plan php care complete fida-idd (plan medicare …...acuerdo con ellos para trabajar con nosotros y...

Usted puede encontrar información sobre el significado de los símbolos y las abreviaciones de esta tabla en las páginas 11 y 12. Si tiene alguna pregunta, por favor llame al Plan PHP Care Complete FIDA-IDD al 1-855-747-5483 y al 711 para los usuarios de TTY, de 8 a. m. a 8 p. m., los siete días de la semana. La llamada es gratuita. Para obtener más información, visite www.phpcares.org.

H9869_2019 Formulary Approved 1

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Plan PHP Care Complete FIDA-IDD (Plan Medicare-Medicaid) | Lista de

medicamentos cubiertos para 2019 (Formulario)

Introducción

Este documento se llama la Lista de medicamentos cubiertos (también llamada la Lista de medicamentos).

Le informa sobre cuáles de sus medicamentos de receta y medicamentos sin receta y artículos están

cubiertos por el Plan PHP Care Complete FIDA-IDD. La Lista de medicamentos también le notifica si hay

reglas especiales o restricciones en algunos de los medicamentos cubiertos por el Plan PHP Care

Complete FIDA-IDD. Términos clave y sus definiciones se encuentran en el último capítulo del Manual del

participante.

Actualizado en 03/2019

Tabla de Contenido

A. Renuncias de garantías .............................................................................................................................. 2

B. Preguntas frecuentes (FAQ) ....................................................................................................................... 3

B1. ¿Qué medicamentos de receta se encuentran en la Lista de medicamentos cubiertos?

(Para abreviar, llamamos “Lista de medicamentos” a la Lista de medicamentos cubiertos). ............ 3

B2. ¿La Lista de medicamentos cambia alguna vez? ................................................................................ 4

B3. ¿Qué sucede si hay un cambio en la Lista de medicamentos? ........................................................... 5

B4. ¿La cobertura de medicamentos tiene alguna restricción o límite o hay que hacer algo en

particular para obtener ciertos medicamentos? .................................................................................. 6

B5. ¿Cómo sabrá si el medicamento que usted quiere tiene limitaciones o si tiene que hacer

algo para obtenerlo? ........................................................................................................................... 6

B6. ¿Qué sucederá si cambiamos nuestras reglas sobre algunos medicamentos (por ejemplo,

autorización (aprobación) previa, límites de cantidad y/o restricciones de tratamiento

progresivo)? ........................................................................................................................................ 7

B7. ¿Cómo puede encontrar un medicamento en la Lista de medicamentos? .......................................... 7

B8. ¿Qué pasará si el medicamento que usted quiere tomar no está en la Lista de

medicamentos? ................................................................................................................................... 7

B9. ¿Qué pasará si usted es un Participante nuevo del Plan PHP Care Complete FIDA-IDD y

no puede encontrar su medicamento en la Lista o tiene problemas para obtener su

medicamento? ................................................................................................................................................ 8

http://www.phpcares.org/



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B10. ¿Puede pedir al plan que haga una excepción para cubrir su medicamento? .................................. 8

B11. ¿Cómo puede pedir una excepción? ................................................................................................. 9

B12. ¿Cuánto tiempo toma obtener una excepción? ................................................................................. 9

B13. ¿Qué son los medicamentos genéricos? ........................................................................................... 9

B14. ¿Qué son los medicamentos de venta libre (OTC)? .......................................................................... 9

B15. ¿El Plan PHP Care Complete FIDA-IDD cubre algún producto de venta libre que no sea

un medicamento? ................................................................................................................................ 9

B16. ¿Cuánto es su copago? ................................................................................................................... 10

B17. ¿Qué son los niveles de medicamentos? ........................................................................................ 10

C. Lista de medicamentos cubiertos ............................................................................................................. 10

D. Lista de medicamentos por enfermedad .................................................................................................. 11

E. Índice de medicamentos cubiertos ..........................................................................................................166

A. Renuncias de garantías

Ésta es una lista de medicamentos que los participantes pueden obtener en el Plan PHP Care Complete

FIDA-IDD.

❖ Partners Health Plan es un plan de cuidados administrados que tiene contratos con Medicare y

New York State Department of Health (Medicaid), para ofrecer beneficios a los Participantes a

través del programa piloto Fully Integrated Duals Advantage for individuals with Intellectual and

Developmental Disabilities (FIDA-IDD, programa para personas con discapacidades intelectuales y

del desarrollo que tienen Medicare y Medicaid).

❖ ATTENTION: If you speak a language other than English, language assistance services, free of

charge, are available to you. Call 41T1-855-747-5483 and 711 for TTY users, 8AM to 8PM, seven

days a week 41T. The call is free.

❖ Si usted habla español, se encuentran disponibles para usted servicios sin cargo de asistencia

con el idioma. Llame al 1-855-747-5483 y al 711 para los usuarios de TTY de 8:00 a. m. a

8:00 p. m., los siete días de la semana. La llamada es gratuita.

❖ Если Вы говорите на русском языке, Вам доступна бесплатная языковая поддержка.

Звоните по телефону 1-855-747-5483 и 711 для пользователей линии TTY/TDD с 08:00 до

20:00, без выходных. Звонок бесплатный.




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❖ 如果您說中文，您可以獲得免費的語言協助服務。請致電 1-855-747-5483，TTY 使用者請致電

711，服務時間為每週七天，上午 8 時至晚上 8 時。本電話為免付費電話。

❖ Usted puede pedir esta información en otros formatos, como letra grande, braille o audio de

manera gratuita. Llame al 1-855-747-5483 y al 711 para los usuarios de TTY, de 8 a. m. a

8 p. m., los siete días de la semana. La llamada es gratuita.

❖ Si quiere realizar una solicitud permanente o cambiarla para un idioma o formato preferido,

llame a Servicios al participante del Plan PHP Care Complete FIDA-IDD al 1-855-747-5483 y al

711 para los usuarios de TTY, de 8 a. m. a 8 p. m., los siete días de la semana. La llamada es

gratuita.

❖ El estado de New York creó un programa del ombudsman del Participante, llamado

Independent Consumer Advocacy Network (ICAN), para proporcionarle a los Participantes

asistencia gratuita, confidencial para los servicios que ofrece el Plan PHP Care Complete

FIDA-IDD. Para comunicarse con ICAN, llame, de manera gratuita, al 1-844-614-8800 (los

usuarios de TTY deben llamar al 711 y luego siga las indicaciones para marcar 844-614-8800)

o vaya a icannys.org.

B. Preguntas frecuentes (FAQ)

Encuentre aquí las respuestas a las preguntas que usted tenga sobre esta Lista de medicamentos

cubiertos. Usted puede leer todas las Preguntas frecuentes para saber más o buscar preguntas y

respuestas.

B1. ¿Qué medicamentos de receta se encuentran en la Lista de medicamentos cubiertos?

(Para abreviar, llamamos “Lista de medicamentos” a la Lista de medicamentos

cubiertos).

Los medicamentos de la Lista de medicamentos cubiertos que comienza en la página 12 son los

medicamentos cubiertos por el Plan PHP Care Complete FIDA-IDD. Estos medicamentos están

disponibles en las farmacias dentro de nuestra red. Una farmacia está en nuestra red si tenemos un

acuerdo con ellos para trabajar con nosotros y proporcionarle servicios a usted. Nos referimos a estas

farmacias como “farmacias de la red”.

• El Plan PHP Care Complete FIDA-IDD cubrirá todos los medicamentos de la Lista, si:

o su médico u otro proveedor dice que usted los necesita para mejorar su salud o para

seguir sano,

o el medicamento es médicamente necesario para su enfermedad, y




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o usted surte la receta en una farmacia de la red del Plan PHP Care Complete FIDA-

IDD.

• El Plan PHP Care Complete FIDA-IDD podría tener pasos adicionales para tener acceso a

ciertos tipos de medicamentos (lea la pregunta B4 de abajo). En algunos casos, es probable

que usted tenga que hacer algo antes de obtener un medicamento, por ejemplo, primero probar

otros medicamentos.

Usted puede también leer una lista actualizada de los medicamentos que cubrimos en nuestro sitio web en

www.phpcares.org o llame a Servicios al participante al 1-855-747-5483 y al 711 para los usuarios de TTY,

de 8 a. m. a 8 p. m., los siete días de la semana.

B2. ¿La Lista de medicamentos cambia alguna vez?

Sí. El Plan PHP Care Complete FIDA-IDD podría agregar o quitar medicamentos de la Lista de

medicamentos durante el año.

También podemos cambiar nuestras reglas sobre algunos medicamentos. Por ejemplo, podríamos:

• Decidir si exigir o no una aprobación previa para algún medicamento. (Aprobación previa

es el permiso del Plan PHP Care Complete FIDA-IDD o su Equipo interdisciplinario (IDT)

antes de que usted pueda obtener un medicamento).

• Aumentar o cambiar la cantidad de un medicamento que usted puede obtener (llamado

límite de cantidad).

• Agregar o cambiar restricciones de tratamiento progresivo de un medicamento. (Terapia

progresiva significa que usted podría tener que probar un medicamento antes que

cubramos otro medicamento).

Para obtener más información acerca de estas reglas para los medicamentos, lea la pregunta B4.

Si está tomando algún medicamento que estuvo cubierto al principio del año, por general no le quitamos o

cambiamos la cobertura de ese medicamento durante el resto del año, a menos que:

• un medicamento nuevo y más económico que es igual de eficiente que un medicamento

que se encuentra actualmente en la Lista de medicamentos llega a estar disponible, o

• nos damos cuenta de que un medicamento no es seguro, o

• un medicamento es eliminado del mercado.

Las preguntas B3 y B6 de abajo tienen más información sobre lo que sucederá cuando cambie la Lista de

medicamentos.

• Usted siempre puede leer la Lista de medicamentos actualizada del Plan PHP Care

Complete FIDA-IDD en internet, en www.phpcares.org.





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• También puede llamar a Servicios al participante para revisar la Lista de medicamentos

actual al 1-855-747-5483 y al 711 para usuarios de TTY, de 8 a. m. a 8 p. m., los siete días

de la semana.

B3. ¿Qué sucede si hay un cambio en la Lista de medicamentos?

Algunos cambios a la Lista de Medicamentos ocurren inmediatamente. Por ejemplo:

• Un medicamento genérico nuevo llega a estar disponible. A veces, un medicamento

nuevo y más económico que es igual de eficiente que un medicamento que se encuentra

actualmente en la Lista de medicamentos llega a estar disponible. Cuando eso ocurre,

podemos eliminar el medicamento actual, pero su costo para el medicamento nuevo será

el mismo. Cuando agregamos el medicamento genérico nuevo, también podemos decidir

mantener el medicamento actual en la lista, pero cambiar sus reglas o límites de cobertura.

o Es posible que no le notifiquemos cuando se haga este cambio, pero le mandaremos

información sobre el cambio específico o los cambios que hemos hecho.

o Usted o su proveedor pueden solicitar una excepción de estos cambios. Le mandaremos

una notificación con los pasos que puede tomar para solicitar una excepción. Por favor lea

la pregunta B10 para más información sobre excepciones.

• Un medicamento es eliminado del mercado. Si la Administración de alimentos y

medicamentos (FDA) dice que algún medicamento que usted toma no es seguro o el

fabricante del medicamento lo retira del mercado, lo quitaremos inmediatamente de la Lista

de medicamentos. Si usted está tomando el medicamento, también le enviaremos una carta y

lo llamaremos para avisarle que el medicamento que no es seguro fue quitado de la Lista de

medicamentos. Si está tomando un medicamento que no es seguro y le enviamos una carta

para informarle de esto, comuníquese con el proveedor que se lo recetó para que elija un

medicamento alternativo.

Podemos hacer otros cambios que pueden afectar las medicinas que usted toma. Podemos

notificarle por adelantado sobre esos otros cambios a la Lista de Medicamentos. Estos cambios pueden

ocurrir si:

• La FDA publica nuevas directrices o hay nuevos lineamientos clínicos sobre un medicamento.

• Agregamos un medicamento genérico que no es nuevo en el Mercado y

o Reemplazamos un medicamento de marca actualmente en la Lista de Medicamentos

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o Cambiamos las reglas de cobertura o los límites del medicamento de marca.

Cuando ocurren estos cambios, le notificaremos por lo menos 30 días antes de que hagamos el cambio a

la Lista de Medicamentos o cuando vaya a rellenar su medicamento. Esto le dará tiempo para hablar con

su médico u otro recetador. Ellos podrán ayudarle a decidir si hay algún otro medicamento similar en la




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Lista de Medicamentos que usted pueda tomar en su lugar o si tiene que pedir una excepción. Después

usted puede:

• Recibir un suministro de 30 días antes de que se haga el cambio a la Lista de

Medicamentos, o

• Solicitar una excepción de estos cambios. Para más información sobre las excepciones,

por favor lea la pregunta B10.

B4. ¿La cobertura de medicamentos tiene alguna restricción o límite o hay que hacer algo

en particular para obtener ciertos medicamentos?

Sí, algunos medicamentos tienen reglas de cobertura o tienen límites en la cantidad que usted puede

obtener. En algunos casos, usted o su médico u otro proveedor tendrán que hacer algo antes de poder

obtener el medicamento. Por ejemplo:

• Aprobación previa (o autorización previa): Para algunos medicamentos, usted o su

médico u otro proveedor debe obtener una aprobación del Plan PHP Care Complete FIDA-

IDD o su Equipo interdisciplinario (IDT) antes de surtir su receta. El Plan PHP Care

Complete FIDA-IDD podría no cubrir el medicamento si usted no consigue la aprobación.

• Límites de cantidad: A veces el Plan PHP Care Complete FIDA-IDD limita la cantidad de

un medicamento que usted puede obtener.

• Tratamiento progresivo: A veces el Plan PHP Care Complete FIDA-IDD exige que usted

siga un tratamiento progresivo. Esto significa que usted tendrá que probar los

medicamentos en un cierto orden para su enfermedad. Usted podría tener que probar un

medicamento antes de que cubramos otro medicamento. Si a su médico le parece que el

primer medicamento no funciona para usted, entonces cubriremos el segundo.

Usted puede verificar si su medicamento tiene algún requisito o límite adicional leyendo las tablas de la

página 12. Usted también puede obtener más información en nuestro sitio web en www.phpcares.org. En

nuestra página web encontrará documentos que explican nuestras restricciones de aprobación previa y

tratamiento progresivo. Usted también puede pedirnos que le enviemos una copia.

Usted también puede pedir una excepción a esos límites. Esto le dará tiempo para hablar con su médico u

otro proveedor médico. Ellos podrán ayudarle a decidir si hay algún otro medicamento similar en la Lista de

medicamentos que usted pueda tomar en su lugar o si tiene que pedir una excepción. Por favor lea las

preguntas B10-B12 para más información sobre las excepciones.

B5. ¿Cómo sabrá si el medicamento que usted quiere tiene limitaciones o si tiene que hacer

algo para obtenerlo?

La Lista de medicamentos cubiertos de la página 12 tiene una columna llamada "Medidas

necesarias, restricciones o límites de uso".




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B6. ¿Qué sucederá si cambiamos nuestras reglas sobre algunos medicamentos (por

ejemplo, autorización (aprobación) previa, límites de cantidad y/o restricciones de

tratamiento progresivo)?

En algunos casos, le avisaremos por adelantado si agregamos o cambiamos requisitos de aprobación

previa, límites de cantidad y/o restricciones de tratamiento progresivo a un medicamento. Para más

información sobre esta notificación por adelantado y situaciones cuando no le notificaremos por adelantado

cuando nuestras reglas sobre los medicamentos en la Lista de medicamentos cambian, por favor lea la

pregunta B3.

B7. ¿Cómo puede encontrar un medicamento en la Lista de medicamentos?

Hay dos maneras de encontrar un medicamento:

• Puede buscar por orden alfabético (si usted sabe cómo se escribe el nombre del

medicamento), o

• Puede buscar por enfermedad.

Para buscar por orden alfabético, vaya a la sección del Índice de medicamentos cubiertos en la página

166. Luego busque el nombre en la Lista de medicamentos.

Para buscar por enfermedad, busque la sección titulada “Lista de medicamentos por enfermedad” de la

página 12. Los medicamentos de esta sección están agrupados en categorías, de acuerdo al tipo de

enfermedades para las que se usan como tratamiento. Por ejemplo, si usted tiene una enfermedad del

corazón, usted debe buscar en la categoría Inhibidores de la enzima convertidora de angiotensina (ACE).

Ahí encontrará los medicamentos que tratan enfermedades del corazón.

B8. ¿Qué pasará si el medicamento que usted quiere tomar no está en la Lista de

medicamentos?

Si usted no encuentra su medicamento en la Lista de medicamentos, llame a Servicios al participante al 1-

855-747-5483 y al 711 para los usuarios de TTY, de 8 a. m. a 8 p. m., los siete días de la semana, y

pregunte por él. Si se entera que el Plan PHP Care Complete FIDA-IDD no cubrirá el medicamento, usted

puede hacer uno de los siguientes:

• Pida a Servicios al participante una lista de medicamentos similares al que quiera tomar.

Luego, muestre la lista a su médico u otro proveedor médico. Éste podrá recetarle un

medicamento de la Lista de medicamentos que sea similar al que usted quiere tomar. O,

• Usted también puede pedir al plan o a su Equipo interdisciplinario (IDT) que haga una

excepción para cubrir su medicamento. Por favor lea las preguntas B10-B12 para más

información sobre las excepciones.




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B9. ¿Qué pasará si usted es un Participante nuevo del Plan PHP Care Complete FIDA-IDD y

no puede encontrar su medicamento en la Lista o tiene problemas para obtener su

medicamento?

Podemos ayudarle. Debemos cubrir un suministro temporario de 30 días de su medicamento, cuando sea

necesario, durante los primeros 90 días que usted sea Participante del Plan PHP Care Complete FIDA-

IDD. Esto le dará tiempo para hablar con su médico u otro proveedor médico. Ellos podrán ayudarle a

decidir si hay algún otro medicamento similar en la Lista de medicamentos que usted pueda tomar en su

lugar o si tiene que pedir una excepción.

Si su receta es escrita por menos de los días indicados, le permitiremos múltiples suministros hasta un

máximo de 30 días de su medicamento.

Cubriremos un suministro de 30 días de su medicamento si:

• Usted está tomando algún medicamento que no esté en nuestra Lista de medicamentos, o

• Las reglas del plan de salud no le permiten obtener la cantidad recetada por su proveedor

médico, o

• El medicamento requiere aprobación previa del Plan PHP Care Complete FIDA-IDD o de su

Equipo interdisciplinario (IDT), o

• Usted toma algún medicamento que forme parte de una restricción de tratamiento progresivo.

Si usted está en una institución de cuidados intermedios u otra institución de cuidados a largo plazo, y

necesita un medicamento que no está en la Lista de Medicamentos o si no puede obtener el medicamento

que necesita, podemos ayudarle. Usted ha estado en el plan por más de 90 días, vive en una institución de

cuidados a largo plazo y necesita un suministro de inmediato:

• Le cubriremos un suministro de 31 días del medicamento que necesite (a menos que

tenga una receta para menos días), aunque sea o no un nuevo Participante del Plan PHP

Care Complete FIDA-IDD.

• Esto es adicional al suministro temporario durante los primeros 90 días de ser Participante

del Plan PHP Care Complete FIDA-IDD.

Si ha estado en el Plan PHP Care Complete FIDA-IDD durante más de 90 días y necesita cambiar su

nivel de cuidados, le cubriremos un suministro transitorio de los medicamentos de receta.

B10. ¿Puede pedir al plan que haga una excepción para cubrir su medicamento?

Sí. Usted puede pedirle al Plan PHP Care Complete FIDA-IDD o a su Equipo interdisciplinario (IDT) que haga

una excepción para cubrir su medicamento si éste no está en la Lista de medicamentos.

Usted también puede pedirle al Plan PHP Care Complete FIDA-IDD o a su IDT un cambio a las reglas de

su medicamento.




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• Por ejemplo, el Plan PHP Care Complete FIDA-IDD podría limitar la cantidad que

cubriremos de un medicamento. Si su medicamento tiene un límite, usted puede pedirnos

a nosotros o a su IDT que cambiemos el límite y que cubramos más.

• Otros ejemplos: Usted puede pedirnos a nosotros o a su IDT que quitemos las

restricciones de tratamiento progresivo o los requisitos de aprobación previa.

B11. ¿Cómo puede pedir una excepción?

Para pedir una excepción, llame a su Administrador de cuidados. Su Administrador de cuidados trabajará

con usted y su proveedor para ayudarle a pedir una excepción. Usted también puede leer el Capítulo 9,

Sección 6.3, página 193, del Manual del participante, para más información sobre excepciones.

B12. ¿Cuánto tiempo toma obtener una excepción?

Primero, el Plan PHP Care Complete FIDA-IDD o su Equipo interdisciplinario (IDT) deben recibir una

declaración de su proveedor médico apoyando su pedido de una excepción. Después de recibir la declaración,

le daremos una decisión sobre su pedido de excepción a más tardar en 72 horas.

Si usted o su proveedor médico piensan que su salud podría deteriorarse si tiene que esperar 72 horas

para obtener una decisión, entonces usted puede pedir una excepción acelerada. Ésta es una decisión

más rápida. Si su proveedor médico apoya su pedido, le daremos una decisión dentro de las 24 horas

después de recibir la declaración de apoyo de su proveedor médico.

B13. ¿Qué son los medicamentos genéricos?

Los medicamentos genéricos están hechos con los mismos ingredientes activos que los medicamentos de

marca. Generalmente cuestan menos que los medicamentos de marca y no tienen marcas tan conocidas.

Los medicamentos genéricos son aprobados por la Administración de alimentos y medicamentos (FDA).

El Plan PHP Care Complete FIDA-IDD cubre tanto medicamentos de marca como medicamentos

genéricos.

B14. ¿Qué son los medicamentos de venta libre (OTC)?

OTC quiere decir “medicamentos que se venden sin receta”. El Plan PHP Care Complete FIDA-IDD cubre

algunos medicamentos de venta libre cuando su proveedor escribe una receta para ellos.

Usted puede leer la Lista de medicamentos del Plan PHP Care Complete FIDA-IDD para ver qué

medicamentos de venta libre están cubiertos.

B15. ¿El Plan PHP Care Complete FIDA-IDD cubre algún producto de venta libre que no sea

un medicamento?

El Plan PHP Care Complete FIDA-IDD cubre algunos productos de venta libre que no son medicamentos

cuando su proveedor escribe una receta para ellos.




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Ejemplos de productos sin receta, que no son medicamentos, incluyen los comprimidos orales de Bufferin

Extra-Strength y las cremas tópicas de hidrocortisona.

Usted puede leer la Lista de medicamentos del Plan PHP Care Complete FIDA-IDD para ver qué productos

de venta libre, que no son medicamentos, están cubiertos.

B16. ¿Cuánto es su copago?

Como Participante del Plan PHP Care Complete FIDA-IDD, usted no tiene copagos por medicamentos de

receta y de venta libre (OTC), siempre y cuando siga las reglas del Plan PHP Care Complete FIDA-IDD.

B17. ¿Qué son los niveles de medicamentos?

Los niveles son grupos de medicamentos de nuestra Lista de medicamentos. Ningún nivel tiene copago.

• Los medicamentos de Nivel 1 son medicamentos genéricos que están cubiertos por

Medicare Parte D.

• Los medicamentos de Nivel 2 son medicamentos de marca que están cubiertos por

Medicare Parte D.

• Los medicamentos de nivel 3 son medicamentos cubiertos por Medicare y medicamentos

sin receta cubiertos por Medicaid (tanto genéricos como de marca).

C. Lista de medicamentos cubiertos

La siguiente lista de medicamentos cubiertos le da información sobre los medicamentos cubiertos por el

Plan PHP Care Complete FIDA-IDD. Si usted tiene problemas para encontrar su medicamento en la lista,

lea el Índice de medicamentos cubiertos que comienza en la página 166. El índice alfabético nombra todos los medicamentos cubiertos por el Plan PHP Care Complete FIDA-IDD.

La primera columna de la tabla tiene el nombre del medicamento. Los medicamentos de marca están

escritos en mayúsculas (por ejemplo, PAXIL o LAMISIL) y los medicamentos genéricos están escritos en

cursivas minúsculas (por ejemplo, ibuprofeno).

La información de la columna titulada “Medidas necesarias, restricciones o límites de uso”, le indica si el

Plan PHP Care Complete FIDA-IDD tiene alguna regla para cubrir su medicamento.

Nota: El símbolo DP (programa dual) junto a un medicamento significa que el medicamento no es un

“medicamento de Parte D”. Estos medicamentos tienen reglas diferentes para las apelaciones.

• Una apelación es una manera formal de pedirnos que revisemos alguna decisión de

cobertura y que la cambiemos, si le parece que hemos cometido un error. Por ejemplo, el

Plan PHP Care Complete FIDA-IDD o su Equipo interdisciplinario (IDT) podría decidir que

un medicamento que usted quiere ya no está cubierto por Medicare o Medicaid.




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• Si usted, su médico u otro proveedor no están de acuerdo con nuestra decisión, usted

puede apelar. Para pedir instrucciones sobre cómo apelar:

o Llame a Servicios al participante al 1-855-747-5483 y al 711 para los usuarios de TTY,

de 8 a. m. a 8 p. m., los siete días de la semana.

o Comuníquese con el Independent Consumer Advocacy Network (ICAN) llamando sin

costo al 1-844-614-8800 (los usuarios de TTY deben llamar al 711 y luego seguir las

indicaciones para llamar al 844-614-8800) o por internet en icannys.org.

o Lea el Capítulo 9 del Manual del participante para aprender como apelar una decisión.

D. Lista de medicamentos por enfermedad

Los medicamentos de esta sección están agrupados en categorías de acuerdo con el tipo de enfermedad

para la que se usan como tratamiento. Por ejemplo, si usted tiene una enfermedad del corazón, usted debe

buscar en la categoría la enzima convertidora de angiotensina (ACE). Ahí encontrará los medicamentos

que tratan enfermedades del corazón.

Estos son los significados de los códigos usados en la columna “Pasos necesarios,

restricciones o límites de uso”:

(g) = Sólo se cubre la versión genérica de este medicamento. La versión de marca no está

cubierta.

M = La versión de marca de este medicamento está en Nivel 3. La versión genérica está en

el Nivel 1.

PA = Autorización previa (aprobación): Usted debe tener aprobación del plan o su Equipo

interdisciplinario (IDT) antes de poder obtener este medicamento.

ST = Terapia progresiva: Usted debe probar otro medicamento antes de poder obtener éste.


12

2019 3 Tier MMP – Partners

Document: 2019 Formulary

Formulary ID: 19410

Updated 02/2019

Effective Date: 03/01/2019

Name of Drug Drug Tier Necessary actions, restrictions, or

limits on use

ANALGESICS

ANALGESICS, OTHER

8HR MUSCLE ACHE-PAIN ER 650 MG 650

MG

3 DP

ACEPHEN 120 MG SUPPOSITORY 120 MG 3 DP

ACEPHEN 120 MG SUPPOSITORY OUTER

120 MG

3 DP



325 MG

3 DP



650 MG

3 DP

acetaminophen 120 mg suppos 120 mg 3 DP

acetaminophen 120 mg suppos outer 120 mg 3 DP

acetaminophen 160 mg/5 ml liq a/f,s/f,cherry 160

mg/5 ml

3 DP

acetaminophen 325 mg tablet 325 mg 3 DP

acetaminophen 325 mg tablet u-d,25x30,uncoated

325 mg

3 DP

acetaminophen 325 mg/10.15 ml outer 325

mg/10.15 ml

3 DP

acetaminophen 500 mg caplet caplet,ex-strength

500 mg

3 DP

acetaminophen 500 mg tablet 500 mg 3 DP

acetaminophen 500 mg tablet asa-free,ex-str 500

mg

3 DP

acetaminophen 500 mg tablet extra strength 500

mg

3 DP

acetaminophen 650 mg suppos 650 mg 3 DP

acetaminophen 650 mg suppos outer 650 mg 3 DP

13


limits on use

acetaminophen 650 mg/20.3 ml outer 650 mg/20.3

ml

3 DP

acetaminophen 80 mg tab chew fruit flavored 80

mg

3 DP

acetaminophen er 650 mg tablet outer 650 mg 3 DP

acetaminophen-codeine oral solution 120 mg-12

mg /5 ml (5 ml), 120-12 mg/5 ml, 300 mg-30 mg

/12.5 ml

1

acetaminophen-codeine oral tablet 300-15 mg,

300-30 mg, 300-60 mg

1

ARTHRITIS PAIN ER 650 MG CAPLT 8 HOUR,

CAPLET 650 MG

3 DP

ARTHRITIS PAIN ER 650 MG CAPLT CAPLET

650 MG

3 DP

ARTHRITIS PAIN ER 650 MG CAPLT

CAPLET, 8 HOUR 650 MG

3 DP

ARTHRITIS PAIN RELIEF ER 650 MG

CAPLET CAPLET 650 MG

3 DP

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

mg

1 PA

butalbital compound w/codeine oral capsule 30-

50-325-40 mg

1 PA; MO

butalbital-acetaminop-caf-cod oral capsule 50-

325-40-30 mg

1 PA

butalbital-acetaminophen oral tablet 50-325 mg 1 PA

butalbital-acetaminophen-caff oral capsule 50-

325-40 mg

1 PA

butalbital-acetaminophen-caff oral tablet 50-325-

40 mg

1 PA

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

mg

1 PA

carisoprodol-asa-codeine oral tablet 200-325-16

mg

1 PA

carisoprodol-aspirin oral tablet 200-325 mg 1 PA

CHILD PAIN-FEVER 160 MG/5 ML 160 MG/5

ML

3 DP

14


limits on use

CHILD PAIN-FEVER 160 MG/5 ML 160 MG/5

ML

3 DP

CHILD PAIN-FEVER 160 MG/5 ML A/F 160

MG/5 ML

3 DP

CHILD PAIN-FEVER 80 MG TAB CHW 80 MG 3 DP

CHILDREN'S MAPAP 80 MG RAPID 80 MG 3 DP

CHILDREN'S SILAPAP ELIXIR 160 MG/5 ML 3 DP

CHILD'S PAIN RELIEVER RAPID TB RAPID

TAB'S 80 MG

3 DP

CHLD ACETAMINOPHEN 160 MG/5 ML A/F,

GLUTEN/F, GRAPE 160 MG/5 ML

3 DP

CHLD ACETAMINOPHEN 160 MG/5 ML

A/F,GLUTEN/F,CHERRY 160 MG/5 ML

3 DP


INNER 160 MG/5 ML (5 ML)

3 DP


OUTER 160 MG/5 ML (5 ML)

3 DP

codeine-butalbital-asa-caff oral capsule 30-50-

325-40 mg

1 PA

FEVERALL 120 MG SUPPOSITORY

CHILDRENS, OUTER 120 MG

3 DP

FEVERALL 120 MG SUPPOSITORY

CHILDREN'S, OUTER 120 MG

3 DP

FEVERALL 325 MG SUPPOSITORY JUNIOR

STR, OUTER 325 MG

3 DP

FEVERALL 650 MG SUPPOSITORY ADULT,

OUTER 650 MG

3 DP

FEVERALL 80 MG SUPPOSITORY INFANT'S,

OUTER 80 MG

3 DP

FEVERALL RECTAL SUPPOSITORY 325 MG,

650 MG

3

GS ARTHRITIS PAIN ER 650 MG CAPLET 650

MG

3 DP

GS INFANT PAIN-FEVER 160 MG/5 CHERRY,

DYE-FREE 160 MG/5 ML

3 DP

GS PAIN RELIEF 500 MG CAPLET 500 MG 3 DP

GS PAIN RELIEF 500 MG TABLET 500 MG 3 DP

15


limits on use

HM ARTHRITIS PAIN ER 650 MG CAPLET, 8

HOUR 650 MG

3 DP

HM CHLD PAIN-FEVER 160 MG/5 ML A/F,

DYE-FREE 160 MG/5 ML

3 DP

HM CHLD PAIN-FEVER 160 MG/5 ML

GLUTEN-F,A/F,ASA/F 160 MG/5 ML

3 DP

HM INFANT PAIN-FEVER 160 MG/5

A/F,GRAPE,W/SYRINGE 160 MG/5 ML

3 DP

HM PAIN RELIEF 500 MG CAPLET 500 MG 3 DP

HM PAIN RELIEF 500 MG CAPLET CAPLET,

EX-STRENGTH 500 MG

3 DP

HM PAIN RELIEF 500 MG TABLET EX-STR,

GLUTEN-FREE 500 MG

3 DP

HM PAIN RELIEVER 325 MG TABLET

REGULAR STRENGTH 325 MG

3 DP

hydrocodone-acetaminophen oral tablet 10-325

mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg

1

hydrocodone-ibuprofen oral tablet 10-200 mg,

7.5-200 mg

1

IBU ORAL TABLET 600 MG, 800 MG 1 MO

ibuprofen-oxycodone oral tablet 400-5 mg 1

INFANT PAIN-FEVER 160 MG/5 ML 160 MG/5

ML

3 DP

MAPAP 160 MG/5 ML LIQUID 160 MG/5 ML 3 DP

MAPAP 160 MG/5 ML SUSPENSION 160 MG/5

ML

3 DP

MAPAP 325 MG TABLET 325 MG 3 DP

MAPAP 325 MG TABLET BOXED 325 MG 3 DP

MAPAP 325 MG TABLET REGULAR

STRENGTH 325 MG

3 DP

MAPAP 325 MG TABLET U-D 325 MG 3 DP

MAPAP 500 MG CAPLET CAPLET 500 MG 3 DP

MAPAP 500 MG CAPLET CAPLET,BOXED

500 MG

3 DP

MAPAP 500 MG CAPSULE 500 MG 3 DP

MAPAP 500 MG GELCAP GELCAP 500 MG 3 DP

16


limits on use

MAPAP 500 MG TABLET 500 MG 3 DP

MAPAP 500 MG TABLET BOXED 500 MG 3 DP

MAPAP 500 MG TABLET U-D 500 MG 3 DP

MAPAP 80 MG TABLET CHEW 80 MG 3 DP

MAPAP ARTHRITIS ER 650 MG CPLT 650 MG 3 DP

oxycodone-acetaminophen oral tablet 10-325 mg,

2.5-325 mg, 5-325 mg, 7.5-325 mg

1

oxycodone-aspirin oral tablet 4.8355-325 mg 1

PAIN & FEVER 325 MG TABLET 325 MG 3 DP

PAIN & FEVER 500 MG CAPLET CAPLET 500

MG

3 DP

PAIN & FEVER 500 MG CAPLET CAPTABS

500 MG

3 DP

PAIN & FEVER 500 MG TABLET EXTRA

STRENGTH 500 MG

3 DP

PAIN & FEVER 500 MG TABLET WITHOUT

ASPIRIN 500 MG

3 DP

PAIN RELIEF 500 MG CAPLET CAPLET, EX-

STRENGTH 500 MG

3 DP

PAIN RELIEF 500 MG CAPLET CAPLET,EX-

STRENGTH 500 MG

3 DP

PAIN RELIEF 500 MG CAPLET EXTRA STR,

CAPLET 500 MG

3 DP

PAIN RELIEF 500 MG TABLET EX-

STRENGTH 500 MG

3 DP

PAIN RELIEF 500 MG TABLET EXTRA

STRENGTH 500 MG

3 DP

PAIN RELIEF ER 650 MG CAPLET

ARTHRITIS PAIN 650 MG

3 DP

PAIN RELIEF ER 650 MG CAPLET CAPLET, 8

HOUR 650 MG

3 DP

PAIN RELIEF ER 650 MG CAPLET CAPLET,

ARTHRITIS 650 MG

3 DP

PAIN RELIEVER 325 MG TABLET REGULAR

STRENGTH 325 MG

3 DP

PAIN RELIEVER 500 MG CAPLET CAPLET,

EX-STRENGTH 500 MG

3 DP

17


limits on use

PAIN RELIEVER 500 MG CAPLET CAPLET,

EX-STRENGTH 500 MG

3 DP

PAIN RELIEVER 500 MG CAPLET CAPLET,X-

STRENGTH 500 MG

3 DP

PAIN RELIEVER 500 MG CAPLET EX-STR,

CAPLET 500 MG

3 DP

PAIN RELIEVER 500 MG TABLET 500 MG 3 DP

PAIN RELIEVER 500 MG TABLET EX-

STR,EASY TAB 500 MG

3 DP

pentazocine-naloxone oral tablet 50-0.5 mg 1 PA

PHARBETOL 325 MG TABLET REG

STRENGTH, BULK 325 MG

3 DP

PHARBETOL 325 MG TABLET REGULAR

STRENGTH 325 MG

3 DP

qc acetaminophen 8-hr 650 mg 650 mg 3 DP

QC ARTHRITIS PAIN ER 650 MG CAPLET 650

MG

3 DP

QC CHILD PAIN RLF 160 MG/5 ML 160 MG/5

ML

3 DP

QC INFNT PAIN RLF 160 MG/5 ML 160 MG/5

ML

3 DP

QC NON-ASPIRIN 500 MG CAPLET XTRA

STRENGTH,CAPLET 500 MG

3 DP

QC NON-ASPIRIN 500 MG GELCAP GELCAP,

EX-STR 500 MG

3 DP

QC NON-ASPIRIN PAIN RELIEF TB EXTRA

STRENGTH 500 MG

3 DP

SB EX-STRENGTH NON-ASPIRIN TAB

SAFETY SEALED 500 MG

3 DP

SB NON-ASPIRIN 325 MG TABLET

REGULAR STR 325 MG

3 DP

SB NON-ASPIRIN 325 MG TABLET


3 DP

SB NON-ASPIRIN 500 MG CAPLET CAPLET

500 MG

3 DP

SB PAIN RELIEVER 500 MG CAPLET EXTRA-

STR,NON-ASA 500 MG

3 DP

18


limits on use

SB PAIN RELIEVER 500 MG GELCAP EX-

STRENGTH, GELCAP 500 MG

3 DP

SM 8 HOUR PAIN RELIEF 650 MG CAPLET

650 MG

3 DP

SM ARTHRITIS PAIN ER 650 MG CAPLET 650

MG

3 DP

SM CHLD PAIN-FEVER 160 MG/5 ML A/F,

ASA/F, GLUTEN-F 160 MG/5 ML

3 DP

SM PAIN RELIEVER 500 MG CAPLET

CAPLET, EXTRA STR 500 MG

3 DP

SM PAIN RELIEVER 500 MG CAPLET

CAPLET, EXTRA STR 500 MG

3 DP

SM PAIN RELIEVER 500 MG GELCAP

GELCAP,EX STRENGTH 500 MG

3 DP

SM PAIN RELIEVER 500 MG TABLET EX-

STR, GLUTEN-FREE 500 MG

3 DP

SM PAIN RELIEVER 500 MG TABLET EXTRA

STRENGTH 500 MG

3 DP

TACTINAL 325 MG TABLET 325 MG 3 DP

TACTINAL 500 MG CAPLET CAPLET,X-

STRENGTH 500 MG

3 DP

TACTINAL 500 MG TABLET EXTRA-

STRENGTH 500 MG

3 DP

tramadol-acetaminophen oral tablet 37.5-325 mg 1

TRI-BUFFERED ASPIRIN 325 MG BOXED 325

MG

3 DP

NONSTEROIDAL ANTI-INFLAMMATORY DRUGS

aspirin 300 mg suppository 300 mg 3 DP

aspirin 325 mg tablet 325 mg 3 DP

aspirin 325 mg tablet coated 325 mg 3 DP

aspirin 325 mg tablet regular strength 325 mg 3 DP

aspirin 600 mg suppository 600 mg 3 DP

aspirin ec 325 mg tablet 325 mg 3 DP

aspirin ec 325 mg tablet orange 325 mg 3 DP

aspirin ec 325 mg tablet regular strength 325 mg 3 DP

19


limits on use

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

50 mg

1 MO

CHILD IBUPROFEN 100 MG/5 ML 100 MG/5

ML

3 DP

CHILDREN IBUPROFEN 100 MG/5 ML 100

MG/5 ML

3 DP

CHILDREN IBUPROFEN 100 MG/5 ML A/F

100 MG/5 ML

3 DP

CHILDREN IBUPROFEN 100 MG/5 ML A/F,

D/F 100 MG/5 ML

3 DP


GLUTEN/F, BERRY 100 MG/5 ML

3 DP


GLUTEN/F, GRAPE 100 MG/5 ML

3 DP


GRAPE 100 MG/5 ML

3 DP

CHILDREN IBUPROFEN 100 MG/5 ML

A/F,BUBBLE GUM 100 MG/5 ML

3 DP


A/F,GLUTEN/F,BUBBLE 100 MG/5 ML

3 DP


BERRY FLAVOR 100 MG/5 ML

3 DP

diclofenac potassium oral tablet 50 mg 1

diclofenac sodium oral tablet extended release 24

hr 100 mg

1

diclofenac sodium oral tablet,delayed release

(dr/ec) 25 mg, 50 mg, 75 mg

1

DICLOZOR TOPICAL KIT 1 % 1

diflunisal oral tablet 500 mg 1

ECPIRIN EC 325 MG TABLET 325 MG 3 DP

etodolac oral capsule 200 mg, 300 mg 1 MO

etodolac oral tablet 400 mg, 500 mg 1 MO

etodolac oral tablet extended release 24 hr 400

mg, 500 mg, 600 mg

1 MO

flurbiprofen oral tablet 100 mg, 50 mg 1

gs aspirin 325 mg tablet 325 mg 3 DP

20


limits on use

GS CHILD IBUPROFEN 100 MG/5 ML

D/F,A/F,BERRY FLAVOR 100 MG/5 ML

3 DP

gs ibuprofen 200 mg caplet 200 mg 3 DP

gs ibuprofen 200 mg tablet 200 mg 3 DP

hm aspirin 325 mg tablet 325 mg 3 DP

hm aspirin 325 mg tablet adult, gluten-free 325 mg 3 DP

hm aspirin ec 325 mg tablet reg strength 325 mg 3 DP

HM CHILD IBUPROFEN 100 MG/5 ML 100

MG/5 ML

3 DP

HM CHILD IBUPROFEN 100 MG/5 ML A/F,

BERRY 100 MG/5 ML

3 DP


BUBBLE GUM 100 MG/5 ML

3 DP


GRAPE 100 MG/5 ML

3 DP

hm ibuprofen 200 mg caplet caplet 200 mg 3 DP

hm ibuprofen 200 mg capsule liquid filled sftgel

200 mg

3 DP

hm ibuprofen 200 mg tablet coated,gluten-free 200

mg

3 DP

HM IBUPROFEN IB 200 MG CAPLET

COATED, GLUTEN-FREE 200 MG

3 DP

HM IBUPROFEN IB 200 MG TABLET

COATED. GLUTEN-FREE 200 MG

3 DP

hydrocodone-ibuprofen oral tablet 5-200 mg 1

IBU-200 200 MG TABLET 200 MG 3 DP

ibuprofen 200 mg caplet caplet 200 mg 3 DP

ibuprofen 200 mg caplet caplet, coated 200 mg 3 DP

ibuprofen 200 mg caplet coated caplet 200 mg 3 DP

ibuprofen 200 mg softgel softgel 200 mg 3 DP

ibuprofen 200 mg tablet 200 mg 3 DP

ibuprofen 200 mg tablet coated 200 mg 3 DP

ibuprofen 200 mg tablet coated caplet 200 mg 3 DP

ibuprofen 200 mg/10 ml susp 100's, u-d cups (otc)

100 mg/5 ml

3 MO; DP

21


limits on use

ibuprofen 200 mg/10 ml susp 30's, u-d cups (otc)

100 mg/5 ml

3 MO; DP

ibuprofen 200 mg/10 ml susp u-d (otc) 100 mg/5

ml

3 MO; DP

ibuprofen oral suspension 100 mg/5 ml 1 MO

ibuprofen oral tablet 400 mg, 600 mg, 800 mg 1 MO

indomethacin oral capsule 25 mg, 50 mg 1 PA

indomethacin oral capsule, extended release 75

mg

1 PA

ketorolac oral tablet 10 mg 1 PA; QL (20 EA per 30 days)

meclofenamate oral capsule 100 mg, 50 mg 1

meloxicam oral tablet 15 mg, 7.5 mg 1 MO

nabumetone oral tablet 500 mg, 750 mg 1

naproxen oral suspension 125 mg/5 ml 1 MO

naproxen oral tablet 250 mg, 375 mg, 500 mg 1 MO

naproxen oral tablet,delayed release (dr/ec) 375

mg, 500 mg

1 MO

naproxen sodium oral tablet 275 mg, 550 mg 1 MO

piroxicam oral capsule 10 mg, 20 mg 1

PROVIL 200 MG TABLET 200 MG 3 DP

qc aspirin 325 mg tablet 325 mg 3 DP

QC CHILD IBUPROFEN 100 MG/5 ML A/F,

BUBBLE GUM 100 MG/5 ML

3 DP

qc ibuprofen 100 mg/5 ml susp children's (otc) 100

mg/5 ml

3 MO; DP

sb aspirin 325 mg tablet 325 mg 3 DP

sb aspirin 325 mg tablet na/f, caffeine-free 325 mg 3 DP

sb ibuprofen 200 mg caplet caplet 200 mg 3 DP

sb ibuprofen 200 mg tablet 200 mg 3 DP

sb ibuprofen 200 mg tablet safety sealed 200 mg 3 DP

sm aspirin 325 mg tablet 325 mg 3 DP

sm ibuprofen 100 mg/5 ml susp (otc) 100 mg/5 ml 3 MO; DP

sm ibuprofen 100 mg/5 ml susp a/f (otc) 100 mg/5

ml

3 MO; DP

22


limits on use

sm ibuprofen 100 mg/5 ml susp children's (otc)

100 mg/5 ml

3 MO; DP

sm ibuprofen 200 mg caplet caplet 200 mg 3 DP

sm ibuprofen 200 mg tablet 200 mg 3 DP

SM IBUPROFEN IB 200 MG CAPLET CAPLET

200 MG

3 DP

SM IBUPROFEN IB 200 MG CAPLET CAPLET,

GLUTEN-FREE 200 MG

3 DP

sulindac oral tablet 150 mg, 200 mg 1

OPIOID ANALGESICS, LONG-ACTING

buprenorphine transdermal patch weekly 10

mcg/hour, 15 mcg/hour, 20 mcg/hour, 5 mcg/hour,

7.5 mcg/hour

1 QL (4 EA per 28 days)

fentanyl transdermal patch 72 hour 100 mcg/hr,

12 mcg/hr, 25 mcg/hr, 37.5 mcg/hour, 50 mcg/hr,

62.5 mcg/hour, 75 mcg/hr, 87.5 mcg/hour


methadone oral solution 10 mg/5 ml 1 QL (1200 ML per 30 days)

methadone oral solution 5 mg/5 ml 1 QL (2400 ML per 30 days)

methadone oral tablet 10 mg 1 QL (240 EA per 30 days)

methadone oral tablet 5 mg 1 QL (180 EA per 30 days)

morphine oral tablet extended release 100 mg, 15

mg, 200 mg, 30 mg, 60 mg


oxycodone oral tablet,oral only,ext.rel.12 hr 10

mg, 15 mg, 20 mg, 30 mg, 40 mg, 60 mg, 80 mg

1 PA

OPIOID ANALGESICS, SHORT-ACTING

butorphanol tartrate nasal spray,non-aerosol 10

mg/ml

1 QL (5 ML per 30 days)

duramorph (pf) injection solution 0.5 mg/ml, 1

mg/ml

1 B/D

fentanyl citrate buccal lozenge on a handle 1,200

mcg, 1,600 mcg, 200 mcg, 400 mcg, 600 mcg, 800

mcg

1 PA; QL (120 EA per 30 days)

hydromorphone (pf) injection solution 1 mg/ml, 10

(mg/ml) (5 ml), 10 mg/ml, 4 mg/ml

1

hydromorphone injection syringe 2 mg/ml 1

hydromorphone oral tablet 2 mg, 4 mg, 8 mg 1 QL (120 EA per 30 days)

23


limits on use

LAZANDA NASAL SPRAY,NON-AEROSOL

100 MCG/SPRAY


LAZANDA NASAL SPRAY,NON-AEROSOL

300 MCG/SPRAY, 400 MCG/SPRAY


meperidine oral solution 50 mg/5 ml 1 PA; QL (900 ML per 30 days)

meperidine oral tablet 100 mg, 50 mg 1 PA; QL (180 EA per 30 days)

morphine oral tablet 15 mg, 30 mg 1 QL (120 EA per 30 days)

nalbuphine injection solution 10 mg/ml 1 B/D

oxycodone oral solution 5 mg/5 ml 1 QL (5400 ML per 30 days)

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

mg, 5 mg


tramadol oral tablet 50 mg 1 QL (240 EA per 30 days)

ANESTHETICS

LOCAL ANESTHETICS

ANODYNE LPT TOPICAL KIT 2.5-2.5 % 1

dermacinrx empricaine topical kit 2.5-2.5 % 1

diclofenac sodium topical gel 1 % 1 MO

LEVA SET TOPICAL KIT 2.5-2.5 % 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

mg/ml)

1

lidocaine topical adhesive patch,medicated 5 % 1 PA; QL (90 EA per 30 days)

lidocaine topical ointment 5 % 1

lidocaine-prilocaine topical cream 2.5-2.5 % 1

lidocaine-prilocaine topical kit 2.5-2.5 % 1

LIDOPAC TOPICAL KIT 5 % 1

lidopril topical kit 2.5-2.5 % 1

lidopril xr topical kit 2.5-2.5 % 1

LIDO-PRILO CAINE PACK TOPICAL KIT 2.5-

2.5 %

1

24


limits on use

liprozonepak topical kit 2.5-2.5 % 1

livixil pak topical kit 2.5-2.5 % 1

MEDOLOR PAK TOPICAL KIT 2.5-2.5 % 1

prilolid topical kit 2.5-2.5 % 1

ZTLIDO TOPICAL ADHESIVE

PATCH,MEDICATED 1.8 %

2 PA

ANTI-ADDICTION/ SUBSTANCE ABUSE TREATMENT AGENTS

ALCOHOL DETERRENTS/ ANTI-CRAVING

acamprosate oral tablet,delayed release (dr/ec)

