUPP, 9 GM CREAM 200 MG- 2 % (9 GRAM) * MONISTAT 3 COMBO PACK 4 % (200 MG)- 2 % (9 GRAM) * monistat 7 cream 7 applicators 2 % (Miconazole * Nitrate) myco nail a 25% solution 25 % * (Undecylenic Acid) NOXAFIL ORAL SUSPENSION 200 MG/5 ML (40 MG/ML) NOXAFIL ORAL TABLET,DELAYED RELEASE (DR/EC) 100 MG nyamyc topical powder 100,000 (Nystatin) unit/gram nystatin oral suspension 100,000 (Nystatin) unit/ml nystatin oral tablet 500,000 unit (Nystatin) nystatin topical cream 100,000 (Nystatin) unit/gram nystatin topical ointment 100,000 (Nystatin) unit/gram nystatin topical powder 100,000 (Nystatin) unit/gram nystatin-triamcinolone topical (Nystatin/Triamcin cream 100,000-0.1 unit/g-% nystatin-triamcinolone topical ointment 100,000-0.1 unit/gram-% nystop topical powder 100,000 unit/gram pv foot odor control 1% powder 1 % * qc 3 day vaginal 4% cream 200 mg/5 gram (4 %) * ) (Nystatin/Triamcin ) (Nystatin) (Tinactin) (Miconazole Nitrate) 59
ra antifungal 1% liquid spray liquid (Tolnaftate) spray 1 % * remedy phytplx antifungal oint 2 % (Miconazole * Nitrate) terbinafine 1% cream 1 % * (Lamisil At) terbinafine hcl oral tablet 250 mg (Lamisil) tolnaftate 1% cream 1 % * (Tinactin) tolnaftate 1% solution 1 % * (Tolnaftate) (Miconazole triple paste af 2% ointment 2 % * Nitrate) voriconazole intravenous solution (Vfend IV) 200 mg voriconazole oral suspension for reconstitution 200 mg/5 ml (40 (Vfend) mg/ml) voriconazole oral tablet 200 mg, 50 (Vfend) mg Antihistamines Antihistamines alavert 10 mg odt non-drowsy, mint (Claritin) 10 mg * ALLEGRA ALLERGY 180 MG TABLET 180 MG * ALLEGRA ALLERGY 60 MG TABLET 60 MG * aller-chlor 4 mg tablet 4 mg * (Chlor-Trimeton) (Claritin-D 12 allerclear d-12hr tablet 5-120 mg * Hour) alavert d-12 allergy-sinus tab 5-120 aller-chlor 2 mg/5 ml syrup 2 mg/5 allerclear d-24hr er tablet nondrowsy 10-240 mg * (Claritin-D 12 (Chlorpheniramine (Claritin-D 24 mg * ml * Hour) Maleate) Hour) 60
allergy 4 mg tablet 4 mg * (Chlor-Trimeton) allerhist-1 1.34 mg tablet 1.34 mg * (Clemastine Fumarate) aller-tec d 5-120 mg tablet 5-120 mg * (Zyrtec-D) ambi 60pse-4cpm tablet 4-60 mg * (Chlorpheniramine/ Pseudoephed) aprodine tablet 2.5-60 mg * (Triprolidine/Pseud oephedrine) banophen 25 mg capsule 25 mg * (Zzzquil) banophen 25 mg tablet 25 mg * (Diphenhydramine HCl) banophen allergy 12.5 mg/5 ml a/f 12.5 mg/5 ml * (Zzzquil) benadryl allergy 25 mg ultratb (Diphenhydramine ultratab 25 mg * HCl) cetirizine hcl 1 mg/1 ml soln children, s/f, grape (otc) 1 mg/ml * (Children'S Zyrtec) cetirizine hcl 10 mg tablet indoor & outdoor 10 mg * (Zyrtec) cetirizine hcl 5 mg chew tab children's,outer,u-d 5 mg * (Zyrtec) cetirizine-pse er 5-120 mg tab 5-120 mg * (Zyrtec-D) child allegra allergy 30 mg/5 ml (Fexofenadine suspension 30 mg/5 ml * HCl) CHILD CLARITIN 5 MG/5 ML SOLN A/F,D/F,S/F,GRAPE 5 MG/5 ML * child triaminic cold & allergy 1-2.5 mg/5 ml * (Dimetapp) child wal-tap cold-allergy elx 1-2.5 mg/5 ml * (Dimetapp) 61
CHILD ZYRTEC 1 MG/ML SOLUTION D/F,S/F,GRAPE 1 MG/ML * CHILDREN'S ZYRTEC 10 MG ODT 10 MG * child's aller-tec 1 mg/ml soln 1 mg/ml * CHILD'S CLARITIN 5 MG TAB CHEW 5 MG * child's wal-dryl 12.5 mg/5 ml a/f,s/f,d/f,bubb gum 12.5 mg/5 ml * child's wal-zyr 10 mg chew tab 10 mg * CLARITIN 10 MG LIQUI-GEL CAP 10 MG * CLARITIN 10 MG REDITABS 10 MG * CLARITIN 10 MG TABLET (OTC) 10 MG * CLARITIN 5 MG REDITABS 5 MG * cold-allergy-sinus oral tablet 2.5-60 mg * compoz 25 mg gelcap 25 mg * cvs allergy 25 mg tablet 25 mg * cvs allergy relief 10 mg sftgl 10 mg * cvs child allergy 10 mg chw tb 24 hr,indoor/outdoor 10 mg * cvs cold & cough nighttime liq 6.25-2.5 mg/5 ml * (Children'S Zyrtec) (Zzzquil) (Zyrtec) (Triprolidine/Pseud oephedrine) (Diphenhydramine HCl) (Diphenhydramine HCl) (Zyrtec) (Zyrtec) (Triaminic Nighttime Cold- Cough) 62
cyproheptadine oral syrup 2 mg/5 ml cyproheptadine oral tablet 4 mg dailyhist-1 1.34 mg tablet 1.34 mg * dayhist allergy 1.34 mg tablet 12 hr relief 1.34 mg * dimaphen elixir a/f, grape, gluten-f 1-2.5 mg/5 ml * dimetapp cold & congest liquid 6.25-2.5 mg/5 ml * (Cyproheptadine HCl) (Cyproheptadine HCl) (Clemastine Fumarate) (Clemastine Fumarate) (Dimetapp) (Triaminic Nighttime Cold- Cough) diphenhist 12.5 mg/5 ml soln 12.5 (Zzzquil) mg/5 ml * diphenhist 25 mg capsule 25 mg * (Zzzquil) diphenhist 25 mg captab captab 25 (Diphenhydramine mg * HCl) diphenhydramine 25 mg capsule (Zzzquil) (otc) 25 mg * diphenhydramine 50 mg capsule (Zzzquil) (otc) 50 mg * diphenhydramine 50 mg tablet 50 (Diphenhydramine mg * HCl) diphenhydramine hcl injection (Diphenhydramine solution 50 mg/ml HCl) (Chlorpheniramine ed chlorped jr syrup 2 mg/5 ml * Maleate) ed-a-hist 4 mg-10 mg tablet 4-10 mg (Chlorpheniramine/ * Phenylephrine) fexofenadine hcl 180 mg tablet (Allegra Allergy) 24hr,original str (otc) 180 mg * fexofenadine hcl 30 mg/5 ml 30 (Fexofenadine mg/5 ml * HCl) 63
fexofenadine hcl 60 mg tablet (Allegra Allergy) indoor/outdoor (otc) 60 mg * hm z-sleep 25 mg softgel 25 mg * (Zzzquil) levocetirizine oral solution 2.5 mg/5 (Xyzal) ml levocetirizine oral tablet 5 mg (Xyzal) loratadine 10 mg tablet 10 mg * (Claritin) loratadine allergy 5 mg/5 ml d/f, a/f, (Children'S s/f 5 mg/5 ml * Claritin) loratadine-d 12 hour tablet nondrowsy 5-120 mg * Hour) (Claritin-D 12 loratadine-d 24hr tablet 10-240 mg (Claritin-D 24 * Hour) q-dryl 12.5 mg/5 ml liquid a/f 12.5 (Zzzquil) mg/5 ml * ra sleep aid 50 mg/30 ml liq 50 (Zzzquil) mg/30 ml * siladryl 12.5 mg/5 ml liquid 12.5 (Zzzquil) mg/5 ml * (Doxylamine sleep aid 25 mg tablet 25 mg * Succinate) sm z-sleep 50 mg/30 ml liquid (Zzzquil) berry,gluten-free 50 mg/30 ml * promethazine oral syrup 6.25 mg/5 pv nyt-time sleep 25 mg caplet 25 simply sleep 25 mg caplet caplet 25 sm allergy relief 1.34 mg tab 1.34 sm sinus and allergy tablet (Promethazine (Diphenhydramine (Diphenhydramine (Clemastine (Chlorpheniramine/ ml mg * mg * mg * maximum strength 4-60 mg * HCl) HCl) HCl) Fumarate) Pseudoephed) PA-HRM; AGE (Max 64 Years) 64
sudogest sinus & allergy tab 4-60 (Chlorpheniramine/ mg * Pseudoephed) TRIAMINIC NIGHTTIME COLD- COUGH CHILDREN'S, GRAPE 6.25-2.5 MG/5 ML * unisom 50 mg sleepgels softgel 50 (Zzzquil) mg * wal-act d cold & allergy tab 2.5-60 (Triprolidine/Pseud mg * oephedrine) wal-dryl allergy 25 mg capsule 25 (Zzzquil) mg * wal-dryl allergy 25 mg minitab (Diphenhydramine minitab, coated 25 mg * HCl) wal-fex allergy 180 mg tablet 180 (Allegra Allergy) mg * wal-fex allergy 60 mg tablet 60 mg * (Allegra Allergy) wal-finate 4 mg tablet 4 mg * (Chlor-Trimeton) (Chlorpheniramine/ wal-finate-d tablet 4-60 mg * Pseudoephed) wal-itin 10 mg odt non-drowsy 10 (Claritin) mg * wal-itin 10 mg tablet non-drowsy 10 (Claritin) mg * wal-itin 5 mg/5 ml syrup children's, (Children'S grape 5 mg/5 ml * Claritin) (Claritin-D 12 wal-itin d 12 hour tablet 5-120 mg * Hour) wal-itin d 24 hour tablet 10-240 mg (Claritin-D 24 * Hour) wal-phed pe sinus-allergy tab 4-10 wal-phed sinus and allergy tab 4-60 (Chlorpheniramine/ (Chlorpheniramine/ mg * mg * Phenylephrine) Pseudoephed) 65
wal-sleep z 25 mg odt 25 mg * (Unisom Sleepmelts) wal-sleep z 25 mg softgel 25 mg * (Zzzquil) wal-sleep z 50 mg/30 ml liquid berry, a/f, d/f, s/f 50 mg/30 ml * (Zzzquil) wal-som 25 mg tablet 25 mg * (Doxylamine Succinate) wal-som 50 mg softgel softgel 50 mg * (Zzzquil) wal-tap elixir 1-2.5 mg/5 ml * (Dimetapp) wal-zyr 10 mg tablet 10 mg * (Zyrtec) wal-zyr d tablet 12 hr 5-120 mg * (Zyrtec-D) wal-zyr solution children's, a/f 1 mg/ml * (Children'S Zyrtec) ZYRTEC 10 MG LIQUID GELS 10 MG * ZYRTEC 10 MG ODT 10 MG * ZYRTEC 10 MG TABLET INDOOR/OUTDOOR 24 HR (OTC) 10 MG * Anti-Infectives (Skin And Mucous Membrane) Anti-Infectives (Skin And Mucous Membrane) ABREVA 10% CREAM 10 % * AVC VAGINAL VAGINAL CREAM 15 % clindamycin phosphate vaginal cream 2 % (Cleocin) metronidazole vaginal gel 0.75 % (Metrogel-Vaginal) terconazole vaginal cream 0.4 %, 0.8 % (Terazol 7) terconazole vaginal suppository 80 mg (Terconazole) 66
Antimigraine Agents Antimigraine Agents dihydroergotamine injection QL (30 per 28 days) (D.H.E.45) solution 1 mg/ml dihydroergotamine nasal spray,nonaerosol 0.5 mg/pump act. (4 mg/ml) QL (8 per 28 days) (Migranal) ERGOMAR SUBLINGUAL QL (40 per 28 days) TABLET 2 MG naratriptan oral tablet 1 mg, 2.5 mg (Amerge) QL (18 per 28 days) rizatriptan oral tablet 10 mg, 5 mg (Maxalt) QL (18 per 28 days) rizatriptan oral tablet,disintegrating QL (18 per 28 days) (Maxalt Mlt) 10 mg, 5 mg sumatriptan 6 mg/0.5 ml syrng (Sumatriptan QL (4 per 28 days) p/f,dehp/f,pvc/f 6 mg/0.5 ml Succinate) sumatriptan nasal spray,nonaerosol 20 mg/actuation, 5 (Imitrex) QL (12 per 28 days) mg/actuation sumatriptan succinate oral tablet QL (18 per 28 days) (Imitrex) 100 mg, 25 mg, 50 mg sumatriptan succinate subcutaneous (Sumatriptan QL (4 per 28 days) cartridge 4 mg/0.5 ml Succinate) sumatriptan succinate subcutaneous QL (4 per 28 days) (Imitrex) cartridge 6 mg/0.5 ml sumatriptan succinate subcutaneous (Sumatriptan QL (4 per 28 days) pen injector 4 mg/0.5 ml Succinate) sumatriptan succinate subcutaneous QL (4 per 28 days) (Sumatriptan pen injector 6 mg/0.5 ml, 6 mg/0.5 Succinate) ml (auto-injector) sumatriptan succinate subcutaneous QL (4 per 28 days) (Imitrex) solution 6 mg/0.5 ml zolmitriptan oral tablet 2.5 mg, 5 QL (12 per 28 days) (Zomig) mg zolmitriptan oral QL (12 per 28 days) (Zomig Zmt) tablet,disintegrating 2.5 mg, 5 mg 67
Antimycobacterials Antimycobacterials CAPASTAT INJECTION RECON SOLN 1 GRAM dapsone oral tablet 100 mg, 25 mg (Dapsone) ethambutol oral tablet 100 mg, 400 mg (Myambutol) isoniazid oral solution 50 mg/5 ml (Isoniazid) isoniazid oral tablet 100 mg, 300 mg (Isoniazid) PASER ORAL GRANULES DR FOR SUSP IN PACKET 4 GRAM PRIFTIN ORAL TABLET 150 MG pyrazinamide oral tablet 500 mg (Pyrazinamide) rifabutin oral capsule 150 mg (Mycobutin) rifampin intravenous recon soln 600 mg (Rifadin) rifampin oral capsule 150 mg, 300 mg (Rifadin) RIFATER ORAL TABLET 50-120- 300 MG SIRTURO ORAL TABLET 100 MG TRECATOR ORAL TABLET 250 MG Antinausea Agents Antinausea Agents AKYNZEO ORAL CAPSULE 300-0.5 MG compro rectal suppository 25 mg (Compazine) cvs motion sickness 50 mg tab 50 mg * (Dimenhydrinate) PA; QL (188 per 168 days) 68
dimenhydrinate injection solution 50 (Dimenhydrinate) mg/ml dramamine 50 mg tablet 50 mg * (Dimenhydrinate) dramamine less drowsy 25 mg tb 25 mg * (Meclizine HCl) driminate 50 mg tablet 50 mg * (Dimenhydrinate) dronabinol oral capsule 10 mg, 2.5 mg, 5 mg (Marinol) EMEND INTRAVENOUS RECON QL (2 per 28 days) SOLN 150 MG EMEND ORAL CAPSULE 125 MG, 80 MG EMEND ORAL CAPSULE 40 MG EMEND ORAL CAPSULE,DOSE PACK 125 MG (1)- 80 MG (2) EMEND ORAL SUSPENSION FOR RECONSTITUTION 125 MG (25 MG/ ML FINAL CONC.) granisetron (pf) intravenous (Granisetron solution 100 mcg/ml HCl/PF) granisetron hcl intravenous solution 1 mg/ml (1 ml) (Granisetron HCl) granisetron hcl oral tablet 1 mg (Granisetron HCl) meclizine 12.5 mg caplet caplet (otc) 12.5 mg * (Meclizine HCl) meclizine 25 mg tablet (otc) 25 mg * (Meclizine HCl) meclizine oral tablet 12.5 mg, 25 mg (Meclizine HCl) motion sickness 25 mg tablet 25 mg * (Meclizine HCl) ondansetron hcl (pf) injection (Ondansetron solution 4 mg/2 ml HCl/PF) ondansetron hcl (pf) injection (Ondansetron syringe 4 mg/2 ml HCl/PF) 69
ondansetron hcl oral solution 4 mg/5 ml ondansetron hcl oral tablet 24 mg, 4 mg, 8 mg ondansetron oral tablet,disintegrating 4 mg, 8 mg phenadoz rectal suppository 12.5 mg, 25 mg prochlorperazine edisylate injection solution 10 mg/2 ml (5 mg/ml) prochlorperazine maleate oral tablet 10 mg, 5 mg prochlorperazine rectal suppository 25 mg promethazine oral tablet 12.5 mg, 25 mg, 50 mg promethazine rectal suppository 12.5 mg, 25 mg, 50 mg promethegan rectal suppository 12.5 mg, 25 mg, 50 mg TRANSDERM-SCOP TRANSDERMAL PATCH 3 DAY 1.5 MG (1 MG OVER 3 DAYS) travel sickness 25 mg tab chew 25 mg * (Zofran) (Zofran) (Zofran Odt) (Phenergan) (Prochlorperazine Edisylate) (Compazine) (Compazine) (Promethazine HCl) (Phenergan) (Phenergan) (Bonine) wal-dram 50 mg tablet 50 mg * (Dimenhydrinate) Antiparasite Agents Antiparasite Agents ALBENZA ORAL TABLET 200 MG ALINIA ORAL SUSPENSION FOR RECONSTITUTION 100 MG/5 ML ALINIA ORAL TABLET 500 MG PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) QL (10 per 30 days) 70
atovaquone oral suspension 750 mg/5 ml (Mepron) atovaquone-proguanil oral tablet 250-100 mg, 62.5-25 mg (Malarone) chloroquine phosphate oral tablet (Chloroquine 250 mg, 500 mg Phosphate) COARTEM ORAL TABLET 20-120 MG DARAPRIM ORAL TABLET 25 MG EMVERM ORAL TABLET,CHEWABLE 100 MG hydroxychloroquine oral tablet 200 mg (Plaquenil) ivermectin oral tablet 3 mg (Stromectol) mefloquine oral tablet 250 mg (Mefloquine HCl) NEBUPENT INHALATION RECON SOLN 300 MG paromomycin oral capsule 250 mg (Paromomycin Sulfate) PENTAM INJECTION RECON SOLN 300 MG PRIMAQUINE ORAL TABLET 26.3 MG QL (6 per 21 days) QL (90 per 30 days) quinine sulfate oral capsule 324 mg (Qualaquin) PA; QL (42 per 7 days) Antiparkinsonian Agents Antiparkinsonian Agents amantadine hcl oral capsule 100 mg (Amantadine HCl) amantadine hcl oral solution 50 mg/5 ml (Amantadine HCl) amantadine hcl oral tablet 100 mg (Amantadine HCl) APOKYN SUBCUTANEOUS CARTRIDGE 10 MG/ML QL (60 per 30 days) 71
AZILECT ORAL TABLET 0.5 MG, 1 MG benztropine oral tablet 0.5 mg, 1 (Benztropine mg, 2 mg Mesylate) bromocriptine oral capsule 5 mg (Parlodel) bromocriptine oral tablet 2.5 mg (Parlodel) cabergoline oral tablet 0.5 mg (Cabergoline) carbidopa oral tablet 25 mg (Lodosyn) carbidopa-levodopa oral tablet 10-100 mg, 25-100 mg, 25-250 mg (Sinemet CR) carbidopa-levodopa oral tablet extended release 25-100 mg, 50-200 (Sinemet CR) mg carbidopa-levodopa-entacapone oral tablet 12.5-50-200 mg, 18.75-75-200 mg, 25-100-200 mg, 31.25- (Stalevo 50) 125-200 mg, 37.5-150-200 mg, 50-200-200 mg entacapone oral tablet 200 mg (Comtan) NEUPRO TRANSDERMAL PATCH 24 HOUR 1 MG/24 HOUR, 2 MG/24 HOUR, 3 MG/24 HOUR, 4 MG/24 HOUR, 6 MG/24 HOUR, 8 MG/24 HOUR pramipexole oral tablet 0.125 mg, 0.25 mg, 0.5 mg, 0.75 mg, 1 mg, 1.5 (Mirapex) mg ropinirole oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg, 5 mg (Requip) ropinirole oral tablet extended release 24 hr 12 mg, 2 mg, 4 mg, 6 (Requip XL) mg, 8 mg selegiline hcl oral capsule 5 mg (Eldepryl) selegiline hcl oral tablet 5 mg (Selegiline HCl) PA-HRM; AGE (Max 64 Years) 72
trihexyphenidyl oral elixir 0.4 mg/ml (Trihexyphenidyl HCl) trihexyphenidyl oral tablet 2 mg, 5 (Trihexyphenidyl mg HCl) Antipsychotic Agents Antipsychotic Agents ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 300 MG ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 400 MG PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) QL (1 per 28 days) ABILIFY MAINTENA QL (1 per 28 days) INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 300 MG, 400 MG aripiprazole oral solution 1 mg/ml (Abilify) QL (900 per 30 days) aripiprazole oral tablet 10 mg, 15 QL (30 per 30 days) (Abilify) mg, 20 mg, 30 mg, 5 mg aripiprazole oral tablet 2 mg (Abilify) QL (60 per 30 days) aripiprazole oral QL (90 per 30 days) (Abilify Discmelt) tablet,disintegrating 10 mg aripiprazole oral QL (60 per 30 days) (Abilify Discmelt) tablet,disintegrating 15 mg ARISTADA INTRAMUSCULAR QL (1.6 per 28 days) SUSPENSION,EXTENDED REL SYRING 441 MG/1.6 ML ARISTADA INTRAMUSCULAR QL (2.4 per 28 days) SUSPENSION,EXTENDED REL SYRING 662 MG/2.4 ML 73
ARISTADA INTRAMUSCULAR QL (3.2 per 28 days) SUSPENSION,EXTENDED REL SYRING 882 MG/3.2 ML chlorpromazine injection solution (Chlorpromazine 25 mg/ml HCl) chlorpromazine oral tablet 10 mg, (Chlorpromazine 100 mg, 200 mg, 25 mg, 50 mg HCl) clozapine oral tablet 100 mg (Clozaril) QL (270 per 30 days) clozapine oral tablet 200 mg (Clozaril) QL (135 per 30 days) clozapine oral tablet 25 mg, 50 mg (Clozaril) QL (90 per 30 days) clozapine oral tablet,disintegrating 100 mg, 12.5 mg, 150 mg, 200 mg, (Fazaclo) ST 25 mg FANAPT ORAL TABLET 1 MG, 10 MG, 12 MG, 2 MG, 4 MG, 6 MG, 8 MG FANAPT ORAL TABLETS,DOSE PACK 1MG(2)-2MG(2)- 4MG(2)- 6MG(2) fluphenazine decanoate injection solution 25 mg/ml fluphenazine hcl injection solution 2.5 mg/ml fluphenazine hcl oral concentrate 5 mg/ml fluphenazine hcl oral elixir 2.5 mg/5 ml fluphenazine hcl oral tablet 1 mg, 10 mg, 2.5 mg, 5 mg GEODON INTRAMUSCULAR RECON SOLN 20 MG/ML (FINAL CONC.) haloperidol decanoate intramuscular solution 100 mg/ml (Fluphenazine Decanoate) (Fluphenazine HCl) (Fluphenazine HCl) (Fluphenazine HCl) (Fluphenazine HCl) (Haloperidol Decanoate) ST; QL (60 per 30 days) ST; QL (8 per 28 days) QL (6 per 28 days) 74
haloperidol decanoate (Haldol Decanoate intramuscular solution 50 mg/ml 50) haloperidol lactate injection (Haloperidol solution 5 mg/ml Lactate) haloperidol lactate oral concentrate (Haloperidol 2 mg/ml Lactate) haloperidol oral tablet 0.5 mg, 1 mg, 10 mg, 2 mg, 20 mg, 5 mg (Haloperidol) INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 117 MG/0.75 ML, 156 MG/ML, 234 MG/1.5 ML, 39 MG/0.25 ML, 78 MG/0.5 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 273 MG/0.875 ML, 410 MG/1.315 ML, 546 MG/1.75 ML, 819 MG/2.625 ML LATUDA ORAL TABLET 120 MG, 20 MG, 40 MG, 60 MG, 80 MG loxapine succinate oral capsule 10 (Loxapine mg, 25 mg, 5 mg, 50 mg Succinate) molindone oral tablet 10 mg (Molindone HCl) QL (240 per 30 days) molindone oral tablet 25 mg (Molindone HCl) QL (270 per 30 days) molindone oral tablet 5 mg (Molindone HCl) QL (120 per 30 days) NUPLAZID ORAL TABLET 17 PA NSO; QL (60 per MG 30 days) olanzapine intramuscular recon soln QL (30 per 30 days) (Zyprexa) 10 mg olanzapine oral tablet 10 mg, 15 QL (30 per 30 days) (Zyprexa) mg, 2.5 mg, 20 mg, 5 mg, 7.5 mg olanzapine oral tablet,disintegrating QL (30 per 30 days) (Zyprexa Zydis) 10 mg, 15 mg, 5 mg 75
olanzapine oral tablet,disintegrating QL (31 per 30 days) (Zyprexa Zydis) 20 mg paliperidone oral tablet extended QL (30 per 30 days) (Invega) release 24hr 1.5 mg, 3 mg, 9 mg paliperidone oral tablet extended QL (60 per 30 days) (Invega) release 24hr 6 mg perphenazine oral tablet 16 mg, 2 mg, 4 mg, 8 mg (Perphenazine) pimozide oral tablet 1 mg, 2 mg (Orap) quetiapine oral tablet 100 mg, 200 QL (90 per 30 days) (Seroquel) mg, 25 mg, 300 mg, 400 mg, 50 mg REXULTI ORAL TABLET 0.25 QL (120 per 30 days) MG REXULTI ORAL TABLET 0.5 MG QL (60 per 30 days) REXULTI ORAL TABLET 1 MG, QL (30 per 30 days) 2 MG, 3 MG, 4 MG RISPERDAL CONSTA QL (4 per 28 days) INTRAMUSCULAR SYRINGE 12.5 MG/2 ML, 25 MG/2 ML, 37.5 MG/2 ML, 50 MG/2 ML risperidone oral solution 1 mg/ml (Risperdal) QL (480 per 30 days) risperidone oral tablet 0.25 mg, 0.5 QL (60 per 30 days) (Risperdal) mg, 1 mg, 2 mg, 3 mg, 4 mg risperidone oral QL (60 per 30 days) tablet,disintegrating 0.25 mg, 0.5 mg, 1 mg, 2 mg (Risperdal M-Tab) risperidone oral QL (120 per 30 days) (Risperdal M-Tab) tablet,disintegrating 3 mg, 4 mg SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 10 MG, 2.5 MG, 5 MG ST; QL (60 per 30 days) thioridazine oral tablet 10 mg, 100 PA NSO-HRM (Thioridazine HCl) mg, 25 mg, 50 mg 76
thiothixene oral capsule 1 mg, 10 mg, 2 mg, 5 mg trifluoperazine oral tablet 1 mg, 10 mg, 2 mg, 5 mg VERSACLOZ ORAL SUSPENSION 50 MG/ML VRAYLAR ORAL CAPSULE 1.5 MG, 3 MG, 4.5 MG, 6 MG VRAYLAR ORAL CAPSULE,DOSE PACK 1.5 MG (1)- 3 MG (6) ziprasidone hcl oral capsule 20 mg, 40 mg, 60 mg, 80 mg ZYPREXA RELPREVV 405 MG VL KIT W/ DILUENT, OUTER 405 MG ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 210 MG (Thiothixene) (Trifluoperazine HCl) (Geodon) Antivirals (Systemic) Antiretrovirals abacavir oral tablet 300 mg (Ziagen) abacavir-lamivudine oral tablet 600-300 mg abacavir-lamivudine-zidovudine oral tablet 300-150-300 mg APTIVUS ORAL CAPSULE 250 MG APTIVUS ORAL SOLUTION 100 MG/ML ATRIPLA ORAL TABLET 600-200-300 MG (Epzicom) (Trizivir) ST; QL (540 per 30 days) QL (30 per 30 days) QL (7 per 30 days) QL (60 per 30 days) 77
COMPLERA ORAL TABLET 200-25-300 MG CRIXIVAN ORAL CAPSULE 200 MG, 400 MG DESCOVY ORAL TABLET 200-25 MG didanosine oral capsule,delayed release(dr/ec) 125 mg, 200 mg, 250 mg, 400 mg EDURANT ORAL TABLET 25 MG EMTRIVA ORAL CAPSULE 200 MG EMTRIVA ORAL SOLUTION 10 MG/ML EPIVIR HBV ORAL SOLUTION 25 MG/5 ML (5 MG/ML) EPZICOM ORAL TABLET 600-300 MG EVOTAZ ORAL TABLET 300-150 MG FUZEON SUBCUTANEOUS RECON SOLN 90 MG GENVOYA ORAL TABLET 150-150-200-10 MG INTELENCE ORAL TABLET 100 MG, 200 MG, 25 MG INVIRASE ORAL CAPSULE 200 MG INVIRASE ORAL TABLET 500 MG ISENTRESS ORAL POWDER IN PACKET 100 MG (Videx EC) 78
ISENTRESS ORAL TABLET 400 MG ISENTRESS ORAL TABLET,CHEWABLE 100 MG, 25 MG KALETRA ORAL SOLUTION 400-100 MG/5 ML KALETRA ORAL TABLET 100-25 MG, 200-50 MG lamivudine oral solution 10 mg/ml (Epivir) lamivudine oral tablet 100 mg, 150 mg, 300 mg (Epivir) lamivudine-zidovudine oral tablet 150-300 mg (Combivir) LEXIVA ORAL SUSPENSION 50 MG/ML LEXIVA ORAL TABLET 700 MG nevirapine oral suspension 50 mg/5 ml (Viramune) nevirapine oral tablet 200 mg (Viramune) nevirapine oral tablet extended release 24 hr 100 mg, 400 mg (Viramune XR) NORVIR ORAL CAPSULE 100 MG NORVIR ORAL SOLUTION 80 MG/ML NORVIR ORAL TABLET 100 MG ODEFSEY ORAL TABLET 200-25-25 MG PREZCOBIX ORAL TABLET 800-150 MG-MG PREZISTA ORAL SUSPENSION 100 MG/ML 79
PREZISTA ORAL TABLET 150 MG, 400 MG, 600 MG, 75 MG, 800 MG RESCRIPTOR ORAL TABLET 200 MG RESCRIPTOR ORAL TABLET, DISPERSIBLE 100 MG RETROVIR INTRAVENOUS SOLUTION 10 MG/ML REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG REYATAZ ORAL POWDER IN PACKET 50 MG SELZENTRY ORAL TABLET 150 MG, 300 MG stavudine oral capsule 15 mg, 20 mg, 30 mg, 40 mg (Zerit) stavudine oral recon soln 1 mg/ml (Zerit) STRIBILD ORAL TABLET 150-150-200-300 MG SUSTIVA ORAL CAPSULE 200 MG, 50 MG SUSTIVA ORAL TABLET 600 MG TIVICAY ORAL TABLET 10 MG, 25 MG, 50 MG TRIUMEQ ORAL TABLET 600-50-300 MG TRUVADA ORAL TABLET 100-150 MG, 133-200 MG, 167-250 MG, 200-300 MG VIDEX 2 GRAM PEDIATRIC ORAL RECON SOLN 10 MG/ML (FINAL) 80
VIDEX 4 GM PEDIATRIC SOLN 10 MG/ML (FINAL) VIRACEPT ORAL TABLET 250 MG, 625 MG VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 HR 100 MG VIREAD ORAL POWDER 40 MG/SCOOP (40 MG/GRAM) VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG, 300 MG VITEKTA ORAL TABLET 150 MG, 85 MG ZIAGEN ORAL SOLUTION 20 MG/ML zidovudine oral capsule 100 mg (Retrovir) zidovudine oral syrup 10 mg/ml (Retrovir) zidovudine oral tablet 300 mg (Zidovudine) Antivirals, Miscellaneous foscarnet intravenous solution 24 mg/ml (Foscavir) RELENZA DISKHALER INHALATION BLISTER WITH DEVICE 5 MG/ACTUATION rimantadine oral tablet 100 mg (Flumadine) SYNAGIS 100 MG/1 ML VIAL 100 MG/ML SYNAGIS INTRAMUSCULAR SOLUTION 50 MG/0.5 ML TAMIFLU ORAL CAPSULE 30 MG TAMIFLU ORAL CAPSULE 45 MG QL (84 per 180 days) QL (48 per 180 days) 81
TAMIFLU ORAL CAPSULE 75 MG TAMIFLU ORAL SUSPENSION FOR RECONSTITUTION 6 MG/ML Hcv Antivirals DAKLINZA ORAL TABLET 30 MG, 60 MG, 90 MG EPCLUSA ORAL TABLET 400-100 MG HARVONI ORAL TABLET 90-400 MG OLYSIO ORAL CAPSULE 150 MG SOVALDI ORAL TABLET 400 MG TECHNIVIE ORAL TABLET 12.5-75-50 MG VIEKIRA PAK ORAL TABLETS,DOSE PACK 12.5 MG- 75 MG -50 MG/250 MG VIEKIRA XR ORAL TABLET, IR - ER, BIPHASIC 24HR 8.33 MG- 50 MG- 33.33 MG-200 MG ZEPATIER ORAL TABLET 50-100 MG Interferons INTRON A 25 MILLION UNIT/2.5 ML 10 MILLION UNIT/ML INTRON A INJECTION RECON SOLN 10 MILLION UNIT (1 ML) INTRON A INJECTION RECON SOLN 18 MILLION UNIT (1 ML), 50 MILLION UNIT (1 ML) QL (42 per 180 days) QL (540 per 180 days) PA; QL (28 per 28 days) PA; QL (28 per 28 days) PA; QL (30 per 30 days) PA; QL (28 per 28 days) PA; QL (28 per 28 days) PA; QL (56 per 28 days) PA; QL (112 per 28 days) PA; QL (84 per 28 days) PA; QL (30 per 30 days) PA NSO PA NSO PA NSO 82
INTRON A INJECTION SOLUTION 6 MILLION UNIT/ML PEGASYS PROCLICK SUBCUTANEOUS PEN INJECTOR 135 MCG/0.5 ML, 180 MCG/0.5 ML PEGASYS SUBCUTANEOUS SOLUTION 180 MCG/ML PEGASYS SUBCUTANEOUS SYRINGE 180 MCG/0.5 ML PEGINTRON SUBCUTANEOUS KIT 120 MCG/0.5 ML, 150 MCG/0.5 ML, 50 MCG/0.5 ML, 80 MCG/0.5 ML SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 MCG, 600 MCG Nucleosides And Nucleotides acyclovir oral capsule 200 mg (Zovirax) acyclovir oral suspension 200 mg/5 ml (Zovirax) acyclovir oral tablet 400 mg, 800 mg (Zovirax) acyclovir sodium intravenous (Acyclovir solution 50 mg/ml Sodium) adefovir oral tablet 10 mg (Hepsera) entecavir oral tablet 0.5 mg, 1 mg (Baraclude) famciclovir oral tablet 125 mg, 250 mg, 500 mg (Famvir) ganciclovir sodium intravenous recon soln 500 mg (Cytovene) ribasphere oral capsule 200 mg (Rebetol) PA NSO PA PA PA PA PA NSO; QL (4 per 28 days) 83
ribasphere oral tablet 200 mg, 400 mg, 600 mg (Copegus) TYZEKA ORAL TABLET 600 MG valacyclovir oral tablet 1 gram, 500 mg (Valtrex) valganciclovir oral tablet 450 mg (Valcyte) VIRAZOLE INHALATION RECON SOLN 6 GRAM Blood Products/Modifiers/Volume Expanders Anticoagulants CEPROTIN (BLUE BAR) INTRAVENOUS RECON SOLN 500 UNIT ELIQUIS ORAL TABLET 2.5 MG, 5 MG enoxaparin subcutaneous solution 300 mg/3 ml enoxaparin subcutaneous syringe 100 mg/ml, 120 mg/0.8 ml, 150 mg/ml, 30 mg/0.3 ml, 40 mg/0.4 ml, 60 mg/0.6 ml, 80 mg/0.8 ml fondaparinux subcutaneous syringe 10 mg/0.8 ml fondaparinux subcutaneous syringe 2.5 mg/0.5 ml fondaparinux subcutaneous syringe 5 mg/0.4 ml fondaparinux subcutaneous syringe 7.5 mg/0.6 ml (Lovenox) (Lovenox) (Arixtra) (Arixtra) (Arixtra) (Arixtra) QL (24 per 30 days) QL (15 per 30 days) QL (12 per 30 days) QL (18 per 30 days) 84
heparin (porcine) in 5 % dex intravenous parenteral solution 12,500 unit/250 ml, 20,000 unit/500 ml (40 unit/ml), 25,000 unit/500 ml (50 unit/ml) heparin (porcine) in 5 % dex intravenous parenteral solution 25,000 unit/250 ml(100 unit/ml) heparin (porcine) in nacl (pf) intravenous parenteral solution 1,000 unit/500 ml heparin (porcine) injection solution 1,000 unit/ml, 10,000 unit/ml, 20,000 unit/ml, 5,000 unit/ml heparin, porcine (pf) injection solution 5,000 unit/0.5 ml heparin, porcine (pf) injection syringe 5,000 unit/0.5 ml heparin-0.45% nacl 25,000 units/250 ml (100 units/ml) bag latex-free, inner 25,000 unit/250 ml heparin-d5w 25,000 units/250 ml (100 units/ml) bag excel container 25,000 unit/250 ml(100 unit/ml) IPRIVASK SUBCUTANEOUS RECON SOLN 15 MG jantoven oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg PRADAXA ORAL CAPSULE 110 MG, 150 MG, 75 MG (Heparin Sodium,Porcine/D5 W) (Heparin Sod,Pork In 0.45% NaCl) (Heparin Sodium,Porcine/Ns /PF) (Heparin Sodium,Porcine) (Heparin Sodium,Porcine/PF ) (Heparin Sodium,Porcine/PF ) (Heparin Sod,Pork In 0.45% NaCl) (Heparin Sodium,Porcine/D5 W) (Coumadin) PA; QL (24 per 28 days) ST; QL (60 per 30 days) 85
warfarin oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg XARELTO ORAL TABLET 10 MG, 15 MG, 20 MG XARELTO ORAL TABLETS,DOSE PACK 15 MG (42)- 20 MG (9) Blood Formation Modifiers CINRYZE INTRAVENOUS RECON SOLN 500 UNIT (5 ML) EPOGEN 10,000 UNITS/ML VIAL SDV, P/F, OUTER 10,000 UNIT/ML EPOGEN INJECTION SOLUTION 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML GRANIX SUBCUTANEOUS SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML LEUKINE INJECTION RECON SOLN 250 MCG MIRCERA INJECTION SYRINGE 100 MCG/0.3 ML, 200 MCG/0.3 ML, 50 MCG/0.3 ML, 75 MCG/0.3 ML MOZOBIL SUBCUTANEOUS SOLUTION 24 MG/1.2 ML (20 MG/ML) (Coumadin) NEULASTA SUBCUTANEOUS SYRINGE 6 MG/0.6ML NEULASTA SUBCUTANEOUS SYRINGE, W/ WEARABLE INJECTOR 6 MG/0.6 ML PA PA; QL (12 per 28 days) PA; QL (12 per 28 days) PA; QL (0.6 per 28 days) 86
NEUMEGA SUBCUTANEOUS RECON SOLN 5 MG NEUPOGEN INJECTION SOLUTION 300 MCG/ML, 480 MCG/1.6 ML NEUPOGEN INJECTION SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML PROCRIT 10,000 UNITS/ML VIAL 4'S, MDV, OUTER 20,000 UNIT/2 ML PROCRIT INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML PROCRIT INJECTION SOLUTION 40,000 UNIT/ML PROMACTA ORAL TABLET 12.5 MG, 25 MG, 50 MG, 75 MG ZARXIO INJECTION SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML Hematologic Agents, Miscellaneous aminocaproic acid oral solution 250 (Aminocaproic mg/ml (25 %) Acid) aminocaproic acid oral tablet 1,000 (Aminocaproic mg, 500 mg Acid) anagrelide oral capsule 0.5 mg, 1 mg (Agrylin) protamine intravenous solution 10 mg/ml (Protamine Sulfate) tranexamic acid intravenous solution 1,000 mg/10 ml (100 (Tranexamic Acid) mg/ml) PA; QL (12 per 28 days) PA; QL (12 per 28 days) PA; QL (6 per 28 days) PA; QL (30 per 30 days) 87
tranexamic acid oral tablet 650 mg (Lysteda) QL (30 per 30 days) Platelet-Aggregation Inhibitors aspirin-dipyridamole oral capsule, er multiphase 12 hr 25-200 mg (Aggrenox) BRILINTA ORAL TABLET 60 MG, 90 MG cilostazol oral tablet 100 mg, 50 mg (Pletal) clopidogrel oral tablet 300 mg, 75 mg (Plavix) dipyridamole oral tablet 25 mg, 50 mg, 75 mg (Persantine) EFFIENT ORAL TABLET 10 MG, QL (30 per 30 days) 5 MG pentoxifylline oral tablet extended release 400 mg (Pentoxifylline) Caloric Agents Caloric Agents AMINO ACIDS 15 % INTRAVENOUS PARENTERAL SOLUTION 15 % AMINOSYN 10 % INTRAVENOUS PARENTERAL SOLUTION 10 % AMINOSYN 3.5 % INTRAVENOUS PARENTERAL SOLUTION 3.5 % AMINOSYN 7 % INTRAVENOUS PARENTERAL SOLUTION 7 % AMINOSYN 7 % WITH ELECTROLYTES INTRAVENOUS PARENTERAL SOLUTION 7 % 88
AMINOSYN 8.5 % INTRAVENOUS PARENTERAL SOLUTION 8.5 % AMINOSYN 8.5 %- ELECTROLYTES INTRAVENOUS PARENTERAL SOLUTION 8.5 % AMINOSYN II 10 % INTRAVENOUS PARENTERAL SOLUTION 10 % AMINOSYN II 15 % INTRAVENOUS PARENTERAL SOLUTION 15 % AMINOSYN II 7 % INTRAVENOUS PARENTERAL SOLUTION 7 % AMINOSYN II 8.5 % INTRAVENOUS PARENTERAL SOLUTION 8.5 % AMINOSYN II 8.5 %- ELECTROLYTES INTRAVENOUS PARENTERAL SOLUTION 8.5 % AMINOSYN M 3.5 % INTRAVENOUS PARENTERAL SOLUTION 3.5 % AMINOSYN-HBC 7% INTRAVENOUS PARENTERAL SOLUTION 7 % AMINOSYN-PF 10 % INTRAVENOUS PARENTERAL SOLUTION 10 % AMINOSYN-PF 7 % (SULFITE- FREE) INTRAVENOUS PARENTERAL SOLUTION 7 % 89
AMINOSYN-RF 5.2 % INTRAVENOUS PARENTERAL SOLUTION 5.2 % CLINIMIX 5%/D15W SULFITE FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX 5%/D25W SULFITE- FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX 2.75%/D5W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 2.75 % CLINIMIX 4.25%/D10W SULF FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX 4.25%/D5W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX 4.25%-D20W SULF- FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX 4.25%-D25W SULF- FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX 5%-D20W(SULFITE- FREE) INTRAVENOUS PARENTERAL SOLUTION 5 % 90
