qualified health plan formulary · provided by elixir . introduction . the total health care (thc)...

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QUALIFIED HEALTH PLAN FORMULARY Effective January 2021

Provided by Elixir

Introduction

The Total Health Care (THC) Qualified Health Plan 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. 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 & Elixir, 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 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. Any drug not found in this Formulary listing shall be considered a non-formulary drug.

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Tier Guidelines

The Certificate of Coverage provided upon enrollment has specific information regarding co-payments, co-insurance, annual deductible requirements and maximum out of pocket limits associated with the corresponding pharmacy benefit.

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, Elixir 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.

Generic Tier 1

Preferred Brand Tier 2

Non-Preferred Brand Non- Preferred Generic

Tier 3

Specialty Tier 4

Preventive Tier 5 $0 co-pay at in-network pharmacies

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Saving on Out-Of-Pocket Costs Total Health Care has designed its prescription drug plan to encourage the use of generic and preferred brand name drugs. Choosing non-preferred drugs may mean paying higher out-of-pocket expenses (such as coinsurance and co-payments) or not receiving coverage at all. Members may also pay less for generic drugs or they may be asked to pay the cost difference between brand name drugs and their generic alternatives, which are preferred by the plan.

Benefit Coverage and Limitations

This formulary does not define benefit coverage and limitations. Many members have specific benefit inclusions, exclusions, copayments, coinsurance or a lack of coverage, which are not reflected in the THC Qualified Health Plan Formulary. 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. Preventive Medications

Total Health Care covers certain preventive services for $0 co-pay when delivered by in-network pharmacies. These drugs are indicated on the THC Qualified Health Plan Formulary under Drug Tier 5. Examples of preventive medications include aspirin, contraceptives, iron supplementations, smoking cessation products and Vitamin D drugs. These drugs are available with standard drug coverage recommendations and are only available for certain populations. 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 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 located on the Total Health Care Qualified Health Plan 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.

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• 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 coverages may include, but are not limited to:

• OTC medications or their equivalents unless otherwise specified in the Formulary listing. • Drug products used for cosmetic purposes. • Drug products for sexual dysfunction. • Experimental drug products, or any drug product used in an experimental manner. • Foreign drugs or drugs not approved by the United States Food & Drug Administration (FDA).

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 in lowercase lettering wherever an FDA-approved generic drug product is available. If a member or physician requests a brand name product in lieu of an approved generic, the member, based upon their coverage, will be required to pay the difference in cost between the brand/non-preferred brand and the generic drug, plus the brand/non-preferred brand copay.

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,

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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 Elixir Specialty Pharmacy to provide Specialty Bio-Pharmaceutical Pharmacy products to our members. These medications are to be filled exclusively through Elixir Specialty Pharmacy. A Specialty Drug Prior Authorization Request form must be completed and faxed to Elixir 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, Elixir obtains authorization from Total Health Care. If the specialty prior authorization is approved, Total Health Care notifies Elixir Specialty Pharmacy. Then, Elixir 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 Elixir at 1-844-222-5584 or Elixir Specialty Pharmacy at 1-877-437-9012.

Contact Information

The Total Health Care Qualified Health Plan 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. 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

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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 Step Therapy Criteria

Aminosalicylic Acid Derivative Agents

APRISO, DELZICOL

PENTASA, mesalamine DR

Prior use of APRISO or mesalamine DR in the last 90 days.

Angiotensin Receptor Blocker and Calcium Channel Blocker

amlodipine-valsartan

amlodipine-olmesartan

Prior use of amlodipine-valsartan in the last 90 days.

Antidiabetic Agents – DPP4

alogliptin, alogliptin-metformin alogliptin- pioglitazone

JANUVIA, JANUMET, JANUMET XR, ONGLYZA, TRADJENTA

Prior use of alogliptin, alogliptin-metformin, or alogliptin-pioglitazone in the last 90 days.

Antidiabetic Agents – SGLT-2

INVOKANA, INVOKAMET, INVOKAMET XR, JARDIANCE, SYNJARDY, SYNJARDY XR

FARXIGA, XIGDUO XR

Prior use of TWO of the following: INVOKANA, INVOKAMET, JARDIANCE, SYNJARDY in the last 180 days.

Antiemetic Agents ondansetron, granisetron

ANZEMET, aprepitant

Prior use of ondansetron AND granisetron in the last 90 days.

Antiglaucoma Agents latanoprost, bimatoprost, travoprost

LUMIGAN, TRAVATAN-Z, ZIOPTAN

Prior use of TWO of the following: latanoprost, bimatoprost or travoprost in the last 90 days.

Antimigraine sumatriptan, rizatriptan, naratriptan, zolmitriptan

almotriptan, eletriptan, frovatriptan

Prior use of TWO of the following: sumatriptan, rizatriptan, zolmitriptan, naratriptan in the last 90 days.

Anti-Parkinson's Agents – MAO-B inhibitors

selegiline tablet EMSAM Prior use of selegiline tablet in the last 90 days.

Anti-Parkinson's Agents

ropinirole immediate-release, pramipexole immediate-release

ropinirole extended-release, pramipexole extended-release

Prior use of ropinirole immediate-release AND pramipexole immediate-release in the last 90 days.

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Anti-platelet Agents clopidogrel prasugrel Prior use of clopidogrel in the last 90 days.

Antipsychotics quetiapine IR, olanzapine, risperidone, ziprasidone

quetiapine ER

Prior use for 30 days of quetiapine IR, olanzapine, risperidone, or ziprasidone

Beta2 Agonist (nebulizer)

albuterol nebulizer solution

levalbuterol nebulizer solution

Prior use of albuterol nebulizer solution in the last 90 days.

Coreg CR carvedilol IR carvedilol ER Prior use of carvedilol IR in the last 90 days.

HMG-CoA Reductase Inhibitor

atorvastatin, simvastatin, rosuvastatin

LIVALO, ezetimibe-simvastatin

Prior use of TWO of the following: atorvastatin, rosuvastatin, simvastatin in the last 90 days.

Hypnotic Agents temazepam, zaleplon, zolpidem IR, zolpidem ER, eszopiclone

ramelteon, BELSOMRA

Prior use of TWO of the following: temazepam, zaleplon, zolpidem, zolpidem ER, eszopiclone in the last 90 days.

Nasal Corticosteroids flunisolide fluticasone, NASACORT OTC, budesonide OTC

azelastine, BECONASE AQ, mometasone, QNASL

Prior use of TWO of the following: flunisolide, fluticasone, NASACORT OTC or budesonide OTC nasal in the last 180 days.

Pediculicides malathion 0.5% NATROBA Prior use of malathion 0.5% within the last 90 days.

Pleuromutilin Antibiotic

mupirocin ALTABAX Prior use of mupirocin in the last 90 days.

Propranolol ER propranolol IR propranolol ER Prior use of propranolol IR in the last 90 days.

Retinoic Acid Derivatives

tretinoin 0.025%, tretinoin 0.05%, tretinoin 0.1%, tretinoin 0.01%, DIFFERIN OTC 0.1% GEL

tretinoin 0.04% gel adapalene-benz peroxide gel, clindamycin-tretinoin

Prior use of tretinoin 0.025%, tretinoin 0.05%, tretinoin 0.01%, tretinoin 0.1%, or DIFFERIN OTC 0.1% GEL in the last 90 days.

Topical Scalp Corticosteroids

ketoconazole 2% shampoo

CAPEX SHAMPOO

Prior use of ketoconazole 2% shampoo in the last 90 days.

Topical Corticosteroids

clobetasol, desonide, betamethasone,

calcipotriene -betamethasone

Prior use of TWO of the following: clobetasol, desonide, betamethasone, flucinolone,

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flucinolone, flucinonide, hydrocortisone, triamcinolone

flucinonide, hydrocortisone, or triamcinolone in the last 90 days.

Urinary Antispasmodics

oxybutynin, oxybutynin ER, OXYTROL OTC, oxybutynin syrup

tolterodine, tolterodine ER, trospium, trospium ER, darifenacin, solifenacin, TOVIAZ

Prior use of OXYTROL OTC, oxybutynin, oxybutynin ER, or oxybutynin syrup in the last 90 days.

Vascepa omega-3-acid icosapent ethyl Prior use of omega-3 acid capsule in the last 90 days.

Vyvanse amphetamine ER VYVANSE Prior use of amphetamine ER capsule in the last 90 days.

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

CURRENT AS OF 1/1/2021

lowercase italics = Generic drugsUPPERCASE BOLD = Brand name drugs

StatusT1 = Covered

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

Drug Status Notes

*Adhd/Anti-Narcolepsy/Anti-Obesity/Anorexiants*amphetamine-dextroamphet er oral capsule extended release 24 hour 10 mg, 15 mg, 5 mg

T2QL (30 EA per 30 days); AL (Min 6 Years)

amphetamine-dextroamphet er oral capsule extended release 24 hour 20 mg, 25 mg, 30 mg


amphetamine-dextroamphetamine oral tablet 10 mg, 12.5 mg, 15 mg


amphetamine-dextroamphetamine oral tablet 20 mg, 5 mg, 7.5 mg


amphetamine-dextroamphetamine oral tablet 30 mg


armodafinil oral tablet 150 mg, 250 mg T1 QL (30 EA per 30 days)

armodafinil tablet 200 mg oral 200 mg T3 PA

armodafinil tablet 50 mg oral 50 mg T3 PA

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


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


caffeine citrate solution 20 mg/ml oral 20 mg/ml T1

caffeine citrate solution 60 mg/3ml intravenous60 mg/3ml

T1

caffeine-sodium benzoate solution 125-125 mg/ml injection 125-125 mg/ml

T1

DAYTRANA PATCH 10 MG/9HR TRANSDERMAL 10 MG/9HR T3

PA; QL (30 EA per 30 days); AL (Min 6 Years and Max 17 Years)







dexmethylphenidate hcl er oral capsule extended release 24 hour 10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 35 mg, 40 mg, 5 mg


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Drug Status Notes

dexmethylphenidate hcl oral tablet 10 mg, 5 mg T1QL (150 EA per 30 days); AL (Min 6 Years)

dexmethylphenidate hcl oral tablet 2.5 mg T1QL (90 EA per 30 days); AL (Min 6 Years)

dextroamphetamine sulfate er oral capsule extended release 24 hour 10 mg, 15 mg, 5 mg

T1

dextroamphetamine sulfate oral tablet 10 mg T1 QL (180 EA per 30 days)

dextroamphetamine sulfate oral tablet 5 mg T1 QL (360 EA per 30 days)

diethylpropion hcl er tablet extended release 24 hour 75 mg oral 75 mg

T1

diethylpropion hcl tablet 25 mg oral 25 mg T1

DOPRAM INTRAVENOUS SOLUTION 20 MG/ML T1

guanfacine hcl er oral tablet extended release 24 hour 1 mg, 2 mg, 3 mg, 4 mg

T1 QL (60 EA per 30 days)

methamphetamine hcl tablet 5 mg oral 5 mg T1AL (Min 6 Years and Max 17 Years)

methylphenidate hcl er (cd) oral capsule extended release 10 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg


methylphenidate hcl er (la) oral capsule extended release 24 hour 10 mg, 20 mg, 30 mg, 40 mg, 60 mg

T1QL (30 EA per 30 days); AL (Min 4 Years and Max 10 Years)

methylphenidate hcl er oral tablet extended release 10 mg


methylphenidate hcl er oral tablet extended release 20 mg


methylphenidate hcl er oral tablet extended release 24 hour 18 mg, 27 mg


methylphenidate hcl er oral tablet extended release 24 hour 36 mg, 54 mg


methylphenidate hcl oral solution 5 mg/5ml T1QL (600 ML per 30 days); AL (Min 4 Years and Max 10 Years)

methylphenidate hcl oral tablet 10 mg T1QL (300 EA per 30 days); AL (Min 4 Years)



methylphenidate hcl solution 10 mg/5ml oral 10 mg/5ml

T1PA; AL (Min 6 Years and Max 17 Years)

modafinil tablet 100 mg oral 100 mg T1 PA

modafinil tablet 200 mg oral 200 mg T1 PA

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Drug Status Notesphendimetrazine tartrate er capsule extended release 24 hour 105 mg oral 105 mg

T1

phendimetrazine tartrate tablet 35 mg oral 35 mg T1

phentermine hcl capsule 15 mg oral 15 mg T1

phentermine hcl capsule 30 mg oral 30 mg T1

phentermine hcl capsule 37.5 mg oral 37.5 mg T1

phentermine hcl tablet 37.5 mg oral 37.5 mg T1

VYVANSE CAPSULE 10 MG ORAL 10 MG T3ST; QL (30 EA per 30 days); AL (Min 6 Years and Max 17 Years)







*Aminoglycosides*neomycin sulfate tablet 500 mg oral 500 mg T1

paromomycin sulfate capsule 250 mg oral 250 mg T4 PA

tobramycin nebulization solution 300 mg/5ml inhalation 300 mg/5ml

T4 PA

*Analgesics - Anti-Inflammatory*ARCALYST SOLUTION RECONSTITUTED 220 MG SUBCUTANEOUS 220 MG T4 PA

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


diclofenac potassium tablet 50 mg oral 50 mg T1

diclofenac sodium er tablet extended release 24 hour 100 mg oral 100 mg

T1

diclofenac sodium tablet delayed release 25 mg oral 25 mg

T1


T1


T1

diclofenac-misoprostol tablet delayed release 50-0.2 mg oral 50-0.2 mg

T3

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Drug Status Notesdiclofenac-misoprostol tablet delayed release 75-0.2 mg oral 75-0.2 mg

T3

ENBREL SOLUTION PREFILLED SYRINGE 50 MG/ML SUBCUTANEOUS 50 MG/ML

T4 PA

ENBREL SOLUTION RECONSTITUTED 25 MG SUBCUTANEOUS 25 MG T4 PA

ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 25 MG/0.5ML T4 PA

ENBREL SURECLICK SOLUTION AUTO-INJECTOR 50 MG/ML SUBCUTANEOUS 50 MG/ML

T4 PA

etodolac capsule 200 mg oral 200 mg T1

etodolac capsule 300 mg oral 300 mg T1

etodolac er tablet extended release 24 hour 400 mg oral 400 mg

T1


T1


T1

etodolac tablet 400 mg oral 400 mg T1

etodolac tablet 500 mg oral 500 mg T1

flurbiprofen tablet 100 mg oral 100 mg T1

flurbiprofen tablet 50 mg oral 50 mg T1

HUMIRA PEN PEN-INJECTOR KIT 40 MG/0.8ML SUBCUTANEOUS 40 MG/0.8ML T4 PA

HUMIRA PREFILLED SYRINGE KIT 20 MG/0.4ML SUBCUTANEOUS 20 MG/0.4ML T4 PA

HUMIRA PREFILLED SYRINGE KIT 40 MG/0.8ML SUBCUTANEOUS 40 MG/0.8ML T4 PA

HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 10 MG/0.2ML T4 PA

IBU TABLET 400 MG ORAL 400 MG T1

ibuprofen oral suspension 100 mg/5ml T1

ibuprofen tablet 600 mg oral 600 mg T1

ibuprofen tablet 800 mg oral 800 mg T1

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

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

indomethacin er capsule extended release 75 mg oral 75 mg

T1 AL (Max 64 Years)

ketoprofen er capsule extended release 24 hour 200 mg oral 200 mg


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Drug Status Notesketorolac tromethamine tablet 10 mg oral 10 mg T1 QL (20 EA per 5 days)

KINERET SOLUTION PREFILLED SYRINGE 100 MG/0.67ML SUBCUTANEOUS 100 MG/0.67ML

T4 PA

leflunomide tablet 10 mg oral 10 mg T1

leflunomide tablet 20 mg oral 20 mg T1

meclofenamate sodium capsule 100 mg oral 100 mg

T3

meclofenamate sodium capsule 50 mg oral 50 mg T3

meloxicam tablet 15 mg oral 15 mg T1

meloxicam tablet 7.5 mg oral 7.5 mg T1

nabumetone tablet 500 mg oral 500 mg T1 QL (120 EA per 30 days)

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

naproxen sodium tablet 275 mg oral 275 mg T3

naproxen sodium tablet 550 mg oral 550 mg T3

naproxen suspension 125 mg/5ml oral 125 mg/5ml

T1QL (300 ML per 30 days); AL (Max 12 Years)

naproxen tablet 250 mg oral 250 mg T1



naproxen tablet delayed release 375 mg oral 375 mg

T1

naproxen tablet delayed release 500 mg oral 500 mg

T1

oxaprozin tablet 600 mg oral 600 mg T3

piroxicam capsule 10 mg oral 10 mg T1

piroxicam capsule 20 mg oral 20 mg T1

RIDAURA CAPSULE 3 MG ORAL 3 MG T4 PA

RINVOQ ORAL TABLET EXTENDED RELEASE 24 HOUR 15 MG T4 PA

sulindac tablet 150 mg oral 150 mg T1

sulindac tablet 200 mg oral 200 mg T1

tolmetin sodium capsule 400 mg oral 400 mg T1

tolmetin sodium tablet 600 mg oral 600 mg T3

XELJANZ TABLET 5 MG ORAL 5 MG T4 PA

XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HOUR 11 MG T4 PA

*Analgesics - Nonnarcotic*

aspirin 81 oral tablet chewable 81 mg T5QL (60 EA per 30 days); AL (Min 40 Years and Max 79 Years)

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Drug Status Notesaspirin ec low dose oral tablet delayed release 81 mg


aspirin ec oral tablet delayed release 325 mg T5QL (30 EA per 30 days); AL (Min 40 Years and Max 79 Years)

aspirin oral tablet 325 mg T5QL (30 EA per 30 days); AL (Min 40 Years and Max 79 Years)

BAC TABLET 50-325-40 MG ORAL 50-325-40 MG T1

butalbital-acetaminophen oral tablet 50-325 mg T1

butalbital-apap-caffeine capsule 50-300-40 mg oral 50-300-40 mg

T1

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

T3

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

T1

diflunisal tablet 500 mg oral 500 mg T1

salsalate tablet 500 mg oral 500 mg T1

salsalate tablet 750 mg oral 750 mg T1

*Analgesics - Opioid*acetaminophen-codeine #2 tablet 300-15 mg oral300-15 mg


acetaminophen-codeine #3 tablet 300-30 mg oral300-30 mg


acetaminophen-codeine #4 tablet 300-60 mg oral300-60 mg


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

T1

buprenorphine hcl solution 0.3 mg/ml injection0.3 mg/ml

T3 PA

buprenorphine hcl tablet sublingual 2 mg sublingual 2 mg

T3 PA

buprenorphine hcl tablet sublingual 8 mg sublingual 8 mg

T3 PA

buprenorphine hcl-naloxone hcl sublingual film12-3 mg

T3 PA; QL (30 EA per 30 days)

buprenorphine hcl-naloxone hcl sublingual film2-0.5 mg, 4-1 mg


buprenorphine hcl-naloxone hcl sublingual film8-2 mg


buprenorphine hcl-naloxone hcl tablet sublingual 2-0.5 mg sublingual 2-0.5 mg


buprenorphine hcl-naloxone hcl tablet sublingual 8-2 mg sublingual 8-2 mg


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Drug Status Notesbuprenorphine transdermal patch weekly 10 mcg/hr, 20 mcg/hr, 5 mcg/hr

T3 PA

butalbital-apap-caff-cod capsule 50-325-40-30 mg oral 50-325-40-30 mg

T1

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

T1

butorphanol tartrate solution 1 mg/ml injection 1 mg/ml

T3

butorphanol tartrate solution 10 mg/ml nasal 10 mg/ml

T3

butorphanol tartrate solution 2 mg/ml injection 2 mg/ml

T3

codeine sulfate tablet 15 mg oral 15 mg T1

codeine sulfate tablet 30 mg oral 30 mg T1

EMBEDA ORAL CAPSULE EXTENDED RELEASE 100-4 MG, 20-0.8 MG, 30-1.2 MG, 50-2 MG, 60-2.4 MG, 80-3.2 MG

T3 PA

ENDOCET TABLET 5-325 MG ORAL 5-325 MG T1 QL (360 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 solution 7.5-325 mg/15ml oral 7.5-325 mg/15ml

T1

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


hydrocodone-acetaminophen tablet 5-325 mg oral5-325 mg


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


hydrocodone-ibuprofen oral tablet 10-200 mg T3 PA

hydrocodone-ibuprofen tablet 5-200 mg oral 5-200 mg


hydrocodone-ibuprofen tablet 7.5-200 mg oral7.5-200 mg


hydromorphone hcl er tablet extended release 24 hour 12 mg oral 12 mg

T3 PA


T3 PA


T3 PA


T3 PA

hydromorphone hcl liquid 1 mg/ml oral 1 mg/ml T3

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Drug Status Noteshydromorphone hcl suppository 3 mg rectal 3 mg T3

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



levorphanol tartrate tablet 2 mg oral 2 mg T1

meperidine hcl solution 100 mg/ml injection 100 mg/ml

T3


T3

meperidine hcl solution 50 mg/5ml oral 50 mg/5ml

T1


T3

meperidine hcl tablet 100 mg oral 100 mg T1

meperidine hcl tablet 50 mg oral 50 mg T1

METHADONE HCL INTENSOL CONCENTRATE 10 MG/ML ORAL 10 MG/ML

T1

methadone hcl solution 10 mg/5ml oral 10 mg/5ml

T1

methadone hcl solution 10 mg/ml injection 10 mg/ml

T3

methadone hcl solution 5 mg/5ml oral 5 mg/5ml T1

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

methadone hcl tablet 5 mg oral 5 mg T1

METHADOSE TABLET SOLUBLE 40 MG ORAL 40 MG T1

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

T1

morphine sulfate (pf) solution 0.5 mg/ml injection0.5 mg/ml

T3

morphine sulfate (pf) solution 1 mg/ml injection 1 mg/ml

T3

morphine sulfate (pf) solution 10 mg/ml intravenous 10 mg/ml

T3


T3


T3


T3

8

Drug Status Notesmorphine sulfate device 10 mg/0.7ml intramuscular 10 mg/0.7ml

T3

morphine sulfate er tablet extended release 100 mg oral 100 mg








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

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

T1

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

T1

morphine sulfate suppository 10 mg rectal 10 mg T3




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

nalbuphine hcl solution 10 mg/ml injection 10 mg/ml

T3

nalbuphine hcl solution 20 mg/ml injection 20 mg/ml

T3

NUCYNTA ER TABLET EXTENDED RELEASE 12 HOUR 100 MG ORAL 100 MG T3 PA





OXAYDO TABLET 7.5 MG ORAL 7.5 MG T3 PA; QL (180 EA per 30 days)

oxycodone hcl capsule 5 mg oral 5 mg T3 QL (180 EA per 30 days)

oxycodone hcl concentrate 100 mg/5ml oral 100 mg/5ml

T3

oxycodone hcl oral tablet 5 mg T3 PA; QL (180 EA per 30 days)

oxycodone hcl solution 5 mg/5ml oral 5 mg/5ml T1

oxycodone hcl tablet 10 mg oral 10 mg T1 QL (180 EA per 30 days)


9

Drug Status Notesoxycodone hcl tablet 20 mg oral 20 mg T1 QL (180 EA per 30 days)


oxycodone-acetaminophen tablet 10-325 mg oral10-325 mg


oxycodone-acetaminophen tablet 2.5-325 mg oral2.5-325 mg

T1

oxycodone-acetaminophen tablet 7.5-325 mg oral7.5-325 mg


oxycodone-aspirin tablet 4.8355-325 mg oral4.8355-325 mg

T1

oxymorphone hcl er tablet extended release 12 hour 10 mg oral 10 mg

T3 PA


T3 PA


T3 PA


T3 PA


T3 PA


T3 PA

oxymorphone hcl er tablet extended release 12 hour 7.5 mg oral 7.5 mg

T3 PA

pentazocine-naloxone hcl tablet 50-0.5 mg oral50-0.5 mg

T1

tramadol hcl er (biphasic) tablet extended release 24 hour 300 mg oral 300 mg


tramadol hcl er capsule extended release 24 hour 150 mg oral 150 mg


tramadol hcl er tablet extended release 24 hour 100 mg oral 100 mg


tramadol hcl er tablet extended release 24 hour 200 mg oral 200 mg


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

tramadol-acetaminophen tablet 37.5-325 mg oral37.5-325 mg

T1

*Androgens-Anabolic*ANADROL-50 TABLET 50 MG ORAL 50 MG T4 PA

ANDRODERM PATCH 24 HOUR 2 MG/24HR TRANSDERMAL 2 MG/24HR T3 PA

10

Drug Status NotesANDRODERM PATCH 24 HOUR 4 MG/24HR TRANSDERMAL 4 MG/24HR T3 PA

methitest tablet 10 mg oral 10 mg T3

oxandrolone tablet 10 mg oral 10 mg T3 PA

oxandrolone tablet 2.5 mg oral 2.5 mg T3 PA

testosterone cypionate solution 100 mg/ml intramuscular 100 mg/ml

T1 GR-M

testosterone cypionate solution 200 mg/ml intramuscular 200 mg/ml

T1 GR-M

testosterone enanthate intramuscular solution200 mg/ml

T1 GR-M

testosterone gel 25 mg/2.5gm (1%) transdermal25 mg/2.5gm (1%)

T3 PA

testosterone solution 30 mg/act transdermal 30 mg/act

T3 PA

testosterone transdermal gel 20.25 mg/1.25gm (1.62%), 20.25 mg/act (1.62%), 40.5 mg/2.5gm (1.62%)

T3 PA

testosterone transdermal gel 50 mg/5gm (1%) T3

*Anorectal And Related Products*ANALPRAM-HC LOTION 2.5-1 % EXTERNAL 2.5-1 % T3

COLOCORT ENEMA 100 MG/60ML RECTAL 100 MG/60ML T1

CORTIFOAM FOAM 10 % EXTERNAL 10 % T3 PA

lidocaine-hydrocortisone ace gel 2.8-0.55 % rectal 2.8-0.55 %

T3

lidocaine-hydrocortisone ace kit 2-2 % rectal 2-2 %

T3 PA

lidocaine-hydrocortisone ace kit 3-0.5 % rectal 3-0.5 %

T1

lidocaine-hydrocortisone ace kit 3-1 % rectal 3-1 %

T1

lidocaine-hydrocortisone ace kit 3-2.5 % rectal 3-2.5 %

T1

PROCTOFOAM HC FOAM 1-1 % EXTERNAL 1-1 % T3

PROCTOZONE-HC CREAM 2.5 % EXTERNAL 2.5 % T1

RECTIV OINTMENT 0.4 % RECTAL 0.4 % T3

11

Drug Status Notes

*Antacids*magnesium oxide oral tablet 400 mg T1

sodium bicarbonate oral tablet 650 mg T1

*Anthelmintics*albendazole oral tablet 200 mg T3 PA

ivermectin tablet 3 mg oral 3 mg T3 QL (10 EA per 30 days)

reeses pinworm medicine suspension 144 (50 base) mg/ml oral 144 (50 base) mg/ml

T1

*Antianginal Agents*DILATRATE-SR CAPSULE EXTENDED RELEASE 40 MG ORAL 40 MG T3

isosorbide dinitrate oral tablet 30 mg T1

isosorbide dinitrate tablet 10 mg oral 10 mg T1



isosorbide mononitrate er tablet extended release 24 hour 120 mg oral 120 mg

T1


T1


T1

isosorbide mononitrate tablet 10 mg oral 10 mg T1

isosorbide mononitrate tablet 20 mg oral 20 mg T1

NITRO-BID OINTMENT 2 % TRANSDERMAL 2 % T3

NITRO-DUR PATCH 24 HOUR 0.3 MG/HR TRANSDERMAL 0.3 MG/HR T3

NITRO-DUR PATCH 24 HOUR 0.8 MG/HR TRANSDERMAL 0.8 MG/HR T3

nitroglycerin er capsule extended release 2.5 mg oral 2.5 mg

T1

nitroglycerin patch 24 hour 0.1 mg/hr transdermal 0.1 mg/hr

T1


T1


T1


T1

nitroglycerin solution 0.4 mg/spray translingual0.4 mg/spray

T3

12

Drug Status Notesnitroglycerin sublingual tablet sublingual 0.3 mg, 0.4 mg, 0.6 mg

T1

NITRO-TIME CAPSULE EXTENDED RELEASE 6.5 MG ORAL 6.5 MG T1

NITRO-TIME CAPSULE EXTENDED RELEASE 9 MG ORAL 9 MG T1

RANEXA TABLET EXTENDED RELEASE 12 HOUR 1000 MG ORAL 1000 MG T3 PA

RANEXA TABLET EXTENDED RELEASE 12 HOUR 500 MG ORAL 500 MG T3 PA

*Antianxiety Agents*alprazolam er tablet extended release 24 hour 1 mg oral 1 mg


alprazolam er tablet extended release 24 hour 2 mg oral 2 mg


alprazolam tablet 0.25 mg oral 0.25 mg T1 AL (Max 64 Years)

alprazolam tablet 0.5 mg oral 0.5 mg T1 AL (Max 64 Years)

alprazolam tablet 1 mg oral 1 mg T1 AL (Max 64 Years)

alprazolam tablet 2 mg oral 2 mg T1 AL (Max 64 Years)

alprazolam tablet dispersible 0.25 mg oral 0.25 mg


alprazolam tablet dispersible 0.5 mg oral 0.5 mg T3 AL (Max 64 Years)

alprazolam tablet dispersible 1 mg oral 1 mg T3 AL (Max 64 Years)

alprazolam tablet dispersible 2 mg oral 2 mg T3 AL (Max 64 Years)

alprazolam xr tablet extended release 24 hour 0.5 mg oral 0.5 mg


alprazolam xr tablet extended release 24 hour 3 mg oral 3 mg


buspirone hcl tablet 10 mg oral 10 mg T1




buspirone hcl tablet 7.5 mg oral 7.5 mg T1

chlordiazepoxide hcl capsule 10 mg oral 10 mg T1 AL (Max 64 Years)



clorazepate dipotassium tablet 15 mg oral 15 mg T1 AL (Max 64 Years)

clorazepate dipotassium tablet 3.75 mg oral 3.75 mg


clorazepate dipotassium tablet 7.5 mg oral 7.5 mg T1 AL (Max 64 Years)

diazepam solution 5 mg/5ml oral 5 mg/5ml T1 AL (Max 64 Years)

13

Drug Status Notesdiazepam solution 5 mg/ml injection 5 mg/ml T1 AL (Max 64 Years)

diazepam tablet 10 mg oral 10 mg T1 AL (Max 64 Years)



droperidol injection solution 2.5 mg/ml T1

hydroxyzine hcl solution 25 mg/ml intramuscular25 mg/ml


hydroxyzine hcl solution 50 mg/ml intramuscular50 mg/ml


hydroxyzine hcl syrup 10 mg/5ml oral 10 mg/5ml T1 AL (Max 64 Years)

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



hydroxyzine pamoate capsule 100 mg oral 100 mg


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

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

LORAZEPAM INTENSOL CONCENTRATE 2 MG/ML ORAL 2 MG/ML T1

lorazepam solution 2 mg/ml injection 2 mg/ml T1

lorazepam solution 4 mg/ml injection 4 mg/ml T1

lorazepam tablet 0.5 mg oral 0.5 mg T1

lorazepam tablet 1 mg oral 1 mg T1

lorazepam tablet 2 mg oral 2 mg T1

meprobamate tablet 200 mg oral 200 mg T1 AL (Max 64 Years)

meprobamate tablet 400 mg oral 400 mg T1 AL (Max 64 Years)

oxazepam capsule 10 mg oral 10 mg T1

oxazepam oral capsule 15 mg, 30 mg T1

*Antiarrhythmics*amiodarone hcl tablet 200 mg oral 200 mg T1

disopyramide phosphate capsule 100 mg oral 100 mg

T1

disopyramide phosphate capsule 150 mg oral 150 mg

T1

dofetilide capsule 125 mcg oral 125 mcg T3



flecainide acetate tablet 100 mg oral 100 mg T1



14

Drug Status Notesmexiletine hcl capsule 150 mg oral 150 mg T1

mexiletine hcl capsule 200 mg oral 200 mg T1

mexiletine hcl capsule 250 mg oral 250 mg T1

MULTAQ TABLET 400 MG ORAL 400 MG T3 PA

NORPACE CR CAPSULE EXTENDED RELEASE 12 HOUR 100 MG ORAL 100 MG T3

PACERONE TABLET 400 MG ORAL 400 MG T1

propafenone hcl er capsule extended release 12 hour 225 mg oral 225 mg

T3


T3


T3

propafenone hcl tablet 150 mg oral 150 mg T1



quinidine gluconate er tablet extended release 324 mg oral 324 mg

T1

quinidine sulfate tablet 200 mg oral 200 mg T1

quinidine sulfate tablet 300 mg oral 300 mg T1

*Antiasthmatic And Bronchodilator Agents*ADVAIR HFA AEROSOL 115-21 MCG/ACT INHALATION 115-21 MCG/ACT T2 QL (12 GM per 30 days)