333 mg

1 MO

disulfiram oral tablet 250 mg, 500 mg 1 MO

OPIOID DEPENDENCE TREATMENTS

buprenorphine hcl sublingual tablet 2 mg, 8 mg 1

buprenorphine-naloxone sublingual tablet 2-0.5

mg, 8-2 mg

1 MO

LUCEMYRA ORAL TABLET 0.18 MG 2 PA; QL (224 EA per 14 days)

naltrexone oral tablet 50 mg 1

OPIOID REVERSAL AGENTS

naloxone injection solution 0.4 mg/ml 1

naloxone injection syringe 0.4 mg/ml, 1 mg/ml 1

NARCAN NASAL SPRAY,NON-AEROSOL 4

MG/ACTUATION

2

SMOKING CESSATION AGENTS

bupropion hcl (smoking deter) oral tablet extended

release 12 hr 150 mg

1

CHANTIX CONTINUING MONTH BOX ORAL

TABLET 1 MG


CHANTIX ORAL TABLET 0.5 MG, 1 MG 2 QL (336 EA per 365 days)

CHANTIX STARTING MONTH BOX ORAL

TABLETS,DOSE PACK 0.5 MG (11)- 1 MG (42)


hm nicotine 14 mg/24hr patch step 2 (otc) 14

mg/24 hr

3 DP

hm nicotine 2 mg chewing gum mint 2 mg 3 DP

hm nicotine 2 mg lozenge mint, 3 quittube 2 mg 3 DP

25


limits on use

hm nicotine 21 mg/24hr patch step 1 (otc) 21

mg/24 hr

3 DP

hm nicotine 7 mg/24hr patch step 3 (otc) 7 mg/24

hr

3 DP

NICODERM CQ 14 MG/24HR PATCH 14

MG/24 HR

3 DP

NICODERM CQ 14 MG/24HR PATCH OUTER

14 MG/24 HR

3 DP

NICODERM CQ 21 MG/24HR PATCH 21

MG/24 HR

3 DP

NICODERM CQ 21 MG/24HR PATCH CLEAR

PATCH 21 MG/24 HR

3 DP

NICODERM CQ 21 MG/24HR PATCH OUTER

21 MG/24 HR

3 DP

NICODERM CQ 7 MG/24HR PATCH 7 MG/24

HR

3 DP

NICORELIEF 2 MG GUM 2 MG 3 DP

NICORELIEF 4 MG GUM 4 MG 3 DP

NICORETTE 2 MG CHEWING GUM

CINNAMON SURGE 2 MG

3 DP

NICORETTE 2 MG CHEWING GUM FRESH

MINT 2 MG

3 DP

NICORETTE 2 MG CHEWING GUM FRUIT

CHILL 2 MG

3 DP

NICORETTE 2 MG CHEWING GUM MINT 2

MG

3 DP


ORIGINAL FLAVOR 2 MG

3 DP

NICORETTE 2 MG CHEWING GUM STARTER

KIT 2 MG

3 DP

NICORETTE 2 MG CHEWING GUM WHITE

ICE MINT 2 MG

3 DP

NICORETTE 2 MG LOZENGE 2 MG 3 DP

NICORETTE 2 MG LOZENGE CHERRY 2 MG 3 DP

NICORETTE 2 MG LOZENGE MINT 2 MG 3 DP

NICORETTE 2 MG LOZENGE ORIGINAL 2

MG

3 DP

26


limits on use

NICORETTE 2 MG MINI LOZENGE 2 MG 3 DP

NICORETTE 2 MG MINI LOZENGE MINT 2

MG

3 DP

NICORETTE 4 MG CHEWING GUM 4 MG 3 DP


CINNAMON SURGE 4 MG

3 DP

NICORETTE 4 MG CHEWING GUM FRESH

MINT 4 MG

3 DP

NICORETTE 4 MG CHEWING GUM FRUIT

CHILL 4 MG

3 DP


ORIGINAL 4 MG

3 DP


ORIGINAL FLAVOR 4 MG

3 DP

NICORETTE 4 MG CHEWING GUM WHITE

ICE MINT 4 MG

3 DP

NICORETTE 4 MG LOZENGE 4 MG 3 DP

NICORETTE 4 MG LOZENGE CHERRY 4 MG 3 DP

NICORETTE 4 MG LOZENGE MINT 4 MG 3 DP

NICORETTE 4 MG LOZENGE ORIGINAL 4

MG

3 DP

NICORETTE 4 MG MINI LOZENGE 4 MG 3 DP

nicotine 14 mg/24hr patch (otc) 14 mg/24 hr 3 DP

nicotine 14 mg/24hr patch clear, step 2, outer (otc)

14 mg/24 hr

3 DP

nicotine 14 mg/24hr patch outer (otc) 14 mg/24 hr 3 DP

nicotine 14 mg/24hr patch step 2 (otc) 14 mg/24 hr 3 DP

nicotine 2 mg chewing gum 2 mg 3 DP

nicotine 2 mg chewing gum coated,cinnamon,s/f 2

mg

3 DP

nicotine 2 mg chewing gum cool mint/coated 2 mg 3 DP

nicotine 2 mg chewing gum fruit wave, coated 2

mg

3 DP

nicotine 2 mg chewing gum mint 2 mg 3 DP

nicotine 2 mg chewing gum original 2 mg 3 DP

nicotine 2 mg chewing gum refill 2 mg 3 DP

27


limits on use

nicotine 2 mg chewing gum s/f 2 mg 3 DP

nicotine 2 mg chewing gum s/f,coated 2 mg 3 DP

nicotine 2 mg chewing gum s/f,coated fruit 2 mg 3 DP

nicotine 2 mg chewing gum starter kit 2 mg 3 DP

nicotine 2 mg chewing gum sugar free 2 mg 3 DP

nicotine 2 mg lozenge mint 2 mg 3 DP

nicotine 2 mg lozenge mint, 3 quittube 2 mg 3 DP

nicotine 2 mg lozenge outer 2 mg 3 DP

nicotine 2 mg mini lozenge mini,mint,3 quittube 2

mg

3 DP



nicotine 21 mg/24hr patch outer, clear, step 1 (otc)

21 mg/24 hr

3 DP


nicotine 4 mg chewing gum 4 mg 3 DP

nicotine 4 mg chewing gum coated, mint 4 mg 3 DP

nicotine 4 mg chewing gum coated,cinnamon,s/f 4

mg

3 DP

nicotine 4 mg chewing gum cool mint/coated 4 mg 3 DP

nicotine 4 mg chewing gum fruit wave/coated 4 mg 3 DP

nicotine 4 mg chewing gum mint 4 mg 3 DP

nicotine 4 mg chewing gum original 4 mg 3 DP

nicotine 4 mg chewing gum refill kit,s/f 4 mg 3 DP

nicotine 4 mg chewing gum s/f,coated 4 mg 3 DP

nicotine 4 mg chewing gum s/f,coated fruit 4 mg 3 DP

nicotine 4 mg chewing gum starter kit 4 mg 3 DP

nicotine 4 mg lozenge 4 mg 3 DP

nicotine 4 mg lozenge mint 4 mg 3 DP

nicotine 4 mg lozenge mint, 3 quittube 4 mg 3 DP

nicotine 4 mg lozenge outer 4 mg 3 DP

nicotine 4 mg mini lozenge mini,mint,3 quittube 4

mg

3 DP

28


limits on use



nicotine 7 mg/24hr patch outer, clear, step 3 (otc)

7 mg/24 hr

3 DP


NICOTROL INHALATION CARTRIDGE 10

MG

2

NICOTROL NS NASAL SPRAY,NON-

AEROSOL 10 MG/ML

2

sm nicotine 14 mg/24hr patch step 2 (otc) 14

mg/24 hr

3 DP

sm nicotine 2 mg chewing gum 2 mg 3 DP

sm nicotine 2 mg lozenge 2 mg 3 DP

sm nicotine 21 mg/24hr patch outer (otc) 21 mg/24

hr

3 DP

sm nicotine 4 mg chewing gum 4 mg 3 DP

sm nicotine 4 mg lozenge 4 mg 3 DP

sm nicotine 7 mg/24hr patch step 3 (otc) 7 mg/24

hr

3 DP

ANTIBACTERIALS

AMINOGLYCOSIDES

amikacin injection solution 500 mg/2 ml 1

gentak ophthalmic (eye) ointment 0.3 % (3

mg/gram)

1

gentamicin in nacl (iso-osm) intravenous

piggyback 100 mg/100 ml, 60 mg/50 ml, 80

mg/100 ml, 80 mg/50 ml

1

gentamicin injection solution 40 mg/ml 1

gentamicin ophthalmic (eye) drops 0.3 % 1

gentamicin ophthalmic (eye) ointment 0.3 % (3

mg/gram)

1

gentamicin topical cream 0.1 % 1

gentamicin topical ointment 0.1 % 1

neomycin oral tablet 500 mg 1

paromomycin oral capsule 250 mg 1

29


limits on use

streptomycin intramuscular recon soln 1 gram 1

TOBRADEX OPHTHALMIC (EYE)

OINTMENT 0.3-0.1 %

2

tobramycin ophthalmic (eye) drops 0.3 % 1

tobramycin sulfate injection recon soln 1.2 gram 1

tobramycin sulfate injection solution 10 mg/ml, 40

mg/ml

1

tobramycin-dexamethasone ophthalmic (eye)

drops,suspension 0.3-0.1 %

1

ANTIBACTERIALS, OTHER

acetic acid otic (ear) solution 2 % 1

ak-poly-bac ophthalmic (eye) ointment 500-10,000

unit/gram

1

bacitracin 500 unit/gm ointmnt 500 unit/gram 3 DP

bacitracin 500 unit/gm ointmnt 500 unit/gram 3 DP

bacitracin ophthalmic (eye) ointment 500

unit/gram

1

bacitracin zn 500 unit/gm oint 500 unit/gram 3 DP

bacitracin zn 500 unit/gm oint u-d,144x.94gm pkt

500 unit/gram

3 DP

bacitracin zn 500 unit/gm oint usp 500 unit/gram 3 DP

bacitracin-polymyxin b ophthalmic (eye) ointment

500-10,000 unit/gram

1

BACTROBAN NASAL NASAL OINTMENT 2

%

2

CASTELLANI PAINT MODIFIED 1.5 % 3 DP

clindamycin hcl oral capsule 150 mg, 300 mg, 75

mg

1

clindamycin in 0.9 % sod chlor intravenous


mg/50 ml

1

clindamycin in 5 % dextrose intravenous


mg/50 ml

1

clindamycin palmitate hcl oral recon soln 75 mg/5

ml

1

30


limits on use

clindamycin pediatric oral recon soln 75 mg/5 ml 1

clindamycin phosphate injection solution 150

(mg/ml) (6 ml), 150 mg/ml

1

clindamycin phosphate intravenous solution 300

mg/2 ml, 600 mg/4 ml, 900 mg/6 ml

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 phosphate vaginal cream 2 % 1

colistin (colistimethate na) injection recon soln

150 mg

1

daptomycin intravenous recon soln 350 mg, 500

mg

1 PA

hm bacitracin zn 500 unit/gm 500 unit/gram 3 DP

linezolid in dextrose 5% intravenous piggyback

600 mg/300 ml

1 B/D

linezolid oral suspension for reconstitution 100

mg/5 ml

1

linezolid oral tablet 600 mg 1

linezolid-0.9% sodium chloride intravenous

parenteral solution 600 mg/300 ml

1 B/D

methenamine hippurate oral tablet 1 gram 1

metro i.v. intravenous piggyback 500 mg/100 ml 1

metronidazole in nacl (iso-os) intravenous

piggyback 500 mg/100 ml

1

metronidazole oral capsule 375 mg 1

metronidazole oral tablet 250 mg, 500 mg 1

metronidazole topical cream 0.75 % 1

metronidazole topical gel 0.75 %, 1 % 1

metronidazole topical gel with pump 1 % 1

metronidazole topical lotion 0.75 % 1

metronidazole vaginal gel 0.75 % 1

mupirocin topical ointment 2 % 1

31


limits on use

neomycin-bacitracin-poly-hc ophthalmic (eye)

ointment 3.5-400-10,000 mg-unit/g-1%

1

neomycin-bacitracin-polymyxin ophthalmic (eye)

ointment 3.5-400-10,000 mg-unit-unit/g

1

neomycin-polymyxin b-dexameth ophthalmic (eye)

drops,suspension 3.5mg/ml-10,000 unit/ml-0.1 %

1

neomycin-polymyxin b-dexameth ophthalmic (eye)

ointment 3.5 mg/g-10,000 unit/g-0.1 %

1

neomycin-polymyxin-gramicidin ophthalmic (eye)

drops 1.75 mg-10,000 unit-0.025mg/ml

1

neomycin-polymyxin-hc ophthalmic (eye)

drops,suspension 3.5-10,000-10 mg-unit-mg/ml

1

nitrofurantoin macrocrystal oral capsule 100 mg,

25 mg, 50 mg


nitrofurantoin monohyd/m-cryst oral capsule 100

mg


nitrofurantoin monohyd/m-cryst oral capsule 100

mg (75/25)


polymyxin b sulfate injection recon soln 500,000

unit

1

polymyxin b sulf-trimethoprim ophthalmic (eye)

drops 10,000 unit- 1 mg/ml

1

SM ANTIBIOTIC 500 UNIT/GM OINT 500

UNIT/GRAM

3 DP

tinidazole oral tablet 250 mg, 500 mg 1

trimethoprim oral tablet 100 mg 1

TRIPLE ANTIBIOTIC OINTMENT 3.5MG-400

UNIT- 5,000 UNIT/GRAM

3 DP

vancomycin injection recon soln 100 gram 1

vancomycin intravenous recon soln 1,000 mg, 1.25

gram, 1.5 gram, 10 gram, 250 mg, 5 gram, 500

mg, 750 mg

1

vancomycin oral capsule 125 mg, 250 mg 1

BETA-LACTAM, CEPHALOSPORINS

cefaclor oral capsule 250 mg, 500 mg 1

cefaclor oral tablet extended release 12 hr 500 mg 1

32


limits on use

cefadroxil oral capsule 500 mg 1

cefadroxil oral suspension for reconstitution 250

mg/5 ml, 500 mg/5 ml

1

cefadroxil oral tablet 1 gram 1

cefazolin in dextrose (iso-os) intravenous

piggyback 1 gram/50 ml

1

cefazolin injection recon soln 1 gram, 500 mg 1

cefazolin intravenous recon soln 1 gram 1

cefdinir oral capsule 300 mg 1

cefdinir oral suspension for reconstitution 125


1

cefepime in dextrose 5 % intravenous piggyback 1

gram/50 ml, 2 gram/50 ml

1

cefepime in dextrose,iso-osm intravenous

piggyback 1 gram/50 ml, 2 gram/100 ml

1

cefepime injection recon soln 1 gram, 2 gram 1

cefotaxime injection recon soln 1 gram, 2 gram,

500 mg

1

cefoxitin in dextrose, iso-osm intravenous


1

cefoxitin intravenous recon soln 1 gram, 10 gram,

2 gram

1

cefpodoxime oral suspension for reconstitution

100 mg/5 ml, 50 mg/5 ml

1

cefpodoxime oral tablet 100 mg, 200 mg 1

cefprozil oral suspension for reconstitution 125


1

cefprozil oral tablet 250 mg, 500 mg 1

ceftazidime in d5w intravenous piggyback 1


1

ceftazidime injection recon soln 1 gram, 2 gram, 6

gram

1

ceftriaxone in dextrose,iso-os intravenous


1

ceftriaxone injection recon soln 1 gram, 10 gram,

100 gram, 2 gram, 250 mg, 500 mg

1

ceftriaxone intravenous recon soln 1 gram, 2 gram 1

33


limits on use

cefuroxime axetil oral tablet 250 mg, 500 mg 1

cefuroxime sodium injection recon soln 750 mg 1

cefuroxime sodium intravenous recon soln 1.5

gram, 7.5 gram

1

cephalexin oral capsule 250 mg, 500 mg 1

cephalexin oral suspension for reconstitution 125


1

cephalexin oral tablet 250 mg, 500 mg 1

SUPRAX ORAL CAPSULE 400 MG 2

TAZICEF INJECTION RECON SOLN 1 GRAM,

2 GRAM, 6 GRAM

1

TAZICEF INTRAVENOUS RECON SOLN 1

GRAM, 2 GRAM

1

TEFLARO INTRAVENOUS RECON SOLN 400

MG, 600 MG

2 PA

BETA-LACTAM, OTHER

aztreonam injection recon soln 1 gram 1

doripenem intravenous recon soln 500 mg 1 PA

ertapenem injection recon soln 1 gram 1 PA

imipenem-cilastatin intravenous recon soln 250

mg, 500 mg

1 B/D

meropenem intravenous recon soln 1 gram, 500

mg

1

meropenem-0.9% sodium chloride intravenous

piggyback 1 gram/50 ml, 500 mg/50 ml

1

VABOMERE INTRAVENOUS RECON SOLN 2

GRAM

2 PA

BETA-LACTAM, PENICILLINS

amoxicillin oral capsule 250 mg, 500 mg 1

amoxicillin oral suspension for reconstitution 125

mg/5 ml, 200 mg/5 ml, 250 mg/5 ml, 400 mg/5 ml

1

amoxicillin oral tablet 500 mg, 875 mg 1

amoxicillin oral tablet,chewable 125 mg, 250 mg 1

34


limits on use

amoxicillin-pot clavulanate oral suspension for

reconstitution 200-28.5 mg/5 ml, 250-62.5 mg/5

ml, 400-57 mg/5 ml, 600-42.9 mg/5 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 1,000-62.5 mg

1

amoxicillin-pot clavulanate oral tablet,chewable

200-28.5 mg, 400-57 mg

1

ampicillin oral capsule 500 mg 1

ampicillin sodium injection recon soln 1 gram, 10

gram, 125 mg

1

ampicillin sodium intravenous recon soln 1 gram 1

ampicillin-sulbactam injection recon soln 1.5

gram, 15 gram, 3 gram

1

ampicillin-sulbactam intravenous recon soln 1.5

gram, 3 gram

1

BICILLIN L-A INTRAMUSCULAR SYRINGE

1,200,000 UNIT/2 ML, 2,400,000 UNIT/4 ML,

600,000 UNIT/ML

2

dicloxacillin oral capsule 250 mg, 500 mg 1

nafcillin in dextrose iso-osm intravenous

piggyback 1 gram/50 ml

1

nafcillin injection recon soln 1 gram 1

nafcillin intravenous recon soln 1 gram, 2 gram 1

penicillin g procaine intramuscular syringe 1.2

million unit/2 ml

1

penicillin g sodium injection recon soln 5 million

unit

1

penicillin v potassium oral recon soln 125 mg/5

ml, 250 mg/5 ml

1

penicillin v potassium oral tablet 250 mg, 500 mg 1

piperacillin-tazobactam intravenous recon soln

13.5 gram, 2.25 gram, 3.375 gram, 4.5 gram, 40.5

gram

1

MACROLIDES

azithromycin intravenous recon soln 500 mg 1

35


limits on use

azithromycin oral packet 1 gram 1

azithromycin oral suspension for reconstitution

100 mg/5 ml, 200 mg/5 ml

1

azithromycin oral tablet 250 mg, 250 mg (6 pack),

500 mg, 500 mg (3 pack), 600 mg

1

clarithromycin oral suspension for reconstitution

125 mg/5 ml, 250 mg/5 ml

1

clarithromycin oral tablet 250 mg, 500 mg 1

clarithromycin oral tablet extended release 24 hr

500 mg

1

DIFICID ORAL TABLET 200 MG 2 PA

ery pads topical swab 2 % 1

erythrocin (as stearate) oral tablet 250 mg 1

ERYTHROCIN INTRAVENOUS RECON SOLN

500 MG

2

erythromycin ethylsuccinate oral suspension for

reconstitution 200 mg/5 ml

1

erythromycin ethylsuccinate oral tablet 400 mg 1

erythromycin ophthalmic (eye) ointment 5

mg/gram (0.5 %)

1

erythromycin oral tablet 250 mg, 500 mg 1

erythromycin with ethanol topical gel 2 % 1

erythromycin with ethanol topical solution 2 % 1

QUINOLONES

ciprofloxacin (mixture) oral tablet, er multiphase

24 hr 1,000 mg, 500 mg

1

ciprofloxacin hcl ophthalmic (eye) drops 0.3 % 1

ciprofloxacin hcl oral tablet 100 mg, 250 mg, 500

mg, 750 mg

1

ciprofloxacin in 5 % dextrose intravenous


1

ciprofloxacin oral suspension,microcapsule recon

250 mg/5 ml, 500 mg/5 ml

1

levofloxacin in d5w intravenous piggyback 500

mg/100 ml, 750 mg/150 ml

1

36


limits on use

levofloxacin intravenous solution 25 mg/ml 1

levofloxacin oral solution 250 mg/10 ml 1

levofloxacin oral tablet 250 mg, 500 mg, 750 mg 1

moxifloxacin in nacl (iso-osm) intravenous


1

moxifloxacin ophthalmic (eye) drops 0.5 % 1

moxifloxacin oral tablet 400 mg 1

moxifloxacin-sod.ace,sul-water intravenous


1

ofloxacin ophthalmic (eye) drops 0.3 % 1

ofloxacin oral tablet 300 mg, 400 mg 1

SULFONAMIDES

silver sulfadiazine topical cream 1 % 1

ssd topical cream 1 % 1

sulfacetamide sodium (acne) topical suspension 10

%

1

sulfacetamide sodium ophthalmic (eye) drops 10

%

1

sulfacetamide sodium ophthalmic (eye) ointment

10 %

1

sulfadiazine oral tablet 500 mg 1

sulfamethoxazole-trimethoprim oral suspension

200-40 mg/5 ml

1

sulfamethoxazole-trimethoprim oral tablet 400-80

mg, 800-160 mg

1

TETRACYCLINES

doxy-100 intravenous recon soln 100 mg 1

doxycycline hyclate oral capsule 100 mg, 50 mg 1

doxycycline hyclate oral tablet 100 mg, 20 mg 1

doxycycline monohydrate oral capsule 100 mg, 50

mg

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

37


limits on use

MORGIDOX 1X 50 KIT 50 MG 1

morgidox oral capsule 50 mg 1

tetracycline oral capsule 250 mg, 500 mg 1

ANTICONVULSANTS

ANTICONVULSANTS, OTHER

BRIVIACT ORAL SOLUTION 10 MG/ML 2 ST; MO

BRIVIACT ORAL TABLET 10 MG, 100 MG, 25

MG, 50 MG, 75 MG

2 ST; MO

EPIDIOLEX ORAL SOLUTION 100 MG/ML 2 PA; MO

levetiracetam oral solution 100 mg/ml, 500 mg/5

ml (5 ml)

1 MO

levetiracetam oral tablet 1,000 mg, 250 mg, 500

mg, 750 mg

1 MO

levetiracetam oral tablet extended release 24 hr

500 mg, 750 mg

1 MO

ROWEEPRA ORAL TABLET 1,000 MG, 750

MG

1 MO

roweepra oral tablet 500 mg 1 MO

ROWEEPRA XR ORAL TABLET EXTENDED

RELEASE 24 HR 500 MG, 750 MG

1 MO

SPRITAM ORAL TABLET FOR SUSPENSION

1,000 MG, 250 MG, 500 MG

2 ST; MO; QL (60 EA per 30 days)

SPRITAM ORAL TABLET FOR SUSPENSION

750 MG


CALCIUM CHANNEL MODIFYING AGENTS

CELONTIN ORAL CAPSULE 300 MG 2 MO

ethosuximide oral capsule 250 mg 1 MO

ethosuximide oral solution 250 mg/5 ml 1 MO

LYRICA ORAL CAPSULE 100 MG, 150 MG,

200 MG, 225 MG, 25 MG, 300 MG, 50 MG, 75

MG

2 MO

LYRICA ORAL SOLUTION 20 MG/ML 2 MO

zonisamide oral capsule 100 mg, 25 mg, 50 mg 1 MO

GAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENTS

38


limits on use

clobazam oral suspension 2.5 mg/ml 1 PA; MO; QL (480 ML per 30 days)

clobazam oral tablet 10 mg, 20 mg 1 PA; MO; QL (60 EA per 30 days)

DIASTAT ACUDIAL RECTAL KIT 12.5-15-

17.5-20 MG, 5-7.5-10 MG

2

DIASTAT RECTAL KIT 2.5 MG 2

diazepam rectal kit 12.5-15-17.5-20 mg, 2.5 mg, 5-

7.5-10 mg

1 MO

divalproex oral capsule, delayed rel sprinkle 125

mg

1 MO

divalproex oral tablet extended release 24 hr 250

mg, 500 mg

1 MO

divalproex oral tablet,delayed release (dr/ec) 125

mg, 250 mg, 500 mg

1 MO

gabapentin oral capsule 100 mg, 300 mg, 400 mg 1 MO

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

ml (5 ml), 300 mg/6 ml (6 ml)

1 MO

gabapentin oral tablet 600 mg, 800 mg 1 MO

phenobarbital oral elixir 20 mg/5 ml (4 mg/ml) 1 PA; MO

phenobarbital oral tablet 100 mg, 15 mg, 16.2 mg,

30 mg, 32.4 mg, 60 mg, 64.8 mg, 97.2 mg

1 PA; MO

primidone oral tablet 250 mg, 50 mg 1 MO

SABRIL ORAL TABLET 500 MG 2 PA; MO; QL (180 EA per 30 days)

SYMPAZAN ORAL FILM 10 MG, 20 MG, 5 MG 2 PA; QL (60 EA per 30 days)

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

valproic acid (as sodium salt) oral solution 250

mg/5 ml, 250 mg/5 ml (5 ml), 500 mg/10 ml (10

ml)

1 MO

valproic acid oral capsule 250 mg 1 MO

vigabatrin oral powder in packet 500 mg 1 PA; MO

vigabatrin oral tablet 500 mg 1 PA; QL (180 EA per 30 days)

VIGADRONE ORAL POWDER IN PACKET

500 MG

1 PA; MO

GLUTAMATE REDUCING AGENTS

felbamate oral suspension 600 mg/5 ml 1 MO

felbamate oral tablet 400 mg, 600 mg 1 MO

39


limits on use

FYCOMPA ORAL SUSPENSION 0.5 MG/ML 2 ST; MO

FYCOMPA ORAL TABLET 10 MG, 12 MG, 2

MG, 4 MG, 6 MG, 8 MG


lamotrigine oral tablet extended release 24hr 100

mg, 200 mg, 25 mg, 250 mg, 300 mg, 50 mg

1 MO

lamotrigine oral tablet, chewable dispersible 25

mg, 5 mg

1 MO

SUBVENITE ORAL TABLET 100 MG, 150 MG,

200 MG, 25 MG

1 MO

SUBVENITE STARTER (BLUE) KIT ORAL

TABLETS,DOSE PACK 25 MG (35)

1

SUBVENITE STARTER (GREEN) KIT ORAL

TABLETS,DOSE PACK 25 MG (84) -100 MG

(14)

1

SUBVENITE STARTER (ORANGE) KIT ORAL

TABLETS,DOSE PACK 25 MG (42) -100 MG

(7)

1

topiramate oral capsule, sprinkle 15 mg, 25 mg 1 MO

topiramate oral tablet 100 mg, 200 mg, 25 mg, 50

mg

1 MO

SODIUM CHANNEL AGENTS

APTIOM ORAL TABLET 200 MG, 400 MG, 800

MG


APTIOM ORAL TABLET 600 MG 2 ST; MO; QL (60 EA per 30 days)

BANZEL ORAL SUSPENSION 40 MG/ML 2 PA; MO; QL (2400 ML per 30 days)

BANZEL ORAL TABLET 200 MG, 400 MG 2 PA; MO; QL (240 EA per 30 days)

carbamazepine oral suspension 100 mg/5 ml 1 MO

carbamazepine oral tablet 200 mg 1 MO

carbamazepine oral tablet extended release 12 hr

100 mg, 200 mg, 400 mg

1 MO

carbamazepine oral tablet,chewable 100 mg 1 MO

DILANTIN ORAL CAPSULE 30 MG 2 MO

epitol oral tablet 200 mg 1 MO

oxcarbazepine oral suspension 300 mg/5 ml (60

mg/ml)

1 MO

oxcarbazepine oral tablet 150 mg, 300 mg, 600 mg 1 MO

40


limits on use

PEGANONE ORAL TABLET 250 MG 2 MO

PHENYTEK ORAL CAPSULE 200 MG, 300 MG 2 MO

phenytoin oral suspension 100 mg/4 ml, 125 mg/5

ml

1 MO

phenytoin oral tablet,chewable 50 mg 1 MO

phenytoin sodium extended oral capsule 100 mg,

200 mg, 300 mg

1 MO

VIMPAT ORAL SOLUTION 10 MG/ML 2 ST; MO; QL (1200 ML per 30 days)

VIMPAT ORAL TABLET 100 MG, 150 MG, 200

MG, 50 MG


ANTIDEMENTIA AGENTS

ANTIDEMENTIA AGENTS, OTHER

ergoloid oral tablet 1 mg 1 PA; MO

CHOLINESTERASE INHIBITORS

donepezil oral tablet 10 mg, 23 mg, 5 mg 1 MO

donepezil oral tablet,disintegrating 10 mg, 5 mg 1 MO

galantamine oral capsule,ext rel. pellets 24 hr 16

mg, 24 mg, 8 mg

1 MO

galantamine oral tablet 12 mg, 4 mg, 8 mg 1 MO

rivastigmine tartrate oral capsule 1.5 mg, 3 mg,

4.5 mg, 6 mg

1 MO

rivastigmine transdermal patch 24 hour 13.3

mg/24 hour, 4.6 mg/24 hr, 9.5 mg/24 hr

1 MO

N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONIST

memantine oral capsule,sprinkle,er 24hr 14 mg,

21 mg, 28 mg, 7 mg

1 MO; QL (30 EA per 30 days)

memantine oral tablet 10 mg, 5 mg 1 MO

memantine oral tablets,dose pack 5-10 mg 1

NAMENDA XR ORAL CAP,SPRINKLE,ER

24HR DOSE PACK 7-14-21-28 MG

2

ANTIDEPRESSANTS

ANTIDEPRESSANTS, OTHER

bupropion hcl oral tablet 100 mg, 75 mg 1 MO

bupropion hcl oral tablet extended release 24 hr

150 mg, 300 mg, 450 mg

1 MO

41


limits on use

bupropion hcl oral tablet sustained-release 12 hr

100 mg, 150 mg, 200 mg

1 MO

FORFIVO XL ORAL TABLET EXTENDED

RELEASE 24 HR 450 MG

2 MO

mirtazapine oral tablet 15 mg, 30 mg, 45 mg, 7.5

mg

1 MO

mirtazapine oral tablet,disintegrating 15 mg, 30

mg, 45 mg

1 MO

nefazodone oral tablet 100 mg, 150 mg, 200 mg,

250 mg, 50 mg

1 MO

perphenazine-amitriptyline oral tablet 2-10 mg, 2-

25 mg, 4-10 mg, 4-25 mg, 4-50 mg

1 PA; MO

trazodone oral tablet 100 mg, 150 mg, 300 mg, 50

mg

1 MO

MONOAMINE OXIDASE INHIBITORS

EMSAM TRANSDERMAL PATCH 24 HOUR

12 MG/24 HR, 6 MG/24 HR, 9 MG/24 HR

2 MO

MARPLAN ORAL TABLET 10 MG 2 MO

phenelzine oral tablet 15 mg 1 MO

tranylcypromine oral tablet 10 mg 1 MO

SSRIS/ SNRIS

citalopram oral solution 10 mg/5 ml 1 MO

citalopram oral tablet 10 mg, 20 mg, 40 mg 1 MO

desvenlafaxine succinate oral tablet extended

release 24 hr 100 mg, 25 mg, 50 mg

1 MO

escitalopram oxalate oral solution 5 mg/5 ml 1 MO

escitalopram oxalate oral tablet 10 mg, 20 mg, 5

mg

1 MO

FETZIMA ORAL CAPSULE,EXT REL 24HR

DOSE PACK 20 MG (2)- 40 MG (26)

2 ST

FETZIMA ORAL CAPSULE,EXTENDED

RELEASE 24 HR 120 MG, 20 MG, 40 MG, 80

MG

2 ST; MO

fluoxetine oral capsule 10 mg, 20 mg, 40 mg 1 MO

fluoxetine oral capsule,delayed release(dr/ec) 90

mg

1 MO

42


limits on use

fluoxetine oral solution 20 mg/5 ml (4 mg/ml) 1 MO

fluoxetine oral tablet 10 mg, 20 mg 1 MO

fluvoxamine oral tablet 100 mg, 25 mg, 50 mg 1 MO

maprotiline oral tablet 25 mg, 50 mg, 75 mg 1 MO

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

mg

1 MO

paroxetine hcl oral tablet extended release 24 hr

12.5 mg, 25 mg, 37.5 mg

1 MO

PAXIL ORAL SUSPENSION 10 MG/5 ML 2 MO

sertraline oral concentrate 20 mg/ml 1 MO

sertraline oral tablet 100 mg, 25 mg, 50 mg 1 MO

TRINTELLIX ORAL TABLET 10 MG, 20 MG, 5

MG

2 ST; MO

venlafaxine oral capsule,extended release 24hr

150 mg, 37.5 mg, 75 mg

1 MO

venlafaxine oral tablet 100 mg, 25 mg, 37.5 mg, 50

mg, 75 mg

1 MO

venlafaxine oral tablet extended release 24hr 150

mg, 225 mg, 37.5 mg, 75 mg

1 MO

VIIBRYD ORAL TABLET 10 MG, 20 MG, 40

MG

2 ST; MO

VIIBRYD ORAL TABLETS,DOSE PACK 10

MG (7)- 20 MG (23)

2 ST

TRICYCLICS

amitriptyline oral tablet 10 mg, 100 mg, 150 mg,

25 mg, 50 mg, 75 mg

1 PA; MO

amoxapine oral tablet 100 mg, 150 mg, 25 mg, 50

mg

1 MO

clomipramine oral capsule 25 mg, 50 mg, 75 mg 1 PA; MO

desipramine oral tablet 10 mg, 100 mg, 150 mg,

25 mg, 50 mg, 75 mg

1 MO

doxepin oral capsule 10 mg, 100 mg, 150 mg, 25

mg, 50 mg, 75 mg

1 PA; MO

doxepin oral concentrate 10 mg/ml 1 PA; MO

imipramine hcl oral tablet 10 mg, 25 mg, 50 mg 1 PA; MO

43


limits on use

imipramine pamoate oral capsule 100 mg, 125 mg,

150 mg, 75 mg

1 PA; MO

nortriptyline oral capsule 10 mg, 25 mg, 50 mg, 75

mg

1 MO

nortriptyline oral solution 10 mg/5 ml 1 MO

protriptyline oral tablet 10 mg, 5 mg 1 MO

trimipramine oral capsule 100 mg, 25 mg, 50 mg 1 PA; MO

ANTIEMETICS

ANTIEMETICS, OTHER

chlorpromazine oral tablet 10 mg, 100 mg, 200

mg, 25 mg, 50 mg

1 MO

DRIMINATE 50 MG TABLET 50 MG 3 DP

meclizine 12.5 mg caplet caplet (otc) 12.5 mg 3 DP

meclizine 12.5 mg tablet (otc) 12.5 mg 3 DP

meclizine 25 mg tablet chew 25 mg 3 DP

meclizine 25 mg tablet chew raspberry 25 mg 3 DP

meclizine oral tablet 12.5 mg, 25 mg 1

metoclopramide hcl oral solution 5 mg/5 ml 1

metoclopramide hcl oral tablet 10 mg, 5 mg 1

MOTION SICKNESS 50 MG TABLET 50 MG 3 DP

MOTION-TIME 25 MG TABLET CHEW 25 MG 3 DP

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

prochlorperazine maleate oral tablet 10 mg, 5 mg 1

prochlorperazine rectal suppository 25 mg 1

promethazine oral tablet 12.5 mg, 25 mg, 50 mg 1 PA

promethazine rectal suppository 12.5 mg, 25 mg 1 PA

promethazine rectal suppository 50 mg 1

promethegan rectal suppository 50 mg 1 PA

SB MOTION SICKNESS 50 MG TAB 50 MG 3 DP

scopolamine base transdermal patch 3 day 1 mg

over 3 days

1

SM MOTION SICKNESS 50 MG TAB 50 MG 3 DP

44


limits on use

TRAVEL SICKNESS 25 MG TAB CHEW 25

MG

3 DP

TRAVEL SICKNESS 50 MG TABLET 50 MG 3 DP

trimethobenzamide oral capsule 300 mg 1 PA

EMETOGENIC THERAPY ADJUNCTS

aprepitant oral capsule 125 mg, 40 mg, 80 mg 1 B/D

aprepitant oral capsule,dose pack 125 mg (1)- 80

mg (2)

1 B/D

dronabinol oral capsule 10 mg, 2.5 mg, 5 mg 1 B/D

EMEND ORAL SUSPENSION FOR

RECONSTITUTION 125 MG (25 MG/ ML

FINAL CONC.)

2 B/D

granisetron hcl oral tablet 1 mg 1 B/D

ondansetron hcl oral solution 4 mg/5 ml 1 B/D

ondansetron hcl oral tablet 24 mg, 4 mg, 8 mg 1 B/D

ondansetron oral tablet,disintegrating 4 mg, 8 mg 1 B/D

SYNDROS ORAL SOLUTION 5 MG/ML 2 PA

ANTIFUNGALS

ANTIFUNGALS

abelcet intravenous suspension 5 mg/ml 2 B/D

ALEVAZOL 1% OINTMENT 1 % 3 DP

AMBISOME INTRAVENOUS SUSPENSION

FOR RECONSTITUTION 50 MG

2 B/D

amphotericin b injection recon soln 50 mg 1 B/D

ANTIFUNGAL 1% CREAM 1 % 3 DP


ANTI-FUNGAL 1% POWDER 1 % 3 DP


CARRINGTON ANTIFUNGAL 2% CREAM 2 % 3 DP

caspofungin intravenous recon soln 50 mg, 70 mg 1 PA

ciclopirox topical cream 0.77 % 1

ciclopirox topical solution 8 % 1

ciclopirox topical suspension 0.77 % 1

45


limits on use

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

%

1

clotrimazole 1% cream (otc) 1 % 3 DP

clotrimazole 1% cream 1 % 3 DP

clotrimazole mucous membrane troche 10 mg 1

clotrimazole topical cream 1 % 1

clotrimazole topical solution 1 % 1

econazole topical cream 1 % 1

ERAXIS(WATER DILUENT) INTRAVENOUS

RECON SOLN 100 MG, 50 MG

2 PA

fluconazole in dextrose(iso-o) intravenous

piggyback 200 mg/100 ml, 400 mg/200 ml

1

fluconazole in nacl (iso-osm) intravenous

piggyback 200 mg/100 ml, 400 mg/200 ml

1

fluconazole oral suspension for reconstitution 10

mg/ml, 40 mg/ml

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 mg/5

ml

1

INZO ANTIFUNGAL 2% CREAM 2 % 3 DP

itraconazole oral capsule 100 mg 1

itraconazole oral solution 10 mg/ml 1

ketoconazole oral tablet 200 mg 1

ketoconazole topical cream 2 % 1

ketoconazole topical shampoo 2 % 1

LAMISIL AF DEFENS 1% SPRAY PWD 1 % 3 DP

MENTAX TOPICAL CREAM 1 % 2

miconazole 100 mg vag supp 100 mg 3 DP

MICONAZOLE 7 100 MG VAG SUPP 100 MG 3 DP

MICONAZOLE 7 CREAM 2 % 3 DP

miconazole nitrate 2% cream 2 % 3 DP

miconazole nitrate 2% cream 2 % 3 DP

46


limits on use

miconazole nitrate 2% cream w/applicator 2 % 3 DP

MYCAMINE INTRAVENOUS RECON SOLN

100 MG, 50 MG

2 PA

NOXAFIL ORAL SUSPENSION 200 MG/5 ML

(40 MG/ML)

2 PA

NOXAFIL ORAL TABLET,DELAYED

RELEASE (DR/EC) 100 MG

2 PA

nyamyc topical powder 100,000 unit/gram 1

nystatin oral suspension 100,000 unit/ml 1

nystatin oral tablet 500,000 unit 1

nystatin topical cream 100,000 unit/gram 1

nystatin topical ointment 100,000 unit/gram 1

nystatin topical powder 100,000 unit/gram 1

nystop topical powder 100,000 unit/gram 1

qc tolnaftate 1% cream 1 % 3 DP

SM ANTIFUNGAL 1% CREAM 1 % 3 DP

SM ANTIFUNGAL 1% CREAM 1 % 3 DP

SM ATHLETE'S 1% FOOT CREAM 1 % 3 DP

SM MICONAZOLE 7 100 MG VAG SUP 100

MG

3 DP

SM MICONAZOLE 7 CREAM W/REUSABLE

APPLIC 2 %

3 DP

sm miconazole nitrate 2% cream w/disp

applicators 2 %

3 DP

terbinafine 1% cream 1 % 3 DP

terbinafine 1% cream antifungal 1 % 3 DP

terbinafine hcl oral tablet 250 mg 1

terconazole vaginal cream 0.4 %, 0.8 % 1

terconazole vaginal suppository 80 mg 1

tolnaftate 1% cream 1 % 3 DP

tolnaftate 1% powder 1 % 3 DP

tolnaftate af 1% cream 1 % 3 DP

voriconazole intravenous solution 200 mg 1

voriconazole oral suspension for reconstitution

200 mg/5 ml (40 mg/ml)

1

47


limits on use

voriconazole oral tablet 200 mg, 50 mg 1

ANTIGOUT AGENTS

ANTIGOUT AGENTS

allopurinol oral tablet 100 mg, 300 mg 1 MO

colchicine oral capsule 0.6 mg 1 MO

colchicine oral tablet 0.6 mg 1 MO

probenecid oral tablet 500 mg 1 MO

probenecid-colchicine oral tablet 500-0.5 mg 1 MO

ULORIC ORAL TABLET 40 MG, 80 MG 2 ST; MO

ANTI-INFLAMMATORY AGENTS

GLUCOCORTICOIDS

ala-cort topical cream 1 %, 2.5 % 1

alclometasone topical cream 0.05 % 1

alclometasone topical ointment 0.05 % 1

betamethasone dipropionate topical cream 0.05 % 1

betamethasone dipropionate topical lotion 0.05 % 1

betamethasone dipropionate topical ointment 0.05

%

1

betamethasone valerate topical cream 0.1 % 1

betamethasone valerate topical lotion 0.1 % 1

betamethasone valerate topical ointment 0.1 % 1

betamethasone, augmented topical cream 0.05 % 1

betamethasone, augmented topical gel 0.05 % 1

betamethasone, augmented topical lotion 0.05 % 1

betamethasone, augmented topical ointment 0.05

%

1

clobetasol scalp solution 0.05 % 1

clobetasol topical cream 0.05 % 1

clobetasol topical gel 0.05 % 1

clobetasol topical ointment 0.05 % 1

clobetasol-emollient topical cream 0.05 % 1

desonide topical cream 0.05 % 1

48


limits on use

desonide topical lotion 0.05 % 1

desonide topical ointment 0.05 % 1

desoximetasone topical cream 0.05 %, 0.25 % 1

desoximetasone topical gel 0.05 % 1

desoximetasone topical ointment 0.05 %, 0.25 % 1

dexamethasone intensol oral drops 1 mg/ml 1

dexamethasone oral elixir 0.5 mg/5 ml 1

dexamethasone oral solution 0.5 mg/5 ml 1

dexamethasone oral tablet 0.5 mg, 0.75 mg, 1 mg,

1.5 mg, 2 mg, 4 mg, 6 mg

1

fluocinolone topical cream 0.01 %, 0.025 % 1

fluocinolone topical ointment 0.025 % 1

fluocinolone topical solution 0.01 % 1

fluocinonide topical gel 0.05 % 1

fluocinonide topical ointment 0.05 % 1

fluocinonide topical solution 0.05 % 1

fluocinonide-e topical cream 0.05 % 1

fluocinonide-emollient topical cream 0.05 % 1

fluticasone topical cream 0.05 % 1

fluticasone topical lotion 0.05 % 1

fluticasone topical ointment 0.005 % 1

halobetasol propionate topical cream 0.05 % 1

halobetasol propionate topical ointment 0.05 % 1

hm hydrocortisone 1% cream max str, w/aloe (otc)

1 %

3 DP

hm hydrocortisone 1% cream plus 12 moisturizers

(otc) 1 %

3 DP

hydrocortisone 1% cream (otc) 1 % 3 DP

hydrocortisone 1% cream carton (otc) 1 % 3 DP

hydrocortisone 1% cream maximum strength (otc)

1 %

3 DP

hydrocortisone 1% cream u-d, 48's, foil 1 % 3 DP

hydrocortisone 1% ointment (otc) 1 % 3 DP

hydrocortisone 1% ointment carton (otc) 1 % 3 DP

49


limits on use

hydrocortisone 1% ointment maximum strength

(otc) 1 %

3 DP

hydrocortisone butyrate topical cream 0.1 % 1

hydrocortisone butyrate topical ointment 0.1 % 1

hydrocortisone butyrate topical solution 0.1 % 1

hydrocortisone butyr-emollient topical cream 0.1

%

1

hydrocortisone plus 1% cream moisturizer,max.

str (otc) 1 %

3 DP

hydrocortisone topical cream 1 %, 2.5 % 1

hydrocortisone topical cream with perineal

applicator 1 %

1

hydrocortisone topical lotion 2.5 % 1

hydrocortisone topical ointment 1 %, 2.5 % 1

hydrocortisone valerate topical cream 0.2 % 1

hydrocortisone valerate topical ointment 0.2 % 1

hydrocortisone-aloe 1% cream 1 % 3 DP

HYDROSKIN 1% CREAM 1 % 3 DP

methylprednisolone oral tablets,dose pack 4 mg 1

mometasone topical cream 0.1 % 1

mometasone topical ointment 0.1 % 1

mometasone topical solution 0.1 % 1

prednisolone oral solution 15 mg/5 ml 1

prednisolone sodium phosphate oral solution 15

mg/5 ml (3 mg/ml), 25 mg/5 ml (5 mg/ml), 5 mg

base/5 ml (6.7 mg/5 ml)

1

prednisone oral solution 5 mg/5 ml 1

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

mg, 5 mg, 50 mg

1

prednisone oral tablets,dose pack 10 mg, 10 mg

(48 pack), 5 mg, 5 mg (48 pack)

1

sb hydrocortisone 1% ointment maximum strength

(otc) 1 %

3 DP

SB HYDROCORTISONE PLUS 1% CRM MAX

STR, W/ALOE 1 %

3 DP

50


limits on use

sm hydrocortisone 1% ointment maximum strength

(otc) 1 %

3 DP

sm hydrocortisone-aloe 1% crm 1 % 3 DP

triamcinolone acetonide topical cream 0.025 %,

0.1 %, 0.5 %

1

triamcinolone acetonide topical lotion 0.025 %,

0.1 %

1

triamcinolone acetonide topical ointment 0.025 %,

0.1 %, 0.5 %

1

triderm topical cream 0.1 % 1

ANTIMIGRAINE AGENTS

ERGOT ALKALOIDS

dihydroergotamine injection solution 1 mg/ml 1 PA

dihydroergotamine nasal spray,non-aerosol 0.5

mg/pump act. (4 mg/ml)


ergotamine-caffeine oral tablet 1-100 mg 1

PROPHYLACTIC

AIMOVIG AUTOINJECTOR (2 PACK)

