2019 formulary (list of covered drugs) · or at the time the member requests a refill of the drug,...

2019 Formulary (List of Covered Drugs)Please read: This document contains information about the drugs we cover in this plan.

This formulary was updated on July 1, 2019. For more recent information or other questions, please contactSimply Complete (HMO SNP), Member Services Department toll-free at 1-877-577-0115 or, for TTY users, 711.From October 1 to March 31, we are open seven days a week from 8:00 a.m. - 8:00 p.m. ET. Beginning April 1to September 30, we are open Monday through Friday, 8:00 a.m. - 8:00 p.m. ET., or visithttps://shop.simplyhealthcareplans.com/medicare.

Formulario 2019 (Lista de Medicamentos Cubiertos)Favor, leer: Este documento contiene información sobre los medicamentos que cubrimosen este plan.

Este formulario se actualizó el 1.º de julio de 2019. Para obtener información más reciente o para preguntas,por favor llame a Simply Complete (HMO SNP), Servicios al Afiliado sin cargo al 1-877-577-0115 o, para usuariosde TTY, al 711. Del 1 de octubre al 31 de marzo, atendemos siete días a la semana de 8:00 a.m. - 8:00 p.m. ET.Del 1 de abril al 30 de septiembre, atendemos de lunes a viernes, de 8:00 a.m. - 8:00 p.m. ET., o visitehttps://shop.simplyhealthcareplans.com/medicare. Continúa en la página 13.

Broward, Hernando, Hillsborough, Miami-Dade, Orange, Osceola, Palm Beach, Pasco, Pinellas,Polk, SeminoleY0114_19_35071_I_C_ES_LP_304 08/27/2018 Simply_19261_ED_CG12_v15_1908_1

Note to existing members:This formulary has changed since last year. Pleasereview this document to make sure that it still containsthe drugs you take.

When this drug list (formulary) refers to “we,” “us,” or“our,” it means Simply Healthcare Plans. When it refersto “plan” or “our plan,” it means Simply Complete(HMO SNP).

This document includes a list of the drugs (formulary)for our plan which is current as of August 1, 2019. Foran updated formulary, please contact us. Our contactinformation, along with the date we last updated theformulary, appears on the front and back cover pages.

You must generally use network pharmacies to use yourprescription drug benefit. Benefits, formulary, pharmacynetwork, and/or copayments/coinsurance may changeon January 1, 2020, and from time to time during theyear.

The Formulary, pharmacy network, and/or providernetwork may change at any time. You will receive noticewhen necessary.

Effective Date August 1, 2019 2 Simply_19261_ED_CG12_v15_1908_1

What is the Simply Complete (HMOSNP) formulary?A formulary is a list of covered drugs selectedby our plan in consultation with a team ofhealth care providers, which represents theprescription therapies believed to be anecessary part of a quality treatment program.Our plan will generally cover the drugs listedin our formulary as long as the drug ismedically necessary, the prescription is filledat a plan network pharmacy, and other planrules are followed. For more information onhow to fill your prescriptions, please reviewyour Evidence of Coverage.

Can the formulary (drug list) change?Generally, if you are taking a drug on our2019 formulary that was covered at thebeginning of the year, we will not discontinueor reduce coverage of the drug during the2019 coverage year except when a new, lessexpensive generic drug becomesavailable, when new information about thesafety or effectiveness of a drug is released, orthe drug is removed from the market. (Seebullets below for more information onchanges that affect members currently takingthe drug.) Other types of formulary changes,such as removing a drug from our formulary,will not affect members who are currentlytaking the drug. It will remain available atthe same cost sharing for those memberstaking it for the remainder of the coverageyear. We feel it is important that you havecontinued access for the remainder of thecoverage year. Below are changes to the drug

list that will also affect members currentlytaking a drug:

New generic drugs. We mayimmediately remove a brand name drugon our Drug List if we are replacing itwith a new generic drug that will appearon the same or lower cost sharing tier andwith the same or fewer restrictions. Also,when adding the new generic drug, wemay decide to keep the brand name drugon our Drug List, but immediately moveit to a different cost-sharing tier or addnew restrictions. If you are currentlytaking that brand name drug, we maynot tell you in advance before we makethat change, but we will later provide youwith information about the specificchange(s) we have made.

If we make such a change, you oryour prescriber can ask us to makean exception and continue to coverthe brand name drug for you. Thenotice we provide you will alsoinclude information on the steps youmay take to request an exception, andyou can also find information in thesection below entitled “How do Irequest an exception to the SimplyComplete (HMO SNP)’sFormulary?”


Drugs removed from the market. If theFood and Drug Administration deems adrug on our formulary to be unsafe orthe drug’s manufacturer removes the drugfrom the market, we will immediatelyremove the drug from our formulary andprovide notice to members who take thedrug.Other changes. We may make otherchanges that affect members currentlytaking a drug. For instance, we may adda generic drug that is not new to marketto replace a brand name drug currentlyon the formulary or add new restrictionsto the brand name drug or move it to adifferent cost-sharing tier. Or we maymake changes based on new clinicalguidelines. If we remove drugs from ourformulary, or add prior authorization,quantity limits and/or step therapyrestrictions on a drug or move a drug toa higher cost-sharing tier, we must notifyaffected members of the change at least30 days before the change becomeseffective, or at the time the memberrequests a refill of the drug, at which timethe member will receive a 30-day supplyof the drug.

The enclosed formulary is current as ofAugust 1, 2019. To get updated informationabout the drugs covered by our plan, pleasecontact us. Our contact information appearson the front and back cover pages. If anyother type of approved formulary change(nonmaintenance change) is made during theyear, we will notify you by sending you a list

of these changes, or by sending you anupdated formulary.

How do I use the formulary?There are two ways to find your drug withinthe formulary:

Medical Condition

The formulary begins on page 11. The drugsin this formulary are grouped into categoriesdepending on the type of medical conditionsthat they are used to treat. For example, drugsused to treat a heart condition are listedunder the category, “Cardiovascular,Hypertension/Lipids.” If you know whatyour drug is used for, look for the categoryname in the list that begins on page 11. Thenlook under the category name for your drug.

Alphabetical Listing

If you are not sure what category to lookunder, you should look for your drug in theIndex that begins on page 182. The Indexprovides an alphabetical list of all of the drugsincluded in this document. Both brand-namedrugs and generic drugs are listed in theIndex. Look in the Index and find your drug.Next to your drug, you will see the pagenumber where you can find coverageinformation. Turn to the page listed in theIndex and find the name of your drug in thefirst column of the list.

What are generic drugs?Our plan covers both brand-name drugs andgeneric drugs. A generic drug is approved bythe FDA as having the same active ingredient


as the brand-name drug. Generally, genericdrugs cost less than brand-name drugs.

Are there any restrictions on mycoverage?Some covered drugs may have additionalrequirements or limits on coverage. Theserequirements and limits may include:

Prior Authorization: Our plan requires youor your physician to get prior authorizationfor certain drugs. This means that you willneed to get approval from our plan beforeyou fill your prescriptions. If you don't getapproval, our plan may not cover the drug.

Quantity Limits: For certain drugs, our planlimits the amount of the drug that ourplan will cover. For example, our planprovides 30 tablets per prescription fordonepezil. This may be in addition to astandard one-month or three-month supply.

Step Therapy: In some cases, our planrequires you to first try certain drugs to treatyour medical condition before we will coveranother drug for that condition. For example,if Drug A and Drug B both treat yourmedical condition, our plan may not coverDrug B unless you try Drug A first. If Drug Adoes not work for you, our plan will thencover Drug B.

You can find out if your drug has anyadditional requirements or limits by lookingin the formulary that begins on page 11. Youcan also get more information about therestrictions applied to specific covered drugsby visiting our website. We have posted

online documents that explain our priorauthorization and step therapy restrictions.You may also ask us to send you a copy. Ourcontact information, along with the date welast updated the formulary, appears on thefront and back cover pages.

You can ask our plan to make an exceptionto these restrictions or limits or for a list ofother, similar drugs that may treat yourhealth condition. See the section, “How doI request an exception to the SimplyComplete (HMO SNP)'s formulary?” onpage 6 for information about how torequest an exception.

What if my drug is not on the formulary?If your drug is not included in this formulary(list of covered drugs), you should firstcontact Member Services and ask if your drugis covered.

If you learn that our plan does not cover yourdrug, you have two options:

You can ask Member Services for a list ofsimilar drugs that are covered by our plan.When you receive the list, show it to yourdoctor and ask him or her to prescribe asimilar drug that is covered by our plan.

You can ask our plan to make an exceptionand cover your drug. See below forinformation about how to request anexception.


How do I request an exception to theSimply Complete (HMO SNP)'sformulary?You can ask our plan to make an exceptionto our coverage rules. There are several typesof exceptions that you can ask us to make:

You can ask us to cover a drug even if it isnot on our formulary. If approved, this drugwill be covered at a predeterminedcost-sharing level, and you would not be ableto ask us to provide the drug at a lowercost-sharing level.

You can ask us to waive coveragerestrictions or limits on your drug. Forexample, for certain drugs, our plan limitsthe amount of the drug that we will cover. Ifyour drug has a quantity limit, you can askus to waive the limit and cover a greateramount.

Generally, our plan will only approve yourrequest for an exception if the alternativedrugs included on the plan’s formulary, thelower cost-sharing drug or additionalutilization restrictions would not be aseffective in treating your condition and/orwould cause you to have adverse medicaleffects.

You should contact us to ask us for an initialcoverage decision for a formulary orutilization restriction exception. When yourequest a formulary or utilizationrestriction exception you should submit astatement from your prescriber orphysician supporting your request.

Generally, we must make our decision within72 hours of getting your prescriber’ssupporting statement. You can request anexpedited (fast) exception if you or yourdoctor believe that your health could beseriously harmed by waiting up to 72 hoursfor a decision. If your request to expedite isgranted, we must give you a decision no laterthan 24 hours after we get a supportingstatement from your doctor or otherprescriber.

What do I do before I can talk to mydoctor about changing my drugs orrequesting an exception?As a new or continuing member in our planyou may be taking drugs that are not on ourformulary. Or, you may be taking a drug thatis on our formulary but your ability to get itis limited. For example, you may need a priorauthorization from us before you can fill yourprescription. You should talk to your doctorto decide if you should switch to anappropriate drug that we cover or request aformulary exception so that we will cover thedrug you take. While you talk to your doctorto determine the right course of action foryou, we may cover your drug in certain casesduring the first 90 days you are a member ofour plan.

For each of your drugs that is not on ourformulary, or if your ability to get your drugsis limited, we will cover a temporary 30-daysupply. If your prescription is written forfewer days, we will allow refills to provide upto a maximum 30 day supply ofmedication. After your first 30-day supply,


we will not pay for these drugs, even if youhave been a member of the plan less than 90days.

If you are a resident of a long-term-carefacility and, you need a drug that is not onour formulary, or if your ability to get yourdrugs is limited, but you are past the first 90days of membership in our plan, we willcover a 34-day emergency supply of that drugwhile you pursue a formulary exception.

During the time when you are getting atemporary supply of a drug, you should talkto your prescriber or prescribing physicianto decide what to do when your supply runsout. You can call Member Services to ask fora list of covered drugs that treat the samemedical condition. This list can help yourdoctor find a covered drug that might workfor you while you pursue a formularyexception. Please refer to the Evidence ofCoverage for more information aboutexceptions.

For more informationFor more detailed information about ourplan prescription drug coverage, please reviewyour Evidence of Coverage and other planmaterials.

If you have questions about our plan, pleasecontact us. Our contact information, alongwith the date we last updated the formulary,appears on the front and back cover pages.

If you have general questions about Medicareprescription drug coverage, please callMedicare at 1-800-MEDICARE

(1-800-633-4227), 24 hours a day/7 days a week. TTY users should call1-877-486-2048. Or, visithttp://www.medicare.gov.

Our plan’s formularyThe formulary on page 11 provides coverageinformation about the drugs covered by ourplan. If you have trouble finding your drugin the list, turn to the Index that begins onpage 182.

The first column of the chart lists the drugname. Brand-name drugs are capitalized (e.g.,SPIRIVA) and generic drugs are listed inlowercase italics (e.g., atenolol).

The information in the Requirements/Limitscolumn tells you if our plan has any specialrequirements for coverage of your drug.

QLL – Quantity Limits: Restricts thefrequency, amount or dosage of medicationfor which you can obtain benefits each timeyou get a prescription filled (most often seton a monthly basis).

PAR – Prior Authorization: The process ofobtaining approval for certain prescriptionsbefore benefits will be approved. You, yourdoctor or other network provider will needto request prior authorization before you fillthe prescription.

ST – Step Therapy: The process of firsttrying a certain drug or drugs to determineif that drug or those drugs will treat yourmedical condition before your plan will coveranother drug for that condition.


B/D PAR – Part B vs. Part D: This drugmay be covered under either your Part Dprescription drug benefits or as a Part B drugunder your medical benefits, as determinedby Medicare.

LA – Limited Access: This prescription maybe available only at certain pharmacies. Formore information, consult your PharmacyDirectory or call Member Services at1-877-577-0115, From October 1 to March31, we are open seven days a week from 8:00a.m. - 8:00 p.m. ET. Beginning April 1 toSeptember 30, we are open Monday throughFriday, 8:00 a.m. - 8:00 p.m. ET. TTY/TDDusers should call 711.

MO – Mail Orders: Prescription drugsavailable through mail order. Allow up to 14days from the date the prescription is orderedto process and mail. For first time users ofthe home delivery pharmacy have at least a30-day supply of medication on hand whena request is placed with home deliverypharmacy.

ED – Excluded Drugs: This prescriptiondrug is not normally covered in a MedicarePrescription Drug Plan. The amount you paywhen you fill a prescription for this drug doesnot count towards your total drug costs (thatis, the amount you pay does not help youqualify for catastrophic coverage). Inaddition, if you are receiving extra help topay for your prescriptions, you will not getany extra help to pay for this drug. Pleaserefer to your Evidence of Coverage for moreinformation.

CG – Coverage Gap: We provide additionalcoverage of this prescription drug in thecoverage gap. Please refer to your Evidenceof Coverage for more information about thiscoverage.


Cost-sharing for up to a 90-day supply of a covered Part D prescription drug duringthe Initial Coverage Stage:

Cost-Sharing Tier 1: Preferred Generic

$0.00

Network Pharmacy cost-sharing (30-day to90-day supply) or Mail-Order Pharmacy(30-day to 90-day supply) orLong-Term-Care Pharmacy (34-day supply)

Cost-Sharing Tier 2: Generic

$0.00

Network Pharmacy cost-sharing (30-day to90-day supply) or Mail-Order Pharmacy(30-day to 90-day supply) orLong-Term-Care Pharmacy (34-day supply)

Cost-Sharing Tier 3: Preferred Brand$0.00 - $8.50. The amount you pay isdetermined by the covered Part D

Network Pharmacy cost-sharing (30-day to90-day supply) or Mail-Order Pharmacy

prescription and your low-income subsidy(30-day to 90-day supply) orLong-Term-Care Pharmacy (34-day supply)

coverage. Please refer to your LIS Rider forthe specific amount you pay.

Cost-Sharing Tier 4: Nonpreferred Brand$0.00 - $8.50. The amount you pay isdetermined by the covered Part D

Network Pharmacy cost-sharing (30-day)or Mail-Order Pharmacy (30-day supply)

prescription and your low-income subsidyor Long-Term-Care Pharmacy (34-daysupply)


Cost-Sharing Tier 5: Specialty Tier*$0.00 - $8.50. The amount you pay isdetermined by the covered Part D

Network Pharmacy cost-sharing (30-daysupply) or Mail-Order Pharmacy (30-day

prescription and your low-income subsidysupply) or Long-Term-Care Pharmacy(34-day supply)


Please refer to our Evidence of Coverage for more information on cost sharing.

The amount you pay will depend if you qualify for low-income subsidy (LIS), also knownas Medicare's "Extra Help" program.


Your costs will be the same if you use a pharmacy that offers standard cost-sharing or apharmacy that offers preferred cost-sharing.

* A long-term supply is not available for drugs in the Tier 4: Non-preferred brand tieror Tier 5: Specialty Tier** Mail-Order Pharmacy – Mail-order service allows you to order a 30–90-day supply ofdrugs. The drugs available through our plan’s mail-order service are marked as “mail-order”drugs in our drug list.


Covered Medications by Therapeutic CategoryLegendGeneric drugs are shown in lowercase italic (e.g., atenolol).

Brand-name drugs are shown in capital letters (e.g., SPIRIVA).

QLL – Quantity Limits: Restricts the frequency, amount or dosage of medication forwhich you can obtain benefits each time you get a prescription filled (most often set on amonthly basis).

PAR – Prior Authorization: The process of obtaining approval for certain prescriptionsbefore benefits will be approved. You, your doctor or other network provider will need torequest prior authorization before you fill the prescription.

ST – Step Therapy: The process of first trying a certain drug or drugs to determine if thatdrug or those drugs will treat your medical condition before your plan will cover anotherdrug for that condition.

B/D PAR – Part B vs. Part D: This drug may be covered under either your Part Dprescription drug benefits or as a Part B drug under your medical benefits, as determinedby Medicare.

LA – Limited Access: This prescription may be available only at certain pharmacies. Formore information, consult your Pharmacy Directory or call Member Services at1-877-577-0115, From October 1 to March 31, we are open seven days a week from 8:00a.m. - 8:00 p.m. ET. Beginning April 1 to September 30, we are open Monday throughFriday, 8:00 a.m. - 8:00 p.m. ET. TTY/TDD users should call 711.

MO – Mail Orders: Prescription drugs available through mail order. Allow up to 14 daysfrom the date the prescription is ordered to process and mail. For first time users of thehome delivery pharmacy have at least a 30-day supply of medication on hand when a requestis placed with home delivery pharmacy.

ED – Excluded Drugs: This prescription drug is not normally covered in a MedicarePrescription Drug Plan. The amount you pay when you fill a prescription for this drug doesnot count towards your total drug costs (that is, the amount you pay does not help youqualify for catastrophic coverage). In addition, if you are receiving extra help to pay for your

prescriptions, you will not get any extra help to pay for this drug. Please refer to yourEvidence of Coverage for more information.

CG – Coverage Gap: We provide additional coverage of this prescription drug in thecoverage gap. Please refer to your Evidence of Coverage for more information about thiscoverage.

Importante para los miembros existentes:Este formulario ha cambiado desde el año pasado.Revise este documento para asegurarse de que aúncontenga los medicamentos que toma.

Cuando esta lista de medicamentos (formulario) serefiere a “nosotros,” “nos” o “nuestro,” está hablandode Simply Healthcare Plans. Cuando se refiere a “plan”o “nuestro plan,” está hablando de Simply Complete(HMO SNP).

Este documento incluye una lista de los medicamentos(formulario) de nuestro plan, la cual está actualizada al1.º de agosto de 2019. Para obtener un formularioactualizado, comuníquese con nosotros. Nuestrainformación de contacto, junto con la fecha de la últimaactualización del formulario, figura en la portada ycontraportada.

Para poder utilizar su beneficio para medicamentosrecetados, por lo general, debe recurrir a farmacias de lared. Los beneficios, el formulario la red de farmacias, y/o los copagos/coseguros pueden cambiar a partir del 1.°de enero de 2020, y periódicamente durante el año.

El formulario, la red de farmacias y/o la red deproveedores pueden cambiar en cualquier momento.Recibirá una notificación cuando sea necesario.

Fecha de vigencia 1.º de agosto de 2019 13 Simply_19261_ED_CG12_v15_1908_1

¿Qué es el formulario de SimplyComplete (HMO SNP)?Un formulario es una lista de medicamentoscubiertos seleccionados por nuestro plan enconsulta con un equipo de proveedores deatención de la salud, que representa lasterapias recetadas consideradas como unaparte necesaria de un programa detratamiento de calidad. Nuestro plan,generalmente, cubrirá los medicamentosenumerados en nuestro formulario siemprey cuando el mismo sea médicamentenecesario, la receta se complete en unafarmacia de la red y se cumplan otras normasdel plan. Para obtener más información sobrecómo abastecer sus recetas, consulte suEvidencia de Cobertura.

¿Puede cambiar el formulario (lista demedicamentos)?Por lo general, si está tomando unmedicamento de nuestro formulario2019 que tenía cobertura a principios de año,no discontinuaremos ni reduciremos lacobertura del medicamento durante el añode cobertura 2019, excepto si está disponibleun medicamento genérico más barato ocuando se divulgue nueva información sobrela seguridad o efectividad de unmedicamento, o si el medicamento se retiradel mercado. (Consulte las viñetas acontinuación para obtener más informaciónsobre los cambios que afectan a los miembrosque actualmente toman el medicamento).Otros tipos de cambios en el formulario,como eliminar un medicamento de nuestroformulario, no afectarán a los miembros que

estén tomando actualmente dichomedicamento. Seguirá disponible con lamisma distribución de costos para losmiembros que lo tomen durante el resto delaño de cobertura. Para nosotros es importanteque tenga acceso continuo durante el restodel año de cobertura. A continuación semuestran los cambios en la lista demedicamentos que también afectarán a losmiembros que actualmente toman unmedicamento:

Nuevos medicamentos genéricos.Podemos eliminar inmediatamente unmedicamento de marca de nuestra Listade Medicamentos si lo estamosreemplazando con un medicamentogenérico nuevo que aparecerá en elmismo nivel de distribución de costos ouno inferior y con las mismas o menosrestricciones. Además, cuando agregamosel nuevo medicamento genérico,podemos decidir mantener elmedicamento de marca en nuestra Listade Medicamentos, pero moverloinmediatamente a un nivel diferente dedistribución de costos o agregar nuevasrestricciones. Si actualmente estátomando ese medicamento de marca, esposible que no le informemos conanticipación antes de hacer ese cambio,pero luego le brindaremos informaciónsobre los cambios específicos que hemosrealizado.


Si realizamos dicho cambio, usted osu emisor de recetas puedensolicitarnos hacer una excepción yque continuemos cubriendo elmedicamento de marca para usted.El aviso que le proporcionamostambién incluirá información sobrelos pasos que puede seguir parasolicitar una excepción, y tambiénpuede encontrar información en lasiguiente sección titulada “¿Cómosolicito una excepción para elFormulario de Simply Complete(HMO SNP)?”

Medicamentos eliminados delmercado. Si la Administración deAlimentos y Medicamentos considera queun medicamento de nuestro formulariono es seguro o si el fabricante delmedicamento lo retira del mercado,retiraremos inmediatamente elmedicamento de nuestro formulario einformaremos a los miembros que tomandicho medicamento.

Otros cambios. Es posible que hagamosotros cambios que afecten a los miembrosque actualmente toman un medicamento.Por ejemplo, podemos agregar unmedicamento genérico que no sea nuevoen el mercado para reemplazar unmedicamento de marca actualmenteincluido en el formulario o agregarnuevas restricciones al medicamento demarca o moverlo a un nivel diferente decosto compartido. O podemos hacercambios basados en nuevas pautasclínicas. Si eliminamos medicamentosde nuestro formulario o agregamos unaautorización previa, límites de cantidady/o restricciones de terapia escalonada deun medicamento, o cambiamos unmedicamento a un nivel superior dedistribución de costos, debemos notificardicho cambio a los miembros afectadosal menos 30 días antes de que dichocambio se haga efectivo o en el momentoen que el miembro solicite que le resurtanel medicamento, momento en el que elmiembro recibirá suministro delmedicamento por 30 días.

El formulario adjunto está actualizado al 1.ºde agosto de 2019. Para obtener informaciónactualizada sobre los medicamentos que cubrenuestro plan, comuníquese con nosotros.Nuestra información de contacto figura enla portada y contraportada. Si se realizacualquier otro tipo de cambio en elformulario aprobado (que no sea demantenimiento) durante el año, lo


notificaremos enviándole una lista de dichoscambios o un formulario actualizado.

¿Cómo utilizo el formulario?Existen dos maneras de encontrar sumedicamento dentro del formulario:

Afección médica

l formulario comienza en la página 11. Losmedicamentos en este formulario estánagrupados en categorías basadas en el tipo deafección médica para los que se utilizan. Porejemplo, los medicamentos para tratar unaafección cardíaca están enumerados en lacategoría “Cardiovascular, Hypertension/Lipids”. Si usted sabe para qué se usa sumedicamento, busque el nombre de lacategoría en la lista que empieza en lapágina 11. Luego busque su medicamentobajo el nombre de la categoríacorrespondiente.

Lista en orden alfabético

Si no está seguro en qué categoría buscar,debe buscar su medicamento en el Índice quecomienza en la página 182. El Índice brindauna lista alfabética de todos los medicamentosincluidos en este documento. Tanto losmedicamentos de marca como losmedicamentos genéricos se enumeran en elÍndice. Busque en el Índice y encuentre sumedicamento. Al lado de su medicamentoverá el número de página en la que puedeencontrar información de cobertura. Vaya ala página que se enumera en el Índice yencuentre el nombre de su medicamento enla primera columna de la lista.

¿Qué son los medicamentos genéricos?Nuestro plan cubre medicamentos de marcay medicamentos genéricos. Un medicamentogenérico es aquel aprobado por la FDAporque tiene el mismo ingrediente activo queel medicamento de marca. Generalmente, losmedicamentos genéricos son más económicosque los medicamentos de marca.

¿Existe alguna restricción en micobertura?Algunos medicamentos cubiertos puedentener requisitos adicionales o límites decobertura. Estos requisitos y límites puedenincluir:

Autorización previa: Nuestro plan requiereque usted o su médico tengan unaautorización previa para determinadosmedicamentos. Esto significa que necesitaobtener aprobación de nuestro plan antes depoder abastecer su receta. Si no obtiene laaprobación, nuestro plan podría no cubrir elmedicamento.

Límites de cantidad: Para ciertosmedicamentos, nuestro plan limita lacantidad del medicamento que nuestroplan cubrirá. Por ejemplo, nuestro planofrece 30 tabletas por receta dedonepezil. Esto puede ser adicional a unsuministro estándar de un mes o tres meses.

Terapia escalonada: En algunos casos,nuestro plan requiere que usted pruebe ciertosmedicamentos para tratar su afección médicaantes de cubrir otro medicamento para esaafección. Por ejemplo, si el Medicamento A


y el Medicamento B tratan su afecciónmédica, es posible que nuestro plan no cubrael medicamento B a menos que pruebe elmedicamento A primero. Si el medicamentoA no funciona para usted, nuestro plancubrirá el medicamento B.

Usted puede averiguar si su medicamentotiene requisitos o límites adicionalesconsultando el formulario que empieza en lapágina 11. También puede obtener másinformación sobre las restricciones que seaplican a determinados medicamentoscubiertos visitando nuestro sitio web. Hemospublicado documentos en línea que explicannuestra autorización previa y las restriccionesde terapia escalonada. También puedesolicitarnos que le enviemos unacopia. Nuestra información de contacto,junto con la fecha de la última actualizacióndel formulario, figura en la portada ycontraportada.

Puede solicitar una excepción a nuestro planpara estas restricciones o límites, o solicitaruna lista de otros medicamentos similares quepuedan tratar su afección médica. Consultela sección “¿Cómo solicito una excepción alformulario de Simply Complete (HMOSNP)?” en la página 17 para obtenerinformación sobre cómo solicitar unaexcepción.

¿Qué sucede si mi medicamento no seencuentra en el formulario?Si su medicamento no está incluido en esteformulario (lista de medicamentos cubiertos),primero debe comunicarse con el Servicio de

Atención al Cliente de y consultar si sumedicamento está cubierto.

Si le informan que nuestro plan no cubre sumedicamento, tiene dos opciones:

Puede solicitar al Servicio de Atención alCliente de una lista de medicamentossimilares que estén cubiertos por nuestroplan. Cuando reciba la lista, muéstresela a sumédico y pídale que le recete unmedicamento similar que esté cubierto pornuestro plan.

Puede solicitar al plan que realice unaexcepción y brindar cobertura para sumedicamento. Consulte lo que se describe acontinuación para obtener información sobrecómo solicitar una excepción.

¿Cómo solicito una excepción para elformulario de Simply Complete (HMOSNP)?Puede solicitar que nuestro plan haga unaexcepción a nuestras reglas de cobertura.Existen varios tipos de excepciones que puedesolicitarnos:

Puede solicitarnos que cubramos unmedicamento aunque no esté en nuestroformulario. Si se aprueba, este medicamentoestará cubierto a un nivel de distribución decostos predeterminado, y usted no podrásolicitarnos que le suministremos dichomedicamento a un nivel de distribución decostos menor.

Puede solicitar que eximamos lasrestricciones o limitaciones de cobertura


de su medicamento. Por ejemplo, paraciertos medicamentos, nuestro plan limita lacantidad del medicamento que cubriremos.Si su medicamento tiene un límite decantidad, puede solicitar que eximamos ellímite y que cubramos más.

Por lo general, nuestro plan aprobará susolicitud de una excepción únicamente si losmedicamentos alternativos incluidos en elformulario del plan, el medicamento demenor nivel o las restricciones de utilizaciónadicional no son favorables para tratar suafección y/o harán que padezca efectosmédicos adversos.

Debe comunicarse con nosotros parasolicitarnos una decisión de cobertura inicialpara una excepción de formulario o derestricción de utilización. Al solicitar unaexcepción de formulario o de restricciónde utilización deberá enviar unadeclaración de su emisor de recetas omédico justificando su solicitud. Por logeneral, debemos tomar nuestra decisióndentro de las 72 horas después de obtener ladeclaración en la que su emisor de recetasrealiza la justificación. Puede solicitar unaexcepción urgente (rápida) si usted o sumédico creen que su salud corre un riesgograve al esperar hasta 72 horas por unadecisión. Si se le otorga la solicitud deagilización, debemos darle una respuestadentro de las 24 horas luego de recibir ladeclaración justificatoria del médico o de otroemisor de recetas.

¿Qué hago antes de hablar con mimédico sobre cambiar mismedicamentos o solicitar una excepción?Como miembro nuevo o que continúa ennuestro plan, podría estar tomandomedicamentos que no están en nuestroformulario. O podría estar tomando unmedicamento que está en nuestro formulario,pero su capacidad para obtenerlo es limitada.Por ejemplo, puede necesitar una autorizaciónprevia de nuestra parte antes de poderabastecer su receta. Deberá hablar con sumédico para decidir si debe cambiar a unmedicamento adecuado que cubramos osolicitar una excepción al formulario para quecubramos el medicamento que está tomando.Mientras consulta con su médico el curso deacción acorde para usted, podemos cubrir sumedicamento en ciertos casos durante losprimeros 90 días en los que usted es miembrode nuestro plan.

Para cada uno de sus medicamentos que noesté en nuestro formulario o si su capacidadpara obtener sus medicamentos es limitada,cubriremos un suministro temporal para 30días. Si en su receta figuran menos días,permitiremos que le entreguenabastecimientos hasta un suministro máximode 30 días de medicamento. Luego de suprimer suministro para 30 días, no pagaremosestos medicamentos, aunque sea miembrodel plan por menos de 90 días.

Si usted es residente de un centro de cuidadoa largo plazo y necesita un medicamento queno está en nuestro formulario o si sucapacidad para obtener sus medicamentos es


limitada, pero ya pasaron los primeros 90 díasde membresía en nuestro plan, cubriremosun suministro de emergencia de 34 días paraese medicamento mientras solicita unaexcepción al formulario.

Mientras obtenga el suministro temporal deun medicamento, debe hablar con su médicoo con el médico emisor de la receta paradecidir qué debe hacer cuando se termine elsuministro temporal. Puede llamar al Serviciode Atención al Cliente de para solicitar unalista de medicamentos cubiertos que tratenla misma afección médica. Esta lista puedeayudar a que su médico encuentre unmedicamento cubierto que le dé resultadomientras usted sigue tramitando unaexcepción al formulario. Consulte laEvidencia de Cobertura para obtener másinformación sobre las excepciones.

Para obtener más informaciónPara obtener información más detallada sobrela cobertura de medicamentos recetados denuestro plan, consulte su Evidencia deCobertura y otros materiales del plan.

Si tiene alguna pregunta sobre nuestro plan,comuníquese con nosotros. Nuestrainformación de contacto, junto con la fechade la última actualización del formulario,figura en la portada y contraportada.

Si tiene preguntas generales sobre la coberturade medicamentos recetados de Medicare,llame a Medicare al 1-800-MEDICARE(1-800-633-4227), las 24 horas del día, lossiete días a la semana. Los usuarios de TTY

deben llamar al 1-877-486-2048. O visitehttp://www.medicare.gov.

El formulario de nuestro planEl formulario en la página 23 proporcionainformación de cobertura sobre losmedicamentos cubiertos por nuestro plan. Sitiene problemas para encontrar sumedicamento en la lista, consulte el Índiceque comienza en la página 182.

La primera columna del cuadro enumera elnombre del medicamento. Los medicamentosde marca figuran en letra mayúscula (por ej.,SPIRIVA) y los medicamentos genéricosestán enumerados en letra minúscula y cursiva(por ej., atenolol).

La información en la columna Requisitos/Límites le indica si nuestro plan tiene algunosrequisitos especiales para la cobertura de sumedicamento.

QLL - Límites de cantidad: Limita lafrecuencia, cantidad o dosis de medicamentopara la cual puede obtener beneficios cadavez que se le abastezca una receta(generalmente una vez por mes).

PAR - Autorización previa: El proceso deobtener la aprobación para determinadasrecetas antes de aprobar los beneficios. Usted,su médico u otro proveedor de la rednecesitarán solicitar autorización previa antesde abastecer la receta.

ST - Terapia escalonada: El proceso deprobar por primera vez determinadomedicamento o medicamentos para


determinar si el o los mismos tratarán suafección médica antes de que su plan cubraotro medicamento para dicha afección.

B/D PAR – Parte B vs. Parte D: Estemedicamento puede estar cubierto por losbeneficios para los medicamentos recetadosde la Parte D o como un medicamento de laParte B bajo sus beneficios médicos, segúnlo determine Medicare.

LA - Acceso limitado: Esta receta puede estardisponible solo en ciertas farmacias. Para másinformación, consulte su Directorio deFarmacias o llame al Servicio a Afiliados al1-877-577-0115, del 1 de octubre al 31 demarzo, atendemos siete días a la semana de8:00 a.m. - 8:00 p.m. ET. Del 1 de abril al30 de septiembre, atendemos de lunes aviernes, de 8:00 a.m. - 8:00 p.m. ET. losusuarios de TTY/TDD deben llamar al 711.

MO - Pedidos por correo: Medicamentosrecetados que se pueden ordenar por correo.Espere hasta 14 días a partir de la fecha enque la receta es ordenada para procesarla yenviarla por correo. Para los usuarios nuevosde la farmacia de entrega a domicilio, tengaal menos un suministro de 30 días demedicamentos a mano cuando se realiza unasolicitud a la farmacia de entrega a domicilio.

ED – Medicamentos excluidos: Por logeneral, este medicamento con receta no estácubierto en un Plan de MedicamentosRecetados de Medicare. El monto que pagacuando abastece una receta para estemedicamento no cuenta para el costo total

de sus medicamentos (es decir, el monto quepaga no lo ayuda a calificar para unacobertura catastrófica). Además, si recibeayuda extra para pagar sus medicamentosrecetados, no recibirá ayuda extra para pagareste medicamento. Consulte su Evidencia deCobertura para obtener más información.

CG - Etapa sin cobertura: Brindamoscobertura adicional de este medicamentorecetado en la etapa sin cobertura. Tenga abien consultar su Evidencia deCobertura para más información sobre estacobertura.


Distribución de costos por un suministro 90 días de un medicamento recetado ycubierto de la Parte D durante la Etapa de Cobertura Inicial:

Distribución de costos Nivel 1: Medicamentos genéricos preferidos

$0.00

Farmacia de la red con distribución decostos (suministro para 30 a 90 días) oFarmacia de venta por correo (suministropara 30 a 90 días) o Farmacia de centro deatención a largo plazo (suministro para 34días)

Distribución de costos Nivel 2: Medicamentos genéricos

$0.00

Farmacia de la red con distribución decostos (suministro para 30 a 90 días) oFarmacia de venta por correo (suministropara 30 a 90 días) o Farmacia de centro deatención a largo plazo (suministro para 34días)

Distribución de costos Nivel 3: Medicamentos de marca preferidos

$0.00 - $8.50. por receta - El monto quepaga se determina por la receta de la Parte

Farmacia de la red con distribución decostos (suministro para 30 a 90 días) o

D cubierta y su cobertura de subsidio porFarmacia de venta por correo (suministro

bajos ingresos. Consulte su LIS Rider paraconocer el monto específico que paga.

para 30 a 90 días) o Farmacia de centro deatención a largo plazo (suministro para 34días)

Distribución de costos Nivel 4: Medicamentos de marca no preferidos

$0.00 - $8.50. por receta - El monto quepaga se determina por la receta de la Parte

Farmacia de la red con distribución decostos (suministro para 30 a 90 días) o

D cubierta y su cobertura de subsidio porFarmacia de venta por correo (suministro


para 30 a 90 días) o Farmacia de centro deatención a largo plazo (suministro para 34días)

Distribución de costos Nivel 5: Medicamentos especializados*$0.00 - $8.50. por receta - El monto quepaga se determina por la receta de la Parte

Farmacia de la red con distribución decostos (suministro para 30 días) o Farmacia

D cubierta y su cobertura de subsidio porde venta por correo (suministro para 30


Distribución de costos Nivel 5: Medicamentos especializados*días) o Farmacia de centro de atención alargo plazo (suministro para 34 días)


Tenga a bien consultar nuestra Evidencia de Cobertura para obtener más información sobrela distribución de costos.

El monto a pagar dependerá de si califica para el subsidio por bajos ingresos (LIS), tambiénconocido como programa de “Ayuda Extra” (Extra Help) de Medicare.

Sus costos pueden ser iguales si utiliza una farmacia que ofrezca una distribución de costosestándar o una farmacia que ofrezca una distribución de costos preferidos.

* El suministro prolongado no está disponible para los medicamentos del Nivel 4: Nivel demarca no preferido o Nivel 5: Medicamentos Especiales** Pedido de farmacia por correo – Servicio de pedido de farmacia le permite pedir unsuministro de medicamentos de 30 a 90. Los medicamentos disponibles a través del serviciode venta por correo de nuestro plan figuran como medicamentos de “venta por correo” ennuestra lista de medicamentos.


Medicamentos cubiertos por la Categoría TerapéuticaLeyendaLos medicamentos genéricos figuran en letra minúscula y cursiva (por ej., atenolol).

Los medicamentos de marca figuran en letra mayúscula (por ej., SPIRIVA).

QLL - Límites de cantidad: Limita la frecuencia, cantidad o dosis de medicamento parala cual puede obtener beneficios cada vez que se le abastezca una receta (generalmente unavez por mes).

PAR - Autorización previa: El proceso de obtener la aprobación para determinadas recetasantes de aprobar los beneficios. Usted, su médico u otro proveedor de la red necesitaránsolicitar autorización previa antes de abastecer la receta.

ST - Terapia escalonada: El proceso de probar por primera vez determinado medicamentoo medicamentos para determinar si el o los mismos tratarán su afección médica antes deque su plan cubra otro medicamento para dicha afección.

B/D - Parte B vs. Parte D: Este medicamento puede estar cubierto por los beneficios paralos medicamentos recetados de la Parte D o como un medicamento de la Parte B bajo susbeneficios médicos, según lo determine Medicare.

LA - Acceso limitado: Esta receta puede estar disponible solo en ciertas farmacias. Paramás información, consulte su Directorio de Farmacias o llame al Servicio a Afiliados al1-877-577-0115, del 1 de octubre al 31 de marzo, atendemos siete días a la semana de 8:00a.m. - 8:00 p.m. ET. Del 1 de abril al 30 de septiembre, atendemos de lunes a viernes, de8:00 a.m. - 8:00 p.m. ET. Los usuarios de TTY/TDD deben llamar al 711.

MO - Pedidos por correo: Medicamentos recetados que se pueden ordenar por correo.Espere hasta 14 días a partir de la fecha en que la receta es ordenada para procesarla y enviarlapor correo. Para los usuarios nuevos de la farmacia de entrega a domicilio, tenga al menosun suministro de 30 días de medicamentos a mano cuando se realiza una solicitud a lafarmacia de entrega a domicilio.

ED – Medicamentos excluidos: Por lo general, este medicamento con receta no estácubierto en un Plan de Medicamentos Recetados de Medicare. El monto que paga cuandoabastece una receta para este medicamento no cuenta para el costo total de sus medicamentos(es decir, el monto que paga no lo ayuda a calificar para una cobertura catastrófica). Además,

si recibe ayuda extra para pagar sus medicamentos recetados, no recibirá ayuda extra parapagar este medicamento. Consulte su Evidencia de Cobertura para obtener más información.

