qualified health plan formulary...this formulary does not define benefit coverage and limitations....

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QUALIFIED HEALTH PLAN FORMULARY Effective December 2019

Provided by EnvisionRx

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 & EnvisionRx, 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, Envision Specialty Pharmacy.

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

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

Gender Restriction (GR)

Drug coverage may depend on patient gender.

Step Therapy Required (ST)

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

Custom (C) Drug coverage has unique restrictions.

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, and SD Biosensor GlucoNavii glucometer, Glucocard Vital test strips, Glucocard Expression test strips, SD

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Biosensor GlucoNavii test strips, lancets, insulin syringes, alcohol swabs and ketone strips. These supplies are to be filled through J&B Medical Supply. If you have any questions about our diabetic supply program, please contact J&B Medical Supply at 1-844-236-7933.

Specialty Bio-Pharmaceutical Pharmacy Program

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

Contact Information

The Total Health Care 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, mesalamine

PENTASA, ASACOL HD

Prior use of APRISO, DELZICOL, or mesalamine 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, RELPAX, 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 EFFIENT Prior use of clopidogrel in the last 90 days.

Antiprotozoal Antibiotic

metronidazole immediate- release

FLAGYL ER Prior use of metronidazole immediate-release in the last 90 days.

Beta2 Agonist (nebulizer)

albuterol nebulizer solution

levalbuterol nebulizer solution

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

Coreg CR carvedilol immediate-release

COREG CR Prior use of carvedilol immediate-release 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 immediate-release, zolpidem extended-release, eszopiclone

ROZEREM, 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% ULESFIA, 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 immediate-release

propranolol extended-release

Prior use of propranolol immediate-release 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 1.2-0.025%

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.

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Topical Scalp Corticosteroids

ketoconazole 2% shampoo

CAPEX SHAMPOO

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

Topical Corticosteroids

clobetasol, desonide, betamethasone, flucinolone, flucinonide, hydrocortisone, triamcinolone

calcip-beta, TACLONEX SUSP

Prior use of TWO of the following: clobetasol, desonide, betamethasone, flucinolone, flucinonide, hydrocortisone, or triamcinolone in the last 90 days.

Urinary Antispasmodics

oxybutynin, oxybutynin er, OXYTROL OTC, oxybutynin syrup, GELNIQUE

tolterodine, tolterodine er, trospium, trospium er, darifenacin, TOVIAZ, VESICARE

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

Vascepa omega-3-acid VASCEPA 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 EnvisionRx. The presence of a medication on this formulary list does not guarantee coverage.

CURRENT AS OF 11/1/2019

lowercase italics = Generic drugsUPPERCASE BOLD = Brand name drugs

StatusT1 = Tier 1T2 = Tier 2T3 = Tier 3T4 = Tier 4T5 = Tier 5

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

Drug Status Notes

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

T3QL (30 EA per 30 days); AL (Min 6 Years and Max 17 Years)

amphetamine-dextroamphet er capsule extended release 24 hour 15 mg oral 15 mg










amphetamine-dextroamphetamine tablet 10 mg oral 10 mg

T1AL (Min 6 Years and Max 17 Years)

amphetamine-dextroamphetamine tablet 12.5 mg oral 12.5 mg










amphetamine-dextroamphetamine tablet 7.5 mg oral 7.5 mg


armodafinil tablet 150 mg oral 150 mg T3 PA



atomoxetine hcl capsule 10 mg oral 10 mg T3QL (30 EA per 30 days); AL (Min 6 Years and Max 17 Years)

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Drug Status Notes







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 capsule extended release 24 hour 10 mg oral 10 mg

T3PA; QL (30 EA per 30 days); AL (Min 6 Years and Max 17 Years)













dexmethylphenidate hcl tablet 10 mg oral 10 mg T1AL (Min 6 Years and Max 17 Years)

dexmethylphenidate hcl tablet 2.5 mg oral 2.5 mg T1AL (Min 6 Years and Max 17 Years)

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Drug Status Notes

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

dextroamphetamine sulfate er capsule extended release 24 hour 10 mg oral 10 mg






dextroamphetamine sulfate tablet 10 mg oral 10 mg


dextroamphetamine sulfate tablet 5 mg oral 5 mg T1AL (Min 6 Years and Max 17 Years)

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

FOCALIN XR CAPSULE EXTENDED RELEASE 24 HOUR 25 MG ORAL 25 MG T3


FOCALIN XR CAPSULE EXTENDED RELEASE 24 HOUR 35 MG ORAL 35 MG T3


guanfacine hcl er tablet extended release 24 hour 1 mg oral 1 mg








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

methylphenidate hcl er (cd) capsule extended release 10 mg oral 10 mg












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Drug Status Notesmethylphenidate hcl er (la) capsule extended release 24 hour 20 mg oral 20 mg


methylphenidate hcl er (la) capsule extended release 24 hour 30 mg oral 30 mg


methylphenidate hcl er (la) capsule extended release 24 hour 40 mg oral 40 mg


methylphenidate hcl er oral tablet extended release 24 hour 18 mg, 27 mg, 36 mg, 54 mg

T2 QL (30 EA per 30 days)

methylphenidate hcl er tablet extended release 10 mg oral 10 mg












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

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

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

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

methylphenidate hcl tablet 10 mg oral 10 mg T1AL (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

phendimetrazine 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

STRATTERA CAPSULE 10 MG ORAL 10 MG T3

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



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Drug Status NotesSTRATTERA CAPSULE 18 MG ORAL 18 MG T3










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*ACTEMRA SOLUTION PREFILLED SYRINGE 162 MG/0.9ML SUBCUTANEOUS162 MG/0.9ML

T4 PA

ARCALYST SOLUTION RECONSTITUTED 220 MG SUBCUTANEOUS 220 MG T4 PA

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



diclofenac potassium tablet 50 mg oral 50 mg T1

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

T1

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Drug Status Notesdiclofenac sodium tablet delayed release 25 mg oral 25 mg

T1

diclofenac sodium tablet delayed release 50 mg oral 50 mg

T1

diclofenac sodium tablet delayed release 75 mg oral 75 mg

T1

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

T3

diclofenac-misoprostol tablet delayed release 75-0.2 mg oral 75-0.2 mg

T3

ENBREL MINI SUBCUTANEOUS SOLUTION CARTRIDGE 50 MG/ML T4 PA

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

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Drug Status Notesibuprofen 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


ketorolac 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 dr tablet delayed release 375 mg oral375 mg

T1

naproxen dr tablet delayed release 500 mg oral500 mg

T1

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



ORENCIA SOLUTION PREFILLED SYRINGE 125 MG/ML SUBCUTANEOUS125 MG/ML

T4 PA

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

sulindac tablet 150 mg oral 150 mg T1

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Drug Status Notessulindac tablet 200 mg oral 200 mg T1

tolmetin sodium capsule 400 mg oral 400 mg T1

tolmetin sodium tablet 200 mg oral 200 mg T3

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)

aspirin 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)

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-apap-caffeine tablet 50-325-40 mg oral50-325-40 mg

T1

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

T1

choline-mag trisalicylate liquid 500 mg/5ml oral500 mg/5ml

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

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Drug Status Notesbuprenorphine 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


buprenorphine transdermal patch weekly 10 mcg/hr, 20 mcg/hr, 5 mcg/hr

T3 PA

butalbital-apap-caff-cod capsule 50-300-40-30 mg oral 50-300-40-30 mg

T1

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

ENDOCET TABLET 5-325 MG ORAL 5-325 MG T1 QL (360 EA per 30 days)

fentanyl patch 72 hour 100 mcg/hr transdermal100 mcg/hr


fentanyl patch 72 hour 12 mcg/hr transdermal 12 mcg/hr








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Drug Status Noteshydrocodone-acetaminophen oral tablet 2.5-325 mg

T1

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 tablet 10-200 mg oral 10-200 mg


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 er 24 hour abuse-deterrent 12 mg oral 12 mg

T3 PA


T3 PA


T3 PA


T3 PA

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

hydromorphone 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

10

Drug Status Notesmethadone 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

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

T1

morphine sulfate solution 10 mg/ml injection 10 mg/ml

T3

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

T1

morphine sulfate suppository 10 mg rectal 10 mg T3




11

Drug Status Notesmorphine sulfate tablet 15 mg oral 15 mg T1 QL (180 EA per 30 days)

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 ABUSE-DETERRENT 5 MG ORAL 5 MG T3 PA; QL (180 EA per 30 days)

OXAYDO TABLET ABUSE-DETERRENT 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 solution 5 mg/5ml oral 5 mg/5ml T1

oxycodone hcl tablet 10 mg oral 10 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

oxycodone-ibuprofen tablet 5-400 mg oral 5-400 mg


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

T3 PA

12

Drug Status Notesoxymorphone hcl er tablet extended release 12 hour 15 mg oral 15 mg

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

VICODIN ES TABLET 7.5-300 MG ORAL7.5-300 MG T2 QL (180 EA per 30 days)

VICODIN HP TABLET 10-300 MG ORAL10-300 MG T2 QL (180 EA per 30 days)

VICODIN TABLET 5-300 MG ORAL 5-300 MG T2 QL (180 EA per 30 days)

*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

ANDRODERM 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

13

Drug Status Notestestosterone 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 Agents*ANALPRAM-HC LOTION 2.5-1 % RECTAL2.5-1 % T3

anucort-hc suppository 25 mg rectal 25 mg T1 QL (12 EA per 30 days)

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

CORTIFOAM FOAM 10 % RECTAL 10 % T3 PA

hydrocortisone ace-pramoxine cream 2.5-1 % rectal 2.5-1 %

T3

hydrocortisone acetate suppository 30 mg rectal30 mg


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

pramcort cream 1-1 % rectal 1-1 % T1 QL (60 GM per 30 days)

PROCTOFOAM HC FOAM 1-1 % RECTAL1-1 % T3

PROCTOZONE-HC CREAM 2.5 % RECTAL2.5 % T1

RECTIV OINTMENT 0.4 % RECTAL 0.4 % T3

*Antacids*magnesium oxide oral tablet 400 mg T1

sodium bicarbonate oral tablet 650 mg T1

14

Drug Status Notes

*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 er tablet extended release 40 mg oral 40 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

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

T1

15

Drug Status NotesNITRO-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)

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

16

Drug Status Notesdiazepam tablet 10 mg oral 10 mg T1 AL (Max 64 Years)

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

diazepam tablet 5 mg oral 5 mg T1 AL (Max 64 Years)

droperidol solution 2.5 mg/ml injection 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 capsule 15 mg oral 15 mg T1

oxazepam oral capsule 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



17

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

T2 QL (18 GM per 30 days)

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

18

Drug Status Notesalbuterol sulfate nebulization solution 1.25 mg/3ml inhalation 1.25 mg/3ml

T1

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

ANORO 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


19

Drug Status NotesDALIRESP TABLET 500 MCG ORAL 500 MCG T2 QL (30 EA per 30 days)

DULERA 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

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

20

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

metaproterenol sulfate tablet 10 mg oral 10 mg T1

metaproterenol sulfate tablet 20 mg oral 20 mg 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 HFA AEROSOL SOLUTION 108 (90 BASE) MCG/ACT INHALATION 108 (90 BASE) MCG/ACT

T3 QL (8.5 GM per 30 days)

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


PROVENTIL HFA AEROSOL SOLUTION 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


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


21

Drug Status NotesSTRIVERDI 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

THEOCHRON ORAL TABLET EXTENDED RELEASE 12 HOUR 200 MG T1

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

T1


T1


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


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

ELIQUIS STARTER PACK ORAL TABLET5 MG T2 QL (60 EA per 30 days)

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

T4PA; C (Cover For 7 days supply per 30 days, requiring PA thereafter)

22

Drug Status Notes

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


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




enoxaparin sodium solution 300 mg/3ml injection300 mg/3ml








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

23

Drug Status Notesheparin lock flush solution 100 unit/ml intravenous 100 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

PRADAXA CAPSULE 150 MG ORAL 150 MG T3 PA

PRADAXA 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 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



BANZEL SUSPENSION 40 MG/ML ORAL 40 MG/ML T3

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

T1

24

Drug Status Notescarbamazepine er capsule extended release 12 hour 200 mg oral 200 mg

T1

carbamazepine er capsule extended release 12 hour 300 mg oral 300 mg

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

clobazam 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 100 MG ORAL 100 MG T2

DILANTIN CAPSULE 30 MG ORAL 30 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

divalproex sodium tablet delayed release 250 mg oral 250 mg

T1

25

Drug Status Notesdivalproex sodium tablet delayed release 500 mg oral 500 mg

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 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




26

Drug Status Noteslamotrigine 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 CAPSULE 25 MG ORAL 25 MG T3 PA



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

T1

oxcarbazepine tablet 150 mg oral 150 mg T1



PEGANONE TABLET 250 MG ORAL 250 MG T3

phenytoin sodium extended capsule 100 mg oral100 mg

T1


T1


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, 300 mg

T3 PA

pregabalin oral solution 20 mg/ml T3 PA

primidone tablet 250 mg oral 250 mg T1

primidone tablet 50 mg oral 50 mg T1

tiagabine hcl oral tablet 12 mg, 16 mg T3

tiagabine hcl tablet 2 mg oral 2 mg T3

27

Drug Status Notestiagabine 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)



*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

28

Drug Status Notesbupropion 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)






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)

duloxetine hcl capsule delayed release particles 20 mg oral 20 mg






29

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

EMSAM PATCH 24 HOUR 6 MG/24HR TRANSDERMAL 6 MG/24HR T3 ST; QL (30 EA per 30 days)

