doctors healthcare plans, inc. · h4140 _pdg 2 0 19 _c | dhcp formulary _1 9 5 5 7 _v 2019 form...

H4140_PDG2019_C | DHCP FORMULARY_19557_V33

2019

FORMULARY List of Covered DrugsPLEASE READ: THIS DOCUMENT CONTAINS INFORMATION

ABOUT THE DRUGS WE COVER IN THIS PLAN

This formulary was updated on December 1, 2019. For more recent information or other questions, please contact Doctors HealthCare Plans Member Services Department at (786) 460-3427 or (toll-free) at (833) 342-7463 or, for TTY users, dial 711, Monday through Sunday 8:00 a.m. – 8:00p.m. ET, or visit us online at: www.doctorshcp.com.

FORMULARIO Lista de medicamentos cubiertosLEA LO SIGUIENTE: ESTE DOCUMENTO CONTIENE INFORMACIÓN ACERCA DE LOS MEDICAMENTOS QUE CUBRIMOS EN ESTE PLAN

Este formulario se actualizó el 01 de diciembre de 2019. Para obtener información más reciente o si tiene otras preguntas, comuníquese con Doctors HealthCare Plans Departamento de Servicios al Asociado al (786) 460-3427 o al número de teléfono gratuito (833) 342-7463. Los usuarios de TTY deben llamar al 711, lunes a domingo 8:00 a.m. – 8:00 p.m. ET, o visite www.doctorshcp.com

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Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take.

When this drug list (formulary) refers to “we,” “us”, or “our,” it means Doctors HealthCare Plans, Inc. When it refers to “plan” or “our plan,” it means Doctors HealthCare Plans, Inc.

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

You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2019 and from time to time during the year.

What is the Doctors HealthCare Plans, Inc. Formulary?A formulary is a list of covered drugs selected by Doctors HealthCare Plans, Inc. in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Doctors HealthCare Plans will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Doctors HealthCare Plans network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage (EOC).

Can the Formulary (drug list) change?Generally, if you are taking a drug on our 2019 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2019 coverage year except when a new, less expensive generic drug becomes available, when new information about the safety or effectiveness of a drug is released, or the drug is removed from the market. (See bullets below for more information on changes that affect members currently taking the drug.) Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. Below are changes to the drug list that will also affect members currently taking a drug:

• New generic drugs. We may immediately remove a brand name drug on our Drug List if we are replacing it with a newgeneric drug that will appear on the same or lower cost sharing tier and with the same or fewer restrictions. Also, whenadding the new generic drug, we may decide to keep the brand name drug on our Drug List, but immediately move itto a different cost-sharing tier or add new restrictions. If you are currently taking that brand name drug, we may not tellyou in advance before we make that change, but we will later provide you with information about the specific change(s)we have made.

– If we make such a change, you or your prescriber can ask us to make an exception and continue to cover the brandname drug for you. The notice we provide you will also include information on the steps you may take to requestan exception, and you can also find information in the section below entitled “How do I request an exception to theDoctors HealthCare Plans, Inc. Formulary?”


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• Drugs removed from the market. If the Food and Drug Administration deems a drug on our formulary to be unsafe orthe drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formularyand provide notice to members who take the drug.

• Other changes. We may make other changes that affect members currently taking a drug. For instance, we may add ageneric drug that is not new to market to replace a brand name drug currently on the formulary or add new restrictionsto the brand name drug or move it to a different cost-sharing tier. Or we may make changes based on new clinicalguidelines. If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapyrestrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change atleast 30 days before the change becomes effective, or at the time the member requests a refill of the drug, at whichtime the member will receive a 30-day supply of the drug.

The enclosed formulary is current as of December 1, 2019. To get updated information about the drugs covered by Doctors HealthCare Plans please contact us. Our contact information appears on the front and back cover pages. If any other type of approved formulary change (non-maintenance change) is made during the year, we will notify you by sending you a list of these changes, or by sending you an updated formulary.

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

Medical Condition

The formulary begins on page 19. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category Cardiovascular Agents. If you know what your drug is used for, look for the category name in the list that begins on page 19. Then look under the category name for your drug.

Alphabetical Listing

If you are not sure what category to look under, you should look for your drug in the Index that begins on page 155. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list.

What are generic drugs?Doctors HealthCare Plans covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs.


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Are there any restrictions on my coverage?Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:

• Prior Authorization: Doctors HealthCare Plans requires you [or your physician] to get prior authorization for certaindrugs. This means that you will need to get approval from Doctors HealthCare Plans before you fill your prescriptions. Ifyou don’t get approval, the plan may not cover the drug.

• Quantity Limits: For certain drugs, Doctors HealthCare Plans limits the amount of the drug that our plan will cover. Forexample, Doctors HealthCare Plans provides 30 capsules per prescription for omeprazole. This may be in addition to astandard one-month or three-month supply.

• Step Therapy: In some cases, Doctors HealthCare Plans requires you to first try certain drugs to treat your medicalcondition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat yourmedical condition, Doctors HealthCare Plans may not cover Drug B unless you try Drug A first. If Drug A does not workfor you, the plan will then cover Drug B.

You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 19. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted on line documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

You can ask Doctors HealthCare Plans to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, “How do I request an exception to the Doctors HealthCare Plans formulary?” on page 5 for information about how to request an exception.

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

If you learn that Doctors HealthCare Plans does not cover your drug, you have two options:

• You can ask Member Services for a list of similar drugs that are covered by Doctors HealthCare Plans. When you receivethe list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by the plan.

• You can ask Doctors HealthCare Plans to make an exception and cover your drug. See below for information about howto request an exception.


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How do I request an exception to the Doctors HealthCare Plans, Inc. Formulary?You can ask Doctors HealthCare Plans to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.

• You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level.

• You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. Ifapproved this would lower the amount you must pay for your drug.

• You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, DoctorsHealthCare Plans limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us towaive the limit and cover a greater amount.

Generally, Doctors HealthCare Plans will only approve your request for an exception if the alternative drugs included on the plan’s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

You should contact us to ask us for an initial coverage decision for a formulary, or utilization restriction exception. When you request a formulary or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber.

What do I do before I can talk to my doctor about changing my drugs or requesting an exception?As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan.

For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply. If your prescription is written for fewer days, we’ll allow refills to provide up to a maximum 30-day supply of medication. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days.

If you are a resident of a long-term care (LTC) facility and you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug while you pursue a formulary exception.


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Members experiencing a level of care change may access a refill upon admission or discharge to an LTC facility. Members in need of a one-time Transition Fill, or who are prescribed a Non-Formulary drug as a result of a level of care change, can be placed in transition via manual override at point of sale or by contacting Doctors HealthCare Plans for an override. The plan may provide an extension of the Transition Period, on a case-by-case basis, to the extent that a Member’s exception request or appeal has not been processed by the end of the minimum Transition Period and until such time that a transition has been made (either through a switch to a formulary drug or a decision on an exception request).

For more informationFor more detailed information about your Doctors HealthCare Plans prescription drug coverage, please review your Evidence of Coverage (EOC) and other plan materials.

If you have questions about Doctors HealthCare Plans, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800- MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY users should call 1-877-486-2048. Or, visit http://www.medicare.gov.

Doctors HealthCare Plans FormularyThe formulary that begins on the next page provides coverage information about the drugs covered by our plan. If you have trouble finding your drug in the list, turn to the Index that begins on page 155.

The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., LYRICA) and generic drugs are listed in lower-case italics (e.g., gabapentin).

The information in the Requirements/Limits column tells you if Doctors HealthCare Plans has any special requirements for coverage of your drug.


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Cost-Sharing for a one-month supply of a covered Part D prescription drug during the Initial Coverage Stage Miami-Dade County

TIER 1 PREFERRED GENERICS

TIER 2 GENERICS

TIER 3 PREFERRED

BRANDS

TIER 4 NON-PREFERRED

DRUGSTIER 5

SPECIALTYDrMax HMO-POS H4140-001

$0 $0 $0 $35 33%

DrPlus HMO-POS SNP H4140-002

$0 $0 $0

$35 33%

You may pay $0.00-$8.50 per prescription. The amount you pay

depends on your Part D prescription and your low-income subsidy

coverage. Please refer to your LIS Rider for the specific amount you will pay.

DrCare HMO-POS SNP H4140-003

$0 $0 $20 $45 33%

DrExtra HMO-POS SNP H4140-004

$0 $0 $20 $45 33%

Network Pharmacy cost-sharing (30-day supply) or Mail-Order Pharmacy (30-day supply) or Long-Term Care Pharmacy (31-day supply). Coverage during the gap on Tier 1 and 2. Excluded drugs are covered at $0 cost sharing through the year.

Important Note: The amount you pay depends on your Part D prescription and your low-income subsidy coverage. Please refer to your Evidence of Coverage (EOC) for more information about this coverage.


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LegendGeneric drugs are shown in lowercase italic (e.g., gabapentin). Brand-name drugs are shown in capital letters (e.g., LYRICA).

The Index provides an alphabetical list of all of the drugs included in this document. Both brand-name drugs and generic drugs are listed. Find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list.

LEGEND

TIER NAME

1 Preferred generics

2 Generics

3 Preferred brands

4 Non-preferred drugs

5 Specialty


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SYMBOL NAME DESCRIPTION

ED Excluded Drugs This prescription drug is not normally covered in a Medicare Prescription Drug Plan. The amount you pay when you fill a prescription for this drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug.

PA Prior Authorization The process of obtaining approval for certain prescriptions before benefits will be approved. You, your doctor or other network provider will need to request prior authorization before you fill the prescription.

PA Part B vs D Determination This drug may be covered under either your Part D prescription drug benefits or as a Part B drug under your medical benefits, as determined by Medicare.

QL Quality Limits Restricts the frequency, amount or dosage of medication for which you can obtain benefits each time you get a prescription filled (most often set on a monthly basis).

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


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Nota para los asociados actuales: Este Formulario ha cambiado con respecto al año pasado. Revise este documento para asegurarse de que aún contiene los medicamentos que toma.

Cuando esta lista de medicamentos (Formulario) menciona “nosotros”, “nos” o “nuestro”, hace referencia a Doctors HealthCare Plans, Inc. Cuando dice “plan” o “nuestro plan”, hace referencia a Doctors HealthCare Plans, Inc.Este documento incluye una lista de los medicamentos (Formulario) de nuestro plan, la cual está en vigencia desde el 1 de diciembre de 2019. Para obtener un formulario actualizado, comuníquese con nosotros. Nuestra información de contacto, junto con la fecha de la última actualización del Formulario, aparece en las páginas de la portada y la portada posterior.Gemente, debe concurrir a las farmacias de la red para usar el beneficio de medicamentos con receta. Los beneficios, el formulario, la red de farmacias o los copagos/el coseguro pueden cambiar el 1.º de enero de 2019 y periódicamente durante el año.

¿Qué es el Formulario de Doctors HealthCare Plans, Inc.?Un Formulario es una lista de medicamentos cubiertos seleccionados por Doctors HealthCare Plans con la colaboración de un equipo de proveedores de atención médica, que representa los tratamientos con receta que se considera que son parte necesaria de un programa de tratamiento de calidad. Normalmente, Doctors HealthCare Plans cubrirá los medicamentos incluidos en el formulario, siempre que el medicamento sea médicamente necesario, el medicamento con receta se obtenga en una farmacia de la red de Doctors HealthCare Plans y se cumpla con otras normas del plan. Para obtener más información sobre cómo obtener sus medicamentos con receta, consulte la Evidencia de Cobertura (EOC).

¿Puede cambiar el Formulario (lista de medicamentos)?En general, si usted toma un medicamento de nuestro Formulario para 2019 que estaba cubierto al comienzo del año, nosotros no discontinuaremos ni reduciremos la cobertura del medicamento durante el año de cobertura 2019, excepto cuando esté disponible un nuevo medicamento genérico de menor costo, cuando se dé a conocer nueva información acerca de la seguridad o eficacia del medicamento, o el medicamento sea retirado del mercado. (Consulte los puntos a continuación para obtener más información sobre cambios que afectan a los asociados que actualmente toman el medicamento). Otros tipos de cambios en el Formulario, por ejemplo, la eliminación de un medicamento, no afectarán a los asociados que estén actualmente tomando el medicamento. Por el resto del año de cobertura, continuará disponible al mismo costo compartido para aquellos asociados que estén tomándolo. A continuación se incluyencambios en la Lista de medicamentos que también afectarán a los asociados que actualmente toman un medicamento:

Nuevos medicamentos genéricos. Podemos eliminar inmediatamente un medicamento de marca de nuestra Lista demedicamentos si lo reemplazamos con un nuevo medicamento genérico que aparecerá en el mismo nivel de costocompartido o en un nivel de costo compartido más bajo y con las mismas restricciones o menos. Además, cuandoagreguemos el nuevo medicamento genérico, podemos decidir mantener el medicamento de marca en nuestra Lista demedicamentos pero inmediatamente moverlo a un nivel de costo compartido diferente o agregar nuevas restricciones.Si actualmente está tomando ese medicamento de marca, quizás no le informemos con antelación antes de querealicemos el cambio, pero más adelante le proporcionaremos información sobre los cambios específicos que hemosrealizado.

– Si realizamos un cambio, usted o la persona autorizada a dar recetas pueden solicitarnos que hagamos una excepcióny sigamos cubriendo el medicamento de marca para usted. El aviso que le proporcionaremos también incluiráinformación sobre los pasos que puede tomar para solicitar una excepción, y usted también puede encontrarinformación en la sección a continuación titulada “¿Cómo puedo solicitar que se haga una excepción al Formulario deDoctors HealthCare Plans, Inc.?”


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• Medicamentos retirados del mercado. Si la Administración de Drogas y Alimentos considera que un medicamentode nuestro Formulario es inseguro o el fabricante del medicamento lo retira del mercado, eliminaremos de inmediatodicho medicamento de nuestro Formulario y les notificaremos a los asociados que toman el medicamento encuestión.

• Otros cambios. Podemos hacer otros cambios que afectan a los asociados que actualmente toman un medicamento.Por ejemplo, podemos agregar un medicamento genérico que no es nuevo en el mercado para reemplazar unmedicamento de marca que actualmente se encuentre en el Formulario o agregar nuevas restricciones almedicamento de marca o moverlo a un nivel de costo compartido diferente. O bien, podemos hacer cambios enfunción de las nuevas pautas clínicas. Si retiramos medicamentos de nuestro Formulario, [o] agregamos autorizacionesprevias, restricciones de límite de cantidad o de tratamiento escalonado en un medicamento o si pasamos unmedicamento a un nivel superior de costo compartido, debemos notificarles a los asociados afectados por el cambio almenos 30 días antes de que entre en vigencia dicho cambio, o cuando el asociado solicite un resurtido delmedicamento, momento en el cual el asociado recibirá un suministro del medicamento para 30 días.

El Formulario adjunto está vigente a partir del 1 de diciembre de 2019. Para recibir información actualizada sobre los medicamentos cubiertos por Doctors HealthCare Plans, comuníquese con nosotros. Nuestra información de contacto aparece en las páginas de la portada y la portada posterior. Si se realiza cualquier otro tipo de cambio en el formulario aprobado (que no sea de mantenimiento) durante el año, lo notificaremos enviándole una lista de dichos cambios o un formulario actualizado.

¿Cómo utilizo el Formulario?Hay dos formas para encontrar su medicamento dentro del Formulario:

Afección médica

El Formulario comienza en la página 19. Los medicamentos de este Formulario están agrupados en categorías según el tipo de afección médica para cuyo tratamiento se los emplea. Por ejemplo, los medicamentos utilizados para tratar una afección cardíaca se enumeran dentro de la categoría Cardiovascular Agents. Si sabe para qué se utiliza su medicamento, busque el nombre de la categoría en la lista que empieza en la página 19. Luego, busque su medicamento debajo del nombre de la categoría.

Listado alfabético

Si no está seguro de qué categoría consultar, debe buscar su medicamento en el Índice que comienza en la página 155. El Índice proporciona una lista alfabética de todos los medicamentos incluidos en este documento. En el Índice, están tanto los medicamentos de marca como los genéricos. Busque en el Índice y encuentre su medicamento. Junto a su medicamento, verá el número de página donde puede encontrar información acerca de la cobertura. Vaya a la página que figura en el Índice y encuentre el nombre de su medicamento en la primera columna de la lista.


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¿Qué son los medicamentos genéricos?Doctors HealthCare Plans cubre tanto los medicamentos de marca como los genéricos. Un medicamento genérico está aprobado por la Administración de Drogas y Alimentos (FDA) dado que se considera que tiene el mismo ingrediente activo que el medicamento de marca. Normalmente, los medicamentos genéricos cuestan menos que los de marca.

¿Hay alguna restricción en mi cobertura?Algunos medicamentos cubiertos pueden tener requisitos o límites adicionales de cobertura. Estos requisitos y límites pueden incluir:

• Autorización previa: Doctors HealthCare Plans exige que usted [o su médico] obtenga una autorización previa paradeterminados medicamentos. Esto significa que necesitará contar con la aprobación de Doctors HealthCare Plansantes de obtener sus medicamentos con receta. Si no consigue la autorización, es posible que el plan no cubra elmedicamento.

• Límites de cantidad: Para ciertos medicamentos, Doctors HealthCare Plans limita la cantidad del medicamento quecubrirá. Por ejemplo, Doctors HealthCare Plans proporciona 30 cápsulas por receta para omeprazole. Esto puede sercomplementario a un suministro estándar para un mes o tres meses.

• Tratamiento escalonado: En algunos casos, Doctors HealthCare Plans requiere que usted primero pruebe ciertosmedicamentos para tratar su afección médica antes de que cubramos otro medicamento para esa enfermedad. Porejemplo, si el medicamento A y el medicamento B tratan su afección médica, es posible que Doctors HealthCare Plansno cubra el medicamento B a menos que usted pruebe primero el medicamento A. Si el medicamento A no funcionapara usted, entonces el plan cubrirá el medicamento B.

Para averiguar si su medicamento tiene requisitos o límites adicionales, consulte el Formulario que empieza en la página 19. También puede obtener más información sobre las restricciones que se aplican a medicamentos cubiertos específicosen nuestro sitio web. Hemos publicado documentos en línea que explica(n) nuestra(s) restricciones de autorización previay tratamiento escalonado. También puede pedirnos que le enviemos una copia. Nuestra información de contacto, juntocon la fecha de la última actualización del Formulario, aparece en las páginas de la portada y la portada posterior.

Puede pedirle a Doctors HealthCare Plans que haga una excepción a estas restricciones o límites, o puede solicitarle una lista de otros medicamentos similares que puedan tratar su afección médica. Consulte la sección “¿Cómo solicito una excepción al Formulario de Doctors HealthCare Plans?” en la página 13 para obtener información acerca de cómo solicitar una excepción.


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¿Qué pasa si mi medicamento no está en el Formulario?Si el medicamento que toma no está incluido en este Formulario (lista de medicamentos cubiertos), primero debe comunicarse con el Departamento de Servicios al Asociado y preguntar si su medicamento está cubierto.

Si resulta que Doctors HealthCare Plans no cubre el medicamento que toma, tiene dos alternativas:

• Puede pedir al Departamento de Servicios al Asociado una lista de medicamentos similares que estén cubiertospor Doctors HealthCare Plans. Cuando reciba la lista, muéstresela a su médico y pídale que le recete unmedicamento similar que esté cubierto por el plan.

• Puede solicitar que Doctors HealthCare Plans haga una excepción y cubra su medicamento. Consulte a continuaciónpara obtener información sobre cómo solicitar una excepción.

¿Cómo puedo solicitar que se haga una excepción al Formulario de Doctors HealthCare Plans, Inc.?Puede solicitarle a Doctors HealthCare Plans que haga una excepción a nuestras normas de cobertura. Hay varios tipos de excepciones que puede solicitarnos.

• Puede pedirnos que cubramos un medicamento, incluso si no está en nuestro Formulario. Si se aprueba, estemedicamento estará cubierto a un nivel de costo compartido predeterminado, y usted no podrá pedirnos que lebrindemos el medicamento a un nivel de costo compartido menor.

• Puede pedirnos que cubramos un medicamento del Formulario a un nivel de costo compartido menor si estemedicamento no está incluido en el nivel de medicamentos especializados. Si se aprueba, esto reduciría el monto queusted debe pagar por su medicamento.

• Puede pedirnos que no apliquemos restricciones o límites de cobertura para su medicamento. Por ejemplo,para ciertos medicamentos, Doctors HealthCare Plans limita la cantidad del medicamento que cubriremos. Si sumedicamento tiene un límite de cantidad, puede pedirnos que hagamos una excepción al límite y cubramos unacantidad mayor.

Por lo general, Doctors HealthCare Plans solo aprobará su pedido de excepción si los medicamentos alternativos incluidos en el Formulario del plan, [el medicamento de menor costo compartido] o las restricciones de uso adicionales no fueran tan efectivos para tratar su afección o pudieran causarle efectos médicos adversos.

Debe comunicarse con nosotros para solicitarnos una decisión inicial de cobertura para una excepción al Formulario, o a la restricción de uso. Cuando solicita una excepción al Formulario, o a la restricción de uso, debe presentar unadeclaración de su médico o de la persona autorizada a dar recetas que respalde su solicitud. Por lo general,debemos tomar una decisión dentro de las 72 horas a partir de la fecha de haber recibido la declaración que respalda susolicitud por parte de la persona autorizada a dar recetas.

Puede solicitar una excepción acelerada (rápida) si usted o su médico consideran que esperar 72 horas para la toma de la decisión podría perjudicar gravemente su salud. Si se le concede el trámite rápido de la excepción, debemos comunicarle nuestra decisión a más tardar dentro de las 24 horas después de haber recibido la declaración de respaldo de su médico o de otra persona autorizada a dar recetas.


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¿Qué debo hacer antes de hablar con mi médico sobre el cambio de los medicamentos que tomo o la solicitud de una excepción?Como asociado nuevo o permanente de nuestro plan, es posible que esté tomando medicamentos que no están incluidos en el Formulario. También es posible que esté tomando un medicamento incluido en el Formulario pero su capacidad de conseguirlo sea limitada. Por ejemplo, puede necesitar nuestra autorización previa antes de poder obtener su medicamento con receta. Debe consultar con su médico para decidir si debe cambiar su medicamento por uno apropiado que nosotros cubramos o solicitar una excepción al formulario para que le cubramos el medicamento que toma. Mientras evalúa con su médico el procedimiento adecuado para seguir en su caso, podemos cubrir su medicamento, en ciertos casos, durante los primeros 90 días en que usted sea asociado de nuestro plan.

Para cada uno de los medicamentos que no están incluidos en el Formulario o si su capacidad para conseguir los medicamentos es limitada, cubriremos un suministro temporal para 30 días. Si su receta está indicada para menos días, permitiremos que realice resurtidos por un máximo de hasta 30 días del medicamento. Después del primer suministro para 30 días, no seguiremos pagando estos medicamentos, incluso si ha sido asociado del plan durante menos de 90 dias.

Si es residente de un centro de atención a largo plazo y necesita un medicamento que no está en el Formulario o si su capacidad para conseguir los medicamentos es limitada, pero ya pasaron los primeros 90 días de membresía en nuestro plan, cubriremos un suministro de emergencia del medicamento para 31 días mientras solicita la excepción al formulario.

Los asociados que están experimentando un cambio en el nivel de atención pueden acceder a un reabastecimiento luego de la admisión o la dada de alta de un centro de atención a largo plazo. Los asociados con necesidad de un reabastecimiento de transición única o aquel que le han formulado un medicamento que no es de receta como resultado de un cambio en el nivel de atención, pueden ser puestos en transición por medio de una anulación manual en punto de venta o comunicándose con Doctors HealthCare Plans. El plan puede proporcionar una extensión al período de transición, según él caso, en la medida en que la solicitud de excepción o apelación de unasociado no haya sido procesada al final del período mínimo de transición y hasta el momento en que la transición se haya realizado (ya sea mediante el cambio a un medicamento recetado o a la decisión de un pedido de excepción).


14

Para obtener más informaciónPara obtener información más detallada sobre la cobertura para medicamentos con receta de Doctors HealthCare Plans, consulte la Evidencia de cobertura (EOC) y otra documentación del plan.

Si tiene alguna pregunta sobre Doctors HealthCare Plans, comuníquese con nosotros. Nuestra información de contacto, junto con la fecha de la última actualización del Formulario, aparece en las páginas de la portada y la portada posterior.

Si tiene preguntas generales sobre su cobertura para medicamentos con receta de Medicare, llame a Medicare al 1-800-MEDICARE (1-800-633-4227), las 24 horas, los 7 días de la semana. Los usuarios de TTY deben llamar al 1-877-486-2048. O visite http://www.medicare.gov.

Formulario de Doctors HealthCare PlansEl formulario a continuación proporciona información acerca de la cobertura de los medicamentos cubiertos por Doctors HealthCare Plans. Si tiene alguna dificultad para encontrar el medicamento que toma en la lista, consulte el Índice que comienza en la página 155.

La primera columna de la tabla menciona el nombre del medicamento. Los medicamentos de marca están en letra mayúscula (por ejemplo, LYRICA), y los medicamentos genéricos están en letra minúscula y cursiva (por ejemplo, gabapentin).

La información incluida en la columna de Requisitos/límites indica si Doctors HealthCare Plans tiene algún requisito especial para la cobertura del medicamento.


15

Distribución de costos por un suministro de un mes de un medicamento recetado y cubierto de la Parte D durante la Etapa de Cobertura Inicial Condado de Miami-Dade

NIVEL 1 MEDICAMENTOS

GENÉRICOS PREFERIDOS


GENÉRICOS


DE MARCA PREFERIDOS

NIVEL 4 MEDICAMENTOS NO PREFERIDOS

NIVEL 5 MEDICAMENTOS ESPECIALIZADOS

DrMax HMO-POS H4140-001

$0 $0 $0 $35 33%

DrPlus HMO-POS SNP H4140-002

$0 $0 $0

$35 33%

Usted puede pagar $0.00-$8.50 por receta. El monto que paga se determina por la receta de la Parte D cubierta y su

cobertura de subsidio por bajos ingresos. Consulte su LIS Rider para conocer el

monto específico que paga.DrCare HMO-POS SNP H4140-003

$0 $0 $20 $45 33%

DrExtra HMO-POS SNP H4140-004

$0 $0 $20 $45 33%

Farmacia de la red con distribución de costos (suministro para 30 días) o Farmacia de venta por correo (suministro para 30 días) o Farmacia de atención a largo plazo (suministro para 31 días). Cobertura durante el período sin cobertura en el Nivel 1 y 2. Los medicamentos excluidos tienen cobertura con una distribución de costos de $0 durante todo el año.

Nota importante: El monto que paga se determina por la receta de la Parte D cubierta y su cobertura de subsidio por bajos ingresos. Para obtener información más detallada acerca de la cobertura para medicamentos, lea su Evidencia de Cobertura (EOC).


16

LeyendaLos medicamentos genéricos figuran en letra minúscula y cursiva (por ej., gabapentin). Los medicamentos de marca figuran en letra mayúscula (por ej., LYRICA).

El Índice brinda una lista alfabética de todos los medicamentos incluidos en este documento. Tanto los medicamentos de marca como los medicamentos genéricos se enumeran en el Índice. Encuentre su medicamento. Al lado de su medicamento verá el número de página en la que puede encontrar información de cobertura. Vaya a la página que se enumera en el Índice y encuentre el nombre de su medicamento en la primera columna de la lista.

LEYENDA

NIVEL NOMBRE

1 Medicamentos genéricos preferidos

2 Medicamentos genéricos

3 Medicamentos de marca preferidos

4 Medicamentos no preferidos

5 Medicamentos especializados


17

SÍMBOLO NOMBRE DESCRIPCIÓN

ED Medicamento Excluido Este medicamento con receta, generalmente, no está cubierto en un plan de medicamentos con receta de Medicare. El monto que paga cuando obtiene uno de estos medicamentos con receta no se tiene en cuenta en sus costos totales de medicamentos (es decir, el monto que usted paga no lo ayuda a calificar para la cobertura en situaciones catastróficas). Además, si recibe ayuda adicional para pagar sus medicamentos con receta, no recibirá ninguna ayuda adicional para pagar este medicamento.

PA Autorización previa El proceso de obtener la aprobación para determinadas recetas antes de aprobar los beneficios. Usted, su médico u otro proveedor de la red necesitarán solicitar autorización previa antes de abastecer la receta.

PA Parte B vs D Determinación Este medicamento puede estar cubierto por los beneficios para los medicamentos recetados de la Parte D o como un medicamento de la Parte B bajo sus beneficios médicos, según lo determine Medicare.

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

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


18

Doctors HealthCare Plans, Inc. (List of Covered Drugs/Lista demedicamentos cubiertos)

DRUG NAMENOMBRE DELMEDICAMENTO

DRUG TIERNIVEL DEMEDICAMENTO

REQUIREMENTS/LIMITSREQUISITOS/ LIMITES

Analgesics

Nonsteroidal Anti-inflammatory Drugscelecoxib (50 mg capsule, 100mg capsule, 400 mg capsule)

2 QL (60 PER 30 DAYS)

celecoxib 200 mg capsule 2 QL (60 PER 30 DAYS)

diclofenac epolamine 2 PA

diclofenac potassium 1

diclofenac sodium (dr 25 mg tab,dr 50 mg tab, dr 75 mg tab, ec25 mg tab, ec 50 mg tab, ec 75mg tab)

1

diclofenac sodium er 1

diclofenac sodium-misoprostol 4

diflunisal 2

ec-naproxen 1

etodolac (200 mg capsule, 300mg capsule, 400 mg tablet, 500mg tablet)

2

etodolac er 4

FLECTOR 4 PA, QL (60 PER 30 DAYS)

flurbiprofen 2

ibu 1

ibuprofen (100 mg/5 ml susp,400 mg tablet, 600 mg tablet,800 mg tablet)

1

indomethacin (25 mg capsule,50 mg capsule)

2 PA

indomethacin er 4 PA

ketoprofen er 200 mg capsule 4

You can find information on what the symbols and abbreviations on this table mean by going to page numbers 8 and 9.Puede encontrar información sobre lo que significan los símbolos y las abreviaturas de esta tabla en las páginas 17 y 18.