ADVAIR HFA AEROSOL 230-21 MCG/ACT INHALATION 230-21 MCG/ACT T2 QL (12 GM per 30 days)

ADVAIR HFA AEROSOL 45-21 MCG/ACT INHALATION 45-21 MCG/ACT T2 QL (12 GM per 30 days)

albuterol sulfate er tablet extended release 12 hour 4 mg oral 4 mg

T1

albuterol sulfate er tablet extended release 12 hour 8 mg oral 8 mg

T1

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

T1

albuterol sulfate nebulization solution (5 mg/ml) 0.5% inhalation (5 mg/ml) 0.5%

T1

albuterol sulfate nebulization solution 0.63 mg/3ml inhalation 0.63 mg/3ml

T1

albuterol sulfate nebulization solution 1.25 mg/3ml inhalation 1.25 mg/3ml

T1

albuterol sulfate syrup 2 mg/5ml oral 2 mg/5ml T1

15

Drug Status NotesANORO ELLIPTA AEROSOL POWDER BREATH ACTIVATED 62.5-25 MCG/INH INHALATION 62.5-25 MCG/INH

T2

ARCAPTA NEOHALER CAPSULE 75 MCG INHALATION 75 MCG T3 PA; QL (30 EA per 30 days)

ARNUITY ELLIPTA AEROSOL POWDER BREATH ACTIVATED 100 MCG/ACT INHALATION 100 MCG/ACT


ARNUITY ELLIPTA AEROSOL POWDER BREATH ACTIVATED 200 MCG/ACT INHALATION 200 MCG/ACT


ASMANEX (120 METERED DOSES) AEROSOL POWDER BREATH ACTIVATED 220 MCG/INH INHALATION220 MCG/INH


ASMANEX (7 METERED DOSES) AEROSOL POWDER BREATH ACTIVATED 110 MCG/INH INHALATION110 MCG/INH


ASMANEX HFA INHALATION AEROSOL100 MCG/ACT T2 QL (13 GM per 1 day)

ASMANEX HFA INHALATION AEROSOL200 MCG/ACT T2 QL (13 GM per 30 days)

ATROVENT HFA AEROSOL SOLUTION 17 MCG/ACT INHALATION 17 MCG/ACT T3 QL (12.9 GM per 30 days)

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


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


BROVANA NEBULIZATION SOLUTION 15 MCG/2ML INHALATION 15 MCG/2ML T3 PA; QL (120 ML per 30 days)

budesonide suspension 0.25 mg/2ml inhalation0.25 mg/2ml


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


budesonide suspension 1 mg/2ml inhalation 1 mg/2ml


COMBIVENT RESPIMAT AEROSOL SOLUTION 20-100 MCG/ACT INHALATION 20-100 MCG/ACT

T3 QL (4 GM per 30 days)

DALIRESP TABLET 500 MCG ORAL 500 MCG T2 QL (30 EA per 30 days)

16

Drug Status NotesDULERA AEROSOL 100-5 MCG/ACT INHALATION 100-5 MCG/ACT T3 QL (13 GM per 30 days)

DULERA AEROSOL 200-5 MCG/ACT INHALATION 200-5 MCG/ACT T3 QL (13 GM per 30 days)

ELIXOPHYLLIN ELIXIR 80 MG/15ML ORAL 80 MG/15ML T2

FASENRA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 30 MG/ML T4 PA

FLOVENT DISKUS AEROSOL POWDER BREATH ACTIVATED 100 MCG/BLIST INHALATION 100 MCG/BLIST






FLOVENT HFA AEROSOL 110 MCG/ACT INHALATION 110 MCG/ACT T2 QL (12 GM per 30 days)

FLOVENT HFA AEROSOL 220 MCG/ACT INHALATION 220 MCG/ACT T2 QL (12 GM per 30 days)

FLOVENT HFA AEROSOL 44 MCG/ACT INHALATION 44 MCG/ACT T2 QL (10.6 GM per 30 days)

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, 250-50 mcg/dose, 500-50 mcg/dose


INCRUSE ELLIPTA AEROSOL POWDER BREATH ACTIVATED 62.5 MCG/INH INHALATION 62.5 MCG/INH


ipratropium bromide solution 0.02 % inhalation0.02 %

T1

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

T1

levalbuterol hcl nebulization solution 0.31 mg/3ml inhalation 0.31 mg/3ml

T1 ST

levalbuterol hcl nebulization solution 0.63 mg/3ml inhalation 0.63 mg/3ml

T1 ST

17

Drug Status Noteslevalbuterol hcl nebulization solution 1.25 mg/0.5ml inhalation 1.25 mg/0.5ml

T1 ST

levalbuterol tartrate aerosol 45 mcg/act inhalation 45 mcg/act


metaproterenol sulfate syrup 10 mg/5ml oral 10 mg/5ml

T1

montelukast sodium packet 4 mg oral 4 mg T1

montelukast sodium tablet 10 mg oral 10 mg T1

montelukast sodium tablet chewable 4 mg oral 4 mg

T1

montelukast sodium tablet chewable 5 mg oral 5 mg

T1

PERFOROMIST NEBULIZATION SOLUTION 20 MCG/2ML INHALATION 20 MCG/2ML

T3 PA; QL (120 ML per 30 days)

PROAIR RESPICLICK AEROSOL POWDER BREATH ACTIVATED 108 (90 BASE) MCG/ACT INHALATION 108 (90 BASE) MCG/ACT


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


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


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

T3 QL (10.6 GM per 30 days)

SEREVENT DISKUS AEROSOL POWDER BREATH ACTIVATED 50 MCG/DOSE INHALATION 50 MCG/DOSE


SPIRIVA HANDIHALER CAPSULE 18 MCG INHALATION 18 MCG T2 QL (30 EA per 30 days)

SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION 1.25 MCG/ACT, 2.5 MCG/ACT


STRIVERDI RESPIMAT AEROSOL SOLUTION 2.5 MCG/ACT INHALATION2.5 MCG/ACT


terbutaline sulfate solution 1 mg/ml injection 1 mg/ml

T1

terbutaline sulfate tablet 2.5 mg oral 2.5 mg T1

terbutaline sulfate tablet 5 mg oral 5 mg T1

18

Drug Status Notestheophylline er tablet extended release 12 hour 300 mg oral 300 mg

T1

theophylline er tablet extended release 12 hour 450 mg oral 450 mg

T1


T1


T1

theophylline solution 80 mg/15ml oral 80 mg/15ml

T1

TUDORZA PRESSAIR AEROSOL POWDER BREATH ACTIVATED 400 MCG/ACT INHALATION 400 MCG/ACT


VENTOLIN HFA AEROSOL SOLUTION 108 (90 BASE) MCG/ACT INHALATION 108 (90 BASE) MCG/ACT


WIXELA INHUB INHALATION AEROSOL POWDER BREATH ACTIVATED 100-50 MCG/DOSE, 250-50 MCG/DOSE, 500-50 MCG/DOSE


XOLAIR SOLUTION RECONSTITUTED 150 MG SUBCUTANEOUS 150 MG T4 PA

zafirlukast tablet 10 mg oral 10 mg T3

zafirlukast tablet 20 mg oral 20 mg T3

zileuton er tablet extended release 12 hour 600 mg oral 600 mg

T4 PA

ZYFLO TABLET 600 MG ORAL 600 MG T4 PA

*Anticoagulants*ELIQUIS DVT/PE STARTER PACK ORAL TABLET 5 MG T2 QL (60 EA per 30 days)

ELIQUIS ORAL TABLET 2.5 MG, 5 MG T2 QL (60 EA per 30 days)

enoxaparin sodium injection solution 300 mg/3ml T3 PA

enoxaparin sodium solution 100 mg/ml subcutaneous 100 mg/ml

T3PA; Cover For 7 days supply per 30 days, requiring PA thereafter

enoxaparin sodium solution 120 mg/0.8ml subcutaneous 120 mg/0.8ml


enoxaparin sodium solution 150 mg/ml subcutaneous 150 mg/ml






19

Drug Status Notesenoxaparin sodium solution 60 mg/0.6ml subcutaneous 60 mg/0.6ml




fondaparinux sodium solution 10 mg/0.8ml subcutaneous 10 mg/0.8ml

T4 PA

fondaparinux sodium solution 2.5 mg/0.5ml subcutaneous 2.5 mg/0.5ml

T4 PA

fondaparinux sodium solution 5 mg/0.4ml subcutaneous 5 mg/0.4ml

T4 PA

fondaparinux sodium solution 7.5 mg/0.6ml subcutaneous 7.5 mg/0.6ml

T4 PA

FRAGMIN SOLUTION 10000 UNIT/ML SUBCUTANEOUS 10000 UNIT/ML T4 PA

FRAGMIN SOLUTION 12500 UNIT/0.5ML SUBCUTANEOUS 12500 UNIT/0.5ML T4 PA


FRAGMIN SOLUTION 18000 UNT/0.72ML SUBCUTANEOUS 18000 UNT/0.72ML T4 PA




heparin lock flush solution 10 unit/ml intravenous10 unit/ml

T1

heparin sod (porcine) in d5w solution 100 unit/ml intravenous 100 unit/ml

T1

heparin sodium (porcine) pf solution 5000 unit/0.5ml injection 5000 unit/0.5ml

T1

heparin sodium (porcine) solution 1000 unit/ml injection 1000 unit/ml

T1


T1


T1


T1

heparin sodium lock flush solution 100 unit/ml intravenous 100 unit/ml

T1

PRADAXA CAPSULE 150 MG ORAL 150 MG T3 PA

20

Drug Status NotesPRADAXA CAPSULE 75 MG ORAL 75 MG T3 PA

warfarin sodium tablet 1 mg oral 1 mg T1



warfarin sodium tablet 2.5 mg oral 2.5 mg T1





warfarin sodium tablet 7.5 mg oral 7.5 mg T1

XARELTO ORAL TABLET 2.5 MG T2 QL (60 EA per 30 days)

XARELTO STARTER PACK ORAL TABLET THERAPY PACK 15 & 20 MG T2 QL (51 EA per 365 days)

XARELTO TABLET 10 MG ORAL 10 MG T2 QL (30 EA per 30 days)



*Anticonvulsants*APTIOM TABLET 200 MG ORAL 200 MG T3 PA

APTIOM TABLET 400 MG ORAL 400 MG T3 PA



carbamazepine er capsule extended release 12 hour 100 mg oral 100 mg

T1


T1


T1

carbamazepine er tablet extended release 12 hour 100 mg oral 100 mg

T1


T1


T1

carbamazepine suspension 100 mg/5ml oral 100 mg/5ml

T1

carbamazepine tablet 200 mg oral 200 mg T1

carbamazepine tablet chewable 100 mg oral 100 mg

T1

CELONTIN CAPSULE 300 MG ORAL 300 MG T2

21

Drug Status Notesclobazam oral suspension 2.5 mg/ml T3 PA

clobazam oral tablet 10 mg, 20 mg T3 PA

clonazepam tablet 0.5 mg oral 0.5 mg T1

clonazepam tablet 1 mg oral 1 mg T1

clonazepam tablet 2 mg oral 2 mg T1

clonazepam tablet dispersible 0.125 mg oral0.125 mg

T1

clonazepam tablet dispersible 0.25 mg oral 0.25 mg

T1

clonazepam tablet dispersible 0.5 mg oral 0.5 mg T1

clonazepam tablet dispersible 1 mg oral 1 mg T1

clonazepam tablet dispersible 2 mg oral 2 mg T1

DILANTIN CAPSULE 30 MG ORAL 30 MG T2

DILANTIN ORAL CAPSULE 100 MG T2

divalproex sodium capsule delayed release sprinkle 125 mg oral 125 mg

T1

divalproex sodium er tablet extended release 24 hour 250 mg oral 250 mg

T1

divalproex sodium er tablet extended release 24 hour 500 mg oral 500 mg

T1

divalproex sodium tablet delayed release 125 mg oral 125 mg

T1


T1


T1

ethosuximide capsule 250 mg oral 250 mg T1

ethosuximide solution 250 mg/5ml oral 250 mg/5ml

T3

felbamate suspension 600 mg/5ml oral 600 mg/5ml

T4

felbamate tablet 400 mg oral 400 mg T3

felbamate tablet 600 mg oral 600 mg T3

FYCOMPA TABLET 10 MG ORAL 10 MG T3 PA






gabapentin capsule 100 mg oral 100 mg T1

gabapentin capsule 300 mg oral 300 mg T1

22

Drug Status Notesgabapentin capsule 400 mg oral 400 mg T1

gabapentin solution 250 mg/5ml oral 250 mg/5ml T1

gabapentin tablet 600 mg oral 600 mg T1

gabapentin tablet 800 mg oral 800 mg T1

GABITRIL ORAL TABLET 12 MG T3

LAMICTAL ODT ORAL KIT 21 X 25 MG & 7 X 50 MG, 25 & 50 & 100 MG, 42 X 50 MG & 14X100 MG

T3

lamotrigine er tablet extended release 24 hour 100 mg oral 100 mg

T3


T3


T3


T3


T3


T3

lamotrigine tablet 100 mg oral 100 mg T1




lamotrigine tablet chewable 25 mg oral 25 mg T1

lamotrigine tablet chewable 5 mg oral 5 mg T1

levetiracetam er tablet extended release 24 hour 500 mg oral 500 mg

T3

levetiracetam er tablet extended release 24 hour 750 mg oral 750 mg

T3

levetiracetam solution 100 mg/ml oral 100 mg/ml T1

levetiracetam solution 500 mg/5ml intravenous500 mg/5ml

T1

levetiracetam tablet 1000 mg oral 1000 mg T1 QL (90 EA per 30 days)




LYRICA SOLUTION 20 MG/ML ORAL 20 MG/ML T3 PA

oxcarbazepine suspension 300 mg/5ml oral 300 mg/5ml

T1

23

Drug Status Notesoxcarbazepine tablet 150 mg oral 150 mg T1

oxcarbazepine tablet 300 mg oral 300 mg T1

oxcarbazepine tablet 600 mg oral 600 mg T1

PEGANONE TABLET 250 MG ORAL 250 MG T3

phenytoin sodium extended capsule 200 mg oral200 mg

T1

phenytoin sodium extended capsule 300 mg oral300 mg

T1

phenytoin sodium extended oral capsule 100 mg T1

phenytoin sodium solution 50 mg/ml injection 50 mg/ml

T1

phenytoin suspension 125 mg/5ml oral 125 mg/5ml

T1

phenytoin tablet chewable 50 mg oral 50 mg T1

pregabalin oral capsule 100 mg, 150 mg, 200 mg, 225 mg, 25 mg, 50 mg, 75 mg


pregabalin oral capsule 300 mg T1 QL (60 EA per 30 days)

primidone tablet 250 mg oral 250 mg T1

primidone tablet 50 mg oral 50 mg T1

rufinamide oral suspension 40 mg/ml T3

tiagabine hcl oral tablet 12 mg, 16 mg T3

tiagabine hcl tablet 2 mg oral 2 mg T3

tiagabine hcl tablet 4 mg oral 4 mg T3

topiramate capsule sprinkle 15 mg oral 15 mg T1

topiramate capsule sprinkle 25 mg oral 25 mg T1

topiramate tablet 100 mg oral 100 mg T1




valproic acid capsule 250 mg oral 250 mg T1

valproic acid solution 250 mg/5ml oral 250 mg/5ml

T1

vigabatrin oral packet 500 mg T4 PA

VIMPAT TABLET 100 MG ORAL 100 MG T3 PA




zonisamide capsule 100 mg oral 100 mg T1 QL (180 EA per 30 days)

zonisamide capsule 25 mg oral 25 mg T1 QL (360 EA per 30 days)

24

Drug Status Noteszonisamide capsule 50 mg oral 50 mg T1 QL (360 EA per 30 days)

*Antidepressants*amitriptyline hcl tablet 10 mg oral 10 mg T1 AL (Max 64 Years)

amitriptyline hcl tablet 100 mg oral 100 mg T1 AL (Max 64 Years)





amoxapine tablet 100 mg oral 100 mg T1 AL (Max 64 Years)




bupropion hcl er (sr) tablet extended release 12 hour 100 mg oral 100 mg

T1


T1


T1

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

T1

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

T1

bupropion hcl tablet 100 mg oral 100 mg T1

bupropion hcl tablet 75 mg oral 75 mg T1

citalopram hydrobromide solution 10 mg/5ml oral 10 mg/5ml

T1

citalopram hydrobromide tablet 10 mg oral 10 mg

T1


T1



clomipramine hcl capsule 25 mg oral 25 mg T3 AL (Max 64 Years)



desipramine hcl tablet 10 mg oral 10 mg T3 QL (60 EA per 30 days)





25

Drug Status Notesdesipramine hcl tablet 75 mg oral 75 mg T3 QL (60 EA per 30 days)

desvenlafaxine er tablet extended release 24 hour 100 mg oral 100 mg


desvenlafaxine er tablet extended release 24 hour 50 mg oral 50 mg


desvenlafaxine succinate er oral tablet extended release 24 hour 25 mg


desvenlafaxine succinate er tablet extended release 24 hour 100 mg oral 100 mg


desvenlafaxine succinate er tablet extended release 24 hour 50 mg oral 50 mg


doxepin hcl capsule 10 mg oral 10 mg T1 AL (Max 64 Years)





doxepin hcl concentrate 10 mg/ml oral 10 mg/ml T1 AL (Max 64 Years)

doxepin hcl oral capsule 150 mg T1

duloxetine hcl capsule delayed release particles 20 mg oral 20 mg






EMSAM PATCH 24 HOUR 12 MG/24HR TRANSDERMAL 12 MG/24HR T3 ST; QL (30 EA per 30 days)



escitalopram oxalate solution 5 mg/5ml oral 5 mg/5ml

T1

escitalopram oxalate tablet 10 mg oral 10 mg T1 QL (45 EA per 30 days)



FETZIMA CAPSULE EXTENDED RELEASE 24 HOUR 120 MG ORAL 120 MG T3 PA



26

Drug Status NotesFETZIMA CAPSULE EXTENDED RELEASE 24 HOUR 80 MG ORAL 80 MG T3 PA

fluoxetine hcl capsule 10 mg oral 10 mg T1



fluoxetine hcl capsule delayed release 90 mg oral90 mg


fluoxetine hcl solution 20 mg/5ml oral 20 mg/5ml T1

fluvoxamine maleate tablet 100 mg oral 100 mg T1



imipramine hcl tablet 10 mg oral 10 mg T1 AL (Max 64 Years)



imipramine pamoate capsule 100 mg oral 100 mg T3 AL (Max 64 Years)




maprotiline hcl tablet 25 mg oral 25 mg T1



MARPLAN TABLET 10 MG ORAL 10 MG T3

mirtazapine tablet 15 mg oral 15 mg T1 AL (Max 64 Years)



mirtazapine tablet 7.5 mg oral 7.5 mg T1 AL (Max 64 Years)

mirtazapine tablet dispersible 15 mg oral 15 mg T3 AL (Max 64 Years)



nefazodone hcl tablet 100 mg oral 100 mg T1





nortriptyline hcl capsule 10 mg oral 10 mg T1




27

Drug Status Notesnortriptyline hcl solution 10 mg/5ml oral 10 mg/5ml

T1

paroxetine hcl er tablet extended release 24 hour 12.5 mg oral 12.5 mg

T3

paroxetine hcl er tablet extended release 24 hour 25 mg oral 25 mg

T3

paroxetine hcl er tablet extended release 24 hour 37.5 mg oral 37.5 mg

T3

paroxetine hcl tablet 10 mg oral 10 mg T1




phenelzine sulfate tablet 15 mg oral 15 mg T1

protriptyline hcl tablet 10 mg oral 10 mg T1

protriptyline hcl tablet 5 mg oral 5 mg T1

sertraline hcl concentrate 20 mg/ml oral 20 mg/ml

T1

sertraline hcl tablet 100 mg oral 100 mg T1



tranylcypromine sulfate tablet 10 mg oral 10 mg T3

trazodone hcl tablet 100 mg oral 100 mg T1



trimipramine maleate capsule 100 mg oral 100 mg

T1

trimipramine maleate capsule 25 mg oral 25 mg T1

trimipramine maleate capsule 50 mg oral 50 mg T1

venlafaxine hcl er capsule extended release 24 hour 150 mg oral 150 mg

T1

venlafaxine hcl er capsule extended release 24 hour 37.5 mg oral 37.5 mg

T1

venlafaxine hcl er capsule extended release 24 hour 75 mg oral 75 mg

T1

venlafaxine hcl tablet 100 mg oral 100 mg T1


venlafaxine hcl tablet 37.5 mg oral 37.5 mg T1



VIIBRYD TABLET 10 MG ORAL 10 MG T3 PA

28

Drug Status NotesVIIBRYD TABLET 20 MG ORAL 20 MG T3 PA

VIIBRYD TABLET 40 MG ORAL 40 MG T3 PA

*Antidiabetics*acarbose tablet 100 mg oral 100 mg T1

acarbose tablet 25 mg oral 25 mg T1

acarbose tablet 50 mg oral 50 mg T1

alogliptin benzoate oral tablet 12.5 mg, 25 mg, 6.25 mg


alogliptin-metformin hcl oral tablet 12.5-1000 mg T2 QL (60 EA per 30 days)

alogliptin-metformin hcl oral tablet 12.5-500 mg T2 QL (30 EA per 30 days)

alogliptin-pioglitazone oral tablet 12.5-15 mg, 12.5-30 mg, 12.5-45 mg, 25-15 mg, 25-30 mg, 25-45 mg


AVANDIA TABLET 2 MG ORAL 2 MG T3

BYETTA 10 MCG PEN SOLUTION PEN-INJECTOR 10 MCG/0.04ML SUBCUTANEOUS 10 MCG/0.04ML

T3 PA; QL (2.4 ML per 30 days)

BYETTA 5 MCG PEN SOLUTION PEN-INJECTOR 5 MCG/0.02ML SUBCUTANEOUS 5 MCG/0.02ML


CYCLOSET TABLET 0.8 MG ORAL 0.8 MG T3

FARXIGA TABLET 5 MG ORAL 5 MG T3 ST; QL (30 EA per 30 days)

FIASP FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML T2

FIASP PENFILL SOLUTION CARTRIDGE 100 UNIT/ML SUBCUTANEOUS 100 UNIT/ML

T2

FIASP SUBCUTANEOUS SOLUTION 100 UNIT/ML T2

glimepiride tablet 1 mg oral 1 mg T1



glipizide er tablet extended release 24 hour 10 mg oral 10 mg


glipizide er tablet extended release 24 hour 2.5 mg oral 2.5 mg


glipizide er tablet extended release 24 hour 5 mg oral 5 mg


glipizide tablet 10 mg oral 10 mg T1

glipizide tablet 5 mg oral 5 mg T1

glipizide-metformin hcl tablet 2.5-250 mg oral2.5-250 mg

T1

29

Drug Status Notesglipizide-metformin hcl tablet 2.5-500 mg oral2.5-500 mg

T1

glipizide-metformin hcl tablet 5-500 mg oral 5-500 mg

T1

GLUCAGEN HYPOKIT SOLUTION RECONSTITUTED 1 MG INJECTION 1 MG T2 QL (2 EA per 30 days)

glucagon emergency kit 1 mg injection 1 mg T3 QL (2 EA per 30 days)

glyburide micronized tablet 1.5 mg oral 1.5 mg T1

glyburide micronized tablet 3 mg oral 3 mg T1

glyburide micronized tablet 6 mg oral 6 mg T1

glyburide tablet 1.25 mg oral 1.25 mg T1

glyburide tablet 2.5 mg oral 2.5 mg T1

glyburide tablet 5 mg oral 5 mg T1

glyburide-metformin tablet 1.25-250 mg oral1.25-250 mg

T1

glyburide-metformin tablet 2.5-500 mg oral 2.5-500 mg

T1

glyburide-metformin tablet 5-500 mg oral 5-500 mg

T1

goodsense glucose tablet chewable 4-6 gm-mg oral 4-6 gm-mg

T1

HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS SOLUTION 500 UNIT/ML T2 QL (20 ML per 30 days)

INVOKAMET TABLET 150-1000 MG ORAL150-1000 MG T2 QL (60 EA per 30 days)




INVOKAMET XR TABLET EXTENDED RELEASE 24 HOUR 150-1000 MG ORAL150-1000 MG


INVOKAMET XR TABLET EXTENDED RELEASE 24 HOUR 150-500 MG ORAL 150-500 MG






30

Drug Status NotesINVOKANA TABLET 100 MG ORAL 100 MG T2 QL (30 EA per 30 days)

INVOKANA TABLET 300 MG ORAL 300 MG T2 QL (30 EA per 30 days)

JANUMET ORAL TABLET 50-1000 MG, 50-500 MG T2 ST; QL (60 EA per 30 days)

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

T2 ST; QL (30 EA per 30 days)

JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG T2 ST; QL (30 EA per 30 days)

JARDIANCE TABLET 10 MG ORAL 10 MG T2 QL (30 EA per 30 days)

JARDIANCE TABLET 25 MG ORAL 25 MG T2 QL (30 EA per 30 days)

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

T2

LANTUS SOLUTION 100 UNIT/ML SUBCUTANEOUS 100 UNIT/ML T2

LEVEMIR FLEXTOUCH SOLUTION PEN-INJECTOR 100 UNIT/ML SUBCUTANEOUS100 UNIT/ML

T2

LEVEMIR SOLUTION 100 UNIT/ML SUBCUTANEOUS 100 UNIT/ML T2

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

T1

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

T1

metformin hcl tablet 1000 mg oral 1000 mg T1



miglitol tablet 25 mg oral 25 mg T3

nateglinide tablet 120 mg oral 120 mg T1

nateglinide tablet 60 mg oral 60 mg T1

NOVOLIN 70/30 FLEXPEN RELION SUBCUTANEOUS SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML

T2

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

T2

NOVOLIN 70/30 SUSPENSION (70-30) 100 UNIT/ML SUBCUTANEOUS (70-30) 100 UNIT/ML

T2

31

Drug Status NotesNOVOLIN N FLEXPEN SUSPENSION PEN-INJECTOR 100 UNIT/ML SUBCUTANEOUS100 UNIT/ML

T2

NOVOLIN N RELION SUSPENSION 100 UNIT/ML SUBCUTANEOUS 100 UNIT/ML T2

NOVOLIN N SUSPENSION 100 UNIT/ML SUBCUTANEOUS 100 UNIT/ML T2

NOVOLIN R FLEXPEN SOLUTION PEN-INJECTOR 100 UNIT/ML INJECTION 100 UNIT/ML

T2

NOVOLIN R RELION SOLUTION 100 UNIT/ML INJECTION 100 UNIT/ML T2

NOVOLIN R SOLUTION 100 UNIT/ML INJECTION 100 UNIT/ML T2

NOVOLOG FLEXPEN SOLUTION PEN-INJECTOR 100 UNIT/ML SUBCUTANEOUS100 UNIT/ML

T2

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

T2

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

T2

NOVOLOG PENFILL SUBCUTANEOUS SOLUTION CARTRIDGE 100 UNIT/ML T2

NOVOLOG SOLUTION 100 UNIT/ML SUBCUTANEOUS 100 UNIT/ML T2

ONGLYZA TABLET 2.5 MG ORAL 2.5 MG T3 ST; QL (30 EA per 30 days)

ONGLYZA TABLET 5 MG ORAL 5 MG T3 ST; QL (30 EA per 30 days)

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

T2 QL (1.5 ML per 30 days)

OZEMPIC (1 MG/DOSE) SUBCUTANEOUS SOLUTION PEN-INJECTOR 2 MG/1.5ML T2 QL (3 ML per 30 days)

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



pioglitazone hcl-glimepiride tablet 30-2 mg oral30-2 mg

T3

pioglitazone hcl-glimepiride tablet 30-4 mg oral30-4 mg

T3

pioglitazone hcl-metformin hcl tablet 15-500 mg oral 15-500 mg

T3

32

Drug Status Notespioglitazone hcl-metformin hcl tablet 15-850 mg oral 15-850 mg

T3

repaglinide tablet 0.5 mg oral 0.5 mg T1

repaglinide tablet 1 mg oral 1 mg T1

repaglinide tablet 2 mg oral 2 mg T1

RYBELSUS ORAL TABLET 14 MG, 3 MG, 7 MG T2 QL (30 EA per 30 days)

SYMLINPEN 120 SOLUTION PEN-INJECTOR 2700 MCG/2.7ML SUBCUTANEOUS 2700 MCG/2.7ML

T3 PA

SYMLINPEN 60 SOLUTION PEN-INJECTOR 1500 MCG/1.5ML SUBCUTANEOUS 1500 MCG/1.5ML

T3 PA

SYNJARDY TABLET 12.5-1000 MG ORAL12.5-1000 MG T2 QL (60 EA per 30 days)

SYNJARDY TABLET 12.5-500 MG ORAL12.5-500 MG T2 QL (60 EA per 30 days)

SYNJARDY TABLET 5-1000 MG ORAL 5-1000 MG T2 QL (60 EA per 30 days)

SYNJARDY TABLET 5-500 MG ORAL 5-500 MG T2 QL (60 EA per 30 days)

SYNJARDY XR TABLET EXTENDED RELEASE 24 HOUR 10-1000 MG ORAL 10-1000 MG


SYNJARDY XR TABLET EXTENDED RELEASE 24 HOUR 12.5-1000 MG ORAL12.5-1000 MG






tolbutamide tablet 500 mg oral 500 mg T1

TOUJEO SOLOSTAR SOLUTION PEN-INJECTOR 300 UNIT/ML SUBCUTANEOUS300 UNIT/ML

T2

TRADJENTA TABLET 5 MG ORAL 5 MG T3 ST; QL (30 EA per 30 days)

TRESIBA FLEXTOUCH SOLUTION PEN-INJECTOR 100 UNIT/ML SUBCUTANEOUS100 UNIT/ML

T2

TRESIBA FLEXTOUCH SOLUTION PEN-INJECTOR 200 UNIT/ML SUBCUTANEOUS200 UNIT/ML

T2

33

Drug Status NotesTRESIBA SOLUTION 100 UNIT/ML SUBCUTANEOUS 100 UNIT/ML T2

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


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


VICTOZA SOLUTION PEN-INJECTOR 18 MG/3ML SUBCUTANEOUS 18 MG/3ML T2 QL (9 ML per 30 days)

XIGDUO XR TABLET EXTENDED RELEASE 24 HOUR 10-1000 MG ORAL 10-1000 MG








*Antidiarrheal/Probiotic Agents*diphenoxylate-atropine liquid 2.5-0.025 mg/5ml oral 2.5-0.025 mg/5ml

T1

diphenoxylate-atropine tablet 2.5-0.025 mg oral2.5-0.025 mg

T1

loperamide hcl oral capsule 2 mg T1

loperamide hcl oral liquid 1 mg/5ml T1

loperamide hcl oral tablet 2 mg T1

MOTOFEN TABLET 1-0.025 MG ORAL 1-0.025 MG T3 PA

*Antidotes And Specific Antagonists*acetylcysteine solution 200 mg/ml intravenous200 mg/ml

