2021 Essential Health Benefits Enhanced Formulary
Effective July 1, 2021
For the most current list of covered medications or if you have questions:
Call the number on your member ID card
Visit your plan’s website on your member ID card or log on to the OptumRx app to: • Find a participating retail pharmacy by ZIP code • Look up possible lower-cost medication alternatives • Compare medication pricing and options
EHB Enhanced Understanding your formulary
What is a formulary? About this formulary A formulary is a list of prescribed medications or other When differences between this formulary and your pharmacy care products, services or supplies chosen for benefit plan exist, the benefit plan documents rule. their safety, cost, and effectiveness. Medications are This may not be a complete list of medications that are listed by categories or classes and are placed into cost covered by your plan. Please review your benefit plan for levels known as tiers. It includes both brand and generic full details. prescription medications.
® To create the list, OptumRx is guided by the Pharmacy and When does the formulary change? Therapeutics Committee. This group of doctors, nurses, and pharmacists reviews which medications will be covered, how • Medications, including generics, may be added at any time. well the drugs work, and overall value. They also make sure • Medications may move to a lower tier at any time. there are safe and covered options. • Medications may move to a higher tier or be excluded from coverage on January 1 of each year. How do I use my formulary? If a medication changes tiers, you may have to pay a different You and your doctor can use the formulary to help you amount for that medication. choose the most cost-effective prescription medications. This guide tells you if a medication is generic or brand, and Why are some medications excluded if special rules apply. If your medication is not listed here, from coverage? please visit your plan’s website or call the number on your A medication may be excluded from coverage under your member ID card. pharmacy benefit when it works the same as or similar to another prescription or over-the-counter (OTC) medication. What are tiers? Tiers are the different cost levels you pay for a medication. What if I don’t agree with a decision about an Each tier is assigned a cost, set by your employer or excluded medication? plan sponsor. You, your authorized representative, or your doctor can ask for a coverage request by calling the number on your member ID card.
Medication tips
What is the difference between brand-name and generic medications? Generic medications contain the same active ingredients (offer the same effect) as brand-name medications, but they often cost less. What if my doctor writes a brand-name prescription? Over-the-counter If your doctor gives you a prescription for a brand-name medication, ask if a medications (OTC) generic or lower-cost option could be right for you. Generic medications are Talk to your doctor about OTC usually your lowest-cost option. options. Even though OTC What if I am taking a specialty medication? medications may not be covered by your pharmacy benefit, Specialty medications are used to treat complex conditions and are generally they may cost less than a higher in cost. Please note, not all specialty medications are listed in the prescription medication. formulary. Our specialty pharmacy can provide most of your specialty medications along with helpful programs and services. Call 1-855-427-4682 and ask if you can have your prescriptions delivered right to your home or doctor’s office.
2 Reading your formulary
The formulary gives you choices so you and your doctor can decide your best course of treatment. In this formulary, brand-name medications are shown in UPPERCASE (for example, CLOBEX). Generic medications are shown in lowercase (for example, clobetasol).
Tier information Using lower tier or preferred medications can help you lower your out-of-pocket cost. Your plan may have multiple or no tiers. Please note: If you have a high-deductible plan, the tier cost levels will apply once you meet your deductible.
Drug Tier Includes Helpful Tips
Tier LC Lower-cost Use Tier LC drugs to lower your out-of-pocket costs. generic
Tier 1 $ Generic Use Tier 1 generic drugs instead of brand-name drugs to help reduce your out-of-pocket costs.
Tier 2 $$ Preferred Preferred brand-name drugs will generally have lower copayments than non-preferred brand-name drugs.
Tier 3 $$$ Non-Preferred Many Tier 3 drugs have lower-cost options in Tier LC, 1 or 2. Ask your doctor if they could work for you.
Tier 4 $$$$ Generic specialty Generally higher in copayment and cost. These drugs are sometimes and preferred used for complex and chronic conditions and may require special brand specialty monitoring and handling.
Tier 5 $$$$$ Non-Preferred Generally highest in copayment and cost. These drugs are sometimes Specialty used for complex and chronic conditions and may require special monitoring and handling. Highest cost medications.
Drug list information In this drug list, some medications are noted with letters next to them to help you see which ones may have coverage requirements or limits. Your benefit plan decides how these medications may be covered.
M Authorized generic or cobranded product
PA Prior Authorization – Your doctor is required to give OptumRx more information to determine coverage.
PV Preventive drugs – May have coverage and no copayments when health care reform requirements are met.
PV* Preventive drugs – Available at $0 if Health Care Reform copay waiver is approved.
QL Quantity Limit – Medication may be limited to a certain quantity.
ST Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered.
3 Table of Contents Analgesics...... 5 Anesthetics...... 7 Anti-Addiction/Substance Abuse Treatment Agents...... 8 Antibacterials...... 8 Anticonvulsants...... 11 Antidementia Agents...... 12 Antidepressants...... 13 Antiemetics...... 14 Antifungals...... 14 Antigout Agents...... 15 Antimigraine Agents...... 15 Antimyasthenic Agents...... 16 Antimycobacterials...... 16 Antineoplastics...... 16 Antiparasitics...... 20 Antiparkinson Agents...... 20 Antipsychotics...... 21 Antivirals...... 22 Anxiolytics...... 24 Bipolar Agents...... 24 Blood Glucose Monitoring...... 24 Blood Glucose Regulators...... 25 Blood Products and Modifiers...... 26 Cardiovascular Agents...... 28 Central Nervous System Agents...... 32 Dental and Oral Agents...... 33 Dermatological Agents...... 33 Electrolytes/Minerals/Metals/Vitamins...... 34 Gastrointestinal Agents...... 37 Genetic or Enzyme Disorder: Replacement, Modifiers, Treatment...... 38 Genitourinary Agents...... 39 Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)...... 40 Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)...... 42 Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins)...... 42 Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers)...... 42 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)...... 46 Hormonal Agents, Suppressant (Adrenal)...... 47 Hormonal Agents, Suppressant (Pituitary)...... 47 Hormonal Agents, Suppressant (Thyroid)...... 47 Immunological Agents...... 47 Inflammatory Bowel Disease Agents...... 50 Metabolic Bone Disease Agents...... 50 Miscellaneous Therapeutic Agents...... 51 Ophthalmic Agents...... 53 Otic Agents...... 55 Respiratory Tract/Pulmonary Agents...... 55 Skeletal Muscle Relaxants...... 58 Sleep Disorder Agents...... 58
4 Drug Name Drug Tier Notes Drug Name Drug Tier Notes Analgesics diflunisal oral 1 acetaminophen ec-naproxen 1 1 intravenous solution etodolac 1 bac 1 etodolac er 1 butalbital-apap-caffeine fenoprofen calcium oral 3 oral capsule 50-325-40 1 capsule 400 mg mg fenoprofen calcium oral butalbital-apap-caffeine 3 1 tablet oral tablet flurbiprofen oral 1 butalbital-aspirin- 1 caffeine gnp aspirin low dose 1 PV goodsense aspirin low Nonsteroidal Anti- 1 PV inflammatory Drugs dose adult aspirin regimen 1 PV ibuprofen lysine 1 ibuprofen oral aspirin adult low 1 strength oral tablet 1 PV suspension delayed release inavix 1 aspirin childrens 1 PV indomethacin er 1 aspirin ec low dose 1 PV indomethacin oral LC aspirin ec low strength 1 PV capsule 25 mg indomethacin oral aspirin ec oral tablet 1 delayed release 325 1 PV capsule 50 mg mg indomethacin sodium 1 aspirin low dose 1 PV ketoprofen er 1 aspirin oral tablet 1 PV ketoprofen oral capsule 1 aspirin oral tablet 50 mg, 75 mg 1 PV delayed release ketorolac tromethamine 1 BAYER ASPIRIN 3 PV injection BAYER ASPIRIN EC ketorolac tromethamine 3 PV 1 LOW DOSE intramuscular ketorolac tromethamine celecoxib oral 1 QL 1 QL oral diclofenac potassium 1 meclofenamate sodium 1 diclofenac sodium er 1 oral diclofenac sodium 1 QL meloxicam oral capsule 1 external gel 1 % meloxicam oral tablet LC diclofenac sodium 1 PA external solution nabumetone oral 1 naproxen oral tablet diclofenac sodium oral 1 1 250 mg diclofenac-misoprostol 1
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
5 Drug Name Drug Tier Notes Drug Name Drug Tier Notes naproxen oral tablet methadose oral tablet LC 1 375 mg, 500 mg soluble naproxen oral tablet methadose sugar-free 1 1 delayed release mitigo 1 naproxen sodium oral 1 morphine sulfate er 1 PA; QL tablet 275 mg, 550 mg morphine sulfate er 1 PA; QL oxaprozin 1 beads piroxicam oral 1 NUCYNTA ER 3 PA; QL qc aspirin low dose oral 1 PV OXYCONTIN 2 PA; QL tablet delayed release oxymorphone hcl er 1 PA; QL salsalate oral 1 tramadol hcl er 1 QL ST JOSEPH LOW tramadol hcl er DOSE ORAL TABLET 3 PV 1 QL DELAYED RELEASE (biphasic) sulindac oral 1 XTAMPZA ER 2 PA; QL tolmetin sodium 1 Opioid Analgesics, Short-acting Opioid Analgesics, acetaminophen- Long-acting 1 QL codeine buprenorphine 1 PA; QL acetaminophen- transdermal 1 QL codeine #2 fentanyl 1 PA; QL acetaminophen- hydrocodone bitartrate 1 QL 1 PA; QL codeine #3 er acetaminophen- 1 QL hydromorphone hcl er 1 PA; QL codeine #4 HYSINGLA ER 2 PA; QL apap-caff- levorphanol tartrate oral dihydrocodeine oral 1 PA; QL 3 PA; QL tablet 2 mg capsule methadone hcl injection 1 ascomp-codeine 1 methadone hcl intensol 1 butalbital- methadone hcl oral acetaminophen oral 1 1 concentrate capsule methadone hcl oral butalbital- 1 solution acetaminophen oral 1 tablet 50-325 mg methadone hcl oral 1 PA tablet butalbital-apap-caff-cod 1 methadone hcl oral butalbital-apap-caffeine 1 tablet soluble oral capsule 50-300-40 1 mg methadose oral 1 butalbital-asa-caff- concentrate 10 mg/ml 1 codeine
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
6 Drug Name Drug Tier Notes Drug Name Drug Tier Notes butorphanol tartrate oxycodone- 1 injection acetaminophen oral butorphanol tartrate tablet 10-325 mg, 2.5- 1 QL 1 QL nasal 325 mg, 5-325 mg, 7.5- 325 mg codeine sulfate 1 QL oxycodone-aspirin 1 QL duramorph 1 oxymorphone hcl 1 QL endocet 1 QL pentazocine-naloxone fentanyl citrate buccal 1 QL 1 PA; QL hcl lozenge on a handle tramadol hcl ir 1 QL hydrocodone- 1 QL tramadol- acetaminophen 1 QL acetaminophen hydrocodone-ibuprofen 1 QL Anesthetics hydromorphone hcl injection solution 1 Local Anesthetics 1 mg/ml, 2 mg/ml, 4 ethyl chloride 1 mg/ml glydo 1 hydromorphone hcl oral 1 QL lidocaine external 1 hydromorphone hcl pf 1 ointment 5 % morphine sulfate lidocaine external patch 1 (concentrate) oral 5 % 1 QL solution 100 mg/5ml, lidocaine hcl (pf) 1 20 mg/ml injection solution 2 % morphine sulfate (pf) lidocaine hcl external 1 1 injection solution morphine sulfate (pf) lidocaine hcl injection 1 intravenous solution 2 1 solution 2 % mg/ml, 4 mg/ml lidocaine hcl 1 morphine sulfate mouth/throat injection solution 2 1 lidocaine hcl mg/ml, 4 mg/ml 1 urethral/mucosal morphine sulfate oral 1 QL lidocaine viscous hcl LC oxycodone hcl oral 1 QL lidocaine-prilocaine capsule 1 external cream oxycodone hcl oral concentrate 100 1 QL LIDOCAINE- TETRACAINE mg/5ml 3 EXTERNAL CREAM 7- oxycodone hcl oral 1 QL 7 % solution oxycodone hcl oral 1 QL tablet
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
7 Drug Name Drug Tier Notes Drug Name Drug Tier Notes Anti- nicotine polacrilex 1 PV; QL Addiction/Substance mouth/throat Abuse Treatment nicotine step 1 1 PV; QL Agents nicotine step 2 1 PV; QL Alcohol Deterrents/Anti- nicotine step 3 1 PV; QL craving NICOTROL 3 ST; PV; QL acamprosate calcium 1 NICOTROL NS 3 ST; PV; QL disulfiram oral 1 Antibacterials naltrexone hcl oral 1 Aminoglycosides VIVITROL 5 amikacin sulfate 1 Opioid Dependence injection Treatments gentamicin in saline 1 buprenorphine hcl gentamicin sulfate 1 1 injection external buprenorphine hcl gentamicin sulfate 1 QL 1 sublingual injection buprenorphine hcl- neomycin sulfate oral LC 1 QL naloxone hcl paromomycin sulfate 1 Opioid Reversal oral Agents streptomycin sulfate 1 naloxone hcl injection 1 intramuscular NARCAN 2 tobramycin sulfate 1 Smoking Cessation injection Agents Antbacterials, Other bupropion hcl er aztreonam 1 1 PV; QL (smoking det) Antibacterials, Other CHANTIX 3 ST; PV; QL ALTABAX 3 CHANTIX bacitracin intramuscular 1 CONTINUING MONTH 3 ST; PV; QL chloramphenicol sod PAK 1 succinate CHANTIX STARTING 3 ST; PV; QL MONTH PAK clindamycin hcl oral 1 clindamycin palmitate goodsense nicotine 1 mouth/throat lozenge 4 1 PV; QL hcl mg clindamycin phosphate 1 habitrol 1 PV; QL in d5w clindamycin phosphate NICORETTE 1 MOUTH/THROAT 3 PV; QL injection GUM 2 MG clindamycin phosphate 1 vaginal
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
8 Drug Name Drug Tier Notes Drug Name Drug Tier Notes colistimethate sodium tinidazole oral 1 1 (cba) trimethoprim oral LC CORTISPORIN 3 vancomycin hcl in daptomycin 1 dextrose intravenous fosfomycin solution 1-5 gm/200ml- 1 1 tromethamine %, 500-5 mg/100ml-%, 750-5 mg/150ml-% iodine tincture external 1 tincture 2 % vancomycin hcl in nacl intravenous solution 1- 1 lincomycin hcl injection 1 0.9 gm/200ml-%, 500- linezolid in sodium 0.9 mg/100ml-% 1 chloride VANCOMYCIN HCL IN linezolid intravenous 1 NACL SOLUTION 750- 3 linezolid oral 1 QL 0.9 MG/150ML-% INTRAVENOUS mafenide acetate 1 external vancomycin hcl in nacl solution 750-0.9 1 methenamine hippurate 1 mg/150ml-% metronidazole in nacl intravenous intravenous solution 5- vancomycin hcl LC 1 0.79 mg/ml-%, 500- intravenous 0.79 mg/100ml-% vancomycin hcl oral 1 metronidazole in nacl intravenous solution 1 XIFAXAN 3 PA 500-0.74 mg/100ml-% ZYVOX INTRAVENOUS metronidazole oral LC 3 SOLUTION 200 metronidazole vaginal 1 MG/100ML mupirocin external 1 Beta-lactam, NEO-SYNALAR Cephalosporins 3 EXTERNAL CREAM cefaclor 1 nitrofurantoin 1 cefaclor er 1 nitrofurantoin 1 cefadroxil 1 macrocrystal cefazolin sodium 1 nitrofurantoin injection monohydrate 1 macrocrystals cefazolin sodium intravenous solution 1 polymyxin b sulfate 1 reconstituted injection cefazolin sodium- PRIMSOL 3 dextrose intravenous 1 silver sulfadiazine solution 1-4 gm/50ml- 1 external %, 2-4 gm/100ml-% ssd 1
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
9 Drug Name Drug Tier Notes Drug Name Drug Tier Notes cefazolin sodium- Beta-lactam, dextrose intravenous 1 Penicillins solution reconstituted amoxicillin LC cefdinir 1 amoxicillin-potassium 1 cefepime hcl 1 clavulanate er cefepime-dextrose 1 amoxicillin-potassium 1 cefixime 1 clavulanate oral cefotaxime sodium 1 ampicillin 1 cefotetan disodium 1 ampicillin sodium 1 cefotetan disodium- ampicillin-sulbactam 1 1 dextrose sodium cefoxitin sodium 1 AUGMENTIN ORAL SUSPENSION 3 cefpodoxime proxetil 1 RECONSTITUTED cefprozil 1 125-31.25 MG/5ML ceftazidime and BICILLIN L-A 3 1 dextrose dicloxacillin sodium LC ceftazidime injection 1 nafcillin sodium 1 ceftriaxone sodium in 1 oxacillin sodium 1 dextrose penicillin g potassium 1 ceftriaxone sodium 1 injection penicillin g sodium 1 ceftriaxone sodium penicillin v potassium LC 1 intravenous piperacillin sod- ceftriaxone sodium- tazobactam so 1 dextrose intravenous solution reconstituted 2.25 (2- 1 cefuroxime axetil 1 0.25) gm, 3.375 (3- cephalexin oral capsule 0.375) gm, 4.5 (4-0.5) LC 250 mg, 500 mg gm, 40.5 (36-4.5) gm cephalexin oral capsule Carbapenems 1 750 mg ertapenem sodium 1 cephalexin oral imipenem-cilastatin 1 suspension 1 reconstituted meropenem 1 cephalexin oral tablet 1 Macrolides azithromycin tazicef injection 1 LC intravenous tazicef intravenous 1 solution reconstituted azithromycin oral LC clarithromycin er 1 clarithromycin oral 1
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
