2022 essential health benefits base formulary

2022 Essential Health Benefits Base FormularyEffective July 1, 2022

For the most current list of covered medications or if you have questions:Call the number on your member ID card.

Visit your plan’s website on your member ID card or log on to the Optum Rx app to:

• Find a participating retail pharmacy by ZIP code.

• Look up possible lower-cost medication alternatives.

• Compare medication pricing and options.

EHB Base

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Understanding your formularyWhat is a formulary?A formulary is a list of prescribed medications or other pharmacy care products, services or supplies chosen for their safety, cost, and effectiveness. Medications are listed by categories or classes and are placed into cost levels known as tiers. It includes both brand and generic prescription medications.

To create the list, Optum Rx® is guided by the Pharmacy and Therapeutics Committee. This group of doctors and pharmacists reviews which medications will be covered, how well the drugs work, and overall value. They also make sure there are safe and covered options.

How do I use my formulary?You and your doctor can use the formulary to help you choose the most cost-effective prescription medications. This guide tells you if a medication is generic or brand, and if special rules apply. If your medication is not listed here, please visit your plan’s website or call the number on your member ID card.

What are tiers?Tiers are the different cost levels you pay for a medication. Each tier is assigned a cost, set by your employer or plan sponsor.

When does the formulary change?• Medications, including generics, may be added at any time.• Medications may move to a lower tier at any time.• Medications may move to a higher tier or be excluded from coverage

on January 1 of each year.

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

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

What if I don’t agree with a decision about an excluded medication?You, your authorized representative, or your doctor can ask for a coverage request by calling the number on your member ID card.

Medication tipsWhat is the difference between brand-name and generic medications?Generic medications contain the same active ingredients (offer the same effect) as brand-name medications, but they often cost less.

What if my doctor writes a brand-name prescription?If your doctor gives you a prescription for a brand-name medication, ask if a generic or lower-cost option could be right for you. Generic medications are usually your lowest-cost option.

What if I am taking a specialty medication?Specialty medications are used to treat complex conditions and are generally higher in cost. Please note, not all specialty medications are listed in the formulary. Our specialty pharmacy can provide most of your specialty medications along with helpful programs and services. Call 1-855-427-4682 and ask if you can have your prescriptions delivered right to your home or doctor’s office.

About this formularyWhen differences between this formulary and your benefit plan exist, the benefit plan documents rule. This may not be a complete list of medications that are covered by your plan. Please review your benefit plan for full details.

Over-the-counter medications (OTC)Talk to your doctor about OTC options. Even though OTC medications may not be covered by your pharmacy benefit, they may cost less than a prescription medication.

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

Tier informationUsing lower tier or preferred medications can help you lower your out-of-pocket cost. Your plan may have multiple or no tiers. Please note: If you have a high-deductible plan, the tier cost levels will apply once you meet your deductible.

Drug tier Includes Helpful tips

Tier 1 $ Generic Use tier 1 drugs to lower your out-of-pocket costs.

Tier 2 $$ Preferred Preferred brand-name drugs will generally have lower copayments than non-preferred brand-name drugs.

Tier 3 $$$ Non-preferred Many tier 3 drugs have lower-cost options in tier 1 or 2. Ask your doctor if they could work for you.

Tier 4 $$$$ Specialty Generally highest in copayment and cost. These drugs are sometimes used for complex and chronic conditions and may require special monitoring and handling.

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

M Authorized generic or cobranded product

PA Prior authorization – Your doctor is required to give Optum Rx more information to determine coverage.

PV Preventive drugs – May have coverage and no copayments when health care reform requirements are met.

PV* Preventive drugs – Available at $0 if Health Care Reform copay waiver is approved.

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

SP Specialty medication – Medication is designated as specialty.

ST Step therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered.

Essential Health Benefits Base Formulary

Table of Contents

Analgesics ......................................................................................................................................................... 5Anesthetics ........................................................................................................................................................ 7Anti-Addiction/Substance Abuse Treatment Agents .....................................................................................7Antibacterials .....................................................................................................................................................8Anticonvulsants .............................................................................................................................................. 11Antidementia Agents ...................................................................................................................................... 12Antidepressants .............................................................................................................................................. 12Antiemetics ...................................................................................................................................................... 13Antifungals .......................................................................................................................................................13Antigout Agents .............................................................................................................................................. 14Antimigraine Agents ....................................................................................................................................... 14Antimyasthenic Agents .................................................................................................................................. 15Antimycobacterials ......................................................................................................................................... 15Antineoplastics ................................................................................................................................................15Antiparasitics ...................................................................................................................................................18Antiparkinson Agents ..................................................................................................................................... 18Antipsychotics .................................................................................................................................................19Antivirals .......................................................................................................................................................... 19Anxiolytics ....................................................................................................................................................... 21Bipolar Agents .................................................................................................................................................22Blood Glucose Monitoring ............................................................................................................................. 22Blood Glucose Regulators ............................................................................................................................. 23Blood Products and Modifiers ....................................................................................................................... 24Cardiovascular Agents ................................................................................................................................... 25Central Nervous System Agents ....................................................................................................................28Dental and Oral Agents ...................................................................................................................................29Dermatological Agents ................................................................................................................................... 30Electrolytes/Minerals/Metals/Vitamins .......................................................................................................... 31Gastrointestinal Agents ..................................................................................................................................33Genetic or Enzyme Disorder: Replacement, Modifiers, Treatment ............................................................ 34Genitourinary Agents ......................................................................................................................................35Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal) ................................................................36Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) ...............................................................37Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins) ................................................... 38Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) ................................... 38Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) ................................................................ 42Hormonal Agents, Suppressant (Adrenal) ....................................................................................................42Hormonal Agents, Suppressant (pituitary) ................................................................................................... 42Hormonal Agents, Suppressant (Thyroid) .................................................................................................... 43Immunological Agents ....................................................................................................................................43Inflammatory Bowel Disease Agents ............................................................................................................ 45Metabolic Bone Disease Agents .................................................................................................................... 46Miscellaneous Therapeutic Agents ............................................................................................................... 46Ophthalmic Agents ......................................................................................................................................... 48Otic Agents ...................................................................................................................................................... 50Respiratory Tract/Pulmonary Agents ............................................................................................................51Skeletal Muscle Relaxants ..............................................................................................................................53Sleep Disorder Agents ....................................................................................................................................53

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Drug Name Drug Tier Notes

Analgesics

Nonsteroidal Anti-inflammatory Drugs

adult aspirin regimen 1 PV

aspirin adult low dose 1 PV

aspirin adult low strength

1 PV

aspirin childrens 1 PV

aspirin ec low dose 1 PV

aspirin ec low strength 1 PV

aspirin ec oral tablet delayed release 325 mg

1 PV

aspirin low dose 1 PV

aspirin oral tablet 1 PV

aspirin oral tablet delayed release

1 PV

BAYER ASPIRIN 3 PV

BAYER ASPIRIN EC LOW DOSE

3 PV

celecoxib oral 1 QL

diclofenac potassium oral tablet 50 mg

1

diclofenac sodium er 1

diclofenac sodium external gel 1 %

1 QL

diclofenac sodium external solution

1 PA

diclofenac sodium oral 1

diclofenac-misoprostol 1

diflunisal oral 1

ec-naproxen 1

etodolac 1

etodolac er 1

fenoprofen calcium oral capsule 400 mg

3

fenoprofen calcium oral tablet

3


flurbiprofen oral 1

goodsense aspirin adults

1 PV

goodsense aspirin low dose

1 PV

ibuprofen oral suspension 100 mg/5ml

1

ibuprofen oral tablet 400 mg, 600 mg, 800 mg

1

indomethacin er 1

indomethacin oral capsule 25 mg, 50 mg

1

ketoprofen oral 1

ketorolac tromethamine injection

1

ketorolac tromethamine intramuscular

1

ketorolac tromethamine oral

1 QL

mefenamic acid oral 3

meloxicam oral tablet 1

nabumetone oral 1

naproxen oral tablet 1

naproxen oral tablet delayed release

1

naproxen sodium oral tablet 275 mg, 550 mg

1

oxaprozin 1

piroxicam oral 1

ST JOSEPH LOW DOSE

3 PV

sulindac oral 1

Opioid Analgesics, Long-acting

buprenorphine 3 PA; QL

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

5


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

1 PA; QL

hydrocodone bitartrate er oral tablet er 24 hour abuse-deterrent

1 PA; QL

hydromorphone hcl er 3 PA; QL

methadone hcl injection 1

methadone hcl oral solution

1

methadone hcl oral tablet

1 PA

methadone hcl oral tablet soluble

1

methadose oral tablet soluble

1

mitigo 3

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

3 PA; QL

morphine sulfate er oral tablet extended release 15 mg, 30 mg

1 PA; QL

NUCYNTA ER 3 PA; QL

OXYCONTIN 2 PA; QL

oxymorphone hcl er 3 PA; QL

tramadol hcl er (biphasic)

3 PA; QL

tramadol hcl er oral tablet extended release 24 hour

3 PA; QL

XTAMPZA ER 2 PA; QL

Opioid Analgesics, Short-acting

acetaminophen-codeine

1 QL

acetaminophen-codeine #2

1 QL



1 QL


1 QL

apap-caff-dihydrocodeine oral capsule

3 PA; QL

ascomp-codeine 3

bac 1

butalbital-acetaminophen oral tablet 50-325 mg

1

butalbital-apap-caff-cod 3

butalbital-apap-caffeine 1

butalbital-asa-caff-codeine

3

butalbital-aspirin-caffeine

1

butorphanol tartrate injection

1

butorphanol tartrate nasal

3 QL

carisoprodol-aspirin-codeine

3

codeine sulfate 1 QL

duramorph injection solution 0.5 mg/ml

3

endocet 1 QL

fentanyl citrate buccal lozenge on a handle

3 PA; QL

hydrocodone-acetaminophen

1 QL

hydrocodone-ibuprofen 1 QL

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

3

hydromorphone hcl oral 1 QL

hydromorphone hcl pf 3


6


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

1 QL

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

3

morphine sulfate (pf) injection solution 10 mg/ml, 8 mg/ml

1

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

3

morphine sulfate injection solution 2 mg/ml, 4 mg/ml

3

morphine sulfate intravenous solution 4 mg/ml

3

morphine sulfate oral 1 QL

NUCYNTA 3 PA; QL

oxycodone hcl oral capsule

1 QL

oxycodone hcl oral solution

1 QL

oxycodone hcl oral tablet

1 QL

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

1 QL

oxymorphone hcl 1 QL

pentazocine-naloxone hcl

1 QL

tramadol hcl oral tablet 50 mg

1 QL

tramadol-acetaminophen

1 QL


Anesthetics

Local Anesthetics

glydo 1

lidocaine external ointment 5 %

1

lidocaine external patch 5 %

1

lidocaine hcl external solution

1

lidocaine hcl urethral/mucosal

1

lidocaine viscous hcl 1

lidocaine-prilocaine external cream

1

LIDOCAINE-TETRACAINE

3 PA

Anti-Addiction/Substance Abuse Treatment Agents

Alcohol Deterrents/Anti-craving

acamprosate calcium 3

disulfiram oral 3

naltrexone hcl oral 1

VIVITROL 4 SP

Opioid Dependence Treatments

buprenorphine hcl injection

1

buprenorphine hcl sublingual

1 QL

buprenorphine hcl-naloxone hcl

1 QL

Opioid Reversal Agents

KLOXXADO 2

naloxone hcl injection 1


7


naloxone hcl nasal 1

NARCAN 2

Smoking Cessation Agents

APO-VARENICLINE 3 ST; PV; QL

bupropion hcl er (smoking det)

1 PV; QL

goodsense nicotine mouth/throat lozenge 4 mg

1 PV; QL

habitrol 1 PV; QL

NICORETTE MOUTH/THROAT GUM 2 MG

3 PV; QL

NICORETTE MOUTH/THROAT LOZENGE 4 MG

3 PV; QL

nicotine polacrilex mini 1 PV; QL

nicotine polacrilex mouth/throat

1 PV; QL

nicotine step 1 1 PV; QL



nicotine transdermal kit 1 PV; QL

NICOTROL 3 ST; PV; QL

NICOTROL NS 3 ST; PV; QL

varenicline tartrate 1 PV; QL

Antibacterials

Aminoglycosides

amikacin sulfate injection

1

gentamicin sulfate external

1

neomycin sulfate oral 1

paromomycin sulfate oral

1

streptomycin sulfate intramuscular

3


Antibacterials, Other

ALTABAX 3

aztreonam 1

clindamycin hcl oral 1

clindamycin palmitate hcl

1

clindamycin phosphate in d5w

1

clindamycin phosphate injection

1

clindamycin phosphate vaginal

1

daptomycin 1

fosfomycin tromethamine

3

iodine tincture external tincture 2 %

1

linezolid in sodium chloride

1

linezolid intravenous 1

linezolid oral 3 QL

mafenide acetate external

1

methenamine hippurate 3

metronidazole in nacl 1

metronidazole oral tablet

1

metronidazole vaginal 1

mupirocin external 1

nitrofurantoin macrocrystal oral capsule 100 mg, 50 mg

1

nitrofurantoin monohydrate macrocrystals

1

polymyxin b sulfate injection

1

silver sulfadiazine external

1


8


ssd 1

trimethoprim oral 1

vancomycin hcl intravenous solution reconstituted 1 gm, 1.25 gm, 1.5 gm, 100 gm, 500 mg, 750 mg

1

vancomycin hcl oral 3 QL

vandazole 1

XEPI 3

XIFAXAN 3 PA

Beta-lactam, Cephalosporins

cefaclor 1

cefaclor er 1

cefadroxil oral capsule 1

cefadroxil oral suspension reconstituted

1

cefazolin sodium injection

1

cefazolin sodium intravenous solution reconstituted

1

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

1

cefazolin sodium-dextrose intravenous solution reconstituted

1

cefdinir 1

cefepime hcl injection 1

cefepime hcl intravenous solution

1

cefepime-dextrose 1

cefotaxime sodium 1

cefotetan disodium 1


cefotetan disodium-dextrose

1

cefoxitin sodium 1

cefpodoxime proxetil 3

cefprozil 1

ceftazidime and dextrose

1

ceftazidime injection 1

ceftazidime intravenous 1

ceftriaxone sodium in dextrose

1

ceftriaxone sodium injection

1

ceftriaxone sodium intravenous

1

ceftriaxone sodium-dextrose

1

cefuroxime axetil 1

cephalexin oral capsule 250 mg, 500 mg

1

cephalexin oral suspension reconstituted

1

tazicef injection 1

tazicef intravenous solution reconstituted

1

Beta-lactam, Penicillins

amoxicillin 1

amoxicillin-potassium clavulanate

1

amoxicillin-potassium clavulanate er

3

ampicillin 1

ampicillin sodium 1

ampicillin-sulbactam sodium

1

BICILLIN L-A 3


9


dicloxacillin sodium 1

nafcillin sodium 1

oxacillin sodium 1

penicillin g potassium injection solution reconstituted 20000000 unit

1

penicillin v potassium 1

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

1

Carbapenems

ertapenem sodium 3

imipenem-cilastatin 3

VABOMERE 3

Macrolides

azithromycin intravenous

1

azithromycin oral 1

clarithromycin oral suspension reconstituted

3

clarithromycin oral tablet

1

DIFICID ORAL TABLET

3

erythromycin base 3

erythromycin ethylsuccinate oral

3

erythromycin oral 3

Quinolones

BAXDELA ORAL 3

CIPRO ORAL SUSPENSION RECONSTITUTED

3


ciprofloxacin hcl oral tablet 250 mg, 500 mg, 750 mg

1

levofloxacin oral 1

moxifloxacin hcl in nacl 1

moxifloxacin hcl oral 1

ofloxacin oral 1

Sulfonamides

sulfadiazine oral 3

sulfamethoxazole-trimethoprim

1

sulfatrim pediatric 1

Tetracyclines

avidoxy 1

demeclocycline hcl 3

doxy 100 1

doxycycline hyclate intravenous

1

doxycycline hyclate oral capsule

1

doxycycline hyclate oral tablet 100 mg, 20 mg

1

doxycycline monohydrate oral capsule 100 mg, 50 mg

1

doxycycline monohydrate oral suspension reconstituted

3

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

1

minocycline hcl oral capsule

1

mondoxyne nl 1

tetracycline hcl oral 3


10


Anticonvulsants

Anticonvulsants, Other

BRIVIACT ORAL 3 ST

EPIDIOLEX 4 PA; SP

levetiracetam er 1

levetiracetam in nacl 1

levetiracetam intravenous

1

levetiracetam oral 1

roweepra 1

Calcium Channel Modifying Agents

CELONTIN 3

ethosuximide oral 1

zonisamide oral 1

Gamma-aminobutyric Acid (GABA) Augmenting Agents

clobazam 1 PA

DIACOMIT 4 PA; SP

diazepam rectal 1 QL

gabapentin oral 1

pentobarbital sodium injection

1

phenobarbital oral 1

phenobarbital sodium injection

1

primidone oral 1

tiagabine hcl 1

valproate sodium intravenous

1

valproic acid oral 1

Glutamate Reducing Agents

felbamate 1

FYCOMPA 3


lamotrigine er 1

lamotrigine oral 1

lamotrigine starter kit-blue

1

lamotrigine starter kit-green

1

lamotrigine starter kit-orange

1

subvenite 1

subvenite starter kit-blue

1

subvenite starter kit-green

1

subvenite starter kit-orange

1

topiramate er 1

topiramate oral 1

Sodium Channel Agents

carbamazepine er 1

carbamazepine oral 1

DILANTIN ORAL CAPSULE 30 MG

3

epitol 1

fosphenytoin sodium injection solution 500 mg pe/10ml

1

lacosamide 1

oxcarbazepine 1

phenytoin infatabs 1

phenytoin oral 1

phenytoin sodium extended

1

phenytoin sodium injection

1

rufinamide 1 PA

VIMPAT ORAL 3


11


Antidementia Agents

Antidementia Agents, Other

NAMZARIC ORAL CAPSULE EXTENDED RELEASE 24 HOUR

2 QL

Cholinesterase Inhibitors

donepezil hcl 1

galantamine hydrobromide

1

galantamine hydrobromide er

1

rivastigmine 3

rivastigmine tartrate 1

N-methyl-D-aspartate (NMDA) Receptor Antagonist

memantine hcl 1

memantine hcl er 3 QL

Antidepressants

Antidepressants, Other

bupropion hcl er (sr) 1 QL

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

1 QL

bupropion hcl oral 1

chlordiazepoxide-amitriptyline

1

mirtazapine oral tablet 15 mg, 30 mg, 45 mg

1

olanzapine-fluoxetine hcl

1 QL

perphenazine-amitriptyline

1


Monoamine Oxidase Inhibitors

EMSAM 3 ST; QL

MARPLAN 3

phenelzine sulfate oral 3

tranylcypromine sulfate 3

SSRI/SNRI (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitors)