EMSAM PATCH 24 HOUR 9 MG/24HR TRANSDERMAL 9 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




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)

30

Drug Status Notesmirtazapine tablet 30 mg oral 30 mg T1 AL (Max 64 Years)

mirtazapine tablet 45 mg oral 45 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




nortriptyline 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



31

Drug Status Notestrimipramine 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



*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, 25-15 mg, 25-30 mg, 25-45 mg


alogliptin-pioglitazone tablet 12.5-45 mg oral12.5-45 mg


AVANDIA TABLET 2 MG ORAL 2 MG T3

BYDUREON SUSPENSION RECONSTITUTED ER 2 MG SUBCUTANEOUS 2 MG


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

T3 PA; QL (1.2 ML per 30 days)

chlorpropamide tablet 100 mg oral 100 mg T1

32

Drug Status Noteschlorpropamide tablet 250 mg oral 250 mg T1

CYCLOSET TABLET 0.8 MG ORAL 0.8 MG T3

FARXIGA TABLET 10 MG ORAL 10 MG T3 ST; QL (30 EA per 30 days)

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

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

T2

FIASP SOLUTION 100 UNIT/ML SUBCUTANEOUS 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

glipizide-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

33

Drug Status Notesgoodsense glucose tablet chewable 4-6 gm-mg oral 4-6 gm-mg

T1

HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS SOLUTION 500 UNIT/ML T3 QL (20 ML per 30 days)

INVOKANA 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 TABLET 50-1000 MG ORAL 50-1000 MG T3 ST; QL (60 EA per 30 days)

JANUMET TABLET 50-500 MG ORAL 50-500 MG T3 ST; QL (60 EA per 30 days)

JANUMET XR TABLET EXTENDED RELEASE 24 HOUR 100-1000 MG ORAL100-1000 MG

T3 ST; QL (30 EA per 30 days)

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


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


JANUVIA TABLET 100 MG ORAL 100 MG T3 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



34

Drug Status Notesmiglitol 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 SUSPENSION (70-30) 100 UNIT/ML SUBCUTANEOUS (70-30) 100 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 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

35

Drug Status Notespioglitazone hcl-metformin hcl tablet 15-500 mg oral 15-500 mg

T3

pioglitazone 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

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

tolazamide tablet 250 mg oral 250 mg T1

tolazamide tablet 500 mg oral 500 mg T1

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

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)

*Antidiarrheals*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

36

Drug Status NotesMOTOFEN 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

deferoxamine mesylate solution reconstituted 2 gm injection 2 gm

T1

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

T1

RADIOGARDASE CAPSULE 0.5 GM ORAL0.5 GM T3 PA

*Antidotes*acetylcysteine solution 200 mg/ml intravenous200 mg/ml

T1

CHEMET CAPSULE 100 MG ORAL 100 MG T3

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

T4 PA

FERRIPROX TABLET 500 MG ORAL 500 MG T4 PA

JADENU TABLET 180 MG ORAL 180 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

37

Drug Status NotesANZEMET 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

CESAMET CAPSULE 1 MG ORAL 1 MG T3 PA

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 tablet dispersible 4 mg oral 4 mg T1 QL (10 EA per 30 days)

ondansetron tablet dispersible 8 mg oral 8 mg T1 QL (10 EA per 30 days)

trimethobenzamide hcl capsule 300 mg oral 300 mg

T1

*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

38

Drug Status Notesgriseofulvin ultramicrosize tablet 250 mg oral250 mg

T3

itraconazole capsule 100 mg oral 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


levocetirizine 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


39

Drug Status NotesPROMETHEGAN 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)



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

cholestyramine powder 4 gm/dose oral 4 gm/dose T1 QL (378 GM 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

fenofibrate 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

40

Drug Status Notesgemfibrozil tablet 600 mg oral 600 mg T1

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)

pravastatin sodium tablet 10 mg oral 10 mg T1




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

PREVALITE POWDER 4 GM/DOSE ORAL4 GM/DOSE T1 QL (239.4 GM per 30 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)

TRIGLIDE ORAL TABLET 160 MG T1 PA

VASCEPA CAPSULE 1 GM ORAL 1 GM T3 ST; QL (120 EA per 30 days)

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

T1

amlodipine besy-benazepril hcl capsule 10-40 mg oral 10-40 mg

T1

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

T1

41

Drug Status Notesamlodipine besy-benazepril hcl capsule 5-10 mg oral 5-10 mg

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


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

42

Drug Status Notesbisoprolol-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


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

CORZIDE ORAL TABLET 80-5 MG T1

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 maleate tablet 20 mg oral 20 mg T1

43

Drug Status Notesenalapril maleate tablet 5 mg oral 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

eprosartan mesylate tablet 600 mg oral 600 mg T2 QL (30 EA per 30 days)

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




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

44

Drug Status Noteslosartan 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

moexipril hcl tablet 15 mg oral 15 mg T1

moexipril hcl tablet 7.5 mg oral 7.5 mg T1

moexipril-hydrochlorothiazide tablet 15-12.5 mg oral 15-12.5 mg

T1

moexipril-hydrochlorothiazide tablet 15-25 mg oral 15-25 mg

T1

moexipril-hydrochlorothiazide tablet 7.5-12.5 mg oral 7.5-12.5 mg

T1

nadolol-bendroflumethiazide tablet 40-5 mg oral40-5 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



45

Drug Status Notesphenoxybenzamine 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

TEKTURNA HCT TABLET 300-25 MG ORAL 300-25 MG T3

TEKTURNA TABLET 150 MG ORAL 150 MG T3

TEKTURNA TABLET 300 MG ORAL 300 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)

46

Drug Status Notesterazosin hcl capsule 10 mg oral 10 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

*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

47

Drug Status Noteslinezolid 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)

metronidazole capsule 375 mg oral 375 mg T1

metronidazole tablet 250 mg oral 250 mg T1

metronidazole tablet 500 mg oral 500 mg T1

pentamidine isethionate injection solution reconstituted 300 mg

T3

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

tinidazole tablet 250 mg oral 250 mg T3

tinidazole tablet 500 mg oral 500 mg T3

trimethoprim tablet 100 mg oral 100 mg T1

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

48

Drug Status Notespyridostigmine 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

*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 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

isoniazid tablet 100 mg oral 100 mg T1

isoniazid tablet 300 mg oral 300 mg T1

pyrazinamide tablet 500 mg oral 500 mg T3

rifabutin capsule 150 mg oral 150 mg T2 PA

RIFAMATE CAPSULE 150-300 MG ORAL150-300 MG T3

rifampin capsule 150 mg oral 150 mg T1

rifampin capsule 300 mg oral 300 mg T1

RIFATER TABLET 50-120-300 MG ORAL50-120-300 MG T3

*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

AFINITOR TABLET 2.5 MG ORAL 2.5 MG T4 PA

AFINITOR TABLET 5 MG ORAL 5 MG T4 PA

AFINITOR TABLET 7.5 MG ORAL 7.5 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

49

Drug Status Notescapecitabine 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 1 X 80 & 1 X 20 MG ORAL 1 X 80 & 1 X 20 MG T4 PA

COMETRIQ (140 MG DAILY DOSE) KIT 1 X 80 & 3 X 20 MG ORAL 1 X 80 & 3 X 20 MG T4 PA

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

cyclophosphamide oral tablet 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

ELIGARD 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

exemestane tablet 25 mg oral 25 mg T3

FARYDAK CAPSULE 10 MG ORAL 10 MG T4 PA



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

FIRMAGON SOLUTION RECONSTITUTED 120 MG SUBCUTANEOUS 120 MG 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

50

Drug Status NotesGLEOSTINE CAPSULE 100 MG ORAL 100 MG T4 PA

GLEOSTINE CAPSULE 40 MG ORAL 40 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

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

INLYTA 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





KISQALI FEMARA (400 MG DOSE) ORAL TABLET THERAPY PACK 200 & 2.5 MG T4 PA

KISQALI FEMARA (600 MG DOSE) ORAL TABLET THERAPY PACK 200 & 2.5 MG T4 PA

KISQALI FEMARA(200 MG DOSE) ORAL TABLET THERAPY PACK 200 & 2.5 MG T4 PA

KYPROLIS SOLUTION RECONSTITUTED 60 MG INTRAVENOUS 60 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



51

Drug Status Notesleucovorin calcium tablet 5 mg oral 5 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

megestrol 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




52

Drug Status NotesSPRYCEL TABLET 100 MG ORAL 100 MG T4 PA

SPRYCEL TABLET 140 MG ORAL 140 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

SYLATRON KIT 200 MCG SUBCUTANEOUS 200 MCG 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



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

TYKERB TABLET 250 MG ORAL 250 MG T4 PA

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

53

Drug Status NotesVANTAS 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

ZYKADIA CAPSULE 150 MG ORAL 150 MG T4 PA

*Antiparkinson 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

bromocriptine 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

carbidopa-levodopa tablet dispersible 25-100 mg oral 25-100 mg

T1

54

Drug Status Notescarbidopa-levodopa tablet dispersible 25-250 mg oral 25-250 mg

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






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

55

Drug Status Notesropinirole hcl er tablet extended release 24 hour 12 mg oral 12 mg


ropinirole hcl er tablet extended release 24 hour 2 mg oral 2 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

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

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

aripiprazole tablet 10 mg oral 10 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


56

Drug Status Notesclozapine tablet 25 mg oral 25 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


haloperidol 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





INVEGA SUSTENNA SUSPENSION PREFILLED SYRINGE 117 MG/0.75ML INTRAMUSCULAR 117 MG/0.75ML

T4 PA

57

Drug Status NotesINVEGA SUSTENNA SUSPENSION PREFILLED SYRINGE 156 MG/ML INTRAMUSCULAR 156 MG/ML

T4 PA


T4 PA


T4 PA


T4 PA

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




58

Drug Status Notespaliperidone 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 edisylate injection solution 5 mg/ml

T3

prochlorperazine edisylate solution 10 mg/2ml injection 10 mg/2ml

T3

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 tablet extended release 24 hour 150 mg oral 150 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



59

Drug Status NotesREXULTI TABLET 4 MG ORAL 4 MG T4 PA

RISPERIDONE M-TAB TABLET DISPERSIBLE 0.5 MG ORAL 0.5 MG T3

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




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 capsule 20 mg oral 20 mg T2




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

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

60

Drug Status Notesabacavir 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

APTIVUS 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)

ATRIPLA TABLET 600-200-300 MG ORAL600-200-300 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)

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)

EMTRIVA CAPSULE 200 MG ORAL 200 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)

61

Drug Status NotesEVOTAZ 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)

FUZEON SOLUTION RECONSTITUTED 90 MG SUBCUTANEOUS 90 MG T4 QL (60 EA per 30 days)

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



INVIRASE CAPSULE 200 MG ORAL 200 MG T4 QL (300 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


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)

62

Drug Status Notesoseltamivir phosphate capsule 45 mg oral 45 mg T1 QL (10 EA per 10 days)

oseltamivir phosphate capsule 75 mg oral 75 mg T1 QL (10 EA per 10 days)

oseltamivir phosphate oral suspension reconstituted 6 mg/ml


PEGASYS PROCLICK SOLUTION 135 MCG/0.5ML SUBCUTANEOUS 135 MCG/0.5ML

T4 PA

PEGASYS 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)




REBETOL SOLUTION 40 MG/ML ORAL 40 MG/ML T4 PA

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


RESCRIPTOR TABLET 200 MG ORAL 200 MG T4 QL (180 EA per 30 days)

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



ribasphere ribapak (1000 pack) tablet therapy pack 400 & 600 mg oral 400 & 600 mg

T4 PA

RIBASPHERE RIBAPAK (1200 PACK) TABLET THERAPY PACK 600 MG ORAL600 MG

T4 PA

RIBASPHERE RIBAPAK (800 PACK) TABLET THERAPY PACK 400 MG ORAL400 MG

T4 PA

RIBASPHERE TABLET 200 MG ORAL 200 MG T4 PA

63

Drug Status Notesribavirin 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)

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)

TRUVADA TABLET 100-150 MG ORAL 100-150 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

VIDEX EC ORAL CAPSULE DELAYED RELEASE 125 MG T3 QL (60 EA per 30 days)

VIDEX SOLUTION RECONSTITUTED 2 GM ORAL 2 GM T4 QL (603 ML per 30 days)

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)



64

Drug Status Noteszidovudine 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)

*Assorted 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

azathioprine 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

DEPEN TITRATABS TABLET 250 MG ORAL 250 MG T4

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

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

65

Drug Status Notessodium 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

THALOMID CAPSULE 100 MG ORAL 100 MG T4 PA




ZORTRESS TABLET 0.25 MG ORAL 0.25 MG T4 PA



*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

carvedilol tablet 25 mg oral 25 mg T1

carvedilol tablet 3.125 mg oral 3.125 mg T1

66

Drug Status Notescarvedilol tablet 6.25 mg oral 6.25 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 tablet 120 mg oral 120 mg T1

67

Drug Status Notessotalol hcl tablet 160 mg oral 160 mg T1



timolol maleate tablet 10 mg oral 10 mg T1



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

T4 PA

*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


68

Drug Status Notesdiltiazem hcl tablet 60 mg oral 60 mg T1


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


felodipine 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)

69

Drug Status NotesTAZTIA XT CAPSULE EXTENDED RELEASE 24 HOUR 180 MG ORAL 180 MG T1 QL (30 EA per 30 days)



verapamil hcl er capsule extended release 24 hour 100 mg oral 100 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

