healthy michigan formulary - thcmi.comthe total health care healthy michigan formulary is designed...

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HEALTHY MICHIGAN FORMULARY Effective June 2020

Provided by EnvisionRx

Introduction

The Total Health Care (THC) Healthy Michigan Formulary was developed to serve as a guide for physicians, pharmacists, health care professionals and members in the selection of cost-effective drug therapy. Total Health Care recognizes that drug therapy is an integral part of effective health management.

In order to streamline drug coverage policies for Medicaid members and providers, the Michigan Department of Health and Human Services (MDHHS) has worked with Medicaid health plan providers, including Total Health Care, to create a formulary that is common across all contracted Medicaid Health. This is known as the Michigan Medicaid Managed Care Common Formulary.

Total Health Care continually reviews new and existing medications to ensure the Formulary remains responsive to the needs of our members and health professionals. Criteria used to evaluate drug selection for the formulary includes, but is not limited to: safety, efficacy and cost-effectiveness data, as well as comparison of relevant benefits of similar prescription or over-the counter (OTC) agents while minimizing potential duplications.

Notice

The information contained in this formulary is provided by THC, solely for the convenience of medical providers and members. THC does not warrant or assure accuracy of this information, nor is it intended to be comprehensive in nature.

This formulary is not intended to be a substitute for the knowledge, expertise, skill or judgment of the medical provider in their choice of prescription drugs. Total Health Care assumes no responsibility for the actions or omissions of any medical provider based upon reliance, in whole or in part, on the information contained herein. The medical provider should consult the drug manufacturer’s product literature or standard references for more detailed information.

How to Read the Formulary

Drug Name

All formulary drugs are listed either by their generic names (in lowercase) or by their brand names (in uppercase). Drugs are grouped together by their therapeutic drug category. Specific drug listings may be accessed by using the index, using the covered generic name or the covered brand name of the drug. The

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brand names listed are for reference use only, and do not denote coverage, unless specifically noted. Any drug not found in this Formulary listing shall be considered a non-formulary drug.

Requirements/Limits

This field includes potential limitations to the formulary drug. It also may contain additional information about the coverage of the drug such as applicable quantity limits (QL). For certain agents within the Healthy Michigan Formulary, a recommended prescribing guideline may apply. Prescribing Guidelines Prescribing guidelines may apply to select drugs on the THC formulary. Prescribing guidelines may vary by benefit design but may include: Prior Authorization Required (PA)

Drug requires prior authorization through a specific physician request process.

Over the Counter Drugs (OTC)

Drug coverage is available for drugs that are available OTC with an authorized prescription from your provider.

Specialty Drugs (SP)

Drug requires processing through THC’s contracted specialty pharmacy, Envision Specialty Pharmacy.

Quantity Limit (QL) Drug coverage may be limited to specific quantities per prescription and/or time period.

Age Limit (AL) Drug coverage may depend on patient age.

Gender Restriction (GR) Drug coverage may depend on patient gender.

Step Therapy Required (ST)

Drug coverage requires that an alternative or trial of another drug be used before the medication is covered.

Custom (C) Drug coverage has unique restrictions.

Benefit Coverage and Limitations

This formulary does not define benefit coverage and limitations. Members should contact Total Health Care at 1-800-826-2862 if they have questions regarding their coverage. Please note that the formulary process is evolutionary and changes can occur throughout the year. Prior Authorization (PA) Drugs indicated with a “PA” require Prior Authorization for coverage. A prescriber may complete a Prior Authorization form that can be found on the Total Health Care website at www.THCmi.com. You may also request a form by calling Total Health Care at 1-844-222-5584. Completed prior authorization forms should be faxed to 1-866-422-9119. Prior Authorization review of prescribing guidelines will be evaluated utilizing

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the established drug review criteria approved by Total Health Care. If the request does not meet the approved criteria, the request will not be approved and alternative therapy may be recommended along with the proper course of alternative action. The requesting provider will be provided written notification of Total Health Care review decisions. THC’s website has a contact link where members can contact THC’s Pharmacy Department to ask for an exception request. Non-Formulary Agents Drugs not found on the Total Health Care Healthy Michigan Formulary, or any updates published by Total Health Care, shall be considered a non-formulary drug. Requests for coverage of non-formulary agents may be requested by the health professional depending on specific coverage parameters. Review for non-formulary drug requests will require a Prior Authorization request with documentation of medical necessity. Generally, the following basic medical necessity guidelines are used in conducting a review:

The patient has failed an appropriate trial of formulary or preferred agents. The use of preferred or formulary agent is contraindicated in the patient. The formulary drug or preferred agents are not suited for the present patient care need, and the drug

selected is required for patient safety. If the request does not meet the established guidelines request, it will not be approved and alternative therapy may be recommended along with the proper course of alternative action. Common Drug Exclusions The member’s plan design may exclude certain drug classes. Prior authorization is generally not available for drugs that are specifically excluded by benefit design. Common excluded coverage may include, but are not limited to:

Drug products used for cosmetic purposes. Drug products for sexual dysfunction. Drug products for infertility treatment. Experimental drug products or any drug product used in an experimental manner. Drug products identified by the Drug Efficacy Study Implementation (DESI) as being category 5

(less-than-effective for all indications) or category 6 (removed from the market). Foreign drugs or drugs not approved by the United States Food & Drug Administration (FDA).

Healthy Michigan Carve Out List The State of Michigan has a carve-out list for the Healthy Michigan formulary. The carve-out drugs include mental health, HIV/AIDS, Oncology, Hemophilia and other miscellaneous drugs that have been added to the State's 100% carve-out list. These drugs must be billed directly by the pharmacies at point-of-sale to the Michigan Department of Community Health's contracted Pharmacy Benefits Manager (PBM). A list of the carve-out drugs can be found at https://michigan.fhsc.com/Providers/DrugInfo.asp. Mandated Generic Substitution Total Health Care advocates the use of cost-effective generic drugs where FDA- approved generic equivalent drugs are available. Generic products are listed in the Formulary and noted as “generic” wherever an FDA-approved generic drug product is available. The brand names listed in the formulary are for reference only.

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Total Health Care Pharmacy and Therapeutics (P&T) Committee

Total Health Care’s Pharmacy & Therapeutics Committee meets quarterly to review and recommend medications for formulary consideration. The Committee considers clinical information on drugs that are new to the market and drugs that are typically included in an outpatient pharmacy benefit. This assures that the formulary remains responsive to patient and physician needs. The Committee is composed of physicians, pharmacists, and health care professionals. The Committee also uses reference materials from our Pharmacy Benefits Manager's Pharmacy and Therapeutics Advisory Panel. Product Selection Criteria The primary goal of the THC Pharmacy & Therapeutics Committee is to maintain and update the formulary based upon an objective analysis of the safety, efficacy, approved indications, adverse effects, contraindications, patient administration/compliance considerations and cost effectiveness of available drugs. When a drug is considered for formulary inclusion, it will be reviewed relative to similar drugs including those currently in the THC Formulary. Physicians may request a copy of THC’s drug criteria by calling the Pharmacy Department at 1-800-826-2862.

Diabetic Testing Supplies Total Health Care works with J&B Medical Supply to provide diabetic testing supplies to our members. Covered diabetic testing supplies include Glucocard Vital glucometer, Glucocard Expression glucometer, and SD Biosensor GlucoNavii glucometer, Glucocard Vital test strips, Glucocard Expression test strips, SD Biosensor GlucoNavii test strips, lancets, insulin syringes, alcohol swabs and ketone strips. These supplies are to be filled through J&B Medical Supply. If you have any questions about our diabetic supply program, please contact J&B Medical Supply at 1-844-236-7933.

Specialty Bio-Pharmaceutical Pharmacy Program

Total Health Care works with Envision Specialty Pharmacy to provide Specialty Bio-Pharmaceutical Pharmacy products to our members. These medications are to be filled exclusively through Envision Specialty Pharmacy. A Specialty Drug Prior Authorization Request form must be completed and faxed to EnvisionRx at 1-866-422-9119 with supporting documentation and the prescription. A prescriber may obtain a Specialty Drug Prior Authorization Request form found on the Total Health Care website at www.THCmi.com. Once the order is received, EnvisionRx obtains authorization from Total Health Care. If the specialty prior authorization is approved, Total Health Care notifies Envision Specialty Pharmacy. Then, Envision Specialty Pharmacy staff ships the medication directly to the physician's office or the patient’s home. All packages are individually marked for each patient and refrigerated items are shipped in insulated containers. Where appropriate, each shipment includes needles, syringes and alcohol swabs. If you have any questions about our Specialty Bio-Pharmaceutical Pharmacy program, please contact EnvisionRx at 1-844-222-5584 or Envision Specialty Pharmacy at 1-866-909-5170.

Contact Information

The Total Health Care Healthy Michigan formulary is designed to assist physicians, members and other health care professionals in the selection of cost-effective agents. Total Health Care encourages your input and feedback on how we can assist in improving this document and the formulary management process.

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You may contact THC at 1-800-826-2862.

Medication Limitations Quantity Limitations Quantity Limitations are on medications throughout the formulary and are indicated with a "QL" notation. These are medications that have a daily dose restriction, quantity/days’ supply limitation, and/or a limitation on the duration of therapy. Age Limitations Age Limitations are on medications throughout the formulary and are indicated with an "AL" notation. Coverage for a medication is indicated by the age limitation. This could be a minimum age, maximum age, and/or the combination of a minimum and maximum age edit.

Gender Restrictions

Gender restrictions are indicated with a “GR” on the formulary and require the member to be a specific gender for coverage. Step Therapy Criteria Step Therapy medications are indicated with a “ST” on the formulary and require that an alternative, first line medication be tried and failed before the requested medication can be covered. The online claims adjudication system will automatically allow for the requested medication to be filled based on electronic claims history indicating that the first line medication was filled.

Step-Therapy Criteria Therapy Class First Line Second Line Third Line Step Therapy Criteria

5-Aminosalicylic Acid Derivative Agents

balsalazide sulfasalazine sulfasalazine dr

APRISO, DELZICOL, mesalamine DR 1.2gm

PENTASA, mesalamine DR 800mg

Second Line: Prior use of balsalazide or sulfasalazine/dr within the last 180 days. Third Line: Prior use of APRISO, DELZICOL, or mesalamine DR 1.2gm within the last 180 days.

Acne Topical Differin 0.1% OTC Gel

Tretinoin 0.025% Cream

Prior use of Differin 0.1% OTC Gel within the last 90 days.

Antidiabetics metformin alogliptin, alogliptin-metformin, alogliptin- pioglitazone

Prior use of metformin at a minimum dose of 1,500mg/day for at least 90 days within the last 180 days.

Antiemetics ondansetron tablet, ondansetron odt,

granisetron tablet

Prior use of ondansetron within the last 180 days.

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ondansetron solution

Antimigraine Agents

naratriptan, rizatriptan, rizatriptan odt, sumatriptan tablet, sumatriptan injection (PA required)

zolmitriptan, zolmitriptan odt

Prior use of TWO first line agents within the last 180 days.

Heart Failure High dose ACEI or ARB

ENTRESTO *Prior use of high dose ACEI or ARB within the last 180 days.

Immunosuppressant Agents

mycophenolate tablet, capsule, suspension

mycophenolic acid dr tablet

Prior use of mycophenolate tablet, capsule, or suspension within the last 180 days.

Nitroglycerin nitroglycerin SL tab nitroglycerin spray

Prior use of nitroglycerin SL tab in the last 180 days.

Opthalmic ketotifen 0.025% drops

azelastine 0.05% drops

Prior use of ketotifen 0.025% within the last 180 days.

Pediculicides permethrin 1% lotion, pyrethrins-piperonyl butoxide

malathion 0.5% lotion spinosad 0.9%

Prior use of permethrin 1% lotion or pyrethrins- piperonyl butoxide in the last 180 days.

Proton Pump Inhibitors

omeprazole, pantoprazole

lansoprazole, NEXIUM

Prior use of TWO different step 1 drug entities within the last 180 days

Respiratory Agents

albuterol HFA (generic for Ventolain or ProAir) SEREVENT, INCRUSE ELLITA

levalbuterol tartrate HFA inhaler BEVESPI

Prior use of albuterol HFA once within the last 180 days. Prior 60-day use of SEREVENT or INCRUSE ELLIPTA within the last 90 days

Urinary Antispasmodics

oxybutynin tablet, oxybutynin ER tablet, oxybutynin syrup

tolterodine tablet, tolterodine ER capsule, trospium

Prior use of oxybutynin tablet/syrup in the last 180 days.

*High does equivalent example includes, but not limited to the following: • Enalapril Maleate 10 MG Tablet BID

*Formulary Disclaimer: Coverage for some drugs may be limited to specific dosage forms and/or strengths. The benefit design determines what is covered. The medications listed on this formulary are subject to change pursuant to the formulary management activities of EnvisionRx. The presence of a medication on this formulary list does not guarantee coverage.

CURRENT AS OF 6/1/2020

lowercase italics = Generic drugsUPPERCASE BOLD = Brand name drugs

StatusT1 = Covered

NotesAL = Age LimitC = Custom RestrictionGR-F = Female OnlyGR-M = Male OnlyPA = Prior AuthorizationQL = Quantity LimitST = Step Therapy

Drug Status Notes

*5-Ht4 Receptor Agonists***

MOTEGRITY ORAL TABLET 1 MG, 2 MG T1PA; QL (30 EA per 30 days); AL (Min 18 Years)

*Adhd/Anti-Narcolepsy/Anti-Obesity/Anorexiants*caffeine citrate oral solution 20 mg/ml T1 AL (Max 1 Years)

*Agents For Narcotic Withdrawal***

LUCEMYRA ORAL TABLET 0.18 MG T1PA; QL (224 EA per 14 days); AL (Min 18 Years)

*Amino Acids***ENDARI ORAL PACKET 5 GM T1 PA

*Aminoglycosides*BETHKIS INHALATION NEBULIZATION SOLUTION 300 MG/4ML T1 PA

KITABIS PAK INHALATION NEBULIZATION SOLUTION 300 MG/5ML T1 PA

neomycin sulfate oral tablet 500 mg T1

paromomycin sulfate oral capsule 250 mg T1

TOBI PODHALER INHALATION CAPSULE28 MG T1 PA

tobramycin inhalation nebulization solution 300 mg/5ml

T1 PA

*Analgesics - Anti-Inflammatory*ACTEMRA ACTPEN SUBCUTANEOUS SOLUTION AUTO-INJECTOR 162 MG/0.9ML

T1 PA

ACTEMRA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 162 MG/0.9ML T1 PA

celecoxib oral capsule 100 mg, 200 mg, 400 mg, 50 mg

T1 QL (30 EA per 30 days)

diclofenac sodium er oral tablet extended release 24 hour 100 mg

T1

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Drug Status Notesdiclofenac sodium oral tablet delayed release 25 mg, 50 mg, 75 mg

T1

ENBREL SUBCUTANEOUS KIT 25 MG T1 QL (4 EA per 28 days)

ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 25 MG/0.5ML T1 PA; QL (2 ML per 28 days)

ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 50 MG/ML T1 PA; QL (4 ML per 28 days)

ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 50 MG/ML T1 PA; QL (4 ML per 28 days)

etodolac oral capsule 200 mg, 300 mg T1 QL (60 EA per 30 days)

etodolac oral tablet 400 mg, 500 mg T1 QL (60 EA per 30 days)

flurbiprofen oral tablet 100 mg, 50 mg T1

HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 40 MG/0.8ML

T1 PA; QL (6 EA per 28 days)

HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 80 MG/0.8ML


HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 80 MG/0.8ML & 40MG/0.4ML


HUMIRA PEN PEN-INJECTOR KIT 40 MG/0.8ML SUBCUTANEOUS 40 MG/0.8ML T1 PA; QL (4 EA per 28 days)

HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.4ML T1 PA; QL (2 EA per 28 days)

HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML T1 PA; QL (4 EA per 28 days)

HUMIRA PEN-CD/UC/HS STARTER PEN-INJECTOR KIT 40 MG/0.8ML SUBCUTANEOUS 40 MG/0.8ML


HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 80 MG/0.8ML


HUMIRA PEN-PS/UV/ADOL HS START PEN-INJECTOR KIT 40 MG/0.8ML SUBCUTANEOUS 40 MG/0.8ML


HUMIRA PEN-PS/UV/ADOL HS START SUBCUTANEOUS PEN-INJECTOR KIT 80 MG/0.8ML & 40MG/0.4ML


HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 10 MG/0.1ML, 10 MG/0.2ML, 20 MG/0.2ML, 20 MG/0.4ML, 40 MG/0.4ML


HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 40 MG/0.8ML T1 PA; QL (4 EA per 28 days)

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Drug Status Notesibuprofen junior strength oral tablet chewable100 mg

T1

ibuprofen oral capsule 200 mg T1 QL (60 EA per 30 days)

ibuprofen oral suspension 100 mg/5ml T1 QL (480 ML per 30 days)

ibuprofen oral tablet 200 mg, 400 mg, 600 mg, 800 mg

T1

indomethacin oral capsule 25 mg, 50 mg T1 AL (Max 64 Years)

infants ibuprofen oral suspension 50 mg/1.25ml T1

ketorolac tromethamine oral tablet 10 mg T1 AL (Max 64 Years)

leflunomide oral tablet 10 mg, 20 mg T1 QL (30 EA per 30 days)

meloxicam oral tablet 15 mg, 7.5 mg T1 QL (30 EA per 30 days)

nabumetone oral tablet 500 mg, 750 mg T1 QL (60 EA per 30 days)

naproxen dr oral tablet delayed release 375 mg, 500 mg

T1

naproxen oral suspension 125 mg/5ml T1 PA; AL (Max 12 Years)

naproxen oral tablet 250 mg, 375 mg, 500 mg T1

naproxen sodium oral capsule 220 mg T1

naproxen sodium oral tablet 220 mg T1 QL (90 EA per 30 days)

OLUMIANT ORAL TABLET 1 MG, 2 MG T1 PA; QL (30 EA per 30 days)

ORENCIA CLICKJECT SUBCUTANEOUS SOLUTION AUTO-INJECTOR 125 MG/ML T1 PA

ORENCIA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 125 MG/ML, 50 MG/0.4ML, 87.5 MG/0.7ML

T1 PA

piroxicam oral capsule 10 mg, 20 mg T1 QL (30 EA per 30 days)

sm ibuprofen jr oral tablet 100 mg T1

sulindac oral tablet 150 mg, 200 mg T1

XELJANZ ORAL TABLET 10 MG, 5 MG T1 PA; QL (60 EA per 30 days)

XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HOUR 11 MG T1 PA; QL (30 EA per 30 days)

*Analgesics - Nonnarcotic*ACEPHEN RECTAL SUPPOSITORY 325 MG T1

acetaminophen 8 hour oral tablet 650 mg T1

acetaminophen er oral tablet extended release650 mg

T1

acetaminophen extra strength oral tablet 500 mg T1

acetaminophen oral elixir 160 mg/5ml T1

acetaminophen oral liquid 160 mg/5ml T1

acetaminophen oral solution 160 mg/5ml T1

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Drug Status Notesacetaminophen oral suspension 160 mg/5ml T1

acetaminophen oral tablet 325 mg T1

acetaminophen oral tablet chewable 80 mg T1

acetaminophen rapid tabs child oral tablet dispersible 80 mg

T1

acetaminophen rectal suppository 120 mg, 650 mg

T1

apap 500 oral liquid 500 mg/5ml T1

aspirin ec low dose oral tablet delayed release 81 mg


aspirin ec oral tablet delayed release 325 mg T1QL (30 EA per 30 days); AL (Min 40 Years and Max 79 Years)

aspirin oral tablet 325 mg T1QL (30 EA per 30 days); AL (Min 40 Years and Max 79 Years)

aspirin oral tablet chewable 81 mg T1 QL (30 EA per 30 days)

aspirin rectal suppository 300 mg, 600 mg T1

buffered aspirin oral tablet 325 mg T1AL (Min 40 Years and Max 79 Years)

butalbital-acetaminophen oral tablet 50-325 mg T1QL (120 EA per 30 days); AL (Min 10 Years and Max 64 Years)

butalbital-apap-caffeine oral tablet 50-325-40 mg T1QL (120 EA per 30 days); AL (Min 10 Years and Max 64 Years)

butalbital-aspirin-caffeine oral capsule 50-325-40 mg

T1QL (120 EA per 30 days); AL (Max 64 Years)

choline-mag trisalicylate oral liquid 500 mg/5ml T1

eq acetaminophen junior oral tablet dispersible160 mg

T1

extra strength acetaminophen oral capsule 500 mg

T1

infants pain relief oral suspension 80 mg/0.8ml T1

non-aspirin extra strength oral tablet dispersible500 mg

T1

pain relief childrens oral suspension 160 mg/5ml T1

q-pap infants oral solution 80 mg/0.8ml T1

*Analgesics - Opioid*acetaminophen-codeine #2 oral tablet 300-15 mg T1 QL (180 EA per 30 days)

acetaminophen-codeine #3 oral tablet 300-30 mg T1 QL (180 EA per 30 days)

acetaminophen-codeine #4 oral tablet 300-60 mg T1 QL (180 EA per 30 days)

acetaminophen-codeine oral solution 120-12 mg/5ml

T1 QL (240 ML per 30 days)

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Drug Status Notesbutalbital-apap-caff-cod oral capsule 50-325-40-30 mg


butalbital-asa-caff-codeine oral capsule 50-325-40-30 mg


codeine sulfate oral tablet 15 mg, 30 mg, 60 mg T1 QL (180 EA per 30 days)

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


hydrocodone-acetaminophen oral solution 7.5-325 mg/15ml


hydrocodone-acetaminophen oral tablet 10-325 mg, 7.5-325 mg


hydrocodone-acetaminophen oral tablet 5-325 mg T1 QL (360 EA per 30 days)

hydromorphone hcl oral liquid 1 mg/ml T1 QL (960 ML per 30 days)

hydromorphone hcl oral tablet 2 mg, 4 mg, 8 mg T1 QL (240 EA per 30 days)

hydromorphone hcl rectal suppository 3 mg T1 QL (120 EA per 30 days)

meperidine hcl oral solution 50 mg/5ml T1QL (300 ML per 30 days); AL (Max 64 Years)

meperidine hcl oral tablet 100 mg, 50 mg T1QL (180 EA per 30 days); AL (Max 64 Years)

METHADONE HCL INTENSOL ORAL CONCENTRATE 10 MG/ML T1 QL (240 ML per 30 days)

methadone hcl oral solution 10 mg/5ml T1 QL (600 ML per 30 days)

methadone hcl oral solution 5 mg/5ml T1 QL (900 ML per 30 days)

methadone hcl oral tablet 10 mg, 5 mg T1 QL (240 EA per 30 days)

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


morphine sulfate er oral tablet extended release100 mg, 15 mg, 200 mg, 30 mg, 60 mg


morphine sulfate oral solution 10 mg/5ml, 20 mg/5ml


morphine sulfate oral tablet 15 mg, 30 mg T1 QL (180 EA per 30 days)

oxycodone hcl oral solution 5 mg/5ml T1 QL (600 ML per 30 days)

oxycodone hcl oral tablet 10 mg, 15 mg, 20 mg, 30 mg, 5 mg


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


oxycodone-acetaminophen oral tablet 5-325 mg T1 QL (360 EA per 30 days)

pentazocine-naloxone hcl oral tablet 50-0.5 mg T1 QL (360 EA per 30 days)

tramadol hcl oral tablet 50 mg T1 QL (240 EA per 30 days)

*Androgens-Anabolic*danazol oral capsule 100 mg, 200 mg, 50 mg T1

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Drug Status Notestestosterone cypionate intramuscular solution 100 mg/ml, 200 mg/ml