CG - Etapa sin cobertura: Brindamos cobertura adicional de este medicamento recetadoen la etapa sin cobertura. Tenga a bien consultar su Evidencia de Cobertura para másinformación sobre esta cobertura.

Requirements/LimitsRequisitos/Límites

Drug TierNivel de medicamento

Drug NameNombre del medicamento

Anti - InfectivesMO; CG; QLL (960 per30 days)

2abacavir oral solution

MO; CG; QLL (60 per30 days)

2abacavir oral tablet

QLL (30 per 30 days)5abacavir-lamivudineQLL (60 per 30 days)5abacavir-lamivudine-zidovudineB/D PAR5ABELCETMO; CG1acyclovir oral capsuleMO; CG1acyclovir oral suspension 200 mg/5 mlMO; CG1acyclovir oral tabletB/D PAR; MO; CG1acyclovir sodium 50 mg/ml intravenous

solutionPAR; MO; CG2adefovirMO; CG2albendazole

5ALBENZAQLL (6 per 30 days)4ALINIA ORAL TABLETMO; CG1amantadine hclB/D PAR4AMBISOMEMO; CG1amikacin injection solution 1,000 mg/4

ml, 500 mg/2 mlMO; CG1amoxicillin oral capsuleMO; CG1amoxicillin oral suspension for

reconstitutionMO; CG1amoxicillin oral tabletMO; CG1amoxicillin oral tablet,chewable 125 mg,

250 mgMO; CG2amoxicillin-pot clavulanate

You can find information on what the symbols and abbreviations on this table mean by going to the Legend on pagenumber 11.Puede encontrar información sobre lo que significan los símbolos y las abreviaturas en esta tabla visitando la Leyenda enla página número 23.Simply_19261_ED_CG12_v15_1908_1 25 Effective Date August 1, 2019




B/D PAR; MO; CG2amphotericin bMO; CG1ampicillin oral capsule 500 mgMO; CG1ampicillin sodium injectionCG1ampicillin sodium intravenousMO; CG2ampicillin-sulbactam injection recon soln

1.5 gram, 3 gramCG2ampicillin-sulbactam injection recon soln

15 gramCG2ampicillin-sulbactam intravenous recon

soln 1.5 gramMO; CG2ampicillin-sulbactam intravenous recon

soln 3 gramQLL (120 per 30 days)5APTIVUS ORAL CAPSULEQLL (380 per 30 days)5APTIVUS ORAL SOLUTIONQLL (60 per 30 days)5atazanavir oral capsule 150 mg, 200 mgQLL (30 per 30 days)5atazanavir oral capsule 300 mgPAR5atovaquoneMO; CG2atovaquone-proguanilQLL (30 per 30 days)5ATRIPLA

4AVELOX IN NACL (ISO-OSMOTIC)

5AVYCAZMO; CG1azithromycin intravenousMO3azithromycin oral packetMO; CG1azithromycin oral suspension for

reconstitutionMO; CG1azithromycin oral tablet 250 mg, 250

mg (6 pack), 500 mg, 600 mg





MO; CG2aztreonamPAR5BARACLUDE ORAL SOLUTIONB/D PAR5BETHKIS

4BICILLIN C-R4BICILLIN L-A

QLL (30 per 30 days)5BIKTARVYMO3BILTRICIDE

4CAPASTATPAR; LA5CAYSTONMO; CG1cefaclor oral capsuleMO; CG1cefaclor oral suspension for reconstitution

125 mg/5 ml, 250 mg/5 mlCG1cefaclor oral suspension for reconstitution

375 mg/5 mlMO; CG2cefadroxil oral capsuleMO; CG2cefadroxil oral suspension for

reconstitution 250 mg/5 ml, 500 mg/5ml

MO; CG2cefadroxil oral tabletMO; CG2cefazolin injection recon soln 1 gram,

500 mgCG2cefazolin injection recon soln 10 gram,

100 gram, 20 gram, 300 gCG2cefazolin intravenousMO; CG2cefdinirMO; CG2cefepime in dextrose 5 %MO; CG2cefepime injectionMO; CG2cefixime





CG2cefotaxime injection recon soln 1 gram,500 mg

CG2cefotetan injection solutionCG2cefoxitin in dextrose, iso-osmMO; CG2cefoxitin intravenous recon soln 1 gram,

2 gramCG2cefoxitin intravenous recon soln 10 gramMO; CG2cefpodoximeMO; CG2cefprozilMO; CG2ceftazidime injection recon soln 1 gram,

2 gramCG2ceftazidime injection recon soln 6 gramMO; CG2ceftriaxone injection recon soln 1 gram,

2 gram, 250 mg, 500 mgCG2ceftriaxone injection recon soln 10 gram,

100 gramMO; CG2ceftriaxone intravenousMO; CG2cefuroxime axetil oral tabletMO; CG2cefuroxime sodium injection recon soln

750 mgMO; CG2cefuroxime sodium intravenous recon soln

1.5 gramCG2cefuroxime sodium intravenous recon soln

7.5 gramMO; CG1cephalexin oral capsuleMO; CG1cephalexin oral suspension for

reconstitutionCG1chloramphenicol sod succinate





MO; CG1chloroquine phosphateB/D PAR5cidofovirQLL (30 per 30 days)5CIMDUOMO; CG2ciprofloxacin (mixture) oral tablet, er

multiphase 24 hr 500 mg, 1,000 mgMO; CG1ciprofloxacin hcl oral tabletMO; CG1ciprofloxacin in 5 % dextroseCG2ciprofloxacin oral suspensionMO; CG2clarithromycinMO; CG1clindamycin hclMO; CG1clindamycin in 5 % dextroseMO; CG1clindamycin palmitate hclMO; CG1clindamycin pediatricMO; CG1clindamycin phosphate injection solution

150 mg/mlCG1clindamycin phosphate intravenous

solution 300 mg/2 ml, 900 mg/6 mlMO; CG1clindamycin phosphate intravenous

solution 600 mg/4 mlMO; CG1clotrimazole mucous membrane

4COARTEMMO; CG2colistin (colistimethate na)QLL (30 per 30 days)5COMPLERAPAR5CRESEMBAQLL (360 per 30 days)4CRIXIVAN ORAL CAPSULE 200

MGQLL (180 per 30 days)4CRIXIVAN ORAL CAPSULE 400

MG





5DALVANCEMO; CG2dapsone oral

5DAPTOMYCIN INTRAVENOUSRECON SOLN 350 MG

5daptomycin intravenous recon soln 500mg

5DARAPRIMQLL (30 per 30 days)5DELSTRIGOMO; CG2demeclocyclineQLL (30 per 30 days)5DESCOVYMO; CG1dicloxacillinCG; QLL (60 per 30days)

2didanosine oral capsule,delayedrelease(dr/ec) 200 mg


2didanosine oral capsule,delayedrelease(dr/ec) 250 mg, 400 mg

PAR5DIFICID4DORIPENEM

QLL (30 per 30 days)5DOVATOMO; CG2doxy-100CG2doxycycline hyclate intravenousMO; CG2doxycycline hyclate oral capsuleMO; CG2doxycycline hyclate oral tablet 100 mg,

150 mg, 20 mg, 75 mgMO; CG2doxycycline hyclate oral tablet,delayed

release (dr/ec) 100 mg, 150 mg, 200 mg,50 mg, 75 mg

MO; CG2doxycycline monohydrate oral capsule





MO; CG2doxycycline monohydrate oral suspensionfor reconstitution

MO; CG2doxycycline monohydrate oral tabletMO; CG1e.e.s. 400 oral tabletQLL (30 per 30 days)5EDURANTMO; CG; QLL (120 per30 days)

2efavirenz oral capsule 200 mg


2efavirenz oral capsule 50 mg

QLL (30 per 30 days)5efavirenz oral tabletQLL (30 per 30 days)4EMTRIVA ORAL CAPSULEQLL (850 per 30 days)4EMTRIVA ORAL SOLUTIONPAR5entecavirPAR; QLL (30 per 30days)

5EPCLUSA

MO; CG2ertapenemMO; CG2ery-tab oral tablet,delayed release (dr/ec)

250 mg, 333 mgMO3ERY-TAB ORAL TABLET,

DELAYED RELEASE (DR/EC) 500MG

5ERYPED 2005ERYPED 400

MO; CG2erythrocin (as stearate) oral tablet 250mg

4ERYTHROCIN INTRAVENOUSRECON SOLN 500 MG





MO; CG2erythromycin ethylsuccinate oralsuspension for reconstitution

MO; CG1erythromycin ethylsuccinate oral tabletMO; CG1erythromycin oral capsule,delayed

release(dr/ec)MO; CG1erythromycin oral tabletMO; CG1ethambutolQLL (30 per 30 days)5EVOTAZMO; CG; QLL (60 per30 days)

2famciclovir oral tablet 125 mg, 250 mg

MO; CG; QLL (21 per 7days)

2famciclovir oral tablet 500 mg

MO; CG1fluconazoleCG1fluconazole in dextrose(iso-o)MO; CG2fluconazole in nacl (iso-osm) intravenous

piggyback 200 mg/100 mlCG1fluconazole in nacl (iso-osm) intravenous

piggyback 400 mg/200 mlMO; CG2flucytosine oral capsule 250 mg

5flucytosine oral capsule 500 mgQLL (120 per 30 days)5fosamprenavirQLL (60 per 30 days)5FUZEON SUBCUTANEOUS

RECON SOLNB/D PAR; MO; CG2ganciclovir sodium intravenous recon solnMO; CG1gentamicin in nacl (iso-osm) intravenous

piggyback 100 mg/100 ml, 100 mg/50ml, 60 mg/50 ml, 80 mg/50 ml





CG1gentamicin in nacl (iso-osm) intravenouspiggyback 120 mg/100 ml, 80 mg/100ml

MO; CG1gentamicin injectionMO; CG1gentamicin sulfate (ped) (pf )QLL (30 per 30 days)5GENVOYAMO; CG2griseofulvin microsizeMO; CG2griseofulvin ultramicrosizePAR; QLL (28 per 28days)

5HARVONI

MO; CG1hydroxychloroquineMO; CG2imipenem-cilastatinQLL (120 per 30 days)5INTELENCE ORAL TABLET 100

MGQLL (60 per 30 days)5INTELENCE ORAL TABLET 200

MGQLL (480 per 30 days)4INTELENCE ORAL TABLET 25

MG4INVANZ INJECTION

QLL (120 per 30 days)5INVIRASE ORAL TABLETQLL (60 per 30 days)5ISENTRESS HDQLL (180 per 30 days)5ISENTRESS ORAL POWDER IN

PACKETQLL (120 per 30 days)5ISENTRESS ORAL TABLETQLL (180 per 30 days)5ISENTRESS ORAL TABLET,

CHEWABLE 100 MGMO; QLL (720 per 30days)

3ISENTRESS ORAL TABLET,CHEWABLE 25 MG





CG2isoniazid injectionMO; CG2isoniazid oral solutionMO; CG1isoniazid oral tabletPAR; MO; CG2itraconazole oral capsuleMO; CG2ivermectinQLL (30 per 30 days)5JULUCAQLL (300 per 30 days)4KALETRA ORAL TABLET 100-25

MGQLL (120 per 30 days)5KALETRA ORAL TABLET 200-50

MGMO; CG1ketoconazole oralMO; CG; QLL (960 per30 days)

2lamivudine oral solution

MO; CG2lamivudine oral tablet 100 mgMO; CG; QLL (60 per30 days)

2lamivudine oral tablet 150 mg


2lamivudine oral tablet 300 mg


1lamivudine-zidovudine

CG1levofloxacin in d5w intravenouspiggyback 250 mg/50 ml

MO; CG1levofloxacin in d5w intravenouspiggyback 500 mg/100 ml, 750 mg/150ml

MO; CG1levofloxacin intravenousMO; CG1levofloxacin oralQLL (1800 per 30 days)4LEXIVA ORAL SUSPENSION





QLL (120 per 30 days)5LEXIVA ORAL TABLETMO3LINCOCINCG1lincomycinCG2linezolid in dextrose 5%PAR; MO; CG; QLL(1800 per 30 days)

2linezolid oral suspension forreconstitution

PAR; QLL (56 per 28days)

5linezolid oral tablet


2lopinavir-ritonavir

MO; CG2mefloquineMO; CG2meropenemMO; CG2methenamine hippurateMO; CG2metronidazole in nacl (iso-os)MO; CG1metronidazole oralMO; CG1minocycline oral capsuleMO; CG2moderibaMO; CG2mondoxyne nl

4MONUROLMO; CG2morgidoxMO; CG2moxifloxacin oralCG2moxifloxacin-sod.ace,sul-waterCG2moxifloxacin-sod.chloride(iso)

5MYCAMINEMO; CG2nafcillin injection recon soln 1 gram, 2

gram5nafcillin injection recon soln 10 gram5nafcillin intravenous recon soln 1 gram





MO; CG2nafcillin intravenous recon soln 2 gramB/D PAR4NEBUPENTMO; CG1neomycinCG; QLL (1200 per 30days)

2nevirapine oral suspension


2nevirapine oral tablet

MO; CG2nevirapine oral tablet extended release24 hr 100 mg


2nevirapine oral tablet extended release24 hr 400 mg

PAR; MO; CG2nitrofurantoinPAR; MO; CG2nitrofurantoin macrocrystalPAR; MO; CG2nitrofurantoin monohyd/m-crystQLL (360 per 30 days)4NORVIR ORAL POWDER IN

PACKETMO; QLL (480 per 30days)

3NORVIR ORAL SOLUTION

MO; QLL (360 per 30days)

3NORVIR ORAL TABLET

5NOXAFIL INTRAVENOUSPAR5NOXAFIL ORALMO; CG1nystatin oral suspensionMO; CG1nystatin oral tabletQLL (30 per 30 days)5ODEFSEYCG2ofloxacin oral tablet 300 mgMO; CG2ofloxacin oral tablet 400 mgMO; CG2okebo oral capsule 75 mg





5ORBACTIVMO; CG2oseltamivirMO; CG1paromomycinMO; CG2paser

3PENICILLIN G POT INDEXTROSE INTRAVENOUSPIGGYBACK 1 MILLION UNIT/50ML, 2 MILLION UNIT/50 ML

MO3PENICILLIN G POT INDEXTROSE INTRAVENOUSPIGGYBACK 3 MILLION UNIT/50ML

MO; CG1penicillin g potassiumMO; CG1penicillin g sodiumMO; CG1penicillin v potassium

4PENTAMCG2pentamidineQLL (30 per 30 days)5PIFELTROMO; CG2piperacillin-tazobactam intravenous

recon soln 2.25 gram, 3.375 gram, 4.5gram, 40.5 gram

MO; CG2praziquantelQLL (30 per 30 days)5PREZCOBIXQLL (400 per 30 days)5PREZISTA ORAL SUSPENSIONQLL (180 per 30 days)4PREZISTA ORAL TABLET 150 MGQLL (60 per 30 days)5PREZISTA ORAL TABLET 600 MG,

800 MGQLL (300 per 30 days)4PREZISTA ORAL TABLET 75 MG





4PRIFTIN4PRIMAQUINE

MO; CG1pyrazinamidePAR; MO; CG2quinine sulfateQLL (60 per 180 days)4RELENZA DISKHALERQLL (180 per 30 days)4RESCRIPTOR ORAL TABLET

4RETROVIR INTRAVENOUSQLL (240 per 30 days)5REYATAZ ORAL POWDER IN

PACKETMO; CG2ribasphere oral capsule

5ribasphere oral tablet 600 mg5ribasphere ribapak oral tablets,dose pack

600-600 mg (28)-mg (28)MO; CG2ribavirin oral capsule

5ribavirin oral tablet 200 mgMO; CG2rifabutinMO; CG1rifampin

4RIFATERMO; CG2rimantadineMO; CG; QLL (360 per30 days)

2ritonavir

QLL (1840 per 30 days)5SELZENTRY ORAL SOLUTIONQLL (120 per 30 days)5SELZENTRY ORAL TABLET 150

MG, 300 MGQLL (120 per 30 days)4SELZENTRY ORAL TABLET 25

MGQLL (60 per 30 days)4SELZENTRY ORAL TABLET 75

MG





PAR; LA5SIRTUROPAR5SIVEXTRO INTRAVENOUSPAR; QLL (6 per 30days)

5SIVEXTRO ORAL


2stavudine oral capsule 15 mg, 20 mg


2stavudine oral capsule 30 mg, 40 mg

MO; CG1streptomycinQLL (30 per 30 days)5STRIBILDMO; CG2sulfadiazineMO; CG1sulfamethoxazole-trimethoprimMO; CG1sulfatrim

4SUPRAX ORAL CAPSULE4SUPRAX ORAL SUSPENSION FOR

RECONSTITUTION 500 MG/5 ML4SUPRAX ORAL TABLET,

CHEWABLEQLL (30 per 30 days)5SYMFIQLL (30 per 30 days)5SYMFI LOQLL (30 per 30 days)5SYMTUZAPAR; LA5SYNAGIS

5SYNERCID3TAZICEF INJECTION RECON

SOLN 1 GRAMMO3TAZICEF INJECTION RECON

SOLN 2 GRAM, 6 GRAMCG2TAZICEF INTRAVENOUS

5TEFLARO





QLL (30 per 30 days)5tenofovir disoproxil fumarateMO; CG1terbinafine hcl oralMO; CG2tetracycline

5TIGECYCLINEMO; CG2tinidazoleQLL (60 per 30 days)4TIVICAY ORAL TABLET 10 MGQLL (60 per 30 days)5TIVICAY ORAL TABLET 25 MG,

50 MGQLL (224 per 28 days)5TOBI PODHALER INHALATION

CAPSULE, W/INHALATIONDEVICE

B/D PAR; QLL (280 per28 days)

5tobramycin in 0.225% nacl fornebulization

5tobramycin sulfate injection recon solnMO; CG1tobramycin sulfate injection solution

4TRECATORMO; CG1trimethoprimQLL (30 per 30 days)5TRIUMEQQLL (10.64 per 28 days)5TROGARZOQLL (30 per 30 days)5TRUVADAMO; QLL (30 per 30days)

3TYBOST


2valacyclovir oral tablet 1 gram


2valacyclovir oral tablet 500 mg

5valganciclovir oral tablet





CG2vancomycin in 0.9 % sodium chlintravenous piggyback 500 mg/100 ml,750 mg/150 ml

MO; CG2vancomycin intravenous recon soln 1,000mg, 10 gram, 500 mg

CG2VANCOMYCIN INTRAVENOUSRECON SOLN 1.25 GRAM, 1.5GRAM, 250 MG


5vancomycin oral capsule 125 mg


5vancomycin oral capsule 250 mg


5VEMLIDY

QLL (1200 per 30 days)4VIDEX 2 GRAM PEDIATRICQLL (1200 per 30 days)4VIDEX 4 GRAM PEDIATRICQLL (90 per 30 days)4VIDEX EC ORAL CAPSULE,

DELAYED RELEASE(DR/EC) 125MG

QLL (300 per 30 days)5VIRACEPT ORAL TABLET 250 MGQLL (120 per 30 days)5VIRACEPT ORAL TABLET 625 MGQLL (1200 per 30 days)4VIRAMUNE ORAL SUSPENSIONQLL (240 per 30 days)5VIREAD ORAL POWDERQLL (30 per 30 days)5VIREAD ORAL TABLET 150 MG,

200 MG, 250 MGMO; CG2voriconazole intravenousPAR5voriconazole oral suspension for

reconstitutionPAR5voriconazole oral tablet 200 mg





PAR4VORICONAZOLE ORAL TABLET50 MG


5VOSEVI

PAR; QLL (9 per 3 days)4XIFAXAN ORAL TABLET 200 MGPAR; QLL (84 per 28days)

5XIFAXAN ORAL TABLET 550 MG

MO3XOFLUZAQLL (960 per 30 days)4ZIAGEN ORAL SOLUTIONMO; CG; QLL (180 per30 days)

2zidovudine oral capsule


2zidovudine oral syrup


2zidovudine oral tablet

Antineoplastic / Immunosuppressant DrugsPAR; QLL (120 per 30days)

5abiraterone

B/D PAR; CG2adriamycin intravenous recon soln 10mg

B/D PAR; CG2adriamycin intravenous solutionB/D PAR; CG2adrucil intravenous solution 2.5 gram/

50 mlB/D PAR; MO; CG2adrucil intravenous solution 5 gram/100

ml, 500 mg/10 mlPAR5AFINITORPAR5AFINITOR DISPERZPAR; QLL (240 per 30days)

5ALECENSA





PAR5ALIMTAPAR; LA5ALIQOPAPAR; QLL (30 per 30days)

5ALUNBRIG ORAL TABLET 180MG


5ALUNBRIG ORAL TABLET 30 MG


5ALUNBRIG ORAL TABLET 90 MG


5ALUNBRIG ORAL TABLETS,DOSEPACK


1anastrozole

B/D PAR5ARRANON5ARSENIC TRIOXIDE

PAR5ARZERRAB/D PAR4ASTAGRAF XLPAR5AVASTINPAR5azacitidineB/D PAR4AZASANB/D PAR; MO; CG1azathioprineB/D PAR; CG2azathioprine sodium solution for

injectionPAR; LA; QLL (90 per30 days)

5BALVERSA ORAL TABLET 3 MG

PAR; LA; QLL (60 per30 days)




PAR; LA5BAVENCIO





PAR5BELEODAQB/D PAR5BESPONSAPAR; QLL (300 per 30days)

5bexarotene


1bicalutamide

B/D PAR5BICNUB/D PAR; MO; CG2bleomycinPAR5BLINCYTO INTRAVENOUS KITPAR5BORTEZOMIBPAR; QLL (120 per 30days)

5BOSULIF ORAL TABLET 100 MG


5BOSULIF ORAL TABLET 400 MG,500 MG


5BRAFTOVI ORAL CAPSULE 50MG


5BRAFTOVI ORAL CAPSULE 75MG

B/D PAR; CG2busulfanB/D PAR4BUSULFEXPAR; LA; QLL (30 per30 days)

5CABOMETYX

PAR; LA5CALQUENCEPAR; LA; QLL (90 per30 days)

5CAPRELSA ORAL TABLET 100 MG


5CAPRELSA ORAL TABLET 300 MG

B/D PAR; MO; CG2carboplatin intravenous solutionB/D PAR5carmustine





B/D PAR; MO; CG2cisplatin intravenous solutionB/D PAR5cladribineB/D PAR5clofarabineB/D PAR5CLOLARPAR; QLL (56 per 28days)

5COMETRIQ ORAL CAPSULE 100MG/DAY(80 MG X1-20 MG X1)


5COMETRIQ ORAL CAPSULE 140MG/DAY(80 MG X1-20 MG X3)


5COMETRIQ ORAL CAPSULE 60MG/DAY (20 MG X 3/DAY)


5COPIKTRA


5COTELLIC

B/D PAR; MO; CG2cyclophosphamide oral capsuleB/D PAR; CG2cyclosporine intravenousB/D PAR; MO; CG2cyclosporine modifiedB/D PAR; MO; CG2cyclosporine oral capsulePAR5CYRAMZAB/D PAR; MO; CG2cytarabineB/D PAR; MO; CG2cytarabine (pf ) injection solution 100

mg/5 ml (20 mg/ml), 2 gram/20 ml (100mg/ml)

B/D PAR; CG2cytarabine (pf ) injection solution 20 mg/ml

B/D PAR; MO; CG2dacarbazineB/D PAR5dactinomycinPAR; LA5DARZALEX





B/D PAR; CG2daunorubicin intravenous solutionPAR; QLL (30 per 30days)

5DAURISMO ORAL TABLET 100MG


5DAURISMO ORAL TABLET 25MG

B/D PAR5decitabineB/D PAR5dexrazoxane hclB/D PAR5docetaxel intravenous solution 160 mg/

16 ml (10 mg/ml), 160 mg/8 ml (20 mg/ml), 20 mg/2 ml (10 mg/ml), 20 mg/ml(1 ml), 80 mg/4 ml (20 mg/ml), 80 mg/8 ml (10 mg/ml)

B/D PAR5DOCETAXEL INTRAVENOUSSOLUTION 20 MG/ML

B/D PAR; CG1doxorubicin intravenous recon soln 10mg

B/D PAR; MO; CG1doxorubicin intravenous recon soln 50mg

B/D PAR; MO; CG2doxorubicin intravenous solutionPAR5doxorubicin, peg-liposomal

4DROXIAPAR; QLL (1 per 28days)

4ELIGARD


4ELIGARD (3 MONTH)


4ELIGARD (4 MONTH)






4ELIGARD (6 MONTH)

PAR5ELITEK4EMCYT

PAR5EMPLICITIB/D PAR4ENVARSUS XRB/D PAR; MO; CG2epirubicin intravenous solutionPAR5ERBITUXPAR; QLL (30 per 30days)

5ERIVEDGE

PAR5ERLEADAPAR; QLL (30 per 30days)

5erlotinib oral tablet 100 mg, 150 mg


5erlotinib oral tablet 25 mg

PAR5ERWINAZEB/D PAR5ETOPOPHOSB/D PAR; MO; CG2etoposide intravenousB/D PAR5EVOMELAMO; CG; QLL (60 per30 days)

2exemestane

QLL (30 per 30 days)5FARESTONPAR; QLL (60 per 30days)

5FARYDAK ORAL CAPSULE 10 MG


5FARYDAK ORAL CAPSULE 15 MG,20 MG

PAR5FASLODEX






5FIRMAGON KIT W DILUENTSYRINGE SUBCUTANEOUSRECON SOLN 120 MG


4FIRMAGON KIT W DILUENTSYRINGE SUBCUTANEOUSRECON SOLN 80 MG

B/D PAR; MO; CG2fludarabine intravenous recon solnB/D PAR; MO; CG2fluorouracil intravenousMO; CG1flutamideB/D PAR5FOLOTYNPAR5fulvestrantPAR5GAZYVAB/D PAR; MO; CG2gemcitabine intravenous recon soln 1

gram, 200 mgB/D PAR5gemcitabine intravenous recon soln 2

gramB/D PAR5gemcitabine intravenous solution 1 gram/

26.3 ml (38 mg/ml), 2 gram/52.6 ml(38 mg/ml), 200 mg/5.26 ml (38 mg/ml)

B/D PAR; MO; CG2gengraf oral capsule 100 mg, 25 mgB/D PAR; MO; CG2gengraf oral solutionPAR; QLL (30 per 30days)

5GILOTRIF

PAR4GLEOSTINEPAR5HALAVENB/D PAR5HERCEPTIN HYLECTA





B/D PAR5HERCEPTIN INTRAVENOUSRECON SOLN 150 MG

MO; CG1hydroxyureaPAR; QLL (30 per 30days)

5IBRANCE


5ICLUSIG ORAL TABLET 15 MG


5ICLUSIG ORAL TABLET 45 MG

B/D PAR5idarubicinPAR; LA; QLL (30 per30 days)

5IDHIFA ORAL TABLET 100 MG


5IDHIFA ORAL TABLET 50 MG

B/D PAR; MO; CG2ifosfamide intravenous recon solnB/D PAR; MO; CG2ifosfamide intravenous solution 1 gram/

20 mlB/D PAR; CG2ifosfamide intravenous solution 3 gram/

60 mlPAR; QLL (240 per 30days)

5imatinib oral tablet 100 mg


5imatinib oral tablet 400 mg


5IMBRUVICA ORAL CAPSULE 140MG


5IMBRUVICA ORAL CAPSULE 70MG


5IMBRUVICA ORAL TABLET 140MG






5IMBRUVICA ORAL TABLET 280MG, 420 MG, 560 MG

PAR; LA5IMFINZIPAR; QLL (240 per 30days)

5INLYTA ORAL TABLET 1 MG


5INLYTA ORAL TABLET 5 MG

5IRESSAB/D PAR; MO; CG2irinotecan intravenous solution 100 mg/

5 ml, 40 mg/2 mlB/D PAR; CG2irinotecan intravenous solution 500 mg/

25 mlPAR5ISTODAXPAR5IXEMPRAPAR; QLL (150 per 30days)

5JAKAFI ORAL TABLET 10 MG









PAR5JEVTANAPAR5KADCYLAPAR5KEYTRUDA INTRAVENOUS

SOLUTIONPAR5KHAPZORY






5KISQALI FEMARA CO-PACKORAL TABLET 200 MG/DAY(200MG X 1)-2.5 MG






5KISQALI ORAL TABLET 200 MG/DAY (200 MG X 1)





PAR5KYPROLISPAR; LA5LARTRUVOPAR; QLL (30 per 30days)

5LENVIMA ORAL CAPSULE 10MG/DAY (10 MG X 1), 4 MG


5LENVIMA ORAL CAPSULE 12MG/DAY (4 MG X 3), 18 MG/DAY(10 MG X 1-4 MG X2), 24 MG/DAY(10 MG X 2-4 MG X 1)


5LENVIMA ORAL CAPSULE 14MG/DAY(10 MG X 1-4 MG X 1), 20MG/DAY (10 MG X 2), 8 MG/DAY(4 MG X 2)


1letrozole





B/D PAR; MO; CG1leucovorin calcium injection recon soln100 mg, 200 mg, 350 mg, 50 mg

B/D PAR; CG1leucovorin calcium injection recon soln500 mg

MO; CG1leucovorin calcium oral4LEUKERAN

PAR; MO; CG2leuprolide subcutaneous kitPAR; CG2levoleucovorin calcium intravenous recon

soln 50 mgPAR5levoleucovorin calcium intravenous

solutionPAR5LIBTAYOPAR5LONSURFPAR; QLL (30 per 30days)

5LORBRENA ORAL TABLET 100MG


5LORBRENA ORAL TABLET 25 MG

PAR5LUMOXITIPAR; QLL (1 per 28days)

5LUPRON DEPOT


5LUPRON DEPOT (3 MONTH)










5LUPRON DEPOT-PEDINTRAMUSCULAR KIT 11.25 MG,15 MG


5LYNPARZA ORAL TABLET

MO3LYSODREN5MARQIBO5MATULANE

PAR; CG2megestrol oral suspension 400 mg/10 ml(10 ml), 800 mg/20 ml (20 ml)

PAR; MO; CG2megestrol oral suspension 400 mg/10 ml(40 mg/ml), 625 mg/5 ml

PAR; MO; CG2megestrol oral tabletPAR; QLL (90 per 30days)

5MEKINIST ORAL TABLET 0.5 MG


5MEKINIST ORAL TABLET 2 MG


5MEKTOVI

B/D PAR; CG2melphalan hclMO; CG1mercaptopurinePAR; MO; CG2mesnaPAR4MESNEX ORALMO; CG1methotrexate sodiumCG1methotrexate sodium (pf ) injection recon

solnMO; CG1methotrexate sodium (pf ) injection

solution





B/D PAR4MITOMYCIN INTRAVENOUSRECON SOLN 20 MG, 5 MG

B/D PAR5mitomycin intravenous recon soln 40 mgB/D PAR; MO; CG1mitoxantroneB/D PAR; CG2mycophenolate mofetil hclB/D PAR; MO; CG2mycophenolate mofetil oral capsuleB/D PAR5mycophenolate mofetil oral suspension

for reconstitutionB/D PAR; MO; CG2mycophenolate mofetil oral tabletB/D PAR; MO; CG2mycophenolate sodiumPAR; LA5MYLOTARGPAR; LA; QLL (180 per30 days)

5NERLYNX


5NEXAVAR

QLL (30 per 30 days)5nilutamidePAR; QLL (3 per 28days)

5NINLARO

B/D PAR5NIPENTPAR5NULOJIXPAR4octreotide acetate injection solution 1,

000 mcg/mlPAR; MO; CG2octreotide acetate injection solution 100

mcg/ml, 200 mcg/ml, 50 mcg/mlPAR4OCTREOTIDE ACETATE

INJECTION SOLUTION 500MCG/ML






5ODOMZO

PAR5ONCASPARPAR5OPDIVOB/D PAR; MO; CG2oxaliplatin intravenous recon soln 100

mgB/D PAR; CG2oxaliplatin intravenous recon soln 50 mgB/D PAR; MO; CG2oxaliplatin intravenous solutionB/D PAR; MO; CG2paclitaxelPAR5PERJETAPAR; LA; QLL (120 per30 days)

5POMALYST ORAL CAPSULE 1 MG


5POMALYST ORAL CAPSULE 2 MG


5POMALYST ORAL CAPSULE 3MG, 4 MG

B/D PAR5POTELIGEOB/D PAR5PROGRAF INTRAVENOUSB/D PAR4PROGRAF ORAL GRANULES IN

PACKETPAR5PURIXANB/D PAR5RAPAMUNE ORAL SOLUTIONPAR; LA; QLL (60 per30 days)

5REVLIMID ORAL CAPSULE 10MG


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


5REVLIMID ORAL CAPSULE 5 MG

B/D PAR5RITUXAN





B/D PAR5RITUXAN HYCELAPAR5ROMIDEPSINPAR; LA; QLL (180 per30 days)

5RUBRACA ORAL TABLET 200 MG


5RUBRACA ORAL TABLET 250MG, 300 MG


5RYDAPT

PAR5SANDOSTATIN LAR DEPOTINTRAMUSCULAR SUSPENSION,EXTENDED REL RECON

PAR5SIGNIFORPAR; QLL (1 per 28days)

5SIGNIFOR LAR

B/D PAR5SIMULECTB/D PAR5sirolimus oral solutionB/D PAR; MO; CG2sirolimus oral tablet 0.5 mg, 1 mgB/D PAR4SIROLIMUS ORAL TABLET 2 MG

5SOLTAMOXPAR5SOMATULINE DEPOTPAR; QLL (30 per 30days)

5SPRYCEL


5STIVARGA


5SUTENT ORAL CAPSULE 12.5 MG


5SUTENT ORAL CAPSULE 25 MG,37.5 MG, 50 MG





PAR5SYLVANT INTRAVENOUSRECON SOLN 100 MG

PAR5SYNRIBO4TABLOID

B/D PAR; MO; CG2tacrolimus oral capsule 0.5 mg, 1 mgB/D PAR5tacrolimus oral capsule 5 mgPAR; QLL (120 per 30days)

5TAFINLAR


5TAGRISSO ORAL TABLET 40 MG


5TAGRISSO ORAL TABLET 80 MG


5TALZENNA ORAL CAPSULE 0.25MG


5TALZENNA ORAL CAPSULE 1 MG

MO; CG1tamoxifenPAR; QLL (30 per 30days)

5TARCEVA ORAL TABLET 100 MG,150 MG


5TARCEVA ORAL TABLET 25 MG


5TARGRETIN TOPICAL


5TASIGNA ORAL CAPSULE 150MG, 200 MG


5TASIGNA ORAL CAPSULE 50 MG






5TECENTRIQ INTRAVENOUSSOLUTION 1,200 MG/20 ML (60MG/ML)


5TECENTRIQ INTRAVENOUSSOLUTION 840 MG/14 ML (60MG/ML)

PAR5temsirolimusPAR; QLL (30 per 30days)

5THALOMID ORAL CAPSULE 100MG, 50 MG


5THALOMID ORAL CAPSULE 150MG, 200 MG

B/D PAR; MO; CG2thiotepaPAR; QLL (60 per 30days)

5TIBSOVO

B/D PAR; MO; CG2toposarB/D PAR5topotecanQLL (30 per 30 days)5toremifenePAR5TORISELB/D PAR5TREANDA INTRAVENOUS

RECON SOLNPAR; QLL (1 per 84days)

5TRELSTAR INTRAMUSCULARSUSPENSION FORRECONSTITUTION 11.25 MG









5tretinoin (chemotherapy)4TREXALL ORAL TABLET 10 MG,

15 MGB/D PAR5TRISENOX INTRAVENOUS

SOLUTION 2 MG/MLPAR; LA; QLL (180 per30 days)

5TYKERB

PAR5VECTIBIXPAR5VELCADEPAR; LA; QLL (60 per30 days)

4VENCLEXTA ORAL TABLET 10MG






5VENCLEXTA STARTING PACK


5VERZENIO

B/D PAR; MO; CG2vinblastine intravenous solutionB/D PAR; MO; CG2vincristineB/D PAR; MO; CG2vinorelbinePAR; LA; QLL (60 per30 days)

5VITRAKVI ORAL CAPSULE 100MG


5VITRAKVI ORAL CAPSULE 25 MG


5VITRAKVI ORAL SOLUTION






5VIZIMPRO ORAL TABLET 15 MG


5VIZIMPRO ORAL TABLET 30 MG,45 MG


5VOTRIENT

B/D PAR5VYXEOSPAR; QLL (60 per 30days)

5XALKORI

4XATMEPPAR; QLL (1.7 per 28days)

5XGEVA


5XOSPATA


5XTANDI

PAR5YERVOYB/D PAR5YONDELISPAR; QLL (120 per 30days)

5YONSA

PAR5ZALTRAPB/D PAR5ZANOSARPAR; LA; QLL (90 per30 days)

5ZEJULA


5ZELBORAF


5ZOLINZA

B/D PAR5ZORTRESS






5ZYDELIG


5ZYKADIA


5ZYTIGA ORAL TABLET 250 MG


5ZYTIGA ORAL TABLET 500 MG

Autonomic / Cns Drugs, Neurology / PsychQLL (1 per 28 days)5ABILIFY MAINTENAPAR; QLL (120 per 30days)

5ABSTRAL SUBLINGUAL TABLET200 MCG, 800 MCG

CG; QLL (900 per 30days)

1acetaminophen-codeine oral solution 120mg-12 mg /5 ml (5 ml), 240 mg-24 mg/10 ml (10 ml), 300 mg-30 mg /12.5ml


1acetaminophen-codeine oral solution120-12 mg/5 ml


1acetaminophen-codeine oral tablet


2almotriptan malate


2alprazolam


2alprazolam intensol

PAR; MO; CG2amitriptylinePAR; MO; CG2amitriptyline-chlordiazepoxidePAR; MO; CG1amoxapine






5AMPYRA

PAR; LA5APOKYNPAR; QLL (30 per 30days)

4APTENSIO XR

ST5APTIOMMO; CG; QLL (900 per30 days)

2aripiprazole oral solution


2aripiprazole oral tablet 10 mg





QLL (30 per 30 days)5aripiprazole oral tablet 20 mg, 30 mgMO; CG; QLL (180 per30 days)


QLL (90 per 30 days)5aripiprazole oral tablet,disintegrating 10mg

QLL (60 per 30 days)5aripiprazole oral tablet,disintegrating 15mg

QLL (4.8 per 365 days)5ARISTADA INITIOQLL (3.9 per 60 days)5ARISTADA INTRAMUSCULAR

SUSPENSION,EXTENDED RELSYRING 1,064 MG/3.9 ML

QLL (1.6 per 30 days)5ARISTADA INTRAMUSCULARSUSPENSION,EXTENDED RELSYRING 441 MG/1.6 ML







PAR; MO; CG; QLL (30per 30 days)

2armodafinil oral tablet 150 mg, 200 mg,250 mg


2armodafinil oral tablet 50 mg

PAR; MO; CG; QLL(180 per 30 days)

2ascomp with codeine


2atomoxetine oral capsule 10 mg, 18 mg,25 mg, 40 mg


2atomoxetine oral capsule 100 mg, 60 mg,80 mg


5AUBAGIO

MO; CG1baclofen oralPAR; QLL (2400 per 30days)

5BANZEL ORAL SUSPENSION


5BANZEL ORAL TABLET 200 MG


5BANZEL ORAL TABLET 400 MG


4BELBUCA

5benztropine injectionPAR; MO; CG1benztropine oral





PAR4BRIVIACT INTRAVENOUSPAR; QLL (600 per 30days)

5BRIVIACT ORAL SOLUTION


5BRIVIACT ORAL TABLET 10 MG


5BRIVIACT ORAL TABLET 100MG, 75 MG





MO; CG2bromocriptineMO; CG; QLL (240 per30 days)

2buprenorphine hcl sublingual tablet 2mg


2buprenorphine hcl sublingual tablet 8mg


2buprenorphine transdermal patch weekly10 mcg/hour, 15 mcg/hour, 20 mcg/hour,5 mcg/hour


4BUPRENORPHINETRANSDERMAL PATCH WEEKLY7.5 MCG/HOUR


2buprenorphine-naloxone sublingualtablet 2-0.5 mg


2buprenorphine-naloxone sublingualtablet 8-2 mg


1bupropion hcl oral tablet 100 mg






1bupropion hcl oral tablet 75 mg


1bupropion hcl oral tablet extended release24 hr 150 mg


1bupropion hcl oral tablet extended release24 hr 300 mg


1bupropion hcl oral tablet sustained-release 12 hr 100 mg


1bupropion hcl oral tablet sustained-release 12 hr 150 mg, 200 mg

MO; CG1buspironePAR; MO; CG; QLL(180 per 30 days)