70

Drug Status NotesCAVERJECT IMPULSE KIT 10 MCG INTRACAVERNOSAL 10 MCG T3 PA

isoxsuprine hcl tablet 10 mg oral 10 mg T1

OPSUMIT TABLET 10 MG ORAL 10 MG T4 PA

sildenafil citrate tablet 20 mg oral 20 mg T4 PA

tadalafil oral tablet 2.5 mg, 5 mg T3 PA

TRACLEER TABLET 125 MG ORAL 125 MG T4 PA

TRACLEER TABLET 62.5 MG ORAL 62.5 MG T4 PA

TYVASO STARTER SOLUTION 0.6 MG/ML INHALATION 0.6 MG/ML 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 suspension reconstituted 125 mg/5ml oral125 mg/5ml


cefdinir suspension reconstituted 250 mg/5ml oral250 mg/5ml


cefditoren 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

71

Drug Status Notescefpodoxime 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*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


drospiren-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


72

Drug Status NotesJUNEL 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)

LARIN FE 1/20 TABLET 1-20 MG-MCG ORAL 1-20 MG-MCG T5 GR-F; QL (28 EA per 21 days)

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


levonorg-eth estrad triphasic oral tablet T5 QL (28 EA per 21 days)

LO LOESTRIN FE ORAL TABLET 1 MG-10 MCG / 10 MCG 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)

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

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

NORA-BE TABLET 0.35 MG ORAL 0.35 MG T5 GR-F; QL (28 EA per 21 days)

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


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


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


norethin-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

T5 QL (28 EA per 1 day)

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

OGESTREL ORAL TABLET 0.5-50 MG-MCG T5 PA; QL (28 EA per 21 days)

73

Drug Status NotesTAYTULLA 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)

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

ZOVIA 1/35E (28) TABLET 1-35 MG-MCG ORAL 1-35 MG-MCG T5 GR-F; QL (28 EA per 28 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

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

DEXAMETHASONE 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

hydrocortisone tablet 20 mg oral 20 mg T1

74

Drug Status Noteshydrocortisone tablet 5 mg oral 5 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 oral solution 15 mg/5ml T1

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




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

75

Drug Status Notespromethazine-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

*Cyclin-Dependent Kinases (Cdk) Inhibitors***IBRANCE CAPSULE 100 MG ORAL 100 MG T4 PA

IBRANCE CAPSULE 125 MG ORAL 125 MG T4 PA

IBRANCE CAPSULE 75 MG ORAL 75 MG T4 PA

KISQALI 200 DOSE ORAL TABLET 200 MG T4 PA



*Dermatologicals*acitretin capsule 10 mg oral 10 mg T4 PA

acitretin capsule 17.5 mg oral 17.5 mg T4 PA

acitretin capsule 25 mg oral 25 mg T4 PA

acne treatment gel 10 % external 10 % T1

acyclovir ointment 5 % external 5 % T4 PA

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

amcinonide 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 PA

ammonium lactate external lotion 12 % T1 PA

ANECREAM CREAM 4 % EXTERNAL 4 % T1 QL (90 GM per 30 days)

76

Drug Status NotesASPERCREME 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

calcipotriene-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)

77

Drug Status NotesCEM-UREA SOLUTION 45 % EXTERNAL45 % T3

ciclopirox solution 8 % external 8 % T1

CLINDACIN PAC KIT 1 % EXTERNAL 1 % T1

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 gel 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 foam 0.05 % external 0.05 %

T3

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

CORDRAN TAPE 4 MCG/SQCM EXTERNAL 4 MCG/SQCM T3 PA; QL (1 EA per 30 days)

CORTISPORIN CREAM 3.5-10000-0.5 EXTERNAL 3.5-10000-0.5 T1

CORTISPORIN OINTMENT 1 % EXTERNAL 1 % T3

78

Drug Status NotesCOSENTYX (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

DENAVIR CREAM 1 % EXTERNAL 1 % T4 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 % transdermal 1 % T1 QL (200 GM per 30 days)

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

diflorasone diacetate cream 0.05 % external 0.05 %


diflorasone diacetate ointment 0.05 % external0.05 %


docosanol external cream 10 % T1

doxepin hcl external cream 5 % T3

DRITHO-CREME HP CREAM 1 % EXTERNAL 1 % T3

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 pad 2 % external 2 % T1

erythromycin solution 2 % external 2 % T1

ethyl chloride aerosol external T1

EUCERIN EXTERNAL CREAM T1

EURAX CREAM 10 % EXTERNAL 10 % T2 PA

EURAX EXTERNAL LOTION 10 % T2 PA

EXELDERM CREAM 1 % EXTERNAL 1 % T3 QL (30 GM per 30 days)

EXELDERM SOLUTION 1 % EXTERNAL 1 % T3 QL (30 ML per 30 days)

EXODERM LOTION 25-1 % EXTERNAL25-1 % T1

FINACEA GEL 15 % EXTERNAL 15 % T3 PA

79

Drug Status Notesfinasteride 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

halcinonide external cream 0.1 % T3 PA; QL (100 GM per 30 days)

halobetasol propionate cream 0.05 % external0.05 %


halobetasol propionate ointment 0.05 % external0.05 %


HALOG OINTMENT 0.1 % EXTERNAL 0.1 % T3 QL (100 GM per 30 days)

hydrocortisone ace-pramoxine cream 2.5-1 % external 2.5-1 %


hydrocortisone butyr lipo base cream 0.1 % external 0.1 %

T1

hydrocortisone butyrate ointment 0.1 % external0.1 %

T1

80

Drug Status Noteshydrocortisone 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 lotion 10 % external 10 % T1 PA

lc-4 lidocaine cream 4 % external 4 % T1 QL (90 GM per 30 days)

lidocaine cream 4 % external 4 % T1 QL (90 GM per 30 days)

lidocaine cream 4 % external 4 % T1 QL (200 GM per 30 days)

lidocaine hcl external cream 3 % T1 QL (85 GM per 30 days)

lidocaine hcl external gel 2 % T1 QL (90 EA 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

LIDOCREAM CREAM 4 % EXTERNAL 4 % T1 QL (90 GM per 30 days)

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 cream 0.75 % external 0.75 % T3

metronidazole gel 0.75 % external 0.75 % T3

metronidazole lotion 0.75 % external 0.75 % T1

81

Drug Status Notesmiconazole nitrate external cream 2 % T1

MIRVASO GEL 0.33 % EXTERNAL 0.33 % T3 PA

mometasone furoate cream 0.1 % external 0.1 % T1

mometasone furoate ointment 0.1 % external 0.1 %

T1

mometasone furoate solution 0.1 % external 0.1 %

T1

mupirocin ointment 2 % external 2 % T1

NAFTIN GEL 1 % EXTERNAL 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

82

Drug Status Notessalicylic acid external solution 26 % T1

salicylic acid foam 6 % external 6 % T3

salicylic acid gel 6 % external 6 % T1

salicylic acid lotion 6 % external 6 % T1

salicylic acid shampoo 6 % external 6 % T1

salicylic acid wart remover liquid 27.5 % external27.5 %

T1

salrix suspension 50 % external 50 % T1

SANTYL OINTMENT 250 UNIT/GM EXTERNAL 250 UNIT/GM T3

selenium sulfide lotion 2.5 % external 2.5 % T1

silver nitrate ointment 10 % external 10 % 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

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 lotion 10-5 % external 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 cream 0.1 % external 0.1 % T4 PA

TAZORAC CREAM 0.05 % EXTERNAL 0.05 % T4 PA

TAZORAC GEL 0.05 % EXTERNAL 0.05 % T4 PA

TAZORAC GEL 0.1 % EXTERNAL 0.1 % T4 PA

83

Drug Status Notes

tretinoin cream 0.025 % external 0.025 % T1QL (45 GM per 30 days); AL (Max 28 Years)



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 %


ULESFIA LOTION 5 % EXTERNAL 5 % T3 ST; QL (454 GM per 30 days)

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

ure-k external cream 50 % T1

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

84

Drug Status Notes

*Diagnostic Products*GLUCOCARD EXPRESSION TEST IN VITRO STRIP T1

GLUCOCARD VITAL TEST IN VITRO STRIP T1

ketone test in vitro strip T1

*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

*Direct-Acting P2y12 Inhibitors***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)

*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

chlorothiazide tablet 250 mg oral 250 mg T1

chlorothiazide tablet 500 mg oral 500 mg T1

chlorthalidone tablet 25 mg oral 25 mg T1

85

Drug Status Noteschlorthalidone 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



hydrochlorothiazide 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

methyclothiazide tablet 5 mg oral 5 mg T1

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)

86

Drug Status Notesalendronate sodium tablet 5 mg oral 5 mg T1 QL (30 EA per 30 days)

alendronate sodium tablet 70 mg oral 70 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

chorionic 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 solution 0.01 % nasal0.01 %

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

etidronate disodium tablet 200 mg oral 200 mg T3

etidronate disodium tablet 400 mg oral 400 mg T3

FORTEO SOLUTION 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

87

Drug Status NotesGENOTROPIN MINIQUICK SOLUTION RECONSTITUTED 0.6 MG SUBCUTANEOUS 0.6 MG

T4 PA


T4 PA

GENOTROPIN MINIQUICK SOLUTION RECONSTITUTED 1 MG SUBCUTANEOUS1 MG

T4 PA


T4 PA


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

KUVAN TABLET SOLUBLE 100 MG ORAL100 MG T4 PA

levocarnitine oral tablet 330 mg T3

88

Drug Status Noteslevocarnitine solution 1 gm/10ml oral (rx) 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


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



PROLIA SOLUTION PREFILLED SYRINGE 60 MG/ML SUBCUTANEOUS 60 MG/ML

T4 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

SAMSCA TABLET 30 MG ORAL 30 MG T4 PA

SANDOSTATIN LAR DEPOT KIT 10 MG INTRAMUSCULAR 10 MG T4 PA



SENSIPAR TABLET 30 MG ORAL 30 MG T4 PA



SIGNIFOR LAR SUSPENSION RECONSTITUTED ER 20 MG INTRAMUSCULAR 20 MG

T4 PA

89

Drug Status NotesSIGNIFOR LAR SUSPENSION RECONSTITUTED ER 40 MG INTRAMUSCULAR 40 MG

T4 PA

SIGNIFOR LAR SUSPENSION RECONSTITUTED ER 60 MG INTRAMUSCULAR 60 MG

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

SOMATULINE 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

*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

EEMT HS TABLET 0.625-1.25 MG ORAL0.625-1.25 MG T2

EEMT TABLET 1.25-2.5 MG ORAL 1.25-2.5 MG T2

estradiol patch twice weekly 0.025 mg/24hr transdermal 0.025 mg/24hr


90

Drug Status Notesestradiol patch twice weekly 0.0375 mg/24hr transdermal 0.0375 mg/24hr








estradiol patch weekly 0.025 mg/24hr transdermal 0.025 mg/24hr




estradiol patch weekly 0.05 mg/24hr transdermal0.05 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


91

Drug Status NotesPREMARIN TABLET 0.3 MG ORAL 0.3 MG T3 GR-F

PREMARIN TABLET 0.45 MG ORAL 0.45 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

PREMPRO TABLET 0.625-5 MG ORAL0.625-5 MG T3 GR-F

*Estrogen-Selective Estrogen Receptor Modulator Comb***DUAVEE TABLET 0.45-20 MG ORAL 0.45-20 MG T3 GR-F; QL (30 EA per 30 days)

*Fluoroquinolones*CIPRO ORAL SUSPENSION RECONSTITUTED 250 MG/5ML (5%) T3

ciprofloxacin hcl tablet 100 mg oral 100 mg T1




ciprofloxacin suspension reconstituted 500 mg/5ml (10%) oral 500 mg/5ml (10%)

T3

ciprofloxacin-ciproflox hcl er tablet extended release 24 hour 1000 mg oral 1000 mg

T1

ciprofloxacin-ciproflox hcl er tablet extended release 24 hour 500 mg oral 500 mg

T3

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

92

Drug Status Notes

*Gastrointestinal Agents - Misc.*alosetron hcl tablet 0.5 mg oral 0.5 mg T4 PA

alosetron hcl tablet 1 mg oral 1 mg T4 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

CIMZIA KIT 2 X 200 MG SUBCUTANEOUS2 X 200 MG T4 PA

CIMZIA PREFILLED KIT 2 X 200 MG/ML SUBCUTANEOUS 2 X 200 MG/ML T4 PA

cromolyn sodium concentrate 100 mg/5ml oral100 mg/5ml

T1

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

mesalamine tablet delayed release 800 mg oral800 mg


metoclopramide hcl solution 5 mg/5ml oral 5 mg/5ml

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)

93

Drug Status NotesPHOSLYRA 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 CAPSULE 100 MG ORAL 100 MG T3 PA

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

potassium citrate er tablet extended release 10 meq (1080 mg) oral 10 meq (1080 mg)

T1


T3


T1

potassium citrate-citric acid solution 1100-334 mg/5ml oral 1100-334 mg/5ml

T1

silodosin oral capsule 4 mg, 8 mg T3

94

Drug Status Notessod 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-probenecid tablet 0.5-500 mg oral 0.5-500 mg

T1

COLCRYS TABLET 0.6 MG ORAL 0.6 MG T3 QL (20 EA per 30 days)

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



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)

dipyridamole tablet 25 mg oral 25 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


95

Drug Status Notesprasugrel hcl oral tablet 10 mg, 5 mg T3 ST; 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