CLINIMIX E 2.75%/D10W SUL FREE INTRAVENOUS PARENTERAL SOLUTION 2.75 % CLINIMIX E 2.75%/D5W SULF FREE INTRAVENOUS PARENTERAL SOLUTION 2.75 % CLINIMIX E 4.25%/D10W SUL FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX E 4.25%/D25W SUL FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX E 4.25%/D5W SULF FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX E 5%/D15W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX E 5%/D20W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX E 5%/D25W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINISOL SF 15 % INTRAVENOUS PARENTERAL SOLUTION 15 % cysteine (l-cysteine) intravenous solution 50 mg/ml (Cysteine HCl) 91
dex4 glucose 4 gm tablet chew grape flavor 4 gram * (Dextrose) dextrose 10 % in water (d10w) (Dextrose 10 % in intravenous parenteral solution 10 Water) % dextrose 20 % in water (d20w) (Dextrose 20 % in intravenous parenteral solution 20 Water) % dextrose 25 % in water (d25w) (Dextrose 25 % in intravenous syringe Water) dextrose 40 % in water (d40w) (Dextrose 40 % in intravenous parenteral solution 40 Water) % dextrose 5 % in ringers intravenous (Dextrose 5 % In parenteral solution 5 % Ringers) dextrose 5 % in water (d5w) (Dextrose 5 % in intravenous parenteral solution Water) dextrose 50 % in water (d50w) (Dextrose 50 % in intravenous parenteral solution Water) dextrose 50 % in water (d50w) (Dextrose 50 % in intravenous syringe Water) dextrose 70 % in water (d70w) (Dextrose 70 % in intravenous parenteral solution Water) FREAMINE HBC 6.9 % INTRAVENOUS PARENTERAL SOLUTION 6.9 % FREAMINE III 10 % INTRAVENOUS PARENTERAL SOLUTION 10 % gluco burst 40% gel 40 % * (Dextrose) glucose 4 gram tablet chew na/f, caffeine free 4 gram * (Dextrose) glucose 40% gel tropical fruit 40 % * (Dextrose) 92
glutose 15 gel 3 pak, outer, u-d 40 % * HEPATAMINE 8% INTRAVENOUS PARENTERAL SOLUTION 8 % HEPATASOL 8 % INTRAVENOUS PARENTERAL SOLUTION 8 % insta-glucose gel 24 gram/31 gram * INTRALIPID INTRAVENOUS EMULSION 20 %, 30 % KABIVEN INTRAVENOUS EMULSION 3.31-9.8-3.9 % NEPHRAMINE 5.4 % INTRAVENOUS PARENTERAL SOLUTION 5.4 % NUTRILIPID INTRAVENOUS EMULSION 20 % PERIKABIVEN INTRAVENOUS EMULSION 2.36-6.8-3.5 % PREMASOL 10 % INTRAVENOUS PARENTERAL SOLUTION 10 % PREMASOL 6 % INTRAVENOUS PARENTERAL SOLUTION 6 % PROCALAMINE 3% INTRAVENOUS PARENTERAL SOLUTION 3 % PROSOL 20 % INTRAVENOUS PARENTERAL SOLUTION smoflipid intravenous emulsion 20 % (Dextrose) (Dextrose/Dextrin/ Maltose) (Fat Emul/Soy/Mct/Oli v/fish Oil) 93
TRAVASOL 10 % INTRAVENOUS PARENTERAL SOLUTION 10 % TROPHAMINE 10 % INTRAVENOUS PARENTERAL SOLUTION 10 % TROPHAMINE 6% INTRAVENOUS PARENTERAL SOLUTION 6 % Cardiovascular Agents Alpha-Adrenergic Agents clonidine hcl oral tablet 0.1 mg, 0.2 mg, 0.3 mg clonidine transdermal patch weekly 0.1 mg/24 hr, 0.2 mg/24 hr clonidine transdermal patch weekly 0.3 mg/24 hr clorpres oral tablet 0.1-15 mg, 0.2-15 mg, 0.3-15 mg doxazosin oral tablet 1 mg, 2 mg, 4 mg, 8 mg (Catapres) (Catapres-Tts 1) (Catapres-Tts 1) (Clonidine HCl/Chlorthalidon e) (Cardura) guanfacine oral tablet 1 mg, 2 mg (Tenex) midodrine oral tablet 10 mg, 2.5 mg, 5 mg NORTHERA ORAL CAPSULE 100 MG, 200 MG, 300 MG phenylephrine hcl injection solution 10 mg/ml prazosin oral capsule 1 mg, 2 mg, 5 mg Angiotensin Ii Receptor Antagonists (Midodrine HCl) (Vazculep) (Minipress) QL (4 per 28 days) QL (8 per 28 days) PA-HRM; AGE (Max 64 Years) PA; QL (180 per 30 days) 94
BENICAR HCT ORAL TABLET 20-12.5 MG, 40-12.5 MG, 40-25 MG BENICAR ORAL TABLET 20 MG, 40 MG, 5 MG candesartan oral tablet 16 mg, 32 mg, 4 mg, 8 mg candesartan-hydrochlorothiazid oral tablet 16-12.5 mg, 32-12.5 mg, 32-25 mg ENTRESTO ORAL TABLET 24-26 MG, 49-51 MG, 97-103 MG irbesartan oral tablet 150 mg, 300 mg, 75 mg irbesartan-hydrochlorothiazide oral tablet 150-12.5 mg, 300-12.5 mg losartan oral tablet 100 mg, 25 mg, 50 mg losartan-hydrochlorothiazide oral tablet 100-12.5 mg, 100-25 mg, 50-12.5 mg telmisartan oral tablet 20 mg, 40 mg, 80 mg telmisartan-hydrochlorothiazid oral tablet 40-12.5 mg, 80-12.5 mg, 80-25 mg 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 valsartan oral tablet 160 mg, 320 mg, 40 mg, 80 mg valsartan-hydrochlorothiazide oral tablet 160-12.5 mg, 160-25 mg, 320-12.5 mg, 320-25 mg, 80-12.5 mg (Atacand) (Atacand HCT) (Avapro) (Avalide) (Cozaar) (Hyzaar) (Micardis) (Micardis HCT) (Diovan) (Diovan HCT) PA; QL (60 per 30 days) 95
Angiotensin-Converting Enzyme Inhibitors benazepril oral tablet 10 mg, 20 mg, 40 mg, 5 mg benazepril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg, 5-6.25 mg captopril oral tablet 100 mg, 12.5 mg, 25 mg, 50 mg captopril-hydrochlorothiazide oral tablet 25-15 mg, 25-25 mg, 50-15 mg, 50-25 mg enalapril maleate oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg enalaprilat intravenous solution 1.25 mg/ml enalapril-hydrochlorothiazide oral tablet 10-25 mg, 5-12.5 mg fosinopril oral tablet 10 mg, 20 mg, 40 mg fosinopril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg lisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 30 mg, 40 mg, 5 mg lisinopril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg (Lotensin) (Lotensin HCT) (Captopril) (Captopril/Hydroch lorothiazide) (Vasotec) (Enalaprilat Dihydrate) (Vaseretic) (Fosinopril Sodium) (Fosinopril/Hydroc hlorothiazide) (Zestril) (Zestoretic) moexipril oral tablet 15 mg, 7.5 mg (Moexipril HCl) moexipril-hydrochlorothiazide oral (Moexipril/Hydroc tablet 15-12.5 mg, 15-25 mg, 7.5- hlorothiazide) 12.5 mg perindopril erbumine oral tablet 2 mg, 4 mg, 8 mg (Aceon) 96
quinapril oral tablet 10 mg, 20 mg, 40 mg, 5 mg quinapril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg ramipril oral capsule 1.25 mg, 10 mg, 2.5 mg, 5 mg trandolapril oral tablet 1 mg, 2 mg, 4 mg Antiarrhythmic Agents amiodarone oral tablet 100 mg, 200 mg, 400 mg disopyramide phosphate oral capsule 100 mg, 150 mg dofetilide oral capsule 125 mcg, 250 mcg, 500 mcg flecainide oral tablet 100 mg, 150 mg, 50 mg lidocaine (pf) intravenous syringe 50 mg/5 ml (1 %) lidocaine in 5 % dextrose (pf) intravenous parenteral solution 8 mg/ml (0.8 %) mexiletine oral capsule 150 mg, 200 mg, 250 mg MULTAQ ORAL TABLET 400 MG pacerone oral tablet 100 mg, 200 mg, 400 mg procainamide injection solution 100 mg/ml, 500 mg/ml propafenone oral capsule,extended release 12 hr 225 mg, 325 mg, 425 mg (Accupril) (Accuretic) (Altace) (Mavik) (Cordarone) (Norpace) (Tikosyn) (Tambocor) (Lidocaine HCl/PF) (Lidocaine HCl/D5w/PF) (Mexiletine HCl) (Cordarone) (Procainamide HCl) (Rythmol SR) 97
propafenone oral tablet 150 mg, 225 (Rythmol) mg, 300 mg quinidine gluconate oral tablet (Quinidine extended release 324 mg Gluconate) quinidine sulfate oral tablet 200 mg, 300 mg (Quinidine Sulfate) quinidine sulfate oral tablet extended release 300 mg (Quinidine Sulfate) Beta-Adrenergic Blocking Agents acebutolol oral capsule 200 mg, 400 mg (Sectral) atenolol oral tablet 100 mg, 25 mg, 50 mg (Tenormin) atenolol-chlorthalidone oral tablet 100-25 mg, 50-25 mg (Tenoretic 50) betaxolol oral tablet 10 mg, 20 mg (Betaxolol HCl) bisoprolol fumarate oral tablet 10 mg, 5 mg (Zebeta) bisoprolol-hydrochlorothiazide oral tablet 10-6.25 mg, 2.5-6.25 mg, 5- (Ziac) 6.25 mg BYSTOLIC ORAL TABLET 10 MG, 2.5 MG, 20 MG, 5 MG carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg, 6.25 mg (Coreg) esmolol intravenous solution 100 mg/10 ml (10 mg/ml) (Brevibloc) labetalol intravenous solution 5 mg/ml (Labetalol HCl) labetalol oral tablet 100 mg, 200 mg, 300 mg (Trandate) 98
metoprolol succinate oral tablet extended release 24 hr 100 mg, 200 mg, 25 mg, 50 mg metoprolol ta-hydrochlorothiaz oral tablet 100-25 mg, 100-50 mg, 50-25 mg metoprolol tartrate intravenous solution 5 mg/5 ml metoprolol tartrate intravenous syringe 5 mg/5 ml metoprolol tartrate oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 75 mg nadolol oral tablet 20 mg, 40 mg, 80 mg (Toprol XL) (Lopressor HCT) (Metoprolol Tartrate) (Metoprolol Tartrate) (Lopressor) (Corgard) pindolol oral tablet 10 mg, 5 mg (Pindolol) propranolol intravenous solution 1 mg/ml (Propranolol HCl) propranolol oral capsule,extended release 24 hr 120 mg, 160 mg, 60 (Inderal LA) mg, 80 mg propranolol oral solution 20 mg/5 ml (4 mg/ml), 40 mg/5 ml (8 mg/ml) (Propranolol HCl) propranolol oral tablet 10 mg, 20 mg, 40 mg, 60 mg, 80 mg (Propranolol HCl) propranolol-hydrochlorothiazid (Propranolol/Hydro oral tablet 40-25 mg, 80-25 mg chlorothiazid) sorine oral tablet 120 mg, 160 mg, 240 mg, 80 mg (Betapace) sotalol 120 mg tablet 120 mg (Betapace) sotalol af oral tablet 120 mg (Betapace) sotalol oral tablet 160 mg, 240 mg, 80 mg (Betapace) timolol maleate oral tablet 10 mg, 20 mg, 5 mg (Timolol Maleate) 99
Calcium-Channel Blocking Agents cartia xt oral capsule,extended release 24hr 120 mg, 180 mg, 240 mg, 300 mg diltiazem 24hr er 180 mg cap 180 mg diltiazem 24hr er 360 mg cap 360 mg diltiazem hcl intravenous recon soln 100 mg diltiazem hcl intravenous solution 5 mg/ml diltiazem hcl oral capsule, extended release 180 mg, 360 mg, 420 mg diltiazem hcl oral capsule,extended release 12 hr 120 mg, 60 mg, 90 mg diltiazem hcl oral capsule,extended release 24hr 120 mg, 240 mg, 300 mg diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg, 90 mg diltiazem hcl oral tablet extended release 24 hr 180 mg, 240 mg, 300 mg, 360 mg, 420 mg dilt-xr oral capsule,ext release degradable 120 mg, 180 mg, 240 mg matzim la oral tablet extended release 24 hr 180 mg, 240 mg, 300 mg, 360 mg, 420 mg taztia xt oral capsule, extended release 120 mg, 180 mg, 240 mg, 300 mg, 360 mg (Cardizem CD) (Cardizem CD) (Cardizem CD) (Cardizem CD) (Cardizem CD) (Cardizem CD) (Cardizem CD) (Cardizem CD) (Cardizem CD) (Cardizem LA) (Cardizem CD) (Cardizem CD) (Cardizem CD) 100
verapamil intravenous syringe 2.5 mg/ml verapamil oral capsule, 24 hr er pellet ct 100 mg, 200 mg, 300 mg verapamil oral capsule,ext rel. pellets 24 hr 120 mg, 180 mg, 240 mg, 360 mg verapamil oral tablet 120 mg, 40 mg, 80 mg verapamil oral tablet extended release 120 mg, 180 mg, 240 mg Cardiovascular Agents, Miscellaneous CORLANOR ORAL TABLET 5 MG, 7.5 MG DEMSER ORAL CAPSULE 250 MG (Verapamil HCl) (Verelan Pm) (Verelan) (Calan) (Calan SR) digitek oral tablet 125 mcg (Lanoxin) digitek oral tablet 250 mcg (Lanoxin) digox 125 mcg tablet 125 mcg (Lanoxin) ST (High Risk Med for Ages 65 and Older and Dose is Greater Than 125mcg Per Day); QL (30 per 30 days) PA-HRM; (High Risk Med for Ages 65 and Older and Dose is Greater Than 125mcg Per Day); QL (30 per 30 days); AGE (Max 64 Years) (High Risk Med for Ages 65 and Older and Dose is Greater Than 125mcg Per Day); QL (30 per 30 days) 101
digox 250 mcg tablet 250 mcg (Lanoxin) digoxin 0.25 mg/ml syringe 250 mcg/ml digoxin injection solution 250 mcg/ml DIGOXIN ORAL SOLUTION 50 MCG/ML (Digoxin) (Digoxin) digoxin oral tablet 125 mcg (Lanoxin) digoxin oral tablet 250 mcg (Lanoxin) dobutamine in d5w intravenous parenteral solution 1,000 mg/250 ml (4,000 mcg/ml), 250 mg/250 ml (1 mg/ml), 500 mg/250 ml (2,000 mcg/ml) dobutamine intravenous solution 250 mg/20 ml (12.5 mg/ml), 500 mg/40 ml (12.5 mg/ml) (Dobutamine HCl/D5W) (Dobutamine HCl) PA-HRM; (High Risk Med for Ages 65 and Older and Dose is Greater Than 125mcg Per Day); QL (30 per 30 days); AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; QL (300 per 30 days); AGE (Max 64 Years) (High Risk Med for Ages 65 and Older and Dose is Greater Than 125mcg Per Day); QL (30 per 30 days) PA-HRM; (High Risk Med for Ages 65 and Older and Dose is Greater Than 125mcg Per Day); QL (30 per 30 days); AGE (Max 64 Years) 102
dopamine in 5 % dextrose intravenous solution 200 mg/250 ml (800 mcg/ml), 400 mg/250 ml (1,600 mcg/ml), 800 mg/250 ml (3,200 mcg/ml) dopamine intravenous solution 200 mg/5 ml (40 mg/ml), 400 mg/5 ml (80 mg/ml), 800 mg/10 ml (80 mg/ml), 800 mg/5 ml (160 mg/ml) ephedrine sulfate injection solution 50 mg/ml epinephrine hcl (pf) intravenous solution 1 mg/ml (1 ml) epinephrine injection auto-injector 0.15 mg/0.15 ml, 0.3 mg/0.3 ml epinephrine injection solution 1 mg/ml (1 ml) epinephrine injection syringe 0.1 mg/ml EPIPEN 2-PAK INJECTION AUTO-INJECTOR 0.3 MG/0.3 ML EPIPEN INJECTION AUTO- INJECTOR 0.3 MG/0.3 ML EPIPEN JR 2-PAK INJECTION AUTO-INJECTOR 0.15 MG/0.3 ML ethamolin intravenous solution 5 % FIRAZYR SUBCUTANEOUS SYRINGE 30 MG/3 ML hydralazine injection solution 20 mg/ml hydralazine oral tablet 10 mg, 100 mg, 25 mg, 50 mg (Dopamine HCl/D5W) (Dopamine HCl) (Ephedrine Sulfate) (Epinephrine HCl/PF) (Adrenaclick) (Epinephrine) (Epinephrine) (Ethanolamine Oleate) (Hydralazine HCl) (Hydralazine HCl) 103
LANOXIN ORAL TABLET 187.5 MCG LANOXIN ORAL TABLET 62.5 MCG milrinone in 5 % dextrose intravenous piggyback 20 mg/100 ml (200 mcg/ml), 40 mg/200 ml (200 mcg/ml) milrinone intravenous solution 1 mg/ml norepinephrine bitartrate intravenous solution 1 mg/ml papaverine injection solution 30 mg/ml papaverine oral capsule, extended release 150 mg RANEXA ORAL TABLET EXTENDED RELEASE 12 HR 1,000 MG, 500 MG Dihydropyridines afeditab cr oral tablet extended release 30 mg, 60 mg amlodipine oral tablet 10 mg, 2.5 mg, 5 mg amlodipine-benazepril oral capsule 10-20 mg, 10-40 mg, 2.5-10 mg, 5-10 mg, 5-20 mg, 5-40 mg (Milrinone Lactate/D5W) (Milrinone Lactate) (Levophed Bitartrate) (Papaverine HCl) (Papaverine HCl) (Adalat CC) (Norvasc) (Lotrel) PA-HRM; (High Risk Med for Ages 65 and Older and Dose is Greater Than 125mcg Per Day); QL (30 per 30 days); AGE (Max 64 Years) (High Risk Med for Ages 65 and Older and Dose is Greater Than 125mcg Per Day); QL (30 per 30 days) PA PA 104
amlodipine-valsartan oral tablet 10-160 mg, 10-320 mg, 5-160 mg, 5- (Exforge) 320 mg amlodipine-valsartan-hcthiazid oral tablet 10-160-12.5 mg, 10-160-25 mg, 10-320-25 mg, 5-160-12.5 mg, (Exforge HCT) 5-160-25 mg AZOR ORAL TABLET 10-20 MG, 10-40 MG, 5-20 MG, 5-40 MG CLEVIPREX INTRAVENOUS EMULSION 50 MG/100 ML felodipine oral tablet extended release 24 hr 10 mg, 2.5 mg, 5 mg (Felodipine) isradipine oral capsule 2.5 mg, 5 mg (Isradipine) nicardipine oral capsule 20 mg, 30 mg (Nicardipine HCl) nifedical xl oral tablet extended release 24hr 30 mg, 60 mg (Procardia XL) nifedipine er 30 mg tablet f/c 30 mg (Adalat CC) nifedipine oral tablet extended release 24hr 30 mg (Adalat CC) nifedipine oral tablet extended release 24hr 60 mg, 90 mg (Procardia XL) Diuretics amiloride oral tablet 5 mg (Amiloride HCl) amiloride-hydrochlorothiazide oral (Amiloride/Hydroc tablet 5-50 mg hlorothiazide) bumetanide injection solution 0.25 mg/ml (Bumetanide) bumetanide oral tablet 0.5 mg, 1 mg, 2 mg (Bumetanide) chlorothiazide oral tablet 250 mg, 500 mg (Chlorothiazide) 105
chlorothiazide sodium intravenous recon soln 500 mg (Sodium Diuril) chlorthalidone oral tablet 25 mg, 50 mg (Chlorthalidone) DYRENIUM ORAL CAPSULE 100 MG, 50 MG furosemide injection solution 10 mg/ml (Furosemide) furosemide injection syringe 10 mg/ml (Furosemide) furosemide oral solution 10 mg/ml, 40 mg/5 ml (8 mg/ml) (Furosemide) furosemide oral tablet 20 mg, 40 mg, 80 mg (Lasix) hydrochlorothiazide oral capsule 12.5 mg (Microzide) hydrochlorothiazide oral tablet 12.5 (Hydrochlorothiazi mg, 25 mg, 50 mg de) indapamide oral tablet 1.25 mg, 2.5 mg (Indapamide) methyclothiazide oral tablet 5 mg (Methyclothiazide) metolazone oral tablet 10 mg, 2.5 mg, 5 mg (Zaroxolyn) torsemide oral tablet 10 mg, 100 mg, 20 mg, 5 mg (Demadex) triamterene-hydrochlorothiazid oral capsule 37.5-25 mg, 50-25 mg (Dyazide) triamterene-hydrochlorothiazid oral tablet 37.5-25 mg, 75-50 mg (Maxzide) Dyslipidemics 106
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 atorvastatin oral tablet 10 mg, 20 mg, 40 mg, 80 mg cholestyramine light oral powder 4 gram cholestyramine light oral powder in packet 4 gram (Caduet) (Lipitor) (Cholestyramine/A spartame) (Questran) cholestyramine packet 4 gram (Questran) colestipol hcl granules packet 5 gram (Colestid) colestipol oral granules 5 gram (Colestid) colestipol oral tablet 1 gram (Colestid) endur-acin sr 500 mg tablet 500 mg * (Slo-Niacin) fenofibrate micronized oral capsule 130 mg, 134 mg, 200 mg, 43 mg, 67 (Lofibra) mg fenofibrate nanocrystallized oral tablet 145 mg, 48 mg (Tricor) fenofibrate oral tablet 120 mg, 160 mg, 40 mg, 54 mg (Lofibra) fenofibric acid (choline) oral capsule,delayed release(dr/ec) 135 (Trilipix) mg, 45 mg fenofibric acid oral tablet 105 mg, 35 mg (Fibricor) gemfibrozil oral tablet 600 mg (Lopid) JUXTAPID ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG, 5 MG, 60 MG PA 107
KYNAMRO SUBCUTANEOUS SYRINGE 200 MG/ML LIVALO ORAL TABLET 1 MG, 2 MG, 4 MG lovastatin oral tablet 10 mg, 20 mg, 40 mg (Mevacor) niacin 50 mg caplet 50 mg * (Slo-Niacin) niacin 500 mg capsule sa 500 mg * (Niacin) niacin 500 mg tablet 500 mg * (Slo-Niacin) niacin oral tablet extended release 24 hr 1,000 mg, 500 mg, 750 mg (Niaspan) niacin tr 500 mg caplet caplet 500 mg * (Slo-Niacin) niacinamide 500 mg tablet 500 mg * (Niacinamide) niacor oral tablet 500 mg (Niacin) omega-3 acid ethyl esters oral capsule 1 gram (Lovaza) PRALUENT PEN SUBCUTANEOUS PEN INJECTOR 150 MG/ML, 75 MG/ML PRALUENT SYRINGE SUBCUTANEOUS SYRINGE 150 MG/ML, 75 MG/ML pravastatin oral tablet 10 mg, 20 mg, 40 mg, 80 mg (Pravachol) prevalite oral powder 4 gram (Cholestyramine/A spartame) prevalite packet outer 4 gram (Cholestyramine/A spartame) REPATHA PUSHTRONEX SUBCUTANEOUS WEARABLE INJECTOR 420 MG/3.5 ML PA; QL (4 per 28 days) QL (30 per 30 days) PA; QL (2 per 28 days) PA; QL (2 per 28 days) PA; QL (3.5 per 28 days) 108
REPATHA SURECLICK PA; QL (3 per 28 days) SUBCUTANEOUS PEN INJECTOR 140 MG/ML REPATHA SYRINGE PA; QL (3 per 28 days) SUBCUTANEOUS SYRINGE 140 MG/ML rosuvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg (Crestor) simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg (Zocor) simvastatin oral tablet 80 mg (Zocor) QL (30 per 30 days) VASCEPA ORAL CAPSULE 0.5 GRAM, 1 GRAM WELCHOL ORAL POWDER IN PACKET 3.75 GRAM WELCHOL ORAL TABLET 625 MG ZETIA ORAL TABLET 10 MG Renin-Angiotensin- Aldosterone System Inhibitors eplerenone oral tablet 25 mg, 50 mg (Inspra) spironolactone oral tablet 100 mg, 25 mg, 50 mg (Aldactone) spironolacton-hydrochlorothiaz oral (Aldactazide) tablet 25-25 mg Vasodilators BIDIL ORAL TABLET 20-37.5 MG isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 mg, 5 mg (Isochron) isosorbide dinitrate oral tablet extended release 40 mg (Isochron) 109
isosorbide dinitrate sublingual (Isosorbide tablet 2.5 mg, 5 mg Dinitrate) isosorbide mononitrate oral tablet (Isosorbide 10 mg, 20 mg Mononitrate) isosorbide mononitrate oral tablet extended release 24 hr 120 mg, 30 (Imdur) mg, 60 mg minitran transdermal patch 24 hour 0.1 mg/hr, 0.2 mg/hr, 0.6 mg/hr (Nitro-Dur) minitran transdermal patch 24 hour 0.4 mg/hr (Nitro-Dur) minoxidil oral tablet 10 mg, 2.5 mg (Minoxidil) NITRO-BID TRANSDERMAL OINTMENT 2 % nitroglycerin in 5 % dextrose intravenous solution 100 mg/250 ml (Nitroglycerin/D5 (400 mcg/ml), 25 mg/250 ml (100 W) mcg/ml), 50 mg/250 ml (200 mcg/ml) nitroglycerin intravenous solution 50 mg/10 ml (5 mg/ml) (Nitroglycerin) nitroglycerin sublingual tablet 0.3 mg, 0.4 mg, 0.6 mg (Nitrostat) nitroglycerin transdermal patch 24 hour 0.1 mg/hr, 0.2 mg/hr, 0.6 (Nitro-Dur) mg/hr nitroglycerin transdermal patch 24 hour 0.4 mg/hr (Nitro-Dur) NITROSTAT SUBLINGUAL TABLET 0.3 MG, 0.4 MG, 0.6 MG PROGLYCEM ORAL SUSPENSION 50 MG/ML Central Nervous System Agents QL (30 per 30 days) QL (60 per 30 days) QL (30 per 30 days) QL (60 per 30 days) 110
Central Nervous System Agents AMPYRA ORAL TABLET EXTENDED RELEASE 12 HR 10 MG caffeine citrated intravenous solution 60 mg/3 ml (20 mg/ml) caffeine citrated oral solution 60 mg/3 ml (20 mg/ml) caffeine-sodium benzoate injection solution 250 mg/ml (125 mg/ml caffeine) clonidine hcl oral tablet extended release 12 hr 0.1 mg dexmethylphenidate oral tablet 10 mg, 2.5 mg, 5 mg dextroamphetamine oral capsule, extended release 10 mg, 15 mg, 5 mg dextroamphetamine oral tablet 10 mg, 5 mg dextroamphetamine-amphetamine oral capsule,extended release 24hr 10 mg, 15 mg, 5 mg dextroamphetamine-amphetamine oral capsule,extended release 24hr 20 mg, 25 mg, 30 mg dextroamphetamine-amphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 30 mg, 5 mg, 7.5 mg flumazenil intravenous solution 0.1 mg/ml guanfacine oral tablet extended release 24 hr 1 mg, 2 mg, 3 mg, 4 mg (Cafcit) (Cafcit) (Caffeine/Sodium Benzoate) (Kapvay) (Focalin) (Dexedrine) (Dexedrine) (Adderall XR) (Adderall XR) (Adderall) (Romazicon) (Intuniv) PA; QL (60 per 30 days) QL (60 per 30 days) QL (120 per 30 days) QL (180 per 30 days) QL (30 per 30 days) QL (60 per 30 days) QL (60 per 30 days) 111
lithium carbonate oral capsule 150 mg, 300 mg, 600 mg lithium carbonate oral tablet 300 mg lithium carbonate oral tablet extended release 300 mg, 450 mg lithium citrate oral solution 8 meq/5 ml methylphenidate cd 20 mg cap 20 mg methylphenidate cd 40 mg cap 40 mg methylphenidate oral capsule, er biphasic 30-70 10 mg, 50 mg, 60 mg methylphenidate oral capsule, er biphasic 30-70 30 mg methylphenidate oral capsule,er biphasic 50-50 20 mg, 40 mg methylphenidate oral solution 10 mg/5 ml, 5 mg/5 ml methylphenidate oral tablet 10 mg, 20 mg, 5 mg methylphenidate oral tablet extended release 10 mg, 20 mg methylphenidate oral tablet extended release 24hr 18 mg, 27 mg, 54 mg methylphenidate oral tablet extended release 24hr 36 mg NUEDEXTA ORAL CAPSULE 20-10 MG (Lithium Carbonate) (Lithobid) (Lithobid) (Lithium Citrate) (Metadate Cd) (Metadate Cd) (Metadate Cd) (Metadate Cd) (Metadate Cd) (Methylin) (Ritalin) (Methylphenidate HCl) (Concerta) (Concerta) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (60 per 30 days) QL (30 per 30 days) QL (900 per 30 days) QL (90 per 30 days) QL (90 per 30 days) QL (30 per 30 days) QL (60 per 30 days) QL (60 per 30 days) 112
QUILLIVANT XR ORAL SUSPENSION,EXT REL 24HR,RECON 5 MG/ML (25 MG/5 ML) riluzole oral tablet 50 mg (Rilutek) SAVELLA ORAL TABLET 100 MG, 12.5 MG, 25 MG, 50 MG SAVELLA ORAL TABLETS,DOSE PACK 12.5 MG (5)-25 MG(8)-50 MG(42) STRATTERA ORAL CAPSULE 10 MG, 100 MG, 18 MG, 25 MG, 40 MG, 60 MG, 80 MG tetrabenazine oral tablet 12.5 mg, 25 mg (Xenazine) Contraceptives Contraceptives AFTERA 1.5 MG TABLET 1.5 MG * 3 $0 altavera (28) oral tablet 0.15-0.03 mg (Amethyst) alyacen 1/35 (28) oral tablet 1-35 mg-mcg (Modicon) alyacen 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 mcg (Modicon) amethia lo oral tablets,dose pack,3 month 0.10 mg-20 mcg (84)/10 mcg (Seasonique) (7) amethia oral tablets,dose pack,3 month 0.15 mg-30 mcg (84)/10 mcg (Seasonique) (7) apri oral tablet 0.15-0.03 mg (Desogen) aranelle (28) oral tablet 0.5/1/0.5-35 mg-mcg (Modicon) QL (60 per 30 days) QL (60 per 30 days) PA; QL (112 per 28 days) QL (6 per 365 days) QL (91 per 84 days) QL (91 per 84 days) 113
ashlyna oral tablets,dose pack,3 month 0.15 mg-30 mcg (84)/10 mcg (Seasonique) (7) aubra oral tablet 0.1-20 mg-mcg (Amethyst) aviane oral tablet 0.1-20 mg-mcg (Amethyst) azurette (28) oral tablet 0.15-0.02 mgx21 /0.01 mg x 5 (Mircette) balziva (28) oral tablet 0.4-35 mgmcg (Modicon) bekyree (28) oral tablet 0.15-0.02 mgx21 /0.01 mg x 5 (Mircette) blisovi 24 fe oral tablet 1 mg-20 mcg (24)/75 mg (4) (Loestrin Fe) blisovi fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg (21)/75 mg (7) (Loestrin Fe) blisovi fe 1/20 (28) oral tablet 1 mg- (Loestrin Fe) 20 mcg (21)/75 mg (7) briellyn oral tablet 0.4-35 mg-mcg (Modicon) camila oral tablet 0.35 mg (Nor-Q-D) camrese lo oral tablets,dose pack,3 month 0.10 mg-20 mcg (84)/10 mcg (7) camrese oral tablets,dose pack,3 month 0.15 mg-30 mcg (84)/10 mcg (7) caziant (28) oral tablet 0.1/.125/.15-25 mg-mcg cryselle (28) oral tablet 0.3-30 mgmcg cyclafem 1/35 (28) oral tablet 1-35 mg-mcg cyclafem 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 mcg (Seasonique) (Seasonique) (Desogen) (Norgestrel-Ethinyl Estradiol) (Modicon) (Modicon) cyred oral tablet 0.15-0.03 mg (Desogen) QL (91 per 84 days) QL (91 per 84 days) 114
dasetta 1/35 (28) oral tablet 1-35 mg-mcg (Modicon) dasetta 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 mcg (Modicon) daysee oral tablets,dose pack,3 QL (91 per 84 days) month 0.15 mg-30 mcg (84)/10 mcg (7) (Seasonique) deblitane oral tablet 0.35 mg (Nor-Q-D) delyla (28) oral tablet 0.1-20 mgmcg (Amethyst) desog-e.estradiol/e.estradiol oral tablet 0.15-0.02 mgx21 /0.01 mg x 5 (Mircette) desogestrel-ethinyl estradiol oral tablet 0.15-0.03 mg (Desogen) drospirenone-ethinyl estradiol oral tablet 3-0.02 mg, 3-0.03 mg (Yaz) econtra ez 1.5 mg tablet inner 1.5 QL (6 per 365 days) (Aftera) mg * elinest oral tablet 0.3-30 mg-mcg (Norgestrel-Ethinyl Estradiol) ELLA ORAL TABLET 30 MG QL (6 per 365 days) emoquette oral tablet 0.15-0.03 mg (Desogen) enpresse oral tablet 50-30 (6)/75-40 (5)/125-30(10) (Amethyst) enskyce oral tablet 0.15-0.03 mg (Desogen) errin oral tablet 0.35 mg (Nor-Q-D) estarylla oral tablet 0.25-35 mg-mcg (Ortho-Cyclen) fallback solo 1.5 mg tablet inner 1.5 QL (6 per 365 days) (Aftera) mg * falmina (28) oral tablet 0.1-20 mgmcg (Amethyst) femynor oral tablet 0.25-35 mg-mcg (Ortho-Cyclen) gianvi (28) oral tablet 3-0.02 mg (Yaz) gildagia oral tablet 0.4-35 mg-mcg (Modicon) 115
gildess 1.5/30 (21) oral tablet 1.5-30 (Loestrin) mg-mcg gildess 1/20 (21) oral tablet 1-20 mg-mcg (Loestrin) gildess 24 fe oral tablet 1 mg-20 mcg (24)/75 mg (4) (Loestrin Fe) gildess fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg (21)/75 mg (7) (Loestrin Fe) gildess fe 1/20 (28) oral tablet 1 mg- 20 mcg (21)/75 mg (7) (Loestrin Fe) heather oral tablet 0.35 mg (Nor-Q-D) introvale oral tablets,dose pack,3 (Levonorgestrelmonth 0.15 mg-30 mcg Ethin Estradiol) jencycla oral tablet 0.35 mg (Nor-Q-D) jolessa oral tablets,dose pack,3 (Levonorgestrelmonth 0.15 mg-30 mcg Ethin Estradiol) jolivette oral tablet 0.35 mg (Nor-Q-D) juleber oral tablet 0.15-0.03 mg (Desogen) junel 1.5/30 (21) oral tablet 1.5-30 mg-mcg (Loestrin) junel 1/20 (21) oral tablet 1-20 mgmcg (Loestrin) junel fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg (21)/75 mg (7) (Loestrin Fe) junel fe 1/20 (28) oral tablet 1 mg- 20 mcg (21)/75 mg (7) (Loestrin Fe) junel fe 24 oral tablet 1 mg-20 mcg (24)/75 mg (4) (Loestrin Fe) kariva (28) oral tablet 0.15-0.02 mgx21 /0.01 mg x 5 (Mircette) kelnor 1/35 (28) oral tablet 1-35 mg-mcg (Demulen 1-50-21) kimidess (28) oral tablet 0.15-0.02 mgx21 /0.01 mg x 5 (Mircette) QL (91 per 84 days) QL (91 per 84 days) 116
kurvelo oral tablet 0.15-0.03 mg (Amethyst) l norgest/e.estradiol-e.estrad oral QL (91 per 84 days) tablets,dose pack,3 month 0.10 mg- 20 mcg (84)/10 mcg (7), 0.15 mg-30 mcg (84)/10 mcg (7) (Seasonique) larin 1.5/30 (21) oral tablet 1.5-30 mg-mcg (Loestrin) larin 1/20 (21) oral tablet 1-20 mgmcg (Loestrin) larin 24 fe oral tablet 1 mg-20 mcg (24)/75 mg (4) (Loestrin Fe) larin fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg (21)/75 mg (7) (Loestrin Fe) larin fe 1/20 (28) oral tablet 1 mg- 20 mcg (21)/75 mg (7) (Loestrin Fe) larissia oral tablet 0.1-20 mg-mcg (Amethyst) leena 28 oral tablet 0.5/1/0.5-35 mg-mcg (Modicon) lessina oral tablet 0.1-20 mg-mcg (Amethyst) levonest (28) oral tablet 50-30 (6)/75-40 (5)/125-30(10) (Amethyst) levonor-eth estrad 0.15-0.03 outer QL (91 per 84 days) (Amethyst) 0.15-0.03 mg levonorgestrel 1.5 mg tablet (otc) QL (6 per 365 days) (Aftera) 1.5 mg * levonorgestrel oral tablet 0.75 mg (Plan B One-Step) QL (12 per 365 days) levonorgestrel oral tablet 1.5 mg (Plan B One-Step) QL (6 per 365 days) levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg (Amethyst) levonorgestrel-ethinyl estrad oral tablets,dose pack,3 month 0.15 mg- 30 mcg (Amethyst) QL (91 per 84 days) 117
levonorg-eth estrad triphasic oral QL (91 per 84 days) tablet 50-30 (6)/75-40 (5)/125-30(10) (Amethyst) levora-28 oral tablet 0.15-0.03 mg (Amethyst) lomedia 24 fe oral tablet 1 mg-20 mcg (24)/75 mg (4) (Loestrin Fe) loryna (28) oral tablet 3-0.02 mg (Yaz) low-ogestrel (28) oral tablet 0.3-30 (Norgestrel-Ethinyl mg-mcg Estradiol) lutera (28) oral tablet 0.1-20 mgmcg (Amethyst) lyza oral tablet 0.35 mg (Nor-Q-D) marlissa oral tablet 0.15-0.03 mg (Amethyst) microgestin 1.5/30 (21) oral tablet 1.5-30 mg-mcg (Loestrin) microgestin 1/20 (21) oral tablet 1-20 mg-mcg (Loestrin) microgestin fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg (21)/75 mg (7) (Loestrin Fe) microgestin fe 1/20 (28) oral tablet 1 mg-20 mcg (21)/75 mg (7) (Loestrin Fe) mono-linyah oral tablet 0.25-35 mgmcg (Ortho-Cyclen) mononessa (28) oral tablet 0.25-35 mg-mcg (Ortho-Cyclen) my way 1.5 mg tablet (otc) 1.5 mg * (Aftera) QL (6 per 365 days) myzilra oral tablet 50-30 (6)/75-40 (5)/125-30(10) (Amethyst) necon 0.5/35 (28) oral tablet 0.5-35 mg-mcg (Modicon) necon 1/35 (28) oral tablet 1-35 mgmcg (Modicon) necon 1/50 (28) oral tablet 1-50 mgmcg (Norinyl 1+50) 118
necon 10/11 (28) oral tablet 0.5-35/1-35 mg-mcg/mg-mcg (Modicon) necon 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 mcg (Modicon) next choice one dose 1.5 mg tb (otc) 1.5 mg * (Aftera) next choice one dose oral tablet 1.5 mg (Plan B One-Step) nikki (28) oral tablet 3-0.02 mg (Yaz) nora-be oral tablet 0.35 mg (Nor-Q-D) norethindrone (contraceptive) oral tablet 0.35 mg (Nor-Q-D) norethindrone ac-eth estradiol oral tablet 1-20 mg-mcg (Loestrin) norethindrone-e.estradiol-iron oral tablet 1 mg-20 mcg (24)/75 mg (4) (Loestrin Fe) norg-ee 0.18-0.215-0.25/0.035 3x28 day regimen 0.18/0.215/0.25 mg-35 (Ortho-Cyclen) mcg (28) norgestimate-ethinyl estradiol oral tablet 0.18/0.215/0.25 mg-25 mcg, (Ortho-Cyclen) 0.25-35 mg-mcg norlyroc oral tablet 0.35 mg (Nor-Q-D) nortrel 0.5/35 (28) oral tablet 0.5-35 (Modicon) mg-mcg nortrel 1/35 (21) oral tablet 1-35 mg-mcg (Modicon) nortrel 1/35 (28) oral tablet 1-35 mg-mcg (Modicon) nortrel 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 mcg (Modicon) NUVARING VAGINAL RING 0.12-0.015 MG/24 HR ocella oral tablet 3-0.03 mg (Yaz) QL (6 per 365 days) QL (6 per 365 days) ST; QL (1 per 28 days) 119