2butalbital compound w/codeine


1butalbital-acetaminophen oral tablet 50-325 mg


1butalbital-acetaminophen-caff oral tablet50-325-40 mg


2butorphanol tartrate injection solution1 mg/ml


2butorphanol tartrate injection solution2 mg/ml


2butorphanol tartrate nasal

PAR4BUTRANS TRANSDERMALPATCH WEEKLY 7.5 MCG/HOUR

MO; CG2carbamazepine oral capsule, ermultiphase 12 hr





MO; CG1carbamazepine oral suspension 100 mg/5 ml

CG1carbamazepine oral suspension 200 mg/10 ml

MO; CG1carbamazepine oral tabletMO; CG2carbamazepine oral tablet extended

release 12 hrMO; CG1carbamazepine oral tablet,chewable

4CARBATROL5carbidopa

MO; CG1carbidopa-levodopa oral tabletMO; CG1carbidopa-levodopa oral tablet extended

releaseMO; CG2carbidopa-levodopa-entacaponePAR; MO; CG2carisoprodol oral tablet 250 mgPAR; MO; CG2celecoxib

4CELONTIN ORAL CAPSULE 300MG

4CEREBYX INJECTIONSOLUTION 500 MG PE/10 ML


2chlordiazepoxide hcl

MO; CG1chlorpromazineCG2chlorzoxazone oral tablet 250 mgPAR; MO; CG2chlorzoxazone oral tablet 500 mgMO; CG; QLL (600 per30 days)

1citalopram oral solution






1citalopram oral tablet 10 mg






5clobazam oral suspension


2clobazam oral tablet 10 mg


5clobazam oral tablet 20 mg

PAR; MO; CG2clomipramineMO; CG; QLL (1200 per30 days)

1clonazepam oral tablet 0.5 mg


1clonazepam oral tablet 1 mg


1clonazepam oral tablet 2 mg


2clonazepam oral tablet,disintegrating0.125 mg


2clonazepam oral tablet,disintegrating0.25 mg


2clonazepam oral tablet,disintegrating 0.5mg


2clonazepam oral tablet,disintegrating 1mg


2clonazepam oral tablet,disintegrating 2mg





MO; CG2clorazepate dipotassiumMO; CG; QLL (270 per30 days)

2clozapine oral tablet 100 mg








2clozapine oral tablet,disintegrating 100mg


2clozapine oral tablet,disintegrating 12.5mg

QLL (180 per 30 days)5clozapine oral tablet,disintegrating 150mg

QLL (120 per 30 days)5CLOZAPINE ORAL TABLET,DISINTEGRATING 200 MG


2clozapine oral tablet,disintegrating 25mg


2codeine sulfate oral tablet

PAR; CG; QLL (180 per30 days)

2codeine-butalbital-asa-caff


5COPAXONE SUBCUTANEOUSSYRINGE 40 MG/ML

PAR; MO; CG2cyclobenzaprine oral tabletPAR; QLL (60 per 30days)

5dalfampridine





MO; CG2dantroleneQLL (30 per 30 days)4DAYTRANAPAR; MO; CG2desipramineMO; CG; QLL (120 per30 days)

2desvenlafaxine succinate oral tabletextended release 24 hr 100 mg






2dexmethylphenidate oral capsule,erbiphasic 50-50 10 mg, 15 mg, 25 mg,30 mg, 35 mg, 40 mg, 5 mg


2dexmethylphenidate oral capsule,erbiphasic 50-50 20 mg


1dexmethylphenidate oral tablet


2dextroamphetamine oral capsule,extended release 10 mg, 5 mg


2dextroamphetamine oral capsule,extended release 15 mg


1dextroamphetamine oral solution


1dextroamphetamine oral tablet 10 mg


1dextroamphetamine oral tablet 5 mg


2dextroamphetamine-amphetamine oralcapsule,extended release 24hr






1dextroamphetamine-amphetamine oraltablet 10 mg, 12.5 mg, 15 mg, 20 mg,5 mg, 7.5 mg


1dextroamphetamine-amphetamine oraltablet 30 mg

4DIASTAT5DIASTAT ACUDIAL RECTAL KIT

12.5-15-17.5-20 MG4DIASTAT ACUDIAL RECTAL KIT

5-7.5-10 MGMO; CG; QLL (1200 per30 days)

2diazepam oral solution 5 mg/5 ml (1 mg/ml)


2diazepam oral solution 5 mg/5 ml (1 mg/ml, 5 ml)


2diazepam oral tablet 10 mg





MO; CG2diazepam rectalPAR; QLL (60 per 30days)

4DICLOFENAC EPOLAMINE

MO; CG1diclofenac potassiumMO; CG1diclofenac sodium oralMO; CG; QLL (300 per30 days)

2diclofenac sodium topical drops






2diclofenac sodium topical gel 1 %

MO; CG2diclofenac-misoprostolMO; CG1diflunisalPAR5dihydroergotamine injectionQLL (8 per 28 days)5dihydroergotamine nasal

4DILANTIN EXTENDED ORALCAPSULE 100 MG

4DILANTIN INFATABS4DILANTIN ORAL CAPSULE 30

MG4DILANTIN-125

MO; CG1divalproexMO; CG; QLL (30 per30 days)

1donepezil

PAR; MO; CG2doxepin oralMO; CG; QLL (180 per30 days)

2duloxetine oral capsule,delayed release(dr/ec) 20 mg








2duramorph (pf ) injection solution 0.5mg/ml


1duramorph (pf ) injection solution 1 mg/ml





CG1ec-naproxenMO; CG; QLL (9 per 30days)

2eletriptan


5EMSAM


1endocet oral tablet 10-325 mg, 2.5-325mg, 5-325 mg, 7.5-325 mg

MO; CG2entacaponePAR; LA5EPIDIOLEXMO; CG1epitolQLL (480 per 30 days)4EQUETRO ORAL CAPSULE, ER

MULTIPHASE 12 HR 100 MGQLL (240 per 30 days)4EQUETRO ORAL CAPSULE, ER

MULTIPHASE 12 HR 200 MGQLL (180 per 30 days)4EQUETRO ORAL CAPSULE, ER

MULTIPHASE 12 HR 300 MGPAR; MO; CG2ergoloidMO; CG; QLL (600 per30 days)

1escitalopram oxalate oral solution


1escitalopram oxalate oral tablet 10 mg





MO; CG2ethosuximideMO; CG1etodolac oral capsuleMO; CG1etodolac oral tablet





MO; CG2etodolac oral tablet extended release 24hr

ST; QLL (720 per 30days)

4FANAPT ORAL TABLET 1 MG

ST; QLL (60 per 30 days)5FANAPT ORAL TABLET 10 MG,12 MG







ST; QLL (90 per 30 days)5FANAPT ORAL TABLET 8 MGST; QLL (16 per 365days)

4FANAPT ORAL TABLETS,DOSEPACK

QLL (180 per 30 days)4FAZACLO ORAL TABLET,DISINTEGRATING 150 MG

QLL (120 per 30 days)5FAZACLO ORAL TABLET,DISINTEGRATING 200 MG

MO; CG2felbamate4FENOPROFEN ORAL CAPSULE

400 MGMO; CG1fenoprofen oral tabletPAR; QLL (120 per 30days)

5fentanyl citrate buccal lozenge on ahandle


2fentanyl transdermal


5FENTORA






4FETZIMA ORAL CAPSULE,EXTREL 24HR DOSE PACK


4FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR 120MG, 80 MG


4FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR 20MG


4FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR 40MG


4FLECTOR


1fluoxetine oral capsule 10 mg






1fluoxetine oral solution


1fluoxetine oral tablet 10 mg





MO; CG1fluphenazine decanoateMO; CG1fluphenazine hcl injection





MO; CG1fluphenazine hcl oral elixirMO; CG1fluphenazine hcl oral tabletMO; CG1flurbiprofenMO; CG; QLL (90 per30 days)

1fluvoxamine oral capsule,extended release24hr 100 mg


1fluvoxamine oral capsule,extended release24hr 150 mg


1fluvoxamine oral tablet 100 mg





MO; CG2fosphenytoinMO; CG; QLL (12 per30 days)

2frovatriptan

QLL (720 per 30 days)4FYCOMPA ORAL SUSPENSIONQLL (30 per 30 days)4FYCOMPA ORAL TABLET 10 MG,

12 MGQLL (180 per 30 days)4FYCOMPA ORAL TABLET 2 MGQLL (90 per 30 days)5FYCOMPA ORAL TABLET 4 MGQLL (60 per 30 days)4FYCOMPA ORAL TABLET 6 MGQLL (45 per 30 days)5FYCOMPA ORAL TABLET 8 MGMO; CG; QLL (1080 per30 days)

1gabapentin oral capsule 100 mg










1gabapentin oral solution 250 mg/5 ml


1gabapentin oral solution 250 mg/5 ml(5 ml), 300 mg/6 ml (6 ml)


1gabapentin oral tablet 600 mg


1gabapentin oral tablet 800 mg


2galantamine oral capsule,ext rel. pellets24 hr


2galantamine oral solution


2galantamine oral tablet

QLL (6 per 28 days)4GEODON INTRAMUSCULARPAR; QLL (30 per 30days)

5GILENYA ORAL CAPSULE 0.5 MG


5glatiramer subcutaneous syringe 40 mg/ml


5glatopa subcutaneous syringe 20 mg/ml


5glatopa subcutaneous syringe 40 mg/ml


2guanfacine oral tablet extended release24 hr

MO; CG1guanidineMO; CG1haloperidolMO; CG1haloperidol decanoate





MO; CG1haloperidol lactate injectionCG1haloperidol lactate intramuscularMO; CG1haloperidol lactate oralPAR; QLL (30 per 30days)

5HETLIOZ


1hydrocodone-acetaminophen oral solution7.5-325 mg/15 ml


1hydrocodone-acetaminophen oral tablet10-300 mg, 10-325 mg, 2.5-325 mg,5-300 mg, 5-325 mg, 7.5-300 mg, 7.5-325 mg


1hydrocodone-ibuprofen oral tablet 10-200 mg, 5-200 mg, 7.5-200 mg

MO; CG1hydromorphone (pf ) injection solution10 (mg/ml) (5 ml), 10 mg/ml


2hydromorphone (pf ) injection solution 2mg/ml


1hydromorphone injection solution 1 mg/ml






1hydromorphone oral liquid


1hydromorphone oral tablet






2hydromorphone oral tablet extendedrelease 24 hr 12 mg, 8 mg


5hydromorphone oral tablet extendedrelease 24 hr 16 mg, 32 mg

MO; CG1ibuCG2ibuprofen lysine (pf )MO; CG1ibuprofen oral suspensionMO; CG1ibuprofen oral tablet 400 mg, 600 mg,

800 mgMO; CG; QLL (28 per 7days)

2ibuprofen-oxycodone

PAR; MO; CG2imipramine hclPAR; MO; CG2imipramine pamoateQLL (0.75 per 28 days)5INVEGA SUSTENNA

INTRAMUSCULAR SYRINGE 117MG/0.75 ML

QLL (1 per 28 days)5INVEGA SUSTENNAINTRAMUSCULAR SYRINGE 156MG/ML

QLL (1.5 per 28 days)5INVEGA SUSTENNAINTRAMUSCULAR SYRINGE 234MG/1.5 ML







QLL (0.875 per 90 days)5INVEGA TRINZAINTRAMUSCULAR SYRINGE 273MG/0.875 ML




MO; CG1ketoprofen oral capsule 25 mg, 75 mgCG1ketoprofen oral capsule 50 mgMO; CG2ketoprofen oral capsule,ext rel. pellets 24

hr 200 mgPAR; MO; CG2ketorolac injection cartridge 30 mg/mlPAR; MO; CG2ketorolac injection solution 15 mg/ml,

30 mg/ml (1 ml)PAR; MO; CG2ketorolac intramuscular cartridgePAR; MO; CG2ketorolac intramuscular solutionPAR; CG2ketorolac intramuscular syringePAR; MO; CG2ketorolac oralPAR; QLL (120 per 30days)

5KEVEYIS


4KHEDEZLA ORAL TABLETEXTENDED RELEASE 24HR 100MG






4KHEDEZLA ORAL TABLETEXTENDED RELEASE 24HR 50MG

4LAMICTAL STARTER (BLUE) KIT5LAMICTAL STARTER (GREEN)

KIT4LAMICTAL STARTER (ORANGE)

KITMO; CG1lamotrigine oral tabletMO; CG2lamotrigine oral tablet extended release

24hrMO; CG1lamotrigine oral tablet, chewable

dispersibleMO; CG2lamotrigine oral tablet,disintegratingMO; CG2lamotrigine oral tablets,dose packPAR; QLL (30 per 30days)

5LATUDA ORAL TABLET 120 MG,60 MG


5LATUDA ORAL TABLET 20 MG






5LAZANDA

CG2levetiracetam in nacl (iso-os) intravenouspiggyback 1,000 mg/100 ml, 1,500 mg/100 ml





5levetiracetam in nacl (iso-os) intravenouspiggyback 500 mg/100 ml

MO; CG2levetiracetam intravenousMO; CG1levetiracetam oral solution 100 mg/mlCG1levetiracetam oral solution 500 mg/5 ml

(5 ml)MO; CG1levetiracetam oral tabletMO; CG; QLL (180 per30 days)

2levetiracetam oral tablet extended release24 hr 500 mg


2levetiracetam oral tablet extended release24 hr 750 mg

MO; CG1lithium carbonateMO3lithium citrate oral solution 8 meq/5 mlMO; CG2lorazepam intensolMO; CG2lorazepam oralMO; CG; QLL (180 per30 days)

1lorcet (hydrocodone)


1lorcet hd


1lorcet plus oral tablet 7.5-325 mg

MO; CG2loxapine succinatePAR; MO; QLL (180 per30 days)

3LYRICA ORAL CAPSULE 100 MG

PAR; MO; QLL (120 per30 days)









3LYRICA ORAL CAPSULE 225 MG,300 MG








3LYRICA ORAL SOLUTION


2maprotiline oral tablet 25 mg


2maprotiline oral tablet 50 mg

MO; CG2maprotiline oral tablet 75 mg4MARPLAN

MO; CG2meclofenamateMO; CG2mefenamic acidMO; CG1meloxicam oral tabletPAR; MO; CG; QLL (30per 30 days)

2memantine oral capsule,sprinkle,er 24hr


2memantine oral solution


2memantine oral tablet 10 mg


2memantine oral tablet 5 mg


2memantine oral tablets,dose pack






2meperidine oral tablet

PAR; MO; CG2meprobamate5MESTINON ORAL SYRUP


2metadate er

PAR; MO; CG2metaxalone oral tablet 800 mgCG; QLL (30 per 30days)

1methadone injection solution


1methadone oral solution


1methadone oral tablet


5methamphetamine


2methylphenidate hcl oral capsule, erbiphasic 30-70


2methylphenidate hcl oral capsule,erbiphasic 50-50 10 mg, 20 mg, 40 mg,60 mg


2methylphenidate hcl oral capsule,erbiphasic 50-50 30 mg


2methylphenidate hcl oral solution 10 mg/5 ml


2methylphenidate hcl oral solution 5 mg/5 ml


1methylphenidate hcl oral tablet






2methylphenidate hcl oral tablet extendedrelease 20 mg


2methylphenidate hcl oral tablet extendedrelease 24hr 18 mg, 27 mg, 54 mg


2methylphenidate hcl oral tablet extendedrelease 24hr 36 mg

MO; CG2methylphenidate hcl oral tablet,chewable5migergot


1mirtazapine oral tablet 15 mg






1mirtazapine oral tablet 7.5 mg


2mirtazapine oral tablet,disintegrating 15mg






2modafinil oral tablet 100 mg


2modafinil oral tablet 200 mg

CG2molindone






1morphine (pf ) injection solution 0.5 mg/ml


1morphine (pf ) injection solution 1 mg/ml


1morphine (pf ) intravenous patientcontrol.analgesia soln 30 mg/30 ml


1morphine concentrate oral solution


2morphine oral capsule, er multiphase 24hr


2morphine oral capsule,extend.releasepellets 10 mg, 20 mg, 30 mg, 50 mg, 60mg, 80 mg


5morphine oral capsule,extend.releasepellets 100 mg


1morphine oral solution


1morphine oral tablet


2morphine oral tablet extended release100 mg, 200 mg


2morphine oral tablet extended release 15mg, 30 mg, 60 mg

MO; CG1nabumetoneMO; CG; QLL (60 per30 days)

1nalbuphine injection solution 10 mg/ml


1nalbuphine injection solution 20 mg/ml





MO; CG1nalfon oral capsule 400 mgMO; CG1naloxoneMO; CG2naltrexoneMO; CG1naproxenMO; CG1naproxen sodium oral tablet 275 mg,

550 mgMO; CG1naproxen sodium oral tablet, er

multiphase 24 hr 375 mgMO; CG; QLL (9 per 30days)

1naratriptan

MO3NARCAN NASAL SPRAY,NON-AEROSOL 4 MG/ACTUATION


2nefazodone oral tablet 100 mg










4NEUPRO

PAR; MO; CG1nortriptyline oral capsulePAR; MO; CG1NORTRIPTYLINE ORAL

SOLUTION






4NUCYNTA ER ORAL TABLETEXTENDED RELEASE 12 HR 100MG, 50 MG


5NUCYNTA ER ORAL TABLETEXTENDED RELEASE 12 HR 150MG, 200 MG, 250 MG

QLL (181 per 30 days)4NUCYNTA ORAL TABLET 100MG, 50 MG

QLL (242 per 30 days)4NUCYNTA ORAL TABLET 75 MGPAR; MO; QLL (60 per30 days)

3NUEDEXTA


5NUPLAZID ORAL CAPSULE


5NUPLAZID ORAL TABLET 10 MG


2olanzapine intramuscular


1olanzapine oral tablet 10 mg




1olanzapine oral tablet 2.5 mg






1olanzapine oral tablet 7.5 mg






2olanzapine oral tablet,disintegrating 10mg








2olanzapine-fluoxetine oral capsule 12-25mg, 12-50 mg, 6-50 mg


2olanzapine-fluoxetine oral capsule 3-25mg, 6-25 mg


5ONFI ORAL SUSPENSION


5ONFI ORAL TABLET 10 MG


5ONFI ORAL TABLET 20 MG

PAR; MO; CG2orphenadrine citrateMO; CG1oxaprozinMO; CG; QLL (120 per30 days)

2oxazepam

MO; CG1oxcarbazepineMO; CG; QLL (180 per30 days)

1oxycodone oral capsule


2oxycodone oral concentrate






1oxycodone oral solution


1oxycodone oral tablet


2oxycodone oral tablet,oral only,ext.rel.12hr 10 mg, 20 mg, 40 mg

PAR; CG; QLL (60 per30 days)

2oxycodone oral tablet,oral only,ext.rel.12hr 15 mg, 30 mg, 60 mg


5OXYCODONE ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 80MG


1oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg


1oxycodone-aspirin


4OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 10MG, 15 MG, 20 MG, 30 MG, 40MG


5OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 60MG, 80 MG


2oxymorphone oral tablet


2oxymorphone oral tablet extended release12 hr


2paliperidone oral tablet extended release24hr 1.5 mg






2paliperidone oral tablet extended release24hr 3 mg

QLL (60 per 30 days)5paliperidone oral tablet extended release24hr 6 mg

QLL (30 per 30 days)5paliperidone oral tablet extended release24hr 9 mg


1paroxetine hcl oral tablet 10 mg








2paroxetine hcl oral tablet extended release24 hr 12.5 mg


2paroxetine hcl oral tablet extended release24 hr 25 mg


2paroxetine hcl oral tablet extended release24 hr 37.5 mg

QLL (900 per 30 days)4PAXIL ORAL SUSPENSION4PEGANONE5PENNSAID TOPICAL SOLUTION

IN METERED-DOSE PUMPMO; CG1perphenazinePAR; MO; CG2perphenazine-amitriptylineQLL (1 per 28 days)5PERSERISMO; CG1phenelzine






1phenobarbital oral elixir


1phenobarbital oral tablet 100 mg




1phenobarbital oral tablet 16.2 mg











4PHENYTEKCG1phenytoin oral suspension 100 mg/4 mlMO; CG1phenytoin oral suspension 125 mg/5 mlMO; CG1phenytoin oral tablet,chewableMO; CG1phenytoin sodium extendedMO; CG1phenytoin sodium intravenous solutionMO; CG2pimozideMO; CG1piroxicamMO; CG1pramipexole oral tablet





MO; CG2pramipexole oral tablet extended release24 hr

MO; CG1primidoneMO; CG; QLL (1920 per30 days)

1procentra

PAR; MO; CG2protriptyline5pyridostigmine bromide oral syrup

MO; CG1pyridostigmine bromide oral tablet 60mg

MO; CG2pyridostigmine bromide oral tabletextended release


1quetiapine oral tablet 100 mg












2quetiapine oral tablet extended release24 hr 150 mg













MO; CG2rasagilinePAR; QLL (60 per 30days)

5REXULTI ORAL TABLET 0.25 MG,0.5 MG, 1 MG, 2 MG


5REXULTI ORAL TABLET 3 MG, 4MG

QLL (2 per 28 days)4RISPERDAL CONSTAINTRAMUSCULAR SYRINGE 12.5MG/2 ML, 25 MG/2 ML

QLL (2 per 28 days)5RISPERDAL CONSTAINTRAMUSCULAR SYRINGE 37.5MG/2 ML, 50 MG/2 ML


1risperidone oral solution


1risperidone oral tablet 0.25 mg


1risperidone oral tablet 0.5 mg


1risperidone oral tablet 1 mg












2risperidone oral tablet,disintegrating0.25 mg


2risperidone oral tablet,disintegrating 0.5mg


2risperidone oral tablet,disintegrating 1mg








2rivastigmine tartrate


2rivastigmine transdermal


2rizatriptan

MO; CG1ropinirole oral tabletMO; CG2ropinirole oral tablet extended release 24

hrMO; CG1roweepra oral tablet 500 mgQLL (30 per 30 days)4ROZEREMPAR; LA; QLL (180 per30 days)

5SABRIL





QLL (60 per 30 days)5SAPHRIS SUBLINGUAL TABLET10 MG

QLL (240 per 30 days)4SAPHRIS SUBLINGUAL TABLET2.5 MG

QLL (120 per 30 days)4SAPHRIS SUBLINGUAL TABLET5 MG

MO; CG2selegiline hclMO; CG; QLL (300 per30 days)

1sertraline oral concentrate


1sertraline oral tablet 100 mg






4SPRITAM ORAL TABLET FORSUSPENSION 1,000 MG, 250 MG,500 MG


4SPRITAM ORAL TABLET FORSUSPENSION 750 MG

MO; CG1sulindacMO; CG2sumatriptan nasal sprayMO; CG; QLL (9 per 30days)

1sumatriptan succinate oral

MO; CG2sumatriptan succinate subcutaneouscartridge

MO; CG2sumatriptan succinate subcutaneous peninjector





MO; CG2sumatriptan succinate subcutaneoussolution


5SYMPAZAN ORAL FILM 10 MG,20 MG


4SYMPAZAN ORAL FILM 5 MG

PAR; LA5TECFIDERA4TEGRETOL ORAL SUSPENSION4TEGRETOL ORAL TABLET4TEGRETOL XR


2temazepam


1tencon oral tablet 50-325 mg


5tetrabenazine oral tablet 12.5 mg


5tetrabenazine oral tablet 25 mg

ST; MO; CG2thioridazineMO; CG1thiothixeneMO; CG2tiagabineMO; CG2tizanidine oral capsuleMO; CG1tizanidine oral tabletPAR; QLL (180 per 30days)

5tolcapone

MO; CG2tolmetinPAR; MO; CG1topiramate oral capsule, sprinkle






1topiramate oral tablet 100 mg








1tramadol oral tablet


2tramadol oral tablet extended release 24hr


2tramadol oral tablet, er multiphase 24hr


1tramadol-acetaminophen

MO; CG2tranylcypromineMO; CG1trazodone oral tablet 100 mg, 150 mg,

50 mgMO; CG2trazodone oral tablet 300 mgMO; CG; QLL (30 per30 days)

1triazolam

MO; CG1trifluoperazinePAR; MO; CG1trihexyphenidylPAR; MO; CG2trimipramineST; QLL (60 per 30 days)4TRINTELLIX ORAL TABLET 10

MG





ST; QLL (30 per 30 days)4TRINTELLIX ORAL TABLET 20MG


4TRINTELLIX ORAL TABLET 5 MG

PAR4TROKENDI XR ORAL CAPSULE,EXTENDED RELEASE 24HR 100MG, 25 MG, 50 MG

PAR5TROKENDI XR ORAL CAPSULE,EXTENDED RELEASE 24HR 200MG

PAR; LA5TYSABRIMO; CG1valproate sodiumMO; CG1valproic acidMO; CG1valproic acid (as sodium salt) oral

solution 250 mg/5 mlCG1valproic acid (as sodium salt) oral

solution 250 mg/5 ml (5 ml), 500 mg/10 ml (10 ml)


1venlafaxine oral capsule,extended release24hr 150 mg


1venlafaxine oral capsule,extended release24hr 37.5 mg


1venlafaxine oral capsule,extended release24hr 75 mg


1venlafaxine oral tablet 100 mg








1venlafaxine oral tablet 37.5 mg






2venlafaxine oral tablet extended release24hr 150 mg




2venlafaxine oral tablet extended release24hr 37.5 mg



QLL (600 per 30 days)4VERSACLOZMO; CG; QLL (180 per30 days)

1vicodin


1vicodin es


1vicodin hp


5vigabatrin oral powder in packet


5vigabatrin oral tablet


4VIIBRYD ORAL TABLET 10 MG

ST; QLL (60 per 30 days)4VIIBRYD ORAL TABLET 20 MGST; QLL (30 per 30 days)4VIIBRYD ORAL TABLET 40 MG





ST; QLL (30 per 30 days)4VIIBRYD ORAL TABLETS,DOSEPACK 10 MG (7)- 20 MG (23)

QLL (1200 per 30 days)4VIMPAT INTRAVENOUSQLL (1200 per 30 days)5VIMPAT ORAL SOLUTIONQLL (120 per 30 days)4VIMPAT ORAL TABLET 100 MGQLL (60 per 30 days)4VIMPAT ORAL TABLET 150 MGQLL (60 per 30 days)5VIMPAT ORAL TABLET 200 MGQLL (240 per 30 days)4VIMPAT ORAL TABLET 50 MG

4VIVLODEXPAR; QLL (30 per 30days)

5VRAYLAR ORAL CAPSULE


4VRAYLAR ORAL CAPSULE,DOSEPACK

QLL (30 per 30 days)4VYVANSE ORAL CAPSULEPAR; LA; QLL (540 per30 days)

5XYREM


2zaleplon oral capsule 10 mg


2zaleplon oral capsule 5 mg

5ZELAPARPAR; MO; CG; QLL(180 per 30 days)

1zenzedi oral tablet 10 mg


1zenzedi oral tablet 5 mg


2ziprasidone hcl oral capsule 20 mg


2ziprasidone hcl oral capsule 40 mg






2ziprasidone hcl oral capsule 60 mg, 80mg


2zolmitriptan


2zolpidem

4ZOMIG NASALMO; CG1zonisamideQLL (2 per 28 days)4ZYPREXA RELPREVV

INTRAMUSCULAR SUSPENSIONFOR RECONSTITUTION 210 MG

QLL (2 per 28 days)5ZYPREXA RELPREVVINTRAMUSCULAR SUSPENSIONFOR RECONSTITUTION 300 MG,405 MGCardiovascular, Hypertension / Lipids

MO; CG1acebutololCG1afeditab cr

4ALDACTAZIDE ORAL TABLET50-50 MG

MO; CG2aliskirenPAR4ALTOPREVMO; CG1amilorideMO; CG1amiloride-hydrochlorothiazideMO; CG1amiodarone oralMO; CG1amlodipine besylate tabletMO; CG2amlodipine-atorvastatinMO; CG1amlodipine-benazepril





MO; CG2amlodipine-olmesartanMO; CG2amlodipine-valsartanMO; CG2amlodipine-valsartan-

hydrochlorothiazideST; MO; CG; QLL (60per 30 days)

2aspirin-dipyridamole

MO; CG1atenololMO; CG1atenolol-chlorthalidoneMO; CG1atorvastatinMO; CG1benazeprilMO; CG1benazepril-hydrochlorothiazideMO; CG1betaxolol oralMO; QLL (180 per 30days)

3BIDIL

MO; CG1bisoprolol fumarateMO; CG1bisoprolol-hydrochlorothiazideMO; QLL (60 per 30days)

3BRILINTA

MO; CG1bumetanideST4BYSTOLICMO; CG1candesartanMO; CG1candesartan-hydrochlorothiazideMO; CG1captoprilMO; CG1captopril-hydrochlorothiazide

4CARDIZEM LA ORAL TABLETEXTENDED RELEASE 24 HR 120MG

MO; CG1cartia xt





MO; CG1carvedilolMO; CG1chlorothiazideMO; CG1chlorthalidone oral tablet 25 mg, 50 mgMO; CG1cholestyramine lightMO; CG1cilostazolMO; CG1clonidine hcl oral tabletMO; CG; QLL (4 per 28days)

2clonidine transdermal patch


1clopidogrel oral tablet 300 mg


1clopidogrel oral tablet 75 mg

MO; CG2colesevelam oral tabletMO; CG1colestipolPAR; QLL (60 per 30days)

4CORLANOR

MO3COUMADIN ORAL5DEMSER4DIBENZYLINE

MO; CG1digitek oral tablet 125 mcgPAR; MO; CG1digitek oral tablet 250 mcgMO; CG1digox oral tablet 125 mcgPAR; MO; CG1digox oral tablet 250 mcgPAR; MO; CG2digoxin injection solutionMO3digoxin oral solution 50 mcg/mlMO; CG1digoxin oral tablet 125 mcgPAR; MO; CG1digoxin oral tablet 250 mcg

4DILATRATE-SR





MO; CG1dilt-xrMO; CG1diltiazem hcl oral capsule,ext.rel 24h

degradableMO; CG1diltiazem hcl oral capsule,extended

release 12 hrMO; CG1diltiazem hcl oral capsule,extended

release 24 hrMO; CG1diltiazem hcl oral capsule,extended

release 24hrMO; CG1diltiazem hcl oral tabletMO; CG2diltiazem hcl oral tablet extended release

24 hrPAR; MO; CG2disopyramide phosphate oral capsuleMO; CG2dofetilideMO; CG1doxazosin

4DUTOPROL4DYRENIUM4EDARBI


3ELIQUIS ORAL TABLET 2.5 MG


3ELIQUIS ORAL TABLET 5 MG


3ELIQUIS ORAL TABLETS,DOSEPACK

MO; CG1enalapril maleateMO; CG1enalapril-hydrochlorothiazideMO; CG; QLL (84 per28 days)

2enoxaparin subcutaneous solution






2enoxaparin subcutaneous syringe 100mg/ml, 150 mg/ml

MO; CG; QLL (22.4 per28 days)

1enoxaparin subcutaneous syringe 120mg/0.8 ml


2enoxaparin subcutaneous syringe 30 mg/0.3 ml







PAR4ENTRESTOMO; CG2eplerenoneMO; CG1eprosartanCG1ethacrynate sodiumMO; CG2ethacrynic acidMO; CG2ezetimibePAR; MO; CG; QLL (30per 30 days)

2ezetimibe-simvastatin

MO; CG1felodipineMO; CG1fenofibrate micronizedMO; CG1fenofibrate nanocrystallized oral tablet

145 mg, 48 mgMO3fenofibrate oral capsule

4FENOFIBRATE ORAL TABLET 120MG

MO; CG1fenofibrate oral tablet 160 mg, 54 mg





MO; CG2fenofibrate oral tablet 40 mgMO; CG1fenofibric acidMO; CG1fenofibric acid (choline) oral capsule,

delayed release(dr/ec) 45 mg, 135 mgMO; CG1flecainideMO; CG2fluvastatinQLL (24 per 30 days)5fondaparinux subcutaneous syringe 10

mg/0.8 mlMO; CG; QLL (15 per30 days)

2fondaparinux subcutaneous syringe 2.5mg/0.5 ml

QLL (12 per 30 days)5fondaparinux subcutaneous syringe 5 mg/0.4 ml

QLL (18 per 30 days)5fondaparinux subcutaneous syringe 7.5mg/0.6 ml

MO; CG1fosinoprilMO; CG1fosinopril-hydrochlorothiazideMO; CG1furosemide injectionMO; CG1furosemide oral solution 10 mg/ml, 40

mg/5 ml (8 mg/ml)MO; CG1furosemide oral tabletMO; CG1gemfibrozilPAR; MO; CG2guanfacine oral tabletCG1heparin (porcine) in 5 % dex

intravenous parenteral solution 20,000unit/500 ml (40 unit/ml)





MO; CG1heparin (porcine) in 5 % dexintravenous parenteral solution 25,000unit/250 ml(100 unit/ml), 25,000 unit/500 ml (50 unit/ml)

B/D PAR; CG1heparin (porcine) in nacl (pf )B/D PAR; MO; CG1heparin (porcine) injection solutionMO; CG1heparin (porcine) injection syringe 5,000

unit/mlB/D PAR; CG1HEPARIN(PORCINE) IN 0.45%

NACL INTRAVENOUSPARENTERAL SOLUTION 12,500UNIT/250 ML

MO; CG1heparin(porcine) in 0.45% naclintravenous parenteral solution 25,000unit/250 ml

B/D PAR; MO; CG1heparin(porcine) in 0.45% naclintravenous parenteral solution 25,000unit/500 ml

MO; CG1heparin, porcine (pf ) injectionMO; CG2hydralazine injectionMO; CG1hydralazine oralMO; CG1hydrochlorothiazideMO; CG1indapamideMO; CG1irbesartanMO; CG1irbesartan-hydrochlorothiazideMO; CG1isosorbide dinitrate oral tabletCG1isosorbide dinitrate oral tablet extended

release





MO; CG1isosorbide mononitrateMO; CG2isradipineMO; CG1jantovenPAR; LA; QLL (30 per30 days)

5JUXTAPID

PAR; LA; QLL (4 per 28days)

5KYNAMRO

MO; CG1labetalol oral4LANOXIN ORAL TABLET 125

MCG, 62.5 MCGPAR4LANOXIN ORAL TABLET 250

MCGMO; CG1lisinoprilMO; CG1lisinopril-hydrochlorothiazideMO; CG1losartanMO; CG1losartan-hydrochlorothiazideMO; CG1lovastatinMO; CG2matzim laMO; CG2methyclothiazideMO; CG2metolazoneMO; CG1metoprolol succinateMO; CG1metoprolol tartrate intravenous solutionCG1metoprolol tartrate intravenous syringeMO; CG1metoprolol tartrate oralMO; CG1metoprolol tartrate-hydrochlorothiazideMO; CG1mexiletineMO; CG1minoxidil oralMO; CG1moexipril





QLL (60 per 30 days)4MULTAQMO; CG2nadololMO; CG2nadolol-bendroflumethiazideMO; CG1niacin oral tablet 500 mgMO; CG2niacin oral tablet extended release 24 hrMO; CG1niacorMO; CG1nicardipine oralMO; CG1nifedipine oral tablet extended releaseMO; CG1nifedipine oral tablet extended release

24hrMO; CG2nimodipineMO; CG2nisoldipineMO; CG2nitro-bid

4NITRO-DUR TRANSDERMALPATCH 24 HOUR 0.3 MG/HR, 0.8MG/HR

MO; CG2nitroglycerin sublingualMO; CG1nitroglycerin transdermal patch 24 hourMO; CG2nitroglycerin translingual spray,non-

aerosolMO; CG2olmesartanMO; CG2olmesartan-amlodipine-

hydrochlorothiazideMO; CG2olmesartan-hydrochlorothiazideMO; CG2omega-3 acid ethyl estersMO; CG1pacerone oral tablet 100 mg, 200 mg,

400 mgMO; CG1pentoxifylline





MO; CG1perindopril erbumine5phenoxybenzamine

MO; CG1pindololQLL (60 per 30 days)4PRADAXAPAR; QLL (2 per 28days)

5PRALUENT PEN


2prasugrel

MO; CG1pravastatin4PRAXBIND

MO; CG1prazosinMO; CG1prevalitePAR; LA; QLL (30 per30 days)

5PROMACTA ORAL TABLET 12.5MG, 25 MG, 75 MG


5PROMACTA ORAL TABLET 50MG

MO; CG2propafenone oral capsule,extended release12 hr

MO; CG1propafenone oral tabletMO; CG2propranolol oral capsule,extended release

24 hrMO; CG1propranolol oral tabletMO; CG1propranolol-hydrochlorothiazideMO; CG1quinaprilMO; CG1quinapril-hydrochlorothiazideMO; CG2quinidine gluconate oralMO; CG1quinidine sulfate oral tabletMO; CG1ramipril





ST; MO3RANEXAST; MO; CG2ranolazinePAR; QLL (3.5 per 28days)

5REPATHA PUSHTRONEX


5REPATHA SURECLICK


5REPATHA SYRINGE

MO; CG1rosuvastatinMO; CG1simvastatinMO; CG1sorine oral tablet 120 mg, 160 mg, 80

mgCG1sorine oral tablet 240 mgMO; CG2sotalol afMO; CG1sotalol oral tablet 120 mgMO; CG2sotalol oral tablet 160 mg, 240 mg, 80

mgMO; CG1spironolactoneMO; CG1spironolactone-hydrochlorothiazideMO; CG1taztia xtMO3TEKTURNAMO3TEKTURNA HCTMO; CG1telmisartanMO; CG2telmisartan-amlodipineMO; CG1telmisartan-hydrochlorothiazideMO; CG1terazosin capsuleMO; CG1timolol maleate oralMO; CG1torsemide oral





MO; CG1trandolaprilMO; CG2trandolapril-verapamilMO; CG1triamterene-hydrochlorothiazide oral

capsuleMO; CG1triamterene-hydrochlorothiazide oral

tabletPAR; LA; QLL (60 per30 days)

5UPTRAVI ORAL TABLET


5UPTRAVI ORAL TABLETS,DOSEPACK

MO; CG1valsartanMO; CG1valsartan-hydrochlorothiazideMO3VASCEPA

4VECAMYLMO; CG1verapamil oral capsule, 24 hr er pellet ctMO; CG1verapamil oral capsule,ext rel. pellets 24

hr 120 mg, 180 mg, 240 mgMO3verapamil oral capsule,ext rel. pellets 24

hr 360 mgMO; CG1verapamil oral tabletMO; CG1verapamil oral tablet extended releaseMO; CG1warfarinMO; QLL (30 per 30days)

3XARELTO ORAL TABLET 10 MG,20 MG


3XARELTO ORAL TABLET 15 MG


3XARELTO ORAL TABLET 2.5 MG






3XARELTO ORAL TABLETS,DOSEPACKDermatologicals/Topical Therapy

MO; CG2acitretin oral capsule 10 mg5acitretin oral capsule 17.5 mg, 25 mg


2acyclovir topical cream


2acyclovir topical ointment

4ACZONE TOPICAL GEL WITHPUMP

MO; CG2adapalene topical creamMO; CG2adapalene topical gelMO; CG2adapalene topical gel with pumpMO3ALA-CORT TOPICAL CREAM 1 %MO; CG1ala-cort topical cream 2.5 %MO; CG1alclometasoneMO; CG2amcinonide topical creamMO; CG2amcinonide topical lotionMO; CG1ammonium lactateMO; CG2amnesteemMO; CG2apexicon eMO; CG2azelaic acid

4AZELEXMO; CG1betamethasone dipropionateMO; CG1betamethasone valerateMO; CG1betamethasone, augmented






2calcipotriene scalp


2calcipotriene topical

MO; CG2calcipotriene-betamethasoneMO; CG; QLL (120 per30 days)

2calcitrene

MO; CG2calcitriol topical4CAPEX

MO; CG1ciclodan topical solutionMO; CG1ciclopiroxMO; CG2claravis oral capsule 10 mg, 20 mg, 40

mg4CLARAVIS ORAL CAPSULE 30 MG

MO; CG1clindacin etz topical swabMO; CG1clindacin pMO; CG2clindamycin phosphate topical foamMO; CG1clindamycin phosphate topical gelMO; CG1clindamycin phosphate topical lotionMO; CG1clindamycin phosphate topical solutionMO; CG1clindamycin phosphate topical swabMO; CG2clindamycin-benzoyl peroxide topical gelMO; CG2clindamycin-tretinoinMO; CG2clobetasol scalpMO; CG; QLL (100 per30 days)

2clobetasol topical foam

MO; CG2clobetasol topical gelMO; CG2clobetasol topical lotion






2clobetasol topical ointment

MO; CG2clobetasol topical shampooMO; CG2clobetasol topical spray,non-aerosolMO; CG; QLL (120 per30 days)