SUBCUTANEOUS AUTO-INJECTOR 70

MG/ML

2 PA; MO

AIMOVIG AUTOINJECTOR SUBCUTANEOUS

AUTO-INJECTOR 70 MG/ML

2 PA; MO

SEROTONIN (5-HT) 1B/1D RECEPTOR AGONISTS

rizatriptan oral tablet 10 mg, 5 mg 1 QL (12 EA per 30 days)

rizatriptan oral tablet,disintegrating 10 mg, 5 mg 1 QL (12 EA per 30 days)

sumatriptan nasal spray,non-aerosol 20

mg/actuation, 5 mg/actuation


sumatriptan succinate oral tablet 100 mg, 25 mg,

50 mg


sumatriptan succinate subcutaneous cartridge 4

mg/0.5 ml, 6 mg/0.5 ml


sumatriptan succinate subcutaneous pen injector 4

mg/0.5 ml, 6 mg/0.5 ml, 6 mg/0.5 ml (auto-

injector)


sumatriptan succinate subcutaneous solution 6

mg/0.5 ml


51


limits on use

sumatriptan succinate subcutaneous syringe 6

mg/0.5 ml


ANTIMYASTHENIC AGENTS

PARASYMPATHOMIMETICS

guanidine oral tablet 125 mg 1

pyridostigmine bromide oral tablet 60 mg 1 MO

pyridostigmine bromide oral tablet extended

release 180 mg

1 MO

ANTIMYCOBACTERIALS

ANTIMYCOBACTERIALS, OTHER

dapsone oral tablet 100 mg, 25 mg 1 MO

rifabutin oral capsule 150 mg 1

ANTITUBERCULARS

ethambutol oral tablet 100 mg, 400 mg 1

isoniazid oral tablet 100 mg, 300 mg 1

PASER ORAL GRANULES DR FOR SUSP IN

PACKET 4 GRAM

2

PRIFTIN ORAL TABLET 150 MG 2

pyrazinamide oral tablet 500 mg 1

rifampin intravenous recon soln 600 mg 1

rifampin oral capsule 150 mg, 300 mg 1

RIFATER ORAL TABLET 50-120-300 MG 2

SIRTURO ORAL TABLET 100 MG 2 PA

TRECATOR ORAL TABLET 250 MG 2

ANTINEOPLASTICS

ALKYLATING AGENTS

cyclophosphamide oral capsule 25 mg, 50 mg 1 B/D

GLEOSTINE ORAL CAPSULE 10 MG, 100 MG,

40 MG

2 PA

HEXALEN ORAL CAPSULE 50 MG 2 PA

LEUKERAN ORAL TABLET 2 MG 2

MATULANE ORAL CAPSULE 50 MG 2

52


limits on use

VALCHLOR TOPICAL GEL 0.016 % 2 MO

ANTIANDROGENS

abiraterone oral tablet 250 mg 1 PA; MO

bicalutamide oral tablet 50 mg 1 MO

ERLEADA ORAL TABLET 60 MG 2 PA; MO

flutamide oral capsule 125 mg 1 MO

nilutamide oral tablet 150 mg 1 MO

XTANDI ORAL CAPSULE 40 MG 2 PA; MO

YONSA ORAL TABLET 125 MG 2 PA; MO

ZYTIGA ORAL TABLET 500 MG 2 PA; MO

ANTIANGIOGENIC AGENTS

POMALYST ORAL CAPSULE 1 MG, 2 MG, 3

MG, 4 MG

2 PA; MO

REVLIMID ORAL CAPSULE 10 MG, 15 MG,

2.5 MG, 20 MG, 25 MG, 5 MG

2 PA; MO; LA

THALOMID ORAL CAPSULE 100 MG, 150

MG, 200 MG, 50 MG

2 MO

ANTIESTROGENS/MODIFIERS

DEPO-PROVERA INTRAMUSCULAR

SUSPENSION 400 MG/ML

2 PA; MO

EMCYT ORAL CAPSULE 140 MG 2

FARESTON ORAL TABLET 60 MG 2 PA; MO

SOLTAMOX ORAL SOLUTION 10 MG/5 ML 2 MO

tamoxifen oral tablet 10 mg, 20 mg 1 MO

toremifene oral tablet 60 mg 1 PA

ANTIMETABOLITES

DROXIA ORAL CAPSULE 200 MG, 300 MG,

400 MG

2 MO

fluorouracil topical cream 0.5 %, 5 % 1

fluorouracil topical solution 2 %, 5 % 1

hydroxyurea oral capsule 500 mg 1 MO

mercaptopurine oral tablet 50 mg 1 MO

PURIXAN ORAL SUSPENSION 20 MG/ML 2 MO

53


limits on use

TABLOID ORAL TABLET 40 MG 2 PA

ANTINEOPLASTICS, OTHER

diclofenac sodium topical gel 3 % 1

leucovorin calcium oral tablet 10 mg, 15 mg, 25

mg, 5 mg

1

LONSURF ORAL TABLET 15-6.14 MG, 20-8.19

MG

2 PA

LYNPARZA ORAL CAPSULE 50 MG 2 PA; MO

LYNPARZA ORAL TABLET 100 MG, 150 MG 2 PA; MO

MESNEX ORAL TABLET 400 MG 2

NINLARO ORAL CAPSULE 2.3 MG, 3 MG, 4

MG

2 PA; MO

ODOMZO ORAL CAPSULE 200 MG 2 PA; MO

SYLATRON SUBCUTANEOUS KIT 200 MCG,

300 MCG, 600 MCG

2 PA; MO

SYNRIBO SUBCUTANEOUS RECON SOLN

3.5 MG

2 PA; MO

VENCLEXTA ORAL TABLET 10 MG, 100 MG,

50 MG

2 PA; MO

VENCLEXTA STARTING PACK ORAL

TABLETS,DOSE PACK 10 MG-50 MG- 100 MG

2 PA

ZOLINZA ORAL CAPSULE 100 MG 2 PA

ZYDELIG ORAL TABLET 100 MG, 150 MG 2 PA; MO

AROMATASE INHIBITORS, 3RD GENERATION

anastrozole oral tablet 1 mg 1 MO

exemestane oral tablet 25 mg 1 MO

letrozole oral tablet 2.5 mg 1 MO

ENZYME INHIBITORS

COPIKTRA ORAL CAPSULE 15 MG, 25 MG 2 PA; MO

TALZENNA ORAL CAPSULE 0.25 MG, 1 MG 2 PA

VIZIMPRO ORAL TABLET 15 MG, 30 MG, 45

MG

2 PA; MO

MOLECULAR TARGET INHIBITORS

54


limits on use

AFINITOR DISPERZ ORAL TABLET FOR

SUSPENSION 2 MG, 3 MG, 5 MG

2 PA; MO

AFINITOR ORAL TABLET 10 MG, 2.5 MG, 5

MG, 7.5 MG

2 PA; MO

ALECENSA ORAL CAPSULE 150 MG 2 PA; MO

ALUNBRIG ORAL TABLET 180 MG, 30 MG,

90 MG

2 PA; MO

ALUNBRIG ORAL TABLETS,DOSE PACK 90

MG (7)- 180 MG (23)

2 PA

BOSULIF ORAL TABLET 100 MG, 400 MG,

500 MG

2 PA; MO

BRAFTOVI ORAL CAPSULE 50 MG, 75 MG 2 PA; MO

CABOMETYX ORAL TABLET 20 MG, 40 MG,

60 MG

2 PA; MO

CALQUENCE ORAL CAPSULE 100 MG 2 PA; MO

CAPRELSA ORAL TABLET 100 MG, 300 MG 2 PA; MO

COMETRIQ ORAL CAPSULE 100 MG/DAY(80

MG X1-20 MG X1), 140 MG/DAY(80 MG X1-20

MG X3), 60 MG/DAY (20 MG X 3/DAY)

2 PA; MO

COTELLIC ORAL TABLET 20 MG 2 PA; MO

ERIVEDGE ORAL CAPSULE 150 MG 2 PA; MO

FARYDAK ORAL CAPSULE 10 MG, 15 MG, 20

MG

2 PA

GILOTRIF ORAL TABLET 20 MG, 30 MG, 40

MG

2 PA; MO

IBRANCE ORAL CAPSULE 100 MG, 125 MG,

75 MG

2 PA; MO

ICLUSIG ORAL TABLET 15 MG, 45 MG 2 PA; MO

IDHIFA ORAL TABLET 100 MG, 50 MG 2 PA; MO

imatinib oral tablet 100 mg, 400 mg 1 PA; MO

IMBRUVICA ORAL CAPSULE 140 MG, 70 MG 2 PA; MO

IMBRUVICA ORAL TABLET 140 MG, 280 MG,

420 MG, 560 MG

2 PA; MO

INLYTA ORAL TABLET 1 MG, 5 MG 2 PA; MO

IRESSA ORAL TABLET 250 MG 2 PA

55


limits on use

JAKAFI ORAL TABLET 10 MG, 15 MG, 20

MG, 25 MG, 5 MG

2 PA; MO

KISQALI FEMARA CO-PACK ORAL TABLET

200 MG/DAY(200 MG X 1)-2.5 MG, 400

MG/DAY(200 MG X 2)-2.5 MG, 600

MG/DAY(200 MG X 3)-2.5 MG

2 PA; MO

KISQALI ORAL TABLET 200 MG/DAY (200

MG X 1), 400 MG/DAY (200 MG X 2), 600

MG/DAY (200 MG X 3)

2 PA; MO

LENVIMA ORAL CAPSULE 10 MG/DAY (10

MG X 1), 12 MG/DAY (4 MG X 3), 14

MG/DAY(10 MG X 1-4 MG X 1), 18 MG/DAY

(10 MG X 1-4 MG X2), 20 MG/DAY (10 MG X

2), 24 MG/DAY(10 MG X 2-4 MG X 1), 4 MG, 8

MG/DAY (4 MG X 2)

2 PA; MO

LORBRENA ORAL TABLET 100 MG, 25 MG 2 PA; MO

MEKINIST ORAL TABLET 0.5 MG, 2 MG 2 PA; MO

MEKTOVI ORAL TABLET 15 MG 2 PA; MO

NERLYNX ORAL TABLET 40 MG 2 PA

NEXAVAR ORAL TABLET 200 MG 2 PA

RUBRACA ORAL TABLET 200 MG, 250 MG,

300 MG

2 PA; MO

RYDAPT ORAL CAPSULE 25 MG 2 PA; MO

SPRYCEL ORAL TABLET 100 MG, 140 MG, 20

MG, 50 MG, 70 MG, 80 MG

2 PA; MO

STIVARGA ORAL TABLET 40 MG 2 PA

SUTENT ORAL CAPSULE 12.5 MG, 25 MG,

37.5 MG, 50 MG

2 PA

TAFINLAR ORAL CAPSULE 50 MG, 75 MG 2 PA; MO

TAGRISSO ORAL TABLET 40 MG, 80 MG 2 PA

TARCEVA ORAL TABLET 100 MG, 150 MG,

25 MG

2 PA; MO

TASIGNA ORAL CAPSULE 150 MG, 200 MG,

50 MG

2 PA; MO

TIBSOVO ORAL TABLET 250 MG 2 PA; MO

TYKERB ORAL TABLET 250 MG 2 PA; MO

56


limits on use

VERZENIO ORAL TABLET 100 MG, 150 MG,

200 MG, 50 MG

2 PA; MO

VOTRIENT ORAL TABLET 200 MG 2 PA; MO

XALKORI ORAL CAPSULE 200 MG, 250 MG 2 PA; MO

ZEJULA ORAL CAPSULE 100 MG 2 PA; MO

ZELBORAF ORAL TABLET 240 MG 2 PA; MO

ZYKADIA ORAL CAPSULE 150 MG 2 PA; MO

RETINOIDS

bexarotene oral capsule 75 mg 1 MO

PANRETIN TOPICAL GEL 0.1 % 2 PA

TARGRETIN TOPICAL GEL 1 % 2 PA

tretinoin (chemotherapy) oral capsule 10 mg 1

TREATMENT ADJUNCTS

LYSODREN ORAL TABLET 500 MG 2 MO

MOLECULAR TARGET INHIBITORS

DAURISMO ORAL TABLET 100 MG, 25 MG 2 PA; MO

VITRAKVI ORAL CAPSULE 100 MG, 25 MG 2 PA; MO

VITRAKVI ORAL SOLUTION 20 MG/ML 2 PA; MO

XOSPATA ORAL TABLET 40 MG 2 PA; MO

ANTIPARASITICS

ANTHELMINTICS

albendazole oral tablet 200 mg 1

ALBENZA ORAL TABLET 200 MG 2

BILTRICIDE ORAL TABLET 600 MG 2

ivermectin oral tablet 3 mg 1

praziquantel oral tablet 600 mg 1

ANTIPROTOZOALS

ALINIA ORAL SUSPENSION FOR

RECONSTITUTION 100 MG/5 ML

2

ALINIA ORAL TABLET 500 MG 2

atovaquone oral suspension 750 mg/5 ml 1

atovaquone-proguanil oral tablet 250-100 mg,

62.5-25 mg

1

57


limits on use

BENZNIDAZOLE ORAL TABLET 100 MG,

12.5 MG

1 PA

chloroquine phosphate oral tablet 250 mg, 500 mg 1

COARTEM ORAL TABLET 20-120 MG 2

DARAPRIM ORAL TABLET 25 MG 2

hydroxychloroquine oral tablet 200 mg 1 MO

mefloquine oral tablet 250 mg 1

NEBUPENT INHALATION RECON SOLN 300

MG

2 B/D; MO

PENTAM INJECTION RECON SOLN 300 MG 2 PA

PRIMAQUINE ORAL TABLET 26.3 MG 1

quinine sulfate oral capsule 324 mg 1

PEDICULICIDES/ SCABICIDES

GS LICE KILLING SHAMPOO W/NIT COMB

0.33-4 %

3 DP

HM LICE TREATMENT 1% CRM RINSE 1 % 3 DP

LICE KILLING SHAMPOO W/COMB 0.33-4 % 3 DP

LICE KILLING SHAMPOO W/NIT COMB 0.33-

4 %

3 DP

LICE TREATMENT 1% CREME RINSE 1 NIT

REMOVAL COMB 1 %

3 DP

LICE TREATMENT SHAMPOO 1 NIT COMB

INCLUDED 0.33-4 %

3 DP

lindane topical shampoo 1 % 1

malathion topical lotion 0.5 % 1

permethrin topical cream 5 % 1

SB LICE KILLING SHAMPOO MAXIMUM

STRENGTH 0.33-4 %

3 DP

SM LICE TREATMENT 1% CRM RINSE 1 % 3 DP

ANTIPARKINSON AGENTS

ANTICHOLINERGICS

benztropine oral tablet 0.5 mg, 1 mg, 2 mg 1 PA; MO

trihexyphenidyl oral elixir 0.4 mg/ml 1 PA; MO

trihexyphenidyl oral tablet 2 mg, 5 mg 1 PA; MO

58


limits on use

ANTIPARKINSON AGENTS, OTHER

amantadine hcl oral capsule 100 mg 1 MO

amantadine hcl oral solution 50 mg/5 ml 1 MO

amantadine hcl oral tablet 100 mg 1 MO

entacapone oral tablet 200 mg 1 MO

GOCOVRI ORAL CAPSULE,EXTENDED

RELEASE 24HR 137 MG, 68.5 MG

2 PA; MO

tolcapone oral tablet 100 mg 1 MO

DOPAMINE AGONISTS

APOKYN SUBCUTANEOUS CARTRIDGE 10

MG/ML

2 PA; MO

bromocriptine oral capsule 5 mg 1 MO

bromocriptine oral tablet 2.5 mg 1 MO

NEUPRO TRANSDERMAL PATCH 24 HOUR 1

MG/24 HOUR, 2 MG/24 HOUR, 3 MG/24

HOUR, 4 MG/24 HOUR, 6 MG/24 HOUR, 8

MG/24 HOUR

2 MO

pramipexole oral tablet 0.125 mg, 0.25 mg, 0.5

mg, 0.75 mg, 1 mg, 1.5 mg

1 MO

pramipexole oral tablet extended release 24 hr

0.375 mg, 0.75 mg, 1.5 mg, 2.25 mg, 3 mg, 3.75

mg, 4.5 mg

1 MO

ropinirole oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg,

3 mg, 4 mg, 5 mg

1 MO

ropinirole oral tablet extended release 24 hr 12

mg, 2 mg, 4 mg, 6 mg, 8 mg

1 MO

DOPAMINE PRECURSORS/ L-AMINO ACID DECARBOXYLASE INHIBITORS

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

mg, 25-250 mg

1 MO

carbidopa-levodopa oral tablet extended release

25-100 mg, 50-200 mg

1 MO

carbidopa-levodopa oral tablet,disintegrating 10-

100 mg, 25-100 mg, 25-250 mg

1 MO

carbidopa-levodopa-entacapone oral tablet 12.5-

50-200 mg, 18.75-75-200 mg, 25-100-200 mg,

31.25-125-200 mg, 37.5-150-200 mg, 50-200-200

mg

1 MO

59


limits on use

MONOAMINE OXIDASE B (MAO-B) INHIBITORS

rasagiline oral tablet 0.5 mg, 1 mg 1 MO

selegiline hcl oral capsule 5 mg 1 MO

selegiline hcl oral tablet 5 mg 1 MO

ANTIPSYCHOTICS

1ST GENERATION/ TYPICAL

fluphenazine decanoate injection solution 25

mg/ml

1 MO

fluphenazine hcl injection solution 2.5 mg/ml 1

fluphenazine hcl oral concentrate 5 mg/ml 1

fluphenazine hcl oral elixir 2.5 mg/5 ml 1 MO

fluphenazine hcl oral tablet 1 mg, 10 mg, 2.5 mg, 5

mg

1 MO

haloperidol decanoate intramuscular solution 100

mg/ml, 50 mg/ml

1 MO

haloperidol lactate injection solution 5 mg/ml 1

haloperidol lactate intramuscular syringe 5 mg/ml 1

haloperidol lactate oral concentrate 2 mg/ml 1 MO

haloperidol oral tablet 0.5 mg, 1 mg, 10 mg, 2 mg,

20 mg, 5 mg

1 MO

loxapine succinate oral capsule 10 mg, 25 mg, 5

mg, 50 mg

1 MO

molindone oral tablet 10 mg, 25 mg, 5 mg 1 MO

pimozide oral tablet 1 mg, 2 mg 1 MO

thioridazine oral tablet 10 mg, 100 mg, 25 mg, 50

mg

1 PA; MO

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

trifluoperazine oral tablet 1 mg, 10 mg, 2 mg, 5

mg

1 MO

2ND GENERATION/ ATYPICAL

ABILIFY MAINTENA INTRAMUSCULAR

SUSPENSION,EXTENDED REL RECON 300

MG, 400 MG

2 PA; MO; QL (1 EA per 28 days)

60


limits on use

ABILIFY MAINTENA INTRAMUSCULAR

SUSPENSION,EXTENDED REL SYRING 300

MG, 400 MG


aripiprazole oral solution 1 mg/ml 1 MO; QL (900 ML per 30 days)

aripiprazole oral tablet 10 mg, 15 mg, 2 mg, 20

mg, 30 mg, 5 mg


aripiprazole oral tablet,disintegrating 10 mg, 15

mg


ARISTADA INITIO INTRAMUSCULAR


MG/2.4 ML

2 PA

ARISTADA INTRAMUSCULAR

SUSPENSION,EXTENDED REL SYRING 1,064

MG/3.9 ML

2 PA; MO; QL (3.9 ML per 56 days)



MG/1.6 ML




MG/2.4 ML




MG/3.2 ML


FANAPT ORAL TABLET 1 MG, 10 MG, 12

MG, 2 MG, 4 MG, 6 MG, 8 MG


FANAPT ORAL TABLETS,DOSE PACK

1MG(2)-2MG(2)- 4MG(2)-6MG(2)

2 PA

GEODON INTRAMUSCULAR RECON SOLN

20 MG/ML (FINAL CONC.)

2 B/D; QL (6 EA per 3 days)

INVEGA SUSTENNA INTRAMUSCULAR

SYRINGE 117 MG/0.75 ML



SYRINGE 156 MG/ML

2 PA; MO; QL (1 ML per 28 days)










61


limits on use

INVEGA TRINZA INTRAMUSCULAR












LATUDA ORAL TABLET 120 MG, 20 MG, 40

MG, 60 MG


LATUDA ORAL TABLET 80 MG 2 PA; MO; QL (60 EA per 30 days)

NUPLAZID ORAL CAPSULE 34 MG 2 PA; MO; QL (30 EA per 30 days)

NUPLAZID ORAL TABLET 10 MG 2 PA; MO; QL (30 EA per 30 days)

NUPLAZID ORAL TABLET 17 MG 2 PA; MO; QL (60 EA per 30 days)

olanzapine intramuscular recon soln 10 mg 1 QL (90 EA per 30 days)

olanzapine oral tablet 10 mg, 15 mg, 2.5 mg, 20

mg, 5 mg, 7.5 mg


olanzapine oral tablet,disintegrating 10 mg, 15

mg, 20 mg, 5 mg


paliperidone oral tablet extended release 24hr 1.5

mg, 3 mg, 9 mg


paliperidone oral tablet extended release 24hr 6

mg


PERSERIS ABDOMINAL SUBCUTANEOUS

SUSPENSION,EXTEND REL SYR KIT 120 MG,

90 MG

2 PA; MO

quetiapine oral tablet 100 mg, 200 mg, 300 mg,

400 mg


quetiapine oral tablet 25 mg, 50 mg 1 MO; QL (90 EA per 30 days)

quetiapine oral tablet extended release 24 hr 150

mg, 200 mg


quetiapine oral tablet extended release 24 hr 300

mg, 400 mg, 50 mg


REXULTI ORAL TABLET 0.25 MG, 0.5 MG, 1

MG, 2 MG, 3 MG, 4 MG


62


limits on use

RISPERDAL CONSTA INTRAMUSCULAR

SYRINGE 12.5 MG/2 ML, 25 MG/2 ML, 37.5

MG/2 ML, 50 MG/2 ML


risperidone oral solution 1 mg/ml 1 MO; QL (240 ML per 30 days)

risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2

mg, 3 mg


risperidone oral tablet 4 mg 1 MO; QL (120 EA per 30 days)

risperidone oral tablet,disintegrating 0.25 mg, 0.5

mg, 1 mg, 2 mg, 3 mg


risperidone oral tablet,disintegrating 4 mg 1 MO; QL (120 EA per 30 days)

SAPHRIS (BLACK CHERRY) SUBLINGUAL

TABLET 10 MG, 5 MG


SAPHRIS SUBLINGUAL TABLET 10 MG, 5

MG


SAPHRIS SUBLINGUAL TABLET 2.5 MG 2 MO; QL (60 EA per 30 days)

VRAYLAR ORAL CAPSULE 1.5 MG, 3 MG, 4.5

MG, 6 MG


VRAYLAR ORAL CAPSULE,DOSE PACK 1.5

MG (1)- 3 MG (6)


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

80 mg


ZYPREXA RELPREVV INTRAMUSCULAR

SUSPENSION FOR RECONSTITUTION 210

MG, 300 MG


ZYPREXA RELPREVV INTRAMUSCULAR


MG


TREATMENT-RESISTANT

clozapine oral tablet 100 mg 1 MO; QL (270 EA per 30 days)

clozapine oral tablet 200 mg 1 MO; QL (120 EA per 30 days)

clozapine oral tablet 25 mg, 50 mg 1 MO; QL (90 EA per 30 days)

clozapine oral tablet,disintegrating 100 mg 1 MO; QL (270 EA per 30 days)

clozapine oral tablet,disintegrating 12.5 mg, 25

mg

1 MO



VERSACLOZ ORAL SUSPENSION 50 MG/ML 2 MO; QL (540 ML per 30 days)

63


limits on use

ANTISPASTICITY AGENTS

ANTISPASTICITY AGENTS

baclofen oral tablet 10 mg, 20 mg, 5 mg 1 MO

dantrolene oral capsule 100 mg, 25 mg, 50 mg 1 MO

tizanidine oral tablet 2 mg, 4 mg 1 MO

ANTIVIRALS

ANTI-CYTOMEGALOVIRUS (CMV) AGENTS

ganciclovir sodium intravenous solution 50 mg/ml 1 B/D

PREVYMIS ORAL TABLET 240 MG, 480 MG 2 PA

valganciclovir oral recon soln 50 mg/ml 1 MO

valganciclovir oral tablet 450 mg 1 MO

ZIRGAN OPHTHALMIC (EYE) GEL 0.15 % 2 ST

ANTI-HEPATITIS B (HBV) AGENTS

ADEFOVIR ORAL TABLET 10 MG 1 PA

BARACLUDE ORAL SOLUTION 0.05 MG/ML 2 MO

entecavir oral tablet 0.5 mg, 1 mg 1 MO

EPIVIR HBV ORAL SOLUTION 25 MG/5 ML

(5 MG/ML)

2 MO

lamivudine oral solution 10 mg/ml 1 MO

lamivudine oral tablet 100 mg, 300 mg 1 MO; QL (30 EA per 30 days)

lamivudine oral tablet 150 mg 1 MO; QL (60 EA per 30 days)

PEGASYS PROCLICK SUBCUTANEOUS PEN

INJECTOR 180 MCG/0.5 ML

2 PA

PEGASYS SUBCUTANEOUS SOLUTION 180

MCG/ML

2 PA

PEGASYS SUBCUTANEOUS SYRINGE 180

MCG/0.5 ML

2 PA

tenofovir disoproxil fumarate oral tablet 300 mg 1 MO

VEMLIDY ORAL TABLET 25 MG 2 MO

VIREAD ORAL POWDER 40 MG/SCOOP (40

MG/GRAM)

2 MO

VIREAD ORAL TABLET 150 MG, 200 MG, 250

MG

2 MO

64


limits on use

ANTI-HEPATITIS C (HCV) AGENTS, DIRECT ACTING AGENTS

MAVYRET ORAL TABLET 100-40 MG 2 PA

VOSEVI ORAL TABLET 400-100-100 MG 2 PA

ANTI-HEPATITIS C (HCV) AGENTS, OTHER

INTRON A INJECTION RECON SOLN 10

MILLION UNIT (1 ML), 18 MILLION UNIT (1

ML), 50 MILLION UNIT (1 ML)

2 PA

INTRON A INJECTION SOLUTION 10

MILLION UNIT/ML, 6 MILLION UNIT/ML

2 PA

RIBAVIRIN ORAL CAPSULE 200 MG 1

RIBAVIRIN ORAL TABLET 200 MG 1

ANTIHERPETIC AGENTS

ABREVA 10% CREAM 10 % 3 DP

acyclovir oral capsule 200 mg 1 MO

acyclovir oral suspension 200 mg/5 ml 1 MO

acyclovir oral tablet 400 mg, 800 mg 1 MO

acyclovir sodium intravenous solution 50 mg/ml 1 B/D

acyclovir topical ointment 5 % 1

DENAVIR TOPICAL CREAM 1 % 2

famciclovir oral tablet 125 mg, 250 mg, 500 mg 1 MO

trifluridine ophthalmic (eye) drops 1 % 1

valacyclovir oral tablet 1 gram, 500 mg 1 MO

ZOVIRAX TOPICAL CREAM 5 % 2

ANTI-HIV AGENTS, INTEGRASE INHIBITORS (INSTI)

GENVOYA ORAL TABLET 150-150-200-10

MG


ISENTRESS HD ORAL TABLET 600 MG 2 MO; QL (60 EA per 30 days)

ISENTRESS ORAL POWDER IN PACKET 100

MG

2 MO

ISENTRESS ORAL TABLET 400 MG 2 MO; QL (120 EA per 30 days)

ISENTRESS ORAL TABLET,CHEWABLE 100

MG, 25 MG


JULUCA ORAL TABLET 50-25 MG 2 MO; QL (30 EA per 30 days)

65


limits on use

STRIBILD ORAL TABLET 150-150-200-300

MG


TIVICAY ORAL TABLET 10 MG 2 MO; QL (300 EA per 30 days)



TRIUMEQ ORAL TABLET 600-50-300 MG 2 MO; QL (30 EA per 30 days)

ANTI-HIV AGENTS, NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS

(NNRTI)

ATRIPLA ORAL TABLET 600-200-300 MG 2 MO; QL (30 EA per 30 days)

COMPLERA ORAL TABLET 200-25-300 MG 2 MO; QL (30 EA per 30 days)

DELSTRIGO ORAL TABLET 100-300-300 MG 2 MO; QL (30 EA per 30 days)

EDURANT ORAL TABLET 25 MG 2 MO; QL (30 EA per 30 days)

efavirenz oral capsule 200 mg 1 MO; QL (120 EA per 30 days)

efavirenz oral capsule 50 mg 1 MO; QL (360 EA per 30 days)

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

INTELENCE ORAL TABLET 100 MG, 25 MG 2 MO; QL (120 EA per 30 days)

INTELENCE ORAL TABLET 200 MG 2 MO; QL (60 EA per 30 days)

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

nevirapine oral tablet extended release 24 hr 100

mg


nevirapine oral tablet extended release 24 hr 400

mg


ODEFSEY ORAL TABLET 200-25-25 MG 2 MO; QL (30 EA per 30 days)

PIFELTRO ORAL TABLET 100 MG 2 MO; QL (30 EA per 30 days)

RESCRIPTOR ORAL TABLET 200 MG 2 MO; QL (180 EA per 30 days)

RESCRIPTOR ORAL TABLET, DISPERSIBLE

100 MG


SYMFI LO ORAL TABLET 400-300-300 MG 2 MO; QL (30 EA per 30 days)

VIRAMUNE ORAL SUSPENSION 50 MG/5 ML 2 MO

ANTI-HIV AGENTS, NUCLEOSIDE AND NUCLEOTIDE REVERSE TRANSCRIPTASE

INHIBITORS (NRTI)

abacavir oral solution 20 mg/ml 1 MO

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

66


limits on use

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

abacavir-lamivudine-zidovudine oral tablet 300-

150-300 mg


CIMDUO ORAL TABLET 300-300 MG 2 MO; QL (30 EA per 30 days)

DESCOVY ORAL TABLET 200-25 MG 2 MO; QL (30 EA per 30 days)

didanosine oral capsule,delayed release(dr/ec)

125 mg



200 mg



250 mg, 400 mg


EMTRIVA ORAL CAPSULE 200 MG 2 MO; QL (30 EA per 30 days)

EMTRIVA ORAL SOLUTION 10 MG/ML 2 MO

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

stavudine oral capsule 15 mg, 20 mg 1 MO; QL (120 EA per 30 days)

stavudine oral capsule 30 mg, 40 mg 1 MO; QL (60 EA per 30 days)

TRUVADA ORAL TABLET 100-150 MG, 133-

200 MG, 167-250 MG, 200-300 MG


VIDEX 2 GRAM PEDIATRIC ORAL RECON

SOLN 10 MG/ML (FINAL)

2 MO

VIDEX 4 GRAM PEDIATRIC ORAL RECON

SOLN 10 MG/ML (FINAL)

2 MO

VIDEX EC ORAL CAPSULE,DELAYED

RELEASE(DR/EC) 125 MG


ZERIT ORAL RECON SOLN 1 MG/ML 2 MO

zidovudine oral capsule 100 mg 1 MO; QL (180 EA per 30 days)

zidovudine oral syrup 10 mg/ml 1 MO

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

ANTI-HIV AGENTS, OTHER

BIKTARVY ORAL TABLET 50-200-25 MG 2 MO; QL (30 EA per 30 days)

FUZEON SUBCUTANEOUS RECON SOLN 90

MG

2 MO

selzentry oral solution 20 mg/ml 2 MO

SELZENTRY ORAL TABLET 150 MG, 75 MG 2 MO; QL (60 EA per 30 days)

SELZENTRY ORAL TABLET 25 MG, 300 MG 2 MO; QL (120 EA per 30 days)

67


limits on use

SYMFI ORAL TABLET 600-300-300 MG 2 MO; QL (30 EA per 30 days)

SYMTUZA ORAL TABLET 800-150-200-10 MG 2 MO; QL (30 EA per 30 days)

TYBOST ORAL TABLET 150 MG 2 MO; QL (30 EA per 30 days)

ANTI-HIV AGENTS, PROTEASE INHIBITORS

APTIVUS ORAL CAPSULE 250 MG 2 MO; QL (120 EA per 30 days)

APTIVUS ORAL SOLUTION 100 MG/ML 2 MO

atazanavir oral capsule 150 mg, 300 mg 1 MO; QL (30 EA per 30 days)

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

CRIXIVAN ORAL CAPSULE 200 MG 2 MO; QL (360 EA per 30 days)

CRIXIVAN ORAL CAPSULE 400 MG 2 MO; QL (180 EA per 30 days)

EVOTAZ ORAL TABLET 300-150 MG 2 MO; QL (30 EA per 30 days)

fosamprenavir oral tablet 700 mg 1 MO; QL (120 EA per 30 days)

INVIRASE ORAL TABLET 500 MG 2 MO; QL (120 EA per 30 days)

KALETRA ORAL TABLET 100-25 MG 2 MO; QL (240 EA per 30 days)

KALETRA ORAL TABLET 200-50 MG 2 MO; QL (120 EA per 30 days)

LEXIVA ORAL SUSPENSION 50 MG/ML 2 MO

lopinavir-ritonavir oral solution 400-100 mg/5 ml 1 MO

NORVIR ORAL POWDER IN PACKET 100 MG 2 MO; QL (360 EA per 30 days)

NORVIR ORAL SOLUTION 80 MG/ML 2 MO

PREZCOBIX ORAL TABLET 800-150 MG-MG 2 MO; QL (30 EA per 30 days)

PREZISTA ORAL SUSPENSION 100 MG/ML 2 MO

PREZISTA ORAL TABLET 150 MG 2 MO; QL (180 EA per 30 days)




REYATAZ ORAL POWDER IN PACKET 50

MG

2 MO

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

VIRACEPT ORAL TABLET 250 MG 2 MO; QL (300 EA per 30 days)

VIRACEPT ORAL TABLET 625 MG 2 MO; QL (120 EA per 30 days)

ANTI-INFLUENZA AGENTS

oseltamivir oral capsule 30 mg 1 QL (84 EA per 180 days)

68


limits on use

oseltamivir oral capsule 45 mg, 75 mg 1 QL (42 EA per 180 days)

oseltamivir oral suspension for reconstitution 6

mg/ml


RELENZA DISKHALER INHALATION

BLISTER WITH DEVICE 5 MG/ACTUATION


rimantadine oral tablet 100 mg 1

ANXIOLYTICS

ANXIOLYTICS, OTHER

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

7.5 mg

1 MO

hydroxyzine pamoate oral capsule 100 mg, 25 mg,

50 mg

1 PA

BENZODIAZEPINES

ALPRAZOLAM INTENSOL ORAL

CONCENTRATE 1 MG/ML


alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg 1 QL (120 EA per 30 days)

alprazolam oral tablet 2 mg 1 QL (150 EA per 30 days)

alprazolam oral tablet extended release 24 hr 0.5

mg, 1 mg


alprazolam oral tablet extended release 24 hr 2

mg


alprazolam oral tablet extended release 24 hr 3

mg


clonazepam oral tablet 0.5 mg, 1 mg 1 PA; MO; QL (90 EA per 30 days)

clonazepam oral tablet 2 mg 1 PA; MO; QL (300 EA per 30 days)

clonazepam oral tablet,disintegrating 0.125 mg,

0.25 mg, 0.5 mg, 1 mg


clonazepam oral tablet,disintegrating 2 mg 1 PA; MO; QL (300 EA per 30 days)

clorazepate dipotassium oral tablet 15 mg 1 PA; QL (180 EA per 30 days)

clorazepate dipotassium oral tablet 3.75 mg, 7.5

mg


diazepam intensol oral concentrate 5 mg/ml 1 PA; QL (240 ML per 30 days)

diazepam oral concentrate 5 mg/ml 1 PA; QL (240 ML per 30 days)

diazepam oral solution 5 mg/5 ml (1 mg/ml), 5

mg/5 ml (1 mg/ml, 5 ml)

1 PA; QL (1200 ML per 30 days)

diazepam oral tablet 10 mg, 2 mg, 5 mg 1 PA; QL (120 EA per 30 days)

69


limits on use

lorazepam intensol oral concentrate 2 mg/ml 1 QL (150 ML per 30 days)

lorazepam oral concentrate 2 mg/ml 1 QL (150 ML per 30 days)

lorazepam oral tablet 0.5 mg, 1 mg 1 QL (90 EA per 30 days)

lorazepam oral tablet 2 mg 1 QL (150 EA per 30 days)

BIPOLAR AGENTS

MOOD STABILIZERS

carbamazepine oral capsule, er multiphase 12 hr

100 mg, 200 mg, 300 mg

1 MO

EQUETRO ORAL CAPSULE, ER

MULTIPHASE 12 HR 100 MG, 200 MG, 300

MG

2 MO

lamotrigine oral tablet 100 mg, 150 mg, 200 mg,

25 mg

1 MO

lithium carbonate oral capsule 150 mg, 300 mg,

600 mg

1 MO

lithium carbonate oral tablet 300 mg 1 MO

lithium carbonate oral tablet extended release 300

mg, 450 mg

1 MO

lithium citrate oral solution 8 meq/5 ml 1 MO

BLOOD GLUCOSE REGULATORS

ANTIDIABETIC AGENTS

acarbose oral tablet 100 mg, 25 mg, 50 mg 1 ST; MO; QL (90 EA per 30 days)

alogliptin oral tablet 12.5 mg, 25 mg, 6.25 mg 1 ST; MO; QL (30 EA per 30 days)

alogliptin-metformin oral tablet 12.5-1,000 mg,

12.5-500 mg


alogliptin-pioglitazone oral tablet 12.5-15 mg,

12.5-30 mg, 12.5-45 mg, 25-15 mg, 25-30 mg, 25-

45 mg


AVANDIA ORAL TABLET 2 MG, 4 MG 2 ST; MO; QL (60 EA per 30 days)

DM2 COMBO PACK, TABLET AND STRIP 500

MG


glimepiride oral tablet 1 mg 1 MO; QL (240 EA per 30 days)



70


limits on use

glipizide oral tablet 10 mg 1 MO; QL (120 EA per 30 days)

glipizide oral tablet 5 mg 1 MO; QL (240 EA per 30 days)

glipizide oral tablet extended release 24hr 10 mg 1 MO; QL (60 EA per 30 days)

glipizide oral tablet extended release 24hr 2.5 mg 1 MO; QL (240 EA per 30 days)

glipizide oral tablet extended release 24hr 5 mg 1 MO; QL (90 EA per 30 days)

glipizide-metformin oral tablet 2.5-250 mg 1 MO; QL (240 EA per 30 days)

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

mg


glyburide micronized oral tablet 1.5 mg, 3 mg 1 PA; MO; QL (90 EA per 30 days)

glyburide micronized oral tablet 6 mg 1 PA; MO; QL (60 EA per 30 days)

glyburide oral tablet 1.25 mg, 2.5 mg 1 PA; MO; QL (60 EA per 30 days)

glyburide oral tablet 5 mg 1 PA; MO

glyburide-metformin oral tablet 1.25-250 mg 1 PA; MO; QL (240 EA per 30 days)

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

mg


INVOKAMET ORAL TABLET 150-1,000 MG,

150-500 MG, 50-1,000 MG


INVOKAMET ORAL TABLET 50-500 MG 2 ST; MO; QL (120 EA per 30 days)

INVOKAMET XR ORAL TABLET, IR - ER,

BIPHASIC 24HR 150-1,000 MG, 150-500 MG,

50-1,000 MG, 50-500 MG


INVOKANA ORAL TABLET 100 MG, 300 MG 2 ST; MO; QL (30 EA per 30 days)

JANUMET ORAL TABLET 50-1,000 MG, 50-

500 MG


JANUMET XR ORAL TABLET, ER

MULTIPHASE 24 HR 100-1,000 MG


JANUMET XR ORAL TABLET, ER

MULTIPHASE 24 HR 50-1,000 MG, 50-500 MG


JANUVIA ORAL TABLET 100 MG, 25 MG, 50

MG


JENTADUETO ORAL TABLET 2.5-1,000 MG,

2.5-500 MG, 2.5-850 MG


JENTADUETO XR ORAL TABLET, IR - ER,

BIPHASIC 24HR 2.5-1,000 MG


JENTADUETO XR ORAL TABLET, IR - ER,

BIPHASIC 24HR 5-1,000 MG


71


limits on use

KORLYM ORAL TABLET 300 MG 2 PA; MO

metformin oral tablet 1,000 mg 1 MO; QL (75 EA per 30 days)

metformin oral tablet 500 mg 1 MO; QL (150 EA per 30 days)

metformin oral tablet 850 mg 1 MO; QL (90 EA per 30 days)

metformin oral tablet extended release 24 hr 500

mg


metformin oral tablet extended release 24 hr 750

mg


nateglinide oral tablet 120 mg, 60 mg 1 ST; MO; QL (90 EA per 30 days)

OZEMPIC SUBCUTANEOUS PEN INJECTOR

0.25 MG OR 0.5 MG(2 MG/1.5 ML), 1

MG/DOSE (2 MG/1.5 ML)

2 ST; MO; QL (3 ML per 28 days)

pioglitazone oral tablet 15 mg, 30 mg, 45 mg 1 ST; MO; QL (30 EA per 30 days)

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

850 mg


repaglinide oral tablet 0.5 mg, 1 mg 1 ST; MO; QL (120 EA per 30 days)

repaglinide oral tablet 2 mg 1 ST; MO

SEGLUROMET ORAL TABLET 2.5-1,000 MG,

7.5-1,000 MG, 7.5-500 MG


SEGLUROMET ORAL TABLET 2.5-500 MG 2 ST; MO; QL (120 EA per 30 days)

STEGLATRO ORAL TABLET 15 MG, 5 MG 2 ST; MO; QL (30 EA per 30 days)

STEGLUJAN ORAL TABLET 15-100 MG, 5-100

MG


SYMLINPEN 120 SUBCUTANEOUS PEN

INJECTOR 2,700 MCG/2.7 ML

2 PA; MO

SYMLINPEN 60 SUBCUTANEOUS PEN

INJECTOR 1,500 MCG/1.5 ML

2 PA; MO

TRADJENTA ORAL TABLET 5 MG 2 ST; MO; QL (30 EA per 30 days)

TRULICITY SUBCUTANEOUS PEN

INJECTOR 0.75 MG/0.5 ML, 1.5 MG/0.5 ML


VICTOZA 2-PAK SUBCUTANEOUS PEN

INJECTOR 0.6 MG/0.1 ML (18 MG/3 ML)


VICTOZA 3-PAK SUBCUTANEOUS PEN

INJECTOR 0.6 MG/0.1 ML (18 MG/3 ML)


BLOOD GLUCOSE REGULATORS

72


limits on use

alcohol pads topical pads, medicated 1

assure id insulin safety syringe 1 ml 29 gauge x

1/2"

1 MO

gauze pad topical bandage 2 x 2 " 1

insulin syringe-needle u-100 syringe 0.3 ml 29

gauge, 1/2 ml 28 gauge

1

insulin syringe-needle u-100 syringe 1 ml 29

gauge x 1/2"

1 MO

pen needle, diabetic needle 29 gauge x 1/2" 1

GLYCEMIC AGENTS

GLUCAGEN DIAGNOSTIC KIT INJECTION

RECON SOLN 1 MG/ML


GLUCAGEN HYPOKIT INJECTION RECON

SOLN 1 MG


GLUCAGON EMERGENCY KIT (HUMAN)

INJECTION RECON SOLN 1 MG


GLUCAGON HCL INJECTION RECON SOLN 1

MG


hm glucose 4 gram tablet chew orange flavor 4

gram

3 DP

hm glucose 4 gram tablet chew raspberry flavor 4

gram

3 DP

PROGLYCEM ORAL SUSPENSION 50 MG/ML 2 MO

sm glucose 4 gram tab chew 6's 4 gram 3 DP

INSULINS

HUMALOG JUNIOR KWIKPEN U-100

SUBCUTANEOUS INSULIN PEN, HALF-UNIT

100 UNIT/ML

2 MO

HUMALOG KWIKPEN INSULIN

SUBCUTANEOUS INSULIN PEN 100

UNIT/ML, 200 UNIT/ML (3 ML)

2 MO

HUMALOG MIX 50-50 INSULN U-100

SUBCUTANEOUS SUSPENSION 100 UNIT/ML

(50-50)

2 MO

HUMALOG MIX 50-50 KWIKPEN


UNIT/ML (50-50)

2 MO

73


limits on use

HUMALOG MIX 75-25 KWIKPEN


UNIT/ML (75-25)

2 MO

HUMALOG MIX 75-25(U-100)INSULN


(75-25)

2 MO

HUMALOG U-100 INSULIN SUBCUTANEOUS

CARTRIDGE 100 UNIT/ML

2 MO


SOLUTION 100 UNIT/ML

2 MO


SOLUTION 100 UNIT/ML (PREFILLED

SYRINGE)

2

HUMULIN 70/30 U-100 INSULIN


(70-30)

2

HUMULIN N NPH U-100 INSULIN


2

HUMULIN R REGULAR U-100 INSULN

INJECTION SOLUTION 100 UNIT/ML

2

HUMULIN R U-500 (CONC) INSULIN

SUBCUTANEOUS SOLUTION 500 UNIT/ML

2 MO

HUMULIN R U-500 (CONC) KWIKPEN


UNIT/ML (3 ML)

2 MO

LANTUS SOLOSTAR U-100 INSULIN


UNIT/ML (3 ML)

2 MO

LANTUS U-100 INSULIN SUBCUTANEOUS


2 MO

LEVEMIR FLEXTOUCH U-100 INSULN


UNIT/ML (3 ML)

2 MO

LEVEMIR U-100 INSULIN SUBCUTANEOUS


2 MO

NOVOLIN 70/30 U-100 INSULIN


(70-30)

2

74


limits on use

NOVOLIN N NPH U-100 INSULIN


2

NOVOLIN R REGULAR U-100 INSULN

INJECTION SOLUTION 100 UNIT/ML

2

NOVOLOG FLEXPEN U-100 INSULIN


UNIT/ML

2 MO

NOVOLOG MIX 70-30 U-100 INSULN


(70-30)

2 MO

NOVOLOG MIX 70-30FLEXPEN U-100


UNIT/ML (70-30)

2 MO

NOVOLOG PENFILL U-100 INSULIN

SUBCUTANEOUS CARTRIDGE 100 UNIT/ML

2 MO

NOVOLOG U-100 INSULIN ASPART


2 MO

TOUJEO MAX U-300 SOLOSTAR


UNIT/ML (3 ML)

2 MO

TOUJEO SOLOSTAR U-300 INSULIN


UNIT/ML (1.5 ML)

2 MO

BLOOD PRODUCTS/ MODIFIERS/ VOLUME EXPANDERS

ANTICOAGULANTS

COUMADIN ORAL TABLET 1 MG, 10 MG, 2

MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG

2 MO

ELIQUIS ORAL TABLET 2.5 MG, 5 MG 2 MO

ELIQUIS ORAL TABLETS,DOSE PACK 5 MG

(74 TABS)

2

enoxaparin subcutaneous solution 300 mg/3 ml 1

enoxaparin subcutaneous syringe 100 mg/ml, 120

mg/0.8 ml, 150 mg/ml, 30 mg/0.3 ml, 40 mg/0.4 ml,

60 mg/0.6 ml, 80 mg/0.8 ml

1

fondaparinux subcutaneous syringe 10 mg/0.8 ml,

2.5 mg/0.5 ml, 5 mg/0.4 ml, 7.5 mg/0.6 ml

1

FRAGMIN SUBCUTANEOUS SOLUTION

25,000 ANTI-XA UNIT/ML

2

75


limits on use

FRAGMIN SUBCUTANEOUS SYRINGE 10,000

ANTI-XA UNIT/ML, 12,500 ANTI-XA UNIT/0.5

ML, 15,000 ANTI-XA UNIT/0.6 ML, 18,000

ANTI-XA UNIT/0.72 ML, 2,500 ANTI-XA

UNIT/0.2 ML, 5,000 ANTI-XA UNIT/0.2 ML,

7,500 ANTI-XA UNIT/0.3 ML

2

heparin (porcine) injection cartridge 5,000 unit/ml

(1 ml)

1

heparin (porcine) injection solution 1,000 unit/ml 1

heparin (porcine) injection solution 10,000

unit/ml, 5,000 unit/ml

1 B/D

heparin, porcine (pf) injection solution 1,000

unit/ml, 5,000 unit/0.5 ml

1

jantoven oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3

mg, 4 mg, 5 mg, 6 mg, 7.5 mg

1 MO

PRADAXA ORAL CAPSULE 110 MG, 150 MG,

75 MG

2 MO

warfarin oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3

mg, 4 mg, 5 mg, 6 mg, 7.5 mg

1 MO

XARELTO ORAL TABLET 10 MG, 15 MG, 2.5

MG, 20 MG

2 MO

XARELTO ORAL TABLETS,DOSE PACK 15

MG (42)- 20 MG (9)

2

BLOOD FORMATION MODIFIERS

anagrelide oral capsule 0.5 mg, 1 mg 1 MO

ARANESP (IN POLYSORBATE) INJECTION

SOLUTION 100 MCG/ML, 150 MCG/0.75 ML,

200 MCG/ML, 25 MCG/ML, 300 MCG/ML, 40

MCG/ML, 60 MCG/ML

2 PA; MO

ARANESP (IN POLYSORBATE) INJECTION

SYRINGE 10 MCG/0.4 ML, 100 MCG/0.5 ML,

150 MCG/0.3 ML, 200 MCG/0.4 ML, 25

MCG/0.42 ML, 300 MCG/0.6 ML, 40 MCG/0.4

ML, 500 MCG/ML, 60 MCG/0.3 ML

2 PA; MO

DOPTELET (10 TAB PACK) ORAL TABLET 20

MG

2 PA

DOPTELET (15 TAB PACK) ORAL TABLET 20

MG

2 PA

76


limits on use

DOPTELET ORAL TABLET 20 MG, 20 MG (15

PACK)