T1

CHEMET CAPSULE 100 MG ORAL 100 MG T3

deferasirox oral tablet 180 mg T4 PA

deferasirox oral tablet soluble 125 mg, 250 mg, 500 mg

T4 PA

deferiprone oral tablet 500 mg T4 PA

deferoxamine mesylate solution reconstituted 2 gm injection 2 gm

T1

JADENU TABLET 360 MG ORAL 360 MG T4 PA

34

Drug Status NotesJADENU TABLET 90 MG ORAL 90 MG T4 PA

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

T1 QL (2 ML per 90 days)

naloxone hcl solution prefilled syringe 2 mg/2ml injection 2 mg/2ml


naltrexone hcl tablet 50 mg oral 50 mg T1

NARCAN NASAL LIQUID 4 MG/0.1ML T1

pentetate calcium trisodium solution 200 mg/ml combination 200 mg/ml

T1

pentetate zinc trisodium solution 200 mg/ml combination 200 mg/ml

T1

physostigmine salicylate solution 1 mg/ml injection 1 mg/ml

T1

RADIOGARDASE CAPSULE 0.5 GM ORAL0.5 GM T3 PA

VIVITROL SUSPENSION RECONSTITUTED 380 MG INTRAMUSCULAR 380 MG

T4 PA

*Antiemetics*AKYNZEO CAPSULE 300-0.5 MG ORAL300-0.5 MG T4 PA

ANZEMET TABLET 100 MG ORAL 100 MG T3 ST

ANZEMET TABLET 50 MG ORAL 50 MG T3 ST

aprepitant capsule 125 mg oral 125 mg T3 ST

aprepitant capsule 80 mg oral 80 mg T3 ST

dimenhydrinate solution 50 mg/ml injection 50 mg/ml

T3

dronabinol capsule 10 mg oral 10 mg T4 PA

dronabinol capsule 2.5 mg oral 2.5 mg T3 PA

dronabinol capsule 5 mg oral 5 mg T3 PA

granisetron hcl tablet 1 mg oral 1 mg T3 QL (10 EA per 30 days)

meclizine hcl oral tablet 25 mg T1

meclizine hcl tablet 12.5 mg oral (rx) 12.5 mg T1

ondansetron hcl solution 4 mg/5ml oral 4 mg/5ml T1 QL (50 ML per 30 days)

ondansetron hcl tablet 24 mg oral 24 mg T1 QL (5 EA per 30 days)



ondansetron oral tablet dispersible 4 mg, 8 mg T1 QL (15 EA per 30 days)

trimethobenzamide hcl capsule 300 mg oral 300 mg

T1

35

Drug Status Notes

*Antifungals*CRESEMBA CAPSULE 186 MG ORAL 186 MG T4 PA

fluconazole suspension reconstituted 10 mg/ml oral 10 mg/ml


fluconazole suspension reconstituted 40 mg/ml oral 40 mg/ml


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




flucytosine capsule 250 mg oral 250 mg T4 PA

flucytosine capsule 500 mg oral 500 mg T4 PA

griseofulvin microsize suspension 125 mg/5ml oral 125 mg/5ml

T3

griseofulvin microsize tablet 500 mg oral 500 mg T3

griseofulvin ultramicrosize tablet 125 mg oral125 mg

T3

griseofulvin ultramicrosize tablet 250 mg oral250 mg

T3

itraconazole oral capsule 100 mg T4 PA

ketoconazole tablet 200 mg oral 200 mg T1

nystatin tablet 500000 unit oral 500000 unit T1

terbinafine hcl tablet 250 mg oral 250 mg T1

voriconazole tablet 200 mg oral 200 mg T4 PA

voriconazole tablet 50 mg oral 50 mg T4 PA

*Antihistamines*carbinoxamine maleate tablet 4 mg oral 4 mg T1 AL (Max 64 Years)

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

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

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

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

diphenhydramine hcl elixir 12.5 mg/5ml oral (rx)12.5 mg/5ml


diphenhydramine hcl solution 50 mg/ml injection50 mg/ml


fexofenadine hcl oral tablet 180 mg T1 QL (30 EA per 30 days)

fexofenadine hcl oral tablet 60 mg T1 QL (60 EA per 30 days)

kp diphenhydramine hcl capsule 50 mg oral 50 mg


36

Drug Status Noteslevocetirizine dihydrochloride tablet 5 mg oral (rx) 5 mg


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

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

promethazine hcl solution 25 mg/ml injection 25 mg/ml


promethazine hcl solution 50 mg/ml injection 50 mg/ml


promethazine hcl syrup 6.25 mg/5ml oral 6.25 mg/5ml


promethazine hcl tablet 12.5 mg oral 12.5 mg T1 AL (Max 64 Years)

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

promethazine hcl tablet 50 mg oral 50 mg T1 AL (Max 64 Years)

PROMETHEGAN SUPPOSITORY 12.5 MG RECTAL 12.5 MG T1

QL (12 EA per 30 days); AL (Max 64 Years)

PROMETHEGAN SUPPOSITORY 25 MG RECTAL 25 MG T1


PROMETHEGAN SUPPOSITORY 50 MG RECTAL 50 MG T1


*Antihyperlipidemics*atorvastatin calcium tablet 10 mg oral 10 mg T1 QL (30 EA per 30 days)

atorvastatin calcium tablet 20 mg oral 20 mg T1 QL (30 EA per 30 days)



colesevelam hcl oral packet 3.75 gm T3 PA

colesevelam hcl oral tablet 625 mg T3 PA

colestipol hcl granules 5 gm oral 5 gm T1

colestipol hcl tablet 1 gm oral 1 gm T1

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

ezetimibe-simvastatin tablet 10-10 mg oral 10-10 mg








fenofibrate micronized capsule 134 mg oral 134 mg

T1

37

Drug Status Notesfenofibrate micronized capsule 200 mg oral 200 mg

T1

fenofibrate micronized capsule 43 mg oral 43 mg T1

fenofibrate micronized capsule 67 mg oral 67 mg T1

fenofibrate tablet 145 mg oral 145 mg T1




fenofibric acid capsule delayed release 135 mg oral 135 mg

T3

fenofibric acid capsule delayed release 45 mg oral 45 mg

T3

FIBRICOR TABLET 105 MG ORAL 105 MG T1

FIBRICOR TABLET 35 MG ORAL 35 MG T1

fluvastatin sodium capsule 20 mg oral 20 mg T3

fluvastatin sodium capsule 40 mg oral 40 mg T3

gemfibrozil tablet 600 mg oral 600 mg T1

icosapent ethyl oral capsule 1 gm T3 ST; QL (120 EA per 30 days)

LIVALO TABLET 1 MG ORAL 1 MG T3 ST; QL (30 EA per 30 days)



lovastatin tablet 10 mg oral 10 mg T1



niacin er (antihyperlipidemic) tablet extended release 1000 mg oral 1000 mg

T3


T3


T3

NIACOR TABLET 500 MG ORAL 500 MG T1

omega-3-acid ethyl esters capsule 1 gm oral 1 gm T3 QL (120 EA per 30 days)

PRALUENT SUBCUTANEOUS SOLUTION AUTO-INJECTOR 150 MG/ML, 75 MG/ML T2 PA; QL (2 ML per 28 days)

pravastatin sodium tablet 10 mg oral 10 mg T1




PREVALITE PACKET 4 GM ORAL 4 GM T1 QL (60 EA per 30 days)

38

Drug Status NotesPREVALITE POWDER 4 GM/DOSE ORAL4 GM/DOSE T1 QL (239.4 GM per 30 days)

REPATHA PUSHTRONEX SYSTEM SUBCUTANEOUS SOLUTION CARTRIDGE420 MG/3.5ML


REPATHA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 140 MG/ML T2 PA; QL (2 ML per 28 days)

REPATHA SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 140 MG/ML T2 PA; QL (2 ML per 28 days)

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




simvastatin tablet 10 mg oral 10 mg T1




simvastatin tablet 80 mg oral 80 mg T1 QL (30 EA per 30 days)

*Antihypertensives*aliskiren fumarate oral tablet 150 mg, 300 mg T3

amlodipine besy-benazepril hcl capsule 10-20 mg oral 10-20 mg

T1


T1

amlodipine besy-benazepril hcl capsule 2.5-10 mg oral 2.5-10 mg

T1


T1


T1


T1

amlodipine besylate-valsartan tablet 10-160 mg oral 10-160 mg

T1


T1


T1


T1

amlodipine-olmesartan tablet 10-20 mg oral 10-20 mg

T3 ST

39

Drug Status Notesamlodipine-olmesartan tablet 10-40 mg oral 10-40 mg

T3 ST


T3 ST


T3 ST

atenolol-chlorthalidone tablet 100-25 mg oral100-25 mg

T1

atenolol-chlorthalidone tablet 50-25 mg oral 50-25 mg

T1

benazepril hcl tablet 10 mg oral 10 mg T1




benazepril-hydrochlorothiazide tablet 10-12.5 mg oral 10-12.5 mg

T1


T1

benazepril-hydrochlorothiazide tablet 20-25 mg oral 20-25 mg

T1


T1

bisoprolol-hydrochlorothiazide tablet 10-6.25 mg oral 10-6.25 mg

T1

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

T1

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

T1

candesartan cilexetil tablet 16 mg oral 16 mg T3 QL (30 EA per 30 days)

candesartan cilexetil tablet 32 mg oral 32 mg T3 QL (30 EA per 30 days)

candesartan cilexetil-hctz tablet 16-12.5 mg oral16-12.5 mg


candesartan cilexetil-hctz tablet 32-12.5 mg oral32-12.5 mg


candesartan cilexetil-hctz tablet 32-25 mg oral32-25 mg


captopril tablet 100 mg oral 100 mg T1

captopril tablet 12.5 mg oral 12.5 mg T1



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

T1

40

Drug Status Notescaptopril-hydrochlorothiazide tablet 25-25 mg oral 25-25 mg

T1


T1


T1

clonidine hcl tablet 0.1 mg oral 0.1 mg T1



clonidine patch weekly 0.1 mg/24hr transdermal0.1 mg/24hr

T3


T3


T3

doxazosin mesylate tablet 1 mg oral 1 mg T1 AL (Max 64 Years)




EDARBI TABLET 40 MG ORAL 40 MG T3 PA

EDARBI TABLET 80 MG ORAL 80 MG T3 PA

enalapril maleate tablet 10 mg oral 10 mg T1

enalapril maleate tablet 2.5 mg oral 2.5 mg T1



enalapril-hydrochlorothiazide tablet 10-25 mg oral 10-25 mg

T1

enalapril-hydrochlorothiazide tablet 5-12.5 mg oral 5-12.5 mg

T1

eplerenone tablet 25 mg oral 25 mg T3

eplerenone tablet 50 mg oral 50 mg T3

fosinopril sodium tablet 10 mg oral 10 mg T1



fosinopril sodium-hctz tablet 10-12.5 mg oral 10-12.5 mg

T1

fosinopril sodium-hctz tablet 20-12.5 mg oral 20-12.5 mg

T1

guanfacine hcl tablet 1 mg oral 1 mg T1

guanfacine hcl tablet 2 mg oral 2 mg T1

hydralazine hcl tablet 10 mg oral 10 mg T1

41

Drug Status Noteshydralazine hcl tablet 100 mg oral 100 mg T1



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



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

T1

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

T1

lisinopril tablet 10 mg oral 10 mg T1

lisinopril tablet 2.5 mg oral 2.5 mg T1





lisinopril-hydrochlorothiazide tablet 10-12.5 mg oral 10-12.5 mg

T1

lisinopril-hydrochlorothiazide tablet 20-12.5 mg oral 20-12.5 mg

T1

lisinopril-hydrochlorothiazide tablet 20-25 mg oral 20-25 mg

T1

losartan potassium tablet 100 mg oral 100 mg T1

losartan potassium tablet 25 mg oral 25 mg T1 QL (30 EA per 30 days)

losartan potassium tablet 50 mg oral 50 mg T1 QL (30 EA per 30 days)

losartan potassium-hctz tablet 100-12.5 mg oral100-12.5 mg

T1

losartan potassium-hctz tablet 100-25 mg oral100-25 mg

T1

losartan potassium-hctz tablet 50-12.5 mg oral50-12.5 mg

T1

methyldopa tablet 250 mg oral 250 mg T1

methyldopa tablet 500 mg oral 500 mg T1

metoprolol-hydrochlorothiazide tablet 100-25 mg oral 100-25 mg

T1


T1


T1

minoxidil tablet 10 mg oral 10 mg T1

minoxidil tablet 2.5 mg oral 2.5 mg T1

42

Drug Status Notesmoexipril hcl tablet 15 mg oral 15 mg T1

moexipril hcl tablet 7.5 mg oral 7.5 mg T1

olmesartan medoxomil tablet 20 mg oral 20 mg T1 QL (30 EA per 30 days)



olmesartan medoxomil-hctz tablet 20-12.5 mg oral 20-12.5 mg


olmesartan medoxomil-hctz tablet 40-12.5 mg oral 40-12.5 mg


olmesartan medoxomil-hctz tablet 40-25 mg oral40-25 mg


perindopril erbumine tablet 2 mg oral 2 mg T1



phenoxybenzamine hcl capsule 10 mg oral 10 mg T3 PA

prazosin hcl capsule 1 mg oral 1 mg T1



propranolol-hctz tablet 40-25 mg oral 40-25 mg T1

propranolol-hctz tablet 80-25 mg oral 80-25 mg T1

quinapril hcl tablet 10 mg oral 10 mg T1




quinapril-hydrochlorothiazide tablet 10-12.5 mg oral 10-12.5 mg

T1

quinapril-hydrochlorothiazide tablet 20-12.5 mg oral 20-12.5 mg

T1

quinapril-hydrochlorothiazide tablet 20-25 mg oral 20-25 mg

T1

ramipril capsule 1.25 mg oral 1.25 mg T1

ramipril capsule 10 mg oral 10 mg T1

ramipril capsule 2.5 mg oral 2.5 mg T1

ramipril capsule 5 mg oral 5 mg T1

TEKTURNA HCT TABLET 150-12.5 MG ORAL 150-12.5 MG T3

TEKTURNA HCT TABLET 150-25 MG ORAL 150-25 MG T3

TEKTURNA HCT TABLET 300-12.5 MG ORAL 300-12.5 MG T3

43

Drug Status NotesTEKTURNA HCT TABLET 300-25 MG ORAL 300-25 MG T3

telmisartan tablet 20 mg oral 20 mg T1 QL (30 EA per 30 days)



telmisartan-hctz tablet 40-12.5 mg oral 40-12.5 mg


telmisartan-hctz tablet 80-12.5 mg oral 80-12.5 mg


telmisartan-hctz tablet 80-25 mg oral 80-25 mg T3 QL (30 EA per 30 days)

terazosin hcl capsule 1 mg oral 1 mg T1 AL (Max 64 Years)




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



trandolapril-verapamil hcl er tablet extended release 1-240 mg oral 1-240 mg








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




valsartan-hydrochlorothiazide tablet 160-12.5 mg oral 160-12.5 mg

T1

valsartan-hydrochlorothiazide tablet 160-25 mg oral 160-25 mg

T1


T1

valsartan-hydrochlorothiazide tablet 320-25 mg oral 320-25 mg

T1


T1

44

Drug Status Notes

*Anti-Infective Agents - Misc.*ALINIA SUSPENSION RECONSTITUTED 100 MG/5ML ORAL 100 MG/5ML T4 PA

ALINIA TABLET 500 MG ORAL 500 MG T4 PA

atovaquone suspension 750 mg/5ml oral 750 mg/5ml

T3

clindamycin hcl capsule 150 mg oral 150 mg T1



clindamycin palmitate hcl solution reconstituted 75 mg/5ml oral 75 mg/5ml

T1

dapsone tablet 100 mg oral 100 mg T1

dapsone tablet 25 mg oral 25 mg T1

HYOPHEN ORAL TABLET 81.6 MG T1

linezolid solution 600 mg/300ml intravenous 600 mg/300ml

T3

linezolid suspension reconstituted 100 mg/5ml oral 100 mg/5ml


linezolid tablet 600 mg oral 600 mg T3 QL (28 EA per 14 days)

MACROBID ORAL CAPSULE 100 MG T1

methenamine hippurate oral tablet 1 gm T1

methenamine mandelate oral tablet 0.5 gm T1

metronidazole capsule 375 mg oral 375 mg T1

metronidazole tablet 250 mg oral 250 mg T1

metronidazole tablet 500 mg oral 500 mg T1

MONUROL ORAL PACKET 3 GM T3

nitrofurantoin macrocrystal oral capsule 100 mg, 50 mg

T1

nitrofurantoin monohyd macro capsule 100 mg oral 100 mg

T1

nitrofurantoin oral suspension 25 mg/5ml T3

pentamidine isethionate injection solution reconstituted 300 mg

T3

PHOSPHASAL ORAL TABLET 81.6 MG T1

SIVEXTRO TABLET 200 MG ORAL 200 MG T3 PA

sulfamethoxazole-trimethoprim suspension 200-40 mg/5ml oral 200-40 mg/5ml

T1

sulfamethoxazole-trimethoprim tablet 400-80 mg oral 400-80 mg

T1

sulfamethoxazole-trimethoprim tablet 800-160 mg oral 800-160 mg

T1

45

Drug Status Notestinidazole tablet 250 mg oral 250 mg T3

tinidazole tablet 500 mg oral 500 mg T3

trimethoprim tablet 100 mg oral 100 mg T1

URIMAR-T ORAL TABLET 120 MG T1

USTELL ORAL CAPSULE 120 MG T1

vancomycin hcl in dextrose intravenous solution1-5 gm/200ml-%

T1

vancomycin hcl intravenous solution reconstituted1 gm, 500 mg, 750 mg

T1

vancomycin hcl intravenous solution reconstituted10 gm

T3

XIFAXAN TABLET 200 MG ORAL 200 MG T4 PA

XIFAXAN TABLET 550 MG ORAL 550 MG T4 PA

*Antimalarials*atovaquone-proguanil hcl tablet 250-100 mg oral250-100 mg


atovaquone-proguanil hcl tablet 62.5-25 mg oral62.5-25 mg


chloroquine phosphate tablet 250 mg oral 250 mg T1

chloroquine phosphate tablet 500 mg oral 500 mg T1

COARTEM ORAL TABLET 20-120 MG T3

DARAPRIM TABLET 25 MG ORAL 25 MG T4 PA

hydroxychloroquine sulfate tablet 200 mg oral200 mg

T1

mefloquine hcl tablet 250 mg oral 250 mg T1

primaquine phosphate tablet 26.3 mg oral 26.3 mg

T1

quinine sulfate capsule 324 mg oral 324 mg T1

*Antimyasthenic/Cholinergic Agents*MESTINON SOLUTION 60 MG/5ML ORAL60 MG/5ML T2 PA

pyridostigmine bromide er tablet extended release 180 mg oral 180 mg

T2 PA

pyridostigmine bromide oral solution 60 mg/5ml T2 PA

pyridostigmine bromide tablet 60 mg oral 60 mg T1

*Antimycobacterial Agents*cycloserine capsule 250 mg oral 250 mg T3 PA

ethambutol hcl tablet 100 mg oral 100 mg T1

ethambutol hcl tablet 400 mg oral 400 mg T1

isoniazid syrup 50 mg/5ml oral 50 mg/5ml T1

46

Drug Status Notesisoniazid tablet 100 mg oral 100 mg T1

isoniazid tablet 300 mg oral 300 mg T1

PRIFTIN ORAL TABLET 150 MG T2

pyrazinamide tablet 500 mg oral 500 mg T3

rifabutin capsule 150 mg oral 150 mg T2 PA

rifampin capsule 150 mg oral 150 mg T1

rifampin capsule 300 mg oral 300 mg T1

*Antineoplastics And Adjunctive Therapies*abiraterone acetate oral tablet 250 mg T4 PA

ACTIMMUNE SOLUTION 2000000 UNIT/0.5ML SUBCUTANEOUS 2000000 UNIT/0.5ML

T4 PA

AFINITOR TABLET 10 MG ORAL 10 MG T4 PA

anastrozole tablet 1 mg oral 1 mg T1

bexarotene capsule 75 mg oral 75 mg T4 PA

bicalutamide tablet 50 mg oral 50 mg T1

BOSULIF TABLET 100 MG ORAL 100 MG T4 PA

BOSULIF TABLET 500 MG ORAL 500 MG T4 PA

capecitabine tablet 150 mg oral 150 mg T4 PA

capecitabine tablet 500 mg oral 500 mg T4 PA

CAPRELSA TABLET 100 MG ORAL 100 MG T4 PA

CAPRELSA TABLET 300 MG ORAL 300 MG T4 PA

COMETRIQ (100 MG DAILY DOSE) KIT 80 & 20 MG ORAL 80 & 20 MG T4 PA

COMETRIQ (140 MG DAILY DOSE) KIT 3 X 20 MG & 80 MG ORAL 3 X 20 MG & 80 MG

T4 PA

COMETRIQ (60 MG DAILY DOSE) KIT 20 MG ORAL 20 MG T4 PA

cyclophosphamide oral capsule 25 mg, 50 mg T3 PA

DEPO-PROVERA SUSPENSION 400 MG/ML INTRAMUSCULAR 400 MG/ML T3

ELIGARD KIT 22.5 MG SUBCUTANEOUS22.5 MG T4 PA

ELIGARD KIT 30 MG SUBCUTANEOUS 30 MG T4 PA

ELIGARD KIT 45 MG SUBCUTANEOUS 45 MG T4 PA

47

Drug Status NotesELIGARD KIT 7.5 MG SUBCUTANEOUS7.5 MG T4 PA

EMCYT CAPSULE 140 MG ORAL 140 MG T3

ERIVEDGE CAPSULE 150 MG ORAL 150 MG T4 PA

everolimus oral tablet 2.5 mg, 5 mg, 7.5 mg T4 PA

exemestane tablet 25 mg oral 25 mg T3

FARYDAK CAPSULE 10 MG ORAL 10 MG T4 PA

FARYDAK CAPSULE 20 MG ORAL 20 MG T4 PA

FASLODEX SOLUTION 250 MG/5ML INTRAMUSCULAR 250 MG/5ML T4 PA

FIRMAGON (240 MG DOSE) SOLUTION RECONSTITUTED 120 MG/VIAL SUBCUTANEOUS 120 MG/VIAL

T4 PA

FIRMAGON SOLUTION RECONSTITUTED 80 MG SUBCUTANEOUS 80 MG T4 PA

flutamide capsule 125 mg oral 125 mg T3

GILOTRIF TABLET 20 MG ORAL 20 MG T4 PA



GLEOSTINE CAPSULE 10 MG ORAL 10 MG T4 PA



hydroxyprogesterone caproate solution 1.25 gm/5ml intramuscular 1.25 gm/5ml

T4 PA; GR-F

hydroxyurea capsule 500 mg oral 500 mg T1

IBRANCE CAPSULE 100 MG ORAL 100 MG T4 PA



IBRANCE ORAL TABLET 100 MG, 125 MG, 75 MG T4 PA

ICLUSIG TABLET 15 MG ORAL 15 MG T4 PA

ICLUSIG TABLET 45 MG ORAL 45 MG T4 PA

imatinib mesylate tablet 100 mg oral 100 mg T4 PA

imatinib mesylate tablet 400 mg oral 400 mg T4 PA

IMBRUVICA CAPSULE 140 MG ORAL 140 MG T4 PA

INLYTA TABLET 1 MG ORAL 1 MG T4 PA

48

Drug Status NotesINLYTA TABLET 5 MG ORAL 5 MG T4 PA

INTRON A SOLUTION 6000000 UNIT/ML INJECTION 6000000 UNIT/ML T4 PA

INTRON A SOLUTION RECONSTITUTED 10000000 UNIT INJECTION 10000000 UNIT T4 PA



JAKAFI TABLET 10 MG ORAL 10 MG T4 PA





KYPROLIS SOLUTION RECONSTITUTED 60 MG INTRAVENOUS 60 MG T4 PA

lapatinib ditosylate oral tablet 250 mg T4 PA

letrozole tablet 2.5 mg oral 2.5 mg T1GR-F; QL (30 EA per 30 days); AL (Min 18 Years)

leucovorin calcium tablet 10 mg oral 10 mg T1




LEUKERAN TABLET 2 MG ORAL 2 MG T4 PA

leuprolide acetate kit 1 mg/0.2ml injection 1 mg/0.2ml

T4 PA

LUPRON DEPOT (1-MONTH) KIT 3.75 MG INTRAMUSCULAR 3.75 MG T4 PA




LUPRON DEPOT (4-MONTH) KIT 30 MG INTRAMUSCULAR 30 MG T4 PA

LUPRON DEPOT (6-MONTH) KIT 45 MG INTRAMUSCULAR 45 MG T4 PA

LYSODREN ORAL TABLET 500 MG T3 PA

MATULANE CAPSULE 50 MG ORAL 50 MG T4 PA

49

Drug Status Notesmegestrol acetate suspension 400 mg/10ml oral400 mg/10ml

T1

megestrol acetate tablet 20 mg oral 20 mg T1

megestrol acetate tablet 40 mg oral 40 mg T1

MEKINIST TABLET 0.5 MG ORAL 0.5 MG T4 PA

MEKINIST TABLET 2 MG ORAL 2 MG T4 PA

mercaptopurine tablet 50 mg oral 50 mg T1

MESNEX TABLET 400 MG ORAL 400 MG T4 PA

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

T1

methotrexate sodium injection solution 50 mg/2ml T1

methotrexate sodium solution reconstituted 1 gm injection 1 gm

T1

methotrexate tablet 2.5 mg oral 2.5 mg T1

MYLERAN TABLET 2 MG ORAL 2 MG T4 PA

NEXAVAR TABLET 200 MG ORAL 200 MG T4 PA

ODOMZO CAPSULE 200 MG ORAL 200 MG T4 PA

POMALYST CAPSULE 1 MG ORAL 1 MG T4 PA




SPRYCEL TABLET 100 MG ORAL 100 MG T4 PA






STIVARGA TABLET 40 MG ORAL 40 MG T4 PA

SUTENT CAPSULE 12.5 MG ORAL 12.5 MG T4 PA

SUTENT CAPSULE 25 MG ORAL 25 MG T4 PA

SUTENT CAPSULE 50 MG ORAL 50 MG T4 PA

TABLOID TABLET 40 MG ORAL 40 MG T4 PA

TAFINLAR CAPSULE 50 MG ORAL 50 MG T4 PA

TAFINLAR CAPSULE 75 MG ORAL 75 MG T4 PA

tamoxifen citrate tablet 10 mg oral 10 mg T5

tamoxifen citrate tablet 20 mg oral 20 mg T5

TARCEVA TABLET 100 MG ORAL 100 MG T4 PA

TARCEVA TABLET 150 MG ORAL 150 MG T4 PA

50

Drug Status NotesTARCEVA TABLET 25 MG ORAL 25 MG T4 PA

TASIGNA CAPSULE 150 MG ORAL 150 MG T4 PA

TASIGNA CAPSULE 200 MG ORAL 200 MG T4 PA

TASIGNA ORAL CAPSULE 50 MG T4 PA

toremifene citrate oral tablet 60 mg T4 PA

TRELSTAR MIXJECT SUSPENSION RECONSTITUTED 22.5 MG INTRAMUSCULAR 22.5 MG

T4 PA

tretinoin capsule 10 mg oral 10 mg T4 PA

TREXALL TABLET 10 MG ORAL 10 MG T3 PA



TREXALL TABLET 7.5 MG ORAL 7.5 MG T3 PA

VALSTAR SOLUTION 40 MG/ML INTRAVESICAL 40 MG/ML T4 PA

VANTAS KIT 50 MG SUBCUTANEOUS 50 MG T4 PA

VOTRIENT TABLET 200 MG ORAL 200 MG T4 PA

XALKORI CAPSULE 200 MG ORAL 200 MG T4 PA

XALKORI CAPSULE 250 MG ORAL 250 MG T4 PA

ZOLADEX IMPLANT 10.8 MG SUBCUTANEOUS 10.8 MG T3 PA

ZOLADEX IMPLANT 3.6 MG SUBCUTANEOUS 3.6 MG T3 PA

ZOLINZA CAPSULE 100 MG ORAL 100 MG T4 PA

ZYDELIG TABLET 100 MG ORAL 100 MG T4 PA

ZYDELIG TABLET 150 MG ORAL 150 MG T4 PA

*Antiparkinson And Related Therapy Agents*amantadine hcl capsule 100 mg oral 100 mg T1

amantadine hcl syrup 50 mg/5ml oral 50 mg/5ml T1

amantadine hcl tablet 100 mg oral 100 mg T1

benztropine mesylate solution 1 mg/ml injection 1 mg/ml

T3

benztropine mesylate tablet 0.5 mg oral 0.5 mg T1 AL (Max 64 Years)

benztropine mesylate tablet 1 mg oral 1 mg T1 AL (Max 64 Years)

benztropine mesylate tablet 2 mg oral 2 mg T1 AL (Max 64 Years)

bromocriptine mesylate capsule 5 mg oral 5 mg T3

51

Drug Status Notesbromocriptine mesylate tablet 2.5 mg oral 2.5 mg T1

carbidopa tablet 25 mg oral 25 mg T3

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

T1

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

T1

carbidopa-levodopa tablet 10-100 mg oral 10-100 mg

T1


T1


T1

carbidopa-levodopa tablet dispersible 10-100 mg oral 10-100 mg

T1


T1


T1

entacapone tablet 200 mg oral 200 mg T3

NEUPRO PATCH 24 HOUR 1 MG/24HR TRANSDERMAL 1 MG/24HR T3 PA






pramipexole dihydrochloride er tablet extended release 24 hour 0.375 mg oral 0.375 mg








pramipexole dihydrochloride er tablet extended release 24 hour 3 mg oral 3 mg




52

Drug Status Notespramipexole dihydrochloride er tablet extended release 24 hour 4.5 mg oral 4.5 mg


pramipexole dihydrochloride tablet 0.125 mg oral0.125 mg

T1


T1


T1


T1

pramipexole dihydrochloride tablet 1 mg oral 1 mg

T1


T1

rasagiline mesylate tablet 0.5 mg oral 0.5 mg T3

rasagiline mesylate tablet 1 mg oral 1 mg T3

ropinirole hcl er tablet extended release 24 hour 12 mg oral 12 mg










ropinirole hcl tablet 0.25 mg oral 0.25 mg T1

ropinirole hcl tablet 0.5 mg oral 0.5 mg T1

ropinirole hcl tablet 1 mg oral 1 mg T1





selegiline hcl capsule 5 mg oral 5 mg T1

selegiline hcl tablet 5 mg oral 5 mg T1

tolcapone tablet 100 mg oral 100 mg T4 PA

trihexyphenidyl hcl oral tablet 5 mg T1

*Antipsychotics/Antimanic Agents*ABILIFY MAINTENA INTRAMUSCULAR PREFILLED SYRINGE 300 MG T4 PA

aripiprazole solution 1 mg/ml oral 1 mg/ml T3 PA

53

Drug Status Notesaripiprazole tablet 10 mg oral 10 mg T1 QL (30 EA per 30 days)

aripiprazole tablet 15 mg oral 15 mg T1 QL (30 EA per 30 days)





aripiprazole tablet dispersible 10 mg oral 10 mg T3 PA

aripiprazole tablet dispersible 15 mg oral 15 mg T3 PA

chlorpromazine hcl tablet 10 mg oral 10 mg T1





clozapine oral tablet dispersible 12.5 mg T3

clozapine tablet 100 mg oral 100 mg T1




clozapine tablet dispersible 100 mg oral 100 mg T3

clozapine tablet dispersible 25 mg oral 25 mg T3

FANAPT TABLET 1 MG ORAL 1 MG T4 PA







fluphenazine decanoate solution 25 mg/ml injection 25 mg/ml

T3

fluphenazine hcl concentrate 5 mg/ml oral 5 mg/ml

T3

fluphenazine hcl elixir 2.5 mg/5ml oral 2.5 mg/5ml

T1

fluphenazine hcl solution 2.5 mg/ml injection 2.5 mg/ml

T3

fluphenazine hcl tablet 1 mg oral 1 mg T1


fluphenazine hcl tablet 2.5 mg oral 2.5 mg T1


54

Drug Status Noteshaloperidol decanoate solution 100 mg/ml intramuscular 100 mg/ml