19





ketoprofen (25 mg capsule, 75mg capsule)

2

ketorolac tromethamine (15mg/ml vial, 30 mg/ml vial, 30mg/ml carpuject, 60 mg/2 mlcarpuject)

2

ketorolac 10 mg tablet 1 PA, QL (20 PER 30 OVER TIME)

meclofenamate sodium 4

mefenamic acid 4

meloxicam (7.5 mg tablet, 15 mgtablet)

1

nabumetone 2

naproxen 125 mg/5 ml suspen 2

naproxen (250 mg tablet, dr 375mg tablet, 375 mg tablet, 500 mgkit, 500 mg tablet, dr 500 mgtablet)

1

naproxen sodium 2

naproxen sodium ds 2

oxaprozin 2

piroxicam 2

salsalate 1

sulindac 1

tolmetin sodium (200 mg tab,400 mg cap)

2

tolmetin sodium 600 mg tab 4

Opioid Analgesics, Long-actingEMBEDA (ER 20-0.8 MGCAPSULE, ER 30-1.2 MGCAPSULE, ER 50-2 MGCAPSULE, ER 60-2.4 MGCAPSULE)

3


20





EMBEDA (ER 80-3.2 MGCAPSULE, ER 100-4 MGCAPSULE)

5

fentanyl (12 mcg/hr patch, 25mcg/hr patch, 37.5 mcg/hr patch,50 mcg/hr patch, 100 mcg/hrpatch)

2

fentanyl (62.5 mcg/hr patch, 87.5mcg/hr patch)

5

fentanyl 75 mcg/hr patch 4

hydromorphone er (er 16 mgtab, er 32 mg tab)

5

hydromorphone er (er 8 mg tab,er 12 mg tab)

4

levorphanol tartrate 5

methadone hcl (hcl 5 mg tablet,5 mg/5 ml solution, 10 mg/5 mlsolution, hcl 10 mg tablet, hcl 10mg/ml syringe)

2

methadone hcl (10 mg/ml vial,200 mg/20 ml vl)

4

morphine sulfate er (er 10 mgcap, er 20 mg cap, er 45 mgcap, er 50 mg cap, er 75 mgcap, er 80 mg cap, er 90 mgcap, er 120 mg cap)

4

morphine sulfate er (er 30 mgcap, er 40 mg cap, er 60 mgcap)


morphine sulfate er 100 mg cap 5

morphine sulfate er (er 15 mgtablet, er 30 mg tablet, er 60 mgtablet, er 100 mg tablet, er 200mg tablet)

2

oxymorphone hcl er 4


21





tramadol hcl er (er 100 mgtablet, er 200 mg tablet, er 300mg tablet, hcl er 100 mg tablet,hcl er 200 mg tablet, hcl er 300mg tablet)

2

Opioid Analgesics, Short-actingABSTRAL 5 PA

acetaminophen-codeine(acetamin-codein 300-30mg/12.5, acetaminop-codeine120-12 mg/5, acetaminophen-cod #2 tablet, acetaminophen-cod #3 tablet, acetaminophen-cod #4 tablet)

1

asa-butalb-caffeine-codeine 2 PA

ascomp with codeine 4 PA

butalb-acetaminoph-caff-codeine50-300-30 cap (generic fioricetwith codeine)

2 PA

butalbital compound-codeine 2 PA

butorphanol 10 mg/ml spray 2

codeine sulfate 2

DURAMORPH 4

endocet (5-325 tablet, 7.5-325mg tablet, 10-325 mg tablet)

2

fentanyl citrate (cit 1,200 mcg,citrate 600 mcg, citrate 800 mcg)

5 PA

fentanyl citrate otfc 200 mcg 4 PA

fentanyl citrate otfc 400 mcg 4 PA, QL (120 PER 30 DAYS)


22





hydrocodone-acetaminophen(hydrocodone-acetamin 2.5-108/5, hydrocodone-acetamin 5-217/10, hydrocodone-acetamin5-300 mg, hydrocodone-acetamin 7.5-300, hydrocodone-acetamin 10-300 mg,hydrocodone-acetamn 7.5-325/15)

2

hydrocodone-acetaminophen (5-325 mg, 7.5-325, 10-325 mg)

1

hydrocodone-acetaminophen(7.5-325 mg tablet, 5-325 mgtablet, 10- 325 mg tablet)

1

hydrocodone-acetaminophen(7.5-325 mg/15 ml solution, 2.5-108 mg/5 ml solution, 5-217mg/10 ml solution, 2.5-325 mgtablet, 7.5-300 mg tablet, 10-300mg tablet)

2

hydrocodone-acetaminophen(7.5-325 mg/15 ml solution, 2.5-108 mg/5 ml solution, 5-217mg/10 ml solution, 2.5-325 mgtablet, 7.5-300 mg tablet, 10-300mg tablet)

2

hydrocodone-acetaminophen 5-300 mg tablet

2

hydrocodone-ibuprofen (5-200mg tablet, 7.5-200 mg tablet, 10-200 mg tablet)

2

hydromorphone 8 mg tablet 2 QL (180 PER 30 DAYS)


23





hydromorphone hcl (1 mg/mlvial, 1 mg/ml solution, 2 mg/mlcarpujct, 2 mg/ml isecure, 2mg/ml vial, 2 mg tablet, hcl 2mg/ml amp, 4 mg/ml vial, 4 mgtablet, 5 mg/5 ml soln, 10 mg/mlvial, hcl 10 mg/ml vl, hcl 10mg/ml amp, 50 mg/5 ml vial, 500mg/50 ml via, 500 mg/50 ml vl)

2

lorcet 2

lorcet hd 2

lorcet plus 2

morphine sulfate (5 mg/mlsyringe, sulf 10 mg/5 ml soln,sulf 20 mg/5 ml soln, sulf 100mg/5 ml conc, sulfate ir 15 mgtab, sulfate ir 30 mg tab)

2

morphine sulfate (2 mg/mlcarpuject, 2 mg/ml syringe, 2mg/ml isecure syr, 4 mg/mlcarpuject, 4 mg/ml syringe, 4mg/ml isecure syr, 8 mg/mlcarpuject, 8 mg/ml isecuresyrng, 8 mg/ml syringe, 10mg/ml syringe, 10 mg/ml isecuresyrg, 10 mg/ml carpuject)

4

nalbuphine hcl (10 mg/ml ampul,20 mg/ml ampul, 100 mg/10 mlvial, 200 mg/10 ml vial)

4

naloxone 0.4 mg/ml carpuject 2

oxycodone hcl (5 mg capsule, 10mg tablet, 20 mg tablet)


oxycodone hcl (oxycodon 10mg/0.5 ml oral syr, oxycodonehcl 100 mg/5 ml conc)

4

oxycodone hcl (5 mg/5 ml soln, 5mg tablet, 15 mg tablet, 30 mgtablet)

2


24





oxycodone hcl-ibuprofen 2

oxycodone-acetaminophen(oxycodon-acetaminophen 2.5-325, oxycodon-acetaminophen7.5-325, oxycodone-acetaminophen 5-325,oxycodone-acetaminophen 10-325)

2

oxycodone-acetaminophen (2.5-325 mg tablet, 7.5-325 mgtablet, 5-325 mg tablet, 10-325mg tablet)

2

oxycodone-acetaminophen 5-325 mg/5 ml solution

2 QL (1200 PER 20 DAYS)

oxycodone-aspirin 4.8355-325mg tablet

2

oxymorphone hcl 4

tramadol hcl 1

tramadol hcl-acetaminophen 2

vicodin 2

vicodin es 2

vicodin hp 2

Anesthetics

Local Anestheticsanodyne lpt 2 QL (30 PER 30 DAYS)

dermacinrx empricaine 2 QL (30 PER 30 DAYS)

leva set 2 QL (30 PER 30 DAYS)

lido-prilo caine pack 2 QL (30 PER 30 DAYS)

lidocaine 5% patch 4 PA

lidocaine 5% ointment 4 PA, QL (120 PER 30 DAYS)


25





lidocaine hcl (0.5% vial, 2% 40mg/2 ml vl, 2% ampul, 2% 40mg/2 ml, 2% vial, 2% 100 mg/5ml)

2

lidocaine hcl (jel urojet ac, jelly,jelly uro-jet)


lidocaine hcl 4% solution 2 QL (50 PER 30 DAYS)

lidocaine hcl viscous 1

lidocaine-prilocaine 2 QL (30 PER 30 DAYS)

lidopril 2 QL (30 PER 30 DAYS)

lidopril xr 2 QL (30 PER 30 DAYS)

liprozonepak 2 QL (30 PER 30 DAYS)

livixil pak 2 QL (30 PER 30 DAYS)

lp lite pak 2 QL (30 PER 30 DAYS)

medolor pak 2 QL (30 PER 30 DAYS)

prilolid 2 QL (30 PER 30 DAYS)

prilovix 2 QL (30 PER 30 DAYS)

prilovix lite plus 2 QL (30 PER 30 DAYS)

Anti-Addiction/Substance Abuse Treatment Agents

Alcohol Deterrents/Anti-cravingacamprosate calcium 2

disulfiram 2

VIVITROL 5 PA

Opioid Dependence Treatmentsbuprenorphine hcl (2 mg tablet,8 mg tablet)

2

buprenorphine hcl (0.3 mg/mlvial, 0.3 mg/ml crpjct)

4


26





bupreno-nalox 2-0.5 mg sl film 2 QL (360 PER 30 DAYS)

buprenor-nalox 12-3 mg sl film 2 QL (60 PER 30 DAYS)

buprenorp-nalox 4-1 mg sl film 2 QL (180 PER 30 DAYS)

buprenorp-nalox 8-2 mg sl film 2 QL (90 PER 30 DAYS)

buprenorphin-naloxon 8-2 mg sl 2 QL (90 PER 30 DAYS)

buprenorphn-naloxn 2-0.5 mg sl 2 QL (360 PER 30 DAYS)

butorphanol tartrate (1 mg/mlvial, 2 mg/ml vial, 4 mg/2 ml vial)

4

naltrexone hcl 2

Opioid Reversal Agentsnaloxone hcl (0.4 mg/ml vial, 2mg/2 ml syringe, 4 mg/10 mlvial)

2

NARCAN 3

Smoking Cessation Agentsbupropion hcl sr 150 mg tablet 2 QL (60 PER 30 DAYS)

CHANTIX (0.5 MG TABLET, 1MG CONT MONTH BOX, 1 MGTABLET, STARTING MONTHBOX)

4 QL (504 PER 365 OVER TIME)

NICOTROL 4 QL (2688 PER 365 OVER TIME)

NICOTROL NS 4 QL (360 PER 365 OVER TIME)

Antibacerials

Antibacterials, Otherclindamycin hcl 300 mg capsule 2


27





Antibacterials

Aminoglycosidesamikacin sulf 500 mg/2 ml vial 2

ARIKAYCE 5 PA

gentak 1

gentamicin sulfate (0.3% drop, 3mg/ml drop)

1

gentamicin sulfate (0.1%ointment, 0.1% cream, 10 mg/mlvial, 40 mg/ml vial, 80 mg/2 mlvial, 800 mg/20 ml vial)

2

gentamicin sulfate in ns (iso 100mg/100 ml, isoton 60 mg/50 ml,isoton 80 mg/100 ml, 80 mg/ns50 ml pb, isoton 80 mg/50 ml, 80mg/ns 100 ml pb, 100 mg/ns 100ml)

2

neomycin sulfate 2

neomycin-polymyxin b (40 mg/mlamp, 40 mg/ml vl)

2

paromomycin sulfate 2

streptomycin sulfate 4

tobramycin 0.3% eye drop 1

tobramycin sulfate (1.2 gm vial,1.2 gram/30 ml vial, 10 mg/mlvial, 40 mg/ml vial, 80 mg/2 mlvial, 1,200 mg/30 ml vial)

2

TOBREX 0.3% EYE OINTMENT 4

Antibacterials, Otherbaciim 2

bacitracin (500 unit/gm ophth,50,000 unit vial)

2


28





BACTROBAN NASAL 4

chloramphenicol sod succinate 4

CLEOCIN 100 MG VAGINALOVULE

4

clindamycin hcl (75 mg capsule,150 mg capsule)

2

clindamycin palmitate hcl 2

clindamycin pediatric 2

clindamycin phosphate 1% foam 4

clindamycin phosphate (ph 1%solution, ph 1% gel, 2% vaginalcream, ph 9 g/60 ml vial, ph 300mg/2 ml vl, ph 600 mg/4 ml vl,phos 1% pledget, phosp 1%lotion, phosphate 1% gel, 300mg/2 ml addvan, 600 mg/4 mladdvan, ph 900 mg/6 ml vl, 900mg/6 ml addvan)

2

clindamycin phosphate-d5w 2

colistimethate 4

CORTISPORIN (CREAM,OINTMENT)

4

CUBICIN 5

CUBICIN RF 5

DALVANCE 5

daptomycin 5

lincomycin hcl 2

linezolid 100 mg/5 ml susp 4 PA, QL (1800 PER 30 DAYS)

linezolid 600 mg tablet 5 PA, QL (56 PER 28 DAYS)

linezolid-d5w 4

mafenide acetate 2


29





methenamine hippurate 2

metronidazole (0.75% cream,top 1% gel pump, topical 0.75%gl, 0.75% lotion, topical 1% gel,vaginal 0.75% gl, 250 mg tablet,375 mg capsule, 500 mg/100 ml)

2

metronidazole 500 mg tablet 1

MONUROL 4

mupirocin (cream, ointment) 2

neomycin-bacitracin-poly-hc 2

neomycin-poly-hc eye drops 2

nitrofurantoin mcr 100 mg cap 1 QL (360 PER 365 OVER TIME)



nitrofurantoin 25 mg/5 ml susp 4 QL (7200 PER 365 OVER TIME)

nitrofurantoin mono-macro 1 QL (180 PER 365 OVER TIME)

ORBACTIV 5

polymyxin b sulfate 2

silver sulfadiazine 3

SIVEXTRO (200 MG VIAL, 200MG TABLET)


SSD 3

SULFAMYLON 8.5% CREAM 4

SYNERCID 5

tigecycline 5

trimethoprim 1

TYGACIL 5

vancomycin hcl 125 mg capsule 4 PA

vancomycin hcl (250 mg/5 mlsoln, hcl 250 mg capsule)

5 PA


30





vancomycin hcl (1 gm vial, 1 gmadd-van vial, hcl 10 gm vial, hcl100 gm smartpak, hcl 250 mgvial, 500 mg a-v vial, 500 mgvial, hcl 750 mg vial)

2

VANDAZOLE 3

XIFAXAN 5 PA

Beta-lactam, CephalosporinsAVYCAZ 5

cefaclor (125 mg/5 ml susp, 250mg/5 ml susp, 250 mg capsule,375 mg/5 ml suspen)

1

cefaclor er 1

cefadroxil (1 gm tablet, 250 mg/5ml susp, 500 mg/5 ml susp, 500mg capsule)

2

cefazolin sodium (1 gm add-vanvial, 1 gm vial, 10 gm vial, 20 gmbulk vial, sod 100 gm bulk bag,sod 300 gm bulk bag, 500 mgvial)

2

cefdinir (125 mg/5 ml susp, 250mg/5 ml susp, 300 mg capsule)

2

cefepime hcl (1 gm vial, 2 gramvial)

2

cefixime 400 mg capsule 1

cefixime (100 mg/5 ml susp, 200mg/5 ml susp)

4

cefotaxime sodium (1 gm vial, 2gm vial, 500 mg vial)

2

cefotetan (1 gm vial, 2 gm vial) 2

cefoxitin 2

cefpodoxime proxetil (50 mg/5ml susp, 100 mg tablet, 100mg/5 ml susp, 200 mg tablet)

2


31





cefprozil (125 mg/5 ml susp, 250mg/5 ml susp, 250 mg tablet,500 mg tablet)

2

ceftazidime (1 gm vial, 2 gm vial,6 gm vial)

2

ceftriaxone (1 gm add-vant vial,1 gm vial, 2 gm add vial, 2 gmvial, 10 gm vial, 100 gram bulkbag, 250 mg vial, 500 mg vial)

2

cefuroxime 2

cefuroxime sodium 2

cephalexin (250 mg capsule,500 mg capsule, 750 mgcapsule)

1

cephalexin (125 mg/5 ml susp,250 mg tablet, 250 mg/5 mlsusp, 500 mg tablet)

2

SUPRAX (100 MG TABLETCHEWABLE, 200 MG TABLETCHEWABLE, 400 MGCAPSULE, 500 MG/5 MLSUSPENSION)

3

tazicef (1 gram vial, 1 gm add-vantage vial, 2 gm add-vantagevial, 2 gram vial, 6 gram vial)

3

TEFLARO 5

Beta-lactam, OtherAZACTAM-ISO-OSMOTICDEXTROSE

4

aztreonam 1 gm vial 4

ertapenem 4

imipenem-cilastatin sodium 4

INVANZ 1 GM VIAL 4


32





meropenem 2

Beta-lactam, Penicillinsamoxicillin (125 mg tab chew,125 mg/5 ml susp, 200 mg/5 mlsusp, 250 mg capsule, 250 mgtab chew, 250 mg/5 ml susp,400 mg/5 ml susp, 500 mgtablet, 500 mg capsule, 875 mgtablet)

1

amoxicillin-clavulanate pot er 2

amoxicillin-clavulanate potass(200-28.5 mg tab chew, 200-28.5 mg/5 ml sus, 250-62.5 mg/5ml sus, 250-125 mg tablet, 400-57 mg tab chew, 500-125 mgtablet, 600-42.9 mg/5 ml sus,875-125 mg tablet)

2

ampicillin sodium (1 gm add-vantage vl, 1 gm vial, 10 gm vial,10 gm bottle, 125 mg vial)

2

ampicillin trihydrate (250 mgcapsule, 500 mg capsule)

1

ampicillin-sulbactam (ampicillin-sulb 1.5 g add vial, ampicillin-sulb 3 gm add vial, ampicillin-sulbactam 1.5 gm vl, ampicillin-sulbactam 3 gm vial, ampicillin-sulbactam 15 gm vl)

2

AUGMENTIN 125-31.25 MG/5ML

4

BICILLIN C-R 4

BICILLIN L-A 4

dicloxacillin sodium 1

nafcillin sodium (1 gm vial, 2 gmvial, 2 gm add-vant vial, 10 gmbulk vial)

4


33





oxacillin 10 gm vial 5

oxacillin sodium (1 gm vial, 2 gmvial)

4

penicillin g potassium 2

penicillin g sodium 2

penicillin gk-iso-osm dextrose(pen g 2 million unit/50 ml, pen g3 million unit/50 ml)

4

penicillin v potassium (125 mg/5ml soln, 250 mg tablet, 250 mg/5ml soln, 500 mg tablet)

1

piperacillin-tazobactam(piperacil-tazo 2.25 gm add vl,piperacil-tazo 3.375 gm add vl,piperacil-tazo 4.5 gm add vial,piperacil-tazobact 2.25 gm vl,piperacil-tazobact 3.375 gm vl,piperacil-tazobact 4.5 gm vial,piperacil-tazobact 13.5 gm vl,piperacil-tazobact 40.5 gram)

2

MacrolidesAZASITE 4

azithromycin (1 gm pwd packet,100 mg/5 ml susp, 200 mg/5 mlsusp, i.v. 500 mg vial)

2

azithromycin (250 mg tablet, 500mg tablet, 600 mg tablet)

1

clarithromycin (125 mg/5 ml sus,250 mg tablet, 250 mg/5 ml sus,500 mg tablet)

2

clarithromycin er 2

DIFICID 5

ery 2

ERY-TAB 2


34





ERYPED 200 4

ERYPED 400 5

ERYTHROCIN LACTOBIONATE(LACT 500 MG VIAL, 500 MGADDVAN VIAL)

4

ERYTHROCIN STEARATE 2

erythromycin (0.5% eyeointment, dr 250 mg tablet, dr333 mg tablet, dr 500 mg tablet)

1

erythromycin (2% gel, 2%solution, 250 mg filmtab, dr 250mg cap, 500 mg filmtab)

2

erythromycin 400 mg/5 ml susp 5

erythromycin ethylsuccinate (200mg/5 ml susp, es 400 mg tab)

2

ZMAX 4

QuinolonesBESIVANCE 4

CILOXAN 0.3% OINTMENT 4

ciprofloxacin (250 mg/5 ml susp,500 mg/5 ml susp)

2

ciprofloxacin er 2

ciprofloxacin hcl (0.3% eye drop,hcl 100 mg tab, hcl 250 mg tab,hcl 500 mg tab, hcl 750 mg tab)

1

ciprofloxacn-d5w 200 mg/100 ml 2

gatifloxacin 2

levofloxacin 0.5% eye drops 2

levofloxacin (25 mg/ml solution,250 mg/10 ml soln, 500 mg/20ml vial, 500 mg/20 ml soln, 750mg/30 ml vial)

4


35





levofloxacin (250 mg tablet, 500mg tablet, 750 mg tablet)

1

levofloxacin-d5w (500 mg/100,750 mg/150)

2

MOXEZA 4

moxifloxacin (drop, drops) 2

moxifloxacin 400 mg/250 ml bag 4

moxifloxacin hcl 400 mg tablet 2

ofloxacin 0.3% eye drops 1

ofloxacin (300 mg tablet, 400 mgtablet)

2

VIGAMOX 4

XEPI 4

Sulfonamidessulfacetamide sodium (drops,ointment)

2

sulfacetamide sodium (sod topsusp, sodium lotn)

4

sulfadiazine 2

sulfamethoxazole-tmp susp 2

sulfamethoxazole-trimethoprim(ds tablet, ss tablet)

1

sulfamethoxazole-tmp iv vial 4

TetracyclinesARESTIN 5

demeclocycline hcl 2

doxy 100 2

doxycycline hyclate (50 mg cap,100 mg tab, 100 mg cap)

1


36





doxycycline hyclate 20 mg tab 2

doxycycline hyclate (dr 50 mgtab, dr 75 mg tab, dr 100 mg tab,dr 150 mg tab, dr 200 mg tab)

4

doxycycline monohydrate (50mg cap, 100 mg cap, 150 mgcap)

1

doxycycline monohydrate (25mg/5 ml susp, mono 50 mgtablet, mono 100 mg tablet,mono 150 mg tablet)

2

doxycycline monohydrate (75mg tablet, 75 mg capsule)

4

minocycline hcl (50 mg capsule,75 mg capsule, 100 mg capsule)

2

minocycline hcl (50 mg tablet, 75mg tablet, 100 mg tablet)

4

NUZYRA (150 MG TABLET-7DAY, 150 MG-7 DAY WITHLOAD, 150 MG TABLET)

5 PA, QL (30 PER 14 DAYS)

NUZYRA 100 MG VIAL 5 PA, QL (15 PER 14 DAYS)

okebo 100 mg capsule 1

okebo 75 mg capsule 4

tetracycline hcl 2

VIBRAMYCIN 50 MG/5 MLSYRUP

4

Anticonvulsant

Gamma-Aminobutyric Acid (Gaba) Augmenting AgentsSYMPAZAN 5


37





Anticonvulsants

Anticonvulsants, OtherAPTIOM 5 ST

BRIVIACT (10 MG/ML ORALSOLN, 10 MG TABLET, 25 MGTABLET, 50 MG TABLET, 75MG TABLET, 100 MG TABLET)

5

BRIVIACT 50 MG/5 ML VIAL 4

EPIDIOLEX 5 PA - FOR NEW STARTS ONLY

FYCOMPA (0.5 MG/ML ORALSUSP, 2 MG TABLET, 6 MGTABLET, 12 MG TABLET)

4

FYCOMPA (4 MG TABLET, 8MG TABLET, 10 MG TABLET)

5

levetiracetam (100 mg/ml soln,500 mg/5 ml soln)

2

levetiracetam (250 mg tablet,500 mg tablet, 750 mg tablet,1,000 mg tablet)

1

levetiracetam 500 mg/5 ml vial 4

levetiracetam er 2

levetiracetam-nacl (500 mg/100,1,000mg/100)

4

roweepra 500 mg tablet 1

roweepra xr 2

SPRITAM 4

Calcium Channel Modifying AgentsCELONTIN 4

ethosuximide (250 mg/5 ml soln,250 mg capsule)

2


38





LYRICA (25 MG CAPSULE, 50MG CAPSULE, 75 MGCAPSULE, 100 MG CAPSULE,150 MG CAPSULE, 200 MGCAPSULE, 225 MG CAPSULE)


LYRICA 300 MG CAPSULE 3 QL (60 PER 30 DAYS)

LYRICA 20 MG/ML ORALSOLUTION


pregabalin (25 mg capsule, 50mg capsule, 75 mg capsule, 100mg capsule, 150 mg capsule,200 mg capsule, 225 mgcapsule)


pregabalin 300 mg capsule 1 QL (60 PER 30 DAYS)

pregabalin 20 mg/ml solution 1 QL (900 PER 30 DAYS)

zonisamide 2

Gamma-aminobutyric Acid (GABA) Augmenting Agentsclobazam (2.5 mg/mlsuspension, 10 mg tablet)

4

clobazam 20 mg tablet 5

clonazepam (0.5 mg tablet, 1 mgtablet, 2 mg tablet)

1

clonazepam (0.125 mg odt, 0.25mg odt, 0.5 mg odt, 1 mg odt)


clonazepam 2 mg odt 2 QL (300 PER 30 DAYS)

clonazepam (0.125 mg odt, 0.5mg odt, 1 mg odt)


DIASTAT 4

DIASTAT ACUDIAL 4

diazepam 20 mg rectal gel syst 4

divalproex dr 125 mg cap sprnk 1

divalproex sodium (dr 125 mgtab, dr 250 mg tab, dr 500 mgtab)

2


39





divalproex sodium er 2

gabapentin (100 mg capsule,300 mg capsule)


gabapentin 400 mg capsule 1 QL (270 PER 30 DAYS)

gabapentin (250 mg/5 ml soln,300 mg/6 ml soln)

2 QL (2160 PER 30 DAYS)

gabapentin 600 mg tablet 1 QL (180 PER 30 DAYS)

gabapentin 800 mg tablet 1 QL (150 PER 30 DAYS)

GABITRIL (12 MG TABLET, 16MG TABLET)

4

ONFI (2.5 MG/MLSUSPENSION, 20 MG TABLET)

5

ONFI 10 MG TABLET 4

phenobarbital (15 mg tablet,16.2 mg tablet, 20 mg/5 ml soln,20 mg/5 ml elix, 30 mg tablet,32.4 mg tablet, 60 mg tablet,64.8 mg tablet, 97.2 mg tablet,100 mg tablet)

2 PA - FOR NEW STARTS ONLY

primidone 2

SABRIL (500 MG TABLET, 500MG POWDER PACKET)


tiagabine hcl (2 mg tablet, 4 mgtablet)

4

valproate sodium 4

valproic acid (250 mg capsule,250 mg/5 ml soln, 500 mg/10 mlsol)

2

vigabatrin 500 mg tablet 5

vigadrone 5


40





Glutamate Reducing Agentsfelbamate 600 mg/5 ml susp 5

felbamate (400 mg tablet, 600mg tablet)

4

lamotrigine (25 mg tablet, 100mg tablet, 150 mg tablet, 200 mgtablet)

1

lamotrigine (5 mg disper tablet,25 mg disper tab)

2

lamotrigine er 4

lamotrigine odt (odt 25 mg tablet,odt 50 mg tablet, odt 100 mgtablet)

4

topiramate (15 mg cap, 25 mgcap)

2

topiramate (25 mg tablet, 50 mgtablet, 100 mg tablet, 200 mgtablet)

1

Sodium Channel AgentsBANZEL (40 MG/MLSUSPENSION, 200 MGTABLET, 400 MG TABLET)

5

carbamazepine (100 mg tabchew, 100 mg/5 ml susp)

2

carbamazepine 200 mg tablet 1

carbamazepine er (er 100 mgcap, er 100 mg tablet, er 200 mgtablet, er 200 mg cap, er 300 mgcap, er 400 mg tablet)

2

CARBATROL 4

DILANTIN (30 MG CAPSULE,50 MG INFATAB, 100 MGCAPSULE)

4


41





DILANTIN-125 4

epitol 2

fosphenytoin 100 mg pe/2 ml vl 2

oxcarbazepine 300 mg/5 mlsusp

4

oxcarbazepine (150 mg tablet,300 mg tablet, 600 mg tablet)

2

PEGANONE 4

PHENYTEK 3

phenytoin (50 mg infatab, 50 mgtablet chew, 100 mg/4 ml susp,125 mg/5 ml susp)

2

phenytoin sodium (50 mg/ml vial,50 mg/ml ampul, 100 mg/2 mlvial, 250 mg/5 ml vial)

4

phenytoin sodium extended 2

TEGRETOL (100 MG/5 MLSUSP, 200 MG TABLET)

4

TEGRETOL XR 4

VIMPAT (10 MG/MLSOLUTION, 50 MG TABLET,100 MG TABLET, 150 MGTABLET, 200 MG/20 ML VIAL,200 MG TABLET)

4

Antidementia Agents

Cholinesterase Inhibitorsdonepezil hcl (5 mg tablet, 10mg tablet)

1

donepezil hcl 23 mg tablet 2

donepezil hcl odt 1

galantamine er 2


42





galantamine hbr 2

galantamine hydrobromide 4

rivastigmine (1.5 mg capsule, 3mg capsule, 4.5 mg capsule, 6mg capsule)

2

rivastigmine (4.6 mg/24hr patch,9.5 mg/24hr patch, 13.3 mg/24hrptch)

4

N-methyl-D-aspartate (NMDA) Receptor Antagonistmemantine hcl (hcl 2 mg/mlsolution, hcl 5 mg tablet, 5-10mg titration pk, hcl 10 mg tablet)

2 PA

memantine hcl er 2 PA, QL (30 PER 30 DAYS)

NAMENDA XR TITRATIONPACK

3 PA, QL (56 PER 365 OVER TIME)

NAMENDA XR (7 MGCAPSULE, 14 MG CAPSULE,21 MG CAPSULE, 28 MGCAPSULE)


Antidepressants

Antidepressants, OtherAPLENZIN 5 ST, QL (30 PER 30 DAYS)

bupropion hcl 1

bupropion hcl sr (sr 100 mgtablet, sr 200 mg tablet)


bupropion hcl xl 150 mg tablet 2 QL (90 PER 30 DAYS)



FORFIVO XL 4 QL (30 PER 30 DAYS)

mirtazapine 15 mg tablet 1


43





mirtazapine (7.5 mg tablet, 15mg odt, 30 mg tablet, 30 mg odt,45 mg tablet, 45 mg odt)

2

SPRAVATO (56 MG PACK, 84MG PACK)


Monoamine Oxidase InhibitorsEMSAM 5 ST, QL (30 PER 30 DAYS)

MARPLAN 4

phenelzine sulfate 2

tranylcypromine sulfate 4

SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin andNorepinephrine Reuptake Inhibitor

citalopram hbr (10 mg/5 ml soln,20 mg/10 ml sol)

2

citalopram hbr (10 mg tablet, 20mg tablet, 40 mg tablet)

1

desvenlafaxine er 100 mg tab 4 ST, QL (120 PER 30 DAYS)

desvenlafaxine er 50 mg tab 4 ST, QL (30 PER 30 DAYS)

desvenlafaxine suc er 100 mg 4 ST, QL (120 PER 30 DAYS)

desvenlafaxine suc er 25 mg tb 4 ST, QL (30 PER 30 DAYS)

duloxetine hcl (dr 20 mg cap, dr60 mg cap)


duloxetine hcl dr 30 mg cap 2 QL (90 PER 30 DAYS)

duloxetine hcl dr 40 mg cap 4 QL (90 PER 30 DAYS)

escitalopram oxalate (oxalate 5mg/5 ml, 5 mg tablet, 10 mgtablet, 20 mg tablet)

1

FETZIMA 20-40 MG TITRATIONPAK

4 ST, QL (56 PER 365 OVER TIME)

FETZIMA (ER 20 MGCAPSULE, ER 40 MGCAPSULE, ER 80 MGCAPSULE, ER 120 MGCAPSULE)

4 ST, QL (30 PER 30 DAYS)


44





fluoxetine dr 4 ST, QL (4 PER 28 DAYS)

fluoxetine hcl (10 mg capsule, 20mg capsule, 40 mg capsule)

1

fluoxetine hcl (hcl 10 mg tablet,hcl 20 mg tablet, 20 mg/5 mlsolution)

2

fluvoxamine maleate 2

fluvoxamine maleate er 4 ST, QL (60 PER 30 DAYS)

maprotiline hcl 2

nefazodone hcl 2

olanzapine-fluoxetine hcl (3-25mg, 6-25 mg)


olanzapine-fluoxetine hcl (6-50mg, 12-50 mg, 12-25 mg)


paroxetine cr 2

paroxetine er 2

paroxetine hcl 1

paroxetine mesylate 4 QL (30 PER 30 DAYS)

PAXIL 10 MG/5 MLSUSPENSION

4

PEXEVA (10 MG TABLET, 20MG TABLET)


PEXEVA 30 MG TABLET 4 QL (60 PER 30 DAYS)

PEXEVA 40 MG TABLET 4 QL (30 PER 30 DAYS)

sertraline 20 mg/ml oral conc 2

sertraline hcl (25 mg tablet, 50mg tablet, 100 mg tablet)