citalopram hydrobromide oral tablet

1

desvenlafaxine succinate er

3 QL

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

1 QL

escitalopram oxalate oral tablet

1

FETZIMA 3 ST; QL

FETZIMA TITRATION 3 ST; QL

fluoxetine hcl oral capsule

1

fluvoxamine maleate 3

fluvoxamine maleate er 3 QL

nefazodone hcl 3

paroxetine hcl oral tablet

1

paroxetine mesylate 1 QL

sertraline hcl oral concentrate

1

sertraline hcl oral tablet 1

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

1


12


trazodone hcl oral tablet 300 mg

3

TRINTELLIX 3 ST; QL

venlafaxine hcl 1

venlafaxine hcl er oral capsule extended release 24 hour

1

VIIBRYD 3 PA; QL

VIIBRYD STARTER PACK

3 PA; QL

Tricyclics

amitriptyline hcl oral 3

amoxapine 3

clomipramine hcl oral 3

desipramine hcl oral 3

doxepin hcl oral capsule

3

doxepin hcl oral concentrate

3

imipramine hcl oral 1

imipramine pamoate 3

nortriptyline hcl oral capsule

1

nortriptyline hcl oral solution

3

protriptyline hcl 3

trimipramine maleate oral

3

Antiemetics

Antiemetics, Other

compro 3

dimenhydrinate injection

1

droperidol injection 1

meclizine hcl oral tablet 1

metoclopramide hcl injection

1


metoclopramide hcl oral solution

1

metoclopramide hcl oral tablet

1

perphenazine oral 1

prochlorperazine 3

prochlorperazine maleate oral

1

scopolamine 1

Emetogenic Therapy Adjuncts

AKYNZEO ORAL 3 QL

aprepitant oral capsule 125 mg, 40 mg, 80 mg

3 QL

dronabinol 3 PA; QL

fosaprepitant dimeglumine

1

granisetron hcl intravenous

1

granisetron hcl oral 1 QL

ondansetron hcl injection

1

ondansetron hcl oral solution

1 QL

ondansetron hcl oral tablet 4 mg, 8 mg

1

ondansetron odt 1

palonosetron hcl 1

Antifungals

ABELCET 3

AMBISOME 3

amphotericin b intravenous

1

amphotericin b liposome

3

caspofungin acetate 3

ciclodan 1

ciclopirox external 1


13


ciclopirox olamine external

1

clotrimazole external 1

clotrimazole mouth/throat

1

clotrimazole-betamethasone

1

CRESEMBA ORAL 3 PA

econazole nitrate external

1

ERTACZO 3 PA

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

1

fluconazole oral 1

flucytosine oral 1

griseofulvin microsize oral

3

griseofulvin ultramicrosize

3

GYNAZOLE-1 3

itraconazole oral capsule

3 PA

ketoconazole external cream

1

ketoconazole external shampoo

1

ketoconazole oral 1

LULICONAZOLE 3 PA

MENTAX 3 PA

miconazole 3 1

naftifine hcl 1

nyamyc 1

nystatin external 1

nystatin mouth/throat 1

nystatin oral 3


nystatin-triamcinolone 1

nystop 1

oxiconazole nitrate 3

posaconazole 3 PA

SULCONAZOLE NITRATE EXTERNAL CREAM

3 PA

tavaborole 1 PA

terbinafine hcl oral 1 QL

terconazole vaginal cream

1

voriconazole oral tablet 3 PA

Antigout Agents

allopurinol oral 1

allopurinol sodium 1

colchicine oral tablet 1

colchicine-probenecid 1

febuxostat 1 ST

probenecid 1

Antimigraine Agents

Calcitonin Gene-Related Peptide (CGRP) Receptor Antagonist

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

2 PA; QL

EMGALITY 2 PA; QL

Ergot Alkaloids

dihydroergotamine mesylate injection

3 PA; QL

ergotamine-caffeine 3 PA

Serotonin (5-HT) Receptor Agonists

almotriptan malate 3 QL

eletriptan hydrobromide 3 QL


14


naratriptan hcl 1 QL

rizatriptan benzoate 1 QL

sumatriptan succinate oral

1 QL

sumatriptan succinate refill subcutaneous solution cartridge

3 QL

sumatriptan succinate subcutaneous solution

1 QL

sumatriptan succinate subcutaneous solution auto-injector

3 QL

sumatriptan-naproxen sodium

3 QL

ZOLMITRIPTAN NASAL SOLUTION 2.5 MG

3 ST; QL

zolmitriptan nasal solution 5 mg

1 QL

zolmitriptan oral 1 QL

ZOMIG NASAL 3 ST; QL

Antimyasthenic Agents

Parasympathomimetics

pyridostigmine bromide er

1

pyridostigmine bromide oral

1

Antimycobacterials

Antimycobacterials, Other

dapsone oral 3

rifabutin 3

Antituberculars

CAPASTAT SULFATE 3

cycloserine oral 1

ethambutol hcl oral 3

isoniazid injection 1


isoniazid oral 1

PASER 3

PRIFTIN 3

pyrazinamide oral 1

rifampin intravenous 1

rifampin oral 1

SIRTURO 3

TRECATOR 3

Antineoplastics

Alkylating Agents

busulfan 4 SP

cyclophosphamide injection

4 SP

cyclophosphamide oral capsule

3

CYCLOPHOSPHAMIDE ORAL TABLET

2

GLEOSTINE 4 SP

LEUKERAN 2

MATULANE 4 SP

melphalan 4 SP

melphalan hcl 4 SP

MYLERAN 2

temozolomide 4 PA; SP

ZANOSAR 4 SP

Antiandrogens

abiraterone acetate 4 PA; SP

bicalutamide 1

flutamide 1

nilutamide 4 SP

ORGOVYX 4 PA; SP

XTANDI 4 PA; SP

Antiangiogenic Agents

lenalidomide 4 PA; SP

POMALYST 4 PA; SP


15


REVLIMID 4 PA; SP

THALOMID 4 PA; SP

Antiestrogens/Modifiers

EMCYT 3

SOLTAMOX 3 PV*

tamoxifen citrate oral tablet 10 mg

1

tamoxifen citrate oral tablet 20 mg

1 PV*

toremifene citrate 1

Antimetabolites

capecitabine 4 PA; SP

decitabine 4 PA; SP

DROXIA 3

fludarabine phosphate 4 SP

fluorouracil intravenous 4 SP

hydroxyurea oral 1

mercaptopurine oral 1

TABLOID 4 SP

Antineoplastics, Other

AMELUZ 3

daunorubicin hcl 4 SP

diclofenac sodium external gel 3 %

1 ST; QL

ETHYOL 4

FLUOROPLEX 3

FLUOROURACIL EXTERNAL CREAM 0.5 %

2

fluorouracil external cream 5 %

1

fluorouracil external solution

1

IXEMPRA KIT 4 SP


leucovorin calcium injection

1

leucovorin calcium oral 1

mitomycin intravenous 4 SP

mitoxantrone hcl 4 PA; SP

mutamycin 4 SP

NINLARO 4 PA; SP

ONUREG 4 PA; SP

paclitaxel 4 SP

PIQRAY 4 PA; SP

PROLEUKIN 4 SP

ROZLYTREK 4 PA; SP

SYNRIBO 4 PA; SP

ZOLINZA 4 PA; SP

Aromatase Inhibitors, 3rd Generation

anastrozole oral 1 PV*

exemestane 1 PV*

letrozole oral 1

Enzyme Inhibitors

etoposide oral 4 SP

HYCAMTIN ORAL 4 SP

RUBRACA 4 PA; SP

Molecular Target Inhibitors

AFINITOR DISPERZ 4 PA; SP

ALECENSA 4 PA; SP

BELEODAQ 4 PA; SP

BOSULIF 4 PA; SP

CABOMETYX 4 PA; SP

CAPRELSA ORAL TABLET 100 MG

4 PA; SP; QL

CAPRELSA ORAL TABLET 300 MG

4 PA; SP

COMETRIQ 4 PA; SP

COTELLIC 4 PA; SP


16


ERIVEDGE 4 PA; SP

erlotinib hcl oral tablet 100 mg, 150 mg

4 PA; SP

erlotinib hcl oral tablet 25 mg

4 PA; SP; QL

everolimus oral tablet 10 mg, 2.5 mg, 5 mg, 7.5 mg

4 PA; SP; QL

everolimus oral tablet soluble

4 PA; SP

FARYDAK 4 PA; SP

GILOTRIF 4 PA; SP; QL

IBRANCE 4 PA; SP

ICLUSIG ORAL TABLET 10 MG, 15 MG

4 PA; SP; QL

ICLUSIG ORAL TABLET 30 MG, 45 MG

4 PA; SP

imatinib mesylate 4 PA; SP

IMBRUVICA 4 PA; SP; QL

INLYTA 4 PA; SP

JAKAFI ORAL TABLET 10 MG

4 PA; SP; QL

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

4 PA; SP

KOSELUGO 4 PA; SP

lapatinib ditosylate 4 PA; SP

LENVIMA ORAL CAPSULE THERAPY PACK 10 & 4 MG, 10 MG, 10 MG & 2 X 4 MG, 2 X 10 MG, 2 X 10 MG & 4 MG, 2 X 4 MG, 3 X 4 MG, 4 MG

4 PA; SP

LYNPARZA 4 PA; SP

MEKINIST 4 PA; SP

NEXAVAR 4 PA; SP


QINLOCK 4 PA; SP

RETEVMO 4 PA; SP

RYDAPT 4 PA; SP

SPRYCEL 4 PA; SP

STIVARGA 4 PA; SP

sunitinib malate 4 PA; SP

SUTENT 4 PA; SP

TABRECTA 4 PA; SP

TAFINLAR 4 PA; SP

TAGRISSO ORAL TABLET 40 MG

4 PA; SP; QL

TAGRISSO ORAL TABLET 80 MG

4 PA; SP

TASIGNA 4 PA; SP

TUKYSA 4 PA; SP

TURALIO 4 PA; SP

VENCLEXTA 4 PA; SP

VENCLEXTA STARTING PACK

4 PA; SP

VOTRIENT 4 PA; SP

XALKORI 4 PA; SP

ZELBORAF 4 PA; SP

ZYDELIG 4 PA; SP

ZYKADIA 4 PA; SP

Monoclonal Antibody/Antibody-Drug Conjugate

ADCETRIS 4 PA; SP

RITUXAN 4 PA; SP

RITUXAN HYCELA 4 PA; SP

RUXIENCE 4 PA; SP

Retinoids

bexarotene 4 PA; SP

PANRETIN 3

TARGRETIN EXTERNAL

4 PA; SP


17


tretinoin oral 4 SP

Treatment Adjuncts

MESNEX ORAL 4 SP

Antiparasitics

Anthelmintics

albendazole oral 3 PA

EMVERM 2

ivermectin external lotion

1

ivermectin oral 1 PA; QL

praziquantel oral 3

Antiprotozoals

atovaquone 3

atovaquone-proguanil hcl oral tablet 250-100 mg

3

atovaquone-proguanil hcl oral tablet 62.5-25 mg

1

BENZNIDAZOLE 3

chloroquine phosphate oral

3

COARTEM 3

hydroxychloroquine sulfate oral

1

IMPAVIDO 3

mefloquine hcl 1

nitazoxanide oral 3

pentamidine isethionate 1

primaquine phosphate 1

pyrimethamine oral 4 PA; SP

quinine sulfate oral 3 PA

Pediculicides/Scabicides

crotan 1

lindane 3

malathion 1


permethrin external 1

spinosad 1

sulfurated lime 1

Antiparkinson Agents

Anticholinergics

benztropine mesylate 1

trihexyphenidyl hcl 1

Antiparkinson Agents, Other

amantadine hcl oral 1

carbidopa-levodopa-entacapone oral tablet 12.5-50-200 mg, 18.75-75-200 mg

1

carbidopa-levodopa-entacapone oral tablet 18.75-200-75 mg

1

entacapone 1

tolcapone 1

Dopamine Agonists

APOKYN 4 PA; SP; QL

apomorphine hcl subcutaneous

4 PA; SP; QL

bromocriptine mesylate oral

1

NEUPRO 3 ST

pramipexole dihydrochloride

1

pramipexole dihydrochloride er

1

ropinirole hcl 1

ropinirole hcl er 1

Dopamine Precursors and/or L-Amino Acid Decarboxylase Inhibitors

carbidopa-levodopa er oral tablet extended release 50-200 mg

1


18


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

1

carbidopa-levodopa oral tablet dispersible 25-100 mg

1

Dopamine Precursors/L-Amino Acid Decarboxylase Inhibitors

carbidopa oral 3

carbidopa-levodopa er oral tablet extended release 25-100 mg

1

carbidopa-levodopa oral tablet 25-100 mg

1

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

1

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

1

Monoamine Oxidase B (MAO-B) Inhibitors

rasagiline mesylate oral 1

selegiline hcl oral 1

Antipsychotics

1st Generation/Typical

chlorpromazine hcl oral tablet

3

fluphenazine hcl oral tablet

3

haloperidol decanoate intramuscular

1

haloperidol lactate 1

haloperidol oral 1


loxapine succinate 3

pimozide 1

thioridazine hcl oral 1

thiothixene 3

trifluoperazine hcl 3

2nd Generation/Atypical

ABILIFY MAINTENA 3

aripiprazole oral tablet 1 QL

asenapine maleate 1 QL

FANAPT 3 ST; QL

FANAPT TITRATION PACK

3 ST; QL

INVEGA SUSTENNA 3

INVEGA TRINZA 3

LATUDA 3 PA; QL

olanzapine oral tablet 1 QL

paliperidone er 3 QL

quetiapine fumarate 1 QL

quetiapine fumarate er 3 QL

REXULTI 3 QL

RISPERDAL CONSTA 3

risperidone oral tablet 1 QL

ziprasidone hcl 3 QL

Treatment-Resistant

clozapine oral tablet 3 QL

Antivirals

MOLNUPIRAVIR 3 QL

PAXLOVID 3 QL

Anti-cytomegalovirus (CMV) Agents

cidofovir intravenous 1

valganciclovir hcl 3

Anti-hepatitis B (HBV) Agents

adefovir dipivoxil 4 SP


19


BARACLUDE ORAL SOLUTION

4 SP; QL

entecavir 4 SP; QL

EPIVIR HBV ORAL SOLUTION

4 SP

lamivudine oral tablet 100 mg

4 SP

VEMLIDY 4 SP

Anti-hepatitis C (HCV) Agents, Other

INTRON A 4 PA; SP

Anti-hepatitis C (HCV) Agents

EPCLUSA 4 PA; SP; QL

HARVONI 4 PA; SP; QL

MAVYRET 4 PA; SP; QL

PEGASYS 4 PA; SP

ribavirin oral 4 SP

ZEPATIER 4 PA; SP; QL

Antiherpetic Agents

acyclovir external ointment

1

acyclovir oral capsule 1

acyclovir oral suspension

3

acyclovir oral tablet 1

acyclovir sodium 1

famciclovir oral 1

valacyclovir hcl oral 1 QL

Anti-HIV Agents, Integrase Inhibitors (INSTI)

BIKTARVY 3 QL

DOVATO 2 QL

ISENTRESS 2

ISENTRESS HD 2

JULUCA 2 QL


TIVICAY 2

TIVICAY PD 2

TYBOST 2

Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI)

COMPLERA 2 QL

EDURANT 2

efavirenz 3

efavirenz-emtricitab-tenofovir

3 QL

efavirenz-lamivudine-tenofovir

3 QL

etravirine 1

INTELENCE ORAL TABLET 25 MG

2

nevirapine 3

nevirapine er 3

PIFELTRO 3

Anti-HIV Agents, Nucleoside And Nucleotide Reverse Transcriptase Inhibitors (NRTI)

abacavir sulfate oral solution

3

abacavir sulfate oral tablet

1

abacavir sulfate-lamivudine

1 QL

abacavir-lamivudine-zidovudine

3 QL

CIMDUO 2 QL

emtricitabine 1

emtricitabine-tenofovir df oral tablet 100-150 mg, 133-200 mg, 167-250 mg

3 QL


20


emtricitabine-tenofovir df oral tablet 200-300 mg

3 PV*; QL

EMTRIVA ORAL SOLUTION

2

lamivudine oral solution 3

lamivudine oral tablet 150 mg, 300 mg

1

lamivudine-zidovudine 1 QL

ODEFSEY 3 QL

stavudine 1

tenofovir disoproxil fumarate

1 PV*

TRIUMEQ 2 QL

VIREAD ORAL POWDER

2

VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG

2

zidovudine 3

Anti-HIV Agents, Other

FUZEON 2

maraviroc 1 PA

RUKOBIA 2

SELZENTRY 2 PA

Anti-HIV Agents, Protease Inhibitors

APTIVUS 2

atazanavir sulfate 3

EVOTAZ 2 QL

fosamprenavir calcium 3

lopinavir-ritonavir oral solution

3

lopinavir-ritonavir oral tablet

1

NORVIR ORAL PACKET

2


NORVIR ORAL SOLUTION

2

PREZCOBIX 2 QL

PREZISTA 2

REYATAZ ORAL PACKET

2

ritonavir 3

SYMTUZA 3 QL

VIRACEPT 2

Anti-influenza Agents

oseltamivir phosphate oral

3 QL

RELENZA DISKHALER 3 QL

rimantadine hcl 1

Anxiolytics

Anxiolytics, Other

buspirone hcl oral tablet 10 mg, 15 mg, 30 mg, 5 mg

1

hydroxyzine hcl intramuscular

1

hydroxyzine hcl oral 1

hydroxyzine pamoate oral capsule 100 mg

3

hydroxyzine pamoate oral capsule 25 mg, 50 mg

1

meprobamate 3

Benzodiazepines

alprazolam er 1 QL

alprazolam oral tablet 1 QL

alprazolam xr 1 QL

chlordiazepoxide hcl 1 QL

clonazepam oral tablet 1 QL

clorazepate dipotassium

1 QL

diazepam intensol 1


21


diazepam oral 1

estazolam 1 QL

lorazepam injection 1

lorazepam intensol 3 QL

lorazepam oral concentrate 2 mg/ml

3 QL

lorazepam oral tablet 1 QL

oxazepam 3 QL

triazolam 1 QL

Bipolar Agents

Mood Stabilizers

divalproex sodium er 1

divalproex sodium oral 1

lithium carbonate er 1

lithium carbonate oral 1

Blood Glucose Monitoring

ACCU-CHEK FASTCLIX LANCET KIT

2

ACCU-CHEK FASTCLIX LANCETS

2

ACCU-CHEK SAFE-T PRO LANCETS

2

ACCU-CHEK SOFTCLIX LANCET DEVICE KIT

2

ACCU-CHEK SOFTCLIX LANCETS

2

CEQUR SIMPLICITY 2U

3

CHEMSTRIP 10 MD 3

CHEMSTRIP 10/SG 3

CHEMSTRIP 2 GP 3

CHEMSTRIP 5 OB 3

CHEMSTRIP 7 3

CHEMSTRIP 9 3


CHEMSTRIP K 3

CHEMSTRIP UGK 3

CONTOUR CONTROL SOLUTION

2

CONTOUR MONITOR DEVICE

2

CONTOUR MONITOR KIT W/DEVICE

2

CONTOUR NEXT CONTROL SOLUTION

2

CONTOUR NEXT EZ KIT W/DEVICE

2

CONTOUR NEXT LINK KIT W/DEVICE

2

CONTOUR NEXT MONITOR KIT W/DEVICE

2

CONTOUR NEXT ONE KIT

2

CONTOUR NEXT TEST STRIPS

2 QL

CONTOUR TEST STRIPS

2 QL

CVS KETONE CARE 3

EMBRACE PRESSURE ACTIVATED 21G

2

EMBRACE PRESSURE ACTIVATED 28G

2

INPEN 100-BLUE-LILLY-HUMALOG

3

INPEN 100-BLUE-NOVOLOG-FIASP

3

INPEN 100-GREY-LILLY-HUMALOG

3

INPEN 100-GREY-NOVOLOG-FIASP

3

INPEN 100-PINK-LILLY-HUMALOG

3


22


INPEN 100-PINK-NOVOLOG-FIASP

3

KETO-DIASTIX 3

KETONE TEST 3

KETOSTIX 3

LANCETS 2

NOVOPEN ECHO 3

ONETOUCH CLUB LANCETS FINE PT

2

ONETOUCH DELICA LANCETS 30G

2

ONETOUCH DELICA LANCETS 33G

2

ONETOUCH DELICA LANCING DEV

3

ONETOUCH DELICA PLUS LANCET30G

2

ONETOUCH DELICA PLUS LANCET33G

2

ONETOUCH DELICA PLUS LANCING

3

ONETOUCH FINEPOINT LANCETS

2

ONETOUCH ULTRASOFT LANCETS

2

Blood Glucose Regulators

Antidiabetic Agents

acarbose oral 3

BYDUREON BCISE AUTOINJECTOR

2 ST; QL

BYETTA 10 MCG PEN 2 ST; QL

BYETTA 5 MCG PEN 2 ST; QL

FARXIGA 2 ST

glimepiride 1

glipizide er 1

glipizide ir 1


glipizide xl 1

glipizide-metformin hcl 3

glyburide micronized 1

glyburide oral 1

glyburide-metformin 3

GLYXAMBI 2 ST

JANUMET 2 ST

JANUMET XR 2 ST

JANUVIA 2 ST

JARDIANCE 2 ST

JENTADUETO 2 ST

JENTADUETO XR 2 ST

metformin hcl er 1

metformin hcl oral tablet

1

miglitol 3

nateglinide 3

OZEMPIC 2 ST; QL

pioglitazone hcl 1

pioglitazone hcl-glimepiride

3

pioglitazone hcl-metformin hcl

3

repaglinide 3

RYBELSUS 2 ST; QL

SOLIQUA 2 ST; QL

SYNJARDY 2 ST

SYNJARDY XR 2 ST

TRADJENTA 2 ST

TRULICITY 2 ST; QL

VICTOZA 2 ST; QL

XIGDUO XR 2 ST

XULTOPHY 2 ST; QL

Glycemic Agents

diazoxide oral 1

glucagon emergency kit 1


23


GLUCAGON EMERGENCY KIT

2Made by Fresenius

Insulins

HUMALOG 2

HUMALOG KWIKPEN 2

HUMALOG MIX 50/50 KWIKPEN

2

HUMALOG MIX 50/50 VIAL

2

HUMALOG MIX 75/25 KWIKPEN

2

HUMALOG MIX 75/25 VIAL

2

HUMALOG U-100 JUNIOR KWIKPEN

2

HUMULIN 70/30 KWIKPEN

2

HUMULIN 70/30 VIAL 2

HUMULIN N KWIKPEN 2

HUMULIN N VIAL 2

HUMULIN R U-500 KWIKPEN

2

HUMULIN R U-500 VIAL

2

HUMULIN R VIAL 2

LANTUS SOLOSTAR 2

LANTUS U-100 VIAL 2

LEVEMIR U-100 FLEXTOUCH

3 PA

LEVEMIR U-100 VIAL 3 PA

TOUJEO MAX SOLOSTAR

2

TOUJEO SOLOSTAR 2

TRESIBA 3 PA

TRESIBA FLEXTOUCH

3 PA


Blood Products and Modifiers

SOLIRIS 4 PA; SP

Anticoagulants

ELIQUIS 2 QL

ELIQUIS DVT/PE STARTER PACK

2 QL

enoxaparin sodium 4 SP; QL

fondaparinux sodium 4 SP; QL

heparin sodium (porcine) injection solution prefilled syringe

1

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

1

jantoven 1

PRADAXA 2 QL

SAVAYSA 3 QL

warfarin sodium oral 1

XARELTO 2 QL

XARELTO STARTER PACK

2 QL

ZONTIVITY 3

Blood Formation Modifiers

anagrelide hcl 3

ARANESP (ALBUMIN FREE)

