rx formulary m1 drug list lwwa

052163_2021 Last Updated 11-30-2021

Metallic M1 - List of Covered Drugs (Formulary)

Effective 12-01-2021 The Metallic M1 Formulary is used by these plans

Balance HSA Qualified 1500 Gold

Balance HSA Qualified 3000 Silver

Balance HSA Qualified 6200 Bronze

Balance HSA Qualified 3000 Silver + Family Dental

Choice HSA Qualified 1500 Gold

Choice HSA Qualified 3000 Silver

Choice HSA Qualified 3000 Silver + Family Dental

Choice HSA Qualified 6200 Bronze

What is the list of covered drugs (Formulary) This document contains a list of generic brand and specialty drugs covered under your plan

How is the list of covered drugs developed The drug list is developed with an independent committee of physicians pharmacists and other healthcare providers called the Pharmacy and Therapeutics Committee This independent committee reviews and selects drugs for coverage based on each drugs safety effectiveness and cost The committee meets at least quarterly to review new drugs to market to determine placement on this list and also reviews updated safety effectiveness and cost information for existing drugs to ensure the formulary remains up to date with current medical evidence

How do I use the Formulary Drugs are listed by categories depending on the type of medical conditions that they are used to treat If you know what your drug is used for look for the category name in the list that begins below Then look under the category name for your drug

If you are not sure what category to look under you can also search for the drug in the Index The Index provides an alphabetical list of all of the drugs included in this document Next to the name of the drug in the Index you will see the page number where you can find coverage information Turn to the page listed in the Index and find the name of your drug in the first column of the list

ii

How does this drug list help me understand my drug coverage Drug coverage is based on your coverage contract Coverage for a specific drug is subject to the rules outlined in your member booklet This document will tell you if a drug is included on the formulary attached to your plan

Will this drug list (Formulary) change This drug list (Formulary) is updated throughout the year If you are taking a drug and it will be removed from the formulary or moved to a higher cost sharing tier we will notify you of this change via letter We also post information on upcoming formulary changes on our website on the ldquoUpcoming Formulary Changesrdquo page

Are there any restrictions on my coverage Some covered drugs may have additional requirements or limits on coverage These can be seen in the column next to the drug name on the list These requirements and limits may include

bull Prior Authorization some drugs require prior approval before they are coveredbull Quantity Limits for some drugs we limit the amount of the drug that we will cover For example

we will cover 18 per 30 day supply of zolmitriptan oral tabletsbull Step Therapy for some drugs we require that you first try certain drugs to treat your medical

condition before we will cover another drug for that condition For example if Drug A and Drug Bboth treat your medical condition we may not cover Drug B unless you try Drug A first If Drug Adoes not work for you then we will then cover Drug B

Drugs subject to these restrictions will generally mean that your physician or healthcare provider may need to provide additional information on your medical condition before the drug will be covered at the pharmacy Information on this process is on our website on the ldquoDrugs Requiring Approvalrdquo page

Metallic Formulary The first column of the chart lists the drug name Brand name drugs are capitalized (eg JANUVIA) and generic drugs are listed in lower-case italics (eg metformin oral tablet) The information in the RequirementsLimits column tells you if we have any special requirements for coverage of your drug

COVERAGE NOTES ABBREVIATIONS

ABBREVIATION DESCRIPTION EXPLANATION

Utilization Management Restrictions

PA Prior Authorization Restriction You (or your physician) are required to get prior authorization from us before you fill your prescription for this drug

iii


Without prior approval we may not cover this drug

QL Quantity Limit Restriction We limit the amount of this drug that is covered per prescription or within a specific time frame

ST Step Therapy Restriction Before we will provide coverage for this drug you must first try another drug to treat your medical condition This drug may only be covered if the other drug does not work for you

Other Special Requirements for Coverage

LA Limited Access Drug Some drugs under your plan may only be filled at an in-network specialty pharmacy These are drugs where the FDA has restricted distribution or are drugs that require special handling provider coordination or patient education that cannot be met by a network retail pharmacy

Vac Vaccines For more information on the coverage of vaccines administered at a Pharmacy please see your member booklet or contact Customer Service

OCh Oral Chemo Oral Chemotherapy Drug Certain oral chemotherapy drugs may be covered under your medical plan Please check your member booklet for more details

The amount you pay for a covered drug will depend on if you have met any applicable deductible for the plan year if you have met any applicable maximum out of pocket for the plan year and what tier the medication is on More information on applicable deductibles and maximum out of pockets can be found in your member booklet

Metallic M1 Formulary

Drug Tier Includes

iv

Formulary Drugs (1) Formulary Drugs include Preferred Generic Preferred Brand Non-Preferred and Specialty Drugs Medical plan cost shares apply to formulary drugs Once you have satisfied your medical deductible you will pay your applicable coinsurance until you reach your out of pocket maximum limit

ACA PV The ACA PV tier includes Affordable Care Act (ACA) Preventive medications The ACA makes certain preventive medications available to you at no cost Coverage of any medication as ACA PV (including over-the-counter (OTC) medications) requires a prescription from a licensed health care provider

MB (Medical Benefit) The MB tier includes medical benefit drugs normally administered in a clinic infusion center or provided by a home infusion service These drugs and their services are covered under the medical benefit not under the pharmacy benefit This drug may require prior authorization

1

Drug Name Drug Tier Requirements Limits

ANTI - INFECTIVES

ANTIFUNGAL AGENTS

AMBISOME INTRAVENOUS SUSPENSION FOR RECONSTITUTION 50 MG

MB

amphotericin b injection recon soln 50 mg MB

CANCIDAS INTRAVENOUS RECON SOLN 50 MG 70 MG

MB

clotrimazole mucous membrane troche 10 mg 1

CRESEMBA INTRAVENOUS RECON SOLN 372 MG

MB

CRESEMBA ORAL CAPSULE 186 MG 1 PA

ERAXIS(WATER DILUENT) INTRAVENOUS RECON SOLN 100 MG 50 MG

MB

fluconazole oral suspension for reconstitution 10 mgml 40 mgml

1

fluconazole oral tablet 100 mg 150 mg 200 mg 50 mg

1

flucytosine oral capsule 250 mg 500 mg 1

griseofulvin microsize oral suspension 125 mg5 ml

1

griseofulvin microsize oral tablet 500 mg 1

griseofulvin ultramicrosize oral tablet 125 mg 250 mg

1

itraconazole oral capsule 100 mg 1

itraconazole oral solution 10 mgml 1

ketoconazole oral tablet 200 mg 1

MYCAMINE INTRAVENOUS RECON SOLN 100 MG 50 MG

MB

NOXAFIL ORAL SUSPENSION 200 MG5 ML (40 MGML)

1

nystatin oral suspension 100000 unitml 1

nystatin oral tablet 500000 unit 1

ORAVIG BUCCAL MUCO-ADHESIVE BUCCAL TABLET 50 MG

1

posaconazole oral tabletdelayed release (drec) 100 mg

1

terbinafine hcl oral tablet 250 mg 1

voriconazole intravenous recon soln 200 mg MB

2


voriconazole oral suspension for reconstitution 200 mg5 ml (40 mgml)

1

voriconazole oral tablet 200 mg 50 mg 1

ANTIVIRALS

abacavir oral solution 20 mgml 1 QL (60 per 30 days)

abacavir oral tablet 300 mg 1 QL (60 per 30 days)

abacavir-lamivudine oral tablet 600-300 mg 1 QL (30 per 30 days)

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

1 QL (60 per 30 days)

acyclovir oral capsule 200 mg 1

acyclovir oral suspension 200 mg5 ml 1

acyclovir oral tablet 400 mg 800 mg 1

adefovir oral tablet 10 mg 1

amantadine hcl oral capsule 100 mg 1

amantadine hcl oral solution 50 mg5 ml 1

amantadine hcl oral tablet 100 mg 1

APTIVUS ORAL CAPSULE 250 MG 1 QL (120 per 30 days)

atazanavir oral capsule 150 mg 300 mg 1 QL (30 per 30 days)

atazanavir oral capsule 200 mg 1 QL (60 per 30 days)

BARACLUDE ORAL SOLUTION 005 MGML 1

BIKTARVY ORAL TABLET 50-200-25 MG 1 QL (30 per 30 days)

CABENUVA INTRAMUSCULAR SUSPENSIONEXTENDED RELEASE 400 MG2 ML- 600 MG2 ML 600 MG3 ML- 900 MG3 ML

1 PA

cidofovir intravenous solution 75 mgml MB

CIMDUO ORAL TABLET 300-300 MG 1 QL (30 per 30 days)

COMPLERA ORAL TABLET 200-25-300 MG 1 QL (30 per 30 days)

CYTOVENE INTRAVENOUS RECON SOLN 500 MG

MB

DESCOVY ORAL TABLET 200-25 MG 1 QL (30 per 30 days)

didanosine oral capsuledelayed release(drec) 250 mg 400 mg


DOVATO ORAL TABLET 50-300 MG 1 QL (30 per 30 days)

EDURANT ORAL TABLET 25 MG 1 QL (30 per 30 days)

efavirenz oral capsule 200 mg 50 mg 1 QL (30 per 30 days)

efavirenz oral tablet 600 mg 1 QL (30 per 30 days)

3


efavirenz-emtricitabin-tenofov oral tablet 600-200-300 mg

1

efavirenz-lamivu-tenofov disop oral tablet 400-300-300 mg 600-300-300 mg

1

emtricitabine oral capsule 200 mg 1 QL (30 per 30 days)

emtricitabine-tenofovir (tdf) oral tablet 100-150 mg 133-200 mg 167-250 mg 200-300 mg

1

EMTRIVA ORAL SOLUTION 10 MGML 1 QL (720 per 30 days)

entecavir oral tablet 05 mg 1 mg 1

EPCLUSA ORAL TABLET 200-50 MG 400-100 MG

1 PA LA

EPIVIR HBV ORAL SOLUTION 25 MG5 ML (5 MGML)

1

etravirine oral tablet 100 mg 200 mg 1 QL (60 per 30 days)

EVOTAZ ORAL TABLET 300-150 MG 1 QL (30 per 30 days)

famciclovir oral tablet 125 mg 250 mg 500 mg 1

fosamprenavir oral tablet 700 mg 1 QL (60 per 30 days)

FUZEON SUBCUTANEOUS RECON SOLN 90 MG


GANCICLOVIR INTRAVENOUS SOLUTION 500 MG250 ML (2 MGML)

MB

ganciclovir sodium intravenous recon soln 500 mg MB

GENVOYA ORAL TABLET 150-150-200-10 MG


HARVONI ORAL PELLETS IN PACKET 3375-150 MG 45-200 MG

1 LA

HARVONI ORAL TABLET 45-200 MG 90-400 MG

1 PA LA

INTELENCE ORAL TABLET 100 MG 200 MG 25 MG


INVIRASE ORAL TABLET 500 MG 1 QL (120 per 30 days)

ISENTRESS HD ORAL TABLET 600 MG 1 QL (60 per 30 days)

ISENTRESS ORAL POWDER IN PACKET 100 MG


ISENTRESS ORAL TABLET 400 MG 1 QL (60 per 30 days)

ISENTRESS ORAL TABLETCHEWABLE 100 MG 25 MG


JULUCA ORAL TABLET 50-25 MG 1 QL (30 per 30 days)

KALETRA ORAL TABLET 100-25 MG 1 QL (60 per 30 days)

4



lamivudine oral solution 10 mgml 1 QL (900 per 30 days)

lamivudine oral tablet 100 mg 1

lamivudine oral tablet 150 mg 300 mg 1 QL (60 per 30 days)

lamivudine-zidovudine oral tablet 150-300 mg 1 QL (60 per 30 days)

LEXIVA ORAL SUSPENSION 50 MGML 1 QL (60 per 30 days)

lopinavir-ritonavir oral solution 400-100 mg5 ml 1 QL (320 per 30 days)

lopinavir-ritonavir oral tablet 100-25 mg 200-50 mg


MAVYRET ORAL TABLET 100-40 MG 1 PA LA

nevirapine oral suspension 50 mg5 ml 1 QL (60 per 30 days)

nevirapine oral tablet 200 mg 1 QL (60 per 30 days)

nevirapine oral tablet extended release 24 hr 100 mg 400 mg


NORVIR ORAL POWDER IN PACKET 100 MG 1 QL (360 per 30 days)

NORVIR ORAL SOLUTION 80 MGML 1 QL (480 per 30 days)

ODEFSEY ORAL TABLET 200-25-25 MG 1 QL (30 per 30 days)

oseltamivir oral capsule 30 mg 1 QL (40 per 365 days)

oseltamivir oral capsule 45 mg 75 mg 1 QL (20 per 365 days)

oseltamivir oral suspension for reconstitution 6 mgml


PREVYMIS INTRAVENOUS SOLUTION 240 MG12 ML 480 MG24 ML

MB PA

PREZCOBIX ORAL TABLET 800-150 MG-MG 1 QL (30 per 30 days)

PREZISTA ORAL SUSPENSION 100 MGML 1 QL (30 per 30 days)

PREZISTA ORAL TABLET 150 MG 600 MG 75 MG


PREZISTA ORAL TABLET 800 MG 1 QL (30 per 30 days)

RAPIVAB (PF) INTRAVENOUS SOLUTION 200 MG20 ML (10 MGML)

MB

RELENZA DISKHALER INHALATION BLISTER WITH DEVICE 5 MGACTUATION


REYATAZ ORAL POWDER IN PACKET 50 MG


ribavirin inhalation recon soln 6 gram MB

rimantadine oral tablet 100 mg 1

ritonavir oral tablet 100 mg 1 QL (360 per 30 days)

5


SELZENTRY ORAL SOLUTION 20 MGML 1 QL (8 per 30 days)

SELZENTRY ORAL TABLET 150 MG 25 MG 300 MG 75 MG


SOVALDI ORAL PELLETS IN PACKET 150 MG 200 MG

1 LA

SOVALDI ORAL TABLET 200 MG 400 MG 1 PA LA

stavudine oral capsule 15 mg 20 mg 40 mg 1 QL (120 per 30 days)

STRIBILD ORAL TABLET 150-150-200-300 MG


SYNAGIS INTRAMUSCULAR SOLUTION 100 MGML 50 MG05 ML

MB LA

tenofovir disoproxil fumarate oral tablet 300 mg 1 QL (30 per 30 days)

TIVICAY ORAL TABLET 10 MG 25 MG 50 MG


TIVICAY PD ORAL TABLET FOR SUSPENSION 5 MG


TRIUMEQ ORAL TABLET 600-50-300 MG 1 QL (30 per 30 days)

TROGARZO INTRAVENOUS SOLUTION 200 MG133 ML (150 MGML)

MB PA

TYBOST ORAL TABLET 150 MG 1 QL (30 per 30 days)

valacyclovir oral tablet 1 gram 500 mg 1

valganciclovir oral recon soln 50 mgml 1

valganciclovir oral tablet 450 mg 1

VEMLIDY ORAL TABLET 25 MG 1

VIEKIRA PAK ORAL TABLETSDOSE PACK 125 MG-75 MG -50 MG250 MG

1 PA

VIRACEPT ORAL TABLET 250 MG 1 QL (90 per 30 days)


VIREAD ORAL POWDER 40 MGSCOOP (40 MGGRAM)


VIREAD ORAL TABLET 150 MG 200 MG 250 MG


VOSEVI ORAL TABLET 400-100-100 MG 1 PA LA

ZEPATIER ORAL TABLET 50-100 MG 1 PA LA

zidovudine oral capsule 100 mg 1 QL (60 per 30 days)

zidovudine oral syrup 10 mgml 1 QL (960 per 30 days)

zidovudine oral tablet 300 mg 1 QL (60 per 30 days)

CEPHALOSPORINS

6


AVYCAZ INTRAVENOUS RECON SOLN 25 GRAM

MB

cefaclor oral capsule 250 mg 500 mg 1

cefaclor oral suspension for reconstitution 125 mg5 ml 250 mg5 ml 375 mg5 ml

1

cefaclor oral tablet extended release 12 hr 500 mg 1

cefadroxil oral capsule 500 mg 1

cefadroxil oral suspension for reconstitution 250 mg5 ml 500 mg5 ml

1

cefadroxil oral tablet 1 gram 1

cefazolin in dextrose (iso-os) intravenous piggyback 1 gram50 ml

MB

cefazolin injection recon soln 1 gram 10 gram 100 gram 20 gram 300 g 500 mg

MB

cefazolin intravenous recon soln 1 gram MB

cefdinir oral capsule 300 mg 1

cefdinir oral suspension for reconstitution 125 mg5 ml 250 mg5 ml

1

cefditoren pivoxil oral tablet 200 mg 400 mg 1

CEFEPIME IN DEXTROSE 5 INTRAVENOUS PIGGYBACK 1 GRAM50 ML 2 GRAM50 ML

MB

cefepime in dextroseiso-osm intravenous piggyback 1 gram50 ml 2 gram100 ml

MB

cefepime injection recon soln 1 gram 2 gram MB

cefixime oral capsule 400 mg 1

cefixime oral suspension for reconstitution 100 mg5 ml 200 mg5 ml

1

CEFOTAN INJECTION RECON SOLN 1 GRAM 2 GRAM

MB

cefotaxime injection recon soln 1 gram MB

CEFOTETAN IN DEXTROSE ISO-OSM INTRAVENOUS PIGGYBACK 1 GRAM50 ML 2 GRAM50 ML

MB

cefotetan injection recon soln 1 gram 2 gram MB

cefotetan intravenous recon soln 10 gram MB

cefoxitin intravenous recon soln 10 gram MB

cefpodoxime oral suspension for reconstitution 100 mg5 ml 50 mg5 ml

1

7


cefpodoxime oral tablet 100 mg 200 mg 1

cefprozil oral suspension for reconstitution 125 mg5 ml 250 mg5 ml

1

cefprozil oral tablet 250 mg 500 mg 1

CEFTAZIDIME IN D5W INTRAVENOUS PIGGYBACK 1 GRAM50 ML 2 GRAM50 ML

MB

ceftazidime injection recon soln 1 gram 2 gram 6 gram

MB

ceftriaxone in dextroseiso-os intravenous piggyback 1 gram50 ml 2 gram50 ml

MB

ceftriaxone injection recon soln 1 gram 10 gram 2 gram 250 mg 500 mg

MB

CEFTRIAXONE INJECTION RECON SOLN 100 GRAM

MB

ceftriaxone intravenous recon soln 1 gram 2 gram MB

cefuroxime axetil oral tablet 250 mg 500 mg 1

cephalexin oral capsule 250 mg 500 mg 750 mg 1

cephalexin oral suspension for reconstitution 125 mg5 ml 250 mg5 ml

1

cephalexin oral tablet 250 mg 500 mg 1

SUPRAX ORAL SUSPENSION FOR RECONSTITUTION 500 MG5 ML

1

SUPRAX ORAL TABLETCHEWABLE 100 MG 200 MG

1

tazicef injection recon soln 1 gram 2 gram 6 gram

MB

tazicef intravenous recon soln 1 gram 2 gram MB

TEFLARO INTRAVENOUS RECON SOLN 400 MG 600 MG

MB

ZERBAXA INTRAVENOUS RECON SOLN 15 GRAM

MB

ERYTHROMYCINS amp OTHER MACROLIDES

azithromycin oral packet 1 gram 1

azithromycin oral suspension for reconstitution 100 mg5 ml 200 mg5 ml

1

azithromycin oral tablet 250 mg 500 mg 600 mg 1

clarithromycin oral suspension for reconstitution 125 mg5 ml 250 mg5 ml

1

clarithromycin oral tablet 250 mg 500 mg 1

8


clarithromycin oral tablet extended release 24 hr 500 mg

1

DIFICID ORAL TABLET 200 MG 1

ees 400 oral tablet 400 mg 1

ery-tab oral tabletdelayed release (drec) 250 mg 333 mg

1

erythrocin (as stearate) oral tablet 250 mg 1

erythromycin ethylsuccinate oral suspension for reconstitution 200 mg5 ml 400 mg5 ml

1

erythromycin ethylsuccinate oral tablet 400 mg 1

erythromycin oral capsuledelayed release(drec) 250 mg

1

erythromycin oral tablet 250 mg 500 mg 1

erythromycin oral tabletdelayed release (drec) 250 mg 333 mg 500 mg

1

MISCELLANEOUS ANTIINFECTIVES

albendazole oral tablet 200 mg 1

ALINIA ORAL SUSPENSION FOR RECONSTITUTION 100 MG5 ML

1 PA ST

amikacin injection solution 500 mg2 ml MB

atovaquone oral suspension 750 mg5 ml 1

atovaquone-proguanil oral tablet 250-100 mg 625-25 mg

1

bacitracin intramuscular recon soln 50000 unit 1

CAYSTON INHALATION SOLUTION FOR NEBULIZATION 75 MGML

1 PA LA QL (84 per 30 days)

chloramphenicol sod succinate intravenous recon soln 1 gram

MB

chloroquine phosphate oral tablet 250 mg 500 mg 1

clindamycin hcl oral capsule 150 mg 300 mg 75 mg

1

clindamycin pediatric oral recon soln 75 mg5 ml 1

clindamycin phosphate injection solution 150 mgml

MB

COARTEM ORAL TABLET 20-120 MG 1

CUBICIN INTRAVENOUS RECON SOLN 500 MG

MB

CUBICIN RF INTRAVENOUS RECON SOLN 500 MG

MB

9


CYCLOSERINE ORAL CAPSULE 250 MG 1

dapsone oral tablet 100 mg 25 mg 1

EMVERM ORAL TABLETCHEWABLE 100 MG

1

ethambutol oral tablet 100 mg 400 mg 1

gentamicin injection solution 20 mg2 ml 40 mgml

MB

gentamicin sulfate (ped) (pf) injection solution 20 mg2 ml

MB

hydroxychloroquine oral tablet 200 mg 1

imipenem-cilastatin intravenous recon soln 250 mg 500 mg

MB

INVANZ INJECTION RECON SOLN 1 GRAM MB

isoniazid injection solution 100 mgml 1

isoniazid oral solution 50 mg5 ml 1

isoniazid oral tablet 100 mg 300 mg 1

ivermectin oral tablet 3 mg 1

LINCOCIN INJECTION SOLUTION 300 MGML

MB

linezolid in dextrose 5 intravenous piggyback 600 mg300 ml

MB

linezolid oral suspension for reconstitution 100 mg5 ml

1

linezolid oral tablet 600 mg 1

linezolid-09 sodium chloride intravenous parenteral solution 600 mg300 ml

MB

mefloquine oral tablet 250 mg 1

meropenem intravenous recon soln 1 gram 500 mg

MB

MEROPENEM-09 SODIUM CHLORIDE INTRAVENOUS PIGGYBACK 1 GRAM50 ML 500 MG50 ML

MB

metronidazole oral capsule 375 mg 1

metronidazole oral tablet 250 mg 500 mg 1

neomycin oral tablet 500 mg 1

nitazoxanide oral tablet 500 mg 1

paromomycin oral capsule 250 mg 1

10


PASER ORAL GRANULES DR FOR SUSP IN PACKET 4 GRAM

1

PENTAM INJECTION RECON SOLN 300 MG MB

pentamidine inhalation recon soln 300 mg 1

pentamidine injection recon soln 300 mg MB

polymyxin b sulfate injection recon soln 500000 unit

MB

praziquantel oral tablet 600 mg 1

PRIFTIN ORAL TABLET 150 MG 1

primaquine oral tablet 263 mg 1

pyrazinamide oral tablet 500 mg 1

pyrimethamine oral tablet 25 mg 1 PA

quinine sulfate oral capsule 324 mg 1

rifabutin oral capsule 150 mg 1

rifampin oral capsule 150 mg 300 mg 1

SIRTURO ORAL TABLET 100 MG 1 PA

SIRTURO ORAL TABLET 20 MG 1

SIVEXTRO ORAL TABLET 200 MG 1 PA QL (6 per 30 days)

STREPTOMYCIN INTRAMUSCULAR RECON SOLN 1 GRAM

1

tinidazole oral tablet 250 mg 500 mg 1

tobramycin in 0225 nacl inhalation solution for nebulization 300 mg5 ml

1

tobramycin inhalation solution for nebulization 300 mg4 ml

1

tobramycin sulfate injection recon soln 12 gram 1

tobramycin sulfate injection solution 10 mgml MB

tobramycin sulfate injection solution 40 mgml 1

TOBRAMYCIN WITH NEBULIZER INHALATION SOLUTION FOR NEBULIZATION 300 MG5 ML

1 PA ST

TRECATOR ORAL TABLET 250 MG 1

TYGACIL INTRAVENOUS RECON SOLN 50 MG

MB

XENLETA INTRAVENOUS SOLUTION 150 MG15 ML

MB

XIFAXAN ORAL TABLET 200 MG 550 MG 1 PA QL (60 per 30 days)

11


PENICILLINS

amoxicillin oral capsule 250 mg 500 mg 1

amoxicillin oral suspension for reconstitution 125 mg5 ml 200 mg5 ml 250 mg5 ml 400 mg5 ml

1

amoxicillin oral tablet 500 mg 875 mg 1

amoxicillin oral tabletchewable 125 mg 250 mg 1

amoxicillin-pot clavulanate oral suspension for reconstitution 200-285 mg5 ml 250-625 mg5 ml 400-57 mg5 ml 600-429 mg5 ml

1

amoxicillin-pot clavulanate oral tablet 250-125 mg 500-125 mg 875-125 mg

1

amoxicillin-pot clavulanate oral tablet extended release 12 hr 1000-625 mg

1

amoxicillin-pot clavulanate oral tabletchewable 200-285 mg 400-57 mg

1

ampicillin oral capsule 500 mg 1

ampicillin-sulbactam injection recon soln 15 gram MB

BICILLIN C-R INTRAMUSCULAR SYRINGE 1200000 UNIT 2 ML(900K300K)

MB

dicloxacillin oral capsule 250 mg 500 mg 1

MOXATAG ORAL TABLET ER MULTIPHASE 24 HR 775 MG

1

nafcillin in dextrose iso-osm intravenous piggyback 1 gram50 ml 2 gram100 ml

MB

nafcillin injection recon soln 1 gram 10 gram 2 gram

MB

nafcillin intravenous recon soln 1 gram 2 gram MB

oxacillin in dextrose(iso-osm) intravenous piggyback 1 gram50 ml 2 gram50 ml

MB

oxacillin injection recon soln 1 gram 10 gram 2 gram

MB

penicillin g procaine intramuscular syringe 12 million unit2 ml 600000 unitml

MB

penicillin v potassium oral recon soln 125 mg5 ml 250 mg5 ml

1

penicillin v potassium oral tablet 250 mg 500 mg 1

piperacillin-tazobactam intravenous recon soln 135 gram 225 gram 3375 gram 45 gram 405 gram

MB

12


QUINOLONES

BAXDELA INTRAVENOUS RECON SOLN 300 MG

MB

BAXDELA ORAL TABLET 450 MG 1

ciprofloxacin hcl oral tablet 100 mg 250 mg 500 mg 750 mg

1

ciprofloxacin oral suspensionmicrocapsule recon 250 mg5 ml 500 mg5 ml

1

FACTIVE ORAL TABLET 320 MG 1 ST QL (210 per 30 days)

levofloxacin oral solution 250 mg10 ml 1

levofloxacin oral tablet 250 mg 500 mg 750 mg 1

moxifloxacin oral tablet 400 mg 1

ofloxacin oral tablet 300 mg 400 mg 1

SULFAS amp RELATED AGENTS

sulfadiazine oral tablet 500 mg 1

sulfamethoxazole-trimethoprim oral suspension 200-40 mg5 ml

1

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

1

sulfatrim oral suspension 200-40 mg5 ml 1

TETRACYCLINES

avidoxy oral tablet 100 mg 1 ST

demeclocycline oral tablet 150 mg 300 mg 1

doxycycline hyclate oral capsule 100 mg 50 mg 1

doxycycline hyclate oral tablet 100 mg 150 mg 20 mg 50 mg 75 mg

1

doxycycline hyclate oral tabletdelayed release (drec) 100 mg 150 mg 200 mg 50 mg 75 mg

1

doxycycline monohydrate oral capsule 100 mg 150 mg 50 mg 75 mg

1

doxycycline monohydrate oral suspension for reconstitution 25 mg5 ml

1

doxycycline monohydrate oral tablet 100 mg 150 mg 50 mg 75 mg

1

minocycline oral capsule 100 mg 50 mg 75 mg 1

minocycline oral tablet 100 mg 50 mg 75 mg 1

mondoxyne nl oral capsule 100 mg 75 mg 1

tetracycline oral capsule 250 mg 500 mg 1

13


URINARY TRACT AGENTS

fosfomycin tromethamine oral packet 3 gram 1

methenamine hippurate oral tablet 1 gram 1

methenamine mandelate oral tablet 05 g 1 gram 1

nitrofurantoin macrocrystal oral capsule 100 mg 25 mg 50 mg

1

nitrofurantoin monohydm-cryst oral capsule 100 mg

1

nitrofurantoin oral suspension 25 mg5 ml 1

PRIMSOL ORAL SOLUTION 50 MG5 ML 1

trimethoprim oral tablet 100 mg 1

VANCOMYCIN

vancomycin oral capsule 125 mg 250 mg 1

vancomycin oral recon soln 50 mgml 1

VIBATIV INTRAVENOUS RECON SOLN 750 MG

MB

ANTINEOPLASTIC amp IMMUNOSUPPRESSANT DRUGS

ADJUNCTIVE AGENTS

KEPIVANCE INTRAVENOUS RECON SOLN 625 MG

MB

leucovorin calcium injection recon soln 100 mg 200 mg 350 mg 50 mg 500 mg

MB

leucovorin calcium injection solution 10 mgml MB

leucovorin calcium oral tablet 10 mg 15 mg 25 mg 5 mg

1

VISTOGARD ORAL GRANULES IN PACKET 10 GRAM

1

VORAXAZE INTRAVENOUS RECON SOLN 1000 UNIT

MB

XGEVA SUBCUTANEOUS SOLUTION 120 MG17 ML (70 MGML)

1 LA


abiraterone oral tablet 250 mg 1 PA OCh LA

abiraterone oral tablet 500 mg 1 PA ST OCh LA

ABRAXANE INTRAVENOUS SUSPENSION FOR RECONSTITUTION 100 MG

MB PA LA

ADAKVEO INTRAVENOUS SOLUTION 10 MGML

MB PA

14


ADCETRIS INTRAVENOUS RECON SOLN 50 MG

MB PA LA

AFINITOR ORAL TABLET 10 MG 1 OCh LA

ALECENSA ORAL CAPSULE 150 MG 1 PA OCh LA QL (240 per 30 days)

ALIMTA INTRAVENOUS RECON SOLN 100 MG 500 MG

MB PA

ALIQOPA INTRAVENOUS RECON SOLN 60 MG

MB PA

anastrozole oral tablet 1 mg ACA PV OCh QL (30 per 30 days)

ARRANON INTRAVENOUS SOLUTION 250 MG50 ML

MB PA LA

ARZERRA INTRAVENOUS SOLUTION 1000 MG50 ML 100 MG5 ML

MB PA LA

ASPARLAS INTRAVENOUS SOLUTION 750 UNITML

MB PA

AVASTIN INTRAVENOUS SOLUTION 25 MGML

MB PA LA

azathioprine oral tablet 50 mg 1

BALVERSA ORAL TABLET 3 MG 4 MG 5 MG

1 PA OCh

BAVENCIO INTRAVENOUS SOLUTION 20 MGML

MB PA

BELEODAQ INTRAVENOUS RECON SOLN 500 MG

MB PA

BELRAPZO INTRAVENOUS SOLUTION 25 MGML

MB PA LA

BENDAMUSTINE INTRAVENOUS SOLUTION 25 MGML

MB PA LA

BENDEKA INTRAVENOUS SOLUTION 25 MGML

MB PA LA

BESPONSA INTRAVENOUS RECON SOLN 09 MG (025 MGML INITIAL)

MB PA LA

bexarotene oral capsule 75 mg 1 PA ST OCh

bicalutamide oral tablet 50 mg 1 OCh QL (30 per 30 days)

BLINCYTO INTRAVENOUS KIT 35 MCG MB PA

BORTEZOMIB INTRAVENOUS RECON SOLN 35 MG

MB

BOSULIF ORAL TABLET 100 MG 400 MG 500 MG

1 PA ST OCh LA

BRAFTOVI ORAL CAPSULE 50 MG 75 MG 1 PA OCh LA

15


BUSULFEX INTRAVENOUS SOLUTION 60 MG10 ML

MB

CABOMETYX ORAL TABLET 20 MG 40 MG 60 MG

1 PA ST OCh LA

CALQUENCE ORAL CAPSULE 100 MG 1 PA ST OCh

capecitabine oral tablet 150 mg 1 OCh LA QL (210 per 30 days)


CAPRELSA ORAL TABLET 100 MG 300 MG 1 PA OCh

CLOLAR INTRAVENOUS SOLUTION 20 MG20 ML

MB PA

COMETRIQ ORAL CAPSULE 100 MGDAY(80 MG X1-20 MG X1) 140 MGDAY(80 MG X1-20 MG X3) 60 MGDAY (20 MG X 3DAY)

1 PA OCh

COPIKTRA ORAL CAPSULE 15 MG 25 MG 1 PA OCh

COTELLIC ORAL TABLET 20 MG 1 PA OCh LA

cyclophosphamide intravenous recon soln 1 gram 2 gram 500 mg

MB

cyclophosphamide oral capsule 25 mg 50 mg 1 OCh

CYCLOPHOSPHAMIDE ORAL TABLET 25 MG 50 MG

1 OCh

cyclosporine modified oral capsule 100 mg 25 mg 50 mg

1

cyclosporine modified oral solution 100 mgml 1

cyclosporine oral capsule 100 mg 25 mg 1

CYRAMZA INTRAVENOUS SOLUTION 10 MGML

MB PA LA

DACOGEN INTRAVENOUS RECON SOLN 50 MG

MB PA LA

DARZALEX INTRAVENOUS SOLUTION 20 MGML

MB PA LA

DAURISMO ORAL TABLET 100 MG 25 MG 1 PA OCh LA

decitabine intravenous recon soln 50 mg MB LA

ELIGARD (3 MONTH) SUBCUTANEOUS SYRINGE 225 MG

1 PA


1 PA


1 PA

16


ELIGARD SUBCUTANEOUS SYRINGE 75 MG (1 MONTH)

1 PA

ELZONRIS INTRAVENOUS SOLUTION 1000 MCGML

MB PA

EMCYT ORAL CAPSULE 140 MG 1 OCh

EMPLICITI INTRAVENOUS RECON SOLN 300 MG 400 MG

MB PA LA

ENHERTU INTRAVENOUS RECON SOLN 100 MG

MB PA LA

ERBITUX INTRAVENOUS SOLUTION 100 MG50 ML 200 MG100 ML

MB PA LA

ERLEADA ORAL TABLET 60 MG 1 PA OCh LA

erlotinib oral tablet 100 mg 150 mg 25 mg 1 PA OCh LA

etoposide intravenous solution 20 mgml MB

etoposide oral capsule 50 mg 1 OCh

everolimus (antineoplastic) oral tablet 10 mg 1 PA OCh LA QL (30 per 30 days)

everolimus (antineoplastic) oral tablet 25 mg 5 mg 75 mg

1 PA ST OCh LA

everolimus (antineoplastic) oral tablet for suspension 2 mg

1 PA OCh LA QL (150 per 30 days)





everolimus (immunosuppressive) oral tablet 025 mg 05 mg 075 mg

1 PA

exemestane oral tablet 25 mg ACA PV OCh QL (30 per 30 days)

FASLODEX INTRAMUSCULAR SYRINGE 250 MG5 ML

MB PA

FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 120 MG 80 MG

1 PA LA

fludarabine intravenous recon soln 50 mg MB

fluorouracil intravenous solution 25 gram50 ml 5 gram100 ml 500 mg10 ml

MB PA

flutamide oral capsule 125 mg 1 OCh QL (180 per 30 days)

FOLOTYN INTRAVENOUS SOLUTION 20 MGML (1 ML) 40 MG2 ML (20 MGML)

MB PA LA

fulvestrant intramuscular syringe 250 mg5 ml MB

17


GAMIFANT INTRAVENOUS SOLUTION 5 MGML

MB PA

GAZYVA INTRAVENOUS SOLUTION 1000 MG40 ML

MB PA LA

gemcitabine intravenous recon soln 1 gram 2 gram 200 mg

MB

gemcitabine intravenous solution 2 gram526 ml (38 mgml) 200 mg526 ml (38 mgml)

MB

gengraf oral capsule 100 mg 25 mg 1

gengraf oral solution 100 mgml 1

GILOTRIF ORAL TABLET 20 MG 30 MG 40 MG

1 PA OCh LA

GLEOSTINE ORAL CAPSULE 10 MG 100 MG 40 MG

1 PA OCh

HALAVEN INTRAVENOUS SOLUTION 1 MG2 ML (05 MGML)

MB PA LA

HERCEPTIN HYLECTA SUBCUTANEOUS SOLUTION 600 MG-10000 UNIT5 ML

MB LA

HERCEPTIN INTRAVENOUS RECON SOLN 150 MG

MB PA LA

HERZUMA INTRAVENOUS RECON SOLN 150 MG

MB PA LA

HYCAMTIN ORAL CAPSULE 025 MG 1 MG 1 OCh LA

hydroxyurea oral capsule 500 mg 1 OCh

IBRANCE ORAL CAPSULE 100 MG 125 MG 75 MG

1 PA OCh LA

IBRANCE ORAL TABLET 100 MG 125 MG 75 MG

1 OCh LA

ICLUSIG ORAL TABLET 10 MG 15 MG 30 MG 45 MG

1 PA ST OCh

IDHIFA ORAL TABLET 100 MG 50 MG 1 PA OCh LA

imatinib oral tablet 100 mg 1 OCh LA QL (90 per 30 days)


IMBRUVICA ORAL CAPSULE 140 MG 70 MG 1 PA ST OCh

IMBRUVICA ORAL TABLET 140 MG 280 MG 420 MG 560 MG

1 PA ST OCh

IMFINZI INTRAVENOUS SOLUTION 50 MGML

MB PA LA

18


IMLYGIC INJECTION SUSPENSION 10EXP6 (1 MILLION) PFUML 10EXP8 (100 MILLION) PFUML

MB

INFUGEM INTRAVENOUS PIGGYBACK 1200 MG120 ML (10 MGML) 1300 MG130 ML (10 MGML) 1400 MG140 ML (10 MGML) 1500 MG150 ML (10 MGML) 1600 MG160 ML (10 MGML) 1700 MG170 ML (10 MGML) 1800 MG180 ML (10 MGML) 1900 MG190 ML (10 MGML) 2000 MG200 ML (10 MGML) 2200 MG220 ML (10 MGML)

MB

INLYTA ORAL TABLET 1 MG 5 MG 1 PA OCh LA

IRESSA ORAL TABLET 250 MG 1 PA OCh LA

ISTODAX INTRAVENOUS RECON SOLN 10 MG2 ML

MB PA LA

IXEMPRA INTRAVENOUS RECON SOLN 15 MG 45 MG

MB PA LA

JAKAFI ORAL TABLET 10 MG 15 MG 20 MG 25 MG 5 MG

1 PA OCh LA

JEVTANA INTRAVENOUS SOLUTION 10 MGML (FIRST DILUTION)

MB PA LA

KADCYLA INTRAVENOUS RECON SOLN 100 MG 160 MG

MB PA LA

KANJINTI INTRAVENOUS RECON SOLN 150 MG 420 MG

MB PA LA

KEYTRUDA INTRAVENOUS SOLUTION 25 MGML

MB PA

KISQALI FEMARA CO-PACK ORAL TABLET 200 MGDAY(200 MG X 1)-25 MG 400 MGDAY(200 MG X 2)-25 MG 600 MGDAY(200 MG X 3)-25 MG

1 PA ST OCh LA

KISQALI ORAL TABLET 200 MGDAY (200 MG X 1) 400 MGDAY (200 MG X 2) 600 MGDAY (200 MG X 3)

1 PA ST OCh LA

KYMRIAH INTRAVENOUS SUSPENSION 02X10EXP6 TO 25X10EXP8 CELL 06 TO 6 X 10EXP8 CELL

MB PA

KYPROLIS INTRAVENOUS RECON SOLN 10 MG 30 MG 60 MG

MB PA

lapatinib oral tablet 250 mg 1 PA OCh LA QL (180 per 30 days)

19


LENVIMA ORAL CAPSULE 10 MGDAY (10 MG X 1) 12 MGDAY (4 MG X 3) 14 MGDAY(10 MG X 1-4 MG X 1) 18 MGDAY (10 MG X 1-4 MG X2) 20 MGDAY (10 MG X 2) 24 MGDAY(10 MG X 2-4 MG X 1) 4 MG 8 MGDAY (4 MG X 2)

1 PA ST OCh LA

letrozole oral tablet 25 mg ACA PV OCh QL (30 per 30 days)

LEUKERAN ORAL TABLET 2 MG 1 OCh

leuprolide subcutaneous kit 1 mg02 ml 1 PA

LIBTAYO INTRAVENOUS SOLUTION 50 MGML

MB PA

LONSURF ORAL TABLET 15-614 MG 20-819 MG

1 PA ST OCh LA

LUMOXITI INTRAVENOUS RECON SOLN 1 MG

MB

LUPKYNIS ORAL CAPSULE 79 MG 1 PA ST

LUPRON DEPOT (3 MONTH) INTRAMUSCULAR SYRINGE KIT 1125 MG 225 MG

1 PA

LUPRON DEPOT (4 MONTH) INTRAMUSCULAR SYRINGE KIT 30 MG

1 PA


1 PA

LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 375 MG 75 MG

1 PA

LUPRON DEPOT-PED (3 MONTH) INTRAMUSCULAR SYRINGE KIT 1125 MG 30 MG

1 PA

LUPRON DEPOT-PED INTRAMUSCULAR KIT 1125 MG 15 MG 75 MG (PED)

1 PA

LYNPARZA ORAL TABLET 100 MG 150 MG 1 PA ST OCh LA

LYSODREN ORAL TABLET 500 MG 1 OCh

MARQIBO INTRAVENOUS KIT 5 MG31 ML(016 MGML) FINAL

MB PA

MATULANE ORAL CAPSULE 50 MG 1 OCh

megestrol oral suspension 400 mg10 ml (40 mgml)




megestrol oral tablet 20 mg 1 OCh QL (480 per 30 days)

20



MEKINIST ORAL TABLET 05 MG 2 MG 1 PA ST OCh LA

MEKTOVI ORAL TABLET 15 MG 1 PA OCh LA

melphalan hcl intravenous recon soln 50 mg MB

melphalan oral tablet 2 mg 1 OCh QL (63 per 21 days)

mercaptopurine oral tablet 50 mg 1 OCh QL (300 per 30 days)

methotrexate sodium (pf) injection recon soln 1 gram

1

methotrexate sodium (pf) injection solution 25 mgml

1

methotrexate sodium injection solution 25 mgml 1

methotrexate sodium oral tablet 25 mg 1 OCh

mitoxantrone intravenous concentrate 2 mgml MB PA LA

mycophenolate mofetil oral capsule 250 mg 1

mycophenolate mofetil oral tablet 500 mg 1

mycophenolate sodium oral tabletdelayed release (drec) 180 mg 360 mg

1

MYLOTARG INTRAVENOUS RECON SOLN 45 MG (1 MGML INITIAL CONC)

MB PA LA

NERLYNX ORAL TABLET 40 MG 1 PA OCh LA QL (180 per 30 days)

NEXAVAR ORAL TABLET 200 MG 1 PA ST OCh LA

nilutamide oral tablet 150 mg 1 OCh QL (60 per 30 days)

NINLARO ORAL CAPSULE 23 MG 3 MG 4 MG

1 PA ST OCh LA

NULOJIX INTRAVENOUS RECON SOLN 250 MG

MB PA

octreotide acetate injection solution 1000 mcgml 100 mcgml 200 mcgml 50 mcgml 500 mcgml

1

octreotide acetate injection syringe 100 mcgml (1 ml) 50 mcgml (1 ml) 500 mcgml (1 ml)

1

OGIVRI INTRAVENOUS RECON SOLN 150 MG 420 MG

MB PA LA

ONCASPAR INJECTION SOLUTION 750 UNITML

MB

ONIVYDE INTRAVENOUS DISPERSION 43 MGML

MB PA

OPDIVO INTRAVENOUS SOLUTION 100 MG10 ML 240 MG24 ML 40 MG4 ML

MB PA LA

21


PADCEV INTRAVENOUS RECON SOLN 20 MG 30 MG

MB PA LA

PEMAZYRE ORAL TABLET 135 MG 45 MG 9 MG

1 PA ST OCh

PERJETA INTRAVENOUS SOLUTION 420 MG14 ML (30 MGML)

MB PA LA

PIQRAY ORAL TABLET 200 MGDAY (200 MG X 1) 250 MGDAY (200 MG X1-50 MG X1) 300 MGDAY (150 MG X 2)

1 PA OCh LA

POLIVY INTRAVENOUS RECON SOLN 140 MG

MB PA LA

PORTRAZZA INTRAVENOUS SOLUTION 800 MG50 ML (16 MGML)

MB PA LA

POTELIGEO INTRAVENOUS SOLUTION 4 MGML

MB PA

PROGRAF INTRAVENOUS SOLUTION 5 MGML

MB

QINLOCK ORAL TABLET 50 MG 1 OCh

RETEVMO ORAL CAPSULE 40 MG 1 PA OCh LA QL (240 per 30 days)


RITUXAN HYCELA SUBCUTANEOUS SOLUTION 1400 MG117 ML (120 MGML) 1600 MG134 ML (120 MGML)

MB LA

RITUXAN INTRAVENOUS CONCENTRATE 10 MGML

MB PA LA

RUBRACA ORAL TABLET 200 MG 250 MG 300 MG

1 PA ST OCh LA

RYDAPT ORAL CAPSULE 25 MG 1 PA ST OCh LA

SARCLISA INTRAVENOUS SOLUTION 20 MGML

MB

SIGNIFOR SUBCUTANEOUS SOLUTION 03 MGML (1 ML) 06 MGML (1 ML) 09 MGML (1 ML)

1 PA ST

SIMULECT INTRAVENOUS RECON SOLN 10 MG 20 MG

MB

sirolimus oral solution 1 mgml 1

sirolimus oral tablet 05 mg 1 mg 2 mg 1

SOLTAMOX ORAL SOLUTION 20 MG10 ML 1 OCh

22


SOMATULINE DEPOT SUBCUTANEOUS SYRINGE 120 MG05 ML 60 MG02 ML 90 MG03 ML

1 PA LA

SPRYCEL ORAL TABLET 100 MG 140 MG 20 MG 50 MG 70 MG 80 MG

1 PA ST OCh LA

STIVARGA ORAL TABLET 40 MG 1 PA ST OCh LA

sunitinib oral capsule 125 mg 25 mg 375 mg 50 mg

1 PA OCh LA

SUPPRELIN LA IMPLANT KIT 50 MG (65 MCGDAY)

MB PA LA

SUTENT ORAL CAPSULE 125 MG 25 MG 375 MG 50 MG

1 PA ST OCh LA

SYLVANT INTRAVENOUS RECON SOLN 100 MG 400 MG

MB PA LA

SYNRIBO SUBCUTANEOUS RECON SOLN 35 MG

1 PA ST

TABLOID ORAL TABLET 40 MG 1 OCh

tacrolimus oral capsule 05 mg 1 mg 5 mg 1

TAFINLAR ORAL CAPSULE 50 MG 75 MG 1 PA OCh LA

TAGRISSO ORAL TABLET 40 MG 80 MG 1 PA OCh LA

TALZENNA ORAL CAPSULE 025 MG 1 MG 1 PA OCh LA

tamoxifen oral tablet 10 mg 20 mg 1 OCh QL (60 per 30 days)

TARGRETIN TOPICAL GEL 1 1 PA ST

TASIGNA ORAL CAPSULE 150 MG 200 MG 50 MG

1 PA ST OCh LA

TECENTRIQ INTRAVENOUS SOLUTION 1200 MG20 ML (60 MGML) 840 MG14 ML (60 MGML)

MB PA LA

TEMODAR INTRAVENOUS RECON SOLN 100 MG

MB PA LA

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

1 OCh LA

temsirolimus intravenous recon soln 30 mg3 ml (10 mgml) (first)

MB PA LA

THALOMID ORAL CAPSULE 100 MG 150 MG 200 MG 50 MG

1 OCh LA

TIBSOVO ORAL TABLET 250 MG 1 PA OCh

toremifene oral tablet 60 mg 1 OCh

TORISEL INTRAVENOUS RECON SOLN 30 MG3 ML (10 MGML) (FIRST)

MB PA LA

23


TREANDA INTRAVENOUS RECON SOLN 100 MG 25 MG

MB PA LA

TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 1125 MG 225 MG 375 MG

MB PA

tretinoin (antineoplastic) oral capsule 10 mg 1 OCh

TREXALL ORAL TABLET 10 MG 15 MG 5 MG 75 MG

1 PA ST OCh QL (15 per 30 days)

TRUXIMA INTRAVENOUS SOLUTION 10 MGML

MB PA LA

TUKYSA ORAL TABLET 150 MG 50 MG 1 PA ST OCh QL (120 per 30 days)

UKONIQ ORAL TABLET 200 MG 1 PA OCh QL (120 per 30 days)

UNITUXIN INTRAVENOUS SOLUTION 35 MGML

MB PA

VANTAS IMPLANT KIT 50 MG (50 MCGDAY)

MB PA LA

VECTIBIX INTRAVENOUS SOLUTION 100 MG5 ML (20 MGML) 400 MG20 ML (20 MGML)

MB PA LA

VELCADE INJECTION RECON SOLN 35 MG MB LA

VENCLEXTA ORAL TABLET 10 MG 100 MG 50 MG

1 PA ST OCh

VENCLEXTA STARTING PACK ORAL TABLETSDOSE PACK 10 MG-50 MG- 100 MG

1 PA OCh

VERZENIO ORAL TABLET 100 MG 150 MG 200 MG 50 MG

1 PA ST OCh LA

VIDAZA INJECTION RECON SOLN 100 MG MB PA LA

VITRAKVI ORAL CAPSULE 100 MG 1 PA OCh LA

VITRAKVI ORAL CAPSULE 25 MG 1 PA ST OCh LA

VITRAKVI ORAL SOLUTION 20 MGML 1 PA OCh LA

VOTRIENT ORAL TABLET 200 MG 1 PA ST OCh LA

VYXEOS INTRAVENOUS RECON SOLN 44-100 MG

MB PA

WELIREG ORAL TABLET 40 MG 1 PA OCh QL (90 per 30 days)

XALKORI ORAL CAPSULE 200 MG 1 PA OCh LA QL (75 per 30 days)


XERMELO ORAL TABLET 250 MG 1 PA ST

XOSPATA ORAL TABLET 40 MG 1 PA OCh

XTANDI ORAL CAPSULE 40 MG 1 PA OCh LA

24


XTANDI ORAL TABLET 40 MG 80 MG 1 PA OCh LA

YERVOY INTRAVENOUS SOLUTION 200 MG40 ML (5 MGML) 50 MG10 ML (5 MGML)