ogestrel (28) oral tablet 0.5-50 mgmcg Estradiol) (Norgestrel-Ethinyl opcicon one-step 1.5 mg tablet 1.5 QL (6 per 365 days) (Aftera) mg * option 2 1.5 mg tablet 1.5 mg * (Aftera) QL (6 per 365 days) orsythia oral tablet 0.1-20 mg-mcg (Amethyst) philith oral tablet 0.4-35 mg-mcg (Modicon) pimtrea (28) oral tablet 0.15-0.02 mgx21 /0.01 mg x 5 (Mircette) pirmella oral tablet 0.5/0.75/1 mg- 35 mcg, 1-35 mg-mcg (Modicon) PLAN B ONE-STEP 1.5 MG QL (6 per 365 days) 3 $0 TABLET (OTC) 1.5 MG * portia oral tablet 0.15-0.03 mg (Amethyst) previfem oral tablet 0.25-35 mg-mcg (Ortho-Cyclen) quasense oral tablets,dose pack,3 (Levonorgestrel- QL (91 per 84 days) month 0.15 mg-30 mcg Ethin Estradiol) react 1.5 mg tablet 1.5 mg * (Aftera) QL (6 per 365 days) reclipsen (28) oral tablet 0.15-0.03 mg (Desogen) setlakin oral tablets,dose pack,3 (Levonorgestrel- QL (91 per 84 days) month 0.15 mg-30 mcg Ethin Estradiol) sharobel oral tablet 0.35 mg (Nor-Q-D) sprintec (28) oral tablet 0.25-35 mgmcg (Ortho-Cyclen) sronyx oral tablet 0.1-20 mg-mcg (Amethyst) syeda oral tablet 3-0.03 mg (Yaz) tarina fe 1/20 (28) oral tablet 1 mg- 20 mcg (21)/75 mg (7) (Loestrin Fe) tilia fe oral tablet 1-20(5)/1-30(7) /1mg-35mcg (9) (Loestrin Fe) tri-estarylla oral tablet 0.18/0.215/0.25 mg-35 mcg (28) (Ortho-Cyclen) 120
tri-legest fe oral tablet 1-20(5)/1-30(7) /1mg-35mcg (9) (Loestrin Fe) tri-linyah oral tablet 0.18/0.215/0.25 mg-35 mcg (28) (Ortho-Cyclen) tri-lo-estarylla oral tablet 0.18/0.215/0.25 mg-25 mcg (Ortho-Cyclen) tri-lo-marzia oral tablet 0.18/0.215/0.25 mg-25 mcg (Ortho-Cyclen) tri-lo-sprintec oral tablet 0.18/0.215/0.25 mg-25 mcg (Ortho-Cyclen) trinessa (28) oral tablet 0.18/0.215/0.25 mg-35 mcg (28) (Ortho-Cyclen) tri-previfem (28) oral tablet 0.18/0.215/0.25 mg-35 mcg (28) (Ortho-Cyclen) tri-sprintec (28) oral tablet 0.18/0.215/0.25 mg-35 mcg (28) (Ortho-Cyclen) trivora (28) oral tablet 50-30 (6)/75-40 (5)/125-30(10) (Amethyst) velivet triphasic regimen (28) oral tablet 0.1/.125/.15-25 mg-mcg (Desogen) vestura (28) oral tablet 3-0.02 mg (Yaz) vienva oral tablet 0.1-20 mg-mcg (Amethyst) viorele (28) oral tablet 0.15-0.02 mgx21 /0.01 mg x 5 (Mircette) vyfemla (28) oral tablet 0.4-35 mgmcg (Modicon) wera (28) oral tablet 0.5-35 mg-mcg (Modicon) xulane transdermal patch weekly 150-35 mcg/24 hr (Ortho Evra) zarah oral tablet 3-0.03 mg (Yaz) zenchent (28) oral tablet 0.4-35 mgmcg (Modicon) zovia 1/35e (28) oral tablet 1-35 mg-mcg (Demulen 1-50-21) QL (3 per 28 days) 121
zovia 1/50e (28) oral tablet 1-50 mg-mcg Cough And Cold Products Cough And Cold Products 15dm-5peh-2cpm liquid strawberry 2-5-15 mg/5 ml * 25cpd-200gfn liquid 25-200 mg/5 ml * 30pse-150gfn-15dm liquid 30-15- 150 mg/5 ml * 30pse-3brm-15dm oral liquid 3-30- 15 mg/5 ml * 3brm-15dm-30pse liquid 3-30-15 mg/5 ml * 3brm-30dm-50pse liquid (otc) 3-50- 30 mg/5 ml * 50pse-3brm-30dm oral liquid 3-50- 30 mg/5 ml * actinel pediatric liquid 15-5-50 mg/5 ml * adt robitussin linger cold syr 15 mg/5 ml * adt robitussin peak cld dm max 10-200 mg/5 ml * adult robitussin peak cold liq nondrowsy 10-100 mg/5 ml * adult wal-tussin dm max liq a/f,cherry menthol 10-200 mg/5 ml * adult wal-tussin dm syrup a/f,cherry,adult 10-100 mg/5 ml * adult wal-tussin liquid 100 mg/5 ml * (Demulen 1-50-21) (Chlorpheniramine/ Phenyleph/Dm) (Vanacof G) (Trispec Pse) (Neo Dm) (Neo Dm) (Neo Dm) (Neo Dm) (Trispec Pse) (Dextromethorphan Hbr) (G-Zyncof) (G-Zyncof) (G-Zyncof) (Cough Formula Dm) (Robitussin Mucus-Chest Congest) 122
alka-seltzer plus mucus-conges 10- (Guaifenesin/Dextr 200 mg * omethorphan) (Dall-nite liquid 12.5-30-1,000 mg/30 Methorphan/Aceta ml * min/doxylamn) ambi 10peh-4cpm-20dm tablet 4-10- (Chlorpheniramine/ 20 mg * Phenyleph/Dm) ambi 20dm-4cpm tablet 4-20 mg * (Coricidin Hbp) ambi 40pse-400gfn-20dm tablet 40-20-400 mg * (Poly-Vent Dm) ambi 60pse-4cpm-20dm tablet 4-60- (Chlorpheniramin/ 20 mg * Pseudoephed/Dm) benzonatate 100 mg capsule 100 mg * (Zonatuss) 3 $0 benzonatate 150 mg capsule 150 mg * (Zonatuss) 3 $0 benzonatate 200 mg capsule 200 mg * (Zonatuss) 3 $0 bio-dtuss dmx liquid 1-30-20 mg/5 ml * (Neo Dm) bionel pediatric liquid 15-5-50 mg/5 ml * (Trispec Pse) biospec dmx liquid 15-25 mg/5 ml * (G-Zyncof) bp 8 cough oral suspension a/f, (Guaifenesin/Dm/P grape (otc) 30-15-175 mg/5 ml * seudoephedrine) bpm-pse-dm liquid a/f, cotton candy (otc) 4-20-20 mg/5 ml * (Neo Dm) bromfed dm cough syrup 2-30-10 (Brompheniramine/ mg/5 ml * Pseudoephed/Dm) 3 $0 bromphenir-pseudoephed-dm syr (Brompheniramine/ (rx) 2-30-10 mg/5 ml * Pseudoephed/Dm) brom-pse-dm cough syrup butter (Brompheniramine/ scotch (otc) 2-30-10 mg/5 ml * Pseudoephed/Dm) 123
centergy dm pediatric drops 1-2-3 mg/ml * cheracol d cough formula 10-100 mg/5 ml * cheratussin dac syrup 30-10-100 mg/5 ml * child sudafed pe cough-cold lq 2.5-5 mg/5 ml * child triaminic cgh-congst syr 5-100 mg/5 ml * child wal-tussin 7.5 mg odt 7.5 mg * children's mucinex cough liq a/f 5-100 mg/5 ml * children's silfedrine liq 15 mg/5 ml * childs sudafed 15 mg/5 ml liq nondrowsy,a/f,s/f 15 mg/5 ml * chl mucinex chest congest liq a/f 100 mg/5 ml * chld triaminic cgh-sor thr sus 160-5 mg/5 ml * codituss dm syrup 8.33-5-10 mg/5 ml * cold multi-symptom day-night pseudoephedrine-free 2-5-10-325 mg * cold relief multi-symp caplet cplt,12 day,12 night 2-5-10-325 mg * cold-flu relief d/n softgel 10-5- 325mg(d)/ 15-325-6.25mg * (Chlorpheniramine/ Phenyleph/Dm) (G-Zyncof) (Tusnel C) (Dextromethorphan /Phenylephrine) (Cough Formula Dm) (Dextromethorphan Hbr) (G-Zyncof) (Pseudoephedrine HCl) (Pseudoephedrine HCl) (Robitussin Mucus-Chest Congest) (Child Tylenol Plus Cough-Sore) (Pyrilamine/Pe/De xtromethorphan) (Dm Hb/Pe/Acetaminop hen/chlorph) (Dm Hb/Pe/Acetaminop hen/chlorph) (Vicks Dayquil- Nyquil) 124
cold-flu relief liquid 12.5-30-1,000 mg/30 ml * (D- Methorphan/Aceta min/doxylamn) congestac tablet 60-400 mg * (Poly-Vent Ir) congest-eze 60-400 mg caplet 60-400 mg * (Poly-Vent Ir) coricidin hbp cold-multi sympt 6.25-15-325 mg/15 ml * (D- Methorphan/Aceta min/doxylamn) coricidin hbp softgel 10-200 mg * (Guaifenesin/Dextr omethorphan) cough & cold tablet 4-30 mg * (Coricidin Hbp) cvs chest cong relief pe tab 10-400 mg * (Maxiphen) cvs chest congest relief dm tb 20-400 mg * (Allfen Dm) cvs child cold-cough day liq 2.5-5 (Dextromethorphan mg/5 ml * /Phenylephrine) (Robitussin cvs child's chest congest liq 100 Mucus-Chest mg/5 ml * Congest) cvs cough & sore throat susp 160-5 mg/5 ml * cvs daytime-nighttime cold-flu multi-symp,twin pack 6.25-5-10-325 mg/15 ml * cvs tussin cgh 15 mg liq gels nondrowsy, liq gels 15 mg * cvs tussin dm cough-chest liq 10-200 mg/5 ml * daytime cold & cough liquid 1,000-30 mg/30 ml * (Child Tylenol Plus Cough-Sore) (Dm/Pe/Acetamino phen/doxylamine) (Robitussin) (G-Zyncof) (Triaminic) 125
daytime cold-flu liquid a/f, glutenfree 5-10-325 mg/15 ml * (D- Methorphan/Pe/Ac etaminophen) (Dextromethorphan Hbr) (Dextromethorphan Hb/Doxylamine) daytime cough liquid a/f, gluten-free 5 mg/5 ml * daytime-nighttime cough liquid 15mg/15ml(d)/ 12.5-30mg/30ml * delsym cough+chest cngst dm lq 5-100 mg/5 ml * (G-Zyncof) despec-dm tablet 30-10-200 mg * (Poly-Vent Dm) dextromethorphan er 30 mg/5 ml 30 mg/5 ml * (Delsym) diabetic tussin dm liquid 10-100 mg/5 ml * (G-Zyncof) diabetic tussin dm max-str liq 10-200 mg/5 ml * (G-Zyncof) ed bron gp liquid 5-100 mg/5 ml * (Despec) entre-cough liquid 30-15-175 mg/5 ml * (Trispec Pse) expectorant 100 mg/5 ml syrup 100 mg/5 ml * expectorant dm cough liquid 20-300 mg/5 ml * expectorant max cough-cold 30-15 mg/5 ml * geri-tussin dm syrup 10-100 mg/5 ml * guaifenesin 200 mg tablet (otc) 200 mg * guaifenesin dac oral solution 30-10- 100 mg/5 ml * guaifenesin er 600 mg tablet 600 mg * (Robitussin Mucus-Chest Congest) (G-Zyncof) (Dextromethorphan /Pseudoephed) (Cough Formula Dm) (Allfen) (Tusnel C) (Mucinex) 126
head congestion day-night pack 2-5- 10-325 mg * hydrocodone-chlorphen er susp 10-8 mg/5 ml * hydrocodone-homatropine 5-1.5 mg tablet 5-1.5 mg * hydromet syrup 5-1.5 mg/5 ml * (Dm Hb/Pe/Acetaminop hen/chlorph) (Tussionex) 3 $0 (Tussigon) 3 $0 (Hydrocodone Bit/Homatrop Me- Br) 3 $0 liquibid d-r tablet 10-400 mg * (Maxiphen) lohist-dm syrup 2-5-10 mg/5 ml * (Ala-Hist Dm) 3 $0 lortuss ex liquid 30-10-100 mg/5 ml (Tusnel C) * mar-cof bp liquid 2-30-7.5 mg/5 ml (Bromphenira/Pseu 3 $0 * doephed/codein) mar-cof cg liquid 7.5-225 mg/5 ml * (M-Clear Wc) 3 $0 M-END DM SYRUP 2-15-15 MG/5 ML * MUCINEX FAST-MAX COLD- FLU-THRT 10-20-650-400 MG * mucus dm 600-30 mg tablet 30-600 (Mucinex Dm) mg * mucus dm max 1,200-60 mg tab 60- (Mucinex Dm) 1,200 mg * mucus relief 400 mg tablet d/f 400 (Allfen) mg * nasal-sinus decongest tab 30 mg * (Sudafed 12-Hour) mesehist dm oral syrup 2-15-15 (Chlorpheniramin/ mg/5 ml * Pseudoephed/Dm) nasohist dm pediatric drops 1-2-3 mg/ml * NEO DM SYRUP 3-50-30 MG/5 ML * (Chlorpheniramine/ Phenyleph/Dm) 127
neo-tuss liquid 30-200 mg/5 ml * (G-Zyncof) NEXAFED 30 MG TABLET 30 MG * (Dm/Pnight time cold med liquid 6.25-30- Ephed/Acetaminop 15-500 mg/15 ml * h/doxylam) NIGHT TIME COLD-FLU RLF SFTGL SFTGL, MULTI- SYMPTOM 6.25-15-325 MG * night time cough & sore throat 12.5-30-1,000 mg/30 ml * nighttime cough liquid gluten-free, cherry 6.25-15 mg/15 ml * nohist-dm liquid 4-10-15 mg/5 ml * pecgen dmx 125-15 mg/5 ml liq 15-125 mg/5 ml * pedia relief cough-cold liquid a/f, cherry 1-15-5 mg/5 ml * pediacare multi-symt cold liq non drowsy, grape 2.5-5 mg/5 ml * phenylhistine dh liquid (otc) 2-30-10 mg/5 ml * poly-tussin liquid 9.375-10 mg/5 ml * promethazine vc-codeine syrup 6.25-5-10 mg/5 ml * promethazine-codeine syrup 6.25-10 mg/5 ml * promethazine-dm syrup 6.25-15 mg/5 ml * (D- Methorphan/Aceta min/doxylamn) (Dextromethorphan Hb/Doxylamine) (Chlorpheniramine/ Phenyleph/Dm) (G-Zyncof) (Chlorpheniramin/ Pseudoephed/Dm) (Dextromethorphan /Phenylephrine) (P-Ephed HCl/Cod/Chlorphe nir) (Chlorcyclizine/Co deine) (Promethazine/Phe nyleph/codeine) (Promethazine HCl/Codeine) (Promethazine/Dex tromethorphan) 3 $0 3 $0 3 $0 128
pseudoephed 30 mg/5 ml soln 30 mg/5 ml * pseudoephedrine 30 mg tablet 30 mg * pseudoephedrine 60 mg tablet exstr, non drowsy (otc) 60 mg * pv flu relief therapy liquid daytime 5-10-325 mg/15 ml * pv night-time softgel multisympt.,softgel 6.25-30-15-325 mg * (Pseudoephedrine HCl) (Sudafed 12-Hour) (Sudafed 12-Hour) (D- Methorphan/Pe/Ac etaminophen) (Dm/P- Ephed/Acetaminop h/doxylam) pv tussin pe liquid 5-100 mg/5 ml * (Despec) q-tapp dm elixir 1-15-5 mg/5 ml * (Brompheniramine/ Pseudoephed/Dm) (Robitussin q-tussin 100 mg/5 ml solution a/f, Mucus-Chest non-drowsy 100 mg/5 ml * Congest) q-tussin dm syrup 10-100 mg/5 ml * ra child plus cough-runny nose pseudoephedrine free 1-5-160 mg/5 ml * ra daytime-nighttime softgel cold-flu relief 10-5-325mg(d)/ 15-325- 6.25mg * ra flu formula gelcap 12.5-5-10-325 mg * ra maximum strength flu tablet 2-15-500 mg * ra mucus relief 400 mg tablet 400 mg * (Cough Formula Dm) (Dextromethorphn/ Acetaminoph/Cp) (Vicks Dayquil- Nyquil) (Dm/Pe/Acetamino ph/diphenhydram) (Coricidin Hbp) (Allfen) 129
ra multi-symptom cold caplet nighttime,cplt 2-5-10-325 mg * (Dm Hb/Pe/Acetaminop hen/chlorph) (Cough Formula Dm) (Dextromethorphan ra tussin dm syrup a/f 10-100 mg/5 ml * ra tussin max strn cough syrup 15 mg/5 ml * Hbr) refenesen 200 mg tablet 200 mg * (Allfen) refenesen pe caplet 10-400 mg * (Maxiphen) relcof c liquid 6.3-100 mg/5 ml * (M-Clear Wc) 3 $0 REZIRA SOLUTION 60-5 MG/5 ML * robafen 100 mg/5 ml syrup 100 mg/5 ml * robafen cough 15 mg liquidgel nondrowsy,liquidgel 15 mg * robafen-dm syrup 10-100 mg/5 ml * robitussin cough-chest-cong dm 10-200 mg * ROBITUSSIN LONG-ACTING LIQ 1-7.5 MG/5 ML * robitussin pediatric cough syp a/f,long-acting 7.5 mg/5 ml * rydex liquid 1.3-10-6.3 mg/5 ml * rynex dm liquid a/f, prof use only 1-2.5-5 mg/5 ml * safetussin dm liquid 10-100 mg/5 ml * scot-tussin 100 mg/5 ml liq 100 mg/5 ml * (Robitussin Mucus-Chest Congest) 3 $0 (Robitussin) (Cough Formula Dm) (Guaifenesin/Dextr omethorphan) (Dextromethorphan Hbr) (Bromphenira/Pseu doephed/codein) (Brompheniram/Ph enylephrine/dm) (G-Zyncof) (Robitussin Mucus-Chest Congest) 130
scot-tussin dm s-f liquid 2-15 mg/5 ml * siltussin sa 100 mg/5 ml syr 100 mg/5 ml * sm adult nasal decongestant lq 15 mg/5 ml * sm childrens plus cold susp grape,multi-symptom 1-2.5-5-160 mg/5 ml * sm cold & cough liquid children's, day time 2.5-5 mg/5 ml * sm cold-cough child elixir 1-15-5 mg/5 ml * sm cough & runny nose liquid 1-5 mg/5 ml * sm cough-head congestion lq 20-10- 66.7 mg/5 ml * sm flu severe cold-congestion maximum strength 4-60-30-1,000 mg * sm mucus relief cough liquid childrens, a/f 5-100 mg/5 ml * sm nite time cold-flu liquid 7.5-60- 30-1,000 mg/30 ml * sm nite time cold-flu rel sfgl softgel 6.25-30-15-325 mg * sm pain reliever cold caplet 2-30- 15-325 mg * sm pedia relief liquid 1-15-5 mg/5 ml * (Vicks Children'S Nyquil) (Robitussin Mucus-Chest Congest) (Pseudoephedrine HCl) (Dm Hb/Pe/Acetaminop hen/chlorph) (Dextromethorphan /Phenylephrine) (Brompheniramine/ Pseudoephed/Dm) (Vicks Children'S Nyquil) (Trispec Pse) (Dm Hb/Pseudoephed/A cetamin/cp) (G-Zyncof) (Dm/P- Ephed/Acetaminop h/doxylam) (Dm/P- Ephed/Acetaminop h/doxylam) (Dm Hb/Pseudoephed/A cetamin/cp) (Chlorpheniramin/ Pseudoephed/Dm) 131
sm severe cold m-s caplet 30-15-500 (Dm/Pseudoephed/ mg * Acetaminophen) sm tussin cf syrup 30-10-100 mg/5 (Guaifenesin/Dm/P ml * seudoephedrine) sudafed 30 mg tablet nondrowsy,max-str 30 mg * (Sudafed 12-Hour) sudogest 30 mg tablet boxed 30 mg * (Sudafed 12-Hour) sudogest 60 mg tablet 60 mg * (Sudafed 12-Hour) suphedrin liquid 15 mg/5 ml * (Pseudoephedrine HCl) suphedrine pe combo pack cplt 5- (Diphenhydram/Pe/ 10-325 mg * Dm/Acetamin/Gg) THERAFLU COLD AND COUGH POWDER 10-20-650 MG * THERAFLU MULTI-SYMP COLD CPLT 5-10-325 MG * TRIAMINIC COUGH-SORE THROAT LQ A/F,CHILDREN'S 160-5 MG/5 ML * triaminic daytime cold-cough (Dextromethorphan children's, cherry 2.5-5 mg/5 ml * /Phenylephrine) tri-dex pe oral syrup 2-10-15 mg/5 (Chlorpheniramine/ ml * Phenyleph/Dm) trymine cg liquid 7.5-225 mg/5 ml * (M-Clear Wc) tusnel diabetic liquid (otc) 10-100 mg/5 ml * (G-Zyncof) TUSNEL LIQUID A/F,A/F,D/F 30-15-200 MG/5 ML * TUSNEL PEDIATRIC LIQUID (RX) 15-5-50 MG/5 ML * TUSSI PRES-B LIQUID 4-10-30 MG/5 ML * 132
tussin cf cough-cold syrup a/f 5-10- 100 mg/5 ml * (Maxiphen Dmx) tussin cold-congestion gelcap liquid (Guaifenesin/Dm/P gelcap 30-10-200 mg * seudoephedrine) tussin dm syrup 15-100 mg/5 ml * (Cough Formula Dm) VANACOF LIQUID 1-30-12.5 MG/5 ML * vicks dayquil cough liquid a/f,8 hr (Dextromethorphan rlf 5 mg/5 ml * Hbr) (Dvicks dayquil liquicaps cold & flu 5- Methorphan/Pe/Ac 10-325 mg * etaminophen) vicks nature fusion cough liq 5 mg/5 (Dextromethorphan ml * Hbr) vicks nyquil severe cold-flu 6.25-5- (Dm/Pe/Acetamino 10-325 mg/15 ml * phen/doxylamine) virdec dm drops 1-3.5-3 mg/ml * (Chlorpheniramine/ Phenyleph/Dm) virtussin ac liquid 10-100 mg/5 ml * (M-Clear Wc) v-r infant non-asa cold drp 15-5-160 (Dm/Pseudoephed/ mg/1.6 ml * Acetaminophen) v-r non-aspirin flu gelcap gelatin (Dm/Pseudoephed/ caplet 30-15-500 mg * Acetaminophen) v-r pedia relief inf drops (Dextromethorphan decongestant + 7.5-2.5 mg/0.8 ml * /Pseudoephed) vr triacting cold-cough liq 1-15-5 (Chlorpheniramin/ mg/5 ml * Pseudoephed/Dm) v-r tussin cf syrup 30-10-100 mg/5 (Guaifenesin/Dm/P ml * seudoephedrine) wal-phed 30 mg tablet non-drowsy 30 mg * (Sudafed 12-Hour) wal-phed pe day-night combo pk (Diphenhydram/Pe/ gluten-free 5-10-325 mg * Dm/Acetamin/Gg) 133
wal-tussin cough 15 mg softgel 15 mg * (Robitussin) wal-tussin cough 15 mg/5 ml 15 (Dextromethorphan mg/5 ml * Hbr) wal-tussin cough-cold cf liq pseudoephedrine free 5-10-100 (Maxiphen Dmx) mg/5 ml * zephrex-d 30 mg tablet 30 mg * (Sudafed 12-Hour) ZONATUSS 150 MG CAPSULE 150 MG * 3 $0 zyncof 20-400 mg/5 ml liquid 20-400 mg/5 ml * (G-Zyncof) Dental And Oral Agents Dental And Oral Agents cevimeline oral capsule 30 mg (Evoxac) chlorhexidine gluconate mucous membrane mouthwash 0.12 % oralone dental paste 0.1 % periogard mucous membrane mouthwash 0.12 % pilocarpine hcl oral tablet 5 mg, 7.5 mg PREVIDENT 5000 SENSITIVE DENTAL PASTE 1.1-5 % triamcinolone acetonide dental paste 0.1 % (Peridex) (Triamcinolone Acetonide) (Peridex) (Salagen) (Triamcinolone Acetonide) Dermatological Agents Dermatological Agents, Other 8-MOP ORAL CAPSULE 10 MG acitretin oral capsule 10 mg, 17.5 mg, 25 mg (Soriatane) acne medication 10% lotion 10 % * (Benzoyl Peroxide) 134
ACNE MEDICATION 5% LOTION 5 % * acneclear gel 10 % * (Benzoyl Peroxide) acyclovir topical ointment 5 % (Zovirax) QL (30 per 30 days) ALCOHOL PADS TOPICAL PADS, MEDICATED ALCOHOL PREP PADS amlactin 12% lotion 12 % * (Ammonium Lactate) ammonium lactate 12% cream (Ammonium fragrance free (otc) 12 % * Lactate) ammonium lactate 12% lotion (otc) (Ammonium 12 % * Lactate) ammonium lactate topical cream 12 % (Lac-Hydrin) ammonium lactate topical lotion 12 % (Lac-Hydrin) ANACAINE TOPICAL OINTMENT 10 % benzoyl peroxide 10% gel aqueous (otc) 10 % * (Benzoyl Peroxide) benzoyl peroxide 5% gel aqueous (otc) 5 % * (Benzoyl Peroxide) BETADINE 5% SPRAY 5 % * calcipotriene scalp solution 0.005 % (Calcipotriene) calcipotriene topical cream 0.005 % (Dovonex) calcipotriene topical ointment 0.005 % (Calcipotriene) calcitrene topical ointment 0.005 % (Calcipotriene) calcitriol topical ointment 3 mcg/gram (Vectical) CASTELLANI PAINT MODIFIED 1.5 % * 135
CONDYLOX TOPICAL GEL 0.5 % COSENTYX (150 MG/ML) 300 MG DOSE-2 PENS 150 MG/ML COSENTYX (150 MG/ML) 300 MG DOSE-2 SYRINGES 150 MG/ML COSENTYX PEN SUBCUTANEOUS PEN INJECTOR 150 MG/ML COSENTYX SUBCUTANEOUS SYRINGE 150 MG/ML (Coleman 100 Max cutter backwoods 25% spray 25 % * Insect Repel) (Coleman 100 Max cutter skinsations 7% spray 7 % * Insect Repel) cvs skin treatment body lotion 12 % (Ammonium * Lactate) fluorouracil topical cream 0.5 %, 5 (Carac) % fluorouracil topical solution 2 %, 5 (Fluorouracil) % (Ammonium geri-hydrolac 12% lotion 12 % * Lactate) (Ammonium geri-hydrolac 5% lotion 5 % * Lactate) imiquimod topical cream in packet 5 (Aldara) % INSECT REPELLENT 20% SPRAY 20 % * LACTINOL HX CREAM * lobana bath oil * (Mineral Oil) methoxsalen rapid oral capsule 10 (Oxsoralen-Ultra) mg PA PA PA PA QL (340 per 180 days) QL (354 per 180 days) PA NSO; QL (24 per 30 days) QL (236 per 180 days) 136
NATRAPEL 20% SPRAY 20 % * QL (354 per 180 days) off active 15% spray 15 % * (Coleman 100 Max QL (340 per 180 days) Insect Repel) off deep woods 25% spray 25 % * (Coleman 100 Max QL (340 per 180 days) Insect Repel) off deep woods dry 25% spray 25 % (Coleman High- QL (226 per 180 days) * Dry Insect Repel) off familycare 15% rplnt i spr 15 % (Coleman High- QL (142 per 180 days) * Dry Insect Repel) PANRETIN TOPICAL GEL 0.1 % persa-gel 10% 12's,max-strength 10 % * (Benzoyl Peroxide) PICATO TOPICAL GEL 0.015 % QL (3 per 56 days) PICATO TOPICAL GEL 0.05 % QL (2 per 56 days) podocon topical liquid 25 % (Podophyllum Resin) podofilox topical solution 0.5 % (Condylox) potassium hydroxide topical (Potassium solution 5 % Hydroxide) pv acne pimple 10% gel 10 % * (Benzoyl Peroxide) repel sportsmen 25% spray 25 % * (Coleman 100 Max QL (368 per 180 days) Insect Repel) repel sportsmen max 40% spray 40 (Coleman 100 Max QL (368 per 180 days) % * Insect Repel) SANTYL TOPICAL OINTMENT 250 UNIT/GRAM TALTZ AUTOINJECTOR PA SUBCUTANEOUS AUTO- INJECTOR 80 MG/ML TALTZ SYRINGE PA SUBCUTANEOUS SYRINGE 80 MG/ML TOLAK TOPICAL CREAM 4 % 137
VALCHLOR TOPICAL GEL 0.016 % zenatane oral capsule 10 mg, 20 mg, (Isotretinoin) 30 mg, 40 mg zinc oxide 20% ointment 20 % * (Boudreauxs) ZOVIRAX TOPICAL CREAM 5 % QL (15 per 30 days) Dermatological Antibacterials bacitracin 500 unit/gm ointmnt 500 unit/gram * (Bacitracin) bacitraycin plus 500 unit/gm 500 unit/gram * (Bacitracin) clindamycin phosphate topical gel 1 % (Cleocin T) clindamycin phosphate topical lotion 1 % (Cleocin T) clindamycin phosphate topical solution 1 % (Cleocin T) clindamycin phosphate topical swab 1 % (Cleocin T) (Neomycin cvs triple antibiotic ointment 3.5mg- Su/Bacitrac 400 unit- 5,000 unit/gram * Zn/Poly) ery pads topical swab 2 % (Erythromycin Base/Ethanol) erythromycin with ethanol topical gel 2 % (Erygel) erythromycin with ethanol topical (Erythromycin solution 2 % Base/Ethanol) erythromycin with ethanol topical swab 2 % gentamicin topical cream 0.1 % (Erythromycin Base/Ethanol) (Gentamicin Sulfate) 138
gentamicin topical ointment 0.1 % (Gentamicin Sulfate) metronidazole topical cream 0.75 % (Metrocream) metronidazole topical gel 0.75 %, 1 % (Rosadan) metronidazole topical lotion 0.75 % (Metrolotion) mupirocin calcium topical cream 2 % (Bactroban) mupirocin topical ointment 2 % (Centany) neomycin-polymyxin b gu irrigation (Neosporin G.U. solution 40 mg-200,000 unit/ml Irrigant) (Neomycin neosporin ointment 3.5mg-400 unit- Su/Bacitrac 5,000 unit/gram * Zn/Poly) rosadan topical cream 0.75 % (Metrocream) selenium sulfide topical lotion 2.5 % (Selenium Sulfide) selenium sulfide topical shampoo 2.25 % (Selenium Sulfide) silver nitrate topical ointment 10 % (Silver Nitrate) silver nitrate topical solution 0.5 %, 10 %, 25 %, 50 % (Silver Nitrate) silver sulfadiazine topical cream 1 % (Silvadene) ssd topical cream 1 % (Silvadene) sulfacetamide sodium (acne) topical suspension 10 % (Klaron) (Neomycin triple antibiotic ointment carton Su/Bacitrac 3.5mg-400 unit- 5,000 unit/gram * Zn/Poly) Dermatological Anti- Inflammatory Agents ala-cort topical cream 1 % (Anusol-HC) ala-scalp topical lotion 2 % (Scalacort) 139
(Alclometasone alclometasone topical cream 0.05 % Dipropionate) alclometasone topical ointment 0.05 (Alclometasone % Dipropionate) aquanil hc 1% lotion 1 % * (Cortizone-10) beta hc 1% lotion 1 % * (Cortizone-10) betamethasone valerate topical (Luxiq) foam 0.12 % betamethasone, augmented topical (Diprolene AF) cream 0.05 % betamethasone, augmented topical (Diprolene) lotion 0.05 % betamethasone, augmented topical (Diprolene) ointment 0.05 % clobetasol 0.05% cream 0.05 % (Temovate) (Clobetasol clobetasol scalp solution 0.05 % Propionate) clobetasol topical foam 0.05 % (Olux) (Clobetasol clobetasol topical gel 0.05 % Propionate) betamethasone dipropionate topical betamethasone dipropionate topical betamethasone dipropionate topical betamethasone valerate topical betamethasone valerate topical betamethasone valerate topical betamethasone, augmented topical (Betamethasone (Betamethasone (Betamethasone (Betamethasone (Betamethasone (Betamethasone (Betamethasone cream 0.05 % lotion 0.05 % ointment 0.05 % cream 0.1 % lotion 0.1 % ointment 0.1 % gel 0.05 % Dipropionate) Dipropionate) Dipropionate) Valerate) Valerate) Valerate) Dipropionate) 140
clobetasol topical lotion 0.05 % (Clobex) clobetasol topical ointment 0.05 % (Temovate) clobetasol topical shampoo 0.05 % (Clobex) clobetasol-emollient topical cream 0.05 % (Temovate) clocortolone pivalate topical cream 0.1 % (Cloderm) colocort rectal enema 100 mg/60 ml (Cortenema) cormax scalp solution 0.05 % (Clobetasol Propionate) cortizone-10 1% creme maximum strength 1 % * (Hydrocortisone) CORTIZONE-10 1% LOTION 1 % * cortizone-10 1% ointment 1 % * (Hydrocortisone) dermarest eczema 1% lotion 1 % * (Cortizone-10) desonide topical cream 0.05 % (Desowen) desonide topical ointment 0.05 % (Desonide) desoximetasone topical cream 0.05 %, 0.25 % (Topicort) desoximetasone topical gel 0.05 % (Topicort) desoximetasone topical ointment 0.05 %, 0.25 % (Topicort) ELIDEL TOPICAL CREAM 1 % fluocinonide topical cream 0.05 % (Vanos) fluocinonide topical gel 0.05 % (Fluocinonide) fluocinonide topical ointment 0.05 % (Fluocinonide) fluocinonide topical solution 0.05 % (Fluocinonide) fluticasone topical cream 0.05 % (Cutivate) fluticasone topical ointment 0.005 % (Fluticasone Propionate) 141
halobetasol propionate topical (Ultravate) cream 0.05 % halobetasol propionate topical (Ultravate) ointment 0.05 % hydro skin 1% lotion 1 % * (Cortizone-10) hydrocortisone 0.5% cream (otc) (Hydrocortisone) 0.5 % * hydrocortisone 0.5% ointment 0.5 % (Hydrocortisone) * hydrocortisone 1% cream maximum (Hydrocortisone) strength (otc) 1 % * hydrocortisone 1% cream maximum (Hydrocortisone strength 1 % * Acetate) hydrocortisone 1% lotion (otc) 1 % (Cortizone-10) 3 $0 * hydrocortisone 1% ointment carton (Hydrocortisone) (otc) 1 % * hydrocortisone acet-aloe vera (Hydrocortisone topical gel 2 % Acetate/Aloe V) hydrocortisone buty 0.1% cream 0.1 (Hydrocortisone % Butyrate) hydrocortisone butyrate topical (Locoid) ointment 0.1 % hydrocortisone butyrate topical (Locoid) solution 0.1 % hydrocortisone rectal enema 100 (Cortenema) mg/60 ml hydrocortisone topical cream 1 %, (Anusol-HC) 2.5 % hydrocortisone topical lotion 2.5 % (Scalacort) hydrocortisone topical ointment 1 (Hydrocortisone) %, 2.5 % hydrocortisone butyr-emollient (Hydrocortisone topical cream 0.1 % Butyrate) 142
hydrocortisone valerate topical (Hydrocortisone cream 0.2 % Valerate) hydrocortisone valerate topical ointment 0.2 % (Westcort) mometasone topical cream 0.1 % (Elocon) mometasone topical ointment 0.1 % (Elocon) mometasone topical solution 0.1 % (Elocon) neosporin 1% anti-itch cream 1 % * (Hydrocortisone) ONFI ORAL TABLET 10 MG, 20 MG prednicarbate topical cream 0.1 % (Dermatop) prednicarbate topical ointment 0.1 % (Dermatop) preparation h hc 1% cream 1 % * (Hydrocortisone) procto-med hc topical cream with perineal applicator 2.5 % (Hydrocortisone) procto-pak topical cream with perineal applicator 1 % (Hydrocortisone) proctosol hc rectal cream 2.5 % (Hydrocortisone) proctosol-hc 2.5% cream 2.5 % (Hydrocortisone) proctozone-hc topical cream with perineal applicator 2.5 % (Hydrocortisone) recort plus 1% cream 1 % * (Hydrocortisone) tacrolimus topical ointment 0.03 %, 0.1 % (Protopic) triamcinolone acetonide topical (Triamcinolone cream 0.025 %, 0.1 %, 0.5 % Acetonide) triamcinolone acetonide topical (Triamcinolone lotion 0.025 %, 0.1 % triamcinolone acetonide topical ointment 0.025 %, 0.1 %, 0.5 % trianex topical ointment 0.05 % Acetonide) (Triamcinolone Acetonide) (Triamcinolone Acetonide) PA NSO; QL (60 per 30 days) 143
u-cort topical cream 1-10 % (Hydrocortisone Acetate/Urea) Dermatological Retinoids adapalene topical cream 0.1 % (Differin) adapalene topical gel 0.1 % (Differin) TAZORAC TOPICAL CREAM 0.05 %, 0.1 % tretinoin gel micro 0.04% tube 0.04 PA (Retin-A Micro) % tretinoin gel micro 0.1% tube 0.1 % (Retin-A Micro) PA tretinoin microspheres topical gel PA (Retin-A Micro) with pump 0.04 %, 0.1 % tretinoin topical cream 0.025 %, PA (Retin-A) 0.05 %, 0.1 % tretinoin topical gel 0.01 %, 0.025 (Retin-A) PA %, 0.05 % Scabicides And Pediculicides cvs lice killing shampoo maximum strength 0.33-4 % * (Piperonyl Butoxide/Pyrethrin s) cvs permethrin 1% lotion 1 % * (Nix) malathion topical lotion 0.5 % (Ovide) NIX 1% CREME RINSE LIQUID W/ NIT COMB 1 % * permethrin topical cream 5 % (Elimite) ra lice treatment 1% crm rinse 2x59ml, 2 combs 1 % * (Nix) sm lice treatment permethrin 2's 1 % * (Nix) v-r lice cream rinse 1 % * (Nix) Devices Devices 144
ASSURE ID INSULIN SAFETY SYRINGE 1 ML 29 GAUGE X 1/2" BD INSULIN SYR 0.3 ML 31GX5/16 0.3 ML 31 GAUGE X 5/16 BD INSULIN SYR 0.5 ML 31GX5/16" 0.5 ML 31 GAUGE X 5/16 BD INSULIN SYR 1 ML 31GX5/16" 1 ML 31 GAUGE X 5/16 BD ULTRA-FINE PEN NDL 8MMX31G SHORT 31 GAUGE X 5/16" INSULIN SYRINGE-NEEDLE U- 100 SYRINGE 0.3 ML 29 GAUGE, 1 ML 29 GAUGE X 1/2", 1/2 ML 28 GAUGE PEN NEEDLE, DIABETIC NEEDLE 29 GAUGE X 1/2" VGO 40 DISPOSABLE DEVICE Disinfectants (For Non- Dermatologic Use) Disinfectants (For Non- Dermatologic Use) sm iodine tincture * (Iodine) Enzyme Replacement/Modifiers Enzyme Replacement/Modifiers ADAGEN INTRAMUSCULAR SOLUTION 250 UNIT/ML ALDURAZYME INTRAVENOUS SOLUTION 2.9 MG/5 ML 145
CEREZYME INTRAVENOUS RECON SOLN 400 UNIT CREON ORAL CAPSULE,DELAYED RELEASE(DR/EC) 12,000-38,000-60,000 UNIT, 24,000-76,000-120,000 UNIT, 3,000-9,500-15,000 UNIT, 36,000-114,000-180,000 UNIT, 6,000-19,000-30,000 UNIT ELAPRASE INTRAVENOUS SOLUTION 6 MG/3 ML ELITEK INTRAVENOUS RECON SOLN 1.5 MG, 7.5 MG FABRAZYME INTRAVENOUS RECON SOLN 35 MG KANUMA INTRAVENOUS SOLUTION 2 MG/ML KRYSTEXXA INTRAVENOUS SOLUTION 8 MG/ML KUVAN ORAL TABLET,SOLUBLE 100 MG MYOZYME INTRAVENOUS RECON SOLN 50 MG NAGLAZYME INTRAVENOUS SOLUTION 5 MG/5 ML ORFADIN ORAL CAPSULE 10 MG, 2 MG, 20 MG, 5 MG pancrelipase 5000 oral capsule,delayed release(dr/ec) 5,000-17,000-27,000 unit PULMOZYME INHALATION SOLUTION 1 MG/ML (Zenpep) PA 146
STRENSIQ SUBCUTANEOUS SOLUTION 100 MG/ML, 40 MG/ML VIMIZIM INTRAVENOUS SOLUTION 5 MG/5 ML (1 MG/ML) VPRIV INTRAVENOUS RECON SOLN 400 UNIT ZAVESCA ORAL CAPSULE 100 MG ZENPEP ORAL CAPSULE,DELAYED RELEASE(DR/EC) 10,000-34,000-55,000 UNIT, 15,000-51,000-82,000 UNIT, 20,000-68,000-109,000 UNIT, 25,000-85,000-136,000 UNIT, 3,000-10,000-16,000 UNIT, 40,000-136,000-218,000 UNIT, 5,000-17,000-27,000 UNIT Eye, Ear, Nose, Throat Agents Eye, Ear, Nose, Throat Agents, Miscellaneous AKTEN (PF) OPHTHALMIC GEL 3.5 % alcaine ophthalmic drops 0.5 % (Proparacaine HCl) altacaine ophthalmic drops 0.5 % (Tetravisc) altamist 0.65% nose spray 0.65 % * (Little Remedies) apraclonidine ophthalmic drops 0.5 % artificial tears 1.4 % drops 1.4 % * (Iopidine) (Polyvinyl Alcohol) PA; LA PA QL (90 per 30 days) 147
artificial tears drops p/f, sterile 0.1-0.3 % * (Dextran 70/Hypromellose/P F) artificial tears eye drops strl 0.1-0.3 % * (Tears Naturale) artificial tears eye ointment 83-15 % (Genteal Pm) * atropine ophthalmic drops 1 % (Isopto Atropine) atropine ophthalmic ointment 1 % (Atropine Sulfate) atropine-care ophthalmic drops 1 % (Isopto Atropine) ayr saline 0.65% nose drops 0.65 % * (Sodium Chloride) ayr saline 0.65% nose spray 0.65 % * (Little Remedies) azelastine nasal aerosol,spray 137 mcg (0.1 %) (Astepro) azelastine ophthalmic drops 0.05 % (Azelastine HCl) (Dextran bion tears eye drops 0.1-0.3 % * 70/Hypromellose/P F) carteolol ophthalmic drops 1 % (Carteolol HCl) cromolyn ophthalmic drops 4 % (Cromolyn Sodium) cvs artificial tears drops sterile 1- (Glycerin/Propylen 0.3 % * e Glycol) cvs lubricant 0.5% eye drops sterile 0.5 % * (Refresh Tears) cvs lubricant dry eye rlf 1% 1 % * cvs lubricant eye ointment p/f 57.3-42.5 % * cvs lubricant gel eye drops 0.25-0.3 % * (Carboxymethylcel lulose Sodium) (Genteal Pm) (Carboxymethylcel l/hypromellose) QL (30 per 25 days) 148
cvs lubricating eye drops dry eye soln 0.5-0.9 % * cvs natural tears drops 0.1-0.3 % * (Refresh Optive) (Dextran 70/Hypromellose/P F) cyclopentolate ophthalmic drops 0.5 (Cyclogyl) %, 1 %, 2 % CYSTARAN OPHTHALMIC DROPS 0.44 % deep sea 0.65% nose spray 0.65 % * (Little Remedies) (Oxymetazoline dristan long lasting mist 0.05 % * HCl) epinastine ophthalmic drops 0.05 % (Elestat) (Genteal Mild To eq gentle 0.3% eye drops 0.3 % * Moderate) eq revive plus 0.5% eye drops 0.5 % (Carboxymethylcel * lulose Sodium) flucaine ophthalmic drops 0.25-0.5 (Proparacaine/Fluo % rescein Sod) GENTEAL GEL DROPS 0.25-0.3 % * GENTEAL MILD 0.2% EYE DROPS 0.2 % * GENTEAL MILD-MODERATE EYE DROP P/F, DRY EYE RELIEF 0.3 % * GENTEAL SEVERE 0.3% EYE GEL P/F, STRL, INNER 0.3 % * genteal tears 0.1%-0.3% drop 0.1- (Tears Naturale) 0.3 % * (Isopto homatropaire ophthalmic drops 5 % Homatropine) homatropine hbr ophthalmic drops (Isopto 5 % Homatropine) 149