T1

*Anorectal Agents*hydrocortisone rectal cream 1 % T1

hydrocortisone rectal enema 100 mg/60ml T1

PROCTOZONE-HC RECTAL CREAM 2.5 % T1

*Antacids*ACID GONE ORAL SUSPENSION 95-358 MG/15ML T1

aluminum hydroxide gel oral suspension 320 mg/5ml

T1

antacid calcium extra strength oral tablet chewable 750 mg

T1

antacid plus anti-gas fast act oral suspension200-200-20 mg/5ml

T1

antacid/simethicone ds oral suspension 400-400-40 mg/5ml

T1

calcium antacid ultra oral tablet chewable 1000 mg

T1

calcium carbonate antacid oral tablet chewable500 mg

T1

magnesium oxide oral capsule 400 mg T1

magnesium oxide oral tablet 250 mg, 400 mg T1

MAOX ORAL TABLET 420 MG T1

ri-mox oral suspension 225-200 mg/5ml T1

sodium bicarbonate oral tablet 325 mg, 650 mg T1

URO-MAG ORAL CAPSULE 140 MG T1

*Anthelmintics*benznidazole oral tablet 100 mg, 12.5 mg T1 PA

ivermectin oral tablet 3 mg T1

PIN-X ORAL SUSPENSION 50 MG/ML T1

PIN-X ORAL TABLET CHEWABLE 720.5 MG T1

*Antianginal Agents*isosorbide dinitrate er oral tablet extended release 40 mg

T1

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

T1

isosorbide mononitrate er oral tablet extended release 24 hour 120 mg, 30 mg, 60 mg

T1

isosorbide mononitrate oral tablet 10 mg, 20 mg T1

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Drug Status NotesNITRO-BID TRANSDERMAL OINTMENT 2 % T1

nitroglycerin er oral capsule extended release 2.5 mg, 6.5 mg, 9 mg

T1

nitroglycerin sublingual tablet sublingual 0.3 mg, 0.4 mg, 0.6 mg

T1

nitroglycerin transdermal patch 24 hour 0.1 mg/hr, 0.2 mg/hr, 0.4 mg/hr, 0.6 mg/hr


nitroglycerin translingual solution 0.4 mg/spray T1 ST

RANEXA ORAL TABLET EXTENDED RELEASE 12 HOUR 1000 MG, 500 MG T1 PA

*Antianxiety Agents*hydroxyzine hcl oral syrup 10 mg/5ml T1 AL (Max 12 Years)

hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg T1 AL (Max 64 Years)

hydroxyzine pamoate oral capsule 25 mg, 50 mg T1 AL (Max 64 Years)

*Antiarrhythmics*amiodarone hcl oral tablet 100 mg, 200 mg, 400 mg

T1

disopyramide phosphate oral capsule 100 mg, 150 mg

T1 AL (Max 64 Years)

flecainide acetate oral tablet 100 mg, 150 mg, 50 mg

T1

mexiletine hcl oral capsule 150 mg, 200 mg, 250 mg

T1

propafenone hcl oral tablet 150 mg, 225 mg, 300 mg

T1

quinidine sulfate er oral tablet extended release300 mg

T1

quinidine sulfate oral tablet 200 mg, 300 mg T1

*Antiasthmatic And Bronchodilator Agents*albuterol sulfate hfa aerosol solution 108 (90 base) mcg/act inhalation 108 (90 base) mcg/act

T1 QL (18 GM per 30 days)

albuterol sulfate hfa aerosol solution 108 (90 base) mcg/act inhalation 108 (90 base) mcg/act

T1 QL (8.5 GM per 30 days)

albuterol sulfate inhalation nebulization solution(2.5 mg/3ml) 0.083%, (5 mg/ml) 0.5%

T1

albuterol sulfate inhalation nebulization solution0.63 mg/3ml, 1.25 mg/3ml


albuterol sulfate oral syrup 2 mg/5ml T1

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Drug Status NotesARMONAIR RESPICLICK 113 INHALATION AEROSOL POWDER BREATH ACTIVATED 113 MCG/ACT


ARMONAIR RESPICLICK 232 INHALATION AEROSOL POWDER BREATH ACTIVATED 232 MCG/ACT


ARMONAIR RESPICLICK 55 INHALATION AEROSOL POWDER BREATH ACTIVATED 55 MCG/ACT


ATROVENT HFA INHALATION AEROSOL SOLUTION 17 MCG/ACT T1 QL (12.9 GM per 30 days)

BEVESPI AEROSPHERE INHALATION AEROSOL 9-4.8 MCG/ACT T1 ST

budesonide inhalation suspension 0.25 mg/2ml, 0.5 mg/2ml, 1 mg/2ml

T1QL (120 ML per 30 days); AL (Max 6 Years)

COMBIVENT RESPIMAT INHALATION AEROSOL SOLUTION 20-100 MCG/ACT T1 QL (4 GM per 30 days)

cromolyn sodium inhalation nebulization solution20 mg/2ml

T1

DULERA INHALATION AEROSOL 100-5 MCG/ACT, 200-5 MCG/ACT T1

QL (13 GM per 30 days); AL (Max 17 Years)

FLOVENT HFA INHALATION AEROSOL110 MCG/ACT, 220 MCG/ACT T1

QL (12 GM per 30 days); AL (Max 12 Years)

FLOVENT HFA INHALATION AEROSOL44 MCG/ACT T1

QL (10.6 GM per 30 days); AL (Max 12 Years)

fluticasone-salmeterol aerosol powder breath activated 113-14 mcg/act inhalation 113-14 mcg/act






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

T1QL (60 EA per 30 days); AL (Min 4 Years)

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


INCRUSE ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 62.5 MCG/INH


ipratropium bromide inhalation solution 0.02 % T1

ipratropium-albuterol inhalation solution 0.5-2.5 (3) mg/3ml


8

Drug Status Noteslevalbuterol tartrate inhalation aerosol 45 mcg/act

T1 ST; QL (15 GM per 25 days)

metaproterenol sulfate oral tablet 10 mg, 20 mg T1

montelukast sodium oral packet 4 mg T1QL (30 EA per 30 days); AL (Max 5 Years)

montelukast sodium oral tablet 10 mg T1 QL (30 EA per 30 days)

montelukast sodium oral tablet chewable 4 mg, 5 mg


PULMICORT FLEXHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 180 MCG/ACT, 90 MCG/ACT


QVAR REDIHALER INHALATION AEROSOL BREATH ACTIVATED 40 MCG/ACT, 80 MCG/ACT

T1 QL (10.6 GM per 30 days)

SEREVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 50 MCG/DOSE


SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION 1.25 MCG/ACT T1

PA; QL (4 GM per 30 days); AL (Min 6 Years)

STRIVERDI RESPIMAT INHALATION AEROSOL SOLUTION 2.5 MCG/ACT T1 QL (4 GM per 30 days)

SYMBICORT INHALATION AEROSOL160-4.5 MCG/ACT, 80-4.5 MCG/ACT T1

QL (10.2 GM per 30 days); AL (Max 17 Years)

terbutaline sulfate oral tablet 2.5 mg, 5 mg T1

THEOCHRON ORAL TABLET EXTENDED RELEASE 12 HOUR 200 MG T1

theophylline er oral tablet extended release 12 hour 100 mg, 300 mg, 450 mg

T1

theophylline er oral tablet extended release 24 hour 400 mg, 600 mg

T1

theophylline oral elixir 80 mg/15ml T1

theophylline oral solution 80 mg/15ml T1

WIXELA INHUB INHALATION AEROSOL POWDER BREATH ACTIVATED 100-50 MCG/DOSE


WIXELA INHUB INHALATION AEROSOL POWDER BREATH ACTIVATED 250-50 MCG/DOSE, 500-50 MCG/DOSE


*Anticoagulants*ELIQUIS DVT/PE STARTER PACK ORAL TABLET 5 MG T1

PA; QL (74 EA per 90 days); AL (Min 18 Years)

ELIQUIS ORAL TABLET 2.5 MG, 5 MG T1PA; QL (60 EA per 30 days); AL (Min 18 Years)

9

Drug Status Notesenoxaparin sodium subcutaneous solution 100 mg/ml, 120 mg/0.8ml, 150 mg/ml, 30 mg/0.3ml, 40 mg/0.4ml, 60 mg/0.6ml, 80 mg/0.8ml

T1 PA

heparin sodium (porcine) injection solution10000 unit/ml, 20000 unit/ml, 5000 unit/ml

T1

heparin sodium (porcine) pf injection solution5000 unit/0.5ml

T1

warfarin sodium oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg

T1

XARELTO ORAL TABLET 10 MG, 15 MG, 20 MG T1

PA; QL (30 EA per 30 days); AL (Min 18 Years)

XARELTO ORAL TABLET 2.5 MG T1 PA

XARELTO STARTER PACK ORAL TABLET THERAPY PACK 15 & 20 MG T1 PA; QL (51 EA per 90 days)

*Antidiabetics*acarbose oral tablet 100 mg T1 QL (120 EA per 30 days)

acarbose oral tablet 25 mg, 50 mg T1 QL (90 EA per 30 days)

ADMELOG SOLOSTAR SOLUTION PEN-INJECTOR 100 UNIT/ML SUBCUTANEOUS100 UNIT/ML


ADMELOG SOLUTION 100 UNIT/ML SUBCUTANEOUS 100 UNIT/ML T1 QL (60 ML per 30 days)

alogliptin benzoate tablet 12.5 mg oral 12.5 mg T1 ST; QL (30 EA per 30 days)

alogliptin benzoate tablet 25 mg oral 25 mg T1 ST; QL (30 EA per 30 days)

alogliptin benzoate tablet 6.25 mg oral 6.25 mg T1 ST; QL (30 EA per 30 days)

alogliptin-metformin hcl tablet 12.5-1000 mg oral12.5-1000 mg

T1 ST; QL (30 EA per 30 days)

alogliptin-metformin hcl tablet 12.5-500 mg oral12.5-500 mg


alogliptin-pioglitazone tablet 12.5-15 mg oral12.5-15 mg






alogliptin-pioglitazone tablet 25-15 mg oral 25-15 mg






BAQSIMI ONE PACK NASAL POWDER 3 MG/DOSE T1

QL (2 EA per 30 days); AL (Min 4 Years)

10

Drug Status NotesBAQSIMI TWO PACK NASAL POWDER 3 MG/DOSE T1

QL (1 EA per 30 days); AL (Min 4 Years)

BASAGLAR KWIKPEN SOLUTION PEN-INJECTOR 100 UNIT/ML SUBCUTANEOUS100 UNIT/ML


chlorpropamide oral tablet 100 mg, 250 mg T1 AL (Max 64 Years)

glimepiride oral tablet 1 mg, 2 mg, 4 mg T1

glipizide er oral tablet extended release 24 hour10 mg, 2.5 mg, 5 mg

T1

glipizide oral tablet 10 mg, 5 mg T1

glipizide-metformin hcl oral tablet 2.5-250 mg, 2.5-500 mg, 5-500 mg

T1

GLUCAGEN HYPOKIT INJECTION SOLUTION RECONSTITUTED 1 MG T1 QL (1 EA per 30 days)

GLUCAGON EMERGENCY INJECTION KIT 1 MG T1 QL (1 EA per 30 days)

glyburide micronized oral tablet 1.5 mg, 3 mg, 6 mg

T1

glyburide oral tablet 1.25 mg, 2.5 mg, 5 mg T1

glyburide-metformin oral tablet 1.25-250 mg, 2.5-500 mg, 5-500 mg

T1

HUMALOG MIX 50/50 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (50-50) 100 UNIT/ML


HUMALOG MIX 50/50 SUBCUTANEOUS SUSPENSION (50-50) 100 UNIT/ML T1 QL (60 ML per 30 days)

HUMALOG MIX 75/25 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (75-25) 100 UNIT/ML


HUMALOG MIX 75/25 SUBCUTANEOUS SUSPENSION (75-25) 100 UNIT/ML T1 QL (60 ML per 30 days)

HUMALOG SOLUTION 100 UNIT/ML SUBCUTANEOUS 100 UNIT/ML T1 QL (30 ML per 30 days)

HUMULIN 70/30 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML


HUMULIN 70/30 SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML T1 QL (60 ML per 30 days)

HUMULIN N KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR 100 UNIT/ML


HUMULIN N SUBCUTANEOUS SUSPENSION 100 UNIT/ML T1 QL (60 ML per 30 days)

11

Drug Status NotesHUMULIN R INJECTION SOLUTION 100 UNIT/ML T1 QL (60 ML per 30 days)

HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS SOLUTION 500 UNIT/ML T1 PA

insulin lispro solution 100 unit/ml subcutaneous100 unit/ml


INVOKANA ORAL TABLET 100 MG, 300 MG T1 PA; QL (30 EA per 30 days)

JANUMET ORAL TABLET 50-1000 MG, 50-500 MG T1 PA; QL (60 EA per 30 days)

JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR 100-1000 MG, 50-1000 MG, 50-500 MG


JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG T1 PA; QL (30 EA per 30 days)

JARDIANCE ORAL TABLET 10 MG, 25 MG T1 PA; QL (30 EA per 30 days)

JENTADUETO ORAL TABLET 2.5-1000 MG, 2.5-500 MG, 2.5-850 MG T1 PA; QL (60 EA per 30 days)

metformin hcl er oral tablet extended release 24 hour 500 mg, 750 mg

T1

metformin hcl oral tablet 1000 mg, 500 mg, 850 mg

T1

nateglinide oral tablet 120 mg, 60 mg T1 QL (90 EA per 30 days)

NOVOLIN 70/30 SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML T1 QL (60 ML per 30 days)

NOVOLIN N SUBCUTANEOUS SUSPENSION 100 UNIT/ML T1 QL (60 ML per 30 days)

NOVOLIN R INJECTION SOLUTION 100 UNIT/ML T1 QL (60 ML per 30 days)

NOVOLOG MIX 70/30 FLEXPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML


NOVOLOG MIX 70/30 SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML T1 QL (60 ML per 30 days)

OZEMPIC (0.25 OR 0.5 MG/DOSE) SUBCUTANEOUS SOLUTION PEN-INJECTOR 2 MG/1.5ML

T1 PA; QL (1.5 ML per 28 days)

OZEMPIC (1 MG/DOSE) SUBCUTANEOUS SOLUTION PEN-INJECTOR 2 MG/1.5ML T1 PA; QL (3 ML per 28 days)

pioglitazone hcl oral tablet 15 mg, 30 mg, 45 mg T1 QL (30 EA per 30 days)

repaglinide oral tablet 0.5 mg, 1 mg, 2 mg T1 QL (120 EA per 30 days)

STEGLATRO ORAL TABLET 15 MG, 5 MG T1 QL (30 EA per 30 days)

12

Drug Status NotesTANZEUM SUBCUTANEOUS PEN-INJECTOR 30 MG, 50 MG T1 PA; QL (4 EA per 28 days)

tolazamide oral tablet 250 mg, 500 mg T1

tolbutamide oral tablet 500 mg T1

TRADJENTA ORAL TABLET 5 MG T1 PA; QL (30 EA per 30 days)

TRULICITY SUBCUTANEOUS SOLUTION PEN-INJECTOR 0.75 MG/0.5ML, 1.5 MG/0.5ML

T1 PA; QL (2 ML per 28 days)

VICTOZA SUBCUTANEOUS SOLUTION PEN-INJECTOR 18 MG/3ML T1 PA; QL (6 ML per 30 days)

*Antidiarrheal/Probiotic Agents*pink bismuth maximum strength oral suspension525 mg/15ml

T1

pink bismuth oral suspension 262 mg/15ml T1

pink bismuth oral tablet chewable 262 mg T1

SOOTHE ORAL TABLET 262 MG T1

*Antidiarrheals*diphenoxylate-atropine oral tablet 2.5-0.025 mg T1

loperamide hcl oral capsule 2 mg T1

loperamide hcl oral suspension 1 mg/7.5ml T1

pink bismuth maximum strength oral suspension525 mg/15ml

T1

pink bismuth oral suspension 262 mg/15ml T1

pink bismuth oral tablet chewable 262 mg T1

SOOTHE ORAL TABLET 262 MG T1

*Antidotes*CHEMET ORAL CAPSULE 100 MG T1

naloxone hcl injection solution 0.4 mg/ml, 1 mg/ml


naloxone hcl injection solution cartridge 0.4 mg/ml


naloxone hcl injection solution prefilled syringe 2 mg/2ml


NARCAN NASAL LIQUID 4 MG/0.1ML T1 QL (2 EA per 90 days)

*Antiemetics*dimenhydrinate oral tablet 50 mg T1

dronabinol oral capsule 10 mg, 2.5 mg, 5 mg T1 PA

granisetron hcl oral tablet 1 mg T1 ST; QL (4 EA per 30 days)

meclizine hcl oral tablet 12.5 mg, 25 mg T1

meclizine hcl oral tablet chewable 25 mg T1

13

Drug Status Notes

ondansetron hcl oral solution 4 mg/5ml T1QL (300 ML per 30 days); AL (Max 12 Years)

ondansetron hcl oral tablet 24 mg T1 QL (30 EA per 30 days)

ondansetron hcl oral tablet 4 mg, 8 mg T1 QL (90 EA per 30 days)

ondansetron oral tablet dispersible 4 mg, 8 mg T1 QL (90 EA per 30 days)

*Antifungals*fluconazole oral suspension reconstituted 10 mg/ml, 40 mg/ml


fluconazole oral tablet 100 mg, 150 mg, 200 mg, 50 mg

T1

griseofulvin microsize oral suspension 125 mg/5ml

T1

griseofulvin microsize oral tablet 500 mg T1

griseofulvin ultramicrosize oral tablet 125 mg, 250 mg

T1

itraconazole oral capsule 100 mg T1

ketoconazole oral tablet 200 mg T1 QL (60 EA per 30 days)

nystatin oral tablet 500000 unit T1

terbinafine hcl oral tablet 250 mg T1 QL (30 EA per 30 days)

*Antihistamines*carbinoxamine maleate oral solution 4 mg/5ml T1

carbinoxamine maleate oral tablet 4 mg T1

cetirizine hcl allergy child oral solution 5 mg/5ml T1QL (300 ML per 30 days); AL (Max 12 Years)

cetirizine hcl oral tablet 10 mg, 5 mg T1 QL (30 EA per 30 days)

childrens loratadine oral syrup 5 mg/5ml T1QL (300 ML per 30 days); AL (Max 12 Years)

chlorpheniramine maleate er oral tablet extended release 12 mg

T1

chlorpheniramine maleate oral tablet 4 mg T1

clemastine fumarate oral syrup 0.67 mg/5ml T1

clemastine fumarate oral tablet 1.34 mg, 2.68 mg T1

cyproheptadine hcl oral syrup 2 mg/5ml T1 AL (Max 64 Years)

cyproheptadine hcl oral tablet 4 mg T1 AL (Max 64 Years)

diphenhydramine cough oral syrup 12.5 mg/5ml T1

diphenhydramine hcl injection solution 50 mg/ml T1 AL (Max 64 Years)

diphenhydramine hcl oral capsule 25 mg, 50 mg T1 AL (Max 64 Years)

diphenhydramine hcl oral liquid 12.5 mg/5ml T1

diphenhydramine hcl oral tablet 25 mg T1 AL (Max 64 Years)

loratadine oral tablet 10 mg T1 QL (30 EA per 30 days)

14

Drug Status Notes

promethazine hcl oral syrup 6.25 mg/5ml T1AL (Min 2 Years and Max 64 Years)

promethazine hcl oral tablet 12.5 mg, 25 mg, 50 mg

T1AL (Min 2 Years and Max 64 Years)

promethazine hcl rectal suppository 12.5 mg, 25 mg, 50 mg

T1AL (Min 2 Years and Max 64 Years)

*Antihyperlipidemics*atorvastatin calcium oral tablet 10 mg, 20 mg, 40 mg, 80 mg


cholestyramine light oral packet 4 gm T1 QL (60 EA per 30 days)

cholestyramine oral packet 4 gm T1 QL (60 EA per 30 days)

cholestyramine oral powder 4 gm/dose T1 QL (378 GM per 30 days)

colestipol hcl oral granules 5 gm T1

colestipol hcl oral tablet 1 gm T1

ezetimibe oral tablet 10 mg T1 QL (30 EA per 30 days)

fenofibrate micronized oral capsule 134 mg, 200 mg, 43 mg, 67 mg


fenofibrate oral capsule 50 mg T1 QL (30 EA per 30 days)

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


fenofibric acid oral capsule delayed release 135 mg, 45 mg


gemfibrozil oral tablet 600 mg T1 QL (60 EA per 30 days)

LIPOFEN ORAL CAPSULE 50 MG T1 QL (30 EA per 30 days)

lovastatin oral tablet 10 mg, 20 mg T1 QL (30 EA per 30 days)

lovastatin oral tablet 40 mg T1 QL (60 EA per 30 days)

omega-3-acid ethyl esters oral capsule 1 gm T1 PA

pravastatin sodium oral tablet 10 mg, 20 mg, 40 mg, 80 mg


PREVALITE ORAL POWDER 4 GM/DOSE T1 QL (240 GM per 30 days)

rosuvastatin calcium oral tablet 10 mg, 20 mg, 40 mg, 5 mg


simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg, 80 mg


*Antihypertensives*aliskiren fumarate oral tablet 150 mg, 300 mg T1 PA; QL (30 EA per 30 days)

amlodipine besy-benazepril hcl oral capsule 10-20 mg, 10-40 mg, 2.5-10 mg, 5-10 mg, 5-20 mg, 5-40 mg


amlodipine besylate-valsartan oral tablet 10-160 mg, 10-320 mg, 5-160 mg, 5-320 mg

T1

15

Drug Status Notesatenolol-chlorthalidone oral tablet 100-25 mg, 50-25 mg

T1

benazepril hcl oral tablet 10 mg, 5 mg T1 QL (45 EA per 30 days)

benazepril hcl oral tablet 20 mg, 40 mg T1 QL (60 EA per 30 days)

benazepril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg, 5-6.25 mg

T1

bisoprolol-hydrochlorothiazide oral tablet 10-6.25 mg


bisoprolol-hydrochlorothiazide oral tablet 2.5-6.25 mg, 5-6.25 mg


captopril-hydrochlorothiazide oral tablet 25-15 mg, 25-25 mg, 50-15 mg, 50-25 mg

T1

clonidine hcl oral tablet 0.1 mg, 0.2 mg, 0.3 mg T1

doxazosin mesylate oral tablet 1 mg, 2 mg, 4 mg T1 QL (30 EA per 30 days)

doxazosin mesylate oral tablet 8 mg T1 QL (60 EA per 30 days)

enalapril maleate oral tablet 10 mg, 20 mg T1 QL (60 EA per 30 days)

enalapril maleate oral tablet 2.5 mg, 5 mg T1 QL (45 EA per 30 days)

enalapril-hydrochlorothiazide oral tablet 10-25 mg, 5-12.5 mg


EPANED ORAL SOLUTION 1 MG/ML T1 AL (Max 12 Years)

fosinopril sodium oral tablet 10 mg, 20 mg T1 QL (45 EA per 30 days)

fosinopril sodium oral tablet 40 mg T1 QL (60 EA per 30 days)

guanfacine hcl oral tablet 1 mg, 2 mg T1 QL (60 EA per 30 days)

hydralazine hcl injection solution 20 mg/ml T1

hydralazine hcl oral tablet 10 mg, 25 mg, 50 mg T1 QL (120 EA per 30 days)

hydralazine hcl oral tablet 100 mg T1 QL (90 EA per 30 days)

irbesartan oral tablet 150 mg, 300 mg, 75 mg T1 QL (30 EA per 30 days)

irbesartan-hydrochlorothiazide oral tablet 150-12.5 mg, 300-12.5 mg


lisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 30 mg, 40 mg, 5 mg

T1

lisinopril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg

T1

losartan potassium oral tablet 100 mg, 25 mg, 50 mg

T1

losartan potassium-hctz oral tablet 100-12.5 mg, 100-25 mg, 50-12.5 mg

T1

methyldopa oral tablet 250 mg, 500 mg T1 AL (Max 64 Years)

methyldopa-hydrochlorothiazide oral tablet 250-15 mg, 250-25 mg

T1

16

Drug Status Notesmetoprolol-hydrochlorothiazide oral tablet 100-25 mg, 100-50 mg, 50-25 mg

T1

minoxidil oral tablet 10 mg, 2.5 mg T1

perindopril erbumine oral tablet 2 mg, 4 mg T1 QL (45 EA per 30 days)

prazosin hcl oral capsule 1 mg, 2 mg, 5 mg T1 QL (60 EA per 30 days)

