FORMULARIO COMPLETO...beneficios, el Formulario, la red de farmacias o los copagos/el coseguro...

2017

FORMULARIO COMPLETOCARE N’ CARE CHOICE PREMIUM (PPO) CARE N’ CARE CHOICE PLUS (PPO) CARE N’ CARE CHOICE (PPO)CARE N’ CARE CLASSIC (HMO)

(LISTA DE MEDICAMENTOS CUBIERTOS)

LEA LO SIGUIENTE: ESTE DOCUMENTO CONTIENE INFORMACIÓN ACERCA DE LOS MEDICAMENTOS QUE CUBRIMOS EN ESTE PLAN

ID de formulario 00017381, Versión 8. Este Formulario fue actualizado el 12/01/2016. Para obtener información más reciente o si tiene otras preguntas, póngase en contacto con el médico conserje de Care N’ Care Health Plan al 1-877-374-7993 (TTY 711) del 1 de octubre al 14 de febrero: de 8:00 a.m. a 8:00 p.m., hora estándar del centro, los siete días de la semana. Del 15 de febrero al 30 de septiembre: de 8:00 a.m. a 8:00 p.m., hora estándar del centro, de lunes a viernes. También puede enviar un correo electrónico a su médico conserje a [email protected] o visite www.cnchealthplan.com

Care N’ Care es una organización de Medicare Advantage que tiene un contrato con Medicare. La inscripción en Care N’ Care depende de la renovación del contrato.

Y0107_16_170_SPFinal01

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Nota para los miembros actuales: este Formulario ha cambiado con respecto al año pasado. Revise este documento para asegurarse de que aún contiene los medicamentos que toma.

Cuando esta Lista de medicamentos (Formulario) menciona “nosotros”, “nos” o “nuestro”, hace referencia a Care N’ Care Insurance Company, Inc. Cuando menciona “plan” o “nuestro plan,” hace referencia a Care N’ Care Health Plan (PPO) y Care N’ Care Health Plan (HMO).

Este documento incluye una lista de los medicamentos (Formulario) de nuestro plan, la cual está en vigencia desde el 12/01/2016. Para obtener un Formulario actualizado, póngase en contacto con nosotros. Nuestra información de contacto, junto con la fecha de la última actualización del Formulario, aparece en las páginas de la portada y la portada posterior.

Generalmente, debe concurrir a las farmacias de la red para usar el beneficio de medicamentos con receta. Los beneficios, el Formulario, la red de farmacias o los copagos/el coseguro pueden cambiar el lunes, 1 de enero de 2018 y periódicamente durante el año.

Esta información está disponible de forma gratuita en otros idiomas. Llame a su médico conserje al 1-877-374-7993.

This information is available for free in other languages. Please call our Member Services at 1-877-374-7993 for additional information.

Esta información está disponible en distintos formatos, tamaño de letra grande, cintas de audio y en español o Vietnamita. Llame a su médico conserje al número que figura arriba si necesita información sobre el plan en otro formato o idioma.

¿En qué consiste el Formulario de Care N’ Care Health Plan?Un formulario es una lista de medicamentos cubiertos seleccionados por Care N’ Care Health Plan con la colaboración de un equipo de proveedores de atención médica, que representa los tratamientos con receta que se considera que son parte necesaria de un programa de tratamiento de calidad. Normalmente, Care N’ Care Health Plan cubrirá los medicamentos incluidos en el formulario siempre que el medicamento sea necesario desde el punto de vista médico, el medicamento con receta se obtenga en una farmacia de la red de Care N’ Care Health Plan y se cumpla con otras normas del plan Para obtener más información sobre cómo obtener sus medicamentos con receta, consulte la Evidencia de cobertura.

¿Puede cambiar el Formulario (lista de medicamentos)?En general, si usted toma un medicamento de nuestro Formulario para 2017 que estaba cubierto al comienzo del año, nosotros no discontinuaremos ni reduciremos la cobertura del medicamento durante el año de cobertura 2017, excepto cuando esté disponible un nuevo medicamento genérico de menor costo o cuando se dé a conocer nueva información adversa acerca de la seguridad o eficacia del medicamento. Otros tipos de cambios en el Formulario, como por ejemplo, la eliminación de un medicamento de nuestro Formulario, no afectarán a los miembros que estén actualmente tomando el medicamento. Continuará disponible al mismo costo compartido para aquellos miembros que estén tomándolo por el resto del año de cobertura. Consideramos que es importante que tenga acceso continuo a los medicamentos del Formulario que estaban disponibles cuando eligió nuestro plan durante el resto del año de cobertura, salvo en los casos en los que usted podría ahorrar más dinero o que nosotros podríamos garantizarle su seguridad.

Si retiramos medicamentos de nuestro Formulario, o agregamos autorizaciones previas, límites de cantidad o restricciones de tratamientos escalonados en relación con un medicamento, o si pasamos un medicamento a un nivel superior de costo compartido, debemos notificar sobre el cambio a los miembros afectados por el cambio al menos 60 días antes de que entre en vigencia dicho cambio, o cuando el miembro solicite un resurtido del medicamento, momento en el cual el miembro recibirá un suministro del medicamento para 60 días. Si la Administración de Drogas y Alimentos considera que un medicamento de nuestro Formulario es inseguro o el fabricante del medicamento lo retira del mercado, eliminaremos de inmediato dicho medicamento de nuestro

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Formulario y notificaremos a los miembros que toman el medicamento en cuestión. El Formulario adjunto está vigente a partir del 12/01/2016. Para recibir información actualizada sobre los medicamentos cubiertos por Care N’ Care Health Plan, comuníquese con nosotros. Nuestra información de contacto aparece en las páginas de la portada y la portada posterior. Si el plan realiza algún cambio negativo en el formulario que no sea de mantenimiento, los miembros afectados recibirán un aviso por escrito que explique el cambio y se actualizará el formulario que aparece en nuestro sitio web.

¿Cómo utilizo el Formulario?Hay dos formas para encontrar su medicamento dentro del Formulario:

Afección médica

El Formulario empieza en la página 1. Los medicamentos de este Formulario están agrupados en categorías según el tipo de afección médica para cuyo tratamiento se los emplea. Por ejemplo, los medicamentos utilizados para tratar una afección cardíaca se enumeran dentro de la categoría “Agentes Cardiovasculares”. Si sabe para qué se utiliza su medicamento, busque el nombre de la categoría en la lista que empieza en la página 1. Luego busque su medicamento debajo del nombre de la categoría.

Listado alfabético

Si no está seguro de qué categoría debe consultar, debe buscar su medicamento en el Índice que comienza en la página 90. El Índice proporciona una lista alfabética de todos los medicamentos incluidos en este documento. En el Índice, están tanto los medicamentos de marca como los genéricos. Busque en el Índice y encuentre su medicamento. Junto a su medicamento, verá el número de página donde puede encontrar información acerca de la cobertura. Vaya a la página que figura en el Índice y encuentre el nombre de su medicamento en la primera columna de la lista.

¿Qué son los medicamentos genéricos?Care N’ Care Health Plan cubre tanto los medicamentos de marca como los genéricos. Un medicamento genérico está aprobado por la Administración de Drogas y Alimentos (Food and Drug Administration, FDA) dado que se considera que tiene el mismo ingrediente activo que el medicamento de marca. Normalmente, los medicamentos genéricos cuestan menos que los de marca.

¿Hay alguna restricción en mi cobertura?Algunos medicamentos cubiertos pueden tener requisitos o límites adicionales de cobertura. Estos requisitos y límites pueden incluir:

• Autorización previa: el plan exige que usted o su médico obtengan una autorización previa paradeterminados medicamentos. Esto significa que necesitará contar con la aprobación de Care N’ CareHealth Plan antes de obtener sus medicamentos con receta. Si no tienen la aprobación, es posible queno cubramos el medicamento.

• Límites de cantidad: para ciertos medicamentos, el plan limita la cantidad del medicamento que cubrirá.Por ejemplo, Care N’ Care Health Plan provee 30 comprimidos por receta de Januvia, comprimidos de100 mg. Esto puede ser complementario a un suministro estándar para un mes o tres meses.

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• Tratamiento escalonado: En algunos casos, Care N’ Care Health Plan requiere que usted primeropruebe ciertos medicamentos para tratar su enfermedad antes de que cubramos otro medicamento paraesa enfermedad. Por ejemplo, si el medicamento A y el medicamento B tratan su afección médica, esposible que el plan no cubra el medicamento B a menos que usted pruebe primero el medicamento A.Si el medicamento A no funciona para usted, entonces cubriremos el medicamento B.

Puede averiguar si su medicamento tiene requisitos adicionales o límites consultando el Formulario que empieza en la página 1. También puede obtener más información sobre las restricciones que se aplican a medicamentos cubiertos específicos en nuestro sitio web. Hemos publicado documentos en Internet que explican nuestra autorización previa y las restricciones de tratamientos escalonados. También puede pedirnos que le enviemos una copia. Nuestra información de contacto, junto con la fecha de la última actualización del Formulario, aparece en las páginas de la portada y la portada posterior.

Puede pedirle a Care N’ Care Health Plan que haga una excepción a estas restricciones o límites o puede solicitarle una lista de otros medicamentos similares que puedan tratar su afección médica. Para obtener información sobre cómo solicitar una excepción, consulte la sección titulada “¿Cómo puedo solicitar que se haga una excepción al formulario de Care N’ Care Health Plan?” en la página iii.

¿Qué pasa si mi medicamento no está en el Formulario?Si el medicamento que toma no está incluido en este Formulario (lista de medicamentos cubiertos), primero debe ponerse en contacto con el Departamento de Servicios para los miembros y preguntar si su medicamento está cubierto.

Si resulta que Care N’ Care Health Plan no cubre el medicamento que toma, tiene dos alternativas:

• Puede pedir al Departamento de Servicios para los miembros una lista de medicamentos similaresque estén cubiertos por el plan. Cuando reciba la lista, muéstresela a su médico y pídale que le receteun medicamento similar que esté cubierto por Care N’ Care Health Plan.

• Puede solicitarnos que hagamos una excepción y cubramos el medicamento. Consulte más abajopara obtener información sobre cómo solicitar una excepción.

¿Cómo puedo solicitar que se haga una excepción al Formulario de Care N’ Care Health Plan?Puede solicitarle a Care N’ Care Health Plan que haga una excepción a nuestras normas de cobertura. Hay varios tipos de excepciones que puede solicitarnos.

Puede pedirnos que cubramos un medicamento, incluso si no está en nuestro Formulario. Si se aprueba, este medicamento estará cubierto a un nivel de costo compartido predeterminado, y usted no podrá pedirnos que proporcionemos el medicamento a un nivel de costo compartido menor.

• Puede pedirnos que cubramos un medicamento del formulario a un nivel de costo compartido menorsi este medicamento no está incluido en el nivel de medicamentos especializados. Si se aprueba, estoreduciría el monto que usted debe pagar por su medicamento.

• Puede pedirnos que no apliquemos restricciones o límites de cobertura para su medicamento. Porejemplo, para ciertos medicamentos, el plan limita la cantidad del medicamento que cubriremos.Si su medicamento tiene un límite de cantidad, puede pedirnos que hagamos una excepción allímite y cubramos una cantidad mayor.

Por lo general, Care N’ Care Health Plan solo aprobará su pedido de excepción si los demás medicamentos incluidos en el formulario del plan, el medicamento de menor costo compartido o las restricciones de uso adicionales no fueran tan efectivos para tratar su enfermedad o pudieran causarle efectos médicos adversos.

Debe ponerse en contacto con nosotros para solicitarnos una decisión inicial de cobertura respecto de una excepción al Formulario, al nivel o a la restricción de uso. Cuando solicita una excepción al Formulario, al nivel o a la restricción de uso, debe presentar una declaración de su médico o de la persona autorizada a dar recetas que respalde su solicitud. Por lo general, debemos tomar una decisión dentro de las 72 horas a partir de la fecha de haber recibido la declaración que respalda su solicitud por parte de la persona autorizada a dar recetas. Puede solicitar una excepción acelerada (rápida) si usted o su médico consideran que esperar 72 horas para la toma de la decisión podría perjudicar gravemente su salud. Si se le concede el trámite rápido de la excepción, debemos comunicarle nuestra decisión a más tardar dentro de las 24 horas después de haber recibido la declaración de respaldo de su médico o de otra persona autorizada a dar recetas.

¿Qué debo hacer antes de hablar con mi médico sobre el cambio de los medicamentos que tomo o la solicitud de una excepción?Como miembro nuevo o permanente de nuestro plan, es posible que esté tomando medicamentos que no están incluidos en el Formulario. También es posible que esté tomando un medicamento incluido en el Formulario pero su capacidad de conseguirlo sea limitada. Por ejemplo, puede necesitar nuestra autorización previa antes de poder obtener su medicamento con receta. Debe consultar con su médico para decidir si debe cambiar su medicamento por uno apropiado que nosotros cubramos o solicitar una excepción al Formulario para que le cubramos el medicamento que toma. Mientras evalúa con su médico el procedimiento adecuado a seguir en su caso, podemos cubrir su medicamento en ciertos casos durante los primeros 90 días en que usted sea miembro de nuestro plan.

Para cada uno de los medicamentos que no están incluidos en el Formulario o si su capacidad para conseguir los medicamentos es limitada, cubriremos un suministro temporal para 30 días (a menos que tenga una receta para menos días) cuando acuda a una farmacia de la red. Después del primer suministro para 30 días, no seguiremos pagando estos medicamentos, incluso si ha sido miembro del plan durante menos de 90 días.

Si reside en un centro de atención a largo plazo, le permitiremos resurtir su receta hasta que le hayamos provisto un suministro de transición de 91 a 98 días, de manera consistente con incremento de provisión (a menos que tenga una receta para menos días). Cubriremos más de un resurtido de estos medicamentos durante los primeros 90 días en que usted sea miembro del plan. Si necesita un medicamento que no está en el Formulario o si su capacidad para conseguir los medicamentos es limitada, pero ya pasaron los primeros 90 días de membresía en nuestro plan, cubriremos un suministro de emergencia del medicamento para 31 días (a menos que tenga una receta para menos días) mientras solicita la excepción al Formulario.

• Transición entre los años del plan: Debido a que la lista de medicamentos cubiertos que apareceen el formulario está sujeta a cambios de un año al otro, tenemos una política de transición para losmiembros actuales de Care N’ Care Health Plan que toman medicamentos que no estarán cubiertosen el nuevo año del plan o medicamentos que tendrán una tratamiento escalonado, autorización

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previa, o restricción en el límite de cantidad en el nuevo año del plan. Durante los primeros 90 días del nuevo año del plan, Care N’ Care Health Plan cubrirá un suministro temporario para 30 días (a menos que presente una receta para menos de 30 días, en cuyo caso permitiremos obtener múltiples surtidos hasta un total de 30 días) del medicamento con receta no incluido en el formulario (o medicamentos que tienen un tratamiento escalonado, requieren autorización previa o tienen restricción en el límite de cantidad) una vez que haya obtenido la receta de los medicamentos surtidos dentro los últimos 120 días desde la fecha en que intentó obtener un surtido. Además, los miembros a los que se les otorgó una excepción en el año del plan anterior y que continúan en el mismo plan para el nuevo año del plan se les permitirá un suministro temporario de 30 días (a menos que presente una receta para menos de 30 días, en cuyo caso permitiremos obtener múltiples surtidos hasta durante un total de 30 días).

• Transición de emergencia y cambios en el nivel de atención: Es posible que haya un cambio en elentorno de tratamiento a causa del nivel de atención que se necesita. Estas transiciones incluyen a:

Si recibe el alta del hospital o un centro de enfermería especializada y se trasladaa un ámbito domiciliario

Si ingresa a un hospital o centro de atención de enfermería especializada desdeun ámbito domiciliario

Si se traslada desde un centro de enfermería especializada a otro y este nuevocentro recibe los suministros de una farmacia diferente

Si finaliza su estadía de la Parte A de Medicare en un centro de atención deenfermería especializada (en donde los pagos incluyen todos los gastosde farmacia) y necesita utilizar ahora los beneficios de su plan de la Parte D

Si abandona el estado de hospicio y vuelven a la cobertura de la Parte A y Bde Medicare

Si se encuentra fuera del período de transición y experimenta un cambio en el nivel de atención, Care N’ Care Health Plan le permitirá obtener resurtido de los medicamentos del formulario durante 30/31 días (30 días en una farmacia minorista y 31 días en un entorno de atención a largo plazo [LTC]) y surtido de transición durante 30/31 días de emergencia (30 días en una farmacia minorista y 31 días en un entorno de LTC) para los medicamentos no incluidos en el formulario pero que requieren autorización previa o tratamiento escalonado). Esto ocurrirá según cada caso particular una vez que se haya presentado una excepción o apelación pero no se haya completado al finalizar el período de transición. Todos los surtidos de transición para los nuevos miembros, ya sean en farmacias minoristas o en entornos LTC, se tramitarán de manera automática. Si solicita un surtido fuera de los primeros 90 días con Care N’ Care Health Plan, usted o su farmacéutico deberá comunicarse con nosotros al 1-855-791-5302, los 7 días de la semana, 24 horas al día (los usuarios de TTY/TDD deben llamar al 711) así le implementamos nuestra política de transición. Si se inscribe en nuestro plan mientras vivía en su hogar y luego se convierte en residente de un centro LTC, comuníquese con nosotros al 1-855-791-5302, los 7 días de la semana, 24 horas al día (los usuarios de TTY/TDD deben llamar al 711) para informarnos que ahora es residente de un centro LTC. Podemos implementar una política de transición de LTC para usted. Esta política no aplica a licencias de corto plazo (es decir, feriados o vacaciones) de un LTC o un centro hospitalario.

Le enviaremos un aviso por escrito a través del correo de primera clase de E.E. U.U. dentro de los tres días hábiles a partir del momento en el que recibimos la transacción del surtido de transición de la farmacia. Esta incluirá una explicación del carácter temporal del surtido con receta, las instrucciones para identificar una alternativa terapéutica adecuada que se encuentre en nuestro formulario, una explicación de su derecho a solicitar una excepción al formulario y el procedimiento para solicitar la excepción al formulario.

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Para obtener más informaciónPara obtener información más detallada sobre la cobertura para medicamentos con receta de Care N’ Care Health Plan, consulte la Evidencia de cobertura y la demás documentación del plan.

Si tiene alguna pregunta sobre Care N’ Care Health Plan, póngase en contacto con nosotros. Nuestra información de contacto, junto con la fecha de la última actualización del Formulario, aparece en las páginas de la portada y la portada posterior.

Si tiene preguntas generales sobre su cobertura para medicamentos con receta de Medicare, llame a Medicare al 1-800-MEDICARE (1-800-633-4227), durante las 24 horas, los 7 días de la semana. Los usuarios de TTY deben llamar al 1-877-486-2048. O, visite http://www.medicare.gov.

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Formulario de Care N’ Care Health PlanEl formulario que se incluye más abajo brinda información sobre los medicamentos que cubre Care N’ Care Health Plan. Si tiene alguna dificultad para encontrar en la lista el medicamento que toma, consulte el Índice que comienza en la página 90.

La primera columna de la tabla menciona el nombre del medicamento. Los medicamentos de marca están en letra mayúscula (p. ej., JANUVIA), y los medicamentos genéricos están en letra minúscula y cursiva (p. ej., atorvastatin).

La información incluida en la columna de Requisitos/Límites indica si Care N’ Care Health Plan tiene algún requisito especial para la cobertura del medicamento. Todos los medicamentos de la Lista de medicamentos del plan se encuentran en uno de los cinco niveles de costo compartido. En la segunda columna de esta tabla, se indica el nivel de cada medicamento.

• Nivel 1: medicamentos genéricos preferidos: Menor costo, medicamentos genéricoso de marca comúnmente utilizados

• Nivel 2: medicamentos genéricos: Medicamentos genéricos o de marca que el plan ofrecea un costo mayor para usted que los medicamentos genéricos preferidos del nivel 1.

• Nivel 3: medicamentos de marca preferidos: Varios medicamentos de marca conocidosy algunos medicamentos genéricos de alto costo

• Nivel 4: medicamentos de marca no preferidos: Medicamentos genéricos no preferidosy medicamentos de marca no preferidos

• Nivel 5: medicamentos especializados: Medicamentos únicos o de alto costo

• Tier 4 – Non-Preferred Drugs $90 copay $180 copay• Tier 5 – Specialty Drugs 33% coinsurance 33% coinsurance

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Durante la Etapa de cobertura inicial, el plan paga la parte que le corresponde de los costos de susmedicamentos recetados cubiertos y usted paga la suya (el monto de su copago o coseguro). Su parte del costo variará según el medicamento y el lugar donde surta su receta. A continuación, encontrará un resumen delmonto de su copago según el nivel del medicamento.

Pedido por correo ominorista estándardentro de la red(hasta un suministropara 30 días)

Pedido por correo ominorista estándardentro de la red(hasta un suministro para 90días)

Care N’ Care Choice Premium (PPO) • Nivel 1 - Medicamentos genéricos

preferidos• Nivel 2 - Medicamentos genéricos• Nivel 3 - Medicamentos de marca

preferidos• Nivel 4 - Medicamentos de marca no• preferidos• Nivel 5 - Medicamentos de especialidad

Copago de $0

Copago de $10

Copago de $40

Copago de $85

Coseguro del 33%

Copago de $0

Copago de $20

Copago de $80

Copago de $170

Coseguro del 33%

Care N’ Care Choice Plus (PPO) • Nivel 1 - Medicamentos genéricos



Copago de $0

Copago de $12

Copago de $45

Copago de $90

Coseguro del 33%

Copago de $0

Copago de $24

Copago de $90

Copago de $180

Coseguro del 33%

Care N’ Care Choice (PPO) • Nivel 1 - Medicamentos genéricos



Copago de $4

Copago de $15

Copago de $45

Copago de $100

Coseguro del 33%

Copago de $8

Copago de $30

Copago de $90

Copago de $200

Coseguro del 33%

Care N' Care Classic (HMO) • Nivel 1 - Medicamentos genéricos



Copago de $0

Copago de $8

Copago de $40

Copago de $90

Coseguro del 33%

Copago de $0

Copago de $16

Copago de $80

Copago de $180

Coseguro del 33%

Para conocer más detalles sobre el beneficio de medicamentos recetados, consulte su Evidencia de cobertura.

You can find information on what the symbols and abbreviations on this table mean by going to page 1 of the

introduction. Formulary ID: 17381, Ver. 6 Last Updated 12/01/2016 Effective Date: 01/01/2017

1

LEGEND

1: Tier 1 - Preferred Generics

2: Tier 2 - Generics

3: Tier 3 - Preferred Brands

4: Tier 4 - Non-Preferred Drugs

5: Tier 5 - Specialty

BD: Part B vs Part D determination. This prescription drug may be covered under Medicare Part B or D

depending upon the circumstances.

LA: Limited Access. This prescription drug is limited to certain pharmacies.

NMO: Not available through Mail Order.

PA: Prior Authorization. You (or your physician) are required to get prior authorization before you fill your

prescription for this drug. Without prior approval, we may not cover this drug.

QL: Quantity Limit. There is a limit on the amount of this drug that is covered per prescription, or within a

specific time frame.

ST: Step Therapy. In some cases, you may be required to first try certain drugs to treat your medical condition

before we will cover another drug for that condition.



2

Drug Drug Tier Requirements/Limits

ANALGESICS

OPIOID ANALGESICS, LONG-ACTING

EMBEDA ORAL CAPSULE EXTENDED RELEASE* 100-4

MG 5 NMO; QL (60 EA per 30 days)

EMBEDA ORAL CAPSULE EXTENDED RELEASE* 20-

0.8 MG, 30-1.2 MG, 50-2 MG, 60-2.4 MG, 80-3.2 MG 4 NMO; QL (60 EA per 30 days)

FENTANYL TRANSDERMAL PATCH 72 HR 100

MCG/HR, 12 MCG/HR, 25 MCG/HR, 37.5 MCG/HR, 50

MCG/HR, 62.5 MCG/HR, 75 MCG/HR, 87.5 MCG/HR

3 NMO; QL (10 EA per 30 days)

hydromorphone hcl er oral 12 mg, 8 mg 4 NMO; QL (60 EA per 30 days)

hydromorphone hcl er oral 16 mg, 32 mg 5 NMO; QL (60 EA per 30 days)

HYSINGLA ER ORAL 100 MG, 120 MG 5 PA; NMO; QL (60 EA per 30

days)

HYSINGLA ER ORAL 20 MG, 30 MG, 40 MG, 60 MG, 80

MG 4

PA; NMO; QL (60 EA per 30

days)

LEVORPHANOL TARTRATE ORAL TABLET 2 MG 3 NMO; QL (240 EA per 30 days)

METHADONE HCL INJECTION SOLUTION 10 MG/ML 4 NMO; QL (360 ML per 30 days)

METHADONE HCL ORAL SOLUTION 10 MG/5ML 3 NMO; QL (1800 ML per 30 days)

METHADONE HCL ORAL SOLUTION 5 MG/5ML 3 NMO; QL (3600 ML per 30 days)

METHADONE HCL ORAL TABLET 10 MG, 5 MG 3 NMO; QL (240 EA per 30 days)

MORPHINE SULFATE ER BEADS ORAL CAPSULE

EXTENDED RELEASE 24 HOUR 120 MG, 30 MG, 45 MG,

60 MG, 75 MG, 90 MG


MORPHINE SULFATE ER ORAL CAPSULE EXTENDED

RELEASE 24 HOUR 10 MG, 100 MG, 20 MG, 30 MG, 50

MG, 60 MG, 80 MG


MORPHINE SULFATE ER ORAL TABLET

EXTENDEDRELEASE* 100 MG, 200 MG 3 NMO; QL (90 EA per 30 days)

morphine sulfate er oral tablet extendedrelease* 15 mg, 30

mg, 60 mg 2 NMO; QL (90 EA per 30 days)

OPANA ER ORAL 10 MG, 15 MG, 20 MG, 30 MG, 40 MG,

5 MG, 7.5 MG 3 NMO; QL (60 EA per 30 days)

OPANA ORAL TABLET 10 MG, 5 MG 3 NMO; QL (180 EA per 30 days)

OXYCODONE HCL ER ORAL 10 MG, 20 MG 3 NMO; QL (60 EA per 30 days)

OXYCODONE HCL ER ORAL 40 MG, 80 MG 4 NMO; QL (60 EA per 30 days)

OXYCONTIN ORAL 15 MG, 30 MG, 60 MG 4 NMO; QL (60 EA per 30 days)

Care N' Care Health Plan (List of Covered Drugs)



3


oxymorphone hcl er oral tablet extended release 12 hr* 10 mg,

15 mg, 20 mg, 30 mg, 40 mg, 5 mg, 7.5 mg 4 NMO; QL (60 EA per 30 days)

SUBSYS SUBLINGUAL LIQUID† 100 MCG, 200 MCG,

400 MCG 5


days)

SUBSYS SUBLINGUAL LIQUID† 600 MCG, 800 MCG 5 PA; NMO; QL (240 EA per 30

days)

tramadol hcl er (biphasic) oral tablet extended release 24 hr*

300 mg 2 NMO; QL (30 EA per 30 days)

tramadol hcl er oral tablet extended release 24 hr* 100 mg,

200 mg 2 NMO; QL (30 EA per 30 days)

OPIOID ANALGESICS, SHORT-ACTING

ABSTRAL SUBLINGUAL TABLET SUBLINGUAL 100

MCG 4


days)

ABSTRAL SUBLINGUAL TABLET SUBLINGUAL 200

MCG, 300 MCG, 400 MCG, 600 MCG, 800 MCG 5


days)

acetaminophen-codeine #2 oral tablet 300-15 mg 2 NMO; QL (180 EA per 30 days)

acetaminophen-codeine #3 oral tablet 300-30 mg 2 NMO; QL (180 EA per 30 days)

ACETAMINOPHEN-CODEINE #4 ORAL TABLET 300-60


acetaminophen-codeine oral solution 120-12 mg/5ml 2 NMO; QL (5000 ML per 30 days)

ASCOMP-CODEINE ORAL CAPSULE 50-325-40-30 MG 3 PA; NMO; QL (180 EA per 30

days)

BUTALBITAL-APAP-CAFF-COD ORAL CAPSULE 50-

325-40-30 MG 3


days)

BUTALBITAL-APAP-CAFFEINE ORAL TABLET 50-325-

40 MG 3


days)

BUTALBITAL-ASA-CAFF-CODEINE ORAL CAPSULE

50-325-40-30 MG 3


days)

BUTALBITAL-ASPIRIN-CAFFEINE ORAL CAPSULE 50-

325-40 MG 3


days)

butorphanol tartrate injection solution 1 mg/ml 2 NMO; QL (960 ML per 30 days)

butorphanol tartrate injection solution 2 mg/ml 2 NMO; QL (480 ML per 30 days)

butorphanol tartrate nasal solution 10 mg/ml 2 NMO; QL (10 ML per 30 days)

capital/codeine oral suspension 120-12 mg/5ml 2 NMO; QL (5010 ML per 30 days)

codeine sulfate oral tablet 15 mg, 30 mg 2 NMO; QL (180 EA per 30 days)

CODEINE SULFATE ORAL TABLET 60 MG 3 NMO; QL (180 EA per 30 days)

duramorph injection solution 0.5 mg/ml 2 BD; NMO; QL (7200 ML per 30

days)



4


duramorph injection solution 1 mg/ml 2 BD; NMO; QL (3600 ML per 30

days)

fentanyl citrate buccal lollipop 1200 mcg, 1600 mcg, 400 mcg,

600 mcg, 800 mcg 5


days)

fentanyl citrate buccal lollipop 200 mcg 4 PA; NMO; QL (120 EA per 30

days)

FENTORA BUCCAL TABLET 100 MCG, 200 MCG, 400

MCG, 600 MCG, 800 MCG 5


days)

hydrocodone-acetaminophen oral solution 7.5-325 mg/15ml 2 NMO; QL (5500 ML per 30 days)

hydrocodone-acetaminophen oral tablet 10-325 mg, 2.5-325

mg, 5-325 mg, 7.5-325 mg 2 NMO; QL (360 EA per 30 days)

hydrocodone-ibuprofen oral tablet 5-200 mg, 7.5-200 mg 2 NMO; QL (150 EA per 30 days)

hydromorphone hcl oral liquid† 1 mg/ml 4 NMO; QL (1920 ML per 30 days)

hydromorphone hcl oral tablet 2 mg, 4 mg 2 NMO; QL (360 EA per 30 days)

HYDROMORPHONE HCL ORAL TABLET 8 MG 3 NMO; QL (240 EA per 30 days)

LAZANDA NASAL SOLUTION 100 MCG/ACT, 300

MCG/ACT, 400 MCG/ACT 5


days)

morphine sulfate (concentrate) oral solution 100 mg/5ml 2 NMO; QL (600 ML per 30 days)

morphine sulfate oral solution 10 mg/5ml 2 NMO; QL (3600 ML per 30 days)

morphine sulfate oral solution 20 mg/5ml 2 NMO; QL (2700 ML per 30 days)

morphine sulfate oral tablet 15 mg, 30 mg 2 NMO; QL (180 EA per 30 days)

oxycodone hcl oral concentrate 100 mg/5ml 2 NMO; QL (360 ML per 30 days)

oxycodone hcl oral tablet 10 mg, 15 mg, 5 mg 2 NMO; QL (180 EA per 30 days)

OXYCODONE HCL ORAL TABLET 20 MG, 30 MG 3 NMO; QL (180 EA per 30 days)

OXYCODONE-ACETAMINOPHEN ORAL TABLET 10-

325 MG 3 NMO; QL (180 EA per 30 days)

oxycodone-acetaminophen oral tablet 5-325 mg 2 NMO; QL (360 EA per 30 days)

OXYCODONE-ACETAMINOPHEN ORAL TABLET 7.5-

325 MG 3 NMO; QL (240 EA per 30 days)

oxycodone-aspirin oral tablet 4.8355-325 mg 2 NMO; QL (360 EA per 30 days)

oxycodone-ibuprofen oral tablet 5-400 mg 2 NMO; QL (240 EA per 30 days)

OXYMORPHONE HCL ORAL TABLET 10 MG, 5 MG 3 NMO; QL (180 EA per 30 days)

SYNALGOS-DC ORAL CAPSULE 356.4-30-16 MG 4 NMO; QL (330 EA per 30 days)

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

tramadol-acetaminophen oral tablet 37.5-325 mg 1 NMO; QL (360 EA per 30 days)

ANESTHETICS

LOCAL ANESTHETICS



5


lidocaine hcl (pf) injection solution 0.5 % 1 NMO

lidocaine hcl injection solution 2 % 1 NMO

lidocaine-prilocaine external cream 2.5-2.5 % 2 NMO

ANTI-ADDICTION/SUBSTANCE ABUSE

TREATMENT AGENTS

ALCOHOL DETERRENTS/ANTI-CRAVING

acamprosate calcium oral tablet delayed release 333 mg 2

disulfiram oral tablet 250 mg 2

disulfiram oral tablet 500 mg 1

naltrexone hcl oral tablet 50 mg 1 NMO

VIVITROL INTRAMUSCULAR* SUSPENSION

RECONSTITUTED 380 MG 5 NMO

OPIOID ANTAGONISTS

BUPRENORPHINE HCL SUBLINGUAL TABLET

SUBLINGUAL 2 MG 3


days)

BUPRENORPHINE HCL SUBLINGUAL TABLET

SUBLINGUAL 8 MG 3


days)

BUPRENORPHINE HCL-NALOXONE HCL SUBLINGUAL

TABLET SUBLINGUAL 2-0.5 MG 3


days)

BUPRENORPHINE HCL-NALOXONE HCL SUBLINGUAL

TABLET SUBLINGUAL 8-2 MG 3


days)

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

SUBOXONE SUBLINGUAL FILM 12-3 MG, 2-0.5 MG, 4-1

MG, 8-2 MG 4 PA; NMO

SMOKING CESSATION AGENTS

buproban oral tablet extended release 12 hr* 150 mg 2 NMO

bupropion hcl er (smoking det) oral tablet extended release 12

hr* 150 mg 1 NMO

bupropion hcl er (xl) oral tablet extended release 24 hr* 150

mg 2

CHANTIX CONTINUING MONTH PAK ORAL TABLET 1

MG 3 NMO

CHANTIX ORAL TABLET 0.5 MG, 1 MG 3 NMO

CHANTIX STARTING MONTH PAK ORAL TABLET 0.5

MG X 11 & 1 MG X 42 3 NMO

NICOTROL INHALATION INHALER 10 MG 4 NMO

ANTIBACTERIALS



6


AMINOGLYCOSIDES

AMIKACIN SULFATE INJECTION SOLUTION 500

MG/2ML 3 NMO

gentamicin in saline intravenous* solution 0.8-0.9 mg/ml-%,

1-0.9 mg/ml-%, 1.2-0.9 mg/ml-%, 1.6-0.9 mg/ml-%2 NMO

gentamicin sulfate injection solution 40 mg/ml 2 NMO

gentamicin sulfate intravenous* solution 10 mg/ml 2 NMO

neomycin sulfate oral tablet 500 mg 1 NMO

PAROMOMYCIN SULFATE ORAL CAPSULE 250 MG 3 NMO

STREPTOMYCIN SULFATE INTRAMUSCULAR*

SOLUTION RECONSTITUTED 1 GM 3 NMO

TOBI PODHALER INHALATION CAPSULE 28 MG 5 NMO

tobramycin inhalation nebulization solution 300 mg/5ml 2 BD; NMO

tobramycin sulfate injection solution 10 mg/ml, 80 mg/2ml 2 NMO

ANTIBACTERIALS, OTHER

chloramphenicol sod succinate intravenous* solution

reconstituted 1 gm 2 NMO

clindamycin hcl oral capsule 150 mg, 300 mg, 75 mg 1 NMO

clindamycin palmitate hcl oral solution reconstituted 75

mg/5ml 2 NMO

CLINDAMYCIN PHOSPHATE IN D5W INTRAVENOUS*

SOLUTION 300 MG/50ML, 600 MG/50ML, 900 MG/50ML 3 NMO

CLINDAMYCIN PHOSPHATE INJECTION SOLUTION

300 MG/2ML, 600 MG/4ML, 900 MG/6ML 3 NMO

colistimethate sodium injection solution reconstituted 150 mg 4 BD; NMO

CUBICIN INTRAVENOUS* SOLUTION


lincomycin hcl injection solution 300 mg/ml 2 BD; NMO

linezolid intravenous* solution 600 mg/300ml 5 NMO

linezolid oral suspension reconstituted 100 mg/5ml 4 NMO

linezolid oral tablet 600 mg 5 NMO; QL (60 EA per 30 days)