ipratropium bromide nasal spray,non-aerosol 0.03 % (Atrovent) ipratropium bromide nasal spray,non-aerosol 0.06 % (Atrovent) isopto tears 0.5% eye drops 0.5 % * (Genteal Mild To Moderate) LACRISERT OPHTHALMIC INSERT 5 MG lubricant 0.5-0.9% eye drops 0.5- (Carboxymethylcel 0.9 % * l/glycerin/pf) lubricant 0.5-0.9% eye drops 0.5-0.9 % * (Refresh Optive) lubricant 0.6% eye drops 0.6 % * (Propylene Glycol) lubrifresh pm eye ointment 83-15 % * (Genteal Pm) muro-128 2% eye drops 2 % * (Sodium Chloride) muro-128 5% eye drops 5 % * (Sodium Chloride) muro-128 5% eye ointment 5 % * (Sodium Chloride) naphazoline ophthalmic drops 0.1 % (Naphazoline HCl) nasal decongestant 0.05% spray 0.05 % * (Afrin) natural balance tears drops 0.4 % * (Genteal Mild To Moderate) nature's tears drops 0.4 % * (Genteal Mild To Moderate) neo-synephrine 12 hour spray 0.05 (Oxymetazoline % * HCl) ocean 0.65% nasal spray 0.65 % * (Little Remedies) olopatadine ophthalmic drops 0.1 % (Patanol) PATADAY OPHTHALMIC DROPS 0.2 % phenylephrine hcl ophthalmic drops 10 %, 2.5 % (Mydfrin) QL (30 per 28 days) QL (15 per 10 days) ST 150
proparacaine ophthalmic drops 0.5 % pure & gentle eye drops lubricant 0.3 % * pv artificial tears 0.4 % * pv lubricant 1.4 % eye drops 1.4 % * pv pure-gentle eye drops sterile 0.3 % * REFRESH CELLUVISC 1% EYE DROPS 1 % * REFRESH CLASSIC EYE DROPS U-D,P/F,30X.4ML 1.4-0.6 % * REFRESH LACRI-LUBE OINTMENT 56.8-42.5 % * REFRESH OPTIVE EYE DROPS 0.5-0.9 % * retaine cmc 0.5% eye drops 0.5 % * (Proparacaine HCl) (Genteal Mild To Moderate) (Genteal Mild To Moderate) (Polyvinyl Alcohol) (Genteal Mild To Moderate) (Carboxymethylcel lulose Sodium) saline mist 0.65% nose spry 0.65 % * (Little Remedies) sea soft 0.65% nasal mist 0.65 % * (Little Remedies) sm lubricant eye drops strl 0.4-0.3 % * (Systane) sodium chloride 5% eye drop 5 % * (Sodium Chloride) sodium chloride 5% eye oint 5 % * (Sodium Chloride) SYSTANE 0.3-0.4% EYE DROPS 0.4-0.3 % * SYSTANE GEL EYE DROPS 0.4-0.3 % * tears again 1.4 % drops 1.4 % * (Polyvinyl Alcohol) tears again eye ointment 80-20 % * (Genteal Pm) 151
tears naturale free drops u- d,36x.9ml,p/f 0.1-0.3 % * tetracaine hcl (pf) ophthalmic drops 0.5 % ultra fresh pm ointment * vicks qlearquil 0.05% mist 0.05 % * (Dextran 70/Hypromellose/P F) (Tetracaine HCl/PF) (Lanolin/Mineral Oil/Petrolatum) (Oxymetazoline HCl) vicks sinex 12 hour spray 0.05 % * (Afrin) Eye, Ear, Nose, Throat Anti-Infectives Agents acetic acid otic solution 2 % (Acetic Acid) bacitracin ophthalmic ointment 500 unit/gram (Bacitracin) bacitracin-polymyxin b ophthalmic (Bacitracin/Polymy ointment 500-10,000 unit/gram xin B Sulfate) bleph-10 ophthalmic drops 10 % (Sulfacetamide Sodium) CIPRODEX OTIC DROPS,SUSPENSION 0.3-0.1 % ciprofloxacin hcl ophthalmic drops 0.3 % (Ciloxan) ciprofloxacin hcl otic dropperette 0.2 % (Cetraxal) COLY-MYCIN S OTIC DROPS,SUSPENSION 3.3-3-10-0.5 MG/ML erythromycin ophthalmic ointment 5 mg/gram (0.5 %) (Ilotycin) gatifloxacin ophthalmic drops 0.5 % (Zymaxid) gentak ophthalmic ointment 0.3 % (3 mg/gram) (Garamycin) gentamicin ophthalmic drops 0.3 % (Garamycin) 152
gentamicin ophthalmic ointment 0.3 % (3 mg/gram) (Garamycin) levofloxacin ophthalmic drops 0.5 % (Levofloxacin) MOXEZA OPHTHALMIC DROPS, VISCOUS 0.5 % NATACYN OPHTHALMIC DROPS,SUSPENSION 5 % neomycin-bacitracin-poly-hc (Neomycin Su/Baci ophthalmic ointment 3.5-400-10,000 Zn/Poly/HC) mg-unit/g-1% neomycin-bacitracin-polymyxin ophthalmic ointment 3.5-400-10,000 mg-unit-unit/g neomycin-polymyxin b-dexameth ophthalmic drops,suspension 3.5mg/ml-10,000 unit/ml-0.1 % neomycin-polymyxin b-dexameth ophthalmic ointment 3.5 mg/g- 10,000 unit/g-0.1 % neomycin-polymyxin-gramicidin ophthalmic drops 1.75 mg-10,000 unit-0.025mg/ml neomycin-polymyxin-hc ophthalmic drops,suspension 3.5-10,000-10 mgunit-mg/ml neomycin-polymyxin-hc otic drops,suspension 3.5-10,000-1 mg/ml-unit/ml-% neomycin-polymyxin-hc otic solution 3.5-10,000-1 mg/mlunit/ml-% neo-polycin hc ophthalmic ointment 3.5-400-10,000 mg-unit/g-1% (Neomycin Su/Bacitra/Polymy xin) (Maxitrol) (Maxitrol) (Neosporin) (Neomycin/Polymy xin B Sulf/HC) (Neomycin/Polymy xin B Sulf/HC) (Cortisporin) (Neomycin Su/Baci Zn/Poly/HC) 153
neo-polycin ophthalmic ointment 3.5-400-10,000 mg-unit-unit/g (Neomycin Su/Bacitra/Polymy xin) ofloxacin ophthalmic drops 0.3 % (Floxin) ofloxacin otic drops 0.3 % (Floxin) polymyxin b sulf-trimethoprim ophthalmic drops 10,000 unit- 1 mg/ml (Polytrim) REFRESH OPTIVE ADVANCED DROPS 0.5-1-0.5 % * sulfacetamide sodium ophthalmic (Sulfacetamide drops 10 % Sodium) sulfacetamide sodium ophthalmic (Sulfacetamide ointment 10 % Sodium) sulfacetamide-prednisolone (Sulfacetamide/Pre ophthalmic drops 10 %-0.23 % dnisolone Sp) (0.25 %) TOBRADEX OPHTHALMIC OINTMENT 0.3-0.1 % TOBRADEX ST OPHTHALMIC DROPS,SUSPENSION 0.3-0.05 % tobramycin ophthalmic drops 0.3 % (Tobrex) tobramycin-dexamethasone ophthalmic drops,suspension 0.3-0.1 (Tobradex) % trifluridine ophthalmic drops 1 % (Viroptic) VIGAMOX OPHTHALMIC DROPS 0.5 % ZIRGAN OPHTHALMIC GEL 0.15 % ZYLET OPHTHALMIC DROPS,SUSPENSION 0.3-0.5 % Eye, Ear, Nose, Throat Anti-Inflammatory Agents 154
ALREX OPHTHALMIC DROPS,SUSPENSION 0.2 % bromfenac ophthalmic drops 0.09 % dexamethasone sodium phosphate ophthalmic drops 0.1 % diclofenac sodium ophthalmic drops 0.1 % DUREZOL OPHTHALMIC DROPS 0.05 % flunisolide nasal spray,non-aerosol 25 mcg (0.025 %) fluorometholone ophthalmic drops,suspension 0.1 % flurbiprofen sodium ophthalmic drops 0.03 % fluticasone nasal spray,suspension 50 mcg/actuation ILEVRO OPHTHALMIC DROPS,SUSPENSION 0.3 % ketorolac ophthalmic drops 0.4 %, 0.5 % LOTEMAX OPHTHALMIC DROPS,GEL 0.5 % LOTEMAX OPHTHALMIC DROPS,SUSPENSION 0.5 % LOTEMAX OPHTHALMIC OINTMENT 0.5 % NEVANAC OPHTHALMIC DROPS,SUSPENSION 0.1 % prednisolone acetate ophthalmic drops,suspension 1 % prednisolone sodium phosphate ophthalmic drops 1 % (Bromfenac Sodium) (Dexamethasone Sod Phosphate) (Diclofenac Sodium) (Flunisolide) (FML) (Ocufen) (Fluticasone Propionate) (Acular) (Omnipred) (Prednisolone Sod Phosphate) ST QL (50 per 25 days) 155
PROLENSA OPHTHALMIC DROPS 0.07 % RESTASIS MULTIDOSE OPHTHALMIC DROPS 0.05 % RESTASIS OPHTHALMIC DROPPERETTE 0.05 % XIIDRA OPHTHALMIC DROPPERETTE 5 % Gastrointestinal Agents Antiflatulents bicarsim forte 125 mg tablet 125 mg * (Simethicone) cvs gas relief 125 mg chew tab extra strength 125 mg * (Gas-X) cvs gas relief 125 mg softgel softgel 125 mg * (Phazyme) cvs gas relief 80 mg tab chew 80 mg * (Gas-X) gas relief 125 mg chew tablet max str,lactose-free 125 mg * (Gas-X) gas relief 80 mg tablet chew lactosefree 80 mg * (Gas-X) gas-x ultra strength softgel 180 mg * (Phazyme) inf gas rel 20 mg/0.3 ml drop (Simethicone) 20mg/0.3ml, dye free 40 mg/0.6 ml * mi-acid gas 80 mg tab chew 80 mg * (Gas-X) mytab gas 80 mg tablet chew 80 mg * (Gas-X) mytab gas max str 125 mg tab 125 mg * (Gas-X) simethicone 180 mg softgel 180 mg * (Phazyme) QL (5.5 per 30 days) QL (60 per 30 days) PA; QL (60 per 30 days) 156
v-r anti-gas 166 mg softgel 166 mg * (Phazyme) Antiulcer Agents And Acid Suppressants acid reducer 20 mg tablet maximum strength 20 mg * (Pepcid Ac) amoxicil-clarithromy-lansopraz oral (Prevpac) combo pack 500-500-30 mg CARAFATE ORAL SUSPENSION 100 MG/ML cimetidine hcl oral solution 300 mg/5 ml (Cimetidine HCl) cimetidine oral tablet 200 mg, 300 (Rx Product Only) (Cimetidine) mg, 400 mg, 800 mg cvs cimetidine 200 mg tablet (otc) 200 mg * (Tagamet Hb) esomeprazole sodium intravenous recon soln 20 mg, 40 mg (Nexium I.V.) famotidine (pf) intravenous solution 20 mg/2 ml (Famotidine) famotidine (pf)-nacl (iso-os) (Famotidine In intravenous piggyback 20 mg/50 ml Nacl,Iso-Osm/PF) famotidine 20 mg/2 ml vial latexfree, p/f, sdv 20 mg/2 ml (Famotidine/PF) famotidine 40 mg/4 ml vial 25's,outer 10 mg/ml (Famotidine) famotidine oral tablet 20 mg, 40 mg (Pepcid) (Rx Product Only) gnp acid reducer 10 mg tablet 10 mg * (Pepcid Ac) lansoprazole dr 15 mg capsule na/f (otc) 15 mg * (Prevacid 24hr) lansoprazole oral capsule,delayed (Rx Product Only) (Prevacid) release(dr/ec) 15 mg, 30 mg 157
misoprostol oral tablet 100 mcg, 200 mcg (Cytotec) omeprazole dr 20 mg tablet 20 mg * (Omeprazole) omeprazole mag dr 20.6 mg cap two (Omeprazole 14-days course 20 mg * Magnesium) omeprazole oral capsule,delayed release(dr/ec) 10 mg, 20 mg, 40 mg (Prilosec) omeprazole-sodium bicarbonate (Rx Product Only) (Zegerid) oral capsule 20-1.1 mg-gram pantoprazole intravenous recon soln (Protonix IV) 40 mg pantoprazole oral tablet,delayed release (dr/ec) 20 mg, 40 mg (Protonix) PRILOSEC OTC 20.6 MG TABLET OTC 20 MG * pub famotidine 20 mg tablet max strength (otc) 20 mg * (Pepcid Ac) pv acid relief 200 mg tablet 200 mg * (Tagamet Hb) ra omeprazole-bicarb 20-1,100 3x14 day course (otc) 20-1.1 mggram (Zegerid Otc) * ranitidine 150 mg tablet maximum strength (otc) 150 mg * (Zantac) ranitidine 75 mg tablet s/f, sodiumfree 75 mg * (Zantac) ranitidine hcl injection solution 50 (Rx Product Only) (Ranitidine HCl) mg/2 ml (25 mg/ml) ranitidine hcl oral capsule 150 mg, (Rx Product Only) (Ranitidine HCl) 300 mg ranitidine hcl oral syrup 15 mg/ml (Ranitidine HCl) (Rx Product Only) ranitidine hcl oral tablet 150 mg, (Rx Product Only) (Zantac) 300 mg 158
sucralfate oral suspension 100 mg/ml (Sucralfate) sucralfate oral tablet 1 gram (Carafate) wal-zan 75 mg tablet 75 mg * (Zantac) ZANTAC 150 MG TABLET TWIN PACK(2X45TABS) (OTC) 150 MG * ZANTAC 150 MG TABLET TWIN PK, MAX STRGTH (OTC) 150 MG * ZANTAC 75 MG TABLET 75 MG * Gastrointestinal Agents, Other acid gone antacid liquid 95-358 mg/15 ml * (Gaviscon) almacone liquid 200-200-20 mg/5 (Maalox Maximum ml * Strength) almacone-2 liquid 400-400-40 mg/5 (Maalox Maximum ml * aluminum hydroxide gel sugar-free 320 mg/5 ml * AMITIZA ORAL CAPSULE 24 MCG, 8 MCG antacid plus e-s liquid 500-450-40 mg/5 ml * antacid ultra tablet chew 400 mg (1,000 mg) * antacid xtra strength chew tab extra-strength 300 mg (750 mg) * antacid-antigas liquid 200-200-20 mg/5 ml * anti-diarrheal 2 mg caplet caplet 2 mg * Strength) (Aluminum Hydroxide) (Maalox Maximum Strength) (Tums) (Tums) (Maalox Maximum Strength) (Imodium A-D) QL (60 per 30 days) 159
bismatrol suspension 262 mg/15 ml * BUPHENYL ORAL TABLET 500 MG calci-chew tablet 500 mg calcium (1,250 mg) * calcium 500 mg chewable tablet tab chew,p/f 500 mg calcium (1,250 mg) * calcium antacid 500 mg chw tab assorted fruit 200 mg calcium (500 mg) * CALCIUM-500 MG TABLET CHEWABLE SOY FREE, YEAST FREE 500-100 MG-UNIT * cal-gest 500 mg tablet chew 200 mg calcium (500 mg) * CARBAGLU ORAL TABLET, DISPERSIBLE 200 MG child soothe 400 mg tab chew 400 mg * children pepto 400 mg tab chew bubble gum, na/f 400 mg * comfort gel max str susp max-str 400-400-40 mg/5 ml * comfort gel suspension regular str, cherry 200-200-20 mg/5 ml * constulose oral solution 10 gram/15 ml cromolyn oral concentrate 100 mg/5 ml cvs antacid-antigas tab chew 1,000-60 mg * (Pepto-Bismol) (Tums) (Tums) (Tums) (Tums) (Tums) (Tums) (Maalox Maximum Strength) (Maalox Maximum Strength) (Lactulose) (Gastrocrom) (Calcium Carbonate/Simethi cone) 160
cvs anti-diarrheal 2 mg sftgel softgel (Loperamide HCl) 2 mg * cvs anti-diarrheal suspension 262 mg/15 ml * (Pepto-Bismol) cvs loperamide 1 mg/7.5 ml liq mint 1 mg/7.5 ml * (Loperamide HCl) diamode 2 mg tablet outer, f/c 2 mg * (Imodium A-D) dicyclomine oral capsule 10 mg (Bentyl) dicyclomine oral solution 10 mg/5 ml (Dicyclomine HCl) dicyclomine oral tablet 20 mg (Bentyl) diphenoxylate-atropine oral liquid (Diphenoxylate 2.5-0.025 mg/5 ml HCl/Atropine) diphenoxylate-atropine oral tablet 2.5-0.025 mg (Lomotil) enulose oral solution 10 gram/15 ml (Lactulose) flanax antacid liquid 200-200-20 (Maalox Maximum mg/5 ml * Strength) foaming antacid liquid 95-358 mg/15 ml * (Gaviscon) GATTEX 5 MG 30-VIAL KIT 5 MG GATTEX ONE-VIAL SUBCUTANEOUS KIT 5 MG gelusil antacid & antigas liq 400- (Maalox Maximum 400-40 mg/5 ml * Strength) gelusil tablet chewable cool mint 200-200-25 mg * (Almacone) generlac oral solution 10 gram/15 ml (Lactulose) glycopyrrolate injection solution 0.2 mg/ml (Robinul) PA PA 161
glycopyrrolate oral tablet 1 mg, 2 mg imodium a-d 1 mg/7.5 ml liquid mint 1 mg/7.5 ml * IMODIUM A-D 2 MG CAPLET CAPLET 2 MG * kaopectate 262 mg/15 ml susp vanilla flavor 262 mg/15 ml * kionex 15 gm/60 ml suspension 15-19.3 gram/60 ml kionex oral powder (Robinul) (Loperamide HCl) (Pepto-Bismol) (Sodium Polystyrene Sulfon/Sorb) (Sodium Polystyrene Sulfon/Sorb) lactulose oral solution 10 gram/15 ml (Lactulose) LINZESS ORAL CAPSULE 145 MCG, 290 MCG loperamide 1 mg/5 ml liquid 1 mg/5 ml * (Loperamide HCl) loperamide oral capsule 2 mg (Loperamide HCl) LOTRONEX ORAL TABLET 0.5 MG, 1 MG maalox advanced suspension (Maalox Maximum regular strength 200-200-20 mg/5 Strength) ml * MAGNEBIND 300 TABLET 250-300 MG * magnesium 500 mg capsule s/f,na/f 500 mg * (Uromag) magnesium oxide 250 mg tablet 250 mg * (Magox 400) magnesium oxide 400 mg tablet s/f,p/f,gluten-free 400 mg * (Magox 400) QL (30 per 30 days) 162
magnesium oxide 500 mg tablet (Magox 400) p/f,s/f,lactose-free 500 mg * masanti liquid 400-400-40 mg/5 ml (Maalox Maximum * Strength) metoclopramide hcl oral tablet 10 (Reglan) mg, 5 mg mgo 400 mg tablet 400 mg * (Magox 400) mi-acid ds tablet 700-300 mg * (Rolaids) mintox maximum strength susp max (Maalox Maximum str, lemon creme 400-400-40 mg/5 Strength) ml * mintox plus tablet chewable 200- (Almacone) 200-25 mg * MOVANTIK ORAL TABLET 12.5 MG, 25 MG NUTRESTORE ORAL POWDER IN PACKET 5 GRAM OCALIVA ORAL TABLET 10 MG, 5 MG phillips 500 mg caplet 500 mg * (Magox 400) (Pepto-Bismol Topink bismuth tablet chew 262 mg * Go) medi-first pep-t-med tab chew 262 methscopolamine oral tablet 2.5 mg, metoclopramide hcl injection metoclopramide hcl oral solution 5 mi acid suspension 200-200-20 mintox suspension mint creme 200- (Pepto-Bismol To- (Methscopolamine (Metoclopramide (Metoclopramide (Maalox Maximum (Maalox Maximum mg * 5 mg solution 5 mg/ml mg/5 ml mg/5 ml, 400-400-40 mg/5 ml * 200-20 mg/5 ml * Go) Bromide) HCl) HCl) Strength) Strength) QL (30 per 30 days) PA; QL (30 per 30 days) 163
ra loperamide 1 mg/7.5 ml susp mint (Loperamide HCl) 1 mg/7.5 ml * ra magnesium 500 mg capsule 500 mg * (Uromag) RAVICTI ORAL LIQUID 1.1 GRAM/ML RELISTOR ORAL TABLET 150 MG RELISTOR SUBCUTANEOUS SOLUTION 12 MG/0.6 ML RELISTOR SUBCUTANEOUS SYRINGE 12 MG/0.6 ML, 8 MG/0.4 ML ri-gel ii suspension 400-400-40 (Maalox Maximum mg/5 ml * Strength) ri-mox suspension 200-200-20 mg/5 (Maalox Maximum ml * Strength) sm foaming antacid tablet chew 80-20 mg * (Gaviscon) sm stomach relief caplet 262 mg * (Kaopectate) sodium bicarb 650 mg tablet 10 gr (Sodium 650 mg * Bicarbonate) (Sodium sodium polystyrene (sorb free) oral Polystyrene suspension 15 gram/60 ml Sulfonate) sodium polystyrene sulfonate rectal enema 30 gram/120 ml soothe 262 mg caplet caplet 262 mg * soothe 262 mg/15 ml suspension s/f,cherry 262 mg/15 ml * (Sodium Polystyrene Sulfonate) (Kaopectate) (Pepto-Bismol) PA PA; QL (90 per 30 days) PA; QL (28 per 28 days) PA; QL (28 per 28 days) 164
sps (with sorbitol) oral suspension 15-20 gram/60 ml (Sodium Polystyrene Sulfon/Sorb) ursodiol oral capsule 300 mg (Actigall) ursodiol oral tablet 250 mg, 500 mg (Urso) VIBERZI ORAL TABLET 100 MG, 75 MG Laxatives alophen pills 5 mg * (Dulcolax) bisac-evac 10 mg suppository 10 mg (Dulcolax) * bisacodyl 10 mg suppository 10 mg * (Dulcolax) bisacodyl ec 5 mg tablet 5 mg * (Dulcolax) biscolax 10 mg suppository 10 mg * (Dulcolax) BLADDER CONTROL PAD X- LONG 9'S,X-LONG * COLACE 100 MG CAPSULE 100 MG * cvs enema disposable 19-7 gram/118 ml * (Enema) cvs fiber therapy 500 mg caplt soluble, caplet 500 mg * (Citrucel) cvs kids 100 mg mini enema 100 mg/5 ml * (Docusate Sodium) cvs purelax powder 14 once-daily doses 17 gram/dose * (Gavilax) cvs purelax powder packet s/f, 10 daily doses 17 gram * (Miralax) cvs senna laxative 8.6 mg tab 8.6 mg (Senokot) * cvs stool softener softgel softgel 240 mg * (Surfak) doc-q-lace 100 mg softgel 100 mg * (Colace) ST; QL (60 per 30 days) 165
docu liquid 50 mg/5 ml 50 mg/5 ml (Docusate Sodium) * docusate sodium 100 mg tablet (Docusate Sodium) crushable 100 mg * docusate sodium-senna tablet 8.6-50 (Sennosides/Docus mg * ate Sodium) docusol mini-enema outer 283 mg * (Docusate Sodium) dok 100 mg softgel softgel 100 mg * (Colace) dok 100 mg tablet 100 mg * (Docusate Sodium) dulcolax ss 100 mg softgel 100 mg * (Colace) enema disposable 19-7 gram/118 ml (Enema) * enema ready to use latex-free 19-7 (Enema) gram/118 ml * enemeez mini enema 5cc tubes, (Docusate Sodium) outer 283 mg/5 ml * enemeez plus mini enema outer 283- (Docusol Plus) 20 mg/5 ml * (Psyllium Seed eq fiber therapy powder * (With Sugar)) equalactin 500 mg tab chew 500 mg (Calcium * Polycarbophil) fiber tablet unboxed 625 mg * (Fibercon) fiber therapy powder 2 gram/19 (Citrucel) gram * fiber-lax captabs 500mg (Fibercon) polycarbophil 625 mg * fibertab oral tablet 625 mg * (Fibercon) FLEET BISACODYL 10 MG ENEMA 10 MG/30 ML * gavilyte-c oral recon soln 240- (Golytely) 22.72-6.72-5.84 gram gavilyte-g oral recon soln 236- (Golytely) 22.74-6.74-5.86 gram 166
gavilyte-n oral recon soln 420 gram (Nulytely with Flavor Packs) gentlelax powder 30 once-daily doses 17 gram/dose * (Gavilax) glycolax powder 7 doses (otc) 17 gram/dose * (Gavilax) 3 $0 healthylax powder packet 14x17gm, outer 17 gram * (Miralax) hydrocil instant packet * (Psyllium Seed) KONSYL 6 GM PACKET S/F, GLUTEN-F, OUTER 6 GRAM * konsyl fiber 625 mg caplet caplet, s/f (Fibercon) 625 mg * konsyl psyllium fiber packet orange, (Psyllium Husk gluten free 3.4 gram * (With Sugar)) magic bullet 10 mg suppos 10 mg * (Dulcolax) milk of magnesia suspension 400 (Milk Of mg/5 ml * Magnesia) mineral oil laxative * (Mineral Oil) MOVIPREP ORAL POWDER IN PACKET 100-7.5-2.691 GRAM natural fiber lax powder * (Psyllium Seed (With Sugar)) oral saline laxative liquid s/f, ginger (Na Phos,M-B/Na lemon 7.2-2.7 gram/15 ml * Phos,Di-Ba) peg 3350-electrolytes oral recon soln 236-22.74-6.74-5.86 gram, 240-22.72-6.72-5.84 gram (Golytely) peg-electrolyte soln oral recon soln (Nulytely with 420 gram Flavor Packs) peri-colace tablet 8.6-50 mg * (Sennosides/Docus ate Sodium) phillips' lax liqui-gels 100 mg * (Colace) 167
phosphate oral saline laxative s/f, (Na Phos,M-B/Na ginger lemon 7.2-2.7 gram/15 ml * Phos,Di-Ba) polyethylene glycol 3350 oral (Polyethylene powder 17 gram/dose Glycol 3350) polyethylene glycol 3350 oral (Polyethylene powder in packet 17 gram Glycol 3350) polyethylene glycol 3350 powd 14 once-daily doses (otc) 17 gram/dose (Gavilax) * polyethylene glycol 3350 powd 17 grams pkts,outer (otc) 17 gram * (Miralax) polyethylene glycol 3350 powd outer,s/f (otc) 17 gram * (Miralax) promolaxin 100 mg tablet 100 mg * (Docusate Sodium) pv senna 8.6 mg softgel 8.6 mg * (Sennosides) ra enema twin pack 2 x 4.5oz, rtu 19-7 gram/118 ml * (Enema) ra laxative peg 3350 powder 14 once-daily doses 17 gram/dose * (Gavilax) reguloid powder orange * (Psyllium Seed (With Sugar)) senexon 8.8 mg/5 ml liquid 8.8 mg/5 ml * (Sennosides) senexon tablet 8.6 mg * (Senokot) senna 8.8 mg/5 ml syrup a/f, chocolate 8.8 mg/5 ml * (Sennosides) senna-lax 8.6 mg tablet 8.6 mg * (Senokot) senokot-s tablet 8.6-50 mg * (Sennosides/Docus ate Sodium) silace 50 mg/5 ml liquid 50 mg/5 ml * (Docusate Sodium) silace 60 mg/15 ml syrup 60 mg/15 ml * (Docusate Sodium) 168
sm clearlax powder 14 once-daily doses 17 gram/dose * (Gavilax) sm fiber laxative 500 mg cplt 500 mg * (Citrucel) sm fiber smooth powder * (Psyllium Seed) smoothlax powder packet 10 oncedaily doses 17 gram * (Miralax) trilyte with flavor packets oral recon (Nulytely with soln 420 gram Flavor Packs) Phosphate Binders calcium acetate oral capsule 667 mg (Phoslo) calcium acetate oral tablet 667 mg (Calcium Acetate) calphron 667 mg tablet 667 mg * (Calcium Acetate) eliphos oral tablet 667 mg (Calcium Acetate) (Calcium magnebind 400 oral tablet 400-200- Carbonate/Mag 1 mg Carb/Fa) PHOSLYRA ORAL SOLUTION 667 MG (169 MG CALCIUM)/5 ML RENAGEL ORAL TABLET 400 MG, 800 MG RENVELA ORAL POWDER IN PACKET 0.8 GRAM, 2.4 GRAM RENVELA ORAL TABLET 800 MG Genitourinary Agents Antispasmodics, Urinary MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR 25 MG, 50 MG oxybutynin chloride oral syrup 5 mg/5 ml (Oxybutynin Chloride) 169
oxybutynin chloride oral tablet 5 mg oxybutynin chloride oral tablet extended release 24hr 10 mg, 15 mg, 5 mg tolterodine oral capsule,extended release 24hr 2 mg, 4 mg (Oxybutynin Chloride) (Ditropan XL) (Detrol LA) tolterodine oral tablet 1 mg, 2 mg (Detrol) TOVIAZ ORAL TABLET EXTENDED RELEASE 24 HR 4 MG, 8 MG trospium oral capsule,extended release 24hr 60 mg trospium oral tablet 20 mg Genitourinary Agents, Miscellaneous alfuzosin oral tablet extended release 24 hr 10 mg tamsulosin oral capsule,extended release 24hr 0.4 mg terazosin oral capsule 1 mg, 10 mg, 2 mg, 5 mg Heavy Metal Antagonists Heavy Metal Antagonists deferoxamine injection recon soln 2 gram, 500 mg DEPEN TITRATABS ORAL TABLET 250 MG EXJADE ORAL TABLET, DISPERSIBLE 125 MG, 250 MG, 500 MG FERRIPROX ORAL SOLUTION 100 MG/ML (Trospium Chloride) (Trospium Chloride) (Uroxatral) (Flomax) (Terazosin HCl) (Desferal) 170
FERRIPROX ORAL TABLET 500 MG sodium thiosulfate intravenous solution 1 gram/10 ml (100 mg/ml), 12.5 gram/50 ml (250 mg/ml) SYPRINE ORAL CAPSULE 250 MG Hormonal Agents, Stimulant/Replacement/Modif ying Androgens ANDRODERM TRANSDERMAL PATCH 24 HOUR 2 MG/24 HOUR, 4 MG/24 HR ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP 20.25 MG/1.25 GRAM (1.62 %) (Sodium Thiosulfate) ANDROGEL TRANSDERMAL GEL IN PACKET 1.62 % (20.25 MG/1.25 GRAM), 1.62 % (40.5 MG/2.5 GRAM) androxy oral tablet 10 mg (Fluoxymesterone) danazol oral capsule 100 mg, 200 mg, 50 mg (Danazol) oxandrolone oral tablet 10 mg, 2.5 mg (Oxandrin) testosterone cypionate intramuscular oil 100 mg/ml, 200 mg/ml testosterone enanthate intramuscular oil 200 mg/ml testosterone transdermal gel 50 mg/5 gram (1 %) (Depo- Testosterone) (Testosterone Enanthate) (Testim) PA; QL (30 per 30 days) PA; QL (150 per 30 days) PA; QL (150 per 30 days) PA PA; QL (5 per 28 days) PA; QL (300 per 30 days) 171
testosterone transdermal gel in metered-dose pump 1.25 gram/ actuation (1 %) testosterone transdermal gel in packet 1 % (25 mg/2.5gram) testosterone transdermal gel in packet 1 % (50 mg/5 gram) Estrogens And Antiestrogens amabelz oral tablet 0.5-0.1 mg, 1-0.5 mg COMBIPATCH TRANSDERMAL PATCH SEMIWEEKLY 0.05-0.14 MG/24 HR, 0.05-0.25 MG/24 HR DUAVEE ORAL TABLET 0.45-20 MG ESTRACE VAGINAL CREAM 0.01 % (0.1 MG/GRAM) estradiol oral tablet 0.5 mg, 1 mg, 2 mg estradiol transdermal patch semiweekly 0.025 mg/24 hr, 0.0375 mg/24 hr, 0.05 mg/24 hr, 0.075 mg/24 hr, 0.1 mg/24 hr estradiol transdermal patch weekly 0.025 mg/24 hr, 0.0375 mg/24 hr, 0.05 mg/24 hr, 0.06 mg/24 hr, 0.075 mg/24 hr, 0.1 mg/24 hr estradiol valerate intramuscular oil 10 mg/ml, 20 mg/ml, 40 mg/ml estradiol-norethindrone acet oral tablet 0.5-0.1 mg, 1-0.5 mg estropipate oral tablet 0.75 mg, 1.5 mg, 3 mg (Vogelxo) (Androgel) (Testim) (Activella) (Vagifem) (Vivelle-Dot) (Climara) (Delestrogen) (Activella) (Estropipate) PA; QL (300 per 30 days) PA; QL (300 per 30 days) PA; QL (300 per 30 days) PA-HRM; AGE (Max 64 Years) PA-HRM; QL (8 per 28 days); AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; QL (8 per 28 days); AGE (Max 64 Years) PA-HRM; QL (4 per 28 days); AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) 172
FEMRING VAGINAL RING 0.05 MG/24 HR, 0.1 MG/24 HR MENEST ORAL TABLET 0.3 MG, 0.625 MG, 1.25 MG, 2.5 MG mimvey lo oral tablet 0.5-0.1 mg (Activella) mimvey oral tablet 1-0.5 mg (Activella) QL (1 per 84 days) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PREMARIN INJECTION RECON SOLN 25 MG PREMARIN ORAL TABLET 0.3 MG, 0.45 MG, 0.625 MG, 0.9 MG, PA-HRM; AGE (Max 64 Years) 1.25 MG PREMARIN VAGINAL CREAM 0.625 MG/GRAM PREMPHASE ORAL TABLET PA-HRM; AGE (Max 0.625 MG (14)/ 0.625MG-5MG(14) 64 Years) PREMPRO ORAL TABLET 0.3-1.5 MG, 0.45-1.5 MG, 0.625-2.5 MG, 0.625-5 MG PA-HRM; AGE (Max 64 Years) raloxifene oral tablet 60 mg (Evista) VAGIFEM VAGINAL TABLET 10 QL (18 per 28 days) MCG yuvafem vaginal tablet 10 mcg (Vagifem) QL (18 per 28 days) Glucocorticoids/Mineraloco rticoids a-hydrocort injection recon soln 100 mg (Hydrocortisone Sod Succinate) betamethasone acet,sod phos injection suspension 6 mg/ml (Celestone) cortisone oral tablet 25 mg (Cortisone Acetate) dexamethasone oral elixir 0.5 mg/5 (Dexamethasone) ml 173
dexamethasone oral tablet 0.5 mg, 0.75 mg, 1 mg, 1.5 mg, 2 mg, 4 mg, 6 mg dexamethasone sodium phosphate injection solution 10 mg/ml, 4 mg/ml fludrocortisone oral tablet 0.1 mg (Dexamethasone) (Dexamethasone Sod Phosphate) (Fludrocortisone Acetate) hydrocortisone oral tablet 10 mg, 20 (Cortef) mg, 5 mg methylprednisolone acetate injection suspension 40 mg/ml, 80 mg/ml (Depo-Medrol) methylprednisolone oral tablet 16 (Medrol) mg, 32 mg, 4 mg, 8 mg methylprednisolone oral (Medrol) tablets,dose pack 4 mg methylprednisolone sodium succ injection recon soln 125 mg, 40 mg (Solu-Medrol) methylprednisolone ss 1 gm vl mdv,latex-free 1,000 mg (Solu-Medrol) prednisolone sodium phosphate oral solution 15 mg/5 ml (3 mg/ml), 25 mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml) (Pediapred) prednisone oral solution 5 mg/5 ml (Prednisone) prednisone oral tablet 1 mg, 2.5 mg, (Prednisone) 20 mg, 5 mg, 50 mg prednisone oral tablet 10 mg (Prednisone) prednisone oral tablets,dose pack 10 mg, 10 mg (48 pack), 5 mg, 5 mg (48 pack) (Prednisone) SOLU-CORTEF (PF) INJECTION RECON SOLN 100 MG/2 ML 174
triamcinolone acetonide injection suspension 10 mg/ml, 40 mg/ml Pituitary desmopressin injection solution 4 mcg/ml desmopressin nasal solution 0.1 mg/ml (refrigerate) desmopressin nasal spray,nonaerosol 10 mcg/spray (0.1 ml) desmopressin oral tablet 0.1 mg, 0.2 mg GENOTROPIN MINIQUICK SUBCUTANEOUS SYRINGE 0.2 MG/0.25 ML, 0.4 MG/0.25 ML, 0.6 MG/0.25 ML, 0.8 MG/0.25 ML, 1 MG/0.25 ML, 1.2 MG/0.25 ML, 1.4 MG/0.25 ML, 1.6 MG/0.25 ML, 1.8 MG/0.25 ML, 2 MG/0.25 ML GENOTROPIN SUBCUTANEOUS CARTRIDGE 12 MG/ML (36 UNIT/ML), 5 MG/ML (15 UNIT/ML) INCRELEX SUBCUTANEOUS SOLUTION 10 MG/ML LUPRON DEPOT-PED (3 MONTH) INTRAMUSCULAR SYRINGE KIT 30 MG LUPRON DEPOT-PED INTRAMUSCULAR KIT 11.25 MG, 15 MG, 7.5 MG (PED) (Triamcinolone Acetonide) (Desmopressin Acetate) (DDAVP) (Desmopressin Acetate) (DDAVP) QL (15 per 30 days) QL (15 per 30 days) PA PA QL (1 per 84 days) 175
NORDITROPIN FLEXPRO SUBCUTANEOUS PEN INJECTOR 10 MG/1.5 ML (6.7 MG/ML), 15 MG/1.5 ML (10 MG/ML), 30 MG/3 ML (10 MG/ML), 5 MG/1.5 ML (3.3 MG/ML) octreotide acet 50 mcg/ml syr outer,single-dose,10 50 mcg/ml (1 ml) octreotide acetate injection solution 1,000 mcg/ml, 100 mcg/ml, 200 mcg/ml, 500 mcg/ml octreotide acetate injection solution 50 mcg/ml SAIZEN CLICK.EASY SUBCUTANEOUS CARTRIDGE 8.8 MG/1.5 ML (FNL) SAIZEN SUBCUTANEOUS RECON SOLN 5 MG, 8.8 MG SANDOSTATIN LAR 10 MG KIT 10 MG SANDOSTATIN LAR 20 MG KIT 20 MG SANDOSTATIN LAR 30 MG KIT 30 MG SANDOSTATIN LAR DEPOT INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 10 MG, 20 MG, 30 MG SEROSTIM SUBCUTANEOUS RECON SOLN 4 MG, 5 MG, 6 MG (Octreotide Acetate) (Sandostatin) (Octreotide Acetate) PA PA PA PA 176
SOMATULINE DEPOT SUBCUTANEOUS SYRINGE 120 MG/0.5 ML, 60 MG/0.2 ML, 90 MG/0.3 ML SOMAVERT SUBCUTANEOUS RECON SOLN 10 MG, 15 MG, 20 MG, 25 MG, 30 MG SUPPRELIN LA IMPLANT KIT 50 MG (65 MCG/DAY) Progestins DEPO-PROVERA INTRAMUSCULAR SOLUTION 400 MG/ML hydroxyprogesterone caproate intramuscular oil 250 mg/ml medroxyprogesterone intramuscular suspension 150 mg/ml medroxyprogesterone intramuscular syringe 150 mg/ml medroxyprogesterone oral tablet 10 mg, 2.5 mg, 5 mg MEGACE ES ORAL SUSPENSION 625 MG/5 ML megestrol oral suspension 400 mg/10 ml (40 mg/ml), 625 mg/5 ml norethindrone acetate oral tablet 5 mg progesterone in oil intramuscular oil 50 mg/ml progesterone micronized oral capsule 100 mg, 200 mg Thyroid And Antithyroid Agents (Hydroxyprogester one Caproate) (Depo-Provera) (Depo-Provera) (Provera) (Megace Es) (Aygestin) (Progesterone) (Prometrium) QL (1 per 28 days) QL (1 per 360 days) QL (10 per 28 days) PA NSO QL (1 per 84 days) QL (1 per 84 days) 177
levothyroxine intravenous recon soln 100 mcg, 200 mcg, 500 mcg levothyroxine 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 liothyronine oral tablet 25 mcg, 5 mcg, 50 mcg (Levothyroxine Sodium) (Levoxyl) (Cytomel) methimazole oral tablet 10 mg, 5 mg (Tapazole) propylthiouracil oral tablet 50 mg (Propylthiouracil) Immunological Agents Immunological Agents ARCALYST SUBCUTANEOUS RECON SOLN 220 MG ASTAGRAF XL ORAL CAPSULE,EXTENDED RELEASE 24HR 0.5 MG, 1 MG, 5 MG AUBAGIO ORAL TABLET 14 MG, 7 MG azathioprine oral tablet 50 mg (Imuran) azathioprine sodium injection recon (Azathioprine soln 100 mg Sodium) CARIMUNE NF NANOFILTERED INTRAVENOUS RECON SOLN 6 GRAM CELLCEPT INTRAVENOUS INTRAVENOUS RECON SOLN 500 MG CIMZIA POWDER FOR PA RECONST SUBCUTANEOUS KIT 400 MG (200 MG X 2 VIALS) CIMZIA SUBCUTANEOUS PA SYRINGE KIT 400 MG/2 ML (200 MG/ML X 2) PA; QL (28 per 28 days) 178
cyclosporine intravenous solution (Sandimmune) 250 mg/5 ml cyclosporine modified oral capsule (Neoral) 100 mg, 25 mg, 50 mg cyclosporine modified oral solution (Neoral) 100 mg/ml cyclosporine oral capsule 100 mg, (Sandimmune) 25 mg ENBREL SUBCUTANEOUS PA RECON SOLN 25 MG (1 ML) ENBREL SUBCUTANEOUS PA SYRINGE 25 MG/0.5ML (0.51), 50 MG/ML (0.98 ML) ENBREL SURECLICK PA SUBCUTANEOUS PEN INJECTOR 50 MG/ML (0.98 ML) ENVARSUS XR ORAL TABLET EXTENDED RELEASE 24 HR 0.75 MG, 1 MG, 4 MG FLEBOGAMMA DIF INTRAVENOUS SOLUTION 10 %, 5 % GAMASTAN S/D INTRAMUSCULAR SOLUTION 15-18 % RANGE GAMMAGARD LIQUID INJECTION SOLUTION 10 % GAMMAPLEX INTRAVENOUS SOLUTION 5 % gengraf oral capsule 100 mg, 25 (Neoral) mg, 50 mg gengraf oral solution 100 mg/ml (Neoral) 179