QBRELIS ORAL SOLUTION 1 MG/ML T1 AL (Max 12 Years)

quinapril hcl oral tablet 10 mg, 20 mg, 40 mg, 5 mg


quinapril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg

T1

ramipril oral capsule 1.25 mg, 10 mg, 2.5 mg, 5 mg


TEKTURNA HCT ORAL TABLET 150-12.5 MG, 150-25 MG, 300-12.5 MG, 300-25 MG T1 PA; QL (30 EA per 30 days)

terazosin hcl oral capsule 1 mg, 5 mg T1 QL (30 EA per 30 days)

terazosin hcl oral capsule 10 mg, 2 mg T1 QL (60 EA per 30 days)

trandolapril oral tablet 1 mg, 2 mg, 4 mg T1 QL (30 EA per 30 days)

valsartan oral tablet 160 mg, 40 mg, 80 mg T1 QL (60 EA per 30 days)

valsartan oral tablet 320 mg T1 QL (30 EA per 30 days)

valsartan-hydrochlorothiazide oral tablet 160-12.5 mg, 160-25 mg, 320-12.5 mg, 320-25 mg, 80-12.5 mg


*Anti-Infective Agents - Misc.*atovaquone oral suspension 750 mg/5ml T1 PA

clindamycin hcl oral capsule 150 mg, 300 mg, 75 mg

T1

clindamycin palmitate hcl oral solution reconstituted 75 mg/5ml


dapsone oral tablet 100 mg, 25 mg T1

linezolid oral suspension reconstituted 100 mg/5ml

T1 PA

linezolid oral tablet 600 mg T1 PA

metronidazole oral tablet 250 mg, 500 mg T1

sulfamethoxazole-trimethoprim oral suspension200-40 mg/5ml

T1

sulfamethoxazole-trimethoprim oral tablet 400-80 mg, 800-160 mg

T1

tinidazole oral tablet 250 mg, 500 mg T1

trimethoprim oral tablet 100 mg T1

vancomycin hcl intravenous solution reconstituted5000 mg

T1

17

Drug Status Notes

*Antimalarials*chloroquine phosphate oral tablet 250 mg, 500 mg


hydroxychloroquine sulfate oral tablet 200 mg T1

KRINTAFEL ORAL TABLET 150 MG T1PA; QL (60 EA per 30 days); AL (Min 16 Years)

mefloquine hcl oral tablet 250 mg T1 PA

primaquine phosphate oral tablet 26.3 mg T1

*Antimyasthenic Agents*

FIRDAPSE ORAL TABLET 10 MG T1PA; QL (240 EA per 30 days); AL (Min 18 Years)

MESTINON ORAL SYRUP 60 MG/5ML T1 AL (Max 12 Years)

pyridostigmine bromide oral solution 60 mg/5ml T1 AL (Max 12 Years)

pyridostigmine bromide oral tablet 60 mg T1

*Antimyasthenic/Cholinergic Agents*MESTINON ORAL SYRUP 60 MG/5ML T1 AL (Max 12 Years)

pyridostigmine bromide oral tablet 60 mg T1

*Antimycobacterial Agents*cycloserine oral capsule 250 mg T1

ethambutol hcl oral tablet 100 mg, 400 mg T1

isoniazid oral syrup 50 mg/5ml T1 AL (Max 12 Years)

isoniazid oral tablet 100 mg, 300 mg T1

PRIFTIN ORAL TABLET 150 MG T1 QL (24 EA per 28 days)

pyrazinamide oral tablet 500 mg T1

rifabutin oral capsule 150 mg T1

rifampin oral capsule 150 mg, 300 mg T1

TRECATOR ORAL TABLET 250 MG T1

*Antineoplastic - Bcl-2 Inhibitors***VENCLEXTA ORAL TABLET 10 MG, 100 MG, 50 MG T1 PA

VENCLEXTA STARTING PACK ORAL TABLET THERAPY PACK 10 & 50 & 100 MG

T1 PA

*Antineoplastic - Xpo1 Inhibitors***XPOVIO (100 MG ONCE WEEKLY) ORAL TABLET THERAPY PACK 20 MG T1 PA

XPOVIO (60 MG ONCE WEEKLY) ORAL TABLET THERAPY PACK 20 MG T1 PA

XPOVIO (80 MG ONCE WEEKLY) ORAL TABLET THERAPY PACK 20 MG T1 PA

18

Drug Status NotesXPOVIO (80 MG TWICE WEEKLY) ORAL TABLET THERAPY PACK 20 MG T1 PA

*Antineoplastics And Adjunctive Therapies*AFINITOR DISPERZ ORAL TABLET SOLUBLE 2 MG, 3 MG, 5 MG T1 PA; QL (60 EA per 30 days)

AFINITOR ORAL TABLET 10 MG T1 PA; QL (30 EA per 30 days)

ALKERAN ORAL TABLET 2 MG T1 PA

anastrozole oral tablet 1 mg T1

bexarotene oral capsule 75 mg T1 PA

bicalutamide oral tablet 50 mg T1

BRAFTOVI ORAL CAPSULE 50 MG T1 PA

capecitabine oral tablet 150 mg, 500 mg T1 PA

cyclophosphamide oral capsule 25 mg, 50 mg T1 PA

DAURISMO ORAL TABLET 100 MG, 25 MG T1 PA

EMCYT ORAL CAPSULE 140 MG T1 PA

ERIVEDGE ORAL CAPSULE 150 MG T1 PA; QL (30 EA per 30 days)

ERLEADA ORAL TABLET 60 MG T1 PA; QL (120 EA per 30 days)

etoposide oral capsule 50 mg T1 PA

everolimus oral tablet 2.5 mg, 5 mg, 7.5 mg T1 PA; QL (30 EA per 30 days)

exemestane oral tablet 25 mg T1

FARESTON ORAL TABLET 60 MG T1 PA

FARYDAK ORAL CAPSULE 10 MG, 15 MG, 20 MG T1 PA

flutamide oral capsule 125 mg T1 PA

GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG T1 PA

HEXALEN ORAL CAPSULE 50 MG T1 PA

HYCAMTIN ORAL CAPSULE 0.25 MG, 1 MG T1 PA

hydroxyurea oral capsule 500 mg T1

INTRON A INJECTION SOLUTION10000000 UNIT/ML, 6000000 UNIT/ML T1 PA

INTRON A INJECTION SOLUTION RECONSTITUTED 10000000 UNIT, 18000000 UNIT, 50000000 UNIT

T1 PA

JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 25 MG, 5 MG T1 PA; QL (60 EA per 30 days)

letrozole oral tablet 2.5 mg T1QL (30 EA per 30 days); AL (Min 18 Years)

19

Drug Status Notesleucovorin calcium oral tablet 10 mg, 15 mg, 25 mg, 5 mg

T1

LEUKERAN ORAL TABLET 2 MG T1 PA

leuprolide acetate injection kit 1 mg/0.2ml T1 PA

LONSURF ORAL TABLET 15-6.14 MG, 20-8.19 MG T1 PA

LYSODREN ORAL TABLET 500 MG T1 PA

MATULANE ORAL CAPSULE 50 MG T1 PA

megestrol acetate oral suspension 400 mg/10ml T1

megestrol acetate oral tablet 20 mg, 40 mg T1

mercaptopurine oral tablet 50 mg T1

MESNEX ORAL TABLET 400 MG T1 PA

methotrexate oral tablet 2.5 mg T1

methotrexate sodium (pf) injection solution 25 mg/ml, 50 mg/2ml

T1

methotrexate sodium injection solution 25 mg/ml, 50 mg/2ml

T1

MYLERAN ORAL TABLET 2 MG T1 PA

nilutamide oral tablet 150 mg T1 PA

NUBEQA ORAL TABLET 300 MG T1 PA

ODOMZO ORAL CAPSULE 200 MG T1 PA

POMALYST ORAL CAPSULE 1 MG, 2 MG, 3 MG, 4 MG T1 PA; QL (30 EA per 30 days)

TABLOID ORAL TABLET 40 MG T1 PA

tamoxifen citrate oral tablet 10 mg, 20 mg T1 QL (60 EA per 30 days)

temozolomide oral capsule 100 mg, 140 mg, 180 mg, 20 mg, 250 mg, 5 mg

T1 PA

tretinoin oral capsule 10 mg T1 PA

XATMEP ORAL SOLUTION 2.5 MG/ML T1 PA

XTANDI ORAL CAPSULE 40 MG T1 PA; QL (120 EA per 30 days)

ZOLINZA ORAL CAPSULE 100 MG T1 PA

ZYTIGA ORAL TABLET 250 MG T1 PA; QL (120 EA per 30 days)

*Antiparkinson Agents*amantadine hcl oral capsule 100 mg T1 QL (120 EA per 30 days)

amantadine hcl oral syrup 50 mg/5ml T1 QL (1200 ML per 30 days)

bromocriptine mesylate oral capsule 5 mg T1 QL (90 EA per 30 days)

bromocriptine mesylate oral tablet 2.5 mg T1 QL (180 EA per 30 days)

carbidopa-levodopa er oral tablet extended release 25-100 mg, 50-200 mg

T1

20

Drug Status Notescarbidopa-levodopa oral tablet 10-100 mg, 25-100 mg, 25-250 mg

T1

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

T1

entacapone oral tablet 200 mg T1 QL (120 EA per 30 days)

pramipexole dihydrochloride oral tablet 0.125 mg, 0.25 mg, 0.5 mg, 0.75 mg, 1 mg, 1.5 mg


ropinirole hcl oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg, 5 mg


selegiline hcl oral capsule 5 mg T1 QL (60 EA per 30 days)

*Antipsychotics/Antimanic Agents*prochlorperazine maleate oral tablet 10 mg, 5 mg T1 QL (120 EA per 30 days)

prochlorperazine rectal suppository 25 mg T1 QL (60 EA per 30 days)

*Antiseptics & Disinfectants*povidone-iodine external solution 10 % T1

*Antivirals*acyclovir oral capsule 200 mg T1

acyclovir oral suspension 200 mg/5ml T1 AL (Max 12 Years)

acyclovir oral tablet 400 mg, 800 mg T1

adefovir dipivoxil oral tablet 10 mg T1 QL (30 EA per 30 days)

entecavir oral tablet 0.5 mg, 1 mg T1 QL (30 EA per 30 days)

famciclovir oral tablet 125 mg, 250 mg, 500 mg T1 QL (90 EA per 30 days)

lamivudine oral tablet 100 mg T1 QL (30 EA per 30 days)

oseltamivir phosphate oral capsule 30 mg, 45 mg, 75 mg


oseltamivir phosphate oral suspension reconstituted 6 mg/ml


RELENZA DISKHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 5 MG/BLISTER


rimantadine hcl oral tablet 100 mg T1

valacyclovir hcl oral tablet 1 gm T1 QL (90 EA per 30 days)

valacyclovir hcl oral tablet 500 mg T1 QL (30 EA per 30 days)

valganciclovir hcl oral tablet 450 mg T1 PA; QL (60 EA per 30 days)

VEMLIDY ORAL TABLET 25 MG T1 PA; QL (30 EA per 30 days)

*Assorted Classes*azathioprine oral tablet 50 mg T1 QL (240 EA per 30 days)

cyclosporine modified oral capsule 100 mg, 25 mg, 50 mg

T1

cyclosporine modified oral solution 100 mg/ml T1 AL (Max 12 Years)

21

Drug Status Notescyclosporine oral capsule 100 mg, 25 mg T1

mycophenolate mofetil oral capsule 250 mg T1

mycophenolate mofetil oral suspension reconstituted 200 mg/ml


mycophenolate mofetil oral tablet 500 mg T1

mycophenolic acid oral tablet delayed release180 mg, 360 mg

T1 ST

REVLIMID ORAL CAPSULE 10 MG, 15 MG, 2.5 MG, 20 MG, 25 MG, 5 MG T1 PA; QL (30 EA per 30 days)

sirolimus oral tablet 0.5 mg, 1 mg, 2 mg T1

sodium polystyrene sulfonate oral powder T1

sodium polystyrene sulfonate rectal suspension 30 gm/120ml

T1

SPS ORAL SUSPENSION 15 GM/60ML T1

sterile water for irrigation irrigation solution T1

tacrolimus oral capsule 0.5 mg, 1 mg, 5 mg T1

THALOMID ORAL CAPSULE 100 MG, 150 MG, 200 MG, 50 MG T1 PA

*Beta Blockers*acebutolol hcl oral capsule 200 mg, 400 mg T1

atenolol oral tablet 100 mg, 25 mg, 50 mg T1

betaxolol hcl oral tablet 10 mg, 20 mg T1

bisoprolol fumarate oral tablet 10 mg T1 QL (60 EA per 30 days)

bisoprolol fumarate oral tablet 5 mg T1 QL (45 EA per 30 days)

carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg, 6.25 mg

T1

HEMANGEOL ORAL SOLUTION 4.28 MG/ML T1 AL (Max 4 Years)

labetalol hcl oral tablet 100 mg, 200 mg, 300 mg T1

metoprolol succinate er oral tablet extended release 24 hour 100 mg, 25 mg, 50 mg


metoprolol succinate er oral tablet extended release 24 hour 200 mg


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

T1

nadolol oral tablet 20 mg, 40 mg, 80 mg T1

propranolol hcl er oral capsule extended release 24 hour 120 mg, 160 mg


propranolol hcl er oral capsule extended release 24 hour 60 mg


22

Drug Status Notespropranolol hcl er oral capsule extended release 24 hour 80 mg


propranolol hcl oral solution 20 mg/5ml, 40 mg/5ml

T1

propranolol hcl oral tablet 10 mg, 20 mg, 40 mg, 60 mg, 80 mg

T1

sotalol hcl (af) oral tablet 120 mg, 160 mg, 80 mg T1 QL (60 EA per 30 days)

sotalol hcl oral tablet 120 mg, 160 mg, 240 mg, 80 mg


*Calcitonin Gene-Related Peptide (Cgrp) Receptor Antag***AIMOVIG SUBCUTANEOUS SOLUTION AUTO-INJECTOR 140 MG/ML, 70 MG/ML T1

PA; QL (1 ML per 30 days); AL (Min 18 Years)

AJOVY SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 225 MG/1.5ML T1


EMGALITY (300 MG DOSE) SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 100 MG/ML

T1PA; QL (3 ML per 30 days); AL (Min 18 Years)

EMGALITY SUBCUTANEOUS SOLUTION AUTO-INJECTOR 120 MG/ML T1


*Calcium Channel Blockers*amlodipine besylate oral tablet 10 mg, 2.5 mg, 5 mg


CARTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 240 MG, 300 MG


CARTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR 180 MG T1 QL (60 EA per 30 days)

diltiazem hcl er beads oral capsule extended release 24 hour 420 mg


diltiazem hcl er oral capsule extended release 24 hour 120 mg, 180 mg


diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg, 90 mg

T1

dilt-xr oral capsule extended release 24 hour 240 mg


felodipine er oral tablet extended release 24 hour10 mg


felodipine er oral tablet extended release 24 hour2.5 mg, 5 mg


isradipine oral capsule 2.5 mg, 5 mg T1 QL (60 EA per 30 days)

MATZIM LA ORAL TABLET EXTENDED RELEASE 24 HOUR 180 MG, 300 MG T1 QL (30 EA per 30 days)

23

Drug Status Notesnicardipine hcl oral capsule 20 mg, 30 mg T1 QL (30 EA per 30 days)

NIFEDICAL XL ORAL TABLET EXTENDED RELEASE 24 HOUR 30 MG, 60 MG


nifedipine er oral tablet extended release 24 hour30 mg, 60 mg, 90 mg


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


nifedipine oral capsule 10 mg, 20 mg T1QL (120 EA per 30 days); AL (Max 64 Years)

nimodipine oral capsule 30 mg T1

TAZTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG


verapamil hcl er oral capsule extended release 24 hour 100 mg, 120 mg, 200 mg, 240 mg, 300 mg


verapamil hcl er oral capsule extended release 24 hour 180 mg


verapamil hcl er oral tablet extended release 120 mg, 180 mg, 240 mg


verapamil hcl oral tablet 120 mg, 40 mg, 80 mg T1

*Cardiotonics*digoxin oral tablet 125 mcg, 250 mcg T1

*Cardiovascular Agents - Misc.*ADCIRCA ORAL TABLET 20 MG T1 PA; QL (60 EA per 30 days)

ADEMPAS ORAL TABLET 0.5 MG, 1 MG, 1.5 MG, 2 MG, 2.5 MG T1 PA; QL (90 EA per 30 days)

LETAIRIS ORAL TABLET 10 MG, 5 MG T1 PA; QL (30 EA per 30 days)

niacin flush free oral capsule 500 mg T1

NIACIN FLUSH-FREE EX ST ORAL CAPSULE 750 MG T1

sildenafil citrate oral tablet 20 mg T1 PA

TRACLEER ORAL TABLET 125 MG, 62.5 MG T1 PA; QL (60 EA per 30 days)

TRACLEER ORAL TABLET SOLUBLE 32 MG T1

PA; AL (Min 3 Years and Max 12 Years)

*Cephalosporins*cefaclor oral capsule 250 mg, 500 mg T1

cefaclor oral suspension reconstituted 125 mg/5ml, 250 mg/5ml, 375 mg/5ml


cefadroxil oral capsule 500 mg T1

24

Drug Status Notescefadroxil oral suspension reconstituted 250 mg/5ml, 500 mg/5ml


cefadroxil oral tablet 1 gm T1

cefdinir oral capsule 300 mg T1

cefdinir oral suspension reconstituted 125 mg/5ml, 250 mg/5ml

T1

cefixime oral capsule 400 mg T1

cefixime oral suspension reconstituted 100 mg/5ml, 200 mg/5ml


cefpodoxime proxetil oral suspension reconstituted 100 mg/5ml, 50 mg/5ml


cefpodoxime proxetil oral tablet 100 mg, 200 mg T1

cefprozil oral suspension reconstituted 125 mg/5ml, 250 mg/5ml


cefprozil oral tablet 250 mg, 500 mg T1

ceftriaxone sodium injection solution reconstituted 250 mg


cefuroxime axetil oral tablet 250 mg, 500 mg T1

cephalexin oral capsule 250 mg, 500 mg T1

cephalexin oral suspension reconstituted 125 mg/5ml, 250 mg/5ml

T1

SUPRAX ORAL SUSPENSION RECONSTITUTED 500 MG/5ML T1 AL (Max 12 Years)

*Cgrp Receptor Antagonists - Monocolonal Antibodies***AIMOVIG SUBCUTANEOUS SOLUTION AUTO-INJECTOR 140 MG/ML, 70 MG/ML T1


AJOVY SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 225 MG/1.5ML T1


EMGALITY (300 MG DOSE) SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 100 MG/ML

T1PA; QL (3 ML per 30 days); AL (Min 18 Years)

EMGALITY SUBCUTANEOUS SOLUTION AUTO-INJECTOR 120 MG/ML T1


*Contraceptives*AMETHYST ORAL TABLET 90-20 MCG T1 GR-F

ARANELLE ORAL TABLET 0.5/1/0.5-35 MG-MCG T1 GR-F

AVIANE ORAL TABLET 0.1-20 MG-MCG T1 GR-F

BALZIVA ORAL TABLET 0.4-35 MG-MCG T1 GR-F

drospirenone-ethinyl estradiol oral tablet 3-0.03 mg

T1 GR-F

25

Drug Status NotesELLA ORAL TABLET 30 MG T1 GR-F

GIANVI ORAL TABLET 3-0.02 MG T1 GR-F

JUNEL 1/20 ORAL TABLET 1-20 MG-MCG T1 GR-F

KARIVA ORAL TABLET 0.15-0.02/0.01 MG (21/5) T1 GR-F

levonorgestrel oral tablet 0.75 mg, 1.5 mg T1 GR-F

LEVORA 0.15/30 (28) ORAL TABLET 0.15-30 MG-MCG T1 GR-F

LOMEDIA 24 FE ORAL TABLET 1-20 MG-MCG(24) T1 GR-F

LOW-OGESTREL ORAL TABLET 0.3-30 MG-MCG T1 GR-F

medroxyprogesterone acetate intramuscular suspension 150 mg/ml

T1 GR-F; QL (1 ML per 75 days)

MICROGESTIN 1.5/30 ORAL TABLET 1.5-30 MG-MCG T1 GR-F

MICROGESTIN FE 1.5/30 ORAL TABLET1.5-30 MG-MCG T1 GR-F

MICROGESTIN FE 1/20 ORAL TABLET 1-20 MG-MCG T1 GR-F

NECON 0.5/35 (28) ORAL TABLET 0.5-35 MG-MCG T1 GR-F

NECON 1/35 (28) ORAL TABLET 1-35 MG-MCG T1 GR-F

NECON 10/11 (28) ORAL TABLET 35 MCG T1 GR-F

NORA-BE ORAL TABLET 0.35 MG T1 GR-F

norethin ace-eth estrad-fe oral tablet chewable 1-20 mg-mcg(24)

T1 PA; GR-F

norethin-eth estradiol-fe tablet chewable 0.4-35 mg-mcg oral 0.4-35 mg-mcg

T1 PA; GR-F

NORTREL 7/7/7 ORAL TABLET 0.5/0.75/1-35 MG-MCG T1 GR-F

NUVARING VAGINAL RING 0.12-0.015 MG/24HR T1 GR-F; QL (3 EA per 84 days)

OGESTREL ORAL TABLET 0.5-50 MG-MCG T1 GR-F

QUASENSE ORAL TABLET 0.15-0.03 MG T1 GR-F

RECLIPSEN ORAL TABLET 0.15-30 MG-MCG T1 GR-F

SPRINTEC 28 ORAL TABLET 0.25-35 MG-MCG T1 GR-F

TRI-LEGEST FE ORAL TABLET 1-20/1-30/1-35 MG-MCG T1 GR-F

26

Drug Status NotesTRINESSA LO ORAL TABLET0.18/0.215/0.25 MG-25 MCG T1 GR-F

TRI-SPRINTEC ORAL TABLET0.18/0.215/0.25 MG-35 MCG T1 GR-F

TRIVORA (28) ORAL TABLET 50-30/75-40/ 125-30 MCG T1 GR-F

VELIVET ORAL TABLET 0.1/0.125/0.15 -0.025 MG T1 GR-F

XULANE TRANSDERMAL PATCH WEEKLY 150-35 MCG/24HR T1 GR-F; QL (9 EA per 84 days)

ZOVIA 1/35E (28) ORAL TABLET 1-35 MG-MCG T1 GR-F

ZOVIA 1/50E (28) ORAL TABLET 1-50 MG-MCG T1 GR-F

*Corticosteroids*dexamethasone oral elixir 0.5 mg/5ml T1

dexamethasone oral solution 0.5 mg/5ml T1

dexamethasone oral tablet 0.5 mg, 0.75 mg, 1 mg, 1.5 mg, 2 mg, 4 mg, 6 mg

T1

fludrocortisone acetate oral tablet 0.1 mg T1

hydrocortisone oral tablet 10 mg, 20 mg, 5 mg T1

methylprednisolone oral tablet 16 mg, 32 mg, 4 mg, 8 mg

T1

methylprednisolone oral tablet therapy pack 4 mg T1

prednisolone oral solution 15 mg/5ml T1

prednisolone sodium phosphate oral solution 15 mg/5ml, 6.7 (5 base) mg/5ml

T1

prednisone (pak) oral tablet 5 mg T1

prednisone oral solution 5 mg/5ml T1

prednisone oral tablet 1 mg, 10 mg, 2.5 mg, 20 mg, 5 mg, 50 mg

T1

prednisone oral tablet therapy pack 10 mg (21), 5 mg (21)

T1

*Cough/Cold/Allergy*acetylcysteine inhalation solution 10 %, 20 % T1

cheratussin ac oral solution 100-10 mg/5ml T1 QL (240 ML per 30 days)

cheratussin dac oral solution 30-10-100 mg/5ml T1 QL (240 ML per 30 days)

dextromethorphan-guaifenesin oral solution 10-100 mg/5ml


guaifenesin oral solution 100 mg/5ml T1

guaifenesin oral syrup 100 mg/5ml T1

27

Drug Status Notesguaifenesin oral tablet 200 mg, 400 mg T1

guaifenesin-dm oral syrup 100-10 mg/5ml T1 QL (240 ML per 30 days)

loratadine-d 12hr oral tablet extended release 12 hour 5-120 mg

T1

loratadine-d 24hr oral tablet extended release 24 hour 10-240 mg

T1

promethazine-dm oral syrup 6.25-15 mg/5ml T1 QL (240 ML per 30 days)

pseudoeph-bromphen-dm oral syrup 30-2-10 mg/5ml


sodium chloride inhalation nebulization solution0.9 %, 7 %

T1

tussin dm max adult oral liquid 10-200 mg/5ml T1 QL (240 ML per 30 days)