METHENAMINE HIPPURATE ORAL TABLET 1 GM 3 NMO

metronidazole in nacl intravenous* solution 500-0.79

mg/100ml-% 2 NMO

metronidazole oral capsule 375 mg 2 NMO

metronidazole oral tablet 250 mg, 500 mg 2 NMO

NITROFURANTOIN MACROCRYSTAL ORAL CAPSULE

100 MG 3 PA; NMO



7


nitrofurantoin macrocrystal oral capsule 25 mg, 50 mg 2 PA; NMO

nitrofurantoin monohyd macro oral capsule 100 mg 2 PA; NMO

nitrofurantoin oral suspension 25 mg/5ml 2 PA; NMO

polymyxin b sulfate injection solution reconstituted 500000

unit 2 NMO

SYNERCID INTRAVENOUS* SOLUTION

RECONSTITUTED 150-350 MG 5 BD; NMO

TINIDAZOLE ORAL TABLET 250 MG, 500 MG 3 NMO

trimethoprim oral tablet 100 mg 1 NMO

TYGACIL INTRAVENOUS* SOLUTION

RECONSTITUTED 50 MG 4 BD; NMO

VANCOMYCIN HCL INTRAVENOUS* SOLUTION

RECONSTITUTED 10 GM, 1000 MG, 500 MG 3 NMO

vancomycin hcl oral capsule 125 mg, 250 mg 4 NMO

XIFAXAN ORAL TABLET 200 MG 4 PA; NMO

XIFAXAN ORAL TABLET 550 MG 5 PA; NMO

BETA-LACTAM, CEPHALOSPORINS

CEFACLOR ER ORAL TABLET EXTENDED RELEASE 12

HR* 500 MG 3 NMO

cefaclor oral capsule 250 mg, 500 mg 2 NMO

cefadroxil oral capsule 500 mg 1 NMO

cefadroxil oral suspension reconstituted 250 mg/5ml, 500

mg/5ml 2 NMO

cefadroxil oral tablet 1 gm 2 NMO

CEFAZOLIN SODIUM INJECTION SOLUTION

RECONSTITUTED 1 GM, 10 GM, 500 MG 3 NMO

cefdinir oral capsule 300 mg 2 NMO

cefdinir oral suspension reconstituted 125 mg/5ml, 250

mg/5ml 2 NMO

cefepime hcl injection solution reconstituted 1 gm, 2 gm 4 NMO

CEFIXIME ORAL SUSPENSION RECONSTITUTED 100

MG/5ML, 200 MG/5ML 3 NMO

cefotaxime sodium injection solution reconstituted 2 gm, 500

mg 2 NMO

cefotetan disodium injection solution reconstituted 1 gm, 2 gm 4 NMO

cefoxitin sodium injection solution reconstituted 10 gm 4 NMO

cefoxitin sodium intravenous* solution reconstituted 1 gm, 2

gm 4 NMO



8


cefpodoxime proxetil oral suspension reconstituted 100

mg/5ml, 50 mg/5ml 4 NMO

cefpodoxime proxetil oral tablet 100 mg, 200 mg 4 NMO

cefprozil oral suspension reconstituted 125 mg/5ml, 250

mg/5ml 2 NMO

cefprozil oral tablet 250 mg, 500 mg 2 NMO

CEFTAZIDIME INJECTION SOLUTION

RECONSTITUTED 1 GM, 2 GM, 6 GM 3 NMO

CEFTIN ORAL SUSPENSION RECONSTITUTED 125

MG/5ML, 250 MG/5ML 4 NMO

CEFTRIAXONE SODIUM INJECTION SOLUTION

RECONSTITUTED 250 MG, 500 MG 3 NMO

CEFTRIAXONE SODIUM INTRAVENOUS* SOLUTION

RECONSTITUTED 1 GM, 10 GM, 2 GM 3 NMO

cefuroxime axetil oral tablet 250 mg, 500 mg 2 NMO

CEFUROXIME SODIUM INJECTION SOLUTION

RECONSTITUTED 1.5 GM, 7.5 GM, 750 MG 3 NMO

cephalexin oral capsule 250 mg, 500 mg 1 NMO

cephalexin oral suspension reconstituted 125 mg/5ml, 250

mg/5ml 2 NMO

cephalexin oral tablet 250 mg 1 NMO

CLAFORAN INTRAVENOUS* SOLUTION

RECONSTITUTED 1 GM 4 NMO

FORTAZ INTRAVENOUS* SOLUTION


SUPRAX ORAL CAPSULE 400 MG 3 NMO

SUPRAX ORAL SUSPENSION RECONSTITUTED 500

MG/5ML 3 NMO

SUPRAX ORAL TABLET CHEWABLE 100 MG, 200 MG 3 NMO

TAZICEF INJECTION SOLUTION RECONSTITUTED 2

GM 3 BD; NMO

TEFLARO INTRAVENOUS* SOLUTION


ZERBAXA INTRAVENOUS* SOLUTION

RECONSTITUTED 1.5 (1-0.5) GM 4 NMO

BETA-LACTAM, OTHER

AZACTAM IN DEXTROSE INTRAVENOUS* SOLUTION

2 GM 4 NMO

aztreonam injection solution reconstituted 1 gm 4 NMO



9


CAYSTON INHALATION SOLUTION RECONSTITUTED

75 MG 5 PA; NMO

DORIBAX INTRAVENOUS* SOLUTION


IMIPENEM-CILASTATIN INTRAVENOUS* SOLUTION


INVANZ INJECTION SOLUTION RECONSTITUTED 1

GM 4 NMO

meropenem intravenous* solution reconstituted 500 mg 4 NMO

BETA-LACTAM, PENICILLINS

amoxicillin oral capsule 250 mg, 500 mg 1 NMO

amoxicillin oral suspension reconstituted 125 mg/5ml, 200

mg/5ml, 250 mg/5ml, 400 mg/5ml 1 NMO

amoxicillin oral tablet 500 mg, 875 mg 1 NMO

amoxicillin oral tablet chewable 125 mg, 250 mg 1 NMO

AMOXICILLIN-POT CLAVULANATE ER ORAL TABLET

EXTENDED RELEASE 12 HR* 1000-62.5 MG 3 NMO

amoxicillin-pot clavulanate oral suspension reconstituted 200-

28.5 mg/5ml, 250-62.5 mg/5ml, 400-57 mg/5ml, 600-42.9

mg/5ml

2 NMO

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

mg, 875-125 mg 2 NMO

amoxicillin-pot clavulanate oral tablet chewable 200-28.5 mg,

400-57 mg 2 NMO

ampicillin oral capsule 250 mg 1 NMO

ampicillin oral capsule 500 mg 2 NMO

ampicillin oral suspension reconstituted 125 mg/5ml, 250

mg/5ml 2 NMO

ampicillin sodium injection solution reconstituted 1 gm, 125

mg 2 NMO

ampicillin sodium intravenous* solution reconstituted 10 gm 2 NMO

AMPICILLIN-SULBACTAM SODIUM INJECTION

SOLUTION RECONSTITUTED 3 (2-1) GM 3 NMO

AMPICILLIN-SULBACTAM SODIUM INTRAVENOUS*

SOLUTION RECONSTITUTED 1.5 (1-0.5) GM, 15 (10-5)

GM

3 NMO

BACTOCILL IN DEXTROSE INTRAVENOUS*

SOLUTION 1 GM/50ML, 2 GM/50ML 4 NMO

BICILLIN C-R 900/300 INTRAMUSCULAR*

SUSPENSION 900000-300000 UNIT/2ML 3 NMO



10


BICILLIN C-R INTRAMUSCULAR* SUSPENSION

1200000 UNIT/2ML 3 NMO

BICILLIN L-A INTRAMUSCULAR* SUSPENSION

1200000 UNIT/2ML, 2400000 UNIT/4ML, 600000 UNIT/ML 3 NMO

dicloxacillin sodium oral capsule 250 mg 1 NMO

dicloxacillin sodium oral capsule 500 mg 2 NMO

NAFCILLIN SODIUM INJECTION SOLUTION


nafcillin sodium injection solution reconstituted 10 gm 4 NMO

oxacillin sodium injection solution reconstituted 10 gm, 2 gm 4 NMO

PENICILLIN G POT IN DEXTROSE INTRAVENOUS*

SOLUTION 40000 UNIT/ML, 60000 UNIT/ML 3 NMO

PENICILLIN G POTASSIUM INJECTION SOLUTION

RECONSTITUTED 5000000 UNIT 3 NMO

PENICILLIN G PROCAINE INTRAMUSCULAR*

SUSPENSION 600000 UNIT/ML 4 NMO

PENICILLIN G SODIUM INJECTION SOLUTION


penicillin v potassium oral solution reconstituted 125 mg/5ml,

250 mg/5ml 2 NMO

penicillin v potassium oral tablet 250 mg, 500 mg 1 NMO

piperacillin sod-tazobactam so intravenous* solution

reconstituted 3.375 (3-0.375) gm, 4.5 (4-0.5) gm 4 NMO

ZOSYN INTRAVENOUS* SOLUTION 2-0.25 GM/50ML, 3-

0.375 GM/50ML 4 NMO

MACROLIDES

azithromycin intravenous* solution reconstituted 500 mg 2 NMO

azithromycin oral packet 1 gm 2 NMO

azithromycin oral suspension reconstituted 100 mg/5ml, 200

mg/5ml 2 NMO

azithromycin oral tablet 250 mg, 250 mg (6 pack), 500 mg 1 NMO

azithromycin oral tablet 600 mg 2 NMO

clarithromycin er oral tablet extended release 24 hr* 500 mg 2 NMO

clarithromycin oral suspension reconstituted 125 mg/5ml, 250

mg/5ml 2 NMO

clarithromycin oral tablet 250 mg, 500 mg 2 NMO

DIFICID ORAL TABLET 200 MG 5 NMO

E.E.S. GRANULES ORAL SUSPENSION

RECONSTITUTED 200 MG/5ML 3 NMO



11


ERYPED 200 ORAL SUSPENSION RECONSTITUTED 200

MG/5ML 3 NMO

ERYPED 400 ORAL SUSPENSION RECONSTITUTED 400

MG/5ML 3 NMO

ERY-TAB ORAL TABLET DELAYED RELEASE 250 MG,

333 MG, 500 MG 3 NMO

erythrocin lactobionate intravenous* solution reconstituted

500 mg 4 NMO

erythrocin stearate oral tablet 250 mg 2 NMO

erythromycin base oral capsule delayed release particles 250

mg 2 NMO

erythromycin base oral tablet 250 mg, 500 mg 2 NMO

erythromycin ethylsuccinate oral tablet 400 mg 2 NMO

PCE ORAL TABLET DELAYED RELEASE 333 MG, 500

MG 4 NMO

ZMAX ORAL SUSPENSION RECONSTITUTED 2 GM 4 NMO

QUINOLONES

AVELOX INTRAVENOUS* SOLUTION 400 MG/250ML 4 NMO

CIPRO IN D5W INTRAVENOUS* SOLUTION 400

MG/200ML 4 NMO

ciprofloxacin hcl oral tablet 100 mg, 250 mg, 500 mg, 750 mg 1 NMO

ciprofloxacin in d5w intravenous* solution 200 mg/100ml 2 NMO

ciprofloxacin intravenous* solution 400 mg/40ml 2 NMO

ciprofloxacin oral suspension reconstituted 250 mg/5ml (5%),

500 mg/5ml (10%) 4 NMO

ciprofloxacin-ciproflox hcl er oral tablet extended release 24

hr* 1000 mg, 500 mg 2 NMO

levofloxacin in d5w intravenous* solution 500 mg/100ml 4 NMO

levofloxacin in d5w intravenous* solution 750 mg/150ml 2 NMO

levofloxacin intravenous* solution 25 mg/ml 4 NMO

LEVOFLOXACIN ORAL SOLUTION 25 MG/ML 3 NMO

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

moxifloxacin hcl intravenous* solution 400 mg/250ml 2 NMO

MOXIFLOXACIN HCL ORAL TABLET 400 MG 3 NMO

SULFONAMIDES

sulfadiazine oral tablet 500 mg 2 NMO

sulfamethoxazole-trimethoprim intravenous* solution 400-80

mg/5ml 2 NMO



12


sulfamethoxazole-trimethoprim oral suspension 200-40

mg/5ml 2 NMO

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

160 mg 1 NMO

TETRACYCLINES

demeclocycline hcl oral tablet 150 mg, 300 mg 4 NMO

doxycycline hyclate intravenous* solution reconstituted 100

mg 4 NMO

doxycycline hyclate oral capsule 100 mg, 50 mg 2 NMO

doxycycline hyclate oral tablet 100 mg 2 NMO

DOXYCYCLINE HYCLATE ORAL TABLET 20 MG 3 NMO

doxycycline hyclate oral tablet delayed release 100 mg, 150

mg, 200 mg, 50 mg, 75 mg 4 NMO

doxycycline monohydrate oral capsule 100 mg, 50 mg 1 NMO

doxycycline monohydrate oral suspension reconstituted 25

mg/5ml 2 NMO

doxycycline monohydrate oral tablet 100 mg 2 NMO

DOXYCYCLINE MONOHYDRATE ORAL TABLET 150

MG, 50 MG, 75 MG 3 NMO

minocycline hcl er oral tablet extended release 24 hr* 135 mg,

45 mg, 90 mg 4 NMO

minocycline hcl oral capsule 100 mg, 50 mg, 75 mg 2 NMO

MINOCYCLINE HCL ORAL TABLET 100 MG, 50 MG, 75

MG 3 NMO

VIBRAMYCIN ORAL SYRUP 50 MG/5ML 4 NMO

ANTICONVULSANTS

ANTICONVULSANTS, OTHER

CEREBYX INJECTION SOLUTION 500 MG PE/10ML 4 NMO

fosphenytoin sodium injection solution 100 mg pe/2ml 2 NMO

LEVETIRACETAM ER ORAL TABLET EXTENDED

RELEASE 24 HR* 500 MG, 750 MG 3

LEVETIRACETAM IN NACL INTRAVENOUS*

SOLUTION 1000 MG/100ML, 1500 MG/100ML, 500

MG/100ML

4 NMO

levetiracetam intravenous* solution 500 mg/5ml 1 NMO

levetiracetam oral solution 100 mg/ml 2

levetiracetam oral tablet 1000 mg, 250 mg, 500 mg, 750 mg 1

roweepra oral tablet 500 mg 2



13


SPRITAM ORAL 1000 MG, 250 MG, 500 MG, 750 MG 4

BARBITURATES

phenobarbital oral elixir 20 mg/5ml 1 PA

phenobarbital oral tablet 100 mg, 15 mg, 16.2 mg, 30 mg, 60

mg 1 PA

phenobarbital oral tablet 32.4 mg, 64.8 mg, 97.2 mg 2 PA

BENZODIAZEPINES

clonazepam oral tablet 0.5 mg, 1 mg 2 QL (180 EA per 30 days)

clonazepam oral tablet 2 mg 2 QL (300 EA per 30 days)

clonazepam oral tablet dispersible 0.125 mg, 0.25 mg, 0.5 mg,

1 mg 2 QL (180 EA per 30 days)

clonazepam oral tablet dispersible 2 mg 2 QL (300 EA per 30 days)

DIAZEPAM GEL 10 MG, 2.5 MG, 20 MG 3 NMO

ONFI ORAL SUSPENSION 2.5 MG/ML 4

ONFI ORAL TABLET 10 MG, 20 MG 4 QL (60 EA per 30 days)

CALCIUM CHANNEL MODIFYING AGENTS

CELONTIN ORAL CAPSULE 300 MG 3

ethosuximide oral capsule 250 mg 1

ethosuximide oral solution 250 mg/5ml 1

LYRICA ORAL CAPSULE 150 MG, 200 MG, 225 MG, 25

MG, 50 MG, 75 MG 3 QL (120 EA per 30 days)

LYRICA ORAL CAPSULE 300 MG 3 QL (60 EA per 30 days)

LYRICA ORAL SOLUTION 20 MG/ML 3 QL (900 ML per 30 days)

zonisamide oral capsule 100 mg, 25 mg, 50 mg 2

GAMMA-AMINOBUTYRIC ACID (GABA)

AUGMENTING AGENTS

divalproex sodium er oral tablet extended release 24 hr* 250

mg, 500 mg 2

divalproex sodium oral tablet delayed release 125 mg, 250 mg,

500 mg 1

FYCOMPA ORAL SUSPENSION 0.5 MG/ML 4

FYCOMPA ORAL TABLET 10 MG, 12 MG, 2 MG, 4 MG, 6

MG, 8 MG 4

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

gabapentin oral solution 250 mg/5ml 2

gabapentin oral tablet 600 mg, 800 mg 2

GABITRIL ORAL TABLET 12 MG, 16 MG 4



14


POTIGA ORAL TABLET 200 MG, 300 MG, 400 MG, 50

MG 3

primidone oral tablet 250 mg, 50 mg 1

SABRIL ORAL PACKET 500 MG 5 NMO

SABRIL ORAL TABLET 500 MG 5 NMO

tiagabine hcl oral tablet 2 mg, 4 mg 2

valproate sodium intravenous* solution 500 mg/5ml 1 NMO

valproic acid oral capsule 250 mg 2

valproic acid oral syrup 250 mg/5ml 2

GLUTAMATE REDUCING AGENTS

felbamate oral suspension 600 mg/5ml 2

felbamate oral tablet 400 mg 2

felbamate oral tablet 600 mg 4

LAMICTAL STARTER ORAL KIT 25 (35) MG, 25 (42)-100

(7) MG, 25 (84)-100(14) MG 4 NMO

LAMICTAL XR ORAL KIT 25 & 50 & 100 MG, 25 (21)-50

(7) MG, 50 & 100 & 200 MG 4 NMO

LAMOTRIGINE ER ORAL TABLET EXTENDED

RELEASE 24 HR* 100 MG, 200 MG, 25 MG, 250 MG, 300

MG, 50 MG

3

lamotrigine oral tablet 100 mg, 150 mg, 200 mg, 25 mg 1

lamotrigine oral tablet chewable 25 mg, 5 mg 1

LAMOTRIGINE ORAL TABLET DISPERSIBLE 100 MG,

200 MG, 25 MG, 50 MG 3

TOPIRAMATE ER ORAL 100 MG, 150 MG, 200 MG, 25

MG, 50 MG 3

topiramate oral capsule sprinkle 15 mg, 25 mg 2

topiramate oral tablet 100 mg, 25 mg, 50 mg 1

topiramate oral tablet 200 mg 2

TROKENDI XR ORAL CAPSULE EXTENDED RELEASE

24 HOUR 100 MG, 200 MG, 25 MG, 50 MG 4

SODIUM CHANNEL AGENTS

APTIOM ORAL TABLET 200 MG 4 QL (30 EA per 30 days)

APTIOM ORAL TABLET 400 MG 5 NMO; QL (30 EA per 30 days)



BANZEL ORAL SUSPENSION 40 MG/ML 4 QL (2400 ML per 30 days)



15


BANZEL ORAL TABLET 200 MG, 400 MG 4 QL (240 EA per 30 days)

BRIVIACT INTRAVENOUS* SOLUTION 50 MG/5ML 4 PA; NMO

BRIVIACT ORAL SOLUTION 10 MG/ML 5 PA; NMO

BRIVIACT ORAL TABLET 10 MG 4 PA

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

MG 5 PA; NMO

carbamazepine er oral capsule extended release 12 hour 100

mg, 200 mg, 300 mg 2

carbamazepine er oral tablet extended release 12 hr* 100 mg,

200 mg, 400 mg 2

carbamazepine oral suspension 100 mg/5ml 2

carbamazepine oral tablet 200 mg 2

DILANTIN ORAL CAPSULE 30 MG 3

epitol oral tablet 200 mg 2

oxcarbazepine oral suspension 300 mg/5ml 1

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

OXTELLAR XR ORAL TABLET EXTENDED RELEASE

24 HR* 150 MG, 300 MG, 600 MG 4

PEGANONE ORAL TABLET 250 MG 3

phenytoin oral suspension 125 mg/5ml 1

phenytoin oral tablet chewable 50 mg 2

phenytoin sodium extended oral capsule 100 mg, 200 mg, 300

mg 1

phenytoin sodium injection solution 50 mg/ml 1 NMO

TEGRETOL-XR ORAL TABLET EXTENDED RELEASE

12 HR* 100 MG 3

VIMPAT INTRAVENOUS* SOLUTION 200 MG/20ML 4 PA; NMO; QL (1200 ML per 30

days)

VIMPAT ORAL SOLUTION 10 MG/ML 4 PA; QL (1200 ML per 30 days)

VIMPAT ORAL TABLET 100 MG, 150 MG, 200 MG, 50

MG 4 PA; QL (60 EA per 30 days)

ANTIDEMENTIA AGENTS

ANTIDEMENTIA AGENTS, OTHER

ergoloid mesylates oral tablet 1 mg 2 PA

CHOLINESTERASE INHIBITORS

donepezil hcl oral tablet 10 mg, 5 mg 1

DONEPEZIL HCL ORAL TABLET 23 MG 3



16


donepezil hcl oral tablet dispersible 10 mg, 5 mg 2

galantamine hydrobromide er oral capsule extended release

24 hour 16 mg, 24 mg, 8 mg 2

galantamine hydrobromide oral solution 4 mg/ml 2

galantamine hydrobromide oral tablet 12 mg, 4 mg, 8 mg 2

memantine hcl oral tablet 10 mg, 5 mg 2

MEMANTINE HCL ORAL TABLET 5 (28)-10 (21) MG 3 NMO

rivastigmine tartrate oral capsule 1.5 mg, 3 mg, 4.5 mg, 6 mg 2

rivastigmine transdermal patch 24 hr 13.3 mg/24hr, 4.6

mg/24hr, 9.5 mg/24hr 2 QL (30 EA per 30 days)

N-METHYL-D-ASPARTATE (NMDA)

RECEPTOR ANTAGONIST

memantine hcl oral solution 2 mg/ml 2

NAMENDA XR ORAL CAPSULE EXTENDED RELEASE

24 HOUR 14 MG, 21 MG, 28 MG, 7 MG 3

NAMENDA XR TITRATION PACK ORAL CAPSULE

EXTENDED RELEASE 24 HOUR 7 & 14 & 21 &28 MG 3 NMO

NAMZARIC ORAL CAPSULE EXTENDED RELEASE 24

HOUR 14-10 MG, 28-10 MG 3

ANTIDEPRESSANTS

ANTIDEPRESSANTS, OTHER

bupropion hcl er (sr) oral tablet extended release 12 hr* 100

mg, 150 mg, 200 mg 1

bupropion hcl er (xl) oral tablet extended release 24 hr* 300

mg 1

bupropion hcl oral tablet 100 mg, 75 mg 1

FORFIVO XL ORAL TABLET EXTENDED RELEASE 24

HR* 450 MG 3 QL (30 EA per 30 days)

maprotiline hcl oral tablet 25 mg, 50 mg, 75 mg 2

mirtazapine oral tablet 15 mg, 30 mg, 45 mg, 7.5 mg 1

mirtazapine oral tablet dispersible 15 mg, 30 mg, 45 mg 2

NEFAZODONE HCL ORAL TABLET 100 MG, 150 MG,

200 MG, 250 MG, 50 MG 3

trazodone hcl oral tablet 100 mg, 150 mg, 50 mg 1

trazodone hcl oral tablet 300 mg 2

VIIBRYD ORAL TABLET 10 MG, 20 MG, 40 MG 4

VIIBRYD STARTER PACK ORAL KIT 10 & 20 MG 4 NMO



17


MONOAMINE OXIDASE INHIBITORS

EMSAM TRANSDERMAL PATCH 24 HR 12 MG/24HR, 6

MG/24HR, 9 MG/24HR 5 NMO; QL (30 EA per 30 days)

MARPLAN ORAL TABLET 10 MG 4

phenelzine sulfate oral tablet 15 mg 2

tranylcypromine sulfate oral tablet 10 mg 2

SEROTONIN/NOREPINEPHRINE REUPTAKE

INHIBITORS

BRISDELLE ORAL CAPSULE 7.5 MG 4

citalopram hydrobromide oral solution 10 mg/5ml 2

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

duloxetine hcl oral capsule delayed release particles 20 mg, 30

mg, 40 mg, 60 mg 2

escitalopram oxalate oral solution 5 mg/5ml 2

escitalopram oxalate oral tablet 10 mg, 20 mg, 5 mg 1

FETZIMA ORAL CAPSULE EXTENDED RELEASE 24

HOUR 120 MG, 20 MG, 40 MG, 80 MG 4 QL (30 EA per 30 days)

FETZIMA TITRATION ORAL 20 & 40 MG 4 NMO

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

FLUOXETINE HCL ORAL CAPSULE DELAYED

RELEASE 90 MG 3

fluoxetine hcl oral solution 20 mg/5ml 2

fluoxetine hcl oral tablet 10 mg, 20 mg 2

FLUOXETINE HCL ORAL TABLET 60 MG 3

FLUVOXAMINE MALEATE ER ORAL CAPSULE

EXTENDED RELEASE 24 HOUR 100 MG, 150 MG 3

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

paroxetine hcl er oral tablet extended release 24 hr* 12.5 mg,

25 mg, 37.5 mg 2

paroxetine hcl oral tablet 10 mg, 20 mg, 30 mg, 40 mg 1

PAXIL ORAL SUSPENSION 10 MG/5ML 4

PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR*

100 MG, 25 MG, 50 MG 4

SARAFEM ORAL TABLET 10 MG, 20 MG 4

sertraline hcl oral concentrate 20 mg/ml 1

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

TRINTELLIX ORAL TABLET 10 MG, 20 MG, 5 MG 4 ST



18


venlafaxine hcl er oral capsule extended release 24 hour 150

mg, 37.5 mg, 75 mg 1

VENLAFAXINE HCL ER ORAL TABLET EXTENDED

RELEASE 24 HR* 150 MG, 37.5 MG, 75 MG 3

venlafaxine hcl er oral tablet extended release 24 hr* 225 mg 4

venlafaxine hcl oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 75

mg 1

TRICYCLICS

amitriptyline hcl oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50

mg, 75 mg 2 PA

amoxapine oral tablet 100 mg 1

amoxapine oral tablet 150 mg, 25 mg, 50 mg 2

CLOMIPRAMINE HCL ORAL CAPSULE 25 MG, 50 MG,

75 MG 3 PA

desipramine hcl oral tablet 10 mg, 25 mg, 50 mg 1

desipramine hcl oral tablet 100 mg, 150 mg, 75 mg 2

doxepin hcl oral capsule 10 mg, 100 mg, 150 mg, 25 mg, 50

mg, 75 mg 2 PA

doxepin hcl oral concentrate 10 mg/ml 2 PA

imipramine hcl oral tablet 10 mg, 25 mg, 50 mg 2 PA

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

mg 4 PA

nortriptyline hcl oral capsule 10 mg, 25 mg, 50 mg, 75 mg 1

nortriptyline hcl oral solution 10 mg/5ml 2

PROTRIPTYLINE HCL ORAL TABLET 10 MG, 5 MG 3

trimipramine maleate oral capsule 100 mg, 25 mg, 50 mg 2 PA

ANTIEMETICS

ANTIEMETICS, OTHER

meclizine hcl oral tablet 12.5 mg, 25 mg 1 NMO

TRANSDERM-SCOP (1.5 MG) TRANSDERMAL PATCH

72 HR 1 MG/3DAYS 4 NMO

trimethobenzamide hcl oral capsule 300 mg 2 PA; NMO

EMETOGENIC THERAPY ADJUNCTS

AKYNZEO ORAL CAPSULE 300-0.5 MG 4 BD; NMO

ALOXI INTRAVENOUS* SOLUTION 0.25 MG/5ML 4 BD; NMO

CESAMET ORAL CAPSULE 1 MG 4 BD; NMO; QL (60 EA per 30

days)



19


dronabinol oral capsule 10 mg 5 PA; NMO; QL (60 EA per 30

days)

dronabinol oral capsule 2.5 mg 2 PA; NMO; QL (60 EA per 30

days)

dronabinol oral capsule 5 mg 4 PA; NMO; QL (60 EA per 30

days)

EMEND INTRAVENOUS* SOLUTION RECONSTITUTED

150 MG 4 BD; NMO

EMEND ORAL CAPSULE 80 & 125 MG 4 BD; NMO; QL (12 EA per 30

days)

EMEND ORAL SUSPENSION RECONSTITUTED 125 MG 4 BD; NMO

granisetron hcl intravenous* solution 0.1 mg/ml, 1 mg/ml 1 BD; NMO; QL (60 ML per 30

days)

granisetron hcl oral tablet 1 mg 1 BD; NMO; QL (60 EA per 30

days)

ondansetron hcl injection solution 4 mg/2ml, 4 mg/2ml (2ml

syringe) 1 BD; NMO

ondansetron hcl oral solution 4 mg/5ml 1 BD; NMO

ondansetron hcl oral tablet 24 mg 1 BD; NMO; QL (30 EA per 30

days)

ondansetron hcl oral tablet 4 mg, 8 mg 1 BD; NMO; QL (90 EA per 30

days)

ondansetron oral tablet dispersible 4 mg 1 BD; NMO; QL (90 EA per 30

days)

ondansetron oral tablet dispersible 8 mg 2 BD; NMO; QL (90 EA per 30

days)

SANCUSO TRANSDERMAL PATCH 3.1 MG/24HR 3 NMO; QL (4 EA per 28 days)

ANTIFUNGALS

ANTIFUNGALS

ABELCET INTRAVENOUS* SUSPENSION 5 MG/ML 4 BD; NMO

AMBISOME INTRAVENOUS* SUSPENSION


amphotericin b injection solution reconstituted 50 mg 4 BD; NMO

CANCIDAS INTRAVENOUS* SOLUTION

RECONSTITUTED 50 MG, 70 MG 5 BD; NMO

ERAXIS INTRAVENOUS* SOLUTION RECONSTITUTED

100 MG, 50 MG 4 NMO

fluconazole in sodium chloride intravenous* solution 200-0.9

mg/100ml-%, 400-0.9 mg/200ml-% 2 NMO



20


fluconazole oral suspension reconstituted 10 mg/ml, 40 mg/ml 2 NMO

fluconazole oral tablet 100 mg, 150 mg, 200 mg, 50 mg 2 NMO

flucytosine oral capsule 250 mg, 500 mg 5 NMO

griseofulvin microsize oral suspension 125 mg/5ml 4 NMO

griseofulvin ultramicrosize oral tablet 125 mg, 250 mg 4 NMO

ITRACONAZOLE ORAL CAPSULE 100 MG 3 PA; NMO

ketoconazole oral tablet 200 mg 1 NMO

LAMISIL ORAL PACKET 125 MG, 187.5 MG 4 NMO

MYCAMINE INTRAVENOUS* SOLUTION


MYCAMINE INTRAVENOUS* SOLUTION


NOXAFIL ORAL SUSPENSION 40 MG/ML 5 NMO

NOXAFIL ORAL TABLET DELAYED RELEASE 100 MG 5 NMO

nystatin oral tablet 500000 unit 2 NMO

ORAVIG BUCCAL TABLET 50 MG 3 NMO

SPORANOX ORAL SOLUTION 10 MG/ML 5 PA; NMO

terbinafine hcl oral tablet 250 mg 1 NMO

voriconazole intravenous* solution reconstituted 200 mg 4 NMO

voriconazole oral suspension reconstituted 40 mg/ml 5 NMO; QL (300 ML per 30 days)

voriconazole oral tablet 200 mg, 50 mg 5 NMO; QL (120 EA per 30 days)

ANTIGOUT AGENTS

ANTIGOUT AGENTS

allopurinol oral tablet 100 mg, 300 mg 1

colchicine oral capsule 0.6 mg 2 NMO

colchicine oral tablet 0.6 mg 2 NMO

colchicine-probenecid oral tablet 0.5-500 mg 2

probenecid oral tablet 500 mg 2

ULORIC ORAL TABLET 40 MG, 80 MG 4

ANTI-INFLAMMATORY AGENTS

NONSTEROIDAL ANTI-INFLAMMATORY

DRUGS

CELECOXIB ORAL CAPSULE 100 MG, 200 MG, 400 MG 3

celecoxib oral capsule 50 mg 2

diclofenac potassium oral tablet 50 mg 2



21


diclofenac sodium er oral tablet extended release 24 hr* 100

mg 1

diclofenac sodium oral tablet delayed release 25 mg, 50 mg,

75 mg 1

DICLOFENAC-MISOPROSTOL ORAL TABLET

DELAYED RELEASE 50-0.2 MG, 75-0.2 MG 3

diflunisal oral tablet 500 mg 2

ETODOLAC ER ORAL TABLET EXTENDED RELEASE

24 HR* 400 MG, 500 MG, 600 MG 3

etodolac oral capsule 200 mg, 300 mg 2

etodolac oral tablet 400 mg, 500 mg 2

flurbiprofen oral tablet 100 mg, 50 mg 2

ibuprofen oral suspension 100 mg/5ml 1 NMO

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

INDOCIN ORAL SUSPENSION 25 MG/5ML 3 PA

INDOMETHACIN ER ORAL CAPSULE EXTENDED

RELEASE* 75 MG 3 PA

indomethacin oral capsule 25 mg, 50 mg 1 PA

ketoprofen er oral capsule extended release 24 hour 200 mg 4

ketoprofen oral capsule 50 mg, 75 mg 2

ketorolac tromethamine intramuscular* solution 60 mg/2ml 2 PA; NMO

MEFENAMIC ACID ORAL CAPSULE 250 MG 3

meloxicam oral suspension 7.5 mg/5ml 1

meloxicam oral tablet 15 mg, 7.5 mg 1

nabumetone oral tablet 500 mg, 750 mg 1

naproxen dr oral tablet delayed release 375 mg, 500 mg 1

naproxen oral suspension 125 mg/5ml 1

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

naproxen sodium oral tablet 275 mg 1

naproxen sodium oral tablet 550 mg 2

OXAPROZIN ORAL TABLET 600 MG 3

piroxicam oral capsule 10 mg, 20 mg 2

sulindac oral tablet 150 mg, 200 mg 1

tolmetin sodium oral capsule 400 mg 2

tolmetin sodium oral tablet 600 mg 2

ANTIMIGRAINE AGENTS

ERGOT ALKALOIDS



22


dihydroergotamine mesylate injection solution 1 mg/ml 1 NMO; QL (24 ML per 28 days)

migergot suppository 2-100 mg 1 NMO; QL (20 EA per 28 days)

PROPHYLACTIC

divalproex sodium oral 125 mg 2

timolol maleate oral tablet 10 mg 1

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

AGONISTS

almotriptan malate oral tablet 12.5 mg, 6.25 mg 2 NMO

dihydroergotamine mesylate nasal solution 4 mg/ml 1 NMO

frovatriptan succinate oral tablet 2.5 mg 2 NMO

IMITREX STATDOSE REFILL SUBCUTANEOUS* 4

MG/0.5ML 4 NMO

naratriptan hcl oral tablet 1 mg, 2.5 mg 2 NMO

RELPAX ORAL TABLET 20 MG, 40 MG 4 NMO

rizatriptan benzoate oral tablet 10 mg, 5 mg 2 NMO

rizatriptan benzoate oral tablet dispersible 10 mg, 5 mg 2 NMO

sumatriptan nasal solution 20 mg/act, 5 mg/act 2 NMO

sumatriptan succinate oral tablet 100 mg, 25 mg, 50 mg 1 NMO

sumatriptan succinate refill subcutaneous* 4 mg/0.5ml, 6

mg/0.5ml 2 NMO

sumatriptan succinate subcutaneous* 6 mg/0.5ml 4 NMO

sumatriptan succinate subcutaneous* solution 6 mg/0.5ml 2 NMO

TREXIMET ORAL TABLET 85-500 MG 4 NMO

zolmitriptan oral tablet 2.5 mg, 5 mg 2 NMO

zolmitriptan oral tablet dispersible 2.5 mg, 5 mg 2 NMO

ZOMIG NASAL SOLUTION 5 MG 4 NMO

ANTIMYASTHENIC AGENTS

PARASYMPATHOMIMETICS

guanidine hcl oral tablet 125 mg 2 NMO

MESTINON ORAL SYRUP 60 MG/5ML 3 NMO

pyridostigmine bromide er oral tablet extendedrelease* 180

mg 2 NMO

pyridostigmine bromide oral tablet 60 mg 2 NMO

ANTIMYCOBACTERIALS

ANTIMYCOBACTERIALS, OTHER

dapsone oral tablet 100 mg, 25 mg 2



23


pyrazinamide oral tablet 500 mg 2 NMO

RIFABUTIN ORAL CAPSULE 150 MG 3 NMO

ANTITUBERCULARS

CAPASTAT SULFATE INJECTION SOLUTION


ETHAMBUTOL HCL ORAL TABLET 100 MG, 400 MG 3 NMO

isoniazid injection solution 100 mg/ml 1 NMO

isoniazid oral syrup 50 mg/5ml 1

isoniazid oral tablet 100 mg, 300 mg 1

PASER ORAL PACKET 4 GM 4 NMO

PRIFTIN ORAL TABLET 150 MG 4 NMO

RIFAMATE ORAL CAPSULE 150-300 MG 4 NMO

rifampin intravenous* solution reconstituted 600 mg 2 NMO

rifampin oral capsule 150 mg 1 NMO

rifampin oral capsule 300 mg 2 NMO

RIFATER ORAL TABLET 50-120-300 MG 4 NMO

SIRTURO ORAL TABLET 100 MG 5 NMO

TRECATOR ORAL TABLET 250 MG 4 NMO

ANTINEOPLASTICS

ALKYLATING AGENTS

BICNU INTRAVENOUS* SOLUTION RECONSTITUTED

100 MG 4 BD; NMO

BUSULFEX INTRAVENOUS* SOLUTION 6 MG/ML 5 BD; NMO

CARBOPLATIN INTRAVENOUS* SOLUTION 150

MG/15ML 3 BD; NMO

cisplatin intravenous* solution 100 mg/100ml 4 BD; NMO

cyclophosphamide oral capsule 25 mg, 50 mg 1 BD; NMO

GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG, 5

MG 4 NMO

HEXALEN ORAL CAPSULE 50 MG 5 NMO

IFOSFAMIDE INTRAVENOUS* SOLUTION

RECONSTITUTED 1 GM 3 BD; NMO

LEUKERAN ORAL TABLET 2 MG 3 NMO

melphalan hcl intravenous* solution reconstituted 50 mg 4 BD; NMO

MUSTARGEN INJECTION SOLUTION RECONSTITUTED

10 MG 5 BD; NMO

oxaliplatin intravenous* solution 100 mg/20ml 4 BD; NMO



24


THIOTEPA INJECTION SOLUTION RECONSTITUTED 15

MG 5 BD; NMO

TREANDA INTRAVENOUS* SOLUTION


YONDELIS INTRAVENOUS* SOLUTION

RECONSTITUTED 1 MG 5 PA; NMO

ZANOSAR INTRAVENOUS* SOLUTION


ANTIANGIOGENIC AGENTS

AVASTIN INTRAVENOUS* SOLUTION 100 MG/4ML 5 BD; NMO

AVASTIN INTRAVENOUS* SOLUTION 400 MG/16ML 3 BD; NMO

CYRAMZA INTRAVENOUS* SOLUTION 100 MG/10ML,

500 MG/50ML 5 BD; NMO

REVLIMID ORAL CAPSULE 10 MG, 15 MG, 2.5 MG, 20

MG, 25 MG, 5 MG 5 PA; LA; NMO

THALOMID ORAL CAPSULE 100 MG, 150 MG, 200 MG,

50 MG 5 PA; NMO

ZALTRAP INTRAVENOUS* SOLUTION 100 MG/4ML 5 BD; NMO

ANTIMETABOLITES

ADRUCIL INTRAVENOUS* SOLUTION 500 MG/10ML 3 BD; NMO

ALIMTA INTRAVENOUS* SOLUTION


ARRANON INTRAVENOUS* SOLUTION 5 MG/ML 4 BD; NMO

azacitidine injection suspension reconstituted 100 mg 5 BD; NMO

cladribine intravenous* solution 10 mg/10ml 5 BD; NMO

CLOLAR INTRAVENOUS* SOLUTION 1 MG/ML 4 BD; NMO

CYTARABINE (PF) INJECTION SOLUTION 100 MG/ML 3 BD; NMO

cytarabine injection solution 20 mg/ml 2 BD; NMO

decitabine intravenous* solution reconstituted 50 mg 2 BD; NMO

DROXIA ORAL CAPSULE 200 MG, 300 MG, 400 MG 4

fludarabine phosphate intravenous* solution reconstituted 50

mg 1 BD; NMO

FLUOROURACIL INTRAVENOUS* SOLUTION 2.5

GM/50ML 3 BD; NMO

GEMCITABINE HCL INTRAVENOUS* SOLUTION


mercaptopurine oral tablet 50 mg 2 NMO

methotrexate oral tablet 2.5 mg 2 BD; NMO



25


methotrexate sodium (pf) injection solution 1 gm/40ml 1 BD; NMO

methotrexate sodium injection solution reconstituted 1 gm 1 BD; NMO

PURIXAN ORAL SUSPENSION 2000 MG/100ML 4 NMO

TABLOID ORAL TABLET 40 MG 3 NMO

TREXALL ORAL TABLET 10 MG, 15 MG, 5 MG, 7.5 MG 4 BD; NMO

ANTINEOPLASTICS

ABRAXANE INTRAVENOUS* SUSPENSION


ACTIMMUNE SUBCUTANEOUS* SOLUTION 2000000

UNIT/0.5ML 5 PA; LA; NMO

AFINITOR DISPERZ ORAL TABLET SOLUBLE 2 MG, 3


AFINITOR DISPERZ ORAL TABLET SOLUBLE 5 MG 5 NMO; QL (60 EA per 30 days)