10 Drug Name Drug Tier Notes Drug Name Drug Tier Notes DIFICID ORAL doxycycline hyclate oral 3 1 TABLET capsule erythromycin base 1 doxycycline hyclate oral 1 erythromycin tablet 100 mg, 20 mg 1 ethylsuccinate oral doxycycline erythromycin oral 1 monohydrate oral 1 capsule 100 mg, 50 mg ZITHROMAX ORAL 3 PACKET doxycycline monohydrate oral 1 Quinolones suspension BAXDELA ORAL 3 reconstituted CIPRO ORAL doxycycline 1 SUSPENSION 3 monohydrate oral tablet RECONSTITUTED MINOCIN 3 ciprofloxacin hcl oral INTRAVENOUS 1 tablet 100 mg, 750 mg minocycline hcl oral 1 ciprofloxacin hcl oral mondoxyne nl oral LC 1 tablet 250 mg, 500 mg capsule 100 mg ciprofloxacin in d5w 1 morgidox oral 1 levofloxacin in d5w 1 tetracycline hcl oral 1 levofloxacin 1 Anticonvulsants intravenous Anticonvulsants, levofloxacin oral 1 Other moxifloxacin hcl in nacl 1 BRIVIACT ORAL 3 ST moxifloxacin hcl oral 1 EPIDIOLEX 5 PA ofloxacin oral 1 levetiracetam er 1 Sulfonamides levetiracetam in nacl 1 sulfadiazine oral 1 levetiracetam 1 sulfamethoxazole- intravenous trimethoprim 1 levetiracetam oral 1 intravenous roweepra 1 sulfamethoxazole- LC trimethoprim oral Calcium Channel Modifying Agents sulfatrim pediatric LC CELONTIN 3 Tetracyclines ethosuximide oral 1 avidoxy 1 zonisamide oral 1 demeclocycline hcl 1 Gamma-aminobutyric doxy 100 1 Acid (GABA) doxycycline hyclate Augmenting Agents 1 intravenous clobazam 1 PA
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
11 Drug Name Drug Tier Notes Drug Name Drug Tier Notes DIACOMIT 5 PA carbamazepine oral 1 diazepam rectal 1 QL suspension carbamazepine oral gabapentin oral 1 LC tablet pentobarbital sodium 1 carbamazepine oral injection 1 tablet chewable phenobarbital oral 1 DILANTIN ORAL phenobarbital sodium 3 1 CAPSULE 30 MG injection epitol LC primidone oral LC fosphenytoin sodium 1 tiagabine hcl 1 oxcarbazepine 1 valproate sodium LC intravenous phenytoin infatabs 1 valproic acid oral LC phenytoin oral 1 phenytoin sodium Glutamate Reducing 1 Agents extended phenytoin sodium felbamate 1 1 injection FYCOMPA 3 rufinamide 1 PA lamotrigine er 1 VIMPAT ORAL 3 lamotrigine oral 1 Antidementia Agents lamotrigine starter kit- 1 blue Antidementia Agents, Other lamotrigine starter kit- 1 green NAMZARIC ORAL CAPSULE EXTENDED lamotrigine starter kit- 2 QL 1 RELEASE 24 HOUR orange 14-10 MG subvenite 1 Cholinesterase subvenite starter kit- Inhibitors 1 blue donepezil hcl 1 subvenite starter kit- galantamine 1 1 green hydrobromide subvenite starter kit- galantamine 1 1 orange hydrobromide er topiramate er 1 rivastigmine 1 topiramate oral 1 rivastigmine tartrate 1 Sodium Channel N-methyl-D-aspartate Agents (NMDA) Receptor BANZEL 3 PA Antagonist carbamazepine er 1 memantine hcl er 1 QL memantine hcl oral 1
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
12 Drug Name Drug Tier Notes Drug Name Drug Tier Notes NAMZARIC ORAL citalopram CAPSULE EXTENDED hydrobromide oral LC RELEASE 24 HOUR 2 QL tablet 21-10 MG, 28-10 MG, desvenlafaxine 1 QL 7-10 MG succinate er Antidepressants duloxetine hcl oral 1 QL Antidepressants, escitalopram oxalate 1 Other FETZIMA 3 ST; QL APLENZIN 3 ST; QL FETZIMA TITRATION 3 ST; QL bupropion hcl er (sr) 1 QL fluoxetine hcl (pmdd) 1 bupropion hcl er (xl) oral tablet extended fluoxetine hcl oral 1 QL LC release 24 hour 150 capsule mg, 300 mg fluoxetine hcl oral bupropion hcl oral 1 capsule delayed 1 QL release chlordiazepoxide- 1 fluoxetine hcl oral amitriptyline 1 solution mirtazapine oral tablet LC fluoxetine hcl oral tablet mirtazapine oral tablet LC LC 10 mg dispersible 15 mg fluoxetine hcl oral tablet 1 mirtazapine oral tablet 20 mg, 60 mg dispersible 30 mg, 45 1 mg fluvoxamine maleate 1 olanzapine-fluoxetine fluvoxamine maleate er 1 QL 1 QL hcl maprotiline hcl 1 perphenazine- nefazodone hcl 3 1 amitriptyline paroxetine hcl LC Monoamine Oxidase paroxetine hcl er 1 Inhibitors paroxetine mesylate 1 QL EMSAM 3 QL PAXIL ORAL 2 ST MARPLAN 3 SUSPENSION phenelzine sulfate oral 1 sertraline hcl oral 1 tranylcypromine sulfate 1 trazodone hcl oral SSRI/SNRI (Selective tablet 100 mg, 150 mg, LC Serotonin Reuptake 50 mg Inhibitors/Serotonin trazodone hcl oral 1 and Norepinephrine tablet 300 mg Reuptake Inhibitors) TRINTELLIX 3 ST; QL citalopram hydrobromide oral 1 venlafaxine hcl 1 solution
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
13 Drug Name Drug Tier Notes Drug Name Drug Tier Notes venlafaxine hcl er oral metoclopramide hcl LC capsule extended 1 oral solution release 24 hour metoclopramide hcl LC venlafaxine hcl er oral oral tablet tablet extended release 1 metoclopramide hcl 1 24 hour 225 mg oral tablet dispersible VIIBRYD 3 QL perphenazine oral 1 VIIBRYD STARTER 3 QL prochlorperazine 1 PACK prochlorperazine 1 Tricyclics edisylate injection amitriptyline hcl oral LC prochlorperazine amoxapine 1 maleate oral tablet 10 LC clomipramine hcl oral 1 mg desipramine hcl oral 1 prochlorperazine maleate oral tablet 5 1 doxepin hcl oral LC mg capsule scopolamine 1 doxepin hcl oral LC concentrate Emetogenic Therapy Adjuncts imipramine hcl oral 1 AKYNZEO ORAL 3 QL imipramine pamoate 1 ANZEMET 3 QL nortriptyline hcl oral LC capsule aprepitant 1 QL nortriptyline hcl oral dronabinol 1 PA; QL 1 solution fosaprepitant 1 protriptyline hcl 1 dimeglumine trimipramine maleate granisetron hcl 1 1 oral intravenous Antiemetics granisetron hcl oral 1 QL ondansetron hcl Antiemetics, Other 1 injection compro 1 ondansetron hcl oral dimenhydrinate 1 QL 1 solution injection ondansetron hcl oral 1 QL droperidol injection 1 tablet 24 mg meclizine hcl oral tablet ondansetron hcl oral LC 1 12.5 mg, 25 mg tablet 4 mg, 8 mg meclizine hcl oral tablet 1 ondansetron odt 1 chewable palonosetron hcl 1 metoclopramide hcl LC injection Antifungals ABELCET 3
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
14 Drug Name Drug Tier Notes Drug Name Drug Tier Notes AMBISOME 3 nyamyc 1 caspofungin acetate 1 nystatin external cream LC ciclodan 1 nystatin external 1 ciclopirox external 1 ointment ciclopirox olamine nystatin external 1 1 external powder clotrimazole external LC nystatin mouth/throat 1 clotrimazole nystatin oral 1 1 mouth/throat nystatin-triamcinolone 1 clotrimazole- nystop 1 1 betamethasone oxiconazole nitrate 3 CRESEMBA 3 OXISTAT EXTERNAL 3 econazole nitrate LOTION 1 external posaconazole 1 fluconazole in sodium tavaborole 1 PA chloride intravenous LC solution 200-0.9 terbinafine hcl oral LC QL mg/100ml-% terconazole 1 fluconazole in sodium voriconazole 1 chloride intravenous intravenous 1 solution 400-0.9 voriconazole oral 1 mg/200ml-% Antigout Agents fluconazole oral LC allopurinol oral LC flucytosine oral 1 allopurinol sodium 1 griseofulvin microsize 1 oral colchicine oral tablet 1 griseofulvin colchicine-probenecid 1 1 ultramicrosize febuxostat 1 ST GYNAZOLE-1 3 probenecid 1 itraconazole oral 1 PA Antimigraine Agents KERYDIN 3 PA Ergot Alkaloids ketoconazole external dihydroergotamine 1 1 PA; QL cream mesylate injection ketoconazole external dihydroergotamine 1 1 PA; QL shampoo mesylate nasal ketoconazole oral LC ergotamine-caffeine 1 micafungin sodium 1 miconazole 3 1 naftifine hcl 1
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
15 Drug Name Drug Tier Notes Drug Name Drug Tier Notes Prophylactic pyridostigmine bromide 1 AIMOVIG oral SUBCUTANEOUS Antimycobacterials SOLUTION AUTO- 2 PA; QL Antimycobacterials, INJECTOR 140 Other MG/ML, 70 MG/ML dapsone oral 1 EMGALITY 2 PA; QL rifabutin 1 EMGALITY (300 MG 2 PA; QL DOSE) Antituberculars Serotonin (5-HT) CAPASTAT SULFATE 3 1b/1d Receptor cycloserine oral 1 Agonists ethambutol hcl oral 1 almotriptan malate 1 QL isoniazid injection 1 eletriptan hydrobromide 1 QL isoniazid oral syrup 1 naratriptan hcl 1 QL isoniazid oral tablet 100 1 rizatriptan benzoate 1 QL mg sumatriptan nasal 1 QL isoniazid oral tablet 300 LC sumatriptan succinate mg 1 QL oral PASER 3 sumatriptan succinate PRIFTIN 3 1 QL refill pyrazinamide oral 1 sumatriptan succinate 1 QL rifampin intravenous 1 subcutaneous rifampin oral 1 sumatriptan-naproxen 3 QL sodium SIRTURO 3 ZOLMITRIPTAN TRECATOR 3 3 ST; QL NASAL Antineoplastics zolmitriptan oral 1 QL Alkylating Agents ZOMIG NASAL 3 ST; QL BENDEKA 5 PA Antimyasthenic busulfan 4 Agents carboplatin 4 Parasympathomimeti carmustine 4 cs cisplatin intravenous 4 GUANIDINE HCL 3 solution neostigmine cyclophosphamide methylsulfate 4 1 injection intravenous solution 10 mg/10ml, 5 mg/10ml cyclophosphamide oral 1 pyridostigmine bromide dacarbazine 4 1 er GLEOSTINE 5
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
16 Drug Name Drug Tier Notes Drug Name Drug Tier Notes ifosfamide 4 cladribine 4 LEUKERAN 2 clofarabine 4 MATULANE 4 cytarabine 4 melphalan 4 cytarabine (pf) 4 melphalan hcl 4 decitabine 4 PA MYLERAN 2 DROXIA 3 oxaliplatin 4 floxuridine injection 4 paraplatin 4 fludarabine phosphate 4 TEMODAR fluorouracil intravenous 4 4 INTRAVENOUS FOLOTYN 4 PA temozolomide 4 PA gemcitabine hcl 4 ZANOSAR 4 hydroxyurea oral 1 ZEPZELCA 5 PA mercaptopurine oral 1 Antiandrogens NIPENT 5 abiraterone acetate 4 PA TABLOID 4 bicalutamide 1 Antineoplastics, flutamide 1 Other nilutamide 4 ABRAXANE 4 XTANDI 5 PA adriamycin 4 Antiangiogenic ARRANON 4 Agents arsenic trioxide 4 POMALYST 5 PA intravenous REVLIMID 4 PA azacitidine 4 THALOMID 4 PA bleomycin sulfate 4 Antiestrogens/Modifie dactinomycin 4 rs daunorubicin hcl 4 EMCYT 3 dexrazoxane hcl 4 fulvestrant 4 diclofenac sodium 1 ST; QL SOLTAMOX 3 PV* external gel 3 % tamoxifen citrate oral docetaxel 4 1 tablet 10 mg doxorubicin hcl 4 tamoxifen citrate oral doxorubicin hcl 1 PV* 4 tablet 20 mg liposomal toremifene citrate 1 epirubicin hcl 4 Antimetabolites ETHYOL 5 ALIMTA 4 FLUOROPLEX 3 capecitabine 4 PA
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
17 Drug Name Drug Tier Notes Drug Name Drug Tier Notes FLUOROURACIL vincristine sulfate 4 EXTERNAL CREAM 2 vinorelbine tartrate 4 0.5 % VYXEOS 5 PA fluorouracil external 1 cream 5 % ZALTRAP 4 PA fluorouracil external ZOLINZA 4 PA 4 solution Aromatase Inhibitors, HALAVEN 4 PA 3rd Generation idarubicin hcl 4 anastrozole oral 1 PV* irinotecan hcl 4 exemestane 1 PV* ISTODAX (OVERFILL) 4 PA letrozole oral 1 IXEMPRA KIT 4 Enzyme Inhibitors leucovorin calcium etoposide intravenous 4 1 injection etoposide oral 4 leucovorin calcium oral 1 HYCAMTIN ORAL 5 levoleucovorin calcium 4 KYPROLIS 4 PA levoleucovorin calcium RUBRACA 4 PA 4 pf toposar 4 LONSURF 5 PA topotecan hcl 4 MARQIBO 5 Molecular Target mitomycin intravenous 4 Inhibitors mitoxantrone hcl 4 PA AFINITOR DISPERZ 5 PA mutamycin 4 BELEODAQ 5 PA NINLARO 5 PA BOSULIF 5 PA ONCASPAR 4 CABOMETYX 4 PA ONIVYDE 5 CAPRELSA ORAL 4 PA; QL ONUREG 5 PA TABLET 100 MG CAPRELSA ORAL paclitaxel 4 4 PA TABLET 300 MG PICATO 3 ST COMETRIQ 5 PA PIQRAY 5 PA COTELLIC 5 PA PROLEUKIN 4 ERIVEDGE 4 PA ROZLYTREK 5 PA erlotinib hcl oral tablet 4 PA SYNRIBO 5 PA 100 mg, 150 mg teniposide 4 erlotinib hcl oral tablet 4 PA; QL TOTECT 5 25 mg VELCADE 4 PA everolimus oral tablet 4 PA; QL vinblastine sulfate 4 2.5 mg, 5 mg, 7.5 mg FARYDAK 5 PA
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
18 Drug Name Drug Tier Notes Drug Name Drug Tier Notes GILOTRIF 5 PA; QL TUKYSA 5 PA IBRANCE 5 PA TURALIO 5 PA ICLUSIG ORAL TYKERB 4 PA TABLET 10 MG, 15 5 PA; QL VENCLEXTA 5 PA MG VENCLEXTA 5 PA ICLUSIG ORAL STARTING PACK TABLET 30 MG, 45 5 PA MG VOTRIENT 5 PA imatinib mesylate 4 PA XALKORI 4 PA IMBRUVICA 5 PA ZELBORAF 5 PA INLYTA 5 PA ZYDELIG 5 PA JAKAFI ORAL TABLET ZYKADIA 5 PA 4 PA; QL 10 MG Monoclonal JAKAFI ORAL TABLET Antibody/Antibody- 15 MG, 20 MG, 25 MG, 4 PA Drug Conjugate 5 MG ADCETRIS 4 PA JEVTANA 4 PA ARZERRA 4 PA KOSELUGO 5 PA AVASTIN 5 PA lapatinib ditosylate 4 PA BAVENCIO 5 PA LENVIMA ORAL BLINCYTO 5 PA CAPSULE THERAPY CYRAMZA 5 PA PACK 10 & 4 MG, 10 MG, 10 MG & 2 X 4 5 PA DARZALEX 5 PA MG, 2 X 10 MG, 2 X 10 EMPLICITI 5 PA MG & 4 MG, 2 X 4 MG, ENHERTU 5 PA 3 X 4 MG, 4 MG ERBITUX 4 PA LYNPARZA 4 PA GAZYVA 5 PA MEKINIST 4 PA HERCEPTIN 5 PA NEXAVAR 4 PA HERCEPTIN 5 PA QINLOCK 5 PA HYLECTA RYDAPT 5 PA KADCYLA 5 PA SPRYCEL 4 PA KANJINTI 4 PA STIVARGA 5 PA MVASI 4 PA SUTENT 4 PA OPDIVO 5 PA TAFINLAR 4 PA PADCEV 5 PA TAGRISSO ORAL 5 PA; QL PERJETA 4 PA TABLET 40 MG POLIVY 5 PA TAGRISSO ORAL 5 PA TABLET 80 MG RITUXAN 5 PA TASIGNA 5 PA RITUXAN HYCELA 5 PA
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
19 Drug Name Drug Tier Notes Drug Name Drug Tier Notes RUXIENCE 4 PA nitazoxanide 1 TECENTRIQ 5 PA pentamidine isethionate 1 TRAZIMERA 4 PA primaquine phosphate 1 UNITUXIN 5 PA pyrimethamine oral 4 PA YERVOY 4 PA quinine sulfate oral 1 PA ZIRABEV 4 PA Pediculicides/Scabici Retinoids des bexarotene 4 PA crotan 1 PANRETIN 3 lindane 3 TARGRETIN malathion 1 5 PA EXTERNAL permethrin external 1 tretinoin oral 4 spinosad 1 Treatment Adjuncts sulfurated lime 1 ELITEK 5 Antiparkinson Agents mesna 4 Anticholinergics MESNEX ORAL 5 benztropine mesylate 1 Antiparasitics injection benztropine mesylate Anthelmintics LC oral albendazole oral 1 PA trihexyphenidyl hcl oral 1 EMVERM 2 solution ivermectin external 1 trihexyphenidyl hcl oral LC ivermectin oral 1 tablet 2 mg praziquantel oral 1 trihexyphenidyl hcl oral 1 SKLICE 3 tablet 5 mg Antiprotozoals Antiparkinson Agents, Other ALINIA 2 amantadine hcl oral 1 atovaquone oral 1 carbidopa-levodopa- atovaquone-proguanil entacapone oral tablet 1 1 hcl 12.5-50-200 mg, 18.75- BENZNIDAZOLE 3 75-200 mg chloroquine phosphate entacapone 1 LC QL oral tolcapone 1 COARTEM 3 Dopamine Agonists hydroxychloroquine LC QL APOKYN 4 PA; QL sulfate oral bromocriptine mesylate 1 IMPAVIDO 3 oral mefloquine hcl 1 NEUPRO 3 ST
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
20 Drug Name Drug Tier Notes Drug Name Drug Tier Notes pramipexole Antipsychotics 1 dihydrochloride 1st pramipexole Generation/Typical 1 dihydrochloride er chlorpromazine hcl 1 ropinirole hcl 1 injection ropinirole hcl er 1 chlorpromazine hcl oral 1 Dopamine Precursors fluphenazine 1 and/or L-Amino Acid decanoate injection Decarboxylase fluphenazine hcl 1 Inhibitors injection carbidopa-levodopa er fluphenazine hcl oral 1 oral tablet extended 1 concentrate release 50-200 mg fluphenazine hcl oral 1 carbidopa-levodopa elixir oral tablet 10-100 mg, 1 fluphenazine hcl oral 25-250 mg LC tablet 1 mg carbidopa-levodopa oral tablet dispersible 1 fluphenazine hcl oral 25-100 mg tablet 10 mg, 2.5 mg, 5 1 mg Dopamine haloperidol decanoate Precursors/L-Amino 1 Acid Decarboxylase intramuscular Inhibitors haloperidol lactate 1 carbidopa oral 1 haloperidol oral tablet carbidopa-levodopa er 0.5 mg, 1 mg, 2 mg, 5 LC oral tablet extended 1 mg release 25-100 mg haloperidol oral tablet 1 carbidopa-levodopa 10 mg, 20 mg 1 oral tablet 25-100 mg loxapine succinate 1 carbidopa-levodopa molindone hcl 1 oral tablet dispersible 1 pimozide 1 10-100 mg, 25-250 mg thioridazine hcl oral 1 carbidopa-levodopa- entacapone oral tablet thiothixene 1 25-100-200 mg, 31.25- trifluoperazine hcl 1 1 125-200 mg, 37.5-150- 2nd 200 mg, 50-200-200 Generation/Atypical mg ABILIFY MAINTENA 3 Monoamine Oxidase B (MAO-B) Inhibitors aripiprazole 1 QL rasagiline mesylate oral 1 asenapine maleate 1 QL selegiline hcl oral 1 FANAPT 3 ST; QL
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21 Drug Name Drug Tier Notes Drug Name Drug Tier Notes FANAPT TITRATION Anti-hepatitis C (HCV) 3 ST; QL PACK Agents INVEGA SUSTENNA 3 EPCLUSA 4 PA; QL INVEGA TRINZA 3 HARVONI 4 PA; QL LATUDA 3 QL MAVYRET 4 PA; QL olanzapine PEGASYS 4 PA 1 intramuscular ribavirin oral 4 olanzapine oral 1 QL ZEPATIER 5 PA; QL paliperidone er 1 QL Anti-hepatitis C (HCV) quetiapine fumarate 1 QL Agents, Other quetiapine fumarate er 1 QL INTRON A 5 PA REXULTI 3 QL Antiherpetic Agents RISPERDAL CONSTA 3 acyclovir external 1 risperidone 1 QL acyclovir oral LC SAPHRIS 2 QL acyclovir sodium 1 ziprasidone hcl 1 QL DENAVIR 3 ziprasidone mesylate 1 famciclovir oral 1 ZYPREXA RELPREVV 3 valacyclovir hcl oral 1 QL Treatment-Resistant Anti-HIV Agents, clozapine 1 QL Integrase Inhibitors (INSTI) Antivirals BIKTARVY 3 Anti-cytomegalovirus (CMV) Agents GENVOYA 3 cidofovir intravenous 1 ISENTRESS 2 ganciclovir sodium 1 ISENTRESS HD 2 valganciclovir hcl 1 JULUCA 2 Anti-hepatitis B (HBV) STRIBILD 3 Agents TIVICAY 2 adefovir dipivoxil 4 TIVICAY PD 2 BARACLUDE ORAL TYBOST 2 5 QL SOLUTION Anti-HIV Agents, Non- entecavir 4 QL nucleoside Reverse EPIVIR HBV ORAL Transcriptase 4 SOLUTION Inhibitors (NNRTI) lamivudine oral tablet COMPLERA 2 4 100 mg EDURANT 2 VEMLIDY 5 efavirenz 1
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