MB PA LA

YESCARTA INTRAVENOUS SUSPENSION MB PA

YONDELIS INTRAVENOUS RECON SOLN 1 MG

MB PA

YONSA ORAL TABLET 125 MG 1 PA OCh LA

ZALTRAP INTRAVENOUS SOLUTION 100 MG4 ML (25 MGML) 200 MG8 ML (25 MGML)

MB PA LA

ZANOSAR INTRAVENOUS RECON SOLN 1 GRAM

MB

ZEJULA ORAL CAPSULE 100 MG 1 OCh

ZELBORAF ORAL TABLET 240 MG 1 PA ST OCh LA

ZOLADEX SUBCUTANEOUS IMPLANT 108 MG 36 MG

MB PA LA

ZOLINZA ORAL CAPSULE 100 MG 1 PA ST OCh LA

ZYKADIA ORAL TABLET 150 MG 1 PA ST OCh LA QL (90 per 30 days)

AUTONOMIC amp CNS DRUGS NEUROLOGY amp PSYCH

ANTICONVULSANTS

BRIVIACT ORAL SOLUTION 10 MGML 1 ST QL (150 per 30 days)

BRIVIACT ORAL TABLET 10 MG 100 MG 25 MG 50 MG 75 MG

1 ST QL (60 per 30 days)

carbamazepine oral capsule er multiphase 12 hr 100 mg 200 mg 300 mg

1

carbamazepine oral suspension 100 mg5 ml 200 mg10 ml

1

carbamazepine oral tablet 200 mg 1

carbamazepine oral tablet extended release 12 hr 100 mg 200 mg 400 mg

1

carbamazepine oral tabletchewable 100 mg 1

CELONTIN ORAL CAPSULE 300 MG 1

clobazam oral suspension 25 mgml 1

clobazam oral tablet 10 mg 20 mg 1

clonazepam oral tablet 05 mg 1 mg 2 mg 1

25


clonazepam oral tabletdisintegrating 0125 mg 025 mg 05 mg 1 mg 2 mg

1

diazepam rectal kit 25 mg 1

DILANTIN EXTENDED ORAL CAPSULE 100 MG

1

DILANTIN INFATABS ORAL TABLETCHEWABLE 50 MG

1

DILANTIN ORAL CAPSULE 30 MG 1

DILANTIN-125 ORAL SUSPENSION 125 MG5 ML

1

divalproex oral capsule delayed rel sprinkle 125 mg

1

divalproex oral tablet extended release 24 hr 250 mg 500 mg

1

divalproex oral tabletdelayed release (drec) 125 mg 250 mg 500 mg

1

EPIDIOLEX ORAL SOLUTION 100 MGML 1 PA LA QL (400 per 30 days)

epitol oral tablet 200 mg 1

ethosuximide oral capsule 250 mg 1

ethosuximide oral solution 250 mg5 ml 1

felbamate oral suspension 600 mg5 ml 1

felbamate oral tablet 400 mg 600 mg 1

FINTEPLA ORAL SOLUTION 22 MGML 1

gabapentin oral capsule 100 mg 300 mg 400 mg 1

gabapentin oral solution 250 mg5 ml 300 mg6 ml (6 ml)

1

gabapentin oral tablet 600 mg 800 mg 1

lamotrigine oral tablet 100 mg 150 mg 200 mg 25 mg

1

lamotrigine oral tablet disintegrating dose pk 25 mg (21) -50 mg (7) 25 mg(14)-50 mg (14)-100 mg (7) 50 mg (42) -100 mg (14)

1

lamotrigine oral tablet extended release 24hr 100 mg 200 mg 25 mg 250 mg 300 mg 50 mg

1

lamotrigine oral tablet chewable dispersible 25 mg 5 mg

1

lamotrigine oral tabletdisintegrating 100 mg 200 mg 25 mg 50 mg

1

26


lamotrigine oral tabletsdose pack 25 mg (35) 25 mg (42) -100 mg (7) 25 mg (84) -100 mg (14)

1

levetiracetam oral solution 100 mgml 500 mg5 ml (5 ml)

1

levetiracetam oral tablet 1000 mg 250 mg 500 mg 750 mg

1

levetiracetam oral tablet extended release 24 hr 500 mg 750 mg

1

oxcarbazepine oral suspension 300 mg5 ml (60 mgml)

1

oxcarbazepine oral tablet 150 mg 300 mg 600 mg 1

phenobarbital oral elixir 20 mg5 ml (4 mgml) 1

phenobarbital oral tablet 100 mg 15 mg 162 mg 30 mg 324 mg 60 mg 648 mg 972 mg

1

phenytoin oral suspension 100 mg4 ml 125 mg5 ml

1

phenytoin oral tabletchewable 50 mg 1

phenytoin sodium extended oral capsule 100 mg 200 mg 300 mg

1

pregabalin oral capsule 100 mg 150 mg 200 mg 225 mg 25 mg 300 mg 50 mg 75 mg

1 PA ST

pregabalin oral solution 20 mgml 1 PA ST

pregabalin oral tablet extended release 24 hr 165 mg 330 mg 825 mg

1 PA ST

primidone oral tablet 250 mg 50 mg 1

roweepra oral tablet 1000 mg 500 mg 750 mg 1

rufinamide oral suspension 40 mgml 1 PA

rufinamide oral tablet 200 mg 400 mg 1 PA

subvenite oral tablet 100 mg 150 mg 200 mg 25 mg

1

subvenite starter (blue) kit oral tabletsdose pack 25 mg (35)

1

subvenite starter (green) kit oral tabletsdose pack 25 mg (84) -100 mg (14)

1

subvenite starter (orange) kit oral tabletsdose pack 25 mg (42) -100 mg (7)

1

SYMPAZAN ORAL FILM 10 MG 20 MG 5 MG 1 PA QL (30 per 30 days)

tiagabine oral tablet 12 mg 16 mg 2 mg 4 mg 1

topiramate oral capsule sprinkle 15 mg 25 mg 1

27


topiramate oral tablet 100 mg 200 mg 25 mg 50 mg

1

valproic acid (as sodium salt) oral solution 250 mg5 ml 500 mg10 ml (10 ml)

1

valproic acid oral capsule 250 mg 1

vigabatrin oral powder in packet 500 mg 1 PA LA

vigabatrin oral tablet 500 mg 1 PA LA

vigadrone oral powder in packet 500 mg 1 PA ST

VIMPAT ORAL SOLUTION 10 MGML 1 PA ST QL (6 per 30 days)

VIMPAT ORAL TABLET 100 MG 150 MG 200 MG 50 MG


XCOPRI MAINTENANCE PACK ORAL TABLET 250MGDAY(150 MG X1-100MG X1)

1 PA ST

XCOPRI MAINTENANCE PACK ORAL TABLET 350 MGDAY (200 MG X1-150MG X1)

1

XCOPRI ORAL TABLET 100 MG 150 MG 200 MG 50 MG

1

XCOPRI TITRATION PACK ORAL TABLETSDOSE PACK 125 MG (14)- 25 MG (14) 150 MG (14)- 200 MG (14) 50 MG (14)- 100 MG (14)

1

zonisamide oral capsule 100 mg 25 mg 50 mg 1

ANTIPARKINSONISM AGENTS

APOKYN SUBCUTANEOUS CARTRIDGE 10 MGML


benztropine injection solution 1 mgml 1

benztropine oral tablet 05 mg 1 mg 2 mg 1

bromocriptine oral capsule 5 mg 1

bromocriptine oral tablet 25 mg 1

carbidopa oral tablet 25 mg 1

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

1

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

1

carbidopa-levodopa oral tabletdisintegrating 10-100 mg 25-100 mg 25-250 mg

1

28


carbidopa-levodopa-entacapone oral tablet 125-50-200 mg 1875-75-200 mg 25-100-200 mg 3125-125-200 mg 375-150-200 mg 50-200-200 mg

1

entacapone oral tablet 200 mg 1

pramipexole oral tablet 0125 mg 025 mg 05 mg 075 mg 1 mg 15 mg

1

pramipexole oral tablet extended release 24 hr 0375 mg 075 mg 15 mg 225 mg 3 mg 375 mg 45 mg

1

rasagiline oral tablet 05 mg 1 mg 1

ropinirole oral tablet 025 mg 05 mg 1 mg 2 mg 3 mg 4 mg 5 mg

1

ropinirole oral tablet extended release 24 hr 12 mg 2 mg 4 mg 6 mg 8 mg

1

selegiline hcl oral capsule 5 mg 1

selegiline hcl oral tablet 5 mg 1

tolcapone oral tablet 100 mg 1

trihexyphenidyl oral elixir 04 mgml 1

trihexyphenidyl oral tablet 2 mg 5 mg 1

MIGRAINE amp CLUSTER HEADACHE THERAPY

AIMOVIG AUTOINJECTOR SUBCUTANEOUS AUTO-INJECTOR 140 MGML 70 MGML

1 PA ST

AJOVY AUTOINJECTOR SUBCUTANEOUS AUTO-INJECTOR 225 MG15 ML

1 ST

AJOVY SYRINGE SUBCUTANEOUS SYRINGE 225 MG15 ML

1 PA ST

almotriptan malate oral tablet 125 mg 625 mg 1 QL (18 per 30 days)

dihydroergotamine injection solution 1 mgml 1

dihydroergotamine nasal spraynon-aerosol 05 mgpump act (4 mgml)


eletriptan oral tablet 20 mg 40 mg 1 QL (18 per 30 days)

EMGALITY PEN SUBCUTANEOUS PEN INJECTOR 120 MGML

1 PA ST

EMGALITY SYRINGE SUBCUTANEOUS SYRINGE 120 MGML 300 MG3 ML (100 MGML X 3)

1 PA ST

ergotamine-caffeine oral tablet 1-100 mg 1

frovatriptan oral tablet 25 mg 1 QL (18 per 30 days)

29


migergot rectal suppository 2-100 mg 1

naratriptan oral tablet 1 mg 25 mg 1 QL (18 per 30 days)

ONZETRA XSAIL NASAL AEROSOL POWDR BREATH ACTIVATED 11 MG


rizatriptan oral tablet 10 mg 5 mg 1 QL (18 per 30 days)

rizatriptan oral tabletdisintegrating 10 mg 5 mg 1 QL (18 per 30 days)

sumatriptan nasal spraynon-aerosol 20 mgactuation 5 mgactuation


sumatriptan succinate oral tablet 100 mg 25 mg 50 mg


sumatriptan succinate subcutaneous cartridge 4 mg05 ml 6 mg05 ml


sumatriptan succinate subcutaneous pen injector 4 mg05 ml 6 mg05 ml


sumatriptan succinate subcutaneous solution 6 mg05 ml


UBRELVY ORAL TABLET 100 MG 50 MG 1 QL (16 per 30 days)

VYEPTI INTRAVENOUS SOLUTION 100 MGML

MB PA

zolmitriptan oral tablet 25 mg 5 mg 1 QL (18 per 30 days)

zolmitriptan oral tabletdisintegrating 25 mg 5 mg


ZOMIG NASAL SPRAYNON-AEROSOL 25 MG 5 MG


MISCELLANEOUS NEUROLOGICAL THERAPY

AUSTEDO ORAL TABLET 12 MG 6 MG 9 MG

1 PA LA

dalfampridine oral tablet extended release 12 hr 10 mg


donepezil oral tablet 10 mg 23 mg 5 mg 1

donepezil oral tabletdisintegrating 10 mg 5 mg 1

EXONDYS-51 INTRAVENOUS SOLUTION 50 MGML

MB PA

galantamine oral capsuleext rel pellets 24 hr 16 mg 24 mg 8 mg

1

galantamine oral solution 4 mgml 1

galantamine oral tablet 12 mg 4 mg 8 mg 1

memantine oral capsulesprinkleer 24hr 14 mg 21 mg 28 mg 7 mg

1

30


memantine oral solution 2 mgml 1

memantine oral tablet 10 mg 5 mg 1

NUEDEXTA ORAL CAPSULE 20-10 MG 1

ONPATTRO INTRAVENOUS SOLUTION 2 MGML

MB PA

RADICAVA INTRAVENOUS SOLUTION 30 MG100 ML

MB PA

rivastigmine tartrate oral capsule 15 mg 3 mg 45 mg 6 mg

1

rivastigmine transdermal patch 24 hour 133 mg24 hour 46 mg24 hour 95 mg24 hour

1

tetrabenazine oral tablet 125 mg 25 mg 1 LA

TYSABRI INTRAVENOUS SOLUTION 300 MG15 ML

MB PA ST LA

VYONDYS-53 INTRAVENOUS SOLUTION 50 MGML

MB PA

ZOLGENSMA INTRAVENOUS KIT 2 X 10EXP13 VGML

MB LA

MUSCLE RELAXANTS amp ANTISPASMODIC THERAPY

baclofen oral tablet 10 mg 20 mg 5 mg 1

carisoprodol oral tablet 250 mg 350 mg 1

carisoprodol-aspirin oral tablet 200-325 mg 1

carisoprodol-aspirin-codeine oral tablet 200-325-16 mg

1 PA ST

chlorzoxazone oral tablet 250 mg 375 mg 750 mg 1 ST

chlorzoxazone oral tablet 500 mg 1

cyclobenzaprine oral tablet 10 mg 5 mg 75 mg 1

dantrolene oral capsule 100 mg 25 mg 50 mg 1

meprobamate oral tablet 200 mg 400 mg 1

metaxalone oral tablet 400 mg 800 mg 1

methocarbamol oral tablet 500 mg 750 mg 1

orphenadrine citrate injection solution 30 mgml 1

orphenadrine citrate oral tablet extended release 100 mg

1

pyridostigmine bromide oral syrup 60 mg5 ml 1

pyridostigmine bromide oral tablet 60 mg 1

pyridostigmine bromide oral tablet extended release 180 mg

1

31


tizanidine oral capsule 2 mg 4 mg 6 mg 1

tizanidine oral tablet 2 mg 4 mg 1

vanadom oral tablet 350 mg 1

NARCOTIC ANALGESICS

acetaminophen-caff-dihydrocod oral capsule 3205-30-16 mg

1 PA ST

acetaminophen-caff-dihydrocod oral tablet 325-30-16 mg

1 PA ST

acetaminophen-codeine oral solution 120-12 mg5 ml 300 mg-30 mg 125 ml

1 PA ST

acetaminophen-codeine oral tablet 300-15 mg 300-30 mg 300-60 mg

1 PA ST

ascomp with codeine oral capsule 30-50-325-40 mg

1 PA ST

buprenorphine hcl injection solution 03 mgml 1 PA ST

buprenorphine hcl injection syringe 03 mgml 1 PA ST

buprenorphine hcl sublingual tablet 2 mg 8 mg 1

buprenorphine transdermal patch weekly 10 mcghour 15 mcghour 20 mcghour 5 mcghour 75 mcghour

1

butalbital compound wcodeine oral capsule 30-50-325-40 mg

1 PA ST

butalbital-acetaminop-caf-cod oral capsule 50-300-40-30 mg 50-325-40-30 mg

1 PA ST

butalbital-acetaminophen-caff oral capsule 50-300-40 mg 50-325-40 mg

1

butalbital-acetaminophen-caff oral tablet 50-325-40 mg

1

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

1

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

1

codeine sulfate oral tablet 15 mg 30 mg 60 mg 1 PA ST

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

1 PA ST

diskets oral tabletsoluble 40 mg 1 PA ST

DSUVIA SUBLINGUAL TABLET IN APPLICATOR 30 MCG

MB

32


duramorph (pf) injection solution 05 mgml 1 mgml

MB PA ST

dvorah oral tablet 325-30-16 mg 1 PA ST

endocet oral tablet 10-325 mg 25-325 mg 5-325 mg 75-325 mg

1 PA ST

fentanyl citrate buccal lozenge on a handle 1200 mcg 1600 mcg 200 mcg 400 mcg 600 mcg 800 mcg

1 PA

fentanyl transdermal patch 72 hour 100 mcghr 12 mcghr 25 mcghr 375 mcghour 50 mcghr 625 mcghour 75 mcghr 875 mcghour

1 PA ST

hydrocodone bitartrate oral capsule oral only er 12hr 10 mg 15 mg 20 mg 30 mg 40 mg 50 mg

1 PA ST QL (60 per 30 days)

hydrocodone bitartrate oral tabletoral onlyextrel24 hr 100 mg 120 mg 20 mg 30 mg 40 mg 60 mg 80 mg

1 PA ST

hydrocodone-acetaminophen oral solution 10-325 mg15 ml(15 ml)

1 PA ST

hydrocodone-acetaminophen oral solution 75-325 mg15 ml

1 PA

hydrocodone-acetaminophen oral tablet 10-300 mg 10-325 mg 5-300 mg 5-325 mg 75-300 mg 75-325 mg

1 PA ST

hydrocodone-ibuprofen oral tablet 10-200 mg 5-200 mg 75-200 mg

1 PA ST

HYDROMORPHONE INJECTION SYRINGE 05 MG05 ML

1 PA ST

hydromorphone oral liquid 1 mgml 1 PA ST

hydromorphone oral tablet 2 mg 4 mg 8 mg 1 PA ST

hydromorphone oral tablet extended release 24 hr 12 mg 16 mg 32 mg 8 mg


hydromorphone rectal suppository 3 mg 1 PA ST

levorphanol tartrate oral tablet 2 mg 3 mg 1 PA ST

meperidine oral solution 50 mg5 ml 1 PA ST

meperidine oral tablet 50 mg 1 PA ST

methadone injection solution 10 mgml 1 PA ST

methadone oral concentrate 10 mgml 1 PA ST

methadone oral solution 10 mg5 ml 5 mg5 ml 1 PA ST

methadone oral tablet 10 mg 5 mg 1 PA ST

methadone oral tabletsoluble 40 mg 1 PA ST

33


methadose oral concentrate 10 mgml 1 PA ST

methadose oral tabletsoluble 40 mg 1 PA ST

morphine (pf) injection solution 05 mgml MB PA ST

morphine concentrate oral solution 100 mg5 ml (20 mgml)

1 PA ST

morphine oral capsule er multiphase 24 hr 120 mg 30 mg 45 mg 60 mg 75 mg 90 mg


morphine oral capsuleextendrelease pellets 10 mg 100 mg 20 mg 50 mg 80 mg


morphine oral capsuleextendrelease pellets 30 mg 60 mg


morphine oral solution 10 mg5 ml 20 mg5 ml (4 mgml)

1 PA ST

morphine oral tablet 15 mg 30 mg 1 PA ST

morphine oral tablet extended release 100 mg 15 mg 200 mg 30 mg 60 mg


morphine rectal suppository 10 mg 20 mg 30 mg 5 mg

1 PA ST

oxycodone oral capsule 5 mg 1 PA ST

oxycodone oral concentrate 20 mgml 1 PA ST

oxycodone oral solution 5 mg5 ml 1 PA ST

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

1 PA ST

oxycodone-acetaminophen oral tablet 10-325 mg 25-300 mg 25-325 mg 5-325 mg 75-325 mg

1 PA ST

oxycodone-acetaminophen oral tablet 5-300 mg 1 PA

OXYCONTIN ORAL TABLETORAL ONLYEXTREL12 HR 10 MG 15 MG 20 MG 30 MG 40 MG


OXYCONTIN ORAL TABLETORAL ONLYEXTREL12 HR 60 MG 80 MG


oxymorphone oral tablet 10 mg 5 mg 1 PA ST

oxymorphone oral tablet extended release 12 hr 10 mg 15 mg 20 mg 30 mg 40 mg 5 mg 75 mg


SUBLOCADE SUBCUTANEOUS SOLUTION EXTENDED REL SYRINGE 100 MG05 ML 300 MG15 ML

MB

tencon oral tablet 50-325 mg 1

NON-NARCOTIC ANALGESICS

34


adult aspirin regimen oral tabletdelayed release (drec) 81 mg

ACA PV

aspirin low dose oral tabletdelayed release (drec) 81 mg

ACA PV

aspirin oral tablet 325 mg ACA PV

aspirin oral tabletchewable 81 mg ACA PV

aspirin oral tabletdelayed release (drec) 325 mg 81 mg

ACA PV

aspir-trin oral tabletdelayed release (drec) 325 mg

ACA PV

bayer aspirin oral tablet 325 mg ACA PV

BAYER CHEWABLE ASPIRIN ORAL TABLETCHEWABLE 81 MG

ACA PV

buprenorphine-naloxone sublingual film 12-3 mg 1 QL (60 per 30 days)

buprenorphine-naloxone sublingual film 2-05 mg 4-1 mg 8-2 mg


buprenorphine-naloxone sublingual tablet 2-05 mg 8-2 mg


butorphanol nasal spraynon-aerosol 10 mgml 1 PA ST QL (5 per 30 days)

cataflam oral tablet 50 mg 1

celecoxib oral capsule 100 mg 200 mg 400 mg 50 mg

1

childrens aspirin oral tabletchewable 81 mg ACA PV

cholinemagnesium salicylate oral liquid 500 mg5 ml

1

diclofenac potassium oral tablet 50 mg 1

diclofenac sodium oral tablet extended release 24 hr 100 mg

1

diclofenac sodium oral tabletdelayed release (drec) 25 mg 50 mg 75 mg

1

diclofenac sodium topical drops 15 1

diclofenac sodium topical gel 1 1

diclofenac-misoprostol oral tabletirdelayed relbiphasic 50-200 mg-mcg 75-200 mg-mcg

1

diflunisal oral tablet 500 mg 1

DUEXIS ORAL TABLET 800-266 MG 1 ST

ecotrin low strength oral tabletdelayed release (drec) 81 mg

ACA PV

ecotrin oral tabletdelayed release (drec) 325 mg ACA PV

35


etodolac oral capsule 200 mg 300 mg 1

etodolac oral tablet 400 mg 500 mg 1

etodolac oral tablet extended release 24 hr 400 mg 500 mg 600 mg

1

EUFLEXXA INTRA-ARTICULAR SYRINGE 10 MGML(MW 24 -36 MILLION)

MB

fenoprofen oral tablet 600 mg 1

flurbiprofen oral tablet 100 mg 1

ibu oral tablet 400 mg 600 mg 800 mg 1

ibuprofen oral suspension 100 mg5 ml 1

ibuprofen oral tablet 400 mg 600 mg 800 mg 1

ibuprofen-famotidine oral tablet 800-266 mg 1 PA

indomethacin oral capsule 25 mg 50 mg 1

indomethacin oral capsule extended release 75 mg

1

ketoprofen oral capsule 25 mg 50 mg 75 mg 1

ketoprofen oral capsuleext rel pellets 24 hr 200 mg

1

ketorolac injection cartridge 15 mgml 1

ketorolac injection solution 15 mgml 30 mgml MB

ketorolac injection solution 30 mgml (1 ml) 1

ketorolac intramuscular solution 60 mg2 ml 1

ketorolac intramuscular syringe 60 mg2 ml 1

ketorolac oral tablet 10 mg 1

KLOXXADO NASAL SPRAYNON-AEROSOL 8 MGACTUATION

1

meclofenamate oral capsule 100 mg 50 mg 1

mefenamic acid oral capsule 250 mg 1

meloxicam oral tablet 15 mg 75 mg 1

MONOVISC INTRA-ARTICULAR SYRINGE 88 MG4 ML

MB LA

nabumetone oral tablet 500 mg 750 mg 1

nalbuphine injection solution 10 mgml MB PA ST

naloxone injection solution 04 mgml 1

naloxone injection syringe 04 mgml 1 mgml 1

naltrexone oral tablet 50 mg 1

naproxen oral suspension 125 mg5 ml 1

36


naproxen oral tablet 250 mg 375 mg 500 mg 1

naproxen oral tabletdelayed release (drec) 375 mg 500 mg

1

naproxen sodium oral tablet 275 mg 550 mg 1

NARCAN NASAL SPRAYNON-AEROSOL 4 MGACTUATION

1

NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HR 100 MG 150 MG 200 MG 250 MG 50 MG


ORTHOVISC INTRA-ARTICULAR SYRINGE 30 MG2 ML

MB

oxaprozin oral tablet 600 mg 1

pentazocine-naloxone oral tablet 50-05 mg 1 PA ST

piroxicam oral capsule 10 mg 20 mg 1

salsalate oral tablet 500 mg 750 mg 1

st joseph aspirin oral tabletchewable 81 mg ACA PV

st joseph aspirin oral tabletdelayed release (drec) 81 mg

ACA PV

sulindac oral tablet 150 mg 200 mg 1

tolmetin oral capsule 400 mg 1

tolmetin oral tablet 200 mg 600 mg 1

tramadol oral tablet 50 mg 1 PA ST

tramadol oral tablet extended release 24 hr 100 mg 200 mg 300 mg

1 PA ST

tramadol oral tablet er multiphase 24 hr 100 mg 200 mg 300 mg

1 PA ST

tramadol-acetaminophen oral tablet 375-325 mg 1 PA ST

VIVITROL INTRAMUSCULAR SUSPENSIONEXTENDED REL RECON 380 MG

MB

PSYCHOTHERAPEUTIC DRUGS

ABILIFY MAINTENA INTRAMUSCULAR SUSPENSIONEXTENDED REL RECON 300 MG 400 MG

1

ABILIFY MAINTENA INTRAMUSCULAR SUSPENSIONEXTENDED REL SYRING 300 MG 400 MG

1

37


ADHANSIA XR ORAL CAPSULE ER BIPHASIC 20-80 25 MG 35 MG 45 MG 55 MG 70 MG 85 MG

1 PA ST

ADZENYS XR-ODT ORAL TABLETDISINTEG ER BIPHASE 24H 125 MG 157 MG 188 MG 31 MG 63 MG 94 MG

1 ST

alprazolam intensol oral concentrate 1 mgml 1

alprazolam oral tablet 025 mg 05 mg 1 mg 2 mg

1

alprazolam oral tablet extended release 24 hr 05 mg 1 mg 2 mg 3 mg

1

alprazolam oral tabletdisintegrating 025 mg 05 mg 1 mg 2 mg

1

amitriptyline oral tablet 10 mg 100 mg 150 mg 25 mg 50 mg 75 mg

1

amitriptyline-chlordiazepoxide oral tablet 125-5 mg 25-10 mg

1

amoxapine oral tablet 100 mg 150 mg 25 mg 50 mg

1

AMPHETAMINE ORAL SUSPEN IR - ER BIPHASIC 24HR 125 MGML

1 ST

amphetamine sulfate oral tablet 10 mg 5 mg 1

APLENZIN ORAL TABLET EXTENDED RELEASE 24 HR 174 MG 348 MG 522 MG

1 ST

aripiprazole oral solution 1 mgml 1

aripiprazole oral tablet 10 mg 15 mg 2 mg 20 mg 30 mg 5 mg

1

aripiprazole oral tabletdisintegrating 10 mg 15 mg

1

ARISTADA INITIO INTRAMUSCULAR SUSPENSIONEXTENDED REL SYRING 675 MG24 ML

MB

ARISTADA INTRAMUSCULAR SUSPENSIONEXTENDED REL SYRING 1064 MG39 ML 441 MG16 ML 662 MG24 ML 882 MG32 ML

MB

armodafinil oral tablet 150 mg 200 mg 250 mg 50 mg

1

asenapine maleate sublingual tablet 10 mg 25 mg 5 mg

1

38


atomoxetine oral capsule 10 mg 100 mg 18 mg 25 mg 40 mg 60 mg 80 mg

1

BELSOMRA ORAL TABLET 10 MG 15 MG 20 MG 5 MG

1 ST

bupropion hcl oral tablet 100 mg 75 mg 1

bupropion hcl oral tablet extended release 24 hr 150 mg 300 mg

1

bupropion hcl oral tablet sustained-release 12 hr 100 mg 150 mg 200 mg

1

buspirone oral tablet 10 mg 15 mg 30 mg 5 mg 75 mg

1

chlordiazepoxide hcl oral capsule 10 mg 25 mg 5 mg

1

chlorpromazine injection solution 25 mgml 1

chlorpromazine oral tablet 10 mg 100 mg 200 mg 25 mg 50 mg

1

citalopram oral solution 10 mg5 ml 1

citalopram oral tablet 10 mg 20 mg 40 mg 1

clomipramine oral capsule 25 mg 50 mg 75 mg 1

clonidine hcl oral tablet extended release 12 hr 01 mg

1

clorazepate dipotassium oral tablet 15 mg 375 mg 75 mg

1

clozapine oral tablet 100 mg 200 mg 25 mg 50 mg

1

clozapine oral tabletdisintegrating 100 mg 125 mg 150 mg 200 mg 25 mg

1

COTEMPLA XR-ODT ORAL TABLETDISINTEG ER BIPHASE 24H 173 MG 259 MG 86 MG

1 ST

DAYTRANA TRANSDERMAL PATCH 24 HOUR 10 MG9 HR 15 MG9 HR 20 MG9 HR 30 MG9 HR

1 ST

desipramine oral tablet 10 mg 100 mg 150 mg 25 mg 50 mg 75 mg

1

DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE 24 HR 100 MG 50 MG

1 ST

desvenlafaxine succinate oral tablet extended release 24 hr 100 mg 25 mg 50 mg

1

39


dexmethylphenidate oral capsuleer biphasic 50-50 10 mg 15 mg 20 mg 25 mg 30 mg 35 mg 40 mg 5 mg

1

dexmethylphenidate oral tablet 10 mg 25 mg 5 mg

1

dextroamphetamine oral capsule extended release 10 mg 15 mg 5 mg

1

dextroamphetamine oral solution 5 mg5 ml 1

dextroamphetamine oral tablet 10 mg 15 mg 20 mg 30 mg 5 mg

1

dextroamphetamine-amphetamine oral capsuleextended release 24hr 10 mg 15 mg 20 mg 25 mg 30 mg 5 mg

1

dextroamphetamine-amphetamine oral tablet 10 mg 125 mg 15 mg 20 mg 30 mg 5 mg 75 mg

1

diazepam injection solution 5 mgml MB

diazepam injection syringe 5 mgml MB

diazepam intensol oral concentrate 5 mgml 1

diazepam oral solution 5 mg5 ml (1 mgml) 1

diazepam oral tablet 10 mg 2 mg 5 mg 1

doxepin oral capsule 10 mg 100 mg 150 mg 25 mg 50 mg 75 mg

1

doxepin oral concentrate 10 mgml 1

duloxetine oral capsuledelayed release(drec) 20 mg 30 mg 40 mg 60 mg

1

DYANAVEL XR ORAL SUSPEN IR - ER BIPHASIC 24HR 25 MGML

1 ST

EDLUAR SUBLINGUAL TABLET 10 MG 5 MG

1 ST

EMSAM TRANSDERMAL PATCH 24 HOUR 12 MG24 HR 6 MG24 HR 9 MG24 HR

1 ST

ergoloid oral tablet 1 mg 1

escitalopram oxalate oral solution 5 mg5 ml 1

escitalopram oxalate oral tablet 10 mg 20 mg 5 mg

1

estazolam oral tablet 1 mg 2 mg 1

eszopiclone oral tablet 1 mg 2 mg 3 mg 1

FANAPT ORAL TABLET 1 MG 10 MG 12 MG 2 MG 4 MG 6 MG 8 MG

1 PA ST

40


FANAPT ORAL TABLETSDOSE PACK 1MG(2)-2MG(2)- 4MG(2)-6MG(2)

1 PA ST

FETZIMA ORAL CAPSULEEXT REL 24HR DOSE PACK 20 MG (2)- 40 MG (26)

1 ST

FETZIMA ORAL CAPSULEEXTENDED RELEASE 24 HR 120 MG 20 MG 40 MG 80 MG

1 ST

fluoxetine oral capsule 10 mg 20 mg 40 mg 1

fluoxetine oral capsuledelayed release(drec) 90 mg

1

fluoxetine oral solution 20 mg5 ml (4 mgml) 1

fluoxetine oral tablet 10 mg 20 mg 1

fluoxetine oral tablet 60 mg 1 PA

fluphenazine hcl injection solution 25 mgml 1

fluphenazine hcl oral concentrate 5 mgml 1

fluphenazine hcl oral elixir 25 mg5 ml 1

fluphenazine hcl oral tablet 1 mg 10 mg 25 mg 5 mg

1

flurazepam oral capsule 15 mg 30 mg 1

fluvoxamine oral capsuleextended release 24hr 100 mg 150 mg

1

fluvoxamine oral tablet 100 mg 25 mg 50 mg 1

guanfacine oral tablet extended release 24 hr 1 mg 2 mg 3 mg 4 mg

1

haloperidol decanoate intramuscular solution 100 mgml 50 mgml

1

haloperidol lactate injection solution 5 mgml 1

haloperidol lactate oral concentrate 2 mgml 1

haloperidol oral tablet 05 mg 1 mg 10 mg 2 mg 20 mg 5 mg

1

HETLIOZ LQ ORAL SUSPENSION 4 MGML 1 PA ST LA

HETLIOZ ORAL CAPSULE 20 MG 1 PA ST LA

imipramine hcl oral tablet 10 mg 25 mg 50 mg 1

imipramine pamoate oral capsule 100 mg 125 mg 150 mg 75 mg

1

INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 117 MG075 ML 156 MGML 234 MG15 ML 39 MG025 ML 78 MG05 ML

1

41


JORNAY PM ORAL CAPSULEDEL RELEXT REL SPRINK 100 MG 20 MG 40 MG 60 MG 80 MG

1 ST

LATUDA ORAL TABLET 120 MG 20 MG 40 MG 60 MG 80 MG

1 PA ST

lithium carbonate oral capsule 150 mg 300 mg 600 mg

1

lithium carbonate oral tablet 300 mg 1

lithium carbonate oral tablet extended release 300 mg 450 mg

1

lorazepam intensol oral concentrate 2 mgml 1

lorazepam oral concentrate 2 mgml 1

lorazepam oral tablet 05 mg 1 mg 2 mg 1

loxapine succinate oral capsule 10 mg 25 mg 5 mg 50 mg

1

maprotiline oral tablet 25 mg 50 mg 75 mg 1

MARPLAN ORAL TABLET 10 MG 1

methamphetamine oral tablet 5 mg 1

METHYLIN ORAL SOLUTION 10 MG5 ML 5 MG5 ML

1

methylphenidate hcl oral caper sprinklebiphasic 40-60 10 mg 15 mg 20 mg 30 mg 40 mg 50 mg 60 mg

1

methylphenidate hcl oral capsule er biphasic 30-70 10 mg 20 mg 30 mg 40 mg 50 mg 60 mg

1

methylphenidate hcl oral capsuleer biphasic 50-50 10 mg 20 mg 30 mg 40 mg 60 mg

1

methylphenidate hcl oral solution 10 mg5 ml 5 mg5 ml

1

methylphenidate hcl oral tablet 10 mg 20 mg 5 mg

1

methylphenidate hcl oral tablet extended release 10 mg 20 mg

1

methylphenidate hcl oral tablet extended release 24hr 18 mg 27 mg 36 mg 54 mg

1

methylphenidate hcl oral tabletchewable 10 mg 25 mg 5 mg

1

midazolam oral syrup 2 mgml 1

mirtazapine oral tablet 15 mg 30 mg 45 mg 75 mg

1

42


mirtazapine oral tabletdisintegrating 15 mg 30 mg 45 mg

1

modafinil oral tablet 100 mg 200 mg 1

molindone oral tablet 10 mg 25 mg 5 mg 1

MYDAYIS ORAL CAPSULE ER TRIPHASIC 24 HR 125 MG 25 MG 375 MG 50 MG

1 ST

nefazodone oral tablet 100 mg 150 mg 200 mg 250 mg 50 mg

1

nortriptyline oral capsule 10 mg 25 mg 50 mg 75 mg

1

nortriptyline oral solution 10 mg5 ml 1

NUPLAZID ORAL CAPSULE 34 MG 1 PA LA

NUPLAZID ORAL TABLET 10 MG 1 PA LA

olanzapine intramuscular recon soln 10 mg 1

olanzapine oral tablet 10 mg 15 mg 25 mg 20 mg 5 mg 75 mg

1

olanzapine oral tabletdisintegrating 10 mg 15 mg 20 mg 5 mg

1

olanzapine-fluoxetine oral capsule 12-25 mg 12-50 mg 3-25 mg 6-25 mg 6-50 mg

1

oxazepam oral capsule 10 mg 15 mg 30 mg 1

paliperidone oral tablet extended release 24hr 15 mg 3 mg 6 mg 9 mg

1

paroxetine hcl oral tablet 10 mg 20 mg 30 mg 40 mg

1

paroxetine hcl oral tablet extended release 24 hr 125 mg 25 mg 375 mg

1

paroxetine mesylate(menopsym) oral capsule 75 mg

1

perphenazine oral tablet 16 mg 2 mg 4 mg 8 mg 1

perphenazine-amitriptyline oral tablet 2-10 mg 2-25 mg 4-10 mg 4-25 mg 4-50 mg

1

phenelzine oral tablet 15 mg 1

pimozide oral tablet 1 mg 2 mg 1

procentra oral solution 5 mg5 ml 1

protriptyline oral tablet 10 mg 5 mg 1

quetiapine oral tablet 100 mg 200 mg 25 mg 300 mg 400 mg 50 mg

1

43


quetiapine oral tablet extended release 24 hr 150 mg 200 mg 300 mg 400 mg 50 mg

1

QUILLICHEW ER ORAL TABLETCHEWIR-ERBIPHASIC24HR 20 MG 30 MG 40 MG

1 ST

QUILLIVANT XR ORAL SUSPENSIONEXT REL 24HRRECON 5 MGML (25 MG5 ML)

1 ST

ramelteon oral tablet 8 mg 1

RELEXXII ORAL TABLET EXTENDED RELEASE 24HR 72 MG

1 ST

REXULTI ORAL TABLET 025 MG 05 MG 1 MG 2 MG 3 MG 4 MG

1 PA ST

RISPERDAL CONSTA INTRAMUSCULAR SUSPENSIONEXTENDED REL RECON 125 MG2 ML 25 MG2 ML 375 MG2 ML 50 MG2 ML

1

risperidone oral solution 1 mgml 1

risperidone oral tablet 025 mg 05 mg 1 mg 2 mg 3 mg 4 mg

1

risperidone oral tabletdisintegrating 025 mg 05 mg 1 mg 2 mg 3 mg 4 mg

1

seconal sodium oral capsule 100 mg 1

sertraline oral concentrate 20 mgml 1

sertraline oral tablet 100 mg 25 mg 50 mg 1

SPRAVATO NASAL SPRAYNON-AEROSOL 56 MG (28 MG X 2) 84 MG (28 MG X 3)

MB PA

SUNOSI ORAL TABLET 150 MG 1 PA QL (30 per 30 days)


temazepam oral capsule 15 mg 225 mg 30 mg 75 mg

1

thioridazine oral tablet 10 mg 100 mg 25 mg 50 mg

1

thiothixene oral capsule 1 mg 10 mg 2 mg 5 mg 1

tranylcypromine oral tablet 10 mg 1

trazodone oral tablet 100 mg 150 mg 300 mg 50 mg

1

triazolam oral tablet 0125 mg 025 mg 1

trifluoperazine oral tablet 1 mg 10 mg 2 mg 5 mg

1

trimipramine oral capsule 100 mg 25 mg 50 mg 1

44


TRINTELLIX ORAL TABLET 10 MG 20 MG 5 MG

1 ST

venlafaxine oral capsuleextended release 24hr 150 mg 375 mg 75 mg

1

venlafaxine oral tablet 100 mg 25 mg 375 mg 50 mg 75 mg

1

venlafaxine oral tablet extended release 24hr 150 mg 225 mg 375 mg 75 mg

1

VERSACLOZ ORAL SUSPENSION 50 MGML 1 PA ST

VRAYLAR ORAL CAPSULE 15 MG 3 MG 45 MG 6 MG

1 PA ST

VRAYLAR ORAL CAPSULEDOSE PACK 15 MG (1)- 3 MG (6)

1 PA ST

VYVANSE ORAL CAPSULE 10 MG 20 MG 30 MG 40 MG 50 MG 60 MG 70 MG

1 PA ST

VYVANSE ORAL TABLETCHEWABLE 10 MG 20 MG 30 MG 40 MG 50 MG 60 MG

1 PA ST

XYREM ORAL SOLUTION 500 MGML 1 PA QL (540 per 30 days)

zaleplon oral capsule 10 mg 5 mg 1

ZENZEDI ORAL TABLET 15 MG 25 MG 20 MG 30 MG 75 MG

1 ST

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

1

zolpidem oral tablet 10 mg 5 mg 1

zolpidem oral tabletext release multiphase 125 mg 625 mg

1

zolpidem sublingual tablet 175 mg 35 mg 1

ZOLPIMIST ORAL SPRAYNON-AEROSOL 5 MGSPRAY (01 ML)

1 ST

ZULRESSO INTRAVENOUS SOLUTION 5 MGML

MB

CARDIOVASCULAR HYPERTENSION amp LIPIDS

ANTIARRHYTHMIC AGENTS

amiodarone oral tablet 100 mg 200 mg 400 mg 1

disopyramide phosphate oral capsule 100 mg 150 mg

1

dofetilide oral capsule 125 mcg 250 mcg 500 mcg 1

flecainide oral tablet 100 mg 150 mg 50 mg 1

mexiletine oral capsule 150 mg 200 mg 250 mg 1

45


MULTAQ ORAL TABLET 400 MG 1

NORPACE CR ORAL CAPSULE EXTENDED RELEASE 100 MG 150 MG

1

pacerone oral tablet 100 mg 200 mg 400 mg 1

procainamide injection solution 100 mgml 500 mgml

MB

propafenone oral capsuleextended release 12 hr 225 mg 325 mg 425 mg

1

propafenone oral tablet 150 mg 225 mg 300 mg 1

quinidine gluconate oral tablet extended release 324 mg

1

quinidine sulfate oral tablet 200 mg 300 mg 1

sorine oral tablet 120 mg 160 mg 240 mg 80 mg 1

sotalol af oral tablet 120 mg 160 mg 80 mg 1

sotalol oral tablet 120 mg 160 mg 240 mg 80 mg 1

ANTIHYPERTENSIVE THERAPY

acebutolol oral capsule 200 mg 400 mg 1

aliskiren oral tablet 150 mg 300 mg 1

amiloride oral tablet 5 mg 1

amiloride-hydrochlorothiazide oral tablet 5-50 mg 1

amlodipine oral tablet 10 mg 25 mg 5 mg 1

amlodipine-benazepril oral capsule 10-20 mg 10-40 mg 25-10 mg 5-10 mg 5-20 mg 5-40 mg

1 ST

amlodipine-olmesartan oral tablet 10-20 mg 10-40 mg 5-20 mg 5-40 mg

1 ST

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

1 ST

amlodipine-valsartan-hcthiazid oral tablet 10-160-125 mg 10-160-25 mg 10-320-25 mg 5-160-125 mg 5-160-25 mg

1

atenolol oral tablet 100 mg 25 mg 50 mg 1

atenolol-chlorthalidone oral tablet 100-25 mg 50-25 mg

1

benazepril oral tablet 10 mg 20 mg 40 mg 5 mg 1

benazepril-hydrochlorothiazide oral tablet 10-125 mg 20-125 mg 20-25 mg 5-625 mg

1

betaxolol oral tablet 10 mg 20 mg 1

bisoprolol fumarate oral tablet 10 mg 5 mg 1

46


bisoprolol-hydrochlorothiazide oral tablet 10-625 mg 25-625 mg 5-625 mg

1

bumetanide injection solution 025 mgml 1

bumetanide oral tablet 05 mg 1 mg 2 mg 1

BYSTOLIC ORAL TABLET 10 MG 25 MG 20 MG 5 MG

1 ST

candesartan oral tablet 16 mg 32 mg 4 mg 8 mg 1

candesartan-hydrochlorothiazid oral tablet 16-125 mg 32-125 mg 32-25 mg

1

captopril oral tablet 100 mg 125 mg 25 mg 50 mg

1

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

1

cartia xt oral capsuleextended release 24hr 120 mg 180 mg 240 mg 300 mg

1

carvedilol oral tablet 125 mg 25 mg 3125 mg 625 mg

1

carvedilol phosphate oral capsule er multiphase 24 hr 10 mg 20 mg 40 mg 80 mg

1

chlorthalidone oral tablet 25 mg 50 mg 1

clonidine hcl oral tablet 01 mg 02 mg 03 mg 1

clonidine transdermal patch weekly 01 mg24 hr 02 mg24 hr 03 mg24 hr

1

diltiazem hcl oral capsuleextrel 24h degradable 120 mg 180 mg 240 mg

1

diltiazem hcl oral capsuleextended release 12 hr 120 mg 60 mg 90 mg

1

diltiazem hcl oral capsuleextended release 24 hr 180 mg 240 mg 300 mg 360 mg 420 mg

1

diltiazem hcl oral capsuleextended release 24hr 120 mg 180 mg 240 mg 300 mg 360 mg

1

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

1

diltiazem hcl oral tablet extended release 24 hr 180 mg 240 mg 300 mg 360 mg 420 mg

1

dilt-xr oral capsuleextrel 24h degradable 120 mg 180 mg 240 mg

1

doxazosin oral tablet 1 mg 2 mg 4 mg 8 mg 1

EDARBI ORAL TABLET 40 MG 80 MG 1 ST

47


EDARBYCLOR ORAL TABLET 40-125 MG 40-25 MG

1 ST

enalapril maleate oral solution 1 mgml 1

enalapril maleate oral tablet 10 mg 25 mg 20 mg 5 mg

1

enalaprilat intravenous solution 125 mgml MB

enalapril-hydrochlorothiazide oral tablet 10-25 mg 5-125 mg

1

EPANED ORAL SOLUTION 1 MGML 1

eplerenone oral tablet 25 mg 50 mg 1

epoprostenol (glycine) intravenous recon soln 05 mg 15 mg

MB PA LA

eprosartan oral tablet 600 mg 1

ethacrynic acid oral tablet 25 mg 1

felodipine oral tablet extended release 24 hr 10 mg 25 mg 5 mg

1

FLOLAN INTRAVENOUS RECON SOLN 05 MG 15 MG

MB PA LA

fosinopril oral tablet 10 mg 20 mg 40 mg 1

fosinopril-hydrochlorothiazide oral tablet 10-125 mg 20-125 mg

1

furosemide oral solution 10 mgml 40 mg5 ml (8 mgml)

1

furosemide oral tablet 20 mg 40 mg 80 mg 1

guanfacine oral tablet 1 mg 2 mg 1

hydralazine oral tablet 10 mg 100 mg 25 mg 50 mg

1

hydrochlorothiazide oral capsule 125 mg 1

hydrochlorothiazide oral tablet 125 mg 25 mg 50 mg

1

indapamide oral tablet 125 mg 25 mg 1

irbesartan oral tablet 150 mg 300 mg 75 mg 1

irbesartan-hydrochlorothiazide oral tablet 150-125 mg 300-125 mg

1

isradipine oral capsule 25 mg 5 mg 1

labetalol oral tablet 100 mg 200 mg 300 mg 1

lisinopril oral tablet 10 mg 25 mg 20 mg 30 mg 40 mg 5 mg

1

48


lisinopril-hydrochlorothiazide oral tablet 10-125 mg 20-125 mg 20-25 mg

1

losartan oral tablet 100 mg 25 mg 50 mg 1

losartan-hydrochlorothiazide oral tablet 100-125 mg 100-25 mg 50-125 mg

1

matzim la oral tablet extended release 24 hr 180 mg 240 mg 300 mg 360 mg 420 mg

1

methyldopa oral tablet 250 mg 500 mg 1

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

1

methyldopate intravenous solution 250 mg5 ml MB

metolazone oral tablet 10 mg 25 mg 5 mg 1

metoprolol succinate oral tablet extended release 24 hr 100 mg 200 mg 25 mg 50 mg

1

metoprolol ta-hydrochlorothiaz oral tablet 100-25 mg 100-50 mg 50-25 mg

1

metoprolol tartrate oral tablet 100 mg 25 mg 375 mg 50 mg 75 mg

1

metyrosine oral capsule 250 mg 1

minoxidil oral tablet 10 mg 25 mg 1

moexipril oral tablet 15 mg 75 mg 1

nadolol oral tablet 20 mg 40 mg 80 mg 1

nadolol-bendroflumethiazide oral tablet 80-5 mg 1

nebivolol oral tablet 10 mg 25 mg 20 mg 5 mg 1

nicardipine oral capsule 20 mg 30 mg 1

nifedipine oral capsule 10 mg 20 mg 1

nifedipine oral tablet extended release 24hr 30 mg 60 mg 90 mg

1

nifedipine oral tablet extended release 30 mg 60 mg 90 mg

1

nimodipine oral capsule 30 mg 1

nisoldipine oral tablet extended release 24 hr 17 mg 20 mg 255 mg 30 mg 34 mg 40 mg 85 mg

1

olmesartan oral tablet 20 mg 40 mg 5 mg 1

olmesartan-amlodipin-hcthiazid oral tablet 20-5-125 mg 40-10-125 mg 40-10-25 mg 40-5-125 mg 40-5-25 mg

1

olmesartan-hydrochlorothiazide oral tablet 20-125 mg 40-125 mg 40-25 mg

1 ST

49


ORENITRAM ORAL TABLET EXTENDED RELEASE 0125 MG 025 MG 1 MG 25 MG 5 MG

1 PA LA

perindopril erbumine oral tablet 2 mg 4 mg 8 mg 1

phenoxybenzamine oral capsule 10 mg 1

pindolol oral tablet 10 mg 5 mg 1

prazosin oral capsule 1 mg 2 mg 5 mg 1

propranolol oral capsuleextended release 24 hr 120 mg 160 mg 60 mg 80 mg

1

propranolol oral solution 20 mg5 ml (4 mgml) 40 mg5 ml (8 mgml)

1

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

1

propranolol-hydrochlorothiazid oral tablet 40-25 mg 80-25 mg

1

QBRELIS ORAL SOLUTION 1 MGML 1

quinapril oral tablet 10 mg 20 mg 40 mg 5 mg 1

quinapril-hydrochlorothiazide oral tablet 10-125 mg 20-125 mg 20-25 mg

1

ramipril oral capsule 125 mg 10 mg 25 mg 5 mg

1

spironolactone oral tablet 100 mg 25 mg 50 mg 1

spironolacton-hydrochlorothiaz oral tablet 25-25 mg

1

taztia xt oral capsuleextended release 24 hr 120 mg 180 mg 240 mg 300 mg 360 mg

1

TEKTURNA HCT ORAL TABLET 150-125 MG 150-25 MG 300-125 MG 300-25 MG

1

telmisartan oral tablet 20 mg 40 mg 80 mg 1

telmisartan-amlodipine oral tablet 40-10 mg 40-5 mg 80-10 mg 80-5 mg

1 ST

telmisartan-hydrochlorothiazid oral tablet 40-125 mg 80-125 mg 80-25 mg

1

terazosin oral capsule 1 mg 10 mg 2 mg 5 mg 1

tiadylt er oral capsuleextended release 24 hr 120 mg 180 mg 240 mg 300 mg 360 mg 420 mg