2 PA

EPOGEN INJECTION SOLUTION 10,000

UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML,

20,000 UNIT/ML, 3,000 UNIT/ML, 4,000

UNIT/ML

2 PA; MO

GRANIX SUBCUTANEOUS SOLUTION 300

MCG/ML, 480 MCG/1.6 ML

2 PA

GRANIX SUBCUTANEOUS SYRINGE 300

MCG/0.5 ML, 480 MCG/0.8 ML

2 PA

LEUKINE INJECTION RECON SOLN 250 MCG 2 PA

NEULASTA SUBCUTANEOUS SYRINGE 6

MG/0.6ML

2 PA

NEULASTA SUBCUTANEOUS SYRINGE, W/

WEARABLE INJECTOR 6 MG/0.6 ML

2 PA

NEUPOGEN INJECTION SOLUTION 300

MCG/ML, 480 MCG/1.6 ML

2 PA

NEUPOGEN INJECTION SYRINGE 300

MCG/0.5 ML, 480 MCG/0.8 ML

2 PA

NIVESTYM SUBCUTANEOUS SYRINGE 300

MCG/0.5 ML, 480 MCG/0.8 ML

2 PA

PROCRIT INJECTION SOLUTION 10,000

UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML,

20,000 UNIT/ML, 3,000 UNIT/ML, 4,000

UNIT/ML, 40,000 UNIT/ML

2 PA; MO

PROMACTA ORAL TABLET 12.5 MG, 25 MG,

50 MG, 75 MG


ZARXIO INJECTION SYRINGE 300 MCG/0.5

ML, 480 MCG/0.8 ML

2 PA

HEMOSTASIS AGENTS

MEPHYTON 5 MG TABLET 5 MG 3 DP

tranexamic acid oral tablet 650 mg 1 MO

VITAMIN K-1 1 MG/0.5 ML AMPUL LATEX-

FREE, SDV 1 MG/0.5 ML

3 DP

VITAMIN K-1 1 MG/0.5 ML AMPUL

SDV,LATEX-FREE 1 MG/0.5 ML

3 DP

VITAMIN K-1 10 MG/ML AMPUL LATEX-

FREE, SDV 10 MG/ML

3 DP

77


limits on use

VITAMIN K-1 10 MG/ML AMPUL

SDV,LATEX-FREE 10 MG/ML

3 DP

PLATELET MODIFYING AGENTS

ASPIR EC 81 MG TABLET 81 MG 3 DP

aspirin 81 mg chewable tablet 81 mg 3 DP

aspirin 81 mg chewable tablet child low dose 81

mg

3 DP

aspirin 81 mg chewable tablet gluten-free, orange

81 mg

3 DP

aspirin 81 mg chewable tablet low dose 81 mg 3 DP

aspirin 81 mg chewable tablet low dose, cherry 81

mg

3 DP

aspirin 81 mg chewable tablet orange 81 mg 3 DP

aspirin 81 mg chewable tablet orange,gluten-free

81 mg

3 DP

aspirin 81 mg chewable tablet tab chew,orange 81

mg

3 DP

aspirin 81 mg chewable tablet u-d 81 mg 3 DP

aspirin ec 81 mg tablet 81 mg 3 DP

aspirin ec 81 mg tablet adult low dose 81 mg 3 DP

aspirin ec 81 mg tablet low dose 81 mg 3 DP

aspirin ec 81 mg tablet low dose sfty coated 81 mg 3 DP

aspirin ec 81 mg tablet u-d,10x10 81 mg 3 DP

aspirin ec 81 mg tablet u-d,25x30 81 mg 3 DP

aspirin-dipyridamole oral capsule, er multiphase

12 hr 25-200 mg

1 MO

ASPIR-LOW EC 81 MG TABLET 81 MG 3 DP

BRILINTA ORAL TABLET 60 MG, 90 MG 2 MO

CHILD ASPIRIN 81 MG CHEW TAB

CHILDREN'S 81 MG

3 DP

cilostazol oral tablet 100 mg, 50 mg 1 MO

clopidogrel oral tablet 75 mg 1 MO

dipyridamole oral tablet 25 mg, 50 mg, 75 mg 1 PA; MO

gs aspirin 81 mg chewable tab 81 mg 3 DP

78


limits on use

hm aspirin 81 mg chewable tab adlt low

dose,orange 81 mg

3 DP

hm aspirin ec 81 mg tablet 81 mg 3 DP

hm aspirin ec 81 mg tablet low dose 81 mg 3 DP

prasugrel oral tablet 10 mg, 5 mg 1 MO

qc aspirin 81 mg chewable tab low dose, orange

81 mg

3 DP

qc aspirin ec 81 mg tablet 81 mg 3 DP

sb aspirin ec 81 mg tablet adult low strength 81

mg

3 DP

sb aspirin ec 81 mg tablet low dose,sfty coated 81

mg

3 DP

sm aspirin 81 mg chewable tab adult low strength

81 mg

3 DP

sm aspirin ec 81 mg tablet adult low strength 81

mg

3 DP

SM CHILD ASPIRIN 81 MG CHW TAB

CHILDREN'S 81 MG

3 DP

CARDIOVASCULAR AGENTS

ALPHA-ADRENERGIC AGONISTS

clonidine hcl oral tablet 0.1 mg, 0.2 mg, 0.3 mg 1 MO

clonidine transdermal patch weekly 0.1 mg/24 hr,

0.2 mg/24 hr, 0.3 mg/24 hr

1 MO

guanfacine oral tablet 1 mg, 2 mg 1 PA; MO

methyldopa oral tablet 250 mg, 500 mg 1 PA; MO

midodrine oral tablet 10 mg, 2.5 mg, 5 mg 1

NORTHERA ORAL CAPSULE 100 MG, 200

MG, 300 MG

2 MO

ALPHA-ADRENERGIC BLOCKING AGENTS

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

phenoxybenzamine oral capsule 10 mg 1 PA

prazosin oral capsule 1 mg, 2 mg, 5 mg 1 MO

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

ANGIOTENSIN II RECEPTOR ANTAGONISTS

irbesartan oral tablet 150 mg, 300 mg, 75 mg 1 MO

79


limits on use

losartan oral tablet 100 mg, 25 mg, 50 mg 1 MO

olmesartan oral tablet 20 mg, 40 mg, 5 mg 1 MO

valsartan oral tablet 160 mg, 320 mg, 40 mg, 80

mg

1 MO

ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITORS

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

captopril oral tablet 100 mg, 12.5 mg, 25 mg, 50

mg

1 MO

enalapril maleate oral tablet 10 mg, 2.5 mg, 20

mg, 5 mg

1 MO

fosinopril oral tablet 10 mg, 20 mg, 40 mg 1 MO

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

40 mg, 5 mg

1 MO

moexipril oral tablet 15 mg, 7.5 mg 1 MO

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

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

mg

1 MO

trandolapril oral tablet 1 mg, 2 mg, 4 mg 1 MO

ANTIARRHYTHMICS

amiodarone oral tablet 100 mg, 200 mg, 400 mg 1 MO

disopyramide phosphate oral capsule 100 mg, 150

mg

1 PA; MO

dofetilide oral capsule 125 mcg, 250 mcg, 500 mcg 1 MO

flecainide oral tablet 100 mg, 150 mg, 50 mg 1 MO

mexiletine oral capsule 150 mg, 200 mg, 250 mg 1 MO

MULTAQ ORAL TABLET 400 MG 2 MO

NORPACE CR ORAL CAPSULE, EXTENDED

RELEASE 100 MG, 150 MG

2 PA; MO

propafenone oral tablet 150 mg, 225 mg, 300 mg 1 MO

quinidine gluconate oral tablet extended release

324 mg

1 MO

quinidine sulfate oral tablet 200 mg, 300 mg 1 MO

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

sotalol af oral tablet 120 mg, 160 mg, 80 mg 1 MO

80


limits on use

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

BETA-ADRENERGIC BLOCKING AGENTS

acebutolol oral capsule 200 mg, 400 mg 1 MO

atenolol oral tablet 100 mg, 25 mg, 50 mg 1 MO

betaxolol oral tablet 10 mg, 20 mg 1 MO

bisoprolol fumarate oral tablet 10 mg, 5 mg 1 MO

BYSTOLIC ORAL TABLET 10 MG, 2.5 MG, 20

MG, 5 MG

2 MO

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

6.25 mg

1 MO

labetalol oral tablet 100 mg, 200 mg, 300 mg 1 MO

metoprolol succinate oral tablet extended release

24 hr 100 mg, 200 mg, 25 mg, 50 mg

1 MO

metoprolol ta-hydrochlorothiaz oral tablet 100-25

mg, 100-50 mg, 50-25 mg

1 MO

metoprolol tartrate oral tablet 100 mg, 25 mg, 50

mg

1 MO

nadolol oral tablet 20 mg, 40 mg, 80 mg 1 MO

pindolol oral tablet 10 mg, 5 mg 1 MO

propranolol oral capsule,extended release 24 hr

120 mg, 160 mg, 60 mg, 80 mg

1 MO

propranolol oral solution 20 mg/5 ml (4 mg/ml),

40 mg/5 ml (8 mg/ml)

1 MO

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

mg, 80 mg

1 MO

timolol maleate oral tablet 10 mg, 20 mg, 5 mg 1 MO

CALCIUM CHANNEL BLOCKING AGENTS

amlodipine oral tablet 10 mg, 2.5 mg, 5 mg 1 MO

cartia xt oral capsule,extended release 24hr 120

mg, 180 mg, 240 mg, 300 mg

1 MO

diltiazem hcl oral capsule,ext.rel 24h degradable

120 mg, 180 mg, 240 mg

1 MO

diltiazem hcl oral capsule,extended release 12 hr

120 mg, 60 mg, 90 mg

1 MO

diltiazem hcl oral capsule,extended release 24 hr

120 mg, 180 mg, 240 mg, 300 mg, 360 mg, 420 mg

1 MO

81


limits on use

diltiazem hcl oral capsule,extended release 24hr

120 mg, 180 mg, 240 mg, 300 mg, 360 mg

1 MO

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

mg

1 MO

dilt-xr oral capsule,ext.rel 24h degradable 120

mg, 180 mg, 240 mg

1 MO

felodipine oral tablet extended release 24 hr 10

mg, 2.5 mg, 5 mg

1 MO

isradipine oral capsule 2.5 mg, 5 mg 1 MO

nifedical xl oral tablet extended release 24hr 30

mg, 60 mg

1 MO

nifedipine oral capsule 10 mg, 20 mg 1 PA; MO

nifedipine oral tablet extended release 24hr 30 mg,

60 mg, 90 mg

1 MO

nifedipine oral tablet extended release 30 mg, 60

mg, 90 mg

1 MO

nimodipine oral capsule 30 mg 1

taztia xt oral capsule,extended release 24 hr 120

mg, 180 mg, 240 mg, 300 mg, 360 mg

1 MO

verapamil oral capsule, 24 hr er pellet ct 100 mg,

200 mg, 300 mg

1 MO

verapamil oral capsule,ext rel. pellets 24 hr 120

mg, 180 mg, 240 mg, 360 mg

1 MO

verapamil oral tablet 120 mg, 40 mg, 80 mg 1 MO

verapamil oral tablet extended release 120 mg (24

hours)

1

verapamil oral tablet extended release 120 mg,

180 mg, 240 mg

1 MO

CARDIOVASCULAR AGENTS, OTHER

amiloride-hydrochlorothiazide oral tablet 5-50 mg 1 MO

amlodipine-benazepril oral capsule 10-20 mg, 10-

40 mg, 2.5-10 mg, 5-10 mg, 5-20 mg, 5-40 mg

1 MO

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

40 mg, 5-20 mg, 5-40 mg

1 MO

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

320 mg, 5-160 mg, 5-320 mg

1 MO

82


limits on use

amlodipine-valsartan-hcthiazid oral tablet 10-160-

12.5 mg, 10-160-25 mg, 10-320-25 mg, 5-160-12.5

mg, 5-160-25 mg

1 MO

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

25 mg

1 MO

benazepril-hydrochlorothiazide oral tablet 10-12.5

mg, 20-12.5 mg, 20-25 mg, 5-6.25 mg

1 MO

bisoprolol-hydrochlorothiazide oral tablet 10-6.25

mg, 2.5-6.25 mg, 5-6.25 mg

1 MO

captopril-hydrochlorothiazide oral tablet 25-15

mg, 25-25 mg, 50-15 mg, 50-25 mg

1 MO

CORLANOR ORAL TABLET 5 MG, 7.5 MG 2 PA; MO

DEMSER ORAL CAPSULE 250 MG 2 PA

digitek oral tablet 125 mcg 1 MO; QL (30 EA per 30 days)

digitek oral tablet 250 mcg 1 PA; MO

digox oral tablet 125 mcg 1 MO; QL (30 EA per 30 days)

digox oral tablet 250 mcg 1 PA; MO

digoxin oral solution 50 mcg/ml 1 PA; MO

digoxin oral tablet 125 mcg 1 MO; QL (30 EA per 30 days)

digoxin oral tablet 250 mcg 1 PA; MO

enalapril-hydrochlorothiazide oral tablet 10-25

mg, 5-12.5 mg

1 MO

ENTRESTO ORAL TABLET 24-26 MG, 49-51

MG, 97-103 MG

2 MO

fosinopril-hydrochlorothiazide oral tablet 10-12.5

mg, 20-12.5 mg

1 MO

irbesartan-hydrochlorothiazide oral tablet 150-

12.5 mg, 300-12.5 mg

1 MO

lisinopril-hydrochlorothiazide oral tablet 10-12.5

mg, 20-12.5 mg, 20-25 mg

1 MO

losartan-hydrochlorothiazide oral tablet 100-12.5

mg, 100-25 mg, 50-12.5 mg

1 MO

methyldopa-hydrochlorothiazide oral tablet 250-

15 mg, 250-25 mg

1 PA; MO

moexipril-hydrochlorothiazide oral tablet 15-12.5

mg, 15-25 mg, 7.5-12.5 mg

1 MO

83


limits on use

olmesartan-amlodipin-hcthiazid oral tablet 20-5-

12.5 mg, 40-10-12.5 mg, 40-10-25 mg, 40-5-12.5

mg, 40-5-25 mg

1 MO

olmesartan-hydrochlorothiazide oral tablet 20-

12.5 mg, 40-12.5 mg, 40-25 mg

1 MO

pentoxifylline oral tablet extended release 400 mg 1 MO

propranolol-hydrochlorothiazid oral tablet 40-25

mg, 80-25 mg

1 MO

quinapril-hydrochlorothiazide oral tablet 10-12.5

mg, 20-12.5 mg, 20-25 mg

1 MO

RANEXA ORAL TABLET EXTENDED

RELEASE 12 HR 1,000 MG, 500 MG

2 ST; MO

spironolacton-hydrochlorothiaz oral tablet 25-25

mg

1 MO

TEKTURNA HCT ORAL TABLET 150-12.5

MG, 150-25 MG, 300-12.5 MG, 300-25 MG

2 MO

TEKTURNA ORAL TABLET 150 MG, 300 MG 2 MO

triamterene-hydrochlorothiazid oral capsule 37.5-

25 mg

1 MO

triamterene-hydrochlorothiazid oral tablet 37.5-25

mg, 75-50 mg

1 MO

valsartan-hydrochlorothiazide oral tablet 160-12.5

mg, 160-25 mg, 320-12.5 mg, 320-25 mg, 80-12.5

mg

1 MO

DIURETICS, CARBONIC ANHYDRASE INHIBITORS

acetazolamide oral capsule, extended release 500

mg

1 MO

acetazolamide oral tablet 125 mg, 250 mg 1 MO

KEVEYIS ORAL TABLET 50 MG 2 PA; MO

methazolamide oral tablet 25 mg, 50 mg 1 MO

DIURETICS, LOOP

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

furosemide injection solution 10 mg/ml 1

furosemide injection syringe 10 mg/ml 1

furosemide oral solution 10 mg/ml, 40 mg/5 ml (8

mg/ml)

1 MO

84


limits on use

furosemide oral tablet 20 mg, 40 mg, 80 mg 1 MO

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

DIURETICS, POTASSIUM-SPARING

amiloride oral tablet 5 mg 1 MO

eplerenone oral tablet 25 mg, 50 mg 1 MO

spironolactone oral tablet 100 mg, 25 mg, 50 mg 1 MO

DIURETICS, THIAZIDE

chlorothiazide oral tablet 250 mg, 500 mg 1 MO

chlorthalidone oral tablet 25 mg, 50 mg 1 MO

hydrochlorothiazide oral capsule 12.5 mg 1 MO

hydrochlorothiazide oral tablet 12.5 mg, 25 mg, 50

mg

1 MO

indapamide oral tablet 1.25 mg, 2.5 mg 1 MO

methyclothiazide oral tablet 5 mg 1 MO

metolazone oral tablet 10 mg, 2.5 mg, 5 mg 1 MO

DYSLIPIDEMICS, FIBRIC ACID DERIVATIVES

fenofibrate micronized oral capsule 134 mg, 200

mg, 43 mg, 67 mg

1 MO

fenofibrate nanocrystallized oral tablet 145 mg,

160 mg, 48 mg

1 MO

fenofibrate oral tablet 160 mg, 54 mg 1 MO

fenofibric acid (choline) oral capsule,delayed

release(dr/ec) 135 mg, 45 mg

1 MO

fenofibric acid oral tablet 35 mg 1 MO

gemfibrozil oral tablet 600 mg 1 MO

DYSLIPIDEMICS, HMG COA REDUCTASE INHIBITORS

atorvastatin oral tablet 10 mg, 20 mg, 40 mg, 80

mg

1 MO

LIVALO ORAL TABLET 1 MG, 2 MG, 4 MG 2 MO

lovastatin oral tablet 10 mg, 20 mg, 40 mg 1 MO

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

mg

1 MO

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

mg

1 MO

85


limits on use

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

80 mg

1 MO

DYSLIPIDEMICS, OTHER

cholestyramine (with sugar) oral powder 4 gram 1 MO

cholestyramine (with sugar) oral powder in packet

4 gram

1 MO

cholestyramine light oral powder 4 gram 1 MO

cholestyramine light oral powder in packet 4 gram 1 MO

colesevelam oral powder in packet 3.75 gram 1 MO

colesevelam oral tablet 625 mg 1 MO

colestipol oral granules 5 gram 1 MO

colestipol oral packet 5 gram 1 MO

colestipol oral tablet 1 gram 1 MO

ezetimibe oral tablet 10 mg 1 MO

ezetimibe-simvastatin oral tablet 10-10 mg, 10-20

mg, 10-40 mg, 10-80 mg

1 MO

JUXTAPID ORAL CAPSULE 10 MG, 20 MG, 30

MG, 40 MG, 5 MG, 60 MG

2 PA; MO

KYNAMRO SUBCUTANEOUS SYRINGE 200

MG/ML

2 PA; MO

niacin 500 mg tablet 500 mg 3 DP

niacin oral tablet extended release 24 hr 1,000 mg,

500 mg, 750 mg

1 MO

niacin tr 500 mg caplet caplet 500 mg 3 DP

niacin tr 500 mg capsule 500 mg 3 DP

niacinamide 500 mg tablet 500 mg 3 DP

omega-3 acid ethyl esters oral capsule 1 gram 1 MO

prevalite oral powder 4 gram 1 MO

prevalite oral powder in packet 4 gram 1 MO

REPATHA PUSHTRONEX SUBCUTANEOUS

WEARABLE INJECTOR 420 MG/3.5 ML

2 PA; MO

REPATHA SURECLICK SUBCUTANEOUS

PEN INJECTOR 140 MG/ML

2 PA; MO

86


limits on use

REPATHA SYRINGE SUBCUTANEOUS

SYRINGE 140 MG/ML

2 PA; MO

TRIKLO ORAL CAPSULE 1 GRAM 1 MO

VASODILATORS, DIRECT-ACTING ARTERIAL

hydralazine oral tablet 10 mg, 100 mg, 25 mg, 50

mg

1 MO

minoxidil oral tablet 10 mg, 2.5 mg 1 MO

VASODILATORS, DIRECT-ACTING ARTERIAL/ VENOUS

isosorbide dinitrate oral tablet 10 mg, 20 mg, 30

mg, 5 mg

1 MO

isosorbide dinitrate oral tablet extended release 40

mg

1 MO

isosorbide mononitrate oral tablet 10 mg, 20 mg 1 MO

isosorbide mononitrate oral tablet extended

release 24 hr 120 mg, 30 mg, 60 mg

1 MO

NITRO-BID TRANSDERMAL OINTMENT 2 % 2 MO

NITRO-DUR TRANSDERMAL PATCH 24

HOUR 0.3 MG/HR, 0.8 MG/HR

2 MO

nitroglycerin sublingual tablet 0.3 mg, 0.4 mg, 0.6

mg

1 MO

nitroglycerin transdermal patch 24 hour 0.1

mg/hr, 0.2 mg/hr, 0.4 mg/hr, 0.6 mg/hr

1 MO

nitroglycerin translingual aerosol,spray 400

mcg/spray

1 MO

nitroglycerin translingual spray,non-aerosol 400

mcg/spray

1 MO

CENTRAL NERVOUS SYSTEM AGENTS

ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, AMPHETAMINES

dextroamphetamine oral capsule, extended release

10 mg



15 mg



5 mg


dextroamphetamine oral tablet 10 mg 1 PA; MO; QL (180 EA per 30 days)

dextroamphetamine oral tablet 5 mg 1 PA; MO; QL (60 EA per 30 days)

87


limits on use

dextroamphetamine-amphetamine oral

capsule,extended release 24hr 10 mg, 15 mg, 20

mg, 25 mg, 30 mg, 5 mg


dextroamphetamine-amphetamine oral tablet 10

mg, 20 mg, 30 mg, 5 mg, 7.5 mg


dextroamphetamine-amphetamine oral tablet 12.5

mg


dextroamphetamine-amphetamine oral tablet 15

mg


ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, NON-

AMPHETAMINES

atomoxetine oral capsule 10 mg, 100 mg, 18 mg,

25 mg, 40 mg, 60 mg, 80 mg

1 MO

clonidine hcl oral tablet extended release 12 hr 0.1

mg


dexmethylphenidate oral capsule,er biphasic 50-

50 10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 35 mg, 40

mg, 5 mg

1 PA; MO

dexmethylphenidate oral tablet 10 mg, 2.5 mg, 5

mg

1 PA; MO

guanfacine oral tablet extended release 24 hr 1

mg, 2 mg, 3 mg, 4 mg

1 MO

methylphenidate hcl oral capsule, er biphasic 30-

70 10 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg

1 PA; MO

methylphenidate hcl oral capsule,er biphasic 50-

50 20 mg, 30 mg, 40 mg, 60 mg

1 PA; MO

methylphenidate hcl oral solution 10 mg/5 ml, 5

mg/5 ml

1 PA; MO

methylphenidate hcl oral tablet 10 mg, 20 mg, 5

mg

1 PA; MO

methylphenidate hcl oral tablet extended release

10 mg

1 PA; MO


20 mg



24hr 18 mg



24hr 27 mg


88


limits on use


24hr 36 mg



24hr 54 mg


methylphenidate hcl oral tablet,chewable 10 mg,

2.5 mg, 5 mg

1 PA; MO

CENTRAL NERVOUS SYSTEM, OTHER

AUSTEDO ORAL TABLET 12 MG, 6 MG, 9

MG

2 PA; MO

FIRDAPSE ORAL TABLET 10 MG 2 PA

INGREZZA ORAL CAPSULE 40 MG, 80 MG 2 PA; MO

NUEDEXTA ORAL CAPSULE 20-10 MG 2 PA

riluzole oral tablet 50 mg 1 MO

tetrabenazine oral tablet 12.5 mg, 25 mg 1 PA; MO

FIBROMYALGIA AGENTS

duloxetine oral capsule,delayed release(dr/ec) 20

mg, 30 mg, 60 mg

1 MO

SAVELLA ORAL TABLET 100 MG, 12.5 MG,

25 MG, 50 MG

2 MO

SAVELLA ORAL TABLETS,DOSE PACK 12.5

MG (5)-25 MG(8)-50 MG(42)

2

MULTIPLE SCLEROSIS AGENTS

AUBAGIO ORAL TABLET 14 MG, 7 MG 2 PA; MO

BETASERON SUBCUTANEOUS KIT 0.3 MG 2 PA; MO

BETASERON SUBCUTANEOUS RECON

SOLN 0.3 MG

2 PA

dalfampridine oral tablet extended release 12 hr

10 mg

1 PA; MO

EXTAVIA SUBCUTANEOUS RECON SOLN

0.3 MG

2 PA; MO

GILENYA ORAL CAPSULE 0.5 MG 2 PA; MO

glatiramer subcutaneous syringe 20 mg/ml, 40

mg/ml

1 PA; MO

GLATOPA SUBCUTANEOUS SYRINGE 20

MG/ML, 40 MG/ML

1 PA; MO

89


limits on use

REBIF (WITH ALBUMIN) SUBCUTANEOUS

SYRINGE 22 MCG/0.5 ML, 44 MCG/0.5 ML

2 PA; MO

REBIF REBIDOSE SUBCUTANEOUS PEN

INJECTOR 22 MCG/0.5 ML, 44 MCG/0.5 ML

2 PA; MO

REBIF REBIDOSE SUBCUTANEOUS PEN

INJECTOR 8.8MCG/0.2ML-22 MCG/0.5ML (6)

2 PA

REBIF TITRATION PACK SUBCUTANEOUS

SYRINGE 8.8MCG/0.2ML-22 MCG/0.5ML (6)

2 PA

TECFIDERA ORAL CAPSULE,DELAYED

RELEASE(DR/EC) 120 MG (14)- 240 MG (46)

2 PA

TECFIDERA ORAL CAPSULE,DELAYED

RELEASE(DR/EC) 120 MG, 240 MG

2 PA; MO

DENTAL AND ORAL AGENTS

DENTAL AND ORAL AGENTS

cevimeline oral capsule 30 mg 1 MO

chlorhexidine gluconate mucous membrane

mouthwash 0.12 %

1

periogard mucous membrane mouthwash 0.12 % 1

pilocarpine hcl oral tablet 5 mg, 7.5 mg 1 MO

triamcinolone acetonide dental paste 0.1 % 1

DERMATOLOGICAL AGENTS

DERMATOLOGICAL AGENTS

acitretin oral capsule 10 mg, 17.5 mg, 25 mg 1 PA

ACNE MEDICATION 10% GEL 10 % 3 DP

ACNE MEDICATION 5% GEL 5 % 3 DP

adapalene topical gel 0.1 % 1

adapalene-benzoyl peroxide topical gel with pump

0.1-2.5 %

1

ammonium lactate topical cream 12 % 1

ammonium lactate topical lotion 12 % 1

AMNESTEEM ORAL CAPSULE 10 MG, 20

MG, 40 MG

1

benzoyl peroxide 10% gel aqueous (otc) 10 % 3 DP

calcipotriene scalp solution 0.005 % 1

90


limits on use

calcipotriene topical cream 0.005 % 1

calcipotriene topical ointment 0.005 % 1

CLARAVIS ORAL CAPSULE 10 MG, 20 MG,

30 MG, 40 MG

1

clindamycin-benzoyl peroxide topical gel 1-5 %,

1.2 %(1 % base) -5 %

1

clindamycin-benzoyl peroxide topical gel with

pump 1-5 %, 1.2-2.5 %

1

clotrimazole-betamethasone topical cream 1-0.05

%

1

clotrimazole-betamethasone topical lotion 1-0.05

%

1

COLEMAN BOTANICALS INSECT SPR 30 % 3 DP

COLEMAN HIGH-DRY 25% REPEL SPR 25 % 3 DP

COLEMAN SKINSMART INSECT REP 20 % 3 DP

COLEMAN SKINSMART INSECT REP 20 % 3 DP

COLEMAN SPORTSMN 40% REPEL SPR 40 % 3 DP

COSENTYX (2 SYRINGES) SUBCUTANEOUS

SYRINGE 150 MG/ML

2 PA; MO

COSENTYX PEN (2 PENS) SUBCUTANEOUS

PEN INJECTOR 150 MG/ML

2 PA; MO

COSENTYX PEN SUBCUTANEOUS PEN

INJECTOR 150 MG/ML

2 PA; MO

COSENTYX SUBCUTANEOUS SYRINGE 150

MG/ML

2 PA; MO

CUTTER BACKWOODS 25% SPRAY 25 % 3 DP

CUTTER BACKWOODS 25% SPRAY 25 % 3 DP

CUTTER BACKWOODS DRY 25% SPRAY 25

%

3 DP

CUTTER LEMON EUCALYPTUS SPRAY 30 % 3 DP

CUTTER NATURAL REPELLENT2 SPRY 5-2

%

3 DP

CUTTER SKINSATIONS 7% SPRAY 7 % 3 DP

CVS INSECT REPELLENT 15% SPRAY 15 % 3 DP

CVS TOTAL HOME INSECT 30% SPR 30 % 3 DP

DOXEPIN TOPICAL CREAM 5 % 1 MO

91


limits on use

DUPIXENT SUBCUTANEOUS SYRINGE 200

MG/1.14 ML, 300 MG/2 ML

2 PA; MO

ELIDEL TOPICAL CREAM 1 % 2 ST

erythromycin-benzoyl peroxide topical gel 3-5 % 1

EUCRISA TOPICAL OINTMENT 2 % 2 PA

GS ANTI-ITCH 1% CREAM 1 % 3 DP

HYDRO SKIN 1% LOTION 1 % 3 DP

hydrocortisone 1% cream 1 % 3 DP

hydrocortisone-min oil-wht pet topical ointment 1

%

1

imiquimod topical cream in packet 5 % 1

isotretinoin oral capsule 10 mg, 20 mg, 30 mg, 40

mg

1

methoxsalen oral capsule,liqd-filled,rapid rel 10

mg

1 PA

myorisan oral capsule 10 mg, 20 mg, 30 mg, 40

mg

1

NATRAPEL 20% SPRAY 20 % 3 DP

nystatin-triamcinolone topical cream 100,000-0.1

unit/g-%

1

nystatin-triamcinolone topical ointment 100,000-

0.1 unit/gram-%

1

OFF ACTIVE 15% SPRAY 15 % 3 DP

OFF DEEP WOODS 25% SPRAY 25 % 3 DP

OFF DEEP WOODS 25% SPRAY 25 % 3 DP

OFF DEEP WOODS DRY 25% SPRAY 25 % 3 DP

OFF DEEP WOODS SPORTMN 25% SPR 25 % 3 DP

OFF DEEP WOODS SPORTMN 30% SPR 30 % 3 DP

OFF DEEP WOODS SPORTMN 98.25% 98.25 % 3 DP

OFF FAMILYCARE 15% RPLNT I SPR 15 % 3 DP

OFF FAMILYCARE 5% RPLNT II SPR 5 % 3 DP

OFF FAMILYCARE 7% RPLNT SPRAY 7 % 3 DP

pimecrolimus topical cream 1 % 1 ST

podofilox topical solution 0.5 % 1

92


limits on use

prednicarbate topical cream 0.1 % 1

prednicarbate topical ointment 0.1 % 1

REGRANEX TOPICAL GEL 0.01 % 2 PA; QL (15 GM per 30 days)

REPEL 100 98.11% SPRAY 98.11 % 3 DP

REPEL FAMILY 10% SPRAY 10 % 3 DP

REPEL FAMILY 15% SPRAY 15 % 3 DP

REPEL HUNTER'S 25% SPRAY 25 % 3 DP

REPEL LEMON EUCALYPTUS 30% SPR 30 % 3 DP

REPEL SPORTSMEN 25% SPRAY 25 % 3 DP

REPEL SPORTSMEN DRY 25% SPRAY 25 % 3 DP

REPEL SPORTSMEN MAX 40% LOTION 40 % 3 DP

REPEL SPORTSMEN MAX 40% SPRAY 40 % 3 DP

REPEL SPORTSMEN MAX 40% SPRAY 40 % 3 DP

REPEL TICK DEFENSE 15% SPRAY 15 % 3 DP

SANTYL TOPICAL OINTMENT 250

UNIT/GRAM

2

selenium sulfide topical lotion 2.5 % 1

STELARA SUBCUTANEOUS SOLUTION 45

MG/0.5 ML

2 PA; MO

STELARA SUBCUTANEOUS SYRINGE 45

MG/0.5 ML, 90 MG/ML

2 PA; MO

tacrolimus topical ointment 0.03 %, 0.1 % 1 ST

tazarotene topical cream 0.1 % 1

TAZORAC TOPICAL CREAM 0.05 % 2

TAZORAC TOPICAL GEL 0.05 %, 0.1 % 2

TREMFYA SUBCUTANEOUS SYRINGE 100

MG/ML

2 PA; MO

tretinoin (emollient) topical cream 0.05 % 1

tretinoin topical cream 0.025 %, 0.05 %, 0.1 % 1

tretinoin topical gel 0.01 %, 0.025 % 1

ULTRATHON 25% REPELLENT SPRAY 25 % 3 DP

ULTRATHON 34.34% REPEL LOTION 34.34 % 3 DP

ZENATANE ORAL CAPSULE 10 MG, 20 MG,

30 MG, 40 MG

1

93


limits on use

zinc oxide 20% ointment 20 % 3 DP

ELECTROLYTES/MINERALS/ METALS/ VITAMINS

ELECTROLYTE/MINERAL REPLACEMENT

AMINOSYN 7 % WITH ELECTROLYTES

INTRAVENOUS PARENTERAL SOLUTION 7

%

2 B/D

aminosyn 8.5 %-electrolytes intravenous

parenteral solution 8.5 %

1 B/D

AMINOSYN II 10 % INTRAVENOUS

PARENTERAL SOLUTION 10 %

2 B/D

AMINOSYN II 15 % INTRAVENOUS


2 B/D

AMINOSYN II 8.5 % INTRAVENOUS

PARENTERAL SOLUTION 8.5 %

2 B/D

aminosyn ii 8.5 %-electrolytes intravenous


1 B/D

AMINOSYN-HBC 7% INTRAVENOUS


2 B/D

AMINOSYN-PF 10 % INTRAVENOUS


2 B/D

AMINOSYN-PF 7 % (SULFITE-FREE)


%

2 B/D

AMINOSYN-RF 5.2 % INTRAVENOUS

PARENTERAL SOLUTION 5.2 %

2 B/D

AQUADEKS PEDIATRIC LIQUID 400

MCG/ML

3 DP

BALANCED B-50 TABLET 3 DP

biotin 300 mcg tablet s/f,p/f,lactose-free 300 mcg 3 DP

biotin 5 mg tablet 5 mg 3 DP

CALCITRATE 200 MG (950 MG) TAB 200 MG

(950 MG)

3 DP

calcium 600 mg tablet 600 mg calcium (1,500 mg) 3 DP

CALCIUM 600 MG TABLET 600 MG

CALCIUM (1,500 MG)

3 DP

CALCIUM 600-VIT D3 200 TABLET 600

MG(1,500MG) -200 UNIT

3 DP

94


limits on use

calcium carb 1,250 mg/5 ml sus 40's,u-d,a/f 500

mg/5 ml (1,250 mg/5 ml)

3 DP

calcium carb 1,250 mg/5 ml sus 500 mg/5 ml

(1,250 mg/5 ml)

3 DP

calcium carb 1,250 mg/5 ml sus s/f, a/f, na/f 500

mg/5 ml (1,250 mg/5 ml)

3 DP

calcium carb 500 (1,250) mg tb 500 mg calcium

(1,250 mg)

3 DP

calcium carbonate 1.25 gm tab 500 mg calcium

(1,250 mg)

3 DP

calcium carbonate 648 mg tab 260 mg calcium

(648 mg)

3 DP

calcium gluconate 500 mg tab 45 mg (500 mg) 3 DP

CARBAGLU ORAL TABLET, DISPERSIBLE

200 MG

2 PA; MO

CERTAVITE SR-ANTIOXIDANT TAB 0.4-300-

250 MG-MCG-MCG

3 DP

CHILD CHEW + IRON TAB CHEW 3 DP

CHILD CHEW VITAMIN TABLET 3 DP

child ferrous sulfate 15 mg/ml 15 mg iron (75

mg)/ml

3 DP

clinimix 4.25%/d10w sulf free intravenous


1 B/D

clinimix 4.25%-d25w sulf-free intravenous


1 B/D

clinisol sf 15 % intravenous parenteral solution 15

%

1 B/D

d10 %-0.45 % sodium chloride intravenous

parenteral solution

1

d2.5 %-0.45 % sodium chloride intravenous

parenteral solution

1

d5 % and 0.9 % sodium chloride intravenous

parenteral solution

1

d5 %-0.45 % sodium chloride intravenous

parenteral solution

1

DEKAS ESSENTIAL CAPSULE 2,000 UNIT-

2000 UNIT-1,000 MCG

3 DP

95


limits on use

DEKAS ESSENTIAL LIQUID 2,000 UNIT-

2,000 MCG/ML

3 DP

DEKAS PLUS CHEWABLE TABLET 200

MCG-1,000 MCG-10 MG

3 DP

DEKAS PLUS LIQUID 500 MCG/ML 3 DP

DEKAS PLUS SOFTGEL 200 MCG-1,000 MCG-

10 MG

3 DP

dextrose 10 % and 0.2 % nacl intravenous

parenteral solution

1

dextrose 10 % in water (d10w) intravenous

parenteral solution 10 %

1


parenteral solution

1


piggyback 5 %

1

dextrose 5%-0.2 % sod chloride intravenous

parenteral solution

1

dextrose 5%-0.3 % sod.chloride intravenous

parenteral solution

1

DEXTROSE WITH SODIUM CHLORIDE

INTRAVENOUS PARENTERAL SOLUTION 5-

0.2 %

1

ELDERTONIC ELIXIR 0.5-0.6-7-0.7 MG 3 DP

ENDARI ORAL POWDER IN PACKET 5

GRAM

2 PA

FERGON 27 MG TABLET 240 MG (27 MG

IRON)

3 DP

FER-IN-SOL 15 MG/ML DROPS 15 MG IRON

(75 MG)/ML

3 DP

FEROSUL 220 MG/5 ML ELIXIR 220 MG (44

MG IRON)/5 ML

3 DP

FEROSUL 325 MG TABLET F/C 325 MG (65

MG IRON)

3 DP

FEROSUL 325 MG TABLET F/C,BLISTER

PACK 325 MG (65 MG IRON)

3 DP

FERRO-TIME 325 MG TABLET F/C, GREEN

325 MG (65 MG IRON)

3 DP

96


limits on use

ferrous fumarate 324 mg tab 324 mg (106 mg

iron)

3 DP

ferrous gluconate 324 mg tab 324 mg (37.5 mg

iron), 324 mg (38 mg iron)

3 DP

ferrous sulf 15 mg iron/ml drp 15 mg iron (75

mg)/ml

3 DP

ferrous sulf 15 mg iron/ml drp gluten-free 15 mg

iron (75 mg)/ml

3 DP

ferrous sulf 220 mg/5 ml elix 220 mg (44 mg

iron)/5 ml

3 DP

ferrous sulf 220 mg/5 ml liq 220 mg (44 mg iron)/5

ml

3 DP

ferrous sulf 300 mg/5 ml liq 300 mg (60 mg iron)/5

ml

3 DP

ferrous sulf ec 324 mg tablet 324 mg (65 mg iron) 3 DP

ferrous sulf ec 325 mg tablet 325 mg (65 mg iron) 3 DP

ferrous sulf ec 325 mg tablet u-d, inner 325 mg (65

mg iron)

3 DP

ferrous sulf ec 325 mg tablet u-d, outer 325 mg (65

mg iron)

3 DP

ferrous sulfate 325 mg tablet 325 mg (65 mg iron) 3 DP

ferrous sulfate 325 mg tablet f/c 325 mg (65 mg

iron)

3 DP

ferrous sulfate 325 mg tablet f/c, green 325 mg (65

mg iron)

3 DP

ferrous sulfate 325 mg tablet f/c, red 325 mg (65

mg iron)

3 DP

ferrous sulfate 325 mg tablet u-d,10x10, film coat

325 mg (65 mg iron)

3 DP

FERROUSUL 325 MG TABLET 325 MG (65

MG IRON)

3 DP

FLUORIDE (SODIUM) ORAL TABLET 1 MG

(2.2 MG SOD. FLUORIDE)

1

folic acid 1 mg tablet (rx) 1 mg 3 MO; DP

folic acid 1 mg tablet 10x10, u-d, inner (rx) 1 mg 3 MO; DP

folic acid 1 mg tablet inner,u-d,robot-rdy (rx) 1 mg 3 MO; DP

folic acid 1 mg tablet outer,u-d,robot-rdy (rx) 1 mg 3 MO; DP

97


limits on use

folic acid 1 mg tablet u-d,inner,10x10 (rx) 1 mg 3 MO; DP

folic acid 1 mg tablet u-d,outer,10x10 (rx) 1 mg 3 MO; DP

folic acid 400 mcg tablet 400 mcg 3 DP

folic acid 400 mcg tablet s/f,p/f,lactose-free 400

mcg

3 DP

folic acid 5 mg/ml vial latex-free, mdv 5 mg/ml 3 DP

HEMOCYTE TABLET 324 MG (106 MG IRON) 3 DP

hydroxocobalamin 1,000 mcg/ml 1,000 mcg/ml 3 DP

ICAPS MV TABLET 100-1.66-0.83 MCG-MG-

MG

3 DP

IFEREX 150 CAPSULE 150 MG IRON 3 DP

INFED 100 MG/2 ML VIAL

10S,OUTER,L/F,SDV 50 MG/ML

3 DP

intralipid intravenous emulsion 20 % 2 B/D

INTRALIPID INTRAVENOUS EMULSION 30

%

2 B/D

IRON 325 MG TABLET 325 MG (65 MG IRON) 3 DP

ISOLYTE S PH 7.4 INTRAVENOUS

PARENTERAL SOLUTION

2

ISOLYTE-P IN 5 % DEXTROSE


%

2

ISOLYTE-S INTRAVENOUS PARENTERAL

SOLUTION

2

klor-con 10 oral tablet extended release 10 meq 1 MO

klor-con 8 oral tablet extended release 8 meq 1 MO

klor-con m10 oral tablet,er particles/crystals 10

meq

1 MO

KLOR-CON M15 ORAL TABLET,ER

PARTICLES/CRYSTALS 15 MEQ

2 MO

klor-con m20 oral tablet,er particles/crystals 20

meq

1 MO

KLOR-CON SPRINKLE ORAL CAPSULE,

EXTENDED RELEASE 10 MEQ, 8 MEQ

1 MO

K-SOL ORAL LIQUID 20 MEQ/15 ML 1 MO

98


limits on use

levocarnitine (with sugar) oral solution 100 mg/ml 1 MO

levocarnitine oral tablet 330 mg 1 MO

MAG64 DR 64 MG TABLET 64 MG 3 DP

MAGNEBIND 300 TABLET 250-300 MG 3 DP

magnesium 250 mg tablet 250 mg 3 DP

magnesium oxide 400 mg tablet 400 mg (241.3 mg

magnesium)

3 DP

magnesium oxide 400 mg tablet p/f,soy-free 400

mg (241.3 mg magnesium)

3 DP

magnesium oxide 400 mg tablet s/f,p/f,gluten-free

400 mg (241.3 mg magnesium)

3 DP

magnesium oxide 420 mg tablet 420 mg 3 DP

magnesium oxide 500 mg tablet p/f,s/f,lactose-free

500 mg

3 DP

magnesium sulfate injection solution 4 meq/ml (50

%)

1

MERIBIN 5 MG CAPSULE 5 MG 3 DP

NASCOBAL 500 MCG NASAL SPRAY OUTER

500 MCG/SPRAY

3 MO; DP

normosol-r intravenous parenteral solution 1

normosol-r ph 7.4 intravenous parenteral solution 1

NU-MAG 71.5 MG TABLET 71.5 MG 3 DP

OCUVITE WITH LUTEIN TABLET 1,000

UNIT-200 MG-60 UNIT-2 MG

3 DP

ONCOVITE TABLET 3 DP

ONE DAILY TABLET 3 DP

ONE DAILY TABLET MEN'S FORMULA 3 DP

OS-CAL 500-VIT D3 600 CAPLET 500MG

(1,250MG) -600 UNIT

3 DP

OYSCO-500 TABLET 500 MG CALCIUM

(1,250 MG)

3 DP

OYSTER SHELL CALCIUM 500 MG

CAPLET,P/F,SOY-FREE 500 MG CALCIUM

(1,250 MG)

3 DP

OYSTER SHELL CALCIUM 500 MG TB 500

MG CALCIUM (1,250 MG)

3 DP

99


limits on use

OYSTER SHELL CALCIUM 500 MG TB

500MG ELEMENTAL 500 MG CALCIUM

(1,250 MG)

3 DP

OYSTER SHELL CALCIUM 500 MG TB

500MG ELEMENTAL CA 500 MG CALCIUM

(1,250 MG)

3 DP

PEDIALYTE ELECTROLYTE SINGLES 4'S 3 DP

PEDIALYTE FREEZER POPS 3 DP

PEDIALYTE SOLUTION 3 DP

PEDIALYTE SOLUTION READY-TO-USE 3 DP

plenamine intravenous parenteral solution 15 % 1 B/D

POLY-VI-SOL DROPS 750-35-400 UNIT-MG-

UNIT/ML

3 DP

POLY-VI-SOL WITH IRON DROPS 750 UNIT-

400 UNIT-10 MG/ML

3 DP

potassium chlorid-d5-0.45%nacl intravenous

parenteral solution 20 meq/l

1

potassium chloride in water intravenous

piggyback 40 meq/100 ml

1

potassium chloride oral capsule, extended release

10 meq, 8 meq

1 MO

potassium chloride oral liquid 20 meq/15 ml, 40

meq/15 ml

1 MO

potassium chloride oral tablet extended release 10

meq, 20 meq, 8 meq

1 MO

potassium chloride oral tablet,er particles/crystals

10 meq, 20 meq

1 MO

potassium citrate oral tablet extended release 10

meq (1,080 mg), 15 meq, 5 meq (540 mg)

1 MO

PROSIGHT TABLET 5,000-60-30 UNIT-MG-

UNIT

3 DP

SM CALCIUM 500-VIT D3 400 TAB 500

MG(1,250MG) -400 UNIT

3 DP

sod fer gluc cplx 62.5 mg/5 ml 10's,sdv,outer 62.5

mg/5 ml

3 DP

sod fer gluc cplx 62.5 mg/5 ml sdv,inner 62.5 mg/5

ml

3 DP

100


limits on use

sod fer gluc cplx 62.5 mg/5 ml sdv,outer 62.5 mg/5

ml

3 DP

sodium bicarb 10 grain tablet 650 mg 3 DP

sodium bicarb 650 mg tablet 10 gr 650 mg 3 DP

sodium chloride 0.45 % intravenous parenteral

solution 0.45 %

1

sodium chloride 0.9 % injection solution 1

sodium chloride 0.9 % intravenous parenteral

solution

1

sodium chloride 0.9 % intravenous piggyback 1

sodium chloride 1,000 mg tab inner 1,000 mg 3 DP

sodium chloride 1,000 mg tab outer 1,000 mg 3 DP

sodium chloride 3 % intravenous parenteral

solution 3 %

1

sodium chloride irrigation solution 0.9 % 1

STRESS FORMULA WITH IRON TAB 500 MG-

400 MCG- 18 MG IRON

3 DP

STRESS FORMULA WITH ZINC TAB 3 DP

THERA M PLUS TABLET 9 MG IRON-400

MCG

3 DP

TOTAL B WITH VIT C CAPLET 3 DP

TRI-VI-SOL DROPS 750 UNIT-35 MG -400

UNIT/ML

3 DP

VENOFER 200 MG/10 ML VIAL 200 MG

IRON/10 ML

3 DP

VENOFER 50 MG/2.5 ML VIAL 10'S,SDV,P/F

50 MG IRON/2.5 ML

3 DP

VITA-BEE WITH C TABLET 3 DP

ELECTROLYTE/MINERAL/METAL MODIFIERS

biotin 5,000 mcg capsule mx-str 5 mg 3 DP

biotin 5,000 mcg softgel s/f, p/f,gluten-free 5 mg 3 DP

EXJADE ORAL TABLET, DISPERSIBLE 125

MG, 250 MG, 500 MG

2 PA; MO

FERRIPROX ORAL TABLET 500 MG 2 PA

FERRLECIT 62.5 MG/5 ML VIAL 10'S,SUV,NO

LATEX 62.5 MG/5 ML

3 DP

101


limits on use

FERRLECIT 62.5 MG/5 ML VIAL LATEX-

FREE, SUV 62.5 MG/5 ML

3 DP

JADENU ORAL TABLET 180 MG, 360 MG, 90

MG

2 PA; MO

JADENU SPRINKLE ORAL GRANULES IN

PACKET 180 MG, 360 MG, 90 MG

2 PA; MO

JYNARQUE ORAL TABLETS, SEQUENTIAL

45 MG (AM)/ 15 MG (PM), 60 MG (AM)/ 30 MG

(PM), 90 MG (AM)/ 30 MG (PM)

2 PA; MO

kionex (with sorbitol) oral suspension 15-19.3

gram/60 ml

1

kionex oral powder 1

SAMSCA ORAL TABLET 15 MG, 30 MG 2

sodium polystyrene (sorb free) oral suspension 15

gram/60 ml

1

sodium polystyrene sulfonate oral powder 1

sodium polystyrene sulfonate oral suspension 15

gram/60 ml

1

sodium polystyrene sulfonate rectal enema 30


1

sps (with sorbitol) oral suspension 15-20 gram/60

ml

1

sps (with sorbitol) rectal enema 30-40 gram/120

ml

1

trientine oral capsule 250 mg 1 PA

VENOFER 100 MG/5 ML VIAL 10'S,SDV,P/F

100 MG IRON/5 ML

3 DP

VENOFER 100 MG/5 ML VIAL 25'S,SDV,P/F

100 MG IRON/5 ML

3 DP

VENOFER 100 MG/5 ML VIAL LATEX-

FREE,SUV,P/F 100 MG IRON/5 ML

3 DP

PHOSPHATE BINDERS

calcium acetate oral capsule 667 mg 1 MO

FOSRENOL ORAL POWDER IN PACKET

1,000 MG, 750 MG

2 MO

lanthanum oral tablet,chewable 1,000 mg, 500 mg,

750 mg

1 MO

102


limits on use

sevelamer carbonate oral powder in packet 0.8

gram, 2.4 gram

1 MO

sevelamer carbonate oral tablet 800 mg 1 MO

VITAMINS

ANIMAL SHAPES TABLET CHEW

CHILDREN'S

3 DP

BALANCED B-100 TABLET 100 MG 3 DP

B-COMPLEX WITH B12 TABLET 3 DP

CALCITRATE + VIT D CAPLET 315-250 MG-

UNIT

3 DP

calcitriol oral capsule 0.25 mcg, 0.5 mcg 1 MO

calcitriol oral solution 1 mcg/ml 1 MO

calcitriol topical ointment 3 mcg/gram 1

calcium 500 mg chewable tablet p/f,s/f,gluten-f

500-100 mg-unit

3 DP

calcium 500+d tablet chew 500 mg(1,250mg) -400

unit

3 DP

calcium 600-vit d3 400 tablet 600 mg(1,500mg) -

400 unit

3 DP

CERTAVITE-ANTIOXIDANT TABLET 18-400

MG-MCG

3 DP

cyanocobalamin 1,000 mcg/ml 25's, latex-free,suv

1,000 mcg/ml

3 MO; DP

cyanocobalamin 1,000 mcg/ml 25's, mdv 1,000

mcg/ml

3 MO; DP

cyanocobalamin 1,000 mcg/ml inner,latex-free

1,000 mcg/ml

3 MO; DP

cyanocobalamin 1,000 mcg/ml latex-

free,mdv,inner 1,000 mcg/ml

3 MO; DP

cyanocobalamin 1,000 mcg/ml latex-

free,outer,mdv 1,000 mcg/ml

3 MO; DP

cyanocobalamin 1,000 mcg/ml mdv,5's 1,000

mcg/ml

3 MO; DP

cyanocobalamin 1,000 mcg/ml mdv,inner,latex-

free 1,000 mcg/ml

3 MO; DP

cyanocobalamin 1,000 mcg/ml mdv,outer,latex-

free 1,000 mcg/ml

3 MO; DP

103


limits on use

cyanocobalamin 1,000 mcg/ml outer,latex-free

1,000 mcg/ml

3 MO; DP

cyanocobalamin 10,000 mcg/10 inner,latex-

free,mdv 1,000 mcg/ml

3 MO; DP

cyanocobalamin 10,000 mcg/10 mdv, inner, l/f

1,000 mcg/ml

3 MO; DP

cyanocobalamin 10,000 mcg/10 mdv, outer, l/f

1,000 mcg/ml

3 MO; DP

cyanocobalamin 10,000 mcg/10 outer,latex-


3 MO; DP

cyanocobalamin 30,000 mcg/30 inner,latex-


3 MO; DP

cyanocobalamin 30,000 mcg/30 mdv, inner, l/f

1,000 mcg/ml

3 MO; DP

cyanocobalamin 30,000 mcg/30 mdv, outer, l/f

1,000 mcg/ml

3 MO; DP

cyanocobalamin 30,000 mcg/30 outer,latex-


3 MO; DP

ergocalciferol 8,000 units/ml 8,000 unit/ml 3 DP

OYSCO 500-VIT D3 200 TABLET 500

MG(1,250MG) -200 UNIT

3 DP

OYSTER SHELL 500-VIT D3 200 TB 500

MG(1,250MG) -200 UNIT

3 DP

OYSTER SHELL 500-VIT D3 200 TB CAPLET

500 MG(1,250MG) -200 UNIT

3 DP

OYSTER SHELL 500-VIT D3 200 TB U-D,

10X10 500 MG(1,250MG) -200 UNIT

3 DP

paricalcitol oral capsule 1 mcg, 2 mcg, 4 mcg 1 MO

PRENATAL VITAMIN PLUS LOW IRON

ORAL TABLET 27 MG IRON- 1 MG

2 MO

PRENATAL VITAMIN TABLET (OTC) 27 MG

IRON- 0.8 MG

3 DP

PRENATAL VITAMINS TABLET W/ FOLIC

ACID 28 MG IRON- 800 MCG

3 DP

pyridoxine 100 mg/ml vial 25's, mdv 100 mg/ml 3 DP

pyridoxine 100 mg/ml vial inner,p/f,mdv,ltx-fr 100

mg/ml

3 DP

104


limits on use

pyridoxine 100 mg/ml vial outer,p/f,mdv,ltx-fr 100

mg/ml

3 DP

RENAL VITAMIN TABLET 0.8 MG 3 DP

SM PEDIATRIC ELECTROLYTE SOLN 3 DP

SM VITAMIN B-1 100 MG TABLET 100 MG 3 DP

STRESS FORMULA TABLET 3 DP

SUPERPLEX-T TABLET 3 DP

TAB-A-VITE TABLET 3 DP

TAB-A-VITE WITH IRON TABLET 3 DP

THERA TABLET 400 MCG 3 DP

THERA-M TABLET W/BETA CAROTENE 9

MG IRON-400 MCG

3 DP

thiamine 200 mg/2 ml vial 25's, mdv 100 mg/ml 3 DP

thiamine 200 mg/2 ml vial mdv 100 mg/ml 3 DP

vitamin a 10,000 unit capsule soluble 10,000 unit 3 DP

VITAMIN AND MINERALS TABLET 3 DP

VITAMIN B COMPLEX CAPSULE 3 DP

VITAMIN B-1 100 MG TABLET 100 MG 3 DP

VITAMIN B-12 1,000 MCG TABLET 1,000

MCG

3 DP

VITAMIN B-12 1,000 MCG TABLET

P/F,STARCH/SOY-FREE 1,000 MCG

3 DP



VITAMIN C 250 MG TABLET 250 MG 3 DP

VITAMIN C 250 MG TABLET CHEW 250 MG 3 DP

VITAMIN C 500 MG CAPLET COATED

CAPLET 500 MG

3 DP

VITAMIN C 500 MG TABLET 500 MG 3 DP

VITAMIN C 500 MG TABLET CHEW 500 MG 3 DP

VITAMIN C 500 MG TABLET U-D 500 MG 3 DP

VITAMIN D2 1.25 MG(50,000 UNIT) 50,000

UNIT

3 MO; DP

VITAMIN D2 1.25 MG(50,000 UNIT) CAPSULE

50,000 UNIT

3 MO; DP

105


limits on use

vitamin d2 1.25 mg(50,000 unit) softgel 50,000

unit

3 MO; DP

VITAMIN D2 1.25 MG(50,000 UNIT) U-

D,10X10,INNER 50,000 UNIT

3 MO; DP

VITAMIN D2 1.25 MG(50,000 UNIT) U-

D,10X10,OUTER 50,000 UNIT

3 MO; DP

VITAMIN D3 1,000 UNIT TABLET 1,000 UNIT 3 DP

vitamin d3 1,000 unit tablet gluten/f, d/f 1,000 unit 3 DP

VITAMIN D3 1,000 UNIT TABLET S/F,P/F

1,000 UNIT

3 DP

VITAMIN D3 2,000 UNIT SOFTGEL 2,000

UNIT

3 DP

VITAMIN D3 2,000 UNIT SOFTGEL SOY-

FREE,SOFTGEL 2,000 UNIT

3 DP

vitamin d3 2,000 unit tablet 2,000 unit 3 DP

VITAMIN D3 2,000 UNIT TABLET 2,000 UNIT 3 DP

vitamin d3 400 unit/ml drop supplement drop 400

unit/ml

3 DP

V-R VITAMIN C 250 MG TAB CHEW 250 MG 3 DP

V-R VITAMIN C 500 MG TAB CHEW 500 MG 3 DP

GASTROINTESTINAL AGENTS

ANTISPASMODICS, GASTROINTESTINAL

dicyclomine oral capsule 10 mg 1 MO

dicyclomine oral solution 10 mg/5 ml 1 MO

dicyclomine oral tablet 20 mg 1 MO

diphenoxylate-atropine oral liquid 2.5-0.025 mg/5

ml

1

diphenoxylate-atropine oral tablet 2.5-0.025 mg 1

glycopyrrolate oral tablet 1 mg, 2 mg 1 MO

GASTROINTESTINAL AGENTS, OTHER

ACID GONE ANTACID LIQUID 95-358 MG/15

ML

3 DP

ALMACONE CHEWABLE TABLET 200-200-25

MG

3 DP

106


limits on use

ALMACONE SUSPENSION 200-200-20 MG/5

ML

3 DP

ALMACONE-2 LIQUID 400-400-40 MG/5 ML 3 DP

aluminum hydroxide gel sugar-free 320 mg/5 ml 3 DP

ANTACID 500 MG CHEWABLE TABLET

INNER 200 MG CALCIUM (500 MG)