T1

haloperidol decanoate solution 50 mg/ml intramuscular 50 mg/ml

T1

haloperidol lactate concentrate 2 mg/ml oral 2 mg/ml

T1

haloperidol lactate solution 5 mg/ml injection 5 mg/ml

T1

haloperidol tablet 0.5 mg oral 0.5 mg T1

haloperidol tablet 1 mg oral 1 mg T1





LATUDA TABLET 120 MG ORAL 120 MG T3 PA




lithium carbonate capsule 150 mg oral 150 mg T1



lithium carbonate er tablet extended release 300 mg oral 300 mg

T1

lithium carbonate er tablet extended release 450 mg oral 450 mg

T1

lithium carbonate tablet 300 mg oral 300 mg T1

lithium solution 8 meq/5ml oral 8 meq/5ml T1

loxapine succinate capsule 10 mg oral 10 mg T1




olanzapine solution reconstituted 10 mg intramuscular 10 mg

T2

olanzapine tablet 10 mg oral 10 mg T1


olanzapine tablet 2.5 mg oral 2.5 mg T1



olanzapine tablet 7.5 mg oral 7.5 mg T1

olanzapine tablet dispersible 10 mg oral 10 mg T2

55

Drug Status Notesolanzapine tablet dispersible 15 mg oral 15 mg T2



paliperidone er tablet extended release 24 hour 1.5 mg oral 1.5 mg

T4 PA

paliperidone er tablet extended release 24 hour 3 mg oral 3 mg

T4 PA


T4 PA


T4 PA

perphenazine tablet 16 mg oral 16 mg T1




prochlorperazine maleate tablet 10 mg oral 10 mg

T1

prochlorperazine maleate tablet 5 mg oral 5 mg T1

prochlorperazine suppository 25 mg rectal 25 mg T1

quetiapine fumarate er oral tablet extended release 24 hour 150 mg, 200 mg, 50 mg


quetiapine fumarate er oral tablet extended release 24 hour 300 mg, 400 mg


quetiapine fumarate tablet 100 mg oral 100 mg T1






REXULTI TABLET 0.25 MG ORAL 0.25 MG T4 PA

REXULTI TABLET 0.5 MG ORAL 0.5 MG T4 PA

REXULTI TABLET 1 MG ORAL 1 MG T4 PA




risperidone solution 1 mg/ml oral 1 mg/ml T3

risperidone tablet 0.25 mg oral 0.25 mg T1

risperidone tablet 0.5 mg oral 0.5 mg T1

risperidone tablet 1 mg oral 1 mg T1


56

Drug Status Notesrisperidone tablet 3 mg oral 3 mg T1


risperidone tablet dispersible 0.25 mg oral 0.25 mg

T3

risperidone tablet dispersible 1 mg oral 1 mg T3



SAPHRIS TABLET SUBLINGUAL 10 MG SUBLINGUAL 10 MG T3 PA

SAPHRIS TABLET SUBLINGUAL 5 MG SUBLINGUAL 5 MG T3 PA

thioridazine hcl tablet 10 mg oral 10 mg T2




thiothixene capsule 1 mg oral 1 mg T1




trifluoperazine hcl tablet 1 mg oral 1 mg T1




ziprasidone hcl oral capsule 20 mg, 40 mg, 60 mg, 80 mg

T1

*Antiseptics & Disinfectants*chlorhexidine gluconate solution 20 % 20 % T3

*Antivirals*abacavir sulfate oral solution 20 mg/ml T4 QL (900 ML per 30 days)

abacavir sulfate tablet 300 mg oral 300 mg T3 QL (60 EA per 30 days)

abacavir sulfate-lamivudine tablet 600-300 mg oral 600-300 mg


abacavir-lamivudine-zidovudine tablet 300-150-300 mg oral 300-150-300 mg


acyclovir capsule 200 mg oral 200 mg T1

acyclovir suspension 200 mg/5ml oral 200 mg/5ml


acyclovir tablet 400 mg oral 400 mg T1

acyclovir tablet 800 mg oral 800 mg T1

adefovir dipivoxil tablet 10 mg oral 10 mg T4 PA

57

Drug Status NotesAPTIVUS CAPSULE 250 MG ORAL 250 MG T4 QL (120 EA per 30 days)

APTIVUS SOLUTION 100 MG/ML ORAL100 MG/ML T4 QL (300 ML per 30 days)

atazanavir sulfate oral capsule 300 mg T4 QL (30 EA per 30 days)

BARACLUDE SOLUTION 0.05 MG/ML ORAL 0.05 MG/ML T4 PA

BIKTARVY ORAL TABLET 50-200-25 MG T4 QL (30 EA per 30 days)

COMPLERA TABLET 200-25-300 MG ORAL 200-25-300 MG T4 QL (30 EA per 30 days)

CRIXIVAN CAPSULE 200 MG ORAL 200 MG T4 QL (360 EA per 30 days)

CRIXIVAN CAPSULE 400 MG ORAL 400 MG T4 QL (180 EA per 30 days)

DESCOVY ORAL TABLET 200-25 MG T4 QL (30 EA per 30 days)

didanosine capsule delayed release 200 mg oral200 mg






EDURANT TABLET 25 MG ORAL 25 MG T4 QL (30 EA per 30 days)

efavirenz oral capsule 200 mg T4 QL (90 EA per 30 days)

efavirenz oral capsule 50 mg T4 QL (360 EA per 30 days)

efavirenz oral tablet 600 mg T4 QL (30 EA per 30 days)

efavirenz-emtricitab-tenofovir oral tablet 600-200-300 mg


efavirenz-lamivudine-tenofovir oral tablet 400-300-300 mg


efavirenz-lamivudine-tenofovir oral tablet 600-300-300 mg

T4

emtricitabine oral capsule 200 mg T4

emtricitabine-tenofovir df oral tablet 200-300 mg T4 QL (30 EA per 30 days)

EMTRIVA SOLUTION 10 MG/ML ORAL 10 MG/ML T4

EPIVIR HBV SOLUTION 5 MG/ML ORAL 5 MG/ML T3 QL (1800 ML per 30 days)

EVOTAZ TABLET 300-150 MG ORAL 300-150 MG T4 QL (30 EA per 30 days)

famciclovir tablet 125 mg oral 125 mg T3 QL (90 EA per 30 days)



fosamprenavir calcium oral tablet 700 mg T4 QL (120 EA per 30 days)

58

Drug Status NotesFUZEON SOLUTION RECONSTITUTED 90 MG SUBCUTANEOUS 90 MG T4 QL (60 EA per 30 days)

GENVOYA ORAL TABLET 150-150-200-10 MG T4 QL (30 EA per 30 days)

INTELENCE TABLET 100 MG ORAL 100 MG T4 QL (120 EA per 30 days)



INVIRASE TABLET 500 MG ORAL 500 MG T4 QL (120 EA per 30 days)

ISENTRESS TABLET 400 MG ORAL 400 MG T4 QL (60 EA per 30 days)

ISENTRESS TABLET CHEWABLE 100 MG ORAL 100 MG T4 QL (60 EA per 30 days)

ISENTRESS TABLET CHEWABLE 25 MG ORAL 25 MG T4 QL (60 EA per 30 days)

KALETRA TABLET 100-25 MG ORAL 100-25 MG T4 QL (360 EA per 30 days)

KALETRA TABLET 200-50 MG ORAL 200-50 MG T4 QL (180 EA per 30 days)

lamivudine solution 10 mg/ml oral 10 mg/ml T3 QL (900 ML per 30 days)

lamivudine tablet 100 mg oral 100 mg T2 QL (90 EA per 30 days)



lamivudine-zidovudine tablet 150-300 mg oral150-300 mg


LEXIVA SUSPENSION 50 MG/ML ORAL 50 MG/ML T4 QL (180 ML per 30 days)

lopinavir-ritonavir solution 400-100 mg/5ml oral400-100 mg/5ml


MAVYRET ORAL TABLET 100-40 MG T4 PA

nevirapine er tablet extended release 24 hour 400 mg oral 400 mg


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

NORVIR SOLUTION 80 MG/ML ORAL 80 MG/ML T4 QL (450 ML per 30 days)

oseltamivir phosphate capsule 30 mg oral 30 mg T1 QL (10 EA per 10 days)



oseltamivir phosphate oral suspension reconstituted 6 mg/ml


59

Drug Status NotesPEGASYS SOLUTION 180 MCG/ML SUBCUTANEOUS 180 MCG/ML T4 PA

PEGINTRON KIT 50 MCG/0.5ML SUBCUTANEOUS 50 MCG/0.5ML T4 PA

PREZCOBIX TABLET 800-150 MG ORAL800-150 MG T4 QL (30 EA per 30 days)

PREZISTA SUSPENSION 100 MG/ML ORAL 100 MG/ML T4 QL (480 ML per 30 days)

PREZISTA TABLET 150 MG ORAL 150 MG T4 QL (240 EA per 30 days)




RELENZA DISKHALER AEROSOL POWDER BREATH ACTIVATED 5 MG/BLISTER INHALATION 5 MG/BLISTER


REYATAZ CAPSULE 150 MG ORAL 150 MG T4 QL (60 EA per 30 days)



ribavirin capsule 200 mg oral 200 mg T4 PA

rimantadine hcl tablet 100 mg oral 100 mg T1

ritonavir oral tablet 100 mg T4 QL (360 EA per 30 days)

SELZENTRY TABLET 150 MG ORAL 150 MG T4 QL (120 EA per 30 days)

SELZENTRY TABLET 300 MG ORAL 300 MG T4 QL (120 EA per 30 days)

sofosbuvir-velpatasvir tablet 400-100 mg oral400-100 mg


stavudine capsule 15 mg oral 15 mg T1 QL (60 EA per 30 days)




STRIBILD TABLET 150-150-200-300 MG ORAL 150-150-200-300 MG T4 QL (30 EA per 30 days)

tenofovir disoproxil fumarate oral tablet 300 mg T4 QL (30 EA per 30 days)

TIVICAY TABLET 50 MG ORAL 50 MG T4 QL (30 EA per 30 days)

TRIUMEQ TABLET 600-50-300 MG ORAL600-50-300 MG T4 QL (30 EA per 30 days)

60

Drug Status NotesTRUVADA TABLET 100-150 MG ORAL 100-150 MG T4 QL (30 EA per 30 days)

TRUVADA TABLET 133-200 MG ORAL 133-200 MG T4 QL (30 EA per 30 days)

TRUVADA TABLET 167-250 MG ORAL 167-250 MG T4 QL (30 EA per 30 days)

valacyclovir hcl tablet 1 gm oral 1 gm T1

valacyclovir hcl tablet 500 mg oral 500 mg T1

valganciclovir hcl solution reconstituted 50 mg/ml oral 50 mg/ml

T4 PA

valganciclovir hcl tablet 450 mg oral 450 mg T4 PA

VIRACEPT TABLET 250 MG ORAL 250 MG T4 QL (300 EA per 30 days)

VIRACEPT TABLET 625 MG ORAL 625 MG T4 QL (120 EA per 30 days)

VIRAMUNE SUSPENSION 50 MG/5ML ORAL 50 MG/5ML T2 QL (1200 ML per 30 days)

VIREAD TABLET 150 MG ORAL 150 MG T4 QL (30 EA per 30 days)



ZEPATIER TABLET 50-100 MG ORAL 50-100 MG T4 PA

zidovudine capsule 100 mg oral 100 mg T1 QL (180 EA per 30 days)

zidovudine syrup 50 mg/5ml oral 50 mg/5ml T1 QL (1800 ML per 30 days)

zidovudine tablet 300 mg oral 300 mg T1 QL (60 EA per 30 days)

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

acebutolol hcl capsule 400 mg oral 400 mg T1

atenolol tablet 100 mg oral 100 mg T1



betaxolol hcl tablet 10 mg oral 10 mg T1

betaxolol hcl tablet 20 mg oral 20 mg T1

bisoprolol fumarate tablet 10 mg oral 10 mg T1

bisoprolol fumarate tablet 5 mg oral 5 mg T1

BYSTOLIC TABLET 10 MG ORAL 10 MG T3

BYSTOLIC TABLET 2.5 MG ORAL 2.5 MG T3



carvedilol phosphate er oral capsule extended release 24 hour 10 mg, 20 mg, 40 mg, 80 mg

T3 ST

carvedilol tablet 12.5 mg oral 12.5 mg T1

61

Drug Status Notescarvedilol tablet 25 mg oral 25 mg T1



labetalol hcl tablet 100 mg oral 100 mg T1



metoprolol succinate er tablet extended release 24 hour 100 mg oral 100 mg








metoprolol tartrate tablet 100 mg oral 100 mg T1



nadolol tablet 20 mg oral 20 mg T1



pindolol tablet 10 mg oral 10 mg T1

pindolol tablet 5 mg oral 5 mg T1

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

T1 ST


T1 ST


T1 ST


T1 ST

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

T1

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

T1

propranolol hcl tablet 10 mg oral 10 mg T1





sotalol hcl (af) tablet 120 mg oral 120 mg T1

sotalol hcl (af) tablet 160 mg oral 160 mg T1

62

Drug Status Notessotalol hcl (af) tablet 80 mg oral 80 mg T1

sotalol hcl tablet 120 mg oral 120 mg T1




timolol maleate tablet 10 mg oral 10 mg T1



*Calcium Channel Blockers*AFEDITAB CR TABLET EXTENDED RELEASE 24 HOUR 30 MG ORAL 30 MG T1 QL (30 EA per 30 days)

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

amlodipine besylate tablet 2.5 mg oral 2.5 mg T1 QL (30 EA per 30 days)

amlodipine besylate tablet 5 mg oral 5 mg T1 QL (30 EA per 30 days)

CARTIA XT CAPSULE EXTENDED RELEASE 24 HOUR 120 MG ORAL 120 MG T1 QL (30 EA per 30 days)




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


diltiazem hcl er beads oral capsule extended release 24 hour 360 mg


diltiazem hcl er capsule extended release 12 hour 120 mg oral 120 mg








diltiazem hcl tablet 120 mg oral 120 mg T1




dilt-xr capsule extended release 24 hour 240 mg oral 240 mg


63

Drug Status Notesfelodipine er tablet extended release 24 hour 10 mg oral 10 mg


felodipine er tablet extended release 24 hour 2.5 mg oral 2.5 mg


felodipine er tablet extended release 24 hour 5 mg oral 5 mg


isradipine capsule 2.5 mg oral 2.5 mg T1

isradipine capsule 5 mg oral 5 mg T1

nicardipine hcl capsule 20 mg oral 20 mg T1

nicardipine hcl capsule 30 mg oral 30 mg T1

nifedipine capsule 10 mg oral 10 mg T1

nifedipine capsule 20 mg oral 20 mg T1

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






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


nimodipine capsule 30 mg oral 30 mg T3

nisoldipine er tablet extended release 24 hour 17 mg oral 17 mg

T3


T1

nisoldipine er tablet extended release 24 hour 25.5 mg oral 25.5 mg

T1


T1


T3


T1

nisoldipine er tablet extended release 24 hour 8.5 mg oral 8.5 mg

T3

TAZTIA XT CAPSULE EXTENDED RELEASE 24 HOUR 120 MG ORAL 120 MG T1 QL (30 EA per 30 days)




64

Drug Status Notesverapamil hcl er capsule extended release 24 hour 100 mg oral 100 mg


verapamil hcl er capsule extended release 24 hour 120 mg oral 120 mg












verapamil hcl er tablet extended release 120 mg oral 120 mg






verapamil hcl tablet 120 mg oral 120 mg T1



*Cardiotonics*digoxin solution 0.05 mg/ml oral 0.05 mg/ml T1

digoxin tablet 125 mcg oral 125 mcg T1

digoxin tablet 250 mcg oral 250 mcg T1

*Cardiovascular Agents - Misc.*ADCIRCA TABLET 20 MG ORAL 20 MG T4 PA

ADEMPAS TABLET 0.5 MG ORAL 0.5 MG T4 PA

ADEMPAS TABLET 1 MG ORAL 1 MG T4 PA


ADEMPAS TABLET 2 MG ORAL 2 MG T4 PA


ambrisentan oral tablet 10 mg, 5 mg T4 PA

CORLANOR ORAL TABLET 5 MG, 7.5 MG T3 PA

OPSUMIT TABLET 10 MG ORAL 10 MG T4 PA

sildenafil citrate tablet 20 mg oral 20 mg T1 PA

tadalafil oral tablet 2.5 mg, 5 mg T3 PA

TRACLEER TABLET 125 MG ORAL 125 MG T4 PA

65

Drug Status NotesTRACLEER TABLET 62.5 MG ORAL 62.5 MG T4 PA

TYVASO STARTER SOLUTION 0.6 MG/ML INHALATION 0.6 MG/ML T4 PA

UPTRAVI TABLET 1000 MCG ORAL 1000 MCG T4 PA








VENTAVIS SOLUTION 10 MCG/ML INHALATION 10 MCG/ML T4 PA

VENTAVIS SOLUTION 20 MCG/ML INHALATION 20 MCG/ML T4 PA

*Cephalosporins*cefaclor capsule 250 mg oral 250 mg T1

cefaclor capsule 500 mg oral 500 mg T1

cefaclor suspension reconstituted 125 mg/5ml oral 125 mg/5ml

T1


T1


T1

cefadroxil capsule 500 mg oral 500 mg T1

cefadroxil suspension reconstituted 250 mg/5ml oral 250 mg/5ml

T1

cefadroxil suspension reconstituted 500 mg/5ml oral 500 mg/5ml

T1

cefadroxil tablet 1 gm oral 1 gm T1

cefdinir capsule 300 mg oral 300 mg T1

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

T1

66

Drug Status Notescefditoren pivoxil tablet 400 mg oral 400 mg T2

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

T1

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

T1

cefpodoxime proxetil tablet 100 mg oral 100 mg T1

cefpodoxime proxetil tablet 200 mg oral 200 mg T1

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

T1

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

T1

cefprozil tablet 250 mg oral 250 mg T1

cefprozil tablet 500 mg oral 500 mg T1

cefuroxime axetil tablet 250 mg oral 250 mg T1

cefuroxime axetil tablet 500 mg oral 500 mg T1

cephalexin capsule 250 mg oral 250 mg T1

cephalexin capsule 500 mg oral 500 mg T1

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

T1

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

T1

cephalexin tablet 250 mg oral 250 mg T1

cephalexin tablet 500 mg oral 500 mg T1

SUPRAX SUSPENSION RECONSTITUTED 500 MG/5ML ORAL 500 MG/5ML T3

*Chemicals*coal tar solution T1

iodine strong (lugol's) solution (otc) T1

*Contraceptives*ARANELLE ORAL TABLET 0.5/1/0.5-35 MG-MCG T5 QL (28 EA per 28 days)

BALCOLTRA ORAL TABLET 0.1-20 MG-MCG(21) T5 PA; QL (28 EA per 21 days)

BALZIVA ORAL TABLET 0.4-35 MG-MCG T5 GR-F; QL (28 EA per 21 days)

DEPO-SUBQ PROVERA 104 SUSPENSION PREFILLED SYRINGE 104 MG/0.65ML SUBCUTANEOUS 104 MG/0.65ML

T3 GR-F; QL (1 ML per 90 days)

desogestrel-ethinyl estradiol oral tablet 0.15-0.02/0.01 mg (21/5)


desogestrel-ethinyl estradiol oral tablet 0.15-30 mg-mcg


67

Drug Status Notesdrospiren-eth estrad-levomefol oral tablet 3-0.02-0.451 mg, 3-0.03-0.451 mg


drospirenone-ethinyl estradiol oral tablet 3-0.02 mg, 3-0.03 mg


ELLA TABLET 30 MG ORAL 30 MG T5 GR-F; QL (1 EA per 30 days)

ethynodiol diac-eth estradiol oral tablet 1-50 mg-mcg


GIANVI ORAL TABLET 3-0.02 MG T5 PA; QL (28 EA per 21 days)

JASMIEL ORAL TABLET 3-0.02 MG T5 PA; QL (28 EA per 21 days)

JUNEL 1.5/30 TABLET 1.5-30 MG-MCG ORAL 1.5-30 MG-MCG T5 GR-F; QL (21 EA per 21 days)

JUNEL FE 1.5/30 TABLET 1.5-30 MG-MCG ORAL 1.5-30 MG-MCG T5 GR-F; QL (28 EA per 21 days)

levonorgest-eth est & eth est oral tablet 42-21-21-7 days


levonorgest-eth estrad 91-day oral tablet 0.15-0.03 &0.01 mg


levonorgest-eth estrad 91-day oral tablet 0.15-0.03 mg


levonorgest-eth estrad 91-day tablet 0.1-0.02 & 0.01 mg oral 0.1-0.02 & 0.01 mg

T5 GR-F; QL (91 EA per 91 days)

levonorgestrel tablet 1.5 mg oral (otc) 1.5 mg T5 GR-F; QL (1 EA per 30 days)

levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg, 0.15-30 mg-mcg


levonorgestrel-ethinyl estrad oral tablet 90-20 mcg


LO LOESTRIN FE ORAL TABLET 1 MG-10 MCG / 10 MCG T5 PA; QL (28 EA per 21 days)

LORYNA ORAL TABLET 3-0.02 MG T5 PA; QL (28 EA per 21 days)

LOW-OGESTREL TABLET 0.3-30 MG-MCG ORAL 0.3-30 MG-MCG T5 GR-F; QL (28 EA per 21 days)

LO-ZUMANDIMINE ORAL TABLET 3-0.02 MG T5 PA; QL (28 EA per 21 days)

medroxyprogesterone acetate suspension 150 mg/ml intramuscular 150 mg/ml

T5 GR-F; QL (1 ML per 90 days)

NIKKI ORAL TABLET 3-0.02 MG T5 PA; QL (28 EA per 21 days)

norethin ace-eth estrad-fe oral tablet 1-20 mg-mcg


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


norethindrone acet-ethinyl est oral tablet 1-20 mg-mcg


norethindrone oral tablet 0.35 mg T5 GR-F; QL (28 EA per 21 days)

68

Drug Status Notesnorethin-eth estradiol-fe oral tablet chewable 0.4-35 mg-mcg, 0.8-25 mg-mcg


norgestimate-eth estradiol oral tablet 0.25-35 mg-mcg


norgestim-eth estrad triphasic oral tablet0.18/0.215/0.25 mg-35 mcg


NORTREL 0.5/35 (28) TABLET 0.5-35 MG-MCG ORAL 0.5-35 MG-MCG T5 GR-F; QL (28 EA per 21 days)

NORTREL 1/35 (28) TABLET 1-35 MG-MCG ORAL 1-35 MG-MCG T5 GR-F; QL (28 EA per 21 days)

NORTREL 7/7/7 TABLET 0.5/0.75/1-35 MG-MCG ORAL 0.5/0.75/1-35 MG-MCG T5 GR-F; QL (28 EA per 21 days)

NUVARING RING 0.12-0.015 MG/24HR VAGINAL 0.12-0.015 MG/24HR T5 PA; GR-F

OCELLA ORAL TABLET 3-0.03 MG T5 PA; QL (28 EA per 21 days)

SLYND ORAL TABLET 4 MG T5 PA; QL (28 EA per 21 days)

SYEDA ORAL TABLET 3-0.03 MG T5 PA; QL (28 EA per 21 days)

TAYTULLA ORAL CAPSULE 1-20 MG-MCG(24) T5 PA; QL (28 EA per 21 days)

TRI-LEGEST FE ORAL TABLET 1-20/1-30/1-35 MG-MCG T5 PA; QL (28 EA per 21 days)

TRI-LO-SPRINTEC ORAL TABLET0.18/0.215/0.25 MG-25 MCG T5 GR-F; QL (28 EA per 21 days)

TWIRLA TRANSDERMAL PATCH WEEKLY 120-30 MCG/24HR T5 PA; QL (3 EA per 28 days)

VELIVET TABLET 0.1/0.125/0.15 -0.025 MG ORAL 0.1/0.125/0.15 -0.025 MG T5 GR-F; QL (28 EA per 21 days)

XULANE PATCH WEEKLY 150-35 MCG/24HR TRANSDERMAL 150-35 MCG/24HR

T5 PA; GR-F

ZARAH ORAL TABLET 3-0.03 MG T5 PA; QL (28 EA per 21 days)

ZOVIA 1/35E (28) TABLET 1-35 MG-MCG ORAL 1-35 MG-MCG T5 GR-F; QL (28 EA per 28 days)

ZUMANDIMINE ORAL TABLET 3-0.03 MG T5 PA; QL (28 EA per 21 days)

*Corticosteroids*betamethasone sod phos & acet suspension 6 (3-3) mg/ml injection 6 (3-3) mg/ml

T1

budesonide oral capsule delayed release particles3 mg

T3

cortisone acetate tablet 25 mg oral 25 mg T1

DEPO-MEDROL SUSPENSION 20 MG/ML INJECTION 20 MG/ML T3

69

Drug Status NotesDEXAMETHASONE INTENSOL CONCENTRATE 1 MG/ML ORAL 1 MG/ML T3

dexamethasone oral solution 0.5 mg/5ml T1

dexamethasone oral tablet therapy pack 1.5 mg (21), 1.5 mg (35), 1.5 mg (51)

T3

dexamethasone sodium phosphate solution 10 mg/ml injection 10 mg/ml

T1

dexamethasone sodium phosphate solution 120 mg/30ml injection 120 mg/30ml

T1

dexamethasone tablet 0.5 mg oral 0.5 mg T1


dexamethasone tablet 1 mg oral 1 mg T1





fludrocortisone acetate tablet 0.1 mg oral 0.1 mg T1

hydrocortisone tablet 10 mg oral 10 mg T1



methylprednisolone tablet 16 mg oral 16 mg T1




methylprednisolone tablet therapy pack 4 mg oral4 mg

T1

MILLIPRED TABLET 5 MG ORAL 5 MG T3

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

T1

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

T1

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

T1

PREDNISONE INTENSOL CONCENTRATE 5 MG/ML ORAL 5 MG/ML T3

prednisone solution 5 mg/5ml oral 5 mg/5ml T1

prednisone tablet 1 mg oral 1 mg T1


prednisone tablet 2.5 mg oral 2.5 mg T1


70

Drug Status Notesprednisone tablet 5 mg oral 5 mg T1


prednisone tablet therapy pack 5 mg (48) oral 5 mg (48)

T1

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

acetylcysteine solution 20 % inhalation 20 % T1

benzonatate capsule 100 mg oral 100 mg T1

benzonatate capsule 200 mg oral 200 mg T1

BROMFED DM SYRUP 30-2-10 MG/5ML ORAL 30-2-10 MG/5ML T1

hydrocod polst-cpm polst er suspension extended release 10-8 mg/5ml oral 10-8 mg/5ml

T1

hydrocodone-homatropine syrup 5-1.5 mg/5ml oral 5-1.5 mg/5ml

T1

promethazine vc/codeine syrup 6.25-5-10 mg/5ml oral 6.25-5-10 mg/5ml

T1

promethazine-codeine solution 6.25-10 mg/5ml oral 6.25-10 mg/5ml

T1

promethazine-dm syrup 6.25-15 mg/5ml oral6.25-15 mg/5ml

T1

sodium chloride nebulization solution 0.9 % inhalation (rx) 0.9 %

T1

sodium chloride nebulization solution 10 % inhalation 10 %

T1


T1


T1

*Dermatologicals*acitretin oral capsule 10 mg, 17.5 mg, 25 mg T3 PA

acne treatment gel 10 % external 10 % T1

acyclovir external ointment 5 % T3 PA

adapalene external gel 0.1 % T1 QL (45 GM per 30 days)

adapalene-benzoyl peroxide gel 0.1-2.5 % external 0.1-2.5 %

T3ST; QL (45 GM per 30 days); AL (Max 28 Years)

alclometasone dipropionate cream 0.05 % external 0.05 %

T1

alclometasone dipropionate ointment 0.05 % external 0.05 %

T1

ALTABAX OINTMENT 1 % EXTERNAL 1 % T3 ST

71

Drug Status Notesamcinonide cream 0.1 % external 0.1 % T3

amcinonide lotion 0.1 % external 0.1 % T3

amcinonide ointment 0.1 % external 0.1 % T3

ammonium lactate external cream 12 % T1 QL (385 GM per 30 days)

ammonium lactate external lotion 12 % T1 QL (500 G4M per 30 days)

ANECREAM CREAM 4 % EXTERNAL 4 % T1 QL (90 GM per 30 days)

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

ASPERCREME W/LIDOCAINE CREAM 4 % EXTERNAL 4 % T1 QL (90 GM per 30 days)

AVITA GEL 0.025 % EXTERNAL 0.025 % T1QL (45 GM per 30 days); AL (Max 28 Years)

BASIS OVERNIGHT EXTERNAL CREAM T1

BENZEPRO FOAM 5.3 % EXTERNAL 5.3 % T3

BENZEPRO SHORT CONTACT FOAM 9.8 % EXTERNAL 9.8 % T3

benzoyl peroxide-erythromycin gel 5-3 % external5-3 %

T1

betamethasone dipropionate aug cream 0.05 % external 0.05 %


betamethasone dipropionate aug external gel 0.05 %


betamethasone dipropionate aug lotion 0.05 % external 0.05 %


betamethasone dipropionate aug ointment 0.05 % external 0.05 %


betamethasone dipropionate cream 0.05 % external 0.05 %


betamethasone dipropionate lotion 0.05 % external 0.05 %


betamethasone dipropionate ointment 0.05 % external 0.05 %


betamethasone valerate cream 0.1 % external 0.1 %


betamethasone valerate foam 0.12 % external0.12 %

T3

betamethasone valerate lotion 0.1 % external 0.1 %


betamethasone valerate ointment 0.1 % external0.1 %


calcipotriene cream 0.005 % external 0.005 % T3

calcipotriene solution 0.005 % external 0.005 % T3

72

Drug Status Notescalcipotriene-betameth diprop ointment 0.005-0.064 % external 0.005-0.064 %

T3 ST; QL (60 GM per 30 days)

CALCITRENE OINTMENT 0.005 % EXTERNAL 0.005 % T3

CAPEX SHAMPOO 0.01 % EXTERNAL 0.01 % T3 ST; QL (120 ML per 30 days)

CEM-UREA SOLUTION 45 % EXTERNAL45 % T3

ciclopirox solution 8 % external 8 % T1

CLINDACIN PAC KIT 1 % EXTERNAL 1 % T1

clindamycin phos-benzoyl perox external gel 1.2-5 %


clindamycin phos-benzoyl perox gel 1-5 % external 1-5 %

T3

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

clindamycin phosphate foam 1 % external 1 % T3

clindamycin phosphate lotion 1 % external 1 % T1

clindamycin phosphate solution 1 % external 1 % T1

clobetasol propionate e cream 0.05 % external0.05 %


clobetasol propionate external cream 0.05 % T1

clobetasol propionate gel 0.05 % external 0.05 % T1 QL (120 GM per 30 days)

clobetasol propionate lotion 0.05 % external 0.05 %

T3

clobetasol propionate ointment 0.05 % external0.05 %


clobetasol propionate shampoo 0.05 % external0.05 %

T3

clobetasol propionate solution 0.05 % external0.05 %


CLODERM CREAM 0.1 % EXTERNAL 0.1 % T3

clotrimazole external cream 1 % T1 QL (50 GM per 30 days)

clotrimazole external solution 1 % T1

clotrimazole-betamethasone cream 1-0.05 % external 1-0.05 %


clotrimazole-betamethasone lotion 1-0.05 % external 1-0.05 %


CONDYLOX GEL 0.5 % EXTERNAL 0.5 % T3 PA

CORDRAN LOTION 0.05 % EXTERNAL0.05 % T3 PA

73

Drug Status NotesCORTISPORIN CREAM 3.5-10000-0.5 EXTERNAL 3.5-10000-0.5 T1

CORTISPORIN OINTMENT 1 % EXTERNAL 1 % T3

COSENTYX (300 MG DOSE) SOLUTION PREFILLED SYRINGE 150 MG/ML SUBCUTANEOUS 150 MG/ML

T4 PA

COSENTYX SENSOREADY PEN SOLUTION AUTO-INJECTOR 150 MG/ML SUBCUTANEOUS 150 MG/ML

T4 PA

CROTAN EXTERNAL LOTION 10 % T2 PA

DENAVIR EXTERNAL CREAM 1 % T3 PA

desonide cream 0.05 % external 0.05 % T3 QL (120 GM per 30 days)

desonide lotion 0.05 % external 0.05 % T3

desonide ointment 0.05 % external 0.05 % T1 QL (120 GM per 30 days)

desoximetasone cream 0.05 % external 0.05 % T1 QL (200 GM per 30 days)

desoximetasone cream 0.25 % external 0.25 % T1 QL (200 GM per 30 days)

desoximetasone gel 0.05 % external 0.05 % T1 QL (120 GM per 30 days)

desoximetasone ointment 0.05 % external 0.05 % T3 QL (120 GM per 30 days)

desoximetasone ointment 0.25 % external 0.25 % T1 QL (200 GM per 30 days)

diclofenac sodium gel 1 % external (rx) 1 % T1 QL (200 GM per 30 days)