4 PA; SP

MOZOBIL 4 PA; SP; QL

NEULASTA 4 PA; SP

NEULASTA ONPRO 4 PA; SP

NIVESTYM 4 PA; SP

PROCRIT 4 PA; SP

PROMACTA 4 PA; SP

REBLOZYL 4 PA; SP

RETACRIT 4 PA; SP


24


Hemostasis Agents

ALPHANATE 4 SP

aminocaproic acid oral tablet

1

COAGADEX 4 SP

CORIFACT 4 SP

ELOCTATE 4 SP

FEIBA 4 SP

HEMLIBRA 4 SP

HUMATE-P 4 SP

NOVOEIGHT 4 SP

NOVOSEVEN RT 4 SP

NUWIQ 4 SP

OBIZUR 4 SP

RECOMBINATE 4 SP

RIASTAP 4 SP

RIXUBIS 4 SP

XYNTHA 4 SP

XYNTHA SOLOFUSE 4 SP

Platelet Modifying Agents

aspirin-dipyridamole er 3

BRILINTA 2

CABLIVI 4 PA; SP; QL

cilostazol 1

clopidogrel bisulfate oral

1

dipyridamole oral 1

eptifibatide intravenous solution 200 mg/100ml

3

prasugrel hcl 3

Cardiovascular Agents

Alpha-adrenergic Agonists

clonidine 3


clonidine hcl oral 1

guanfacine hcl 1

methyldopa 1

midodrine hcl 1

Alpha-adrenergic Blocking Agents

doxazosin mesylate oral

1

phenoxybenzamine hcl oral

1

prazosin hcl oral 1

Angiotensin II Receptor Antagonists

candesartan cilexetil 1

irbesartan 1

losartan potassium oral 1

olmesartan medoxomil oral

1

telmisartan 1

valsartan 1

Angiotensin-converting Enzyme (ACE) Inhibitors

benazepril hcl oral 1

captopril oral 1

enalapril maleate oral tablet

1

fosinopril sodium 1

lisinopril oral 1

moexipril hcl 1

perindopril erbumine 1

quinapril hcl 1

ramipril 1

trandolapril 1

Antiarrhythmics

amiodarone hcl oral tablet 200 mg

1


25


disopyramide phosphate

1

dofetilide 3

flecainide acetate 1

mexiletine hcl oral 1

procainamide hcl injection solution 100 mg/ml

3

propafenone hcl 1

quinidine sulfate 1

sorine 1

sotalol hcl (af) 1

sotalol hcl oral 1

Beta-adrenergic Blocking Agents

acebutolol hcl oral 1

atenolol oral 1

betaxolol hcl oral 1

bisoprolol fumarate oral 1

carvedilol 1

labetalol hcl oral 1

metoprolol succinate er 1

metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg

1

nebivolol hcl 1

pindolol 3

propranolol hcl er 3

propranolol hcl intravenous

1

propranolol hcl oral 1

timolol maleate oral 3

Calcium Channel Blocking Agents

amlodipine besylate oral

1

cartia xt 1


diltiazem hcl er 1

diltiazem hcl er beads 1

diltiazem hcl er coated beads oral capsule extended release 24 hour

1

diltiazem hcl oral 1

dilt-xr 1

felodipine er 1

nifedipine er oral tablet extended release 24 hour 30 mg, 60 mg

1

nifedipine er oral tablet extended release 24 hour 90 mg

3

nifedipine er osmotic release oral tablet extended release 24 hour 30 mg, 60 mg

1

nifedipine er osmotic release oral tablet extended release 24 hour 90 mg

3

nimodipine oral 3

taztia xt 1

tiadylt er 1

verapamil hcl er oral capsule extended release 24 hour

3

verapamil hcl er oral tablet extended release

1

verapamil hcl oral 1

Cardiovascular Agents, Other

aliskiren fumarate 3

amiloride-hydrochlorothiazide

1

amlodipine besylate-benazepril hcl

1


26


amlodipine besylate-valsartan

3

amlodipine-atorvastatin 1

amlodipine-olmesartan 3

atenolol-chlorthalidone 1

benazepril-hydrochlorothiazide

1

bisoprolol-hydrochlorothiazide

1

CORLANOR 3 PA; QL

DEMSER 3

digitek 1

digox 1

digoxin oral solution 3

digoxin oral tablet 125 mcg, 250 mcg

1

enalapril-hydrochlorothiazide

1

ENTRESTO 2 QL

epinephrine pf 1

fosinopril sodium-hctz 1

irbesartan-hydrochlorothiazide

1

lisinopril-hydrochlorothiazide

1

losartan potassium-hctz 1

mannitol intravenous solution 20 %

3

metoprolol-hydrochlorothiazide

1

metyrosine 1

olmesartan medoxomil-hctz

1

pentoxifylline er 1

quinapril-hydrochlorothiazide

1

ranolazine er 3

spironolactone-hctz 1


triamterene-hctz 1

valsartan-hydrochlorothiazide

1

VYNDAMAX 4 PA; SP; QL

Diuretics, Carbonic Anhydrase Inhibitors

acetazolamide er 3

acetazolamide oral 3

methazolamide oral tablet 25 mg

1

methazolamide oral tablet 50 mg

3

Diuretics, Loop

bumetanide oral 1

ethacrynic acid 3

furosemide oral 1

torsemide 1

Diuretics, Potassium-sparing

amiloride hcl oral 1

eplerenone 1

spironolactone oral 1

triamterene oral 3

Diuretics, Thiazide

chlorthalidone 1

hydrochlorothiazide oral

1

indapamide 1

metolazone 3

Dyslipidemics, Fibric Acid Derivatives

fenofibrate micronized oral capsule 134 mg, 200 mg, 43 mg

3

fenofibrate micronized oral capsule 67 mg

1


27


fenofibrate oral capsule 134 mg, 150 mg, 200 mg, 50 mg

3

fenofibrate oral capsule 67 mg

1

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

1

fenofibric acid oral capsule delayed release

3

gemfibrozil oral 1

Dyslipidemics, HMG CoA Reductase Inhibitors

atorvastatin calcium oral tablet 10 mg, 20 mg

1 PV*

atorvastatin calcium oral tablet 40 mg, 80 mg

1

lovastatin oral 1 PV

pravastatin sodium 1

rosuvastatin calcium 1

simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg

1 PV*

simvastatin oral tablet 80 mg

1

Dyslipidemics, Other

cholestyramine light 3

cholestyramine oral 3

colesevelam hcl oral tablet

3

colestipol hcl 3

ezetimibe 1

ezetimibe-simvastatin 3

NEXLETOL 2 PA; QL

NEXLIZET 2 PA; QL


niacin er (antihyperlipidemic)

3

omega-3-acid ethyl esters

3

prevalite 3

REPATHA 2 PA; QL

REPATHA PUSHTRONEX SYSTEM

2 PA; QL

REPATHA SURECLICK

2 PA; QL

Vasodilators, Direct-acting Arterial/Venous

isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 mg, 5 mg

1

isosorbide mononitrate 1

isosorbide mononitrate er

1

nitroglycerin sublingual 1

nitroglycerin transdermal

1

nitroglycerin translingual

3

RECTIV 3

Vasodilators, Direct-acting Arterial

hydralazine hcl oral 1

minoxidil oral 1

Central Nervous System Agents

Attention Deficit Hyperactivity Disorder Agents, Amphetamines

amphetamine sulfate 3 PA; QL

amphetamine-dextroamphetamine

1 PA; QL


28


amphetamine-dextroamphetamine er

1 PA; QL

dextroamphetamine sulfate er

3 PA; QL

dextroamphetamine sulfate oral solution

3 PA; QL

dextroamphetamine sulfate oral tablet 10 mg, 5 mg

1 PA; QL

VYVANSE 2 PA; QL

Attention Deficit Hyperactivity Disorder Agents, Non-amphetamines

atomoxetine hcl 3 QL

clonidine hcl er 1

dexmethylphenidate hcl 1 PA; QL

dexmethylphenidate hcl er

3 PA; QL

guanfacine hcl er 3

methylphenidate hcl er (cd)

3 PA; QL

methylphenidate hcl er (la)

3 PA; QL

methylphenidate hcl er (xr)

3 PA; QL

methylphenidate hcl er oral tablet extended release 10 mg, 18 mg, 20 mg, 27 mg, 36 mg, 54 mg

3 PA; QL

methylphenidate hcl er oral tablet extended release 24 hour

3 PA; QL

methylphenidate hcl oral solution

3 PA; QL

methylphenidate hcl oral tablet

1 PA; QL

methylphenidate hcl oral tablet chewable

3 PA; QL


Central Nervous System, Other

caffeine citrate oral 1

riluzole 3 PA; QL

tetrabenazine 4 PA; SP

Fibromyalgia Agents

pregabalin 1 QL

SAVELLA 3 ST; QL

SAVELLA TITRATION PACK

3 ST; QL

Multiple Sclerosis Agents

AVONEX PEN 4 PA; SP; QL

AVONEX PREFILLED 4 PA; SP; QL

BAFIERTAM 4 PA; SP; QL

BETASERON 4 PA; SP; QL

COPAXONE 4 PA; SP; QL

dalfampridine er 4 PA; SP; QL

dimethyl fumarate oral 4 PA; SP; QL

dimethyl fumarate starter pack

4 PA; SP; QL

GILENYA 4 PA; SP; QL

glatiramer acetate 4 PA; SP; QL

glatopa 4 PA; SP; QL

MAYZENT ORAL TABLET 0.25 MG, 2 MG

4 PA; SP; QL

MAYZENT STARTER PACK ORAL TABLET THERAPY PACK 12 X 0.25 MG

4 PA; SP; QL

TYSABRI 4 PA; SP; QL

Dental and Oral Agents

cavarest 1

cevimeline hcl 1

chlorhexidine gluconate mouth/throat

1


29


DEBACTEROL 3

easygel 1

fluoridex daily renewal 1

oralone 1

periogard 1

pilocarpine hcl oral 1

PREVIDENT MOUTH/THROAT

3

sodium fluoride 5000 plus

1

sodium fluoride 5000 ppm dental cream

1

sodium fluoride 5000 ppm dental gel

1

sodium fluoride dental 1

sodium fluoride mouth/throat

3

triamcinolone acetonide mouth/throat

1

Dermatological Agents

accutane 1 PA

acitretin 3

adapalene external cream

1 PA

adapalene external gel 1 PA

adapalene-benzoyl peroxide external gel

1

ammonium lactate external

1

amnesteem 1 PA

azelaic acid external 1

AZELEX 3

benzoyl peroxide-erythromycin

1

calcipotriene external cream

3


calcipotriene external ointment

3

calcipotriene external solution

3

calcitriol external 3

claravis 1 PA

clindacin etz external swab

1

clindacin-p 1

clindamycin phosphate-benzoyl peroxide

1

clindamycin phosphate external gel

3

clindamycin phosphate external lotion

3

clindamycin phosphate external solution

1

clindamycin phosphate external swab

1

coal tar external 1

CONDYLOX 3

DUPIXENT 4 PA; SP; QL

EPIDUO FORTE 3

ery 1

erythromycin external 1

imiquimod external cream 5 %

1

isotretinoin oral capsule 10 mg, 20 mg, 30 mg, 40 mg

1 PA

ivermectin external cream

1

lactic acid e 1

lactic acid external 1

methoxsalen rapid 1

metronidazole external 1

MIRVASO 2

myorisan 1 PA


30


neuac external gel 1

pimecrolimus 1 ST

podofilox external 1

REGRANEX 3 PA

rosadan external cream 1

rosadan external gel 1

SANTYL 3

selenium sulfide external lotion

1

STELARA INTRAVENOUS

4 PA; SP

STELARA SUBCUTANEOUS

4 PA; SP; QL

sulfacetamide sodium (acne)

1

tacrolimus external 1

TALTZ 4 PA; SP

tazarotene external cream

3 PA

TREMFYA 4 PA; SP

tretinoin external cream 1 PA

tretinoin external gel 0.01 %, 0.025 %

1 PA

zenatane 1 PA

Electrolytes/Minerals/Metals/Vitamins

Electrolyte/Mineral Replacement

CARBAGLU 4 SP

carglumic acid 4 SP

corvita 150 1

ferocon 1

ferotrinsic 1

ferrocite plus 1

fluoritab 1 PV

foltrin 1

hemocyte-f 1


iodine strong oral 1

klor-con 1

klor-con 10 1

klor-con m10 1

klor-con m15 1

klor-con m20 1

k-tan plus 1

levocarnitine oral solution

1

levocarnitine oral tablet 1

levocarnitine sf 1

na ferric gluc cplx in sucrose

1

nafrinse 1 PV

nafrinse drops 1 PV

polysaccharide iron forte

1

potassium chloride crys er

1

potassium chloride er 1

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

1

potassium chloride oral 1

potassium citrate er 1

purevit dualfe plus 1

se-tan plus 1

sod citrate-citric acid 1

sodium acetate intravenous solution 2 meq/ml

1

sodium fluoride oral solution 1.1 (0.5 f) mg/ml

1 PV


31


sodium fluoride oral tablet

1 PV

sodium fluoride oral tablet chewable

1 PV

tl-hem 150 1

trigels-f forte 1

Electrolyte/Mineral/Metal Modifiers

CHEMET 3

deferasirox oral tablet soluble

3 PA

deferiprone 3 PA

sodium polystyrene sulfonate

1

sps 3

trientine hcl 4 PA; SP

VELTASSA 3

Phosphate Binders

calcium acetate (phos binder)

1

calcium acetate oral tablet 667 mg

1

FOSRENOL ORAL PACKET

3

lanthanum carbonate 3

PHOSLYRA 3

sevelamer carbonate oral tablet

3

VELPHORO 3

Vitamins

adc/f (0.5mg/ml) 1

airavite 1

b-6 folic acid 1

biocel 1

bp vit 3 1

b-plex 1

b-plex plus 1


cyanocobalamin injection solution 1000 mcg/ml

1

ergocalciferol oral capsule

1

fabb 1

fa-vitamin b-6-vitamin b-12

1

folate 1 PV

folbee 1

folbee plus 1

folic acid oral tablet 1 mg

1

folic acid oral tablet 400 mcg, 800 mcg

1 PV

folplex 2.2 1

hydroxocobalamin acetate

1

lysiplex plus oral tablet 1

MASONATAL 3 PV

multi-vitamin/fluoride 1

multivitamin/fluoride oral tablet chewable

1

multi-vitamin/fluoride/iron

1

NASCOBAL 3

nephronex oral tablet 1

nufol 1

nutrifac zx 1

ONE VITE WOMENS 3 PV

ONE-A-DAY WOMENS PRENATAL 1

3 PV

phytonadione injection 1

phytonadione oral 1

prenatal multi +dha 1 PV

prenatal oral tablet 27-0.8 mg

1 PV


32


prenatal oral tablet 27-1 mg

1

prenatal vitamin plus low iron

1

preplus 1

pyridoxine hcl injection 1

thiamine hcl injection 1

triphrocaps 1

tri-vite/fluoride 1

v-c forte 1

virt-caps 1

virt-gard 1

vita s forte 1

vitacel 1

vitamin d (ergocalciferol) oral capsule 1.25 mg (50000 ut)

