2016 prescription drug list - sunshine health · formulary the ambetter from sunshine health...

2016 Prescription Drug ListEffective September 1, 2016

Ambetter.SunshineHealth.com

Formulary IntroductionFORMULARY

The Ambetter from Sunshine Health Formulary, or Preferred Drug List, is a guide to available brand and generic drugs that are approved by the Food and Drug Administration (FDA) and covered through your prescription drug benefit. Generic drugs have the same active ingredients as their brand name counterparts and should be considered the first line of treatment. The FDA requires generics to be safe and work the same as brand name drugs. If there is no generic available, there may be more than one brand name drug to treat a condition. Preferred brand name drugs are listed on Tier 2 to help identify brand drugs that are clinically appropriate, safe, and cost-effective treatment options, if a generic medication on the formulary is not suitable for your condition.

Please note, the Formulary is not meant to be a complete list of the drugs covered under your prescription benefit. Not all dosage forms or strengths of a drug may be covered. This list is periodically reviewed and updated and may be subject to change. Drugs may be added or removed, or additional requirements may be added in order to approve continued usage of a specific drug.

Specific prescription benefit plan designs may not cover certain products or categories, regardless of their appearance in this document. Please check your benefits for coverage limitations and your share of cost for your drugs.

Drug List Key:

Brand name drugs are listed in CAPS and generic drugs are lower case.Drugs are covered under different copay tiers depending on your benefit:

Tier 0 - No copayment for those drugs that are used for prevention and are mandated by Affordable Care Act. Select oral contraceptives, vitamin D, folic acid for women of child bearing age, over-the-counter (OTC) aspirin, and smoking cessation products may be covered under this tier. Certain age or gender limits apply.

Tier 1 - Lowest copayment for those drugs that offer the greatest value compared to other drugs used to treat similarconditions. Select over-the-counter (OTC), generic or brand name drugs may be covered under this tier.

Tier 2 - Medium copayment covers brand name drugs that are generally more affordable, or may be preferred compared to other drugs to treat the same conditions.

Tier 3 - Highest copayment covers higher cost brand name drugs. This tier may also cover non-specialty drugs that are not on the Preferred Drug List but approval has been granted for coverage.

Tier 4 - Coverage for this tier is for “specialty” drugs used to treat complex, chronic conditions that may require specialhandling, storage or clinical management. For members who do not have a four Tier plan, these drugs may be covered under Tier 3.

Prior Authorization for Non-Formulary Drugs

To obtain prior authorization for a non-formulary drug, your provider must fill out the Prior Authorization form. US Script will respond via fax or phone within 48 hours of receipt of all necessary information, except during weekends and holidays. If the request is disapproved, the notice of disapproval will contain a clear explanation of the specific reasons for disapproving the prior authorization request, or if the request was incomplete, the explanation will identify the missing material information that is necessary to complete the request.

LEGEND

TIER DESCRIPTION

0 Preventative

1 Generics

2 Preferred Brands

3 Non-Preferred Brands

4 Specialty

TYPE DESCRIPTION

PA Prior Authorization Prior Authorization required before prescription can be filled.

ST Step TherapyRequires trial and failure of one or more preferred products prior tocoverage.

GL Gender Limit Drug is limited to specific gender.

AL Age Limit Drug is limited to specific age.

MDD Max Daily Dose A limit on the number of times the drug can be taken per day.

MPL Max Package Limit A limit on the amount of drug covered per prescription.

MFL Max Fill Limit There is a limit on the number of times this drug can be refilled.

MDS Max Days Supply There is a limit on the amount of this drug that is covered.

C Custom This drug has unique restrictions.

S Specialty DrugSpecialty drugs are high-cost drugs used to treat complex or rareconditions, such as multiple sclerosis, rheumatoid arthritis, hepatitisC, and hemophilia.

FAL Female Age LimitThis prescription drug may only be covered if you are a female andmeet the minimum or maximum age limit.

MAL Male Age LimitThis prescription drug may only be covered if you are a male andmeet the minimum or maximum age limit.

PAGE 2 LAST UPDATED 09/2016

MDS2 Max Days Supply There is a limit on the amount of this drug that is covered.


LIST OF COVERED OVER-THE-COUNTER MEDICATIONS PRODUCT DESCRIPTION BRAND/GEN TIER LIMITS & RESTRICTIONS

ANALGESICS

NONSTEROIDAL ANTI-INFLAMMATORY DRUGS

aspirin (chew tab 81 mg, tab 81 mg, tab 325mg, tab delayed release 81 mg) generic 0

FAL Female - 11 to 79 yrsold

MAL Male - 45 to 79 yrs old

ibuprofen susp 100 mg/5ml generic 1

ANESTHETICS

LOCAL ANESTHETICS

lidocaine hcl gel 2% generic 1

ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS

SMOKING CESSATION AGENTS

COMMIT BRAND 0

NICODERM CQ BRAND 0 MDD 1 per day

NICORETTE BRAND 0

NICORETTE MINI BRAND 0

NICORETTE REFILL BRAND 0

NICORETTE STARTER KIT BRAND 0

nicotine (patch 24hr 7 mg/24hr, patch 24hr 21mg/24hr, patch 24hr 14 mg/24hr) generic 0 MDD 1 per day

NICOTINE KIT 21-14-7 MG/24HR BRAND 0

NICOTINE MINI BRAND 0

nicotine polacrilex generic 0

ANTIEMETICS

ANTIEMETICS, OTHER

meclizine hcl (tab 12.5 mg, tab 25 mg) generic 1


PRODUCT DESCRIPTION BRAND/GEN TIER LIMITS & RESTRICTIONS

ANTIFUNGALS

clotrimazole (topical) (cream, soln) generic 1

clotrimazole vaginal cream 1% generic 1

LOTRIMIN ULTRA BRAND 2 MPL 1 / 30 day

CARDIOVASCULAR AGENTS

DYSLIPIDEMICS, OTHER

niacin tab cr 750 mg generic 1

niacinamide (tab 100 mg, tab 500 mg) generic 1

DENTAL AND ORAL AGENTS

stannous fluoride conc 0.63% generic 0

DERMATOLOGICAL AGENTS

benzoyl peroxide (foam 5.3%, gel 5%, gel 10%,liq 4%, liq 10%, lotion 6%) generic 1 AL At least 12 yrs old

hydrocortisone (topical) (cream, oint) generic 1

lactic acid (ammonium lactate) (cream, lotion) generic 1

PANOXYL-4 CREAMY WASH BRAND 3 AL At least 12 yrs old

GASTROINTESTINAL AGENTS

GASTROINTESTINAL AGENTS, OTHER

loperamide hcl cap 2 mg generic 1

HISTAMINE2 (H2) RECEPTOR ANTAGONISTS

cimetidine generic 1

famotidine tab 20 mg generic 1

ranitidine hcl tab 150 mg generic 1

LAXATIVES

bisacodyl tab delayed release 5 mg generic 1

calcium polycarbophil generic 1



docusate calcium generic 1

docusate sodium (cap 100 mg, cap 250 mg) generic 1

PROTON PUMP INHIBITORS

CVS OMEPRAZOLE BRAND 1 MDD 2 per day

EQ OMEPRAZOLE BRAND 1 MDD 2 per day

EQL OMEPRAZOLE BRAND 1 MDD 2 per day

GNP OMEPRAZOLE BRAND 1 MDD 2 per day

HM OMEPRAZOLE BRAND 1 MDD 2 per day

KLS OMEPRAZOLE BRAND 1 MDD 2 per day

lansoprazole generic 1 MDD 1 per day

NEXIUM 24HR CAP DR 20 MG BRAND 1 MDD 2 per day

omeprazole delayed release tab 20 mg generic 1 MDD 2 per day

omeprazole magnesium generic 1 MDD 4 per day

OMEPRAZOLE TAB DR 20 MG BRAND 1 MDD 2 per day

omeprazole-sodium bicarbonate generic 1 MDD 1 per day

PREVACID 24HR BRAND 1 MDD 1 per day

PRILOSEC OTC BRAND 1 MDD 4 per day

PX OMEPRAZOLE BRAND 1 MDD 2 per day

RA OMEPRAZOLE BRAND 1 MDD 2 per day

SB OMEPRAZOLE BRAND 1 MDD 2 per day

SM OMEPRAZOLE BRAND 1 MDD 2 per day

SW OMEPRAZOLE BRAND 1 MDD 2 per day

TGT OMEPRAZOLE BRAND 1 MDD 2 per day

ZEGERID OTC BRAND 1 MDD 1 per day



GENITOURINARY AGENTS

GENITOURINARY AGENTS, OTHER

GYNOL II BRAND 0

nonoxynol-9 generic 0

TODAY SPONGE BRAND 0

PHOSPHATE BINDERS

calcium acetate (phosphate binder) generic 1

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (SEX HORMONES/MODIFIERS)

PROGESTINS

levonorgestrel (emergency oc) generic 0 GL Female

PLAN B ONE-STEP BRAND 0 GL Female

MISCELLANEOUS THERAPEUTIC AGENTS

AIMSCO LUBRICATED BRAND 0

ELEXA NATURAL FEEL BRAND 0

ELEXA STIMULATING BRAND 0

ELEXA ULTRA SENSITIVE BRAND 0

FANTASY LUBRICATED BRAND 0

FANTASY LUBRICATED/SPERMICIDE BRAND 0

FC FEMALE CONDOM BRAND 0

FC2 FEMALE CONDOM BRAND 0

KAMELEON LUBRICATED BRAND 0

KIMONO BRAND 0

KIMONO MICRO THIN PLUS BRAND 0

KIMONO PLUS BRAND 0

KIMONO PS BRAND 0

KIMONO PS PLUS BRAND 0



KIMONO SENSATION BRAND 0

KIMONO SENSATION PLUS BRAND 0

MAXX BRAND 0

MAXX PLUS BRAND 0

NOVA MAX PLUS KETONE TEST BRAND 1

PRECISION XTRA KETONE BRAND 1

PREMIUM CONDOMS LUBRICATED BRAND 0

PTS PANELS KETONE TEST BRAND 1

REALITY LATEX/ULTRA TEXTURED BRAND 0

REALITY LATEX/ULTRA THIN BRAND 0

TROJAN MAGNUM WARM SENSATIONS BRAND 0

TROJAN SUPRAS SPERMICIDAL BRAND 0

TROJAN TWISTED PLEASURE BRAND 0

TRUSTEX COLOR CONDOMS + LUBE BRAND 0

TRUSTEX LUB/RIBBED/STUDDED BRAND 0

TRUSTEX LUB/SPERMICIDE EX ST BRAND 0

TRUSTEX LUB/SPERMICIDE XL BRAND 0

TRUSTEX LUBRICATED BRAND 0

TRUSTEX LUBRICATED EX LARGE BRAND 0

TRUSTEX LUBRICATED EXTRA ST BRAND 0

TRUSTEX LUBRICATED/SPERMICIDE BRAND 0

TRUSTEX NATURAL CONDOMS + LUBE BRAND 0

TRUSTEX RIA LUB/SPERMICIDE BRAND 0

TRUSTEX RIA LUBRICATED BRAND 0

TRUSTEX-NONOXYNOL-9/RIB/STUD BRAND 0

OPHTHALMIC AGENTS

OPHTHALMIC AGENTS, OTHER

ketotifen fumarate (ophth) generic 1



ZADITOR BRAND 1

RESPIRATORY TRACT/PULMONARY AGENTS

ANTI-INFLAMMATORIES, INHALED CORTICOSTEROIDS

budesonide (nasal) generic 1PA

MPL 3 / 90 day

FLONASE ALLERGY RELIEF BRAND 1 MPL 1 / 30 day

fluticasone propionate (nasal) generic 1 MPL 3 / 90 day

ANTIHISTAMINES

ALLEGRA ALLERGY CHILDRENS (TAB 30MG, TAB DISP 30 MG) BRAND 1 MDD 2 per day

ALLEGRA ALLERGY CHILDRENSSUSPENSION 30 MG/5ML BRAND 1

MDS 900 ML / 30 DAY

MDS2 2700 ML / 90 DAY

ALLEGRA ALLERGY TAB 180 MG BRAND 1 MDD 1 per day

ALLEGRA ALLERGY TAB 60 MG BRAND 1 MDD 2 per day

cetirizine hcl (cap 10 mg, chew tab 5 mg, chewtab 10 mg, tab 5 mg, tab 10 mg) generic 1 MDD 1 per day

cetirizine hcl oral soln 1 mg/ml (5 mg/5ml) generic 1MDS 300 ML / 30 DAY

MDS2 900 ML / 90 DAY

CLARITIN (CAP 10 MG, CHEW TAB 5 MG,SYRUP 5 MG/5ML, TAB 10 MG) BRAND 1

CLARITIN REDITABS BRAND 1

diphenhydramine hcl (cap 50 mg, elixir 12.5mg/5ml) generic 1

fexofenadine hcl susp 30 mg/5ml (6 mg/ml) generic 1MDS 900 ML / 30 DAY

MDS2 2700 ML / 90 DAY

fexofenadine hcl tab 180 mg generic 1 MDD 1 per day

fexofenadine hcl tab 60 mg generic 1 MDD 2 per day

loratadine (rapidly-disintegrating tab 10 mg,syrup 5 mg/5ml, tab 10 mg) generic 1



ZYRTEC ALLERGY (CAP 10 MG, TAB 10 MG) BRAND 1 MDD 1 per day

ZYRTEC CHILDRENS ALLERGY (CHEW TAB5 MG, CHEW TAB 10 MG) BRAND 1 MDD 1 per day

ZYRTEC CHILDRENS ALLERGY (SYRUP 1MG/ML, SYRUP 5 MG/5ML) BRAND 1

MDS 300 / 30 DAY

MDS2 900 / 90 DAY

ZYRTEC CHILDRENS HIVES RELIEF BRAND 1MDS 300 ML / 30 DAY


ZYRTEC HIVES RELIEF BRAND 1 MDD 1 per day

RESPIRATORY TRACT AGENTS, OTHER

cetirizine-pseudoephedrine generic 1 MDD 2 per day

CLARITIN-D 12 HOUR BRAND 1 MDD 2 per day

CLARITIN-D 24 HOUR BRAND 1 MDD 1 per day

fexofenadine-pseudoephedrine tab sr 12hr 60-120 mg generic 1 MDD 2 per day

fexofenadine-pseudoephedrine tab sr 24hr 180-240 mg generic 1 MDD 1 per day

loratadine & pseudoephedrine tab sr 12hr 5-120 mg generic 1 MDD 2 per day

loratadine & pseudoephedrine tab sr 24hr 10-240 mg generic 1 MDD 1 per day

ZYRTEC-D ALLERGY & CONGESTION BRAND 1 MDD 2 per day

THERAPEUTIC NUTRIENTS/MINERALS/ELECTROLYTES

ELECTROLYTE/MINERAL REPLACEMENT

FER-IN-SOL BRAND 0 AL Up to 1 yrs old

ferrous sulfate (tab 325 mg mg elemental fe),tab ec 325 mg mg fe equivalent)) generic 0

ferrous sulfate soln 75 mg/ml (15 mg/mlelemental fe) generic 0 AL Up to 1 yrs old

cholecalciferol tab 400 unit generic 0



DRISDOL BRAND 0

ergocalciferol soln 8000 unit/ml generic 0

ergocalciferol tab 400 unit generic 0 AL At least 65 yrs old

folic acid tab 1 mg generic 0GL Female


folic acid tab 400 mcg generic 0 FAL Female - 12 to 55 yrsold

niacin (tab 50 mg, tab 100 mg, tab 250 mg, tab500 mg) generic 1


LIST OF COVERED PRESCRIPTION MEDICATIONS PRODUCT DESCRIPTION BRAND/GEN TIER LIMITS & RESTRICTIONS

ANALGESICS

NONSTEROIDAL ANTI-INFLAMMATORY DRUGS

celecoxib (cap 50 mg, cap 100 mg, cap 200mg) generic 1

PA

MDD 2 per day

celecoxib cap 400 mg generic 1PA

MDD 1 per day

choline & magnesium salicylates tab 1000 mg generic 1

diclofenac potassium generic 1

diclofenac sodium (tab delayed release 25 mg,tab delayed release 50 mg, tab delayed release75 mg, tab sr 24hr 100 mg)

generic 1

diclofenac w/ misoprostol generic 1

diflunisal tab 500 mg generic 1

etodolac (cap 200 mg, cap 300 mg, tab 400mg, tab 500 mg) generic 1

fenoprofen calcium tab 600 mg generic 1 MDD 1 per day

FLECTOR BRAND 3PA

MDD 2 per day

flurbiprofen (tab 50 mg, tab 100 mg) generic 1

ibuprofen (susp 100 mg/5ml, tab 400 mg, tab600 mg, tab 800 mg) generic 1

indomethacin (cap 25 mg, cap 50 mg, cap cr 75mg) generic 1

ketoprofen (cap 50 mg, cap 75 mg) generic 1

ketorolac tromethamine tab 10 mg generic 1 MDS 20 / 30 DAY

meclofenamate sodium (cap 50 mg, cap 100mg) generic 1

mefenamic acid cap 250 mg generic 1



meloxicam (tab 7.5 mg, tab 15 mg) generic 1 MDD 1 per day

meloxicam susp 7.5 mg/5ml generic 1

MOBIC SUSPENSION 7.5 MG/5ML BRAND 1

nabumetone generic 1

naproxen (susp 125 mg/5ml, tab 250 mg, tab375 mg, tab 500 mg, tab ec 500 mg) generic 1

naproxen sodium tab 550 mg generic 1

oxaprozin generic 1

piroxicam (cap 10 mg, cap 20 mg) generic 1

salsalate generic 1

sulindac (tab 150 mg, tab 200 mg) generic 1

tolmetin sodium generic 1

OPIOID ANALGESICS, LONG-ACTING

BUTRANS BRAND 3

PA

MDS 4 / 28 DAY

MDS2 12 / 84 DAY

EMBEDA BRAND 3PA

MDD 2 per day

EXALGO (TB24 DETER 12 MG, TB24 DETER16 MG, TB24 DETER 8 MG) BRAND 2

PA

MDD 2 per day

EXALGO TB24 DETER 32 MG BRAND 2PA

MDD 1 per day

fentanyl (patch 72hr 25 mcg/hr, patch 72hr 100mcg/hr, patch 72hr 12 mcg/hr, patch 72hr 75mcg/hr, patch 72hr 50 mcg/hr)

generic 1 MDS 10 / 30 DAY

hydromorphone hcl (tab er 24hr deter 12 mg,tab er 24hr deter 8 mg, tab er 24hr deter 16mg)

generic 1PA

MDD 2 per day

hydromorphone hcl tab er 24hr deter 32 mg generic 2PA

MDD 1 per day



levorphanol tartrate generic 1

methadone hcl conc 10 mg/ml generic 1 MDS 300 ML / 30 DAY

methadone hcl soln 10 mg/5ml generic 1 MDS 1500 ML / 30 DAY

methadone hcl soln 5 mg/5ml generic 1 MDS 3000 ML / 30 DAY

METHADONE HCL SOLUTION 10 MG/ML BRAND 1

methadone hcl tab 10 mg generic 1 MDD 10 per day

methadone hcl tab 5 mg generic 1 MDD 4 per day

methadone hcl tab for oral susp 40 mg generic 1 MDD 2 per day

METHADOSE CONC 10 MG/ML BRAND 1 MDS 300 ML / 30 DAY

METHADOSE SUGAR-FREE BRAND 1 MDS 300 ML / 30 DAY

morphine sulfate (cap 24hr 80 mg, cap 24hr 20mg, cap 24hr 50 mg, cap 24hr 30 mg, cap 24hr100 mg, cap 24hr 60 mg)

generic 1PA

MDD 2 per day

morphine sulfate (tab 15 mg, tab 30 mg, tab 60mg, tab 100 mg, tab 200 mg) generic 1 MDD 2 per day

NUCYNTA ER BRAND 2PA

MDD 2 per day

oxycodone hcl (tab er deter 10 mg, tab er deter20 mg, tab er deter 40 mg, tab er deter 80 mg) generic 1

PA

MDD 2 per day

OXYCONTIN (TB12 DETER 40 MG, TB12DETER 80 MG, TB12 DETER 20 MG, TB12DETER 10 MG)

BRAND 3PA

MDD 2 per day

OXYCONTIN (TB12 DETER 60 MG, TB12DETER 30 MG, TB12 DETER 15 MG) BRAND 3 PA

oxymorphone hcl (tab 5 mg, tab 7.5 mg, tab 10mg, tab 15 mg, tab 20 mg, tab 30 mg) generic 3

PA

MDD 2 per day

oxymorphone hcl tab sr 12hr 40 mg generic 3PA

MDD 4 per day

tramadol hcl (tab 24hr biphasic release 300 mg,tab 24hr 300 mg, tab 24hr 200 mg, tab 24hr100 mg)

generic 1 MDD 1 per day



ZOHYDRO ER BRAND 3PA

MDD 2 per day

OPIOID ANALGESICS, SHORT-ACTING

acetaminophen w/ codeine soln 120-12 mg/5ml generic 1 MDS 2250 ML / 30 DAY

acetaminophen w/ codeine tab 300-15 mg generic 1 MDD 13 per day



butalbital-acetaminophen-caff w/ cod cap 50-325-40-30 mg generic 1 MDD 6 per day

butalbital-aspirin-caffeine w/cod generic 1 MDD 6 per day

butorphanol tartrate (inj 1 mg/ml, inj 2 mg/ml) generic 1

butorphanol tartrate nasal soln 10 mg/ml generic 1PA

MPL 1 / 30 day

codeine sulfate (oral soln 30 mg/5ml, tab 15mg) generic 1

fentanyl citrate (fentnyl citrte lozenge hndle 200mcg, fentnyl citrte lozenge hndle 400 mcg,fentnyl citrte lozenge hndle 600 mcg, fentnylcitrte lozenge hndle 800 mcg, fentnyl citrtelozenge hndle 1200 mcg, fentnyl citrte lozengehndle 1600 mcg)

generic 1PA

MDD 4 per day

hydrocodone-acetaminophen (soln 7.5-500mg/15ml, soln 10-325 mg/15ml, tab 2.5-325mg)

generic 1

hydrocodone-acetaminophen (tab 2.5-500 mg,tab 5-500 mg, tab 7.5-500 mg, tab 10-500 mg) generic 1 MDD 8 per day

hydrocodone-acetaminophen (tab 5-300 mg,tab 7.5-300 mg, tab 10-300 mg) generic 1 MDD 13 per day

hydrocodone-acetaminophen (tab 5-325 mg,tab 7.5-325 mg, tab 10-325 mg) generic 1 MDD 12 per day

hydrocodone-acetaminophen (tab 7.5-650 mg,tab 10-660 mg, tab 10-650 mg) generic 1 MDD 6 per day



hydrocodone-acetaminophen (tab 7.5-750 mg,tab 10-750 mg) generic 1 MDD 5 per day

hydrocodone-acetaminophen soln 7.5-325mg/15ml generic 1 MDS 5400 ML / 30 DAY

hydrocodone-ibuprofen (tab 2.5-200 mg, tab 5-200 mg, tab 10-200 mg) generic 1

hydrocodone-ibuprofen tab 7.5-200 mg generic 1 MDD 5 per day

hydromorphone hcl (liqd 1 mg/ml, preservativefree (pf) inj 10 mg/ml) generic 1

hydromorphone hcl (tab 2 mg, tab 4 mg, tab 8mg) generic 1 MDD 8 per day

meperidine hcl (inj 25 mg/ml, inj 50 mg/ml, inj100 mg/ml) generic 1

meperidine hcl (tab 50 mg, tab 100 mg) generic 1 MDD 6 per day

meperidine hcl oral soln 50 mg/5ml generic 1 MDS 500 ML / CLAIM(S)

morphine sulfate (inj 0.5 mg/ml, inj 1 mg/ml) generic 1

morphine sulfate (tab 15 mg, tab 30 mg) generic 1 MDD 6 per day

morphine sulfate oral soln 10 mg/5ml generic 1 MDS 3000 ML / 30 DAY

morphine sulfate oral soln 20 mg/5ml generic 1 MDS 1500 ML / 30 DAY

nalbuphine hcl generic 1 MDD 8 per day

NUCYNTA BRAND 2PA

MDD 6 per day

oxycodone hcl (tab 5 mg, tab 10 mg, tab 15mg, tab 20 mg) generic 1 MDD 12 per day

oxycodone hcl tab 30 mg generic 1 MDD 24 per day

oxycodone w/ acetaminophen (w/ tab 5-325mg, w/ tab 7.5-325 mg, w/ tab 10-325 mg) generic 1 MDD 12 per day

oxycodone w/ acetaminophen tab 7.5-500 mg generic 1 MDD 8 per day

oxycodone-ibuprofen generic 1 MDD 1 per day

oxymorphone hcl (tab 5 mg, tab 10 mg) generic 1 MDD 12 per day



pentazocine w/ naloxone generic 1

TALWIN BRAND 3

tramadol hcl tab 50 mg generic 1 MDD 8 per day

tramadol-acetaminophen generic 1 MDD 8 per day

ZOLVIT BRAND 2

ANESTHETICS

LOCAL ANESTHETICS

lidocaine hcl (local anesth.) (inj 0.5%, inj 1%,preservative free (pf) inj 0.5%, preservative free(pf) inj 1%, preservative free (pf) inj 2%,preservative free (pf) inj 4%)

generic 1

lidocaine hcl gel 2% generic 1

lidocaine hcl laryngotracheal soln 4% generic 1

lidocaine hcl viscous soln 2% generic 1 MDS 120 ML / 30 DAY

lidocaine-prilocaine cream 2.5-2.5% generic 1

XYLOCAINE SOLUTION 1 % BRAND 3

ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS

ALCOHOL DETERRENTS/ANTI-CRAVING

acamprosate calcium generic 1

CAMPRAL BRAND 2

disulfiram generic 1

naltrexone hcl tab 50 mg generic 1

OPIOID DEPENDENCE TREATMENTS

buprenorphine hcl (sl tab 2 mg, sl tab 8 mg) generic 1PA

MDD 3 per day

buprenorphine hcl inj 0.3 mg/ml (base equiv) generic 1

buprenorphine hcl-naloxone hcl dihydrate generic 3PA

MDD 3 per day



SUBOXONE (FILM 2-0.5 MG, FILM 4-1 MG) BRAND 3PA

MDD 3 per day

SUBOXONE (FILM 8-2 MG, FILM 12-3 MG) BRAND 3PA

MDD 2 per day

OPIOID REVERSAL AGENTS

naloxone hcl (inj 0.4 mg/ml, inj 1 mg/ml) generic 1

SMOKING CESSATION AGENTS

bupropion hcl (smoking deterrent) generic 0 MDD 2 per day

CHANTIX BRAND 0 MDD 2 per day

CHANTIX CONTINUING MONTH PAK BRAND 0 MDD 2 per day

CHANTIX STARTING MONTH PAK BRAND 0

NICOTROL BRAND 0 MPL 1 / day

NICOTROL NS BRAND 0 MPL 1 / day

ZYBAN BRAND 0 MDD 2 per day

ANTIBACTERIALS

AMINOGLYCOSIDES

amikacin sulfate (inj 1 gm/4ml mg/ml), inj 500mg/2ml mg/ml)) generic 1

gentamicin in saline (gentamicsale j 0.8 mg/ml,gentamicsale j 1 mg/ml, gentamicsale j 1.2mg/ml, gentamicsale j 1.6 mg/ml)

generic 1

GENTAMICIN IN SALINE (GENTAMICSALESOLUTION 0.9-0.9 MG/ML-%,GENTAMICSALE SOLUTION 1.4-0.9 MG/ML-%)

BRAND 1

gentamicin sulfate (inj 40 mg/ml, iv soln 10mg/ml) generic 1

gentamicin sulfate (ophth) (oint, soln) generic 1

kanamycin sulfate generic 3



neomycin sulfate generic 1

paromomycin sulfate generic 1

streptomycin sulfate for inj 1 gm generic 3

TOBRADEX OINTMENT 0.3-0.1 % BRAND 3

tobramycin (ophth) generic 1

tobramycin sulfate (inj 10 mg/ml (baseequivalent), inj 80 mg/2ml (40 mg/ml)) generic 1

TOBRAMYCIN SULFATE IN SALINE BRAND 1

ANTIBACTERIALS, OTHER

acetic acid generic 1

ALTABAX (1 %, OINTMENT 1 %) BRAND 2

bacitracin (ophthalmic) generic 3

bacitracin intramuscular for soln 50000 unit generic 3

chloramphenicol sodium succinate generic 4PA

S Specialty Drug

clindamycin hcl (cap 75 mg, cap 150 mg, cap300 mg) generic 1

clindamycin palmitate hydrochloride generic 1

clindamycin phosphate (inj 9 gm/60ml, inj 300mg/2ml, inj 600 mg/4ml, inj 900 mg/6ml, iv soln300 mg/2ml, iv soln 600 mg/4ml, iv soln 900mg/6ml)

generic 1

clindamycin phosphate (topical) (foam, gel,lotion, soln) generic 1 AL At least 12 yrs old

clindamycin phosphate vaginal generic 1

CUBICIN BRAND 3

LINCOCIN BRAND 3

linezolid (for susp 100 mg/5ml, iv soln 600mg/300ml (2 mg/ml)) generic 1

LINEZOLID IN SODIUM CHLORIDE BRAND 1

linezolid tab 600 mg generic 1

PA

MDD 2 per day

MDS 28 / CLAIM(S)

C QL: 14 daysupply/claim



mafenide acetate generic 3

methenamine hippurate generic 1

metronidazole (tab 250 mg, tab 500 mg) generic 1

metronidazole (topical) (cream 0.75%, gel0.75%, gel 1%, lotion 0.75%) generic 1

metronidazole vaginal generic 1

MONUROL BRAND 3

mupirocin calcium (topical) generic 1

mupirocin oint 2% generic 1

nitrofurantoin generic 1

nitrofurantoin macrocrystal (cap 50 mg, cap100 mg) generic 1

nitrofurantoin monohyd macro generic 1

polymyxin b sulfate for inj 500000 unit generic 1

SULFAMYLON (CREAM 85 MG/GM, PACKET5 %) BRAND 3

trimethoprim tab 100 mg generic 1

TYGACIL BRAND 3

vancomycin hcl (cap 125 mg, cap 250 mg) generic 1

MDD 4 per day

MDS 40 / CLAIM(S)


vancomycin hcl (inj 10 gm, inj 500 mg, inj 1000mg) generic 1

VIBATIV RECON SOLN 750 MG BRAND 3

XIFAXAN BRAND 3PA

AL At least 12 yrs old

ZYVOX SOLUTION 200 MG/100ML BRAND 2

BETA-LACTAM, CEPHALOSPORINS

CEDAX (CAP 400 MG, RECON SUSP 90MG/5ML, RECON SUSP 180 MG/5ML) BRAND 3



cefaclor (cap 250 mg, cap 500 mg, for susp125 mg/5ml, for susp 250 mg/5ml, for susp 375mg/5ml)

generic 1

cefaclor monohydrate generic 1

cefadroxil (cap 500 mg, for susp 250 mg/5ml,for susp 500 mg/5ml, tab 1 gm) generic 1

cefazolin sodium (inj 1 gm, inj 10 gm, inj 20 gm,inj 500 mg) generic 1

cefdinir (cap 300 mg, for susp 125 mg/5ml, forsusp 250 mg/5ml) generic 1 AL At least 2 yrs old

cefditoren pivoxil (tab 200 mg, tab 400 mg) generic 3

CEFDITOREN PIVOXIL TAB 200 MG BRAND 3

cefepime hcl (inj 1 gm, inj 2 gm) generic 1

cefixime generic 1

cefotaxime sodium (inj 1 gm, inj 2 gm, inj 10gm) generic 1

cefotetan disodium generic 3

cefoxitin sodium generic 1

cefpodoxime proxetil (for susp 50 mg/5ml, forsusp 100 mg/5ml, tab 100 mg, tab 200 mg) generic 1

cefprozil (for susp 125 mg/5ml, for susp 250mg/5ml, tab 250 mg, tab 500 mg) generic 1

ceftazidime (inj 1 gm, inj 2 gm, inj 6 gm) generic 1

CEFTIBUTEN CAP 400 MG BRAND 1

CEFTIBUTEN RECON SUSP 180 MG/5ML BRAND 3

CEFTIN RECON SUSP 125 MG/5ML BRAND 2

ceftriaxone sodium (inj 1 gm, inj 2 gm, inj 250mg, inj 500 mg) generic 1

cefuroxime axetil (for susp 125 mg/5ml, tab 250mg, tab 500 mg) generic 1

cefuroxime sodium (inj 1.5 gm, inj 7.5 gm, inj750 mg) generic 1



cephalexin (cap 250 mg, cap 500 mg, cap 750mg, for susp 125 mg/5ml, for susp 250 mg/5ml,tab 250 mg, tab 500 mg)

generic 1

SPECTRACEF BRAND 3

SUPRAX (RECON SUSP 100 MG/5ML,RECON SUSP 200 MG/5ML, TAB 400 MG) BRAND 2

TEFLARO BRAND 3

BETA-LACTAM, OTHER

AZACTAM IN DEXTROSE BRAND 3

aztreonam generic 1

imipenem-cilastatin generic 1

INVANZ BRAND 3

meropenem generic 1

BETA-LACTAM, PENICILLINS

amoxicillin & pot clavulanate (chew tab 200-28.5 mg, chew tab 400-57 mg, for susp 200-28.5 mg/5ml, for susp 250-62.5 mg/5ml, forsusp 400-57 mg/5ml, for susp 600-42.9mg/5ml, tab 250-125 mg, tab 500-125 mg, tab875-125 mg, tab sr 12hr 1000-62.5 mg)

generic 1

amoxicillin (cap 250 mg, cap 500 mg, chew tab125 mg, chew tab 250 mg, for susp 125mg/5ml, for susp 200 mg/5ml, for susp 250mg/5ml, for susp 400 mg/5ml, tab 500 mg, tab875 mg)

generic 1

ampicillin & sulbactam sodium (inj 1-0.5 gm, inj2-1 gm, iv soln 10-5 gm) generic 1

ampicillin (cap 250 mg, cap 500 mg) generic 1

AMPICILLIN (RECON SUSP 125 MG/5ML,RECON SUSP 250 MG/5ML) BRAND 1

ampicillin sodium (inj 1 gm, iv soln 10 gm) generic 1

dicloxacillin sodium generic 1

nafcillin sodium (inj 1 gm, inj 10 gm) generic 1

oxacillin sodium (inj 1 gm, inj 10 gm) generic 1



PENICILLIN G POT IN DEXTROSE(PENICILLSOLUTION 40000 UNIT/ML,PENICILLSOLUTION 60000 UNIT/ML)

BRAND 1

penicillin g potassium for inj 5000000 unit generic 1

PENICILLIN G PROCAINE BRAND 3

penicillin g sodium generic 3

penicillin v potassium (for soln 125 mg/5ml, forsoln 250 mg/5ml, tab 250 mg, tab 500 mg) generic 1

piperacillin sodium-tazobactam sodium generic 1

TIMENTIN RECON SOLN 3.1 GM BRAND 3

MACROLIDES

AZASITE BRAND 3

azithromycin (iv soln 500 mg, powd pack susp1 gm, susp 100 mg/5ml) generic 1

azithromycin for susp 200 mg/5ml generic 1 MPL 1 / day

azithromycin tab 250 mg generic 1 C Limited to 6 tablets perclaim

azithromycin tab 500 mg generic 1 C Limited to 4 tablets perclaim

azithromycin tab 600 mg generic 1 MDS 8 / 28 DAY

clarithromycin (for susp 125 mg/5ml, for susp250 mg/5ml, tab 250 mg, tab 500 mg, tab sr24hr 500 mg)

generic 1

DIFICID BRAND 2

E.E.S. 400 BRAND 3

E.E.S. GRANULES BRAND 3

ERY-TAB BRAND 3

ERYPED 200 BRAND 3

ERYPED 400 BRAND 3

erythromycin (acne aid) (pads, soln) generic 1 AL At least 12 yrs old

erythromycin (ophth) generic 1



ERYTHROMYCIN BASE (TAB 250 MG, TAB500 MG) BRAND 3

ERYTHROMYCIN ETHYLSUCCINATE TAB400 MG BRAND 3

erythromycin w/ delayed release particles cap250 mg generic 3

KETEK TAB 300 MG BRAND 3

MDD 2 per day

MDS 20 / CLAIM(S)


KETEK TAB 400 MG BRAND 3

MDD 2 per day

MDS 28 / CLAIM(S)