HUMIRA PEDIATRIC CROHN'S START SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML, 40 MG/0.8 ML (6 PACK) HUMIRA PEN CROHN'S-UC-HS START SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML HUMIRA PEN PSORIASIS- UVEITIS SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML HUMIRA PEN SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML HUMIRA SUBCUTANEOUS SYRINGE KIT 10 MG/0.2 ML, 20 MG/0.4 ML, 40 MG/0.8 ML HYPERRAB S/D (PF) INTRAMUSCULAR SOLUTION 150 UNIT/ML, 150 UNIT/ML (10 ML) HYQVIA IG COMPONENT SUBCUTANEOUS SOLUTION 10 GRAM/100 ML (10 %), 2.5 GRAM/25 ML (10 %), 20 GRAM/200 ML (10 %), 30 GRAM/300 ML (10 %), 5 GRAM/50 ML (10 %) HYQVIA SUBCUTANEOUS SOLUTION 10 GRAM /100 ML (10 %), 2.5 GRAM /25 ML (10 %), 20 GRAM /200 ML (10 %), 30 GRAM /300 ML (10 %), 5 GRAM /50 ML (10 %) PA PA PA PA PA 180
ILARIS (PF) SUBCUTANEOUS RECON SOLN 180 MG/1.2 ML (150 MG/ML) IMOGAM RABIES-HT (PF) INTRAMUSCULAR SOLUTION 150 UNIT/ML KINERET SUBCUTANEOUS SYRINGE 100 MG/0.67 ML leflunomide oral tablet 10 mg, 20 mg mycophenolate mofetil oral capsule 250 mg mycophenolate mofetil oral suspension for reconstitution 200 mg/ml mycophenolate mofetil oral tablet 500 mg mycophenolate sodium oral tablet,delayed release (dr/ec) 180 mg, 360 mg NULOJIX INTRAVENOUS RECON SOLN 250 MG OCTAGAM INTRAVENOUS SOLUTION 10 %, 5 % ORENCIA (WITH MALTOSE) INTRAVENOUS RECON SOLN 250 MG ORENCIA SUBCUTANEOUS SYRINGE 125 MG/ML PRIVIGEN INTRAVENOUS SOLUTION 10 % PROGRAF INTRAVENOUS SOLUTION 5 MG/ML (Arava) (Cellcept) (Cellcept) (Cellcept) (Myfortic) PA PA; QL (18.76 per 28 days) PA PA 181
RAPAMUNE ORAL SOLUTION 1 MG/ML RIDAURA ORAL CAPSULE 3 MG sirolimus oral tablet 0.5 mg, 1 mg, 2 mg tacrolimus oral capsule 0.5 mg, 1 mg, 5 mg TYSABRI INTRAVENOUS SOLUTION 300 MG/15 ML ZORTRESS ORAL TABLET 0.25 MG, 0.5 MG, 0.75 MG Vaccines ACTHIB (PF) INTRAMUSCULAR RECON SOLN 10 MCG/0.5 ML ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SUSPENSION 2 LF-(2.5-5-3-5 MCG)-5LF/0.5 ML ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SYRINGE 2 LF-(2.5-5-3-5 MCG)-5LF/0.5 ML BCG (TICE STRAIN) VIAL LATEX-FREE, OUTER 50 MG BCG VACCINE, LIVE (PF) PERCUTANEOUS SUSPENSION FOR RECONSTITUTION 50 MG BEXSERO (PF) INTRAMUSCULAR SYRINGE 50-50-50-25 MCG/0.5 ML (Rapamune) (Hecoria) PA; LA; QL (15 per 28 days) ; QL (120 per 30 days) 182
BOOSTRIX TDAP INTRAMUSCULAR SUSPENSION 2.5-8-5 LF-MCG- LF/0.5ML BOOSTRIX TDAP INTRAMUSCULAR SYRINGE 2.5-8-5 LF-MCG-LF/0.5ML CERVARIX VACCINE (PF) INTRAMUSCULAR SYRINGE 20-20 MCG/0.5 ML COMVAX (PF) INTRAMUSCULAR SUSPENSION 5-7.5-125 MCG/0.5 ML DAPTACEL (DTAP PEDIATRIC) (PF) INTRAMUSCULAR SUSPENSION 15-10-5 LF-MCG- LF/0.5ML ENGERIX-B (PF) INTRAMUSCULAR SYRINGE 20 MCG/ML ENGERIX-B 20 MCG/ML VIAL 10'S,ADULT,P/F,OUTER 20 MCG/ML ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SUSPENSION 10 MCG/0.5 ML ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SYRINGE 10 MCG/0.5 ML GARDASIL (PF) INTRAMUSCULAR SUSPENSION 20-40-40-20 MCG/0.5 ML ; QL (3 per 365 days) ; QL (3 per 365 days) ; QL (3 per 365 days) ; QL (3 per 365 days) QL (1.5 per 365 days) 183
GARDASIL (PF) INTRAMUSCULAR SYRINGE 20-40-40-20 MCG/0.5 ML GARDASIL 9 (PF) INTRAMUSCULAR SUSPENSION 0.5 ML GARDASIL 9 (PF) INTRAMUSCULAR SYRINGE 0.5 ML HAVRIX (PF) INTRAMUSCULAR SUSPENSION 1,440 ELISA UNIT/ML HAVRIX (PF) INTRAMUSCULAR SYRINGE 1,440 ELISA UNIT/ML, 720 ELISA UNIT/0.5 ML HIBERIX (PF) INTRAMUSCULAR RECON SOLN 10 MCG/0.5 ML IMOVAX RABIES VACCINE (PF) INTRAMUSCULAR RECON SOLN 2.5 UNIT INFANRIX (DTAP) (PF) INTRAMUSCULAR SUSPENSION 25-58-10 LF-MCG- LF/0.5ML IPOL INJECTION SUSPENSION 40-8-32 UNIT/0.5 ML IPOL INJECTION SYRINGE 40-8- 32 UNIT/0.5 ML IXIARO (PF) INTRAMUSCULAR SYRINGE 6 MCG/0.5 ML QL (1.5 per 365 days) QL (1.5 per 365 days) QL (1.5 per 365 days) 184
KINRIX (PF) INTRAMUSCULAR SUSPENSION 25 LF-58 MCG-10 LF/0.5 ML KINRIX (PF) INTRAMUSCULAR SYRINGE 25 LF-58 MCG-10 LF/0.5 ML MENACTRA (PF) INTRAMUSCULAR SOLUTION 4 MCG/0.5 ML MENHIBRIX (PF) INTRAMUSCULAR RECON SOLN 5-2.5 MCG/0.5 ML MENOMUNE - A/C/Y/W-135 (PF) SUBCUTANEOUS RECON SOLN 50 MCG MENVEO A-C-Y-W-135-DIP (PF) INTRAMUSCULAR KIT 10-5 MCG/0.5 ML MENVEO MENA COMPONENT (PF) INTRAMUSCULAR RECON SOLN 10 MCG /0.5 ML (FINAL) MENVEO MENCYW-135 COMPNT (PF) INTRAMUSCULAR RECON SOLN 5 MCG X 3/ 0.5 ML (FINAL) M-M-R II (PF) SUBCUTANEOUS RECON SOLN 1,000-12,500 TCID50/0.5 ML PEDIARIX (PF) INTRAMUSCULAR SYRINGE 10 MCG-25LF-25 MCG-10LF/0.5 ML PEDVAX HIB (PF) INTRAMUSCULAR SOLUTION 7.5 MCG/0.5 ML QL (2 per 365 days) 185
PENTACEL (PF) INTRAMUSCULAR KIT 15 LF UNIT-20 MCG-5 LF/0.5 ML PROQUAD (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 10EXP3-4.3-3- 3.99 TCID50/0.5 QUADRACEL (PF) INTRAMUSCULAR SUSPENSION 15 LF-48 MCG- 5 LF UNIT/0.5ML RABAVERT (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 2.5 UNIT RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION 10 MCG/ML, 40 MCG/ML RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 10 MCG/ML, 5 MCG/0.5 ML ROTARIX ORAL SUSPENSION FOR RECONSTITUTION 10EXP6 CCID50/ML ROTATEQ VACCINE ORAL SUSPENSION 2 ML TENIVAC (PF) INTRAMUSCULAR SYRINGE 5-2 LF UNIT/0.5 ML TETANUS TOXOID,ADSORBED (PF) INTRAMUSCULAR SUSPENSION 5 LF UNIT/0.5 ML QL (2 per 365 days) ; QL (3 per 365 days) ; QL (3 per 365 days) 186
TETANUS,DIPHTHERIA TOX PED(PF) INTRAMUSCULAR SUSPENSION 5-25 LF UNIT/0.5 ML TETANUS-DIPHTHERIA TOXOIDS-TD INTRAMUSCULAR SUSPENSION 2-2 LF UNIT/0.5 ML TRUMENBA INTRAMUSCULAR SYRINGE 120 MCG/0.5 ML TWINRIX (PF) INTRAMUSCULAR SUSPENSION 720 ELISA UNIT - 20 MCG/ML TWINRIX (PF) INTRAMUSCULAR SYRINGE 720 ELISA UNIT -20 MCG/ML TYPHIM VI INTRAMUSCULAR SOLUTION 25 MCG/0.5 ML TYPHIM VI INTRAMUSCULAR SYRINGE 25 MCG/0.5 ML VAQTA (PF) INTRAMUSCULAR SUSPENSION 50 UNIT/ML VAQTA (PF) INTRAMUSCULAR SYRINGE 25 UNIT/0.5 ML, 50 UNIT/ML VAQTA 25 UNITS/0.5 ML VIAL SDV, OUTER 25 UNIT/0.5 ML VARIVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 1,350 UNIT/0.5 ML QL (2 per 365 days) 187
YF-VAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 10 EXP4.74 UNIT/0.5 ML ZOSTAVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 19,400 UNIT/0.65 ML Inflammatory Bowel Disease Agents Inflammatory Bowel Disease Agents alosetron oral tablet 0.5 mg, 1 mg (Alosetron HCl) APRISO ORAL CAPSULE,EXTENDED RELEASE 24HR 0.375 GRAM ASACOL HD ORAL TABLET,DELAYED RELEASE (DR/EC) 800 MG balsalazide oral capsule 750 mg (Colazal) budesonide oral capsule,delayed,extend.release 3 mg (Entocort EC) DELZICOL ORAL CAPSULE (WITH DEL REL TABLETS) 400 MG DIPENTUM ORAL CAPSULE 250 MG mesalamine oral tablet,delayed release (dr/ec) 800 mg (Asacol Hd) Irrigating Solutions Irrigating Solutions acetic acid irrigation solution 0.25 % (Acetic Acid) QL (1 per 365 days) ST 188
LACTATED RINGERS IRRIGATION SOLUTION ringers irrigation solution (Ringers Solution) sodium chloride irrigation solution (Sodium Chloride 0.9 % Irrig Solution) sorbitol irrigation solution 3 %, 3.3 % (Sorbitol Solution) sorbitol-mannitol urethral solution (Mannitol/Sorbitol 2.7-0.54 g/100 ml Solution) water for irrigation, sterile (Water For irrigation solution Irrigation,Sterile) Metabolic Bone Disease Agents Metabolic Bone Disease Agents alendronate oral solution 70 mg/75 ml alendronate oral tablet 10 mg, 40 mg, 5 mg alendronate oral tablet 35 mg, 70 mg calcitonin (salmon) nasal spray,non-aerosol 200 unit/actuation (Alendronate Sodium) (Fosamax) (Fosamax) (Miacalcin) calcitriol intravenous solution 1 mcg/ml (Calcitriol) calcitriol oral capsule 0.25 mcg, 0.5 mcg (Rocaltrol) calcitriol oral solution 1 mcg/ml (Rocaltrol) doxercalciferol intravenous solution 4 mcg/2 ml (Doxercalciferol) doxercalciferol oral capsule 0.5 mcg, 1 mcg, 2.5 mcg (Hectorol) QL (300 per 28 days) QL (4 per 28 days) QL (3.7 per 28 days) 189
FORTEO SUBCUTANEOUS PEN INJECTOR 20 MCG/DOSE - 600 MCG/2.4 ML FORTICAL NASAL SPRAY,NON- AEROSOL 200 UNIT/ACTUATION ibandronate intravenous solution 3 mg/3 ml ibandronate intravenous syringe 3 mg/3 ml (Ibandronate Sodium) (Boniva) PA; QL (2.4 per 28 days) QL (3.7 per 28 days) QL (3 per 84 days) QL (3 per 84 days) ibandronate oral tablet 150 mg (Boniva) QL (1 per 28 days) MIACALCIN INJECTION SOLUTION 200 UNIT/ML NATPARA SUBCUTANEOUS PA; QL (2 per 28 days) CARTRIDGE 100 MCG/DOSE, 25 MCG/DOSE, 50 MCG/DOSE, 75 MCG/DOSE paricalcitol hemodialysis port injection solution 2 mcg/ml (Zemplar) PARICALCITOL HEMODIALYSIS PORT INJECTION SOLUTION 5 MCG/ML paricalcitol oral capsule 1 mcg, 2 mcg, 4 mcg (Zemplar) PROLIA SUBCUTANEOUS QL (1 per 180 days) SYRINGE 60 MG/ML RAYALDEE ORAL CAPSULE,EXTENDED RELEASE PA; QL (60 per 30 days) 24 HR 30 MCG risedronate oral tablet 150 mg (Actonel) QL (1 per 28 days) risedronate oral tablet 30 mg, 5 mg (Actonel) QL (30 per 28 days) 190
ZEMPLAR INTRAVENOUS SOLUTION 2 MCG/ML, 5 MCG/ML zoledronic acid intravenous solution 4 mg/5 ml zoledronic acid-mannitol-water intravenous piggyback 4 mg/100 ml zoledronic acid-mannitol-water intravenous solution 5 mg/100 ml ZOMETA INTRAVENOUS SOLUTION 4 MG/100 ML Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents ACTEMRA INTRAVENOUS SOLUTION 200 MG/10 ML (20 MG/ML), 400 MG/20 ML (20 MG/ML), 80 MG/4 ML (20 MG/ML) ACTEMRA SUBCUTANEOUS SYRINGE 162 MG/0.9 ML ACTIMMUNE SUBCUTANEOUS SOLUTION 100 MCG/0.5 ML allopurinol oral tablet 100 mg, 300 mg amifostine crystalline intravenous recon soln 500 mg anticoag citrate phos dextrose solution 2.63-222 gram-mg/100ml AVONEX (WITH ALBUMIN) INTRAMUSCULAR KIT 30 MCG (Zometa) (Zoledronic Acid/Mannitol- Water) (Reclast) (Zyloprim) (Ethyol) (Citrate Phosphate Dextros Soln) QL (100 per 300 days) PA PA ST 191
AVONEX INTRAMUSCULAR PEN INJECTOR KIT 30 MCG/0.5 ML AVONEX INTRAMUSCULAR SYRINGE KIT 30 MCG/0.5 ML BENLYSTA INTRAVENOUS RECON SOLN 120 MG, 400 MG BETASERON SUBCUTANEOUS KIT 0.3 MG bethanechol chloride oral tablet 10 mg, 25 mg, 5 mg, 50 mg (Urecholine) buspirone oral tablet 10 mg, 15 mg, 30 mg, 5 mg, 7.5 mg (Buspirone HCl) CERDELGA ORAL CAPSULE 84 MG CETYLEV ORAL TABLET, EFFERVESCENT 2.5 GRAM, 500 MG colchicine oral tablet 0.6 mg (Colcrys) COPAXONE SUBCUTANEOUS SYRINGE 20 MG/ML, 40 MG/ML CYSTADANE ORAL POWDER 1 GRAM/1.7 ML droperidol injection solution 2.5 mg/ml (Droperidol) dutasteride oral capsule 0.5 mg (Avodart) dutasteride-tamsulosin oral capsule, er multiphase 24 hr 0.5-0.4 mg (Jalyn) ELMIRON ORAL CAPSULE 100 MG ergoloid oral tablet 1 mg EXONDYS 51 INTRAVENOUS SOLUTION 50 MG/ML (Ergoloid Mesylates) ST ST PA ST PA QL (30 per 30 days) PA; LA 192
EXTAVIA SUBCUTANEOUS KIT 0.3 MG finasteride oral tablet 5 mg (Proscar) fomepizole intravenous solution 1 gram/ml (Fomepizole) FUSILEV INTRAVENOUS RECON SOLN 50 MG GAUZE PAD TOPICAL BANDAGE 2 X 2 " GILENYA ORAL CAPSULE 0.5 MG GLUCAGEN HYPOKIT INJECTION RECON SOLN 1 MG GLUCAGON EMERGENCY KIT (HUMAN) INJECTION KIT 1 MG guanidine oral tablet 125 mg (Guanidine HCl) hydroxyzine hcl intramuscular solution 25 mg/ml, 50 mg/ml (Hydroxyzine HCl) hydroxyzine hcl oral solution 10 mg/5 ml (Hydroxyzine HCl) hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg (Hydroxyzine HCl) hydroxyzine pamoate oral capsule 100 mg, 25 mg, 50 mg (Vistaril) INFLECTRA INTRAVENOUS RECON SOLN 100 MG KEVEYIS ORAL TABLET 50 MG LEMTRADA INTRAVENOUS SOLUTION 12 MG/1.2 ML leucovorin calcium 200 mg vial sdv, p/f, latex-free 200 mg leucovorin calcium injection recon soln 100 mg, 350 mg, 50 mg (Leucovorin Calcium) (Leucovorin Calcium) ST QL (28 per 28 days) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA PA NSO; QL (120 per 30 days) PA 193
leucovorin calcium oral tablet 10 (Leucovorin mg, 15 mg, 25 mg, 5 mg Calcium) levocarnitine (with sugar) oral (Levocarnitine solution 100 mg/ml (With Sugar)) levocarnitine oral tablet 330 mg (Carnitor) levoleucovorin intravenous recon soln 50 mg (Fusilev) mesna intravenous solution 100 mg/ml (Mesnex) MESNEX ORAL TABLET 400 MG MESTINON ORAL SYRUP 60 MG/5 ML MESTINON TIMESPAN ORAL TABLET EXTENDED RELEASE 180 MG MINERAL OIL HEAVY * morrhuate sodium intravenous (Sodium solution 5 % Morrhuate) ORENCIA CLICKJECT SUBCUTANEOUS AUTO- INJECTOR 125 MG/ML ORFADIN ORAL SUSPENSION 4 MG/ML OTEZLA ORAL TABLET 30 MG OTEZLA STARTER ORAL TABLETS,DOSE PACK 10 MG (4)-20 MG (4)-30 MG (47), 10 MG (4)-20 MG (4)-30 MG(19) PA PA; QL (60 per 30 days) PA; QL (60 per 30 days) 194
OTREXUP (PF) SUBCUTANEOUS AUTO- INJECTOR 10 MG/0.4 ML, 12.5 MG/0.4 ML, 15 MG/0.4 ML, 17.5 MG/0.4 ML, 20 MG/0.4 ML, 22.5 MG/0.4 ML, 25 MG/0.4 ML, 7.5 MG/0.4 ML PANTILINERS PAD * PLEGRIDY SUBCUTANEOUS PEN INJECTOR 125 MCG/0.5 ML, 63 MCG/0.5 ML- 94 MCG/0.5 ML PLEGRIDY SUBCUTANEOUS SYRINGE 125 MCG/0.5 ML, 63 MCG/0.5 ML- 94 MCG/0.5 ML probenecid oral tablet 500 mg (Probenecid) probenecid-colchicine oral tablet (Probenecid/Colchi 500-0.5 mg cine) PROCYSBI ORAL CAPSULE, DELAYED REL SPRINKLE 25 MG, 75 MG pv extra cleansing douche * (Acetic Acid) pyridostigmine bromide oral tablet 60 mg (Mestinon) pyridostigmine bromide oral tablet extended release 180 mg (Mestinon) qc mineral oil heavy * (Mineral Oil) ra feminine care douche * (Acetic Acid) RASUVO (PF) SUBCUTANEOUS AUTO-INJECTOR 10 MG/0.2 ML, 12.5 MG/0.25 ML, 15 MG/0.3 ML, 17.5 MG/0.35 ML, 20 MG/0.4 ML, 22.5 MG/0.45 ML, 25 MG/0.5 ML, 27.5 MG/0.55 ML, 30 MG/0.6 ML, 7.5 MG/0.15 ML ST ST 195
REBIF (WITH ALBUMIN) SUBCUTANEOUS SYRINGE 22 MCG/0.5 ML, 44 MCG/0.5 ML REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 22 MCG/0.5 ML, 44 MCG/0.5 ML, 8.8MCG/0.2ML-22 MCG/0.5ML (6) REBIF TITRATION PACK SUBCUTANEOUS SYRINGE 8.8MCG/0.2ML-22 MCG/0.5ML (6) REMICADE INTRAVENOUS PA RECON SOLN 100 MG sb disp douche extra clns v&w * (Acetic Acid) SENSIPAR ORAL TABLET 30 MG, 60 MG, 90 MG SIGNIFOR SUBCUTANEOUS QL (60 per 30 days) SOLUTION 0.3 MG/ML (1 ML), 0.6 MG/ML (1 ML), 0.9 MG/ML (1 ML) SIMPONI ARIA INTRAVENOUS PA SOLUTION 12.5 MG/ML SIMPONI SUBCUTANEOUS PEN PA INJECTOR 100 MG/ML, 50 MG/0.5 ML SIMPONI SUBCUTANEOUS PA SYRINGE 100 MG/ML, 50 MG/0.5 ML STELARA INTRAVENOUS PA SOLUTION 130 MG/26 ML STELARA SUBCUTANEOUS PA SYRINGE 45 MG/0.5 ML, 90 MG/ML STERILE PADS 2" X 2" 2 X 2 " 196
summer's eve dche-xtra clns 12's,extra-cleansing * (Acetic Acid) summer's eve douche-ultra clns 12's,2pk,ultra clns * (Acetic Acid) SYNAREL NASAL SPRAY,NON- AEROSOL 2 MG/ML TECFIDERA ORAL QL (14 per 30 days) CAPSULE,DELAYED RELEASE(DR/EC) 120 MG TECFIDERA ORAL QL (60 per 30 days) CAPSULE,DELAYED RELEASE(DR/EC) 120 MG (14)- 240 MG (46), 240 MG THALOMID ORAL CAPSULE 100 PA NSO; QL (60 per MG, 150 MG, 200 MG, 50 MG 30 days) topical light mineral oil * (Mineral Oil) TYBOST ORAL TABLET 150 MG QL (30 per 30 days) ULORIC ORAL TABLET 40 MG, QL (30 per 30 days) 80 MG XELJANZ ORAL TABLET 5 MG PA; QL (60 per 30 days) XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HR 11 MG PA; QL (30 per 30 days) ZINBRYTA SUBCUTANEOUS ST SYRINGE 150 MG/ML Ophthalmic Agents Antiglaucoma Agents acetazolamide oral capsule, extended release 500 mg acetazolamide oral tablet 125 mg, 250 mg acetazolamide sodium injection recon soln 500 mg (Diamox Sequels) (Acetazolamide) (Acetazolamide Sodium) 197
ALPHAGAN P OPHTHALMIC DROPS 0.1 % AZOPT OPHTHALMIC DROPS,SUSPENSION 1 % betaxolol ophthalmic drops 0.5 % (Betaxolol HCl) bimatoprost ophthalmic drops 0.03 % (Bimatoprost) brimonidine ophthalmic drops 0.15 %, 0.2 % (Alphagan P) COMBIGAN OPHTHALMIC DROPS 0.2-0.5 % dorzolamide ophthalmic drops 2 % (Trusopt) dorzolamide-timolol ophthalmic drops 22.3-6.8 mg/ml (Cosopt) latanoprost ophthalmic drops 0.005 % (Xalatan) levobunolol ophthalmic drops 0.25 %, 0.5 % (Betagan) LUMIGAN OPHTHALMIC DROPS 0.01 % methazolamide oral tablet 25 mg, 50 (Neptazane) mg metipranolol ophthalmic drops 0.3 % (Metipranolol) PHOSPHOLINE IODIDE OPHTHALMIC DROPS 0.125 % pilocarpine hcl ophthalmic drops 1 %, 2 %, 4 % (Isopto Carpine) SIMBRINZA OPHTHALMIC DROPS,SUSPENSION 1-0.2 % timolol maleate ophthalmic drops 0.25 %, 0.5 % (Timoptic) timolol maleate ophthalmic gel forming solution 0.25 %, 0.5 % (Timoptic-Xe) (drops: 0.15%, 0.20%) QL (2.5 per 25 days) 198
TRAVATAN Z OPHTHALMIC DROPS 0.004 % travoprost (benzalkonium) ophthalmic drops 0.004 % Replacement Preparations Replacement Preparations calcitrate + vit d caplet 315-250 mg-unit * calcitrate 200 mg (950 mg) tab 200 mg (950 mg) * calcium 1,000 + d3 caplet 1,000 mg(2,500 mg)-800 unit * calcium 500+d tablet chew 500 mg(1,250mg) -400 unit * calcium 600 + vit d 400 caplet s/f, p/f, caplet 600 mg(1,500mg) -400 unit * calcium 600 + vit d 400 softgl 600 mg(1,500mg) -400 unit * calcium 600 + vit d tablet 600-125 mg-unit * calcium 600 + vitamin d sftgl rapid release, sftgl 600 mg(1,500mg) -500 unit * calcium 600 mg tablet 600 mg (1,500 mg) * calcium 600+d softgel 600 mg calcium- 200 unit * calcium 600-vit d3 200 tablet 600 mg(1,500mg) -200 unit * calcium 600-vit d3 400 tablet 600 mg(1,500mg) -400 unit * (Travoprost (Benzalkonium)) (Citracal-Vitamin D) (Calcium Citrate) (Caltrate 600 Plus D3) (Calcium 600 + Vit D) (Caltrate 600 Plus D3) (Calcium Carbonate/Vitamin D3) (Caltrate 600 Plus D3) (Calcium Carbonate/Vitamin D3) (Calcium Carbonate) (Calcium Carbonate/Vitamin D3) (Caltrate 600 Plus D3) (Caltrate 600 Plus D3) QL (2.5 per 25 days) QL (2.5 per 25 days) 199
calcium carb 1,250 mg/5 ml sus 500 mg/5 ml (1,250 mg/5 ml) * calcium carbonate 648 mg tab 260 mg calcium (648 mg) * calcium chloride intravenous solution 100 mg/ml (10 %) calcium chloride intravenous syringe 100 mg/ml (10 %) calcium citrate - vit d caplet caplet, coated 315-200 mg-unit * calcium gluconate 500 mg tab 45 mg (500 mg) * calcium gluconate intravenous solution 100 mg/ml (10%) calcium with vit d tablet 600-125 mg-unit * CALTRATE 600 + D SOFT CHEW TAB VANILLA CREME 600 MG (1,500 MG)-800 UNIT * CALTRATE 600 PLUS D3 TABLET 600 MG(1,500MG) -800 UNIT * citracal + d maximum caplet 315-250 mg-unit * citrus calcium + d tablet 315-250 mg-unit * cvs calcium + vitamin d3 sftgl absorbable 600 mg(1,500mg) -500 unit * cvs calcium 500 + vit d tablet oyster shell 500 mg(1,250mg) -125 unit * (Calcium Carbonate) (Calcium Carbonate) (Calcium Chloride) (Calcium Chloride) (Citracal-Vitamin D) (Calcium Gluconate) (Calcium Gluconate) (Calcium Carbonate/Vitamin D2) (Citracal-Vitamin D) (Citracal-Vitamin D) (Calcium Carbonate/Vitamin D3) (Caltrate 600 Plus D3) 200
cvs calcium 600-vit d3 800 tab p/f, s/f,gluten-free 600 mg(1,500mg) - 800 unit * cvs magnesium 250 mg tablet 250 mg * (Caltrate 600 Plus D3) (Magnesium) cvs pediatric electrolyte soln * (Pedialyte) cvs pediatric electrolyte soln a/f, p/f * (Pedialyte) d10 %-0.45 % sodium chloride (Dextrose 10 % intravenous parenteral solution and 0.45 % NaCl) d2.5 %-0.45 % sodium chloride (Dextrose 2.5 % intravenous parenteral solution and 0.45 % NaCl) d5 % and 0.9 % sodium chloride (Dextrose 5 % and intravenous parenteral solution 0.9 % NaCl) d5 %-0.45 % sodium chloride (Dextrose 5 %-0.45 intravenous parenteral solution % NaCl) dextrose 10 % and 0.2 % nacl (Dextrose 10 % intravenous parenteral solution and 0.2 % NaCl) dextrose 5 %-lactated ringers (Dextrose 5%- intravenous parenteral solution Lactated Ringers) dextrose 5%-0.2 % sod chloride (Dextrose 5 %-0.2 intravenous parenteral solution % NaCl) dextrose 5%-0.3 % sod.chloride (Dextrose 5 % and intravenous parenteral solution 0.3 % NaCl) dextrose with sodium chloride (Dextrose 5 %-0.2 intravenous parenteral solution 5- % NaCl) 0.2 % dextrose-kcl-nacl intravenous solution 5-0.224-0.225 % effer-k oral tablet, effervescent 25 meq electrolyte-48 in d5w intravenous parenteral solution (Potassium Chloride/D5-0.2%NaCl) (Klor-Con-Ef) (Electrolyte-48 Solution/D5W) 201
eql calcium 600 mg + d softgel 600 mg(1,500mg) -100 unit * gnp calcium 500-vit d3 600 tab 500mg (1,250mg) -600 unit * gnp calcium 600+d3+min chew tb p/f,gluten/f,yeast/f 600 mg calcium- 800 unit-40 mg * hm calcium 600+d plus tab chew gluten-free 600 mg calcium- 800 unit-40 mg * hm calcium citrate-vit d cplt caplet, gluten-free 315-250 mg-unit * HYPERLYTE CR INTRAVENOUS SOLUTION 25-20-5-5-30-30 MEQ/20 ML IONOSOL-B IN D5W INTRAVENOUS PARENTERAL SOLUTION 5 % IONOSOL-MB IN D5W INTRAVENOUS PARENTERAL SOLUTION 5 % ISOLYTE M IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION ISOLYTE-H IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION 5 % ISOLYTE-P IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION 5 % (Calcium Carbonate/Vitamin D3) (Caltrate 600 Plus D3) (Ca/D3/Mag Ox/Zinc/Cop/Mang /Bor) (Ca/D3/Mag Ox/Zinc/Cop/Mang /Bor) (Citracal-Vitamin D) ISOLYTE-S INTRAVENOUS PARENTERAL SOLUTION k-effervescent oral tablet, effervescent 25 meq (Klor-Con-Ef) 202
KELP 150 MCG TABLET 150 MCG * KLOR-CON 10 ORAL TABLET EXTENDED RELEASE 10 MEQ klor-con m10 oral tablet,er (Potassium particles/crystals 10 meq Chloride) klor-con m15 oral tablet,er (Potassium particles/crystals 15 meq Chloride) klor-con m20 oral tablet,er (Potassium particles/crystals 20 meq Chloride) klor-con sprinkle oral capsule, (Potassium extended release 10 meq, 8 meq Chloride) (Calcium liquid calcium 600-vit d3 sfgl 600 Carbonate/Vitamin mg(1,500mg) -400 unit * D3) liquid calcium 600-vit d3 sfgl (Calcium softgel,p/f,gluten-f 600 mg(1,500mg) Carbonate/Vitamin -500 unit * D3) liquid calcium with vitamin d softgel, s/f, p/f 600 mg calcium- 200 (Calcium Carbonate/Vitamin unit * D3) mag delay dr 64 mg tablet 64 mg * (Slow-Mag) mag64 dr 64 mg tablet 64 mg * (Slow-Mag) mag-g 500 mg tablet 27 mg (500 mg) * (Magonate) magnesium 250 mg tablet 250 mg * (Magnesium) (Magnesium magnesium 300 mg capsule 300 mg Oxide/Mag Aa * Chelate) magnesium chloride injection solution 200 mg/ml (20 %) magnesium gluc 500 mg tablet 27 mg (500 mg) * (Magnesium Chloride) (Magonate) 203
magnesium sulfate in d5w intravenous piggyback 1 gram/100 ml, 4 gram/100 ml magnesium sulfate in water intravenous parenteral solution 20 gram/500 ml (4 %), 40 gram/1,000 ml (4 %) magnesium sulfate in water intravenous piggyback 2 gram/50 ml (4 %), 4 gram/100 ml (4 %), 4 gram/50 ml (8 %) magnesium sulfate injection solution 4 meq/ml (50 %) magnesium sulfate injection syringe 4 meq/ml natural calcium 500 mg tablet 500 mg calcium (1,250 mg) * NORMOSOL-M IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION NORMOSOL-R PH 7.4 INTRAVENOUS PARENTERAL SOLUTION (Magnesium Sulfate/D5W) (Magnesium Sulfate in Water) (Magnesium Sulfate in Water) (Magnesium Sulfate) (Magnesium Sulfate) (Calcium Carbonate) nu-mag 71.5 mg tablet 71.5 mg * (Slow-Mag) NUTRILYTE II INTRAVENOUS SOLUTION 35-20-5 MEQ/20 ML NUTRILYTE INTRAVENOUS SOLUTION 25-40.6-5 MEQ/20 ML oysco 500-vit d3 200 tablet 500 (Caltrate 600 Plus mg(1,250mg) -200 unit * D3) oysco d tablet 250-125 mg-unit * (Caltrate 600 Plus D3) oysco-500 tablet 500 mg calcium (Calcium (1,250 mg) * Carbonate) 204
oyster shell 250 mg + vit d tb 250- (Caltrate 600 Plus 125 mg-unit * D3) oyster shell 500-vit d3 200 tb 500 (Caltrate 600 Plus mg(1,250mg) -200 unit * D3) oyster shell calcium 500 mg tb (Calcium 500mg elemental ca 500 mg calcium Carbonate) (1,250 mg) * oyster shell calcium tablet 500 (Caltrate 600 Plus mg(1,250mg) -400 unit * D3) oyster shell calcium-vit d tab (Caltrate 600 Plus p/f,s/f,gluten-free 500 mg(1,250mg) D3) -400 unit * oystercal-d 500 mg-400 unit tb 500 (Caltrate 600 Plus mg(1,250mg) -400 unit * D3) pediatric electrolyte solution * (Pedialyte) PHOS-NAK PACKET 280-160-250 MG * phospha 250 neutral oral tablet 250 mg (K-Phos Neutral) PLASMA-LYTE 148 INTRAVENOUS PARENTERAL SOLUTION PLASMA-LYTE A INTRAVENOUS PARENTERAL SOLUTION PLASMA-LYTE-56 IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION 5 % potassium acetate intravenous (Potassium solution 2 meq/ml, 4 meq/ml Acetate) potassium bicarb and chloride oral (Pot Chloride/Pot tablet, effervescent 25 meq Bicarb/Cit Ac) potassium bicarb-citric acid oral tablet, effervescent 25 meq (Klor-Con-Ef) 205
potassium chlorid-d5-0.45%nacl intravenous parenteral solution 10 meq/l, 20 meq/l, 30 meq/l, 40 meq/l potassium chloride in 0.9%nacl intravenous parenteral solution 20 meq/l, 40 meq/l potassium chloride in 5 % dex intravenous parenteral solution 20 meq/l, 30 meq/l, 40 meq/l potassium chloride in lr-d5 intravenous parenteral solution 20 meq/l potassium chloride intravenous piggyback 10 meq/100 ml, 20 meq/100 ml, 30 meq/100 ml, 40 meq/100 ml potassium chloride intravenous solution 2 meq/ml potassium chloride oral capsule, extended release 10 meq, 8 meq potassium chloride oral liquid 20 meq/15 ml, 40 meq/15 ml potassium chloride oral packet 20 meq potassium chloride oral tablet extended release 8 meq potassium chloride oral tablet,er particles/crystals 10 meq potassium chloride oral tablet,er particles/crystals 20 meq potassium chloride-0.45 % nacl intravenous parenteral solution 20 meq/l (Potassium Chloride/D5-0.45nacl) (Potassium Chloride In 0.9%NaCl) (Potassium Chloride In D5w) (Potassium Chloride In Lr-D5) (Potassium Chloride) (Potassium Chloride) (Potassium Chloride) (Potassium Chloride) (Klor-Con) (Klor-Con 10) (Klor-Con 10) (Potassium Chloride) (Potassium Chloride-0.45% NaCl) 206
potassium chloride-d5-0.2%nacl intravenous parenteral solution 10 meq/l, 20 meq/l, 30 meq/l, 40 meq/l potassium chloride-d5-0.3%nacl intravenous parenteral solution 20 meq/l potassium chloride-d5-0.9%nacl intravenous parenteral solution 20 meq/l, 40 meq/l potassium citrate oral tablet extended release 10 meq (1,080 mg), 15 meq, 5 meq (540 mg) potassium citrate-citric acid oral packet 3,300-1,002 mg potassium cl 10 meq/50 ml sol 10 meq/50 ml potassium cl 20 meq/50 ml sol 20 meq/50 ml potassium cl er 10 meq tablet 10 meq potassium cl er 10 meq tablet f/c 10 meq potassium cl er 20 meq tablet 20 meq potassium phosphate m-/d-basic intravenous solution 3 mmol/ml ra cal 600-vit d3-min chew tab 600 mg calcium- 400 unit-40 mg * ra hi-cal plus vitamin d tab 500 mg(1,250mg) -200 unit * (Potassium Chloride/D5-0.2%NaCl) (Potassium Chloride/D5-0.3%NaCl) (Potassium Chloride/D5-0.9%NaCl) (Urocit-K) (Potassium Citrate/Citric Acid) (Potassium Chloride) (Potassium Chloride) (Potassium Chloride) (Klor-Con 10) (Potassium Chloride) (Potassium Phos,M-Basic-D- Basic) (Ca/D3/Mag Ox/Zinc/Cop/Mang /Bor) (Caltrate 600 Plus D3) 207
ra oyster shell-vitamin d tab s/f, p/f 250 (625)-125 mg-unit * (Calcium Carbonate/Vitamin D2) ra pediatric electrolyte soln a/f * (Pedialyte) ra pediatric freezer pops * (Pedialyte) ringers intravenous parenteral solution (Ringers Solution) sm calcium 600-vit d3 800 tab 600 (Caltrate 600 Plus mg(1,500mg) -800 unit * D3) sm pediatric electrolyte soln * (Pedialyte) sodium acetate intravenous solution 2 meq/ml, 4 meq/ml (Sodium Acetate) sodium bicarbonate intravenous (Sodium solution 1 meq/ml (8.4 %) Bicarbonate) sodium bicarbonate intravenous syringe 10 meq/10 ml (8.4 %), 4.2 % (Sodium (0.5 meq/ml), 7.5 % (0.9 meq/ml), Bicarbonate) 8.4 % (1 meq/ml) sodium chloride 0.45 % intravenous parenteral solution 0.45 % sodium chloride 0.9 % intravenous parenteral solution 0.9 % sodium chloride 3 % intravenous parenteral solution 3 % sodium chloride 5 % intravenous parenteral solution 5 % sodium chloride intravenous parenteral solution 2.5 meq/ml, 4 meq/ml sodium lactate intravenous solution 5 meq/ml sodium phosphate intravenous solution 3 mmol/ml (Sodium Chloride 0.45 %) (0.9 % Sodium Chloride) (Sodium Chloride 3 %) (Sodium Chloride 5 %) (Sodium Chloride) (Sodium Lactate) (Sodium Phos,M- Basic-D-Basic) 208
TPN ELECTROLYTES II IV SOLN 25'S,20ML/50ML FTV 18-18-5-4.5-35 MEQ/20 ML TPN ELECTROLYTES INTRAVENOUS SOLUTION 35-20-5 MEQ/20 ML virt-phos 250 neutral oral tablet 250 mg v-r calcium 400 + d 133 caplet 400-133.3 mg-unit * Respiratory Tract Agents Anti-Inflammatories, Inhaled Corticosteroids ADVAIR DISKUS INHALATION BLISTER WITH DEVICE 100-50 MCG/DOSE, 250-50 MCG/DOSE, 500-50 MCG/DOSE ADVAIR HFA INHALATION HFA AEROSOL INHALER 115-21 MCG/ACTUATION, 230-21 MCG/ACTUATION, 45-21 MCG/ACTUATION BREO ELLIPTA INHALATION BLISTER WITH DEVICE 100-25 MCG/DOSE, 200-25 MCG/DOSE DULERA INHALATION HFA AEROSOL INHALER 100-5 MCG/ACTUATION, 200-5 MCG/ACTUATION FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 50 MCG/ACTUATION (K-Phos Neutral) (Caltrate 600 Plus D3) QL (60 per 30 days) QL (12 per 28 days) QL (60 per 30 days) QL (13 per 28 days) QL (60 per 30 days) 209
FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 250 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 220 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 44 MCG/ACTUATION QVAR INHALATION AEROSOL 40 MCG/ACTUATION, 80 MCG/ACTUATION Antileukotrienes montelukast oral granules in packet 4 mg (Singulair) montelukast oral tablet 10 mg (Singulair) montelukast oral tablet,chewable 4 mg, 5 mg (Singulair) zafirlukast oral tablet 10 mg, 20 mg (Accolate) Bronchodilators albuterol sulfate inhalation solution for nebulization 0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 mg /3 ml (0.083 %), 5 (Albuterol Sulfate) mg/ml albuterol sulfate oral syrup 2 mg/5 ml (Albuterol Sulfate) albuterol sulfate oral tablet 2 mg, 4 mg (Albuterol Sulfate) albuterol sulfate oral tablet extended release 12 hr 4 mg, 8 mg (Vospire ER) QL (120 per 30 days) QL (12 per 28 days) QL (24 per 28 days) QL (21.2 per 28 days) QL (17.4 per 25 days) 210
ATROVENT HFA INHALATION HFA AEROSOL INHALER 17 MCG/ACTUATION COMBIVENT RESPIMAT INHALATION MIST 20-100 MCG/ACTUATION ipratropium bromide inhalation solution 0.02 % ipratropium-albuterol inhalation solution for nebulization 0.5 mg-3 mg(2.5 mg base)/3 ml metaproterenol oral syrup 10 mg/5 ml metaproterenol oral tablet 10 mg, 20 mg PROAIR HFA INHALATION HFA AEROSOL INHALER 90 MCG/ACTUATION PROAIR RESPICLICK INHALATION AEROSOL POWDR BREATH ACTIVATED 90 MCG/ACTUATION SEREVENT DISKUS INHALATION BLISTER WITH DEVICE 50 MCG/DOSE SPIRIVA RESPIMAT INHALATION MIST 1.25 MCG/ACTUATION, 2.5 MCG/ACTUATION SPIRIVA WITH HANDIHALER INHALATION CAPSULE, W/INHALATION DEVICE 18 MCG (Ipratropium Bromide) (Ipratropium/Albut erol Sulfate) (Metaproterenol Sulfate) (Metaproterenol Sulfate) QL (25.8 per 28 days) QL (8 per 30 days) 211
STRIVERDI RESPIMAT INHALATION MIST 2.5 MCG/ACTUATION terbutaline oral tablet 2.5 mg, 5 mg terbutaline subcutaneous solution 1 mg/ml theochron oral tablet extended release 12 hr 100 mg, 200 mg, 300 mg theophylline in dextrose 5 % intravenous parenteral solution 200 mg/100 ml, 200 mg/50 ml, 400 mg/250 ml, 400 mg/500 ml, 800 mg/250 ml theophylline oral solution 80 mg/15 ml theophylline oral tablet extended release 12 hr 100 mg, 200 mg, 300 mg, 450 mg theophylline oral tablet extended release 24 hr 400 mg, 600 mg TUDORZA PRESSAIR INHALATION AEROSOL POWDR BREATH ACTIVATED 400 MCG/ACTUATION, 400 MCG/ACTUATION (30 ACTUAT) VENTOLIN HFA INHALATION HFA AEROSOL INHALER 90 MCG/ACTUATION Respiratory Tract Agents, Other acetylcysteine intravenous solution 200 mg/ml (20 %) (Terbutaline Sulfate) (Terbutaline Sulfate) (Theophylline Anhydrous) (Theophylline/D5 W) (Theophylline Anhydrous) (Theophylline Anhydrous) (Theophylline Anhydrous) (Acetadote) QL (2 per 28 days) 212