1

vitamin k1 injection 1

vitamins acd-fluoride 1

vp-pnv-dha 1

vp-vite rx 1

wescaps 1

westab mini 1

westab one 1

yl folic acid 1 PV

Gastrointestinal Agents

Antispasmodics, Gastrointestinal

CUVPOSA 3

dicyclomine hcl oral 1

glycopyrrolate injection solution 0.2 mg/ml, 0.4 mg/2ml

1

glycopyrrolate oral solution

1


glycopyrrolate oral tablet 1 mg, 2 mg

1

glycopyrrolate pf 1

hyoscyamine sulfate oral

1

hyoscyamine sulfate sl 1

hyoscyamine sulfate sublingual

1

methscopolamine bromide oral

3

Gastrointestinal Agents, Other

alvimopan 1

amoxicill-clarithro-lansopraz

1

cromolyn sodium oral 1

diphenoxylate-atropine 1

GATTEX 4 PA; SP

loperamide hcl oral capsule

1

MOTEGRITY 3 ST; QL

MOTOFEN 3 PA

OMECLAMOX-PAK 2

PYLERA 2

SYMPROIC 2 ST; QL

ursodiol oral capsule 300 mg

1

ursodiol oral tablet 1

Histamine2 (H2) Receptor Antagonists

cimetidine hcl 1

cimetidine oral 1

famotidine intravenous 1

famotidine oral suspension reconstituted

1

famotidine oral tablet 20 mg, 40 mg

1


33


famotidine premixed 1

nizatidine 1

Irritable Bowel Syndrome Agents

alosetron hcl 3 PA

LINZESS 2 ST; QL

Laxatives

bisacodyl ec 1 PV; QL

cascara sagrada oral fluid extract

1

citroma 1 PV; QL

clearlax 1 PV; QL

CLENPIQ 3

constulose 1

enulose 1

gavilax oral powder 1 PV; QL

gavilyte-c 1 PV; QL

gavilyte-g 1 PV; QL

gavilyte-n with flavor pack

1 PV; QL

generlac 1

gentle laxative oral 1 PV; QL

gentlelax 1 PV; QL

glycolax 1 PV; QL

lactulose encephalopathy

1

lactulose oral solution 1

magnesium citrate oral solution

1 PV; QL

mineral oil heavy oral 1

mm clearlax 1 PV; QL

peg 3350-kcl-na bicarb-nacl

1 PV; QL

peg-3350/electrolytes 1 PV; QL

peg-3350/electrolytes/ascorbat

1


peg-kcl-nacl-nasulf-na asc-c

1

polyethylene glycol 3350 oral powder

1 PV; QL

qc magnesium citrate 1 PV; QL

SUPREP BOWEL PREP KIT

3

Protectants

misoprostol oral 1

sucralfate oral 1

Proton Pump Inhibitors

DEXILANT 2 QL

DEXLANSOPRAZOLE 2 QL

esomeprazole sodium 1

lansoprazole oral capsule delayed release

1 QL

omeprazole oral capsule delayed release

1 QL

pantoprazole sodium intravenous

1 QL

pantoprazole sodium oral

1 QL

rabeprazole sodium oral tablet delayed release

1 QL

Genetic or Enzyme Disorder: Replacement, Modifiers, Treatment

CERDELGA 4 PA; SP

CHOLBAM 4 PA; SP

CREON 2

CYSTAGON 4 SP

EVRYSDI 4 PA; SP; QL

GALAFOLD 4 PA; SP; QL

miglustat 4 PA; SP


34


MYALEPT 4 PA; SP

nitisinone 4 PA; SP

ORFADIN ORAL CAPSULE 20 MG

4 PA; SP

ORFADIN ORAL SUSPENSION

4 PA; SP

PROLASTIN-C 4 PA; SP

REVCOVI 4 PA; SP

sapropterin dihydrochloride

4 PA; SP

sod benz-sod phenylacet

1

sodium phenylbutyrate oral

4 SP

STRENSIQ 4 PA; SP

SUCRAID 4 SP

TEGSEDI 4 PA; SP

ZENPEP 2

Genitourinary Agents

Antispasmodics, Urinary

darifenacin hydrobromide er

1

flavoxate hcl 1

GELNIQUE 3 ST

MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HOUR

2

oxybutynin chloride er 1

oxybutynin chloride oral 1

solifenacin succinate 1

tolterodine tartrate 1

tolterodine tartrate er 1

TOVIAZ 3

trospium chloride 1

trospium chloride er 1


Benign Prostatic Hypertrophy Agents

alfuzosin hcl er 1

dutasteride oral 1

dutasteride-tamsulosin hcl

1

finasteride oral tablet 5 mg

1

silodosin 1

tadalafil oral tablet 2.5 mg, 5 mg

1 PA; QL

tamsulosin hcl 1

terazosin hcl 1

Genitourinary Agents, Other

acetic acid irrigation 1

argyle sterile saline 1

bethanechol chloride oral

1

curity sterile saline 1

ELMIRON 3 PA

ENCARE 3 PV; QL

glycine irrigation 1

glycine urologic 1

OPTIONS GYNOL II CONTRACEPTIVE

3 PV; QL

penicillamine oral tablet 4 SP

phenazo oral tablet 200 mg

1

phenazopyridine hcl oral tablet 100 mg, 200 mg

1

RENACIDIN 3

sodium chloride irrigation

1

sorbitol-mannitol 1

TODAY SPONGE 3 PV; QL


35


VCF VAGINAL CONTRACEPTIVE VAGINAL FILM

3 PV; QL

VCF VAGINAL CONTRACEPTIVE VAGINAL FOAM

3 PV; QL

vcf vaginal contraceptive vaginal gel

1 PV; QL

Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)

ala-cort 1

alclometasone dipropionate

1

amcinonide external lotion

1

betamethasone dipropionate aug external cream

1

betamethasone dipropionate aug external gel

3

betamethasone dipropionate aug external lotion

3

betamethasone dipropionate aug external ointment

3

betamethasone dipropionate external

1

betamethasone valerate external cream

1

betamethasone valerate external lotion

1

betamethasone valerate external ointment

1

clobetasol prop emollient base

3


clobetasol propionate external cream

3

clobetasol propionate external gel

3

clobetasol propionate external lotion

3

clobetasol propionate external ointment

3

clobetasol propionate external shampoo

3

clobetasol propionate external solution

3

clodan external shampoo

3

DEPO-MEDROL INJECTION SUSPENSION 20 MG/ML

3

desonide external cream

3

desonide external lotion 3

desonide external ointment

3

desoximetasone external cream 0.25 %

1

desoximetasone external gel

3

desoximetasone external liquid

3

desoximetasone external ointment 0.25 %

3

dexamethasone intensol

1

dexamethasone oral elixir

3

dexamethasone oral solution

1

dexamethasone oral tablet

1


36


dexamethasone sod phosphate pf

1

dexamethasone sodium phosphate injection

1

diflorasone diacetate external cream

3

fludrocortisone acetate oral

1

fluocinolone acetonide body

1

fluocinolone acetonide external

1

fluocinolone acetonide scalp

1

fluocinonide emulsified base

1

fluocinonide external 1

flurandrenolide external cream

3

fluticasone propionate external cream

1

fluticasone propionate external ointment

1

halcinonide 3 ST

halobetasol propionate external cream

3

halobetasol propionate external ointment

3

hydrocortisone butyrate external solution

1

hydrocortisone external cream 1 %, 2.5 %

1

hydrocortisone external lotion 2.5 %

1

hydrocortisone external ointment 1 %, 2.5 %

1

hydrocortisone oral 1

hydrocortisone valerate external cream

1


KENALOG-80 3

methylprednisolone acetate injection suspension 40 mg/ml, 80 mg/ml

1

methylprednisolone oral

1

mometasone furoate external

1

nolix external cream 3

prednicarbate 1

prednisolone oral solution

1

prednisolone sodium phosphate oral solution 15 mg/5ml, 25 mg/5ml

1

prednisone oral tablet 1

prednisone oral tablet therapy pack

1

SOLU-CORTEF INJECTION SOLUTION RECONSTITUTED 1000 MG

3

triamcinolone acetonide external cream

1

triamcinolone acetonide external lotion

1

triamcinolone acetonide external ointment 0.025 %, 0.1 %, 0.5 %

1

triamcinolone acetonide injection suspension 40 mg/ml

1

triderm 1

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)

cabergoline 1


37


CHORIONIC GONADOTROPIN INTRAMUSCULAR

4 PA; SP

desmopressin ace spray refrig

3

desmopressin acetate oral

3

desmopressin acetate spray

3

INCRELEX 4 PA; SP

NORDITROPIN FLEXPRO

4 PA; SP

NOVAREL INTRAMUSCULAR SOLUTION RECONSTITUTED 10000 UNIT

4 PA; SP

NUTROPIN AQ NUSPIN 10

4 PA; SP


4 PA; SP


4 PA; SP

oxytocin injection 1

PREGNYL 4 PA; SP

vasopressin 1

VASOSTRICT INTRAVENOUS SOLUTION 20 UNIT/ML

3

Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins)

mifepristone 1


Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers)

Androgens

danazol oral 3

INTRAROSA 3 ST

oxandrolone oral 1 PA; QL

testosterone cypionate intramuscular

1 PA

testosterone enanthate intramuscular

1 PA

testosterone transdermal gel 1.62 %, 12.5 mg/act (1%), 20.25 mg/1.25gm (1.62%), 20.25 mg/act (1.62%), 25 mg/2.5gm (1%), 40.5 mg/2.5gm (1.62%), 50 mg/5gm (1%)

3 PA

testosterone transdermal solution

3 PA

Estrogens

afirmelle 1 PV

altavera 1 PV

alyacen 1/35 1 PV

alyacen 7/7/7 1 PV

amabelz 1

amethia 1 PV; QL

amethyst 1 PV

ANNOVERA 3 PV; QL

apri 1 PV

aranelle 1 PV

ashlyna 1 PV; QL

aubra 1 PV

aubra eq 1 PV

aurovela 1.5/30 1 PV


38


aurovela 1/20 1 PV

aurovela 24 fe 1 PV

aurovela fe 1.5/30 1 PV

aurovela fe 1/20 1 PV

aviane 1 PV

ayuna 1 PV

azurette 1 PV

balziva 1 PV

BIJUVA 3

blisovi 24 fe 1 PV

blisovi fe 1.5/30 1 PV

blisovi fe 1/20 1 PV

briellyn 1 PV

camrese 1 PV; QL

camrese lo 1 PV; QL

caziant 1 PV

charlotte 24 fe 1 PV

chateal 1 PV

chateal eq 1 PV

COMBIPATCH 3

cryselle-28 1 PV

cyclafem 1/35 1 PV

cyclafem 7/7/7 1 PV

cyred 1 PV

cyred eq 1 PV

dasetta 1/35 1 PV

dasetta 7/7/7 1 PV

daysee 1 PV; QL

delyla 1 PV

desogestrel-ethinyl estradiol

1 PV

DIVIGEL 3

dolishale 1 PV

dotti 1


drospiren-eth estrad-levomefol

1 PV

drospirenone-ethinyl estradiol

1 PV

DUAVEE 2

elinest 1 PV

eluryng 1 PV

emoquette 1 PV

enpresse-28 1 PV

enskyce 1 PV

estarylla 1 PV

estradiol oral 1

estradiol transdermal 1

estradiol vaginal cream 1

estradiol vaginal tablet 3

estradiol valerate intramuscular

1

estradiol-norethindrone acet

1

ethynodiol diac-eth estradiol

1 PV

etonogestrel-ethinyl estradiol

1 PV

falmina 1 PV

fayosim 1 PV; QL

femynor 1 PV

fyavolv 1

gemmily 1 PV

hailey 1.5/30 1 PV

hailey 24 fe 1 PV

hailey fe 1.5/30 1 PV

hailey fe 1/20 1 PV

iclevia 1 PV; QL

introvale 1 PV; QL

isibloom 1 PV

jaimiess 1 PV; QL


39


jasmiel 1 PV

jinteli 1

jolessa 1 PV; QL

juleber 1 PV

junel 1.5/30 1 PV

junel 1/20 1 PV

junel fe 1.5/30 1 PV

junel fe 1/20 1 PV

junel fe 24 1 PV

kaitlib fe 1 PV

kalliga 1 PV

kariva 1 PV

kelnor 1/35 1 PV

kelnor 1/50 1 PV

kurvelo 1 PV

larin 1.5/30 1 PV

larin 1/20 1 PV

larin 24 fe 1 PV

larin fe 1.5/30 1 PV

larin fe 1/20 1 PV

larissia 1 PV

layolis fe 1 PV

leena 1 PV

lessina 1 PV

levonest 1 PV

levonorgest-eth est & eth est

1 PV; QL

levonorgest-eth estrad 91-day

1 PV; QL

levonorgestrel-ethinyl estrad

1 PV

levonorg-eth estrad triphasic

1 PV

levora 0.15/30 (28) 1 PV

lillow 1 PV

lojaimiess 1 PV; QL


loryna 1 PV

low-ogestrel 1 PV

lo-zumandimine 1 PV

lutera 1 PV

lyllana 1

marlissa 1 PV

MENEST 2

merzee 1 PV

microgestin 1.5/30 1 PV

microgestin 1/20 1 PV

microgestin 24 fe 1 PV

microgestin fe 1.5/30 1 PV

microgestin fe 1/20 1 PV

mili 1 PV

mimvey 1

mono-linyah 1 PV

NATAZIA 2 PV

necon 0.5/35 (28) 1 PV

nikki 1 PV

norethin ace-eth estrad-fe

1 PV

norethindrone acet-ethinyl est

1 PV

norethindrone-eth estradiol

1

norethin-eth estradiol-fe 1 PV

norgestimate-eth estradiol

1 PV

norgestimate-ethinyl estradiol triphasic

1 PV

nortrel 0.5/35 (28) 1 PV

nortrel 1/35 (21) 1 PV

nortrel 1/35 (28) 1 PV

nortrel 7/7/7 1 PV

nylia 1/35 1 PV

nylia 7/7/7 1 PV


40


nymyo 1 PV

ocella 1 PV

orsythia 1 PV

philith 1 PV

pimtrea 1 PV

pirmella 1/35 1 PV

pirmella 7/7/7 1 PV

portia-28 1 PV

PREMARIN ORAL 2

PREMARIN VAGINAL 2

PREMPHASE 2

PREMPRO 2

previfem 1 PV

reclipsen 1 PV

rivelsa 1 PV; QL

setlakin 1 PV; QL

simliya 1 PV

simpesse 1 PV; QL

sprintec 28 1 PV

sronyx 1 PV

syeda 1 PV

tarina 24 fe 1 PV

tarina fe 1/20 1 PV

tarina fe 1/20 eq 1 PV

taysofy 1 PV

tilia fe 1 PV

tri femynor 1 PV

tri-estarylla 1 PV

tri-legest fe 1 PV

tri-linyah 1 PV

tri-lo-estarylla 1 PV

tri-lo-marzia 1 PV

tri-lo-mili 1 PV

tri-lo-sprintec 1 PV

tri-mili 1 PV


tri-nymyo 1 PV

tri-previfem 1 PV

tri-sprintec 1 PV

trivora (28) 1 PV

tri-vylibra 1 PV

tri-vylibra lo 1 PV

tyblume 1 PV

tydemy 1 PV

velivet 1 PV

vestura 1 PV

vienva 1 PV

viorele 1 PV

volnea 1 PV

vyfemla 1 PV

vylibra 1 PV

wera 1 PV

wymzya fe 1 PV

xulane 1 PV

yuvafem 3

zafemy 1 PV

zovia 1/35 (28) 1 PV

zovia 1/35e (28) 1 PV

zumandimine 1 PV

Progestins

aftera 1 PV

camila 1 PV

deblitane 1 PV

DEPO-SUBQ PROVERA 104

3 QL

econtra ez 1 PV

econtra one-step 1 PV

ELLA 3 PV

errin 1 PV

heather 1 PV


41


hydroxyprogesterone caproate intramuscular oil

4 PA; SP

incassia 1 PV

jencycla 1 PV

KYLEENA 3 PV

levonorgestrel 1 PV

LILETTA (52 MG) 3 PV

lyleq 1 PV

lyza 1 PV

MAKENA SUBCUTANEOUS

4 PA; SP

medroxyprogesterone acetate intramuscular

1 PV; QL

medroxyprogesterone acetate oral

1

megestrol acetate oral 1

MIRENA (52 MG) 3 PV

my choice 1 PV

my way 1 PV

new day 1 PV

NEXPLANON 3 PV

nora-be 1 PV

norethindrone acetate oral

1

norethindrone oral 1 PV

norlyda 1 PV

norlyroc 1 PV

opcicon one-step 1 PV

option 2 1 PV

progesterone intramuscular

1

progesterone oral 1

react 1 PV

sharobel 1 PV

SKYLA 3 PV

take action 1 PV


tulana 1 PV

Selective Estrogen Receptor Modifying Agents

OSPHENA 3

raloxifene hcl 1 PV*

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)

euthyrox 1

levo-t 1

levothyroxine sodium oral tablet

1

levoxyl 1

liothyronine sodium intravenous

1

liothyronine sodium oral 1

np thyroid 1

unithroid 1

Hormonal Agents, Suppressant (Adrenal)

LYSODREN 2

Hormonal Agents, Suppressant (pituitary)

leuprolide acetate injection

4 PA; SP

LUPRON DEPOT (1-MONTH)

4 PA; SP

LUPRON DEPOT (3-MONTH)

4 PA; SP

LUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT 30MG

4 PA; SP

LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT 45MG

4 PA; SP


42


LUPRON DEPOT-PED (1-MONTH)

4 PA; SP

LUPRON DEPOT-PED (3-MONTH)

4 PA; SP

octreotide acetate 4 PA; SP

SIGNIFOR 4 PA; SP; QL

SOMATULINE DEPOT 4 PA; SP

SOMAVERT 4 PA; SP

SYNAREL 2

Hormonal Agents, Suppressant (Thyroid)

Antithyroid Agents

methimazole oral 1

propylthiouracil oral 1

Immunological Agents

Angioedema Agents

BERINERT 4 PA; SP; QL

CINRYZE 4 PA; SP

icatibant acetate 4 PA; SP; QL

sajazir 4 PA; SP; QL

Immune Suppressants

AVSOLA 4 PA; SP

AZASAN 3

azathioprine oral 1

azathioprine sodium 1

CIMZIA 4 PA; SP

CIMZIA PREFILLED KIT

4 PA; SP

CIMZIA STARTER KIT 4 PA; SP

cyclosporine intravenous

1 SP

cyclosporine modified 1 SP

cyclosporine oral 1 SP

ENBREL 4 PA; SP


ENBREL MINI 4 PA; SP

ENBREL SURECLICK 4 PA; SP

everolimus oral tablet 0.25 mg, 0.5 mg, 0.75 mg, 1 mg

1 SP

gengraf 1 SP

HUMIRA 4 PA; SP

HUMIRA PEDIATRIC CROHNS START

4 PA; SP

HUMIRA PEN 4 PA; SP

HUMIRA PEN-CD/UC/HS STARTER

4 PA; SP

HUMIRA PEN-PEDIATRIC UC START

4 PA; SP

HUMIRA PEN-PS/UV/ADOL HS START

4 PA; SP

HUMIRA PEN-PSOR/UVEIT STARTER

4 PA; SP

INFLECTRA 4 PA; SP

KINERET 4 PA; SP

methotrexate oral 1

methotrexate sodium 1

methotrexate sodium (pf)

1

mycophenolate mofetil hcl

1 SP

mycophenolate mofetil intravenous

1 SP

mycophenolate mofetil oral

1 SP

mycophenolate sodium 1 SP

ORENCIA CLICKJECT 4 PA; SP

ORENCIA SUBCUTANEOUS

4 PA; SP

SANDIMMUNE ORAL SOLUTION

2 SP


43


SIMPONI 4 PA; SP

SIMPONI ARIA 4 PA; SP

sirolimus oral 1 SP

SKYRIZI 4 PA; SP

SKYRIZI (150 MG DOSE)

4 PA; SP

SKYRIZI PEN 4 PA; SP

tacrolimus oral 1 SP

temsirolimus 4 SP

XELJANZ 4 PA; SP

XELJANZ XR 4 PA; SP

ZORTRESS ORAL TABLET 1 MG

3 SP

Immunoglobulins

BIVIGAM 4 PA; SP

CUVITRU 4 PA; SP

FLEBOGAMMA DIF 4 PA; SP

GAMASTAN 4 PA; SP

GAMMAGARD 4 PA; SP

GAMMAGARD S/D LESS IGA

4 PA; SP

GAMMAKED 4 PA; SP

GAMMAPLEX 4 PA; SP

GAMUNEX-C 4 PA; SP

HEPAGAM B 4

HIZENTRA 4 PA; SP

HYPERHEP B 4

HYPERRHO S/D 4 SP

HYQVIA 4 PA; SP

MICRHOGAM ULTRA-FILTERED PLUS

4 SP

NABI-HB 4

OCTAGAM 4 PA; SP

PRIVIGEN 4 PA; SP

RHOGAM ULTRA-FILTERED PLUS

4 SP


RHOPHYLAC 4

SYNAGIS 4 PA; SP

WINRHO SDF 4 SP

Immunomodulators

ACTEMRA ACTPEN 4 PA; SP

ACTEMRA SUBCUTANEOUS

4 PA; SP

ACTIMMUNE 4 PA; SP

BENLYSTA SUBCUTANEOUS

4 PA; SP

GAMIFANT 4 PA; SP

ILARIS 4 PA; SP; QL

leflunomide oral 1

OTEZLA 4 PA; SP

RINVOQ 4 PA; SP

ULTOMIRIS 4 PA; SP

XOLAIR 4 PA; SP

Vaccines

ACTHIB 2 PV

ADACEL 2 PV

AFLURIA QUADRIVALENT

2 PV

BEXSERO 2 PV

BOOSTRIX 2 PV

COMIRNATY 2 PV

DAPTACEL 2 PV

DIPHTHERIA-TETANUS TOXOIDS DT

2 PV

ENGERIX-B 2 PV

FLUAD QUADRIVALENT

2 PV

FLUARIX QUADRIVALENT

2 PV

FLUBLOK QUADRIVALENT

2 PV


44


FLUCELVAX QUADRIVALENT

2 PV

FLULAVAL QUADRIVALENT

2 PV

FLUMIST QUADRIVALENT

2 PV

FLUZONE HIGH-DOSE QUADRIVALENT

2 PV

FLUZONE QUADRIVALENT

2 PV

GARDASIL 9 2 PV

HAVRIX 2 PV

HEPLISAV-B 2 PV

HIBERIX 2 PV

INFANRIX 2 PV

IPOL 2 PV

JANSSEN COVID-19 VACCINE

2 PV

KINRIX 2 PV

MENACTRA 2 PV

MENQUADFI 2 PV

MENVEO 2 PV

M-M-R II 2 PV

MODERNA COVID-19 VACCINE

2 PV

PEDIARIX 2 PV

PEDVAX HIB 2 PV

PENTACEL 2 PV

PFIZER COVID-19 VAC-TRIS 5-11Y

2 PV

PFIZER-BIONT COVID-19 VAC-TRIS

2 PV

PFIZER-BIONTECH COVID-19 VACC

2 PV

PNEUMOVAX 23 2 PV

PREHEVBRIO 2 PV

PREVNAR 13 2 PV


PREVNAR 20 2

PROQUAD 2 PV

QUADRACEL 2 PV

RECOMBIVAX HB 2 PV

ROTARIX 2 PV

ROTATEQ 2 PV

SHINGRIX 2 PV

TDVAX 2 PV

TENIVAC 2 PV

TETANUS-DIPHTHERIA TOXOIDS TD

2 PV

TRUMENBA 2 PV

TWINRIX 2 PV

VAQTA 2 PV

VARIVAX 2 PV

VAXELIS 2 PV

Inflammatory Bowel Disease Agents

Aminosalicylates

balsalazide disodium 1

DIPENTUM 3

mesalamine er oral capsule 0.375 gm

1

mesalamine oral capsule delayed release 400 mg

1

mesalamine oral tablet delayed release 1.2 gm

1

mesalamine rectal 1

mesalamine-cleanser 1

PENTASA 3

Glucocorticoids

budesonide er 3

budesonide oral 3

CORTIFOAM 3


45


hydrocortisone (perianal)