3 DP

ANTACID 500 MG CHEWABLE TABLET

OUTER 200 MG CALCIUM (500 MG)

3 DP

ANTACID ANTI-GAS LIQUID MAXIMUM

STRENGTH 400-400-40 MG/5 ML

3 DP

ANTACID EX-STR 750 MG TAB CHEW

GLUTEN-F,ASSTD BERRY 300 MG (750 MG)

3 DP

ANTACID LIQUID 200-200-20 MG/5 ML 3 DP

ANTACID MAXIMUM STRENGTH LIQ 400-

400-40 MG/5 ML

3 DP

ANTACID PLUS ANTI-GAS RELF LIQ

MINT,REG-STRENGTH 200-200-20 MG/5 ML

3 DP

ANTACID PLUS ANTI-GAS RELF LIQ

REGULAR STR,ORIGINAL 200-200-20 MG/5

ML

3 DP

ANTACID PLUS ANTI-GAS SUSP MAX STR,

CHERRY 400-400-40 MG/5 ML

3 DP

ANTACID SUSPENSION 200-200-20 MG/5 ML 3 DP

ANTACID XTRA STRENGTH CHEW TAB

EXTRA STRENGTH 300 MG (750 MG)

3 DP

ANTACID-ANTIGAS LIQUID 200-200-20 MG/5

ML

3 DP

ANTACID-SIMETHICONE LIQUID 400-400-40

MG/5 ML

3 DP

ANTI-DIARRHEAL 2 MG CAPLET 2 MG 3 DP

ANTI-DIARRHEAL 2 MG CAPLET CAPLET 2

MG

3 DP

ANTI-DIARRHEAL 2 MG CAPLET CPLT

EASY TO SWALLOW 2 MG

3 DP

ANTI-DIARRHEAL 2 MG SOFTGEL SOFTGEL

2 MG

3 DP

ANTI-DIARRHEAL 2 MG TABLET 2 MG 3 DP

107


limits on use

BISMATROL 525 MG/30 ML SUSP 262 MG/15

ML

3 DP

BISMATROL TABLET CHEW 262 MG 3 DP

bismuth 262 mg tablet chew 262 mg 3 DP

CALCIUM ANTACID 1,000 MG TAB ULTRA,

MAX-STR 400 MG CALCIUM (1,000 MG)

3 DP

CALCIUM ANTACID 500 MG CHW TAB

ASSORTED FRUIT 200 MG CALCIUM (500

MG)

3 DP

CALCIUM ANTACID 500 MG CHW TAB

GLUTEN-F, PEPPERMINT 200 MG CALCIUM

(500 MG)

3 DP

CALCIUM ANTACID 500 MG CHW TAB REG

STR, PEPPERMINT 200 MG CALCIUM (500

MG)

3 DP

CALCIUM ANTACID 750 MG TB CHEW

GLUTEN-FREE 300 MG (750 MG)

3 DP

CAL-GEST 500 MG TABLET CHEW 200 MG

CALCIUM (500 MG)

3 DP

enulose oral solution 10 gram/15 ml 1 MO

GAS RELIEF 125 MG SOFTGEL SOFTGEL 125

MG

3 DP

GATTEX 30-VIAL SUBCUTANEOUS KIT 5

MG

2 PA; MO

GATTEX ONE-VIAL SUBCUTANEOUS KIT 5

MG

2 PA; MO

gavilyte-c oral recon soln 240-22.72-6.72 -5.84

gram

1

GAVISCON 80-14.2 MG TAB CHEW 80-14.2

MG

3 DP

GAVISCON ES TABLET CHEW EXTRA

STRENGTH 160-105 MG

3 DP

GAVISCON EXTRA STRENGTH LIQUID 254-

237.5 MG/5 ML

3 DP

GAVISCON LIQUID 95-358 MG/15 ML 3 DP

generlac oral solution 10 gram/15 ml 1 MO

108


limits on use

GS ADV ANTACID-ANTIGAS LIQUID 200-

200-20 MG/5 ML

3 DP

GS ANTACID 500 MG CHEWABLE TAB 215

MG CALCIUM (500 MG)

3 DP

GS ANTACID PLUS ANTI-GAS LIQ 200-200-

20 MG/5 ML

3 DP

GS ANTI-DIARRHEAL 2 MG CAPLET 2 MG 3 DP

GS CAL ANTACID 500 MG CHEW TAB 200

MG CALCIUM (500 MG)

3 DP

GS STOMACH RLF 262 MG CHEW TAB

GLUTEN-FREE 262 MG

3 DP

HM ADV ANTACID-ANTIGAS SUSP MAX-

STRENGTH, CHERRY 400-400-40 MG/5 ML

3 DP

HM ANTACID ANTI-GAS SUSPENSION

ORIGINAL, MAX STR 400-400-40 MG/5 ML

3 DP

HM ANTACID-ANTIGAS SUSPENSION 200-

200-20 MG/5 ML

3 DP

HM ANTACID-ANTIGAS SUSPENSION REG

STR, MINT 200-200-20 MG/5 ML

3 DP

HM ANTACID-ANTIGAS SUSPENSION REG

STR, ORIGINAL 200-200-20 MG/5 ML

3 DP

HM ANTI-DIARRHEAL 2 MG CAPLET

CAPLET, GLUTEN-FREE 2 MG

3 DP

HM CAL ANTACID 500 MG CHEW TAB

ASSORTED FRUIT 200 MG CALCIUM (500

MG)

3 DP

HM CAL ANTACID 750 MG CHEW TAB 320

MG CALCIUM (750 MG)

3 DP



3 DP


S/F,EX-STR, ORANGE 300 MG (750 MG)

3 DP

LIQUID ANTACID SUSPENSION REGULAR


3 DP

loperamide 1 mg/5 ml liquid 1 mg/5 ml 3 DP

loperamide oral capsule 2 mg 1 MO

MAG-AL PLUS SUSPENSION 200-200-20

MG/5 ML

3 DP

109


limits on use

MI ACID SUSPENSION 200-200-20 MG/5 ML,

400-400-40 MG/5 ML

3 DP

MI-ACID DS TABLET 700-300 MG 3 DP

MINTOX PLUS TABLET CHEWABLE 200-200-

25 MG

3 DP

MINTOX SUSPENSION MINT CREME 200-

200-20 MG/5 ML

3 DP

OCALIVA ORAL TABLET 10 MG, 5 MG 2 PA; MO

PEPTIC RELIEF 262 MG CHEW TAB 262 MG 3 DP

PEPTIC RELIEF 262 MG/15 ML 262 MG/15 ML 3 DP

QC ANTACID 500 MG CHEW TABLET 200

MG CALCIUM (500 MG)

3 DP

QC ANTACID SUSPENSION REGULAR


3 DP

QC ANTACID-ANTIGAS SUSPENSION

REGULAR STRENGTH 200-200-20 MG/5 ML

3 DP

QC ANTI-DIARRHEAL 2 MG CAPLET

CAPLET 2 MG

3 DP

RECTIV RECTAL OINTMENT 0.4 % (W/W) 2

RELISTOR ORAL TABLET 150 MG 2 PA

RELISTOR SUBCUTANEOUS SOLUTION 12

MG/0.6 ML

2 PA

RELISTOR SUBCUTANEOUS SYRINGE 12

MG/0.6 ML, 8 MG/0.4 ML

2 PA

RULOX SUSPENSION 200-200-20 MG/5 ML 3 DP

SB ANTACID 500 MG CHEW TABLET 200 MG

CALCIUM (500 MG)

3 DP

SB ANTACID XTRA STR CHEW TAB EXTRA

STRENGTH 300 MG (750 MG)

3 DP

SB ANTI-DIARRHEA 2 MG CAPLET 2 MG 3 DP

SEROSTIM SUBCUTANEOUS RECON SOLN 4

MG, 5 MG, 6 MG

2 PA; MO

SM ADV ANTACID-ANTIGAS LIQUID 200-

200-20 MG/5 ML

3 DP

SM ANTACID MAX STRENGTH SUSP

ORIGINAL 400-400-40 MG/5 ML

3 DP

110


limits on use

SM ANTACID SUSPENSION 200-200-20 MG/5

ML

3 DP

SM ANTACID-ANTIGAS LIQUID 200-200-20

MG/5 ML

3 DP

SM ANTI-DIARRHEAL 2 MG CAPLET 2 MG 3 DP

SM ANTI-DIARRHEAL 2 MG CAPLET

CAPLET 2 MG

3 DP

SM CAL ANTACID 500 MG CHEW TAB 215

MG CALCIUM (500 MG)

3 DP

SM CAL ANTACID 750 MG CHEW TAB 320

MG CALCIUM (750 MG)

3 DP

SM CAL ANTACID 750 MG CHEW TAB


3 DP

SM GAS RELIEF 125 MG SOFTGEL SOFTGEL

125 MG

3 DP

SM STOMACH RELIEF 262 MG/15 ML

REGULAR STRENGTH 262 MG/15 ML

3 DP

SM STOMACH RLF 262 MG CHEW TAB 262

MG

3 DP

STOMACH RLF 262 MG/15 ML SUSP

ORIGINAL STRENGTH 262 MG/15 ML

3 DP

TUMS 750 MG CHEWY BITES 300 MG (750

MG)

3 DP

TUMS E-X TABLET CHEWABLE ASSORTED

FRUIT 300 MG (750 MG)

3 DP

TUMS E-X TABLET CHEWABLE E-X 300 MG

(750 MG)

3 DP

TUMS E-X TABLET CHEWABLE E-X 300 MG

(750 MG)

3 DP

TUMS E-X TABLET CHEWABLE E-X,

SINGLE ROLL 300 MG (750 MG)

3 DP

TUMS E-X TABLET CHEWABLE E-X,3-ROLL

300 MG (750 MG)

3 DP

TUMS E-X TABLET CHEWABLE S/F,

ORANGE CREAM 300 MG (750 MG)

3 DP

TUMS KIDS 300 MG (750) CHEWTAB

CHERRY BLAST 300 MG (750 MG)

3 DP

111


limits on use

TUMS SMOOTHIES CHEW TABLET 300 MG

(750 MG)

3 DP

TUMS SMOOTHIES CHEW TABLET ASSTD

TROPICAL FRUIT 300 MG (750 MG)

3 DP

TUMS SMOOTHIES CHEW TABLET BERRY

FUSION, EX-STR 300 MG (750 MG)

3 DP

TUMS SMOOTHIES CHEW TABLET

PEPPERMINT, EX-STR 300 MG (750 MG)

3 DP

TUMS TABLET CHEWABLE 200 MG

CALCIUM (500 MG)

3 DP

TUMS TABLET CHEWABLE 3-ROLL,

PEPPERMINT 200 MG CALCIUM (500 MG)

3 DP

TUMS TABLET CHEWABLE ASSORTED

FRUIT 200 MG CALCIUM (500 MG)

3 DP

TUMS TABLET CHEWABLE PEPPERMINT

200 MG CALCIUM (500 MG)

3 DP

TUMS ULTRA TABLET CHEWABLE 400 MG

CALCIUM (1,000 MG)

3 DP

TUMS ULTRA TABLET CHEWABLE

ASSORTED BERRIES 400 MG CALCIUM

(1,000 MG)

3 DP

TUMS ULTRA TABLET CHEWABLE

ASSORTED FRUIT 400 MG CALCIUM (1,000

MG)

3 DP

TUMS ULTRA TABLET CHEWABLE TROP

FRUIT,GLUTEN-F 400 MG CALCIUM (1,000

MG)

3 DP

TUMS X-STR 750 TABLET CHEWABLE

ASST'D FRUIT FLAVOR 300 MG (750 MG)

3 DP

ursodiol oral capsule 300 mg 1 MO

ursodiol oral tablet 250 mg, 500 mg 1 MO

XERMELO ORAL TABLET 250 MG 2 PA

HISTAMINE2 (H2) RECEPTOR ANTAGONISTS

ACID CONTROLLER 20 MG TABLET

MAXIMUM STRENGTH 20 MG

3 DP

ACID REDUCER 10 MG TABLET 10 MG 3 DP

112


limits on use

ACID REDUCER 10 MG TABLET ORIGINAL

STRENGTH 10 MG

3 DP

ACID REDUCER 20 MG TABLET MAX

STRENGTH 20 MG

3 DP

ACID REDUCER 20 MG TABLET MAXIMUM

STRENGTH 20 MG

3 DP

ACID REDUCER 20 MG TABLET MAX-STR

20 MG

3 DP

cimetidine 200 mg tablet blister pack (otc) 200 mg 3 MO; DP

cimetidine hcl oral solution 300 mg/5 ml 1 MO

cimetidine oral tablet 200 mg, 300 mg, 400 mg,

800 mg

1 MO

famotidine 10 mg tablet 10 mg 3 DP

famotidine oral tablet 20 mg, 40 mg 1 MO

HEARTBURN RELIEF 10 MG TABLET 10 MG 3 DP

HM ACID REDUCER 150 MG TABLET


3 DP

HM ACID REDUCER 75 MG TABLET


3 DP

hm famotidine 10 mg tablet original strength 10

mg

3 DP

ranitidine 150 mg tablet maximum strength (otc)

150 mg

3 MO; DP

ranitidine 75 mg tablet s/f, sodium-free 75 mg 3 DP

ranitidine hcl oral syrup 15 mg/ml 1 MO

ranitidine hcl oral tablet 150 mg, 300 mg 1 MO

SB ACID REDUCER 150 MG TABLET


3 DP

SM ACID REDUCER 10 MG TABLET 10 MG 3 DP


SM ACID REDUCER 150 MG TABLET


3 DP



SM ACID REDUCER 75 MG TABLET


3 DP

113


limits on use

SM HEARTBURN RELIEF 200 MG TAB 200

MG

3 DP

IRRITABLE BOWEL SYNDROME AGENTS

alosetron oral tablet 0.5 mg, 1 mg 1 QL (60 EA per 30 days)

AMITIZA ORAL CAPSULE 24 MCG, 8 MCG 2 MO; QL (60 EA per 30 days)

LINZESS ORAL CAPSULE 145 MCG, 290

MCG, 72 MCG


XIFAXAN ORAL TABLET 200 MG 2 PA

XIFAXAN ORAL TABLET 550 MG 2 PA; MO

LAXATIVES

BISAC-EVAC 10 MG SUPPOSITORY 10 MG 3 DP

BISAC-EVAC 10 MG SUPPOSITORY OUTER

10 MG

3 DP

bisacodyl 10 mg suppository 10 mg 3 DP

bisacodyl ec 5 mg tablet 5 mg 3 DP

BISA-LAX EC 5 MG TABLET 5 MG 3 DP

BISCOLAX 10 MG SUPPOSITORY 10 MG 3 DP

calcium polycarbophil 625 mg 625 mg 3 DP

CITRUCEL 500 MG CAPLET 500 MG 3 DP

CITRUCEL POWDER 3 DP

CITRUCEL POWDER S-F S/F 3 DP

CLEARLAX POWDER 14 ONCE-DAILY

DOSES 17 GRAM/DOSE

3 DP

CLEARLAX POWDER 17 GRAM/DOSE 3 DP

CLEARLAX POWDER 30 ONCE-DAILY

DOSES 17 GRAM/DOSE

3 DP

CLEARLAX POWDER 7 ONCE-DAILY DOSES

17 GRAM/DOSE

3 DP

constulose oral solution 10 gram/15 ml 1 MO

DOC-Q-LACE 100 MG SOFTGEL 100 MG 3 DP

DOCU LIQUID 100 MG/10 ML INNER 50 MG/5

ML

3 DP

DOCU LIQUID 100 MG/10 ML OUTER 50

MG/5 ML

3 DP

114


limits on use

DOCU LIQUID 50 MG/5 ML 50 MG/5 ML 3 DP

docusate sodium 100 mg softgel inner, softgel 100

mg

3 DP

docusate sodium 100 mg softgel outer, softgel 100

mg

3 DP

docusate sodium 100 mg softgel softgel 100 mg 3 DP

docusate sodium 50 mg/5 ml liq 100's, u-d 50 mg/5

ml

3 DP

DOCUSATE SODIUM-SENNA TABLET 8.6-50

MG

3 DP

DOCUSIL 100 MG SOFTGEL 100 MG 3 DP

DOCUSOL MINI-ENEMA OUTER 283 MG 3 DP

DOK 100 MG SOFTGEL SOFTGEL 100 MG 3 DP

DOK 100 MG TABLET 100 MG 3 DP

DUCODYL EC 5 MG TABLET 5 MG 3 DP

ENEMA DISPOSABLE 19-7 GRAM/118 ML 3 DP

ENEMA READY TO USE LATEX-FREE 19-7

GRAM/118 ML

3 DP

ENEMEEZ MINI ENEMA 5CC TUBES, OUTER

283 MG/5 ML

3 DP

ENEMEEZ PLUS MINI ENEMA OUTER 283-20

MG/5 ML

3 DP

EX-LAX MAXIMUM STR 25 MG TAB 25 MG 3 DP

FIBER LAXATIVE 625 MG CAPLET CAPLET

625 MG

3 DP

FIBER LAXATIVE 625 MG TABLET 625 MG 3 DP

FIBER TABLET UNBOXED 625 MG 3 DP

FIBER TABS 625 MG 3 DP

FIBER THERAPY POWDER 2 GRAM/19

GRAM

3 DP

FIBER-LAX CAPTABS 500MG

POLYCARBOPHIL 625 MG

3 DP

FLEET BISACODYL 10 MG ENEMA 10 MG/30

ML

3 DP

FLEET ENEMA 2X133ML, TWIN PACK 19-7

GRAM/118 ML

3 DP

115


limits on use

FLEET PEDIA-LAX ENEMA 9.5-3.5 GRAM/59

ML

3 DP

FLEET PEDIA-LAX SUPPOSITORIES 3 DP

GAVILAX POWDER 14 DAY 17 GRAM/DOSE 3 DP

GAVILAX POWDER 30 DAY 17 GRAM/DOSE 3 DP

gavilyte-g oral recon soln 236-22.74-6.74 -5.86

gram

1

gavilyte-n oral recon soln 420 gram 1

glycerin pediatric suppository infants & children 3 DP

GLYCOLAX POWDER 15 DOSES (OTC) 17

GRAM/DOSE

3 DP


GRAM/DOSE

3 DP


GRAM/DOSE

3 DP

GS MILK OF MAGNESIA SUSPENSION 400

MG/5 ML

3 DP

HEALTHYLAX POWDER PACKET 14X17GM,

INNER 17 GRAM

3 DP

HEALTHYLAX POWDER PACKET 14X17GM,

OUTER 17 GRAM

3 DP

HM CLEARLAX POWDER 14 ONCE-DAILY

DOSES 17 GRAM/DOSE

3 DP


DOSES 17 GRAM/DOSE

3 DP


DOSES 17 GRAM/DOSE

3 DP

HM ENEMA READY TO USE 19-7 GRAM/118

ML

3 DP

HM ENEMA READY TO USE TWIN PAK

LATEX-FREE 19-7 GRAM/118 ML

3 DP

HM FIBER 500 MG CAPLET 500 MG 3 DP

HM FIBER POWDER 3.4 GRAM/5.8 GRAM 3 DP

HM LAXATIVE EC 5 MG TABLET 5 MG 3 DP

HM MILK OF MAGNESIA SUSPENSION

MINT 400 MG/5 ML

3 DP

116


limits on use

HM MILK OF MAGNESIA SUSPENSION

ORIGINAL 400 MG/5 ML

3 DP

HM SENNA 8.6 MG TABLET 8.6 MG 3 DP

HM STOOL SOFTENER 100 MG SFTGL

SOFTGEL 100 MG

3 DP

HM STOOL SOFTENER 100 MG TAB 100 MG 3 DP

KAO-TIN 240 MG SOFTGEL 240 MG 3 DP

KONSYL 6 GM PACKET S/F, GLUTEN-F,

OUTER 6 GRAM

3 DP

KONSYL EASY MIX FIBER POWDER 4.3

GRAM/6 GRAM

3 DP

KONSYL FIBER 625 MG CAPLET CAPLET

625 MG

3 DP

KONSYL FIBER 625 MG CAPLET CAPLET,

S/F 625 MG

3 DP

KONSYL FORMULA-D FIBER POWDER

GLUTEN FREE,61 DOSES 3.4 GRAM/ 6.5

GRAM

3 DP

KONSYL ORIGINAL FIBER POWDER S/F,

GLUTEN FREE 6 GRAM/6 GRAM

3 DP

KONSYL ORIGINAL FIBER POWDER

S/F,GLUTN-F,75 DOSES 6 GRAM/6 GRAM

3 DP

KONSYL PSYLLIUM FIBER POWDER

GLUTEN FREE, ORANGE 3.4 GRAM/11

GRAM

3 DP

KONSYL PSYLLIUM FIBER POWDER

S/F,GLUTEN/F,ORANGE 3.5 GRAM/5.8 GRAM

3 DP

KRISTALOSE ORAL PACKET 20 GRAM 2 ST; MO

lactulose oral packet 10 gram 1 ST; MO

lactulose oral solution 10 gram/15 ml, 10 gram/15

ml (15 ml), 20 gram/30 ml

1 MO

LAXATIVE EC 5 MG TABLET 5 MG 3 DP

magnesium citrate solution lemon 3 DP

MILK OF MAGNESIA SUSPENSION 100'S, U-

D 400 MG/5 ML

3 DP

MILK OF MAGNESIA SUSPENSION 400 MG/5

ML

3 DP

117


limits on use

MILK OF MAGNESIA SUSPENSION CHERRY

400 MG/5 ML

3 DP

MILK OF MAGNESIA SUSPENSION MINT 400

MG/5 ML

3 DP

MILK OF MAGNESIA SUSPENSION NA/F 400

MG/5 ML

3 DP

MILK OF MAGNESIA SUSPENSION

REGULAR 400 MG/5 ML

3 DP

MILK OF MAGNESIA SUSPENSION

STIMULANT FREE 400 MG/5 ML

3 DP

mineral oil usp 3 DP

NATURAL FIBER LAX POWDER 3 DP

NATURAL FIBER LAX POWDER ORIGINAL

TEXTURE 3.4 GRAM/7 GRAM

3 DP

peg 3350-electrolytes oral recon soln 240-22.72-

6.72 -5.84 gram

1

peg-3350 with flavor packs oral recon soln 420

gram

1

peg-electrolyte soln oral recon soln 420 gram 1

polyethylene glycol 3350 oral powder 17

gram/dose

1

polyethylene glycol 3350 oral powder in packet 17

gram

1

polyethylene glycol 3350 powd 14 once-daily

doses (otc) 17 gram/dose

3 DP

polyethylene glycol 3350 powd 30 once-daily

doses (otc) 17 gram/dose

3 DP

polyethylene glycol 3350 powd 7 once-daily doses

(otc) 17 gram/dose

3 DP

polyethylene glycol 3350 powd inner (otc) 17

gram

3 DP

polyethylene glycol 3350 powd outer (otc) 17

gram

3 DP

QC MILK OF MAGNESIA SUSPENSION 400

MG/5 ML

3 DP

QC NATURAL VEG LAXATIVE TABLET 8.6

MG

3 DP

118


limits on use

QC NATURA-LAX 17 GM POWDER 17

GRAM/DOSE

3 DP

QC READY TO USE ENEMA LATEX-FREE 19-

7 GRAM/118 ML

3 DP

QC READY TO USE ENEMA TWIN PACK 19-7

GRAM/118 ML

3 DP

REGULOID LAXATIVE POWDER 3 DP

REGULOID POWDER 3 DP

REGULOID POWDER ORANGE 3 DP

sb bisacodyl ec 5 mg tablet 5 mg 3 DP

SENEXON 8.6 MG TABLET 8.6 MG 3 DP

SENEXON-S TABLET 8.6-50 MG 3 DP

SENNA 8.6 MG TABLET 8.6 MG 3 DP

SENNA 8.8 MG/5 ML SYRUP A/F,

CHOCOLATE 8.8 MG/5 ML

3 DP

SENNA LAXATIVE 8.6 MG TABLET 8.6 MG 3 DP

SENNA PLUS TABLET 8.6-50 MG 3 DP

SENNA-LAX 8.6 MG TABLET 8.6 MG 3 DP

SENNA-TIME 8.6 MG TABLET 8.6 MG 3 DP

SENNA-TIME S TABLET 8.6-50 MG 3 DP

SENNO TABLET 8.6 MG 3 DP

sennosides-docusate sodium tab 8.6-50 mg 3 DP

SENOKOT 8.6 MG TABLET 8.6 MG 3 DP

SILACE 50 MG/5 ML LIQUID 50 MG/5 ML 3 DP

SILACE 60 MG/15 ML SYRUP 60 MG/15 ML 3 DP

SM CLEARLAX POWDER 14 ONCE-DAILY

DOSES 17 GRAM/DOSE

3 DP

SM CLEARLAX POWDER 17 GRAM/DOSE 3 DP


DOSES 17 GRAM/DOSE

3 DP


DOSES 17 GRAM/DOSE

3 DP

SM FIBER 625 MG CAPLET 625 MG 3 DP

SM FIBER LAXATIVE 500 MG CPLT 500 MG 3 DP

119


limits on use

SM FIBER LAXATIVE 625 MG TAB CAPLET

625 MG

3 DP

SM FIBER POWDER 3 DP

SM FIBER POWDER 3.4 GRAM/11 GRAM 3 DP

SM GENTLE LAXATIVE EC 5 MG TAB 5 MG 3 DP

SM MILK OF MAGNESIA SUSPENSION 400

MG/5 ML

3 DP

SM NAT LAX PLUS STOOL SOFTENER 8.6-50

MG

3 DP

SM SENNA LAXATIVE 8.6 MG TAB 8.6 MG 3 DP

SM STOOL SOFTENER 100 MG SFTGL

GLUTEN-FREE, SOFTGEL 100 MG

3 DP


SOFTGEL 100 MG

3 DP


SOFTGEL,GLUTEN-FREE 240 MG

3 DP


SOFTGEL, EX-STR 250 MG

3 DP

SM STOOL SOFTENER-LAXATIVE TAB 8.6-

50 MG

3 DP

STOOL SOFTENER 100 MG CAPSULE 100 MG 3 DP

STOOL SOFTENER 100 MG CAPSULE

ORIGINAL 100 MG

3 DP

STOOL SOFTENER 100 MG SOFTGEL

SOFTGEL 100 MG

3 DP


SOFTGEL 240 MG

3 DP


SOFTGEL, EX-STR 250 MG

3 DP

STOOL SOFTENER-LAXATIVE TABLET 8.6-

50 MG

3 DP

STOOL SOFTENER-STIM LAX TABLET 8.6-50

MG

3 DP

trilyte with flavor packets oral recon soln 420

gram

1

WOMEN'S LAXATIVE 5 MG TABLET 5 MG 3 DP

120


limits on use

PROTECTANTS

misoprostol oral tablet 100 mcg, 200 mcg 1 MO

sucralfate oral tablet 1 gram 1 MO

PROTON PUMP INHIBITORS

gs omeprazole dr 20 mg tablet 14 day course 20

mg

3 DP

HEARTBURN TREATMNT 24 HR 15 MG

1X14, SODIUM FREE 15 MG

3 DP

HEARTBURN TREATMNT 24 HR 15 MG

3X14, SODIUM FREE 15 MG

3 DP

hm lansoprazole dr 15 mg cap gluten-free,1 bottle

(otc) 15 mg

3 MO; DP


(otc) 15 mg

3 MO; DP


(otc) 15 mg

3 MO; DP

hm omeprazole dr 20 mg tablet 2x14 day course

20 mg

3 DP

hm omeprazole dr 20 mg tablet 3x14 day course

20 mg

3 DP

lansoprazole dr 15 mg capsule (otc) 15 mg 3 MO; DP

lansoprazole dr 15 mg capsule 1x14 day course

(otc) 15 mg

3 MO; DP

lansoprazole dr 15 mg capsule 1x14 day

course,na/f (otc) 15 mg

3 MO; DP

lansoprazole dr 15 mg capsule 2-14 day treatment

(otc) 15 mg

3 MO; DP

lansoprazole dr 15 mg capsule 24hr, 3 bottles

(otc) 15 mg

3 MO; DP


(otc) 15 mg

3 MO; DP


(otc) 15 mg

3 MO; DP

lansoprazole dr 15 mg capsule 3x14 day

course,na/f (otc) 15 mg

3 MO; DP

lansoprazole dr 15 mg capsule na/f (otc) 15 mg 3 MO; DP

121


limits on use

lansoprazole oral capsule,delayed release(dr/ec)

15 mg, 30 mg

1 MO

omeprazole dr 20 mg tablet 14 day course 20 mg 3 DP

omeprazole dr 20 mg tablet 1x14 day course 20

mg

3 DP

omeprazole dr 20 mg tablet 20 mg 3 DP


mg

3 DP


mg

3 DP

omeprazole oral capsule,delayed release(dr/ec) 10

mg, 20 mg, 40 mg

1 MO

pantoprazole oral tablet,delayed release (dr/ec) 20

mg, 40 mg

1 MO

PREVACID 24HR DR 15 MG CAPSULE NA/F

15 MG

3 DP

PREVACID 24HR DR 15 MG CAPSULE NA/F,

2 BOTTLES 15 MG

3 DP

PREVACID 24HR DR 15 MG CAPSULE NA/F,

3 BOTTLES 15 MG

3 DP

sm lansoprazole dr 15 mg cap gluten-free,1 bottle

(otc) 15 mg

3 MO; DP

sm lansoprazole dr 15 mg cap gluten-free,3 bottle

(otc) 15 mg

3 MO; DP

sm omeprazole dr 20 mg tablet 14 day course 20

mg

3 DP

sm omeprazole dr 20 mg tablet 2x14 day course 20

mg

3 DP

sm omeprazole dr 20 mg tablet 3x14 day course 20

mg

3 DP

GENETIC OR ENZYME DISORDER: REPLACEMENT, MODIFIERS, TREATMENT

GENETIC OR ENZYME DISORDER: REPLACEMENT, MODIFIERS, TREATMENT

ARALAST NP INTRAVENOUS RECON SOLN

1,000 MG, 500 MG

2 PA; MO

CERDELGA ORAL CAPSULE 84 MG 2 PA; MO

CHOLBAM ORAL CAPSULE 250 MG, 50 MG 2 PA; MO

122


limits on use

CREON ORAL CAPSULE,DELAYED

RELEASE(DR/EC) 12,000-38,000 -60,000 UNIT,

24,000-76,000 -120,000 UNIT, 3,000-9,500-

15,000 UNIT, 36,000-114,000- 180,000 UNIT,

6,000-19,000 -30,000 UNIT

2 MO

CYSTADANE ORAL POWDER 1 GRAM/1.7

ML

2 MO

CYSTAGON ORAL CAPSULE 150 MG, 50 MG 2 PA; MO

GALAFOLD ORAL CAPSULE 123 MG 2 PA; MO

GLASSIA INTRAVENOUS SOLUTION 1

GRAM/50 ML (2 %)

2 PA; MO

KUVAN ORAL POWDER IN PACKET 100 MG,

500 MG

2 PA; MO

KUVAN ORAL TABLET,SOLUBLE 100 MG 2 PA; MO

NITYR ORAL TABLET 10 MG, 2 MG, 5 MG 2 PA; MO

ORFADIN ORAL CAPSULE 10 MG, 2 MG, 20

MG, 5 MG

2 PA; MO

ORFADIN ORAL SUSPENSION 4 MG/ML 2 PA; MO

PROLASTIN-C INTRAVENOUS RECON SOLN

1,000 MG

2 PA; MO

PROLASTIN-C INTRAVENOUS SOLUTION

1,000 MG (+/-)/20 ML

2 PA; MO

RAVICTI ORAL LIQUID 1.1 GRAM/ML 2 PA; MO

sodium phenylbutyrate oral powder 0.94

gram/gram

1 PA; MO

sodium phenylbutyrate oral tablet 500 mg 1 PA; MO

SUCRAID ORAL SOLUTION 8,500 UNIT/ML 2 PA; MO

XURIDEN ORAL GRANULES IN PACKET 2

GRAM

2 PA; MO

ZEMAIRA INTRAVENOUS RECON SOLN

1,000 MG

2 PA; MO

ZENPEP ORAL CAPSULE,DELAYED

RELEASE(DR/EC) 10,000-32,000 -42,000 UNIT,

15,000-47,000 -63,000 UNIT, 20,000-63,000-

84,000 UNIT, 25,000-79,000- 105,000 UNIT,

3,000-10,000 -14,000-UNIT, 40,000-126,000-

168,000 UNIT, 5,000-17,000- 24,000 UNIT

2 MO

GENITOURINARY AGENTS

123


limits on use

ANTISPASMODICS, URINARY

darifenacin oral tablet extended release 24 hr 15

mg, 7.5 mg

1 ST; MO

flavoxate oral tablet 100 mg 1 MO

MYRBETRIQ ORAL TABLET EXTENDED



oxybutynin chloride oral syrup 5 mg/5 ml 1 MO

oxybutynin chloride oral tablet 5 mg 1 MO

oxybutynin chloride oral tablet extended release

24hr 10 mg, 15 mg, 5 mg

1 MO

tolterodine oral capsule,extended release 24hr 2

mg, 4 mg

1 MO

tolterodine oral tablet 1 mg, 2 mg 1 MO

TOVIAZ ORAL TABLET EXTENDED


2 MO

BENIGN PROSTATIC HYPERTROPHY AGENTS

alfuzosin oral tablet extended release 24 hr 10 mg 1 MO

dutasteride oral capsule 0.5 mg 1 MO

finasteride oral tablet 5 mg 1 MO

tamsulosin oral capsule 0.4 mg 1 MO

GENITOURINARY AGENTS, OTHER

bethanechol chloride oral tablet 10 mg, 25 mg, 5

mg, 50 mg

1

ELMIRON ORAL CAPSULE 100 MG 2

THIOLA ORAL TABLET 100 MG 2 PA

HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (ADRENAL)

HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (ADRENAL)

ACTHAR H.P. INJECTION GEL 80 UNIT/ML 2 PA

cortisone oral tablet 25 mg 1

dexamethasone sodium phosphate injection

solution 4 mg/ml

1 B/D

fludrocortisone oral tablet 0.1 mg 1 MO

hydrocortisone oral tablet 10 mg, 20 mg, 5 mg 1 MO

124


limits on use

hydrocortisone topical cream with perineal

applicator 2.5 %

1

methylprednisolone acetate injection suspension

40 mg/ml, 80 mg/ml

1

prednisone intensol oral concentrate 5 mg/ml 1

procto-med hc topical cream with perineal

applicator 2.5 %

1

procto-pak topical cream with perineal applicator

1 %

1

proctosol hc topical cream with perineal

applicator 2.5 %

1

proctozone-hc topical cream with perineal

applicator 2.5 %

1

HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (SEX

HORMONES/ MODIFIERS)

ANABOLIC STEROIDS

ANADROL-50 ORAL TABLET 50 MG 2 PA

oxandrolone oral tablet 10 mg, 2.5 mg 1 MO

ANDROGENS

DANAZOL ORAL CAPSULE 100 MG, 200 MG,

50 MG

1

methyltestosterone oral capsule 10 mg 1 PA; MO

testosterone cypionate intramuscular oil 100

mg/ml, 200 mg/ml

1 MO

testosterone enanthate intramuscular oil 200

mg/ml

1

testosterone transdermal gel 50 mg/5 gram (1 %) 1 PA; MO

testosterone transdermal gel in metered-dose

pump 12.5 mg/ 1.25 gram (1 %)

1 PA; MO

testosterone transdermal gel in packet 1 % (25

mg/2.5gram), 1 % (50 mg/5 gram), 1.62 % (20.25

mg/1.25 gram), 1.62 % (40.5 mg/2.5 gram)

1 PA; MO

testosterone transdermal solution in metered pump

w/app 30 mg/actuation (1.5 ml)

1 PA; MO

ESTROGENS

estradiol oral tablet 0.5 mg, 1 mg, 2 mg 1 MO

125


limits on use

estradiol transdermal patch semiweekly 0.025

mg/24 hr, 0.0375 mg/24 hr, 0.05 mg/24 hr, 0.075

mg/24 hr, 0.1 mg/24 hr

1 MO

estradiol transdermal patch weekly 0.025 mg/24

hr, 0.0375 mg/24 hr, 0.05 mg/24 hr, 0.06 mg/24

hr, 0.075 mg/24 hr, 0.1 mg/24 hr

1 MO

estradiol vaginal cream 0.01 % (0.1 mg/gram) 1 MO

estradiol vaginal tablet 10 mcg 1 MO

estradiol valerate intramuscular oil 20 mg/ml, 40

mg/ml

1

ESTRING VAGINAL RING 2 MG (7.5 MCG /24

HOUR)

2 MO

estropipate oral tablet 0.75 mg 1 PA; MO

MENEST ORAL TABLET 0.3 MG, 0.625 MG,

1.25 MG

2 PA; MO

PREMARIN ORAL TABLET 0.3 MG, 0.45 MG,

0.625 MG, 0.9 MG, 1.25 MG

2 MO

PREMARIN VAGINAL CREAM 0.625

MG/GRAM

2 MO

yuvafem vaginal tablet 10 mcg 1 MO

HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (SEX

HORMONES/ MODIFIERS)

AFTERA 1.5 MG TABLET 1.5 MG 3 DP

ALTAVERA (28) ORAL TABLET 0.15-0.03 MG 1 MO

alyacen 1/35 (28) oral tablet 1-35 mg-mcg 1 MO

amabelz oral tablet 0.5-0.1 mg, 1-0.5 mg 1 MO

apri oral tablet 0.15-0.03 mg 1 MO

aranelle (28) oral tablet 0.5/1/0.5-35 mg-mcg 1 MO

AUBRA EQ ORAL TABLET 0.1-20 MG-MCG 1 MO

aubra oral tablet 0.1-20 mg-mcg 1 MO

aviane oral tablet 0.1-20 mg-mcg 1 MO

balziva (28) oral tablet 0.4-35 mg-mcg 1 MO

blisovi fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg

(21)/75 mg (7)

1 MO

126


limits on use

blisovi fe 1/20 (28) oral tablet 1 mg-20 mcg

(21)/75 mg (7)

1 MO

briellyn oral tablet 0.4-35 mg-mcg 1 MO

caziant (28) oral tablet 0.1/.125/.15-25 mg-mcg 1 MO

CHATEAL EQ (28) ORAL TABLET 0.15-0.03

MG

1 MO

COMBIPATCH TRANSDERMAL PATCH

SEMIWEEKLY 0.05-0.14 MG/24 HR, 0.05-0.25

MG/24 HR

2 MO

cryselle (28) oral tablet 0.3-30 mg-mcg 1 MO

cyclafem 1/35 (28) oral tablet 1-35 mg-mcg 1 MO

cyclafem 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35

mcg

1 MO

CYRED EQ ORAL TABLET 0.15-0.03 MG 1 MO

CYRED ORAL TABLET 0.15-0.03 MG 1 MO

delyla (28) oral tablet 0.1-20 mg-mcg 1 MO

desog-e.estradiol/e.estradiol oral tablet 0.15-0.02

mgx21 /0.01 mg x 5

1 MO

desogestrel-ethinyl estradiol oral tablet 0.15-0.03

mg

1 MO

drospirenone-ethinyl estradiol oral tablet 3-0.03

mg

1 MO

ECONTRA EZ 1.5 MG TABLET INNER 1.5 MG 3 DP

ECONTRA EZ 1.5 MG TABLET OUTER 1.5

MG

3 DP

emoquette oral tablet 0.15-0.03 mg 1 MO

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

30(10)

1 MO

ENSKYCE ORAL TABLET 0.15-0.03 MG 1 MO

ESTARYLLA ORAL TABLET 0.25-35 MG-

MCG

1 MO

estradiol-norethindrone acet oral tablet 0.5-0.1

mg, 1-0.5 mg

1 MO

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

mcg, 1-50 mg-mcg

1 MO

falmina (28) oral tablet 0.1-20 mg-mcg 1 MO

127


limits on use

femynor oral tablet 0.25-35 mg-mcg 1 MO

FYAVOLV ORAL TABLET 0.5-2.5 MG-MCG 1 MO

fyavolv oral tablet 1-5 mg-mcg 1 MO

introvale oral tablets,dose pack,3 month 0.15 mg-

30 mcg (91)

1 MO

ISIBLOOM ORAL TABLET 0.15-0.03 MG 1 MO

jinteli oral tablet 1-5 mg-mcg 1 MO

juleber oral tablet 0.15-0.03 mg 1 MO

junel 1.5/30 (21) oral tablet 1.5-30 mg-mcg 1 MO

junel 1/20 (21) oral tablet 1-20 mg-mcg 1 MO

junel fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg

(21)/75 mg (7)

1 MO

junel fe 1/20 (28) oral tablet 1 mg-20 mcg (21)/75

mg (7)

1 MO

kariva (28) oral tablet 0.15-0.02 mgx21 /0.01 mg x

5

1 MO

kelnor 1/35 (28) oral tablet 1-35 mg-mcg 1 MO

KELNOR 1-50 ORAL TABLET 1-50 MG-MCG 1 MO

kimidess (28) oral tablet 0.15-0.02 mgx21 /0.01

mg x 5

1 MO

KURVELO (28) ORAL TABLET 0.15-0.03 MG 1 MO

larin 1.5/30 (21) oral tablet 1.5-30 mg-mcg 1 MO

larin 1/20 (21) oral tablet 1-20 mg-mcg 1 MO

larin fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg

(21)/75 mg (7)

1 MO

larin fe 1/20 (28) oral tablet 1 mg-20 mcg (21)/75

mg (7)

1 MO

larissia oral tablet 0.1-20 mg-mcg 1 MO

leena 28 oral tablet 0.5/1/0.5-35 mg-mcg 1 MO

lessina oral tablet 0.1-20 mg-mcg 1 MO

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

30(10)

1 MO

levonorgestrel-ethinyl estrad oral tablet 0.1-20

mg-mcg, 0.15-0.03 mg

1 MO

128


limits on use

levonorgestrel-ethinyl estrad oral tablets,dose

pack,3 month 0.15 mg-30 mcg (91)

1 MO

levonorg-eth estrad triphasic oral tablet 50-30

(6)/75-40 (5)/125-30(10)

1 MO

levora-28 oral tablet 0.15-0.03 mg 1 MO

LILLOW (28) ORAL TABLET 0.15-0.03 MG 1 MO

lopreeza oral tablet 1-0.5 mg 1 MO

low-ogestrel (28) oral tablet 0.3-30 mg-mcg 1 MO

lutera (28) oral tablet 0.1-20 mg-mcg 1 MO

marlissa (28) oral tablet 0.15-0.03 mg 1 MO

microgestin 1.5/30 (21) oral tablet 1.5-30 mg-mcg 1 MO

microgestin 1/20 (21) oral tablet 1-20 mg-mcg 1 MO

microgestin fe 1.5/30 (28) oral tablet 1.5 mg-30

mcg (21)/75 mg (7)

1 MO

microgestin fe 1/20 (28) oral tablet 1 mg-20 mcg

(21)/75 mg (7)

1 MO

MILI ORAL TABLET 0.25-35 MG-MCG 1 MO

mimvey lo oral tablet 0.5-0.1 mg 1 MO

MIMVEY ORAL TABLET 1-0.5 MG 1 MO

mononessa (28) oral tablet 0.25-35 mg-mcg 1 MO

MY WAY 1.5 MG TABLET (OTC) 1.5 MG 3 DP

necon 0.5/35 (28) oral tablet 0.5-35 mg-mcg 1 MO

necon 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 mcg 1 MO

norethindrone ac-eth estradiol oral tablet 1-20

mg-mcg, 1-5 mg-mcg

1 MO

norgestimate-ethinyl estradiol oral tablet

0.18/0.215/0.25 mg-35 mcg (28), 0.25-35 mg-mcg

1 MO

NORLYDA ORAL TABLET 0.35 MG 1 MO

nortrel 0.5/35 (28) oral tablet 0.5-35 mg-mcg 1 MO

nortrel 1/35 (21) oral tablet 1-35 mg-mcg (21) 1 MO

nortrel 1/35 (28) oral tablet 1-35 mg-mcg 1 MO

nortrel 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35

mcg

1 MO

NUVARING VAGINAL RING 0.12-0.015

MG/24 HR

2 MO

129


limits on use

ocella oral tablet 3-0.03 mg 1 MO

OPCICON ONE-STEP 1.5 MG TABLET 1.5 MG 3 DP

OPTION 2 1.5 MG TABLET 1.5 MG 3 DP

orsythia oral tablet 0.1-20 mg-mcg 1 MO

pimtrea (28) oral tablet 0.15-0.02 mgx21 /0.01 mg

x 5

1 MO

pirmella oral tablet 1-35 mg-mcg 1 MO

PLAN B ONE-STEP 1.5 MG TABLET (OTC) 1.5

MG

3 DP

portia 28 oral tablet 0.15-0.03 mg 1 MO

PREMPHASE ORAL TABLET 0.625 MG (14)/

0.625MG-5MG(14)

2 MO

PREMPRO ORAL TABLET 0.3-1.5 MG, 0.45-

1.5 MG, 0.625-2.5 MG, 0.625-5 MG

2 MO

previfem oral tablet 0.25-35 mg-mcg 1 MO

quasense oral tablets,dose pack,3 month 0.15 mg-

30 mcg (91)

1 MO

REACT 1.5 MG TABLET 1.5 MG 3 DP

reclipsen (28) oral tablet 0.15-0.03 mg 1 MO

setlakin oral tablets,dose pack,3 month 0.15 mg-30

mcg (91)

1 MO

sprintec (28) oral tablet 0.25-35 mg-mcg 1 MO

sronyx oral tablet 0.1-20 mg-mcg 1 MO

TAKE ACTION 1.5 MG TABLET 1.5 MG 3 DP

tarina fe 1/20 (28) oral tablet 1 mg-20 mcg (21)/75

mg (7)

1 MO

TARINA FE 1-20 EQ (28) ORAL TABLET 1

MG-20 MCG (21)/75 MG (7)

1 MO

TRI FEMYNOR ORAL TABLET 0.18/0.215/0.25

MG-35 MCG (28)

1 MO

TRI-ESTARYLLA ORAL TABLET

0.18/0.215/0.25 MG-35 MCG (28)