1

trazodone 300 mg tablet 2

trazodone hcl (50 mg tablet, 100mg tablet, 150 mg tablet)

1


45





TRINTELLIX 4 ST, QL (30 PER 30 DAYS)

venlafaxine hcl 1

venlafaxine hcl er (er 37.5 mgcap, er 75 mg cap, er 150 mgcap, er 150 mg tab, er 225 mgtab)

1

venlafaxine hcl er (er 37.5 mgtab, er 75 mg tab)

2

VIIBRYD 10-20 MG STARTERPACK

4 ST, QL (60 PER 365 OVER TIME)

VIIBRYD (10 MG TABLET, 20MG TABLET, 40 MG TABLET)


Tricyclicsamitriptyline hcl 2 PA - FOR NEW STARTS ONLY

amoxapine 2

chlordiazepoxide-amitriptyline 2 PA - FOR NEW STARTS ONLY

clomipramine hcl 4 PA - FOR NEW STARTS ONLY

desipramine hcl 2

doxepin hcl (10 mg/ml oral conc,10 mg capsule, 25 mg capsule,50 mg capsule, 75 mg capsule,100 mg capsule, 150 mgcapsule)


imipramine hcl 1 PA - FOR NEW STARTS ONLY

imipramine pamoate 4 PA - FOR NEW STARTS ONLY

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

1

nortriptyline hcl (10 mg/5 mlsoln, 20 mg/10 ml soln)

2

perphenazine-amitriptyline 2 PA - FOR NEW STARTS ONLY

protriptyline hcl 2


46





trimipramine maleate 4 PA - FOR NEW STARTS ONLY

Antiemetics

Antiemetics, Othercompro 2

doxylamine succ-pyridoxine hcl 4

meclizine hcl 1

MOTEGRITY 4 PA, QL (30 PER 30 DAYS)

phenadoz 12.5 mg suppository 4 PA

phenadoz 25 mg suppository 4

prochlorperazine 2

prochlorperazine edisylate 4

prochlorperazine maleate 1

promethazine hcl (12.5 mgsuppos, 25 mg suppository, 50mg suppository)

2 PA

promethazine hcl (6.25 mg/5 mlsyrp, 6.25 mg/5 ml soln, 12.5 mgtablet, 25 mg tablet, 50 mgtablet)

1 PA

promethazine hcl (25 mg/ml vial,25 mg/ml ampul, 50 mg/ml vial,50 mg/ml ampul)

4

promethegan 25 mg suppository 4 PA

promethegan 50 mg suppository 2 PA

scopolamine 4 QL (10 PER 30 DAYS)

TRANSDERM-SCOP 4

trimethobenzamide hcl 2 PA - Part B vs D Determination


47





Emetogenic Therapy AdjunctsALOXI 4

ANZEMET 100 MG TABLET 5 QL (5 PER 30 OVER TIME)

ANZEMET 50 MG TABLET 4 QL (5 PER 30 OVER TIME)

aprepitant 125-80-80 mg pack 2 PA - Part B vs D Determination,QL (6 PER 30 OVER TIME)

aprepitant 125 mg capsule 2 PA - Part B vs D Determination,QL (2 PER 30 OVER TIME)



dronabinol 4 PA, QL (60 PER 30 OVER TIME)

EMEND 125 MG POWDERPACKET

4 PA - Part B vs D Determination,QL (6 PER 30 OVER TIME)

granisetron hcl 1 mg tablet 2 PA - Part B vs D Determination,QL (30 PER 30 OVER TIME)

granisetron hcl (0.1 mg/ml vial, 1mg/ml vial, 4 mg/4 ml vial)

2

ondansetron hcl (hcl 4 mg/2 mlvial, hcl 4 mg/2 ml syr, hcl 4mg/2 ml amp, 4 mg/2 ml isecure)


ondansetron 4 mg/5 ml solution 2 PA - Part B vs D Determination,QL (450 PER 30 DAYS)

ondansetron hcl (4 mg tablet, 8mg tablet)

2 PA - Part B vs D Determination

ondansetron hcl 24 mg tablet 2 PA - Part B vs D Determination,QL (14 PER 28 OVER TIME)

ondansetron odt 1 PA - Part B vs D Determination

SANCUSO 5 QL (2 PER 30 OVER TIME)


48





Antifungals

ABELCET 5 PA - Part B vs D Determination

AMBISOME 5 PA - Part B vs D Determination

amphotericin b 4 PA - Part B vs D Determination

CANCIDAS 5

ciclopirox (0.77% gel, 0.77%cream, 0.77% topical susp, 1%shampoo, 8% solution)

2

clotrimazole 1% cream 1

clotrimazole (1% solution, 10 mgtroche)

2

CRESEMBA (186 MGCAPSULE, 372 MG VIAL)

5

econazole nitrate 4

ERAXIS (WATER DILUENT) 5

EXELDERM (CREAM,SOLUTION)

4

fluconazole (10 mg/ml susp, 40mg/ml susp, 50 mg tablet, 100mg tablet, 200 mg tablet)

2

fluconazole 150 mg tablet 1

fluconazole in saline (200mg/100 ml, 400 mg/200 ml)

2

fluconazole-nacl (200 mg/100ml, 400 mg/200 ml)

2

flucytosine 5

griseofulvin 125 mg/5 ml susp 2

griseofulvin micro 500 mg tab 4

griseofulvin ultramicrosize 4

gynazole 1 4


49





itraconazole (10 mg/ml solution,100 mg capsule)

4 PA

ketoconazole 2% foam 4

ketoconazole 2% shampoo 1

ketoconazole (2% cream, 200mg tablet)

2

MENTAX 4

miconazole 3 2

MYCAMINE 100 MG VIAL 5

MYCAMINE 50 MG VIAL 4

naftifine hcl (1% cream, 2%cream)

3

naftifine hcl 1% gel 4

NAFTIN (1% GEL, 2% GEL) 4

NATACYN 4

NOXAFIL (40 MG/MLSUSPENSION, DR 100 MGTABLET)

5 PA

nyamyc 2

nystatin (100,000 unit/gm cream,100,000 unit/gm oint, 100,000unit/gm powd, 500,000 unit oraltab)

2

nystatin (100,000 unit/ml susp,500,000 unit/5 ml sus)

1

nystatin-triamcinolone (cream,ointm)

2

nystop 2

ONMEL 5 PA

oxiconazole nitrate 2

OXISTAT 1% LOTION 4


50





posaconazole dr 100 mg tablet 5 PA

SPORANOX 10 MG/MLSOLUTION

5 PA

terbinafine hcl 1 QL (84 PER 180 OVER TIME)

terconazole (0.4% cream, 0.8%cream, 80 mg suppository)

2

voriconazole 40 mg/ml susp 5

voriconazole (50 mg tablet, 200mg tablet, 200 mg vial)

4

Antigout Agents

allopurinol 1

colchicine 0.6 mg tablet 2

febuxostat 1 ST

probenecid 2

probenecid-colchicine 2

ULORIC 3 ST

Antimigraine Agents

Anitmigraine Agents, OtherAJOVY 4 PA, QL (240 PER 30 DAYS)

EMGALITY PEN 4 PA, QL (240 PER 30 DAYS)

EMGALITY 120 MG/MLSYRINGE


EMGALITY SYRINGE (100MG/ML SYR(1 OF 3), 300 MG(100 MG X3SYR))


Ergot Alkaloidsdihydroergotamine 1 mg/ml amp 5


51





dihydroergotamine 4 mg/ml spry 5 QL (8 PER 30 OVER TIME)

ergotamine-caffeine 2

migergot 4

Serotonin (5-HT) 1b/1d Receptor Agonistsalmotriptan malate 4 QL (12 PER 30 OVER TIME)

frovatriptan succinate 4 QL (12 PER 30 OVER TIME)

naratriptan hcl 2 QL (9 PER 30 OVER TIME)

rizatriptan (5 mg tablet, 5 mgodt, 10 mg odt, 10 mg tablet)


sumatriptan 4 QL (12 PER 30 OVER TIME)

sumatriptan succinate (4 mg/0.5ml cart, 4 mg/0.5 ml inject)


sumatriptan succinate (6 mg/0.5ml refill, 6 mg/0.5 ml syrng)


sumatriptan succinate (25 mgtablet, 50 mg tablet, 100 mgtablet)


sumatriptan succinate (6 mg/0.5ml vial, 6 mg/0.5 ml inject)


zolmitriptan 2 QL (12 PER 30 OVER TIME)

zolmitriptan 2.5 mg odt 2 QL (12 PER 30 OVER TIME)

zolmitriptan 5 mg odt 2 QL (9 PER 30 OVER TIME)

ZOMIG 2.5 MG NASAL SPRAY 4 QL (18 PER 30 OVER TIME)

ZOMIG 5 MG NASAL SPRAY 4 QL (12 PER 30 OVER TIME)

Antimyasthenic Agents

Parasympathomimeticsguanidine hcl 4

MESTINON 60 MG/5 MLSYRUP

5


52





pyridostigmine 60 mg/5 ml soln 5

pyridostigmine bromide (30 mgtablet, 60 mg tablet)

2

pyridostigmine bromide er 4

Antimycobacterials

Antimycobacterials, Otherdapsone (25 mg tablet, 100 mgtablet)

2

rifabutin 2

AntitubercularsCAPASTAT SULFATE 4

ethambutol hcl 2

isoniazid (100 mg tablet, 300 mgtablet)

1

isoniazid (50 mg/5 ml solution,100 mg/ml vial)

4

PASER 4

PRIFTIN 4

pyrazinamide 2

rifampin (150 mg capsule, 300mg capsule)

2

rifampin iv 600 mg vial 4

RIFATER 4

SIRTURO 5

TRECATOR 4


53





Antineoplastics

Alkylating AgentsBICNU 5

BUSULFEX 5

cyclophosphamide (25 mgcapsule, 50 mg capsule)


dacarbazine 200 mg vial 2

GLEOSTINE (10 MG CAPSULE,40 MG CAPSULE, 100 MGCAPSULE)

4

HEXALEN 5

ifosfamide 1 gm vial 4

KISQALI FEMARA 200 MG CO-PACK

5 PA - FOR NEW STARTS ONLY,QL (49 PER 28 OVER TIME)




5 PA - FOR NEW STARTS ONLY,QL (91 PER 28 DAYS)

LEUKERAN 4

MATULANE 5

melphalan hcl 5

MUSTARGEN 5

oxaliplatin 100 mg/20 ml vial 4

thiotepa 5

TREANDA 100 MG VIAL 5 PA - Part B vs D Determination

VALCHLOR 5 PA - FOR NEW STARTS ONLY

YONDELIS 5

ZANOSAR 4


54





Antiandrogensabiraterone acetate 5 PA - FOR NEW STARTS ONLY

bicalutamide 2

ERLEADA 3 QL (120 PER 30 DAYS)

flutamide 2

NILANDRON 5

nilutamide 5

NUBEQA 5 PA - FOR NEW STARTS ONLY

XTANDI 5 PA - FOR NEW STARTS ONLY

YONSA 5 PA - FOR NEW STARTS ONLY,QL (120 PER 30 DAYS)

ZYTIGA 250 MG TABLET 5 PA - FOR NEW STARTS ONLY

Antiangiogenic AgentsPOMALYST 5 PA - FOR NEW STARTS ONLY

REVLIMID 5 PA - FOR NEW STARTS ONLY

THALOMID 5 PA - FOR NEW STARTS ONLY

Antiestrogens/ModifiersEMCYT 5

FARESTON 5

FASLODEX 5

fulvestrant 5

SOLTAMOX 4

tamoxifen citrate 2

toremifene citrate 5

Antimetabolitesadrucil 500 mg/10 ml vial 2


55





ALIMTA 500 MG VIAL 5

ARRANON 5

cladribine 5

clofarabine 5

CLOLAR 5

cytarabine (20 mg/ml vial, 1000mg/50 ml vial)

2

DROXIA 4

fluorouracil (2.5 gm/50 ml btl, 2.5gm/50 ml vial, 500 mg/10 ml vial,1,000 mg/20 ml vl, 2,500 mg/50ml vl)


fluorouracil (5 gm/100 ml btl, 5gm/100 ml vial, 5,000 mg/100ml)

2

FOLOTYN 40 MG/2 ML VIAL 5 PA - FOR NEW STARTS ONLY

gemcitabine hcl 1 gram vial 4

hydroxyurea 2

LONSURF 15 MG-6.14 MGTABLET


LONSURF 20 MG-8.19 MGTABLET


mercaptopurine 2

NIPENT 5

PURIXAN 5

TABLOID 4

VYXEOS 5

Antineoplastics, OtherABRAXANE 5

adriamycin 20 mg/10 ml vial 2


56





AVASTIN 5 PA - FOR NEW STARTS ONLY

azacitidine 5

BALVERSA 5

BAVENCIO 5

BELEODAQ 5 PA - FOR NEW STARTS ONLY

bleomycin sulfate 30 unit vial 2

carboplatin (50 mg/5 ml vial, 150mg/15 ml vial, 150 mg vial, 450mg/45 ml vial, 600 mg/60 ml vial)

2

cisplatin (50 mg/50 ml vial, 100mg/100 ml vial, 200 mg/200 mlvial)

2

COPIKTRA 5 PA - FOR NEW STARTS ONLY

COSMEGEN 5

COTELLIC 5 PA - FOR NEW STARTS ONLY,QL (90 PER 30 DAYS)

CYRAMZA 5 PA - FOR NEW STARTS ONLY

DARZALEX 5 PA - FOR NEW STARTS ONLY

daunorubicin hcl (20 mg/4 mlvial, 20 mg vial, 50 mg/10 mlvial)

4

decitabine 5 PA - FOR NEW STARTS ONLY

dexrazoxane 250 mg vial 5

docetaxel (20 mg/2 ml vial, 20mg/ml vial, 80 mg/4 ml vial, 80mg/8 ml vial, 160 mg/16 ml vial,160 mg/8 ml vial)

5

doxorubicin 50 mg/25 ml vial 2

doxorubicin hcl liposome 5

ELITEK 5

EMPLICITI 5 PA - FOR NEW STARTS ONLY


57





epirubicin 200 mg/100 ml vial 2

ERBITUX 100 MG/50 ML VIAL 5 PA - FOR NEW STARTS ONLY

ERWINAZE 5

FARYDAK 5 PA - FOR NEW STARTS ONLY,QL (6 PER 21 OVER TIME)

fludarabine 50 mg vial 4

FUSILEV 5

HALAVEN 5 PA - FOR NEW STARTS ONLY

HERCEPTIN 150 MG VIAL 5

HERCEPTIN 440 MG VIAL 5 PA - FOR NEW STARTS ONLY

HERCEPTIN HYLECTA 5 PA - FOR NEW STARTS ONLY

IBRANCE 5 PA - FOR NEW STARTS ONLY

idarubicin hcl 5

IDHIFA 5 QL (30 PER 30 DAYS)

IMFINZI 5 PA - FOR NEW STARTS ONLY

irinotecan hcl 100 mg/5 ml vl 4

ISTODAX 5 PA - FOR NEW STARTS ONLY

JEVTANA 5 PA - FOR NEW STARTS ONLY

KADCYLA 100 MG VIAL 5 PA - FOR NEW STARTS ONLY

KEYTRUDA 5 PA - FOR NEW STARTS ONLY

KISQALI 5 PA - FOR NEW STARTS ONLY,QL (63 PER 28 OVER TIME)

LARTRUVO 5 PA - FOR NEW STARTS ONLY

leucovorin calcium (5 mg tab, 10mg tab, 15 mg tab, 25 mg tab)

2

leucovorin calcium (50 mg vial,100 mg vial, 200 mg vial, 350mg vial, 500 mg vl)

4

levoleucovorin calcium (175mg/17.5 ml, 250 mg/25 ml vl)

5


58





LORBRENA 5 PA - FOR NEW STARTS ONLY

LYNPARZA (50 MG CAPSULE,100 MG TABLET, 150 MGTABLET)


mitomycin (5 mg vial, 40 mg vial) 5

mitomycin 20 mg/40 ml-water 5 PA - Part B vs D Determination

mitoxantrone hcl 2 PA - FOR NEW STARTS ONLY

MYLOTARG 5

NINLARO 5 PA - FOR NEW STARTS ONLY

OPDIVO (40 MG/4 ML VIAL,100 MG/10 ML VIAL)


paclitaxel 2

PERJETA 5 PA - FOR NEW STARTS ONLY

POLIVY 5 PA - FOR NEW STARTS ONLY

PROLEUKIN 5

RITUXAN 5 PA - FOR NEW STARTS ONLY

ROZLYTREK 5 PA - FOR NEW STARTS ONLY

RUBRACA (200 MG TABLET,300 MG TABLET)


RYDAPT 5 PA - FOR NEW STARTS ONLY,QL (224 PER 28 DAYS)

SYLATRON 5 PA - FOR NEW STARTS ONLY

SYLATRON 4-PACK 5 PA - FOR NEW STARTS ONLY

SYLVANT 100 MG VIAL 5 PA

SYNRIBO 5 PA - FOR NEW STARTS ONLY

TECENTRIQ 1,200 MG/20 MLVIAL


TRISENOX 10 MG/10 MLAMPULE

5

TURALIO 5 PA - FOR NEW STARTS ONLY


59





VECTIBIX 100 MG/5 ML VIAL 5

VELCADE 5 PA - FOR NEW STARTS ONLY

VERZENIO 5 QL (60 PER 30 DAYS)

vinblastine sulfate 2

vincasar pfs 1 mg/ml vial 2

vincristine 1 mg/ml vial 2

vinorelbine 50 mg/5 ml vial 2

XPOVIO 5 PA - FOR NEW STARTS ONLY

YERVOY 50 MG/10 ML VIAL 5 PA - FOR NEW STARTS ONLY

ZALTRAP 100 MG/4 ML VIAL 5 PA - FOR NEW STARTS ONLY

ZEJULA 5 PA - FOR NEW STARTS ONLY,QL (90 PER 30 DAYS)

ZOLINZA 5 PA - FOR NEW STARTS ONLY

Aromatase Inhibitors, 3rd Generationanastrozole 1

exemestane 2

letrozole 1

Enzyme InhibitorsETOPOPHOS 5

etoposide (100 mg/5 ml vial, 500mg/25 ml vial, 1,000 mg/50 mlvial)

2

KYPROLIS 5 PA - FOR NEW STARTS ONLY

PIQRAY 5

TALZENNA 5 PA - FOR NEW STARTS ONLY

toposar 2

topotecan hcl 4 mg vial 5

ZYDELIG 5 PA - FOR NEW STARTS ONLY


60





Molecular Target InhibitorsAFINITOR 5 PA - FOR NEW STARTS ONLY,

QL (30 PER 30 DAYS)

AFINITOR DISPERZ 5 PA - FOR NEW STARTS ONLY

ALECENSA 5 PA - FOR NEW STARTS ONLY,QL (240 PER 30 DAYS)

ALIQOPA 5

ALUNBRIG 90 MG-180 MG TABPACK


ALUNBRIG (90 MG TABLET,180 MG TABLET)


ALUNBRIG 30 MG TABLET 5 PA - FOR NEW STARTS ONLY,QL (180 PER 30 DAYS)

BOSULIF 5 PA - FOR NEW STARTS ONLY

BRAFTOVI 5 PA - FOR NEW STARTS ONLY

CABOMETYX 5 PA - FOR NEW STARTS ONLY

CALQUENCE 5 QL (60 PER 30 DAYS)

CAPRELSA 100 MG TABLET 5 PA - FOR NEW STARTS ONLY,QL (60 PER 30 DAYS)

CAPRELSA 300 MG TABLET 5 PA - FOR NEW STARTS ONLY

COMETRIQ 5 PA - FOR NEW STARTS ONLY

DAURISMO 100 MG TABLET 5 PA - FOR NEW STARTS ONLY

DAURISMO 25 MG TABLET 4 PA - FOR NEW STARTS ONLY

ERIVEDGE 5 PA - FOR NEW STARTS ONLY

erlotinib hcl (100 mg tablet, 150mg tablet)


erlotinib hcl 25 mg tablet 5 PA - FOR NEW STARTS ONLY,QL (90 PER 30 DAYS)

GILOTRIF 5 PA - FOR NEW STARTS ONLY,QL (30 PER 30 DAYS)


61





ICLUSIG 15 MG TABLET 5 PA - FOR NEW STARTS ONLY,QL (60 PER 30 DAYS)

ICLUSIG 45 MG TABLET 5 PA - FOR NEW STARTS ONLY

imatinib mesylate 5 PA - FOR NEW STARTS ONLY

IMBRUVICA (140 MGCAPSULE, 420 MG TABLET,560 MG TABLET)


INLYTA 5 PA - FOR NEW STARTS ONLY

INREBIC 5 PA

IRESSA 5 PA - FOR NEW STARTS ONLY

JAKAFI 5 PA - FOR NEW STARTS ONLY,QL (60 PER 30 DAYS)

LENVIMA 5 PA - FOR NEW STARTS ONLY

MEKINIST 5 PA - FOR NEW STARTS ONLY

MEKTOVI 5 PA - FOR NEW STARTS ONLY

NERLYNX 5 QL (180 PER 30 DAYS)

NEXAVAR 5 PA - FOR NEW STARTS ONLY

ODOMZO 5 PA - FOR NEW STARTS ONLY

SPRYCEL 5 PA - FOR NEW STARTS ONLY

STIVARGA 5 PA - FOR NEW STARTS ONLY

SUTENT 5 PA - FOR NEW STARTS ONLY

TAFINLAR 5 PA - FOR NEW STARTS ONLY

TAGRISSO 5 PA - FOR NEW STARTS ONLY,QL (30 PER 30 DAYS)

TARCEVA (100 MG TABLET,150 MG TABLET)


TARCEVA 25 MG TABLET 5 PA - FOR NEW STARTS ONLY,QL (90 PER 30 DAYS)

TASIGNA 5 PA - FOR NEW STARTS ONLY

TIBSOVO 5 PA - FOR NEW STARTS ONLY


62





TORISEL 5

TYKERB 5 PA - FOR NEW STARTS ONLY

VENCLEXTA (10 MG TABLET,50 MG TABLET)


VENCLEXTA 100 MG TABLET 5 PA - FOR NEW STARTS ONLY

VENCLEXTA STARTING PACK 5 PA - FOR NEW STARTS ONLY

VITRAKVI (20 MG/MLSOLUTION, 25 MG CAPSULE,100 MG CAPSULE)


VIZIMPRO 5 PA - FOR NEW STARTS ONLY

VOTRIENT 5 PA - FOR NEW STARTS ONLY

XALKORI 5 PA - FOR NEW STARTS ONLY

XOSPATA 5 PA - FOR NEW STARTS ONLY

ZELBORAF 5 PA - FOR NEW STARTS ONLY

ZYKADIA (150 MG TABLET,150 MG CAPSULE)


Retinoidsbexarotene 5 PA - FOR NEW STARTS ONLY

PANRETIN 5

TARGRETIN 1% GEL 5 PA - FOR NEW STARTS ONLY

tretinoin 10 mg capsule 5

Treatment Adjunctsmesna 2

MESNEX 400 MG TABLET 5

Antiparasitics

Anthelminticsalbendazole 4


63





ALBENZA 5

BILTRICIDE 3

ivermectin 3 mg tablet 2

praziquantel 1

AntiprotozoalsALINIA (100 MG/5 MLSUSPENSION, 500 MGTABLET)

5

atovaquone 5

atovaquone-proguanil hcl 2

chloroquine phosphate 2

COARTEM 4

DARAPRIM 5 PA

hydroxychloroquine sulfate 1

mefloquine hcl 2

NEBUPENT 4 PA - Part B vs D Determination

PENTAM 300 4

primaquine 4

quinine sulfate 2 PA

tinidazole 2

Pediculicides/ScabicidesEURAX 10% CREAM 4

lindane 1% shampoo 4

malathion 4

permethrin 2

SKLICE 4


64





Antiparkinson Agents

Anticholinergicsbenztropine mesylate (0.5 mgtab, 1 mg tablet, 2 mg tablet)

1 PA

benztropine mesylate (2 mg/2 mlvial, 2 mg/2 ml ampule)

2

trihexyphenidyl 2 mg/5 ml elx 2 PA

trihexyphenidyl hcl (2 mg tablet,5 mg tablet)

1 PA

Antiparkinson Agents, Otherentacapone 2

NOURIANZ 5 PA

tolcapone 5

Dopamine AgonistsAPOKYN 5 PA, QL (60 PER 30 DAYS)

bromocriptine mesylate (2.5 mgtablet, 5 mg capsule)

4

INBRIJA 5 PA, QL (300 PER 30 DAYS)

NEUPRO 4 ST

pramipexole dihydrochloride 2

ropinirole er 2

ropinirole hcl 1

Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitorscarbidopa 5

carbidopa-levodopa (carbidopa-levo 10-100 mg odt, carbidopa-levo 25-250 mg odt, carbidopa-levodopa 10-100 tab, carbidopa-levodopa 25-250 tab, carbidopa-levodopa 25-100 tab)

2


65





carbidopa-levodopa er 2

carbidopa-levodopa-entacapone 4

STALEVO 100 5

STALEVO 125 5

STALEVO 150 5

STALEVO 200 5

STALEVO 50 5

STALEVO 75 5

Monoamine Oxidase B (MAO-B) Inhibitorsrasagiline mesylate 2

selegiline hcl (5 mg tablet, 5 mgcapsule)

2

ZELAPAR 5

Antipsychotics

1st Generation/Typicalchlorpromazine 25 mg/ml amp 2

chlorpromazine hcl (10 mgtablet, 25 mg tablet, 50 mgtablet, 100 mg tablet, 200 mgtablet)


fluphenazine decanoate 2

fluphenazine hcl (1 mg tablet,2.5 mg tablet, 5 mg tablet, 10 mgtablet)

1

fluphenazine hcl (2.5 mg/ml vial,2.5 mg/5 ml elix, 5 mg/ml conc)

2

haloperidol 1


66





haloperidol decanoate (dec 50mg/ml vial, dec 100 mg/ml vial,dec 100 mg/ml amp, dec 500mg/5 ml vl, decan 50 mg/mlamp)

1

haloperidol decanoate 100 1

haloperidol lactate (2 mg/mlconc, 5 mg/ml syring, 5 mg/mlampul, 5 mg/ml vial, 50 mg/10ml vl)

1

loxapine 2

molindone hcl 2

perphenazine 2

pimozide 4

thioridazine hcl 1 PA - FOR NEW STARTS ONLY

thiothixene 2

trifluoperazine hcl 2

2nd Generation/AtypicalABILIFY MAINTENA (ER 300MG SYR, ER 300 MG VL, ER400 MG SYR)

5

aripiprazole 1 mg/ml solution 4 QL (750 PER 30 DAYS)

aripiprazole (10 mg tablet, 15 mgtablet, 30 mg tablet)


aripiprazole (2 mg tablet, 5 mgtablet)


aripiprazole 20 mg tablet 4 QL (60 PER 30 DAYS)

aripiprazole odt 5 QL (60 PER 30 DAYS)

ARISTADA (ER 441 MG/1.6 MLSYRN, ER 662 MG/2.4 MLSYRN, ER 882 MG/3.2 MLSYRN)

5


67





ARISTADA ER 1064 MG/3.9 MLSYR

5 QL (3.9 PER 56 OVER TIME)

ARISTADA INITIO 5

FANAPT TITRATION PACK 4 ST, QL (8 PER 180 OVER TIME)

FANAPT (1 MG TABLET, 2 MGTABLET, 4 MG TABLET)


FANAPT (6 MG TABLET, 8 MGTABLET, 10 MG TABLET, 12MG TABLET)


GEODON 20 MG/ML VIAL 4 QL (60 PER 30 DAYS)

INVEGA SUSTENNA (78MG/0.5 ML, 117 MG/0.75 ML,156 MG/ML SYRG, 234 MG/1.5ML)

5

INVEGA SUSTENNA 39MG/0.25 ML

4

INVEGA TRINZA 5

LATUDA (20 MG TABLET, 40MG TABLET, 60 MG TABLET,120 MG TABLET)


LATUDA 80 MG TABLET 5 QL (60 PER 30 DAYS)

NUPLAZID (10 MG TABLET, 34MG CAPSULE)


NUPLAZID 17 MG TABLET 5 PA - FOR NEW STARTS ONLY,QL (60 PER 30 DAYS)

olanzapine (2.5 mg tablet, 5 mgtablet, 7.5 mg tablet, 10 mgtablet, 15 mg tablet, 20 mgtablet)


olanzapine 10 mg vial 2

olanzapine odt 4 QL (30 PER 30 DAYS)

paliperidone er (er 1.5 mg tablet,er 3 mg tablet)



68





paliperidone er 6 mg tablet 5 QL (60 PER 30 DAYS)

paliperidone er 9 mg tablet 5 QL (30 PER 30 DAYS)

PERSERIS 5

quetiapine fumarate (25 mg tab,50 mg tab, 100 mg tab, 200 mgtab)


quetiapine fumarate (300 mgtab, 400 mg tab)


quetiapine er 200 mg tablet 2 PA - FOR NEW STARTS ONLY,QL (90 PER 30 DAYS)

quetiapine fumarate er (er 50 mgtablet, er 150 mg tablet, er 300mg tablet, er 400 mg tablet)


REXULTI 5 QL (30 PER 30 DAYS)

RISPERDAL CONSTA (12.5 MGSYR, 25 MG SYR)

4

RISPERDAL CONSTA (37.5 MGSYR, 50 MG SYR)

5

risperidone 1 mg/ml solution 2 QL (240 PER 30 DAYS)

risperidone (0.25 mg tablet, 0.5mg tablet, 1 mg tablet, 2 mgtablet, 3 mg tablet, 4 mg tablet)


risperidone odt 2 QL (60 PER 30 DAYS)

SAPHRIS 4 QL (60 PER 30 DAYS)

VRAYLAR 1.5 MG-3 MG PACK 4 ST, QL (14 PER 365 OVER TIME)

VRAYLAR (1.5 MG CAPSULE, 3MG CAPSULE, 4.5 MGCAPSULE, 6 MG CAPSULE)


ziprasidone hcl 2 QL (60 PER 30 DAYS)

ZYPREXA RELPREVV (210 MGVIAL, 210 MG VL KIT)

4

ZYPREXA RELPREVV (300 MGVL KIT, 300 MG VIAL, 405 MGVL KIT, 405 MG VIAL)



69





Treatment-Resistantclozapine (25 mg tablet, 100 mgtablet)


clozapine 200 mg tablet 2 QL (120 PER 30 DAYS)

clozapine 50 mg tablet 2 QL (180 PER 30 DAYS)

clozapine odt (odt 25 mg tablet,odt 100 mg tablet)


clozapine odt 12.5 mg tablet 4 QL (90 PER 30 DAYS)

clozapine odt 150 mg tablet 4 QL (180 PER 30 DAYS)

clozapine odt 200 mg tablet 5 QL (120 PER 30 DAYS)

VERSACLOZ 5 QL (540 PER 30 DAYS)

Antispasticity Agents

baclofen (5 mg tablet, 10 mgtablet)

1

baclofen 20 mg tablet 2

BOTOX 4 PA

dantrolene sodium (25 mg cap,50 mg cap, 100 mg cap)

2

GABLOFEN 40,000 MCG/20 MLVIAL

5

LIORESAL INTRATHECAL (10MG/5 ML K, 10 MG/5 MLAMPULE, 40 MG/20 MLAMPULE, 40 MG/20 ML K)

5

LIORESAL IT 0.05 MG/1 MLAMP


tizanidine hcl (2 mg tablet, 4 mgtablet)

1

XEOMIN 50 UNIT VIAL 4 PA


70





Antivirals

Anti-HIV Agents, Integrase Inhibitors (INSTI)BIKTARVY 5 QL (30 PER 30 DAYS)