2clobetasol-emollient topical cream

MO; CG2clodanMO; CG2clotrimazole topical creamMO; CG1clotrimazole topical solutionMO; CG1clotrimazole-betamethasone topical creamMO; CG2clotrimazole-betamethasone topical lotion

4CORTISPORIN TOPICALPAR; QLL (2 per 28days)

5COSENTYX


5COSENTYX (2 SYRINGES)


5COSENTYX PEN


5COSENTYX PEN (2 PENS)

CG2crotanMO; CG2dapsone topicalQLL (5 per 30 days)5DENAVIR

4DESONATEMO; CG2desonideMO; CG2desoximetasone topical creamMO; CG2desoximetasone topical gelMO; CG2desoximetasone topical ointment






5diclofenac sodium topical gel 3 %

MO; CG2diflorasone5doxepin topical

MO; CG1econazolePAR; QLL (100 per 90days)

4ELIDEL

MO; CG2ery padsMO; CG1erythromycin with ethanol topical gelMO; CG1erythromycin with ethanol topical

solutionMO; CG2erythromycin with ethanol topical swabMO; CG2erythromycin-benzoyl peroxide

4EURAX4EXELDERM4FINACEA TOPICAL GEL

MO; CG2fluocinolone topical cream 0.01 %MO; CG; QLL (120 per30 days)

2fluocinolone topical cream 0.025 %


2fluocinolone topical ointment


2fluocinolone topical solution


1fluocinonide topical cream 0.05 %

QLL (120 per 30 days)5fluocinonide topical cream 0.1 %MO; CG; QLL (240 per30 days)

1fluocinonide topical gel






1fluocinonide topical ointment


1fluocinonide topical solution


1fluocinonide-e


1FLUOCINONIDE-EMOLLIENT

5FLUOROURACIL TOPICALCREAM 0.5 %

MO; CG2fluorouracil topical cream 5 %MO; CG2fluorouracil topical solutionMO; CG2flurandrenolide topical creamMO; CG2flurandrenolide topical lotionMO; CG1fluticasone propionate topical creamMO; CG1fluticasone propionate topical ointmentMO; CG1gentamicin topicalMO; CG1glydoMO; CG2halobetasol propionate topical creamMO; CG2halobetasol propionate topical ointment

5HALOG TOPICAL CREAM4HALOG TOPICAL OINTMENT

MO; CG2hydrocortisone butyrate topical ointmentMO; CG2hydrocortisone butyrate topical solutionMO; CG2hydrocortisone topical cream 1 %MO; CG1hydrocortisone topical cream 2.5 %MO; CG1hydrocortisone topical lotion 2.5 %MO; CG2hydrocortisone topical ointment 1 %





MO; CG1hydrocortisone topical ointment 2.5 %MO; CG2hydrocortisone valerateMO; CG2imiquimod topical cream in packetMO; CG1ketoconazole topical creamMO; CG2ketoconazole topical foamMO; CG1ketoconazole topical shampooMO; CG2lidocaine (pf ) injection solution 10 mg/

ml (1 %), 5 mg/ml (0.5 %)MO; CG2lidocaine hcl injection solution 10 mg/ml

(1 %), 20 mg/ml (2 %)PAR; MO; CG1lidocaine hcl mucous membrane jellyMO; CG1lidocaine hcl mucous membrane jelly in

applicatorPAR; MO; CG; QLL(300 per 30 days)

1lidocaine hcl mucous membrane solution4 % (40 mg/ml)


2lidocaine topical adhesive patch,medicated


1lidocaine topical ointment

PAR; MO; CG1lidocaine viscousMO; CG; QLL (30 per30 days)

2lidocaine-prilocaine topical cream

MO; CG2lindane topical shampooMO; CG2malathion

4MENTAXPAR5methoxsalenMO; CG2metronidazole topical creamMO; CG2metronidazole topical gel





MO; CG2metronidazole topical lotionMO; CG1mometasone topicalMO; CG1mupirocin topical creamMO; CG1mupirocin topical ointmentMO; CG2myorisanMO; CG2naftifine

4NAFTIN TOPICAL GEL 1 %MO3NAFTIN TOPICAL GEL 2 %MO; CG2neuacMO; CG1nyamycMO; CG1nystatin topicalMO; CG2nystatin-triamcinoloneMO; CG1nystopMO; CG2oxiconazole

4OXISTAT TOPICAL LOTION5PANDEL5PANRETIN

MO; CG1permethrin topical creamPAR; MO; CG; QLL(100 per 90 days)

2pimecrolimus

MO; CG2podofiloxMO; CG1prednicarbateMO; CG2prudoxinMO; CG2rosadan topical creamMO; CG2rosadan topical gelQLL (30 per 30 days)4SANTYLMO; CG2selenium sulfide topical lotionMO3silver sulfadiazine





4SKLICEMO3ssdPAR; QLL (1 per 28days)

5STELARA SUBCUTANEOUSSYRINGE

MO; CG2sulfacetamide sodium (acne)4SULFAMYLON TOPICAL CREAM5TACLONEX TOPICAL

SUSPENSIONPAR; MO; CG; QLL(100 per 90 days)

2tacrolimus topical

PAR5TALTZ AUTOINJECTORPAR5TALTZ AUTOINJECTOR (2 PACK)PAR5TALTZ AUTOINJECTOR (3 PACK)PAR5TALTZ SYRINGEPAR; MO; CG2tazarotenePAR4TAZORAC TOPICAL CREAM 0.05

%PAR4TAZORAC TOPICAL GELPAR; MO; CG; QLL (45per 30 days)

2tretinoin


2tretinoin microspheres

MO; CG2triamcinolone acetonide topical aerosolMO; CG1triamcinolone acetonide topical creamMO; CG1triamcinolone acetonide topical lotionMO; CG1triamcinolone acetonide topical ointment

0.025 %, 0.1 %, 0.5 %MO; CG1triderm topical cream





B/D PAR4UVADEXPAR5VALCHLOR

5VEREGENMO; CG2zenataneQLL (5 per 30 days)4ZOVIRAX TOPICAL CREAM

5ZYCLARA TOPICAL CREAM INMETERED-DOSE PUMP

4ZYCLARA TOPICAL CREAM INPACKETDiagnostics / Miscellaneous Agents


2acamprosate

5ADAGENMO; CG; QLL (30 per30 days)

1alendronate oral tablet 40 mg

MO; CG1anagrelidePAR; LA5ARALAST NPPAR5BUPHENYL ORAL TABLETMO; CG; QLL (60 per30 days)

1bupropion hcl (smoking deter)

PAR; LA5CARBAGLUMO; CG2cevimelinePAR; QLL (60 per 30days)

4CHANTIX


4CHANTIX CONTINUINGMONTH BOX


4CHANTIX STARTING MONTHBOX





B/D PAR3CLINIMIX 4.25%/D5W SULFITFREE

B/D PAR3CLINIMIX E 2.75%/D10W SULFREE

B/D PAR3CLINIMIX E 2.75%/D5W SULFFREE

B/D PAR3CLINIMIX N9G20E 2.75%-D10W(SF)

CG1d10 %-0.45 % sodium chlorideCG1d2.5 %-0.45 % sodium chlorideMO; CG1d5 % and 0.9 % sodium chlorideMO; CG1d5 %-0.45 % sodium chloridePAR5deferasiroxCG1dextrose 10 % and 0.2 % naclMO; CG1dextrose 10 % in water (d10w)CG1dextrose 20 % in water (d20w)CG1dextrose 25 % in water (d25w)CG1dextrose 30 % in water (d30w)CG1dextrose 40 % in water (d40w)MO; CG1dextrose 5 % in water (d5w)MO; CG2dextrose 5 %-lactated ringersCG1dextrose 5%-0.2 % sod chlorideCG1dextrose 5%-0.3 % sod.chlorideMO; CG1dextrose 50 % in water (d50w)MO; CG1dextrose 70 % in water (d70w)CG1dextrose with sodium chlorideMO; CG2disulfiram

5etidronate disodium oral tablet 400 mg





PAR; LA5EXJADEPAR5FERRIPROX

5FOSRENOL ORAL POWDER INPACKET

PAR; LA5INCRELEXPAR5JADENUPAR5JADENU SPRINKLEMO; CG1kionex (with sorbitol)MO; CG2lactated ringers irrigation

5lanthanumB/D PAR; MO; CG2levocarnitine (with sugar)MO; CG2levocarnitine oral tabletMO; CG2midodrineMO; CG2neomycin-polymyxin b gu irrigation

solutionQLL (120 per 30 days)4NICOTROL NSPAR; QLL (540 per 30days)

5NORTHERA ORAL CAPSULE 100MG





PAR; LA5ORFADIN4PHYSIOLYTE

MO; CG2pilocarpine hcl oralPAR; LA5PROLASTIN-C INTRAVENOUS

RECON SOLN





PAR5PROLASTIN-C INTRAVENOUSSOLUTION


5RAVICTI

MO; CG2riluzoleST; MO; CG; QLL (30per 30 days)

2risedronate oral tablet 30 mg

QLL (540 per 30 days)5sevelamer carbonate oral powder inpacket 0.8 gram

QLL (180 per 30 days)5sevelamer carbonate oral powder inpacket 2.4 gram


2sevelamer carbonate oral tablet

CG2sodium benzoate-sod phenylacetMO; CG1sodium chloride 0.9 % intravenousMO3sodium chloride irrigationPAR5sodium phenylbutyrateMO; CG1sodium polystyrene sulfonate oralCG1sodium polystyrene sulfonate rectal

5trientineQLL (180 per 30 days)5VELPHORO

5VELTASSA ORAL POWDER INPACKET 16.8 GRAM, 25.2 GRAM

4VELTASSA ORAL POWDER INPACKET 8.4 GRAM

MO3water for irrigation, sterilePAR; LA5ZEMAIRA





PAR; MO; CG2zoledronic acid-mannitol-water 5 mg/100 mlEar, Nose / Throat Medications

MO; CG1acetic acid otic (ear)MO; CG; QLL (30 per25 days)

2azelastine nasal

MO; CG1chlorhexidine gluconate mucousmembrane

4CIPRO HCMO3CIPRODEX

4COLY-MYCIN SMO; CG2fluocinolone acetonide oil otic (ear)MO; CG2hydrocortisone-acetic acidMO; CG; QLL (30 per30 days)

1ipratropium bromide nasal

MO; CG1neomycin-polymyxin-hc otic (ear)MO; CG1ofloxacin otic (ear)MO; CG; QLL (31 per30 days)

2olopatadine nasal

MO; CG2oraloneMO; CG1paroex oral rinseMO; CG1periogardMO; CG2triamcinolone acetonide dental

Endocrine/DiabetesMO; CG; QLL (90 per30 days)

1acarbose oral tablet 100 mg









PAR5ACTHAR H.P.QLL (60 per 30 days)4ACTOPLUS MET XR ORAL

TABLET, ER MULTIPHASE 24 HR15-1,000 MG

QLL (45 per 30 days)4ACTOPLUS MET XR ORALTABLET, ER MULTIPHASE 24 HR30-1,000 MG

MO; CG2alcohol padsPAR5ALDURAZYMEPAR5ANADROL-50PAR; MO; QLL (150 per30 days)

3ANDROGEL TRANSDERMAL GELIN METERED-DOSE PUMP 20.25MG/1.25 GRAM (1.62 %)

PAR; MO; QLL (112.5per 30 days)

3ANDROGEL TRANSDERMAL GELIN PACKET 1.62 % (20.25 MG/1.25GRAM)


3ANDROGEL TRANSDERMAL GELIN PACKET 1.62 % (40.5 MG/2.5GRAM)

ST4APIDRA SOLOSTAR U-100INSULIN

ST4APIDRA U-100 INSULINPAR; MO; QLL (120 per30 days)

3AVANDIA ORAL TABLET 2 MG


3AVANDIA ORAL TABLET 4 MG

MO; QLL (4 per 28 days)3BYDUREON BCISE





MO; QLL (4 per 28 days)3BYDUREON SUBCUTANEOUSPEN INJECTOR

MO; QLL (2.4 per 30days)

3BYETTA SUBCUTANEOUS PENINJECTOR 10 MCG/DOSE(250MCG/ML) 2.4 ML

MO; QLL (1.2 per 30days)

3BYETTA SUBCUTANEOUS PENINJECTOR 5 MCG/DOSE (250MCG/ML) 1.2 ML

MO; CG2cabergolineMO; CG; QLL (4 per 30days)

2calcitonin (salmon)

MO; CG2calcitriol oral capsulePAR5CERDELGAPAR5CEREZYME INTRAVENOUS

RECON SOLN 400 UNITPAR; MO; CG2chorionic gonadotropin, human

intramuscularB/D PAR; QLL (60 per30 days)

5cinacalcet oral tablet 30 mg, 60 mg


5cinacalcet oral tablet 90 mg

MO; CG2cortisoneST; QLL (180 per 30days)

4CYCLOSET

MO; CG2danazolMO; CG1deltasone oral tablet 20 mgMO; CG2desmopressin injectionMO; CG2desmopressin nasal spray with pump





MO; CG2desmopressin nasal spray,non-aerosolMO; CG2desmopressin oralMO; CG1dexamethasone intensolMO; CG1dexamethasone oral elixirMO; CG1dexamethasone oral solutionMO; CG1dexamethasone oral tabletMO; CG1dexamethasone sodium phos (pf )MO; CG1dexamethasone sodium phosphate

injectionCG2doxercalciferol intravenousB/D PAR; MO; CG2doxercalciferol oral capsule 0.5 mcgMO; CG2doxercalciferol oral capsule 1 mcg

5doxercalciferol oral capsule 2.5 mcgPAR5ELAPRASEPAR5FABRAZYMEMO; CG1fludrocortisoneMO; CG; QLL (200 per30 days)

2gauze pads 2 x 2


1glimepiride oral tablet 1 mg






1glipizide oral tablet 10 mg


1glipizide oral tablet 5 mg






1glipizide oral tablet extended release 24hr10 mg


1glipizide oral tablet extended release 24hr2.5 mg


1glipizide oral tablet extended release 24hr5 mg


1glipizide-metformin oral tablet 2.5-250mg


1glipizide-metformin oral tablet 2.5-500mg, 5-500 mg

4GLUCAGEN HYPOKITMO3GLUCAGON EMERGENCY KIT

(HUMAN)PAR; MO; CG; QLL(240 per 30 days)

1glyburide micronized oral tablet 1.5 mg


1glyburide micronized oral tablet 3 mg


1glyburide micronized oral tablet 6 mg


1glyburide oral tablet 1.25 mg


1glyburide oral tablet 2.5 mg


1glyburide oral tablet 5 mg


1glyburide-metformin oral tablet 1.25-250 mg






1glyburide-metformin oral tablet 2.5-500mg, 5-500 mg

MO3HUMALOG JUNIOR KWIKPENU-100

MO3HUMALOG KWIKPEN INSULINMO3HUMALOG MIX 50-50 INSULN

U-100MO3HUMALOG MIX 50-50 KWIKPENMO3HUMALOG MIX 75-25 KWIKPENMO3HUMALOG MIX 75-25(U-

100)INSULNMO3HUMALOG U-100 INSULINMO; CG2HUMULIN 70/30 U-100 INSULINMO; CG2HUMULIN 70/30 U-100 KWIKPENMO; CG2HUMULIN N NPH INSULIN

KWIKPENMO; CG2HUMULIN N NPH U-100

INSULINMO; CG2HUMULIN R REGULAR U-100

INSULNPAR5HUMULIN R U-500 (CONC)

INSULINPAR5HUMULIN R U-500 (CONC)

KWIKPENMO; CG1hydrocortisone oral

3INSULIN LISPROMO; CG; QLL (200 per30 days)

2insulin pen needle






2insulin syringe (disp) u-100 0.3 ml, 1ml, 1/2 ml


3JANUMET


3JANUMET XR ORAL TABLET, ERMULTIPHASE 24 HR 100-1,000MG


3JANUMET XR ORAL TABLET, ERMULTIPHASE 24 HR 50-1,000 MG,50-500 MG


3JANUVIA ORAL TABLET 100 MG






3JARDIANCE


3JENTADUETO


3JENTADUETO XR ORAL TABLET,IR - ER, BIPHASIC 24HR 2.5-1,000MG


3JENTADUETO XR ORAL TABLET,IR - ER, BIPHASIC 24HR 5-1,000MG

PAR5KANUMA






4KOMBIGLYZE XR ORAL TABLET,ER MULTIPHASE 24 HR 2.5-1,000MG


4KOMBIGLYZE XR ORAL TABLET,ER MULTIPHASE 24 HR 5-1,000MG, 5-500 MG

PAR5KORLYMPAR5KUVANMO3LANTUS SOLOSTAR U-100

INSULINMO3LANTUS U-100 INSULINMO3LEVEMIR FLEXTOUCH U-100

INSULNMO3LEVEMIR U-100 INSULINMO; CG1levothyroxine oralMO3levoxyl oral tablet 100 mcg, 112 mcg,

125 mcg, 137 mcg, 150 mcg, 175 mcg,200 mcg, 25 mcg, 50 mcg, 75 mcg, 88mcg

MO; CG1liothyronine oralPAR5LUMIZYMEMO; CG; QLL (60 per30 days)

1metformin oral tablet 1,000 mg


1metformin oral tablet 500 mg


1metformin oral tablet 850 mg


1metformin oral tablet extended release24 hr 500 mg






1metformin oral tablet extended release24 hr 750 mg

MO; CG1methimazole oral tablet 10 mg, 5 mgMO; CG1methylprednisoloneMO; CG1methylprednisolone acetateMO; CG1methylprednisolone sodium succ injection

recon soln 125 mg, 40 mgMO; CG1methylprednisolone sodium succ

intravenous5methyltestosterone oral capsule

B/D PAR5MIACALCIN INJECTIONMO; CG; QLL (90 per30 days)

2miglitol oral tablet 100 mg





PAR; LA5miglustatMO; CG2millipred oral tabletPAR; LA5MYALEPTPAR; LA5NAGLAZYMEMO; CG; QLL (90 per30 days)

1nateglinide oral tablet 120 mg


1nateglinide oral tablet 60 mg


5NATPARA






2needles, insulin disp.,safety

PAR; MO; CG2novarel intramuscular recon soln 10,000unit

PAR4NOVAREL INTRAMUSCULARRECON SOLN 5,000 UNIT

ST4NOVOLIN 70/30 U-100 INSULINST4NOVOLIN N NPH U-100 INSULINST4NOVOLIN R REGULAR U-100

INSULNST4NOVOLOG FLEXPEN U-100

INSULINST4NOVOLOG MIX 70-30 U-100

INSULNST4NOVOLOG MIX 70-30FLEXPEN

U-100ST4NOVOLOG PENFILL U-100

INSULINST4NOVOLOG U-100 INSULIN

ASPARTPAR; MO; CG2np thyroid oral tablet 120 mg, 15 mgPAR; MO; CG; QLL (60per 30 days)

2oxandrolone oral tablet 10 mg


2oxandrolone oral tablet 2.5 mg

MO3OZEMPICMO; CG2pamidronate intravenous recon soln





MO; CG2pamidronate intravenous solution 30 mg/10 ml (3 mg/ml), 90 mg/10 ml (9 mg/ml)

B/D PAR; MO; CG2pamidronate intravenous solution 60 mg/10 ml (6 mg/ml)

B/D PAR; CG2paricalcitol hemodialysis port injectionB/D PAR; CG2paricalcitol intravenous solution 2 mcg/

mlB/D PAR; MO; CG2paricalcitol intravenous solution 5 mcg/

mlMO; CG2paricalcitol oral capsule 1 mcg, 2 mcg

5paricalcitol oral capsule 4 mcgMO; CG; QLL (90 per30 days)

1pioglitazone oral tablet 15 mg






2pioglitazone-glimepiride


2pioglitazone-metformin

MO; CG1prednisolone oral solution 15 mg/5 mlMO; CG2prednisolone sodium phosphate oral

solution 10 mg/5 ml, 20 mg/5 ml (4 mg/ml)





MO; CG1prednisolone sodium phosphate oralsolution 15 mg/5 ml (3 mg/ml), 25 mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7mg/5 ml)

MO; CG2prednisolone sodium phosphate oraltablet,disintegrating

MO; CG1prednisone intensolMO; CG1prednisone oral solutionMO; CG1prednisone oral tabletMO; CG1prednisone oral tablets,dose pack 10 mg

(48 pack), 5 mg, 5 mg (48 pack)PAR; MO; CG2pregnyl

5PROGLYCEMMO; CG1propylthiouracilMO; CG; QLL (960 per30 days)

1repaglinide oral tablet 0.5 mg


1repaglinide oral tablet 1 mg


1repaglinide oral tablet 2 mg


2repaglinide-metformin


5SAMSCA ORAL TABLET 15 MG


5SAMSCA ORAL TABLET 30 MG


5SENSIPAR ORAL TABLET 30 MG,60 MG






5SENSIPAR ORAL TABLET 90 MG

4SOLU-CORTEF (PF) INJECTIONRECON SOLN 250 MG/2 ML

PAR5SOMAVERT5STIMATE

PAR; LA5STRENSIQPAR; QLL (11 per 30days)

5SYMLINPEN 120


5SYMLINPEN 60

PAR5SYNARELMO; QLL (60 per 30days)

3SYNJARDY


3SYNJARDY XR ORAL TABLET, IR- ER, BIPHASIC 24HR 10-1,000MG, 12.5-1,000 MG, 5-1,000 MG


3SYNJARDY XR ORAL TABLET, IR- ER, BIPHASIC 24HR 25-1,000 MG

MO3SYNTHROIDPAR; MO; CG2testosterone cypionatePAR; MO; CG2testosterone enanthatePAR; MO; CG; QLL(300 per 30 days)

2testosterone transdermal gel in metered-dose pump 12.5 mg/ 1.25 gram (1 %)


2testosterone transdermal gel in metered-dose pump 20.25 mg/1.25 gram (1.62%)






2testosterone transdermal gel in packet 1% (25 mg/2.5gram), 1 % (50 mg/5gram)

PAR; MO; CG; QLL(112.5 per 30 days)

2testosterone transdermal gel in packet1.62 % (20.25 mg/1.25 gram)


2testosterone transdermal gel in packet1.62 % (40.5 mg/2.5 gram)

PAR; CG1thyroid (pork) oral tablet 120 mg, 30mg, 60 mg

PAR; MO; CG1thyroid (pork) oral tablet 15 mg, 90 mg4THYROLAR-14THYROLAR-1/24THYROLAR-1/44THYROLAR-24THYROLAR-34TIROSINT


1tolazamide oral tablet 250 mg


1tolazamide oral tablet 500 mg


1tolbutamide

MO3TOUJEO MAX U-300 SOLOSTARMO3TOUJEO SOLOSTAR U-300

INSULINMO; QLL (30 per 30days)

3TRADJENTA

MO; QLL (2 per 28 days)3TRULICITY





MO3unithroid oral tablet 100 mcg, 112 mcg,125 mcg, 150 mcg, 175 mcg, 200 mcg,25 mcg, 300 mcg, 50 mcg, 75 mcg, 88mcg

MO; CG1unithroid oral tablet 137 mcgCG2veripred 20MO; QLL (9 per 30 days)3VICTOZA 2-PAKMO; QLL (9 per 30 days)3VICTOZA 3-PAKPAR5VIMIZIMPAR5VPRIVPAR5ZOLEDRONIC AC-MANNITOL-

0.9NACLPAR; MO; CG2zoledronic acid intravenous solution 4

mg/5 mlPAR; CG2zoledronic acid-mannitol-water 5 mg/

100 ml intravenous piggyback 4 mg/100mlGastroenterology


5alosetron

PAR4ALOXIMO; QLL (60 per 30days)

3AMITIZA

B/D PAR; MO; CG;QLL (5 per 30 days)

2aprepitant oral capsule 125 mg










2aprepitant oral capsule,dose pack

MO3APRISOMO3ASACOL HDCG2atropine injection syringe 0.05 mg/mlMO; CG2atropine injection syringe 0.1 mg/mlMO; CG2balsalazide

5budesonide oral capsule,delayed,extend.release

PAR; MO; CG2budesonide oral tablet,delayed andext.release

5CANASAMO; CG2carafate oral suspensionPAR; LA5CHENODALPAR; MO; CG2chlordiazepoxide-clidiniumPAR; QLL (120 per 30days)

5CHOLBAM

MO; CG1cimetidineMO; CG1cimetidine hcl oralMO; CG1colocortMO; CG1compazine rectalMO; CG1comproMO; CG1constuloseMO3CREON

5CYSTADANEQLL (30 per 30 days)4DEXILANT





MO; CG1dicyclomine intramuscularPAR; MO; CG1dicyclomine oral capsulePAR; MO; CG1dicyclomine oral solutionPAR; MO; CG1dicyclomine oral tablet

5DIPENTUMPAR; MO; CG1diphenoxylate-atropineB/D PAR; QLL (120 per30 days)

5dronabinol oral capsule 10 mg


2dronabinol oral capsule 2.5 mg, 5 mg

MO3EMEND (FOSAPREPITANT)B/D PAR; MO; QLL (5per 30 days)

3EMEND ORAL CAPSULE 125 MG

B/D PAR; MO; QLL (1per 28 days)

3EMEND ORAL CAPSULE 40 MG

B/D PAR; MO; QLL (15per 30 days)

3EMEND ORAL SUSPENSION FORRECONSTITUTION


5ENTYVIO

MO; CG1enuloseMO; CG; QLL (30 per30 days)

2esomeprazole magnesium

CG2esomeprazole sodium intravenous reconsoln 20 mg

MO; CG2esomeprazole sodium intravenous reconsoln 40 mg

MO; CG1famotidine (pf )MO; CG2famotidine (pf )-nacl (iso-os)





MO; CG2famotidine intravenous solutionMO; CG1famotidine oral suspensionMO; CG1famotidine oral tablet 20 mg, 40 mgPAR5GATTEX 30-VIALPAR5GATTEX ONE-VIALMO; CG1gavilyte-cMO; CG1gavilyte-gMO; CG1gavilyte-nMO; CG1generlacMO; CG1glycopyrrolate injectionMO; CG2glycopyrrolate oral tablet 1 mg, 2 mg

4GOLYTELY ORAL POWDER INPACKET

MO; CG2granisetron hcl intravenous solution 1mg/ml (1 ml)


2granisetron hcl oral

MO; CG1hydrocortisone rectalMO; CG1hydrocortisone topical cream with

perineal applicator 1 %4KRISTALOSE

CG2lactulose oral packetMO; CG1lactulose oral solutionMO; CG; QLL (30 per30 days)

2lansoprazole oral capsule,delayedrelease(dr/ec)


3LINZESS

MO; CG1loperamide oral capsule





MO; CG1meclizine oral tablet 12.5 mg, 25 mgMO; CG2mesalamine oral tablet,delayed release

(dr/ec) 1.2 gramMO; CG2MESALAMINE ORAL TABLET,

DELAYED RELEASE (DR/EC) 800MG

MO; CG2mesalamine rectal enema5mesalamine rectal suppository

MO; CG2mesalamine with cleansing wipeMO; CG2methscopolamineMO; CG1metoclopramide hcl injection solutionMO; CG1metoclopramide hcl oral solutionMO; CG1metoclopramide hcl oral tabletMO; CG1metoclopramide hcl oral tablet,

disintegrating 10 mgMO; CG1misoprostolMO; QLL (30 per 30days)

3MOVANTIK

4MOVIPREPMO; CG2nizatidineMO; CG; QLL (30 per30 days)

1omeprazole oral capsule,delayedrelease(dr/ec)


2ondansetron disintegrating tablet

MO; CG2ondansetron hcl (pf )B/D PAR; MO; CG;QLL (450 per 30 days)

2ondansetron hcl oral solution





B/D PAR; CG; QLL (30per 30 days)

2ondansetron hcl oral tablet 24 mg


2ondansetron hcl oral tablet 4 mg, 8 mg

4OSMOPREPMO; CG2palonosetron intravenous solution 0.25

mg/5 mlST4PANCREAZE ORAL CAPSULE,

DELAYED RELEASE(DR/EC) 10,500-35,500- 61,500 UNIT, 16,800-56,800- 98,400 UNIT, 2,600-6,200-10,850 UNIT, 4,200-14,200- 24,600UNIT

ST5PANCREAZE ORAL CAPSULE,DELAYED RELEASE(DR/EC) 21,000-54,700- 83,900 UNIT

MO; CG2pantoprazole intravenousMO; CG; QLL (30 per30 days)

1pantoprazole oral

MO; CG1peg 3350-electrolytes oral recon soln 236-22.74-6.74 -5.86 gram

CG1peg 3350-electrolytes oral recon soln 240-22.72-6.72 -5.84 gram

CG1peg-electrolyte soln4PENTASA ORAL CAPSULE,

EXTENDED RELEASE 250 MG5PENTASA ORAL CAPSULE,

EXTENDED RELEASE 500 MG





ST5PERTZYE ORAL CAPSULE,DELAYED RELEASE(DR/EC) 16,000-57,500- 60,500 UNIT, 24,000-86,250- 90,750 UNIT

ST4PERTZYE ORAL CAPSULE,DELAYED RELEASE(DR/EC) 4,000-14,375- 15,125 UNIT, 8,000-28,750- 30,250 UNIT

MO; CG1polyethylene glycol 3350MO; CG1prochlorperazineMO; CG1prochlorperazine edisylateMO; CG1prochlorperazine maleateMO; CG1procto-pakMO; CG1proctosol hc topicalMO; CG1proctozone-hc

5PYLERAMO; CG; QLL (30 per30 days)

2rabeprazole

MO; CG2ranitidine hcl injectionMO; CG2ranitidine hcl oral capsuleMO; CG1ranitidine hcl oral syrupMO; CG1ranitidine hcl oral tablet 150 mg, 300

mgMO; QLL (30 per 30days)

3RECTIV


5RELISTOR SUBCUTANEOUSSOLUTION






5RELISTOR SUBCUTANEOUSSYRINGE 12 MG/0.6 ML


5RELISTOR SUBCUTANEOUSSYRINGE 8 MG/0.4 ML

PAR5REMICADEPAR; QLL (4 per 28days)

5SANCUSO


2scopolamine transdermal

5SUCRAIDMO; CG1sucralfate oral tabletMO; CG1sulfasalazine

4SUPREP BOWEL PREP KITQLL (10 per 28 days)4TRANSDERM-SCOPMO; CG1trilyte with flavor packetsMO; CG2trimethobenzamide oral

4UCERIS RECTALMO; CG2ursodiolPAR5VIBERZI

5VIOKACEST4ZENPEP ORAL CAPSULE,

DELAYED RELEASE(DR/EC) 10,000-32,000 -42,000 UNIT, 15,000-47,000 -63,000 UNIT, 20,000-63,000- 84,000 UNIT, 25,000-79,000-105,000 UNIT, 3,000-10,000 -14,000-UNIT, 40,000-126,000- 168,000UNIT, 5,000-17,000- 24,000 UNITImmunology, Vaccines / Biotechnology





MO3ACTHIB (PF)PAR5ACTIMMUNEMO3ADACEL(TDAP ADOLESN/

ADULT)(PF)PAR5ARANESP (IN POLYSORBATE)

INJECTION SOLUTION 100MCG/ML, 200 MCG/ML, 300MCG/ML

PAR4ARANESP (IN POLYSORBATE)INJECTION SOLUTION 25 MCG/ML, 40 MCG/ML, 60 MCG/ML

PAR4ARANESP (IN POLYSORBATE)INJECTION SYRINGE 10 MCG/0.4ML, 25 MCG/0.42 ML, 40 MCG/0.4ML, 60 MCG/0.3 ML

PAR5ARANESP (IN POLYSORBATE)INJECTION SYRINGE 100 MCG/0.5 ML, 150 MCG/0.3 ML, 200MCG/0.4 ML, 300 MCG/0.6 ML,500 MCG/ML

PAR5ARCALYSTB/D PAR5ATGAMPAR; QLL (4 per 28days)

5AVONEX (WITH ALBUMIN)


5AVONEX INTRAMUSCULAR PENINJECTOR KIT


5AVONEX INTRAMUSCULARSYRINGE KIT

MO3BCG VACCINE, LIVE (PF)





PAR5BETASERON SUBCUTANEOUSKIT

MO3BEXSEROMO3BOOSTRIX TDAPPAR4BOTOXMO3DAPTACEL (DTAP PEDIATRIC)

(PF)B/D PAR; MO3ENGERIX-B (PF)B/D PAR; MO3ENGERIX-B PEDIATRIC (PF)

INTRAMUSCULAR SYRINGEPAR4EPOGEN INJECTION SOLUTION

10,000 UNIT/ML, 2,000 UNIT/ML,20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML

PAR; QLL (1.2 per 28days)

5FULPHILA

PAR5GAMUNEX-CMO3GARDASIL 9 (PF)PAR5GENOTROPINPAR5GENOTROPIN MINIQUICKPAR5GRANIXMO3HAVRIX (PF) INTRAMUSCULAR

SUSPENSIONMO3HAVRIX (PF) INTRAMUSCULAR

SYRINGE 1,440 ELISA UNIT/ML3HAVRIX (PF) INTRAMUSCULAR

SYRINGE 720 ELISA UNIT/0.5 MLMO3HIBERIX (PF)





PAR5HUMATROPEPAR; LA5ILARIS (PF) SUBCUTANEOUS

SOLUTIONMO3IMOVAX RABIES VACCINE (PF)MO3INFANRIX (DTAP) (PF)

INTRAMUSCULAR SUSPENSION4INTRON A INJECTION RECON

SOLN 10 MILLION UNIT (1 ML),18 MILLION UNIT (1 ML)

5INTRON A INJECTION RECONSOLN 50 MILLION UNIT (1 ML)

5INTRON A INJECTIONSOLUTION

MO3IPOLMO3IXIARO (PF)

3KINRIX (PF) INTRAMUSCULARSUSPENSION

MO3KINRIX (PF) INTRAMUSCULARSYRINGE

PAR5LEUKINE INJECTION RECONSOLN

MO3M-M-R II (PF)MO3MENACTRA (PF)

INTRAMUSCULAR SOLUTIONMO3MENVEO A-C-Y-W-135-DIP (PF)PAR5MOZOBILPAR; QLL (1.2 per 28days)

5NEULASTA





PAR4NEUPOGEN INJECTIONSOLUTION 300 MCG/ML

PAR5NEUPOGEN INJECTIONSOLUTION 480 MCG/1.6 ML

PAR5NEUPOGEN INJECTIONSYRINGE

PAR5NORDITROPIN FLEXPROPAR5NUTROPIN AQ NUSPINPAR5OCTAGAMPAR5OMNITROPEMO3PEDIARIX (PF)MO3PEDVAX HIB (PF)

5PEGASYS5PEGASYS PROCLICK

SUBCUTANEOUS PEN INJECTOR180 MCG/0.5 ML

5PEGINTRON SUBCUTANEOUSKIT 50 MCG/0.5 ML

MO3PENTACEL (PF)PAR; QLL (1 per 28days)

5PLEGRIDY

PAR4PROCRIT INJECTIONSOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML

PAR5PROCRIT INJECTIONSOLUTION 20,000 UNIT/2 ML,20,000 UNIT/ML, 40,000 UNIT/ML

B/D PAR5PROLEUKIN





MO3PROQUAD (PF)MO3QUADRACEL (PF)MO3RABAVERT (PF)B/D PAR; MO3RECOMBIVAX HB (PF)

INTRAMUSCULAR SUSPENSION10 MCG/ML, 40 MCG/ML

B/D PAR; MO3RECOMBIVAX HB (PF)INTRAMUSCULAR SYRINGE 10MCG/ML

B/D PAR3RECOMBIVAX HB (PF)INTRAMUSCULAR SYRINGE 5MCG/0.5 ML

3ROTARIXMO3ROTATEQ VACCINEPAR5SAIZENPAR5SEROSTIM SUBCUTANEOUS

RECON SOLN 4 MG, 5 MG, 6 MGMO3SHINGRIX (PF)

3STAMARIL (PF)PAR5SYLATRONMO3TDVAXMO3TENIVAC (PF) INTRAMUSCULAR

SYRINGEMO3TETANUS,DIPHTHERIA TOX

PED(PF)MO3TRUMENBAMO3TWINRIX (PF) INTRAMUSCULAR

SYRINGE





3TYPHIM VI INTRAMUSCULARSOLUTION

MO3TYPHIM VI INTRAMUSCULARSYRINGE

MO3VAQTA (PF)MO3VARIVAX (PF)MO3VARIZIG INTRAMUSCULAR

SOLUTIONPAR4XEOMIN INTRAMUSCULAR

RECON SOLN 50 UNITMO3YF-VAX (PF)PAR5ZARXIOPAR5ZOMACTON SUBCUTANEOUS

RECON SOLN 10 MGPAR4ZOMACTON SUBCUTANEOUS

RECON SOLN 5 MGPAR5ZORBTIVEMO3ZOSTAVAX (PF)

Musculoskeletal / RheumatologyMO; CG; QLL (300 per28 days)

1alendronate oral solution


1alendronate oral tablet 10 mg, 5 mg


1alendronate oral tablet 35 mg, 70 mg

MO; CG1allopurinolPAR5BENLYSTAMO; CG2colchicine oral tablet

5DEPEN TITRATABS






5ENBREL MINI


5ENBREL SUBCUTANEOUSRECON SOLN

PAR; QLL (4.08 per 28days)

5ENBREL SUBCUTANEOUSSYRINGE 25 MG/0.5ML (0.51)


5ENBREL SUBCUTANEOUSSYRINGE 50 MG/ML (0.98 ML)


5ENBREL SURECLICK


5FORTEO

ST; QLL (4 per 28 days)4FOSAMAX PLUS DPAR; QLL (6 per 365days)

5HUMIRA PEDIATRIC CROHNSSTART SUBCUTANEOUSSYRINGE KIT 40 MG/0.8 ML


5HUMIRA PEDIATRIC CROHNSSTART SUBCUTANEOUSSYRINGE KIT 40 MG/0.8 ML (6PACK)


5HUMIRA PEN


5HUMIRA PEN CROHNS-UC-HSSTART


5HUMIRA PEN PSOR-UVEITS-ADOL HS


5HUMIRA SUBCUTANEOUSSYRINGE KIT 10 MG/0.2 ML, 20MG/0.4 ML






5HUMIRA SUBCUTANEOUSSYRINGE KIT 40 MG/0.8 ML


5HUMIRA(CF) PEDI CROHNSSTARTER SUBCUTANEOUSSYRINGE KIT 80 MG/0.8 ML


5HUMIRA(CF) PEDI CROHNSSTARTER SUBCUTANEOUSSYRINGE KIT 80 MG/0.8 ML-40MG/0.4 ML


5HUMIRA(CF) PEN CROHNS-UC-HS


5HUMIRA(CF) PEN PSOR-UV-ADOL HS


5HUMIRA(CF) PENSUBCUTANEOUS PEN INJECTORKIT 40 MG/0.4 ML


5HUMIRA(CF) SUBCUTANEOUSSYRINGE KIT 10 MG/0.1 ML, 20MG/0.2 ML


5HUMIRA(CF) SUBCUTANEOUSSYRINGE KIT 40 MG/0.4 ML

B/D PAR; MO; CG2ibandronate intravenousMO; CG; QLL (1 per 28days)

2ibandronate oral

MO; CG2leflunomideMO; CG1probenecidMO; CG1probenecid-colchicinePAR; QLL (2 per 365days)

4PROLIA






2raloxifene

5RIDAURAST; MO; CG; QLL (1per 28 days)


ST; MO; CG; QLL (4per 28 days)

2risedronate oral tablet 35 mg, 35 mg (12pack), 35 mg (4 pack)

ST; MO; CG; QLL (30per 30 days)



2risedronate oral tablet,delayed release (dr/ec)

QLL (60 per 30 days)4SAVELLA ORAL TABLET 100 MGQLL (480 per 30 days)4SAVELLA ORAL TABLET 12.5 MGQLL (240 per 30 days)4SAVELLA ORAL TABLET 25 MGQLL (120 per 30 days)4SAVELLA ORAL TABLET 50 MGQLL (110 per 365 days)4SAVELLA ORAL TABLETS,DOSE

PACKST; MO3ULORICPAR; QLL (60 per 30days)

5XELJANZ


5XELJANZ XR

Obstetrics / GynecologyMO; CG1altavera (28)MO; CG2alyacen 1/35 (28)MO; CG1alyacen 7/7/7 (28)PAR; MO; CG2amabelzMO; CG2amethia





MO; CG2amethyst (28)MO; CG1apriMO; CG2aranelle (28)MO; CG2ashlynaMO; CG1aubraMO; CG1avianeMO; CG2azurette (28)MO; CG2balziva (28)MO; CG2bekyree (28)MO; CG1blisovi 24 feMO; CG1blisovi fe 1.5/30 (28)MO; CG1blisovi fe 1/20 (28)MO; CG2briellynMO; CG1camilaMO; CG2camreseMO; CG2caziant (28)MO; CG1chateal (28)