acetylcysteine solution 100 mg/ml (10 %), 200 mg/ml (20 %) CINQAIR INTRAVENOUS SOLUTION 10 MG/ML cromolyn inhalation solution for nebulization 20 mg/2 ml cromolyn sodium nasal spray 5.2 mg/spray (4 %) * DALIRESP ORAL TABLET 500 MCG ESBRIET ORAL CAPSULE 267 MG KALYDECO ORAL GRANULES IN PACKET 50 MG, 75 MG KALYDECO ORAL TABLET 150 MG NUCALA SUBCUTANEOUS RECON SOLN 100 MG OFEV ORAL CAPSULE 100 MG, 150 MG ORKAMBI ORAL TABLET 100-125 MG, 200-125 MG PROLASTIN-C INTRAVENOUS RECON SOLN 1,000 MG sodium chloride 0.9% inhal vl u-d, suv, p/f (rx) 0.9 % * XOLAIR SUBCUTANEOUS RECON SOLN 150 MG (Acetadote) (Cromolyn Sodium) (Nasalcrom) (Pulmosal) 3 $0 Skeletal Muscle Relaxants Skeletal Muscle Relaxants baclofen oral tablet 10 mg, 20 mg (Baclofen) carisoprodol oral tablet 250 mg, 350 mg (Soma) PA QL (30 per 30 days) PA; QL (270 per 30 days) PA; QL (60 per 30 days) PA; QL (60 per 30 days) PA; LA; QL (1 per 28 days) PA PA; QL (120 per 30 days) PA PA-HRM; QL (120 per 30 days); AGE (Max 64 Years) 213
chlorzoxazone oral tablet 500 mg cyclobenzaprine oral tablet 10 mg, 5 mg dantrolene oral capsule 100 mg, 25 mg, 50 mg (Parafon Forte DSC) (Fexmid) (Dantrium) metaxall oral tablet 800 mg (Skelaxin) metaxalone oral tablet 400 mg, 800 mg methocarbamol oral tablet 500 mg, 750 mg revonto intravenous recon soln 20 mg tizanidine oral capsule 2 mg, 4 mg, 6 mg (Skelaxin) (Robaxin) (Dantrium) (Zanaflex) tizanidine oral tablet 2 mg, 4 mg (Zanaflex) Sleep Disorder Agents Sleep Disorder Agents armodafinil oral tablet 150 mg, 200 mg, 250 mg, 50 mg BELSOMRA ORAL TABLET 10 MG, 15 MG, 20 MG, 5 MG eszopiclone oral tablet 1 mg, 2 mg, 3 mg (Nuvigil) (Lunesta) HETLIOZ ORAL CAPSULE 20 MG ROZEREM ORAL TABLET 8 MG XYREM ORAL SOLUTION 500 MG/ML PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA QL (30 per 30 days) PA-HRM; QL (30 per 30 days); AGE (Max 64 Years) PA LA 214
zaleplon oral capsule 10 mg, 5 mg (Sonata) zolpidem oral tablet 10 mg, 5 mg (Ambien) zolpidem oral tablet,ext release multiphase 12.5 mg, 6.25 mg Vasodilating Agents Vasodilating Agents (Ambien CR) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any nonbenzodiazepine hypnotic drug); QL (60 per 30 days); AGE (Max 64 Years) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any nonbenzodiazepine hypnotic drug); QL (30 per 30 days); AGE (Max 64 Years) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any nonbenzodiazepine hypnotic drug); QL (30 per 30 days); AGE (Max 64 Years) 215
ADCIRCA ORAL TABLET 20 MG ADEMPAS ORAL TABLET 0.5 MG, 1 MG, 1.5 MG, 2 MG, 2.5 MG epoprostenol (glycine) intravenous recon soln 0.5 mg, 1.5 mg LETAIRIS ORAL TABLET 10 MG, 5 MG (Flolan) OPSUMIT ORAL TABLET 10 MG ORENITRAM ORAL TABLET EXTENDED RELEASE 0.125 MG, 0.25 MG, 1 MG, 2.5 MG REMODULIN INJECTION SOLUTION 1 MG/ML, 10 MG/ML, 2.5 MG/ML, 5 MG/ML sildenafil intravenous solution 10 mg/12.5 ml (Revatio) sildenafil oral tablet 20 mg (Revatio) TRACLEER ORAL TABLET 125 MG, 62.5 MG TYVASO INHALATION SOLUTION FOR NEBULIZATION 1.74 MG/2.9 ML (0.6 MG/ML) TYVASO REFILL KIT INHALATION SOLUTION FOR NEBULIZATION 1.74 MG/2.9 ML (0.6 MG/ML) TYVASO STARTER KIT INHALATION SOLUTION FOR NEBULIZATION 1.74 MG/2.9 ML PA; QL (60 per 30 days) PA; QL (90 per 30 days) PA; QL (30 per 30 days) PA; QL (30 per 30 days) PA PA; QL (37.5 per 1 day) PA; QL (90 per 30 days) PA; LA; QL (60 per 30 days) 216
UPTRAVI ORAL TABLET 1,000 MCG, 1,200 MCG, 1,400 MCG, 1,600 MCG, 400 MCG, 600 MCG, 800 MCG UPTRAVI ORAL TABLET 200 MCG UPTRAVI ORAL TABLETS,DOSE PACK 200 MCG (140)- 800 MCG (60) Vitamins And Minerals Vitamins And Minerals a thru z advanced formula tab gluten-free 18-400 mg-mcg * a thru z advanced formula tab new formula * a thru z select 50+ formula tb advanced formula 0.4-300-250 mgmcg-mcg * a thru z select men 50+ tablet 300-600-300 mcg * a thru z select multivit tab 500-300- 250 mcg * a thru z select tablet adults 50+,iron-free 0.4-300-250 mg-mcgmcg * a thru z select tablet new formulation * a thru z select women's tablet * abc plus tablet 0.4-300-250 mgmcg-mcg * adult multi gummies 200 mcg * (Multivitamin/Iron/ Folic Acid) (Multivitamin with Minerals/Lut) (Biocel) (Biocel) (Biocel) (Biocel) (Multivitamin with Minerals/Lut) (Mv,Fe,Min/Lutein ) (Biocel) (One-A-Day Vitacraves) PA; QL (60 per 30 days) PA; QL (240 per 30 days) PA; QL (200 per 365 days) 217
adult one daily gummies 200 mcg * (One-A-Day Vitacraves) adults' 50+ daily formula tab 0.4-300-250 mg-mcg-mcg * (Biocel) adults 50+ multivitamin tablet 0.4-300-250 mg-mcg-mcg * (Biocel) adults' daily formula tablet 18-400 (Multivitamin/Iron/ mg-mcg * Folic Acid) animal chews tablet * (Multivitamin) antioxidant softgel softgel * (Beta-Carotene(A)- Vits C,E/Mins) apatate forte liquid * (Multivitamin with Minerals) b complete tablet * (Vitamin B Complex) b complex capsule * (Vitamin B Complex) b complex formula #1 tablet * (Vitamin B Complex) b complex tablet * (Vitamin B Complex) b-12 500 mcg tablet 500 mcg * (B-12) b-12 dots 500 mcg tablet 500 mcg * (B-12) balance b-100 tablet * (Vitamin B Complex) balance b-50 tablet * (Vitamin B Complex) balance b-50 tablet inner,p/f,gluten/f (Vitamin B * Complex) balanced b-100 tablet * (Vitamin B Complex) balanced b-100 tablet 100 mg * (Vit B Complex 100 No.3/Herbal) 218
balanced b-50 tablet * (Vitamin B Complex) balanced b-50 tablet * (Vitamin B Complex) balanced b-complex caplet p/f,nolactose 400 mcg * (Dialyvite 800) b-complex plus vitamin c cplt caplet * (Vita-Bee with C) b-complex with b12 tablet * (Vitamin B Complex) b-complex with c tablet * (Vita-Bee with C) b-complex with vit c caplet s/f,p/f,gluten-free 400 mcg * (Dialyvite 800) biosupp liquid * (Multivitamin with Minerals) biotin 300 mcg tablet 300 mcg * (Biotin) biovol syrup * (Multivitamin with Minerals) c complex 500 mg tablet sa 500 mg * (Ascorbic Acid) calcidol drops 8,000 unit/ml * (Drisdol) centamin liquid 9 mg iron/15 ml * (Multivit- Minerals/Ferrous Gluc) central-vite seniors tablet * (Multivit with Iron- Minerals) (Multivitcentram-care multivit-min liq 9 mg Minerals/Ferrous iron/15 ml * Gluc) centravites 50 plus tablet * (Multivit with Iron- Minerals) centrum complete multivit tab 18-400 mg-mcg * (Multivitamin/Iron/ Folic Acid) 219
centrum multivit-mineral liq 9 mg iron/15 ml * centrum silver tablet adults 50 + 0.4-300-250 mg-mcg-mcg * century adults 50+ tablet gluten free 0.4-300-250 mg-mcg-mcg * century mature tablet * cerovite liquid 9 mg iron/15 ml * certavite sr-antioxidant tab 0.4-300- 250 mg-mcg-mcg * certavite-antioxidant liquid 9 mg iron/15 ml * certavite-antioxidant tablet 18-400 mg-mcg * child chew + iron tab chew * (Multivit- Minerals/Ferrous Gluc) (Biocel) (Biocel) century ultimate women's tab 18-400 mg-mcg * cerovite advanced form tab 18-400 mg-mcg * (Multivitamin with Minerals/Lut) (Multivitamin/Iron/ Folic Acid) (Multivitamin/Iron/ Folic Acid) (Multivit- Minerals/Ferrous Gluc) (Biocel) (Multivit- Minerals/Ferrous Gluc) (Multivitamin/Iron/ Folic Acid) (Multivitamin with Iron) child chew vitamin tablet * (Multivitamin) child ferrous sulfate 15 mg/ml 15 mg iron (75 mg)/ml * (Fer-In-Sol) children's chewable vitamin * (Multivitamin) childrens multivit tab chew * (Multivitamin) complete multi 50+ tablet 500-300- 250 mcg * complete multivitamin tab * (Biocel) (Multivit,Th Iron,Other Min) 220
complete senior tablet * (Multivit with Iron- Minerals) cvs bal b-100 tablet * (Vitamin B Complex) cvs bal b-50 tablet * (Vitamin B Complex) cvs balanced b-150 tablet * (Vitamin B Complex) cvs b-complex-vit c caplet caplet * (Vita-Bee with C) cvs child vit-mineral tab * (Multivit with Iron- Minerals) cvs children's chewable vit * (Multivitamin) cvs childs vit with c tab chew * (Multivitamin) cvs child's vitamin-iron tb * (Multivitamin with Iron) cvs daily gummies complete adult vit (One-A-Day 200 mcg * Vitacraves) cvs daily multiple tablet * (Multivitamin) cvs daily multiple tablet for women * (Multivitamin) cvs daily teen multi-vitamin 18-400 (Multivitamin/Iron/ mg-mcg * Folic Acid) cvs gummy swirls chewable * (Multivitamin) cvs iron 27 mg tablet 240 mg (27 mg (Fergon) iron) * cvs men's daily gummies p/f, glutenfree 200 mcg * Vitacraves) (One-A-Day cvs men's multi-vit tablet * (Multivitamin) cvs prenatal vitamin tablet * (Prenatal Vit Calc,Iron,Folic) cvs spectravite adult 50+ tabs 0.4-300-250 mg-mcg-mcg * (Biocel) cvs spectravite advanced tab 18-400 (Multivitamin/Iron/ mg-mcg * Folic Acid) 221
cvs spectravite liquid * (Pediavit) cvs spectravite senior * (Multivitamin with Minerals/Lut) cvs spectravite senior tab * (Multivit with Iron- Minerals) cvs spectravite senior tablet 500-300-250 mcg * (Biocel) cvs spectravite tablet chew * (Multivitamin with cvs spectravite ultra women tb 18-400 mg-mcg * cvs super b complx & c cplt caplet, p/f * cvs vision formula tablet 1,000 unit- 200 mg-60 unit-2 mg * cvs vitamin b-100 complx tb * cvs vitamin c 1,000 mg tb chw 1,000 mg * cvs vitamin d3 1,000 unit sfgl softgel 1,000 unit * cvs women's daily gummies p/f, gluten-free 200 mcg * cyanocobalamin 1,000 mcg/ml 25's 1,000 mcg/ml * d3 dots 2,000 unit tablet p/f 2,000 unit * daily multi vitamin-iron tab * daily multiple tablet 18-400 mg-mcg * daily multiple vitamin tab sugar coated * Iron) (Multivitamin/Iron/ Folic Acid) (Vita-Bee with C) (Vits A,C,E/Lutein/Mine rals) (Vitamin B Complex) (Ascorbic Acid) (D3-50) (One-A-Day Vitacraves) (Cyanocobalamin (Vitamin B-12)) 3 $0 (Vitamin D3) (Multivitamin with Iron) (Multivitamin/Iron/ Folic Acid) (Multivitamin) 222
daily multivitamin-iron tablet 18- (Multivitamin/Iron/ 400 mg-mcg * Folic Acid) daily value multivitamin tab s/f * (Multivitamin) daily vit formula + iron tab 18-400 (Multivitamin/Iron/ mg-mcg * Folic Acid) daily vitamin + iron tablet * (Multivitamin with Iron) daily vitamin formula tablet * (Multivitamin) daily vitamin formula tablet * (Multivitamin with Minerals) daily vitamin tablet p/f,na/f * (Multivitamin) daily vite tablet s/f, p/f * (Multivitamin) daily vite tablet s/f,p/f * (Multivitamin) daily vite with iron tablet * (Multivitamin with Iron) dino-life extra c tab chew * (Multivitamin) dino-life iron-zinc tb chew * (Multivit with Iron- Minerals) dino-life tablet chewable * (Multivitamin) eldertonic elixir 0.5-0.6-7-0.7 mg * (B1,B2,B3,B6,B12 /Dexpan/Zn/Mang) ellis tonic * (Multivitamin with Minerals) (Pedi Mv eq child complete chew tablet 18 mg No.58/Ferrous iron * Fumarate) eq complete multivitamin tab 0.4-300-250 mg-mcg-mcg * (Biocel) eq complete multivitamin tab glutenfree 18-400 mg-mcg * Folic Acid) (Multivitamin/Iron/ eql central-vite select tablet * eql century mature tablet 500-300- 250 mcg * (Multivitamin with Minerals/Lut) (Biocel) 223
eql chewable multi vitamin tab * (Multivitamin) eql child's multivit tab chew with vitamin c * (Multivitamin) eql childs multivit-mineral tb * (Multivit with Iron- Minerals) (Vits eql eye health plus lutein tab 1,000 A,C,E/Lutein/Mine unit-200 mg-60 unit-2 mg * rals) eql one daily 50 plus tablet * (Multivitamin with Minerals) eql one daily essential tablet * (Multivitamin) eql one daily maximum tablet 18-0.4 mg * eql one daily men's tablet * ergocalciferol 8,000 units/ml 8,000 unit/ml * essentia tablet 18-400 mg-mcg * essential balance tablet * essential daily tablet w/iron & calcium 18-0.4 mg * ferocon capsule 110-0.5 mg * ferretts 325 mg tablet 325 mg (106 mg iron) * ferrex 150 capsule outer, u-d 150 mg iron * ferrex 150 plus capsule 150-50-50 mg * ferrocite tablet 324 mg (106 mg iron) * (Tab A Vite) (Multivitamin with Minerals) (Drisdol) (Multivitamin/Iron/ Folic Acid) (Mv,Fe,Min/Lutein ) (Tab A Vite) (Iron Fum/Vit C/B12-If/Fa) 3 $0 (Ferrous Fumarate) (Pic 200) (Iron Aspgly,Ps/C/Succi nic Acid) (Ferrous Fumarate) 224
ferrous fumarate 324 mg tab 324 mg (Ferrous Fumarate) (106 mg iron) * ferrous gluconate 240 mg tab 240mg=27mg elemental 240 mg (27 (Fergon) mg iron) * ferrous gluconate 324 mg tab 324 mg (36 mg iron), 324 mg (37.5 mg iron), 324 mg (38 mg iron) * (Fergon) ferrous sulf 220 mg/5 ml elix 220 mg (Ferrous Sulfate) (44 mg iron)/5 ml * ferrous sulf 300 mg/5 ml liq 300 mg (60 mg iron)/5 ml * (Ferrous Sulfate) ferrous sulf ec 324 mg tablet 324 mg (Ferrous Sulfate) (65 mg iron) * ferrous sulfate 325 mg tablet red 325 mg (65 mg iron) * (Slow Fe) flintstones complete tablet * (Multivit with Iron- Minerals) flintstones extra c tab chew * (Multivitamin) flintstones tablet chewable * (Multivitamin) (Pedi Mv flintstones with iron tab chew 18 mg No.79/Ferrous iron * Fumarate) folic acid 1 mg tablet (rx) 1 mg * (Folic Acid) 3 $0 folic acid 1,000 mcg tablet p/f,s/f (otc) 1 mg * (Folic Acid) FOLIC ACID 20 MG CAPSULE 20 MG * folic acid 400 mcg tablet s/f,p/f,lactose-free 400 mcg * (Folic Acid) fosfree tablet 175.5-14.5 mg * (Calcium/Multivita min with Iron) geravim liquid * (Pediavit) geriaton liquid * (Pediavit) 225
gnp century mature tablet glutenfree 0.4-300-250 mg-mcg-mcg * (Biocel) gnp century tablet gluten-free 18- (Multivitamin/Iron/ 400 mg-mcg * Folic Acid) gnp one daily essential tablet * (Multivitamin) gs prenatal vitamins tablet 28-800 (Pnv133/Ferrous mg-mcg * Fumarate/Fa) gummi bear multivit tab chew multivit & minerals * (Multivitamin) hair vitamins * (Multivitamin with Iron) (Vits healthy eyes caplet caplet 1,000 A,C,E/Lutein/Mine unit-200 mg-60 unit-2 mg * rals) hemocyte tablet u-u,blister pk 324 mg (106 mg iron) * (Ferrous Fumarate) hi-b complex tablet * (Vitamin B Complex) hm complete 50+ tablet 0.4-300-250 (Biocel) mg-mcg-mcg * hm one daily with iron tablet glutenfree 18-400 mg-mcg * Folic Acid) (Multivitamin/Iron/ hm super vitamin b complex glutenfree 400 mcg * (Dialyvite 800) honey bears chew tab * (Multivitamin) honey bears-iron-zinc tab chew * (Multivit with Iron- Minerals) icaps plus tablet lactose free * (Multivitamin with Minerals) iferex 150 capsule 150 mg iron * (Pic 200) iron 27 mg tablet 236 mg (27 mg iron) * (Fergon) iron 28 mg tablet 256 mg (28 mg iron) * (Fergon) 226
kenwood therapeutic liquid * (Multivitamin,Ther apeutic) life-pack women's p/f,s/f 0.8 mg * (Multivit with Iron- Minerals) LIQUI-E LIQUID 400 UNIT/15 ML * little animals child tb chw * (Multivitamin) little animals-iron tab chew * (Multivitamin with Iron) lysiplex plus liquid * (Pediavit) MACUVITE EYE CARE TABLET 7,160 UNIT-113 MG-100 UNIT * MACUVITE TABLET 5,000-60-30 UNIT-MG-UNIT * mega multivitamin-mineral tab * (Multivitamin with Minerals) mega multivit-chelated min tab * (Multivitamin with Minerals) MEPHYTON 5 MG TABLET 5 MG * 3 $0 milltrium senior multivit tab * (Multivitamin with Minerals/Lut) multi complete-iron tablet 18-400 (Multivitamin/Iron/ mg-mcg * Folic Acid) multi-day plus iron tablet 18-400 (Multivitamin/Iron/ mg-mcg * Folic Acid) multi-delyn with iron liquid 10 mg (Multivitamin/Ferr iron/5 ml * ous Gluconate) multiple vitamin with iron tab * (Multivitamin with Iron) multiple vitamin w-minerals tb * (Multivitamin with Minerals) multiple vitamins tablet one daily * (Multivitamin) multivitamin child tab chew * (Multivitamin) 227
multi-vitamin daily tablet * (Multivitamin) (Multivitmultivitamin-mineral liquid 9 mg Minerals/Ferrous iron/15 ml * Gluc) multivit-fluor 0.5 mg tab chew (Pedi M.Vit No.17 chewable, d/f, s/f 0.5 mg with Fluoride) multivit-iron child tab chew (Multivitamin with children's * Iron) multivit-mineral hp cap * (Multivitamin,Ther and Minerals) multivit-minerals tablet s/f,p/f * (Multivitamin with Minerals) my favorite multiple liquid * (Multivitamin) myvitalife soft-gel capsule * (Multivitamin with Minerals) NASCOBAL 500 MCG NASAL SPRAY 500 MCG/SPRAY * nephplex rx tablet 1-60-300-12.5 mg-mg-mcg-mg * (Vit B Cmplx No3/Fa/C/Biot/Zin c) (Iron Fum/Docusate/Fa/ 3 $0 3 $0 nephron fa tablet 66.6-75-1 mg * 3 $0 Bcomp,C) nephro-vite rx tablet 1-60-300 mgmg-mcg * 3/Fa/Vit C/Biotin) (Vit B Cmplx 3 $0 niacinamide er 500 mg tablet 500 mg * (Niacinamide) nu-iron 150 capsule 150 mg iron * (Pic 200) ocutabs tablet s/f, w/lutein * (Beta-Carotene(A)- Vits C,E/Mins) oncovite tablet * (Multivitamin,Ther apeutic) one daily complete tablet * (Multivitamin with Minerals) 228
one daily essential tablet * (Multivitamin) one daily multivitamin tab * (Multivitamin) one daily multivitamin tablet * (Multivitamin with Iron) one daily multivitamin tablet 400 mcg * (Quintabs) one daily multivitamin-iron tb 18- (Multivitamin/Iron/ 400 mg-mcg * Folic Acid) one daily plus iron tablet 18-400 (Multivitamin/Iron/ mg-mcg * Folic Acid) one daily tablet * (Multivitamin) one daily tablet * (Multivitamin with Iron) one daily tablet men's formula * (Multivitamin) one daily with minerals tablet * (Multivitamin with Minerals) one-a-day essential tablet * (Multivitamin) one-a-day max formula tab * (Multivitamin with Minerals) one-a-day teen advantage tab 18- (Multivitamin/Iron/ 400 mg-mcg * Folic Acid) one-a-day teen advantage tab 9 mg (Multivits,Ca,Mine iron-400 mcg * rals/iron/fa) pharmacist multi-vite tab * (Multivitamin) pnv prenatal plus multivit tab s/f, (Pnv with gluten-free 27 mg iron- 1 mg Ca,No.72/Iron/Fa) poly-iron 150 mg capsule 150 mg iron * (Pic 200) poly-vita drops 1,500-35-400 unitmg-unit/ml * poly-vita with iron drops 1,500 unit- 400 unit-10 mg/ml * (Pediatric Multivitamin No.20) (Ped Multivit #46/Iron Sulfate) (All Rx Prenatal Vitamins Covered) 229
poly-vitamin drops 1,500-35-400 unit-mg-unit/ml * (Pediatric Multivitamin No.20) poly-vitamin tab chew * (Multivitamin) polyvitamin w-iron drops 1,500 (Ped Multivit unit-400 unit-10 mg/ml * #46/Iron Sulfate) (Prenatal Vit prenatal tablet (otc) 27-0.8 mg * No.130/Iron/Fa) (Prenatal prenatal tablet 27 mg iron- 800 mcg Vit#96/Ferrous * Fum/Fa) prenatal tablet 28 mg iron- 800 mcg * prenatal vitamin plus low iron oral tablet 27 mg iron- 1 mg prenatal vitamin tablet 28 mg iron- 800 mcg * prenatal vitamins tablet phosphorus free 28 mg iron- 800 mcg * prosight tablet 5,000-60-30 unit-mgunit * (Prenatal Vit/Iron Fumarate/Fa) (Pnv with Ca,No.72/Iron/Fa) (Prenatal Vit/Iron Fumarate/Fa) (Prenatal) (A/C/E/Zinc/Sod Selenate/Copper) pub multivitamin 50 plus tab * (Multivitamin with Minerals/Lut) pv b-100 complex * (Vitamin B Complex) pv b-50 complex * (Vitamin B Complex) pv kid's gummy bear tab chew chewable * (Multivitamin) pv kid's vit + extra c chew tb * (Multivitamin) pv kid's vit + iron tab chew * (Multivitamin with Iron) pv kid's vit complete tab chew * (Multivitamin) pv kid's vitamins chew tab * (Multivitamin) (All Rx Prenatal Vitamins Covered) 230
pv kids vitamins+iron tab chew 15 mg iron * pv multivital platinum tablet * pv multivital platinum tablet w/lutein & lycopene 500-300-250 mcg * pv prenatal formula tablet 28 mg iron- 800 mcg * pv prenatal formula tablet 28 mg iron- 800 mcg * pv stress 500 plus zinc tab * pyridoxine 100 mg/ml vial 25's 100 mg/ml * qc child complete vit chew tab 18 mg iron * (Ped Multivit #17/Iron Fumarate) (Multivitamin with Minerals/Lut) (Biocel) (Prenatal Vit No.131/Iron/Fa) (Prenatal Vit/Iron Fumarate/Fa) (Multivitamin,Stres s Formula/Zn) (Pyridoxine HCl) 3 $0 (Pedi Mv No.67/Ferrous Fumarate) qc children's chewable tablet * (Multivitamin) qc maximum daily multivit tab 18- (Tab A Vite) 0.4 mg * qc multi-vite 50 & over tablet (Multivitamin with w/lycopene * Minerals/Lut) qc multi-vite tablet 18-400 mg-mcg (Multivitamin/Iron/ * Folic Acid) qc women's daily multivit tab 18-0.4 (Tab A Vite) mg * (Vitamin B ra balanced b-100 tablet 0.4 mg * Complex/Folic Acid) (Vitamin B ra b-complex tablet p/f * Complex) (Vitamin B ra b-complex tablet p/f * Complex) 231
ra central vite select tab p/f * (Multivitamin with Minerals/Lut) ra central-vite select tab p/f * (Multivit with Iron- Minerals) ra central-vite senior tablet 0.4-300- 250 mg-mcg-mcg * (Biocel) ra central-vite tablet 0.4-300-250 mg-mcg-mcg * (Biocel) ra central-vite tablet 18-400 mgmcg * Folic Acid) (Multivitamin/Iron/ ra one daily energy tablet * (Multivitamin with Minerals) ra one daily plus iron tablet * (Multivitamin with Iron) ra one daily tablet p/f * (Multivitamin) ra prenatal tablet 28 mg iron- 800 (Prenatal Vit/Iron mcg * Fumarate/Fa) ra therapeutic m multivit tab 18-0.4 mg * (Tab A Vite) ra vit b-12 1,000 mcg/ml liq 1,000 (Cyanocobalamin mcg/ml * (Vitamin B-12)) ra vitamin b-12 1,000 mcg tab timed-release 1,000 mcg * (B-12) ra vitamin c 1,000 mg tab sa w/bioflavonoids 1,000 mg * (Ascorbic Acid) ra vitamin c 500 mg tab chew p/f 500 mg * (Ascorbic Acid) ra vitamin c tr 500 mg caplet caplet,p/f,s/f 500 mg * (Ascorbic Acid) rena-vite rx tablet 1-60-300 mg-mgmcg * 3/Fa/Vit C/Biotin) (Vit B Cmplx 3 $0 scooby-doo one a day tablet * (Multivit with Iron- Minerals) 232
senior tabs 0.4-300-250 mg-mcgmcg * (Biocel) sentry senior multivitamin tab sodium/f,yeast/f 500-300-250 mcg * (Biocel) sentry senior tablet 0.4-300-250 mgmcg-mcg * (Biocel) sentry tablet 18-400 mg-mcg * (Multivitamin/Iron/ Folic Acid) sm airshield effervescent tab 5,000- (Vit A,C,E/Dietary 1000-30 unit-mg-unit * Supp No.12) sm animal shapes tab chew * (Multivitamin) sm animal shapes tab chew toddlers * (Multivitamin) sm animal shapes w-iron tab (Multivitamin with children's * Iron) (Vits sm antioxidant vitamins tablet 1,000 A,C,E/Lutein/Mine unit-200 mg-60 unit-2 mg * rals) sm b complex with vit c tablet gluten-free * (Vita-Bee with C) sm complete multi-vit-mineral advanced formula 18-400 mg-mcg * sm complete senior formula tab * sm complete senior formula tab 0.4-300-250 mg-mcg-mcg * sm hair, skin and nails caplet caplet, gluten-free * sm multivitamin w-iron tab * sm natural balanced b-100 tab 100 mg * (Multivitamin/Iron/ Folic Acid) (Multivit with Iron- Minerals) (Biocel) (Multivitamin with Minerals) (Multivitamin with Iron) (Vit B Complex 100 Cmb #2/Herbs) 233
sm opti-vitamin tablet 1,000 unit- 200 mg-60 unit-2 mg * sm prenatal vitamins tablet 28 mg iron- 800 mcg * sm super b complex-c caplet caplet * sm therapeutic m tablet 27-0.4 mg * sm vitamin b complex tablet glutenfree 0.4 mg * sm vitamin b-100 complex tab gluten-free 0.4 mg * sm vitamin d3 4,000 unit sftgl softgel, gluten-free 4,000 unit * sodium fluoride oral tablet 1 mg fluoride (2.2 mg) stress b tablet * stress b with zinc tablet * stress formula tablet * stress formula with iron tab * stress formula with iron tab 500 mg- 400 mcg- 18 mg iron * stress formula with zinc tab * (Vits A,C,E/Lutein/Mine rals) (Prenatal) (Vita-Bee with C) (Multivit,Tx,Iron/C alcm/fa/mins) (Vitamin B Complex/Folic Acid) (Vitamin B Complex/Folic Acid) (D3-50) (Pedi M.Vit No.17 with Fluoride) (Vitamin B Complex) (Multivitamin,Stres s Formula/Zn) (Multivitamin,Stres s Formula) (Iron/Mv,Stress Form) (Vit B Comp/C/Fa/Iron/Vi t E) (Multivitamin,Stres s Formula/Zn) 234
stress-c with iron tablet 500 mg-400 mcg- 18 mg iron * sunvite tablet 18 mg iron-400 mcg- 25 mcg * (Vit B Comp/C/Fa/Iron/Vi t E) (Mv-Min/Iron Fum/Fa/K/Lyco/Lu tn) super b complex-c caplet caplet * (Vita-Bee with C) (Vitamin B super b maxi complex caplet 0.4 mg Complex/Folic * Acid) super b with vit c capsule * (B Complex with Vitamin C) super b-50 complex capsule * (Vitamin B Complex) super b-50 complex plus tab * super b-complex folic-vit c tb p/f 400 mcg * (Vitamin B Complex) (Dialyvite 800) super multiple vit-mineral tab * (Multivit with Iron- Minerals) super multivitamin tablet * (Multivitamin) super quints b-50 tablet 0.4 mg * (Vitamin B Complex/Folic Acid) super quints b-50 tablets * (Vitamin B Complex) super thera vite m tablet * (Multivitamin,Ther and Minerals) superior 35 vit-mineral tab sa * (Multivit with Iron- Minerals) superplex-t tablet * (Vita-Bee with C) support liquid * (Multivitamin with Minerals) 235
support-500 softgel * (B Complex with Vitamin C) 3 $0 sv hair, skin and nails caplet 1 mg (Mv,Ca,Min/Iron iron-66.7 mcg-1,000 mcg * Gluc/Fa/Biotin) tab-a-vite tablet * (Multivitamin) tab-a-vite with iron tablet * (Multivitamin with Iron) tab-a-vite-minerals tablet * (Multivitamin with Minerals) thera m plus tablet 9 mg iron-400 (Multivits,Ca,Mine mcg * rals/iron/fa) thera tablet * (Multivitamin,Ther apeutic) thera-d 2000 tablet 2,000 unit * (Vitamin D3) theradex m tablet 27-0.4 mg * (Multivit,Tx,Iron/C alcm/fa/mins) thera-m caplet caplet 27-0.4 mg * (Multivit,Tx,Iron/C alcm/fa/mins) thera-m tablet w/beta carotene 9 mg (Multivits,Ca,Mine iron-400 mcg * rals/iron/fa) therapeutic-m caplet p/f, s/f, caplet 9 (Multivits,Ca,Mine mg iron-400 mcg * rals/iron/fa) thera-tabs tablet * (Multivitamin,Ther apeutic) theratrum compl 50 plus tab * (Multivitamin with Minerals/Lut) theratrum complete 50 plus (Multivit with Ironp/f,caplet * Minerals) thiamine 200 mg/2 ml vial 25's,mdv,outer 100 mg/ml * (Thiamine HCl) 3 $0 thiamine 500 mg tablet 500 mg * (Thiamine HCl) total b with vit c caplet * (Vita-Bee with C) totalday multiple tablet sa * (Multivitamin with Minerals) 236
tri-vi-sol drops 750 unit-35 mg -400 unit/ml * tri-vita drops 1,500-35-400 unit-mgunit/ml * tri-vitamin drops 1,500-35-400 unitmg-unit/ml * ultra b-100 complex tablet * v-c forte capsule 1 mg * vic-forte capsule 1 mg * vision plus lutein vitamin tab * vision vitamins * vision vitamins tablet w/lutein,p/f 1,000 unit-200 mg-60 unit-2 mg * vit d2 1.25 mg (50,000 unit) 50,000 unit * VITAFOL FE+ (WITH DOCUSATE) ORAL CAPSULE 90 MG IRON-1 MG -50 MG-200 MG vitalets tablet chewable child, orange,s/f * vitamin a 10,000 units capsule soluble 10,000 unit * vitamin a 25,000 units capsule softgel 25,000 unit * (Vit A Palmitate/Vit C/Vit D3) (Pedi Multivit A,C,And D3 No.21) (Pedi Multivit A,C,And D3 No.21) (Vitamin B Complex) (Multivitamin- Minerals No.7/Fa) (Multivitamin- Minerals No.7/Fa) (Multivitamin with Minerals/Lut) (Beta-Carotene(A)- Vits C,E/Mins) (Vits A,C,E/Lutein/Mine rals) 3 $0 3 $0 (Drisdol) 3 $0 (Multivitamin with Iron) (Vitamin A) (Vitamin A) 237
vitamin and minerals tablet * (Multivitamin,Ther and Minerals) (Vit B vitamin b complex tablet 500 mg- Comp/C/Fa/Iron/Vi 400 mcg- 18 mg iron * t E) vitamin b complex-vit c cap * (B Complex with Vitamin C) vitamin b complex-vit c tablet * (Vita-Bee with C) vitamin b-12 1,000 mcg tablet 1,000 mcg * (B-12) vitamin b-12 100 mcg tablet 100 mcg * (B-12) vitamin b-12 250 mcg tablet 250 mcg * (B-12) vitamin b12 500 mcg tablet 500 mcg * (B-12) vitamin b-12 tr 1,000 mcg tab (Cyanocobalamin lactose free 1,000 mcg * (Vitamin B-12)) vitamin b12-folic acid tablet 500- (Cyanocobalamin/ 400 mcg * Folic Acid) vitamin b-6 250 mg tablet p/f 250 mg * (Pyridoxine HCl) vitamin b-6 50 mg tablet 50 mg * (Pyridoxine HCl) (Folic Acid/B vitamin b-complex & c caplet p/f,no Cmplx C/Rice lactose,cplt 400-500 mcg-mg * Bran) vitamin c 1,000 mg tablet 1,000 mg * (Ascorbic Acid) vitamin c 1,500 mg tablet sa na/f,s/f,starch/free 1,500 mg * (Ascorbic Acid) vitamin c 250 mg tablet 250 mg * (Ascorbic Acid) vitamin c 250 mg tablet chew 250 mg * (Ascorbic Acid) 238
vitamin c 500 mg tablet chew 500 mg * (Ascorbic Acid) vitamin c 500 mg/5 ml liquid 500 mg/5 ml * (Ascorbic Acid) vitamin d 1,000 unit tablet 1,000 unit * (Vitamin D3) vitamin d3 1,000 unit tablet s/f,p/f 1,000 unit * (Vitamin D3) vitamin d3 1,000 units softgel softgel, p/f, s/f 1,000 unit * (D3-50) vitamin d3 10,000 unit softgel softgel 10,000 unit * (D3-50) vitamin d3 2,000 unit tablet s/f,p/f 2,000 unit * (Vitamin D3) vitamin d3 400 unit tab chew orange, p/f 400 unit * (Vitamin D3) vitamin d3 400 unit tablet s/f,p/f 400 unit * (Vitamin D3) vitamin d3 400 unit/5 ml liq 400 (Cholecalciferol unit/5 ml * (Vitamin D3)) vitamin d3 5,000 unit capsule s/f, p/f 5,000 unit * (D3-50) vitamin d3 5,000 unit/ml drops a/f, p/f,gluten-free 5,000 unit/ml * (Just D) vitamin k 100 mcg tablet p/f, glutenfree 100 mcg * (Phytonadione) vitamins for hair tablet * (Multivitamin) vitrum 50+ senior tablet 500-300- 250 mcg * (Biocel) vitrum senior tablet f/f,p/f * (Multivitamin with Minerals/Lut) v-r natural b-100 tablet * (Vitamin B Complex) 239
yelets tablet 18-400 mg-mcg * (Multivitamin/Iron/ Folic Acid) zoo chews gummie tablet * (Multivitamin) 2
INDEX 3 3 day vaginal... 59 30pse-150gfn-15dm... 122 30pse-3brm-15dm... 122 3-day vaginal... 57 5 50pse-3brm-30dm... 122 8 8-MOP... 134 A a thru z advanced formula... 217 a thru z high potency... 217 a thru z select... 217 a thru z select 50+ formula... 217 a thru z select women's... 217 abacavir... 77 abacavir-lamivudine... 77 abacavir-lamivudine-zidovudine... 77 abc plus... 217 ABELCET... 56 ABILIFY MAINTENA... 73 ABRAXANE... 31 ABREVA... 66 acamprosate... 16 acarbose... 52 acebutolol... 98 acephen... 3 acetaminophen... 3 acetaminophen-codeine... 3 acetazolamide... 197 acetazolamide sodium... 197 acetic acid... 152, 188 acetylcysteine... 212, 213 acid gone antacid... 159 acid reducer (famotidine)... 157 acid relief (cimetidine)... 158 acitretin... 134 acne medication... 134, 137 ACNE MEDICATION... 135 acne-clear... 135 ACTEMRA... 191 ACTHIB (PF)... 182 ACTIMMUNE... 191 actinel pediatric... 122 acyclovir... 83, 135 acyclovir sodium... 83 ADACEL(TDAP ADOLESN/ADULT)(PF) 182 ADAGEN... 145 adapalene... 144 ADCETRIS... 31 ADCIRCA... 215, 216 adefovir... 83 ADEMPAS... 216 adriamycin... 31 adrucil... 31 adt robitussin peak cld dm max... 122 adult multivitamin gummies 217 adult nasal decongestant... 131 adult one daily gummies... 218 adult robitussin lingering cld 122 adult robitussin peak cold dm... 122 adult wal-tussin... 122 adult wal-tussin dm max... 122 adults 50 plus... 218 adults 50+ daily formula... 218 adults' daily formula... 218 ADVAIR DISKUS... 209 ADVAIR HFA... 209 ADVIL... 11, 12 af 57 afeditab cr... 104 AFINITOR... 32 AFINITOR DISPERZ... 32 AFTERA... 113 a-hydrocort... 173 airshield... 233 AKTEN (PF)... 147 AKYNZEO... 68 ala-cort... 139 ala-scalp... 139 alavert... 60 alavert d-12 allergy-sinus... 60 ALBENZA... 70 albuterol sulfate... 210 alcaine... 147 alclometasone... 140 ALCOHOL PADS... 135 ALCOHOL PREP PADS... 135 ALDURAZYME... 145 ALECENSA... 32 alendronate... 189 alfuzosin... 170 ALIMTA... 32 ALINIA... 70 alka-seltzer plus mucus-conges... 123 ALLEGRA ALLERGY... 60 aller-chlor... 60 allerclear d-12hr... 60 allerclear d-24hr... 60 allergy (chlorpheniramine)... 61 allergy (diphenhydramine)... 62 allergy relief (cetirizine)... 62 allergy relief (clemastine)... 64 allerhist-1... 61 aller-tec d... 61 all-nite cold-flu... 123 I-1 Formulario ICS Community Care Plus FIDA-MMP per il 2016 ID del formulario:16508.000, Versione: 19 In vigore da: 1 Dicembre 2016