22 Drug Name Drug Tier Notes Drug Name Drug Tier Notes efavirenz-emtricitab- TRIUMEQ 2 1 tenofovir TRUVADA 2 efavirenz-lamivudine- VIREAD ORAL 1 2 tenofovir POWDER INTELENCE 2 VIREAD ORAL nevirapine 1 TABLET 150 MG, 200 2 nevirapine er 1 MG, 250 MG SYMFI 2 zidovudine 1 SYMFI LO 2 Anti-HIV Agents, Other Anti-HIV Agents, Nucleoside and FUZEON 2 Nucleotide Reverse RUKOBIA 2 Transcriptase SELZENTRY 2 PA Inhibitors (NRTI) TROGARZO 3 PA abacavir sulfate 1 Anti-HIV Agents, abacavir sulfate- 1 Protease Inhibitors lamivudine APTIVUS 2 abacavir-lamivudine- 1 zidovudine atazanavir sulfate 1 CIMDUO 2 CRIXIVAN 2 DESCOVY 3 PA; PV* EVOTAZ 2 emtricitabine 1 fosamprenavir calcium 1 emtricitabine-tenofovir INVIRASE 2 df oral tablet 100-150 KALETRA ORAL 1 2 mg, 133-200 mg, 167- TABLET 250 mg LEXIVA ORAL 2 emtricitabine-tenofovir SUSPENSION df oral tablet 200-300 1 PV* lopinavir-ritonavir 1 mg NORVIR ORAL 2 EMTRIVA 2 PACKET lamivudine oral solution 1 NORVIR ORAL 2 lamivudine oral tablet SOLUTION 1 150 mg, 300 mg PREZCOBIX 2 lamivudine-zidovudine 1 PREZISTA 2 ODEFSEY 3 REYATAZ ORAL 2 RETROVIR PACKET 2 INTRAVENOUS ritonavir 1 stavudine 1 VIRACEPT 2 tenofovir disoproxil 1 PV* fumarate
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
23 Drug Name Drug Tier Notes Drug Name Drug Tier Notes Anti-influenza Agents lorazepam oral 1 QL oseltamivir phosphate concentrate 2 mg/ml 1 QL oral lorazepam oral tablet 1 QL RELENZA DISKHALER 3 QL oxazepam 1 QL rimantadine hcl 1 triazolam 1 QL Anxiolytics Bipolar Agents Anxiolytics, Other Mood Stabilizers buspirone hcl oral divalproex sodium er 1 LC tablet 10 mg, 5 mg divalproex sodium oral 1 buspirone hcl oral lithium LC tablet 15 mg, 30 mg, 1 7.5 mg lithium carbonate er LC hydroxyzine hcl lithium carbonate oral LC intramuscular solution 1 Blood Glucose 25 mg/ml Monitoring hydroxyzine hcl ACCU-CHEK intramuscular solution LC FASTCLIX LANCET 2 50 mg/ml KIT hydroxyzine hcl oral LC ACCU-CHEK hydroxyzine pamoate SOFTCLIX LANCET 2 LC oral DEVICE KIT CEQUR SIMPLICITY Benzodiazepines 3 2U alprazolam er 1 QL CHEMSTRIP UGK 3 alprazolam intensol 1 QL CONTOUR CONTROL 2 alprazolam oral tablet 1 QL SOLUTION alprazolam xr 1 QL CONTOUR MONITOR 2 chlordiazepoxide hcl 1 QL DEVICE clonazepam oral 1 QL CONTOUR MONITOR 2 clorazepate KIT W/DEVICE 1 QL dipotassium CONTOUR NEXT 2 diazepam injection 1 CONTROL SOLUTION CONTOUR NEXT EZ diazepam intensol 1 2 KIT W/DEVICE diazepam 1 intramuscular CONTOUR NEXT LINK 2 diazepam oral 1 CONTOUR NEXT MONITOR KIT 2 estazolam 1 QL W/DEVICE lorazepam injection 1 CONTOUR NEXT ONE 2 lorazepam intensol 1 QL KIT
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24 Drug Name Drug Tier Notes Drug Name Drug Tier Notes CONTOUR NEXT glyburide-metformin 1 2 QL TEST STRIPS GLYXAMBI 2 ST CONTOUR TEST 2 QL JANUMET 2 ST STRIPS JANUMET XR 2 ST INPEN 100-BLUE- 3 LILLY JANUVIA 2 ST INPEN 100-BLUE- JARDIANCE 2 ST 3 NOVO JENTADUETO 2 ST INPEN 100-GRAY- JENTADUETO XR 2 ST 3 LILLY metformin hcl er oral INPEN 100-GREY- tablet extended release LC 3 NOVO 24 hour 500 mg INPEN 100-PINK- metformin hcl er oral 3 LILLY tablet extended release 1 INPEN 100-PINK- 24 hour 750 mg 3 NOVO metformin hcl oral 1 KETOSTIX 3 solution metformin hcl oral LANCETS 2 LC tablet NOVOPEN ECHO 3 miglitol 1 ONETOUCH DELICA 3 LANCING DEV nateglinide 1 ONETOUCH DELICA OZEMPIC 2 ST; QL 3 PLUS LANCING pioglitazone hcl 1 Blood Glucose pioglitazone hcl- 1 Regulators glimepiride Antidiabetic Agents pioglitazone hcl- 1 acarbose oral 1 metformin hcl BYDUREON BCISE repaglinide 1 2 ST; QL AUTOINJECTOR SYNJARDY 2 ST BYETTA 10 MCG PEN 2 ST; QL SYNJARDY XR 2 ST BYETTA 5 MCG PEN 2 ST; QL TRADJENTA 2 ST FARXIGA 2 ST TRULICITY 2 ST; QL glimepiride LC VICTOZA 2 ST; QL glipizide er LC XIGDUO XR 2 ST glipizide ir LC Glycemic Agents glipizide xl LC diazoxide oral 1 glipizide-metformin hcl 1 glucagon emergency kit 1 glyburide micronized LC 1 mg injection 1 mg glyburide oral LC
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
25 Drug Name Drug Tier Notes Drug Name Drug Tier Notes GLUCAGON NOVOLIN N FLEXPEN 3 EMERGENCY KIT 1 2 Made by Lilly NOVOLIN N FLEXPEN 3 MG INJECTION 1 MG RELION GLUCAGON Made by 2 NOVOLIN N RELION 3 EMERGENCY KIT Fresenius NOVOLIN N VIAL 3 Insulins NOVOLIN R FLEXPEN 3 HUMALOG KWIKPEN 2 NOVOLIN R FLEXPEN HUMALOG MIX 50/50 3 2 RELION KWIKPEN NOVOLIN R RELION 3 HUMALOG MIX 50/50 2 VIAL NOVOLIN R VIAL 3 HUMALOG MIX 75/25 NOVOLOG FLEXPEN 3 2 KWIKPEN NOVOLOG MIX 70/30 3 HUMALOG MIX 75/25 FLEXPEN 2 VIAL NOVOLOG MIX 70/30 3 HUMALOG U-100 VIAL 2 JUNIOR KWIKPEN NOVOLOG PENFILL 3 HUMALOG VIAL 2 NOVOLOG U-100 VIAL 3 HUMULIN 70/30 TOUJEO MAX 2 2 KWIKPEN SOLOSTAR HUMULIN 70/30 VIAL 2 TOUJEO SOLOSTAR 2 HUMULIN N KWIKPEN 2 TRESIBA 3 HUMULIN N VIAL 2 TRESIBA 3 HUMULIN R U-500 FLEXTOUCH 2 KWIKPEN Blood Products and HUMULIN R U-500 Modifiers 2 VIAL CEPROTIN 5 HUMULIN R VIAL 2 SOLIRIS 5 PA LANTUS SOLOSTAR 2 Anticoagulants LANTUS U-100 VIAL 2 argatroban 1 LEVEMIR U-100 bivalirudin 2 1 FLEXTOUCH trifluoroacetate LEVEMIR U-100 VIAL 2 ELIQUIS 2 QL NOVOLIN 70/30 ELIQUIS DVT/PE 3 2 QL FLEXPEN STARTER PACK NOVOLIN 70/30 enoxaparin sodium 1 QL 3 FLEXPEN RELION fondaparinux sodium 1 QL NOVOLIN 70/30 3 heparin (porcine) in RELION nacl intravenous 1 NOVOLIN 70/30 VIAL 3 solution
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
26 Drug Name Drug Tier Notes Drug Name Drug Tier Notes heparin sod (porcine) in FEIBA 4 1 d5w HEMLIBRA 5 heparin sodium 1 HEMOFIL M 5 (porcine) HUMATE-P 4 heparin sodium 1 (porcine) pf KOATE 4 jantoven LC KOATE-DVI 4 PRADAXA 2 QL KOGENATE FS 5 SAVAYSA 3 QL KOVALTRY 5 THROMBATE III 5 NOVOEIGHT 4 warfarin sodium oral LC NOVOSEVEN RT 4 XARELTO 2 QL NUWIQ 4 XARELTO STARTER OBIZUR 5 2 QL PACK PROFILNINE 4 ZONTIVITY 3 protamine sulfate 1 Blood Formation intravenous Modifiers RECOMBINATE 4 ADAKVEO 5 PA RIASTAP 4 anagrelide hcl 1 RIXUBIS 5 ARANESP (ALBUMIN tranexamic acid oral 1 4 PA FREE) VONVENDI 5 MOZOBIL 4 PA; QL XYNTHA 4 NEULASTA 5 PA XYNTHA SOLOFUSE 4 NEULASTA ONPRO 5 PA Platelet Modifying NIVESTYM 4 PA Agents PROMACTA 5 PA aspirin-dipyridamole er 1 REBLOZYL 5 PA BRILINTA 2 RETACRIT 4 PA CABLIVI 5 PA; QL Hemostasis Agents cilostazol 1 ADVATE 4 clopidogrel bisulfate 1 ALPHANATE 4 oral aminocaproic acid dipyridamole oral 1 1 intravenous eptifibatide 1 aminocaproic acid oral 1 prasugrel hcl 1 BENEFIX 4 COAGADEX 5 CORIFACT 4 ELOCTATE 5
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
27 Drug Name Drug Tier Notes Drug Name Drug Tier Notes Cardiovascular moexipril hcl LC Agents perindopril erbumine 1 Alpha-adrenergic quinapril hcl LC Agonists ramipril LC clonidine 1 trandolapril LC clonidine hcl oral tablet LC 0.1 mg, 0.2 mg Antiarrhythmics clonidine hcl oral tablet adenosine intravenous 1 0.3 mg solution 12 mg/4ml, 6 1 mg/2ml guanfacine hcl LC amiodarone hcl 1 methyldopa LC disopyramide 1 midodrine hcl 1 phosphate Alpha-adrenergic dofetilide 1 Blocking Agents flecainide acetate 1 doxazosin mesylate LC oral ibutilide fumarate 1 phenoxybenzamine hcl lidocaine hcl (cardiac) 1 intravenous solution oral 1 prefilled syringe 100 phentolamine mesylate 1 mg/5ml, 50 mg/5ml injection lidocaine hcl (cardiac) 1 prazosin hcl oral LC pf Angiotensin II lidocaine in d5w Receptor Antagonists intravenous solution 4- 1 candesartan cilexetil 1 5 mg/ml-%, 8-5 mg/ml- irbesartan 1 % losartan potassium oral LC mexiletine hcl oral 1 olmesartan medoxomil procainamide hcl 1 1 oral injection telmisartan 1 propafenone hcl 1 valsartan 1 propafenone hcl er 1 Angiotensin- quinidine gluconate er 1 converting Enzyme quinidine sulfate 1 (ACE) Inhibitors sorine oral tablet 120 1 benazepril hcl oral LC mg, 160 mg, 240 mg captopril oral 1 sorine oral tablet 80 mg LC enalapril maleate oral LC sotalol hcl (af) 1 enalaprilat 1 sotalol hcl oral tablet fosinopril sodium LC 120 mg, 160 mg, 240 1 mg lisinopril oral LC
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
28 Drug Name Drug Tier Notes Drug Name Drug Tier Notes sotalol hcl oral tablet 80 Calcium Channel LC mg Blocking Agents Beta-adrenergic amlodipine besylate LC Blocking Agents oral acebutolol hcl oral 1 cartia xt 1 atenolol oral LC diltiazem hcl er 1 betaxolol hcl oral 1 diltiazem hcl er beads 1 bisoprolol fumarate oral LC diltiazem hcl er coated 1 BYSTOLIC 2 beads diltiazem hcl carvedilol LC 1 intravenous carvedilol phosphate er 1 diltiazem hcl oral 1 esmolol hcl intravenous 1 solution 100 mg/10ml dilt-xr 1 esmolol hcl-sodium felodipine er 1 1 chloride matzim la 1 labetalol hcl nicardipine hcl 1 1 intravenous solution intravenous labetalol hcl oral 1 nifedipine er 1 metoprolol succinate er 1 nifedipine er osmotic 1 metoprolol tartrate release 1 intravenous nimodipine oral 1 metoprolol tartrate oral nisoldipine er 1 tablet 100 mg, 25 mg, LC taztia xt 1 50 mg tiadylt er 1 metoprolol tartrate oral 1 tablet 37.5 mg, 75 mg verapamil hcl er 1 verapamil hcl pindolol 1 1 intravenous propranolol hcl er 1 verapamil hcl oral tablet propranolol hcl LC 1 120 mg, 80 mg intravenous verapamil hcl oral tablet propranolol hcl oral 1 1 40 mg solution Cardiovascular propranolol hcl oral Agents, Other tablet 10 mg, 20 mg, 40 LC mg, 80 mg aliskiren fumarate 1 propranolol hcl oral alprostadil injection 1 1 tablet 60 mg amiloride- LC timolol maleate oral 1 hydrochlorothiazide amlodipine besylate- 1 benazepril hcl
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29 Drug Name Drug Tier Notes Drug Name Drug Tier Notes amlodipine besylate- lisinopril- 1 LC valsartan hydrochlorothiazide amlodipine-atorvastatin 1 losartan potassium-hctz LC amlodipine-olmesartan 1 methyldopa- 1 amlodipine-valsartan- hydrochlorothiazide 1 hctz metoprolol- 1 atenolol-chlorthalidone LC hydrochlorothiazide benazepril- metyrosine 1 1 hydrochlorothiazide milrinone lactate 1 bisoprolol- milrinone lactate in LC 1 hydrochlorothiazide dextrose candesartan cilexetil- norepinephrine 1 1 hctz bitartrate intravenous captopril- olmesartan medoxomil- 1 1 hydrochlorothiazide hctz CORLANOR 3 PA; QL olmesartan-amlodipine- 1 DEMSER 3 hctz digitek LC pentoxifylline er 1 digox LC phenylephrine hcl intravenous solution 10 1 digoxin injection 1 mg/ml digoxin oral LC propranolol-hctz 1 dobutamine hcl 1 quinapril- 1 dobutamine in d5w 1 hydrochlorothiazide dopamine hcl ranolazine er 1 1 intravenous spironolactone-hctz LC dopamine in d5w 1 telmisartan-amlodipine 1 enalapril- telmisartan-hctz 1 hydrochlorothiazide 1 trandolapril-verapamil oral tablet 10-25 mg 1 hcl er enalapril- hydrochlorothiazide LC triamterene-hctz LC oral tablet 5-12.5 mg valsartan- 1 ENTRESTO 2 QL hydrochlorothiazide ephedrine sulfate VYNDAMAX 5 PA; QL 1 intravenous solution Diuretics, Carbonic epinephrine pf 1 Anhydrase Inhibitors fosinopril sodium-hctz 1 acetazolamide er 1 irbesartan- acetazolamide oral 1 1 hydrochlorothiazide acetazolamide sodium 1
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
30 Drug Name Drug Tier Notes Drug Name Drug Tier Notes methazolamide oral 1 Dyslipidemics, HMG Diuretics, Loop CoA Reductase Inhibitors bumetanide LC atorvastatin calcium ethacrynate sodium 1 oral tablet 10 mg, 20 LC PV* ethacrynic acid 1 mg furosemide injection LC atorvastatin calcium furosemide oral oral tablet 40 mg, 80 LC LC solution 10 mg/ml mg furosemide oral LIVALO 3 ST 1 solution 8 mg/ml lovastatin oral 1 PV furosemide oral tablet LC pravastatin sodium 1 torsemide LC rosuvastatin calcium 1 Diuretics, Potassium- simvastatin oral tablet sparing 10 mg, 20 mg, 40 mg, 5 LC PV* amiloride hcl oral 1 mg simvastatin oral tablet eplerenone 1 LC 80 mg spironolactone oral LC Dyslipidemics, Other triamterene oral 1 cholestyramine light 1 Diuretics, Thiazide cholestyramine oral 1 chlorthalidone LC colesevelam hcl 1 hydrochlorothiazide LC oral colestipol hcl 1 indapamide LC ezetimibe 1 metolazone 1 ezetimibe-simvastatin 1 Dyslipidemics, Fibric NEXLETOL 2 PA; QL Acid Derivatives NEXLIZET 2 PA; QL fenofibrate micronized 1 niacin er 1 fenofibrate oral capsule 1 (antihyperlipidemic) omega-3-acid ethyl fenofibrate oral tablet 1 PA 145 mg, 160 mg, 48 1 esters mg, 54 mg PRALUENT 2 PA; QL fenofibric acid oral prevalite 1 capsule delayed 1 REPATHA 2 PA; QL release REPATHA gemfibrozil oral LC PUSHTRONEX 2 PA; QL SYSTEM REPATHA 2 PA; QL SURECLICK
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31 Drug Name Drug Tier Notes Drug Name Drug Tier Notes Vasodilators, Direct- dextroamphetamine 1 PA; QL acting Arterial sulfate hydralazine hcl dextroamphetamine 1 1 PA; QL injection sulfate er hydralazine hcl oral LC VYVANSE 2 PA; QL minoxidil oral 1 Attention Deficit Vasodilators, Direct- Hyperactivity acting Disorder Agents, Arterial/Venous Non-amphetamines DILATRATE-SR 3 atomoxetine hcl 1 QL isosorbide dinitrate oral clonidine hcl er 1 tablet 10 mg, 20 mg, 30 1 DAYTRANA 3 ST; PA; QL mg, 5 mg dexmethylphenidate hcl 1 PA; QL isosorbide mononitrate 1 dexmethylphenidate hcl 1 PA; QL isosorbide mononitrate er er oral tablet extended 1 guanfacine hcl er 1 release 24 hour 120 mg methylphenidate hcl er 1 PA; QL isosorbide mononitrate er oral tablet extended methylphenidate hcl er LC 1 PA; QL release 24 hour 30 mg, (cd) 60 mg methylphenidate hcl er 1 PA; QL NITRO-BID 3 (la) methylphenidate hcl er nitroglycerin 1 1 PA; QL (xr) nitroglycerin in d5w 1 methylphenidate hcl 1 PA; QL NITROMIST 3 oral nitroprusside sodium 1 QUILLIVANT XR 3 ST; PA; QL RECTIV 3 relexxii 1 PA; QL sodium nitroprusside 1 Central Nervous Central Nervous System, Other System Agents caffeine citrate 1 Attention Deficit GRALISE ORAL 3 ST; QL Hyperactivity TABLET Disorder Agents, Amphetamines riluzole 1 PA; QL amphetamine sulfate 1 PA; QL tetrabenazine 4 PA amphetamine- Fibromyalgia Agents 1 PA; QL dextroamphetamine pregabalin oral 1 QL amphetamine- SAVELLA 3 ST; QL 1 PA; QL dextroamphetamine er SAVELLA TITRATION 3 ST; QL PACK
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32 Drug Name Drug Tier Notes Drug Name Drug Tier Notes Multiple Sclerosis periogard LC Agents pilocarpine hcl oral 1 AVONEX PEN 4 PA; QL prevident mouth/throat 1 AVONEX PREFILLED 4 PA; QL sodium fluoride 5000 1 BAFIERTAM 4 PA; QL enamel BETASERON 4 PA; QL sodium fluoride 5000 1 COPAXONE 4 PA; QL plus sodium fluoride 5000 dalfampridine er 4 PA; QL 1 ppm dimethyl fumarate oral 4 PA; QL sodium fluoride 5000 dimethyl fumarate 1 4 PA; QL sensitive starter pack sodium fluoride dental 1 GILENYA 5 PA; QL triamcinolone acetonide 1 glatiramer acetate 4 PA; QL mouth/throat glatopa 4 PA; QL Dermatological MAYZENT 5 PA; QL Agents MAYZENT STARTER accutane 1 PA 5 PA; QL PACK acitretin 1 TECFIDERA 4 PA; QL adapalene external 1 PA TYSABRI 5 PA; QL cream Dental and Oral adapalene external gel 1 PA Agents adapalene-benzoyl 1 cavarest 1 peroxide external gel cevimeline hcl 1 ammonium lactate 1 chlorhexidine gluconate external LC mouth/throat amnesteem 1 PA CLINPRO 5000 3 azelaic acid external 1 DEBACTEROL 3 AZELEX 3 DENTA 5000 PLUS 3 benzoyl peroxide- 1 DENTAGEL 3 erythromycin calcipotriene external easygel 1 1 cream FLUORIDEX 3 calcipotriene external 1 fluoridex daily renewal 1 ointment FLUORIDEX calcipotriene external 1 ENHANCED 3 solution WHITENING calcipotriene-betameth FLUORIDEX 3 diprop external 1 QL SENSITIVITY RELIEF suspension oralone 1 calcitriol external 1
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
33 Drug Name Drug Tier Notes Drug Name Drug Tier Notes claravis 1 PA STELARA 4 PA; QL clindacin etz external SUBCUTANEOUS 1 swab sulfacetamide sodium 1 clindacin-p 1 (acne) clindamycin phosphate- tacrolimus external 1 1 benzoyl peroxide ointment clindamycin phosphate TALTZ 5 PA 1 external tazarotene external 1 clindamycin-tretinoin 1 TAZORAC EXTERNAL 3 coal tar external 1 CREAM 0.05 % TAZORAC EXTERNAL CONDYLOX 3 3 GEL dapsone external 1 TREMFYA 4 PA doxepin hcl external 3 tretinoin external 1 PA DUPIXENT 4 PA; QL tretinoin microsphere 1 PA EPIDUO FORTE 3 tretinoin microsphere 1 PA ery 1 pump erythromycin external 1 zenatane 1 PA imiquimod external 1 Electrolytes/Minerals/ cream 5 % Metals/Vitamins isotretinoin oral 1 PA Electrolyte/Mineral lactic acid e 1 Replacement lactic acid external 1 calcium chloride 1 methoxsalen rapid 1 calcium gluconate 1 metronidazole external 1 intravenous MIRVASO 2 CARBAGLU 4 chromic chloride myorisan 1 PA 1 intravenous neuac external gel 1 dextrose in lactated 1 pimecrolimus 1 ringers podofilox external 1 dextrose intravenous 1 REGRANEX 3 PA dextrose-nacl 1 rosadan external cream 1 dextrose-sodium 1 rosadan external gel 1 chloride SANTYL 3 effer-k oral tablet 1 selenium sulfide effervescent 25 meq 1 external lotion ferocon 1 STELARA ferotrinsic 1 4 PA INTRAVENOUS ferraplus 90 1
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