AFINITOR ORAL TABLET 10 MG, 2.5 MG, 5 MG, 7.5 MG 5 NMO; QL (30 EA per 30 days)

ALECENSA ORAL CAPSULE 150 MG 5 NMO

amifostine intravenous* solution reconstituted 500 mg 5 BD; NMO

BELEODAQ INTRAVENOUS* SOLUTION


bexarotene oral capsule 75 mg 5 NMO

bicalutamide oral tablet 50 mg 1 NMO; QL (30 EA per 30 days)

bleomycin sulfate injection solution reconstituted 30 unit 1 BD; NMO

BOSULIF ORAL TABLET 100 MG 5 PA; NMO; QL (120 EA per 30

days)

BOSULIF ORAL TABLET 500 MG 5 PA; NMO; QL (30 EA per 30

days)

CABOMETYX ORAL TABLET 20 MG, 40 MG, 60 MG 5 NMO

CAPRELSA ORAL TABLET 100 MG 5 NMO; QL (60 EA per 30 days)

CAPRELSA ORAL TABLET 300 MG 5 NMO; QL (30 EA per 30 days)

COMETRIQ (100 MG DAILY DOSE) ORAL KIT 1 X 80 &

1 X 20 MG 5 NMO; QL (60 EA per 30 days)

COMETRIQ (140 MG DAILY DOSE) ORAL KIT 1 X 80 &

3 X 20 MG 5 NMO; QL (120 EA per 30 days)

COMETRIQ (60 MG DAILY DOSE) ORAL KIT 20 MG 5 NMO; QL (90 EA per 30 days)

COSMEGEN INTRAVENOUS* SOLUTION

RECONSTITUTED 0.5 MG 4 BD; NMO

COTELLIC ORAL TABLET 20 MG 5 LA; NMO

DACARBAZINE INTRAVENOUS* SOLUTION




26


DARZALEX INTRAVENOUS* SOLUTION 100 MG/5ML 4 LA; NMO

daunorubicin hcl intravenous* injectable 5 mg/ml 2 BD; NMO

DEPO-PROVERA INTRAMUSCULAR* SUSPENSION 400

MG/ML 3 BD; NMO

dexrazoxane intravenous* solution reconstituted 250 mg 5 BD; NMO

DOCEFREZ INTRAVENOUS* SOLUTION


DOCETAXEL INTRAVENOUS* CONCENTRATE 80

MG/4ML 5 BD; NMO

DOCETAXEL INTRAVENOUS* SOLUTION 80 MG/8ML 5 BD; NMO

DOXIL INTRAVENOUS* INJECTABLE 2 MG/ML 5 BD; NMO

DOXORUBICIN HCL INTRAVENOUS* SOLUTION 2

MG/ML 3 BD; NMO

doxorubicin hcl liposomal intravenous* injectable 2 mg/ml 5 BD; NMO

ELIGARD SUBCUTANEOUS* KIT 22.5 MG, 30 MG, 45

MG, 7.5 MG 4 BD; NMO

ELITEK INTRAVENOUS* SOLUTION RECONSTITUTED

1.5 MG 5 BD; NMO

ELITEK INTRAVENOUS* SOLUTION RECONSTITUTED

7.5 MG 4 BD; NMO

EMCYT ORAL CAPSULE 140 MG 3 NMO

EMPLICITI INTRAVENOUS* SOLUTION

RECONSTITUTED 300 MG, 400 MG 5 PA; NMO

ERBITUX INTRAVENOUS* SOLUTION 100 MG/50ML 5 BD; NMO

ERIVEDGE ORAL CAPSULE 150 MG 5 NMO

ERWINAZE INJECTION SOLUTION RECONSTITUTED

10000 UNIT 3 PA; NMO

ETOPOPHOS INTRAVENOUS* SOLUTION


etoposide intravenous* solution 500 mg/25ml 1 BD; NMO

FARESTON ORAL TABLET 60 MG 3 QL (30 EA per 30 days)

FARYDAK ORAL CAPSULE 10 MG, 15 MG, 20 MG 5 PA; NMO

FASLODEX INTRAMUSCULAR* SOLUTION 250

MG/5ML 5 BD; NMO

FIRMAGON SUBCUTANEOUS* SOLUTION


flutamide oral capsule 125 mg 1 NMO

GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG 5 PA; NMO

GLEEVEC ORAL TABLET 100 MG 5 NMO; QL (180 EA per 30 days)



27


GLEEVEC ORAL TABLET 400 MG 5 NMO; QL (60 EA per 30 days)

HALAVEN INTRAVENOUS* SOLUTION 1 MG/2ML 5 BD; NMO

HERCEPTIN INTRAVENOUS* SOLUTION


hydroxyprogesterone caproate intramuscular* solution 1.25

gm/5ml 5 PA; NMO

hydroxyurea oral capsule 500 mg 1 NMO

IBRANCE ORAL CAPSULE 100 MG, 125 MG, 75 MG 5 PA; NMO

ICLUSIG ORAL TABLET 15 MG 5 PA; NMO; QL (60 EA per 30

days)

ICLUSIG ORAL TABLET 45 MG 5 PA; NMO

idarubicin hcl intravenous* solution 10 mg/10ml 5 BD; NMO

imatinib mesylate oral tablet 100 mg 5 NMO; QL (180 EA per 30 days)

imatinib mesylate oral tablet 400 mg 5 NMO; QL (60 EA per 30 days)

IMBRUVICA ORAL CAPSULE 140 MG 5 PA; NMO

INLYTA ORAL TABLET 1 MG 5 NMO; QL (180 EA per 30 days)

INLYTA ORAL TABLET 5 MG 5 NMO; QL (60 EA per 30 days)

INTRON A INJECTION SOLUTION 6000000 UNIT/ML 5 BD; NMO

INTRON A INJECTION SOLUTION RECONSTITUTED

10000000 UNIT 5 BD; NMO

INTRON A INJECTION SOLUTION RECONSTITUTED

18000000 UNIT, 50000000 UNIT 4 BD

IRESSA ORAL TABLET 250 MG 5 NMO

irinotecan hcl intravenous* solution 100 mg/5ml 4 BD; NMO

ISTODAX INTRAVENOUS* SOLUTION


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


KADCYLA INTRAVENOUS* SOLUTION


KEPIVANCE INTRAVENOUS* SOLUTION

RECONSTITUTED 6.25 MG 4 BD; NMO

KEYTRUDA INTRAVENOUS* SOLUTION 100 MG/4ML 5 PA; NMO

KEYTRUDA INTRAVENOUS* SOLUTION


LENVIMA 10 MG DAILY DOSE ORAL 10 MG 5 NMO

LENVIMA 14 MG DAILY DOSE ORAL 10 & 4 MG 5 NMO

LENVIMA 18 MG DAILY DOSE ORAL 10 & 4 (2) MG 5 NMO



28


LENVIMA 20 MG DAILY DOSE ORAL 10 (2) MG 5 NMO

LENVIMA 24 MG DAILY DOSE ORAL 10 (2) & 4 MG 5 NMO

LENVIMA 8 MG DAILY DOSE ORAL 4 (2) MG 5 NMO

leucovorin calcium injection solution reconstituted 100 mg,

350 mg 1 BD; NMO

leucovorin calcium oral tablet 10 mg, 15 mg, 25 mg, 5 mg 1 NMO

leuprolide acetate injection kit 1 mg/0.2ml 1 PA; NMO

LEVOLEUCOVORIN CALCIUM INTRAVENOUS*

SOLUTION 175 MG/17.5ML 3 BD; NMO

LONSURF ORAL TABLET 15-6.14 MG, 20-8.19 MG 5 NMO

LUPRON DEPOT INTRAMUSCULAR* KIT 22.5 MG 5 PA; NMO; QL (1 EA per 90 days)

LUPRON DEPOT INTRAMUSCULAR* KIT 3.75 MG, 7.5

MG 5 PA; NMO; QL (1 EA per 30 days)

LUPRON DEPOT INTRAMUSCULAR* KIT 30 MG, 45 MG 5 PA; NMO; QL (1 EA per 112

days)

LYNPARZA ORAL CAPSULE 50 MG 5 PA; NMO

LYSODREN ORAL TABLET 500 MG 3 NMO

MATULANE ORAL CAPSULE 50 MG 5 NMO

megestrol acetate oral suspension 40 mg/ml 1 PA; NMO

megestrol acetate oral tablet 20 mg, 40 mg 1 PA; NMO

MEKINIST ORAL TABLET 0.5 MG, 2 MG 5 NMO

MESNA INTRAVENOUS* SOLUTION 100 MG/ML 3 BD; NMO

MESNEX ORAL TABLET 400 MG 5 NMO

MITOMYCIN INTRAVENOUS* SOLUTION

RECONSTITUTED 20 MG, 40 MG, 5 MG 3 BD; NMO

mitoxantrone hcl intravenous* concentrate 25 mg/12.5ml 1 BD; NMO

NEXAVAR ORAL TABLET 200 MG 5 LA; NMO; QL (120 EA per 30

days)

NILANDRON ORAL TABLET 150 MG 3 NMO; QL (60 EA per 30 days)

NILUTAMIDE ORAL TABLET 150 MG 3 NMO; QL (60 EA per 30 days)

NINLARO ORAL CAPSULE 2.3 MG, 3 MG, 4 MG 5 NMO

ODOMZO ORAL CAPSULE 200 MG 5 LA; NMO

OPDIVO INTRAVENOUS* SOLUTION 40 MG/4ML 5 PA; NMO

PACLITAXEL INTRAVENOUS* CONCENTRATE 300

MG/50ML 3 BD; NMO

PERJETA INTRAVENOUS* SOLUTION 420 MG/14ML 5 BD; NMO

POMALYST ORAL CAPSULE 1 MG, 2 MG, 3 MG, 4 MG 5 LA; NMO



29


PROLEUKIN INTRAVENOUS* SOLUTION

RECONSTITUTED 22000000 UNIT 5 BD; NMO

RITUXAN INTRAVENOUS* SOLUTION 500 MG/50ML 3 PA; NMO

SOLTAMOX ORAL SOLUTION 10 MG/5ML 4

SPRYCEL ORAL TABLET 100 MG, 50 MG, 70 MG, 80 MG 5 NMO; QL (60 EA per 30 days)

SPRYCEL ORAL TABLET 140 MG 5 NMO; QL (30 EA per 30 days)

SPRYCEL ORAL TABLET 20 MG 5 NMO; QL (90 EA per 30 days)

STIVARGA ORAL TABLET 40 MG 5 PA; NMO

SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 37.5 MG, 50

MG 5 NMO

SYLATRON SUBCUTANEOUS* KIT 200 MCG, 300 MCG,

600 MCG 5 NMO

SYNRIBO SUBCUTANEOUS* SOLUTION

RECONSTITUTED 3.5 MG 5 NMO

TAFINLAR ORAL CAPSULE 50 MG, 75 MG 5 NMO

TAGRISSO ORAL TABLET 40 MG, 80 MG 5 LA; NMO

tamoxifen citrate oral tablet 10 mg, 20 mg 1

TARCEVA ORAL TABLET 100 MG, 150 MG 5 NMO; QL (30 EA per 30 days)

TARCEVA ORAL TABLET 25 MG 5 NMO; QL (90 EA per 30 days)

TASIGNA ORAL CAPSULE 150 MG, 200 MG 5 NMO; QL (120 EA per 30 days)

TECENTRIQ INTRAVENOUS* SOLUTION 1200

MG/20ML 4 BD; NMO

toposar intravenous* solution 1 gm/50ml 1 BD; NMO

TOPOTECAN HCL INTRAVENOUS* SOLUTION


TORISEL INTRAVENOUS* SOLUTION 25 MG/ML 5 BD; NMO

TRELSTAR MIXJECT INTRAMUSCULAR* SUSPENSION

RECONSTITUTED 11.25 MG, 22.5 MG, 3.75 MG 5 BD; NMO

tretinoin oral capsule 10 mg 5 NMO

TRISENOX INTRAVENOUS* SOLUTION 10 MG/10ML 3 BD; NMO

TYKERB ORAL TABLET 250 MG 5 NMO; QL (150 EA per 30 days)

UVADEX INJECTION SOLUTION 20 MCG/ML 4 BD; NMO

VECTIBIX INTRAVENOUS* SOLUTION 100 MG/5ML 4 BD; NMO

VELCADE INJECTION SOLUTION RECONSTITUTED 3.5

MG 5 BD; NMO

VENCLEXTA ORAL TABLET 10 MG, 50 MG 4 PA; LA; NMO

VENCLEXTA ORAL TABLET 100 MG 5 PA; LA; NMO

VENCLEXTA STARTING PACK ORAL 10 & 50 & 100 MG 4 PA; LA; NMO



30


VINBLASTINE SULFATE INTRAVENOUS* SOLUTION 1

MG/ML 3 BD; NMO

VINCASAR PFS INTRAVENOUS* SOLUTION 1 MG/ML 3 BD; NMO

VINCRISTINE SULFATE INTRAVENOUS* SOLUTION 1

MG/ML 3 BD; NMO

VINORELBINE TARTRATE INTRAVENOUS* SOLUTION

50 MG/5ML 3 BD; NMO

VOTRIENT ORAL TABLET 200 MG 5 NMO; QL (120 EA per 30 days)

XALKORI ORAL CAPSULE 200 MG, 250 MG 5 NMO; QL (60 EA per 30 days)

XTANDI ORAL CAPSULE 40 MG 5 PA; ST; NMO; QL (120 EA per 30

days)

YERVOY INTRAVENOUS* SOLUTION 50 MG/10ML 5 BD; NMO

ZELBORAF ORAL TABLET 240 MG 5 NMO; QL (240 EA per 30 days)

ZOLINZA ORAL CAPSULE 100 MG 5 NMO; QL (120 EA per 30 days)

ZYDELIG ORAL TABLET 100 MG 5 NMO; QL (90 EA per 30 days)

ZYDELIG ORAL TABLET 150 MG 5 NMO; QL (60 EA per 30 days)

ZYKADIA ORAL CAPSULE 150 MG 3 NMO

ZYTIGA ORAL TABLET 250 MG 5 PA; NMO; QL (120 EA per 30

days)

AROMATASE INHIBITORS, 3RD

GENERATION

anastrozole oral tablet 1 mg 1

exemestane oral tablet 25 mg 2 QL (60 EA per 30 days)

letrozole oral tablet 2.5 mg 1

ANTIPARASITICS

ANTHELMINTICS

ALBENZA ORAL TABLET 200 MG 3 NMO

BILTRICIDE ORAL TABLET 600 MG 4 NMO

EMVERM ORAL TABLET CHEWABLE 100 MG 3 NMO

IVERMECTIN ORAL TABLET 3 MG 3 NMO

ANTIPROTOZOALS

ALINIA ORAL SUSPENSION RECONSTITUTED 100

MG/5ML 4 NMO; QL (180 ML per 30 days)

ALINIA ORAL TABLET 500 MG 4 NMO

atovaquone oral suspension 750 mg/5ml 5 NMO

ATOVAQUONE-PROGUANIL HCL ORAL TABLET 250-

100 MG, 62.5-25 MG 3 NMO



31


chloroquine phosphate oral tablet 250 mg 1

chloroquine phosphate oral tablet 500 mg 2

COARTEM ORAL TABLET 20-120 MG 4 NMO

DARAPRIM ORAL TABLET 25 MG 3 NMO

hydroxychloroquine sulfate oral tablet 200 mg 2

mefloquine hcl oral tablet 250 mg 2

NEBUPENT INHALATION SOLUTION


PENTAM INJECTION SOLUTION RECONSTITUTED 300

MG 4 NMO

PRIMAQUINE PHOSPHATE ORAL TABLET 26.3 MG 4 NMO

quinine sulfate oral capsule 324 mg 4 NMO

ANTIPARKINSON AGENTS

ANTICHOLINERGICS

benztropine mesylate injection solution 1 mg/ml 1 NMO

benztropine mesylate oral tablet 0.5 mg, 1 mg, 2 mg 1 PA

trihexyphenidyl hcl oral elixir 0.4 mg/ml 1 PA

trihexyphenidyl hcl oral tablet 2 mg, 5 mg 1 PA

ANTIPARKINSON AGENTS, OTHER

amantadine hcl oral capsule 100 mg 2

amantadine hcl oral syrup 50 mg/5ml 2

amantadine hcl oral tablet 100 mg 2

entacapone oral tablet 200 mg 2

DOPAMINE AGONISTS

APOKYN SUBCUTANEOUS* SOLUTION 10 MG/ML 5 LA; NMO; QL (60 ML per 30

days)

bromocriptine mesylate oral capsule 5 mg 1

bromocriptine mesylate oral tablet 2.5 mg 2

NEUPRO TRANSDERMAL PATCH 24 HR 1 MG/24HR, 2

MG/24HR, 3 MG/24HR, 4 MG/24HR, 6 MG/24HR, 8

MG/24HR

4

PRAMIPEXOLE DIHYDROCHLORIDE ER 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

3

pramipexole dihydrochloride oral tablet 0.125 mg, 0.25 mg,

0.5 mg, 0.75 mg, 1 mg, 1.5 mg 1



32


ropinirole hcl er oral tablet extended release 24 hr* 12 mg, 2

mg, 4 mg, 6 mg, 8 mg 2

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

mg, 5 mg 1

DOPAMINE PRECURSORS/ L-AMINO ACID

DECARBOXYLASE INHIBITORS

CARBIDOPA ORAL TABLET 25 MG 3

carbidopa-levodopa er oral tablet extendedrelease* 25-100

mg, 50-200 mg 2

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

mg 1

carbidopa-levodopa oral tablet dispersible 10-100 mg 2

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

mg 1

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

2

MONOAMINE OXIDASE B (MAO-B)

INHIBITORS

AZILECT ORAL TABLET 0.5 MG, 1 MG 3 QL (30 EA per 30 days)

selegiline hcl oral capsule 5 mg 2

selegiline hcl oral tablet 5 mg 2

ZELAPAR ORAL TABLET DISPERSIBLE 1.25 MG 4

ANTIPSYCHOTICS

1ST GENERATION/TYPICAL

CHLORPROMAZINE HCL INJECTION SOLUTION 50

MG/2ML 3 BD; NMO

chlorpromazine hcl oral tablet 10 mg, 25 mg 2 BD

chlorpromazine hcl oral tablet 100 mg, 200 mg, 50 mg 2

compro suppository 25 mg 2 NMO

FLUPHENAZINE DECANOATE INJECTION SOLUTION

25 MG/ML 3 NMO

fluphenazine hcl injection solution 2.5 mg/ml 2 NMO

fluphenazine hcl oral concentrate 5 mg/ml 2

fluphenazine hcl oral elixir 2.5 mg/5ml 2

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

haloperidol decanoate intramuscular* solution 100 mg/ml 2 NMO

haloperidol decanoate intramuscular* solution 50 mg/ml 1 NMO



33


haloperidol lactate injection solution 5 mg/ml 2 NMO

haloperidol lactate oral concentrate 2 mg/ml 1

haloperidol oral tablet 0.5 mg, 1 mg, 10 mg, 2 mg, 20 mg, 5

mg 1

loxapine succinate oral capsule 10 mg, 25 mg, 5 mg, 50 mg 2

MOLINDONE HCL ORAL TABLET 10 MG, 25 MG, 5 MG 4

PERPHENAZINE ORAL TABLET 16 MG 3

perphenazine oral tablet 2 mg, 4 mg, 8 mg 2

PERPHENAZINE-AMITRIPTYLINE ORAL TABLET 2-10

MG, 2-25 MG, 4-10 MG, 4-25 MG, 4-50 MG 3 PA

pimozide oral tablet 1 mg, 2 mg 2

prochlorperazine edisylate injection solution 5 mg/ml 2 NMO

prochlorperazine maleate oral tablet 10 mg, 5 mg 1

prochlorperazine suppository 25 mg 2 NMO

thioridazine hcl oral tablet 10 mg, 100 mg, 25 mg, 50 mg 2 PA

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

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

2ND GENERATION/ATYPICAL

ABILIFY MAINTENA INTRAMUSCULAR* SUSPENSION

RECONSTITUTED 300 MG, 300 MG (1.5ML SYRINGE),

400 MG

4

ARIPIPRAZOLE ORAL TABLET 10 MG, 15 MG, 20 MG,

30 MG 3 QL (30 EA per 30 days)

ARIPIPRAZOLE ORAL TABLET 2 MG, 5 MG 3 QL (60 EA per 30 days)

ARIPIPRAZOLE ORAL TABLET DISPERSIBLE 10 MG, 15


ARISTADA INTRAMUSCULAR* 441 MG/1.6ML 4 ST

ARISTADA INTRAMUSCULAR* 662 MG/2.4ML, 882

MG/3.2ML 5 ST; NMO

EQUETRO ORAL CAPSULE EXTENDED RELEASE 12

HOUR 100 MG, 200 MG, 300 MG 4

FANAPT ORAL TABLET 1 MG, 10 MG, 12 MG, 2 MG, 4

MG, 6 MG, 8 MG 4 NMO; QL (60 EA per 30 days)

FANAPT TITRATION PACK ORAL TABLET 1 & 2 & 4 &

6 MG 4 NMO

GEODON INTRAMUSCULAR* SOLUTION

RECONSTITUTED 20 MG 4 NMO; QL (60 EA per 30 days)



34


INVEGA SUSTENNA INTRAMUSCULAR* SUSPENSION

117 MG/0.75ML 5 NMO; QL (0.75 ML per 28 days)


156 MG/ML 5 NMO; QL (1 ML per 28 days)







INVEGA TRINZA INTRAMUSCULAR* SUSPENSION 273

MG/0.875ML 5 NMO; QL (0.875 ML per 90 days)







LATUDA ORAL TABLET 120 MG, 20 MG, 40 MG 3 QL (30 EA per 30 days)

LATUDA ORAL TABLET 60 MG, 80 MG 3 QL (60 EA per 30 days)

NUPLAZID ORAL TABLET 17 MG 5 PA; NMO

olanzapine intramuscular* solution reconstituted 10 mg 4 NMO

olanzapine oral tablet 10 mg, 15 mg, 2.5 mg, 20 mg, 5 mg, 7.5

mg 1

OLANZAPINE ORAL TABLET DISPERSIBLE 10 MG, 15

MG, 20 MG, 5 MG 3 QL (30 EA per 30 days)

olanzapine-fluoxetine hcl oral capsule 12-25 mg, 12-50 mg, 3-

25 mg, 6-25 mg, 6-50 mg 4

PALIPERIDONE ER ORAL TABLET EXTENDED

RELEASE 24 HR* 1.5 MG, 3 MG, 6 MG 3 QL (60 EA per 30 days)

PALIPERIDONE ER ORAL TABLET EXTENDED

RELEASE 24 HR* 9 MG 3 QL (30 EA per 30 days)

quetiapine fumarate oral tablet 100 mg, 200 mg, 25 mg, 300

mg, 400 mg, 50 mg 1

REXULTI ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG,

3 MG, 4 MG 5


days)

RISPERDAL CONSTA INTRAMUSCULAR*

SUSPENSION RECONSTITUTED 12.5 MG, 25 MG 4 NMO

RISPERDAL CONSTA INTRAMUSCULAR*

SUSPENSION RECONSTITUTED 37.5 MG, 50 MG 5 NMO



35


risperidone oral solution 1 mg/ml 2

risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4

mg 1

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

mg, 3 mg, 4 mg 2

SAPHRIS SUBLINGUAL TABLET SUBLINGUAL 10 MG,

2.5 MG, 5 MG 4 QL (60 EA per 30 days)

SEROQUEL XR ORAL TABLET EXTENDED RELEASE

24 HR* 150 MG, 200 MG, 300 MG, 400 MG, 50 MG 3

VRAYLAR ORAL 1.5 & 3 MG 4 ST; NMO

VRAYLAR ORAL CAPSULE 1.5 MG 5 ST; NMO; QL (120 EA per 30

days)

VRAYLAR ORAL CAPSULE 3 MG 5 ST; NMO; QL (60 EA per 30

days)

VRAYLAR ORAL CAPSULE 4.5 MG, 6 MG 5 ST; NMO; QL (30 EA per 30

days)

ziprasidone hcl oral capsule 20 mg, 40 mg, 60 mg, 80 mg 2

ZYPREXA RELPREVV INTRAMUSCULAR*

SUSPENSION RECONSTITUTED 210 MG 4 NMO

TREATMENT-RESISTANT

clozapine oral tablet 100 mg 2 NMO; QL (270 EA per 30 days)

clozapine oral tablet 200 mg, 25 mg 2 NMO; QL (120 EA per 30 days)

clozapine oral tablet 50 mg 2 NMO; QL (180 EA per 30 days)

CLOZAPINE ORAL TABLET DISPERSIBLE 100 MG, 25


CLOZAPINE ORAL TABLET DISPERSIBLE 12.5 MG 4 NMO; QL (90 EA per 30 days)

clozapine oral tablet dispersible 150 mg 4 NMO; QL (270 EA per 30 days)

clozapine oral tablet dispersible 200 mg 5 NMO; QL (120 EA per 30 days)

VERSACLOZ ORAL SUSPENSION 50 MG/ML 4 NMO; QL (540 ML per 30 days)

ANTIVIRALS

ANTI-CYTOMEGALOVIRUS (CMV) AGENTS

cidofovir intravenous* solution 75 mg/ml 4 BD; NMO

GANCICLOVIR SODIUM INTRAVENOUS* SOLUTION


valganciclovir hcl oral tablet 450 mg 5 NMO

ANTIHEPATITIS AGENTS

adefovir dipivoxil oral tablet 10 mg 5 PA; NMO; QL (30 EA per 30

days)



36


BARACLUDE ORAL SOLUTION 0.05 MG/ML 5 NMO; QL (600 ML per 30 days)

DAKLINZA ORAL TABLET 30 MG, 60 MG, 90 MG 5 PA; NMO

entecavir oral tablet 0.5 mg, 1 mg 5 NMO; QL (30 EA per 30 days)

HARVONI ORAL TABLET 90-400 MG 5 PA; NMO

PEGASYS PROCLICK SUBCUTANEOUS* SOLUTION

135 MCG/0.5ML, 180 MCG/0.5ML 5 PA; NMO

PEGASYS SUBCUTANEOUS* SOLUTION 180

MCG/0.5ML, 180 MCG/ML 5 PA; NMO

PEG-INTRON REDIPEN SUBCUTANEOUS* KIT 120

MCG/0.5ML, 150 MCG/0.5ML, 50 MCG/0.5ML, 80

MCG/0.5ML

5 PA; NMO

PEGINTRON SUBCUTANEOUS* KIT 120 MCG/0.5ML,

150 MCG/0.5ML, 50 MCG/0.5ML, 80 MCG/0.5ML 5 PA; NMO

REBETOL ORAL SOLUTION 40 MG/ML 5 PA; NMO

RIBASPHERE ORAL TABLET 400 MG 4 PA; NMO

RIBASPHERE ORAL TABLET 600 MG 5 PA; NMO

ribasphere ribapak oral tablet 400 & 600 mg, 400 mg 5 PA; NMO

RIBASPHERE RIBAPAK ORAL TABLET 600 MG 5 PA; NMO

RIBAVIRIN ORAL CAPSULE 200 MG 3 PA; NMO; QL (180 EA per 30

days)

RIBAVIRIN ORAL TABLET 200 MG 3 PA; NMO; QL (180 EA per 30

days)

SOVALDI ORAL TABLET 400 MG 5 PA; NMO; QL (30 EA per 30

days)

TYZEKA ORAL TABLET 600 MG 5 PA; NMO; QL (30 EA per 30

days)

ZEPATIER ORAL TABLET 50-100 MG 5 PA; NMO

ANTIHERPETIC AGENTS

acyclovir oral capsule 200 mg 1 NMO

acyclovir oral suspension 200 mg/5ml 2 NMO

acyclovir oral tablet 400 mg, 800 mg 1 NMO

acyclovir sodium intravenous* solution 50 mg/ml 2 BD; NMO

valacyclovir hcl oral tablet 1 gm, 500 mg 2 NMO

ANTI-HIV AGENTS, NON-NUCLEOSIDE

REVERSE TRANSCRIPTASE INHIBITORS

EDURANT ORAL TABLET 25 MG 5 NMO; QL (30 EA per 30 days)

INTELENCE ORAL TABLET 100 MG 5 NMO; QL (120 EA per 30 days)

INTELENCE ORAL TABLET 200 MG 5 NMO; QL (60 EA per 30 days)



37


INTELENCE ORAL TABLET 25 MG 4 QL (120 EA per 30 days)

NEVIRAPINE ER ORAL TABLET EXTENDED RELEASE

24 HR* 100 MG, 400 MG 3

NEVIRAPINE ORAL SUSPENSION 50 MG/5ML 3 QL (1200 ML per 30 days)

NEVIRAPINE ORAL TABLET 200 MG 3 QL (60 EA per 30 days)

RESCRIPTOR ORAL TABLET 100 MG 4 QL (360 EA per 30 days)

RESCRIPTOR ORAL TABLET 200 MG 4 QL (180 EA per 30 days)

SUSTIVA ORAL CAPSULE 200 MG 4 QL (120 EA per 30 days)

SUSTIVA ORAL CAPSULE 50 MG 4 QL (480 EA per 30 days)

SUSTIVA ORAL TABLET 600 MG 4 QL (30 EA per 30 days)

TYBOST ORAL TABLET 150 MG 4

ANTI-HIV AGENTS, NUCLEOSIDE AND

NUCLEOTIDE REVERSE TRANSCRIPTASE

INHIBITORS

abacavir sulfate oral tablet 300 mg 4 QL (60 EA per 30 days)

abacavir-lamivudine-zidovudine oral tablet 300-150-300 mg 5 NMO; QL (60 EA per 30 days)

DESCOVY ORAL TABLET 200-25 MG 5 NMO

DIDANOSINE ORAL CAPSULE DELAYED RELEASE 125

MG 3 QL (90 EA per 30 days)




MG, 400 MG 3 QL (30 EA per 30 days)

EMTRIVA ORAL CAPSULE 200 MG 4 QL (30 EA per 30 days)

EMTRIVA ORAL SOLUTION 10 MG/ML 4 QL (680 ML per 28 days)

EPIVIR HBV ORAL SOLUTION 5 MG/ML 3

EPZICOM ORAL TABLET 600-300 MG 5 NMO; QL (30 EA per 30 days)

EVOTAZ ORAL TABLET 300-150 MG 5 NMO; QL (30 EA per 30 days)

LAMIVUDINE ORAL SOLUTION 10 MG/ML 3 QL (960 ML per 30 days)

LAMIVUDINE ORAL TABLET 100 MG 3

LAMIVUDINE ORAL TABLET 150 MG 3 QL (60 EA per 30 days)

LAMIVUDINE ORAL TABLET 300 MG 3 QL (30 EA per 30 days)

lamivudine-zidovudine oral tablet 150-300 mg 4 QL (60 EA per 30 days)

PREZCOBIX ORAL TABLET 800-150 MG 5 NMO; QL (30 EA per 30 days)

RETROVIR INTRAVENOUS* SOLUTION 10 MG/ML 4 NMO

STAVUDINE ORAL CAPSULE 15 MG, 20 MG 3 QL (120 EA per 30 days)

STAVUDINE ORAL CAPSULE 30 MG, 40 MG 3 QL (60 EA per 30 days)



38


STAVUDINE ORAL SOLUTION RECONSTITUTED 1

MG/ML 3

TRUVADA ORAL TABLET 100-150 MG, 133-200 MG,

167-250 MG 5 NMO

TRUVADA ORAL TABLET 200-300 MG 5 NMO; QL (30 EA per 30 days)

VIDEX ORAL SOLUTION RECONSTITUTED 2 GM 4 QL (1200 ML per 30 days)

VIREAD ORAL POWDER 40 MG/GM 5 NMO; QL (240 GM per 30 days)

VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG, 300


ZIAGEN ORAL SOLUTION 20 MG/ML 4 QL (960 ML per 30 days)

ZIDOVUDINE ORAL CAPSULE 100 MG 3 QL (180 EA per 30 days)

ZIDOVUDINE ORAL SYRUP 50 MG/5ML 3 QL (1680 ML per 28 days)

ZIDOVUDINE ORAL TABLET 300 MG 3 QL (60 EA per 30 days)

ANTI-HIV AGENTS, OTHER

FUZEON SUBCUTANEOUS* SOLUTION

RECONSTITUTED 90 MG 5 NMO; QL (60 EA per 30 days)

ISENTRESS ORAL PACKET 100 MG 3

ISENTRESS ORAL TABLET 400 MG 5 NMO; QL (120 EA per 30 days)

ISENTRESS ORAL TABLET CHEWABLE 100 MG 4 QL (180 EA per 30 days)

ISENTRESS ORAL TABLET CHEWABLE 25 MG 3 QL (180 EA per 30 days)

SELZENTRY ORAL TABLET 150 MG 5 NMO; QL (240 EA per 30 days)

SELZENTRY ORAL TABLET 300 MG 5 NMO; QL (120 EA per 30 days)

TIVICAY ORAL TABLET 10 MG, 25 MG 4

TIVICAY ORAL TABLET 50 MG 5 NMO

VITEKTA ORAL TABLET 150 MG, 85 MG 5 NMO; QL (30 EA per 30 days)

ANTI-HIV AGENTS, PROTEASE INHIBITORS

APTIVUS ORAL CAPSULE 250 MG 5 NMO; QL (120 EA per 30 days)

APTIVUS ORAL SOLUTION 100 MG/ML 5 NMO; QL (285 ML per 28 days)

CRIXIVAN ORAL CAPSULE 200 MG 3 QL (450 EA per 30 days)

CRIXIVAN ORAL CAPSULE 400 MG 3 QL (270 EA per 30 days)

INVIRASE ORAL CAPSULE 200 MG 4 QL (300 EA per 30 days)

INVIRASE ORAL TABLET 500 MG 5 NMO; QL (120 EA per 30 days)