4CLEOCIN VAGINALSUPPOSITORY

MO; CG1clindamycin phosphate vaginalPAR; QLL (8 per 28days)

4COMBIPATCH

PAR4CRINONEMO; CG1cryselle (28)MO; CG2cyclafem 1/35 (28)MO; CG1cyclafem 7/7/7 (28)MO; CG1cyredMO; CG2dasetta 1/35 (28)





MO; CG1dasetta 7/7/7 (28)MO; CG2dayseeMO; CG1deblitaneCG1delyla (28)

4DEPO-ESTRADIOL4DEPO-PROVERA

INTRAMUSCULAR SUSPENSION400 MG/ML

4DEPO-SUBQ PROVERA 104MO; CG2desog-e.estradiol/e.estradiolMO; CG1desogestrel-ethinyl estradiolPAR4DIVIGELMO; CG2drospirenone-e.estradiol-lm.fa oral tablet

3-0.02-0.451 mg (24) (4)MO; CG2drospirenone-ethinyl estradiolPAR4ELESTRINMO; CG1elinest

3ELLAMO; CG1emoquetteMO; CG1enpresseMO; CG1enskyceMO; CG1errinMO; CG1estaryllaPAR; MO; CG1estradiol oralPAR; MO; CG; QLL (8per 28 days)

2estradiol transdermal patch semiweekly


2estradiol transdermal patch weekly





MO; CG2estradiol vaginalMO; CG2estradiol valerate intramuscular oil 20

mg/ml, 40 mg/mlPAR; MO; CG2estradiol-norethindrone acet oral tablet

0.5-0.1 mgQLL (1 per 90 days)4ESTRINGPAR4EVAMISTMO; CG1falmina (28)MO; CG2fayosimQLL (1 per 90 days)4FEMRINGMO; CG2femynorPAR; MO; CG1fyavolvMO; CG2gianvi (28)MO; CG1heatherPAR; MO; CG; QLL (25per 147 days)

2hydroxyprogesterone caproate

MO; CG2introvaleMO; CG1jencyclaPAR; MO; CG1jinteliMO; CG2jolessaMO; CG1jolivetteMO; CG1juleberMO; CG1junel 1.5/30 (21)MO; CG1junel 1/20 (21)MO; CG1junel fe 1.5/30 (28)MO; CG1junel fe 1/20 (28)MO; CG1junel fe 24MO; CG2kaitlib fe





MO; CG2kariva (28)MO; CG2kelnor 1/35 (28)MO; CG1kurvelo (28)MO; CG2l norgest/e.estradiol-e.estrad oral tablets,

dose pack,3 month 0.15 mg-30 mcg(84)/10 mcg (7)

MO; CG1larin 1.5/30 (21)MO; CG1larin 1/20 (21)MO; CG1larin 24 feMO; CG1larin fe 1.5/30 (28)MO; CG1larin fe 1/20 (28)MO; CG2layolis feMO; CG2leena 28MO; CG1lessinaMO; CG1levonest (28)MO; CG1levonorg-eth estrad triphasicMO; CG1levonorgestrel-ethinyl estrad oral tablet

0.1-20 mg-mcg, 0.15-0.03 mgMO; CG2levonorgestrel-ethinyl estrad oral tablet

90-20 mcg (28)MO; CG2levonorgestrel-ethinyl estrad oral tablets,

dose pack,3 monthMO; CG1levora-28CG2lo-zumandimine (28)PAR; MO; CG2lopreeza oral tablet 0.5-0.1 mgMO; CG2loryna (28)MO; CG1low-ogestrel (28)






5LUPANETA PACK (1 MONTH)


5LUPANETA PACK (3 MONTH)

MO; CG1lutera (28)MO; CG1lyzaMO; CG1marlissa (28)MO; CG2medroxyprogesterone intramuscular

suspensionMO; CG1medroxyprogesterone oralPAR4MENEST ORAL TABLET 0.3 MG,

0.625 MG, 1.25 MGPAR; QLL (4 per 28days)

4MENOSTAR

MO; CG1metronidazole vaginalMO; CG2mibelas 24 feMO; CG1miconazole-3 vaginal suppositoryMO; CG1microgestin 1.5/30 (21)MO; CG1microgestin 1/20 (21)CG1microgestin fe 1.5/30 (28)MO; CG1microgestin fe 1/20 (28)PAR; MO; CG2mimvey loPAR; QLL (8 per 28days)

4MINIVELLE

MO; CG1mono-linyahMO; CG1mononessa (28)MO; CG2necon 0.5/35 (28)MO; CG2nikki (28)





MO; CG1nora-beMO; CG2noreth-ethinyl estradiol-ironMO; CG1norethindrone (contraceptive)PAR; MO; CG1norethindrone ac-eth estradiol oral tablet

0.5-2.5 mg-mcg, 1-5 mg-mcgMO; CG1norethindrone ac-eth estradiol oral tablet

1-20 mg-mcgMO; CG2norethindrone acetateMO; CG1norethindrone-e.estradiol-iron oral tabletMO; CG1norgestimate-ethinyl estradiolCG1norlyrocMO; CG2nortrel 0.5/35 (28)MO; CG2nortrel 1/35 (21)MO; CG2nortrel 1/35 (28)MO; CG1nortrel 7/7/7 (28)MO; CG2ocellaMO; CG1ogestrel (28)MO; CG1orsythiaMO; CG2philithMO; CG2pimtrea (28)MO; CG1pirmella oral tablet 0.5/0.75/1 mg- 35

mcgMO; CG2pirmella oral tablet 1-35 mg-mcgMO; CG1portia 28PAR; MO3PREMARIN ORALMO3PREMARIN VAGINALPAR; MO3PREMPHASEPAR; MO3PREMPRO





MO; CG1previfemMO; CG2progesterone micronizedMO; CG1reclipsen (28)MO; CG2rivelsaMO; CG2setlakinMO; CG1sharobelCG2simpesseMO; CG1sprintec (28)MO; CG1sronyxMO; CG2syedaMO; CG1tarina fe 1-20 eq (28)MO; CG1tarina fe 1/20 (28)MO; CG1terconazole vaginal creamMO; CG2terconazole vaginal suppositoryMO; CG2tilia feMO; CG2tranexamic acid oralMO; CG1tri-estaryllaMO; CG2tri-legest feMO; CG1tri-linyahMO; CG1tri-lo-estaryllaCG1tri-lo-miliMO; CG1tri-lo-sprintecMO; CG1tri-previfem (28)MO; CG1tri-sprintec (28)MO; CG1trivora (28)MO3vandazoleMO; CG2velivet triphasic regimen (28)MO; CG1vienva





MO; CG2vyfemla (28)MO; CG2wera (28)MO; CG2wymzya feMO; CG2xulaneMO; CG2yuvafemMO; CG2zarahMO; CG2zenchent (28)MO; CG2zovia 1/35e (28)CG2zumandimine (28)

OphthalmologyMO; CG2acetazolamide oral capsule, extended

releaseMO; CG1acetazolamide oral tabletMO; CG2acetazolamide sodium solution for

injection4ACUVAIL (PF)4ALOCRIL4ALOMIDE

MO3ALPHAGAN P OPHTHALMIC(EYE) DROPS 0.1 %

MO; CG2apraclonidineMO3atropine ophthalmic (eye) dropsMO; CG2azelastine ophthalmic (eye)

4AZOPTMO; CG1bacitracin ophthalmic (eye)MO; CG1bacitracin-polymyxin b ophthalmic (eye)

4BEPREVEMO; CG2betaxolol ophthalmic (eye)





4BETIMOL4BETOPTIC S

MO; CG2bimatoprost ophthalmic (eye)4BLEPHAMIDE4BLEPHAMIDE S.O.P.

MO; CG1brimonidineMO; CG2bromfenacMO; CG1carteololMO; CG1ciprofloxacin hcl ophthalmic (eye)MO3COMBIGANMO; CG1cromolyn ophthalmic (eye)

5CYSTARANMO; CG1dexamethasone sodium phosphate

ophthalmic (eye)MO; CG1diclofenac sodium ophthalmic (eye)MO; CG1dorzolamideMO; CG2dorzolamide-timololMO3DUREZOLMO; CG2epinastineMO; CG1erythromycin ophthalmic (eye)MO3FLAREXMO; CG2fluorometholoneMO; CG1flurbiprofen ophthalmic (eye)MO3FML FORTEMO3FML S.O.P.MO; CG2gatifloxacinMO; CG1gentak ophthalmic (eye) ointmentMO; CG1gentamicin ophthalmic (eye) drops





CG1gentamicin ophthalmic (eye) ointmentMO3ILEVRO

4IOPIDINE OPHTHALMIC (EYE)DROPPERETTE

MO; CG2ketorolac ophthalmic (eye)QLL (60 per 30 days)4LACRISERT

4LASTACAFTMO; CG1latanoprostMO; CG1levobunolol ophthalmic (eye) drops 0.5

%MO; CG1levofloxacin ophthalmic (eye)MO3LUMIGAN OPHTHALMIC (EYE)

DROPS 0.01 %MO3MAXIDEXMO; CG1methazolamideMO; CG2MOXIFLOXACIN OPHTHALMIC

(EYE)4NATACYN

MO; CG1neo-polycinMO; CG2neo-polycin hcMO; CG2neomycin-bacitracin-poly-hcMO; CG1neomycin-bacitracin-polymyxinMO; CG1neomycin-polymyxin b-dexamethMO; CG1neomycin-polymyxin-gramicidinMO; CG2neomycin-polymyxin-hc ophthalmic (eye)MO; CG1ofloxacin ophthalmic (eye)MO; CG2olopatadine ophthalmic (eye)MO3PAZEO





4PHOSPHOLINE IODIDEMO; CG2pilocarpine hcl ophthalmic (eye) drops 1

%, 2 %, 4 %MO; CG1polycinMO; CG1polymyxin b sulf-trimethoprimMO3PRED MILD

4PRED-GMO; CG1prednisolone acetateMO; CG1prednisolone sodium phosphate

ophthalmic (eye)4SIMBRINZA

MO; CG1sulfacetamide sodium ophthalmic (eye)MO; CG1sulfacetamide-prednisoloneMO; CG1timolol maleate ophthalmic (eye) dropsMO; CG2timolol maleate ophthalmic (eye) gel

forming solutionMO3TOBRADEX OPHTHALMIC (EYE)

OINTMENTMO3TOBRADEX STMO; CG1tobramycinMO; CG2tobramycin-dexamethasone ophthalmic

(eye)MO3TRAVATAN ZMO; CG2trifluridinePAR; MO; QLL (60 per30 days)

3XIIDRA

4ZIOPTAN (PF)4ZIRGAN





4ZYLETRespiratory And Allergy

B/D PAR; MO; CG2acetylcysteinePAR; QLL (60 per 30days)

5ADCIRCA

PAR; LA5ADEMPASMO; CG2adrenalin injection solution 1 mg/mlMO; QLL (60 per 30days)

3ADVAIR DISKUS


3ADVAIR HFA


2albuterol sulfate inhalation solution fornebulization 0.63 mg/3 ml, 1.25 mg/3ml


1albuterol sulfate inhalation solution fornebulization 2.5 mg /3 ml (0.083 %)


1albuterol sulfate inhalation solution fornebulization 2.5 mg/0.5 ml, 5 mg/ml

MO; CG1albuterol sulfate oral syrupMO; CG2albuterol sulfate oral tabletMO; CG2albuterol sulfate oral tablet extended

release 12 hr 4 mgMO; CG1albuterol sulfate oral tablet extended

release 12 hr 8 mgPAR; LA; QLL (30 per30 days)

5ambrisentan

CG1aminophylline intravenous






3ANORO ELLIPTA

QLL (30 per 30 days)4ARCAPTA NEOHALERMO; QLL (30 per 30days)

3ARNUITY ELLIPTA


3ASMANEX HFA

MO; QLL (1 per 30 days)3ASMANEX TWISTHALERINHALATION AEROSOL POWDRBREATH ACTIVATED 110 MCG(30 DOSES), 220 MCG (120DOSES), 220 MCG (30 DOSES),220 MCG (60 DOSES)

QLL (2 per 30 days)3ASMANEX TWISTHALERINHALATION AEROSOL POWDRBREATH ACTIVATED 220 MCG(14 DOSES)


3ATROVENT HFA

MO; CG; ED1benzonatate oral capsule 100 mg, 200mg


5bosentan

QLL (60 per 30 days)4BREO ELLIPTAB/D PAR; QLL (120 per30 days)

5BROVANA


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






2budesonide inhalation suspension fornebulization 1 mg/2 ml

PAR; MO; CG2carbinoxamine maleate oral liquidPAR; MO; CG2carbinoxamine maleate oral tablet 4 mgMO; CG1cetirizine oral solution 1 mg/mlPAR5CINRYZEPAR; MO; CG2clemastine oral tablet 2.68 mgQLL (8 per 30 days)4COMBIVENT RESPIMATB/D PAR; MO; CG;QLL (240 per 30 days)

2cromolyn inhalation

PAR; MO; CG2cyproheptadinePAR; QLL (30 per 30days)

4DALIRESP

MO; CG2desloratadineMO; CG2diphenhydramine hcl injection solution

50 mg/mlMO; CG2diphenhydramine hcl injection syringeMO; QLL (13 per 30days)

3DULERA

4ELIXOPHYLLIN ORAL ELIXIR 80MG/15 ML


1epinephrine injection auto-injector 0.15mg/0.3 ml, 0.3 mg/0.3 ml


5ESBRIET ORAL CAPSULE


5ESBRIET ORAL TABLET 267 MG






5ESBRIET ORAL TABLET 801 MG

PAR5FIRAZYRMO; QLL (60 per 30days)

3FLOVENT DISKUS INHALATIONBLISTER WITH DEVICE 100MCG/ACTUATION, 50 MCG/ACTUATION


3FLOVENT DISKUS INHALATIONBLISTER WITH DEVICE 250MCG/ACTUATION


3FLOVENT HFA INHALATIONHFA AEROSOL INHALER 110MCG/ACTUATION






1flunisolide nasal spray,non-aerosol 25mcg (0.025 %)


3fluticasone propion-salmeterol inhalationblister with device


1fluticasone propionate nasal

MO; CG; ED1hydrocodone-homatropine oral syrup 5-1.5 mg/5 ml

PAR; MO; CG2hydroxyzine hcl intramuscular





PAR; MO; CG2hydroxyzine hcl oral solution 10 mg/5ml

PAR; MO; CG2hydroxyzine hcl oral tabletPAR; MO; CG2hydroxyzine pamoateB/D PAR; MO; CG1ipratropium bromide inhalationB/D PAR; MO; CG;QLL (540 per 30 days)

2ipratropium-albuterol inhalation


5KALYDECO ORAL GRANULES INPACKET 25 MG






5KALYDECO ORAL TABLET


5LETAIRIS


2levalbuterol hcl inhalation solution fornebulization 0.31 mg/3 ml, 1.25 mg/0.5ml, 1.25 mg/3 ml


2levalbuterol hcl inhalation solution fornebulization 0.63 mg/3 ml


3LEVALBUTEROL HFA

MO; CG2levocetirizine oral tabletMO; CG1metaproterenol oral syrupMO; CG2mometasone nasalMO; CG2montelukast oral granules in packet





MO; CG1montelukast oral tabletMO; CG1montelukast oral tablet,chewablePAR; QLL (60 per 30days)

5OFEV


5OPSUMIT


5ORKAMBI ORAL TABLET


5PERFOROMIST

PAR; MO; CG2phenadozPAR; CG2phenergan rectalMO; QLL (18 per 30days)

3PROAIR HFA

MO; QLL (2 per 30 days)3PROAIR RESPICLICKPAR; MO; CG2promethazine injection solutionPAR; MO; CG2promethazine oralPAR; MO; CG2promethazine rectal suppository 12.5 mg,

25 mgPAR; CG2promethazine rectal suppository 50 mgMO; CG; ED; QLL (180per 30 days)

1promethazine-codeine

MO; CG; ED; QLL (180per 30 days)

1promethazine-dm

PAR; MO; CG2promethazine-phenylephrinePAR; MO; CG2prometheganQLL (14 per 30 days)4PROVENTIL HFAB/D PAR5PULMOZYME





MO; QLL (9 per 30 days)3QVAR INHALATION AEROSOL40 MCG/ACTUATION


3QVAR REDIHALER INHALATIONHFA AEROSOL BREATHACTIVATED 40 MCG/ACTUATION


3QVAR REDIHALER INHALATIONHFA AEROSOL BREATHACTIVATED 80 MCG/ACTUATION


5REVATIO ORAL SUSPENSIONFOR RECONSTITUTION


3SEREVENT DISKUS


5sildenafil (antihypertensive) intravenous


5sildenafil (antihypertensive) oralsuspension for reconstitution


2sildenafil (antihypertensive) oral tablet

MO; QLL (4 per 30 days)3SPIRIVA RESPIMATMO; QLL (30 per 30days)

3SPIRIVA WITH HANDIHALER

MO; QLL (4 per 30 days)3STIOLTO RESPIMATMO; QLL (11 per 30days)

3SYMBICORT

QLL (2 per 28 days)4SYMJEPIPAR; QLL (60 per 30days)

5tadalafil (antihypertensive)





MO; CG1terbutalineMO; CG1theophylline oral tablet extended release

12 hrMO; CG1theophylline oral tablet extended release

24 hrPAR; LA; QLL (60 per30 days)

5TRACLEER ORAL TABLET


5TRACLEER ORAL TABLET FORSUSPENSION

MO; QLL (1 per 30 days)3TUDORZA PRESSAIRPAR; QLL (81.2 per 30days)

5TYVASO


5VENTAVIS


3VENTOLIN HFA


3wixela inhub


5XOLAIR SUBCUTANEOUSRECON SOLN

MO; CG2zafirlukast5zileuton

UrologicalsMO; CG2alfuzosinMO; CG2bethanechol chlorideMO; CG; ED; QLL (4per 30 days)

1CIALIS ORAL TABLET 10 MG, 20MG


2darifenacin






2dutasteride


2dutasteride-tamsulosin

4ELMIRONMO; CG1finasteride oral tablet 5 mgMO; CG1flavoxateST; QLL (30 per 30 days)4GELNIQUE TRANSDERMAL GEL

IN METERED-DOSE PUMP 100MG/GRAM (10 %)

ST; QLL (30 per 30 days)4GELNIQUE TRANSDERMAL GELIN PACKET

QLL (30 per 30 days)4MYRBETRIQMO; CG; QLL (600 per30 days)

1oxybutynin chloride oral syrup


1oxybutynin chloride oral tablet


2oxybutynin chloride oral tablet extendedrelease 24hr 10 mg, 15 mg


2oxybutynin chloride oral tablet extendedrelease 24hr 5 mg

QLL (8 per 28 days)4OXYTROLMO; CG2potassium citrate

5PROCYSBIMO3RAPAFLOMO; CG; ED; QLL (4per 30 days)

1sildenafil

MO; CG2silodosin






2solifenacin

MO; CG1tamsulosinMO; CG; QLL (30 per30 days)

2tolterodine oral capsule,extended release24hr


2tolterodine oral tablet

QLL (30 per 30 days)4TOVIAZMO; CG; QLL (30 per30 days)

2trospium oral capsule,extended release24hr


2trospium oral tablet

QLL (30 per 30 days)4VESICAREVitamins, Hematinics / Electrolytes

B/D PAR3AMINOSYN 10 %B/D PAR4AMINOSYN 7 % WITH

ELECTROLYTESB/D PAR3AMINOSYN 8.5 %B/D PAR3AMINOSYN 8.5 %-

ELECTROLYTESB/D PAR3AMINOSYN II 10 %B/D PAR3AMINOSYN II 15 %B/D PAR3AMINOSYN II 8.5 %B/D PAR3AMINOSYN II 8.5 %-

ELECTROLYTESB/D PAR3AMINOSYN M 3.5 %B/D PAR3AMINOSYN-HBC 7%B/D PAR3AMINOSYN-PF 10 %





B/D PAR3AMINOSYN-PF 7 % (SULFITE-FREE)

B/D PAR4AMINOSYN-RF 5.2 %MO; CG1calcium acetate oral capsuleMO; CG1calcium acetate oral tablet 667 mgB/D PAR3CLINIMIX 5%/D15W SULFITE

FREEB/D PAR3CLINIMIX 5%/D25W SULFITE-

FREEB/D PAR3CLINIMIX 4.25%-D25W SULF-

FREEB/D PAR3CLINIMIX 4.25%/D10W SULF

FREEB/D PAR3CLINIMIX 5%-D20W(SULFITE-

FREE)B/D PAR4CLINIMIX E 4.25%/D10W SUL

FREEB/D PAR3CLINIMIX E 4.25%/D25W SUL

FREEB/D PAR3CLINIMIX E 4.25%/D5W SULF

FREEB/D PAR3CLINIMIX E 5%/D15W SULFIT



FREEB/D PAR3CLINIMIX N14G30E 4.25%-D15W

SF





B/D PAR3CLINIMIX N9G15E 2.75%-D7.5WSF

B/D PAR; MO; CG2clinisol sf 15 %MO; CG; ED1ergocalciferol (vitamin d2) oral capsule

50,000 unitMO; CG; ED1folic acid oral tablet 1 mgB/D PAR4FREAMINE HBC 6.9 %B/D PAR; CG2freamine iii 10 %B/D PAR3HEPATAMINE 8%B/D PAR; CG1intralipid intravenous emulsion 20 %B/D PAR4INTRALIPID INTRAVENOUS

EMULSION 30 %4IONOSOL-MB IN D5W4ISOLYTE S PH 7.44ISOLYTE-P IN 5 % DEXTROSE4ISOLYTE-S

MO; CG1k-tab oral tablet extended release 10meq, 20 meq

MO3k-tab oral tablet extended release 8 meqMO3klor-con 10MO3klor-con 8MO; CG1klor-con m10MO; CG2klor-con m15MO; CG1klor-con m20MO; CG1klor-con sprinkle oral capsule, extended

release 8 meqMO; CG2lactated ringers intravenousMO; CG1magnesium sulfate injection solution





CG1magnesium sulfate injection syringeB/D PAR3NEPHRAMINE 5.4 %CG1normosol-m in 5 % dextroseCG1normosol-r in 5 % dextrose

4NORMOSOL-R PH 7.4B/D PAR; CG1nutrilipid

4PHOSLYRA4PLASMA-LYTE 1484PLASMA-LYTE A

B/D PAR; CG2plenamineCG1potassium chlorid-d5-0.45%nacl

intravenous parenteral solution 10 meq/l, 30 meq/l, 40 meq/l

MO; CG1potassium chlorid-d5-0.45%naclintravenous parenteral solution 20 meq/l

CG1potassium chloride in 0.9%naclintravenous parenteral solution 20 meq/l, 40 meq/l

CG1potassium chloride in 5 % dexintravenous parenteral solution 20 meq/l, 30 meq/l, 40 meq/l

MO; CG2potassium chloride in lr-d5 intravenousparenteral solution 20 meq/l

CG2potassium chloride in lr-d5 intravenousparenteral solution 40 meq/l





MO; CG1potassium chloride in water intravenouspiggyback 10 meq/100 ml, 10 meq/50ml

CG1potassium chloride in water intravenouspiggyback 20 meq/100 ml, 20 meq/50ml, 40 meq/100 ml

MO; CG1potassium chloride intravenousMO; CG1potassium chloride oral capsule, extended

releaseMO; CG1potassium chloride oral liquidMO; CG1potassium chloride oral tablet extended

releaseMO; CG1potassium chloride oral tablet,er particles/

crystalsCG1potassium chloride-0.45 % naclMO; CG1potassium chloride-d5-0.2%nacl

intravenous parenteral solution 20 meq/l

CG1potassium chloride-d5-0.2%naclintravenous parenteral solution 30 meq/l, 40 meq/l

CG1potassium chloride-d5-0.3%naclintravenous parenteral solution 20 meq/l

MO; CG1potassium chloride-d5-0.9%naclintravenous parenteral solution 20 meq/l





CG2potassium chloride-d5-0.9%naclintravenous parenteral solution 40 meq/l

B/D PAR; MO; CG2premasol 10 %B/D PAR3PREMASOL 6 %B/D PAR3PROCALAMINE 3%B/D PAR; MO3PROSOL 20 %MO; CG1sodium chloride 0.45 % intravenous

parenteral solutionCG1sodium chloride 0.45 % intravenous

piggybackMO; CG1sodium chloride 3% intravenous

injection solutionMO; CG1sodium chloride 5% intravenous

injection solutionMO; CG1sodium chloride intravenous parenteral

solution 2.5 meq/mlB/D PAR; MO; CG2travasol 10 %B/D PAR; MO3TROPHAMINE 10 %B/D PAR3TROPHAMINE 6%


Index of DrugsLegendGeneric drugs are shown in lowercase italic (e.g., atenolol).

Brand-name drugs are shown in capital letters (e.g., SPIRIVA).

The Index provides an alphabetical list of all of the drugs included in this document. Bothbrand-name drugs and generic drugs are listed. Find your drug. Next to your drug, you willsee the page number where you can find coverage information. Turn to the page listed inthe Index and find the name of your drug in the first column of the list.

Índice de medicamentosLeyendaLos medicamentos genéricos figuran en letra minúscula y cursiva (por ej., atenolol).

Los medicamentos de marca figuran en letra mayúscula (por ej., SPIRIVA).

El Índice brinda una lista alfabética de todos los medicamentos incluidos en este documento.Tanto los medicamentos de marca como los medicamentos genéricos se enumeran en elÍndice. Encuentre su medicamento. Al lado de su medicamento verá el número de páginaen la que puede encontrar información de cobertura. Vaya a la página que se enumera enel Índice y encuentre el nombre de su medicamento en la primera columna de la lista.

Drug Name PageNombre del Medicamento Páginaabacavir oral solution............................25abacavir oral tablet................................25abacavir-lamivudine.............................25abacavir-lamivudine-zidovudine............25ABELCET...........................................25ABILIFY MAINTENA........................61abiraterone............................................42ABSTRAL SUBLINGUAL TABLET

200 MCG, 800 MCG.......................61acamprosate........................................121acarbose oral tablet 100 mg..................125acarbose oral tablet 25 mg....................125

acarbose oral tablet 50 mg....................126acebutolol............................................101acetaminophen-codeine oral solution 120

mg-12 mg /5 ml (5 ml), 240 mg-24 mg/10 ml (10 ml), 300 mg-30 mg /12.5ml......................................................61

acetaminophen-codeine oral solution 120-12 mg/5 ml.........................................61

acetaminophen-codeine oral tablet..........61acetazolamide oral capsule, extended

release...............................................163acetazolamide oral tablet......................163

Simply_19261_ED_CG12_v15_1908_1 182 Effective Date August 1, 2019

acetazolamide sodium solution forinjection...........................................163

acetic acid otic (ear).............................125acetylcysteine.......................................167acitretin oral capsule 10 mg..................113acitretin oral capsule 17.5 mg, 25

mg....................................................113ACTHAR H.P...................................126ACTHIB (PF)....................................147ACTIMMUNE.................................147ACTOPLUS MET XR ORAL

TABLET, ER MULTIPHASE 24 HR15-1,000 MG..................................126

ACTOPLUS MET XR ORALTABLET, ER MULTIPHASE 24 HR30-1,000 MG..................................126

ACUVAIL (PF)..................................163acyclovir oral capsule..............................25acyclovir oral suspension 200 mg/5 ml.....25acyclovir oral tablet................................25acyclovir sodium 50 mg/ml intravenous

solution...............................................25acyclovir topical cream.........................113acyclovir topical ointment.....................113ACZONE TOPICAL GEL WITH

PUMP.............................................113ADACEL(TDAP ADOLESN/

ADULT)(PF)...................................147ADAGEN..........................................121adapalene topical cream.......................113adapalene topical gel............................113adapalene topical gel with pump...........113ADCIRCA.........................................167adefovir................................................25ADEMPAS........................................167adrenalin injection solution 1 mg/ml....167

adriamycin intravenous recon soln 10mg......................................................42

adriamycin intravenous solution.............42adrucil intravenous solution 2.5 gram/50

ml......................................................42adrucil intravenous solution 5 gram/100

ml, 500 mg/10 ml...............................42ADVAIR DISKUS.............................167ADVAIR HFA...................................167afeditab cr...........................................101AFINITOR..........................................42AFINITOR DISPERZ........................42ALA-CORT TOPICAL CREAM 1

%.....................................................113ala-cort topical cream 2.5 %................113albendazole...........................................25ALBENZA...........................................25albuterol sulfate inhalation solution for

nebulization 0.63 mg/3 ml, 1.25 mg/3ml....................................................167

albuterol sulfate inhalation solution fornebulization 2.5 mg /3 ml (0.083%)...................................................167

albuterol sulfate inhalation solution fornebulization 2.5 mg/0.5 ml, 5 mg/ml....................................................167

albuterol sulfate oral syrup....................167albuterol sulfate oral tablet...................167albuterol sulfate oral tablet extended

release 12 hr 4 mg.............................167albuterol sulfate oral tablet extended

release 12 hr 8 mg.............................167alclometasone......................................113alcohol pads.........................................126ALDACTAZIDE ORAL TABLET 50-

50 MG............................................101


ALDURAZYME................................126ALECENSA.........................................42alendronate oral solution......................152alendronate oral tablet 10 mg, 5 mg.....152alendronate oral tablet 35 mg, 70

mg....................................................152alendronate oral tablet 40 mg...............121alfuzosin.............................................174ALIMTA..............................................43ALINIA ORAL TABLET.....................25ALIQOPA...........................................43aliskiren..............................................101allopurinol..........................................152almotriptan malate................................61ALOCRIL..........................................163ALOMIDE........................................163alosetron.............................................139ALOXI...............................................139ALPHAGAN P OPHTHALMIC (EYE)

DROPS 0.1 %.................................163alprazolam............................................61alprazolam intensol................................61altavera (28).......................................155ALTOPREV.......................................101ALUNBRIG ORAL TABLET 180

MG...................................................43ALUNBRIG ORAL TABLET 30

MG...................................................43ALUNBRIG ORAL TABLET 90

MG...................................................43ALUNBRIG ORAL TABLETS,DOSE

PACK................................................43alyacen 1/35 (28)................................155alyacen 7/7/7 (28)...............................155amabelz..............................................155amantadine hcl.....................................25

AMBISOME.......................................25ambrisentan........................................167amcinonide topical cream.....................113amcinonide topical lotion.....................113amethia..............................................155amethyst (28)......................................156amikacin injection solution 1,000 mg/4

ml, 500 mg/2 ml.................................25amiloride............................................101amiloride-hydrochlorothiazide..............101aminophylline intravenous...................167AMINOSYN 10 %............................176AMINOSYN 7 % WITH

ELECTROLYTES...........................176AMINOSYN 8.5 %...........................176AMINOSYN 8.5 %-

ELECTROLYTES...........................176AMINOSYN II 10 %........................176AMINOSYN II 15 %........................176AMINOSYN II 8.5 %.......................176AMINOSYN II 8.5 %-

ELECTROLYTES...........................176AMINOSYN M 3.5 %......................176AMINOSYN-HBC 7%.....................176AMINOSYN-PF 10 %......................176AMINOSYN-PF 7 % (SULFITE-

FREE).............................................177AMINOSYN-RF 5.2 %.....................177amiodarone oral..................................101AMITIZA..........................................139amitriptyline.........................................61amitriptyline-chlordiazepoxide...............61amlodipine besylate tablet....................101amlodipine-atorvastatin.......................101amlodipine-benazepril.........................101amlodipine-olmesartan........................102


amlodipine-valsartan...........................102amlodipine-valsartan-

hydrochlorothiazide...........................102ammonium lactate...............................113amnesteem..........................................113amoxapine............................................61amoxicillin oral capsule..........................25amoxicillin oral suspension for

reconstitution......................................25amoxicillin oral tablet............................25amoxicillin oral tablet,chewable 125 mg,

250 mg...............................................25amoxicillin-pot clavulanate....................25amphotericin b......................................26ampicillin oral capsule 500 mg...............26ampicillin sodium injection....................26ampicillin sodium intravenous................26ampicillin-sulbactam injection recon soln

1.5 gram, 3 gram................................26ampicillin-sulbactam injection recon soln

15 gram..............................................26ampicillin-sulbactam intravenous recon

soln 1.5 gram......................................26ampicillin-sulbactam intravenous recon

soln 3 gram.........................................26AMPYRA.............................................62ANADROL-50..................................126anagrelide...........................................121anastrozole............................................43ANDROGEL TRANSDERMAL GEL

IN METERED-DOSE PUMP 20.25MG/1.25 GRAM (1.62 %).............126

ANDROGEL TRANSDERMAL GELIN PACKET 1.62 % (20.25 MG/1.25GRAM)...........................................126

ANDROGEL TRANSDERMAL GELIN PACKET 1.62 % (40.5 MG/2.5GRAM)...........................................126

ANORO ELLIPTA............................168apexicon e...........................................113APIDRA SOLOSTAR U-100

INSULIN........................................126APIDRA U-100 INSULIN................126APOKYN............................................62apraclonidine......................................163aprepitant oral capsule 125 mg.............139aprepitant oral capsule 40 mg...............139aprepitant oral capsule 80 mg...............140aprepitant oral capsule,dose pack..........140apri....................................................156APRISO.............................................140APTENSIO XR...................................62APTIOM.............................................62APTIVUS ORAL CAPSULE...............26APTIVUS ORAL SOLUTION...........26ARALAST NP...................................121aranelle (28).......................................156ARANESP (IN POLYSORBATE)

INJECTION SOLUTION 100MCG/ML, 200 MCG/ML, 300MCG/ML.......................................147

ARANESP (IN POLYSORBATE)INJECTION SOLUTION 25 MCG/ML, 40 MCG/ML, 60 MCG/ML..................................................147

ARANESP (IN POLYSORBATE)INJECTION SYRINGE 10 MCG/0.4 ML, 25 MCG/0.42 ML, 40MCG/0.4 ML, 60 MCG/0.3ML..................................................147

ARANESP (IN POLYSORBATE)INJECTION SYRINGE 100 MCG/


0.5 ML, 150 MCG/0.3 ML, 200MCG/0.4 ML, 300 MCG/0.6 ML,500 MCG/ML................................147

ARCALYST.......................................147ARCAPTA NEOHALER...................168aripiprazole oral solution........................62aripiprazole oral tablet 10 mg................62aripiprazole oral tablet 15 mg................62aripiprazole oral tablet 2 mg..................62aripiprazole oral tablet 20 mg, 30 mg.....62aripiprazole oral tablet 5 mg..................62aripiprazole oral tablet,disintegrating 10

mg......................................................62aripiprazole oral tablet,disintegrating 15

mg......................................................62ARISTADA INITIO...........................62ARISTADA INTRAMUSCULAR

SUSPENSION,EXTENDED RELSYRING 1,064 MG/3.9 ML.............62

ARISTADA INTRAMUSCULARSUSPENSION,EXTENDED RELSYRING 441 MG/1.6 ML................62



armodafinil oral tablet 150 mg, 200 mg,250 mg...............................................63

armodafinil oral tablet 50 mg................63ARNUITY ELLIPTA.........................168ARRANON.........................................43ARSENIC TRIOXIDE........................43ARZERRA...........................................43ASACOL HD....................................140

ascomp with codeine..............................63ashlyna...............................................156ASMANEX HFA...............................168ASMANEX TWISTHALER

INHALATION AEROSOL POWDRBREATH ACTIVATED 110 MCG(30 DOSES), 220 MCG (120DOSES), 220 MCG (30 DOSES),220 MCG (60 DOSES)...................168

ASMANEX TWISTHALERINHALATION AEROSOL POWDRBREATH ACTIVATED 220 MCG(14 DOSES)....................................168

aspirin-dipyridamole............................102ASTAGRAF XL...................................43atazanavir oral capsule 150 mg, 200

mg......................................................26atazanavir oral capsule 300 mg..............26atenolol...............................................102atenolol-chlorthalidone........................102ATGAM............................................147atomoxetine oral capsule 10 mg, 18 mg,

25 mg, 40 mg.....................................63atomoxetine oral capsule 100 mg, 60 mg,

80 mg.................................................63atorvastatin.........................................102atovaquone............................................26atovaquone-proguanil............................26ATRIPLA.............................................26atropine injection syringe 0.05 mg/

ml....................................................140atropine injection syringe 0.1 mg/ml.....140atropine ophthalmic (eye) drops............163ATROVENT HFA............................168AUBAGIO...........................................63aubra..................................................156


AVANDIA ORAL TABLET 2MG.................................................126

AVANDIA ORAL TABLET 4MG.................................................126

AVASTIN............................................43AVELOX IN NACL (ISO-

OSMOTIC)......................................26aviane.................................................156AVONEX (WITH ALBUMIN)........147AVONEX INTRAMUSCULAR PEN

INJECTOR KIT.............................147AVONEX INTRAMUSCULAR

SYRINGE KIT................................147AVYCAZ.............................................26azacitidine............................................43AZASAN.............................................43azathioprine..........................................43azathioprine sodium solution for

injection.............................................43azelaic acid.........................................113azelastine nasal...................................125azelastine ophthalmic (eye)...................163AZELEX............................................113azithromycin intravenous.......................26azithromycin oral packet........................26azithromycin oral suspension for

reconstitution......................................26azithromycin oral tablet 250 mg, 250 mg

(6 pack), 500 mg, 600 mg...................26AZOPT.............................................163aztreonam.............................................27azurette (28).......................................156bacitracin ophthalmic (eye)..................163bacitracin-polymyxin b ophthalmic

(eye).................................................163baclofen oral..........................................63

balsalazide..........................................140BALVERSA ORAL TABLET 3

MG...................................................43BALVERSA ORAL TABLET 4

MG...................................................43BALVERSA ORAL TABLET 5

MG...................................................43balziva (28)........................................156BANZEL ORAL SUSPENSION.........63BANZEL ORAL TABLET 200

MG...................................................63BANZEL ORAL TABLET 400

MG...................................................63BARACLUDE ORAL

SOLUTION.....................................27BAVENCIO........................................43BCG VACCINE, LIVE (PF).............147bekyree (28)........................................156BELBUCA...........................................63BELEODAQ.......................................44benazepril...........................................102benazepril-hydrochlorothiazide.............102BENLYSTA.......................................152benzonatate oral capsule 100 mg, 200

mg....................................................168benztropine injection.............................63benztropine oral....................................63BEPREVE.........................................163BESPONSA.........................................44betamethasone dipropionate.................113betamethasone valerate.........................113betamethasone, augmented...................113BETASERON SUBCUTANEOUS

KIT.................................................148betaxolol ophthalmic (eye)....................163betaxolol oral.......................................102


bethanechol chloride............................174BETHKIS............................................27BETIMOL.........................................164BETOPTIC S....................................164bexarotene.............................................44BEXSERO.........................................148bicalutamide.........................................44BICILLIN C-R....................................27BICILLIN L-A.....................................27BICNU................................................44BIDIL................................................102BIKTARVY..........................................27BILTRICIDE.......................................27bimatoprost ophthalmic (eye)................164bisoprolol fumarate..............................102bisoprolol-hydrochlorothiazide..............102bleomycin..............................................44BLEPHAMIDE.................................164BLEPHAMIDE S.O.P.......................164BLINCYTO INTRAVENOUS

KIT...................................................44blisovi 24 fe........................................156blisovi fe 1.5/30 (28)...........................156blisovi fe 1/20 (28)..............................156BOOSTRIX TDAP...........................148BORTEZOMIB..................................44bosentan.............................................168BOSULIF ORAL TABLET 100

MG...................................................44BOSULIF ORAL TABLET 400 MG,

500 MG............................................44BOTOX.............................................148BRAFTOVI ORAL CAPSULE 50

MG...................................................44BRAFTOVI ORAL CAPSULE 75

MG...................................................44

BREO ELLIPTA................................168briellyn...............................................156BRILINTA........................................102brimonidine........................................164BRIVIACT INTRAVENOUS.............64BRIVIACT ORAL SOLUTION.........64BRIVIACT ORAL TABLET 10

MG...................................................64BRIVIACT ORAL TABLET 100 MG,

75 MG..............................................64BRIVIACT ORAL TABLET 25

MG...................................................64BRIVIACT ORAL TABLET 50

MG...................................................64bromfenac...........................................164bromocriptine........................................64BROVANA........................................168budesonide inhalation suspension for

nebulization 0.25 mg/2 ml, 0.5 mg/2ml....................................................168

budesonide inhalation suspension fornebulization 1 mg/2 ml.....................169

budesonide oral capsule,delayed,extend.release....................................140

budesonide oral tablet,delayed andext.release..........................................140

bumetanide.........................................102BUPHENYL ORAL TABLET...........121buprenorphine hcl sublingual tablet 2

mg......................................................64buprenorphine hcl sublingual tablet 8

mg......................................................64buprenorphine transdermal patch weekly