DOVATO 5

GENVOYA 5 QL (30 PER 30 DAYS)

ISENTRESS (25 MG TABLETCHEW, 100 MG POWDERPACKET)

3

ISENTRESS (100 MG TABLETCHEW, 400 MG TABLET)

5

STRIBILD 5 QL (30 PER 30 DAYS)

TIVICAY (25 MG TABLET, 50MG TABLET)

5

TIVICAY 10 MG TABLET 4

TRIUMEQ 5 QL (30 PER 30 DAYS)

Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI)ATRIPLA 5 QL (30 PER 30 DAYS)

COMPLERA 5 QL (30 PER 30 DAYS)

DELSTRIGO 5

EDURANT 5

INTELENCE (100 MG TABLET,200 MG TABLET)

5

INTELENCE 25 MG TABLET 4

nevirapine 50 mg/5 ml susp 4

nevirapine 200 mg tablet 2

nevirapine er 4

ODEFSEY 5 QL (30 PER 30 DAYS)

PIFELTRO 5


71





RESCRIPTOR (100 MGTABLET, 200 MG TABLET)

4

SUSTIVA 50 MG CAPSULE 4

SUSTIVA (200 MG CAPSULE,600 MG TABLET)

5

SYMFI 5 QL (30 PER 30 DAYS)

SYMFI LO 5 QL (30 PER 30 DAYS)

VIRAMUNE 50 MG/5 ML SUSP 5

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

abacavir 20 mg/ml solution 2

abacavir 300 mg tablet 4

abacavir-lamivudine 5 QL (30 PER 30 DAYS)

abacavir-lamivudine-zidovudine 5 QL (60 PER 30 DAYS)

CIMDUO 5

DESCOVY 5 QL (30 PER 30 DAYS)

didanosine (dr 125 mg capsule,dr 250 mg capsule, dr 400 mgcapsule)

2

didanosine dr 200 mg capsule 2 QL (60 PER 30 DAYS)

EMTRIVA (10 MG/MLSOLUTION, 200 MG CAPSULE)

4

EPZICOM 5 QL (30 PER 30 DAYS)

JULUCA 5 QL (30 PER 30 DAYS)

lamivudine (10 mg/ml oral soln,150 mg tablet)

2

lamivudine 300 mg tablet 4

lamivudine-zidovudine 4 QL (60 PER 30 DAYS)

RETROVIR 200 MG/20 ML VIAL 4


72





stavudine 2

TRUVADA 5 QL (30 PER 30 DAYS)

VIDEX 4

VIDEX EC 125 MG CAPSULE 4

VIREAD (150 MG TABLET, 200MG TABLET, 250 MG TABLET,300 MG TABLET, POWDER)

5

ZERIT 1 MG/ML SOLUTION 4

ZIAGEN 20 MG/ML SOLUTION 4

zidovudine (50 mg/5 ml syrup,100 mg capsule, 300 mg tablet)

2

Anti-HIV Agents, OtherFUZEON 5 QL (60 PER 30 DAYS)

ISENTRESS HD 4 QL (60 PER 30 DAYS)

SELZENTRY 20 MG/ML ORALSOLN

2

SELZENTRY (150 MG TABLET,300 MG TABLET)

5

SELZENTRY (25 MG TABLET,75 MG TABLET)

4

TROGARZO 5

TYBOST 3

Anti-HIV Agents, Protease InhibitorsAPTIVUS (100 MG/MLSOLUTION, 250 MG CAPSULE)

5

CRIXIVAN 3

EVOTAZ 5 QL (30 PER 30 DAYS)

INVIRASE (200 MG CAPSULE,500 MG TABLET)

5

KALETRA (80 MG-20 MG/MLSOLN, 100-25 MG TABLET)

4


73





KALETRA 200-50 MG TABLET 5

LEXIVA 50 MG/MLSUSPENSION

4

LEXIVA 700 MG TABLET 5

lopinavir-ritonavir 2

NORVIR 100 MG POWDERPACKET

5

NORVIR (80 MG/MLSOLUTION, 100 MG TABLET,100 MG SOFTGEL CAP)

4

PREZCOBIX 5 QL (30 PER 30 DAYS)

PREZISTA (100 MG/MLSUSPENSION, 600 MGTABLET, 800 MG TABLET)

5

PREZISTA (75 MG TABLET,150 MG TABLET)

4

REYATAZ (50 MG POWDERPACKET, 150 MG CAPSULE,200 MG CAPSULE, 300 MGCAPSULE)

5

SYMTUZA 5

VIRACEPT (250 MG TABLET,625 MG TABLET)

5

Anti-cytomegalovirus (CMV) Agentscidofovir 5

ganciclovir 500 mg vial 2

valganciclovir hcl (hcl 50 mg/ml,450 mg tablet)

5

ZIRGAN 4

Anti-hepatitis B (HBV) Agentsadefovir dipivoxil 5


74





BARACLUDE 0.05 MG/MLSOLUTION


entecavir 5 QL (30 PER 30 DAYS)

EPIVIR HBV 25 MG/5 ML SOLN 4

INTRON A (10 MILLION UNITSVIL, 18 MILLION UNIT/3 ML, 50MILLION UNITS VIL)


lamivudine 100 mg tablet 2

lamivudine hbv 2

Anti-hepatitis C (HCV) Agents, Direct Acting AgentsEPCLUSA 5 PA, QL (84 PER 365 OVER TIME)

HARVONI 90-400 MG TABLET 5 PA, QL (168 PER 365 OVERTIME)

ledipasvir-sofosbuvir 5 PA, QL (168 PER 365 OVERTIME)

sofosbuvir-velpatasvir 5 PA, QL (84 PER 365 OVER TIME)

SOVALDI 400 MG TABLET 5 PA, QL (336 PER 365 OVERTIME)

TECHNIVIE 5 PA, QL (168 PER 365 OVERTIME)

VOSEVI 5 PA

Anti-hepatitis C (HCV) Agents, Othermoderiba (400-400 mg, 600-600mg)

5

moderiba 200 mg tablet 4

PEGASYS (180 MCG/ML VIAL,180 MCG/0.5 ML SYRINGE)

5 PA

PEGASYS PROCLICK 135MCG/0.5

5

PEGASYS PROCLICK 180MCG/0.5

5 PA


75





ribasphere 200 mg capsule 2

ribasphere (200 mg tablet, 400mg tablet, 600 mg tablet)

4

RIBASPHERE RIBAPAK 400-400 MG

5

ribavirin 200 mg capsule 2

ribavirin 200 mg tablet 4

Anti-influenza Agentsamantadine (50 mg/5 mlsolution, 100 mg/10 ml soln)

1

amantadine (100 mg tablet, 100mg capsule)

2

oseltamivir phos 75 mg capsule 2 QL (110 PER 365 OVER TIME)

oseltamivir phosphate (30 mgcapsule, 45 mg capsule)


oseltamivir 6 mg/ml suspension 2 QL (2250 PER 365 OVER TIME)

RELENZA 4 QL (240 PER 365 OVER TIME)

rimantadine hcl 2

TAMIFLU 6 MG/MLSUSPENSION


Antiherpetic Agentsacyclovir (5% cream, 200 mg/5ml susp)

2

acyclovir 5% ointment 4

acyclovir (200 mg capsule, 400mg tablet, 800 mg tablet)

1

acyclovir sodium (500 mg/10 mlvial, 1,000 mg/20 ml vial)


DENAVIR 5

famciclovir 2


76





trifluridine 2

valacyclovir 2 QL (120 PER 30 DAYS)

ZOVIRAX 5% CREAM 4

Anxiolytics

Anxiolytics, Otherbuspirone hcl 1

hydroxyzine pamoate 1 PA

Benzodiazepinesalprazolam (0.25 mg tablet, 0.5mg tablet, 1 mg tablet)


alprazolam 2 mg tablet 1 QL (150 PER 30 DAYS)

alprazolam er (er 0.5 mg tablet,er 1 mg tablet)


alprazolam er 2 mg tablet 2 QL (150 PER 30 DAYS)

alprazolam er 3 mg tablet 2 QL (90 PER 30 DAYS)

alprazolam intensol 2

alprazolam odt (odt 0.25 mg tab,odt 0.5 mg tab, odt 1 mg tab)


alprazolam odt 2 mg tab 2 QL (150 PER 30 DAYS)

alprazolam xr (0.5 mg tablet, 1mg tablet)


alprazolam xr 2 mg tablet 2 QL (150 PER 30 DAYS)

alprazolam xr 3 mg tablet 2 QL (90 PER 30 DAYS)

chlordiazepoxide 10 mg capsule 2 QL (900 PER 30 DAYS)



clorazepate 15 mg tablet 2 QL (180 PER 30 DAYS)


77





clorazepate 3.75 mg tablet 2

clorazepate 7.5 mg tablet 2 QL (360 PER 30 DAYS)

diazepam (2 mg tablet, 5 mg/5ml solution, 5 mg tablet, 5 mg/mloral conc, 10 mg tablet)

2

lorazepam 2 mg/ml oral concent 2

lorazepam (0.5 mg tablet, 1 mgtablet)


lorazepam 2 mg tablet 1 QL (150 PER 30 DAYS)

lorazepam intensol 2

NAYZILAM 5 PA - FOR NEW STARTS ONLY,QL (10 PER 30 DAYS)

oxazepam 2 QL (120 PER 30 DAYS)

temazepam 1 QL (30 PER 30 DAYS)

Beta-Adrenergic Blocking Agents

bisoprolol-hctz 10-6.25 mg tab 1

Bipolar Agents

Mood StabilizersEQUETRO 4

lithium 3

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

1

lithium carbonate er 1


78





Blood Glucose Regulators

Antidiabetic Agentsacarbose 1

ACTOPLUS MET XR 15-1,000MG TB


ACTOPLUS MET XR 30-1,000MG TB


AVANDIA 2 MG TABLET 4 QL (120 PER 30 DAYS)

AVANDIA 4 MG TABLET 4 QL (60 PER 30 DAYS)

BYDUREON 3 QL (4 PER 28 DAYS)

BYDUREON BCISE 4 QL (3.4 PER 28 DAYS)

BYDUREON PEN 3 QL (4 PER 28 DAYS)

BYETTA 10 MCG DOSE PENINJ

4 QL (2.4 PER 30 DAYS)

BYETTA 5 MCG DOSE PEN INJ 4 QL (1.2 PER 30 DAYS)

CYCLOSET 4

glimepiride 1 mg tablet 1 QL (240 PER 30 DAYS)



glipizide 10 mg tablet 1 QL (120 PER 30 DAYS)

glipizide 5 mg tablet 1 QL (240 PER 30 DAYS)

glipizide er 10 mg tablet 1 QL (60 PER 30 DAYS)

glipizide er 2.5 mg tablet 1 QL (240 PER 30 DAYS)

glipizide er 5 mg tablet 1 QL (120 PER 30 DAYS)

glipizide xl 10 mg tablet 1 QL (60 PER 30 DAYS)

glipizide xl 2.5 mg tablet 1 QL (240 PER 30 DAYS)

glipizide xl 5 mg tablet 1 QL (120 PER 30 DAYS)


79





glipizide-metformin (2.5-500 mg,5-500 mg)


glipizide-metformin 2.5-250 mg 1 QL (240 PER 30 DAYS)

glyburide 1.25 mg tablet 2 PA, QL (480 PER 30 DAYS)

glyburide 2.5 mg tablet 2 PA, QL (240 PER 30 DAYS)

glyburide 5 mg tablet 2 PA, QL (120 PER 30 DAYS)

glyburide micro 1.5 mg tab 2 PA, QL (240 PER 30 DAYS)

glyburide micro 3 mg tablet 2 PA, QL (120 PER 30 DAYS)

glyburide micro 6 mg tablet 2 PA, QL (60 PER 30 DAYS)

glyburid-metformin 1.25-250 mg 2 PA, QL (240 PER 30 DAYS)

glyburide-metformin hcl (2.5-500mg, 5-500 mg)


INVOKAMET 150-1,000 MGTABLET


INVOKAMET 150-500 MGTABLET


INVOKAMET 50-500 MGTABLET


INVOKAMET XR (50-500 MGTABLET, 50-1,000 MG TAB,150-500 MG TABLET)


INVOKANA 100 MG TABLET 3 QL (90 PER 30 DAYS)

INVOKANA 300 MG TABLET 3 QL (30 PER 30 DAYS)

JANUMET 3 QL (60 PER 30 DAYS)

JANUMET XR (50-500 MGTABLET, 50-1,000 MG TABLET)


JANUMET XR 100-1,000 MGTABLET


JANUVIA 3

JARDIANCE 10 MG TABLET 3 QL (60 PER 30 DAYS)


80





JARDIANCE 25 MG TABLET 3 QL (30 PER 30 DAYS)

JENTADUETO 3 QL (60 PER 30 DAYS)

JENTADUETO XR 2.5 MG-1,000 MG


JENTADUETO XR 5 MG-1,000MG TB


KOMBIGLYZE XR 2.5-1,000 MGTAB


KOMBIGLYZE XR 5-1,000 MGTAB


KOMBIGLYZE XR 5-500 MGTABLET


metformin er 500 mg gastrc-tb 1 QL (120 PER 30 DAYS)

metformin er 500 mg osmotic tb 1

metformin hcl 1,000 mg tablet 1 QL (60 PER 30 DAYS)

metformin hcl 500 mg tablet 1 QL (150 PER 30 DAYS)

metformin hcl 850 mg tablet 1 QL (90 PER 30 DAYS)

metformin hcl er 500 mg tablet 1 QL (120 PER 30 DAYS)

metformin hcl er 750 mg tablet 1 QL (60 PER 30 DAYS)

metformin hcl er 500 mg tablet(excludes ndcs 00591-2411-01,68180-0338-01, 68682-0017-10)


miglitol 4

nateglinide 1

ONGLYZA 2.5 MG TABLET 3 QL (60 PER 30 DAYS)

ONGLYZA 5 MG TABLET 3 QL (30 PER 30 DAYS)

OZEMPIC 0.25-0.5 MG DOSEPEN

3 QL (1.5 PER 28 DAYS)

OZEMPIC 1 MG DOSE PEN 3 QL (3 PER 28 DAYS)

pioglitazone hcl 15 mg tablet 1 QL (60 PER 30 DAYS)


81







pioglitazone-glimepiride 2 QL (45 PER 30 DAYS)

pioglitazone-metformin 2 QL (90 PER 30 DAYS)

repaglinide 1

repaglinide-metformin hcl 2 QL (150 PER 30 DAYS)

RIOMET 4 QL (765 PER 30 DAYS)

SYMLINPEN 120 5 PA

SYMLINPEN 60 5 PA

SYNJARDY (5-1,000 MGTABLET, 12.5-1,000 MGTABLET)


SYNJARDY (5-500 MGTABLET, 12.5-500 MG TABLET)


tolazamide 250 mg tablet 1 QL (240 PER 30 DAYS)

tolazamide 500 mg tablet 1 QL (120 PER 30 DAYS)

tolbutamide 1 QL (180 PER 30 DAYS)

TRADJENTA 3

TRULICITY 3 QL (2 PER 28 DAYS)

VICTOZA 2-PAK 3 QL (9 PER 30 DAYS)

VICTOZA 3-PAK 3 QL (9 PER 30 DAYS)

Glycemic AgentsBAQSIMI 4

GLUCAGEN 4

GLUCAGON EMERGENCY KIT 3

PROGLYCEM 5


82





InsulinsBASAGLAR KWIKPEN U-100 3

HUMALOG (100 UNITS/MLCARTRIDGE, 100 UNIT/MLVIAL)

3

HUMALOG JUNIOR KWIKPEN 3

HUMALOG KWIKPEN U-100 3

HUMALOG KWIKPEN U-200 3

HUMALOG MIX 50-50 3

HUMALOG MIX 50-50KWIKPEN

3

HUMALOG MIX 75-25 3

HUMALOG MIX 75-25KWIKPEN

3

HUMULIN R U-500 3

HUMULIN R U-500 KWIKPEN 3

insulin lispro 3

insulin lispro kwikpen u-100 3

LANTUS 3

LANTUS SOLOSTAR 3

LEVEMIR 3

LEVEMIR FLEXTOUCH 3

NOVOLOG (100 UNIT/MLCARTRIDGE, 100 UNIT/MLVIAL)

3

NOVOLOG FLEXPEN 3

NOVOLOG MIX 70-30 3

NOVOLOG MIX 70-30FLEXPEN

3


83





TOUJEO MAX SOLOSTAR 3

TOUJEO SOLOSTAR 3

TRESIBA 3

TRESIBA FLEXTOUCH U-100 3

TRESIBA FLEXTOUCH U-200 3

Blood Products/Modifiers/Volume Expanders

Anticoagulantsargatroban 5

argatroban-0.9% nacl (50mg/50ml-0.9%nacl, 125 mg/125-0.9%nacl)

5

COUMADIN 4

ELIQUIS DVT-PE TREATSTART 5MG


ELIQUIS 2.5 MG TABLET 3 QL (60 PER 30 DAYS)

ELIQUIS 5 MG TABLET 3 QL (90 PER 30 DAYS)

enoxaparin 30 mg/0.3 ml syr 4 QL (10.5 PER 90 OVER TIME)

enoxaparin 40 mg/0.4 ml syr 4 QL (14 PER 90 OVER TIME)

enoxaparin 60 mg/0.6 ml syr 4 QL (21 PER 90 OVER TIME)

enoxaparin sodium (100 mg/mlsyringe, 150 mg/ml syringe)


enoxaparin sodium (80 mg/0.8ml syr, 120 mg/0.8 ml syr)


enoxaparin 300 mg/3 ml vial 4 QL (105 PER 90 OVER TIME)

fondaparinux 10 mg/0.8 ml syr 5 QL (28 PER 90 OVER TIME)

fondaparinux 2.5 mg/0.5 ml syr 4 QL (17.5 PER 90 OVER TIME)

fondaparinux 5 mg/0.4 ml syr 5 QL (14 PER 90 OVER TIME)

fondaparinux 7.5 mg/0.6 ml syr 5 QL (21 PER 90 OVER TIME)


84





FRAGMIN (2,500 UNITS/0.2 MLSYR, 5,000 UNITS/0.2 ML SYR)

4

FRAGMIN (7,500 UNITS/0.3 MLSYR, 10,000 UNITS/MLSYRING, 12,500 UNITS/0.5 ML,15,000 UNITS/0.6 ML, 18,000UNITS/0.72 ML, 95,000UNITS/3.8 ML VL)

5

heparin sodium (5,000 unit/mlcarpujct, sod 5,000 unit/ml vial,sod 10,000 unit/ml vl, sod20,000 unit/ml vl, 40,000 unit/4ml vial, 50,000 unit/10 ml vial,50,000 unit/5 ml vial)

2

heparin sodium (sod 1,000unit/ml vial, 10,000 unit/10 mlvial, 30,000 unit/30 ml vial)


heparin-1/2ns 25,000 units/500 2

heparin 25,000 unit/500-1/2 ns 2

heparin sodium-d5w (heparin20,000 unit/500 ml-d5w, heparin25,000 unit/250 ml-d5w, heparin-d5w 25,000 unit/250 ml)

2

jantoven 1

PRADAXA 4 QL (60 PER 30 DAYS)

warfarin sodium 1

XARELTO STARTER PACK 3 QL (102 PER 365 OVER TIME)

XARELTO (10 MG TABLET, 20MG TABLET)


XARELTO 15 MG TABLET 3 QL (60 PER 30 DAYS)

XARELTO 2.5 MG TABLET 3 QL (60 PER 30 DAYS)

Blood Formation Modifiersanagrelide hcl 2


85





ARANESP (10 MCG/0.4 MLSYRINGE, 25 MCG/0.42 MLSYRING, 25 MCG/ML VIAL, 40MCG/ML VIAL, 40 MCG/0.4 MLSYRINGE, 60 MCG/0.3 MLSYRINGE)

4 PA

ARANESP (60 MCG/ML VIAL,100 MCG/ML VIAL, 100MCG/0.5 ML SYRINGE, 150MCG/0.3 ML SYRINGE, 200MCG/0.4 ML SYRINGE, 200MCG/ML VIAL, 300 MCG/0.6 MLSYRINGE, 300 MCG/ML VIAL,500 MCG/1 ML SYRINGE)

5 PA

DOPTELET (30 TAB PK) 20 MGTAB


GRANIX (300 MCG/ML VIAL,300 MCG/0.5 ML SYRINGE, 300MCG/0.5 ML SAFE SYR, 480MCG/0.8 ML SYRINGE, 480MCG/0.8 ML SAFE SYR, 480MCG/1.6 ML VIAL)

5 PA

LEUKINE 5 PA

MOZOBIL 5 PA, QL (38.4 PER 365 OVERTIME)

NEULASTA (6 MG/0.6 MLSYRINGE, ONPRO 6 MG/0.6ML KIT)

5 PA

NEUPOGEN (300 MCG/MLVIAL, 300 MCG/0.5 ML SYR,480 MCG/1.6 ML VIAL, 480MCG/0.8 ML SYR)

5 PA, ST

NIVESTYM (300 MCG/ML VIAL,300 MCG/0.5 ML SYRING, 480MCG/0.8 ML SYRING, 480MCG/1.6 ML VIAL)

5 PA

PROCRIT (2,000 UNITS/MLVIAL, 3,000 UNITS/ML VIAL,4,000 UNITS/ML VIAL, 10,000UNITS/ML VIAL)

4 PA


86





PROCRIT (20,000 UNITS/MLVIAL, 40,000 UNITS/ML VIAL)

5 PA

PROMACTA (12.5 MG SUSPENPACKET, 12.5 MG TABLET, 25MG TABLET, 50 MG TABLET,75 MG TABLET)

5 PA

RETACRIT (2,000 UNIT/MLVIAL, 3,000 UNIT/ML VIAL,4,000 UNIT/ML VIAL, 10,000UNIT/ML VIAL)


RETACRIT 40,000 UNIT/MLVIAL


ZARXIO 5 PA

Hemostasis Agentstranexamic acid 1,000 mg/10 ml 2

tranexamic acid 650 mg tablet 1

Platelet Modifying Agentsaspirin-dipyridamole er 2

BRILINTA 3

CABLIVI (11 MG VIAL, 11 MGKIT)

5 PA

cilostazol 1

clopidogrel 1

EFFIENT 4

prasugrel hcl 2 QL (30 PER 30 DAYS)

Cardiovascular Agents

Alpha-adrenergic Agonistsclonidine 2

clonidine hcl (0.1 mg tablet, 0.2mg tablet, 0.3 mg tablet)

1


87





guanfacine hcl 4 PA

LUCEMYRA 5 PA, QL (224 PER 30 DAYS)

methyldopa 2 PA

methyldopa-hydrochlorothiazide 2 PA

methyldopate hcl 4

midodrine hcl 2

Alpha-adrenergic Blocking Agentsphenoxybenzamine hcl 5

prazosin hcl 2

Angiotensin II Receptor Antagonistscandesartan cilexetil 1

candesartan-hydrochlorothiazid 1

EDARBI 4

EDARBYCLOR 4

eprosartan mesylate 1

irbesartan 1

irbesartan-hydrochlorothiazide 1

losartan potassium 1

losartan-hydrochlorothiazide 1

olmesartan medoxomil 2

olmesartan-hydrochlorothiazide 2

telmisartan 1

telmisartan-hydrochlorothiazid 1

valsartan 1

valsartan-hydrochlorothiazide 1


88





Angiotensin-converting Enzyme (ACE) Inhibitorsbenazepril hcl 1

benazepril-hydrochlorothiazide 1

captopril 1

captopril-hydrochlorothiazide 1

enalapril maleate 1

enalapril-hydrochlorothiazide 1

fosinopril sodium 1

fosinopril-hydrochlorothiazide 1

lisinopril 1

lisinopril-hydrochlorothiazide 1

moexipril hcl 1

moexipril-hydrochlorothiazide 1

perindopril erbumine 1

quinapril hcl 1

quinapril-hydrochlorothiazide 1

ramipril 1

trandolapril 1

trandolapril-verapamil er (er 1-240 mg, er 2-240 mg, er 4-240mg)

1

Antiarrhythmicsamiodarone hcl (100 mg tablet,200 mg tablet, 400 mg tablet)

1

amiodarone hcl (150 mg/3 mlvial, 450 mg/9 ml vial, 900 mg/18ml vial)

2

disopyramide phosphate 2 PA


89





dofetilide 4

flecainide acetate 2

mexiletine hcl 2

MULTAQ 3

pacerone 200 mg tablet 1

procainamide hcl (500 mg/mlvial, 1,000 mg/2 ml vl, 1,000mg/10 ml vl)

4

propafenone hcl 2

propafenone hcl er 4

quinidine gluconate (80 mg/mlvial, er 324 mg tab)

4

quinidine sulfate 2

sorine 2

sotalol (120 mg tablet, 160 mgtablet, 240 mg tablet)

2

sotalol 80 mg tablet 1

sotalol af 2

Beta-adrenergic Blocking Agentsacebutolol hcl 1

atenolol 1

atenolol-chlorthalidone 1

betaxolol hcl (10 mg tablet, 20mg tablet)

2

bisoprolol fumarate 2

bisoprolol-hydrochlorothiazide(2.5-6.25 mg tb, 5-6.25 mg tab)

1

BYSTOLIC 3

carvedilol 1


90





carvedilol er (er 10 mg capsule,er 20 mg capsule, er 40 mgcapsule)

1

carvedilol er 80 mg capsule 2

labetalol hcl (100 mg tablet, 200mg tablet, 300 mg tablet)

2

labetalol hcl (100 mg/20 ml vl,200 mg/40 ml vl)

1

metoprolol succinate 2

metoprolol tartrate (tart 5 mg/5ml amp, tart 5 mg/5 ml vial, 5mg/5 ml carpuject, tartrate 25mg tab, tartrate 50 mg tab,tartrate 100 mg tab)

1

metoprolol-hydrochlorothiazide 2

nadolol 2

nadolol-bendroflumethiazide 2

pindolol 2

propranolol hcl (10 mg tablet, 20mg/5 ml soln, 20 mg tablet, 40mg tablet, 40 mg/5 ml soln, 60mg tablet, 80 mg tablet)

2

propranolol 1 mg/ml vial 4

propranolol hcl er 2

propranolol-hydrochlorothiazid 2

timolol maleate (5 mg tablet, 10mg tablet, 20 mg tablet)

2

Calcium Channel Blocking Agentsamlodipine besylate 1

amlodipine besylate-benazepril 1

amlodipine-atorvastatin 2


91





amlodipine-olmesartan 2

amlodipine-valsartan 1

amlodipine-valsartan-hctz (5-160-12.5 mg, 5-160-25 mg, 10-160-12.5mg, 10-320-25 mg)

2

CARDIZEM LA 120 MG TABLET 4

cartia xt 2

dilt-xr 2

diltiazem 12hr er 2

diltiazem 24hr er 2

diltiazem 24hr er (cd) 2

diltiazem 24hr er (xr) 2

diltiazem hcl (30 mg tablet, 60mg tablet, 90 mg tablet, 120 mgtablet)

1

diltiazem hcl (25 mg/5 ml vial, 50mg/10 ml vial, 100 mg add-vanvial, 125 mg/25 ml vial)

4

felodipine er 2

isradipine 4

matzim la 2

nicardipine hcl (20 mg capsule,30 mg capsule)

3

nicardipine hcl (25 mg/10 mlampule, 25 mg/10 ml vial)

4

nifedipine er 2

nimodipine 5

nisoldipine 4

olmesartan-amlodipine-hctz 2

taztia xt 2


92





telmisartan-amlodipine 2

verapamil er (er 120 mg capsule,er 180 mg capsule, er 240 mgcapsule)

2

verapamil er (er 120 mg tablet,er 180 mg tablet, er 240 mgtablet)

1

verapamil er pm 2

verapamil 360 mg cap pellet 3

verapamil hcl (40 mg tablet, 80mg tablet, 120 mg tablet)

1

verapamil hcl (5 mg/2 ml vial, 5mg/2 ml ampul, 10 mg/4 ml vial)

2

verapamil sr 2

Cardiovascular Agents, Otheraliskiren 2

CORLANOR (5 MG TABLET,7.5 MG TABLET)


DEMSER 5

digitek 125 mcg tablet 1 QL (30 PER 30 DAYS)

digitek 250 mcg tablet 1 PA

digox 125 mcg tablet 2 QL (30 PER 30 DAYS)

digox 250 mcg tablet 1

digoxin 500 mcg/2 ml ampule 4

digoxin 0.05 mg/ml solution 2 PA

digoxin 0.25 mg/ml syringe 4 PA

digoxin (0.125 mg tablet, 125mcg tablet)


digoxin (0.25 mg tablet, 250 mcgtablet)

1 PA


93





ENTRESTO 3 QL (60 PER 30 DAYS)

LANOXIN 125 MCG TABLET 4 QL (30 PER 30 DAYS)

LANOXIN 187.5 MCG TABLET 4 PA, QL (30 PER 30 DAYS)

LANOXIN 250 MCG TABLET 4 PA

LANOXIN 62.5 MCG TABLET 4 QL (60 PER 30 DAYS)

NORTHERA 5 PA

pentoxifylline 1

PRALUENT PEN 5 PA, QL (2 PER 28 DAYS)

RANEXA 3 ST

ranolazine er 3 ST

REPATHA PUSHTRONEX 5 PA, QL (3.5 PER 28 DAYS)

REPATHA SURECLICK 5 PA, QL (3 PER 28 DAYS)

REPATHA SYRINGE 5 PA, QL (3 PER 28 DAYS)

TEKTURNA 4

TEKTURNA HCT 4

Diuretics, Carbonic Anhydrase Inhibitorsacetazolamide 2

acetazolamide er 2

acetazolamide sodium 2

Diuretics, Loopbumetanide (0.5 mg tablet, 1 mgtablet, 2 mg tablet)

1

bumetanide (0.25 mg/ml vial, 1mg/4 ml vial, 2.5 mg/10 ml vial)

2

EDECRIN 5

ethacrynic acid 5


94





furosemide (10 mg/ml solution,20 mg tablet, 20 mg/2 ml vial, 40mg/4 ml vial, 40 mg/4 ml syringe,40 mg/5 ml soln, 40 mg tablet,80 mg tablet, 100 mg/10 mlsyring, 100 mg/10 ml vial)

1

torsemide 1

Diuretics, Potassium-sparingALDACTAZIDE 50-50 TABLET 4

amiloride hcl 2

amiloride-hydrochlorothiazide 1

DYRENIUM 4

eplerenone 2

spironolactone 1

spironolactone-hctz 2

triamterene 2

triamterene-hydrochlorothiazid(37.5-25 mg cp, 37.5-25 mg tb,75-50 mg tab)

1

Diuretics, Thiazidechlorothiazide 2

chlorothiazide sodium 4

chlorthalidone 1

DIURIL 4

hydrochlorothiazide (12.5 mg tb,12.5 mg cp, 25 mg tab, 50 mgtab)

1

indapamide 1

methyclothiazide 2

metolazone 2


95





Dyslipidemics, Fibric Acid Derivativesfenofibrate (40 mg tablet, 43 mgcapsule, 50 mg capsule, 130 mgcapsule, 145 mg tablet, 150 mgcapsule, 200 mg capsule)

2

fenofibrate (48 mg tablet, 54 mgtablet, 67 mg capsule, 134 mgcapsule, 160 mg tablet)

1

fenofibric acid (35 mg tablet, dr45 mg cap, 105 mg tablet, dr135 mg cap)

2

gemfibrozil 1

Dyslipidemics, HMG CoA Reductase Inhibitorsatorvastatin calcium 1

fluvastatin er 4

fluvastatin sodium 4

LIVALO 4 ST

lovastatin 1

pravastatin sodium 1

rosuvastatin calcium 1

simvastatin (5 mg tablet, 10 mgtablet, 20 mg tablet, 40 mgtablet)