KALETRA ORAL SOLUTION 400-100 MG/5ML 5 NMO

KALETRA ORAL TABLET 100-25 MG 4 QL (300 EA per 30 days)

KALETRA ORAL TABLET 200-50 MG 5 NMO; QL (150 EA per 30 days)

LEXIVA ORAL SUSPENSION 50 MG/ML 3 QL (1575 ML per 28 days)



39


LEXIVA ORAL TABLET 700 MG 5 NMO; QL (120 EA per 30 days)

NORVIR ORAL CAPSULE 100 MG 4 QL (360 EA per 30 days)

NORVIR ORAL SOLUTION 80 MG/ML 4 QL (480 ML per 30 days)

NORVIR ORAL TABLET 100 MG 4 QL (360 EA per 30 days)

PREZISTA ORAL SUSPENSION 100 MG/ML 4

PREZISTA ORAL TABLET 150 MG 4 QL (240 EA per 30 days)

PREZISTA ORAL TABLET 600 MG 5 NMO; QL (60 EA per 30 days)

PREZISTA ORAL TABLET 75 MG 4 QL (480 EA per 30 days)

PREZISTA ORAL TABLET 800 MG 5 NMO

REYATAZ ORAL CAPSULE 150 MG, 200 MG 5 NMO; QL (60 EA per 30 days)

REYATAZ ORAL CAPSULE 300 MG 5 NMO; QL (30 EA per 30 days)

REYATAZ ORAL PACKET 50 MG 5 NMO

TRIUMEQ ORAL TABLET 600-50-300 MG 5 NMO; QL (30 EA per 30 days)

VIRACEPT ORAL TABLET 250 MG 5 NMO; QL (300 EA per 30 days)

VIRACEPT ORAL TABLET 625 MG 5 NMO; QL (120 EA per 30 days)

ANTI-INFLUENZA AGENTS

RELENZA DISKHALER INHALATION AEROSOL

POWDER, BREATH ACTIVATED 5 MG/BLISTER 4 NMO

RIMANTADINE HCL ORAL TABLET 100 MG 3 NMO

TAMIFLU ORAL CAPSULE 30 MG, 45 MG, 75 MG 3 NMO

TAMIFLU ORAL SUSPENSION RECONSTITUTED 6

MG/ML 3 NMO; QL (540 ML per 30 days)

VIRAZOLE INHALATION SOLUTION RECONSTITUTED

6 GM 5 BD; NMO

ANTIVIRALS, OTHER

ATRIPLA ORAL TABLET 600-200-300 MG 5 NMO; QL (30 EA per 30 days)

COMPLERA ORAL TABLET 200-25-300 MG 5 NMO; QL (30 EA per 30 days)

famciclovir oral tablet 125 mg, 250 mg, 500 mg 2 NMO

GENVOYA ORAL TABLET 150-150-200-10 MG 5 NMO; QL (60 EA per 30 days)

ODEFSEY ORAL TABLET 200-25-25 MG 5 NMO

STRIBILD ORAL TABLET 150-150-200-300 MG 5 NMO; QL (30 EA per 30 days)

ANXIOLYTICS

ANXIOLYTICS, OTHER

buspirone hcl oral tablet 10 mg, 15 mg, 30 mg, 5 mg, 7.5 mg 1 NMO

hydroxyzine hcl intramuscular* solution 25 mg/ml, 50 mg/ml 4 PA; NMO

hydroxyzine hcl oral syrup 10 mg/5ml 4 PA; NMO



40


hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg 2 PA; NMO

hydroxyzine pamoate oral capsule 100 mg, 25 mg, 50 mg 2 PA; NMO

BENZODIAZEPINES

alprazolam er oral tablet extended release 24 hr* 0.5 mg 2 QL (90 EA per 30 days)

alprazolam er oral tablet extended release 24 hr* 1 mg, 3 mg 2 NMO; QL (90 EA per 30 days)

alprazolam intensol oral concentrate 1 mg/ml 2 NMO; QL (300 ML per 30 days)

alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg 2 NMO; QL (180 EA per 30 days)

ALPRAZOLAM ORAL TABLET DISPERSIBLE 0.25 MG,

0.5 MG, 1 MG 3 NMO; QL (360 EA per 30 days)

alprazolam xr oral tablet extended release 24 hr* 0.5 mg 2 NMO; QL (90 EA per 30 days)

chlordiazepoxide hcl oral capsule 10 mg, 25 mg, 5 mg 2 NMO; QL (120 EA per 30 days)

clorazepate dipotassium oral tablet 15 mg, 3.75 mg, 7.5 mg 2 NMO; QL (180 EA per 30 days)

DIAZEPAM INTENSOL ORAL CONCENTRATE 5 MG/ML 3 NMO; QL (240 ML per 30 days)

DIAZEPAM ORAL SOLUTION 1 MG/ML 3 NMO; QL (1200 ML per 30 days)

diazepam oral tablet 10 mg 2 NMO; QL (120 EA per 30 days)



lorazepam intensol oral concentrate 2 mg/ml 2 NMO; QL (240 ML per 30 days)

lorazepam oral tablet 0.5 mg, 1 mg, 2 mg 2 NMO; QL (150 EA per 30 days)

OXAZEPAM ORAL CAPSULE 10 MG, 15 MG, 30 MG 3 NMO; QL (120 EA per 30 days)

BIPOLAR AGENTS

MOOD STABILIZERS

carbamazepine oral tablet chewable 100 mg 1

lithium carbonate er oral tablet extendedrelease* 300 mg, 450

mg 1

lithium carbonate oral capsule 150 mg, 300 mg, 600 mg 1

lithium carbonate oral tablet 300 mg 1

lithium oral solution 8 meq/5ml 2

BLOOD GLUCOSE REGULATORS

ANTIDIABETIC AGENTS

acarbose oral tablet 100 mg, 50 mg 2 QL (90 EA per 30 days)

acarbose oral tablet 25 mg 1 QL (90 EA per 30 days)

ASSURE ID INSULIN SAFETY SYR 29G X 1/2" 1 ML 3 NMO

BYDUREON SUBCUTANEOUS* 2 MG 3

BYETTA 10 MCG PEN SUBCUTANEOUS* 10

MCG/0.04ML 3



41


BYETTA 5 MCG PEN SUBCUTANEOUS* 5 MCG/0.02ML 3

COMFORT ASSIST INSULIN SYRINGE 29G X 1/2" 1 ML 3 NMO

CVS GAUZE STERILE PAD 2"X2" 3 NMO

CYCLOSET ORAL TABLET 0.8 MG 4

EXEL COMFORT POINT PEN NEEDLE 29G X 12MM 3 NMO

EXEL PEN NEEDLES 1/2" 29G X 12MM 3

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

glipizide er oral tablet extended release 24 hr* 10 mg, 2.5 mg,

5 mg 1

glipizide oral tablet 10 mg, 5 mg 1

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


GLOBAL ALCOHOL PREP EASE PAD 70 % 3 NMO

INVOKAMET ORAL TABLET 150-1000 MG, 150-500 MG,

50-1000 MG, 50-500 MG 3

INVOKANA ORAL TABLET 100 MG, 300 MG 3

JANUMET ORAL TABLET 50-1000 MG, 50-500 MG 3 QL (60 EA per 30 days)

JANUMET XR ORAL TABLET EXTENDED RELEASE 24

HR* 100-1000 MG 3 QL (30 EA per 30 days)

JANUMET XR ORAL TABLET EXTENDED RELEASE 24

HR* 50-1000 MG, 50-500 MG 3 QL (60 EA per 30 days)

JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG 3 QL (30 EA per 30 days)

JARDIANCE ORAL TABLET 10 MG, 25 MG 3 QL (30 EA per 30 days)

JENTADUETO ORAL TABLET 2.5-1000 MG, 2.5-500 MG,

2.5-850 MG 3 QL (60 EA per 30 days)

JENTADUETO XR ORAL TABLET EXTENDED

RELEASE 24 HR* 2.5-1000 MG 4 QL (60 EA per 30 days)

JENTADUETO XR ORAL TABLET EXTENDED

RELEASE 24 HR* 5-1000 MG 4 QL (30 EA per 30 days)

KORLYM ORAL TABLET 300 MG 5 PA; LA; NMO; QL (120 EA per

30 days)

metformin hcl er (osm) oral tablet extended release 24 hr*


metformin hcl er oral tablet extended release 24 hr* 500 mg 1 QL (120 EA per 30 days)

metformin hcl er oral tablet extended release 24 hr* 750 mg 1 QL (90 EA per 30 days)

metformin hcl oral tablet 1000 mg, 500 mg, 850 mg 1

miglitol oral tablet 100 mg, 25 mg, 50 mg 2

nateglinide oral tablet 120 mg, 60 mg 2



42


pioglitazone hcl oral tablet 15 mg 1

pioglitazone hcl oral tablet 30 mg, 45 mg 2

pioglitazone hcl-glimepiride oral tablet 30-2 mg, 30-4 mg 2 QL (30 EA per 30 days)

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

mg 2 QL (90 EA per 30 days)

PREFERRED PLUS INSULIN SYRINGE 28G X 1/2" 0.5 ML 3 NMO

RELI-ON INSULIN SYRINGE 29G 0.3 ML 3 NMO

repaglinide oral tablet 0.5 mg, 1 mg, 2 mg 2

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

RIOMET ORAL SOLUTION 500 MG/5ML 4

SYMLINPEN 120 SUBCUTANEOUS* 2700 MCG/2.7ML 4 PA; QL (10.8 ML per 28 days)

symlinpen 60 subcutaneous* 1500 mcg/1.5ml 1 PA; QL (10.8 ML per 28 days)

SYNJARDY ORAL TABLET 12.5-1000 MG, 12.5-500 MG,

5-1000 MG, 5-500 MG3

tolazamide oral tablet 250 mg, 500 mg 1

tolbutamide oral tablet 500 mg 1

TRADJENTA ORAL TABLET 5 MG 3 QL (30 EA per 30 days)

VICTOZA SUBCUTANEOUS* 18 MG/3ML 3 QL (9 ML per 30 days)

GLYCEMIC AGENTS

GLUCAGEN HYPOKIT INJECTION SOLUTION


GLUCAGON EMERGENCY INJECTION KIT 1 MG 3 NMO

PROGLYCEM ORAL SUSPENSION 50 MG/ML 3

INSULINS

LANTUS SOLOSTAR SUBCUTANEOUS* 100 UNIT/ML 3

LANTUS SUBCUTANEOUS* SOLUTION 100 UNIT/ML 3

LEVEMIR FLEXTOUCH SUBCUTANEOUS* 100

UNIT/ML 3

LEVEMIR SUBCUTANEOUS* SOLUTION 100 UNIT/ML 3

NOVOLIN 70/30 SUBCUTANEOUS* SUSPENSION (70-

30) 100 UNIT/ML3

NOVOLIN N SUBCUTANEOUS* SUSPENSION 100

UNIT/ML 3

NOVOLIN R INJECTION SOLUTION 100 UNIT/ML 3

NOVOLOG FLEXPEN SUBCUTANEOUS* 100 UNIT/ML 3

NOVOLOG MIX 70/30 FLEXPEN SUBCUTANEOUS* (70-

30) 100 UNIT/ML3



43


NOVOLOG MIX 70/30 SUBCUTANEOUS* SUSPENSION

(70-30) 100 UNIT/ML 3

NOVOLOG PENFILL SUBCUTANEOUS* 100 UNIT/ML 3

NOVOLOG SUBCUTANEOUS* SOLUTION 100 UNIT/ML 3

TOUJEO SOLOSTAR SUBCUTANEOUS* 300 UNIT/ML 3

BLOOD PRODUCTS/MODIFIERS/ VOLUME

EXPANDERS

ANTICOAGULANTS

argatroban intravenous* solution 250 mg/2.5ml 4 BD; NMO

ELIQUIS ORAL TABLET 2.5 MG, 5 MG 3

enoxaparin sodium injection solution 300 mg/3ml 4 NMO

enoxaparin sodium subcutaneous* solution 100 mg/ml, 120

mg/0.8ml, 150 mg/ml, 30 mg/0.3ml, 40 mg/0.4ml, 60 mg/0.6ml,

80 mg/0.8ml

4 NMO

fondaparinux sodium subcutaneous* solution 10 mg/0.8ml, 5

mg/0.4ml, 7.5 mg/0.6ml 5 NMO

fondaparinux sodium subcutaneous* solution 2.5 mg/0.5ml 4 NMO

FRAGMIN SUBCUTANEOUS* SOLUTION 10000

UNIT/ML, 12500 UNIT/0.5ML, 15000 UNIT/0.6ML, 18000

UNT/0.72ML, 7500 UNIT/0.3ML, 95000 UNIT/3.8ML

5 NMO

FRAGMIN SUBCUTANEOUS* SOLUTION 2500

UNIT/0.2ML, 5000 UNIT/0.2ML 4 NMO

heparin (porcine) in d5w intravenous* solution 40-5 unit/ml-

%, 50-5 unit/ml-% 1 BD; NMO

heparin sod (porcine) in d5w intravenous* solution 100

unit/ml 1 BD; NMO

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

10000 unit/ml, 20000 unit/ml, 5000 unit/ml 1 NMO

jantoven oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5

mg, 6 mg, 7.5 mg 1

PRADAXA ORAL CAPSULE 110 MG, 150 MG, 75 MG 4

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

4 mg, 5 mg, 6 mg, 7.5 mg 1

XARELTO ORAL TABLET 10 MG, 15 MG, 20 MG 3

XARELTO STARTER PACK ORAL 15 & 20 MG 3 NMO

BLOOD FORMATION MODIFIERS

ARANESP (ALBUMIN FREE) INJECTION 100

MCG/0.5ML, 150 MCG/0.3ML, 200 MCG/0.4ML, 300

MCG/0.6ML, 500 MCG/ML

5 PA; NMO



44


ARANESP (ALBUMIN FREE) INJECTION 25

MCG/0.42ML, 40 MCG/0.4ML, 60 MCG/0.3ML 3 PA; NMO

ARANESP (ALBUMIN FREE) INJECTION SOLUTION 100

MCG/ML, 200 MCG/ML, 300 MCG/ML 5 PA; NMO

ARANESP (ALBUMIN FREE) INJECTION SOLUTION 25

MCG/ML, 40 MCG/ML, 60 MCG/ML 3 PA; NMO

EPOGEN INJECTION SOLUTION 10000 UNIT/ML, 2000

UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000

UNIT/ML

4 PA; NMO

LEUKINE INTRAVENOUS* SOLUTION

RECONSTITUTED 250 MCG 5 PA; NMO

MIRCERA INJECTION 100 MCG/0.3ML, 50 MCG/0.3ML,

75 MCG/0.3ML 4 BD; NMO

MOZOBIL SUBCUTANEOUS* SOLUTION 24 MG/1.2ML 5 PA; NMO; QL (9.6 ML per 30

days)

NEULASTA SUBCUTANEOUS* 6 MG/0.6ML 5 PA; NMO

NEUPOGEN INJECTION 300 MCG/0.5ML, 480

MCG/0.8ML 5 PA; NMO

NEUPOGEN INJECTION SOLUTION 300 MCG/ML 4 PA; NMO

NEUPOGEN INJECTION SOLUTION 480 MCG/1.6ML 5 PA; NMO

PROCRIT INJECTION SOLUTION 10000 UNIT/ML, 2000

UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML 3 PA; NMO

PROCRIT INJECTION SOLUTION 20000 UNIT/ML, 40000

UNIT/ML 5 PA; NMO

PROMACTA ORAL TABLET 12.5 MG, 25 MG, 50 MG, 75

MG 5


days)

tranexamic acid intravenous* solution 1000 mg/10ml 1 BD; NMO

tranexamic acid oral tablet 650 mg 2 NMO

ZARXIO INJECTION 300 MCG/0.5ML, 480 MCG/0.8ML 3 PA; NMO

PLATELET MODIFYING AGENTS

anagrelide hcl oral capsule 0.5 mg, 1 mg 1

aspirin-dipyridamole er oral capsule extended release 12 hour

25-200 mg 2

BRILINTA ORAL TABLET 60 MG, 90 MG 3

cilostazol oral tablet 100 mg, 50 mg 1

clopidogrel bisulfate oral tablet 300 mg 2 NMO

clopidogrel bisulfate oral tablet 75 mg 1

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

EFFIENT ORAL TABLET 10 MG 4



45


CARDIOVASCULAR AGENTS

ALPHA-ADRENERGIC AGONISTS

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

clonidine hcl transdermal patch weekly 0.1 mg/24hr, 0.2

mg/24hr, 0.3 mg/24hr 2

guanfacine hcl oral tablet 1 mg, 2 mg 1 PA

midodrine hcl oral tablet 10 mg, 2.5 mg, 5 mg 2 NMO

ALPHA-ADRENERGIC BLOCKING AGENTS

DEMSER ORAL CAPSULE 250 MG 4 NMO

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

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

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

ANGIOTENSIN II RECEPTOR ANTAGONISTS

BENICAR ORAL TABLET 20 MG, 40 MG, 5 MG 4

candesartan cilexetil oral tablet 16 mg, 32 mg, 4 mg, 8 mg 2

eprosartan mesylate oral tablet 600 mg 2

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

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

telmisartan oral tablet 20 mg, 40 mg, 80 mg 1

valsartan oral tablet 160 mg, 320 mg, 40 mg, 80 mg 2

ANGIOTENSIN-CONVERTING ENZYME

(ACE) INHIBITORS

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

captopril oral tablet 100 mg, 12.5 mg, 25 mg, 50 mg 2

enalapril maleate oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg 1

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

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

mg 1

moexipril hcl oral tablet 15 mg, 7.5 mg 2

perindopril erbumine oral tablet 2 mg, 4 mg, 8 mg 1

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

ramipril oral capsule 1.25 mg, 10 mg, 2.5 mg, 5 mg 1

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

ANTIARRHYTHMICS

amiodarone hcl intravenous* solution 150 mg/3ml 1 BD; NMO

amiodarone hcl oral tablet 200 mg 1



46


amiodarone hcl oral tablet 400 mg 2

disopyramide phosphate oral capsule 100 mg, 150 mg 1 PA

dofetilide oral capsule 125 mcg, 250 mcg, 500 mcg 2

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

mexiletine hcl oral capsule 150 mg, 200 mg, 250 mg 2

MULTAQ ORAL TABLET 400 MG 4

NORPACE CR ORAL CAPSULE EXTENDED RELEASE

12 HOUR 100 MG, 150 MG 4 PA

pacerone oral tablet 100 mg, 200 mg, 400 mg 1

PROPAFENONE HCL ER ORAL CAPSULE EXTENDED

RELEASE 12 HOUR 225 MG, 325 MG, 425 MG 3

propafenone hcl oral tablet 150 mg, 225 mg, 300 mg 2

quinidine gluconate er oral tablet extendedrelease* 324 mg 1

quinidine sulfate oral tablet 200 mg, 300 mg 1

ANTIHYPERTENSIVE COMBINATIONS

ALDACTAZIDE ORAL TABLET 50-50 MG 4

amiloride-hydrochlorothiazide oral tablet 5-50 mg 1

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

mg, 2.5-10 mg, 5-10 mg, 5-20 mg, 5-40 mg 1

AMLODIPINE BESYLATE-VALSARTAN ORAL TABLET

10-160 MG, 10-320 MG, 5-160 MG, 5-320 MG 3

AMLODIPINE-VALSARTAN-HCTZ ORAL TABLET 10-

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

MG, 5-160-25 MG

3

atenolol-chlorthalidone oral tablet 100-25 mg, 50-25 mg 1

AZOR ORAL TABLET 10-20 MG, 10-40 MG, 5-20 MG, 5-

40 MG 4

benazepril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-

12.5 mg, 20-25 mg, 5-6.25 mg 2

BENICAR HCT ORAL TABLET 20-12.5 MG, 40-12.5 MG,

40-25 MG 4

bisoprolol-hydrochlorothiazide oral tablet 10-6.25 mg, 2.5-

6.25 mg, 5-6.25 mg 1

candesartan cilexetil-hctz oral tablet 16-12.5 mg, 32-12.5 mg,

32-25 mg 2

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

50-15 mg, 50-25 mg 2

clorpres oral tablet 0.1-15 mg, 0.2-15 mg, 0.3-15 mg 1



47


enalapril-hydrochlorothiazide oral tablet 10-25 mg, 5-12.5 mg 1

fosinopril sodium-hctz oral tablet 10-12.5 mg, 20-12.5 mg 1

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

12.5 mg 1

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

mg, 20-25 mg 1

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

50-12.5 mg 1

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

25 mg 1 PA

metoprolol-hydrochlorothiazide oral tablet 100-25 mg, 100-50

mg, 50-25 mg 2

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

mg, 20-25 mg 1

spironolactone-hctz oral tablet 25-25 mg 1

TELMISARTAN-HCTZ ORAL TABLET 40-12.5 MG, 80-

12.5 MG, 80-25 MG 3

triamterene-hctz oral capsule 37.5-25 mg, 50-25 mg 1

triamterene-hctz oral tablet 37.5-25 mg, 75-50 mg 1

TRIBENZOR 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 4

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

mg, 320-12.5 mg, 320-25 mg, 80-12.5 mg 1

BETA-ADRENERGIC BLOCKING AGENTS

acebutolol hcl oral capsule 200 mg, 400 mg 1

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

bisoprolol fumarate oral tablet 10 mg, 5 mg 1

BYSTOLIC ORAL TABLET 10 MG, 2.5 MG, 20 MG, 5 MG 3

carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg, 6.25 mg 1

COREG CR ORAL CAPSULE EXTENDED RELEASE 24

HOUR 10 MG, 20 MG, 40 MG, 80 MG 4

labetalol hcl intravenous* solution 5 mg/ml 2 NMO

labetalol hcl oral tablet 100 mg, 200 mg 1

labetalol hcl oral tablet 300 mg 2

metoprolol succinate er oral tablet extended release 24 hr*

100 mg, 25 mg, 50 mg 1

metoprolol succinate er oral tablet extended release 24 hr*

200 mg 2



48


metoprolol tartrate intravenous* solution 1 mg/ml, 5 mg/5ml 1 NMO

metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg 1

nadolol oral tablet 20 mg, 40 mg, 80 mg 2

pindolol oral tablet 10 mg, 5 mg 2

propranolol hcl er oral capsule extended release 24 hour 120

mg, 160 mg, 60 mg, 80 mg 2

propranolol hcl intravenous* solution 1 mg/ml 1 NMO

propranolol hcl oral solution 20 mg/5ml, 40 mg/5ml 1

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

mg 1

sotalol hcl (af) oral tablet 120 mg 1

sotalol hcl oral tablet 160 mg, 240 mg, 80 mg 1

timolol maleate oral tablet 20 mg, 5 mg 1

CALCIUM CHANNEL BLOCKING AGENTS

afeditab cr oral tablet extended release 24 hr* 30 mg, 60 mg 1

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

CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24

HR* 120 MG 4

cartia xt oral capsule extended release 24 hour 120 mg, 180

mg, 240 mg, 300 mg 1

diltiazem hcl er beads oral capsule extended release 24 hour

180 mg 1

diltiazem hcl er beads oral capsule extended release 24 hour

360 mg, 420 mg 2

diltiazem hcl er coated beads oral capsule extended release 24

hour 120 mg, 240 mg, 300 mg 1

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

60 mg, 90 mg 2

diltiazem hcl intravenous* solution 50 mg/10ml 1 NMO

diltiazem hcl intravenous* solution reconstituted 100 mg 1 NMO

diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg, 90 mg 1

dilt-xr oral capsule extended release 24 hour 120 mg, 180 mg,

240 mg 1

felodipine er oral tablet extended release 24 hr* 10 mg, 2.5

mg, 5 mg 1

ISRADIPINE ORAL CAPSULE 2.5 MG, 5 MG 3

matzim la oral tablet extended release 24 hr* 180 mg, 240 mg,

300 mg, 360 mg, 420 mg 2



49


nicardipine hcl oral capsule 20 mg, 30 mg 1

nifedical xl oral tablet extended release 24 hr* 30 mg, 60 mg 1

nifedipine er osmotic release oral tablet extended release 24

hr* 30 mg, 60 mg 1

nifedipine er osmotic release oral tablet extended release 24

hr* 90 mg 2

nimodipine oral capsule 30 mg 4

NISOLDIPINE ER ORAL TABLET EXTENDED RELEASE

24 HR* 17 MG, 20 MG, 25.5 MG, 30 MG, 34 MG, 40 MG,

8.5 MG

3

taztia xt oral capsule extended release 24 hour 120 mg, 180

mg, 240 mg, 300 mg, 360 mg 1

verapamil hcl er oral capsule extended release 24 hour 100

mg, 120 mg, 180 mg, 200 mg, 240 mg, 300 mg 2

VERAPAMIL HCL ER ORAL CAPSULE EXTENDED

RELEASE 24 HOUR 360 MG 3

verapamil hcl er oral tablet extendedrelease* 120 mg, 180 mg,

240 mg 1

verapamil hcl intravenous* solution 2.5 mg/ml 1 NMO

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

CARDIOVASCULAR AGENTS, OTHER

AMLODIPINE-ATORVASTATIN ORAL TABLET 10-10

MG, 10-20 MG, 10-40 MG, 10-80 MG, 2.5-10 MG, 2.5-20

MG, 2.5-40 MG, 5-10 MG, 5-20 MG, 5-40 MG, 5-80 MG

3

digitek oral tablet 125 mcg, 250 mcg 1

digoxin injection solution 0.25 mg/ml 1 NMO

digoxin oral solution 0.05 mg/ml 1

digoxin oral tablet 125 mcg, 250 mcg 1

pentoxifylline er oral tablet extendedrelease* 400 mg 1

RANEXA ORAL TABLET EXTENDED RELEASE 12 HR*

1000 MG, 500 MG 3

DIURETICS, CARBONIC ANHYDRASE

INHIBITORS

acetazolamide oral tablet 125 mg 1

acetazolamide oral tablet 250 mg 2

METHAZOLAMIDE ORAL TABLET 25 MG, 50 MG 4

DIURETICS, LOOP

bumetanide injection solution 0.25 mg/ml 1 NMO



50


EDECRIN ORAL TABLET 25 MG 4

furosemide injection solution 10 mg/ml, 10 mg/ml (4ml

syringe) 1 NMO

furosemide oral solution 10 mg/ml, 8 mg/ml 1

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

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

DIURETICS, POTASSIUM-SPARING

amiloride hcl oral tablet 5 mg 1

eplerenone oral tablet 25 mg, 50 mg 2

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

DIURETICS, THIAZIDE

chlorothiazide oral tablet 250 mg, 500 mg 2

CHLOROTHIAZIDE SODIUM INTRAVENOUS*

SOLUTION RECONSTITUTED 500 MG 3 NMO

chlorthalidone oral tablet 25 mg, 50 mg 1

DIURIL ORAL SUSPENSION 250 MG/5ML 4

hydrochlorothiazide oral capsule 12.5 mg 1

hydrochlorothiazide oral tablet 12.5 mg, 25 mg, 50 mg 1

indapamide oral tablet 1.25 mg, 2.5 mg 1

methyclothiazide oral tablet 5 mg 1

metolazone oral tablet 10 mg, 5 mg 2

metolazone oral tablet 2.5 mg 1

DYSLIPIDEMICS, FIBRIC ACID

DERIVATIVES

fenofibrate micronized oral capsule 130 mg, 134 mg, 200 mg,

43 mg, 67 mg 2

fenofibrate oral capsule 150 mg, 50 mg 2

fenofibrate oral tablet 145 mg, 160 mg, 48 mg, 54 mg 2

fenofibric acid oral capsule delayed release 135 mg, 45 mg 2

gemfibrozil oral tablet 600 mg 1

DYSLIPIDEMICS, HMG COA REDUCTASE

INHIBITORS

atorvastatin calcium oral tablet 10 mg, 20 mg, 40 mg, 80 mg 1

FLUVASTATIN SODIUM ER ORAL TABLET EXTENDED

RELEASE 24 HR* 80 MG 3

fluvastatin sodium oral capsule 20 mg, 40 mg 2



51


LIVALO ORAL TABLET 1 MG, 2 MG, 4 MG 3

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

pravastatin sodium oral tablet 10 mg, 20 mg, 40 mg, 80 mg 1

rosuvastatin calcium oral tablet 10 mg, 20 mg, 40 mg, 5 mg 2

simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg, 80 mg 1

DYSLIPIDEMICS, OTHER

cholestyramine light oral packet 4 gm 2

cholestyramine light oral powder 4 gm/dose 2

colestipol hcl oral granules 5 gm 2

colestipol hcl oral tablet 1 gm 2

JUXTAPID ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40

MG, 5 MG, 60 MG 5


days)

KYNAMRO SUBCUTANEOUS* 200 MG/ML 4 PA

niacin er (antihyperlipidemic) oral tablet extendedrelease*

1000 mg, 500 mg, 750 mg 2

niacor oral tablet 500 mg 1 NMO

omega-3-acid ethyl esters oral capsule 1 gm 2

PRALUENT SUBCUTANEOUS* 150 MG/ML, 75 MG/ML 5 PA; NMO

REPATHA PUSHTRONEX SYSTEM SUBCUTANEOUS*

420 MG/3.5ML 5 PA; NMO

REPATHA SUBCUTANEOUS* 140 MG/ML 5 PA; NMO

REPATHA SURECLICK SUBCUTANEOUS* 140 MG/ML 5 PA; NMO

WELCHOL ORAL TABLET 625 MG 3

ZETIA ORAL TABLET 10 MG 4

VASODILATORS, DIRECT-ACTING

ARTERIAL/VENOUS

ISOSORBIDE DINITRATE ER ORAL TABLET

EXTENDEDRELEASE* 40 MG 3

isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 mg, 5 mg 2

isosorbide mononitrate er oral tablet extended release 24 hr*

120 mg, 30 mg, 60 mg 1

isosorbide mononitrate oral tablet 10 mg, 20 mg 1

minitran transdermal patch 24 hr 0.1 mg/hr, 0.2 mg/hr, 0.4

mg/hr, 0.6 mg/hr 1

NITRO-BID TRANSDERMAL OINTMENT 2 % 3

nitroglycerin transdermal patch 24 hr 0.1 mg/hr, 0.2 mg/hr,

0.4 mg/hr, 0.6 mg/hr 1



52


NITROGLYCERIN TRANSLINGUAL SOLUTION 0.4

MG/SPRAY 4

nitrostat sublingual tablet sublingual 0.3 mg, 0.4 mg 1

NITROSTAT SUBLINGUAL TABLET SUBLINGUAL 0.6

MG 3

VASODILATORS, DIRECT-ACTING

ARTERIAL

BIDIL ORAL TABLET 20-37.5 MG 4

hydralazine hcl injection solution 20 mg/ml 1 NMO

hydralazine hcl oral tablet 10 mg, 100 mg, 25 mg, 50 mg 1

minoxidil oral tablet 10 mg, 2.5 mg 1

CENTRAL NERVOUS SYSTEM AGENTS

ATTENTION DEFICIT HYPERACTIVITY

DISORDER AGENTS, AMPHETAMINES

AMPHETAMINE-DEXTROAMPHET ER ORAL CAPSULE

EXTENDED RELEASE 24 HOUR 10 MG, 15 MG, 20 MG,

25 MG, 30 MG, 5 MG

3 PA

amphetamine-dextroamphetamine oral tablet 10 mg, 12.5 mg,

15 mg, 20 mg, 30 mg, 5 mg, 7.5 mg 2

dextroamphetamine sulfate er oral capsule extended release

24 hour 10 mg, 15 mg, 5 mg 4 PA

DEXTROAMPHETAMINE SULFATE ORAL TABLET 10

MG, 5 MG 3 PA

VYVANSE ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40

MG, 50 MG, 60 MG, 70 MG 4 PA

zenzedi oral tablet 15 mg, 20 mg, 30 mg 4

ATTENTION DEFICIT HYPERACTIVITY

DISORDER AGENTS, NON-AMPHETAMINES

CLONIDINE HCL ER ORAL TABLET EXTENDED

RELEASE 12 HR* 0.1 MG 3 QL (120 EA per 30 days)

DAYTRANA TRANSDERMAL PATCH 15 MG/9HR 4 PA

guanfacine hcl er oral tablet extended release 24 hr* 1 mg, 2

mg, 3 mg, 4 mg 4 PA

METHYLPHENIDATE HCL ER (CD) ORAL CAPSULE

EXTENDED RELEASE* 10 MG, 30 MG, 50 MG, 60 MG 3 PA

METHYLPHENIDATE HCL ER (LA) ORAL CAPSULE

EXTENDED RELEASE 24 HOUR 20 MG, 40 MG 3 PA



53


METHYLPHENIDATE HCL ER ORAL TABLET

EXTENDED RELEASE 24 HR* 18 MG, 27 MG, 36 MG, 54

MG

3 PA

METHYLPHENIDATE HCL ER ORAL TABLET

EXTENDEDRELEASE* 20 MG 3 PA

METHYLPHENIDATE HCL ORAL SOLUTION 10

MG/5ML, 5 MG/5ML 3 PA

methylphenidate hcl oral tablet 10 mg, 20 mg, 5 mg 2 PA

STRATTERA ORAL CAPSULE 10 MG, 18 MG, 25 MG, 40

MG, 60 MG, 80 MG 4 PA; QL (60 EA per 30 days)

STRATTERA ORAL CAPSULE 100 MG 4 PA; QL (30 EA per 30 days)

CENTRAL NERVOUS SYSTEM, OTHER

riluzole oral tablet 50 mg 4

tetrabenazine oral tablet 12.5 mg 5 PA; NMO; QL (90 EA per 30

days)

tetrabenazine oral tablet 25 mg 5 PA; NMO; QL (120 EA per 30

days)

FIBROMYALGIA AGENTS

LYRICA ORAL CAPSULE 100 MG 3 QL (120 EA per 30 days)

SAVELLA ORAL TABLET 100 MG, 12.5 MG, 25 MG, 50


SAVELLA TITRATION PACK ORAL 12.5 & 25 & 50 MG 3 NMO

MULTIPLE SCLEROSIS AGENTS

AMPYRA ORAL TABLET EXTENDED RELEASE 12 HR*

10 MG 5


days)

AVONEX INTRAMUSCULAR* KIT 30 MCG 5 PA; NMO

AVONEX PEN INTRAMUSCULAR* 30 MCG/0.5ML 5 PA; NMO

AVONEX PREFILLED INTRAMUSCULAR* 30

MCG/0.5ML 5 PA; NMO

BETASERON SUBCUTANEOUS* KIT 0.3 MG 5 PA; NMO

COPAXONE SUBCUTANEOUS* 20 MG/ML, 40 MG/ML 5 PA; NMO

GILENYA ORAL CAPSULE 0.5 MG 5 PA; NMO

PLEGRIDY STARTER PACK SUBCUTANEOUS* 63 & 94

MCG/0.5ML 5 PA; NMO

PLEGRIDY SUBCUTANEOUS* 125 MCG/0.5ML 5 PA; NMO

TECFIDERA ORAL 120 & 240 MG 5 PA; NMO

TECFIDERA ORAL CAPSULE DELAYED RELEASE 120

MG, 240 MG 5


days)