1

timolol maleate oral tablet 10 mg 20 mg 5 mg 1

torsemide oral tablet 10 mg 100 mg 20 mg 5 mg 1

trandolapril oral tablet 1 mg 2 mg 4 mg 1

50


trandolapril-verapamil oral tablet ir - er biphasic 24hr 1-240 mg 2-180 mg 2-240 mg 4-240 mg

1 ST

triamterene oral capsule 100 mg 50 mg 1

triamterene-hydrochlorothiazid oral capsule 375-25 mg

1

triamterene-hydrochlorothiazid oral tablet 375-25 mg 75-50 mg

1

valsartan oral tablet 160 mg 320 mg 40 mg 80 mg

1

valsartan-hydrochlorothiazide oral tablet 160-125 mg 160-25 mg 320-125 mg 320-25 mg 80-125 mg

1

veletri intravenous recon soln 05 mg 15 mg MB PA LA

verapamil oral capsule 24 hr er pellet ct 100 mg 200 mg 300 mg

1

verapamil oral capsuleext rel pellets 24 hr 120 mg 180 mg 240 mg 360 mg

1

verapamil oral tablet 120 mg 40 mg 80 mg 1

verapamil oral tablet extended release 120 mg 180 mg 240 mg

1

CARDIAC GLYCOSIDES

digitek oral tablet 125 mcg (0125 mg) 250 mcg (025 mg)

1

digox oral tablet 125 mcg (0125 mg) 250 mcg (025 mg)

1

digoxin oral solution 50 mcgml (005 mgml) 1

digoxin oral tablet 125 mcg (0125 mg) 250 mcg (025 mg)

1

COAGULATION THERAPY

ADVATE INTRAVENOUS RECON SOLN 1000 (+-) UNIT 1500 (+-) UNIT 2000 (+-) UNIT 250 (+-) UNIT 3000 (+-) UNIT 4000 (+-) UNIT 500 (+-) UNIT

MB

ADYNOVATE INTRAVENOUS SOLUTION 1000 (+-) UNIT 1500 (+-) UNIT 2000 (+-) UNIT 250 (+-) UNIT 3000 (+-) UNIT 500 (+-) UNIT 750 (+-) UNIT

MB LA

51


AFSTYLA INTRAVENOUS RECON SOLN 1000 (+-) UNIT RANGE 1500 (+-) UNIT RANGE 2000 (+-) UNIT RANGE 2500 (+-) UNIT RANGE 250 (+-) UNIT RANGE 3000 (+-) UNIT RANGE 500 (+-) UNIT RANGE

MB LA

ALPHANATE INTRAVENOUS RECON SOLN 1000 (400 VWF) UNIT10 ML 1500 (600 VWF) UNIT10 ML 2000 (800 VWF) UNIT10 ML 250 (100 VWF) UNIT5 ML 500 (200 VWF) UNIT5 ML

MB LA

ALPHANINE SD INTRAVENOUS RECON SOLN 1000 (+-) UNIT 1500 (+-) UNIT 500 (+-) UNIT

MB LA

ALPROLIX INTRAVENOUS RECON SOLN 1000 UNIT 2000 UNIT 250 UNIT 3000 UNIT 4000 UNIT 500 UNIT

MB LA

aminocaproic acid oral solution 250 mgml (25 ) 1

aminocaproic acid oral tablet 1000 mg 500 mg 1

ANDEXXA INTRAVENOUS RECON SOLN 200 MG

MB

aspirin-dipyridamole oral capsule er multiphase 12 hr 25-200 mg

1

BENEFIX INTRAVENOUS RECON SOLN 1000 UNIT 2000 UNIT 250 UNIT 3000 UNIT 500 UNIT

MB LA

BRILINTA ORAL TABLET 60 MG 90 MG 1

CABLIVI INJECTION KIT 11 MG 1 PA

cilostazol oral tablet 100 mg 50 mg 1

clopidogrel oral tablet 300 mg 75 mg 1

COAGADEX INTRAVENOUS RECON SOLN 250 (+-) UNIT RANGE 500 (+-) UNIT RANGE

MB

CORIFACT INTRAVENOUS RECON SOLN 1000-1600 UNIT

MB LA

dipyridamole oral tablet 25 mg 50 mg 75 mg 1

DOPTELET (15 TAB PACK) ORAL TABLET 20 MG

1 PA LA

ELIQUIS DVT-PE TREAT 30D START ORAL TABLETSDOSE PACK 5 MG (74 TABS)

1

ELIQUIS ORAL TABLET 25 MG 5 MG 1

52


ELOCTATE INTRAVENOUS RECON SOLN 1000 UNIT 1500 UNIT 2000 UNIT 250 UNIT 3000 UNIT 4000 UNIT 5000 UNIT 500 UNIT 6000 UNIT 750 UNIT

MB LA

enoxaparin subcutaneous solution 300 mg3 ml 1

enoxaparin subcutaneous syringe 100 mgml 120 mg08 ml 150 mgml 30 mg03 ml 40 mg04 ml 60 mg06 ml 80 mg08 ml

1

ESPEROCT INTRAVENOUS RECON SOLN 1000 (+-) UNIT 1500 (+-) UNIT 2000 (+-) UNIT 3000 (+-) UNIT 500 (+-) UNIT

MB LA

FEIBA NF INTRAVENOUS RECON SOLN 1750-3250 UNIT 350-650 UNIT 700-1300 UNIT

MB LA

FIBRYGA INTRAVENOUS RECON SOLN 1 GRAM (700 MG- 1300 MG)

MB

fondaparinux subcutaneous syringe 10 mg08 ml 25 mg05 ml 5 mg04 ml 75 mg06 ml

1

FRAGMIN SUBCUTANEOUS SOLUTION 25000 ANTI-XA UNITML

1

FRAGMIN SUBCUTANEOUS SYRINGE 10000 ANTI-XA UNITML 12500 ANTI-XA UNIT05 ML 15000 ANTI-XA UNIT06 ML 18000 ANTI-XA UNIT072 ML 2500 ANTI-XA UNIT02 ML 5000 ANTI-XA UNIT02 ML 7500 ANTI-XA UNIT03 ML

1

HEMLIBRA SUBCUTANEOUS SOLUTION 105 MG07 ML 150 MGML 30 MGML 60 MG04 ML

1 PA LA

HEMOFIL M HIGH INTRAVENOUS RECON SOLN 801-1500 UNIT

MB

HEMOFIL M LOW INTRAVENOUS RECON SOLN 220-400 UNIT

MB

HEMOFIL M MID INTRAVENOUS RECON SOLN 401-800 UNIT

MB

HEMOFIL M SUPER HIGH INTRAVENOUS RECON SOLN 1501-2000 UNIT

MB

hep flush-10 (pf) intravenous solution 10 unitml MB

heparin (porcine) in 5 dex intravenous parenteral solution 25000 unit250 ml(100 unitml) 25000 unit500 ml (50 unitml)

MB

heparin (porcine) injection cartridge 5000 unitml (1 ml)

1

53


heparin (porcine) injection solution 1000 unitml 10000 unitml 20000 unitml 5000 unitml

1

heparin lock flush (porcine) intravenous solution 100 unitml

MB

heparin lockflush(porcine)(pf) intravenous syringe 100 unitml

MB

HEPARIN(PORCINE) IN 045 NACL INTRAVENOUS PARENTERAL SOLUTION 12500 UNIT250 ML

MB

heparin(porcine) in 045 nacl intravenous parenteral solution 25000 unit250 ml 25000 unit500 ml

MB

heparin porcine (pf) injection solution 1000 unitml

MB

heparin porcine (pf) injection syringe 5000 unit05 ml

1

heparin porcine (pf) intravenous solution 100 unitml (1 ml)

MB

heparin porcine (pf) intravenous syringe 10 unitml 100 unitml

MB

HUMATE-P INTRAVENOUS RECON SOLN 1000-2400 UNIT 250-600 UNIT 500-1200 UNIT

MB LA

IDELVION INTRAVENOUS RECON SOLN 1000 (+-) UNIT 2000 (+-) UNIT 250 (+-) UNIT 3500 (+-) UNIT 500 (+-) UNIT

MB LA

IXINITY INTRAVENOUS RECON SOLN 1000 UNIT 1500 UNIT 2000 UNIT 250 UNIT 3000 UNIT 500 UNIT

MB LA

jantoven oral tablet 1 mg 10 mg 2 mg 25 mg 3 mg 4 mg 5 mg 6 mg 75 mg

1

JIVI INTRAVENOUS RECON SOLN 1000 (+-) UNIT 2000 (+-) UNIT 3000 (+-) UNIT 500 (+-) UNIT

MB LA

KOATE INTRAVENOUS RECON SOLN 1000 (+-) UNIT 250 (+-) UNIT 500 (+-) UNIT

MB

KOGENATE FS INTRAVENOUS RECON SOLN 1000 (+-) UNIT 2000 (+-) UNIT 250 (+-) UNIT 3000 (+-) UNIT 500 (+-) UNIT

MB

KOVALTRY INTRAVENOUS RECON SOLN 1000 (+-) UNIT 2000 (+-) UNIT 250 (+-) UNIT 3000 (+-) UNIT 500 (+-) UNIT

MB

54


MONONINE INTRAVENOUS RECON SOLN 1000 (+-) UNIT

MB LA

MULPLETA ORAL TABLET 3 MG 1 PA LA

NOVOEIGHT INTRAVENOUS RECON SOLN 1000 (+-) UNIT 1500 (+-) UNIT 2000 (+-) UNIT 250 (+-) UNIT 3000 (+-) UNIT 500 (+-) UNIT

MB LA

NOVOSEVEN RT INTRAVENOUS RECON SOLN 1 MG (1000 MCG) 2 MG (2000 MCG) 5 MG (5000 MCG) 8 MG (8000 MCG)

MB LA

NPLATE SUBCUTANEOUS RECON SOLN 125 MCG 250 MCG 500 MCG

MB LA

NUWIQ INTRAVENOUS RECON SOLN 1000 (+-) UNIT 2000 (+-) UNIT 2500 UNIT 250 (+-) UNIT 3000 UNIT 4000 UNIT 500 (+-) UNIT

MB LA

OBIZUR INTRAVENOUS RECON SOLN 500 (+-) UNIT RANGE

MB

pentoxifylline oral tablet extended release 400 mg 1

phytonadione (vitamin k1) oral tablet 5 mg 1

prasugrel oral tablet 10 mg 5 mg 1

PROFILNINE INTRAVENOUS RECON SOLN 1000 (+-) UNIT 1500 (+-) UNIT 500 (+-) UNIT

MB LA

PROMACTA ORAL POWDER IN PACKET 125 MG

1 PA ST LA


1 LA

PROMACTA ORAL TABLET 125 MG 25 MG 50 MG 75 MG

1 PA ST LA

REBINYN INTRAVENOUS RECON SOLN 1000 (+-) UNIT 2000 (+-) UNIT 500 (+-) UNIT

MB LA

RECOMBINATE INTRAVENOUS RECON SOLN 1000 (+-) UNIT 1500 (+-) UNIT 2000 (+-) UNIT 250 (+-) UNIT 500 (+-) UNIT

MB LA

RIASTAP INTRAVENOUS RECON SOLN 1 GRAM (900MG-1300MG)

MB LA

RIXUBIS INTRAVENOUS RECON SOLN 1000 UNIT 2000 UNIT 250 UNIT 3000 UNIT 500 UNIT

MB LA

55


tranexamic acid intravenous solution 1000 mg10 ml (100 mgml)

MB

TRETTEN INTRAVENOUS RECON SOLN 2500 UNIT

MB LA

VONVENDI INTRAVENOUS RECON SOLN 1300 (+-) UNIT RANGE 650 (+-) UNIT RANGE

MB LA

warfarin oral tablet 1 mg 10 mg 2 mg 25 mg 3 mg 4 mg 5 mg 6 mg 75 mg

1

WILATE INTRAVENOUS RECON SOLN 1000-1000 UNIT 500-500 UNIT

MB LA

XARELTO DVT-PE TREAT 30D START ORAL TABLETSDOSE PACK 15 MG (42)- 20 MG (9)

1

XARELTO ORAL TABLET 10 MG 15 MG 25 MG 20 MG

1

XYNTHA INTRAVENOUS SOLUTION 1000 (+-) UNIT 2000 (+-) UNIT 250 (+-) UNIT 500 (+-) UNIT

MB LA

XYNTHA SOLOFUSE INTRAVENOUS SYRINGE 1000 (+-) UNIT 2000 (+-) UNIT 250 (+-) UNIT 3000 (+-) UNIT 500 (+-) UNIT

MB LA

ZONTIVITY ORAL TABLET 208 MG 1

LIPIDCHOLESTEROL LOWERING AGENTS

amlodipine-atorvastatin oral tablet 10-10 mg 10-20 mg 10-40 mg 10-80 mg 25-10 mg 25-20 mg 25-40 mg 5-10 mg 5-20 mg 5-40 mg 5-80 mg

1 ST

atorvastatin oral tablet 10 mg 20 mg ACA PV

atorvastatin oral tablet 40 mg 80 mg 1

cholestyramine (with sugar) oral powder 4 gram 1

cholestyramine (with sugar) oral powder in packet 4 gram

1

cholestyramine light oral powder 4 gram 1

cholestyramine light oral powder in packet 4 gram 1

colesevelam oral powder in packet 375 gram 1

colesevelam oral tablet 625 mg 1

colestipol oral granules 5 gram 1

colestipol oral packet 5 gram 1

colestipol oral tablet 1 gram 1

ezetimibe oral tablet 10 mg 1

56


ezetimibe-simvastatin oral tablet 10-10 mg 10-20 mg 10-40 mg 10-80 mg

1

fenofibrate micronized oral capsule 130 mg 134 mg 200 mg 43 mg 67 mg

1

fenofibrate nanocrystallized oral tablet 145 mg 48 mg

1

FENOFIBRATE ORAL CAPSULE 150 MG 50 MG

1

fenofibrate oral tablet 120 mg 160 mg 40 mg 54 mg

1

fenofibric acid (choline) oral capsuledelayed release(drec) 135 mg 45 mg

1

fenofibric acid oral tablet 105 mg 35 mg 1

fluvastatin oral capsule 20 mg 40 mg ACA PV

fluvastatin oral tablet extended release 24 hr 80 mg

ACA PV

gemfibrozil oral tablet 600 mg 1

icosapent ethyl oral capsule 1 gram 1 PA ST QL (120 per 30 days)

JUXTAPID ORAL CAPSULE 10 MG 20 MG 30 MG 40 MG 5 MG 60 MG


LIPOFEN ORAL CAPSULE 150 MG 50 MG 1

lovastatin oral tablet 10 mg 20 mg 40 mg ACA PV

niacin oral tablet 500 mg 1

niacin oral tablet extended release 24 hr 1000 mg 500 mg 750 mg

1

NIACOR ORAL TABLET 500 MG 1

omega-3 acid ethyl esters oral capsule 1 gram 1

pravastatin oral tablet 10 mg 20 mg 40 mg 80 mg

ACA PV

prevalite oral powder 4 gram 1

prevalite oral powder in packet 4 gram 1

REPATHA PUSHTRONEX SUBCUTANEOUS WEARABLE INJECTOR 420 MG35 ML

1 PA ST

REPATHA SURECLICK SUBCUTANEOUS PEN INJECTOR 140 MGML

1 PA ST

REPATHA SYRINGE SUBCUTANEOUS SYRINGE 140 MGML

1 PA ST

rosuvastatin oral tablet 10 mg 5 mg ACA PV

rosuvastatin oral tablet 20 mg 40 mg 1

57


simvastatin oral tablet 10 mg 20 mg 40 mg 5 mg ACA PV

simvastatin oral tablet 80 mg 1

VASCEPA ORAL CAPSULE 05 GRAM 1 GRAM


ZYPITAMAG ORAL TABLET 2 MG 4 MG 1 PA ST

MISCELLANEOUS CARDIOVASCULAR AGENTS

CORLANOR ORAL SOLUTION 5 MG5 ML 1 PA

CORLANOR ORAL TABLET 5 MG 75 MG 1 PA

ENTRESTO ORAL TABLET 24-26 MG 49-51 MG 97-103 MG

1 PA ST

GIAPREZA INTRAVENOUS SOLUTION 25 MGML

MB

ranolazine oral tablet extended release 12 hr 1000 mg 500 mg

1 ST

NITRATES

GONITRO SUBLINGUAL POWDER IN PACKET 400 MCG

1

isosorbide dinitrate oral tablet 10 mg 20 mg 30 mg 40 mg 5 mg

1

isosorbide mononitrate oral tablet 10 mg 20 mg 1

isosorbide mononitrate oral tablet extended release 24 hr 120 mg 30 mg 60 mg

1

MINITRAN TRANSDERMAL PATCH 24 HOUR 01 MGHR 02 MGHR 04 MGHR 06 MGHR


nitro-bid transdermal ointment 2 1

NITRO-DUR TRANSDERMAL PATCH 24 HOUR 01 MGHR 02 MGHR 03 MGHR 04 MGHR 06 MGHR 08 MGHR


nitroglycerin in 5 dextrose intravenous solution 25 mg250 ml (100 mcgml) 50 mg500 ml (100 mcgml)

MB

nitroglycerin sublingual tablet 03 mg 04 mg 06 mg

1

nitroglycerin transdermal patch 24 hour 01 mghr 02 mghr 04 mghr 06 mghr

1

nitroglycerin translingual spraynon-aerosol 400 mcgspray

1

nitro-time oral capsule extended release 25 mg 65 mg 9 mg

1

58


DERMATOLOGICALSTOPICAL THERAPY

ANTIPSORIATIC ANTISEBORRHEIC

acitretin oral capsule 10 mg 175 mg 25 mg 1

calcipotriene scalp solution 0005 1

calcipotriene topical cream 0005 1

calcipotriene topical ointment 0005 1

calcipotriene-betamethasone topical ointment 0005-0064

1

calcitriol topical ointment 3 mcggram 1

COSENTYX (2 SYRINGES) SUBCUTANEOUS SYRINGE 150 MGML

1 PA ST LA

COSENTYX PEN (2 PENS) SUBCUTANEOUS PEN INJECTOR 150 MGML

1 PA ST LA

COSENTYX PEN SUBCUTANEOUS PEN INJECTOR 150 MGML

1 PA ST LA

COSENTYX SUBCUTANEOUS SYRINGE 150 MGML 75 MG05 ML

1 PA ST LA

hydrocortisone-pramoxine topical cream 25-1 1

ILUMYA SUBCUTANEOUS SYRINGE 100 MGML

1 PA ST LA

selenium sulfide topical lotion 25 1

selenium sulfide topical shampoo 225 23 1

SILIQ SUBCUTANEOUS SYRINGE 210 MG15 ML

1 PA ST LA

SKYRIZI SUBCUTANEOUS PEN INJECTOR 150 MGML

1 PA ST LA

SKYRIZI SUBCUTANEOUS SYRINGE 150 MGML

1 PA ST LA

SKYRIZI SUBCUTANEOUS SYRINGE KIT 150MG166ML(75 MG083 ML X2)

1 PA ST LA

STELARA INTRAVENOUS SOLUTION 130 MG26 ML

MB PA LA

STELARA SUBCUTANEOUS SOLUTION 45 MG05 ML

1 PA ST LA

STELARA SUBCUTANEOUS SYRINGE 45 MG05 ML 90 MGML

1 PA ST LA

sulfacetamide sodium topical cleanser 10 1

sulfacetamide sodium topical cleanser gel 10 1

59


sulfacetamide sodium topical shampoo 10 1

TALTZ AUTOINJECTOR (2 PACK) SUBCUTANEOUS AUTO-INJECTOR 80 MGML

1 PA ST LA


1 PA ST LA

TALTZ AUTOINJECTOR SUBCUTANEOUS AUTO-INJECTOR 80 MGML

1 PA ST LA

TALTZ SYRINGE SUBCUTANEOUS SYRINGE 80 MGML

1 PA ST LA

TREMFYA SUBCUTANEOUS AUTO-INJECTOR 100 MGML

1 PA ST LA

TREMFYA SUBCUTANEOUS SYRINGE 100 MGML

1 PA ST LA

BURN THERAPY

silver sulfadiazine topical cream 1 1

ssd topical cream 1 1

MISCELLANEOUS DERMATOLOGICALS

ammonium lactate topical cream 12 1

ammonium lactate topical lotion 12 1


DUPIXENT PEN SUBCUTANEOUS PEN INJECTOR 200 MG114 ML 300 MG2 ML

1 PA ST LA QL (2 per 30 days)

DUPIXENT SYRINGE SUBCUTANEOUS SYRINGE 200 MG114 ML 300 MG2 ML


EUCRISA TOPICAL OINTMENT 2 1 PA ST

FLUOROURACIL TOPICAL CREAM 05 1 PA ST

fluorouracil topical cream 5 1 PA ST

fluorouracil topical solution 2 5 1

LEVULAN TOPICAL SOLUTION 20 1

methoxsalen oral capsuleliqd-filledrapid rel 10 mg

1

PANRETIN TOPICAL GEL 01 1

PICATO TOPICAL GEL 0015 005 1

pimecrolimus topical cream 1 1

podofilox topical solution 05 1

prudoxin topical cream 5 1

60


REGRANEX TOPICAL GEL 001 1

SCENESSE SUBCUTANEOUS IMPLANT 16 MG

MB PA

tacrolimus topical ointment 003 01 1

UVADEX INJECTION SOLUTION 20 MCGML 1

VALCHLOR TOPICAL GEL 0016 1 PA ST LA

THERAPY FOR ACNE

accutane oral capsule 20 mg 30 mg 40 mg 1

adapalene topical cream 01 1 ST

adapalene topical gel 03 1 ST

adapalene topical gel with pump 03 1 ST

ADAPALENE TOPICAL LOTION 01 1 ST

adapalene topical solution 01 1 ST

adapalene topical swab 01 1 ST

adapalene-benzoyl peroxide topical gel with pump 01-25

1

amnesteem oral capsule 10 mg 20 mg 40 mg 1 PA ST

avita topical cream 0025 1

AVITA TOPICAL GEL 0025 1 ST

azelaic acid topical gel 15 1

AZELEX TOPICAL CREAM 20 1 ST

claravis oral capsule 10 mg 20 mg 30 mg 1 PA ST

claravis oral capsule 40 mg 1

clindacin p topical swab 1 1

clindamycin phosphate topical foam 1 1

clindamycin phosphate topical gel 1 1

clindamycin phosphate topical lotion 1 1

clindamycin phosphate topical solution 1 1

clindamycin phosphate topical swab 1 1

clindamycin-benzoyl peroxide topical gel 1-5 12 (1 base) -5

1

clindamycin-benzoyl peroxide topical gel with pump 1-5

1

clindamycin-tretinoin topical gel 12-0025 1

dapsone topical gel 5 1

ery pads topical swab 2 1

61


erygel topical gel 2 1

erythromycin with ethanol topical gel 2 1

erythromycin with ethanol topical solution 2 1

erythromycin-benzoyl peroxide topical gel 3-5 1

isotretinoin oral capsule 10 mg 20 mg 25 mg 30 mg 35 mg 40 mg

1

metronidazole topical cream 075 1

metronidazole topical gel 075 1 1

metronidazole topical gel with pump 1 1

metronidazole topical lotion 075 1

myorisan oral capsule 10 mg 20 mg 30 mg 40 mg

1

rosadan topical cream 075 1

rosadan topical gel 075 1

tazarotene topical cream 01 1 ST

tretinoin microspheres topical gel 004 01 1

tretinoin microspheres topical gel with pump 004 01

1

tretinoin topical cream 0025 005 01 1

tretinoin topical gel 001 0025 005 1

zenatane oral capsule 10 mg 20 mg 30 mg 40 mg 1

TOPICAL ANESTHETICS

lidocaine hcl injection solution 10 mgml (1 ) 1

lidocaine hcl laryngotracheal solution 4 1

lidocaine hcl mucous membrane jelly 2 1

lidocaine hcl mucous membrane jelly in applicator 2

1

lidocaine hcl mucous membrane solution 4 (40 mgml)

1

lidocaine hcl-hydrocortison ac topical cream 3-05

1

lidocaine topical adhesive patchmedicated 5 1

lidocaine topical ointment 5 1

lidocaine viscous mucous membrane solution 2 1

lidocaine-prilocaine topical cream 25-25 1

lidocaine-prilocaine topical kit 25-25 1

62


LIDOCAINE-TETRACAINE TOPICAL CREAM 7-7

1 ST

SYNERA TOPICAL PATCH MEDICATED SELF-HEATING 70-70 MG

1 ST

TOPICAL ANTIBACTERIALS

ALCORTIN A TOPICAL GEL 2-1-1 1 ST

ALCORTIN A TOPICAL GEL IN PACKET 2-1-1

1 ST

ALTABAX TOPICAL OINTMENT 1 1

gentamicin topical cream 01 1

gentamicin topical ointment 01 1

mafenide acetate topical packet 50 gram 1

mupirocin calcium topical cream 2 1

mupirocin topical ointment 2 1

sulfacetamide sodium (acne) topical suspension 10

1

SULFAMYLON TOPICAL CREAM 85 MGG 1

TOPICAL ANTIFUNGALS

ciclodan topical cream 077 1

ciclodan topical solution 8 1

ciclopirox topical cream 077 1

ciclopirox topical gel 077 1

ciclopirox topical shampoo 1 1

ciclopirox topical solution 8 1

ciclopirox topical suspension 077 1

ciclopirox-ure-camph-menth-euc topical solution 8

1

clotrimazole topical cream 1 1

clotrimazole topical solution 1 1

clotrimazole-betamethasone topical cream 1-005

1

clotrimazole-betamethasone topical lotion 1-005

1

econazole topical cream 1 1

EXELDERM TOPICAL CREAM 1 1

EXELDERM TOPICAL SOLUTION 1 1

63


JUBLIA TOPICAL SOLUTION WITH APPLICATOR 10

1 PA ST

ketoconazole topical cream 2 1

ketoconazole topical foam 2 1

ketoconazole topical shampoo 2 1

ketodan topical foam 2 1

LULICONAZOLE TOPICAL CREAM 1 1

LUZU TOPICAL CREAM 1 1

MENTAX TOPICAL CREAM 1 1

naftifine topical cream 1 2 1

naftifine topical gel 1 1

nyamyc topical powder 100000 unitgram 1

nystatin topical cream 100000 unitgram 1

nystatin topical ointment 100000 unitgram 1

nystatin topical powder 100000 unitgram 1

nystatin-triamcinolone topical cream 100000-01 unitg-

1

nystatin-triamcinolone topical ointment 100000-01 unitgram-

1

nystop topical powder 100000 unitgram 1

oxiconazole topical cream 1 1

OXISTAT TOPICAL LOTION 1 1

tavaborole topical solution with applicator 5 1 PA ST

TOPICAL ANTIVIRALS

acyclovir topical cream 5 1

acyclovir topical ointment 5 1

DENAVIR TOPICAL CREAM 1 1

TOPICAL CORTICOSTEROIDS

ala-cort topical cream 1 1

alclometasone topical cream 005 1

alclometasone topical ointment 005 1

amcinonide topical cream 01 1

amcinonide topical lotion 01 1

apexicon e topical cream 005 1

beser topical lotion 005 1

betamethasone dipropionate topical cream 005 1

64


betamethasone dipropionate topical lotion 005 1

betamethasone dipropionate topical ointment 005

1

betamethasone valerate topical cream 01 1

betamethasone valerate topical foam 012 1

betamethasone valerate topical lotion 01 1

betamethasone valerate topical ointment 01 1

betamethasone augmented topical cream 005 1

betamethasone augmented topical gel 005 1

betamethasone augmented topical lotion 005 1

betamethasone augmented topical ointment 005

1

clobetasol scalp solution 005 1

clobetasol topical cream 005 1

clobetasol topical foam 005 1

clobetasol topical gel 005 1

clobetasol topical lotion 005 1

clobetasol topical ointment 005 1

clobetasol topical shampoo 005 1

clobetasol topical spraynon-aerosol 005 1

clobetasol-emollient topical cream 005 1

clobetasol-emollient topical foam 005 1

CLOCORTOLONE PIVALATE TOPICAL CREAM 01

1 ST

CLODERM TOPICAL CREAM 01 1 ST

desonide topical cream 005 1

desonide topical lotion 005 1

desonide topical ointment 005 1

desoximetasone topical cream 005 025 1

desoximetasone topical gel 005 1

desoximetasone topical ointment 005 025 1

desoximetasone topical spraynon-aerosol 025 1

diflorasone topical cream 005 1

diflorasone topical ointment 005 1

fluocinolone and shower cap scalp oil 001 1

fluocinolone topical cream 001 0025 1

65


fluocinolone topical oil 001 1

fluocinolone topical ointment 0025 1

fluocinolone topical solution 001 1

fluocinonide topical cream 005 01 1

fluocinonide topical gel 005 1

fluocinonide topical ointment 005 1

fluocinonide topical solution 005 1

fluocinonide-e topical cream 005 1

flurandrenolide topical cream 005 1

flurandrenolide topical lotion 005 1

flurandrenolide topical ointment 005 1

fluticasone propionate topical cream 005 1

fluticasone propionate topical lotion 005 1

fluticasone propionate topical ointment 0005 1

halcinonide topical cream 01 1

halobetasol propionate topical cream 005 1

halobetasol propionate topical ointment 005 1

hydrocortisone butyrate topical cream 01 1

hydrocortisone butyrate topical lotion 01 1

hydrocortisone butyrate topical ointment 01 1

hydrocortisone butyrate topical solution 01 1

hydrocortisone butyr-emollient topical cream 01

1

hydrocortisone topical cream 1 25 1

hydrocortisone topical lotion 25 1

hydrocortisone topical ointment 1 25 1

hydrocortisone valerate topical cream 02 1

hydrocortisone valerate topical ointment 02 1

mometasone topical cream 01 1

mometasone topical ointment 01 1

mometasone topical solution 01 1

prednicarbate topical cream 01 1

prednicarbate topical ointment 01 1

scalacort topical lotion 2 1

66


triamcinolone acetonide topical aerosol 0147 mggram

1

triamcinolone acetonide topical cream 0025 01 05

1

triamcinolone acetonide topical lotion 0025 01

1

triamcinolone acetonide topical ointment 0025 005 01 05

1

triderm topical cream 01 05 1

TOPICAL ENZYMES

SANTYL TOPICAL OINTMENT 250 UNITGRAM


TOPICAL SCABICIDES PEDICULICIDES

crotan topical lotion 10 1

EURAX TOPICAL CREAM 10 1

EURAX TOPICAL LOTION 10 1

ivermectin topical lotion 05 1

lindane topical shampoo 1 1

malathion topical lotion 05 1

permethrin topical cream 5 1

spinosad topical suspension 09 1

ULESFIA TOPICAL LOTION 5 1

DIAGNOSTICS amp MISCELLANEOUS AGENTS

IRRIGATING SOLUTIONS

PHYSIOLYTE IRRIGATION SOLUTION 140-5-3-98 MEQL

MB

PHYSIOSOL IRRIGATION IRRIGATION SOLUTION 140-5-3-98 MEQL

MB

MISCELLANEOUS AGENTS

acamprosate oral tabletdelayed release (drec) 333 mg

1

acetic acid irrigation solution 025 1

anagrelide oral capsule 05 mg 1 mg 1

ARALAST NP INTRAVENOUS RECON SOLN 1000 MG 500 MG

MB PA LA

CARBAGLU ORAL TABLET DISPERSIBLE 200 MG

1 PA LA

67


cevimeline oral capsule 30 mg 1

CHEMET ORAL CAPSULE 100 MG 1

deferasirox oral granules in packet 180 mg 360 mg 90 mg

1 PA LA

deferasirox oral tablet 180 mg 1 PA LA

deferasirox oral tablet 360 mg 90 mg 1 ST LA

deferasirox oral tablet dispersible 125 mg 250 mg 500 mg

1 ST LA

deferiprone oral tablet 500 mg 1 PA

disulfiram oral tablet 250 mg 500 mg 1

EMPAVELI SUBCUTANEOUS SOLUTION 1080 MG20 ML

1 PA

FERRIPROX ORAL SOLUTION 100 MGML 1 PA

FERRIPROX ORAL TABLET 1000 MG 1 PA

GIVLAARI SUBCUTANEOUS SOLUTION 189 MGML

MB PA LA

GLASSIA INTRAVENOUS SOLUTION 1 GRAM50 ML (2 )

MB PA LA

INCRELEX SUBCUTANEOUS SOLUTION 10 MGML

1 PA LA

levocarnitine (with sugar) oral solution 100 mgml 1

levocarnitine oral solution 100 mgml 1

levocarnitine oral tablet 330 mg 1

midodrine oral tablet 10 mg 25 mg 5 mg 1

nitisinone oral capsule 10 mg 2 mg 5 mg 1 PA LA

NITYR ORAL TABLET 10 MG 2 MG 5 MG 1 PA LA

pilocarpine hcl oral tablet 5 mg 1

PROLASTIN-C INTRAVENOUS SOLUTION 1000 MG (+-)20 ML

MB

RAVICTI ORAL LIQUID 11 GRAMML 1 PA ST LA QL (10 per 30 days)

RECLAST INTRAVENOUS PIGGYBACK 5 MG100 ML

MB

riluzole oral tablet 50 mg 1

risedronate oral tablet 30 mg 1

sodium chloride 09 injection solution MB

sodium chloride 09 intravenous parenteral solution

MB

sodium chloride 09 intravenous piggyback MB

68


sodium phenylbutyrate oral powder 094 gramgram

1 PA

sodium phenylbutyrate oral tablet 500 mg 1 PA

SOLIRIS INTRAVENOUS SOLUTION 300 MG30 ML

MB PA LA

trientine oral capsule 250 mg 1 PA QL (240 per 30 days)

XURIDEN ORAL GRANULES IN PACKET 2 GRAM

1 PA QL (120 per 30 days)

ZEMAIRA INTRAVENOUS RECON SOLN 1000 MG

MB PA LA

ZOKINVY ORAL CAPSULE 50 MG 75 MG 1 PA ST

SMOKING DETERRENTS

bupropion hcl (smoking deter) oral tablet extended release 12 hr 150 mg

ACA PV

nicorette buccal gum 4 mg ACA PV

nicotine (polacrilex) buccal gum 2 mg 4 mg ACA PV

nicotine (polacrilex) buccal lozenge 2 mg 4 mg ACA PV

nicotine (polacrilex) buccal mini lozenge 2 mg 4 mg

ACA PV

nicotine transdermal patch 24 hour 14 mg24 hr 21 mg24 hr 7 mg24 hr

ACA PV

nicotine transdermal patch td daily sequential 21-14-7 mg24 hr

ACA PV

NICOTROL INHALATION CARTRIDGE 10 MG

ACA PV

NICOTROL NS NASAL SPRAYNON-AEROSOL 10 MGML

ACA PV

quit 2 buccal gum 2 mg ACA PV

quit 2 buccal lozenge 2 mg ACA PV



stop smoking aid buccal lozenge 2 mg 4 mg ACA PV

varenicline oral tablet 05 mg 1 mg ACA PV QL (180 per 365 days)

EAR NOSE amp THROAT MEDICATIONS


ARESTIN DENTAL CARTRIDGE 1 MG MB

azelastine nasal aerosolspray 137 mcg (01 ) 1

69


azelastine nasal spraynon-aerosol 2055 mcg (015 )

1

chlorhexidine gluconate mucous membrane mouthwash 012

1

denta 5000 plus dental cream 11 1

dentagel dental gel 11 1

fluoride (sodium) dental cream 11 1

fluoride (sodium) dental gel 11 1

fluoride (sodium) dental paste 11 1

ipratropium bromide nasal spraynon-aerosol 21 mcg (003 ) 42 mcg (006 )

1

olopatadine nasal spraynon-aerosol 06 1

oralone dental paste 01 1

paroex oral rinse mucous membrane mouthwash 012

1

periogard mucous membrane mouthwash 012 1


sf 5000 plus dental cream 11 1

sf dental gel 11 1

sodium fluoride 5000 dry mouth dental gel 11 1

sodium fluoride 5000 plus dental cream 11 1

sodium fluoride-pot nitrate dental paste 11-5 1

triamcinolone acetonide dental paste 01 1

MISCELLANEOUS OTIC PREPARATIONS

acetic acid otic (ear) solution 2 1

ciprofloxacin hcl otic (ear) dropperette 02 1

flac otic oil otic (ear) drops 001 1

fluocinolone acetonide oil otic (ear) drops 001 1

hydrocortisone-acetic acid otic (ear) drops 1-2 1

ofloxacin otic (ear) drops 03 1

OTIC STEROID ANTIBIOTIC

CIPRO HC OTIC (EAR) DROPSSUSPENSION 02-1

1

ciprofloxacin-dexamethasone otic (ear) dropssuspension 03-01

1

neomycin-polymyxin-hc otic (ear) dropssuspension 35-10000-1 mgml-unitml-

1

70


neomycin-polymyxin-hc otic (ear) solution 35-10000-1 mgml-unitml-

1

OTOVEL OTIC (EAR) SOLUTION 03-0025 (025 ML)

1

ENDOCRINEDIABETES

ADRENAL HORMONES

ACTHAR INJECTION GEL 80 UNITML 1 PA LA

decadron oral tablet 05 mg 1

dexamethasone intensol oral drops 1 mgml 1

dexamethasone oral elixir 05 mg5 ml 1

dexamethasone oral solution 05 mg5 ml 1

dexamethasone oral tablet 05 mg 075 mg 1 mg 15 mg 2 mg 4 mg 6 mg

1

dexamethasone oral tabletsdose pack 15 mg (21 tabs) 15 mg (35 tabs) 15 mg (51 tabs)

1

dexamethasone sodium phos (pf) injection solution 10 mgml

1

dexamethasone sodium phosphate injection solution 10 mgml 4 mgml

1

dexamethasone sodium phosphate injection syringe 4 mgml

1

fludrocortisone oral tablet 01 mg 1

hydrocortisone oral tablet 10 mg 20 mg 5 mg 1

methylprednisolone acetate injection suspension 40 mgml 80 mgml

1

methylprednisolone oral tablet 16 mg 32 mg 4 mg 8 mg

1

methylprednisolone oral tabletsdose pack 4 mg 1

millipred dp oral tabletsdose pack 5 mg (21 tabs) 5 mg (48 tabs)

1

millipred oral tablet 5 mg 1

prednisolone oral solution 15 mg5 ml 1

prednisolone sodium phosphate oral solution 10 mg5 ml 15 mg5 ml (3 mgml) 20 mg5 ml (4 mgml) 25 mg5 ml (5 mgml) 5 mg base5 ml (67 mg5 ml)

1

prednisolone sodium phosphate oral tabletdisintegrating 10 mg 15 mg 30 mg

1

prednisone intensol oral concentrate 5 mgml 1

71


prednisone oral solution 5 mg5 ml 1

prednisone oral tablet 1 mg 10 mg 25 mg 20 mg 5 mg 50 mg

1

prednisone oral tabletsdose pack 10 mg 5 mg 1

triamcinolone acetonide injection suspension 40 mgml

MB

ANTITHYROID AGENTS

methimazole oral tablet 10 mg 5 mg 1

propylthiouracil oral tablet 50 mg 1

SSKI ORAL SOLUTION 1 GRAMML 1

BLOOD GLUCOSE MONITORING DEVICES amp SUPPLIES

CONTOUR NEXT TEST STRIPS STRIP 1

CONTOUR TEST STRIPS STRIP 1

ONETOUCH ULTRA TEST STRIP 1

ONETOUCH VERIO TEST STRIPS STRIP 1

DIABETES SUPPLIES amp DURABLE MEDICAL EQUIPMENT

AEROCHAMBER MINI SPACER 1

AEROCHAMBER PLUS FLOW-VU SPACER 1

GLUCAGEN DIAGNOSTIC KIT INJECTION RECON SOLN 1 MGML

1

GLUCAGON HCL INJECTION RECON SOLN 1 MGML

1

INSULIN SYRINGE-NEEDLE U-100 SYRINGE 05 ML 29 GAUGE X 12

1

TRIJARDY XR ORAL TABLET IR - ER BIPHASIC 24HR 10-5-1000 MG 125-25-1000 MG 25-5-1000 MG 5-25-1000 MG

1 PA ST

GLUCOSE ELEVATING AGENTS

BAQSIMI NASAL SPRAYNON-AEROSOL 3 MGACTUATION

1

diazoxide oral suspension 50 mgml 1

GLUCAGEN HYPOKIT INJECTION RECON SOLN 1 MG

1

GLUCAGON (HCL) EMERGENCY KIT INJECTION RECON SOLN 1 MG

1

glucagon emergency kit (human) injection recon soln 1 mg

1

INSULIN SYRINGESMISCELLANEOUS DURABLE MEDICAL EQU

72


FREESTYLE LIBRE 14 DAY SENSOR KIT 1

FREESTYLE LIBRE 2 SENSOR KIT 1

NOVOPEN ECHO SUBCUTANEOUS INSULIN PEN

1

PEN NEEDLE DIABETIC NEEDLE 29 GAUGE X 12

1

INSULIN THERAPY

FIASP FLEXTOUCH U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)

1

FIASP PENFILL U-100 INSULIN SUBCUTANEOUS CARTRIDGE 100 UNITML (3 ML)

1

FIASP U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNITML

1

HUMALOG JUNIOR KWIKPEN U-100 SUBCUTANEOUS INSULIN PEN HALF-UNIT 100 UNITML

1

HUMALOG KWIKPEN INSULIN SUBCUTANEOUS INSULIN PEN 100 UNITML

1 ST

HUMALOG KWIKPEN INSULIN SUBCUTANEOUS INSULIN PEN 200 UNITML (3 ML)

1

HUMALOG MIX 50-50 INSULN U-100 SUBCUTANEOUS SUSPENSION 100 UNITML (50-50)

1 ST

HUMALOG MIX 50-50 KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNITML (50-50)

1 ST


1 ST

HUMALOG MIX 75-25(U-100)INSULN SUBCUTANEOUS SUSPENSION 100 UNITML (75-25)

1 ST

HUMALOG U-100 INSULIN SUBCUTANEOUS CARTRIDGE 100 UNITML

1 ST

HUMALOG U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNITML

1 ST

73


HUMULIN 7030 U-100 INSULIN SUBCUTANEOUS SUSPENSION 100 UNITML (70-30)

1 ST

HUMULIN 7030 U-100 KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNITML (70-30)

1 ST

HUMULIN N NPH INSULIN KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)

1 ST

HUMULIN N NPH U-100 INSULIN SUBCUTANEOUS SUSPENSION 100 UNITML

1 ST

HUMULIN R REGULAR U-100 INSULN INJECTION SOLUTION 100 UNITML

1 ST

HUMULIN R U-500 (CONC) INSULIN SUBCUTANEOUS SOLUTION 500 UNITML

1

HUMULIN R U-500 (CONC) KWIKPEN SUBCUTANEOUS INSULIN PEN 500 UNITML (3 ML)

1

INSULIN ASP PRT-INSULIN ASPART SUBCUTANEOUS INSULIN PEN 100 UNITML (70-30)

1

INSULIN ASP PRT-INSULIN ASPART SUBCUTANEOUS SOLUTION 100 UNITML (70-30)

1

INSULIN ASPART U-100 SUBCUTANEOUS CARTRIDGE 100 UNITML

1

INSULIN ASPART U-100 SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)

1

INSULIN ASPART U-100 SUBCUTANEOUS SOLUTION 100 UNITML

1

LANTUS SOLOSTAR U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)

1

LANTUS U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNITML

1

LEVEMIR FLEXTOUCH U-100 INSULN SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)

1

LEVEMIR U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNITML

1

NOVOLIN 70-30 FLEXPEN U-100 SUBCUTANEOUS INSULIN PEN 100 UNITML (70-30)

1

74


NOVOLIN N FLEXPEN SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)

1

NOVOLIN R FLEXPEN SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)

1

NOVOLOG FLEXPEN U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)

1

NOVOLOG MIX 70-30 U-100 INSULN SUBCUTANEOUS SOLUTION 100 UNITML (70-30)

1

NOVOLOG MIX 70-30FLEXPEN U-100 SUBCUTANEOUS INSULIN PEN 100 UNITML (70-30)

1

NOVOLOG PENFILL U-100 INSULIN SUBCUTANEOUS CARTRIDGE 100 UNITML

1

NOVOLOG U-100 INSULIN ASPART SUBCUTANEOUS SOLUTION 100 UNITML

1

RELION NOVOLIN 7030 SUBCUTANEOUS SUSPENSION 100 UNITML (70-30)

1

RELION NOVOLIN N SUBCUTANEOUS SUSPENSION 100 UNITML

1

RELION NOVOLIN R INJECTION SOLUTION 100 UNITML

1

SOLIQUA 10033 SUBCUTANEOUS INSULIN PEN 100 UNIT-33 MCGML

1 PA ST

TOUJEO MAX U-300 SOLOSTAR SUBCUTANEOUS INSULIN PEN 300 UNITML (3 ML)

1

TOUJEO SOLOSTAR U-300 INSULIN SUBCUTANEOUS INSULIN PEN 300 UNITML (15 ML)

1

TRESIBA FLEXTOUCH U-100 SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)

1


1

TRESIBA U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNITML

1

XULTOPHY 10036 SUBCUTANEOUS INSULIN PEN 100 UNIT-36 MG ML (3 ML)

1 PA ST

MISCELLANEOUS HORMONES

75


ALDURAZYME INTRAVENOUS SOLUTION 29 MG5 ML

MB PA LA

ANDRODERM TRANSDERMAL PATCH 24 HOUR 2 MG24 HOUR 4 MG24 HR


BRINEURA INTRAVENTRICULAR KIT 300 MG10 ML (150MG5ML X2)

MB PA

cabergoline oral tablet 05 mg 1

calcitonin (salmon) injection solution 200 unitml 1

calcitonin (salmon) nasal spraynon-aerosol 200 unitactuation

1

calcitriol oral capsule 025 mcg 05 mcg 1

calcitriol oral solution 1 mcgml 1

CERDELGA ORAL CAPSULE 84 MG 1 PA LA

CEREZYME INTRAVENOUS RECON SOLN 400 UNIT

MB PA LA

cinacalcet oral tablet 30 mg 60 mg 90 mg 1 PA

CRYSVITA SUBCUTANEOUS SOLUTION 10 MGML 20 MGML 30 MGML

MB PA LA

danazol oral capsule 100 mg 200 mg 50 mg 1

DEPO-TESTOSTERONE INTRAMUSCULAR OIL 100 MGML

1

desmopressin nasal spraynon-aerosol 10 mcgspray (01 ml)

1

desmopressin oral tablet 01 mg 02 mg 1

doxercalciferol oral capsule 05 mcg 1 mcg 25 mcg

1

ELAPRASE INTRAVENOUS SOLUTION 6 MG3 ML

MB PA LA

ELELYSO INTRAVENOUS RECON SOLN 200 UNIT

MB PA LA

FABRAZYME INTRAVENOUS RECON SOLN 35 MG 5 MG

MB PA LA

GALAFOLD ORAL CAPSULE 123 MG 1 PA LA

JYNARQUE ORAL TABLET 15 MG 30 MG 1 PA QL (60 per 30 days)

JYNARQUE ORAL TABLETS SEQUENTIAL 45 MG (AM) 15 MG (PM) 60 MG (AM) 30 MG (PM) 90 MG (AM) 30 MG (PM)


KANUMA INTRAVENOUS SOLUTION 2 MGML

MB PA LA

76


KORLYM ORAL TABLET 300 MG 1 PA ST

LUMIZYME INTRAVENOUS RECON SOLN 50 MG

MB PA LA

MEPSEVII INTRAVENOUS SOLUTION 2 MGML

MB PA LA

methyltestosterone oral capsule 10 mg 1

miglustat oral capsule 100 mg 1 PA LA

MYALEPT SUBCUTANEOUS RECON SOLN 5 MGML (FINAL CONC)

1 PA LA

NAGLAZYME INTRAVENOUS SOLUTION 5 MG5 ML

MB PA LA

NATPARA SUBCUTANEOUS CARTRIDGE 100 MCGDOSE 25 MCGDOSE 50 MCGDOSE 75 MCGDOSE

1 PA ST LA

oxandrolone oral tablet 10 mg 25 mg 1

PALYNZIQ SUBCUTANEOUS SYRINGE 10 MG05 ML 25 MG05 ML 20 MGML

1 PA LA

pamidronate intravenous solution 30 mg10 ml (3 mgml)

MB

PARICALCITOL HEMODIALYSIS PORT INJECTION SOLUTION 5 MCGML

MB

paricalcitol intravenous solution 5 mcgml MB

paricalcitol oral capsule 1 mcg 2 mcg 4 mcg 1

PARSABIV INTRAVENOUS SOLUTION 5 MGML

MB PA

SAMSCA ORAL TABLET 15 MG 1 PA LA QL (60 per 30 days)

sapropterin oral powder in packet 100 mg 500 mg 1 PA LA

sapropterin oral tabletsoluble 100 mg 1 PA LA

SOMAVERT SUBCUTANEOUS RECON SOLN 10 MG 15 MG 20 MG 25 MG 30 MG


STRENSIQ SUBCUTANEOUS SOLUTION 18 MG045 ML 28 MG07 ML 40 MGML 80 MG08 ML

1 PA

SYNAREL NASAL SPRAYNON-AEROSOL 2 MGML

1

TEPEZZA INTRAVENOUS RECON SOLN 500 MG

MB PA LA

testosterone cypionate intramuscular oil 100 mgml 200 mgml

1

77


testosterone enanthate intramuscular oil 200 mgml

1

testosterone transdermal gel 50 mg5 gram (1 ) 1 QL (60 per 30 days)

testosterone transdermal gel in metered-dose pump 10 mg05 gram actuation 2025 mg125 gram (162 )


testosterone transdermal gel in metered-dose pump 125 mg 125 gram (1 )


testosterone transdermal gel in packet 1 (25 mg25gram) 162 (2025 mg125 gram)


testosterone transdermal gel in packet 1 (50 mg5 gram) 162 (405 mg25 gram)


testosterone transdermal solution in metered pump wapp 30 mgactuation (15 ml)


VIMIZIM INTRAVENOUS SOLUTION 5 MG5 ML (1 MGML)