ZITHROMAX PACKET 1 GM BRAND 1

QUINOLONES

AVELOX (SOLUTION 400 MG/250ML, TAB400 MG) BRAND 3

AVELOX ABC PACK BRAND 3

BESIVANCE BRAND 3

CETRAXAL BRAND 1

CIPRO IN D5W SOLUTION 200 MG/100ML BRAND 3

ciprofloxacin (for oral susp 250 mg/5ml (5%) (5gm/100ml), for oral susp 500 mg/5ml (10%) (10gm/100ml), iv soln 400 mg/40ml (1%))

generic 1

ciprofloxacin 200 mg/100ml in d5w generic 3

ciprofloxacin hcl (ophth) generic 1

ciprofloxacin hcl (otic) generic 1

ciprofloxacin hcl (tab 100 mg, tab 250 mg, tab500 mg, tab 750 mg) generic 1

ciprofloxacin-ciprofloxacin hcl generic 1

FACTIVE BRAND 3

gatifloxacin (ophth) generic 1



levofloxacin (iv soln 25 mg/ml, oral soln 25mg/ml, tab 250 mg, tab 500 mg, tab 750 mg) generic 1

levofloxacin (ophth) generic 1

levofloxacin in d5w iv soln 500 mg/100ml generic 1

moxifloxacin hcl tab 400 mg (base equiv) generic 1

NOROXIN BRAND 3

ofloxacin generic 1

ofloxacin (ophth) generic 1

ofloxacin (otic) generic 1

ZYMAXID BRAND 3

SULFONAMIDES

silver sulfadiazine generic 1

sulfacetamide sodium ophth soln 10% generic 1 MPL 1 / day

sulfadiazine tab 500 mg generic 1

sulfamethoxazole-trimethoprim (iv soln 400-80mg/5ml, susp 200-40 mg/5ml, tab 400-80 mg,tab 800-160 mg)

generic 1

TETRACYCLINES

demeclocycline hcl (tab 150 mg, tab 300 mg) generic 1

doxycycline (monohydrate) (cap 50 mg, cap100 mg, tab 100 mg) generic 1 MDD 2 per day

doxycycline hyclate (cap 50 mg, cap 100 mg,tab 20 mg, tab 100 mg) generic 1 MDD 2 per day

doxycycline hyclate for inj 100 mg generic 1

doxycycline monohydrate cap 75 mg generic 1

minocycline hcl (cap 50 mg, cap 75 mg, cap100 mg, tab 50 mg, tab 75 mg, tab 100 mg) generic 1 MDD 3 per day

tetracycline hcl (cap 250 mg, cap 500 mg) generic 1 MDD 8 per day



ANTICONVULSANTS

ANTICONVULSANTS, OTHER

levetiracetam (tab 250 mg, tab 500 mg, tab 750mg, tab sr 24hr 750 mg, tab sr 24hr 500 mg) generic 1 MDD 4 per day

levetiracetam inj 500 mg/5ml (100 mg/ml) generic 1 MDS 900 ML / 30 DAY

levetiracetam oral soln 100 mg/ml generic 1MDS 900 ML / 30 DAY

MDS2 2700 ML / 90 DAY

levetiracetam tab 1000 mg generic 1 MDD 3 per day

POTIGA BRAND 3PA

MDD 3 per day

CALCIUM CHANNEL MODIFYING AGENTS

CELONTIN BRAND 3 MDD 4 per day

ethosuximide cap 250 mg generic 1 MDD 6 per day

ethosuximide soln 250 mg/5ml generic 1MDS 900 ML / 30 DAY

MDS2 2700 ML / 90 DAY

zonisamide (cap 25 mg, cap 50 mg, cap 100mg) generic 1 MDD 6 per day

GAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENTS

DIASTAT ACUDIAL BRAND 3 MPL 1 / day

DIASTAT PEDIATRIC BRAND 3 MPL 1 / day

diazepam (anticonvulsant) generic 3 MPL 1 / day

divalproex sodium (tab delayed release 125mg, tab delayed release 250 mg, tab delayedrelease 500 mg, tab sr 24 hr 500 mg, tab sr 24hr 250 mg)

generic 1

gabapentin (cap 100 mg, cap 300 mg, cap 400mg, tab 600 mg, tab 800 mg) generic 1

gabapentin oral soln 250 mg/5ml generic 1MDS 1800 ML / 30 DAY

MDS2 5400 ML / 90 DAY



ONFI (TAB 5 MG, TAB 10 MG, TAB 20 MG) BRAND 3PA

MDD 2 per day

ONFI SUSPENSION 2.5 MG/ML BRAND 3PA

MDS 480 ML / 30 DAY

phenobarbital (elixir 20 mg/5ml, tab 16.2 mg,tab 30 mg, tab 32.4 mg, tab 64.8 mg, tab 97.2mg, tab 100 mg)

generic 1

primidone generic 1

SABRIL BRAND 4

PA

MDD 6 per day

S Specialty Drug

tiagabine hcl generic 1

valproate sodium generic 1

valproic acid generic 1

GLUTAMATE REDUCING AGENTS

felbamate susp 600 mg/5ml generic 1MDS 900 ML / 30 DAY

MDS2 2700 ML / 90 DAY

felbamate tab 400 mg generic 1 MDD 9 per day

felbamate tab 600 mg generic 1 MDD 6 per day

lamotrigine (tab 25 mg, tab 100 mg, tab 150mg, tab 200 mg, tab chewable dispersible 5mg, tab chewable dispersible 25 mg)

generic 1

topiramate (tab 100 mg, tab 200 mg) generic 1 MDD 2 per day

topiramate (tab 25 mg, tab 50 mg) generic 1 MDD 4 per day

topiramate sprinkle cap 15 mg generic 1 MDD 6 per day

topiramate sprinkle cap 25 mg generic 1 MDD 8 per day

SODIUM CHANNEL AGENTS

BANZEL SUSPENSION 40 MG/ML BRAND 2

PA

MDS 2400 ML / 30 DAY

MDS2 7200 ML / 90 DAY



BANZEL TAB 200 MG BRAND 2PA

MDD 2 per day

BANZEL TAB 400 MG BRAND 2PA

MDD 8 per day

carbamazepine (cap 200 mg, tab 200 mg) generic 1ST

MDD 6 per day

carbamazepine (cap 300 mg, tab 400 mg) generic 1ST

MDD 4 per day

carbamazepine (chew tab 100 mg, susp 100mg/5ml, tab 200 mg) generic 1

carbamazepine cap sr 12hr 100 mg generic 1 ST

DILANTIN (CAP 30 MG, CAP 100 MG,SUSPENSION 125 MG/5ML) BRAND 2

DILANTIN INFATABS BRAND 2

fosphenytoin sodium generic 1

oxcarbazepine (tab 150 mg, tab 300 mg) generic 1 MDD 3 per day

oxcarbazepine susp 300 mg/5ml (60 mg/ml) generic 1MDS 1200 ML / 30 DAY

MDS2 3600 ML / 90 DAY

oxcarbazepine tab 600 mg generic 1 MDD 4 per day

PEGANONE BRAND 3

PHENYTEK CAP 200 MG BRAND 2

PHENYTEK CAP 300 MG BRAND 3

phenytoin (chew tab 50 mg, susp 125 mg/5ml) generic 1

phenytoin sodium extended generic 1

phenytoin sodium inj 50 mg/ml generic 1

TEGRETOL (CHEW TAB 100 MG,SUSPENSION 100 MG/5ML, TAB 200 MG) BRAND 2

VIMPAT (TAB 50 MG, TAB 100 MG, TAB 150MG, TAB 200 MG) BRAND 3

PA

MDD 2 per day



VIMPAT SOLUTION 10 MG/ML BRAND 3

PA


MDS2 3600 ML / 90 DAY

VIMPAT SOLUTION 200 MG/20ML BRAND 3 MDS 1200 ML / 30 DAY

ANTIDEMENTIA AGENTS

ANTIDEMENTIA AGENTS, OTHER

ergoloid mesylates generic 3

CHOLINESTERASE INHIBITORS

donepezil hydrochloride (orally disintegratingtab 10 mg, tab 10 mg) generic 1 MDD 2 per day

donepezil hydrochloride (orally disintegratingtab 5 mg, tab 5 mg) generic 1 MDD 1 per day

galantamine hydrobromide (cap 24hr 8 mg, cap24hr 24 mg, cap 24hr 16 mg) generic 1 MDD 1 per day

galantamine hydrobromide (tab 4 mg, tab 8 mg,tab 12 mg) generic 1 MDD 2 per day

galantamine hydrobromide oral soln 4 mg/ml generic 1 MDD 6 per day

rivastigmine tartrate generic 1

N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONIST

memantine hcl (oral solution 2 mg/ml, tab 5 mg(28) & 10 mg (21) titration pak) generic 1

memantine hcl tab 10 mg generic 1 MDD 2 per day

memantine hcl tab 5 mg generic 1 MDD 1 per day

NAMENDA SOLUTION 10 MG/5ML BRAND 2

NAMENDA TITRATION PAK BRAND 2

ANTIDEPRESSANTS

ANTIDEPRESSANTS, OTHER

bupropion hcl (tab 100 mg, tab 150 mg, tab 200mg) generic 1 MDD 2 per day



bupropion hcl (tab 24hr 150 mg, tab 24hr 300mg) generic 1 MDD 1 per day

bupropion hcl (tab 75 mg, tab 100 mg) generic 1 MDD 3 per day

mirtazapine (orally disintegrating tab 15 mg,orally disintegrating tab 30 mg, orallydisintegrating tab 45 mg, tab 7.5 mg, tab 15mg, tab 30 mg, tab 45 mg)

generic 1 MDD 1 per day

perphenazine-amitriptyline generic 1 MDD 4 per day

WELLBUTRIN SR (TAB ER 12H 150 MG, TABER 12H 100 MG) BRAND 3 MDD 2 per day

WELLBUTRIN TAB 75 MG BRAND 3 MDD 3 per day

MONOAMINE OXIDASE INHIBITORS

EMSAM (9 MG/24HR, PATCH 24HR 6MG/24HR, PATCH 24HR 9 MG/24HR, PATCH24HR 12 MG/24HR)

BRAND 3 MDD 1 per day

MARPLAN BRAND 2 MDD 6 per day

phenelzine sulfate generic 1

tranylcypromine sulfate generic 1

SSRIS/SNRIS (SELECTIVE SEROTONIN REUPTAKE INHIBITORS/SEROTONIN AND NOREPINEPHRINEREUPTAKE INHIBITOR

BRINTELLIX BRAND 3PA

MDD 1 per day

citalopram hydrobromide (tab 10 mg, tab 20mg) generic 1 MDD 1.5 per day

citalopram hydrobromide oral soln 10 mg/5ml generic 1MDS 600 ML / 30 DAY

MDS2 1800 ML / 90 DAY

citalopram hydrobromide tab 40 mg (baseequiv) generic 1 MDD 1 per day

escitalopram oxalate (tab 5 mg, tab 10 mg) generic 1 MDD 1.5 per day

escitalopram oxalate soln 5 mg/5ml (baseequiv) generic 1

MDS 600 ML / 30 DAY

MDS2 1800 ML / 90 DAY



escitalopram oxalate tab 20 mg (base equiv) generic 1 MDD 1 per day

fluoxetine hcl (cap 10 mg, tab 10 mg, tab 60mg) generic 1 MDD 1 per day

fluoxetine hcl (cap 20 mg, tab 20 mg) generic 1 MDD 3 per day

fluoxetine hcl (pmdd) cap 10 mg generic 1 MDD 1 per day

fluoxetine hcl (pmdd) cap 20 mg generic 1 MDD 3 per day

fluoxetine hcl cap 40 mg generic 1 MDD 2 per day

fluoxetine hcl solution 20 mg/5ml generic 1MDS 600 ML / 30 DAY

MDS2 1800 ML / 90 DAY

fluvoxamine maleate (tab 25 mg, tab 50 mg) generic 1 MDD 2 per day

fluvoxamine maleate tab 100 mg generic 1 MDD 3 per day

maprotiline hcl generic 3

nefazodone hcl generic 3

OLEPTRO BRAND 3ST

MDD 1 per day

paroxetine hcl (tab 10 mg, tab 20 mg, tab 40mg) generic 1 MDD 1 per day

paroxetine hcl (tab 24hr 37.5 mg, tab 24hr 25mg) generic 1

PA

MDD 2 per day

paroxetine hcl oral susp 10 mg/5ml (baseequiv) generic 3

PA

MDS 900 ML / 30 DAY

MDS2 2700 ML / 90 DAY

paroxetine hcl tab 30 mg generic 1 MDD 2 per day

paroxetine hcl tab sr 24hr 12.5 mg generic 1PA

MDD 1 per day

PAXIL SUSPENSION 10 MG/5ML BRAND 3

PA

MDS 900 ML / 30 DAY

MDS2 2700 ML / 90 DAY



PRISTIQ (TAB ER 24H 25 MG, TAB ER 24H50 MG) BRAND 2

ST

MDD 1 per day

PRISTIQ TAB ER 24H 100 MG BRAND 2ST

MDD 4 per day

sertraline hcl (tab 25 mg, tab 50 mg) generic 1 MDD 1.5 per day

sertraline hcl oral conc 20 mg/ml generic 1MDS 300 ML / 30 DAY


sertraline hcl tab 100 mg generic 1 MDD 2 per day

trazodone hcl (tab 50 mg, tab 100 mg, tab 150mg, tab 300 mg) generic 1

venlafaxine hcl (cap 24hr 150 mg, tab 24hr 150mg) generic 1 MDD 2 per day

venlafaxine hcl (cap 24hr 37.5 mg, cap 24hr 75mg, tab 24hr 75 mg, tab 24hr 37.5 mg) generic 1 MDD 1 per day

venlafaxine hcl (tab 25 mg, tab 37.5 mg, tab 50mg, tab 75 mg, tab 100 mg) generic 1 MDD 3 per day

VENLAFAXINE HCL ER (ER TAB ER 24H 37.5MG, ER TAB ER 24H 75 MG) BRAND 3 MDD 1 per day

VENLAFAXINE HCL ER TAB ER 24H 150 MG BRAND 1 MDD 2 per day

VENLAFAXINE HCL ER TAB ER 24H 225 MG BRAND 1 MDD 1 per day

VIIBRYD (TAB 10 MG, TAB 20 MG, TAB 40MG) BRAND 2 MDD 1 per day

VIIBRYD KIT 10 & 20 & 40 MG BRAND 2 MDS 1 / 365 DAY

TRICYCLICS

amitriptyline hcl (tab 10 mg, tab 25 mg, tab 50mg, tab 75 mg, tab 100 mg, tab 150 mg) generic 1

amoxapine generic 3

clomipramine hcl generic 1

desipramine hcl (tab 10 mg, tab 25 mg, tab 50mg, tab 75 mg, tab 100 mg, tab 150 mg) generic 1



doxepin hcl (cap 10 mg, cap 25 mg, cap 50 mg,cap 75 mg, cap 100 mg, cap 150 mg, conc 10mg/ml)

generic 1

imipramine hcl (tab 10 mg, tab 25 mg, tab 50mg) generic 1

imipramine pamoate generic 1

nortriptyline hcl (cap 10 mg, cap 25 mg, cap 50mg, cap 75 mg) generic 1

protriptyline hcl generic 1

trimipramine maleate (cap 25 mg, cap 50 mg,cap 100 mg) generic 1

ANTIEMETICS

ANTIEMETICS, OTHER

meclizine hcl (tab 12.5 mg, tab 25 mg) generic 1

metoclopramide hcl (tab 5 mg, tab 10 mg) generic 1

MDD 6 per day

MDS 504 / 365 DAY

CLIMIT = 84 DAYSSUPPLY PER 365DAYS

metoclopramide hcl inj 5 mg/ml generic 1

metoclopramide hcl soln 5 mg/5ml (10mg/10ml) generic 1

MDD 60 per day

MDS 5040 ML / 365 DAY

CLIMIT = 84 DAYSSUPPLY PER 365DAYS

perphenazine generic 1

prochlorperazine generic 1

prochlorperazine maleate (tab 5 mg, tab 10 mg) generic 1

TRANSDERM-SCOP BRAND 2

trimethobenzamide hcl cap 300 mg generic 1

EMETOGENIC THERAPY ADJUNCTS

ALOXI BRAND 3



ANZEMET SOLUTION 20 MG/ML BRAND 3

ANZEMET TAB 100 MG BRAND 3

PA

MDS 5 / 30 DAY

MDS2 15 / 90 DAY

ANZEMET TAB 50 MG BRAND 3PA

MDS 5 / 30 DAY

CESAMET BRAND 3

dronabinol generic 1

EMEND (CAP 40 MG, CAP 125 MG) BRAND 2PA

MDS 2 / 30 DAY

EMEND CAP 80 MG BRAND 2PA

MDS 4 / 30 DAY

granisetron hcl (inj 0.1 mg/ml, inj 1 mg/ml) generic 1

granisetron hcl tab 1 mg generic 1 MDS 10 / 30 DAY

ondansetron generic 1MDS 30 / 30 DAY

MDS2 90 / 90 DAY

ondansetron hcl (tab 4 mg, tab 8 mg) generic 1MDS 30 / 30 DAY

MDS2 90 / 90 DAY

ondansetron hcl inj 4 mg/2ml (2 mg/ml) generic 1

ondansetron hcl oral soln 4 mg/5ml generic 1MDS 100 ML / 30 DAY


ondansetron hcl tab 24 mg generic 1MDS 4 / 28 DAY

MDS2 12 / 84 DAY

ANTIFUNGALS

ABELCET BRAND 3

AMBISOME BRAND 3

AMPHOTEC RECON SUSP 50 MG BRAND 3

amphotericin b for inj 50 mg generic 3



CANCIDAS BRAND 3

ciclopirox & vitamin e generic 1

ciclopirox (gel 0.77%, shampoo 1%, solution8%) generic 1

ciclopirox olamine (cream, susp) generic 1

clotrimazole (topical) (cream, soln) generic 1

clotrimazole troche 10 mg generic 1

econazole nitrate generic 1

ERAXIS (50 MG, RECON SOLN 50 MG, 100MG, RECON SOLN 100 MG) BRAND 3

ERTACZO BRAND 3 MPL 1 / 30 day

EXELDERM CREAM 1 % BRAND 3 MPL 1 / 30 day

EXELDERM SOLUTION 1 % BRAND 3 MPL 3 / 90 day

fluconazole (for susp 10 mg/ml, for susp 40mg/ml, tab 50 mg, tab 100 mg, tab 150 mg, tab200 mg)

generic 1

flucytosine generic 1

griseofulvin microsize susp 125 mg/5ml generic 1ST


griseofulvin microsize tab 500 mg generic 1 AL At least 2 yrs old

griseofulvin ultramicrosize generic 1

GYNAZOLE-1 BRAND 3

itraconazole cap 100 mg generic 1PA

MDD 4 per day

ketoconazole (topical) (cream, shampoo) generic 1

ketoconazole tab 200 mg generic 1

MENTAX BRAND 2 MPL 1 / 30 day

MICONAZOLE 3 BRAND 3

MYCAMINE BRAND 3



NAFTIFINE HCL CREAM 1 % BRAND 1 MPL 1 / 30 day

NAFTIN (CREAM 1 %, CREAM 2 %, GEL 1 %) BRAND 3 MPL 1 / 30 day

NATACYN BRAND 2 MPL 1 / 30 day

NOXAFIL SUSPENSION 40 MG/ML BRAND 3 MDS 600 ML / 30 DAY

nystatin (mouth-throat) generic 1

nystatin (topical) (*nystatin topical powder**,nystatin cream 100000 unit/gm, nystatin oint100000 unit/gm)

generic 1

nystatin tab 500000 unit generic 1

nystatin-triamcinolone generic 1

OXISTAT (CREAM 1 %, LOTION 1 %) BRAND 2 MPL 1 / 30 day

SPORANOX SOLUTION 10 MG/ML BRAND 3PA

MDS 600 ML / 30 DAY

terbinafine hcl tab 250 mg generic 1 MDD 1 per day

terconazole vaginal (cream 0.4%, cream 0.8%,suppos 80 mg) generic 1 MPL 1 / day

voriconazole (tab 50 mg, tab 200 mg) generic 1 MDD 4 per day

ANTIGOUT AGENTS

allopurinol generic 1

COLCHICINE TAB 0.6 MG BRAND 2 C QL: 6 caps/claim

colchicine tab 0.6 mg generic 2 C QL: 6 caps/claim

colchicine w/ probenecid generic 1

COLCRYS BRAND 2 C QL: 6 caps/claim

probenecid generic 1

ULORIC BRAND 3PA

MDD 1 per day



ANTIMIGRAINE AGENTS

ERGOT ALKALOIDS

CAFERGOT BRAND 2

D.H.E. 45 BRAND 2

dihydroergotamine mesylate inj 1 mg/ml generic 1

dihydroergotamine mesylate nasal spray 4mg/ml generic 1

ST

MDS 8 ML / 30 DAY

MDS2 24 ML / 90 DAY

ERGOMAR BRAND 3 MDS 20 / 30 DAY

MIGRANAL BRAND 2

ST

MDS 8 ML / 30 DAY

MDS2 24 ML / 90 DAY

SEROTONIN (5-HT) 1B/1D RECEPTOR AGONISTS

almotriptan malate tab 12.5 mg generic 3

ST


MDS 12 / 30 DAY

MDS2 36 / 90 DAY

almotriptan malate tab 6.25 mg generic 3

ST


MDS 9 / 30 DAY

AXERT TAB 12.5 MG BRAND 3

ST


MDS 12 / 30 DAY

MDS2 36 / 90 DAY

AXERT TAB 6.25 MG BRAND 3

ST


MDS 9 / 30 DAY

FROVA BRAND 3ST




IMITREX (SOLUTION 5 MG/ACT, SOLUTION20 MG/ACT) BRAND 1 AL At least 18 yrs old

naratriptan hcl generic 1AL At least 18 yrs old

MDS 9 / 30 DAY

RELPAX BRAND 3

ST


MDS 6 / 30 DAY

rizatriptan benzoate (oral tab 10 mg (base eq),orally tab 10 mg) generic 1


MDS 18 / 30 DAY

rizatriptan benzoate (oral tab 5 mg (base eq),orally tab 5 mg) generic 1


MDS 12 / 90 DAY

rizatriptan benzoate (tab 10 mg, tab 10 mg(base equivalent)) generic 1


MDS 54 / 90 DAY

rizatriptan benzoate (tab 5 mg, tab 5 mg (baseequivalent)) generic 1


MDS 12 / 30 DAY

sumatriptan (5 mg/act, 20 mg/act) generic 1AL At least 18 yrs old

MDS 6 / 30 DAY

sumatriptan succinate (inj 6 mg/0.5ml, solutionauto-injector 4 mg/0.5ml, solution auto-injector6 mg/0.5ml, solution cartridge 4 mg/0.5ml,solution cartridge 6 mg/0.5ml, solution prefilledsyringe 4 mg/0.5ml, solution prefilled syringe 6mg/0.5ml)

generic 1AL At least 18 yrs old

MDS 4 / 30 DAY

sumatriptan succinate (tab 25 mg, tab 50 mg,tab 100 mg) generic 1


MDS 9 / 30 DAY

sumatriptan succinate inj 4 mg/0.5ml generic 1AL At least 18 yrs old

MPL 2 / 30 day

zolmitriptan (orally disintegrating tab 2.5 mg,orally disintegrating tab 5 mg, tab 2.5 mg, tab 5mg)

generic 1

ST


MDS 9 / 30 DAY



ZOMIG (SOLUTION 2.5 MG, SOLUTION 5MG) BRAND 2

ST


MDS 6 / 30 DAY

ZOMIG (TAB 2.5 MG, TAB 5 MG) BRAND 2

ST


MDS 9 / 30 DAY

ZOMIG ZMT BRAND 2

ST


MDS 9 / 30 DAY

ANTIMYASTHENIC AGENTS

PARASYMPATHOMIMETICS

guanidine hcl generic 2

MESTINON (SYRUP 60 MG/5ML, TAB ER 180MG) BRAND 2

MYTELASE BRAND 3

pyridostigmine bromide generic 1

ANTIMYCOBACTERIALS

ANTIMYCOBACTERIALS, OTHER

dapsone (tab 25 mg, tab 100 mg) generic 3

MYCOBUTIN BRAND 3 PA

rifabutin generic 1

ANTITUBERCULARS

CAPASTAT SULFATE BRAND 3

CYCLOSERINE BRAND 3 MDD 4 per day

ethambutol hcl (tab 100 mg, tab 400 mg) generic 1

isoniazid (inj 100 mg/ml, tab 100 mg, tab 300mg) generic 1



ISONIAZID SYRUP 50 MG/5ML BRAND 1

PASER BRAND 3 MDD 3 per day

PRIFTIN BRAND 3

pyrazinamide generic 1

RIFAMATE BRAND 3

rifampin (cap 150 mg, cap 300 mg, for inj 600mg) generic 1

RIFATER BRAND 3 MDD 6 per day

SEROMYCIN BRAND 3 MDD 4 per day

TRECATOR BRAND 3 MDD 4 per day

ANTINEOPLASTICS

ALKYLATING AGENTS

ALKERAN TAB 2 MG BRAND 2

BICNU BRAND 4PA

S Specialty Drug

BUSULFEX BRAND 4PA

S Specialty Drug

CEENU BRAND 4PA

S Specialty Drug

cyclophosphamide generic 4PA

S Specialty Drug

dacarbazine for inj 200 mg generic 4PA

S Specialty Drug

DAUNOXOME BRAND 4PA

S Specialty Drug

HEXALEN BRAND 4PA

S Specialty Drug



IFEX RECON SOLN 1 GM BRAND 4PA

S Specialty Drug

ifosfamide & mesna generic 4PA

S Specialty Drug

ifosfamide (for inj 1 gm, iv inj 1 gm/20ml (50mg/ml)) generic 4

PA

S Specialty Drug

LEUKERAN BRAND 4PA

S Specialty Drug

lomustine generic 4PA

S Specialty Drug

MATULANE BRAND 4PA

S Specialty Drug

melphalan hcl generic 1

MUSTARGEN BRAND 4PA

S Specialty Drug

MYLERAN BRAND 4PA

S Specialty Drug

TEMODAR BRAND 4PA

S Specialty Drug

temozolomide generic 4PA

S Specialty Drug

TREANDA (RECON SOLN 25 MG, RECONSOLN 100 MG) BRAND 4

PA

S Specialty Drug

ZANOSAR BRAND 4PA

S Specialty Drug

ANTIANDROGENS

bicalutamide generic 4PA

S Specialty Drug



CASODEX BRAND 4PA

S Specialty Drug

flutamide generic 4PA

S Specialty Drug

NILANDRON BRAND 3 MDD 2 per day

XTANDI BRAND 4PA

S Specialty Drug

ZYTIGA BRAND 4PA

S Specialty Drug

ANTIANGIOGENIC AGENTS

REVLIMID (CAP 2.5 MG, CAP 5 MG, CAP 10MG, CAP 15 MG, CAP 25 MG) BRAND 4

PA

S Specialty Drug

THALOMID BRAND 4PA

S Specialty Drug

ANTIESTROGENS/MODIFIERS

EMCYT BRAND 4 S Specialty Drug

FARESTON BRAND 2

FASLODEX (125 MG/2.5ML, SOLUTION 250MG/5ML) BRAND 4

PA

S Specialty Drug

SOLTAMOX BRAND 3 PA

tamoxifen citrate (tab 10 mg, tab 20 mg) generic 0

ANTIMETABOLITES

ALIMTA RECON SOLN 100 MG BRAND 4

ALIMTA RECON SOLN 500 MG BRAND 4PA

S Specialty Drug

capecitabine generic 4PA

S Specialty Drug



cladribine generic 4

CLOLAR BRAND 4PA

S Specialty Drug

cytarabine (for inj 100 mg, for inj 500 mg, inj pf20 mg/ml, inj pf 100 mg/ml) generic 4

PA

S Specialty Drug

DEPOCYT BRAND 4PA

S Specialty Drug

DROXIA BRAND 3

floxuridine for inj 0.5 gm generic 4PA

S Specialty Drug

fluorouracil inj 500 mg/10ml (50 mg/ml) generic 4PA

S Specialty Drug

FOLOTYN SOLUTION 20 MG/ML BRAND 4PA

S Specialty Drug

gemcitabine hcl (inj 2 gm, inj 200 mg) generic 4PA

S Specialty Drug

GEMZAR RECON SOLN 200 MG BRAND 4PA

S Specialty Drug

HYDREA BRAND 3

hydroxyurea generic 1

mercaptopurine generic 1

NIPENT BRAND 4PA

S Specialty Drug

pentostatin generic 4PA

S Specialty Drug

PURINETHOL BRAND 3

TABLOID BRAND 4PA

S Specialty Drug



XELODA BRAND 4PA

S Specialty Drug

ANTINEOPLASTICS, OTHER

ABRAXANE BRAND 4PA

S Specialty Drug

ARRANON BRAND 4PA

S Specialty Drug

azacitidine generic 4PA

S Specialty Drug

bleomycin sulfate for inj 15 unit generic 4PA

S Specialty Drug

CAMPATH BRAND 4PA

S Specialty Drug

CAMPTOSAR (SOLUTION 40 MG/2ML,SOLUTION 100 MG/5ML) BRAND 4

PA

S Specialty Drug

carboplatin iv soln 50 mg/5ml generic 4PA

S Specialty Drug

CERUBIDINE BRAND 4PA

S Specialty Drug

cisplatin inj 100 mg/100ml (1 mg/ml) generic 4PA

S Specialty Drug

COSMEGEN BRAND 4PA

S Specialty Drug

DACOGEN BRAND 4PA

S Specialty Drug

dactinomycin generic 4PA

S Specialty Drug



daunorubicin hcl (for inj 20 mg, inj 5 mg/ml(base equiv)) generic 4

PA

S Specialty Drug

decitabine generic 4PA

S Specialty Drug

DOCEFREZ BRAND 4PA

S Specialty Drug

DOCETAXEL (CONC 20 MG/ML, CONC 20MG/0.5ML, SOLUTION 20 MG/2ML) BRAND 4

PA

S Specialty Drug

docetaxel (inj conc 20 mg/ml, inj conc 20mg/0.5ml (40 mg/ml), soln iv infusion 20mg/2ml)

generic 4PA

S Specialty Drug

DOXIL BRAND 4PA

S Specialty Drug

doxorubicin hcl (for inj 10 mg, for inj 50 mg, inj2 mg/ml) generic 4

PA

S Specialty Drug

DOXORUBICIN HCL (RECON SOLN 10 MG,RECON SOLN 50 MG) BRAND 4

PA

S Specialty Drug

doxorubicin hcl liposomal generic 4PA

S Specialty Drug

ELOXATIN (SOLUTION 50 MG/10ML,SOLUTION 100 MG/20ML) BRAND 4

PA

S Specialty Drug

ELSPAR BRAND 4PA

S Specialty Drug

epirubicin hcl (inj 50 mg/25ml mg/ml), iv soln 50mg/25ml mg/ml)) generic 4

PA

S Specialty Drug

ERWINAZE BRAND 4PA

S Specialty Drug

FLUDARA BRAND 4PA

S Specialty Drug



fludarabine phosphate (for inj 50 mg, inj 25mg/ml) generic 4

PA

S Specialty Drug

HALAVEN BRAND 4PA

S Specialty Drug

IDAMYCIN PFS (SOLUTION 5 MG/5ML,SOLUTION 10 MG/10ML) BRAND 4

PA

S Specialty Drug

idarubicin hcl (inj 5 mg/5ml mg/ml), inj 10mg/10ml mg/ml)) generic 4

PA

S Specialty Drug

irinotecan hcl (inj 40 mg/2ml mg/ml), inj 100mg/5ml mg/ml)) generic 4

PA

S Specialty Drug

ISTODAX BRAND 4PA

S Specialty Drug

IXEMPRA KIT RECON SOLN 15 MG BRAND 4PA

S Specialty Drug

JEVTANA BRAND 4PA

S Specialty Drug

leucovorin calcium (for inj 50 mg, for inj 100mg, for inj 200 mg, for inj 350 mg, for inj 500mg, inj 10 mg/ml, tab 5 mg, tab 10 mg, tab 15mg, tab 25 mg)

generic 1

LEUCOVORIN CALCIUM RECON SOLN 50MG BRAND 1

LYSODREN BRAND 4PA

S Specialty Drug

mitomycin for inj 20 mg generic 4PA

S Specialty Drug

mitoxantrone hcl inj conc 25 mg/12.5ml (2mg/ml) generic 4

PA

S Specialty Drug

NAVELBINE SOLUTION 10 MG/ML BRAND 4PA

S Specialty Drug



OFORTA BRAND 4PA

S Specialty Drug

ONCASPAR BRAND 4PA

S Specialty Drug

ONTAK BRAND 4PA

S Specialty Drug

oxaliplatin (soln 50 mg/10ml, soln 50 mg/10ml,soln 100 mg/20ml, soln 100 mg/20ml) generic 4

PA

S Specialty Drug

paclitaxel (conc 100 mg/16.7ml mg/ml), conc150 mg/25ml mg/ml)) generic 4

PA

S Specialty Drug

PHOTOFRIN BRAND 4PA

S Specialty Drug

PROLEUKIN BRAND 4PA

S Specialty Drug

SYLATRON BRAND 4PA

S Specialty Drug

SYNRIBO BRAND 4PA

S Specialty Drug

TAXOTERE (CONC 20 MG/0.5ML, CONC 20MG/ML) BRAND 4

PA

S Specialty Drug

TENIPOSIDE BRAND 4PA

S Specialty Drug

thiotepa generic 4PA

S Specialty Drug

TRISENOX BRAND 4PA

S Specialty Drug

UVADEX BRAND 4PA

S Specialty Drug



VALSTAR BRAND 4PA

S Specialty Drug

VELCADE BRAND 4PA

S Specialty Drug

VIDAZA BRAND 4PA

S Specialty Drug

vinblastine sulfate for inj 10 mg generic 4PA

S Specialty Drug

vincristine sulfate generic 4PA

S Specialty Drug

vinorelbine tartrate (inj 10 mg/ml, inj 10 mg/ml(base equiv)) generic 4

PA

S Specialty Drug

VORAXAZE BRAND 4PA

S Specialty Drug

VUMON BRAND 4PA

S Specialty Drug

ZALTRAP SOLUTION 100 MG/4ML BRAND 4PA

S Specialty Drug

ZOLINZA BRAND 4PA

S Specialty Drug

AROMATASE INHIBITORS, 3RD GENERATION

anastrozole tab 1 mg generic 1

ARIMIDEX BRAND 4

AROMASIN BRAND 4PA

S Specialty Drug

exemestane generic 4 S Specialty Drug

FEMARA BRAND 4 PA



letrozole tab 2.5 mg generic 1

ENZYME INHIBITORS

ETOPOPHOS BRAND 4PA

S Specialty Drug

etoposide (cap 50 mg, inj 1 gm/50ml (20mg/ml), inj 100mg/5ml (20 mg/ml), inj500mg/25ml (20 mg/ml))

generic 4PA

S Specialty Drug

HYCAMTIN BRAND 4PA

S Specialty Drug

topotecan hcl for inj 4 mg generic 4PA

S Specialty Drug

MOLECULAR TARGET INHIBITORS

AFINITOR BRAND 4PA

S Specialty Drug

BOSULIF BRAND 4PA

S Specialty Drug

CAPRELSA BRAND 4PA

S Specialty Drug

COMETRIQ (100 MG DAILY DOSE) BRAND 4PA

S Specialty Drug


S Specialty Drug


S Specialty Drug

ERIVEDGE BRAND 4PA

S Specialty Drug

GLEEVEC BRAND 4PA

S Specialty Drug



imatinib mesylate generic 4PA

S Specialty Drug

INLYTA BRAND 4PA

S Specialty Drug

JAKAFI BRAND 4PA

S Specialty Drug

KYPROLIS RECON SOLN 60 MG BRAND 4PA

S Specialty Drug

NEXAVAR BRAND 4PA

S Specialty Drug

NINLARO BRAND 4PA

MDS 4 / 28 DAYS

SPRYCEL BRAND 4PA

S Specialty Drug

STIVARGA BRAND 4PA

S Specialty Drug

SUTENT (CAP 12.5 MG, CAP 25 MG, CAP 50MG) BRAND 4

PA

S Specialty Drug

TARCEVA BRAND 4PA

S Specialty Drug

TASIGNA BRAND 4PA

S Specialty Drug

TORISEL BRAND 4PA

S Specialty Drug

TYKERB BRAND 4PA

S Specialty Drug

VANDETANIB BRAND 4PA

S Specialty Drug



VOTRIENT BRAND 4PA

S Specialty Drug

XALKORI BRAND 4PA

S Specialty Drug

ZELBORAF BRAND 4PA

S Specialty Drug

MONOCLONAL ANTIBODIES

ADCETRIS BRAND 4PA

S Specialty Drug

ARZERRA BRAND 4PA

S Specialty Drug

AVASTIN SOLUTION 100 MG/4ML BRAND 4PA

S Specialty Drug

BEXXAR BRAND 4PA

S Specialty Drug

ERBITUX BRAND 4PA

S Specialty Drug

HERCEPTIN BRAND 4PA

S Specialty Drug

PERJETA BRAND 4PA

S Specialty Drug

RITUXAN BRAND 4PA

S Specialty Drug

VECTIBIX SOLUTION 100 MG/5ML BRAND 4PA

S Specialty Drug

YERVOY BRAND 4PA

S Specialty Drug



RETINOIDS

bexarotene generic 4

PA

MPL 1 / 30 day

S Specialty Drug

PANRETIN BRAND 3

TARGRETIN CAP 75 MG BRAND 4

PA

MPL 1 / 30 day

S Specialty Drug

TARGRETIN GEL 1 % BRAND 4PA

S Specialty Drug

tretinoin (chemotherapy) generic 1

ANTIPARASITICS

ANTIHELMINTHICS

ALBENZA BRAND 3

BILTRICIDE BRAND 3

ivermectin generic 1

mebendazole chew tab 100 mg generic 1

SKLICE BRAND 3

STROMECTOL BRAND 3

ANTIPROTOZOALS

ALINIA (RECON SUSP 100 MG/5ML, TAB 500MG) BRAND 2

atovaquone susp 750 mg/5ml generic 1

atovaquone-proguanil hcl generic 1

MDS 12 / 3 DAY

C Limit of 3 claims every180 days

MDS2 36 / 180 DAY

chloroquine phosphate (tab 250 mg, tab 500mg) generic 1



COARTEM BRAND 2

MDS 24 / 3 DAY


MDS2 72 / 180 DAY

DARAPRIM BRAND 3 MDD 3 per day

hydroxychloroquine sulfate generic 1

MALARONE BRAND 2

MDS 12 / 3 DAY


MDS2 36 / 180 DAY

mefloquine hcl generic 1

MEPRON BRAND 3

NEBUPENT BRAND 3

PENTAM BRAND 3

PRIMAQUINE PHOSPHATE TAB 26.3 MG BRAND 3

primaquine phosphate tab 26.3 mg (15 mgbase) generic 3

quinine sulfate cap 324 mg generic 1 MDS 84 / 365 DAY

PEDICULICIDES/SCABICIDES

EURAX BRAND 3

lindane generic 3

malathion generic 1

NATROBA BRAND 1

permethrin generic 1

SPINOSAD BRAND 2

ULESFIA BRAND 3

ANTIPARKINSON AGENTS

ANTICHOLINERGICS

benztropine mesylate (inj 1 mg/ml, tab 0.5 mg,tab 1 mg, tab 2 mg) generic 1



trihexyphenidyl hcl (elixir 0.4 mg/ml, tab 2 mg,tab 5 mg) generic 1

ANTIPARKINSON AGENTS, OTHER

amantadine hcl (cap 100 mg, syrup 50 mg/5ml,tab 100 mg) generic 1

CARBIDOPA-LEVODOPA-ENTACAPONE(TAB 12.5-50-200 MG, TAB 18.75-75-200 MG,TAB 25-100-200 MG, TAB 31.25-125-200 MG,TAB 37.5-150-200 MG, TAB 50-200-200 MG)

BRAND 1

carbidopa-levodopa-entacapone (tabs 12.5-50-200 mg, tabs 18.75-75-200 mg, tabs 25-100-200 mg, tabs 31.25-125-200 mg, tabs 37.5-150-200 mg, tabs 50-200-200 mg)

generic 1

entacapone generic 1 MDD 8 per day

STALEVO 100 BRAND 1

STALEVO 125 BRAND 1

STALEVO 150 BRAND 1

STALEVO 200 BRAND 1

STALEVO 50 BRAND 1

STALEVO 75 BRAND 1

TASMAR BRAND 3

tolcapone generic 3

DOPAMINE AGONISTS

APOKYN BRAND 4PA

S Specialty Drug

bromocriptine mesylate (cap 5 mg, tab 2.5 mg) generic 1

NEUPRO BRAND 2

pramipexole dihydrochloride (tab 0.25 mg, tab0.5 mg, tab 0.75 mg, tab 1 mg, tab 1.5 mg) generic 1

pramipexole dihydrochloride tab 0.125 mg generic 1 MDD 4 per day

ropinirole hydrochloride (tab 0.25 mg, tab 0.5mg, tab 1 mg, tab 2 mg, tab 3 mg, tab 4 mg, tab5 mg)

generic 1



ropinirole hydrochloride (tab 24hr 12 mg, tab24hr 8 mg) generic 1

ST

MDD 2 per day

ropinirole hydrochloride (tab 24hr 2 mg, tab24hr 4 mg, tab 24hr 6 mg) generic 1

ST

MDD 1 per day

DOPAMINE PRECURSORS/L-AMINO ACID DECARBOXYLASE INHIBITORS

carbidopa generic 1

carbidopa-levodopa generic 1

LODOSYN BRAND 1

MONOAMINE OXIDASE B (MAO-B) INHIBITORS

AZILECT BRAND 2PA

MDD 1 per day

selegiline hcl (cap 5 mg, tab 5 mg) generic 1

ANTIPSYCHOTICS

1ST GENERATION/TYPICAL

chlorpromazine hcl (inj 25 mg/ml, inj 50mg/2ml) generic 3

chlorpromazine hcl (tab 10 mg, tab 25 mg, tab50 mg, tab 100 mg, tab 200 mg) generic 1

fluphenazine hcl (elixir 2.5 mg/5ml, inj 2.5mg/ml, oral conc 5 mg/ml, tab 1 mg, tab 2.5mg, tab 5 mg, tab 10 mg)

generic 1

haloperidol generic 1

haloperidol decanoate generic 1 MFL 1 / 28 day

haloperidol lactate inj 5 mg/ml generic 1

loxapine succinate generic 1

ORAP BRAND 3

pimozide generic 1

thioridazine hcl generic 1

thiothixene generic 1



trifluoperazine hcl generic 1

2ND GENERATION/ATYPICAL

aripiprazole (tab 2 mg, tab 5 mg, tab 10 mg, tab15 mg, tab 20 mg, tab 30 mg) generic 3

PA


MDD 1 per day

aripiprazole oral solution 1 mg/ml generic 3

PA


MDS 900 ML / 30 DAY

MDS2 2700 ML / 90 DAY

FANAPT BRAND 2PA

MDD 2 per day

FANAPT TITRATION PACK BRAND 2PA

MPL 2 / 365 day

INVEGA (TAB ER 24H 1.5 MG, TAB ER 24H 3MG, TAB ER 24H 9 MG) BRAND 2

PA

MDD 1 per day

INVEGA TAB ER 24H 6 MG BRAND 2PA

MDD 2 per day

LATUDA BRAND 3PA

MDD 1 per day

olanzapine (tab 15 mg, tab 20 mg) generic 1 MDD 2 per day

olanzapine (tab 2.5 mg, tab 5 mg, tab 7.5 mg,tab 10 mg) generic 1 MDD 1 per day

olanzapine for im inj 10 mg generic 1 MDS 6 / 28 DAY

quetiapine fumarate generic 1AL At least 10 yrs old

MDD 2 per day

RISPERDAL CONSTA BRAND 2PA

MFL 2 / 28 day

risperidone (tab 0.25 mg, tab 0.5 mg, tab 1 mg,tab 2 mg, tab 3 mg) generic 1 MDD 2 per day



risperidone (tab 0.25 mg, tab 0.5 mg, tab 1 mg,tab 2 mg, tab 3 mg, tab 4 mg) generic 1