54


TYSABRI INTRAVENOUS* CONCENTRATE 300

MG/15ML 5 PA; NMO

DENTAL AND ORAL AGENTS

DENTAL AND ORAL AGENTS

CEVIMELINE HCL ORAL CAPSULE 30 MG 3

chlorhexidine gluconate mouth/throat solution 0.12 % 1 NMO

clotrimazole mouth/throat troche 10 mg 1 NMO

lidocaine viscous mouth/throat solution 2 % 1 NMO

nystatin mouth/throat suspension 100000 unit/ml 1 NMO

pilocarpine hcl oral tablet 5 mg 2

PILOCARPINE HCL ORAL TABLET 7.5 MG 3

triamcinolone acetonide mouth/throat paste 0.1 % 2 NMO

DERMATOLOGICAL AGENTS

DERMATOLOGICAL AGENTS

8-MOP ORAL CAPSULE 10 MG 4 NMO

ACANYA EXTERNAL GEL 1.2-2.5 % 4 NMO

acitretin oral capsule 10 mg, 17.5 mg, 25 mg 5 PA; NMO

acyclovir external ointment 5 % 4 NMO

ADAPALENE EXTERNAL CREAM 0.1 % 3 NMO

ADAPALENE EXTERNAL GEL 0.1 %, 0.3 % 3 NMO

ALA SCALP EXTERNAL LOTION 2 % 4 NMO

alclometasone dipropionate external cream 0.05 % 1 NMO

alclometasone dipropionate external ointment 0.05 % 1 NMO

ALTABAX EXTERNAL OINTMENT 1 % 4 NMO

AMCINONIDE EXTERNAL CREAM 0.1 % 3 NMO

AMCINONIDE EXTERNAL LOTION 0.1 % 3 NMO

AMCINONIDE EXTERNAL OINTMENT 0.1 % 3 NMO

ammonium lactate external cream 12 % 1 NMO

ammonium lactate external lotion 12 % 1 NMO

AZELEX EXTERNAL CREAM 20 % 4 NMO

benzoyl peroxide-erythromycin external gel 5-3 % 2 NMO

betamethasone dipropionate aug external cream 0.05 % 1 NMO

betamethasone dipropionate aug external lotion 0.05 % 2 NMO

betamethasone dipropionate aug external ointment 0.05 % 2 NMO

betamethasone dipropionate external cream 0.05 % 2 NMO



55


betamethasone dipropionate external lotion 0.05 % 2 NMO

betamethasone dipropionate external ointment 0.05 % 2 NMO

betamethasone valerate external cream 0.1 % 2 NMO

betamethasone valerate external foam 0.12 % 2 NMO

betamethasone valerate external lotion 0.1 % 2 NMO

betamethasone valerate external ointment 0.1 % 2 NMO

calcipotriene external cream 0.005 % 4 NMO

calcipotriene external ointment 0.005 % 4 NMO

calcipotriene external solution 0.005 % 4 NMO

calcipotriene-betameth diprop external ointment 0.005-0.064

% 4 NMO

CALCITRIOL EXTERNAL OINTMENT 3 MCG/GM 4 NMO

CAPEX EXTERNAL SHAMPOO 0.01 % 4 NMO

ciclopirox external gel 0.77 % 2 NMO

ciclopirox external shampoo 1 % 2 NMO

ciclopirox olamine external cream 0.77 % 1 NMO

ciclopirox olamine external suspension 0.77 % 2 NMO

claravis oral capsule 10 mg, 20 mg, 30 mg, 40 mg 4 NMO

clindamycin phos-benzoyl perox external gel 1-5 % 4 NMO

clindamycin phosphate external foam 1 % 2 NMO

clindamycin phosphate external gel 1 % 2 NMO

clindamycin phosphate external lotion 1 % 2 NMO

clindamycin phosphate external solution 1 % 2 NMO

clindamycin phosphate external swab 1 % 2 NMO

CLOBETASOL PROPIONATE E EXTERNAL CREAM 0.05

% 3 NMO

CLOBETASOL PROPIONATE EXTERNAL FOAM 0.05 % 3 NMO

CLOBETASOL PROPIONATE EXTERNAL GEL 0.05 % 3 NMO

CLOBETASOL PROPIONATE EXTERNAL LIQUID† 0.05

% 3 NMO

CLOBETASOL PROPIONATE EXTERNAL LOTION 0.05

% 3 NMO

CLOBETASOL PROPIONATE EXTERNAL OINTMENT

0.05 % 3 NMO

CLOBETASOL PROPIONATE EXTERNAL SHAMPOO

0.05 % 3 NMO



56


CLOBETASOL PROPIONATE EXTERNAL SOLUTION

0.05 % 3 NMO

CLODERM PUMP EXTERNAL CREAM 0.1 % 4 NMO

clotrimazole external cream 1 % 1 NMO

clotrimazole external solution 1 % 1 NMO

CONDYLOX EXTERNAL GEL 0.5 % 4 NMO

CORDRAN EXTERNAL TAPE 4 MCG/SQCM 4 NMO

CORTISPORIN EXTERNAL CREAM 3.5-10000-0.5 4 NMO

CORTISPORIN EXTERNAL OINTMENT 1 % 4 NMO

COSENTYX SENSOREADY PEN SUBCUTANEOUS* 150

MG/ML 5 ST; NMO

COSENTYX SUBCUTANEOUS* 150 MG/ML 5 ST; NMO

DENAVIR EXTERNAL CREAM 1 % 4 NMO

DESONATE EXTERNAL GEL 0.05 % 4 NMO

DESONIDE EXTERNAL CREAM 0.05 % 3 NMO

DESONIDE EXTERNAL LOTION 0.05 % 3 NMO

DESONIDE EXTERNAL OINTMENT 0.05 % 3 NMO

DESOXIMETASONE EXTERNAL CREAM 0.05 %, 0.25 % 3 NMO

DESOXIMETASONE EXTERNAL GEL 0.05 % 3 NMO

DESOXIMETASONE EXTERNAL OINTMENT 0.25 % 3 NMO

diclofenac sodium transdermal gel 1 % 2 NMO

diclofenac sodium transdermal gel 3 % 5 PA; NMO; QL (100 GM per 30

days)

diclofenac sodium transdermal solution 1.5 % 4 NMO

DIFFERIN EXTERNAL LOTION 0.1 % 4 NMO

DIFLORASONE DIACETATE EXTERNAL CREAM 0.05 % 3 NMO

DIFLORASONE DIACETATE EXTERNAL OINTMENT

0.05 % 4 NMO

econazole nitrate external cream 1 % 2 NMO

ELIDEL EXTERNAL CREAM 1 % 4 PA; NMO

EPIDUO EXTERNAL GEL 0.1-2.5 % 4 NMO

EPIDUO FORTE EXTERNAL GEL 0.3-2.5 % 4 NMO

ery external pad 2 % 1 NMO

erythromycin external gel 2 % 1 NMO

erythromycin external solution 2 % 1 NMO

EURAX EXTERNAL CREAM 10 % 4 NMO

EURAX EXTERNAL LOTION 10 % 4 NMO



57


EXELDERM EXTERNAL CREAM 1 % 4 NMO

EXELDERM EXTERNAL SOLUTION 1 % 4 NMO

FINACEA EXTERNAL GEL 15 % 4 NMO

FLUOCINOLONE ACETONIDE BODY EXTERNAL OIL

0.01 % 3 NMO

FLUOCINOLONE ACETONIDE EXTERNAL CREAM 0.01

%, 0.025 % 3 NMO

FLUOCINOLONE ACETONIDE EXTERNAL OINTMENT

0.025 % 3 NMO

FLUOCINOLONE ACETONIDE EXTERNAL SOLUTION

0.01 % 3 NMO

fluocinonide external cream 0.1 % 4 NMO

FLUOCINONIDE EXTERNAL GEL 0.05 % 3 NMO

FLUOCINONIDE EXTERNAL OINTMENT 0.05 % 3 NMO

FLUOCINONIDE EXTERNAL SOLUTION 0.05 % 3 NMO

FLUOCINONIDE-E EXTERNAL CREAM 0.05 % 3 NMO

FLUOROURACIL EXTERNAL CREAM 5 % 3 NMO

FLUOROURACIL EXTERNAL SOLUTION 2 %, 5 % 3 NMO

fluticasone propionate external cream 0.05 % 1 NMO

FLUTICASONE PROPIONATE EXTERNAL LOTION 0.05

% 3 NMO

fluticasone propionate external ointment 0.005 % 1 NMO

gentamicin sulfate external cream 0.1 % 1 NMO

gentamicin sulfate external ointment 0.1 % 2 NMO

HALOBETASOL PROPIONATE EXTERNAL CREAM 0.05

% 3 NMO

HALOBETASOL PROPIONATE EXTERNAL OINTMENT

0.05 % 3 NMO

HALOG EXTERNAL CREAM 0.1 % 4 NMO

HALOG EXTERNAL OINTMENT 0.1 % 4 NMO

HYDROCORTISONE BUTYRATE EXTERNAL

OINTMENT 0.1 % 3 NMO

HYDROCORTISONE BUTYRATE EXTERNAL

SOLUTION 0.1 % 3 NMO

HYDROCORTISONE ENEMA 100 MG/60ML 3 NMO

hydrocortisone external cream 1 %, 2.5 % 1 NMO

hydrocortisone external lotion 2.5 % 1 NMO

hydrocortisone external ointment 1 %, 2.5 % 1 NMO



58


HYDROCORTISONE VALERATE EXTERNAL CREAM

0.2 % 3 NMO

HYDROCORTISONE VALERATE EXTERNAL

OINTMENT 0.2 % 3 NMO

IMIQUIMOD EXTERNAL CREAM 5 % 3 NMO

ketoconazole external cream 2 % 2 NMO

ketoconazole external foam 2 % 2 NMO

ketoconazole external shampoo 2 % 1 NMO

LIDOCAINE EXTERNAL OINTMENT 5 % 3 NMO

LIDOCAINE EXTERNAL PATCH 5 % 3 PA; NMO; QL (90 EA per 30

days)

lidocaine hcl external gel 2 %, 2 % (10ml applicator) 1 NMO

lidocaine hcl external solution 4 % 1 NMO

MALATHION EXTERNAL LOTION 0.5 % 3 NMO

MENTAX EXTERNAL CREAM 1 % 4 NMO

methoxsalen rapid oral capsule 10 mg 2 PA; NMO

METRONIDAZOLE EXTERNAL CREAM 0.75 % 3 NMO

METRONIDAZOLE EXTERNAL GEL 0.75 %, 1 % 3 NMO

METRONIDAZOLE EXTERNAL LOTION 0.75 % 3 NMO

mometasone furoate external cream 0.1 % 1 NMO

mometasone furoate external ointment 0.1 % 1 NMO

mometasone furoate external solution 0.1 % 1 NMO

MUPIROCIN CALCIUM EXTERNAL CREAM 2 % 3 NMO

mupirocin external ointment 2 % 1 NMO

NAFTIFINE HCL EXTERNAL CREAM 1 %, 2 % 3 NMO

NAFTIN EXTERNAL CREAM 2 % 4 NMO

NAFTIN EXTERNAL GEL 1 % 4 NMO

nystatin external cream 100000 unit/gm 1 NMO

nystatin external ointment 100000 unit/gm 1 NMO

nystatin external powder 100000 unit/gm 1 NMO

oxiconazole nitrate external cream 1 % 4 NMO

OXISTAT EXTERNAL LOTION 1 % 4 NMO

PANDEL EXTERNAL CREAM 0.1 % 4 NMO

PANRETIN EXTERNAL GEL 0.1 % 5 NMO

PERMETHRIN EXTERNAL CREAM 5 % 3 NMO

PICATO EXTERNAL GEL 0.015 %, 0.05 % 5 NMO



59


podofilox external solution 0.5 % 2 NMO

PREDNICARBATE EXTERNAL CREAM 0.1 % 3 NMO

PREDNICARBATE EXTERNAL OINTMENT 0.1 % 3 NMO

procto-med hc cream 2.5 % 1 NMO

proctozone-hc cream 2.5 % 2 NMO

REGRANEX EXTERNAL GEL 0.01 % 5 PA; NMO

SANTYL EXTERNAL OINTMENT 250 UNIT/GM 3 NMO

selenium sulfide external lotion 2.5 % 1 NMO

silver sulfadiazine external cream 1 % 1 NMO

SKLICE EXTERNAL LOTION 0.5 % 4 NMO

SOOLANTRA EXTERNAL CREAM 1 % 4 NMO

STELARA SUBCUTANEOUS* 45 MG/0.5ML, 90 MG/ML 5 ST; NMO

SULFACETAMIDE SODIUM EXTERNAL SUSPENSION

10 % 3 NMO

SULFAMYLON EXTERNAL CREAM 85 MG/GM 4 NMO

TACLONEX EXTERNAL SUSPENSION 0.005-0.064 % 4 NMO

tacrolimus external ointment 0.03 %, 0.1 % 4 PA; NMO

TARGRETIN EXTERNAL GEL 1 % 5 NMO

TAZORAC EXTERNAL CREAM 0.05 %, 0.1 % 4 NMO

TAZORAC EXTERNAL GEL 0.05 %, 0.1 % 4 NMO

TOLAK EXTERNAL CREAM 4 % 3 NMO

TOPICORT SPRAY EXTERNAL LIQUID† 0.25 % 4 NMO

TRETINOIN EXTERNAL CREAM 0.025 %, 0.05 %, 0.1 % 3 NMO

TRETINOIN EXTERNAL GEL 0.01 %, 0.025 % 3 NMO

tretinoin external gel 0.05 % 4 NMO

tretinoin microsphere external gel 0.04 %, 0.1 % 4 NMO

TRIAMCINOLONE ACETONIDE EXTERNAL AEROSOL,

SOLUTION 0.147 MG/GM 3 NMO

triamcinolone acetonide external cream 0.025 %, 0.1 %, 0.5 % 1 NMO

triamcinolone acetonide external lotion 0.025 % 1 NMO

triamcinolone acetonide external lotion 0.1 % 2 NMO

triamcinolone acetonide external ointment 0.025 %, 0.1 %, 0.5

% 1 NMO

UCERIS FOAM 2 MG/ACT 4 ST; NMO

VALCHLOR EXTERNAL GEL 0.016 % 5 NMO

ZIANA EXTERNAL GEL 1.2-0.025 % 4 NMO



60


ZONALON EXTERNAL CREAM 5 % 3 NMO

ZOVIRAX EXTERNAL CREAM 5 % 4 NMO

ENZYME REPLACEMENT/ MODIFIERS

ENZYME REPLACEMENT/ MODIFIERS

ADAGEN INTRAMUSCULAR* SOLUTION 250 UNIT/ML 5 PA; LA; NMO

ALDURAZYME INTRAVENOUS* SOLUTION 2.9

MG/5ML 5 PA; LA; NMO

CEREZYME INTRAVENOUS* SOLUTION

RECONSTITUTED 400 UNIT 5 PA; LA; NMO

CYSTADANE ORAL POWDER 5 NMO

ELAPRASE INTRAVENOUS* SOLUTION 6 MG/3ML 5 PA; NMO

FABRAZYME INTRAVENOUS* SOLUTION

RECONSTITUTED 35 MG 5 PA; LA; NMO

KANUMA INTRAVENOUS* SOLUTION 20 MG/10ML 5 PA; NMO

KUVAN ORAL TABLET SOLUBLE 100 MG 5 PA; LA; NMO

levocarnitine oral solution 1 gm/10ml 1 BD

levocarnitine oral tablet 330 mg 1 BD

NAGLAZYME INTRAVENOUS* SOLUTION 1 MG/ML 5 PA; NMO

ORFADIN ORAL CAPSULE 10 MG, 2 MG, 5 MG 5 NMO

ORFADIN ORAL SUSPENSION 4 MG/ML 5 LA; NMO

RAVICTI ORAL LIQUID† 1.1 GM/ML 4

sodium phenylbutyrate oral powder 3 gm/tsp 2

ZAVESCA ORAL CAPSULE 100 MG 5 PA; NMO

GASTROINTESTINAL AGENTS

ANTISPASMODICS, GASTROINTESTINAL

atropine sulfate injection solution 0.05 mg/ml, 0.1 mg/ml 1 NMO

BENTYL INTRAMUSCULAR* SOLUTION 10 MG/ML 4 NMO

CUVPOSA ORAL SOLUTION 1 MG/5ML 4

dicyclomine hcl intramuscular* solution 10 mg/ml 1 NMO

dicyclomine hcl oral capsule 10 mg 1 NMO

dicyclomine hcl oral solution 10 mg/5ml 1 NMO

dicyclomine hcl oral tablet 20 mg 1 NMO

glycopyrrolate injection solution 4 mg/20ml 1 NMO

glycopyrrolate oral tablet 1 mg, 2 mg 2 NMO

methscopolamine bromide oral tablet 2.5 mg, 5 mg 2 NMO

ROBINUL INJECTION SOLUTION 0.4 MG/2ML 3 NMO



61


ROBINUL-FORTE ORAL TABLET 2 MG 3 NMO

DIGESTIVE ENZYMES

CREON ORAL CAPSULE DELAYED RELEASE

PARTICLES 12000 UNIT, 24000 UNIT, 3000-9500 UNIT,

36000 UNIT, 6000 UNIT

4 ST

PANCREAZE ORAL CAPSULE DELAYED RELEASE

PARTICLES 10500 UNIT, 16800 UNIT, 21000 UNIT, 4200

UNIT

3

PERTZYE ORAL CAPSULE DELAYED RELEASE

PARTICLES 16000 UNIT, 8000 UNIT 4 ST

VIOKACE ORAL TABLET 10440 UNIT, 20880 UNIT 4

ZENPEP ORAL CAPSULE DELAYED RELEASE

PARTICLES 10000 UNIT, 15000 UNIT, 20000 UNIT, 25000

UNIT, 3000-10000 UNIT, 40000 UNIT, 5000 UNIT

3

GASTROINTESTINAL AGENTS, OTHER

AMOXICILL-CLARITHRO-LANSOPRAZ ORAL 3 NMO

cromolyn sodium oral concentrate 100 mg/5ml 1

diphenoxylate-atropine oral liquid† 2.5-0.025 mg/5ml 1 NMO

diphenoxylate-atropine oral tablet 2.5-0.025 mg 1 NMO

GATTEX SUBCUTANEOUS* KIT 5 MG 5 NMO

loperamide hcl oral capsule 2 mg 1 NMO

metoclopramide hcl injection solution 5 mg/ml 1 NMO

metoclopramide hcl oral solution 5 mg/5ml 1 NMO

metoclopramide hcl oral tablet 10 mg 1

metoclopramide hcl oral tablet 5 mg 1 NMO

METOCLOPRAMIDE HCL ORAL TABLET DISPERSIBLE

5 MG 3 NMO

MOVANTIK ORAL TABLET 12.5 MG, 25 MG 4 NMO

PYLERA ORAL CAPSULE 140-125-125 MG 4 NMO

RELISTOR ORAL TABLET 150 MG 3 PA; NMO

RELISTOR SUBCUTANEOUS* SOLUTION 12 MG/0.6ML,

12 MG/0.6ML (0.6ML SYRINGE), 8 MG/0.4ML 4 PA; NMO

ursodiol oral capsule 300 mg 2

ursodiol oral tablet 250 mg, 500 mg 2

HISTAMINE2 (H2) RECEPTOR

ANTAGONISTS

cimetidine hcl oral solution 300 mg/5ml 2

cimetidine oral tablet 200 mg 2 NMO



62


cimetidine oral tablet 300 mg, 400 mg, 800 mg 2

famotidine intravenous* solution 20 mg/2ml 2 NMO

famotidine oral suspension reconstituted 40 mg/5ml 2

famotidine oral tablet 20 mg, 40 mg 1

famotidine premixed intravenous* solution 20-0.9 mg/50ml-% 2 NMO

nizatidine oral capsule 150 mg, 300 mg 1

nizatidine oral solution 15 mg/ml 2

ranitidine hcl injection solution 150 mg/6ml 2 NMO

RANITIDINE HCL ORAL CAPSULE 150 MG, 300 MG 3

ranitidine hcl oral syrup 15 mg/ml 2

ranitidine hcl oral tablet 150 mg, 300 mg 1

IRRITABLE BOWEL SYNDROME AGENTS

alosetron hcl oral tablet 0.5 mg, 1 mg 5 NMO

AMITIZA ORAL CAPSULE 24 MCG, 8 MCG 3

LINZESS ORAL CAPSULE 145 MCG, 290 MCG 3

LAXATIVES

enulose oral solution 10 gm/15ml 1

gavilyte-c oral solution reconstituted 240 gm 1 NMO

generlac oral solution 10 gm/15ml 1

GOLYTELY ORAL SOLUTION RECONSTITUTED 227.1

GM 4 NMO

lactulose oral solution 10 gm/15ml 1

MOVIPREP ORAL SOLUTION RECONSTITUTED 100 GM 4 NMO

OSMOPREP ORAL TABLET 1.102-0.398 GM 4 NMO

peg 3350-kcl-na bicarb-nacl oral solution reconstituted 420

gm 1 NMO

peg-3350/electrolytes oral solution reconstituted 236 gm 1 NMO

polyethylene glycol 3350 oral powder 1 NMO

PREPOPIK ORAL PACKET 10-3.5-12 MG-GM-GM 4 NMO

SUPREP BOWEL PREP ORAL SOLUTION 4 NMO

PROTECTANTS

CARAFATE ORAL SUSPENSION 1 GM/10ML 3

misoprostol oral tablet 100 mcg 1

misoprostol oral tablet 200 mcg 2

sucralfate oral tablet 1 gm 1

PROTON PUMP INHIBITORS



63


DEXILANT ORAL CAPSULE DELAYED RELEASE 30

MG, 60 MG 3 ST; QL (30 EA per 30 days)

esomeprazole sodium intravenous* solution reconstituted 20

mg 2 NMO

lansoprazole oral capsule delayed release 15 mg, 30 mg 2

omeprazole oral capsule delayed release 10 mg, 40 mg 1

omeprazole oral capsule delayed release 20 mg 2

pantoprazole sodium oral tablet delayed release 20 mg, 40 mg 1

rabeprazole sodium oral tablet delayed release 20 mg 2

GENITOURINARY AGENTS

ANTISPASMODICS, URINARY

bethanechol chloride oral tablet 10 mg, 25 mg, 5 mg 1 NMO

bethanechol chloride oral tablet 50 mg 2 NMO

darifenacin hydrobromide er oral tablet extended release 24

hr* 15 mg, 7.5 mg 2

MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24

HR* 25 MG, 50 MG 3 ST

oxybutynin chloride er oral tablet extended release 24 hr* 10

mg, 15 mg, 5 mg 2

oxybutynin chloride oral syrup 5 mg/5ml 1

oxybutynin chloride oral tablet 5 mg 1

tolterodine tartrate er oral capsule extended release 24 hour 2

mg, 4 mg 2

tolterodine tartrate oral tablet 1 mg, 2 mg 2

trospium chloride er oral capsule extended release 24 hour 60

mg 2

trospium chloride oral tablet 20 mg 2

VESICARE ORAL TABLET 10 MG, 5 MG 3

BENIGN PROSTATIC HYPERTROPHY

AGENTS

alfuzosin hcl er oral tablet extended release 24 hr* 10 mg 1

CARDURA XL ORAL TABLET EXTENDED RELEASE 24

HR* 4 MG, 8 MG 4

dutasteride oral capsule 0.5 mg 2

dutasteride-tamsulosin hcl oral capsule 0.5-0.4 mg 2

finasteride oral tablet 5 mg 1

RAPAFLO ORAL CAPSULE 4 MG, 8 MG 4



64


tamsulosin hcl oral capsule 0.4 mg 2

GENITOURINARY AGENTS, OTHER

CYSTAGON ORAL CAPSULE 150 MG, 50 MG 3

ELMIRON ORAL CAPSULE 100 MG 4 NMO

lithostat oral tablet 250 mg 2 NMO

neomycin-polymyxin b gu irrigation solution 40-200000 1 NMO

potassium citrate er oral tablet extendedrelease* 10 meq

(1080 mg), 15 meq (1620 mg), 5 meq (540 mg) 2 NMO

sodium chloride irrigation solution 0.9 % 1 NMO

PHOSPHATE BINDERS

calcium acetate (phos binder) oral capsule 667 mg 2

eliphos oral tablet 667 mg 1

RENVELA ORAL PACKET 0.8 GM, 2.4 GM 3

RENVELA ORAL TABLET 800 MG 3

VAGINAL PRODUCTS

CLEOCIN VAGINAL SUPPOSITORY 100 MG 3 NMO

clindamycin phosphate vaginal cream 2 % 2 NMO

ESTRACE VAGINAL CREAM 0.1 MG/GM 4

ESTRING VAGINAL RING 2 MG 4

FEMRING VAGINAL RING 0.05 MG/24HR, 0.1 MG/24HR 4

metronidazole vaginal gel 0.75 % 2 NMO

miconazole 3 vaginal suppository 200 mg 1 NMO

PREMARIN VAGINAL CREAM 0.625 MG/GM 3

terconazole vaginal cream 0.4 % 2 NMO

terconazole vaginal suppository 80 mg 2 NMO

VAGIFEM VAGINAL TABLET 10 MCG 4

zazole vaginal cream 0.8 % 1 NMO

HORMONAL AGENTS, STIMULANT/

REPLACEMENT/ MODIFYING (ADRENAL)

GLUCOCORTICOIDS/MINERALOCORTICOI

DS

a-hydrocort injection solution reconstituted 100 mg 1 NMO

budesonide oral capsule delayed release particles 3 mg 4 NMO

cortisone acetate oral tablet 25 mg 2 NMO

DEPO-MEDROL INJECTION SUSPENSION 20 MG/ML 4 NMO

dexamethasone intensol oral concentrate 1 mg/ml 1 NMO



65


dexamethasone oral elixir 0.5 mg/5ml 1 NMO

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

mg, 4 mg, 6 mg 1 NMO

dexamethasone sodium phosphate injection solution 10 mg/ml,

120 mg/30ml 1 NMO

DEXPAK 13 DAY ORAL 1.5 MG (51) 4 NMO

fludrocortisone acetate oral tablet 0.1 mg 1

hydrocortisone oral tablet 10 mg, 20 mg, 5 mg 2 NMO

methylprednisolone acetate injection suspension 40 mg/ml, 80

mg/ml 1 NMO

methylprednisolone oral 4 mg 2 NMO

methylprednisolone oral tablet 16 mg, 32 mg, 8 mg 1 NMO

methylprednisolone oral tablet 4 mg 2 NMO

methylprednisolone sodium succ injection solution

reconstituted 125 mg, 40 mg 1 NMO

MILLIPRED ORAL SOLUTION 10 MG/5ML 4 NMO

MILLIPRED ORAL TABLET 5 MG 4 NMO

prednisolone sodium phosphate oral solution 15 mg/5ml, 25

mg/5ml, 6.7 (5 base) mg/5ml 2 NMO

PREDNISOLONE SODIUM PHOSPHATE ORAL TABLET

DISPERSIBLE 10 MG 3 NMO

prednisolone sodium phosphate oral tablet dispersible 15 mg,

30 mg 4 NMO

prednisone intensol oral concentrate 5 mg/ml 1 NMO

prednisone oral 10 mg (21), 10 mg (48), 5 mg (21), 5 mg (48) 1 NMO

prednisone oral solution 5 mg/5ml 1 NMO

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

mg 1 NMO

SOLU-CORTEF INJECTION SOLUTION


SOLU-MEDROL INJECTION SOLUTION

RECONSTITUTED 2 GM, 500 MG 4 NMO

UCERIS ORAL TABLET EXTENDED RELEASE 24 HR* 9

MG 5 ST; NMO

VERIPRED 20 ORAL SOLUTION 20 MG/5ML 4 NMO

HORMONAL AGENTS, STIMULANT/

REPLACEMENT/ MODIFYING (SEX

HORMONES/ MODIFIERS)



66


ANABOLIC STEROIDS

ANADROL-50 ORAL TABLET 50 MG 4 NMO

OXANDROLONE ORAL TABLET 10 MG, 2.5 MG 3 PA; NMO

ANDROGENS

ANDRODERM TRANSDERMAL PATCH 24 HR 2

MG/24HR, 4 MG/24HR 3 PA

ANDROGEL PUMP TRANSDERMAL GEL 20.25 MG/ACT

(1.62%) 4 PA

ANDROGEL TRANSDERMAL GEL 20.25 MG/1.25GM

(1.62%), 40.5 MG/2.5GM (1.62%) 4 PA

AXIRON TRANSDERMAL SOLUTION 30 MG/ACT 4 PA

danazol oral capsule 100 mg, 200 mg, 50 mg 2 NMO

testosterone cypionate intramuscular* solution 100 mg/ml 1 NMO

testosterone cypionate intramuscular* solution 200 mg/ml 2 NMO

testosterone enanthate intramuscular* solution 200 mg/ml 2 NMO

TESTOSTERONE TRANSDERMAL GEL 10 MG/ACT

(2%), 25 MG/2.5GM (1%), 50 MG/5GM (1%) 3 PA

CONTRACEPTIVES

amethia oral tablet 0.15-0.03 &0.01 mg 1

amethyst oral tablet 90-20 mcg 1

apri oral tablet 0.15-30 mg-mcg 1 NMO

aranelle oral tablet 0.5/1/0.5-35 mg-mcg 1

aviane oral tablet 0.1-20 mg-mcg 1

balziva oral tablet 0.4-35 mg-mcg 1

bekyree oral tablet 0.15-0.02/0.01 mg (21/5) 1

BEYAZ ORAL TABLET 3-0.02-0.451 MG 4

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

blisovi fe 1.5/30 oral tablet 1.5-30 mg-mcg 1

blisovi fe 1/20 oral tablet 1-20 mg-mcg 1

briellyn oral tablet 0.4-35 mg-mcg 1

camila oral tablet 0.35 mg 1

caziant oral tablet 0.1/0.125/0.15 -0.025 mg 2

cryselle-28 oral tablet 0.3-30 mg-mcg 1 NMO

cyclafem 1/35 oral tablet 1-35 mg-mcg 1

cyclafem 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg 1

DEPO-SUBQ PROVERA 104 SUBCUTANEOUS*

SUSPENSION 104 MG/0.65ML 4 NMO



67


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

mg 1

emoquette oral tablet 0.15-30 mg-mcg 1

enpresse-28 oral tablet 1

errin oral tablet 0.35 mg 1 NMO

introvale oral tablet 0.15-0.03 mg 1

jolivette oral tablet 0.35 mg 1

juleber oral tablet 0.15-30 mg-mcg 1

junel 1.5/30 oral tablet 1.5-30 mg-mcg 1

junel 1/20 oral tablet 1-20 mg-mcg 1

junel fe 1.5/30 oral tablet 1.5-30 mg-mcg 1

junel fe 1/20 oral tablet 1-20 mg-mcg 1

kaitlib fe oral tablet chewable 0.8-25 mg-mcg 2

kariva oral tablet 0.15-0.02/0.01 mg (21/5) 1 NMO

kelnor 1/35 oral tablet 1-35 mg-mcg 1

kimidess oral tablet 0.15-0.02/0.01 mg (21/5) 1

larissia oral tablet 0.1-20 mg-mcg 1

lessina oral tablet 0.1-20 mg-mcg 1

levonorg-eth estrad triphasic oral tablet 1

levora 0.15/30 (28) oral tablet 0.15-30 mg-mcg 1

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

MCG 4

loryna oral tablet 3-0.02 mg 2

LOSEASONIQUE ORAL TABLET 0.1-0.02 & 0.01 MG 4

lutera oral tablet 0.1-20 mg-mcg 1

lyza oral tablet 0.35 mg 2

marlissa oral tablet 0.15-30 mg-mcg 1

medroxyprogesterone acetate intramuscular* suspension 150

mg/ml 1 NMO

microgestin 1.5/30 oral tablet 1.5-30 mg-mcg 1

microgestin 1/20 oral tablet 1-20 mg-mcg 1

microgestin fe 1.5/30 oral tablet 1.5-30 mg-mcg 1

microgestin fe 1/20 oral tablet 1-20 mg-mcg 1

mononessa oral tablet 0.25-35 mg-mcg 1

necon 0.5/35 (28) oral tablet 0.5-35 mg-mcg 1

necon 1/35 (28) oral tablet 1-35 mg-mcg 1



68


necon 10/11 (28) oral tablet 35 mcg 1

necon 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg 1

norethindrone oral tablet 0.35 mg 2

norgestim-eth estrad triphasic oral tablet 0.18/0.215/0.25 mg-

25 mcg 2

norgestim-eth estrad triphasic oral tablet 0.18/0.215/0.25 mg-

35 mcg 1

nortrel 0.5/35 (28) oral tablet 0.5-35 mg-mcg 1

nortrel 1/35 (21) oral tablet 1-35 mg-mcg 1

nortrel 1/35 (28) oral tablet 1-35 mg-mcg 1

nortrel 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg 1

NUVARING VAGINAL RING 0.12-0.015 MG/24HR 3

ogestrel oral tablet 0.5-50 mg-mcg 1

orsythia oral tablet 0.1-20 mg-mcg 1

portia-28 oral tablet 0.15-30 mg-mcg 1

previfem oral tablet 0.25-35 mg-mcg 1

quasense oral tablet 0.15-0.03 mg 1

reclipsen oral tablet 0.15-30 mg-mcg 1

SAFYRAL ORAL TABLET 3-0.03-0.451 MG 4

setlakin oral tablet 0.15-0.03 mg 1

sprintec 28 oral tablet 0.25-35 mg-mcg 1

sronyx oral tablet 0.1-20 mg-mcg 1

tri-legest fe oral tablet 1-20/1-30/1-35 mg-mcg 1

tri-lo-estarylla oral tablet 0.18/0.215/0.25 mg-25 mcg 2

tri-lo-sprintec oral tablet 0.18/0.215/0.25 mg-25 mcg 2

trinessa (28) oral tablet 0.18/0.215/0.25 mg-35 mcg 1

tri-previfem oral tablet 0.18/0.215/0.25 mg-35 mcg 1

tri-sprintec oral tablet 0.18/0.215/0.25 mg-35 mcg 1 NMO

trivora (28) oral tablet 1

velivet oral tablet 0.1/0.125/0.15 -0.025 mg 1

vestura oral tablet 3-0.02 mg 2

vienva oral tablet 0.1-20 mg-mcg 2

vyfemla oral tablet 0.4-35 mg-mcg 1

xulane transdermal patch weekly 150-35 mcg/24hr 2

zovia 1/35e (28) oral tablet 1-35 mg-mcg 1

zovia 1/50e (28) oral tablet 1-50 mg-mcg 1



69


ESTROGENS

CLIMARA PRO TRANSDERMAL PATCH WEEKLY

0.045-0.015 MG/DAY 4 PA

COMBIPATCH TRANSDERMAL PATCH BIWEEKLY

0.05-0.14 MG/DAY, 0.05-0.25 MG/DAY 4 PA

DEPO-ESTRADIOL INTRAMUSCULAR* OIL 5 MG/ML 4 NMO

DIVIGEL TRANSDERMAL GEL 0.5 MG/0.5GM 4 PA

DUAVEE ORAL TABLET 0.45-20 MG 4 PA

estradiol oral tablet 0.5 mg, 1 mg, 2 mg 1 PA

estradiol transdermal patch biweekly 0.025 mg/24hr, 0.0375

mg/24hr, 0.05 mg/24hr, 0.075 mg/24hr, 0.1 mg/24hr 2 PA

ESTRADIOL TRANSDERMAL PATCH WEEKLY 0.025

MG/24HR, 0.0375 MG/24HR, 0.05 MG/24HR, 0.06

MG/24HR, 0.075 MG/24HR, 0.1 MG/24HR

3 PA

estradiol valerate intramuscular* oil 20 mg/ml, 40 mg/ml 2 NMO

estradiol-norethindrone acet oral tablet 0.5-0.1 mg, 1-0.5 mg 2 PA

estropipate oral tablet 0.75 mg, 1.5 mg, 3 mg 1 PA

EVAMIST TRANSDERMAL SOLUTION 1.53 MG/SPRAY 4 PA

fyavolv oral tablet 0.5-2.5 mg-mcg, 1-5 mg-mcg 1 PA

JINTELI ORAL TABLET 1-5 MG-MCG 3 PA

MENEST ORAL TABLET 0.3 MG, 0.625 MG, 1.25 MG, 2.5

MG 4 PA

MENOSTAR TRANSDERMAL PATCH WEEKLY 14

MCG/24HR 4 PA

norethindrone-eth estradiol oral tablet 1-5 mg-mcg 2 PA

PREFEST ORAL TABLET 1/1-0.09 MG (15/15) 4 PA

PREMARIN INJECTION SOLUTION RECONSTITUTED

25 MG 3 PA; NMO

PREMARIN ORAL TABLET 0.3 MG, 0.45 MG, 0.625 MG,

0.9 MG, 1.25 MG 3 PA

PREMPHASE ORAL TABLET 0.625-5 MG 3 PA

PREMPRO ORAL TABLET 0.3-1.5 MG, 0.45-1.5 MG,

0.625-2.5 MG, 0.625-5 MG 3 PA

PROGESTINS

MAKENA INTRAMUSCULAR* OIL 250 MG/ML 5 PA; NMO

medroxyprogesterone acetate oral tablet 10 mg, 2.5 mg, 5 mg 1

MEGACE ES ORAL SUSPENSION 625 MG/5ML 4 PA



70


MEGESTROL ACETATE ORAL SUSPENSION 625

MG/5ML 3 PA

NORETHINDRONE ACETATE ORAL TABLET 5 MG 3

progesterone micronized oral capsule 100 mg, 200 mg 2

SELECTIVE ESTROGEN RECEPTOR

MODIFYING AGENTS

raloxifene hcl oral tablet 60 mg 2

HORMONAL AGENTS,

STIMULANT/REPLACEMENT/ MODIFYING

(PITUITARY)

HORMONAL AGENTS,


(PITUITARY)

chorionic gonadotropin intramuscular* solution reconstituted

10000 unit 2 PA; NMO

DDAVP NASAL SOLUTION 0.01 % 4

desmopressin ace rhinal tube nasal solution 0.01 % 1

desmopressin ace spray refrig nasal solution 0.01 % 2

desmopressin acetate injection solution 4 mcg/ml 1 NMO

desmopressin acetate oral tablet 0.1 mg, 0.2 mg 2

INCRELEX SUBCUTANEOUS* SOLUTION 40 MG/4ML 5 PA; LA; NMO

NORDITROPIN FLEXPRO SUBCUTANEOUS*

SOLUTION 10 MG/1.5ML, 15 MG/1.5ML, 30 MG/3ML, 5

MG/1.5ML

5 PA; NMO

NUTROPIN AQ NUSPIN 10 SUBCUTANEOUS*

SOLUTION 10 MG/2ML 5 PA; NMO

NUTROPIN AQ NUSPIN 20 SUBCUTANEOUS*

SOLUTION 20 MG/2ML 5 PA; NMO

SEROSTIM SUBCUTANEOUS* SOLUTION

RECONSTITUTED 4 MG, 5 MG, 6 MG 5 PA; NMO

STIMATE NASAL SOLUTION 1.5 MG/ML 4

ZORBTIVE SUBCUTANEOUS* SOLUTION

RECONSTITUTED 8.8 MG 5 PA; NMO

HORMONAL AGENTS,


(THYROID)



71


HORMONAL AGENTS,


(THYROID)

levothyroxine sodium oral tablet 100 mcg, 112 mcg, 125 mcg,

137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50

mcg, 75 mcg, 88 mcg

1

levoxyl oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150

mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg 1

liothyronine sodium intravenous* solution 10 mcg/ml 2 NMO

liothyronine sodium oral tablet 25 mcg, 5 mcg, 50 mcg 1

SYNTHROID ORAL TABLET 100 MCG, 112 MCG, 125

MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG,

300 MCG, 50 MCG, 75 MCG, 88 MCG

3

TIROSINT ORAL CAPSULE 100 MCG, 112 MCG, 125

MCG, 13 MCG, 137 MCG, 150 MCG, 25 MCG, 50 MCG, 75

MCG, 88 MCG

3

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 1

HORMONAL AGENTS, SUPPRESSANT

(PARATHYROID)