MB PA LA

VPRIV INTRAVENOUS RECON SOLN 400 UNIT

MB PA LA

NON-INSULIN HYPOGLYCEMIC AGENTS

acarbose oral tablet 100 mg 25 mg 50 mg 1

ALOGLIPTIN-PIOGLITAZONE ORAL TABLET 125-15 MG 125-30 MG 125-45 MG 25-15 MG 25-30 MG 25-45 MG

1 PA ST

BYDUREON BCISE SUBCUTANEOUS AUTO-INJECTOR 2 MG085 ML

1 PA ST

BYETTA SUBCUTANEOUS PEN INJECTOR 10 MCGDOSE(250 MCGML) 24 ML 5 MCGDOSE (250 MCGML) 12 ML

1 PA ST

CYCLOSET ORAL TABLET 08 MG 1

FARXIGA ORAL TABLET 10 MG 5 MG 1 PA ST

glimepiride oral tablet 1 mg 2 mg 4 mg 1

glipizide oral tablet 10 mg 5 mg 1

glipizide oral tablet extended release 24hr 10 mg 25 mg 5 mg

1

glipizide-metformin oral tablet 25-250 mg 25-500 mg 5-500 mg

1

glyburide micronized oral tablet 15 mg 3 mg 6 mg

1

glyburide oral tablet 125 mg 25 mg 5 mg 1

78


glyburide-metformin oral tablet 125-250 mg 25-500 mg 5-500 mg

1

GLYXAMBI ORAL TABLET 10-5 MG 25-5 MG

1 PA ST

JANUMET ORAL TABLET 50-1000 MG 50-500 MG

1 PA ST

JANUMET XR ORAL TABLET ER MULTIPHASE 24 HR 100-1000 MG 50-1000 MG 50-500 MG

1 PA ST

JANUVIA ORAL TABLET 100 MG 25 MG 50 MG

1 PA ST

JARDIANCE ORAL TABLET 10 MG 25 MG 1 PA ST

JENTADUETO ORAL TABLET 25-1000 MG 25-500 MG 25-850 MG

1 PA ST

JENTADUETO XR ORAL TABLET IR - ER BIPHASIC 24HR 25-1000 MG 5-1000 MG

1 PA ST

metformin oral solution 500 mg5 ml 1 PA

metformin oral tablet 1000 mg 500 mg 850 mg 1

metformin oral tablet extended release 24 hr 500 mg 750 mg

1

metformin oral tablet extended release 24hr 1000 mg 500 mg

1 PA ST

metformin oral tableter gastretention 24 hr 1000 mg 500 mg

1 ST

miglitol oral tablet 100 mg 25 mg 50 mg 1

nateglinide oral tablet 120 mg 60 mg 1

OZEMPIC SUBCUTANEOUS PEN INJECTOR 025 MG OR 05 MG(2 MG15 ML) 1 MGDOSE (2 MG15 ML) 1 MGDOSE (4 MG3 ML)

1 PA ST

pioglitazone oral tablet 15 mg 30 mg 45 mg 1

pioglitazone-glimepiride oral tablet 30-2 mg 30-4 mg

1

pioglitazone-metformin oral tablet 15-500 mg 15-850 mg

1

QTERN ORAL TABLET 10-5 MG 5-5 MG 1 PA ST

repaglinide oral tablet 05 mg 1 mg 2 mg 1

repaglinide-metformin oral tablet 1-500 mg 2-500 mg

1

79


RIOMET ER ORAL SUSPENSIONEXTENDED REL RECON 500 MG5 ML

1 PA ST

RYBELSUS ORAL TABLET 14 MG 3 MG 7 MG

1 PA ST

SYMLINPEN 120 SUBCUTANEOUS PEN INJECTOR 2700 MCG27 ML

1 PA ST


1 PA ST

SYNJARDY ORAL TABLET 125-1000 MG 125-500 MG 5-1000 MG 5-500 MG

1 PA ST

SYNJARDY XR ORAL TABLET IR - ER BIPHASIC 24HR 10-1000 MG 125-1000 MG 25-1000 MG 5-1000 MG

1 PA ST

TRADJENTA ORAL TABLET 5 MG 1 PA ST

TRULICITY SUBCUTANEOUS PEN INJECTOR 075 MG05 ML 15 MG05 ML 3 MG05 ML 45 MG05 ML

1 PA ST

XIGDUO XR ORAL TABLET IR - ER BIPHASIC 24HR 10-1000 MG 10-500 MG 25-1000 MG 5-1000 MG 5-500 MG

1 PA ST

THYROID HORMONES

ARMOUR THYROID ORAL TABLET 120 MG 15 MG 180 MG 240 MG 30 MG 300 MG 60 MG 90 MG

1

levothyroxine 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

1

levoxyl oral tablet 100 mcg 112 mcg 125 mcg 137 mcg 150 mcg 175 mcg 200 mcg 25 mcg 50 mcg 75 mcg 88 mcg

1

liothyronine oral tablet 25 mcg 5 mcg 50 mcg 1

np thyroid oral tablet 120 mg 15 mg 30 mg 60 mg 90 mg

1

SYNTHROID ORAL TABLET 100 MCG 112 MCG 125 MCG 137 MCG 150 MCG 175 MCG 200 MCG 25 MCG 300 MCG 50 MCG 75 MCG 88 MCG

1

unithroid 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

1

westhroid oral tablet 130 mg 195 mg 325 mg 65 mg 975 mg

1

80


GASTROENTEROLOGY

ANTIDIARRHEALS amp ANTISPASMODICS

anaspaz oral tabletdisintegrating 0125 mg 1

atropine injection syringe 005 mgml 01 mgml 1

belladonna alkaloids-opium rectal suppository 162-30 mg 162-60 mg

1 PA ST

chlordiazepoxide-clidinium oral capsule 5-25 mg 1

dicyclomine intramuscular solution 10 mgml MB

dicyclomine oral capsule 10 mg 1

dicyclomine oral solution 10 mg5 ml 1

dicyclomine oral tablet 20 mg 1

diphenoxylate-atropine oral liquid 25-0025 mg5 ml

1

diphenoxylate-atropine oral tablet 25-0025 mg 1

DONNATAL ORAL TABLET 162-01037 -00194 MG

1

ed-spaz oral tabletdisintegrating 0125 mg 1

glycopyrrolate injection solution 02 mgml 1

glycopyrrolate oral tablet 1 mg 2 mg 1

hyoscyamine sulfate oral drops 0125 mgml 1

hyoscyamine sulfate oral elixir 0125 mg5 ml 1

hyoscyamine sulfate oral tablet 0125 mg 1

hyoscyamine sulfate oral tablet extended release 12 hr 0375 mg

1

hyoscyamine sulfate oral tabletdisintegrating 0125 mg

1

hyoscyamine sulfate sublingual tablet 0125 mg 1

hyosyne oral drops 0125 mgml 1

hyosyne oral elixir 0125 mg5 ml 1

loperamide oral capsule 2 mg 1

methscopolamine oral tablet 25 mg 5 mg 1

MOTOFEN ORAL TABLET 1-0025 MG 1

opium tincture oral tincture 10 mgml (morphine) 1

oscimin oral tablet 0125 mg 1

oscimin sl sublingual tablet 0125 mg 1

81


oscimin sr oral tablet extended release 12 hr 0375 mg

1

phenobarb-hyoscy-atropine-scop oral elixir 162-01037 -00194 mg5 ml

1

phenobarb-hyoscy-atropine-scop oral tablet 162-01037 -00194 mg

1

phenohytro oral elixir 162-01037 -00194 mg5 ml

1

phenohytro oral tablet 162-01037 -00194 mg 1

symax fastabs oral tabletdisintegrating 0125 mg 1

symax-sl sublingual tablet 0125 mg 1

symax-sr oral tablet extended release 12 hr 0375 mg

1

MISCELLANEOUS GASTROINTESTINAL AGENTS

AKYNZEO (NETUPITANT) ORAL CAPSULE 300-05 MG


alosetron oral tablet 05 mg 1 mg 1

ALOXI INTRAVENOUS SOLUTION 025 MG5 ML

MB

AMITIZA ORAL CAPSULE 24 MCG 8 MCG 1 PA

anucort-hc rectal suppository 25 mg 1

aprepitant oral capsule 125 mg 40 mg 1 QL (1 per 30 days)

aprepitant oral capsule 80 mg 1 QL (2 per 30 days)

aprepitant oral capsuledose pack 125 mg (1)- 80 mg (2)


balsalazide oral capsule 750 mg 1

budesonide oral capsuledelayedextendrelease 3 mg

1

calcium acetate(phosphat bind) oral capsule 667 mg

1

calcium acetate(phosphat bind) oral tablet 667 mg 1

CHOLBAM ORAL CAPSULE 250 MG 50 MG 1

CIMZIA POWDER FOR RECONST SUBCUTANEOUS KIT 400 MG (200 MG X 2 VIALS)

1 PA ST LA

CIMZIA SUBCUTANEOUS SYRINGE KIT 400 MG2 ML (200 MGML X 2)

1 PA ST LA

CLENPIQ ORAL SOLUTION 10 MG-35 GRAM -12 GRAM160 ML

ACA PV

82


compro rectal suppository 25 mg 1

constulose oral solution 10 gram15 ml 1

CORTIFOAM RECTAL FOAM 10 (80 MG) 1

CREON ORAL CAPSULEDELAYED RELEASE(DREC) 12000-38000 -60000 UNIT 24000-76000 -120000 UNIT 3000-9500- 15000 UNIT 36000-114000- 180000 UNIT 6000-19000 -30000 UNIT

1 PA

cromolyn oral concentrate 100 mg5 ml 1

DIPENTUM ORAL CAPSULE 250 MG 1 PA ST

doxylamine-pyridoxine (vit b6) oral tabletdelayed release (drec) 10-10 mg

1

dronabinol oral capsule 10 mg 25 mg 5 mg 1

EMEND ORAL SUSPENSION FOR RECONSTITUTION 125 MG (25 MG ML FINAL CONC)

1

ENTYVIO INTRAVENOUS RECON SOLN 300 MG

MB PA LA

enulose oral solution 10 gram15 ml 1

gavilyte-c oral recon soln 240-2272-672 -584 gram

ACA PV

gavilyte-g oral recon soln 236-2274-674 -586 gram

ACA PV

gavilyte-n oral recon soln 420 gram ACA PV

generlac oral solution 10 gram15 ml 1

granisetron hcl oral tablet 1 mg 1 QL (6 per 30 days)

hemmorex-hc rectal suppository 25 mg 30 mg 1

hydrocortisone acetate rectal suppository 25 mg 30 mg

1

hydrocortisone rectal enema 100 mg60 ml 1

hydrocortisone topical cream with perineal applicator 1 25

1

hydrocortisone-pramoxine rectal cream 1-1 25-1 25-1 (4g)

1

INFLECTRA INTRAVENOUS RECON SOLN 100 MG

MB PA LA

lactulose oral packet 10 gram 1

lactulose oral solution 10 gram15 ml 20 gram30 ml

1

83


lanthanum oral tabletchewable 1000 mg 500 mg 750 mg

1

lidocaine hcl-hydrocortison ac rectal cream 3-05

1

LIDOCAINE HCL-HYDROCORTISON AC RECTAL GEL 3 -25 (7 GRAM)

1

lidocaine hcl-hydrocortison ac rectal kit 2 -2 (7 gram)

1 ST

lidocaine hcl-hydrocortison ac rectal kit 3-05 3-1 (7 gram)

1 PA ST

lidocaine-hydrocortisone-aloe rectal gel 28-055

1

lidocaine-hydrocortisone-aloe rectal kit 3-25 (7 gram)

1 PA ST

LINZESS ORAL CAPSULE 145 MCG 290 MCG 72 MCG

1 PA

LIVMARLI ORAL SOLUTION 95 MGML 1 PA ST QL (90 per 30 days)

meclizine oral tablet 125 mg 25 mg 1

mesalamine oral capsuleextended release 24hr 0375 gram

1

mesalamine oral tabletdelayed release (drec) 12 gram 800 mg

1

mesalamine rectal enema 4 gram60 ml 1

mesalamine rectal suppository 1000 mg 1

mesalamine with cleansing wipe rectal enema kit 4 gram60 ml

1 ST

metoclopramide hcl injection solution 5 mgml MB

metoclopramide hcl injection syringe 5 mgml MB

metoclopramide hcl oral solution 5 mg5 ml 1

metoclopramide hcl oral tablet 10 mg 5 mg 1

metoclopramide hcl oral tabletdisintegrating 10 mg 5 mg

1

MOVANTIK ORAL TABLET 125 MG 25 MG 1 PA ST

NULYTELY LEMON-LIME ORAL RECON SOLN 420 GRAM

ACA PV

ondansetron hcl intravenous solution 2 mgml MB

ondansetron hcl oral solution 4 mg5 ml 1 QL (100 per 30 days)

ondansetron hcl oral tablet 4 mg 8 mg 1 QL (9 per 30 days)

ondansetron oral tabletdisintegrating 4 mg 8 mg 1 QL (9 per 30 days)

84


OSMOPREP ORAL TABLET 15 GRAM ACA PV

peg 3350-electrolytes oral recon soln 236-2274-674 -586 gram

ACA PV

peg3350-sod sul-nacl-kcl-asb-c oral powder in packet 100-75-2691 gram

ACA PV

peg-electrolyte soln oral recon soln 420 gram ACA PV

peg-prep oral kit 5-210 mg-gram ACA PV

PLENVU ORAL POWDER IN PACKET SEQUENTIAL 140-9-52 GRAM

ACA PV

prochlorperazine edisylate injection solution 10 mg2 ml (5 mgml) 5 mgml

1

prochlorperazine maleate oral tablet 10 mg 5 mg 1

prochlorperazine rectal suppository 25 mg 1

procto-med hc topical cream with perineal applicator 25

1

procto-pak topical cream with perineal applicator 1

1

proctosol hc topical cream with perineal applicator 25

1

proctozone-hc topical cream with perineal applicator 25

1

RECTIV RECTAL OINTMENT 04 (WW) 1

RELISTOR ORAL TABLET 150 MG 1

RELISTOR SUBCUTANEOUS SOLUTION 12 MG06 ML

1

RELISTOR SUBCUTANEOUS SYRINGE 12 MG06 ML 8 MG04 ML

1

REMICADE INTRAVENOUS RECON SOLN 100 MG

MB PA LA

RENFLEXIS INTRAVENOUS RECON SOLN 100 MG

MB PA LA

scopolamine base transdermal patch 3 day 1 mg over 3 days

1

sevelamer carbonate oral powder in packet 08 gram 24 gram

1

sevelamer carbonate oral tablet 800 mg 1

sevelamer hcl oral tablet 400 mg 800 mg 1

sodium polystyrene sulfonate oral powder 1

85


sps (with sorbitol) oral suspension 15-20 gram60 ml

1

sps (with sorbitol) rectal enema 30-40 gram120 ml

1

SUCRAID ORAL SOLUTION 8500 UNITML 1 PA ST QL (2 per 30 days)

sulfasalazine oral tablet 500 mg 1

sulfasalazine oral tabletdelayed release (drec) 500 mg

1

SUPREP BOWEL PREP KIT ORAL RECON SOLN 175-313-16 GRAM

ACA PV ST

trimethobenzamide oral capsule 300 mg 1

ursodiol oral capsule 300 mg 1

ursodiol oral tablet 250 mg 500 mg 1

VARUBI ORAL TABLET 90 MG 1

VELPHORO ORAL TABLETCHEWABLE 500 MG

1 ST

VIBERZI ORAL TABLET 100 MG 75 MG 1 PA ST

ZENPEP ORAL CAPSULEDELAYED RELEASE(DREC) 10000-32000 -42000 UNIT 15000-47000 -63000 UNIT 20000-63000- 84000 UNIT 3000-10000 -14000-UNIT 40000-126000- 168000 UNIT 5000-17000- 24000 UNIT

1 PA

ZENPEP ORAL CAPSULEDELAYED RELEASE(DREC) 25000-79000- 105000 UNIT

1

ULCER THERAPY

amoxicil-clarithromy-lansopraz oral combo pack 500-500-30 mg

1

cimetidine hcl oral solution 300 mg5 ml 1

cimetidine oral tablet 200 mg 300 mg 400 mg 800 mg

1

DEXILANT ORAL CAPSULEBIPHASE DELAYED RELEAS 30 MG 60 MG

1 ST

esomeprazole magnesium oral capsuledelayed release(drec) 20 mg 40 mg

1

famotidine (pf) intravenous solution 20 mg2 ml MB

famotidine oral suspension 40 mg5 ml (8 mgml) 1

famotidine oral tablet 20 mg 40 mg 1

86


lansoprazole oral capsuledelayed release(drec) 15 mg 30 mg

1

lansoprazole oral tabletdisintegrat delay rel 15 mg 30 mg

1

misoprostol oral tablet 100 mcg 200 mcg 1

nizatidine oral capsule 150 mg 300 mg 1

nizatidine oral solution 150 mg10 ml 1

omeprazole oral capsuledelayed release(drec) 10 mg 20 mg 40 mg

1

pantoprazole oral tabletdelayed release (drec) 20 mg 40 mg

1

rabeprazole oral tabletdelayed release (drec) 20 mg

1

sucralfate oral suspension 100 mgml 1

sucralfate oral tablet 1 gram 1

IMMUNOLOGY VACCINES amp BIOTECHNOLOGY

BIOTECHNOLOGY DRUGS

ARANESP (IN POLYSORBATE) INJECTION SOLUTION 100 MCGML 200 MCGML 25 MCGML 40 MCGML 60 MCGML

1 LA

ARANESP (IN POLYSORBATE) INJECTION SYRINGE 10 MCG04 ML 100 MCG05 ML 150 MCG03 ML 200 MCG04 ML 25 MCG042 ML 300 MCG06 ML 40 MCG04 ML 500 MCGML 60 MCG03 ML

1 LA

EPOGEN INJECTION SOLUTION 10000 UNITML 2000 UNITML 20000 UNIT2 ML 20000 UNITML 3000 UNITML 4000 UNITML

1 LA

GRANIX SUBCUTANEOUS SOLUTION 300 MCGML 480 MCG16 ML

1

GRANIX SUBCUTANEOUS SYRINGE 300 MCG05 ML 480 MCG08 ML

1

LEUKINE INJECTION RECON SOLN 250 MCG 1 PA ST

MIRCERA INJECTION SYRINGE 100 MCG03 ML 150 MCG03 ML 200 MCG03 ML 30 MCG03 ML 50 MCG03 ML 75 MCG03 ML

MB

MOZOBIL SUBCUTANEOUS SOLUTION 24 MG12 ML (20 MGML)

MB LA

NEUPOGEN INJECTION SOLUTION 300 MCGML 480 MCG16 ML

1 PA ST

87


NEUPOGEN INJECTION SYRINGE 300 MCG05 ML 480 MCG08 ML

1 PA ST

NIVESTYM INJECTION SOLUTION 300 MCGML 480 MCG16 ML

1

NIVESTYM SUBCUTANEOUS SYRINGE 300 MCG05 ML 480 MCG08 ML

1

PROCRIT INJECTION SOLUTION 10000 UNITML 2000 UNITML 20000 UNIT2 ML 20000 UNITML 3000 UNITML 4000 UNITML 40000 UNITML

1 LA

UDENYCA SUBCUTANEOUS SYRINGE 6 MG06 ML

1 PA ST

ZARXIO INJECTION SYRINGE 300 MCG05 ML 480 MCG08 ML

1 PA ST

ZIEXTENZO SUBCUTANEOUS SYRINGE 6 MG06 ML

1 PA ST

GROWTH HORMONES

GENOTROPIN MINIQUICK SUBCUTANEOUS SYRINGE 02 MG025 ML 04 MG025 ML 06 MG025 ML 08 MG025 ML 1 MG025 ML 12 MG025 ML 14 MG025 ML 16 MG025 ML 18 MG025 ML 2 MG025 ML

1 PA ST LA

GENOTROPIN SUBCUTANEOUS CARTRIDGE 12 MGML (36 UNITML) 5 MGML (15 UNITML)

1 PA ST LA

OMNITROPE SUBCUTANEOUS CARTRIDGE 10 MG15 ML (67 MGML) 5 MG15 ML (33 MGML)

1 PA ST LA

OMNITROPE SUBCUTANEOUS RECON SOLN 58 MG

1 PA ST LA

SEROSTIM SUBCUTANEOUS RECON SOLN 4 MG 5 MG 6 MG

1 PA ST LA

INTERFERONS

AUBAGIO ORAL TABLET 14 MG 7 MG 1 PA LA

AVONEX INTRAMUSCULAR PEN INJECTOR KIT 30 MCG05 ML


AVONEX INTRAMUSCULAR SYRINGE KIT 30 MCG05 ML


BETASERON SUBCUTANEOUS KIT 03 MG 1 PA LA QL (14 per 30 days)

dimethyl fumarate oral capsuledelayed release(drec) 120 mg


88


dimethyl fumarate oral capsuledelayed release(drec) 120 mg (14)- 240 mg (46)




GILENYA ORAL CAPSULE 05 MG 1 PA LA QL (30 per 30 days)

glatiramer subcutaneous syringe 20 mgml 1 PA LA QL (30 per 30 days)


glatopa subcutaneous syringe 20 mgml 1 PA LA QL (30 per 30 days)


LEMTRADA INTRAVENOUS SOLUTION 12 MG12 ML

MB PA ST LA

MAVENCLAD (10 TABLET PACK) ORAL TABLET 10 MG

1 LA













MAYZENT ORAL TABLET 025 MG 2 MG 1 PA ST LA QL (30 per 30 days)

MAYZENT STARTER PACK ORAL TABLETSDOSE PACK 025 MG (12 TABS)


OCREVUS INTRAVENOUS SOLUTION 30 MGML

MB PA LA

PEGASYS SUBCUTANEOUS SOLUTION 180 MCGML

1 PA LA

PEGASYS SUBCUTANEOUS SYRINGE 180 MCG05 ML

1 PA LA

PLEGRIDY INTRAMUSCULAR SYRINGE 125 MCG05 ML


PLEGRIDY SUBCUTANEOUS PEN INJECTOR 125 MCG05 ML


PLEGRIDY SUBCUTANEOUS PEN INJECTOR 63 MCG05 ML- 94 MCG05 ML


89


PLEGRIDY SUBCUTANEOUS SYRINGE 125 MCG05 ML


PLEGRIDY SUBCUTANEOUS SYRINGE 63 MCG05 ML- 94 MCG05 ML


POMALYST ORAL CAPSULE 1 MG 2 MG 3 MG 4 MG

1 PA ST OCh LA

PONVORY 14-DAY STARTER PACK ORAL TABLETSDOSE PACK 2 MG (2) - 10 MG (3)


PONVORY ORAL TABLET 20 MG 1 PA LA QL (30 per 30 days)

REBIF (WITH ALBUMIN) SUBCUTANEOUS SYRINGE 22 MCG05 ML 44 MCG05 ML


REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 22 MCG05 ML 44 MCG05 ML


REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 88MCG02ML-22 MCG05ML (6)


REBIF TITRATION PACK SUBCUTANEOUS SYRINGE 88MCG02ML-22 MCG05ML (6)


REVLIMID ORAL CAPSULE 10 MG 15 MG 25 MG 20 MG 25 MG 5 MG

1 PA ST OCh LA

ribavirin oral capsule 200 mg 1 LA

ribavirin oral tablet 200 mg 1 LA

ZEPOSIA ORAL CAPSULE 092 MG 1 LA QL (30 per 30 days)

ZEPOSIA STARTER KIT ORAL CAPSULEDOSE PACK 023-046-092 MG

1 LA QL (30 per 30 days)

ZEPOSIA STARTER PACK ORAL CAPSULEDOSE PACK 023 MG (4)- 046 MG (3)


INTERLEUKINS

ACTIMMUNE SUBCUTANEOUS SOLUTION 100 MCG05 ML

1 PA LA

ARCALYST SUBCUTANEOUS RECON SOLN 220 MG

1 LA

ILARIS (PF) SUBCUTANEOUS SOLUTION 150 MGML

MB PA LA

imiquimod topical cream in packet 5 1

INTRON A INJECTION RECON SOLN 10 MILLION UNIT (1 ML) 18 MILLION UNIT (1 ML) 50 MILLION UNIT (1 ML)

1 PA LA

PROLEUKIN INTRAVENOUS RECON SOLN 22 MILLION UNIT

MB LA

90


VACCINES amp MISCELLANEOUS IMMUNOLOGICALS

ACTHIB (PF) INTRAMUSCULAR RECON SOLN 10 MCG05 ML

1 Vac

ADACEL(TDAP ADOLESNADULT)(PF) INTRAMUSCULAR SUSPENSION 2 LF-(25-5-3-5 MCG)-5LF05 ML

1 Vac

ADACEL(TDAP ADOLESNADULT)(PF) INTRAMUSCULAR SYRINGE 2 LF-(25-5-3-5 MCG)-5LF05 ML

1 Vac

AFLURIA QD 2021-22(3YR UP)(PF) INTRAMUSCULAR SYRINGE 60 MCG (15 MCG X 4)05 ML

1 Vac

AFLURIA QD 2021-22(6-35MO)(PF) INTRAMUSCULAR SYRINGE 30 MCG (75 MCG X 4)025 ML

1 Vac

AFLURIA QUAD 2021-2022(6MO UP) INTRAMUSCULAR SUSPENSION 60 MCG (15 MCG X 4)05 ML

1 Vac

ASCENIV INTRAVENOUS SOLUTION 10 MB PA LA

ATGAM INTRAVENOUS SOLUTION 50 MGML

MB

BCG VACCINE LIVE (PF) PERCUTANEOUS SUSPENSION FOR RECONSTITUTION 50 MG

1 Vac

BEXSERO INTRAMUSCULAR SYRINGE 50-50-50-25 MCG05 ML

1 Vac

BIOTHRAX INTRAMUSCULAR SUSPENSION 05 MLDOSE

1 Vac

BIVIGAM INTRAVENOUS SOLUTION 10 MB PA LA

BOOSTRIX TDAP INTRAMUSCULAR SUSPENSION 25-8-5 LF-MCG-LF05ML

1 Vac

BOOSTRIX TDAP INTRAMUSCULAR SYRINGE 25-8-5 LF-MCG-LF05ML

1 Vac

BOTOX INJECTION RECON SOLN 100 UNIT 200 UNIT

MB

CUTAQUIG SUBCUTANEOUS SOLUTION 165

MB LA

CUVITRU SUBCUTANEOUS SOLUTION 1 GRAM5 ML (20 ) 10 GRAM50 ML (20 ) 2 GRAM10 ML (20 ) 4 GRAM20 ML (20 ) 8 GRAM40 ML (20 )

MB LA

91


DAPTACEL (DTAP PEDIATRIC) (PF) INTRAMUSCULAR SUSPENSION 15-10-5 LF-MCG-LF05ML

1 Vac

DYSPORT INTRAMUSCULAR RECON SOLN 300 UNIT 500 UNIT

MB LA

ENGERIX-B (PF) INTRAMUSCULAR SUSPENSION 20 MCGML

1 Vac

ENGERIX-B (PF) INTRAMUSCULAR SYRINGE 20 MCGML

1 Vac

ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SYRINGE 10 MCG05 ML

1 Vac

FLEBOGAMMA DIF INTRAVENOUS SOLUTION 10 5

MB PA

FLUAD QUAD 2021-22(65Y UP)(PF) INTRAMUSCULAR SYRINGE 60 MCG (15 MCG X 4)05 ML

1 Vac

FLUARIX QUAD 2021-2022 (PF) INTRAMUSCULAR SYRINGE 60 MCG (15 MCG X 4)05 ML

1 Vac

FLUBLOK QUAD 2021-2022 (PF) INTRAMUSCULAR SYRINGE 180 MCG (45 MCG X 4)05 ML

1 Vac

FLUCELVAX QUAD 2021-2022 (PF) INTRAMUSCULAR SYRINGE 60 MCG (15 MCG X 4)05 ML

1 Vac

FLUCELVAX QUAD 2021-2022 INTRAMUSCULAR SUSPENSION 60 MCG (15 MCG X 4)05 ML

1 Vac

FLULAVAL QUAD 2021-2022 (PF) INTRAMUSCULAR SYRINGE 60 MCG (15 MCG X 4)05 ML

1 Vac

FLUMIST QUAD 2021-2022 NASAL NASAL SPRAY SYRINGE 10EXP65-75 FF UNIT02 ML

1 Vac

FLUZONE HIGHDOSE QUAD 21-22 PF INTRAMUSCULAR SYRINGE 240 MCG07 ML

1 Vac

FLUZONE QUAD 2021-2022 (PF) INTRAMUSCULAR SUSPENSION 60 MCG (15 MCG X 4)05 ML

1 Vac

FLUZONE QUAD 2021-2022 (PF) INTRAMUSCULAR SYRINGE 60 MCG (15 MCG X 4)05 ML

1 Vac

92


FLUZONE QUAD 2021-2022 INTRAMUSCULAR SUSPENSION 60 MCG (15 MCG X 4)05 ML

1 Vac

GAMASTAN INTRAMUSCULAR SOLUTION 15-18 RANGE

MB

GAMASTAN SD INTRAMUSCULAR SOLUTION 15-18 RANGE

MB

GAMMAGARD LIQUID INJECTION SOLUTION 10

MB LA

GAMMAGARD S-D (IGA lt 1 MCGML) INTRAVENOUS RECON SOLN 10 GRAM 5 GRAM

MB PA LA

GAMMAKED INJECTION SOLUTION 1 GRAM10 ML (10 ) 10 GRAM100 ML (10 ) 20 GRAM200 ML (10 ) 5 GRAM50 ML (10 )

MB LA

GAMMAPLEX (WITH SORBITOL) INTRAVENOUS SOLUTION 5

MB PA LA

GAMMAPLEX INTRAVENOUS SOLUTION 10

MB PA LA

GAMUNEX-C INJECTION SOLUTION 1 GRAM10 ML (10 ) 10 GRAM100 ML (10 ) 25 GRAM25 ML (10 ) 20 GRAM200 ML (10 ) 40 GRAM400 ML (10 ) 5 GRAM50 ML (10 )

MB LA

GARDASIL 9 (PF) INTRAMUSCULAR SUSPENSION 05 ML

1 Vac

GARDASIL 9 (PF) INTRAMUSCULAR SYRINGE 05 ML

1 Vac

GRASTEK SUBLINGUAL TABLET 2800 BAU 1 PA

HAVRIX (PF) INTRAMUSCULAR SYRINGE 1440 ELISA UNITML 720 ELISA UNIT05 ML

1 Vac

HEPLISAV-B (PF) INTRAMUSCULAR SYRINGE 20 MCG05 ML

1 Vac

HIBERIX (PF) INTRAMUSCULAR RECON SOLN 10 MCG05 ML

1 Vac

HIZENTRA SUBCUTANEOUS SOLUTION 1 GRAM5 ML (20 ) 10 GRAM50 ML (20 ) 2 GRAM10 ML (20 ) 4 GRAM20 ML (20 )

MB LA

93


HYQVIA SUBCUTANEOUS SOLUTION 10 GRAM 100 ML (10 ) 25 GRAM 25 ML (10 ) 20 GRAM 200 ML (10 ) 30 GRAM 300 ML (10 ) 5 GRAM 50 ML (10 )

MB LA

IMOVAX RABIES VACCINE (PF) INTRAMUSCULAR RECON SOLN 25 UNIT

1 Vac

INFANRIX (DTAP) (PF) INTRAMUSCULAR SYRINGE 25-58-10 LF-MCG-LF05ML

1 Vac

IPOL INJECTION SUSPENSION 40-8-32 UNIT05 ML

1 Vac

IXIARO (PF) INTRAMUSCULAR SYRINGE 6 MCG05 ML

1 Vac

KINRIX (PF) INTRAMUSCULAR SYRINGE 25 LF-58 MCG-10 LF05 ML

1 Vac

MENACTRA (PF) INTRAMUSCULAR SOLUTION 4 MCG05 ML

1 Vac

MENQUADFI (PF) INTRAMUSCULAR SOLUTION 10 MCG05 ML

1 Vac

MENVEO A-C-Y-W-135-DIP (PF) INTRAMUSCULAR KIT 10-5 MCG05 ML

1 Vac

M-M-R II (PF) SUBCUTANEOUS RECON SOLN 1000-12500 TCID5005 ML

1 Vac

MYOBLOC INTRAMUSCULAR SOLUTION 10000 UNIT2 ML 2500 UNIT05 ML 5000 UNITML

MB LA

OCTAGAM INTRAVENOUS SOLUTION 10 5

MB PA LA

ORALAIR SUBLINGUAL TABLET 300 INDX REACTIVITY

1 PA

PANZYGA INTRAVENOUS SOLUTION 10 MB PA

PEDIARIX (PF) INTRAMUSCULAR SYRINGE 10 MCG-25LF-25 MCG-10LF05 ML

1 Vac

PEDVAX HIB (PF) INTRAMUSCULAR SOLUTION 75 MCG05 ML

1 Vac

PENTACEL (PF) INTRAMUSCULAR KIT 15 LF UNIT-20 MCG-5 LF05 ML 15LF-48MCG-62DU -10 MCG05ML

1 Vac

PENTACEL ACTHIB COMPONENT (PF) INTRAMUSCULAR RECON SOLN 10 MCG05 ML

1 Vac

PNEUMOVAX-23 INJECTION SOLUTION 25 MCG05 ML

1 Vac

94


PNEUMOVAX-23 INJECTION SYRINGE 25 MCG05 ML

1 Vac

PREVNAR 13 (PF) INTRAMUSCULAR SYRINGE 05 ML

1 Vac

PRIVIGEN INTRAVENOUS SOLUTION 10 MB PA LA

PROQUAD (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 10EXP3-43-3- 399 TCID5005

1 Vac

PROVENGE INTRAVENOUS SUSPENSION 50 MILLION CELL250 ML

MB PA

QUADRACEL (PF) INTRAMUSCULAR SUSPENSION 15 LF-48 MCG- 5 LF UNIT05ML

1 Vac

RABAVERT (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 25 UNIT

1 Vac

RAGWITEK SUBLINGUAL TABLET 12 AMB A 1 UNIT

1 PA

RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION 10 MCGML 40 MCGML 5 MCG05 ML

1 Vac

RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 10 MCGML 5 MCG05 ML

1 Vac

SHINGRIX (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 50 MCG05 ML

1 Vac

STAMARIL (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 1000 UNIT05 ML

1 Vac

TDVAX INTRAMUSCULAR SUSPENSION 2-2 LF UNIT05 ML

1 Vac

TENIVAC (PF) INTRAMUSCULAR SUSPENSION 5 LF UNIT- 2 LF UNIT05ML

1 Vac

TENIVAC (PF) INTRAMUSCULAR SYRINGE 5-2 LF UNIT05 ML

1 Vac

TETANUSDIPHTHERIA TOX PED(PF) INTRAMUSCULAR SUSPENSION 5-25 LF UNIT05 ML

1 Vac

THYMOGLOBULIN INTRAVENOUS RECON SOLN 25 MG

MB

TRUMENBA INTRAMUSCULAR SYRINGE 120 MCG05 ML

1 Vac

95


TWINRIX (PF) INTRAMUSCULAR SYRINGE 720 ELISA UNIT- 20 MCGML

1 Vac

TYPHIM VI INTRAMUSCULAR SOLUTION 25 MCG05 ML

1 Vac

TYPHIM VI INTRAMUSCULAR SYRINGE 25 MCG05 ML

1 Vac

VAQTA (PF) INTRAMUSCULAR SUSPENSION 25 UNIT05 ML 50 UNITML

1 Vac

VAQTA (PF) INTRAMUSCULAR SYRINGE 25 UNIT05 ML 50 UNITML

1 Vac

VARIVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 1350 UNIT05 ML

1 Vac

VAXELIS (PF) INTRAMUSCULAR SUSPENSION 15 UNIT-5 UNIT- 10 MCG05 ML

1 Vac

VAXELIS (PF) INTRAMUSCULAR SYRINGE 15 UNIT-5 UNIT- 10 MCG05 ML

1 Vac

XEMBIFY SUBCUTANEOUS SOLUTION 1 GRAM5 ML (20 ) 10 GRAM50 ML (20 ) 2 GRAM10 ML (20 ) 4 GRAM20 ML (20 )

MB LA

XEOMIN INTRAMUSCULAR RECON SOLN 100 UNIT 200 UNIT 50 UNIT

MB LA

YF-VAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 10 EXP474 UNIT05 ML

1 Vac

ZOSTAVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 19400 UNIT065 ML

1 Vac

MUSCULOSKELETAL amp RHEUMATOLOGY

GOUT THERAPY

allopurinol oral tablet 100 mg 300 mg 1

COLCHICINE ORAL CAPSULE 06 MG 1

colchicine oral tablet 06 mg 1

febuxostat oral tablet 40 mg 80 mg 1

KRYSTEXXA INTRAVENOUS SOLUTION 8 MGML

MB PA LA

MITIGARE ORAL CAPSULE 06 MG 1

probenecid oral tablet 500 mg 1

probenecid-colchicine oral tablet 500-05 mg 1

96


OSTEOPOROSIS THERAPY

alendronate oral solution 70 mg75 ml 1

alendronate oral tablet 10 mg 35 mg 5 mg 70 mg 1

EVENITY SUBCUTANEOUS SYRINGE 105 MG117 ML 210MG234ML ( 105MG117MLX2)

1 PA ST LA

FORTEO SUBCUTANEOUS PEN INJECTOR 20 MCGDOSE (600MCG24ML)


FOSAMAX PLUS D ORAL TABLET 70 MG- 2800 UNIT 70 MG- 5600 UNIT

1

ibandronate oral tablet 150 mg 1

PROLIA SUBCUTANEOUS SYRINGE 60 MGML

1 ST LA

raloxifene oral tablet 60 mg 1 OCh

risedronate oral tablet 150 mg 35 mg 5 mg 1

risedronate oral tabletdelayed release (drec) 35 mg

1

TYMLOS SUBCUTANEOUS PEN INJECTOR 80 MCG (3120 MCG156 ML)

1 PA ST LA

OTHER RHEUMATOLOGICALS

ACTEMRA ACTPEN SUBCUTANEOUS PEN INJECTOR 162 MG09 ML

1 PA ST LA

ACTEMRA INTRAVENOUS SOLUTION 200 MG10 ML (20 MGML) 400 MG20 ML (20 MGML) 80 MG4 ML (20 MGML)

MB PA LA

ACTEMRA SUBCUTANEOUS SYRINGE 162 MG09 ML

1 PA ST LA

BENLYSTA INTRAVENOUS RECON SOLN 120 MG 400 MG

MB PA LA

BENLYSTA SUBCUTANEOUS AUTO-INJECTOR 200 MGML

1 PA LA

BENLYSTA SUBCUTANEOUS SYRINGE 200 MGML

1 PA LA

ENBREL MINI SUBCUTANEOUS CARTRIDGE 50 MGML (1 ML)

1 PA ST LA

ENBREL SUBCUTANEOUS RECON SOLN 25 MG (1 ML)

1 PA ST LA

ENBREL SUBCUTANEOUS SOLUTION 25 MG05 ML

1 PA ST LA

97


ENBREL SUBCUTANEOUS SYRINGE 25 MG05 ML (05) 50 MGML (1 ML)

1 PA ST LA

ENBREL SURECLICK SUBCUTANEOUS PEN INJECTOR 50 MGML (1 ML)

1 PA ST LA

HUMIRA PEN CROHNS-UC-HS START SUBCUTANEOUS PEN INJECTOR KIT 40 MG08 ML

1 PA ST LA

HUMIRA PEN PSOR-UVEITS-ADOL HS SUBCUTANEOUS PEN INJECTOR KIT 40 MG08 ML

1 PA ST LA

HUMIRA PEN SUBCUTANEOUS PEN INJECTOR KIT 40 MG08 ML

1 PA ST LA

HUMIRA SUBCUTANEOUS SYRINGE KIT 40 MG08 ML

1 PA ST LA

HUMIRA(CF) PEDI CROHNS STARTER SUBCUTANEOUS SYRINGE KIT 80 MG08 ML 80 MG08 ML-40 MG04 ML

1 PA ST LA

HUMIRA(CF) PEN CROHNS-UC-HS SUBCUTANEOUS PEN INJECTOR KIT 80 MG08 ML

1 PA ST LA

HUMIRA(CF) PEN PEDIATRIC UC SUBCUTANEOUS PEN INJECTOR KIT 80 MG08 ML

1 PA ST LA

HUMIRA(CF) PEN PSOR-UV-ADOL HS SUBCUTANEOUS PEN INJECTOR KIT 80 MG08 ML-40 MG04 ML

1 PA ST LA

HUMIRA(CF) PEN SUBCUTANEOUS PEN INJECTOR KIT 40 MG04 ML

1 PA ST LA

HUMIRA(CF) SUBCUTANEOUS SYRINGE KIT 10 MG01 ML 20 MG02 ML 40 MG04 ML

1 PA ST LA

KEVZARA SUBCUTANEOUS PEN INJECTOR 150 MG114 ML 200 MG114 ML

1 PA ST LA

KEVZARA SUBCUTANEOUS SYRINGE 150 MG114 ML 200 MG114 ML

1 PA ST LA

leflunomide oral tablet 10 mg 20 mg 1

OLUMIANT ORAL TABLET 1 MG 2 MG 1 PA ST LA

ORENCIA (WITH MALTOSE) INTRAVENOUS RECON SOLN 250 MG

MB PA LA

ORENCIA CLICKJECT SUBCUTANEOUS AUTO-INJECTOR 125 MGML

1 PA ST LA

98


ORENCIA SUBCUTANEOUS SYRINGE 125 MGML 50 MG04 ML 875 MG07 ML

1 PA ST LA

OTEZLA ORAL TABLET 30 MG 1 PA ST LA

OTEZLA STARTER ORAL TABLETSDOSE PACK 10 MG (4)-20 MG (4)-30 MG (47)

1 PA ST LA

penicillamine oral capsule 250 mg 1 PA

penicillamine oral tablet 250 mg 1 PA

RIDAURA ORAL CAPSULE 3 MG 1

RINVOQ ORAL TABLET EXTENDED RELEASE 24 HR 15 MG

1 PA ST LA

SAVELLA ORAL TABLET 100 MG 125 MG 25 MG 50 MG

1 PA ST

SAVELLA ORAL TABLETSDOSE PACK 125 MG (5)-25 MG(8)-50 MG(42)

1 PA ST

SIMPONI ARIA INTRAVENOUS SOLUTION 125 MGML

MB PA LA

SIMPONI SUBCUTANEOUS PEN INJECTOR 100 MGML 50 MG05 ML

1 PA ST LA

SIMPONI SUBCUTANEOUS SYRINGE 100 MGML 50 MG05 ML

1 PA ST LA

XELJANZ ORAL SOLUTION 1 MGML 1 PA ST LA

XELJANZ ORAL TABLET 10 MG 5 MG 1 PA ST LA

XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HR 11 MG 22 MG

1 PA ST LA

OBSTETRICS amp GYNECOLOGY

DIAPHRAGMS AND OTHER NON-ORAL CONTRACEPTIVES

CAYA CONTOURED VAGINAL DIAPHRAGM 65-80 MM

ACA PV

FC2 FEMALE CONDOM ACA PV

FEMCAP VAGINAL DEVICE 22 MM ACA PV

KYLEENA INTRAUTERINE INTRAUTERINE DEVICE 175 MCG24 HRS (5 YRS) 195 MG

ACA PV

LILETTA INTRAUTERINE INTRAUTERINE DEVICE 201 MCG24 HRS (6 YRS) 52 MG

ACA PV ST

MIRENA INTRAUTERINE INTRAUTERINE DEVICE 20 MCG24 HOURS (7 YRS) 52 MG

ACA PV

PARAGARD T 380A INTRAUTERINE INTRAUTERINE DEVICE 380 SQUARE MM

ACA PV

99


SKYLA INTRAUTERINE INTRAUTERINE DEVICE 14 MCG24 HRS (3 YRS) 135 MG

ACA PV

WIDE-SEAL DIAPHRAGM 60 VAGINAL DIAPHRAGM 60 MM

ACA PV

ESTROGENS amp PROGESTINS

amabelz oral tablet 05-01 mg 1-05 mg 1

ANGELIQ ORAL TABLET 025-05 MG 05-1 MG

1

camila oral tablet 035 mg ACA PV

COMBIPATCH TRANSDERMAL PATCH SEMIWEEKLY 005-014 MG24 HR 005-025 MG24 HR

1

covaryx hs oral tablet 0625-125 mg 1

covaryx oral tablet 125-25 mg 1

CRINONE VAGINAL GEL 4 1

deblitane oral tablet 035 mg ACA PV

DEPO-ESTRADIOL INTRAMUSCULAR OIL 5 MGML

1

DEPO-PROVERA INTRAMUSCULAR SUSPENSION 150 MGML

MB

DEPO-PROVERA INTRAMUSCULAR SYRINGE 150 MGML

MB

DEPO-SUBQ PROVERA 104 SUBCUTANEOUS SYRINGE 104 MG065 ML

ACA PV

DIVIGEL TRANSDERMAL GEL IN PACKET 025 MG025 GRAM (01 ) 05 MG05 GRAM (01 ) 075 MG075 GRAM (01) 1 MGGRAM (01 ) 125 MG125 GRAM (01 )


dotti transdermal patch semiweekly 0025 mg24 hr 00375 mg24 hr 005 mg24 hr 0075 mg24 hr 01 mg24 hr


DUAVEE ORAL TABLET 045-20 MG 1

eemt hs oral tablet 0625-125 mg 1

eemt oral tablet 125-25 mg 1

errin oral tablet 035 mg ACA PV

estradiol oral tablet 05 mg 1 mg 2 mg 1

estradiol transdermal patch semiweekly 0025 mg24 hr 00375 mg24 hr 005 mg24 hr 0075 mg24 hr 01 mg24 hr


100


estradiol transdermal patch weekly 0025 mg24 hr 00375 mg24 hr 005 mg24 hr 006 mg24 hr 0075 mg24 hr 01 mg24 hr


estradiol vaginal cream 001 (01 mggram) 1

estradiol vaginal tablet 10 mcg 1

estradiol valerate intramuscular oil 20 mgml 40 mgml

1

estradiol-norethindrone acet oral tablet 05-01 mg 1-05 mg

1

ESTRING VAGINAL RING 2 MG (75 MCG 24 HOUR)

1

estrogens-methyltestosterone oral tablet 0625-125 mg 125-25 mg

1

EVAMIST TRANSDERMAL SPRAYNON-AEROSOL 153 MGSPRAY (17)


FEMRING VAGINAL RING 005 MG24 HR 01 MG24 HR

1

fyavolv oral tablet 05-25 mg-mcg 1-5 mg-mcg 1

heather oral tablet 035 mg ACA PV

hydroxyprogest(pf)(preg presv) intramuscular oil 250 mgml (1 ml)

1

hydroxyprogesterone cap(ppres) intramuscular oil 250 mgml

1

hydroxyprogesterone caproate intramuscular oil 250 mgml

1

incassia oral tablet 035 mg ACA PV

jencycla oral tablet 035 mg ACA PV

jinteli oral tablet 1-5 mg-mcg 1

lyleq oral tablet 035 mg ACA PV

lyllana transdermal patch semiweekly 0025 mg24 hr 00375 mg24 hr 005 mg24 hr 0075 mg24 hr 01 mg24 hr


lyza oral tablet 035 mg ACA PV

medroxyprogesterone intramuscular suspension 150 mgml

ACA PV

medroxyprogesterone intramuscular syringe 150 mgml

ACA PV

medroxyprogesterone oral tablet 10 mg 25 mg 5 mg

1

101


MENEST ORAL TABLET 03 MG 0625 MG 125 MG 25 MG

1

MENOSTAR TRANSDERMAL PATCH WEEKLY 14 MCG24 HR


mimvey oral tablet 1-05 mg 1

nora-be oral tablet 035 mg ACA PV

norethindrone (contraceptive) oral tablet 035 mg ACA PV

norethindrone acetate oral tablet 5 mg 1

norethindrone ac-eth estradiol oral tablet 05-25 mg-mcg 1-5 mg-mcg

1

norlyda oral tablet 035 mg ACA PV

PREMARIN INJECTION RECON SOLN 25 MG 1

PREMARIN ORAL TABLET 03 MG 045 MG 0625 MG 09 MG 125 MG

1

PREMARIN VAGINAL CREAM 0625 MGGRAM

1

PREMPHASE ORAL TABLET 0625 MG (14) 0625MG-5MG(14)

1

PREMPRO ORAL TABLET 03-15 MG 045-15 MG 0625-25 MG 0625-5 MG

1

progesterone intramuscular oil 50 mgml 1

progesterone micronized oral capsule 100 mg 200 mg

1

sharobel oral tablet 035 mg ACA PV

tulana oral tablet 035 mg ACA PV

yuvafem vaginal tablet 10 mcg 1

MISCELLANEOUS OBGYN

ANNOVERA VAGINAL RING 015-0013 MG24 HOUR

ACA PV

clindamycin phosphate vaginal cream 2 1

eluryng vaginal ring 012-0015 mg24 hr ACA PV

etonogestrel-ethinyl estradiol vaginal ring 012-0015 mg24 hr

ACA PV

fem ph vaginal gel 09-0025 1

GYNAZOLE-1 VAGINAL CREAM 2 1

gynol ii vaginal gel 3 ACA PV

INTRAROSA VAGINAL INSERT 65 MG 1

isoxsuprine oral tablet 10 mg 20 mg 1

102


LUPANETA PACK (1 MONTH) KIT SYRINGE AND TABLET 375 MG -5 MG (30)

1 PA LA

metronidazole vaginal gel 075 1

NEXPLANON SUBDERMAL IMPLANT 68 MG ACA PV

OSPHENA ORAL TABLET 60 MG 1

PHEXXI VAGINAL GEL 18-1-04 ACA PV

terconazole vaginal cream 04 08 1

terconazole vaginal suppository 80 mg 1

TODAY CONTRACEPTIVE SPONGE VAGINAL CONTRACEPTIVE SPONGE 1000 MG

ACA PV

tranexamic acid oral tablet 650 mg 1

TWIRLA TRANSDERMAL PATCH WEEKLY 120-30 MCG24 HR

ACA PV

vandazole vaginal gel 075 1

VCF CONTRACEPTIVE FILM VAGINAL FILM 28

ACA PV

VCF CONTRACEPTIVE GEL VAGINAL GEL 4

ACA PV

xulane transdermal patch weekly 150-35 mcg24 hr

ACA PV

zafemy transdermal patch weekly 150-35 mcg24 hr

ACA PV

ORAL CONTRACEPTIVES amp RELATED AGENTS

afirmelle oral tablet 01-20 mg-mcg ACA PV

after pill oral tablet 15 mg ACA PV

altavera (28) oral tablet 015-003 mg ACA PV

alyacen 135 (28) oral tablet 1-35 mg-mcg ACA PV

alyacen 777 (28) oral tablet 050751 mg- 35 mcg

ACA PV

amethia oral tabletsdose pack3 month 015 mg-30 mcg (84)10 mcg (7)

ACA PV

amethyst (28) oral tablet 90-20 mcg (28) ACA PV

apri oral tablet 015-003 mg ACA PV

aranelle (28) oral tablet 05105-35 mg-mcg ACA PV

ashlyna oral tabletsdose pack3 month 015 mg-30 mcg (84)10 mcg (7)

ACA PV

aubra eq oral tablet 01-20 mg-mcg ACA PV

103


aubra oral tablet 01-20 mg-mcg ACA PV

aurovela 1530 (21) oral tablet 15-30 mg-mcg ACA PV


aurovela 24 fe oral tablet 1 mg-20 mcg (24)75 mg (4)

ACA PV

aurovela fe 1530 (28) oral tablet 15 mg-30 mcg (21)75 mg (7)

ACA PV

aurovela fe 1-20 (28) oral tablet 1 mg-20 mcg (21)75 mg (7)

ACA PV

aviane oral tablet 01-20 mg-mcg ACA PV

ayuna oral tablet 015-003 mg ACA PV

azurette (28) oral tablet 015-002 mgx21 001 mg x 5

ACA PV

BALCOLTRA ORAL TABLET 01 MG-002 MG (21)365 MG(7)