34 Drug Name Drug Tier Notes Drug Name Drug Tier Notes ferrocite plus 1 polysaccharide iron 1 fluoritab 1 PV forte potassium acetate foltrin 1 1 intravenous hemocyte-f 1 potassium chloride crys 1 iodine strong oral 1 er kcl in dextrose-nacl 1 potassium chloride er 1 kcl-lactated ringers-d5w 1 potassium chloride in 1 klor-con 1 dextrose klor-con 10 1 potassium chloride in 1 klor-con m10 1 nacl potassium chloride KLOR-CON M15 3 1 intravenous klor-con m20 1 potassium chloride oral 1 klor-con/ef 1 potassium citrate er 1 k-prime 1 potassium 1 k-tan plus 1 phosphates(71 meq k) lactated ringers 1 purevit dualfe plus 1 intravenous ringers 1 levocarnitine oral 1 solution se-tan plus 1 levocarnitine oral tablet 1 sod citrate-citric acid LC sodium acetate levocarnitine sf 1 1 intravenous magnesium chloride 1 sodium bicarbonate injection 1 intravenous magnesium sulfate in 1 d5w sodium chloride (pf) 1 magnesium sulfate sodium chloride 1 1 injection injection magnesium sulfate sodium chloride 1 1 intravenous intravenous na ferric gluc cplx in sodium fluoride oral 1 PV 1 sucrose sodium phosphates 1 nafrinse 1 PV tl-hem 150 1 nafrinse drops 1 PV virt-phos 250 neutral 1 nutrilipid 1 Electrolyte/Mineral/Me phosphorous 1 tal Modifiers phospho-trin 250 CHEMET 3 1 neutral clovique 4 PA deferasirox 1 PA
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
35 Drug Name Drug Tier Notes Drug Name Drug Tier Notes deferasirox granules 1 PA folic acid oral tablet 1 1 deferiprone 1 PA mg sodium polystyrene folplex 2.2 1 1 sulfonate hydroxocobalamin 1 sps 1 acetate trientine hcl 4 PA lysiplex plus oral tablet 1 VELTASSA 3 multi prenatal 1 PV Phosphate Binders multi-vit/iron/fluoride 1 calcium acetate (phos multi-vitamin/fluoride 1 1 binder) multivitamin/fluoride 1 calcium acetate oral oral solution 1 tablet 667 mg multivitamin/fluoride FOSRENOL ORAL oral tablet chewable 1 3 PACKET 0.25 mg, 0.5 mg, 1 mg multi- lanthanum carbonate 1 1 vitamin/fluoride/iron PHOSLYRA 3 NASCOBAL 3 sevelamer carbonate 1 nephronex oral tablet 1 sevelamer hcl 1 nufol 1 Vitamins nutrifac zx 1 adc/f (0.5mg/ml) 1 ONE VITE WOMENS 3 PV airavite 1 ONE-A-DAY WOMENS 3 PV b-6 folic acid 1 PRENATAL 1 biocel 1 phytonadione injection 1 bp vit 3 1 phytonadione oral 1 b-plex 1 prenatal multi +dha 1 PV b-plex plus 1 prenatal oral tablet 27- 1 PV cod liver oil oral oil 1 0.8 mg cyanocobalamin prenatal oral tablet 27-1 LC injection solution 1000 1 mg mcg/ml prenatal plus iron 1 ergocalciferol oral prenatal vitamin plus 1 LC capsule low iron fabb 1 preplus LC fa-vitamin b-6-vitamin 1 pyridoxine hcl injection 1 b-12 thiamine hcl injection 1 folbee 1 tri-vite/fluoride 1 folbee plus 1 v-c forte 1 folic acid injection 1
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
36 Drug Name Drug Tier Notes Drug Name Drug Tier Notes virt-caps 1 glycopyrrolate pf 1 virt-gard 1 hyoscyamine sulfate 1 vita s forte 1 oral vitacel 1 hyoscyamine sulfate sl 1 hyoscyamine sulfate vita-min 1 1 sublingual vitamin d (ergocalciferol) oral methscopolamine 1 3 capsule 1.25 mg bromide oral (50000 ut) oscimin 1 vitamin k1 injection 1 Gastrointestinal vitamins acd-fluoride 1 Agents, Other vp-pnv-dha 1 alvimopan 1 amoxicill-clarithro- vp-vite rx 1 1 lansopraz westab mini 1 cromolyn sodium oral 1 westab one 1 diphenoxylate-atropine 1 Gastrointestinal Agents GATTEX 5 PA loperamide hcl oral Antispasmodics, 1 Gastrointestinal capsule atropine sulfate MOTOFEN 3 injection solution 8 1 OMECLAMOX-PAK 2 mg/20ml PYLERA 2 atropine sulfate sodium bicarbonate injection solution 1 1 oral powder prefilled syringe 0.5 mg/5ml SYMPROIC 2 ST; QL CUVPOSA 3 ursodiol oral 1 dicyclomine hcl Histamine2 (H2) 1 intramuscular Receptor Antagonists dicyclomine hcl oral cimetidine hcl 1 LC capsule cimetidine oral tablet dicyclomine hcl oral 200 mg, 300 mg, 400 1 1 solution mg dicyclomine hcl oral cimetidine oral tablet LC LC tablet 800 mg ED-SPAZ 1 famotidine intravenous 1 glycopyrrolate injection famotidine oral 1 solution suspension 1 reconstituted glycopyrrolate oral 1 tablet 1 mg, 2 mg
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
37 Drug Name Drug Tier Notes Drug Name Drug Tier Notes famotidine oral tablet peg- LC 20 mg 3350/electrolytes/ascor 1 famotidine oral tablet bat 1 40 mg peg-kcl-nacl-nasulf-na 1 famotidine premixed 1 asc-c nizatidine 1 qc magnesium citrate 1 PV; QL SUPREP BOWEL Irritable Bowel 3 Syndrome Agents PREP KIT alosetron hcl 1 PA Protectants LINZESS 2 ST; QL misoprostol oral 1 sucralfate oral Laxatives 1 suspension bisacodyl ec 1 PV; QL sucralfate oral tablet LC cascara sagrada oral 1 fluid extract Proton Pump Inhibitors citroma 1 PV; QL DEXILANT 2 QL clearlax 1 PV; QL esomeprazole sodium 1 CLENPIQ 3 lansoprazole oral constulose LC capsule delayed 1 QL enulose 1 release gavilax oral powder 1 PV; QL lansoprazole oral tablet gavilyte-c 1 PV; QL delayed release 1 QL dispersible 15 mg gavilyte-g 1 PV; QL omeprazole oral gavilyte-h 1 capsule delayed LC QL gavilyte-n with flavor release 1 PV; QL pack pantoprazole sodium LC QL generlac 1 intravenous gentle laxative oral 1 PV; QL pantoprazole sodium 1 QL glycolax 1 PV; QL oral packet lactulose pantoprazole sodium 1 encephalopathy oral tablet delayed LC QL release lactulose oral solution LC rabeprazole sodium magnesium citrate oral 1 PV; QL oral tablet delayed 1 QL solution release mineral oil heavy oral 1 Genetic or Enzyme mm clearlax 1 PV; QL Disorder: peg 3350-kcl-na bicarb- Replacement, 1 PV; QL nacl Modifiers, Treatment peg-3350/electrolytes 1 PV; QL ALDURAZYME 4 PA
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
38 Drug Name Drug Tier Notes Drug Name Drug Tier Notes CERDELGA 5 PA ZENPEP ORAL CHOLBAM 5 PA CAPSULE DELAYED RELEASE PARTICLES CREON 2 10000-32000 UNIT, CYSTAGON 5 15000-47000 UNIT, 2 ELAPRASE 4 PA 20000-63000 UNIT, 3000-14000 UNIT, EVRYSDI 5 PA; QL 40000-126000 UNIT, FABRAZYME 4 PA 5000-24000 UNIT KANUMA 5 PA Genitourinary Agents KUVAN 4 PA Antispasmodics, LUMIZYME 4 PA Urinary darifenacin MEPSEVII 5 PA 1 hydrobromide er miglustat 4 PA flavoxate hcl 1 MYALEPT 5 PA GELNIQUE 3 ST NAGLAZYME 4 PA MYRBETRIQ 2 nitisinone 4 PA oxybutynin chloride er 1 ORFADIN ORAL 5 PA CAPSULE 20 MG oxybutynin chloride oral 1 ORFADIN ORAL solifenacin succinate 1 5 PA SUSPENSION tolterodine tartrate 1 PROLASTIN-C 5 PA tolterodine tartrate er 1 RAVICTI 5 PA TOVIAZ 3 REVCOVI 5 PA trospium chloride 1 sapropterin trospium chloride er 1 4 PA dihydrochloride urin ds 1 sod benz-sod 1 Benign Prostatic phenylacet Hypertrophy Agents sodium phenylbutyrate 4 alfuzosin hcl er 1 oral dutasteride oral 1 STRENSIQ 4 PA dutasteride-tamsulosin 1 SUCRAID 5 hcl TEGSEDI 5 PA finasteride oral tablet 5 LC VIMIZIM 5 PA mg ZEMAIRA 5 PA silodosin 1 tadalafil oral tablet 2.5 1 PA; QL mg, 5 mg tamsulosin hcl LC terazosin hcl LC
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
39 Drug Name Drug Tier Notes Drug Name Drug Tier Notes Genitourinary Agents, Hormonal Agents, Other Stimulant/Replaceme acetic acid irrigation 1 nt/Modifying (Adrenal) aminoacetic acid 1 ala-cort external cream 1 argyle sterile saline 1 1 % bethanechol chloride ala-cort external cream 1 LC oral 2.5 % curity sterile saline 1 alclometasone 1 ELMIRON 2 dipropionate ENCARE 3 PV; QL amcinonide external 1 glycine irrigation 1 lotion glycine urologic 1 beser external lotion 1 neomycin-polymyxin b betamethasone 1 1 gu dipropionate aug penicillamine oral betamethasone 4 PA 1 capsule dipropionate external penicillamine oral tablet 4 betamethasone sod phos & acet injection phenazo oral tablet 200 1 LC suspension 6 (3-3) mg mg/ml phenazopyridine hcl betamethasone 1 oral tablet 100 mg, 200 LC valerate external mg clobetasol prop 1 RENACIDIN 3 emollient base sodium chloride 1 clobetasol propionate e 1 irrigation clobetasol propionate sorbitol irrigation 1 1 emulsion solution 3.3 % clobetasol propionate 1 sorbitol-mannitol 1 external TODAY SPONGE 3 PV; QL clocortolone pivalate 1 VCF VAGINAL clodan external 1 CONTRACEPTIVE 3 PV; QL shampoo VAGINAL FILM DEPO-MEDROL vcf vaginal INJECTION 3 contraceptive vaginal 1 PV; QL SUSPENSION 20 gel MG/ML desonide external 1 cream desonide external lotion 1
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
40 Drug Name Drug Tier Notes Drug Name Drug Tier Notes desonide external fluticasone propionate 1 1 ointment external desoximetasone halcinonide 3 1 external cream 0.25 % halobetasol propionate 1 desoximetasone external cream 1 external gel halobetasol propionate 1 desoximetasone external ointment 1 external liquid hydrocortisone butyrate 1 desoximetasone external cream external ointment 0.25 1 hydrocortisone butyrate 1 % external ointment dexamethasone hydrocortisone butyrate LC 1 intensol external solution dexamethasone oral hydrocortisone external LC 1 elixir cream 1 % dexamethasone oral hydrocortisone external LC LC solution cream 2.5 % dexamethasone oral hydrocortisone external LC 1 tablet lotion 2.5 % dexamethasone oral hydrocortisone external 1 1 tablet therapy pack ointment 1 %, 2.5 % dexamethasone sod hydrocortisone oral LC phosphate pf injection LC solution hydrocortisone valerate 1 dexamethasone sod methylprednisolone phosphate pf injection acetate injection 1 LC solution prefilled suspension 40 mg/ml, syringe 80 mg/ml methylprednisolone dexamethasone LC sodium phosphate LC oral injection methylprednisolone fludrocortisone acetate sodium succ injection 1 oral solution reconstituted LC 1000 mg, 125 mg, 40 fluocinolone acetonide 1 mg body methylprednisolone fluocinolone acetonide sodium succ injection 1 1 external solution reconstituted fluocinolone acetonide 500 mg 1 scalp mometasone furoate 1 fluocinonide emulsified external 1 base prednicarbate 1 fluocinonide external 1
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
41 Drug Name Drug Tier Notes Drug Name Drug Tier Notes prednisolone oral desmopressin ace LC 1 solution spray refrig prednisolone sodium desmopressin acetate 1 phosphate oral solution 1 injection 10 mg/5ml, 20 mg/5ml desmopressin acetate 1 prednisolone sodium oral phosphate oral solution desmopressin acetate LC 1 15 mg/5ml, 25 mg/5ml, spray 6.7 (5 base) mg/5ml INCRELEX 4 PA prednisolone sodium NORDITROPIN phosphate oral tablet 1 4 PA dispersible FLEXPRO prednisone intensol LC novarel intramuscular solution reconstituted 4 PA prednisone oral LC 10000 unit SOLU-CORTEF NUTROPIN AQ 4 PA INJECTION NUSPIN 10 SOLUTION 3 NUTROPIN AQ RECONSTITUTED 4 PA 1000 MG NUSPIN 20 NUTROPIN AQ TEXACORT 3 4 PA NUSPIN 5 tovet external foam 1 oxytocin injection 1 triamcinolone acetonide LC external cream pregnyl 4 PA triamcinolone acetonide Hormonal Agents, 1 external lotion Stimulant/Replaceme nt/Modifying triamcinolone acetonide (Prostaglandins) external ointment 0.025 1 %, 0.05 %, 0.5 % KORLYM 5 PA; QL triamcinolone acetonide mifepristone 1 LC external ointment 0.1 % Hormonal Agents, triamcinolone acetonide Stimulant/Replaceme injection suspension 40 1 nt/Modifying (Sex mg/ml Hormones/Modifiers) triderm LC Androgens Hormonal Agents, danazol oral 1 Stimulant/Replaceme INTRAROSA 3 nt/Modifying METHITEST 3 PA (Pituitary) oxandrolone oral 1 PA; QL ACTHAR 4 PA testosterone cypionate 1 PA cabergoline 1 intramuscular chorionic gonadotropin 4 PA intramuscular
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
42 Drug Name Drug Tier Notes Drug Name Drug Tier Notes testosterone enanthate blisovi 24 fe 1 PV 1 PA intramuscular blisovi fe 1.5/30 1 PV testosterone blisovi fe 1/20 1 PV transdermal gel 1.62 %, 12.5 mg/act (1%), briellyn 1 PV 20.25 mg/1.25gm camrese 1 PV; QL (1.62%), 20.25 mg/act 1 PA camrese lo 1 PV; QL (1.62%), 25 mg/2.5gm (1%), 40.5 mg/2.5gm caziant 1 PV (1.62%), 50 mg/5gm charlotte 24 fe 1 PV (1%) chateal 1 PV testosterone 1 PA chateal eq 1 PV transdermal solution COMBIPATCH 3 Estrogens cryselle-28 1 PV afirmelle 1 PV cyclafem 1/35 1 PV altavera 1 PV cyclafem 7/7/7 1 PV alyacen 1/35 1 PV cyred 1 PV alyacen 7/7/7 1 PV cyred eq 1 PV amabelz 1 dasetta 1/35 1 PV amethia 1 PV; QL dasetta 7/7/7 1 PV amethia lo 1 PV; QL daysee 1 PV; QL amethyst 1 PV delyla 1 PV apri 1 PV desogestrel-ethinyl 1 PV aranelle 1 PV estradiol ashlyna 1 PV; QL DIVIGEL 3 aubra 1 PV dotti 1 aubra eq 1 PV drospiren-eth estrad- 1 PV aurovela 1.5/30 1 PV levomefol aurovela 1/20 1 PV drospirenone-ethinyl 1 PV aurovela 24 fe 1 PV estradiol aurovela fe 1.5/30 1 PV DUAVEE 2 aurovela fe 1/20 1 PV elinest 1 PV aviane 1 PV eluryng 1 PV ayuna 1 PV emoquette 1 PV azurette 1 PV enpresse-28 1 PV balziva 1 PV enskyce 1 PV bekyree 1 PV estarylla 1 PV BIJUVA 3 estradiol oral LC estradiol transdermal 1
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
43 Drug Name Drug Tier Notes Drug Name Drug Tier Notes estradiol vaginal 1 larin 1.5/30 1 PV estradiol valerate larin 1/20 1 PV 1 intramuscular larin 24 fe 1 PV estradiol-norethindrone 1 larin fe 1.5/30 1 PV acet larin fe 1/20 1 PV ethynodiol diac-eth 1 PV estradiol larissia 1 PV etonogestrel-ethinyl layolis fe 1 PV 1 PV estradiol leena 1 PV EVAMIST 3 lessina 1 PV falmina 1 PV levonest 1 PV fayosim 1 PV; QL levonorgest-eth est & 1 PV; QL femynor 1 PV eth est levonorgest-eth estrad fyavolv 1 1 PV; QL 91-day gemmily 1 PV levonorgestrel-ethinyl 1 PV hailey 1.5/30 1 PV estrad hailey 24 fe 1 PV levonorg-eth estrad 1 PV hailey fe 1.5/30 1 PV triphasic hailey fe 1/20 1 PV levora 0.15/30 (28) 1 PV iclevia 1 PV; QL lillow 1 PV introvale 1 PV; QL lojaimiess 1 PV; QL isibloom 1 PV loryna 1 PV jaimiess 1 PV; QL low-ogestrel 1 PV jasmiel 1 PV lo-zumandimine 1 PV jinteli 1 lutera 1 PV jolessa 1 PV; QL lyllana 1 juleber 1 PV marlissa 1 PV junel 1.5/30 1 PV melodetta 24 fe 1 PV junel 1/20 1 PV MENEST 2 junel fe 1.5/30 1 PV merzee 1 PV junel fe 1/20 1 PV mibelas 24 fe 1 PV junel fe 24 1 PV microgestin 1.5/30 1 PV kalliga 1 PV microgestin 1/20 1 PV kariva 1 PV microgestin 24 fe 1 PV kelnor 1/35 1 PV microgestin fe 1.5/30 1 PV kelnor 1/50 1 PV microgestin fe 1/20 1 PV kurvelo 1 PV mili 1 PV
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
44 Drug Name Drug Tier Notes Drug Name Drug Tier Notes mimvey 1 simpesse 1 PV; QL mono-linyah 1 PV sprintec 28 1 PV NATAZIA 2 PV sronyx 1 PV necon 0.5/35 (28) 1 PV syeda 1 PV nikki 1 PV tarina 24 fe 1 PV norethin ace-eth tarina fe 1/20 1 PV 1 PV estrad-fe tarina fe 1/20 eq 1 PV norethindrone acet- 1 PV tilia fe 1 PV ethinyl est tri femynor 1 PV norethindrone-eth 1 estradiol tri-estarylla 1 PV norethin-eth estradiol-fe 1 PV tri-legest fe 1 PV norgestimate-eth tri-linyah 1 PV 1 PV estradiol tri-lo-estarylla 1 PV norgestimate-ethinyl tri-lo-marzia 1 PV 1 PV estradiol triphasic tri-lo-mili 1 PV nortrel 0.5/35 (28) 1 PV tri-lo-sprintec 1 PV nortrel 1/35 (21) 1 PV tri-mili 1 PV nortrel 1/35 (28) 1 PV tri-nymyo 1 PV nortrel 7/7/7 1 PV tri-previfem 1 PV nylia 7/7/7 1 PV tri-sprintec 1 PV nymyo 1 PV trivora (28) 1 PV ocella 1 PV tri-vylibra 1 PV orsythia 1 PV tri-vylibra lo 1 PV philith 1 PV tyblume 1 PV pimtrea 1 PV tydemy 1 PV pirmella 1/35 1 PV velivet 1 PV pirmella 7/7/7 1 PV vestura 1 PV portia-28 1 PV vienva 1 PV PREMARIN ORAL 2 viorele 1 PV PREMPHASE 2 volnea 1 PV PREMPRO 2 vyfemla 1 PV previfem 1 PV vylibra 1 PV reclipsen 1 PV wera 1 PV rivelsa 1 PV; QL wymzya fe 1 PV setlakin 1 PV; QL xulane 1 PV simliya 1 PV yuvafem 1
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
45 Drug Name Drug Tier Notes Drug Name Drug Tier Notes zafemy 1 PV norethindrone acetate 1 zarah 1 PV oral zovia 1/35 (28) 1 PV norethindrone oral 1 PV zovia 1/35e (28) 1 PV norlyda 1 PV zumandimine 1 PV norlyroc 1 PV Progestins preventeza 1 PV progesterone camila 1 PV 1 intramuscular deblitane 1 PV progesterone DEPO-SUBQ 1 3 QL micronized oral PROVERA 104 sharobel 1 PV ELLA 3 PV SKYLA 3 PV errin 1 PV tulana 1 PV heather 1 PV Selective Estrogen hydroxyprogesterone Receptor Modifying caproate intramuscular 4 PA Agents oil OSPHENA 3 incassia 1 PV raloxifene hcl 1 PV* jencycla 1 PV Hormonal Agents, KYLEENA 3 PV Stimulant/Replaceme levonorgestrel 1 PV nt/Modifying (Thyroid) LILETTA (52 MG) 3 PV euthyrox LC lyleq 1 PV levo-t oral tablet 100 lyza 1 PV mcg, 112 mcg, 125 mcg, 137 mcg, 150 MAKENA LC 4 PA mcg, 175 mcg, 200 SUBCUTANEOUS mcg, 25 mcg, 50 mcg, medroxyprogesterone 75 mcg, 88 mcg 1 PV; QL acetate intramuscular levo-t oral tablet 300 1 medroxyprogesterone mcg LC acetate oral levothyroxine sodium 1 megestrol acetate oral intravenous 1 suspension levothyroxine sodium megestrol acetate oral oral tablet 100 mcg, LC tablet 20 mg 112 mcg, 125 mcg, 137 megestrol acetate oral mcg, 150 mcg, 175 LC 1 tablet 40 mg mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 MIRENA (52 MG) 3 PV mcg NEXPLANON 3 PV levothyroxine sodium 1 nora-be 1 PV oral tablet 300 mcg
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