*Dermatologicals*acitretin oral capsule 10 mg, 17.5 mg, 25 mg T1 PA

alclometasone dipropionate external cream 0.05 %


alclometasone dipropionate external ointment0.05 %


ammonium lactate external cream 12 % T1 QL (140 GM per 30 days)

ammonium lactate external lotion 12 % T1 QL (225 GM per 30 days)

AMNESTEEM ORAL CAPSULE 10 MG, 20 MG, 40 MG T1 PA; QL (60 EA per 30 days)

ANECREAM CREAM 4 % EXTERNAL 4 % T1

ASPERCREME LIDOCAINE PATCH 4 % EXTERNAL 4 % T1 QL (30 EA per 30 days)

ASPERCREME W/LIDOCAINE CREAM 4 % EXTERNAL 4 % T1

bacitracin external ointment 500 unit/gm T1

bacitracin zinc external ointment 500 unit/gm T1

BASIS OVERNIGHT EXTERNAL CREAM T1

benzoyl peroxide creamy wash external liquid† 4 %

T1

benzoyl peroxide external gel 10 % T1 QL (113.4 GM per 30 days)

benzoyl peroxide external gel 2.5 %, 5 % T1

benzoyl peroxide wash external liquid 10 %, 5 % T1

betamethasone dipropionate aug external cream0.05 %


betamethasone dipropionate aug external gel 0.05 %


betamethasone dipropionate aug external lotion0.05 %


28

Drug Status Notesbetamethasone dipropionate aug external ointment 0.05 %


betamethasone dipropionate external cream 0.05 %


betamethasone dipropionate external lotion 0.05 %


betamethasone dipropionate external ointment0.05 %


betamethasone valerate external cream 0.1 % T1 QL (454 GM per 30 days)

betamethasone valerate external lotion 0.1 % T1 QL (60 ML per 30 days)

betamethasone valerate external ointment 0.1 % T1 QL (45 GM per 30 days)

calcipotriene external ointment 0.005 % T1 PA; QL (120 GM per 30 days)

calcipotriene external solution 0.005 % T1 PA; QL (60 ML per 30 days)

capsaicin external cream 0.025 %, 0.075 %, 0.1 %

T1

ciclopirox external solution 8 % T1 QL (6.6 ML per 28 days)

CLARAVIS ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG T1 PA; QL (60 EA per 30 days)

clindamycin phosphate external solution 1 % T1 QL (180 ML per 30 days)

clindamycin phosphate external swab 1 % T1 QL (60 EA per 30 days)

clobetasol propionate external cream 0.05 % T1 PA; QL (60 GM per 30 days)

clobetasol propionate external ointment 0.05 % T1 PA; QL (60 GM per 30 days)

clobetasol propionate external solution 0.05 % T1 PA; QL (50 ML per 30 days)

clotrimazole external cream 1 % T1

clotrimazole external solution 1 % T1

clotrimazole-betamethasone external cream 1-0.05 %


CORTIZONE-10/ALOE EXTERNAL CREAM 1 % T1

desonide external ointment 0.05 % T1 QL (30 GM per 30 days)

diclofenac sodium transdermal gel 1 % T1 QL (100 GM per 30 days)

diclofenac sodium transdermal gel 3 % T1 PA

DIFFERIN GEL 0.1 % EXTERNAL (OTC)0.1 % T1 QL (45 GM per 30 days)

docosanol external cream 10 % T1

DRYSOL EXTERNAL SOLUTION 20 % T1

ELIDEL EXTERNAL CREAM 1 % T1 PA; QL (30 GM per 30 days)

erythromycin external solution 2 % T1

EUCERIN EXTERNAL CREAM T1

fluocinolone acetonide external cream 0.01 % T1 QL (45 GM per 30 days)

29

Drug Status Notesfluocinolone acetonide external cream 0.025 % T1 QL (60 GM per 30 days)

fluocinolone acetonide external ointment 0.025 % T1 QL (60 GM per 30 days)

fluocinonide external cream 0.05 % T1 QL (30 GM per 30 days)

fluocinonide external ointment 0.05 % T1 QL (30 GM per 30 days)

fluocinonide external solution 0.05 % T1 QL (60 ML per 30 days)

fluocinonide-e external cream 0.05 % T1 QL (30 GM per 30 days)

fluorouracil external cream 0.5 %, 5 % T1 PA

fluticasone propionate external cream 0.05 % T1 QL (60 GM per 30 days)

fluticasone propionate external ointment 0.005 % T1 QL (60 GM per 30 days)

gentamicin sulfate external cream 0.1 % T1

gentamicin sulfate external ointment 0.1 % T1

halobetasol propionate external cream 0.05 % T1 QL (50 GM per 30 days)

halobetasol propionate external ointment 0.05 % T1 QL (50 GM per 30 days)

hydrocortisone external cream 0.5 %, 1 %, 2.5 % T1

hydrocortisone external lotion 1 %, 2.5 % T1

hydrocortisone external ointment 0.5 %, 1 %, 2.5 %

T1

hydrocortisone valerate external cream 0.2 % T1 QL (120 GM per 30 days)

imiquimod external cream 5 % T1 QL (12 EA per 28 days)

isopropyl alcohol wipes external 70 % T1

isotretinoin capsule 10 mg oral 10 mg T1 PA; QL (60 EA per 30 days)




ketoconazole external cream 2 % T1 QL (60 GM per 30 days)

ketoconazole external shampoo 2 % T1 QL (120 ML per 30 days)

lc-4 lidocaine cream 4 % external 4 % T1

lice killing maximum strength external shampoo0.33-4 %


lice treatment external liquid 0.33-4 % T1 QL (60 ML per 30 days)

lice treatment external liquid 1 % T1 QL (120 ML per 30 days)

LICIDE TREATMENT COMBINATION KITT1 QL (1 EA per 30 days)

lidocaine cream 4 % external 4 % T1

lidocaine hcl external gel 2 % T1

lidocaine-prilocaine external cream 2.5-2.5 % T1 QL (30 GM per 30 days)

LIDOCREAM CREAM 4 % EXTERNAL 4 % T1

lindane external lotion 1 % T1 QL (60 ML per 30 days)

lindane external shampoo 1 % T1 QL (60 ML per 30 days)

30

Drug Status NotesLMX 4 CREAM 4 % EXTERNAL 4 % T1

malathion external lotion 0.5 % T1 ST; QL (59 ML per 30 days)

metronidazole external cream 0.75 % T1

metronidazole external gel 0.75 % T1

miconazole nitrate external cream 2 % T1

mometasone furoate external cream 0.1 % T1 QL (45 GM per 30 days)

mometasone furoate external ointment 0.1 % T1 QL (60 GM per 30 days)

mometasone furoate external solution 0.1 % T1 QL (60 ML per 30 days)

mupirocin external ointment 2 % T1 QL (22 GM per 30 days)

MYORISAN ORAL CAPSULE 10 MG, 20 MG, 40 MG T1 PA; QL (60 EA per 30 days)

MYORISAN ORAL CAPSULE 30 MG T1 PA

nystatin external cream 100000 unit/gm T1

nystatin external ointment 100000 unit/gm T1

nystatin external powder 100000 unit/gm T1 QL (60 GM per 30 days)

permethrin external cream 5 % T1 QL (60 GM per 30 days)

permethrin lice treatment external lotion 1 % T1 QL (59 ML per 30 days)

podofilox external solution 0.5 % T1

RID ESSENTIAL LICE ELIMINATION EXTERNAL KIT 0.33-4 % T1 QL (177 ML per 30 days)

SANTYL EXTERNAL OINTMENT 250 UNIT/GM T1 QL (60 GM per 30 days)

selenium sulfide external lotion 2.5 % T1

SILIQ SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 210 MG/1.5ML T1 PA

silver sulfadiazine external cream 1 % T1

spinosad external suspension 0.9 % T1 ST; QL (240 ML per 180 days)

sulfacetamide sodium (acne) external lotion 10 % T1

sulfacetamide sodium-sulfur external emulsion10-5 %

T1

tacrolimus external ointment 0.03 %, 0.1 % T1 PA

terbinafine hcl external cream 1 % T1

tolnaftate external aerosol powder 1 % T1

tolnaftate external cream 1 % T1

tolnaftate external powder 1 % T1

tretinoin external cream 0.025 % T1 QL (20 GM per 30 days)

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


triamcinolone acetonide external lotion 0.025 % T1

triamcinolone acetonide external lotion 0.1 % T1 QL (480 ML per 30 days)

31

Drug Status Notestriamcinolone acetonide external ointment 0.025 %, 0.1 %


triamcinolone acetonide external ointment 0.5 % T1

triple antibiotic external ointment 3.5-400-5000 T1

trixaicin external cream 0.025 % T1

urea external cream 40 % T1 QL (85 GM per 30 days)

vitamin e external liquid 24000 unit T1

vitamin e skin external oil 56000 unit T1

ZENATANE ORAL CAPSULE 10 MG T1 PA

ZENATANE ORAL CAPSULE 20 MG, 40 MG T1 PA; QL (60 EA per 30 days)

*Diagnostic Products*BAYER CONTOUR NEXT TEST IN VITRO STRIP T1

FREESTYLE LITE TEST IN VITRO STRIP T1

FREESTYLE TEST IN VITRO STRIP T1

GLUCOCARD EXPRESSION TEST IN VITRO STRIP T1

GLUCOCARD VITAL TEST IN VITRO STRIP T1

GLUCONAVII BLOOD GLUCOSE TEST IN VITRO STRIP T1

ketone test in vitro strip T1

KETOSTIX IN VITRO STRIP T1

ONETOUCH ULTRA BLUE IN VITRO STRIP T1

ONETOUCH VERIO STRIP IN VITRO T1

PRECISION XTRA KETONE IN VITRO STRIP T1

*Dietary Products/Dietary Management Products*CARDIOTEK RX ORAL TABLET T1

CEREFOLIN ORAL TABLET 6-1-50-5 MG T1

FOLBIC ORAL TABLET 2.5-25-2 MG T1

l-methylfolate-b6-b12 oral tablet 1.13-25-2 mg, 3-35-2 mg

T1

methylfol-algae-b12-acetylcyst oral tablet 6-90.314-2-600 mg

T1

PODIAPN ORAL CAPSULE 5-2-35-300 MG T1

PROSTAMEN ORAL CAPSULE T1

32

Drug Status NotesVITA-RESPA ORAL TABLET 2.2-25-1.3 MG T1

*Digestive Aids*CREON ORAL CAPSULE DELAYED RELEASE PARTICLES 12000 UNIT, 24000-76000 UNIT, 3000-9500 UNIT, 36000 UNIT, 6000 UNIT

T1

PANCREAZE ORAL CAPSULE DELAYED RELEASE PARTICLES 10500 UNIT, 16800 UNIT, 21000 UNIT, 2600 UNIT, 4200 UNIT

T1

PERTZYE ORAL CAPSULE DELAYED RELEASE PARTICLES 16000 UNIT, 24000-86250 UNIT


PERTZYE ORAL CAPSULE DELAYED RELEASE PARTICLES 8000 UNIT T1 QL (720 EA per 30 days)

VIOKACE ORAL TABLET 10440 UNIT, 20880 UNIT T1 QL (480 EA per 30 days)

ZENPEP ORAL CAPSULE DELAYED RELEASE PARTICLES 10000 UNIT, 15000-51000 UNIT, 20000-63000 UNIT, 20000-68000 UNIT, 25000 UNIT, 3000-10000 UNIT, 40000-126000 UNIT, 40000-136000 UNIT, 5000 UNIT

T1

ZENPEP ORAL CAPSULE DELAYED RELEASE PARTICLES 10000-32000 UNIT, 3000-14000 UNIT, 5000-24000 UNIT


ZENPEP ORAL CAPSULE DELAYED RELEASE PARTICLES 15000-47000 UNIT, 25000-79000 UNIT


*Diuretics*acetazolamide er oral capsule extended release 12 hour 500 mg


acetazolamide oral tablet 125 mg, 250 mg T1 QL (120 EA per 30 days)

amiloride hcl oral tablet 5 mg T1 QL (120 EA per 30 days)

amiloride-hydrochlorothiazide oral tablet 5-50 mg


bumetanide oral tablet 0.5 mg, 1 mg, 2 mg T1

CAROSPIR ORAL SUSPENSION 25 MG/5ML T1 AL (Max 12 Years)

chlorothiazide oral tablet 250 mg, 500 mg T1

chlorthalidone oral tablet 25 mg, 50 mg T1 QL (120 EA per 30 days)

DIURIL ORAL SUSPENSION 250 MG/5ML T1 AL (Max 12 Years)

furosemide oral solution 10 mg/ml, 8 mg/ml T1 AL (Max 12 Years)

furosemide oral tablet 20 mg, 40 mg, 80 mg T1

hydrochlorothiazide oral capsule 12.5 mg T1

33

Drug Status Noteshydrochlorothiazide oral tablet 12.5 mg, 25 mg, 50 mg

T1

indapamide oral tablet 1.25 mg, 2.5 mg T1 QL (30 EA per 30 days)

methyclothiazide oral tablet 5 mg T1

metolazone oral tablet 10 mg, 2.5 mg, 5 mg T1 QL (30 EA per 30 days)

spironolactone oral tablet 100 mg, 25 mg, 50 mg T1 QL (60 EA per 30 days)

spironolactone-hctz oral tablet 25-25 mg T1 QL (90 EA per 30 days)

torsemide oral tablet 10 mg, 20 mg T1 QL (120 EA per 30 days)

torsemide oral tablet 100 mg, 5 mg T1 QL (60 EA per 30 days)

triamterene-hctz oral capsule 37.5-25 mg, 50-25 mg

T1

triamterene-hctz oral tablet 37.5-25 mg, 75-50 mg T1

*Endocrine And Metabolic Agents - Misc.*alendronate sodium oral tablet 10 mg, 40 mg, 5 mg


alendronate sodium oral tablet 35 mg, 70 mg T1 QL (4 EA per 28 days)

cabergoline oral tablet 0.5 mg T1

calcitonin (salmon) nasal solution 200 unit/act T1 QL (3.7 ML per 30 days)

calcitriol oral capsule 0.25 mcg, 0.5 mcg T1 QL (120 EA per 30 days)

calcitriol oral solution 1 mcg/ml T1 AL (Max 12 Years)

DDAVP RHINAL TUBE NASAL SOLUTION0.01 % T1 PA

desmopressin ace spray refrig nasal solution 0.01 %

T1 PA

desmopressin acetate oral tablet 0.1 mg, 0.2 mg T1 QL (180 EA per 30 days)

desmopressin acetate spray nasal solution 0.01 % T1 PA

FORTEO SUBCUTANEOUS SOLUTION 600 MCG/2.4ML T1 PA; QL (2.4 ML per 30 days)

ibandronate sodium oral tablet 150 mg T1 QL (1 EA per 28 days)

INCRELEX SUBCUTANEOUS SOLUTION40 MG/4ML T1 PA

NORDITROPIN FLEXPRO SUBCUTANEOUS SOLUTION 10 MG/1.5ML, 15 MG/1.5ML, 30 MG/3ML, 5 MG/1.5ML

T1 PA

octreotide acetate injection solution 100 mcg/ml, 1000 mcg/ml, 200 mcg/ml, 50 mcg/ml

T1 PA

ORILISSA ORAL TABLET 150 MG, 200 MG T1 PA; AL (Min 18 Years)

raloxifene hcl oral tablet 60 mg T1QL (30 EA per 30 days); AL (Min 40 Years)

34

Drug Status NotesSENSIPAR ORAL TABLET 30 MG, 60 MG T1 PA; QL (60 EA per 30 days)

SENSIPAR ORAL TABLET 90 MG T1 PA; QL (120 EA per 30 days)

STIMATE NASAL SOLUTION 1.5 MG/ML T1 PA

TYMLOS SUBCUTANEOUS SOLUTION PEN-INJECTOR 3120 MCG/1.56ML T1 PA

*Estrogens*estradiol oral tablet 0.5 mg, 1 mg, 2 mg T1 AL (Max 64 Years)

estradiol transdermal patch twice weekly 0.025 mg/24hr, 0.0375 mg/24hr, 0.05 mg/24hr, 0.075 mg/24hr, 0.1 mg/24hr


estradiol transdermal patch weekly 0.025 mg/24hr, 0.0375 mg/24hr, 0.05 mg/24hr, 0.06 mg/24hr, 0.075 mg/24hr, 0.1 mg/24hr


estradiol-norethindrone acet oral tablet 0.5-0.1 mg, 1-0.5 mg


estropipate oral tablet 0.75 mg, 1.5 mg, 3 mg T1 AL (Max 64 Years)

MENEST ORAL TABLET 0.3 MG, 0.625 MG, 1.25 MG, 2.5 MG T1 AL (Max 64 Years)

norethindrone-eth estradiol oral tablet 0.5-2.5 mg-mcg, 1-5 mg-mcg


PREMARIN ORAL TABLET 0.3 MG, 0.45 MG, 0.625 MG, 0.9 MG, 1.25 MG T1

QL (30 EA per 30 days); AL (Max 64 Years)

PREMPHASE ORAL TABLET 0.625-5 MG T1QL (30 EA per 30 days); AL (Max 64 Years)

PREMPRO ORAL TABLET 0.3-1.5 MG, 0.45-1.5 MG, 0.625-2.5 MG, 0.625-5 MG T1

QL (30 EA per 30 days); AL (Max 64 Years)

*Fluoroquinolones*CIPRO ORAL SUSPENSION RECONSTITUTED 250 MG/5ML (5%), 500 MG/5ML (10%)


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

T1

levofloxacin oral solution 25 mg/ml T1 AL (Max 12 Years)

levofloxacin oral tablet 250 mg, 500 mg, 750 mg T1

ofloxacin oral tablet 400 mg T1

*Gastrointestinal Agents - Misc.*AMITIZA ORAL CAPSULE 24 MCG, 8 MCG T1 PA; QL (60 EA per 30 days)

APRISO ORAL CAPSULE EXTENDED RELEASE 24 HOUR 0.375 GM T1 ST; QL (120 EA per 30 days)

balsalazide disodium oral capsule 750 mg T1

35

Drug Status Notescalcium acetate (phos binder) oral capsule 667 mg

T1

calcium acetate (phos binder) oral tablet 667 mg T1

CIMZIA PREFILLED SUBCUTANEOUS KIT 2 X 200 MG/ML T1 PA

CIMZIA STARTER KIT SUBCUTANEOUS KIT 6 X 200 MG/ML T1 PA; QL (6 EA per 28 days)

CIMZIA SUBCUTANEOUS KIT 2 X 200 MG T1 PA

FOSRENOL ORAL TABLET CHEWABLE1000 MG, 500 MG, 750 MG T1 PA

gas relief oral liquid 40 mg/0.6ml T1

infants gas relief oral suspension 40 mg/0.6ml T1

mesalamine oral capsule delayed release 400 mg T1 ST; QL (180 EA per 30 days)

mesalamine oral tablet delayed release 1.2 gm T1 QL (120 EA per 30 days)

mesalamine oral tablet delayed release 800 mg T1 ST; QL (180 EA per 30 days)

mesalamine rectal enema 4 gm T1

mesalamine tablet delayed release 800 mg oral800 mg


metoclopramide hcl oral solution 5 mg/5ml T1

metoclopramide hcl oral tablet 10 mg, 5 mg T1

PENTASA ORAL CAPSULE EXTENDED RELEASE 250 MG, 500 MG T1 ST; QL (240 EA per 30 days)

PHOSLYRA ORAL SOLUTION 667 MG/5ML T1

RENAGEL ORAL TABLET 400 MG T1 PA

sevelamer carbonate oral tablet 800 mg T1 PA

sevelamer hcl oral tablet 800 mg T1 PA

simethicone oral tablet chewable 125 mg, 80 mg T1

sulfasalazine oral tablet 500 mg T1

sulfasalazine oral tablet delayed release 500 mg T1

ursodiol oral capsule 300 mg T1 QL (150 EA per 30 days)

ursodiol oral tablet 250 mg, 500 mg T1

*Genitourinary Agents - Miscellaneous*alfuzosin hcl er oral tablet extended release 24 hour 10 mg

T1

cytra-2 oral solution 500-334 mg/5ml T1

cytra-k oral solution 1100-334 mg/5ml T1

ELMIRON ORAL CAPSULE 100 MG T1 PA; QL (90 EA per 30 days)

finasteride oral tablet 5 mg T1 GR-M; QL (30 EA per 30 days)

K-PHOS NO 2 ORAL TABLET 305-700 MG T1

36

Drug Status NotesPHENAZO ORAL TABLET 200 MG T1

phenazopyridine hcl oral tablet 100 mg T1

potassium citrate er oral tablet extended release10 meq (1080 mg), 5 meq (540 mg)

T1

sodium chloride irrigation solution 0.9 % T1

tamsulosin hcl oral capsule 0.4 mg T1 QL (60 EA per 30 days)

TARON-CRYSTALS ORAL PACKET 3300-1002 MG T1

*Glycopeptides***FIRST-VANCOMYCIN 25 ORAL SOLUTION 25 MG/ML T1

FIRST-VANCOMYCIN 50 ORAL SOLUTION 50 MG/ML T1

FIRVANQ ORAL SOLUTION RECONSTITUTED 25 MG/ML, 50 MG/ML T1

vancomycin hcl intravenous solution reconstituted10 gm, 1000 mg, 500 mg, 750 mg

T1

*Gout Agents*allopurinol oral tablet 100 mg, 300 mg T1

colchicine oral capsule 0.6 mg T1 QL (60 EA per 30 days)

colchicine oral tablet 0.6 mg T1 QL (60 EA per 30 days)

colchicine-probenecid oral tablet 0.5-500 mg T1

febuxostat oral tablet 40 mg, 80 mg T1 PA; QL (30 EA per 30 days)

probenecid oral tablet 500 mg T1

*Hematological Agents - Misc.*anagrelide hcl oral capsule 0.5 mg, 1 mg T1

cilostazol oral tablet 100 mg, 50 mg T1 QL (60 EA per 30 days)

clopidogrel bisulfate oral tablet 300 mg T1 QL (1 EA per 30 days)

clopidogrel bisulfate oral tablet 75 mg T1 QL (30 EA per 30 days)

dipyridamole oral tablet 25 mg, 50 mg, 75 mg T1 QL (120 EA per 30 days)

pentoxifylline er oral tablet extended release 400 mg

T1

*Hematopoietic Agents*ARANESP (ALBUMIN FREE) INJECTION SOLUTION 10 MCG/0.4ML, 100 MCG/ML, 150 MCG/0.75ML, 200 MCG/ML, 25 MCG/ML, 300 MCG/ML, 40 MCG/ML, 60 MCG/ML

T1 PA

37

Drug Status NotesARANESP (ALBUMIN FREE) INJECTION SOLUTION PREFILLED SYRINGE 100 MCG/0.5ML, 150 MCG/0.3ML, 200 MCG/0.4ML, 25 MCG/0.42ML, 300 MCG/0.6ML, 40 MCG/0.4ML, 500 MCG/ML, 60 MCG/0.3ML

T1 PA

b-12 oral tablet 500 mcg T1

cyanocobalamin injection solution 1000 mcg/ml T1

D 1000 PLUS ALOE ORAL TABLET T1

DROXIA ORAL CAPSULE 200 MG, 300 MG, 400 MG T1

EPOGEN INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML

T1 PA

fabb oral tablet 2.2-25-1 mg T1

ferronate oral tablet 325 mg T1

ferrous gluconate oral tablet 225 (27 fe) mg, 240 (27 fe) mg, 324 (37.5 fe) mg, 324 (38 fe) mg, 325 (36 fe) mg