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

diflorasone diacetate external cream 0.05 % T3 PA; QL (120 GM per 30 days)

diflorasone diacetate external ointment 0.05 % T3 PA; QL (120 GM per 30 days)

docosanol external cream 10 % T1

DRITHO-CREME HP EXTERNAL CREAM1 % T3 PA

DUPIXENT SUBCUTANEOUS SOLUTION PEN-INJECTOR 300 MG/2ML T4 PA

DUPIXENT SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 300 MG/2ML T4 PA

econazole nitrate cream 1 % external 1 % T1 QL (85 GM per 30 days)

ERTACZO CREAM 2 % EXTERNAL 2 % T3

erythromycin gel 2 % external 2 % T1

erythromycin solution 2 % external 2 % T1

ethyl chloride aerosol external T1

EUCERIN EXTERNAL CREAM T1

EXELDERM CREAM 1 % EXTERNAL 1 % T3 QL (30 GM per 30 days)

EXELDERM SOLUTION 1 % EXTERNAL 1 % T3 QL (30 ML per 30 days)

74

Drug Status NotesEXODERM LOTION 25-1 % EXTERNAL25-1 % T1

FINACEA GEL 15 % EXTERNAL 15 % T3 PA

finasteride tablet 1 mg oral 1 mg T1

fluocinolone acetonide body external oil 0.01 % T1 QL (128.28 ML per 30 days)

fluocinolone acetonide cream 0.01 % external0.01 %


fluocinolone acetonide cream 0.025 % external0.025 %


fluocinolone acetonide ointment 0.025 % external0.025 %


fluocinolone acetonide scalp external oil 0.01 % T1 QL (128.28 ML per 30 days)

fluocinolone acetonide solution 0.01 % external0.01 %


fluocinonide emulsified base cream 0.05 % external 0.05 %


fluocinonide gel 0.05 % external 0.05 % T1 QL (120 GM per 30 days)

fluocinonide ointment 0.05 % external 0.05 % T1 QL (120 GM per 30 days)

fluocinonide solution 0.05 % external 0.05 % T1 QL (120 ML per 30 days)

fluorouracil cream 5 % external 5 % T3

fluorouracil solution 2 % external 2 % T1

fluorouracil solution 5 % external 5 % T1

flurandrenolide cream 0.05 % external 0.05 % T3 PA

flurandrenolide lotion 0.05 % external 0.05 % T3 PA

fluticasone propionate cream 0.05 % external0.05 %


fluticasone propionate lotion 0.05 % external0.05 %

T3

fluticasone propionate ointment 0.005 % external0.005 %


gentamicin sulfate cream 0.1 % external 0.1 % T1

gentamicin sulfate ointment 0.1 % external 0.1 % T1

halobetasol propionate cream 0.05 % external0.05 %


halobetasol propionate ointment 0.05 % external0.05 %


HALOG CREAM 0.1 % EXTERNAL 0.1 % T3 QL (100 GM per 30 days)

HALOG OINTMENT 0.1 % EXTERNAL 0.1 % T3 QL (100 GM per 30 days)

hydrocortisone butyr lipo base cream 0.1 % external 0.1 %

T1

75

Drug Status Noteshydrocortisone butyrate ointment 0.1 % external0.1 %

T1

hydrocortisone butyrate solution 0.1 % external0.1 %

T1

hydrocortisone cream 1 % external (otc) 1 % T1 QL (120 GM per 30 days)

hydrocortisone cream 2.5 % external 2.5 % T3 QL (90 GM per 30 days)

hydrocortisone external lotion 1 % T1 QL (240 GM per 30 days)

hydrocortisone external ointment 1 % T1 QL (90 GM per 30 days)

hydrocortisone lotion 2.5 % external 2.5 % T1 QL (120 ML per 30 days)

hydrocortisone ointment 2.5 % external 2.5 % T1 QL (90 GM per 30 days)

hydrocortisone valerate cream 0.2 % external 0.2 %


hydrocortisone valerate ointment 0.2 % external0.2 %


hydroquinone external cream 4 % T1

imiquimod cream 5 % external 5 % T3 QL (12 EA per 28 days)

ketoconazole cream 2 % external 2 % T1

ketoconazole shampoo 2 % external 2 % T1

lactic acid e cream 10-3500 %-unt/30gm external (rx) 10-3500 %-unt/30gm

T1 PA

lactic acid external lotion 10 % T1

lidocaine cream 4 % external 4 % T1 QL (90 GM per 30 days)

lidocaine hcl external cream 3 % T1 QL (85 GM per 30 days)

lidocaine hcl lotion 3 % external 3 % T1 QL (100 ML per 30 days)

lidocaine hcl solution 4 % external 4 % T1 QL (100 ML per 30 days)

lidocaine patch 5 % external 5 % T3 PA

lidocaine-prilocaine cream 2.5-2.5 % external2.5-2.5 %

T1

lindane shampoo 1 % external 1 % T3

LMX 4 CREAM 4 % EXTERNAL 4 % T1 QL (90 GM per 30 days)

mafenide acetate packet 5 % external 5 % T3

malathion external lotion 0.5 % T2

MENTAX CREAM 1 % EXTERNAL 1 % T3

methoxsalen rapid capsule 10 mg oral 10 mg T3 PA

metronidazole external cream 0.75 % T1

metronidazole external gel 0.75 % T1

metronidazole lotion 0.75 % external 0.75 % T1

miconazole nitrate external cream 2 % T1

MIRVASO GEL 0.33 % EXTERNAL 0.33 % T3 PA

mometasone furoate cream 0.1 % external 0.1 % T1

76

Drug Status Notesmometasone furoate ointment 0.1 % external 0.1 %

T1

mometasone furoate solution 0.1 % external 0.1 %

T1

mupirocin ointment 2 % external 2 % T1

naftifine hcl external gel 1 % T3 PA; QL (60 GM per 30 days)

NATROBA SUSPENSION 0.9 % EXTERNAL0.9 % T3 ST; QL (120 ML per 30 days)

NYAMYC EXTERNAL POWDER 100000 UNIT/GM T1

nystatin cream 100000 unit/gm external 100000 unit/gm

T1

nystatin external powder 100000 unit/gm T1

nystatin ointment 100000 unit/gm external100000 unit/gm

T1

nystatin-triamcinolone cream 100000-0.1 unit/gm-% external 100000-0.1 unit/gm-%

T3

nystatin-triamcinolone ointment 100000-0.1 unit/gm-% external 100000-0.1 unit/gm-%

T1

NYSTOP EXTERNAL POWDER 100000 UNIT/GM T1

oxiconazole nitrate cream 1 % external 1 % T3

permethrin cream 5 % external 5 % T1 QL (120 GM per 30 days)

pimecrolimus external cream 1 % T3 PA; QL (100 GM per 30 days)

podocon solution 25 % external 25 % T3

podofilox solution 0.5 % external 0.5 % T1

PR BENZOYL PEROXIDE WASH LIQUID 7 % EXTERNAL 7 % T3

prednicarbate cream 0.1 % external 0.1 % T1 QL (120 GM per 30 days)

prednicarbate ointment 0.1 % external 0.1 % T1 QL (120 GM per 30 days)

pyrogallic acid ointment 25-2 % external 25-2 % T1

REGRANEX GEL 0.01 % EXTERNAL 0.01 % T4 PA

ROSADAN KIT 0.75 % (CREAM) EXTERNAL 0.75 % (CREAM) T3

ROSADAN KIT 0.75 % (GEL) EXTERNAL0.75 % (GEL) T3

salicylic acid cream 6 % external 6 % T1

salicylic acid external solution 26 % T1

salicylic acid foam 6 % external 6 % T3

salicylic acid gel 6 % external 6 % T1

77

Drug Status Notessalicylic acid lotion 6 % external 6 % T1

salicylic acid shampoo 6 % external 6 % T1

salicylic acid wart remover liquid 27.5 % external27.5 %

T1

SANTYL OINTMENT 250 UNIT/GM EXTERNAL 250 UNIT/GM T3

selenium sulfide lotion 2.5 % external 2.5 % T1

silver nitrate solution 0.5 % external 0.5 % T1

silver nitrate solution 10 % external 10 % T1



SKLICE LOTION 0.5 % EXTERNAL 0.5 % T3 PA

SKYRIZI (150 MG DOSE) SUBCUTANEOUS PREFILLED SYRINGE KIT 75 MG/0.83ML T4 PA

SSD CREAM 1 % EXTERNAL 1 % T1 QL (85 GM per 30 days)

STELARA SOLUTION PREFILLED SYRINGE 45 MG/0.5ML SUBCUTANEOUS45 MG/0.5ML

T4 PA

sulfacetamide sodium (acne) lotion 10 % external10 %

T3

sulfacetamide sodium liquid 10 % external 10 % T3

sulfacetamide sodium-sulfur external lotion 10-5 %

T3

SULFAMYLON CREAM 85 MG/GM EXTERNAL 85 MG/GM T3 QL (56.7 GM per 30 days)

SYNALAR (CREAM) KIT 0.025 % EXTERNAL 0.025 % T3

SYNALAR (OINTMENT) KIT 0.025 % EXTERNAL 0.025 % T3

TACLONEX SUSPENSION 0.005-0.064 % EXTERNAL 0.005-0.064 % T3 ST; QL (60 GM per 30 days)

tacrolimus ointment 0.03 % external 0.03 % T3

tacrolimus ointment 0.1 % external 0.1 % T3

tazarotene external cream 0.1 % T3 PA

TAZORAC EXTERNAL CREAM 0.05 % T3 PA

TAZORAC EXTERNAL GEL 0.05 %, 0.1 % T3 PA

tretinoin cream 0.025 % external 0.025 % T1QL (45 GM per 30 days); AL (Max 28 Years)



78

Drug Status Notes

tretinoin gel 0.01 % external 0.01 % T1QL (45 GM per 30 days); AL (Max 28 Years)

tretinoin microsphere gel 0.04 % external 0.04 % T3ST; QL (20 GM per 30 days); AL (Max 28 Years)

triamcinolone acetonide aerosol solution 0.147 mg/gm external 0.147 mg/gm

T3 PA

triamcinolone acetonide cream 0.025 % external0.025 %


triamcinolone acetonide cream 0.1 % external 0.1 %


triamcinolone acetonide cream 0.5 % external 0.5 %


triamcinolone acetonide lotion 0.025 % external0.025 %


triamcinolone acetonide lotion 0.1 % external 0.1 %


triamcinolone acetonide ointment 0.025 % external 0.025 %


triamcinolone acetonide ointment 0.1 % external0.1 %


triamcinolone acetonide ointment 0.5 % external0.5 %


UMECTA MOUSSE FOAM 40 % EXTERNAL 40 % T3

urea cream 39 % external 39 % T3



urea nail gel 45 % external 45 % T3

urea-c40 lotion 40 % external 40 % T3

VECTICAL OINTMENT 3 MCG/GM EXTERNAL 3 MCG/GM T3 PA

VELTIN GEL 1.2-0.025 % EXTERNAL 1.2-0.025 % T3

ST; QL (30 GM per 30 days); AL (Max 28 Years)

VEREGEN OINTMENT 15 % EXTERNAL15 % T3 PA

*Diagnostic Products*GLUCOCARD EXPRESSION TEST IN VITRO STRIP T1

GLUCOCARD VITAL TEST IN VITRO STRIP T1

ketone test in vitro strip T1

79

Drug Status Notes

*Digestive Aids*CREON CAPSULE DELAYED RELEASE PARTICLES 12000 UNIT ORAL 12000 UNIT T2

CREON CAPSULE DELAYED RELEASE PARTICLES 24000-76000 UNIT ORAL24000-76000 UNIT

T2

CREON CAPSULE DELAYED RELEASE PARTICLES 3000-9500 UNIT ORAL 3000-9500 UNIT

T2

CREON CAPSULE DELAYED RELEASE PARTICLES 36000 UNIT ORAL 36000 UNIT T2

CREON CAPSULE DELAYED RELEASE PARTICLES 6000 UNIT ORAL 6000 UNIT T2

ZENPEP CAPSULE DELAYED RELEASE PARTICLES 25000-79000 UNIT ORAL25000-79000 UNIT

T2

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


acetazolamide tablet 125 mg oral 125 mg T1

acetazolamide tablet 250 mg oral 250 mg T1

amiloride hcl tablet 5 mg oral 5 mg T1

amiloride-hydrochlorothiazide tablet 5-50 mg oral 5-50 mg

T1

bumetanide solution 0.25 mg/ml injection 0.25 mg/ml

T1

bumetanide tablet 0.5 mg oral 0.5 mg T1

bumetanide tablet 1 mg oral 1 mg T1

bumetanide tablet 2 mg oral 2 mg T1

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

chlorothiazide tablet 250 mg oral 250 mg T1

chlorothiazide tablet 500 mg oral 500 mg T1

chlorthalidone tablet 25 mg oral 25 mg T1

chlorthalidone tablet 50 mg oral 50 mg T1

ethacrynic acid tablet 25 mg oral 25 mg T3

furosemide solution 10 mg/ml oral 10 mg/ml T1

furosemide solution 8 mg/ml oral 8 mg/ml T1

furosemide tablet 20 mg oral 20 mg T1



80

Drug Status Noteshydrochlorothiazide capsule 12.5 mg oral 12.5 mg

T1

hydrochlorothiazide tablet 12.5 mg oral 12.5 mg T1

hydrochlorothiazide tablet 25 mg oral 25 mg T1

hydrochlorothiazide tablet 50 mg oral 50 mg T1

indapamide tablet 1.25 mg oral 1.25 mg T1

indapamide tablet 2.5 mg oral 2.5 mg T1

methazolamide tablet 25 mg oral 25 mg T3

methazolamide tablet 50 mg oral 50 mg T3

metolazone tablet 10 mg oral 10 mg T1

metolazone tablet 2.5 mg oral 2.5 mg T1

metolazone tablet 5 mg oral 5 mg T1

spironolactone tablet 100 mg oral 100 mg T1



spironolactone-hctz tablet 25-25 mg oral 25-25 mg

T1

torsemide tablet 10 mg oral 10 mg T1




triamterene oral capsule 100 mg T3

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

T1

triamterene-hctz tablet 37.5-25 mg oral 37.5-25 mg

T1

triamterene-hctz tablet 75-50 mg oral 75-50 mg T1

*Endocrine And Metabolic Agents - Misc.*alendronate sodium tablet 10 mg oral 10 mg T1 QL (30 EA per 30 days)

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



cabergoline tablet 0.5 mg oral 0.5 mg T1

calcitonin (salmon) solution 200 unit/act nasal200 unit/act

T1

calcitriol capsule 0.25 mcg oral 0.25 mcg T1

calcitriol capsule 0.5 mcg oral 0.5 mcg T1

calcitriol solution 1 mcg/ml oral 1 mcg/ml T3

81

Drug Status Noteschorionic gonadotropin solution reconstituted 10000 unit intramuscular 10000 unit

T4 PA

CYSTADANE POWDER ORAL T4 PA

DDAVP RHINAL TUBE NASAL SOLUTION0.01 % T1

desmopressin ace spray refrig solution 0.01 % nasal 0.01 %

T3

desmopressin acetate solution 4 mcg/ml injection4 mcg/ml

T4 PA

desmopressin acetate spray nasal solution 0.01 % T1

desmopressin acetate tablet 0.1 mg oral 0.1 mg T1

desmopressin acetate tablet 0.2 mg oral 0.2 mg T1

doxercalciferol capsule 0.5 mcg oral 0.5 mcg T3 PA

doxercalciferol capsule 1 mcg oral 1 mcg T3 PA

doxercalciferol capsule 2.5 mcg oral 2.5 mcg T3 PA

FORTEO SOLUTION PEN-INJECTOR 600 MCG/2.4ML SUBCUTANEOUS 600 MCG/2.4ML

T4 PA

FOSAMAX PLUS D TABLET 70-2800 MG-UNIT ORAL 70-2800 MG-UNIT T3 PA

FOSAMAX PLUS D TABLET 70-5600 MG-UNIT ORAL 70-5600 MG-UNIT T3 PA

ganirelix acetate solution prefilled syringe 250 mcg/0.5ml subcutaneous 250 mcg/0.5ml

T4 PA

GENOTROPIN MINIQUICK SOLUTION RECONSTITUTED 0.2 MG SUBCUTANEOUS 0.2 MG

T4 PA


T4 PA


T4 PA


T4 PA

GENOTROPIN MINIQUICK SOLUTION RECONSTITUTED 1 MG SUBCUTANEOUS1 MG

T4 PA


T4 PA

82

Drug Status NotesGENOTROPIN MINIQUICK SOLUTION RECONSTITUTED 1.4 MG SUBCUTANEOUS 1.4 MG

T4 PA


T4 PA


T4 PA

GENOTROPIN MINIQUICK SOLUTION RECONSTITUTED 2 MG SUBCUTANEOUS2 MG

T4 PA

GENOTROPIN SOLUTION RECONSTITUTED 12 MG SUBCUTANEOUS 12 MG

T4 PA

GENOTROPIN SOLUTION RECONSTITUTED 5 MG SUBCUTANEOUS5 MG

T4 PA

GONAL-F RFF REDIJECT SOLUTION 300 UNIT/0.5ML SUBCUTANEOUS 300 UNIT/0.5ML

T4 PA

GONAL-F RFF REDIJECT SOLUTION 450 UNT/0.75ML SUBCUTANEOUS 450 UNT/0.75ML

T4 PA

GONAL-F RFF REDIJECT SOLUTION 900 UNIT/1.5ML SUBCUTANEOUS 900 UNIT/1.5ML

T4 PA

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

INCRELEX SOLUTION 40 MG/4ML SUBCUTANEOUS 40 MG/4ML T4 PA

levocarnitine oral tablet 330 mg T3

levocarnitine solution 1 gm/10ml oral 1 gm/10ml T3

MIACALCIN SOLUTION 200 UNIT/ML INJECTION 200 UNIT/ML T4

nitisinone oral capsule 10 mg, 2 mg, 5 mg T4 PA

octreotide acetate solution 100 mcg/ml injection100 mcg/ml

T4 PA


T4 PA


T4 PA

octreotide acetate solution 50 mcg/ml injection 50 mcg/ml

T4 PA

83

Drug Status Notesoctreotide acetate solution 500 mcg/ml injection500 mcg/ml

T4 PA

OSPHENA TABLET 60 MG ORAL 60 MG T3 QL (30 EA per 30 days)

paricalcitol capsule 1 mcg oral 1 mcg T3 PA



raloxifene hcl tablet 60 mg oral 60 mg T5 PA

risedronate sodium tablet 150 mg oral 150 mg T3 QL (1 EA per 28 days)




SAMSCA TABLET 15 MG ORAL 15 MG T4 PA

SANDOSTATIN LAR DEPOT KIT 10 MG INTRAMUSCULAR 10 MG T4 PA



sapropterin dihydrochloride oral tablet soluble100 mg

T4 PA

SENSIPAR TABLET 30 MG ORAL 30 MG T4 PA



SIGNIFOR LAR SUSPENSION RECONSTITUTED ER 20 MG INTRAMUSCULAR 20 MG

T4 PA


T4 PA


T4 PA

SIGNIFOR SOLUTION 0.3 MG/ML SUBCUTANEOUS 0.3 MG/ML T4 PA



SOMATULINE DEPOT SOLUTION 120 MG/0.5ML SUBCUTANEOUS 120 MG/0.5ML

T4 PA

84

Drug Status NotesSOMATULINE DEPOT SOLUTION 60 MG/0.2ML SUBCUTANEOUS 60 MG/0.2ML T4 PA

SOMATULINE DEPOT SOLUTION 90 MG/0.3ML SUBCUTANEOUS 90 MG/0.3ML T4 PA

SOMAVERT SOLUTION RECONSTITUTED 10 MG SUBCUTANEOUS 10 MG

T4 PA


T4 PA


T4 PA

STIMATE SOLUTION 1.5 MG/ML NASAL1.5 MG/ML T4 PA

tolvaptan oral tablet 30 mg T4 PA

*Estrogens*COMBIPATCH PATCH TWICE WEEKLY 0.05-0.14 MG/DAY TRANSDERMAL 0.05-0.14 MG/DAY

T3

COMBIPATCH PATCH TWICE WEEKLY 0.05-0.25 MG/DAY TRANSDERMAL 0.05-0.25 MG/DAY

T3

DUAVEE TABLET 0.45-20 MG ORAL 0.45-20 MG T3 GR-F; QL (30 EA per 30 days)

estradiol patch twice weekly 0.025 mg/24hr transdermal 0.025 mg/24hr










estradiol patch weekly 0.025 mg/24hr transdermal 0.025 mg/24hr


estradiol patch weekly 0.0375 mg/24hr transdermal 0.0375 mg/24hr


estradiol patch weekly 0.05 mg/24hr transdermal0.05 mg/24hr




85

Drug Status Notesestradiol patch weekly 0.075 mg/24hr transdermal 0.075 mg/24hr




estradiol tablet 0.5 mg oral 0.5 mg T1 GR-F

estradiol tablet 1 mg oral 1 mg T1 GR-F

estradiol tablet 2 mg oral 2 mg T1 GR-F

estradiol valerate oil 20 mg/ml intramuscular 20 mg/ml

T1 GR-F

estradiol valerate oil 40 mg/ml intramuscular 40 mg/ml

T1 GR-F

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

T1

estradiol-norethindrone acet tablet 1-0.5 mg oral1-0.5 mg

T1

ESTROGEL GEL 0.75 MG/1.25 GM (0.06%) TRANSDERMAL 0.75 MG/1.25 GM (0.06%) T3 GR-F

EVAMIST SOLUTION 1.53 MG/SPRAY TRANSDERMAL 1.53 MG/SPRAY T3 GR-F

JINTELI TABLET 1-5 MG-MCG ORAL 1-5 MG-MCG T1 GR-F; QL (28 EA per 28 days)

MENEST TABLET 0.3 MG ORAL 0.3 MG T3 GR-F



norethindrone-eth estradiol tablet 0.5-2.5 mg-mcg oral 0.5-2.5 mg-mcg


PREMARIN TABLET 0.3 MG ORAL 0.3 MG T3 GR-F





PREMPHASE TABLET 0.625-5 MG ORAL0.625-5 MG T3 GR-F

PREMPRO TABLET 0.3-1.5 MG ORAL 0.3-1.5 MG T3 GR-F

PREMPRO TABLET 0.45-1.5 MG ORAL0.45-1.5 MG T3 GR-F

PREMPRO TABLET 0.625-2.5 MG ORAL0.625-2.5 MG T3 GR-F

86

Drug Status NotesPREMPRO TABLET 0.625-5 MG ORAL0.625-5 MG T3 GR-F

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

T3

ciprofloxacin hcl tablet 100 mg oral 100 mg T1




levofloxacin tablet 250 mg oral 250 mg T1



moxifloxacin hcl tablet 400 mg oral 400 mg T3

ofloxacin tablet 400 mg oral 400 mg T1

*Gastrointestinal Agents - Misc.*alosetron hcl oral tablet 0.5 mg, 1 mg T3 PA

AMITIZA CAPSULE 24 MCG ORAL 24 MCG T3 PA

AMITIZA CAPSULE 8 MCG ORAL 8 MCG T3 PA

APRISO CAPSULE EXTENDED RELEASE 24 HOUR 0.375 GM ORAL 0.375 GM T3 QL (120 EA per 30 days)

balsalazide disodium capsule 750 mg oral 750 mg T1

calcium acetate (phos binder) capsule 667 mg oral 667 mg

T1

CALPHRON TABLET 667 MG ORAL 667 MG T1

cromolyn sodium oral concentrate 100 mg/5ml T3

DIPENTUM CAPSULE 250 MG ORAL 250 MG T3 PA

generlac solution 10 gm/15ml oral 10 gm/15ml T1

lanthanum carbonate oral tablet chewable 1000 mg, 500 mg, 750 mg

T3 PA

LINZESS CAPSULE 145 MCG ORAL 145 MCG T3 PA

LINZESS CAPSULE 290 MCG ORAL 290 MCG T3 PA

mesalamine enema 4 gm rectal 4 gm T3 QL (1680 ML per 28 days)

mesalamine oral capsule delayed release 400 mg T3 QL (180 EA per 30 days)

mesalamine oral tablet delayed release 1.2 gm T3 QL (60 EA per 30 days)

mesalamine rectal suppository 1000 mg T4 PA

87

Drug Status Notesmesalamine tablet delayed release 800 mg oral800 mg


metoclopramide hcl solution 10 mg/10ml oral 10 mg/10ml

T1

metoclopramide hcl tablet 10 mg oral 10 mg T1

metoclopramide hcl tablet 5 mg oral 5 mg T1

PENTASA CAPSULE EXTENDED RELEASE 250 MG ORAL 250 MG T3 ST; QL (240 EA per 30 days)

PENTASA CAPSULE EXTENDED RELEASE 500 MG ORAL 500 MG T3 ST; QL (240 EA per 30 days)

PHOSLYRA SOLUTION 667 MG/5ML ORAL 667 MG/5ML T3 PA

RENVELA PACKET 0.8 GM ORAL 0.8 GM T3 PA

sevelamer carbonate oral tablet 800 mg T3 PA

sevelamer carbonate packet 2.4 gm oral 2.4 gm T3 PA

sevelamer hcl oral tablet 800 mg T3 PA

sulfasalazine tablet 500 mg oral 500 mg T1

sulfasalazine tablet delayed release 500 mg oral500 mg

T1

ursodiol capsule 300 mg oral 300 mg T3

ursodiol tablet 250 mg oral 250 mg T3

ursodiol tablet 500 mg oral 500 mg T3

VELPHORO TABLET CHEWABLE 500 MG ORAL 500 MG T3 PA

*Genitourinary Agents - Miscellaneous*acetic acid solution 0.25 % irrigation 0.25 % T1

alfuzosin hcl er tablet extended release 24 hour 10 mg oral 10 mg

T3

aminoacetic acid solution 1.5 % irrigation 1.5 % T1

ARGYLE STERILE SALINE SOLUTION 0.9 % IRRIGATION 0.9 % T1

CARDURA XL TABLET EXTENDED RELEASE 24 HOUR 4 MG ORAL 4 MG T3

CYTRA-3 SYRUP 550-500-334 MG/5ML ORAL 550-500-334 MG/5ML T1

ELMIRON ORAL CAPSULE 100 MG T3

finasteride tablet 5 mg oral 5 mg T1

neomycin-polymyxin b gu solution 40-200000 irrigation 40-200000

T1

phenazopyridine hcl oral tablet 200 mg T1

phenazopyridine hcl tablet 100 mg oral 100 mg T1

88

Drug Status Notespotassium citrate er tablet extended release 10 meq (1080 mg) oral 10 meq (1080 mg)

T1

potassium citrate er tablet extended release 15 meq (1620 mg) oral 15 meq (1620 mg)

T3

potassium citrate er tablet extended release 5 meq (540 mg) oral 5 meq (540 mg)

T1

potassium citrate-citric acid solution 1100-334 mg/5ml oral 1100-334 mg/5ml

T1

silodosin oral capsule 4 mg, 8 mg T3

sod citrate-citric acid solution 500-334 mg/5ml oral 500-334 mg/5ml

T1

sorbitol solution 3 % irrigation 3 % T1

sorbitol solution 3.3 % irrigation 3.3 % T1

sorbitol-mannitol solution 2.7-0.54 gm/100ml irrigation 2.7-0.54 gm/100ml

T1

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

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

allopurinol tablet 300 mg oral 300 mg T1

colchicine oral capsule 0.6 mg T3 QL (60 EA per 30 days)

colchicine oral tablet 0.6 mg T2 QL (60 EA per 30 days)

colchicine-probenecid oral tablet 0.5-500 mg T1

probenecid tablet 500 mg oral 500 mg T1

ULORIC TABLET 40 MG ORAL 40 MG T3 PA

ULORIC TABLET 80 MG ORAL 80 MG T3 PA

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

anagrelide hcl capsule 1 mg oral 1 mg T1

aspirin-dipyridamole er capsule extended release 12 hour 25-200 mg oral 25-200 mg

T3

BERINERT KIT 500 UNIT INTRAVENOUS500 UNIT T4 PA

BRILINTA TABLET 60 MG ORAL 60 MG T2 QL (60 EA per 30 days)

BRILINTA TABLET 90 MG ORAL 90 MG T2 QL (60 EA per 30 days)

CEPROTIN SOLUTION RECONSTITUTED 1000 UNIT INTRAVENOUS 1000 UNIT T4 PA

cilostazol tablet 100 mg oral 100 mg T1

cilostazol tablet 50 mg oral 50 mg T1

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

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

89

Drug Status Notesdipyridamole tablet 25 mg oral 25 mg T1

dipyridamole tablet 50 mg oral 50 mg T1

dipyridamole tablet 75 mg oral 75 mg T1

FIRAZYR SOLUTION 30 MG/3ML SUBCUTANEOUS 30 MG/3ML T4 PA

KALBITOR SOLUTION 10 MG/ML SUBCUTANEOUS 10 MG/ML T4 PA

pentoxifylline er tablet extended release 400 mg oral 400 mg


prasugrel hcl oral tablet 10 mg, 5 mg T3 ST; QL (30 EA per 30 days)

ZONTIVITY TABLET 2.08 MG ORAL 2.08 MG T3 QL (30 EA per 30 days)

*Hematopoietic Agents*ARANESP (ALBUMIN FREE) SOLUTION 100 MCG/ML INJECTION 100 MCG/ML T4 PA

ARANESP (ALBUMIN FREE) SOLUTION 200 MCG/ML INJECTION 200 MCG/ML T4 PA





ARANESP (ALBUMIN FREE) SOLUTION PREFILLED SYRINGE 100 MCG/0.5ML INJECTION 100 MCG/0.5ML

T4 PA


T4 PA


T4 PA


T4 PA


T4 PA


T4 PA

90

Drug Status NotesARANESP (ALBUMIN FREE) SOLUTION PREFILLED SYRINGE 500 MCG/ML INJECTION 500 MCG/ML

T4 PA


T4 PA

b-6 folic acid capsule 8.333-100-1 mg oral 8.333-100-1 mg

T1

cyanocobalamin solution 1000 mcg/ml injection1000 mcg/ml

T1

DROXIA CAPSULE 200 MG ORAL 200 MG T2



EPOGEN SOLUTION 10000 UNIT/ML INJECTION 10000 UNIT/ML T4 PA





fe tabs tablet delayed release 325 (65 fe) mg oral325 (65 fe) mg

T5

ferotrinsic capsule oral T1

ferraplus 90 tablet 90-1 mg oral 90-1 mg T1

ferrous sulfate elixir 220 (44 fe) mg/5ml oral 220 (44 fe) mg/5ml

T5

folic acid injection solution 5 mg/ml T1

folic acid oral tablet 1 mg, 800 mcg T5 QL (30 EA per 30 days)

folic acid tablet 400 mcg oral 400 mcg T5 QL (30 EA per 30 days)

hematinic/folic acid tablet 324-1 mg oral 324-1 mg

T1

HEMATOGEN FA CAPSULE 200-250-0.01-1 MG ORAL 200-250-0.01-1 MG T1

HEMATOGEN FORTE CAPSULE 460-60-0.01-1 MG ORAL (RX) 460-60-0.01-1 MG T1

iron 27 tablet 240 (27 fe) mg oral 240 (27 fe) mg T5

iron tablet 325 (65 fe) mg oral 325 (65 fe) mg T5

LEUKINE SOLUTION RECONSTITUTED 250 MCG INJECTION 250 MCG T4 PA

91

Drug Status NotesNEULASTA SOLUTION PREFILLED SYRINGE 6 MG/0.6ML SUBCUTANEOUS 6 MG/0.6ML

T4 PA

poly-iron 150 forte capsule 150-25-1 mg-mcg-mg oral 150-25-1 mg-mcg-mg

T1

PROCRIT SOLUTION 10000 UNIT/ML INJECTION 10000 UNIT/ML T4 PA






PROMACTA TABLET 12.5 MG ORAL 12.5 MG T3 PA

PROMACTA TABLET 25 MG ORAL 25 MG T3 PA



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

T4 PA

ZARXIO SOLUTION PREFILLED SYRINGE 300 MCG/0.5ML INJECTION 300 MCG/0.5ML

T4 PA

ZARXIO SOLUTION PREFILLED SYRINGE 480 MCG/0.8ML INJECTION 480 MCG/0.8ML

T4 PA

*Hemostatics*aminocaproic acid oral tablet 1000 mg, 500 mg T3

*Hypnotics/Sedatives/Sleep Disorder Agents*BELSOMRA TABLET 10 MG ORAL 10 MG T3 ST; QL (30 EA per 30 days)