ARANESP (ALBUMIN FREE) SOLUTION PREFILLED SYRINGE 500 MCG/ML INJECTION 500 MCG/ML

T4 PA


T4 PA

b-6 folic acid capsule 400-1000-50 mcg-mcg-mg oral 400-1000-50 mcg-mcg-mg

T1

cyanocobalamin solution 1000 mcg/ml injection1000 mcg/ml

T1

DROXIA CAPSULE 200 MG ORAL 200 MG T2

DROXIA CAPSULE 300 MG ORAL 300 MG T2

96

Drug Status NotesDROXIA CAPSULE 400 MG ORAL 400 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 oral tablet 1 mg, 800 mcg T5 QL (30 EA per 30 days)

folic acid solution 5 mg/ml injection 5 mg/ml T1

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 460-60-0.01-1 MG T1

INFED SOLUTION 50 MG/ML INJECTION50 MG/ML T4 PA

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

NEULASTA 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



97

Drug Status NotesPROCRIT SOLUTION 3000 UNIT/ML INJECTION 3000 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, 3000 UNIT/ML, 4000 UNIT/ML, 40000 UNIT/ML

T4 PA

tl gard rx tablet 2.2-25-1 mg oral 2.2-25-1 mg T1

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

*Hepatitis C Agent - Combinations***MAVYRET ORAL TABLET 100-40 MG T4 PA

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


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

*Hypnotics*estazolam tablet 1 mg oral 1 mg T1

estazolam tablet 2 mg oral 2 mg T1

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

98

Drug Status Notesphenobarbital 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






ramelteon oral tablet 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

triazolam oral tablet 0.125 mg, 0.25 mg T1 AL (Max 64 Years)

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 tablet extended release 12.5 mg oral 12.5 mg

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

zolpidem tartrate er tablet extended release 6.25 mg oral 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)

*Interleukin-5 Antagonists (Igg1 Kappa)***FASENRA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 30 MG/ML T4 PA

*Laxatives*GAVILYTE-G SOLUTION RECONSTITUTED 236 GM ORAL 236 GM T1

GAVILYTE-N WITH FLAVOR PACK SOLUTION RECONSTITUTED 420 GM ORAL 420 GM

T1

GOLYTELY 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

99

Drug Status Noteslactulose oral packet 10 gm T3 PA; QL (30 EA per 30 days)

lactulose solution 10 gm/15ml oral 10 gm/15ml T1

MOVIPREP SOLUTION RECONSTITUTED 100 GM ORAL 100 GM T3

OSMOPREP TABLET 1.102-0.398 GM ORAL 1.102-0.398 GM T3

peg 3350/electrolytes oral solution reconstituted240 gm


polyethylene glycol 3350 oral powder T1

PREPOPIK PACKET 10-3.5-12 MG-GM-GM ORAL 10-3.5-12 MG-GM-GM T3 PA

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 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)



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

ERY-TAB TABLET DELAYED RELEASE 333 MG ORAL 333 MG T3

ERYTHROCIN STEARATE TABLET 250 MG ORAL 250 MG T3

erythromycin base capsule delayed release particles 250 mg oral 250 mg

T3

erythromycin base tablet 250 mg oral 250 mg T3

erythromycin base tablet 500 mg oral 500 mg T3

erythromycin ethylsuccinate tablet 400 mg oral400 mg

T3

100

Drug Status Notes

*Medical Devices*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)

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 SHORT 30G X 1/2" 0.3 ML 30G X 1/2" 0.3 ML T1 QL (200 EA per 30 days)

101

Drug Status NotesULTILET 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)

RELPAX TABLET 40 MG ORAL 40 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

EFFER-K TABLET EFFERVESCENT 20 MEQ ORAL 20 MEQ T3

102

Drug Status Notesfluoritab 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

K-TAB ORAL TABLET EXTENDED RELEASE 20 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 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

*Mouth/Throat/Dental Agents*cevimeline hcl capsule 30 mg oral 30 mg T3 PA

chlorhexidine gluconate solution 0.12 % mouth/throat 0.12 %

T1

clotrimazole lozenge 10 mg mouth/throat 10 mg T1

FLUORIDEX DAILY RENEWAL CONCENTRATE 0.63 % MOUTH/THROAT0.63 %

T1

103

Drug Status NotesFLUORIDEX 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 29-1 mg oral 29-1 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

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



LORZONE TABLET 375 MG ORAL 375 MG T3

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)



104

Drug Status Notestizanidine 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

BACTROBAN NASAL OINTMENT 2 % NASAL 2 % T3

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 %


ipratropium 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


105

Drug Status Notes

*Neuromuscular Agents*riluzole tablet 50 mg oral 50 mg T4

*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

bacitra-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

106

Drug Status Notesbrimonidine 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

EMADINE SOLUTION 0.05 % OPHTHALMIC 0.05 % T3

epinastine hcl solution 0.05 % ophthalmic 0.05 % T3

erythromycin ointment 5 mg/gm ophthalmic 5 mg/gm

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

107

Drug Status Notesgatifloxacin solution 0.5 % ophthalmic 0.5 % T3

GENTAK OPHTHALMIC OINTMENT 0.3 % T1

gentamicin sulfate solution 0.3 % ophthalmic 0.3 %

T1

HOMATROPAIRE SOLUTION 5 % OPHTHALMIC 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 solution 0.5 % ophthalmic 0.5 % T1 PA

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)

metipranolol solution 0.3 % ophthalmic 0.3 % T1

MOXEZA SOLUTION 0.5 % OPHTHALMIC0.5 % T3

moxifloxacin hcl solution 0.5 % ophthalmic 0.5 % T3

NATACYN 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

108

Drug Status NotesNEVANAC SUSPENSION 0.1 % OPHTHALMIC 0.1 % T3

ofloxacin solution 0.3 % ophthalmic 0.3 % T1

olopatadine hcl solution 0.1 % ophthalmic 0.1 % T1

olopatadine hcl solution 0.2 % ophthalmic 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 suspension 1 % ophthalmic1 %

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

timolol 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 %


109

Drug Status NotesTOBREX OINTMENT 0.3 % OPHTHALMIC0.3 % T2

TRAVATAN Z SOLUTION 0.004 % OPHTHALMIC 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

*Orexin Receptor Antagonists***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)



*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

CIPRODEX SUSPENSION 0.3-0.1 % OTIC0.3-0.1 % T3

ciprofloxacin hcl solution 0.2 % otic 0.2 % T1

COLY-MYCIN S SUSPENSION 3.3-3-10-0.5 MG/ML OTIC 3.3-3-10-0.5 MG/ML 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

*Passive Immunizing Agents - Combinations***HYQVIA KIT 2.5 GM/25ML SUBCUTANEOUS 2.5 GM/25ML T4 PA

110

Drug Status NotesHYQVIA SUBCUTANEOUS KIT 10 GM/100ML, 20 GM/200ML, 30 GM/300ML, 5 GM/50ML

T4 PA

*Passive Immunizing Agents*HYPERRHO S/D SOLUTION PREFILLED SYRINGE 1500 UNIT INTRAMUSCULAR1500 UNIT

T2 GR-F

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






111

Drug Status Notesamoxicillin-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 SF ORAL SUSPENSION T1

ORA-PLUS ORAL LIQUID T1

ORA-SWEET ORAL SYRUP T1

simple syrup oral syrup T1

*Phosphatidylinositol 3-Kinase (Pi3k) Inhibitors***ZYDELIG TABLET 100 MG ORAL 100 MG T4 PA

ZYDELIG TABLET 150 MG ORAL 150 MG T4 PA

*Phosphodiesterase 4 (Pde4) Inhibitors***OTEZLA TABLET 30 MG ORAL 30 MG T4 PA

*Potassium Removing Agents***sodium polystyrene sulfonate powder oral T1

SPS SUSPENSION 15 GM/60ML ORAL 15 GM/60ML T1

*Progestins*hydroxyprogesterone caproate intramuscular oil250 mg/ml

T4 PA; GR-F

112

Drug Status Notesmedroxyprogesterone 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

*Protease-Activated Receptor-1 (Par-1) Antagonists***ZONTIVITY TABLET 2.08 MG ORAL 2.08 MG T3 QL (30 EA per 30 days)

*Psychotherapeutic And Neurological Agents - Misc.*acamprosate calcium tablet delayed release 333 mg oral 333 mg

T3

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 KIT 30 MCG INTRAMUSCULAR30 MCG 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

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

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



113

Drug Status Notesdonepezil 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

galantamine 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

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


NUEDEXTA CAPSULE 20-10 MG ORAL 20-10 MG T4 PA

olanzapine-fluoxetine hcl capsule 12-25 mg oral12-25 mg

T3

olanzapine-fluoxetine hcl capsule 12-50 mg oral12-50 mg

T3

olanzapine-fluoxetine hcl capsule 3-25 mg oral 3-25 mg

T3


T3


T3

114

Drug Status Notesperphenazine-amitriptyline tablet 2-10 mg oral 2-10 mg

T1

perphenazine-amitriptyline tablet 2-25 mg oral 2-25 mg

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


T3 PA


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

*Pulmonary Fibrosis Agents - Kinase Inhibitors***OFEV CAPSULE 100 MG ORAL 100 MG T4 PA

OFEV CAPSULE 150 MG ORAL 150 MG T4 PA

*Pulmonary Fibrosis Agents***ESBRIET CAPSULE 267 MG ORAL 267 MG T4 PA

*Pulmonary Hypertension - Prostacyclin Receptor Agonist***UPTRAVI TABLET 1000 MCG ORAL 1000 MCG T4 PA

115

Drug Status NotesUPTRAVI TABLET 1200 MCG ORAL 1200 MCG T4 PA

UPTRAVI TABLET 1400 MCG ORAL 1400 MCG T4 PA






*Respiratory Agents - Misc.*KALYDECO TABLET 150 MG ORAL 150 MG T4 PA

PULMOZYME SOLUTION 1 MG/ML INHALATION 1 MG/ML T4 PA; QL (60 ML per 30 days)

*Serotonin Modulators***nefazodone hcl tablet 100 mg oral 100 mg T1











*Sodium-Glucose Co-Transporter 2 Inhibitor-Biguanide Comb***INVOKAMET TABLET 150-1000 MG ORAL150-1000 MG T2 QL (60 EA per 30 days)

INVOKAMET TABLET 150-500 MG ORAL150-500 MG T2 QL (60 EA per 30 days)



116

Drug Status NotesINVOKAMET 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






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






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








117

Drug Status Notes

*Steroids - Mouth/Throat/Dental***triamcinolone acetonide paste 0.1 % mouth/throat0.1 %


*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 capsule 75 mg oral 75 mg

T3

doxycycline monohydrate suspension reconstituted 25 mg/5ml oral 25 mg/5ml

T1

doxycycline monohydrate tablet 100 mg oral 100 mg

T1

doxycycline 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

levothyroxine-liothyronine oral tablet 60 mg T1

LEVOXYL ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 50 MCG, 75 MCG, 88 MCG

T1

LEVOXYL TABLET 137 MCG ORAL 137 MCG T1

118

Drug Status Notesliothyronine sodium tablet 25 mcg oral 25 mcg T1

liothyronine sodium tablet 5 mcg oral 5 mcg T1

liothyronine sodium tablet 50 mcg oral 50 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, 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 16.25 MG ORAL 16.25 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 TABLET 100 MCG ORAL 100 MCG T2












119

Drug Status NotesTHYROLAR-1 TABLET 60 (12.5-50) MG (MCG) ORAL 60 (12.5-50) MG (MCG) T3

THYROLAR-1/2 TABLET 30 (6.25-25) MG (MCG) ORAL 30 (6.25-25) MG (MCG) T3

THYROLAR-1/4 TABLET 15 (3.1-12.5) MG (MCG) ORAL 15 (3.1-12.5) MG (MCG) T3

THYROLAR-2 TABLET 120 (25-100) MG (MCG) ORAL 120 (25-100) MG (MCG) T3

THYROLAR-3 TABLET 180 (37.5-150) MG (MCG) ORAL 180 (37.5-150) MG (MCG) T3

UNITHROID DIRECT TABLET 100 MCG ORAL 100 MCG T1











WESTHROID TABLET 65 MG ORAL 65 MG T1

*Topical Anesthetic Gases***ethyl chloride aerosol external T1

*Ulcer Drugs*belladonna alkaloids-opium suppository 16.2-30 mg rectal 16.2-30 mg


belladonna alkaloids-opium suppository 16.2-60 mg rectal 16.2-60 mg


CARAFATE ORAL SUSPENSION 1 GM/10ML T3

120

Drug Status Noteschlordiazepoxide-clidinium capsule 5-2.5 mg oral5-2.5 mg

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



cvs esomeprazole magnesium capsule delayed release 20 mg oral 20 mg


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)

esomeprazole magnesium capsule delayed release 20 mg oral (otc) 20 mg


famotidine oral tablet 20 mg T1

famotidine suspension reconstituted 40 mg/5ml oral 40 mg/5ml

T1

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

GOODSENSE ESOMEPRAZOLE CAPSULE DELAYED RELEASE 20 MG ORAL 20 MG T1 QL (60 EA per 30 days)

heartburn treatment 24 hour capsule delayed release 20 mg oral 20 mg


hm esomeprazole magnesium dr capsule delayed release 20 mg oral 20 mg


hyoscyamine sulfate 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)