1

hydrocortisone ace-pramoxine external cream 1-1 %

1

hydrocortisone rectal 1

procto-med hc 1

procto-pak 1

proctosol hc 1

proctozone-hc 1

Sulfonamides

sulfasalazine oral 1

Metabolic Bone Disease Agents

alendronate sodium oral solution

1

alendronate sodium oral tablet 10 mg, 5 mg

1

alendronate sodium oral tablet 35 mg, 70 mg

1 QL

calcitonin (salmon) injection

1

calcitonin (salmon) nasal

1 QL

calcitriol intravenous 1

calcitriol oral 1

cinacalcet hcl 3 PA

doxercalciferol intravenous

1

ibandronate sodium 1 QL

pamidronate disodium 4 SP

paricalcitol 1

PROLIA 4 PA; SP; QL

RAYALDEE 3

risedronate sodium oral tablet 150 mg, 35 mg

1 QL


risedronate sodium oral tablet 30 mg, 5 mg

1

risedronate sodium oral tablet delayed release

1 QL

TERIPARATIDE (RECOMBINANT)

4 PA; SP

XGEVA 4 PA; SP

zoledronic acid 4 SP

Miscellaneous Therapeutic Agents

AEROCHAMBER MINI CHAMBER

2

AEROCHAMBER MV 2

AEROCHAMBER PLUS FLO-VU

2

AEROCHAMBER PLUS FLOW VU

2

AEROCHAMBER W/FLOWSIGNAL

2

ALCOHOL PREP PADS PAD

3

ALCOHOL PREP PADS PAD 70 %

3

AUM MINI INSULIN PEN NEEDLE

2

AUM READYGARD DUO PEN NEEDLE

2

AUM SAFETY PEN NEEDLE

2

BD AUTOSHIELD DUO PEN NEEDLES

2

bd posiflush 1

BD ULTRA-FINE INSULIN SYRINGES

2

BD ULTRA-FINE PEN NEEDLES

2

benzalkonium chloride external solution

1


46


BOTOX 4PA; Non-Cosmetic; SP

BREATHE EASE LARGE

2

BREATHE EASE MEDIUM

2

BREATHE EASE SMALL

2

CAYA 3 PV; QL

CLEVER CHOICE HOLDING CHAMBER

2

COMPACT SPACE CHAMBER

2

COMPACT SPACE CHAMBER/LG MASK

2

COMPACT SPACE CHAMBER/MED MASK

2

COMPACT SPACE CHAMBER/SM MASK

2

deferoxamine mesylate 1

DIASCREEN 1B 3

DIASCREEN 1K STRIP 3

DROPLET MICRON 2

DROPSAFE ALCOHOL PREP

3

EASIVENT 2

ergoloid mesylates oral 3

FC FEMALE CONDOM 3 PV; QL

FC2 FEMALE CONDOM

3 PV; QL

FEMCAP 3 PV; QL

FLEXICHAMBER 2

FLEXICHAMBER ADULT MASK/SMALL

2

FLEXICHAMBER CHILD MASK/LARGE

2

FLEXICHAMBER CHILD MASK/SMALL

2


heparin lock flush 1

heparin sodium lock flush

1

INSPIREASE RESERVOIR BAGS

2

INSULIN PEN NEEDLES

2

INSULIN SYRINGES 2

J-TIP KIT W/VIAL ADAPTERS

3

methergine 1 QL

methylergonovine maleate oral

1 QL

MICROCHAMBER 2

monoject flush syringe 1

monoject sodium chloride flush

1

normal saline flush 1

NOVOFINE AUTOCOVER PEN NEEDLE

2

NOVOFINE PEN NEEDLE

2

NOVOFINE PLUS PEN NEEDLE

2

NOVOTWIST PEN NEEDLE

2

OPTICHAMBER DIAMOND

2

OPTICHAMBER DIAMOND-LG MASK

2

OPTICHAMBER DIAMOND-MD MASK

2

OPTICHAMBER DIAMOND-SM MASK

2

PANDA MASK LARGE 2

PANDA MASK MEDIUM

2

PANDA MASK SMALL 2


47


PARAGARD INTRAUTERINE COPPER

3 PV

PEDIATRIC PANDA MASK

2

POCKET SPACER 2

PRO COMFORT SPACER ADULT

2

PRO COMFORT SPACER CHILD

2

PRO COMFORT SPACER INFANT

2

PROCARE SPACER/ADULT MASK

2

PROCARE SPACER/CHILD MASK

2

sodium chloride flush 1

THYROGEN 4 PA; SP

ULTIGUARD SAFEPACK SYR/NEEDLE

2

VISTOGARD 3

VORTEX VALVED HOLDING CHAMBER

2

WIDE-SEAL DIAPHRAGM 60

3 PV; QL


3 PV; QL


3 PV; QL


3 PV; QL


3 PV; QL


3 PV; QL


3 PV; QL



3 PV; QL

XIAFLEX 4 PA; SP

ZOKINVY 4 PA; SP; QL

Ophthalmic Agents

Aminoglycosides

gentak 1

gentamicin sulfate ophthalmic

1

neomycin-polymyxin-gramicidin

1

TOBRADEX OPHTHALMIC OINTMENT

3

TOBRADEX ST 3

tobramycin ophthalmic 1

tobramycin-dexamethasone

1

TOBREX 3

Antibacterials, Other

ak-poly-bac 1

bacitracin ophthalmic 1

bacitracin-polymyxin b ophthalmic

1

bacitra-neomycin-polymyxin-hc

1

neomycin-bacitracin zn-polymyx

1

neomycin-polymyxin-dexameth ophthalmic ointment

1

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

1

neomycin-polymyxin-hc ophthalmic

1

neo-polycin 1

neo-polycin hc 1


48


polycin 1

polymyxin b-trimethoprim

1

Anti-cytomegalovirus (CMV) Agents

ZIRGAN 3

Antifungals

NATACYN 2

Antiherpetic Agents

trifluridine 1

Macrolides

AZASITE 3

erythromycin ophthalmic

1

Ophthalmic Agents, Other

atropine sulfate ophthalmic ointment

1

atropine sulfate ophthalmic solution 1 %

1

cyclopentolate hcl ophthalmic

1

cyclosporine ophthalmic

1 PA

CYSTADROPS 4 PA; SP; QL

CYSTARAN 4 PA; SP; QL

homatropaire 1

PRED-G S.O.P. 3

RESTASIS 2 PA

RESTASIS MULTIDOSE

2 PA

sulfacetamide-prednisolone ophthalmic solution

1

XIIDRA 2 PA

ZYLET 3


Ophthalmic Anti-allergy Agents

ALOCRIL 3 PA

ALOMIDE 3

altafrin 1

azelastine hcl ophthalmic

1

cromolyn sodium ophthalmic

1

epinastine hcl 1

olopatadine hcl ophthalmic

1

phenylephrine hcl ophthalmic

1

ZERVIATE 3 ST

Ophthalmic Antiglaucoma Agents

ALPHAGAN P OPHTHALMIC SOLUTION 0.1 %

2

apraclonidine hcl 1

betaxolol hcl ophthalmic

1

BETIMOL 3

brimonidine tartrate ophthalmic solution 0.2 %

1

brinzolamide 1

carteolol hcl 1

COMBIGAN 2

dorzolamide hcl ophthalmic

1

dorzolamide hcl-timolol mal

1

dorzolamide hcl-timolol mal pf

1

IOPIDINE 3

levobunolol hcl 1


49


pilocarpine hcl ophthalmic

1

RHOPRESSA 2 QL

ROCKLATAN 2 QL

SIMBRINZA 2

timolol maleate (once-daily)

1

timolol maleate ocudose

1

timolol maleate ophthalmic solution

1

timolol maleate pf 1

Ophthalmic Anti-inflammatories

bromfenac sodium (once-daily)

1 QL

dexamethasone sodium phosphate ophthalmic

1

diclofenac sodium ophthalmic

1

difluprednate 1

DUREZOL 3 PA

EYSUVIS 3 PA

FLAREX 3

fluorometholone 1

flurbiprofen sodium 1

FML 2

ketorolac tromethamine ophthalmic

1

loteprednol etabonate ophthalmic suspension

1

prednisolone acetate ophthalmic

1

prednisolone sodium phosphate ophthalmic

1

PROLENSA 2 QL


Ophthalmic Prostaglandin and Prostamide Analogs

bimatoprost ophthalmic 1 QL

latanoprost ophthalmic 1

LUMIGAN 2 QL

travoprost (bak free) 1 QL

ZIOPTAN 3 QL

Quinolones

BESIVANCE 3

ciprofloxacin hcl ophthalmic

1

gatifloxacin ophthalmic 1

levofloxacin ophthalmic 1

moxifloxacin hcl (2x day)

1

moxifloxacin hcl ophthalmic solution

1

ofloxacin ophthalmic 1

Sulfonamides

sulfacetamide sodium ophthalmic

1

Otic Agents

acetic acid otic 1

CIPRO HC 3

ciprofloxacin hcl otic 1 ST

ciprofloxacin-dexamethasone

3

CORTISPORIN-TC 3

flac 1

fluocinolone acetonide otic

1

hydrocortisone-acetic acid

1

neomycin-polymyxin-hc otic

1

ofloxacin otic 1


50


Respiratory Tract/Pulmonary Agents

Antihistamines

azelastine hcl nasal solution 0.1 %, 137 mcg/spray

1 QL

carbinoxamine maleate oral solution

1

carbinoxamine maleate oral tablet 4 mg

1

cetirizine hcl oral solution

1

clemastine fumarate oral tablet 2.68 mg

1

cyproheptadine hcl oral 1

desloratadine oral tablet

3

diphenhydramine hcl injection

1

diphenhydramine hcl oral elixir

1

levocetirizine dihydrochloride oral

1

olopatadine hcl nasal 3 QL

promethazine hcl oral 1

promethazine hcl rectal 3

promethegan rectal suppository 12.5 mg, 25 mg

3

Anti-inflammatories, Inhaled Corticosteroids

ADVAIR HFA 2 QL

ARNUITY ELLIPTA 2 QL

ASMANEX (120 METERED DOSES)

2 ST; QL


2 ST; QL



2 ST; QL


2 ST; QL

ASMANEX HFA 2 ST; QL

BREO ELLIPTA 2 QL

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

3 QL

FLOVENT DISKUS 2 QL

FLOVENT HFA 2 QL

flunisolide nasal 1 QL

fluticasone propionate nasal

1

fluticasone-salmeterol inhalation aerosol powder breath activated 100-50 mcg/dose, 250-50 mcg/dose, 500-50 mcg/dose

1 QL

FLUTICASONE-SALMETEROL INHALATION AEROSOL POWDER BREATH ACTIVATED 113-14 MCG/ACT, 232-14 MCG/ACT, 55-14 MCG/ACT

3 M; QL

mometasone furoate nasal

1 QL

PULMICORT FLEXHALER

2 QL

QVAR REDIHALER 2 QL

SYMBICORT 2 QL

wixela inhub 1 QL

Antileukotrienes

montelukast sodium oral tablet

1


51


montelukast sodium oral tablet chewable

1

zafirlukast 3

zileuton er 3 ST

Bronchodilators, Anticholinergic

ATROVENT HFA 3 QL

BREZTRI AEROSPHERE

2 QL

ipratropium bromide inhalation

1 QL

ipratropium bromide nasal

1

SPIRIVA HANDIHALER

2 QL

SPIRIVA RESPIMAT 2 QL

STIOLTO RESPIMAT 2 QL

TRELEGY ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 100-62.5-25 MCG/INH

2 QL

Bronchodilators, Sympathomimetic

albuterol sulfate hfa 1 QL

albuterol sulfate inhalation

1 QL

arformoterol tartrate 1 QL

AUVI-Q INJECTION SOLUTION AUTO-INJECTOR 0.1 MG/0.1ML

3 QL

epinephrine (anaphylaxis)

1

epinephrine injection solution auto-injector

1

formoterol fumarate inhalation

1 QL

levalbuterol hcl inhalation

1 QL


SEREVENT DISKUS 2 QL

STRIVERDI RESPIMAT

2 QL

Cystic Fibrosis Agents

KALYDECO 4 PA; SP

ORKAMBI 4 PA; SP; QL

PULMOZYME 4 PA; SP

tobramycin inhalation 4 SP

Mast Cell Stabilizers

cromolyn sodium inhalation

3

Phosphodiesterase Inhibitors, Airways Disease

DALIRESP ORAL TABLET 500 MCG

3 PA

theophylline er 3

Pulmonary Antihypertensives

ADEMPAS 4 PA; SP; QL

alyq 4 PA; SP; QL

ambrisentan 4 PA; SP; QL

bosentan 4 PA; SP; QL

OPSUMIT 4 PA; SP; QL

ORENITRAM 4 PA; SP

sildenafil citrate intravenous

4 PA; SP

sildenafil citrate oral suspension reconstituted

4 PA; SP; QL

sildenafil citrate oral tablet 20 mg

4 PA; SP; QL

tadalafil (pah) 4 PA; SP; QL

TRACLEER 32 MG 4 PA; SP; QL

treprostinil 4 PA; SP

TYVASO 4 PA; SP; QL

TYVASO REFILL 4 PA; SP; QL


52


TYVASO STARTER 4 PA; SP; QL

UPTRAVI ORAL 4 PA; SP; QL

VENTAVIS 4 PA; SP; QL

Pulmonary Fibrosis Agents

OFEV 4 PA; SP

Respiratory Tract Agents, Other

acetylcysteine inhalation

1

ANORO ELLIPTA 2 QL

benzonatate 1

COMBIVENT RESPIMAT

2 QL

hydrocodone-homatropine

1 PA; QL

hydromet 1 PA; QL

ipratropium-albuterol 1 QL

NUCALA 4 PA; SP; QL

sodium chloride inhalation

1

TRELEGY ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 200-62.5-25 MCG/INH

2 QL

TUZISTRA XR 3 PA; QL

Skeletal Muscle Relaxants

baclofen oral tablet 10 mg, 20 mg

1

carisoprodol oral tablet 350 mg

1

chlorzoxazone oral tablet 500 mg

1

cyclobenzaprine hcl oral tablet 10 mg, 5 mg

1

metaxalone oral tablet 800 mg

3


methocarbamol injection

1

methocarbamol oral 1

orphenadrine citrate er 1

orphenadrine citrate injection

1

tizanidine hcl oral tablet 1

Sleep Disorder Agents

GABA Receptor Modulators

eszopiclone 1 QL

temazepam 1 QL

zaleplon 1 QL

zolpidem tartrate er 1 QL

zolpidem tartrate oral 1 QL

Sleep Disorders, Other

BELSOMRA 3 ST; QL

doxepin hcl oral tablet 3 QL

HETLIOZ 4 PA; SP; QL

ramelteon 3 QL

Wakefulness Promoting Agents

armodafinil 3 PA; QL

modafinil 1 PA; QL

SUNOSI 2 PA; QL


53

Index of Drugs

abacavir sulfate.........................20abacavir sulfate-lamivudine...... 20abacavir-lamivudine-zidovudine.................................20ABELCET..................................13ABILIFY MAINTENA................. 19abiraterone acetate................... 15acamprosate calcium.................. 7acarbose................................... 23ACCU-CHEK FASTCLIX LANCET KIT............................. 22ACCU-CHEK FASTCLIX LANCETS................................. 22ACCU-CHEK SAFE-T PRO LANCETS................................. 22ACCU-CHEK SOFTCLIX LANCET DEVICE KIT...............22ACCU-CHEK SOFTCLIX LANCETS................................. 22accutane................................... 30acebutolol hcl............................ 26acetaminophen-codeine..............6acetaminophen-codeine #2.........6acetaminophen-codeine #3.........6acetaminophen-codeine #4.........6acetazolamide...........................27acetazolamide er.......................27acetic acid........................... 35, 50acetylcysteine........................... 53acitretin..................................... 30ACTEMRA................................ 44ACTEMRA ACTPEN.................44ACTHIB.....................................44ACTIMMUNE............................ 44acyclovir.................................... 20acyclovir sodium....................... 20ADACEL....................................44adapalene................................. 30adapalene-benzoyl peroxide.....30adc/f (0.5mg/ml)........................ 32ADCETRIS................................17adefovir dipivoxil ....................... 19ADEMPAS................................ 52adult aspirin regimen...................5ADVAIR HFA............................ 51AEROCHAMBER MINI CHAMBER................................ 46AEROCHAMBER MV............... 46AEROCHAMBER PLUS FLO-VU............................................. 46AEROCHAMBER PLUS FLOW VU..................................46

AEROCHAMBER W/FLOWSIGNAL...................... 46AFINITOR DISPERZ.................16afirmelle.................................... 38AFLURIA QUADRIVALENT......44aftera.........................................41AIMOVIG...................................14airavite...................................... 32ak-poly-bac............................... 48AKYNZEO.................................13ala-cort...................................... 36albendazole...............................18albuterol sulfate.........................52albuterol sulfate hfa...................52alclometasone dipropionate...... 36ALCOHOL PREP PADS........... 46ALECENSA...............................16alendronate sodium.................. 46alfuzosin hcl er.......................... 35aliskiren fumarate......................26allopurinol..................................14allopurinol sodium..................... 14almotriptan malate.................... 14ALOCRIL...................................49ALOMIDE..................................49alosetron hcl..............................34ALPHAGAN P........................... 49ALPHANATE.............................25alprazolam................................ 21alprazolam er............................ 21alprazolam xr............................ 21ALTABAX....................................8altafrin....................................... 49altavera..................................... 38alvimopan..................................33alyacen 1/35..............................38alyacen 7/7/7.............................38alyq........................................... 52amabelz.................................... 38amantadine hcl..........................18AMBISOME...............................13ambrisentan.............................. 52amcinonide................................36AMELUZ................................... 16amethia..................................... 38amethyst................................... 38amikacin sulfate.......................... 8amiloride hcl..............................27amiloride-hydrochlorothiazide... 26aminocaproic acid..................... 25amiodarone hcl......................... 25amitriptyline hcl......................... 13amlodipine besylate.................. 26

amlodipine besylate-benazepril hcl............................................. 26amlodipine besylate-valsartan.. 27amlodipine-atorvastatin.............27amlodipine-olmesartan..............27ammonium lactate.....................30amnesteem............................... 30amoxapine................................ 13amoxicill-clarithro-lansopraz..... 33amoxicillin................................... 9amoxicillin-potassium clavulanate..................................9amoxicillin-potassium clavulanate er..............................9amphetamine sulfate.................28amphetamine-dextroamphetamine.................. 28amphetamine-dextroamphetamine er.............. 29amphotericin b.......................... 13amphotericin b liposome........... 13ampicillin..................................... 9ampicillin sodium.........................9ampicillin-sulbactam sodium....... 9anagrelide hcl............................24anastrozole............................... 16ANNOVERA..............................38ANORO ELLIPTA..................... 53apap-caff-dihydrocodeine........... 6APOKYN................................... 18apomorphine hcl....................... 18APO-VARENICLINE................... 8apraclonidine hcl....................... 49aprepitant.................................. 13apri............................................ 38APTIVUS...................................21aranelle..................................... 38ARANESP (ALBUMIN FREE)...24arformoterol tartrate.................. 52argyle sterile saline................... 35aripiprazole............................... 19armodafinil ................................ 53ARNUITY ELLIPTA...................51ascomp-codeine..........................6asenapine maleate....................19ashlyna......................................38ASMANEX (120 METERED DOSES).................................... 51ASMANEX (14 METERED DOSES).................................... 51ASMANEX (30 METERED DOSES).................................... 51