(PARATHYROID)

SENSIPAR ORAL TABLET 30 MG 3 QL (120 EA per 30 days)

SENSIPAR ORAL TABLET 60 MG 5 NMO; QL (150 EA per 30 days)

SENSIPAR ORAL TABLET 90 MG 5 NMO; QL (120 EA per 30 days)


(PITUITARY)


(PITUITARY)

cabergoline oral tablet 0.5 mg 2 NMO

LUPRON DEPOT INTRAMUSCULAR* KIT 11.25 MG 5 PA; NMO; QL (1 EA per 28 days)

LUPRON DEPOT-PED INTRAMUSCULAR* KIT 11.25

MG 5 PA; NMO; QL (1 EA per 90 days)

LUPRON DEPOT-PED INTRAMUSCULAR* KIT 15 MG 5 PA; NMO; QL (1 EA per 28 days)

octreotide acetate injection solution 100 mcg/ml, 200 mcg/ml 1 PA

octreotide acetate injection solution 1000 mcg/ml, 500 mcg/ml 5 PA; NMO

octreotide acetate injection solution 50 mcg/ml 2 PA



72


SANDOSTATIN LAR DEPOT INTRAMUSCULAR* KIT 10

MG, 20 MG, 30 MG 5 PA; NMO

SIGNIFOR SUBCUTANEOUS* SOLUTION 0.3 MG/ML,

0.6 MG/ML, 0.9 MG/ML 4 QL (60 ML per 30 days)

SOMATULINE DEPOT SUBCUTANEOUS* SOLUTION

120 MG/0.5ML, 60 MG/0.2ML, 90 MG/0.3ML 5 PA; NMO

SOMAVERT SUBCUTANEOUS* SOLUTION

RECONSTITUTED 10 MG, 15 MG, 20 MG 5 PA; LA; NMO

SYNAREL NASAL SOLUTION 2 MG/ML 5 NMO


(THYROID)

ANTITHYROID AGENTS

methimazole oral tablet 10 mg, 5 mg 1

propylthiouracil oral tablet 50 mg 1

IMMUNOLOGICAL AGENTS

IMMUNE SUPPRESSANTS

ASTAGRAF XL ORAL CAPSULE EXTENDED RELEASE

24 HOUR 0.5 MG, 1 MG 4 BD

ASTAGRAF XL ORAL CAPSULE EXTENDED RELEASE

24 HOUR 5 MG 5 BD; NMO

AZASAN ORAL TABLET 100 MG, 75 MG 3 BD

azathioprine oral tablet 50 mg 1 BD

AZATHIOPRINE SODIUM INJECTION SOLUTION


BENLYSTA INTRAVENOUS* SOLUTION


CELLCEPT INTRAVENOUS INTRAVENOUS*

SOLUTION RECONSTITUTED 500 MG 4 BD; NMO

CIMZIA PREFILLED SUBCUTANEOUS* KIT 2 X 200

MG/ML 5 PA; ST; NMO

CIMZIA SUBCUTANEOUS* KIT 2 X 200 MG 5 PA; ST; NMO

cyclosporine intravenous* solution 50 mg/ml 2 BD; NMO

cyclosporine modified oral capsule 100 mg, 25 mg, 50 mg 2 BD

cyclosporine modified oral solution 100 mg/ml 2 BD

cyclosporine oral capsule 100 mg, 25 mg 2 BD

ENBREL SUBCUTANEOUS* 25 MG/0.5ML, 50 MG/ML 5 PA; NMO

ENBREL SUBCUTANEOUS* SOLUTION




73


ENBREL SURECLICK SUBCUTANEOUS* 50 MG/ML 5 PA; NMO

ENVARSUS XR ORAL TABLET EXTENDED RELEASE

24 HR* 0.75 MG, 1 MG, 4 MG 4 BD

gengraf oral capsule 100 mg, 25 mg, 50 mg 2 BD

gengraf oral solution 100 mg/ml 2 BD

HUMIRA PEDIATRIC CROHNS START

SUBCUTANEOUS* 40 MG/0.8ML, 40 MG/0.8ML (6

PACK)

5 PA; NMO

HUMIRA PEN SUBCUTANEOUS* 40 MG/0.8ML 5 PA; NMO

HUMIRA PEN-CROHNS STARTER SUBCUTANEOUS* 40

MG/0.8ML 5 PA; NMO

HUMIRA PEN-PSORIASIS STARTER SUBCUTANEOUS*

40 MG/0.8ML 5 PA; NMO

HUMIRA SUBCUTANEOUS* 10 MG/0.2ML, 20

MG/0.4ML, 40 MG/0.8ML 5 PA; NMO

KINERET SUBCUTANEOUS* 100 MG/0.67ML 5 PA; ST; NMO

mycophenolate mofetil oral capsule 250 mg 1 BD

MYCOPHENOLATE MOFETIL ORAL SUSPENSION

RECONSTITUTED 200 MG/ML 3 BD

mycophenolate mofetil oral tablet 500 mg 2 BD

mycophenolic acid oral tablet delayed release 180 mg, 360 mg 2 BD

NULOJIX INTRAVENOUS* SOLUTION


OTREXUP SUBCUTANEOUS* 10 MG/0.4ML, 12.5

MG/0.4ML, 15 MG/0.4ML, 17.5 MG/0.4ML, 20 MG/0.4ML,

22.5 MG/0.4ML, 25 MG/0.4ML, 7.5 MG/0.4ML

4

PROGRAF INTRAVENOUS* SOLUTION 5 MG/ML 4 BD; NMO

RAPAMUNE ORAL SOLUTION 1 MG/ML 5 BD; NMO

RHEUMATREX ORAL TABLET 2.5 MG 3 BD

SANDIMMUNE ORAL CAPSULE 100 MG, 25 MG 3 BD

SANDIMMUNE ORAL SOLUTION 100 MG/ML 3 BD

SIMPONI ARIA INTRAVENOUS* SOLUTION 50 MG/4ML 5 ST; NMO

SIMPONI SUBCUTANEOUS* 100 MG/ML, 50 MG/0.5ML 5 ST; NMO

SIMULECT INTRAVENOUS* SOLUTION


sirolimus oral tablet 0.5 mg 2 BD

sirolimus oral tablet 1 mg 4 BD

sirolimus oral tablet 2 mg 5 BD; NMO



74


tacrolimus oral capsule 0.5 mg, 1 mg 2 BD

tacrolimus oral capsule 5 mg 4 BD

ZORTRESS ORAL TABLET 0.25 MG 3 BD

ZORTRESS ORAL TABLET 0.5 MG, 0.75 MG 5 BD; NMO

IMMUNIZING AGENTS, PASSIVE

ATGAM INTRAVENOUS* INJECTABLE 50 MG/ML 5 BD; NMO

BIVIGAM INTRAVENOUS* SOLUTION 10 GM/100ML 5 BD; NMO

CARIMUNE NF INTRAVENOUS* SOLUTION

RECONSTITUTED 6 GM 5 PA; NMO

FLEBOGAMMA DIF INTRAVENOUS* SOLUTION 5

GM/50ML 3 BD; NMO

GAMMAGARD INJECTION SOLUTION 2.5 GM/25ML 5 PA; NMO

GAMMAKED INJECTION SOLUTION 1 GM/10ML 3 BD; NMO

GAMMAPLEX INTRAVENOUS* SOLUTION 10

GM/200ML 5 PA; NMO

GAMUNEX-C INJECTION SOLUTION 1 GM/10ML 3 PA; NMO

HYPERRAB S/D INTRAMUSCULAR* INJECTABLE 150

UNIT/ML, 150 UNIT/ML (10ML) 4 NMO

SYNAGIS INTRAMUSCULAR* SOLUTION 50 MG/0.5ML 5 NMO

THYMOGLOBULIN INTRAVENOUS* SOLUTION


VARIZIG INTRAMUSCULAR* SOLUTION 125

UNIT/1.2ML 4 NMO

IMMUNOMODULATORS

ACTEMRA INTRAVENOUS* SOLUTION 200 MG/10ML,

400 MG/20ML, 80 MG/4ML 5 ST; NMO

ACTEMRA SUBCUTANEOUS* 162 MG/0.9ML 5 ST; NMO

ARCALYST SUBCUTANEOUS* SOLUTION


ILARIS SUBCUTANEOUS* SOLUTION


leflunomide oral tablet 10 mg, 20 mg 2

ORENCIA CLICKJECT SUBCUTANEOUS* 125 MG/ML 5 PA; ST; NMO

ORENCIA INTRAVENOUS* SOLUTION

RECONSTITUTED 250 MG 5 PA; ST; NMO

ORENCIA SUBCUTANEOUS* 125 MG/ML 5 PA; ST; NMO

XELJANZ ORAL TABLET 5 MG 5 ST; NMO

VACCINES



75


ACTHIB INTRAMUSCULAR* SOLUTION

RECONSTITUTED 3 NMO

ADACEL INTRAMUSCULAR* SUSPENSION 5-2-15.5 LF-

MCG/0.5 3 NMO

BCG VACCINE INJECTION INJECTABLE 4 NMO

BEXSERO INTRAMUSCULAR* 3 NMO

BOOSTRIX INTRAMUSCULAR* SUSPENSION 5-2.5-18.5

, 5-2.5-18.5 (0.5ML SYRINGE) 3 NMO

CERVARIX INTRAMUSCULAR* SUSPENSION 3 NMO

DAPTACEL INTRAMUSCULAR* SUSPENSION 10-15-5 3 NMO

diphtheria-tetanus toxoids dt intramuscular* suspension 25-5

lfu/0.5ml 2 BD; NMO

ENGERIX-B INJECTION SUSPENSION 10 MCG/0.5ML,

10 MCG/0.5ML (0.5ML SYRINGE), 20 MCG/ML 3 BD; NMO

GARDASIL 9 INTRAMUSCULAR* 4 NMO

GARDASIL 9 INTRAMUSCULAR* SUSPENSION 3 NMO

GARDASIL INTRAMUSCULAR* SUSPENSION 3 NMO

GARDASIL INTRAMUSCULAR* SUSPENSION (0.5ML

SYRINGE) 4 NMO

HAVRIX INTRAMUSCULAR* SUSPENSION 1440 EL

U/ML, 720 EL U/0.5ML 3 NMO

HIBERIX INJECTION SOLUTION RECONSTITUTED 10

MCG 4 NMO

IMOVAX RABIES INTRAMUSCULAR* INJECTABLE 2.5

UNIT/ML 4 BD; NMO

INFANRIX INTRAMUSCULAR* SUSPENSION 25-58-10 3 NMO

IPOL INJECTION INJECTABLE 3 NMO

IXIARO INTRAMUSCULAR* SUSPENSION 3 NMO

MENACTRA INTRAMUSCULAR* INJECTABLE 4 NMO

MENHIBRIX INTRAMUSCULAR* SOLUTION

RECONSTITUTED 5-5-2.5 MCG 3 NMO

MENOMUNE SUBCUTANEOUS* INJECTABLE 3 NMO

MENVEO INTRAMUSCULAR* SOLUTION

RECONSTITUTED 3 NMO

M-M-R II SUBCUTANEOUS* INJECTABLE 3 NMO

PEDVAX HIB INTRAMUSCULAR* SUSPENSION 7.5

MCG/0.5ML 3 NMO

PROQUAD SUBCUTANEOUS* INJECTABLE 3 NMO

QUADRACEL INTRAMUSCULAR* SUSPENSION 3 NMO



76


RABAVERT INTRAMUSCULAR* SUSPENSION

RECONSTITUTED 3 BD; NMO

RECOMBIVAX HB INJECTION SUSPENSION 10

MCG/ML, 10 MCG/ML (1ML SYRINGE), 40 MCG/ML, 5

MCG/0.5ML

3 BD; NMO

ROTARIX ORAL SUSPENSION RECONSTITUTED 3 NMO

ROTATEQ ORAL SOLUTION 3 NMO

TENIVAC INTRAMUSCULAR* INJECTABLE 5-2 LFU 3 BD; NMO

TETANUS-DIPHTHERIA TOXOIDS TD

INTRAMUSCULAR* SUSPENSION 2-2 LF/0.5ML 3 BD; NMO

TRUMENBA INTRAMUSCULAR* 4 NMO

TWINRIX INTRAMUSCULAR* SUSPENSION 720-20 3 BD; NMO

TYPHIM VI INTRAMUSCULAR* SOLUTION 25

MCG/0.5ML, 25 MCG/0.5ML (0.5ML SYRINGE) 3 NMO

VAQTA INTRAMUSCULAR* SUSPENSION 25

UNIT/0.5ML, 50 UNIT/ML 3 NMO

VARIVAX SUBCUTANEOUS* INJECTABLE 1350

PFU/0.5ML 3 NMO

YF-VAX SUBCUTANEOUS* INJECTABLE 3 NMO

ZOSTAVAX SUBCUTANEOUS* SOLUTION

RECONSTITUTED 19400 UNT/0.65ML 3 NMO

INFLAMMATORY BOWEL DISEASE AGENTS

AMINOSALICYLATES

APRISO ORAL CAPSULE EXTENDED RELEASE 24

HOUR 0.375 GM 3

ASACOL HD ORAL TABLET DELAYED RELEASE 800

MG 4 NMO

balsalazide disodium oral capsule 750 mg 2 NMO

DIPENTUM ORAL CAPSULE 250 MG 4

LIALDA ORAL TABLET DELAYED RELEASE 1.2 GM 3 NMO

MESALAMINE ORAL TABLET DELAYED RELEASE 800

MG 3 NMO

mesalamine-cleanser kit 4 gm 1 NMO

SFROWASA ENEMA 4 GM/60ML 4 NMO

SULFONAMIDES

sulfasalazine oral tablet 500 mg 1

sulfasalazine oral tablet delayed release 500 mg 1

METABOLIC BONE DISEASE AGENTS



77


METABOLIC BONE DISEASE AGENTS

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

alendronate sodium oral tablet 40 mg 1 NMO

CALCITONIN (SALMON) NASAL SOLUTION 200

UNIT/ACT 3 BD

calcitriol intravenous* solution 1 mcg/ml 1 BD; NMO

calcitriol oral capsule 0.25 mcg, 0.5 mcg 1 BD

calcitriol oral solution 1 mcg/ml 1 BD

doxercalciferol intravenous* solution 4 mcg/2ml 2 BD; NMO

doxercalciferol oral capsule 0.5 mcg, 1 mcg, 2.5 mcg 2 BD

FORTEO SUBCUTANEOUS* SOLUTION 600 MCG/2.4ML 5 PA; NMO

IBANDRONATE SODIUM INTRAVENOUS* SOLUTION 3

MG/3ML 3 BD; NMO

IBANDRONATE SODIUM ORAL TABLET 150 MG 3

MIACALCIN INJECTION SOLUTION 200 UNIT/ML 4 BD; NMO

NATPARA SUBCUTANEOUS* 25 MCG 5 NMO

pamidronate disodium intravenous* solution 30 mg/10ml, 6

mg/ml, 90 mg/10ml 1 BD; NMO

paricalcitol intravenous* solution 2 mcg/ml 2 BD; NMO

PARICALCITOL INTRAVENOUS* SOLUTION 5

MCG/ML 3 BD; NMO

PARICALCITOL ORAL CAPSULE 1 MCG, 2 MCG, 4 MCG 3 BD

PROLIA SUBCUTANEOUS* SOLUTION 60 MG/ML 4 PA; NMO

RISEDRONATE SODIUM ORAL TABLET 150 MG, 35

MG, 35 MG (12 PACK), 35 MG (4 PACK), 5 MG 3

risedronate sodium oral tablet 30 mg 4 NMO

RISEDRONATE SODIUM ORAL TABLET DELAYED

RELEASE 35 MG 3

XGEVA SUBCUTANEOUS* SOLUTION 120 MG/1.7ML 5 PA; NMO

zoledronic acid intravenous* concentrate 4 mg/5ml 2 BD; NMO

zoledronic acid intravenous* solution 5 mg/100ml 2 BD; NMO

MISCELLANEOUS

MISCELLANEOUS

ADRENACLICK INJECTION 0.15 MG/0.15ML, 0.3

MG/0.3ML 4 NMO

BOTOX INJECTION SOLUTION RECONSTITUTED 100

UNIT 4 PA; NMO



78


CINRYZE INTRAVENOUS* SOLUTION


epinephrine injection 0.3 mg/0.3ml 2 NMO

EPIPEN 2-PAK INJECTION 0.3 MG/0.3ML 3 NMO

FIRAZYR SUBCUTANEOUS* SOLUTION 30 MG/3ML 5 NMO

methylergonovine maleate oral tablet 0.2 mg 1 NMO

NORTHERA ORAL CAPSULE 100 MG, 200 MG, 300 MG 5 PA; NMO

NUEDEXTA ORAL CAPSULE 20-10 MG 3 PA

VPRIV INTRAVENOUS* SOLUTION RECONSTITUTED

400 UNIT 5 PA; NMO

OPHTHALMIC AGENTS

OPHTHALMIC PROSTAGLANDIN AND

PROSTAMIDE ANALOGS

bimatoprost ophthalmic solution 0.03 % 2

latanoprost ophthalmic solution 0.005 % 1

LUMIGAN OPHTHALMIC SOLUTION 0.01 % 3

TRAVATAN Z OPHTHALMIC SOLUTION 0.004 % 3

travoprost ophthalmic solution 0.004 % 2

OPHTHALMIC AGENTS, OTHER

APRACLONIDINE HCL OPHTHALMIC SOLUTION 0.5 % 3 NMO

atropine sulfate ophthalmic solution 1 % 2

naphazoline hcl ophthalmic solution 0.1 % 1 NMO

pilocarpine hcl ophthalmic solution 1 %, 2 %, 4 % 2

proparacaine hcl ophthalmic solution 0.5 % 1 NMO

RESTASIS OPHTHALMIC EMULSION 0.05 % 3

OPHTHALMIC ANTI INFECTIVES

AZASITE OPHTHALMIC SOLUTION 1 % 3 NMO

bacitracin ophthalmic ointment 500 unit/gm 2 NMO

bacitracin-polymyxin b ophthalmic ointment 500-10000

unit/gm 1 NMO

ciprofloxacin hcl ophthalmic solution 0.3 % 1 NMO

erythromycin ophthalmic ointment 5 mg/gm 1 NMO

GATIFLOXACIN OPHTHALMIC SOLUTION 0.5 % 3 NMO

gentamicin sulfate ophthalmic ointment 0.3 % 1 NMO

gentamicin sulfate ophthalmic solution 0.3 % 1 NMO

levofloxacin ophthalmic solution 0.5 % 2 NMO



79


MOXEZA OPHTHALMIC SOLUTION 0.5 % 3 NMO

neomycin-bacitracin zn-polymyx ophthalmic ointment 5-400-

10000 2 NMO

neomycin-polymyxin-gramicidin ophthalmic solution 1.75-

10000-.025 2 NMO

ofloxacin ophthalmic solution 0.3 % 1 NMO

polymyxin b-trimethoprim ophthalmic solution 10000-0.1

unit/ml-% 1 NMO

sulfacetamide sodium ophthalmic solution 10 % 1 NMO

tobramycin ophthalmic solution 0.3 % 1 NMO

TOBREX OPHTHALMIC OINTMENT 0.3 % 3 NMO

trifluridine ophthalmic solution 1 % 4 NMO

VIGAMOX OPHTHALMIC SOLUTION 0.5 % 3 NMO

ZIRGAN OPHTHALMIC GEL 0.15 % 4 NMO

OPHTHALMIC ANTI-ALLERGY AGENTS

azelastine hcl ophthalmic solution 0.05 % 2 NMO

cromolyn sodium ophthalmic solution 4 % 1 NMO

epinastine hcl ophthalmic solution 0.05 % 2 NMO

OLOPATADINE HCL OPHTHALMIC SOLUTION 0.1 % 3 NMO

PATADAY OPHTHALMIC SOLUTION 0.2 % 3 NMO

PAZEO OPHTHALMIC SOLUTION 0.7 % 3 NMO

OPHTHALMIC ANTIGLAUCOMA AGENTS

ALPHAGAN P OPHTHALMIC SOLUTION 0.1 %, 0.15 % 3

AZOPT OPHTHALMIC SUSPENSION 1 % 3

betaxolol hcl ophthalmic solution 0.5 % 2

brimonidine tartrate ophthalmic solution 0.15 % 2

brimonidine tartrate ophthalmic solution 0.2 % 1

carteolol hcl ophthalmic solution 1 % 1

COMBIGAN OPHTHALMIC SOLUTION 0.2-0.5 % 3

dorzolamide hcl ophthalmic solution 2 % 1

dorzolamide hcl-timolol mal ophthalmic solution 22.3-6.8

mg/ml 1

levobunolol hcl ophthalmic solution 0.5 % 1

metipranolol ophthalmic solution 0.3 % 2

PHOSPHOLINE IODIDE OPHTHALMIC SOLUTION

RECONSTITUTED 0.125 % 4

SIMBRINZA OPHTHALMIC SUSPENSION 1-0.2 % 4



80


timolol maleate ophthalmic gel forming solution 0.25 %, 0.5 % 2

timolol maleate ophthalmic solution 0.25 %, 0.5 % 1

OPHTHALMIC ANTI-INFLAMMATORIES

bacitra-neomycin-polymyxin-hc ophthalmic ointment 1 % 2 NMO

BLEPHAMIDE OPHTHALMIC SUSPENSION 10-0.2 % 3 NMO

BLEPHAMIDE S.O.P. OPHTHALMIC OINTMENT 10-0.2

% 3 NMO

bromfenac sodium ophthalmic solution 0.09 % 2 NMO

CYSTARAN OPHTHALMIC SOLUTION 0.44 % 5 PA; NMO

dexamethasone sodium phosphate ophthalmic solution 0.1 % 1 NMO

diclofenac sodium ophthalmic solution 0.1 % 1 NMO

DUREZOL OPHTHALMIC EMULSION 0.05 % 3 NMO

FLAREX OPHTHALMIC SUSPENSION 0.1 % 4 NMO

fluorometholone ophthalmic suspension 0.1 % 2 NMO

flurbiprofen sodium ophthalmic solution 0.03 % 1 NMO

ILEVRO OPHTHALMIC SUSPENSION 0.3 % 4 NMO

ketorolac tromethamine ophthalmic solution 0.4 %, 0.5 % 1 NMO

LOTEMAX OPHTHALMIC GEL 0.5 % 3 NMO

LOTEMAX OPHTHALMIC OINTMENT 0.5 % 3 NMO

LOTEMAX OPHTHALMIC SUSPENSION 0.5 % 3 NMO

MAXIDEX OPHTHALMIC SUSPENSION 0.1 % 4 NMO

neomycin-polymyxin-dexameth ophthalmic ointment 3.5-

10000-0.1 1 NMO

neomycin-polymyxin-dexameth ophthalmic suspension 3.5-

10000-0.1 1 NMO

neomycin-polymyxin-hc ophthalmic suspension 3.5-10000-1 2 NMO

prednisolone acetate ophthalmic suspension 1 % 2 NMO

prednisolone sodium phosphate ophthalmic solution 1 % 2 NMO

sulfacetamide-prednisolone ophthalmic solution 10-0.23 % 1 NMO

TOBRADEX OPHTHALMIC OINTMENT 0.3-0.1 % 3 NMO

TOBRADEX OPHTHALMIC SUSPENSION 0.3-0.1 % 3 NMO

TOBRADEX ST OPHTHALMIC SUSPENSION 0.3-0.05 % 3 NMO

tobramycin-dexamethasone ophthalmic suspension 0.3-0.1 % 2 NMO

VEXOL OPHTHALMIC SUSPENSION 1 % 4 NMO

OTIC AGENTS

OTIC AGENTS



81


acetic acid otic solution 2 % 1 NMO

CIPRO HC OTIC SUSPENSION 0.2-1 % 4 NMO

CIPRODEX OTIC SUSPENSION 0.3-0.1 % 4 NMO

fluocinolone acetonide otic oil 0.01 % 2 NMO

hydrocortisone-acetic acid otic solution 1-2 % 2 NMO

neomycin-polymyxin-hc otic solution 1 % 1 NMO

neomycin-polymyxin-hc otic suspension 3.5-10000-1 1 NMO

ofloxacin otic solution 0.3 % 2 NMO

RESPIRATORY TRACT AGENTS

ANTIHISTAMINES

carbinoxamine maleate oral solution 4 mg/5ml 1 PA; NMO

carbinoxamine maleate oral tablet 4 mg 1 PA; NMO

cetirizine hcl oral syrup 1 mg/ml 1 NMO

clemastine fumarate oral tablet 2.68 mg 1 PA; NMO

cyproheptadine hcl oral syrup 2 mg/5ml 1 PA; NMO

cyproheptadine hcl oral tablet 4 mg 1 PA; NMO

diphenhydramine hcl injection solution 50 mg/ml 1 NMO

levocetirizine dihydrochloride oral solution 2.5 mg/5ml 1 NMO

levocetirizine dihydrochloride oral tablet 5 mg 1 NMO

promethazine hcl injection solution 25 mg/ml, 50 mg/ml 1 PA; NMO

promethazine hcl oral syrup 6.25 mg/5ml 1 PA; NMO

promethazine hcl oral tablet 12.5 mg, 25 mg, 50 mg 1 PA; NMO

promethazine hcl suppository 12.5 mg, 25 mg, 50 mg 4 PA; NMO

promethazine vc plain oral syrup 6.25-5 mg/5ml 2 PA; NMO

ANTI-INFLAMMATORIES, INHALED

CORTICOSTEROIDS

ARNUITY ELLIPTA INHALATION AEROSOL POWDER,

BREATH ACTIVATED 100 MCG/ACT, 200 MCG/ACT 3

BUDESONIDE INHALATION SUSPENSION 0.25

MG/2ML, 0.5 MG/2ML 3 BD

budesonide inhalation suspension 1 mg/2ml 2 BD

FLOVENT DISKUS INHALATION AEROSOL POWDER,

BREATH ACTIVATED 100 MCG/BLIST, 250 MCG/BLIST,

50 MCG/BLIST

3

FLOVENT HFA INHALATION AEROSOL† 110

MCG/ACT, 220 MCG/ACT, 44 MCG/ACT 3



82


PULMICORT FLEXHALER INHALATION AEROSOL

POWDER, BREATH ACTIVATED 180 MCG/ACT, 90

MCG/ACT

3

PULMICORT INHALATION SUSPENSION 0.25 MG/2ML,

0.5 MG/2ML, 1 MG/2ML 3 BD

ANTILEUKOTRIENES

montelukast sodium oral packet 4 mg 2

montelukast sodium oral tablet 10 mg 1

montelukast sodium oral tablet chewable 4 mg, 5 mg 2

zafirlukast oral tablet 10 mg, 20 mg 2

ZYFLO CR ORAL TABLET EXTENDED RELEASE 12

HR* 600 MG 4

ZYFLO ORAL TABLET 600 MG 4

BRONCHODILATORS, ANTICHOLINERGIC

ATROVENT HFA INHALATION AEROSOL, SOLUTION

17 MCG/ACT 3

ipratropium bromide inhalation solution 0.02 % 1 BD

SPIRIVA HANDIHALER INHALATION CAPSULE 18

MCG 3

SPIRIVA RESPIMAT INHALATION AEROSOL,

SOLUTION 1.25 MCG/ACT, 2.5 MCG/ACT 3

BRONCHODILATORS,

PHOSPHODIESTERASE INHIBITORS

(XANTHINES)

aminophylline intravenous* solution 25 mg/ml 1 NMO

ELIXOPHYLLIN ORAL ELIXIR 80 MG/15ML 3

theophylline er oral tablet extended release 12 hr* 100 mg,

200 mg, 300 mg, 450 mg 1

theophylline er oral tablet extended release 24 hr* 400 mg,

600 mg 1

BRONCHODILATORS, SYMPATHOMIMETIC

ADVAIR DISKUS INHALATION AEROSOL POWDER,

BREATH ACTIVATED 100-50 MCG/DOSE, 250-50

MCG/DOSE, 500-50 MCG/DOSE

3

ADVAIR HFA INHALATION AEROSOL† 115-21

MCG/ACT, 230-21 MCG/ACT, 45-21 MCG/ACT 3

albuterol sulfate er oral tablet extended release 12 hr* 4 mg, 8

mg 2



83


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

0.083%, (5 mg/ml) 0.5%, 0.63 mg/3ml, 1.25 mg/3ml 1 BD

albuterol sulfate oral syrup 2 mg/5ml 1

albuterol sulfate oral tablet 2 mg, 4 mg 2

BREO ELLIPTA INHALATION AEROSOL POWDER,

BREATH ACTIVATED 100-25 MCG/INH, 200-25

MCG/INH

3

COMBIVENT RESPIMAT INHALATION AEROSOL,

SOLUTION 20-100 MCG/ACT 4

ipratropium-albuterol inhalation solution 0.5-2.5 (3) mg/3ml 1 BD

levalbuterol hcl inhalation nebulization solution 0.31 mg/3ml,

0.63 mg/3ml, 1.25 mg/0.5ml 2 BD

PROAIR HFA INHALATION AEROSOL, SOLUTION 108

(90 BASE) MCG/ACT 3

PROAIR RESPICLICK INHALATION AEROSOL

POWDER, BREATH ACTIVATED 108 (90 BASE)

MCG/ACT

3

PROVENTIL HFA INHALATION AEROSOL, SOLUTION

108 (90 BASE) MCG/ACT 3

SEREVENT DISKUS INHALATION AEROSOL POWDER,

BREATH ACTIVATED 50 MCG/DOSE 3

STIOLTO RESPIMAT INHALATION AEROSOL,

SOLUTION 2.5-2.5 MCG/ACT 3

SYMBICORT INHALATION AEROSOL† 160-4.5

MCG/ACT, 80-4.5 MCG/ACT 3

terbutaline sulfate injection solution 1 mg/ml 4 NMO

TERBUTALINE SULFATE ORAL TABLET 2.5 MG, 5 MG 3

VENTOLIN HFA INHALATION AEROSOL, SOLUTION

108 (90 BASE) MCG/ACT 3

MAST CELL STABILIZERS

cromolyn sodium inhalation nebulization solution 20 mg/2ml 1 BD

NASAL AGENTS

azelastine hcl nasal solution 0.1 %, 0.15 % 2 NMO

BACTROBAN NASAL NASAL OINTMENT 2 % 4 NMO

BECONASE AQ NASAL SUSPENSION 42 MCG/SPRAY 4 NMO

budesonide nasal suspension 32 mcg/act 2 NMO

DYMISTA NASAL SUSPENSION 137-50 MCG/ACT 4 NMO

flunisolide nasal solution 25 mcg/act (0.025%) 2 NMO

fluticasone propionate nasal suspension 50 mcg/act 1 NMO



84


ipratropium bromide nasal solution 0.03 %, 0.06 % 1

mometasone furoate nasal suspension 50 mcg/act 2 NMO; QL (34 GM per 30 days)

OLOPATADINE HCL NASAL SOLUTION 0.6 % 3 NMO

OMNARIS NASAL SUSPENSION 50 MCG/ACT 4 NMO

VERAMYST NASAL SUSPENSION 27.5 MCG/SPRAY 4 NMO

ZETONNA NASAL AEROSOL, SOLUTION 37 MCG/ACT 4 NMO

PULMONARY ANTIHYPERTENSIVES

ADCIRCA ORAL TABLET 20 MG 5 PA; NMO; QL (60 EA per 30

days)

ADEMPAS ORAL TABLET 0.5 MG 5 NMO; QL (90 EA per 30 days)

ADEMPAS ORAL TABLET 1 MG, 1.5 MG, 2 MG, 2.5 MG 5 NMO

LETAIRIS ORAL TABLET 10 MG, 5 MG 5 PA; NMO; QL (30 EA per 30

days)

OPSUMIT ORAL TABLET 10 MG 5 PA; NMO; QL (30 EA per 30

days)

REMODULIN INJECTION SOLUTION 1 MG/ML, 10

MG/ML, 2.5 MG/ML, 5 MG/ML 5 BD; NMO

sildenafil citrate oral tablet 20 mg 2 PA; QL (90 EA per 30 days)

TRACLEER ORAL TABLET 125 MG, 62.5 MG 5 PA; LA; NMO; QL (60 EA per 30

days)

VENTAVIS INHALATION SOLUTION 20 MCG/ML 5 BD; NMO; QL (270 ML per 30

days)

RESPIRATORY TRACT AGENTS, OTHER

acetylcysteine inhalation solution 10 %, 20 % 1 BD; NMO

ARALAST NP INTRAVENOUS* SOLUTION


DALIRESP ORAL TABLET 500 MCG 4 QL (30 EA per 30 days)

ESBRIET ORAL CAPSULE 267 MG 5 PA; NMO

GLASSIA INTRAVENOUS* SOLUTION 1000 MG/50ML 5 PA; NMO

KALYDECO ORAL PACKET 50 MG, 75 MG 5 PA; NMO

KALYDECO ORAL TABLET 150 MG 5 PA; NMO

NUCALA SUBCUTANEOUS* SOLUTION


OFEV ORAL CAPSULE 100 MG 5 NMO

ORKAMBI ORAL TABLET 200-125 MG 5 PA; NMO

PROLASTIN-C INTRAVENOUS* SOLUTION


PULMOZYME INHALATION SOLUTION 1 MG/ML 5 BD; NMO



85


XOLAIR SUBCUTANEOUS* SOLUTION

RECONSTITUTED 150 MG 5 PA; LA; NMO

ZEMAIRA INTRAVENOUS* SOLUTION


SKELETAL MUSCLE RELAXANTS

SKELETAL MUSCLE RELAXANTS

baclofen oral tablet 10 mg, 20 mg 1

chlorzoxazone oral tablet 500 mg 4 PA; NMO

cyclobenzaprine hcl oral tablet 10 mg, 5 mg, 7.5 mg 4 PA; NMO

dantrolene sodium oral capsule 100 mg, 25 mg, 50 mg 4 NMO

metaxalone oral tablet 800 mg 4 PA; NMO

methocarbamol oral tablet 500 mg, 750 mg 4 PA; NMO

orphenadrine citrate er oral tablet extended release 12 hr*

100 mg 1 PA; NMO

TIZANIDINE HCL ORAL CAPSULE 2 MG, 4 MG, 6 MG 3

tizanidine hcl oral tablet 2 mg, 4 mg 1

SLEEP DISORDER AGENTS

BENZODIAZEPINES

ESTAZOLAM ORAL TABLET 1 MG 3 NMO; QL (60 EA per 30 days)

ESTAZOLAM ORAL TABLET 2 MG 3 NMO; QL (30 EA per 30 days)

FLURAZEPAM HCL ORAL CAPSULE 15 MG 3 NMO; QL (60 EA per 30 days)

FLURAZEPAM HCL ORAL CAPSULE 30 MG 3 NMO; QL (30 EA per 30 days)

TEMAZEPAM ORAL CAPSULE 15 MG, 22.5 MG, 30 MG 3 NMO; QL (30 EA per 30 days)

TEMAZEPAM ORAL CAPSULE 7.5 MG 3 NMO; QL (120 EA per 30 days)

TRIAZOLAM ORAL TABLET 0.125 MG 3 NMO; QL (30 EA per 30 days)

TRIAZOLAM ORAL TABLET 0.25 MG 3 NMO; QL (60 EA per 30 days)

GABA RECEPTOR MODULATORS

EDLUAR SUBLINGUAL TABLET SUBLINGUAL 10 MG,

5 MG 4


days)

ESZOPICLONE ORAL TABLET 1 MG 3 PA; NMO; QL (90 EA per 30

days)

ESZOPICLONE ORAL TABLET 2 MG, 3 MG 3 PA; NMO; QL (30 EA per 30

days)

zaleplon oral capsule 10 mg, 5 mg 4 PA; NMO

zolpidem tartrate er oral tablet extendedrelease* 12.5 mg,

6.25 mg 4


days)



86


zolpidem tartrate oral tablet 10 mg, 5 mg 4 PA; NMO; QL (90 EA per 365

days)

SLEEP DISORDERS, OTHER

ARMODAFINIL ORAL TABLET 150 MG, 200 MG, 250

MG, 50 MG 3 PA

HETLIOZ ORAL CAPSULE 20 MG 5 NMO; QL (30 EA per 30 days)

MODAFINIL ORAL TABLET 100 MG, 200 MG 3 PA; QL (30 EA per 30 days)

NUVIGIL ORAL TABLET 150 MG, 200 MG, 250 MG, 50

MG 4 PA

ROZEREM ORAL TABLET 8 MG 4 QL (30 EA per 30 days)

SILENOR ORAL TABLET 3 MG, 6 MG 3

XYREM ORAL SOLUTION 500 MG/ML 5 PA; LA; NMO; QL (540 ML per

30 days)