1

simvastatin 80 mg tablet 1 PA

Dyslipidemics, Othercholestyramine (packet, powder) 2

cholestyramine light (packet,powder)

2

colesevelam hcl 3.75 g packet 4

colesevelam 625 mg tablet 2 QL (180 PER 30 DAYS)


96





colestipol hcl (hcl 1 gm tablet,hcl granules, hcl granulespacket, micronized 1 gm tab)

2

ezetimibe 2

ezetimibe-simvastatin 2

JUXTAPID 5 PA, QL (30 PER 30 DAYS)

KYNAMRO 5 PA, QL (4 PER 28 DAYS)

niacin er (er 750 mg tablet, er1,000 mg tablet)

4

niacin er 500 mg tablet 2

niacor 2

omega-3 acid ethyl esters 2

prevalite (packet, powder) 2

triklo 2

VASCEPA 4

WELCHOL 3.75G PACKET 4

WELCHOL 625 MG TABLET 3

Vasodilators, Direct-acting Arterialhydralazine hcl (10 mg tablet, 25mg tablet, 50 mg tablet, 100 mgtablet)

1

hydralazine 20 mg/ml vial 4

minoxidil 2

Vasodilators, Direct-acting Arterial/VenousBIDIL 3

isosorbide dinitrate (5 mg tab, 10mg tab, 20 mg tab)

2

isosorbide dinitrate er 2

isosorbide mononitrate 1


97





isosorbide mononitrate er 1

minitran 2

NITRO-BID 3

NITRO-DUR (0.3 MG/HRPATCH, 0.8 MG/HR PATCH)

4

nitroglycerin (0.3 mg tablet, 0.4mg tablet)

1

nitroglycerin (lingual 0.4 mg, 0.6mg tablet sl, 400 mcg spray)

2

nitroglycerin 5 mg/ml vial 4

nitroglycerin patch 2

NITROSTAT 3

Central Nervous System Agents

Attention Deficit Hyperactivity Disorder Agents, Amphetaminesdextroamphetamine 10 mg tab 2 PA, QL (180 PER 30 DAYS)

dextroamphetamine 5 mg tab 2 PA, QL (90 PER 30 DAYS)

dextroamphetamine er 10 mgcap


dextroamphetamine er 15 mgcap


dextroamphetamine er 5 mg cap 4 PA, QL (60 PER 30 DAYS)

dextroamphetamine-amphet er 4 PA, QL (30 PER 30 DAYS)

dextroamphetamine-amphetamine


VYVANSE (10 MG CAPSULE,20 MG CAPSULE, 30 MGCAPSULE, 40 MG CAPSULE,50 MG CAPSULE, 60 MGCAPSULE, 70 MG CAPSULE)



98





Attention Deficit Hyperactivity Disorder Agents, Non-amphetaminesatomoxetine hcl (10 mg capsule,18 mg capsule, 25 mg capsule,40 mg capsule, 60 mg capsule,100 mg capsule)


atomoxetine hcl 80 mg capsule 2 PA, QL (30 PER 30 DAYS)

clonidine hcl er 4

dexmethylphenidate hcl 2 PA, QL (60 PER 30 DAYS)

dexmethylphenidate er 20 mg cp 4 PA, QL (60 PER 30 DAYS)

dexmethylphenidate hcl er (er 10mg cp, er 15 mg cp, er 25 mgcp, er 30 mg cp, er 35 mg cp, er40 mg cp)


guanfacine hcl er 4 PA

metadate er 4 PA, QL (90 PER 30 DAYS)

methylphenidate 5 mg chew tab 2 PA, QL (90 PER 30 DAYS)

methylphenidate er (er 18 mgtab, er 27 mg tab, er 54 mg tab)


methylphenidate er 36 mg tab 4 PA, QL (60 PER 30 DAYS)



methylphenidate er(la) 30mg cp 4 PA, QL (30 PER 30 DAYS)

methylphenidate hcl (5 mg/5 mlsoln, 10 mg/5 ml sol)

4 PA

methylphenidate 10 mg chewtab


methylphenidate hcl (2.5 mgchew tb, 5 mg tablet, 5 mg chewtab, 10 mg tablet, 20 mg tablet)


methylphenidate hcl cd 4 PA, QL (30 PER 30 DAYS)

methylphenidate hcl er (cd) 4 PA, QL (30 PER 30 DAYS)


99





methylphenidate la (30 mg cap,60 mg cap)


Central Nervous System, Otherbutalb-acetamin-caff 50-325-40tab (generic fioricet)

1 PA

butalbit-acetaminophen-caff 50-325-40 cap (generic zebutal)


butalbital-acetaminophn 50-300 1 PA, QL (360 PER 30 DAYS)

butalbital-acetaminophn 50-325 1 PA, QL (360 PER 30 DAYS)

butalb-acetamin-caff 50-325-40 1 PA, QL (360 PER 30 DAYS)

butalbital-acetaminophn 50-325tab (generic tencon)


butalbital-asa-caffeine cap 50-325-40 (generic fiorinal)

1 PA

INGREZZA 5 PA, QL (30 PER 30 DAYS)

INGREZZA INITIATION PACK 5 PA, QL (28 PER 365 OVER TIME)

NUEDEXTA 4 PA

riluzole 2 PA

tencon 4 PA, QL (360 PER 30 DAYS)

tetrabenazine 5 PA

TIGLUTIK 4

VYNDAQEL 5 PA, QL (120 PER 30 DAYS)

Fibromyalgia AgentsSAVELLA TITRATION PACK 3 QL (110 PER 365 OVER TIME)

SAVELLA (12.5 MG TABLET, 25MG TABLET, 50 MG TABLET,100 MG TABLET)


Multiple Sclerosis AgentsAMPYRA 5 PA, QL (60 PER 30 DAYS)


100





AUBAGIO 5 PA, QL (30 PER 30 DAYS)

AVONEX (30 MCG VIAL KIT,PREFILLED SYR 30 MCG KT)


AVONEX PEN 5 PA, QL (4 PER 28 DAYS)

BETASERON 0.3 MG KIT 5 PA, QL (15 PER 30 DAYS)

COPAXONE 20 MG/MLSYRINGE


COPAXONE 40 MG/MLSYRINGE


dalfampridine er 5 PA, QL (60 PER 30 DAYS)

FIRDAPSE 5 PA - FOR NEW STARTS ONLY,QL (240 PER 30 DAYS)

GILENYA 0.25 MG CAPSULE 5 PA, QL (30 PER 30 DAYS)

GILENYA 0.5 MG CAPSULE 5 PA, QL (30 PER 30 DAYS)

glatopa 20 mg/ml syringe 5 PA, QL (30 PER 30 DAYS)

MAYZENT (0.25 MG TABLET, 2MG TABLET)

5 PA

PLEGRIDY 125 MCG/0.5 MLSYRING


PLEGRIDY 125 MCG/0.5 MLPEN


PLEGRIDY PEN INJ STARTERPACK


REBIF (22 MCG/0.5 MLSYRINGE, 44 MCG/0.5 MLSYRINGE)


REBIF TITRATION PACK 5 PA, QL (8.4 PER 365 OVERTIME)

REBIF REBIDOSE (22 MCG/0.5ML, 44 MCG/0.5 ML)


REBIF REBIDOSE TITRATIONPACK

5 PA, QL (8.4 PER 365 OVERTIME)


101





TECFIDERA (DR 120 MGCAPSULE, DR 240 MGCAPSULE)


TECFIDERA STARTER PACK 5 PA, QL (120 PER 365 OVERTIME)

TYSABRI 5 PA

Dental and Oral Agents

cevimeline hcl 4

chlorhexidine gluconate 1

KEPIVANCE 5

paroex 1

periogard 1

pilocarpine hcl (5 mg tablet, 7.5mg tablet)

2

triamcinolone 0.1% paste 2

Dermatological Agents

acitretin (10 mg capsule, 25 mgcapsule)

4

acitretin 17.5 mg capsule 5

adapalene (0.1% gel, 0.1%solution, 0.1% cream, 0.3% gelpump, 0.3% gel)

2 PA

ammonium lactate (cream,lotion)

2

azelaic acid 2

calcipotriene (cream, ointment) 4

calcipotriene 0.005% solution 2

calcipotriene-betamethasone dp 4 QL (400 PER 28 DAYS)


102





calcitriol 3 mcg/g ointment 4

claravis 4 PA

clindamycin phos-benzoyl perox(pero 1.2-2.5%, perox 1.2-5%)

4

clindamycin phos-tretinoin 4 PA

clindamycin-benzoyl peroxide(clinda-benzoyl 1-5% pump,clindamycin-benzoyl 1-5%)

4

clotrimazole-betamethasone(crm, lot)

2

CONDYLOX 0.5% GEL 4

COSENTYX (2 SYRINGES) 5 PA

COSENTYX PEN 5 PA

COSENTYX PEN (2 PENS) 5 PA

COSENTYX SYRINGE 5 PA

diclofenac 1.5% topical soln 4 PA

diclofenac sodium 1% gel 2 QL (1000 PER 30 DAYS)

diclofenac sodium 3% gel 5 PA

doxepin 5% cream 4 QL (90 PER 30 DAYS)

DUOBRII 5 PA, QL (200 PER 30 DAYS)

ELIDEL 4

erythromycin-benzoyl peroxide 2

FINACEA (FOAM, GEL) 4

fluorouracil 0.5% cream 5

fluorouracil (2% topical soln, 5%cream, 5% topical soln)

2

imiquimod 5% cream packet 2

imiquimod 3.75% cream pump 5

klofensaid ii 4 PA


103





methoxsalen 5

MIRVASO (GEL, GEL PUMP) 4 PA

myorisan 4 PA

PICATO 5

pimecrolimus 2

podofilox 2

RECTIV 4

REGRANEX 5 PA

SANTYL 4

selenium sulfide 2.5% lotion 1

STELARA (45 MG/0.5 MLSYRINGE, 90 MG/MLSYRINGE)

5 PA

SYNALAR 0.025% CREAM 4

TACLONEX 0.005%-0.064%SUSPENS


tacrolimus (0.03%, 0.1%) 4 PA

TALTZ AUTOINJECTOR 5 PA

TALTZ AUTOINJECTOR (2PACK)

5 PA

TALTZ AUTOINJECTOR (3PACK)

5 PA

TALTZ SYRINGE 5 PA

TALTZ SYRINGE (2 PACK) 5 PA

TALTZ SYRINGE (3 PACK) 5 PA

tazarotene 4 PA

TAZORAC 0.05% CREAM 4 PA

TAZORAC (0.05% GEL, 0.1%GEL, 0.1% CREAM)



104





tretinoin (0.01% gel, 0.025% gel,0.025% cream, 0.05% gel,0.05% cream, 0.1% cream)

4 PA

tretinoin microsphere (gel 0.04%tube, gel 0.04% pump, gel 0.1%tube, gel 0.1% pump)

4 PA

VEREGEN 5

VERIPRED 20 4

zenatane 4 PA

ZYCLARA (2.5% CREAMPUMP, 3.75% CREAM PUMP,3.75% CREAM)

5

ZYFLO CR 5

Electrolytes/Minerals/Metals/Vitamins

Electrolyte/Mineral ReplacementAMINOSYN II WITHELECTROLYTES


AMINOSYN 7%-ELECTROLYTESOL


AMINOSYN 8.5%-ELECTROLYTES SOL


CARBAGLU 5

CLINIMIX (2.75%-5%SOLUTION, 4.25%-5%SOLUTION, 4.25%-25%SOLUTION, 4.25%-20%SOLUTION, 4.25%-10%SOLUTION, 5%-25%SOLUTION, 5%-15%SOLUTION)


CLINIMIX E 4 PA - Part B vs D Determination

dextrose 10%-0.2% nacl 2


105






dextrose 2.5%-0.45% nacl 2


dextrose 5%-0.2% nacl-kcl 2










dextrose 5%-1/2ns-kcl 2

dextrose 5%-ns-kcl 2

dextrose 5%-potassium chloride(20 in solution, 40 in solution)

2

dextrose in lactated ringers 2

dextrose in water (5%-water vial,5%-water 50 ml, 5%-water 100ml, 5%-water iv soln, 10%-wateriv solution)

1

fluoride 2

FLUORITAB (0.5 MG TABLETCHEW, 1 MG TABLET CHEW)

2

glucose in water 1

IONOSOL MB-DEXTROSE 5% 4

ISOLYTE P WITH DEXTROSE 4

ISOLYTE S IV SOLUTION-EXCEL

4


106





klor-con 20 meq packet 3

KLOR-CON 10 3

KLOR-CON 8 3

klor-con m10 2

KLOR-CON M15 2

klor-con m20 2

klor-con sprinkle 3

lactated ringers injection 2

ludent fluoride 2

magnesium sulfate (syringe, vial) 2

NORMOSOL-M ANDDEXTROSE

4

NORMOSOL-R ANDDEXTROSE

1

NORMOSOL-R PH 7.4 4

PLASMA-LYTE 148 4

PLASMA-LYTE A PH 7.4 4

potassium chl-normal saline 2

potassium chloride (2 meq/mlconc, er 8 meq tablet, er 10 meqtablet, 10 meq/100 ml sol, er 10meq capsule, 10 meq/5 ml conc,20 meq packet, 20 meq/10 mlconc, 20 meq/100 ml sol, 40meq/20 ml conc, 40 meq/100 mlsol, 60 meq/30 ml conc)

1

potassium chloride (er 8 meqcapsule, 10% (20 meq/15ml),10% (40 meq/30ml), 20% (40meq/15ml), er 20 meq tablet)

2

kcl 20 meq in d5w-lact ringer 2

potassium chloride proamp 1


107





potassium chloride-nacl 2

potassium cl 20meq/100ml-water

1

potassium citrate er 2

PROCALAMINE 4 PA - Part B vs D Determination

sodium chloride (saline 0.45%soln-excel con, sodium chloride0.45% soln, sodium chloride0.9% 250 ml, sodium chloride0.9% 50 ml, sodium chloride0.9% soln, sodium chloride 0.9%500 ml, sodium chloride 0.9%1,000 ml, sodium chloride 0.9%sol-excel, sodium chloride 0.9%solution, sodium chloride 0.9%100 ml, sodium chloride 3% ivsoln, sodium chloride 5% iv soln,sodium chloride 50 meq/20 ml,sodium chloride 100 meq/40 ml)

1

sodium chloride-water 1

sodium fluoride (0.25 (0.55) mg,0.5 mg(1.1 mg), 1 mg (2.2 mg))

2

sodium lactate 2

TPN ELECTROLYTES 4

TPN ELECTROLYTES II 4

Electrolyte/Mineral/Metal ModifiersCUPRIMINE 5

deferasirox (125 mg tb susp, 250mg tb susp, 500 mg tb susp)

5 PA

DEPEN 5

EXJADE 5 PA

FERRIPROX (100 MG/MLSOLUTION, 500 MG TABLET,1,000 MG TABLET)

5 PA


108





JADENU 5 PA

JYNARQUE (15 MG TABLET,30 MG TABLET, 45 MG-15 MGTABLET, 60 MG-30 MGTABLET, 90 MG-30 MGTABLET)

5 PA

kionex 15 gm/60 ml suspension 2

penicillamine 5 QL (120 PER 30 DAYS)

SAMSCA 15 MG TABLET 5 QL (60 PER 30 DAYS)

SAMSCA 30 MG TABLET 5 QL (60 PER 30 DAYS)

sodium polystyrene sulfonate(sod polystyren sulf 15 g/60 ml,sodium polystyrene sulf powder,sps 15 gm/60 ml suspension,sps 30 gm/120 ml enema, sps50 gm/200 ml enema)

2

SPS 15 GM/60 MLSUSPENSION

2

SYPRINE 5

Phosphate Binderscalcium acetate (667 mgcapsule, 667 mg tablet, 667 mggelcap)

2

eliphos 2

FOSRENOL (500 MG TABLETCHEW, 750 MG TABLETCHEW, 750 MG POWDERPACKET, 1,000 MG POWDERPACK, 1,000 MG TABLETCHEW)

5

PHOSLYRA 4

RENAGEL 800 MG TABLET 5

RENVELA (0.8 GM POWDERPACKET, 2.4 GM POWDERPACKET, 800 MG TABLET)

5


109





sevelamer 0.8 gm powderpacket


sevelamer 2.4 gm powderpacket


sevelamer carbonate 800 mg tab 1

sevelamer hcl 5

VELPHORO 5

VitaminsAZESCO 2

m-natal plus 2

PREGENNA 2

prenatal vitamins 2

TRICARE PRENATAL DHAONE

2

TRINAZ 2

zalvit 2

Gastointestinal Agents

Gastrointestinal Agents, Otherdiphenoxylate-atrop 2.5-0.025 2

Gastrointestinal Agents

Antispasmodics, GastrointestinalCUVPOSA 4

dicyclomine hcl (10 mg capsule,10 mg/5 ml soln, 20 mg/2 ml vial,20 mg/2 ml ampul, 20 mg tablet)

1

glycopyrrolate (1 mg tablet, 2 mgtablet)

2


110





glycopyrrolate (0.2 mg/ml vial,0.4 mg/2 ml vl, 1 mg/5 ml vial, 4mg/20 ml vial)

4

methscopolamine bromide 4

Gastrointestinal Agents, OtherCHENODAL 5

CHOLBAM 5 PA

cromolyn 100 mg/5 ml oral conc 4

diphenoxylat-atrop 2.5-0.025/5 1

GATTEX 5 PA

lansoprazol-amoxicil-clarithro 2

loperamide 2

metoclopramide hcl (5 mg tablet,5 mg/5 ml soln, 10 mg tablet, 10mg/10 ml sol)

1

metoclopramide 10 mg/2 ml vial 2

metoclopramide hcl odt 4

MOVANTIK 4 QL (30 PER 30 DAYS)

OCALIVA 5 PA, QL (30 PER 30 DAYS)

PYLERA 5

RELISTOR (12 MG/0.6 MLSYRINGE, 12 MG/0.6 ML VIAL)


RELISTOR 8 MG/0.4 MLSYRINGE


ursodiol 300 mg capsule 3

ursodiol (250 mg tablet, 500 mgtablet)

4

Histamine2 (H2) Receptor Antagonistscimetidine (200 mg tablet, 300mg tablet, 300 mg/5 ml soln, 400mg tablet, 800 mg tablet)

2


111





famotidine 40 mg/5 ml susp 4

famotidine (20 mg tablet, 20 mgpiggyback, 40 mg tablet)

1

famotidine 20 mg/2 ml vial 2

nizatidine 150 mg capsule 2

nizatidine 300 mg capsule 1

nizatidine 15 mg/ml solution 4

ranitidine hcl (15 mg/ml syrup,150 mg/10 ml syrup, 150 mgtablet, 150 mg capsule, 300 mgcapsule, 300 mg tablet)

1

ranitidine hcl 50 mg/2 ml vial 2

Irritable Bowel Syndrome Agentsalosetron hcl 5 PA

AMITIZA 3 QL (60 PER 30 DAYS)

LINZESS 3 QL (30 PER 30 DAYS)

Laxativesconstulose 2

enulose 1

gavilyte-c 1

gavilyte-g 1

gavilyte-n 2

generlac 1

GOLYTELY PACKET 4

KRISTALOSE 4

lactulose (10 gm/15 ml solution,10 gm packet, 20 gm/30 mlsolution)

2

MOVIPREP 3


112





peg 3350-electrolyte 2

peg-3350 and electrolytes 1

polyethylene glycol 3350 2

PREPOPIK 4

SUPREP 3

trilyte with flavor packets 2

ProtectantsCARAFATE 1 GM/10 ML SUSP 4

misoprostol 2

sucralfate 2

Proton Pump InhibitorsDEXILANT 4 QL (30 PER 30 DAYS)

esomeprazole magnesium 2 QL (30 PER 30 DAYS)

esomeprazole sodium 2

lansoprazole (dr 15 mg capsule,dr 30 mg capsule)


NEXIUM PACKETS (DR 2.5MG, DR 5 MG, DR 10 MG, DR20 MG, DR 40 MG)


omeprazole (dr 10 mg capsule,dr 20 mg capsule)


omeprazole dr 40 mg capsule 1 QL (30 PER 30 DAYS)

pantoprazole sodium (dr 20 mgtab, dr 40 mg tab)


pantoprazole sodium 40 mg vial 2

rabeprazole sod dr 20 mg tab 2 QL (30 PER 30 DAYS)

Genetic or Enzyme Disorder: Replacement, Modifiers, Treatment

ADAGEN 5 PA


113





ALDURAZYME 5 PA

BUPHENYL 500 MG TABLET 5

CERDELGA 5 PA

CEREZYME 400 UNITS VIAL 5 PA

CREON (DR 3,000 CAPSULE,DR 6,000 CAPSULE, DR 12,000CAPSULE, DR 24,000CAPSULE)

3

CREON DR 36,000 UNITSCAPSULE

5

CYSTADANE 5

CYSTAGON 4

ELAPRASE 5 PA

EXONDYS 51 5 PA

FABRAZYME 35 MG VIAL 5 PA

GALAFOLD 5 PA

KANUMA 5 PA

KUVAN (100 MG TABLET, 100MG POWDER PACKET, 500MG POWDER PACKET)

5 PA

LUMIZYME 5 PA

miglustat 5 PA

NAGLAZYME 5 PA

NITYR 5

ORFADIN (2 MG CAPSULE, 4MG/ML SUSPENSION, 5 MGCAPSULE, 10 MG CAPSULE)

5

PALYNZIQ 5 PA

PROCYSBI 5 PA

RAVICTI 5 PA


114





sodium phenylbutyrate powder 5

STRENSIQ 5 PA

SUCRAID 5

TEGSEDI 5 PA, QL (6 PER 30 DAYS)

VPRIV 5 PA

ZAVESCA 5 PA

ZENPEP (DR 20,000 UNITCAPSULE, DR 40,000 UNITCAPSULE)

5

ZENPEP (DR 3,000 UNITCAPSULE, DR 5,000 UNITCAPSULE, DR 10,000 UNITCAPSULE, DR 15,000 UNITCAPSULE, DR 25,000 UNITCAPSULE)

3

Genitourinary Agents

Antispasmodics, Urinarydarifenacin er 4

flavoxate hcl 2

GELNIQUE (GEL PUMP, GELSACHET, GEL SACHETS)

4 ST

MYRBETRIQ 3

oxybutynin chloride (5 mg/5 mlsyrup, 5 mg tablet)

1

oxybutynin chloride er 2

solifenacin succinate 1

tolterodine tartrate 2

tolterodine tartrate er 2

TOVIAZ 4


115





trospium chloride 2

trospium chloride er 2

VESICARE 3

Benign Prostatic Hypertrophy Agentsalfuzosin hcl er 1

CARDURA XL 4

doxazosin mesylate 1

dutasteride 4

dutasteride-tamsulosin 4

finasteride 5 mg tablet 1

RAPAFLO 3

silodosin 2

tamsulosin hcl 1

terazosin hcl 1

Genitourinary Agents, Otherbethanechol chloride 2

CIALIS (10 MG TABLET, 20 MGTABLET)

2 ED, QL (4 PER 30 OVER TIME)

CORLANOR 5 MG/5 ML ORALSOLN

4

ELMIRON 4

sildenafil citrate (25 mg tablet,50 mg tablet, 100 mg tablet)

1 ED, QL (4 PER 30 OVER TIME)

tadalafil 20 mg tablet 5 PA

THIOLA EC 5 PA, QL (180 PER 30 DAYS)

Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)

ala-cort 2.5% cream 1


116





alclometasone dipropionate (diproint, dipro crm)

2

amcinonide (cream, lotion,ointment)

4

apexicon e 4

betamethasone dipropaugmented (crm, gel, lot, oin)

2

betamethasone dipropionate(crm, lot, oint)

2

betamethasone valer 0.12%foam

4

betamethasone valerate (vacream, va lotion, valer ointm)

2

CAPEX SHAMPOO 4

clobetasol emollient (emollientcrm, emollnt foam)

4

clobetasol emulsion 4

clobetasol propionate (cream,gel, ointment, shampoo)

4

clobetasol 0.05% solution 2

clodan 0.05% shampoo 4

colocort 2

CORDRAN 4 MCG/SQ CMTAPE LARGE

4

cortisone acetate 2

DEPO-MEDROL 20 MG/MLVIAL

4

DESONATE 4

desonide (cream, lotion,ointment)

2

desoximetasone (0.05% gel,0.05% ointment, 0.05% cream,0.25% cream, 0.25% ointment,0.25% spray)

4


117





dexamethasone (0.5 mg/5 mlelx, 0.5 mg/5 ml liq, 6 day 1.5mg tab, 10 day 1.5 mg tb, 13 day1.5 mg tb)

2

dexamethasone (0.5 mg tablet,0.75 mg tablet, 1 mg tablet, 1.5mg tablet, 2 mg tablet, 4 mgtablet, 6 mg tablet)

1

dexamethasone intensol 2

dexamethasone sodiumphosphate (4 mg/ml vial, 4mg/ml syringe, 10 mg/ml vial, 20mg/5 ml vial, 100 mg/10 ml vl,120 mg/30 ml vl)

1

fludrocortisone acetate 2

fluocinolone acetonide (0.01%solution, 0.01% cream, 0.01%body oil, 0.025% cream, 0.025%ointment)

2

fluocinonide 0.1% cream 5

fluocinonide 0.05% gel 4

fluocinonide (ointment, solution) 2

fluocinonide-e 2

flurandrenolide 0.05% cream 4

fluticasone propionate (0.005%oint, 0.05% cream, 0.05% lotion)

2

halobetasol propionate (cream,ointmnt)

2

hydrocortisone (2.5% cream,2.5% ointment, 2.5% lotion, 5mg tablet, 10 mg tablet, 20 mgtablet, 100 mg/60 ml)

1

hydrocortisone butyr 0.1% lotn 1


118





hydrocortisone butyrate(hydrocort buty lipid crm,hydrocort buty lipo cream,hydrocortisone butyr oint,hydrocortisone butyr soln)

4

hydrocortisone valerate (cream,ointmt)

4

KENALOG-40 4

methylprednisolone (4 mg tablet,4 mg dosepk)

1

methylprednisolone (8 mg tab,16 mg tab, 32 mg tab)

2

methylprednisolone acetate (40mg/ml vl, 80 mg/ml vl)

2

methylprednisolone sodium succ(40 mg vl, 125 mg)

2

methylprednisolone ss 1 gm vl 4

millipred 5 mg tablet 4

mometasone furoate (cream,oint, soln)

1

PANDEL 5

prednicarbate (cream, ointment) 2

prednisolone 2

prednisolone sodium phosphate(5 mg/5 ml soln, 10 mg/5 mlsoln, 15 mg/5 ml soln, 20 mg/5ml soln, sod ph 25 mg/5 ml)

2

prednisone (1 mg tablet, 2.5 mgtablet, 5 mg tab dose pack, 5 mgtablet, 5 mg/5 ml solution, 10 mgtab dose pack, 10 mg tablet, 20mg tablet, 50 mg tablet)

1

SOLU-CORTEF (100 MG ACT-O-VIAL, 100 MG VIAL, 250 MGACT-O-VIAL)

4


119





SOLU-MEDROL 2,000 MG VIAL 4

SYNALAR 0.025% CREAM KIT 4

triamcinolone 0.147 mg/g spray 4

triamcinolone acetonide (0.025%lotion, 0.025% oint, 0.025%cream, 0.1% ointment, 0.1%cream, 0.1% lotion, 0.5%ointment, 0.5% cream)

1

triderm 0.1% cream 1

UCERIS 2 MG RECTAL FOAM 4

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)

ACTHAR 5 PA

chorionic gonad 10,000 unit vl 4 PA

desmopressin acetate (0.01%spray, 0.01% solution, acetate0.1 mg tb, acetate 0.2 mg tb)

2

desmopressin acetate (ac 4mcg/ml vial, ac 4 mcg/ml ampul,40 mcg/10 ml vial)

4

EGRIFTA 1 MG VIAL 5 PA, QL (60 PER 30 DAYS)

EGRIFTA 2 MG VIAL 5 PA, QL (60 PER 30 DAYS)

GENOTROPIN (MINIQUICK 0.4MG, MINIQUICK 0.6 MG,MINIQUICK 0.8 MG,MINIQUICK 1 MG, MINIQUICK1.2 MG, MINIQUICK 1.4 MG,MINIQUICK 1.6 MG,MINIQUICK 1.8 MG,MINIQUICK 2 MG, 5 MGCARTRIDGE, 12 MGCARTRIDGE)

5 PA

GENOTROPIN MINIQUICK 0.2MG

4 PA


120





HUMATROPE (5 MG VIAL, 6MG CARTRIDGE, 12 MGCARTRIDGE, 24 MGCARTRIDGE)

5 PA

INCRELEX 5

NORDITROPIN FLEXPRO 5 PA

NORDITROPIN NORDIFLEX 5 PA

NOVAREL 10,000 UNITS VIAL 4 PA

NUTROPIN AQ NUSPIN 5 PA

OMNITROPE (5 MG/1.5 ML, 10MG/1.5 ML)

5 PA

PREGNYL 4 PA

SAIZEN (5 MG VIAL, 8.8 MGVIAL)

5 PA

SAIZEN-SAIZENPREP 5 PA

SEROSTIM 5 PA

STIMATE 5

ZOMACTON 10 MG VIAL 5 PA

ZOMACTON 5 MG VIAL 4 PA

ZORBTIVE 5 PA

Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins)

KORLYM 5 PA, QL (120 PER 30 DAYS)

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

Anabolic SteroidsANADROL-50 5 PA

oxandrolone 10 mg tablet 4 PA, QL (60 PER 30 DAYS)

oxandrolone 2.5 mg tablet 3 PA, QL (240 PER 30 DAYS)


121





AndrogensANDRODERM 3 PA

ANDROGEL (1.62%(1.25G)GEL PCKT, 1.62% GEL PUMP,1.62%(2.5G) GEL PCKT)

3 PA

danazol 2

methyltestosterone 5 PA

testosterone (1.62% (2.5 g) pkt,1.62%(1.25 g) pkt, 1.62% gelpump, 12.5 mg/1.25 gram)

3 PA

testosterone (25 mg/2.5 gm pkt,50 mg/5 gram gel, 50 mg/5 grampkt)


testosterone cypionate(testosteron 1,000 mg/10 ml,testosteron 2,000 mg/10 ml,testosterone 100 mg/ml,testosterone 200 mg/ml,testosterone 500 mg/2.5 ml,testosterone 500 mg/5 ml,testosterone 1,000 mg/5 ml,testosterone 6,000 mg/30ml)

2 PA

testosterone enanthate 2 PA

Estrogensalyacen 1-35 28 tablet 2

amabelz 4 PA

amethia 2 QL (91 PER 91 DAYS)

amethia lo 2 QL (91 PER 91 DAYS)

apri 2

aranelle 2

ashlyna 2 QL (91 PER 91 DAYS)

aubra 2


122





aubra eq 2

aviane 2

balziva 2

bekyree 2

BIJUVA 4 PA

blisovi 24 fe 2

blisovi fe 2

briellyn 2

camrese lo 2 QL (91 PER 91 DAYS)

caziant 2

CLIMARA PRO 4 PA

COMBIPATCH 4 PA

cryselle 2

cyclafem 2

delyla 2

DEPO-ESTRADIOL 4

desogestr-eth estrad eth estra 2

drosp-ee-levomef 3-0.02-0.451 2

drospirenone-ee 3-0.03 mg tab 2

emoquette 2

enpresse 2

ESTRACE 0.01% CREAM 4

estradiol 0.01% cream 2


123





estradiol (tds 0.025 mg/day,0.025 mg patch, 0.0375 mg/daypatch, tds 0.0375 mg/day,0.0375 mg patch, 0.05 mg patch,tds 0.05 mg/day, 0.06 mg/daypatch, tds 0.06 mg/day, tds0.075 mg/day, 0.075 mg patch,0.075 mg/day patch, 0.1 mgpatch, tds 0.1 mg/day)