54

ASMANEX (60 METERED DOSES).................................... 51ASMANEX HFA........................ 51aspirin......................................... 5aspirin adult low dose................. 5aspirin adult low strength............ 5aspirin childrens.......................... 5aspirin ec.....................................5aspirin ec low dose..................... 5aspirin ec low strength................ 5aspirin low dose.......................... 5aspirin-dipyridamole er..............25atazanavir sulfate......................21atenolol..................................... 26atenolol-chlorthalidone..............27atomoxetine hcl.........................29atorvastatin calcium.................. 28atovaquone............................... 18atovaquone-proguanil hcl..........18atropine sulfate......................... 49ATROVENT HFA...................... 52aubra.........................................38aubra eq....................................38AUM MINI INSULIN PEN NEEDLE....................................46AUM READYGARD DUO PEN NEEDLE....................................46AUM SAFETY PEN NEEDLE... 46aurovela 1.5/30......................... 38aurovela 1/20............................ 39aurovela 24 fe........................... 39aurovela fe 1.5/30..................... 39aurovela fe 1/20........................ 39AUVI-Q......................................52aviane....................................... 39avidoxy......................................10AVONEX PEN...........................29AVONEX PREFILLED.............. 29AVSOLA....................................43ayuna........................................ 39AZASAN....................................43AZASITE................................... 49azathioprine.............................. 43azathioprine sodium..................43azelaic acid............................... 30azelastine hcl...................... 49, 51AZELEX.................................... 30azithromycin..............................10aztreonam................................... 8azurette..................................... 39b-6 folic acid..............................32bac.............................................. 6bacitracin...................................48

bacitracin-polymyxin b.............. 48bacitra-neomycin-polymyxin-hc 48baclofen.................................... 53BAFIERTAM............................. 29balsalazide disodium.................45balziva.......................................39BARACLUDE............................ 20BAXDELA................................. 10BAYER ASPIRIN........................ 5BAYER ASPIRIN EC LOW DOSE..........................................5BD AUTOSHIELD DUO PEN NEEDLES................................. 46bd posiflush...............................46BD ULTRA-FINE INSULIN SYRINGES............................... 46BD ULTRA-FINE PEN NEEDLES................................. 46BELEODAQ.............................. 16BELSOMRA.............................. 53benazepril hcl............................25benazepril-hydrochlorothiazide. 27BENLYSTA............................... 44benzalkonium chloride.............. 46BENZNIDAZOLE...................... 18benzonatate.............................. 53benzoyl peroxide-erythromycin. 30benztropine mesylate................18BERINERT................................43BESIVANCE............................. 50betamethasone dipropionate.... 36betamethasone dipropionate aug............................................ 36betamethasone valerate........... 36BETASERON............................29betaxolol hcl........................ 26, 49bethanechol chloride.................35BETIMOL.................................. 49bexarotene................................ 17BEXSERO.................................44bicalutamide..............................15BICILLIN L-A...............................9BIJUVA..................................... 39BIKTARVY................................ 20bimatoprost............................... 50biocel.........................................32bisacodyl ec.............................. 34bisoprolol fumarate................... 26bisoprolol-hydrochlorothiazide.. 27BIVIGAM................................... 44blisovi 24 fe............................... 39blisovi fe 1.5/30......................... 39blisovi fe 1/20............................ 39

BOOSTRIX............................... 44bosentan................................... 52BOSULIF...................................16BOTOX..................................... 47bp vit 3...................................... 32b-plex........................................ 32b-plex plus.................................32BREATHE EASE LARGE......... 47BREATHE EASE MEDIUM.......47BREATHE EASE SMALL..........47BREO ELLIPTA........................ 51BREZTRI AEROSPHERE.........52briellyn.......................................39BRILINTA..................................25brimonidine tartrate................... 49brinzolamide..............................49BRIVIACT................................. 11bromfenac sodium (once-daily).50bromocriptine mesylate.............18budesonide......................... 45, 51budesonide er........................... 45bumetanide............................... 27buprenorphine.............................5buprenorphine hcl....................... 7buprenorphine hcl-naloxone hcl............................................... 7bupropion hcl............................ 12bupropion hcl er (smoking det)... 8bupropion hcl er (sr)..................12bupropion hcl er (xl).................. 12buspirone hcl.............................21busulfan.................................... 15butalbital-acetaminophen............6butalbital-apap-caff-cod.............. 6butalbital-apap-caffeine...............6butalbital-asa-caff-codeine..........6butalbital-aspirin-caffeine............ 6butorphanol tartrate.....................6BYDUREON BCISE AUTOINJECTOR...................... 23BYETTA 10 MCG PEN............. 23BYETTA 5 MCG PEN............... 23cabergoline............................... 37CABLIVI.................................... 25CABOMETYX........................... 16caffeine citrate...........................29calcipotriene..............................30calcitonin (salmon).................... 46calcitriol............................... 30, 46calcium acetate......................... 32calcium acetate (phos binder)...32camila........................................41camrese.................................... 39

55

camrese lo................................ 39candesartan cilexetil ................. 25CAPASTAT SULFATE..............15capecitabine..............................16CAPRELSA...............................16captopril .................................... 25CARBAGLU.............................. 31carbamazepine......................... 11carbamazepine er..................... 11carbidopa.................................. 19carbidopa-levodopa.................. 19carbidopa-levodopa er........ 18, 19carbidopa-levodopa-entacapone......................... 18, 19carbinoxamine maleate.............51carglumic acid........................... 31carisoprodol.............................. 53carisoprodol-aspirin-codeine.......6carteolol hcl...............................49cartia xt..................................... 26carvedilol...................................26cascara sagrada....................... 34caspofungin acetate..................13cavarest.................................... 29CAYA........................................ 47caziant.......................................39cefaclor....................................... 9cefaclor er................................... 9cefadroxil .....................................9cefazolin sodium......................... 9cefazolin sodium-dextrose.......... 9cefdinir........................................ 9cefepime hcl................................9cefepime-dextrose...................... 9cefotaxime sodium...................... 9cefotetan disodium......................9cefotetan disodium-dextrose.......9cefoxitin sodium.......................... 9cefpodoxime proxetil ................... 9cefprozil .......................................9ceftazidime..................................9ceftazidime and dextrose............ 9ceftriaxone sodium......................9ceftriaxone sodium in dextrose... 9ceftriaxone sodium-dextrose.......9cefuroxime axetil ......................... 9celecoxib..................................... 5CELONTIN................................11cephalexin...................................9CEQUR SIMPLICITY 2U.......... 22CERDELGA.............................. 34cetirizine hcl.............................. 51cevimeline hcl........................... 29

charlotte 24 fe........................... 39chateal...................................... 39chateal eq................................. 39CHEMET...................................32CHEMSTRIP 10 MD................. 22CHEMSTRIP 10/SG..................22CHEMSTRIP 2 GP....................22CHEMSTRIP 5 OB....................22CHEMSTRIP 7..........................22CHEMSTRIP 9..........................22CHEMSTRIP K......................... 22CHEMSTRIP UGK.................... 22chlordiazepoxide hcl................. 21chlordiazepoxide-amitriptyline...12chlorhexidine gluconate............ 29chloroquine phosphate..............18chlorpromazine hcl....................19chlorthalidone............................27chlorzoxazone...........................53CHOLBAM................................ 34cholestyramine..........................28cholestyramine light.................. 28CHORIONIC GONADOTROPIN.................... 38ciclodan.....................................13ciclopirox................................... 13ciclopirox olamine..................... 14cidofovir.....................................19cilostazol................................... 25CIMDUO................................... 20cimetidine..................................33cimetidine hcl............................ 33CIMZIA......................................43CIMZIA PREFILLED KIT...........43CIMZIA STARTER KIT............. 43cinacalcet hcl............................ 46CINRYZE.................................. 43CIPRO.......................................10CIPRO HC................................ 50ciprofloxacin hcl.................. 10, 50ciprofloxacin-dexamethasone... 50citalopram hydrobromide.......... 12citroma...................................... 34claravis......................................30clarithromycin............................10clearlax......................................34clemastine fumarate..................51CLENPIQ.................................. 34CLEVER CHOICE HOLDING CHAMBER................................ 47clindacin etz.............................. 30clindacin-p.................................30clindamycin hcl............................8

clindamycin palmitate hcl............ 8clindamycin phosphate......... 8, 30clindamycin phosphate in d5w.... 8clindamycin phosphate-benzoyl peroxide.......................30clobazam...................................11clobetasol prop emollient base. 36clobetasol propionate................36clodan....................................... 36clomipramine hcl....................... 13clonazepam...............................21clonidine....................................25clonidine hcl.............................. 25clonidine hcl er.......................... 29clopidogrel bisulfate.................. 25clorazepate dipotassium........... 21clotrimazole...............................14clotrimazole-betamethasone.....14clozapine...................................19COAGADEX..............................25coal tar...................................... 30COARTEM................................ 18codeine sulfate............................6colchicine.................................. 14colchicine-probenecid............... 14colesevelam hcl........................ 28colestipol hcl............................. 28COMBIGAN.............................. 49COMBIPATCH.......................... 39COMBIVENT RESPIMAT......... 53COMETRIQ...............................16COMIRNATY............................ 44COMPACT SPACE CHAMBER................................ 47COMPACT SPACE CHAMBER/LG MASK............... 47COMPACT SPACE CHAMBER/MED MASK............47COMPACT SPACE CHAMBER/SM MASK.............. 47COMPLERA..............................20compro...................................... 13CONDYLOX..............................30constulose.................................34CONTOUR CONTROL SOLUTION................................22CONTOUR MONITOR DEVICE.....................................22CONTOUR MONITOR KIT W/DEVICE................................ 22CONTOUR NEXT CONTROL SOLUTION................................22

56

CONTOUR NEXT EZ KIT W/DEVICE................................ 22CONTOUR NEXT LINK KIT W/DEVICE................................ 22CONTOUR NEXT MONITOR KIT W/DEVICE..........................22CONTOUR NEXT ONE KIT......22CONTOUR NEXT TEST STRIPS..................................... 22CONTOUR TEST STRIPS........22COPAXONE..............................29CORIFACT................................25CORLANOR..............................27CORTIFOAM............................ 45CORTISPORIN-TC................... 50corvita 150................................ 31COTELLIC................................ 16CREON..................................... 34CRESEMBA..............................14cromolyn sodium...........33, 49, 52crotan........................................ 18cryselle-28.................................39curity sterile saline.................... 35CUVITRU.................................. 44CUVPOSA................................ 33CVS KETONE CARE................22cyanocobalamin........................ 32cyclafem 1/35............................39cyclafem 7/7/7...........................39cyclobenzaprine hcl.................. 53cyclopentolate hcl..................... 49cyclophosphamide.................... 15CYCLOPHOSPHAMIDE........... 15cycloserine................................ 15cyclosporine........................ 43, 49cyclosporine modified............... 43cyproheptadine hcl....................51cyred......................................... 39cyred eq.................................... 39CYSTADROPS......................... 49CYSTAGON..............................34CYSTARAN.............................. 49dalfampridine er........................ 29DALIRESP................................ 52danazol..................................... 38dapsone.................................... 15DAPTACEL............................... 44daptomycin..................................8darifenacin hydrobromide er..... 35dasetta 1/35.............................. 39dasetta 7/7/7............................. 39daunorubicin hcl........................16daysee...................................... 39

DEBACTEROL..........................30deblitane................................... 41decitabine..................................16deferasirox................................ 32deferiprone................................32deferoxamine mesylate.............47delyla.........................................39demeclocycline hcl....................10DEMSER...................................27DEPO-MEDROL....................... 36DEPO-SUBQ PROVERA 104...41desipramine hcl.........................13desloratadine............................ 51desmopressin ace spray refrig..38desmopressin acetate...............38desmopressin acetate spray..... 38desogestrel-ethinyl estradiol..... 39desonide................................... 36desoximetasone........................36desvenlafaxine succinate er......12dexamethasone........................ 36dexamethasone intensol........... 36dexamethasone sod phosphate pf............................. 37dexamethasone sodium phosphate........................... 37, 50DEXILANT................................ 34DEXLANSOPRAZOLE..............34dexmethylphenidate hcl............ 29dexmethylphenidate hcl er........ 29dextroamphetamine sulfate.......29dextroamphetamine sulfate er.. 29DIACOMIT................................ 11DIASCREEN 1B........................47DIASCREEN 1K........................47diazepam............................ 11, 22diazepam intensol..................... 21diazoxide...................................23diclofenac potassium.................. 5diclofenac sodium........... 5, 16, 50diclofenac sodium er................... 5diclofenac-misoprostol................ 5dicloxacillin sodium................... 10dicyclomine hcl..........................33DIFICID..................................... 10diflorasone diacetate.................37diflunisal...................................... 5difluprednate............................. 50digitek........................................27digox......................................... 27digoxin.......................................27dihydroergotamine mesylate.....14DILANTIN..................................11

diltiazem hcl.............................. 26diltiazem hcl er.......................... 26diltiazem hcl er beads............... 26diltiazem hcl er coated beads... 26dilt-xr......................................... 26dimenhydrinate......................... 13dimethyl fumarate..................... 29dimethyl fumarate starter pack..29DIPENTUM............................... 45diphenhydramine hcl.................51diphenoxylate-atropine..............33DIPHTHERIA-TETANUS TOXOIDS DT............................ 44dipyridamole..............................25disopyramide phosphate...........26disulfiram.....................................7divalproex sodium..................... 22divalproex sodium er.................22DIVIGEL....................................39dofetilide....................................26dolishale....................................39donepezil hcl............................. 12dorzolamide hcl.........................49dorzolamide hcl-timolol mal...... 49dorzolamide hcl-timolol mal pf.. 49dotti ........................................... 39DOVATO...................................20doxazosin mesylate.................. 25doxepin hcl..........................13, 53doxercalciferol...........................46doxy 100................................... 10doxycycline hyclate................... 10doxycycline monohydrate......... 10dronabinol................................. 13droperidol.................................. 13DROPLET MICRON................. 47DROPSAFE ALCOHOL PREP. 47drospiren-eth estrad-levomefol. 39drospirenone-ethinyl estradiol...39DROXIA.................................... 16DUAVEE................................... 39duloxetine hcl............................ 12DUPIXENT................................30duramorph...................................6DUREZOL.................................50dutasteride................................ 35dutasteride-tamsulosin hcl........ 35EASIVENT................................ 47easygel......................................30ec-naproxen................................ 5econazole nitrate.......................14econtra ez................................. 41econtra one-step....................... 41

57

EDURANT.................................20efavirenz................................... 20efavirenz-emtricitab-tenofovir....20efavirenz-lamivudine-tenofovir.. 20eletriptan hydrobromide............ 14elinest........................................39ELIQUIS....................................24ELIQUIS DVT/PE STARTER PACK........................................ 24ELLA......................................... 41ELMIRON..................................35ELOCTATE............................... 25eluryng...................................... 39EMBRACE PRESSURE ACTIVATED 21G...................... 22EMBRACE PRESSURE ACTIVATED 28G...................... 22EMCYT..................................... 16EMGALITY................................14emoquette................................. 39EMSAM.....................................12emtricitabine..............................20emtricitabine-tenofovir df.....20, 21EMTRIVA.................................. 21EMVERM.................................. 18enalapril maleate.......................25enalapril-hydrochlorothiazide.... 27ENBREL....................................43ENBREL MINI........................... 43ENBREL SURECLICK.............. 43ENCARE................................... 35endocet....................................... 6ENGERIX-B.............................. 44enoxaparin sodium....................24enpresse-28.............................. 39enskyce.....................................39entacapone............................... 18entecavir................................... 20ENTRESTO.............................. 27enulose..................................... 34EPCLUSA................................. 20EPIDIOLEX............................... 11EPIDUO FORTE....................... 30epinastine hcl............................ 49epinephrine............................... 52epinephrine (anaphylaxis).........52epinephrine pf........................... 27epitol......................................... 11EPIVIR HBV..............................20eplerenone................................ 27eptifibatide.................................25ergocalciferol.............................32ergoloid mesylates.................... 47

ergotamine-caffeine.................. 14ERIVEDGE............................... 17erlotinib hcl................................17errin...........................................41ERTACZO.................................14ertapenem sodium.................... 10ery............................................. 30erythromycin................. 10, 30, 49erythromycin base.....................10erythromycin ethylsuccinate......10escitalopram oxalate................. 12esomeprazole sodium...............34estarylla.....................................39estazolam..................................22estradiol.................................... 39estradiol valerate.......................39estradiol-norethindrone acet..... 39eszopiclone............................... 53ethacrynic acid.......................... 27ethambutol hcl...........................15ethosuximide.............................11ethynodiol diac-eth estradiol..... 39ETHYOL....................................16etodolac...................................... 5etodolac er.................................. 5etonogestrel-ethinyl estradiol.... 39etoposide.................................. 16etravirine................................... 20euthyrox.................................... 42everolimus...........................17, 43EVOTAZ....................................21EVRYSDI.................................. 34exemestane.............................. 16EYSUVIS.................................. 50ezetimibe...................................28ezetimibe-simvastatin............... 28fabb........................................... 32falmina...................................... 39famciclovir................................. 20famotidine................................. 33famotidine premixed..................34FANAPT....................................19FANAPT TITRATION PACK..... 19FARXIGA.................................. 23FARYDAK................................. 17fa-vitamin b-6-vitamin b-12....... 32fayosim......................................39FC FEMALE CONDOM............ 47FC2 FEMALE CONDOM.......... 47febuxostat................................. 14FEIBA........................................25felbamate.................................. 11felodipine er.............................. 26

FEMCAP................................... 47femynor..................................... 39fenofibrate................................. 28fenofibrate micronized...............27fenofibric acid............................28fenoprofen calcium......................5fentanyl....................................... 6fentanyl citrate.............................6ferocon...................................... 31ferotrinsic.................................. 31ferrocite plus............................. 31FETZIMA...................................12FETZIMA TITRATION...............12finasteride................................. 35flac............................................ 50FLAREX.................................... 50flavoxate hcl.............................. 35FLEBOGAMMA DIF..................44flecainide acetate...................... 26FLEXICHAMBER...................... 47FLEXICHAMBER ADULT MASK/SMALL........................... 47FLEXICHAMBER CHILD MASK/LARGE...........................47FLEXICHAMBER CHILD MASK/SMALL........................... 47FLOVENT DISKUS................... 51FLOVENT HFA......................... 51FLUAD QUADRIVALENT......... 44FLUARIX QUADRIVALENT......44FLUBLOK QUADRIVALENT.....44FLUCELVAX QUADRIVALENT...................... 45fluconazole................................14fluconazole in sodium chloride..14flucytosine................................. 14fludarabine phosphate.............. 16fludrocortisone acetate..............37FLULAVAL QUADRIVALENT... 45FLUMIST QUADRIVALENT......45flunisolide.................................. 51fluocinolone acetonide........ 37, 50fluocinolone acetonide body..... 37fluocinolone acetonide scalp.....37fluocinonide...............................37fluocinonide emulsified base.....37fluoridex daily renewal.............. 30fluoritab..................................... 31fluorometholone........................ 50FLUOROPLEX..........................16fluorouracil ................................ 16FLUOROURACIL......................16fluoxetine hcl............................. 12