1 MO

tri-legest fe oral tablet 1-20(5)/1-30(7) /1mg-

35mcg (9)

1 MO

130


limits on use

TRI-MILI ORAL TABLET 0.18/0.215/0.25 MG-

35 MCG (28)

1 MO

trinessa (28) oral tablet 0.18/0.215/0.25 mg-35

mcg (28)

1 MO

tri-previfem (28) oral tablet 0.18/0.215/0.25 mg-35

mcg (28)

1 MO

tri-sprintec (28) oral tablet 0.18/0.215/0.25 mg-35

mcg (28)

1 MO

trivora (28) oral tablet 50-30 (6)/75-40 (5)/125-

30(10)

1 MO

tri-vylibra oral tablet 0.18/0.215/0.25 mg-35 mcg

(28)

1 MO

velivet triphasic regimen (28) oral tablet

0.1/.125/.15-25 mg-mcg

1 MO

vienva oral tablet 0.1-20 mg-mcg 1 MO

vyfemla (28) oral tablet 0.4-35 mg-mcg 1 MO

vylibra oral tablet 0.25-35 mg-mcg 1 MO

xulane transdermal patch weekly 150-35 mcg/24

hr

1 MO

zarah oral tablet 3-0.03 mg 1 MO

zovia 1/35e (28) oral tablet 1-35 mg-mcg 1 MO

PROGESTINS

camila oral tablet 0.35 mg 1 MO

deblitane oral tablet 0.35 mg 1 MO

DEPO-SUBQ PROVERA 104

SUBCUTANEOUS SYRINGE 104 MG/0.65 ML

2 MO

errin oral tablet 0.35 mg 1 MO

INCASSIA ORAL TABLET 0.35 MG 1 MO

jolivette oral tablet 0.35 mg 1 MO

lyza oral tablet 0.35 mg 1 MO

medroxyprogesterone intramuscular suspension

150 mg/ml

1 MO

medroxyprogesterone intramuscular syringe 150

mg/ml

1 MO

medroxyprogesterone oral tablet 10 mg, 2.5 mg, 5

mg

1 MO

131


limits on use

megestrol oral suspension 400 mg/10 ml (10 ml),

400 mg/10 ml (40 mg/ml), 625 mg/5 ml

1 PA; MO

megestrol oral tablet 20 mg, 40 mg 1 PA

nora-be oral tablet 0.35 mg 1 MO

norethindrone (contraceptive) oral tablet 0.35 mg 1 MO

norethindrone acetate oral tablet 5 mg 1 MO

norlyroc oral tablet 0.35 mg 1 MO

progesterone micronized oral capsule 100 mg, 200

mg

1 MO

sharobel oral tablet 0.35 mg 1 MO

TULANA ORAL TABLET 0.35 MG 1 MO

SELECTIVE ESTROGEN RECEPTOR MODIFYING AGENTS

DUAVEE ORAL TABLET 0.45-20 MG 2 MO

raloxifene oral tablet 60 mg 1 MO

HORMONAL AGENTS, STIMULANT/REPLACEMENT/ MODIFYING (PITUITARY)

HORMONAL AGENTS, STIMULANT/REPLACEMENT/ MODIFYING (PITUITARY)

desmopressin nasal spray with pump 10 mcg/spray

(0.1 ml)

1 MO

desmopressin nasal spray,non-aerosol 10

mcg/spray (0.1 ml)

1 MO

desmopressin oral tablet 0.1 mg, 0.2 mg 1 MO

EGRIFTA SUBCUTANEOUS RECON SOLN 1

MG, 2 MG

2 PA; MO

GENOTROPIN MINIQUICK SUBCUTANEOUS

SYRINGE 0.2 MG/0.25 ML, 0.4 MG/0.25 ML,

0.6 MG/0.25 ML, 0.8 MG/0.25 ML, 1 MG/0.25

ML, 1.2 MG/0.25 ML, 1.4 MG/0.25 ML, 1.6

MG/0.25 ML, 1.8 MG/0.25 ML, 2 MG/0.25 ML

2 PA; MO

GENOTROPIN SUBCUTANEOUS

CARTRIDGE 12 MG/ML (36 UNIT/ML), 5

MG/ML (15 UNIT/ML)

2 PA; MO

HUMATROPE INJECTION CARTRIDGE 12

MG (36 UNIT), 24 MG (72 UNIT), 6 MG (18

UNIT)

2 PA; MO

HUMATROPE INJECTION RECON SOLN 5 (15

UNIT) MG

2 PA; MO

132


limits on use

INCRELEX SUBCUTANEOUS SOLUTION 10

MG/ML

2 PA

NOCTIVA NASAL SPRAY,NON-AEROSOL

0.83 MCG/SPRAY (0.1 ML), 1.66 MCG/SPRAY

(0.1 ML)

2 PA; MO

NORDITROPIN FLEXPRO SUBCUTANEOUS

PEN INJECTOR 10 MG/1.5 ML (6.7 MG/ML),

15 MG/1.5 ML (10 MG/ML), 30 MG/3 ML (10

MG/ML), 5 MG/1.5 ML (3.3 MG/ML)

2 PA; MO

NUTROPIN AQ NUSPIN SUBCUTANEOUS

PEN INJECTOR 10 MG/2 ML (5 MG/ML), 20

MG/2 ML (10 MG/ML), 5 MG/2 ML (2.5

MG/ML)

2 PA; MO

OMNITROPE SUBCUTANEOUS CARTRIDGE

10 MG/1.5 ML (6.7 MG/ML), 5 MG/1.5 ML (3.3

MG/ML)

2 PA; MO

OMNITROPE SUBCUTANEOUS RECON

SOLN 5.8 MG

2 PA; MO

HORMONAL AGENTS, STIMULANT/REPLACEMENT/ MODIFYING (THYROID)

HORMONAL AGENTS, STIMULANT/REPLACEMENT/ MODIFYING (THYROID)

LEVO-T 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

2 MO

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 MO

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

2 MO

liothyronine oral tablet 25 mcg, 5 mcg, 50 mcg 1 MO

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

2 MO

unithroid oral tablet 100 mcg, 112 mcg, 125 mcg,

150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50

mcg, 75 mcg, 88 mcg

2 MO

HORMONAL AGENTS, SUPPRESSANT (PITUITARY)

HORMONAL AGENTS, SUPPRESSANT (PITUITARY)

133


limits on use

cabergoline oral tablet 0.5 mg 1 MO

ELIGARD (3 MONTH) SUBCUTANEOUS

SYRINGE 22.5 MG

2 PA; MO


SYRINGE 30 MG

2 PA; MO


SYRINGE 45 MG

2 PA; MO

ELIGARD SUBCUTANEOUS SYRINGE 7.5

MG (1 MONTH)

2 PA; MO

FIRMAGON KIT W DILUENT SYRINGE

SUBCUTANEOUS RECON SOLN 120 MG

2 PA

FIRMAGON KIT W DILUENT SYRINGE

SUBCUTANEOUS RECON SOLN 80 MG

2 PA; MO

FIRMAGON SUBCUTANEOUS RECON SOLN

120 MG

2 PA

leuprolide subcutaneous kit 1 mg/0.2 ml 1 MO

leuprolide subcutaneous solution 1 mg/0.2 ml 1

LUPRON DEPOT (3 MONTH)

INTRAMUSCULAR SYRINGE KIT 11.25 MG

2 PA



2 PA; MO


INTRAMUSCULAR SYRINGE KIT 30 MG

2 PA; MO


INTRAMUSCULAR SYRINGE KIT 45 MG

2 PA; MO

LUPRON DEPOT INTRAMUSCULAR

SYRINGE KIT 3.75 MG

2 PA

LUPRON DEPOT INTRAMUSCULAR

SYRINGE KIT 7.5 MG

2 PA; MO

LUPRON DEPOT-PED (3 MONTH)


2 PA; MO

LUPRON DEPOT-PED INTRAMUSCULAR KIT

7.5 MG (PED)

2 PA; MO

octreotide acetate injection solution 1,000 mcg/ml,

500 mcg/ml

1 PA; MO

134


limits on use

OCTREOTIDE ACETATE INJECTION

SOLUTION 100 MCG/ML, 200 MCG/ML, 50

MCG/ML

1 PA; MO

ORILISSA ORAL TABLET 150 MG 2 PA; MO

ORILISSA ORAL TABLET 200 MG 2 PA

SIGNIFOR SUBCUTANEOUS SOLUTION 0.3

MG/ML (1 ML), 0.6 MG/ML (1 ML), 0.9 MG/ML

(1 ML)

2 PA; MO

SOMATULINE DEPOT SUBCUTANEOUS

SYRINGE 120 MG/0.5 ML, 60 MG/0.2 ML, 90

MG/0.3 ML

2 PA; MO

SOMAVERT SUBCUTANEOUS RECON SOLN

10 MG, 15 MG, 20 MG, 25 MG, 30 MG

2 PA; MO

SYNAREL NASAL SPRAY,NON-AEROSOL 2

MG/ML

2 PA

TRELSTAR INTRAMUSCULAR SUSPENSION

FOR RECONSTITUTION 11.25 MG, 3.75 MG

2 PA; MO

TRELSTAR INTRAMUSCULAR SUSPENSION

FOR RECONSTITUTION 22.5 MG

2 PA

TRELSTAR INTRAMUSCULAR SYRINGE

11.25 MG/2 ML, 3.75 MG/2 ML

2 PA; MO

TRELSTAR INTRAMUSCULAR SYRINGE

22.5 MG/2 ML

2 PA

HORMONAL AGENTS, SUPPRESSANT (THYROID)

ANTITHYROID AGENTS

methimazole oral tablet 10 mg, 5 mg 1 MO

propylthiouracil oral tablet 50 mg 1 MO

IMMUNOLOGICAL AGENTS

ANGIOEDEMA AGENTS

CINRYZE INTRAVENOUS RECON SOLN 500

UNIT (5 ML)

2 PA; MO

FIRAZYR SUBCUTANEOUS SYRINGE 30

MG/3 ML

2 PA

HAEGARDA SUBCUTANEOUS RECON SOLN

2,000 UNIT, 3,000 UNIT

2 PA; MO

IMMUNE SUPPRESSANTS

135


limits on use

ASTAGRAF XL ORAL CAPSULE,EXTENDED

RELEASE 24HR 0.5 MG, 1 MG, 5 MG

2 B/D; MO

azathioprine oral tablet 50 mg 1 B/D; MO

CIMZIA POWDER FOR RECONST

SUBCUTANEOUS KIT 400 MG (200 MG X 2

VIALS)

2 PA; MO

CIMZIA STARTER KIT SUBCUTANEOUS

SYRINGE KIT 400 MG/2 ML (200 MG/ML X 2)

2 PA; MO

CIMZIA SUBCUTANEOUS SYRINGE KIT 400

MG/2 ML (200 MG/ML X 2)

2 PA; MO

cyclosporine modified oral capsule 100 mg, 25

mg, 50 mg

1 B/D; MO

cyclosporine modified oral solution 100 mg/ml 1 B/D; MO

cyclosporine oral capsule 100 mg, 25 mg 1 B/D; MO

DEPEN TITRATABS ORAL TABLET 250 MG 2 PA; MO

ENBREL MINI SUBCUTANEOUS

CARTRIDGE 50 MG/ML (0.98 ML)

2 PA; MO

ENBREL SUBCUTANEOUS RECON SOLN 25

MG (1 ML)

2 PA; MO

ENBREL SUBCUTANEOUS SYRINGE 25

MG/0.5ML (0.51), 50 MG/ML (0.98 ML)

2 PA; MO

ENBREL SURECLICK SUBCUTANEOUS PEN

INJECTOR 50 MG/ML (0.98 ML)

2 PA; MO

ENVARSUS XR ORAL TABLET EXTENDED

RELEASE 24 HR 0.75 MG, 1 MG, 4 MG

2 B/D; MO

gengraf oral capsule 100 mg, 25 mg 1 B/D; MO

gengraf oral solution 100 mg/ml 1 B/D; MO

HUMIRA PEDIATRIC CROHNS START

SUBCUTANEOUS SYRINGE KIT 40 MG/0.8

ML

2 PA; MO

HUMIRA PEDIATRIC CROHNS START


ML (6 PACK)

2 PA

HUMIRA PEN CROHNS-UC-HS START

SUBCUTANEOUS PEN INJECTOR KIT 40

MG/0.8 ML

2 PA; MO

136


limits on use

HUMIRA PEN PSOR-UVEITS-ADOL HS


MG/0.8 ML

2 PA; MO

HUMIRA PEN SUBCUTANEOUS PEN

INJECTOR KIT 40 MG/0.8 ML

2 PA; MO

HUMIRA SUBCUTANEOUS SYRINGE KIT 10

MG/0.2 ML, 20 MG/0.4 ML, 40 MG/0.8 ML

2 PA; MO

HUMIRA(CF) PEDI CROHNS STARTER


ML

2 PA; MO

HUMIRA(CF) PEDI CROHNS STARTER


ML-40 MG/0.4 ML

2 PA

HUMIRA(CF) PEN CROHNS-UC-HS


MG/0.8 ML

2 PA

HUMIRA(CF) PEN PSOR-UV-ADOL HS


MG/0.8 ML-40 MG/0.4 ML

2 PA

HUMIRA(CF) PEN SUBCUTANEOUS PEN


2 PA; MO

HUMIRA(CF) PEN SUBCUTANEOUS PEN


2 PA

HUMIRA(CF) SUBCUTANEOUS SYRINGE

KIT 10 MG/0.1 ML, 20 MG/0.2 ML, 40 MG/0.4

ML

2 PA; MO

KINERET SUBCUTANEOUS SYRINGE 100

MG/0.67 ML

2 PA; MO

methotrexate sodium (pf) injection solution 25

mg/ml

1

methotrexate sodium injection solution 25 mg/ml 1

methotrexate sodium oral tablet 2.5 mg 1 MO

mycophenolate mofetil oral capsule 250 mg 1 B/D; MO

mycophenolate mofetil oral suspension for

reconstitution 200 mg/ml

1 B/D; MO

mycophenolate mofetil oral tablet 500 mg 1 B/D; MO

mycophenolate sodium oral tablet,delayed release

(dr/ec) 180 mg, 360 mg

1 B/D; MO

137


limits on use

ORENCIA CLICKJECT SUBCUTANEOUS

AUTO-INJECTOR 125 MG/ML

2 PA; MO

ORENCIA SUBCUTANEOUS SYRINGE 125

MG/ML, 50 MG/0.4 ML, 87.5 MG/0.7 ML

2 PA; MO

RAPAMUNE ORAL SOLUTION 1 MG/ML 2 B/D; MO

SANDIMMUNE ORAL SOLUTION 100 MG/ML 2 B/D; MO

SIMPONI SUBCUTANEOUS PEN INJECTOR

100 MG/ML, 50 MG/0.5 ML

2 PA; MO

SIMPONI SUBCUTANEOUS SYRINGE 100

MG/ML, 50 MG/0.5 ML

2 PA; MO

sirolimus oral solution 1 mg/ml 1

sirolimus oral tablet 0.5 mg, 1 mg, 2 mg 1 B/D; MO

tacrolimus oral capsule 0.5 mg, 1 mg, 5 mg 1 B/D; MO

TREXALL ORAL TABLET 10 MG, 15 MG, 5

MG, 7.5 MG

2 ST; MO

XATMEP ORAL SOLUTION 2.5 MG/ML 2 PA; MO

ZORTRESS ORAL TABLET 0.25 MG, 0.5 MG,

0.75 MG, 1 MG

2 B/D; MO

IMMUNIZING AGENTS, PASSIVE

BIVIGAM INTRAVENOUS SOLUTION 10 % 2 B/D; MO

CARIMUNE NF NANOFILTERED

INTRAVENOUS RECON SOLN 6 GRAM

2 B/D; MO

FLEBOGAMMA DIF INTRAVENOUS

SOLUTION 10 %

2 B/D; MO

GAMMAGARD LIQUID INJECTION

SOLUTION 10 %

2 B/D; MO

GAMMAGARD S-D (IGA < 1 MCG/ML)

INTRAVENOUS RECON SOLN 10 GRAM, 5

GRAM

2 B/D; MO

GAMMAKED INJECTION SOLUTION 1

GRAM/10 ML (10 %)

2 B/D; MO

GAMMAPLEX (WITH SORBITOL)

INTRAVENOUS SOLUTION 5 %

2 B/D; MO

GAMMAPLEX INTRAVENOUS SOLUTION 10

%

2 B/D; MO

138


limits on use

GAMMAPLEX INTRAVENOUS SOLUTION 10

% (100 ML), 10 % (200 ML)

2 B/D

GAMUNEX-C INJECTION SOLUTION 1

GRAM/10 ML (10 %)

2 B/D; MO

HYPERRAB (PF) INTRAMUSCULAR


2

HYPERRAB S/D (PF) INTRAMUSCULAR

SOLUTION 150 UNIT/ML, 150 UNIT/ML (10

ML)

2

PRIVIGEN INTRAVENOUS SOLUTION 10 % 2 B/D; MO

IMMUNOMODULATORS

ACTEMRA ACTPEN SUBCUTANEOUS PEN

INJECTOR 162 MG/0.9 ML

2 PA; MO

ACTEMRA SUBCUTANEOUS SYRINGE 162

MG/0.9 ML

2 PA; MO

ACTIMMUNE SUBCUTANEOUS SOLUTION

100 MCG/0.5 ML

2 PA

ARCALYST SUBCUTANEOUS RECON SOLN

220 MG

2 PA; MO

BENLYSTA SUBCUTANEOUS AUTO-

INJECTOR 200 MG/ML

2 PA; MO

BENLYSTA SUBCUTANEOUS SYRINGE 200

MG/ML

2 PA; MO

leflunomide oral tablet 10 mg, 20 mg 1 MO

OTEZLA ORAL TABLET 30 MG 2 PA; MO

OTEZLA STARTER ORAL TABLETS,DOSE

PACK 10 MG (4)-20 MG (4)-30 MG (47), 10 MG

(4)-20 MG (4)-30 MG(19)

2 PA

XOLAIR SUBCUTANEOUS RECON SOLN 150

MG

2 PA; MO

XOLAIR SUBCUTANEOUS SYRINGE 150

MG/ML, 75 MG/0.5 ML

2 PA; MO

VACCINES

ACTHIB (PF) INTRAMUSCULAR RECON

SOLN 10 MCG/0.5 ML

2

ADACEL(TDAP ADOLESN/ADULT)(PF)

INTRAMUSCULAR SUSPENSION 2 LF-(2.5-5-

3-5 MCG)-5LF/0.5 ML

2

139


limits on use

ADACEL(TDAP ADOLESN/ADULT)(PF)

INTRAMUSCULAR SYRINGE 2 LF-(2.5-5-3-5

MCG)-5LF/0.5 ML

2

BCG VACCINE, LIVE (PF) PERCUTANEOUS

SUSPENSION FOR RECONSTITUTION 50 MG

2

BEXSERO INTRAMUSCULAR SYRINGE 50-

50-50-25 MCG/0.5 ML

2

BOOSTRIX TDAP INTRAMUSCULAR

SUSPENSION 2.5-8-5 LF-MCG-LF/0.5ML

2

BOOSTRIX TDAP INTRAMUSCULAR

SYRINGE 2.5-8-5 LF-MCG-LF/0.5ML

2

DAPTACEL (DTAP PEDIATRIC) (PF)

INTRAMUSCULAR SUSPENSION 15-10-5 LF-

MCG-LF/0.5ML

2

ENGERIX-B (PF) INTRAMUSCULAR

SYRINGE 20 MCG/ML

2 B/D

ENGERIX-B PEDIATRIC (PF)

INTRAMUSCULAR SYRINGE 10 MCG/0.5 ML

2 B/D

GARDASIL 9 (PF) INTRAMUSCULAR

SUSPENSION 0.5 ML

2

GARDASIL 9 (PF) INTRAMUSCULAR

SYRINGE 0.5 ML

2

HAVRIX (PF) INTRAMUSCULAR

SUSPENSION 1,440 ELISA UNIT/ML, 720

ELISA UNIT/0.5 ML

2

HAVRIX (PF) INTRAMUSCULAR SYRINGE

1,440 ELISA UNIT/ML, 720 ELISA UNIT/0.5

ML

2

HEPLISAV-B (PF) INTRAMUSCULAR

SOLUTION 20 MCG/0.5 ML

2 B/D

HEPLISAV-B (PF) INTRAMUSCULAR

SYRINGE 20 MCG/0.5 ML

2 B/D

HIBERIX (PF) INTRAMUSCULAR RECON

SOLN 10 MCG/0.5 ML

2

IMOVAX RABIES VACCINE (PF)

INTRAMUSCULAR RECON SOLN 2.5 UNIT

2

INFANRIX (DTAP) (PF) INTRAMUSCULAR

SUSPENSION 25-58-10 LF-MCG-LF/0.5ML

2

140


limits on use

INFANRIX (DTAP) (PF) INTRAMUSCULAR

SYRINGE 25-58-10 LF-MCG-LF/0.5ML

2

IPOL INJECTION SUSPENSION 40-8-32

UNIT/0.5 ML

2

IXIARO (PF) INTRAMUSCULAR SYRINGE 6

MCG/0.5 ML

2

KEDRAB (PF) INTRAMUSCULAR SOLUTION

150 UNIT/ML

2

KINRIX (PF) INTRAMUSCULAR

SUSPENSION 25 LF-58 MCG-10 LF/0.5 ML

2

KINRIX (PF) INTRAMUSCULAR SYRINGE 25

LF-58 MCG-10 LF/0.5 ML

2

MENACTRA (PF) INTRAMUSCULAR

SOLUTION 4 MCG/0.5 ML

2

MENVEO A-C-Y-W-135-DIP (PF)

INTRAMUSCULAR KIT 10-5 MCG/0.5 ML

2

M-M-R II (PF) SUBCUTANEOUS RECON

SOLN 1,000-12,500 TCID50/0.5 ML

2

PEDIARIX (PF) INTRAMUSCULAR SYRINGE

10 MCG-25LF-25 MCG-10LF/0.5 ML

2

PEDVAX HIB (PF) INTRAMUSCULAR

SOLUTION 7.5 MCG/0.5 ML

2

PENTACEL ACTHIB COMPONENT (PF)

INTRAMUSCULAR RECON SOLN 10 MCG/0.5

ML

2

PROQUAD (PF) SUBCUTANEOUS

SUSPENSION FOR RECONSTITUTION

10EXP3-4.3-3- 3.99 TCID50/0.5

2

QUADRACEL (PF) INTRAMUSCULAR

SUSPENSION 15 LF-48 MCG- 5 LF

UNIT/0.5ML

2

RABAVERT (PF) INTRAMUSCULAR

SUSPENSION FOR RECONSTITUTION 2.5

UNIT

2

RECOMBIVAX HB (PF) INTRAMUSCULAR

SUSPENSION 10 MCG/ML, 40 MCG/ML

2 B/D

RECOMBIVAX HB (PF) INTRAMUSCULAR

SYRINGE 10 MCG/ML, 5 MCG/0.5 ML

2 B/D

141


limits on use

ROTARIX ORAL SUSPENSION FOR

RECONSTITUTION 10EXP6 CCID50/ML

2

ROTATEQ VACCINE ORAL SOLUTION 2 ML 2

SHINGRIX (PF) INTRAMUSCULAR


MCG/0.5 ML


SHINGRIX GE ANTIGEN COMPONENT

INTRAMUSCULAR SUSPENSION FOR

RECONSTITUTION 50 MCG

2

TENIVAC (PF) INTRAMUSCULAR

SUSPENSION 5 LF UNIT- 2 LF UNIT/0.5ML

2

TENIVAC (PF) INTRAMUSCULAR SYRINGE

5-2 LF UNIT/0.5 ML

2

tetanus,diphtheria tox ped(pf) intramuscular

suspension 5-25 lf unit/0.5 ml

1

tetanus-diphtheria toxoids-td intramuscular

suspension 2-2 lf unit/0.5 ml

1

TICE BCG INTRAVESICAL SUSPENSION

FOR RECONSTITUTION 50 MG

2

TRUMENBA INTRAMUSCULAR SYRINGE

120 MCG/0.5 ML

2

TWINRIX (PF) INTRAMUSCULAR SYRINGE

720 ELISA UNIT- 20 MCG/ML

2

TYPHIM VI INTRAMUSCULAR SOLUTION 25

MCG/0.5 ML

2

TYPHIM VI INTRAMUSCULAR SYRINGE 25

MCG/0.5 ML

2

VAQTA (PF) INTRAMUSCULAR

SUSPENSION 25 UNIT/0.5 ML, 50 UNIT/ML

2

VAQTA (PF) INTRAMUSCULAR SYRINGE 25

UNIT/0.5 ML, 50 UNIT/ML

2

VARIVAX (PF) SUBCUTANEOUS

SUSPENSION FOR RECONSTITUTION 1,350

UNIT/0.5 ML

2

VARIZIG INTRAMUSCULAR RECON SOLN

125 UNIT

2

VARIZIG INTRAMUSCULAR SOLUTION 125

UNIT/1.2 ML

2

142


limits on use

VAXCHORA BUFFER COMPONENT ORAL

SUSPENSION FOR RECONSTITUTION

2

VAXCHORA VACCINE ORAL SUSPENSION

FOR RECONSTITUTION 4X10EXP8 TO 2X

10EXP9 CF UNIT

2

YF-VAX (PF) SUBCUTANEOUS SUSPENSION

FOR RECONSTITUTION 10 EXP4.74 UNIT/0.5

ML

2

ZOSTAVAX (PF) SUBCUTANEOUS

SUSPENSION FOR RECONSTITUTION 19,400

UNIT/0.65 ML


INFLAMMATORY BOWEL DISEASE AGENTS

AMINOSALICYLATES

balsalazide oral capsule 750 mg 1

DELZICOL ORAL CAPSULE (WITH DEL REL

TABLETS) 400 MG

2 MO

DIPENTUM ORAL CAPSULE 250 MG 2 MO

mesalamine oral tablet,delayed release (dr/ec) 1.2

gram

1 MO

mesalamine rectal enema 4 gram/60 ml 1 MO

mesalamine rectal suppository 1,000 mg 1 MO

mesalamine with cleansing wipe rectal enema kit 4

gram/60 ml

1 MO

PENTASA ORAL CAPSULE, EXTENDED

RELEASE 250 MG, 500 MG

2 MO

GLUCOCORTICOIDS

BUDESONIDE ORAL

CAPSULE,DELAYED,EXTEND.RELEASE 3

MG

1

hydrocortisone rectal enema 100 mg/60 ml 1

methylprednisolone oral tablet 16 mg, 32 mg, 4

mg, 8 mg

1

SULFONAMIDES

sulfasalazine oral tablet 500 mg 1 MO

sulfasalazine oral tablet,delayed release (dr/ec)

500 mg

1 MO

METABOLIC BONE DISEASE AGENTS

143


limits on use

METABOLIC BONE DISEASE AGENTS

alendronate oral tablet 10 mg, 35 mg, 40 mg, 5

mg, 70 mg

1 MO

calcitonin (salmon) nasal spray,non-aerosol 200

unit/actuation

1 MO

doxercalciferol intravenous solution 4 mcg/2 ml 1 MO

doxercalciferol oral capsule 0.5 mcg, 1 mcg, 2.5

mcg

1 MO

etidronate disodium oral tablet 200 mg, 400 mg 1 MO

FORTEO SUBCUTANEOUS PEN INJECTOR

20 MCG/DOSE - 600 MCG/2.4 ML

2 PA; MO

ibandronate oral tablet 150 mg 1 MO

NATPARA SUBCUTANEOUS CARTRIDGE

100 MCG/DOSE, 25 MCG/DOSE, 50

MCG/DOSE, 75 MCG/DOSE

2 PA; MO

PROLIA SUBCUTANEOUS SYRINGE 60

MG/ML

2 PA; MO

risedronate oral tablet 150 mg, 35 mg, 5 mg 1 MO

risedronate oral tablet 30 mg, 35 mg (12 pack), 35

mg (4 pack)

1

SENSIPAR ORAL TABLET 30 MG, 60 MG 2 MO; QL (60 EA per 30 days)

SENSIPAR ORAL TABLET 90 MG 2 MO; QL (120 EA per 30 days)

TYMLOS SUBCUTANEOUS PEN INJECTOR

80 MCG (3,120 MCG/1.56 ML)

2 PA; MO

XGEVA SUBCUTANEOUS SOLUTION 120

MG/1.7 ML (70 MG/ML)

2 PA

OPHTHALMIC AGENTS

OPHTHALMIC PROSTAGLANDIN AND PROSTAMIDE ANALOGS

latanoprost ophthalmic (eye) drops 0.005 % 1 MO

LUMIGAN OPHTHALMIC (EYE) DROPS 0.01

%

2 MO

TRAVATAN Z OPHTHALMIC (EYE) DROPS

0.004 %

2 MO

OPHTHALMIC AGENTS, OTHER

ARTIFICIAL TEARS 1.4% DROPS 1.4 % 3 DP

144


limits on use

ARTIFICIAL TEARS EYE OINTMENT 83-15 % 3 DP

CYSTARAN OPHTHALMIC (EYE) DROPS

0.44 %

2 MO

GENTEAL GEL DROPS 0.25-0.3 % 3 DP

GENTEAL MILD-MODERATE EYE DROP P/F,

DRY EYE RELIEF 0.3 %

3 DP

GENTEAL TEARS 0.1%-0.2%-0.3% 0.1-0.3-0.2

%

3 DP

GENTEAL TEARS 0.1%-0.3% DROP 0.1-0.3 % 3 DP

GENTEAL TEARS 0.1%-0.3% DROP 0.1-0.3 % 3 DP

GENTEAL TEARS SEVERE 0.3% GEL OUTER

0.3 %

3 DP

GS LUBRICAT PLUS 0.5% EYE DRPS P/F,

30X0.4ML 0.5 %

3 DP

HM LUBRICAT PLUS 0.5% EYE DRPS P/F,

SUV, STERILE 0.5 %

3 DP

HM LUBRICATING TEARS EYE DROPS 0.4-

0.3 %

3 DP

LIQUITEARS 1.4% DROPS 1.4 % 3 DP

LUBRICANT 0.5-0.9% EYE DROPS 0.5-0.9 % 3 DP

LUBRICANT EYE 0.4%-0.3% DROP P/F 0.4-0.3

%

3 DP

LUBRICANT EYE DROPS 0.4-0.3 % 3 DP

LUBRICANT EYE DROPS DRY EYE

THERAPY 0.4-0.3 %

3 DP

LUBRICANT PM EYE OINTMENT P/F 57.3-

42.5 %

3 DP

LUBRICATING PLUS 0.5% EYE DRPS P/F,

30X0.4ML 0.5 %

3 DP

LUBRIFRESH PM EYE OINTMENT 83-15 % 3 DP

MURO-128 2% EYE DROPS 2 % 3 DP

MURO-128 5% EYE DROPS 5 % 3 DP

MURO-128 5% EYE OINTMENT 5 % 3 DP

NATACYN OPHTHALMIC (EYE)

DROPS,SUSPENSION 5 %

2

NATURE'S TEARS EYE DROPS 0.1-0.3 % 3 DP

145


limits on use

OXERVATE OPHTHALMIC (EYE) DROPS

0.002 %

2 PA

proparacaine ophthalmic (eye) drops 0.5 % 1

REFRESH CELLUVISC 1% EYE DROPS 1 % 3 DP

REFRESH CLASSIC EYE DROPS U-

D,P/F,30X.4ML 1.4-0.6 %

3 DP

REFRESH CLASSIC EYE DROPS U-

D,P/F,50X.4ML 1.4-0.6 %

3 DP

REFRESH LACRI-LUBE OINTMENT 56.8-42.5

%

3 DP

REFRESH OPTIVE ADVANCED DROPS 0.5-1-

0.5 %

3 DP

REFRESH OPTIVE EYE DROPS 0.5-0.9 % 3 DP

REFRESH OPTIVE SENSITIVE DROPS

30X0.4ML, P/F 0.5-0.9 %

3 DP

REFRESH OPTIVE SENSITIVE DROPS

60X0.4ML, P/F 0.5-0.9 %

3 DP

REFRESH PLUS 0.5% EYE DROPS 30X0.4ML

0.5 %

3 DP

REFRESH PLUS 0.5% EYE DROPS

70X0.4ML,U-D 0.5 %

3 DP

REFRESH PLUS 0.5% EYE DROPS U-

D,50X.4ML 0.5 %

3 DP

REFRESH TEARS 0.5% EYE DROP 0.5 % 3 DP

RESTASIS MULTIDOSE OPHTHALMIC (EYE)

DROPS 0.05 %

2 MO; QL (11 ML per 30 days)

RESTASIS OPHTHALMIC (EYE)

DROPPERETTE 0.05 %


SM LUBRICANT EYE DROPS STRL 0.4-0.3 % 3 DP

SM LUBRICATING TEARS EYE DROPS

STERILE 0.4-0.3 %

3 DP

sodium chloride 5% eye drop 5 % 3 DP

sodium chloride 5% eye oint 5 % 3 DP

sodium chloride 5% eye oint sterile 5 % 3 DP

sulfacetamide-prednisolone ophthalmic (eye)

drops 10 %-0.23 % (0.25 %)

1

146


limits on use

SYSTANE 0.3% EYE GEL 0.3 % 3 DP

SYSTANE 0.3-0.4% EYE DROP P/F 0.4-0.3 % 3 DP

SYSTANE 0.3-0.4% EYE DROP U-

D,P/F,0.014X28 VL 0.4-0.3 %

3 DP

SYSTANE 0.3-0.4% EYE DROPS 0.4-0.3 % 3 DP

SYSTANE 0.3-0.4% EYE DROPS POCKET

PACK, 2X5ML 0.4-0.3 %

3 DP

SYSTANE 0.3-0.4% EYE DROPS TWIN PACK,

2X20ML 0.4-0.3 %

3 DP

SYSTANE BALANCE 0.6% EYE DROP

CLINICAL STRENGTH 0.6 %

3 DP

SYSTANE ULTRA 0.4-0.3% EYE DRP 0.4-0.3

%

3 DP

TEARS NATURALE FREE DROPS U-

D,36X.9ML,P/F 0.1-0.3 %

3 DP

ULTRA LUBRICANT EYE DROPS 0.4-0.3 % 3 DP

XIIDRA OPHTHALMIC (EYE) DROPPERETTE

5 %


OPHTHALMIC ANTI-ALLERGY AGENTS

azelastine ophthalmic (eye) drops 0.05 % 1

cromolyn ophthalmic (eye) drops 4 % 1

epinastine ophthalmic (eye) drops 0.05 % 1

olopatadine ophthalmic (eye) drops 0.1 % 1

OPHTHALMIC ANTIGLAUCOMA AGENTS

ALPHAGAN P OPHTHALMIC (EYE) DROPS

0.1 %

2 MO

atropine ophthalmic (eye) drops 1 % 1 MO

AZOPT OPHTHALMIC (EYE)

DROPS,SUSPENSION 1 %

2 ST; MO

brimonidine ophthalmic (eye) drops 0.15 %, 0.2 % 1 MO

carteolol ophthalmic (eye) drops 1 % 1 MO

COMBIGAN OPHTHALMIC (EYE) DROPS 0.2-

0.5 %

2 MO

dorzolamide ophthalmic (eye) drops 2 % 1 MO

dorzolamide-timolol ophthalmic (eye) drops 22.3-

6.8 mg/ml

1 MO

147


limits on use

FML FORTE OPHTHALMIC (EYE)

DROPS,SUSPENSION 0.25 %

2

levobunolol ophthalmic (eye) drops 0.5 % 1 MO

PHOSPHOLINE IODIDE OPHTHALMIC (EYE)

DROPS 0.125 %

2 MO

pilocarpine hcl ophthalmic (eye) drops 1 %, 2 %,

4 %

1 MO

SIMBRINZA OPHTHALMIC (EYE)

DROPS,SUSPENSION 1-0.2 %

2 MO

timolol maleate ophthalmic (eye) drops 0.25 %,

0.5 %

1 MO

timolol maleate ophthalmic (eye) gel forming

solution 0.25 %, 0.5 %

1 MO

OPHTHALMIC ANTI-INFLAMMATORIES

dexamethasone sodium phosphate ophthalmic

(eye) drops 0.1 %

1

diclofenac sodium ophthalmic (eye) drops 0.1 % 1

DUREZOL OPHTHALMIC (EYE) DROPS 0.05

%

2

fluorometholone ophthalmic (eye)

drops,suspension 0.1 %

1

flurbiprofen sodium ophthalmic (eye) drops 0.03

%

1

ketorolac ophthalmic (eye) drops 0.4 %, 0.5 % 1

prednisolone acetate ophthalmic (eye)

drops,suspension 1 %

1

prednisolone sodium phosphate ophthalmic (eye)

drops 1 %

1

OTIC AGENTS

OTIC AGENTS

acetic acid-aluminum acetate otic (ear) drops 2 % 1

CIPRODEX OTIC (EAR) DROPS,SUSPENSION

0.3-0.1 %

2

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

neomycin-polymyxin-hc otic (ear)

drops,suspension 3.5-10,000-1 mg/ml-unit/ml-%

1

148


limits on use

neomycin-polymyxin-hc otic (ear) solution 3.5-

10,000-1 mg/ml-unit/ml-%

1

ofloxacin otic (ear) drops 0.3 % 1

RESPIRATORY TRACT/ PULMONARY AGENTS

ANTIHISTAMINES

ALL DAY ALLERGY 10 MG CHEW TAB 10

MG

3 DP

ALL DAY ALLERGY 10 MG TABLET 10 MG 3 DP

ALL DAY ALLERGY 10 MG TABLET

INDOOR/OUTDOOR 10 MG

3 DP

ALL DAY ALLERGY 10 MG TABLET

INDOOR/OUTDOOR 24 HR 10 MG

3 DP

ALLER-CHLOR 4 MG TABLET 4 MG 3 DP

ALLERGY (LORATADINE) 10 MG TAB 10 MG 3 DP

ALLERGY 25 MG CAPSULE 25 MG 3 DP

ALLERGY 4 MG TABLET 4 MG 3 DP

ALLERGY RELIEF 10 MG TABLET 10 MG 3 DP

ALLERGY RELIEF 10 MG TABLET NON-

DROWSY,24 HOUR 10 MG

3 DP

ALLERGY RELIEF 180 MG TABLET 180 MG 3 DP

ALLERGY RELIEF 25 MG SOFTGEL

SOFTGEL 25 MG

3 DP

ALLERGY RELIEF 5 MG/5 ML SOLN A/F 5

MG/5 ML

3 DP

ALLERGY RELIEF SYRUP A/F 5 MG/5 ML 3 DP

ALLERGY-TIME 4 MG TABLET 4 MG 3 DP

azelastine nasal aerosol,spray 137 mcg (0.1 %) 1 MO

azelastine nasal spray,non-aerosol 0.15 % (205.5

mcg)

1 MO

BANOPHEN 12.5 MG/5 ML SOLUTION 12.5

MG/5 ML

3 DP

BANOPHEN 25 MG CAPSULE 25 MG 3 DP

BANOPHEN 25 MG TABLET 25 MG 3 DP

BANOPHEN 50 MG CAPSULE 50 MG 3 DP

cetirizine hcl 1 mg/ml soln (otc) 1 mg/ml 3 DP

149


limits on use

cetirizine hcl 1 mg/ml soln children, s/f, grape

(otc) 1 mg/ml

3 DP

cetirizine hcl 1 mg/ml soln children's (otc) 1 mg/ml 3 DP

cetirizine hcl 10 mg tablet 10 mg 3 DP

cetirizine hcl 10 mg tablet f/c,u-d,10x10,inner 10

mg

3 DP

cetirizine hcl 10 mg tablet f/c,u-d,10x10,outer 10

mg

3 DP

cetirizine hcl 10 mg tablet indoor & outdoor 10

mg

3 DP

cetirizine hcl 10 mg tablet indoor/outdoor 24 hr 10

mg

3 DP

cetirizine hcl 10 mg tablet indoor-outdoor,24hr 10

mg

3 DP

cetirizine hcl 10 mg tablet outer 10 mg 3 DP

cetirizine hcl 10 mg tablet u-d,10x10 10 mg 3 DP

cetirizine hcl 5 mg tablet 5 mg 3 DP

cetirizine hcl 5 mg tablet indoor & outdoor 5 mg 3 DP

cetirizine hcl 5 mg/5 ml soln inner 5 mg/5 ml 3 DP

cetirizine hcl 5 mg/5 ml soln outer 5 mg/5 ml 3 DP

cetirizine hcl 5 mg/5 ml syrup 40's, u-d cups 5

mg/5 ml

3 DP

cetirizine oral solution 1 mg/ml 1

cetirizine-pse er 5-120 mg tab 12 hr relief 5-120

mg

3 DP

cetirizine-pse er 5-120 mg tab 5-120 mg 3 DP

CHILD ALL DAY ALLERGY 1 MG/ML 1

MG/ML

3 DP

CHILD ALL DAY ALLERGY 1 MG/ML 1

MG/ML

3 DP

CHILD ALL DAY ALLERGY 1 MG/ML

BUBBLE GUM 1 MG/ML

3 DP

CHILD ALL DAY ALLERGY 1 MG/ML

D/F,GLUTEN/F,GRAPE 1 MG/ML

3 DP

CHILD ALLERGY 5 MG/5 ML SOLN 5 MG/5

ML

3 DP

150


limits on use

CHILD ALLERGY RELIEF 1 MG/ML

S/F,D/F,GLUTEN-FREE 1 MG/ML

3 DP

CHILD ALLERGY RLF 12.5 MG/5 ML 12.5

MG/5 ML

3 DP

CHILD CETIRIZINE 10 MG CHEW TB

CHEWABLE, ALLERGY 10 MG

3 DP

child loratadine 5 mg/5 ml syr 5 mg/5 ml 3 DP

child loratadine 5 mg/5 ml syr grape, s/f 5 mg/5 ml 3 DP

CHILD'S ALLERGY 12.5 MG/5 ML

A/F,CHERRY,CHILD 12.5 MG/5 ML

3 DP

chlorpheniramine 4 mg tablet 4 mg 3 DP

clemastine oral tablet 2.68 mg 1 PA

cyproheptadine oral syrup 2 mg/5 ml 1 PA

cyproheptadine oral tablet 4 mg 1 PA

DIPHEDRYL ALLERGY CAPSULE 25 MG 3 DP

DIPHENHIST 12.5 MG/5 ML SOLN 12.5 MG/5

ML

3 DP

DIPHENHIST 25 MG CAPTAB CAPTAB 25

MG

3 DP

diphenhydramine 25 mg caplet caplet 25 mg 3 DP

diphenhydramine 25 mg capsule (otc) 25 mg 3 DP

diphenhydramine 25 mg capsule u-d, 10x10 (otc)

25 mg

3 DP

diphenhydramine 50 mg capsule (otc) 50 mg 3 DP

diphenhydramine hcl injection solution 50 mg/ml 1 B/D

ED-A-HIST 4 MG-10 MG TABLET 4-10 MG 3 DP

fexofenadine hcl 180 mg tablet 24 hour, non-

drowsy (otc) 180 mg

3 DP

fexofenadine hcl 180 mg tablet 24 hour, outer (otc)

180 mg

3 DP

fexofenadine hcl 180 mg tablet 24hr,original str

(otc) 180 mg

3 DP

fexofenadine hcl 180 mg tablet allergy, 24hr (otc)

180 mg

3 DP

fexofenadine hcl 180 mg tablet f/c, 10x10,u-d,inner

(otc) 180 mg

3 DP

151


limits on use

fexofenadine hcl 180 mg tablet f/c, 10x10,u-d,outer

(otc) 180 mg

3 DP

fexofenadine hcl 180 mg tablet non-drowsy, 24hr

(otc) 180 mg

3 DP

fexofenadine hcl 30 mg/5 ml 30 mg/5 ml 3 DP

fexofenadine hcl 60 mg tablet (otc) 60 mg 3 DP

fexofenadine hcl 60 mg tablet 12 hour, non-drowsy

(otc) 60 mg

3 DP

fexofenadine hcl 60 mg tablet indoor/outdoor (otc)

60 mg

3 DP

fexofenadine hcl 60 mg tablet u-d, 10x10,outer

(otc) 60 mg

3 DP

GS ALL DAY ALLERGY 10 MG TAB 10 MG 3 DP

GS ALLER-EASE 180 MG TABLET 180 MG 3 DP

GS NIGHTTIME SLEEP AID 25 MG 25 MG 3 DP

HM ALL DAY ALLERGY 10 MG TAB


3 DP

HM ALLERGY 25 MG CAPSULE MULTI-

SYMPTOM 25 MG

3 DP

HM ALLERGY 25 MG TABLET MINITABS 25

MG

3 DP

HM ALLERGY RELIEF 25 MG CAP 25 MG 3 DP

HM ALLERGY RELIEF 4 MG TABLET 4

HOUR, GLUTEN-FREE 4 MG

3 DP

HM CHILD ALLERGY 12.5 MG/5 ML

A/F,CHERRY 12.5 MG/5 ML

3 DP

HM CHILD CETIRIZINE 1 MG/ML D/F, S/F,

BUBBLEGUM 1 MG/ML

3 DP

HM CHILD CETIRIZINE 1 MG/ML

D/F,GRAPE,S/F,GLUT-F 1 MG/ML

3 DP

hm child loratadine 5 mg/5 ml a/f, grape 5 mg/5

ml

3 DP

hm child loratadine 5 mg/5 ml a/f, s/f, grape 5

mg/5 ml

3 DP

hm fexofenadine hcl 180 mg tab (otc) 180 mg 3 DP

152


limits on use

hm fexofenadine hcl 180 mg tab 24 hour, gluten-

free (otc) 180 mg

3 DP

hm fexofenadine hcl 180 mg tab 24 hour, non-

drowsy (otc) 180 mg

3 DP

hm fexofenadine hcl 60 mg tab 12 hour, non-

drowsy (otc) 60 mg

3 DP

hm loratadine 10 mg tablet 10 mg 3 DP

hydroxyzine hcl oral solution 10 mg/5 ml 1 PA

hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg 1 PA

levocetirizine oral solution 2.5 mg/5 ml 1 MO

levocetirizine oral tablet 5 mg 1 MO

loratadine 10 mg softgel 10 mg 3 DP

loratadine 10 mg tablet 10 mg 3 DP

loratadine 10 mg tablet 10x10,u-d,outer 10 mg 3 DP

loratadine 10 mg tablet non-drowsy 10 mg 3 DP

loratadine 10 mg tablet non-drowsy, 24hr 10 mg 3 DP

loratadine 5 mg/5 ml soln child's,a/f,s/f,d/f 5 mg/5

ml

3 DP

loratadine 5 mg/5 ml syrup children's 5 mg/5 ml 3 DP

loratadine 5 mg/5 ml syrup children's, a/f, d/f 5

mg/5 ml

3 DP

loratadine allergy 5 mg/5 ml d/f, a/f, s/f 5 mg/5 ml 3 DP

NIGHTTIME SLEEP AID 25 MG CPLT MINI-

CAPLET 25 MG

3 DP

NON-DROWSY ALLERGY 10 MG TAB 10 MG 3 DP

PHARBEDRYL 25 MG CAPSULE 25 MG 3 DP

promethazine oral syrup 6.25 mg/5 ml 1 PA

QC CHILD ALLERGY 12.5 MG/5 ML 12.5

MG/5 ML

3 DP

qc loratadine 10 mg tablet non-drowsy 10 mg 3 DP

QC NIGHTTIME SLEEP 25 MG TAB 25 MG 3 DP

SB ALLERGY 10 MG TABLET ORIGINAL

STRENGTH 10 MG

3 DP

SB ALLERGY MED 25 MG TABLET

MINITABS 25 MG

3 DP

153


limits on use

SB ALLERGY MEDICINE 25 MG CAP 25 MG 3 DP

sb chlorpheniramine 4 mg tab 4 mg 3 DP

SB SLEEP TABLET 25 MG 3 DP

SILADRYL 12.5 MG/5 ML LIQUID 12.5 MG/5

ML

3 DP

SLEEP TABS 25 MG TABLET 25 MG 3 DP

SM ALL DAY ALLERGY 10 MG TAB


3 DP

SM ALLERGY 4-HR 4 MG TABLET 4 MG 3 DP

SM ALLERGY RELIEF 12.5 MG/5 ML 12.5

MG/5 ML

3 DP

SM ALLERGY RELIEF 12.5 MG/5 ML

CHILDREN'S, CHERRY 12.5 MG/5 ML

3 DP

SM ALLERGY RELIEF 25 MG CAP 25 MG 3 DP

SM ALLERGY RELIEF 25 MG CAP GLUTEN

FREE 25 MG

3 DP

SM CHILD ALL DAY ALLER 1 MG/ML

CHERRY 1 MG/ML

3 DP

SM CHILD ALL DAY ALLER 1 MG/ML S/F,

GRAPE 1 MG/ML

3 DP

sm child loratadine 5 mg/5 ml s/f, a/f, gluten/f 5

mg/5 ml

3 DP

sm fexofenadine hcl 180 mg tab 24hr, gluten-free

(otc) 180 mg

3 DP

sm loratadine 10 mg tablet 10 mg 3 DP

sm loratadine 10 mg tablet non-drowsy 10 mg 3 DP

sm loratadine 10 mg tablet non-drowsy,gluten-f 10

mg

3 DP

sm loratadine 5 mg/5 ml syrup 5 mg/5 ml 3 DP

SM SLEEP AID NIGHT TIME CAPLET

CAPLET 25 MG

3 DP

SUDOGEST SINUS AND ALLERGY TAB 4-60

MG

3 DP

ANTI-INFLAMMATORIES, INHALED CORTICOSTEROIDS

154


limits on use

ARNUITY ELLIPTA INHALATION BLISTER

WITH DEVICE 100 MCG/ACTUATION, 200

MCG/ACTUATION, 50 MCG/ACTUATION

2 MO

budesonide inhalation suspension for nebulization

0.25 mg/2 ml, 0.5 mg/2 ml, 1 mg/2 ml

1 B/D; MO

FLOVENT DISKUS INHALATION BLISTER

WITH DEVICE 100 MCG/ACTUATION, 250


2 MO

FLOVENT HFA INHALATION HFA AEROSOL

INHALER 110 MCG/ACTUATION, 220


2 MO

flunisolide nasal spray,non-aerosol 25 mcg (0.025

%)