10 mcg/hour, 15 mcg/hour, 20 mcg/hour, 5 mcg/hour.................................64


BUPRENORPHINETRANSDERMAL PATCH WEEKLY7.5 MCG/HOUR.............................64

buprenorphine-naloxone sublingual tablet2-0.5 mg............................................64

buprenorphine-naloxone sublingual tablet8-2 mg...............................................64

bupropion hcl (smoking deter)..............121bupropion hcl oral tablet 100 mg............64bupropion hcl oral tablet 75 mg..............65bupropion hcl oral tablet extended release

24 hr 150 mg.....................................65bupropion hcl oral tablet extended release

24 hr 300 mg.....................................65bupropion hcl oral tablet sustained-release

12 hr 100 mg.....................................65bupropion hcl oral tablet sustained-release

12 hr 150 mg, 200 mg........................65buspirone..............................................65busulfan................................................44BUSULFEX.........................................44butalbital compound w/codeine..............65butalbital-acetaminophen oral tablet 50-

325 mg...............................................65butalbital-acetaminophen-caff oral tablet

50-325-40 mg....................................65butorphanol tartrate injection solution 1

mg/ml.................................................65butorphanol tartrate injection solution 2

mg/ml.................................................65butorphanol tartrate nasal......................65BUTRANS TRANSDERMAL PATCH

WEEKLY 7.5 MCG/HOUR.............65BYDUREON BCISE........................126BYDUREON SUBCUTANEOUS

PEN INJECTOR............................127

BYETTA SUBCUTANEOUS PENINJECTOR 10 MCG/DOSE(250MCG/ML) 2.4 ML.........................127

BYETTA SUBCUTANEOUS PENINJECTOR 5 MCG/DOSE (250MCG/ML) 1.2 ML.........................127

BYSTOLIC........................................102cabergoline..........................................127CABOMETYX....................................44calcipotriene scalp................................114calcipotriene topical.............................114calcipotriene-betamethasone.................114calcitonin (salmon)..............................127calcitrene.............................................114calcitriol oral capsule............................127calcitriol topical...................................114calcium acetate oral capsule..................177calcium acetate oral tablet 667 mg........177CALQUENCE....................................44camila................................................156camrese...............................................156CANASA...........................................140candesartan.........................................102candesartan-hydrochlorothiazide...........102CAPASTAT.........................................27CAPEX..............................................114CAPRELSA ORAL TABLET 100

MG...................................................44CAPRELSA ORAL TABLET 300

MG...................................................44captopril.............................................102captopril-hydrochlorothiazide...............102carafate oral suspension........................140CARBAGLU.....................................121carbamazepine oral capsule, er multiphase

12 hr..................................................65


carbamazepine oral suspension 100 mg/5ml......................................................66

carbamazepine oral suspension 200 mg/10 ml.................................................66

carbamazepine oral tablet......................66carbamazepine oral tablet extended release

12 hr..................................................66carbamazepine oral tablet,chewable........66CARBATROL.....................................66carbidopa..............................................66carbidopa-levodopa oral tablet................66carbidopa-levodopa oral tablet extended

release.................................................66carbidopa-levodopa-entacapone..............66carbinoxamine maleate oral liquid.......169carbinoxamine maleate oral tablet 4

mg....................................................169carboplatin intravenous solution.............44CARDIZEM LA ORAL TABLET

EXTENDED RELEASE 24 HR 120MG.................................................102

carisoprodol oral tablet 250 mg..............66carmustine............................................44carteolol..............................................164cartia xt..............................................102carvedilol............................................103CAYSTON..........................................27caziant (28)........................................156cefaclor oral capsule...............................27cefaclor oral suspension for reconstitution

125 mg/5 ml, 250 mg/5 ml.................27cefaclor oral suspension for reconstitution

375 mg/5 ml.......................................27cefadroxil oral capsule............................27cefadroxil oral suspension for reconstitution

250 mg/5 ml, 500 mg/5 ml.................27

cefadroxil oral tablet..............................27cefazolin injection recon soln 1 gram, 500

mg......................................................27cefazolin injection recon soln 10 gram,

100 gram, 20 gram, 300 g...................27cefazolin intravenous.............................27cefdinir.................................................27cefepime in dextrose 5 %........................27cefepime injection..................................27cefixime................................................27cefotaxime injection recon soln 1 gram,

500 mg...............................................28cefotetan injection solution.....................28cefoxitin in dextrose, iso-osm...................28cefoxitin intravenous recon soln 1 gram,

2 gram................................................28cefoxitin intravenous recon soln 10

gram...................................................28cefpodoxime...........................................28cefprozil................................................28ceftazidime injection recon soln 1 gram,

2 gram................................................28ceftazidime injection recon soln 6

gram...................................................28ceftriaxone injection recon soln 1 gram, 2

gram, 250 mg, 500 mg........................28ceftriaxone injection recon soln 10 gram,

100 gram............................................28ceftriaxone intravenous..........................28cefuroxime axetil oral tablet....................28cefuroxime sodium injection recon soln

750 mg...............................................28cefuroxime sodium intravenous recon soln

1.5 gram.............................................28cefuroxime sodium intravenous recon soln

7.5 gram.............................................28


celecoxib................................................66CELONTIN ORAL CAPSULE 300

MG...................................................66cephalexin oral capsule...........................28cephalexin oral suspension for

reconstitution......................................28CERDELGA......................................127CEREBYX INJECTION SOLUTION

500 MG PE/10 ML...........................66CEREZYME INTRAVENOUS

RECON SOLN 400 UNIT............127cetirizine oral solution 1 mg/ml............169cevimeline...........................................121CHANTIX........................................121CHANTIX CONTINUING MONTH

BOX................................................121CHANTIX STARTING MONTH

BOX................................................121chateal (28)........................................156CHENODAL....................................140chloramphenicol sod succinate.................28chlordiazepoxide hcl...............................66chlordiazepoxide-clidinium..................140chlorhexidine gluconate mucous

membrane.........................................125chloroquine phosphate............................29chlorothiazide......................................103chlorpromazine......................................66chlorthalidone oral tablet 25 mg, 50

mg....................................................103chlorzoxazone oral tablet 250 mg...........66chlorzoxazone oral tablet 500 mg...........66CHOLBAM......................................140cholestyramine light.............................103chorionic gonadotropin, human

intramuscular...................................127

CIALIS ORAL TABLET 10 MG, 20MG.................................................174

ciclodan topical solution.......................114ciclopirox............................................114cidofovir................................................29cilostazol.............................................103CIMDUO...........................................29cimetidine...........................................140cimetidine hcl oral...............................140cinacalcet oral tablet 30 mg, 60 mg......127cinacalcet oral tablet 90 mg..................127CINRYZE.........................................169CIPRO HC.......................................125CIPRODEX......................................125ciprofloxacin (mixture) oral tablet, er

multiphase 24 hr 500 mg, 1,000mg......................................................29

ciprofloxacin hcl ophthalmic (eye).........164ciprofloxacin hcl oral tablet....................29ciprofloxacin in 5 % dextrose.................29ciprofloxacin oral suspension...................29cisplatin intravenous solution.................45citalopram oral solution.........................66citalopram oral tablet 10 mg..................67citalopram oral tablet 20 mg..................67citalopram oral tablet 40 mg..................67cladribine.............................................45claravis oral capsule 10 mg, 20 mg, 40

mg....................................................114CLARAVIS ORAL CAPSULE 30

MG.................................................114clarithromycin.......................................29clemastine oral tablet 2.68 mg..............169CLEOCIN VAGINAL

SUPPOSITORY..............................156clindacin etz topical swab....................114


clindacin p..........................................114clindamycin hcl.....................................29clindamycin in 5 % dextrose..................29clindamycin palmitate hcl......................29clindamycin pediatric............................29clindamycin phosphate injection solution

150 mg/ml..........................................29clindamycin phosphate intravenous

solution 300 mg/2 ml, 900 mg/6 ml.....29clindamycin phosphate intravenous

solution 600 mg/4 ml..........................29clindamycin phosphate topical foam......114clindamycin phosphate topical gel.........114clindamycin phosphate topical lotion.....114clindamycin phosphate topical

solution.............................................114clindamycin phosphate topical swab......114clindamycin phosphate vaginal.............156clindamycin-benzoyl peroxide topical

gel....................................................114clindamycin-tretinoin..........................114CLINIMIX 4.25%-D25W SULF-

FREE...............................................177CLINIMIX 4.25%/D10W SULF

FREE...............................................177CLINIMIX 4.25%/D5W SULFIT

FREE...............................................122CLINIMIX 5%-D20W(SULFITE-

FREE).............................................177CLINIMIX 5%/D15W SULFITE

FREE...............................................177CLINIMIX 5%/D25W SULFITE-

FREE...............................................177CLINIMIX E 2.75%/D10W SUL

FREE...............................................122

CLINIMIX E 2.75%/D5W SULFFREE...............................................122

CLINIMIX E 4.25%/D10W SULFREE...............................................177

CLINIMIX E 4.25%/D25W SULFREE...............................................177

CLINIMIX E 4.25%/D5W SULFFREE...............................................177

CLINIMIX E 5%/D15W SULFITFREE...............................................177



CLINIMIX N14G30E 4.25%-D15WSF....................................................177

CLINIMIX N9G15E 2.75%-D7.5WSF....................................................178

CLINIMIX N9G20E 2.75%-D10W(SF)......................................122

clinisol sf 15 %....................................178clobazam oral suspension........................67clobazam oral tablet 10 mg....................67clobazam oral tablet 20 mg....................67clobetasol scalp.....................................114clobetasol topical foam.........................114clobetasol topical gel.............................114clobetasol topical lotion........................114clobetasol topical ointment...................115clobetasol topical shampoo....................115clobetasol topical spray,non-aerosol........115clobetasol-emollient topical cream.........115clodan.................................................115clofarabine............................................45CLOLAR.............................................45clomipramine........................................67


clonazepam oral tablet 0.5 mg................67clonazepam oral tablet 1 mg...................67clonazepam oral tablet 2 mg...................67clonazepam oral tablet,disintegrating

0.125 mg............................................67clonazepam oral tablet,disintegrating 0.25

mg......................................................67clonazepam oral tablet,disintegrating 0.5

mg......................................................67clonazepam oral tablet,disintegrating 1

mg......................................................67clonazepam oral tablet,disintegrating 2

mg......................................................67clonidine hcl oral tablet........................103clonidine transdermal patch.................103clopidogrel oral tablet 300 mg..............103clopidogrel oral tablet 75 mg................103clorazepate dipotassium..........................68clotrimazole mucous membrane..............29clotrimazole topical cream....................115clotrimazole topical solution.................115clotrimazole-betamethasone topical

cream...............................................115clotrimazole-betamethasone topical

lotion................................................115clozapine oral tablet 100 mg..................68clozapine oral tablet 200 mg..................68clozapine oral tablet 25 mg....................68clozapine oral tablet 50 mg....................68clozapine oral tablet,disintegrating 100

mg......................................................68clozapine oral tablet,disintegrating 12.5

mg......................................................68clozapine oral tablet,disintegrating 150

mg......................................................68

CLOZAPINE ORAL TABLET,DISINTEGRATING 200 MG..........68

clozapine oral tablet,disintegrating 25mg......................................................68

COARTEM.........................................29codeine sulfate oral tablet.......................68codeine-butalbital-asa-caff.....................68colchicine oral tablet............................152colesevelam oral tablet..........................103colestipol.............................................103colistin (colistimethate na)......................29colocort...............................................140COLY-MYCIN S...............................125COMBIGAN....................................164COMBIPATCH................................156COMBIVENT RESPIMAT..............169COMETRIQ ORAL CAPSULE 100

MG/DAY(80 MG X1-20 MGX1)....................................................45

COMETRIQ ORAL CAPSULE 140MG/DAY(80 MG X1-20 MGX3)....................................................45

COMETRIQ ORAL CAPSULE 60MG/DAY (20 MG X 3/DAY)............45

compazine rectal..................................140COMPLERA.......................................29compro................................................140constulose............................................140COPAXONE SUBCUTANEOUS

SYRINGE 40 MG/ML......................68COPIKTRA........................................45CORLANOR....................................103cortisone..............................................127CORTISPORIN TOPICAL..............115COSENTYX.....................................115COSENTYX (2 SYRINGES)............115


COSENTYX PEN.............................115COSENTYX PEN (2 PENS).............115COTELLIC.........................................45COUMADIN ORAL........................103CREON............................................140CRESEMBA........................................29CRINONE........................................156CRIXIVAN ORAL CAPSULE 200

MG...................................................29CRIXIVAN ORAL CAPSULE 400

MG...................................................29cromolyn inhalation.............................169cromolyn ophthalmic (eye)....................164crotan.................................................115cryselle (28).........................................156cyclafem 1/35 (28)..............................156cyclafem 7/7/7 (28).............................156cyclobenzaprine oral tablet.....................68cyclophosphamide oral capsule................45CYCLOSET......................................127cyclosporine intravenous.........................45cyclosporine modified.............................45cyclosporine oral capsule.........................45cyproheptadine....................................169CYRAMZA.........................................45cyred...................................................156CYSTADANE...................................140CYSTARAN......................................164cytarabine.............................................45cytarabine (pf ) injection solution 100 mg/

5 ml (20 mg/ml), 2 gram/20 ml (100mg/ml)...............................................45

cytarabine (pf ) injection solution 20 mg/ml......................................................45

d10 %-0.45 % sodium chloride...........122d2.5 %-0.45 % sodium chloride..........122

d5 % and 0.9 % sodium chloride.........122d5 %-0.45 % sodium chloride.............122dacarbazine..........................................45dactinomycin.........................................45dalfampridine.......................................68DALIRESP........................................169DALVANCE........................................30danazol...............................................127dantrolene.............................................69dapsone oral..........................................30dapsone topical....................................115DAPTACEL (DTAP PEDIATRIC)

(PF).................................................148DAPTOMYCIN INTRAVENOUS

RECON SOLN 350 MG..................30daptomycin intravenous recon soln 500

mg......................................................30DARAPRIM........................................30darifenacin.........................................174DARZALEX........................................45dasetta 1/35 (28).................................156dasetta 7/7/7 (28)................................157daunorubicin intravenous solution..........46DAURISMO ORAL TABLET 100

MG...................................................46DAURISMO ORAL TABLET 25

MG...................................................46daysee.................................................157DAYTRANA.......................................69deblitane.............................................157decitabine.............................................46deferasirox...........................................122DELSTRIGO......................................30deltasone oral tablet 20 mg...................127delyla (28)..........................................157demeclocycline.......................................30


DEMSER..........................................103DENAVIR.........................................115DEPEN TITRATABS........................152DEPO-ESTRADIOL........................157DEPO-PROVERA

INTRAMUSCULAR SUSPENSION400 MG/ML...................................157

DEPO-SUBQ PROVERA 104..........157DESCOVY..........................................30desipramine...........................................69desloratadine.......................................169desmopressin injection..........................127desmopressin nasal spray with pump......127desmopressin nasal spray,non-aerosol.....128desmopressin oral.................................128desog-e.estradiol/e.estradiol...................157desogestrel-ethinyl estradiol...................157DESONATE.....................................115desonide..............................................115desoximetasone topical cream................115desoximetasone topical gel.....................115desoximetasone topical ointment...........115desvenlafaxine succinate oral tablet

extended release 24 hr 100 mg.............69desvenlafaxine succinate oral tablet

extended release 24 hr 25 mg...............69desvenlafaxine succinate oral tablet

extended release 24 hr 50 mg...............69dexamethasone intensol........................128dexamethasone oral elixir.....................128dexamethasone oral solution.................128dexamethasone oral tablet....................128dexamethasone sodium phos (pf )...........128dexamethasone sodium phosphate

injection...........................................128

dexamethasone sodium phosphateophthalmic (eye)................................164

DEXILANT......................................140dexmethylphenidate oral capsule,er

biphasic 50-50 10 mg, 15 mg, 25 mg,30 mg, 35 mg, 40 mg, 5 mg................69

dexmethylphenidate oral capsule,erbiphasic 50-50 20 mg.........................69

dexmethylphenidate oral tablet...............69dexrazoxane hcl.....................................46dextroamphetamine oral capsule, extended

release 10 mg, 5 mg.............................69dextroamphetamine oral capsule, extended

release 15 mg......................................69dextroamphetamine oral solution............69dextroamphetamine oral tablet 10 mg.....69dextroamphetamine oral tablet 5 mg.......69dextroamphetamine-amphetamine oral

capsule,extended release 24hr...............69dextroamphetamine-amphetamine oral

tablet 10 mg, 12.5 mg, 15 mg, 20 mg,5 mg, 7.5 mg......................................70

dextroamphetamine-amphetamine oraltablet 30 mg.......................................70

dextrose 10 % and 0.2 % nacl.............122dextrose 10 % in water (d10w)............122dextrose 20 % in water (d20w)............122dextrose 25 % in water (d25w)............122dextrose 30 % in water (d30w)............122dextrose 40 % in water (d40w)............122dextrose 5 % in water (d5w)................122dextrose 5 %-lactated ringers................122dextrose 5%-0.2 % sod chloride...........122dextrose 5%-0.3 % sod.chloride...........122dextrose 50 % in water (d50w)............122dextrose 70 % in water (d70w)............122


dextrose with sodium chloride...............122DIASTAT............................................70DIASTAT ACUDIAL RECTAL KIT

12.5-15-17.5-20 MG.........................70DIASTAT ACUDIAL RECTAL KIT

5-7.5-10 MG.....................................70diazepam oral solution 5 mg/5 ml (1 mg/

ml).....................................................70diazepam oral solution 5 mg/5 ml (1 mg/

ml, 5 ml)............................................70diazepam oral tablet 10 mg....................70diazepam oral tablet 2 mg......................70diazepam oral tablet 5 mg......................70diazepam rectal.....................................70DIBENZYLINE................................103DICLOFENAC EPOLAMINE...........70diclofenac potassium..............................70diclofenac sodium ophthalmic (eye).......164diclofenac sodium oral............................70diclofenac sodium topical drops...............70diclofenac sodium topical gel 1 %...........71diclofenac sodium topical gel 3 %.........116diclofenac-misoprostol............................71dicloxacillin..........................................30dicyclomine intramuscular...................141dicyclomine oral capsule.......................141dicyclomine oral solution......................141dicyclomine oral tablet.........................141didanosine oral capsule,delayed release(dr/

ec) 200 mg..........................................30didanosine oral capsule,delayed release(dr/

ec) 250 mg, 400 mg............................30DIFICID.............................................30diflorasone...........................................116diflunisal..............................................71digitek oral tablet 125 mcg...................103

digitek oral tablet 250 mcg...................103digox oral tablet 125 mcg.....................103digox oral tablet 250 mcg.....................103digoxin injection solution.....................103digoxin oral solution 50 mcg/ml............103digoxin oral tablet 125 mcg..................103digoxin oral tablet 250 mcg..................103dihydroergotamine injection...................71dihydroergotamine nasal........................71DILANTIN EXTENDED ORAL

CAPSULE 100 MG..........................71DILANTIN INFATABS......................71DILANTIN ORAL CAPSULE 30

MG...................................................71DILANTIN-125..................................71DILATRATE-SR...............................103dilt-xr.................................................104diltiazem hcl oral capsule,ext.rel 24h

degradable........................................104diltiazem hcl oral capsule,extended release

12 hr................................................104diltiazem hcl oral capsule,extended release

24 hr................................................104diltiazem hcl oral capsule,extended release

24hr.................................................104diltiazem hcl oral tablet.......................104diltiazem hcl oral tablet extended release

24 hr................................................104DIPENTUM.....................................141diphenhydramine hcl injection solution

50 mg/ml..........................................169diphenhydramine hcl injection

syringe..............................................169diphenoxylate-atropine.........................141disopyramide phosphate oral capsule......104disulfiram...........................................122


divalproex.............................................71DIVIGEL..........................................157docetaxel intravenous solution 160 mg/16

ml (10 mg/ml), 160 mg/8 ml (20 mg/ml), 20 mg/2 ml (10 mg/ml), 20 mg/ml(1 ml), 80 mg/4 ml (20 mg/ml), 80 mg/8 ml (10 mg/ml).................................46

DOCETAXEL INTRAVENOUSSOLUTION 20 MG/ML..................46

dofetilide.............................................104donepezil..............................................71DORIPENEM....................................30dorzolamide........................................164dorzolamide-timolol............................164DOVATO............................................30doxazosin............................................104doxepin oral..........................................71doxepin topical....................................116doxercalciferol intravenous....................128doxercalciferol oral capsule 0.5 mcg.......128doxercalciferol oral capsule 1 mcg..........128doxercalciferol oral capsule 2.5 mcg.......128doxorubicin intravenous recon soln 10

mg......................................................46doxorubicin intravenous recon soln 50

mg......................................................46doxorubicin intravenous solution............46doxorubicin, peg-liposomal.....................46doxy-100..............................................30doxycycline hyclate intravenous...............30doxycycline hyclate oral capsule...............30doxycycline hyclate oral tablet 100 mg,

150 mg, 20 mg, 75 mg........................30doxycycline hyclate oral tablet,delayed

release (dr/ec) 100 mg, 150 mg, 200 mg,50 mg, 75 mg.....................................30

doxycycline monohydrate oral capsule......30doxycycline monohydrate oral suspension

for reconstitution.................................31doxycycline monohydrate oral tablet........31dronabinol oral capsule 10 mg..............141dronabinol oral capsule 2.5 mg, 5

mg....................................................141drospirenone-e.estradiol-lm.fa oral tablet

3-0.02-0.451 mg (24) (4).................157drospirenone-ethinyl estradiol...............157DROXIA.............................................46DULERA...........................................169duloxetine oral capsule,delayed release(dr/

ec) 20 mg............................................71duloxetine oral capsule,delayed release(dr/



ec) 60 mg............................................71duramorph (pf ) injection solution 0.5 mg/

ml......................................................71duramorph (pf ) injection solution 1 mg/

ml......................................................71DUREZOL.......................................164dutasteride..........................................175dutasteride-tamsulosin.........................175DUTOPROL....................................104DYRENIUM.....................................104e.e.s. 400 oral tablet...............................31ec-naproxen...........................................72econazole.............................................116EDARBI............................................104EDURANT.........................................31efavirenz oral capsule 200 mg.................31efavirenz oral capsule 50 mg...................31


efavirenz oral tablet...............................31ELAPRASE........................................128ELESTRIN........................................157eletriptan..............................................72ELIDEL.............................................116ELIGARD...........................................46ELIGARD (3 MONTH).....................46ELIGARD (4 MONTH).....................46ELIGARD (6 MONTH).....................47elinest.................................................157ELIQUIS ORAL TABLET 2.5

MG.................................................104ELIQUIS ORAL TABLET 5 MG......104ELIQUIS ORAL TABLETS,DOSE

PACK..............................................104ELITEK...............................................47ELIXOPHYLLIN ORAL ELIXIR 80

MG/15 ML.....................................169ELLA.................................................157ELMIRON........................................175EMCYT...............................................47EMEND (FOSAPREPITANT).........141EMEND ORAL CAPSULE 125

MG.................................................141EMEND ORAL CAPSULE 40

MG.................................................141EMEND ORAL SUSPENSION FOR

RECONSTITUTION....................141emoquette...........................................157EMPLICITI........................................47EMSAM..............................................72EMTRIVA ORAL CAPSULE.............31EMTRIVA ORAL SOLUTION..........31enalapril maleate.................................104enalapril-hydrochlorothiazide...............104ENBREL MINI.................................153

ENBREL SUBCUTANEOUS RECONSOLN..............................................153

ENBREL SUBCUTANEOUSSYRINGE 25 MG/0.5ML(0.51)..............................................153

ENBREL SUBCUTANEOUSSYRINGE 50 MG/ML (0.98ML).................................................153

ENBREL SURECLICK.....................153endocet oral tablet 10-325 mg, 2.5-325

mg, 5-325 mg, 7.5-325 mg.................72ENGERIX-B (PF).............................148ENGERIX-B PEDIATRIC (PF)

INTRAMUSCULAR SYRINGE.....148enoxaparin subcutaneous solution.........104enoxaparin subcutaneous syringe 100 mg/

ml, 150 mg/ml..................................105enoxaparin subcutaneous syringe 120 mg/

0.8 ml..............................................105enoxaparin subcutaneous syringe 30 mg/




0.8 ml..............................................105enpresse...............................................157enskyce................................................157entacapone............................................72entecavir...............................................31ENTRESTO......................................105ENTYVIO.........................................141enulose................................................141ENVARSUS XR..................................47EPCLUSA...........................................31


EPIDIOLEX........................................72epinastine............................................164epinephrine injection auto-injector 0.15

mg/0.3 ml, 0.3 mg/0.3 ml.................169epirubicin intravenous solution...............47epitol....................................................72eplerenone...........................................105EPOGEN INJECTION SOLUTION

10,000 UNIT/ML, 2,000 UNIT/ML,20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML..................................................148

eprosartan...........................................105EQUETRO ORAL CAPSULE, ER

MULTIPHASE 12 HR 100 MG.......72EQUETRO ORAL CAPSULE, ER

MULTIPHASE 12 HR 200 MG.......72EQUETRO ORAL CAPSULE, ER

MULTIPHASE 12 HR 300 MG.......72ERBITUX...........................................47ergocalciferol (vitamin d2) oral capsule

50,000 unit......................................178ergoloid.................................................72ERIVEDGE.........................................47ERLEADA...........................................47erlotinib oral tablet 100 mg, 150 mg......47erlotinib oral tablet 25 mg.....................47errin...................................................157ertapenem.............................................31ERWINAZE........................................47ery pads...............................................116ery-tab oral tablet,delayed release (dr/ec)

250 mg, 333 mg.................................31ERY-TAB ORAL TABLET,DELAYED

RELEASE (DR/EC) 500 MG...........31ERYPED 200.......................................31

ERYPED 400.......................................31erythrocin (as stearate) oral tablet 250

mg......................................................31ERYTHROCIN INTRAVENOUS

RECON SOLN 500 MG..................31erythromycin ethylsuccinate oral suspension

for reconstitution.................................32erythromycin ethylsuccinate oral tablet....32erythromycin ophthalmic (eye)..............164erythromycin oral capsule,delayed

release(dr/ec).......................................32erythromycin oral tablet.........................32erythromycin with ethanol topical

gel....................................................116erythromycin with ethanol topical

solution.............................................116erythromycin with ethanol topical

swab.................................................116erythromycin-benzoyl peroxide..............116ESBRIET ORAL CAPSULE.............169ESBRIET ORAL TABLET 267

MG.................................................169ESBRIET ORAL TABLET 801

MG.................................................170escitalopram oxalate oral solution............72escitalopram oxalate oral tablet 10 mg....72escitalopram oxalate oral tablet 20 mg....72escitalopram oxalate oral tablet 5 mg......72esomeprazole magnesium......................141esomeprazole sodium intravenous recon

soln 20 mg........................................141esomeprazole sodium intravenous recon

soln 40 mg........................................141estarylla..............................................157estradiol oral.......................................157


estradiol transdermal patchsemiweekly........................................157

estradiol transdermal patch weekly........157estradiol vaginal..................................158estradiol valerate intramuscular oil 20 mg/

ml, 40 mg/ml....................................158estradiol-norethindrone acet oral tablet

0.5-0.1 mg.......................................158ESTRING.........................................158ethacrynate sodium..............................105ethacrynic acid....................................105ethambutol............................................32ethosuximide.........................................72etidronate disodium oral tablet 400

mg....................................................122etodolac oral capsule...............................72etodolac oral tablet.................................72etodolac oral tablet extended release 24

hr.......................................................73ETOPOPHOS....................................47etoposide intravenous.............................47EURAX.............................................116EVAMIST..........................................158EVOMELA.........................................47EVOTAZ.............................................32EXELDERM.....................................116exemestane............................................47EXJADE............................................123ezetimibe............................................105ezetimibe-simvastatin..........................105FABRAZYME...................................128falmina (28).......................................158famciclovir oral tablet 125 mg, 250

mg......................................................32famciclovir oral tablet 500 mg................32famotidine (pf )...................................141

famotidine (pf )-nacl (iso-os).................141famotidine intravenous solution............142famotidine oral suspension....................142famotidine oral tablet 20 mg, 40 mg....142FANAPT ORAL TABLET 1 MG........73FANAPT ORAL TABLET 10 MG, 12

MG...................................................73FANAPT ORAL TABLET 2 MG........73FANAPT ORAL TABLET 4 MG........73FANAPT ORAL TABLET 6 MG........73FANAPT ORAL TABLET 8 MG........73FANAPT ORAL TABLETS,DOSE

PACK................................................73FARESTON........................................47FARYDAK ORAL CAPSULE 10

MG...................................................47FARYDAK ORAL CAPSULE 15 MG,

20 MG..............................................47FASLODEX........................................47fayosim...............................................158FAZACLO ORAL TABLET,

DISINTEGRATING 150 MG..........73FAZACLO ORAL TABLET,

DISINTEGRATING 200 MG..........73felbamate..............................................73felodipine............................................105FEMRING........................................158femynor...............................................158fenofibrate micronized.........................105fenofibrate nanocrystallized oral tablet

145 mg, 48 mg.................................105fenofibrate oral capsule.........................105FENOFIBRATE ORAL TABLET 120

MG.................................................105fenofibrate oral tablet 160 mg, 54

mg....................................................105


fenofibrate oral tablet 40 mg................106fenofibric acid.....................................106fenofibric acid (choline) oral capsule,

delayed release(dr/ec) 45 mg, 135mg....................................................106

FENOPROFEN ORAL CAPSULE 400MG...................................................73

fenoprofen oral tablet.............................73fentanyl citrate buccal lozenge on a

handle................................................73fentanyl transdermal..............................73FENTORA..........................................73FERRIPROX.....................................123FETZIMA ORAL CAPSULE,EXT REL

24HR DOSE PACK..........................74FETZIMA ORAL CAPSULE,

EXTENDED RELEASE 24 HR 120MG, 80 MG......................................74

FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR 20MG...................................................74

FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR 40MG...................................................74

FINACEA TOPICAL GEL................116finasteride oral tablet 5 mg...................175FIRAZYR..........................................170FIRMAGON KIT W DILUENT

SYRINGE SUBCUTANEOUSRECON SOLN 120 MG..................48

FIRMAGON KIT W DILUENTSYRINGE SUBCUTANEOUSRECON SOLN 80 MG....................48

FLAREX............................................164flavoxate.............................................175flecainide............................................106

FLECTOR...........................................74FLOVENT DISKUS INHALATION

BLISTER WITH DEVICE 100MCG/ACTUATION, 50 MCG/ACTUATION.................................170

FLOVENT DISKUS INHALATIONBLISTER WITH DEVICE 250MCG/ACTUATION......................170

FLOVENT HFA INHALATION HFAAEROSOL INHALER 110 MCG/ACTUATION.................................170



fluconazole............................................32fluconazole in dextrose(iso-o)..................32fluconazole in nacl (iso-osm) intravenous

piggyback 200 mg/100 ml...................32fluconazole in nacl (iso-osm) intravenous

piggyback 400 mg/200 ml...................32flucytosine oral capsule 250 mg...............32flucytosine oral capsule 500 mg...............32fludarabine intravenous recon soln..........48fludrocortisone.....................................128flunisolide nasal spray,non-aerosol 25 mcg

(0.025 %)........................................170fluocinolone acetonide oil otic (ear).......125fluocinolone topical cream 0.01 %........116fluocinolone topical cream 0.025 %......116fluocinolone topical ointment...............116fluocinolone topical solution.................116fluocinonide topical cream 0.05 %.......116fluocinonide topical cream 0.1 %.........116


fluocinonide topical gel.........................116fluocinonide topical ointment...............117fluocinonide topical solution.................117fluocinonide-e......................................117FLUOCINONIDE-

EMOLLIENT.................................117fluorometholone...................................164fluorouracil intravenous.........................48FLUOROURACIL TOPICAL

CREAM 0.5 %................................117fluorouracil topical cream 5 %.............117fluorouracil topical solution..................117fluoxetine oral capsule 10 mg..................74fluoxetine oral capsule 20 mg..................74fluoxetine oral capsule 40 mg..................74fluoxetine oral solution...........................74fluoxetine oral tablet 10 mg....................74fluoxetine oral tablet 20 mg....................74fluoxetine oral tablet 60 mg....................74fluphenazine decanoate..........................74fluphenazine hcl injection......................74fluphenazine hcl oral elixir.....................75fluphenazine hcl oral tablet....................75flurandrenolide topical cream...............117flurandrenolide topical lotion...............117flurbiprofen...........................................75flurbiprofen ophthalmic (eye)................164flutamide..............................................48fluticasone propion-salmeterol inhalation

blister with device..............................170fluticasone propionate nasal..................170fluticasone propionate topical cream......117fluticasone propionate topical

ointment...........................................117fluvastatin...........................................106

fluvoxamine oral capsule,extended release24hr 100 mg......................................75

fluvoxamine oral capsule,extended release24hr 150 mg......................................75

fluvoxamine oral tablet 100 mg..............75fluvoxamine oral tablet 25 mg................75fluvoxamine oral tablet 50 mg................75FML FORTE.....................................164FML S.O.P.........................................164folic acid oral tablet 1 mg.....................178FOLOTYN..........................................48fondaparinux subcutaneous syringe 10 mg/

0.8 ml..............................................106fondaparinux subcutaneous syringe 2.5

mg/0.5 ml.........................................106fondaparinux subcutaneous syringe 5 mg/

0.4 ml..............................................106fondaparinux subcutaneous syringe 7.5

mg/0.6 ml.........................................106FORTEO..........................................153FOSAMAX PLUS D.........................153fosamprenavir.......................................32fosinopril.............................................106fosinopril-hydrochlorothiazide..............106fosphenytoin..........................................75FOSRENOL ORAL POWDER IN

PACKET.........................................123FREAMINE HBC 6.9 %..................178freamine iii 10 %................................178frovatriptan...........................................75FULPHILA.......................................148fulvestrant.............................................48furosemide injection.............................106furosemide oral solution 10 mg/ml, 40 mg/

5 ml (8 mg/ml).................................106furosemide oral tablet...........................106


FUZEON SUBCUTANEOUSRECON SOLN.................................32

fyavolv................................................158FYCOMPA ORAL SUSPENSION.....75FYCOMPA ORAL TABLET 10 MG,

12 MG..............................................75FYCOMPA ORAL TABLET 2

MG...................................................75FYCOMPA ORAL TABLET 4



MG...................................................75gabapentin oral capsule 100 mg..............75gabapentin oral capsule 300 mg..............75gabapentin oral capsule 400 mg.............75gabapentin oral solution 250 mg/5 ml....76gabapentin oral solution 250 mg/5 ml (5

ml), 300 mg/6 ml (6 ml).....................76gabapentin oral tablet 600 mg................76gabapentin oral tablet 800 mg................76galantamine oral capsule,ext rel. pellets 24

hr.......................................................76galantamine oral solution.......................76galantamine oral tablet..........................76GAMUNEX-C..................................148ganciclovir sodium intravenous recon

soln....................................................32GARDASIL 9 (PF)............................148gatifloxacin.........................................164GATTEX 30-VIAL............................142GATTEX ONE-VIAL.......................142gauze pads 2 x 2..................................128gavilyte-c.............................................142gavilyte-g............................................142

gavilyte-n............................................142GAZYVA.............................................48GELNIQUE TRANSDERMAL GEL

IN METERED-DOSE PUMP 100MG/GRAM (10 %)........................175

GELNIQUE TRANSDERMAL GELIN PACKET....................................175

gemcitabine intravenous recon soln 1gram, 200 mg.....................................48

gemcitabine intravenous recon soln 2gram...................................................48

gemcitabine intravenous solution 1 gram/26.3 ml (38 mg/ml), 2 gram/52.6 ml(38 mg/ml), 200 mg/5.26 ml (38 mg/ml).....................................................48

gemfibrozil..........................................106generlac...............................................142gengraf oral capsule 100 mg, 25 mg........48gengraf oral solution...............................48GENOTROPIN................................148GENOTROPIN MINIQUICK........148gentak ophthalmic (eye) ointment.........164gentamicin in nacl (iso-osm) intravenous

piggyback 100 mg/100 ml, 100 mg/50ml, 60 mg/50 ml, 80 mg/50 ml...........32

gentamicin in nacl (iso-osm) intravenouspiggyback 120 mg/100 ml, 80 mg/100ml......................................................33

gentamicin injection..............................33gentamicin ophthalmic (eye) drops........164gentamicin ophthalmic (eye)

ointment...........................................165gentamicin sulfate (ped) (pf )..................33gentamicin topical...............................117GENVOYA.........................................33GEODON INTRAMUSCULAR.......76


gianvi (28)..........................................158GILENYA ORAL CAPSULE 0.5

MG...................................................76GILOTRIF..........................................48glatiramer subcutaneous syringe 40 mg/

ml......................................................76glatopa subcutaneous syringe 20 mg/

ml......................................................76glatopa subcutaneous syringe 40 mg/

ml......................................................76GLEOSTINE......................................48glimepiride oral tablet 1 mg.................128glimepiride oral tablet 2 mg.................128glimepiride oral tablet 4 mg.................128glipizide oral tablet 10 mg...................128glipizide oral tablet 5 mg.....................128glipizide oral tablet extended release 24hr

10 mg...............................................129glipizide oral tablet extended release 24hr

2.5 mg..............................................129glipizide oral tablet extended release 24hr

5 mg.................................................129glipizide-metformin oral tablet 2.5-250

mg....................................................129glipizide-metformin oral tablet 2.5-500

mg, 5-500 mg...................................129GLUCAGEN HYPOKIT..................129GLUCAGON EMERGENCY KIT

(HUMAN)......................................129glyburide micronized oral tablet 1.5

mg....................................................129glyburide micronized oral tablet 3

mg....................................................129glyburide micronized oral tablet 6

mg....................................................129glyburide oral tablet 1.25 mg...............129

glyburide oral tablet 2.5 mg.................129glyburide oral tablet 5 mg....................129glyburide-metformin oral tablet 1.25-250

mg....................................................129glyburide-metformin oral tablet 2.5-500

mg, 5-500 mg...................................130glycopyrrolate injection.........................142glycopyrrolate oral tablet 1 mg, 2 mg.....142glydo...................................................117GOLYTELY ORAL POWDER IN

PACKET.........................................142granisetron hcl intravenous solution 1 mg/

ml (1 ml)..........................................142granisetron hcl oral..............................142GRANIX...........................................148griseofulvin microsize.............................33griseofulvin ultramicrosize......................33guanfacine oral tablet..........................106guanfacine oral tablet extended release 24

hr.......................................................76guanidine..............................................76HALAVEN..........................................48halobetasol propionate topical cream.....117halobetasol propionate topical

ointment...........................................117HALOG TOPICAL CREAM............117HALOG TOPICAL

OINTMENT..................................117haloperidol............................................76haloperidol decanoate.............................76haloperidol lactate injection....................77haloperidol lactate intramuscular............77haloperidol lactate oral...........................77HARVONI..........................................33HAVRIX (PF) INTRAMUSCULAR

SUSPENSION................................148


HAVRIX (PF) INTRAMUSCULARSYRINGE 1,440 ELISA UNIT/ML..................................................148

HAVRIX (PF) INTRAMUSCULARSYRINGE 720 ELISA UNIT/0.5ML..................................................148

heather...............................................158heparin (porcine) in 5 % dex intravenous

parenteral solution 20,000 unit/500 ml(40 unit/ml).....................................106

heparin (porcine) in 5 % dex intravenousparenteral solution 25,000 unit/250ml(100 unit/ml), 25,000 unit/500 ml(50 unit/ml).....................................107

heparin (porcine) in nacl (pf )...............107heparin (porcine) injection solution.......107heparin (porcine) injection syringe 5,000

unit/ml.............................................107HEPARIN(PORCINE) IN 0.45%

NACL INTRAVENOUSPARENTERAL SOLUTION 12,500UNIT/250 ML................................107

heparin(porcine) in 0.45% naclintravenous parenteral solution 25,000unit/250 ml......................................107

heparin(porcine) in 0.45% naclintravenous parenteral solution 25,000unit/500 ml......................................107

heparin, porcine (pf ) injection..............107HEPATAMINE 8%...........................178HERCEPTIN HYLECTA...................48HERCEPTIN INTRAVENOUS

RECON SOLN 150 MG..................49HETLIOZ...........................................77HIBERIX (PF)...................................148