58

fluphenazine hcl........................ 19flurandrenolide.......................... 37flurbiprofen.................................. 5flurbiprofen sodium................... 50flutamide................................... 15fluticasone propionate.........37, 51fluticasone-salmeterol............... 51FLUTICASONE-SALMETEROL..........................51fluvoxamine maleate................. 12fluvoxamine maleate er.............12FLUZONE HIGH-DOSE QUADRIVALENT...................... 45FLUZONE QUADRIVALENT.... 45FML...........................................50folate......................................... 32folbee........................................ 32folbee plus.................................32folic acid.................................... 32folplex 2.2..................................32foltrin......................................... 31fondaparinux sodium.................24formoterol fumarate...................52fosamprenavir calcium.............. 21fosaprepitant dimeglumine........13fosfomycin tromethamine............8fosinopril sodium....................... 25fosinopril sodium-hctz............... 27fosphenytoin sodium................. 11FOSRENOL.............................. 32furosemide................................ 27FUZEON................................... 21fyavolv.......................................39FYCOMPA................................ 11gabapentin................................ 11GALAFOLD...............................34galantamine hydrobromide....... 12galantamine hydrobromide er... 12GAMASTAN..............................44GAMIFANT............................... 44GAMMAGARD.......................... 44GAMMAGARD S/D LESS IGA..44GAMMAKED............................. 44GAMMAPLEX........................... 44GAMUNEX-C............................ 44GARDASIL 9.............................45gatifloxacin................................ 50GATTEX....................................33gavilax.......................................34gavilyte-c...................................34gavilyte-g...................................34gavilyte-n with flavor pack.........34GELNIQUE............................... 35

gemfibrozil .................................28gemmily.....................................39generlac.................................... 34gengraf......................................43gentak....................................... 48gentamicin sulfate................. 8, 48gentle laxative........................... 34gentlelax....................................34GILENYA.................................. 29GILOTRIF................................. 17glatiramer acetate..................... 29glatopa...................................... 29GLEOSTINE............................. 15glimepiride.................................23glipizide er.................................23glipizide ir.................................. 23glipizide xl................................. 23glipizide-metformin hcl.............. 23glucagon emergency kit ............ 23GLUCAGON EMERGENCY KIT............................................ 24glyburide................................... 23glyburide micronized................. 23glyburide-metformin.................. 23glycine.......................................35glycine urologic......................... 35glycolax..................................... 34glycopyrrolate............................33glycopyrrolate pf........................33glydo........................................... 7GLYXAMBI................................23goodsense aspirin adults............ 5goodsense aspirin low dose........5goodsense nicotine..................... 8granisetron hcl.......................... 13griseofulvin microsize................14griseofulvin ultramicrosize.........14guanfacine hcl...........................25guanfacine hcl er.......................29GYNAZOLE-1........................... 14habitrol........................................ 8hailey 1.5/30..............................39hailey 24 fe................................39hailey fe 1.5/30..........................39hailey fe 1/20.............................39halcinonide................................37halobetasol propionate..............37haloperidol................................ 19haloperidol decanoate...............19haloperidol lactate.....................19HARVONI..................................20HAVRIX.....................................45heather......................................41

HEMLIBRA................................25hemocyte-f................................ 31HEPAGAM B.............................44heparin lock flush...................... 47heparin sodium (porcine).......... 24heparin sodium (porcine) pf...... 24heparin sodium lock flush......... 47HEPLISAV-B.............................45HETLIOZ...................................53HIBERIX....................................45HIZENTRA................................ 44homatropaire.............................49HUMALOG................................24HUMALOG KWIKPEN.............. 24HUMALOG MIX 50/50 KWIKPEN................................. 24HUMALOG MIX 50/50 VIAL......24HUMALOG MIX 75/25 KWIKPEN................................. 24HUMALOG MIX 75/25 VIAL......24HUMALOG U-100 JUNIOR KWIKPEN................................. 24HUMATE-P............................... 25HUMIRA....................................43HUMIRA PEDIATRIC CROHNS START......................43HUMIRA PEN........................... 43HUMIRA PEN-CD/UC/HS STARTER................................. 43HUMIRA PEN-PEDIATRIC UC START...................................... 43HUMIRA PEN-PS/UV/ADOL HS START................................ 43HUMIRA PEN-PSOR/UVEIT STARTER................................. 43HUMULIN 70/30 KWIKPEN...... 24HUMULIN 70/30 VIAL...............24HUMULIN N KWIKPEN............ 24HUMULIN N VIAL..................... 24HUMULIN R U-500 KWIKPEN..24HUMULIN R U-500 VIAL.......... 24HUMULIN R VIAL..................... 24HYCAMTIN............................... 16hydralazine hcl.......................... 28hydrochlorothiazide...................27hydrocodone bitartrate er............6hydrocodone-acetaminophen..... 6hydrocodone-homatropine........ 53hydrocodone-ibuprofen............... 6hydrocortisone.................... 37, 46hydrocortisone (perianal).......... 46hydrocortisone ace-pramoxine..46hydrocortisone butyrate............ 37

59

hydrocortisone valerate.............37hydrocortisone-acetic acid........ 50hydromet................................... 53hydromorphone hcl..................... 6hydromorphone hcl er................. 6hydromorphone hcl pf................. 6hydroxocobalamin acetate........ 32hydroxychloroquine sulfate....... 18hydroxyprogesterone caproate. 42hydroxyurea.............................. 16hydroxyzine hcl......................... 21hydroxyzine pamoate................21hyoscyamine sulfate................. 33hyoscyamine sulfate sl..............33HYPERHEP B...........................44HYPERRHO S/D.......................44HYQVIA.................................... 44ibandronate sodium.................. 46IBRANCE.................................. 17ibuprofen..................................... 5icatibant acetate........................43iclevia........................................ 39ICLUSIG....................................17ILARIS.......................................44imatinib mesylate...................... 17IMBRUVICA.............................. 17imipenem-cilastatin................... 10imipramine hcl...........................13imipramine pamoate................. 13imiquimod..................................30IMPAVIDO................................ 18incassia..................................... 42INCRELEX................................ 38indapamide............................... 27indomethacin...............................5indomethacin er.......................... 5INFANRIX................................. 45INFLECTRA.............................. 43INLYTA..................................... 17INPEN 100-BLUE-LILLY-HUMALOG................................22INPEN 100-BLUE-NOVOLOG-FIASP........................................22INPEN 100-GREY-LILLY-HUMALOG................................22INPEN 100-GREY-NOVOLOG-FIASP.................... 22INPEN 100-PINK-LILLY-HUMALOG................................22INPEN 100-PINK-NOVOLOG-FIASP........................................23INSPIREASE RESERVOIR BAGS........................................ 47

INSULIN PEN NEEDLES..........47INSULIN SYRINGES................ 47INTELENCE..............................20INTRAROSA............................. 38INTRON A.................................20introvale.................................... 39INVEGA SUSTENNA................19INVEGA TRINZA...................... 19iodine strong............................. 31iodine tincture..............................8IOPIDINE.................................. 49IPOL..........................................45ipratropium bromide.................. 52ipratropium-albuterol................. 53irbesartan.................................. 25irbesartan-hydrochlorothiazide..27ISENTRESS..............................20ISENTRESS HD....................... 20isibloom.....................................39isoniazid.................................... 15isosorbide dinitrate....................28isosorbide mononitrate..............28isosorbide mononitrate er......... 28isotretinoin.................................30itraconazole...............................14ivermectin............................18, 30IXEMPRA KIT........................... 16jaimiess..................................... 39JAKAFI......................................17JANSSEN COVID-19 VACCINE.................................. 45jantoven.................................... 24JANUMET................................. 23JANUMET XR........................... 23JANUVIA...................................23JARDIANCE..............................23jasmiel.......................................40jencycla..................................... 42JENTADUETO.......................... 23JENTADUETO XR.................... 23jinteli ..........................................40jolessa.......................................40J-TIP KIT W/VIAL ADAPTERS. 47juleber....................................... 40JULUCA.................................... 20junel 1.5/30............................... 40junel 1/20.................................. 40junel fe 1.5/30........................... 40junel fe 1/20.............................. 40junel fe 24................................. 40kaitlib fe.....................................40kalliga........................................40KALYDECO.............................. 52

kariva........................................ 40kelnor 1/35................................ 40kelnor 1/50................................ 40KENALOG-80........................... 37ketoconazole.............................14KETO-DIASTIX......................... 23KETONE TEST......................... 23ketoprofen................................... 5ketorolac tromethamine........ 5, 50KETOSTIX................................ 23KINERET.................................. 43KINRIX...................................... 45klor-con..................................... 31klor-con 10................................ 31klor-con m10............................. 31klor-con m15............................. 31klor-con m20............................. 31KLOXXADO................................ 7KOSELUGO..............................17k-tan plus.................................. 31kurvelo...................................... 40KYLEENA................................. 42labetalol hcl............................... 26lacosamide................................11lactic acid.................................. 30lactic acid e............................... 30lactulose....................................34lactulose encephalopathy......... 34lamivudine...........................20, 21lamivudine-zidovudine.............. 21lamotrigine................................ 11lamotrigine er............................ 11lamotrigine starter kit-blue.........11lamotrigine starter kit-green...... 11lamotrigine starter kit-orange.... 11LANCETS................................. 23lansoprazole..............................34lanthanum carbonate................ 32LANTUS SOLOSTAR............... 24LANTUS U-100 VIAL................ 24lapatinib ditosylate.................... 17larin 1.5/30................................ 40larin 1/20................................... 40larin 24 fe.................................. 40larin fe 1.5/30............................ 40larin fe 1/20............................... 40larissia.......................................40latanoprost................................ 50LATUDA....................................19layolis fe.................................... 40leena......................................... 40leflunomide................................44lenalidomide..............................15

60

LENVIMA.................................. 17lessina.......................................40letrozole.................................... 16leucovorin calcium.................... 16LEUKERAN...............................15leuprolide acetate......................42levalbuterol hcl.......................... 52LEVEMIR U-100 FLEXTOUCH.24LEVEMIR U-100 VIAL...............24levetiracetam.............................11levetiracetam er........................ 11levetiracetam in nacl................. 11levobunolol hcl.......................... 49levocarnitine..............................31levocarnitine sf.......................... 31levocetirizine dihydrochloride....51levofloxacin......................... 10, 50levonest.....................................40levonorgest-eth est & eth est.... 40levonorgest-eth estrad 91-day.. 40levonorgestrel........................... 42levonorgestrel-ethinyl estrad.....40levonorg-eth estrad triphasic.....40levora 0.15/30 (28)....................40levo-t......................................... 42levothyroxine sodium................ 42levoxyl....................................... 42lidocaine......................................7lidocaine hcl................................ 7lidocaine hcl urethral/mucosal.....7lidocaine viscous hcl................... 7lidocaine-prilocaine..................... 7LIDOCAINE-TETRACAINE.........7LILETTA (52 MG)......................42lillow.......................................... 40lindane...................................... 18linezolid....................................... 8linezolid in sodium chloride......... 8LINZESS................................... 34liothyronine sodium................... 42lisinopril ..................................... 25lisinopril-hydrochlorothiazide.....27lithium carbonate.......................22lithium carbonate er.................. 22lojaimiess.................................. 40loperamide hcl...........................33lopinavir-ritonavir.......................21lorazepam................................. 22lorazepam intensol....................22loryna........................................ 40losartan potassium....................25losartan potassium-hctz............ 27loteprednol etabonate............... 50

lovastatin...................................28low-ogestrel...............................40loxapine succinate.................... 19lo-zumandimine.........................40LULICONAZOLE.......................14LUMIGAN..................................50LUPRON DEPOT (1-MONTH)..42LUPRON DEPOT (3-MONTH)..42LUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT 30MG..42LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT 45MG..42LUPRON DEPOT-PED (1-MONTH)....................................43LUPRON DEPOT-PED (3-MONTH)....................................43lutera......................................... 40lyleq...........................................42lyllana........................................40LYNPARZA............................... 17lysiplex plus...............................32LYSODREN.............................. 42lyza............................................42mafenide acetate........................ 8magnesium citrate.....................34MAKENA...................................42malathion.................................. 18mannitol.................................... 27maraviroc.................................. 21marlissa.....................................40MARPLAN.................................12MASONATAL............................32MATULANE.............................. 15MAVYRET.................................20MAYZENT.................................29MAYZENT STARTER PACK.... 29meclizine hcl............................. 13medroxyprogesterone acetate.. 42mefenamic acid...........................5mefloquine hcl...........................18megestrol acetate..................... 42MEKINIST................................. 17meloxicam...................................5melphalan................................. 15melphalan hcl............................15memantine hcl...........................12memantine hcl er...................... 12MENACTRA..............................45MENEST................................... 40MENQUADFI............................ 45MENTAX................................... 14MENVEO.................................. 45meprobamate............................21

mercaptopurine......................... 16merzee...................................... 40mesalamine...............................45mesalamine er oral capsule 0.375 gm................................... 45mesalamine-cleanser................45MESNEX...................................18metaxalone............................... 53metformin hcl er........................ 23metformin hcl ir ......................... 23methadone hcl............................ 6methadose.................................. 6methazolamide..........................27methenamine hippurate.............. 8methergine................................ 47methimazole..............................43methocarbamol......................... 53methotrexate............................. 43methotrexate sodium................ 43methotrexate sodium (pf).......... 43methoxsalen rapid.....................30methscopolamine bromide........33methyldopa............................... 25methylergonovine maleate........47methylphenidate hcl.................. 29methylphenidate hcl er..............29methylphenidate hcl er (cd).......29methylphenidate hcl er (la)........29methylphenidate hcl er (xr)....... 29methylprednisolone...................37methylprednisolone acetate...... 37metoclopramide hcl...................13metolazone............................... 27metoprolol succinate er.............26metoprolol tartrate.....................26metoprolol-hydrochlorothiazide.27metronidazole....................... 8, 30metronidazole in nacl.................. 8metyrosine................................ 27mexiletine hcl............................ 26miconazole 3.............................14MICRHOGAM ULTRA-FILTERED PLUS...................... 44MICROCHAMBER.................... 47microgestin 1.5/30.....................40microgestin 1/20........................40microgestin 24 fe.......................40microgestin fe 1.5/30.................40microgestin fe 1/20....................40midodrine hcl.............................25mifepristone.............................. 38miglitol.......................................23miglustat....................................34

61

mili .............................................40mimvey......................................40mineral oil heavy....................... 34minocycline hcl..........................10minoxidil .................................... 28MIRENA (52 MG)......................42mirtazapine............................... 12MIRVASO................................. 30misoprostol................................34mitigo.......................................... 6mitomycin..................................16mitoxantrone hcl........................16mm clearlax...............................34M-M-R II.................................... 45modafinil ....................................53MODERNA COVID-19 VACCINE.................................. 45moexipril hcl.............................. 25MOLNUPIRAVIR.......................19mometasone furoate........... 37, 51mondoxyne nl............................10monoject flush syringe.............. 47monoject sodium chloride flush.47mono-linyah.............................. 40montelukast sodium............ 51, 52morphine sulfate......................... 7morphine sulfate (concentrate)... 7morphine sulfate (pf)................... 7morphine sulfate er..................... 6MOTEGRITY.............................33MOTOFEN................................ 33moxifloxacin hcl...................10, 50moxifloxacin hcl (2x day)...........50moxifloxacin hcl in nacl............. 10MOZOBIL..................................24multivitamin/fluoride.................. 32multi-vitamin/fluoride................. 32multi-vitamin/fluoride/iron.......... 32mupirocin.................................... 8mutamycin.................................16my choice..................................42my way......................................42MYALEPT................................. 35mycophenolate mofetil .............. 43mycophenolate mofetil hcl........ 43mycophenolate sodium............. 43MYLERAN.................................15myorisan................................... 30MYRBETRIQ.............................35na ferric gluc cplx in sucrose.....31NABI-HB................................... 44nabumetone................................ 5nafcillin sodium......................... 10

nafrinse..................................... 31nafrinse drops........................... 31naftifine hcl................................14naloxone hcl............................7, 8naltrexone hcl..............................7NAMZARIC............................... 12naproxen..................................... 5naproxen sodium........................ 5naratriptan hcl........................... 15NARCAN.....................................8NASCOBAL.............................. 32NATACYN.................................49NATAZIA...................................40nateglinide.................................23nebivolol hcl.............................. 26necon 0.5/35 (28)......................40nefazodone hcl..........................12neomycin sulfate......................... 8neomycin-bacitracin zn-polymyx.....................................48neomycin-polymyxin-dexameth 48neomycin-polymyxin-gramicidin..................................48neomycin-polymyxin-hc...... 48, 50neo-polycin................................48neo-polycin hc...........................48nephronex................................. 32neuac........................................ 31NEULASTA............................... 24NEULASTA ONPRO.................24NEUPRO...................................18nevirapine................................. 20nevirapine er............................. 20new day.....................................42NEXAVAR.................................17NEXLETOL............................... 28NEXLIZET.................................28NEXPLANON............................42niacin er (antihyperlipidemic).... 28NICORETTE............................... 8nicotine........................................8nicotine polacrilex....................... 8nicotine polacrilex mini................8nicotine step 1.............................8nicotine step 2.............................8nicotine step 3.............................8NICOTROL................................. 8NICOTROL NS........................... 8nifedipine er.............................. 26nifedipine er osmotic release.... 26nikki...........................................40nilutamide..................................15nimodipine.................................26

NINLARO.................................. 16nitazoxanide..............................18nitisinone...................................35nitrofurantoin macrocrystal..........8nitrofurantoin monohydrate macrocrystals..............................8nitroglycerin...............................28NIVESTYM................................24nizatidine...................................34nolix...........................................37nora-be......................................42NORDITROPIN FLEXPRO....... 38norethin ace-eth estrad-fe.........40norethindrone............................42norethindrone acetate............... 42norethindrone acet-ethinyl est...40norethindrone-eth estradiol....... 40norethin-eth estradiol-fe............ 40norgestimate-eth estradiol........ 40norgestimate-ethinyl estradiol triphasic.....................................40norlyda...................................... 42norlyroc..................................... 42normal saline flush.................... 47nortrel 0.5/35 (28)..................... 40nortrel 1/35 (21)........................ 40nortrel 1/35 (28)........................ 40nortrel 7/7/7...............................40nortriptyline hcl..........................13NORVIR.................................... 21NOVAREL.................................38NOVOEIGHT............................ 25NOVOFINE AUTOCOVER PEN NEEDLE........................... 47NOVOFINE PEN NEEDLE....... 47NOVOFINE PLUS PEN NEEDLE....................................47NOVOPEN ECHO.....................23NOVOSEVEN RT..................... 25NOVOTWIST PEN NEEDLE.... 47np thyroid.................................. 42NUCALA................................... 53NUCYNTA...................................7NUCYNTA ER.............................6nufol.......................................... 32nutrifac zx..................................32NUTROPIN AQ NUSPIN 10..... 38NUTROPIN AQ NUSPIN 20..... 38NUTROPIN AQ NUSPIN 5....... 38NUWIQ......................................25nyamyc......................................14nylia 1/35...................................40nylia 7/7/7..................................40