2 PA

estradiol (0.5 mg tablet, 1 mgtablet, 2 mg tablet)

1 PA

estradiol valerate 2

estradiol-norethindrone acetat 1 PA

ESTRING 4 QL (1 PER 90 OVER TIME)

falmina 2

FEMRING 4 QL (1 PER 90 OVER TIME)

femynor 2

fyavolv 4 PA

gianvi 2

gildagia 2

hailey 24 fe 4

introvale 2 QL (91 PER 91 DAYS)

jinteli 1 PA

juleber 2

junel 1 mg-20 mcg tablet 2

junel fe 2

junel fe 24 2

kaitlib fe 2

kariva 2

kelnor 1-35 2


124





kimidess 2

larin 2

larin fe 2

larissia 2

LAYOLIS FE 2

leena 2

lessina 2

levonest 2

levonor-eth estrad 0.15-0.03 2 QL (91 PER 91 DAYS)

levonorgestrel-eth estradiol (0.1-0.02 mg, triphasic)

2

levora-28 2

LO LOESTRIN FE 4

loryna 2

low-ogestrel 2

lutera 2

marlissa 2

MENEST (0.3 MG TABLET,0.625 MG TABLET, 1.25 MGTABLET)


microgestin 2

microgestin fe 2

mimvey 4 PA

mimvey lo 4 PA

MINASTRIN 24 FE 4

mononessa 2

necon (0.5-35-28 tablet, 7-7-7-28 tablet)

2


125





nikki 2

norethin-eth estra-ferrous fum(noret-estr-fe 0.4-0.035(21)-75,noreth-estrad-fe 1-0.02(24)-75,norethin-estra-fe 0.8-0.025 mg)

2

norethind-eth estrad 1-0.02 mg 2

norethindron-ethinyl estradiol(norethin-eth 1 mg-5 mcg,norethind-eth 0.5-2.5)

4 PA

norgestimate-ethinyl estradiol 2

nortrel (0.5-35-28 tablet, 1-35 28tablet, 7-7-7-28 tablet)

2

NUVARING 4

ocella 2

ogestrel 2

orsythia 2

pimtrea 2

pirmella (1-35-28 tablet, 1-35 28tablet)

2

portia 2

PREMARIN VAGINAL CREAM-APPL

3

PREMARIN (0.3 MG TABLET,0.45 MG TABLET, 0.625 MGTABLET, 0.9 MG TABLET, 1.25MG TABLET)

4 PA

PREMPHASE 4 PA

PREMPRO 4 PA

previfem 2

quasense 2 QL (91 PER 91 DAYS)

reclipsen 2


126





setlakin 2 QL (91 PER 91 DAYS)

sprintec 2

sronyx 2

tarina fe 2

tarina fe 1-20 eq 2

tri-legest fe 2

tri-lo-estarylla 2

tri-lo-sprintec 2

tri-previfem 2

tri-sprintec 2

trinessa 2

trivora-28 2

velivet 2

vestura 2

vienva 2

vyfemla 2

wymzya fe 2

xulane 4

yuvafem 4

zarah 2

zenchent 2

zovia 1-35e 2

Progestinscamila 2

CRINONE 4 PA

deblitane 2

DEPO-PROVERA 400 MG/MLVIAL



127





DEPO-SUBQ PROVERA 104 4 QL (0.65 PER 90 OVER TIME)

errin 2

hydroxyprogesterone caproate(hydroxyprogest 250 mg/ml vial,hydroxyprogesterone 1.25g/5ml)

5 PA

jolivette 2

lyza 2

MAKENA 250 MG/ML VIAL 5 PA

medroxyprogesterone 150mg/ml


medroxyprogesterone acetate(2.5 mg tab, 5 mg tab, 10 mgtab)

1

megestrol acet 400 mg/10 ml 1 PA, PA - FOR NEW STARTSONLY

megestrol acetate (20 mg tablet,acet 40 mg/ml susp, 40 mgtablet, 625 mg/5 ml susp)


nora-be 2

norethindrone 2

norethindrone ac (lupaneta) 2

norethindrone acetate 2

norlyroc 2

progesterone (100 mg capsule,200 mg capsule)

2

sharobel 2

Selective Estrogen Receptor Modifying AgentsOSPHENA 3

raloxifene hcl 2


128





Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)

levothyroxine sodium (25 mcgtablet, 50 mcg tablet, 75 mcgtablet, 88 mcg tablet, 100 mcgtablet, 112 mcg tablet, 125 mcgtablet, 137 mcg tablet, 150 mcgtablet, 175 mcg tablet, 200 mcgtablet, 300 mcg tablet)

1

LEVOXYL 3

liothyronine sodium (5 mcg tab,25 mcg tab, 50 mcg tab)

2

liothyronine sod 10 mcg/ml vl 4

SYNTHROID 3

THYROLAR-1 4

THYROLAR-1/2 4

THYROLAR-1/4 4

THYROLAR-2 4

THYROLAR-3 4

TIROSINT (13 MCG CAPSULE,25 MCG CAPSULE, 50 MCGCAPSULE, 75 MCG CAPSULE,88 MCG CAPSULE, 100 MCGCAPSULE, 112 MCGCAPSULE, 125 MCGCAPSULE, 137 MCGCAPSULE, 150 MCGCAPSULE)

4

TIROSINT-SOL 4

UNITHROID 3

Hormonal Agents, Suppressant (Adrenal)

LYSODREN 3


129





Hormonal Agents, Suppressant (Pituitary)

cabergoline 2

ELIGARD (22.5 MG SYRINGEB, 22.5 MG SYRINGE KIT)


ELIGARD (30 MG SYRINGE B,30 MG SYRINGE KIT)


ELIGARD (45 MG SYRINGE B,45 MG SYRINGE KIT)


ELIGARD (7.5 MG SYRINGE B,7.5 MG SYRINGE KIT)


FIRMAGON (2 X 120 MG KIT,120 MG VIAL)


FIRMAGON 80 MG KIT 4 PA - FOR NEW STARTS ONLY,QL (1 PER 28 OVER TIME)

leuprolide acetate (1 mg/0.2 mlkit, 14 mg/2.8 ml vl, 14 mg/2.8ml kt)


LUPANETA PK 11.25-5 MG3MO KIT


LUPANETA PK 3.75-5 MG 1MOKIT


LUPRON DEPOT (11.25 MG3MO KIT, 22.5 MG 3MO KIT)


LUPRON DEPOT (3.75 MG KIT,7.5 MG KIT)


LUPRON DEPOT 45 MG 6MOKIT


LUPRON DEPOT-4 MONTH KIT 5 PA - FOR NEW STARTS ONLY,QL (1 PER 112 OVER TIME)

LUPRON DEPO 11.25MG(LUPANETA)


LUPRON DEPOT 3.75MG(LUPANETA)



130





LUPRON DEPOT-PED (11.25MG KIT, 15 MG KIT)


LUPRON DEPOT-PED 7.5 MGKIT


LUPRON DEPOT-PED 11.25MG 3MO


LUPRON DEPOT-PED 30 MG3MO KIT


octreotide acetate (acet 0.05mg/ml vl, acet 50 mcg/ml amp,acet 50 mcg/ml vial, acet 100mcg/ml vl, acet 100 mcg/ml amp,acet 200 mcg/ml vl, acet 500mcg/ml vl, acet 500 mcg/ml amp,1,000 mcg/5 ml vial)

4 PA

SANDOSTATIN LAR DEPOT 5 PA

SIGNIFOR 5 PA, QL (60 PER 30 DAYS)

SIGNIFOR LAR (20 MG VIAL,20 MG KIT, 40 MG KIT, 40 MGVIAL, 60 MG VIAL, 60 MG KIT)


SOMATULINE DEPOT (60MG/0.2 ML, 90 MG/0.3 ML)

5 PA

SOMATULINE DEPOT 120MG/0.5 ML


SOMAVERT 5 PA

SYNAREL 5

TRELSTAR 11.25 MG VIAL 5 PA - FOR NEW STARTS ONLY,QL (1 PER 84 OVER TIME)




131





Hormonal Agents, Suppressant (Thyroid)

Antithyroid Agentsmethimazole 1

propylthiouracil 2

Immunological Agents

Angioedema AgentsBERINERT (500 UNIT VIAL, 500UNIT KIT)

5 PA

CINRYZE 5 PA

FIRAZYR 5 PA

icatibant 5

RUCONEST 5 PA

Immune SuppressantsASTAGRAF XL (0.5 MGCAPSULE, 1 MG CAPSULE)


ASTAGRAF XL 5 MG CAPSULE 5 PA - Part B vs D Determination

AZASAN 4 PA - Part B vs D Determination

azathioprine 2 PA - Part B vs D Determination

azathioprine sodium 2

BENLYSTA (120 MG VIAL, 200MG/ML SYRINGE, 200 MG/MLAUTOINJECT, 400 MG VIAL)

5 PA

CELLCEPT 500 MG VIAL 4

CIMZIA (2X200 MG/MLSYRINGE KIT, 2X200MG/ML(X3)START KT, 200 MGVIAL KIT)

5 PA


132





cyclosporine 250 mg/5 ml ampul 2

cyclosporine (25 mg capsule,100 mg capsule)


cyclosporine modified (25 mg,50 mg, 100 mg, 100mg/ml)


DUPIXENT 200 MG/1.14 MLSYRING

5 PA

ENBREL (25 MG KIT, 25MG/0.5 ML SYRINGE, 50MG/ML SYRINGE)

5 PA

ENBREL MINI 5 PA

ENBREL SURECLICK 5 PA

gengraf (25 mg capsule, 50 mgcapsule, 100 mg/ml solution, 100mg capsule)


HUMIRA 5 PA

HUMIRA PEDIATRIC CROHN'S 5 PA

HUMIRA PEN 5 PA

HUMIRA PEN CROHN'S-UC-HS 5 PA

HUMIRA PEN PSORIASIS-STARTER PACK

5 PA

HUMIRA(CF) 5 PA

HUMIRA(CF) PEDIATRICCROHN'S

5 PA

HUMIRA(CF) PEN 40 MG/0.4ML

5 PA

HUMIRA(CF) PEN CROHN'S-UC-HS

5 PA

HUMIRA(CF) PEN PSOR-UV-ADOL HS

5 PA

INFLECTRA 5 PA

KEVZARA (150 MG/1.14 MLSYRINGE, 200 MG/1.14 MLSYRINGE)

5 PA


133





KINERET 5 PA

methotrexate (1 gm vial, 2.5 mgtablet, 50 mg/2 ml vial, 250mg/10 ml vial)

1

methotrexate sodium 1

mycophenolate 200 mg/ml susp 5 PA - Part B vs D Determination

mycophenolate mofetil (250 mgcapsule, 500 mg tablet)


mycophenolate 500 mg vial 2

mycophenolic acid 4 PA - Part B vs D Determination

NULOJIX 5 PA - FOR NEW STARTS ONLY

ORENCIA (50 MG/0.4 MLSYRINGE, 87.5 MG/0.7 MLSYRINGE, 125 MG/MLSYRINGE, 250 MG VIAL)

5 PA

ORENCIA CLICKJECT 5 PA, QL (4 PER 28 DAYS)

PROGRAF 5 MG/ML AMPULE 4

PROGRAF (0.2 MG GRANULEPACKET, 1 MG GRANULEPACKET)


RAPAMUNE 1 MG/ML ORALSOLN


REMICADE 5 PA

SANDIMMUNE 100 MG/MLSOLN


SIMPONI (50 MG/0.5 MLSYRINGE, 50 MG/0.5 ML PENINJEC, 100 MG/ML PENINJECTOR, 100 MG/MLSYRINGE)

5 PA

SIMPONI ARIA 5 PA

sirolimus (0.5 mg tablet, 1 mgtablet)



134





sirolimus (1 mg/ml solution, 2 mgtablet)


tacrolimus (0.5 mg capsule, 1mg capsule)


tacrolimus 5 mg capsule 4 PA - Part B vs D Determination

TREXALL 4

XATMEP 5

ZORTRESS (0.5 MG TABLET,0.75 MG TABLET)


ZORTRESS 0.25 MG TABLET 4 PA - FOR NEW STARTS ONLY

ZORTRESS 1 MG TABLET 5 PA - FOR NEW STARTS ONLY,PA - Part B vs D Determination

Immunizing Agents, PassiveATGAM 5

BIVIGAM 5 PA

CARIMUNE NF 6 GM VIAL 5 PA

FLEBOGAMMA DIF 10% VIAL 5 PA

GAMASTAN S-D 3 PA

GAMMAGARD LIQUID 5 PA

GAMMAGARD S-D 5 PA

GAMMAKED (1 GRAM/10 MLVIAL, 5 GRAM/50 ML VIAL, 10GRAM/100 ML VIAL, 20GRAM/200 ML VIAL)

5 PA

GAMMAPLEX (5 GRAM/100 MLVIAL, 10 GRAM/200 ML VIAL,20 GRAM/400 ML VIAL)

5 PA

GAMUNEX-C 5 PA

HIZENTRA 5 PA

HYPERRAB S-D 3


135





IMOGAM RABIES-HT 3

OCTAGAM 5 PA

PANZYGA 5 PA

PRIVIGEN 5 PA

SYNAGIS 50 MG/0.5 ML VIAL 5 PA

THYMOGLOBULIN 5

VARIZIG 125 UNIT/1.2 ML VIAL 3

ImmunomodulatorsACTEMRA 162 MG/0.9 MLSYRINGE

5 PA, QL (3.6 PER 28 DAYS)

ACTEMRA (200 MG/10 MLVIAL, 400 MG/20 ML VIAL)

5 PA

ACTEMRA 80 MG/4 ML VIAL 4 PA

ACTEMRA ACTPEN 5 PA, QL (3.6 PER 28 DAYS)

ACTIMMUNE 5 PA - FOR NEW STARTS ONLY

ARCALYST 5 PA

ILARIS 5 PA, QL (2 PER 28 DAYS)

leflunomide 2

OTEZLA (28 DAY STARTERPACK, 30 MG TABLET)

5 PA

RIDAURA 5

SIMULECT 20 MG VIAL 5

STELARA 130 MG/26 ML VIAL 5 PA

TAVALISSE 5 PA

XELJANZ 5 PA

XELJANZ XR 5 PA


136





VaccinesACTHIB 3

ADACEL TDAP (SYRINGE,VIAL)

3

BCG VACCINE (TICE STRAIN) 4

BEXSERO 3

BOOSTRIX TDAP (SYRINGE,VIAL)

3

DAPTACEL DTAP 3

DIPHTHERIA-TETANUSTOXOIDS-PED

2

ENGERIX-B 20 MCG/ML SYRN 3 PA - Part B vs D Determination

ENGERIX-B PEDIATRIC-ADOLESCENT


GARDASIL 9 (9 VIAL, 9SYRINGE)

3

HAVRIX (720 UNITS/0.5 MLVIAL, 720 UNIT/0.5 MLSYRINGE, 1,440 UNITS/MLVIAL, 1,440 UNITS/MLSYRINGE)

3

HIBERIX 3

IMOVAX RABIES VACCINE 3 PA - Part B vs D Determination

INFANRIX DTAP VIAL 3

IPOL 3

IXIARO 3

KINRIX (TIP-LOK SYRINGE,VIAL)

3

M-M-R II VACCINE 3

MENACTRA 3

MENVEO A-C-Y-W-135-DIP 3


137





PEDIARIX 3

PEDVAXHIB 3

PENTACEL ACTHIBCOMPONENT

3

PROQUAD 3

QUADRACEL DTAP-IPV 3

RABAVERT 3 PA - Part B vs D Determination

RECOMBIVAX HB (5 MCG/0.5ML SYR, 10 MCG/ML VIAL, 10MCG/ML SYR, 40 MCG/MLVIAL)


ROTARIX 3

ROTATEQ 3

SHINGRIX 3

TDVAX 3

TENIVAC SYRINGE 3

TRUMENBA 3

TWINRIX 3

TYPHIM VI (25 MCG/0.5 MLSYRNG, 25 MCG/0.5 ML AL)

3

VAQTA (25 UNITS/0.5 MLSYRINGE, 25 UNITS/0.5 MLVIAL, 50 UNITS/ML SYRINGE,50 UNITS/ML VIAL)

3

VARIVAX VACCINE 3

YF-VAX 3

ZOSTAVAX 3


138





Inflammatory Bowel Disease Agents

AminosalicylatesAPRISO 3

balsalazide disodium 2

CANASA 5

DIPENTUM 5

LIALDA 3

mesalamine 1,000 mg supp 2

mesalamine (dr 1.2 gm tablet, 4gm/60 ml kit, 800 mg dr tablet)

4

mesalamine dr 4 QL (180 PER 30 DAYS)

PENTASA 4

Glucocorticoidsbudesonide ec 4

budesonide er 2 ST

procto-med hc 2

procto-pak 2

proctosol-hc 2

proctozone-hc 2

UCERIS 9 MG ER TABLET 5 ST

Sulfonamidessulfasalazine 2

sulfasalazine dr 2

Metabolic Bone Disease Agents

alendronate sod 70 mg/75 ml 2


139





alendronate sodium (5 mg tablet,10 mg tab, 35 mg tab, 40 mgtab)

1

alendronate sodium 70 mg tab 1 QL (4 PER 28 DAYS)

BINOSTO 4 QL (4 PER 28 DAYS)

calcitonin-salmon 2 QL (3.7 PER 30 DAYS)

calcitriol (1 mcg/ml solution, 1mcg/ml ampul)

2

calcitriol (0.25 mcg capsule, 0.5mcg capsule)

1

cinacalcet hcl (60 mg tablet, 90mg tablet)


cinacalcet hcl 30 mg tablet 3 PA - Part B vs D Determination

doxercalciferol (0.5 mcg cap, 1mcg capsule, 2.5 mcg cap, 4mcg/2 ml vl, 4 mcg/2 ml amp)

4

etidronate disodium 2

FORTEO 5 PA

ibandronate sodium 150 mg tab 2 QL (1 PER 28 DAYS)

ibandronate 3 mg/3 ml vial 2

MIACALCIN (200 UNIT/MLVIAL, 400 UNIT/2 ML VIAL)


NATPARA 5 PA, QL (2 PER 28 DAYS)

pamidronate disodium (30 mg/10ml vial, 60 mg/10 ml vial, 90mg/10 ml vial)


paricalcitol (1 mcg capsule, 2mcg capsule, 4 mcg capsule)


paricalcitol (2 mcg/ml vial, 5mcg/ml vial, 10 mcg/2 ml vial)

4

PROLIA 4 PA, QL (2 PER 365 OVER TIME)

RAYALDEE 5 PA


140





risedronate sodium (5 mg tablet,30 mg tab)

3

risedronate sodium 150 mg tab 3 QL (1 PER 28 DAYS)

risedronate sodium 35 mg tab 3 QL (4 PER 28 DAYS)

risedronate sodium dr 2 QL (4 PER 28 DAYS)

SENSIPAR (60 MG TABLET, 90MG TABLET)


SENSIPAR 30 MG TABLET 3 PA - Part B vs D Determination

XGEVA 5 PA

zoledronic acid 5 mg/100 ml 4 PA

zoledronic acid (4 mg/5 ml vial, 4mg vial)

4

ZOMETA 4 MG/100 MLINJECTION

5

Miscellaneous Therapeutic Agents

AMINOSYN II (7% IVSOLUTION, 10% IV SOLUTION)


AMINOSYN-HBC 4 PA - Part B vs D Determination

AMINOSYN-PF 4 PA - Part B vs D Determination

AMINOSYN-RF 4 PA - Part B vs D Determination

assure id insulin safety 1 QL (200 PER 30 DAYS)

FREAMINE HBC 4 PA - Part B vs D Determination

HEPATAMINE 4 PA - Part B vs D Determination

insulin pen needles 1 QL (200 PER 30 DAYS)

insulin safety needles 1 QL (200 PER 30 DAYS)

insulin syringes u-100 0.3 ml 1 QL (200 PER 30 DAYS)

insulin syringes u-100 1/2 ml 1 QL (200 PER 30 DAYS)

insulin syringes u-100 1 ml 1 QL (200 PER 30 DAYS)


141





INTRALIPID 20% IV FAT EMUL 4 PA - Part B vs D Determination

KEVEYIS 5 PA, QL (120 PER 30 DAYS)

lactated ringers irrigation 2

levocarnitine (1 g/10 ml soln,330 mg tablet)

2

MYALEPT 5 PA

NEPHRAMINE 4 PA - Part B vs D Determination

NUTRILIPID 4 PA - Part B vs D Determination

PHYSIOLYTE 4

PHYSIOSOL 4

plenamine 4 PA - Part B vs D Determination

PREMASOL 4 PA - Part B vs D Determination

PROSOL 4 PA - Part B vs D Determination

sodium chloride (irrig., prcss sol) 3

TRAVASOL 4 PA - Part B vs D Determination

TROPHAMINE 10% IVSOLUTION


sterile water for irrigation 1

Ophthalmic Agents

Ophthalmic Agents, Otheratropine 1% eye drops 2

bacitracin-polymyxin 2

CEQUA 4 QL (60 PER 30 DAYS)

CYSTARAN 5 PA, QL (60 PER 28 OVER TIME)

EYLEA 5

ISOPTO ATROPINE 2

LACRISERT 4


142





LUCENTIS (0.3 MG/0.05 MLSYRING, 0.3 MG/0.05 ML VIAL,0.5 MG/0.05 ML SYRING, 0.5MG/0.05 ML VIAL)

5

neomycin-bacitracin-polymyxin 2

neomycin-polymyxin-gramicidin 2

OXERVATE 5 PA, QL (60 PER 30 DAYS)

polymyxin b sul-trimethoprim 1

proparacaine hcl 2

RESTASIS 3

RESTASIS MULTIDOSE 3

XIIDRA 4 PA, QL (60 PER 30 DAYS)

Ophthalmic Anti-allergy AgentsALOCRIL 4

azelastine hcl 0.05% drops 2

BEPREVE 4

cromolyn 4% eye drops 1

EMADINE 4

epinastine hcl 2

LASTACAFT 4

olopatadine hcl (0.1% drops,0.2% drop)

2

PAZEO 3

Ophthalmic Anti-inflammatoriesALOMIDE 4

ALREX 3

BLEPHAMIDE 4

BLEPHAMIDE S.O.P. 4


143





bromfenac sodium 4

dexamethasone 0.1% eye drop 2

diclofenac 0.1% eye drops 1

DUREZOL 3

FLAREX 3

fluorometholone 2

flurbiprofen sodium 1

FML FORTE 3

FML S.O.P. 3

ILEVRO 3 QL (6 PER 30 OVER TIME)

ketorolac tromethamine (0.4%solution, 0.5% solution)

2

LOTEMAX 0.5% OPHTHALMICGEL


LOTEMAX 0.5% EYE DROPS 4

LOTEMAX 0.5% EYEOINTMENT


loteprednol etabonate 4

MAXIDEX 3

neomycin-polymyxin-dexameth(neomyc-polym-dexamet ointm,neomyc-polym-dexameth drop)

2

NEVANAC 3 QL (6 PER 30 OVER TIME)

PRED MILD 3

PRED-G (1% DROPS, S.O.P.OINTMENT)

4

prednisolone ac 1% eye drop 2

prednisolone sod 1% eye drop 2

PROLENSA 4 QL (12 PER 365 OVER TIME)


144





sulfacetamide-prednisolone 2

TOBRADEX EYE OINTMENT 4

TOBRADEX ST 4

tobramycin-dexamethasone 2

ZYLET 4

Ophthalmic Antiglaucoma AgentsALPHAGAN P 0.1% DROPS 3

apraclonidine hcl 2

AZOPT 3

betaxolol hcl 0.5% eye drop 2

BETIMOL 4

BETOPTIC S 4

brimonidine tartrate 1

carteolol hcl 1

dorzolamide hcl 2

dorzolamide-timolol (2%-0.5%,eye drops)

2

IOPIDINE 1% EYE DROPS 4

levobunolol hcl 1

methazolamide 2

metipranolol 2

PHOSPHOLINE IODIDE 4

pilocarpine hcl (1% drops, 2%drops, 4% drops)

2

SIMBRINZA 4

timolol 0.5% eye drop 4

timolol maleate (0.25% drop,0.5% drops)

1


145





timolol maleate (0.25% gfs,0.25%, 0.5% gfs, 0.5%)

2

TIMOPTIC-XE (EYE SOLN,GEL-SOLUTION)

2

Ophthalmic Prostaglandin and Prostamide Analogsbimatoprost 0.03% eye drops 2

COMBIGAN 3

latanoprost 0.005% eye drops 1

LUMIGAN 0.01% EYE DROPS 3

TRAVATAN Z 3

Otic Agents

acetic acid 2% ear solution 2

CIPRO HC 4

CIPRODEX 3

ciprofloxacin 0.2% otic soln 2

COLY-MYCIN S 4

fluocinolone acetonide oil 2

hydrocortisone-acetic acid 2

neomycin-polymyxin-hc ear susp 2

neomycin-polymyxin-hydrocort 2

Respiratory Tract/Pulmonary Agents

Anti-inflammatories, Inhaled CorticosteroidsARNUITY ELLIPTA (100 MCG,200 MCG)


ARNUITY ELLIPTA 50 MCGINH



146





ASMANEX (TWISTHALER 110MCG #30, TWISTHALER 220MCG #60, TWISTHALER 220MCG #30, TWISTHALR 220MCG #120)


ASMANEX HFA 3 QL (26 PER 30 DAYS)

BREO ELLIPTA 3 QL (60 PER 30 DAYS)

budesonide (0.25 mg/2 ml susp,0.5 mg/2 ml susp, 1 mg/2 ml inhsusp)

4 PA - Part B vs D Determination,QL (120 PER 30 DAYS)

FLOVENT 250 MCG DISKUS 3 QL (240 PER 30 DAYS)

FLOVENT DISKUS (50 MCG,100 MCG)


FLOVENT HFA (HFA 110 MCGINHALER, HFA 220 MCGINHALER)


FLOVENT HFA 44 MCGINHALER

3 QL (21.2 PER 30 DAYS)

flunisolide 1 QL (50 PER 30 DAYS)

fluticasone prop 50 mcg spray 1

mometasone furoate 50 mcgspry


QVAR 40 MCG ORAL INHALER 3 QL (17.4 PER 30 DAYS)

QVAR 80 MCG ORAL INHALER 3 QL (26.1 PER 30 DAYS)

QVAR REDIHALER 3 QL (21.2 PER 30 DAYS)

Antihistaminesazelastine hcl (0.1% (137 mcg)spry, 0.15% nasal spray)


cetirizine hcl 1

cyproheptadine hcl (2 mg/5 mlsyrup, 2 mg/5 ml soln, 4 mgtablet, 4 mg/10 ml syrp)

2 PA


147





desloratadine 5 mg tablet 2

diphenhydramine 50 mg/ml vial 2

DYMISTA 3

hydroxyzine hcl (10 mg/5 mlsyrup, 10 mg/5 ml soln, 50mg/25 ml syrup)

2 PA

hydroxyzine hcl (10 mg tablet,25 mg tablet, 50 mg tablet)

1 PA

hydroxyzine hcl (25 mg/ml vial,50 mg/ml vial, 100 mg/2 ml vial,500 mg/10 ml vial)

4

levocetirizine 5 mg tablet 2

olopatadine 665 mcg nasal spry 4 QL (30.5 PER 30 DAYS)

Antileukotrienesmontelukast sodium (4 mggranules, 4 mg tab chew, 5 mgtab chew)

2

montelukast sod 10 mg tablet 1

zafirlukast 2

ZYFLO 5 ST

Bronchodilators, AnticholinergicATROVENT HFA 4 QL (25.8 PER 30 DAYS)

COMBIVENT RESPIMAT 3 QL (8 PER 30 DAYS)

INCRUSE ELLIPTA 3 QL (30 PER 30 DAYS)

ipratropium br 0.02% soln 1 PA - Part B vs D Determination,QL (312.5 PER 30 DAYS)

ipratropium bromide (0.03%spray, 0.06% spray)

2

ipratropium-albuterol 2 PA - Part B vs D Determination,QL (540 PER 30 DAYS)


148





SPIRIVA 3 QL (30 PER 30 DAYS)

SPIRIVA RESPIMAT 3 QL (4 PER 30 DAYS)

Bronchodilators, SympathomimeticADRENALIN 4

albuterol sulfate (2.5 mg/0.5 mlsol, 5 mg/ml solution, 15 mg/3 mlsolution, 20 mg/4 ml solution)


albuterol sulfate (sulf 2 mg/5 mlsyrup, sulfate 2 mg tab, sulfate 4mg tab, sulfate er 4 mg tab,sulfate er 8 mg tab)

2

albuterol sul 0.63 mg/3 ml sol 2 PA - Part B vs D Determination,QL (375 PER 30 DAYS)

albuterol sul 1.25 mg/3 ml sol 1 PA - Part B vs D Determination,QL (375 PER 30 DAYS)

albuterol sul 2.5 mg/3 ml soln 1 PA - Part B vs D Determination,QL (525 PER 30 DAYS)

albuterol sulfate hfa 2

BROVANA 5 PA - Part B vs D Determination,QL (120 PER 30 DAYS)

epinephrine (0.15 mg auto-injct,0.3 mg auto-inject)

2

epinephrine 0.15 mg auto-injct(covered ndcs 00115-1695-49,54505-0101-01, 54505-0101-02)

2

epinephrine 0.15 mg auto-injct(covered ndcs 49502-0101-01,49502-0101-02)

2

epinephrine 0.3 mg auto-inject(covered ndcs 00115-1694-49)

2

epinephrine 0.3 mg auto-inject(covered ndcs 49502-0102-01,49502-0102-02, 54505-0102-01,54505-0102-02)

2


149





EPIPEN 2-PAK 3

EPIPEN JR 2-PAK 3

levalbuterol concentrate 4 PA - Part B vs D Determination,QL (90 PER 30 DAYS)

levalbuterol 1.25 mg/3 ml sol 4 PA - Part B vs D Determination,QL (90 PER 30 DAYS)

levalbuterol hcl (0.31 mg/3 mlsol, 0.63 mg/3 ml sol)


levalbuterol tartrate hfa 2 QL (30 PER 30 DAYS)

metaproterenol sulfate (10 mgtablet, 10 mg/5 ml syr, 20 mgtablet)

4

PERFOROMIST 4 PA - Part B vs D Determination,QL (120 PER 30 DAYS)

PROAIR DIGIHALER 3 QL (2 PER 30 DAYS)

PROAIR HFA 3 QL (17 PER 30 DAYS)

PROAIR RESPICLICK 3 QL (2 PER 30 DAYS)

PROVENTIL HFA 4 QL (14 PER 30 DAYS)

SEREVENT DISKUS 3 QL (60 PER 30 DAYS)

terbutaline sulfate (2.5 mg tab, 5mg tab)

4

terbutaline sulf 1 mg/ml vial 5

Cystic Fibrosis AgentsBETHKIS 5 PA - Part B vs D Determination

CAYSTON 5 PA

KALYDECO (25 MGGRANULES PACKET, 50 MGGRANULES PACKET, 75 MGGRANULES PACKET, 150 MGTABLET)

5 PA

ORKAMBI (100-125 MGGRANULE PKT, 150-188 MGGRANULE PKT)

5 PA


150





ORKAMBI (100 MG TABLET,200 MG TABLET)


PULMOZYME 5 PA

TOBI PODHALER 5 QL (224 PER 56 OVER TIME)

tobramycin 300 mg/5 ml ampule 5 PA - Part B vs D Determination

Mast Cell Stabilizerscromolyn 20 mg/2 ml neb soln 2 PA - Part B vs D Determination