1 MO

fluticasone nasal spray,suspension 50

mcg/actuation

1 MO

mometasone nasal spray,non-aerosol 50

mcg/actuation

1 MO

QVAR INHALATION AEROSOL 40


2 MO

QVAR REDIHALER INHALATION HFA

AEROSOL BREATH ACTIVATED 40


2 MO

ANTILEUKOTRIENES

montelukast oral granules in packet 4 mg 1 MO

montelukast oral tablet 10 mg 1 MO

montelukast oral tablet,chewable 4 mg, 5 mg 1 MO

XYREM ORAL SOLUTION 500 MG/ML 2 PA; LA

zafirlukast oral tablet 10 mg, 20 mg 1 ST; MO

BRONCHODILATORS, ANTICHOLINERGIC

INCRUSE ELLIPTA INHALATION BLISTER

WITH DEVICE 62.5 MCG/ACTUATION

2 MO

ipratropium bromide inhalation solution 0.02 % 1 B/D; MO

SPIRIVA RESPIMAT INHALATION MIST 1.25

MCG/ACTUATION, 2.5 MCG/ACTUATION

2 MO

SPIRIVA WITH HANDIHALER INHALATION

CAPSULE, W/INHALATION DEVICE 18 MCG

2 MO

155


limits on use

TUDORZA PRESSAIR INHALATION

AEROSOL POWDR BREATH ACTIVATED 400

MCG/ACTUATION

2 MO

TUDORZA PRESSAIR INHALATION

AEROSOL POWDR BREATH ACTIVATED 400

MCG/ACTUATION (30 ACTUAT)

2

BRONCHODILATORS, SYMPATHOMIMETIC

albuterol sulfate inhalation solution for

nebulization 0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 mg /3

ml (0.083 %), 2.5 mg/0.5 ml, 5 mg/ml

1 B/D; MO

albuterol sulfate oral syrup 2 mg/5 ml 1 MO

albuterol sulfate oral tablet 2 mg, 4 mg 1 MO

albuterol sulfate oral tablet extended release 12 hr

4 mg, 8 mg

1 MO

epinephrine injection auto-injector 0.15 mg/0.15

ml, 0.15 mg/0.3 ml, 0.3 mg/0.3 ml


levalbuterol hcl inhalation solution for

nebulization 0.31 mg/3 ml, 0.63 mg/3 ml, 1.25

mg/3 ml

1 B/D; MO

metaproterenol oral syrup 10 mg/5 ml 1 MO

metaproterenol oral tablet 10 mg, 20 mg 1 MO

SEREVENT DISKUS INHALATION BLISTER

WITH DEVICE 50 MCG/DOSE

2 MO

STRIVERDI RESPIMAT INHALATION MIST

2.5 MCG/ACTUATION

2 MO

terbutaline oral tablet 2.5 mg, 5 mg 1 MO

VENTOLIN HFA INHALATION HFA

AEROSOL INHALER 90 MCG/ACTUATION

2 MO

CYSTIC FIBROSIS AGENTS

KALYDECO ORAL GRANULES IN PACKET

50 MG, 75 MG

2 PA; MO

KALYDECO ORAL TABLET 150 MG 2 PA; MO

ORKAMBI ORAL GRANULES IN PACKET

100-125 MG, 150-188 MG

2 PA; MO

ORKAMBI ORAL TABLET 100-125 MG, 200-

125 MG

2 PA; MO

156


limits on use

PULMOZYME INHALATION SOLUTION 1

MG/ML

2 B/D; MO

SYMDEKO ORAL TABLETS, SEQUENTIAL

100-150 MG (D)/ 150 MG (N)

2 PA; MO

tobramycin in 0.225 % nacl inhalation solution for

nebulization 300 mg/5 ml

1 B/D; MO

tobramycin with nebulizer inhalation solution for

nebulization 300 mg/5 ml

1 B/D; MO

MAST CELL STABILIZERS

cromolyn inhalation solution for nebulization 20

mg/2 ml

1 B/D; MO

cromolyn sodium nasal spray 5.2 mg/spray (4 %) 3 DP

PHOSPHODIESTERASE INHIBITORS, AIRWAYS DISEASE

DALIRESP ORAL TABLET 250 MCG, 500

MCG

2 MO

theophylline oral elixir 80 mg/15 ml 1 MO

theophylline oral solution 80 mg/15 ml 1 MO

theophylline oral tablet extended release 12 hr 100

mg, 200 mg, 300 mg, 450 mg

1 MO

theophylline oral tablet extended release 24 hr 400

mg, 600 mg

1 MO

PULMONARY ANTIHYPERTENSIVES

ADEMPAS ORAL TABLET 0.5 MG, 1 MG, 1.5

MG, 2 MG, 2.5 MG

2 PA; MO

LETAIRIS ORAL TABLET 10 MG, 5 MG 2 PA; MO

REVATIO ORAL SUSPENSION FOR

RECONSTITUTION 10 MG/ML

2 PA; MO

sildenafil (antihypertensive) oral tablet 20 mg 1 PA; MO

VENTAVIS INHALATION SOLUTION FOR

NEBULIZATION 10 MCG/ML, 20 MCG/ML

2 PA; MO

PULMONARY FIBROSIS AGENTS

ESBRIET ORAL CAPSULE 267 MG 2 PA; MO

ESBRIET ORAL TABLET 267 MG, 801 MG 2 PA; MO

OFEV ORAL CAPSULE 100 MG, 150 MG 2 PA; MO

RESPIRATORY TRACT AGENTS, OTHER

157


limits on use

acetylcysteine solution 100 mg/ml (10 %), 200

mg/ml (20 %)

1 B/D

ADVAIR DISKUS INHALATION BLISTER

WITH DEVICE 100-50 MCG/DOSE, 250-50

MCG/DOSE, 500-50 MCG/DOSE

2 MO

ADVAIR HFA INHALATION HFA AEROSOL

INHALER 115-21 MCG/ACTUATION, 230-21

MCG/ACTUATION, 45-21 MCG/ACTUATION

2 MO

ALL DAY ALLERGY-D TABLET 12 HOUR 5-

120 MG

3 DP

ALL DAY ALLERGY-D TABLET 5-120 MG 3 DP

ALL DAY ALLERGY-D TABLET INDOOR &

OUTDOOR 5-120 MG

3 DP

ALLERGY D-12 TABLET TAB.SR 12H 5-120

MG

3 DP

ALLERGY RELIEF D-24HR TABLET 10-240

MG

3 DP

ALLERGY RELIEF-NASAL DECONG TB

NON-DROWSY 10-240 MG

3 DP

ALLERGY-CONGESTION RLF 12H TAB NON-

DROWSY 5-120 MG

3 DP

ANORO ELLIPTA INHALATION BLISTER

WITH DEVICE 62.5-25 MCG/ACTUATION

2 MO

APRODINE TABLET 2.5-60 MG 3 DP

benzonatate 100 mg capsule 100 mg 3 DP

benzonatate 100 mg capsule softgel 100 mg 3 DP

benzonatate 200 mg capsule 200 mg 3 DP

benzonatate 200 mg capsule softgel 200 mg 3 DP

BREO ELLIPTA INHALATION BLISTER

WITH DEVICE 100-25 MCG/DOSE, 200-25

MCG/DOSE

2 MO

BROTAPP DM LIQUID 1-15-5 MG/5 ML 3 DP

CHEST CONGST-COUGH RELIEF TAB 20-400

MG

3 DP

CHEST-SINUS CONGST RLF TABLET 10-400

MG

3 DP

158


limits on use

CHILD MUCUS RELIEF COUGH LIQ A/F,

CHERRY 5-100 MG/5 ML

3 DP

CHILD MUCUS RELIEF COUGH LIQ

A/F,CHERRY,CHILD 5-100 MG/5 ML

3 DP

CHILDREN'S COLD-ALLERGY ELIXIR

A/F,GRAPE,CHILD 1-2.5 MG/5 ML

3 DP

CHILDREN'S COLD-COUGH ELIXIR A/F,RED

GRAPE,CHILD 1-2.5-5 MG/5 ML

3 DP

CHILDREN'S MUCUS RELIEF LIQ A/F 100

MG/5 ML

3 DP

CHILDREN'S MUCUS RELIEF LIQ

A/F,GRAPE,CHILD 100 MG/5 ML

3 DP

CHILDREN'S SILFEDRINE LIQ 15 MG/5 ML 3 DP

CHL MUCINEX CHEST CONGEST LIQ A/F

100 MG/5 ML

3 DP

COLD-ALLERGY ELIXIR CHILDRENS, A/F 1-

2.5 MG/5 ML

3 DP

COLD-ALLERGY ELIXIR CHILDREN'S,A/F 1-

2.5 MG/5 ML

3 DP

COLD-COUGH ELIXIR 1-2.5-5 MG/5 ML 3 DP

COMBIVENT RESPIMAT INHALATION MIST

20-100 MCG/ACTUATION

2 ST; MO

COUGH DM ER 30 MG/5 ML SUSP 12 HOUR,

A/F 30 MG/5 ML

3 DP

COUGH DM ER 30 MG/5 ML SUSP

12HR,A/F,GLUTEN-FREE 30 MG/5 ML

3 DP

COUGH SYRUP 10-100 MG/5 ML 3 DP

COUGH SYRUP 200 MG/10 ML 100 MG/5 ML 3 DP

COUGH-COLD TABLET 4-30 MG 3 DP

COUGHTAB 200 MG TABLET 200 MG 3 DP

cromolyn oral concentrate 100 mg/5 ml 1

CUVPOSA ORAL SOLUTION 1 MG/5 ML (0.2

MG/ML)

2 MO

DEEP SEA 0.65% NOSE SPRAY 0.65 % 3 DP

dextromethorphan er 30 mg/5 ml 30 mg/5 ml 3 DP

DIABETIC SILTUSSIN DAS-NA LIQ 100 MG/5

ML

3 DP

159


limits on use

DIABETIC SILTUSSIN-DM LIQUID 10-100

MG/5 ML

3 DP

DIMAPHEN DM ELIXIR GRAPE,

A/F,GLUTEN-F 1-2.5-5 MG/5 ML

3 DP

DIMAPHEN ELIXIR A/F, GRAPE, GLUTEN-F

1-2.5 MG/5 ML

3 DP

DIMAPHEN ELIXIR GRAPE,A/F,GLUTEN-F 1-

2.5 MG/5 ML

3 DP

DULERA INHALATION HFA AEROSOL

INHALER 100-5 MCG/ACTUATION, 200-5

MCG/ACTUATION

2 MO

ENDACOF-DM LIQUID 1-2.5-5 MG/5 ML 3 DP

EXTRA ACTION COUGH SYRUP 10-100 MG/5

ML

3 DP

fluticasone-salmeterol inhalation aerosol powdr

breath activated 113-14 mcg/actuation, 232-14

mcg/actuation, 55-14 mcg/actuation

1 MO

GNP ALL DAY ALLERGY-D TABLET 5-120

MG

3 DP

GS CHILD COLD-ALLERGY SOLUTION 1-2.5

MG/5 ML

3 DP

GS CHILD MUCUS RLF COUGH LIQ 5-100

MG/5 ML

3 DP

GS NASAL DECONG PE 10 MG TAB 10 MG 3 DP

GS NASAL SPRAY 0.05% 0.05 % 3 DP

GS TUSSIN DM COUGH SYRUP 10-100 MG/5

ML

3 DP

GS TUSSIN DM COUGH-CHEST SOLN 10-100

MG/5 ML

3 DP

GS TUSSIN DM MAX LIQUID 10-200 MG/5

ML

3 DP

GS TUSSIN MUCUS-CONG 100 MG/5 100

MG/5 ML

3 DP

GS TUSSIN MUCUS-CONG 200 MG/10 100

MG/5 ML

3 DP

guaifenesin 100 mg/5 ml liquid 100 mg/5 ml 3 DP

guaifenesin 100 mg/5 ml soln outer 100 mg/5 ml 3 DP

160


limits on use

guaifenesin 100 mg/5 ml syrup 100 mg/5 ml 3 DP

guaifenesin 200 mg/10 ml soln 100's,u-d, outer,a/f

100 mg/5 ml

3 DP

guaifenesin 200 mg/10 ml soln inner 100 mg/5 ml 3 DP


guaifenesin 300 mg/15 ml soln 100's,u-d,outer, a/f

100 mg/5 ml

3 DP

guaifenesin 300 mg/15 ml soln inner 100 mg/5 ml 3 DP


guaifenesin dm syrup (otc) 10-100 mg/5 ml 3 DP

guaifenesin dm syrup inner (otc) 10-100 mg/5 ml 3 DP

guaifenesin dm syrup outer (otc) 10-100 mg/5 ml 3 DP

guaifenesin er 1,200 mg tablet 1,200 mg 3 DP

HM ADT TUSSIN COUGH CONG DM LQ 10-

100 MG/5 ML

3 DP

HM ADULT TUSSIN CHEST CONG LIQ

A/F,CHERRY,NO-DROWSY 100 MG/5 ML

3 DP

HM ADULT TUSSIN CHEST CONG LIQ

A/F,GLUTEN-FREE 100 MG/5 ML

3 DP

HM ADULT TUSSIN DM SYRUP 10-100 MG/5

ML

3 DP

HM ALLERGY COMPLETE-D TABLET 5-120

MG

3 DP

HM ALLERGY RLF-NASAL DECONG TB

NON-DROWSY,24 HR RLF 10-240 MG

3 DP

HM CHEST CONGEST RLF 400 MG TB

CAPLET,D/F 400 MG

3 DP

HM MUCUS ER 1,200 MG TABLET 1,200 MG 3 DP

HM MUCUS ER 600 MG TABLET GLUTEN-

FREE, 12 HOUR 600 MG

3 DP

HM NASAL DECONGEST 30 MG TAB NON-

DROWSY, MAX STR 30 MG

3 DP

ipratropium bromide nasal spray,non-aerosol 0.03

%

1 MO

ipratropium bromide nasal spray,non-aerosol 42

mcg (0.06 %)

1

161


limits on use

ipratropium-albuterol inhalation solution for

nebulization 0.5 mg-3 mg(2.5 mg base)/3 ml

1 B/D; MO

KIDKARE COUGH & COLD LIQUID 1-15-5

MG/5 ML

3 DP

LORATADINE-D 12 HOUR TABLET 12 HOUR

5-120 MG

3 DP

LORATADINE-D 12 HOUR TABLET NON-

DROWSY 5-120 MG

3 DP

LORATADINE-D 24HR TABLET 10-240 MG 3 DP

LORATADINE-D 24HR TABLET NON-

DROWSY 10-240 MG

3 DP

MUCINEX DM ER 1,200-60 MG TAB BI-

LAYER, MAX-STR 60-1,200 MG

3 DP

MUCINEX DM ER 600-30 MG TABLET 30-600

MG

3 DP

MUCINEX ER 1,200 MG TABLET MAX STR,

BI-LAYER 1,200 MG

3 DP

MUCINEX ER 600 MG TABLET 600 MG 3 DP

MUCINEX ER 600 MG TABLET BI-LAYER, 12

HOURS 600 MG

3 DP

MUCINEX ER 600 MG TABLET INNER 600

MG

3 DP

MUCINEX ER 600 MG TABLET OUTER 600

MG

3 DP

MUCINEX FAST-MAX DM MAX LIQUID

MAXIMUM STRENGTH 5-100 MG/5 ML

3 DP

MUCUS RELIEF 400 MG TABLET 400 MG 3 DP

MUCUS RELIEF 400 MG TABLET D/F 400 MG 3 DP

MUCUS RELIEF DM TABLET D/F 20-400 MG 3 DP

MUCUS RELIEF SINUS TABLET 10-400 MG 3 DP

NASAL DECONGESTANT 0.05% SPRAY 0.05

%

3 DP

NASAL DECONGESTANT 0.05% SPRAY

12HR, MAXIMUM STR. 0.05 %

3 DP

NASAL DECONGESTANT 30 MG TAB 30 MG 3 DP

162


limits on use

NASAL DECONGESTANT 30 MG TAB NON-

DROWSY,MAX-STR 30 MG

3 DP

NASAL DECONGESTANT PE 10 MG TB 10

MG

3 DP

NASAL DECONGESTANT PE 10 MG TB

MAX-STR 10 MG

3 DP

NASAL DECONGESTANT PE 10 MG TB NON-

DROWSY, MAX STR. 10 MG

3 DP

NASAL

DECONGESTANT(PSEUDOEPHEDRINE)30

MG/5 ML 30 MG/5 ML

3 DP

NASAL SPRAY 0.05% 12 HOUR RELIEF 0.05

%

3 DP

NASAL SPRAY 0.05% 12 HOUR,NO DRIP 0.05

%

3 DP

NASAL SPRAY 0.05% 12 HOUR,ORIGINAL

0.05 %

3 DP

NASAL SPRAY 0.05% 12 HOUR,SINUS 0.05 % 3 DP

NASAL SPRAY 0.05% 12HR, ORIGINAL 0.05

%

3 DP

PEDIA RELIEF COUGH-COLD LIQUID A/F,

CHERRY 1-15-5 MG/5 ML

3 DP

PEDIATRIC COUGH-COLD LIQUID 1-15-5

MG/5 ML

3 DP

promethazine vc oral syrup 6.25-5 mg/5 ml 1 PA

promethazine-phenylephrine oral syrup 6.25-5

mg/5 ml

1 PA

pseudoephed 30 mg/5 ml soln 30 mg/5 ml 3 DP

pseudoephedrine 30 mg tablet 30 mg 3 DP

QC MUCUS RELIEF 400 MG CAPLET 400 MG 3 DP

QC MUCUS RELIEF DM TABLET 20-400 MG 3 DP

QC TUSSIN CF LIQUID 5-10-100 MG/5 ML 3 DP

ROBAFEN 100 MG/5 ML SYRUP 100 MG/5 ML 3 DP

ROBAFEN CF LIQUID A/F,MULTI-CLD

SYMPTM 5-10-100 MG/5 ML

3 DP

ROBAFEN DM CGH-CHEST CONG SYRP 10-

100 MG/5 ML

3 DP

163


limits on use

ROBAFEN DM COUGH LIQUID 10-100 MG/5

ML

3 DP

ROBAFEN-DM SYRUP A/F, NON-NARCOTIC

10-100 MG/5 ML

3 DP

ROBAFEN-DM SYRUP A/F,NON-DROWSY

10-100 MG/5 ML

3 DP

SB 12HR NASAL SPRAY 0.05% 0.05 % 3 DP

SB ALLERFED COLD-ALLERGY TAB 4-10

MG

3 DP

SB COUGH CONTROL SYRUP 100 MG/5 ML 3 DP

SB MUCUS RELIEF DM TABLET DYE-FREE

20-400 MG

3 DP

SILTUSSIN DM COUGH SYRUP 10-100 MG/5

ML

3 DP

SILTUSSIN DM DAS LIQUID 10-100 MG/5 ML 3 DP

SILTUSSIN SA 100 MG/5 ML SYR 100 MG/5

ML

3 DP

SINUS RELIEF 0.05% NASAL SPRAY ULTRA

FINE,12 HOUR 0.05 %

3 DP

SM ALL DAY ALLERGY-D TABLET 5-120

MG

3 DP

SM CHEST CONG RELIEF PE CAPLET 10-400

MG

3 DP

SM CHEST CONGEST RLF DM CAPLET

CAPLET,D/F 20-400 MG

3 DP

SM CHEST CONGESTION RELIEF CAP

CAPLET,D/F 400 MG

3 DP

SM CHILD COLD-ALLERGY LIQUID

CHILDRENS 1-2.5 MG/5 ML

3 DP

SM LORATA-DINE D 24HR TABLET 10-240

MG

3 DP

SM MUCUS RELIEF COUGH LIQUID

CHILDRENS, A/F 5-100 MG/5 ML

3 DP

SM NASAL 0.05% SPRAY 12 HOUR,

ORIGINAL 0.05 %

3 DP

SM NASAL DECONGEST 30 MG TAB 30 MG 3 DP

SM NASAL SPRAY 0.05% 0.05 % 3 DP

164


limits on use

SM TUSSIN CF SYRUP A/F 5-10-100 MG/5 ML 3 DP

SM TUSSIN DM LIQUID 10-100 MG/5 ML 3 DP

SM TUSSIN DM SYRUP 10-100 MG/5 ML 3 DP

SM TUSSIN DM SYRUP A/F 10-100 MG/5 ML 3 DP

STIOLTO RESPIMAT INHALATION MIST 2.5-

2.5 MCG/ACTUATION

2 MO

SUDOGEST 30 MG TABLET 30 MG 3 DP

SUDOGEST 30 MG TABLET BOXED 30 MG 3 DP

SUDOGEST PE 10 MG TABLET 10 MG 3 DP

SUPHEDRIN 30 MG TABLET 30 MG 3 DP

SUPHEDRINE SINUS CONG 30 MG TB 30 MG 3 DP

SYMBICORT INHALATION HFA AEROSOL

INHALER 160-4.5 MCG/ACTUATION, 80-4.5

MCG/ACTUATION

2 MO

TESSALON PERLE 100 MG CAP 100 MG 3 DP

TRELEGY ELLIPTA INHALATION BLISTER

WITH DEVICE 100-62.5-25 MCG

2 MO

TUSNEL DIABETIC LIQUID (OTC) 10-100

MG/5 ML

3 DP

TUSSIN CF COUGH-COLD LIQUID A/F,NON-

DROWSY 5-10-100 MG/5 ML

3 DP

TUSSIN CF COUGH-COLD SYRUP A/F 5-10-

100 MG/5 ML

3 DP

TUSSIN CF COUGH-COLD SYRUP A/F, NON-


3 DP

TUSSIN CF COUGH-COLD SYRUP A/F,NON-


3 DP

TUSSIN DM LIQUID A/F 10-100 MG/5 ML 3 DP

TUSSIN DM LIQUID S/F,A/F 10-100 MG/5 ML 3 DP

TUSSIN DM MAX LIQUID A/F 10-200 MG/5

ML

3 DP

TUSSIN DM MAX LIQUID A/F, NON-

DROWSY 10-200 MG/5 ML

3 DP

TUSSIN DM SYRUP 10-100 MG/5 ML 3 DP

TUSSIN MUCUS-CONG 200 MG/10 100 MG/5

ML

3 DP

165


limits on use

SKELETAL MUSCLE RELAXANTS

SKELETAL MUSCLE RELAXANTS

carisoprodol oral tablet 250 mg, 350 mg 1 PA

chlorzoxazone oral tablet 500 mg 1 PA

cyclobenzaprine oral tablet 10 mg, 5 mg 1 PA

METAXALL ORAL TABLET 800 MG 1

metaxalone oral tablet 800 mg 1

methocarbamol oral tablet 500 mg, 750 mg 1 PA

orphenadrine citrate oral tablet extended release

100 mg

1 PA

SLEEP DISORDER AGENTS

GABA RECEPTOR MODULATORS

temazepam oral capsule 15 mg, 22.5 mg, 30 mg,

7.5 mg


zaleplon oral capsule 10 mg, 5 mg 1 QL (90 EA per 365 days)

zolpidem oral tablet 10 mg, 5 mg 1 QL (90 EA per 365 days)

SLEEP DISORDERS, OTHER

armodafinil oral tablet 150 mg, 200 mg, 250 mg,

50 mg

1 PA; MO

HETLIOZ ORAL CAPSULE 20 MG 2 PA; MO

MODAFINIL ORAL TABLET 100 MG, 200 MG 1 PA; MO

ROZEREM ORAL TABLET 8 MG 2 QL (30 EA per 30 days)

SILENOR ORAL TABLET 3 MG, 6 MG 2

166

E. Index of Covered Drugs

1 12 HOUR NASAL SPRAY 163

8 8 HOUR PAIN RELIEVER . 18

8HR MUSCLE ACHES-PAIN

.......................................... 12

A abacavir ................................ 65

abacavir-lamivudine ............. 66

abacavir-lamivudine-

zidovudine ........................ 66

abelcet................................... 44

ABILIFY MAINTENA .. 59, 60

abiraterone ............................ 52

ABREVA ............................. 64

acamprosate .......................... 24

acarbose ................................ 69

acebutolol ............................. 80

ACEPHEN ........................... 12

acetaminophen .......... 12, 13, 17

acetaminophen-codeine ........ 13

acetazolamide ....................... 83

acetic acid ............................. 29

acetic acid-aluminum acetate

........................................ 147

acetylcysteine ..................... 157

ACID CONTROLLER ....... 111

ACID GONE ANTACID ... 105

ACID REDUCER

(CIMETIDINE) .............. 112

ACID REDUCER

(FAMOTIDINE) .... 111, 112

ACID REDUCER

(RANITIDINE) .............. 112

acitretin ................................. 89

ACNE MEDICATION ......... 89

ACTEMRA ........................ 138

ACTEMRA ACTPEN ........ 138

ACTHAR H.P. ................... 123

ACTHIB (PF) ..................... 138

ACTIMMUNE ................... 138

acyclovir ............................... 64

acyclovir sodium .................. 64

ADACEL(TDAP

ADOLESN/ADULT)(PF)

................................ 138, 139

adapalene .............................. 89

adapalene-benzoyl peroxide . 89

ADEFOVIR .......................... 63

ADEMPAS ......................... 156

ADULT TUSSIN CHEST

CONGESTION ...... 159, 160

ADULT TUSSIN COUGH

CONGEST DM .............. 160

ADULT TUSSIN DM ........ 160

ADVAIR DISKUS ............. 157

ADVAIR HFA ................... 157

ADVANCED ANTACID-

ANTIGAS .............. 108, 109

AFINITOR ........................... 54

AFINITOR DISPERZ .......... 54

AFTERA ............................ 125

AIMOVIG AUTOINJECTOR

.......................................... 50

AIMOVIG AUTOINJECTOR

(2 PACK) .......................... 50

ak-poly-bac ........................... 29

ala-cort .................................. 47

albendazole ........................... 56

ALBENZA ........................... 56

albuterol sulfate .................. 155

alclometasone ....................... 47

alcohol pads .......................... 72

ALECENSA ......................... 54

alendronate ......................... 143

ALEVAZOL ......................... 44

alfuzosin ............................. 123

ALINIA ................................ 56

ALL DAY ALLERGY

(CETIRIZINE) ...... 148, 149,

151, 153

ALL DAY ALLERGY-D .. 157,

159, 163

ALLER-CHLOR ................ 148

ALLER-EASE .................... 151

ALLERFED COLD AND

ALLERGY ..................... 163

ALLERGY

(CHLORPHENIRAMINE)

........................................ 148

ALLERGY

(DIPHENHYDRAMINE)

................................ 148, 151

ALLERGY 4-HOUR .......... 153

ALLERGY AND

CONGESTION RELIEF 157

ALLERGY COMPLETE-D

........................................ 160

ALLERGY D-12 ................ 157

ALLERGY MEDICINE .... 152,

153

ALLERGY RELIEF

(CETIRIZINE) ............... 152

ALLERGY RELIEF

(FEXOFENADINE) ....... 148

ALLERGY RELIEF

(LORATADINE) ............ 148

ALLERGY RELIEF D-24HR

........................................ 157

ALLERGY

RELIEF(CHLORPHENIRA

MN) ................................ 151

ALLERGY

RELIEF(DIPHENHYDRA

MIN) ....................... 148, 153

ALLERGY RELIEF,NASAL

DECONGEST ........ 157, 160

ALLERGY-TIME .............. 148

allopurinol ............................. 47

ALMACONE ............. 105, 106

ALMACONE-2 .................. 106

alogliptin ............................... 69

alogliptin-metformin ............. 69

alogliptin-pioglitazone .......... 69

alosetron ............................. 113

ALPHAGAN P ................... 146

alprazolam ............................ 68

ALPRAZOLAM INTENSOL

.......................................... 68

ALTAVERA (28) ............... 125

aluminum hydroxide gel ..... 106

ALUNBRIG ......................... 54

alyacen 1/35 (28) ................ 125

amabelz ............................... 125

amantadine hcl ...................... 58

AMBISOME ......................... 44

amikacin ............................... 28

amiloride ............................... 84

amiloride-hydrochlorothiazide

.......................................... 81

AMINOSYN 7 % WITH

ELECTROLYTES ............ 93

aminosyn 8.5 %-electrolytes 93

AMINOSYN II 10 % ............ 93

167

AMINOSYN II 15 % ........... 93

AMINOSYN II 8.5 % .......... 93

aminosyn ii 8.5 %-electrolytes

.......................................... 93

AMINOSYN-HBC 7% ........ 93

AMINOSYN-PF 10 % ......... 93

AMINOSYN-PF 7 %

(SULFITE-FREE) ............ 93

AMINOSYN-RF 5.2 % ........ 93

amiodarone ........................... 79

AMITIZA ........................... 113

amitriptyline ......................... 42

amlodipine ............................ 80

amlodipine-benazepril .......... 81

amlodipine-olmesartan ......... 81

amlodipine-valsartan ............ 81

amlodipine-valsartan-hcthiazid

.......................................... 82

ammonium lactate ................ 89

AMNESTEEM ..................... 89

amoxapine ............................ 42

amoxicillin ............................ 33

amoxicillin-pot clavulanate .. 34

amphotericin b ...................... 44

ampicillin .............................. 34

ampicillin sodium ................. 34

ampicillin-sulbactam ............ 34

ANADROL-50 ................... 124

anagrelide ............................. 75

anastrozole ............................ 53

ANIMAL SHAPE VITAMINS

........................................ 102

ANODYNE LPT .................. 23

ANORO ELLIPTA ............ 157

ANTACID .......... 106, 109, 110

ANTACID (CALCIUM

CARBONATE) ..... 106, 108,

109

ANTACID ANTI-GAS ..... 106,

108, 110

ANTACID CALCIUM ...... 110

ANTACID EXT STR

(CALCIUM CARB) ....... 106

ANTACID EXTRA-

STRENGTH ........... 106, 109

ANTACID MAXIMUM

STRENGTH ........... 106, 109

ANTACID PLUS ANTI-GAS

................................ 106, 108

ANTACID-ANTIGAS ...... 108,

109

ANTACID-SIMETHICONE

........................................ 106

ANTIBIOTIC (BACITRACIN

ZINC) ............................... 31

ANTI-DIARRHEA ............ 109

ANTI-DIARRHEAL

(LOPERAMIDE)... 106, 108,

109, 110

ANTIFUNGAL

(CLOTRIMAZOLE) .. 44, 46

ANTIFUNGAL

(TOLNAFTATE) ....... 44, 46

ANTIFUNGAL CREAM

(MICONAZOLE) ............. 44

ANTI-ITCH (HC)................. 91

APOKYN ............................. 58

aprepitant .............................. 44

apri ...................................... 125

APRODINE ........................ 157

APTIOM ............................... 39

APTIVUS ............................. 67

AQUADEKS PEDIATRIC .. 93

ARALAST NP ................... 121

aranelle (28) ........................ 125

ARANESP (IN

POLYSORBATE) ............ 75

ARCALYST ....................... 138

aripiprazole ........................... 60

ARISTADA .......................... 60

ARISTADA INITIO............. 60

armodafinil ......................... 165

ARNUITY ELLIPTA ......... 154

ARTHRITIS PAIN RELIEF

(ACETAM) ... 13, 14, 15, 17,

18

ARTIFICIAL TEARS

(PETRO/MIN) ................ 144

ARTIFICIAL TEARS

(POLYVIN ALC) ........... 143

ascomp with codeine ............ 13

ASPIR-81 ............................. 77

aspirin ..... 18, 19, 20, 21, 77, 78

aspirin-dipyridamole ............ 77

ASPIR-LOW ........................ 77

assure id insulin safety ......... 72

ASTAGRAF XL................. 135

atazanavir.............................. 67

atenolol ................................. 80

atenolol-chlorthalidone ......... 82

ATHLETE'S FOOT

(TERBINAFINE) ............. 46

atomoxetine .......................... 87

atorvastatin ........................... 84

atovaquone ............................ 56

atovaquone-proguanil ........... 56

ATRIPLA ............................. 65

atropine ............................... 146

AUBAGIO ............................ 88

aubra ................................... 125

AUBRA EQ ........................ 125

AUSTEDO ........................... 88

AVANDIA ........................... 69

aviane .................................. 125

azathioprine ........................ 135

azelastine .................... 146, 148

azithromycin ................... 34, 35

AZOPT ............................... 146

aztreonam ............................. 33

B B COMPLEX-VITAMIN B12

........................................ 102

bacitracin .............................. 29

bacitracin zinc ................. 29, 30

bacitracin-polymyxin b ......... 29

baclofen ................................ 63

BACTROBAN NASAL ....... 29

BALANCED B-100 ........... 102

BALANCED B-50 ............... 93

balsalazide .......................... 142

balziva (28) ......................... 125

BANOPHEN ...................... 148

BANZEL .............................. 39

BARACLUDE ...................... 63

BCG VACCINE, LIVE (PF)

........................................ 139

benazepril ............................. 79

benazepril-hydrochlorothiazide

.......................................... 82

BENLYSTA ....................... 138

BENZNIDAZOLE ............... 57

benzonatate ......................... 157

benzoyl peroxide .................. 89

benztropine ........................... 57

betamethasone dipropionate . 47

betamethasone valerate ......... 47

betamethasone, augmented ... 47

BETASERON ....................... 88

betaxolol ............................... 80

168

bethanechol chloride .......... 123

bexarotene ............................ 56

BEXSERO .......................... 139

bicalutamide ......................... 52

BICILLIN L-A ..................... 34

BIKTARVY ......................... 66

BILTRICIDE ........................ 56

biotin............................. 93, 100

BISAC-EVAC .................... 113

bisacodyl..................... 113, 118

BISA-LAX ......................... 113

BISCOLAX ........................ 113

BISMATROL ..................... 107

bismuth subsalicylate ......... 107

bisoprolol fumarate .............. 80

bisoprolol-hydrochlorothiazide

.......................................... 82

BIVIGAM .......................... 137

blisovi fe 1.5/30 (28) .......... 125

blisovi fe 1/20 (28) ............. 126

BOOSTRIX TDAP ............ 139

BOSULIF ............................. 54

BRAFTOVI .......................... 54

BREO ELLIPTA ................ 157

briellyn ............................... 126

BRILINTA ........................... 77

brimonidine ........................ 146

BRIVIACT ........................... 37

bromocriptine ....................... 58

BROTAPP DM .................. 157

budesonide .......................... 154

BUDESONIDE .................. 142

bumetanide ........................... 83

buprenorphine....................... 22

buprenorphine hcl ................. 24

buprenorphine-naloxone....... 24

bupropion hcl.................. 40, 41

bupropion hcl (smoking deter)

.......................................... 24

buspirone .............................. 68

butalbital compound w/codeine

.......................................... 13

butalbital-acetaminop-caf-cod

.......................................... 13

butalbital-acetaminophen ..... 13

butalbital-acetaminophen-caff

.......................................... 13

butalbital-aspirin-caffeine .... 13

butorphanol tartrate .............. 22

BYSTOLIC .......................... 80

C cabergoline ......................... 133

CABOMETYX ..................... 54

calcipotriene ................... 89, 90

calcitonin (salmon) ............. 143

CALCITRATE ..................... 93

CALCITRATE-VITAMIN D

........................................ 102

calcitriol .............................. 102

CALCIUM 500 WITH D ..... 99

CALCIUM 600..................... 93

CALCIUM 600 + D(3) ......... 93

calcium acetate ................... 101

CALCIUM ANTACID...... 107,

108, 110

CALCIUM ANTACID

ULTRA MAX ST ........... 107

calcium carbonate ........... 93, 94

calcium carbonate-vitamin d3

........................................ 102

calcium gluconate ................. 94

calcium polycarbophil ........ 113

CAL-GEST ANTACID ...... 107

CALQUENCE ...................... 54

camila ................................. 130

CAPRELSA.......................... 54

captopril ................................ 79

captopril-hydrochlorothiazide

.......................................... 82

CARBAGLU ........................ 94

carbamazepine ................ 39, 69

carbidopa-levodopa .............. 58

carbidopa-levodopa-

entacapone ........................ 58

CARIMUNE NF

NANOFILTERED.......... 137

carisoprodol ........................ 165

carisoprodol-asa-codeine ...... 13

carisoprodol-aspirin .............. 13

carteolol .............................. 146

cartia xt ................................. 80

carvedilol .............................. 80

caspofungin .......................... 44

CASTELLANI PAINT

MODIFIED ...................... 29

caziant (28) ......................... 126

cefaclor ................................. 31

cefadroxil .............................. 32

cefazolin ............................... 32

cefazolin in dextrose (iso-os) 32

cefdinir .................................. 32

cefepime ............................... 32

cefepime in dextrose 5 % ..... 32

cefepime in dextrose,iso-osm

.......................................... 32

cefotaxime ............................ 32

cefoxitin ................................ 32

cefoxitin in dextrose, iso-osm

.......................................... 32

cefpodoxime ......................... 32

cefprozil ................................ 32

ceftazidime ........................... 32

ceftazidime in d5w ............... 32

ceftriaxone ............................ 32

ceftriaxone in dextrose,iso-os

.......................................... 32

cefuroxime axetil .................. 33

cefuroxime sodium ............... 33

celecoxib ............................... 19

CELONTIN .......................... 37

cephalexin ............................. 33

CERDELGA ....................... 121

CERTAVITE SENIOR-

ANTIOXIDANT .............. 94

CERTAVITE-

ANTIOXIDANT ............ 102

cetirizine ..................... 148, 149

cetirizine-pseudoephedrine . 149

cevimeline ............................. 89

CHANTIX ............................ 24

CHANTIX CONTINUING

MONTH BOX .................. 24

CHANTIX STARTING

MONTH BOX .................. 24

CHATEAL EQ (28) ........... 126

CHEST CONGESTION

RELIEF ................... 160, 163

CHEST CONGESTION

RELIEF DM ................... 163

CHEST CONGESTION

RELIEF PE ..................... 163

CHEST CONGESTION-

COUGH RELIEF ........... 157

CHEST-SINUS

CONGESTION RELIEF 157

CHILD ALLERGY

RELF(CETIRIZINE) ...... 150

CHILD IBUPROFEN ........... 19

CHILD MUCINEX CHEST

CONGESTION ............... 158

169

CHILD MUCUS RELIEF

COUGH .................. 158, 159

CHILD MUCUS RELIEF

EXPECTORANT ........... 158

CHILDREN'S

ACETAMINOPHEN ....... 14

CHILDREN'S ALLERGY

(DIPHENHYD) ..... 150, 151,

152

CHILDREN'S ALLERGY

RELIEF(LOR) ................ 149

CHILDREN'S ASPIRIN 77, 78

CHILDREN'S CETIRIZINE

................................ 150, 151

CHILDREN'S COLD AND

COUGH (PE) ................. 158

CHILDREN'S COLD-

ALLERGY (PE) ..... 158, 159

CHILDREN'S IBUPROFEN

.............................. 19, 20, 21

CHILDREN'S MAPAP ........ 14

CHILDREN'S PAIN RELIEF

.......................................... 17

CHILDREN'S PAIN

RELIEVER....................... 14

CHILDREN'S PAIN-FEVER

RELIEF .......... 13, 14, 15, 18

CHILDREN'S SILAPAP ..... 14

CHILDREN'S SILFEDRINE

........................................ 158

CHILD'S ALL DAY

ALLERGY(CETIR) ...... 149,

153

CHILDS CHEW VITE......... 94

CHILDS/IRON..................... 94

chlorhexidine gluconate ....... 89

chloroquine phosphate.......... 57

chlorothiazide ....................... 84

chlorpheniramine maleate . 150,

153

chlorpromazine ..................... 43

chlorthalidone ....................... 84

chlorzoxazone..................... 165

CHOLBAM ........................ 121

cholecalciferol (vitamin d3) 105

cholestyramine (with sugar) . 85

cholestyramine light ............. 85

ciclopirox .............................. 44

ciclopirox-ure-camph-menth-

euc .................................... 45

cilostazol ............................... 77

CIMDUO .............................. 66

cimetidine ........................... 112

cimetidine hcl ..................... 112

CIMZIA .............................. 135

CIMZIA POWDER FOR

RECONST ...................... 135

CIMZIA STARTER KIT ... 135

CINRYZE ........................... 134

CIPRODEX ........................ 147

ciprofloxacin ......................... 35

ciprofloxacin (mixture)......... 35

ciprofloxacin hcl ................... 35

ciprofloxacin in 5 % dextrose

.......................................... 35

citalopram ............................. 41

CITRUCEL ........................ 113

CITRUCEL (SUCROSE) ... 113

CITRUCEL SUGAR FREE

........................................ 113

CLARAVIS .......................... 90

clarithromycin ...................... 35

CLEARLAX ....... 113, 115, 118

clemastine ........................... 150

clindamycin hcl .................... 29

clindamycin in 0.9 % sod chlor

.......................................... 29

clindamycin in 5 % dextrose 29

clindamycin palmitate hcl .... 29

clindamycin pediatric ........... 30

clindamycin phosphate ......... 30

clindamycin-benzoyl peroxide

.......................................... 90

clinimix 4.25%/d10w sulf free

.......................................... 94

clinimix 4.25%-d25w sulf-free

.......................................... 94

clinisol sf 15 % ..................... 94

clobazam ............................... 38

clobetasol .............................. 47

clobetasol-emollient ............. 47

clomipramine ........................ 42

clonazepam ........................... 68

clonidine ............................... 78

clonidine hcl ................... 78, 87

clopidogrel ............................ 77

clorazepate dipotassium ....... 68

clotrimazole .......................... 45

clotrimazole-betamethasone . 90

clozapine ............................... 62

COARTEM ........................... 57

codeine-butalbital-asa-caff ... 14

colchicine .............................. 47

COLD AND ALLERGY

(BROMPHEN-PE) . 158, 163

COLD AND COUGH ELIXIR

........................................ 158

COLEMAN BOTANICALS

INSECT ............................ 90

COLEMAN HIGH-DRY

INSECT REPEL ............... 90

COLEMAN SKINSMART

INSECT REP .................... 90

COLEMAN SPORTSMEN

INSECT REPEL ............... 90

colesevelam .......................... 85

colestipol ............................... 85

colistin (colistimethate na) ... 30

COMBIGAN ...................... 146

COMBIPATCH .................. 126

COMBIVENT RESPIMAT 158

COMETRIQ ......................... 54

COMPLERA ........................ 65

constulose ........................... 113

COPIKTRA .......................... 53

CORLANOR ........................ 82

cortisone ............................. 123

COSENTYX ......................... 90

COSENTYX (2 SYRINGES)

.......................................... 90

COSENTYX PEN ................ 90

COSENTYX PEN (2 PENS) 90

COTELLIC ........................... 54

COUGH AND COLD

(CHLORPHEN-DM) ...... 158

COUGH CONTROL

(GUAIFENESIN) ........... 163

COUGH DM ER ................ 158

COUGH SUPPRESSANT-

EXPECTORANT ........... 158

COUGH SYRUP ................ 158

COUGH SYRUP DM ......... 159

COUGHTAB ...................... 158

COUMADIN ........................ 74

CREON ............................... 122

CRIXIVAN ........................... 67

cromolyn ............. 146, 156, 158

cryselle (28) ........................ 126

CUTTER BACKWOODS .... 90

170

CUTTER BACKWOODS

DRY ................................. 90

CUTTER LEMON

EUCALYPTUS ................ 90

CUTTER NATURAL

REPELLENT2 ................. 90

CUTTER SKINSATIONS ... 90

CUVPOSA ......................... 158

cyanocobalamin (vitamin b-12)

................................ 102, 103

cyclafem 1/35 (28) ............. 126

cyclafem 7/7/7 (28) ............ 126

cyclobenzaprine .................. 165

cyclophosphamide ................ 51

cyclosporine ....................... 135

cyclosporine modified ........ 135

cyproheptadine ................... 150

CYRED .............................. 126

CYRED EQ ........................ 126

CYSTADANE .................... 122

CYSTAGON ...................... 122

CYSTARAN ...................... 144

D d10 %-0.45 % sodium chloride

.......................................... 94

d2.5 %-0.45 % sodium

chloride ............................. 94

d5 % and 0.9 % sodium

chloride ............................. 94

d5 %-0.45 % sodium chloride

.......................................... 94

dalfampridine ....................... 88

DALIRESP ......................... 156

DANAZOL......................... 124

dantrolene ............................. 63

dapsone ................................. 51

DAPTACEL (DTAP

PEDIATRIC) (PF).......... 139

daptomycin ........................... 30

DARAPRIM ......................... 57

darifenacin .......................... 123

DAURISMO......................... 56

deblitane ............................. 130

DEEP SEA NASAL ........... 158

DEKAS ESSENTIAL .... 94, 95

DEKAS PLUS (FOLIC ACID)

.......................................... 95

DEKAS PLUS LIQUID ....... 95

DELSTRIGO ........................ 65

delyla (28) .......................... 126

DELZICOL ........................ 142

DEMSER .............................. 82

DENAVIR ............................ 64

DEPEN TITRATABS ........ 135

DEPO-PROVERA................ 52

DEPO-SUBQ PROVERA 104

........................................ 130

dermacinrx empricaine ......... 23

DESCOVY ........................... 66

desipramine .......................... 42

desmopressin ...................... 131

desog-e.estradiol/e.estradiol

........................................ 126

desogestrel-ethinyl estradiol

........................................ 126

desonide .......................... 47, 48

desoximetasone .................... 48

desvenlafaxine succinate ...... 41

dexamethasone ..................... 48

dexamethasone intensol ........ 48

dexamethasone sodium

phosphate ................ 123, 147

dexmethylphenidate.............. 87

dextroamphetamine .............. 86

dextroamphetamine-

amphetamine .................... 87

dextromethorphan polistirex

........................................ 158

dextromethorphan-guaifenesin

........................................ 160

dextrose 10 % and 0.2 % nacl

.......................................... 95

dextrose 10 % in water (d10w)

.......................................... 95

dextrose 5 % in water (d5w). 95

dextrose 5%-0.2 % sod

chloride ............................. 95

dextrose 5%-0.3 %

sod.chloride ...................... 95

DEXTROSE WITH SODIUM

CHLORIDE ...................... 95

DIABETIC SILTUSSIN DAS-

NA .................................. 158

DIABETIC SILTUSSIN-DM

........................................ 159

DIASTAT ............................. 38

DIASTAT ACUDIAL .......... 38

diazepam ......................... 38, 68

diazepam intensol ................. 68

diclofenac potassium ............ 19

diclofenac sodium .... 19, 23, 53,

147

dicloxacillin .......................... 34

DICLOZOR .......................... 19

dicyclomine ........................ 105

didanosine ............................. 66

DIFICID ............................... 35

diflunisal ............................... 19

digitek ................................... 82

digox ..................................... 82

digoxin .................................. 82

dihydroergotamine ................ 50

DILANTIN ........................... 39

diltiazem hcl ................... 80, 81

dilt-xr .................................... 81

DIMAPHEN (PE) ............... 159

DIMAPHEN DM ................ 159

DIPENTUM ....................... 142

DIPHEDRYL ..................... 150

DIPHENHIST ..................... 150

diphenhydramine hcl .......... 150

diphenoxylate-atropine ....... 105

dipyridamole ......................... 77

disopyramide phosphate ....... 79

disulfiram .............................. 24

divalproex ............................. 38

DM2 ...................................... 69

DOC-Q-LACE .................... 113

DOCU ......................... 113, 114

docusate sodium ................. 114

DOCUSIL ........................... 114

DOCUSOL ......................... 114

dofetilide ............................... 79

DOK ................................... 114

donepezil ............................... 40

DOPTELET .......................... 76

DOPTELET (10 TAB PACK)

.......................................... 75

DOPTELET (15 TAB PACK)

.......................................... 75

doripenem ............................. 33

dorzolamide ........................ 146

dorzolamide-timolol ........... 146

doxazosin .............................. 78

doxepin ................................. 42

DOXEPIN ............................. 90

doxercalciferol .................... 143

doxy-100 ............................... 36

doxycycline hyclate .............. 36

doxycycline monohydrate .... 36

171

DRIMINATE ....................... 43

dronabinol............................. 44

drospirenone-ethinyl estradiol

........................................ 126

DROXIA .............................. 52

DUAVEE ........................... 131

DUCODYL ........................ 114

DULERA ............................ 159

duloxetine ............................. 88

DUPIXENT .......................... 91

duramorph (pf) ..................... 22

DUREZOL ......................... 147

dutasteride .......................... 123

E E.C. PRIN ............................. 19

econazole .............................. 45

ECONTRA EZ ................... 126

ED A-HIST ........................ 150

EDURANT ........................... 65

efavirenz ............................... 65

EGRIFTA ........................... 131

ELDERTONIC ..................... 95

ELIDEL ................................ 91

ELIGARD .......................... 133

ELIGARD (3 MONTH) ..... 133



ELIQUIS .............................. 74

ELMIRON .......................... 123

EMCYT ................................ 52

EMEND ................................ 44

emoquette ........................... 126

EMSAM ............................... 41

EMTRIVA ............................ 66

enalapril maleate .................. 79

enalapril-hydrochlorothiazide

.......................................... 82

ENBREL ............................ 135

ENBREL MINI .................. 135

ENBREL SURECLICK ..... 135

ENDACOF - DM ............... 159

ENDARI ............................... 95

ENEMA ...................... 114, 118

ENEMA DISPOSABLE .... 114

ENEMEEZ ......................... 114

ENEMEEZ PLUS .............. 114

ENGERIX-B (PF) .............. 139

ENGERIX-B PEDIATRIC

(PF) ................................. 139

enoxaparin ............................ 74

enpresse .............................. 126

ENSKYCE.......................... 126

entacapone ............................ 58

entecavir ............................... 63

ENTRESTO.......................... 82

enulose ................................ 107

ENVARSUS XR ................ 135

EPIDIOLEX ......................... 37

epinastine ............................ 146

epinephrine ......................... 155

epitol ..................................... 39

EPIVIR HBV ........................ 63

eplerenone ............................ 84

EPOGEN .............................. 76

EQUETRO ........................... 69

ERAXIS(WATER DILUENT)