THERAPEUTIC NUTRIENTS/ MINERALS/

ELECTROLYTES

ELECTROLYTE/MINERAL MODIFIERS

CHEMET ORAL CAPSULE 100 MG 4 NMO

DEPEN TITRATABS ORAL TABLET 250 MG 5 NMO

EXJADE ORAL TABLET SOLUBLE 125 MG 3 PA

EXJADE ORAL TABLET SOLUBLE 250 MG, 500 MG 5 PA; NMO

FERRIPROX ORAL SOLUTION 100 MG/ML 5 NMO

FERRIPROX ORAL TABLET 500 MG 4

kionex oral powder 1 NMO

SAMSCA ORAL TABLET 15 MG, 30 MG 5 PA; NMO

sodium polystyrene sulfonate oral suspension 15 gm/60ml 1 NMO

sps oral suspension 15 gm/60ml 1 NMO

SYPRINE ORAL CAPSULE 250 MG 3 NMO

ELECTROLYTE/MINERAL REPLACEMENT

ammonium chloride intravenous* solution 5 meq/ml 1 NMO

CARBAGLU ORAL TABLET 200 MG 5 NMO

dextrose in lactated ringers intravenous* solution 5 % 1 NMO

dextrose-nacl intravenous* solution 10-0.2 %, 10-0.45 %, 2.5-

0.45 %, 5-0.2 %, 5-0.225 %, 5-0.33 %, 5-0.45 %, 5-0.9 % 1 NMO

IONOSOL-B IN D5W INTRAVENOUS* SOLUTION 3 NMO

IONOSOL-MB IN D5W INTRAVENOUS* SOLUTION 3 NMO

ISOLYTE-P IN D5W INTRAVENOUS* SOLUTION 3 NMO



87


ISOLYTE-S INTRAVENOUS* SOLUTION 3 NMO

kcl in dextrose-nacl intravenous* solution 10-5-0.45 meq/l-%-

%, 20-5-0.2 meq/l-%-%, 20-5-0.225 meq/l-%-%, 20-5-0.33

meq/l-%-%, 20-5-0.45 meq/l-%-%, 20-5-0.9 meq/l-%-%, 30-5-

0.45 meq/l-%-%, 40-5-0.45 meq/l-%-%, 40-5-0.9 meq/l-%-%

1 NMO

kcl-lactated ringers-d5w intravenous* solution 20 meq/l 1 NMO

klor-con 10 oral tablet extendedrelease* 10 meq 1

klor-con m15 oral tablet extendedrelease* 15 meq 2

KUVAN ORAL PACKET 100 MG, 500 MG 5 PA; LA; NMO

lactated ringers intravenous* solution 1 NMO

magnesium sulfate injection solution 50 %, 50 % (10ml

syringe) 1 NMO

normosol-m in d5w intravenous* solution 1 NMO

normosol-r in d5w intravenous* solution 1 NMO

NORMOSOL-R PH 7.4 INTRAVENOUS* SOLUTION 3 NMO

PLASMA-LYTE 148 INTRAVENOUS* SOLUTION 3 NMO

PLASMA-LYTE A INTRAVENOUS* SOLUTION 3 NMO

PLASMA-LYTE-56 IN D5W INTRAVENOUS* SOLUTION 3 NMO

potassium chloride crys er oral tablet extendedrelease* 10

meq, 20 meq 1

potassium chloride er oral capsule extended release* 10 meq,

8 meq 2

potassium chloride er oral tablet extendedrelease* 8 meq 1

potassium chloride in dextrose intravenous* solution 20-5

meq/l-%, 40-5 meq/l-% 1 NMO

potassium chloride in nacl intravenous* solution 20-0.45

meq/l-%, 20-0.9 meq/l-% 1 NMO

potassium chloride in nacl intravenous* solution 40-0.9 meq/l-

% 4 NMO

potassium chloride intravenous* solution 10 meq/100ml, 2

meq/ml, 20 meq/100ml, 40 meq/100ml 1 NMO

potassium chloride oral solution 20 meq/15ml (10%), 40

meq/15ml (20%) 2

ringers intravenous* solution 1 NMO

sodium chloride injection solution 2.5 meq/ml 1 NMO

sodium chloride intravenous* solution 0.45 %, 3 %, 5 % 1 NMO

sodium chloride intravenous* solution 0.9 % 2 NMO

tpn electrolytes intravenous* solution 1 BD; NMO



88


NUTRIENTS

AMINOSYN II INTRAVENOUS* SOLUTION 10 %, 7 %,

8.5 % 3 BD; NMO

aminosyn ii/electrolytes intravenous* solution 8.5 % 1 BD; NMO

AMINOSYN/ELECTROLYTES INTRAVENOUS*

SOLUTION 7 % 4 BD; NMO

aminosyn/electrolytes intravenous* solution 8.5 % 1 BD; NMO

AMINOSYN-HBC INTRAVENOUS* SOLUTION 7 % 3 BD; NMO

AMINOSYN-PF INTRAVENOUS* SOLUTION 10 %, 7 % 3 BD; NMO

AMINOSYN-RF INTRAVENOUS* SOLUTION 5.2 % 4 BD; NMO

CLINIMIX E/DEXTROSE (2.75/10) INTRAVENOUS*

SOLUTION 2.75 % 3 BD; NMO









CLINIMIX E/DEXTROSE (5/15) INTRAVENOUS*






CLINIMIX/DEXTROSE (2.75/5) INTRAVENOUS*










CLINIMIX/DEXTROSE (5/15) INTRAVENOUS*






89




clinisol sf intravenous* solution 15 % 1 BD; NMO

dextrose intravenous* solution 10 %, 5 % 1 BD; NMO

FREAMINE HBC INTRAVENOUS* SOLUTION 6.9 % 4 BD; NMO

hepatamine intravenous* solution 8 % 1 BD; NMO

INTRALIPID INTRAVENOUS* EMULSION 30 % 4 BD; NMO

NEPHRAMINE INTRAVENOUS* SOLUTION 5.4 % 3 BD; NMO

nutrilipid intravenous* emulsion 20 % 1 BD; NMO

plenamine intravenous* solution 15 % 2 BD; NMO

PREMASOL INTRAVENOUS* SOLUTION 10 % 3 BD; NMO

premasol intravenous* solution 6 % 1 BD; NMO

PROCALAMINE INTRAVENOUS* SOLUTION 3 % 3 BD; NMO

PROSOL INTRAVENOUS* SOLUTION 20 % 3 BD; NMO

TRAVASOL INTRAVENOUS* SOLUTION 10 % 3 BD; NMO

TROPHAMINE INTRAVENOUS* SOLUTION 10 % 3 BD; NMO

VITAMINS

prenatal oral tablet 27-1 mg 1 NMO

sodium fluoride oral tablet 2.2 (1 f) mg 1 NMO

90

8 8-MOP .................................... 54

A abacavir sulfate ....................... 37

abacavir-lamivudine-zidovudine

............................................ 37

ABELCET .............................. 19

ABILIFY MAINTENA .......... 33

ABRAXANE .......................... 25

ABSTRAL ................................ 3

acamprosate calcium ................ 5

ACANYA ............................... 54

acarbose .................................. 40

acebutolol hcl ......................... 47

acetaminophen-codeine ............ 3

acetaminophen-codeine #2 ....... 3

acetaminophen-codeine #3 ....... 3

ACETAMINOPHEN-

CODEINE #4 ....................... 3

acetazolamide ......................... 49

acetic acid ......................... 80, 81

acetylcysteine ......................... 84

acitretin ................................... 54

ACTEMRA ............................ 74

ACTHIB ........................... 74, 75

ACTIMMUNE ....................... 25

acyclovir ........................... 36, 54

acyclovir sodium .................... 36

ADACEL ................................ 75

ADAGEN ............................... 60

ADAPALENE ........................ 54

ADCIRCA .............................. 84

adefovir dipivoxil ................... 35

ADEMPAS ............................. 84

ADRENACLICK ................... 77

ADRUCIL .............................. 24

ADVAIR DISKUS ................. 82

ADVAIR HFA ....................... 82

afeditab cr ............................... 48

AFINITOR ............................. 25

AFINITOR DISPERZ ............ 25

a-hydrocort ............................. 64

AKYNZEO............................. 18

ALA SCALP .......................... 54

ALBENZA ............................. 30

albuterol sulfate ...................... 83

albuterol sulfate er .................. 82

alclometasone dipropionate .... 54

ALDACTAZIDE .................... 46

ALDURAZYME .................... 60

ALECENSA ........................... 25

alendronate sodium........... 76, 77

alfuzosin hcl er ....................... 63

ALIMTA ................................ 24

ALINIA .................................. 30

allopurinol .............................. 20

almotriptan malate .................. 22

alosetron hcl ........................... 62

ALOXI.................................... 18

ALPHAGAN P ....................... 79

alprazolam .............................. 40

ALPRAZOLAM ..................... 40

alprazolam er .......................... 40

alprazolam intensol................. 40

alprazolam xr .......................... 40

ALTABAX ............................. 54

amantadine hcl ........................ 31

AMBISOME .......................... 19

AMCINONIDE ...................... 54

amethia ................................... 66

amethyst.................................. 66

amifostine ............................... 25

AMIKACIN SULFATE ....... 5, 6

amiloride hcl ........................... 50

amiloride-hydrochlorothiazide46

aminophylline ......................... 82

AMINOSYN II ....................... 88

aminosyn ii/electrolytes .......... 88

aminosyn/electrolytes ............. 88

AMINOSYN/ELECTROLYTE

S .......................................... 88

AMINOSYN-HBC ................. 88

AMINOSYN-PF ..................... 88

AMINOSYN-RF .................... 88

amiodarone hcl ................. 45, 46

AMITIZA ............................... 62

amitriptyline hcl ..................... 18

amlodipine besy-benazepril hcl

............................................ 46

amlodipine besylate ................ 48

AMLODIPINE BESYLATE-

VALSARTAN .................... 46

AMLODIPINE-

ATORVASTATIN ............. 49

AMLODIPINE-VALSARTAN-

HCTZ .................................. 46

ammonium chloride ................ 86

ammonium lactate .................. 54

amoxapine............................... 18

AMOXICILL-CLARITHRO-

LANSOPRAZ..................... 61

amoxicillin ................................ 9

amoxicillin-pot clavulanate ...... 9

AMOXICILLIN-POT

CLAVULANATE ER .......... 9

AMPHETAMINE-

DEXTROAMPHET ER ..... 52

amphetamine-

dextroamphetamine ............ 52

amphotericin b ........................ 19

ampicillin .................................. 9

ampicillin sodium ..................... 9

AMPICILLIN-SULBACTAM

SODIUM .............................. 9

AMPYRA ............................... 53

ANADROL-50 ................. 65, 66

anagrelide hcl.......................... 44

anastrozole .............................. 30

ANDRODERM ...................... 66

ANDROGEL .......................... 66

ANDROGEL PUMP .............. 66

APOKYN ............................... 31

APRACLONIDINE HCL ....... 78

apri .......................................... 66

APRISO .................................. 76

APTIOM ................................. 14

APTIVUS ............................... 38

ARALAST NP........................ 84

aranelle ................................... 66

ARANESP (ALBUMIN FREE)

...................................... 43, 44

ARCALYST ........................... 74

argatroban ............................... 43

ARIPIPRAZOLE .................... 33

ARISTADA ............................ 33

ARMODAFINIL .................... 86

ARNUITY ELLIPTA ............. 81

ARRANON ............................ 24

ASACOL HD ......................... 76

ASCOMP-CODEINE ............... 3

aspirin-dipyridamole er .......... 44

Alphabetical Listing

91

ASSURE ID INSULIN

SAFETY SYR .................... 40

ASTAGRAF XL .................... 72

atenolol ................................... 47

atenolol-chlorthalidone........... 46

ATGAM ................................. 74

atorvastatin calcium................ 50

atovaquone ............................. 30

ATOVAQUONE-PROGUANIL

HCL .................................... 30

ATRIPLA ............................... 39

atropine sulfate ................. 60, 78

ATROVENT HFA ................. 82

AVASTIN .............................. 24

AVELOX ............................... 11

aviane ..................................... 66

AVONEX ............................... 53

AVONEX PEN ...................... 53

AVONEX PREFILLED ......... 53

AXIRON ................................ 66

azacitidine............................... 24

AZACTAM IN DEXTROSE ... 8

AZASAN ................................ 72

AZASITE ............................... 78

azathioprine ............................ 72

AZATHIOPRINE SODIUM .. 72

azelastine hcl .................... 79, 83

AZELEX ................................ 54

AZILECT ............................... 32

azithromycin ........................... 10

AZOPT ................................... 79

AZOR ..................................... 46

aztreonam ................................. 8

B bacitracin ................................ 78

bacitracin-polymyxin b .......... 78

bacitra-neomycin-polymyxin-hc

............................................ 80

baclofen .................................. 85

BACTOCILL IN DEXTROSE 9

BACTROBAN NASAL ......... 83

balsalazide disodium .............. 76

balziva .................................... 66

BANZEL .......................... 14, 15

BARACLUDE ....................... 36

BCG VACCINE ..................... 75

BECONASE AQ .................... 83

bekyree ................................... 66

BELEODAQ .......................... 25

benazepril hcl ......................... 45

benazepril-hydrochlorothiazide

............................................ 46

BENICAR .............................. 45

BENICAR HCT ..................... 46

BENLYSTA ........................... 72

BENTYL ................................ 60

benzoyl peroxide-erythromycin

............................................ 54

benztropine mesylate .............. 31

betamethasone dipropionate .. 54,

55

betamethasone dipropionate aug

............................................ 54

betamethasone valerate........... 55

BETASERON ........................ 53

betaxolol hcl ........................... 79

bethanechol chloride............... 63

bexarotene .............................. 25

BEXSERO .............................. 75

BEYAZ ................................... 66

bicalutamide ........................... 25

BICILLIN C-R ....................... 10

BICILLIN C-R 900/300 ........... 9

BICILLIN L-A ....................... 10

BICNU.................................... 23

BIDIL ..................................... 52

BILTRICIDE .......................... 30

bimatoprost ............................. 78

bisoprolol fumarate................. 47

bisoprolol-hydrochlorothiazide

............................................ 46

BIVIGAM .............................. 74

bleomycin sulfate ................... 25

BLEPHAMIDE ...................... 80

BLEPHAMIDE S.O.P. ........... 80

blisovi 24 fe ............................ 66

blisovi fe 1.5/30 ...................... 66

blisovi fe 1/20 ......................... 66

BOOSTRIX ............................ 75

BOSULIF ............................... 25

BOTOX .................................. 77

BREO ELLIPTA .................... 83

briellyn.................................... 66

BRILINTA ............................. 44

brimonidine tartrate ................ 79

BRISDELLE .......................... 17

BRIVIACT ............................. 15

bromfenac sodium .................. 80

bromocriptine mesylate .......... 31

budesonide .................. 64, 81, 83

BUDESONIDE....................... 81

bumetanide ............................. 49

BUPRENORPHINE HCL ........ 5

BUPRENORPHINE HCL-

NALOXONE HCL ............... 5

buproban ................................... 5

bupropion hcl .......................... 16

bupropion hcl er (smoking det) 5

bupropion hcl er (sr) ............... 16

bupropion hcl er (xl) ........... 5, 16

buspirone hcl .......................... 39

BUSULFEX ........................... 23

BUTALBITAL-APAP-CAFF-

COD ...................................... 3

BUTALBITAL-APAP-

CAFFEINE ........................... 3

BUTALBITAL-ASA-CAFF-

CODEINE............................. 3

BUTALBITAL-ASPIRIN-

CAFFEINE ........................... 3

butorphanol tartrate .................. 3

BYDUREON .......................... 40

BYETTA 10 MCG PEN ......... 40

BYETTA 5 MCG PEN ........... 41

BYSTOLIC............................. 47

C cabergoline ............................. 71

CABOMETYX ....................... 25

calcipotriene ........................... 55

calcipotriene-betameth diprop 55

CALCITONIN (SALMON) ... 77

calcitriol .................................. 77

CALCITRIOL ........................ 55

calcium acetate (phos binder) . 64

camila ..................................... 66

CANCIDAS ............................ 19

candesartan cilexetil ............... 45

candesartan cilexetil-hctz ....... 46

CAPASTAT SULFATE ......... 23

CAPEX ................................... 55

capital/codeine .......................... 3

CAPRELSA ............................ 25

captopril .................................. 45

captopril-hydrochlorothiazide 46

CARAFATE ........................... 62

CARBAGLU .......................... 86

carbamazepine .................. 15, 40

carbamazepine er .................... 15

CARBIDOPA ......................... 32

carbidopa-levodopa ................ 32

92

carbidopa-levodopa er ............ 32

carbidopa-levodopa-entacapone

............................................ 32

carbinoxamine maleate ........... 81

CARBOPLATIN .................... 23

CARDIZEM LA ..................... 48

CARDURA XL ...................... 63

CARIMUNE NF .................... 74

carteolol hcl ............................ 79

cartia xt ................................... 48

carvedilol ................................ 47

CAYSTON ............................... 9

caziant..................................... 66

cefaclor ..................................... 7

CEFACLOR ER ....................... 7

cefadroxil .................................. 7

CEFAZOLIN SODIUM ........... 7

cefdinir ..................................... 7

cefepime hcl ............................. 7

CEFIXIME ............................... 7

cefotaxime sodium ................... 7

cefotetan disodium ................... 7

cefoxitin sodium ....................... 7

cefpodoxime proxetil................ 8

cefprozil .................................... 8

CEFTAZIDIME ....................... 8

CEFTIN .................................... 8

CEFTRIAXONE SODIUM ..... 8

cefuroxime axetil ...................... 8

CEFUROXIME SODIUM ....... 8

celecoxib................................. 20

CELECOXIB ......................... 20

CELLCEPT INTRAVENOUS

............................................ 72

CELONTIN ............................ 13

cephalexin................................. 8

CEREBYX ............................. 12

CEREZYME .......................... 60

CERVARIX ........................... 75

CESAMET ............................. 18

cetirizine hcl ........................... 81

CEVIMELINE HCL .............. 54

CHANTIX ................................ 5

CHANTIX CONTINUING

MONTH PAK ...................... 5

CHANTIX STARTING

MONTH PAK ...................... 5

CHEMET ............................... 86

chloramphenicol sod succinate. 6

chlordiazepoxide hcl .............. 40

chlorhexidine gluconate ......... 54

chloroquine phosphate ............ 31

chlorothiazide ......................... 50

CHLOROTHIAZIDE SODIUM

............................................ 50

chlorpromazine hcl ................. 32

CHLORPROMAZINE HCL .. 32

chlorthalidone ......................... 50

chlorzoxazone ......................... 85

cholestyramine light ............... 51

chorionic gonadotropin........... 70

ciclopirox ................................ 55

ciclopirox olamine .................. 55

cidofovir ................................. 35

cilostazol ................................. 44

cimetidine ......................... 61, 62

cimetidine hcl ......................... 61

CIMZIA .................................. 72

CIMZIA PREFILLED ............ 72

CINRYZE ............................... 78

CIPRO HC .............................. 81

CIPRO IN D5W ..................... 11

CIPRODEX ............................ 81

ciprofloxacin ........................... 11

ciprofloxacin hcl ............... 11, 78

ciprofloxacin in d5w ............... 11

ciprofloxacin-ciproflox hcl er . 11

cisplatin .................................. 23

citalopram hydrobromide ....... 17

cladribine ................................ 24

CLAFORAN ............................ 8

claravis.................................... 55

clarithromycin ........................ 10

clarithromycin er .................... 10

clemastine fumarate ................ 81

CLEOCIN ............................... 64

CLIMARA PRO ..................... 69

clindamycin hcl ........................ 6

clindamycin palmitate hcl ........ 6

clindamycin phos-benzoyl perox

............................................ 55

clindamycin phosphate ..... 55, 64

CLINDAMYCIN PHOSPHATE

.............................................. 6

CLINDAMYCIN PHOSPHATE

IN D5W ................................ 6

CLINIMIX E/DEXTROSE

(2.75/10) ............................. 88

CLINIMIX E/DEXTROSE

(2.75/5) ............................... 88

CLINIMIX E/DEXTROSE

(4.25/10) ............................. 88

CLINIMIX E/DEXTROSE

(4.25/25) ............................. 88

CLINIMIX E/DEXTROSE

(4.25/5) ............................... 88

CLINIMIX E/DEXTROSE

(5/15) .................................. 88

CLINIMIX E/DEXTROSE

(5/20) .................................. 88

CLINIMIX E/DEXTROSE

(5/25) .................................. 88

CLINIMIX/DEXTROSE

(2.75/5) ............................... 88

CLINIMIX/DEXTROSE

(4.25/10) ............................. 88

CLINIMIX/DEXTROSE

(4.25/20) ............................. 88

CLINIMIX/DEXTROSE

(4.25/25) ............................. 88

CLINIMIX/DEXTROSE

(4.25/5) ............................... 88

CLINIMIX/DEXTROSE (5/15)