T1

ferrous sulfate oral elixir 220 (44 fe) mg/5ml T1 AL (Max 12 Years)

ferrous sulfate oral liquid 220 (44 fe) mg/5ml T1 AL (Max 12 Years)

ferrous sulfate oral solution 75 (15 fe) mg/ml T1 AL (Max 12 Years)

ferrous sulfate oral syrup 300 (60 fe) mg/5ml T1 AL (Max 12 Years)

ferrous sulfate oral tablet delayed release 324 (65 fe) mg, 325 (65 fe) mg

T1

folbee oral tablet 2.5-25-1 mg T1

FOLGARD ORAL TABLET T1

folic acid oral tablet 1 mg, 800 mcg T1

folic acid oral tablet 400 mcg T1 QL (30 EA per 30 days)

folinic-plus oral tablet 4-50-2 mg T1

folplex 2.2 oral tablet 2.2-25-0.5 mg T1

FOLTABS 800 ORAL TABLET 800-10-115 MCG-MG-MCG T1

FULPHILA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 6 MG/0.6ML T1 PA

GRANIX SUBCUTANEOUS SOLUTION 300 MCG/ML, 480 MCG/1.6ML T1 PA

GRANIX SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 300 MCG/0.5ML, 480 MCG/0.8ML

T1 PA

hm iron oral tablet 200 (65 fe) mg T1

38

Drug Status Noteshm slow release iron oral tablet extended release45 mg

T1

homocysteine formula oral tablet 800-50-100 mcg-mg-mcg

T1

iron 100 plus oral tablet 100-250-0.025-1 mg T1

iron oral tablet 325 (65 fe) mg T1

NEUPOGEN INJECTION SOLUTION 300 MCG/ML, 480 MCG/1.6ML T1 PA

NEUPOGEN INJECTION SOLUTION PREFILLED SYRINGE 300 MCG/0.5ML, 480 MCG/0.8ML

T1 PA

NIVESTYM INJECTION SOLUTION PREFILLED SYRINGE 300 MCG/0.5ML, 480 MCG/0.8ML

T1 PA

PROCRIT INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML, 40000 UNIT/ML

T1 PA

RETACRIT INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML, 40000 UNIT/ML

T1 PA

slow iron oral tablet extended release 160 (50 fe) mg

T1

slow release iron oral tablet extended release47.5 mg

T1

sm slow release iron oral tablet extended release142 (45 fe) mg

T1

vitamin b-12 oral tablet 1000 mcg T1

ZARXIO INJECTION SOLUTION PREFILLED SYRINGE 300 MCG/0.5ML, 480 MCG/0.8ML

T1 PA

*Hypnotics*midazolam hcl injection solution 10 mg/10ml, 10 mg/2ml, 2 mg/2ml, 25 mg/5ml, 5 mg/5ml, 5 mg/ml, 50 mg/10ml


*Isocitrate Dehydrogenase-1 (Idh1) Inhibitors***TIBSOVO ORAL TABLET 250 MG T1 PA; QL (60 EA per 30 days)

*Isocitrate Dehydrogenase-2 (Idh2) Inhibitors***IDHIFA ORAL TABLET 100 MG, 50 MG T1 PA

*Laxatives*bisacodyl ec oral tablet delayed release 5 mg T1

39

Drug Status Notesbisacodyl rectal suppository 10 mg T1

cvs laxative dietary supplemnt oral tablet 500 mg T1

cvs senna-extra oral tablet 17.2 mg T1

cvs stool softener oral capsule 50 mg T1

docusate calcium oral capsule 240 mg T1

docusate sodium oral capsule 100 mg, 250 mg T1

docusate sodium oral liquid 150 mg/15ml T1

docusate sodium oral tablet 100 mg T1

DOCUSOL MINI RECTAL ENEMA 283 MG/5ML T1

enema rectal enema T1

ENEMEEZ PLUS RECTAL ENEMA 20-283 MG T1

GAVILYTE-G ORAL SOLUTION RECONSTITUTED 236 GM T1

GAVILYTE-N WITH FLAVOR PACK ORAL SOLUTION RECONSTITUTED 420 GM

T1

geri-mucil oral powder 68 % T1

lactulose oral solution 10 gm/15ml T1

magnesium citrate oral solution 1.745 gm/30ml T1

METAMUCIL MULTIHEALTH FIBER ORAL POWDER 63 % T1

milk of magnesia oral suspension 400 mg/5ml T1

mineral oil rectal enema T1

natural fiber laxative oral powder 28.3 %, 58.6 % T1

natural fiber therapy oral powder 48.57 % T1

peg 3350/electrolytes oral solution reconstituted240 gm

T1

polyethylene glycol 3350 oral powder 17 gm/scoop

T1

qc natural vegetable oral powder 95 % T1

senna laxative oral tablet 25 mg T1

senna oral capsule 8.6 mg T1

senna oral syrup 8.8 mg/5ml T1

senna oral tablet 8.6 mg T1

SENNA SMOOTH ORAL TABLET 15 MG T1

senna-docusate sodium oral tablet 8.6-50 mg T1

sen-o-tabs oral tablet 187 mg T1

40

Drug Status Notes

*Macrolides*azithromycin oral packet 1 gm T1

azithromycin oral suspension reconstituted 100 mg/5ml, 200 mg/5ml

T1

azithromycin oral tablet 250 mg, 500 mg, 600 mg T1

clarithromycin oral suspension reconstituted 125 mg/5ml, 250 mg/5ml

T1

clarithromycin oral tablet 250 mg, 500 mg T1

*Medical Devices*ACCU-CHEK MULTICLIX LANCETS T1

adult aerosol mask T1 QL (4 EA per 365 days)

ADVOCATE INSULIN PEN NEEDLES 29G X 12.7MM T1 QL (200 EA per 30 days)

ASSURE DOSE CONTROL IN VITRO SOLUTION NORMAL T1

BAYER CONTOUR NEXT CONTROL IN VITRO SOLUTION NORMAL T1

BD AUTOSHIELD 29G X 5MM , 29G X 8MM T1 QL (200 EA per 30 days)

BD AUTOSHIELD DUO 30G X 5 MM T1 QL (200 EA per 30 days)

BD INSULIN SYR ULTRAFINE II 31G X 5/16" 0.5 ML T1 QL (200 EA per 30 days)

BD INSULIN SYRINGE 26G X 1/2" 1 ML, 27.5G X 5/8" 2 ML, 29G X 1/2" 2 ML, U-100 1 ML


BD INSULIN SYRINGE MICROFINE 27G X 5/8" 1 ML, 28G X 1/2" 0.3 ML, 28G X 1/2" 0.5 ML


BD INSULIN SYRINGE U/F 30G X 1/2" 1 ML T1 QL (200 EA per 30 days)

BD INSULIN SYRINGE U-40 25G X 5/8" 1 ML T1 QL (200 EA per 30 days)

BD INSULIN SYRINGE U-500 31G X 6MM 0.5 ML T1 QL (200 EA per 30 days)

BD INSULIN SYRINGE ULTRAFINE 31G X 15/64" 0.3 ML, 31G X 15/64" 0.5 ML, 31G X 15/64" 1 ML


BD INTEGRA SYRINGE 25G X 1" 1 ML T1 QL (200 EA per 30 days)

BD LANCET DEVICE T1

BD PEN T1 QL (1 EA per 365 days)

CAREFINE PEN NEEDLES 30G X 8 MM , 32G X 5 MM T1 QL (200 EA per 30 days)

41

Drug Status Notescareone insulin syringe 30g x 1/2" 0.3 ml, 30g x 1/2" 0.5 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 1 ml


CAYA VAGINAL DIAPHRAGM T1

COMFORT ASSIST INSULIN SYRINGE29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML


condoms T1 QL (36 EA per 30 days)

CURITY ALCOHOL PREPS PAD 70 % T1

EASIVENT T1 QL (4 EA per 365 days)

EASIVENT MASK LARGE T1 QL (4 EA per 365 days)

EASIVENT MASK MEDIUM T1 QL (4 EA per 365 days)

EASIVENT MASK SMALL T1 QL (4 EA per 365 days)

easy comfort insulin syringe 30g x 5/16" 1 ml T1 QL (200 EA per 30 days)

EASY TOUCH INSULIN SYRINGE 27G X 1/2" 0.5 ML, 27G X 1/2" 1 ML T1 QL (200 EA per 30 days)

elite-thin insulin syringe 28g x 5/16" 1 ml, 29g x 5/16" 0.5 ml, 29g x 5/16" 1 ml


EXEL COMFORT POINT INSULIN SYR29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML


FC2 FEMALE CONDOM T1 QL (36 EA per 30 days)

FIFTY50 PEN NEEDLES 32G X 6 MM T1 QL (200 EA per 30 days)

FREESTYLE CONTROL SOLUTION IN VITRO LIQUID T1

GLUCOCARD EXPRESSION CONTROL IN VITRO SOLUTION T1

GLUCOCARD EXPRESSION MONITOR KIT W/DEVICE T1 QL (1 EA per 365 days)

GLUCOCARD VITAL MONITOR KITW/DEVICE T1 QL (1 EA per 365 days)

h-e-b incontrol pen needles 31g x 5 mm T1 QL (200 EA per 30 days)

HM ULTICARE INSULIN SYRINGE 31G X 5/16" 0.3 ML T1 QL (200 EA per 30 days)

IN-CHECK INSPIRATORY FLOW MTR DEVICE T1 QL (4 EA per 365 days)

insulin syringe 29g x 1" 0.3 ml, 29g x 1/2" 1 ml T1 QL (200 EA per 30 days)

kmart valu insulin syringe 30g u-100 0.3 ml, u-100 0.5 ml


LITE TOUCH PEN NEEDLES 31G X 5 MM T1 QL (200 EA per 30 days)

LITETOUCH PEN NEEDLES 31G X 8 MM T1 QL (200 EA per 30 days)

MASK VORTEX T1 QL (4 EA per 365 days)

42

Drug Status NotesMONOJECT INSULIN SYRINGE 25G X 5/8" 1 ML T1 QL (200 EA per 30 days)

ONETOUCH DELICA LANCETS 30G T1

ONETOUCH DELICA LANCETS 33G T1

ONETOUCH ULTRA CONTROL IN VITRO SOLUTION T1

ONETOUCH VERIO SOLUTION IN VITRO T1 QL (1 EA per 365 days)

one-way valved inspiratory mouthpiece T1 QL (4 EA per 365 days)

peak flow meter device T1 QL (4 EA per 365 days)

pediatric medium mask T1 QL (4 EA per 365 days)

pediatric small mask T1 QL (4 EA per 365 days)

pen needles 29g x 12mm , 32g x 4 mm T1 QL (200 EA per 30 days)

premium condoms lubricated T1 QL (36 EA per 30 days)

qc insulin syringe 29g 0.3 ml, 29g 0.5 ml, 29g 1 ml, 30g 0.5 ml


RELI-ON INSULIN SYRINGE 30G 0.3 ML T1 QL (200 EA per 30 days)

SURE-LANCE THIN LANCETS 28G T1

TECHLITE PEN NEEDLES 31G X 6 MM , 32G X 8 MM T1 QL (200 EA per 30 days)

TERUMO INSULIN SYRINGE 30G X 3/8" 0.5 ML, 30G X 3/8" 1 ML T1 QL (200 EA per 30 days)

TERUMO SURGUARD INSULIN SYR 28G X 1/2" 1 ML T1 QL (200 EA per 30 days)

THINPRO INSULIN SYRINGE 31G X 3/8" 0.3 ML, 31G X 3/8" 0.5 ML, 31G X 3/8" 1 ML T1 QL (200 EA per 30 days)

TRUSTEX NON-LUBRICATED T1 QL (36 EA per 30 days)

ULTICARE INSULIN SYRINGE 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML T1 QL (200 EA per 30 days)

ULTICARE MICRO PEN NEEDLES 31G X 8 MM T1 QL (200 EA per 30 days)

ULTILET INSULIN SYRINGE 29G X 7/16" 0.3 ML, 29G X 7/16" 0.5 ML T1 QL (200 EA per 30 days)

VORTEX HOLDING CHAMBER/MASK DEVICE T1 QL (4 EA per 365 days)

WIDE-SEAL DIAPHRAGM 60 VAGINAL DIAPHRAGM 2 % T1




43

Drug Status NotesWIDE-SEAL DIAPHRAGM 80 VAGINAL DIAPHRAGM 2 % T1




*Migraine Products*naratriptan hcl oral tablet 1 mg, 2.5 mg T1 QL (9 EA per 30 days)

rizatriptan benzoate oral tablet 10 mg, 5 mg T1 QL (9 EA per 30 days)

rizatriptan benzoate oral tablet dispersible 10 mg, 5 mg


sumatriptan nasal solution 20 mg/act, 5 mg/act T1 PA; QL (6 EA per 30 days)

sumatriptan succinate oral tablet 100 mg, 25 mg, 50 mg


sumatriptan succinate refill subcutaneous solution cartridge 4 mg/0.5ml, 6 mg/0.5ml


sumatriptan succinate subcutaneous solution 6 mg/0.5ml


sumatriptan succinate subcutaneous solution auto-injector 4 mg/0.5ml, 6 mg/0.5ml


zolmitriptan oral tablet 2.5 mg, 5 mg T1 ST; QL (9 EA per 30 days)

zolmitriptan oral tablet dispersible 2.5 mg, 5 mg T1 ST; QL (9 EA per 30 days)

*Minerals & Electrolytes*BEELITH ORAL TABLET 362-20 MG T1

cal-citrate plus vitamin d oral tablet 250-100 mg-unit

T1

calcium + d3 oral tablet 600-200 mg-unit T1

calcium 500 + d oral tablet 500-125 mg-unit T1

calcium 500 + d3 oral tablet 500-600 mg-unit T1

calcium 500+d oral tablet 500-200 mg-unit T1

calcium 500+d3 oral tablet 500-400 mg-unit T1

calcium 600 + d oral tablet 600-200 mg-unit T1

calcium 600 oral tablet 1500 (600 ca) mg T1

calcium 600+d oral tablet 600-800 mg-unit T1

calcium 600+d3 oral tablet 600-400 mg-unit T1

calcium carbonate oral suspension 1250 (500 ca) mg/5ml

T1

calcium carbonate oral tablet 1250 (500 ca) mg, 600 mg

T1

44

Drug Status Notescalcium carbonate oral tablet chewable 260 mg T1

calcium carbonate-vitamin d oral tablet 600-200 mg-unit, 600-400 mg-unit

T1

calcium citrate + d3 maximum oral tablet 315-250 mg-unit

T1

calcium citrate oral granules 760 mg/3.5gm T1

calcium citrate oral tablet 200 mg, 950 mg T1

calcium citrate-vitamin d oral tablet 315-200 mg-unit

T1

calcium oral tablet 600-200 mg-unit T1

calcium oral tablet chewable 500 mg T1

calcium/vitamin d3 gummies oral tablet chewable200-200 mg-unit

T1

chelated magnesium oral tablet 100 mg T1

DISNEY CALCIUM + VITAMIN D3 ORAL TABLET CHEWABLE 250-135-200 MG-MG-UNIT

T1

GLYCOPHOS INTRAVENOUS SOLUTION1 MMOLE/ML T1

K-PHOS ORAL TABLET 500 MG T1

mag glycinate oral tablet 100 mg T1

MAG64 ORAL TABLET DELAYED RELEASE 64 MG T1

MAGINEX ORAL TABLET DELAYED RELEASE 615 MG T1

magnesium chloride injection solution 200 mg/ml T1

magnesium citrate oral tablet 100 mg T1

magnesium gluconate oral tablet 27.5 mg, 500 mg, 550 mg

T1

magnesium oral capsule 300 mg, 400 mg T1

magnesium oral tablet 200 mg, 250 mg, 30 mg T1

magnesium oxide -mg supplement oral capsule400 mg

T1

magnesium oxide -mg supplement oral tablet 250 mg

T1

magnesium oxide oral tablet 400 (240 mg) mg, 400 (241.3 mg) mg, 500 mg

T1

magnesium sulfate in d5w intravenous solution10-5 mg/ml-%

T1

magnesium sulfate injection solution 50 % T1

magnesium sulfate intravenous solution 2 gm/50ml, 4 gm/50ml

T1

45

Drug Status NotesMAGONATE ORAL LIQUID 54 (MAG EQUIV) MG/5ML T1

MAGONATE ORAL TABLET 500 (27 MG) MG T1

MAG-TAB SR ORAL TABLET EXTENDED RELEASE 84 MG (7MEQ) T1

ORALYTE ORAL SOLUTION T1

oyster shell calcium 250+d oral tablet 250-125 mg-unit

T1

oyster shell calcium oral tablet 500 mg T1

oyster shell calcium plus d oral tablet 500-125 mg-unit

T1

oyster shell calcium/d oral tablet 250-125 mg-unit T1

oyster shell calcium/d3 oral tablet 500-400 mg-unit

T1

oyster shell/d oral tablet 500-200 mg-unit T1

phos-nak oral packet 280-160-250 mg T1

PHOSPHA 250 NEUTRAL ORAL TABLET155-852-130 MG T1

pot bicarb-pot chloride oral tablet effervescent 25 meq

T1

potassium bicarbonate oral tablet effervescent 25 meq

T1

potassium chloride crys er oral tablet extended release 10 meq, 20 meq

T1

potassium chloride er oral capsule extended release 10 meq, 8 meq

T1

potassium chloride er oral tablet extended release10 meq, 20 meq, 8 meq

T1

potassium phosphates intravenous solution 15 mmole/5ml, 150 mmole/50ml, 45 mmole/15ml

T1

ra magnesium oral capsule 500 mg T1

ra oyster shell calcium/d oral tablet 500-200 mg-unit

T1

slow magnesium/calcium oral tablet delayed release 64-106 mg

T1

SLOW-MAG ORAL TABLET DELAYED RELEASE 71.5-119 MG T1

sodium fluoride oral solution 1.1 (0.5 f) mg/ml T1QL (120 ML per 30 days); AL (Max 16 Years)

sodium fluoride oral tablet chewable 0.55 (0.25 f) mg, 1.1 (0.5 f) mg, 2.2 (1 f) mg


46

Drug Status Notessodium phosphate intravenous solution 3 mmole/ml

T1

*Monobactams***CAYSTON INHALATION SOLUTION RECONSTITUTED 75 MG T1 PA

*Mouth/Throat/Dental Agents*chlorhexidine gluconate mouth/throat solution0.12 %

T1

clotrimazole mouth/throat lozenge 10 mg T1 QL (150 EA per 30 days)

DENTAGEL DENTAL GEL 1.1 % T1

lidocaine viscous mouth/throat solution 2 % T1

nystatin mouth/throat suspension 100000 unit/ml T1

pilocarpine hcl oral tablet 5 mg, 7.5 mg T1

sf 5000 plus dental cream 1.1 % T1

triamcinolone acetonide mouth/throat paste 0.1 % T1 QL (5 GM per 30 days)

*Multivitamins*APETIGEN ORAL ELIXIR T1

APETIGEN-PLUS ORAL SOLUTION T1

b complex formula 1 oral tablet T1

b complex oral capsule T1

b complex-c oral tablet T1

b complex-c-biotin-e-fa oral tablet 0.4 mg T1

b-100 complex oral tablet T1

b-100 complex oral tablet extended release T1

b-100 cr oral tablet extended release T1

b-complex/b-12 sublingual liquid T1

benfotiamine multi-b oral capsule T1

bp folinatal plus b oral tablet 1 mg T1GR-F; QL (30 EA per 30 days); AL (Min 12 Years and Max 55 Years)

brewers yeast oral tablet T1

childrens chewable vitamins oral tablet chewable T1

childrens multivitamin oral tablet chewable 60 mg

T1

childrens vitamins/iron oral tablet chewable 15 mg

T1

COMPLETE FORMULATION PEDIATRIC ORAL SOLUTION 45 MG/0.5ML T1

47

Drug Status Notes

cvs prenatal gummy oral tablet chewable 0.4-113.5 mg

T1GR-F; QL (30 EA per 30 days); AL (Min 12 Years and Max 55 Years)

daily multiple vitamins/min oral tablet T1

daily vitamin formula+iron oral tablet T1

daily vite oral tablet T1

DIALYVITE 3000 ORAL TABLET 3 MG T1

DIALYVITE 5000 ORAL TABLET 5 MG T1

DIALYVITE 800 PLUS D ORAL WAFER 800 MCG T1

DIALYVITE 800/ZINC ORAL TABLET 0.8 MG T1

DIALYVITE SUPREME D ORAL TABLET 3 MG T1

DIALYVITE TABLET ORAL T1

DIALYVITE/ZINC ORAL TABLET T1

DINO-LIFE W/IRON-ZINC ORAL TABLET CHEWABLE 30-200-3 T1

e-400/selenium oral capsule 400-50 unit-mcg T1

ecee plus oral tablet T1

eql one daily womens oral tablet T1

FOLBEE PLUS CZ ORAL TABLET 5 MG T1

gnp b-complex plus vitamin c oral tablet T1

hm vitamin b100 complex oral tablet T1

multi adult gummies oral tablet chewable T1

multi-delyn/iron oral liquid T1

multi-vit/fluoride oral solution 0.25 mg/ml T1QL (60 ML per 30 days); AL (Max 12 Years)

multi-vitamin hp/minerals oral capsule T1

multi-vitamin/fluoride oral solution 0.5 mg/ml T1QL (60 ML per 30 days); AL (Max 12 Years)

multivitamin/fluoride oral tablet chewable 0.25 mg, 1 mg


multi-vitamin/fluoride/iron oral solution 0.25-10 mg/ml


multivitamins pediatric oral solution T1

multivitamins/fluoride oral tablet chewable 0.5 mg


MYKIDZ IRON ORAL SUSPENSION 10 MG/2ML T1

48

Drug Status Notes

mynatal plus oral tablet T1GR-F; QL (30 EA per 30 days); AL (Min 12 Years and Max 55 Years)

mynate 90 plus oral tablet extended release T1GR-F; QL (30 EA per 30 days); AL (Min 12 Years and Max 55 Years)

NEPHROCAPS QT ORAL TABLET DISPERSIBLE 1 MG T1

NEPHRONEX ORAL LIQUID T1

NEPHRONEX TABLET ORAL T1

NEWGEN ORAL TABLET 32-1 MG T1GR-F; QL (30 EA per 30 days); AL (Min 12 Years and Max 55 Years)

niacin flush free oral capsule 400-100 mg T1

OBSTETRIX DHA ORAL 29-1 & 387 MG T1GR-F; QL (60 EA per 30 days); AL (Min 12 Years and Max 55 Years)

OBSTETRIX EC ORAL TABLET 29-1 MG T1GR-F; QL (30 EA per 30 days); AL (Min 12 Years and Max 55 Years)

polyvitamin oral solution 35 mg/ml T1

poly-vitamin/iron oral solution 10 mg/ml T1

prenatal 19 oral tablet 29-1 mg T1GR-F; QL (30 EA per 30 days); AL (Min 12 Years and Max 55 Years)

prenatal 19 oral tablet chewable 29-1 mg T1GR-F; QL (30 EA per 30 days); AL (Min 12 Years and Max 55 Years)

prenatal complete oral tablet 14-0.4 mg T1GR-F; QL (30 EA per 30 days); AL (Min 12 Years and Max 55 Years)

prenatal low iron oral tablet 27-1 mg T1GR-F; QL (30 EA per 30 days); AL (Min 12 Years and Max 55 Years)

prenatal multi +dha oral capsule 27-0.8-228 mg T1GR-F; QL (30 EA per 30 days); AL (Min 12 Years and Max 55 Years)

prenatal oral tablet 27-0.8 mg, 28-0.8 mg T1GR-F; QL (30 EA per 30 days); AL (Min 12 Years and Max 55 Years)

prenatal plus iron oral tablet 29-1 mg T1GR-F; QL (30 EA per 30 days); AL (Min 12 Years and Max 55 Years)