46 Drug Name Drug Tier Notes Drug Name Drug Tier Notes levoxyl LC LUPRON DEPOT (6- liothyronine sodium MONTH) 1 4 PA intravenous INTRAMUSCULAR KIT 45MG liothyronine sodium oral 1 LUPRON DEPOT-PED np thyroid 1 (1-MONTH) 5 PA unithroid oral tablet 100 INTRAMUSCULAR KIT mcg, 112 mcg, 125 11.25 MG mcg, 137 mcg, 150 LC LUPRON DEPOT-PED mcg, 175 mcg, 200 (1-MONTH) 4 PA mcg, 25 mcg, 50 mcg, INTRAMUSCULAR KIT 75 mcg, 88 mcg 15 MG, 7.5 MG unithroid oral tablet 300 1 LUPRON DEPOT-PED mcg (3-MONTH) 5 PA Hormonal Agents, INTRAMUSCULAR KIT Suppressant 11.25 MG (PED) (Adrenal) LUPRON DEPOT-PED LYSODREN 2 (3-MONTH) 4 PA Hormonal Agents, INTRAMUSCULAR KIT Suppressant 30 MG (PED) (Pituitary) octreotide acetate 4 PA leuprolide acetate SIGNIFOR 5 PA; QL 4 PA injection SOMATULINE DEPOT 5 PA LUPRON DEPOT (1- SOMAVERT 5 PA MONTH) 5 PA INTRAMUSCULAR KIT SYNAREL 2 3.75 MG Hormonal Agents, LUPRON DEPOT (1- Suppressant MONTH) (Thyroid) 4 PA INTRAMUSCULAR KIT Antithyroid Agents 7.5 MG methimazole oral 1 LUPRON DEPOT (3- propylthiouracil oral 1 MONTH) 5 PA INTRAMUSCULAR KIT Immunological 11.25 MG Agents LUPRON DEPOT (3- Angioedema Agents MONTH) BERINERT 5 PA; QL 4 PA INTRAMUSCULAR KIT CINRYZE 5 PA 22.5 MG icatibant acetate 4 PA LUPRON DEPOT (4- MONTH) Immune 4 PA INTRAMUSCULAR KIT Suppressants 30MG AVSOLA 4 PA AZASAN 3
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
47 Drug Name Drug Tier Notes Drug Name Drug Tier Notes azathioprine oral 1 mycophenolate mofetil 1 azathioprine sodium 1 hcl mycophenolate mofetil CIMZIA 4 PA 1 oral CIMZIA PREFILLED 4 PA KIT mycophenolate sodium 1 CIMZIA STARTER KIT 4 PA ORENCIA 5 PA cyclosporine ORENCIA CLICKJECT 5 PA 1 intravenous PROGRAF 3 cyclosporine modified 1 INTRAVENOUS cyclosporine oral 1 RENFLEXIS 4 PA SANDIMMUNE ORAL ENBREL 5 PA 2 SOLUTION ENBREL MINI 5 PA SIMPONI 4 PA ENBREL SURECLICK 5 PA SIMPONI ARIA 4 PA everolimus oral tablet 0.25 mg, 0.5 mg, 0.75 1 sirolimus oral 1 mg SKYRIZI (150 MG 4 PA gengraf 1 DOSE) HUMIRA 4 PA tacrolimus oral 1 HUMIRA PEDIATRIC temsirolimus 4 4 PA CROHNS START TREXALL 3 HUMIRA PEN 4 PA XELJANZ 4 PA HUMIRA PEN- XELJANZ XR 4 PA 4 PA CD/UC/HS STARTER ZORTRESS ORAL 3 HUMIRA PEN- TABLET 1 MG PEDIATRIC UC 4 PA Immunoglobulins START BIVIGAM 5 PA HUMIRA PEN- PS/UV/ADOL HS 4 PA CARIMUNE NF 5 PA START CUVITRU 5 PA HUMIRA PEN- CYTOGAM 4 PA PSOR/UVEIT 4 PA FLEBOGAMMA DIF 5 PA STARTER GAMASTAN 4 PA INFLECTRA 4 PA GAMMAGARD 5 PA KINERET 5 PA GAMMAGARD S/D 5 PA methotrexate oral 1 LESS IGA methotrexate sodium 1 GAMMAKED 5 PA methotrexate sodium 1 GAMMAPLEX 5 PA (pf) GAMUNEX-C 5 PA HEPAGAM B 5
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
48 Drug Name Drug Tier Notes Drug Name Drug Tier Notes HIZENTRA 5 PA DIPHTHERIA- HYPERHEP B 5 TETANUS TOXOIDS 2 PV DT HYPERRHO S/D 4 ENGERIX-B 2 PV HYQVIA 5 PA FLUAD 2 PV MICRHOGAM ULTRA- 4 FLUAD FILTERED PLUS 2 PV QUADRIVALENT NABI-HB 5 FLUARIX 2 PV OCTAGAM 5 PA QUADRIVALENT PRIVIGEN 5 PA FLUBLOK 2 PV RHOGAM ULTRA- QUADRIVALENT 4 FILTERED PLUS FLUCELVAX 2 PV RHOPHYLAC 4 QUADRIVALENT SYNAGIS 4 PA FLULAVAL 2 PV THYMOGLOBULIN 3 QUADRIVALENT FLUMIST WINRHO SDF 4 2 PV QUADRIVALENT Immunomodulators FLUZONE HIGH- ACTEMRA 5 PA DOSE 2 PV ACTEMRA ACTPEN 5 PA QUADRIVALENT ACTIMMUNE 4 PA FLUZONE 2 PV ALFERON N 4 QUADRIVALENT GAMIFANT 5 PA GARDASIL 9 2 PV ILARIS 4 PA; QL HAVRIX 2 PV leflunomide oral 1 HEPLISAV-B 2 PV OTEZLA 4 PA HIBERIX 2 PV RINVOQ 4 PA INFANRIX 2 PV ULTOMIRIS 5 PA IPOL 2 PV XOLAIR 4 PA KINRIX 2 PV Vaccines MENACTRA 2 PV ACTHIB 2 PV MENQUADFI 2 PV ADACEL 2 PV MENVEO 2 PV AFLURIA M-M-R II 2 PV 2 PV QUADRIVALENT PEDIARIX 2 PV BEXSERO 2 PV PEDVAX HIB 2 PV BOOSTRIX 2 PV PENTACEL 2 PV DAPTACEL 2 PV PNEUMOVAX 23 2 PV PREVNAR 13 2 PV PROQUAD 2 PV
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
49 Drug Name Drug Tier Notes Drug Name Drug Tier Notes QUADRACEL 2 PV hydrocortisone ace- RECOMBIVAX HB 2 PV pramoxine external 1 cream 1-1 % ROTARIX 2 PV hydrocortisone rectal 1 ROTATEQ 2 PV procto-med hc 1 SHINGRIX 2 PV procto-pak 1 TDVAX 2 PV proctozone-hc 1 TENIVAC 2 PV Sulfonamides TETANUS- DIPHTHERIA 2 PV sulfasalazine oral 1 TOXOIDS TD Metabolic Bone TRUMENBA 2 PV Disease Agents alendronate sodium TWINRIX 2 PV 1 oral solution VAQTA 2 PV alendronate sodium 1 VARIVAX 2 PV oral tablet 10 mg, 5 mg VAXELIS 2 PV alendronate sodium Inflammatory Bowel oral tablet 35 mg, 70 LC QL Disease Agents mg Aminosalicylates calcitonin (salmon) 1 QL balsalazide disodium 1 calcitriol intravenous 1 DIPENTUM 3 calcitriol oral 1 mesalamine er oral cinacalcet hcl 1 PA 1 capsule 0.375 gm doxercalciferol 1 mesalamine oral intravenous capsule delayed 1 FORTEO 4 PA release 400 mg ibandronate sodium 1 QL mesalamine oral tablet 1 MIACALCIN delayed release 1.2 gm 3 INJECTION mesalamine rectal 1 pamidronate disodium 4 mesalamine-cleanser 1 paricalcitol 1 PENTASA 3 PROLIA 4 PA; QL Glucocorticoids RAYALDEE 3 budesonide er 1 risedronate sodium oral 1 QL budesonide oral 1 tablet 150 mg, 35 mg CORTIFOAM 3 risedronate sodium oral 1 hydrocortisone tablet 30 mg, 5 mg 1 (perianal) risedronate sodium oral 1 QL tablet delayed release
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50 Drug Name Drug Tier Notes Drug Name Drug Tier Notes TERIPARATIDE COMPACT SPACE 4 PA (RECOMBINANT) CHAMBER/MED 2 XGEVA 4 PA MASK COMPACT SPACE zoledronic acid 4 2 CHAMBER/SM MASK Miscellaneous Therapeutic Agents deferoxamine mesylate 1 albumin human 1 dexmedetomidine hcl in nacl intravenous 1 albumin-zlb 1 solution alburx 1 dexmedetomidine hcl ALCOHOL PREP intravenous solution 1 3 PADS PAD 200 mcg/2ml ALCOHOL PREP DROPLET MICRON 2 3 PADS PAD 70 % EASIVENT 2 argyle sterile water 1 ergoloid mesylates oral 3 bal in oil 1 FC FEMALE CONDOM 3 PV; QL BD AUTOSHIELD DUO FC2 FEMALE 2 3 PV; QL PEN NEEDLES CONDOM BD ULTRA-FINE 2 FEMCAP 3 PV; QL INSULIN SYRINGES FLEXICHAMBER BD ULTRA-FINE PEN 2 2 ADULT MASK/SMALL NEEDLES FLEXICHAMBER BD VEO INSULIN SYR 2 2 CHILD MASK/LARGE U/F 1/2UNIT FLEXICHAMBER benzalkonium chloride 2 1 CHILD MASK/SMALL external solution flumazenil intravenous 1 PA; Non- BOTOX 4 Cosmetic fomepizole 1 BREATHE EASE heparin lock flush 1 2 LARGE heparin sodium lock 1 BREATHE EASE flush 2 MEDIUM hetastarch-nacl 1 BREATHE EASE INSPIREASE 2 2 SMALL RESERVOIR BAGS CAYA 3 PV; QL INSULIN PEN 2 CLEVER CHOICE NEEDLES 2 HOLDING CHAMBER COMFORT TOUCH 3 ALCOHOL PREP COMPACT SPACE 2 CHAMBER/LG MASK
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51 Drug Name Drug Tier Notes Drug Name Drug Tier Notes INSULIN SYRINGES NOVOTWIST PEN 2 28G X 1/2" 0.5 ML, NEEDLE 28G X 1/2" 1 ML, 29G NOZIN NASAL 3 X 1/2" 0.3 ML, 29G X SANITIZER POPSWAB 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 1/2" 0.3 PANDA MASK LARGE 2 ML, 30G X 1/2" 0.5 ML, PANDA MASK 2 30G X 1/2" 1 ML, 30G MEDIUM X 5/16" 0.3 ML, 30G X PANDA MASK SMALL 2 5/16" 0.5 ML, 30G X 2 5/16" 1 ML, 31G X PARAGARD 15/64" 0.3 ML, 31G X INTRAUTERINE 3 PV 15/64" 0.5 ML, 31G X COPPER 15/64" 1 ML, 31G X PEDIATRIC PANDA 2 5/16" 0.3 ML, 31G X MASK 5/16" 0.5 ML, 31G X POCKET SPACER 2 5/16" 1 ML, 32G X PRO COMFORT 5/16" 0.5 ML, 32G X 2 5/16" 1 ML SPACER ADULT J-TIP KIT W/VIAL PRO COMFORT 3 2 ADAPTERS SPACER CHILD PRO COMFORT kedbumin 1 2 SPACER INFANT lactated ringers 1 irrigation PROCARE SPACER/ADULT 2 MAXICOMFORT SYR 2 MASK 27G X 1/2" PROCARE 2 methergine 1 QL SPACER/CHILD MASK methylergonovine 1 QL ringers irrigation 1 maleate oral saline flush 1 MICROCHAMBER 2 saline flush zr 1 monoject flush syringe 1 sodium chloride flush 1 monoject sodium 1 sodium nitrite chloride flush 1 intravenous n-acetyl-l-cysteine oral 1 sodium thiosulfate 1 normal saline flush 1 intravenous NOVOFINE sterile water for 1 AUTOCOVER PEN 2 irrigation NEEDLE swabflush saline flush 1 NOVOFINE PEN 2 NEEDLE THYROGEN 4 PA NOVOFINE PLUS PEN TRUE COMFORT PRO 2 3 NEEDLE ALCOHOL PREP
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52 Drug Name Drug Tier Notes Drug Name Drug Tier Notes TRUE COMFORT PRO TOBRADEX INSULIN SYR 32G X 2 OPHTHALMIC 3 5/16" 0.5 ML OINTMENT TRUE COMFORT PRO TOBRADEX ST 3 PEN NEEDLES 31G X tobramycin ophthalmic LC 8 MM , 32G X 5 MM , 2 tobramycin- 32G X 6 MM , 33G X 4 1 MM , 33G X 5 MM , dexamethasone 33G X 6 MM TOBREX ULTIGUARD OPHTHALMIC 3 SAFEPACK 2 OINTMENT SYR/NEEDLE Antibacterials, Other VISTOGARD 3 ak-poly-bac 1 water for irrigation, bacitracin ophthalmic 1 1 sterile bacitracin-polymyxin b 1 WIDE-SEAL ophthalmic 3 PV; QL DIAPHRAGM 60 bacitra-neomycin- 1 WIDE-SEAL polymyxin-hc 3 PV; QL DIAPHRAGM 65 neomycin-bacitracin zn- 1 WIDE-SEAL polymyx 3 PV; QL DIAPHRAGM 70 neomycin-polymyxin- WIDE-SEAL dexameth ophthalmic LC 3 PV; QL DIAPHRAGM 75 ointment WIDE-SEAL neomycin-polymyxin- 3 PV; QL DIAPHRAGM 80 dexameth ophthalmic LC WIDE-SEAL suspension 3.5-10000- 3 PV; QL DIAPHRAGM 85 0.1 WIDE-SEAL neomycin-polymyxin-hc 3 PV; QL 1 DIAPHRAGM 90 ophthalmic WIDE-SEAL neo-polycin 1 3 PV; QL DIAPHRAGM 95 neo-polycin hc 1 XIAFLEX 4 PA polycin 1 ZOKINVY 5 PA; QL polymyxin b- LC Ophthalmic Agents trimethoprim Aminoglycosides Anti-cytomegalovirus (CMV) Agents gentak 1 ZIRGAN 3 gentamicin sulfate 1 ophthalmic Antifungals neomycin-polymyxin- NATACYN 2 1 gramicidin Antiherpetic Agents trifluridine 1
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53 Drug Name Drug Tier Notes Drug Name Drug Tier Notes Macrolides Ophthalmic AZASITE 3 Antiglaucoma Agents erythromycin ALPHAGAN P 1 ophthalmic OPHTHALMIC 2 SOLUTION 0.1 % Ophthalmic Agents, Other apraclonidine hcl 1 atropine sulfate AZOPT 2 1 ophthalmic ointment betaxolol hcl 1 atropine sulfate ophthalmic LC ophthalmic solution 1 % BETIMOL 3 cyclopentolate hcl brimonidine tartrate 1 1 ophthalmic ophthalmic CYSTARAN 5 PA; QL brinzolamide 1 homatropaire 1 carteolol hcl 1 RESTASIS 2 PA COMBIGAN 2 RESTASIS dorzolamide hcl 2 PA 1 MULTIDOSE ophthalmic sulfacetamide- dorzolamide hcl-timolol 1 prednisolone 1 mal ophthalmic solution dorzolamide hcl-timolol 1 XIIDRA 2 PA mal pf Ophthalmic Anti- IOPIDINE 3 allergy Agents levobunolol hcl 1 ALOCRIL 3 PHOSPHOLINE 2 ALOMIDE 3 IODIDE altafrin 1 pilocarpine hcl 1 azelastine hcl ophthalmic 1 ophthalmic RHOPRESSA 2 QL BEPREVE 3 ST ROCKLATAN 2 QL cromolyn sodium SIMBRINZA 2 1 ophthalmic timolol maleate epinastine hcl 1 ophthalmic gel forming 1 LASTACAFT 3 ST solution olopatadine hcl timolol maleate 1 ophthalmic ophthalmic solution LC 0.25 %, 0.5 % phenylephrine hcl 1 ophthalmic timolol maleate ophthalmic solution 0.5 1 ZERVIATE 3 ST % (daily) timolol maleate pf 1
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54 Drug Name Drug Tier Notes Drug Name Drug Tier Notes Ophthalmic Anti- moxifloxacin hcl (2x 1 inflammatories day) bromfenac sodium moxifloxacin hcl 1 QL 1 (once-daily) ophthalmic solution dexamethasone ofloxacin ophthalmic 1 sodium phosphate 1 Sulfonamides ophthalmic sulfacetamide sodium diclofenac sodium 1 1 ophthalmic ophthalmic Otic Agents DUREZOL 3 acetic acid otic 1 FLAREX 3 CIPRO HC 3 fluorometholone 1 CIPRODEX 2 flurbiprofen sodium 1 ciprofloxacin hcl otic 1 ST FML 2 ciprofloxacin- 1 ILEVRO 3 QL dexamethasone ketorolac tromethamine 1 CORTISPORIN-TC 3 ophthalmic flac 1 loteprednol etabonate 1 fluocinolone acetonide ophthalmic suspension 1 otic prednisolone acetate 1 hydrocortisone-acetic ophthalmic 1 acid prednisolone sodium 1 neomycin-polymyxin-hc phosphate ophthalmic 1 otic PROLENSA 2 QL ofloxacin otic 1 Ophthalmic Prostaglandin and Respiratory Prostamide Analogs Tract/Pulmonary Agents bimatoprost ophthalmic 1 QL Antihistamines latanoprost ophthalmic 1 azelastine hcl nasal 1 QL LUMIGAN 2 QL carbinoxamine maleate 1 travoprost (bak free) 1 QL oral solution ZIOPTAN 3 QL carbinoxamine maleate 1 Quinolones oral tablet 4 mg BESIVANCE 3 cetirizine hcl oral 1 ciprofloxacin hcl solution 1 ophthalmic clemastine fumarate 1 gatifloxacin ophthalmic 1 oral tablet 2.68 mg levofloxacin ophthalmic 1 cyproheptadine hcl oral 1 desloratadine 1
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55 Drug Name Drug Tier Notes Drug Name Drug Tier Notes dexchlorpheniramine fluticasone-salmeterol 3 maleate oral inhalation aerosol diphen oral elixir 1 powder breath activated 100-50 1 QL diphenhydramine hcl 1 mcg/dose, 250-50 injection mcg/dose, 500-50 diphenhydramine hcl mcg/dose 1 oral elixir FLUTICASONE- levocetirizine SALMETEROL 1 dihydrochloride oral INHALATION AEROSOL POWDER olopatadine hcl nasal 1 QL 1 QL BREATH ACTIVATED promethazine hcl 1 113-14 MCG/ACT, 232- injection 14 MCG/ACT, 55-14 promethazine hcl oral MCG/ACT LC solution mometasone furoate 1 QL promethazine hcl oral nasal LC syrup PULMICORT 2 QL promethazine hcl oral FLEXHALER 1 tablet 12.5 mg, 50 mg SYMBICORT 2 QL promethazine hcl oral LC wixela inhub 1 QL tablet 25 mg Antileukotrienes promethazine hcl rectal 1 montelukast sodium LC promethegan 1 oral ryvent 1 zafirlukast 1 Anti-inflammatories, zileuton er 3 ST Inhaled Corticosteroids Bronchodilators, Anticholinergic ADVAIR HFA 2 QL ATROVENT HFA 3 QL ARNUITY ELLIPTA 2 QL INCRUSE ELLIPTA 2 QL BREO ELLIPTA 2 QL ipratropium bromide LC QL budesonide inhalation 1 QL inhalation FLOVENT DISKUS 2 QL ipratropium bromide LC FLOVENT HFA 2 QL nasal flunisolide nasal 1 QL SPIRIVA 2 QL fluticasone propionate HANDIHALER 1 nasal SPIRIVA RESPIMAT 2 QL STIOLTO RESPIMAT 2 QL
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56 Drug Name Drug Tier Notes Drug Name Drug Tier Notes TRELEGY ELLIPTA ORKAMBI 5 PA; QL INHALATION PULMOZYME 4 PA AEROSOL POWDER 2 QL BREATH ACTIVATED tobramycin inhalation 4 100-62.5-25 MCG/INH Mast Cell Stabilizers Bronchodilators, cromolyn sodium 1 Sympathomimetic inhalation albuterol sulfate hfa 1 QL Phosphodiesterase albuterol sulfate Inhibitors, Airways inhalation nebulization Disease solution (2.5 mg/3ml) 1 QL aminophylline 1 0.083%, 0.63 mg/3ml, intravenous 1.25 mg/3ml DALIRESP ORAL 3 PA albuterol sulfate TABLET 500 MCG inhalation nebulization LC QL ELIXOPHYLLIN 2 solution (5 mg/ml) 0.5%, 2.5 mg/0.5ml THEO-24 3 albuterol sulfate oral theophylline 1 3 syrup theophylline er 1 AUVI-Q INJECTION theophylline in d5w 1 SOLUTION AUTO- 3 QL Pulmonary INJECTOR 0.1 Antihypertensives MG/0.1ML ADEMPAS 4 PA; QL BROVANA 3 QL alyq 4 PA; QL epinephrine 1 (anaphylaxis) ambrisentan 4 PA; QL epinephrine injection bosentan 4 PA; QL 1 solution auto-injector epoprostenol sodium 4 PA isoproterenol hcl OPSUMIT 4 PA; QL 1 injection ORENITRAM 5 PA levalbuterol hcl sildenafil citrate 1 QL 4 PA inhalation intravenous PERFOROMIST 3 QL sildenafil citrate oral PROAIR HFA 2 QL suspension 4 PA; QL PROAIR RESPICLICK 2 QL reconstituted sildenafil citrate oral SEREVENT DISKUS 2 QL 4 PA; QL tablet 20 mg VENTOLIN HFA 2 QL tadalafil (pah) 4 PA; QL Cystic Fibrosis Agents TRACLEER 32 MG 5 PA; QL BETHKIS 4 treprostinil 4 PA KALYDECO 5 PA TYVASO 5 PA; QL
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57 Drug Name Drug Tier Notes Drug Name Drug Tier Notes TYVASO REFILL 5 PA; QL baclofen oral tablet 10 LC TYVASO STARTER 5 PA; QL mg baclofen oral tablet 20 UPTRAVI 5 PA; QL 1 mg, 5 mg VELETRI 5 PA carisoprodol oral tablet 1 VENTAVIS 5 PA; QL 250 mg Pulmonary Fibrosis carisoprodol oral tablet LC Agents 350 mg OFEV 5 PA chlorzoxazone oral 1 Respiratory Tract tablet 500 mg Agents, Other cyclobenzaprine hcl LC acetylcysteine oral tablet 10 mg, 5 mg 1 inhalation cyclobenzaprine hcl 1 acetylcysteine oral tablet 7.5 mg 1 intravenous dantrolene sodium 1 ANORO ELLIPTA 2 QL intravenous azelastine-fluticasone 1 QL metaxalone 1 benzonatate oral methocarbamol 1 capsule 100 mg, 200 LC injection mg methocarbamol oral LC benzonatate oral 1 orphenadrine citrate er 1 capsule 150 mg orphenadrine citrate COMBIVENT 1 2 QL injection RESPIMAT revonto 1 hydrocodone- 1 PA; QL homatropine tizanidine hcl oral 1 hydromet 1 PA; QL Sleep Disorder Agents ipratropium-albuterol 1 QL GABA Receptor NUCALA 4 PA; QL Modulators sodium chloride 1 eszopiclone 1 QL inhalation temazepam 1 QL TRELEGY ELLIPTA INHALATION zaleplon 1 QL AEROSOL POWDER 2 QL zolpidem tartrate er 1 QL BREATH ACTIVATED zolpidem tartrate oral 1 QL 200-62.5-25 MCG/INH Sleep Disorders, TUZISTRA XR 3 PA; QL Other Skeletal Muscle armodafinil 1 PA; QL Relaxants BELSOMRA 3 ST; QL baclofen intrathecal 1 doxepin hcl oral tablet 1 QL
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58 Drug Name Drug Tier Notes HETLIOZ 5 PA; QL modafinil 1 PA; QL ramelteon 1 QL SUNOSI 2 PA; QL