PA

MDD 2 per day

risperidone soln 1 mg/ml generic 1

PA

MDS 240 ML / 30 DAY


risperidone tab 4 mg generic 1 MDD 4 per day

SAPHRIS (SL TAB 5 MG, SL TAB 10 MG) BRAND 2PA

MDD 2 per day

SEROQUEL XR (TAB ER 24H 400 MG, TABER 24H 300 MG) BRAND 2

PA


MDD 2 per day

SEROQUEL XR (TAB ER 24H 50 MG, TAB ER24H 200 MG, TAB ER 24H 150 MG) BRAND 2

PA


MDD 1 per day

ziprasidone hcl generic 1AL At least 18 yrs old

MDD 2 per day

TREATMENT-RESISTANT

clozapine (tab 25 mg, tab 50 mg, tab 100 mg,tab 200 mg) generic 1

ANTIVIRALS

ANTI-CYTOMEGALOVIRUS (CMV) AGENTS

cidofovir iv inj 75 mg/ml generic 3

FOSCAVIR BRAND 3

ganciclovir sodium generic 1

VALCYTE RECON SOLN 50 MG/ML BRAND 2PA

MDS 540 ML / 30 DAY

VALCYTE TAB 450 MG BRAND 2PA

MDD 4 per day



valganciclovir hcl generic 1PA

MDD 4 per day

VISTIDE BRAND 3

ZIRGAN BRAND 2

ANTI-HEPATITIS B (HBV) AGENTS

adefovir dipivoxil generic 4

PA

MDD 1 per day

S Specialty Drug

BARACLUDE (TAB 0.5 MG, TAB 1 MG) BRAND 4

PA

MDD 1 per day

S Specialty Drug

BARACLUDE SOLUTION 0.05 MG/ML BRAND 4

PA

MDS 600 ML / 30 DAY

S Specialty Drug

entecavir generic 4

PA

MDD 1 per day

S Specialty Drug

EPIVIR HBV SOLUTION 5 MG/ML BRAND 2MDS 1800 ML / 30 DAY

S Specialty Drug

EPIVIR HBV TAB 100 MG BRAND 2MDD 3 per day

S Specialty Drug

HEPSERA BRAND 4

PA

MDD 1 per day

S Specialty Drug

lamivudine (hbv) generic 1MDD 3 per day

S Specialty Drug

TYZEKA BRAND 4

PA

MDD 1 per day

S Specialty Drug



ANTI-HEPATITIS C (HCV) AGENTS

EPCLUSA BRAND 4 PA

HARVONI BRAND 4

PA

MDD 1 per day

S Specialty Drug

INCIVEK BRAND 4MDD 6 per day

S Specialty Drug

INFERGEN BRAND 4PA

S Specialty Drug

INTRON A RECON SOLN 18000000 UNIT BRAND 4PA

S Specialty Drug

PEG-INTRON BRAND 4

PA

MDS 4 / 28 DAY

S Specialty Drug

PEG-INTRON REDIPEN BRAND 4

PA

MDS 4 / 28 DAY

S Specialty Drug

PEG-INTRON REDIPEN PAK 4 BRAND 4

PA

MDS 4 / 28 DAY

S Specialty Drug

PEGASYS KIT 180 MCG/0.5ML BRAND 4

PA

MDS 1 / 28 DAY

S Specialty Drug

PEGASYS PROCLICK BRAND 4

PA

MPL 2 / 28 day

S Specialty Drug

PEGASYS SOLUTION 180 MCG/0.5ML BRAND 4

PA

MPL 2 / 28 day

S Specialty Drug



PEGASYS SOLUTION 180 MCG/ML BRAND 4

PA

MPL 4 / 28 day

S Specialty Drug

PEGINTRON BRAND 4

PA

MDS 4 / 28 DAY

S Specialty Drug

REBETOL SOLUTION 40 MG/ML BRAND 4

PA


S Specialty Drug

ribavirin (hepatitis c) generic 1 MDD 7 per day

SOVALDI BRAND 4

PA

MDD 1 per day

S Specialty Drug

VICTRELIS BRAND 4

PA

MDD 12 per day

S Specialty Drug

ANTI-HIV AGENTS, INTEGRASE INHIBITORS (INSTI)

GENVOYA BRAND 3 MDD 1 per day

ISENTRESS (CHEW TAB 25 MG, CHEW TAB100 MG) BRAND 2

ISENTRESS TAB 400 MG BRAND 2 MDD 2 per day

STRIBILD BRAND 2 MDD 1 per day

TIVICAY TAB 50 MG BRAND 2

ANTI-HIV AGENTS, NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS (NNRTI)

ATRIPLA BRAND 3 MDD 1 per day

COMPLERA BRAND 2 MDD 1 per day

EDURANT BRAND 2 MDD 1 per day



INTELENCE TAB 100 MG BRAND 2 MDD 4 per day



nevirapine susp 50 mg/5ml generic 1MDS 1200 ML / 30 DAY

MDS2 3600 ML / 90 DAY

nevirapine tab 200 mg generic 1 MDD 2 per day

nevirapine tab sr 24hr 400 mg generic 1 MDD 1 per day

ODEFSEY BRAND 3 MDD 1 per day

RESCRIPTOR TAB 100 MG BRAND 2 MDD 12 per day

RESCRIPTOR TAB 200 MG BRAND 2 MDD 6 per day

SUSTIVA CAP 200 MG BRAND 2 MDD 2 per day

SUSTIVA CAP 50 MG BRAND 2 MDD 3 per day

SUSTIVA TAB 600 MG BRAND 2 MDD 1 per day

VIRAMUNE SUSPENSION 50 MG/5ML BRAND 2MDS 1200 ML / 30 DAY

MDS2 3600 ML / 90 DAY

VIRAMUNE TAB 200 MG BRAND 2 MDD 2 per day

VIRAMUNE XR TAB ER 24H 100 MG BRAND 2 MDD 3 per day

VIRAMUNE XR TAB ER 24H 400 MG BRAND 2 MDD 1 per day

ANTI-HIV AGENTS, NUCLEOSIDE AND NUCLEOTIDE REVERSE TRANSCRIPTASE INHIBITORS (NRTI)

abacavir sulfate generic 1 MDD 2 per day

abacavir sulfate-lamivudine-zidovudine generic 1 MDD 2 per day

COMBIVIR BRAND 3 MDD 2 per day

DESCOVY BRAND 2 MDD 1 per day

didanosine (capsule 125 mg, capsule 200 mg) generic 1 MDD 2 per day



didanosine (capsule 250 mg, capsule 400 mg) generic 1 MDD 1 per day

EMTRIVA CAP 200 MG BRAND 2 MDD 1 per day

EMTRIVA SOLUTION 10 MG/ML BRAND 2

EPIVIR SOLUTION 10 MG/ML BRAND 2 MDS 900 ML / 30 DAY

EPIVIR TAB 150 MG BRAND 2 MDD 2 per day

EPIVIR TAB 300 MG BRAND 2 MDD 1 per day

EPZICOM BRAND 2 MDD 1 per day

lamivudine oral soln 10 mg/ml generic 1 MDS 900 ML / 30 DAY

lamivudine tab 150 mg generic 1 MDD 2 per day

lamivudine tab 300 mg generic 1 MDD 1 per day

lamivudine-zidovudine generic 1 MDD 2 per day

RETROVIR CAP 100 MG BRAND 3 MDD 6 per day

RETROVIR SOLUTION 10 MG/ML BRAND 1

RETROVIR SYRUP 50 MG/5ML BRAND 3MDS 1800 ML / 30 DAY

MDS2 5400 ML / 90 DAY

RETROVIR TAB 300 MG BRAND 3 MDD 2 per day

stavudine (cap 15 mg, cap 20 mg, cap 30 mg,cap 40 mg) generic 1 MDD 2 per day

stavudine for oral soln 1 mg/ml generic 1MDS 2400 ML / 30 DAY

MDS2 7200 ML / 90 DAY

TRIZIVIR BRAND 2 MDD 2 per day

TRUVADA TAB 200-300 MG BRAND 2PA

MDD 1 per day

VIDEX BRAND 2

VIDEX EC (EC CAP DR 125 MG, EC CAP DR200 MG) BRAND 3 MDD 2 per day

VIDEX EC (EC CAP DR 250 MG, EC CAP DR400 MG) BRAND 3 MDD 1 per day



VIREAD (POWDER 40 MG/GM, TAB 300 MG) BRAND 2

VIREAD (TAB 150 MG, TAB 200 MG, TAB 250MG) BRAND 2 MDD 1 per day

ZIAGEN SOLUTION 20 MG/ML BRAND 2

ZIAGEN TAB 300 MG BRAND 3 MDD 2 per day

zidovudine cap 100 mg generic 1 MDD 6 per day

zidovudine syrup 10 mg/ml generic 1MDS 1800 ML / 30 DAY

MDS2 5400 ML / 90 DAY

zidovudine tab 300 mg generic 1 MDD 2 per day

ANTI-HIV AGENTS, OTHER

FUZEON BRAND 4

PA

MPL 1 / 30 day

S Specialty Drug

SELZENTRY TAB 150 MG BRAND 2 MDD 2 per day

SELZENTRY TAB 300 MG BRAND 2 MDD 4 per day

TRIUMEQ BRAND 3 MDD 1 per day

TYBOST BRAND 2 MDD 1 per day

ANTI-HIV AGENTS, PROTEASE INHIBITORS

APTIVUS CAP 250 MG BRAND 2 MDD 4 per day

APTIVUS SOLUTION 100 MG/ML BRAND 2 MDS 300 ML / 30 DAY

CRIXIVAN CAP 200 MG BRAND 2 MDD 9 per day

CRIXIVAN CAP 400 MG BRAND 2 MDD 6 per day

INVIRASE CAP 200 MG BRAND 2 MDD 10 per day

INVIRASE TAB 500 MG BRAND 2 MDD 4 per day

KALETRA (TAB 100-25 MG, TAB 200-50 MG) BRAND 2 MDD 4 per day

KALETRA SOLUTION 400-100 MG/5ML BRAND 2 MDS 375 ML / 30 DAY



LEXIVA SUSPENSION 50 MG/ML BRAND 2 MDS 1680 ML / 30 DAY

LEXIVA TAB 700 MG BRAND 2 MDD 4 per day

NORVIR (CAP 100 MG, TAB 100 MG) BRAND 2 MDD 12 per day

NORVIR SOLUTION 80 MG/ML BRAND 2 MDS 450 ML / 30 DAY

PREZISTA (TAB 75 MG, TAB 150 MG, TAB400 MG, TAB 600 MG) BRAND 2 MDD 2 per day

PREZISTA SUSPENSION 100 MG/ML BRAND 2 MDS 360 ML / 30 DAY

PREZISTA TAB 800 MG BRAND 2 MDD 1 per day

REYATAZ (CAP 150 MG, CAP 200 MG) BRAND 2 MDD 2 per day

REYATAZ CAP 100 MG BRAND 2 MDD 4 per day

REYATAZ CAP 300 MG BRAND 2 MDD 1 per day

VIRACEPT TAB 250 MG BRAND 2 MDD 10 per day

VIRACEPT TAB 625 MG BRAND 2 MDD 4 per day

ANTI-INFLUENZA AGENTS

RELENZA DISKHALER BRAND 2 MPL 1 / 30 day

rimantadine hydrochloride generic 1 MDD 2 per day

TAMIFLU (CAP 45 MG, CAP 75 MG) BRAND 2 MDS 10 / 30 DAY

TAMIFLU CAP 30 MG BRAND 2 MDS 20 / 30 DAY

TAMIFLU RECON SUSP 6 MG/ML BRAND 2 MDS 120 ML / 30 DAY

ANTIHERPETIC AGENTS

acyclovir (tab 400 mg, tab 800 mg) generic 1 MDD 5 per day

acyclovir cap 200 mg generic 1 MDS 50 / 30 DAY

acyclovir susp 200 mg/5ml generic 1 MDS 400 ML / 30 DAY

acyclovir topical generic 1

DENAVIR BRAND 3



famciclovir (tab 125 mg, tab 250 mg) generic 1PA

MDD 3 per day

famciclovir tab 500 mg generic 1PA

MDD 4 per day

trifluridine generic 1

valacyclovir hcl tab 1 gm generic 1 MDD 4 per day

valacyclovir hcl tab 500 mg generic 1 MDD 2 per day

ANXIOLYTICS

ANXIOLYTICS, OTHER

buspirone hcl (tab 7.5 mg, tab 10 mg, tab 15mg, tab 30 mg) generic 1

buspirone hcl tab 5 mg generic 1 MDD 1 per day

meprobamate generic 1

BENZODIAZEPINES

alprazolam (tab 0.25 mg, tab 0.5 mg, tab 1 mg,tab 2 mg) generic 1 MDD 4 per day

clonazepam (tab 0.5 mg, tab 1 mg, tab 2 mg) generic 1

diazepam (tab 2 mg, tab 5 mg, tab 10 mg) generic 1 MDD 4 per day

lorazepam (tab 0.5 mg, tab 2 mg) generic 1 MDD 3 per day

lorazepam tab 1 mg generic 1 MDD 4 per day

BIPOLAR AGENTS

MOOD STABILIZERS

EQUETRO CAP ER 12H 100 MG BRAND 3ST

MDD 2 per day


MDD 8 per day




MDD 4 per day

lithium generic 1

lithium carbonate (cap 150 mg, cap 300 mg,cap 600 mg, tab 300 mg, tab cr 300 mg, tab cr450 mg)

generic 1

BLOOD GLUCOSE REGULATORS

ANTIDIABETIC AGENTS

acarbose generic 1 MDD 3 per day

ACTOPLUS MET BRAND 2 MDD 2 per day

AVANDIA BRAND 3 MDD 1 per day

BYETTA 10 MCG PEN BRAND 2

PA

MDS 1.2 ML / 30 DAY

MDS2 3.6 ML / 90 DAY

BYETTA 5 MCG PEN BRAND 2

PA

MDS 2.4 ML / 30 DAY

MDS2 7.2 ML / 90 DAY

chlorpropamide tab 100 mg generic 1 MDD 3 per day

CYCLOSET BRAND 3 MDD 6 per day

glimepiride (tab 1 mg, tab 2 mg) generic 1 MDD 1 per day

glimepiride tab 4 mg generic 1 MDD 2 per day

glipizide (tab 24hr 2.5 mg, tab 24hr 5 mg, tab24hr 10 mg) generic 1 MDD 2 per day

glipizide (tab 5 mg, tab 10 mg) generic 1 MDD 4 per day

glipizide-metformin hcl (tab 2.5-500 mg, tab2.5-250 mg) generic 1 MDD 2 per day

glipizide-metformin hcl tab 5-500 mg generic 1 MDD 4 per day

glyburide (tab 1.25 mg, tab 2.5 mg, tab 5 mg) generic 1 MDD 4 per day



glyburide micronized generic 1 MDD 4 per day

GLYBURIDE TAB 5 MG BRAND 1 MDD 4 per day

glyburide-metformin (tab 1.25-250 mg, tab 2.5-500 mg) generic 1 MDD 2 per day

glyburide-metformin tab 5-500 mg generic 1 MDD 4 per day

GLYSET BRAND 3

INVOKANA BRAND 3PA

MDD 1 per day

JANUVIA BRAND 2PA

MDD 1 per day

lidocaine oint 5% generic 1

metformin hcl (tab 24hr osmotic 1000 mg, tab24hr 750 mg) generic 1 MDD 2 per day

metformin hcl tab 1000 mg generic 1 MDD 2.5 per day

metformin hcl tab 500 mg generic 1 MDD 5 per day

metformin hcl tab 850 mg generic 1 MDD 3 per day

metformin hcl tab sr 24hr 500 mg generic 1 MDD 4 per day

nateglinide generic 1 MDD 3 per day

ONGLYZA BRAND 3 MDD 1 per day

pioglitazone hcl generic 1 MDD 1 per day

pioglitazone hcl-metformin hcl generic 1 MDD 2 per day

PRANDIMET BRAND 3 MDD 2 per day

PRANDIN BRAND 3 MDD 4 per day

repaglinide generic 1 MDD 4 per day

SYMLINPEN 120 BRAND 2

PA

MDS 10.8 ML / 30 DAY

MDS2 32.4 ML / 90 DAY



SYMLINPEN 60 BRAND 2

PA

MDS 6 ML / 30 DAY

MDS2 18 ML / 90 DAY

tolazamide generic 1 MDD 4 per day

tolbutamide generic 1 MDD 6 per day

TRADJENTA BRAND 2 MDD 1 per day

VICTOZA BRAND 2

PA

MDS 9 ML / 30 DAY

MDS2 27 ML / 90 DAY

GLYCEMIC AGENTS

GLUCAGEN DIAGNOSTIC BRAND 3 MPL 12 / 365 day

GLUCAGEN HYPOKIT BRAND 3 MPL 12 / 365 day

GLUCAGON EMERGENCY BRAND 3 MPL 12 / 365 day

PROGLYCEM BRAND 3

INSULINS

APIDRA BRAND 2

APIDRA SOLOSTAR BRAND 3

HUMALOG BRAND 2

HUMALOG KWIKPEN SOLN PEN 100UNIT/ML BRAND 2

HUMALOG MIX 50/50 BRAND 2

HUMALOG MIX 50/50 KWIKPEN BRAND 2

HUMALOG MIX 50/50 PEN BRAND 2

HUMALOG MIX 75/25 BRAND 2

HUMALOG MIX 75/25 KWIKPEN BRAND 2

HUMALOG MIX 75/25 PEN BRAND 2

HUMALOG PEN BRAND 2



HUMULIN 70/30 BRAND 2

HUMULIN 70/30 KWIKPEN BRAND 2

HUMULIN 70/30 PEN BRAND 2

HUMULIN N BRAND 2

HUMULIN N KWIKPEN BRAND 2

HUMULIN N PEN BRAND 2

HUMULIN R BRAND 2

HUMULIN R U-500 (CONCENTRATED) BRAND 2

LANTUS BRAND 2

LANTUS SOLOSTAR BRAND 2

LEVEMIR BRAND 2

LEVEMIR FLEXPEN BRAND 2

LEVEMIR FLEXTOUCH BRAND 2

NOVOLIN 70/30 BRAND 2

NOVOLIN 70/30 RELION BRAND 2

NOVOLIN N BRAND 2

NOVOLIN N RELION BRAND 2

NOVOLIN R BRAND 2

NOVOLIN R RELION BRAND 2

NOVOLOG BRAND 2

NOVOLOG FLEXPEN BRAND 2

NOVOLOG MIX 70/30 BRAND 2

NOVOLOG MIX 70/30 FLEXPEN BRAND 2

NOVOLOG PENFILL BRAND 2

RELION 70/30 BRAND 2

RELION N BRAND 2

RELION R BRAND 2



BLOOD PRODUCTS/MODIFIERS/VOLUME EXPANDERS

ANTICOAGULANTS

COUMADIN BRAND 2

ELIQUIS BRAND 2 MDS 74 / 30 DAY

enoxaparin sodium (inj 100 mg/ml, inj 150mg/ml) generic 4

MDS 60 / 30 DAYS

S Specialty Drug

enoxaparin sodium (inj 80 mg/0.8ml, inj 120mg/0.8ml) generic 4

MDS 48 / 30 DAYS

S Specialty Drug

enoxaparin sodium inj 30 mg/0.3ml generic 4MDS 18 ML / 30 DAYS

S Specialty Drug

enoxaparin sodium inj 300 mg/3ml generic 4MDS 180 ML / 30 DAYS

S Specialty Drug


S Specialty Drug


S Specialty Drug

fondaparinux sodium (inj 2.5 mg/0.5ml,subcutaneous inj 2.5 mg/0.5ml) generic 4

PA

MDS 4.5 / 9 DAY

CPA is required fortreatment that is longerthan 9 days every 180days

S Specialty Drug

MDS2 4.5 / 180 DAY

fondaparinux sodium inj 10 mg/0.8ml generic 4

PA

MDS 7.2 ML / 9 DAY


S Specialty Drug

MDS2 7.2 ML / 180 DAY



fondaparinux sodium inj 5 mg/0.4ml generic 4

PA

MDS 3.6 ML / 9 DAY


S Specialty Drug

MDS2 3.6 ML / 180 DAY

fondaparinux sodium inj 7.5 mg/0.6ml generic 4

PA

MDS 5.4 ML / 21 DAY


S Specialty Drug

MDS2 5.4 ML / 180 DAY

FRAGMIN (SOLUTION 2500 UNIT/0.2ML,SOLUTION 5000 UNIT/0.2ML, SOLUTION7500 UNIT/0.3ML, SOLUTION 10000UNIT/ML, SOLUTION 12500 UNIT/0.5ML,SOLUTION 15000 UNIT/0.6ML, SOLUTION18000 UNT/0.72ML, SOLUTION 25000UNIT/ML)

BRAND 4PA

S Specialty Drug

HEPARIN (PORCINE) IN NACL(HEPAR(PORCE) SOLUTION 50-0.45UNIT/ML-%, HEPAR(PORCE) SOLUTION 100-0.45 UNIT/ML-%)

BRAND 1

heparin sodium (porcine) (inj 5000 unit/ml, inj10000 unit/ml, inj 20000 unit/ml) generic 1

heparin sodium (porcine) 40 unit/ml in d5w generic 1

PRADAXA (CAP 75 MG, CAP 150 MG) BRAND 2 MDD 2 per day

warfarin sodium (tab 1 mg, tab 2 mg, tab 2.5mg, tab 3 mg, tab 4 mg, tab 5 mg, tab 6 mg, tab7.5 mg, tab 10 mg)

generic 1

XARELTO (TAB 10 MG, TAB 20 MG) BRAND 2 MDD 1 per day

XARELTO TAB 15 MG BRAND 2 MDD 2 per day



BLOOD FORMATION MODIFIERS

anagrelide hcl generic 1

ARANESP (ALBUMIN FREE) (SOLN PRSYR150 MCG/0.3ML, SOLN PRSYR 200MCG/0.4ML, SOLN PRSYR 300 MCG/0.6ML,SOLN PRSYR 500 MCG/ML, SOLUTION 40MCG/ML, SOLUTION 60 MCG/ML, SOLUTION100 MCG/ML)

BRAND 4PA

S Specialty Drug

ARANESP (ALBUMIN FREE) SOLUTION 25MCG/ML BRAND 4 S Specialty Drug

EPOGEN BRAND 4PA

S Specialty Drug

LEUKINE (RECON SOLN 250 MCG,SOLUTION 500 MCG/ML) BRAND 4

PA

S Specialty Drug

MOZOBIL BRAND 4PA

S Specialty Drug

NEULASTA BRAND 4PA

S Specialty Drug

NEULASTA ONPRO BRAND 4PA

S Specialty Drug

NEUPOGEN BRAND 4PA

S Specialty Drug

NPLATE BRAND 4PA

S Specialty Drug

OMONTYS SOLUTION 10 MG/ML BRAND 3

PROCRIT BRAND 4PA

S Specialty Drug

PROMACTA BRAND 4PA

S Specialty Drug



COAGULANTS

tranexamic acid (iv soln 1000 mg/10ml (100mg/ml), tab 650 mg) generic 1

PLATELET MODIFYING AGENTS

AGGRENOX BRAND 2PA

MDD 2 per day

aspirin-dipyridamole generic 1PA

MDD 2 per day

BRILINTA TAB 90 MG BRAND 2

cilostazol generic 1

clopidogrel bisulfate tab 300 mg (base equiv) generic 1

clopidogrel bisulfate tab 75 mg (base equiv) generic 1 MDD 1 per day

dipyridamole generic 1

EFFIENT BRAND 2 MDD 1 per day

REOPRO BRAND 3

ticlopidine hcl generic 1

CARDIOVASCULAR AGENTS

ALPHA-ADRENERGIC AGONISTS

clonidine hcl (tab 0.1 mg, tab 0.2 mg, tab 0.3mg) generic 1 MDD 8 per day

guanabenz acetate generic 1

guanfacine hcl generic 1

methyldopa (tab 250 mg, tab 500 mg) generic 1 MDD 6 per day

methyldopate hcl generic 3

midodrine hcl generic 1

ALPHA-ADRENERGIC BLOCKING AGENTS

DIBENZYLINE BRAND 3



doxazosin mesylate generic 1

phenoxybenzamine hcl generic 3

prazosin hcl (cap 1 mg, cap 2 mg, cap 5 mg) generic 1 MDD 4 per day

ANGIOTENSIN II RECEPTOR ANTAGONISTS

BENICAR BRAND 2 MDD 1 per day

candesartan cilexetil generic 1 MDD 1 per day

EDARBI BRAND 3ST

MDD 1 per day

eprosartan mesylate generic 1 MDD 1 per day

irbesartan generic 1 MDD 1 per day

losartan potassium generic 1 MDD 1 per day

MICARDIS BRAND 3 MDD 1 per day

telmisartan generic 1 MDD 1 per day

TEVETEN TAB 400 MG BRAND 3ST

MDD 2 per day

TEVETEN TAB 600 MG BRAND 3ST

MDD 1 per day

valsartan generic 1 MDD 1 per day

ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITORS

benazepril hcl generic 1

captopril generic 1

enalapril maleate generic 1

fosinopril sodium generic 1

lisinopril generic 1

moexipril hcl generic 1

perindopril erbumine generic 1



quinapril hcl generic 1

ramipril generic 1

trandolapril generic 1

ANTIARRHYTHMICS

amiodarone hcl (inj 150 mg/3ml (50 mg/ml), tab100 mg, tab 200 mg, tab 400 mg) generic 1

AMIODARONE HCL SOLUTION 900 MG/18ML BRAND 1

disopyramide phosphate (cap 100 mg, cap 150mg) generic 1

flecainide acetate generic 1

mexiletine hcl (cap 150 mg, cap 200 mg, cap250 mg) generic 1

MULTAQ BRAND 3

PROCAINAMIDE HCL SOLUTION 500 MG/ML BRAND 1

propafenone hcl generic 1

quinidine sulfate generic 1

sotalol hcl (tab 80 mg, tab 120 mg, tab 160 mg) generic 1 MDD 2 per day

sotalol hcl tab 240 mg generic 1

TIKOSYN BRAND 2

BETA-ADRENERGIC BLOCKING AGENTS

acebutolol hcl (cap 200 mg, cap 400 mg) generic 1

atenolol (tab 25 mg, tab 50 mg, tab 100 mg) generic 1

betaxolol hcl generic 1

bisoprolol fumarate generic 1

BYSTOLIC (TAB 2.5 MG, TAB 5 MG, TAB 10MG) BRAND 2 MDD 1 per day

BYSTOLIC TAB 20 MG BRAND 2 MDD 2 per day

carvedilol generic 1

labetalol hcl (iv soln 5 mg/ml, tab 100 mg, tab200 mg, tab 300 mg) generic 1



LEVATOL BRAND 3

metoprolol succinate generic 1

metoprolol tartrate (inj 1 mg/ml, tab 25 mg, tab50 mg, tab 100 mg) generic 1

nadolol (tab 20 mg, tab 40 mg, tab 80 mg) generic 1

pindolol generic 1

propranolol hcl (cap sr 24hr 80 mg, cap sr 24hr60 mg, cap sr 24hr 120 mg, cap sr 24hr 160mg, inj 1 mg/ml, oral soln 20 mg/5ml, oral soln40 mg/5ml, tab 10 mg, tab 20 mg, tab 40 mg,tab 60 mg, tab 80 mg)

generic 1

timolol maleate (tab 5 mg, tab 10 mg, tab 20mg) generic 1

CALCIUM CHANNEL BLOCKING AGENTS

amlodipine besylate generic 1

diltiazem hcl (cap sr 12hr 90 mg, cap sr 12hr120 mg, cap sr 12hr 60 mg, cap sr 24hr 240mg, cap sr 24hr 120 mg, cap sr 24hr 180 mg, ivsoln 50 mg/10ml (5 mg/ml), tab 30 mg, tab 60mg, tab 90 mg, tab 120 mg)

generic 1

diltiazem hcl coated beads generic 1

diltiazem hcl extended release beads (beadscap 24hr 360 mg, beads cap 24hr 180 mg,beads cap 24hr 300 mg, beads cap 24hr 240mg, beads cap 24hr 120 mg)

generic 1

DILTIAZEM HCL RECON SOLN 100 MG BRAND 1

felodipine generic 1

isradipine generic 1

nicardipine hcl (cap 20 mg, cap 30 mg, iv soln2.5 mg/ml) generic 1



nifedipine (cap 10 mg, cap 20 mg, tab sr 24hr60 mg, tab sr 24hr osmotic release 60 mg, tabsr 24hr osmotic 60 mg, tab sr 24hr osmoticrelease 30 mg, tab sr 24hr osmotic 30 mg, tabsr 24hr osmotic 90 mg, tab sr 24hr 30 mg, tabsr 24hr 90 mg)

generic 1

nimodipine generic 1

nisoldipine (tab 24hr 30 mg, tab 24hr 8.5 mg,tab 24hr 17 mg, tab 24hr 34 mg, tab 24hr 40mg, tab 24hr 20 mg)

generic 1

verapamil hcl (cap sr 24hr 100 mg, cap sr 24hr240 mg, cap sr 24hr 120 mg, cap sr 24hr 180mg, cap sr 24hr 360 mg, cap sr 24hr 200 mg,cap sr 24hr 300 mg, iv soln 2.5 mg/ml, tab 40mg, tab 80 mg, tab 120 mg, tab cr 120 mg, tabcr 180 mg, tab cr 240 mg)

generic 1

CARDIOVASCULAR AGENTS, OTHER

amiloride & hydrochlorothiazide generic 1

amlodipine besylate-benazepril hcl generic 1

atenolol & chlorthalidone generic 1

benazepril & hydrochlorothiazide generic 1

BIDIL BRAND 2

digoxin (inj 0.25 mg/ml, oral soln 0.05 mg/ml,tab 125 mcg (0.125 mg), tab 250 mcg (0.25mg))

generic 1

enalapril maleate & hydrochlorothiazide generic 1

fosinopril sodium & hydrochlorothiazide generic 1

LANOXIN (SOLUTION 0.25 MG/ML, TAB 62.5MCG, TAB 125 MCG, TAB 187.5 MCG, TAB250 MCG)

BRAND 2

lisinopril & hydrochlorothiazide generic 1

losartan potassium & hydrochlorothiazide generic 1 MDD 1 per day

pentoxifylline tab cr 400 mg generic 1 MDD 3 per day

RANEXA TAB ER 12H 500 MG BRAND 2 MDD 3 per day



spironolactone & hydrochlorothiazide generic 1

TEKTURNA BRAND 2 MDD 1 per day

triamterene & hydrochlorothiazide (cap 37.5-25mg, tab 37.5-25 mg, tab 75-50 mg) generic 1

valsartan-hydrochlorothiazide generic 1

DIURETICS, CARBONIC ANHYDRASE INHIBITORS

acetazolamide cap sr 12hr 500 mg generic 1 MDD 2 per day

acetazolamide sodium generic 1

acetazolamide tab 125 mg generic 1 MDD 8 per day

acetazolamide tab 250 mg generic 1 MDD 4 per day

DIURETICS, LOOP

bumetanide (tab 0.5 mg, tab 1 mg, tab 2 mg) generic 1 MDD 5 per day

bumetanide inj 0.25 mg/ml generic 1

EDECRIN BRAND 3 MDD 16 per day

furosemide (inj 10 mg/ml, oral soln 8 mg/ml,oral soln 10 mg/ml, tab 20 mg, tab 40 mg, tab80 mg)

generic 1

torsemide (iv soln 20 mg/2ml (10 mg/ml), tab 5mg, tab 10 mg, tab 20 mg, tab 100 mg) generic 1

DIURETICS, POTASSIUM-SPARING

amiloride hcl tab 5 mg generic 1

DYRENIUM BRAND 3 MDD 3 per day

eplerenone generic 1

spironolactone (tab 25 mg, tab 50 mg, tab 100mg) generic 1

DIURETICS, THIAZIDE

chlorothiazide generic 1

chlorthalidone generic 1



hydrochlorothiazide (cap 12.5 mg, tab 12.5 mg,tab 25 mg, tab 50 mg) generic 1 MDD 2 per day

indapamide tab 1.25 mg generic 1 MDD 1 per day

indapamide tab 2.5 mg generic 1 MDD 2 per day

methyclothiazide tab 5 mg generic 1

metolazone generic 1 MDD 2 per day

DYSLIPIDEMICS, FIBRIC ACID DERIVATIVES

fenofibrate (tab 48 mg, tab 54 mg, tab 145 mg,tab 160 mg) generic 1 MDD 1 per day

fenofibrate micronized (cap 67 mg, cap 134mg, cap 200 mg) generic 1 MDD 1 per day

gemfibrozil tab 600 mg generic 1 MDD 2 per day

DYSLIPIDEMICS, HMG COA REDUCTASE INHIBITORS

ALTOPREV BRAND 3 MDD 1 per day

atorvastatin calcium (tab 10 mg, tab 20 mg, tab40 mg, tab 80 mg) generic 1 MDD 1 per day

CRESTOR BRAND 2 ST

fluvastatin sodium cap 20 mg generic 3 MDD 1 per day

fluvastatin sodium cap 40 mg generic 3 MDD 2 per day

LIVALO BRAND 3ST

MDD 1 per day

lovastatin (tab 10 mg, tab 20 mg) generic 1 MDD 1 per day

lovastatin tab 40 mg generic 1 MDD 2 per day

pravastatin sodium generic 1 MDD 1 per day

simvastatin generic 1 MDD 1 per day

DYSLIPIDEMICS, OTHER

ADVICOR (TAB ER 24H 1000-40 MG, TAB ER24H 750-20 MG, TAB ER 24H 500-20 MG) BRAND 3

PA

MDD 1 per day



ADVICOR TAB ER 24H 1000-20 MG BRAND 3PA

MDD 2 per day

cholestyramine light powder 4 gm/dose generic 1MDS 720 GM / 30 DAY

MDS2 2160 GM / 90 DAY

cholestyramine light powder packets 4 gm generic 1 MDD 6 per day

cholestyramine powder 4 gm/dose generic 1MDS 756 GM / 30 DAY

MDS2 2268 GM / 90 DAY

cholestyramine powder packets 4 gm generic 1 MDD 6 per day

colestipol hcl (granule packets 5 gm, granules 5gm) generic 1 MDD 6 per day

colestipol hcl tab 1 gm generic 1 MDD 16 per day

niacin (antihyperlipidemic) generic 1 MDD 2 per day

NIASPAN (TAB ER 500 MG, TAB ER 750 MG) BRAND 2 MDD 2 per day

NIASPAN TAB ER 1000 MG BRAND 2ST

MDD 2 per day

omega-3-acid ethyl esters generic 1ST

MDD 4 per day

SIMCOR (TAB ER 24H 1000-40 MG, TAB ER24H 500-40 MG, TAB ER 24H 750-20 MG,TAB ER 24H 500-20 MG)

BRAND 2PA

MDD 1 per day

SIMCOR TAB ER 24H 1000-20 MG BRAND 2PA

MDD 2 per day

VYTORIN BRAND 2ST

MDD 1 per day

WELCHOL PACKET 3.75 GM BRAND 2 MDD 1 per day

WELCHOL TAB 625 MG BRAND 2 MDD 7 per day

ZETIA BRAND 2ST

MDD 1 per day



VASODILATORS, DIRECT-ACTING ARTERIAL

hydralazine hcl (inj 20 mg/ml, tab 10 mg, tab 25mg, tab 50 mg, tab 100 mg) generic 1

minoxidil (tab 2.5 mg, tab 10 mg) generic 1

VASODILATORS, DIRECT-ACTING ARTERIAL/VENOUS

isosorbide dinitrate (tab 5 mg, tab 10 mg, tab20 mg, tab 30 mg, tab cr 40 mg) generic 1

isosorbide mononitrate (tab 20 mg, tab sr 24hr120 mg, tab sr 24hr 30 mg, tab sr 24hr 60 mg) generic 1

MONOKET TAB 20 MG BRAND 3

NITRO-BID BRAND 3

nitroglycerin (iv soln 5 mg/ml, td patch 24hr 0.4mg/hr, td patch 24hr 0.1 mg/hr, td patch 24hr0.2 mg/hr, td patch 24hr 0.6 mg/hr)

generic 1

NITROSTAT BRAND 2

CENTRAL NERVOUS SYSTEM AGENTS

ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, AMPHETAMINES

amphetamine-dextroamphetamine (cap 24hr 30mg, cap 24hr 20 mg, cap 24hr 25 mg) generic 1

AL 6 to 18 yrs old

MDD 2 per day

C PA required for age >18

amphetamine-dextroamphetamine (cap 24hr 5mg, cap 24hr 10 mg) generic 1

AL 6 to 18 yrs old

MDD 1 per day


amphetamine-dextroamphetamine (tab 5 mg,tab 7.5 mg, tab 10 mg, tab 12.5 mg, tab 15 mg,tab 20 mg)

generic 1AL At least 6 yrs old

MDD 3 per day

amphetamine-dextroamphetamine cap sr 24hr15 mg generic 1

AL 6 to 18 yrs old


amphetamine-dextroamphetamine tab 30 mg generic 1 AL At least 6 yrs old



DESOXYN BRAND 3AL At least 6 yrs old

MDD 5 per day

dextroamphetamine sulfate (cap 24hr 15 mg,cap 24hr 10 mg) generic 1

AL 6 to 18 yrs old

MDD 4 per day


dextroamphetamine sulfate (tab 5 mg, tab 10mg) generic 1


MDD 4 per day

dextroamphetamine sulfate cap sr 24hr 5 mg generic 1AL 6 to 18 yrs old


methamphetamine hcl generic 3AL At least 6 yrs old

MDD 5 per day

VYVANSE BRAND 2

AL 6 to 17 yrs old

MDD 1 per day


ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, NON-AMPHETAMINES

dexmethylphenidate hcl (tab 2.5 mg, tab 5 mg,tab 10 mg) generic 1


MDD 2 per day

guanfacine hcl (adhd) generic 1

PA


MDD 1 per day

INTUNIV BRAND 2

PA


MDD 1 per day

methylphenidate hcl (cap 24hr 20 mg (la), cap24hr 40 mg, cap 24hr 40 mg (la), cap 24hr 20mg)

generic 1 AL 6 to 18 yrs old



methylphenidate hcl (cap cr 10 mg, cap cr 20mg, cap cr 30 mg, cap cr 40 mg, cap cr 50 mg,cap cr 60 mg, tab sa osm 18 mg, tab sa osm 27mg, tab sr 24hr 27 mg, tab sr 24hr 18 mg)

generic 1AL 6 to 18 yrs old

MDD 1 per day

methylphenidate hcl (cap sr 24hr 30 mg (la),cap sr 24hr 30 mg, tab cr 10 mg, tab cr 20 mg) generic 1

AL 6 to 18 yrs old

MDD 3 per day

methylphenidate hcl (soln 5 mg/5ml, soln 10mg/5ml) generic 1


MDS 900 / 30 DAY

methylphenidate hcl (tab 5 mg, tab 10 mg, tab20 mg) generic 1


MDD 5 per day

methylphenidate hcl (tab sa osm 36 mg, tab saosm 54 mg, tab sr 24hr 36 mg, tab sr 24hr 54mg)

generic 1AL 6 to 18 yrs old

MDD 2 per day

METHYLPHENIDATE HCL ER (ER TAB ER24H 54 MG, ER TAB ER 24H 36 MG) BRAND 1

AL 6 to 18 yrs old

MDD 2 per day

METHYLPHENIDATE HCL ER TAB ER 24H 27MG BRAND 1

AL 6 to 18 yrs old

MDD 1 per day

STRATTERA (CAP 10 MG, CAP 18 MG, CAP25 MG, CAP 40 MG) BRAND 2

PA


MDD 2 per day

STRATTERA (CAP 60 MG, CAP 80 MG, CAP100 MG) BRAND 2

PA


MDD 1 per day

CENTRAL NERVOUS SYSTEM, OTHER

butalbital-acetaminophen-caffeine (cap 50-325-40 mg, cap 50-500-40 mg, cap 50-300-40 mg,tab 50-325-40 mg, tab 50-500-40 mg)

generic 1

butalbital-aspirin-caffeine cap 50-325-40 mg generic 1

HORIZANT TAB ER 600 MG BRAND 3

NUEDEXTA BRAND 3

ORBIVAN BRAND 2



RILUTEK BRAND 3

riluzole generic 3

tetrabenazine generic 4PA

S Specialty Drug

XENAZINE BRAND 4PA

S Specialty Drug

FIBROMYALGIA AGENTS

duloxetine hcl (cap 20 mg, cap 30 mg, cap 60mg) generic 1 MDD 2 per day

LYRICA (CAP 225 MG, CAP 300 MG) BRAND 2PA

MDD 2 per day

LYRICA (CAP 25 MG, CAP 50 MG, CAP 75MG, CAP 100 MG, CAP 150 MG, CAP 200MG)