121

Drug Status Notesmethscopolamine bromide tablet 2.5 mg oral 2.5 mg


methscopolamine bromide tablet 5 mg oral 5 mg T3 AL (Max 64 Years)

misoprostol tablet 100 mcg oral 100 mcg T1

misoprostol tablet 200 mcg oral 200 mcg T1

NEXIUM 24HR CAPSULE DELAYED RELEASE 20 MG ORAL 20 MG T1 QL (60 EA per 30 days)

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

omeprazole 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


ranitidine hcl capsule 150 mg oral 150 mg T3

ranitidine hcl capsule 300 mg oral 300 mg T3

ranitidine hcl oral tablet 150 mg, 75 mg T1

ranitidine hcl syrup 75 mg/5ml oral 75 mg/5ml T1

ranitidine hcl tablet 300 mg oral 300 mg T1

sm esomeprazole magnesium capsule 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


ZEGERID OTC CAPSULE 20-1100 MG ORAL 20-1100 MG T1 QL (30 EA per 30 days)

*Urinary Anti-Infectives*HYOPHEN ORAL TABLET 81.6 MG T1

MACROBID ORAL CAPSULE 100 MG T1

122

Drug Status Notesmethenamine hippurate tablet 1 gm oral 1 gm T1

methenamine mandelate tablet 0.5 gm oral 0.5 gm T1

MONUROL PACKET 3 GM ORAL 3 GM T3

nitrofurantoin macrocrystal capsule 100 mg oral100 mg

T1

nitrofurantoin macrocrystal capsule 50 mg oral50 mg

T1

nitrofurantoin monohyd macro capsule 100 mg oral 100 mg

T1

nitrofurantoin suspension 25 mg/5ml oral 25 mg/5ml

T3

URETRON D/S TABLET ORAL T1

URIMAR-T TABLET 120 MG ORAL 120 MG T1

urin ds oral tablet T1

USTELL CAPSULE 120 MG ORAL 120 MG 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 tablet extended release 24 hour 10 mg oral 10 mg

T1


T1


T1

oxybutynin chloride syrup 5 mg/5ml oral 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

solifenacin succinate oral tablet 10 mg, 5 mg T3 ST

tolterodine tartrate er capsule extended release 24 hour 2 mg oral 2 mg

T2 ST

123

Drug Status Notestolterodine 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)

FLUARIX QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML

T5QL (0.5 ML per 365 days); AL (Min 6 Months)

FLULAVAL QUADRIVALENT INTRAMUSCULAR SUSPENSION T5


FLUZONE HIGH-DOSE INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML


FLUZONE QUADRIVALENT INTRAMUSCULAR SUSPENSION T5


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 0.25 ML

T5QL (0.25 ML per 365 days); AL (Min 6 Months and Max 35 Months)

FLUZONE QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML


124

Drug Status NotesSHINGRIX INTRAMUSCULAR SUSPENSION RECONSTITUTED 50 MCG/0.5ML

T1QL (2 EA per 1 lifetime); AL (Min 50 Years)

ZOSTAVAX SUSPENSION RECONSTITUTED 19400 UNT/0.65ML SUBCUTANEOUS 19400 UNT/0.65ML

T5 AL (Min 50 Years)

*Vaginal 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 suppository 80 mg vaginal 80 mg T3

terconazole vaginal cream 0.8 % 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








125

Drug Status Notesmidodrine 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

*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

POTABA CAPSULE 500 MG ORAL 500 MG T3

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 d oral liquid 400 unit/ml T5

vitamin d3 capsule 250 mcg (10000 ut) oral 250 mcg (10000 ut)


vitamin d3 liquid 5000 unit/ml oral 5000 unit/ml T5

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

126

Indexabacavir sulfate .................... 60, 61abacavir sulfate-lamivudine ....... 61abacavir-lamivudine-zidovudine 61ABILIFY MAINTENA ............ 56abiraterone acetate .....................49acamprosate calcium ................ 113acarbose ......................................32acebutolol hcl ..............................66acetaminophen-codeine ................ 8acetaminophen-codeine #2 ........... 8acetaminophen-codeine #3 ........... 8acetaminophen-codeine #4 ........... 8ACETASOL HC ..................... 110acetazolamide ............................. 85acetazolamide er .........................85acetic acid ...........................94, 110acetylcysteine ........................ 37, 75acitretin .......................................76acne treatment .............................76ACTEMRA ..................................5ACTIMMUNE .......................... 49ACUVAIL ................................106acyclovir ................................61, 76adapalene-benzoyl peroxide ....... 76ADCIRCA ..................................70adefovir dipivoxil ........................ 61ADEMPAS .................................70ADRENALIN .......................... 125ADVAIR HFA ...........................18AFEDITAB CR .........................68AFINITOR ................................ 49AFLURIA QUADRIVALENT...................................................124AIMOVIG (140 MG DOSE) .... 68AKYNZEO ................................ 37albendazole ................................. 15albuterol sulfate .................... 18, 19albuterol sulfate er ......................18albuterol sulfate hfa ....................18alclometasone dipropionate ........76alendronate sodium .............. 86, 87alfuzosin hcl er ............................94ALINIA ......................................47allergy spray 24 hour ................105allopurinol .................................. 95almotriptan malate ....................102ALOCRIL ................................106alogliptin benzoate ......................32alogliptin-metformin hcl ............. 32alogliptin-pioglitazone ................32ALOMIDE ...............................106

alosetron hcl ............................... 93ALPHAGAN P ........................ 106alprazolam .................................. 16alprazolam er ..............................16alprazolam xr ..............................16alprostadil ...................................65ALTABAX .................................76ALTACAINE .......................... 106amantadine hcl ............................54ambrisentan ................................ 70amcinonide ..................................76amiloride hcl ...............................85amiloride-hydrochlorothiazide ... 85aminoacetic acid .........................94aminocaproic acid ...................... 98amiodarone hcl ........................... 17AMITIZA .................................. 93amitriptyline hcl ..........................28amlodipine besy-benazepril hcl...............................................41, 42amlodipine besylate .................... 68amlodipine besylate-valsartan ....42amlodipine-olmesartan ............... 42ammonium lactate .......................76amoxapine ...................................28amoxicillin ................................ 111amoxicillin-pot clavulanate...........................................111, 112amoxicillin-pot clavulanate er ..111amphetamine-dextroamphet er ..... 1amphetamine-dextroamphetamine .......................1ampicillin .................................. 112AMPYRA .................................113ANADROL-50 ...........................13anagrelide hcl ............................. 95ANALPRAM-HC ......................14anastrozole ..................................49ANDRODERM ..........................13ANECREAM .............................76ANORO ELLIPTA ...................19anucort-hc ...................................14ANZEMET ................................ 38apraclonidine hcl ...................... 106aprepitant ....................................38APRISO ..................................... 93APTIOM ....................................24APTIVUS ...................................61ARANESP (ALBUMIN FREE) ........................................ 96ARCALYST ................................ 5

ARCAPTA NEOHALER .........19ARGYLE STERILE SALINE . 94aripiprazole .................................56armodafinil ................................... 1ARMOUR THYROID ............118ARNUITY ELLIPTA ............... 19ascorbic acid .............................126ASMANEX (120 METERED DOSES) ......................................19ASMANEX (7 METERED DOSES) ......................................19ASMANEX HFA .......................19ASPERCREME LIDOCAINE 77ASPERCREME W/LIDOCAINE ........................ 77aspirin ........................................... 8aspirin 81 ...................................... 8aspirin ec ...................................... 8aspirin ec low dose ....................... 8aspirin-dipyridamole er .............. 95atazanavir sulfate ........................61atenolol ....................................... 66atenolol-chlorthalidone .............. 42atomoxetine hcl .........................1, 2atorvastatin calcium ................... 40atovaquone ..................................47atovaquone-proguanil hcl ...........48ATRIPLA .................................. 61atropine sulfate ......................... 106ATROVENT HFA .................... 19AUBAGIO ............................... 113AVANDIA ..................................32AVITA ....................................... 77AVONEX ................................. 113AVONEX PEN ........................ 113AVONEX PREFILLED ......... 113AZASAN ....................................65AZASITE .................................106azathioprine ................................ 65azelastine hcl .................... 105, 106azithromycin ............................. 100AZOPT .....................................106b-6 folic acid ............................... 96bacitracin ..................................106bacitracin-polymyxin b ............. 106bacitra-neomycin-polymyxin-hc106baclofen .....................................104BACTROBAN NASAL .......... 105balanced salt .............................106BALCOLTRA ........................... 72balsalazide disodium .................. 93

127

BALZIVA .................................. 72BANZEL ....................................24BARACLUDE ........................... 61BASIS OVERNIGHT ...............77BD INSULIN SYRINGE ........101BD PEN NEEDLE ORIGINAL U/F ...................... 101BD SAFETYGLIDE INSULIN SYRINGE .............. 101BD VEO INSULIN SYRINGE U/F ............................................101BECONASE AQ ..................... 105belladonna alkaloids-opium ..... 120BELSOMRA ........................... 110benazepril hcl ..............................42benazepril-hydrochlorothiazide ..42BENZEPRO .............................. 77BENZEPRO SHORT CONTACT ................................ 77benzonatate ................................. 75benzoyl peroxide-erythromycin ...77benztropine mesylate ...................54BEPREVE ............................... 106BERINERT ............................... 95BESIVANCE ........................... 106betamethasone dipropionate .......77betamethasone dipropionate aug .............................................. 77betamethasone sod phos & acet ..74betamethasone valerate .............. 77betaxolol hcl ........................66, 106bethanechol chloride .................123BETOPTIC-S .......................... 106bexarotene ...................................49bicalutamide ............................... 49BICILLIN L-A ........................ 112BIKTARVY ...............................61bimatoprost ............................... 106bisoprolol fumarate .................... 66bisoprolol-hydrochlorothiazide...............................................42, 43BLEPHAMIDE S.O.P. ........... 106BOSULIF ...................................49BREO ELLIPTA ...................... 19BRILINTA ...........................85, 95brimonidine tartrate ..................107BROMFED DM ........................ 75bromfenac sodium (once-daily) 107bromocriptine mesylate ...............54BROVANA ................................ 19budesonide ............................ 19, 74bumetanide ..................................85

buprenorphine ...............................9buprenorphine hcl .....................8, 9buprenorphine hcl-naloxone hcl ...9bupropion hcl ........................28, 29bupropion hcl er (smoking det) .113bupropion hcl er (sr) ...................28bupropion hcl er (xl) ...................28buspirone hcl .............................. 16butalbital-acetaminophen ............. 8butalbital-apap-caff-cod ............... 9butalbital-apap-caffeine ............... 8butalbital-asa-caff-codeine ...........9butalbital-aspirin-caffeine ............ 8butorphanol tartrate ..................... 9BYDUREON ............................. 32BYETTA 10 MCG PEN ........... 32BYETTA 5 MCG PEN ............. 32BYSTOLIC ................................66cabergoline ................................. 87caffeine citrate .............................. 2caffeine-sodium benzoate ..............2calcipotriene ............................... 77calcipotriene-betameth diprop ....77calcitonin (salmon) ..................... 87CALCITRENE ..........................77calcitriol ......................................87calcium acetate (phos binder) .....93CALPHRON ............................. 93candesartan cilexetil ...................43candesartan cilexetil-hctz ........... 43capecitabine ................................50CAPEX .......................................77CAPRELSA ...............................50captopril ......................................43captopril-hydrochlorothiazide ....43CARAFATE ............................ 120carbamazepine ............................25carbamazepine er ..................24, 25carbidopa ....................................54carbidopa-levodopa ..............54, 55carbidopa-levodopa er ................54carbinoxamine maleate ...............39CARDURA XL ..........................94carisoprodol ..............................104carteolol hcl .............................. 107CARTIA XT .............................. 68carvedilol .............................. 66, 67carvedilol phosphate er .............. 66CAVERJECT IMPULSE .........71cefaclor ....................................... 71cefadroxil .................................... 71cefdinir ........................................71

cefditoren pivoxil ........................ 71cefpodoxime proxetil .............71, 72cefprozil ...................................... 72cefuroxime axetil .........................72celecoxib ....................................... 5CELONTIN ............................... 25CEM-UREA .............................. 78cephalexin ................................... 72CEPROTIN ............................... 95CESAMET .................................38cetirizine hcl ................................39cevimeline hcl ........................... 103CHEMET ...................................37cherry ........................................112chlordiazepoxide hcl ...................16chlordiazepoxide-amitriptyline .113chlordiazepoxide-clidinium ...... 121chlorhexidine gluconate ......60, 103chloroquine phosphate ................48chlorothiazide ............................. 85chlorpromazine hcl ..................... 56chlorpropamide .....................32, 33chlorthalidone .......................85, 86chlorzoxazone ........................... 104cholestyramine ............................40choline-mag trisalicylate .............. 8chorionic gonadotropin .............. 87ciclopirox .................................... 78cilostazol ..................................... 95CILOXAN ............................... 107cimetidine ..................................121cimetidine hcl ............................121CIMZIA ..................................... 93CIMZIA PREFILLED ............. 93CIPRO ....................................... 92CIPRO HC .............................. 110CIPRODEX ............................. 110ciprofloxacin ............................... 92ciprofloxacin hcl ......... 92, 107, 110ciprofloxacin-ciproflox hcl er ..... 92citalopram hydrobromide ........... 29clarithromycin ...........................100clarithromycin er ...................... 100CLEOCIN ................................125CLINDACIN PAC .................... 78clindamycin hcl ...........................47clindamycin palmitate hcl ...........47clindamycin phos-benzoyl perox .78clindamycin phosphate ....... 78, 125clobazam ..................................... 25clobetasol propionate ................. 78clobetasol propionate e ...............78