49

Drug Status Notes

PRENATAL-U ORAL CAPSULE 106.5-1 MG T1GR-F; QL (30 EA per 30 days); AL (Min 12 Years and Max 55 Years)

pretab oral tablet 29-1 mg T1GR-F; QL (30 EA per 30 days); AL (Min 12 Years and Max 55 Years)

qc childrens vitamins/extra c oral tablet chewableT1

ra b-complex/vitamin c cr oral tablet extended release

T1

rabano yodado oral liquid T1

RENAL ORAL CAPSULE 1 MG T1

renal vitamin oral tablet 0.8 mg T1

rena-vite rx tablet 1 mg oral (otc) 1 mg T1

SCOOBY-DOO ONE A DAY ORAL TABLET CHEWABLE T1

SUPERVITE ORAL LIQUID T1

TARON-BC ORAL 20-1 MG & 2 X 25 MG T1GR-F; QL (90 EA per 30 days); AL (Min 12 Years and Max 55 Years)

trinatal rx 1 oral tablet 60-1 mg T1GR-F; QL (30 EA per 30 days); AL (Min 12 Years and Max 55 Years)

TRINATE ORAL TABLET T1GR-F; QL (30 EA per 30 days); AL (Min 12 Years and Max 55 Years)

tri-tabs dha oral 32-1 mg T1GR-F; QL (60 EA per 30 days); AL (Min 12 Years and Max 55 Years)

TRI-VI-FLOR ORAL SUSPENSION 0.25 MG/ML T1

tri-vi-floro oral suspension 0.5 mg/ml T1

TRI-VI-SOL ORAL SOLUTION 750-400-35 UNIT-MG/ML T1

tri-vit/fluoride oral solution 0.25 mg/ml, 0.5 mg/ml


tri-vit/fluoride/iron oral solution 0.25-10 mg/ml T1QL (60 ML per 30 days); AL (Max 12 Years)

tri-vitamin oral solution 1500-400-35 T1 QL (50 ML per 25 days)

VINATE II ORAL TABLET 29-1 MG T1GR-F; QL (30 EA per 30 days); AL (Min 12 Years and Max 55 Years)

50

Drug Status Notes

VINATE M ORAL TABLET 27-1 MG T1GR-F; QL (30 EA per 30 days); AL (Min 12 Years and Max 55 Years)

virt-vite gt oral tablet 90-1 mg T1GR-F; QL (30 EA per 30 days); AL (Min 12 Years and Max 55 Years)

vita-bee/c oral tablet T1

VITAL-D RX ORAL TABLET 1 MG T1

vitamin b complex-c oral capsule T1

vitamin b-complex 100 injection injectable T1

vitamin b-complex oral tablet T1

vita-min oral capsule T1

vol-care rx tablet 1 mg oral 1 mg T1

vp-heme ob oral tablet 28-6-1 mg T1GR-F; QL (30 EA per 30 days); AL (Min 12 Years and Max 55 Years)

vp-vite rx tablet 1 mg oral 1 mg T1

*Musculoskeletal Therapy Agents*baclofen oral tablet 10 mg, 20 mg T1

chlorzoxazone oral tablet 500 mg T1AL (Min 18 Years and Max 64 Years)

cyclobenzaprine hcl oral tablet 10 mg, 5 mg T1AL (Min 15 Years and Max 64 Years)

dantrolene sodium oral capsule 100 mg, 25 mg, 50 mg


methocarbamol oral tablet 500 mg T1 AL (Max 64 Years)

methocarbamol oral tablet 750 mg T1AL (Min 15 Years and Max 64 Years)

orphenadrine citrate er oral tablet extended release 12 hour 100 mg

T1QL (60 EA per 30 days); AL (Min 18 Years and Max 64 Years)

tizanidine hcl oral tablet 2 mg, 4 mg T1 AL (Min 18 Years)

*Nasal Agents - Systemic And Topical*allergy spray 24 hour nasal aerosol 55 mcg/act T1 QL (16.9 ML per 30 days)

azelastine hcl nasal solution 0.1 % T1 QL (30 ML per 30 days)

childrens silfedrine oral liquid 15 mg/5ml T1

cromolyn sodium nasal aerosol solution 5.2 mg/act

T1

cvs nasal allergy spray nasal aerosol 55 mcg/act T1 QL (16.9 ML per 30 days)

eq nasal allergy nasal aerosol 55 mcg/act T1 QL (16.9 ML per 30 days)

flunisolide nasal solution 25 mcg/act (0.025%) T1 QL (25 ML per 30 days)

51

Drug Status Notesfluticasone propionate nasal suspension 50 mcg/act


gnp 24 hour nasal allergy nasal aerosol 55 mcg/act

T1 QL (16.9 ML per 30 days)

goodsense nasal allergy spray nasal aerosol 55 mcg/act

T1 QL (16.9 ML per 30 days)

ipratropium bromide nasal solution 0.03 %, 0.06 %


long acting nasal spray nasal solution 0.05 % T1

NASACORT ALLERGY 24HR CHILDREN NASAL AEROSOL 55 MCG/ACT T1 QL (10.8 ML per 30 days)

NASACORT ALLERGY 24HR NASAL AEROSOL 55 MCG/ACT T1 QL (16.9 ML per 30 days)

nasal allergy 24 hour nasal aerosol 55 mcg/act T1 QL (16.9 ML per 30 days)

nasal decongestant oral liquid 30 mg/5ml T1

pseudoephedrine hcl er oral tablet extended release 12 hour 120 mg

T1

ra nasal allergy nasal aerosol 55 mcg/act T1 QL (16.9 ML per 30 days)

saline mist spray nasal solution 0.65 % T1

triamcinolone acetonide nasal aerosol 55 mcg/act T1 QL (16.9 GM per 30 days)

*Neprilysin Inhib (Arni)-Angiotensin Ii Recept Antag Comb***ENTRESTO ORAL TABLET 24-26 MG, 49-51 MG, 97-103 MG T1

ST; QL (60 EA per 30 days); AL (Min 18 Years)

*Nutrients*alba-lybe nr oral liquid 325-10-50 mg/5ml T1

fish oil oral capsule 1000 mg, 1200 mg, 500 mg T1

fish oil oral capsule delayed release 1000 mg, 1200 mg

T1

prenatal dha oral capsule 200 mg T1

*Ophthalmic Agents*allergy eye ophthalmic solution 0.025-0.3 % T1

apraclonidine hcl ophthalmic solution 0.5 % T1 QL (10 ML per 30 days)

artificial tears ophthalmic ointment 83-15 % T1

artificial tears ophthalmic solution 0.1-0.3 %, 0.4 %

T1

atropine sulfate ophthalmic ointment 1 % T1

atropine sulfate ophthalmic solution 1 % T1

azelastine hcl ophthalmic solution 0.05 % T1 ST; QL (6 ML per 30 days)

bacitracin ophthalmic ointment 500 unit/gm T1

52

Drug Status Notesbacitracin-polymyxin b ophthalmic ointment 500-10000 unit/gm

T1

bacitra-neomycin-polymyxin-hc ophthalmic ointment 1 %

T1

betaxolol hcl ophthalmic solution 0.5 % T1

BIOLLE GEL TEARS OPHTHALMIC GEL1 % T1

brimonidine tartrate ophthalmic solution 0.2 % T1

carteolol hcl ophthalmic solution 1 % T1

ciprofloxacin hcl ophthalmic solution 0.3 % T1 QL (10 ML per 30 days)

cromolyn sodium ophthalmic solution 4 % T1

cvs lubricant drops ophthalmic gel 1 % T1

cyclopentolate hcl ophthalmic solution 1 %, 2 % T1

dexamethasone sodium phosphate ophthalmic solution 0.1 %

T1

diclofenac sodium ophthalmic solution 0.1 % T1

dorzolamide hcl ophthalmic solution 2 % T1 QL (10 ML per 30 days)

dorzolamide hcl-timolol mal ophthalmic solution22.3-6.8 mg/ml


erythromycin ophthalmic ointment 5 mg/gm T1

eye allergy relief ophthalmic solution 0.027-0.315 %

T1

fluorometholone ophthalmic suspension 0.1 % T1 QL (15 ML per 30 days)

flurbiprofen sodium ophthalmic solution 0.03 % T1

GENTAK OPHTHALMIC OINTMENT 0.3 % T1

gentamicin sulfate ophthalmic solution 0.3 % T1

HOMATROPAIRE OPHTHALMIC SOLUTION 5 % T1

ketorolac tromethamine ophthalmic solution 0.5 %


ketotifen fumarate ophthalmic solution 0.025 % T1 QL (10 ML per 30 days)

latanoprost ophthalmic solution 0.005 % T1 QL (2.5 ML per 25 days)

levobunolol hcl ophthalmic solution 0.5 % T1

levofloxacin ophthalmic solution 0.5 % T1

lubricant drops ophthalmic solution 1.4 % T1

lubricant drops/dual-action ophthalmic solution0.5-0.9 %

T1

lubricant eye drops ophthalmic solution 0.4-0.3 %, 0.5 %, 0.6 %

T1

lubricant eye ophthalmic ointment T1

53

Drug Status Notesmetipranolol ophthalmic solution 0.3 % T1

naphazoline hcl ophthalmic solution 0.1 % T1

neomycin-bacitracin zn-polymyx ophthalmic ointment 5-400-10000

T1

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

T1

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

T1

neomycin-polymyxin-gramicidin ophthalmic solution 1.75-10000-.025

T1

ofloxacin ophthalmic solution 0.3 % T1

phenylephrine hcl ophthalmic solution 2.5 % T1

PHOSPHOLINE IODIDE OPHTHALMIC SOLUTION RECONSTITUTED 0.125 % T1

pilocarpine hcl ophthalmic solution 1 %, 2 %, 4 %

T1

polymyxin b-trimethoprim ophthalmic solution10000-0.1 unit/ml-%

T1

prednisolone acetate ophthalmic suspension 1 % T1

prednisolone sodium phosphate ophthalmic solution 1 %

T1

proparacaine hcl ophthalmic solution 0.5 % T1

px artificial tears ophthalmic solution 5-6 mg/ml T1

ra artificial tears ophthalmic solution 1-0.3 % T1

REFRESH LIQUIGEL OPHTHALMIC SOLUTION 1 % T1

REFRESH OPTIVE SENSITIVE OPHTHALMIC SOLUTION 0.5-0.9 % T1

sm dry eye relief ophthalmic solution 0.2-0.2-1 % T1

sodium chloride (hypertonic) ophthalmic ointment5 %

T1

sodium chloride (hypertonic) ophthalmic solution5 %

T1

sulfacetamide sodium ophthalmic ointment 10 % T1

sulfacetamide sodium ophthalmic solution 10 % T1

sulfacetamide-prednisolone ophthalmic solution10-0.23 %

T1

SYSTANE OPHTHALMIC GEL 0.4-0.3 % T1

timolol maleate ophthalmic solution 0.25 %, 0.5 %

T1

tobramycin ophthalmic solution 0.3 % T1

54

Drug Status Notestobramycin-dexamethasone ophthalmic suspension 0.3-0.1 %

T1

trifluridine ophthalmic solution 1 % T1

tropicamide ophthalmic solution 0.5 %, 1 % T1

ZADITOR OPHTHALMIC SOLUTION 0.025 % T1 QL (10 ML per 30 days)

*Otic Agents*acetic acid otic solution 2 % T1

acetic acid-aluminum acetate otic solution 2 % T1

antipyrine-benzocaine otic solution 5.4-1.4 % T1

CIPRODEX OTIC SUSPENSION 0.3-0.1 % T1 QL (7.5 ML per 30 days)

ciprofloxacin hcl otic solution 0.2 % T1 QL (14 EA per 30 days)

hydrocortisone-acetic acid otic solution 1-2 % T1

neomycin-polymyxin-hc otic solution 3.5-10000-1 T1

neomycin-polymyxin-hc otic suspension 3.5-10000-1

T1

ofloxacin otic solution 0.3 % T1 QL (5 ML per 30 days)

*Oxytocics*

methylergonovine maleate oral tablet 0.2 mg T1QL (28 EA per 180 days); AL (Min 12 Years)

*Passive Immunizing Agents*RHOGAM ULTRA-FILTERED PLUS INTRAMUSCULAR SOLUTION PREFILLED SYRINGE 1500 UNIT

T1 GR-F

SYNAGIS INTRAMUSCULAR SOLUTION100 MG/ML, 50 MG/0.5ML T1 PA

*Penicillins*amoxicillin oral capsule 250 mg, 500 mg T1

amoxicillin oral suspension reconstituted 125 mg/5ml, 200 mg/5ml, 250 mg/5ml, 400 mg/5ml

T1

amoxicillin oral tablet 500 mg, 875 mg T1

amoxicillin oral tablet chewable 125 mg, 250 mg T1 AL (Max 12 Years)

amoxicillin-pot clavulanate er oral tablet extended release 12 hour 1000-62.5 mg

T1

amoxicillin-pot clavulanate oral suspension reconstituted 200-28.5 mg/5ml, 250-62.5 mg/5ml, 400-57 mg/5ml, 600-42.9 mg/5ml

T1

amoxicillin-pot clavulanate oral tablet 250-125 mg, 500-125 mg, 875-125 mg

T1

amoxicillin-pot clavulanate oral tablet chewable200-28.5 mg, 400-57 mg


55

Drug Status Notesampicillin oral capsule 250 mg, 500 mg T1

ampicillin oral suspension reconstituted 125 mg/5ml, 250 mg/5ml

T1

dicloxacillin sodium oral capsule 250 mg, 500 mg T1

penicillin v potassium oral solution reconstituted125 mg/5ml, 250 mg/5ml

T1

penicillin v potassium oral tablet 250 mg, 500 mg T1

*Pharmaceutical Adjuvants*cherry oral syrup T1

ORA-BLEND ORAL SUSPENSION T1

ORA-SWEET ORAL SYRUP T1

simple syrup oral syrup T1

*Phosphodiesterase 4 (Pde4) Inhibitors***OTEZLA ORAL TABLET 30 MG T1 PA

OTEZLA ORAL TABLET THERAPY PACK10 & 20 & 30 MG T1 PA

*Potassium Removing Agents***sodium polystyrene sulfonate oral powder T1

sodium polystyrene sulfonate rectal suspension 30 gm/120ml

T1

SPS ORAL SUSPENSION 15 GM/60ML T1

*Prenatal Mv & Minerals W/ Fa-Omega Fatty Acids W/O Iron***cvs prenatal gummy oral tablet chewable 0.4-113.5 mg

T1

*Progestins*medroxyprogesterone acetate oral tablet 10 mg, 2.5 mg, 5 mg

T1

norethindrone acetate oral tablet 5 mg T1 QL (60 EA per 30 days)

progesterone micronized oral capsule 100 mg T1 QL (30 EA per 30 days)

progesterone micronized oral capsule 200 mg T1 QL (60 EA per 30 days)

*Psychotherapeutic And Neurological Agents - Misc.*AUBAGIO ORAL TABLET 14 MG, 7 MG T1 PA; QL (30 EA per 30 days)

AVONEX INTRAMUSCULAR KIT 30 MCG T1 PA; QL (4 EA per 28 days)

AVONEX PREFILLED INTRAMUSCULAR PREFILLED SYRINGE KIT 30 MCG/0.5ML T1 PA; QL (4 EA per 28 days)

bupropion hcl er (smoking det) oral tablet extended release 12 hour 150 mg


56

Drug Status Notesdalfampridine er oral tablet extended release 12 hour 10 mg

T1PA; QL (60 EA per 30 days); AL (Min 18 Years and Max 70 Years)

donepezil hcl oral tablet 10 mg T1QL (60 EA per 30 days); AL (Min 40 Years)

donepezil hcl oral tablet 5 mg T1QL (30 EA per 30 days); AL (Min 40 Years)

GILENYA ORAL CAPSULE 0.5 MG T1 PA

glatiramer acetate subcutaneous solution prefilled syringe 40 mg/ml


GLATOPA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 20 MG/ML T1 PA; QL (30 ML per 30 days)

memantine hcl oral tablet 10 mg, 5 mg T1QL (60 EA per 30 days); AL (Min 40 Years)

memantine hcl oral tablet 28 x 5 mg & 21 x 10 mg T1QL (49 EA per 365 days); AL (Min 40 Years)

nicotine polacrilex mouth/throat gum 2 mg T1 QL (900 EA per 30 days)

nicotine polacrilex mouth/throat gum 4 mg T1 QL (720 EA per 30 days)

nicotine polacrilex mouth/throat lozenge 2 mg, 4 mg


nicotine step 1 transdermal patch 24 hour 21 mg/24hr


nicotine transdermal kit 21-14-7 mg/24hr T1 QL (56 EA per 56 days)

nicotine transdermal patch 24 hour 14 mg/24hr, 7 mg/24hr


rivastigmine tartrate oral capsule 1.5 mg, 3 mg, 4.5 mg, 6 mg


TECFIDERA ORAL 120 & 240 MG T1 PA; QL (60 EA per 365 days)

TECFIDERA ORAL CAPSULE DELAYED RELEASE 120 MG, 240 MG T1 PA; QL (60 EA per 30 days)

XYREM ORAL SOLUTION 500 MG/ML T1 PA; QL (540 ML per 30 days)

*Respiratory Agents - Misc.*PULMOZYME INHALATION SOLUTION 1 MG/ML T1 PA

*Sglt2 Inhibitor - Dpp-4 Inhibitor Combinations***STEGLUJAN ORAL TABLET 15-100 MG, 5-100 MG T1 PA; AL (Min 18 Years)

*Sodium-Glucose Co-Transporter 2 Inhibitor-Biguanide Comb***INVOKAMET ORAL TABLET 150-1000 MG, 150-500 MG, 50-1000 MG, 50-500 MG T1 PA; QL (60 EA per 30 days)

57

Drug Status NotesINVOKAMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR 150-1000 MG, 150-500 MG, 50-1000 MG, 50-500 MG


SEGLUROMET ORAL TABLET 2.5-1000 MG, 2.5-500 MG, 7.5-1000 MG, 7.5-500 MG T1 PA

SYNJARDY ORAL TABLET 12.5-1000 MG, 12.5-500 MG, 5-1000 MG, 5-500 MG T1 PA; QL (60 EA per 30 days)

SYNJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR 10-1000 MG, 25-1000 MG


SYNJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR 12.5-1000 MG, 5-1000 MG


*Steroids - Mouth/Throat/Dental***triamcinolone acetonide mouth/throat paste 0.1 % T1 QL (5 GM per 30 days)

*Tetracyclines*doxycycline hyclate oral tablet 100 mg T1

doxycycline monohydrate oral capsule 100 mg, 50 mg

T1

doxycycline monohydrate oral suspension reconstituted 25 mg/5ml


doxycycline monohydrate oral tablet 100 mg, 50 mg

T1

minocycline hcl oral capsule 100 mg, 50 mg, 75 mg

T1

*Thyroid Agents*ARMOUR THYROID ORAL TABLET 120 MG, 15 MG, 180 MG, 240 MG, 30 MG, 300 MG, 60 MG, 90 MG


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

T1

LEVOXYL ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 50 MCG, 75 MCG, 88 MCG

T1

liothyronine sodium oral tablet 25 mcg, 5 mcg, 50 mcg

T1

methimazole oral tablet 10 mg, 5 mg T1

NATURE-THROID ORAL TABLET 113.75 MG, 130 MG, 146.25 MG, 16.25 MG, 162.5 MG, 195 MG, 260 MG, 32.5 MG, 325 MG, 48.75 MG, 65 MG, 81.25 MG, 97.5 MG


58

Drug Status Notesnp thyroid oral tablet 120 mg, 30 mg, 60 mg, 90 mg


np thyroid oral tablet 15 mg T1

propylthiouracil oral tablet 50 mg T1

SYNTHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG

T1

thyroid oral tablet 65 mg T1

UNITHROID DIRECT ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG

T1

UNITHROID ORAL TABLET 137 MCG T1

WESTHROID ORAL TABLET 130 MG, 195 MG, 32.5 MG, 65 MG, 97.5 MG T1 AL (Max 64 Years)

WP THYROID ORAL TABLET 113.75 MG, 130 MG, 16.25 MG, 32.5 MG, 48.75 MG, 65 MG, 81.25 MG, 97.5 MG


*Transthyretin Stabilizers***

VYNDAMAX ORAL CAPSULE 61 MG T1PA; QL (30 EA per 30 days); AL (Min 18 Years)

VYNDAQEL ORAL CAPSULE 20 MG T1PA; QL (120 EA per 30 days); AL (Min 18 Years)

*Ulcer Drugs*cimetidine 200 oral tablet 200 mg T1

cimetidine hcl oral solution 300 mg/5ml T1 AL (Max 12 Years)

cimetidine oral tablet 300 mg, 400 mg, 800 mg T1

cvs esomeprazole magnesium capsule delayed release 20 mg oral 20 mg


dicyclomine hcl oral capsule 10 mg T1 AL (Max 64 Years)

dicyclomine hcl oral solution 10 mg/5ml T1 AL (Max 64 Years)

dicyclomine hcl oral tablet 20 mg T1 AL (Max 64 Years)

esomeprazole magnesium capsule delayed release 20 mg oral (otc) 20 mg


famotidine oral tablet 10 mg, 20 mg, 40 mg T1

FIRST-LANSOPRAZOLE ORAL SUSPENSION 3 MG/ML T1 AL (Max 12 Years)

FIRST-OMEPRAZOLE ORAL SUSPENSION 2 MG/ML T1 AL (Max 12 Years)

glycopyrrolate oral tablet 1 mg, 2 mg T1

59

Drug Status NotesGOODSENSE ESOMEPRAZOLE CAPSULE DELAYED RELEASE 20 MG ORAL 20 MG T1 QL (60 EA per 30 days)

heartburn treatment 24 hour capsule delayed release 20 mg oral 20 mg


hm esomeprazole magnesium dr capsule delayed release 20 mg oral 20 mg


hyoscyamine sulfate er oral tablet extended release 12 hour 0.375 mg


hyoscyamine sulfate oral elixir 0.125 mg/5ml T1 AL (Max 64 Years)

hyoscyamine sulfate oral solution 0.125 mg/ml T1 AL (Max 64 Years)

hyoscyamine sulfate oral tablet 0.125 mg T1 AL (Max 64 Years)

hyoscyamine sulfate oral tablet dispersible 0.125 mg


hyoscyamine sulfate sublingual tablet sublingual0.125 mg


lansoprazole oral capsule delayed release 15 mg T1

lansoprazole oral capsule delayed release 30 mg T1 QL (30 EA per 30 days)

misoprostol oral tablet 100 mcg, 200 mcg T1 QL (120 EA per 30 days)

omeprazole magnesium oral capsule delayed release 20.6 (20 base) mg


omeprazole oral capsule delayed release 10 mg, 20 mg, 40 mg


pantoprazole sodium oral tablet delayed release20 mg


pantoprazole sodium oral tablet delayed release40 mg


sm esomeprazole magnesium capsule delayed release 20 mg oral 20 mg


sucralfate oral tablet 1 gm T1 QL (120 EA per 30 days)

*Urinary Anti-Infectives*methenamine hippurate oral tablet 1 gm T1

methenamine mandelate oral tablet 0.5 gm, 1 gm T1

nitrofurantoin macrocrystal oral capsule 100 mg, 50 mg


nitrofurantoin monohyd macro oral capsule 100 mg


nitrofurantoin oral suspension 25 mg/5ml T1 AL (Max 12 Years)

*Urinary Antispasmodics*bethanechol chloride oral tablet 10 mg, 25 mg, 5 mg, 50 mg


bethanechol chloride oral tablet 10 mg, 25 mg, 5 mg, 50 mg


60

Drug Status Notesflavoxate hcl oral tablet 100 mg T1

oxybutynin chloride er oral tablet extended release 24 hour 10 mg, 15 mg


oxybutynin chloride er oral tablet extended release 24 hour 5 mg


oxybutynin chloride oral syrup 5 mg/5ml T1 QL (150 ML per 30 days)

oxybutynin chloride oral tablet 5 mg T1 QL (90 EA per 30 days)

OXYTROL FOR WOMEN PATCH TWICE WEEKLY 3.9 MG/24HR TRANSDERMAL3.9 MG/24HR

T1

tolterodine tartrate er oral capsule extended release 24 hour 2 mg, 4 mg


tolterodine tartrate oral tablet 1 mg, 2 mg T1 ST; QL (60 EA per 30 days)

trospium chloride er oral capsule extended release 24 hour 60 mg

T1 ST

trospium chloride oral tablet 20 mg T1 ST; QL (60 EA per 30 days)