BELSOMRA TABLET 15 MG ORAL 15 MG T3 ST; QL (30 EA per 30 days)



estazolam tablet 1 mg oral 1 mg T1

estazolam tablet 2 mg oral 2 mg T1

92

Drug Status Notes

eszopiclone tablet 1 mg oral 1 mg T1QL (30 EA per 30 days); AL (Max 64 Years)



flurazepam hcl capsule 15 mg oral 15 mg T1 AL (Max 64 Years)

flurazepam hcl capsule 30 mg oral 30 mg T1 AL (Max 64 Years)

HETLIOZ CAPSULE 20 MG ORAL 20 MG T4 PA

phenobarbital elixir 20 mg/5ml oral 20 mg/5ml T1

phenobarbital tablet 100 mg oral 100 mg T1


phenobarbital tablet 16.2 mg oral 16.2 mg T1






ROZEREM TABLET 8 MG ORAL 8 MG T3 ST; QL (30 EA per 30 days)

temazepam capsule 15 mg oral 15 mg T1

temazepam capsule 22.5 mg oral 22.5 mg T3

temazepam capsule 30 mg oral 30 mg T1

temazepam capsule 7.5 mg oral 7.5 mg T3

zaleplon capsule 10 mg oral 10 mg T1QL (30 EA per 30 days); AL (Max 64 Years)

zaleplon capsule 5 mg oral 5 mg T1QL (30 EA per 30 days); AL (Max 64 Years)

zolpidem tartrate er oral tablet extended release12.5 mg, 6.25 mg


zolpidem tartrate tablet 10 mg oral 10 mg T1QL (30 EA per 30 days); AL (Max 64 Years)

zolpidem tartrate tablet 5 mg oral 5 mg T1QL (30 EA per 30 days); AL (Max 64 Years)

*Laxatives*GAVILYTE-C ORAL SOLUTION RECONSTITUTED 240 GM T5 QL (4000 ML per 365 days)

GAVILYTE-G SOLUTION RECONSTITUTED 236 GM ORAL 236 GM T1

GAVILYTE-N WITH FLAVOR PACK SOLUTION RECONSTITUTED 420 GM ORAL 420 GM

T1

93

Drug Status NotesGOLYTELY SOLUTION RECONSTITUTED 227.1 GM ORAL 227.1 GM T1 QL (1 EA per 365 days)

KRISTALOSE PACKET 20 GM ORAL 20 GM T3 PA

lactulose oral packet 10 gm T3 PA

lactulose solution 10 gm/15ml oral 10 gm/15ml T1

OSMOPREP TABLET 1.102-0.398 GM ORAL 1.102-0.398 GM T3

peg-3350/electrolytes/ascorbat oral solution reconstituted 100 gm

T3

polyethylene glycol 3350 oral powder 17 gm/scoop

T1

SUPREP BOWEL PREP KIT SOLUTION 17.5-3.13-1.6 GM/177ML ORAL 17.5-3.13-1.6 GM/177ML

T3

*Macrolides*azithromycin oral tablet 500 mg T1 QL (6 EA per 30 days)

azithromycin packet 1 gm oral 1 gm T1 QL (2 EA per 30 days)

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

T1

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

T1

azithromycin tablet 250 mg oral 250 mg T1 QL (6 EA per 5 days)

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

clarithromycin er tablet extended release 24 hour 500 mg oral 500 mg

T1

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

T1

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

T1

clarithromycin tablet 250 mg oral 250 mg T1

clarithromycin tablet 500 mg oral 500 mg T1

DIFICID TABLET 200 MG ORAL 200 MG T3 PA

ERYTHROCIN STEARATE TABLET 250 MG ORAL 250 MG T3

erythromycin base capsule delayed release particles 250 mg oral 250 mg

T3

erythromycin base oral tablet delayed release 333 mg

T3

erythromycin base tablet 250 mg oral 250 mg T3

erythromycin base tablet 500 mg oral 500 mg T3

94

Drug Status Noteserythromycin ethylsuccinate tablet 400 mg oral400 mg

T3

*Medical Devices And Supplies*BD INSULIN SYRINGE 25G X 1" 1 ML T1 QL (200 EA per 30 days)

BD PEN NEEDLE ORIGINAL U/F 29G X 12.7MM T1 QL (200 EA per 30 days)

BD SAFETYGLIDE INSULIN SYRINGE 31G X 15/64" 0.5 ML T1 QL (200 EA per 30 days)

BD VEO INSULIN SYRINGE U/F 31G X 15/64" 0.3 ML, 31G X 15/64" 1 ML T1 QL (200 EA per 30 days)

COMFORT EZ PEN NEEDLES 32G X 5 MM T1 QL (200 EA per 30 days)

FREESTYLE LIBRE SENSOR SYSTEM T1

insulin syringe 28g x 1/2" 0.5 ml 28g x 1/2" 0.5 ml


insulin syringe 28g x 1/2" 1 ml 28g x 1/2" 1 ml T1 QL (200 EA per 30 days)

insulin syringe 29g x 1/2" 0.5 ml 29g x 1/2" 0.5 ml


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

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

MAGELLAN INSULIN SAFETY SYR 29G X 1/2" 0.3 ML 29G X 1/2" 0.3 ML T1 QL (200 EA per 30 days)

OMNIFLEX DIAPHRAGM VAGINAL DIAPHRAGM T5

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

pen needles 31g x 6 mm 31g x 6 mm T1 QL (200 EA per 30 days)




TECHLITE PEN NEEDLES 31G X 5 MM31G X 5 MM T1 QL (200 EA per 30 days)

ULTILET INSULIN SYRINGE 30G X 1/2" 0.5 ML 30G X 1/2" 0.5 ML T1 QL (200 EA per 30 days)

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



ULTILET INSULIN SYRINGE 30G X 5/16" 1 ML 30G X 5/16" 1 ML T1 QL (200 EA per 30 days)


95

Drug Status NotesULTILET INSULIN SYRINGE 31G X 5/16" 1 ML 31G X 5/16" 1 ML T1 QL (200 EA per 30 days)

ULTILET INSULIN SYRINGE SHORT 30G X 1/2" 0.3 ML 30G X 1/2" 0.3 ML T1 QL (200 EA per 30 days)

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

*Migraine Products*almotriptan malate tablet 12.5 mg oral 12.5 mg T3 ST; QL (9 EA per 30 days)

almotriptan malate tablet 6.25 mg oral 6.25 mg T3 ST; QL (9 EA per 30 days)

eletriptan hydrobromide tablet 20 mg oral 20 mg T3 ST; QL (9 EA per 30 days)

eletriptan hydrobromide tablet 40 mg oral 40 mg T3 ST; QL (9 EA per 30 days)

ergotamine-caffeine oral tablet 1-100 mg T3 QL (40 EA per 28 days)

frovatriptan succinate tablet 2.5 mg oral 2.5 mg T3 ST; QL (9 EA per 30 days)

naratriptan hcl tablet 1 mg oral 1 mg T2 QL (9 EA per 30 days)

naratriptan hcl tablet 2.5 mg oral 2.5 mg T2 QL (9 EA per 30 days)

RELPAX TABLET 20 MG ORAL 20 MG T3 ST; QL (9 EA per 30 days)

rizatriptan benzoate tablet 10 mg oral 10 mg T1 QL (12 EA per 30 days)

rizatriptan benzoate tablet 5 mg oral 5 mg T1 QL (12 EA per 30 days)

rizatriptan benzoate tablet dispersible 10 mg oral10 mg


rizatriptan benzoate tablet dispersible 5 mg oral 5 mg


sumatriptan solution 20 mg/act nasal 20 mg/act T3

sumatriptan solution 5 mg/act nasal 5 mg/act T3

sumatriptan succinate solution 6 mg/0.5ml subcutaneous 6 mg/0.5ml


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


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

T4 PA

sumatriptan succinate tablet 100 mg oral 100 mg T1 QL (9 EA per 30 days)



zolmitriptan tablet 2.5 mg oral 2.5 mg T1 QL (6 EA per 30 days)

zolmitriptan tablet 5 mg oral 5 mg T1 QL (6 EA per 30 days)

zolmitriptan tablet dispersible 2.5 mg oral 2.5 mg T1 QL (6 EA per 30 days)

zolmitriptan tablet dispersible 5 mg oral 5 mg T1 QL (6 EA per 30 days)

*Minerals & Electrolytes*EFFER-K TABLET EFFERVESCENT 10 MEQ ORAL 10 MEQ T3

96

Drug Status NotesEFFER-K TABLET EFFERVESCENT 20 MEQ ORAL 20 MEQ T3

fluoritab tablet chewable 1.1 (0.5 f) mg oral 1.1 (0.5 f) mg

T5

iodine strong solution 5 % oral 5 % T1

KLOR-CON M15 TABLET EXTENDED RELEASE 15 MEQ ORAL 15 MEQ T3

K-PRIME TABLET EFFERVESCENT 25 MEQ ORAL 25 MEQ T1

MONOJECT SODIUM CHLORIDE FLUSH SOLUTION 0.9 % INTRAVENOUS 0.9 % T3

PHOSPHO-TRIN 250 NEUTRAL TABLET 155-852-130 MG ORAL 155-852-130 MG T1

pot bicarb-pot chloride oral tablet effervescent 25 meq

T1

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

T1

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

T1

potassium chloride er capsule extended release 10 meq oral 10 meq

T1

potassium chloride er capsule extended release 8 meq oral 8 meq

T1

potassium chloride er oral tablet extended release20 meq

T1

potassium chloride er tablet extended release 10 meq oral 10 meq

T1

potassium chloride er tablet extended release 8 meq oral 8 meq

T1

potassium chloride packet 20 meq oral 20 meq T3

sodium chloride solution 0.9 % intravenous 0.9 % T3

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

T5

sodium fluoride tablet chewable 2.2 (1 f) mg oral2.2 (1 f) mg

T5

zinc sulfate capsule 220 (50 zn) mg oral (otc) 220 (50 zn) mg

T1

*Miscellaneous Therapeutic Classes*alprostadil solution 500 mcg/ml injection 500 mcg/ml

T1

AZASAN TABLET 100 MG ORAL 100 MG T3 PA

AZASAN TABLET 75 MG ORAL 75 MG T3 PA

97

Drug Status Notesazathioprine tablet 50 mg oral 50 mg T1

CUPRIMINE CAPSULE 250 MG ORAL 250 MG T4 PA

cyclosporine capsule 100 mg oral 100 mg T3

cyclosporine capsule 25 mg oral 25 mg T3

cyclosporine modified capsule 100 mg oral 100 mg

T3

cyclosporine modified capsule 25 mg oral 25 mg T1

everolimus oral tablet 0.25 mg, 0.5 mg, 0.75 mg T4 PA

GENGRAF SOLUTION 100 MG/ML ORAL100 MG/ML T3

mycophenolate mofetil capsule 250 mg oral 250 mg

T1

mycophenolate mofetil suspension reconstituted 200 mg/ml oral 200 mg/ml

T4

mycophenolate mofetil tablet 500 mg oral 500 mg T1

mycophenolate sodium tablet delayed release 180 mg oral 180 mg

T3 PA

mycophenolate sodium tablet delayed release 360 mg oral 360 mg

T3 PA

penicillamine oral tablet 250 mg T4

RAPAMUNE SOLUTION 1 MG/ML ORAL 1 MG/ML T4 PA

REVLIMID CAPSULE 10 MG ORAL 10 MG T4 PA


REVLIMID CAPSULE 2.5 MG ORAL 2.5 MG T4 PA




SANDIMMUNE SOLUTION 100 MG/ML ORAL 100 MG/ML T4 PA

sirolimus tablet 0.5 mg oral 0.5 mg T4 PA

sodium polystyrene sulfonate powder oral T1

SPS SUSPENSION 15 GM/60ML ORAL 15 GM/60ML T1

sterile water for irrigation irrigation solution T1

SYPRINE CAPSULE 250 MG ORAL 250 MG T4

tacrolimus capsule 0.5 mg oral 0.5 mg T1

tacrolimus capsule 1 mg oral 1 mg T1

tacrolimus capsule 5 mg oral 5 mg T3

98

Drug Status NotesTHALOMID CAPSULE 100 MG ORAL 100 MG T4 PA

THALOMID CAPSULE 150 MG ORAL 150 MG T4 PA



ZORTRESS TABLET 0.75 MG ORAL 0.75 MG T4 PA

*Mouth/Throat/Dental Agents*cevimeline hcl capsule 30 mg oral 30 mg T3 PA

chlorhexidine gluconate solution 0.12 % mouth/throat 0.12 %

T1

FLUORIDEX DAILY RENEWAL CONCENTRATE 0.63 % MOUTH/THROAT0.63 %

T1

FLUORIDEX PASTE 1.1 % DENTAL 1.1 % T1

lidocaine hcl solution 4 % mouth/throat 4 % T1 QL (100 ML per 30 days)

nystatin suspension 100000 unit/ml mouth/throat100000 unit/ml

T1

ORAVIG TABLET 50 MG BUCCAL 50 MG T4 PA

pilocarpine hcl tablet 5 mg oral 5 mg T1

pilocarpine hcl tablet 7.5 mg oral 7.5 mg T1

sf 5000 plus cream 1.1 % dental 1.1 % T1

sf dental gel 1.1 % T1

triamcinolone acetonide paste 0.1 % mouth/throat0.1 %


*Multivitamins*multivitamin/fluoride solution 0.25 mg/ml oral0.25 mg/ml

T1

prenatal tablet 27-0.8 mg oral (otc) 27-0.8 mg T5

TARON-PREX CAPSULE 30-1.2-265 MG ORAL 30-1.2-265 MG T1

thrivite 19 tablet 1 mg oral 1 mg T5

vitamins acd-fluoride solution 0.25 mg/ml oral0.25 mg/ml

T1

*Musculoskeletal Therapy Agents*baclofen tablet 10 mg oral 10 mg T1

baclofen tablet 20 mg oral 20 mg T1

carisoprodol tablet 350 mg oral 350 mg T1

99

Drug Status Noteschlorzoxazone oral tablet 375 mg T3

chlorzoxazone tablet 500 mg oral 500 mg T1 AL (Max 64 Years)

cyclobenzaprine hcl tablet 10 mg oral 10 mg T1 AL (Max 64 Years)

cyclobenzaprine hcl tablet 5 mg oral 5 mg T1 AL (Max 64 Years)

dantrolene sodium capsule 100 mg oral 100 mg T1



metaxalone tablet 800 mg oral 800 mg T3 PA; AL (Max 64 Years)

methocarbamol tablet 500 mg oral 500 mg T1 AL (Max 64 Years)

methocarbamol tablet 750 mg oral 750 mg T1 AL (Max 64 Years)

orphenadrine citrate er tablet extended release 12 hour 100 mg oral 100 mg


tizanidine hcl capsule 2 mg oral 2 mg T3 QL (90 EA per 30 days)



tizanidine hcl tablet 2 mg oral 2 mg T1 QL (90 EA per 30 days)

tizanidine hcl tablet 4 mg oral 4 mg T1 QL (90 EA per 30 days)

*Nasal Agents - Systemic And Topical*allergy spray 24 hour aerosol 55 mcg/act nasal55 mcg/act


azelastine hcl solution 0.1 % nasal 0.1 % T1

azelastine hcl solution 0.15 % nasal 0.15 % T3 ST

BECONASE AQ SUSPENSION 42 MCG/SPRAY NASAL 42 MCG/SPRAY T3 ST

cvs nasal allergy spray aerosol 55 mcg/act nasal55 mcg/act


eq nasal allergy aerosol 55 mcg/act nasal 55 mcg/act


FLONASE SENSIMIST SUSPENSION 27.5 MCG/SPRAY NASAL 27.5 MCG/SPRAY T1 QL (15.8 ML per 30 days)

flunisolide solution 25 mcg/act (0.025%) nasal 25 mcg/act (0.025%)


fluticasone propionate nasal suspension 50 mcg/act


gnp 24 hour nasal allergy aerosol 55 mcg/act nasal 55 mcg/act


goodsense nasal allergy spray aerosol 55 mcg/act nasal 55 mcg/act


ipratropium bromide solution 0.03 % nasal 0.03 %


100

Drug Status Notesipratropium bromide solution 0.06 % nasal 0.06 %


mometasone furoate suspension 50 mcg/act nasal50 mcg/act

T3 ST

nasal allergy 24 hour aerosol 55 mcg/act nasal55 mcg/act


QNASL AEROSOL SOLUTION 80 MCG/ACT NASAL 80 MCG/ACT T3 ST

ra nasal allergy aerosol 55 mcg/act nasal 55 mcg/act


triamcinolone acetonide aerosol 55 mcg/act nasal (otc) 55 mcg/act


triamcinolone acetonide aerosol 55 mcg/act nasal (rx) 55 mcg/act


*Neuromuscular Agents*riluzole oral tablet 50 mg T1

*Nutrients*nac capsule 600 mg oral 600 mg T1

*Ophthalmic Agents*ACUVAIL SOLUTION 0.45 % OPHTHALMIC 0.45 % T3

ALOCRIL SOLUTION 2 % OPHTHALMIC2 % T3 PA

ALOMIDE SOLUTION 0.1 % OPHTHALMIC 0.1 % T3 PA

ALPHAGAN P SOLUTION 0.1 % OPHTHALMIC 0.1 % T3

ALTACAINE SOLUTION 0.5 % OPHTHALMIC 0.5 % T1

apraclonidine hcl solution 0.5 % ophthalmic 0.5 %

T3

atropine sulfate ointment 1 % ophthalmic 1 % T1

atropine sulfate solution 1 % ophthalmic 1 % T1

AZASITE SOLUTION 1 % OPHTHALMIC 1 % T3 PA

azelastine hcl solution 0.05 % ophthalmic 0.05 % T1 QL (6 ML per 30 days)

AZOPT SUSPENSION 1 % OPHTHALMIC 1 % T3 QL (15 ML per 30 days)

bacitracin ointment 500 unit/gm ophthalmic 500 unit/gm

T1

bacitracin-polymyxin b ointment 500-10000 unit/gm ophthalmic 500-10000 unit/gm

T1

101

Drug Status Notesbacitra-neomycin-polymyxin-hc ointment 1 % ophthalmic 1 %

T1

balanced salt solution intraocular T1

BEPREVE SOLUTION 1.5 % OPHTHALMIC 1.5 % T3 PA

BESIVANCE SUSPENSION 0.6 % OPHTHALMIC 0.6 % T3

betaxolol hcl solution 0.5 % ophthalmic 0.5 % T1

BETOPTIC-S SUSPENSION 0.25 % OPHTHALMIC 0.25 % T2 PA

bimatoprost ophthalmic solution 0.03 % T1 QL (5 ML per 30 days)

BLEPHAMIDE S.O.P. OINTMENT 10-0.2 % OPHTHALMIC 10-0.2 % T2

brimonidine tartrate solution 0.15 % ophthalmic0.15 %

T3

brimonidine tartrate solution 0.2 % ophthalmic0.2 %

T1

bromfenac sodium (once-daily) solution 0.09 % ophthalmic 0.09 %

T3

carteolol hcl solution 1 % ophthalmic 1 % T1

CILOXAN OINTMENT 0.3 % OPHTHALMIC 0.3 % T3

ciprofloxacin hcl solution 0.3 % ophthalmic 0.3 %

T1

COMBIGAN SOLUTION 0.2-0.5 % OPHTHALMIC 0.2-0.5 % T3

cromolyn sodium solution 4 % ophthalmic 4 % T1

cvs sodium chloride ointment 5 % ophthalmic 5 % T1

cyclopentolate hcl solution 1 % ophthalmic 1 % T1

cyclopentolate hcl solution 2 % ophthalmic 2 % T1

CYSTARAN SOLUTION 0.44 % OPHTHALMIC 0.44 % T4

dexamethasone sodium phosphate solution 0.1 % ophthalmic 0.1 %

T1

diclofenac sodium solution 0.1 % ophthalmic 0.1 %

T1

dorzolamide hcl solution 2 % ophthalmic 2 % T1

dorzolamide hcl-timolol mal solution 22.3-6.8 mg/ml ophthalmic 22.3-6.8 mg/ml

T1

DUREZOL EMULSION 0.05 % OPHTHALMIC 0.05 % T3

epinastine hcl solution 0.05 % ophthalmic 0.05 % T3

102

Drug Status Noteserythromycin ointment 5 mg/gm ophthalmic 5 mg/gm

T1

eye allergy relief ophthalmic solution 0.025-0.3 % T1

FLAREX SUSPENSION 0.1 % OPHTHALMIC 0.1 % T3

FLUCAINE SOLUTION 0.25-0.5 % OPHTHALMIC 0.25-0.5 % T1

fluorometholone suspension 0.1 % ophthalmic 0.1 %

T1

flurbiprofen sodium solution 0.03 % ophthalmic0.03 %

T1

FML OINTMENT 0.1 % OPHTHALMIC 0.1 % T2

gatifloxacin solution 0.5 % ophthalmic 0.5 % T3

GENTAK OPHTHALMIC OINTMENT 0.3 % T1

gentamicin sulfate solution 0.3 % ophthalmic 0.3 %

T1

HOMATROPAIRE OPHTHALMIC SOLUTION 5 % T1

IOPIDINE SOLUTION 1 % OPHTHALMIC1 % T3

ketorolac tromethamine solution 0.4 % ophthalmic 0.4 %

T1

ketorolac tromethamine solution 0.5 % ophthalmic 0.5 %

T1

LACRISERT INSERT 5 MG OPHTHALMIC5 MG T3 PA

LASTACAFT SOLUTION 0.25 % OPHTHALMIC 0.25 % T3 PA

latanoprost solution 0.005 % ophthalmic 0.005 % T1 QL (5 ML per 30 days)

levobunolol hcl solution 0.5 % ophthalmic 0.5 % T1

levofloxacin ophthalmic solution 0.5 % T1

LOTEMAX OINTMENT 0.5 % OPHTHALMIC 0.5 % T3

LOTEMAX SUSPENSION 0.5 % OPHTHALMIC 0.5 % T3

LUMIGAN SOLUTION 0.01 % OPHTHALMIC 0.01 % T3 ST; QL (7.5 ML per 30 days)

moxifloxacin hcl (2x day) ophthalmic solution 0.5 %

T3

moxifloxacin hcl solution 0.5 % ophthalmic 0.5 % T3

103

Drug Status NotesNATACYN SUSPENSION 5 % OPHTHALMIC 5 % T3 PA

neomycin-bacitracin zn-polymyx ointment 5-400-10000 ophthalmic 5-400-10000

T1

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

T1

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

T1

neomycin-polymyxin-gramicidin solution 1.75-10000-.025 ophthalmic 1.75-10000-.025

T1

neomycin-polymyxin-hc suspension 3.5-10000-1 ophthalmic 3.5-10000-1

T1

NEVANAC SUSPENSION 0.1 % OPHTHALMIC 0.1 % T3

ofloxacin solution 0.3 % ophthalmic 0.3 % T1

olopatadine hcl solution 0.1 % ophthalmic (rx)0.1 %

T1

olopatadine hcl solution 0.2 % ophthalmic (rx)0.2 %

T3 PA

PHOSPHOLINE IODIDE SOLUTION RECONSTITUTED 0.125 % OPHTHALMIC0.125 %

T2 PA

pilocarpine hcl solution 1 % ophthalmic 1 % T1



polymyxin b-trimethoprim solution 10000-0.1 unit/ml-% ophthalmic 10000-0.1 unit/ml-%

T1

PRED MILD SUSPENSION 0.12 % OPHTHALMIC 0.12 % T2

prednisolone acetate ophthalmic suspension 1 % T1

prednisolone sodium phosphate solution 1 % ophthalmic 1 %

T1

proparacaine hcl solution 0.5 % ophthalmic 0.5 %

T1

SIMBRINZA SUSPENSION 1-0.2 % OPHTHALMIC 1-0.2 % T3 QL (8 ML per 30 days)

sodium chloride (hypertonic) ophthalmic solution5 %

T1

sulfacetamide sodium solution 10 % ophthalmic10 %

T1

sulfacetamide-prednisolone solution 10-0.23 % ophthalmic 10-0.23 %

T1

104

Drug Status Notestimolol maleate gel forming solution 0.25 % ophthalmic 0.25 %

T3

timolol maleate gel forming solution 0.5 % ophthalmic 0.5 %

T3

timolol maleate solution 0.25 % ophthalmic 0.25 %

T1

timolol maleate solution 0.5 % ophthalmic 0.5 % T1

TOBRADEX OINTMENT 0.3-0.1 % OPHTHALMIC 0.3-0.1 % T3 QL (3.5 GM per 30 days)

TOBRADEX ST SUSPENSION 0.3-0.05 % OPHTHALMIC 0.3-0.05 % T2 QL (5 ML per 30 days)

tobramycin solution 0.3 % ophthalmic 0.3 % T1

tobramycin-dexamethasone suspension 0.3-0.1 % ophthalmic 0.3-0.1 %


TOBREX OINTMENT 0.3 % OPHTHALMIC0.3 % T2

travoprost (bak free) ophthalmic solution 0.004 % T3 ST; QL (5 ML per 30 days)

trifluridine solution 1 % ophthalmic 1 % T3

tropicamide solution 0.5 % ophthalmic 0.5 % T1

tropicamide solution 1 % ophthalmic 1 % T1

ZIOPTAN SOLUTION 0.0015 % OPHTHALMIC 0.0015 % T3 ST; QL (30 EA per 30 days)

ZIRGAN GEL 0.15 % OPHTHALMIC 0.15 % T3

*Otic Agents*ACETASOL HC SOLUTION 2-1 % OTIC 2-1 % T3

acetic acid solution 2 % otic 2 % T1

CIPRO HC SUSPENSION 0.2-1 % OTIC 0.2-1 % T3 PA

ciprofloxacin-dexamethasone otic suspension 0.3-0.1 %

T3

fluocinolone acetonide oil 0.01 % otic 0.01 % T3

neomycin-polymyxin-hc solution 3.5-10000-1 otic3.5-10000-1

T1

neomycin-polymyxin-hc suspension 3.5-10000-1 otic 3.5-10000-1

T1

ofloxacin solution 0.3 % otic 0.3 % T1

*Oxytocics*methylergonovine maleate oral tablet 0.2 mg T2

105

Drug Status Notes

*Passive Immunizing And Treatment Agents*HYPERRHO S/D SOLUTION PREFILLED SYRINGE 1500 UNIT INTRAMUSCULAR1500 UNIT

T2 GR-F

HYQVIA KIT 2.5 GM/25ML SUBCUTANEOUS 2.5 GM/25ML T4 PA

HYQVIA SUBCUTANEOUS KIT 10 GM/100ML, 20 GM/200ML, 30 GM/300ML, 5 GM/50ML

T4 PA

SYNAGIS SOLUTION 100 MG/ML INTRAMUSCULAR 100 MG/ML T4 PA

SYNAGIS SOLUTION 50 MG/0.5ML INTRAMUSCULAR 50 MG/0.5ML T4 PA

*Penicillins*amoxicillin capsule 250 mg oral 250 mg T1

amoxicillin capsule 500 mg oral 500 mg T1

amoxicillin suspension reconstituted 125 mg/5ml oral 125 mg/5ml

T1


T1


T1


T1

amoxicillin tablet 500 mg oral 500 mg T1

amoxicillin tablet 875 mg oral 875 mg T1

amoxicillin tablet chewable 125 mg oral 125 mg T1

amoxicillin tablet chewable 250 mg oral 250 mg T1

amoxicillin-pot clavulanate er tablet extended release 12 hour 1000-62.5 mg oral 1000-62.5 mg

T3

amoxicillin-pot clavulanate suspension reconstituted 200-28.5 mg/5ml oral 200-28.5 mg/5ml

T1

amoxicillin-pot clavulanate suspension reconstituted 400-57 mg/5ml oral 400-57 mg/5ml

T1

amoxicillin-pot clavulanate suspension reconstituted 600-42.9 mg/5ml oral 600-42.9 mg/5ml

T1

amoxicillin-pot clavulanate tablet 250-125 mg oral 250-125 mg


amoxicillin-pot clavulanate tablet 500-125 mg oral 500-125 mg


106

Drug Status Notesamoxicillin-pot clavulanate tablet 875-125 mg oral 875-125 mg


amoxicillin-pot clavulanate tablet chewable 200-28.5 mg oral 200-28.5 mg

T1

amoxicillin-pot clavulanate tablet chewable 400-57 mg oral 400-57 mg

T1

ampicillin capsule 500 mg oral 500 mg T1

BICILLIN L-A SUSPENSION 1200000 UNIT/2ML INTRAMUSCULAR 1200000 UNIT/2ML

T4 PA

BICILLIN L-A SUSPENSION 600000 UNIT/ML INTRAMUSCULAR 600000 UNIT/ML

T4 PA

dicloxacillin sodium capsule 250 mg oral 250 mg T1

dicloxacillin sodium capsule 500 mg oral 500 mg T1

penicillin v potassium solution reconstituted 125 mg/5ml oral 125 mg/5ml

T1

penicillin v potassium solution reconstituted 250 mg/5ml oral 250 mg/5ml

T1

penicillin v potassium tablet 250 mg oral 250 mg T1

penicillin v potassium tablet 500 mg oral 500 mg T1

*Pharmaceutical Adjuvants*cherry oral syrup T1

flavor sweet oral syrup T1

ORA-BLEND ORAL SUSPENSION T1

ORA-PLUS ORAL LIQUID T1

ORA-SWEET ORAL SYRUP T1

simple syrup oral syrup T1

*Progestins*hydroxyprogesterone caproate intramuscular oil250 mg/ml

T4 PA; GR-F

medroxyprogesterone acetate tablet 10 mg oral10 mg

T1

medroxyprogesterone acetate tablet 2.5 mg oral2.5 mg

T1

medroxyprogesterone acetate tablet 5 mg oral 5 mg

T1

norethindrone acetate tablet 5 mg oral 5 mg T1

progesterone micronized oral capsule 100 mg, 200 mg

T2 GR-F

107

Drug Status Notes

*Psychotherapeutic And Neurological Agents - Misc.*acamprosate calcium oral tablet delayed release333 mg

T1

AMPYRA ORAL TABLET EXTENDED RELEASE 12 HOUR 10 MG T4 PA

AUBAGIO TABLET 14 MG ORAL 14 MG T4 PA

AUBAGIO TABLET 7 MG ORAL 7 MG T4 PA

AVONEX PEN AUTO-INJECTOR KIT 30 MCG/0.5ML INTRAMUSCULAR 30 MCG/0.5ML

T4 PA

AVONEX PREFILLED PREFILLED SYRINGE KIT 30 MCG/0.5ML INTRAMUSCULAR 30 MCG/0.5ML

T4 PA

bupropion hcl er (smoking det) tablet extended release 12 hour 150 mg oral 150 mg

T5

CHANTIX ORAL TABLET 0.5 MG, 1 MG T5 QL (60 EA per 30 days)