ACA PV

balziva (28) oral tablet 04-35 mg-mcg ACA PV

blisovi 24 fe oral tablet 1 mg-20 mcg (24)75 mg (4)

ACA PV

blisovi fe 1530 (28) oral tablet 15 mg-30 mcg (21)75 mg (7)

ACA PV


ACA PV

briellyn oral tablet 04-35 mg-mcg ACA PV

camrese lo oral tabletsdose pack3 month 010 mg-20 mcg (84)10 mcg (7)

ACA PV

camrese oral tabletsdose pack3 month 015 mg-30 mcg (84)10 mcg (7)

ACA PV

caziant (28) oral tablet 0112515-25 mg-mcg ACA PV

charlotte 24 fe oral tabletchewable 1 mg-20 mcg(24) 75 mg (4)

ACA PV

chateal (28) oral tablet 015-003 mg ACA PV

chateal eq (28) oral tablet 015-003 mg ACA PV

cryselle (28) oral tablet 03-30 mg-mcg ACA PV

cyclafem 135 (28) oral tablet 1-35 mg-mcg ACA PV

cyclafem 777 (28) oral tablet 050751 mg- 35 mcg

ACA PV

cyred eq oral tablet 015-003 mg ACA PV

cyred oral tablet 015-003 mg ACA PV

104


dasetta 135 (28) oral tablet 1-35 mg-mcg ACA PV

dasetta 777 (28) oral tablet 050751 mg- 35 mcg

ACA PV

daysee oral tabletsdose pack3 month 015 mg-30 mcg (84)10 mcg (7)

ACA PV

desog-eestradioleestradiol oral tablet 015-002 mgx21 001 mg x 5

ACA PV

desogestrel-ethinyl estradiol oral tablet 015-003 mg

ACA PV

dolishale oral tablet 90-20 mcg (28) ACA PV

drospirenone-eestradiol-lmfa oral tablet 3-002-0451 mg (24) (4) 3-003-0451 mg (21) (7)

ACA PV

drospirenone-ethinyl estradiol oral tablet 3-002 mg 3-003 mg

ACA PV

econtra ez oral tablet 15 mg ACA PV

econtra one-step oral tablet 15 mg ACA PV

elinest oral tablet 03-30 mg-mcg ACA PV

ELLA ORAL TABLET 30 MG ACA PV

emoquette oral tablet 015-003 mg ACA PV

enpresse oral tablet 50-30 (6)75-40 (5)125-30(10)

ACA PV

enskyce oral tablet 015-003 mg ACA PV

estarylla oral tablet 025-35 mg-mcg ACA PV

ethynodiol diac-eth estradiol oral tablet 1-35 mg-mcg 1-50 mg-mcg

ACA PV

falmina (28) oral tablet 01-20 mg-mcg ACA PV

femynor oral tablet 025-35 mg-mcg ACA PV

gemmily oral capsule 1 mg-20 mcg (24)75 mg (4) ACA PV

hailey 24 fe oral tablet 1 mg-20 mcg (24)75 mg (4)

ACA PV

hailey fe 1530 (28) oral tablet 15 mg-30 mcg (21)75 mg (7)

ACA PV


ACA PV

hailey oral tablet 15-30 mg-mcg ACA PV

iclevia oral tabletsdose pack3 month 015 mg-30 mcg (91)

ACA PV

isibloom oral tablet 015-003 mg ACA PV

105


jaimiess oral tabletsdose pack3 month 015 mg-30 mcg (84)10 mcg (7)

ACA PV

jasmiel (28) oral tablet 3-002 mg ACA PV

jolessa oral tabletsdose pack3 month 015 mg-30 mcg (91)

ACA PV

juleber oral tablet 015-003 mg ACA PV

junel 1530 (21) oral tablet 15-30 mg-mcg ACA PV


junel fe 1530 (28) oral tablet 15 mg-30 mcg (21)75 mg (7)

ACA PV


ACA PV

junel fe 24 oral tablet 1 mg-20 mcg (24)75 mg (4) ACA PV

kaitlib fe oral tabletchewable 08mg-25mcg(24) and 75 mg (4)

ACA PV

kalliga oral tablet 015-003 mg ACA PV

kariva (28) oral tablet 015-002 mgx21 001 mg x 5

ACA PV

kelnor 135 (28) oral tablet 1-35 mg-mcg ACA PV

kelnor 1-50 (28) oral tablet 1-50 mg-mcg ACA PV

kurvelo (28) oral tablet 015-003 mg ACA PV

l norgesteestradiol-eestrad oral tabletsdose pack3 month 010 mg-20 mcg (84)10 mcg (7) 015 mg-20 mcg 015 mg-25 mcg 015 mg-30 mcg (84)10 mcg (7)

ACA PV

larin 1530 (21) oral tablet 15-30 mg-mcg ACA PV


larin 24 fe oral tablet 1 mg-20 mcg (24)75 mg (4) ACA PV

larin fe 1530 (28) oral tablet 15 mg-30 mcg (21)75 mg (7)

ACA PV


ACA PV

larissia oral tablet 01-20 mg-mcg ACA PV

layolis fe oral tabletchewable 08mg-25mcg(24) and 75 mg (4)

ACA PV

leena 28 oral tablet 05105-35 mg-mcg ACA PV

lessina oral tablet 01-20 mg-mcg ACA PV

levonest (28) oral tablet 50-30 (6)75-40 (5)125-30(10)

ACA PV

106


levonorgestrel oral tablet 15 mg ACA PV

levonorgestrel-ethinyl estrad oral tablet 01-20 mg-mcg 015-003 mg 90-20 mcg (28)

ACA PV

levonorgestrel-ethinyl estrad oral tabletsdose pack3 month 015 mg-30 mcg (91)

ACA PV

levonorg-eth estrad triphasic oral tablet 50-30 (6)75-40 (5)125-30(10)

ACA PV

levora-28 oral tablet 015-003 mg ACA PV

lillow (28) oral tablet 015-003 mg ACA PV

LO LOESTRIN FE ORAL TABLET 1 MG-10 MCG (24)10 MCG (2)

ACA PV

lojaimiess oral tabletsdose pack3 month 010 mg-20 mcg (84)10 mcg (7)

ACA PV

loryna (28) oral tablet 3-002 mg ACA PV

low-ogestrel (28) oral tablet 03-30 mg-mcg ACA PV

lo-zumandimine (28) oral tablet 3-002 mg ACA PV

lutera (28) oral tablet 01-20 mg-mcg ACA PV

marlissa (28) oral tablet 015-003 mg ACA PV

merzee oral capsule 1 mg-20 mcg (24)75 mg (4) ACA PV

mibelas 24 fe oral tabletchewable 1 mg-20 mcg(24) 75 mg (4)

ACA PV

microgestin 1530 (21) oral tablet 15-30 mg-mcg ACA PV


microgestin fe 1530 (28) oral tablet 15 mg-30 mcg (21)75 mg (7)

ACA PV


ACA PV

mili oral tablet 025-35 mg-mcg ACA PV

mono-linyah oral tablet 025-35 mg-mcg ACA PV

my choice oral tablet 15 mg ACA PV

my way oral tablet 15 mg ACA PV

NATAZIA ORAL TABLET 3 MG2 MG-2 MG 2 MG-3 MG1 MG

ACA PV

necon 0535 (28) oral tablet 05-35 mg-mcg ACA PV

new day oral tablet 15 mg ACA PV

NEXTSTELLIS ORAL TABLET 3 MG- 142 MG (28)

ACA PV

nikki (28) oral tablet 3-002 mg ACA PV

107


noreth-ethinyl estradiol-iron oral tabletchewable 04mg-35mcg(21) and 75 mg (7) 08mg-25mcg(24) and 75 mg (4)

ACA PV


ACA PV

norethindrone-eestradiol-iron oral capsule 1 mg-20 mcg (24)75 mg (4)

ACA PV

norethindrone-eestradiol-iron oral tablet 1 mg-20 mcg (21)75 mg (7) 15 mg-30 mcg (21)75 mg (7)

ACA PV

norethindrone-eestradiol-iron oral tabletchewable 1 mg-20 mcg(24) 75 mg (4)

ACA PV

norgestimate-ethinyl estradiol oral tablet 0180215025 mg-25 mcg 0180215025 mg-35 mcg (28) 025-35 mg-mcg

ACA PV

nortrel 0535 (28) oral tablet 05-35 mg-mcg ACA PV

nortrel 135 (21) oral tablet 1-35 mg-mcg (21) ACA PV


nortrel 777 (28) oral tablet 050751 mg- 35 mcg

ACA PV

nylia 777 (28) oral tablet 050751 mg- 35 mcg ACA PV

nymyo oral tablet 025-35 mg-mcg ACA PV

ocella oral tablet 3-003 mg ACA PV

opcicon one-step oral tablet 15 mg ACA PV

option-2 oral tablet 15 mg ACA PV

orsythia oral tablet 01-20 mg-mcg ACA PV

philith oral tablet 04-35 mg-mcg ACA PV

pimtrea (28) oral tablet 015-002 mgx21 001 mg x 5

ACA PV

pirmella oral tablet 050751 mg- 35 mcg 1-35 mg-mcg

ACA PV

portia 28 oral tablet 015-003 mg ACA PV

previfem oral tablet 025-35 mg-mcg ACA PV

reclipsen (28) oral tablet 015-003 mg ACA PV

rivelsa oral tabletsdose pack3 month 015 mg-20 mcg 015 mg-25 mcg

ACA PV

setlakin oral tabletsdose pack3 month 015 mg-30 mcg (91)

ACA PV

simliya (28) oral tablet 015-002 mgx21 001 mg x 5

ACA PV

108


simpesse oral tabletsdose pack3 month 015 mg-30 mcg (84)10 mcg (7)

ACA PV

SLYND ORAL TABLET 4 MG (28) ACA PV

sprintec (28) oral tablet 025-35 mg-mcg ACA PV

sronyx oral tablet 01-20 mg-mcg ACA PV

syeda oral tablet 3-003 mg ACA PV

tarina 24 fe oral tablet 1 mg-20 mcg (24)75 mg (4)

ACA PV

tarina fe 120 (28) oral tablet 1 mg-20 mcg (21)75 mg (7)

ACA PV

taysofy oral capsule 1 mg-20 mcg (24)75 mg (4) ACA PV

tilia fe oral tablet 1-20(5)1-30(7) 1mg-35mcg (9) ACA PV

tri femynor oral tablet 0180215025 mg-35 mcg (28)

ACA PV

tri-estarylla oral tablet 0180215025 mg-35 mcg (28)

ACA PV

tri-legest fe oral tablet 1-20(5)1-30(7) 1mg-35mcg (9)

ACA PV

tri-linyah oral tablet 0180215025 mg-35 mcg (28)

ACA PV

tri-lo-estarylla oral tablet 0180215025 mg-25 mcg

ACA PV

tri-lo-marzia oral tablet 0180215025 mg-25 mcg

ACA PV

tri-lo-mili oral tablet 0180215025 mg-25 mcg ACA PV

tri-lo-sprintec oral tablet 0180215025 mg-25 mcg

ACA PV

tri-mili oral tablet 0180215025 mg-35 mcg (28) ACA PV

tri-nymyo oral tablet 0180215025 mg-35 mcg (28)

ACA PV

tri-previfem (28) oral tablet 0180215025 mg-35 mcg (28)

ACA PV

tri-sprintec (28) oral tablet 0180215025 mg-35 mcg (28)

ACA PV

trivora (28) oral tablet 50-30 (6)75-40 (5)125-30(10)

ACA PV

tri-vylibra lo oral tablet 0180215025 mg-25 mcg

ACA PV

tri-vylibra oral tablet 0180215025 mg-35 mcg (28)

ACA PV

109


TYBLUME ORAL TABLETCHEWABLE 01 MG- 20 MCG

ACA PV

tydemy oral tablet 3-003-0451 mg (21) (7) ACA PV

velivet triphasic regimen (28) oral tablet 0112515-25 mg-mcg

ACA PV

vestura (28) oral tablet 3-002 mg ACA PV

vienva oral tablet 01-20 mg-mcg ACA PV

viorele (28) oral tablet 015-002 mgx21 001 mg x 5

ACA PV

volnea (28) oral tablet 015-002 mgx21 001 mg x 5

ACA PV

vyfemla (28) oral tablet 04-35 mg-mcg ACA PV

vylibra oral tablet 025-35 mg-mcg ACA PV

wera (28) oral tablet 05-35 mg-mcg ACA PV

wymzya fe oral tabletchewable 04mg-35mcg(21) and 75 mg (7)

ACA PV

zarah oral tablet 3-003 mg ACA PV

zovia 135e (28) oral tablet 1-35 mg-mcg ACA PV

zumandimine (28) oral tablet 3-003 mg ACA PV

OXYTOCICS

methergine oral tablet 02 mg 1

methylergonovine oral tablet 02 mg 1

OPHTHALMOLOGY

ANTIBIOTICS

ak-poly-bac ophthalmic (eye) ointment 500-10000 unitgram

1

AZASITE OPHTHALMIC (EYE) DROPS 1 1

bacitracin ophthalmic (eye) ointment 500 unitgram

1

bacitracin-polymyxin b ophthalmic (eye) ointment 500-10000 unitgram

1

BESIVANCE OPHTHALMIC (EYE) DROPSSUSPENSION 06

1

ciprofloxacin hcl ophthalmic (eye) drops 03 1

erythromycin ophthalmic (eye) ointment 5 mggram (05 )

1

gatifloxacin ophthalmic (eye) drops 05 1

110


gentak ophthalmic (eye) ointment 03 (3 mggram)

1

gentamicin ophthalmic (eye) drops 03 1

levofloxacin ophthalmic (eye) drops 05 1

moxifloxacin ophthalmic (eye) drops 05 1

moxifloxacin ophthalmic (eye) drops viscous 05

1

NATACYN OPHTHALMIC (EYE) DROPSSUSPENSION 5

1

neomycin-bacitracin-polymyxin ophthalmic (eye) ointment 35-400-10000 mg-unit-unitg

1

neomycin-polymyxin-gramicidin ophthalmic (eye) drops 175 mg-10000 unit-0025mgml

1

neo-polycin ophthalmic (eye) ointment 35-400-10000 mg-unit-unitg

1

ofloxacin ophthalmic (eye) drops 03 1

polycin ophthalmic (eye) ointment 500-10000 unitgram

1

polymyxin b sulf-trimethoprim ophthalmic (eye) drops 10000 unit- 1 mgml

1

tobramycin ophthalmic (eye) drops 03 1

TOBREX OPHTHALMIC (EYE) OINTMENT 03

1

ANTIVIRALS

trifluridine ophthalmic (eye) drops 1 1

ZIRGAN OPHTHALMIC (EYE) GEL 015 1

BETA-BLOCKERS

betaxolol ophthalmic (eye) drops 05 1

BETIMOL OPHTHALMIC (EYE) DROPS 025 05

1

BETOPTIC S OPHTHALMIC (EYE) DROPSSUSPENSION 025

1

carteolol ophthalmic (eye) drops 1 1

levobunolol ophthalmic (eye) drops 05 1

timolol maleate ophthalmic (eye) drops 025 05

1

timolol maleate ophthalmic (eye) drops once daily 05

1

111


timolol maleate ophthalmic (eye) gel forming solution 025 05

1

CYCLOPLEGIC MYDRIATICS

atropine ophthalmic (eye) drops 1 1

atropine ophthalmic (eye) ointment 1 1

cyclopentolate ophthalmic (eye) drops 05 1 2

1

homatropaire ophthalmic (eye) drops 5 1

tropicamide ophthalmic (eye) drops 05 1 1

DIRECT ACTING MIOTICS

pilocarpine hcl ophthalmic (eye) drops 1 2 4

1

MISCELLANEOUS OPHTHALMOLOGICS

ALOCRIL OPHTHALMIC (EYE) DROPS 2 1 ST

ALOMIDE OPHTHALMIC (EYE) DROPS 01 1 ST

altacaine ophthalmic (eye) drops 05 1

azelastine ophthalmic (eye) drops 005 1

BEOVU INTRAVITREAL SOLUTION 6 MG005 ML

MB PA LA

bepotastine besilate ophthalmic (eye) drops 15 1 ST

cromolyn ophthalmic (eye) drops 4 1

CYSTARAN OPHTHALMIC (EYE) DROPS 044

1 PA

epinastine ophthalmic (eye) drops 005 1

EYLEA INTRAVITREAL SOLUTION 2 MG005 ML

MB PA LA

EYLEA INTRAVITREAL SYRINGE 2 MG005 ML

MB PA LA

LACRISERT OPHTHALMIC (EYE) INSERT 5 MG

1

LASTACAFT OPHTHALMIC (EYE) DROPS 025

1 ST

LUCENTIS INTRAVITREAL SOLUTION 03 MG005 ML 05 MG005 ML

MB PA LA

LUCENTIS INTRAVITREAL SYRINGE 03 MG005 ML 05 MG005 ML

MB PA LA

LUXTURNA SUBRETINAL SUSPENSION 15 X 10EXP11 VG03 ML (FNL)

MB LA

112


olopatadine ophthalmic (eye) drops 01 02 1

OMIDRIA INTRAOCULAR CONCENTRATE 1-03

MB

proparacaine ophthalmic (eye) drops 05 1

RESTASIS OPHTHALMIC (EYE) DROPPERETTE 005


TETRACAINE HCL (PF) OPHTHALMIC (EYE) DROPS 05

1

tetracaine hcl ophthalmic (eye) drops 05 1

VISUDYNE INTRAVENOUS RECON SOLN 15 MG

MB LA

XIIDRA OPHTHALMIC (EYE) DROPPERETTE 5


NON-STEROIDAL ANTI-INFLAMMATORY AGENTS

ACUVAIL (PF) OPHTHALMIC (EYE) DROPPERETTE 045

1 ST

bromfenac ophthalmic (eye) drops 009 1

diclofenac sodium ophthalmic (eye) drops 01 1

flurbiprofen sodium ophthalmic (eye) drops 003

1

ketorolac ophthalmic (eye) drops 04 05 1

NEVANAC OPHTHALMIC (EYE) DROPSSUSPENSION 01

1

ORAL DRUGS FOR GLAUCOMA

acetazolamide oral capsule extended release 500 mg

1

acetazolamide oral tablet 125 mg 250 mg 1

methazolamide oral tablet 25 mg 50 mg 1

OTHER GLAUCOMA DRUGS

bimatoprost ophthalmic (eye) drops 003 1

brinzolamide ophthalmic (eye) dropssuspension 1

1

COMBIGAN OPHTHALMIC (EYE) DROPS 02-05

1

dorzolamide ophthalmic (eye) drops 2 1

dorzolamide-timolol (pf) ophthalmic (eye) dropperette 2-05

1

113


dorzolamide-timolol ophthalmic (eye) drops 223-68 mgml

1

latanoprost ophthalmic (eye) drops 0005 1

LUMIGAN OPHTHALMIC (EYE) DROPS 001

1 ST

RHOPRESSA OPHTHALMIC (EYE) DROPS 002

1 PA ST

SIMBRINZA OPHTHALMIC (EYE) DROPSSUSPENSION 1-02

1

travoprost ophthalmic (eye) drops 0004 1

STEROID-ANTIBIOTIC COMBINATIONS

neomycin-bacitracin-poly-hc ophthalmic (eye) ointment 35-400-10000 mg-unitg-1

1

neomycin-polymyxin b-dexameth ophthalmic (eye) dropssuspension 35mgml-10000 unitml-01

1

neomycin-polymyxin b-dexameth ophthalmic (eye) ointment 35 mgg-10000 unitg-01

1

neomycin-polymyxin-hc ophthalmic (eye) dropssuspension 35-10000-10 mg-unit-mgml

1

neo-polycin hc ophthalmic (eye) ointment 35-400-10000 mg-unitg-1

1

TOBRADEX OPHTHALMIC (EYE) OINTMENT 03-01

1

TOBRADEX ST OPHTHALMIC (EYE) DROPSSUSPENSION 03-005

1

tobramycin-dexamethasone ophthalmic (eye) dropssuspension 03-01

1

STEROIDS

ALREX OPHTHALMIC (EYE) DROPSSUSPENSION 02

1 ST

dexamethasone sodium phosphate ophthalmic (eye) drops 01

1

difluprednate ophthalmic (eye) drops 005 1

DUREZOL OPHTHALMIC (EYE) DROPS 005

1

fluorometholone ophthalmic (eye) dropssuspension 01

1

FML FORTE OPHTHALMIC (EYE) DROPSSUSPENSION 025

1

114


FML SOP OPHTHALMIC (EYE) OINTMENT 01

1

INVELTYS OPHTHALMIC (EYE) DROPSSUSPENSION 1

1 ST

LOTEMAX OPHTHALMIC (EYE) OINTMENT 05

1 ST

loteprednol etabonate ophthalmic (eye) dropsgel 05

1

loteprednol etabonate ophthalmic (eye) dropssuspension 05

1

MAXIDEX OPHTHALMIC (EYE) DROPSSUSPENSION 01

1

OZURDEX INTRAVITREAL IMPLANT 07 MG MB PA LA

PRED MILD OPHTHALMIC (EYE) DROPSSUSPENSION 012

1

prednisolone acetate ophthalmic (eye) dropssuspension 1

1

prednisolone sodium phosphate ophthalmic (eye) drops 1

1

RETISERT INTRAVITREAL IMPLANT 059 MG

MB PA LA

YUTIQ INTRAVITREAL IMPLANT 018 MG MB PA

STEROID-SULFONAMIDE COMBINATIONS

BLEPHAMIDE OPHTHALMIC (EYE) DROPSSUSPENSION 10-02

1

BLEPHAMIDE SOP OPHTHALMIC (EYE) OINTMENT 10-02

1

sulfacetamide-prednisolone ophthalmic (eye) drops 10 -023 (025 )

1

SULFONAMIDES

sulfacetamide sodium ophthalmic (eye) drops 10

1

sulfacetamide sodium ophthalmic (eye) ointment 10

1

SYMPATHOMIMETICS

apraclonidine ophthalmic (eye) drops 05 1

brimonidine ophthalmic (eye) drops 015 02 1

IOPIDINE OPHTHALMIC (EYE) DROPPERETTE 1

1

115


VASOCONSTRICTOR DECONGESTANTS

phenylephrine hcl ophthalmic (eye) drops 10 25

1

RESPIRATORY ALLERGY COUGH amp COLD

ANTIHISTAMINE amp ANTIALLERGENIC AGENTS

adrenalin injection solution 1 mgml 1 mgml (1 ml)

1

carbinoxamine maleate oral liquid 4 mg5 ml 1 PA ST QL (2 per 30 days)

carbinoxamine maleate oral tablet 4 mg 1 PA ST QL (240 per 30 days)


cetirizine oral solution 1 mgml 1

clemastine oral syrup 05 mg5 ml 1

clemastine oral tablet 268 mg 1

cyproheptadine oral syrup 2 mg5 ml 1

cyproheptadine oral tablet 4 mg 1

desloratadine oral tablet 5 mg 1 PA ST QL (30 per 30 days)

desloratadine oral tabletdisintegrating 25 mg 5 mg

1 PA ST

diphenhydramine hcl injection solution 50 mgml 1

diphenhydramine hcl injection syringe 50 mgml MB

EPINEPHRINE INJECTION AUTO-INJECTOR 015 MG015 ML

1

epinephrine injection auto-injector 015 mg03 ml 03 mg03 ml

1

epinephrine injection solution 1 mgml 1 mgml (1 ml)

1

epinephrine injection syringe 01 mgml 1

hydroxyzine hcl intramuscular solution 25 mgml MB

hydroxyzine hcl oral solution 10 mg5 ml 1

hydroxyzine hcl oral tablet 10 mg 25 mg 50 mg 1

hydroxyzine pamoate oral capsule 100 mg 25 mg 50 mg

1

levocetirizine oral solution 25 mg5 ml 1

levocetirizine oral tablet 5 mg 1

promethazine injection solution 25 mgml MB

promethazine oral syrup 625 mg5 ml 1

promethazine oral tablet 125 mg 25 mg 50 mg 1

116


promethazine rectal suppository 125 mg 25 mg 1

promethegan rectal suppository 125 mg 25 mg 50 mg

1

COUGH amp COLD THERAPY

benzonatate oral capsule 100 mg 150 mg 200 mg 1

brompheniramine-pseudoeph-dm oral syrup 2-30-10 mg5 ml

1

codeine-guaifenesin oral liquid 10-100 mg5 ml 1

g tussin ac oral liquid 10-100 mg5 ml 1

guaiatussin ac oral liquid 10-100 mg5 ml 1

hydrocodone-chlorpheniramine oral suspensionextended rel 12 hr 10-8 mg5 ml

1

hydrocodone-homatropine oral syrup 5-15 mg5 ml

1

hydrocodone-homatropine oral tablet 5-15 mg 1

hydromet oral syrup 5-15 mg5 ml 1

maxi-tuss ac oral liquid 10-100 mg5 ml 1

m-clear wc oral liquid 63-100 mg5 ml 1

promethazine-codeine oral syrup 625-10 mg5 ml 1

promethazine-dm oral syrup 625-15 mg5 ml 1

promethazine-phenyleph-codeine oral syrup 625-5-10 mg5 ml

1

promethazine-phenylephrine oral syrup 625-5 mg5 ml

1

virtussin ac oral liquid 10-100 mg5 ml 1

PULMONARY AGENTS

acetylcysteine solution 100 mgml (10 ) 200 mgml (20 )

1

ADEMPAS ORAL TABLET 05 MG 1 MG 15 MG 2 MG 25 MG

1 PA LA

ADVAIR HFA INHALATION HFA AEROSOL INHALER 115-21 MCGACTUATION 230-21 MCGACTUATION 45-21 MCGACTUATION


ALBUTEROL HFA 90 MCG INHALER 90 MCGACTUATION


albuterol sulfate inhalation inhalation hfa aerosol inhaler 90 mcgactuation


117


albuterol sulfate inhalation inhalation solution for nebulization 063 mg3 ml 125 mg3 ml 25 mg 3 ml (0083 ) 25 mg05 ml 5 mgml

1

albuterol sulfate inhalation oral syrup 2 mg5 ml 1

albuterol sulfate inhalation oral tablet 2 mg 4 mg 1

albuterol sulfate inhalation oral tablet extended release 12 hr 4 mg 8 mg

1

ALVESCO INHALATION HFA AEROSOL INHALER 160 MCGACTUATION 80 MCGACTUATION


alyq oral tablet 20 mg 1 PA

ambrisentan oral tablet 10 mg 5 mg 1 PA LA

aminophylline intravenous solution 250 mg10 ml MB

ANORO ELLIPTA INHALATION BLISTER WITH DEVICE 625-25 MCGACTUATION


arformoterol inhalation solution for nebulization 15 mcg2 ml

1

ARNUITY ELLIPTA INHALATION BLISTER WITH DEVICE 100 MCGACTUATION 200 MCGACTUATION


ARNUITY ELLIPTA INHALATION BLISTER WITH DEVICE 50 MCGACTUATION

1

ATROVENT HFA INHALATION HFA AEROSOL INHALER 17 MCGACTUATION


BERINERT INTRAVENOUS KIT 500 UNIT (10 ML)

MB PA LA

BEVESPI AEROSPHERE INHALATION HFA AEROSOL INHALER 9-48 MCG

1

bosentan oral tablet 125 mg 625 mg 1 PA LA

BREO ELLIPTA INHALATION BLISTER WITH DEVICE 100-25 MCGDOSE



1

BROVANA INHALATION SOLUTION FOR NEBULIZATION 15 MCG2 ML

1

budesonide inhalation suspension for nebulization 025 mg2 ml 05 mg2 ml


budesonide inhalation suspension for nebulization 1 mg2 ml


118


CINQAIR INTRAVENOUS SOLUTION 10 MGML

MB PA

CINRYZE INTRAVENOUS RECON SOLN 500 UNIT (5 ML)

MB PA LA

COMBIVENT RESPIMAT INHALATION MIST 20-100 MCGACTUATION


cromolyn inhalation solution for nebulization 20 mg2 ml

1

DALIRESP ORAL TABLET 250 MCG 500 MCG

1

DULERA INHALATION HFA AEROSOL INHALER 100-5 MCGACTUATION 200-5 MCGACTUATION 50-5 MCGACTUATION


ELIXOPHYLLIN ORAL ELIXIR 80 MG15 ML 1

ESBRIET ORAL CAPSULE 267 MG 1 PA LA QL (270 per 30 days)

ESBRIET ORAL TABLET 267 MG 801 MG 1 PA LA QL (90 per 30 days)

FASENRA PEN SUBCUTANEOUS AUTO-INJECTOR 30 MGML

MB PA LA

FASENRA SUBCUTANEOUS SYRINGE 30 MGML

MB PA LA

FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCGACTUATION 50 MCGACTUATION


FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 250 MCGACTUATION


FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCGACTUATION 44 MCGACTUATION


FLOVENT HFA INHALATION HFA AEROSOL INHALER 220 MCGACTUATION


fluticasone propionate nasal spraysuspension 50 mcgactuation

1

fluticasone propion-salmeterol inhalation blister with device 100-50 mcgdose 250-50 mcgdose 500-50 mcgdose


formoterol fumarate inhalation solution for nebulization 20 mcg2 ml

1

HAEGARDA SUBCUTANEOUS RECON SOLN 2000 UNIT 3000 UNIT

1 PA LA

icatibant subcutaneous syringe 30 mg3 ml 1 PA

119


INCRUSE ELLIPTA INHALATION BLISTER WITH DEVICE 625 MCGACTUATION


ipratropium bromide inhalation solution 002 1

ipratropium-albuterol inhalation solution for nebulization 05 mg-3 mg(25 mg base)3 ml


KALBITOR SUBCUTANEOUS SOLUTION 10 MGML (1 ML)

1 PA LA

KALYDECO ORAL GRANULES IN PACKET 25 MG 50 MG 75 MG

1 PA LA

KALYDECO ORAL TABLET 150 MG 1 PA LA

levalbuterol hcl inhalation solution for nebulization 031 mg3 ml 063 mg3 ml 125 mg05 ml 125 mg3 ml

1

LEVALBUTEROL TARTRATE INHALATION HFA AEROSOL INHALER 45 MCGACTUATION


metaproterenol oral syrup 10 mg5 ml 1

montelukast oral granules in packet 4 mg 1

montelukast oral tablet 10 mg 1

montelukast oral tabletchewable 4 mg 5 mg 1

nebusal inhalation solution for nebulization 3 1

NUCALA SUBCUTANEOUS RECON SOLN 100 MG

MB PA LA

OFEV ORAL CAPSULE 100 MG 150 MG 1 PA LA QL (60 per 30 days)

OPSUMIT ORAL TABLET 10 MG 1 PA LA

ORLADEYO ORAL CAPSULE 110 MG 150 MG


PERFOROMIST INHALATION SOLUTION FOR NEBULIZATION 20 MCG2 ML

1

pulmosal inhalation solution for nebulization 7 1

PULMOZYME INHALATION SOLUTION 1 MGML

1 PA LA

QVAR REDIHALER INHALATION HFA AEROSOL BREATH ACTIVATED 40 MCGACTUATION 80 MCGACTUATION

1

REVATIO INTRAVENOUS SOLUTION 10 MG125 ML

MB LA

RUCONEST INTRAVENOUS RECON SOLN 2100 UNIT

MB PA LA

120


SEREVENT DISKUS INHALATION BLISTER WITH DEVICE 50 MCGDOSE

1

sildenafil (pulmhypertension) intravenous solution 10 mg125 ml

MB

sildenafil (pulmhypertension) oral suspension for reconstitution 10 mgml

1

sildenafil (pulmhypertension) oral tablet 20 mg 1 PA

SINUVA SINUS IMPLANT 1350 MCG MB

sodium chloride inhalation solution for nebulization 09 10 3 7

1

SPIRIVA RESPIMAT INHALATION MIST 125 MCGACTUATION

1



SPIRIVA WITH HANDIHALER INHALATION CAPSULE WINHALATION DEVICE 18 MCG


STIOLTO RESPIMAT INHALATION MIST 25-25 MCGACTUATION

1

STRIVERDI RESPIMAT INHALATION MIST 25 MCGACTUATION

1

SYMBICORT INHALATION HFA AEROSOL INHALER 160-45 MCGACTUATION 80-45 MCGACTUATION


SYMDEKO ORAL TABLETS SEQUENTIAL 100-150 MG (D) 150 MG (N) 50-75 MG (D) 75 MG (N)

1 PA LA

tadalafil (pulm hypertension) oral tablet 20 mg 1 PA

TAKHZYRO SUBCUTANEOUS SOLUTION 300 MG2 ML (150 MGML)

1 PA LA

terbutaline oral tablet 25 mg 5 mg 1

terbutaline subcutaneous solution 1 mgml 1

theophylline oral elixir 80 mg15 ml 1

theophylline oral solution 80 mg15 ml 1

theophylline oral tablet extended release 12 hr 300 mg 450 mg

1


1

TRACLEER ORAL TABLET FOR SUSPENSION 32 MG

1 PA LA

121


TRELEGY ELLIPTA INHALATION BLISTER WITH DEVICE 100-625-25 MCG 200-625-25 MCG

1

TRIKAFTA ORAL TABLETS SEQUENTIAL 100-50-75 MG(D) 150 MG (N) 50-25-375 MG (D)75 MG (N)

1 PA LA

TYVASO INHALATION SOLUTION FOR NEBULIZATION 174 MG29 ML (06 MGML)

1 PA LA

TYVASO REFILL KIT INHALATION SOLUTION FOR NEBULIZATION 174 MG29 ML (06 MGML)

1 PA LA

TYVASO STARTER KIT INHALATION SOLUTION FOR NEBULIZATION 174 MG29 ML

1 PA LA

VENTAVIS INHALATION SOLUTION FOR NEBULIZATION 10 MCGML 20 MCGML

1 PA LA

wixela inhub inhalation blister with device 100-50 mcgdose 250-50 mcgdose 500-50 mcgdose


XOLAIR SUBCUTANEOUS RECON SOLN 150 MG

MB LA

XOLAIR SUBCUTANEOUS SYRINGE 150 MGML 75 MG05 ML

MB PA LA QL (7 per 30 days)

zafirlukast oral tablet 10 mg 20 mg 1

zileuton oral tablet er multiphase 12 hr 600 mg 1 ST

ZYFLO ORAL TABLET 600 MG 1 ST

UROLOGICALS

ANTICHOLINERGICS amp ANTISPASMODICS

darifenacin oral tablet extended release 24 hr 15 mg 75 mg

1

flavoxate oral tablet 100 mg 1

MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR 25 MG 50 MG

1 ST

oxybutynin chloride oral syrup 5 mg5 ml 1

oxybutynin chloride oral tablet 5 mg 1

oxybutynin chloride oral tablet extended release 24hr 10 mg 15 mg 5 mg

1

solifenacin oral tablet 10 mg 5 mg 1

tolterodine oral capsuleextended release 24hr 2 mg 4 mg

1

tolterodine oral tablet 1 mg 2 mg 1

122


trospium oral capsuleextended release 24hr 60 mg

1

trospium oral tablet 20 mg 1

BENIGN PROSTATIC HYPERPLASIA (BPH) THERAPY

alfuzosin oral tablet extended release 24 hr 10 mg 1

dutasteride oral capsule 05 mg 1

dutasteride-tamsulosin oral capsule er multiphase 24 hr 05-04 mg

1

finasteride oral tablet 5 mg 1

silodosin oral capsule 4 mg 8 mg 1

tadalafil oral tablet 25 mg 5 mg 1 PA ST

tamsulosin oral capsule 04 mg 1

CHOLINERGIC STIMULANTS

bethanechol chloride oral tablet 10 mg 25 mg 5 mg 50 mg

1

MISCELLANEOUS UROLOGICALS

CYSTAGON ORAL CAPSULE 150 MG 50 MG 1 PA

ELMIRON ORAL CAPSULE 100 MG 1

hyophen oral tablet 816-012-108 mg 1

K-PHOS NO 2 ORAL TABLET 305-700 MG 1

K-PHOS ORIGINAL ORAL TABLETSOLUBLE 500 MG

1

methen-sod phos-meth blue-hyos oral tablet 816-408-012 mg

1

OXLUMO SUBCUTANEOUS SOLUTION 945 MG05 ML

1 PA

phosphasal oral tablet 816-108-408 mg 1

potassium citrate oral tablet extended release 10 meq (1080 mg) 15 meq 5 meq (540 mg)

1

RENACIDIN IRRIGATION SOLUTION 19806 MG-594 MG-9804MG30ML

1

URELLE ORAL TABLET 81-108-408 MG 1

uretron d-s oral tablet 816-108-408 mg 1

urimar-t oral tablet 120-012-108 mg 1

urogesic-blue oral tablet 816-408-012 mg 1

uryl oral tablet 816-408-012 mg 1

ustell oral capsule 120-012 mg 1

123


utira-c oral tablet 816-108-408 mg 1

URINARY ANESTHETICS

phenazopyridine oral tablet 100 mg 200 mg 1

VITAMINS HEMATINICS amp ELECTROLYTES

ELECTROLYTES

effer-k oral tablet effervescent 25 meq 1

klor-con 10 oral tablet extended release 10 meq 1


klor-con m10 oral tableter particlescrystals 10 meq

1


1


1

klor-con oral packet 20 meq 1

klor-conef oral tablet effervescent 25 meq 1

K-TAB ORAL TABLET EXTENDED RELEASE 10 MEQ

1

k-tab oral tablet extended release 8 meq 1

NORMOSOL-R INTRAVENOUS PARENTERAL SOLUTION

MB

potassium chloride oral capsule extended release 10 meq 8 meq

1

potassium chloride oral liquid 20 meq15 ml 40 meq15 ml

1

potassium chloride oral packet 20 meq 1

potassium chloride oral tablet extended release 10 meq 20 meq 8 meq

1

potassium chloride oral tableter particlescrystals 10 meq 15 meq 20 meq

1

sodium chloride 045 intravenous parenteral solution 045

MB

MISCELLANEOUS VITAMINS HEMATINICS amp ELECTROLYTES

ISOLYTE-S INTRAVENOUS PARENTERAL SOLUTION

MB

PLASMA-LYTE 148 INTRAVENOUS PARENTERAL SOLUTION

MB

124


PLASMA-LYTE A INTRAVENOUS PARENTERAL SOLUTION

MB

VITAMINS amp HEMATINICS

cyanocobalamin (vitamin b-12) injection solution 1000 mcgml

1

ergocalciferol (vitamin d2) oral capsule 1250 mcg (50000 unit)

1

FA-8 ORAL CAPSULE 08 MG ACA PV

FER-IN-SOL ORAL DROPS 15 MG IRON (75 MG)ML

ACA PV

FLORIVA (FLUORIDE-VITAMIN D3) ORAL DROPS 025 MG (055 MG)-400 UNITML

ACA PV

fluoride (sodium) oral drops 05 mg (11 mg sodfluorid)ml

ACA PV

fluoride (sodium) oral tabletchewable 025 mg(055 mg sod fluoride) 05 mg (11 mg sodium fluorid) 1 mg (22 mg sod fluoride)

ACA PV

folic acid injection solution 5 mgml 1

folic acid oral tablet 1 mg 1

folic acid oral tablet 400 mcg 800 mcg ACA PV

hydroxocobalamin intramuscular solution 1000 mcgml

1

INFED INJECTION SOLUTION 50 MGML MB

ludent fluoride oral tabletchewable 025 mg(055 mg sod fluoride) 05 mg (11 mg sodium fluorid) 1 mg (22 mg sod fluoride)

ACA PV

multi-vitamin with fluoride oral drops 025 mgml 05 mgml

ACA PV

multi-vitamin with fluoride oral tabletchewable 025 mg 05 mg 1 mg

ACA PV

multivitamins with fluoride oral tabletchewable 025 mg 05 mg 1 mg

ACA PV

mvc-fluoride oral tabletchewable 025 mg 05 mg 1 mg

ACA PV

NOVAFERRUM ORAL DROPS 15 MG IRONML

ACA PV

tri-vitamin with fluoride oral drops 025 mg fluor (055 mg)ml 05 mg fluoride (11 mg)ml

ACA PV

vitamins acd and fluoride oral drops 025 mg fluor (055 mg)ml 05 mg fluoride (11 mg)ml

ACA PV

125

Index

A abacavir 2 abacavir-lamivudine 2 abacavir-lamivudine-

zidovudine 2 ABILIFY MAINTENA 36 abiraterone 13 ABRAXANE 13 acamprosate 66 acarbose 77 accutane 60 acebutolol 45 acetaminophen-caff-

dihydrocod 31 acetaminophen-codeine 31 acetazolamide 112 acetic acid 66 69 acetylcysteine 116 acitretin 58 ACTEMRA 96 ACTEMRA ACTPEN 96 ACTHAR 70 ACTHIB (PF) 90 ACTIMMUNE 89 ACUVAIL (PF) 112 acyclovir 2 63 ADACEL(TDAP

ADOLESNADULT)(PF) 90 ADAKVEO 13 adapalene 60 ADAPALENE 60 adapalene-benzoyl peroxide 60 ADCETRIS 14 adefovir 2 ADEMPAS 116 ADHANSIA XR 37 adrenalin 115 adult aspirin regimen 34 ADVAIR HFA 116 ADVATE 50 ADYNOVATE 50 ADZENYS XR-ODT 37 AEROCHAMBER MINI 71 AEROCHAMBER PLUS

FLOW-VU 71 AFINITOR 14 afirmelle 102

AFLURIA QD 2021-22(3YR UP)(PF) 90

AFLURIA QD 2021-22(6-35MO)(PF) 90

AFLURIA QUAD 2021-2022(6MO UP) 90

AFSTYLA 51 after pill 102 AIMOVIG AUTOINJECTOR

28 AJOVY AUTOINJECTOR 28 AJOVY SYRINGE 28 ak-poly-bac 109 AKYNZEO (NETUPITANT)

81 ala-cort 63 albendazole 8 albuterol sulfate inhalation 116

117 ALBUTEROL SULFATE

INHALATION 116 alclometasone 63 ALCORTIN A 62 ALDURAZYME 75 ALECENSA 14 alendronate 96 alfuzosin 122 ALIMTA 14 ALINIA 8 ALIQOPA 14 aliskiren 45 allopurinol 95 almotriptan malate 28 ALOCRIL 111 ALOGLIPTIN-

PIOGLITAZONE 77 ALOMIDE 111 alosetron 81 ALOXI 81 ALPHANATE 51 ALPHANINE SD 51 alprazolam 37 alprazolam intensol 37 ALPROLIX 51 ALREX 113 ALTABAX 62 altacaine 111 altavera (28) 102

ALVESCO 117 alyacen 135 (28) 102 alyacen 777 (28) 102 alyq 117 amabelz 99 amantadine hcl 2 AMBISOME 1 ambrisentan 117 amcinonide 63 amethia 102 amethyst (28) 102 amikacin 8 amiloride 45 amiloride-hydrochlorothiazide

45 aminocaproic acid 51 aminophylline 117 amiodarone 44 AMITIZA 81 amitriptyline 37 amitriptyline-chlordiazepoxide

37 amlodipine 45 amlodipine-atorvastatin 55 amlodipine-benazepril 45 amlodipine-olmesartan 45 amlodipine-valsartan 45 amlodipine-valsartan-hcthiazid

45 ammonium lactate 59 amnesteem 60 amoxapine 37 amoxicil-clarithromy-lansopraz

85 amoxicillin 11 amoxicillin-pot clavulanate 11 AMPHETAMINE 37 amphetamine sulfate 37 amphotericin b 1 ampicillin 11 ampicillin-sulbactam 11 anagrelide 66 anaspaz 80 anastrozole 14 ANDEXXA 51 ANDRODERM 75 ANGELIQ 99 ANNOVERA 101

126

ANORO ELLIPTA 117 anucort-hc 81 apexicon e 63 APLENZIN 37 APOKYN 27 apraclonidine 114 aprepitant 81 apri 102 APTIVUS 2 ARALAST NP 66 aranelle (28) 102 ARANESP (IN

POLYSORBATE) 86 ARCALYST 89 ARESTIN 68 arformoterol 117 aripiprazole 37 ARISTADA 37 ARISTADA INITIO 37 armodafinil 37 ARMOUR THYROID 79 ARNUITY ELLIPTA 117 ARRANON 14 ARZERRA 14 ASCENIV 90 ascomp with codeine 31 asenapine maleate 37 ashlyna 102 ASPARLAS 14 aspirin 34 aspirin low dose 34 aspirin-dipyridamole 51 aspir-trin 34 atazanavir 2 atenolol 45 atenolol-chlorthalidone 45 ATGAM 90 atomoxetine 38 atorvastatin 55 atovaquone 8 atovaquone-proguanil 8 atropine 80 111 ATROVENT HFA 117 AUBAGIO 87 aubra 103 aubra eq 102 aurovela 1530 (21) 103 aurovela 120 (21) 103 aurovela 24 fe 103 aurovela fe 1530 (28) 103 aurovela fe 1-20 (28) 103

AUSTEDO 29 AVASTIN 14 aviane 103 avidoxy 12 avita 60 AVITA 60 AVONEX 87 AVYCAZ 6 ayuna 103 AZASITE 109 azathioprine 14 azelaic acid 60 azelastine 68 69 111 AZELEX 60 azithromycin 7 azurette (28) 103 B bacitracin 8 109 bacitracin-polymyxin b 109 baclofen 30 BALCOLTRA 103 balsalazide 81 BALVERSA 14 balziva (28) 103 BAQSIMI 71 BARACLUDE 2 BAVENCIO 14 BAXDELA 12 bayer aspirin 34 BAYER CHEWABLE

ASPIRIN 34 BCG VACCINE LIVE (PF) 90 BELEODAQ 14 belladonna alkaloids-opium 80 BELRAPZO 14 BELSOMRA 38 benazepril 45 benazepril-hydrochlorothiazide

45 BENDAMUSTINE 14 BENDEKA 14 BENEFIX 51 BENLYSTA 96 benzonatate 116 benztropine 27 BEOVU 111 bepotastine besilate 111 BERINERT 117 beser 63 BESIVANCE 109 BESPONSA 14

betamethasone dipropionate 63 64

betamethasone valerate 64 betamethasone augmented 64 BETASERON 87 betaxolol 45 110 bethanechol chloride 122 BETIMOL 110 BETOPTIC S 110 BEVESPI AEROSPHERE 117 bexarotene 14 BEXSERO 90 bicalutamide 14 BICILLIN C-R 11 BIKTARVY 2 bimatoprost 112 BIOTHRAX 90 bisoprolol fumarate 45 bisoprolol-hydrochlorothiazide

46 BIVIGAM 90 BLEPHAMIDE 114 BLEPHAMIDE SOP 114 BLINCYTO 14 blisovi 24 fe 103 blisovi fe 1530 (28) 103 blisovi fe 120 (28) 103 BOOSTRIX TDAP 90 BORTEZOMIB 14 bosentan 117 BOSULIF 14 BOTOX 90 BRAFTOVI 14 BREO ELLIPTA 117 briellyn 103 BRILINTA 51 brimonidine 114 BRINEURA 75 brinzolamide 112 BRIVIACT 24 bromfenac 112 bromocriptine 27 brompheniramine-pseudoeph-

dm 116 BROVANA 117 budesonide 81 117 bumetanide 46 buprenorphine 31 buprenorphine hcl 31 buprenorphine-naloxone 34 bupropion hcl 38

127

bupropion hcl (smoking deter) 68

buspirone 38 BUSULFEX 15 butalbital compound wcodeine

31 butalbital-acetaminop-caf-cod

31 butalbital-acetaminophen-caff

31 butalbital-aspirin-caffeine 31 butorphanol 34 BYDUREON BCISE 77 BYETTA 77 BYSTOLIC 46 C CABENUVA 2 cabergoline 75 CABLIVI 51 CABOMETYX 15 calcipotriene 58 calcipotriene-betamethasone 58 calcitonin (salmon) 75 calcitriol 58 75 calcium acetate(phosphat bind)

81 CALQUENCE 15 camila 99 camrese 103 camrese lo 103 CANCIDAS 1 candesartan 46 candesartan-hydrochlorothiazid

46 capecitabine 15 CAPRELSA 15 captopril 46 captopril-hydrochlorothiazide

46 CARBAGLU 66 carbamazepine 24 carbidopa 27 carbidopa-levodopa 27 carbidopa-levodopa-

entacapone 28 carbinoxamine maleate 115 carisoprodol 30 carisoprodol-aspirin 30 carisoprodol-aspirin-codeine 30 carteolol 110 cartia xt 46

carvedilol 46 carvedilol phosphate 46 cataflam 34 CAYA CONTOURED 98 CAYSTON 8 caziant (28) 103 cefaclor 6 cefadroxil 6 cefazolin 6 cefazolin in dextrose (iso-os) 6 cefdinir 6 cefditoren pivoxil 6 cefepime 6 CEFEPIME IN DEXTROSE 5

6 cefepime in dextroseiso-osm 6 cefixime 6 CEFOTAN 6 cefotaxime 6 cefotetan 6 CEFOTETAN IN

DEXTROSE ISO-OSM 6 cefoxitin 6 cefpodoxime 6 7 cefprozil 7 ceftazidime 7 CEFTAZIDIME IN D5W 7 ceftriaxone 7 CEFTRIAXONE 7 ceftriaxone in dextroseiso-os 7 cefuroxime axetil 7 celecoxib 34 CELONTIN 24 cephalexin 7 CERDELGA 75 CEREZYME 75 cetirizine 115 cevimeline 67 charlotte 24 fe 103 chateal (28) 103 chateal eq (28) 103 CHEMET 67 childrens aspirin 34 chloramphenicol sod succinate

8 chlordiazepoxide hcl 38 chlordiazepoxide-clidinium 80 chlorhexidine gluconate 69 chloroquine phosphate 8 chlorpromazine 38 chlorthalidone 46

chlorzoxazone 30 CHOLBAM 81 cholestyramine (with sugar) 55 cholestyramine light 55 cholinemagnesium salicylate

34 ciclodan 62 ciclopirox 62 ciclopirox-ure-camph-menth-

euc 62 cidofovir 2 cilostazol 51 CIMDUO 2 cimetidine 85 cimetidine hcl 85 CIMZIA 81 CIMZIA POWDER FOR

RECONST 81 cinacalcet 75 CINQAIR 118 CINRYZE 118 CIPRO HC 69 ciprofloxacin 12 ciprofloxacin hcl 12 69 109 ciprofloxacin-dexamethasone

69 citalopram 38 claravis 60 clarithromycin 7 8 clemastine 115 CLENPIQ 81 clindacin p 60 clindamycin hcl 8 clindamycin pediatric 8 clindamycin phosphate 8 60

101 clindamycin-benzoyl peroxide

60 clindamycin-tretinoin 60 clobazam 24 clobetasol 64 clobetasol-emollient 64 CLOCORTOLONE

PIVALATE 64 CLODERM 64 CLOLAR 15 clomipramine 38 clonazepam 24 25 clonidine 46 clonidine hcl 38 46 clopidogrel 51