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59 Index of Drugs abacavir sulfate...... 23 AKYNZEO...... 14 amlodipine besylate...... 29 abacavir sulfate-lamivudine...... 23 ala-cort...... 40 amlodipine besylate-benazepril abacavir-lamivudine- albendazole...... 20 hcl...... 29 zidovudine...... 23 albumin human...... 51 amlodipine besylate-valsartan.. 30 ABELCET...... 14 albumin-zlb...... 51 amlodipine-atorvastatin...... 30 ABILIFY MAINTENA...... 21 alburx...... 51 amlodipine-olmesartan...... 30 abiraterone acetate...... 17 albuterol sulfate...... 57 amlodipine-valsartan-hctz...... 30 ABRAXANE...... 17 albuterol sulfate hfa...... 57 ammonium lactate...... 33 acamprosate calcium...... 8 alclometasone dipropionate...... 40 amnesteem...... 33 acarbose...... 25 ALCOHOL PREP PADS...... 51 amoxapine...... 14 ACCU-CHEK FASTCLIX ALDURAZYME...... 38 amoxicill-clarithro-lansopraz..... 37 LANCET KIT...... 24 alendronate sodium...... 50 amoxicillin...... 10 ACCU-CHEK SOFTCLIX ALFERON N...... 49 amoxicillin-potassium LANCET DEVICE KIT...... 24 alfuzosin hcl er...... 39 clavulanate...... 10 accutane...... 33 ALIMTA...... 17 amoxicillin-potassium acebutolol hcl...... 29 ALINIA...... 20 clavulanate er...... 10 acetaminophen...... 5 aliskiren fumarate...... 29 amphetamine sulfate...... 32 acetaminophen-codeine...... 6 allopurinol...... 15 amphetamine- acetaminophen-codeine #2...... 6 allopurinol sodium...... 15 dextroamphetamine...... 32 acetaminophen-codeine #3...... 6 almotriptan malate...... 16 amphetamine- acetaminophen-codeine #4...... 6 ALOCRIL...... 54 dextroamphetamine er...... 32 acetazolamide...... 30 ALOMIDE...... 54 ampicillin...... 10 acetazolamide er...... 30 alosetron hcl...... 38 ampicillin sodium...... 10 acetazolamide sodium...... 30 ALPHAGAN P...... 54 ampicillin-sulbactam sodium..... 10 acetic acid...... 40, 55 ALPHANATE...... 27 anagrelide hcl...... 27 acetylcysteine...... 58 alprazolam...... 24 anastrozole...... 18 acitretin...... 33 alprazolam er...... 24 ANORO ELLIPTA...... 58 ACTEMRA...... 49 alprazolam intensol...... 24 ANZEMET...... 14 ACTEMRA ACTPEN...... 49 alprazolam xr...... 24 apap-caff-dihydrocodeine...... 6 ACTHAR...... 42 alprostadil...... 29 APLENZIN...... 13 ACTHIB...... 49 ALTABAX...... 8 APOKYN...... 20 ACTIMMUNE...... 49 altafrin...... 54 apraclonidine hcl...... 54 acyclovir...... 22 altavera...... 43 aprepitant...... 14 acyclovir sodium...... 22 alvimopan...... 37 apri...... 43 ADACEL...... 49 alyacen 1/35...... 43 APTIVUS...... 23 ADAKVEO...... 27 alyacen 7/7/7...... 43 aranelle...... 43 adapalene...... 33 alyq...... 57 ARANESP (ALBUMIN FREE)...27 adapalene-benzoyl peroxide.....33 amabelz...... 43 argatroban...... 26 adc/f (0.5mg/ml)...... 36 amantadine hcl...... 20 argyle sterile saline...... 40 ADCETRIS...... 19 AMBISOME...... 15 argyle sterile water...... 51 adefovir dipivoxil...... 22 ambrisentan...... 57 aripiprazole...... 21 ADEMPAS...... 57 amcinonide...... 40 armodafinil...... 58 adenosine...... 28 amethia...... 43 ARNUITY ELLIPTA...... 56 adriamycin...... 17 amethia lo...... 43 ARRANON...... 17 adult aspirin regimen...... 5 amethyst...... 43 arsenic trioxide...... 17 ADVAIR HFA...... 56 amikacin sulfate...... 8 ARZERRA...... 19 ADVATE...... 27 amiloride hcl...... 31 ascomp-codeine...... 6 AFINITOR DISPERZ...... 18 amiloride-hydrochlorothiazide... 29 asenapine maleate...... 21 afirmelle...... 43 aminoacetic acid...... 40 ashlyna...... 43 AFLURIA QUADRIVALENT...... 49 aminocaproic acid...... 27 aspirin...... 5 AIMOVIG...... 16 aminophylline...... 57 aspirin adult low strength...... 5 airavite...... 36 amiodarone hcl...... 28 aspirin childrens...... 5 ak-poly-bac...... 53 amitriptyline hcl...... 14 aspirin ec...... 5 60 aspirin ec low dose...... 5 BARACLUDE...... 22 BIVIGAM...... 48 aspirin ec low strength...... 5 BAVENCIO...... 19 bleomycin sulfate...... 17 aspirin low dose...... 5 BAXDELA...... 11 BLINCYTO...... 19 aspirin-dipyridamole er...... 27 BAYER ASPIRIN...... 5 blisovi 24 fe...... 43 atazanavir sulfate...... 23 BAYER ASPIRIN EC LOW blisovi fe 1.5/30...... 43 atenolol...... 29 DOSE...... 5 blisovi fe 1/20...... 43 atenolol-chlorthalidone...... 30 BD AUTOSHIELD DUO PEN BOOSTRIX...... 49 atomoxetine hcl...... 32 NEEDLES...... 51 bosentan...... 57 atorvastatin calcium...... 31 BD ULTRA-FINE INSULIN BOSULIF...... 18 atovaquone...... 20 SYRINGES...... 51 BOTOX...... 51 atovaquone-proguanil hcl...... 20 BD ULTRA-FINE PEN bp vit 3...... 36 atropine sulfate...... 37, 54 NEEDLES...... 51 b-plex...... 36 ATROVENT HFA...... 56 BD VEO INSULIN SYR U/F b-plex plus...... 36 aubra...... 43 1/2UNIT...... 51 BREATHE EASE LARGE...... 51 aubra eq...... 43 bekyree...... 43 BREATHE EASE MEDIUM...... 51 AUGMENTIN...... 10 BELEODAQ...... 18 BREATHE EASE SMALL...... 51 aurovela 1.5/30...... 43 BELSOMRA...... 58 BREO ELLIPTA...... 56 aurovela 1/20...... 43 benazepril hcl...... 28 briellyn...... 43 aurovela 24 fe...... 43 benazepril-hydrochlorothiazide. 30 BRILINTA...... 27 aurovela fe 1.5/30...... 43 BENDEKA...... 16 brimonidine tartrate...... 54 aurovela fe 1/20...... 43 BENEFIX...... 27 brinzolamide...... 54 AUVI-Q...... 57 benzalkonium chloride...... 51 BRIVIACT...... 11 AVASTIN...... 19 BENZNIDAZOLE...... 20 bromfenac sodium (once-daily).55 aviane...... 43 benzonatate...... 58 bromocriptine mesylate...... 20 avidoxy...... 11 benzoyl peroxide-erythromycin. 33 BROVANA...... 57 AVONEX PEN...... 33 benztropine mesylate...... 20 budesonide...... 50, 56 AVONEX PREFILLED...... 33 BEPREVE...... 54 budesonide er...... 50 AVSOLA...... 47 BERINERT...... 47 bumetanide...... 31 ayuna...... 43 beser...... 40 buprenorphine...... 6 azacitidine...... 17 BESIVANCE...... 55 buprenorphine hcl...... 8 AZASAN...... 47 betamethasone dipropionate.... 40 buprenorphine hcl-naloxone AZASITE...... 54 betamethasone dipropionate hcl...... 8 azathioprine...... 48 aug...... 40 bupropion hcl...... 13 azathioprine sodium...... 48 betamethasone sod phos & bupropion hcl er (smoking det)... 8 azelaic acid...... 33 acet...... 40 bupropion hcl er (sr)...... 13 azelastine hcl...... 54, 55 betamethasone valerate...... 40 bupropion hcl er (xl)...... 13 azelastine-fluticasone...... 58 BETASERON...... 33 buspirone hcl...... 24 AZELEX...... 33 betaxolol hcl...... 29, 54 busulfan...... 16 azithromycin...... 10 bethanechol chloride...... 40 butalbital-acetaminophen...... 6 AZOPT...... 54 BETHKIS...... 57 butalbital-apap-caff-cod...... 6 aztreonam...... 8 BETIMOL...... 54 butalbital-apap-caffeine...... 5, 6 azurette...... 43 bexarotene...... 20 butalbital-asa-caff-codeine...... 6 b-6 folic acid...... 36 BEXSERO...... 49 butalbital-aspirin-caffeine...... 5 bac...... 5 bicalutamide...... 17 butorphanol tartrate...... 7 bacitracin...... 8, 53 BICILLIN L-A...... 10 BYDUREON BCISE bacitracin-polymyxin b...... 53 BIJUVA...... 43 AUTOINJECTOR...... 25 bacitra-neomycin-polymyxin-hc 53 BIKTARVY...... 22 BYETTA 10 MCG PEN...... 25 baclofen...... 58 bimatoprost...... 55 BYETTA 5 MCG PEN...... 25 BAFIERTAM...... 33 biocel...... 36 BYSTOLIC...... 29 bal in oil...... 51 bisacodyl ec...... 38 cabergoline...... 42 balsalazide disodium...... 50 bisoprolol fumarate...... 29 CABLIVI...... 27 balziva...... 43 bisoprolol-hydrochlorothiazide.. 30 CABOMETYX...... 18 BANZEL...... 12 bivalirudin trifluoroacetate...... 26 caffeine citrate...... 32
61 calcipotriene...... 33 cefpodoxime proxetil...... 10 CIPRO HC...... 55 calcipotriene-betameth diprop...33 cefprozil...... 10 CIPRODEX...... 55 calcitonin (salmon)...... 50 ceftazidime...... 10 ciprofloxacin hcl...... 11, 55 calcitriol...... 33, 50 ceftazidime and dextrose...... 10 ciprofloxacin in d5w...... 11 calcium acetate...... 36 ceftriaxone sodium...... 10 ciprofloxacin-dexamethasone... 55 calcium acetate (phos binder)...36 ceftriaxone sodium in dextrose. 10 cisplatin...... 16 calcium chloride...... 34 ceftriaxone sodium-dextrose.....10 citalopram hydrobromide...... 13 calcium gluconate...... 34 cefuroxime axetil...... 10 citroma...... 38 camila...... 46 celecoxib...... 5 cladribine...... 17 camrese...... 43 CELONTIN...... 11 claravis...... 34 camrese lo...... 43 cephalexin...... 10 clarithromycin...... 10 candesartan cilexetil...... 28 CEPROTIN...... 26 clarithromycin er...... 10 candesartan cilexetil-hctz...... 30 CEQUR SIMPLICITY 2U...... 24 clearlax...... 38 CAPASTAT SULFATE...... 16 CERDELGA...... 39 clemastine fumarate...... 55 capecitabine...... 17 cetirizine hcl...... 55 CLENPIQ...... 38 CAPRELSA...... 18 cevimeline hcl...... 33 CLEVER CHOICE HOLDING captopril...... 28 CHANTIX...... 8 CHAMBER...... 51 captopril-hydrochlorothiazide.... 30 CHANTIX CONTINUING clindacin etz...... 34 CARBAGLU...... 34 MONTH PAK...... 8 clindacin-p...... 34 carbamazepine...... 12 CHANTIX STARTING MONTH clindamycin hcl...... 8 carbamazepine er...... 12 PAK...... 8 clindamycin palmitate hcl...... 8 carbidopa...... 21 charlotte 24 fe...... 43 clindamycin phosphate...... 8, 34 carbidopa-levodopa...... 21 chateal...... 43 clindamycin phosphate in d5w.... 8 carbidopa-levodopa er...... 21 chateal eq...... 43 clindamycin phosphate- carbidopa-levodopa- CHEMET...... 35 benzoyl peroxide...... 34 entacapone...... 20, 21 CHEMSTRIP UGK...... 24 clindamycin-tretinoin...... 34 carbinoxamine maleate...... 55 chloramphenicol sod succinate...8 CLINPRO 5000...... 33 carboplatin...... 16 chlordiazepoxide hcl...... 24 clobazam...... 11 CARIMUNE NF...... 48 chlordiazepoxide-amitriptyline...13 clobetasol prop emollient base. 40 carisoprodol...... 58 chlorhexidine gluconate...... 33 clobetasol propionate...... 40 carmustine...... 16 chloroquine phosphate...... 20 clobetasol propionate e...... 40 carteolol hcl...... 54 chlorpromazine hcl...... 21 clobetasol propionate emulsion 40 cartia xt...... 29 chlorthalidone...... 31 clocortolone pivalate...... 40 carvedilol...... 29 chlorzoxazone...... 58 clodan...... 40 carvedilol phosphate er...... 29 CHOLBAM...... 39 clofarabine...... 17 cascara sagrada...... 38 cholestyramine...... 31 clomipramine hcl...... 14 caspofungin acetate...... 15 cholestyramine light...... 31 clonazepam...... 24 cavarest...... 33 chorionic gonadotropin...... 42 clonidine...... 28 CAYA...... 51 chromic chloride...... 34 clonidine hcl...... 28 caziant...... 43 ciclodan...... 15 clonidine hcl er...... 32 cefaclor...... 9 ciclopirox...... 15 clopidogrel bisulfate...... 27 cefaclor er...... 9 ciclopirox olamine...... 15 clorazepate dipotassium...... 24 cefadroxil...... 9 cidofovir...... 22 clotrimazole...... 15 cefazolin sodium...... 9 cilostazol...... 27 clotrimazole-betamethasone.....15 cefazolin sodium-dextrose.... 9, 10 CIMDUO...... 23 clovique...... 35 cefdinir...... 10 cimetidine...... 37 clozapine...... 22 cefepime hcl...... 10 cimetidine hcl...... 37 COAGADEX...... 27 cefepime-dextrose...... 10 CIMZIA...... 48 coal tar...... 34 cefixime...... 10 CIMZIA PREFILLED KIT...... 48 COARTEM...... 20 cefotaxime sodium...... 10 CIMZIA STARTER KIT...... 48 cod liver oil...... 36 cefotetan disodium...... 10 cinacalcet hcl...... 50 codeine sulfate...... 7 cefotetan disodium-dextrose.....10 CINRYZE...... 47 colchicine...... 15 cefoxitin sodium...... 10 CIPRO...... 11 colchicine-probenecid...... 15
62 colesevelam hcl...... 31 cyclafem 1/35...... 43 desmopressin acetate spray..... 42 colestipol hcl...... 31 cyclafem 7/7/7...... 43 desogestrel-ethinyl estradiol..... 43 colistimethate sodium (cba)...... 9 cyclobenzaprine hcl...... 58 desonide...... 40, 41 COMBIGAN...... 54 cyclopentolate hcl...... 54 desoximetasone...... 41 COMBIPATCH...... 43 cyclophosphamide...... 16 desvenlafaxine succinate er...... 13 COMBIVENT RESPIMAT...... 58 cycloserine...... 16 dexamethasone...... 41 COMETRIQ...... 18 cyclosporine...... 48 dexamethasone intensol...... 41 COMFORT TOUCH cyclosporine modified...... 48 dexamethasone sod ALCOHOL PREP...... 51 cyproheptadine hcl...... 55 phosphate pf...... 41 COMPACT SPACE CYRAMZA...... 19 dexamethasone sodium CHAMBER/LG MASK...... 51 cyred...... 43 phosphate...... 41, 55 COMPACT SPACE cyred eq...... 43 dexchlorpheniramine maleate...56 CHAMBER/MED MASK...... 51 CYSTAGON...... 39 DEXILANT...... 38 COMPACT SPACE CYSTARAN...... 54 dexmedetomidine hcl...... 51 CHAMBER/SM MASK...... 51 cytarabine...... 17 dexmedetomidine hcl in nacl.....51 COMPLERA...... 22 cytarabine (pf)...... 17 dexmethylphenidate hcl...... 32 compro...... 14 CYTOGAM...... 48 dexmethylphenidate hcl er...... 32 CONDYLOX...... 34 dacarbazine...... 16 dexrazoxane hcl...... 17 constulose...... 38 dactinomycin...... 17 dextroamphetamine sulfate...... 32 CONTOUR CONTROL dalfampridine er...... 33 dextroamphetamine sulfate er.. 32 SOLUTION...... 24 DALIRESP...... 57 dextrose...... 34 CONTOUR MONITOR danazol...... 42 dextrose in lactated ringers...... 34 DEVICE...... 24 dantrolene sodium...... 58 dextrose-nacl...... 34 CONTOUR MONITOR KIT dapsone...... 16, 34 dextrose-sodium chloride...... 34 W/DEVICE...... 24 DAPTACEL...... 49 DIACOMIT...... 12 CONTOUR NEXT CONTROL daptomycin...... 9 diazepam...... 12, 24 SOLUTION...... 24 darifenacin hydrobromide er..... 39 diazepam intensol...... 24 CONTOUR NEXT EZ KIT DARZALEX...... 19 diazoxide...... 25 W/DEVICE...... 24 dasetta 1/35...... 43 diclofenac potassium...... 5 CONTOUR NEXT LINK...... 24 dasetta 7/7/7...... 43 diclofenac sodium...... 5, 17, 55 CONTOUR NEXT MONITOR daunorubicin hcl...... 17 diclofenac sodium er...... 5 KIT W/DEVICE...... 24 daysee...... 43 diclofenac-misoprostol...... 5 CONTOUR NEXT ONE KIT...... 24 DAYTRANA...... 32 dicloxacillin sodium...... 10 CONTOUR NEXT TEST DEBACTEROL...... 33 dicyclomine hcl...... 37 STRIPS...... 25 deblitane...... 46 DIFICID...... 11 CONTOUR TEST STRIPS...... 25 decitabine...... 17 diflunisal...... 5 COPAXONE...... 33 deferasirox...... 35 digitek...... 30 CORIFACT...... 27 deferasirox granules...... 36 digox...... 30 CORLANOR...... 30 deferiprone...... 36 digoxin...... 30 CORTIFOAM...... 50 deferoxamine mesylate...... 51 dihydroergotamine mesylate.....15 CORTISPORIN...... 9 delyla...... 43 DILANTIN...... 12 CORTISPORIN-TC...... 55 demeclocycline hcl...... 11 DILATRATE-SR...... 32 COTELLIC...... 18 DEMSER...... 30 diltiazem hcl...... 29 CREON...... 39 DENAVIR...... 22 diltiazem hcl er...... 29 CRESEMBA...... 15 DENTA 5000 PLUS...... 33 diltiazem hcl er beads...... 29 CRIXIVAN...... 23 DENTAGEL...... 33 diltiazem hcl er coated beads... 29 cromolyn sodium...... 37, 54, 57 DEPO-MEDROL...... 40 dilt-xr...... 29 crotan...... 20 DEPO-SUBQ PROVERA 104...46 dimenhydrinate...... 14 cryselle-28...... 43 DESCOVY...... 23 dimethyl fumarate...... 33 curity sterile saline...... 40 desipramine hcl...... 14 dimethyl fumarate starter pack..33 CUVITRU...... 48 desloratadine...... 55 DIPENTUM...... 50 CUVPOSA...... 37 desmopressin ace spray refrig..42 diphen...... 56 cyanocobalamin...... 36 desmopressin acetate...... 42 diphenhydramine hcl...... 56
63 diphenoxylate-atropine...... 37 elinest...... 43 ergoloid mesylates...... 51 DIPHTHERIA-TETANUS ELIQUIS...... 26 ergotamine-caffeine...... 15 TOXOIDS DT...... 49 ELIQUIS DVT/PE STARTER ERIVEDGE...... 18 dipyridamole...... 27 PACK...... 26 erlotinib hcl...... 18 disopyramide phosphate...... 28 ELITEK...... 20 errin...... 46 disulfiram...... 8 ELIXOPHYLLIN...... 57 ertapenem sodium...... 10 divalproex sodium...... 24 ELLA...... 46 ery...... 34 divalproex sodium er...... 24 ELMIRON...... 40 erythromycin...... 11, 34, 54 DIVIGEL...... 43 ELOCTATE...... 27 erythromycin base...... 11 dobutamine hcl...... 30 eluryng...... 43 erythromycin ethylsuccinate...... 11 dobutamine in d5w...... 30 EMCYT...... 17 escitalopram oxalate...... 13 docetaxel...... 17 EMGALITY...... 16 esmolol hcl...... 29 dofetilide...... 28 EMGALITY (300 MG DOSE).... 16 esmolol hcl-sodium chloride...... 29 donepezil hcl...... 12 emoquette...... 43 esomeprazole sodium...... 38 dopamine hcl...... 30 EMPLICITI...... 19 estarylla...... 43 dopamine in d5w...... 30 EMSAM...... 13 estazolam...... 24 dorzolamide hcl...... 54 emtricitabine...... 23 estradiol...... 43, 44 dorzolamide hcl-timolol mal...... 54 emtricitabine-tenofovir df...... 23 estradiol valerate...... 44 dorzolamide hcl-timolol mal pf.. 54 EMTRIVA...... 23 estradiol-norethindrone acet..... 44 dotti...... 43 EMVERM...... 20 eszopiclone...... 58 doxazosin mesylate...... 28 enalapril maleate...... 28 ethacrynate sodium...... 31 doxepin hcl...... 14, 34, 58 enalaprilat...... 28 ethacrynic acid...... 31 doxercalciferol...... 50 enalapril-hydrochlorothiazide.... 30 ethambutol hcl...... 16 doxorubicin hcl...... 17 ENBREL...... 48 ethosuximide...... 11 doxorubicin hcl liposomal...... 17 ENBREL MINI...... 48 ethyl chloride...... 7 doxy 100...... 11 ENBREL SURECLICK...... 48 ethynodiol diac-eth estradiol..... 44 doxycycline hyclate...... 11 ENCARE...... 40 ETHYOL...... 17 doxycycline monohydrate...... 11 endocet...... 7 etodolac...... 5 dronabinol...... 14 ENGERIX-B...... 49 etodolac er...... 5 droperidol...... 14 ENHERTU...... 19 etonogestrel-ethinyl estradiol.... 44 DROPLET MICRON...... 51 enoxaparin sodium...... 26 etoposide...... 18 drospiren-eth estrad-levomefol. 43 enpresse-28...... 43 euthyrox...... 46 drospirenone-ethinyl estradiol...43 enskyce...... 43 EVAMIST...... 44 DROXIA...... 17 entacapone...... 20 everolimus...... 18, 48 DUAVEE...... 43 entecavir...... 22 EVOTAZ...... 23 duloxetine hcl...... 13 ENTRESTO...... 30 EVRYSDI...... 39 DUPIXENT...... 34 enulose...... 38 exemestane...... 18 duramorph...... 7 EPCLUSA...... 22 ezetimibe...... 31 DUREZOL...... 55 ephedrine sulfate...... 30 ezetimibe-simvastatin...... 31 dutasteride...... 39 EPIDIOLEX...... 11 fabb...... 36 dutasteride-tamsulosin hcl...... 39 EPIDUO FORTE...... 34 FABRAZYME...... 39 EASIVENT...... 51 epinastine hcl...... 54 falmina...... 44 easygel...... 33 epinephrine...... 57 famciclovir...... 22 ec-naproxen...... 5 epinephrine (anaphylaxis)...... 57 famotidine...... 37, 38 econazole nitrate...... 15 epinephrine pf...... 30 famotidine premixed...... 38 ED-SPAZ...... 37 epirubicin hcl...... 17 FANAPT...... 21 EDURANT...... 22 epitol...... 12 FANAPT TITRATION PACK..... 22 efavirenz...... 22 EPIVIR HBV...... 22 FARXIGA...... 25 efavirenz-emtricitab-tenofovir....23 eplerenone...... 31 FARYDAK...... 18 efavirenz-lamivudine-tenofovir.. 23 epoprostenol sodium...... 57 fa-vitamin b-6-vitamin b-12...... 36 effer-k...... 34 eptifibatide...... 27 fayosim...... 44 ELAPRASE...... 39 ERBITUX...... 19 FC FEMALE CONDOM...... 51 eletriptan hydrobromide...... 16 ergocalciferol...... 36 FC2 FEMALE CONDOM...... 51