BRAND 2PA

MDD 3 per day

LYRICA SOLUTION 20 MG/ML BRAND 2MDS 900 ML / 30 DAY

MDS2 2700 ML / 90 DAY

SAVELLA BRAND 2PA

MDD 2 per day

SAVELLA TITRATION PACK BRAND 2 PA

MULTIPLE SCLEROSIS AGENTS

AMPYRA BRAND 4PA

S Specialty Drug

AVONEX BRAND 4PA

S Specialty Drug

AVONEX PEN BRAND 4PA

S Specialty Drug

AVONEX PREFILLED BRAND 4PA

S Specialty Drug



BETASERON BRAND 4PA

S Specialty Drug

COPAXONE BRAND 4PA

S Specialty Drug

EXTAVIA BRAND 4PA

S Specialty Drug

GILENYA BRAND 4PA

S Specialty Drug

glatiramer acetate generic 4PA

S Specialty Drug

REBIF BRAND 4PA

S Specialty Drug

REBIF REBIDOSE BRAND 4PA

S Specialty Drug

REBIF REBIDOSE TITRATION PACK BRAND 4PA

S Specialty Drug

REBIF TITRATION PACK BRAND 4PA

S Specialty Drug

TYSABRI BRAND 4PA

S Specialty Drug

ZINBRYTA BRAND 4 PA

DENTAL AND ORAL AGENTS

ARESTIN BRAND 3 PA

cevimeline hcl generic 1

chlorhexidine gluconate (mouth-throat) generic 1

GEL-KAM ORAL CARE RINSE BRAND 0

KEPIVANCE BRAND 4PA

S Specialty Drug



pilocarpine hcl (oral) generic 1

stannous fluoride conc 0.63% generic 0

DERMATOLOGICAL AGENTS

acitretin (cap 10 mg, cap 17.5 mg) generic 1 MDD 1 per day

acitretin cap 25 mg generic 1 MDD 2 per day

adapalene (cream, gel) generic 1PA


adapalene gel 0.3% generic 1ST


ADAPALENE LOTION 0.1 % BRAND 1ST


AZELEX BRAND 3ST


benzoyl peroxide (foam 5.3%, foam 9.8%, gel5%, gel 10%, liq 4%, liq 7%, liq 10%, lotion 6%) generic 1 AL At least 12 yrs old

benzoyl peroxide-erythromycin generic 1

PA


MPL 1 / day

calcipotriene (cream, oint, soln (50 mcg/ml)) generic 1 MPL 1 / day

calcipotriene-betamethasone dipropionate generic 1 ST

calcitriol (topical) generic 1 MPL 1 / day

clindamycin phosphate swab 1% generic 1 AL At least 12 yrs old

clindamycin phosphate-benzoyl peroxide generic 1PA


clindamycin phosphate-benzoyl peroxide(refrigerate) generic 1

PA


clotrimazole w/ betamethasone (w/ cream, w/lotion) generic 1



CORTISPORIN (CREAM 3.5-10000-0.5,OINTMENT 1 %) BRAND 2

diclofenac sodium (actinic keratoses) generic 1 MPL 1 / day

diclofenac sodium gel 1% generic 1

DIFFERIN LOTION 0.1 % BRAND 2ST


ELIDEL BRAND 2

PA


MPL 1 / 30 day

EPIDUO BRAND 3ST


FINACEA GEL 15 % BRAND 2

finasteride (alopecia) generic 1

fluorouracil (topical) (cream 5%, soln 2%, soln5%) generic 1 MPL 1 / day

hydrocortisone (topical) (cream 1%, cream2.5%, lotion 2.5%, oint 1%, oint 2.5%) generic 1

imiquimod cream 5% generic 1 MDS 12 / CLAIM(S)

isotretinoin (cap 10 mg, cap 20 mg, cap 30 mg,cap 40 mg) generic 3

PA


lactic acid (ammonium lactate) (cream, lotion) generic 1

lidocaine hcl soln 4% generic 1

lidocaine patch 5% generic 1

LIDODERM BRAND 2

methoxsalen rapid generic 1 MDD 4 per day

OXSORALEN BRAND 2

OXSORALEN ULTRA BRAND 2 MDD 4 per day

PICATO BRAND 2

podofilox generic 1



PRUDOXIN BRAND 3

RECTIV BRAND 3

REGRANEX BRAND 3

SANTYL BRAND 3

selenium sulfide generic 1 MPL 1 / day

SOLARAZE BRAND 2 MPL 1 / day

SORIATANE (CAP 10 MG, CAP 17.5 MG) BRAND 2 MDD 1 per day

SORIATANE CAP 25 MG BRAND 2 MDD 2 per day

STELARA BRAND 4PA

S Specialty Drug

sulfacetamide sodium (acne) generic 1AL At least 12 yrs old

MPL 1 / day

sulfacetamide sodium w/ sulfur (w/ cream 10-5%, w/ wash 9-4.5%) generic 1

ST


sulfacetamide sodium w/ sulfur emulsion 10-5% generic 1 AL At least 12 yrs old

SYNERA BRAND 3

TACLONEX BRAND 3 ST

tacrolimus (topical) generic 1AL At least 2 yrs old

MPL 1 / 30 day

TAZORAC BRAND 2

tretinoin (cream 0.025%, cream 0.05%, cream0.1%, gel 0.01%, gel 0.025%) generic 1 AL At least 12 yrs old

tretinoin microsphere gel 0.1% generic 1PA


VECTICAL BRAND 1 MPL 1 / day

VELTIN BRAND 3ST




VEREGEN BRAND 3

VOLTAREN GEL 1 % BRAND 2

ZIANA BRAND 3ST


ZONALON BRAND 3

ENZYME REPLACEMENT/MODIFIERS

ADAGEN BRAND 4PA

S Specialty Drug

ALDURAZYME BRAND 4PA

S Specialty Drug

BUPHENYL (POWDER 3 GM/TSP, TAB 500MG) BRAND 3

CARBAGLU BRAND 4PA

S Specialty Drug

CEREZYME BRAND 4PA

S Specialty Drug

CREON BRAND 2

CYSTADANE BRAND 4PA

S Specialty Drug

ELAPRASE BRAND 4PA

S Specialty Drug

ELELYSO BRAND 4PA

S Specialty Drug

FABRAZYME RECON SOLN 35 MG BRAND 4PA

S Specialty Drug

KUVAN TAB SOL 100 MG BRAND 4PA

S Specialty Drug

LUMIZYME BRAND 4PA

S Specialty Drug



MYOZYME BRAND 4PA

S Specialty Drug

NAGLAZYME BRAND 4PA

S Specialty Drug

ORFADIN (CAP 2 MG, CAP 5 MG, CAP 10MG) BRAND 4

PA

S Specialty Drug

PANCREAZE BRAND 2

pancrelipase (lipase-protease-amylase) generic 1

sodium phenylbutyrate generic 3

SUCRAID BRAND 3

VPRIV BRAND 4PA

S Specialty Drug

ZAVESCA BRAND 4PA

S Specialty Drug

ZENPEP (CP DR PART 3000-10000, CP DRPART 5000, CP DR PART 10000, CP DRPART 15000, CP DR PART 20000, CP DRPART 25000)

BRAND 2

GASTROINTESTINAL AGENTS

ANTISPASMODICS, GASTROINTESTINAL

atropine sulfate (inj 0.1 mg/ml, inj 0.4 mg/ml, inj1 mg/ml) generic 1

ATROPINE SULFATE SOLUTION 0.05 MG/ML BRAND 1

CANTIL BRAND 3

chlordiazepoxide hcl-clidinium bromide generic 1

dicyclomine hcl (cap 10 mg, oral soln 10mg/5ml, tab 20 mg) generic 1

glycopyrrolate (inj 4 mg/20ml (0.2 mg/ml), tab 1mg, tab 2 mg) generic 1

methscopolamine bromide generic 1



GASTROINTESTINAL AGENTS, OTHER

CHOLBAM BRAND 4PA

S Specialty Drug

diphenoxylate w/ atropine (w/ liq mg/5ml, w/ tabmg) generic 1

ENTEREG BRAND 3

loperamide hcl cap 2 mg generic 1

MOTOFEN BRAND 3

RELISTOR (KIT 12 MG/0.6ML, SOLUTION 8MG/0.4ML, SOLUTION 12 MG/0.6ML) BRAND 2

ursodiol (cap 300 mg, tab 250 mg, tab 500 mg) generic 1

HISTAMINE2 (H2) RECEPTOR ANTAGONISTS

cimetidine (tab 200 mg, tab 300 mg, tab 400mg, tab 800 mg) generic 1

cimetidine hcl generic 1MDS 600 ML / 30 DAY

MDS2 1800 ML / 90 DAY

famotidine (inj 20 mg/2ml, inj 40 mg/4ml, inj200 mg/20ml, inj 500 mg/50ml, tab 20 mg, tab40 mg)

generic 1

famotidine for susp 40 mg/5ml generic 1MDS 300 ML / 30 DAY


FAMOTIDINE PREMIXED BRAND 1

nizatidine (cap 150 mg, cap 300 mg) generic 1

nizatidine oral soln 15 mg/ml generic 1MDS 600 ML / 30 DAY

MDS2 1800 ML / 90 DAY

ranitidine hcl (cap 150 mg, cap 300 mg, inj 50mg/2ml (25 mg/ml), inj 150 mg/6ml (25 mg/ml),tab 150 mg, tab 300 mg)

generic 1

ranitidine hcl syrup 15 mg/ml (75 mg/5ml) generic 1MDS 600 ML / 30 DAY

MDS2 1800 ML / 90 DAY



IRRITABLE BOWEL SYNDROME AGENTS

alosetron hcl generic 1

AMITIZA BRAND 2PA

MDD 2 per day

LOTRONEX BRAND 2

LAXATIVES

GOLYTELY RECON SOLN 236 GM BRAND 0

lactulose generic 1

lactulose (encephalopathy) generic 1

MOVIPREP BRAND 2

OSMOPREP BRAND 3

peg 3350-kcl-sod bicarb-sod chloride-sodsulfate (soln 236 gm, soln 236 gm) generic 0

PREPOPIK BRAND 3

SUPREP BOWEL PREP BRAND 0

VISICOL BRAND 3 MDS 40 / 180 DAY

PROTECTANTS

CARAFATE SUSPENSION 1 GM/10ML BRAND 2MDS 1200 ML / 30 DAY

MDS2 3600 ML / 90 DAY

CARAFATE TAB 1 GM BRAND 2 MDD 4 per day

misoprostol (tab 100 mcg, tab 200 mcg) generic 1 MDD 4 per day

sucralfate tab 1 gm generic 1 MDD 4 per day

PROTON PUMP INHIBITORS

DEXILANT BRAND 3ST

MDD 1 per day

esomeprazole magnesium cap delayed release40 mg (base eq) generic 3

ST

MDD 1 per day



lansoprazole cap delayed release 15 mg generic 1 MDD 1 per day

lansoprazole cap delayed release 30 mg generic 1

omeprazole (cap 10 mg, cap 20 mg, cap 40mg) generic 1 MDD 2 per day

omeprazole-sodium bicarbonate cap 20-1100mg generic 1 MDD 1 per day

pantoprazole sodium ec tab 20 mg (base equiv) generic 1 MDD 1 per day

pantoprazole sodium ec tab 40 mg (base equiv) generic 1

rabeprazole sodium generic 1 MDD 1 per day

GENITOURINARY AGENTS

ANTISPASMODICS, URINARY

DETROL LA BRAND 3PA

MDD 1 per day

ENABLEX BRAND 3PA

MDD 1 per day

flavoxate hcl generic 1

MYRBETRIQ BRAND 3 PA

oxybutynin chloride (syrup 5 mg/5ml, tab 5 mg,tab sr 24hr 15 mg, tab sr 24hr 10 mg, tab sr24hr 5 mg)

generic 1

tolterodine tartrate (cap 24hr 4 mg, cap 24hr 2mg) generic 1 MDD 1 per day

tolterodine tartrate (tab 1 mg, tab 2 mg) generic 1

TOVIAZ BRAND 3PA

MDD 1 per day

trospium chloride cap sr 24hr 60 mg generic 1 MDD 1 per day

trospium chloride tab 20 mg generic 1

VESICARE BRAND 2PA

MDD 1 per day



BENIGN PROSTATIC HYPERTROPHY AGENTS

alfuzosin hcl generic 1 MDD 1 per day

AVODART BRAND 2PA

MDD 1 per day

CIALIS TAB 5 MG BRAND 3PA

MDD 1 per day

dutasteride generic 1PA

MDD 1 per day

finasteride tab 5 mg generic 1

RAPAFLO BRAND 2

tamsulosin hcl generic 1

terazosin hcl generic 1

GENITOURINARY AGENTS, OTHER

bethanechol chloride generic 1 MDD 4 per day

CUPRIMINE BRAND 3

CYSTAGON BRAND 3 PA

ELMIRON BRAND 2

glycine irrigation soln 1.5% generic 1

phenazopyridine hcl (tab 100 mg, tab 200 mg) generic 1

potassium citrate tab cr 10 meq (1080 mg) generic 1

RESECTISOL BRAND 1

sodium chloride (gu irrigant) generic 1

sodium citrate & citric acid generic 1

SORBITOL (SOLUTION 3 %, SOLUTION 3.3%) BRAND 1

SORBITOL-MANNITOL BRAND 1

STENDRA BRAND 3 MDS 4 / 30 DAY



PHOSPHATE BINDERS

calcium acetate (phosphate binder) generic 1

FOSRENOL (CHEW TAB 500 MG, CHEW TAB750 MG, CHEW TAB 1000 MG) BRAND 2

PHOSLYRA BRAND 2

RENAGEL BRAND 3

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (ADRENAL)

A-HYDROCORT BRAND 1

alclometasone dipropionate generic 1

amcinonide (lotion, oint) generic 3

amcinonide cream 0.1% generic 1

betamethasone dipropionate (topical) (cream,lotion, oint) generic 1

betamethasone dipropionate augmented(cream, lotion, oint) generic 1

betamethasone valerate (aerosol foam 0.12%,cream 0.1%, lotion 0.1%, oint 0.1%) generic 1

clobetasol propionate (cream, foam, gel, oint,soln) generic 1

clobetasol propionate emollient base generic 1

CLODERM BRAND 3

CLODERM PUMP BRAND 3

CORDRAN (CREAM 0.05 %, LOTION 0.05 %,TAPE 4 MCG/SQCM) BRAND 3

cortisone acetate tab 25 mg generic 1

DEPO-MEDROL SUSPENSION 20 MG/ML BRAND 3

desonide (cream, lotion, oint) generic 1

desoximetasone (cream 0.25%, gel 0.05%, oint0.25%) generic 1

dexamethasone (elixir 0.5 mg/5ml, soln 0.5mg/5ml, tab 0.5 mg, tab 0.75 mg, tab 1 mg, tab1.5 mg, tab 2 mg, tab 4 mg, tab 6 mg)

generic 1



DEXAMETHASONE INTENSOL BRAND 1

dexamethasone sodium phosphate (inj 4mg/ml, inj 20 mg/5ml, inj 120 mg/30ml) generic 1

diflorasone diacetate cream 0.05% generic 2

diflorasone diacetate oint 0.05% generic 1

fludrocortisone acetate tab 0.1 mg generic 1

fluocinolone acetonide (cream 0.01%, cream0.025%, oil 0.01% (scalp oil), oint 0.025%, soln0.01%)

generic 1

fluocinonide (cream, gel, oint, soln) generic 1

fluocinonide emulsified base generic 1

fluticasone propionate (cream 0.05%, lotion0.05%, oint 0.005%) generic 1

halobetasol propionate generic 1

HALOG BRAND 3

hydrocortisone generic 1

hydrocortisone acetate (rectal) generic 1

hydrocortisone butyrate (cream, oint, soln) generic 1

hydrocortisone valerate generic 1

KENALOG SUSPENSION 40 MG/ML BRAND 3

MEDROL TAB 2 MG BRAND 3

methylprednisolone (tab 4 mg, tab 4 mg dosepack, tab 8 mg, tab 16 mg, tab 32 mg, tabtherapy pack 4 mg (21))

generic 1

methylprednisolone acetate (inj susp 40 mg/ml,inj susp 80 mg/ml) generic 1

methylprednisolone sod succ generic 1

MILLIPRED (SOLUTION 10 MG/5ML, TAB 5MG) BRAND 3

MILLIPRED DP BRAND 3

MILLIPRED DP 12-DAY BRAND 3

mometasone furoate (cream, oint, solution(lotion)) generic 1



ORAPRED ODT BRAND 3

prednicarbate generic 1

prednisolone sodium phosphate (phosph soln6.7 mg/5ml (5 mg/5ml base), phosphate soln15 mg/5ml (base equiv))

generic 1

prednisolone sodium phosphate (tab 10 mg,tab 15 mg, tab 30 mg) generic 3

PREDNISOLONE SODIUM PHOSPHATESOLUTION 25 MG/5ML BRAND 1

prednisolone syrup 15 mg/5ml (usp solutionequivalent) generic 1

prednisone (oral soln 5 mg/5ml, tab 1 mg, tab2.5 mg, tab 5 mg, tab 10 mg, tab 20 mg, tab 50mg)

generic 1

SOLU-CORTEF RECON SOLN 250 MG BRAND 3

SOLU-MEDROL RECON SOLN 2 GM BRAND 3

triamcinolone acetonide (mouth) generic 1

triamcinolone acetonide (topical) (cream0.025%, cream 0.1%, cream 0.5%, lotion0.025%, lotion 0.1%, oint 0.025%, oint 0.1%,oint 0.5%)

generic 1

VERIPRED 20 BRAND 3

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (PITUITARY)

chorionic gonadotropin for inj 10000 unit generic 4PA

S Specialty Drug

desmopressin acetate inj 4 mcg/ml generic 1 PA

desmopressin acetate spray generic 1

desmopressin acetate spray refrigerated generic 1

desmopressin acetate tab 0.1 mg generic 1PA

MDD 6 per day

desmopressin acetate tab 0.2 mg generic 1PA

MDD 8 per day



GENOTROPIN MINIQUICK RECON SOLN 0.2MG BRAND 4

PA

S Specialty Drug

GENOTROPIN RECON SOLN 5 MG BRAND 4PA

S Specialty Drug

HUMATROPE BRAND 4PA

S Specialty Drug

INCRELEX BRAND 4PA

S Specialty Drug

NORDITROPIN BRAND 4PA

S Specialty Drug

NORDITROPIN FLEXPRO (SOLUTION 5MG/1.5ML, SOLUTION 10 MG/1.5ML,SOLUTION 15 MG/1.5ML)

BRAND 4PA

S Specialty Drug

NORDITROPIN NORDIFLEX PEN (PENSOLUTION 5 MG/1.5ML, PEN SOLUTION 10MG/1.5ML, PEN SOLUTION 15 MG/1.5ML)

BRAND 4PA

S Specialty Drug

NUTROPIN BRAND 4PA

S Specialty Drug

NUTROPIN AQ BRAND 4PA

S Specialty Drug

NUTROPIN AQ NUSPIN 10 BRAND 4PA

S Specialty Drug

NUTROPIN AQ PEN SOLUTION 10 MG/2ML BRAND 4PA

S Specialty Drug

OMNITROPE (SOLUTION 5 MG/1.5ML,SOLUTION 10 MG/1.5ML) BRAND 4

PA

S Specialty Drug

SAIZEN BRAND 4PA

S Specialty Drug

SAIZEN CLICK.EASY BRAND 4PA

S Specialty Drug



SEROSTIM BRAND 4PA

S Specialty Drug

STIMATE BRAND 4PA

S Specialty Drug

TEV-TROPIN BRAND 4PA

S Specialty Drug

ZOMACTON BRAND 4PA

S Specialty Drug

ZORBTIVE BRAND 4PA

S Specialty Drug

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (SEX HORMONES/MODIFIERS)

ANDROGENS

ANDRODERM (PATCH 24HR 4 MG/24HR,PATCH 24HR 2 MG/24HR) BRAND 2

PA

MDD 1 per day

ANDROXY BRAND 3

danazol (cap 50 mg, cap 100 mg, cap 200 mg) generic 1

METHITEST BRAND 3

testosterone cypionate (j oil 100 mg/ml, j oil 200mg/ml) generic 1

testosterone enanthate im inj in oil 200 mg/ml generic 1

ESTROGENS

ALORA BRAND 3 GL Female

BEYAZ BRAND 0 GL Female

BREVICON (28) BRAND 0 GL Female

CENESTIN BRAND 3 GL Female

CLIMARA PRO BRAND 3 GL Female

CYCLESSA BRAND 0 GL Female



DEPO-ESTRADIOL BRAND 3 GL Female

DESOGEN BRAND 0 GL Female

desogestrel & ethinyl estradiol generic 0 GL Female

desogestrel-ethinyl estradiol (biphasic) generic 0 GL Female

desogestrel-ethinyl estradiol (triphasic) generic 0 GL Female

DIVIGEL (GEL 0.25 MG/0.25GM, GEL 0.5MG/0.5GM, GEL 1 MG/GM) BRAND 3 GL Female

drospirenone-ethinyl estradiol generic 0 GL Female

ELESTRIN BRAND 3 GL Female

ENJUVIA BRAND 3 GL Female

ESTRACE CREAM 0.1 MG/GM BRAND 3 GL Female

ESTRADERM BRAND 3 GL Female

estradiol (tab 0.5 mg, tab 1 mg, tab 2 mg, tdpatch twice weekly 0.025 mg/24hr, td patchtwice weekly 0.0375 mg/24hr, td patch twiceweekly 0.05 mg/24hr, td patch twice weekly0.075 mg/24hr, td patch twice weekly 0.1mg/24hr, td patch weekly 0.025 mg/24hr, tdpatch weekly 0.0375 mg/24hr (37.5 mcg/24hr),td patch weekly 0.05 mg/24hr, td patch weekly0.06 mg/24hr, td patch weekly 0.075 mg/24hr,td patch weekly 0.1 mg/24hr)

generic 1 GL Female

estradiol valerate generic 1 GL Female

ESTRASORB BRAND 3 GL Female

ESTROGEL BRAND 3 GL Female

estropipate generic 1 GL Female

ESTROSTEP FE BRAND 0 GL Female

ethynodiol diacet & eth estrad generic 0 GL Female

EVAMIST BRAND 3 GL Female



FEMCON FE BRAND 0 GL Female

FEMRING BRAND 3 GL Female

GENERESS FE BRAND 0 GL Female

levonorgestrel & eth estradiol generic 0 GL Female

levonorgestrel-eth estradiol (triphasic) generic 0 GL Female

levonorgestrel-ethinyl estradiol (91-day) generic 0 GL Female

levonorgestrel-ethinyl estradiol (continuous) generic 0 GL Female

LO LOESTRIN FE BRAND 0 GL Female

LO/OVRAL (28) BRAND 0 GL Female

LOESTRIN 1.5/30 (21) BRAND 0 GL Female

LOESTRIN 1/20 (21) BRAND 0 GL Female

LOESTRIN 24 FE BRAND 0 GL Female

LOESTRIN FE 1.5/30 BRAND 0 GL Female

LOESTRIN FE 1/20 BRAND 0 GL Female

LOSEASONIQUE BRAND 0 GL Female

MENEST BRAND 3 GL Female

MENOSTAR BRAND 3 GL Female

MINASTRIN 24 FE BRAND 0 GL Female

MINIVELLE (PATCH TW 0.0375 MG/24HR,PATCH TW 0.05 MG/24HR, PATCH TW 0.075MG/24HR, PATCH TW 0.1 MG/24HR)

BRAND 3 GL Female

MIRCETTE BRAND 0 GL Female

MODICON (28) BRAND 0 GL Female

NATAZIA BRAND 0 GL Female

NECON 10/11 (28) BRAND 0 GL Female



NORDETTE (28) BRAND 0 GL Female

norethin acet & estrad-fe generic 0 GL Female

norethindrone & eth estradiol generic 0 GL Female

norethindrone & ethinyl estradiol-fe generic 0 GL Female

norethindrone acet & eth estra generic 0 GL Female

norethindrone acetate-ethinyl estradiol-fe generic 0 GL Female

norethindrone-eth estradiol (triphasic) generic 0 GL Female

norgestimate-ethinyl estradiol generic 0 GL Female

norgestimate-ethinyl estradiol (triphasic) generic 0 GL Female

norgestrel & ethinyl estradiol generic 0 GL Female

NORINYL 1+35 (28) BRAND 0 GL Female

NUVARING BRAND 0 GL Female

OGESTREL BRAND 0 GL Female

ORTHO EVRA BRAND 0 GL Female

ORTHO TRI-CYCLEN (28) BRAND 0 GL Female

ORTHO TRI-CYCLEN LO BRAND 0 GL Female

ORTHO-CEPT (28) BRAND 0 GL Female

ORTHO-CYCLEN (28) BRAND 0 GL Female

ORTHO-NOVUM 1/35 (28) BRAND 0 GL Female

ORTHO-NOVUM 7/7/7 (28) BRAND 0 GL Female

OVCON-35 (28) BRAND 0 GL Female

PREMARIN (CREAM 0.625 MG/GM, RECONSOLN 25 MG, TAB 0.3 MG, TAB 0.45 MG, TAB0.625 MG, TAB 0.9 MG, TAB 1.25 MG)

BRAND 2 GL Female

PREMPHASE BRAND 2 GL Female



PREMPRO BRAND 2 GL Female

SAFYRAL BRAND 0 GL Female

SEASONALE BRAND 0 GL Female

SEASONIQUE BRAND 0 GL Female

TRI-NORINYL (28) BRAND 0 GL Female

VIVELLE-DOT BRAND 3 GL Female

XULANE BRAND 0 GL Female

YASMIN 28 BRAND 0 GL Female

YAZ BRAND 0 GL Female

ZOVIA 1/50E (28) BRAND 0 GL Female

PROGESTERONE AGONISTS/ANTAGONISTS

ELLA BRAND 0 GL Female

PROGESTINS

AYGESTIN BRAND 0

DEPO-PROVERA SUSPENSION 150 MG/ML BRAND 0 GL Female

DEPO-SUBQ PROVERA 104 BRAND 0 GL Female

IMPLANON BRAND 0 GL Female

levonorgestrel (emergency oc) generic 0 GL Female

LILETTA (52 MG) BRAND 0 GL Female

medroxyprogesterone acetate generic 1

medroxyprogesterone acetate (contraceptive) generic 0 GL Female

MEGACE ES BRAND 3

MEGACE ORAL BRAND 3

megestrol acetate (appetite) generic 3

megestrol acetate (susp 40 mg/ml, tab 20 mg,tab 40 mg) generic 1



MIRENA BRAND 0 GL Female

NEXPLANON BRAND 0 GL Female

NOR-QD BRAND 0 GL Female

norethindrone (contraceptive) generic 0 GL Female

norethindrone acetate tab 5 mg generic 0

ORTHO MICRONOR BRAND 0 GL Female

PLAN B BRAND 0 GL Female

PLAN B ONE-STEP BRAND 0 GL Female

progesterone micronized (cap 100 mg, cap 200mg) generic 1

SKYLA BRAND 0 GL Female

SELECTIVE ESTROGEN RECEPTOR MODIFYING AGENTS

EVISTA (TAB 60 MG, 60 MG) BRAND 2GL Female

MDD 1 per day

raloxifene hcl generic 0GL Female

MDD 1 per day

ANABOLIC STEROIDS

ANADROL-50 BRAND 3

oxandrolone (tab 2.5 mg, tab 10 mg) generic 1

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (THYROID)

levothyroxine sodium (for iv inj 100 mcg, for ivinj 500 mcg, tab 25 mcg, tab 50 mcg, tab 75mcg, tab 88 mcg, tab 100 mcg, tab 112 mcg,tab 125 mcg, tab 137 mcg, tab 150 mcg, tab175 mcg, tab 200 mcg, tab 300 mcg)

generic 1

liothyronine sodium (iv soln 10 mcg/ml, tab 5mcg, tab 25 mcg, tab 50 mcg) generic 1

THYROLAR-1 BRAND 3



THYROLAR-1/2 BRAND 3

THYROLAR-1/4 BRAND 3

THYROLAR-2 BRAND 3

THYROLAR-3 BRAND 3

HORMONAL AGENTS, SUPPRESSANT (PARATHYROID)

SENSIPAR BRAND 4PA

S Specialty Drug

HORMONAL AGENTS, SUPPRESSANT (PITUITARY)

cabergoline generic 1

ELIGARD BRAND 4PA

S Specialty Drug

FIRMAGON BRAND 4PA

S Specialty Drug

leuprolide acetate inj kit 5 mg/ml generic 4PA

S Specialty Drug

LUPRON DEPOT BRAND 4PA

S Specialty Drug

LUPRON DEPOT-PED (KIT 7.5 MG, KIT 11.25MG, KIT 15 MG, KIT 30 MG (PED)) BRAND 4

PA

S Specialty Drug

octreotide acetate generic 4PA

S Specialty Drug

SANDOSTATIN BRAND 4PA

S Specialty Drug

SOMATULINE DEPOT BRAND 4PA

S Specialty Drug

SOMAVERT (RECON SOLN 10 MG, RECONSOLN 15 MG, RECON SOLN 20 MG) BRAND 4

PA

S Specialty Drug



SYNAREL BRAND 4PA

S Specialty Drug

TRELSTAR BRAND 4PA

S Specialty Drug

TRELSTAR DEPOT MIXJECT BRAND 4PA

S Specialty Drug

TRELSTAR LA MIXJECT BRAND 4PA

S Specialty Drug

TRELSTAR MIXJECT BRAND 4PA

S Specialty Drug

ZOLADEX BRAND 4PA

S Specialty Drug

HORMONAL AGENTS, SUPPRESSANT (THYROID)

ANTITHYROID AGENTS

methimazole (tab 5 mg, tab 10 mg) generic 1

propylthiouracil generic 1

IMMUNOLOGICAL AGENTS

IMMUNE SUPPRESSANTS

AZASAN BRAND 3

azathioprine sodium generic 1

azathioprine tab 50 mg generic 1

CELLCEPT INTRAVENOUS BRAND 3

CIMZIA BRAND 4PA

S Specialty Drug

CIMZIA PREFILLED BRAND 4PA

S Specialty Drug

CIMZIA STARTER KIT BRAND 4PA

S Specialty Drug



cyclosporine (cap 25 mg, cap 100 mg, iv soln50 mg/ml) generic 1

cyclosporine modified (for microemulsion) (cap25 mg, cap 50 mg, cap 100 mg, oral soln 100mg/ml)

generic 1

ENBREL (SOLN PRSYR 25 MG/0.5ML, SOLNPRSYR 50 MG/ML) BRAND 4

PA

S Specialty Drug

ENBREL RECON SOLN 25 MG BRAND 4 S Specialty Drug

ENBREL SURECLICK BRAND 4PA

S Specialty Drug

HUMIRA (PREF SY KT 20 MG/0.4ML, PREFSY KT 40 MG/0.8ML) BRAND 4

PA

S Specialty Drug

HUMIRA PEDIATRIC CROHNS START BRAND 4PA

S Specialty Drug

HUMIRA PEN BRAND 4PA

S Specialty Drug

HUMIRA PEN-CROHNS STARTER BRAND 4PA

S Specialty Drug

HUMIRA PEN-PSORIASIS STARTER BRAND 4PA

S Specialty Drug

KINERET BRAND 4PA

S Specialty Drug

methotrexate sodium (for inj 1 gm, inj 25 mg/ml,inj 50 mg/2ml (25 mg/ml), inj 250 mg/10ml (25mg/ml), inj pf 25 mg/ml, inj pf 50 mg/2ml (25mg/ml), inj pf 100 mg/4ml (25 mg/ml), inj pf 200mg/8ml (25 mg/ml), inj pf 250 mg/10ml (25mg/ml), inj pf 1000 mg/40ml (25 mg/ml), tab 2.5mg (base equiv))

generic 1 S Specialty Drug

mycophenolate mofetil (cap 250 mg, tab 500mg) generic 1

mycophenolate sodium generic 1



MYFORTIC BRAND 2

NULOJIX BRAND 4PA

S Specialty Drug

ORENCIA (RECON SOLN 250 MG, SOLNPRSYR 125 MG/ML) BRAND 4

PA

S Specialty Drug

PROGRAF (CAP 1 MG, SOLUTION 5 MG/ML) BRAND 2

RAPAMUNE SOLUTION 1 MG/ML BRAND 2

REMICADE BRAND 4PA

S Specialty Drug

RHEUMATREX BRAND 4PA

S Specialty Drug

SIMPONI (SOLN A-INJ 50 MG/0.5ML, SOLNPRSYR 50 MG/0.5ML) BRAND 4

PA

S Specialty Drug

sirolimus (tab 0.5 mg, tab 1 mg, tab 2 mg) generic 1

tacrolimus (cap 0.5 mg, cap 1 mg, cap 5 mg) generic 1

TREXALL BRAND 4PA

S Specialty Drug

XELJANZ BRAND 4PA

S Specialty Drug

ZORTRESS BRAND 4PA

S Specialty Drug

IMMUNIZING AGENTS, PASSIVE

ATGAM BRAND 4PA

S Specialty Drug

CARIMUNE NF RECON SOLN 3 GM BRAND 4PA

S Specialty Drug

GAMMAGARD S/D BRAND 4PA

S Specialty Drug



GAMMAGARD S/D LESS IGA BRAND 4PA

S Specialty Drug

GAMMAGARD SOLUTION 1 GM/10ML BRAND 4PA

S Specialty Drug

GAMMAKED SOLUTION 1 GM/10ML BRAND 4PA

S Specialty Drug

GAMUNEX-C SOLUTION 1 GM/10ML BRAND 4PA

S Specialty Drug

HIZENTRA BRAND 4PA

S Specialty Drug

HIZENTRA 20% BRAND 4PA

S Specialty Drug

THYMOGLOBULIN BRAND 4PA

S Specialty Drug

IMMUNOMODULATORS

ACTEMRA (SOLUTION 80 MG/4ML,SOLUTION 200 MG/10ML, SOLUTION 400MG/20ML)

BRAND 4PA

S Specialty Drug

ACTIMMUNE BRAND 4PA

S Specialty Drug

ARCALYST BRAND 4PA

S Specialty Drug

leflunomide generic 1 MDD 1 per day

RIDAURA BRAND 3

SIMULECT BRAND 3

VACCINES

ADACEL BRAND 0

AFLURIA BRAND 0



AFLURIA PRESERVATIVE FREE BRAND 0

AGRIFLU BRAND 0

BOOSTRIX BRAND 0

FLUARIX BRAND 0

FLUARIX QUADRIVALENT BRAND 0

FLUCELVAX BRAND 0

FLULAVAL BRAND 0

FLULAVAL QUADRIVALENT BRAND 0

FLUVIRIN BRAND 0

FLUVIRIN PRESERVATIVE FREE BRAND 0

FLUZONE BRAND 0

FLUZONE HIGH-DOSE BRAND 0

FLUZONE PEDIATRIC PF BRAND 0

FLUZONE PRESERVATIVE FREE BRAND 0

FLUZONE QUADRIVALENT (SUSP PRSYR0.5 ML, SUSPENSION, SUSPENSION 0.5 ML) BRAND 0

MENACTRA BRAND 0

MENOMUNE BRAND 0

MENVEO BRAND 0

PNEUMOVAX 23 BRAND 0

PREVNAR 13 BRAND 0

ZOSTAVAX BRAND 0 AL At least 50 yrs old

INFLAMMATORY BOWEL DISEASE AGENTS

AMINOSALICYLATES

APRISO BRAND 2

ASACOL BRAND 2 MDD 12 per day

ASACOL HD BRAND 2 MDD 6 per day

balsalazide disodium generic 1



CANASA BRAND 2

DIPENTUM BRAND 2

LIALDA BRAND 2

mesalamine enema 4 gm generic 1

PENTASA BRAND 2

GLUCOCORTICOIDS

budesonide delayed release particles cap 3 mg generic 1

hydrocortisone (intrarectal) generic 1

hydrocortisone rectal cream 2.5% generic 1

SULFONAMIDES

sulfasalazine (tab 500 mg, tab delayed release500 mg) generic 1

METABOLIC BONE DISEASE AGENTS

ACTONEL TAB 150 MG BRAND 2

PA

MDS 1 / 28 DAY

MDS2 3 / 84 DAY

ACTONEL TAB 30 MG BRAND 2PA

MDD 1 per day

alendronate sodium (tab 35 mg, tab 70 mg) generic 1 MDS 4 / 28 DAY

alendronate sodium (tab 5 mg, tab 10 mg, tab40 mg) generic 1 MDD 1 per day

AREDIA RECON SOLN 30 MG BRAND 4PA

S Specialty Drug

ATELVIA BRAND 2 PA

BONIVA SOLUTION 3 MG/3ML BRAND 4PA

S Specialty Drug

calcitonin (salmon) generic 1 MPL 3 / 90 day

calcitriol (cap 0.25 mcg, cap 0.5 mcg, inj 1mcg/ml, oral soln 1 mcg/ml) generic 1



doxercalciferol (cap 0.5 mcg, cap 1 mcg, cap2.5 mcg, inj 4 mcg/2ml (2 mcg/ml)) generic 1

etidronate disodium generic 1

FORTEO BRAND 4

PA

MPL 1 / 28 day

S Specialty Drug

FOSAMAX PLUS D BRAND 3

PA

MDS 4 / 28 DAY

MDS2 12 / 84 DAY

ibandronate sodium iv soln 3 mg/3ml (baseequivalent) generic 4

PA

S Specialty Drug

ibandronate sodium tab 150 mg (baseequivalent) generic 1 MDS 1 / 28 DAY

pamidronate disodium (for inj 30 mg, for inj 90mg, iv soln 3 mg/ml, iv soln 9 mg/ml) generic 4

PA

S Specialty Drug

PAMIDRONATE DISODIUM SOLUTION 6MG/ML BRAND 4

PA

S Specialty Drug

paricalcitol (cap 1 mcg, cap 2 mcg, cap 4 mcg,iv soln 2 mcg/ml, iv soln 5 mcg/ml) generic 1

PROLIA BRAND 4PA

S Specialty Drug

RECLAST BRAND 4PA

S Specialty Drug

risedronate sodium (tab 5 mg, tab 30 mg) generic 1PA

MDD 1 per day

risedronate sodium tab 150 mg generic 1

PA

MDS 1 / 28 DAY

MDS2 3 / 84 DAY

risedronate sodium tab 35 mg generic 1PA

MDS 4 / 28 DAY



risedronate sodium tab delayed release 35 mg generic 1 PA

SKELID BRAND 3

XGEVA BRAND 4PA

S Specialty Drug

ZEMPLAR (CAP 1 MCG, CAP 2 MCG, CAP 4MCG, SOLUTION 2 MCG/ML, SOLUTION 5MCG/ML)