Phosphodiesterase Inhibitors, Airways Diseaseaminophylline 250 mg/10 ml vl 2

DALIRESP 4 PA

theophylline (80 mg/15 ml soln,er 400 mg tablet, er 600 mgtablet)

2

theophylline anhydrous 2

Pulmonary AntihypertensivesADCIRCA 5 PA, QL (60 PER 30 DAYS)

ADEMPAS 5 PA, QL (90 PER 30 DAYS)

alyq 5 PA

ambrisentan 5 PA, QL (30 PER 30 DAYS)

bosentan 5 PA, QL (60 PER 30 DAYS)

LETAIRIS 5 PA, QL (30 PER 30 DAYS)

OPSUMIT 5 PA, QL (30 PER 30 DAYS)

ORENITRAM ER (ER 0.25 MGTABLET, ER 1 MG TABLET, ER2.5 MG TABLET, ER 5 MGTABLET)

5 PA

ORENITRAM ER 0.125 MGTABLET

4 PA

REMODULIN 5 PA


151





REVATIO 10 MG/ML ORALSUSP

5 PA

sildenafil 2 PA, QL (180 PER 30 OVER TIME)

sildenafil 10 mg/ml oral susp 5 PA

sildenafil 20 mg tablet 2 PA, QL (180 PER 30 OVER TIME)

sildenafil 10 mg/12.5 ml vial 5

treprostinil 5 PA

UPTRAVI 200-800 TITRATIONPACK

5 PA, QL (400 PER 365 OVERTIME)

UPTRAVI (200 MCG TABLET,400 MCG TABLET, 600 MCGTABLET, 800 MCG TABLET,1,000 MCG TABLET, 1,200MCG TABLET, 1,400 MCGTABLET, 1,600 MCG TABLET)


VENTAVIS 5 PA, QL (270 PER 30 DAYS)

Respiratory Tract Agents, Otheracetylcysteine (10% vial, 20%vial)


ADVAIR DISKUS 3 QL (60 PER 30 DAYS)

ADVAIR HFA 3 QL (24 PER 30 DAYS)

ANORO ELLIPTA 3 QL (60 PER 30 DAYS)

ARALAST NP 5 PA

benzonatate 100 mg capsule 1

DULERA 4 QL (13 PER 30 DAYS)

ESBRIET 267 MG CAPSULE 5 PA

ESBRIET 801 MG TABLET 5 PA, QL (90 PER 30 DAYS)

fluticasone-salmeterol (55-14,113-14, 232-14)

1

fluticasone-salmeterol (100-50,250-50, 500-50)



152

ED





GLASSIA 5 PA

OFEV 5 PA

PROLASTIN C 5 PA

promethazine vc 2 PA

promethazine-phenylephrine 2 PA

STIOLTO RESPIMAT 3 QL (4 PER 30 DAYS)

SYMBICORT 160-4.5 MCGINHALER


SYMBICORT 80-4.5 MCGINHALER

3 QL (13.8 PER 30 DAYS)

wixela inhub 1

XOLAIR (75 MG/0.5 MLSYRINGE, 150 MG/MLSYRINGE, 150 MG VIAL)

5 PA

ZEMAIRA 5 PA

Skeletal Muscle Relaxants

carisoprodol 350 mg tablet 4 PA

chlorzoxazone (375 mg tablet,500 mg tablet, 750 mg tablet)

1 PA

cyclobenzaprine hcl (5 mg tablet,10 mg tablet)

2 PA

orphenadrine citrate (30 mg/mlvial, 60 mg/2 ml vial, 60 mg/2 mlampule)

2

orphenadrine citrate er 1 PA

Sleep Disorder Agents

GABA Receptor Modulatorszaleplon 10 mg capsule 1 PA, QL (60 PER 30 DAYS)


153





zaleplon 5 mg capsule 1 PA, QL (30 PER 30 DAYS)

zolpidem tartrate (5 mg tablet,10 mg tablet)


zolpidem tartrate (1.75 mg tab,3.5 mg tablet)


zolpidem tartrate er 4 PA, QL (60 PER 30 DAYS)

Sleep Disorders, Otherarmodafinil (150 mg tablet, 250mg tablet)


armodafinil 200 mg tablet 4 PA, QL (30 PER 30 DAYS)

armodafinil 50 mg tablet 4 PA, QL (60 PER 30 DAYS)

HETLIOZ 5 PA, QL (30 PER 30 DAYS)

modafinil 4 PA, QL (30 PER 30 DAYS)

ramelteon 2 QL (30 PER 30 DAYS)

ROZEREM 4 QL (30 PER 30 DAYS)

SILENOR 3 QL (30 PER 30 DAYS)

XYREM 5 PA, QL (540 PER 30 DAYS)


154

Index of Drugs

Lista en orden alfabéticoAabacavir 72abacavir-lamivudine 72abacavir-lamivudine-zidovudine 72ABELCET 49ABILIFY MAINTENA 67abiraterone acetate 55ABRAXANE 56ABSTRAL 22acamprosate calcium 26acarbose 79acebutolol hcl 90acetaminophen-codeine 22acetazolamide 94acetazolamide er 94acetazolamide sodium 94acetic acid 146acetylcysteine 152acitretin 102ACTEMRA 136ACTEMRA ACTPEN 136ACTHAR 120ACTHIB 137ACTIMMUNE 136ACTOPLUS MET XR 79acyclovir 76acyclovir sodium 76ADACEL TDAP 137ADAGEN 113adapalene 102ADCIRCA 151adefovir dipivoxil 74ADEMPAS 151ADRENALIN 149adriamycin 56adrucil 55ADVAIR DISKUS 152ADVAIR HFA 152AFINITOR 61

AFINITOR DISPERZ 61AJOVY 51ala-cort 116albendazole 63ALBENZA 64albuterol sulfate 149albuterol sulfate hfa 149alclometasone dipropionate 117ALDACTAZIDE 95ALDURAZYME 114ALECENSA 61alendronate sodium 139,140alfuzosin hcl er 116ALIMTA 56ALINIA 64ALIQOPA 61aliskiren 93allopurinol 51almotriptan malate 52ALOCRIL 143ALOMIDE 143alosetron hcl 112ALOXI 48ALPHAGAN P 145alprazolam 77alprazolam er 77alprazolam intensol 77alprazolam odt 77alprazolam xr 77ALREX 143ALUNBRIG 61alyacen 122alyq 151amabelz 122amantadine 76AMBISOME 49ambrisentan 151amcinonide 117amethia 122amethia lo 122

155

amikacin sulfate 28amiloride hcl 95amiloride-hydrochlorothiazide 95aminophylline 151AMINOSYN II 141AMINOSYN II WITH ELECTROLYTES 105AMINOSYN WITH ELECTROLYTES 105AMINOSYN-HBC 141AMINOSYN-PF 141AMINOSYN-RF 141amiodarone hcl 89AMITIZA 112amitriptyline hcl 46amlodipine besylate 91amlodipine besylate-benazepril 91amlodipine-atorvastatin 91amlodipine-olmesartan 92amlodipine-valsartan 92amlodipine-valsartan-hctz 92ammonium lactate 102amoxapine 46amoxicillin 33amoxicillin-clavulanate pot er 33amoxicillin-clavulanate potass 33amphotericin b 49ampicillin sodium 33ampicillin trihydrate 33ampicillin-sulbactam 33AMPYRA 100ANADROL-50 121anagrelide hcl 85anastrozole 60ANDRODERM 122ANDROGEL 122anodyne lpt 25ANORO ELLIPTA 152ANZEMET 48apexicon e 117APLENZIN 43APOKYN 65

apraclonidine hcl 145aprepitant 48apri 122APRISO 139APTIOM 38APTIVUS 73ARALAST NP 152aranelle 122ARANESP 86ARCALYST 136ARESTIN 36argatroban 84argatroban-0.9% nacl 84ARIKAYCE 28aripiprazole 67aripiprazole odt 67ARISTADA 67,68ARISTADA INITIO 68armodafinil 154ARNUITY ELLIPTA 146ARRANON 56asa-butalb-caffeine-codeine 22ascomp with codeine 22ashlyna 122ASMANEX 147ASMANEX HFA 147aspirin-dipyridamole er 87assure id insulin safety 141ASTAGRAF XL 132atenolol 90atenolol-chlorthalidone 90ATGAM 135atomoxetine hcl 99atorvastatin calcium 96atovaquone 64atovaquone-proguanil hcl 64ATRIPLA 71atropine sulfate 142ATROVENT HFA 148AUBAGIO 101

156

aubra 122aubra eq 123AUGMENTIN 33AVANDIA 79AVASTIN 57aviane 123AVONEX 101AVONEX PEN 101AVYCAZ 31azacitidine 57AZACTAM-ISO-OSMOTIC DEXTROSE 32AZASAN 132AZASITE 34azathioprine 132azathioprine sodium 132azelaic acid 102azelastine hcl 143,147AZESCO 110azithromycin 34AZOPT 145aztreonam 32

Bbaciim 28bacitracin 28bacitracin-polymyxin 142baclofen 70BACTROBAN NASAL 29balsalazide disodium 139BALVERSA 57balziva 123BANZEL 41BAQSIMI 82BARACLUDE 75BASAGLAR KWIKPEN U-100 83BAVENCIO 57BCG VACCINE (TICE STRAIN) 137bekyree 123BELEODAQ 57benazepril hcl 89

benazepril-hydrochlorothiazide 89BENLYSTA 132benzonatate 152benztropine mesylate 65BEPREVE 143BERINERT 132BESIVANCE 35betamethasone diprop augmented 117betamethasone dipropionate 117betamethasone valerate 117BETASERON 101betaxolol hcl 90,145bethanechol chloride 116BETHKIS 150BETIMOL 145BETOPTIC S 145bexarotene 63BEXSERO 137bicalutamide 55BICILLIN C-R 33BICILLIN L-A 33BICNU 54BIDIL 97BIJUVA 123BIKTARVY 71BILTRICIDE 64bimatoprost 146BINOSTO 140bisoprolol fumarate 90bisoprolol-hydrochlorothiazide 78,90BIVIGAM 135bleomycin sulfate 57BLEPHAMIDE 143BLEPHAMIDE S.O.P. 143blisovi 24 fe 123blisovi fe 123BOOSTRIX TDAP 137bosentan 151BOSULIF 61BOTOX 70

157

BRAFTOVI 61BREO ELLIPTA 147briellyn 123BRILINTA 87brimonidine tartrate 145BRIVIACT 38bromfenac sodium 144bromocriptine mesylate 65BROVANA 149budesonide 147budesonide ec 139budesonide er 139bumetanide 94BUPHENYL 114buprenorphine hcl 26buprenorphine-naloxone 27bupropion hcl 43bupropion hcl sr 27,43bupropion xl 43buspirone hcl 77BUSULFEX 54butalb-acetamin-caff 50-325-40 tab (genericfioricet) 100butalb-acetaminoph-caff-codeine 50-300-30cap (generic fioricet with codeine) 22butalbit-acetaminophen-caff 50-325-40 cap(generic zebutal) 100butalbital compound-codeine 22butalbital-acetaminophen 100butalbital-acetaminophen-caffe 100butalbital-acetaminophn 50-325 tab (generictencon) 100butalbital-asa-caffeine cap 50-325-40 (genericfiorinal) 100butorphanol tartrate 22,27BYDUREON 79BYDUREON BCISE 79BYDUREON PEN 79BYETTA 79BYSTOLIC 90

Ccabergoline 130CABLIVI 87CABOMETYX 61calcipotriene 102calcipotriene-betamethasone dp 102calcitonin-salmon 140calcitriol 103,140calcium acetate 109CALQUENCE 61camila 127camrese lo 123CANASA 139CANCIDAS 49candesartan cilexetil 88candesartan-hydrochlorothiazid 88CAPASTAT SULFATE 53CAPEX SHAMPOO 117CAPRELSA 61captopril 89captopril-hydrochlorothiazide 89CARAFATE 113CARBAGLU 105carbamazepine 41carbamazepine er 41CARBATROL 41carbidopa 65carbidopa-levodopa 65carbidopa-levodopa er 66carbidopa-levodopa-entacapone 66carboplatin 57CARDIZEM LA 92CARDURA XL 116CARIMUNE NF NANOFILTERED 135carisoprodol 153carteolol hcl 145cartia xt 92carvedilol 90carvedilol er 91

158

CAYSTON 150caziant 123cefaclor 31cefaclor er 31cefadroxil 31cefazolin sodium 31cefdinir 31cefepime hcl 31cefixime 31cefotaxime sodium 31cefotetan 31cefoxitin 31cefpodoxime proxetil 31cefprozil 32ceftazidime 32ceftriaxone 32cefuroxime 32cefuroxime sodium 32celecoxib 19CELLCEPT 132CELONTIN 38cephalexin 32CEQUA 142CERDELGA 114CEREZYME 114cetirizine hcl 147cevimeline hcl 102CHANTIX 27CHENODAL 111chloramphenicol sod succinate 29chlordiazepoxide hcl 77chlordiazepoxide-amitriptyline 46chlorhexidine gluconate 102chloroquine phosphate 64chlorothiazide 95chlorothiazide sodium 95chlorpromazine hcl 66chlorthalidone 95chlorzoxazone 153CHOLBAM 111

cholestyramine 96cholestyramine light 96chorionic gonadotropin 120CIALIS 116ciclopirox 49cidofovir 74cilostazol 87CILOXAN 35CIMDUO 72cimetidine 111CIMZIA 132cinacalcet hcl 140CINRYZE 132CIPRO HC 146CIPRODEX 146ciprofloxacin 35ciprofloxacin er 35ciprofloxacin hcl 35,146ciprofloxacin-d5w 35cisplatin 57citalopram hbr 44cladribine 56claravis 103clarithromycin 34clarithromycin er 34CLEOCIN 29CLIMARA PRO 123clindamycin hcl 27,29clindamycin palmitate hcl 29clindamycin pediatric 29clindamycin phos-benzoyl perox 103clindamycin phos-tretinoin 103clindamycin phosphate 29clindamycin phosphate-d5w 29clindamycin-benzoyl peroxide 103CLINIMIX 105CLINIMIX E 105clobazam 39clobetasol emollient 117clobetasol emulsion 117

159

clobetasol propionate 117clodan 117clofarabine 56CLOLAR 56clomipramine hcl 46clonazepam 39clonazepam (0.125 mg odt, 0.5 mg odt, 1 mgodt) 39clonidine 87clonidine hcl 87clonidine hcl er 99clopidogrel 87clorazepate dipotassium 77,78clotrimazole 49clotrimazole-betamethasone 103clozapine 70clozapine odt 70COARTEM 64codeine sulfate 22colchicine 51colesevelam hcl 96colestipol hcl 97colistimethate 29colocort 117COLY-MYCIN S 146COMBIGAN 146COMBIPATCH 123COMBIVENT RESPIMAT 148COMETRIQ 61COMPLERA 71compro 47CONDYLOX 103constulose 112COPAXONE 101COPIKTRA 57CORDRAN 117CORLANOR 93,116cortisone acetate 117CORTISPORIN 29COSENTYX (2 SYRINGES) 103

COSENTYX PEN 103COSENTYX PEN (2 PENS) 103COSENTYX SYRINGE 103COSMEGEN 57COTELLIC 57COUMADIN 84CREON 114CRESEMBA 49CRINONE 127CRIXIVAN 73cromolyn sodium 111,143,151cryselle 123CUBICIN 29CUBICIN RF 29CUPRIMINE 108CUVPOSA 110cyclafem 123cyclobenzaprine hcl 153cyclophosphamide 54CYCLOSET 79cyclosporine 133cyclosporine modified 133cyproheptadine hcl 147CYRAMZA 57CYSTADANE 114CYSTAGON 114CYSTARAN 142cytarabine 56

Ddacarbazine 54dalfampridine er 101DALIRESP 151DALVANCE 29danazol 122dantrolene sodium 70dapsone 53DAPTACEL DTAP 137daptomycin 29DARAPRIM 64

160

darifenacin er 115DARZALEX 57daunorubicin hcl 57DAURISMO 61deblitane 127decitabine 57deferasirox 108DELSTRIGO 71delyla 123demeclocycline hcl 36DEMSER 93DENAVIR 76DEPEN 108DEPO-ESTRADIOL 123DEPO-MEDROL 117DEPO-PROVERA 127DEPO-SUBQ PROVERA 104 128dermacinrx empricaine 25DESCOVY 72desipramine hcl 46desloratadine 148desmopressin acetate 120desogestr-eth estrad eth estra 123DESONATE 117desonide 117desoximetasone 117desvenlafaxine er 44desvenlafaxine succinate er 44dexamethasone 118dexamethasone intensol 118dexamethasone sodium phosphate 118,144DEXILANT 113dexmethylphenidate hcl 99dexmethylphenidate hcl er 99dexrazoxane 57dextroamphetamine sulfate 98dextroamphetamine sulfate er 98dextroamphetamine-amphet er 98dextroamphetamine-amphetamine 98dextrose 10%-0.2% nacl 105

dextrose 10%-0.45% nacl 106dextrose 2.5%-0.45% nacl 106dextrose 5%-0.2% nacl 106dextrose 5%-0.2% nacl-kcl 106dextrose 5%-0.225% nacl 106dextrose 5%-0.225% nacl-kcl 106dextrose 5%-0.3% nacl 106dextrose 5%-0.3% nacl-kcl 106dextrose 5%-0.33% nacl 106dextrose 5%-0.33% nacl-kcl 106dextrose 5%-0.45% nacl 106dextrose 5%-0.45% nacl-kcl 106dextrose 5%-0.9% nacl 106dextrose 5%-1/2ns-kcl 106dextrose 5%-ns-kcl 106dextrose 5%-potassium chloride 106dextrose in lactated ringers 106dextrose in water 106DIASTAT 39DIASTAT ACUDIAL 39diazepam 39,78diclofenac epolamine 19diclofenac potassium 19diclofenac sodium 19,103,144diclofenac sodium er 19diclofenac sodium-misoprostol 19dicloxacillin sodium 33dicyclomine hcl 110didanosine 72DIFICID 34diflunisal 19digitek 93digox 93digoxin 93dihydroergotamine mesylate 51,52DILANTIN 41DILANTIN-125 42dilt-xr 92diltiazem 12hr er 92diltiazem 24hr er 92

161

diltiazem 24hr er (cd) 92diltiazem 24hr er (xr) 92diltiazem hcl 92DIPENTUM 139diphenhydramine hcl 148diphenoxylate-atropine 110,111DIPHTHERIA-TETANUS TOXOIDS-PED 137disopyramide phosphate 89disulfiram 26DIURIL 95divalproex sodium 39divalproex sodium er 40docetaxel 57dofetilide 90donepezil hcl 42donepezil hcl odt 42DOPTELET 86dorzolamide hcl 145dorzolamide-timolol 145DOVATO 71doxazosin mesylate 116doxepin hcl 46,103doxercalciferol 140doxorubicin hcl 57doxorubicin hcl liposome 57doxy 100 36doxycycline hyclate 36,37doxycycline monohydrate 37doxylamine succ-pyridoxine hcl 47dronabinol 48drospirenone-eth estra-levomef 123drospirenone-ethinyl estradiol 123DROXIA 56DULERA 152duloxetine hcl 44DUOBRII 103DUPIXENT 133DURAMORPH 22DUREZOL 144dutasteride 116

dutasteride-tamsulosin 116DYMISTA 148DYRENIUM 95

Eec-naproxen 19econazole nitrate 49EDARBI 88EDARBYCLOR 88EDECRIN 94EDURANT 71EFFIENT 87EGRIFTA 120ELAPRASE 114ELIDEL 103ELIGARD 130eliphos 109ELIQUIS 84ELITEK 57ELMIRON 116EMADINE 143EMBEDA 20,21EMCYT 55EMEND 48EMGALITY PEN 51EMGALITY SYRINGE 51emoquette 123EMPLICITI 57EMSAM 44EMTRIVA 72enalapril maleate 89enalapril-hydrochlorothiazide 89ENBREL 133ENBREL MINI 133ENBREL SURECLICK 133endocet 22ENGERIX-B ADULT 137ENGERIX-B PEDIATRIC-ADOLESCENT 137enoxaparin sodium 84enpresse 123

162

entacapone 65entecavir 75ENTRESTO 94enulose 112EPCLUSA 75EPIDIOLEX 38epinastine hcl 143epinephrine 149epinephrine 0.15 mg auto-injct (covered ndcs00115-1695-49, 54505-0101-01, 54505-0101-02) 149epinephrine 0.15 mg auto-injct (covered ndcs49502-0101-01, 49502-0101-02) 149epinephrine 0.3 mg auto-inject (covered ndcs00115-1694-49) 149epinephrine 0.3 mg auto-inject (covered ndcs49502-0102-01, 49502-0102-02, 54505-0102-01, 54505-0102-02) 149EPIPEN 2-PAK 150EPIPEN JR 2-PAK 150epirubicin hcl 58epitol 42EPIVIR HBV 75eplerenone 95eprosartan mesylate 88EPZICOM 72EQUETRO 78ERAXIS (WATER DILUENT) 49ERBITUX 58ergotamine-caffeine 52ERIVEDGE 61ERLEADA 55erlotinib hcl 61errin 128ertapenem 32ERWINAZE 58ery 34ERY-TAB 34ERYPED 200 35ERYPED 400 35

ERYTHROCIN LACTOBIONATE 35ERYTHROCIN STEARATE 35erythromycin 35erythromycin ethylsuccinate 35erythromycin-benzoyl peroxide 103ESBRIET 152escitalopram oxalate 44esomeprazole magnesium 113esomeprazole sodium 113ESTRACE 123estradiol 123,124estradiol valerate 124estradiol-norethindrone acetat 124ESTRING 124ethacrynic acid 94ethambutol hcl 53ethosuximide 38etidronate disodium 140etodolac 19etodolac er 19ETOPOPHOS 60etoposide 60EURAX 64EVOTAZ 73EXELDERM 49exemestane 60EXJADE 108EXONDYS 51 114EYLEA 142ezetimibe 97ezetimibe-simvastatin 97

FFABRAZYME 114falmina 124famciclovir 76famotidine 112FANAPT 68FARESTON 55FARYDAK 58

163

FASLODEX 55febuxostat 51felbamate 41felodipine er 92FEMRING 124femynor 124fenofibrate 96fenofibric acid 96fentanyl 21fentanyl citrate 22FERRIPROX 108FETZIMA 44FINACEA 103finasteride 116FIRAZYR 132FIRDAPSE 101FIRMAGON 130FLAREX 144flavoxate hcl 115FLEBOGAMMA DIF 135flecainide acetate 90FLECTOR 19FLOVENT DISKUS 147FLOVENT HFA 147fluconazole 49fluconazole in saline 49fluconazole-nacl 49flucytosine 49fludarabine phosphate 58fludrocortisone acetate 118flunisolide 147fluocinolone acetonide 118fluocinolone acetonide oil 146fluocinonide 118fluocinonide-e 118fluoride 106FLUORITAB 106fluorometholone 144fluorouracil 56,103fluoxetine dr 45

fluoxetine hcl 45fluphenazine decanoate 66fluphenazine hcl 66flurandrenolide 118flurbiprofen 19flurbiprofen sodium 144flutamide 55fluticasone propionate 118,147fluticasone-salmeterol 152fluvastatin er 96fluvastatin sodium 96fluvoxamine maleate 45fluvoxamine maleate er 45FML FORTE 144FML S.O.P. 144FOLOTYN 56fondaparinux sodium 84FORFIVO XL 43FORTEO 140fosinopril sodium 89fosinopril-hydrochlorothiazide 89fosphenytoin sodium 42FOSRENOL 109FRAGMIN 85FREAMINE HBC 141frovatriptan succinate 52fulvestrant 55furosemide 95FUSILEV 58FUZEON 73fyavolv 124FYCOMPA 38

Ggabapentin 40GABITRIL 40GABLOFEN 70GALAFOLD 114galantamine er 42galantamine hbr 43

164

galantamine hydrobromide 43GAMASTAN S-D 135GAMMAGARD LIQUID 135GAMMAGARD S-D 135GAMMAKED 135GAMMAPLEX 135GAMUNEX-C 135ganciclovir sodium 74GARDASIL 9 137gatifloxacin 35GATTEX 111gavilyte-c 112gavilyte-g 112gavilyte-n 112GELNIQUE 115gemcitabine hcl 56gemfibrozil 96generlac 112gengraf 133GENOTROPIN 120gentak 28gentamicin sulfate 28gentamicin sulfate in ns 28GENVOYA 71GEODON 68gianvi 124gildagia 124GILENYA 101GILOTRIF 61GLASSIA 153glatopa 101GLEOSTINE 54glimepiride 79glipizide 79glipizide er 79glipizide xl 79glipizide-metformin 80GLUCAGEN 82GLUCAGON EMERGENCY KIT 82glucose in water 106

glyburide 80glyburide micronized 80glyburide-metformin hcl 80glycopyrrolate 110,111GOLYTELY 112granisetron hcl 48GRANIX 86griseofulvin 49griseofulvin ultramicrosize 49guanfacine hcl 88guanfacine hcl er 99guanidine hcl 52gynazole 1 49

Hhailey 24 fe 124HALAVEN 58halobetasol propionate 118haloperidol 66haloperidol decanoate 67haloperidol decanoate 100 67haloperidol lactate 67HARVONI 75HAVRIX 137heparin sodium 85heparin sodium in 0.45% nacl 85heparin sodium-0.45% nacl 85heparin sodium-d5w 85HEPATAMINE 141HERCEPTIN 58HERCEPTIN HYLECTA 58HETLIOZ 154HEXALEN 54HIBERIX 137HIZENTRA 135HUMALOG 83HUMALOG JUNIOR KWIKPEN 83HUMALOG KWIKPEN U-100 83HUMALOG KWIKPEN U-200 83HUMALOG MIX 50-50 83

165

HUMALOG MIX 50-50 KWIKPEN 83HUMALOG MIX 75-25 83HUMALOG MIX 75-25 KWIKPEN 83HUMATROPE 121HUMIRA 133HUMIRA PEDIATRIC CROHN'S 133HUMIRA PEN 133HUMIRA PEN CROHN'S-UC-HS 133HUMIRA PEN PSORIASIS-STARTERPACK 133HUMIRA(CF) 133HUMIRA(CF) PEDIATRIC CROHN'S 133HUMIRA(CF) PEN 133HUMIRA(CF) PEN CROHN'S-UC-HS 133HUMIRA(CF) PEN PSOR-UV-ADOL HS 133HUMULIN R U-500 83HUMULIN R U-500 KWIKPEN 83hydralazine hcl 97hydrochlorothiazide 95hydrocodone-acetaminophen 23hydrocodone-acetaminophen (7.5-325 mgtablet, 5-325 mg tablet, 10- 325 mg tablet) 23hydrocodone-acetaminophen (7.5-325 mg/15ml solution, 2.5-108 mg/5 ml solution, 5-217mg/10 ml solution, 2.5-325 mg tablet, 7.5-300mg tablet, 10-300 mg tablet) 23hydrocodone-acetaminophen (7.5-325 mg/15ml solution, 2.5-108 mg/5 ml solution, 5-217mg/10 ml solution, 2.5-325 mg tablet, 7.5-300mg tablet, 10-300 mg tablet) 23hydrocodone-acetaminophen 5-300 mg tablet

23hydrocodone-ibuprofen (5-200 mg tablet, 7.5-200 mg tablet, 10-200 mg tablet) 23hydrocortisone 118hydrocortisone butyrate 118,119hydrocortisone valerate 119hydrocortisone-acetic acid 146hydromorphone er 21hydromorphone hcl 23,24

hydroxychloroquine sulfate 64hydroxyprogesterone caproate 128hydroxyurea 56hydroxyzine hcl 148hydroxyzine pamoate 77HYPERRAB S-D 135

Iibandronate sodium 140IBRANCE 58ibu 19ibuprofen 19icatibant 132ICLUSIG 62idarubicin hcl 58IDHIFA 58ifosfamide 54ILARIS 136ILEVRO 144imatinib mesylate 62IMBRUVICA 62IMFINZI 58imipenem-cilastatin sodium 32imipramine hcl 46imipramine pamoate 46imiquimod 103IMOGAM RABIES-HT 136IMOVAX RABIES VACCINE 137INBRIJA 65INCRELEX 121INCRUSE ELLIPTA 148indapamide 95indomethacin 19indomethacin er 19INFANRIX DTAP 137INFLECTRA 133INGREZZA 100INGREZZA INITIATION PACK 100INLYTA 62INREBIC 62

166

insulin lispro 83insulin lispro kwikpen u-100 83insulin pen needles 141insulin safety needles 141insulin syringes u-100 0.3 ml 141insulin syringes u-100 1/2 ml 141insulin syringes u-100 1 ml 141INTELENCE 71INTRALIPID 142INTRON A 75introvale 124INVANZ 32INVEGA SUSTENNA 68INVEGA TRINZA 68INVIRASE 73INVOKAMET 80INVOKAMET XR 80INVOKANA 80IONOSOL MB-DEXTROSE 5% 106IOPIDINE 145IPOL 137ipratropium bromide 148ipratropium-albuterol 148irbesartan 88irbesartan-hydrochlorothiazide 88IRESSA 62irinotecan hcl 58ISENTRESS 71ISENTRESS HD 73ISOLYTE P WITH DEXTROSE 106ISOLYTE S 106isoniazid 53ISOPTO ATROPINE 142isosorbide dinitrate 97isosorbide dinitrate er 97isosorbide mononitrate 97isosorbide mononitrate er 98isradipine 92ISTODAX 58itraconazole 50

ivermectin 64IXIARO 137

JJADENU 109JAKAFI 62jantoven 85JANUMET 80JANUMET XR 80JANUVIA 80JARDIANCE 80,81JENTADUETO 81JENTADUETO XR 81JEVTANA 58jinteli 124jolivette 128juleber 124JULUCA 72junel 124junel fe 124junel fe 24 124JUXTAPID 97JYNARQUE 109

KKADCYLA 58kaitlib fe 124KALETRA 73,74KALYDECO 150KANUMA 114kariva 124kelnor 1-35 124KENALOG-40 119KEPIVANCE 102ketoconazole 50ketoprofen 19,20ketorolac tromethamine 20,144KEVEYIS 142KEVZARA 133KEYTRUDA 58

167

kimidess 125KINERET 134KINRIX 137kionex 109KISQALI 58KISQALI FEMARA CO-PACK 54klofensaid ii 103klor-con 107KLOR-CON 10 107KLOR-CON 8 107klor-con m10 107KLOR-CON M15 107klor-con m20 107klor-con sprinkle 107KOMBIGLYZE XR 81KORLYM 121KRISTALOSE 112KUVAN 114KYNAMRO 97KYPROLIS 60

Llabetalol hcl 91LACRISERT 142lactated ringers 107,142lactulose 112lamivudine 72,75lamivudine hbv 75lamivudine-zidovudine 72lamotrigine 41lamotrigine er 41lamotrigine odt 41LANOXIN 94lansoprazol-amoxicil-clarithro 111lansoprazole 113LANTUS 83LANTUS SOLOSTAR 83larin 125larin fe 125larissia 125

LARTRUVO 58LASTACAFT 143latanoprost 146LATUDA 68LAYOLIS FE 125ledipasvir-sofosbuvir 75leena 125leflunomide 136LENVIMA 62lessina 125LETAIRIS 151letrozole 60leucovorin calcium 58LEUKERAN 54LEUKINE 86leuprolide acetate 130leva set 25levalbuterol concentrate 150levalbuterol hcl 150levalbuterol tartrate hfa 150LEVEMIR 83LEVEMIR FLEXTOUCH 83levetiracetam 38levetiracetam er 38levetiracetam-nacl 38levobunolol hcl 145levocarnitine 142levocetirizine dihydrochloride 148levofloxacin 35,36levofloxacin-d5w 36levoleucovorin calcium 58levonest 125levonorgestrel-eth estradiol 125levora-28 125levorphanol tartrate 21levothyroxine sodium 129LEVOXYL 129LEXIVA 74LIALDA 139lido-prilo caine pack 25