.......................................... 45

ergocalciferol (vitamin d2) 103,

105

ergoloid ................................. 40

ergotamine-caffeine .............. 50

ERIVEDGE .......................... 54

ERLEADA ........................... 52

errin .................................... 130

ertapenem ............................. 33

ery pads................................. 35

ERYTHROCIN .................... 35

erythrocin (as stearate) ......... 35

erythromycin ........................ 35

erythromycin ethylsuccinate. 35

erythromycin with ethanol.... 35

erythromycin-benzoyl peroxide

.......................................... 91

ESBRIET ............................ 156

escitalopram oxalate ............. 41

ESTARYLLA ..................... 126

estradiol ...................... 124, 125

estradiol valerate................. 125

estradiol-norethindrone acet

........................................ 126

ESTRING ........................... 125

estropipate .......................... 125

ethambutol ............................ 51

ethosuximide ........................ 37

ethynodiol diac-eth estradiol

........................................ 126

etidronate disodium ............ 143

etodolac ................................ 19

EUCRISA ............................. 91

EVOTAZ .............................. 67

exemestane ........................... 53

EXJADE ............................. 100

EX-LAX MAXIMUM

STRENGTH ................... 114

EXTAVIA ............................ 88

ezetimibe ............................... 85

ezetimibe-simvastatin ........... 85

F falmina (28) ........................ 126

famciclovir ............................ 64

famotidine ........................... 112

FANAPT ............................... 60

FARESTON ......................... 52

FARYDAK ........................... 54

felbamate .............................. 38

felodipine .............................. 81

femynor ............................... 127

fenofibrate ............................. 84

fenofibrate micronized .......... 84

fenofibrate nanocrystallized . 84

fenofibric acid ....................... 84

fenofibric acid (choline) ....... 84

fentanyl ................................. 22

fentanyl citrate ...................... 22

FERGON .............................. 95

FER-IN-SOL ........................ 95

FEROSUL ............................ 95

FERRIPROX ...................... 100

FERRLECIT ............... 100, 101

FERRO-TIME ...................... 95

ferrous fumarate .................... 96

ferrous gluconate .................. 96

ferrous sulfate ................. 94, 96

FERROUSUL ....................... 96

FETZIMA ............................. 41

FEVERALL .......................... 14

fexofenadine ...... 150, 151, 152,

153

FIBER ................................. 119

FIBER (CALCIUM

POLYCARBOPHIL) ..... 114,

118

FIBER (PSYLLIUM

HUSK/SUGAR) ............. 119

FIBER (WITH ASPARTAME)

........................................ 115

FIBER LAXATIVE (CA

POLYCARBO) ....... 114, 119

172

FIBER LAXATIVE

(METHYLCELLULO) . 115,

118

FIBER THERAPY (M-

CELL/SUGAR) .............. 114

FIBER-LAX ....................... 114

FIBER-TABS ..................... 114

finasteride ........................... 123

FIRAZYR ........................... 134

FIRDAPSE ........................... 88

FIRMAGON....................... 133

FIRMAGON KIT W

DILUENT SYRINGE .... 133

flavoxate ............................. 123

FLEBOGAMMA DIF ........ 137

flecainide .............................. 79

FLEET BISACODYL ........ 114

FLEET ENEMA ................. 114

FLEET GLYCERIN (CHILD)

........................................ 115

FLEET PEDIATRIC .......... 115

FLOVENT DISKUS .......... 154

FLOVENT HFA ................. 154

fluconazole ........................... 45

fluconazole in dextrose(iso-o)

.......................................... 45

fluconazole in nacl (iso-osm)45

flucytosine ............................ 45

fludrocortisone ................... 123

flunisolide ........................... 154

fluocinolone .......................... 48

fluocinonide .......................... 48

fluocinonide-e....................... 48

fluocinonide-emollient ......... 48

FLUORIDE (SODIUM) ....... 96

fluorometholone ................. 147

fluorouracil ........................... 52

fluoxetine ........................ 41, 42

fluphenazine decanoate ........ 59

fluphenazine hcl ................... 59

flurbiprofen........................... 19

flurbiprofen sodium ............ 147

flutamide............................... 52

fluticasone .................... 48, 154

fluticasone-salmeterol ........ 159

fluvoxamine .......................... 42

FML FORTE ...................... 147

folic acid ......................... 96, 97

fondaparinux......................... 74

FORFIVO XL ...................... 41

FORTEO ............................ 143

fosamprenavir ....................... 67

fosinopril .............................. 79

fosinopril-hydrochlorothiazide

.......................................... 82

FOSRENOL ....................... 101

FRAGMIN...................... 74, 75

furosemide ...................... 83, 84

FUZEON .............................. 66

fyavolv ................................ 127

FYAVOLV ......................... 127

FYCOMPA ........................... 39

G gabapentin ............................ 38

GALAFOLD ...................... 122

galantamine .......................... 40

GAMMAGARD LIQUID .. 137

GAMMAGARD S-D (IGA < 1

MCG/ML) ...................... 137

GAMMAKED .................... 137

GAMMAPLEX .......... 137, 138

GAMMAPLEX (WITH

SORBITOL) ................... 137

GAMUNEX-C.................... 138

ganciclovir sodium ............... 63

GARDASIL 9 (PF) ............. 139

GAS RELIEF ..................... 107

GAS RELIEF EXTRA

STRENGTH ................... 110

GATTEX 30-VIAL ............ 107

GATTEX ONE-VIAL ........ 107

gauze pad .............................. 72

GAVILAX .......................... 115

gavilyte-c ............................ 107

gavilyte-g ............................ 115

gavilyte-n ............................ 115

GAVISCON ....................... 107

GAVISCON EXTRA

STRENGTH ................... 107

gemfibrozil ........................... 84

generlac .............................. 107

gengraf ................................ 135

GENOTROPIN .................. 131

GENOTROPIN MINIQUICK

........................................ 131

gentak ................................... 28

gentamicin ............................ 28

gentamicin in nacl (iso-osm) 28

GENTEAL MILD TO

MODERATE .................. 144

GENTEAL GEL ................. 144

GENTEAL TEARS MILD . 144

GENTEAL TEARS

MODERATE .................. 144

GENTEAL TEARS

MODERATE (PF) .......... 144

GENTEAL TEARS SEVERE

GEL ................................ 144

GENTLE LAXATIVE ....... 119

GENVOYA .......................... 64

GEODON ............................. 60

GILENYA ............................ 88

GILOTRIF ............................ 54

GLASSIA ........................... 122

glatiramer .............................. 88

GLATOPA ........................... 88

GLEOSTINE ........................ 51

glimepiride ............................ 69

glipizide ................................ 70

glipizide-metformin .............. 70

GLUCAGEN DIAGNOSTIC

KIT ................................... 72

GLUCAGEN HYPOKIT ...... 72

GLUCAGON EMERGENCY

KIT (HUMAN) ................. 72

GLUCAGON HCL ............... 72

glucose .................................. 72

glyburide ............................... 70

glyburide micronized ............ 70

glyburide-metformin ............. 70

glycerin (child) ................... 115

GLYCOLAX ...................... 115

glycopyrrolate ..................... 105

GOCOVRI ............................ 58

granisetron hcl ...................... 44

GRANIX ............................... 76

griseofulvin microsize .......... 45

guaifenesin .................. 159, 160

guanfacine ....................... 78, 87

guanidine .............................. 51

H HAEGARDA ...................... 134

halobetasol propionate .......... 48

haloperidol ............................ 59

haloperidol decanoate ........... 59

haloperidol lactate ................ 59

HAVRIX (PF) .................... 139

HEALTHYLAX ................. 115

HEARTBURN RELIEF

(CIMETIDINE) .............. 113

173

HEARTBURN RELIEF

(FAMOTIDINE) ............ 112

HEARTBURN TREATMENT

24 HOUR........................ 120

HEMOCYTE ........................ 97

heparin (porcine) .................. 75

heparin, porcine (pf) ............. 75

HEPLISAV-B (PF) ............ 139

HETLIOZ ........................... 165

HEXALEN ........................... 51

HIBERIX (PF).................... 139

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

KWIKPEN ....................... 73

HUMALOG MIX 75-25(U-

100)INSULN .................... 73

HUMALOG U-100 INSULIN

.......................................... 73

HUMATROPE ................... 131

HUMIRA ............................ 136

HUMIRA PEDIATRIC

CROHNS START .......... 135

HUMIRA PEN ................... 136

HUMIRA PEN CROHNS-UC-

HS START ..................... 135

HUMIRA PEN PSOR-

UVEITS-ADOL HS ....... 136

HUMIRA(CF) .................... 136

HUMIRA(CF) PEDI

CROHNS STARTER ..... 136

HUMIRA(CF) PEN............ 136

HUMIRA(CF) PEN

CROHNS-UC-HS .......... 136

HUMIRA(CF) PEN PSOR-

UV-ADOL HS................ 136

HUMULIN 70/30 U-100

INSULIN .......................... 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

hydralazine ........................... 86

hydrochlorothiazide .............. 84

hydrocodone-acetaminophen 15

hydrocodone-ibuprofen .. 15, 20

hydrocortisone . 48, 49, 50, 123,

124, 142

hydrocortisone acetate .......... 91

hydrocortisone butyrate ........ 49

hydrocortisone butyr-emollient

.......................................... 49

HYDROCORTISONE PLUS

.......................................... 49

hydrocortisone valerate ........ 49

hydrocortisone-acetic acid .. 147

hydrocortisone-aloe vera 49, 50

hydrocortisone-min oil-wht pet

.......................................... 91

hydromorphone .................... 22

hydromorphone (pf) ............. 22

HYDROSKIN ...................... 91

HYDROSKIN WITH ALOE 49

hydroxocobalamin ................ 97

hydroxychloroquine.............. 57

hydroxyurea .......................... 52

hydroxyzine hcl .................. 152

hydroxyzine pamoate ........... 68

HYPERRAB (PF)............... 138

HYPERRAB S/D (PF) ....... 138

I ibandronate ......................... 143

IBRANCE ............................ 54

IBU ....................................... 15

IBU-200 ................................ 20

ibuprofen .................. 20, 21, 22

IBUPROFEN IB ............. 20, 22

ibuprofen-oxycodone............ 15

ICAPS MV ........................... 97

ICLUSIG .............................. 54

IDHIFA ................................ 54

IFEREX 150 ......................... 97

imatinib ................................. 54

IMBRUVICA ....................... 54

imipenem-cilastatin .............. 33

imipramine hcl ...................... 42

imipramine pamoate ............. 43

imiquimod ............................ 91

IMOVAX RABIES VACCINE

(PF) ................................. 139

INCASSIA .......................... 130

INCRELEX ........................ 132

INCRUSE ELLIPTA .......... 154

indapamide ........................... 84

indomethacin ........................ 21

INFANRIX (DTAP) (PF) .. 139,

140

INFANTS' PAIN AND

FEVER ....................... 14, 15

INFANTS' PAIN RELIEF ... 15,

17

INFED .................................. 97

INGREZZA .......................... 88

INLYTA ............................... 54

INSECT REPELLENT

(DEET) ............................. 90

insulin syringe-needle u-100 72

INTELENCE ........................ 65

intralipid ............................... 97

INTRALIPID ........................ 97

INTRON A ........................... 64

introvale .............................. 127

INVEGA SUSTENNA ......... 60

INVEGA TRINZA ............... 61

INVIRASE ........................... 67

INVOKAMET ...................... 70

INVOKAMET XR ............... 70

INVOKANA ......................... 70

INZO ANTIFUNGAL .......... 45

IPOL ................................... 140

ipratropium bromide ... 154, 160

ipratropium-albuterol .......... 161

irbesartan .............................. 78

irbesartan-hydrochlorothiazide

.......................................... 82

IRESSA ................................ 54

IRON .................................... 97

ISENTRESS ......................... 64

ISENTRESS HD .................. 64

ISIBLOOM ......................... 127

ISOLYTE S PH 7.4 .............. 97

ISOLYTE-P IN 5 %

DEXTROSE ..................... 97

ISOLYTE-S .......................... 97

isoniazid ................................ 51

isosorbide dinitrate ............... 86

isosorbide mononitrate ......... 86

isotretinoin ............................ 91

isradipine .............................. 81

itraconazole ........................... 45

174

ivermectin ............................. 56

IXIARO (PF) ...................... 140

J JADENU ............................ 101

JADENU SPRINKLE ........ 101

JAKAFI ................................ 55

jantoven ................................ 75

JANUMET ........................... 70

JANUMET XR ..................... 70

JANUVIA............................. 70

JENTADUETO .................... 70

JENTADUETO XR.............. 70

jinteli................................... 127

jolivette ............................... 130

juleber ................................. 127

JULUCA............................... 64

junel 1.5/30 (21) ................. 127

junel 1/20 (21) .................... 127

junel fe 1.5/30 (28) ............. 127

junel fe 1/20 (28) ................ 127

JUXTAPID ........................... 85

JYNARQUE ....................... 101

K KALETRA ........................... 67

KALYDECO ...................... 155

KAO-TIN (DOCUSATE

CALCIUM) .................... 116

kariva (28) .......................... 127

KEDRAB (PF) ................... 140

kelnor 1/35 (28) .................. 127

KELNOR 1-50 ................... 127

ketoconazole ......................... 45

ketorolac ....................... 21, 147

KEVEYIS ............................. 83

KIDKARE COUGH/COLD

........................................ 161

kimidess (28) ...................... 127

KINERET ........................... 136

KINRIX (PF) ...................... 140

kionex ................................. 101

kionex (with sorbitol) ......... 101

KISQALI .............................. 55

KISQALI FEMARA CO-

PACK ............................... 55

klor-con 10 ........................... 97

klor-con 8 ............................. 97

klor-con m10 ........................ 97

KLOR-CON M15 ................. 97

klor-con m20 ........................ 97

KLOR-CON SPRINKLE ..... 97

KONSYL (SUGAR)........... 116

KONSYL EASY MIX........ 116

KONSYL FIBER ............... 116

KONSYL FORMULA-D ... 116

KONSYL SUGAR-FREE .. 116

KONSYL SUGAR-FREE

(ASPARTAME) ............. 116

KORLYM ............................. 71

KRISTALOSE.................... 116

K-SOL .................................. 97

KURVELO (28) ................. 127

KUVAN.............................. 122

KYNAMRO ......................... 85

L labetalol ................................ 80

lactulose .............................. 116

LAMISIL AF ........................ 45

lamivudine ............................ 63

lamivudine-zidovudine ......... 66

lamotrigine...................... 39, 69

lansoprazole ................ 120, 121

lanthanum ........................... 101

LANTUS SOLOSTAR U-100

INSULIN .......................... 73

LANTUS U-100 INSULIN .. 73

larin 1.5/30 (21) .................. 127

larin 1/20 (21) ..................... 127

larin fe 1.5/30 (28) .............. 127

larin fe 1/20 (28) ................. 127

larissia ................................. 127

latanoprost .......................... 143

LATUDA.............................. 61

LAXATIVE (BISACODYL)

................................ 115, 116

LAXATIVE PLUS STOOL

SOFTENER .................... 119

LAZANDA ........................... 23

leena 28............................... 127

leflunomide ......................... 138

LENVIMA............................ 55

lessina ................................. 127

LETAIRIS .......................... 156

letrozole ................................ 53

leucovorin calcium ............... 53

LEUKERAN ........................ 51

LEUKINE ............................. 76

leuprolide ............................ 133

LEVA SET ........................... 23

levalbuterol hcl ................... 155

LEVEMIR FLEXTOUCH U-

100 INSULN .................... 73

LEVEMIR U-100 INSULIN 73

levetiracetam ......................... 37

levobunolol ......................... 147

levocarnitine ......................... 98

levocarnitine (with sugar) ..... 98

levocetirizine ...................... 152

levofloxacin .......................... 36

levofloxacin in d5w .............. 35

levonest (28) ....................... 127

levonorgestrel-ethinyl estrad

................................ 127, 128

levonorg-eth estrad triphasic

........................................ 128

levora-28 ............................. 128

LEVO-T .............................. 132

levothyroxine ...................... 132

levoxyl ................................ 132

LEXIVA ............................... 67

LICE KILLING .................... 57

LICE TREATMENT ............ 57

LICE TREATMENT

(PERMETHRIN) .............. 57

lidocaine ............................... 23

lidocaine hcl .......................... 23

lidocaine-prilocaine .............. 23

LIDOPAC ............................. 23

lidopril .................................. 23

lidopril xr .............................. 23

LIDO-PRILO CAINE PACK

.......................................... 23

LILLOW (28) ..................... 128

lindane .................................. 57

linezolid ................................ 30

linezolid in dextrose 5% ....... 30

linezolid-0.9% sodium chloride

.......................................... 30

LINZESS ............................ 113

liothyronine ......................... 132

liprozonepak ......................... 24

LIQUID ANTACID ........... 108

LIQUITEARS ..................... 144

lisinopril ................................ 79

lisinopril-hydrochlorothiazide

.......................................... 82

lithium carbonate .................. 69

lithium citrate ........................ 69

LIVALO ............................... 84

livixil pak .............................. 24

175

LONSURF ............................ 53

loperamide .......................... 108

lopinavir-ritonavir ................ 67

lopreeza .............................. 128

loratadine .... 150, 151, 152, 153

LORATA-DINE D ............. 163

LORATADINE-D .............. 161

lorazepam ............................. 69

lorazepam intensol................ 69

LORBRENA ........................ 55

losartan ................................. 79

losartan-hydrochlorothiazide 82

lovastatin .............................. 84

low-ogestrel (28) ................ 128

loxapine succinate ................ 59

LUBRICANT EYE ............ 144

LUBRICANT EYE (CMC-

GLYCERIN) .................. 144

LUBRICANT EYE (PG-PEG

400)......................... 144, 145

LUBRICANT EYE (PG-PEG

400)(PF) ......................... 144

LUBRICATING PLUS ...... 144

LUBRIFRESH PM ............. 144

LUCEMYRA ....................... 24

LUMIGAN ......................... 143

LUPRON DEPOT .............. 133

LUPRON DEPOT (3

MONTH) ........................ 133

LUPRON DEPOT (4

MONTH) ........................ 133

LUPRON DEPOT (6

MONTH) ........................ 133

LUPRON DEPOT-PED ..... 133

LUPRON DEPOT-PED (3

MONTH) ........................ 133

lutera (28) ........................... 128

LYNPARZA......................... 53

LYRICA ............................... 37

LYSODREN......................... 56

lyza ..................................... 130

M MAG 64................................ 98

MAG-AL PLUS ................. 108

MAGNEBIND 300 .............. 98

magnesium ........................... 98

magnesium citrate .............. 116

magnesium oxide.................. 98

magnesium sulfate ................ 98

malathion .............................. 57

MAPAP

(ACETAMINOPHEN) .... 15,

16

MAPAP ARTHRITIS PAIN 16

MAPAP EXTRA STRENGTH

.................................... 15, 16

maprotiline............................ 42

marlissa (28) ....................... 128

MARPLAN .......................... 41

MATULANE........................ 51

MAVYRET .......................... 64

meclizine .............................. 43

meclofenamate...................... 21

MEDOLOR PAK ................. 24

medroxyprogesterone ......... 130

mefloquine ............................ 57

megestrol ............................ 131

MEKINIST ........................... 55

MEKTOVI............................ 55

meloxicam ............................ 21

memantine ............................ 40

MENACTRA (PF) ............. 140

MENEST ............................ 125

MENTAX ............................. 45

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

(PF) ................................. 140

meperidine ............................ 23

MEPHYTON ........................ 76

mercaptopurine ..................... 52

MERIBIN ............................. 98

meropenem ........................... 33

meropenem-0.9% sodium

chloride ............................. 33

mesalamine ......................... 142

mesalamine with cleansing

wipe ................................ 142

MESNEX.............................. 53

metaproterenol .................... 155

METAXALL ...................... 165

metaxalone.......................... 165

metformin ............................. 71

methadone ............................ 22

methazolamide...................... 83

methenamine hippurate ........ 30

methimazole ....................... 134

methocarbamol ................... 165

methotrexate sodium .......... 136

methotrexate sodium (pf) ... 136

methoxsalen .......................... 91

methyclothiazide .................. 84

methyldopa ........................... 78

methyldopa-

hydrochlorothiazide .......... 82

methylphenidate hcl ........ 87, 88

methylprednisolone ...... 49, 142

methylprednisolone acetate 124

methyltestosterone .............. 124

metoclopramide hcl .............. 43

metolazone ............................ 84

metoprolol succinate ............. 80

metoprolol ta-hydrochlorothiaz

.......................................... 80

metoprolol tartrate ................ 80

metro i.v. ............................... 30

metronidazole ....................... 30

metronidazole in nacl (iso-os)

.......................................... 30

mexiletine ............................. 79

MI-ACID ............................ 109

MICONAZOLE 7 ........... 45, 46

miconazole nitrate .......... 45, 46

microgestin 1.5/30 (21) ...... 128

microgestin 1/20 (21) ......... 128

microgestin fe 1.5/30 (28) .. 128

microgestin fe 1/20 (28) ..... 128

midodrine .............................. 78

MILI ................................... 128

MILK OF MAGNESIA ..... 115,

116, 117, 119

MIMVEY ........................... 128

mimvey lo ........................... 128

mineral oil ........................... 117

minocycline .......................... 36

minoxidil ............................... 86

MINTOX ............................ 109

MINTOX PLUS ................. 109

mirtazapine ........................... 41

misoprostol ......................... 120

M-M-R II (PF) .................... 140

MODAFINIL ...................... 165

moexipril ............................... 79

moexipril-hydrochlorothiazide

.......................................... 82

molindone ............................. 59

mometasone .................. 49, 154

mononessa (28) ................... 128

montelukast ......................... 154

morgidox ............................... 37

MORGIDOX 1X 50 ............. 37

morphine ......................... 22, 23

176

MOTION SICKNESS .......... 43

MOTION SICKNESS RELIEF

.......................................... 43

MOTION-TIME ................... 43

moxifloxacin......................... 36

moxifloxacin in nacl (iso-osm)

.......................................... 36

moxifloxacin-sod.ace,sul-water

.......................................... 36

MUCINEX ......................... 161

MUCINEX DM .................. 161

MUCINEX FAST-MAX DM

MAX............................... 161

MUCUS RELIEF ....... 161, 162

MUCUS RELIEF COUGH 163

MUCUS RELIEF DM ....... 161,

162, 163

MUCUS RELIEF ER ......... 160

MUCUS RELIEF SINUS .. 161

MULTAQ ............................. 79

mupirocin ............................. 30

MURO 128 ......................... 144

MY WAY ........................... 128

MYCAMINE ........................ 46

mycophenolate mofetil ....... 136

mycophenolate sodium ....... 136

myorisan ............................... 91

MYRBETRIQ .................... 123

N nabumetone .......................... 21

nadolol .................................. 80

nafcillin................................. 34

nafcillin in dextrose iso-osm 34

nalbuphine ............................ 23

naloxone ............................... 24

naltrexone ............................. 24

NAMENDA XR ................... 40

naproxen ............................... 21

naproxen sodium .................. 21

NARCAN ............................. 24

NASAL DECONGESTANT

(OXYMETAZL) ............ 161

NASAL DECONGESTANT

(PE)......................... 159, 162

NASAL DECONGESTANT

(PSEUDOEPH) ..... 160, 161,

162, 163

NASAL SPRAY

(OXYMETAZOLINE) .. 159,

162

NASAL SPRAY 12 HOUR

........................ 161, 162, 163

NASCOBAL ........................ 98

NATACYN ........................ 144

nateglinide ............................ 71

NATPARA ......................... 143

NATRAPEL ......................... 91

NATURAL FIBER

LAXATIVE (SUGAR)... 117

NATURAL FIBER

LAXATIVE THERAPY 117

NATURAL VEG

LAXATIVE(SENNOSID)

........................................ 117

NATURA-LAX .................. 118

NATURE'S TEARS ........... 144

NEBUPENT ......................... 57

necon 0.5/35 (28) ................ 128

necon 7/7/7 (28).................. 128

nefazodone............................ 41

neomycin .............................. 28

neomycin-bacitracin-poly-hc 31

neomycin-bacitracin-

polymyxin ......................... 31

neomycin-polymyxin b-

dexameth .......................... 31

neomycin-polymyxin-

gramicidin ......................... 31

neomycin-polymyxin-hc ..... 31,

147, 148

NERLYNX ........................... 55

NEULASTA ......................... 76

NEUPOGEN ........................ 76

NEUPRO .............................. 58

nevirapine ............................. 65

NEXAVAR .......................... 55

niacin .................................... 85

niacinamide .......................... 85

NICODERM CQ .................. 25

NICORELIEF ....................... 25

NICORETTE .................. 25, 26

nicotine ......... 24, 25, 26, 27, 28

nicotine (polacrilex) 24, 26, 27,

28

NICOTROL .......................... 28

NICOTROL NS .................... 28

nifedical xl ............................ 81

nifedipine .............................. 81

NIGHTTIME SLEEP AID

(DIPHEN) ....................... 152

nilutamide ............................. 52

nimodipine ............................ 81

NINLARO ............................ 53

NITRO-BID .......................... 86

NITRO-DUR ........................ 86

nitrofurantoin macrocrystal .. 31

nitrofurantoin monohyd/m-

cryst .................................. 31

nitroglycerin ......................... 86

NITYR ................................ 122

NIVESTYM ......................... 76

NOCTIVA .......................... 132

NON-ASPIRIN ..................... 17

NON-ASPIRIN EXTRA

STRENGTH ..................... 17

NON-ASPIRIN PAIN RELIEF

.......................................... 17

NON-DROWSY ALLERGY

........................................ 152

nora-be ................................ 131

NORDITROPIN FLEXPRO

........................................ 132

norethindrone (contraceptive)

........................................ 131

norethindrone acetate .......... 131

norethindrone ac-eth estradiol

........................................ 128

norgestimate-ethinyl estradiol

........................................ 128

NORLYDA ......................... 128

norlyroc ............................... 131

normosol-r ............................ 98

normosol-r ph 7.4 ................. 98

NORPACE CR ..................... 79

NORTHERA ........................ 78

nortrel 0.5/35 (28) ............... 128

nortrel 1/35 (21) .................. 128

nortrel 1/35 (28) .................. 128

nortrel 7/7/7 (28) ................. 128

nortriptyline .......................... 43

NORVIR ............................... 67

NOVOLIN 70/30 U-100

INSULIN .......................... 73

NOVOLIN N NPH U-100

INSULIN .......................... 74

NOVOLIN R REGULAR U-

100 INSULN .................... 74

NOVOLOG FLEXPEN U-100

INSULIN .......................... 74

177

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

NOXAFIL ............................ 46

NUEDEXTA ........................ 88

NU-MAG ............................. 98

NUPLAZID .......................... 61

NUTROPIN AQ NUSPIN . 132

NUVARING....................... 128

nyamyc ................................. 46

nystatin ................................. 46

nystatin-triamcinolone .......... 91

nystop ................................... 46

O OCALIVA .......................... 109

ocella .................................. 129

octreotide acetate ................ 133

OCTREOTIDE ACETATE 134

OCUVITE WITH LUTEIN . 98

ODEFSEY ............................ 65

ODOMZO ............................ 53

OFEV ................................. 156

OFF ACTIVE ....................... 91

OFF DEEP WOODS ............ 91

OFF DEEP WOODS DRY .. 91

OFF DEEP WOODS

SPORTSMEN .................. 91

OFF FAMILYCARE (WITH

DEET) .............................. 91

OFF FAMILYCARE(WITH

PICARIDIN) .................... 91

ofloxacin ....................... 36, 148

olanzapine............................. 61

olmesartan ............................ 79

olmesartan-amlodipin-

hcthiazid ........................... 83

olmesartan-

hydrochlorothiazide .......... 83

olopatadine ......................... 146

omega-3 acid ethyl esters ..... 85

omeprazole ................. 120, 121

OMNITROPE..................... 132

ONCOVITE ......................... 98

ondansetron .......................... 44

ondansetron hcl .................... 44

ONE DAILY ........................ 98

OPCICON ONE-STEP....... 129

OPTION-2 .......................... 129

ORENCIA .......................... 137

ORENCIA CLICKJECT .... 137

ORFADIN .......................... 122

ORILISSA .......................... 134

ORKAMBI ......................... 155

orphenadrine citrate ............ 165

orsythia ............................... 129

OS-CAL 500 + D3 ............... 98

oseltamivir ...................... 67, 68

OTEZLA ............................ 138

OTEZLA STARTER .......... 138

oxandrolone ........................ 124

oxcarbazepine ....................... 39

OXERVATE ...................... 145

oxybutynin chloride ............ 123

oxycodone ...................... 22, 23

oxycodone-acetaminophen ... 16

oxycodone-aspirin ................ 16

OYSCO 500/D ................... 103

OYSCO-500 ......................... 98

OYSTER SHELL CALCIUM

500 .............................. 98, 99

OYSTER SHELL CALCIUM-

VIT D3 ........................... 103

OZEMPIC ............................ 71

P PAIN AND FEVER ............. 16

PAIN RELIEF ................ 14, 16

PAIN RELIEF EXTRA

STRENGTH ............... 15, 16

PAIN RELIEVER ... 15, 16, 17,

18

PAIN RELIEVER EXTRA

STRENGTH ............... 17, 18

paliperidone .......................... 61

PANRETIN .......................... 56

pantoprazole ....................... 121

paricalcitol .......................... 103

paromomycin ........................ 28

paroxetine hcl ....................... 42

PASER.................................. 51

PAXIL .................................. 42

PEDIA RELIEF COUGH-

COLD ............................. 162

PEDIALYTE ........................ 99

PEDIALYTE FREEZER

POPS ................................ 99

PEDIALYTE SINGLES ....... 99

PEDIARIX (PF) ................. 140

PEDIATRIC COUGH AND

COLD ............................. 162

PEDIATRIC ELECTROLYTE

........................................ 104

PEDVAX HIB (PF) ............ 140

peg 3350-electrolytes .......... 117

peg-3350 with flavor packs 117

PEGANONE ......................... 40

PEGASYS ............................ 63

PEGASYS PROCLICK ........ 63

peg-electrolyte soln ............ 117

pen needle, diabetic .............. 72

penicillin g procaine ............. 34

penicillin g sodium ............... 34

penicillin v potassium ........... 34

PENTACEL ACTHIB

COMPONENT (PF) ....... 140

PENTAM .............................. 57

PENTASA .......................... 142

pentazocine-naloxone ........... 17

pentoxifylline ........................ 83

PEPTIC RELIEF ................ 109

periogard ............................... 89

permethrin ............................. 57

perphenazine ......................... 43

perphenazine-amitriptyline ... 41

PERSERIS ............................ 61

PHARBEDRYL ................. 152

PHARBETOL ....................... 17

phenelzine ............................. 41

phenobarbital ........................ 38

phenoxybenzamine ............... 78

PHENYTEK ......................... 40

phenytoin .............................. 40

phenytoin sodium extended .. 40

PHOSPHOLINE IODIDE .. 147

PIFELTRO ........................... 65

pilocarpine hcl .............. 89, 147

pimecrolimus ........................ 91

pimozide ............................... 59

pimtrea (28) ........................ 129

pindolol ................................. 80

pioglitazone .......................... 71

pioglitazone-metformin ........ 71

piperacillin-tazobactam ........ 34

pirmella ............................... 129

piroxicam .............................. 21

PLAN B ONE-STEP .......... 129

178

plenamine ............................. 99

podofilox .............................. 91

polyethylene glycol 3350 ... 117

polymyxin b sulfate .............. 31

polymyxin b sulf-trimethoprim

.......................................... 31

POLY-VI-SOL ..................... 99

POLY-VI-SOL WITH IRON

.......................................... 99

POMALYST ........................ 52

portia 28.............................. 129

potassium chlorid-d5-

0.45%nacl ......................... 99

potassium chloride................ 99

potassium chloride in water.. 99

potassium citrate ................... 99

PRADAXA........................... 75

pramipexole .......................... 58

prasugrel ............................... 78

pravastatin ............................ 84

praziquantel .......................... 56

prazosin ................................ 78

prednicarbate ........................ 92

prednisolone ......................... 49

prednisolone acetate ........... 147

prednisolone sodium phosphate

.................................. 49, 147

prednisone ............................ 49

prednisone intensol ............. 124

PREMARIN ....................... 125

PREMPHASE .................... 129

PREMPRO ......................... 129

PRENATAL ....................... 103

PRENATAL VITAMIN ..... 103

PRENATAL VITAMIN PLUS

LOW IRON .................... 103

PREVACID 24HR ............. 121

prevalite ................................ 85

previfem ............................. 129

PREVYMIS .......................... 63

PREZCOBIX ........................ 67

PREZISTA ........................... 67

PRIFTIN ............................... 51

prilolid .................................. 24

PRIMAQUINE ..................... 57

primidone ............................. 38

PRIVIGEN ......................... 138

probenecid ............................ 47

probenecid-colchicine .......... 47

prochlorperazine ................... 43

prochlorperazine maleate ..... 43

PROCRIT ............................. 76

procto-med hc ..................... 124

procto-pak ........................... 124

proctosol hc ........................ 124

proctozone-hc ..................... 124

progesterone micronized .... 131

PROGLYCEM ..................... 72

PROLASTIN-C .................. 122

PROLIA.............................. 143

PROMACTA ........................ 76

promethazine ................ 43, 152

promethazine vc ................. 162

promethazine-phenylephrine

........................................ 162

promethegan ......................... 43

propafenone .......................... 79

proparacaine ....................... 145

propranolol ........................... 80

propranolol-hydrochlorothiazid

.......................................... 83

propylthiouracil .................. 134

PROQUAD (PF)................. 140

PROSIGHT .......................... 99

protriptyline .......................... 43

PROVIL................................ 21

pseudoephedrine hcl ........... 162

PULMOZYME ................... 156

PURIXAN ............................ 52

pyrazinamide ........................ 51

pyridostigmine bromide ....... 51

pyridoxine (vitamin b6) ..... 103,

104

Q QUADRACEL (PF) ........... 140

quasense.............................. 129

quetiapine ............................. 61

quinapril................................ 79

quinapril-hydrochlorothiazide

.......................................... 83

quinidine gluconate .............. 79

quinidine sulfate ................... 79

quinine sulfate ...................... 57

QVAR ................................. 154

QVAR REDIHALER ......... 154

R RABAVERT (PF) .............. 140

raloxifene ............................ 131

ramipril ................................. 79

RANEXA ............................. 83

ranitidine hcl ....................... 112

RAPAMUNE ...................... 137

rasagiline ............................... 59

RAVICTI ............................ 122

REACT ............................... 129

READY-TO-USE ENEMA 115

REBIF (WITH ALBUMIN) . 89

REBIF REBIDOSE .............. 89

REBIF TITRATION PACK . 89

reclipsen (28) ...................... 129

RECOMBIVAX HB (PF) ... 140

RECTIV .............................. 109

REFRESH CELLUVISC .... 145

REFRESH CLASSIC (PF) . 145

REFRESH LACRI-LUBE .. 145

REFRESH OPTIVE ........... 145

REFRESH OPTIVE

ADVANCED .................. 145

REFRESH OPTIVE

SENSITIVE (PF) ............ 145

REFRESH PLUS ................ 145

REFRESH TEARS ............. 145

REGRANEX ........................ 92

REGULOID ........................ 118

REGULOID, SUGAR FREE

........................................ 118

RELENZA DISKHALER .... 68

RELISTOR ......................... 109

RENAL VITAMIN ............ 104

repaglinide ............................ 71

REPATHA PUSHTRONEX 85

REPATHA SURECLICK .... 85

REPATHA SYRINGE ......... 86

REPEL 100 ........................... 92

REPEL FAMILY .................. 92

REPEL HUNTER'S .............. 92

REPEL LEMON

EUCALYPTUS ................ 92

REPEL SPORTSMEN ......... 92

REPEL SPORTSMEN DRY 92

REPEL SPORTSMEN MAX

.......................................... 92

REPEL TICK DEFENSE ..... 92

RESCRIPTOR ...................... 65

RESTASIS .......................... 145

RESTASIS MULTIDOSE .. 145

REVATIO ........................... 156

REVLIMID ........................... 52

REXULTI ............................. 61

REYATAZ ........................... 67

179

RIBAVIRIN ......................... 64

rifabutin ................................ 51

rifampin ................................ 51

RIFATER ............................. 51

riluzole .................................. 88

rimantadine ........................... 68

risedronate .......................... 143

RISPERDAL CONSTA ....... 62

risperidone ............................ 62

ritonavir ................................ 67

rivastigmine .......................... 40

rivastigmine tartrate.............. 40

rizatriptan ............................. 50

ROBAFEN ......................... 162

ROBAFEN CF

(PHENYLEPHRINE)..... 162

ROBAFEN DM .................. 163

ROBAFEN DM COUGH... 163

ROBAFEN DM COUGH-

CHEST CONGEST ........ 162

ropinirole .............................. 58

rosuvastatin........................... 84

ROTARIX .......................... 141

ROTATEQ VACCINE ...... 141

roweepra ............................... 37

ROWEEPRA ........................ 37

ROWEEPRA XR ................. 37

ROZEREM ......................... 165

RUBRACA........................... 55

RULOX .............................. 109

RYDAPT .............................. 55

S SABRIL ................................ 38

SAMSCA ........................... 101

SANDIMMUNE ................ 137

SANTYL .............................. 92

SAPHRIS ............................. 62

SAPHRIS (BLACK

CHERRY) ........................ 62

SAVELLA ............................ 88

scopolamine base.................. 43

SEGLUROMET ................... 71

selegiline hcl ......................... 59

selenium sulfide.................... 92

selzentry ............................... 66

SELZENTRY ....................... 66

SENEXON ......................... 118

SENEXON-S ...................... 118

SENNA....................... 116, 118

SENNA LAX ..................... 118

SENNA LAXATIVE . 118, 119

SENNA PLUS .................... 118

SENNA WITH DOCUSATE

SODIUM ........................ 114

SENNA-TIME S ................ 118

SENNO ............................... 118

sennosides-docusate sodium

........................................ 118

SENOKOT ......................... 118

SENSIPAR ......................... 143

SEREVENT DISKUS ........ 155

SEROSTIM ........................ 109

sertraline ............................... 42

setlakin................................ 129

sevelamer carbonate ........... 102

sharobel .............................. 131

SHINGRIX (PF) ................. 141

SHINGRIX GE ANTIGEN

COMPONENT ............... 141

SIGNIFOR.......................... 134

SILACE .............................. 118

SILADRYL SA .................. 153

sildenafil (antihypertensive)

........................................ 156

SILENOR ........................... 165

SILTUSSIN DM DAS........ 163

SILTUSSIN SA .................. 163

SILTUSSIN-DM ................ 163

silver sulfadiazine ................. 36

SIMBRINZA ...................... 147

SIMPONI............................ 137

simvastatin ............................ 85

SINUS RELIEF

(OXYMETAZOLINE) ... 163

sirolimus ............................. 137

SIRTURO ............................. 51

SLEEP ................................ 153

SLEEP AID

(DIPHENHYDRAMINE)

................................ 151, 153

SLEEP-TABS ..................... 153

sodium bicarbonate............. 100

sodium chloride .......... 100, 145

sodium chloride 0.45 % ...... 100

sodium chloride 0.9 % ........ 100

sodium chloride 3 % ........... 100

sodium ferric gluconat-sucrose

.................................. 99, 100

sodium phenylbutyrate ....... 122

sodium polystyrene (sorb free)

........................................ 101

sodium polystyrene sulfonate

........................................ 101

SOLTAMOX ........................ 52

SOMATULINE DEPOT .... 134

SOMAVERT ...................... 134

sorine .................................... 79

sotalol ................................... 80

sotalol af ............................... 79

SPIRIVA RESPIMAT ........ 154

SPIRIVA WITH

HANDIHALER .............. 154

spironolactone ....................... 84

spironolacton-hydrochlorothiaz

.......................................... 83

sprintec (28) ........................ 129

SPRITAM ............................. 37

SPRYCEL ............................. 55

sps (with sorbitol) ............... 101

sronyx ................................. 129

ssd ......................................... 36

stavudine ............................... 66

STEGLATRO ....................... 71

STEGLUJAN ....................... 71

STELARA ............................ 92

STIOLTO RESPIMAT ....... 164

STIVARGA .......................... 55

STOMACH RELIEF .. 108, 110

STOMACH RELIEF

ORIGINAL ..................... 110

STOOL SOFTENER .. 116, 119

STOOL SOFTENER

(DOCUSATE CAL) ....... 119

STOOL SOFTENER-

LAXATIVE .................... 119

STOOL SOFTENER-

STIMULANT LAXAT .. 119

streptomycin ......................... 29

STRESS FORMULA ......... 104

STRESS FORMULA WITH

IRON .............................. 100

STRESS FORMULA WITH

ZINC ............................... 100

STRIBILD ............................ 65

STRIVERDI RESPIMAT .. 155

SUBVENITE ........................ 39

SUBVENITE STARTER

(BLUE) KIT ..................... 39

180

SUBVENITE STARTER

(GREEN) KIT .................. 39

SUBVENITE STARTER

(ORANGE) KIT ............... 39

SUCRAID .......................... 122

sucralfate ............................ 120

SUDOGEST ....................... 164

SUDOGEST PE ................. 164

SUDOGEST SINUS AND

ALLERGY ..................... 153

sulfacetamide sodium ........... 36

sulfacetamide sodium (acne) 36

sulfacetamide-prednisolone 145

sulfadiazine........................... 36

sulfamethoxazole-trimethoprim

.......................................... 36

sulfasalazine ....................... 142

sulindac................................. 22

sumatriptan ........................... 50

sumatriptan succinate ..... 50, 51

SUPERPLEX-T .................. 104

SUPHEDRIN ..................... 164

SUPHEDRINE ................... 164

SUPRAX .............................. 33

SUTENT............................... 55

SYLATRON......................... 53

SYMBICORT..................... 164

SYMDEKO ........................ 156

SYMFI .................................. 67

SYMFI LO ........................... 65

SYMLINPEN 120 ................ 71

SYMLINPEN 60 .................. 71

SYMPAZAN ........................ 38

SYMTUZA........................... 67

SYNAREL ......................... 134

SYNDROS ........................... 44

SYNRIBO ............................ 53

SYNTHROID ..................... 132

SYSTANE (PF) .................. 146

SYSTANE (PROPYLENE

GLYCOL) ...................... 146

SYSTANE BALANCE ...... 146

SYSTANE GEL ................. 146

SYSTANE ULTRA............ 146

T TAB-A-VITE ..................... 104

TAB-A-VITE/IRON .......... 104

TABLOID ............................ 53

tacrolimus ..................... 92, 137

TACTINAL .......................... 18

TACTINAL EXTRA

STRENGTH ..................... 18

TAFINLAR .......................... 55

TAGRISSO .......................... 55

TAKE ACTION ................. 129

TALZENNA ......................... 53

tamoxifen .............................. 52

tamsulosin ........................... 123

TARCEVA ........................... 55

TARGRETIN ....................... 56

tarina fe 1/20 (28) ............... 129

TARINA FE 1-20 EQ (28) . 129

TASIGNA ............................ 55

tazarotene.............................. 92

TAZICEF.............................. 33

TAZORAC ........................... 92

taztia xt ................................. 81

TEARS NATURALE FREE

(PF) ................................. 146

TECFIDERA ........................ 89

TEFLARO ............................ 33

TEKTURNA ........................ 83

TEKTURNA HCT ............... 83

temazepam .......................... 165

TENIVAC (PF) .................. 141

tenofovir disoproxil fumarate

.......................................... 63

terazosin................................ 78

terbinafine hcl ....................... 46

terbutaline ........................... 155

terconazole............................ 46

TESSALON PERLES ........ 164

testosterone ......................... 124

testosterone cypionate ........ 124

testosterone enanthate......... 124

tetanus,diphtheria tox ped(pf)

........................................ 141

tetanus-diphtheria toxoids-td

........................................ 141

tetrabenazine ......................... 88

tetracycline ........................... 37

THALOMID ......................... 52

theophylline ........................ 156

THERA ............................... 104

THERA M PLUS (FERROUS

FUMARAT) ................... 100

THERA-M .......................... 104

thiamine hcl (vitamin b1) ... 104

THIOLA ............................. 123

thioridazine ........................... 59

thiothixene ............................ 59

tiagabine ............................... 38

TIBSOVO ............................. 55

TICE BCG .......................... 141

timolol maleate ............. 80, 147

tinidazole .............................. 31

TIVICAY .............................. 65

tizanidine .............................. 63

TOBRADEX ........................ 29

tobramycin ............................ 29

tobramycin in 0.225 % nacl 156

tobramycin sulfate ................ 29

tobramycin with nebulizer .. 156

tobramycin-dexamethasone .. 29

tolcapone ............................... 58

tolnaftate ............................... 46

tolterodine ........................... 123

topiramate ............................. 39

toremifene ............................. 52

torsemide .............................. 84

TOTAL B/C ........................ 100

TOTAL HOME INSECT

REPELLENT .................... 90

TOUJEO MAX U-300

SOLOSTAR ..................... 74

TOUJEO SOLOSTAR U-300

INSULIN .......................... 74

TOVIAZ ............................. 123

TRADJENTA ....................... 71

tramadol ................................ 23

tramadol-acetaminophen ...... 18

trandolapril ........................... 79

tranexamic acid ..................... 76

tranylcypromine .................... 41

TRAVATAN Z ................... 143

TRAVEL SICKNESS .......... 44

TRAVEL SICKNESS

(MECLIZINE) .................. 44

trazodone .............................. 41

TRECATOR ......................... 51

TRELEGY ELLIPTA ......... 164

TRELSTAR ........................ 134

TREMFYA ........................... 92

tretinoin ................................. 92

tretinoin (chemotherapy) ...... 56

tretinoin (emollient) .............. 92

TREXALL .......................... 137

TRI FEMYNOR ................. 129

triamcinolone acetonide .. 50, 89

181

triamterene-hydrochlorothiazid

.......................................... 83

TRI-BUFFERED ASPIRIN . 18

triderm .................................. 50

trientine............................... 101

TRI-ESTARYLLA ............. 129

trifluoperazine ...................... 59

trifluridine............................. 64

trihexyphenidyl..................... 57

TRIKLO ............................... 86

tri-legest fe.......................... 129

trilyte with flavor packets ... 119

trimethobenzamide ............... 44

trimethoprim ......................... 31

TRI-MILI ........................... 130

trimipramine ......................... 43

trinessa (28) ........................ 130

TRINTELLIX....................... 42

TRIPLE ANTIBIOTIC ........ 31

tri-previfem (28) ................. 130

tri-sprintec (28) ................... 130

TRIUMEQ ............................ 65

TRI-VI-SOL ....................... 100

trivora (28).......................... 130

tri-vylibra ............................ 130

TRULICITY ......................... 71

TRUMENBA ..................... 141

TRUVADA .......................... 66

TUDORZA PRESSAIR ..... 155

TULANA ........................... 131

TUMS ......................... 110, 111

TUMS E-X ................. 110, 111

TUMS EXTRA STRENGTH

SMOOTHIES ................. 111

TUMS ULTRA .................. 111

TUSNEL DIABETIC ......... 164

TUSSIN CF (PE-DM-GUAIF)

................................ 162, 164

TUSSIN CF COUGH-COLD

........................................ 164

TUSSIN DM .............. 159, 164

TUSSIN DM COUGH AND

CHEST ........................... 159

TUSSIN DM MAX .... 159, 164

TUSSIN MUCUS-CHEST

CONGESTION .............. 164

TWINRIX (PF) .................. 141

TYBOST .............................. 67

TYKERB .............................. 55

TYMLOS ........................... 143

TYPHIM VI ....................... 141

U ULORIC ............................... 47

ULTRA LUBRICANT EYE

........................................ 146

ULTRATHON...................... 92

unithroid ............................. 132

ursodiol ............................... 111

V VABOMERE........................ 33

valacyclovir .......................... 64

VALCHLOR ........................ 52

valganciclovir ....................... 63

valproic acid ......................... 38

valproic acid (as sodium salt)

.......................................... 38

valsartan................................ 79

valsartan-hydrochlorothiazide

.......................................... 83

vancomycin .......................... 31

VAQTA (PF) ...................... 141

VARIVAX (PF) ................. 141

VARIZIG............................ 141

VAXCHORA BUFFER

COMPONENT ............... 142

VAXCHORA VACCINE... 142

velivet triphasic regimen (28)

........................................ 130

VEMLIDY............................ 63

VENCLEXTA ...................... 53

VENCLEXTA STARTING

PACK ............................... 53

venlafaxine ........................... 42

VENOFER.................. 100, 101

VENTAVIS ........................ 156

VENTOLIN HFA ............... 155

verapamil .............................. 81

VERSACLOZ ...................... 62

VERZENIO .......................... 56

VICTOZA 2-PAK ................ 71

VICTOZA 3-PAK ................ 71

VIDEX 2 GRAM PEDIATRIC

.......................................... 66

VIDEX 4 GRAM PEDIATRIC

.......................................... 66

VIDEX EC ........................... 66

vienva ................................. 130

vigabatrin .............................. 38

VIGADRONE ...................... 38

VIIBRYD ............................. 42

VIMPAT ............................... 40

VIRACEPT ........................... 67

VIRAMUNE ......................... 65

VIREAD ............................... 63

VITA-BEE WITH C ........... 100

vitamin a ............................. 104

VITAMIN B-1 .................... 104

VITAMIN B-12 .................. 104

VITAMIN B-6 .................... 104

VITAMIN C ............... 104, 105

VITAMIN D2 ............. 104, 105

VITAMIN D3 ..................... 105

VITAMIN K ......................... 76

VITAMIN K1 ................. 76, 77

VITAMINS AND MINERALS

........................................ 104

VITAMINS B COMPLEX . 104

VITRAKVI ........................... 56

VIZIMPRO ........................... 53

voriconazole ................... 46, 47

VOSEVI ............................... 64

VOTRIENT .......................... 56

VRAYLAR ........................... 62

vyfemla (28) ....................... 130

vylibra ................................. 130

W warfarin ................................. 75

WOMEN'S LAXATIVE

(BISACODYL) ............... 119

X XALKORI ............................ 56

XARELTO ........................... 75

XATMEP ............................ 137

XERMELO ......................... 111

XGEVA .............................. 143

XIFAXAN .......................... 113

XIIDRA .............................. 146

XOLAIR ............................. 138

XOSPATA ............................ 56

XTANDI ............................... 52

xulane ................................. 130

XURIDEN .......................... 122

XYREM .............................. 154

Y YF-VAX (PF) ..................... 142

YONSA ................................ 52

yuvafem .............................. 125

Z zafirlukast ........................... 154

zaleplon ............................... 165

182

zarah ................................... 130

ZARXIO ............................... 76

ZEJULA ............................... 56

ZELBORAF ......................... 56

ZEMAIRA .......................... 122

ZENATANE......................... 92

ZENPEP ............................. 122

ZERIT................................... 66

zidovudine ............................ 66

zinc oxide ............................. 93

ziprasidone hcl ...................... 62

ZIRGAN ............................... 63

ZOLINZA ............................. 53

zolpidem ............................. 165

zonisamide ............................ 37

ZORTRESS ........................ 137

ZOSTAVAX (PF) .............. 142

zovia 1/35e (28) .................. 130

ZOVIRAX ............................ 64

ZTLIDO ................................ 24

ZYDELIG ............................. 53

ZYKADIA ............................ 56

ZYPREXA RELPREVV ...... 62

ZYTIGA ............................... 52

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