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CLODERM ............................... 78clomipramine hcl ........................ 29clonazepam ................................. 25clonidine ..................................... 43clonidine hcl ................................43clopidogrel bisulfate ................... 95clorazepate dipotassium ............. 16clotrimazole ................ 78, 103, 125clotrimazole-betamethasone ....... 78clozapine ............................... 56, 57coal tar ........................................72COARTEM ............................... 48codeine sulfate .............................. 9colchicine-probenecid .................95COLCRYS .................................95colesevelam hcl ........................... 40colestipol hcl ...............................40COLOCORT ............................. 14COLY-MYCIN S .................... 110COMBIGAN ........................... 107COMBIPATCH ........................ 90COMBIVENT RESPIMAT ..... 19COMETRIQ (100 MG DAILY DOSE) .......................... 50COMETRIQ (140 MG DAILY DOSE) .......................... 50COMETRIQ (60 MG DAILY DOSE) ........................................ 50COMFORT EZ PEN NEEDLES ................................101COMPLERA ............................. 61CONDYLOX ............................. 78CORDRAN ................................78CORTIFOAM ........................... 14cortisone acetate .........................74CORTISPORIN ........................ 78CORZIDE ..................................43COSENTYX (300 MG DOSE) .79COSENTYX SENSOREADY PEN ............................................ 79CREON ......................................85CRESEMBA ..............................38CRINONE ............................... 125CRIXIVAN ................................61cromolyn sodium .................93, 107CUPRIMINE .............................65cvs esomeprazole magnesium ... 121cvs nasal allergy spray ............. 105cvs sodium chloride .................. 107cyanocobalamin ..........................96cyclobenzaprine hcl .................. 104cyclopentolate hcl ..................... 107

cyclophosphamide .......................50cycloserine .................................. 49CYCLOSET .............................. 33cyclosporine ................................65cyclosporine modified .................65cyproheptadine hcl ......................39CYSTADANE ........................... 87CYSTARAN ............................ 107CYTRA-3 ...................................94dalfampridine er ....................... 113DALIRESP ................................ 20dantrolene sodium .................... 104dapsone ....................................... 47DARAPRIM .............................. 48darifenacin hydrobromide er ....123DAYTRANA ................................2DDAVP RHINAL TUBE ......... 87deferasirox .................................. 37deferoxamine mesylate ................37demeclocycline hcl ....................118DENAVIR ..................................79DEPEN TITRATABS ...............65DEPO-MEDROL ......................74DEPO-PROVERA .................... 50DEPO-SUBQ PROVERA 104 . 72desipramine hcl ...........................29desmopressin ace spray refrig .... 87desmopressin acetate .................. 87desmopressin acetate spray ........ 87desogestrel-ethinyl estradiol .......72desonide ...................................... 79desoximetasone ........................... 79desvenlafaxine er ........................ 29desvenlafaxine succinate er ........ 29dexamethasone ............................74DEXAMETHASONE INTENSOL ................................74dexamethasone sodium phosphate ............................74, 107dexmethylphenidate hcl .............2, 3dexmethylphenidate hcl er ............ 2dextroamphetamine sulfate ...........3dextroamphetamine sulfate er .......3diazepam ............................... 16, 17diclofenac potassium .................... 5diclofenac sodium ........... 6, 79, 107diclofenac sodium er .....................5diclofenac-misoprostol ................. 6dicloxacillin sodium ..................112dicyclomine hcl ......................... 121didanosine ...................................61diethylpropion hcl .........................3

diethylpropion hcl er .....................3DIFFERIN ................................. 79DIFICID ...................................100diflorasone diacetate .................. 79diflunisal ....................................... 8digoxin ........................................ 70DILANTIN ................................ 25DILATRATE-SR ...................... 15diltiazem hcl ..........................68, 69diltiazem hcl er ........................... 68diltiazem hcl er beads ................. 68dilt-xr .......................................... 69dimenhydrinate ........................... 38DIPENTUM ...............................93diphenhydramine hcl ...................39diphenoxylate-atropine ............... 36dipyridamole ............................... 95disopyramide phosphate ............. 17disulfiram ..................................113divalproex sodium .................25, 26divalproex sodium er .................. 25docosanol ....................................79dofetilide ..................................... 17donepezil hcl ..................... 113, 114DOPRAM .................................... 3dorzolamide hcl ........................ 107dorzolamide hcl-timolol mal .....107doxazosin mesylate ..................... 43doxepin hcl ............................29, 79doxercalciferol ............................87doxycycline hyclate ................... 118doxycycline monohydrate ......... 118DRITHO-CREME HP ............. 79dronabinol ...................................38droperidol ................................... 17drospiren-eth estrad-levomefol ...72drospirenone-ethinyl estradiol ....72DROXIA .............................. 96, 97DUAVEE ................................... 92DULERA ................................... 20duloxetine hcl ..............................29DUREZOL ...............................107econazole nitrate .........................79EDARBI .....................................43EDURANT .................................61EEMT .........................................90EEMT HS .................................. 90efavirenz ......................................61EFFER-K .................................102eletriptan hydrobromide ........... 102ELIGARD ..................................50ELIQUIS ....................................22

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ELIQUIS STARTER PACK ... 22ELIXOPHYLLIN ..................... 20ELLA ......................................... 72ELMIRON .................................94EMADINE ............................... 107EMCYT ..................................... 50EMSAM ..................................... 30EMTRIVA ................................. 61enalapril maleate .................. 43, 44enalapril-hydrochlorothiazide ....44ENBREL ......................................6ENBREL MINI ........................... 6ENBREL SURECLICK ............. 6ENDOCET ...................................9ENDOMETRIN ...................... 125enoxaparin sodium ................22, 23entacapone ..................................55epinastine hcl ............................ 107epinephrine ............................... 125EPIVIR HBV .............................61eplerenone ...................................44EPOGEN ................................... 97eprosartan mesylate ....................44eq nasal allergy .........................105ergoloid mesylates .................... 114ergotamine-caffeine .................. 102ERIVEDGE ............................... 50ERTACZO .................................79ERY-TAB ................................ 100ERYTHROCIN STEARATE 100erythromycin ....................... 79, 107erythromycin base .....................100erythromycin ethylsuccinate ..... 100ESBRIET ................................. 115escitalopram oxalate ...................30esomeprazole magnesium ......... 121estazolam .................................... 98estradiol ........................ 90, 91, 125estradiol valerate ........................ 91estradiol-norethindrone acet ...... 91ESTRING ................................ 125ESTROGEL .............................. 91eszopiclone ..................................98ethacrynic acid ............................86ethambutol hcl ............................ 49ethosuximide ............................... 26ethyl chloride ...................... 79, 120ethynodiol diac-eth estradiol ...... 72etidronate disodium .................... 87etodolac .........................................6etodolac er .................................... 6EUCERIN ..................................79

EURAX ...................................... 79EVAMIST ..................................91EVOTAZ ................................... 62EXELDERM ............................. 79exemestane .................................. 50EXODERM ............................... 79ezetimibe ..................................... 40ezetimibe-simvastatin ..................40famciclovir .................................. 62famotidine ................................. 121FANAPT .................................... 57FARXIGA ..................................33FARYDAK ................................ 50FASENRA ................................. 99FASLODEX ...............................50fe tabs ..........................................97felbamate .....................................26felodipine er ................................ 69fenofibrate ...................................40fenofibrate micronized ................ 40fenofibric acid .............................40fentanyl ......................................... 9ferotrinsic ....................................97ferraplus 90 .................................97FERRIPROX .............................37ferrous sulfate ............................. 97FETZIMA ..................................30fexofenadine hcl .......................... 39FIASP .........................................33FIASP FLEXTOUCH .............. 33FIBRICOR ................................ 40FINACEA .................................. 79finasteride ............................. 80, 94FIRAZYR .................................. 95FIRMAGON ..............................50FIRST-LANSOPRAZOLE .... 121FIRST-PROGESTERONE VGS .......................................... 125FLAREX ..................................107flavor sweet ...............................112flavoxate hcl ..............................123flecainide acetate ........................ 17FLONASE SENSIMIST .........105FLOVENT DISKUS ................. 20FLOVENT HFA ........................20FLUAD .....................................124FLUARIX QUADRIVALENT...................................................124FLUCAINE ............................. 107fluconazole ..................................38flucytosine ................................... 38fludrocortisone acetate ............... 74

FLULAVAL QUADRIVALENT ................. 124flunisolide ................................. 105fluocinolone acetonide ........80, 110fluocinolone acetonide body ....... 80fluocinolone acetonide scalp ...... 80fluocinonide ................................ 80fluocinonide emulsified base .......80FLUORIDEX .......................... 104FLUORIDEX DAILY RENEWAL ..............................103fluoritab .................................... 103fluorometholone ........................107fluorouracil ................................. 80fluoxetine hcl ...............................30fluphenazine decanoate ...............57fluphenazine hcl .......................... 57flurandrenolide ........................... 80flurazepam hcl ............................ 98flurbiprofen ................................... 6flurbiprofen sodium .................. 107flutamide ..................................... 50fluticasone propionate ........ 80, 105fluticasone-salmeterol .................20fluvastatin sodium .......................40fluvoxamine maleate ................... 30FLUZONE HIGH-DOSE .......124FLUZONE QUADRIVALENT ................. 124FML ......................................... 107FOCALIN XR ............................. 3folic acid ..................................... 97fondaparinux sodium .................. 23FORTEO ................................... 87FOSAMAX PLUS D ................. 87fosamprenavir calcium ............... 62fosinopril sodium ........................ 44fosinopril sodium-hctz ................ 44FRAGMIN .................................23FREESTYLE LIBRE SENSOR SYSTEM .................101frovatriptan succinate ...............102furosemide ...................................86FUZEON ....................................62FYCOMPA ................................26gabapentin .................................. 26GABITRIL ................................ 26galantamine hydrobromide .......114galantamine hydrobromide er .. 114ganirelix acetate ......................... 87gatifloxacin ............................... 108GAVILYTE-G ...........................99

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GAVILYTE-N WITH FLAVOR PACK ....................... 99gemfibrozil .................................. 41generlac ...................................... 93GENGRAF ................................ 65GENOTROPIN ......................... 88GENOTROPIN MINIQUICK...............................................87, 88GENTAK ................................. 108gentamicin sulfate ...............80, 108GILENYA ................................114GILOTRIF ................................ 50glatiramer acetate .....................114GLATOPA ...............................114GLEOSTINE .......................50, 51glimepiride ..................................33glipizide .......................................33glipizide er .................................. 33glipizide-metformin hcl ...............33GLUCAGEN HYPOKIT ......... 33GLUCAGON EMERGENCY . 33GLUCOCARD EXPRESSION TEST ................85GLUCOCARD VITAL TEST . 85glyburide ..................................... 33glyburide micronized .................. 33glyburide-metformin ................... 33glycopyrrolate ...........................121gnp 24 hour nasal allergy .........105GOLYTELY ..............................99GONAL-F RFF REDIJECT ....88GOODSENSE ESOMEPRAZOLE .................121goodsense glucose .......................34goodsense nasal allergy spray ..105granisetron hcl ............................38griseofulvin microsize .................38griseofulvin ultramicrosize ... 38, 39guanfacine hcl .............................44guanfacine hcl er .......................... 3GYNAZOLE-1 ........................ 125halcinonide ................................. 80halobetasol propionate ............... 80HALOG ..................................... 80haloperidol ..................................57haloperidol decanoate ................ 57haloperidol lactate ......................57heartburn treatment 24 hour .... 121hematinic/folic acid .................... 97HEMATOGEN FA ................... 97HEMATOGEN FORTE ...........97heparin lock flush ................. 23, 24

heparin sod (porcine) in d5w ......24heparin sodium (porcine) ............24heparin sodium (porcine) pf ....... 24HETLIOZ ..................................98hm esomeprazole magnesium dr...................................................121HOMATROPAIRE ................ 108HUMIRA ..................................... 6HUMIRA PEN ............................ 6HUMULIN R U-500 (CONCENTRATED) ................34hydralazine hcl ............................44hydrochlorothiazide ....................86hydrocod polst-cpm polst er ....... 75hydrocodone-acetaminophen ......10hydrocodone-homatropine ..........75hydrocodone-ibuprofen ...............10hydrocortisone ................ 74, 75, 81hydrocortisone ace-pramoxine...............................................14, 80hydrocortisone acetate ................14hydrocortisone butyr lipo base ... 80hydrocortisone butyrate ........80, 81hydrocortisone valerate .............. 81hydromorphone hcl .....................10hydromorphone hcl er .................10hydroquinone .............................. 81hydroxychloroquine sulfate .........48hydroxyprogesterone caproate.............................................51, 112hydroxyurea ................................ 51hydroxyzine hcl ........................... 17hydroxyzine pamoate .................. 17HYOPHEN .............................. 122hyoscyamine sulfate .................. 121hyoscyamine sulfate sl .............. 121hyosyne ......................................121HYPERRHO S/D .................... 111HYQVIA ..........................110, 111ibandronate sodium .................... 88IBRANCE ..................................76IBU ............................................... 6ibuprofen .......................................7ICLUSIG ................................... 51imatinib mesylate ........................ 51IMBRUVICA ............................ 51imipramine hcl ............................ 30imipramine pamoate ................... 30imiquimod ................................... 81INCRELEX ............................... 88INCRUSE ELLIPTA ................20indapamide ................................. 86

indomethacin .................................7indomethacin er ............................ 7INFED ........................................97INLYTA .....................................51insulin syringe ...........................101insupen pen needles .................. 101INTELENCE .............................62INTRON A ................................ 51INVEGA SUSTENNA ........ 57, 58INVIRASE .................................62INVOKAMET .........................116INVOKAMET XR .................. 117INVOKANA .............................. 34iodine strong ............................. 103iodine strong (lugol's) .................72IOPIDINE ................................108ipratropium bromide ...........20, 105ipratropium-albuterol ................. 20irbesartan ....................................44irbesartan-hydrochlorothiazide ..44iron ..............................................97iron 27 .........................................97ISENTRESS .............................. 62isoniazid ......................................49isosorbide dinitrate .....................15isosorbide dinitrate er .................15isosorbide mononitrate ............... 15isosorbide mononitrate er ...........15isoxsuprine hcl ............................ 71isradipine .................................... 69itraconazole ................................ 39ivermectin ....................................15JADENU .................................... 37JAKAFI ..................................... 51JANUMET .................................34JANUMET XR ..........................34JANUVIA .................................. 34JARDIANCE .............................34JINTELI .................................... 91JUNEL 1.5/30 ............................ 73JUNEL FE 1.5/30 ...................... 73KALBITOR ...............................95KALETRA .................................62KALYDECO ........................... 116ketoconazole ..........................39, 81ketone test ................................... 85ketoprofen er .................................7ketorolac tromethamine ........ 7, 108KINERET ....................................7KISQALI 200 DOSE ................ 76KISQALI 400 DOSE ................ 76KISQALI 600 DOSE ................ 76