allopurinol... 191 ALLZITAL... 3 almacone... 159 almacone-2... 159 aloe vesta antifungal (micon). 56 alophen... 165 alosetron... 188 ALPHAGAN P... 198 alprazolam... 17 ALREX... 154, 155 altacaine... 147 altamist... 147 altavera (28)... 113 aluminum hydroxide gel... 159 alyacen 1/35 (28)... 113 alyacen 7/7/7 (28)... 113 amabelz... 172 amantadine hcl... 71 ambi 10peh-4cpm-20dm... 123 ambi 20dm-4cpm... 123 ambi 40pse-400gfn-20dm... 123 ambi 60pse-4cpm... 61 ambi 60pse-4cpm-20dm... 123 AMBISOME... 56 amethia... 113 amethia lo... 113 amifostine crystalline... 191 amiloride... 105 amiloride-hydrochlorothiazide... 105 AMINO ACIDS 15 %... 88 aminocaproic acid... 87 AMINOSYN 10 %... 88 AMINOSYN 3.5 %... 88 AMINOSYN 7 %... 88 AMINOSYN 7 % WITH ELECTROLYTES... 88 AMINOSYN 8.5 %... 89 AMINOSYN 8.5 %- ELECTROLYTES... 89 AMINOSYN II 10 %... 89 AMINOSYN II 15 %... 89 AMINOSYN II 7 %... 89 AMINOSYN II 8.5 %... 89 AMINOSYN II 8.5 %- ELECTROLYTES... 89 AMINOSYN M 3.5 %... 89 AMINOSYN-HBC 7%... 89 AMINOSYN-PF 10 %... 89 AMINOSYN-PF 7 % (SULFITE-FREE)... 89 AMINOSYN-RF 5.2 %... 90 amiodarone... 97 AMITIZA... 159 amitriptyline... 48 amlactin... 135 amlodipine... 104 amlodipine-atorvastatin 106, 107 amlodipine-benazepril... 104 amlodipine-valsartan... 105 amlodipine-valsartan-hcthiazid... 105 ammonium lactate... 135 amoxapine... 48 amoxicil-clarithromy-lansopraz... 157 amoxicillin... 26 amoxicillin-pot clavulanate... 27 amphotericin b... 56 ampicillin... 27 ampicillin sodium... 27 ampicillin-sulbactam... 27 AMPYRA... 110, 111 ANACAINE... 135 anagrelide... 87 anastrozole... 32 ANDRODERM... 171 ANDROGEL... 171 androxy... 171 animal chews... 218 animal shape vitamins... 233 animal shapes plus iron... 233 antacid anti-gas... 159 antacid anti-gas (ca carb-sim)... 160 antacid extra-strength... 159 anticoag citrate phos dextrose... 191 anti-diarrheal... 161 anti-diarrheal (loperamide).. 159, 161 antifungal (tolnaftate)... 56, 60 antifungal cream... 56 anti-gas maximum strength.. 157 antioxidant... 218 antioxidant vitamins... 233 apatate forte... 218 APOKYN... 71 apraclonidine... 147 apri... 113 APRISO... 188 aprodine... 61 APTIOM... 42 APTIVUS... 77 aquanil hc... 140 aranelle (28)... 113 ARCALYST... 178 aripiprazole... 73 ARISTADA... 73, 74 armodafinil... 214 arthritis pain relief (acetam)... 11 artificial tears (petro/min)... 148 artificial tears (pf)... 148 artificial tears (polyvin alc).. 147 artificial tears(dext70-hypro) 148 artificial tears(glycerin-peg). 148 artificial tears(hypromellose) 151 ASACOL HD... 188 ascomp with codeine... 4 ascorbic acid (vitamin c)... 222, 238 ashlyna... 114 aspirin... 12 aspirin, buffered... 12 aspirin-dipyridamole... 88 I-2 Formulario ICS Community Care Plus FIDA-MMP per il 2016 ID del formulario:16508.000, Versione: 19 In vigore da: 1 Dicembre 2016
aspir-low... 12 ASSURE ID INSULIN SAFETY... 144, 145 ASTAGRAF XL... 178 atenolol... 98 atenolol-chlorthalidone... 98 atorvastatin... 107 atovaquone... 71 atovaquone-proguanil... 71 ATRIPLA... 77 atropine... 42, 148 atropine-care... 148 ATROVENT HFA... 211 AUBAGIO... 178 aubra... 114 AVASTIN... 32 AVC VAGINAL... 66 aviane... 114 AVONEX... 192 AVONEX (WITH ALBUMIN)... 191 ayr saline... 148 azacitidine... 32 azathioprine... 178 azathioprine sodium... 178 azelastine... 148 AZILECT... 72 azithromycin... 25 AZOPT... 198 AZOR... 105 aztreonam... 26 azurette (28)... 114 B b complete... 218 b complex 1... 218 b complex 100... 234 b complex-vitamin b12... 219 b complex-vitamin c-folic acid... 219, 226, 235 b-100 complex... 230 b-12 dots... 218 b-50 complex... 230 bacitracin... 19, 138, 152 bacitracin-polymyxin b... 152 bacitraycin plus... 138 baclofen... 213 bal b-100... 221 bal b-50... 221 balance b-100... 218 balance b-50... 218 balanced b-100... 218, 231 balanced b-150... 221 balanced b-50... 219 balanced b-50 complex... 219 balsalazide... 188 balziva (28)... 114 banophen... 61 banophen allergy... 61 BANZEL... 42, 43 baza antifungal... 56 BCG VACCINE, LIVE (PF) 182 b-complex... 231 b-complex with vitamin c... 219, 221, 233, 238 BD INSULIN PEN NEEDLE UF SHORT... 145 BD INSULIN SYRINGE ULTRA-FINE... 145 bekyree (28)... 114 BELBUCA... 4 BELEODAQ... 32 BELSOMRA... 214 benadryl allergy... 61 benazepril... 96 benazepril-hydrochlorothiazide... 96 BENDEKA... 32 BENICAR... 95 BENICAR HCT... 94, 95 BENLYSTA... 192 benzonatate... 123 benzoyl peroxide... 135 benztropine... 72 BETADINE... 135 beta-hc... 140 betamethasone acet,sod phos 173 betamethasone dipropionate. 140 betamethasone valerate... 140 betamethasone, augmented.. 140 BETASERON... 192 betaxolol... 98, 198 bethanechol chloride... 192 BETHKIS... 18 bexarotene... 32 BEXSERO (PF)... 182 bicalutamide... 32 bicarsim forte... 156 BICILLIN C-R... 27 BICILLIN L-A... 28 BIDIL... 109 bimatoprost... 198 bio-dtuss dmx... 123 bion tears (pf)... 148 bionel pediatric... 123 biospec dmx... 123 biosupp... 219 biotin... 219 biovol... 219 bisac-evac... 165 bisacodyl... 165 biscolax... 165 bismatrol... 160 bisoprolol fumarate... 98 bisoprolol-hydrochlorothiazide... 98 bleomycin... 32 bleph-10... 152 BLINCYTO... 32 blisovi 24 fe... 114 blisovi fe 1.5/30 (28)... 114 blisovi fe 1/20 (28)... 114 blis-to-sol (tolnaftate)... 56 BOOSTRIX TDAP... 183 BOSULIF... 32 bp 8 cough... 123 BREO ELLIPTA... 209 I-3 Formulario ICS Community Care Plus FIDA-MMP per il 2016 ID del formulario:16508.000, Versione: 19 In vigore da: 1 Dicembre 2016
briellyn... 114 BRILINTA... 88 brimonidine... 198 BRINTELLIX... 48 BRIVIACT... 43 bromfed dm... 123 bromfenac... 155 bromocriptine... 72 brompheniramine-pseudoephdm... 122, 123 budesonide... 188 bufferin... 12 bumetanide... 105 BUPHENYL... 160 buprenorphine hcl... 4, 16 buprenorphine-naloxone... 16 buproban... 48 bupropion hcl... 48 bupropion hcl (smoking deter)... 16, 48 buspirone... 192 butalbital compound w/codeine 4 butalbital-acetaminop-caf-cod. 4 butalbital-acetaminophen... 4 butalbital-acetaminophen-caff. 4 butalbital-aspirin-caffeine... 4 BUTRANS... 4 BYSTOLIC... 98 C c complex... 219 cabergoline... 72 CABOMETYX... 33 ca-d3-mag ox-zinc-cop-mangbor... 202, 207 caffeine citrated... 111 caffeine-sodium benzoate... 111 calci-chew... 160 calcidol... 219 calcipotriene... 135 calcitonin (salmon)... 189 calcitrate... 199 calcitrate-vitamin d... 199 calcitrene... 135 calcitriol... 135, 189 calcium 500 + d (d3)... 200 calcium 600... 199 calcium 600 + d(3)... 199 calcium 600 with vitamin d3 203 calcium acetate... 169 calcium antacid... 160 calcium carbonate... 160, 200 calcium carbonate-vitamin d2... 200 calcium carbonate-vitamin d3... 199, 200, 201, 202, 208 CALCIUM CARBONATE- VITAMIN D3... 160 calcium chloride... 200 calcium citrate-vitamin d3.. 200, 202 calcium gluconate... 200 calcium+d... 209 CALDOLOR... 12 cal-gest antacid... 160 calphron... 169 CALTRATE 600 + D... 200 CALTRATE WITH VITAMIN D3... 200 camila... 114 camrese... 114 camrese lo... 114 CANCIDAS... 56 candesartan... 95 candesartan-hydrochlorothiazid... 95 capacet... 4 CAPASTAT... 68 CAPRELSA... 33 captopril... 96 captopril-hydrochlorothiazide 96 CARAFATE... 157 CARBAGLU... 160 carbamazepine... 43 carbidopa... 72 carbidopa-levodopa... 72 carbidopa-levodopa-entacapone... 72 CARIMUNE NF NANOFILTERED... 178 carisoprodol... 213 carteolol... 148 cartia xt... 100 carvedilol... 98 CASTELLANI PAINT MODIFIED... 135 CAYSTON... 26 caziant (28)... 114 cefaclor... 22 cefadroxil... 22 cefazolin... 22 cefazolin in dextrose (iso-os). 22 cefdinir... 22, 23 cefditoren pivoxil... 23 cefepime... 23 CEFEPIME IN DEXTROSE 5 %... 23 CEFEPIME IN DEXTROSE,ISO-OSM... 23 cefotaxime... 23 cefoxitin... 23 cefoxitin in dextrose, iso-osm 23 cefpodoxime... 23 cefprozil... 23 ceftazidime... 23 ceftibuten... 23 ceftriaxone... 24 ceftriaxone in dextrose,iso-os. 24 cefuroxime axetil... 24 cefuroxime sodium... 24 celecoxib... 12 CELLCEPT INTRAVENOUS... 178 CELONTIN... 43 centamin... 219 centergy dm... 124 central vite with lutein... 232 I-4 Formulario ICS Community Care Plus FIDA-MMP per il 2016 ID del formulario:16508.000, Versione: 19 In vigore da: 1 Dicembre 2016
central-vite... 232 central-vite for seniors... 219 central-vite select... 223, 232 central-vite senior... 232 centram-care... 219 centravites 50 plus... 219 centrum... 220 centrum complete... 219 centrum silver... 220 century... 226 century adults 50+... 220 century mature... 220, 223, 226 century ultimate women's... 220 cephalexin... 24 CEPROTIN (BLUE BAR)... 84 CERDELGA... 192 CEREZYME... 146 cerovite... 220 cerovite advanced formula... 220 certavite senior-antioxidant.. 220 certavite-antioxid (iron gluc) 220 certavite-antioxidant... 220 CERVARIX VACCINE (PF)... 183 cetirizine... 61 cetirizine-pseudoephedrine... 61 CETYLEV... 192 cevimeline... 134 CHANTIX... 16 CHANTIX CONTINUING MONTH BOX... 16 CHANTIX STARTING MONTH BOX... 16 cheracol d... 124 cheratussin dac... 124 chest congestion relief + dm 125 chest congestion relief pe... 125 chewable multi vitamin... 224 child allergy relf(cetirizine)... 62 child complete multivitamin 223 child cough and sore throat.. 125 child mucinex chest congestion... 124 child plus cough and runnynose... 129 child triaminic cold-allergy... 61 child triaminic cough-congest... 124 child triaminic cough-sore thr... 124 child vitamin with minerals.. 221 child wal-tap cold-allergy... 61 child wal-tussin cough relief 124 CHILDREN'S ADVIL... 12 children's allegra allergy... 61 children's aller-tec... 62 children's chest congestion... 125 children's chewable... 231 children's chewable complete... 221 children's chewable vitamin. 220 children's chewable w/minerals... 224 CHILDREN'S CLARITIN61, 62 children's cold-cough daytime... 125 children's complete vitamin. 231 children's mapap... 5 children's mucinex cough... 124 children's multivit w/extra c. 224 children's non-aspirin... 5 children's pain reliever... 11 children's pain-fever relief... 5 children's pepto... 160 childrens plus multi-symp cold... 131 children's silfedrine... 124 children's soothe... 160 children's sudafed... 124 children's sudafed pe cough. 124 children's tactinal... 5 children's wal-dryl allergy... 62 children's wal-zyr... 62 CHILDREN'S ZYRTEC ALLERGY... 62 childs chew vite... 220 child's vitamin with iron... 221 child's vitamin with vitamin c... 221 childs/iron... 220 chlophedianol-guaifenesin... 122 chloramphenicol sod succinate... 19 chlordiazepoxide hcl... 18 chlorhexidine gluconate... 134 chloroquine phosphate... 71 chlorothiazide... 105 chlorothiazide sodium... 106 chlorpheniramine-phenyleph-dm... 122 chlorpromazine... 74 chlorthalidone... 106 chlorzoxazone... 214 cholecalciferol (vitamin d3) 222, 239 cholestyramine (with sugar). 107 cholestyramine light... 107 choline,magnesium salicylate 12 ciclopirox... 56 ciclopirox-ure-camph-menth-euc... 56 cilostazol... 88 cimetidine... 157 cimetidine hcl... 157 CIMZIA... 178 CIMZIA POWDER FOR RECONST... 178 CINQAIR... 213 CINRYZE... 86 CIPRODEX... 152 ciprofloxacin... 29 ciprofloxacin hcl... 29, 152 ciprofloxacin in 5 % dextrose 29 ciprofloxacin lactate... 29 citalopram... 48 I-5 Formulario ICS Community Care Plus FIDA-MMP per il 2016 ID del formulario:16508.000, Versione: 19 In vigore da: 1 Dicembre 2016
citracal + d maximum... 200 citrus calcium... 200 clarithromycin... 25 CLARITIN... 62 CLARITIN LIQUI-GEL... 62 CLARITIN REDITABS... 62 clearlax... 169 CLEVIPREX... 105 clindamycin hcl... 20 clindamycin in 5 % dextrose.. 20 clindamycin palmitate hcl... 19 clindamycin pediatric... 20 clindamycin phosphate... 20, 66, 138 CLINIMIX 5%/D15W SULFITE FREE... 90 CLINIMIX 5%/D25W SULFITE-FREE... 90 CLINIMIX 2.75%/D5W SULFIT FREE... 90 CLINIMIX 4.25%/D10W SULF FREE... 90 CLINIMIX 4.25%/D5W SULFIT FREE... 90 CLINIMIX 4.25%-D20W SULF-FREE... 90 CLINIMIX 4.25%-D25W SULF-FREE... 90 CLINIMIX 5%- D20W(SULFITE-FREE)... 90 CLINIMIX E 2.75%/D10W SUL FREE... 91 CLINIMIX E 2.75%/D5W SULF FREE... 91 CLINIMIX E 4.25%/D10W SUL FREE... 91 CLINIMIX E 4.25%/D25W SUL FREE... 91 CLINIMIX E 4.25%/D5W SULF FREE... 91 CLINIMIX E 5%/D15W SULFIT FREE... 91 CLINIMIX E 5%/D20W SULFIT FREE... 91 CLINIMIX E 5%/D25W SULFIT FREE... 91 CLINISOL SF 15 %... 91 clobetasol... 140, 141 clobetasol-emollient... 141 clocortolone pivalate... 141 clomipramine... 49 clonazepam... 18 clonidine... 94 clonidine hcl... 94, 111 clopidogrel... 88 clorazepate dipotassium... 18 clorpres... 94 clotrimazole... 56, 57 clotrimazole-7... 57 clotrimazole-betamethasone... 57 clozapine... 74 COARTEM... 71 codeine sulfate... 5 codituss dm... 124 COLACE... 165 colchicine... 192 cold and cough (diphenhydr-pe)... 62 cold and cough (pe-dm)... 131 cold multi-symptom day/night... 124 cold relief m/s day/night... 124 cold-allergy-sinus... 62 cold-flu relief... 125 cold-flu relief, day/night... 124 colestipol... 107 colistin (colistimethate na)... 20 colocort... 141 COLY-MYCIN S... 152 COMBIGAN... 198 COMBIPATCH... 172 COMBIVENT RESPIMAT. 211 COMETRIQ... 33 comfort gel... 160 comfort gel extra strength... 160 COMPLERA... 78 complete 50+... 226 complete multi 50+... 220 complete multivitamin. 220, 223 complete multivitamin-mineral... 223, 233 complete senior... 221, 233 compoz... 62 compro... 68 COMVAX (PF)... 183 CONDYLOX... 136 congestac... 125 congest-eze... 125 constulose... 160 COPAXONE... 192 coricidin hbp... 125 coricidin hbp cold-multi sympt... 125 CORLANOR... 101 cormax... 141 cortisone... 173 cortizone-10... 141 CORTIZONE-10... 141 COSENTYX... 136 COSENTYX (2 SYRINGES)... 136 COSENTYX PEN... 136 COSENTYX PEN (2 PENS) 136 COTELLIC... 33 cough and cold... 125 cough and runny nose... 131 CREON... 146 critic-aid clear af... 57 CRIXIVAN... 78 cromolyn... 148, 160, 213 cryselle (28)... 114 CUBICIN... 20 cutter backwoods... 136 cutter skinsations... 136 cyanocobalamin (vitamin b-12)... 218, 222, 232, 238 I-6 Formulario ICS Community Care Plus FIDA-MMP per il 2016 ID del formulario:16508.000, Versione: 19 In vigore da: 1 Dicembre 2016
cyclafem 1/35 (28)... 114 cyclafem 7/7/7 (28)... 114 cyclobenzaprine... 214 cyclopentolate... 149 cyclophosphamide... 33 CYCLOPHOSPHAMIDE... 33 CYCLOSET... 52 cyclosporine... 179 cyclosporine modified... 179 cyproheptadine... 63 CYRAMZA... 33 cyred... 114 CYSTADANE... 192 CYSTARAN... 149 cysteine (l-cysteine)... 91 D d10 %-0.45 % sodium chloride... 201 d2.5 %-0.45 % sodium chloride... 201 d3 dots... 222 d5 % and 0.9 % sodium chloride... 201 d5 %-0.45 % sodium chloride... 201 dactinomycin... 33 daily gummies... 221 daily multiple... 221, 222 daily multi-vitamin... 228 daily multivitamin with iron 223 daily multi-vitamins/iron... 222 daily teen multi-vitamin... 221 daily value... 223 daily vitamin... 223 daily vitamin formula... 223 daily vitamin formula + iron 223 daily vitamin formula-minerals... 223 daily vitamin with iron... 223 daily vites/iron... 223 dailyhist-1... 63 daily-vite... 223 DAKLINZA... 82 DALIRESP... 213 danazol... 171 dantrolene... 214 dapsone... 68 DAPTACEL (DTAP PEDIATRIC) (PF)... 183 daptomycin... 20 DARAPRIM... 71 DARZALEX... 33 dasetta 1/35 (28)... 115 dasetta 7/7/7 (28)... 115 dayhist allergy... 63 daysee... 115 daytime cold and cough... 125 daytime cold-flu... 126 day-time cough... 126 daytime-nighttime... 129 daytime-nighttime cold-flu.. 125 daytime-nighttime cough... 126 deblitane... 115 decitabine... 33 decongestant cough... 131 deep sea nasal... 149 deferoxamine... 170 delsym cough-chest congest dm... 126 delyla (28)... 115 DELZICOL... 188 DEMSER... 101 DEPEN TITRATABS... 170 DEPO-PROVERA... 177 dermafungal... 57 dermarest eczema (hydrocort)... 141 DESCOVY... 78 desipramine... 49 desmopressin... 175 desog-e.estradiol/e.estradiol. 115 desogestrel-ethinyl estradiol 115 desonide... 141 desoximetasone... 141 despec-dm (pseudoeph-dmguaif)... 126 dex4 glucose... 92 dexamethasone... 173, 174 dexamethasone sodium phosphate... 155, 174 dexmethylphenidate... 111 dextroamphetamine... 111 dextroamphetamineamphetamine... 111 dextromethorphan polistirex 126 dextrose 10 % and 0.2 % nacl... 201 dextrose 10 % in water (d10w)... 92 dextrose 20 % in water (d20w)... 92 dextrose 25 % in water (d25w)... 92 dextrose 40 % in water (d40w)... 92 dextrose 5 % in ringers... 92 dextrose 5 % in water (d5w).. 92 dextrose 5 %-lactated ringers201 dextrose 5%-0.2 % sod chloride... 201 dextrose 5%-0.3 % sod.chloride... 201 dextrose 50 % in water (d50w)... 92 dextrose 70 % in water (d70w)... 92 dextrose with sodium chloride... 201 dextrose-kcl-nacl... 201 diabetic tussin dm... 126 diamode... 161 diazepam... 18 diazepam intensol... 18 diclofenac potassium... 13 diclofenac sodium... 13, 155 diclofenac-misoprostol... 13 I-7 Formulario ICS Community Care Plus FIDA-MMP per il 2016 ID del formulario:16508.000, Versione: 19 In vigore da: 1 Dicembre 2016
dicloxacillin... 28 dicyclomine... 161 didanosine... 78 DIFICID... 25 diflunisal... 13 digitek... 101 digox... 101, 102 digoxin... 102 DIGOXIN... 102 dihydroergotamine... 67 DILANTIN... 43 diltiazem hcl... 100 dilt-xr... 100 dimaphen (pe)... 63 dimenhydrinate... 69 dimetapp cold-congestion... 63 dino-life... 223 dino-life with extra c... 223 dino-life with iron-zinc... 223 DIPENTUM... 188 diphenhist... 63 diphenhydramine hcl... 63 diphenoxylate-atropine... 161 dipyridamole... 88 disopyramide phosphate... 97 disulfiram... 16 divalproex... 43 dobutamine... 102 dobutamine in d5w... 102 doc-q-lace... 165 docu... 166 docusate sodium... 166 docusol... 166 dofetilide... 97 dok... 166 donepezil... 47 dopamine... 103 dopamine in 5 % dextrose... 103 dorzolamide... 198 dorzolamide-timolol... 198 douche vinegar and water extra... 196 doxazosin... 94 doxepin... 49 doxercalciferol... 189 doxorubicin, peg-liposomal... 33 doxy-100... 30 doxycycline hyclate... 30 doxycycline monohydrate 30, 31 dramamine... 69 dramamine less drowsy... 69 driminate... 69 dristan long lasting... 149 dronabinol... 69 droperidol... 192 drospirenone-ethinyl estradiol... 115 DROXIA... 33 DUAVEE... 172 dulcolax stool softener (dss) 166 DULERA... 209 duloxetine... 49 DUREZOL... 155 dutasteride... 192 dutasteride-tamsulosin... 192 DYRENIUM... 106 E e.c. prin... 13 e.e.s. 400... 25 e.e.s. granules... 25 econazole... 57 econtra ez... 115 ed a-hist... 63 ed bron gp... 126 ed chlorped jr... 63 EDURANT... 78 effer-k... 201 EFFIENT... 88 ELAPRASE... 146 eldertonic... 223 electrolyte-48 in d5w... 201 ELIDEL... 141 ELIGARD... 34 ELIGARD (3 MONTH)... 34 ELIGARD (4 MONTH)... 34 ELIGARD (6 MONTH)... 34 elinest... 115 eliphos... 169 ELIQUIS... 84 ELITEK... 146 ELLA... 115 ellis tonic... 223 ELMIRON... 192 elon dual defense... 57 EMCYT... 34 EMEND... 69 emoquette... 115 EMPLICITI... 34 EMSAM... 49 EMTRIVA... 78 EMVERM... 71 enalapril maleate... 96 enalaprilat... 96 enalapril-hydrochlorothiazide 96 ENBREL... 179 ENBREL SURECLICK... 179 endocet... 5 endodan... 5 endur-acin... 107 enema... 166, 168 enema disposable... 165, 166 enemeez... 166 enemeez plus... 166 ENGERIX-B (PF)... 183 ENGERIX-B PEDIATRIC (PF)... 183 enoxaparin... 84 enpresse... 115 enskyce... 115 entacapone... 72 entecavir... 83 entre-cough... 126 ENTRESTO... 95 enulose... 161 ENVARSUS XR... 179 EPCLUSA... 82 I-8 Formulario ICS Community Care Plus FIDA-MMP per il 2016 ID del formulario:16508.000, Versione: 19 In vigore da: 1 Dicembre 2016
ephedrine sulfate... 103 epinastine... 149 epinephrine... 103 epinephrine hcl (pf)... 103 EPIPEN... 103 EPIPEN 2-PAK... 103 EPIPEN JR 2-PAK... 103 epitol... 43 EPIVIR HBV... 78 eplerenone... 109 EPOGEN... 86 epoprostenol (glycine)... 216 EPZICOM... 78 eq gentle... 149 equalactin... 166 ergocalciferol (vitamin d2). 224, 237 ergoloid... 192 ERGOMAR... 67 ERIVEDGE... 34 errin... 115 ery pads... 138 ery-tab... 25 ERY-TAB... 25 ERYTHROCIN... 25 erythrocin (as stearate)... 25 erythromycin... 26, 152 erythromycin ethylsuccinate. 25, 26 erythromycin with ethanol... 138 ESBRIET... 213 escitalopram oxalate... 49 esmolol... 98 esomeprazole sodium... 157 essentia... 224 essential balance with lutein 224 essential daily... 224 estarylla... 115 ESTRACE... 172 estradiol... 172 estradiol valerate... 172 estradiol-norethindrone acet. 172 estropipate... 172 eszopiclone... 214 ethambutol... 68 ethamolin... 103 ethosuximide... 43, 44 etodolac... 13 ETOPOPHOS... 34 etoposide... 34 EVOTAZ... 78 exemestane... 34 EXJADE... 170 EXONDYS 51... 192 expectorant... 126 expectorant dm... 126 expectorant max strength... 126 EXTAVIA... 193 extra cleansing douche... 195 eye health plus lutein... 224 F FABRAZYME... 146 fallback solo... 115 falmina (28)... 115 famciclovir... 83 famotidine... 157, 158 famotidine (pf)... 157 famotidine (pf)-nacl (iso-os) 157 FANAPT... 74 FARESTON... 34 FARYDAK... 34 FASLODEX... 34 felbamate... 44 felodipine... 105 feminine care douche... 195 FEMRING... 173 femynor... 115 fenofibrate... 107 fenofibrate micronized... 107 fenofibrate nanocrystallized. 107 fenofibric acid... 107 fenofibric acid (choline)... 107 fenoprofen... 13 fentanyl... 5 fentanyl citrate... 5 ferocon... 224 ferretts... 224 ferrex 150... 224 ferrex 150 plus... 224 FERRIPROX... 170, 171 ferrocite... 224 ferrous fumarate... 225 ferrous gluconate... 225, 226 ferrous sulfate... 220, 225 FETZIMA... 49 feverall... 5 fexofenadine... 63, 64 fiber (calcium polycarbophil)... 166 fiber laxative (methylcellulo)169 fiber smooth... 169 fiber therapy (m-cell/sugar).. 166 fiber therapy (m-cellulose)... 165 fiber therapy (psyllium/sugar)... 166 fiber-lax... 166 fibertab... 166 finasteride... 193 FIRAZYR... 103 flanax antacid... 161 FLEBOGAMMA DIF... 179 flecainide... 97 FLECTOR... 13 FLEET BISACODYL... 166 flintstones complete (iron)... 225 flintstones multivitamin... 225 flintstones with iron... 225 flintstones/extra c... 225 FLOVENT DISKUS... 209, 210 FLOVENT HFA... 210 floxuridine... 34 flu formula daytime-nighttime... 129 flu relief therapy daytime... 129 flu severe cold-congestion... 131 flucaine... 149 I-9 Formulario ICS Community Care Plus FIDA-MMP per il 2016 ID del formulario:16508.000, Versione: 19 In vigore da: 1 Dicembre 2016
fluconazole... 57 fluconazole in dextrose(iso-o) 57 fluconazole in nacl (iso-osm) 57, 58 flucytosine... 58 fludrocortisone... 174 flumazenil... 111 flunisolide... 155 fluocinonide... 141 fluorometholone... 155 fluorouracil... 34, 35, 136 fluoxetine... 49 fluphenazine decanoate... 74 fluphenazine hcl... 74 flurbiprofen... 13 flurbiprofen sodium... 155 flutamide... 35 fluticasone... 141, 155 fluvoxamine... 50 foaming antacid... 161, 164 folic acid... 225 FOLIC ACID... 225 fomepizole... 193 fondaparinux... 84 foot odor control... 59 FORTEO... 190 FORTICAL... 190 foscarnet... 81 fosfree... 225 fosinopril... 96 fosinopril-hydrochlorothiazide... 96 fosphenytoin... 44 FREAMINE HBC 6.9 %... 92 FREAMINE III 10 %... 92 fungi cure... 58 FUNGI-NAIL... 58 fungoid-d... 58 furosemide... 106 FUSILEV... 193 FUZEON... 78 FYCOMPA... 44 G gabapentin... 44 GABITRIL... 44 galantamine... 47 GAMASTAN S/D... 179 GAMMAGARD LIQUID... 179 GAMMAPLEX... 179 ganciclovir sodium... 83 GARDASIL (PF)... 183, 184 GARDASIL 9 (PF)... 184 gas relief... 156 gas relief extra strength... 156 gas-x ultra-strength... 156 gatifloxacin... 152 GATTEX 30-VIAL... 161 GATTEX ONE-VIAL... 161 GAUZE PAD... 193 gavilyte-c... 166 gavilyte-g... 166 gavilyte-n... 167 GAZYVA... 35 gelusil antacid and anti-gas.. 161 gemfibrozil... 107 generlac... 161 gengraf... 179 GENOTROPIN... 175 GENOTROPIN MINIQUICK... 175 gentak... 152 gentamicin... 19, 138, 139, 152, 153 gentamicin in nacl (iso-osm).. 19 gentamicin sulfate (ped) (pf).. 19 gentamicin sulfate (pf)... 19 GENTEAL MILD TO MODERATE... 149 GENTEAL GEL... 149 GENTEAL MILD... 149 GENTEAL SEVERE... 149 genteal tears... 149 gentlelax... 167 GENVOYA... 78 GEODON... 74 geravim... 225 geriaton... 225 geri-hydrolac... 136 geri-tussin dm... 126 gianvi (28)... 115 gildagia... 115 gildess 1.5/30 (21)... 116 gildess 1/20 (21)... 116 gildess 24 fe... 116 gildess fe 1.5/30 (28)... 116 gildess fe 1/20 (28)... 116 GILENYA... 193 GILOTRIF... 35 GLEOSTINE... 35 glimepiride... 55 glipizide... 55 glipizide-metformin... 55 GLUCAGEN HYPOKIT... 193 GLUCAGON EMERGENCY KIT (HUMAN)... 193 gluco burst... 92 glucose... 92 glucose gel... 92 glutose 15... 93 glyburide... 55 glyburide micronized... 55 glyburide-metformin... 56 glycolax... 167 glycopyrrolate... 161, 162 glydo... 15 GLYXAMBI... 52 granisetron (pf)... 69 granisetron hcl... 69 GRANIX... 86 griseofulvin microsize... 58 guaifenesin... 126 guaifenesin dac... 126 guanfacine... 94, 111 guanidine... 193 gummi bear multivitamin... 226, 230 I-10 Formulario ICS Community Care Plus FIDA-MMP per il 2016 ID del formulario:16508.000, Versione: 19 In vigore da: 1 Dicembre 2016
gummy swirls... 221 H hair vitamins... 226 hair,skin and nails... 233, 236 halobetasol propionate... 142 haloperidol... 75 haloperidol decanoate... 74, 75 haloperidol lactate... 75 HARVONI... 82 HAVRIX (PF)... 184 head congestion day-night... 127 healthy eyes... 226 healthylax... 167 heather... 116 hemocyte... 226 heparin (porcine)... 85 heparin (porcine) in 5 % dex.. 85 heparin (porcine) in nacl (pf). 85 heparin(porcine) in 0.45% nacl... 85 heparin, porcine (pf)... 85 HEPATAMINE 8%... 93 HEPATASOL 8 %... 93 HERCEPTIN... 35 HETLIOZ... 214 HEXALEN... 35 hi-b complex... 226 HIBERIX (PF)... 184 hi-cal plus vit d... 207 homatropaire... 149 homatropine hbr... 149 honey bears... 226 honey bears with iron-zinc... 226 HUMIRA... 180 HUMIRA PEDIATRIC CROHN'S START... 180 HUMIRA PEN... 180 HUMIRA PEN CROHN'S-UC- HS START... 180 HUMIRA PEN PSORIASIS- UVEITIS... 180 HUMULIN R U-500 (CONC) KWIKPEN... 54 HUMULIN R U-500 (CONCENTRATED)... 54 hydralazine... 103 hydrochlorothiazide... 106 hydrocil instant... 167 hydrocodone-acetaminophen... 6 hydrocodone-chlorpheniramine... 127 hydrocodone-homatropine... 127 hydrocodone-ibuprofen... 6 hydrocortisone... 142, 174 hydrocortisone acet-aloe vera... 142 hydrocortisone acetate... 142 hydrocortisone butyrate... 142 hydrocortisone butyr-emollient... 142 hydrocortisone valerate... 143 hydromet... 127 hydromorphone... 6 hydromorphone (pf)... 6 hydroskin... 142 hydroxychloroquine... 71 hydroxyprogesterone caproate... 177 hydroxyurea... 35 hydroxyzine hcl... 193 hydroxyzine pamoate... 193 HYPERLYTE CR... 202 HYPERRAB S/D (PF)... 180 HYQVIA... 180 HYQVIA IG COMPONENT... 180 HYSINGLA ER... 6 I ibandronate... 190 IBRANCE... 35 ibuprofen... 12, 13, 14, 15 ibuprofen jr strength... 13 icaps plus... 226 ICLUSIG... 35 iferex 150... 226 ifosfamide... 35 ifosfamide-mesna... 35 ILARIS (PF)... 181 ILEVRO... 155 imatinib... 35 IMBRUVICA... 35 imipenem-cilastatin... 26 imipramine hcl... 50 imipramine pamoate... 50 imiquimod... 136 IMLYGIC... 36 imodium a-d... 162 IMODIUM A-D... 162 IMOGAM RABIES-HT (PF)... 181 IMOVAX RABIES VACCINE (PF)... 184 INCRELEX... 175 indapamide... 106 indomethacin... 14 indomethacin sodium... 14 INFANRIX (DTAP) (PF)... 184 infants gas relief... 156 infant's ibuprofen... 14 INFANT'S MOTRIN... 14 infants' non-aspirin cold... 133 INFLECTRA... 193 INLYTA... 36 INSECT REPELLENT (PICARIDIN)... 136 insta-glucose... 93 INSULIN SYRINGE-NEEDLE U-100... 145 INTELENCE... 78 INTRALIPID... 93 INTRON A... 82, 83 introvale... 116 INVANZ... 26 INVEGA SUSTENNA... 75 INVEGA TRINZA... 75 I-11 Formulario ICS Community Care Plus FIDA-MMP per il 2016 ID del formulario:16508.000, Versione: 19 In vigore da: 1 Dicembre 2016
INVIRASE... 78 INVOKAMET... 52 INVOKAMET XR... 52 INVOKANA... 52 inzo antifungal... 58 iodine... 145 IONOSOL-B IN D5W... 202 IONOSOL-MB IN D5W... 202 IPOL... 184 ipratropium bromide... 150, 211 ipratropium-albuterol... 211 IPRIVASK... 85 irbesartan... 95 irbesartan-hydrochlorothiazide... 95 IRESSA... 36 iron high potency... 221 ISENTRESS... 78, 79 ISOLYTE M IN 5 % DEXTROSE... 202 ISOLYTE-H IN 5 % DEXTROSE... 202 ISOLYTE-P IN 5 % DEXTROSE... 202 ISOLYTE-S... 202 isoniazid... 68 isopto tears... 150 isosorbide dinitrate... 109, 110 isosorbide mononitrate... 110 isradipine... 105 itraconazole... 58 ivermectin... 71 IXEMPRA... 36 IXIARO (PF)... 184 J JAKAFI... 36 jantoven... 85 JANUMET... 52 JANUMET XR... 52 JANUVIA... 52 JARDIANCE... 52 jencycla... 116 JENTADUETO... 52 JENTADUETO XR... 53 jolessa... 116 jolivette... 116 jr. acetaminophen... 10 juleber... 116 junel 1.5/30 (21)... 116 junel 1/20 (21)... 116 junel fe 1.5/30 (28)... 116 junel fe 1/20 (28)... 116 junel fe 24... 116 junior mapap... 6 JUXTAPID... 107 K KABIVEN... 93 KALETRA... 79 KALYDECO... 213 KANUMA... 146 kaopectate (bismuth subsalicy)... 162 kariva (28)... 116 k-effervescent... 202 kelnor 1/35 (28)... 116 KELP (IODINE)... 203 ketoconazole... 58 ketoprofen... 14 ketorolac... 14, 155 KEVEYIS... 193 KEYTRUDA... 36 kids mini enema... 165 kid's vitamins... 230 kid's vitamins + extra c... 230 kids vitamins + iron... 231 kid's vitamins + iron... 230 kimidess (28)... 116 KINERET... 181 KINRIX (PF)... 185 kionex... 162 kionex (with sorbitol)... 162 KLOR-CON 10... 203 klor-con m10... 203 klor-con m15... 203 klor-con m20... 203 klor-con sprinkle... 203 konsyl (sugar)... 167 konsyl fiber... 167 KONSYL SUGAR-FREE... 167 KORLYM... 53 KRYSTEXXA... 146 kurvelo... 117 KUVAN... 146 KYNAMRO... 108 KYPROLIS... 36 L l norgest/e.estradiol-e.estrad. 117 labetalol... 98 LACRISERT... 150 LACTATED RINGERS... 189 LACTINOL HX... 136 lactulose... 162 LAMICTAL... 44 LAMISIL (AEROSOL)... 58 lamisil af... 58 LAMISIL AT... 58 lamivudine... 79 lamivudine-zidovudine... 79 lamotrigine... 44 LANOXIN... 104 lansoprazole... 157 LANTUS... 54 LANTUS SOLOSTAR... 54 larin 1.5/30 (21)... 117 larin 1/20 (21)... 117 larin 24 fe... 117 larin fe 1.5/30 (28)... 117 larin fe 1/20 (28)... 117 larissia... 117 LARTRUVO... 36 latanoprost... 198 LATUDA... 75 laxative peg 3350... 168 LAZANDA... 6 leena 28... 117 leflunomide... 181 I-12 Formulario ICS Community Care Plus FIDA-MMP per il 2016 ID del formulario:16508.000, Versione: 19 In vigore da: 1 Dicembre 2016