............................................ 88


............................................ 88


............................................ 89

clinisol sf ................................ 89

CLOBETASOL PROPIONATE

...................................... 55, 56

CLOBETASOL PROPIONATE

E .......................................... 55

CLODERM PUMP ................. 56

CLOLAR ................................ 24

CLOMIPRAMINE HCL ........ 18

clonazepam ............................. 13

clonidine hcl ........................... 45

CLONIDINE HCL ER ........... 52

clopidogrel bisulfate ............... 44

clorazepate dipotassium.......... 40

clorpres ................................... 46

clotrimazole ...................... 54, 56

clozapine ................................. 35

CLOZAPINE .......................... 35

COARTEM............................. 31

codeine sulfate .......................... 3

CODEINE SULFATE .............. 3

colchicine ................................ 20

colchicine-probenecid ............. 20

93

colestipol hcl .......................... 51

colistimethate sodium ............... 6

COMBIGAN .......................... 79

COMBIPATCH ...................... 69

COMBIVENT RESPIMAT ... 83

COMETRIQ (100 MG DAILY

DOSE) ................................ 25


DOSE) ................................ 25


DOSE) ................................ 25

COMFORT ASSIST INSULIN

SYRINGE........................... 41

COMPLERA .......................... 39

compro .................................... 32

CONDYLOX ......................... 56

COPAXONE .......................... 53

CORDRAN ............................ 56

COREG CR ............................ 47

cortisone acetate ..................... 64

CORTISPORIN ...................... 56

COSENTYX........................... 56

COSENTYX SENSOREADY

PEN .................................... 56

COSMEGEN .......................... 25

COTELLIC............................. 25

CREON .................................. 61

CRIXIVAN ............................ 38

cromolyn sodium ........ 61, 79, 83

cryselle-28 .............................. 66

CUBICIN ................................. 6

CUVPOSA ............................. 60

CVS GAUZE STERILE......... 41

cyclafem 1/35 ......................... 66

cyclafem 7/7/7 ........................ 66

cyclobenzaprine hcl ................ 85

cyclophosphamide .................. 23

CYCLOSET ........................... 41

cyclosporine ........................... 72

cyclosporine modified ............ 72

cyproheptadine hcl ................. 81

CYRAMZA ............................ 24

CYSTADANE ........................ 60

CYSTAGON .......................... 64

CYSTARAN .......................... 80

cytarabine ............................... 24

CYTARABINE (PF) .............. 24

D DACARBAZINE ................... 25

DAKLINZA ........................... 36

DALIRESP ............................. 84

danazol.................................... 66

dantrolene sodium .................. 85

dapsone ................................... 22

DAPTACEL ........................... 75

DARAPRIM ........................... 31

darifenacin hydrobromide er .. 63

DARZALEX .......................... 26

daunorubicin hcl ..................... 26

DAYTRANA.......................... 52

DDAVP .................................. 70

decitabine................................ 24

demeclocycline hcl ................. 12

DEMSER ................................ 45

DENAVIR .............................. 56

DEPEN TITRATABS ............ 86

DEPO-ESTRADIOL .............. 69

DEPO-MEDROL ................... 64

DEPO-PROVERA.................. 26

DEPO-SUBQ PROVERA 104

............................................ 66

DESCOVY ............................. 37

desipramine hcl....................... 18

desmopressin ace rhinal tube .. 70

desmopressin ace spray refrig 70

desmopressin acetate .............. 70

DESONATE ........................... 56

DESONIDE ............................ 56

DESOXIMETASONE............ 56

dexamethasone ....................... 65

dexamethasone intensol .......... 64

dexamethasone sodium

phosphate ...................... 65, 80

DEXILANT ...................... 62, 63

DEXPAK 13 DAY ................. 65

dexrazoxane ............................ 26

DEXTROAMPHETAMINE

SULFATE .......................... 52

dextroamphetamine sulfate er 52

dextrose .................................. 89

dextrose in lactated ringers ..... 86

dextrose-nacl .......................... 86

diazepam ................................. 40

DIAZEPAM ..................... 13, 40

DIAZEPAM INTENSOL ....... 40

diclofenac potassium .............. 20

diclofenac sodium....... 21, 56, 80

diclofenac sodium er .............. 21

DICLOFENAC-

MISOPROSTOL ................ 21

dicloxacillin sodium ............... 10

dicyclomine hcl ...................... 60

DIDANOSINE ....................... 37

DIFFERIN .............................. 56

DIFICID ................................. 10

DIFLORASONE DIACETATE

............................................ 56

diflunisal ................................. 21

digitek ..................................... 49

digoxin .................................... 49

dihydroergotamine mesylate . 21,

22

DILANTIN ............................. 15

diltiazem hcl ........................... 48

diltiazem hcl er ....................... 48

diltiazem hcl er beads ............. 48

diltiazem hcl er coated beads .. 48

dilt-xr ...................................... 48

DIPENTUM ........................... 76

diphenhydramine hcl .............. 81

diphenoxylate-atropine ........... 61

diphtheria-tetanus toxoids dt .. 75

dipyridamole ........................... 44

disopyramide phosphate ......... 46

disulfiram .................................. 5

DIURIL................................... 50

divalproex sodium ............ 13, 22

divalproex sodium er .............. 13

DIVIGEL ................................ 69

DOCEFREZ ........................... 26

DOCETAXEL ........................ 26

dofetilide ................................. 46

donepezil hcl ..................... 15, 16

DONEPEZIL HCL ................. 15

DORIBAX ................................ 9

dorzolamide hcl ...................... 79

dorzolamide hcl-timolol mal .. 79

doxazosin mesylate ................. 45

doxepin hcl ............................. 18

doxercalciferol ........................ 77

DOXIL .................................... 26

DOXORUBICIN HCL ........... 26

doxorubicin hcl liposomal ...... 26

doxycycline hyclate ................ 12

DOXYCYCLINE HYCLATE 12

doxycycline monohydrate ...... 12

DOXYCYCLINE

MONOHYDRATE ............. 12

dronabinol ............................... 19

drospirenone-ethinyl estradiol 67

94

DROXIA ................................ 24

DUAVEE ............................... 69

duloxetine hcl ......................... 17

duramorph ............................ 3, 4

DUREZOL ............................. 80

dutasteride .............................. 63

dutasteride-tamsulosin hcl ...... 63

DYMISTA .............................. 83

E E.E.S. GRANULES ............... 10

econazole nitrate ..................... 56

EDECRIN............................... 50

EDLUAR ................................ 85

EDURANT ............................. 36

EFFIENT ................................ 44

ELAPRASE ............................ 60

ELIDEL .................................. 56

ELIGARD .............................. 26

eliphos .................................... 64

ELIQUIS ................................ 43

ELITEK .................................. 26

ELIXOPHYLLIN ................... 82

ELMIRON .............................. 64

EMBEDA ................................. 2

EMCYT .................................. 26

EMEND .................................. 19

emoquette ............................... 67

EMPLICITI ............................ 26

EMSAM ................................. 17

EMTRIVA .............................. 37

EMVERM .............................. 30

enalapril maleate .................... 45

enalapril-hydrochlorothiazide 47

ENBREL ................................ 72

ENBREL SURECLICK ......... 73

ENGERIX-B .......................... 75

enoxaparin sodium ................. 43

enpresse-28 ............................. 67

entacapone .............................. 31

entecavir ................................. 36

enulose .................................... 62

ENVARSUS XR .................... 73

EPIDUO ................................. 56

EPIDUO FORTE.................... 56

epinastine hcl .......................... 79

epinephrine ............................. 78

EPIPEN 2-PAK ...................... 78

epitol ....................................... 15

EPIVIR HBV.......................... 37

eplerenone .............................. 50

EPOGEN ................................ 44

eprosartan mesylate ................ 45

EPZICOM .............................. 37

EQUETRO ............................. 33

ERAXIS.................................. 19

ERBITUX ............................... 26

ergoloid mesylates .................. 15

ERIVEDGE ............................ 26

errin ........................................ 67

ERWINAZE ........................... 26

ery ........................................... 56

ERYPED 200 ......................... 11

ERYPED 400 ......................... 11

ERY-TAB ............................... 11

erythrocin lactobionate ........... 11

erythrocin stearate .................. 11

erythromycin .................... 56, 78

erythromycin base .................. 11

erythromycin ethylsuccinate... 11

ESBRIET ................................ 84

escitalopram oxalate ............... 17

esomeprazole sodium ............. 63

ESTAZOLAM ........................ 85

ESTRACE .............................. 64

estradiol .................................. 69

ESTRADIOL .......................... 69

estradiol valerate..................... 69

estradiol-norethindrone acet ... 69

ESTRING ............................... 64

estropipate .............................. 69

ESZOPICLONE ..................... 85

ETHAMBUTOL HCL ........... 23

ethosuximide .......................... 13

etodolac .................................. 21

ETODOLAC ER .................... 21

ETOPOPHOS ......................... 26

etoposide ................................. 26

EURAX .................................. 56

EVAMIST .............................. 69

EVOTAZ ................................ 37

EXEL COMFORT POINT PEN

NEEDLE ............................ 41

EXEL PEN NEEDLES 1/2 .... 41

EXELDERM .......................... 57

exemestane ............................. 30

EXJADE ................................. 86

F FABRAZYME ....................... 60

famciclovir.............................. 39

famotidine ............................... 62

famotidine premixed ............... 62

FANAPT................................. 33

FANAPT TITRATION PACK

............................................ 33

FARESTON ........................... 26

FARYDAK ............................. 26

FASLODEX ........................... 26

felbamate ................................ 14

felodipine er ............................ 48

FEMRING .............................. 64

fenofibrate............................... 50

fenofibrate micronized ............ 50

fenofibric acid ......................... 50

FENTANYL ............................. 2

fentanyl citrate .......................... 4

FENTORA ................................ 4

FERRIPROX .......................... 86

FETZIMA ............................... 17

FETZIMA TITRATION ........ 17

FINACEA ............................... 57

finasteride ............................... 63

FIRAZYR ............................... 78

FIRMAGON ........................... 26

FLAREX................................. 80

FLEBOGAMMA DIF ............ 74

flecainide acetate .................... 46

FLOVENT DISKUS .............. 81

FLOVENT HFA ..................... 81

fluconazole ............................. 20

fluconazole in sodium chloride

............................................ 19

flucytosine .............................. 20

fludarabine phosphate ............. 24

fludrocortisone acetate ............ 65

flunisolide ............................... 83

fluocinolone acetonide............ 81

FLUOCINOLONE

ACETONIDE ..................... 57

FLUOCINOLONE

ACETONIDE BODY ......... 57

fluocinonide ............................ 57

FLUOCINONIDE .................. 57

FLUOCINONIDE-E............... 57

fluorometholone ..................... 80

FLUOROURACIL ........... 24, 57

fluoxetine hcl .......................... 17

FLUOXETINE HCL .............. 17

FLUPHENAZINE

DECANOATE .................... 32

fluphenazine hcl...................... 32

95

FLURAZEPAM HCL ............ 85

flurbiprofen............................. 21

flurbiprofen sodium ................ 80

flutamide................................. 26

fluticasone propionate ...... 57, 83

FLUTICASONE

PROPIONATE ................... 57

fluvastatin sodium .................. 50

FLUVASTATIN SODIUM ER

............................................ 50

fluvoxamine maleate .............. 17

FLUVOXAMINE MALEATE

ER ....................................... 17

fondaparinux sodium .............. 43

FORFIVO XL ........................ 16

FORTAZ .................................. 8

FORTEO ................................ 77

fosinopril sodium.................... 45

fosinopril sodium-hctz............ 47

fosphenytoin sodium .............. 12

FRAGMIN ............................. 43

FREAMINE HBC .................. 89

frovatriptan succinate ............. 22

furosemide .............................. 50

FUZEON ................................ 38

fyavolv .................................... 69

FYCOMPA ............................ 13

G gabapentin .............................. 13

GABITRIL ............................. 13

galantamine hydrobromide ..... 16

galantamine hydrobromide er. 16

GAMMAGARD ..................... 74

GAMMAKED ........................ 74

GAMMAPLEX ...................... 74

GAMUNEX-C ....................... 74

GANCICLOVIR SODIUM ... 35

GARDASIL ............................ 75

GARDASIL 9 ......................... 75

GATIFLOXACIN .................. 78

GATTEX ................................ 61

gavilyte-c ................................ 62

GEMCITABINE HCL ........... 24

gemfibrozil ............................. 50

generlac .................................. 62

gengraf .................................... 73

gentamicin in saline .................. 6

gentamicin sulfate ........ 6, 57, 78

GENVOYA ............................ 39

GEODON ............................... 33

GILENYA .............................. 53

GILOTRIF .............................. 26

GLASSIA ............................... 84

GLEEVEC ........................ 26, 27

GLEOSTINE .......................... 23

glimepiride.............................. 41

glipizide .................................. 41

glipizide er .............................. 41

glipizide-metformin hcl .......... 41

GLOBAL ALCOHOL PREP

EASE .................................. 41

GLUCAGEN HYPOKIT ....... 42

GLUCAGON EMERGENCY 42

glycopyrrolate ......................... 60

GOLYTELY ........................... 62

granisetron hcl ........................ 19

griseofulvin microsize ............ 20

griseofulvin ultramicrosize ..... 20

guanfacine hcl......................... 45

guanfacine hcl er .................... 52

guanidine hcl .......................... 22

H HALAVEN ............................. 27

HALOBETASOL

PROPIONATE ................... 57

HALOG .................................. 57

haloperidol .............................. 33

haloperidol decanoate ............. 32

haloperidol lactate .................. 33

HARVONI.............................. 36

HAVRIX ................................ 75

heparin (porcine) in d5w ........ 43

heparin sod (porcine) in d5w .. 43

heparin sodium (porcine)........ 43

hepatamine.............................. 89

HERCEPTIN .......................... 27

HETLIOZ ............................... 86

HEXALEN ............................. 23

HIBERIX ................................ 75

HUMIRA ................................ 73

HUMIRA PEDIATRIC

CROHNS START .............. 73

HUMIRA PEN ....................... 73

HUMIRA PEN-CROHNS

STARTER .......................... 73

HUMIRA PEN-PSORIASIS

STARTER .......................... 73

hydralazine hcl ....................... 52

hydrochlorothiazide ................ 50

hydrocodone-acetaminophen .... 4

hydrocodone-ibuprofen ............ 4

hydrocortisone .................. 57, 65

HYDROCORTISONE ........... 57

HYDROCORTISONE

BUTYRATE ....................... 57

HYDROCORTISONE

VALERATE ....................... 58

hydrocortisone-acetic acid ...... 81

hydromorphone hcl ................... 4

HYDROMORPHONE HCL .... 4

hydromorphone hcl er............... 2

hydroxychloroquine sulfate .... 31

hydroxyprogesterone caproate 27

hydroxyurea ............................ 27

hydroxyzine hcl ................ 39, 40

hydroxyzine pamoate.............. 40

HYPERRAB S/D.................... 74

HYSINGLA ER........................ 2

I IBANDRONATE SODIUM .. 77

IBRANCE............................... 27

ibuprofen................................. 21

ICLUSIG ................................ 27

idarubicin hcl .......................... 27

IFOSFAMIDE ........................ 23

ILARIS ................................... 74

ILEVRO ................................. 80

imatinib mesylate.................... 27

IMBRUVICA ......................... 27

IMIPENEM-CILASTATIN ..... 9

imipramine hcl ........................ 18

imipramine pamoate ............... 18

IMIQUIMOD ......................... 58

IMITREX STATDOSE REFILL

............................................ 22

IMOVAX RABIES ................ 75

INCRELEX ............................ 70

indapamide ............................. 50

INDOCIN ............................... 21

indomethacin .......................... 21

INDOMETHACIN ER ........... 21

INFANRIX ............................. 75

INLYTA ................................. 27

INTELENCE .................... 36, 37

INTRALIPID .......................... 89

INTRON A ............................. 27

introvale .................................. 67

INVANZ ................................... 9

INVEGA SUSTENNA ........... 34

INVEGA TRINZA ................. 34

96

INVIRASE ............................. 38

INVOKAMET ........................ 41

INVOKANA .......................... 41

IONOSOL-B IN D5W ........... 86

IONOSOL-MB IN D5W ........ 86

IPOL ....................................... 75

ipratropium bromide ......... 82, 84

ipratropium-albuterol ............. 83

irbesartan ................................ 45

irbesartan-hydrochlorothiazide

............................................ 47

IRESSA .................................. 27

irinotecan hcl .......................... 27

ISENTRESS ........................... 38

ISOLYTE-P IN D5W ............. 86

ISOLYTE-S ............................ 87

isoniazid ................................. 23

isosorbide dinitrate ................. 51

ISOSORBIDE DINITRATE ER

............................................ 51

isosorbide mononitrate ........... 51

isosorbide mononitrate er ....... 51

ISRADIPINE .......................... 48

ISTODAX .............................. 27

ITRACONAZOLE ................. 20

IVERMECTIN ....................... 30

IXIARO .................................. 75

J JAKAFI .................................. 27

jantoven .................................. 43

JANUMET ............................. 41

JANUMET XR ....................... 41

JANUVIA............................... 41

JARDIANCE .......................... 41

JENTADUETO ...................... 41

JENTADUETO XR................ 41

JINTELI ................................. 69

jolivette ................................... 67

juleber ..................................... 67

junel 1.5/30 ............................. 67

junel 1/20 ................................ 67

junel fe 1.5/30 ......................... 67

junel fe 1/20 ............................ 67

JUXTAPID ............................. 51

K KADCYLA ............................ 27

kaitlib fe.................................. 67

KALETRA ............................. 38

KALYDECO .......................... 84

KANUMA .............................. 60

kariva ...................................... 67

kcl in dextrose-nacl ................ 87

kcl-lactated ringers-d5w ......... 87

kelnor 1/35 .............................. 67

KEPIVANCE ......................... 27

ketoconazole ..................... 20, 58

ketoprofen ............................... 21

ketoprofen er........................... 21

ketorolac tromethamine .... 21, 80

KEYTRUDA .......................... 27

kimidess .................................. 67

KINERET ............................... 73

kionex ..................................... 86

klor-con 10 ............................. 87

klor-con m15 .......................... 87

KORLYM ............................... 41

KUVAN............................ 60, 87

KYNAMRO ........................... 51

L labetalol hcl ............................ 47

lactated ringers ....................... 87

lactulose .................................. 62

LAMICTAL STARTER......... 14

LAMICTAL XR ..................... 14

LAMISIL ................................ 20

LAMIVUDINE ...................... 37

lamivudine-zidovudine ........... 37

lamotrigine.............................. 14

LAMOTRIGINE .................... 14

LAMOTRIGINE ER .............. 14

lansoprazole ............................ 63

LANTUS ................................ 42

LANTUS SOLOSTAR........... 42

larissia ..................................... 67

latanoprost .............................. 78

LATUDA................................ 34

LAZANDA ............................... 4

leflunomide ............................. 74

LENVIMA 10 MG DAILY

DOSE.................................. 27

LENVIMA 14 MG DAILY

DOSE.................................. 27

LENVIMA 18 MG DAILY

DOSE.................................. 27

LENVIMA 20 MG DAILY

DOSE.................................. 28

LENVIMA 24 MG DAILY

DOSE.................................. 28

LENVIMA 8 MG DAILY

DOSE.................................. 28

lessina ..................................... 67

LETAIRIS .............................. 84

letrozole .................................. 30

leucovorin calcium ................. 28

LEUKERAN........................... 23

LEUKINE ............................... 44

leuprolide acetate .................... 28

levalbuterol hcl ....................... 83

LEVEMIR .............................. 42

LEVEMIR FLEXTOUCH...... 42

levetiracetam........................... 12

LEVETIRACETAM ER ........ 12

LEVETIRACETAM IN NACL

............................................ 12

levobunolol hcl ....................... 79

levocarnitine ........................... 60

levocetirizine dihydrochloride 81

levofloxacin ...................... 11, 78

LEVOFLOXACIN ................. 11

levofloxacin in d5w ................ 11

LEVOLEUCOVORIN

CALCIUM .......................... 28

levonorg-eth estrad triphasic .. 67

levora 0.15/30 (28) ................. 67

LEVORPHANOL TARTRATE

.............................................. 2

levothyroxine sodium ....... 70, 71

levoxyl .................................... 71

LEXIVA ........................... 38, 39

LIALDA ................................. 76

LIDOCAINE .......................... 58

lidocaine hcl........................ 5, 58

lidocaine hcl (pf)................... 4, 5

lidocaine viscous .................... 54

lidocaine-prilocaine .................. 5

lincomycin hcl .......................... 6

linezolid .................................... 6

LINZESS ................................ 62

liothyronine sodium ................ 71

lisinopril .................................. 45

lisinopril-hydrochlorothiazide 47

lithium..................................... 40

lithium carbonate .................... 40

lithium carbonate er ................ 40

lithostat ................................... 64

LIVALO ................................. 51

LO LOESTRIN FE ................. 67

LONSURF .............................. 28

loperamide hcl ........................ 61

lorazepam ............................... 40

97

lorazepam intensol.................. 40

loryna ...................................... 67

losartan potassium .................. 45

losartan potassium-hctz .......... 47

LOSEASONIQUE ................. 67

LOTEMAX ............................ 80

lovastatin ................................ 51

loxapine succinate .................. 33

LUMIGAN ............................. 78

LUPRON DEPOT ............ 28, 71

LUPRON DEPOT-PED ......... 71

lutera ....................................... 67

LYNPARZA........................... 28

LYRICA ........................... 13, 53

LYSODREN........................... 28

lyza ......................................... 67

M magnesium sulfate .................. 87

MAKENA .............................. 69

MALATHION ........................ 58

maprotiline hcl........................ 16

marlissa................................... 67

MARPLAN ............................ 17

MATULANE ......................... 28

matzim la ................................ 48

MAXIDEX ............................. 80

meclizine hcl .......................... 18

medroxyprogesterone acetate 67,

69

MEFENAMIC ACID ............. 21

mefloquine hcl ........................ 31

MEGACE ES ......................... 69

megestrol acetate .................... 28

MEGESTROL ACETATE ..... 70

MEKINIST ............................. 28

meloxicam .............................. 21

melphalan hcl ......................... 23

memantine hcl ........................ 16

MEMANTINE HCL .............. 16

MENACTRA ......................... 75

MENEST ................................ 69

MENHIBRIX ......................... 75

MENOMUNE ........................ 75

MENOSTAR .......................... 69

MENTAX ............................... 58

MENVEO ............................... 75

mercaptopurine ....................... 24

meropenem ............................... 9

MESALAMINE ..................... 76

mesalamine-cleanser .............. 76

MESNA .................................. 28

MESNEX................................ 28

MESTINON ........................... 22

metaxalone.............................. 85

metformin hcl ......................... 41

metformin hcl er ..................... 41

metformin hcl er (osm) ........... 41

METHADONE HCL ................ 2

METHAZOLAMIDE ............. 49

METHENAMINE HIPPURATE

.............................................. 6

methimazole ........................... 72

methocarbamol ....................... 85

methotrexate ........................... 24

methotrexate sodium .............. 25

methotrexate sodium (pf) ....... 25

methoxsalen rapid................... 58

methscopolamine bromide ..... 60

methyclothiazide .................... 50

methyldopa-hydrochlorothiazide

............................................ 47

methylergonovine maleate ..... 78

methylphenidate hcl ............... 53

METHYLPHENIDATE HCL 53

METHYLPHENIDATE HCL

ER ....................................... 53

METHYLPHENIDATE HCL

ER (CD) .............................. 52

METHYLPHENIDATE HCL

ER (LA) .............................. 52

methylprednisolone ................ 65

methylprednisolone acetate .... 65

methylprednisolone sodium succ

............................................ 65

metipranolol............................ 79

metoclopramide hcl ................ 61

METOCLOPRAMIDE HCL .. 61

metolazone.............................. 50

metoprolol succinate er .......... 47

metoprolol tartrate .................. 48

metoprolol-hydrochlorothiazide

............................................ 47

metronidazole ..................... 6, 64

METRONIDAZOLE .............. 58

metronidazole in nacl ............... 6

mexiletine hcl ......................... 46

MIACALCIN ......................... 77

miconazole 3........................... 64

microgestin 1.5/30 .................. 67

microgestin 1/20 ..................... 67

microgestin fe 1.5/30 .............. 67

microgestin fe 1/20 ................. 67

midodrine hcl .......................... 45

migergot .................................. 22

miglitol ................................... 41

MILLIPRED ........................... 65

minitran................................... 51

minocycline hcl ...................... 12

MINOCYCLINE HCL ........... 12

minocycline hcl er .................. 12

minoxidil................................. 52

MIRCERA .............................. 44

mirtazapine ............................. 16

misoprostol ............................. 62

MITOMYCIN......................... 28

mitoxantrone hcl ..................... 28

M-M-R II ................................ 75

MODAFINIL .......................... 86

moexipril hcl ........................... 45

MOLINDONE HCL ............... 33

mometasone furoate.......... 58, 84

mononessa .............................. 67

montelukast sodium ................ 82

morphine sulfate ....................... 4

morphine sulfate (concentrate) . 4

morphine sulfate er ................... 2

MORPHINE SULFATE ER..... 2

MORPHINE SULFATE ER

BEADS ................................. 2

MOVANTIK .......................... 61

MOVIPREP ............................ 62

MOXEZA ............................... 79

moxifloxacin hcl ..................... 11

MOXIFLOXACIN HCL ........ 11

MOZOBIL .............................. 44

MULTAQ ............................... 46

mupirocin ................................ 58

MUPIROCIN CALCIUM ...... 58

MUSTARGEN ....................... 23

MYCAMINE .......................... 20

mycophenolate mofetil ........... 73

MYCOPHENOLATE

MOFETIL ........................... 73

mycophenolic acid .................. 73

MYRBETRIQ......................... 63

N nabumetone............................. 21

nadolol .................................... 48

nafcillin sodium ...................... 10

NAFCILLIN SODIUM .......... 10

98

NAFTIFINE HCL .................. 58

NAFTIN ................................. 58

NAGLAZYME....................... 60

naloxone hcl ............................. 5

naltrexone hcl ........................... 5

NAMENDA XR ..................... 16

NAMENDA XR TITRATION

PACK ................................. 16

NAMZARIC........................... 16

naphazoline hcl ....................... 78

naproxen ................................. 21

naproxen dr ............................. 21

naproxen sodium .................... 21

naratriptan hcl ......................... 22

nateglinide .............................. 41

NATPARA ............................. 77

NEBUPENT ........................... 31

necon 0.5/35 (28).................... 67

necon 1/35 (28)....................... 67

necon 10/11 (28)..................... 68

necon 7/7/7 ............................. 68

NEFAZODONE HCL ............ 16

neomycin sulfate ...................... 6

neomycin-bacitracin zn-

polymyx .............................. 79

neomycin-polymyxin b gu ..... 64

neomycin-polymyxin-dexameth

............................................ 80

neomycin-polymyxin-

gramicidin........................... 79

neomycin-polymyxin-hc .. 80, 81

NEPHRAMINE ...................... 89

NEULASTA ........................... 44

NEUPOGEN .......................... 44

NEUPRO ................................ 31

NEVIRAPINE ........................ 37

NEVIRAPINE ER .................. 37

NEXAVAR ............................ 28

niacin er (antihyperlipidemic) 51

niacor ...................................... 51

nicardipine hcl ........................ 49

NICOTROL .............................. 5

nifedical xl .............................. 49

nifedipine er osmotic release .. 49

NILANDRON ........................ 28

NILUTAMIDE ....................... 28

nimodipine .............................. 49

NINLARO .............................. 28

NISOLDIPINE ER ................. 49

NITRO-BID ........................... 51

nitrofurantoin ............................ 7

nitrofurantoin macrocrystal ...... 7

NITROFURANTOIN

MACROCRYSTAL ............. 6

nitrofurantoin monohyd macro . 7

nitroglycerin ........................... 51

NITROGLYCERIN................ 52

nitrostat ................................... 52

NITROSTAT .......................... 52

nizatidine ................................ 62

NORDITROPIN FLEXPRO .. 70

norethindrone.......................... 68

NORETHINDRONE

ACETATE .......................... 70

norethindrone-eth estradiol..... 69

norgestim-eth estrad triphasic 68

normosol-m in d5w ................ 87

normosol-r in d5w .................. 87

NORMOSOL-R PH 7.4 ......... 87

NORPACE CR ....................... 46

NORTHERA .......................... 78

nortrel 0.5/35 (28)................... 68

nortrel 1/35 (21)...................... 68

nortrel 1/35 (28)...................... 68

nortrel 7/7/7 ............................ 68

nortriptyline hcl ...................... 18

NORVIR ................................. 39

NOVOLIN 70/30 .................... 42

NOVOLIN N .......................... 42

NOVOLIN R .......................... 42

NOVOLOG ............................ 43

NOVOLOG FLEXPEN .......... 42

NOVOLOG MIX 70/30 ......... 43

NOVOLOG MIX 70/30

FLEXPEN .......................... 42

NOVOLOG PENFILL ........... 43

NOXAFIL .............................. 20

NUCALA ............................... 84

NUEDEXTA .......................... 78

NULOJIX ............................... 73

NUPLAZID ............................ 34

nutrilipid ................................. 89

NUTROPIN AQ NUSPIN 10. 70

NUTROPIN AQ NUSPIN 20. 70

NUVARING ........................... 68

NUVIGIL ............................... 86

nystatin ....................... 20, 54, 58

O octreotide acetate .................... 71

ODEFSEY .............................. 39

ODOMZO............................... 28

OFEV ...................................... 84

ofloxacin ........................... 79, 81

ogestrel ................................... 68

olanzapine ............................... 34

OLANZAPINE ....................... 34

olanzapine-fluoxetine hcl ....... 34

OLOPATADINE HCL ..... 79, 84

omega-3-acid ethyl esters ....... 51

omeprazole ............................. 63

OMNARIS .............................. 84

ondansetron............................. 19

ondansetron hcl ....................... 19

ONFI ....................................... 13

OPANA .................................... 2

OPANA ER .............................. 2

OPDIVO ................................. 28

OPSUMIT............................... 84

ORAVIG................................. 20

ORENCIA .............................. 74

ORENCIA CLICKJECT ........ 74

ORFADIN .............................. 60

ORKAMBI ............................. 84

orphenadrine citrate er ............ 85

orsythia ................................... 68

OSMOPREP ........................... 62

OTREXUP .............................. 73

oxacillin sodium ..................... 10

oxaliplatin ............................... 23

OXANDROLONE ................. 66

OXAPROZIN ......................... 21

OXAZEPAM .......................... 40

oxcarbazepine ......................... 15

oxiconazole nitrate.................. 58

OXISTAT ............................... 58

OXTELLAR XR .................... 15

oxybutynin chloride ................ 63

oxybutynin chloride er ............ 63

oxycodone hcl ........................... 4

OXYCODONE HCL ................ 4

OXYCODONE HCL ER .......... 2

oxycodone-acetaminophen ....... 4

OXYCODONE-

ACETAMINOPHEN ............ 4

oxycodone-aspirin .................... 4

oxycodone-ibuprofen ................ 4

OXYCONTIN .......................... 2

OXYMORPHONE HCL .......... 4

oxymorphone hcl er .................. 3

99

P pacerone ................................. 46

PACLITAXEL ....................... 28

PALIPERIDONE ER ............. 34

pamidronate disodium ............ 77

PANCREAZE ........................ 61

PANDEL ................................ 58

PANRETIN ............................ 58

pantoprazole sodium .............. 63

paricalcitol .............................. 77

PARICALCITOL ................... 77

PAROMOMYCIN SULFATE . 6

paroxetine hcl ......................... 17

paroxetine hcl er ..................... 17

PASER ................................... 23

PATADAY ............................. 79

PAXIL .................................... 17

PAZEO ................................... 79

PCE......................................... 11

PEDVAX HIB ........................ 75

peg 3350-kcl-na bicarb-nacl ... 62

peg-3350/electrolytes ............. 62

PEGANONE .......................... 15

PEGASYS .............................. 36

PEGASYS PROCLICK ......... 36

PEGINTRON ......................... 36

PEG-INTRON REDIPEN ...... 36

PENICILLIN G POT IN

DEXTROSE ....................... 10

PENICILLIN G POTASSIUM

............................................ 10

PENICILLIN G PROCAINE . 10

PENICILLIN G SODIUM ..... 10

penicillin v potassium............. 10

PENTAM ............................... 31

pentoxifylline er ..................... 49

perindopril erbumine .............. 45

PERJETA ............................... 28

PERMETHRIN ...................... 58

perphenazine........................... 33

PERPHENAZINE .................. 33

PERPHENAZINE-

AMITRIPTYLINE ............. 33

PERTZYE .............................. 61

phenelzine sulfate ................... 17

phenobarbital .......................... 13

phenytoin ................................ 15

phenytoin sodium ................... 15

phenytoin sodium extended .... 15

PHOSPHOLINE IODIDE ...... 79

PICATO.................................. 58

pilocarpine hcl .................. 54, 78

PILOCARPINE HCL ............. 54

pimozide ................................. 33

pindolol ................................... 48

pioglitazone hcl ...................... 42

pioglitazone hcl-glimepiride... 42

pioglitazone hcl-metformin hcl

............................................ 42

piperacillin sod-tazobactam so10

piroxicam ................................ 21

PLASMA-LYTE 148 ............. 87

PLASMA-LYTE A ................ 87

PLASMA-LYTE-56 IN D5W 87

PLEGRIDY ............................ 53

PLEGRIDY STARTER PACK

............................................ 53

plenamine ............................... 89

podofilox ................................ 59

polyethylene glycol 3350 ....... 62

polymyxin b sulfate .................. 7

polymyxin b-trimethoprim ..... 79

POMALYST .......................... 28

portia-28 ................................. 68

potassium chloride .................. 87

potassium chloride crys er ...... 87

potassium chloride er.............. 87

potassium chloride in dextrose

............................................ 87

potassium chloride in nacl ...... 87

potassium citrate er ................. 64

POTIGA ................................. 14

PRADAXA ............................. 43

PRALUENT ........................... 51

pramipexole dihydrochloride . 31

PRAMIPEXOLE

DIHYDROCHLORIDE ER31

pravastatin sodium .................. 51

prazosin hcl............................. 45

PREDNICARBATE ............... 59

prednisolone acetate ............... 80

prednisolone sodium phosphate

...................................... 65, 80

PREDNISOLONE SODIUM

PHOSPHATE ..................... 65

prednisone .............................. 65

prednisone intensol ................. 65

PREFERRED PLUS INSULIN

SYRINGE ........................... 42

PREFEST ............................... 69

PREMARIN ..................... 64, 69

premasol ................................. 89

PREMASOL ........................... 89

PREMPHASE......................... 69

PREMPRO ............................. 69

prenatal ................................... 89

PREPOPIK ............................. 62

previfem .................................. 68

PREZCOBIX .......................... 37

PREZISTA ............................. 39

PRIFTIN ................................. 23

PRIMAQUINE PHOSPHATE

............................................ 31

primidone ................................ 14

PRISTIQ ................................. 17

PROAIR HFA ........................ 83

PROAIR RESPICLICK.......... 83

probenecid .............................. 20

PROCALAMINE ................... 89

prochlorperazine ..................... 33

prochlorperazine edisylate ...... 33

prochlorperazine maleate ........ 33

PROCRIT ............................... 44

procto-med hc ......................... 59

proctozone-hc ......................... 59

progesterone micronized ........ 70

PROGLYCEM ....................... 42

PROGRAF .............................. 73

PROLASTIN-C ...................... 84

PROLEUKIN ......................... 29

PROLIA .................................. 77

PROMACTA .......................... 44

promethazine hcl .................... 81

promethazine vc plain............. 81

propafenone hcl ...................... 46

PROPAFENONE HCL ER .... 46

proparacaine hcl...................... 78

propranolol hcl........................ 48

propranolol hcl er ................... 48

propylthiouracil ...................... 72

PROQUAD ............................. 75

PROSOL ................................. 89

PROTRIPTYLINE HCL ........ 18

PROVENTIL HFA ................. 83

PULMICORT ......................... 82

PULMICORT FLEXHALER . 82

PULMOZYME ....................... 84

PURIXAN .............................. 25

PYLERA................................. 61

pyrazinamide .......................... 23

100

pyridostigmine bromide ......... 22

pyridostigmine bromide er ..... 22

Q QUADRACEL ....................... 75

quasense ................................. 68

quetiapine fumarate ................ 34

quinapril hcl............................ 45

quinapril-hydrochlorothiazide 47

quinidine gluconate er ............ 46

quinidine sulfate ..................... 46

quinine sulfate ........................ 31

R RABAVERT .......................... 76

rabeprazole sodium ................ 63

raloxifene hcl .......................... 70

ramipril ................................... 45

RANEXA ............................... 49

ranitidine hcl ........................... 62

RANITIDINE HCL ................ 62

RAPAFLO .............................. 63

RAPAMUNE ......................... 73

RAVICTI ................................ 60

REBETOL .............................. 36

reclipsen ................................. 68

RECOMBIVAX HB .............. 76

REGRANEX .......................... 59

RELENZA DISKHALER ...... 39

RELI-ON INSULIN SYRINGE

............................................ 42

RELISTOR ............................. 61

RELPAX ................................ 22

REMODULIN ........................ 84

RENVELA ............................. 64

repaglinide .............................. 42

repaglinide-metformin hcl ...... 42

REPATHA ............................. 51

REPATHA PUSHTRONEX

SYSTEM ............................ 51

REPATHA SURECLICK ...... 51

RESCRIPTOR ........................ 37

RESTASIS ............................. 78

RETROVIR ............................ 37

REVLIMID ............................ 24

REXULTI ............................... 34

REYATAZ ............................. 39

RHEUMATREX .................... 73

RIBASPHERE ....................... 36

ribasphere ribapak .................. 36

RIBASPHERE RIBAPAK ..... 36

RIBAVIRIN ........................... 36

RIFABUTIN ........................... 23

RIFAMATE............................ 23

rifampin .................................. 23

RIFATER ............................... 23

riluzole .................................... 53

RIMANTADINE HCL ........... 39

ringers ..................................... 87

RIOMET ................................. 42

risedronate sodium ................. 77

RISEDRONATE SODIUM ... 77

RISPERDAL CONSTA ......... 34

risperidone .............................. 35

RITUXAN .............................. 29

rivastigmine ............................ 16

rivastigmine tartrate ................ 16

rizatriptan benzoate ................ 22

ROBINUL .............................. 60

ROBINUL-FORTE ................ 61

ropinirole hcl .......................... 32

ropinirole hcl er ...................... 32

rosuvastatin calcium ............... 51

ROTARIX .............................. 76

ROTATEQ ............................. 76

roweepra ................................. 12

ROZEREM ............................. 86

S SABRIL .................................. 14

SAFYRAL .............................. 68

SAMSCA................................ 86

SANCUSO ............................. 19

SANDIMMUNE .................... 73

SANDOSTATIN LAR DEPOT

............................................ 72

SANTYL ................................ 59

SAPHRIS................................ 35

SARAFEM ............................. 17

SAVELLA .............................. 53

SAVELLA TITRATION PACK

............................................ 53

selegiline hcl ........................... 32

selenium sulfide ...................... 59

SELZENTRY ......................... 38

SENSIPAR ............................. 71

SEREVENT DISKUS ............ 83

SEROQUEL XR..................... 35

SEROSTIM ............................ 70

sertraline hcl ........................... 17

setlakin.................................... 68

SFROWASA .......................... 76

SIGNIFOR.............................. 72

sildenafil citrate ...................... 84

SILENOR ............................... 86

silver sulfadiazine ................... 59

SIMBRINZA .......................... 79

SIMPONI ................................ 73

SIMPONI ARIA ..................... 73

SIMULECT ............................ 73

simvastatin .............................. 51

sirolimus ................................. 73

SIRTURO ............................... 23

SKLICE .................................. 59

sodium chloride ................ 64, 87

sodium fluoride ....................... 89

sodium phenylbutyrate ........... 60

sodium polystyrene sulfonate . 86

SOLTAMOX .......................... 29

SOLU-CORTEF ..................... 65

SOLU-MEDROL ................... 65

SOMATULINE DEPOT ........ 72

SOMAVERT .......................... 72

SOOLANTRA ........................ 59

sotalol hcl................................ 48

sotalol hcl (af) ......................... 48

SOVALDI............................... 36

SPIRIVA HANDIHALER ..... 82

SPIRIVA RESPIMAT ............ 82

spironolactone......................... 50

spironolactone-hctz................. 47

SPORANOX........................... 20

sprintec 28 .............................. 68

SPRITAM ............................... 13

SPRYCEL............................... 29

sps ........................................... 86

sronyx ..................................... 68

STAVUDINE ................... 37, 38

STELARA .............................. 59

STIMATE ............................... 70

STIOLTO RESPIMAT ........... 83

STIVARGA ............................ 29

STRATTERA ......................... 53

STREPTOMYCIN SULFATE . 6

STRIBILD .............................. 39

SUBOXONE ............................ 5

SUBSYS ................................... 3

sucralfate................................. 62

sulfacetamide sodium ............. 79

SULFACETAMIDE SODIUM

............................................ 59

sulfacetamide-prednisolone .... 80

sulfadiazine ............................. 11

101

sulfamethoxazole-trimethoprim

...................................... 11, 12

SULFAMYLON..................... 59

sulfasalazine ........................... 76

sulindac................................... 21

sumatriptan ............................. 22

sumatriptan succinate ............. 22

sumatriptan succinate refill .... 22

SUPRAX .................................. 8

SUPREP BOWEL PREP ....... 62

SUSTIVA ............................... 37

SUTENT................................. 29

SYLATRON........................... 29

SYMBICORT......................... 83

SYMLINPEN 120 .................. 42

symlinpen 60 .......................... 42

SYNAGIS............................... 74

SYNALGOS-DC ...................... 4

SYNAREL ............................. 72

SYNERCID .............................. 7

SYNJARDY ........................... 42

SYNRIBO .............................. 29

SYNTHROID ......................... 71

SYPRINE ............................... 86

T TABLOID .............................. 25

TACLONEX .......................... 59

tacrolimus ......................... 59, 74

TAFINLAR ............................ 29

TAGRISSO ............................ 29

TAMIFLU .............................. 39

tamoxifen citrate ..................... 29

tamsulosin hcl ......................... 64

TARCEVA ............................. 29

TARGRETIN ......................... 59

TASIGNA .............................. 29

TAZICEF ................................. 8

TAZORAC ............................. 59

taztia xt ................................... 49

TECENTRIQ .......................... 29

TECFIDERA .......................... 53

TEFLARO ................................ 8

TEGRETOL-XR .................... 15

telmisartan .............................. 45

TELMISARTAN-HCTZ ........ 47

TEMAZEPAM ....................... 85

TENIVAC .............................. 76

terazosin hcl............................ 45

terbinafine hcl ......................... 20

terbutaline sulfate ................... 83

TERBUTALINE SULFATE .. 83

terconazole.............................. 64

TESTOSTERONE.................. 66

testosterone cypionate ............ 66

testosterone enanthate............. 66

TETANUS-DIPHTHERIA

TOXOIDS TD .................... 76

tetrabenazine ........................... 53

THALOMID ........................... 24

theophylline er ........................ 82

thioridazine hcl ....................... 33

THIOTEPA ............................ 24

thiothixene .............................. 33

THYMOGLOBULIN ............. 74

tiagabine hcl ........................... 14

timolol maleate ........... 22, 48, 80

TINIDAZOLE .......................... 7

TIROSINT .............................. 71

TIVICAY................................ 38

tizanidine hcl .......................... 85

TIZANIDINE HCL ................ 85

TOBI PODHALER .................. 6

TOBRADEX .......................... 80

TOBRADEX ST..................... 80

tobramycin .......................... 6, 79

tobramycin sulfate .................... 6

tobramycin-dexamethasone .... 80

TOBREX ................................ 79

TOLAK .................................. 59

tolazamide .............................. 42

tolbutamide ............................. 42

tolmetin sodium ...................... 21

tolterodine tartrate .................. 63

tolterodine tartrate er .............. 63

TOPICORT SPRAY............... 59

topiramate ............................... 14

TOPIRAMATE ER ................ 14

toposar .................................... 29

TOPOTECAN HCL ............... 29

TORISEL................................ 29

torsemide ................................ 50

TOUJEO SOLOSTAR ........... 43

tpn electrolytes ....................... 87

TRACLEER ........................... 84

TRADJENTA ......................... 42

tramadol hcl .............................. 4

tramadol hcl er .......................... 3

tramadol hcl er (biphasic) ......... 3

tramadol-acetaminophen .......... 4

trandolapril ............................. 45

tranexamic acid ....................... 44

TRANSDERM-SCOP (1.5 MG)

............................................ 18

tranylcypromine sulfate .......... 17

TRAVASOL ........................... 89

TRAVATAN Z ....................... 78

travoprost ................................ 78

trazodone hcl .......................... 16

TREANDA ............................. 24

TRECATOR ........................... 23

TRELSTAR MIXJECT .......... 29

tretinoin............................. 29, 59

TRETINOIN ........................... 59

tretinoin microsphere .............. 59

TREXALL .............................. 25

TREXIMET ............................ 22

triamcinolone acetonide.... 54, 59

TRIAMCINOLONE

ACETONIDE ..................... 59

triamterene-hctz ...................... 47

TRIAZOLAM......................... 85

TRIBENZOR .......................... 47

trifluoperazine hcl ................... 33

trifluridine ............................... 79

trihexyphenidyl hcl ................. 31

tri-legest fe .............................. 68

tri-lo-estarylla ......................... 68

tri-lo-sprintec .......................... 68

trimethobenzamide hcl ........... 18

trimethoprim ............................. 7

trimipramine maleate .............. 18

trinessa (28) ............................ 68

TRINTELLIX ......................... 17

tri-previfem ............................. 68

TRISENOX ............................ 29

tri-sprintec............................... 68

TRIUMEQ .............................. 39

trivora (28) .............................. 68

TROKENDI XR ..................... 14

TROPHAMINE ...................... 89

trospium chloride .................... 63

trospium chloride er ................ 63

TRUMENBA .......................... 76

TRUVADA............................. 38

TWINRIX ............................... 76

TYBOST................................. 37

TYGACIL................................. 7

TYKERB ................................ 29

TYPHIM VI............................ 76

TYSABRI ............................... 54

102

TYZEKA ................................ 36

U UCERIS ............................ 59, 65

ULORIC ................................. 20

unithroid ................................. 71

ursodiol ................................... 61

UVADEX ............................... 29

V VAGIFEM .............................. 64

valacyclovir hcl ...................... 36

VALCHLOR .......................... 59

valganciclovir hcl ................... 35

valproate sodium .................... 14

valproic acid ........................... 14

valsartan ................................. 45

valsartan-hydrochlorothiazide 47

vancomycin hcl ........................ 7

VANCOMYCIN HCL ............. 7

VAQTA .................................. 76

VARIVAX ............................. 76

VARIZIG ............................... 74

VECTIBIX ............................. 29

VELCADE ............................. 29

velivet ..................................... 68

VENCLEXTA ........................ 29

VENCLEXTA STARTING

PACK ................................. 29

venlafaxine hcl ....................... 18

venlafaxine hcl er ................... 18

VENLAFAXINE HCL ER .... 18

VENTAVIS ............................ 84

VENTOLIN HFA ................... 83

VERAMYST .......................... 84

verapamil hcl .......................... 49

verapamil hcl er ...................... 49

VERAPAMIL HCL ER ......... 49

VERIPRED 20 ....................... 65

VERSACLOZ ........................ 35

VESICARE ............................ 63

vestura .................................... 68

VEXOL .................................. 80

VIBRAMYCIN ...................... 12

VICTOZA .............................. 42

VIDEX.................................... 38

vienva ..................................... 68

VIGAMOX ............................. 79

VIIBRYD ............................... 16

VIIBRYD STARTER PACK . 16

VIMPAT ................................. 15

VINBLASTINE SULFATE ... 30

VINCASAR PFS .................... 30

VINCRISTINE SULFATE .... 30

VINORELBINE TARTRATE30

VIOKACE .............................. 61

VIRACEPT ............................ 39

VIRAZOLE ............................ 39

VIREAD ................................. 38

VITEKTA ............................... 38

VIVITROL ............................... 5

voriconazole ........................... 20

VOTRIENT ............................ 30

VPRIV .................................... 78

VRAYLAR ............................. 35

vyfemla ................................... 68

VYVANSE ............................. 52

W warfarin sodium ...................... 43

WELCHOL ............................ 51

X XALKORI .............................. 30

XARELTO ............................. 43

XARELTO STARTER PACK

............................................ 43

XELJANZ .............................. 74

XGEVA .................................. 77

XIFAXAN ................................ 7

XOLAIR ................................. 85

XTANDI ................................. 30

xulane ..................................... 68

XYREM.................................. 86

Y YERVOY ............................... 30

YF-VAX ................................. 76

YONDELIS ............................ 24

Z zafirlukast ............................... 82

zaleplon................................... 85

ZALTRAP .............................. 24

ZANOSAR ............................. 24

ZARXIO ................................. 44

ZAVESCA .............................. 60

zazole ...................................... 64

ZELAPAR .............................. 32

ZELBORAF ........................... 30

ZEMAIRA .............................. 85

ZENPEP ................................. 61

zenzedi .................................... 52

ZEPATIER ............................. 36

ZERBAXA ............................... 8

ZETIA..................................... 51

ZETONNA ............................. 84

ZIAGEN ................................. 38

ZIANA .................................... 59

ZIDOVUDINE ....................... 38

ziprasidone hcl ........................ 35

ZIRGAN ................................. 79

ZMAX .................................... 11

zoledronic acid........................ 77

ZOLINZA ............................... 30

zolmitriptan............................. 22

zolpidem tartrate ..................... 86

zolpidem tartrate er ................. 85

ZOMIG ................................... 22

ZONALON ............................. 60

zonisamide .............................. 13

ZORBTIVE ............................ 70

ZORTRESS ............................ 74

ZOSTAVAX........................... 76

ZOSYN ................................... 10

zovia 1/35e (28) ...................... 68

zovia 1/50e (28) ...................... 68

ZOVIRAX .............................. 60

ZYDELIG ............................... 30

ZYFLO ................................... 82

ZYFLO CR ............................. 82

ZYKADIA .............................. 30

ZYPREXA RELPREVV ........ 35

ZYTIGA ................................. 30

ix

Este Formulario fue actualizado el 12/01/2016. El formulario puede cambiar en cualquier momento. A usted se le notificará al respecto cuando sea necesario. Para obtener información más reciente o si tiene otras preguntas, póngase en contacto con el médico conserje de Care N’ Care Health Plan al 1-877-374-7993 (TTY 711) del 1 de octubre al 14 de febrero: de 8:00 a.m. a 8:00 p.m., hora estándar del centro, los siete días de la semana. Del 15 de febrero al 30 de septiembre: de 8:00 a.m. a 8:00 p.m., hora estándar del centro, de lunes a viernes. También puede enviar un correo electrónico a su médico conserje a [email protected] o visitar www.cnchealthplan.com.

El formulario puede cambiar en cualquier momento. A usted se le notificará al respecto cuando sea necesario.

Care N’ Care cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo.ATENCIÓN: Si habla español o vietnamita, hay servicios de asistencia de idiomas, sin cargo, disponibles para usted. Llame al 1-877-665-2622 (TTY: 711).

Care N’ Care complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.

ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-877-665-2622 (TTY: 711).

Care N’ Care tuân thủ luật dân quyền hiện hành của Liên bang và không phân biệt đối xử dựa trên chủng tộc, màu da, nguồn gốc quốc gia, độ tuổi, khuyết tật, hoặc giới tính.

CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-877-665-2622 (TTY: 711).

Esta información no es una descripción completa de los beneficios. Comuníquese con el plan para obtener más información. Pueden aplicarse ciertas limitaciones, copagos y restricciones. Los beneficios, la prima o los copagos/coseguros pueden cambiar el 1 de enero de cada año.

Care N’ Care es una organización de Medicare Advantage que tiene un contrato con Medicare. La inscripción en Care N’ Care depende de la renovación del contrato.

Este Formulario fue actualizado el 12/01/2016. El formulario puede cambiar en cualquier momento. A usted se le notificará al respecto cuando sea necesario. Para obtener información más reciente o si tiene otras preguntas, póngase en contacto con el médico conserje de Care N’ Care Health Plan al 1-877-374-7993 (TTY 711) del 1 de octubre al 14 de febrero: de 8:00 a.m. a 8:00 p.m., hora estándar del centro, los siete días de la semana. Del 15 de febrero al 30 de septiembre: de 8:00 a.m. a 8:00 p.m., hora estándar del centro, de lunes a viernes. También puede enviar un correo electrónico a su médico conserje a [email protected] o visitar www.cnchealthplan.com.

P L A N D E S A L U D C A R E N ’ C A R E

I N F O R M A C I Ó N D E C O N T A C T O

DIRECCIÓN WEB:Visite Care N’ Care en www.cnchealthplan.com.

INFORMACIÓN DE VENTASLos posibles miembros futuros pueden llamar sin cargo al 1-877-665-2622 si tienen preguntas relacionadas con el programa Medicare Advantage los siete días de la semana, de 8:00 a.m. a 8:00 p.m., hora estándar del centro.

MÉDICO CONSERJELos miembros actuales pueden llamar sin cargo al 1-877-374-7993 si tienen preguntas relacionadas con el programa Medicare Advantage desde el 1 de octubre al 14 de febrero, los siete días de la semana, de 8:00 a.m. a 8:00 p.m., hora estándar del centro, o desde el 15 de febrero al 30 de septiembre, de lunes a viernes, de 8:00 a.m. a 8:00 p.m., hora estándar del centro.

USUARIOS DE TTYLos usuarios de TTY deben llamar sin cargo al 711. si tienen preguntas relacionadas con el programa Medicare Advantage.

BENEFICIO DE MEDICAMENTOS CON RECETALos miembros actuales pueden llamar sin cargo al 1-855-791-5302 si tienen preguntas relacionadas con el programa de medicamentos con receta de la Parte D de Medicare. Los usuarios de TTY deben llamar al 711.

INFORMACIÓN DE MEDICAREPara obtener más información sobre Medicare, comuníquese con Medicare al 1-800-Medicare (1-800-633-4227). Los usuarios de TTY deben llamar al 1-877-486-2048. Puede llamar las 24 horasdel día, los siete días de la semana.O, visite www.medicare.gov en la web.

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