HUMALOG JUNIOR KWIKPEN U-100..................................................130

HUMALOG KWIKPENINSULIN........................................130

HUMALOG MIX 50-50 INSULN U-100..................................................130

HUMALOG MIX 50-50KWIKPEN......................................130

HUMALOG MIX 75-25KWIKPEN......................................130

HUMALOG MIX 75-25(U-100)INSULN..................................130

HUMALOG U-100 INSULIN.........130HUMATROPE.................................149HUMIRA PEDIATRIC CROHNS

START SUBCUTANEOUSSYRINGE KIT 40 MG/0.8 ML......153

HUMIRA PEDIATRIC CROHNSSTART SUBCUTANEOUSSYRINGE KIT 40 MG/0.8 ML (6PACK).............................................153

HUMIRA PEN.................................153HUMIRA PEN CROHNS-UC-HS

START............................................153HUMIRA PEN PSOR-UVEITS-

ADOL HS.......................................153HUMIRA SUBCUTANEOUS

SYRINGE KIT 10 MG/0.2 ML, 20MG/0.4 ML....................................153

HUMIRA SUBCUTANEOUSSYRINGE KIT 40 MG/0.8 ML......154

HUMIRA(CF) PEDI CROHNSSTARTER SUBCUTANEOUSSYRINGE KIT 80 MG/0.8 ML......154

HUMIRA(CF) PEDI CROHNSSTARTER SUBCUTANEOUS


SYRINGE KIT 80 MG/0.8 ML-40MG/0.4 ML....................................154

HUMIRA(CF) PEN CROHNS-UC-HS...................................................154

HUMIRA(CF) PEN PSOR-UV-ADOLHS...................................................154

HUMIRA(CF) PENSUBCUTANEOUS PEN INJECTORKIT 40 MG/0.4 ML........................154

HUMIRA(CF) SUBCUTANEOUSSYRINGE KIT 10 MG/0.1 ML, 20MG/0.2 ML....................................154

HUMIRA(CF) SUBCUTANEOUSSYRINGE KIT 40 MG/0.4 ML......154

HUMULIN 70/30 U-100INSULIN........................................130

HUMULIN 70/30 U-100KWIKPEN......................................130

HUMULIN N NPH INSULINKWIKPEN......................................130

HUMULIN N NPH U-100INSULIN........................................130

HUMULIN R REGULAR U-100INSULN.........................................130

HUMULIN R U-500 (CONC)INSULIN........................................130

HUMULIN R U-500 (CONC)KWIKPEN......................................130

hydralazine injection...........................107hydralazine oral...................................107hydrochlorothiazide.............................107hydrocodone-acetaminophen oral solution

7.5-325 mg/15 ml..............................77hydrocodone-acetaminophen oral tablet

10-300 mg, 10-325 mg, 2.5-325 mg,5-300 mg, 5-325 mg, 7.5-300 mg, 7.5-325 mg...............................................77

hydrocodone-homatropine oral syrup 5-1.5mg/5 ml............................................170

hydrocodone-ibuprofen oral tablet 10-200mg, 5-200 mg, 7.5-200 mg.................77

hydrocortisone butyrate topicalointment...........................................117

hydrocortisone butyrate topicalsolution.............................................117

hydrocortisone oral...............................130hydrocortisone rectal.............................142hydrocortisone topical cream 1 %.........117hydrocortisone topical cream 2.5 %......117hydrocortisone topical cream with perineal

applicator 1 %..................................142hydrocortisone topical lotion 2.5 %.......117hydrocortisone topical ointment 1 %.....117hydrocortisone topical ointment 2.5

%.....................................................118hydrocortisone valerate.........................118hydrocortisone-acetic acid.....................125hydromorphone (pf ) injection solution 10

(mg/ml) (5 ml), 10 mg/ml...................77hydromorphone (pf ) injection solution 2

mg/ml.................................................77hydromorphone injection solution 1 mg/

ml......................................................77hydromorphone injection solution 2 mg/

ml......................................................77hydromorphone injection solution 4 mg/

ml......................................................77hydromorphone oral liquid.....................77hydromorphone oral tablet......................77hydromorphone oral tablet extended release

24 hr 12 mg, 8 mg..............................78hydromorphone oral tablet extended release

24 hr 16 mg, 32 mg............................78


hydroxychloroquine................................33hydroxyprogesterone caproate................158hydroxyurea...........................................49hydroxyzine hcl intramuscular..............170hydroxyzine hcl oral solution 10 mg/5

ml....................................................171hydroxyzine hcl oral tablet....................171hydroxyzine pamoate...........................171ibandronate intravenous......................154ibandronate oral..................................154IBRANCE...........................................49ibu.......................................................78ibuprofen lysine (pf )..............................78ibuprofen oral suspension.......................78ibuprofen oral tablet 400 mg, 600 mg,

800 mg...............................................78ibuprofen-oxycodone..............................78ICLUSIG ORAL TABLET 15 MG.....49ICLUSIG ORAL TABLET 45 MG.....49idarubicin.............................................49IDHIFA ORAL TABLET 100 MG.....49IDHIFA ORAL TABLET 50 MG.......49ifosfamide intravenous recon soln............49ifosfamide intravenous solution 1 gram/20

ml......................................................49ifosfamide intravenous solution 3 gram/60

ml......................................................49ILARIS (PF) SUBCUTANEOUS

SOLUTION...................................149ILEVRO............................................165imatinib oral tablet 100 mg...................49imatinib oral tablet 400 mg...................49IMBRUVICA ORAL CAPSULE 140

MG...................................................49IMBRUVICA ORAL CAPSULE 70

MG...................................................49

IMBRUVICA ORAL TABLET 140MG...................................................49

IMBRUVICA ORAL TABLET 280MG, 420 MG, 560 MG....................50

IMFINZI.............................................50imipenem-cilastatin...............................33imipramine hcl......................................78imipramine pamoate..............................78imiquimod topical cream in packet.......118IMOVAX RABIES VACCINE

(PF).................................................149INCRELEX.......................................123indapamide.........................................107INFANRIX (DTAP) (PF)

INTRAMUSCULARSUSPENSION................................149

INLYTA ORAL TABLET 1 MG.........50INLYTA ORAL TABLET 5 MG.........50INSULIN LISPRO............................130insulin pen needle................................130insulin syringe (disp) u-100 0.3 ml, 1 ml,

1/2 ml..............................................131INTELENCE ORAL TABLET 100

MG...................................................33INTELENCE ORAL TABLET 200

MG...................................................33INTELENCE ORAL TABLET 25

MG...................................................33intralipid intravenous emulsion 20

%.....................................................178INTRALIPID INTRAVENOUS

EMULSION 30 %..........................178INTRON A INJECTION RECON

SOLN 10 MILLION UNIT (1 ML),18 MILLION UNIT (1 ML)..........149


INTRON A INJECTION RECONSOLN 50 MILLION UNIT (1ML).................................................149

INTRON A INJECTIONSOLUTION...................................149

introvale.............................................158INVANZ INJECTION.......................33INVEGA SUSTENNA

INTRAMUSCULAR SYRINGE 117MG/0.75 ML....................................78

INVEGA SUSTENNAINTRAMUSCULAR SYRINGE 156MG/ML............................................78

INVEGA SUSTENNAINTRAMUSCULAR SYRINGE 234MG/1.5 ML......................................78

INVEGA SUSTENNAINTRAMUSCULAR SYRINGE 39MG/0.25 ML....................................78

INVEGA SUSTENNAINTRAMUSCULAR SYRINGE 78MG/0.5 ML......................................78

INVEGA TRINZAINTRAMUSCULAR SYRINGE 273MG/0.875 ML..................................79


INVEGA TRINZAINTRAMUSCULAR SYRINGE 546MG/1.75 ML....................................79


INVIRASE ORAL TABLET................33IONOSOL-MB IN D5W.................178

IOPIDINE OPHTHALMIC (EYE)DROPPERETTE............................165

IPOL.................................................149ipratropium bromide inhalation...........171ipratropium bromide nasal...................125ipratropium-albuterol inhalation..........171irbesartan...........................................107irbesartan-hydrochlorothiazide.............107IRESSA................................................50irinotecan intravenous solution 100 mg/5

ml, 40 mg/2 ml...................................50irinotecan intravenous solution 500 mg/

25 ml.................................................50ISENTRESS HD.................................33ISENTRESS ORAL POWDER IN

PACKET...........................................33ISENTRESS ORAL TABLET.............33ISENTRESS ORAL TABLET,

CHEWABLE 100 MG......................33ISENTRESS ORAL TABLET,

CHEWABLE 25 MG........................33ISOLYTE S PH 7.4...........................178ISOLYTE-P IN 5 % DEXTROSE.....178ISOLYTE-S.......................................178isoniazid injection.................................34isoniazid oral solution............................34isoniazid oral tablet...............................34isosorbide dinitrate oral tablet...............107isosorbide dinitrate oral tablet extended

release...............................................107isosorbide mononitrate.........................108isradipine............................................108ISTODAX...........................................50itraconazole oral capsule.........................34ivermectin.............................................34IXEMPRA...........................................50


IXIARO (PF).....................................149JADENU...........................................123JADENU SPRINKLE.......................123JAKAFI ORAL TABLET 10 MG........50JAKAFI ORAL TABLET 15 MG........50JAKAFI ORAL TABLET 20 MG........50JAKAFI ORAL TABLET 25 MG........50JAKAFI ORAL TABLET 5 MG..........50jantoven..............................................108JANUMET........................................131JANUMET XR ORAL TABLET, ER

MULTIPHASE 24 HR 100-1,000MG.................................................131

JANUMET XR ORAL TABLET, ERMULTIPHASE 24 HR 50-1,000 MG,50-500 MG.....................................131

JANUVIA ORAL TABLET 100MG.................................................131



JARDIANCE.....................................131jencycla...............................................158JENTADUETO................................131JENTADUETO XR ORAL TABLET,

IR - ER, BIPHASIC 24HR 2.5-1,000MG.................................................131

JENTADUETO XR ORAL TABLET,IR - ER, BIPHASIC 24HR 5-1,000MG.................................................131

JEVTANA...........................................50jinteli..................................................158jolessa.................................................158jolivette...............................................158juleber................................................158JULUCA..............................................34

junel 1.5/30 (21)................................158junel 1/20 (21)...................................158junel fe 1.5/30 (28).............................158junel fe 1/20 (28)................................158junel fe 24..........................................158JUXTAPID........................................108k-tab oral tablet extended release 10 meq,

20 meq.............................................178k-tab oral tablet extended release 8

meq..................................................178KADCYLA..........................................50kaitlib fe.............................................158KALETRA ORAL TABLET 100-25

MG...................................................34KALETRA ORAL TABLET 200-50

MG...................................................34KALYDECO ORAL GRANULES IN

PACKET 25 MG............................171KALYDECO ORAL GRANULES IN

PACKET 50 MG............................171KALYDECO ORAL GRANULES IN

PACKET 75 MG............................171KALYDECO ORAL TABLET...........171KANUMA.........................................131kariva (28).........................................159kelnor 1/35 (28)..................................159ketoconazole oral...................................34ketoconazole topical cream....................118ketoconazole topical foam.....................118ketoconazole topical shampoo................118ketoprofen oral capsule 25 mg, 75 mg.....79ketoprofen oral capsule 50 mg.................79ketoprofen oral capsule,ext rel. pellets 24

hr 200 mg..........................................79ketorolac injection cartridge 30 mg/ml....79


ketorolac injection solution 15 mg/ml, 30mg/ml (1 ml)......................................79

ketorolac intramuscular cartridge............79ketorolac intramuscular solution.............79ketorolac intramuscular syringe...............79ketorolac ophthalmic (eye)....................165ketorolac oral.........................................79KEVEYIS.............................................79KEYTRUDA INTRAVENOUS

SOLUTION.....................................50KHAPZORY.......................................50KHEDEZLA ORAL TABLET

EXTENDED RELEASE 24HR 100MG...................................................79

KHEDEZLA ORAL TABLETEXTENDED RELEASE 24HR 50MG...................................................80

KINRIX (PF) INTRAMUSCULARSUSPENSION................................149

KINRIX (PF) INTRAMUSCULARSYRINGE.......................................149

kionex (with sorbitol)...........................123KISQALI FEMARA CO-PACK ORAL

TABLET 200 MG/DAY(200 MG X1)-2.5 MG.........................................51

KISQALI FEMARA CO-PACK ORALTABLET 400 MG/DAY(200 MG X2)-2.5 MG.........................................51

KISQALI FEMARA CO-PACK ORALTABLET 600 MG/DAY(200 MG X3)-2.5 MG.........................................51

KISQALI ORAL TABLET 200 MG/DAY (200 MG X 1)...........................51



klor-con 10.........................................178klor-con 8...........................................178klor-con m10......................................178klor-con m15......................................178klor-con m20......................................178klor-con sprinkle oral capsule, extended

release 8 meq.....................................178KOMBIGLYZE XR ORAL TABLET,

ER MULTIPHASE 24 HR 2.5-1,000MG.................................................132

KOMBIGLYZE XR ORAL TABLET,ER MULTIPHASE 24 HR 5-1,000MG, 5-500 MG..............................132

KORLYM..........................................132KRISTALOSE...................................142kurvelo (28)........................................159KUVAN.............................................132KYNAMRO......................................108KYPROLIS..........................................51l norgest/e.estradiol-e.estrad oral tablets,

dose pack,3 month 0.15 mg-30 mcg(84)/10 mcg (7)................................159

labetalol oral.......................................108LACRISERT......................................165lactated ringers intravenous..................178lactated ringers irrigation.....................123lactulose oral packet.............................142lactulose oral solution...........................142LAMICTAL STARTER (BLUE)

KIT...................................................80LAMICTAL STARTER (GREEN)

KIT...................................................80LAMICTAL STARTER (ORANGE)

KIT...................................................80lamivudine oral solution........................34lamivudine oral tablet 100 mg...............34


lamivudine oral tablet 150 mg...............34lamivudine oral tablet 300 mg...............34lamivudine-zidovudine..........................34lamotrigine oral tablet...........................80lamotrigine oral tablet extended release

24hr...................................................80lamotrigine oral tablet, chewable

dispersible...........................................80lamotrigine oral tablet,disintegrating......80lamotrigine oral tablets,dose pack............80LANOXIN ORAL TABLET 125

MCG, 62.5 MCG...........................108LANOXIN ORAL TABLET 250

MCG...............................................108lansoprazole oral capsule,delayed

release(dr/ec).....................................142lanthanum..........................................123LANTUS SOLOSTAR U-100

INSULIN........................................132LANTUS U-100 INSULIN..............132larin 1.5/30 (21).................................159larin 1/20 (21)....................................159larin 24 fe...........................................159larin fe 1.5/30 (28).............................159larin fe 1/20 (28)................................159LARTRUVO.......................................51LASTACAFT.....................................165latanoprost..........................................165LATUDA ORAL TABLET 120 MG,

60 MG..............................................80LATUDA ORAL TABLET 20 MG.....80LATUDA ORAL TABLET 40 MG.....80LATUDA ORAL TABLET 80 MG.....80layolis fe..............................................159LAZANDA..........................................80leena 28..............................................159

leflunomide.........................................154LENVIMA ORAL CAPSULE 10 MG/

DAY (10 MG X 1), 4 MG.................51LENVIMA ORAL CAPSULE 12 MG/

DAY (4 MG X 3), 18 MG/DAY (10MG X 1-4 MG X2), 24 MG/DAY(10MG X 2-4 MG X 1)..........................51

LENVIMA ORAL CAPSULE 14 MG/DAY(10 MG X 1-4 MG X 1), 20MG/DAY (10 MG X 2), 8 MG/DAY(4 MG X 2).......................................51

lessina.................................................159LETAIRIS..........................................171letrozole................................................51leucovorin calcium injection recon soln

100 mg, 200 mg, 350 mg, 50 mg........52leucovorin calcium injection recon soln

500 mg...............................................52leucovorin calcium oral..........................52LEUKERAN........................................52LEUKINE INJECTION RECON

SOLN..............................................149leuprolide subcutaneous kit.....................52levalbuterol hcl inhalation solution for

nebulization 0.31 mg/3 ml, 1.25 mg/0.5ml, 1.25 mg/3 ml..............................171

levalbuterol hcl inhalation solution fornebulization 0.63 mg/3 ml................171

LEVALBUTEROL HFA....................171LEVEMIR FLEXTOUCH U-100

INSULN.........................................132LEVEMIR U-100 INSULIN.............132levetiracetam in nacl (iso-os) intravenous

piggyback 1,000 mg/100 ml, 1,500 mg/100 ml...............................................80


levetiracetam in nacl (iso-os) intravenouspiggyback 500 mg/100 ml...................81

levetiracetam intravenous.......................81levetiracetam oral solution 100 mg/ml.....81levetiracetam oral solution 500 mg/5 ml

(5 ml).................................................81levetiracetam oral tablet.........................81levetiracetam oral tablet extended release

24 hr 500 mg.....................................81levetiracetam oral tablet extended release

24 hr 750 mg.....................................81levobunolol ophthalmic (eye) drops 0.5

%.....................................................165levocarnitine (with sugar)....................123levocarnitine oral tablet.......................123levocetirizine oral tablet.......................171levofloxacin in d5w intravenous piggyback

250 mg/50 ml.....................................34levofloxacin in d5w intravenous piggyback

500 mg/100 ml, 750 mg/150 ml.........34levofloxacin intravenous.........................34levofloxacin ophthalmic (eye)................165levofloxacin oral....................................34levoleucovorin calcium intravenous recon

soln 50 mg..........................................52levoleucovorin calcium intravenous

solution...............................................52levonest (28).......................................159levonorg-eth estrad triphasic.................159levonorgestrel-ethinyl estrad oral tablet

0.1-20 mg-mcg, 0.15-0.03 mg...........159levonorgestrel-ethinyl estrad oral tablet 90-

20 mcg (28)......................................159levonorgestrel-ethinyl estrad oral tablets,

dose pack,3 month.............................159levora-28............................................159

levothyroxine oral................................132levoxyl oral tablet 100 mcg, 112 mcg, 125

mcg, 137 mcg, 150 mcg, 175 mcg, 200mcg, 25 mcg, 50 mcg, 75 mcg, 88mcg..................................................132

LEXIVA ORAL SUSPENSION..........34LEXIVA ORAL TABLET....................35LIBTAYO............................................52lidocaine (pf ) injection solution 10 mg/ml

(1 %), 5 mg/ml (0.5 %)....................118lidocaine hcl injection solution 10 mg/ml

(1 %), 20 mg/ml (2 %).....................118lidocaine hcl mucous membrane jelly.....118lidocaine hcl mucous membrane jelly in

applicator.........................................118lidocaine hcl mucous membrane solution

4 % (40 mg/ml)................................118lidocaine topical adhesive patch,

medicated.........................................118lidocaine topical ointment....................118lidocaine viscous..................................118lidocaine-prilocaine topical cream.........118LINCOCIN........................................35lincomycin............................................35lindane topical shampoo.......................118linezolid in dextrose 5%.........................35linezolid oral suspension for

reconstitution......................................35linezolid oral tablet................................35LINZESS...........................................142liothyronine oral..................................132lisinopril.............................................108lisinopril-hydrochlorothiazide...............108lithium carbonate..................................81lithium citrate oral solution 8 meq/5

ml......................................................81


lo-zumandimine (28)..........................159LONSURF..........................................52loperamide oral capsule........................142lopinavir-ritonavir................................35lopreeza oral tablet 0.5-0.1 mg.............159lorazepam intensol.................................81lorazepam oral.......................................81LORBRENA ORAL TABLET 100

MG...................................................52LORBRENA ORAL TABLET 25

MG...................................................52lorcet (hydrocodone)...............................81lorcet hd................................................81lorcet plus oral tablet 7.5-325 mg...........81loryna (28).........................................159losartan...............................................108losartan-hydrochlorothiazide................108lovastatin............................................108low-ogestrel (28)..................................159loxapine succinate..................................81LUMIGAN OPHTHALMIC (EYE)

DROPS 0.01 %...............................165LUMIZYME.....................................132LUMOXITI.........................................52LUPANETA PACK (1 MONTH).....160LUPANETA PACK (3 MONTH).....160LUPRON DEPOT..............................52LUPRON DEPOT (3 MONTH).......52LUPRON DEPOT (4 MONTH).......52LUPRON DEPOT (6 MONTH).......52LUPRON DEPOT-PED

INTRAMUSCULAR KIT 11.25 MG,15 MG..............................................53

lutera (28)..........................................160LYNPARZA ORAL TABLET..............53

LYRICA ORAL CAPSULE 100MG...................................................81



LYRICA ORAL CAPSULE 225 MG,300 MG............................................82

LYRICA ORAL CAPSULE 25 MG.....82LYRICA ORAL CAPSULE 50 MG.....82LYRICA ORAL CAPSULE 75 MG.....82LYRICA ORAL SOLUTION..............82LYSODREN........................................53lyza....................................................160M-M-R II (PF)..................................149magnesium sulfate injection solution.....178magnesium sulfate injection syringe.......179malathion...........................................118maprotiline oral tablet 25 mg.................82maprotiline oral tablet 50 mg.................82maprotiline oral tablet 75 mg.................82marlissa (28).......................................160MARPLAN..........................................82MARQIBO..........................................53MATULANE.......................................53matzim la...........................................108MAXIDEX........................................165meclizine oral tablet 12.5 mg, 25

mg....................................................143meclofenamate.......................................82medroxyprogesterone intramuscular

suspension.........................................160medroxyprogesterone oral......................160mefenamic acid.....................................82mefloquine............................................35


megestrol oral suspension 400 mg/10 ml(10 ml), 800 mg/20 ml (20 ml)...........53

megestrol oral suspension 400 mg/10 ml(40 mg/ml), 625 mg/5 ml....................53

megestrol oral tablet...............................53MEKINIST ORAL TABLET 0.5

MG...................................................53MEKINIST ORAL TABLET 2

MG...................................................53MEKTOVI..........................................53meloxicam oral tablet.............................82melphalan hcl........................................53memantine oral capsule,sprinkle,er

24hr...................................................82memantine oral solution.........................82memantine oral tablet 10 mg.................82memantine oral tablet 5 mg...................82memantine oral tablets,dose pack............82MENACTRA (PF)

INTRAMUSCULARSOLUTION...................................149

MENEST ORAL TABLET 0.3 MG,0.625 MG, 1.25 MG.......................160

MENOSTAR.....................................160MENTAX..........................................118MENVEO A-C-Y-W-135-DIP

(PF).................................................149meperidine oral tablet............................83meprobamate........................................83mercaptopurine.....................................53meropenem............................................35mesalamine oral tablet,delayed release (dr/

ec) 1.2 gram......................................143MESALAMINE ORAL TABLET,

DELAYED RELEASE (DR/EC) 800MG.................................................143

mesalamine rectal enema......................143mesalamine rectal suppository...............143mesalamine with cleansing wipe...........143mesna...................................................53MESNEX ORAL.................................53MESTINON ORAL SYRUP...............83metadate er...........................................83metaproterenol oral syrup.....................171metaxalone oral tablet 800 mg...............83metformin oral tablet 1,000 mg...........132metformin oral tablet 500 mg..............132metformin oral tablet 850 mg..............132metformin oral tablet extended release 24

hr 500 mg........................................132metformin oral tablet extended release 24

hr 750 mg........................................133methadone injection solution..................83methadone oral solution.........................83methadone oral tablet............................83methamphetamine.................................83methazolamide....................................165methenamine hippurate.........................35methimazole oral tablet 10 mg, 5

mg....................................................133methotrexate sodium..............................53methotrexate sodium (pf ) injection recon

soln....................................................53methotrexate sodium (pf ) injection

solution...............................................53methoxsalen........................................118methscopolamine.................................143methyclothiazide..................................108methylphenidate hcl oral capsule, er

biphasic 30-70....................................83


methylphenidate hcl oral capsule,erbiphasic 50-50 10 mg, 20 mg, 40 mg,60 mg.................................................83

methylphenidate hcl oral capsule,erbiphasic 50-50 30 mg.........................83

methylphenidate hcl oral solution 10 mg/5 ml...................................................83

methylphenidate hcl oral solution 5 mg/5ml......................................................83

methylphenidate hcl oral tablet...............83methylphenidate hcl oral tablet extended

release 20 mg......................................84methylphenidate hcl oral tablet extended

release 24hr 18 mg, 27 mg, 54 mg.......84methylphenidate hcl oral tablet extended

release 24hr 36 mg..............................84methylphenidate hcl oral tablet,

chewable.............................................84methylprednisolone..............................133methylprednisolone acetate...................133methylprednisolone sodium succ injection

recon soln 125 mg, 40 mg..................133methylprednisolone sodium succ

intravenous.......................................133methyltestosterone oral capsule..............133metoclopramide hcl injection

solution.............................................143metoclopramide hcl oral solution...........143metoclopramide hcl oral tablet..............143metoclopramide hcl oral tablet,

disintegrating 10 mg..........................143metolazone..........................................108metoprolol succinate.............................108metoprolol tartrate intravenous

solution.............................................108

metoprolol tartrate intravenoussyringe..............................................108

metoprolol tartrate oral........................108metoprolol tartrate-

hydrochlorothiazide...........................108metronidazole in nacl (iso-os).................35metronidazole oral.................................35metronidazole topical cream.................118metronidazole topical gel......................118metronidazole topical lotion.................119metronidazole vaginal..........................160mexiletine...........................................108MIACALCIN INJECTION..............133mibelas 24 fe.......................................160miconazole-3 vaginal suppository..........160microgestin 1.5/30 (21).......................160microgestin 1/20 (21)..........................160microgestin fe 1.5/30 (28)....................160microgestin fe 1/20 (28).......................160midodrine...........................................123migergot................................................84miglitol oral tablet 100 mg...................133miglitol oral tablet 25 mg.....................133miglitol oral tablet 50 mg.....................133miglustat.............................................133millipred oral tablet.............................133mimvey lo...........................................160MINIVELLE.....................................160minocycline oral capsule.........................35minoxidil oral.....................................108mirtazapine oral tablet 15 mg................84mirtazapine oral tablet 30 mg................84mirtazapine oral tablet 45 mg................84mirtazapine oral tablet 7.5 mg...............84mirtazapine oral tablet,disintegrating 15

mg......................................................84


mirtazapine oral tablet,disintegrating 30mg......................................................84

mirtazapine oral tablet,disintegrating 45mg......................................................84

misoprostol..........................................143MITOMYCIN INTRAVENOUS

RECON SOLN 20 MG, 5 MG........54mitomycin intravenous recon soln 40

mg......................................................54mitoxantrone.........................................54modafinil oral tablet 100 mg.................84modafinil oral tablet 200 mg.................84moderiba..............................................35moexipril............................................108molindone.............................................84mometasone nasal................................171mometasone topical..............................119mondoxyne nl........................................35mono-linyah........................................160mononessa (28)...................................160montelukast oral granules in packet.......171montelukast oral tablet.........................172montelukast oral tablet,chewable..........172MONUROL........................................35morgidox...............................................35morphine (pf ) injection solution 0.5 mg/

ml......................................................85morphine (pf ) injection solution 1 mg/

ml......................................................85morphine (pf ) intravenous patient

control.analgesia soln 30 mg/30 ml.......85morphine concentrate oral solution..........85morphine oral capsule, er multiphase 24

hr.......................................................85

morphine oral capsule,extend.release pellets10 mg, 20 mg, 30 mg, 50 mg, 60 mg,80 mg.................................................85

morphine oral capsule,extend.release pellets100 mg...............................................85

morphine oral solution...........................85morphine oral tablet..............................85morphine oral tablet extended release 100

mg, 200 mg........................................85morphine oral tablet extended release 15

mg, 30 mg, 60 mg...............................85MOVANTIK.....................................143MOVIPREP......................................143MOXIFLOXACIN OPHTHALMIC

(EYE)...............................................165moxifloxacin oral...................................35moxifloxacin-sod.ace,sul-water...............35moxifloxacin-sod.chloride(iso).................35MOZOBIL........................................149MULTAQ..........................................109mupirocin topical cream.......................119mupirocin topical ointment..................119MYALEPT........................................133MYCAMINE.......................................35mycophenolate mofetil hcl.......................54mycophenolate mofetil oral capsule..........54mycophenolate mofetil oral suspension for

reconstitution......................................54mycophenolate mofetil oral tablet............54mycophenolate sodium...........................54MYLOTARG.......................................54myorisan.............................................119MYRBETRIQ...................................175nabumetone..........................................85nadolol...............................................109nadolol-bendroflumethiazide................109


nafcillin injection recon soln 1 gram, 2gram...................................................35

nafcillin injection recon soln 10 gram.....35nafcillin intravenous recon soln 1

gram...................................................35nafcillin intravenous recon soln 2

gram...................................................36naftifine..............................................119NAFTIN TOPICAL GEL 1 %..........119NAFTIN TOPICAL GEL 2 %..........119NAGLAZYME..................................133nalbuphine injection solution 10 mg/

ml......................................................85nalbuphine injection solution 20 mg/

ml......................................................85nalfon oral capsule 400 mg....................86naloxone...............................................86naltrexone.............................................86naproxen...............................................86naproxen sodium oral tablet 275 mg, 550

mg......................................................86naproxen sodium oral tablet, er multiphase

24 hr 375 mg.....................................86naratriptan...........................................86NARCAN NASAL SPRAY,NON-

AEROSOL 4 MG/ACTUATION.....86NATACYN........................................165nateglinide oral tablet 120 mg..............133nateglinide oral tablet 60 mg................133NATPARA.........................................133NEBUPENT.......................................36necon 0.5/35 (28)...............................160needles, insulin disp.,safety...................134nefazodone oral tablet 100 mg................86nefazodone oral tablet 150 mg................86nefazodone oral tablet 200 mg................86

nefazodone oral tablet 250 mg................86nefazodone oral tablet 50 mg..................86neo-polycin..........................................165neo-polycin hc.....................................165neomycin..............................................36neomycin-bacitracin-poly-hc.................165neomycin-bacitracin-polymyxin............165neomycin-polymyxin b gu irrigation

solution.............................................123neomycin-polymyxin b-dexameth..........165neomycin-polymyxin-gramicidin...........165neomycin-polymyxin-hc ophthalmic

(eye).................................................165neomycin-polymyxin-hc otic (ear).........125NEPHRAMINE 5.4 %......................179NERLYNX..........................................54neuac..................................................119NEULASTA......................................149NEUPOGEN INJECTION

SOLUTION 300 MCG/ML...........150NEUPOGEN INJECTION

SOLUTION 480 MCG/1.6 ML.....150NEUPOGEN INJECTION

SYRINGE.......................................150NEUPRO............................................86nevirapine oral suspension......................36nevirapine oral tablet.............................36nevirapine oral tablet extended release 24

hr 100 mg..........................................36nevirapine oral tablet extended release 24

hr 400 mg..........................................36NEXAVAR...........................................54niacin oral tablet 500 mg.....................109niacin oral tablet extended release 24

hr.....................................................109niacor.................................................109


nicardipine oral...................................109NICOTROL NS...............................123nifedipine oral tablet extended

release...............................................109nifedipine oral tablet extended release

24hr.................................................109nikki (28)...........................................160nilutamide............................................54nimodipine.........................................109NINLARO..........................................54NIPENT..............................................54nisoldipine..........................................109nitro-bid.............................................109NITRO-DUR TRANSDERMAL

PATCH 24 HOUR 0.3 MG/HR, 0.8MG/HR..........................................109

nitrofurantoin.......................................36nitrofurantoin macrocrystal....................36nitrofurantoin monohyd/m-cryst.............36nitroglycerin sublingual........................109nitroglycerin transdermal patch 24

hour.................................................109nitroglycerin translingual spray,non-

aerosol..............................................109nizatidine...........................................143nora-be...............................................161NORDITROPIN FLEXPRO............150noreth-ethinyl estradiol-iron.................161norethindrone (contraceptive)...............161norethindrone ac-eth estradiol oral tablet

0.5-2.5 mg-mcg, 1-5 mg-mcg............161norethindrone ac-eth estradiol oral tablet

1-20 mg-mcg....................................161norethindrone acetate...........................161norethindrone-e.estradiol-iron oral

tablet................................................161

norgestimate-ethinyl estradiol...............161norlyroc...............................................161normosol-m in 5 % dextrose.................179normosol-r in 5 % dextrose..................179NORMOSOL-R PH 7.4...................179NORTHERA ORAL CAPSULE 100

MG.................................................123NORTHERA ORAL CAPSULE 200

MG.................................................123NORTHERA ORAL CAPSULE 300

MG.................................................123nortrel 0.5/35 (28)..............................161nortrel 1/35 (21).................................161nortrel 1/35 (28).................................161nortrel 7/7/7 (28)................................161nortriptyline oral capsule........................86NORTRIPTYLINE ORAL

SOLUTION.....................................86NORVIR ORAL POWDER IN

PACKET...........................................36NORVIR ORAL SOLUTION............36NORVIR ORAL TABLET..................36novarel intramuscular recon soln 10,000

unit..................................................134NOVAREL INTRAMUSCULAR

RECON SOLN 5,000 UNIT.........134NOVOLIN 70/30 U-100

INSULIN........................................134NOVOLIN N NPH U-100

INSULIN........................................134NOVOLIN R REGULAR U-100

INSULN.........................................134NOVOLOG FLEXPEN U-100

INSULIN........................................134NOVOLOG MIX 70-30 U-100

INSULN.........................................134


NOVOLOG MIX 70-30FLEXPEN U-100..................................................134

NOVOLOG PENFILL U-100INSULIN........................................134

NOVOLOG U-100 INSULINASPART..........................................134

NOXAFIL INTRAVENOUS..............36NOXAFIL ORAL................................36np thyroid oral tablet 120 mg, 15

mg....................................................134NUCYNTA ER ORAL TABLET

EXTENDED RELEASE 12 HR 100MG, 50 MG......................................87

NUCYNTA ER ORAL TABLETEXTENDED RELEASE 12 HR 150MG, 200 MG, 250 MG....................87

NUCYNTA ORAL TABLET 100 MG,50 MG..............................................87

NUCYNTA ORAL TABLET 75MG...................................................87

NUEDEXTA.......................................87NULOJIX............................................54NUPLAZID ORAL CAPSULE...........87NUPLAZID ORAL TABLET 10

MG...................................................87nutrilipid............................................179NUTROPIN AQ NUSPIN...............150nyamyc...............................................119nystatin oral suspension..........................36nystatin oral tablet.................................36nystatin topical....................................119nystatin-triamcinolone.........................119nystop.................................................119ocella..................................................161OCTAGAM......................................150

octreotide acetate injection solution 1,000mcg/ml...............................................54

octreotide acetate injection solution 100mcg/ml, 200 mcg/ml, 50 mcg/ml..........54

OCTREOTIDE ACETATEINJECTION SOLUTION 500MCG/ML.........................................54

ODEFSEY...........................................36ODOMZO..........................................55OFEV................................................172ofloxacin ophthalmic (eye)....................165ofloxacin oral tablet 300 mg...................36ofloxacin oral tablet 400 mg...................36ofloxacin otic (ear)...............................125ogestrel (28)........................................161okebo oral capsule 75 mg........................36olanzapine intramuscular.......................87olanzapine oral tablet 10 mg..................87olanzapine oral tablet 15 mg..................87olanzapine oral tablet 2.5 mg.................87olanzapine oral tablet 20 mg..................87olanzapine oral tablet 5 mg....................87olanzapine oral tablet 7.5 mg.................87olanzapine oral tablet,disintegrating 10

mg......................................................88olanzapine oral tablet,disintegrating 15



mg......................................................88olanzapine-fluoxetine oral capsule 12-25

mg, 12-50 mg, 6-50 mg......................88olanzapine-fluoxetine oral capsule 3-25

mg, 6-25 mg.......................................88olmesartan..........................................109


olmesartan-amlodipine-hydrochlorothiazide...........................109

olmesartan-hydrochlorothiazide............109olopatadine nasal.................................125olopatadine ophthalmic (eye)................165omega-3 acid ethyl esters......................109omeprazole oral capsule,delayed release(dr/

ec)....................................................143OMNITROPE..................................150ONCASPAR........................................55ondansetron disintegrating tablet..........143ondansetron hcl (pf )............................143ondansetron hcl oral solution................143ondansetron hcl oral tablet 24 mg.........144ondansetron hcl oral tablet 4 mg, 8

mg....................................................144ONFI ORAL SUSPENSION..............88ONFI ORAL TABLET 10 MG...........88ONFI ORAL TABLET 20 MG...........88OPDIVO.............................................55OPSUMIT........................................172oralone................................................125ORBACTIV........................................37ORFADIN........................................123ORKAMBI ORAL TABLET.............172orphenadrine citrate...............................88orsythia...............................................161oseltamivir............................................37OSMOPREP.....................................144oxaliplatin intravenous recon soln 100

mg......................................................55oxaliplatin intravenous recon soln 50

mg......................................................55oxaliplatin intravenous solution..............55oxandrolone oral tablet 10 mg..............134oxandrolone oral tablet 2.5 mg.............134

oxaprozin..............................................88oxazepam..............................................88oxcarbazepine........................................88oxiconazole..........................................119OXISTAT TOPICAL LOTION........119oxybutynin chloride oral syrup..............175oxybutynin chloride oral tablet.............175oxybutynin chloride oral tablet extended

release 24hr 10 mg, 15 mg.................175oxybutynin chloride oral tablet extended

release 24hr 5 mg..............................175oxycodone oral capsule............................88oxycodone oral concentrate......................88oxycodone oral solution...........................89oxycodone oral tablet..............................89oxycodone oral tablet,oral only,ext.rel.12

hr 10 mg, 20 mg, 40 mg.....................89oxycodone oral tablet,oral only,ext.rel.12

hr 15 mg, 30 mg, 60 mg.....................89OXYCODONE ORAL TABLET,

ORAL ONLY,EXT.REL.12 HR 80MG...................................................89

oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg...............................................89

oxycodone-aspirin..................................89OXYCONTIN ORAL TABLET,ORAL

ONLY,EXT.REL.12 HR 10 MG, 15MG, 20 MG, 30 MG, 40 MG...........89

OXYCONTIN ORAL TABLET,ORALONLY,EXT.REL.12 HR 60 MG, 80MG...................................................89

oxymorphone oral tablet.........................89oxymorphone oral tablet extended release

12 hr..................................................89OXYTROL........................................175


OZEMPIC........................................134pacerone oral tablet 100 mg, 200 mg, 400

mg....................................................109paclitaxel..............................................55paliperidone oral tablet extended release

24hr 1.5 mg.......................................89paliperidone oral tablet extended release

24hr 3 mg..........................................90paliperidone oral tablet extended release

24hr 6 mg..........................................90paliperidone oral tablet extended release

24hr 9 mg..........................................90palonosetron intravenous solution 0.25

mg/5 ml............................................144pamidronate intravenous recon soln......134pamidronate intravenous solution 30 mg/

10 ml (3 mg/ml), 90 mg/10 ml (9 mg/ml)...................................................135

pamidronate intravenous solution 60 mg/10 ml (6 mg/ml)...............................135

PANCREAZE ORAL CAPSULE,DELAYED RELEASE(DR/EC) 10,500-35,500- 61,500 UNIT, 16,800-56,800- 98,400 UNIT, 2,600-6,200-10,850 UNIT, 4,200-14,200- 24,600UNIT..............................................144

PANCREAZE ORAL CAPSULE,DELAYED RELEASE(DR/EC) 21,000-54,700- 83,900 UNIT.............144

PANDEL...........................................119PANRETIN.......................................119pantoprazole intravenous......................144pantoprazole oral.................................144paricalcitol hemodialysis port

injection...........................................135

paricalcitol intravenous solution 2 mcg/ml....................................................135

paricalcitol intravenous solution 5 mcg/ml....................................................135

paricalcitol oral capsule 1 mcg, 2mcg..................................................135

paricalcitol oral capsule 4 mcg..............135paroex oral rinse..................................125paromomycin........................................37paroxetine hcl oral tablet 10 mg..............90paroxetine hcl oral tablet 20 mg..............90paroxetine hcl oral tablet 30 mg..............90paroxetine hcl oral tablet 40 mg.............90paroxetine hcl oral tablet extended release

24 hr 12.5 mg....................................90paroxetine hcl oral tablet extended release

24 hr 25 mg.......................................90paroxetine hcl oral tablet extended release

24 hr 37.5 mg....................................90paser.....................................................37PAXIL ORAL SUSPENSION.............90PAZEO..............................................165PEDIARIX (PF)................................150PEDVAX HIB (PF)...........................150peg 3350-electrolytes oral recon soln 236-

22.74-6.74 -5.86 gram.....................144peg 3350-electrolytes oral recon soln 240-

22.72-6.72 -5.84 gram.....................144peg-electrolyte soln...............................144PEGANONE.......................................90PEGASYS..........................................150PEGASYS PROCLICK