128

clorazepate dipotassium 38 clotrimazole 1 62 clotrimazole-betamethasone 62 clozapine 38 COAGADEX 51 COARTEM 8 codeine sulfate 31 codeine-butalbital-asa-caff 31 codeine-guaifenesin 116 colchicine 95 COLCHICINE 95 colesevelam 55 colestipol 55 COMBIGAN 112 COMBIPATCH 99 COMBIVENT RESPIMAT 118 COMETRIQ 15 COMPLERA 2 compro 82 constulose 82 CONTOUR NEXT TEST

STRIPS 71 CONTOUR TEST STRIPS 71 COPIKTRA 15 CORIFACT 51 CORLANOR 57 CORTIFOAM 82 COSENTYX 58 COSENTYX (2 SYRINGES)

58 COSENTYX PEN 58 COSENTYX PEN (2 PENS) 58 COTELLIC 15 COTEMPLA XR-ODT 38 covaryx 99 covaryx hs 99 CREON 82 CRESEMBA 1 CRINONE 99 cromolyn 82 111 118 crotan 66 cryselle (28) 103 CRYSVITA 75 CUBICIN 8 CUBICIN RF 8 CUTAQUIG 90 CUVITRU 90 cyanocobalamin (vitamin b-12)

124 cyclafem 135 (28) 103 cyclafem 777 (28) 103

cyclobenzaprine 30 cyclopentolate 111 cyclophosphamide 15 CYCLOPHOSPHAMIDE 15 CYCLOSERINE 9 CYCLOSET 77 cyclosporine 15 cyclosporine modified 15 cyproheptadine 115 CYRAMZA 15 cyred 103 cyred eq 103 CYSTAGON 122 CYSTARAN 111 CYTOVENE 2 D DACOGEN 15 dalfampridine 29 DALIRESP 118 danazol 75 dantrolene 30 dapsone 9 60 DAPTACEL (DTAP

PEDIATRIC) (PF) 91 darifenacin 121 DARZALEX 15 dasetta 135 (28) 104 dasetta 777 (28) 104 DAURISMO 15 daysee 104 DAYTRANA 38 deblitane 99 decadron 70 decitabine 15 deferasirox 67 deferiprone 67 demeclocycline 12 DENAVIR 63 denta 5000 plus 69 dentagel 69 DEPO-ESTRADIOL 99 DEPO-PROVERA 99 DEPO-SUBQ PROVERA 104

99 DEPO-TESTOSTERONE 75 DESCOVY 2 desipramine 38 desloratadine 115 desmopressin 75 desog-eestradioleestradiol

104

desogestrel-ethinyl estradiol 104

desonide 64 desoximetasone 64 DESVENLAFAXINE 38 desvenlafaxine succinate 38 dexamethasone 70 dexamethasone intensol 70 dexamethasone sodium phos

(pf) 70 dexamethasone sodium

phosphate 70 113 DEXILANT 85 dexmethylphenidate 39 dextroamphetamine 39 dextroamphetamine-

amphetamine 39 diazepam 25 39 diazepam intensol 39 diazoxide 71 diclofenac potassium 34 diclofenac sodium 34 59 112 diclofenac-misoprostol 34 dicloxacillin 11 dicyclomine 80 didanosine 2 DIFICID 8 diflorasone 64 diflunisal 34 difluprednate 113 digitek 50 digox 50 digoxin 50 dihydroergotamine 28 DILANTIN 25 DILANTIN EXTENDED 25 DILANTIN INFATABS 25 DILANTIN-125 25 diltiazem 46 dilt-xr 46 dimethyl fumarate 87 88 DIPENTUM 82 diphenhydramine hcl 115 diphenoxylate-atropine 80 dipyridamole 51 diskets 31 disopyramide phosphate 44 disulfiram 67 divalproex 25 DIVIGEL 99 dofetilide 44

129

dolishale 104 donepezil 29 DONNATAL 80 DOPTELET (15 TAB PACK)

51 dorzolamide 112 dorzolamide-timolol 113 dorzolamide-timolol (pf) 112 dotti 99 DOVATO 2 doxazosin 46 doxepin 39 doxercalciferol 75 doxycycline hyclate 12 doxycycline monohydrate 12 doxylamine-pyridoxine (vit b6)

82 dronabinol 82 drospirenone-eestradiol-lmfa

104 drospirenone-ethinyl estradiol

104 DSUVIA 31 DUAVEE 99 DUEXIS 34 DULERA 118 duloxetine 39 DUPIXENT PEN 59 DUPIXENT SYRINGE 59 duramorph (pf) 32 DUREZOL 113 dutasteride 122 dutasteride-tamsulosin 122 dvorah 32 DYANAVEL XR 39 DYSPORT 91 E ees 400 8 econazole 62 econtra ez 104 econtra one-step 104 ecotrin 34 ecotrin low strength 34 EDARBI 46 EDARBYCLOR 47 EDLUAR 39 ed-spaz 80 EDURANT 2 eemt 99 eemt hs 99 efavirenz 2

efavirenz-emtricitabin-tenofov 3

efavirenz-lamivu-tenofov disop 3

effer-k 123 ELAPRASE 75 ELELYSO 75 eletriptan 28 ELIGARD 16 ELIGARD (3 MONTH) 15 ELIGARD (4 MONTH) 15 ELIGARD (6 MONTH) 15 elinest 104 ELIQUIS 51 ELIQUIS DVT-PE TREAT

30D START 51 ELIXOPHYLLIN 118 ELLA 104 ELMIRON 122 ELOCTATE 52 eluryng 101 ELZONRIS 16 EMCYT 16 EMEND 82 EMGALITY PEN 28 EMGALITY SYRINGE 28 emoquette 104 EMPAVELI 67 EMPLICITI 16 EMSAM 39 emtricitabine 3 emtricitabine-tenofovir (tdf) 3 EMTRIVA 3 EMVERM 9 enalapril maleate 47 enalaprilat 47 enalapril-hydrochlorothiazide

47 ENBREL 96 97 ENBREL MINI 96 ENBREL SURECLICK 97 endocet 32 ENGERIX-B (PF) 91 ENGERIX-B PEDIATRIC

(PF) 91 ENHERTU 16 enoxaparin 52 enpresse 104 enskyce 104 entacapone 28 entecavir 3

ENTRESTO 57 ENTYVIO 82 enulose 82 EPANED 47 EPCLUSA 3 EPIDIOLEX 25 epinastine 111 epinephrine 115 EPINEPHRINE 115 epitol 25 EPIVIR HBV 3 eplerenone 47 EPOGEN 86 epoprostenol (glycine) 47 eprosartan 47 ERAXIS(WATER DILUENT)

1 ERBITUX 16 ergocalciferol (vitamin d2) 124 ergoloid 39 ergotamine-caffeine 28 ERLEADA 16 erlotinib 16 errin 99 ery pads 60 erygel 61 ery-tab 8 erythrocin (as stearate) 8 erythromycin 8 109 erythromycin ethylsuccinate 8 erythromycin with ethanol 61 erythromycin-benzoyl peroxide

61 ESBRIET 118 escitalopram oxalate 39 esomeprazole magnesium 85 ESPEROCT 52 estarylla 104 estazolam 39 estradiol 99 100 estradiol valerate 100 estradiol-norethindrone acet

100 ESTRING 100 estrogens-methyltestosterone

100 eszopiclone 39 ethacrynic acid 47 ethambutol 9 ethosuximide 25

130

ethynodiol diac-eth estradiol 104

etodolac 35 etonogestrel-ethinyl estradiol

101 etoposide 16 etravirine 3 EUCRISA 59 EUFLEXXA 35 EURAX 66 EVAMIST 100 EVENITY 96 everolimus (antineoplastic) 16 everolimus

(immunosuppressive) 16 EVOTAZ 3 EXELDERM 62 exemestane 16 EXONDYS-51 29 EYLEA 111 ezetimibe 55 ezetimibe-simvastatin 56 F FA-8 124 FABRAZYME 75 FACTIVE 12 falmina (28) 104 famciclovir 3 famotidine 85 famotidine (pf) 85 FANAPT 39 40 FARXIGA 77 FASENRA 118 FASENRA PEN 118 FASLODEX 16 FC2 FEMALE CONDOM 98 febuxostat 95 FEIBA NF 52 felbamate 25 felodipine 47 fem ph 101 FEMCAP 98 FEMRING 100 femynor 104 fenofibrate 56 FENOFIBRATE 56 fenofibrate micronized 56 fenofibrate nanocrystallized 56 fenofibric acid 56 fenofibric acid (choline) 56 fenoprofen 35

fentanyl 32 fentanyl citrate 32 FER-IN-SOL 124 FERRIPROX 67 FETZIMA 40 FIASP FLEXTOUCH U-100

INSULIN 72 FIASP PENFILL U-100

INSULIN 72 FIASP U-100 INSULIN 72 FIBRYGA 52 finasteride 122 FINTEPLA 25 FIRMAGON KIT W

DILUENT SYRINGE 16 flac otic oil 69 flavoxate 121 FLEBOGAMMA DIF 91 flecainide 44 FLOLAN 47 FLORIVA (FLUORIDE-

VITAMIN D3) 124 FLOVENT DISKUS 118 FLOVENT HFA 118 FLUAD QUAD 2021-22(65Y

UP)(PF) 91 FLUARIX QUAD 2021-2022

(PF) 91 FLUBLOK QUAD 2021-2022

(PF) 91 FLUCELVAX QUAD 2021-

2022 91 FLUCELVAX QUAD 2021-

2022 (PF) 91 fluconazole 1 flucytosine 1 fludarabine 16 fludrocortisone 70 FLULAVAL QUAD 2021-

2022 (PF) 91 FLUMIST QUAD 2021-2022

91 fluocinolone 64 65 fluocinolone acetonide oil 69 fluocinolone and shower cap 64 fluocinonide 65 fluocinonide-e 65 fluoride (sodium) 69 124 fluorometholone 113 fluorouracil 16 59 FLUOROURACIL 59

fluoxetine 40 fluphenazine hcl 40 flurandrenolide 65 flurazepam 40 flurbiprofen 35 flurbiprofen sodium 112 flutamide 16 fluticasone propionate 65 118 fluticasone propion-salmeterol

118 fluvastatin 56 fluvoxamine 40 FLUZONE HIGHDOSE

QUAD 21-22 PF 91 FLUZONE QUAD 2021-2022

92 FLUZONE QUAD 2021-2022

(PF) 91 FML FORTE 113 FML SOP 114 folic acid 124 FOLOTYN 16 fondaparinux 52 formoterol fumarate 118 FORTEO 96 FOSAMAX PLUS D 96 fosamprenavir 3 fosfomycin tromethamine 13 fosinopril 47 fosinopril-hydrochlorothiazide

47 FRAGMIN 52 FREESTYLE LIBRE 14 DAY

SENSOR 72 FREESTYLE LIBRE 2

SENSOR 72 frovatriptan 28 fulvestrant 16 furosemide 47 FUZEON 3 fyavolv 100 G g tussin ac 116 gabapentin 25 GALAFOLD 75 galantamine 29 GAMASTAN 92 GAMASTAN SD 92 GAMIFANT 17 GAMMAGARD LIQUID 92

131

GAMMAGARD S-D (IGA lt 1 MCGML) 92

GAMMAKED 92 GAMMAPLEX 92 GAMMAPLEX (WITH

SORBITOL) 92 GAMUNEX-C 92 GANCICLOVIR 3 ganciclovir sodium 3 GARDASIL 9 (PF) 92 gatifloxacin 109 gavilyte-c 82 gavilyte-g 82 gavilyte-n 82 GAZYVA 17 gemcitabine 17 gemfibrozil 56 gemmily 104 generlac 82 gengraf 17 GENOTROPIN 87 GENOTROPIN MINIQUICK

87 gentak 110 gentamicin 9 62 110 gentamicin sulfate (ped) (pf) 9 GENVOYA 3 GIAPREZA 57 GILENYA 88 GILOTRIF 17 GIVLAARI 67 GLASSIA 67 glatiramer 88 glatopa 88 GLEOSTINE 17 glimepiride 77 glipizide 77 glipizide-metformin 77 GLUCAGEN DIAGNOSTIC

KIT 71 GLUCAGEN HYPOKIT 71 GLUCAGON (HCL)

EMERGENCY KIT 71 glucagon emergency kit

(human) 71 GLUCAGON HCL 71 glyburide 77 glyburide micronized 77 glyburide-metformin 78 glycopyrrolate 80 GLYXAMBI 78

GONITRO 57 granisetron hcl 82 GRANIX 86 GRASTEK 92 griseofulvin microsize 1 griseofulvin ultramicrosize 1 guaiatussin ac 116 guanfacine 40 47 GYNAZOLE-1 101 gynol ii 101 H HAEGARDA 118 hailey 104 hailey 24 fe 104 hailey fe 1530 (28) 104 hailey fe 120 (28) 104 HALAVEN 17 halcinonide 65 halobetasol propionate 65 haloperidol 40 haloperidol decanoate 40 haloperidol lactate 40 HARVONI 3 HAVRIX (PF) 92 heather 100 HEMLIBRA 52 hemmorex-hc 82 HEMOFIL M HIGH 52 HEMOFIL M LOW 52 HEMOFIL M MID 52 HEMOFIL M SUPER HIGH52 hep flush-10 (pf) 52 heparin (porcine) 52 53 heparin (porcine) in 5 dex 52 heparin lock flush (porcine) 53 heparin lockflush(porcine)(pf)

53 heparin(porcine) in 045 nacl

53 HEPARIN(PORCINE) IN

045 NACL 53 heparin porcine (pf) 53 HEPLISAV-B (PF) 92 HERCEPTIN 17 HERCEPTIN HYLECTA 17 HERZUMA 17 HETLIOZ 40 HETLIOZ LQ 40 HIBERIX (PF) 92 HIZENTRA 92 homatropaire 111

HUMALOG JUNIOR KWIKPEN U-100 72

HUMALOG KWIKPEN INSULIN 72

HUMALOG MIX 50-50 INSULN U-100 72

HUMALOG MIX 50-50 KWIKPEN 72


HUMALOG MIX 75-25(U-100)INSULN 72

HUMALOG U-100 INSULIN 72

HUMATE-P 53 HUMIRA 97 HUMIRA PEN 97 HUMIRA PEN CROHNS-UC-

HS START 97 HUMIRA PEN PSOR-

UVEITS-ADOL HS 97 HUMIRA(CF) 97 HUMIRA(CF) PEDI

CROHNS STARTER 97 HUMIRA(CF) PEN 97 HUMIRA(CF) PEN

CROHNS-UC-HS 97 HUMIRA(CF) PEN

PEDIATRIC UC 97 HUMIRA(CF) PEN PSOR-

UV-ADOL HS 97 HUMULIN 7030 U-100

INSULIN 73 HUMULIN 7030 U-100

KWIKPEN 73 HUMULIN N NPH INSULIN

KWIKPEN 73 HUMULIN N NPH U-100

INSULIN 73 HUMULIN R REGULAR U-

100 INSULN 73 HUMULIN R U-500 (CONC)

INSULIN 73 HUMULIN R U-500 (CONC)

KWIKPEN 73 HYCAMTIN 17 hydralazine 47 hydrochlorothiazide 47 hydrocodone bitartrate 32 hydrocodone-acetaminophen 32

132

hydrocodone-chlorpheniramine 116

hydrocodone-homatropine 116 hydrocodone-ibuprofen 32 hydrocortisone 65 70 82 hydrocortisone acetate 82 hydrocortisone butyrate 65 hydrocortisone butyr-emollient

65 hydrocortisone valerate 65 hydrocortisone-acetic acid 69 hydrocortisone-pramoxine 58

82 hydromet 116 hydromorphone 32 HYDROMORPHONE 32 hydroxocobalamin 124 hydroxychloroquine 9 hydroxyprogest(pf)(preg presv)

100 hydroxyprogesterone

cap(ppres) 100 hydroxyprogesterone caproate

100 hydroxyurea 17 hydroxyzine hcl 115 hydroxyzine pamoate 115 hyophen 122 hyoscyamine sulfate 80 hyosyne 80 HYQVIA 93 I ibandronate 96 IBRANCE 17 ibu 35 ibuprofen 35 ibuprofen-famotidine 35 icatibant 118 iclevia 104 ICLUSIG 17 icosapent ethyl 56 IDELVION 53 IDHIFA 17 ILARIS (PF) 89 ILUMYA 58 imatinib 17 IMBRUVICA 17 IMFINZI 17 imipenem-cilastatin 9 imipramine hcl 40 imipramine pamoate 40

imiquimod 89 IMLYGIC 18 IMOVAX RABIES VACCINE

(PF) 93 incassia 100 INCRELEX 67 INCRUSE ELLIPTA 119 indapamide 47 indomethacin 35 INFANRIX (DTAP) (PF) 93 INFED 124 INFLECTRA 82 INFUGEM 18 INLYTA 18 INSULIN ASP PRT-INSULIN

ASPART 73 INSULIN ASPART U-100 73 INSULIN SYRINGE-

NEEDLE U-100 71 INTELENCE 3 INTRAROSA 101 INTRON A 89 INVANZ 9 INVEGA SUSTENNA 40 INVELTYS 114 INVIRASE 3 IOPIDINE 114 IPOL 93 ipratropium bromide 69 119 ipratropium-albuterol 119 irbesartan 47 irbesartan-hydrochlorothiazide

47 IRESSA 18 ISENTRESS 3 ISENTRESS HD 3 isibloom 104 ISOLYTE-S 123 isoniazid 9 isosorbide dinitrate 57 isosorbide mononitrate 57 isotretinoin 61 isoxsuprine 101 isradipine 47 ISTODAX 18 itraconazole 1 ivermectin 9 66 IXEMPRA 18 IXIARO (PF) 93 IXINITY 53

J jaimiess 105 JAKAFI 18 jantoven 53 JANUMET 78 JANUMET XR 78 JANUVIA 78 JARDIANCE 78 jasmiel (28) 105 jencycla 100 JENTADUETO 78 JENTADUETO XR 78 JEVTANA 18 jinteli 100 JIVI 53 jolessa 105 JORNAY PM 41 JUBLIA 63 juleber 105 JULUCA 3 junel 1530 (21) 105 junel 120 (21) 105 junel fe 1530 (28) 105 junel fe 120 (28) 105 junel fe 24 105 JUXTAPID 56 JYNARQUE 75 K KADCYLA 18 kaitlib fe 105 KALBITOR 119 KALETRA 3 4 kalliga 105 KALYDECO 119 KANJINTI 18 KANUMA 75 kariva (28) 105 kelnor 135 (28) 105 kelnor 1-50 (28) 105 KEPIVANCE 13 ketoconazole 1 63 ketodan 63 ketoprofen 35 ketorolac 35 112 KEVZARA 97 KEYTRUDA 18 KINRIX (PF) 93 KISQALI 18 KISQALI FEMARA CO-

PACK 18 klor-con 123

133

klor-con 10 123 klor-con 8 123 klor-con m10 123 klor-con m15 123 klor-con m20 123 klor-conef 123 KLOXXADO 35 KOATE 53 KOGENATE FS 53 KORLYM 76 KOVALTRY 53 K-PHOS NO 2 122 K-PHOS ORIGINAL 122 KRYSTEXXA 95 k-tab 123 K-TAB 123 kurvelo (28) 105 KYLEENA 98 KYMRIAH 18 KYPROLIS 18 L l norgesteestradiol-eestrad

105 labetalol 47 LACRISERT 111 lactulose 82 lamivudine 4 lamivudine-zidovudine 4 lamotrigine 25 26 lansoprazole 86 lanthanum 83 LANTUS SOLOSTAR U-100

INSULIN 73 LANTUS U-100 INSULIN 73 lapatinib 18 larin 1530 (21) 105 larin 120 (21) 105 larin 24 fe 105 larin fe 1530 (28) 105 larin fe 120 (28) 105 larissia 105 LASTACAFT 111 latanoprost 113 LATUDA 41 layolis fe 105 leena 28 105 leflunomide 97 LEMTRADA 88 LENVIMA 19 lessina 105 letrozole 19

leucovorin calcium 13 LEUKERAN 19 LEUKINE 86 leuprolide 19 levalbuterol hcl 119 LEVALBUTEROL

TARTRATE 119 LEVEMIR FLEXTOUCH U-

100 INSULN 73 LEVEMIR U-100 INSULIN 73 levetiracetam 26 levobunolol 110 levocarnitine 67 levocarnitine (with sugar) 67 levocetirizine 115 levofloxacin 12 110 levonest (28) 105 levonorgestrel 106 levonorgestrel-ethinyl estrad

106 levonorg-eth estrad triphasic

106 levora-28 106 levorphanol tartrate 32 levothyroxine 79 levoxyl 79 LEVULAN 59 LEXIVA 4 LIBTAYO 19 lidocaine 61 lidocaine hcl 61 lidocaine hcl-hydrocortison ac

61 83 LIDOCAINE HCL-

HYDROCORTISON AC 83 lidocaine viscous 61 lidocaine-hydrocortisone-aloe

83 lidocaine-prilocaine 61 LIDOCAINE-TETRACAINE

62 LILETTA 98 lillow (28) 106 LINCOCIN 9 lindane 66 linezolid 9 linezolid in dextrose 5 9 linezolid-09 sodium chloride

9 LINZESS 83 liothyronine 79

LIPOFEN 56 lisinopril 47 lisinopril-hydrochlorothiazide

48 lithium carbonate 41 LIVMARLI 83 LO LOESTRIN FE 106 lojaimiess 106 LONSURF 19 loperamide 80 lopinavir-ritonavir 4 lorazepam 41 lorazepam intensol 41 loryna (28) 106 losartan 48 losartan-hydrochlorothiazide 48 LOTEMAX 114 loteprednol etabonate 114 lovastatin 56 low-ogestrel (28) 106 loxapine succinate 41 lo-zumandimine (28) 106 LUCENTIS 111 ludent fluoride 124 LULICONAZOLE 63 LUMIGAN 113 LUMIZYME 76 LUMOXITI 19 LUPANETA PACK (1

MONTH) 102 LUPKYNIS 19 LUPRON DEPOT 19 LUPRON DEPOT (3

MONTH) 19 LUPRON DEPOT (4


MONTH) 19 LUPRON DEPOT-PED 19 LUPRON DEPOT-PED (3

MONTH) 19 lutera (28) 106 LUXTURNA 111 LUZU 63 lyleq 100 lyllana 100 LYNPARZA 19 LYSODREN 19 lyza 100 M mafenide acetate 62

134

malathion 66 maprotiline 41 marlissa (28) 106 MARPLAN 41 MARQIBO 19 MATULANE 19 matzim la 48 MAVENCLAD (10 TABLET

PACK) 88 MAVENCLAD (4 TABLET






PACK) 88 MAVYRET 4 MAXIDEX 114 maxi-tuss ac 116 MAYZENT 88 MAYZENT STARTER PACK

88 m-clear wc 116 meclizine 83 meclofenamate 35 medroxyprogesterone 100 mefenamic acid 35 mefloquine 9 megestrol 19 20 MEKINIST 20 MEKTOVI 20 meloxicam 35 melphalan 20 melphalan hcl 20 memantine 29 30 MENACTRA (PF) 93 MENEST 101 MENOSTAR 101 MENQUADFI (PF) 93 MENTAX 63 MENVEO A-C-Y-W-135-DIP

(PF) 93 meperidine 32 meprobamate 30 MEPSEVII 76 mercaptopurine 20

meropenem 9 MEROPENEM-09

SODIUM CHLORIDE 9 merzee 106 mesalamine 83 mesalamine with cleansing

wipe 83 metaproterenol 119 metaxalone 30 metformin 78 methadone 32 methadose 33 methamphetamine 41 methazolamide 112 methenamine hippurate 13 methenamine mandelate 13 methen-sod phos-meth blue-

hyos 122 methergine 109 methimazole 71 methocarbamol 30 methotrexate sodium 20 methotrexate sodium (pf) 20 methoxsalen 59 methscopolamine 80 methyldopa 48 methyldopa-

hydrochlorothiazide 48 methyldopate 48 methylergonovine 109 METHYLIN 41 methylphenidate hcl 41 methylprednisolone 70 methylprednisolone acetate 70 methyltestosterone 76 metoclopramide hcl 83 metolazone 48 metoprolol succinate 48 metoprolol ta-hydrochlorothiaz

48 metoprolol tartrate 48 metronidazole 9 61 102 metyrosine 48 mexiletine 44 mibelas 24 fe 106 microgestin 1530 (21) 106 microgestin 120 (21) 106 microgestin fe 1530 (28) 106 microgestin fe 120 (28) 106 midazolam 41 midodrine 67

migergot 29 miglitol 78 miglustat 76 mili 106 millipred 70 millipred dp 70 mimvey 101 MINITRAN 57 minocycline 12 minoxidil 48 MIRCERA 86 MIRENA 98 mirtazapine 41 42 misoprostol 86 MITIGARE 95 mitoxantrone 20 M-M-R II (PF) 93 modafinil 42 moexipril 48 molindone 42 mometasone 65 mondoxyne nl 12 mono-linyah 106 MONONINE 54 MONOVISC 35 montelukast 119 morphine 33 morphine (pf) 33 morphine concentrate 33 MOTOFEN 80 MOVANTIK 83 MOXATAG 11 moxifloxacin 12 110 MOZOBIL 86 MULPLETA 54 MULTAQ 45 multi-vitamin with fluoride 124 multivitamins with fluoride 124 mupirocin 62 mupirocin calcium 62 mvc-fluoride 124 my choice 106 my way 106 MYALEPT 76 MYCAMINE 1 mycophenolate mofetil 20 mycophenolate sodium 20 MYDAYIS 42 MYLOTARG 20 MYOBLOC 93 myorisan 61

135

MYRBETRIQ 121 N nabumetone 35 nadolol 48 nadolol-bendroflumethiazide 48 nafcillin 11 nafcillin in dextrose iso-osm 11 naftifine 63 NAGLAZYME 76 nalbuphine 35 naloxone 35 naltrexone 35 naproxen 35 36 naproxen sodium 36 naratriptan 29 NARCAN 36 NATACYN 110 NATAZIA 106 nateglinide 78 NATPARA 76 nebivolol 48 nebusal 119 necon 0535 (28) 106 nefazodone 42 neomycin 9 neomycin-bacitracin-poly-hc

113 neomycin-bacitracin-

polymyxin 110 neomycin-polymyxin b-

dexameth 113 neomycin-polymyxin-

gramicidin 110 neomycin-polymyxin-hc 69 70

113 neo-polycin 110 neo-polycin hc 113 NERLYNX 20 NEUPOGEN 86 87 NEVANAC 112 nevirapine 4 new day 106 NEXAVAR 20 NEXPLANON 102 NEXTSTELLIS 106 niacin 56 NIACOR 56 nicardipine 48 nicorette 68 nicotine 68 nicotine (polacrilex) 68

NICOTROL 68 NICOTROL NS 68 nifedipine 48 nikki (28) 106 nilutamide 20 nimodipine 48 NINLARO 20 nisoldipine 48 nitazoxanide 9 nitisinone 67 nitro-bid 57 NITRO-DUR 57 nitrofurantoin 13 nitrofurantoin macrocrystal 13 nitrofurantoin monohydm-

cryst 13 nitroglycerin 57 nitroglycerin in 5 dextrose 57 nitro-time 57 NITYR 67 NIVESTYM 87 nizatidine 86 nora-be 101 noreth-ethinyl estradiol-iron

107 norethindrone (contraceptive)

101 norethindrone acetate 101 norethindrone ac-eth estradiol

101 107 norethindrone-eestradiol-iron

107 norgestimate-ethinyl estradiol

107 norlyda 101 NORMOSOL-R 123 NORPACE CR 45 nortrel 0535 (28) 107 nortrel 135 (21) 107 nortrel 135 (28) 107 nortrel 777 (28) 107 nortriptyline 42 NORVIR 4 NOVAFERRUM 124 NOVOEIGHT 54 NOVOLIN 70-30 FLEXPEN

U-100 73 NOVOLIN N FLEXPEN 74 NOVOLIN R FLEXPEN 74 NOVOLOG FLEXPEN U-100

INSULIN 74

NOVOLOG MIX 70-30 U-100 INSULN 74

NOVOLOG MIX 70-30FLEXPEN U-100 74

NOVOLOG PENFILL U-100 INSULIN 74

NOVOLOG U-100 INSULIN ASPART 74

NOVOPEN ECHO 72 NOVOSEVEN RT 54 NOXAFIL 1 np thyroid 79 NPLATE 54 NUCALA 119 NUCYNTA ER 36 NUEDEXTA 30 NULOJIX 20 NULYTELY LEMON-LIME

83 NUPLAZID 42 NUWIQ 54 nyamyc 63 nylia 777 (28) 107 nymyo 107 nystatin 1 63 nystatin-triamcinolone 63 nystop 63 O OBIZUR 54 ocella 107 OCREVUS 88 OCTAGAM 93 octreotide acetate 20 ODEFSEY 4 OFEV 119 ofloxacin 12 69 110 OGIVRI 20 olanzapine 42 olanzapine-fluoxetine 42 olmesartan 48 olmesartan-amlodipin-

hcthiazid 48 olmesartan-

hydrochlorothiazide 48 olopatadine 69 112 OLUMIANT 97 omega-3 acid ethyl esters 56 omeprazole 86 OMIDRIA 112 OMNITROPE 87 ONCASPAR 20

136

ondansetron 83 ondansetron hcl 83 ONETOUCH ULTRA TEST

71 ONETOUCH VERIO TEST

STRIPS 71 ONIVYDE 20 ONPATTRO 30 ONZETRA XSAIL 29 opcicon one-step 107 OPDIVO 20 opium tincture 80 OPSUMIT 119 option-2 107 ORALAIR 93 oralone 69 ORAVIG 1 ORENCIA 98 ORENCIA (WITH

MALTOSE) 97 ORENCIA CLICKJECT 97 ORENITRAM 49 ORLADEYO 119 orphenadrine citrate 30 orsythia 107 ORTHOVISC 36 oscimin 80 oscimin sl 80 oscimin sr 81 oseltamivir 4 OSMOPREP 84 OSPHENA 102 OTEZLA 98 OTEZLA STARTER 98 OTOVEL 70 oxacillin 11 oxacillin in dextrose(iso-osm)

11 oxandrolone 76 oxaprozin 36 oxazepam 42 oxcarbazepine 26 oxiconazole 63 OXISTAT 63 OXLUMO 122 oxybutynin chloride 121 oxycodone 33 oxycodone-acetaminophen 33 OXYCONTIN 33 oxymorphone 33 OZEMPIC 78

OZURDEX 114 P pacerone 45 PADCEV 21 paliperidone 42 PALYNZIQ 76 pamidronate 76 PANRETIN 59 pantoprazole 86 PANZYGA 93 PARAGARD T 380A 98 paricalcitol 76 PARICALCITOL 76 paroex oral rinse 69 paromomycin 9 paroxetine hcl 42 paroxetine

mesylate(menopsym) 42 PARSABIV 76 PASER 10 PEDIARIX (PF) 93 PEDVAX HIB (PF) 93 peg 3350-electrolytes 84 peg3350-sod sul-nacl-kcl-asb-c

84 PEGASYS 88 peg-electrolyte soln 84 peg-prep 84 PEMAZYRE 21 PEN NEEDLE DIABETIC 72 penicillamine 98 penicillin g procaine 11 penicillin v potassium 11 PENTACEL (PF) 93 PENTACEL ACTHIB

COMPONENT (PF) 93 PENTAM 10 pentamidine 10 pentazocine-naloxone 36 pentoxifylline 54 PERFOROMIST 119 perindopril erbumine 49 periogard 69 PERJETA 21 permethrin 66 perphenazine 42 perphenazine-amitriptyline 42 phenazopyridine 123 phenelzine 42 phenobarb-hyoscy-atropine-

scop 81

phenobarbital 26 phenohytro 81 phenoxybenzamine 49 phenylephrine hcl 115 phenytoin 26 phenytoin sodium extended 26 PHEXXI 102 philith 107 phosphasal 122 PHYSIOLYTE 66 PHYSIOSOL IRRIGATION 66 phytonadione (vitamin k1) 54 PICATO 59 pilocarpine hcl 67 69 111 pimecrolimus 59 pimozide 42 pimtrea (28) 107 pindolol 49 pioglitazone 78 pioglitazone-glimepiride 78 pioglitazone-metformin 78 piperacillin-tazobactam 11 PIQRAY 21 pirmella 107 piroxicam 36 PLASMA-LYTE 148 123 PLASMA-LYTE A 124 PLEGRIDY 88 89 PLENVU 84 PNEUMOVAX-23 93 94 podofilox 59 POLIVY 21 polycin 110 polymyxin b sulfate 10 polymyxin b sulf-trimethoprim

110 POMALYST 89 PONVORY 89 PONVORY 14-DAY

STARTER PACK 89 portia 28 107 PORTRAZZA 21 posaconazole 1 potassium chloride 123 potassium citrate 122 POTELIGEO 21 pramipexole 28 prasugrel 54 pravastatin 56 praziquantel 10 prazosin 49

137

PRED MILD 114 prednicarbate 65 prednisolone 70 prednisolone acetate 114 prednisolone sodium phosphate

70 114 prednisone 71 prednisone intensol 70 pregabalin 26 PREMARIN 101 PREMPHASE 101 PREMPRO 101 prevalite 56 previfem 107 PREVNAR 13 (PF) 94 PREVYMIS 4 PREZCOBIX 4 PREZISTA 4 PRIFTIN 10 primaquine 10 primidone 26 PRIMSOL 13 PRIVIGEN 94 probenecid 95 probenecid-colchicine 95 procainamide 45 procentra 42 prochlorperazine 84 prochlorperazine edisylate 84 prochlorperazine maleate 84 PROCRIT 87 procto-med hc 84 procto-pak 84 proctosol hc 84 proctozone-hc 84 PROFILNINE 54 progesterone 101 progesterone micronized 101 PROGRAF 21 PROLASTIN-C 67 PROLEUKIN 89 PROLIA 96 PROMACTA 54 promethazine 115 116 promethazine-codeine 116 promethazine-dm 116 promethazine-phenyleph-

codeine 116 promethazine-phenylephrine

116 promethegan 116

propafenone 45 proparacaine 112 propranolol 49 propranolol-hydrochlorothiazid

49 propylthiouracil 71 PROQUAD (PF) 94 protriptyline 42 PROVENGE 94 prudoxin 59 pulmosal 119 PULMOZYME 119 pyrazinamide 10 pyridostigmine bromide 30 pyrimethamine 10 Q QBRELIS 49 QINLOCK 21 QTERN 78 QUADRACEL (PF) 94 quetiapine 42 43 QUILLICHEW ER 43 QUILLIVANT XR 43 quinapril 49 quinapril-hydrochlorothiazide

49 quinidine gluconate 45 quinidine sulfate 45 quinine sulfate 10 quit 2 68 quit 4 68 QVAR REDIHALER 119 R RABAVERT (PF) 94 rabeprazole 86 RADICAVA 30 RAGWITEK 94 raloxifene 96 ramelteon 43 ramipril 49 ranolazine 57 RAPIVAB (PF) 4 rasagiline 28 RAVICTI 67 REBIF (WITH ALBUMIN) 89 REBIF REBIDOSE 89 REBIF TITRATION PACK 89 REBINYN 54 RECLAST 67 reclipsen (28) 107 RECOMBINATE 54

RECOMBIVAX HB (PF) 94 RECTIV 84 REGRANEX 60 RELENZA DISKHALER 4 RELEXXII 43 RELION NOVOLIN 7030 74 RELION NOVOLIN N 74 RELION NOVOLIN R 74 RELISTOR 84 REMICADE 84 RENACIDIN 122 RENFLEXIS 84 repaglinide 78 repaglinide-metformin 78 REPATHA PUSHTRONEX 56 REPATHA SURECLICK 56 REPATHA SYRINGE 56 RESTASIS 112 RETEVMO 21 RETISERT 114 REVATIO 119 REVLIMID 89 REXULTI 43 REYATAZ 4 RHOPRESSA 113 RIASTAP 54 ribavirin 4 89 RIDAURA 98 rifabutin 10 rifampin 10 riluzole 67 rimantadine 4 RINVOQ 98 RIOMET ER 79 risedronate 67 96 RISPERDAL CONSTA 43 risperidone 43 ritonavir 4 RITUXAN 21 RITUXAN HYCELA 21 rivastigmine 30 rivastigmine tartrate 30 rivelsa 107 RIXUBIS 54 rizatriptan 29 ropinirole 28 rosadan 61 rosuvastatin 56 roweepra 26 RUBRACA 21 RUCONEST 119

138

rufinamide 26 RYBELSUS 79 RYDAPT 21 S salsalate 36 SAMSCA 76 SANTYL 66 sapropterin 76 SARCLISA 21 SAVELLA 98 scalacort 65 SCENESSE 60 scopolamine base 84 seconal sodium 43 selegiline hcl 28 selenium sulfide 58 SELZENTRY 5 SEREVENT DISKUS 120 SEROSTIM 87 sertraline 43 setlakin 107 sevelamer carbonate 84 sevelamer hcl 84 sf 69 sf 5000 plus 69 sharobel 101 SHINGRIX (PF) 94 SIGNIFOR 21 sildenafil (pulmhypertension)

120 SILIQ 58 silodosin 122 silver sulfadiazine 59 SIMBRINZA 113 simliya (28) 107 simpesse 108 SIMPONI 98 SIMPONI ARIA 98 SIMULECT 21 simvastatin 57 SINUVA 120 sirolimus 21 SIRTURO 10 SIVEXTRO 10 SKYLA 99 SKYRIZI 58 SLYND 108 sodium chloride 120 sodium chloride 045 123 sodium chloride 09 67

sodium fluoride 5000 dry mouth 69

sodium fluoride 5000 plus 69 sodium fluoride-pot nitrate 69 sodium phenylbutyrate 68 sodium polystyrene sulfonate

84 solifenacin 121 SOLIQUA 10033 74 SOLIRIS 68 SOLTAMOX 21 SOMATULINE DEPOT 22 SOMAVERT 76 sorine 45 sotalol 45 sotalol af 45 SOVALDI 5 spinosad 66 SPIRIVA RESPIMAT 120 SPIRIVA WITH

HANDIHALER 120 spironolactone 49 spironolacton-hydrochlorothiaz

49 SPRAVATO 43 sprintec (28) 108 SPRYCEL 22 sps (with sorbitol) 85 sronyx 108 ssd 59 SSKI 71 st joseph aspirin 36 st joseph aspirin 36 STAMARIL (PF) 94 stavudine 5 STELARA 58 STIOLTO RESPIMAT 120 STIVARGA 22 stop smoking aid 68 STRENSIQ 76 STREPTOMYCIN 10 STRIBILD 5 STRIVERDI RESPIMAT 120 SUBLOCADE 33 subvenite 26 subvenite starter (blue) kit 26 subvenite starter (green) kit 26 subvenite starter (orange) kit 26 SUCRAID 85 sucralfate 86

sulfacetamide sodium 58 59 114

sulfacetamide sodium (acne) 62 sulfacetamide-prednisolone 114 sulfadiazine 12 sulfamethoxazole-trimethoprim

12 SULFAMYLON 62 sulfasalazine 85 sulfatrim 12 sulindac 36 sumatriptan 29 sumatriptan succinate 29 sunitinib 22 SUNOSI 43 SUPPRELIN LA 22 SUPRAX 7 SUPREP BOWEL PREP KIT

85 SUTENT 22 syeda 108 SYLVANT 22 symax fastabs 81 symax-sl 81 symax-sr 81 SYMBICORT 120 SYMDEKO 120 SYMLINPEN 120 79 SYMLINPEN 60 79 SYMPAZAN 26 SYNAGIS 5 SYNAREL 76 SYNERA 62 SYNJARDY 79 SYNJARDY XR 79 SYNRIBO 22 SYNTHROID 79 T TABLOID 22 tacrolimus 22 60 tadalafil 122 tadalafil (pulm hypertension)

120 TAFINLAR 22 TAGRISSO 22 TAKHZYRO 120 TALTZ AUTOINJECTOR 59 TALTZ AUTOINJECTOR (2

PACK) 59 TALTZ AUTOINJECTOR (3

PACK) 59

139

TALTZ SYRINGE 59 TALZENNA 22 tamoxifen 22 tamsulosin 122 TARGRETIN 22 tarina 24 fe 108 tarina fe 120 (28) 108 TASIGNA 22 tavaborole 63 taysofy 108 tazarotene 61 tazicef 7 taztia xt 49 TDVAX 94 TECENTRIQ 22 TEFLARO 7 TEKTURNA HCT 49 telmisartan 49 telmisartan-amlodipine 49 telmisartan-hydrochlorothiazid

49 temazepam 43 TEMODAR 22 temozolomide 22 temsirolimus 22 tencon 33 TENIVAC (PF) 94 tenofovir disoproxil fumarate 5 TEPEZZA 76 terazosin 49 terbinafine hcl 1 terbutaline 120 terconazole 102 testosterone 77 testosterone cypionate 76 testosterone enanthate 77 TETANUSDIPHTHERIA

TOX PED(PF) 94 tetrabenazine 30 tetracaine hcl 112 TETRACAINE HCL (PF) 112 tetracycline 12 THALOMID 22 theophylline 120 thioridazine 43 thiothixene 43 THYMOGLOBULIN 94 tiadylt er 49 tiagabine 26 TIBSOVO 22 tilia fe 108

timolol maleate 49 110 111 tinidazole 10 TIVICAY 5 TIVICAY PD 5 tizanidine 31 TOBRADEX 113 TOBRADEX ST 113 tobramycin 10 110 tobramycin in 0225 nacl 10 tobramycin sulfate 10 TOBRAMYCIN WITH

NEBULIZER 10 tobramycin-dexamethasone 113 TOBREX 110 TODAY CONTRACEPTIVE

SPONGE 102 tolcapone 28 tolmetin 36 tolterodine 121 topiramate 26 27 toremifene 22 TORISEL 22 torsemide 49 TOUJEO MAX U-300

SOLOSTAR 74 TOUJEO SOLOSTAR U-300

INSULIN 74 TRACLEER 120 TRADJENTA 79 tramadol 36 tramadol-acetaminophen 36 trandolapril 49 trandolapril-verapamil 50 tranexamic acid 55 102 tranylcypromine 43 travoprost 113 trazodone 43 TREANDA 23 TRECATOR 10 TRELEGY ELLIPTA 121 TRELSTAR 23 TREMFYA 59 TRESIBA FLEXTOUCH U-

100 74 TRESIBA FLEXTOUCH U-

200 74 TRESIBA U-100 INSULIN 74 tretinoin 61 tretinoin (antineoplastic) 23 tretinoin microspheres 61 TRETTEN 55

TREXALL 23 tri femynor 108 triamcinolone acetonide 66 69

71 triamterene 50 triamterene-hydrochlorothiazid

50 triazolam 43 triderm 66 trientine 68 tri-estarylla 108 trifluoperazine 43 trifluridine 110 trihexyphenidyl 28 TRIJARDY XR 71 TRIKAFTA 121 tri-legest fe 108 tri-linyah 108 tri-lo-estarylla 108 tri-lo-marzia 108 tri-lo-mili 108 tri-lo-sprintec 108 trimethobenzamide 85 trimethoprim 13 tri-mili 108 trimipramine 43 TRINTELLIX 44 tri-nymyo 108 tri-previfem (28) 108 tri-sprintec (28) 108 TRIUMEQ 5 tri-vitamin with fluoride 124 trivora (28) 108 tri-vylibra 108 tri-vylibra lo 108 TROGARZO 5 tropicamide 111 trospium 122 TRULICITY 79 TRUMENBA 94 TRUXIMA 23 TUKYSA 23 tulana 101 TWINRIX (PF) 95 TWIRLA 102 TYBLUME 109 TYBOST 5 tydemy 109 TYGACIL 10 TYMLOS 96 TYPHIM VI 95

140

TYSABRI 30 TYVASO 121 TYVASO REFILL KIT 121 TYVASO STARTER KIT 121 U UBRELVY 29 UDENYCA 87 UKONIQ 23 ULESFIA 66 unithroid 79 UNITUXIN 23 URELLE 122 uretron d-s 122 urimar-t 122 urogesic-blue 122 ursodiol 85 uryl 122 ustell 122 utira-c 123 UVADEX 60 V valacyclovir 5 VALCHLOR 60 valganciclovir 5 valproic acid 27 valproic acid (as sodium salt)

27 valsartan 50 valsartan-hydrochlorothiazide

50 vanadom 31 vancomycin 13 vandazole 102 VANTAS 23 VAQTA (PF) 95 varenicline 68 VARIVAX (PF) 95 VARUBI 85 VASCEPA 57 VAXELIS (PF) 95 VCF CONTRACEPTIVE

FILM 102 VCF CONTRACEPTIVE GEL

102 VECTIBIX 23 VELCADE 23 veletri 50 velivet triphasic regimen (28)

109 VELPHORO 85 VEMLIDY 5

VENCLEXTA 23 VENCLEXTA STARTING

PACK 23 venlafaxine 44 VENTAVIS 121 verapamil 50 VERSACLOZ 44 VERZENIO 23 vestura (28) 109 VIBATIV 13 VIBERZI 85 VIDAZA 23 VIEKIRA PAK 5 vienva 109 vigabatrin 27 vigadrone 27 VIMIZIM 77 VIMPAT 27 viorele (28) 109 VIRACEPT 5 VIREAD 5 virtussin ac 116 VISTOGARD 13 VISUDYNE 112 vitamins acd and fluoride 124 VITRAKVI 23 VIVITROL 36 volnea (28) 109 VONVENDI 55 VORAXAZE 13 voriconazole 1 2 VOSEVI 5 VOTRIENT 23 VPRIV 77 VRAYLAR 44 VYEPTI 29 vyfemla (28) 109 vylibra 109 VYONDYS-53 30 VYVANSE 44 VYXEOS 23 W warfarin 55 WELIREG 23 wera (28) 109 westhroid 79 WIDE-SEAL DIAPHRAGM

99 WILATE 55 wixela inhub 121 wymzya fe 109

X XALKORI 23 XARELTO 55 XARELTO DVT-PE TREAT

30D START 55 XCOPRI 27 XCOPRI MAINTENANCE

PACK 27 XCOPRI TITRATION PACK

27 XELJANZ 98 XELJANZ XR 98 XEMBIFY 95 XENLETA 10 XEOMIN 95 XERMELO 23 XGEVA 13 XIFAXAN 10 XIGDUO XR 79 XIIDRA 112 XOLAIR 121 XOSPATA 23 XTANDI 23 24 xulane 102 XULTOPHY 10036 74 XURIDEN 68 XYNTHA 55 XYNTHA SOLOFUSE 55 XYREM 44 Y YERVOY 24 YESCARTA 24 YF-VAX (PF) 95 YONDELIS 24 YONSA 24 YUTIQ 114 yuvafem 101 Z zafemy 102 zafirlukast 121 zaleplon 44 ZALTRAP 24 ZANOSAR 24 zarah 109 ZARXIO 87 ZEJULA 24 ZELBORAF 24 ZEMAIRA 68 zenatane 61 ZENPEP 85 ZENZEDI 44

141

ZEPATIER 5 ZEPOSIA 89 ZEPOSIA STARTER KIT 89 ZEPOSIA STARTER PACK

89 ZERBAXA 7 zidovudine 5 ZIEXTENZO 87 zileuton 121 ziprasidone hcl 44

ZIRGAN 110 ZOKINVY 68 ZOLADEX 24 ZOLGENSMA 30 ZOLINZA 24 zolmitriptan 29 zolpidem 44 ZOLPIMIST 44 ZOMIG 29 zonisamide 27

ZONTIVITY 55 ZOSTAVAX (PF) 95 zovia 135e (28) 109 ZULRESSO 44 zumandimine (28) 109 ZYFLO 121 ZYKADIA 24 ZYPITAMAG 57

051267 (07-01-2021)

Discrimination is Against the Law

LifeWise Health Plan of Washington (LifeWise) complies with applicable Federal and Washington state civil rights laws and does not discriminate on the basis of race color national origin age disability sex gender identity or sexual orientation LifeWise does not exclude people or treat them differently because of race color national origin age disability sex gender identity or sexual orientation LifeWise provides free aids and services to people with disabilities to communicate effectively with us such as qualified sign language interpreters and written information in other formats (large print audio accessible electronic formats other formats) LifeWise provides free language services to people whose primary language is not English such as qualified interpreters and information written in other languages If you need these services contact the Civil Rights Coordinator If you believe that LifeWise has failed to provide these services or discriminated in another way on the basis of race color national origin age disability sex gender identity or sexual orientation you can file a grievance with Civil Rights Coordinator Complaints and Appeals PO Box 91102 Seattle WA 98111 Toll free 855-332-6396 Fax 425-918-5592 TTY 711 Email AppealsDepartmentInquiriesLifeWiseHealthcom You can file a grievance in person or by mail fax or email If you need help filing a grievance the Civil Rights Coordinator is available to help you You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal available at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at US Department of Health and Human Services 200 Independence Ave SW Room 509F HHH Building Washington DC 20201 1-800-368-1019 800-537-7697 (TDD) Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml You can also file a civil rights complaint with the Washington State Office of the Insurance Commissioner electronically through the Office of the Insurance Commissioner Complaint Portal available at httpswwwinsurancewagovfile-complaint-or-check-your-complaint-status or by phone at 800-562-6900 360-586-0241 (TDD) Complaint forms are available at httpsfortresswagovoiconlineservicesccpubcomplaintinformationaspx

Language Assistance

ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten servicios gratuitos de asistencia linguumliacutestica Llame al 800-817-3056 (TTY 711)

注意如果您使用繁體中文您可以免費獲得語言援助服務請致電 800-817-3056（TTY711）

CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ trợ ngocircn ngữ miễn phiacute dagravenh cho bạn Gọi số 800-817-3056 (TTY 711)

주의 한국어를 사용하시는 경우 언어 지원 서비스를 무료로 이용하실 수 있습니다 800-817-3056 (TTY 711) 번으로 전화해 주십시오

ВНИМАНИЕ Если вы говорите на русском языке то вам доступны бесплатные услуги перевода Звоните 800-817-3056 (телетайп 711)

PAUNAWA Kung nagsasalita ka ng Tagalog maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad Tumawag sa 800-817-3056 (TTY 711)

УВАГА Якщо ви розмовляєте українською мовою ви можете звернутися до безкоштовної служби мовної підтримки

Телефонуйте за номером 800-817-3056 (телетайп 711)

បរយតន បរើសនជាអនកនយាយ ភាសាខមែរ បសវាជនយខននកភាសា បោយមនគតឈន ល គអាចមានសរាររបរ ើអនក ចរ ទរសពទ 800-817-3056 (TTY 711)

注意事項日本語を話される場合無料の言語支援をご利用いただけます800-817-3056（TTY711）までお電話にてご連絡ください

ማስታወሻ የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች በነጻ ሊያግዝዎት ተዘጋጀተዋል ወደ ሚከተለው ቁጥር ይደውሉ 800-817-3056 (መስማት ለተሳናቸው 711)

XIYYEEFFANNAA Afaan dubbattu Oroomiffa tajaajila gargaarsa afaanii kanfaltiidhaan ala ni argama Bilbilaa 800-817-3056 (TTY 711)