BRAND 3

zoledronic acid (inj conc for infusion 4 mg/5ml,soln 5 mg/100ml) generic 4

PA

S Specialty Drug

ZOLEDRONIC ACID (RECON SOLN 4 MG,SOLUTION 4 MG/100ML) BRAND 4

PA

S Specialty Drug

ZOMETA BRAND 4PA

S Specialty Drug

MISCELLANEOUS THERAPEUTIC AGENTS

*lancets*** generic 1 MDS 200 / 30 DAY

1ST CHOICE LANCETS SUPER THIN BRAND 1 MDS 200 / 30 DAY

1ST CHOICE LANCETS THIN BRAND 1 MDS 200 / 30 DAY

1ST CHOICE LANCETS ULTRA THIN BRAND 1 MDS 200 / 30 DAY

1ST CHOICE PEN NEEDLES BRAND 1 MDS 150 / 30 DAY

1ST TIER UNIFINE PENTIPS BRAND 1 MDS 150 / 30 DAY

1ST TIER UNIFINE PENTIPS PLUS BRAND 1 MDS 150 / 30 DAY

1ST TIER UNILET COMFORTOUCH BRAND 1 MDS 200 / 30 DAY

ACCU-CHEK ACTIVE GLUCOSE CONT BRAND 1

ACCU-CHEK AVIVA SOLUTION BRAND 1

ACCU-CHEK COMFORT CURVE LINEAR BRAND 1

ACCU-CHEK COMFORT CURVE SOLUTION BRAND 1

ACCU-CHEK COMPACT BLUE CONTROL BRAND 1



ACCU-CHEK COMPACT PLUS CONTROL BRAND 1

ACCU-CHEK FASTCLIX LANCETS BRAND 1 MDS 200 / 30 DAY

ACCU-CHEK INSTANT CONTROL BRAND 1

ACCU-CHEK MULTICLIX LANCETS BRAND 1 MDS 200 / 30 DAY

ACCU-CHEK SAFE-T PRO LANCETS BRAND 1 MDS 200 / 30 DAY

ACCU-CHEK SMARTVIEW CONTROL BRAND 1

ACCU-CHEK SOFT TOUCH LANCETS BRAND 1 MDS 200 / 30 DAY

ACCU-CHEK SOFTCLIX LANCET DEV MISC BRAND 1

ACCU-CHEK SOFTCLIX LANCETS BRAND 1 MDS 200 / 30 DAY

ACCUSURE INSULIN SYRINGE BRAND 1 MDS 450 / 90 DAY

ACCUTREND GLUCOSE CONTROL BRAND 1

acetone (urine) test generic 1 MPL 1 / 30 day

ACTI-LANCE 28G BRAND 1 MDS 200 / 30 DAY

ACTI-LANCE LITE LANCETS 28G BRAND 1 MDS 200 / 30 DAY

ACTI-LANCE SPECIAL LANCETS 17G BRAND 1 MDS 200 / 30 DAY

ACTI-LANCE UNIVERSAL 23G BRAND 1 MDS 200 / 30 DAY

ACTIVE 1ST BLOOD LANCETS 30G BRAND 1 MDS 200 / 30 DAY

ACURA CONTROL (SOLUTION LOW,SOLUTION NORMAL) BRAND 1

ADJUSTABLE LANCING DEVICE BRAND 1

ADVANCE INTUITION CONTROL BRAND 1

ADVOCATE CONTROL SOLUTION LIQUIDLOW BRAND 1

ADVOCATE INSULIN PEN NEEDLES BRAND 1 MDS 150 / 30 DAY

ADVOCATE INSULIN SYRINGE BRAND 1 MDS 450 / 90 DAY

ADVOCATE LANCETS BRAND 1 MDS 200 / 30 DAY

ADVOCATE LANCETS 30G BRAND 1 MDS 200 / 30 DAY



ADVOCATE LANCING DEVICE BRAND 1

ADVOCATE RAPID-SAFE LANCING BRAND 1

ADVOCATE REDI-CODE+ CONTROLSOLUTION LOW BRAND 1

ADVOCATE SAFETY LANCETS BRAND 1 MDS 200 / 30 DAY

ADVOCATE SAFETY LANCETS 26G BRAND 1 MDS 200 / 30 DAY

AF LANCETS SUPER THIN BRAND 1 MDS 200 / 30 DAY

AGAMATRIX CONTROL (SOLUTION,SOLUTION NORMAL) BRAND 1

AGAMATRIX ULTRA-THIN LANCETS BRAND 1 MDS 200 / 30 DAY

ALTERNATE SITE LANCING DEVICE BRAND 1

amiodarone hcl (bulk) generic 1

ANTI-STICK INSULIN SYRINGE BRAND 1 MDS 450 / 90 DAY

AQUA LANCE ADJUSTABLE LANCING BRAND 1

ASCENSIA AUTODISC CONTROL BRAND 1

ASCENSIA AUTODISC CONTROLS BRAND 1

ASSURE 3 CONTROL BRAND 1

ASSURE 4 CONTROL LEVEL 1 & 2 BRAND 1

ASSURE COMFORT LANCETS 28G BRAND 1 MDS 200 / 30 DAY

ASSURE COMFORT LANCETS 30G BRAND 1 MDS 200 / 30 DAY

ASSURE DOSE CONTROL BRAND 1

ASSURE DOSE NORM/HIGH CONTROL BRAND 1

ASSURE HAEMOLANCE PLUS HIGH BRAND 1 MDS 200 / 30 DAY

ASSURE HAEMOLANCE PLUS LOW BRAND 1 MDS 200 / 30 DAY

ASSURE HAEMOLANCE PLUS MICRO BRAND 1 MDS 200 / 30 DAY

ASSURE HAEMOLANCE PLUS NORMAL BRAND 1 MDS 200 / 30 DAY

ASSURE HAEMOLANCE PLUS PED BRAND 1 MDS 200 / 30 DAY



ASSURE ID INSULIN SAFETY SYR BRAND 1 MDS 450 / 90 DAY

ASSURE LANCE LANCETS BRAND 1 MDS 200 / 30 DAY

ASSURE LANCE LANCETS 21G BRAND 1 MDS 200 / 30 DAY

ASSURE LANCE PLUS SAFETY 25G BRAND 1 MDS 200 / 30 DAY

ASSURE LANCE PLUS SAFETY 30G BRAND 1 MDS 200 / 30 DAY

ASSURE LANCETS BRAND 1 MDS 200 / 30 DAY

ASSURE PRISM CONTROL LEVEL 1&2 BRAND 1

ASSURE PRO CONTROL LEVEL 1 & 2 BRAND 1

AURORA HEALTHCARE LANCETS BRAND 1 MDS 200 / 30 DAY

AURORA LANCET SUPER THIN 30G BRAND 1 MDS 200 / 30 DAY

AURORA LANCET THIN 23G BRAND 1 MDS 200 / 30 DAY

AURORA PEN NEEDLES BRAND 1 MDS 150 / 30 DAY

AURORA UNIFINE PENTIPS BRAND 1 MDS 150 / 30 DAY

AUTO-LANCET BRAND 1

AUTO-LANCET MINI BRAND 1

AUTOLET IMPRESSION BRAND 1

AUTOLET LANCING DEVICE BRAND 1

AUTOLET MINI BRAND 1

BAYER BREEZE 2 CONTROL (2 LIQUIDLOW, 2 LIQUID NORMAL) BRAND 1

BAYER CONTOUR (LIQUID LOW, LIQUIDNORMAL) BRAND 1

BAYER CONTOUR NEXT CONTROL BRAND 1

BAYER MICROLET 2 LANCING DEVIC BRAND 1

BAYER MICROLET LANCETS BRAND 1 MDS 200 / 30 DAY

BD AUTOSHIELD (MISC 8MM, MISC 12MM) BRAND 1 MDS 150 / 30 DAY

BD INSULIN SYR ULTRAFINE II BRAND 1 MDS 450 / 90 DAY



BD INSULIN SYRINGE BRAND 1 MDS 450 / 90 DAY

BD INSULIN SYRINGE HALF-UNIT BRAND 1 MDS 450 / 90 DAY

BD INSULIN SYRINGE MICROFINE BRAND 1 MDS 450 / 90 DAY

BD INSULIN SYRINGE ULTRAFINE (MISC29G 1/2" 0.5 ML, MISC 29G 1/2" 0.3 ML, MISC29G 1/2" 1 ML, MISC 30G 1/2" 1 ML, MISC30G 1/2" 0.3 ML, MISC 30G 1/2" 0.5 ML, MISC31G 15/64" 1 ML, MISC 31G 5/16" 1 ML, MISC31G 5/16" 0.5 ML, MISC 31G 5/16" 0.3 ML)

BRAND 1 MDS 450 / 90 DAY

BD INTEGRA INSULIN SYRINGE BRAND 1 MDS 450 / 90 DAY

BD INTEGRA SYRINGE BRAND 1 MDS 450 / 90 DAY

BD LANCET DEVICE BRAND 1

BD LANCET ULTRAFINE 30G BRAND 1 MDS 200 / 30 DAY

BD LANCET ULTRAFINE 33G BRAND 1 MDS 200 / 30 DAY

BD MICROTAINER LANCETS BRAND 1 MDS 200 / 30 DAY

BD PEN NEEDLE MINI U/F BRAND 1 MDS 150 / 30 DAY

BD PEN NEEDLE NANO U/F BRAND 1 MDS 150 / 30 DAY

BD PEN NEEDLE SHORT U/F BRAND 1 MDS 150 / 30 DAY

BD PEN NEEDLE ULTRAFINE BRAND 1 MDS 150 / 30 DAY

BD SAFETY-LOK INSULIN SYRINGE BRAND 1 MDS 450 / 90 DAY

BD SAFETYGLIDE INSULIN SYRINGE BRAND 1 MDS 450 / 90 DAY

blood glucose calibration generic 1

blood glucose monitoring supplies generic 1 MDS 1 / 730 DAY

BULLSEYE MINI SAFETY LANCETS BRAND 1 MDS 200 / 30 DAY

BULLSEYE SAFETY LANCETS BRAND 1 MDS 200 / 30 DAY

CARDIOCOM LANCING DEVICE BRAND 1

CAREFINE PEN NEEDLES BRAND 1 MDS 150 / 30 DAY



CAREONE ADVANCED LANCING DEV BRAND 1

CAREONE INSULIN SYRINGE BRAND 1 MDS 450 / 90 DAY

CAREONE LANCET THIN 23G BRAND 1 MDS 200 / 30 DAY

CAREONE LANCET ULTRA THIN 28G BRAND 1 MDS 200 / 30 DAY

CAREONE ULTIGUARD INSULIN SYR BRAND 1 MDS 450 / 90 DAY

CAREONE UNIFINE PENTIPS BRAND 1 MDS 150 / 30 DAY

CAREONE UNIFINE PENTIPS PLUS BRAND 1 MDS 150 / 30 DAY

CARESENS CONTROL A BRAND 1

CAYA BRAND 0

CHEK-STIX CONTROL BRAND 1 MPL 1 / 30 day

CHEMSTRIP K BRAND 1 MPL 1 / 30 day

CLEANLET LANCETS 28G BRAND 1 MDS 200 / 30 DAY

CLEVER CHEK LANCETS BRAND 1 MDS 200 / 30 DAY

CLEVER CHOICE COMFORT EZ MISC 29G X12MM BRAND 1 MDS 150 / 30 DAY

CLEVER CHOICE GLUCOSE CONTROLLIQUID LOW BRAND 1

CLICKFINE PEN NEEDLES BRAND 1 MDS 150 / 30 DAY

clindamycin phosphate (bulk) generic 1

CLINDAMYCIN PHOSPHATE POWDER BRAND 1

CLOSERCARE BRAND 1

COAGUCHEK LANCETS BRAND 1 MDS 200 / 30 DAY

COMFORT ASSIST INSULIN SYRINGE BRAND 1 MDS 450 / 90 DAY

COMFORT ASSURED LANCETS 28G BRAND 1 MDS 200 / 30 DAY

COMFORT ASSURED LANCETS 33G BRAND 1 MDS 200 / 30 DAY

COMFORT EZ INSULIN SYRINGE BRAND 1 MDS 450 / 90 DAY



COMFORT EZ PEN NEEDLES (PEN MISC31G 5, PEN MISC 31G 6, PEN MISC 31G 8,PEN MISC 32G 4, PEN MISC 32G 6, PENMISC 32G 5)


COMFORT LANCETS BRAND 1 MDS 200 / 30 DAY

CONTROL BRAND 1

COOL CONTROL A BRAND 1

COOL CONTROL B BRAND 1

CVS INSULIN SYRINGE BRAND 1 MDS 450 / 90 DAY

CVS LANCETS 21G BRAND 1 MDS 200 / 30 DAY

CVS LANCETS MICRO THIN 33G BRAND 1 MDS 200 / 30 DAY

CVS LANCETS ORIGINAL BRAND 1 MDS 200 / 30 DAY

CVS LANCETS THIN BRAND 1 MDS 200 / 30 DAY

CVS LANCETS THIN 26G BRAND 1 MDS 200 / 30 DAY

CVS LANCETS ULTRA THIN 30G BRAND 1 MDS 200 / 30 DAY

CVS LANCING DEVICE BRAND 1

CVS ULTRA THIN LANCETS BRAND 1 MDS 200 / 30 DAY

DIASTAR EASY TEST II LANCETS BRAND 1 MDS 200 / 30 DAY

DIASTAR EASY TEST LANCETS BRAND 1 MDS 200 / 30 DAY

DIATRUE CONTROL LEVEL 1 BRAND 1

DIATRUE CONTROL LEVEL 2 BRAND 1

DROPLET LANCETS ULTRA THIN 30G BRAND 1 MDS 200 / 30 DAY

DROPLET LANCING DEVICE BRAND 1

DRUG MART LANCETS THIN 26G BRAND 1 MDS 200 / 30 DAY

DRUG MART LANCETS ULTRA THIN BRAND 1 MDS 200 / 30 DAY

DRUG MART LANCING DEVICE BRAND 1

DRUG MART ON-THE-GO LANCET 30G BRAND 1 MDS 200 / 30 DAY



DRUG MART ULTRA COMFORT SYR BRAND 1 MDS 450 / 90 DAY

DRUG MART UNIFINE PENTIPS BRAND 1 MDS 150 / 30 DAY

DRUG MART UNIFINE PENTIPS PLUS BRAND 1 MDS 150 / 30 DAY

DRUG MART UNILET LANCETS 28G BRAND 1 MDS 200 / 30 DAY

DRUG MART UNILET LANCETS 30G BRAND 1 MDS 200 / 30 DAY

DUANE READE LANCET ALTERN SITE BRAND 1 MDS 200 / 30 DAY

DUANE READE LANCET SUPER THIN BRAND 1 MDS 200 / 30 DAY

DUANE READE LANCET ULTRA THIN BRAND 1 MDS 200 / 30 DAY

DUANE READE UNIFINE PENTIPS BRAND 1 MDS 150 / 30 DAY

E-Z JECT LANCET MICRO-THIN 33G BRAND 1 MDS 200 / 30 DAY

E-Z JECT LANCET SUPER THIN 30G BRAND 1 MDS 200 / 30 DAY

E-Z JECT LANCETS BRAND 1 MDS 200 / 30 DAY

E-Z JECT LANCETS 21G BRAND 1 MDS 200 / 30 DAY

E-Z JECT LANCETS THIN 26G BRAND 1 MDS 200 / 30 DAY

EASY COMFORT INSULIN SYRINGE BRAND 1 MDS 450 / 90 DAY

EASY COMFORT LANCETS BRAND 1 MDS 200 / 30 DAY

EASY COMFORT PEN NEEDLES BRAND 1 MDS 150 / 30 DAY

EASY MINI LANCING DEVICE BRAND 1

EASY PLUS CONTROL (SOLUTION LOW,SOLUTION NORMAL) BRAND 1

EASY PLUS II CONTROL SOLUTION LOW BRAND 1

EASY STEP CONTROL (SOLUTION LOW,SOLUTION NORMAL) BRAND 1

EASY TALK CONTROL (SOLUTION LOW,SOLUTION NORMAL) BRAND 1

EASY TOUCH CONTROL HIGH & LOW BRAND 1

EASY TOUCH HEALTHPRO CONTROL BRAND 1



EASY TOUCH INSULIN SAFETY SYR BRAND 1 MDS 450 / 90 DAY

EASY TOUCH INSULIN SYRINGE BRAND 1 MDS 450 / 90 DAY

EASY TOUCH LANCETS 21G BRAND 1 MDS 200 / 30 DAY



EASY TOUCH LANCETS 26G/TWIST BRAND 1 MDS 200 / 30 DAY








EASY TOUCH LANCING DEVICE BRAND 1

EASY TOUCH PEN NEEDLES BRAND 1 MDS 150 / 30 DAY

EASY TOUCH SAFETY LANCETS 21G BRAND 1 MDS 200 / 30 DAY




EASY TRAK CONTROL (SOLUTION LOW,SOLUTION NORMAL) BRAND 1

EASY TWIST & CAP LANCETS BRAND 1 MDS 200 / 30 DAY

EASYGLUCO CONTROL (SOLUTION LOW,SOLUTION NORMAL) BRAND 1

EASYMAX 15 LEVEL 1 CONTROL BRAND 1

EASYMAX 15 LEVEL 2 CONTROL BRAND 1



EASYMAX CONTROL (SOLUTION LOW,SOLUTION NORMAL) BRAND 1

ECLIPSE CONTROL (LIQUID LOW,SOLUTION NORMAL) BRAND 1

ELEMENT COMPACT CONTROL 2 BRAND 1

ELEMENT COMPACT CONTROL 3 BRAND 1

ELEMENT CONTROL (LIQUID LOW, LIQUIDNORMAL) BRAND 1

ELEMENT PLUS CONTROL (SOLUTIONLOW, SOLUTION NORMAL) BRAND 1

EMBRACE CONTROL BRAND 1

EMBRACE EVO CONTROL LEVEL 1 BRAND 1

EMBRACE EVO CONTROL LEVEL 2 BRAND 1

EMBRACE LANCETS ULTRA THIN 30G BRAND 1 MDS 200 / 30 DAY

EMBRACE PRO GLUCOSE CONTROL BRAND 1

ENVISION CONTROL (SOLUTION LOW,SOLUTION NORMAL) BRAND 1

EQL COLOR LANCETS 21G BRAND 1 MDS 200 / 30 DAY

EQL COLOR LANCETS MICRO 33G BRAND 1 MDS 200 / 30 DAY

EQL INSULIN SYRINGE BRAND 1 MDS 450 / 90 DAY

EQL SHORT PEN NEEDLE BRAND 1 MDS 150 / 30 DAY

EQL SUPER THIN LANCETS 30G BRAND 1 MDS 200 / 30 DAY

EQL THIN LANCETS 26G BRAND 1 MDS 200 / 30 DAY

EQL ULTRA COMFORT INSULIN SYR BRAND 1 MDS 450 / 90 DAY

EQL ULTRA SHORT PEN NEEDLE BRAND 1 MDS 150 / 30 DAY

EVENCARE CONTROL LOW/HIGH BRAND 1

EVENCARE G2 LOW/HIGH CONTROL BRAND 1

EVENCARE G3 LOW/HIGH CONTROL BRAND 1

EVENCARE MINI CONTROL BRAND 1



EVOLUTION CONTROL BRAND 1

EXEL COMFORT POINT INSULIN SYR BRAND 1 MDS 450 / 90 DAY

EXEL COMFORT POINT PEN NEEDLE (EELPEN MISC 29G 12MM, EEL PEN MISC 31G 6MM, EEL PEN MISC 31G 8 MM)


EZ SMART BLOOD GLUCOSE LANCETS BRAND 1 MDS 200 / 30 DAY

EZ-LETS LANCETS 21G BRAND 1 MDS 200 / 30 DAY




FEMCAP BRAND 0

FIFTY50 CONTROL 2.0 BRAND 1

FIFTY50 LANCING DEVICE BRAND 1

FIFTY50 PEN NEEDLES BRAND 1 MDS 150 / 30 DAY

FIFTY50 SAFETY SEAL LANCETS BRAND 1 MDS 200 / 30 DAY

FIFTY50 SUPERIOR COMFORT SYR BRAND 1 MDS 450 / 90 DAY

FIFTY50 UNILET LANCETS 33G BRAND 1 MDS 200 / 30 DAY

FINE 30 BRAND 1 MDS 200 / 30 DAY

FINGERSTIX LANCETS BRAND 1 MDS 200 / 30 DAY

fluticasone propionate (bulk) generic 1

FLUTICASONE PROPIONATE POWDER BRAND 1

FORA CONTROL (SOLUTION LOW,SOLUTION NORMAL) BRAND 1

FORA LANCETS BRAND 1 MDS 200 / 30 DAY

FORA LANCING DEVICE BRAND 1

FORACARE GDH CONTROL (SOLUTIONLOW, SOLUTION NORMAL) BRAND 1

FORTISCARE CONTROL (SOLUTION LOW,SOLUTION NORMAL) BRAND 1



FREDS PHARMACY AUTOLET LANCING BRAND 1

FREDS PHARMACY UNIFINE PENTIP+ BRAND 1 MDS 150 / 30 DAY

FREDS PHARMACY UNIFINE PENTIPS BRAND 1 MDS 150 / 30 DAY

FREDS PHARMACY UNILET LANC 28G BRAND 1 MDS 200 / 30 DAY

FREDS PHARMACY UNILET LANC 30G BRAND 1 MDS 200 / 30 DAY

FREESTYLE CONTROL SOLUTION BRAND 1

FREESTYLE LANCETS BRAND 1 MDS 200 / 30 DAY

FREESTYLE PRECISION INS SYR BRAND 1 MDS 450 / 90 DAY

FREESTYLE UNISTICK II LANCETS BRAND 1 MDS 200 / 30 DAY

GE100 CONTROL BRAND 1

GLOBAL EASE INJECT PEN NEEDLES BRAND 1 MDS 150 / 30 DAY

GLOBAL INJECT EASE INSULIN SYR BRAND 1 MDS 450 / 90 DAY

GLOBAL INJECT EASE LANCETS 28G BRAND 1 MDS 200 / 30 DAY

GLOBAL INJECT EASE LANCETS 30G BRAND 1 MDS 200 / 30 DAY

GLOBAL LANCING DEVICE BRAND 1

GLUCOCARD 01 CONTROL BRAND 1

GLUCOCARD EXPRESSION CONTROL BRAND 1

GLUCOCARD SHINE CONTROL BRAND 1

GLUCOCARD X-SENSOR CONTROL BRAND 1

GLUCOCOM CONTROL LIQUID NORMAL BRAND 1

GLUCOCOM LANCETS 28G BRAND 1 MDS 200 / 30 DAY



GLUCOLAB CONTROL (LIQUID LOW, LIQUIDNORMAL) BRAND 1

GLUCOLET 2 AUTOMATIC LANCING BRAND 1



GLUCOPRO INSULIN SYRINGE BRAND 1 MDS 450 / 90 DAY

glucose blood generic 1MDS 100 / 30 DAY

MDS2 300 / 90 DAY

GLUCOSE CONTROL BRAND 1

GLUCOSOURCE LANCET DEVICE BRAND 1

GLUCOSOURCE LANCETS BRAND 1 MDS 200 / 30 DAY

GMATE CONTROL LEVEL 2 BRAND 1

GNP CLICKFINE PEN NEEDLES BRAND 1 MDS 150 / 30 DAY

GNP INSULIN SYRINGE BRAND 1 MDS 450 / 90 DAY

GNP LANCETS BRAND 1 MDS 200 / 30 DAY

GNP LANCETS 21G BRAND 1 MDS 200 / 30 DAY

GNP LANCETS MICRO THIN 33G BRAND 1 MDS 200 / 30 DAY

GNP LANCETS SUPER THIN 30G BRAND 1 MDS 200 / 30 DAY

GNP LANCETS THIN BRAND 1 MDS 200 / 30 DAY

GNP LANCETS THIN 26G BRAND 1 MDS 200 / 30 DAY

GNP MICRO THIN LANCETS 33G BRAND 1 MDS 200 / 30 DAY

GNP SUPER THIN LANCETS 30G BRAND 1 MDS 200 / 30 DAY

GNP ULTRA COM INSULIN SYRINGE BRAND 1 MDS 450 / 90 DAY

H&H THINLET LANCETS 26G BRAND 1 MDS 200 / 30 DAY

H&H THINLET LANCETS 30G BRAND 1 MDS 200 / 30 DAY

H-E-B INCONTROL ADV LANCING BRAND 1

H-E-B INCONTROL LANCETS 28G BRAND 1 MDS 200 / 30 DAY



H-E-B INCONTROL PEN NEEDLES BRAND 1 MDS 150 / 30 DAY



HAEMOLANCE BRAND 1 MDS 200 / 30 DAY

HAEMOLANCE LOW FLOW LANCETS BRAND 1 MDS 200 / 30 DAY

HAEMOLANCE PLUS BRAND 1 MDS 200 / 30 DAY

HAEMOLANCE PLUS HIGH FLOW BRAND 1 MDS 200 / 30 DAY

HAEMOLANCE PLUS LOW FLOW BRAND 1 MDS 200 / 30 DAY

HAEMOLANCE PLUS MAX FLOW BRAND 1 MDS 200 / 30 DAY

HAEMOLANCE PLUS PEDIATRIC FLOW BRAND 1 MDS 200 / 30 DAY

HEALTH CARE LANCING DEVICE BRAND 1

HEALTHWISE LANCETS 30G BRAND 1 MDS 200 / 30 DAY

HEALTHWISE LANCING PEN BRAND 1

HEALTHWISE MINI PEN NEEDLES BRAND 1 MDS 150 / 30 DAY

HEALTHWISE PEN NEEDLES BRAND 1 MDS 150 / 30 DAY

HEALTHWISE SHORT PEN NEEDLES BRAND 1 MDS 150 / 30 DAY

HEALTHWISE UNIFINE PENTIPS BRAND 1 MDS 150 / 30 DAY

HEALTHY ACCENTS LANCING DEVICE BRAND 1

HEALTHY ACCENTS UNIFINE PENTIP BRAND 1 MDS 150 / 30 DAY

HEALTHY ACCENTS UNILET LANCETS BRAND 1 MDS 200 / 30 DAY

HM LANCETS MICRO THIN 33G BRAND 1 MDS 200 / 30 DAY

HM LANCETS ULTRA THIN 30G BRAND 1 MDS 200 / 30 DAY

HY-VEE INSULIN SYRINGE BRAND 1 MDS 450 / 90 DAY

IN TOUCH GLUCOSE CONTROL BRAND 1

IN TOUCH LANCING DEVICE BRAND 1

IN TOUCH STERILE LANCETS 30G BRAND 1 MDS 200 / 30 DAY

INFINITY CONTROL (SOLUTION LOW,SOLUTION NORMAL) BRAND 1

insulin pen needle generic 1 MDS 150 / 30 DAY



INSULIN SYRINGE BRAND 1 MDS 450 / 90 DAY

INSULIN SYRINGE/NEEDLE(SYRINGE/NEEDLE 28G 1/2" 0.5 ML,SYRINGE/NEEDLE 28G 1/2" 1 ML,SYRINGE/NEEDLE MISC 27G 1/2" 0.5 ML,SYRINGE/NEEDLE MISC 28G 1/2" 1 ML,SYRINGE/NEEDLE MISC 28G 1/2" 0.5 ML)


insulin syringe/needle u-100 generic 1 MDS 450 / 90 DAY

INSUPEN PEN NEEDLES MISC 32G X 4 MM BRAND 1 MDS 150 / 30 DAY

INSUPEN SENSITIVE MISC 32G X 6 MM BRAND 1 MDS 150 / 30 DAY

INSUPEN ULTRAFIN BRAND 1 MDS 150 / 30 DAY

KETOCARE BRAND 1 MPL 1 / 30 day

KETOSTIX BRAND 1 MPL 1 / 30 day

KINNEY LANCETS BRAND 1 MDS 200 / 30 DAY

KINNEY THIN LANCETS BRAND 1 MDS 200 / 30 DAY

KINRAY INSULIN SYRINGE BRAND 1 MDS 450 / 90 DAY

KMART VALU INSULIN SYRINGE 29G MISCU-100 1 ML BRAND 1 MDS 450 / 90 DAY

KMART VALU INSULIN SYRINGE 30G MISCU-100 1 ML BRAND 1 MDS 450 / 90 DAY

KROGER INSULIN SYRINGE BRAND 1 MDS 450 / 90 DAY

KROGER LANCETS 21G BRAND 1 MDS 200 / 30 DAY

KROGER LANCETS MICRO THIN 33G BRAND 1 MDS 200 / 30 DAY

KROGER LANCETS SUPER THIN BRAND 1 MDS 200 / 30 DAY

KROGER LANCETS THIN 26G BRAND 1 MDS 200 / 30 DAY

KROGER LANCETS ULTRATHIN 30G BRAND 1 MDS 200 / 30 DAY

KROGER LANCING DEVICE BRAND 1

KROGER PEN NEEDLES BRAND 1 MDS 150 / 30 DAY



LADY LITE LANCETS BRAND 1 MDS 200 / 30 DAY

LANCET DEVICE BRAND 1

LANCET DEVICE WITH EJECTOR BRAND 1

lancet devices generic 1

LANCETS 28G BRAND 1 MDS 200 / 30 DAY

LANCETS 30G BRAND 1 MDS 200 / 30 DAY

LANCETS MICRO THIN 33G BRAND 1 MDS 200 / 30 DAY

LANCETS MISC BRAND 1 MDS 200 / 30 DAY

LANCETS SUPER THIN 28G BRAND 1 MDS 200 / 30 DAY

LANCETS THIN BRAND 1 MDS 200 / 30 DAY

LANCETS ULTRA FINE BRAND 1 MDS 200 / 30 DAY

LANCETS ULTRA THIN BRAND 1 MDS 200 / 30 DAY

LANCETS ULTRA THIN 30G BRAND 1 MDS 200 / 30 DAY

LANCING DEVICE BRAND 1

LANZO BRAND 1

LEADER ADVANCED LANCING DEVICE BRAND 1

LEADER INSULIN SYRINGE BRAND 1 MDS 450 / 90 DAY

LEADER UNIFINE PENTIPS BRAND 1 MDS 150 / 30 DAY

LEADER UNIFINE PENTIPS PLUS BRAND 1 MDS 150 / 30 DAY

LIBERTY GLUCOSE CONTROL (LIQUIDNORMAL, SOLUTION, SOLUTION NORMAL) BRAND 1

LIBERTY GLUCOSE CONTROL MID BRAND 1

LIBERTY MEDICAL LANCETS BRAND 1 MDS 200 / 30 DAY

LIBERTY MINI LANCING DEVICE BRAND 1

LITE TOUCH LANCETS BRAND 1 MDS 200 / 30 DAY

LITE TOUCH LANCING DEVICE BRAND 1



LITE TOUCH LANCING PEN BRAND 1

LITE TOUCH PEN NEEDLES BRAND 1 MDS 150 / 30 DAY

LITETOUCH INSULIN SYRINGE BRAND 1 MDS 450 / 90 DAY

LITETOUCH LANCETS BRAND 1 MDS 200 / 30 DAY

LITETOUCH PEN NEEDLES BRAND 1 MDS 150 / 30 DAY

LIVE BETTER ADV LANCING DEVICE BRAND 1

LIVE BETTER LANCET SUPER THIN BRAND 1 MDS 200 / 30 DAY

LIVE BETTER LANCET ULTRA THIN BRAND 1 MDS 200 / 30 DAY

LIVE BETTER PEN NEEDLES BRAND 1 MDS 150 / 30 DAY

LONGS INSULIN SYRINGE BRAND 1 MDS 450 / 90 DAY

LONGS LANCETS STANDARD BRAND 1 MDS 200 / 30 DAY

LONGS LANCETS THIN BRAND 1 MDS 200 / 30 DAY

LONGS LANCETS ULTRA THIN BRAND 1 MDS 200 / 30 DAY

MAGELLAN INSULIN SAFETY SYR BRAND 1 MDS 450 / 90 DAY

MAJOR COMFORT LANCETS BRAND 1 MDS 200 / 30 DAY

MAXI-COMFORT INSULIN SYRINGE BRAND 1 MDS 450 / 90 DAY

MAXIMA CONTROL BRAND 1

MEDI-LANCE LANCETS BRAND 1 MDS 200 / 30 DAY

MEDIC INSULIN SYRINGE BRAND 1 MDS 450 / 90 DAY

MEDICHOICE SAFETY LANCET BRAND 1 MDS 200 / 30 DAY

MEDICHOICE SAFETY LANCET EXTRA BRAND 1 MDS 200 / 30 DAY

MEDICHOICE SAFETY LANCET NORM BRAND 1 MDS 200 / 30 DAY

MEDICINE SHOPPE LANCETS BRAND 1 MDS 200 / 30 DAY

MEDICINE SHOPPE LANCETS THIN BRAND 1 MDS 200 / 30 DAY

MEDICINE SHOPPE PEN NEEDLES BRAND 1 MDS 150 / 30 DAY



MEDISENSE GLUCOSE KETONE CONTR BRAND 1

MEDISENSE HI/MID/LOW CONTROL BRAND 1

MEDISENSE HIGH/LOW CONTROL BRAND 1

MEDISENSE MID CONTROL BRAND 1

MEDISENSE THIN LANCETS BRAND 1 MDS 200 / 30 DAY

MEDLANCE EXTRA 21G BRAND 1 MDS 200 / 30 DAY

MEDLANCE LITE 25G BRAND 1 MDS 200 / 30 DAY

MEDLANCE PLUS EXTRA 21G BRAND 1 MDS 200 / 30 DAY

MEDLANCE PLUS LANCETS BRAND 1 MDS 200 / 30 DAY

MEDLANCE PLUS LITE 25G BRAND 1 MDS 200 / 30 DAY

MEDLANCE PLUS SPECIAL 0.8MM BRAND 1 MDS 200 / 30 DAY

MEDLANCE PLUS SUPERLITE 30G BRAND 1 MDS 200 / 30 DAY

MEDLANCE PLUS UNIVERSAL 21G BRAND 1 MDS 200 / 30 DAY

MEDLANCE UNIVERSAL 21G BRAND 1 MDS 200 / 30 DAY

MEIJER LANCETS BRAND 1 MDS 200 / 30 DAY

MEIJER LANCETS THIN BRAND 1 MDS 200 / 30 DAY

MEIJER LANCETS UNIVERSAL 30G BRAND 1 MDS 200 / 30 DAY

MEIJER LANCETS UNIVERSAL 33G BRAND 1 MDS 200 / 30 DAY

MEIJER PEN NEEDLES BRAND 1 MDS 150 / 30 DAY

MEIJER SUPER THIN LANCETS BRAND 1 MDS 200 / 30 DAY

metaproterenol sulfate powder generic 1

MICRODOT CONTROL BRAND 1

MICRODOT CONTROL HIGH/LOW BRAND 1

MICROLET LANCETS BRAND 1 MDS 200 / 30 DAY

MICROTAINER SAFETY FLOW LANCET BRAND 1 MDS 200 / 30 DAY



MINI LANCING DEVICE BRAND 1

MONOJECT INSULIN SYRINGE BRAND 1 MDS 450 / 90 DAY

MONOJECT ULTRA COMFORT SYRINGE BRAND 1 MDS 450 / 90 DAY

MONOLET LANCETS BRAND 1 MDS 200 / 30 DAY

MONOLET OPD LANCETS BRAND 1 MDS 200 / 30 DAY

MONOLETTOR SAFETY LANCETS BRAND 1 MDS 200 / 30 DAY

MOORE MONO INSULIN SYRINGE BRAND 1 MDS 450 / 90 DAY

MS INSULIN SYRINGE BRAND 1 MDS 450 / 90 DAY

MYGLUCOHEALTH CONTROL BRAND 1

MYGLUCOHEALTH LANCETS 30G BRAND 1 MDS 200 / 30 DAY

NETGROUP LANCETS BRAND 1 MDS 200 / 30 DAY

NEUTEK 2TEK CONTROL BRAND 1

NOVA MAX CONTROL BRAND 1

NOVA MAX PLUS GLU/KET CONTROL BRAND 1

NOVA SAFETY LANCETS 23G BRAND 1 MDS 200 / 30 DAY

NOVA SAFETY LANCETS 28G BRAND 1 MDS 200 / 30 DAY

NOVA SUREFLEX LANCETS BRAND 1 MDS 200 / 30 DAY

NOVA SUREFLEX LANCING DEVICE BRAND 1

NOVOFINE BRAND 1 MDS 150 / 30 DAY

NOVOFINE AUTOCOVER BRAND 1 MDS 150 / 30 DAY

NOVOFINE PLUS BRAND 1 MDS 150 / 30 DAY

NOVOTWIST BRAND 1 MDS 150 / 30 DAY

nystatin (bulk) powder generic 1

OMNIFLEX DIAPHRAGM BRAND 0

ON CALL EXPRESS GLUCOSE CONTR BRAND 1

ON CALL LANCETS BRAND 1 MDS 200 / 30 DAY



ON CALL LANCING DEVICE BRAND 1

ON CALL PLUS GLUCOSE CONTROL BRAND 1

ON CALL PLUS LANCETS BRAND 1 MDS 200 / 30 DAY

ON CALL PLUS LANCING DEVICE BRAND 1

ON CALL VIVID GLUCOSE CONTROL BRAND 1

ONETOUCH DELICA LANCETS 33G BRAND 1 MDS 200 / 30 DAY

ONETOUCH DELICA LANCETS FINE BRAND 1 MDS 200 / 30 DAY

ONETOUCH DELICA LANCING DEV BRAND 1

ONETOUCH FINEPOINT LANCETS BRAND 1 MDS 200 / 30 DAY

ONETOUCH LANCETS BRAND 1 MDS 200 / 30 DAY

ONETOUCH ULTRA CONTROL BRAND 1

ONETOUCH ULTRASOFT LANCETS BRAND 1 MDS 200 / 30 DAY

ONETOUCH VERIO SOLUTION BRAND 1

OPTUMRX GLUCOSE CONTROL BRAND 1

ORSINI INSULIN SYRINGE BRAND 1 MDS 450 / 90 DAY

ORTHO DIAPHRAGM ALL-FLEX BRAND 0

ORTHO DIAPHRAGM COIL BRAND 0

ORTHO DIAPHRAGM FLAT BRAND 0

PARAGARD INTRAUTERINE COPPER BRAND 0 GL Female

PC LANCETS SUPER THIN 30G BRAND 1 MDS 200 / 30 DAY

PC UNIFINE PENTIPS BRAND 1 MDS 150 / 30 DAY

PEN NEEDLES (PEN MISC 29G 12MM, PENMISC 31G 6 MM) BRAND 1 MDS 150 / 30 DAY

PEN NEEDLES 3/16" BRAND 1 MDS 150 / 30 DAY

PEN NEEDLES 5/16" BRAND 1 MDS 150 / 30 DAY

PENTIPS (MISC 31G 5, MISC 31G 8, MISC32G 4) BRAND 1 MDS 150 / 30 DAY



PERFECT LANCETS 28G BRAND 1 MDS 200 / 30 DAY

PERFECT LANCETS 30G BRAND 1 MDS 200 / 30 DAY

PHARMACIST CHOICE LANCETS BRAND 1 MDS 200 / 30 DAY

PHARMACY COUNTER LANCETS BRAND 1 MDS 200 / 30 DAY

PHISOHEX BRAND 1

POCKETCHEM EZ CONTROL BRAND 1

PRECISION GLUCOSE KETONE CONTR BRAND 1

PRECISION SURE-DOSE SYRINGE BRAND 1 MDS 450 / 90 DAY

PRECISION SUREDOSE PLUS SYR BRAND 1 MDS 450 / 90 DAY

PREFERRED PLUS INSULIN SYRINGE BRAND 1 MDS 450 / 90 DAY

PREFERRED PLUS LANCETS COLORED BRAND 1 MDS 200 / 30 DAY

PREFERRED PLUS LANCETS THIN BRAND 1 MDS 200 / 30 DAY

PREFERRED PLUS UNIFINE PENTIPS BRAND 1 MDS 150 / 30 DAY

PRENTIF FITTING SET BRAND 0

PRESTIGE GLUCOSE CONTROL LIQUIDLOW BRAND 1

PRODIGY CONTROL SOLUTION SOLUTIONLOW BRAND 1

PRODIGY INSULIN SYRINGE BRAND 1 MDS 450 / 90 DAY

PRODIGY LANCETS 21G BRAND 1 MDS 200 / 30 DAY



PRODIGY LANCING DEVICE BRAND 1

PRODIGY MINI PEN NEEDLES BRAND 1 MDS 150 / 30 DAY

PRODIGY SAFETY LANCETS 26G BRAND 1 MDS 200 / 30 DAY

PRODIGY SHORT PEN NEEDLES BRAND 1 MDS 150 / 30 DAY



PRODIGY TWIST TOP LANCETS 28G BRAND 1 MDS 200 / 30 DAY

PX ADVANCED LANCING DEVICE BRAND 1

PX EXTRA SHORT PEN NEEDLES BRAND 1 MDS 150 / 30 DAY

PX INSULIN SYRINGE BRAND 1 MDS 450 / 90 DAY

PX LANCET AUTO INJECTOR BRAND 1

PX LANCETS BRAND 1 MDS 200 / 30 DAY

PX LANCETS ULTRA THIN BRAND 1 MDS 200 / 30 DAY

PX MINI PEN NEEDLES BRAND 1 MDS 150 / 30 DAY

PX PEN NEEDLE BRAND 1 MDS 150 / 30 DAY

QC ADVANCED LANCING DEVICE BRAND 1

QC INSULIN SYRINGE (MISC 29G 1/2" 0.5ML, MISC 29G 1/2" 1 ML, MISC 29G 1/2" 0.3ML, MISC 31G 5/16" 1 ML, MISC 31G 5/16" 0.5ML)


QC LANCETS SUPER THIN 30G BRAND 1 MDS 200 / 30 DAY

QC LANCETS ULTRA THIN BRAND 1 MDS 200 / 30 DAY

QC PEN NEEDLES BRAND 1 MDS 150 / 30 DAY

QC UNIFINE PENTIPS BRAND 1 MDS 150 / 30 DAY

QC UNILET LANCETS MICRO THIN BRAND 1 MDS 200 / 30 DAY

QUICKTEK CONTROL SOLUTION BRAND 1

QUINTET CONTROL HIGH/NORMAL BRAND 1

RA E-ZJECT COLOR LANCETS 33G BRAND 1 MDS 200 / 30 DAY

RA E-ZJECT LANCETS 28G BRAND 1 MDS 200 / 30 DAY

RA E-ZJECT LANCETS THIN 26G BRAND 1 MDS 200 / 30 DAY

RA E-ZJECT LANCETS THIN 28G BRAND 1 MDS 200 / 30 DAY

RA E-ZJECT LANCETS ULTRA THIN BRAND 1 MDS 200 / 30 DAY

RA INSULIN SYRINGE BRAND 1 MDS 450 / 90 DAY



RA LANCING DEVICE BRAND 1

RA PEN NEEDLES BRAND 1 MDS 150 / 30 DAY

REFUAH PLUS GLUCOSE CONTROL BRAND 1

RELI-ON INSULIN SYRINGE MISC 29G X 1/2"1 ML BRAND 1 MDS 450 / 90 DAY

RELION INSULIN SYRINGE BRAND 1 MDS 450 / 90 DAY

RELION LANCETS MICRO-THIN 33G BRAND 1 MDS 200 / 30 DAY

RELION LANCETS STANDARD 21G BRAND 1 MDS 200 / 30 DAY

RELION LANCETS THIN 26G BRAND 1 MDS 200 / 30 DAY

RELION LANCETS ULTRA-THIN 30G BRAND 1 MDS 200 / 30 DAY

RELION LANCING DEVICE MISC BRAND 1

RELION MINI PEN NEEDLES BRAND 1 MDS 150 / 30 DAY

RELION PEN NEEDLES (PEN MISC 29G12MM, PEN MISC 31G 8 MM, PEN MISC 32G4 MM)