64 febuxostat...... 15 FLUORIDEX...... 33 GAMIFANT...... 49 FEIBA...... 27 fluoridex daily renewal...... 33 GAMMAGARD...... 48 felbamate...... 12 FLUORIDEX ENHANCED GAMMAGARD S/D LESS IGA..48 felodipine er...... 29 WHITENING...... 33 GAMMAKED...... 48 FEMCAP...... 51 FLUORIDEX SENSITIVITY GAMMAPLEX...... 48 femynor...... 44 RELIEF...... 33 GAMUNEX-C...... 48 fenofibrate...... 31 fluoritab...... 35 ganciclovir sodium...... 22 fenofibrate micronized...... 31 fluorometholone...... 55 GARDASIL 9...... 49 fenofibric acid...... 31 FLUOROPLEX...... 17 gatifloxacin...... 55 fenoprofen calcium...... 5 fluorouracil...... 17, 18 GATTEX...... 37 fentanyl...... 6 FLUOROURACIL...... 18 gavilax...... 38 fentanyl citrate...... 7 fluoxetine hcl...... 13 gavilyte-c...... 38 ferocon...... 34 fluoxetine hcl (pmdd)...... 13 gavilyte-g...... 38 ferotrinsic...... 34 fluphenazine decanoate...... 21 gavilyte-h...... 38 ferraplus 90...... 34 fluphenazine hcl...... 21 gavilyte-n with flavor pack...... 38 ferrocite plus...... 35 flurbiprofen...... 5 GAZYVA...... 19 FETZIMA...... 13 flurbiprofen sodium...... 55 GELNIQUE...... 39 FETZIMA TITRATION...... 13 flutamide...... 17 gemcitabine hcl...... 17 finasteride...... 39 fluticasone propionate...... 41, 56 gemfibrozil...... 31 flac...... 55 fluticasone-salmeterol...... 56 gemmily...... 44 FLAREX...... 55 FLUTICASONE- generlac...... 38 flavoxate hcl...... 39 SALMETEROL...... 56 gengraf...... 48 FLEBOGAMMA DIF...... 48 fluvoxamine maleate...... 13 gentak...... 53 flecainide acetate...... 28 fluvoxamine maleate er...... 13 gentamicin in saline...... 8 FLEXICHAMBER ADULT FLUZONE HIGH-DOSE gentamicin sulfate...... 8, 53 MASK/SMALL...... 51 QUADRIVALENT...... 49 gentle laxative...... 38 FLEXICHAMBER CHILD FLUZONE QUADRIVALENT.... 49 GENVOYA...... 22 MASK/LARGE...... 51 FML...... 55 GILENYA...... 33 FLEXICHAMBER CHILD folbee...... 36 GILOTRIF...... 19 MASK/SMALL...... 51 folbee plus...... 36 glatiramer acetate...... 33 FLOVENT DISKUS...... 56 folic acid...... 36 glatopa...... 33 FLOVENT HFA...... 56 FOLOTYN...... 17 GLEOSTINE...... 16 floxuridine...... 17 folplex 2.2...... 36 glimepiride...... 25 FLUAD...... 49 foltrin...... 35 glipizide er...... 25 FLUAD QUADRIVALENT...... 49 fomepizole...... 51 glipizide ir...... 25 FLUARIX QUADRIVALENT...... 49 fondaparinux sodium...... 26 glipizide xl...... 25 FLUBLOK QUADRIVALENT.....49 FORTEO...... 50 glipizide-metformin hcl...... 25 FLUCELVAX fosamprenavir calcium...... 23 glucagon emergency kit...... 25 QUADRIVALENT...... 49 fosaprepitant dimeglumine...... 14 GLUCAGON EMERGENCY fluconazole...... 15 fosfomycin tromethamine...... 9 KIT...... 26 fluconazole in sodium chloride..15 fosinopril sodium...... 28 glyburide...... 25 flucytosine...... 15 fosinopril sodium-hctz...... 30 glyburide micronized...... 25 fludarabine phosphate...... 17 fosphenytoin sodium...... 12 glyburide-metformin...... 25 fludrocortisone acetate...... 41 FOSRENOL...... 36 glycine...... 40 FLULAVAL QUADRIVALENT... 49 fulvestrant...... 17 glycine urologic...... 40 flumazenil...... 51 furosemide...... 31 glycolax...... 38 FLUMIST QUADRIVALENT...... 49 FUZEON...... 23 glycopyrrolate...... 37 flunisolide...... 56 fyavolv...... 44 glycopyrrolate pf...... 37 fluocinolone acetonide...... 41, 55 FYCOMPA...... 12 glydo...... 7 fluocinolone acetonide body..... 41 gabapentin...... 12 GLYXAMBI...... 25 fluocinolone acetonide scalp.....41 galantamine hydrobromide...... 12 gnp aspirin low dose...... 5 fluocinonide...... 41 galantamine hydrobromide er... 12 goodsense aspirin low dose...... 5 fluocinonide emulsified base.....41 GAMASTAN...... 48 goodsense nicotine...... 8
65 GRALISE...... 32 HUMIRA PEDIATRIC iclevia...... 44 granisetron hcl...... 14 CROHNS START...... 48 ICLUSIG...... 19 griseofulvin microsize...... 15 HUMIRA PEN...... 48 idarubicin hcl...... 18 griseofulvin ultramicrosize...... 15 HUMIRA PEN-CD/UC/HS ifosfamide...... 17 guanfacine hcl...... 28 STARTER...... 48 ILARIS...... 49 guanfacine hcl er...... 32 HUMIRA PEN-PEDIATRIC UC ILEVRO...... 55 GUANIDINE HCL...... 16 START...... 48 imatinib mesylate...... 19 GYNAZOLE-1...... 15 HUMIRA PEN-PS/UV/ADOL IMBRUVICA...... 19 habitrol...... 8 HS START...... 48 imipenem-cilastatin...... 10 hailey 1.5/30...... 44 HUMIRA PEN-PSOR/UVEIT imipramine hcl...... 14 hailey 24 fe...... 44 STARTER...... 48 imipramine pamoate...... 14 hailey fe 1.5/30...... 44 HUMULIN 70/30 KWIKPEN...... 26 imiquimod...... 34 hailey fe 1/20...... 44 HUMULIN 70/30 VIAL...... 26 IMPAVIDO...... 20 HALAVEN...... 18 HUMULIN N KWIKPEN...... 26 inavix...... 5 halcinonide...... 41 HUMULIN N VIAL...... 26 incassia...... 46 halobetasol propionate...... 41 HUMULIN R U-500 KWIKPEN..26 INCRELEX...... 42 haloperidol...... 21 HUMULIN R U-500 VIAL...... 26 INCRUSE ELLIPTA...... 56 haloperidol decanoate...... 21 HUMULIN R VIAL...... 26 indapamide...... 31 haloperidol lactate...... 21 HYCAMTIN...... 18 indomethacin...... 5 HARVONI...... 22 hydralazine hcl...... 32 indomethacin er...... 5 HAVRIX...... 49 hydrochlorothiazide...... 31 indomethacin sodium...... 5 heather...... 46 hydrocodone bitartrate er...... 6 INFANRIX...... 49 HEMLIBRA...... 27 hydrocodone-acetaminophen..... 7 INFLECTRA...... 48 hemocyte-f...... 35 hydrocodone-homatropine...... 58 INLYTA...... 19 HEMOFIL M...... 27 hydrocodone-ibuprofen...... 7 INPEN 100-BLUE-LILLY...... 25 HEPAGAM B...... 48 hydrocortisone...... 41, 50 INPEN 100-BLUE-NOVO...... 25 heparin (porcine) in nacl...... 26 hydrocortisone (perianal)...... 50 INPEN 100-GRAY-LILLY...... 25 heparin lock flush...... 51 hydrocortisone ace-pramoxine..50 INPEN 100-GREY-NOVO...... 25 heparin sod (porcine) in d5w.....27 hydrocortisone butyrate...... 41 INPEN 100-PINK-LILLY...... 25 heparin sodium (porcine)...... 27 hydrocortisone valerate...... 41 INPEN 100-PINK-NOVO...... 25 heparin sodium (porcine) pf...... 27 hydrocortisone-acetic acid...... 55 INSPIREASE RESERVOIR heparin sodium lock flush...... 51 hydromet...... 58 BAGS...... 51 HEPLISAV-B...... 49 hydromorphone hcl...... 7 INSULIN PEN NEEDLES...... 51 HERCEPTIN...... 19 hydromorphone hcl er...... 6 INSULIN SYRINGES...... 52 HERCEPTIN HYLECTA...... 19 hydromorphone hcl pf...... 7 INTELENCE...... 23 hetastarch-nacl...... 51 hydroxocobalamin acetate...... 36 INTRAROSA...... 42 HETLIOZ...... 59 hydroxychloroquine sulfate...... 20 INTRON A...... 22 HIBERIX...... 49 hydroxyprogesterone caproate. 46 introvale...... 44 HIZENTRA...... 49 hydroxyurea...... 17 INVEGA SUSTENNA...... 22 homatropaire...... 54 hydroxyzine hcl...... 24 INVEGA TRINZA...... 22 HUMALOG KWIKPEN...... 26 hydroxyzine pamoate...... 24 INVIRASE...... 23 HUMALOG MIX 50/50 hyoscyamine sulfate...... 37 iodine strong...... 35 KWIKPEN...... 26 hyoscyamine sulfate sl...... 37 iodine tincture...... 9 HUMALOG MIX 50/50 VIAL...... 26 HYPERHEP B...... 49 IOPIDINE...... 54 HUMALOG MIX 75/25 HYPERRHO S/D...... 49 IPOL...... 49 KWIKPEN...... 26 HYQVIA...... 49 ipratropium bromide...... 56 HUMALOG MIX 75/25 VIAL...... 26 HYSINGLA ER...... 6 ipratropium-albuterol...... 58 HUMALOG U-100 JUNIOR ibandronate sodium...... 50 irbesartan...... 28 KWIKPEN...... 26 IBRANCE...... 19 irbesartan-hydrochlorothiazide..30 HUMALOG VIAL...... 26 ibuprofen...... 5 irinotecan hcl...... 18 HUMATE-P...... 27 ibuprofen lysine...... 5 ISENTRESS...... 22 HUMIRA...... 48 ibutilide fumarate...... 28 ISENTRESS HD...... 22 icatibant acetate...... 47 isibloom...... 44
66 isoniazid...... 16 klor-con 10...... 35 leuprolide acetate...... 47 isoproterenol hcl...... 57 klor-con m10...... 35 levalbuterol hcl...... 57 isosorbide dinitrate...... 32 KLOR-CON M15...... 35 LEVEMIR U-100 FLEXTOUCH.26 isosorbide mononitrate...... 32 klor-con m20...... 35 LEVEMIR U-100 VIAL...... 26 isosorbide mononitrate er...... 32 klor-con/ef...... 35 levetiracetam...... 11 isotretinoin...... 34 KOATE...... 27 levetiracetam er...... 11 ISTODAX (OVERFILL)...... 18 KOATE-DVI...... 27 levetiracetam in nacl...... 11 itraconazole...... 15 KOGENATE FS...... 27 levobunolol hcl...... 54 ivermectin...... 20 KORLYM...... 42 levocarnitine...... 35 IXEMPRA KIT...... 18 KOSELUGO...... 19 levocarnitine sf...... 35 jaimiess...... 44 KOVALTRY...... 27 levocetirizine dihydrochloride....56 JAKAFI...... 19 k-prime...... 35 levofloxacin...... 11, 55 jantoven...... 27 k-tan plus...... 35 levofloxacin in d5w...... 11 JANUMET...... 25 kurvelo...... 44 levoleucovorin calcium...... 18 JANUMET XR...... 25 KUVAN...... 39 levoleucovorin calcium pf...... 18 JANUVIA...... 25 KYLEENA...... 46 levonest...... 44 JARDIANCE...... 25 KYPROLIS...... 18 levonorgest-eth est & eth est.... 44 jasmiel...... 44 labetalol hcl...... 29 levonorgest-eth estrad 91-day.. 44 jencycla...... 46 lactated ringers...... 35, 52 levonorgestrel...... 46 JENTADUETO...... 25 lactic acid...... 34 levonorgestrel-ethinyl estrad.....44 JENTADUETO XR...... 25 lactic acid e...... 34 levonorg-eth estrad triphasic.....44 JEVTANA...... 19 lactulose...... 38 levora 0.15/30 (28)...... 44 jinteli...... 44 lactulose encephalopathy...... 38 levorphanol tartrate...... 6 jolessa...... 44 lamivudine...... 22, 23 levo-t...... 46 J-TIP KIT W/VIAL ADAPTERS. 52 lamivudine-zidovudine...... 23 levothyroxine sodium...... 46 juleber...... 44 lamotrigine...... 12 levoxyl...... 47 JULUCA...... 22 lamotrigine er...... 12 LEXIVA...... 23 junel 1.5/30...... 44 lamotrigine starter kit-blue...... 12 lidocaine...... 7 junel 1/20...... 44 lamotrigine starter kit-green...... 12 lidocaine hcl...... 7 junel fe 1.5/30...... 44 lamotrigine starter kit-orange.... 12 lidocaine hcl (cardiac)...... 28 junel fe 1/20...... 44 LANCETS...... 25 lidocaine hcl (cardiac) pf...... 28 junel fe 24...... 44 lansoprazole...... 38 lidocaine hcl (pf)...... 7 KADCYLA...... 19 lanthanum carbonate...... 36 lidocaine hcl urethral/mucosal.....7 KALETRA...... 23 LANTUS SOLOSTAR...... 26 lidocaine in d5w...... 28 kalliga...... 44 LANTUS U-100 VIAL...... 26 lidocaine viscous hcl...... 7 KALYDECO...... 57 lapatinib ditosylate...... 19 lidocaine-prilocaine...... 7 KANJINTI...... 19 larin 1.5/30...... 44 LIDOCAINE-TETRACAINE...... 7 KANUMA...... 39 larin 1/20...... 44 LILETTA (52 MG)...... 46 kariva...... 44 larin 24 fe...... 44 lillow...... 44 kcl in dextrose-nacl...... 35 larin fe 1.5/30...... 44 lincomycin hcl...... 9 kcl-lactated ringers-d5w...... 35 larin fe 1/20...... 44 lindane...... 20 kedbumin...... 52 larissia...... 44 linezolid...... 9 kelnor 1/35...... 44 LASTACAFT...... 54 linezolid in sodium chloride...... 9 kelnor 1/50...... 44 latanoprost...... 55 LINZESS...... 38 KERYDIN...... 15 LATUDA...... 22 liothyronine sodium...... 47 ketoconazole...... 15 layolis fe...... 44 lisinopril...... 28 ketoprofen...... 5 leena...... 44 lisinopril-hydrochlorothiazide.....30 ketoprofen er...... 5 leflunomide...... 49 lithium...... 24 ketorolac tromethamine...... 5, 55 LENVIMA...... 19 lithium carbonate...... 24 KETOSTIX...... 25 lessina...... 44 lithium carbonate er...... 24 KINERET...... 48 letrozole...... 18 LIVALO...... 31 KINRIX...... 49 leucovorin calcium...... 18 lojaimiess...... 44 klor-con...... 35 LEUKERAN...... 17 LONSURF...... 18
67 loperamide hcl...... 37 megestrol acetate...... 46 metoclopramide hcl...... 14 lopinavir-ritonavir...... 23 MEKINIST...... 19 metolazone...... 31 lorazepam...... 24 melodetta 24 fe...... 44 metoprolol succinate er...... 29 lorazepam intensol...... 24 meloxicam...... 5 metoprolol tartrate...... 29 loryna...... 44 melphalan...... 17 metoprolol-hydrochlorothiazide.30 losartan potassium...... 28 melphalan hcl...... 17 metronidazole...... 9, 34 losartan potassium-hctz...... 30 memantine hcl...... 12 metronidazole in nacl...... 9 loteprednol etabonate...... 55 memantine hcl er...... 12 metyrosine...... 30 lovastatin...... 31 MENACTRA...... 49 mexiletine hcl...... 28 low-ogestrel...... 44 MENEST...... 44 MIACALCIN...... 50 loxapine succinate...... 21 MENQUADFI...... 49 mibelas 24 fe...... 44 lo-zumandimine...... 44 MENVEO...... 49 micafungin sodium...... 15 LUMIGAN...... 55 MEPSEVII...... 39 miconazole 3...... 15 LUMIZYME...... 39 mercaptopurine...... 17 MICRHOGAM ULTRA- LUPRON DEPOT (1-MONTH)..47 meropenem...... 10 FILTERED PLUS...... 49 LUPRON DEPOT (3-MONTH)..47 merzee...... 44 MICROCHAMBER...... 52 LUPRON DEPOT (4-MONTH) mesalamine...... 50 microgestin 1.5/30...... 44 INTRAMUSCULAR KIT 30MG..47 mesalamine er oral capsule microgestin 1/20...... 44 LUPRON DEPOT (6-MONTH) 0.375 gm...... 50 microgestin 24 fe...... 44 INTRAMUSCULAR KIT 45MG..47 mesalamine-cleanser...... 50 microgestin fe 1.5/30...... 44 LUPRON DEPOT-PED (1- mesna...... 20 microgestin fe 1/20...... 44 MONTH)...... 47 MESNEX...... 20 midodrine hcl...... 28 LUPRON DEPOT-PED (3- metaxalone...... 58 mifepristone...... 42 MONTH)...... 47 metformin hcl er...... 25 miglitol...... 25 lutera...... 44 metformin hcl ir...... 25 miglustat...... 39 lyleq...... 46 methadone hcl...... 6 mili...... 44 lyllana...... 44 methadone hcl intensol...... 6 milrinone lactate...... 30 LYNPARZA...... 19 methadose...... 6 milrinone lactate in dextrose..... 30 lysiplex plus...... 36 methadose sugar-free...... 6 mimvey...... 45 LYSODREN...... 47 methazolamide...... 31 mineral oil heavy...... 38 lyza...... 46 methenamine hippurate...... 9 MINOCIN...... 11 mafenide acetate...... 9 methergine...... 52 minocycline hcl...... 11 magnesium chloride...... 35 methimazole...... 47 minoxidil...... 32 magnesium citrate...... 38 METHITEST...... 42 MIRENA (52 MG)...... 46 magnesium sulfate...... 35 methocarbamol...... 58 mirtazapine...... 13 magnesium sulfate in d5w...... 35 methotrexate...... 48 MIRVASO...... 34 MAKENA...... 46 methotrexate sodium...... 48 misoprostol...... 38 malathion...... 20 methotrexate sodium (pf)...... 48 mitigo...... 6 maprotiline hcl...... 13 methoxsalen rapid...... 34 mitomycin...... 18 marlissa...... 44 methscopolamine bromide...... 37 mitoxantrone hcl...... 18 MARPLAN...... 13 methyldopa...... 28 mm clearlax...... 38 MARQIBO...... 18 methyldopa- M-M-R II...... 49 MATULANE...... 17 hydrochlorothiazide...... 30 modafinil...... 59 matzim la...... 29 methylergonovine maleate...... 52 moexipril hcl...... 28 MAVYRET...... 22 methylphenidate hcl...... 32 molindone hcl...... 21 MAXICOMFORT SYR 27G X methylphenidate hcl er...... 32 mometasone furoate...... 41, 56 1/2"...... 52 methylphenidate hcl er (cd)...... 32 mondoxyne nl...... 11 MAYZENT...... 33 methylphenidate hcl er (la)...... 32 monoject flush syringe...... 52 MAYZENT STARTER PACK.... 33 methylphenidate hcl er (xr)...... 32 monoject sodium chloride flush.52 meclizine hcl...... 14 methylprednisolone...... 41 mono-linyah...... 45 meclofenamate sodium...... 5 methylprednisolone acetate...... 41 montelukast sodium...... 56 medroxyprogesterone acetate.. 46 methylprednisolone sodium morgidox...... 11 mefloquine hcl...... 20 succ...... 41 morphine sulfate...... 7