(711 والبكم الصم هاتف رقم ) 800-817-3056 برقم اتصل بالمجان لك تتوافر اللغوية المساعدة خدمات فإن اللغة اذكر تتحدث كنت إذا ملحوظة

ਧਿਆਨ ਧਿਓ ਜ ਤਸੀ ਪਜਾਬੀ ਬਲਿ ਹ ਤਾ ਭਾਸ਼ਾ ਧਵਿ ਚ ਸਹਾਇਤਾ ਸਵਾ ਤਹਾਡ ਲਈ ਮਫਤ ਉਪਲਬਿ ਹ 800-817-3056 (TTY 711) ਤ ਕਾਲ ਕਰ ACHTUNG Wenn Sie Deutsch sprechen stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfuumlgung Rufnummer 800-817-3056 (TTY 711)

ໂປດຊາບ ຖາວາ ທານເວ າພາສາ ລາວ ການບລການຊວຍເຫ ອດານພາສາ ໂດຍບເສຽຄາ ແມນມພອມໃຫທານ ໂທຣ 800-817-3056 (TTY 711)

ATANSYON Si w pale Kreyogravel Ayisyen gen segravevis egraved pou lang ki disponib gratis pou ou Rele 800-817-3056 (TTY 711)

ATTENTION Si vous parlez franccedilais des services daide linguistique vous sont proposeacutes gratuitement Appelez le 800-817-3056 (ATS 711)

UWAGA Jeżeli moacutewisz po polsku możesz skorzystać z bezpłatnej pomocy językowej Zadzwoń pod numer 800-817-3056 (TTY 711)

ATENCcedilAtildeO Se fala portuguecircs encontram-se disponiacuteveis serviccedilos linguiacutesticos graacutetis Ligue para 800-817-3056 (TTY 711)

ATTENZIONE In caso la lingua parlata sia litaliano sono disponibili servizi di assistenza linguistica gratuiti Chiamare il numero 800-817-3056 (TTY 711)

د یر یبگ تماس 3056-817-800 (TTY 711) با باشد ی م فراهم شما ی برا گان یرا بصورت ی زبان لات یتسه دیکن یم گفتگو فارسی زبان به اگر توجه

ii

How does this drug list help me understand my drug coverage Drug coverage is based on your coverage contract Coverage for a specific drug is subject to the rules outlined in your member booklet This document will tell you if a drug is included on the formulary attached to your plan

Will this drug list (Formulary) change This drug list (Formulary) is updated throughout the year If you are taking a drug and it will be removed from the formulary or moved to a higher cost sharing tier we will notify you of this change via letter We also post information on upcoming formulary changes on our website on the ldquoUpcoming Formulary Changesrdquo page

Are there any restrictions on my coverage Some covered drugs may have additional requirements or limits on coverage These can be seen in the column next to the drug name on the list These requirements and limits may include

bull Prior Authorization some drugs require prior approval before they are coveredbull Quantity Limits for some drugs we limit the amount of the drug that we will cover For example

we will cover 18 per 30 day supply of zolmitriptan oral tabletsbull Step Therapy for some drugs we require that you first try certain drugs to treat your medical

condition before we will cover another drug for that condition For example if Drug A and Drug Bboth treat your medical condition we may not cover Drug B unless you try Drug A first If Drug Adoes not work for you then we will then cover Drug B

Drugs subject to these restrictions will generally mean that your physician or healthcare provider may need to provide additional information on your medical condition before the drug will be covered at the pharmacy Information on this process is on our website on the ldquoDrugs Requiring Approvalrdquo page

Metallic Formulary The first column of the chart lists the drug name Brand name drugs are capitalized (eg JANUVIA) and generic drugs are listed in lower-case italics (eg metformin oral tablet) The information in the RequirementsLimits column tells you if we have any special requirements for coverage of your drug

COVERAGE NOTES ABBREVIATIONS


Utilization Management Restrictions

PA Prior Authorization Restriction You (or your physician) are required to get prior authorization from us before you fill your prescription for this drug

iii











Drug Tier Includes

iv




1


ANTI - INFECTIVES

ANTIFUNGAL AGENTS


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1


1



1



1





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1




1


1



2



1


ANTIVIRALS



















1 PA





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3



1


1



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1








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1 LA


1 PA LA












4
























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5






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1 PA












CEPHALOSPORINS

6



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1




1



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1



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1


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1

7




1



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1



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9





1



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1



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10



1





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1



1


1





1 PA ST



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11


PENICILLINS



1




1


1


1


1




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1


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1



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12


QUINOLONES


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1


1









1


1


TETRACYCLINES





1


1


1


1


1





13







1


1




VANCOMYCIN




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ADJUNCTIVE AGENTS


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1


1


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1 LA





MB PA LA


MB PA

14



MB PA LA




MB PA


MB PA



MB PA LA


MB PA LA


MB PA


MB PA LA



1 PA OCh


MB PA


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MB PA LA


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1 PA ST OCh LA


15



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1 PA ST OCh LA






MB PA


1 PA OCh




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1 OCh


1




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1 PA


1 PA


1 PA

16



1 PA


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1 PA ST OCh LA








1 PA



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1 PA LA



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MB PA LA


17



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1 PA OCh LA


1 PA OCh


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1 PA OCh LA


1 OCh LA


1 PA ST OCh






1 PA ST OCh


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18



MB


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MB PA LA


MB PA LA


1 PA OCh LA


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1 PA ST OCh LA


1 PA ST OCh LA


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19



1 PA ST OCh LA





MB PA


1 PA ST OCh LA


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1 PA


1 PA


1 PA


1 PA


1 PA


1 PA




MB PA







20









1


1







1


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1 PA ST OCh LA


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1


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21



MB PA LA


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1 PA OCh LA


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1 PA ST OCh LA



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1 PA ST


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22



1 PA LA


1 PA ST OCh LA



1 PA OCh LA


MB PA LA


1 PA ST OCh LA


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1 PA ST









1 PA ST OCh LA


MB PA LA


MB PA LA


1 OCh LA


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1 OCh LA




MB PA LA

23



MB PA LA


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1 PA ST OCh


1 PA OCh


1 PA ST OCh LA







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24




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ANTICONVULSANTS





1


1



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25



1



1


1



1


1


1


1










1



1


1


1


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26



1


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1 PA ST



1 PA ST






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1


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27



1


1









1 PA ST


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1











1


1


1

28



1



1


1



1


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1 PA ST


1 ST


1 PA ST







1 PA ST


1 PA ST



29




















MB PA








1 PA LA






MB PA


1




1

30






MB PA


MB PA


1


1



MB PA ST LA


MB PA


MB LA






1 PA ST










1




1

31





NARCOTIC ANALGESICS


1 PA ST


1 PA ST


1 PA ST


1 PA ST


1 PA ST





1


1 PA ST


1 PA ST


1


1


1


1



1 PA ST



MB

32



MB PA ST



1 PA ST


1 PA


1 PA ST




1 PA ST


1 PA ST


1 PA


1 PA ST


1 PA ST


1 PA ST














33






1 PA ST








1 PA ST





1 PA ST





1 PA ST


1 PA ST










MB



34



ACA PV


ACA PV




ACA PV


ACA PV



ACA PV









1



1



1


1




1




ACA PV


35





1


MB









1



1








1





MB LA







36




1



1




MB







ACA PV






1 PA ST


1 PA ST



MB



1


1

37



1 PA ST


1 ST



1


1


1


1


1


1


1 ST



1 ST



1


1


MB


MB


1


1

38



1


1 ST



1


1


1


1



1





1


1


1


1


1 ST


1 ST


1


1 ST


1

39



1


1


1



1


1


1







1



1


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1 ST


1 ST




1




1 PA ST

40



1 PA ST


1 ST


1 ST



1








1



1



1


1




1





1


1

41



1 ST


1 PA ST


1



1





1





1


1


1


1


1


1


1


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42



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1 ST


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1






1


1


1



1


1


1


1



1






1

43



1


1 ST


1 ST



1 ST


1 PA ST


1



1


1





MB PA




1


1




1



1


44



1 ST


1


1


1



1 PA ST


1 PA ST


1 PA ST


1 PA ST




1 ST


1



1



1 ST


MB





1




45




1



MB


1



1












1 ST


1 ST


1 ST


1



1



1



46



1




1 ST



1


1


1


1


1


1




1


1


1


1


1


1


1


1



47



1 ST



1



1




MB PA LA




1


MB PA LA



1


1




1



1




1




1

48



1



1


1



1




1


1


1










1


1



1



1


1 ST

49



1 PA LA






1


1


1


1




1


1



1


1


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1




50



1 ST



1


1


1


1



1


1



1

CARDIAC GLYCOSIDES


1


1



1

COAGULATION THERAPY


MB


MB LA

51



MB LA


MB LA


MB LA


MB LA




MB


1


MB LA






MB


MB LA



1 PA LA


1


52



MB LA



1


MB LA


MB LA


MB


1


1


1


1 PA LA


MB


MB


MB


MB



MB


1

53



1


MB


MB


MB


MB


MB


1


MB


MB


MB LA


MB LA


MB LA


1


MB LA


MB


MB


MB

54



MB LA



MB LA


MB LA


MB LA


MB LA


MB





MB LA


1 PA ST LA


1 LA


1 PA ST LA


MB LA


MB LA


MB LA


MB LA

55



MB


MB LA


MB LA


1


MB LA


1


1


MB LA


MB LA




1 ST





1









56



1


1


1


1


1


1




ACA PV









1




ACA PV




1 PA ST


1 PA ST


1 PA ST



57











1 PA ST


MB


1 ST

NITRATES


1


1



1







MB


1


1


1


1

58









1



1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA



1 PA ST LA




1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


MB PA LA


1 PA ST LA


1 PA ST LA



59




1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA

BURN THERAPY

















1






60




MB PA




THERAPY FOR ACNE









1















1


1




61







1






1






1




TOPICAL ANESTHETICS





1


1


1






62



1 ST


1 ST




1 ST








1


TOPICAL ANTIFUNGALS









1




1


1




63



1 PA ST















1


1





TOPICAL ANTIVIRALS













64




1









1












1 ST













65
























1












66



1


1


1


1


TOPICAL ENZYMES
















MB


MB



1




MB PA LA


1 PA LA

67





1 PA LA




1 ST LA




1 PA




MB PA LA


MB PA LA


1 PA LA









MB



MB





MB


68



1 PA



MB PA LA





MB PA LA


SMOKING DETERRENTS


ACA PV





ACA PV


ACA PV


ACA PV


ACA PV


ACA PV











69



1


1







1




1




sf dental gel 11 1














1


1


1

70



1


1

ENDOCRINEDIABETES

ADRENAL HORMONES







1


1


1


1


1




1


1



1




1


1


71




1



MB

ANTITHYROID AGENTS













1


1


1


1 PA ST



1



1


1


1


72





1


1

INSULIN THERAPY


1


1


1


1


1 ST


1


1 ST


1 ST


1 ST


1 ST


1 ST


1 ST

73



1 ST


1 ST


1 ST


1 ST


1 ST


1


1


1


1


1


1


1


1


1


1


1


1

74



1


1


1


1


1


1


1


1


1


1


1 PA ST


1


1


1


1


1


1 PA ST


75



MB PA LA




MB PA




1





MB PA LA



MB PA LA



1


1



1


MB PA LA


MB PA LA


MB PA LA






MB PA LA

76




MB PA LA


MB PA LA




1 PA LA


MB PA LA


1 PA ST LA



1 PA LA


MB


MB




MB PA







1 PA


1


MB PA LA


1

77



1













MB PA LA


MB PA LA




1 PA ST


1 PA ST


1 PA ST






1


1


1


78



1


1 PA ST


1 PA ST


1 PA ST


1 PA ST



1 PA ST


1 PA ST




1


1 PA ST


1 ST




1 PA ST



1


1




1

79



1 PA ST


1 PA ST


1 PA ST


1 PA ST


1 PA ST


1 PA ST



1 PA ST


1 PA ST

THYROID HORMONES


1


1


1



1


1


1


1

80


GASTROENTEROLOGY





1 PA ST







1



1








1


1










81



1


1


1


1





1






MB









1


1




1 PA ST LA


1 PA ST LA


ACA PV

82






1 PA




1



1


MB PA LA



ACA PV


ACA PV






1



1


1


MB PA LA



1

83



1


1


1


1 ST


1 PA ST


1


1 PA ST


1 PA




1


1




1 ST






1



ACA PV





84




ACA PV


ACA PV




ACA PV


1




1


1


1


1




1


1


MB PA LA


MB PA LA


1


1




85



1


1




1


ACA PV ST






1 ST



1 PA


1

ULCER THERAPY


1



1


1 ST


1




86



1


1





1


1


1




BIOTECHNOLOGY DRUGS


1 LA


1 LA


1 LA


1


1



MB


MB LA


1 PA ST

87



1 PA ST


1


1


1 LA


1 PA ST


1 PA ST


1 PA ST

GROWTH HORMONES


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA

INTERFERONS









88












MB PA ST LA


1 LA

















MB PA LA


1 PA LA


1 PA LA







89







1 PA ST OCh LA













1 PA ST OCh LA








INTERLEUKINS


1 PA LA


1 LA


MB PA LA



1 PA LA


MB LA

90




1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac



MB


1 Vac


1 Vac


1 Vac



1 Vac


1 Vac


MB


MB LA


MB LA

91



1 Vac


MB LA


1 Vac


1 Vac


1 Vac


MB PA


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac

92



1 Vac


MB


MB


MB LA


MB PA LA


MB LA


MB PA LA


MB PA LA


MB LA


1 Vac


1 Vac



1 Vac


1 Vac


1 Vac


MB LA

93



MB LA


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


MB LA


MB PA LA


1 PA



1 Vac


1 Vac


1 Vac


1 Vac


1 Vac

94



1 Vac


1 Vac



1 Vac


MB PA


1 Vac


1 Vac


1 PA


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


MB


1 Vac

95



1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


MB LA


MB LA


1 Vac


1 Vac


GOUT THERAPY






MB PA LA




96






1 PA ST LA




1



1 ST LA




1


1 PA ST LA



1 PA ST LA


MB PA LA


1 PA ST LA


MB PA LA


1 PA LA


1 PA LA


1 PA ST LA


1 PA ST LA


1 PA ST LA

97



1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA




MB PA LA


1 PA ST LA

98



1 PA ST LA



1 PA ST LA





1 PA ST LA


1 PA ST


1 PA ST


MB PA LA


1 PA ST LA


1 PA ST LA




1 PA ST LA




ACA PV




ACA PV


ACA PV ST


ACA PV


ACA PV

99



ACA PV


ACA PV




1



1






1


MB


MB


ACA PV












100







1


1


1


1




1




1


1


1









ACA PV


ACA PV


1

101



1








1




1


1


1


1



1




MISCELLANEOUS OBGYN


ACA PV




ACA PV






102



1 PA LA








ACA PV



ACA PV



ACA PV


ACA PV


ACA PV


ACA PV







ACA PV


ACA PV





ACA PV


103






ACA PV


ACA PV


ACA PV




ACA PV


ACA PV



ACA PV


ACA PV


ACA PV



ACA PV


ACA PV



ACA PV






ACA PV



104




ACA PV


ACA PV


ACA PV


ACA PV



ACA PV


ACA PV







ACA PV




ACA PV





ACA PV


ACA PV


ACA PV



ACA PV


105



ACA PV



ACA PV





ACA PV


ACA PV



ACA PV



ACA PV





ACA PV





ACA PV


ACA PV



ACA PV




ACA PV

106




ACA PV


ACA PV


ACA PV




ACA PV


ACA PV








ACA PV




ACA PV


ACA PV






ACA PV




ACA PV


107



ACA PV


ACA PV


ACA PV


ACA PV


ACA PV


ACA PV





ACA PV









ACA PV


ACA PV





ACA PV


ACA PV


ACA PV

108



ACA PV






ACA PV


ACA PV




ACA PV


ACA PV


ACA PV


ACA PV


ACA PV


ACA PV



ACA PV



ACA PV


ACA PV


ACA PV


ACA PV


ACA PV


ACA PV

109



ACA PV



ACA PV




ACA PV


ACA PV





ACA PV




OXYTOCICS



OPHTHALMOLOGY

ANTIBIOTICS


1



1


1


1



1


110



1





1


1


1


1


1



1


1



1

ANTIVIRALS



BETA-BLOCKERS



1


1




1


1

111



1





1





1







MB PA LA




1 PA



MB PA LA


MB PA LA


1


1 ST


MB PA LA


MB PA LA


MB LA

112




MB





1



MB LA





1 ST




1



1



1






1


1



1

113



1



1 ST


1 PA ST


1




1


1


1


1


1


1


1


1

STEROIDS


1 ST


1



1


1


1

114



1


1 ST


1 ST


1


1


1



1


1


1


MB PA LA




1


1


1

SULFONAMIDES


1


1

SYMPATHOMIMETICS




1

115




1




1











1 PA ST




1


1


1






1






116




1




1





1


1








1


1


PULMONARY AGENTS


1


1 PA LA







117



1




1









1




1




MB PA LA


1





1


1





118



MB PA


MB PA LA




1


1







MB PA LA


MB PA LA










1




1


1 PA LA


119








1 PA LA


1 PA LA



1









MB PA LA






1



1 PA LA


1


MB LA


MB PA LA

120



1


MB


1




1


1






1


1




1 PA LA



1 PA LA






1


1


1 PA LA

121



1


1 PA LA


1 PA LA


1 PA LA


1 PA LA


1 PA LA




MB LA






UROLOGICALS



1



1 ST




1



1


122



1






1







1







1


1


1 PA



1


1







123



URINARY ANESTHETICS



ELECTROLYTES





1


1


1




1



MB


1


1



1


1


MB



MB


MB

124



MB



1


1



ACA PV


ACA PV


ACA PV


ACA PV





1



ACA PV


ACA PV


ACA PV


ACA PV


ACA PV


ACA PV


ACA PV


ACA PV

125

Index







AFLURIA QD 2021-22(6-35MO)(PF) 90













126










127






















128








104






129

















130















2022 (PF) 91 FLUMIST QUAD 2021-2022










131

































132















133





















134


















135















INSULIN 74









136










scop 81




137




116 promethegan 116





138














PACK) 59

139














140














141





051267 (07-01-2021)



Language Assistance






















iii











Drug Tier Includes

iv




1


ANTI - INFECTIVES

ANTIFUNGAL AGENTS


MB



MB



MB



MB


1


1



1



1





MB


1




1


1



2



1


ANTIVIRALS



















1 PA





MB








3



1


1



1




1 PA LA


1








MB





1 LA


1 PA LA












4
























MB PA







MB








5






1 LA






MB LA








MB PA







1 PA












CEPHALOSPORINS

6



MB



1




1



MB


MB




1



MB


MB




1


MB



MB





1

7




1



MB


MB


MB


MB


MB





1



1


1


MB



MB


MB




1



1


8



1




1



1



1



1




1 PA ST




1





MB



1



MB



MB


MB

9





1



MB


MB



MB







MB


MB


1



MB



MB


MB






10



1





MB













1



1


1





1 PA ST



MB


MB


11


PENICILLINS



1




1


1


1


1




MB



1


MB


MB



MB


MB


MB


1



MB

12


QUINOLONES


MB



1


1









1


1


TETRACYCLINES





1


1


1


1


1





13







1


1




VANCOMYCIN




MB


ADJUNCTIVE AGENTS


MB


MB



1


1


MB


1 LA





MB PA LA


MB PA

14



MB PA LA




MB PA


MB PA



MB PA LA


MB PA LA


MB PA


MB PA LA



1 PA OCh


MB PA


MB PA


MB PA LA


MB PA LA


MB PA LA


MB PA LA





MB


1 PA ST OCh LA


15



MB


1 PA ST OCh LA






MB PA


1 PA OCh




MB



1 OCh


1




MB PA LA


MB PA LA


MB PA LA




1 PA


1 PA


1 PA

16



1 PA


MB PA



MB PA LA


MB PA LA


MB PA LA







1 PA ST OCh LA








1 PA



MB PA


1 PA LA



MB PA



MB PA LA


17



MB PA


MB PA LA


MB


MB




1 PA OCh LA


1 PA OCh


MB PA LA


MB LA


MB PA LA


MB PA LA




1 PA OCh LA


1 OCh LA


1 PA ST OCh






1 PA ST OCh


MB PA LA

18



MB


MB




MB PA LA


MB PA LA


1 PA OCh LA


MB PA LA


MB PA LA


MB PA LA


MB PA


1 PA ST OCh LA


1 PA ST OCh LA


MB PA


MB PA


19



1 PA ST OCh LA





MB PA


1 PA ST OCh LA


MB



1 PA


1 PA


1 PA


1 PA


1 PA


1 PA




MB PA







20









1


1







1


MB PA LA





1 PA ST OCh LA


MB PA


1


1


MB PA LA


MB


MB PA


MB PA LA

21



MB PA LA


1 PA ST OCh


MB PA LA


1 PA OCh LA


MB PA LA


MB PA LA


MB PA


MB





MB LA


MB PA LA


1 PA ST OCh LA



MB


1 PA ST


MB




22



1 PA LA


1 PA ST OCh LA



1 PA OCh LA


MB PA LA


1 PA ST OCh LA


MB PA LA


1 PA ST









1 PA ST OCh LA


MB PA LA


MB PA LA


1 OCh LA


MB PA LA


1 OCh LA




MB PA LA

23



MB PA LA


MB PA





MB PA LA




MB PA


MB PA LA


MB PA LA



1 PA ST OCh


1 PA OCh


1 PA ST OCh LA







MB PA







24




MB PA LA



MB PA



MB PA LA


MB




MB PA LA




ANTICONVULSANTS





1


1



1






25



1



1


1



1


1


1


1










1



1


1


1


1


1

26



1


1


1


1


1




1


1



1


1 PA ST



1 PA ST






1


1


1


1




27



1


1









1 PA ST


1


1


1











1


1


1

28



1



1


1



1


1








1 PA ST


1 ST


1 PA ST







1 PA ST


1 PA ST



29




















MB PA








1 PA LA






MB PA


1




1

30






MB PA


MB PA


1


1



MB PA ST LA


MB PA


MB LA






1 PA ST










1




1

31





NARCOTIC ANALGESICS


1 PA ST


1 PA ST


1 PA ST


1 PA ST


1 PA ST





1


1 PA ST


1 PA ST


1


1


1


1



1 PA ST



MB

32



MB PA ST



1 PA ST


1 PA


1 PA ST




1 PA ST


1 PA ST


1 PA


1 PA ST


1 PA ST


1 PA ST














33






1 PA ST








1 PA ST





1 PA ST





1 PA ST


1 PA ST










MB



34



ACA PV


ACA PV




ACA PV


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ACA PV









1



1



1


1




1




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35





1


MB









1



1








1





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36




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1




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1 PA ST


1 PA ST



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1


1

37



1 PA ST


1 ST



1


1


1


1


1


1


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1 ST



1


1


MB


MB


1


1

38



1


1 ST



1


1


1


1



1





1


1


1


1


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1 ST


1


1 ST


1

39



1


1


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1


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40



1 PA ST


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1



1



1


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1





1


1

41



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1


1


1


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42



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1


1






1


1


1



1


1


1


1



1






1

43



1


1 ST


1 ST



1 ST


1 PA ST


1



1


1





MB PA




1


1




1



1


44



1 ST


1


1


1



1 PA ST


1 PA ST


1 PA ST


1 PA ST




1 ST


1



1



1 ST


MB





1




45




1



MB


1



1












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1 ST


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1



1



1



46



1




1 ST



1


1


1


1


1


1




1


1


1


1


1


1


1


1



47



1 ST



1



1




MB PA LA




1


MB PA LA



1


1




1



1




1




1

48



1



1


1



1




1


1


1










1


1



1



1


1 ST

49



1 PA LA






1


1


1


1




1


1



1


1


1



1 ST


1



1




50



1 ST



1


1


1


1



1


1



1

CARDIAC GLYCOSIDES


1


1



1

COAGULATION THERAPY


MB


MB LA

51



MB LA


MB LA


MB LA


MB LA




MB


1


MB LA






MB


MB LA



1 PA LA


1


52



MB LA



1


MB LA


MB LA


MB


1


1


1


1 PA LA


MB


MB


MB


MB



MB


1

53



1


MB


MB


MB


MB


MB


1


MB


MB


MB LA


MB LA


MB LA


1


MB LA


MB


MB


MB

54



MB LA



MB LA


MB LA


MB LA


MB LA


MB





MB LA


1 PA ST LA


1 LA


1 PA ST LA


MB LA


MB LA


MB LA


MB LA

55



MB


MB LA


MB LA


1


MB LA


1


1


MB LA


MB LA




1 ST





1









56



1


1


1


1


1


1




ACA PV









1




ACA PV




1 PA ST


1 PA ST


1 PA ST



57











1 PA ST


MB


1 ST

NITRATES


1


1



1







MB


1


1


1


1

58









1



1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA



1 PA ST LA




1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


MB PA LA


1 PA ST LA


1 PA ST LA



59




1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA

BURN THERAPY

















1






60




MB PA




THERAPY FOR ACNE









1















1


1




61







1






1






1




TOPICAL ANESTHETICS





1


1


1






62



1 ST


1 ST




1 ST








1


TOPICAL ANTIFUNGALS









1




1


1




63



1 PA ST















1


1





TOPICAL ANTIVIRALS













64




1









1












1 ST













65
























1












66



1


1


1


1


TOPICAL ENZYMES
















MB


MB



1




MB PA LA


1 PA LA

67





1 PA LA




1 ST LA




1 PA




MB PA LA


MB PA LA


1 PA LA









MB



MB





MB


68



1 PA



MB PA LA





MB PA LA


SMOKING DETERRENTS


ACA PV





ACA PV


ACA PV


ACA PV


ACA PV


ACA PV











69



1


1







1




1




sf dental gel 11 1














1


1


1

70



1


1

ENDOCRINEDIABETES

ADRENAL HORMONES







1


1


1


1


1




1


1



1




1


1


71




1



MB

ANTITHYROID AGENTS













1


1


1


1 PA ST



1



1


1


1


72





1


1

INSULIN THERAPY


1


1


1


1


1 ST


1


1 ST


1 ST


1 ST


1 ST


1 ST


1 ST

73



1 ST


1 ST


1 ST


1 ST


1 ST


1


1


1


1


1


1


1


1


1


1


1


1

74



1


1


1


1


1


1


1


1


1


1


1 PA ST


1


1


1


1


1


1 PA ST


75



MB PA LA




MB PA




1





MB PA LA



MB PA LA



1


1



1


MB PA LA


MB PA LA


MB PA LA






MB PA LA

76




MB PA LA


MB PA LA




1 PA LA


MB PA LA


1 PA ST LA



1 PA LA


MB


MB




MB PA







1 PA


1


MB PA LA


1

77



1













MB PA LA


MB PA LA




1 PA ST


1 PA ST


1 PA ST






1


1


1


78



1


1 PA ST


1 PA ST


1 PA ST


1 PA ST



1 PA ST


1 PA ST




1


1 PA ST


1 ST




1 PA ST



1


1




1

79



1 PA ST


1 PA ST


1 PA ST


1 PA ST


1 PA ST


1 PA ST



1 PA ST


1 PA ST

THYROID HORMONES


1


1


1



1


1


1


1

80


GASTROENTEROLOGY





1 PA ST







1



1








1


1










81



1


1


1


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1






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1


1




1 PA ST LA


1 PA ST LA


ACA PV

82






1 PA




1



1


MB PA LA



ACA PV


ACA PV






1



1


1


MB PA LA



1

83



1


1


1


1 ST


1 PA ST


1


1 PA ST


1 PA




1


1




1 ST






1



ACA PV





84




ACA PV


ACA PV




ACA PV


1




1


1


1


1




1


1


MB PA LA


MB PA LA


1


1




85



1


1




1


ACA PV ST






1 ST



1 PA


1

ULCER THERAPY


1



1


1 ST


1




86



1


1





1


1


1




BIOTECHNOLOGY DRUGS


1 LA


1 LA


1 LA


1


1



MB


MB LA


1 PA ST

87



1 PA ST


1


1


1 LA


1 PA ST


1 PA ST


1 PA ST

GROWTH HORMONES


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA

INTERFERONS









88












MB PA ST LA


1 LA

















MB PA LA


1 PA LA


1 PA LA







89







1 PA ST OCh LA













1 PA ST OCh LA








INTERLEUKINS


1 PA LA


1 LA


MB PA LA



1 PA LA


MB LA

90




1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac



MB


1 Vac


1 Vac


1 Vac



1 Vac


1 Vac


MB


MB LA


MB LA

91



1 Vac


MB LA


1 Vac


1 Vac


1 Vac


MB PA


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac

92



1 Vac


MB


MB


MB LA


MB PA LA


MB LA


MB PA LA


MB PA LA


MB LA


1 Vac


1 Vac



1 Vac


1 Vac


1 Vac


MB LA

93



MB LA


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


MB LA


MB PA LA


1 PA



1 Vac


1 Vac


1 Vac


1 Vac


1 Vac

94



1 Vac


1 Vac



1 Vac


MB PA


1 Vac


1 Vac


1 PA


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


MB


1 Vac

95



1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


MB LA


MB LA


1 Vac


1 Vac


GOUT THERAPY






MB PA LA




96






1 PA ST LA




1



1 ST LA




1


1 PA ST LA



1 PA ST LA


MB PA LA


1 PA ST LA


MB PA LA


1 PA LA


1 PA LA


1 PA ST LA


1 PA ST LA


1 PA ST LA

97



1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA




MB PA LA


1 PA ST LA

98



1 PA ST LA



1 PA ST LA





1 PA ST LA


1 PA ST


1 PA ST


MB PA LA


1 PA ST LA


1 PA ST LA




1 PA ST LA




ACA PV




ACA PV


ACA PV ST


ACA PV


ACA PV

99



ACA PV


ACA PV




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1






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ACA PV












100







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1


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ACA PV


ACA PV


1

101



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1


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MISCELLANEOUS OBGYN


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102



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ACA PV



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ACA PV





ACA PV


103






ACA PV


ACA PV


ACA PV




ACA PV


ACA PV



ACA PV


ACA PV


ACA PV



ACA PV


ACA PV



ACA PV






ACA PV



104




ACA PV


ACA PV


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ACA PV



ACA PV


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ACA PV





ACA PV


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105



ACA PV



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ACA PV



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ACA PV





ACA PV


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ACA PV


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108



ACA PV






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ACA PV

109



ACA PV



ACA PV




ACA PV


ACA PV





ACA PV




OXYTOCICS



OPHTHALMOLOGY

ANTIBIOTICS


1



1


1


1



1


110



1





1


1


1


1


1



1


1



1

ANTIVIRALS



BETA-BLOCKERS



1


1




1


1

111



1





1





1







MB PA LA




1 PA



MB PA LA


MB PA LA


1


1 ST


MB PA LA


MB PA LA


MB LA

112




MB





1



MB LA





1 ST




1



1



1






1


1



1

113



1



1 ST


1 PA ST


1




1


1


1


1


1


1


1


1

STEROIDS


1 ST


1



1


1


1

114



1


1 ST


1 ST


1


1


1



1


1


1


MB PA LA




1


1


1

SULFONAMIDES


1


1

SYMPATHOMIMETICS




1

115




1




1











1 PA ST




1


1


1






1






116




1




1





1


1








1


1


PULMONARY AGENTS


1


1 PA LA







117



1




1









1




1




MB PA LA


1





1


1





118



MB PA


MB PA LA




1


1







MB PA LA


MB PA LA










1




1


1 PA LA


119








1 PA LA


1 PA LA



1









MB PA LA






1



1 PA LA


1


MB LA


MB PA LA

120



1


MB


1




1


1






1


1




1 PA LA



1 PA LA






1


1


1 PA LA

121



1


1 PA LA


1 PA LA


1 PA LA


1 PA LA


1 PA LA




MB LA






UROLOGICALS



1



1 ST




1



1


122



1






1







1







1


1


1 PA



1


1







123



URINARY ANESTHETICS



ELECTROLYTES





1


1


1




1



MB


1


1



1


1


MB



MB


MB

124



MB



1


1



ACA PV


ACA PV


ACA PV


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1



ACA PV


ACA PV


ACA PV


ACA PV


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ACA PV


ACA PV


ACA PV

125

Index







AFLURIA QD 2021-22(6-35MO)(PF) 90













126










127






















128








104






129

















130















2022 (PF) 91 FLUMIST QUAD 2021-2022










131

































132















133





















134


















135















INSULIN 74









136










scop 81




137




116 promethegan 116





138














PACK) 59

139














140














141





051267 (07-01-2021)



Language Assistance






















iv




1


ANTI - INFECTIVES

ANTIFUNGAL AGENTS


MB



MB



MB



MB


1


1



1



1





MB


1




1


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2



1


ANTIVIRALS



















1 PA





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3



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1 LA


1 PA LA












4
























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5






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MB LA








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1 PA












CEPHALOSPORINS

6



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11


PENICILLINS



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1



MB

12


QUINOLONES


MB



1


1









1


1


TETRACYCLINES





1


1


1


1


1





13







1


1




VANCOMYCIN




MB


ADJUNCTIVE AGENTS


MB


MB



1


1


MB


1 LA





MB PA LA


MB PA

14



MB PA LA




MB PA


MB PA



MB PA LA


MB PA LA


MB PA


MB PA LA



1 PA OCh


MB PA


MB PA


MB PA LA


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1 PA ST OCh LA


15



MB


1 PA ST OCh LA






MB PA


1 PA OCh




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1 OCh


1




MB PA LA


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1 PA


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16



1 PA


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1 PA



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1 PA LA



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MB PA


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1 PA OCh LA


1 PA OCh


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MB LA


MB PA LA


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1 PA OCh LA


1 OCh LA


1 PA ST OCh






1 PA ST OCh


MB PA LA

18



MB


MB




MB PA LA


MB PA LA


1 PA OCh LA


MB PA LA


MB PA LA


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1 PA ST OCh LA


MB PA


MB PA


19



1 PA ST OCh LA





MB PA


1 PA ST OCh LA


MB



1 PA


1 PA


1 PA


1 PA


1 PA


1 PA




MB PA







20









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1


MB PA LA





1 PA ST OCh LA


MB PA


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MB PA LA


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MB PA LA

21



MB PA LA


1 PA ST OCh


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1 PA OCh LA


MB PA LA


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MB LA


MB PA LA


1 PA ST OCh LA



MB


1 PA ST


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22



1 PA LA


1 PA ST OCh LA



1 PA OCh LA


MB PA LA


1 PA ST OCh LA


MB PA LA


1 PA ST









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MB PA LA


MB PA LA


1 OCh LA


MB PA LA


1 OCh LA




MB PA LA

23



MB PA LA


MB PA





MB PA LA




MB PA


MB PA LA


MB PA LA



1 PA ST OCh


1 PA OCh


1 PA ST OCh LA







MB PA







24




MB PA LA



MB PA



MB PA LA


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MB PA LA




ANTICONVULSANTS





1


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25



1



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1


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26



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28



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29




















MB PA








1 PA LA






MB PA


1




1

30






MB PA


MB PA


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1



MB PA ST LA


MB PA


MB LA






1 PA ST










1




1

31





NARCOTIC ANALGESICS


1 PA ST


1 PA ST


1 PA ST


1 PA ST


1 PA ST





1


1 PA ST


1 PA ST


1


1


1


1



1 PA ST



MB

32



MB PA ST



1 PA ST


1 PA


1 PA ST




1 PA ST


1 PA ST


1 PA


1 PA ST


1 PA ST


1 PA ST














33






1 PA ST








1 PA ST





1 PA ST





1 PA ST


1 PA ST










MB



34



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35





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36




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1 PA ST


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37



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38



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40



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41



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42



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1


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43



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1



1


1





MB PA




1


1




1



1


44



1 ST


1


1


1



1 PA ST


1 PA ST


1 PA ST


1 PA ST




1 ST


1



1



1 ST


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45




1



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1



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46



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47



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1


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1


1




1



1




1




1

48



1



1


1



1




1


1


1










1


1



1



1


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49



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1




50



1 ST



1


1


1


1



1


1



1

CARDIAC GLYCOSIDES


1


1



1

COAGULATION THERAPY


MB


MB LA

51



MB LA


MB LA


MB LA


MB LA




MB


1


MB LA






MB


MB LA



1 PA LA


1


52



MB LA



1


MB LA


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1


1


1


1 PA LA


MB


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MB



MB


1

53



1


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1


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MB LA


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1


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54



MB LA



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MB LA


1 PA ST LA


1 LA


1 PA ST LA


MB LA


MB LA


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55



MB


MB LA


MB LA


1


MB LA


1


1


MB LA


MB LA




1 ST





1









56



1


1


1


1


1


1




ACA PV









1




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1 PA ST


1 PA ST


1 PA ST



57











1 PA ST


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1


1



1







MB


1


1


1


1

58









1



1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA



1 PA ST LA




1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


MB PA LA


1 PA ST LA


1 PA ST LA



59




1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA

BURN THERAPY

















1






60




MB PA




THERAPY FOR ACNE









1















1


1




61







1






1






1




TOPICAL ANESTHETICS





1


1


1






62



1 ST


1 ST




1 ST








1


TOPICAL ANTIFUNGALS









1




1


1




63



1 PA ST















1


1





TOPICAL ANTIVIRALS













64




1









1












1 ST













65
























1












66



1


1


1


1


TOPICAL ENZYMES
















MB


MB



1




MB PA LA


1 PA LA

67





1 PA LA




1 ST LA




1 PA




MB PA LA


MB PA LA


1 PA LA









MB



MB





MB


68



1 PA



MB PA LA





MB PA LA


SMOKING DETERRENTS


ACA PV





ACA PV


ACA PV


ACA PV


ACA PV


ACA PV











69



1


1







1




1




sf dental gel 11 1














1


1


1

70



1


1

ENDOCRINEDIABETES

ADRENAL HORMONES







1


1


1


1


1




1


1



1




1


1


71




1



MB

ANTITHYROID AGENTS













1


1


1


1 PA ST



1



1


1


1


72





1


1

INSULIN THERAPY


1


1


1


1


1 ST


1


1 ST


1 ST


1 ST


1 ST


1 ST


1 ST

73



1 ST


1 ST


1 ST


1 ST


1 ST


1


1


1


1


1


1


1


1


1


1


1


1

74



1


1


1


1


1


1


1


1


1


1


1 PA ST


1


1


1


1


1


1 PA ST


75



MB PA LA




MB PA




1





MB PA LA



MB PA LA



1


1



1


MB PA LA


MB PA LA


MB PA LA






MB PA LA

76




MB PA LA


MB PA LA




1 PA LA


MB PA LA


1 PA ST LA



1 PA LA


MB


MB




MB PA







1 PA


1


MB PA LA


1

77



1













MB PA LA


MB PA LA




1 PA ST


1 PA ST


1 PA ST






1


1


1


78



1


1 PA ST


1 PA ST


1 PA ST


1 PA ST



1 PA ST


1 PA ST




1


1 PA ST


1 ST




1 PA ST



1


1




1

79



1 PA ST


1 PA ST


1 PA ST


1 PA ST


1 PA ST


1 PA ST



1 PA ST


1 PA ST

THYROID HORMONES


1


1


1



1


1


1


1

80


GASTROENTEROLOGY





1 PA ST







1



1








1


1










81



1


1


1


1





1






MB









1


1




1 PA ST LA


1 PA ST LA


ACA PV

82






1 PA




1



1


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ACA PV


ACA PV






1



1


1


MB PA LA



1

83



1


1


1


1 ST


1 PA ST


1


1 PA ST


1 PA




1


1




1 ST






1



ACA PV





84




ACA PV


ACA PV




ACA PV


1




1


1


1


1




1


1


MB PA LA


MB PA LA


1


1




85



1


1




1


ACA PV ST






1 ST



1 PA


1

ULCER THERAPY


1



1


1 ST


1




86



1


1





1


1


1




BIOTECHNOLOGY DRUGS


1 LA


1 LA


1 LA


1


1



MB


MB LA


1 PA ST

87



1 PA ST


1


1


1 LA


1 PA ST


1 PA ST


1 PA ST

GROWTH HORMONES


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA

INTERFERONS









88












MB PA ST LA


1 LA

















MB PA LA


1 PA LA


1 PA LA







89







1 PA ST OCh LA













1 PA ST OCh LA








INTERLEUKINS


1 PA LA


1 LA


MB PA LA



1 PA LA


MB LA

90




1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac



MB


1 Vac


1 Vac


1 Vac



1 Vac


1 Vac


MB


MB LA


MB LA

91



1 Vac


MB LA


1 Vac


1 Vac


1 Vac


MB PA


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac

92



1 Vac


MB


MB


MB LA


MB PA LA


MB LA


MB PA LA


MB PA LA


MB LA


1 Vac


1 Vac



1 Vac


1 Vac


1 Vac


MB LA

93



MB LA


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


MB LA


MB PA LA


1 PA



1 Vac


1 Vac


1 Vac


1 Vac


1 Vac

94



1 Vac


1 Vac



1 Vac


MB PA


1 Vac


1 Vac


1 PA


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


MB


1 Vac

95



1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


MB LA


MB LA


1 Vac


1 Vac


GOUT THERAPY






MB PA LA




96






1 PA ST LA




1



1 ST LA




1


1 PA ST LA



1 PA ST LA


MB PA LA


1 PA ST LA


MB PA LA


1 PA LA


1 PA LA


1 PA ST LA


1 PA ST LA


1 PA ST LA

97



1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA




MB PA LA


1 PA ST LA

98



1 PA ST LA



1 PA ST LA





1 PA ST LA


1 PA ST


1 PA ST


MB PA LA


1 PA ST LA


1 PA ST LA




1 PA ST LA




ACA PV




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99



ACA PV


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ACA PV


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ACA PV

109



ACA PV



ACA PV




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ACA PV




OXYTOCICS



OPHTHALMOLOGY

ANTIBIOTICS


1



1


1


1



1


110



1





1


1


1


1


1



1


1



1

ANTIVIRALS



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1


1




1


1

111



1





1





1







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1 PA



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1


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MB LA

112




MB





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1 ST




1



1



1






1


1



1

113



1



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1


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1 ST


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1


1


1

114



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1 ST


1 ST


1


1


1



1


1


1


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1


1


1

SULFONAMIDES


1


1

SYMPATHOMIMETICS




1

115




1




1











1 PA ST




1


1


1






1






116




1




1





1


1








1


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1


1 PA LA







117



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1









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1




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1


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118



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1


1







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1 PA LA


119








1 PA LA


1 PA LA



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1



1 PA LA


1


MB LA


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120



1


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1


1






1


1




1 PA LA



1 PA LA






1


1


1 PA LA

121



1


1 PA LA


1 PA LA


1 PA LA


1 PA LA


1 PA LA




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122



1






1







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123



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125

Index







AFLURIA QD 2021-22(6-35MO)(PF) 90













126










127






















128








104






129

















130















2022 (PF) 91 FLUMIST QUAD 2021-2022










131

































132















133





















134


















135















INSULIN 74









136










scop 81




137




116 promethegan 116





138














PACK) 59

139














140














141





051267 (07-01-2021)



Language Assistance






















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ANTI - INFECTIVES

ANTIFUNGAL AGENTS


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13







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58









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1 PA ST LA


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1 PA ST LA




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1 PA ST LA


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1 PA ST LA



59




1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA

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1






60




MB PA




THERAPY FOR ACNE









1















1


1




61







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1






1




TOPICAL ANESTHETICS





1


1


1






62



1 ST


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63



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TOPICAL ANTIVIRALS













64




1









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65
























1












66



1


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67





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68



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69



1


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70



1


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ENDOCRINEDIABETES

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71




1



MB

ANTITHYROID AGENTS













1


1


1


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1



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72





1


1

INSULIN THERAPY


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73



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74



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75



MB PA LA




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MB PA LA



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76




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77



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79



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1 PA ST


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1


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80


GASTROENTEROLOGY





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81



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84




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ULCER THERAPY


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86



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BIOTECHNOLOGY DRUGS


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87



1 PA ST


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1 PA ST


1 PA ST

GROWTH HORMONES


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1 PA ST LA


1 PA ST LA


1 PA ST LA

INTERFERONS









88












MB PA ST LA


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1 PA LA


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89







1 PA ST OCh LA













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INTERLEUKINS


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90




1 Vac


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MB LA

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1 Vac


MB LA


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92



1 Vac


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95



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96






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1 PA ST LA


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1 PA ST LA


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1 PA ST LA

98



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109



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OXYTOCICS



OPHTHALMOLOGY

ANTIBIOTICS


1



1


1


1



1


110



1





1


1


1


1


1



1


1



1

ANTIVIRALS



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1


1




1


1

111



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1





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112




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120



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122



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123



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1


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124



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125

Index







AFLURIA QD 2021-22(6-35MO)(PF) 90













126










127






















128








104






129

















130















2022 (PF) 91 FLUMIST QUAD 2021-2022










131

































132















133





















134


















135















INSULIN 74









136










scop 81




137




116 promethegan 116





138














PACK) 59

139














140














141





051267 (07-01-2021)