RELION SHORT PEN NEEDLES BRAND 1 MDS 150 / 30 DAY

RELION ULTRA THIN LANCETS 30G BRAND 1 MDS 200 / 30 DAY

RELION ULTRA THIN PLUS LANCETS BRAND 1 MDS 200 / 30 DAY

RENEW ADV CARTRIDGE REFILLS BRAND 1 MDS 200 / 30 DAY

RENEW ADVANCED LANCING DEVICE BRAND 1

REXALL LANCETS ULTRA THIN 30G BRAND 1 MDS 200 / 30 DAY

RIGHTEST GC300 CONTROL LIQUIDNORMAL BRAND 1

RIGHTEST GD500 LANCING DEVICE BRAND 1

RIGHTEST GL300 LANCETS BRAND 1 MDS 200 / 30 DAY

SAFESNAP INSULIN SYRINGE BRAND 1 MDS 450 / 90 DAY

SAFETY LANCET 21G/PRESSURE ACT BRAND 1 MDS 200 / 30 DAY



SAFETY LANCET 28G/PRESSURE ACT BRAND 1 MDS 200 / 30 DAY

SAFETY LANCET 2MM BRAND 1 MDS 200 / 30 DAY

SAFETY LANCETS BRAND 1 MDS 200 / 30 DAY

SAFETY LANCETS 21G BRAND 1 MDS 200 / 30 DAY

SAFETY LANCETS 28G BRAND 1 MDS 200 / 30 DAY

SAFETY LET LANCETS BRAND 1 MDS 200 / 30 DAY

SAFETY SEAL LANCETS BRAND 1 MDS 200 / 30 DAY

SAFETY-GLIDE SYRINGE BRAND 1 MDS 450 / 90 DAY

SAPSCARE TWIST TOP LANCETS BRAND 1 MDS 200 / 30 DAY

SB INSULIN SYRINGE BRAND 1 MDS 450 / 90 DAY

SB LANCETS THIN BRAND 1 MDS 200 / 30 DAY

SB LANCETS ULTRA THIN BRAND 1 MDS 200 / 30 DAY

SCHNUCKS INSULIN SYRINGE BRAND 1 MDS 450 / 90 DAY

SHOPKO AUTOLET LANCING DEVICE BRAND 1

SHOPKO ON-THE-GO LANCETS 30G BRAND 1 MDS 200 / 30 DAY

SHOPKO UNIFINE PENTIPS BRAND 1 MDS 150 / 30 DAY

SHOPKO UNILET LANCETS 28G BRAND 1 MDS 200 / 30 DAY

SHOPKO UNILET LANCETS 30G BRAND 1 MDS 200 / 30 DAY

SIMPLE DIAGNOSTICS LANCING DEV BRAND 1

SM INSULIN SYRINGE BRAND 1 MDS 450 / 90 DAY

SM LANCETS 21G BRAND 1 MDS 200 / 30 DAY

SM LANCETS 33G BRAND 1 MDS 200 / 30 DAY

SM SUPER THIN LANCETS 30G BRAND 1 MDS 200 / 30 DAY

SM THIN LANCETS 26G BRAND 1 MDS 200 / 30 DAY



SMART DIABETES VANTAGE LANCETS BRAND 1 MDS 200 / 30 DAY

SMART DIABETES VANTAGE LANCING BRAND 1

SMART SENSE COLOR LANCETS 33G BRAND 1 MDS 200 / 30 DAY

SMART SENSE STANDARD LANCETS BRAND 1 MDS 200 / 30 DAY

SMART SENSE SUPER THIN LANCETS BRAND 1 MDS 200 / 30 DAY

SMART SENSE THIN LANCETS 26G BRAND 1 MDS 200 / 30 DAY

SMARTEST CONTROL MEDIUM BRAND 1

SMARTEST LANCETS 28G BRAND 1 MDS 200 / 30 DAY

sodium polystyrene sulfonate (bulk) generic 1

SOLARTEK GLUCOSE CONTROL BRAND 1

SOLUS V2 CONTROL SOLUTION LOW BRAND 1

SOLUS V2 LANCETS 28G BRAND 1 MDS 200 / 30 DAY

SOLUS V2 LANCING DEVICE BRAND 1

SOLUS V2 TWIST LANCETS 30G BRAND 1 MDS 200 / 30 DAY

stannous fluoride (bulk) generic 0

STERILANCE TL BRAND 1 MDS 200 / 30 DAY

SUPER THIN LANCETS BRAND 1 MDS 200 / 30 DAY

SURE COMFORT INSULIN SYRINGE (MISC28G 1/2" 1 ML, MISC 28G 1/2" 0.5 ML, MISC29G 1/2" 1 ML, MISC 29G 1/2" 0.3 ML, MISC29G 1/2" 0.5 ML, MISC 30G 5/16" 0.5 ML,MISC 30G 1/2" 0.5 ML, MISC 30G 1/2" 1 ML,MISC 30G 5/16" 0.3 ML, MISC 30G 1/2" 0.3ML, MISC 30G 5/16" 1 ML, MISC 31G 5/16" 0.5ML, MISC 31G 5/16" 1 ML, MISC 31G 5/16" 0.3ML)


SURE COMFORT LANCETS 28G BRAND 1 MDS 200 / 30 DAY

SURE COMFORT LANCETS 30G BRAND 1 MDS 200 / 30 DAY

SURE COMFORT LANCING PEN BRAND 1

SURE COMFORT PEN NEEDLES BRAND 1 MDS 150 / 30 DAY



SURE EDGE GLUCOSE CONTROL(SOLUTION LOW, SOLUTION NORMAL) BRAND 1

SURE-FINE PEN NEEDLES BRAND 1 MDS 150 / 30 DAY

SURE-JECT INSULIN SYRINGE BRAND 1 MDS 450 / 90 DAY

SURE-LANCE FLAT LANCETS BRAND 1 MDS 200 / 30 DAY

SURE-LANCE LANCETS 26G BRAND 1 MDS 200 / 30 DAY

SURE-LANCE THIN LANCETS 28G BRAND 1 MDS 200 / 30 DAY

SURE-LANCE ULTRA THIN LANCETS BRAND 1 MDS 200 / 30 DAY

SURE-PEN BRAND 1

SURE-TEST EASYPLUS CONTROL BRAND 1

SURE-TOUCH LANCETS UNIVERSAL BRAND 1 MDS 200 / 30 DAY

SURECHEK CONTROL SOLUTION(SOLUTION LIQUID LOW, SOLUTION LIQUIDNORMAL)

BRAND 1

SURELITE LANCETS BRAND 1 MDS 200 / 30 DAY

SURESTEP GLUCOSE CONTROL BRAND 1

SURESTEP PRO LOW GLUCOSE BRAND 1

SURESTEP PRO NORMAL GLUCOSE BRAND 1

TAI DOC CONTROL BRAND 1

TECHLITE AST LANCETS BRAND 1 MDS 200 / 30 DAY

TECHLITE LANCETS BRAND 1 MDS 200 / 30 DAY

TECHLITE LANCETS 30G BRAND 1 MDS 200 / 30 DAY

TECHLITE PEN NEEDLES (PEN MISC 31G 8,PEN MISC 31G 6, PEN MISC 31G 5, PENMISC 32G 6, PEN MISC 32G 4)


TELCARE GLUCOSE CONTROL BRAND 1



TERUMO INSULIN SYRINGE (MISC 27G 1/2"0.5 ML, MISC 27G 1/2" 1 ML, MISC 28G 1/2"0.5 ML, MISC 28G 1/2" 1 ML, MISC 29G 1/2"0.5 ML, MISC 29G 1/2" 0.3 ML, MISC 29G 1/2"1 ML, MISC 30G 3/8" 0.5 ML, MISC 30G 3/8"0.3 ML)


TERUMO SURGUARD INSULIN SYR BRAND 1 MDS 450 / 90 DAY

TGT ADVANCED LANCING DEVICE BRAND 1

TGT LANCET ALTERNATE SITE BRAND 1 MDS 200 / 30 DAY

TGT LANCET MICRO THIN 33G BRAND 1 MDS 200 / 30 DAY

TGT LANCET SUPER THIN 30G BRAND 1 MDS 200 / 30 DAY

TGT LANCET THIN 23G BRAND 1 MDS 200 / 30 DAY

TGT LANCET THIN 26G BRAND 1 MDS 200 / 30 DAY

TGT LANCET ULTRA THIN 28G BRAND 1 MDS 200 / 30 DAY

TGT LANCET ULTRA THIN 30G BRAND 1 MDS 200 / 30 DAY

TGT LANCING DEVICE BRAND 1

THINPRO INSULIN SYRINGE (MISC 28G 1/2"0.5 ML, MISC 28G 1/2" 1 ML, MISC 29G 1/2" 1ML, MISC 29G 1/2" 0.3 ML, MISC 29G 1/2" 0.5ML, MISC 30G 3/8" 0.5 ML, MISC 30G 3/8" 0.3ML)


TODAYS HEALTH LANCING DEVICE BRAND 1

TODAYS HEALTH MINI PEN NEEDLES BRAND 1 MDS 150 / 30 DAY

TODAYS HEALTH PEN NEEDLES BRAND 1 MDS 150 / 30 DAY

TODAYS HEALTH SHORT PEN NEEDLE BRAND 1 MDS 150 / 30 DAY

TODAYS HEALTH THIN LANCETS 28G BRAND 1 MDS 200 / 30 DAY

TODAYS HEALTH THIN LANCETS 30G BRAND 1 MDS 200 / 30 DAY

TOPCARE CLICKFINE PEN NEEDLES BRAND 1 MDS 150 / 30 DAY

TOPCARE ULTRA COMFORT INS SYR BRAND 1 MDS 450 / 90 DAY



TRAVEL LANCETS BRAND 1 MDS 200 / 30 DAY

TRUE METRIX AIR BRAND 1 MDS 1 / 730 DAY

TRUE METRIX AIR GLUCOSE METER KITW/DEVICE BRAND 1 MDS 1 / 730 DAY

TRUE METRIX BLOOD GLUCOSE TEST BRAND 1MDS 100 / 30 DAY

MDS2 300 / 90 DAY

TRUE METRIX LEVEL 1 BRAND 1

TRUE METRIX LEVEL 2 BRAND 1

TRUE METRIX METER KIT W/DEVICE BRAND 1 MDS 1 / 730 DAY

TRUECONTROL GLUCOSE CONT LEV 0 BRAND 1

TRUECONTROL GLUCOSE CONT LEV 1 BRAND 1

TRUEDRAW LANCING DEVICE BRAND 1

TRUEPLUS INSULIN SYRINGE BRAND 1 MDS 450 / 90 DAY

TRUEPLUS LANCETS 26G BRAND 1 MDS 200 / 30 DAY




TRUEPLUS SAFETY LANCETS 28G BRAND 1 MDS 200 / 30 DAY

TRUERESULT BLOOD GLUCOSE BRAND 1 MDS 1 / 730 DAY

TRUETEST CONTROL LEVEL 1 BRAND 1



TRUETEST TEST BRAND 1MDS 100 / 30 DAY

MDS2 300 / 90 DAY

TRUETRACK GLUCOSE CONTROL BRAND 1

TRUETRACK TEST BRAND 1MDS 100 / 30 DAY

MDS2 300 / 90 DAY



ULTI-LANCE AUTO-ADJUST DEVICE BRAND 1

ULTI-LANCE AUTOMATIC BRAND 1

ULTI-LANCE MINI ADJUSTABLE BRAND 1

ULTICARE INSULIN SAFETY SYR BRAND 1 MDS 450 / 90 DAY

ULTICARE INSULIN SYRINGE (MISC 28G1/2" 1 ML, MISC 28G 1/2" 0.5 ML, MISC 29G1/2" 1 ML, MISC 29G 1/2" 0.3 ML, MISC 29G1/2" 0.5 ML, MISC 30G 1/2" 1 ML, MISC 30G5/16" 0.5 ML, MISC 30G 5/16" 1 ML, MISC 30G1/2" 0.5 ML, MISC 30G 5/16" 0.3 ML, MISC30G 1/2" 0.3 ML, MISC 31G 5/16" 0.5 ML,MISC 31G 5/16" 1 ML, MISC 31G 5/16" 0.3ML)


ULTICARE MICRO PEN NEEDLES MISC 32GX 4 MM BRAND 1 MDS 150 / 30 DAY

ULTICARE MINI PEN NEEDLES BRAND 1 MDS 150 / 30 DAY

ULTICARE PEN NEEDLES BRAND 1 MDS 150 / 30 DAY

ULTICARE SHORT PEN NEEDLES BRAND 1 MDS 150 / 30 DAY

ULTICARE THIN LANCETS 28G BRAND 1 MDS 200 / 30 DAY

ULTICARE THIN LANCETS 30G BRAND 1 MDS 200 / 30 DAY

ULTILET BASIC LANCETS 30G BRAND 1 MDS 200 / 30 DAY

ULTILET CLASSIC LANCETS BRAND 1 MDS 200 / 30 DAY

ULTILET INSULIN SYRINGE BRAND 1 MDS 450 / 90 DAY

ULTILET INSULIN SYRINGE SHORT BRAND 1 MDS 450 / 90 DAY

ULTILET LANCETS BRAND 1 MDS 200 / 30 DAY

ULTILET PEN NEEDLE BRAND 1 MDS 150 / 30 DAY

ULTILET SAFETY LANCETS 23G BRAND 1 MDS 200 / 30 DAY

ULTRA COMFORT INSULIN SYRINGE BRAND 1 MDS 450 / 90 DAY

ULTRA THIN LANCETS 28G BRAND 1 MDS 200 / 30 DAY



ULTRA THIN LANCETS 30G BRAND 1 MDS 200 / 30 DAY

ULTRA-COMFORT INSULIN SYRINGE BRAND 1 MDS 450 / 90 DAY

ULTRA-THIN II AUTO LANCET BRAND 1 MDS 200 / 30 DAY

ULTRA-THIN II INS SYR SHORT BRAND 1 MDS 450 / 90 DAY

ULTRA-THIN II INSULIN SYRINGE BRAND 1 MDS 450 / 90 DAY

ULTRA-THIN II LANCETS BRAND 1 MDS 200 / 30 DAY

ULTRA-THIN II MINI PEN NEEDLE BRAND 1 MDS 150 / 30 DAY

ULTRA-THIN II PEN NEEDLE SHORT BRAND 1 MDS 150 / 30 DAY

ULTRA-THIN II PEN NEEDLES BRAND 1 MDS 150 / 30 DAY

ULTRATRAK PRO CONTROL BRAND 1

ULTRATRAK ULTIMATE CONTROL BRAND 1

UNIFINE PENTIPS BRAND 1 MDS 150 / 30 DAY

UNIFINE PENTIPS PLUS BRAND 1 MDS 150 / 30 DAY

UNILET COMFORTOUCH LANCET BRAND 1 MDS 200 / 30 DAY

UNILET EXCELITE BRAND 1 MDS 200 / 30 DAY

UNILET EXCELITE II BRAND 1 MDS 200 / 30 DAY

UNILET G.P. LANCET BRAND 1 MDS 200 / 30 DAY

UNILET G.P. SUPERLITE LANCET BRAND 1 MDS 200 / 30 DAY

UNILET GP 28 ULTRA THIN BRAND 1 MDS 200 / 30 DAY

UNILET LANCET BRAND 1 MDS 200 / 30 DAY

UNILET MICRO-THIN 33G BRAND 1 MDS 200 / 30 DAY

UNILET SUPER-THIN 30G BRAND 1 MDS 200 / 30 DAY

UNILET SUPERLITE LANCET BRAND 1 MDS 200 / 30 DAY

UNILET ULTRA-THIN 28G BRAND 1 MDS 200 / 30 DAY



UNISTIK 3 GENTLE BRAND 1 MDS 200 / 30 DAY

UNISTIK SAFETY LANCETS 28G BRAND 1 MDS 200 / 30 DAY

UNISTIK SAFETY LANCETS 30G BRAND 1 MDS 200 / 30 DAY

UNISTIK TOUCH SAFETY LANC 21G BRAND 1 MDS 200 / 30 DAY




UNISTRIP CONTROL SOLUTION LOW BRAND 1

UNIVERSAL 1 LANCETS THIN 26G BRAND 1 MDS 200 / 30 DAY

UNIVERSAL 1 LANCETS ULTRA THIN BRAND 1 MDS 200 / 30 DAY

V-R MONO INSULIN SYRINGE BRAND 1 MDS 450 / 90 DAY

VALUE HEALTH INSULIN SYRINGE BRAND 1 MDS 450 / 90 DAY

VALUE PLUS LANCET STANDARD 21G BRAND 1 MDS 200 / 30 DAY

VALUE PLUS LANCETS SUPER THIN BRAND 1 MDS 200 / 30 DAY

VALUE PLUS LANCETS THIN 26G BRAND 1 MDS 200 / 30 DAY

VALUE PLUS LANCING DEVICE BRAND 1

VALUMARK LANCET SUPER THIN 30G BRAND 1 MDS 200 / 30 DAY

VALUMARK LANCET ULTRA THIN 28G BRAND 1 MDS 200 / 30 DAY

VALUMARK PEN NEEDLES BRAND 1 MDS 150 / 30 DAY

VANISHPOINT INSULIN SYRINGE BRAND 1 MDS 450 / 90 DAY

VICTORY CONTROL LEVEL 1/2 BRAND 1

VIDA MIA AUTOLET LANCING DEV BRAND 1

VIDA MIA UNIFINE PENTIPS BRAND 1 MDS 150 / 30 DAY

VIDA MIA UNILET LANCETS 28G BRAND 1 MDS 200 / 30 DAY

VIDA MIA UNILET LANCETS 30G BRAND 1 MDS 200 / 30 DAY



VISTOGARD BRAND 4

VOCAL POINT CONTROL SOLUTION LOW BRAND 1

VP INSULIN SYRINGE BRAND 1 MDS 450 / 90 DAY

W&F LANCETS 26G BRAND 1 MDS 200 / 30 DAY

W&F LANCETS COLORED 21G BRAND 1 MDS 200 / 30 DAY

WALGREENS ADV TRAVEL LANCETS BRAND 1 MDS 200 / 30 DAY

WALGREENS LANCETS BRAND 1 MDS 200 / 30 DAY

WALGREENS LANCETS MICRO THIN BRAND 1 MDS 200 / 30 DAY

WALGREENS LANCETS SUPER THIN BRAND 1 MDS 200 / 30 DAY

WALGREENS LANCING DEVICE BRAND 1

WALGREENS THIN LANCETS BRAND 1 MDS 200 / 30 DAY

WALGREENS ULTRA THIN LANCETS BRAND 1 MDS 200 / 30 DAY

water for irrigation, sterile generic 1

WD MEDIC INSULIN SYRINGE BRAND 1 MDS 450 / 90 DAY

WEGMANS UNIFINE PENTIPS PLUS BRAND 1 MDS 150 / 30 DAY

WIDE-SEAL DIAPHRAGM 60 BRAND 0








XPRES CONTROL BRAND 1



OPHTHALMIC AGENTS

OPHTHALMIC AGENTS, OTHER

LACRISERT BRAND 3

LASTACAFT BRAND 2

neomycin-bacitracin zn-polymyxin generic 1

neomycin-polymy-dexameth (oint, susp) generic 1

neomycin-polymyxin-hc (ophth) generic 1

polymyxin b-trimethoprim generic 1

proparacaine hcl generic 1

RESTASIS BRAND 2

tobramycin-dexamethasone generic 1

tropicamide (soln 0.5%, soln 1%) generic 1

OPHTHALMIC ANTI-ALLERGY AGENTS

ALOCRIL BRAND 3

ALOMIDE BRAND 3

azelastine hcl (ophth) generic 1 MPL 1 / day

BEPREVE BRAND 3

cromolyn sodium (ophth) generic 1

EMADINE BRAND 3

epinastine hcl (ophth) generic 1

PATADAY BRAND 2

PATANOL BRAND 3

OPHTHALMIC ANTI-INFLAMMATORIES

ALREX BRAND 2

bromfenac sodium (ophth) generic 1

dexamethasone sodium phosphate (ophth) generic 1

diclofenac sodium (ophth) generic 1



DUREZOL BRAND 2

fluorometholone (ophth) generic 1

flurbiprofen sodium generic 1

FML BRAND 3

FML FORTE BRAND 3

ILEVRO BRAND 3

ketorolac tromethamine ophth soln 0.4% generic 1 MPL 1 / 30 day

ketorolac tromethamine ophth soln 0.5% generic 1 MPL 1 / day

LOTEMAX (GEL 0.5 %, OINTMENT 0.5 %,SUSPENSION 0.5 %) BRAND 2

MAXIDEX BRAND 3

NEVANAC BRAND 3

PRED MILD BRAND 3

prednisolone acetate (ophth) generic 1

PREDNISOLONE SODIUM PHOSPHATESOLUTION 1 % BRAND 3

VEXOL BRAND 3

OPHTHALMIC ANTIGLAUCOMA AGENTS

apraclonidine hcl generic 1

AZOPT BRAND 2 MPL 1 / day

betaxolol hcl (ophth) generic 1 MPL 1 / day

brimonidine tartrate ophth soln 0.15% generic 1 MPL 1 / day

brimonidine tartrate ophth soln 0.2% generic 1 MPL 1 / 30 day

carteolol hcl (ophth) generic 1

COMBIGAN BRAND 2

dorzolamide hcl generic 1 MPL 1 / day

dorzolamide hcl-timolol maleate generic 1 MPL 1 / day

IOPIDINE SOLUTION 1 % BRAND 3



levobunolol hcl generic 1 MPL 1 / day

methazolamide (tab 25 mg, tab 50 mg) generic 1 MDD 6 per day

metipranolol generic 1

PHOSPHOLINE IODIDE BRAND 3

pilocarpine hcl generic 1

timolol maleate (ophth) generic 1

OPHTHALMIC PROSTAGLANDIN AND PROSTAMIDE ANALOGS

bimatoprost ophth soln 0.03% generic 3 ST

latanoprost ophth soln 0.005% generic 1

LUMIGAN SOLUTION 0.01 % BRAND 3 ST

TRAVATAN Z BRAND 2

ZIOPTAN BRAND 2

OTIC AGENTS

acetic acid (otic) generic 1

antipyrine-benzocaine otic soln 54-14 mg/ml(5.4-1.4%) generic 1

CIPRO HC BRAND 3

CIPRODEX BRAND 2

COLY-MYCIN S BRAND 3

CORTISPORIN SOLUTION 3.5-10000-1 BRAND 2

CORTISPORIN-TC BRAND 3

fluocinolone acetonide (otic) generic 1

hydrocortisone w/acetic acid generic 1

neomycin-polymyxin-hc (otic) generic 1

RESPIRATORY TRACT/PULMONARY AGENTS

ANTI-INFLAMMATORIES, INHALED CORTICOSTEROIDS

ALVESCO BRAND 3PA

MPL 1 / 30 day



ASMANEX 120 METERED DOSES BRAND 2 MPL 1 / 30 day


ASMANEX 30 METERED DOSES AER POWBA 110 MCG/INH BRAND 2 MPL 3 / 90 day

ASMANEX 30 METERED DOSES AER POWBA 220 MCG/INH BRAND 2 MPL 1 / 30 day



budesonide (inhalation) (susp 0.25 mg/2ml,susp 0.5 mg/2ml) generic 3

PA

MDS 120 / 30 DAY

MDS2 360 / 90 DAY

budesonide (nasal) generic 1PA

MPL 3 / 90 day

budesonide inhalation susp 1 mg/2ml generic 1

PA

MDS 120 ML / 30 DAY


FLOVENT DISKUS BRAND 3 MPL 1 / 30 day

FLOVENT HFA BRAND 3 MPL 1 / 30 day

flunisolide nasal soln 25 mcg/act (0.025%) generic 1 MPL 1 / 30 day

flunisolide nasal soln 29 mcg/act (0.025%) generic 1 MPL 3 / 90 day

fluticasone propionate (nasal) generic 1 MPL 3 / 90 day

mometasone furoate (nasal) generic 1 PA

NASONEX BRAND 2 PA

PULMICORT (SUSPENSION 0.25 MG/2ML,SUSPENSION 0.5 MG/2ML) BRAND 3

PA

MDS 120 / 30 DAY

MDS2 360 / 90 DAY

PULMICORT FLEXHALER BRAND 2PA

MPL 1 / 30 day



PULMICORT SUSPENSION 1 MG/2ML BRAND 2

PA

MDS 120 ML / 30 DAY


QVAR BRAND 2 MPL 1 / 30 day

RHINOCORT AQUA BRAND 3PA

MPL 3 / 90 day

ANTIHISTAMINES

ALLEGRA TAB 60 MG BRAND 1 MDD 2 per day

ASTELIN BRAND 2 MPL 3 / 90 day

ASTEPRO BRAND 2 MPL 1 / 30 day

azelastine hcl (0.1% (137 mcg/), 0.15% (205.5mcg/), 137 mcg/(1 mg/ml)) generic 1 MPL 1 / 30 day

carbinoxamine maleate (soln 4 mg/5ml, tab 4mg) generic 1

cetirizine hcl generic 1MDS 300 ML / 30 DAY


clemastine fumarate (syrup 0.67 mg/5ml (0.5mg/5ml base eq), tab 2.68 mg) generic 1

cyproheptadine hcl (syrup 2 mg/5ml, tab 4 mg) generic 1

desloratadine generic 1 MDD 1 per day

DEXCHLORPHENIRAMINE MALEATE BRAND 3

diphenhydramine hcl (cap 50 mg, elixir 12.5mg/5ml, inj 50 mg/ml) generic 1

hydroxyzine hcl (im soln 50 mg/ml, syrup 10mg/5ml, tab 10 mg, tab 25 mg, tab 50 mg) generic 1

hydroxyzine pamoate (cap 25 mg, cap 50 mg,cap 100 mg) generic 1

levocetirizine dihydrochloride soln 2.5 mg/5ml(0.5 mg/ml) generic 1

MDS 300 ML / 30 DAY


levocetirizine dihydrochloride tab 5 mg generic 1 MDD 1 per day



olopatadine hcl (nasal) generic 1

promethazine hcl (inj 25 mg/ml, inj 50 mg/ml,suppos 12.5 mg, suppos 25 mg, syrup 6.25mg/5ml, tab 12.5 mg, tab 25 mg, tab 50 mg)

generic 1

ANTILEUKOTRIENES

montelukast sodium generic 1 MDD 1 per day

zafirlukast generic 1 MDD 2 per day

ZYFLO CR BRAND 3 MDD 4 per day

BRONCHODILATORS, ANTICHOLINERGIC

ATROVENT HFA BRAND 3 MPL 2 / 30 days

INCRUSE ELLIPTA BRAND 2 MPL 1 / 30 day

ipratropium bromide inhal soln 0.02% generic 1 MDS 450 ML / 30 DAY

ipratropium bromide nasal soln 0.03% (21mcg/spray) generic 1 MDS 30 ML / 30 DAY

ipratropium bromide nasal soln 0.06% (42mcg/spray) generic 1

SPIRIVA HANDIHALER BRAND 2 MDD 1 per day

SPIRIVA RESPIMAT AERO SOLN 1.25MCG/ACT BRAND 2 MPL 1 / 30 day

SPIRIVA RESPIMAT AERO SOLN 2.5MCG/ACT BRAND 2 MPL 3 / 90 day

BRONCHODILATORS, SYMPATHOMIMETIC

ADRENACLICK SOLN A-INJ 0.3 MG/0.3ML BRAND 2 MPL 1 / claim(s)

albuterol sulfate (soln nebu 0.083% (2.5mg/3ml), soln nebu 0.63 mg/3ml (base equiv),soln nebu 1.25 mg/3ml (base equiv))

generic 1 MDS 450 / 30 DAYS

albuterol sulfate (syrup 2 mg/5ml, tab 2 mg, tab4 mg, tab sr 12hr 4 mg, tab sr 12hr 8 mg) generic 1

albuterol sulfate soln nebu 0.5% (5 mg/ml) generic 1 MPL 3 / 30 day

ARCAPTA NEOHALER BRAND 2PA

MPL 3 / 90 day



AUVI-Q SOLN A-INJ 0.3 MG/0.3ML BRAND 2 MPL 1 / claim(s)

BROVANA BRAND 3

PA

MDS 120 ML / 30 DAY


epinephrine hcl generic 1

EPINEPHRINE SOLN A-INJ 0.3 MG/0.3ML BRAND 2 MPL 1 / claim(s)

EPIPEN BRAND 2 MPL 1 / claim(s)

EPIPEN 2-PAK BRAND 2 MPL 1 / claim(s)

EPIPEN JR BRAND 2 MPL 1 / claim(s)

EPIPEN JR 2-PAK BRAND 2 MPL 1 / claim(s)

FORADIL AEROLIZER BRAND 2PA

MDD 2 per day

levalbuterol hcl (soln nebu 0.31 mg/3ml, solnnebu 0.63 mg/3ml, soln nebu 1.25 mg/3ml) generic 1 MDS 360 / 30 DAYS

levalbuterol hcl soln nebu conc 1.25 mg/0.5ml(base equiv) generic 1

MAXAIR AUTOHALER BRAND 2 MPL 1 / 30 day

metaproterenol sulfate (syrup 10 mg/5ml, tab10 mg, tab 20 mg) generic 1

PROAIR HFA BRAND 2 MPL 6 / 90 day

PROVENTIL HFA BRAND 2 MPL 6 / 90 day

SEREVENT DISKUS BRAND 2 MPL 3 / 90 day

terbutaline sulfate (inj 1 mg/ml, tab 2.5 mg, tab5 mg) generic 1

TWINJECT BRAND 2 MPL 1 / claim(s)

VENTOLIN HFA BRAND 2 MPL 6 / 90 day

XOPENEX HFA BRAND 3PA

MPL 2 / 30 day



CYSTIC FIBROSIS AGENTS

CAYSTON BRAND 4PA

S Specialty Drug

KALYDECO TAB 150 MG BRAND 4PA

S Specialty Drug

TOBI BRAND 4

PA

C Custom

S Specialty Drug

tobramycin nebu soln 300 mg/5ml generic 4

PA

C Custom

S Specialty Drug

PHOSPHODIESTERASE INHIBITORS, AIRWAYS DISEASE

aminophylline inj 25 mg/ml generic 1

ELIXOPHYLLIN BRAND 1

LUFYLLIN BRAND 3

theophylline (tab 12hr 200 mg, tab 12hr 450mg, tab 12hr 300 mg, tab 12hr 100 mg, tab24hr 600 mg, tab 24hr 400 mg)

generic 1

PULMONARY ANTIHYPERTENSIVES

ADCIRCA BRAND 4PA

S Specialty Drug

LETAIRIS BRAND 4PA

S Specialty Drug

REMODULIN BRAND 4PA

S Specialty Drug

REVATIO (SOLUTION 10 MG/12.5ML, TAB 20MG) BRAND 4

PA

S Specialty Drug

sildenafil citrate (pulmonary hypertension) (ivsoln 10 mg/12.5ml (base equivalent), tab 20mg)

generic 4PA

S Specialty Drug



TRACLEER TAB 125 MG BRAND 4

PA

MDD 2 per day

S Specialty Drug

TRACLEER TAB 62.5 MG BRAND 4

PA

MDD 1 per day

S Specialty Drug

VENTAVIS BRAND 4PA

S Specialty Drug

RESPIRATORY TRACT AGENTS, OTHER

acetylcysteine (soln 10%, soln 20%) generic 1

ADVAIR DISKUS BRAND 2PA

MPL 1 / 30 day

ADVAIR HFA BRAND 2PA

MPL 1 / 30 day

ARALAST BRAND 4PA

S Specialty Drug

ARALAST NP (RECON SOLN 400 MG,RECON SOLN 800 MG, RECON SOLN 1000MG)

BRAND 4PA

S Specialty Drug

benzonatate cap 100 mg generic 1

MDD 6 per day

MDS 60 / 10 DAY

C LIMIT=10 DAYSUPPLY/CLAIM



MDD 3 per day

MDS 30 / 10 DAY

C LIMIT=10 DAYSUPPLY/CLAIM

BREO ELLIPTA BRAND 2 MPL 1 / 30 day

cromolyn sodium soln nebu 20 mg/2ml generic 1 MDS 240 ML / 30 DAY



HYPERSAL NEBU SOLN 3.5 % BRAND 1

ipratropium-albuterol generic 1 MDS 540 ML / 30 DAYS

NEBUSAL BRAND 1

PROLASTIN RECON SUSP 1000 MG BRAND 4PA

S Specialty Drug

PROLASTIN-C BRAND 4PA

S Specialty Drug

PULMOZYME BRAND 4PA

S Specialty Drug

sodium chloride soln nebu 7% generic 1

SYMBICORT AEROSOL 160-4.5 MCG/ACT BRAND 2PA

MPL 1 / 30 day

SYMBICORT AEROSOL 80-4.5 MCG/ACT BRAND 2PA

MPL 3 / 90 day

TYZINE BRAND 3

XOLAIR BRAND 4PA

S Specialty Drug

ZEMAIRA BRAND 4PA

S Specialty Drug

SKELETAL MUSCLE RELAXANTS

BOTOX BRAND 3 PA

carisoprodol (tab 250 mg, tab 350 mg) generic 1

chlorzoxazone tab 500 mg generic 1

cyclobenzaprine hcl (tab 5 mg, tab 7.5 mg, tab10 mg) generic 1 MDD 3 per day

DYSPORT BRAND 3 PA

DYSPORT (GLABELLAR LINES) BRAND 3 PA



metaxalone tab 800 mg generic 1 MDD 4 per day

methocarbamol (tab 500 mg, tab 750 mg) generic 1

orphenadrine citrate tab sr 12hr 100 mg generic 1 MDD 2 per day

XEOMIN RECON SOLN 50 UNIT BRAND 3 PA

SLEEP DISORDER AGENTS

GABA RECEPTOR MODULATORS

estazolam generic 1

eszopiclone generic 1

ST


MDD 1 per day

LUNESTA BRAND 3

ST


MDD 1 per day

triazolam generic 1

zaleplon cap 10 mg generic 1AL At least 18 yrs old

MDD 2 per day

zaleplon cap 5 mg generic 1AL At least 18 yrs old

MDD 1 per day

zolpidem tartrate (tab 5 mg, tab 10 mg) generic 1AL At least 18 yrs old

MDD 1 per day

SLEEP DISORDERS, OTHER

modafinil tab 100 mg generic 1

PA


MDD 1 per day

modafinil tab 200 mg generic 1

PA


MDD 2 per day



NUVIGIL (TAB 50 MG, TAB 150 MG, TAB 250MG) BRAND 2

PA


MDD 1 per day

NUVIGIL TAB 200 MG BRAND 2PA


ROZEREM BRAND 3

ST


MDD 1 per day

XYREM BRAND 4

PA

MDS 540 ML / 30 DAY

S Specialty Drug

MDS2 1620 ML / 90 DAY

THERAPEUTIC NUTRIENTS/MINERALS/ELECTROLYTES

ELECTROLYTE/MINERAL MODIFIERS

CHEMET BRAND 3

EXJADE BRAND 4PA

S Specialty Drug

FERRIPROX TAB 500 MG BRAND 3

JADENU BRAND 4PA

S Specialty Drug

SAMSCA BRAND 4PA

S Specialty Drug

sodium polystyrene sulfonate (*sodiumpowder**, sodium oral susp 15 gm/60ml) generic 1

SYPRINE BRAND 4PA

S Specialty Drug

ELECTROLYTE/MINERAL REPLACEMENT

*peritoneal dialysis solutions 346 mosm/l** generic 1



AMMONIUM CHLORIDE BRAND 3

calcium chloride inj 10% generic 1

calcium gluconate inj 10% generic 1

DELFLEX-LC/1.5% DEXTROSE BRAND 1

DEXTROSE 5%/ELECTROLYTE #48 BRAND 1

dextrose in lactated ringers generic 1

dextrose in ringers generic 1

DIANEAL LOW CALCIUM/1.5% DEX BRAND 1

DIANEAL PD-2/1.5% DEXTROSE BRAND 1

electrolyte-m in dextrose generic 1

ferrous fumarate-folic acid generic 1 MDD 1 per day

IONOSOL-B IN D5W BRAND 1

IONOSOL-MB IN D5W BRAND 1

irrigation solutions, physiological generic 1

ISOLYTE-P IN D5W BRAND 1

ISOLYTE-S BRAND 1

KCL IN DEXTROSE-NACL SOLUTION 40-5-0.9 MEQ/L-%-% BRAND 1

KCL-LACTATED RINGERS-D5W BRAND 1

KLOR-CON M15 BRAND 1

lactated ringer's generic 1

MAGNESIUM SULFATE (SOLUTION 2GM/50ML, SOLUTION 4 GM/50ML,SOLUTION 4 GM/100ML, SOLUTION 20GM/500ML, SOLUTION 40 GM/1000ML)

BRAND 1

magnesium sulfate inj 50% generic 1

NORMOSOL-M IN D5W BRAND 1

NORMOSOL-R PH 7.4 BRAND 1

parenteral electrolytes generic 1

PLASMA-LYTE 148 BRAND 1



PLASMA-LYTE A BRAND 1

PLASMA-LYTE-56 IN D5W BRAND 1

potassium acetate generic 1

potassium bicarb & chloride generic 1

potassium bicarbonate effer tab 25 meq generic 1

potassium chloride (cap cr 8 meq, cap cr 10meq, inj 2 meq/ml, inj 10 meq/100 ml, inj 10meq/100ml, inj 20 meq/50ml, inj 20 meq/50 ml,inj 30 meq/100 ml, oral liq 10% (20 meq/15ml),oral soln 10% (20 meq/15ml), powder packet20 meq, tab cr 8 meq (600 mg), tab cr 10 meq)

generic 1

POTASSIUM CHLORIDE (SOLUTION 10MEQ/50ML, SOLUTION 30 MEQ/100ML) BRAND 1

POTASSIUM CHLORIDE ER TAB ER 8 MEQ BRAND 1

potassium chloride in dextrose & sodiumchloride (10 meq/l (0.07) 0.4j, 20 meq/l (0.1)0.2% j, 20 meq/l (0.1) 0.33% j, 20 meq/l (0.1)0.4j, 20 meq/l (0.1) 0.9% j, 30 meq/l (0.224%)0.4j, 40 meq/l (0.3%) 0.4j)

generic 1

potassium chloride in dextrose (20 meq/l (0.1) j,40 meq/l (0.3%) j) generic 1

potassium chloride in nacl generic 1

potassium chloride microencapsulated crystalscr generic 1

potassium phosphates generic 1

ringer's generic 1

ringer's irrigation generic 1

sodium acetate (inj 2 meq/ml, inj 4 meq/ml) generic 1

sodium chloride (inj 0.45%, inj 2.5 meq/ml(14.6%), inj 3%, inj 4 meq/ml (23.4%), inj 5%, ivsoln 0.9%)

generic 1

sodium phosphate generic 1

ULTRABAG/DIANEAL PD-2/1.5% DEX BRAND 1

ULTRABAG/DIANEAL/1.5% DEXTROSE BRAND 1



AMINOSYN II IN DEXTROSE 25% BRAND 3

CLINIMIX E/DEXTROSE (5/20) BRAND 3

CLINIMIX/DEXTROSE (2.75/5) BRAND 3




CLINIMIX/DEXTROSE (5/25) BRAND 3

DRISDOL BRAND 0

ergocalciferol cap 50000 unit generic 0

folic acid tab 1 mg generic 0GL Female


lactated ringer's (irrigation) generic 1

ANTISPASTICITY AGENTS

baclofen (tab 10 mg, tab 20 mg) generic 1

dantrolene sodium (cap 25 mg, cap 50 mg, cap100 mg) generic 1 MDD 4 per day

tizanidine hcl generic 1


Index of covered drugs11ST CHOICE LANCETS SUPER THIN 1131ST CHOICE LANCETS THIN 1131ST CHOICE LANCETS ULTRA THIN 1131ST CHOICE PEN NEEDLES 1131ST TIER UNIFINE PENTIPS 1131ST TIER UNIFINE PENTIPS PLUS 1131ST TIER UNILET COMFORTOUCH 113