CHANTIX STARTING MONTH PAK ORAL TABLET 0.5 MG X 11 & 1 MG X 42 T5 QL (60 EA per 30 days)

chlordiazepoxide-amitriptyline tablet 10-25 mg oral 10-25 mg

T1

chlordiazepoxide-amitriptyline tablet 5-12.5 mg oral 5-12.5 mg

T1

dalfampridine er oral tablet extended release 12 hour 10 mg

T4 PA

dimethyl fumarate oral capsule delayed release120 mg, 240 mg

T4 PA

disulfiram tablet 250 mg oral 250 mg T1

disulfiram tablet 500 mg oral 500 mg T1

donepezil hcl tablet 10 mg oral 10 mg T1



donepezil hcl tablet dispersible 10 mg oral 10 mg T1

donepezil hcl tablet dispersible 5 mg oral 5 mg T1

ergoloid mesylates tablet 1 mg oral 1 mg T3 PA

galantamine hydrobromide er capsule extended release 24 hour 16 mg oral 16 mg

T3


T3


T3

108

Drug Status Notesgalantamine hydrobromide tablet 12 mg oral 12 mg

T1

galantamine hydrobromide tablet 4 mg oral 4 mg T1

galantamine hydrobromide tablet 8 mg oral 8 mg T1

GILENYA CAPSULE 0.5 MG ORAL 0.5 MG T4 PA

glatiramer acetate subcutaneous solution prefilled syringe 40 mg/ml

T4 PA

GLATOPA SOLUTION PREFILLED SYRINGE 20 MG/ML SUBCUTANEOUS 20 MG/ML

T4 PA

MAYZENT ORAL TABLET 0.25 MG, 2 MG T4 PA

memantine hcl solution 2 mg/ml oral 2 mg/ml T3 PA

memantine hcl tablet 10 mg oral 10 mg T1 QL (60 EA per 30 days)

memantine hcl tablet 28 x 5 mg & 21 x 10 mg oral28 x 5 mg & 21 x 10 mg


memantine hcl tablet 5 mg oral 5 mg T1 QL (60 EA per 30 days)

NICORETTE MOUTH/THROAT LOZENGE4 MG T5 QL (270 EA per 30 days)

nicotine mini mouth/throat lozenge 2 mg T5 QL (270 EA per 30 days)

nicotine polacrilex mouth/throat gum 2 mg, 4 mg T5 QL (810 EA per 365 days)

nicotine transdermal patch 24 hour 14 mg/24hr, 21 mg/24hr, 7 mg/24hr


NICOTROL INHALATION INHALER 10 MG T5 QL (168 EA per 30 days)

NUEDEXTA CAPSULE 20-10 MG ORAL 20-10 MG T4 PA

olanzapine-fluoxetine hcl oral capsule 12-25 mg, 12-50 mg, 3-25 mg, 6-25 mg, 6-50 mg

T3 PA

perphenazine-amitriptyline tablet 2-10 mg oral 2-10 mg

T1


T1


T1


T1


T1

pimozide tablet 1 mg oral 1 mg T3 PA

pimozide tablet 2 mg oral 2 mg T3 PA

rivastigmine patch 24 hour 13.3 mg/24hr transdermal 13.3 mg/24hr

T3 PA

109

Drug Status Notesrivastigmine patch 24 hour 4.6 mg/24hr transdermal 4.6 mg/24hr

T3 PA

rivastigmine patch 24 hour 9.5 mg/24hr transdermal 9.5 mg/24hr

T3 PA

rivastigmine tartrate capsule 1.5 mg oral 1.5 mg T3

rivastigmine tartrate capsule 3 mg oral 3 mg T3

rivastigmine tartrate capsule 4.5 mg oral 4.5 mg T3

rivastigmine tartrate capsule 6 mg oral 6 mg T3

SAVELLA TABLET 100 MG ORAL 100 MG T3 PA

SAVELLA TABLET 12.5 MG ORAL 12.5 MG T3 PA



tetrabenazine tablet 12.5 mg oral 12.5 mg T4 PA

tetrabenazine tablet 25 mg oral 25 mg T4 PA

XYREM SOLUTION 500 MG/ML ORAL 500 MG/ML T4 PA

*Respiratory Agents - Misc.*ESBRIET CAPSULE 267 MG ORAL 267 MG T4 PA

KALYDECO TABLET 150 MG ORAL 150 MG T4 PA

OFEV CAPSULE 100 MG ORAL 100 MG T4 PA

OFEV CAPSULE 150 MG ORAL 150 MG T4 PA

PULMOZYME SOLUTION 1 MG/ML INHALATION 1 MG/ML T4 PA; QL (60 ML per 30 days)

*Sulfonamides*sulfadiazine tablet 500 mg oral 500 mg T3

*Tetracyclines*demeclocycline hcl tablet 150 mg oral 150 mg T3

demeclocycline hcl tablet 300 mg oral 300 mg T3

doxycycline hyclate capsule 100 mg oral 100 mg T1

doxycycline hyclate capsule 50 mg oral 50 mg T1

doxycycline hyclate tablet 100 mg oral 100 mg T1

doxycycline hyclate tablet 20 mg oral 20 mg T1

doxycycline monohydrate capsule 150 mg oral150 mg

T3

doxycycline monohydrate oral capsule 75 mg T3 PA

doxycycline monohydrate suspension reconstituted 25 mg/5ml oral 25 mg/5ml

T1

doxycycline monohydrate tablet 100 mg oral 100 mg

T1

110

Drug Status Notesdoxycycline monohydrate tablet 150 mg oral 150 mg

T3

doxycycline monohydrate tablet 50 mg oral 50 mg T1

doxycycline monohydrate tablet 75 mg oral 75 mg T1

minocycline hcl capsule 100 mg oral 100 mg T1



tetracycline hcl capsule 250 mg oral 250 mg T3

tetracycline hcl capsule 500 mg oral 500 mg T3

*Thyroid Agents*ARMOUR THYROID ORAL TABLET 180 MG, 240 MG, 300 MG, 90 MG T1

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

liothyronine sodium tablet 25 mcg oral 25 mcg T1



methimazole tablet 10 mg oral 10 mg T1

methimazole tablet 5 mg oral 5 mg T1

NATURE-THROID ORAL TABLET 113.75 MG, 146.25 MG, 16.25 MG, 162.5 MG, 260 MG, 325 MG, 48.75 MG, 81.25 MG, 97.5 MG

T1

NATURE-THROID TABLET 130 MG ORAL130 MG T1

NATURE-THROID TABLET 195 MG ORAL195 MG T1

NATURE-THROID TABLET 32.5 MG ORAL32.5 MG T1

np thyroid oral tablet 120 mg, 15 mg, 30 mg T1

propylthiouracil tablet 50 mg oral 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

T2

WESTHROID TABLET 65 MG ORAL 65 MG T1

*Ulcer Drugs/Antispasmodics/Anticholinergics*belladonna alkaloids-opium suppository 16.2-30 mg rectal 16.2-30 mg

T3QL (12 EA per 30 days); AL (Max 64 Years)

111

Drug Status Notesbelladonna alkaloids-opium suppository 16.2-60 mg rectal 16.2-60 mg

T3QL (12 EA per 30 days); AL (Max 64 Years)

CARAFATE ORAL SUSPENSION 1 GM/10ML T3

cimetidine hcl solution 300 mg/5ml oral 300 mg/5ml

T1

cimetidine oral tablet 200 mg T1

cimetidine tablet 300 mg oral 300 mg T1



dicyclomine hcl capsule 10 mg oral 10 mg T1 AL (Max 64 Years)

dicyclomine hcl solution 10 mg/5ml oral 10 mg/5ml


dicyclomine hcl tablet 20 mg oral 20 mg T1 AL (Max 64 Years)

famotidine oral tablet 20 mg T1

famotidine suspension reconstituted 40 mg/5ml oral 40 mg/5ml


famotidine tablet 40 mg oral 40 mg T1

FIRST-LANSOPRAZOLE SUSPENSION 3 MG/ML ORAL 3 MG/ML T1 QL (150 ML per 30 days)

glycopyrrolate tablet 1 mg oral 1 mg T1

glycopyrrolate tablet 2 mg oral 2 mg T1

hyoscyamine sulfate sl tablet sublingual 0.125 mg sublingual 0.125 mg


hyoscyamine sulfate tablet 0.125 mg oral 0.125 mg


hyoscyamine sulfate tablet dispersible 0.125 mg oral 0.125 mg


hyosyne elixir 0.125 mg/5ml oral 0.125 mg/5ml T1 AL (Max 64 Years)

hyosyne solution 0.125 mg/ml oral 0.125 mg/ml T1 AL (Max 64 Years)

lansoprazole capsule delayed release 30 mg oral30 mg


lansoprazole oral capsule delayed release 15 mg T1 QL (60 EA per 30 days)

methscopolamine bromide oral tablet 2.5 mg, 5 mg


misoprostol tablet 100 mcg oral 100 mcg T1

misoprostol tablet 200 mcg oral 200 mcg T1

nizatidine capsule 150 mg oral 150 mg T1

nizatidine capsule 300 mg oral 300 mg T1

nizatidine solution 15 mg/ml oral 15 mg/ml T1

112

Drug Status Notesomeprazole capsule delayed release 10 mg oral10 mg


omeprazole capsule delayed release 20 mg oral (rx) 20 mg


omeprazole capsule delayed release 40 mg oral40 mg


pantoprazole sodium tablet delayed release 20 mg oral 20 mg


pantoprazole sodium tablet delayed release 40 mg oral 40 mg


propantheline bromide tablet 15 mg oral 15 mg T1

rabeprazole sodium tablet delayed release 20 mg oral 20 mg


sucralfate tablet 1 gm oral 1 gm T1

SYMAX DUOTAB TABLET EXTENDED RELEASE 0.375 MG ORAL 0.375 MG T1 AL (Max 64 Years)

SYMAX-SR TABLET EXTENDED RELEASE 12 HOUR 0.375 MG ORAL 0.375 MG


*Urinary Anti-Infectives*urin ds oral tablet T1

*Urinary Antispasmodics*bethanechol chloride tablet 10 mg oral 10 mg T1

bethanechol chloride tablet 25 mg oral 25 mg T1



darifenacin hydrobromide er tablet extended release 24 hour 15 mg oral 15 mg

T2 ST

darifenacin hydrobromide er tablet extended release 24 hour 7.5 mg oral 7.5 mg

T2 ST

flavoxate hcl tablet 100 mg oral 100 mg T1

oxybutynin chloride er oral tablet extended release 24 hour 5 mg

T1

oxybutynin chloride er tablet extended release 24 hour 10 mg oral 10 mg

T1

oxybutynin chloride er tablet extended release 24 hour 15 mg oral 15 mg

T1

oxybutynin chloride oral syrup 5 mg/5ml T1

oxybutynin chloride tablet 5 mg oral 5 mg T1

OXYTROL FOR WOMEN PATCH TWICE WEEKLY 3.9 MG/24HR TRANSDERMAL3.9 MG/24HR

T1

113

Drug Status Notessolifenacin succinate oral tablet 10 mg, 5 mg T3 ST

tolterodine tartrate er capsule extended release 24 hour 2 mg oral 2 mg

T2 ST

tolterodine tartrate er capsule extended release 24 hour 4 mg oral 4 mg

T2 ST

tolterodine tartrate tablet 1 mg oral 1 mg T1 ST

tolterodine tartrate tablet 2 mg oral 2 mg T1 ST

TOVIAZ TABLET EXTENDED RELEASE 24 HOUR 4 MG ORAL 4 MG T2 ST

TOVIAZ TABLET EXTENDED RELEASE 24 HOUR 8 MG ORAL 8 MG T2 ST

trospium chloride er capsule extended release 24 hour 60 mg oral 60 mg

T1 ST

trospium chloride tablet 20 mg oral 20 mg T1 ST

VESICARE TABLET 10 MG ORAL 10 MG T3 ST

VESICARE TABLET 5 MG ORAL 5 MG T3 ST

*Vaccines*AFLURIA QUADRIVALENT INTRAMUSCULAR SUSPENSION T5

QL (0.5 ML per 365 days); AL (Min 6 Months)

AFLURIA QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.25 ML

T5QL (0.25 ML per 365 days); AL (Min 6 Months and Max 35 Months)

AFLURIA QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML

T5QL (0.5 ML per 365 days); AL (Min 3 Years)

FLUAD INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML T5

QL (0.5 ML per 365 days); AL (Min 65 Years)

FLUAD QUADRIVALENT INTRAMUSCULAR PREFILLED SYRINGE0.5 ML


FLUARIX QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML

T5QL (0.5 ML per 365 days); AL (Min 6 Months)

FLUZONE QUADRIVALENT INTRAMUSCULAR SUSPENSION T5

QL (0.5 ML per 365 days); AL (Min 6 Months)

FLUZONE QUADRIVALENT INTRAMUSCULAR SUSPENSION 0.5 ML T5

QL (0.5 ML per 365 days); AL (Min 3 Years)

FLUZONE QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML


SHINGRIX INTRAMUSCULAR SUSPENSION RECONSTITUTED 50 MCG/0.5ML

T5QL (2 EA per 1 lifetime); AL (Min 50 Years)

114

Drug Status Notes

*Vaginal And Related Products*CLEOCIN SUPPOSITORY 100 MG VAGINAL 100 MG T3

clindamycin phosphate cream 2 % vaginal 2 % T1

clotrimazole vaginal cream 1 % T1 QL (50 GM per 30 days)

CRINONE GEL 4 % VAGINAL 4 % T4 PA

CRINONE GEL 8 % VAGINAL 8 % T4 PA

ENDOMETRIN INSERT 100 MG VAGINAL100 MG T3 PA

estradiol tablet 10 mcg vaginal 10 mcg T3 GR-F

estradiol vaginal cream 0.1 mg/gm T2

ESTRING RING 2 MG VAGINAL 2 MG T3

FIRST-PROGESTERONE VGS SUPPOSITORY 100 MG VAGINAL 100 MG T2 GR-F; QL (30 EA per 30 days)

FIRST-PROGESTERONE VGS SUPPOSITORY 200 MG VAGINAL 200 MG T2 GR-F; QL (30 EA per 30 days)

GYNAZOLE-1 CREAM 2 % VAGINAL 2 % T3

metronidazole vaginal gel 0.75 % T1

miconazole 3 applicator vaginal kit 200 & 2 mg-% (9gm)

T1

miconazole 3 combo pack vaginal kit 200 & 2 mg-% (9gm)

T1

terconazole cream 0.4 % vaginal 0.4 % T1

terconazole vaginal cream 0.8 % T1

terconazole vaginal suppository 80 mg T1

*Vasopressors*ADRENALIN SOLUTION 1 MG/ML INJECTION 1 MG/ML T1 QL (2 ML per 90 days)

epinephrine solution auto-injector 0.15 mg/0.15ml injection 0.15 mg/0.15ml






midodrine hcl tablet 10 mg oral 10 mg T1

midodrine hcl tablet 2.5 mg oral 2.5 mg T1

midodrine hcl tablet 5 mg oral 5 mg T1

SYMJEPI SOLUTION PREFILLED SYRINGE 0.15 MG/0.3ML INJECTION 0.15 MG/0.3ML


115

Drug Status Notes

*Vitamins*ascorbic acid solution 500 mg/ml injection 500 mg/ml

T1

niacin oral tablet 500 mg T1

phytonadione oral tablet 5 mg T2 PA

pyridoxine hcl solution 100 mg/ml injection 100 mg/ml

T3

REPLESTA CHILDRENS WAFER 350 MCG (14000 UT) ORAL 350 MCG (14000 UT) T5

THERA-D 4000 TABLET 100 MCG (4000 UT) ORAL 100 MCG (4000 UT) T5

vitamin d (cholecalciferol) oral capsule 25 mcg (1000 ut)


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

T1

vitamin d oral capsule 50 mcg (2000 ut) T5 QL (60 EA per 30 days)

vitamin d3 capsule 250 mcg (10000 ut) oral 250 mcg (10000 ut)


vitamin d3 oral capsule 1.25 mg (50000 ut) T2 QL (4 EA per 28 days)

vitamin d3 oral capsule 10 mcg (400 unit), 125 mcg (5000 ut)


vitamin d3 tablet 10 mcg (400 unit) oral 10 mcg (400 unit)

T5

vitamin d3 tablet 125 mcg (5000 ut) oral 125 mcg (5000 ut)

T5


T5


T5

vitamin d3 tablet chewable 25 mcg (1000 ut) oral25 mcg (1000 ut)

T5

116

Indexabacavir sulfate .......................... 57abacavir sulfate-lamivudine ....... 57abacavir-lamivudine-zidovudine 57ABILIFY MAINTENA ............ 53abiraterone acetate .....................47acamprosate calcium ................ 108acarbose ......................................29acebutolol hcl ..............................61acetaminophen-codeine ................ 6acetaminophen-codeine #2 ........... 6acetaminophen-codeine #3 ........... 6acetaminophen-codeine #4 ........... 6ACETASOL HC ..................... 105acetazolamide ............................. 80acetazolamide er .........................80acetic acid ...........................88, 105acetylcysteine ........................ 34, 71acitretin .......................................71acne treatment .............................71ACTIMMUNE .......................... 47ACUVAIL ................................101acyclovir ................................57, 71adapalene ....................................71adapalene-benzoyl peroxide ....... 71ADCIRCA ..................................65adefovir dipivoxil ........................ 57ADEMPAS .................................65ADRENALIN .......................... 115ADVAIR HFA ...........................15AFEDITAB CR .........................63AFINITOR ................................ 47AFLURIA QUADRIVALENT...................................................114AKYNZEO ................................ 35albendazole ................................. 12albuterol sulfate .......................... 15albuterol sulfate er ......................15alclometasone dipropionate ........71alendronate sodium .................... 81alfuzosin hcl er ............................88ALINIA ......................................45aliskiren fumarate .......................39allergy spray 24 hour ................100allopurinol .................................. 89almotriptan malate ......................96ALOCRIL ................................101alogliptin benzoate ......................29alogliptin-metformin hcl ............. 29alogliptin-pioglitazone ................29ALOMIDE ...............................101alosetron hcl ............................... 87

ALPHAGAN P ........................ 101alprazolam .................................. 13alprazolam er ..............................13alprazolam xr ..............................13alprostadil ...................................97ALTABAX .................................71ALTACAINE .......................... 101amantadine hcl ............................51ambrisentan ................................ 65amcinonide ..................................72amiloride hcl ...............................80amiloride-hydrochlorothiazide ... 80aminoacetic acid .........................88aminocaproic acid ...................... 92amiodarone hcl ........................... 14AMITIZA .................................. 87amitriptyline hcl ..........................25amlodipine besy-benazepril hcl .. 39amlodipine besylate .................... 63amlodipine besylate-valsartan ....39amlodipine-olmesartan ......... 39, 40ammonium lactate .......................72amoxapine ...................................25amoxicillin ................................ 106amoxicillin-pot clavulanate...........................................106, 107amoxicillin-pot clavulanate er ..106amphetamine-dextroamphet er ..... 1amphetamine-dextroamphetamine .......................1ampicillin .................................. 107AMPYRA .................................108ANADROL-50 ...........................10anagrelide hcl ............................. 89ANALPRAM-HC ......................11anastrozole ..................................47ANDRODERM ....................10, 11ANECREAM .............................72ANORO ELLIPTA ...................16ANZEMET ................................ 35apraclonidine hcl ...................... 101aprepitant ....................................35APRISO ..................................... 87APTIOM ....................................21APTIVUS ...................................58ARANELLE .............................. 67ARANESP (ALBUMIN FREE) .................................. 90, 91ARCALYST ................................ 3ARCAPTA NEOHALER .........16ARGYLE STERILE SALINE . 88

aripiprazole ...........................53, 54armodafinil ................................... 1ARMOUR THYROID ............111ARNUITY ELLIPTA ............... 16ascorbic acid .............................116ASMANEX (120 METERED DOSES) ......................................16ASMANEX (7 METERED DOSES) ......................................16ASMANEX HFA .......................16ASPERCREME LIDOCAINE 72ASPERCREME W/LIDOCAINE ........................ 72aspirin ........................................... 6aspirin 81 ...................................... 5aspirin ec ...................................... 6aspirin ec low dose ....................... 6aspirin-dipyridamole er .............. 89atazanavir sulfate ........................58atenolol ....................................... 61atenolol-chlorthalidone .............. 40atomoxetine hcl .............................1atorvastatin calcium ................... 37atovaquone ..................................45atovaquone-proguanil hcl ...........46atropine sulfate ......................... 101ATROVENT HFA .................... 16AUBAGIO ............................... 108AVANDIA ..................................29AVITA ....................................... 72AVONEX PEN ........................ 108AVONEX PREFILLED ......... 108AZASAN ....................................97AZASITE .................................101azathioprine ................................ 98azelastine hcl .................... 100, 101azithromycin ............................... 94AZOPT .....................................101b-6 folic acid ............................... 91BAC ..............................................6bacitracin ..................................101bacitracin-polymyxin b ............. 101bacitra-neomycin-polymyxin-hc102baclofen .......................................99balanced salt .............................102BALCOLTRA ........................... 67balsalazide disodium .................. 87BALZIVA .................................. 67BARACLUDE ........................... 58BASIS OVERNIGHT ...............72BD INSULIN SYRINGE ..........95

117

BD PEN NEEDLE ORIGINAL U/F ........................ 95BD SAFETYGLIDE INSULIN SYRINGE ................ 95BD VEO INSULIN SYRINGE U/F ..............................................95BECONASE AQ ..................... 100belladonna alkaloids-opium...........................................111, 112BELSOMRA ............................. 92benazepril hcl ..............................40benazepril-hydrochlorothiazide ..40BENZEPRO .............................. 72BENZEPRO SHORT CONTACT ................................ 72benzonatate ................................. 71benzoyl peroxide-erythromycin ...72benztropine mesylate ...................51BEPREVE ............................... 102BERINERT ............................... 89BESIVANCE ........................... 102betamethasone dipropionate .......72betamethasone dipropionate aug .............................................. 72betamethasone sod phos & acet ..69betamethasone valerate .............. 72betaxolol hcl ........................61, 102bethanechol chloride .................113BETOPTIC-S .......................... 102bexarotene ...................................47bicalutamide ............................... 47BICILLIN L-A ........................ 107BIKTARVY ...............................58bimatoprost ............................... 102bisoprolol fumarate .................... 61bisoprolol-hydrochlorothiazide .. 40BLEPHAMIDE S.O.P. ........... 102BOSULIF ...................................47BREO ELLIPTA ...................... 16BRILINTA .................................89brimonidine tartrate ..................102BROMFED DM ........................ 71bromfenac sodium (once-daily) 102bromocriptine mesylate .........51, 52BROVANA ................................ 16budesonide ............................ 16, 69bumetanide ..................................80buprenorphine ...............................7buprenorphine hcl .........................6buprenorphine hcl-naloxone hcl ...6bupropion hcl ..............................25bupropion hcl er (smoking det) .108

bupropion hcl er (sr) ...................25bupropion hcl er (xl) ...................25buspirone hcl .............................. 13butalbital-acetaminophen ............. 6butalbital-apap-caff-cod ............... 7butalbital-apap-caffeine ............... 6butalbital-asa-caff-codeine ...........7butalbital-aspirin-caffeine ............ 6butorphanol tartrate ..................... 7BYETTA 10 MCG PEN ........... 29BYETTA 5 MCG PEN ............. 29BYSTOLIC ................................61cabergoline ................................. 81caffeine citrate .............................. 1caffeine-sodium benzoate ..............1calcipotriene ............................... 72calcipotriene-betameth diprop ....73calcitonin (salmon) ..................... 81CALCITRENE ..........................73calcitriol ......................................81calcium acetate (phos binder) .....87CALPHRON ............................. 87candesartan cilexetil ...................40candesartan cilexetil-hctz ........... 40capecitabine ................................47CAPEX .......................................73CAPRELSA ...............................47captopril ......................................40captopril-hydrochlorothiazide...............................................40, 41CARAFATE ............................ 112carbamazepine ............................21carbamazepine er ........................21carbidopa ....................................52carbidopa-levodopa ....................52carbidopa-levodopa er ................52carbinoxamine maleate ...............36CARDURA XL ..........................88carisoprodol ................................99CAROSPIR ............................... 80carteolol hcl .............................. 102CARTIA XT .............................. 63carvedilol .............................. 61, 62carvedilol phosphate er .............. 61cefaclor ....................................... 66cefadroxil .................................... 66cefdinir ........................................66cefditoren pivoxil ........................ 67cefpodoxime proxetil ...................67cefprozil ...................................... 67cefuroxime axetil .........................67celecoxib ....................................... 3

CELONTIN ............................... 21CEM-UREA .............................. 73cephalexin ................................... 67CEPROTIN ............................... 89cetirizine hcl ................................36cevimeline hcl ............................. 99CHANTIX ............................... 108CHANTIX STARTING MONTH PAK ......................... 108CHEMET ...................................34cherry ........................................107chlordiazepoxide hcl ...................13chlordiazepoxide-amitriptyline .108chlorhexidine gluconate ........57, 99chloroquine phosphate ................46chlorothiazide ............................. 80chlorpromazine hcl ..................... 54chlorthalidone .............................80chlorzoxazone ........................... 100chorionic gonadotropin .............. 82ciclopirox .................................... 73cilostazol ..................................... 89CILOXAN ............................... 102cimetidine ..................................112cimetidine hcl ............................112CIPRO ....................................... 87CIPRO HC .............................. 105ciprofloxacin hcl ................. 87, 102ciprofloxacin-dexamethasone ... 105citalopram hydrobromide ........... 25clarithromycin .............................94clarithromycin er ........................ 94CLEOCIN ................................115CLINDACIN PAC .................... 73clindamycin hcl ...........................45clindamycin palmitate hcl ...........45clindamycin phos-benzoyl perox .73clindamycin phosphate ....... 73, 115clobazam ..................................... 22clobetasol propionate ................. 73clobetasol propionate e ...............73CLODERM ............................... 73clomipramine hcl ........................ 25clonazepam ................................. 22clonidine ..................................... 41clonidine hcl ................................41clopidogrel bisulfate ................... 89clorazepate dipotassium ............. 13clotrimazole ........................ 73, 115clotrimazole-betamethasone ....... 73clozapine ..................................... 54coal tar ........................................67

118

COARTEM ............................... 46codeine sulfate .............................. 7colchicine ....................................89colchicine-probenecid .................89colesevelam hcl ........................... 37colestipol hcl ...............................37COLOCORT ............................. 11COMBIGAN ........................... 102COMBIPATCH ........................ 85COMBIVENT RESPIMAT ..... 16COMETRIQ (100 MG DAILY DOSE) .......................... 47COMETRIQ (140 MG DAILY DOSE) .......................... 47COMETRIQ (60 MG DAILY DOSE) ........................................ 47COMFORT EZ PEN NEEDLES ..................................95COMPLERA ............................. 58CONDYLOX ............................. 73CORDRAN ................................73CORLANOR ............................. 65CORTIFOAM ........................... 11cortisone acetate .........................69CORTISPORIN ........................ 74COSENTYX (300 MG DOSE) .74COSENTYX SENSOREADY PEN ............................................ 74CREON ......................................80CRESEMBA ..............................36CRINONE ............................... 115CRIXIVAN ................................58cromolyn sodium .................87, 102CROTAN ................................... 74CUPRIMINE .............................98cvs nasal allergy spray ............. 100cvs sodium chloride .................. 102cyanocobalamin ..........................91cyclobenzaprine hcl .................. 100cyclopentolate hcl ..................... 102cyclophosphamide .......................47cycloserine .................................. 46CYCLOSET .............................. 29cyclosporine ................................98cyclosporine modified .................98cyproheptadine hcl ......................36CYSTADANE ........................... 82CYSTARAN ............................ 102CYTRA-3 ...................................88dalfampridine er ....................... 108DALIRESP ................................ 16dantrolene sodium .................... 100

dapsone ....................................... 45DARAPRIM .............................. 46darifenacin hydrobromide er ....113DAYTRANA ................................1DDAVP RHINAL TUBE ......... 82deferasirox .................................. 34deferiprone ..................................34deferoxamine mesylate ................34demeclocycline hcl ....................110DENAVIR ..................................74DEPO-MEDROL ......................69DEPO-PROVERA .................... 47DEPO-SUBQ PROVERA 104 . 67DESCOVY .................................58desipramine hcl .....................25, 26desmopressin ace spray refrig .... 82desmopressin acetate .................. 82desmopressin acetate spray ........ 82desogestrel-ethinyl estradiol .......67desonide ...................................... 74desoximetasone ........................... 74desvenlafaxine er ........................ 26desvenlafaxine succinate er ........ 26dexamethasone ............................70DEXAMETHASONE INTENSOL ................................70dexamethasone sodium phosphate ............................70, 102dexmethylphenidate hcl .................2dexmethylphenidate hcl er ............ 1dextroamphetamine sulfate ...........2dextroamphetamine sulfate er .......2diazepam ............................... 13, 14diclofenac potassium .................... 3diclofenac sodium ........... 3, 74, 102diclofenac sodium er .....................3diclofenac-misoprostol ............. 3, 4dicloxacillin sodium ..................107dicyclomine hcl ......................... 112didanosine ...................................58diethylpropion hcl .........................2diethylpropion hcl er .....................2DIFFERIN ................................. 74DIFICID .....................................94diflorasone diacetate .................. 74diflunisal ....................................... 6digoxin ........................................ 65DILANTIN ................................ 22DILATRATE-SR ...................... 12diltiazem hcl ................................63diltiazem hcl er ........................... 63diltiazem hcl er beads ................. 63

dilt-xr .......................................... 63dimenhydrinate ........................... 35dimethyl fumarate ..................... 108DIPENTUM ...............................87diphenhydramine hcl ...................36diphenoxylate-atropine ............... 34dipyridamole ............................... 90disopyramide phosphate ............. 14disulfiram ..................................108divalproex sodium .......................22divalproex sodium er .................. 22docosanol ....................................74dofetilide ..................................... 14donepezil hcl ............................. 108DOPRAM .................................... 2dorzolamide hcl ........................ 102dorzolamide hcl-timolol mal .....102doxazosin mesylate ..................... 41doxepin hcl ..................................26doxercalciferol ............................82doxycycline hyclate ................... 110doxycycline monohydrate . 110, 111DRITHO-CREME HP ............. 74dronabinol ...................................35droperidol ................................... 14drospiren-eth estrad-levomefol ...68drospirenone-ethinyl estradiol ....68DROXIA .................................... 91DUAVEE ................................... 85DULERA ................................... 17duloxetine hcl ..............................26DUPIXENT ............................... 74DUREZOL ...............................102econazole nitrate .........................74EDARBI .....................................41EDURANT .................................58efavirenz ......................................58efavirenz-emtricitab-tenofovir .... 58efavirenz-lamivudine-tenofovir ...58EFFER-K .............................96, 97eletriptan hydrobromide ............. 96ELIGARD ............................47, 48ELIQUIS ....................................19ELIQUIS DVT/PE STARTER PACK ..................... 19ELIXOPHYLLIN ..................... 17ELLA ......................................... 68ELMIRON .................................88EMBEDA .....................................7EMCYT ..................................... 48EMSAM ..................................... 26emtricitabine ............................... 58

119

emtricitabine-tenofovir df ........... 58EMTRIVA ................................. 58enalapril maleate ........................ 41enalapril-hydrochlorothiazide ....41ENBREL ......................................4ENBREL SURECLICK ............. 4ENDOCET ...................................7ENDOMETRIN ...................... 115enoxaparin sodium ................19, 20entacapone ..................................52epinastine hcl ............................ 102epinephrine ............................... 115EPIVIR HBV .............................58eplerenone ...................................41EPOGEN ................................... 91eq nasal allergy .........................100ergoloid mesylates .................... 108ergotamine-caffeine .................... 96ERIVEDGE ............................... 48ERTACZO .................................74ERYTHROCIN STEARATE .. 94erythromycin ....................... 74, 103erythromycin base .......................94erythromycin ethylsuccinate ....... 95ESBRIET ................................. 110escitalopram oxalate ...................26estazolam .................................... 92estradiol ........................ 85, 86, 115estradiol valerate ........................ 86estradiol-norethindrone acet ...... 86ESTRING ................................ 115ESTROGEL .............................. 86eszopiclone ..................................93ethacrynic acid ............................80ethambutol hcl ............................ 46ethosuximide ............................... 22ethyl chloride .............................. 74ethynodiol diac-eth estradiol ...... 68etodolac .........................................4etodolac er .................................... 4EUCERIN ..................................74EVAMIST ..................................86everolimus .............................48, 98EVOTAZ ................................... 58EXELDERM ............................. 74exemestane .................................. 48EXODERM ............................... 75eye allergy relief ....................... 103ezetimibe ..................................... 37ezetimibe-simvastatin ..................37famciclovir .................................. 58famotidine ................................. 112