Language Assistance






















2



1


ANTIVIRALS



















1 PA





MB








3



1


1



1




1 PA LA


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1 LA


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4
























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10



1





MB













1



1


1





1 PA ST



MB


MB


11


PENICILLINS



1




1


1


1


1




MB



1


MB


MB



MB


MB


MB


1



MB

12


QUINOLONES


MB



1


1









1


1


TETRACYCLINES





1


1


1


1


1





13







1


1




VANCOMYCIN




MB


ADJUNCTIVE AGENTS


MB


MB



1


1


MB


1 LA





MB PA LA


MB PA

14



MB PA LA




MB PA


MB PA



MB PA LA


MB PA LA


MB PA


MB PA LA



1 PA OCh


MB PA


MB PA


MB PA LA


MB PA LA


MB PA LA


MB PA LA





MB


1 PA ST OCh LA


15



MB


1 PA ST OCh LA






MB PA


1 PA OCh




MB



1 OCh


1




MB PA LA


MB PA LA


MB PA LA




1 PA


1 PA


1 PA

16



1 PA


MB PA



MB PA LA


MB PA LA


MB PA LA







1 PA ST OCh LA








1 PA



MB PA


1 PA LA



MB PA



MB PA LA


17



MB PA


MB PA LA


MB


MB




1 PA OCh LA


1 PA OCh


MB PA LA


MB LA


MB PA LA


MB PA LA




1 PA OCh LA


1 OCh LA


1 PA ST OCh






1 PA ST OCh


MB PA LA

18



MB


MB




MB PA LA


MB PA LA


1 PA OCh LA


MB PA LA


MB PA LA


MB PA LA


MB PA


1 PA ST OCh LA


1 PA ST OCh LA


MB PA


MB PA


19



1 PA ST OCh LA





MB PA


1 PA ST OCh LA


MB



1 PA


1 PA


1 PA


1 PA


1 PA


1 PA




MB PA







20









1


1







1


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1 PA ST OCh LA


MB PA


1


1


MB PA LA


MB


MB PA


MB PA LA

21



MB PA LA


1 PA ST OCh


MB PA LA


1 PA OCh LA


MB PA LA


MB PA LA


MB PA


MB





MB LA


MB PA LA


1 PA ST OCh LA



MB


1 PA ST


MB




22



1 PA LA


1 PA ST OCh LA



1 PA OCh LA


MB PA LA


1 PA ST OCh LA


MB PA LA


1 PA ST









1 PA ST OCh LA


MB PA LA


MB PA LA


1 OCh LA


MB PA LA


1 OCh LA




MB PA LA

23



MB PA LA


MB PA





MB PA LA




MB PA


MB PA LA


MB PA LA



1 PA ST OCh


1 PA OCh


1 PA ST OCh LA







MB PA







24




MB PA LA



MB PA



MB PA LA


MB




MB PA LA




ANTICONVULSANTS





1


1



1






25



1



1


1



1


1


1


1










1



1


1


1


1


1

26



1


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1



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1 PA ST



1 PA ST






1


1


1


1




27



1


1









1 PA ST


1


1


1











1


1


1

28



1



1


1



1


1








1 PA ST


1 ST


1 PA ST







1 PA ST


1 PA ST



29




















MB PA








1 PA LA






MB PA


1




1

30






MB PA


MB PA


1


1



MB PA ST LA


MB PA


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1 PA ST










1




1

31





NARCOTIC ANALGESICS


1 PA ST


1 PA ST


1 PA ST


1 PA ST


1 PA ST





1


1 PA ST


1 PA ST


1


1


1


1



1 PA ST



MB

32



MB PA ST



1 PA ST


1 PA


1 PA ST




1 PA ST


1 PA ST


1 PA


1 PA ST


1 PA ST


1 PA ST














33






1 PA ST








1 PA ST





1 PA ST





1 PA ST


1 PA ST










MB



34



ACA PV


ACA PV




ACA PV


ACA PV



ACA PV









1



1



1


1




1




ACA PV


35





1


MB









1



1








1





MB LA







36




1



1




MB







ACA PV






1 PA ST


1 PA ST



MB



1


1

37



1 PA ST


1 ST



1


1


1


1


1


1


1 ST



1 ST



1


1


MB


MB


1


1

38



1


1 ST



1


1


1


1



1





1


1


1


1


1 ST


1 ST


1


1 ST


1

39



1


1


1



1


1


1







1



1


1 ST


1 ST


1 ST




1




1 PA ST

40



1 PA ST


1 ST


1 ST



1








1



1



1


1




1





1


1

41



1 ST


1 PA ST


1



1





1





1


1


1


1


1


1


1


1


1



1

42



1




1 ST


1


1






1


1


1



1


1


1


1



1






1

43



1


1 ST


1 ST



1 ST


1 PA ST


1



1


1





MB PA




1


1




1



1


44



1 ST


1


1


1



1 PA ST


1 PA ST


1 PA ST


1 PA ST




1 ST


1



1



1 ST


MB





1




45




1



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1












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1 ST


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1



1



1



46



1




1 ST



1


1


1


1


1


1




1


1


1


1


1


1


1


1



47



1 ST



1



1




MB PA LA




1


MB PA LA



1


1




1



1




1




1

48



1



1


1



1




1


1


1










1


1



1



1


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49



1 PA LA






1


1


1


1




1


1



1


1


1



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1



1




50



1 ST



1


1


1


1



1


1



1

CARDIAC GLYCOSIDES


1


1



1

COAGULATION THERAPY


MB


MB LA

51



MB LA


MB LA


MB LA


MB LA




MB


1


MB LA






MB


MB LA



1 PA LA


1


52



MB LA



1


MB LA


MB LA


MB


1


1


1


1 PA LA


MB


MB


MB


MB



MB


1

53



1


MB


MB


MB


MB


MB


1


MB


MB


MB LA


MB LA


MB LA


1


MB LA


MB


MB


MB

54



MB LA



MB LA


MB LA


MB LA


MB LA


MB





MB LA


1 PA ST LA


1 LA


1 PA ST LA


MB LA


MB LA


MB LA


MB LA

55



MB


MB LA


MB LA


1


MB LA


1


1


MB LA


MB LA




1 ST





1









56



1


1


1


1


1


1




ACA PV









1




ACA PV




1 PA ST


1 PA ST


1 PA ST



57











1 PA ST


MB


1 ST

NITRATES


1


1



1







MB


1


1


1


1

58









1



1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA



1 PA ST LA




1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


MB PA LA


1 PA ST LA


1 PA ST LA



59




1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA

BURN THERAPY

















1






60




MB PA




THERAPY FOR ACNE









1















1


1




61







1






1






1




TOPICAL ANESTHETICS





1


1


1






62



1 ST


1 ST




1 ST








1


TOPICAL ANTIFUNGALS









1




1


1




63



1 PA ST















1


1





TOPICAL ANTIVIRALS













64




1









1












1 ST













65
























1












66



1


1


1


1


TOPICAL ENZYMES
















MB


MB



1




MB PA LA


1 PA LA

67





1 PA LA




1 ST LA




1 PA




MB PA LA


MB PA LA


1 PA LA









MB



MB





MB


68



1 PA



MB PA LA





MB PA LA


SMOKING DETERRENTS


ACA PV





ACA PV


ACA PV


ACA PV


ACA PV


ACA PV











69



1


1







1




1




sf dental gel 11 1














1


1


1

70



1


1

ENDOCRINEDIABETES

ADRENAL HORMONES







1


1


1


1


1




1


1



1




1


1


71




1



MB

ANTITHYROID AGENTS













1


1


1


1 PA ST



1



1


1


1


72





1


1

INSULIN THERAPY


1


1


1


1


1 ST


1


1 ST


1 ST


1 ST


1 ST


1 ST


1 ST

73



1 ST


1 ST


1 ST


1 ST


1 ST


1


1


1


1


1


1


1


1


1


1


1


1

74



1


1


1


1


1


1


1


1


1


1


1 PA ST


1


1


1


1


1


1 PA ST


75



MB PA LA




MB PA




1





MB PA LA



MB PA LA



1


1



1


MB PA LA


MB PA LA


MB PA LA






MB PA LA

76




MB PA LA


MB PA LA




1 PA LA


MB PA LA


1 PA ST LA



1 PA LA


MB


MB




MB PA







1 PA


1


MB PA LA


1

77



1













MB PA LA


MB PA LA




1 PA ST


1 PA ST


1 PA ST






1


1


1


78



1


1 PA ST


1 PA ST


1 PA ST


1 PA ST



1 PA ST


1 PA ST




1


1 PA ST


1 ST




1 PA ST



1


1




1

79



1 PA ST


1 PA ST


1 PA ST


1 PA ST


1 PA ST


1 PA ST



1 PA ST


1 PA ST

THYROID HORMONES


1


1


1



1


1


1


1

80


GASTROENTEROLOGY





1 PA ST







1



1








1


1










81



1


1


1


1





1






MB









1


1




1 PA ST LA


1 PA ST LA


ACA PV

82






1 PA




1



1


MB PA LA



ACA PV


ACA PV






1



1


1


MB PA LA



1

83



1


1


1


1 ST


1 PA ST


1


1 PA ST


1 PA




1


1




1 ST






1



ACA PV





84




ACA PV


ACA PV




ACA PV


1




1


1


1


1




1


1


MB PA LA


MB PA LA


1


1




85



1


1




1


ACA PV ST






1 ST



1 PA


1

ULCER THERAPY


1



1


1 ST


1




86



1


1





1


1


1




BIOTECHNOLOGY DRUGS


1 LA


1 LA


1 LA


1


1



MB


MB LA


1 PA ST

87



1 PA ST


1


1


1 LA


1 PA ST


1 PA ST


1 PA ST

GROWTH HORMONES


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA

INTERFERONS









88












MB PA ST LA


1 LA

















MB PA LA


1 PA LA


1 PA LA







89







1 PA ST OCh LA













1 PA ST OCh LA








INTERLEUKINS


1 PA LA


1 LA


MB PA LA



1 PA LA


MB LA

90




1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac



MB


1 Vac


1 Vac


1 Vac



1 Vac


1 Vac


MB


MB LA


MB LA

91



1 Vac


MB LA


1 Vac


1 Vac


1 Vac


MB PA


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac

92



1 Vac


MB


MB


MB LA


MB PA LA


MB LA


MB PA LA


MB PA LA


MB LA


1 Vac


1 Vac



1 Vac


1 Vac


1 Vac


MB LA

93



MB LA


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


MB LA


MB PA LA


1 PA



1 Vac


1 Vac


1 Vac


1 Vac


1 Vac

94



1 Vac


1 Vac



1 Vac


MB PA


1 Vac


1 Vac


1 PA


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


MB


1 Vac

95



1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


MB LA


MB LA


1 Vac


1 Vac


GOUT THERAPY






MB PA LA




96






1 PA ST LA




1



1 ST LA




1


1 PA ST LA



1 PA ST LA


MB PA LA


1 PA ST LA


MB PA LA


1 PA LA


1 PA LA


1 PA ST LA


1 PA ST LA


1 PA ST LA

97



1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA




MB PA LA


1 PA ST LA

98



1 PA ST LA



1 PA ST LA





1 PA ST LA


1 PA ST


1 PA ST


MB PA LA


1 PA ST LA


1 PA ST LA




1 PA ST LA




ACA PV




ACA PV


ACA PV ST


ACA PV


ACA PV

99



ACA PV


ACA PV




1



1






1


MB


MB


ACA PV












100







1


1


1


1




1




1


1


1









ACA PV


ACA PV


1

101



1








1




1


1


1


1



1




MISCELLANEOUS OBGYN


ACA PV




ACA PV






102



1 PA LA








ACA PV



ACA PV



ACA PV


ACA PV


ACA PV


ACA PV







ACA PV


ACA PV





ACA PV


103






ACA PV


ACA PV


ACA PV




ACA PV


ACA PV



ACA PV


ACA PV


ACA PV



ACA PV


ACA PV



ACA PV






ACA PV



104




ACA PV


ACA PV


ACA PV


ACA PV



ACA PV


ACA PV







ACA PV




ACA PV





ACA PV


ACA PV


ACA PV



ACA PV


105



ACA PV



ACA PV





ACA PV


ACA PV



ACA PV



ACA PV





ACA PV





ACA PV


ACA PV



ACA PV




ACA PV

106




ACA PV


ACA PV


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ACA PV


ACA PV








ACA PV




ACA PV


ACA PV






ACA PV




ACA PV


107



ACA PV


ACA PV


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ACA PV


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ACA PV









ACA PV


ACA PV





ACA PV


ACA PV


ACA PV

108



ACA PV






ACA PV


ACA PV




ACA PV


ACA PV


ACA PV


ACA PV


ACA PV


ACA PV



ACA PV



ACA PV


ACA PV


ACA PV


ACA PV


ACA PV


ACA PV

109



ACA PV



ACA PV




ACA PV


ACA PV





ACA PV




OXYTOCICS



OPHTHALMOLOGY

ANTIBIOTICS


1



1


1


1



1


110



1





1


1


1


1


1



1


1



1

ANTIVIRALS



BETA-BLOCKERS



1


1




1


1

111



1





1





1







MB PA LA




1 PA



MB PA LA


MB PA LA


1


1 ST


MB PA LA


MB PA LA


MB LA

112




MB





1



MB LA





1 ST




1



1



1






1


1



1

113



1



1 ST


1 PA ST


1




1


1


1


1


1


1


1


1

STEROIDS


1 ST


1



1


1


1

114



1


1 ST


1 ST


1


1


1



1


1


1


MB PA LA




1


1


1

SULFONAMIDES


1


1

SYMPATHOMIMETICS




1

115




1




1











1 PA ST




1


1


1






1






116




1




1





1


1








1


1


PULMONARY AGENTS


1


1 PA LA







117



1




1









1




1




MB PA LA


1





1


1





118



MB PA


MB PA LA




1


1







MB PA LA


MB PA LA










1




1


1 PA LA


119








1 PA LA


1 PA LA



1









MB PA LA






1



1 PA LA


1


MB LA


MB PA LA

120



1


MB


1




1


1






1


1




1 PA LA



1 PA LA






1


1


1 PA LA

121



1


1 PA LA


1 PA LA


1 PA LA


1 PA LA


1 PA LA




MB LA






UROLOGICALS



1



1 ST




1



1


122



1






1







1







1


1


1 PA



1


1







123



URINARY ANESTHETICS



ELECTROLYTES





1


1


1




1



MB


1


1



1


1


MB



MB


MB

124



MB



1


1



ACA PV


ACA PV


ACA PV


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1



ACA PV


ACA PV


ACA PV


ACA PV


ACA PV


ACA PV


ACA PV


ACA PV

125

Index







AFLURIA QD 2021-22(6-35MO)(PF) 90













126










127






















128








104






129

















130















2022 (PF) 91 FLUMIST QUAD 2021-2022










131

































132















133





















134


















135















INSULIN 74









136










scop 81




137




116 promethegan 116





138














PACK) 59

139














140














141





051267 (07-01-2021)



Language Assistance






















3



1


1



1




1 PA LA


1








MB





1 LA


1 PA LA












4
























MB PA







MB








5






1 LA






MB LA








MB PA







1 PA












CEPHALOSPORINS

6



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1




1



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1



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1


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1

7




1



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1



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8



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9





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MB







MB


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MB


MB






10



1





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1



1


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MB


11


PENICILLINS



1




1


1


1


1




MB



1


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MB



MB


MB


MB


1



MB

12


QUINOLONES


MB



1


1









1


1


TETRACYCLINES





1


1


1


1


1





13







1


1




VANCOMYCIN




MB


ADJUNCTIVE AGENTS


MB


MB



1


1


MB


1 LA





MB PA LA


MB PA

14



MB PA LA




MB PA


MB PA



MB PA LA


MB PA LA


MB PA


MB PA LA



1 PA OCh


MB PA


MB PA


MB PA LA


MB PA LA


MB PA LA


MB PA LA





MB


1 PA ST OCh LA


15



MB


1 PA ST OCh LA






MB PA


1 PA OCh




MB



1 OCh


1




MB PA LA


MB PA LA


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1 PA


1 PA


1 PA

16



1 PA


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MB PA LA


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MB PA LA







1 PA ST OCh LA








1 PA



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1 PA LA



MB PA



MB PA LA


17



MB PA


MB PA LA


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MB




1 PA OCh LA


1 PA OCh


MB PA LA


MB LA


MB PA LA


MB PA LA




1 PA OCh LA


1 OCh LA


1 PA ST OCh






1 PA ST OCh


MB PA LA

18



MB


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1 PA OCh LA


MB PA LA


MB PA LA


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1 PA ST OCh LA


1 PA ST OCh LA


MB PA


MB PA


19



1 PA ST OCh LA





MB PA


1 PA ST OCh LA


MB



1 PA


1 PA


1 PA


1 PA


1 PA


1 PA




MB PA







20









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1 PA ST OCh LA


MB PA


1


1


MB PA LA


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MB PA LA

21



MB PA LA


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1 PA OCh LA


MB PA LA


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MB PA


MB





MB LA


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1 PA ST OCh LA



MB


1 PA ST


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1 PA LA


1 PA ST OCh LA



1 PA OCh LA


MB PA LA


1 PA ST OCh LA


MB PA LA


1 PA ST









1 PA ST OCh LA


MB PA LA


MB PA LA


1 OCh LA


MB PA LA


1 OCh LA




MB PA LA

23



MB PA LA


MB PA





MB PA LA




MB PA


MB PA LA


MB PA LA



1 PA ST OCh


1 PA OCh


1 PA ST OCh LA







MB PA







24




MB PA LA



MB PA



MB PA LA


MB




MB PA LA




ANTICONVULSANTS





1


1



1






25



1



1


1



1


1


1


1










1



1


1


1


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1

26



1


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27



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1


1


1

28



1



1


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1 PA ST


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1 PA ST







1 PA ST


1 PA ST



29




















MB PA








1 PA LA






MB PA


1




1

30






MB PA


MB PA


1


1



MB PA ST LA


MB PA


MB LA






1 PA ST










1




1

31





NARCOTIC ANALGESICS


1 PA ST


1 PA ST


1 PA ST


1 PA ST


1 PA ST





1


1 PA ST


1 PA ST


1


1


1


1



1 PA ST



MB

32



MB PA ST



1 PA ST


1 PA


1 PA ST




1 PA ST


1 PA ST


1 PA


1 PA ST


1 PA ST


1 PA ST














33






1 PA ST








1 PA ST





1 PA ST





1 PA ST


1 PA ST










MB



34



ACA PV


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1



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35





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1








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36




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1


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37



1 PA ST


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38



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1


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1


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MB PA




1


1




1



1


44



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1


1


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1 PA ST


1 PA ST




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1



1



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45




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46



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1


1


1


1


1


1


1


1



47



1 ST



1



1




MB PA LA




1


MB PA LA



1


1




1



1




1




1

48



1



1


1



1




1


1


1










1


1



1



1


1 ST

49



1 PA LA






1


1


1


1




1


1



1


1


1



1 ST


1



1




50



1 ST



1


1


1


1



1


1



1

CARDIAC GLYCOSIDES


1


1



1

COAGULATION THERAPY


MB


MB LA

51



MB LA


MB LA


MB LA


MB LA




MB


1


MB LA






MB


MB LA



1 PA LA


1


52



MB LA



1


MB LA


MB LA


MB


1


1


1


1 PA LA


MB


MB


MB


MB



MB


1

53



1


MB


MB


MB


MB


MB


1


MB


MB


MB LA


MB LA


MB LA


1


MB LA


MB


MB


MB

54



MB LA



MB LA


MB LA


MB LA


MB LA


MB





MB LA


1 PA ST LA


1 LA


1 PA ST LA


MB LA


MB LA


MB LA


MB LA

55



MB


MB LA


MB LA


1


MB LA


1


1


MB LA


MB LA




1 ST





1









56



1


1


1


1


1


1




ACA PV









1




ACA PV




1 PA ST


1 PA ST


1 PA ST



57











1 PA ST


MB


1 ST

NITRATES


1


1



1







MB


1


1


1


1

58









1



1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA



1 PA ST LA




1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


MB PA LA


1 PA ST LA


1 PA ST LA



59




1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA

BURN THERAPY

















1






60




MB PA




THERAPY FOR ACNE









1















1


1




61







1






1






1




TOPICAL ANESTHETICS





1


1


1






62



1 ST


1 ST




1 ST








1


TOPICAL ANTIFUNGALS









1




1


1




63



1 PA ST















1


1





TOPICAL ANTIVIRALS













64




1









1












1 ST













65
























1












66



1


1


1


1


TOPICAL ENZYMES
















MB


MB



1




MB PA LA


1 PA LA

67





1 PA LA




1 ST LA




1 PA




MB PA LA


MB PA LA


1 PA LA









MB



MB





MB


68



1 PA



MB PA LA





MB PA LA


SMOKING DETERRENTS


ACA PV





ACA PV


ACA PV


ACA PV


ACA PV


ACA PV











69



1


1







1




1




sf dental gel 11 1














1


1


1

70



1


1

ENDOCRINEDIABETES

ADRENAL HORMONES







1


1


1


1


1




1


1



1




1


1


71




1



MB

ANTITHYROID AGENTS













1


1


1


1 PA ST



1



1


1


1


72





1


1

INSULIN THERAPY


1


1


1


1


1 ST


1


1 ST


1 ST


1 ST


1 ST


1 ST


1 ST

73



1 ST


1 ST


1 ST


1 ST


1 ST


1


1


1


1


1


1


1


1


1


1


1


1

74



1


1


1


1


1


1


1


1


1


1


1 PA ST


1


1


1


1


1


1 PA ST


75



MB PA LA




MB PA




1





MB PA LA



MB PA LA



1


1



1


MB PA LA


MB PA LA


MB PA LA






MB PA LA

76




MB PA LA


MB PA LA




1 PA LA


MB PA LA


1 PA ST LA



1 PA LA


MB


MB




MB PA







1 PA


1


MB PA LA


1

77



1













MB PA LA


MB PA LA




1 PA ST


1 PA ST


1 PA ST






1


1


1


78



1


1 PA ST


1 PA ST


1 PA ST


1 PA ST



1 PA ST


1 PA ST




1


1 PA ST


1 ST




1 PA ST



1


1




1

79



1 PA ST


1 PA ST


1 PA ST


1 PA ST


1 PA ST


1 PA ST



1 PA ST


1 PA ST

THYROID HORMONES


1


1


1



1


1


1


1

80


GASTROENTEROLOGY





1 PA ST







1



1








1


1










81



1


1


1


1





1






MB









1


1




1 PA ST LA


1 PA ST LA


ACA PV

82






1 PA




1



1


MB PA LA



ACA PV


ACA PV






1



1


1


MB PA LA



1

83



1


1


1


1 ST


1 PA ST


1


1 PA ST


1 PA




1


1




1 ST






1



ACA PV





84




ACA PV


ACA PV




ACA PV


1




1


1


1


1




1


1


MB PA LA


MB PA LA


1


1




85



1


1




1


ACA PV ST






1 ST



1 PA


1

ULCER THERAPY


1



1


1 ST


1




86



1


1





1


1


1




BIOTECHNOLOGY DRUGS


1 LA


1 LA


1 LA


1


1



MB


MB LA


1 PA ST

87



1 PA ST


1


1


1 LA


1 PA ST


1 PA ST


1 PA ST

GROWTH HORMONES


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA

INTERFERONS









88












MB PA ST LA


1 LA

















MB PA LA


1 PA LA


1 PA LA







89







1 PA ST OCh LA













1 PA ST OCh LA








INTERLEUKINS


1 PA LA


1 LA


MB PA LA



1 PA LA


MB LA

90




1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac



MB


1 Vac


1 Vac


1 Vac



1 Vac


1 Vac


MB


MB LA


MB LA

91



1 Vac


MB LA


1 Vac


1 Vac


1 Vac


MB PA


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac

92



1 Vac


MB


MB


MB LA


MB PA LA


MB LA


MB PA LA


MB PA LA


MB LA


1 Vac


1 Vac



1 Vac


1 Vac


1 Vac


MB LA

93



MB LA


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


MB LA


MB PA LA


1 PA



1 Vac


1 Vac


1 Vac


1 Vac


1 Vac

94



1 Vac


1 Vac



1 Vac


MB PA


1 Vac


1 Vac


1 PA


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


MB


1 Vac

95



1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


MB LA


MB LA


1 Vac


1 Vac


GOUT THERAPY






MB PA LA




96






1 PA ST LA




1



1 ST LA




1


1 PA ST LA



1 PA ST LA


MB PA LA


1 PA ST LA


MB PA LA


1 PA LA


1 PA LA


1 PA ST LA


1 PA ST LA


1 PA ST LA

97



1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA




MB PA LA


1 PA ST LA

98



1 PA ST LA



1 PA ST LA





1 PA ST LA


1 PA ST


1 PA ST


MB PA LA


1 PA ST LA


1 PA ST LA




1 PA ST LA




ACA PV




ACA PV


ACA PV ST


ACA PV


ACA PV

99



ACA PV


ACA PV




1



1






1


MB


MB


ACA PV












100







1


1


1


1




1




1


1


1









ACA PV


ACA PV


1

101



1








1




1


1


1


1



1




MISCELLANEOUS OBGYN


ACA PV




ACA PV






102



1 PA LA








ACA PV



ACA PV



ACA PV


ACA PV


ACA PV


ACA PV







ACA PV


ACA PV





ACA PV


103






ACA PV


ACA PV


ACA PV




ACA PV


ACA PV



ACA PV


ACA PV


ACA PV



ACA PV


ACA PV



ACA PV






ACA PV



104




ACA PV


ACA PV


ACA PV


ACA PV



ACA PV


ACA PV







ACA PV




ACA PV





ACA PV


ACA PV


ACA PV



ACA PV


105



ACA PV



ACA PV





ACA PV


ACA PV



ACA PV



ACA PV





ACA PV





ACA PV


ACA PV



ACA PV




ACA PV

106




ACA PV


ACA PV


ACA PV




ACA PV


ACA PV








ACA PV




ACA PV


ACA PV






ACA PV




ACA PV


107



ACA PV


ACA PV


ACA PV


ACA PV


ACA PV


ACA PV





ACA PV









ACA PV


ACA PV





ACA PV


ACA PV


ACA PV

108



ACA PV






ACA PV


ACA PV




ACA PV


ACA PV


ACA PV


ACA PV


ACA PV


ACA PV



ACA PV



ACA PV


ACA PV


ACA PV


ACA PV


ACA PV


ACA PV

109



ACA PV



ACA PV




ACA PV


ACA PV





ACA PV




OXYTOCICS



OPHTHALMOLOGY

ANTIBIOTICS


1



1


1


1



1


110



1





1


1


1


1


1



1


1



1

ANTIVIRALS



BETA-BLOCKERS



1


1




1


1

111



1





1





1







MB PA LA




1 PA



MB PA LA


MB PA LA


1


1 ST


MB PA LA


MB PA LA


MB LA

112




MB





1



MB LA





1 ST




1



1



1






1


1



1

113



1



1 ST


1 PA ST


1




1


1


1


1


1


1


1


1

STEROIDS


1 ST


1



1


1


1

114



1


1 ST


1 ST


1


1


1



1


1


1


MB PA LA




1


1


1

SULFONAMIDES


1


1

SYMPATHOMIMETICS




1

115




1




1











1 PA ST




1


1


1






1






116




1




1





1


1








1


1


PULMONARY AGENTS


1


1 PA LA







117



1




1









1




1




MB PA LA


1





1


1





118



MB PA


MB PA LA




1


1







MB PA LA


MB PA LA










1




1


1 PA LA


119








1 PA LA


1 PA LA



1









MB PA LA






1



1 PA LA


1


MB LA


MB PA LA

120



1


MB


1




1


1






1


1




1 PA LA



1 PA LA






1


1


1 PA LA

121



1


1 PA LA


1 PA LA


1 PA LA


1 PA LA


1 PA LA




MB LA






UROLOGICALS



1



1 ST




1



1


122



1






1







1







1


1


1 PA



1


1







123



URINARY ANESTHETICS



ELECTROLYTES





1


1


1




1



MB


1


1



1


1


MB



MB


MB

124



MB



1


1



ACA PV


ACA PV


ACA PV


ACA PV





1



ACA PV


ACA PV


ACA PV


ACA PV


ACA PV


ACA PV


ACA PV


ACA PV

125

Index







AFLURIA QD 2021-22(6-35MO)(PF) 90













126










127






















128








104






129

















130















2022 (PF) 91 FLUMIST QUAD 2021-2022










131

































132















133





















134


















135















INSULIN 74









136










scop 81




137




116 promethegan 116





138














PACK) 59

139














140














141





051267 (07-01-2021)



Language Assistance






















4
























MB PA







MB








5






1 LA






MB LA








MB PA







1 PA












CEPHALOSPORINS

6



MB



1




1



MB


MB




1



MB


MB




1


MB



MB





1

7




1



MB


MB


MB


MB


MB





1



1


1


MB



MB


MB




1



1


8



1




1



1



1



1




1 PA ST




1





MB



1



MB



MB


MB

9





1



MB


MB



MB







MB


MB


1



MB



MB


MB






10



1





MB













1



1


1





1 PA ST



MB


MB


11


PENICILLINS



1




1


1


1


1




MB



1


MB


MB



MB


MB


MB


1



MB

12


QUINOLONES


MB



1


1









1


1


TETRACYCLINES





1


1


1


1


1





13







1


1




VANCOMYCIN




MB


ADJUNCTIVE AGENTS


MB


MB



1


1


MB


1 LA





MB PA LA


MB PA

14



MB PA LA




MB PA


MB PA



MB PA LA


MB PA LA


MB PA


MB PA LA



1 PA OCh


MB PA


MB PA


MB PA LA


MB PA LA


MB PA LA


MB PA LA





MB


1 PA ST OCh LA


15



MB


1 PA ST OCh LA






MB PA


1 PA OCh




MB



1 OCh


1




MB PA LA


MB PA LA


MB PA LA




1 PA


1 PA


1 PA

16



1 PA


MB PA



MB PA LA


MB PA LA


MB PA LA







1 PA ST OCh LA








1 PA



MB PA


1 PA LA



MB PA



MB PA LA


17



MB PA


MB PA LA


MB


MB




1 PA OCh LA


1 PA OCh


MB PA LA


MB LA


MB PA LA


MB PA LA




1 PA OCh LA


1 OCh LA


1 PA ST OCh






1 PA ST OCh


MB PA LA

18



MB


MB




MB PA LA


MB PA LA


1 PA OCh LA


MB PA LA


MB PA LA


MB PA LA


MB PA


1 PA ST OCh LA


1 PA ST OCh LA


MB PA


MB PA


19



1 PA ST OCh LA





MB PA


1 PA ST OCh LA


MB



1 PA


1 PA


1 PA


1 PA


1 PA


1 PA




MB PA







20









1


1







1


MB PA LA





1 PA ST OCh LA


MB PA


1


1


MB PA LA


MB


MB PA


MB PA LA

21



MB PA LA


1 PA ST OCh


MB PA LA


1 PA OCh LA


MB PA LA


MB PA LA


MB PA


MB





MB LA


MB PA LA


1 PA ST OCh LA



MB


1 PA ST


MB




22



1 PA LA


1 PA ST OCh LA



1 PA OCh LA


MB PA LA


1 PA ST OCh LA


MB PA LA


1 PA ST









1 PA ST OCh LA


MB PA LA


MB PA LA


1 OCh LA


MB PA LA


1 OCh LA




MB PA LA

23



MB PA LA


MB PA





MB PA LA




MB PA


MB PA LA


MB PA LA



1 PA ST OCh


1 PA OCh


1 PA ST OCh LA







MB PA







24




MB PA LA



MB PA



MB PA LA


MB




MB PA LA




ANTICONVULSANTS





1


1



1






25



1



1


1



1


1


1


1










1



1


1


1


1


1

26



1


1


1


1


1




1


1



1


1 PA ST



1 PA ST






1


1


1


1




27



1


1









1 PA ST


1


1


1











1


1


1

28



1



1


1



1


1








1 PA ST


1 ST


1 PA ST







1 PA ST


1 PA ST



29




















MB PA








1 PA LA






MB PA


1




1

30






MB PA


MB PA


1


1



MB PA ST LA


MB PA


MB LA






1 PA ST










1




1

31





NARCOTIC ANALGESICS


1 PA ST


1 PA ST


1 PA ST


1 PA ST


1 PA ST





1


1 PA ST


1 PA ST


1


1


1


1



1 PA ST



MB

32



MB PA ST



1 PA ST


1 PA


1 PA ST




1 PA ST


1 PA ST


1 PA


1 PA ST


1 PA ST


1 PA ST














33






1 PA ST








1 PA ST





1 PA ST





1 PA ST


1 PA ST










MB



34



ACA PV


ACA PV




ACA PV


ACA PV



ACA PV









1



1



1


1




1




ACA PV


35





1


MB









1



1








1





MB LA







36




1



1




MB







ACA PV






1 PA ST


1 PA ST



MB



1


1

37



1 PA ST


1 ST



1


1


1


1


1


1


1 ST



1 ST



1


1


MB


MB


1


1

38



1


1 ST



1


1


1


1



1





1


1


1


1


1 ST


1 ST


1


1 ST


1

39



1


1


1



1


1


1







1



1


1 ST


1 ST


1 ST




1




1 PA ST

40



1 PA ST


1 ST


1 ST



1








1



1



1


1




1





1


1

41



1 ST


1 PA ST


1



1





1





1


1


1


1


1


1


1


1


1



1

42



1




1 ST


1


1






1


1


1



1


1


1


1



1






1

43



1


1 ST


1 ST



1 ST


1 PA ST


1



1


1





MB PA




1


1




1



1


44



1 ST


1


1


1



1 PA ST


1 PA ST


1 PA ST


1 PA ST




1 ST


1



1



1 ST


MB





1




45




1



MB


1



1












1 ST


1 ST


1 ST


1



1



1



46



1




1 ST



1


1


1


1


1


1




1


1


1


1


1


1


1


1



47



1 ST



1



1




MB PA LA




1


MB PA LA



1


1




1



1




1




1

48



1



1


1



1




1


1


1










1


1



1



1


1 ST

49



1 PA LA






1


1


1


1




1


1



1


1


1



1 ST


1



1




50



1 ST



1


1


1


1



1


1



1

CARDIAC GLYCOSIDES


1


1



1

COAGULATION THERAPY


MB


MB LA

51



MB LA


MB LA


MB LA


MB LA




MB


1


MB LA






MB


MB LA



1 PA LA


1


52



MB LA



1


MB LA


MB LA


MB


1


1


1


1 PA LA


MB


MB


MB


MB



MB


1

53



1


MB


MB


MB


MB


MB


1


MB


MB


MB LA


MB LA


MB LA


1


MB LA


MB


MB


MB

54



MB LA



MB LA


MB LA


MB LA


MB LA


MB





MB LA


1 PA ST LA


1 LA


1 PA ST LA


MB LA


MB LA


MB LA


MB LA

55



MB


MB LA


MB LA


1


MB LA


1


1


MB LA


MB LA




1 ST





1









56



1


1


1


1


1


1




ACA PV









1




ACA PV




1 PA ST


1 PA ST


1 PA ST



57











1 PA ST


MB


1 ST

NITRATES


1


1



1







MB


1


1


1


1

58









1



1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA



1 PA ST LA




1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


MB PA LA


1 PA ST LA


1 PA ST LA



59




1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA

BURN THERAPY

















1






60




MB PA




THERAPY FOR ACNE









1















1


1




61







1






1






1




TOPICAL ANESTHETICS





1


1


1






62



1 ST


1 ST




1 ST








1


TOPICAL ANTIFUNGALS









1




1


1




63



1 PA ST















1


1





TOPICAL ANTIVIRALS













64




1









1












1 ST













65
























1












66



1


1


1


1


TOPICAL ENZYMES
















MB


MB



1




MB PA LA


1 PA LA

67





1 PA LA




1 ST LA




1 PA




MB PA LA


MB PA LA


1 PA LA









MB



MB





MB


68



1 PA



MB PA LA





MB PA LA


SMOKING DETERRENTS


ACA PV





ACA PV


ACA PV


ACA PV


ACA PV


ACA PV











69



1


1







1




1




sf dental gel 11 1














1


1


1

70



1


1

ENDOCRINEDIABETES

ADRENAL HORMONES







1


1


1


1


1




1


1



1




1


1


71




1



MB

ANTITHYROID AGENTS













1


1


1


1 PA ST



1



1


1


1


72





1


1

INSULIN THERAPY


1


1


1


1


1 ST


1


1 ST


1 ST


1 ST


1 ST


1 ST


1 ST

73



1 ST


1 ST


1 ST


1 ST


1 ST


1


1


1


1


1


1


1


1


1


1


1


1

74



1


1


1


1


1


1


1


1


1


1


1 PA ST


1


1


1


1


1


1 PA ST


75



MB PA LA




MB PA




1





MB PA LA



MB PA LA



1


1



1


MB PA LA


MB PA LA


MB PA LA






MB PA LA

76




MB PA LA


MB PA LA




1 PA LA


MB PA LA


1 PA ST LA



1 PA LA


MB


MB




MB PA







1 PA


1


MB PA LA


1

77



1













MB PA LA


MB PA LA




1 PA ST


1 PA ST


1 PA ST






1


1


1


78



1


1 PA ST


1 PA ST


1 PA ST


1 PA ST



1 PA ST


1 PA ST




1


1 PA ST


1 ST




1 PA ST



1


1




1

79



1 PA ST


1 PA ST


1 PA ST


1 PA ST


1 PA ST


1 PA ST



1 PA ST


1 PA ST

THYROID HORMONES


1


1


1



1


1


1


1

80


GASTROENTEROLOGY





1 PA ST







1



1








1


1










81



1


1


1


1





1






MB









1


1




1 PA ST LA


1 PA ST LA


ACA PV

82






1 PA




1



1


MB PA LA



ACA PV


ACA PV






1



1


1


MB PA LA



1

83



1


1


1


1 ST


1 PA ST


1


1 PA ST


1 PA




1


1




1 ST






1



ACA PV





84




ACA PV


ACA PV




ACA PV


1




1


1


1


1




1


1


MB PA LA


MB PA LA


1


1




85



1


1




1


ACA PV ST






1 ST



1 PA


1

ULCER THERAPY


1



1


1 ST


1




86



1


1





1


1


1




BIOTECHNOLOGY DRUGS


1 LA


1 LA


1 LA


1


1



MB


MB LA


1 PA ST

87



1 PA ST


1


1


1 LA


1 PA ST


1 PA ST


1 PA ST

GROWTH HORMONES


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA

INTERFERONS









88












MB PA ST LA


1 LA

















MB PA LA


1 PA LA


1 PA LA







89







1 PA ST OCh LA













1 PA ST OCh LA








INTERLEUKINS


1 PA LA


1 LA


MB PA LA



1 PA LA


MB LA

90




1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac



MB


1 Vac


1 Vac


1 Vac



1 Vac


1 Vac


MB


MB LA


MB LA

91



1 Vac


MB LA


1 Vac


1 Vac


1 Vac


MB PA


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac

92



1 Vac


MB


MB


MB LA


MB PA LA


MB LA


MB PA LA


MB PA LA


MB LA


1 Vac


1 Vac



1 Vac


1 Vac


1 Vac


MB LA

93



MB LA


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


MB LA


MB PA LA


1 PA



1 Vac


1 Vac


1 Vac


1 Vac


1 Vac

94



1 Vac


1 Vac



1 Vac


MB PA


1 Vac


1 Vac


1 PA


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


MB


1 Vac

95



1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


MB LA


MB LA


1 Vac


1 Vac


GOUT THERAPY






MB PA LA




96






1 PA ST LA




1



1 ST LA




1


1 PA ST LA



1 PA ST LA


MB PA LA


1 PA ST LA


MB PA LA


1 PA LA


1 PA LA


1 PA ST LA


1 PA ST LA


1 PA ST LA

97



1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA




MB PA LA


1 PA ST LA

98



1 PA ST LA



1 PA ST LA





1 PA ST LA


1 PA ST


1 PA ST


MB PA LA


1 PA ST LA


1 PA ST LA




1 PA ST LA




ACA PV




ACA PV


ACA PV ST


ACA PV


ACA PV

99



ACA PV


ACA PV




1



1






1


MB


MB


ACA PV












100







1


1


1


1




1




1


1


1









ACA PV


ACA PV


1

101



1








1




1


1


1


1



1




MISCELLANEOUS OBGYN


ACA PV




ACA PV






102



1 PA LA








ACA PV



ACA PV



ACA PV


ACA PV


ACA PV


ACA PV







ACA PV


ACA PV





ACA PV


103






ACA PV


ACA PV


ACA PV




ACA PV


ACA PV



ACA PV


ACA PV


ACA PV



ACA PV


ACA PV



ACA PV






ACA PV



104




ACA PV


ACA PV


ACA PV


ACA PV



ACA PV


ACA PV







ACA PV




ACA PV





ACA PV


ACA PV


ACA PV



ACA PV


105



ACA PV



ACA PV





ACA PV


ACA PV



ACA PV



ACA PV





ACA PV





ACA PV


ACA PV



ACA PV




ACA PV

106




ACA PV


ACA PV


ACA PV




ACA PV


ACA PV








ACA PV




ACA PV


ACA PV






ACA PV




ACA PV


107



ACA PV


ACA PV


ACA PV


ACA PV


ACA PV


ACA PV





ACA PV









ACA PV


ACA PV





ACA PV


ACA PV


ACA PV

108



ACA PV






ACA PV


ACA PV




ACA PV


ACA PV


ACA PV


ACA PV


ACA PV


ACA PV



ACA PV



ACA PV


ACA PV


ACA PV


ACA PV


ACA PV


ACA PV

109



ACA PV



ACA PV




ACA PV


ACA PV





ACA PV




OXYTOCICS



OPHTHALMOLOGY

ANTIBIOTICS


1



1


1


1



1


110



1





1


1


1


1


1



1


1



1

ANTIVIRALS



BETA-BLOCKERS



1


1




1


1

111



1





1





1







MB PA LA




1 PA



MB PA LA


MB PA LA


1


1 ST


MB PA LA


MB PA LA


MB LA

112




MB





1



MB LA





1 ST




1



1



1






1


1



1

113



1



1 ST


1 PA ST


1




1


1


1


1


1


1


1


1

STEROIDS


1 ST


1



1


1


1

114



1


1 ST


1 ST


1


1


1



1


1


1


MB PA LA




1


1


1

SULFONAMIDES


1


1

SYMPATHOMIMETICS




1

115




1




1











1 PA ST




1


1


1






1






116




1




1





1


1








1


1


PULMONARY AGENTS


1


1 PA LA







117



1




1









1




1




MB PA LA


1





1


1





118



MB PA


MB PA LA




1


1







MB PA LA


MB PA LA










1




1


1 PA LA


119








1 PA LA


1 PA LA



1









MB PA LA






1



1 PA LA


1


MB LA


MB PA LA

120



1


MB


1




1


1






1


1




1 PA LA



1 PA LA






1


1


1 PA LA

121



1


1 PA LA


1 PA LA


1 PA LA


1 PA LA


1 PA LA




MB LA






UROLOGICALS



1



1 ST




1



1


122



1






1







1







1


1


1 PA



1


1







123



URINARY ANESTHETICS



ELECTROLYTES





1


1


1




1



MB


1


1



1


1


MB



MB


MB

124



MB



1


1



ACA PV


ACA PV


ACA PV


ACA PV





1



ACA PV


ACA PV


ACA PV


ACA PV


ACA PV


ACA PV


ACA PV


ACA PV

125

Index







AFLURIA QD 2021-22(6-35MO)(PF) 90













126










127






















128








104






129

















130















2022 (PF) 91 FLUMIST QUAD 2021-2022










131

































132















133





















134


















135















INSULIN 74









136










scop 81




137




116 promethegan 116





138














PACK) 59

139














140














141





051267 (07-01-2021)



Language Assistance






















5






1 LA






MB LA








MB PA







1 PA












CEPHALOSPORINS

6



MB



1




1



MB


MB




1



MB


MB




1


MB



MB





1

7




1



MB


MB


MB


MB


MB





1



1


1


MB



MB


MB




1



1


8



1




1



1



1



1




1 PA ST




1





MB



1



MB



MB


MB

9





1



MB


MB



MB







MB


MB


1



MB



MB


MB






10



1





MB













1



1


1





1 PA ST



MB


MB


11


PENICILLINS



1




1


1


1


1




MB



1


MB


MB



MB


MB


MB


1



MB

12


QUINOLONES


MB



1


1









1


1


TETRACYCLINES





1


1


1


1


1





13







1


1




VANCOMYCIN




MB


ADJUNCTIVE AGENTS


MB


MB



1


1


MB


1 LA





MB PA LA


MB PA

14



MB PA LA




MB PA


MB PA



MB PA LA


MB PA LA


MB PA


MB PA LA



1 PA OCh


MB PA


MB PA


MB PA LA


MB PA LA


MB PA LA


MB PA LA





MB


1 PA ST OCh LA


15



MB


1 PA ST OCh LA






MB PA


1 PA OCh




MB



1 OCh


1




MB PA LA


MB PA LA


MB PA LA




1 PA


1 PA


1 PA

16



1 PA


MB PA



MB PA LA


MB PA LA


MB PA LA







1 PA ST OCh LA








1 PA



MB PA


1 PA LA



MB PA



MB PA LA


17



MB PA


MB PA LA


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MB




1 PA OCh LA


1 PA OCh


MB PA LA


MB LA


MB PA LA


MB PA LA




1 PA OCh LA


1 OCh LA


1 PA ST OCh






1 PA ST OCh


MB PA LA

18



MB


MB




MB PA LA


MB PA LA


1 PA OCh LA


MB PA LA


MB PA LA


MB PA LA


MB PA


1 PA ST OCh LA


1 PA ST OCh LA


MB PA


MB PA


19



1 PA ST OCh LA





MB PA


1 PA ST OCh LA


MB



1 PA


1 PA


1 PA


1 PA


1 PA


1 PA




MB PA







20









1


1







1


MB PA LA





1 PA ST OCh LA


MB PA


1


1


MB PA LA


MB


MB PA


MB PA LA

21



MB PA LA


1 PA ST OCh


MB PA LA


1 PA OCh LA


MB PA LA


MB PA LA


MB PA


MB





MB LA


MB PA LA


1 PA ST OCh LA



MB


1 PA ST


MB




22



1 PA LA


1 PA ST OCh LA



1 PA OCh LA


MB PA LA


1 PA ST OCh LA


MB PA LA


1 PA ST









1 PA ST OCh LA


MB PA LA


MB PA LA


1 OCh LA


MB PA LA


1 OCh LA




MB PA LA

23



MB PA LA


MB PA





MB PA LA




MB PA


MB PA LA


MB PA LA



1 PA ST OCh


1 PA OCh


1 PA ST OCh LA







MB PA







24




MB PA LA



MB PA



MB PA LA


MB




MB PA LA




ANTICONVULSANTS





1


1



1






25



1



1


1



1


1


1


1










1



1


1


1


1


1

26



1


1


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1 PA ST



1 PA ST






1


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1




27



1


1









1 PA ST


1


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1











1


1


1

28



1



1


1



1


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1 PA ST


1 ST


1 PA ST







1 PA ST


1 PA ST



29




















MB PA








1 PA LA






MB PA


1




1

30






MB PA


MB PA


1


1



MB PA ST LA


MB PA


MB LA






1 PA ST










1




1

31





NARCOTIC ANALGESICS


1 PA ST


1 PA ST


1 PA ST


1 PA ST


1 PA ST





1


1 PA ST


1 PA ST


1


1


1


1



1 PA ST



MB

32



MB PA ST



1 PA ST


1 PA


1 PA ST




1 PA ST


1 PA ST


1 PA


1 PA ST


1 PA ST


1 PA ST














33






1 PA ST








1 PA ST





1 PA ST





1 PA ST


1 PA ST










MB



34



ACA PV


ACA PV




ACA PV


ACA PV



ACA PV









1



1



1


1




1




ACA PV


35





1


MB









1



1








1





MB LA







36




1



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1 PA ST


1 PA ST



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1


1

37



1 PA ST


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1


1


1


1


1


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1 ST



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MB


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1


1

38



1


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1


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1


1



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1


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1 ST


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1

39



1


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40



1 PA ST


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1

41



1 ST


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1

42



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1






1


1


1



1


1


1


1



1






1

43



1


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1 PA ST


1



1


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MB PA




1


1




1



1


44



1 ST


1


1


1



1 PA ST


1 PA ST


1 PA ST


1 PA ST




1 ST


1



1



1 ST


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45




1



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46



1




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1


1


1


1


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1




1


1


1


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1


1


1


1



47



1 ST



1



1




MB PA LA




1


MB PA LA



1


1




1



1




1




1

48



1



1


1



1




1


1


1










1


1



1



1


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49



1 PA LA






1


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1


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1


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1




50



1 ST



1


1


1


1



1


1



1

CARDIAC GLYCOSIDES


1


1



1

COAGULATION THERAPY


MB


MB LA

51



MB LA


MB LA


MB LA


MB LA




MB


1


MB LA






MB


MB LA



1 PA LA


1


52



MB LA



1


MB LA


MB LA


MB


1


1


1


1 PA LA


MB


MB


MB


MB



MB


1

53



1


MB


MB


MB


MB


MB


1


MB


MB


MB LA


MB LA


MB LA


1


MB LA


MB


MB


MB

54



MB LA



MB LA


MB LA


MB LA


MB LA


MB





MB LA


1 PA ST LA


1 LA


1 PA ST LA


MB LA


MB LA


MB LA


MB LA

55



MB


MB LA


MB LA


1


MB LA


1


1


MB LA


MB LA




1 ST





1









56



1


1


1


1


1


1




ACA PV









1




ACA PV




1 PA ST


1 PA ST


1 PA ST



57











1 PA ST


MB


1 ST

NITRATES


1


1



1







MB


1


1


1


1

58









1



1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA



1 PA ST LA




1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


MB PA LA


1 PA ST LA


1 PA ST LA



59




1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA

BURN THERAPY

















1






60




MB PA




THERAPY FOR ACNE









1















1


1




61







1






1






1




TOPICAL ANESTHETICS





1


1


1






62



1 ST


1 ST




1 ST








1


TOPICAL ANTIFUNGALS









1




1


1




63



1 PA ST















1


1





TOPICAL ANTIVIRALS













64




1









1












1 ST













65
























1












66



1


1


1


1


TOPICAL ENZYMES
















MB


MB



1




MB PA LA


1 PA LA

67





1 PA LA




1 ST LA




1 PA




MB PA LA


MB PA LA


1 PA LA









MB



MB





MB


68



1 PA



MB PA LA





MB PA LA


SMOKING DETERRENTS


ACA PV





ACA PV


ACA PV


ACA PV


ACA PV


ACA PV











69



1


1







1




1




sf dental gel 11 1














1


1


1

70



1


1

ENDOCRINEDIABETES

ADRENAL HORMONES







1


1


1


1


1




1


1



1




1


1


71




1



MB

ANTITHYROID AGENTS













1


1


1


1 PA ST



1



1


1


1


72





1


1

INSULIN THERAPY


1


1


1


1


1 ST


1


1 ST


1 ST


1 ST


1 ST


1 ST


1 ST

73



1 ST


1 ST


1 ST


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1 ST


1


1


1


1


1


1


1


1


1


1


1


1

74



1


1


1


1


1


1


1


1


1


1


1 PA ST


1


1


1


1


1


1 PA ST


75



MB PA LA




MB PA




1





MB PA LA



MB PA LA



1


1



1


MB PA LA


MB PA LA


MB PA LA






MB PA LA

76




MB PA LA


MB PA LA




1 PA LA


MB PA LA


1 PA ST LA



1 PA LA


MB


MB




MB PA







1 PA


1


MB PA LA


1

77



1













MB PA LA


MB PA LA




1 PA ST


1 PA ST


1 PA ST






1


1


1


78



1


1 PA ST


1 PA ST


1 PA ST


1 PA ST



1 PA ST


1 PA ST




1


1 PA ST


1 ST




1 PA ST



1


1




1

79



1 PA ST


1 PA ST


1 PA ST


1 PA ST


1 PA ST


1 PA ST



1 PA ST


1 PA ST

THYROID HORMONES


1


1


1



1


1


1


1

80


GASTROENTEROLOGY





1 PA ST







1



1








1


1










81



1


1


1


1





1






MB









1


1




1 PA ST LA


1 PA ST LA


ACA PV

82






1 PA




1



1


MB PA LA



ACA PV


ACA PV






1



1


1


MB PA LA



1

83



1


1


1


1 ST


1 PA ST


1


1 PA ST


1 PA




1


1




1 ST






1



ACA PV





84




ACA PV


ACA PV




ACA PV


1




1


1


1


1




1


1


MB PA LA


MB PA LA


1


1




85



1


1




1


ACA PV ST






1 ST



1 PA


1

ULCER THERAPY


1



1


1 ST


1




86



1


1





1


1


1




BIOTECHNOLOGY DRUGS


1 LA


1 LA


1 LA


1


1



MB


MB LA


1 PA ST

87



1 PA ST


1


1


1 LA


1 PA ST


1 PA ST


1 PA ST

GROWTH HORMONES


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA

INTERFERONS









88












MB PA ST LA


1 LA

















MB PA LA


1 PA LA


1 PA LA







89







1 PA ST OCh LA













1 PA ST OCh LA








INTERLEUKINS


1 PA LA


1 LA


MB PA LA



1 PA LA


MB LA

90




1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac



MB


1 Vac


1 Vac


1 Vac



1 Vac


1 Vac


MB


MB LA


MB LA

91



1 Vac


MB LA


1 Vac


1 Vac


1 Vac


MB PA


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac

92



1 Vac


MB


MB


MB LA


MB PA LA


MB LA


MB PA LA


MB PA LA


MB LA


1 Vac


1 Vac



1 Vac


1 Vac


1 Vac


MB LA

93



MB LA


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


MB LA


MB PA LA


1 PA



1 Vac


1 Vac


1 Vac


1 Vac


1 Vac

94



1 Vac


1 Vac



1 Vac


MB PA


1 Vac


1 Vac


1 PA


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


MB


1 Vac

95



1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


1 Vac


MB LA


MB LA


1 Vac


1 Vac


GOUT THERAPY






MB PA LA




96






1 PA ST LA




1



1 ST LA




1


1 PA ST LA



1 PA ST LA


MB PA LA


1 PA ST LA


MB PA LA


1 PA LA


1 PA LA


1 PA ST LA


1 PA ST LA


1 PA ST LA

97



1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA


1 PA ST LA




MB PA LA


1 PA ST LA

98



1 PA ST LA



1 PA ST LA





1 PA ST LA


1 PA ST


1 PA ST


MB PA LA


1 PA ST LA


1 PA ST LA




1 PA ST LA




ACA PV




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99



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103






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104




ACA PV


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ACA PV


ACA PV


ACA PV



ACA PV


105



ACA PV



ACA PV





ACA PV


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ACA PV



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ACA PV




ACA PV

106




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ACA PV


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ACA PV


ACA PV








ACA PV




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ACA PV






ACA PV




ACA PV


107



ACA PV


ACA PV


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ACA PV









ACA PV


ACA PV





ACA PV


ACA PV


ACA PV

108



ACA PV






ACA PV


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ACA PV


ACA PV


ACA PV


ACA PV



ACA PV



ACA PV


ACA PV


ACA PV


ACA PV


ACA PV


ACA PV

109



ACA PV



ACA PV




ACA PV


ACA PV





ACA PV




OXYTOCICS



OPHTHALMOLOGY

ANTIBIOTICS


1



1


1


1



1


110



1





1


1


1


1


1



1


1



1

ANTIVIRALS



BETA-BLOCKERS



1


1




1


1

111



1





1





1







MB PA LA




1 PA



MB PA LA


MB PA LA


1


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MB PA LA


MB PA LA


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112




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1



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1






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1



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113



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1


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1 ST


1



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1


1

114



1


1 ST


1 ST


1


1


1



1


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MB PA LA




1


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1

SULFONAMIDES


1


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SYMPATHOMIMETICS




1

115




1




1











1 PA ST




1


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1






1






116




1




1





1


1








1


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PULMONARY AGENTS


1


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117



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118



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1




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1 PA LA


119








1 PA LA


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120



1


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1


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121



1


1 PA LA


1 PA LA


1 PA LA


1 PA LA


1 PA LA




MB LA






UROLOGICALS



1



1 ST




1



1


122



1






1







1







1


1


1 PA



1


1







123



URINARY ANESTHETICS



ELECTROLYTES





1


1


1




1



MB


1


1



1


1


MB



MB


MB

124



MB



1


1



ACA PV


ACA PV


ACA PV


ACA PV





1



ACA PV


ACA PV


ACA PV


ACA PV


ACA PV


ACA PV


ACA PV


ACA PV

125

Index







AFLURIA QD 2021-22(6-35MO)(PF) 90













126










127






















128








104






129

















130















2022 (PF) 91 FLUMIST QUAD 2021-2022










131

































132















133





















134


















135















INSULIN 74









136










scop 81




137




116 promethegan 116





138














PACK) 59

139














140














141





051267 (07-01-2021)



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