LEMTRADA... 193 LENVIMA... 37 lessina... 117 LETAIRIS... 216 letrozole... 37 leucovorin calcium... 193, 194 LEUKERAN... 37 LEUKINE... 86 leuprolide... 37 levetiracetam... 45 levobunolol... 198 levocarnitine... 194 levocarnitine (with sugar)... 194 levocetirizine... 64 levofloxacin... 29, 153 levofloxacin in d5w... 29 levoleucovorin... 194 levonest (28)... 117 levonorgestrel... 117 levonorgestrel-ethinyl estrad 117 levonorg-eth estrad triphasic 118 levora-28... 118 levothyroxine... 177, 178 LEXIVA... 79 lice cream rinse... 144 lice killing... 144 lice treatment... 144 lice treatment (permethrin).. 144 lidocaine... 15 lidocaine (pf)... 15, 97 lidocaine hcl... 15 lidocaine in 5 % dextrose (pf) 97 lidocaine viscous... 15 lidocaine-prilocaine... 16 life-pack women's... 227 linezolid... 20 LINZESS... 162 liothyronine... 178 lipodox... 37 lipodox 50... 37 liquibid d-r... 127 liquid antacid extra strength. 159 liquid calcium with vitamin d... 203 LIQUI-E... 227 lisinopril... 96 lisinopril-hydrochlorothiazide 96 lithium carbonate... 112 lithium citrate... 112 little animals... 227 little animals-iron... 227 LIVALO... 108 lobana bath... 136 lohist-dm... 127 lomedia 24 fe... 118 lomustine... 37 LONSURF... 37 loperamide... 161, 162, 164 loratadine... 64 loratadine-d... 64 lorazepam... 18 lorcet (hydrocodone)... 7 lorcet hd... 7 lorcet plus... 7 lortuss ex... 127 loryna (28)... 118 losartan... 95 losartan-hydrochlorothiazide. 95 LOTEMAX... 155 LOTRONEX... 162 lovastatin... 108 low-ogestrel (28)... 118 loxapine succinate... 75 lubricant dry eye relief... 148 lubricant eye... 148 lubricant eye (cmc-glycer)(pf)... 150 lubricant eye (cmc-glycerin) 150 lubricant eye (pg-peg 400)... 151 lubricant eye (polyv alcohol) 151 lubricant eye (propyl glycol) 150 lubricant eye drops... 148 lubricant gel... 148 lubricating drops... 149 lubrifresh pm... 150 LUMIGAN... 198 LUPRON DEPOT... 37 LUPRON DEPOT (3 MONTH)... 37 LUPRON DEPOT (4 MONTH)... 37 LUPRON DEPOT (6 MONTH)... 37 LUPRON DEPOT-PED... 175 LUPRON DEPOT-PED (3 MONTH)... 175 lutera (28)... 118 LYNPARZA... 38 LYRICA... 45 lysiplex plus... 227 LYSODREN... 38 lyza... 118 M maalox advanced... 162 MACUVITE... 227 MACUVITE EYE CARE... 227 mag 64... 203 mag-delay... 203 mag-g... 203 MAGNEBIND 300... 162 magnebind 400... 169 magnesium... 201, 203 magnesium (oxide/aa chelate)... 203 magnesium chloride... 203 magnesium gluconate... 203 magnesium oxide. 162, 163, 164 magnesium sulfate... 204 magnesium sulfate in d5w... 204 magnesium sulfate in water.. 204 malathion... 144 mapap (acetaminophen)... 7 mapap arthritis pain... 7 mapap extra strength... 7 maprotiline... 50 mar-cof bp... 127 I-13 Formulario ICS Community Care Plus FIDA-MMP per il 2016 ID del formulario:16508.000, Versione: 19 In vigore da: 1 Dicembre 2016
mar-cof cg... 127 margesic... 7 marlissa... 118 MARPLAN... 50 masanti double strength... 163 MATULANE... 38 matzim la... 100 maximum daily multivitamin... 231 maximum strength flu... 129 meclizine... 69 medroxyprogesterone... 177 mefenamic acid... 14 mefloquine... 71 MEFOXIN IN DEXTROSE (ISO-OSM)... 24 mega multiple/chelated mineral... 227 mega multivitamin with mineral... 227 MEGACE ES... 177 megestrol... 38, 177 MEKINIST... 38 meloxicam... 14 memantine... 47 MENACTRA (PF)... 185 M-END DM... 127 MENEST... 173 MENHIBRIX (PF)... 185 MENOMUNE - A/C/Y/W-135 (PF)... 185 men's daily gummies... 221 men's multi-vitamin... 221 men's one daily... 224 MENVEO A-C-Y-W-135-DIP (PF)... 185 MENVEO MENA COMPONENT (PF)... 185 MENVEO MENCYW-135 COMPNT (PF)... 185 MEPHYTON... 227 mercaptopurine... 38 meropenem... 26 mesalamine... 188 mesehist dm... 127 mesna... 194 MESNEX... 194 MESTINON... 194 MESTINON TIMESPAN... 194 metaproterenol... 211 metaxall... 214 metaxalone... 214 metformin... 53 methadone... 7 methadose... 7 methazolamide... 198 methenamine hippurate... 20 methimazole... 178 methocarbamol... 214 methotrexate sodium... 38 methotrexate sodium (pf)... 38 methoxsalen rapid... 136 methscopolamine... 163 methyclothiazide... 106 methylphenidate... 112 methylprednisolone... 174 methylprednisolone acetate.. 174 methylprednisolone sodium succ... 174 metipranolol... 198 metoclopramide hcl... 163 metolazone... 106 metoprolol succinate... 99 metoprolol ta-hydrochlorothiaz... 99 metoprolol tartrate... 99 metronidazole... 20, 66, 139 metronidazole in nacl (iso-os) 20 mexiletine... 97 mgo... 163 MIACALCIN... 190 mi-acid... 163 mi-acid gas relief... 156 micatin... 58 miconazole 7... 58 miconazole nitrate... 57, 58 miconazole-3... 58 microgestin 1.5/30 (21)... 118 microgestin 1/20 (21)... 118 microgestin fe 1.5/30 (28)... 118 microgestin fe 1/20 (28)... 118 midodrine... 94 miglitol... 53 milk of magnesia... 167 milltrium senior... 227 milrinone... 104 milrinone in 5 % dextrose... 104 mimvey... 173 mimvey lo... 173 mineral oil... 195, 197 MINERAL OIL... 194 mineral oil laxative... 167 minitran... 110 minocycline... 31 minoxidil... 110 mintox... 163 mintox maximum strength... 163 mintox plus... 163 MIRCERA... 86 mirtazapine... 50 misoprostol... 158 mitoxantrone... 38 M-M-R II (PF)... 185 moexipril... 96 moexipril-hydrochlorothiazide... 96 molindone... 75 mometasone... 143 MONISTAT 3... 59 monistat 7... 59 mono-linyah... 118 mononessa (28)... 118 montelukast... 210 morphine... 7, 8 MORPHINE... 8 morphine (pf) in 0.9 % nacl... 7 I-14 Formulario ICS Community Care Plus FIDA-MMP per il 2016 ID del formulario:16508.000, Versione: 19 In vigore da: 1 Dicembre 2016
morphine concentrate... 8 morphine in dextrose 5 %... 8 morrhuate sodium... 194 motion sickness... 68 motion sickness (meclizine)... 69 MOVANTIK... 163 MOVIPREP... 167 MOXEZA... 153 moxifloxacin... 29 MOZOBIL... 86 MUCINEX FAST-MAX COLD-FLU-THRT... 127 mucus dm... 127 mucus dm max... 127 mucus relief... 127, 129 mucus relief cough... 131 MULTAQ... 97 multi complete with iron... 227 multi-day with iron... 227 multi-delyn with iron... 227 multiple vitamin-minerals... 227 multiple vitamins... 227 multiple vitamins with iron.. 228 multi-symptom cold night time... 130 multivital platinum... 231 multivitamin 50 plus... 230 multi-vitamin hp/minerals... 228 multivitamin with fluoride... 228 multivitamin with iron. 227, 233 multivitamin with minerals.. 228 multi-vite... 231 multi-vite 50 and over... 231 mupirocin... 139 mupirocin calcium... 139 muro 128... 150 my favorite multiple... 228 my way... 118 myco nail a... 59 mycophenolate mofetil... 181 mycophenolate sodium... 181 MYOZYME... 146 MYRBETRIQ... 169 mytab gas... 156 mytab gas maximum strength... 156 my-vitalife... 228 myzilra... 118 N nabumetone... 14 nadolol... 99 nafcillin... 28 NAGLAZYME... 146 naloxone... 16 naltrexone... 16 NAMENDA XR... 47 NAMZARIC... 48 naphazoline... 150 naproxen... 14 naproxen sodium... 14 naratriptan... 67 NARCAN... 16 nasal and sinus decongestant 127 nasal decongestant (oxymetazl)... 150 NASCOBAL... 228 nasohist dm... 127 NATACYN... 153 nateglinide... 53 NATPARA... 190 NATRAPEL... 137 natural b-100... 239 natural b-100 complex... 233 natural balance... 150 natural calcium... 204 natural fiber laxative therapy 167 natural tears (pf)... 149 nature's tears (hypromellose) 150 NEBUPENT... 71 necon 0.5/35 (28)... 118 necon 1/35 (28)... 118 necon 1/50 (28)... 118 necon 10/11 (28)... 119 necon 7/7/7 (28)... 119 nefazodone... 50 NEO DM... 127 neomycin... 19 neomycin-bacitracin-poly-hc 153 neomycin-bacitracin-polymyxin... 153 neomycin-polymyxin b gu... 139 neomycin-polymyxin b- dexameth... 153 neomycin-polymyxingramicidin... 153 neomycin-polymyxin-hc... 153 neo-polycin... 154 neo-polycin hc... 153 neosporin (neo-bac-polym).. 139 neosporin anti-itch... 143 neo-synephrine 12 h spr (oxym)... 150 neo-tuss... 128 nephplex rx... 228 NEPHRAMINE 5.4 %... 93 nephron fa... 228 nephro-vite rx... 228 NEULASTA... 86 NEUMEGA... 87 NEUPOGEN... 87 NEUPRO... 72 NEVANAC... 155 nevirapine... 79 NEXAFED... 128 NEXAVAR... 38 next choice one dose... 119 niacin... 108 niacinamide... 108, 228 niacor... 108 nicardipine... 105 NICODERM CQ... 16, 17 nicorelief... 17 nicorette... 17 nicotine... 17 nicotine (polacrilex)... 17 NICOTROL... 17 I-15 Formulario ICS Community Care Plus FIDA-MMP per il 2016 ID del formulario:16508.000, Versione: 19 In vigore da: 1 Dicembre 2016
nifedical xl... 105 nifedipine... 105 night time... 129 night time cold medicine... 128 night time cold-flu... 131 night time cold-flu relief... 131 night time cough-sore throat 128 nighttime cough... 128 nikki (28)... 119 NILANDRON... 38 nilutamide... 38 NINLARO... 38 NITE TIME COLD-FLU RELIEF... 128 NITRO-BID... 110 nitrofurantoin macrocrystal... 21 nitrofurantoin monohyd/m-cryst... 21 nitroglycerin... 110 nitroglycerin in 5 % dextrose 110 NITROSTAT... 110 NIX CREME RINSE... 144 nohist-dm... 128 non-aspirin cold... 131 non-aspirin extra strength.. 8, 10 non-aspirin flu... 133 non-aspirin jr strength... 5 nora-be... 119 NORDITROPIN FLEXPRO 176 norepinephrine bitartrate... 104 norethindrone (contraceptive)... 119 norethindrone acetate... 177 norethindrone ac-eth estradiol... 119 norethindrone-e.estradiol-iron... 119 norgestimate-ethinyl estradiol... 119 norlyroc... 119 NORMOSOL-M IN 5 % DEXTROSE... 204 NORMOSOL-R PH 7.4... 204 nortemp... 8 NORTHERA... 94 nortrel 0.5/35 (28)... 119 nortrel 1/35 (21)... 119 nortrel 1/35 (28)... 119 nortrel 7/7/7 (28)... 119 nortriptyline... 50 NORVIR... 79 NOVOLIN 70/30... 54 NOVOLIN N... 54 NOVOLIN R... 54 NOVOLOG... 55 NOVOLOG FLEXPEN... 55 NOVOLOG MIX 70-30... 55 NOVOLOG MIX 70-30 FLEXPEN... 55 NOVOLOG PENFILL... 55 NOXAFIL... 59 NUCALA... 213 NUCYNTA... 9 NUCYNTA ER... 9 NUEDEXTA... 112 nu-iron... 228 NULOJIX... 181 nu-mag... 204 NUPLAZID... 75 NUTRESTORE... 163 NUTRILIPID... 93 NUTRILYTE... 204 NUTRILYTE II... 204 NUVARING... 119 nyamyc... 59 nystatin... 59 nystatin-triamcinolone... 59 nystop... 59 nyt-time sleep... 64 O OCALIVA... 163 ocean nasal... 150 ocella... 119 OCTAGAM... 181 octreotide acetate... 176 ocutabs... 228 ODEFSEY... 79 ODOMZO... 38 OFEV... 213 off active... 137 off deep woods... 137 off deep woods dry... 137 off familycare (with deet)... 137 ofloxacin... 29, 154 ogestrel (28)... 120 olanzapine... 75, 76 olanzapine-fluoxetine... 50 olopatadine... 150 OLYSIO... 82 omega-3 acid ethyl esters... 108 omeprazole... 158 omeprazole magnesium... 158 omeprazole-sodium bicarbonate... 158 ONCASPAR... 38 oncovite... 228 ondansetron... 70 ondansetron hcl... 70 ondansetron hcl (pf)... 69 one daily... 229, 232 one daily 50 plus... 224 one daily complete... 228 one daily energy... 232 one daily essential 224, 226, 229 one daily maximum (with ca)... 224 one daily multi-vit w-mineral... 229 one daily multivitamin... 229 one daily multivit-iron(folic) 229 one daily plus iron 226, 229, 232 one daily plus minerals... 229 one daily with iron... 229 one-a-day essential... 229 one-a-day maximum formula229 one-a-day teen advantage... 229 I-16 Formulario ICS Community Care Plus FIDA-MMP per il 2016 ID del formulario:16508.000, Versione: 19 In vigore da: 1 Dicembre 2016
ONFI... 18, 143 opcicon one-step... 120 OPDIVO... 39 OPSUMIT... 216 option 2... 120 opti-vitamins... 234 oral saline laxative... 167 oralone... 134 ORENCIA... 181 ORENCIA (WITH MALTOSE)... 181 ORENCIA CLICKJECT... 194 ORENITRAM... 216 ORFADIN... 146, 194 ORKAMBI... 213 orsythia... 120 OTEZLA... 194 OTEZLA STARTER... 194 OTREXUP (PF)... 195 oxacillin... 28 oxacillin in dextrose(iso-osm) 28 oxandrolone... 171 oxcarbazepine... 45 OXTELLAR XR... 45 oxybutynin chloride... 169, 170 oxycodone... 9 oxycodone-acetaminophen... 9 oxycodone-aspirin... 9 OXYCONTIN... 9, 10 oxymorphone... 10 oysco 500/d... 204 oysco d... 204 oysco-500... 204 oyster shell calcium 500... 205 oyster shell calcium-vit d2... 208 oyster shell calcium-vit d3... 205 oystercal-d... 205 P pacerone... 97 pain relief... 10 pain relief adult... 5 pain reliever jr strength... 11 paliperidone... 76 pancrelipase 5000... 146 PANRETIN... 137 PANTILINERS... 195 pantoprazole... 158 papaverine... 104 paricalcitol... 190 PARICALCITOL... 190 paromomycin... 71 paroxetine hcl... 50 PASER... 68 PATADAY... 150 PAXIL... 50 pecgen dmx... 128 pedia relief... 131 pedia relief cough-cold... 128 pedia relief infant... 133 pediacare multi-symptom cold... 128 PEDIARIX (PF)... 185 pediatric electrolyte... 201, 205, 208 pediatric freezer pops... 208 pediatric multivitamin.. 227, 233 PEDVAX HIB (PF)... 185 peg 3350-electrolytes... 167 PEGANONE... 45 PEGASYS... 83 PEGASYS PROCLICK... 83 peg-electrolyte soln... 167 PEGINTRON... 83 PEN NEEDLE, DIABETIC. 145 penicillin g pot in dextrose... 28 penicillin g potassium... 28 penicillin g procaine... 28 penicillin v potassium... 28, 29 PENTACEL (PF)... 186 PENTAM... 71 pentoxifylline... 88 pep-t-med... 163 peri-colace... 167 PERIKABIVEN... 93 perindopril erbumine... 96 periogard... 134 permethrin... 144 perphenazine... 76 perphenazine-amitriptyline... 51 persa-gel... 137 pfizerpen-g... 29 pharbetol... 10 pharmacist favorite multi-vit 229 phenadoz... 70 phenelzine... 51 phenobarbital... 45 phenobarbital sodium... 45 phenylephrine hcl... 94, 150 phenylhistine dh... 128 phenytoin... 45 phenytoin sodium... 46 phenytoin sodium extended... 46 philith... 120 phillips... 163 phillips liqui-gels... 167 PHOSLYRA... 169 PHOS-NAK... 205 phospha 250 neutral... 205 phosphate laxative... 168 PHOSPHOLINE IODIDE... 198 phytonadione (vitamin k1)... 239 PICATO... 137 pilocarpine hcl... 134, 198 pimozide... 76 pimtrea (28)... 120 pindolol... 99 pink bismuth... 163 pioglitazone... 53 pioglitazone-glimepiride... 53 pioglitazone-metformin... 53 piperacillin-tazobactam... 29 pirmella... 120 piroxicam... 15 PLAN B ONE-STEP... 120 PLASMA-LYTE 148... 205 PLASMA-LYTE A... 205 I-17 Formulario ICS Community Care Plus FIDA-MMP per il 2016 ID del formulario:16508.000, Versione: 19 In vigore da: 1 Dicembre 2016
PLASMA-LYTE-56 IN 5 % DEXTROSE... 205 PLEGRIDY... 195 podocon... 137 podofilox... 137 polyethylene glycol 3350... 168 poly-iron... 229 polymyxin b sulfate... 21 polymyxin b sulf-trimethoprim... 154 poly-tussin... 128 poly-vita... 229 poly-vita (iron)... 229 poly-vitamin... 230 poly-vitamin with iron... 230 poly-vitamins... 230 POMALYST... 39 portia... 120 PORTRAZZA... 39 potassium acetate... 205 potassium bicarb and chloride... 205 potassium bicarb-citric acid. 205 potassium chlorid-d5-0.45%nacl... 206 potassium chloride... 206, 207 potassium chloride in 0.9%nacl... 206 potassium chloride in 5 % dex... 206 potassium chloride in lr-d5.. 206 potassium chloride-0.45 % nacl... 206 potassium chloride-d5-0.2%nacl... 207 potassium chloride-d5-0.3%nacl... 207 potassium chloride-d5-0.9%nacl... 207 potassium citrate... 207 potassium citrate-citric acid. 207 potassium hydroxide... 137 potassium phosphate m-/d-basic... 207 POTIGA... 46 PRADAXA... 85 PRALUENT PEN... 108 PRALUENT SYRINGE... 108 pramipexole... 72 pravastatin... 108 prazosin... 94 prednicarbate... 143 prednisolone acetate... 155 prednisolone sodium phosphate... 155, 174 prednisone... 174 PREMARIN... 173 PREMASOL 10 %... 93 PREMASOL 6 %... 93 PREMPHASE... 173 PREMPRO... 173 prenatal... 226, 230, 234 prenatal formula... 231 prenatal plus (calcium carb). 229 prenatal tablet... 232 prenatal vit#96-ferrous fum-fa... 230 prenatal vitamin... 221, 230 prenatal vitamin plus low iron... 230 prenatal vitamin with minerals... 230 prenatal vit-iron fumarate-fa 230 preparation h hydrocortisone 143 PREVAIL BLADDER CONTROL PAD... 165 prevalite... 108 PREVIDENT 5000 SENSITIVE... 134 previfem... 120 PREZCOBIX... 79 PREZISTA... 79, 80 PRIFTIN... 68 PRILOSEC OTC... 158 PRIMAQUINE... 71 primidone... 46 PRISTIQ... 51 PRIVIGEN... 181 PROAIR HFA... 211 PROAIR RESPICLICK... 211 probenecid... 195 probenecid-colchicine... 195 procainamide... 97 PROCALAMINE 3%... 93 prochlorperazine... 70 prochlorperazine edisylate... 70 prochlorperazine maleate... 70 PROCRIT... 87 procto-med hc... 143 procto-pak... 143 proctosol hc... 143 proctozone-hc... 143 PROCYSBI... 195 progesterone in oil... 177 progesterone micronized... 177 PROGLYCEM... 110 PROGRAF... 181 PROLASTIN-C... 213 PROLENSA... 156 PROLEUKIN... 39 PROLIA... 190 PROMACTA... 87 promethazine... 64, 70 promethazine vc-codeine... 128 promethazine-codeine... 128 promethazine-dm... 128 promethegan... 70 promolaxin... 168 propafenone... 97, 98 propantheline... 42 proparacaine... 151 propranolol... 99 propranolol-hydrochlorothiazid... 99 propylthiouracil... 178 PROQUAD (PF)... 186 I-18 Formulario ICS Community Care Plus FIDA-MMP per il 2016 ID del formulario:16508.000, Versione: 19 In vigore da: 1 Dicembre 2016
prosight... 230 PROSOL 20 %... 93 protamine... 87 protriptyline... 51 pseudoephedrine hcl... 129 PULMOZYME... 146 pure and gentle eye... 151 purelax... 165 PURIXAN... 39 pyrazinamide... 68 pyridostigmine bromide... 195 pyridoxine (vitamin b6)... 231 Q q-dryl... 64 q-pap... 10 q-pap extra strength... 10 q-tapp dm... 129 q-tussin... 129 q-tussin dm... 129 QUADRACEL (PF)... 186 quasense... 120 quetiapine... 76 QUILLIVANT XR... 113 quinapril... 97 quinapril-hydrochlorothiazide 97 quinidine gluconate... 98 quinidine sulfate... 98 quinine sulfate... 71 QVAR... 210 R RABAVERT (PF)... 186 raloxifene... 173 ramipril... 97 RANEXA... 104 ranitidine hcl... 158 RAPAMUNE... 182 RASUVO (PF)... 195 RAVICTI... 164 RAYALDEE... 190 react... 120 REBIF (WITH ALBUMIN) 196 REBIF REBIDOSE... 196 REBIF TITRATION PACK 196 reclipsen (28)... 120 RECOMBIVAX HB (PF)... 186 recort plus... 143 refenesen... 130 refenesen pe... 130 REFRESH CELLUVISC... 151 REFRESH CLASSIC (PF)... 151 REFRESH LACRI-LUBE... 151 REFRESH OPTIVE... 151 REFRESH OPTIVE ADVANCED... 154 reguloid... 168 relcof c... 130 RELENZA DISKHALER... 81 RELISTOR... 164 remedy phytoplex antifungal. 60 REMICADE... 196 REMODULIN... 216 RENAGEL... 169 rena-vite rx... 232 RENVELA... 169 repaglinide... 53 repaglinide-metformin... 53 REPATHA PUSHTRONEX 108 REPATHA SURECLICK... 109 REPATHA SYRINGE... 109 repel sportsmen... 137 repel sportsmen max... 137 reprexain... 10 RESCRIPTOR... 80 RESTASIS... 156 RESTASIS MULTIDOSE... 156 retaine cmc... 151 RETROVIR... 80 revive plus... 149 REVLIMID... 39 revonto... 214 REXULTI... 76 REYATAZ... 80 REZIRA... 130 ribasphere... 83, 84 RIDAURA... 182 rifabutin... 68 rifampin... 68 RIFATER... 68 ri-gel ii... 164 riluzole... 113 rimantadine... 81 ri-mox... 164 ringers... 189, 208 risedronate... 190 RISPERDAL CONSTA... 76 risperidone... 76 RITUXAN... 39 rivastigmine... 48 rivastigmine tartrate... 48 rizatriptan... 67 robafen... 130 robafen cough... 130 robafen dm... 130 robitussin cough-chest cong dm... 130 ROBITUSSIN LONG-ACTING... 130 robitussin pediatric... 130 ropinirole... 72 rosadan... 139 rosuvastatin... 109 ROTARIX... 186 ROTATEQ VACCINE... 186 ROWEEPRA... 46 roxicet... 10 ROZEREM... 214 rydex... 130 rynex dm... 130 S SABRIL... 46 safe tussin dm... 130 SAIZEN... 176 SAIZEN CLICK.EASY... 176 saline mist... 151 SANDOSTATIN LAR DEPOT... 176 I-19 Formulario ICS Community Care Plus FIDA-MMP per il 2016 ID del formulario:16508.000, Versione: 19 In vigore da: 1 Dicembre 2016
SANTYL... 137 SAPHRIS (BLACK CHERRY)... 76 SAVELLA... 113 scooby-doo one a day... 232 scot-tussin dm... 131 scot-tussin expectorant... 130 sea soft nasal mist... 151 selegiline hcl... 72 selenium sulfide... 139 SELZENTRY... 80 senexon... 168 senior tabs... 233 senna... 168 senna lax... 168 senna laxative... 165 senna with docusate sodium. 166 senokot-s... 168 SENSIPAR... 196 sentry... 233 sentry senior... 233 SEREVENT DISKUS... 211 SEROSTIM... 176 sertraline... 51 setlakin... 120 sharobel... 120 SIGNIFOR... 196 silace... 168 siladryl sa... 64 silapap... 11 sildenafil... 216 SILENOR... 51 siltussin sa... 131 silver nitrate... 139 silver sulfadiazine... 139 SIMBRINZA... 198 simethicone... 156 simply sleep... 64 SIMPONI... 196 SIMPONI ARIA... 196 simvastatin... 109 sinus and allergy(pseudoephed)... 64 sirolimus... 182 SIRTURO... 68 skin treatment... 136 sleep aid (diphenhydramine).. 64 sleep aid (doxylamine)... 64 smoflipid... 93 smoothlax... 169 sodium acetate... 208 sodium bicarbonate... 164, 208 sodium chloride... 151, 189, 208, 213 sodium chloride 0.45 %... 208 sodium chloride 0.9 %... 208 sodium chloride 3 %... 208 sodium chloride 5 %... 208 sodium fluoride... 234 sodium lactate... 208 sodium phosphate... 208 sodium polystyrene (sorb free)... 164 sodium polystyrene sulfonate... 164 sodium thiosulfate... 171 SOLTAMOX... 39 SOLU-CORTEF (PF)... 174 SOMATULINE DEPOT... 177 SOMAVERT... 177 soothe (bismuth subsalicylate)... 164 soothe regular strength... 164 sorbitol... 189 sorbitol-mannitol... 189 sorine... 99 sotalol... 99 sotalol af... 99 SOVALDI... 82 spectravite... 222 spectravite adult 50+... 221 spectravite advanced formula... 221 spectravite senior... 222 spectravite senior w-lycopene... 222 spectravite ultra women... 222 SPIRIVA RESPIMAT... 211 SPIRIVA WITH HANDIHALER... 211 spironolactone... 109 spironolacton-hydrochlorothiaz... 109 sprintec (28)... 120 SPRITAM... 46 SPRYCEL... 39 sps (with sorbitol)... 165 sronyx... 120 ssd... 139 st joseph aspirin... 15 st. joseph aspirin... 15 stavudine... 80 STELARA... 196 STERILE PADS... 196 STIOLTO RESPIMAT... 42 STIVARGA... 39 stomach relief... 164 stool softener... 165 STRATTERA... 113 STRENSIQ... 147 streptomycin... 19 stress 500 plus zinc... 231 stress b with zinc... 234 stress b-biotin... 234 stress formula... 234 stress formula plus iron... 234 stress formula with iron 234, 235 stress formula with zinc... 234 STRIBILD... 80 STRIVERDI RESPIMAT... 212 sucralfate... 159 sudafed... 132 sudogest... 132 sudogest sinus and allergy... 65 sulfacetamide sodium... 154 I-20 Formulario ICS Community Care Plus FIDA-MMP per il 2016 ID del formulario:16508.000, Versione: 19 In vigore da: 1 Dicembre 2016
sulfacetamide sodium (acne) 139 sulfacetamide-prednisolone. 154 sulfadiazine... 30 sulfamethoxazole-trimethoprim... 30 sulfasalazine... 30 sulfatrim... 30 sulindac... 15 sumatriptan... 67 sumatriptan succinate... 67 summer's eve disposable douche... 197 summers eve extra cleansing 197 sunvite... 235 super b complex-vitamin c.. 222, 234, 235 super b maxi complex... 235 super b/c... 235 super b-50 complex... 235 super b-50 complex plus... 235 super multiple... 235 super multivitamin... 235 super quints... 235 super quints b-50... 235 super thera vite m... 235 superior 35... 235 superplex-t... 235 suphedrin... 132 suphedrine pe day-night... 132 suphedrine severe cold max str... 132 support... 235 support-500... 236 SUPPRELIN LA... 177 SUPRAX... 24 SURMONTIL... 51 SUSTIVA... 80 SUTENT... 39 syeda... 120 SYLATRON... 83 SYLVANT... 39 SYMLINPEN 120... 53 SYMLINPEN 60... 54 SYNAGIS... 81 SYNAREL... 197 SYNERCID... 21 SYNJARDY... 54 SYNRIBO... 39 SYPRINE... 171 SYSTANE (PROPYLENE GLYCOL)... 151 SYSTANE GEL... 151 T tab-a-vite... 236 tab-a-vite/iron... 236 tab-a-vite-minerals... 236 TABLOID... 39 tacrolimus... 143, 182 tactinal... 11 tactinal extra strength... 11 TAFINLAR... 39 TAGRISSO... 40 TALTZ AUTOINJECTOR.. 137 TALTZ SYRINGE... 137 TAMIFLU... 81, 82 tamoxifen... 40 tamsulosin... 170 TARCEVA... 40 TARGRETIN... 40 tarina fe 1/20 (28)... 120 TASIGNA... 40 tazicef... 24 TAZORAC... 144 taztia xt... 100 tears again... 151 tears again (pva)... 151 tears naturale free (pf)... 152 TECENTRIQ... 40 TECFIDERA... 197 TECHNIVIE... 82 TEFLARO... 24 telmisartan... 95 telmisartan-hydrochlorothiazid... 95 TEMODAR... 40 tencon... 11 TENIVAC (PF)... 186 terazosin... 170 terbinafine hcl... 60 terbutaline... 212 terconazole... 66 testosterone... 171, 172 testosterone cypionate... 171 testosterone enanthate... 171 TETANUS TOXOID,ADSORBED (PF)... 186 TETANUS,DIPHTHERIA TOX PED(PF)... 187 TETANUS-DIPHTHERIA TOXOIDS-TD... 187 tetrabenazine... 113 tetracaine hcl (pf)... 152 tetracycline... 31 THALOMID... 197 the magic bullet... 167 theochron... 212 theophylline... 212 theophylline in dextrose 5 % 212 thera m plus (ferrous fumarat)... 236 thera vitamin... 236 thera-d... 236 theradex m... 236 THERAFLU DAYTIME COLD-COUGH... 132 THERAFLU MULTI- SYMPTOM COLD... 132 thera-m... 236 therapeutic liquid... 227 therapeutic m + beta-carotene... 232 therapeutic-m... 236 therapeutic-m vitamin/minerals... 234 thera-tabs... 236 I-21 Formulario ICS Community Care Plus FIDA-MMP per il 2016 ID del formulario:16508.000, Versione: 19 In vigore da: 1 Dicembre 2016
theratrum complete 50 plus.. 236 theratrum complete 50 plus/lut... 236 thiamine hcl (vitamin b1)... 236 thioridazine... 76 thiotepa... 40 thiothixene... 77 tiagabine... 46 TICE BCG... 182 tilia fe... 120 timolol maleate... 99, 198 TIVICAY... 80 tizanidine... 214 TOBI PODHALER... 19 TOBRADEX... 154 TOBRADEX ST... 154 tobramycin... 154 tobramycin in 0.225 % nacl... 19 tobramycin in 0.9 % nacl... 19 tobramycin sulfate... 19 tobramycin-dexamethasone. 154 TOLAK... 137 tolazamide... 56 tolbutamide... 56 tolmetin... 15 tolnaftate... 60 tolterodine... 170 topiragen... 46 topiramate... 46 toposar... 40 torsemide... 106 total b/c... 236 totalday multiple... 236 TOUJEO SOLOSTAR... 55 TOVIAZ... 170 TPN ELECTROLYTES... 209 TPN ELECTROLYTES II... 209 TRACLEER... 216 TRADJENTA... 54 tramadol... 11 tramadol-acetaminophen... 11 trandolapril... 97 tranexamic acid... 87, 88 TRANSDERM-SCOP... 70 tranylcypromine... 51 TRAVASOL 10 %... 94 TRAVATAN Z... 199 travel sickness (meclizine)... 70 travoprost (benzalkonium)... 199 trazodone... 51 TREANDA... 40 TRECATOR... 68 TRELSTAR... 40, 41 tretinoin... 144 tretinoin (chemotherapy)... 41 tretinoin microspheres... 144 TREXALL... 41 triacting m-sym cold/cough. 133 triamcinolone acetonide... 134, 143, 175 triaminic cold and cough (pe)... 132 TRIAMINIC COLD AND COUGHNT(PE)... 65 TRIAMINIC COUGH-SORE THROAT... 132 triamterene-hydrochlorothiazid... 106 trianex... 143 TRIBENZOR... 95 tri-buffered aspirin... 15 tri-dex pe... 132 tri-estarylla... 120 trifluoperazine... 77 trifluridine... 154 trihexyphenidyl... 73 tri-legest fe... 121 tri-linyah... 121 tri-lo-estarylla... 121 tri-lo-marzia... 121 tri-lo-sprintec... 121 trilyte with flavor packets... 169 trimethoprim... 21 trimipramine... 51 trinessa (28)... 121 TRINTELLIX... 51 triple antibiotic... 138, 139 triple paste af... 60 tri-previfem (28)... 121 tri-sprintec (28)... 121 TRIUMEQ... 80 tri-vi-sol... 237 tri-vita... 237 tri-vitamin... 237 trivora (28)... 121 TROKENDI XR... 46 TROPHAMINE 10 %... 94 TROPHAMINE 6%... 94 trospium... 170 TRULICITY... 54 TRUMENBA... 187 TRUVADA... 80 trymine cg... 132 TUDORZA PRESSAIR... 212 tusnel diabetic... 132 TUSNEL NEW FORMULA 132 TUSNEL PEDIATRIC... 132 TUSSI PRES-B... 132 tussin cf... 132, 133 tussin cf cough-cold... 133 tussin cold-congestion... 133 tussin cough (dm only)... 125 tussin dm... 130, 133 tussin dm cough and chest... 125 tussin maximum strength... 130 tussin pe... 129 TWINRIX (PF)... 187 TYBOST... 197 TYGACIL... 31 TYKERB... 41 TYPHIM VI... 187 TYSABRI... 182 TYVASO... 216 TYVASO REFILL KIT... 216 TYVASO STARTER KIT... 216 TYZEKA... 84 I-22 Formulario ICS Community Care Plus FIDA-MMP per il 2016 ID del formulario:16508.000, Versione: 19 In vigore da: 1 Dicembre 2016
U u-cort... 144 ULORIC... 197 ultra b-100 complex... 237 ultra fresh pm... 152 ultra strength antacid... 159 unisom sleepgels... 65 UNITUXIN... 41 UPTRAVI... 217 ursodiol... 165 V VAGIFEM... 173 valacyclovir... 84 VALCHLOR... 138 valganciclovir... 84 valproate sodium... 47 valproic acid... 47 valproic acid (as sodium salt) 47 valsartan... 95 valsartan-hydrochlorothiazide 95 VALSTAR... 41 valu-tapp dm... 131 VANACOF... 133 vancomycin... 22 vancomycin in 0.9% sodium cl... 22 vancomycin in dextrose 5 %.. 21 VAQTA (PF)... 187 VARIVAX (PF)... 187 VASCEPA... 109 v-c forte... 237 VELCADE... 41 velivet triphasic regimen (28)... 121 VENCLEXTA... 41 VENCLEXTA STARTING PACK... 41 venlafaxine... 51 VENTOLIN HFA... 212 verapamil... 101 VERSACLOZ... 77 vestura (28)... 121 VGO 40... 145 VIBERZI... 165 vic-forte... 237 vicks dayquil cold-flu relief. 133 vicks dayquil cough... 133 vicks nature fusion cough... 133 vicks nyquil severe cold-flu. 133 vicks qlearquil(oxymetazoline)... 152 vicks sinex 12-hour... 152 vicodin... 11 vicodin es... 11 vicodin hp... 11 VICTOZA 3-PAK... 54 VIDEX 2 GRAM PEDIATRIC... 80 VIDEX 4 GRAM PEDIATRIC... 81 VIEKIRA PAK... 82 VIEKIRA XR... 82 vienva... 121 VIGAMOX... 154 VIIBRYD... 51, 52 VIMIZIM... 147 VIMPAT... 47 vinorelbine... 41 viorele (28)... 121 VIRACEPT... 81 VIRAMUNE XR... 81 VIRAZOLE... 84 virdec dm... 133 VIREAD... 81 virt-phos 250 neutral... 209 virtussin ac... 133 vision... 237 vision formula (with lutein) 222, 237 vision plus lutein... 237 vit b complex-folic acid... 234 VITAFOL FE+ (WITH DOCUSATE)... 237 vitalets... 237 vitamin a... 237 vitamin b complex... 218, 231 vitamin b-100 complex... 222 vitamin b12-folic acid... 238 vitamin b-6... 238 vitamin c... 232, 238, 239 vitamin d3... 234, 239 vitamins and minerals... 238 vitamins b complex... 218, 238 vitamins for hair... 239 VITEKTA... 81 vitrum senior... 239 VOLTAREN... 15 voriconazole... 60 VOTRIENT... 41 VPRIV... 147 VRAYLAR... 77 vyfemla (28)... 121 W wal-act d cold and allergy... 65 wal-dram... 70 wal-dryl allergy... 65 wal-fex allergy... 65 wal-finate... 65 wal-finate-d... 65 wal-itin... 65 wal-itin d... 65 wal-itin d 12 hour... 65 wal-phed... 65, 133 wal-phed pe day-night... 133 wal-phed pe sinus and allergy 65 wal-profen... 15 wal-sleep z... 66 wal-som (diphenhydramine).. 66 wal-som (doxylamine)... 66 wal-tap... 66 wal-tussin cough... 134 wal-tussin cough and cold cf 134 wal-tussin dm... 122 wal-zan 75... 159 wal-zyr (cetirizine)... 66 wal-zyr d... 66 I-23 Formulario ICS Community Care Plus FIDA-MMP per il 2016 ID del formulario:16508.000, Versione: 19 In vigore da: 1 Dicembre 2016
warfarin... 86 water for irrigation, sterile... 189 WELCHOL... 109 wera (28)... 121 womens daily gummies... 222 women's daily multivitamin. 231 X XALKORI... 41 XARELTO... 86 XELJANZ... 197 XELJANZ XR... 197 XIFAXAN... 22 XIIDRA... 156 XOLAIR... 213 XTANDI... 41 xulane... 121 xylon 10... 11 XYREM... 214 Y yelets... 2 YERVOY... 41 YF-VAX (PF)... 188 YONDELIS... 41 yuvafem... 173 Z zafirlukast... 210 zaleplon... 215 ZANTAC... 159 ZANTAC 75... 159 zarah... 121 ZARXIO... 87 ZAVESCA... 147 zebutal... 11 ZELBORAF... 42 ZEMPLAR... 191 zenatane... 138 zenchent (28)... 121 ZENPEP... 147 ZEPATIER... 82 zephrex-d... 134 ZETIA... 109 ZIAGEN... 81 zidovudine... 81 ZINBRYTA... 197 zinc oxide... 138 ziprasidone hcl... 77 ZIRGAN... 154 ZOLADEX... 42 zoledronic acid... 191 zoledronic acid-mannitol-water... 191 ZOLINZA... 42 zolmitriptan... 67 zolpidem... 215 ZOMETA... 191 ZONATUSS... 134 zonisamide... 47 zoo chews... 2 ZORTRESS... 182 ZOSTAVAX (PF)... 188 zovia 1/35e (28)... 121 zovia 1/50e (28)... 122 ZOVIRAX... 138 z-sleep... 64 ZUBSOLV... 17 ZYDELIG... 42 ZYKADIA... 42 ZYLET... 154 zyncof... 134 ZYPREXA RELPREVV... 77 ZYRTEC... 66 ZYTIGA... 42 ZYVOX... 22 Questo formulario è stato aggiornato in data 30/11/2016. Per eventuali domande, si prega di contattare ICS Community Care Plus FIDA-MMP al numero 1.877.ICS.2525, dal lunedì al venerdì, tra le 8:00 e le 20:00. La chiamata è gratuita. Per ulteriori informazioni visitare il sito I-24 Formulario ICS Community Care Plus FIDA-MMP per il 2016 ID del formulario:16508.000, Versione: 19 In vigore da: 1 Dicembre 2016
1.877.ICS.2525 www.icsny.org Ufficio amministrativo Independence Care System 257 Park Ave. South 2nd Floor New York, NY 10010 Centri di assistenza per gli iscritti 400 East Fordham Road 10th floor Bronx, New York 10458 25 Elm Place 5th Floor Brooklyn, NY 11201