*Vaccines*HAVRIX INTRAMUSCULAR SUSPENSION1440 EL U/ML T1

QL (2 ML per 365 days); AL (Min 19 Years)

HAVRIX INTRAMUSCULAR SUSPENSION720 EL U/0.5ML T1


SHINGRIX INTRAMUSCULAR SUSPENSION RECONSTITUTED 50 MCG/0.5ML

T1 QL (2 EA per 1 lifetime)

VAQTA INTRAMUSCULAR SUSPENSION25 UNIT/0.5ML T1


VAQTA INTRAMUSCULAR SUSPENSION50 UNIT/ML T1


ZOSTAVAX SUBCUTANEOUS SOLUTION RECONSTITUTED 19400 UNT/0.65ML T1 AL (Min 60 Years)

*Vaginal Products*clindamycin phosphate vaginal cream 2 % T1 GR-F

clotrimazole 3 vaginal cream 2 % T1 GR-F

clotrimazole vaginal cream 1 % T1 GR-F

estradiol vaginal cream 0.1 mg/gm T1 GR-F; QL (42.5 GM per 30 days)

FIRST-PROGESTERONE VGS 100 VAGINAL SUPPOSITORY 100 MG T1 GR-F



61

Drug Status NotesFIRST-PROGESTERONE VGS 400 VAGINAL SUPPOSITORY 400 MG T1 GR-F


metronidazole vaginal gel 0.75 % T1 GR-F

miconazole 3 combo pack vaginal kit 200 & 2 mg-% (9gm)

T1 GR-F

miconazole 3 vaginal kit T1 GR-F

miconazole 7 vaginal cream 2 % T1 GR-F

miconazole 7 vaginal suppository 100 mg T1 GR-F

OPTIONS GYNOL II CONTRACEPTIVE VAGINAL GEL 3 % T1 GR-F

ra miconazole 3 combo pack app vaginal kit 200 & 2 mg-% (9gm)

T1 GR-F

terconazole vaginal cream 0.4 %, 0.8 % T1 GR-F

TODAY SPONGE VAGINAL 1000 MG T1 GR-F

VCF VAGINAL CONTRACEPTIVE VAGINAL FOAM 12.5 % T1 GR-F

YUVAFEM VAGINAL TABLET 10 MCG T1

*Vasopressors*epinephrine solution auto-injector 0.15 mg/0.15ml injection 0.15 mg/0.15ml


epinephrine solution auto-injector 0.15 mg/0.3ml injection 0.15 mg/0.3ml


epinephrine solution auto-injector 0.3 mg/0.3ml injection 0.3 mg/0.3ml


midodrine hcl oral tablet 10 mg, 2.5 mg, 5 mg T1 QL (90 EA per 30 days)

SYMJEPI SOLUTION PREFILLED SYRINGE 0.15 MG/0.3ML INJECTION 0.15 MG/0.3ML


SYMJEPI SOLUTION PREFILLED SYRINGE 0.3 MG/0.3ML INJECTION 0.3 MG/0.3ML


*Vitamins*AQUA-E ORAL LIQUID 30-2 MG/ML T1

aqueous vitamin e oral solution 15 unit/0.3ml T1 AL (Max 12 Years)

arkaliox oral capsule 200 mg T1

biotin maximum strength oral tablet 10000 mcg T1

biotin oral capsule 1 mg, 2500 mcg, 5 mg T1

biotin oral tablet 1000 mcg, 300 mcg, 5000 mcg, 800 mcg

T1

62

Drug Status NotesCALCIFEROL ORAL SOLUTION 8000 UNIT/ML T1 QL (60 ML per 30 days)

CYTO B7 ORAL LIQUID 5 MG/ML T1

d 2000 oral tablet 50 mcg (2000 ut) T1

d 400 oral tablet 10 mcg (400 unit) T1

d3-1000 oral tablet 25 mcg (1000 ut) T1

e-400 oral capsule 400 unit T1

gnp niacin oral tablet 250 mg T1

gnp vitamin d oral tablet chewable 10 mcg (400 unit)

T1

LIQUI-E ORAL LIQUID 400 UNIT/15ML T1

mega biotin oral capsule 10 mg T1

MEPHYTON ORAL TABLET 5 MG T1 QL (3 EA per 30 days)

natural vitamin d-3 oral tablet 125 mcg (5000 ut) T1

niacin er oral capsule extended release 250 mg, 500 mg

T1

niacin er oral tablet extended release 1000 mg, 750 mg

T1

niacin oral tablet 100 mg, 50 mg T1

niacinamide oral tablet 100 mg, 500 mg T1

niacinamide oral tablet extended release 500 mg T1

pyridoxine hcl oral tablet 100 mg, 25 mg T1

ra niacin oral tablet 500 mg T1

SLO-NIACIN ORAL TABLET EXTENDED RELEASE 500 MG T1

sm niacin cr oral tablet extended release 250 mg T1

vitamin b1 oral tablet 100 mg T1 QL (30 EA per 30 days)

vitamin b-1 oral tablet 100 mg T1 QL (30 EA per 30 days)

vitamin b-1 oral tablet 50 mg T1



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

T1

vitamin d oral liquid 400 unit/ml T1

vitamin d3 oral capsule 1.25 mg (50000 ut), 10 mcg (400 unit), 125 mcg (5000 ut), 25 mcg (1000 ut), 50 mcg (2000 ut)

T1

vitamin d3 oral tablet 1.25 mg (50000 ut) T1

vitamin e oral capsule 100 unit, 1000 unit, 200 unit, 600 unit

T1

63

Drug Status Notesvitamin e oral oil 100 unt/0.25ml T1

vitamin e oral tablet 100 unit, 200 unit, 400 unit T1

wheat germ oil oral oil T1

64

Indexacarbose ......................................10ACCU-CHEK MULTICLIX LANCETS ................................. 41acebutolol hcl ..............................22ACEPHEN ...................................3acetaminophen ..........................3, 4acetaminophen 8 hour .................. 3acetaminophen er ..........................3acetaminophen extra strength .......3acetaminophen rapid tabs child ....4acetaminophen-codeine ................ 4acetaminophen-codeine #2 ........... 4acetaminophen-codeine #3 ........... 4acetaminophen-codeine #4 ........... 4acetazolamide ............................. 33acetazolamide er .........................33acetic acid ...................................55acetic acid-aluminum acetate ..... 55acetylcysteine .............................. 27ACID GONE ............................... 6acitretin .......................................28ACTEMRA ..................................1ACTEMRA ACTPEN ................ 1acyclovir ......................................21ADCIRCA ..................................24adefovir dipivoxil ........................ 21ADEMPAS .................................24ADMELOG ............................... 10ADMELOG SOLOSTAR ........ 10adult aerosol mask ......................41ADVOCATE INSULIN PEN NEEDLES ..................................41AFINITOR ................................ 19AFINITOR DISPERZ .............. 19AIMOVIG ........................... 23, 25AJOVY .................................23, 25alba-lybe nr .................................52albuterol sulfate ............................ 7albuterol sulfate hfa ......................7alclometasone dipropionate ........28alendronate sodium .................... 34alfuzosin hcl er ............................36aliskiren fumarate .......................15ALKERAN ................................ 19allergy eye ...................................52allergy spray 24 hour ..................51allopurinol .................................. 37alogliptin benzoate ......................10alogliptin-metformin hcl ............. 10alogliptin-pioglitazone ................10aluminum hydroxide gel ................6

amantadine hcl ............................20AMETHYST ............................. 25amiloride hcl ...............................33amiloride-hydrochlorothiazide ... 33amiodarone hcl ............................. 7AMITIZA .................................. 35amlodipine besy-benazepril hcl .. 15amlodipine besylate .................... 23amlodipine besylate-valsartan ....15ammonium lactate .......................28AMNESTEEM .......................... 28amoxicillin .................................. 55amoxicillin-pot clavulanate ........ 55amoxicillin-pot clavulanate er ....55ampicillin .................................... 56anagrelide hcl ............................. 37anastrozole ..................................19ANECREAM .............................28antacid calcium extra strength ..... 6antacid plus anti-gas fast act ........6antacid/simethicone ds ..................6antipyrine-benzocaine .................55apap 500 ....................................... 4APETIGEN ............................... 47APETIGEN-PLUS ....................47apraclonidine hcl ........................ 52APRISO ..................................... 35AQUA-E .....................................62aqueous vitamin e ....................... 62ARANELLE .............................. 25ARANESP (ALBUMIN FREE) .................................. 37, 38arkaliox ....................................... 62ARMONAIR RESPICLICK 113 ................................................ 8ARMONAIR RESPICLICK 232 ................................................ 8ARMONAIR RESPICLICK 55 .................................................. 8ARMOUR THYROID ..............58artificial tears ............................. 52ASPERCREME LIDOCAINE 28ASPERCREME W/LIDOCAINE ........................ 28aspirin ........................................... 4aspirin ec ...................................... 4aspirin ec low dose ....................... 4ASSURE DOSE CONTROL ... 41atenolol ....................................... 22atenolol-chlorthalidone .............. 16atorvastatin calcium ................... 15

atovaquone ..................................17atropine sulfate ........................... 52ATROVENT HFA ...................... 8AUBAGIO ................................. 56AVIANE .....................................25AVONEX ................................... 56AVONEX PREFILLED ........... 56azathioprine ................................ 21azelastine hcl ........................ 51, 52azithromycin ............................... 41b complex .................................... 47b complex formula 1 ................... 47b complex-c .................................47b complex-c-biotin-e-fa ...............47b-100 complex .............................47b-100 cr .......................................47b-12 ............................................. 38bacitracin ..............................28, 52bacitracin zinc ............................ 28bacitracin-polymyxin b ............... 53bacitra-neomycin-polymyxin-hc . 53baclofen .......................................51balsalazide disodium .................. 35BALZIVA .................................. 25BAQSIMI ONE PACK .............10BAQSIMI TWO PACK ........... 11BASAGLAR KWIKPEN ......... 11BASIS OVERNIGHT ...............28BAYER CONTOUR NEXT CONTROL ................................ 41BAYER CONTOUR NEXT TEST .......................................... 32b-complex/b-12 ........................... 47BD AUTOSHIELD ................... 41BD AUTOSHIELD DUO ......... 41BD INSULIN SYR ULTRAFINE II .........................41BD INSULIN SYRINGE ..........41BD INSULIN SYRINGE MICROFINE .............................41BD INSULIN SYRINGE U/F .. 41BD INSULIN SYRINGE U-40 .41BD INSULIN SYRINGE U-500 .............................................. 41BD INSULIN SYRINGE ULTRAFINE .............................41BD INTEGRA SYRINGE ........41BD LANCET DEVICE .............41BD PEN ......................................41BEELITH .................................. 44benazepril hcl ..............................16

65

benazepril-hydrochlorothiazide ..16benfotiamine multi-b ...................47benznidazole ................................. 6benzoyl peroxide ......................... 28benzoyl peroxide creamy wash ... 28benzoyl peroxide wash ................28betamethasone dipropionate .......29betamethasone dipropionate aug ........................................ 28, 29betamethasone valerate .............. 29betaxolol hcl ..........................22, 53bethanechol chloride ...................60BETHKIS .................................... 1BEVESPI AEROSPHERE .........8bexarotene ...................................19bicalutamide ............................... 19BIOLLE GEL TEARS ............. 53biotin ........................................... 62biotin maximum strength ............ 62bisacodyl ..................................... 40bisacodyl ec .................................39bisoprolol fumarate .................... 22bisoprolol-hydrochlorothiazide .. 16bp folinatal plus b ....................... 47BRAFTOVI ............................... 19brewers yeast .............................. 47brimonidine tartrate ....................53bromocriptine mesylate ...............20budesonide .................................... 8buffered aspirin .............................4bumetanide ..................................33bupropion hcl er (smoking det) ...56butalbital-acetaminophen ............. 4butalbital-apap-caff-cod ............... 5butalbital-apap-caffeine ............... 4butalbital-asa-caff-codeine ...........5butalbital-aspirin-caffeine ............ 4cabergoline ................................. 34caffeine citrate .............................. 1CALCIFEROL ..........................63calcipotriene ............................... 29calcitonin (salmon) ..................... 34cal-citrate plus vitamin d ............ 44calcitriol ......................................34calcium ........................................45calcium + d3 ............................... 44calcium 500 + d .......................... 44calcium 500 + d3 ........................ 44calcium 500+d ............................ 44calcium 500+d3 .......................... 44calcium 600 .................................44calcium 600 + d .......................... 44

calcium 600+d ............................ 44calcium 600+d3 .......................... 44calcium acetate (phos binder) .....36calcium antacid ultra ....................6calcium carbonate .................44, 45calcium carbonate antacid ............6calcium carbonate-vitamin d ...... 45calcium citrate ............................ 45calcium citrate + d3 maximum ... 45calcium citrate-vitamin d ............45calcium/vitamin d3 gummies ...... 45capecitabine ................................19capsaicin ..................................... 29captopril-hydrochlorothiazide ....16carbidopa-levodopa ....................21carbidopa-levodopa er ................20carbinoxamine maleate ...............14CARDIOTEK RX .....................32CAREFINE PEN NEEDLES ...41careone insulin syringe ...............42CAROSPIR ............................... 33carteolol hcl ................................ 53CARTIA XT .............................. 23carvedilol .................................... 22CAYA .........................................42CAYSTON .................................47cefaclor ....................................... 24cefadroxil .............................. 24, 25cefdinir ........................................25cefixime ....................................... 25cefpodoxime proxetil ...................25cefprozil ...................................... 25ceftriaxone sodium ......................25cefuroxime axetil .........................25celecoxib ....................................... 1cephalexin ................................... 25CEREFOLIN .............................32cetirizine hcl ................................14cetirizine hcl allergy child .......... 14chelated magnesium ....................45CHEMET ...................................13cheratussin ac ............................. 27cheratussin dac ........................... 27cherry ..........................................56childrens chewable vitamins .......47childrens loratadine ....................14childrens multivitamin ................ 47childrens silfedrine ..................... 51childrens vitamins/iron ............... 47chlorhexidine gluconate ..............47chloroquine phosphate ................18chlorothiazide ............................. 33

chlorpheniramine maleate .......... 14chlorpheniramine maleate er ......14chlorpropamide ...........................11chlorthalidone .............................33chlorzoxazone ............................. 51cholestyramine ............................15cholestyramine light ....................15choline-mag trisalicylate .............. 4ciclopirox .................................... 29cilostazol ..................................... 37cimetidine ....................................59cimetidine 200 .............................59cimetidine hcl ..............................59CIMZIA ..................................... 36CIMZIA PREFILLED ............. 36CIMZIA STARTER KIT .........36CIPRO ....................................... 35CIPRODEX ............................... 55ciprofloxacin hcl ............. 35, 53, 55CLARAVIS ............................... 29clarithromycin .............................41clemastine fumarate ....................14clindamycin hcl ...........................17clindamycin palmitate hcl ...........17clindamycin phosphate ......... 29, 61clobetasol propionate ................. 29clonidine hcl ................................16clopidogrel bisulfate ................... 37clotrimazole .................... 29, 47, 61clotrimazole 3 ............................. 61clotrimazole-betamethasone ....... 29codeine sulfate .............................. 5colchicine ....................................37colchicine-probenecid .................37colestipol hcl ...............................15COMBIVENT RESPIMAT ....... 8COMFORT ASSIST INSULIN SYRINGE ................ 42COMPLETE FORMULATION PEDIATRIC ..............................47condoms ...................................... 42CORTIZONE-10/ALOE .......... 29CREON ......................................33cromolyn sodium ...............8, 51, 53CURITY ALCOHOL PREPS . 42cvs esomeprazole magnesium ..... 59cvs laxative dietary supplemnt ....40cvs lubricant drops ..................... 53cvs nasal allergy spray ............... 51cvs prenatal gummy .............. 48, 56cvs senna-extra ........................... 40

66

cvs stool softener .........................40cyanocobalamin ..........................38cyclobenzaprine hcl .................... 51cyclopentolate hcl ....................... 53cyclophosphamide .......................19cycloserine .................................. 18cyclosporine ................................22cyclosporine modified .................21cyproheptadine hcl ......................14CYTO B7 ................................... 63cytra-2 .........................................36cytra-k ......................................... 36D 1000 PLUS ALOE .................38d 2000 ......................................... 63d 400 ........................................... 63d3-1000 ....................................... 63daily multiple vitamins/min .........48daily vitamin formula+iron ........ 48daily vite ......................................48dalfampridine er ......................... 57danazol ..........................................5dantrolene sodium ...................... 51dapsone ....................................... 17DAURISMO .............................. 19DDAVP RHINAL TUBE ......... 34DENTAGEL ..............................47desmopressin ace spray refrig .... 34desmopressin acetate .................. 34desmopressin acetate spray ........ 34desonide ...................................... 29dexamethasone ............................27dexamethasone sodium phosphate ....................................53dextromethorphan-guaifenesin ... 27DIALYVITE ..............................48DIALYVITE 3000 .....................48DIALYVITE 5000 .....................48DIALYVITE 800 PLUS D ........48DIALYVITE 800/ZINC ............48DIALYVITE SUPREME D ..... 48DIALYVITE/ZINC ...................48diclofenac sodium ............. 2, 29, 53diclofenac sodium er .....................1dicloxacillin sodium ....................56dicyclomine hcl ........................... 59DIFFERIN ................................. 29digoxin ........................................ 24diltiazem hcl ................................23diltiazem hcl er ........................... 23diltiazem hcl er beads ................. 23dilt-xr .......................................... 23dimenhydrinate ........................... 13

DINO-LIFE W/IRON-ZINC ... 48diphenhydramine cough ..............14diphenhydramine hcl ...................14diphenoxylate-atropine ............... 13dipyridamole ............................... 37DISNEY CALCIUM + VITAMIN D3 ............................ 45disopyramide phosphate ............... 7DIURIL ......................................33docosanol ....................................29docusate calcium .........................40docusate sodium ..........................40DOCUSOL MINI ......................40donepezil hcl ............................... 57dorzolamide hcl .......................... 53dorzolamide hcl-timolol mal .......53doxazosin mesylate ..................... 16doxycycline hyclate ..................... 58doxycycline monohydrate ........... 58dronabinol ...................................13drospirenone-ethinyl estradiol ....25DROXIA .................................... 38DRYSOL ....................................29DULERA ..................................... 8e-400 ........................................... 63e-400/selenium ............................48EASIVENT ................................42EASIVENT MASK LARGE ....42EASIVENT MASK MEDIUM 42EASIVENT MASK SMALL ....42easy comfort insulin syringe ....... 42EASY TOUCH INSULIN SYRINGE .................................. 42ecee plus ......................................48ELIDEL ..................................... 29ELIQUIS ......................................9ELIQUIS DVT/PE STARTER PACK ....................... 9elite-thin insulin syringe ............. 42ELLA ......................................... 26ELMIRON .................................36EMCYT ..................................... 19EMGALITY ........................ 23, 25EMGALITY (300 MG DOSE)...............................................23, 25enalapril maleate ........................ 16enalapril-hydrochlorothiazide ....16ENBREL ......................................2ENBREL SURECLICK ............. 2ENDARI .......................................1enema ..........................................40ENEMEEZ PLUS ..................... 40

enoxaparin sodium ......................10entacapone ..................................21entecavir ......................................21ENTRESTO ...............................52EPANED ....................................16epinephrine ................................. 62EPOGEN ................................... 38eq acetaminophen junior .............. 4eq nasal allergy ...........................51eql one daily womens ..................48ERIVEDGE ............................... 19ERLEADA .................................19erythromycin ......................... 29, 53esomeprazole magnesium ........... 59estradiol ................................ 35, 61estradiol-norethindrone acet ...... 35estropipate .................................. 35ethambutol hcl ............................ 18etodolac .........................................2etoposide ..................................... 19EUCERIN ..................................29everolimus ...................................19EXEL COMFORT POINT INSULIN SYR ...........................42exemestane ..................................19extra strength acetaminophen .......4eye allergy relief ......................... 53ezetimibe ..................................... 15fabb ............................................. 38famciclovir .................................. 21famotidine ................................... 59FARESTON ...............................19FARYDAK ................................ 19FC2 FEMALE CONDOM ....... 42febuxostat ....................................37felodipine er ................................ 23fenofibrate ...................................15fenofibrate micronized ................ 15fenofibric acid .............................15fentanyl ......................................... 5ferronate ..................................... 38ferrous gluconate ........................ 38ferrous sulfate ............................. 38FIFTY50 PEN NEEDLES ........42finasteride ................................... 36FIRDAPSE ................................ 18FIRST-LANSOPRAZOLE ...... 59FIRST-OMEPRAZOLE .......... 59FIRST-PROGESTERONE VGS 100 ..................................... 61FIRST-PROGESTERONE VGS 200 ..................................... 61

67

FIRST-PROGESTERONE VGS 25 ....................................... 61FIRST-PROGESTERONE VGS 400 ..................................... 62FIRST-PROGESTERONE VGS 50 ....................................... 62FIRST-VANCOMYCIN 25 ......37FIRST-VANCOMYCIN 50 ......37FIRVANQ ..................................37fish oil ......................................... 52flavoxate hcl ................................61flecainide acetate .......................... 7FLOVENT HFA ..........................8fluconazole ..................................14fludrocortisone acetate ............... 27flunisolide ................................... 51fluocinolone acetonide ..........29, 30fluocinonide ................................ 30fluocinonide-e ............................. 30fluorometholone ..........................53fluorouracil ................................. 30flurbiprofen ................................... 2flurbiprofen sodium .................... 53flutamide ..................................... 19fluticasone propionate .......... 30, 52fluticasone-salmeterol ...................8folbee ...........................................38FOLBEE PLUS CZ .................. 48FOLBIC ..................................... 32FOLGARD ................................ 38folic acid ..................................... 38folinic-plus .................................. 38folplex 2.2 ................................... 38FOLTABS 800 ...........................38FORTEO ................................... 34fosinopril sodium ........................ 16FOSRENOL .............................. 36FREESTYLE CONTROL SOLUTION ............................... 42FREESTYLE LITE TEST .......32FREESTYLE TEST ................. 32FULPHILA ................................38furosemide ...................................33gas relief ..................................... 36GAVILYTE-G ...........................40GAVILYTE-N WITH FLAVOR PACK ....................... 40gemfibrozil .................................. 15GENTAK ................................... 53gentamicin sulfate .................30, 53geri-mucil ....................................40GIANVI ..................................... 26

GILENYA ..................................57glatiramer acetate .......................57GLATOPA .................................57GLEOSTINE .............................19glimepiride ..................................11glipizide .......................................11glipizide er .................................. 11glipizide-metformin hcl ...............11GLUCAGEN HYPOKIT ......... 11GLUCAGON EMERGENCY . 11GLUCOCARD EXPRESSION CONTROL ......42GLUCOCARD EXPRESSION MONITOR ......42GLUCOCARD EXPRESSION TEST ................32GLUCOCARD VITAL MONITOR ................................ 42GLUCOCARD VITAL TEST . 32GLUCONAVII BLOOD GLUCOSE TEST ......................32glyburide ..................................... 11glyburide micronized .................. 11glyburide-metformin ................... 11GLYCOPHOS ...........................45glycopyrrolate .............................59gnp 24 hour nasal allergy ...........52gnp b-complex plus vitamin c ..... 48gnp niacin ................................... 63gnp vitamin d .............................. 63GOODSENSE ESOMEPRAZOLE ...................60goodsense nasal allergy spray ....52granisetron hcl ............................13GRANIX .................................... 38griseofulvin microsize .................14griseofulvin ultramicrosize ......... 14guaifenesin ............................27, 28guaifenesin-dm ............................28guanfacine hcl .............................16halobetasol propionate ............... 30HAVRIX .................................... 61heartburn treatment 24 hour ...... 60h-e-b incontrol pen needles .........42HEMANGEOL ......................... 22heparin sodium (porcine) ............10heparin sodium (porcine) pf ....... 10HEXALEN .................................19hm esomeprazole magnesium dr .60hm iron ........................................38hm slow release iron ...................39