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KISQALI FEMARA (400 MG DOSE) ........................................ 51KISQALI FEMARA (600 MG DOSE) ........................................ 51KISQALI FEMARA(200 MG DOSE) ........................................ 51KLOR-CON M15 ....................103kp diphenhydramine hcl ..............39K-PRIME .................................103KRISTALOSE .......................... 99K-TAB ......................................103KUVAN ......................................88KYPROLIS ............................... 51labetalol hcl ................................ 67LACRISERT ........................... 108lactic acid ....................................81lactic acid e .................................81lactulose ....................................100LAMICTAL ODT .....................26lamivudine ...................................62lamivudine-zidovudine ................62lamotrigine ............................26, 27lamotrigine er ............................. 26lansoprazole ..............................121lanthanum carbonate .................. 93LANTUS .................................... 34LANTUS SOLOSTAR ............. 34LARIN FE 1/20 ......................... 73LASTACAFT .......................... 108latanoprost ................................108LATUDA ................................... 58lc-4 lidocaine .............................. 81leflunomide ................................... 7letrozole ...................................... 51leucovorin calcium ................51, 52LEUKERAN ..............................52LEUKINE ..................................97leuprolide acetate ....................... 52levalbuterol hcl ..................... 20, 21levalbuterol tartrate ....................21LEVEMIR ................................. 34LEVEMIR FLEXTOUCH .......34levetiracetam ...............................27levetiracetam er .......................... 27levobunolol hcl ..........................108levocarnitine ......................... 88, 89levocetirizine dihydrochloride .... 39levofloxacin .........................92, 108levonorgest-eth estrad 91-day .... 73levonorgestrel ............................. 73levonorgestrel-ethinyl estrad ...... 73levonorg-eth estrad triphasic ......73

levorphanol tartrate ....................10levothyroxine sodium ................ 118levothyroxine-liothyronine ........118LEVOXYL ...............................118LEXIVA .....................................62lidocaine ..................................... 81lidocaine hcl ........................81, 104lidocaine-hydrocortisone ace ..... 14lidocaine-prilocaine ....................81LIDOCREAM ........................... 81lindane ........................................ 81linezolid .......................................48LINZESS ................................... 93liothyronine sodium .................. 119lisinopril ......................................44lisinopril-hydrochlorothiazide ....44lithium ......................................... 58lithium carbonate ........................58lithium carbonate er ................... 58LIVALO .....................................41LMX 4 ........................................ 81LO LOESTRIN FE ...................73loperamide hcl ............................ 36lopinavir-ritonavir ...................... 62loratadine ....................................39loratadine childrens ....................39lorazepam ................................... 17LORAZEPAM INTENSOL .....17LORZONE .............................. 104losartan potassium ......................45losartan potassium-hctz .............. 45LOTEMAX ..............................108lovastatin .....................................41LOW-OGESTREL ................... 73loxapine succinate .......................58LUMIGAN ...............................108LUPRON DEPOT (1-MONTH) ................................... 52LUPRON DEPOT (3-MONTH) ................................... 52LUPRON DEPOT (4-MONTH) ................................... 52LUPRON DEPOT (6-MONTH) ................................... 52LYRICA .....................................27LYSODREN .............................. 52MACROBID ............................122mafenide acetate ......................... 81MAGELLAN INSULIN SAFETY SYR ..........................101magnesium oxide .........................14malathion .................................... 81

maprotiline hcl ............................30MARPLAN ................................30MATULANE ............................. 52MAVYRET ................................98meclizine hcl ............................... 38meclofenamate sodium ..................7medroxyprogesterone acetate.............................................73, 113mefloquine hcl .............................48megestrol acetate ........................ 52MEKINIST ................................52meloxicam ..................................... 7memantine hcl ...........................114MENEST ................................... 91MENTAX ...................................81meperidine hcl .............................10meprobamate .............................. 17mercaptopurine ...........................52mesalamine ................................. 93MESNEX ................................... 52MESTINON .........................48, 49metaproterenol sulfate ................ 21metaxalone ................................104metformin hcl .............................. 34metformin hcl er ..........................34methadone hcl .............................11METHADONE HCL INTENSOL ................................10METHADOSE .......................... 11methamphetamine hcl ................... 3methazolamide ............................ 86methenamine hippurate .............123methenamine mandelate ........... 123methimazole .............................. 119methitest ......................................13methocarbamol ......................... 104methotrexate ................................52methotrexate sodium ...................52methotrexate sodium (pf) ............ 52methoxsalen rapid .......................81methscopolamine bromide ........ 122methyclothiazide ......................... 86methyldopa ..................................45methylergonovine maleate ........ 110methylphenidate hcl ...................... 4methylphenidate hcl er ..................4methylphenidate hcl er (cd) .......... 3methylphenidate hcl er (la) ...........4methylprednisolone .....................75metipranolol ..............................108metoclopramide hcl .....................93metolazone .................................. 86

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metoprolol succinate er .............. 67metoprolol tartrate ......................67metoprolol-hydrochlorothiazide . 45metronidazole ............... 48, 81, 125mexiletine hcl .............................. 18MIACALCIN ............................ 89miconazole 3 applicator ........... 125miconazole 3 combo pack ......... 125miconazole nitrate ...................... 82midodrine hcl ............................ 126miglitol ........................................35MILLIPRED ............................. 75minocycline hcl ......................... 118minoxidil ..................................... 45mirtazapine ........................... 30, 31MIRVASO ................................. 82misoprostol ............................... 122modafinil ....................................... 4moexipril hcl ............................... 45moexipril-hydrochlorothiazide ... 45mometasone furoate ............82, 105MONOJECT SODIUM CHLORIDE FLUSH .............. 103montelukast sodium .................... 21MONUROL ............................. 123morphine sulfate ................... 11, 12morphine sulfate (concentrate) ...11morphine sulfate (pf) ...................11morphine sulfate er ..................... 11MOTOFEN ................................37MOVIPREP .............................100MOXEZA ................................ 108moxifloxacin hcl ..................92, 108MULTAQ .................................. 18multivitamin/fluoride ................ 104mupirocin ....................................82mycophenolate mofetil ................ 65mycophenolate sodium ................65MYLERAN ................................52nabumetone ...................................7nac .............................................106nadolol ........................................ 67nadolol-bendroflumethiazide ......45NAFTIN ..................................... 82nalbuphine hcl ............................ 12naloxone hcl ................................37naltrexone hcl ............................. 37naproxen ....................................... 7naproxen dr ...................................7naproxen sodium ...........................7naratriptan hcl .......................... 102NARCAN ................................... 37

nasal allergy 24 hour ................105NATACYN .............................. 108nateglinide .................................. 35NATROBA ................................ 82NATURE-THROID ................119nefazodone hcl .................... 31, 116neomycin sulfate ........................... 5neomycin-bacitracin zn-polymyx ..................................... 108neomycin-polymyxin b gu ........... 94neomycin-polymyxin-dexameth .108neomycin-polymyxin-gramicidin...................................................108neomycin-polymyxin-hc .... 108, 110NEULASTA ...............................97NEUPRO ................................... 55NEVANAC .............................. 109nevirapine ................................... 62nevirapine er ...............................62NEXAVAR ................................ 52NEXIUM 24HR .......................122niacin ........................................ 126niacin er (antihyperlipidemic) .... 41NIACOR .................................... 41nicardipine hcl ............................ 69NICORETTE .......................... 114nicotine ..................................... 114nicotine mini ............................. 114nicotine polacrilex .................... 114nifedipine .................................... 69nifedipine er ................................ 69nifedipine er osmotic release ...... 69nimodipine .................................. 69nisoldipine er .............................. 69nitisinone .....................................89NITRO-BID ...............................15NITRO-DUR ............................. 15nitrofurantoin ............................123nitrofurantoin macrocrystal ......123nitrofurantoin monohyd macro .123nitroglycerin ............................... 15nitroglycerin er ........................... 15NITRO-TIME ........................... 16nizatidine ...................................122NORA-BE ..................................73norethin ace-eth estrad-fe ...........73norethindrone acetate ...............113norethindrone acet-ethinyl est .... 73norethindrone-eth estradiol ........ 91norethin-eth estradiol-fe ............. 73norgestimate-eth estradiol .......... 73norgestim-eth estrad triphasic ....73

NORPACE CR ..........................18NORTREL 0.5/35 (28) ..............73NORTREL 1/35 (28) .................73NORTREL 7/7/7 ....................... 73nortriptyline hcl .......................... 31NORVIR .................................... 62NOVOLIN 70/30 ....................... 35NOVOLIN N ............................. 35NOVOLIN N RELION .............35NOVOLIN R ............................. 35NOVOLIN R RELION .............35NOVOLOG ............................... 35NOVOLOG FLEXPEN ............35NOVOLOG MIX 70/30 ............ 35NOVOLOG MIX 70/30 FLEXPEN ..................................35NOVOLOG PENFILL ............. 35np thyroid ..................................119NUCYNTA ER ..........................12NUEDEXTA ............................114NUVARING .............................. 73NYAMYC .................................. 82nystatin ..........................39, 82, 104nystatin-triamcinolone ................82NYSTOP .................................... 82octreotide acetate ........................89ODOMZO ..................................52OFEV ....................................... 115ofloxacin ..................... 92, 109, 110OGESTREL .............................. 73olanzapine ...................................58olanzapine-fluoxetine hcl ..........114olmesartan medoxomil ................45olmesartan medoxomil-hctz ........ 45olopatadine hcl ......................... 109omega-3-acid ethyl esters ........... 41omeprazole ................................122ondansetron ................................ 38ondansetron hcl .......................... 38ONETOUCH VERIO .............101ONGLYZA ................................ 35OPSUMIT ..................................71ORA-BLEND SF .....................112ORA-PLUS ..............................112ORA-SWEET ..........................112ORAVIG ..................................104ORENCIA ................................... 7orphenadrine citrate er .............104oseltamivir phosphate ...........62, 63OSMOPREP ............................100OSPHENA ................................. 89OTEZLA ..................................112

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oxandrolone ................................ 13oxaprozin ...................................... 7OXAYDO ...................................12oxazepam .................................... 17oxcarbazepine ............................. 27oxiconazole nitrate ......................82oxybutynin chloride ...................123oxybutynin chloride er .............. 123oxycodone hcl ............................. 12oxycodone-acetaminophen ..........12oxycodone-aspirin .......................12oxycodone-ibuprofen .................. 12oxymorphone hcl er .............. 12, 13OXYTROL FOR WOMEN ... 123OZEMPIC (0.25 OR 0.5 MG/DOSE) ................................ 35OZEMPIC (1 MG/DOSE) ........35PACERONE ..............................18paliperidone er ............................59pantoprazole sodium .................122paricalcitol ..................................89paromomycin sulfate .....................5paroxetine hcl ............................. 31paroxetine hcl er ......................... 31peg 3350/electrolytes ................ 100PEGANONE ..............................27PEGASYS ..................................63PEGASYS PROCLICK ........... 63PEGINTRON ............................ 63pen needles ................................101penicillin v potassium ............... 112pentamidine isethionate .............. 48PENTASA ..................................93pentazocine-naloxone hcl ........... 13pentetate calcium trisodium ........37pentetate zinc trisodium ..............37pentoxifylline er .......................... 95PERFOROMIST .......................21perindopril erbumine .................. 45permethrin ...................................82perphenazine ...............................59perphenazine-amitriptyline .......115phenazopyridine hcl ....................94phendimetrazine tartrate .............. 4phendimetrazine tartrate er .......... 4phenelzine sulfate ........................31phenobarbital ..............................99phenoxybenzamine hcl ................ 46phentermine hcl .............................4phenytoin .....................................27phenytoin sodium ........................ 27phenytoin sodium extended .........27