SUBCUTANEOUS PEN INJECTOR180 MCG/0.5 ML..........................150

PEGINTRON SUBCUTANEOUSKIT 50 MCG/0.5 ML.....................150


PENICILLIN G POT IN DEXTROSEINTRAVENOUS PIGGYBACK 1MILLION UNIT/50 ML, 2MILLION UNIT/50 ML..................37

PENICILLIN G POT IN DEXTROSEINTRAVENOUS PIGGYBACK 3MILLION UNIT/50 ML..................37

penicillin g potassium............................37penicillin g sodium................................37penicillin v potassium............................37PENNSAID TOPICAL SOLUTION

IN METERED-DOSE PUMP..........90PENTACEL (PF)...............................150PENTAM............................................37pentamidine..........................................37PENTASA ORAL CAPSULE,

EXTENDED RELEASE 250MG.................................................144

PENTASA ORAL CAPSULE,EXTENDED RELEASE 500MG.................................................144

pentoxifylline.......................................109PERFOROMIST...............................172perindopril erbumine...........................110periogard.............................................125PERJETA.............................................55permethrin topical cream.....................119perphenazine.........................................90perphenazine-amitriptyline....................90PERSERIS...........................................90PERTZYE ORAL CAPSULE,

DELAYED RELEASE(DR/EC) 16,000-57,500- 60,500 UNIT, 24,000-86,250- 90,750 UNIT.....................145

PERTZYE ORAL CAPSULE,DELAYED RELEASE(DR/EC) 4,

000-14,375- 15,125 UNIT, 8,000-28,750- 30,250 UNIT..........................145

phenadoz............................................172phenelzine.............................................90phenergan rectal..................................172phenobarbital oral elixir........................91phenobarbital oral tablet 100 mg...........91phenobarbital oral tablet 15 mg.............91phenobarbital oral tablet 16.2 mg..........91phenobarbital oral tablet 30 mg.............91phenobarbital oral tablet 32.4 mg..........91phenobarbital oral tablet 60 mg.............91phenobarbital oral tablet 64.8 mg..........91phenobarbital oral tablet 97.2 mg..........91phenoxybenzamine..............................110PHENYTEK.......................................91phenytoin oral suspension 100 mg/4

ml......................................................91phenytoin oral suspension 125 mg/5

ml......................................................91phenytoin oral tablet,chewable................91phenytoin sodium extended.....................91phenytoin sodium intravenous

solution...............................................91philith................................................161PHOSLYRA......................................179PHOSPHOLINE IODIDE...............166PHYSIOLYTE...................................123PIFELTRO..........................................37pilocarpine hcl ophthalmic (eye) drops 1

%, 2 %, 4 %....................................166pilocarpine hcl oral..............................123pimecrolimus.......................................119pimozide...............................................91pimtrea (28).......................................161pindolol..............................................110


pioglitazone oral tablet 15 mg..............135pioglitazone oral tablet 30 mg..............135pioglitazone oral tablet 45 mg..............135pioglitazone-glimepiride.......................135pioglitazone-metformin........................135piperacillin-tazobactam intravenous recon

soln 2.25 gram, 3.375 gram, 4.5 gram,40.5 gram...........................................37

pirmella oral tablet 0.5/0.75/1 mg- 35mcg..................................................161

pirmella oral tablet 1-35 mg-mcg.........161piroxicam..............................................91PLASMA-LYTE 148..........................179PLASMA-LYTE A.............................179PLEGRIDY.......................................150plenamine...........................................179podofilox.............................................119polycin................................................166polyethylene glycol 3350.......................145polymyxin b sulf-trimethoprim.............166POMALYST ORAL CAPSULE 1

MG...................................................55POMALYST ORAL CAPSULE 2

MG...................................................55POMALYST ORAL CAPSULE 3 MG,

4 MG................................................55portia 28............................................161potassium chlorid-d5-0.45%nacl

intravenous parenteral solution 10 meq/l, 30 meq/l, 40 meq/l.........................179

potassium chlorid-d5-0.45%naclintravenous parenteral solution 20 meq/l.......................................................179

potassium chloride in 0.9%naclintravenous parenteral solution 20 meq/l, 40 meq/l........................................179

potassium chloride in 5 % dex intravenousparenteral solution 20 meq/l, 30 meq/l,40 meq/l...........................................179

potassium chloride in lr-d5 intravenousparenteral solution 20 meq/l...............179

potassium chloride in lr-d5 intravenousparenteral solution 40 meq/l...............179

potassium chloride in water intravenouspiggyback 10 meq/100 ml, 10 meq/50ml....................................................180

potassium chloride in water intravenouspiggyback 20 meq/100 ml, 20 meq/50ml, 40 meq/100 ml...........................180

potassium chloride intravenous.............180potassium chloride oral capsule, extended

release...............................................180potassium chloride oral liquid...............180potassium chloride oral tablet extended

release...............................................180potassium chloride oral tablet,er particles/

crystals..............................................180potassium chloride-0.45 % nacl...........180potassium chloride-d5-0.2%nacl

intravenous parenteral solution 20 meq/l.......................................................180

potassium chloride-d5-0.2%naclintravenous parenteral solution 30 meq/l, 40 meq/l........................................180

potassium chloride-d5-0.3%naclintravenous parenteral solution 20 meq/l.......................................................180




potassium citrate..................................175POTELIGEO......................................55PRADAXA........................................110PRALUENT PEN.............................110pramipexole oral tablet...........................91pramipexole oral tablet extended release

24 hr..................................................92prasugrel.............................................110pravastatin..........................................110PRAXBIND......................................110praziquantel..........................................37prazosin..............................................110PRED MILD.....................................166PRED-G............................................166prednicarbate......................................119prednisolone acetate.............................166prednisolone oral solution 15 mg/5

ml....................................................135prednisolone sodium phosphate ophthalmic

(eye).................................................166prednisolone sodium phosphate oral

solution 10 mg/5 ml, 20 mg/5 ml (4 mg/ml)...................................................135

prednisolone sodium phosphate oralsolution 15 mg/5 ml (3 mg/ml), 25 mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7mg/5 ml)..........................................136

prednisolone sodium phosphate oral tablet,disintegrating....................................136

prednisone intensol..............................136prednisone oral solution........................136prednisone oral tablet...........................136

prednisone oral tablets,dose pack 10 mg(48 pack), 5 mg, 5 mg (48 pack)........136

pregnyl................................................136PREMARIN ORAL...........................161PREMARIN VAGINAL....................161premasol 10 %....................................181PREMASOL 6 %..............................181PREMPHASE...................................161PREMPRO........................................161prevalite..............................................110previfem..............................................162PREZCOBIX......................................37PREZISTA ORAL SUSPENSION......37PREZISTA ORAL TABLET 150

MG...................................................37PREZISTA ORAL TABLET 600 MG,

800 MG............................................37PREZISTA ORAL TABLET 75

MG...................................................37PRIFTIN.............................................38PRIMAQUINE...................................38primidone.............................................92PROAIR HFA...................................172PROAIR RESPICLICK.....................172probenecid...........................................154probenecid-colchicine...........................154PROCALAMINE 3%........................181procentra...............................................92prochlorperazine..................................145prochlorperazine edisylate.....................145prochlorperazine maleate......................145PROCRIT INJECTION SOLUTION

10,000 UNIT/ML, 2,000 UNIT/ML,3,000 UNIT/ML, 4,000 UNIT/ML..................................................150


PROCRIT INJECTION SOLUTION20,000 UNIT/2 ML, 20,000 UNIT/ML, 40,000 UNIT/ML...................150

procto-pak...........................................145proctosol hc topical...............................145proctozone-hc......................................145PROCYSBI........................................175progesterone micronized.......................162PROGLYCEM...................................136PROGRAF INTRAVENOUS.............55PROGRAF ORAL GRANULES IN

PACKET...........................................55PROLASTIN-C INTRAVENOUS

RECON SOLN...............................123PROLASTIN-C INTRAVENOUS

SOLUTION...................................124PROLEUKIN....................................150PROLIA............................................154PROMACTA ORAL TABLET 12.5

MG, 25 MG, 75 MG......................110PROMACTA ORAL TABLET 50

MG.................................................110promethazine injection solution............172promethazine oral................................172promethazine rectal suppository 12.5 mg,

25 mg...............................................172promethazine rectal suppository 50

mg....................................................172promethazine-codeine..........................172promethazine-dm................................172promethazine-phenylephrine.................172promethegan........................................172propafenone oral capsule,extended release

12 hr................................................110propafenone oral tablet.........................110

propranolol oral capsule,extended release24 hr................................................110

propranolol oral tablet..........................110propranolol-hydrochlorothiazide...........110propylthiouracil...................................136PROQUAD (PF)...............................151PROSOL 20 %..................................181protriptyline..........................................92PROVENTIL HFA...........................172prudoxin.............................................119PULMOZYME.................................172PURIXAN...........................................55PYLERA............................................145pyrazinamide........................................38pyridostigmine bromide oral syrup..........92pyridostigmine bromide oral tablet 60

mg......................................................92pyridostigmine bromide oral tablet

extended release...................................92QUADRACEL (PF)..........................151quetiapine oral tablet 100 mg................92quetiapine oral tablet 200 mg................92quetiapine oral tablet 25 mg..................92quetiapine oral tablet 300 mg................92quetiapine oral tablet 400 mg................92quetiapine oral tablet 50 mg..................92quetiapine oral tablet extended release 24

hr 150 mg..........................................92quetiapine oral tablet extended release 24




hr 50 mg............................................93


quinapril............................................110quinapril-hydrochlorothiazide..............110quinidine gluconate oral......................110quinidine sulfate oral tablet..................110quinine sulfate......................................38QVAR INHALATION AEROSOL 40

MCG/ACTUATION......................173QVAR REDIHALER INHALATION

HFA AEROSOL BREATHACTIVATED 40 MCG/ACTUATION.................................173

QVAR REDIHALER INHALATIONHFA AEROSOL BREATHACTIVATED 80 MCG/ACTUATION.................................173

RABAVERT (PF)...............................151rabeprazole..........................................145raloxifene............................................155ramipril..............................................110RANEXA...........................................111ranitidine hcl injection.........................145ranitidine hcl oral capsule....................145ranitidine hcl oral syrup.......................145ranitidine hcl oral tablet 150 mg, 300

mg....................................................145ranolazine...........................................111RAPAFLO.........................................175RAPAMUNE ORAL SOLUTION......55rasagiline..............................................93RAVICTI...........................................124reclipsen (28)......................................162RECOMBIVAX HB (PF)

INTRAMUSCULAR SUSPENSION10 MCG/ML, 40 MCG/ML...........151

RECOMBIVAX HB (PF)INTRAMUSCULAR SYRINGE 10MCG/ML.......................................151

RECOMBIVAX HB (PF)INTRAMUSCULAR SYRINGE 5MCG/0.5 ML.................................151

RECTIV............................................145RELENZA DISKHALER....................38RELISTOR SUBCUTANEOUS

SOLUTION...................................145RELISTOR SUBCUTANEOUS

SYRINGE 12 MG/0.6 ML..............146RELISTOR SUBCUTANEOUS

SYRINGE 8 MG/0.4 ML................146REMICADE......................................146repaglinide oral tablet 0.5 mg...............136repaglinide oral tablet 1 mg..................136repaglinide oral tablet 2 mg..................136repaglinide-metformin.........................136REPATHA PUSHTRONEX.............111REPATHA SURECLICK..................111REPATHA SYRINGE.......................111RESCRIPTOR ORAL TABLET.........38RETROVIR INTRAVENOUS...........38REVATIO ORAL SUSPENSION FOR

RECONSTITUTION....................173REVLIMID ORAL CAPSULE 10

MG...................................................55REVLIMID ORAL CAPSULE 15 MG,

2.5 MG, 20 MG, 25 MG..................55REVLIMID ORAL CAPSULE 5

MG...................................................55REXULTI ORAL TABLET 0.25 MG,

0.5 MG, 1 MG, 2 MG......................93REXULTI ORAL TABLET 3 MG, 4

MG...................................................93


REYATAZ ORAL POWDER INPACKET...........................................38

ribasphere oral capsule...........................38ribasphere oral tablet 600 mg.................38ribasphere ribapak oral tablets,dose pack

600-600 mg (28)-mg (28)..................38ribavirin oral capsule.............................38ribavirin oral tablet 200 mg...................38RIDAURA.........................................155rifabutin...............................................38rifampin...............................................38RIFATER.............................................38riluzole...............................................124rimantadine..........................................38risedronate oral tablet 150 mg..............155risedronate oral tablet 30 mg................124risedronate oral tablet 35 mg, 35 mg (12

pack), 35 mg (4 pack).......................155risedronate oral tablet 5 mg..................155risedronate oral tablet,delayed release (dr/

ec)....................................................155RISPERDAL CONSTA

INTRAMUSCULAR SYRINGE 12.5MG/2 ML, 25 MG/2 ML.................93

RISPERDAL CONSTAINTRAMUSCULAR SYRINGE 37.5MG/2 ML, 50 MG/2 ML.................93

risperidone oral solution.........................93risperidone oral tablet 0.25 mg...............93risperidone oral tablet 0.5 mg.................93risperidone oral tablet 1 mg....................93risperidone oral tablet 2 mg....................93risperidone oral tablet 3 mg....................93risperidone oral tablet 4 mg....................94risperidone oral tablet,disintegrating 0.25

mg......................................................94

risperidone oral tablet,disintegrating 0.5mg......................................................94

risperidone oral tablet,disintegrating 1mg......................................................94




ritonavir...............................................38RITUXAN...........................................55RITUXAN HYCELA..........................56rivastigmine tartrate..............................94rivastigmine transdermal........................94rivelsa.................................................162rizatriptan............................................94ROMIDEPSIN....................................56ropinirole oral tablet..............................94ropinirole oral tablet extended release 24

hr.......................................................94rosadan topical cream..........................119rosadan topical gel...............................119rosuvastatin.........................................111ROTARIX.........................................151ROTATEQ VACCINE......................151roweepra oral tablet 500 mg...................94ROZEREM.........................................94RUBRACA ORAL TABLET 200

MG...................................................56RUBRACA ORAL TABLET 250 MG,

300 MG............................................56RYDAPT.............................................56SABRIL...............................................94SAIZEN............................................151


SAMSCA ORAL TABLET 15MG.................................................136

SAMSCA ORAL TABLET 30MG.................................................136

SANCUSO........................................146SANDOSTATIN LAR DEPOT

INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON.............56

SANTYL............................................119SAPHRIS SUBLINGUAL TABLET 10

MG...................................................95SAPHRIS SUBLINGUAL TABLET

2.5 MG.............................................95SAPHRIS SUBLINGUAL TABLET 5

MG...................................................95SAVELLA ORAL TABLET 100

MG.................................................155SAVELLA ORAL TABLET 12.5

MG.................................................155SAVELLA ORAL TABLET 25

MG.................................................155SAVELLA ORAL TABLET 50

MG.................................................155SAVELLA ORAL TABLETS,DOSE

PACK..............................................155scopolamine transdermal......................146selegiline hcl..........................................95selenium sulfide topical lotion...............119SELZENTRY ORAL SOLUTION.....38SELZENTRY ORAL TABLET 150

MG, 300 MG....................................38SELZENTRY ORAL TABLET 25

MG...................................................38SELZENTRY ORAL TABLET 75

MG...................................................38SENSIPAR ORAL TABLET 30 MG,

60 MG............................................136

SENSIPAR ORAL TABLET 90MG.................................................137

SEREVENT DISKUS.......................173SEROSTIM SUBCUTANEOUS

RECON SOLN 4 MG, 5 MG, 6MG.................................................151

sertraline oral concentrate.......................95sertraline oral tablet 100 mg..................95sertraline oral tablet 25 mg....................95sertraline oral tablet 50 mg....................95setlakin...............................................162sevelamer carbonate oral powder in packet

0.8 gram...........................................124sevelamer carbonate oral powder in packet

2.4 gram...........................................124sevelamer carbonate oral tablet.............124sharobel..............................................162SHINGRIX (PF)...............................151SIGNIFOR..........................................56SIGNIFOR LAR.................................56sildenafil.............................................175sildenafil (antihypertensive)

intravenous.......................................173sildenafil (antihypertensive) oral

suspension for reconstitution...............173sildenafil (antihypertensive) oral

tablet................................................173silodosin..............................................175silver sulfadiazine................................119SIMBRINZA.....................................166simpesse...............................................162SIMULECT........................................56simvastatin..........................................111sirolimus oral solution............................56sirolimus oral tablet 0.5 mg, 1 mg..........56


SIROLIMUS ORAL TABLET 2MG...................................................56

SIRTURO...........................................39SIVEXTRO INTRAVENOUS............39SIVEXTRO ORAL..............................39SKLICE.............................................120sodium benzoate-sod phenylacet............124sodium chloride 0.45 % intravenous

parenteral solution.............................181sodium chloride 0.45 % intravenous

piggyback..........................................181sodium chloride 0.9 % intravenous.......124sodium chloride 3% intravenous injection

solution.............................................181sodium chloride 5% intravenous injection

solution.............................................181sodium chloride intravenous parenteral

solution 2.5 meq/ml..........................181sodium chloride irrigation....................124sodium phenylbutyrate.........................124sodium polystyrene sulfonate oral...........124sodium polystyrene sulfonate rectal........124solifenacin...........................................176SOLTAMOX.......................................56SOLU-CORTEF (PF) INJECTION

RECON SOLN 250 MG/2 ML......137SOMATULINE DEPOT....................56SOMAVERT.....................................137sorine oral tablet 120 mg, 160 mg, 80

mg....................................................111sorine oral tablet 240 mg.....................111sotalol af.............................................111sotalol oral tablet 120 mg.....................111sotalol oral tablet 160 mg, 240 mg, 80

mg....................................................111SPIRIVA RESPIMAT........................173

SPIRIVA WITH HANDIHALER.....173spironolactone.....................................111spironolactone-hydrochlorothiazide.......111sprintec (28)........................................162SPRITAM ORAL TABLET FOR

SUSPENSION 1,000 MG, 250 MG,500 MG............................................95

SPRITAM ORAL TABLET FORSUSPENSION 750 MG...................95

SPRYCEL............................................56sronyx.................................................162ssd......................................................120STAMARIL (PF)...............................151stavudine oral capsule 15 mg, 20 mg......39stavudine oral capsule 30 mg, 40 mg......39STELARA SUBCUTANEOUS

SYRINGE.......................................120STIMATE..........................................137STIOLTO RESPIMAT......................173STIVARGA..........................................56STRENSIQ.......................................137streptomycin..........................................39STRIBILD...........................................39SUCRAID.........................................146sucralfate oral tablet.............................146sulfacetamide sodium (acne).................120sulfacetamide sodium ophthalmic

(eye).................................................166sulfacetamide-prednisolone...................166sulfadiazine...........................................39sulfamethoxazole-trimethoprim..............39SULFAMYLON TOPICAL

CREAM..........................................120sulfasalazine........................................146sulfatrim...............................................39sulindac................................................95


sumatriptan nasal spray.........................95sumatriptan succinate oral.....................95sumatriptan succinate subcutaneous

cartridge.............................................95sumatriptan succinate subcutaneous pen

injector...............................................95sumatriptan succinate subcutaneous

solution...............................................96SUPRAX ORAL CAPSULE................39SUPRAX ORAL SUSPENSION FOR

RECONSTITUTION 500 MG/5ML....................................................39

SUPRAX ORAL TABLET,CHEWABLE.....................................39

SUPREP BOWEL PREP KIT...........146SUTENT ORAL CAPSULE 12.5

MG...................................................56SUTENT ORAL CAPSULE 25 MG,

37.5 MG, 50 MG..............................56syeda...................................................162SYLATRON......................................151SYLVANT INTRAVENOUS RECON

SOLN 100 MG.................................57SYMBICORT....................................173SYMFI.................................................39SYMFI LO...........................................39SYMJEPI...........................................173SYMLINPEN 120.............................137SYMLINPEN 60...............................137SYMPAZAN ORAL FILM 10 MG, 20

MG...................................................96SYMPAZAN ORAL FILM 5 MG.......96SYMTUZA..........................................39SYNAGIS............................................39SYNAREL.........................................137SYNERCID.........................................39SYNJARDY.......................................137

SYNJARDY XR ORAL TABLET, IR -ER, BIPHASIC 24HR 10-1,000 MG,12.5-1,000 MG, 5-1,000 MG.........137

SYNJARDY XR ORAL TABLET, IR -ER, BIPHASIC 24HR 25-1,000MG.................................................137

SYNRIBO...........................................57SYNTHROID...................................137TABLOID...........................................57TACLONEX TOPICAL

SUSPENSION................................120tacrolimus oral capsule 0.5 mg, 1 mg......57tacrolimus oral capsule 5 mg...................57tacrolimus topical................................120tadalafil (antihypertensive)...................173TAFINLAR.........................................57TAGRISSO ORAL TABLET 40

MG...................................................57TAGRISSO ORAL TABLET 80

MG...................................................57TALTZ AUTOINJECTOR...............120TALTZ AUTOINJECTOR (2

PACK).............................................120TALTZ AUTOINJECTOR (3

PACK).............................................120TALTZ SYRINGE.............................120TALZENNA ORAL CAPSULE 0.25

MG...................................................57TALZENNA ORAL CAPSULE 1

MG...................................................57tamoxifen..............................................57tamsulosin...........................................176TARCEVA ORAL TABLET 100 MG,

150 MG............................................57TARCEVA ORAL TABLET 25

MG...................................................57TARGRETIN TOPICAL....................57


tarina fe 1-20 eq (28)..........................162tarina fe 1/20 (28)..............................162TASIGNA ORAL CAPSULE 150 MG,

200 MG............................................57TASIGNA ORAL CAPSULE 50

MG...................................................57tazarotene...........................................120TAZICEF INJECTION RECON

SOLN 1 GRAM................................39TAZICEF INJECTION RECON

SOLN 2 GRAM, 6 GRAM...............39TAZICEF INTRAVENOUS...............39TAZORAC TOPICAL CREAM 0.05

%.....................................................120TAZORAC TOPICAL GEL..............120taztia xt..............................................111TDVAX.............................................151TECENTRIQ INTRAVENOUS

SOLUTION 1,200 MG/20 ML (60MG/ML)...........................................58

TECENTRIQ INTRAVENOUSSOLUTION 840 MG/14 ML (60MG/ML)...........................................58

TECFIDERA.......................................96TEFLARO...........................................39TEGRETOL ORAL

SUSPENSION..................................96TEGRETOL ORAL TABLET.............96TEGRETOL XR.................................96TEKTURNA.....................................111TEKTURNA HCT...........................111telmisartan..........................................111telmisartan-amlodipine........................111telmisartan-hydrochlorothiazide...........111temazepam............................................96temsirolimus..........................................58

tencon oral tablet 50-325 mg.................96TENIVAC (PF) INTRAMUSCULAR

SYRINGE.......................................151tenofovir disoproxil fumarate..................40terazosin capsule..................................111terbinafine hcl oral................................40terbutaline..........................................174terconazole vaginal cream.....................162terconazole vaginal suppository.............162testosterone cypionate...........................137testosterone enanthate...........................137testosterone transdermal gel in metered-

dose pump 12.5 mg/ 1.25 gram (1%)...................................................137

testosterone transdermal gel in metered-dose pump 20.25 mg/1.25 gram (1.62%)...................................................137

testosterone transdermal gel in packet 1 %(25 mg/2.5gram), 1 % (50 mg/5gram)...............................................138

testosterone transdermal gel in packet 1.62% (20.25 mg/1.25 gram)..................138

testosterone transdermal gel in packet 1.62% (40.5 mg/2.5 gram)......................138

TETANUS,DIPHTHERIA TOXPED(PF)..........................................151

tetrabenazine oral tablet 12.5 mg...........96tetrabenazine oral tablet 25 mg..............96tetracycline............................................40THALOMID ORAL CAPSULE 100

MG, 50 MG......................................58THALOMID ORAL CAPSULE 150

MG, 200 MG....................................58theophylline oral tablet extended release

12 hr................................................174


theophylline oral tablet extended release24 hr................................................174

thioridazine..........................................96thiotepa................................................58thiothixene............................................96thyroid (pork) oral tablet 120 mg, 30 mg,

60 mg...............................................138thyroid (pork) oral tablet 15 mg, 90

mg....................................................138THYROLAR-1..................................138THYROLAR-1/2...............................138THYROLAR-1/4...............................138THYROLAR-2..................................138THYROLAR-3..................................138tiagabine...............................................96TIBSOVO...........................................58TIGECYCLINE..................................40tilia fe.................................................162timolol maleate ophthalmic (eye)

drops................................................166timolol maleate ophthalmic (eye) gel

forming solution................................166timolol maleate oral.............................111tinidazole..............................................40TIROSINT........................................138TIVICAY ORAL TABLET 10 MG......40TIVICAY ORAL TABLET 25 MG, 50

MG...................................................40tizanidine oral capsule...........................96tizanidine oral tablet.............................96TOBI PODHALER INHALATION

CAPSULE, W/INHALATIONDEVICE...........................................40

TOBRADEX OPHTHALMIC (EYE)OINTMENT..................................166

TOBRADEX ST...............................166

tobramycin..........................................166tobramycin in 0.225% nacl for

nebulization.......................................40tobramycin sulfate injection recon soln....40tobramycin sulfate injection solution.......40tobramycin-dexamethasone ophthalmic

(eye).................................................166tolazamide oral tablet 250 mg..............138tolazamide oral tablet 500 mg..............138tolbutamide........................................138tolcapone...............................................96tolmetin................................................96tolterodine oral capsule,extended release

24hr.................................................176tolterodine oral tablet...........................176topiramate oral capsule, sprinkle.............96topiramate oral tablet 100 mg................97topiramate oral tablet 200 mg................97topiramate oral tablet 25 mg..................97topiramate oral tablet 50 mg..................97toposar..................................................58topotecan..............................................58toremifene.............................................58TORISEL............................................58torsemide oral......................................111TOUJEO MAX U-300

SOLOSTAR....................................138TOUJEO SOLOSTAR U-300

INSULIN........................................138TOVIAZ............................................176TRACLEER ORAL TABLET............174TRACLEER ORAL TABLET FOR

SUSPENSION................................174TRADJENTA....................................138tramadol oral tablet...............................97


tramadol oral tablet extended release 24hr.......................................................97

tramadol oral tablet, er multiphase 24hr.......................................................97

tramadol-acetaminophen........................97trandolapril.........................................112trandolapril-verapamil.........................112tranexamic acid oral............................162TRANSDERM-SCOP......................146tranylcypromine.....................................97travasol 10 %......................................181TRAVATAN Z...................................166trazodone oral tablet 100 mg, 150 mg,

50 mg.................................................97trazodone oral tablet 300 mg..................97TREANDA INTRAVENOUS RECON

SOLN................................................58TRECATOR.......................................40TRELSTAR INTRAMUSCULAR

SUSPENSION FORRECONSTITUTION 11.25 MG.....58

TRELSTAR INTRAMUSCULARSUSPENSION FORRECONSTITUTION 22.5 MG.......58

TRELSTAR INTRAMUSCULARSUSPENSION FORRECONSTITUTION 3.75 MG.......58

tretinoin..............................................120tretinoin (chemotherapy)........................59tretinoin microspheres..........................120TREXALL ORAL TABLET 10 MG,

15 MG..............................................59tri-estarylla.........................................162tri-legest fe...........................................162tri-linyah............................................162tri-lo-estarylla......................................162

tri-lo-mili...........................................162tri-lo-sprintec......................................162tri-previfem (28).................................162tri-sprintec (28)...................................162triamcinolone acetonide dental.............125triamcinolone acetonide topical

aerosol..............................................120triamcinolone acetonide topical

cream...............................................120triamcinolone acetonide topical

lotion................................................120triamcinolone acetonide topical ointment

0.025 %, 0.1 %, 0.5 %....................120triamterene-hydrochlorothiazide oral

capsule..............................................112triamterene-hydrochlorothiazide oral

tablet................................................112triazolam..............................................97triderm topical cream...........................120trientine..............................................124trifluoperazine.......................................97trifluridine..........................................166trihexyphenidyl......................................97trilyte with flavor packets.....................146trimethobenzamide oral.......................146trimethoprim.........................................40trimipramine........................................97TRINTELLIX ORAL TABLET 10

MG...................................................97TRINTELLIX ORAL TABLET 20

MG...................................................98TRINTELLIX ORAL TABLET 5

MG...................................................98TRISENOX INTRAVENOUS

SOLUTION 2 MG/ML....................59TRIUMEQ..........................................40


trivora (28).........................................162TROGARZO......................................40TROKENDI XR ORAL CAPSULE,

EXTENDED RELEASE 24HR 100MG, 25 MG, 50 MG........................98

TROKENDI XR ORAL CAPSULE,EXTENDED RELEASE 24HR 200MG...................................................98

TROPHAMINE 10 %......................181TROPHAMINE 6%.........................181trospium oral capsule,extended release

24hr.................................................176trospium oral tablet.............................176TRULICITY......................................138TRUMENBA....................................151TRUVADA..........................................40TUDORZA PRESSAIR....................174TWINRIX (PF) INTRAMUSCULAR

SYRINGE.......................................151TYBOST.............................................40TYKERB.............................................59TYPHIM VI INTRAMUSCULAR

SOLUTION...................................152TYPHIM VI INTRAMUSCULAR

SYRINGE.......................................152TYSABRI.............................................98TYVASO...........................................174UCERIS RECTAL.............................146ULORIC...........................................155unithroid oral tablet 100 mcg, 112 mcg,

125 mcg, 150 mcg, 175 mcg, 200 mcg,25 mcg, 300 mcg, 50 mcg, 75 mcg, 88mcg..................................................139

unithroid oral tablet 137 mcg..............139UPTRAVI ORAL TABLET...............112UPTRAVI ORAL TABLETS,DOSE

PACK..............................................112

ursodiol...............................................146UVADEX..........................................121valacyclovir oral tablet 1 gram................40valacyclovir oral tablet 500 mg...............40VALCHLOR.....................................121valganciclovir oral tablet........................40valproate sodium...................................98valproic acid..........................................98valproic acid (as sodium salt) oral solution

250 mg/5 ml.......................................98valproic acid (as sodium salt) oral solution

250 mg/5 ml (5 ml), 500 mg/10 ml (10ml).....................................................98

valsartan.............................................112valsartan-hydrochlorothiazide..............112vancomycin in 0.9 % sodium chl

intravenous piggyback 500 mg/100 ml,750 mg/150 ml...................................41

vancomycin intravenous recon soln 1,000mg, 10 gram, 500 mg..........................41

VANCOMYCIN INTRAVENOUSRECON SOLN 1.25 GRAM, 1.5GRAM, 250 MG...............................41

vancomycin oral capsule 125 mg.............41vancomycin oral capsule 250 mg.............41vandazole............................................162VAQTA (PF)......................................152VARIVAX (PF)..................................152VARIZIG INTRAMUSCULAR

SOLUTION...................................152VASCEPA..........................................112VECAMYL........................................112VECTIBIX..........................................59VELCADE..........................................59velivet triphasic regimen (28)...............162VELPHORO.....................................124


VELTASSA ORAL POWDER INPACKET 16.8 GRAM, 25.2GRAM............................................124

VELTASSA ORAL POWDER INPACKET 8.4 GRAM......................124

VEMLIDY...........................................41VENCLEXTA ORAL TABLET 10

MG...................................................59VENCLEXTA ORAL TABLET 100

MG...................................................59VENCLEXTA ORAL TABLET 50

MG...................................................59VENCLEXTA STARTING PACK......59venlafaxine oral capsule,extended release

24hr 150 mg......................................98venlafaxine oral capsule,extended release

24hr 37.5 mg.....................................98venlafaxine oral capsule,extended release

24hr 75 mg........................................98venlafaxine oral tablet 100 mg...............98venlafaxine oral tablet 25 mg.................98venlafaxine oral tablet 37.5 mg..............99venlafaxine oral tablet 50 mg.................99venlafaxine oral tablet 75 mg.................99venlafaxine oral tablet extended release

24hr 150 mg......................................99venlafaxine oral tablet extended release

24hr 225 mg......................................99venlafaxine oral tablet extended release

24hr 37.5 mg.....................................99venlafaxine oral tablet extended release

24hr 75 mg........................................99VENTAVIS........................................174VENTOLIN HFA.............................174verapamil oral capsule, 24 hr er pellet

ct......................................................112

verapamil oral capsule,ext rel. pellets 24hr 120 mg, 180 mg, 240 mg.............112

verapamil oral capsule,ext rel. pellets 24hr 360 mg........................................112

verapamil oral tablet............................112verapamil oral tablet extended

release...............................................112VEREGEN........................................121veripred 20.........................................139VERSACLOZ......................................99VERZENIO........................................59VESICARE........................................176VIBERZI...........................................146vicodin.................................................99vicodin es..............................................99vicodin hp.............................................99VICTOZA 2-PAK.............................139VICTOZA 3-PAK.............................139VIDEX 2 GRAM PEDIATRIC...........41VIDEX 4 GRAM PEDIATRIC...........41VIDEX EC ORAL CAPSULE,

DELAYED RELEASE(DR/EC) 125MG...................................................41

vienva.................................................162vigabatrin oral powder in packet............99vigabatrin oral tablet.............................99VIIBRYD ORAL TABLET 10 MG.....99VIIBRYD ORAL TABLET 20 MG.....99VIIBRYD ORAL TABLET 40 MG.....99VIIBRYD ORAL TABLETS,DOSE

PACK 10 MG (7)- 20 MG (23)......100VIMIZIM..........................................139VIMPAT INTRAVENOUS...............100VIMPAT ORAL SOLUTION...........100VIMPAT ORAL TABLET 100

MG.................................................100


VIMPAT ORAL TABLET 150MG.................................................100



vinblastine intravenous solution..............59vincristine.............................................59vinorelbine............................................59VIOKACE.........................................146VIRACEPT ORAL TABLET 250

MG...................................................41VIRACEPT ORAL TABLET 625

MG...................................................41VIRAMUNE ORAL

SUSPENSION..................................41VIREAD ORAL POWDER................41VIREAD ORAL TABLET 150 MG,

200 MG, 250 MG.............................41VITRAKVI ORAL CAPSULE 100

MG...................................................59VITRAKVI ORAL CAPSULE 25

MG...................................................59VITRAKVI ORAL SOLUTION.........59VIVLODEX......................................100VIZIMPRO ORAL TABLET 15

MG...................................................60VIZIMPRO ORAL TABLET 30 MG,

45 MG..............................................60voriconazole intravenous........................41voriconazole oral suspension for

reconstitution......................................41voriconazole oral tablet 200 mg..............41VORICONAZOLE ORAL TABLET

50 MG..............................................42VOSEVI..............................................42VOTRIENT........................................60

VPRIV...............................................139VRAYLAR ORAL CAPSULE............100VRAYLAR ORAL CAPSULE,DOSE

PACK..............................................100vyfemla (28).......................................163VYVANSE ORAL CAPSULE............100VYXEOS.............................................60warfarin.............................................112water for irrigation, sterile...................124wera (28)............................................163wixela inhub.......................................174wymzya fe...........................................163XALKORI...........................................60XARELTO ORAL TABLET 10 MG,

20 MG............................................112XARELTO ORAL TABLET 15

MG.................................................112XARELTO ORAL TABLET 2.5

MG.................................................112XARELTO ORAL TABLETS,DOSE

PACK..............................................113XATMEP.............................................60XELJANZ..........................................155XELJANZ XR...................................155XEOMIN INTRAMUSCULAR

RECON SOLN 50 UNIT..............152XGEVA................................................60XIFAXAN ORAL TABLET 200

MG...................................................42XIFAXAN ORAL TABLET 550

MG...................................................42XIIDRA.............................................166XOFLUZA..........................................42XOLAIR SUBCUTANEOUS RECON

SOLN..............................................174XOSPATA............................................60XTANDI.............................................60


xulane................................................163XYREM.............................................100YERVOY.............................................60YF-VAX (PF).....................................152YONDELIS.........................................60YONSA...............................................60yuvafem..............................................163zafirlukast...........................................174zaleplon oral capsule 10 mg..................100zaleplon oral capsule 5 mg....................100ZALTRAP...........................................60ZANOSAR..........................................60zarah..................................................163ZARXIO............................................152ZEJULA..............................................60ZELAPAR..........................................100ZELBORAF........................................60ZEMAIRA.........................................124zenatane.............................................121zenchent (28)......................................163ZENPEP ORAL CAPSULE,DELAYED

RELEASE(DR/EC) 10,000-32,000 -42,000 UNIT, 15,000-47,000 -63,000UNIT, 20,000-63,000- 84,000 UNIT,25,000-79,000- 105,000 UNIT, 3,000-10,000 -14,000-UNIT, 40,000-126,000- 168,000 UNIT, 5,000-17,000- 24,000 UNIT..........................146

zenzedi oral tablet 10 mg.....................100zenzedi oral tablet 5 mg.......................100ZIAGEN ORAL SOLUTION............42zidovudine oral capsule..........................42zidovudine oral syrup.............................42zidovudine oral tablet............................42zileuton..............................................174ZIOPTAN (PF).................................166

ziprasidone hcl oral capsule 20 mg........100ziprasidone hcl oral capsule 40 mg........100ziprasidone hcl oral capsule 60 mg, 80

mg....................................................101ZIRGAN...........................................166ZOLEDRONIC AC-MANNITOL-

0.9NACL........................................139zoledronic acid intravenous solution 4 mg/

5 ml.................................................139zoledronic acid-mannitol-water 5 mg/100

ml....................................................125zoledronic acid-mannitol-water 5 mg/100

ml intravenous piggyback 4 mg/100ml....................................................139

ZOLINZA...........................................60zolmitriptan........................................101zolpidem.............................................101ZOMACTON SUBCUTANEOUS

RECON SOLN 10 MG..................152ZOMACTON SUBCUTANEOUS

RECON SOLN 5 MG....................152ZOMIG NASAL...............................101zonisamide..........................................101ZORBTIVE.......................................152ZORTRESS.........................................60ZOSTAVAX (PF)...............................152zovia 1/35e (28)..................................163ZOVIRAX TOPICAL CREAM.........121zumandimine (28)..............................163ZYCLARA TOPICAL CREAM IN

METERED-DOSE PUMP.............121ZYCLARA TOPICAL CREAM IN

PACKET.........................................121ZYDELIG...........................................61ZYKADIA...........................................61ZYLET..............................................167


ZYPREXA RELPREVVINTRAMUSCULAR SUSPENSIONFOR RECONSTITUTION 210MG.................................................101

ZYPREXA RELPREVVINTRAMUSCULAR SUSPENSION

FOR RECONSTITUTION 300 MG,405 MG..........................................101

ZYTIGA ORAL TABLET 250 MG.....61ZYTIGA ORAL TABLET 500 MG.....61


Simply Healthcare Plans, Inc., is a Medicare-contracted coordinated care plan that has aMedicaid contract with the State of Florida Agency for Health Care Administration to providebenefits or arrange for benefits to be provided to enrollees. Enrollment in Simply HealthcarePlans, Inc. depends on contract renewal.

Simply Healthcare Plans, Inc. es un plan de atención médica coordinada con un contratoMedicare y un contrato Medicaid con la Agencia de Administración de Cuidado de la Salud(AHCA) del estado de la Florida para proveer o coordinar los beneficios a ser proporcionadosa los afiliados. La inscripción en Simply Healthcare Plans, Inc. depende de la renovación delcontrato.

ATENCIÓN: Si usted habla español, servicios de asistencia en español, de forma gratuita,están disponibles para usted. Llame al 1-877-577-0115 (TTY: 711)This formulary was updated on July 1, 2019. For more recent information or other questions,please contact Simply Complete (HMO SNP) Member Services, at 1-877-577-0115 or, for TTYusers, 711, From October 1 to March 31, we are open seven days a week from 8:00 a.m. -8:00 p.m. ET. Beginning April 1 to September 30, we are open Monday through Friday, 8:00a.m. - 8:00 p.m. ET., or visit https://shop.simplyhealthcareplans.com/medicare.

Este formulario se actualizó el 1.º de julio de 2019. Para obtener información más recienteo para preguntas, por favor llame a Simply Healthcare Plans, Servicios al Afiliado sin cargoal 1-877-577-0115 o, para usuarios de TTY, al 711. Del 1 de octubre al 31 de marzo,atendemos siete días a la semana de 8:00 a.m. - 8:00 p.m. ET. Del 1 de abril al 30 deseptiembre, atendemos de lunes a viernes, de 8:00 a.m. - 8:00 p.m. ET., o visitehttps://shop.simplyhealthcareplans.com/medicare.

Y0114_19_35071_I_C_ES_LP_304 H5471_064, 066, 072, 076, 082, 084 FL

2019 formulary (list of covered drugs) · or at the time the member requests a refill of the drug,...

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