HM ULTICARE INSULIN SYRINGE .................................. 42hm vitamin b100 complex ........... 48HOMATROPAIRE .................. 53homocysteine formula .................39HUMALOG ...............................11HUMALOG MIX 50/50 ........... 11HUMALOG MIX 50/50 KWIKPEN .................................11HUMALOG MIX 75/25 ........... 11HUMALOG MIX 75/25 KWIKPEN .................................11HUMIRA ..................................... 2HUMIRA PEDIATRIC CROHNS START .......................2HUMIRA PEN ............................ 2HUMIRA PEN-CD/UC/HS STARTER ................................... 2HUMIRA PEN-PS/UV/ADOL HS START ...................................2HUMULIN 70/30 ...................... 11HUMULIN 70/30 KWIKPEN ..11HUMULIN N .............................11HUMULIN N KWIKPEN ........11HUMULIN R .............................12HUMULIN R U-500 (CONCENTRATED) ................12HYCAMTIN ..............................19hydralazine hcl ............................16hydrochlorothiazide ..............33, 34hydrocodone-acetaminophen ........5hydrocortisone .................. 6, 27, 30hydrocortisone valerate .............. 30hydrocortisone-acetic acid ......... 55hydromorphone hcl .......................5hydroxychloroquine sulfate .........18hydroxyurea ................................ 19hydroxyzine hcl ............................. 7hydroxyzine pamoate .................... 7hyoscyamine sulfate .................... 60hyoscyamine sulfate er ................60ibandronate sodium .................... 34ibuprofen .......................................3ibuprofen junior strength ..............3IDHIFA ......................................39imiquimod ................................... 30IN-CHECK INSPIRATORY FLOW MTR ..............................42INCRELEX ............................... 34INCRUSE ELLIPTA ..................8indapamide ................................. 34indomethacin .................................3

68

infants gas relief ......................... 36infants ibuprofen ...........................3infants pain relief ..........................4insulin lispro ............................... 12insulin syringe .............................42INTRON A ................................ 19INVOKAMET ...........................57INVOKAMET XR .................... 58INVOKANA .............................. 12ipratropium bromide ...............8, 52ipratropium-albuterol ................... 8irbesartan ....................................16irbesartan-hydrochlorothiazide ..16iron ..............................................39iron 100 plus ............................... 39isoniazid ......................................18isopropyl alcohol wipes .............. 30isosorbide dinitrate .......................6isosorbide dinitrate er ...................6isosorbide mononitrate ................. 6isosorbide mononitrate er .............6isotretinoin ..................................30isradipine .................................... 23itraconazole ................................ 14ivermectin ......................................6JAKAFI ..................................... 19JANUMET .................................12JANUMET XR ..........................12JANUVIA .................................. 12JARDIANCE .............................12JENTADUETO ......................... 12JUNEL 1/20 ............................... 26KARIVA .................................... 26ketoconazole ..........................14, 30ketone test ................................... 32ketorolac tromethamine .......... 3, 53KETOSTIX ............................... 32ketotifen fumarate ....................... 53KITABIS PAK ............................ 1kmart valu insulin syringe 30g ... 42K-PHOS ..................................... 45K-PHOS NO 2 ........................... 36KRINTAFEL .............................18labetalol hcl ................................ 22lactulose ......................................40lamivudine ...................................21lansoprazole ................................60latanoprost ..................................53lc-4 lidocaine .............................. 30leflunomide ................................... 3LETAIRIS ................................. 24letrozole ...................................... 19

leucovorin calcium ......................20LEUKERAN ..............................20leuprolide acetate ....................... 20levalbuterol tartrate ......................9levobunolol hcl ............................53levofloxacin ...........................35, 53levonorgestrel ............................. 26LEVORA 0.15/30 (28) .............. 26levothyroxine sodium .................. 58LEVOXYL .................................58lice killing maximum strength .....30lice treatment .............................. 30LICIDE TREATMENT ........... 30lidocaine ..................................... 30lidocaine hcl ................................30lidocaine viscous .........................47lidocaine-prilocaine ....................30LIDOCREAM ........................... 30lindane ........................................ 30linezolid .......................................17liothyronine sodium .................... 58LIPOFEN ...................................15LIQUI-E .....................................63lisinopril ......................................16lisinopril-hydrochlorothiazide ....16LITE TOUCH PEN NEEDLES ..................................42LITETOUCH PEN NEEDLES ..................................42l-methylfolate-b6-b12 ..................32LMX 4 ........................................ 31LOMEDIA 24 FE ......................26long acting nasal spray ...............52LONSURF ................................. 20loperamide hcl ............................ 13loratadine ....................................14loratadine-d 12hr ........................28loratadine-d 24hr ........................28losartan potassium ......................16losartan potassium-hctz .............. 16lovastatin .....................................15LOW-OGESTREL ................... 26lubricant drops ............................53lubricant drops/dual-action ........ 53lubricant eye ............................... 53lubricant eye drops ..................... 53LUCEMYRA ...............................1LYSODREN .............................. 20mag glycinate ..............................45MAG64 .......................................45MAGINEX .................................45magnesium .................................. 45

magnesium chloride ....................45magnesium citrate .................40, 45magnesium gluconate ................. 45magnesium oxide .....................6, 45magnesium oxide -mg supplement .................................. 45magnesium sulfate ...................... 45magnesium sulfate in d5w ...........45MAGONATE ............................ 46MAG-TAB SR ...........................46malathion .................................... 31MAOX ..........................................6MASK VORTEX ...................... 42MATULANE ............................. 20MATZIM LA ............................ 23meclizine hcl ............................... 13medroxyprogesterone acetate...............................................26, 56mefloquine hcl .............................18mega biotin ................................. 63megestrol acetate ........................ 20meloxicam ..................................... 3memantine hcl .............................57MENEST ................................... 35meperidine hcl ...............................5MEPHYTON .............................63mercaptopurine ...........................20mesalamine ................................. 36MESNEX ................................... 20MESTINON ...............................18METAMUCIL MULTIHEALTH FIBER ........ 40metaproterenol sulfate .................. 9metformin hcl .............................. 12metformin hcl er ..........................12methadone hcl ...............................5METHADONE HCL INTENSOL ..................................5methenamine hippurate ...............60methenamine mandelate ............. 60methimazole ................................ 58methocarbamol ........................... 51methotrexate ................................20methotrexate sodium ...................20methotrexate sodium (pf) ............ 20methyclothiazide ......................... 34methyldopa ..................................16methyldopa-hydrochlorothiazide ....................16methylergonovine maleate .......... 55methylfol-algae-b12-acetylcyst ...32methylprednisolone .....................27

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metipranolol ................................54metoclopramide hcl .....................36metolazone .................................. 34metoprolol succinate er .............. 22metoprolol tartrate ......................22metoprolol-hydrochlorothiazide . 17metronidazole ................. 17, 31, 62mexiletine hcl ................................ 7miconazole 3 ............................... 62miconazole 3 combo pack ........... 62miconazole 7 ............................... 62miconazole nitrate ...................... 31MICROGESTIN 1.5/30 ............26MICROGESTIN FE 1.5/30 ......26MICROGESTIN FE 1/20 .........26midazolam hcl .............................39midodrine hcl .............................. 62milk of magnesia ......................... 40mineral oil ...................................40minocycline hcl ........................... 58minoxidil ..................................... 17misoprostol ................................. 60mometasone furoate ....................31MONOJECT INSULIN SYRINGE .................................. 43montelukast sodium ...................... 9morphine sulfate ........................... 5morphine sulfate (concentrate) .....5morphine sulfate er ....................... 5MOTEGRITY ............................. 1multi adult gummies ....................48multi-delyn/iron .......................... 48multi-vit/fluoride ......................... 48multi-vitamin hp/minerals ...........48multivitamin/fluoride .................. 48multi-vitamin/fluoride ................. 48multi-vitamin/fluoride/iron ......... 48multivitamins pediatric ............... 48multivitamins/fluoride .................48mupirocin ....................................31mycophenolate mofetil ................ 22mycophenolic acid ...................... 22MYKIDZ IRON ........................ 48MYLERAN ................................20mynatal plus ................................49mynate 90 plus ............................ 49MYORISAN .............................. 31nabumetone ...................................3nadolol ........................................ 22naloxone hcl ................................13naphazoline hcl ...........................54naproxen ....................................... 3

naproxen dr ...................................3naproxen sodium ...........................3naratriptan hcl ............................ 44NARCAN ................................... 13NASACORT ALLERGY 24HR .......................................... 52NASACORT ALLERGY 24HR CHILDREN ....................52nasal allergy 24 hour ..................52nasal decongestant ......................52nateglinide .................................. 12natural fiber laxative .................. 40natural fiber therapy ...................40natural vitamin d-3 ..................... 63NATURE-THROID ..................58NECON 0.5/35 (28) ................... 26NECON 1/35 (28) ...................... 26NECON 10/11 (28) .................... 26neomycin sulfate ........................... 1neomycin-bacitracin zn-polymyx ....................................... 54neomycin-polymyxin-dexameth ...54neomycin-polymyxin-gramicidin 54neomycin-polymyxin-hc .............. 55NEPHROCAPS QT .................. 49NEPHRONEX ...........................49NEUPOGEN ..............................39NEWGEN .................................. 49niacin .......................................... 63niacin er ...................................... 63niacin flush free .................... 24, 49NIACIN FLUSH-FREE EX ST ............................................... 24niacinamide .................................63nicardipine hcl ............................ 24nicotine ....................................... 57nicotine polacrilex ...................... 57nicotine step 1 ............................. 57NIFEDICAL XL ....................... 24nifedipine .................................... 24nifedipine er ................................ 24nifedipine er osmotic release ...... 24nilutamide ................................... 20nimodipine .................................. 24NITRO-BID .................................7nitrofurantoin ..............................60nitrofurantoin macrocrystal ........60nitrofurantoin monohyd macro ...60nitroglycerin ................................. 7nitroglycerin er ............................. 7NIVESTYM ...............................39non-aspirin extra strength ............ 4

NORA-BE ..................................26NORDITROPIN FLEXPRO ... 34norethin ace-eth estrad-fe ...........26norethindrone acetate .................56norethindrone-eth estradiol ........ 35norethin-eth estradiol-fe ............. 26NORTREL 7/7/7 ....................... 26NOVOLIN 70/30 ....................... 12NOVOLIN N ............................. 12NOVOLIN R ............................. 12NOVOLOG MIX 70/30 ............ 12NOVOLOG MIX 70/30 FLEXPEN ..................................12np thyroid ....................................59NUBEQA ................................... 20NUVARING .............................. 26nystatin ............................14, 31, 47OBSTETRIX DHA ................... 49OBSTETRIX EC ...................... 49octreotide acetate ........................34ODOMZO ..................................20ofloxacin ......................... 35, 54, 55OGESTREL .............................. 26OLUMIANT ................................3omega-3-acid ethyl esters ........... 15omeprazole ..................................60omeprazole magnesium ...............60ondansetron ................................ 14ondansetron hcl .......................... 14ONETOUCH DELICA LANCETS 30G ......................... 43ONETOUCH DELICA LANCETS 33G ......................... 43ONETOUCH ULTRA BLUE .. 32ONETOUCH ULTRA CONTROL ................................ 43ONETOUCH VERIO .........32, 43one-way valved inspiratory .........43OPTIONS GYNOL II CONTRACEPTIVE ................. 62ORA-BLEND ............................ 56ORALYTE .................................46ORA-SWEET ............................56ORENCIA ................................... 3ORENCIA CLICKJECT ........... 3ORILISSA ................................. 34orphenadrine citrate er ...............51oseltamivir phosphate .................21OTEZLA ....................................56oxybutynin chloride .....................61oxybutynin chloride er ................ 61oxycodone hcl ............................... 5

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oxycodone-acetaminophen ............5OXYTROL FOR WOMEN ..... 61oyster shell calcium .................... 46oyster shell calcium 250+d .........46oyster shell calcium plus d ..........46oyster shell calcium/d ................. 46oyster shell calcium/d3 ............... 46oyster shell/d ...............................46OZEMPIC (0.25 OR 0.5 MG/DOSE) ................................ 12OZEMPIC (1 MG/DOSE) ........12pain relief childrens ......................4PANCREAZE ........................... 33pantoprazole sodium ...................60paromomycin sulfate .....................1peak flow meter ...........................43pediatric medium mask ............... 43pediatric small mask ................... 43peg 3350/electrolytes .................. 40pen needles ..................................43penicillin v potassium ................. 56PENTASA ..................................36pentazocine-naloxone hcl ............. 5pentoxifylline er .......................... 37perindopril erbumine .................. 17permethrin ...................................31permethrin lice treatment ............31PERTZYE ................................. 33PHENAZO .................................37phenazopyridine hcl ....................37phenylephrine hcl ........................54PHOSLYRA .............................. 36phos-nak ......................................46PHOSPHA 250 NEUTRAL ..... 46PHOSPHOLINE IODIDE ....... 54pilocarpine hcl ...................... 47, 54pink bismuth ................................13pink bismuth maximum strength . 13PIN-X ........................................... 6pioglitazone hcl ...........................12piroxicam ...................................... 3PODIAPN .................................. 32podofilox ..................................... 31polyethylene glycol 3350 ............ 40polymyxin b-trimethoprim ...........54polyvitamin ................................. 49poly-vitamin/iron ........................ 49POMALYST ..............................20pot bicarb-pot chloride ............... 46potassium bicarbonate ................46potassium chloride crys er ..........46potassium chloride er ................. 46

potassium citrate er .................... 37potassium phosphates ................. 46povidone-iodine .......................... 21pramipexole dihydrochloride ......21pravastatin sodium ......................15prazosin hcl .................................17PRECISION XTRA KETONE ................................... 32prednisolone ............................... 27prednisolone acetate ...................54prednisolone sodium phosphate...............................................27, 54prednisone ...................................27prednisone (pak) ......................... 27PREMARIN .............................. 35premium condoms lubricated ......43PREMPHASE ........................... 35PREMPRO ................................ 35prenatal .......................................49prenatal 19 ..................................49prenatal complete ....................... 49prenatal dha ................................52prenatal low iron ........................ 49prenatal multi +dha ....................49prenatal plus iron ....................... 49PRENATAL-U .......................... 50pretab ..........................................50PREVALITE ............................. 15PRIFTIN ....................................18primaquine phosphate ................ 18probenecid .................................. 37prochlorperazine .........................21prochlorperazine maleate ...........21PROCRIT ..................................39PROCTOZONE-HC ...................6progesterone micronized .............56promethazine hcl .........................15promethazine-dm ........................ 28propafenone hcl ............................ 7proparacaine hcl .........................54propranolol hcl ........................... 23propranolol hcl er .................22, 23propylthiouracil .......................... 59PROSTAMEN ...........................32pseudoeph-bromphen-dm ............28pseudoephedrine hcl er ...............52PULMICORT FLEXHALER ....9PULMOZYME ......................... 57px artificial tears .........................54pyrazinamide ...............................18pyridostigmine bromide .............. 18pyridoxine hcl ............................. 63

QBRELIS ...................................17qc childrens vitamins/extra c ...... 50qc insulin syringe ........................43qc natural vegetable ....................40q-pap infants ................................. 4QUASENSE ...............................26quinapril hcl ................................17quinapril-hydrochlorothiazide ....17quinidine sulfate ............................7quinidine sulfate er ....................... 7QVAR REDIHALER ................. 9ra artificial tears .........................54ra b-complex/vitamin c cr ...........50ra magnesium ..............................46ra miconazole 3 combo pack app .............................................. 62ra nasal allergy ...........................52ra niacin ......................................63ra oyster shell calcium/d .............46rabano yodado ............................ 50raloxifene hcl .............................. 34ramipril ....................................... 17RANEXA ..................................... 7RECLIPSEN ............................. 26REFRESH LIQUIGEL ............ 54REFRESH OPTIVE SENSITIVE ............................... 54RELENZA DISKHALER ........ 21RELI-ON INSULIN SYRINGE .................................. 43RENAGEL .................................36RENAL ...................................... 50renal vitamin ...............................50rena-vite rx ..................................50repaglinide ..................................12RETACRIT ............................... 39REVLIMID ............................... 22RHOGAM ULTRA-FILTERED PLUS .....................55RID ESSENTIAL LICE ELIMINATION ........................ 31rifabutin ...................................... 18rifampin .......................................18rimantadine hcl ...........................21ri-mox ............................................6rivastigmine tartrate ................... 57rizatriptan benzoate .................... 44ropinirole hcl .............................. 21rosuvastatin calcium ...................15saline mist spray ......................... 52SANTYL .................................... 31SCOOBY-DOO ONE A DAY ..50

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SEGLUROMET ........................58selegiline hcl ............................... 21selenium sulfide .......................... 31senna ........................................... 40senna laxative ............................. 40SENNA SMOOTH ....................40senna-docusate sodium ...............40sen-o-tabs ....................................40SENSIPAR .................................35SEREVENT DISKUS .................9sevelamer carbonate ................... 36sevelamer hcl .............................. 36sf 5000 plus ................................. 47SHINGRIX ................................ 61sildenafil citrate .......................... 24SILIQ ......................................... 31silver sulfadiazine ....................... 31simethicone ................................. 36simple syrup ................................ 56simvastatin .................................. 15sirolimus ..................................... 22SLO-NIACIN ............................ 63slow iron ..................................... 39slow magnesium/calcium ............ 46slow release iron .........................39SLOW-MAG ............................. 46sm dry eye relief ..........................54sm esomeprazole magnesium ......60sm ibuprofen jr ..............................3sm niacin cr .................................63sm slow release iron ................... 39sodium bicarbonate ...................... 6sodium chloride .................... 28, 37sodium chloride (hypertonic) ......54sodium fluoride ........................... 46sodium phosphate ....................... 47sodium polystyrene sulfonate 22, 56SOOTHE ................................... 13sotalol hcl ....................................23sotalol hcl (af) .............................23spinosad ...................................... 31SPIRIVA RESPIMAT ................9spironolactone ............................ 34spironolactone-hctz .....................34SPRINTEC 28 ........................... 26SPS ....................................... 22, 56STEGLATRO ........................... 12STEGLUJAN ............................ 57sterile water for irrigation .......... 22STIMATE ..................................35STRIVERDI RESPIMAT .......... 9sucralfate .................................... 60

sulfacetamide sodium ..................54sulfacetamide sodium (acne) ...... 31sulfacetamide sodium-sulfur .......31sulfacetamide-prednisolone ........54sulfamethoxazole-trimethoprim .. 17sulfasalazine ............................... 36sulindac .........................................3sumatriptan ................................. 44sumatriptan succinate .................44sumatriptan succinate refill ........ 44SUPERVITE ............................. 50SUPRAX .................................... 25SURE-LANCE THIN LANCETS 28G ......................... 43SYMBICORT ..............................9SYMJEPI ...................................62SYNAGIS ...................................55SYNJARDY ...............................58SYNJARDY XR ........................ 58SYNTHROID ............................ 59SYSTANE ..................................54TABLOID ..................................20tacrolimus ............................. 22, 31tamoxifen citrate ......................... 20tamsulosin hcl ............................. 37TANZEUM ................................13TARON-BC ............................... 50TARON-CRYSTALS ............... 37TAZTIA XT .............................. 24TECFIDERA .............................57TECHLITE PEN NEEDLES ...43TEKTURNA HCT .................... 17temozolomide .............................. 20terazosin hcl ................................17terbinafine hcl .......................14, 31terbutaline sulfate ......................... 9terconazole ..................................62TERUMO INSULIN SYRINGE .................................. 43TERUMO SURGUARD INSULIN SYR ...........................43testosterone cypionate ...................6THALOMID ..............................22THEOCHRON ............................9theophylline ...................................9theophylline er .............................. 9THINPRO INSULIN SYRINGE .................................. 43thyroid .........................................59TIBSOVO .................................. 39timolol maleate ........................... 54tinidazole .....................................17

tizanidine hcl ...............................51TOBI PODHALER .....................1tobramycin .............................. 1, 54tobramycin-dexamethasone ........ 55TODAY SPONGE .................... 62tolazamide ...................................13tolbutamide ................................. 13tolnaftate ..................................... 31tolterodine tartrate ......................61tolterodine tartrate er ................. 61torsemide .....................................34TRACLEER .............................. 24TRADJENTA ............................13tramadol hcl ..................................5trandolapril .................................17TRECATOR ..............................18tretinoin .................................20, 31triamcinolone acetonide.............................31, 32, 47, 52, 58triamterene-hctz ..........................34trifluridine ...................................55TRI-LEGEST FE ......................26trimethoprim ............................... 17trinatal rx 1 ................................. 50TRINATE .................................. 50TRINESSA LO ..........................27triple antibiotic ........................... 32TRI-SPRINTEC ........................27tri-tabs dha ..................................50TRI-VI-FLOR ........................... 50tri-vi-floro ................................... 50TRI-VI-SOL .............................. 50tri-vit/fluoride ............................. 50tri-vit/fluoride/iron ......................50tri-vitamin ................................... 50TRIVORA (28) ..........................27trixaicin .......................................32tropicamide ................................. 55trospium chloride ........................61trospium chloride er ................... 61TRULICITY ..............................13TRUSTEX NON-LUBRICATED ..........................43tussin dm max adult .................... 28TYMLOS ................................... 35ULTICARE INSULIN SYRINGE .................................. 43ULTICARE MICRO PEN NEEDLES ..................................43ULTILET INSULIN SYRINGE .................................. 43UNITHROID .............................59

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UNITHROID DIRECT ............ 59urea ............................................. 32URO-MAG .................................. 6ursodiol ....................................... 36valacyclovir hcl ...........................21valganciclovir hcl ....................... 21valsartan ..................................... 17valsartan-hydrochlorothiazide ... 17vancomycin hcl ..................... 17, 37VAQTA ......................................61VCF VAGINAL CONTRACEPTIVE ................. 62VELIVET .................................. 27VEMLIDY ................................. 21VENCLEXTA ........................... 18VENCLEXTA STARTING PACK ......................................... 18verapamil hcl .............................. 24verapamil hcl er ..........................24VICTOZA ..................................13VINATE II .................................50VINATE M ................................ 51VIOKACE ................................. 33virt-vite gt ....................................51vita-bee/c .....................................51VITAL-D RX .............................51vita-min ....................................... 51vitamin b complex-c .................... 51vitamin b1 ................................... 63vitamin b-1 .................................. 63vitamin b-12 ................................ 39vitamin b-2 .................................. 63vitamin b-6 .................................. 63vitamin b-complex .......................51vitamin b-complex 100 ................51vitamin d ..................................... 63vitamin d (ergocalciferol) ........... 63vitamin d3 ................................... 63vitamin e ..........................32, 63, 64vitamin e skin .............................. 32VITA-RESPA ............................33vol-care rx ...................................51VORTEX HOLDING CHAMBER/MASK .................. 43vp-heme ob ..................................51vp-vite rx ..................................... 51VYNDAMAX ............................ 59VYNDAQEL ............................. 59warfarin sodium ..........................10WESTHROID ........................... 59wheat germ oil ............................ 64

WIDE-SEAL DIAPHRAGM 60 ................................................ 43WIDE-SEAL DIAPHRAGM 65 ................................................ 43WIDE-SEAL DIAPHRAGM 70 ................................................ 43WIDE-SEAL DIAPHRAGM 75 ................................................ 43WIDE-SEAL DIAPHRAGM 80 ................................................ 44WIDE-SEAL DIAPHRAGM 85 ................................................ 44WIDE-SEAL DIAPHRAGM 90 ................................................ 44WIDE-SEAL DIAPHRAGM 95 ................................................ 44WIXELA INHUB ........................9WP THYROID ..........................59XARELTO .................................10XARELTO STARTER PACK 10XATMEP ................................... 20XELJANZ ....................................3XELJANZ XR .............................3XPOVIO (100 MG ONCE WEEKLY) ................................. 18XPOVIO (60 MG ONCE WEEKLY) ................................. 18XPOVIO (80 MG ONCE WEEKLY) ................................. 18XPOVIO (80 MG TWICE WEEKLY) ................................. 19XTANDI .....................................20XULANE ................................... 27XYREM ..................................... 57YUVAFEM ................................62ZADITOR ..................................55ZARXIO .................................... 39ZENATANE .............................. 32ZENPEP .....................................33ZOLINZA ..................................20zolmitriptan .................................44ZOSTAVAX .............................. 61ZOVIA 1/35E (28) .....................27ZOVIA 1/50E (28) .....................27ZYTIGA .....................................20

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