PHOSLYRA .............................. 94PHOSPHOLINE IODIDE ..... 109PHOSPHO-TRIN 250 NEUTRAL ...............................103physostigmine salicylate ............. 37phytonadione .............................126pilocarpine hcl .................. 104, 109pimecrolimus ...............................82pimozide ....................................115pindolol ....................................... 67pioglitazone hcl ...........................35pioglitazone hcl-glimepiride .......35pioglitazone hcl-metformin hcl ... 36piroxicam ...................................... 7podocon .......................................82podofilox ..................................... 82polyethylene glycol 3350 .......... 100poly-iron 150 forte ......................97polymyxin b-trimethoprim .........109POMALYST ..............................52pot bicarb-pot chloride ............. 103POTABA ..................................126potassium chloride ....................103potassium chloride crys er ........103potassium chloride er ............... 103potassium citrate er .................... 94potassium citrate-citric acid ....... 94PR BENZOYL PEROXIDE WASH ........................................ 82PRADAXA .................................24pramcort ..................................... 14pramipexole dihydrochloride ......55pramipexole dihydrochloride er . 55prasugrel hcl ...............................96pravastatin sodium ......................41prazosin hcl .................................46PRED MILD ............................109prednicarbate ..............................82prednisolone ............................... 75prednisolone acetate .................109prednisolone sodium phosphate.............................................75, 109prednisone ...................................75PREDNISONE INTENSOL .... 75pregabalin ...................................27PREMARIN .............................. 92PREMPHASE ........................... 92PREMPRO ................................ 92prenatal .....................................104PREPOPIK ..............................100PREVALITE ............................. 41PREZCOBIX .............................63

PREZISTA ................................ 63primaquine phosphate ................ 48primidone ....................................27PROAIR HFA ........................... 21PROAIR RESPICLICK ...........21probenecid .................................. 95prochlorperazine .........................59prochlorperazine edisylate ......... 59prochlorperazine maleate ...........59PROCRIT ............................97, 98PROCTOFOAM HC ................ 14PROCTOZONE-HC .................14progesterone micronized ...........113PROLIA .....................................89PROMACTA .............................98promethazine hcl .........................39promethazine vc/codeine .............75promethazine-codeine .................75promethazine-dm ........................ 76PROMETHEGAN .............. 39, 40propafenone hcl .......................... 18propafenone hcl er ......................18propantheline bromide ..............122proparacaine hcl .......................109propranolol hcl ........................... 67propranolol hcl er .......................67propranolol-hctz ......................... 46propylthiouracil ........................ 119protriptyline hcl .......................... 31PROVENTIL HFA ................... 21PULMICORT FLEXHALER ..21PULMOZYME ....................... 116pyrazinamide ...............................49pyridostigmine bromide .............. 49pyridostigmine bromide er ..........49pyridoxine hcl ........................... 126pyrogallic acid ............................ 82QNASL .....................................105quetiapine fumarate .................... 59quetiapine fumarate er ................59quinapril hcl ................................46quinapril-hydrochlorothiazide ....46quinidine gluconate er ................ 18quinidine sulfate ..........................18quinine sulfate .............................48QVAR REDIHALER ............... 21ra nasal allergy .........................105rabeprazole sodium .................. 122RADIOGARDASE ................... 37raloxifene hcl .............................. 89ramelteon .................................... 99ramipril ....................................... 46

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RANEXA ................................... 16ranitidine hcl .............................122RAPAMUNE ............................. 65rasagiline mesylate ..................... 55REBETOL ................................. 63RECTIV .....................................14reeses pinworm medicine ............15REGRANEX ............................. 82RELENZA DISKHALER ........ 63RELPAX ..................................102RENVELA .................................94repaglinide ..................................36REPLESTA CHILDRENS .... 126RESCRIPTOR .......................... 63RETACRIT ............................... 98REVLIMID ............................... 65REXULTI ............................ 59, 60REYATAZ .................................63RIBASPHERE .......................... 63ribasphere ribapak (1000 pack) . 63RIBASPHERE RIBAPAK (1200 PACK) ............................. 63RIBASPHERE RIBAPAK (800 PACK) ............................... 63ribavirin ...................................... 64RIDAURA ....................................7rifabutin ...................................... 49RIFAMATE ...............................49rifampin .......................................49RIFATER .................................. 49riluzole ...................................... 106rimantadine hcl ...........................64risedronate sodium ..................... 89risperidone ..................................60RISPERIDONE M-TAB .......... 60ritonavir ...................................... 64rivastigmine .............................. 115rivastigmine tartrate ................. 115rizatriptan benzoate .................. 102ropinirole hcl .............................. 56ropinirole hcl er ..........................56ROSADAN .................................82rosuvastatin calcium ...................41salicylic acid ......................... 82, 83salicylic acid wart remover .........83salrix ........................................... 83salsalate ........................................ 8SAMSCA ................................... 89SANDIMMUNE ........................65SANDOSTATIN LAR DEPOT .......................................89SANTYL .................................... 83

SAPHRIS ................................... 60SAVELLA ............................... 115selegiline hcl ............................... 56selenium sulfide .......................... 83SELZENTRY ............................ 64SENSIPAR .................................89SEREVENT DISKUS ...............21sertraline hcl ...............................31sevelamer carbonate ................... 94sevelamer hcl .............................. 94sf ................................................104sf 5000 plus ............................... 104SHINGRIX .............................. 125SIGNIFOR .................................90SIGNIFOR LAR ................. 89, 90sildenafil citrate .......................... 71silodosin ......................................94silver nitrate ................................83SIMBRINZA ........................... 109simple syrup .............................. 112simvastatin .................................. 41sirolimus ..................................... 65SIVEXTRO ............................... 48SKLICE ..................................... 83sm esomeprazole magnesium ....122sod citrate-citric acid ..................95sodium bicarbonate .................... 14sodium chloride .................. 76, 103sodium chloride (hypertonic) ....109sodium fluoride ......................... 103sodium polystyrene sulfonate.............................................66, 112sofosbuvir-velpatasvir .................98solifenacin succinate .................123SOMATULINE DEPOT .......... 90SOMAVERT ............................. 90sorbitol ........................................95sorbitol-mannitol ........................ 95sotalol hcl ..............................67, 68sotalol hcl (af) .............................67SPIRIVA HANDIHALER ....... 21SPIRIVA RESPIMAT ..............21spironolactone ............................ 86spironolactone-hctz .....................86SPRYCEL ..................................53SPS ..................................... 66, 112SSD ............................................. 83stavudine ..................................... 64STELARA ................................. 83sterile water for irrigation .......... 66STIMATE ..................................90STIVARGA ............................... 53

STRATTERA ..........................4, 5STRIBILD ................................. 64STRIVERDI RESPIMAT ........ 22sucralfate .................................. 122sulfacetamide sodium ..........83, 109sulfacetamide sodium (acne) ...... 83sulfacetamide sodium-sulfur .......83sulfacetamide-prednisolone ......109sulfadiazine ............................... 118sulfamethoxazole-trimethoprim .. 48SULFAMYLON ........................83sulfasalazine ............................... 94sulindac .....................................7, 8sumatriptan ............................... 102sumatriptan succinate ...............102SUPRAX .................................... 72SUPREP BOWEL PREP KIT...................................................100SUTENT .................................... 53SYLATRON .............................. 53SYMAX DUOTAB ..................122SYMAX-SR ............................. 122SYMLINPEN 120 ..................... 36SYMLINPEN 60 ....................... 36SYNAGIS .................................111SYNALAR (CREAM) .............. 83SYNALAR (OINTMENT) ....... 83SYNJARDY .............................117SYNJARDY XR ...................... 117SYNTHROID .......................... 119SYPRINE ...................................66TABLOID ..................................53TACLONEX ..............................83tacrolimus ............................. 66, 83tadalafil .......................................71TAFINLAR ............................... 53tamoxifen citrate ......................... 53tamsulosin hcl ............................. 95TARCEVA .................................53TARON-PREX ........................104TASIGNA .................................. 53TAYTULLA .............................. 74tazarotene ................................... 83TAZORAC ................................ 83TAZTIA XT ........................ 69, 70TECHLITE PEN NEEDLES .101TEKTURNA ..............................46TEKTURNA HCT .................... 46telmisartan .................................. 46telmisartan-hctz .......................... 46temazepam .................................. 99tenofovir disoproxil fumarate ..... 64

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terazosin hcl ..........................46, 47terbinafine hcl .............................39terbutaline sulfate ....................... 22terconazole ................................125testosterone ................................. 14testosterone cypionate ...........13, 14testosterone enanthate ................ 14tetrabenazine .............................115tetracycline hcl ..........................118THALOMID ..............................66THEOCHRON ..........................22theophylline .................................22theophylline er ............................ 22THERA-D 4000 .......................126thioridazine hcl ........................... 60thiothixene ...................................60thrivite 19 ..................................104THYROLAR-1 ........................120THYROLAR-1/2 .....................120THYROLAR-1/4 .....................120THYROLAR-2 ........................120THYROLAR-3 ........................120tiagabine hcl ......................... 27, 28timolol maleate ................... 68, 109tinidazole .....................................48TIVICAY ................................... 64tizanidine hcl .....................104, 105tl gard rx ..................................... 98TOBRADEX ............................109TOBRADEX ST ......................109tobramycin ............................ 5, 109tobramycin-dexamethasone ...... 109TOBREX ................................. 110tolazamide ...................................36tolbutamide ................................. 36tolcapone .....................................56tolmetin sodium .............................8tolterodine tartrate ....................124tolterodine tartrate er ....... 123, 124topiramate ...................................28toremifene citrate ........................53torsemide .....................................86TOUJEO SOLOSTAR ............. 36TOVIAZ ...................................124TRACLEER .............................. 71TRADJENTA ............................36tramadol hcl ................................13tramadol hcl er ........................... 13tramadol hcl er (biphasic) .......... 13tramadol-acetaminophen ............13trandolapril .................................47trandolapril-verapamil hcl er ..... 47

tranylcypromine sulfate .............. 31TRAVATAN Z ........................ 110trazodone hcl ...................... 31, 116TRELSTAR MIXJECT ........... 53TRESIBA FLEXTOUCH ........ 36tretinoin .................................53, 84tretinoin microsphere ..................84TREXALL ................................. 53triamcinolone acetonide.............................84, 104, 105, 118triamterene ..................................86triamterene-hctz ..........................86triazolam ..................................... 99trifluoperazine hcl .......................60trifluridine .................................110TRIGLIDE ................................ 41TRI-LEGEST FE ......................74TRI-LO-SPRINTEC .................74trimethobenzamide hcl ................38trimethoprim ............................... 48trimipramine maleate ..................32TRIUMEQ .................................64tropicamide ............................... 110trospium chloride ......................124trospium chloride er ................. 124TRULICITY ..............................36TRUVADA ................................ 64TUDORZA PRESSAIR ............22TYKERB ................................... 53TYVASO STARTER ................71ULESFIA ................................... 84ULORIC .................................... 95ULTILET INSULIN SYRINGE ................................ 101ULTILET INSULIN SYRINGE SHORT ......... 101, 102UMECTA MOUSSE .................84UNITHROID DIRECT .......... 120UPTRAVI ........................ 115, 116urea ............................................. 84urea nail ......................................84urea-c40 ......................................84ure-k ............................................84URETRON D/S ....................... 123URIMAR-T ..............................123urin ds ....................................... 123ursodiol ....................................... 94USTELL ...................................123valacyclovir hcl ...........................64valganciclovir hcl ....................... 64valproic acid ............................... 28valsartan ..................................... 47

valsartan-hydrochlorothiazide ... 47VALSTAR ................................. 53VANTAS ....................................54VASCEPA ................................. 41VECTICAL ............................... 84VELIVET .................................. 74VELPHORO ............................. 94VELTIN ..................................... 84venlafaxine hcl ............................ 32venlafaxine hcl er ........................32VENTAVIS ................................71VENTOLIN HFA ......................22verapamil hcl .............................. 70verapamil hcl er ..........................70VEREGEN .................................84VESICARE ..............................124VICODIN ...................................13VICODIN ES .............................13VICODIN HP ............................ 13VICTOZA ..................................36VIDEX ....................................... 64VIDEX EC .................................64vigabatrin ....................................28VIIBRYD ........................... 32, 116VIMPAT .................................... 28VIRACEPT ............................... 64VIRAMUNE ..............................64VIREAD .....................................64vitamin d ................................... 126vitamin d (cholecalciferol) ........126vitamin d (ergocalciferol) ......... 126vitamin d3 ................................. 126vitamins acd-fluoride ................ 104VIVITROL ................................ 37voriconazole ................................39VOTRIENT ............................... 54VYVANSE ................................... 5warfarin sodium ..........................24WESTHROID ......................... 120XALKORI ................................. 54XARELTO .................................24XARELTO STARTER PACK 24XELJANZ ....................................8XELJANZ XR .............................8XIFAXAN ..................................48XIGDUO XR ........................... 117XOLAIR .................................... 22XULANE ................................... 74XYREM ................................... 115zafirlukast ................................... 22zaleplon .......................................99ZARXIO .................................... 98

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ZEGERID OTC ...................... 122ZENPEP .....................................85ZEPATIER ................................98zidovudine ................................... 65zileuton er ................................... 22zinc sulfate ................................ 103ZIOPTAN ................................ 110ziprasidone hcl ............................60ZIRGAN .................................. 110ZOLADEX .................................54ZOLINZA ..................................54zolmitriptan ...............................102zolpidem tartrate .........................99zolpidem tartrate er .................... 99zonisamide .................................. 28ZONTIVITY ........................... 113ZORTRESS ............................... 66ZOSTAVAX ............................ 125ZOVIA 1/35E (28) .....................74ZYDELIG ................................112ZYFLO .......................................22ZYKADIA ................................. 54

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qualified health plan formulary...this formulary does not define benefit coverage and limitations....

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