AA-HYDROCORT 95abacavir sulfate 61abacavir sulfate-lamivudine-zidovudine 61ABELCET 34ABRAXANE 44acamprosate calcium 17acarbose 66ACCU-CHEK ACTIVE GLUCOSE CONT 113ACCU-CHEK AVIVA 113ACCU-CHEK COMFORT CURVE 113ACCU-CHEK COMFORT CURVE LINEAR 113ACCU-CHEK COMPACT BLUE CONTROL 113ACCU-CHEK COMPACT PLUS CONTROL 114ACCU-CHEK FASTCLIX LANCETS 114ACCU-CHEK INSTANT CONTROL 114ACCU-CHEK MULTICLIX LANCETS 114ACCU-CHEK SAFE-T PRO LANCETS 114ACCU-CHEK SMARTVIEW CONTROL 114ACCU-CHEK SOFT TOUCH LANCETS 114ACCU-CHEK SOFTCLIX LANCET DEV 114ACCU-CHEK SOFTCLIX LANCETS 114ACCUSURE INSULIN SYRINGE 114ACCUTREND GLUCOSE CONTROL 114acebutolol hcl 75acetaminophen w/ codeine 15acetazolamide 78acetazolamide sodium 78acetic acid 19acetic acid (otic) 147acetone (urine) test 114

acetylcysteine 153acitretin 86ACTEMRA 109ACTI-LANCE 28G 114ACTI-LANCE LITE LANCETS 28G 114ACTI-LANCE SPECIAL LANCETS 17G 114ACTI-LANCE UNIVERSAL 23G 114ACTIMMUNE 109ACTIVE 1ST BLOOD LANCETS 30G 114ACTONEL 111ACTOPLUS MET 66ACURA CONTROL 114acyclovir 64acyclovir topical 64ADACEL 109ADAGEN 89adapalene 86ADAPALENE 86ADCETRIS 51ADCIRCA 152adefovir dipivoxil 58ADJUSTABLE LANCING DEVICE 114ADRENACLICK 150ADVAIR DISKUS 153ADVAIR HFA 153ADVANCE INTUITION CONTROL 114ADVICOR 79,80ADVOCATE CONTROL SOLUTION 114ADVOCATE INSULIN PEN NEEDLES 114ADVOCATE INSULIN SYRINGE 114ADVOCATE LANCETS 114ADVOCATE LANCETS 30G 114ADVOCATE LANCING DEVICE 115ADVOCATE RAPID-SAFE LANCING 115ADVOCATE REDI-CODE+ CONTROL 115ADVOCATE SAFETY LANCETS 115ADVOCATE SAFETY LANCETS 26G 115AF LANCETS SUPER THIN 115AFINITOR 49AFLURIA 109AFLURIA PRESERVATIVE FREE 110


AGAMATRIX CONTROL 115AGAMATRIX ULTRA-THIN LANCETS 115AGGRENOX 73AGRIFLU 110AIMSCO LUBRICATED 7ALBENZA 52albuterol sulfate 150alclometasone dipropionate 95ALDURAZYME 89alendronate sodium 111alfuzosin hcl 94ALIMTA 42ALINIA 52ALKERAN 40ALLEGRA 149ALLEGRA ALLERGY 9ALLEGRA ALLERGY CHILDRENS 9allopurinol 36almotriptan malate 37ALOCRIL 145ALOMIDE 145ALORA 99alosetron hcl 92ALOXI 33alprazolam 65ALREX 145ALTABAX 19ALTERNATE SITE LANCING DEVICE 115ALTOPREV 79ALVESCO 147amantadine hcl 54AMBISOME 34amcinonide 95amikacin sulfate 18amiloride & hydrochlorothiazide 77amiloride hcl 78aminophylline 152AMINOSYN II IN DEXTROSE 25% 159amiodarone hcl 75AMIODARONE HCL 75amiodarone hcl (bulk) 115

AMITIZA 92amitriptyline hcl 32amlodipine besylate 76amlodipine besylate-benazepril hcl 77AMMONIUM CHLORIDE 157amoxapine 32amoxicillin 22amoxicillin & pot clavulanate 22amphetamine-dextroamphetamine 81AMPHOTEC 34amphotericin b 34ampicillin 22AMPICILLIN 22ampicillin & sulbactam sodium 22ampicillin sodium 22AMPYRA 84ANADROL-50 104anagrelide hcl 72anastrozole 48ANDRODERM 99ANDROXY 99ANTI-STICK INSULIN SYRINGE 115antipyrine-benzocaine 147ANZEMET 34APIDRA 68APIDRA SOLOSTAR 68APOKYN 54apraclonidine hcl 146APRISO 110APTIVUS 63AQUA LANCE ADJUSTABLE LANCING 115ARALAST 153ARALAST NP 153ARANESP (ALBUMIN FREE) 72ARCALYST 109ARCAPTA NEOHALER 150AREDIA 111ARESTIN 85ARIMIDEX 48aripiprazole 56AROMASIN 48


ARRANON 44ARZERRA 51ASACOL 110ASACOL HD 110ASCENSIA AUTODISC CONTROL 115ASCENSIA AUTODISC CONTROLS 115ASMANEX 120 METERED DOSES 148ASMANEX 14 METERED DOSES 148ASMANEX 30 METERED DOSES 148ASMANEX 60 METERED DOSES 148ASMANEX 7 METERED DOSES 148aspirin 4aspirin-dipyridamole 73ASSURE 3 CONTROL 115ASSURE 4 CONTROL LEVEL 1 & 2 115ASSURE COMFORT LANCETS 28G 115ASSURE COMFORT LANCETS 30G 115ASSURE DOSE CONTROL 115ASSURE DOSE NORM/HIGH CONTROL 115ASSURE HAEMOLANCE PLUS HIGH 115ASSURE HAEMOLANCE PLUS LOW 115ASSURE HAEMOLANCE PLUS MICRO 115ASSURE HAEMOLANCE PLUS NORMAL 115ASSURE HAEMOLANCE PLUS PED 115ASSURE ID INSULIN SAFETY SYR 116ASSURE LANCE LANCETS 116ASSURE LANCE LANCETS 21G 116ASSURE LANCE PLUS SAFETY 25G 116ASSURE LANCE PLUS SAFETY 30G 116ASSURE LANCETS 116ASSURE PRISM CONTROL LEVEL 1&2 116ASSURE PRO CONTROL LEVEL 1 & 2 116ASTELIN 149ASTEPRO 149ATELVIA 111atenolol 75atenolol & chlorthalidone 77ATGAM 108atorvastatin calcium 79atovaquone 52atovaquone-proguanil hcl 52

ATRIPLA 60atropine sulfate 90ATROPINE SULFATE 90ATROVENT HFA 150AURORA HEALTHCARE LANCETS 116AURORA LANCET SUPER THIN 30G 116AURORA LANCET THIN 23G 116AURORA PEN NEEDLES 116AURORA UNIFINE PENTIPS 116AUTO-LANCET 116AUTO-LANCET MINI 116AUTOLET IMPRESSION 116AUTOLET LANCING DEVICE 116AUTOLET MINI 116AUVI-Q 151AVANDIA 66AVASTIN 51AVELOX 24AVELOX ABC PACK 24AVODART 94AVONEX 84AVONEX PEN 84AVONEX PREFILLED 84AXERT 37AYGESTIN 103azacitidine 44AZACTAM IN DEXTROSE 22AZASAN 106AZASITE 23azathioprine 106azathioprine sodium 106azelastine hcl 149azelastine hcl (ophth) 145AZELEX 86AZILECT 55azithromycin 23AZOPT 146aztreonam 22

Bbacitracin 19


bacitracin (ophthalmic) 19baclofen 159balsalazide disodium 110BANZEL 27,28BARACLUDE 58BAYER BREEZE 2 CONTROL 116BAYER CONTOUR 116BAYER CONTOUR NEXT CONTROL 116BAYER MICROLET 2 LANCING DEVIC 116BAYER MICROLET LANCETS 116BD AUTOSHIELD 116BD INSULIN SYR ULTRAFINE II 116BD INSULIN SYRINGE 117BD INSULIN SYRINGE HALF-UNIT 117BD INSULIN SYRINGE MICROFINE 117BD INSULIN SYRINGE ULTRAFINE 117BD INTEGRA INSULIN SYRINGE 117BD INTEGRA SYRINGE 117BD LANCET DEVICE 117BD LANCET ULTRAFINE 30G 117BD LANCET ULTRAFINE 33G 117BD MICROTAINER LANCETS 117BD PEN NEEDLE MINI U/F 117BD PEN NEEDLE NANO U/F 117BD PEN NEEDLE SHORT U/F 117BD PEN NEEDLE ULTRAFINE 117BD SAFETY-LOK INSULIN SYRINGE 117BD SAFETYGLIDE INSULIN SYRINGE 117benazepril & hydrochlorothiazide 77benazepril hcl 74BENICAR 74benzonatate 153benzoyl peroxide 5,86benzoyl peroxide-erythromycin 86benztropine mesylate 53BEPREVE 145BESIVANCE 24betamethasone dipropionate (topical) 95betamethasone dipropionate augmented 95betamethasone valerate 95BETASERON 85

betaxolol hcl 75betaxolol hcl (ophth) 146bethanechol chloride 94bexarotene 52BEXXAR 51BEYAZ 99bicalutamide 41BICNU 40BIDIL 77BILTRICIDE 52bimatoprost 147bisacodyl 5bisoprolol fumarate 75bleomycin sulfate 44blood glucose calibration 117blood glucose monitoring supplies 117BONIVA 111BOOSTRIX 110BOSULIF 49BOTOX 154BREO ELLIPTA 153BREVICON (28) 99BRILINTA 73brimonidine tartrate 146BRINTELLIX 30bromfenac sodium (ophth) 145bromocriptine mesylate 54BROVANA 151budesonide 111budesonide (inhalation) 148budesonide (nasal) 9,148BULLSEYE MINI SAFETY LANCETS 117BULLSEYE SAFETY LANCETS 117bumetanide 78BUPHENYL 89buprenorphine hcl 17buprenorphine hcl-naloxone hcl dihydrate 17bupropion hcl 29,30bupropion hcl (smoking deterrent) 18buspirone hcl 65BUSULFEX 40


butalbital-acetaminophen-caffeine 83butalbital-acetaminophen-caffeine w/ codeine 15butalbital-aspirin-caffeine 83butalbital-aspirin-caffeine w/cod 15butorphanol tartrate 15BUTRANS 13BYETTA 10 MCG PEN 66BYETTA 5 MCG PEN 66BYSTOLIC 75

Ccabergoline 105CAFERGOT 37calcipotriene 86calcipotriene-betamethasone dipropionate 86calcitonin (salmon) 111calcitriol 111calcitriol (topical) 86calcium acetate (phosphate binder) 7,95calcium chloride (dihydrate) 157calcium gluconate 157calcium polycarbophil 5CAMPATH 44CAMPRAL 17CAMPTOSAR 44CANASA 111CANCIDAS 35candesartan cilexetil 74CANTIL 90CAPASTAT SULFATE 39capecitabine 42CAPRELSA 49captopril 74CARAFATE 92CARBAGLU 89carbamazepine 28carbidopa 55carbidopa-levodopa 55CARBIDOPA-LEVODOPA-ENTACAPONE 54carbidopa-levodopa-entacapone 54carbinoxamine maleate 149

carboplatin 44CARDIOCOM LANCING DEVICE 117CAREFINE PEN NEEDLES 117CAREONE ADVANCED LANCING DEV 118CAREONE INSULIN SYRINGE 118CAREONE LANCET THIN 23G 118CAREONE LANCET ULTRA THIN 28G 118CAREONE ULTIGUARD INSULIN SYR 118CAREONE UNIFINE PENTIPS 118CAREONE UNIFINE PENTIPS PLUS 118CARESENS CONTROL A 118CARIMUNE NF 108carisoprodol 154carteolol hcl (ophth) 146carvedilol 75CASODEX 42CAYA 118CAYSTON 152CEDAX 20CEENU 40cefaclor 21cefaclor monohydrate 21cefadroxil 21cefazolin sodium 21cefdinir 21cefditoren pivoxil 21CEFDITOREN PIVOXIL 21cefepime hcl 21cefixime 21cefotaxime sodium 21cefotetan disodium 21cefoxitin sodium 21cefpodoxime proxetil 21cefprozil 21ceftazidime 21CEFTIBUTEN 21CEFTIN 21ceftriaxone sodium 21cefuroxime axetil 21cefuroxime sodium 21celecoxib 12


CELLCEPT INTRAVENOUS 106CELONTIN 26CENESTIN 99cephalexin 22CEREZYME 89CERUBIDINE 44CESAMET 34cetirizine hcl 9,149cetirizine-pseudoephedrine 10CETRAXAL 24cevimeline hcl 85CHANTIX 18CHANTIX CONTINUING MONTH PAK 18CHANTIX STARTING MONTH PAK 18CHEK-STIX CONTROL 118CHEMET 156CHEMSTRIP K 118chloramphenicol sodium succinate 19chlordiazepoxide hcl-clidinium bromide 90chlorhexidine gluconate (mouth-throat) 85chloroquine phosphate 52chlorothiazide 78chlorpromazine hcl 55chlorpropamide 66chlorthalidone 78chlorzoxazone 154CHOLBAM 91cholecalciferol 10cholestyramine 80cholestyramine light 80choline & mag salicylate 12chorionic gonadotropin 97CIALIS 94ciclopirox 35ciclopirox & vitamin e 35ciclopirox olamine 35cidofovir 57cilostazol 73cimetidine 5,91cimetidine hcl 91CIMZIA 106

CIMZIA PREFILLED 106CIMZIA STARTER KIT 106CIPRO HC 147CIPRO IN D5W 24CIPRODEX 147ciprofloxacin 24ciprofloxacin hcl 24ciprofloxacin hcl (ophth) 24ciprofloxacin hcl (otic) 24ciprofloxacin in d5w 24ciprofloxacin-ciprofloxacin hcl 24cisplatin 44citalopram hydrobromide 30cladribine 43clarithromycin 23CLARITIN 9CLARITIN REDITABS 9CLARITIN-D 12 HOUR 10CLARITIN-D 24 HOUR 10CLEANLET LANCETS 28G 118clemastine fumarate 149CLEVER CHEK LANCETS 118CLEVER CHOICE COMFORT EZ 118CLEVER CHOICE GLUCOSE CONTROL 118CLICKFINE PEN NEEDLES 118CLIMARA PRO 99clindamycin hcl 19clindamycin palmitate hydrochloride 19clindamycin phosphate 19CLINDAMYCIN PHOSPHATE 118clindamycin phosphate (bulk) 118clindamycin phosphate (topical) 19,86clindamycin phosphate vaginal 19clindamycin phosphate-benzoyl peroxide 86clindamycin phosphate-benzoyl peroxide(refrigerate) 86CLINIMIX E/DEXTROSE (5/20) 159CLINIMIX/DEXTROSE (2.75/5) 159CLINIMIX/DEXTROSE (4.25/10) 159CLINIMIX/DEXTROSE (4.25/25) 159CLINIMIX/DEXTROSE (4.25/5) 159


CLINIMIX/DEXTROSE (5/25) 159clobetasol propionate 95clobetasol propionate emollient base 95CLODERM 95CLODERM PUMP 95CLOLAR 43clomipramine hcl 32clonazepam 65clonidine hcl 73clopidogrel bisulfate 73CLOSERCARE 118clotrimazole 35clotrimazole (topical) 5,35clotrimazole vaginal 5clotrimazole w/ betamethasone 86clozapine 57COAGUCHEK LANCETS 118COARTEM 53codeine sulfate 15COLCHICINE 36colchicine 36colchicine w/ probenecid 36COLCRYS 36colestipol hcl 80COLY-MYCIN S 147COMBIGAN 146COMBIVIR 61COMETRIQ (100 MG DAILY DOSE) 49COMETRIQ (140 MG DAILY DOSE) 49COMETRIQ (60 MG DAILY DOSE) 49COMFORT ASSIST INSULIN SYRINGE 118COMFORT ASSURED LANCETS 28G 118COMFORT ASSURED LANCETS 33G 118COMFORT EZ INSULIN SYRINGE 118COMFORT EZ PEN NEEDLES 119COMFORT LANCETS 119COMMIT 4COMPLERA 60CONTROL 119COOL CONTROL A 119COOL CONTROL B 119

COPAXONE 85CORDRAN 95cortisone acetate 95CORTISPORIN 87,147CORTISPORIN-TC 147COSMEGEN 44COUMADIN 70CREON 89CRESTOR 79CRIXIVAN 63cromolyn sodium 153cromolyn sodium (ophth) 145CUBICIN 19CUPRIMINE 94CVS INSULIN SYRINGE 119CVS LANCETS 21G 119CVS LANCETS MICRO THIN 33G 119CVS LANCETS ORIGINAL 119CVS LANCETS THIN 119CVS LANCETS THIN 26G 119CVS LANCETS ULTRA THIN 30G 119CVS LANCING DEVICE 119CVS OMEPRAZOLE 6CVS ULTRA THIN LANCETS 119CYCLESSA 99cyclobenzaprine hcl 154cyclophosphamide 40CYCLOSERINE 39CYCLOSET 66cyclosporine 107cyclosporine modified (for microemulsion) 107cyproheptadine hcl 149CYSTADANE 89CYSTAGON 94cytarabine 43

DD.H.E. 45 37dacarbazine 40DACOGEN 44dactinomycin 44


danazol 99dantrolene sodium 159dapsone 39DARAPRIM 53daunorubicin hcl 45DAUNOXOME 40decitabine 45DELFLEX-LC/1.5% DEXTROSE 157demeclocycline hcl 25DENAVIR 64DEPO-ESTRADIOL 100DEPO-MEDROL 95DEPO-PROVERA 103DEPO-SUBQ PROVERA 104 103DEPOCYT 43DESCOVY 61desipramine hcl 32desloratadine 149desmopressin acetate 97desmopressin acetate spray 97desmopressin acetate spray refrigerated 97DESOGEN 100desogestrel & ethinyl estradiol 100desogestrel-ethinyl estradiol (biphasic) 100desogestrel-ethinyl estradiol (triphasic) 100desonide 95desoximetasone 95DESOXYN 82DETROL LA 93dexamethasone 95DEXAMETHASONE INTENSOL 96dexamethasone sodium phosphate 96dexamethasone sodium phosphate (ophth) 145DEXCHLORPHENIRAMINE MALEATE 149DEXILANT 92dexmethylphenidate hcl 82dextroamphetamine sulfate 82DEXTROSE 5%/ELECTROLYTE #48 157dextrose in lactated ringers 157dextrose in ringers 157DIANEAL LOW CALCIUM/1.5% DEX 157

DIANEAL PD-2/1.5% DEXTROSE 157DIASTAR EASY TEST II LANCETS 119DIASTAR EASY TEST LANCETS 119DIASTAT ACUDIAL 26DIASTAT PEDIATRIC 26DIATRUE CONTROL LEVEL 1 119DIATRUE CONTROL LEVEL 2 119diazepam 65diazepam (anticonvulsant) 26DIBENZYLINE 73diclofenac potassium 12diclofenac sodium 12diclofenac sodium (actinic keratoses) 87diclofenac sodium (ophth) 145diclofenac sodium (topical) 87diclofenac w/ misoprostol 12dicloxacillin sodium 22dicyclomine hcl 90didanosine 61,62DIFFERIN 87DIFICID 23diflorasone diacetate 96diflunisal 12digoxin 77dihydroergotamine mesylate 37DILANTIN 28DILANTIN INFATABS 28diltiazem hcl 76DILTIAZEM HCL 76diltiazem hcl coated beads 76diltiazem hcl extended release beads 76DIPENTUM 111diphenhydramine hcl 9,149diphenoxylate w/ atropine 91dipyridamole 73disopyramide phosphate 75disulfiram 17divalproex sodium 26DIVIGEL 100DOCEFREZ 45DOCETAXEL 45


docetaxel 45docusate calcium 6docusate sodium 6donepezil hydrochloride 29dorzolamide hcl 146dorzolamide hcl-timolol maleate 146doxazosin mesylate 74doxepin hcl 33doxercalciferol 112DOXIL 45doxorubicin hcl 45DOXORUBICIN HCL 45doxorubicin hcl liposomal 45doxycycline (monohydrate) 25doxycycline hyclate 25DRISDOL 11,159dronabinol 34DROPLET LANCETS ULTRA THIN 30G 119DROPLET LANCING DEVICE 119drospirenone-ethinyl estradiol 100DROXIA 43DRUG MART LANCETS THIN 26G 119DRUG MART LANCETS ULTRA THIN 119DRUG MART LANCING DEVICE 119DRUG MART ON-THE-GO LANCET 30G 119DRUG MART ULTRA COMFORT SYR 120DRUG MART UNIFINE PENTIPS 120DRUG MART UNIFINE PENTIPS PLUS 120DRUG MART UNILET LANCETS 28G 120DRUG MART UNILET LANCETS 30G 120DUANE READE LANCET ALTERN SITE 120DUANE READE LANCET SUPER THIN 120DUANE READE LANCET ULTRA THIN 120DUANE READE UNIFINE PENTIPS 120duloxetine hcl 84DUREZOL 146dutasteride 94DYRENIUM 78DYSPORT 154DYSPORT (GLABELLAR LINES) 154

EE-Z JECT LANCET MICRO-THIN 33G 120E-Z JECT LANCET SUPER THIN 30G 120E-Z JECT LANCETS 120E-Z JECT LANCETS 21G 120E-Z JECT LANCETS THIN 26G 120E.E.S. 400 23E.E.S. GRANULES 23EASY COMFORT INSULIN SYRINGE 120EASY COMFORT LANCETS 120EASY COMFORT PEN NEEDLES 120EASY MINI LANCING DEVICE 120EASY PLUS CONTROL 120EASY PLUS II CONTROL 120EASY STEP CONTROL 120EASY TALK CONTROL 120EASY TOUCH CONTROL HIGH & LOW 120EASY TOUCH HEALTHPRO CONTROL 120EASY TOUCH INSULIN SAFETY SYR 121EASY TOUCH INSULIN SYRINGE 121EASY TOUCH LANCETS 21G 121EASY TOUCH LANCETS 23G 121EASY TOUCH LANCETS 26G 121EASY TOUCH LANCETS 26G/TWIST 121EASY TOUCH LANCETS 28G 121EASY TOUCH LANCETS 28G/TWIST 121EASY TOUCH LANCETS 30G 121EASY TOUCH LANCETS 30G/TWIST 121EASY TOUCH LANCETS 32G 121EASY TOUCH LANCETS 32G/TWIST 121EASY TOUCH LANCETS 33G/TWIST 121EASY TOUCH LANCING DEVICE 121EASY TOUCH PEN NEEDLES 121EASY TOUCH SAFETY LANCETS 21G 121EASY TOUCH SAFETY LANCETS 23G 121EASY TOUCH SAFETY LANCETS 26G 121EASY TOUCH SAFETY LANCETS 28G 121EASY TRAK CONTROL 121EASY TWIST & CAP LANCETS 121EASYGLUCO CONTROL 121


EASYMAX 15 LEVEL 1 CONTROL 121EASYMAX 15 LEVEL 2 CONTROL 121EASYMAX CONTROL 122ECLIPSE CONTROL 122econazole nitrate 35EDARBI 74EDECRIN 78EDURANT 60EFFIENT 73ELAPRASE 89electrolyte-m in dextrose 157ELELYSO 89ELEMENT COMPACT CONTROL 2 122ELEMENT COMPACT CONTROL 3 122ELEMENT CONTROL 122ELEMENT PLUS CONTROL 122ELESTRIN 100ELEXA NATURAL FEEL 7ELEXA STIMULATING 7ELEXA ULTRA SENSITIVE 7ELIDEL 87ELIGARD 105ELIQUIS 70ELIXOPHYLLIN 152ELLA 103ELMIRON 94ELOXATIN 45ELSPAR 45EMADINE 145EMBEDA 13EMBRACE CONTROL 122EMBRACE EVO CONTROL LEVEL 1 122EMBRACE EVO CONTROL LEVEL 2 122EMBRACE LANCETS ULTRA THIN 30G 122EMBRACE PRO GLUCOSE CONTROL 122EMCYT 42EMEND 34EMSAM 30EMTRIVA 62ENABLEX 93enalapril maleate 74

enalapril maleate & hydrochlorothiazide 77ENBREL 107ENBREL SURECLICK 107ENJUVIA 100enoxaparin sodium 70entacapone 54entecavir 58ENTEREG 91ENVISION CONTROL 122EPCLUSA 59EPIDUO 87epinastine hcl (ophth) 145EPINEPHRINE 151epinephrine hcl 151EPIPEN 151EPIPEN 2-PAK 151EPIPEN JR 151EPIPEN JR 2-PAK 151epirubicin hcl 45EPIVIR 62EPIVIR HBV 58eplerenone 78EPOGEN 72eprosartan mesylate 74EPZICOM 62EQ OMEPRAZOLE 6EQL COLOR LANCETS 21G 122EQL COLOR LANCETS MICRO 33G 122EQL INSULIN SYRINGE 122EQL OMEPRAZOLE 6EQL SHORT PEN NEEDLE 122EQL SUPER THIN LANCETS 30G 122EQL THIN LANCETS 26G 122EQL ULTRA COMFORT INSULIN SYR 122EQL ULTRA SHORT PEN NEEDLE 122EQUETRO 65,66ERAXIS 35ERBITUX 51ergocalciferol 11,159ergoloid mesylates 29ERGOMAR 37


ERIVEDGE 49ERTACZO 35ERWINAZE 45ERY-TAB 23ERYPED 200 23ERYPED 400 23erythromycin (acne aid) 23erythromycin (ophth) 23ERYTHROMYCIN BASE 24erythromycin base 24ERYTHROMYCIN ETHYLSUCCINATE 24escitalopram oxalate 30,31esomeprazole magnesium 92estazolam 155ESTRACE 100ESTRADERM 100estradiol 100estradiol valerate 100ESTRASORB 100ESTROGEL 100estropipate 100ESTROSTEP FE 100eszopiclone 155ethambutol hcl 39ethosuximide 26ethynodiol diacet & eth estrad 100etidronate disodium 112etodolac 12ETOPOPHOS 49etoposide 49EURAX 53EVAMIST 100EVENCARE CONTROL LOW/HIGH 122EVENCARE G2 LOW/HIGH CONTROL 122EVENCARE G3 LOW/HIGH CONTROL 122EVENCARE MINI CONTROL 122EVISTA 104EVOLUTION CONTROL 123EXALGO 13EXEL COMFORT POINT INSULIN SYR 123EXEL COMFORT POINT PEN NEEDLE 123

EXELDERM 35exemestane 48EXJADE 156EXTAVIA 85EZ SMART BLOOD GLUCOSE LANCETS 123EZ-LETS LANCETS 21G 123EZ-LETS LANCETS 26G 123EZ-LETS LANCETS 28G 123EZ-LETS LANCETS 30G 123

FFABRAZYME 89FACTIVE 24famciclovir 65famotidine 5,91FAMOTIDINE PREMIXED 91FANAPT 56FANAPT TITRATION PACK 56FANTASY LUBRICATED 7FANTASY LUBRICATED/SPERMICIDE 7FARESTON 42FASLODEX 42FC FEMALE CONDOM 7FC2 FEMALE CONDOM 7felbamate 27felodipine 76FEMARA 48FEMCAP 123FEMCON FE 101FEMRING 101fenofibrate 79fenofibrate micronized 79fenoprofen calcium 12fentanyl 13fentanyl citrate 15FER-IN-SOL 10FERRIPROX 156ferrous fumarate-folic acid 157ferrous sulfate 10fexofenadine hcl 9fexofenadine-pseudoephedrine 10


FIFTY50 CONTROL 2.0 123FIFTY50 LANCING DEVICE 123FIFTY50 PEN NEEDLES 123FIFTY50 SAFETY SEAL LANCETS 123FIFTY50 SUPERIOR COMFORT SYR 123FIFTY50 UNILET LANCETS 33G 123FINACEA 87finasteride 94finasteride (alopecia) 87FINE 30 123FINGERSTIX LANCETS 123FIRMAGON 105flavoxate hcl 93flecainide acetate 75FLECTOR 12FLONASE ALLERGY RELIEF 9FLOVENT DISKUS 148FLOVENT HFA 148floxuridine 43FLUARIX 110FLUARIX QUADRIVALENT 110FLUCELVAX 110fluconazole 35flucytosine 35FLUDARA 45fludarabine phosphate 46fludrocortisone acetate 96FLULAVAL 110FLULAVAL QUADRIVALENT 110flunisolide (nasal) 148fluocinolone acetonide 96fluocinolone acetonide (otic) 147fluocinonide 96fluocinonide emulsified base 96fluorometholone (ophth) 146fluorouracil 43fluorouracil (topical) 87fluoxetine hcl 31fluoxetine hcl (pmdd) 31fluphenazine hcl 55flurbiprofen 12

flurbiprofen sodium 146flutamide 42fluticasone propionate 96FLUTICASONE PROPIONATE 123fluticasone propionate (bulk) 123fluticasone propionate (nasal) 9,148fluvastatin sodium 79FLUVIRIN 110FLUVIRIN PRESERVATIVE FREE 110fluvoxamine maleate 31FLUZONE 110FLUZONE HIGH-DOSE 110FLUZONE PEDIATRIC PF 110FLUZONE PRESERVATIVE FREE 110FLUZONE QUADRIVALENT 110FML 146FML FORTE 146folic acid 11,159FOLOTYN 43fondaparinux sodium 70,71FORA CONTROL 123FORA LANCETS 123FORA LANCING DEVICE 123FORACARE GDH CONTROL 123FORADIL AEROLIZER 151FORTEO 112FORTISCARE CONTROL 123FOSAMAX PLUS D 112FOSCAVIR 57fosinopril sodium 74fosinopril sodium & hydrochlorothiazide 77fosphenytoin sodium 28FOSRENOL 95FRAGMIN 71FREDS PHARMACY AUTOLET LANCING 124FREDS PHARMACY UNIFINE PENTIP+ 124FREDS PHARMACY UNIFINE PENTIPS 124FREDS PHARMACY UNILET LANC 28G 124FREDS PHARMACY UNILET LANC 30G 124FREESTYLE CONTROL SOLUTION 124FREESTYLE LANCETS 124


FREESTYLE PRECISION INS SYR 124FREESTYLE UNISTICK II LANCETS 124FROVA 37furosemide 78FUZEON 63

Ggabapentin 26galantamine hydrobromide 29GAMMAGARD 109GAMMAGARD S/D 108GAMMAGARD S/D LESS IGA 109GAMMAKED 109GAMUNEX-C 109ganciclovir sodium 57gatifloxacin (ophth) 24GE100 CONTROL 124GEL-KAM ORAL CARE RINSE 85gemcitabine hcl 43gemfibrozil 79GEMZAR 43GENERESS FE 101GENOTROPIN 98GENOTROPIN MINIQUICK 98gentamicin in saline 18GENTAMICIN IN SALINE 18gentamicin sulfate 18gentamicin sulfate (ophth) 18GENVOYA 60GILENYA 85glatiramer acetate 85GLEEVEC 49glimepiride 66glipizide 66glipizide-metformin hcl 66GLOBAL EASE INJECT PEN NEEDLES 124GLOBAL INJECT EASE INSULIN SYR 124GLOBAL INJECT EASE LANCETS 28G 124GLOBAL INJECT EASE LANCETS 30G 124GLOBAL LANCING DEVICE 124GLUCAGEN DIAGNOSTIC 68

GLUCAGEN HYPOKIT 68GLUCAGON EMERGENCY 68GLUCOCARD 01 CONTROL 124GLUCOCARD EXPRESSION CONTROL 124GLUCOCARD SHINE CONTROL 124GLUCOCARD X-SENSOR CONTROL 124GLUCOCOM CONTROL 124GLUCOCOM LANCETS 28G 124GLUCOCOM LANCETS 30G 124GLUCOCOM LANCETS 33G 124GLUCOLAB CONTROL 124GLUCOLET 2 AUTOMATIC LANCING 124GLUCOPRO INSULIN SYRINGE 125glucose blood 125GLUCOSE CONTROL 125GLUCOSOURCE LANCET DEVICE 125GLUCOSOURCE LANCETS 125glyburide 66GLYBURIDE 67glyburide micronized 67glyburide-metformin 67glycine (gu irrigant) 94glycopyrrolate 90GLYSET 67GMATE CONTROL LEVEL 2 125GNP CLICKFINE PEN NEEDLES 125GNP INSULIN SYRINGE 125GNP LANCETS 125GNP LANCETS 21G 125GNP LANCETS MICRO THIN 33G 125GNP LANCETS SUPER THIN 30G 125GNP LANCETS THIN 125GNP LANCETS THIN 26G 125GNP MICRO THIN LANCETS 33G 125GNP OMEPRAZOLE 6GNP SUPER THIN LANCETS 30G 125GNP ULTRA COM INSULIN SYRINGE 125GOLYTELY 92granisetron hcl 34griseofulvin microsize 35griseofulvin ultramicrosize 35


guanabenz acetate 73guanfacine hcl 73guanfacine hcl (adhd) 82guanidine hcl 39GYNAZOLE-1 35GYNOL II 7

HH&H THINLET LANCETS 26G 125H&H THINLET LANCETS 30G 125H-E-B INCONTROL ADV LANCING 125H-E-B INCONTROL LANCETS 28G 125H-E-B INCONTROL LANCETS 30G 125H-E-B INCONTROL LANCETS 33G 125H-E-B INCONTROL PEN NEEDLES 125HAEMOLANCE 126HAEMOLANCE LOW FLOW LANCETS 126HAEMOLANCE PLUS 126HAEMOLANCE PLUS HIGH FLOW 126HAEMOLANCE PLUS LOW FLOW 126HAEMOLANCE PLUS MAX FLOW 126HAEMOLANCE PLUS PEDIATRIC FLOW 126HALAVEN 46halobetasol propionate 96HALOG 96haloperidol 55haloperidol decanoate 55haloperidol lactate 55HARVONI 59HEALTH CARE LANCING DEVICE 126HEALTHWISE LANCETS 30G 126HEALTHWISE LANCING PEN 126HEALTHWISE MINI PEN NEEDLES 126HEALTHWISE PEN NEEDLES 126HEALTHWISE SHORT PEN NEEDLES 126HEALTHWISE UNIFINE PENTIPS 126HEALTHY ACCENTS LANCING DEVICE 126HEALTHY ACCENTS UNIFINE PENTIP 126HEALTHY ACCENTS UNILET LANCETS 126HEPARIN (PORCINE) IN NACL 71heparin sod (porcine) in d5w 71

heparin sodium (porcine) 71HEPSERA 58HERCEPTIN 51HEXALEN 40HIZENTRA 109HIZENTRA 20% 109HM LANCETS MICRO THIN 33G 126HM LANCETS ULTRA THIN 30G 126HM OMEPRAZOLE 6HORIZANT 83HUMALOG 68HUMALOG KWIKPEN 68HUMALOG MIX 50/50 68HUMALOG MIX 50/50 KWIKPEN 68HUMALOG MIX 50/50 PEN 68HUMALOG MIX 75/25 68HUMALOG MIX 75/25 KWIKPEN 68HUMALOG MIX 75/25 PEN 68HUMALOG PEN 68HUMATROPE 98HUMIRA 107HUMIRA PEDIATRIC CROHNS START 107HUMIRA PEN 107HUMIRA PEN-CROHNS STARTER 107HUMIRA PEN-PSORIASIS STARTER 107HUMULIN 70/30 69HUMULIN 70/30 KWIKPEN 69HUMULIN 70/30 PEN 69HUMULIN N 69HUMULIN N KWIKPEN 69HUMULIN N PEN 69HUMULIN R 69HUMULIN R U-500 (CONCENTRATED) 69HY-VEE INSULIN SYRINGE 126HYCAMTIN 49hydralazine hcl 81HYDREA 43hydrochlorothiazide 79hydrocodone-acetaminophen 15,16hydrocodone-ibuprofen 16hydrocortisone 96


hydrocortisone (intrarectal) 111hydrocortisone (rectal) 111hydrocortisone (topical) 5,87hydrocortisone acetate (rectal) 96hydrocortisone butyrate 96hydrocortisone valerate 96hydrocortisone w/acetic acid 147hydromorphone hcl 13,16hydroxychloroquine sulfate 53hydroxyurea 43hydroxyzine hcl 149hydroxyzine pamoate 149HYPERSAL 154

Iibandronate sodium 112ibuprofen 4,12IDAMYCIN PFS 46idarubicin hcl 46IFEX 41ifosfamide 41ifosfamide & mesna 41ILEVRO 146imatinib mesylate 50imipenem-cilastatin 22imipramine hcl 33imipramine pamoate 33imiquimod 87IMITREX 38IMPLANON 103IN TOUCH GLUCOSE CONTROL 126IN TOUCH LANCING DEVICE 126IN TOUCH STERILE LANCETS 30G 126INCIVEK 59INCRELEX 98INCRUSE ELLIPTA 150indapamide 79indomethacin 12INFERGEN 59INFINITY CONTROL 126INLYTA 50

insulin pen needle 126INSULIN SYRINGE 127INSULIN SYRINGE/NEEDLE 127insulin syringe/needle u-100 127INSUPEN PEN NEEDLES 127INSUPEN SENSITIVE 127INSUPEN ULTRAFIN 127INTELENCE 61INTRON A 59INTUNIV 82INVANZ 22INVEGA 56INVIRASE 63INVOKANA 67IONOSOL-B IN D5W 157IONOSOL-MB IN D5W 157IOPIDINE 146ipratropium bromide 150ipratropium bromide (nasal) 150ipratropium-albuterol 154irbesartan 74irinotecan hcl 46irrigation solutions, physiological 157ISENTRESS 60ISOLYTE-P IN D5W 157ISOLYTE-S 157isoniazid 39ISONIAZID 40isosorbide dinitrate 81isosorbide mononitrate 81isotretinoin 87isradipine 76ISTODAX 46itraconazole 35ivermectin 52IXEMPRA KIT 46

JJADENU 156JAKAFI 50JANUVIA 67


JEVTANA 46

KKALETRA 63KALYDECO 152KAMELEON LUBRICATED 7kanamycin sulfate 18KCL IN DEXTROSE-NACL 157KCL-LACTATED RINGERS-D5W 157KENALOG 96KEPIVANCE 85KETEK 24KETOCARE 127ketoconazole 35ketoconazole (topical) 35ketoprofen 12ketorolac tromethamine 12ketorolac tromethamine (ophth) 146KETOSTIX 127ketotifen fumarate (ophth) 8KIMONO 7KIMONO MICRO THIN PLUS 7KIMONO PLUS 7KIMONO PS 7KIMONO PS PLUS 7KIMONO SENSATION 8KIMONO SENSATION PLUS 8KINERET 107KINNEY LANCETS 127KINNEY THIN LANCETS 127KINRAY INSULIN SYRINGE 127KLOR-CON M15 157KLS OMEPRAZOLE 6KMART VALU INSULIN SYRINGE 29G 127KMART VALU INSULIN SYRINGE 30G 127KROGER INSULIN SYRINGE 127KROGER LANCETS 21G 127KROGER LANCETS MICRO THIN 33G 127KROGER LANCETS SUPER THIN 127KROGER LANCETS THIN 26G 127KROGER LANCETS ULTRATHIN 30G 127

KROGER LANCING DEVICE 127KROGER PEN NEEDLES 127KUVAN 89KYPROLIS 50

Llabetalol hcl 75LACRISERT 145lactated ringer's 157lactated ringer's (irrigation) 159lactic acid (ammonium lactate) 5,87lactulose 92lactulose (encephalopathy) 92LADY LITE LANCETS 128lamivudine 62lamivudine (hbv) 58lamivudine-zidovudine 62lamotrigine 27LANCET DEVICE 128LANCET DEVICE WITH EJECTOR 128lancet devices 128lancets 113LANCETS 128LANCETS 28G 128LANCETS 30G 128LANCETS MICRO THIN 33G 128LANCETS SUPER THIN 28G 128LANCETS THIN 128LANCETS ULTRA FINE 128LANCETS ULTRA THIN 128LANCETS ULTRA THIN 30G 128LANCING DEVICE 128LANOXIN 77lansoprazole 6,93LANTUS 69LANTUS SOLOSTAR 69LANZO 128LASTACAFT 145latanoprost 147LATUDA 56LEADER ADVANCED LANCING DEVICE 128