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nymyo....................................... 41nystatin......................................14nystatin-triamcinolone............... 14nystop....................................... 14OBIZUR.................................... 25ocella.........................................41OCTAGAM................................44octreotide acetate..................... 43ODEFSEY.................................21OFEV........................................ 53ofloxacin..............................10, 50olanzapine.................................19olanzapine-fluoxetine hcl.......... 12olmesartan medoxomil..............25olmesartan medoxomil-hctz...... 27olopatadine hcl....................49, 51OMECLAMOX-PAK.................. 33omega-3-acid ethyl esters.........28omeprazole............................... 34ondansetron hcl........................ 13ondansetron odt........................ 13ONE VITE WOMENS................32ONE-A-DAY WOMENS PRENATAL 1............................ 32ONETOUCH CLUB LANCETS FINE PT.................................... 23ONETOUCH DELICA LANCETS 30G..........................23ONETOUCH DELICA LANCETS 33G..........................23ONETOUCH DELICA LANCING DEV..........................23ONETOUCH DELICA PLUS LANCET30G............................. 23ONETOUCH DELICA PLUS LANCET33G............................. 23ONETOUCH DELICA PLUS LANCING.................................. 23ONETOUCH FINEPOINT LANCETS................................. 23ONETOUCH ULTRASOFT LANCETS................................. 23ONUREG.................................. 16opcicon one-step.......................42OPSUMIT..................................52OPTICHAMBER DIAMOND......47OPTICHAMBER DIAMOND-LG MASK.................................. 47OPTICHAMBER DIAMOND-MD MASK................................. 47OPTICHAMBER DIAMOND-SM MASK................................. 47option 2..................................... 42

OPTIONS GYNOL II CONTRACEPTIVE................... 35oralone...................................... 30ORENCIA..................................43ORENCIA CLICKJECT............. 43ORENITRAM............................ 52ORFADIN..................................35ORGOVYX................................15ORKAMBI................................. 52orphenadrine citrate.................. 53orphenadrine citrate er..............53orsythia..................................... 41oseltamivir phosphate............... 21OSPHENA................................ 42OTEZLA.................................... 44oxacillin sodium.........................10oxandrolone.............................. 38oxaprozin.................................... 5oxazepam................................. 22oxcarbazepine...........................11oxiconazole nitrate.................... 14oxybutynin chloride................... 35oxybutynin chloride er............... 35oxycodone hcl............................. 7oxycodone-acetaminophen.........7OXYCONTIN...............................6oxymorphone hcl.........................7oxymorphone hcl er.................... 6oxytocin.....................................38OZEMPIC..................................23paclitaxel................................... 16paliperidone er.......................... 19palonosetron hcl........................13pamidronate disodium...............46PANDA MASK LARGE............. 47PANDA MASK MEDIUM...........47PANDA MASK SMALL..............47PANRETIN................................17pantoprazole sodium.................34PARAGARD INTRAUTERINE COPPER...................................48paricalcitol................................. 46paromomycin sulfate...................8paroxetine hcl............................12paroxetine mesylate..................12PASER......................................15PAXLOVID................................ 19PEDIARIX................................. 45PEDIATRIC PANDA MASK...... 48PEDVAX HIB............................ 45peg 3350-kcl-na bicarb-nacl......34peg-3350/electrolytes................34peg-3350/electrolytes/ascorbat.34

PEGASYS.................................20peg-kcl-nacl-nasulf-na asc-c..... 34penicillamine............................. 35penicillin g potassium................10penicillin v potassium................ 10PENTACEL............................... 45pentamidine isethionate............ 18PENTASA................................. 45pentazocine-naloxone hcl........... 7pentobarbital sodium.................11pentoxifylline er......................... 27perindopril erbumine................. 25periogard...................................30permethrin.................................18perphenazine............................ 13perphenazine-amitriptyline........12PFIZER COVID-19 VAC-TRIS 5-11Y........................................ 45PFIZER-BIONT COVID-19 VAC-TRIS................................. 45PFIZER-BIONTECH COVID-19 VACC................................... 45phenazo.................................... 35phenazopyridine hcl.................. 35phenelzine sulfate..................... 12phenobarbital............................ 11phenobarbital sodium................11phenoxybenzamine hcl............. 25phenylephrine hcl......................49phenytoin.................................. 11phenytoin infatabs.....................11phenytoin sodium......................11phenytoin sodium extended...... 11philith.........................................41PHOSLYRA.............................. 32phytonadione............................ 32PIFELTRO................................ 20pilocarpine hcl..................... 30, 50pimecrolimus.............................31pimozide....................................19pimtrea...................................... 41pindolol......................................26pioglitazone hcl......................... 23pioglitazone hcl-glimepiride.......23pioglitazone hcl-metformin hcl.. 23piperacillin sod-tazobactam so..10PIQRAY.................................... 16pirmella 1/35............................. 41pirmella 7/7/7............................ 41piroxicam.....................................5PNEUMOVAX 23...................... 45POCKET SPACER................... 48podofilox....................................31

63

polycin.......................................49polyethylene glycol 3350...........34polymyxin b sulfate..................... 8polymyxin b-trimethoprim..........49polysaccharide iron forte...........31POMALYST.............................. 15portia-28....................................41posaconazole............................14potassium chloride.................... 31potassium chloride crys er........ 31potassium chloride er................31potassium citrate er...................31PRADAXA.................................24pramipexole dihydrochloride..... 18pramipexole dihydrochloride er.18prasugrel hcl............................. 25pravastatin sodium....................28praziquantel.............................. 18prazosin hcl...............................25PRED-G S.O.P......................... 49prednicarbate............................ 37prednisolone............................. 37prednisolone acetate.................50prednisolone sodium phosphate........................... 37, 50prednisone................................ 37pregabalin................................. 29PREGNYL.................................38PREHEVBRIO.......................... 45PREMARIN............................... 41PREMPHASE........................... 41PREMPRO................................41prenatal............................... 32, 33prenatal multi +dha................... 32prenatal vitamin plus low iron....33preplus...................................... 33prevalite.................................... 28PREVIDENT............................. 30previfem.................................... 41PREVNAR 13............................45PREVNAR 20............................45PREZCOBIX............................. 21PREZISTA................................ 21PRIFTIN.................................... 15primaquine phosphate.............. 18primidone.................................. 11PRIVIGEN.................................44PRO COMFORT SPACER ADULT...................................... 48PRO COMFORT SPACER CHILD....................................... 48PRO COMFORT SPACER INFANT..................................... 48

probenecid................................ 14procainamide hcl.......................26PROCARE SPACER/ADULT MASK........................................48PROCARE SPACER/CHILD MASK........................................48prochlorperazine....................... 13prochlorperazine maleate......... 13PROCRIT..................................24procto-med hc........................... 46procto-pak................................. 46proctosol hc...............................46proctozone-hc........................... 46progesterone.............................42PROLASTIN-C..........................35PROLENSA.............................. 50PROLEUKIN............................. 16PROLIA.....................................46PROMACTA..............................24promethazine hcl.......................51promethegan.............................51propafenone hcl........................ 26propranolol hcl.......................... 26propranolol hcl er...................... 26propylthiouracil ..........................43PROQUAD................................45protriptyline hcl..........................13PULMICORT FLEXHALER.......51PULMOZYME........................... 52purevit dualfe plus.....................31PYLERA....................................33pyrazinamide.............................15pyridostigmine bromide.............15pyridostigmine bromide er.........15pyridoxine hcl............................ 33pyrimethamine.......................... 18qc magnesium citrate................34QINLOCK..................................17QUADRACEL............................45quetiapine fumarate.................. 19quetiapine fumarate er.............. 19quinapril hcl...............................25quinapril-hydrochlorothiazide.... 27quinidine sulfate........................ 26quinine sulfate...........................18QVAR REDIHALER.................. 51rabeprazole sodium.................. 34raloxifene hcl.............................42ramelteon.................................. 53ramipril ...................................... 25ranolazine er............................. 27rasagiline mesylate................... 19RAYALDEE...............................46

react.......................................... 42REBLOZYL............................... 24reclipsen....................................41RECOMBINATE........................25RECOMBIVAX HB.................... 45RECTIV.....................................28REGRANEX..............................31RELENZA DISKHALER............ 21RENACIDIN.............................. 35repaglinide................................ 23REPATHA................................. 28REPATHA PUSHTRONEX SYSTEM................................... 28REPATHA SURECLICK........... 28RESTASIS................................ 49RESTASIS MULTIDOSE.......... 49RETACRIT................................ 24RETEVMO................................ 17REVCOVI..................................35REVLIMID................................. 16REXULTI...................................19REYATAZ................................. 21RHOGAM ULTRA-FILTERED PLUS.........................................44RHOPHYLAC............................44RHOPRESSA........................... 50RIASTAP...................................25ribavirin..................................... 20rifabutin..................................... 15rifampin..................................... 15riluzole.......................................29rimantadine hcl..........................21RINVOQ....................................44risedronate sodium................... 46RISPERDAL CONSTA..............19risperidone................................ 19ritonavir..................................... 21RITUXAN.................................. 17RITUXAN HYCELA...................17rivastigmine...............................12rivastigmine tartrate.................. 12rivelsa........................................41RIXUBIS....................................25rizatriptan benzoate.................. 15ROCKLATAN............................ 50ropinirole hcl..............................18ropinirole hcl er......................... 18rosadan..................................... 31rosuvastatin calcium................. 28ROTARIX.................................. 45ROTATEQ.................................45roweepra................................... 11ROZLYTREK............................ 16

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RUBRACA................................ 16rufinamide................................. 11RUKOBIA..................................21RUXIENCE............................... 17RYBELSUS...............................23RYDAPT................................... 17sajazir........................................43SANDIMMUNE......................... 43SANTYL.................................... 31sapropterin dihydrochloride.......35SAVAYSA................................. 24SAVELLA.................................. 29SAVELLA TITRATION PACK... 29scopolamine..............................13selegiline hcl............................. 19selenium sulfide........................ 31SELZENTRY.............................21SEREVENT DISKUS................ 52sertraline hcl..............................12se-tan plus................................ 31setlakin......................................41sevelamer carbonate................ 32sharobel.................................... 42SHINGRIX.................................45SIGNIFOR.................................43sildenafil citrate......................... 52silodosin.................................... 35silver sulfadiazine........................8SIMBRINZA.............................. 50simliya....................................... 41simpesse...................................41SIMPONI...................................44SIMPONI ARIA......................... 44simvastatin................................ 28sirolimus....................................44SIRTURO..................................15SKYLA...................................... 42SKYRIZI.................................... 44SKYRIZI (150 MG DOSE).........44SKYRIZI PEN............................44sod benz-sod phenylacet.......... 35sod citrate-citric acid................. 31sodium acetate..........................31sodium chloride...................35, 53sodium chloride flush................ 48sodium fluoride..............30, 31, 32sodium fluoride 5000 plus......... 30sodium fluoride 5000 ppm.........30sodium phenylbutyrate..............35sodium polystyrene sulfonate... 32solifenacin succinate.................35SOLIQUA.................................. 23SOLIRIS....................................24

SOLTAMOX.............................. 16SOLU-CORTEF........................ 37SOMATULINE DEPOT............. 43SOMAVERT..............................43sorbitol-mannitol........................35sorine........................................ 26sotalol hcl.................................. 26sotalol hcl (af)............................26spinosad....................................18SPIRIVA HANDIHALER............52SPIRIVA RESPIMAT................ 52spironolactone...........................27spironolactone-hctz...................27sprintec 28................................ 41SPRYCEL................................. 17sps............................................ 32sronyx....................................... 41ssd.............................................. 9ST JOSEPH LOW DOSE............5stavudine...................................21STELARA..................................31STIOLTO RESPIMAT............... 52STIVARGA................................17STRENSIQ................................35streptomycin sulfate.................... 8STRIVERDI RESPIMAT........... 52subvenite...................................11subvenite starter kit-blue...........11subvenite starter kit-green........ 11subvenite starter kit-orange...... 11SUCRAID..................................35sucralfate.................................. 34SULCONAZOLE NITRATE.......14sulfacetamide sodium............... 50sulfacetamide sodium (acne).... 31sulfacetamide-prednisolone...... 49sulfadiazine............................... 10sulfamethoxazole-trimethoprim.10sulfasalazine............................. 46sulfatrim pediatric......................10sulfurated lime...........................18sulindac.......................................5sumatriptan succinate............... 15sumatriptan succinate refill subcutaneous solution cartridge.................................... 15sumatriptan-naproxen sodium.. 15sunitinib malate......................... 17SUNOSI.................................... 53SUPREP BOWEL PREP KIT....34SUTENT....................................17syeda........................................ 41SYMBICORT.............................51

SYMPROIC...............................33SYMTUZA.................................21SYNAGIS.................................. 44SYNAREL................................. 43SYNJARDY...............................23SYNJARDY XR.........................23SYNRIBO..................................16TABLOID...................................16TABRECTA...............................17tacrolimus............................31, 44tadalafil ......................................35tadalafil (pah)............................ 52TAFINLAR.................................17TAGRISSO............................... 17take action.................................42TALTZ....................................... 31tamoxifen citrate........................16tamsulosin hcl........................... 35TARGRETIN............................. 17tarina 24 fe................................ 41tarina fe 1/20............................. 41tarina fe 1/20 eq........................ 41TASIGNA.................................. 17tavaborole................................. 14taysofy.......................................41tazarotene................................. 31tazicef..........................................9taztia xt......................................26TDVAX...................................... 45TEGSEDI.................................. 35telmisartan................................ 25temazepam............................... 53temozolomide............................15temsirolimus..............................44TENIVAC.................................. 45tenofovir disoproxil fumarate.....21terazosin hcl..............................35terbinafine hcl............................14terconazole............................... 14TERIPARATIDE (RECOMBINANT)..................... 46testosterone.............................. 38testosterone cypionate..............38testosterone enanthate............. 38TETANUS-DIPHTHERIA TOXOIDS TD............................ 45tetrabenazine............................ 29tetracycline hcl.......................... 10THALOMID............................... 16theophylline er...........................52thiamine hcl...............................33thioridazine hcl.......................... 19thiothixene.................................19

65

THYROGEN..............................48tiadylt er.................................... 26tiagabine hcl..............................11tilia fe.........................................41timolol maleate....................26, 50timolol maleate (once-daily)...... 50timolol maleate ocudose........... 50timolol maleate pf......................50TIVICAY.................................... 20TIVICAY PD.............................. 20tizanidine hcl............................. 53tl-hem 150................................. 32TOBRADEX.............................. 48TOBRADEX ST.........................48tobramycin.......................... 48, 52tobramycin-dexamethasone......48TOBREX................................... 48TODAY SPONGE..................... 35tolcapone.................................. 18tolterodine tartrate.....................35tolterodine tartrate er.................35topiramate................................. 11topiramate er.............................11toremifene citrate...................... 16torsemide.................................. 27TOUJEO MAX SOLOSTAR...... 24TOUJEO SOLOSTAR...............24TOVIAZ..................................... 35TRACLEER...............................52TRADJENTA.............................23tramadol hcl er............................ 6tramadol hcl er (biphasic)............6tramadol hcl ir ............................. 7tramadol-acetaminophen............ 7trandolapril ................................ 25tranylcypromine sulfate............. 12travoprost (bak free)..................50trazodone hcl...................... 12, 13TRECATOR.............................. 15TRELEGY ELLIPTA............52, 53TREMFYA.................................31treprostinil ................................. 52TRESIBA...................................24TRESIBA FLEXTOUCH............24tretinoin............................... 18, 31tri femynor................................. 41triamcinolone acetonide...... 30, 37triamterene................................27triamterene-hctz........................ 27triazolam................................... 22triderm.......................................37trientine hcl................................32tri-estarylla................................ 41

trifluoperazine hcl......................19trifluridine.................................. 49trigels-f forte.............................. 32trihexyphenidyl hcl.................... 18tri-legest fe................................ 41tri-linyah.................................... 41tri-lo-estarylla............................ 41tri-lo-marzia............................... 41tri-lo-mili .................................... 41tri-lo-sprintec............................. 41trimethoprim................................ 9tri-mili ........................................ 41trimipramine maleate................ 13TRINTELLIX..............................13tri-nymyo................................... 41triphrocaps................................ 33tri-previfem................................ 41tri-sprintec................................. 41TRIUMEQ................................. 21tri-vite/fluoride........................... 33trivora (28).................................41tri-vylibra................................... 41tri-vylibra lo................................41trospium chloride.......................35trospium chloride er.................. 35TRULICITY............................... 23TRUMENBA..............................45TUKYSA....................................17tulana........................................ 42TURALIO.................................. 17TUZISTRA XR.......................... 53TWINRIX...................................45tyblume..................................... 41TYBOST....................................20tydemy...................................... 41TYSABRI...................................29TYVASO................................... 52TYVASO REFILL...................... 52TYVASO STARTER..................53ULTIGUARD SAFEPACK SYR/NEEDLE........................... 48ULTOMIRIS.............................. 44unithroid.................................... 42UPTRAVI.................................. 53ursodiol..................................... 33VABOMERE..............................10valacyclovir hcl..........................20valganciclovir hcl.......................19valproate sodium.......................11valproic acid.............................. 11valsartan................................... 25valsartan-hydrochlorothiazide... 27vancomycin hcl........................... 9

vandazole....................................9VAQTA......................................45varenicline tartrate...................... 8VARIVAX.................................. 45vasopressin...............................38VASOSTRICT........................... 38VAXELIS................................... 45v-c forte..................................... 33VCF VAGINAL CONTRACEPTIVE................... 36vcf vaginal contraceptive...........36velivet........................................41VELPHORO.............................. 32VELTASSA............................... 32VEMLIDY.................................. 20VENCLEXTA.............................17VENCLEXTA STARTING PACK........................................ 17venlafaxine hcl.......................... 13venlafaxine hcl er...................... 13VENTAVIS................................ 53verapamil hcl.............................26verapamil hcl er.........................26vestura...................................... 41VICTOZA.................................. 23vienva........................................41VIIBRYD....................................13VIIBRYD STARTER PACK....... 13VIMPAT.....................................11viorele....................................... 41VIRACEPT................................ 21VIREAD.....................................21virt-caps.................................... 33virt-gard.....................................33VISTOGARD.............................48vita s forte................................. 33vitacel........................................33vitamin d (ergocalciferol)...........33vitamin k1..................................33vitamins acd-fluoride................. 33VIVITROL....................................7volnea....................................... 41voriconazole..............................14VORTEX VALVED HOLDING CHAMBER................................ 48VOTRIENT................................17vp-pnv-dha................................ 33vp-vite rx................................... 33vyfemla......................................41vylibra........................................41VYNDAMAX..............................27VYVANSE................................. 29warfarin sodium.........................24

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wera.......................................... 41wescaps.................................... 33westab mini............................... 33westab one................................33WIDE-SEAL DIAPHRAGM 60.. 48WIDE-SEAL DIAPHRAGM 65.. 48WIDE-SEAL DIAPHRAGM 70.. 48WIDE-SEAL DIAPHRAGM 75.. 48WIDE-SEAL DIAPHRAGM 80.. 48WIDE-SEAL DIAPHRAGM 85.. 48WIDE-SEAL DIAPHRAGM 90.. 48WIDE-SEAL DIAPHRAGM 95.. 48WINRHO SDF...........................44wixela inhub.............................. 51wymzya fe................................. 41XALKORI.................................. 17XARELTO................................. 24XARELTO STARTER PACK.....24XELJANZ.................................. 44XELJANZ XR............................ 44XEPI............................................9XGEVA......................................46XIAFLEX................................... 48XIFAXAN.....................................9XIGDUO XR..............................23XIIDRA...................................... 49XOLAIR.....................................44XTAMPZA ER............................. 6XTANDI.....................................15xulane....................................... 41XULTOPHY...............................23XYNTHA................................... 25XYNTHA SOLOFUSE...............25yl folic acid................................ 33yuvafem.................................... 41zafemy...................................... 41zafirlukast..................................52zaleplon.....................................53ZANOSAR.................................15ZELBORAF............................... 17zenatane................................... 31ZENPEP....................................35ZEPATIER................................ 20ZERVIATE................................ 49zidovudine.................................21zileuton er................................. 52ZIOPTAN.................................. 50ziprasidone hcl.......................... 19ZIRGAN.................................... 49ZOKINVY.................................. 48zoledronic acid.......................... 46ZOLINZA...................................16ZOLMITRIPTAN........................15

zolmitriptan................................15zolpidem tartrate....................... 53zolpidem tartrate er................... 53ZOMIG...................................... 15zonisamide................................11ZONTIVITY............................... 24ZORTRESS.............................. 44zovia 1/35 (28).......................... 41zovia 1/35e (28)........................ 41zumandimine.............................41ZYDELIG...................................17ZYKADIA...................................17ZYLET.......................................49

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2022 essential health benefits base formulary

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