FANAPT .................................... 54FARXIGA ..................................29FARYDAK ................................ 48FASENRA ................................. 17FASLODEX ...............................48fe tabs ..........................................91felbamate .....................................22felodipine er ................................ 64fenofibrate ...................................38fenofibrate micronized .......... 37, 38fenofibric acid .............................38fentanyl ......................................... 7ferotrinsic ....................................91ferraplus 90 .................................91ferrous sulfate ............................. 91FETZIMA ............................26, 27fexofenadine hcl .......................... 36FIASP .........................................29FIASP FLEXTOUCH .............. 29FIASP PENFILL ...................... 29FIBRICOR ................................ 38FINACEA .................................. 75finasteride ............................. 75, 88FIRAZYR .................................. 90FIRMAGON ..............................48FIRMAGON (240 MG DOSE) 48FIRST-LANSOPRAZOLE .... 112FIRST-PROGESTERONE VGS .......................................... 115FLAREX ..................................103flavor sweet ...............................107flavoxate hcl ..............................113flecainide acetate ........................ 14FLONASE SENSIMIST .........100FLOVENT DISKUS ................. 17FLOVENT HFA ........................17FLUAD .....................................114FLUAD QUADRIVALENT ...114FLUARIX QUADRIVALENT...................................................114FLUCAINE ............................. 103fluconazole ..................................36flucytosine ................................... 36fludrocortisone acetate ............... 70flunisolide ................................. 100fluocinolone acetonide ........75, 105fluocinolone acetonide body ....... 75fluocinolone acetonide scalp ...... 75fluocinonide ................................ 75fluocinonide emulsified base .......75FLUORIDEX ............................ 99

FLUORIDEX DAILY RENEWAL ................................99fluoritab ...................................... 97fluorometholone ........................103fluorouracil ................................. 75fluoxetine hcl ...............................27fluphenazine decanoate ...............54fluphenazine hcl .......................... 54flurandrenolide ........................... 75flurazepam hcl ............................ 93flurbiprofen ................................... 4flurbiprofen sodium .................. 103flutamide ..................................... 48fluticasone propionate ........ 75, 100fluticasone-salmeterol .................17fluvastatin sodium .......................38fluvoxamine maleate ................... 27FLUZONE QUADRIVALENT ................. 114FML ......................................... 103folic acid ..................................... 91fondaparinux sodium .................. 20FORTEO ................................... 82FOSAMAX PLUS D ................. 82fosamprenavir calcium ............... 58fosinopril sodium ........................ 41fosinopril sodium-hctz ................ 41FRAGMIN .................................20FREESTYLE LIBRE SENSOR SYSTEM ...................95frovatriptan succinate .................96furosemide ...................................80FUZEON ....................................59FYCOMPA ................................22gabapentin ............................ 22, 23GABITRIL ................................ 23galantamine hydrobromide .......109galantamine hydrobromide er .. 108ganirelix acetate ......................... 82gatifloxacin ............................... 103GAVILYTE-C ...........................93GAVILYTE-G ...........................93GAVILYTE-N WITH FLAVOR PACK ....................... 93gemfibrozil .................................. 38generlac ...................................... 87GENGRAF ................................ 98GENOTROPIN ......................... 83GENOTROPIN MINIQUICK...............................................82, 83GENTAK ................................. 103gentamicin sulfate ...............75, 103

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GENVOYA ................................59GIANVI ..................................... 68GILENYA ................................109GILOTRIF ................................ 48glatiramer acetate .....................109GLATOPA ...............................109GLEOSTINE .............................48glimepiride ..................................29glipizide .......................................29glipizide er .................................. 29glipizide-metformin hcl .........29, 30GLUCAGEN HYPOKIT ......... 30glucagon emergency ................... 30GLUCOCARD EXPRESSION TEST ................79GLUCOCARD VITAL TEST . 79glyburide ..................................... 30glyburide micronized .................. 30glyburide-metformin ................... 30glycopyrrolate ...........................112gnp 24 hour nasal allergy .........100GOLYTELY ..............................94GONAL-F RFF REDIJECT ....83goodsense glucose .......................30goodsense nasal allergy spray ..100granisetron hcl ............................35griseofulvin microsize .................36griseofulvin ultramicrosize ......... 36guanfacine hcl .............................41guanfacine hcl er .......................... 2GYNAZOLE-1 ........................ 115halobetasol propionate ............... 75HALOG ..................................... 75haloperidol ..................................55haloperidol decanoate ................ 55haloperidol lactate ......................55hematinic/folic acid .................... 91HEMATOGEN FA ................... 91HEMATOGEN FORTE ...........91heparin lock flush ....................... 20heparin sod (porcine) in d5w ......20heparin sodium (porcine) ............20heparin sodium (porcine) pf ....... 20heparin sodium lock flush ...........20HETLIOZ ..................................93HOMATROPAIRE ................ 103HUMIRA ..................................... 4HUMIRA PEN ............................ 4HUMULIN R U-500 (CONCENTRATED) ................30hydralazine hcl ......................41, 42hydrochlorothiazide ....................81

hydrocod polst-cpm polst er ....... 71hydrocodone-acetaminophen ........7hydrocodone-homatropine ..........71hydrocodone-ibuprofen .................7hydrocortisone ...................... 70, 76hydrocortisone butyr lipo base ... 75hydrocortisone butyrate ..............76hydrocortisone valerate .............. 76hydromorphone hcl ...................7, 8hydromorphone hcl er ...................7hydroquinone .............................. 76hydroxychloroquine sulfate .........46hydroxyprogesterone caproate.............................................48, 107hydroxyurea ................................ 48hydroxyzine hcl ........................... 14hydroxyzine pamoate .................. 14HYOPHEN ................................ 45hyoscyamine sulfate .................. 112hyoscyamine sulfate sl .............. 112hyosyne ......................................112HYPERRHO S/D .................... 106HYQVIA ..................................106ibandronate sodium .................... 83IBRANCE ..................................48IBU ............................................... 4ibuprofen .......................................4ICLUSIG ................................... 48icosapent ethyl ............................ 38imatinib mesylate ........................ 48IMBRUVICA ............................ 48imipramine hcl ............................ 27imipramine pamoate ................... 27imiquimod ................................... 76INCRELEX ............................... 83INCRUSE ELLIPTA ................17indapamide ................................. 81indomethacin .................................4indomethacin er ............................ 4INLYTA ...............................48, 49insulin syringe .............................95insupen pen needles .................... 95INTELENCE .............................59INTRON A ................................ 49INVIRASE .................................59INVOKAMET ...........................30INVOKAMET XR .................... 30INVOKANA .............................. 31iodine strong ............................... 97iodine strong (lugol's) .................67IOPIDINE ................................103ipratropium bromide ...17, 100, 101

ipratropium-albuterol ................. 17irbesartan ....................................42irbesartan-hydrochlorothiazide ..42iron ..............................................91iron 27 .........................................91ISENTRESS .............................. 59isoniazid ................................46, 47isosorbide dinitrate .....................12isosorbide mononitrate ............... 12isosorbide mononitrate er ...........12isradipine .................................... 64itraconazole ................................ 36ivermectin ....................................12JADENU .............................. 34, 35JAKAFI ..................................... 49JANUMET .................................31JANUMET XR ..........................31JANUVIA .................................. 31JARDIANCE .............................31JASMIEL ...................................68JINTELI .................................... 86JUNEL 1.5/30 ............................ 68JUNEL FE 1.5/30 ...................... 68KALBITOR ...............................90KALETRA .................................59KALYDECO ........................... 110ketoconazole ..........................36, 76ketone test ................................... 79ketoprofen er .................................4ketorolac tromethamine ........ 5, 103KINERET ....................................5KLOR-CON M15 ......................97kp diphenhydramine hcl ..............36K-PRIME ...................................97KRISTALOSE .......................... 94KYPROLIS ............................... 49labetalol hcl ................................ 62LACRISERT ........................... 103lactic acid ....................................76lactic acid e .................................76lactulose ......................................94LAMICTAL ODT .....................23lamivudine ...................................59lamivudine-zidovudine ................59lamotrigine ..................................23lamotrigine er ............................. 23lansoprazole ..............................112lanthanum carbonate .................. 87LANTUS .................................... 31LANTUS SOLOSTAR ............. 31lapatinib ditosylate ..................... 49LASTACAFT .......................... 103

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latanoprost ................................103LATUDA ................................... 55leflunomide ................................... 5letrozole ...................................... 49leucovorin calcium ......................49LEUKERAN ..............................49LEUKINE ..................................91leuprolide acetate ....................... 49levalbuterol hcl ..................... 17, 18levalbuterol tartrate ....................18LEVEMIR ................................. 31LEVEMIR FLEXTOUCH .......31levetiracetam ...............................23levetiracetam er .......................... 23levobunolol hcl ..........................103levocarnitine ............................... 83levocetirizine dihydrochloride .... 37levofloxacin .........................87, 103levonorgest-eth est & eth est .......68levonorgest-eth estrad 91-day .... 68levonorgestrel ............................. 68levonorgestrel-ethinyl estrad ...... 68levorphanol tartrate ......................8levothyroxine sodium ................ 111LEXIVA .....................................59lidocaine ..................................... 76lidocaine hcl ..........................76, 99lidocaine-hydrocortisone ace ..... 11lidocaine-prilocaine ....................76lindane ........................................ 76linezolid .......................................45LINZESS ................................... 87liothyronine sodium .................. 111lisinopril ......................................42lisinopril-hydrochlorothiazide ....42lithium ......................................... 55lithium carbonate ........................55lithium carbonate er ................... 55LIVALO .....................................38LMX 4 ........................................ 76LO LOESTRIN FE ...................68loperamide hcl ............................ 34lopinavir-ritonavir ...................... 59loratadine ....................................37loratadine childrens ....................37lorazepam ................................... 14LORAZEPAM INTENSOL .....14LORYNA ................................... 68losartan potassium ......................42losartan potassium-hctz .............. 42LOTEMAX ..............................103lovastatin .....................................38

LOW-OGESTREL ................... 68loxapine succinate .......................55LO-ZUMANDIMINE ...............68LUMIGAN ...............................103LUPRON DEPOT (1-MONTH) ................................... 49LUPRON DEPOT (3-MONTH) ................................... 49LUPRON DEPOT (4-MONTH) ................................... 49LUPRON DEPOT (6-MONTH) ................................... 49LYRICA .....................................23LYSODREN .............................. 49MACROBID ..............................45mafenide acetate ......................... 76MAGELLAN INSULIN SAFETY SYR ............................95magnesium oxide .........................12malathion .................................... 76maprotiline hcl ............................27MARPLAN ................................27MATULANE ............................. 49MAVYRET ................................59MAYZENT ..............................109meclizine hcl ............................... 35meclofenamate sodium ..................5medroxyprogesterone acetate.............................................68, 107mefloquine hcl .............................46megestrol acetate ........................ 50MEKINIST ................................50meloxicam ..................................... 5memantine hcl ...........................109MENEST ................................... 86MENTAX ...................................76meperidine hcl ...............................8meprobamate .............................. 14mercaptopurine ...........................50mesalamine ........................... 87, 88MESNEX ................................... 50MESTINON ...............................46metaproterenol sulfate ................ 18metaxalone ................................100metformin hcl .............................. 31metformin hcl er ..........................31methadone hcl ...............................8METHADONE HCL INTENSOL ..................................8METHADOSE ............................ 8methamphetamine hcl ................... 2methazolamide ............................ 81

methenamine hippurate ...............45methenamine mandelate ............. 45methimazole .............................. 111methitest ......................................11methocarbamol ......................... 100methotrexate ................................50methotrexate sodium ...................50methotrexate sodium (pf) ............ 50methoxsalen rapid .......................76methscopolamine bromide ........ 112methyldopa ..................................42methylergonovine maleate ........ 105methylphenidate hcl ...................... 2methylphenidate hcl er ..................2methylphenidate hcl er (cd) .......... 2methylphenidate hcl er (la) ...........2methylprednisolone .....................70metoclopramide hcl .....................88metolazone .................................. 81metoprolol succinate er .............. 62metoprolol tartrate ......................62metoprolol-hydrochlorothiazide . 42metronidazole ............... 45, 76, 115mexiletine hcl .............................. 15MIACALCIN ............................ 83miconazole 3 applicator ........... 115miconazole 3 combo pack .........115miconazole nitrate ...................... 76midodrine hcl ............................ 115miglitol ........................................31MILLIPRED ............................. 70minocycline hcl ......................... 111minoxidil ..................................... 42mirtazapine ................................. 27MIRVASO ................................. 76misoprostol ............................... 112modafinil ....................................... 2moexipril hcl ............................... 43mometasone furoate ......76, 77, 101MONOJECT SODIUM CHLORIDE FLUSH ................ 97montelukast sodium .................... 18MONUROL ............................... 45morphine sulfate ........................... 9morphine sulfate (concentrate) .....8morphine sulfate (pf) .....................8morphine sulfate er ....................... 9MOTOFEN ................................34moxifloxacin hcl ..................87, 103moxifloxacin hcl (2x day) ..........103MULTAQ .................................. 15multivitamin/fluoride .................. 99

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mupirocin ....................................77mycophenolate mofetil ................ 98mycophenolate sodium ................98MYLERAN ................................50nabumetone ...................................5nac .............................................101nadolol ........................................ 62naftifine hcl ................................. 77nalbuphine hcl .............................. 9naloxone hcl ................................35naltrexone hcl ............................. 35naproxen ....................................... 5naproxen sodium ...........................5naratriptan hcl ............................ 96NARCAN ................................... 35nasal allergy 24 hour ................101NATACYN .............................. 104nateglinide .................................. 31NATROBA ................................ 77NATURE-THROID ................111nefazodone hcl ............................ 27neomycin sulfate ........................... 3neomycin-bacitracin zn-polymyx ..................................... 104neomycin-polymyxin b gu ........... 88neomycin-polymyxin-dexameth .104neomycin-polymyxin-gramicidin...................................................104neomycin-polymyxin-hc .... 104, 105NEULASTA ...............................92NEUPRO ................................... 52NEVANAC .............................. 104nevirapine ................................... 59nevirapine er ...............................59NEXAVAR ................................ 50niacin ........................................ 116niacin er (antihyperlipidemic) .... 38NIACOR .................................... 38nicardipine hcl ............................ 64NICORETTE .......................... 109nicotine ..................................... 109nicotine mini ............................. 109nicotine polacrilex .................... 109NICOTROL .............................109nifedipine .................................... 64nifedipine er ................................ 64nifedipine er osmotic release ...... 64NIKKI ........................................ 68nimodipine .................................. 64nisoldipine er .............................. 64nitisinone .....................................83NITRO-BID ...............................12

NITRO-DUR ............................. 12nitrofurantoin ..............................45nitrofurantoin macrocrystal ........45nitrofurantoin monohyd macro ...45nitroglycerin ......................... 12, 13nitroglycerin er ........................... 12NITRO-TIME ........................... 13nizatidine ...................................112norethin ace-eth estrad-fe ...........68norethindrone ............................. 68norethindrone acetate ...............107norethindrone acet-ethinyl est .... 68norethindrone-eth estradiol ........ 86norethin-eth estradiol-fe ............. 69norgestimate-eth estradiol .......... 69norgestim-eth estrad triphasic ....69NORPACE CR ..........................15NORTREL 0.5/35 (28) ..............69NORTREL 1/35 (28) .................69NORTREL 7/7/7 ....................... 69nortriptyline hcl .................... 27, 28NORVIR .................................... 59NOVOLIN 70/30 ....................... 31NOVOLIN 70/30 FLEXPEN ... 31NOVOLIN 70/30 FLEXPEN RELION .....................................31NOVOLIN N ............................. 32NOVOLIN N FLEXPEN ..........32NOVOLIN N RELION .............32NOVOLIN R ............................. 32NOVOLIN R FLEXPEN ..........32NOVOLIN R RELION .............32NOVOLOG ............................... 32NOVOLOG FLEXPEN ............32NOVOLOG MIX 70/30 ............ 32NOVOLOG MIX 70/30 FLEXPEN ..................................32NOVOLOG PENFILL ............. 32np thyroid ..................................111NUCYNTA ER ............................9NUEDEXTA ............................109NUVARING .............................. 69NYAMYC .................................. 77nystatin ............................36, 77, 99nystatin-triamcinolone ................77NYSTOP .................................... 77OCELLA ................................... 69octreotide acetate ..................83, 84ODOMZO ..................................50OFEV ....................................... 110ofloxacin ..................... 87, 104, 105olanzapine .............................55, 56

olanzapine-fluoxetine hcl ..........109olmesartan medoxomil ................43olmesartan medoxomil-hctz ........ 43olopatadine hcl ......................... 104omega-3-acid ethyl esters ........... 38omeprazole ................................113OMNIFLEX DIAPHRAGM ....95ondansetron ................................ 35ondansetron hcl .......................... 35ONETOUCH VERIO ...............95ONGLYZA ................................ 32OPSUMIT ..................................65ORA-BLEND .......................... 107ORA-PLUS ..............................107ORA-SWEET ..........................107ORAVIG ....................................99orphenadrine citrate er .............100oseltamivir phosphate .................59OSMOPREP ..............................94OSPHENA ................................. 84oxandrolone ................................ 11oxaprozin ...................................... 5OXAYDO .....................................9oxazepam .................................... 14oxcarbazepine ....................... 23, 24oxiconazole nitrate ......................77oxybutynin chloride ...................113oxybutynin chloride er .............. 113oxycodone hcl ......................... 9, 10oxycodone-acetaminophen ..........10oxycodone-aspirin .......................10oxymorphone hcl er .................... 10OXYTROL FOR WOMEN ... 113OZEMPIC (0.25 OR 0.5 MG/DOSE) ................................ 32OZEMPIC (1 MG/DOSE) ........32PACERONE ..............................15paliperidone er ............................56pantoprazole sodium .................113paricalcitol ..................................84paromomycin sulfate .....................3paroxetine hcl ............................. 28paroxetine hcl er ......................... 28peg-3350/electrolytes/ascorbat ...94PEGANONE ..............................24PEGASYS ..................................60PEGINTRON ............................ 60pen needles ..................................95penicillamine ...............................98penicillin v potassium ............... 107pentamidine isethionate .............. 45PENTASA ..................................88

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pentazocine-naloxone hcl ........... 10pentetate calcium trisodium ........35pentetate zinc trisodium ..............35pentoxifylline er .......................... 90PERFOROMIST .......................18perindopril erbumine .................. 43permethrin ...................................77perphenazine ...............................56perphenazine-amitriptyline .......109phenazopyridine hcl ....................88phendimetrazine tartrate .............. 3phendimetrazine tartrate er .......... 3phenelzine sulfate ........................28phenobarbital ..............................93phenoxybenzamine hcl ................ 43phentermine hcl .............................3phenytoin .....................................24phenytoin sodium ........................ 24phenytoin sodium extended .........24PHOSLYRA .............................. 88PHOSPHASAL ......................... 45PHOSPHOLINE IODIDE ..... 104PHOSPHO-TRIN 250 NEUTRAL .................................97physostigmine salicylate ............. 35phytonadione .............................116pilocarpine hcl .................... 99, 104pimecrolimus ...............................77pimozide ....................................109pindolol ....................................... 62pioglitazone hcl ...........................32pioglitazone hcl-glimepiride .......32pioglitazone hcl-metformin hcl...............................................32, 33piroxicam ...................................... 5podocon .......................................77podofilox ..................................... 77polyethylene glycol 3350 ............ 94poly-iron 150 forte ......................92polymyxin b-trimethoprim .........104POMALYST ..............................50pot bicarb-pot chloride ............... 97potassium chloride ......................97potassium chloride crys er ..........97potassium chloride er ................. 97potassium citrate er .................... 89potassium citrate-citric acid ....... 89PR BENZOYL PEROXIDE WASH ........................................ 77PRADAXA ...........................20, 21PRALUENT .............................. 38pramipexole dihydrochloride ......53

pramipexole dihydrochloride er...............................................52, 53prasugrel hcl ...............................90pravastatin sodium ......................38prazosin hcl .................................43PRED MILD ............................104prednicarbate ..............................77prednisolone acetate .................104prednisolone sodium phosphate.............................................70, 104prednisone .............................70, 71PREDNISONE INTENSOL .... 70pregabalin ...................................24PREMARIN .............................. 86PREMPHASE ........................... 86PREMPRO .......................... 86, 87prenatal .......................................99PREVALITE ....................... 38, 39PREZCOBIX .............................60PREZISTA ................................ 60PRIFTIN ....................................47primaquine phosphate ................ 46primidone ....................................24PROAIR RESPICLICK ...........18probenecid .................................. 89prochlorperazine .........................56prochlorperazine maleate ...........56PROCRIT ..................................92PROCTOFOAM HC ................ 11PROCTOZONE-HC .................11progesterone micronized ...........107PROMACTA .............................92promethazine hcl .........................37promethazine vc/codeine .............71promethazine-codeine .................71promethazine-dm ........................ 71PROMETHEGAN .................... 37propafenone hcl .......................... 15propafenone hcl er ......................15propantheline bromide ..............113proparacaine hcl .......................104propranolol hcl ........................... 62propranolol hcl er .......................62propranolol-hctz ......................... 43propylthiouracil ........................ 111protriptyline hcl .......................... 28PULMICORT FLEXHALER ..18PULMOZYME ....................... 110pyrazinamide ...............................47pyridostigmine bromide .............. 46pyridostigmine bromide er ..........46pyridoxine hcl ........................... 116

pyrogallic acid ............................ 77QNASL .....................................101quetiapine fumarate .................... 56quetiapine fumarate er ................56quinapril hcl ................................43quinapril-hydrochlorothiazide ....43quinidine gluconate er ................ 15quinidine sulfate ..........................15quinine sulfate .............................46QVAR REDIHALER ............... 18ra nasal allergy .........................101rabeprazole sodium .................. 113RADIOGARDASE ................... 35raloxifene hcl .............................. 84ramipril ....................................... 43RANEXA ................................... 13RAPAMUNE ............................. 98rasagiline mesylate ..................... 53RECTIV .....................................11reeses pinworm medicine ............12REGRANEX ............................. 77RELENZA DISKHALER ........ 60RELPAX ....................................96RENVELA .................................88repaglinide ..................................33REPATHA .................................39REPATHA PUSHTRONEX SYSTEM ....................................39REPATHA SURECLICK ........ 39REPLESTA CHILDRENS .... 116RETACRIT ............................... 92REVLIMID ............................... 98REXULTI .................................. 56REYATAZ .................................60ribavirin ...................................... 60RIDAURA ....................................5rifabutin ...................................... 47rifampin .......................................47riluzole ...................................... 101rimantadine hcl ...........................60RINVOQ ......................................5risedronate sodium ..................... 84risperidone ............................56, 57ritonavir ...................................... 60rivastigmine ...................... 109, 110rivastigmine tartrate ................. 110rizatriptan benzoate .................... 96ropinirole hcl .............................. 53ropinirole hcl er ..........................53ROSADAN .................................77rosuvastatin calcium ...................39ROZEREM ................................93

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rufinamide ...................................24RYBELSUS ............................... 33salicylic acid ......................... 77, 78salicylic acid wart remover .........78salsalate ........................................ 6SAMSCA ................................... 84SANDIMMUNE ........................98SANDOSTATIN LAR DEPOT .......................................84SANTYL .................................... 78SAPHRIS ................................... 57sapropterin dihydrochloride .......84SAVELLA ............................... 110selegiline hcl ............................... 53selenium sulfide .......................... 78SELZENTRY ............................ 60SENSIPAR .................................84SEREVENT DISKUS ...............18sertraline hcl ...............................28sevelamer carbonate ................... 88sevelamer hcl .............................. 88sf ..................................................99sf 5000 plus ................................. 99SHINGRIX .............................. 114SIGNIFOR .................................84SIGNIFOR LAR ....................... 84sildenafil citrate .......................... 65silodosin ......................................89silver nitrate ................................78SIMBRINZA ........................... 104simple syrup .............................. 107simvastatin .................................. 39sirolimus ..................................... 98SIVEXTRO ............................... 45SKLICE ..................................... 78SKYRIZI (150 MG DOSE) ...... 78SLYND .......................................69sod citrate-citric acid ..................89sodium bicarbonate .................... 12sodium chloride .................... 71, 97sodium chloride (hypertonic) ....104sodium fluoride ........................... 97sodium polystyrene sulfonate ......98sofosbuvir-velpatasvir .................60solifenacin succinate .................114SOMATULINE DEPOT .... 84, 85SOMAVERT ............................. 85sorbitol ........................................89sorbitol-mannitol ........................ 89sotalol hcl ....................................63sotalol hcl (af) .......................62, 63SPIRIVA HANDIHALER ....... 18

SPIRIVA RESPIMAT ..............18spironolactone ............................ 81spironolactone-hctz .....................81SPRYCEL ..................................50SPS ............................................. 98SSD ............................................. 78stavudine ..................................... 60STELARA ................................. 78sterile water for irrigation .......... 98STIMATE ..................................85STIVARGA ............................... 50STRIBILD ................................. 60STRIVERDI RESPIMAT ........ 18sucralfate .................................. 113sulfacetamide sodium ..........78, 104sulfacetamide sodium (acne) ...... 78sulfacetamide sodium-sulfur .......78sulfacetamide-prednisolone ......104sulfadiazine ............................... 110sulfamethoxazole-trimethoprim .. 45SULFAMYLON ........................78sulfasalazine ............................... 88sulindac .........................................5sumatriptan ................................. 96sumatriptan succinate .................96SUPRAX .................................... 67SUPREP BOWEL PREP KIT .94SUTENT .................................... 50SYEDA .......................................69SYMAX DUOTAB ..................113SYMAX-SR ............................. 113SYMJEPI .................................115SYMLINPEN 120 ..................... 33SYMLINPEN 60 ....................... 33SYNAGIS .................................106SYNALAR (CREAM) .............. 78SYNALAR (OINTMENT) ....... 78SYNJARDY ...............................33SYNJARDY XR ........................ 33SYNTHROID .......................... 111SYPRINE ...................................98TABLOID ..................................50TACLONEX ..............................78tacrolimus ............................. 78, 98tadalafil .......................................65TAFINLAR ............................... 50tamoxifen citrate ......................... 50tamsulosin hcl ............................. 89TARCEVA ...........................50, 51TARON-PREX ..........................99TASIGNA .................................. 51TAYTULLA .............................. 69

tazarotene ................................... 78TAZORAC ................................ 78TAZTIA XT .............................. 64TECHLITE PEN NEEDLES ...95TEKTURNA HCT .............. 43, 44telmisartan .................................. 44telmisartan-hctz .......................... 44temazepam .................................. 93tenofovir disoproxil fumarate ..... 60terazosin hcl ................................44terbinafine hcl .............................36terbutaline sulfate ....................... 18terconazole ................................115testosterone ................................. 11testosterone cypionate .................11testosterone enanthate ................ 11tetrabenazine .............................110tetracycline hcl ..........................111THALOMID ..............................99theophylline .................................19theophylline er ............................ 19THERA-D 4000 .......................116thioridazine hcl ........................... 57thiothixene ...................................57thrivite 19 ....................................99tiagabine hcl ............................... 24timolol maleate ................... 63, 105tinidazole .....................................46TIVICAY ................................... 60tizanidine hcl .............................100TOBRADEX ............................105TOBRADEX ST ......................105tobramycin ............................ 3, 105tobramycin-dexamethasone ...... 105TOBREX ................................. 105tolbutamide ................................. 33tolcapone .....................................53tolmetin sodium .............................5tolterodine tartrate ....................114tolterodine tartrate er ............... 114tolvaptan ..................................... 85topiramate ...................................24toremifene citrate ........................51torsemide .....................................81TOUJEO SOLOSTAR ............. 33TOVIAZ ...................................114TRACLEER ........................ 65, 66TRADJENTA ............................33tramadol hcl ................................10tramadol hcl er ........................... 10tramadol hcl er (biphasic) .......... 10tramadol-acetaminophen ............10

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trandolapril .................................44trandolapril-verapamil hcl er ..... 44tranylcypromine sulfate .............. 28travoprost (bak free) ................. 105trazodone hcl .............................. 28TRELSTAR MIXJECT ........... 51TRESIBA ...................................34TRESIBA FLEXTOUCH ........ 33tretinoin ...........................51, 78, 79tretinoin microsphere ..................79TREXALL ................................. 51triamcinolone acetonide79, 99, 101triamterene ..................................81triamterene-hctz ..........................81trifluoperazine hcl .......................57trifluridine .................................105trihexyphenidyl hcl ......................53TRI-LEGEST FE ......................69TRI-LO-SPRINTEC .................69trimethobenzamide hcl ................35trimethoprim ............................... 46trimipramine maleate ..................28TRIUMEQ .................................60tropicamide ............................... 105trospium chloride ......................114trospium chloride er ................. 114TRULICITY ..............................34TRUVADA ................................ 61TUDORZA PRESSAIR ............19TWIRLA ....................................69TYVASO STARTER ................66ULORIC .................................... 89ULTILET INSULIN SYRINGE ............................ 95, 96ULTILET INSULIN SYRINGE SHORT ................... 96UMECTA MOUSSE .................79UPTRAVI .................................. 66urea ............................................. 79urea nail ......................................79urea-c40 ......................................79URIMAR-T ................................46urin ds ....................................... 113ursodiol ....................................... 88USTELL .....................................46valacyclovir hcl ...........................61valganciclovir hcl ....................... 61valproic acid ............................... 24valsartan ..................................... 44valsartan-hydrochlorothiazide ... 44VALSTAR ................................. 51vancomycin hcl ........................... 46

vancomycin hcl in dextrose .........46VANTAS ....................................51VECTICAL ............................... 79VELIVET .................................. 69VELPHORO ............................. 88VELTIN ..................................... 79venlafaxine hcl ............................ 28venlafaxine hcl er ........................28VENTAVIS ................................66VENTOLIN HFA ......................19verapamil hcl .............................. 65verapamil hcl er ..........................65VEREGEN .................................79VESICARE ..............................114VICTOZA ..................................34vigabatrin ....................................24VIIBRYD ............................. 28, 29VIMPAT .................................... 24VIRACEPT ............................... 61VIRAMUNE ..............................61VIREAD .....................................61vitamin d ................................... 116vitamin d (cholecalciferol) ........116vitamin d (ergocalciferol) ......... 116vitamin d3 ................................. 116vitamins acd-fluoride .................. 99VIVITROL ................................ 35voriconazole ................................36VOTRIENT ............................... 51VYVANSE ................................... 3warfarin sodium ..........................21WESTHROID ......................... 111WIXELA INHUB ......................19XALKORI ................................. 51XARELTO .................................21XARELTO STARTER PACK 21XELJANZ ....................................5XELJANZ XR .............................5XIFAXAN ..................................46XIGDUO XR ............................. 34XOLAIR .................................... 19XULANE ................................... 69XYREM ................................... 110zafirlukast ................................... 19zaleplon .......................................93ZARAH ......................................69ZARXIO .................................... 92ZENPEP .....................................80ZEPATIER ................................61zidovudine ................................... 61zileuton er ................................... 19zinc sulfate .................................. 97

ZIOPTAN ................................ 105ziprasidone hcl ............................57ZIRGAN .................................. 105ZOLADEX .................................51ZOLINZA ..................................51zolmitriptan .................................96zolpidem tartrate .........................93zolpidem tartrate er .................... 93zonisamide ............................ 24, 25ZONTIVITY ............................. 90ZORTRESS ............................... 99ZOVIA 1/35E (28) .....................69ZUMANDIMINE ......................69ZYDELIG ..................................51ZYFLO .......................................19

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