LEADER INSULIN SYRINGE 128LEADER UNIFINE PENTIPS 128LEADER UNIFINE PENTIPS PLUS 128leflunomide 109LETAIRIS 152letrozole 49leucovorin calcium 46LEUCOVORIN CALCIUM 46LEUKERAN 41LEUKINE 72leuprolide acetate 105levalbuterol hcl 151LEVATOL 76LEVEMIR 69LEVEMIR FLEXPEN 69LEVEMIR FLEXTOUCH 69levetiracetam 26levobunolol hcl 147levocetirizine dihydrochloride 149levofloxacin 25levofloxacin (ophth) 25levofloxacin in d5w 25levonorgestrel & eth estradiol 101levonorgestrel (emergency oc) 7,103levonorgestrel-eth estradiol (triphasic) 101levonorgestrel-ethinyl estradiol (91-day) 101levonorgestrel-ethinyl estradiol (continuous) 101levorphanol tartrate 14levothyroxine sodium 104LEXIVA 64LIALDA 111LIBERTY GLUCOSE CONTROL 128LIBERTY GLUCOSE CONTROL MID 128LIBERTY MEDICAL LANCETS 128LIBERTY MINI LANCING DEVICE 128lidocaine 67,87lidocaine hcl 4,17,87lidocaine hcl (local anesth.) 17lidocaine hcl (mouth-throat) 17lidocaine-prilocaine 17LIDODERM 87

LILETTA (52 MG) 103LINCOCIN 19lindane 53linezolid 19LINEZOLID IN SODIUM CHLORIDE 19liothyronine sodium 104lisinopril 74lisinopril & hydrochlorothiazide 77LITE TOUCH LANCETS 128LITE TOUCH LANCING DEVICE 128LITE TOUCH LANCING PEN 129LITE TOUCH PEN NEEDLES 129LITETOUCH INSULIN SYRINGE 129LITETOUCH LANCETS 129LITETOUCH PEN NEEDLES 129lithium 66lithium carbonate 66LIVALO 79LIVE BETTER ADV LANCING DEVICE 129LIVE BETTER LANCET SUPER THIN 129LIVE BETTER LANCET ULTRA THIN 129LIVE BETTER PEN NEEDLES 129LO LOESTRIN FE 101LO/OVRAL (28) 101LODOSYN 55LOESTRIN 1.5/30 (21) 101LOESTRIN 1/20 (21) 101LOESTRIN 24 FE 101LOESTRIN FE 1.5/30 101LOESTRIN FE 1/20 101lomustine 41LONGS INSULIN SYRINGE 129LONGS LANCETS STANDARD 129LONGS LANCETS THIN 129LONGS LANCETS ULTRA THIN 129loperamide hcl 5,91loratadine 9loratadine & pseudoephedrine 10lorazepam 65losartan potassium 74losartan potassium & hydrochlorothiazide 77


LOSEASONIQUE 101LOTEMAX 146LOTRIMIN ULTRA 5LOTRONEX 92lovastatin 79loxapine succinate 55LUFYLLIN 152LUMIGAN 147LUMIZYME 89LUNESTA 155LUPRON DEPOT 105LUPRON DEPOT-PED 105LYRICA 84LYSODREN 46

Mmafenide acetate 20MAGELLAN INSULIN SAFETY SYR 129MAGNESIUM SULFATE 157magnesium sulfate 157MAJOR COMFORT LANCETS 129MALARONE 53malathion 53maprotiline hcl 31MARPLAN 30MATULANE 41MAXAIR AUTOHALER 151MAXI-COMFORT INSULIN SYRINGE 129MAXIDEX 146MAXIMA CONTROL 129MAXX 8MAXX PLUS 8mebendazole 52meclizine hcl 4,33meclofenamate sodium 12MEDI-LANCE LANCETS 129MEDIC INSULIN SYRINGE 129MEDICHOICE SAFETY LANCET 129MEDICHOICE SAFETY LANCET EXTRA 129MEDICHOICE SAFETY LANCET NORM 129MEDICINE SHOPPE LANCETS 129

MEDICINE SHOPPE LANCETS THIN 129MEDICINE SHOPPE PEN NEEDLES 129MEDISENSE GLUCOSE KETONE CONTR 130MEDISENSE HI/MID/LOW CONTROL 130MEDISENSE HIGH/LOW CONTROL 130MEDISENSE MID CONTROL 130MEDISENSE THIN LANCETS 130MEDLANCE EXTRA 21G 130MEDLANCE LITE 25G 130MEDLANCE PLUS EXTRA 21G 130MEDLANCE PLUS LANCETS 130MEDLANCE PLUS LITE 25G 130MEDLANCE PLUS SPECIAL 0.8MM 130MEDLANCE PLUS SUPERLITE 30G 130MEDLANCE PLUS UNIVERSAL 21G 130MEDLANCE UNIVERSAL 21G 130MEDROL 96medroxyprogesterone acetate 103medroxyprogesterone acetate (contraceptive) 103mefenamic acid 12mefloquine hcl 53MEGACE ES 103MEGACE ORAL 103megestrol acetate 103megestrol acetate (appetite) 103MEIJER LANCETS 130MEIJER LANCETS THIN 130MEIJER LANCETS UNIVERSAL 30G 130MEIJER LANCETS UNIVERSAL 33G 130MEIJER PEN NEEDLES 130MEIJER SUPER THIN LANCETS 130meloxicam 13melphalan hcl 41memantine hcl 29MENACTRA 110MENEST 101MENOMUNE 110MENOSTAR 101MENTAX 35MENVEO 110meperidine hcl 16


meprobamate 65MEPRON 53mercaptopurine 43meropenem 22mesalamine 111MESTINON 39metaproterenol sulfate 130,151metaxalone 155metformin hcl 67methadone hcl 14METHADONE HCL 14METHADOSE 14METHADOSE SUGAR-FREE 14methamphetamine hcl 82methazolamide 147methenamine hippurate 20methimazole 106METHITEST 99methocarbamol 155methotrexate sodium 107methoxsalen rapid 87methscopolamine bromide 90methyclothiazide 79methyldopa 73methyldopate hcl 73methylphenidate hcl 82,83METHYLPHENIDATE HCL ER 83methylprednisolone 96methylprednisolone acetate 96methylprednisolone sod succ 96metipranolol 147metoclopramide hcl 33metolazone 79metoprolol succinate 76metoprolol tartrate 76metronidazole 20metronidazole (topical) 20metronidazole vaginal 20mexiletine hcl 75MICARDIS 74MICONAZOLE 3 35

MICRODOT CONTROL 130MICRODOT CONTROL HIGH/LOW 130MICROLET LANCETS 130MICROTAINER SAFETY FLOW LANCET 130midodrine hcl 73MIGRANAL 37MILLIPRED 96MILLIPRED DP 96MILLIPRED DP 12-DAY 96MINASTRIN 24 FE 101MINI LANCING DEVICE 131MINIVELLE 101minocycline hcl 25minoxidil 81MIRCETTE 101MIRENA 104mirtazapine 30misoprostol 92mitomycin 46mitoxantrone hcl 46MOBIC 13modafinil 155MODICON (28) 101moexipril hcl 74mometasone furoate 96mometasone furoate (nasal) 148MONOJECT INSULIN SYRINGE 131MONOJECT ULTRA COMFORT SYRINGE 131MONOKET 81MONOLET LANCETS 131MONOLET OPD LANCETS 131MONOLETTOR SAFETY LANCETS 131montelukast sodium 150MONUROL 20MOORE MONO INSULIN SYRINGE 131morphine sulfate 14,16MOTOFEN 91MOVIPREP 92moxifloxacin hcl 25MOZOBIL 72MS INSULIN SYRINGE 131


MULTAQ 75mupirocin 20mupirocin calcium (topical) 20MUSTARGEN 41MYCAMINE 35MYCOBUTIN 39mycophenolate mofetil 107mycophenolate sodium 107MYFORTIC 108MYGLUCOHEALTH CONTROL 131MYGLUCOHEALTH LANCETS 30G 131MYLERAN 41MYOZYME 90MYRBETRIQ 93MYTELASE 39

Nnabumetone 13nadolol 76nafcillin sodium 22NAFTIFINE HCL 36NAFTIN 36NAGLAZYME 90nalbuphine hcl 16naloxone hcl 18naltrexone hcl 17NAMENDA 29NAMENDA TITRATION PAK 29naproxen 13naproxen sodium 13naratriptan hcl 38NASONEX 148NATACYN 36NATAZIA 101nateglinide 67NATROBA 53NAVELBINE 46NEBUPENT 53NEBUSAL 154NECON 10/11 (28) 101nefazodone hcl 31

neomycin sulfate 19neomycin-bacitracin zn-polymyxin 145neomycin-polymy-dexameth 145neomycin-polymyxin-hc (ophth) 145neomycin-polymyxin-hc (otic) 147NETGROUP LANCETS 131NEULASTA 72NEULASTA ONPRO 72NEUPOGEN 72NEUPRO 54NEUTEK 2TEK CONTROL 131NEVANAC 146nevirapine 61NEXAVAR 50NEXIUM 24HR 6NEXPLANON 104niacin 5,11niacin (antihyperlipidemic) 80niacinamide 5NIASPAN 80nicardipine hcl 76NICODERM CQ 4NICORETTE 4NICORETTE MINI 4NICORETTE REFILL 4NICORETTE STARTER KIT 4nicotine 4NICOTINE 4NICOTINE MINI 4nicotine polacrilex 4NICOTROL 18NICOTROL NS 18nifedipine 77NILANDRON 42nimodipine 77NINLARO 50NIPENT 43nisoldipine 77NITRO-BID 81nitrofurantoin 20nitrofurantoin macrocrystal 20


nitrofurantoin monohyd macro 20nitroglycerin 81NITROSTAT 81nizatidine 91nonoxynol-9 7NOR-QD 104NORDETTE (28) 102NORDITROPIN 98NORDITROPIN FLEXPRO 98NORDITROPIN NORDIFLEX PEN 98norethin acet & estrad-fe 102norethindrone & eth estradiol 102norethindrone & ethinyl estradiol-fe 102norethindrone (contraceptive) 104norethindrone acet & eth estra 102norethindrone acetate 104norethindrone acetate-ethinyl estradiol-fe 102norethindrone-eth estradiol (triphasic) 102norgestimate-ethinyl estradiol 102norgestimate-ethinyl estradiol (triphasic) 102norgestrel & ethinyl estradiol 102NORINYL 1+35 (28) 102NORMOSOL-M IN D5W 157NORMOSOL-R PH 7.4 157NOROXIN 25nortriptyline hcl 33NORVIR 64NOVA MAX CONTROL 131NOVA MAX PLUS GLU/KET CONTROL 131NOVA MAX PLUS KETONE TEST 8NOVA SAFETY LANCETS 23G 131NOVA SAFETY LANCETS 28G 131NOVA SUREFLEX LANCETS 131NOVA SUREFLEX LANCING DEVICE 131NOVOFINE 131NOVOFINE AUTOCOVER 131NOVOFINE PLUS 131NOVOLIN 70/30 69NOVOLIN 70/30 RELION 69NOVOLIN N 69NOVOLIN N RELION 69

NOVOLIN R 69NOVOLIN R RELION 69NOVOLOG 69NOVOLOG FLEXPEN 69NOVOLOG MIX 70/30 69NOVOLOG MIX 70/30 FLEXPEN 69NOVOLOG PENFILL 69NOVOTWIST 131NOXAFIL 36NPLATE 72NUCYNTA 16NUCYNTA ER 14NUEDEXTA 83NULOJIX 108NUTROPIN 98NUTROPIN AQ 98NUTROPIN AQ NUSPIN 10 98NUTROPIN AQ PEN 98NUVARING 102NUVIGIL 156nystatin 36nystatin (mouth-throat) 36nystatin (topical) 36,131nystatin-triamcinolone 36

Ooctreotide acetate 105ODEFSEY 61ofloxacin 25ofloxacin (ophth) 25ofloxacin (otic) 25OFORTA 47OGESTREL 102olanzapine 56OLEPTRO 31olopatadine hcl (nasal) 150omega-3-acid ethyl esters 80omeprazole 6,93OMEPRAZOLE 6omeprazole magnesium 6omeprazole-sodium bicarbonate 6,93


OMNIFLEX DIAPHRAGM 131OMNITROPE 98OMONTYS 72ON CALL EXPRESS GLUCOSE CONTR 131ON CALL LANCETS 131ON CALL LANCING DEVICE 132ON CALL PLUS GLUCOSE CONTROL 132ON CALL PLUS LANCETS 132ON CALL PLUS LANCING DEVICE 132ON CALL VIVID GLUCOSE CONTROL 132ONCASPAR 47ondansetron 34ondansetron hcl 34ONETOUCH DELICA LANCETS 33G 132ONETOUCH DELICA LANCETS FINE 132ONETOUCH DELICA LANCING DEV 132ONETOUCH FINEPOINT LANCETS 132ONETOUCH LANCETS 132ONETOUCH ULTRA CONTROL 132ONETOUCH ULTRASOFT LANCETS 132ONETOUCH VERIO 132ONFI 27ONGLYZA 67ONTAK 47OPTUMRX GLUCOSE CONTROL 132ORAP 55ORAPRED ODT 97ORBIVAN 83ORENCIA 108ORFADIN 90orphenadrine citrate 155ORSINI INSULIN SYRINGE 132ORTHO DIAPHRAGM ALL-FLEX 132ORTHO DIAPHRAGM COIL 132ORTHO DIAPHRAGM FLAT 132ORTHO EVRA 102ORTHO MICRONOR 104ORTHO TRI-CYCLEN (28) 102ORTHO TRI-CYCLEN LO 102ORTHO-CEPT (28) 102ORTHO-CYCLEN (28) 102

ORTHO-NOVUM 1/35 (28) 102ORTHO-NOVUM 7/7/7 (28) 102OSMOPREP 92OVCON-35 (28) 102oxacillin sodium 22oxaliplatin 47oxandrolone 104oxaprozin 13oxcarbazepine 28OXISTAT 36OXSORALEN 87OXSORALEN ULTRA 87oxybutynin chloride 93oxycodone hcl 14,16oxycodone w/ acetaminophen 16oxycodone-ibuprofen 16OXYCONTIN 14oxymorphone hcl 14,16

Ppaclitaxel 47pamidronate disodium 112PAMIDRONATE DISODIUM 112PANCREAZE 90pancrelipase (lipase-protease-amylase) 90PANOXYL-4 CREAMY WASH 5PANRETIN 52pantoprazole sodium 93PARAGARD INTRAUTERINE COPPER 132parenteral electrolytes 157paricalcitol 112paromomycin sulfate 19paroxetine hcl 31PASER 40PATADAY 145PATANOL 145PAXIL 31PC LANCETS SUPER THIN 30G 132PC UNIFINE PENTIPS 132peg 3350-kcl-sod bicarb-sod chloride-sod sulfate 92PEG-INTRON 59


PEG-INTRON REDIPEN 59PEG-INTRON REDIPEN PAK 4 59PEGANONE 28PEGASYS 59,60PEGASYS PROCLICK 59PEGINTRON 60PEN NEEDLES 132PEN NEEDLES 3/16" 132PEN NEEDLES 5/16" 132PENICILLIN G POT IN DEXTROSE 23penicillin g potassium 23PENICILLIN G PROCAINE 23penicillin g sodium 23penicillin v potassium 23PENTAM 53PENTASA 111pentazocine w/ naloxone 17PENTIPS 132pentostatin 43pentoxifylline 77PERFECT LANCETS 28G 133PERFECT LANCETS 30G 133perindopril erbumine 74peritoneal dialysis solutions 156PERJETA 51permethrin 53perphenazine 33perphenazine-amitriptyline 30PHARMACIST CHOICE LANCETS 133PHARMACY COUNTER LANCETS 133phenazopyridine hcl 94phenelzine sulfate 30phenobarbital 27phenoxybenzamine hcl 74PHENYTEK 28phenytoin 28phenytoin sodium 28phenytoin sodium extended 28PHISOHEX 133PHOSLYRA 95PHOSPHOLINE IODIDE 147

PHOTOFRIN 47PICATO 87pilocarpine hcl 147pilocarpine hcl (oral) 86pimozide 55pindolol 76pioglitazone hcl 67pioglitazone hcl-metformin hcl 67piperacillin sodium-tazobactam sodium 23piroxicam 13PLAN B 104PLAN B ONE-STEP 7,104PLASMA-LYTE 148 157PLASMA-LYTE A 158PLASMA-LYTE-56 IN D5W 158PNEUMOVAX 23 110POCKETCHEM EZ CONTROL 133podofilox 87polymyxin b sulfate 20polymyxin b-trimethoprim 145potassium acetate 158potassium bicarb & chloride 158potassium bicarbonate 158potassium chloride 158POTASSIUM CHLORIDE 158POTASSIUM CHLORIDE ER 158potassium chloride in dextrose 158potassium chloride in dextrose & sodium chloride 158potassium chloride in nacl 158potassium chloride microencapsulated crystals cr 158potassium citrate (alkalinizer) 94potassium phosphates 158POTIGA 26PRADAXA 71pramipexole dihydrochloride 54PRANDIMET 67PRANDIN 67pravastatin sodium 79prazosin hcl 74PRECISION GLUCOSE KETONE CONTR 133PRECISION SURE-DOSE SYRINGE 133


PRECISION SUREDOSE PLUS SYR 133PRECISION XTRA KETONE 8PRED MILD 146prednicarbate 97prednisolone 97prednisolone acetate (ophth) 146prednisolone sodium phosphate 97PREDNISOLONE SODIUM PHOSPHATE 97,146prednisone 97PREFERRED PLUS INSULIN SYRINGE 133PREFERRED PLUS LANCETS COLORED 133PREFERRED PLUS LANCETS THIN 133PREFERRED PLUS UNIFINE PENTIPS 133PREMARIN 102PREMIUM CONDOMS LUBRICATED 8PREMPHASE 102PREMPRO 103PRENTIF FITTING SET 133PREPOPIK 92PRESTIGE GLUCOSE CONTROL 133PREVACID 24HR 6PREVNAR 13 110PREZISTA 64PRIFTIN 40PRILOSEC OTC 6PRIMAQUINE PHOSPHATE 53primaquine phosphate 53primidone 27PRISTIQ 32PROAIR HFA 151probenecid 36PROCAINAMIDE HCL 75prochlorperazine 33prochlorperazine maleate 33PROCRIT 72PRODIGY CONTROL SOLUTION 133PRODIGY INSULIN SYRINGE 133PRODIGY LANCETS 21G 133PRODIGY LANCETS 26G 133PRODIGY LANCETS 28G 133PRODIGY LANCING DEVICE 133

PRODIGY MINI PEN NEEDLES 133PRODIGY SAFETY LANCETS 26G 133PRODIGY SHORT PEN NEEDLES 133PRODIGY TWIST TOP LANCETS 28G 134progesterone micronized 104PROGLYCEM 68PROGRAF 108PROLASTIN 154PROLASTIN-C 154PROLEUKIN 47PROLIA 112PROMACTA 72promethazine hcl 150propafenone hcl 75proparacaine hcl 145propranolol hcl 76propylthiouracil 106protriptyline hcl 33PROVENTIL HFA 151PRUDOXIN 88PTS PANELS KETONE TEST 8PULMICORT 148,149PULMICORT FLEXHALER 148PULMOZYME 154PURINETHOL 43PX ADVANCED LANCING DEVICE 134PX EXTRA SHORT PEN NEEDLES 134PX INSULIN SYRINGE 134PX LANCET AUTO INJECTOR 134PX LANCETS 134PX LANCETS ULTRA THIN 134PX MINI PEN NEEDLES 134PX OMEPRAZOLE 6PX PEN NEEDLE 134pyrazinamide 40pyridostigmine bromide 39

QQC ADVANCED LANCING DEVICE 134QC INSULIN SYRINGE 134QC LANCETS SUPER THIN 30G 134


QC LANCETS ULTRA THIN 134QC PEN NEEDLES 134QC UNIFINE PENTIPS 134QC UNILET LANCETS MICRO THIN 134quetiapine fumarate 56QUICKTEK CONTROL SOLUTION 134quinapril hcl 75quinidine sulfate 75quinine sulfate 53QUINTET CONTROL HIGH/NORMAL 134QVAR 149

RRA E-ZJECT COLOR LANCETS 33G 134RA E-ZJECT LANCETS 28G 134RA E-ZJECT LANCETS THIN 26G 134RA E-ZJECT LANCETS THIN 28G 134RA E-ZJECT LANCETS ULTRA THIN 134RA INSULIN SYRINGE 134RA LANCING DEVICE 135RA OMEPRAZOLE 6RA PEN NEEDLES 135rabeprazole sodium 93raloxifene hcl 104ramipril 75RANEXA 77ranitidine hcl 5,91RAPAFLO 94RAPAMUNE 108REALITY LATEX/ULTRA TEXTURED 8REALITY LATEX/ULTRA THIN 8REBETOL 60REBIF 85REBIF REBIDOSE 85REBIF REBIDOSE TITRATION PACK 85REBIF TITRATION PACK 85RECLAST 112RECTIV 88REFUAH PLUS GLUCOSE CONTROL 135REGRANEX 88RELENZA DISKHALER 64

RELI-ON INSULIN SYRINGE 135RELION 70/30 69RELION INSULIN SYRINGE 135RELION LANCETS MICRO-THIN 33G 135RELION LANCETS STANDARD 21G 135RELION LANCETS THIN 26G 135RELION LANCETS ULTRA-THIN 30G 135RELION LANCING DEVICE 135RELION MINI PEN NEEDLES 135RELION N 69RELION PEN NEEDLES 135RELION R 69RELION SHORT PEN NEEDLES 135RELION ULTRA THIN LANCETS 30G 135RELION ULTRA THIN PLUS LANCETS 135RELISTOR 91RELPAX 38REMICADE 108REMODULIN 152RENAGEL 95RENEW ADV CARTRIDGE REFILLS 135RENEW ADVANCED LANCING DEVICE 135REOPRO 73repaglinide 67RESCRIPTOR 61RESECTISOL 94RESTASIS 145RETROVIR 62REVATIO 152REVLIMID 42REXALL LANCETS ULTRA THIN 30G 135REYATAZ 64RHEUMATREX 108RHINOCORT AQUA 149ribavirin (hepatitis c) 60RIDAURA 109rifabutin 39RIFAMATE 40rifampin 40RIFATER 40RIGHTEST GC300 CONTROL 135


RIGHTEST GD500 LANCING DEVICE 135RIGHTEST GL300 LANCETS 135RILUTEK 84riluzole 84rimantadine hydrochloride 64ringer's 158ringer's irrigation 158risedronate sodium 112,113RISPERDAL CONSTA 56risperidone 56,57RITUXAN 51rivastigmine tartrate 29rizatriptan benzoate 38ropinirole hydrochloride 54,55ROZEREM 156

SSABRIL 27SAFESNAP INSULIN SYRINGE 135SAFETY LANCET 21G/PRESSURE ACT 135SAFETY LANCET 28G/PRESSURE ACT 136SAFETY LANCET 2MM 136SAFETY LANCETS 136SAFETY LANCETS 21G 136SAFETY LANCETS 28G 136SAFETY LET LANCETS 136SAFETY SEAL LANCETS 136SAFETY-GLIDE SYRINGE 136SAFYRAL 103SAIZEN 98SAIZEN CLICK.EASY 98salsalate 13SAMSCA 156SANDOSTATIN 105SANTYL 88SAPHRIS 57SAPSCARE TWIST TOP LANCETS 136SAVELLA 84SAVELLA TITRATION PACK 84SB INSULIN SYRINGE 136SB LANCETS THIN 136

SB LANCETS ULTRA THIN 136SB OMEPRAZOLE 6SCHNUCKS INSULIN SYRINGE 136SEASONALE 103SEASONIQUE 103selegiline hcl 55selenium sulfide 88SELZENTRY 63SENSIPAR 105SEREVENT DISKUS 151SEROMYCIN 40SEROQUEL XR 57SEROSTIM 99sertraline hcl 32SHOPKO AUTOLET LANCING DEVICE 136SHOPKO ON-THE-GO LANCETS 30G 136SHOPKO UNIFINE PENTIPS 136SHOPKO UNILET LANCETS 28G 136SHOPKO UNILET LANCETS 30G 136sildenafil citrate (pulmonary hypertension) 152silver sulfadiazine 25SIMCOR 80SIMPLE DIAGNOSTICS LANCING DEV 136SIMPONI 108SIMULECT 109simvastatin 79sirolimus 108SKELID 113SKLICE 52SKYLA 104SM INSULIN SYRINGE 136SM LANCETS 21G 136SM LANCETS 33G 136SM OMEPRAZOLE 6SM SUPER THIN LANCETS 30G 136SM THIN LANCETS 26G 136SMART DIABETES VANTAGE LANCETS 137SMART DIABETES VANTAGE LANCING 137SMART SENSE COLOR LANCETS 33G 137SMART SENSE STANDARD LANCETS 137SMART SENSE SUPER THIN LANCETS 137


SMART SENSE THIN LANCETS 26G 137SMARTEST CONTROL MEDIUM 137SMARTEST LANCETS 28G 137sodium acetate 158sodium chloride 158sodium chloride (gu irrigant) 94sodium chloride (inhalant) 154sodium citrate & citric acid 94sodium phenylbutyrate 90sodium phosphate 158sodium polystyrene sulfonate 156sodium polystyrene sulfonate (bulk) 137SOLARAZE 88SOLARTEK GLUCOSE CONTROL 137SOLTAMOX 42SOLU-CORTEF 97SOLU-MEDROL 97SOLUS V2 CONTROL 137SOLUS V2 LANCETS 28G 137SOLUS V2 LANCING DEVICE 137SOLUS V2 TWIST LANCETS 30G 137SOMATULINE DEPOT 105SOMAVERT 105SORBITOL 94SORBITOL-MANNITOL 94SORIATANE 88sotalol hcl 75SOVALDI 60SPECTRACEF 22SPINOSAD 53SPIRIVA HANDIHALER 150SPIRIVA RESPIMAT 150spironolactone 78spironolactone & hydrochlorothiazide 78SPORANOX 36SPRYCEL 50STALEVO 100 54STALEVO 125 54STALEVO 150 54STALEVO 200 54STALEVO 50 54

STALEVO 75 54stannous fluoride 5,86stannous fluoride (bulk) 137stavudine 62STELARA 88STENDRA 94STERILANCE TL 137STIMATE 99STIVARGA 50STRATTERA 83streptomycin sulfate 19STRIBILD 60STROMECTOL 52SUBOXONE 18SUCRAID 90sucralfate 92sulfacetamide sodium (acne) 88sulfacetamide sodium (ophth) 25sulfacetamide sodium w/ sulfur 88sulfadiazine 25sulfamethoxazole-trimethoprim 25SULFAMYLON 20sulfasalazine 111sulindac 13sumatriptan 38sumatriptan succinate 38SUPER THIN LANCETS 137SUPRAX 22SUPREP BOWEL PREP 92SURE COMFORT INSULIN SYRINGE 137SURE COMFORT LANCETS 28G 137SURE COMFORT LANCETS 30G 137SURE COMFORT LANCING PEN 137SURE COMFORT PEN NEEDLES 137SURE EDGE GLUCOSE CONTROL 138SURE-FINE PEN NEEDLES 138SURE-JECT INSULIN SYRINGE 138SURE-LANCE FLAT LANCETS 138SURE-LANCE LANCETS 26G 138SURE-LANCE THIN LANCETS 28G 138SURE-LANCE ULTRA THIN LANCETS 138


SURE-PEN 138SURE-TEST EASYPLUS CONTROL 138SURE-TOUCH LANCETS UNIVERSAL 138SURECHEK CONTROL SOLUTION 138SURELITE LANCETS 138SURESTEP GLUCOSE CONTROL 138SURESTEP PRO LOW GLUCOSE 138SURESTEP PRO NORMAL GLUCOSE 138SUSTIVA 61SUTENT 50SW OMEPRAZOLE 6SYLATRON 47SYMBICORT 154SYMLINPEN 120 67SYMLINPEN 60 68SYNAREL 106SYNERA 88SYNRIBO 47SYPRINE 156

TTABLOID 43TACLONEX 88tacrolimus 108tacrolimus (topical) 88TAI DOC CONTROL 138TALWIN 17TAMIFLU 64tamoxifen citrate 42tamsulosin hcl 94TARCEVA 50TARGRETIN 52TASIGNA 50TASMAR 54TAXOTERE 47TAZORAC 88TECHLITE AST LANCETS 138TECHLITE LANCETS 138TECHLITE LANCETS 30G 138TECHLITE PEN NEEDLES 138TEFLARO 22

TEGRETOL 28TEKTURNA 78TELCARE GLUCOSE CONTROL 138telmisartan 74TEMODAR 41temozolomide 41TENIPOSIDE 47terazosin hcl 94terbinafine hcl 36terbutaline sulfate 151terconazole vaginal 36TERUMO INSULIN SYRINGE 139TERUMO SURGUARD INSULIN SYR 139testosterone cypionate 99testosterone enanthate 99tetrabenazine 84tetracycline hcl 25TEV-TROPIN 99TEVETEN 74TGT ADVANCED LANCING DEVICE 139TGT LANCET ALTERNATE SITE 139TGT LANCET MICRO THIN 33G 139TGT LANCET SUPER THIN 30G 139TGT LANCET THIN 23G 139TGT LANCET THIN 26G 139TGT LANCET ULTRA THIN 28G 139TGT LANCET ULTRA THIN 30G 139TGT LANCING DEVICE 139TGT OMEPRAZOLE 6THALOMID 42theophylline 152THINPRO INSULIN SYRINGE 139thioridazine hcl 55thiotepa 47thiothixene 55THYMOGLOBULIN 109THYROLAR-1 104THYROLAR-1/2 105THYROLAR-1/4 105THYROLAR-2 105THYROLAR-3 105


tiagabine hcl 27ticlopidine hcl 73TIKOSYN 75TIMENTIN 23timolol maleate 76timolol maleate (ophth) 147TIVICAY 60tizanidine hcl 159TOBI 152TOBRADEX 19tobramycin 152tobramycin (ophth) 19tobramycin sulfate 19TOBRAMYCIN SULFATE IN SALINE 19tobramycin-dexamethasone 145TODAY SPONGE 7TODAYS HEALTH LANCING DEVICE 139TODAYS HEALTH MINI PEN NEEDLES 139TODAYS HEALTH PEN NEEDLES 139TODAYS HEALTH SHORT PEN NEEDLE 139TODAYS HEALTH THIN LANCETS 28G 139TODAYS HEALTH THIN LANCETS 30G 139tolazamide 68tolbutamide 68tolcapone 54tolmetin sodium 13tolterodine tartrate 93TOPCARE CLICKFINE PEN NEEDLES 139TOPCARE ULTRA COMFORT INS SYR 139topiramate 27topotecan hcl 49TORISEL 50torsemide 78TOVIAZ 93TRACLEER 153TRADJENTA 68tramadol hcl 14,17tramadol-acetaminophen 17trandolapril 75tranexamic acid 73TRANSDERM-SCOP 33

tranylcypromine sulfate 30TRAVATAN Z 147TRAVEL LANCETS 140trazodone hcl 32TREANDA 41TRECATOR 40TRELSTAR 106TRELSTAR DEPOT MIXJECT 106TRELSTAR LA MIXJECT 106TRELSTAR MIXJECT 106tretinoin 88tretinoin (chemotherapy) 52tretinoin microsphere 88TREXALL 108TRI-NORINYL (28) 103triamcinolone acetonide (mouth) 97triamcinolone acetonide (topical) 97triamterene & hydrochlorothiazide 78triazolam 155trifluoperazine hcl 56trifluridine 65trihexyphenidyl hcl 54trimethobenzamide hcl 33trimethoprim 20trimipramine maleate 33TRISENOX 47TRIUMEQ 63TRIZIVIR 62TROJAN MAGNUM WARM SENSATIONS 8TROJAN SUPRAS SPERMICIDAL 8TROJAN TWISTED PLEASURE 8tropicamide 145trospium chloride 93TRUE METRIX AIR 140TRUE METRIX AIR GLUCOSE METER 140TRUE METRIX BLOOD GLUCOSE TEST 140TRUE METRIX LEVEL 1 140TRUE METRIX LEVEL 2 140TRUE METRIX METER 140TRUECONTROL GLUCOSE CONT LEV 0 140TRUECONTROL GLUCOSE CONT LEV 1 140


TRUEDRAW LANCING DEVICE 140TRUEPLUS INSULIN SYRINGE 140TRUEPLUS LANCETS 26G 140TRUEPLUS LANCETS 28G 140TRUEPLUS LANCETS 30G 140TRUEPLUS LANCETS 33G 140TRUEPLUS SAFETY LANCETS 28G 140TRUERESULT BLOOD GLUCOSE 140TRUETEST CONTROL LEVEL 1 140TRUETEST CONTROL LEVEL 2 140TRUETEST CONTROL LEVEL 3 140TRUETEST TEST 140TRUETRACK GLUCOSE CONTROL 140TRUETRACK TEST 140TRUSTEX COLOR CONDOMS + LUBE 8TRUSTEX LUB/RIBBED/STUDDED 8TRUSTEX LUB/SPERMICIDE EX ST 8TRUSTEX LUB/SPERMICIDE XL 8TRUSTEX LUBRICATED 8TRUSTEX LUBRICATED EX LARGE 8TRUSTEX LUBRICATED EXTRA ST 8TRUSTEX LUBRICATED/SPERMICIDE 8TRUSTEX NATURAL CONDOMS + LUBE 8TRUSTEX RIA LUB/SPERMICIDE 8TRUSTEX RIA LUBRICATED 8TRUSTEX-NONOXYNOL-9/RIB/STUD 8TRUVADA 62TWINJECT 151TYBOST 63TYGACIL 20TYKERB 50TYSABRI 85TYZEKA 58TYZINE 154

UULESFIA 53ULORIC 36ULTI-LANCE AUTO-ADJUST DEVICE 141ULTI-LANCE AUTOMATIC 141ULTI-LANCE MINI ADJUSTABLE 141

ULTICARE INSULIN SAFETY SYR 141ULTICARE INSULIN SYRINGE 141ULTICARE MICRO PEN NEEDLES 141ULTICARE MINI PEN NEEDLES 141ULTICARE PEN NEEDLES 141ULTICARE SHORT PEN NEEDLES 141ULTICARE THIN LANCETS 28G 141ULTICARE THIN LANCETS 30G 141ULTILET BASIC LANCETS 30G 141ULTILET CLASSIC LANCETS 141ULTILET INSULIN SYRINGE 141ULTILET INSULIN SYRINGE SHORT 141ULTILET LANCETS 141ULTILET PEN NEEDLE 141ULTILET SAFETY LANCETS 23G 141ULTRA COMFORT INSULIN SYRINGE 141ULTRA THIN LANCETS 28G 141ULTRA THIN LANCETS 30G 142ULTRA-COMFORT INSULIN SYRINGE 142ULTRA-THIN II AUTO LANCET 142ULTRA-THIN II INS SYR SHORT 142ULTRA-THIN II INSULIN SYRINGE 142ULTRA-THIN II LANCETS 142ULTRA-THIN II MINI PEN NEEDLE 142ULTRA-THIN II PEN NEEDLE SHORT 142ULTRA-THIN II PEN NEEDLES 142ULTRABAG/DIANEAL PD-2/1.5% DEX 158ULTRABAG/DIANEAL/1.5% DEXTROSE 158ULTRATRAK PRO CONTROL 142ULTRATRAK ULTIMATE CONTROL 142UNIFINE PENTIPS 142UNIFINE PENTIPS PLUS 142UNILET COMFORTOUCH LANCET 142UNILET EXCELITE 142UNILET EXCELITE II 142UNILET G.P. LANCET 142UNILET G.P. SUPERLITE LANCET 142UNILET GP 28 ULTRA THIN 142UNILET LANCET 142UNILET MICRO-THIN 33G 142UNILET SUPER-THIN 30G 142


UNILET SUPERLITE LANCET 142UNILET ULTRA-THIN 28G 142UNISTIK 3 GENTLE 143UNISTIK SAFETY LANCETS 28G 143UNISTIK SAFETY LANCETS 30G 143UNISTIK TOUCH SAFETY LANC 21G 143UNISTIK TOUCH SAFETY LANC 23G 143UNISTIK TOUCH SAFETY LANC 28G 143UNISTIK TOUCH SAFETY LANC 30G 143UNISTRIP CONTROL 143UNIVERSAL 1 LANCETS THIN 26G 143UNIVERSAL 1 LANCETS ULTRA THIN 143ursodiol 91UVADEX 47

VV-R MONO INSULIN SYRINGE 143valacyclovir hcl 65VALCYTE 57valganciclovir hcl 58valproate sodium 27valproic acid 27valsartan 74valsartan-hydrochlorothiazide 78VALSTAR 48VALUE HEALTH INSULIN SYRINGE 143VALUE PLUS LANCET STANDARD 21G 143VALUE PLUS LANCETS SUPER THIN 143VALUE PLUS LANCETS THIN 26G 143VALUE PLUS LANCING DEVICE 143VALUMARK LANCET SUPER THIN 30G 143VALUMARK LANCET ULTRA THIN 28G 143VALUMARK PEN NEEDLES 143vancomycin hcl 20VANDETANIB 50VANISHPOINT INSULIN SYRINGE 143VECTIBIX 51VECTICAL 88VELCADE 48VELTIN 88venlafaxine hcl 32

VENLAFAXINE HCL ER 32VENTAVIS 153VENTOLIN HFA 151verapamil hcl 77VEREGEN 89VERIPRED 20 97VESICARE 93VEXOL 146VIBATIV 20VICTORY CONTROL LEVEL 1/2 143VICTOZA 68VICTRELIS 60VIDA MIA AUTOLET LANCING DEV 143VIDA MIA UNIFINE PENTIPS 143VIDA MIA UNILET LANCETS 28G 143VIDA MIA UNILET LANCETS 30G 143VIDAZA 48VIDEX 62VIDEX EC 62VIIBRYD 32VIMPAT 28,29vinblastine sulfate 48vincristine sulfate 48vinorelbine tartrate 48VIRACEPT 64VIRAMUNE 61VIRAMUNE XR 61VIREAD 63VISICOL 92VISTIDE 58VISTOGARD 144VIVELLE-DOT 103VOCAL POINT CONTROL 144VOLTAREN 89VORAXAZE 48voriconazole 36VOTRIENT 51VP INSULIN SYRINGE 144VPRIV 90VUMON 48VYTORIN 80


VYVANSE 82

WW&F LANCETS 26G 144W&F LANCETS COLORED 21G 144WALGREENS ADV TRAVEL LANCETS 144WALGREENS LANCETS 144WALGREENS LANCETS MICRO THIN 144WALGREENS LANCETS SUPER THIN 144WALGREENS LANCING DEVICE 144WALGREENS THIN LANCETS 144WALGREENS ULTRA THIN LANCETS 144warfarin sodium 71water for irrigation, sterile 144WD MEDIC INSULIN SYRINGE 144WEGMANS UNIFINE PENTIPS PLUS 144WELCHOL 80WELLBUTRIN 30WELLBUTRIN SR 30WIDE-SEAL DIAPHRAGM 60 144WIDE-SEAL DIAPHRAGM 65 144WIDE-SEAL DIAPHRAGM 70 144WIDE-SEAL DIAPHRAGM 75 144WIDE-SEAL DIAPHRAGM 80 144WIDE-SEAL DIAPHRAGM 85 144WIDE-SEAL DIAPHRAGM 90 144WIDE-SEAL DIAPHRAGM 95 144

XXALKORI 51XARELTO 71XELJANZ 108XELODA 44XENAZINE 84XEOMIN 155XGEVA 113XIFAXAN 20XOLAIR 154XOPENEX HFA 151XPRES CONTROL 144XTANDI 42

XULANE 103XYLOCAINE 17XYREM 156

YYASMIN 28 103YAZ 103YERVOY 51

ZZADITOR 9zafirlukast 150zaleplon 155ZALTRAP 48ZANOSAR 41ZAVESCA 90ZEGERID OTC 6ZELBORAF 51ZEMAIRA 154ZEMPLAR 113ZENPEP 90ZETIA 80ZIAGEN 63ZIANA 89zidovudine 63ZINBRYTA 85ZIOPTAN 147ziprasidone hcl 57ZIRGAN 58ZITHROMAX 24ZOHYDRO ER 15ZOLADEX 106zoledronic acid 113ZOLEDRONIC ACID 113ZOLINZA 48zolmitriptan 38zolpidem tartrate 155ZOLVIT 17ZOMACTON 99ZOMETA 113ZOMIG 39


ZOMIG ZMT 39ZONALON 89zonisamide 26ZORBTIVE 99ZORTRESS 108ZOSTAVAX 110ZOVIA 1/50E (28) 103ZYBAN 18ZYFLO CR 150ZYMAXID 25ZYRTEC ALLERGY 10ZYRTEC CHILDRENS ALLERGY 10ZYRTEC CHILDRENS HIVES RELIEF 10ZYRTEC HIVES RELIEF 10ZYRTEC-D ALLERGY & CONGESTION 10ZYTIGA 42ZYVOX 20


2016 prescription drug list - sunshine health · formulary the ambetter from sunshine health...

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