168

lidocaine 25lidocaine hcl 26lidocaine hcl viscous 26lidocaine-prilocaine 26lidopril 26lidopril xr 26lincomycin hcl 29lindane 64linezolid 29linezolid-d5w 29LINZESS 112LIORESAL INTRATHECAL 70liothyronine sodium 129liprozonepak 26lisinopril 89lisinopril-hydrochlorothiazide 89lithium 78lithium carbonate 78lithium carbonate er 78LIVALO 96livixil pak 26LO LOESTRIN FE 125LONSURF 56loperamide 111lopinavir-ritonavir 74lorazepam 78lorazepam intensol 78LORBRENA 59lorcet 24lorcet hd 24lorcet plus 24loryna 125losartan potassium 88losartan-hydrochlorothiazide 88LOTEMAX 144loteprednol etabonate 144lovastatin 96low-ogestrel 125loxapine 67lp lite pak 26

LUCEMYRA 88LUCENTIS 143ludent fluoride 107LUMIGAN 146LUMIZYME 114LUPANETA PACK 130LUPRON DEPOT 130LUPRON DEPOT (LUPANETA) 130LUPRON DEPOT-PED 131lutera 125LYNPARZA 59LYRICA 39LYSODREN 129lyza 128

MM-M-R II VACCINE 137m-natal plus 110mafenide acetate 29magnesium sulfate 107MAKENA 128malathion 64maprotiline hcl 45marlissa 125MARPLAN 44MATULANE 54matzim la 92MAXIDEX 144MAYZENT 101meclizine hcl 47meclofenamate sodium 20medolor pak 26medroxyprogesterone acetate 128mefenamic acid 20mefloquine hcl 64megestrol acetate 128MEKINIST 62MEKTOVI 62meloxicam 20melphalan hcl 54

169

memantine hcl 43memantine hcl er 43MENACTRA 137MENEST 125MENTAX 50MENVEO A-C-Y-W-135-DIP 137mercaptopurine 56meropenem 33mesalamine 139mesalamine dr 139mesna 63MESNEX 63MESTINON 52metadate er 99metaproterenol sulfate 150metformin er gastric 81metformin er osmotic 81metformin hcl 81metformin hcl er 81metformin hcl er 500 mg tablet (excludesndcs 00591-2411-01, 68180-0338-01, 68682-0017-10) 81methadone hcl 21methazolamide 145methenamine hippurate 30methimazole 132methotrexate 134methotrexate sodium 134methoxsalen 104methscopolamine bromide 111methyclothiazide 95methyldopa 88methyldopa-hydrochlorothiazide 88methyldopate hcl 88methylphenidate 5 mg chew tab 99methylphenidate er 99methylphenidate er (la) 99methylphenidate hcl 99methylphenidate hcl cd 99methylphenidate hcl er (cd) 99

methylphenidate la 100methylprednisolone 119methylprednisolone acetate 119methylprednisolone sodium succ 119methyltestosterone 122metipranolol 145metoclopramide hcl 111metoclopramide hcl odt 111metolazone 95metoprolol succinate 91metoprolol tartrate 91metoprolol-hydrochlorothiazide 91metronidazole 30mexiletine hcl 90MIACALCIN 140miconazole 3 50microgestin 125microgestin fe 125midodrine hcl 88migergot 52miglitol 81miglustat 114millipred 119mimvey 125mimvey lo 125MINASTRIN 24 FE 125minitran 98minocycline hcl 37minoxidil 97mirtazapine 43,44MIRVASO 104misoprostol 113mitomycin 59mitomycin-sterile water 59mitoxantrone hcl 59modafinil 154moderiba 75moexipril hcl 89moexipril-hydrochlorothiazide 89molindone hcl 67

170

mometasone furoate 119,147mononessa 125montelukast sodium 148MONUROL 30morphine sulfate 24morphine sulfate er 21MOTEGRITY 47MOVANTIK 111MOVIPREP 112MOXEZA 36moxifloxacin 36moxifloxacin hcl 36MOZOBIL 86MULTAQ 90mupirocin 30MUSTARGEN 54MYALEPT 142MYCAMINE 50mycophenolate mofetil 134mycophenolic acid 134MYLOTARG 59myorisan 104MYRBETRIQ 115

Nnabumetone 20nadolol 91nadolol-bendroflumethiazide 91nafcillin sodium 33naftifine hcl 50NAFTIN 50NAGLAZYME 114nalbuphine hcl 24naloxone hcl 24,27naltrexone hcl 27NAMENDA XR 43naproxen 20naproxen sodium 20naproxen sodium ds 20naratriptan hcl 52

NARCAN 27NATACYN 50nateglinide 81NATPARA 140NAYZILAM 78NEBUPENT 64necon 125nefazodone hcl 45neomycin sulfate 28neomycin-bacitracin-poly-hc 30neomycin-bacitracin-polymyxin 143neomycin-polymyxin b 28neomycin-polymyxin-dexameth 144neomycin-polymyxin-gramicidin 143neomycin-polymyxin-hc 30,146neomycin-polymyxin-hydrocort 146NEPHRAMINE 142NERLYNX 62NEULASTA 86NEUPOGEN 86NEUPRO 65NEVANAC 144nevirapine 71nevirapine er 71NEXAVAR 62NEXIUM PACKETS (DR 2.5 MG, DR 5 MG,DR 10 MG, DR 20 MG, DR 40 MG) 113niacin er 97niacor 97nicardipine hcl 92NICOTROL 27NICOTROL NS 27nifedipine er 92nikki 126NILANDRON 55nilutamide 55nimodipine 92NINLARO 59NIPENT 56nisoldipine 92

171

NITRO-BID 98NITRO-DUR 98nitrofurantoin 30nitrofurantoin mono-macro 30nitroglycerin 98nitroglycerin patch 98NITROSTAT 98NITYR 114NIVESTYM 86nizatidine 112nora-be 128NORDITROPIN FLEXPRO 121NORDITROPIN NORDIFLEX 121norethin-eth estra-ferrous fum 126norethindron-ethinyl estradiol 126norethindrone 128norethindrone ac (lupaneta) 128norethindrone acetate 128norgestimate-ethinyl estradiol 126norlyroc 128NORMOSOL-M AND DEXTROSE 107NORMOSOL-R AND DEXTROSE 107NORMOSOL-R PH 7.4 107NORTHERA 94nortrel 126nortriptyline hcl 46NORVIR 74NOURIANZ 65NOVAREL 121NOVOLOG 83NOVOLOG FLEXPEN 83NOVOLOG MIX 70-30 83NOVOLOG MIX 70-30 FLEXPEN 83NOXAFIL 50NUBEQA 55NUEDEXTA 100NULOJIX 134NUPLAZID 68NUTRILIPID 142NUTROPIN AQ NUSPIN 121

NUVARING 126NUZYRA 37nyamyc 50nystatin 50nystatin-triamcinolone 50nystop 50

OOCALIVA 111ocella 126OCTAGAM 136octreotide acetate 131ODEFSEY 71ODOMZO 62OFEV 153ofloxacin 36ogestrel 126okebo 37olanzapine 68olanzapine odt 68olanzapine-fluoxetine hcl 45olmesartan medoxomil 88olmesartan-amlodipine-hctz 92olmesartan-hydrochlorothiazide 88olopatadine hcl 143,148omega-3 acid ethyl esters 97omeprazole 113OMNITROPE 121ondansetron hcl 48ondansetron odt 48ONFI 40ONGLYZA 81ONMEL 50OPDIVO 59OPSUMIT 151ORBACTIV 30ORENCIA 134ORENCIA CLICKJECT 134ORENITRAM ER 151ORFADIN 114

172

ORKAMBI 150,151orphenadrine citrate 153orphenadrine citrate er 153orsythia 126oseltamivir phosphate 76OSPHENA 128OTEZLA 136oxacillin sodium 34oxaliplatin 54oxandrolone 121oxaprozin 20oxazepam 78oxcarbazepine 42OXERVATE 143oxiconazole nitrate 50OXISTAT 50oxybutynin chloride 115oxybutynin chloride er 115oxycodone hcl 24oxycodone hcl-ibuprofen 25oxycodone-acetaminophen 25oxycodone-acetaminophen (2.5-325 mgtablet, 7.5-325 mg tablet, 5-325 mg tablet, 10-325 mg tablet) 25oxycodone-acetaminophen 5-325 mg/5 mlsolution 25oxycodone-aspirin 4.8355-325 mg tablet 25oxymorphone hcl 25oxymorphone hcl er 21OZEMPIC 81

Ppacerone 90paclitaxel 59paliperidone er 68,69PALYNZIQ 114pamidronate disodium 140PANDEL 119PANRETIN 63pantoprazole sodium 113

PANZYGA 136paricalcitol 140paroex 102paromomycin sulfate 28paroxetine cr 45paroxetine er 45paroxetine hcl 45paroxetine mesylate 45PASER 53PAXIL 45PAZEO 143PEDIARIX 138PEDVAXHIB 138peg 3350-electrolyte 113peg-3350 and electrolytes 113PEGANONE 42PEGASYS 75PEGASYS PROCLICK 75penicillamine 109penicillin g potassium 34penicillin g sodium 34penicillin gk-iso-osm dextrose 34penicillin v potassium 34PENTACEL ACTHIB COMPONENT 138PENTAM 300 64PENTASA 139pentoxifylline 94PERFOROMIST 150perindopril erbumine 89periogard 102PERJETA 59permethrin 64perphenazine 67perphenazine-amitriptyline 46PERSERIS 69PEXEVA 45phenadoz 47phenelzine sulfate 44phenobarbital 40phenoxybenzamine hcl 88

173

PHENYTEK 42phenytoin 42phenytoin sodium 42phenytoin sodium extended 42PHOSLYRA 109PHOSPHOLINE IODIDE 145PHYSIOLYTE 142PHYSIOSOL 142PICATO 104PIFELTRO 71pilocarpine hcl 102,145pimecrolimus 104pimozide 67pimtrea 126pindolol 91pioglitazone hcl 81,82pioglitazone-glimepiride 82pioglitazone-metformin 82piperacillin-tazobactam 34PIQRAY 60pirmella 126piroxicam 20PLASMA-LYTE 148 107PLASMA-LYTE A PH 7.4 107PLEGRIDY 101PLEGRIDY PEN 101plenamine 142podofilox 104POLIVY 59polyethylene glycol 3350 113polymyxin b sul-trimethoprim 143polymyxin b sulfate 30POMALYST 55portia 126posaconazole 51potassium chl-normal saline 107potassium chloride 107potassium chloride in d5lr 107potassium chloride proamp 107potassium chloride-nacl 108

potassium chloride-water 108potassium citrate er 108PRADAXA 85PRALUENT PEN 94pramipexole dihydrochloride 65prasugrel hcl 87pravastatin sodium 96praziquantel 64prazosin hcl 88PRED MILD 144PRED-G 144prednicarbate 119prednisolone 119prednisolone acetate 144prednisolone sodium phosphate 119,144prednisone 119pregabalin 39PREGENNA 110PREGNYL 121PREMARIN 126PREMASOL 142PREMPHASE 126PREMPRO 126prenatal vitamins 110PREPOPIK 113prevalite 97previfem 126PREZCOBIX 74PREZISTA 74PRIFTIN 53prilolid 26prilovix 26prilovix lite plus 26primaquine 64primidone 40PRIVIGEN 136PROAIR DIGIHALER 150PROAIR HFA 150PROAIR RESPICLICK 150probenecid 51

174

probenecid-colchicine 51procainamide hcl 90PROCALAMINE 108prochlorperazine 47prochlorperazine edisylate 47prochlorperazine maleate 47PROCRIT 86,87procto-med hc 139procto-pak 139proctosol-hc 139proctozone-hc 139PROCYSBI 114progesterone 128PROGLYCEM 82PROGRAF 134PROLASTIN C 153PROLENSA 144PROLEUKIN 59PROLIA 140PROMACTA 87promethazine hcl 47promethazine vc 153promethazine-phenylephrine 153promethegan 47propafenone hcl 90propafenone hcl er 90proparacaine hcl 143propranolol hcl 91propranolol hcl er 91propranolol-hydrochlorothiazid 91propylthiouracil 132PROQUAD 138PROSOL 142protriptyline hcl 46PROVENTIL HFA 150PULMOZYME 151PURIXAN 56PYLERA 111pyrazinamide 53pyridostigmine bromide 53

pyridostigmine bromide er 53

QQUADRACEL DTAP-IPV 138quasense 126quetiapine fumarate 69quetiapine fumarate er 69quinapril hcl 89quinapril-hydrochlorothiazide 89quinidine gluconate 90quinidine sulfate 90quinine sulfate 64QVAR 147QVAR REDIHALER 147

RRABAVERT 138rabeprazole sodium 113raloxifene hcl 128ramelteon 154ramipril 89RANEXA 94ranitidine hcl 112ranolazine er 94RAPAFLO 116RAPAMUNE 134rasagiline mesylate 66RAVICTI 114RAYALDEE 140REBIF 101REBIF REBIDOSE 101reclipsen 126RECOMBIVAX HB 138RECTIV 104REGRANEX 104RELENZA 76RELISTOR 111REMICADE 134REMODULIN 151RENAGEL 109

175

RENVELA 109repaglinide 82repaglinide-metformin hcl 82REPATHA PUSHTRONEX 94REPATHA SURECLICK 94REPATHA SYRINGE 94RESCRIPTOR 72RESTASIS 143RESTASIS MULTIDOSE 143RETACRIT 87RETROVIR 72REVATIO 152REVLIMID 55REXULTI 69REYATAZ 74ribasphere 76RIBASPHERE RIBAPAK 76ribavirin 76RIDAURA 136rifabutin 53rifampin 53RIFATER 53riluzole 100rimantadine hcl 76RIOMET 82risedronate sodium 141risedronate sodium dr 141RISPERDAL CONSTA 69risperidone 69risperidone odt 69RITUXAN 59rivastigmine 43rizatriptan 52ropinirole er 65ropinirole hcl 65rosuvastatin calcium 96ROTARIX 138ROTATEQ 138roweepra 38roweepra xr 38

ROZEREM 154ROZLYTREK 59RUBRACA 59RUCONEST 132RYDAPT 59

SSABRIL 40SAIZEN 121SAIZEN-SAIZENPREP 121salsalate 20SAMSCA 109SANCUSO 48SANDIMMUNE 134SANDOSTATIN LAR DEPOT 131SANTYL 104SAPHRIS 69SAVELLA 100scopolamine 47selegiline hcl 66selenium sulfide 104SELZENTRY 73SENSIPAR 141SEREVENT DISKUS 150SEROSTIM 121sertraline hcl 45setlakin 127sevelamer carbonate 110sevelamer hcl 110sharobel 128SHINGRIX 138SIGNIFOR 131SIGNIFOR LAR 131sildenafil 152sildenafil citrate 116,152SILENOR 154silodosin 116silver sulfadiazine 30SIMBRINZA 145SIMPONI 134

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SIMPONI ARIA 134SIMULECT 136simvastatin 96sirolimus 134,135SIRTURO 53SIVEXTRO 30SKLICE 64sodium chloride 108,142sodium chloride-water 108sodium fluoride 108sodium lactate 108sodium phenylbutyrate 115sodium polystyrene sulfonate 109sofosbuvir-velpatasvir 75solifenacin succinate 115SOLTAMOX 55SOLU-CORTEF 119SOLU-MEDROL 120SOMATULINE DEPOT 131SOMAVERT 131sorine 90sotalol 90sotalol af 90SOVALDI 75SPIRIVA 149SPIRIVA RESPIMAT 149spironolactone 95spironolactone-hctz 95SPORANOX 51SPRAVATO 44sprintec 127SPRITAM 38SPRYCEL 62SPS 109sronyx 127SSD 30STALEVO 100 66STALEVO 125 66STALEVO 150 66STALEVO 200 66

STALEVO 50 66STALEVO 75 66stavudine 73STELARA 104,136STIMATE 121STIOLTO RESPIMAT 153STIVARGA 62STRENSIQ 115streptomycin sulfate 28STRIBILD 71SUCRAID 115sucralfate 113sulfacetamide sodium 36sulfacetamide-prednisolone 145sulfadiazine 36sulfamethoxazole-trimethoprim 36SULFAMYLON 30sulfasalazine 139sulfasalazine dr 139sulindac 20sumatriptan 52sumatriptan succinate 52SUPRAX 32SUPREP 113SUSTIVA 72SUTENT 62SYLATRON 59SYLATRON 4-PACK 59SYLVANT 59SYMBICORT 153SYMFI 72SYMFI LO 72SYMLINPEN 120 82SYMLINPEN 60 82SYMPAZAN 37SYMTUZA 74SYNAGIS 136SYNALAR 104,120SYNAREL 131SYNERCID 30

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SYNJARDY 82SYNRIBO 59SYNTHROID 129SYPRINE 109

TTABLOID 56TACLONEX 104tacrolimus 104,135tadalafil 116TAFINLAR 62TAGRISSO 62TALTZ AUTOINJECTOR 104TALTZ AUTOINJECTOR (2 PACK) 104TALTZ AUTOINJECTOR (3 PACK) 104TALTZ SYRINGE 104TALTZ SYRINGE (2 PACK) 104TALTZ SYRINGE (3 PACK) 104TALZENNA 60TAMIFLU 76tamoxifen citrate 55tamsulosin hcl 116TARCEVA 62TARGRETIN 63tarina fe 127tarina fe 1-20 eq 127TASIGNA 62TAVALISSE 136tazarotene 104tazicef 32TAZORAC 104taztia xt 92TDVAX 138TECENTRIQ 59TECFIDERA 102TECHNIVIE 75TEFLARO 32TEGRETOL 42TEGRETOL XR 42TEGSEDI 115

TEKTURNA 94TEKTURNA HCT 94telmisartan 88telmisartan-amlodipine 93telmisartan-hydrochlorothiazid 88temazepam 78tencon 100TENIVAC 138terazosin hcl 116terbinafine hcl 51terbutaline sulfate 150terconazole 51testosterone 122testosterone cypionate 122testosterone enanthate 122tetrabenazine 100tetracycline hcl 37THALOMID 55theophylline 151theophylline anhydrous 151THIOLA EC 116thioridazine hcl 67thiotepa 54thiothixene 67THYMOGLOBULIN 136THYROLAR-1 129THYROLAR-1/2 129THYROLAR-1/4 129THYROLAR-2 129THYROLAR-3 129tiagabine hcl 40TIBSOVO 62tigecycline 30TIGLUTIK 100timolol maleate 91,145,146TIMOPTIC-XE 146tinidazole 64TIROSINT 129TIROSINT-SOL 129TIVICAY 71

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tizanidine hcl 70TOBI PODHALER 151TOBRADEX 145TOBRADEX ST 145tobramycin 28,151tobramycin sulfate 28tobramycin-dexamethasone 145TOBREX 28tolazamide 82tolbutamide 82tolcapone 65tolmetin sodium 20tolterodine tartrate 115tolterodine tartrate er 115topiramate 41toposar 60topotecan hcl 60toremifene citrate 55TORISEL 63torsemide 95TOUJEO MAX SOLOSTAR 84TOUJEO SOLOSTAR 84TOVIAZ 115TPN ELECTROLYTES 108TPN ELECTROLYTES II 108TRADJENTA 82tramadol hcl 25tramadol hcl er 22tramadol hcl-acetaminophen 25trandolapril 89trandolapril-verapamil er 89tranexamic acid 87TRANSDERM-SCOP 47tranylcypromine sulfate 44TRAVASOL 142TRAVATAN Z 146trazodone hcl 45TREANDA 54TRECATOR 53TRELSTAR 131

treprostinil 152TRESIBA 84TRESIBA FLEXTOUCH U-100 84TRESIBA FLEXTOUCH U-200 84tretinoin 63,105tretinoin microsphere 105TREXALL 135tri-legest fe 127tri-lo-estarylla 127tri-lo-sprintec 127tri-previfem 127tri-sprintec 127triamcinolone acetonide 102,120triamterene 95triamterene-hydrochlorothiazid 95TRICARE PRENATAL DHA ONE 110triderm 120trifluoperazine hcl 67trifluridine 77trihexyphenidyl hcl 65triklo 97trilyte with flavor packets 113trimethobenzamide hcl 47trimethoprim 30trimipramine maleate 47TRINAZ 110trinessa 127TRINTELLIX 46TRISENOX 59TRIUMEQ 71trivora-28 127TROGARZO 73TROPHAMINE 142trospium chloride 116trospium chloride er 116TRULICITY 82TRUMENBA 138TRUVADA 73TURALIO 59TWINRIX 138

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TYBOST 73TYGACIL 30TYKERB 63TYPHIM VI 138TYSABRI 102

UUCERIS 120,139ULORIC 51UNITHROID 129UPTRAVI 152ursodiol 111

Vvalacyclovir 77VALCHLOR 54valganciclovir hcl 74valproate sodium 40valproic acid 40valsartan 88valsartan-hydrochlorothiazide 88vancomycin hcl 30,31VANDAZOLE 31VAQTA 138VARIVAX VACCINE 138VARIZIG 136VASCEPA 97VECTIBIX 60VELCADE 60velivet 127VELPHORO 110VENCLEXTA 63VENCLEXTA STARTING PACK 63venlafaxine hcl 46venlafaxine hcl er 46VENTAVIS 152verapamil er 93verapamil er pm 93verapamil hcl 93verapamil sr 93

VEREGEN 105VERIPRED 20 105VERSACLOZ 70VERZENIO 60VESICARE 116vestura 127VIBRAMYCIN 37vicodin 25vicodin es 25vicodin hp 25VICTOZA 2-PAK 82VICTOZA 3-PAK 82VIDEX 73VIDEX EC 73vienva 127vigabatrin 40vigadrone 40VIGAMOX 36VIIBRYD 46VIMPAT 42vinblastine sulfate 60vincasar pfs 60vincristine sulfate 60vinorelbine tartrate 60VIRACEPT 74VIRAMUNE 72VIREAD 73VITRAKVI 63VIVITROL 26VIZIMPRO 63voriconazole 51VOSEVI 75VOTRIENT 63VPRIV 115VRAYLAR 69vyfemla 127VYNDAQEL 100VYVANSE 98VYXEOS 56

180

Wwarfarin sodium 85water 142WELCHOL 97wixela inhub 153wymzya fe 127

XXALKORI 63XARELTO 85XATMEP 135XELJANZ 136XELJANZ XR 136XEOMIN 70XEPI 36XGEVA 141XIFAXAN 31XIIDRA 143XOLAIR 153XOSPATA 63XPOVIO 60XTANDI 55xulane 127XYREM 154

YYERVOY 60YF-VAX 138YONDELIS 54YONSA 55yuvafem 127

Zzafirlukast 148zaleplon 153,154ZALTRAP 60zalvit 110ZANOSAR 54zarah 127

ZARXIO 87ZAVESCA 115ZEJULA 60ZELAPAR 66ZELBORAF 63ZEMAIRA 153zenatane 105zenchent 127ZENPEP 115ZERIT 73ZIAGEN 73zidovudine 73ziprasidone hcl 69ZIRGAN 74ZMAX 35zoledronic acid 141ZOLINZA 60zolmitriptan 52zolmitriptan odt 52zolpidem tartrate 154zolpidem tartrate er 154ZOMACTON 121ZOMETA 141ZOMIG 52zonisamide 39ZORBTIVE 121ZORTRESS 135ZOSTAVAX 138zovia 1-35e 127ZOVIRAX 77ZYCLARA 105ZYDELIG 60ZYFLO 148ZYFLO CR 105ZYKADIA 63ZYLET 145ZYPREXA RELPREVV 69ZYTIGA 55

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Discrimination is against the lawDoctors HealthCare Plans, Inc. complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Doctors HealthCare Plans, Inc. does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

Doctors HealthCare Plans, Inc.:

• Provides free aids and services to people with disabilities to communicate effectively with us, such as:– Qualified sign language interpreters– Written information in other formats (large print, audio, accessible electronic formats, other formats)

• Provides free language services to people whose primary language is not English, such as:– Qualified interpreters– Information written in other languages

If you need these services, contact the number on the back of your ID Card.

If you believe that Doctors HealthCare Plans has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with:

Doctors HealthCare Plans, Inc. Attention: Member Services Department 2020 Ponce de Leon Blvd., Suite 901 Coral Gables, FL 33134

Telephone: 786-460-3427 or 833-342-7463, TTY: 711 Fax: 786-578-0283

7 days a week; 8 a.m. to 8 p.m.

You can file a grievance in person by mail or fax. If you need help filing a grievance, our Member Services Representatives are available to help you at the number listed above.

You can also file a civil rights complaint electronically through the U.S. Department of Health and Human Services, Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201

1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

H4140_DHCPNND2019_C

La discriminación es contra la leyDoctors HealthCare Plans, Inc. cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo. Doctors HealthCare Plans, Inc. no excluye a las personas ni las trata de forma diferente debido a su origen étnico, color, nacionalidad, edad, discapacidad o sexo.

Doctors HealthCare Plans, Inc.:

• Proporciona asistencia y servicios gratuitos a las personas con discapacidades para que se comuniquen de manera eficazcon nosotros, como los siguientes:– Intérpretes de lenguaje de señas capacitados.– Información escrita en otros formatos (letra grande, audio, formatos electrónicos accesibles, otros formatos).

• Proporciona servicios lingüísticos gratuitos a personas cuya lengua materna no es el inglés, como los siguientes:– Intérpretes capacitados.– Información escrita en otros idiomas.

Si necesita recibir estos servicios, comuníquese, al número que se encuentra en la parte posterior de su tarjeta de identificación de asociado o comuníquese con el Departamento de Servicios al Asociado usando la información a continuación.

Si considera que Doctors HealthCare no le proporcionó estos servicios o lo discriminó de otra manera por motivos de origen étnico, color, nacionalidad, edad, discapacidad o sexo, puede presentar una queja con:

Doctors HealthCare Plans, Inc. Attention: Member Services Department 2020 Ponce de Leon Blvd., Suite 901 Coral Gables, FL 33134

Telefono: 786-460-3427 o 833-342-7463, TTY: 711 Fax: 786-578-0283

7 días de la semana de 8 a.m. a 8 p.m.

Puede presentar la queja en persona, por teléfono o fax. Si necesita ayuda para hacerlo, nuestros representantes del Departamento de Servicios al Asociado están a su disposición usando la información de contacto detallada anteriormente está a su disposición para brindársela.

También puede presentar un reclamo de derechos civiles ante la Office for Civil Rights (Oficina de Derechos Civiles) del Department of Health and Human Services (Departamento de Salud y Servicios Humanos) de EE. UU. de manera electrónica a través de Office for Civil Rights Complaint Portal, disponible en https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, o bien, por correo postal a la siguiente dirección o por teléfono a los números que figuran a continuación:U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201

1-800-368-1019, 800-537-7697 (TDD)

Puede obtener los formularios de reclamo en el sitio web http://www.hhs.gov/ocr/office/file/index.html.

H4140_DHCPNND2019S_C

MULTI-LANGUAGE INTERPRETER SERVICE

English: ATTENTION: If you do not speak English, language assistance services, free of charge, are available to you. Call 786-460-3427 or 833-342-7463 (TTY: 711).

Español (Spanish): ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 786-460-3427 o 833-342-7463 (TTY: 711).

繁體中文 (Chinese): 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 Call 786-460-3427 or 833-342-7463 (TTY: 711).

Français (French): ATTENTION: Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 786-460-3427 or 833-342-7463 (TTY: 711)

Deutsch (German): ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 786-460-3427 or 833-342-7463 (TTY: 711).

!ુજરાતી (Gujarati): સચુના: જો તમ ેગજુરાતી બોલતા હો, તો િન:શ3ુક ભાષા સહાય સવેાઓ તમારા માટ ેઉપલ=ધ છે. ફોન કરો786-460-3427 or 833-342-7463 (TTY: 711).

Kreyòl Ayisyen (French Creole): ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pouou. Rele 786-460-3427 or 833-342-7463 (TTY: 711).

Italiano (Italian): ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 786-460-3427 or 833-342-7463 (TTY: 711).

한국어 (Korean): 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다.

786-460-3427 or 833-342-7463 (TTY: 711).번으로 전화해 주십시오.

Polski (Polish): UWAGAM: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 786-460-3427 or 833-342-7463 (TTY: 711).

Português (Portuguese): ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 786-460-3427 or 833-342-7463 (TTY: 711).

Русский (Russian): ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 786-460-3427 or 833-342-7463 (TTY: 711).

ภาษาไทย (Thai): เรียน: ถา(คุณพดูภาษาไทยคุณสามารถใชบ(ริการช:วยเหลือทางภาษาไดฟBรี โทร 786-460-3427 or 833-342-7463 (TTY: 711).

Tiếng Việt (Vietnamese): CHÚ Ý: Nu bn nói Ting Vit, có các dch v h tr ngôn ng min phí dành cho bn. Gi s 786-460-3427 or 833-342-7463 (TTY: 711).

Tagalog (Tagalog – Filipino): PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 786-460-3427 or 833-342-7463 (TTY: 711).

Diné Bizaad (Navajo): ANOMPA PA PISAH: [Chahta] makilla ish anompoli hokma, kvna hosh Nahollo Anompa ya pipilla hosh chi tosholahinla. Atoko, hattak yvmma im anompoli chi bvnnakmvt, holhtina pa payah: 786-460-3427 or 833-342-7463 (TTY: 711).

ةیبرعلا (Arabic): فتاھ( 833-342-7463 وأ 786-460-3427 مقرلاب لصتا .كلجأ نم اًناجم ةیوغللا ةدعاسملا تامدخ رفون ،ةیزیلجنإلا ثدحتت نکت مل اذإ :ھیبنت)711:يصن

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2020 PONCE DE LEON BOULEVARD, SUITE 901 CORAL GABLES, FLORIDA 33134

T (786) 578 0965 F (786) 578 0290

This formulary was updated on December 1, 2019. For more recent information or other questions, please contact Doctors HealthCare Plans Member Services Department at (786) 460-3427 or (toll-free) at (833) 342-7463 or, for TTY users, dial 711, Monday through Sunday 8:00 a.m. – 8:00 p.m. ET, or visit us online at: www.doctorshcp.com.

Doctors HealthCare Plans, Inc. is an HMO with a Medicare contract. Enrollment in Doctors HealthCare Plans, Inc. depends on contract renewal.

This information is not a complete description of benefits. Call 786-460-3427 or toll free 833-342-7463 (TTY: 711) for more information.

ATTENTION: If you speak Spanish, language assistance services, free of charge, are available to you. Call 786-460-3427 or 833-342-7463 (TTY: 711).

ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 786-460-3427 o 833-342-7463 (TTY: 711).

Este formulario se actualizó el 1 de noviembre de 2019. Para obtener información más reciente o si tiene otras preguntas, comuníquese con Doctors HealthCare Plans Departamento deServicios al Asociado al (786) 460-3427 o al número de teléfono gratuito (833) 342-7463. Losusuarios de TTY deben llamar al 711, lunes a domingo 8:00 a.m. – 8:00 p.m. ET, o visitewww.doctorshcp.com.

Doctors HealthCare Plans, Inc. es un plan HMO con un contrato de Medicare. La afiliación en Doctors HealthCare Plans, Inc. depende de la renovación del contrato.

Esta información no es una descripción completa de los beneficios. Llame al 786-460-3427 o 833-342-7463 (TTY: 711)

WWW.DOCTORSHCP.COM


doctors healthcare plans, inc. · h4140 _pdg 2 0 19 _c | dhcp formulary _1 9 5 5 7 _v 2019 form...

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