68 morphine sulfate (concentrate)... 7 neomycin-polymyxin-hc...... 53, 55 norethindrone-eth estradiol...... 45 morphine sulfate (pf)...... 7 neo-polycin...... 53 norethin-eth estradiol-fe...... 45 morphine sulfate er...... 6 neo-polycin hc...... 53 norgestimate-eth estradiol...... 45 morphine sulfate er beads...... 6 neostigmine methylsulfate...... 16 norgestimate-ethinyl estradiol MOTOFEN...... 37 NEO-SYNALAR...... 9 triphasic...... 45 moxifloxacin hcl...... 11, 55 nephronex...... 36 norlyda...... 46 moxifloxacin hcl (2x day)...... 55 neuac...... 34 norlyroc...... 46 moxifloxacin hcl in nacl...... 11 NEULASTA...... 27 normal saline flush...... 52 MOZOBIL...... 27 NEULASTA ONPRO...... 27 nortrel 0.5/35 (28)...... 45 multi prenatal...... 36 NEUPRO...... 20 nortrel 1/35 (21)...... 45 multi-vit/iron/fluoride...... 36 nevirapine...... 23 nortrel 1/35 (28)...... 45 multivitamin/fluoride...... 36 nevirapine er...... 23 nortrel 7/7/7...... 45 multi-vitamin/fluoride...... 36 NEXAVAR...... 19 nortriptyline hcl...... 14 multi-vitamin/fluoride/iron...... 36 NEXLETOL...... 31 NORVIR...... 23 mupirocin...... 9 NEXLIZET...... 31 novarel...... 42 mutamycin...... 18 NEXPLANON...... 46 NOVOEIGHT...... 27 MVASI...... 19 niacin er (antihyperlipidemic).... 31 NOVOFINE AUTOCOVER MYALEPT...... 39 nicardipine hcl...... 29 PEN NEEDLE...... 52 mycophenolate mofetil...... 48 NICORETTE...... 8 NOVOFINE PEN NEEDLE...... 52 mycophenolate mofetil hcl...... 48 nicotine polacrilex...... 8 NOVOFINE PLUS PEN mycophenolate sodium...... 48 nicotine step 1...... 8 NEEDLE...... 52 MYLERAN...... 17 nicotine step 2...... 8 NOVOLIN 70/30 FLEXPEN...... 26 myorisan...... 34 nicotine step 3...... 8 NOVOLIN 70/30 FLEXPEN MYRBETRIQ...... 39 NICOTROL...... 8 RELION...... 26 na ferric gluc cplx in sucrose.....35 NICOTROL NS...... 8 NOVOLIN 70/30 RELION...... 26 NABI-HB...... 49 nifedipine er...... 29 NOVOLIN 70/30 VIAL...... 26 nabumetone...... 5 nifedipine er osmotic release.... 29 NOVOLIN N FLEXPEN...... 26 n-acetyl-l-cysteine...... 52 nikki...... 45 NOVOLIN N FLEXPEN nafcillin sodium...... 10 nilutamide...... 17 RELION...... 26 nafrinse...... 35 nimodipine...... 29 NOVOLIN N RELION...... 26 nafrinse drops...... 35 NINLARO...... 18 NOVOLIN N VIAL...... 26 naftifine hcl...... 15 NIPENT...... 17 NOVOLIN R FLEXPEN...... 26 NAGLAZYME...... 39 nisoldipine er...... 29 NOVOLIN R FLEXPEN naloxone hcl...... 8 nitazoxanide...... 20 RELION...... 26 naltrexone hcl...... 8 nitisinone...... 39 NOVOLIN R RELION...... 26 NAMZARIC...... 12, 13 NITRO-BID...... 32 NOVOLIN R VIAL...... 26 naproxen...... 5, 6 nitrofurantoin...... 9 NOVOLOG FLEXPEN...... 26 naproxen sodium...... 6 nitrofurantoin macrocrystal...... 9 NOVOLOG MIX 70/30 naratriptan hcl...... 16 nitrofurantoin monohydrate FLEXPEN...... 26 NARCAN...... 8 macrocrystals...... 9 NOVOLOG MIX 70/30 VIAL...... 26 NASCOBAL...... 36 nitroglycerin...... 32 NOVOLOG PENFILL...... 26 NATACYN...... 53 nitroglycerin in d5w...... 32 NOVOLOG U-100 VIAL...... 26 NATAZIA...... 45 NITROMIST...... 32 NOVOPEN ECHO...... 25 nateglinide...... 25 nitroprusside sodium...... 32 NOVOSEVEN RT...... 27 necon 0.5/35 (28)...... 45 NIVESTYM...... 27 NOVOTWIST PEN NEEDLE.... 52 nefazodone hcl...... 13 nizatidine...... 38 NOZIN NASAL SANITIZER neomycin sulfate...... 8 nora-be...... 46 POPSWAB...... 52 neomycin-bacitracin zn- NORDITROPIN FLEXPRO...... 42 np thyroid...... 47 polymyx...... 53 norepinephrine bitartrate...... 30 NUCALA...... 58 neomycin-polymyxin b gu...... 40 norethin ace-eth estrad-fe...... 45 NUCYNTA ER...... 6 neomycin-polymyxin-dexameth 53 norethindrone...... 46 nufol...... 36 neomycin-polymyxin- norethindrone acetate...... 46 nutrifac zx...... 36 gramicidin...... 53 norethindrone acet-ethinyl est...45 nutrilipid...... 35
69 NUTROPIN AQ NUSPIN 10..... 42 oxacillin sodium...... 10 pentazocine-naloxone hcl...... 7 NUTROPIN AQ NUSPIN 20..... 42 oxaliplatin...... 17 pentobarbital sodium...... 12 NUTROPIN AQ NUSPIN 5...... 42 oxandrolone...... 42 pentoxifylline er...... 30 NUWIQ...... 27 oxaprozin...... 6 PERFOROMIST...... 57 nyamyc...... 15 oxazepam...... 24 perindopril erbumine...... 28 nylia 7/7/7...... 45 oxcarbazepine...... 12 periogard...... 33 nymyo...... 45 oxiconazole nitrate...... 15 PERJETA...... 19 nystatin...... 15 OXISTAT...... 15 permethrin...... 20 nystatin-triamcinolone...... 15 oxybutynin chloride...... 39 perphenazine...... 14 nystop...... 15 oxybutynin chloride er...... 39 perphenazine-amitriptyline...... 13 OBIZUR...... 27 oxycodone hcl...... 7 phenazo...... 40 ocella...... 45 oxycodone-acetaminophen...... 7 phenazopyridine hcl...... 40 OCTAGAM...... 49 oxycodone-aspirin...... 7 phenelzine sulfate...... 13 octreotide acetate...... 47 OXYCONTIN...... 6 phenobarbital...... 12 ODEFSEY...... 23 oxymorphone hcl...... 7 phenobarbital sodium...... 12 OFEV...... 58 oxymorphone hcl er...... 6 phenoxybenzamine hcl...... 28 ofloxacin...... 11, 55 oxytocin...... 42 phentolamine mesylate...... 28 olanzapine...... 22 OZEMPIC...... 25 phenylephrine hcl...... 30, 54 olanzapine-fluoxetine hcl...... 13 paclitaxel...... 18 phenytoin...... 12 olmesartan medoxomil...... 28 PADCEV...... 19 phenytoin infatabs...... 12 olmesartan medoxomil-hctz...... 30 paliperidone er...... 22 phenytoin sodium...... 12 olmesartan-amlodipine-hctz...... 30 palonosetron hcl...... 14 phenytoin sodium extended...... 12 olopatadine hcl...... 54, 56 pamidronate disodium...... 50 philith...... 45 OMECLAMOX-PAK...... 37 PANDA MASK LARGE...... 52 PHOSLYRA...... 36 omega-3-acid ethyl esters...... 31 PANDA MASK MEDIUM...... 52 PHOSPHOLINE IODIDE...... 54 omeprazole...... 38 PANDA MASK SMALL...... 52 phosphorous...... 35 ONCASPAR...... 18 PANRETIN...... 20 phospho-trin 250 neutral...... 35 ondansetron hcl...... 14 pantoprazole sodium...... 38 phytonadione...... 36 ondansetron odt...... 14 PARAGARD INTRAUTERINE PICATO...... 18 ONE VITE WOMENS...... 36 COPPER...... 52 pilocarpine hcl...... 33, 54 ONE-A-DAY WOMENS paraplatin...... 17 pimecrolimus...... 34 PRENATAL 1...... 36 paricalcitol...... 50 pimozide...... 21 ONETOUCH DELICA paromomycin sulfate...... 8 pimtrea...... 45 LANCING DEV...... 25 paroxetine hcl...... 13 pindolol...... 29 ONETOUCH DELICA PLUS paroxetine hcl er...... 13 pioglitazone hcl...... 25 LANCING...... 25 paroxetine mesylate...... 13 pioglitazone hcl-glimepiride...... 25 ONIVYDE...... 18 PASER...... 16 pioglitazone hcl-metformin hcl.. 25 ONUREG...... 18 PAXIL...... 13 piperacillin sod-tazobactam so..10 OPDIVO...... 19 PEDIARIX...... 49 PIQRAY...... 18 OPSUMIT...... 57 PEDIATRIC PANDA MASK...... 52 pirmella 1/35...... 45 oralone...... 33 PEDVAX HIB...... 49 pirmella 7/7/7...... 45 ORENCIA...... 48 peg 3350-kcl-na bicarb-nacl...... 38 piroxicam...... 6 ORENCIA CLICKJECT...... 48 peg-3350/electrolytes...... 38 PNEUMOVAX 23...... 49 ORENITRAM...... 57 peg-3350/electrolytes/ascorbat.38 POCKET SPACER...... 52 ORFADIN...... 39 PEGASYS...... 22 podofilox...... 34 ORKAMBI...... 57 peg-kcl-nacl-nasulf-na asc-c..... 38 POLIVY...... 19 orphenadrine citrate...... 58 penicillamine...... 40 polycin...... 53 orphenadrine citrate er...... 58 penicillin g potassium...... 10 polymyxin b sulfate...... 9 orsythia...... 45 penicillin g sodium...... 10 polymyxin b-trimethoprim...... 53 oscimin...... 37 penicillin v potassium...... 10 polysaccharide iron forte...... 35 oseltamivir phosphate...... 24 PENTACEL...... 49 POMALYST...... 17 OSPHENA...... 46 pentamidine isethionate...... 20 portia-28...... 45 OTEZLA...... 49 PENTASA...... 50 posaconazole...... 15
70 potassium acetate...... 35 PROAIR RESPICLICK...... 57 quinine sulfate...... 20 potassium chloride...... 35 probenecid...... 15 rabeprazole sodium...... 38 potassium chloride crys er...... 35 procainamide hcl...... 28 raloxifene hcl...... 46 potassium chloride er...... 35 PROCARE SPACER/ADULT ramelteon...... 59 potassium chloride in dextrose. 35 MASK...... 52 ramipril...... 28 potassium chloride in nacl...... 35 PROCARE SPACER/CHILD ranolazine er...... 30 potassium citrate er...... 35 MASK...... 52 rasagiline mesylate...... 21 potassium phosphates(71 meq prochlorperazine...... 14 RAVICTI...... 39 k)...... 35 prochlorperazine edisylate...... 14 RAYALDEE...... 50 PRADAXA...... 27 prochlorperazine maleate...... 14 REBLOZYL...... 27 PRALUENT...... 31 procto-med hc...... 50 reclipsen...... 45 pramipexole dihydrochloride..... 21 procto-pak...... 50 RECOMBINATE...... 27 pramipexole dihydrochloride er.21 proctozone-hc...... 50 RECOMBIVAX HB...... 50 prasugrel hcl...... 27 PROFILNINE...... 27 RECTIV...... 32 pravastatin sodium...... 31 progesterone...... 46 REGRANEX...... 34 praziquantel...... 20 progesterone micronized...... 46 RELENZA DISKHALER...... 24 prazosin hcl...... 28 PROGRAF...... 48 relexxii...... 32 prednicarbate...... 41 PROLASTIN-C...... 39 RENACIDIN...... 40 prednisolone...... 42 PROLENSA...... 55 RENFLEXIS...... 48 prednisolone acetate...... 55 PROLEUKIN...... 18 repaglinide...... 25 prednisolone sodium PROLIA...... 50 REPATHA...... 31 phosphate...... 42, 55 PROMACTA...... 27 REPATHA PUSHTRONEX prednisone...... 42 promethazine hcl...... 56 SYSTEM...... 31 prednisone intensol...... 42 promethegan...... 56 REPATHA SURECLICK...... 31 pregabalin...... 32 propafenone hcl...... 28 RESTASIS...... 54 pregnyl...... 42 propafenone hcl er...... 28 RESTASIS MULTIDOSE...... 54 PREMARIN...... 45 propranolol hcl...... 29 RETACRIT...... 27 PREMPHASE...... 45 propranolol hcl er...... 29 RETROVIR...... 23 PREMPRO...... 45 propranolol-hctz...... 30 REVCOVI...... 39 prenatal...... 36 propylthiouracil...... 47 REVLIMID...... 17 prenatal multi +dha...... 36 PROQUAD...... 49 revonto...... 58 prenatal plus iron...... 36 protamine sulfate...... 27 REXULTI...... 22 prenatal vitamin plus low iron....36 protriptyline hcl...... 14 REYATAZ...... 23 preplus...... 36 PULMICORT FLEXHALER...... 56 RHOGAM ULTRA-FILTERED prevalite...... 31 PULMOZYME...... 57 PLUS...... 49 preventeza...... 46 purevit dualfe plus...... 35 RHOPHYLAC...... 49 prevident...... 33 PYLERA...... 37 RHOPRESSA...... 54 previfem...... 45 pyrazinamide...... 16 RIASTAP...... 27 PREVNAR 13...... 49 pyridostigmine bromide...... 16 ribavirin...... 22 PREZCOBIX...... 23 pyridostigmine bromide er...... 16 rifabutin...... 16 PREZISTA...... 23 pyridoxine hcl...... 36 rifampin...... 16 PRIFTIN...... 16 pyrimethamine...... 20 riluzole...... 32 primaquine phosphate...... 20 qc aspirin low dose...... 6 rimantadine hcl...... 24 primidone...... 12 qc magnesium citrate...... 38 ringers...... 35 PRIMSOL...... 9 QINLOCK...... 19 ringers irrigation...... 52 PRIVIGEN...... 49 QUADRACEL...... 50 RINVOQ...... 49 PRO COMFORT SPACER quetiapine fumarate...... 22 risedronate sodium...... 50 ADULT...... 52 quetiapine fumarate er...... 22 RISPERDAL CONSTA...... 22 PRO COMFORT SPACER QUILLIVANT XR...... 32 risperidone...... 22 CHILD...... 52 quinapril hcl...... 28 ritonavir...... 23 PRO COMFORT SPACER quinapril-hydrochlorothiazide.... 30 RITUXAN...... 19 INFANT...... 52 quinidine gluconate er...... 28 RITUXAN HYCELA...... 19 PROAIR HFA...... 57 quinidine sulfate...... 28 rivastigmine...... 12
71 rivastigmine tartrate...... 12 SKLICE...... 20 subvenite starter kit-green...... 12 rivelsa...... 45 SKYLA...... 46 subvenite starter kit-orange...... 12 RIXUBIS...... 27 SKYRIZI (150 MG DOSE)...... 48 SUCRAID...... 39 rizatriptan benzoate...... 16 sod benz-sod phenylacet...... 39 sucralfate...... 38 ROCKLATAN...... 54 sod citrate-citric acid...... 35 sulfacetamide sodium...... 55 ropinirole hcl...... 21 sodium acetate...... 35 sulfacetamide sodium (acne).... 34 ropinirole hcl er...... 21 sodium bicarbonate...... 35, 37 sulfacetamide-prednisolone...... 54 rosadan...... 34 sodium chloride...... 35, 40, 58 sulfadiazine...... 11 rosuvastatin calcium...... 31 sodium chloride (pf)...... 35 sulfamethoxazole-trimethoprim.11 ROTARIX...... 50 sodium chloride flush...... 52 sulfasalazine...... 50 ROTATEQ...... 50 sodium fluoride...... 33, 35 sulfatrim pediatric...... 11 roweepra...... 11 sodium fluoride 5000 enamel....33 sulfurated lime...... 20 ROZLYTREK...... 18 sodium fluoride 5000 plus...... 33 sulindac...... 6 RUBRACA...... 18 sodium fluoride 5000 ppm...... 33 sumatriptan...... 16 rufinamide...... 12 sodium fluoride 5000 sensitive..33 sumatriptan succinate...... 16 RUKOBIA...... 23 sodium nitrite...... 52 sumatriptan succinate refill...... 16 RUXIENCE...... 20 sodium nitroprusside...... 32 sumatriptan-naproxen sodium.. 16 RYDAPT...... 19 sodium phenylbutyrate...... 39 SUNOSI...... 59 ryvent...... 56 sodium phosphates...... 35 SUPREP BOWEL PREP KIT....38 saline flush...... 52 sodium polystyrene sulfonate... 36 SUTENT...... 19 saline flush zr...... 52 sodium thiosulfate...... 52 swabflush saline flush...... 52 salsalate...... 6 solifenacin succinate...... 39 syeda...... 45 SANDIMMUNE...... 48 SOLIRIS...... 26 SYMBICORT...... 56 SANTYL...... 34 SOLTAMOX...... 17 SYMFI...... 23 SAPHRIS...... 22 SOLU-CORTEF...... 42 SYMFI LO...... 23 sapropterin dihydrochloride...... 39 SOMATULINE DEPOT...... 47 SYMPROIC...... 37 SAVAYSA...... 27 SOMAVERT...... 47 SYNAGIS...... 49 SAVELLA...... 32 sorbitol...... 40 SYNAREL...... 47 SAVELLA TITRATION PACK... 32 sorbitol-mannitol...... 40 SYNJARDY...... 25 scopolamine...... 14 sorine...... 28 SYNJARDY XR...... 25 selegiline hcl...... 21 sotalol hcl...... 28, 29 SYNRIBO...... 18 selenium sulfide...... 34 sotalol hcl (af)...... 28 TABLOID...... 17 SELZENTRY...... 23 spinosad...... 20 tacrolimus...... 34, 48 SEREVENT DISKUS...... 57 SPIRIVA HANDIHALER...... 56 tadalafil...... 39 sertraline hcl...... 13 SPIRIVA RESPIMAT...... 56 tadalafil (pah)...... 57 se-tan plus...... 35 spironolactone...... 31 TAFINLAR...... 19 setlakin...... 45 spironolactone-hctz...... 30 TAGRISSO...... 19 sevelamer carbonate...... 36 sprintec 28...... 45 TALTZ...... 34 sevelamer hcl...... 36 SPRYCEL...... 19 tamoxifen citrate...... 17 sharobel...... 46 sps...... 36 tamsulosin hcl...... 39 SHINGRIX...... 50 sronyx...... 45 TARGRETIN...... 20 SIGNIFOR...... 47 ssd...... 9 tarina 24 fe...... 45 sildenafil citrate...... 57 ST JOSEPH LOW DOSE...... 6 tarina fe 1/20...... 45 silodosin...... 39 stavudine...... 23 tarina fe 1/20 eq...... 45 silver sulfadiazine...... 9 STELARA...... 34 TASIGNA...... 19 SIMBRINZA...... 54 sterile water for irrigation...... 52 tavaborole...... 15 simliya...... 45 STIOLTO RESPIMAT...... 56 tazarotene...... 34 simpesse...... 45 STIVARGA...... 19 tazicef...... 10 SIMPONI...... 48 STRENSIQ...... 39 TAZORAC...... 34 SIMPONI ARIA...... 48 streptomycin sulfate...... 8 taztia xt...... 29 simvastatin...... 31 STRIBILD...... 22 TDVAX...... 50 sirolimus...... 48 subvenite...... 12 TECENTRIQ...... 20 SIRTURO...... 16 subvenite starter kit-blue...... 12 TECFIDERA...... 33
72 TEGSEDI...... 39 tolmetin sodium...... 6 tri-lo-sprintec...... 45 telmisartan...... 28 tolterodine tartrate...... 39 trimethoprim...... 9 telmisartan-amlodipine...... 30 tolterodine tartrate er...... 39 tri-mili...... 45 telmisartan-hctz...... 30 topiramate...... 12 trimipramine maleate...... 14 temazepam...... 58 topiramate er...... 12 TRINTELLIX...... 13 TEMODAR...... 17 toposar...... 18 tri-nymyo...... 45 temozolomide...... 17 topotecan hcl...... 18 tri-previfem...... 45 temsirolimus...... 48 toremifene citrate...... 17 tri-sprintec...... 45 teniposide...... 18 torsemide...... 31 TRIUMEQ...... 23 TENIVAC...... 50 TOTECT...... 18 tri-vite/fluoride...... 36 tenofovir disoproxil fumarate.....23 TOUJEO MAX SOLOSTAR...... 26 trivora (28)...... 45 terazosin hcl...... 39 TOUJEO SOLOSTAR...... 26 tri-vylibra...... 45 terbinafine hcl...... 15 tovet...... 42 tri-vylibra lo...... 45 terconazole...... 15 TOVIAZ...... 39 TROGARZO...... 23 TERIPARATIDE TRACLEER...... 57 trospium chloride...... 39 (RECOMBINANT)...... 51 TRADJENTA...... 25 trospium chloride er...... 39 testosterone...... 43 tramadol hcl er...... 6 TRUE COMFORT PRO testosterone cypionate...... 42 tramadol hcl er (biphasic)...... 6 ALCOHOL PREP...... 52 testosterone enanthate...... 43 tramadol hcl ir...... 7 TRUE COMFORT PRO TETANUS-DIPHTHERIA tramadol-acetaminophen...... 7 INSULIN SYR...... 53 TOXOIDS TD...... 50 trandolapril...... 28 TRUE COMFORT PRO PEN tetrabenazine...... 32 trandolapril-verapamil hcl er...... 30 NEEDLES...... 53 tetracycline hcl...... 11 tranexamic acid...... 27 TRULICITY...... 25 TEXACORT...... 42 tranylcypromine sulfate...... 13 TRUMENBA...... 50 THALOMID...... 17 travoprost (bak free)...... 55 TRUVADA...... 23 THEO-24...... 57 TRAZIMERA...... 20 TUKYSA...... 19 theophylline...... 57 trazodone hcl...... 13 tulana...... 46 theophylline er...... 57 TRECATOR...... 16 TURALIO...... 19 theophylline in d5w...... 57 TRELEGY ELLIPTA...... 57, 58 TUZISTRA XR...... 58 thiamine hcl...... 36 TREMFYA...... 34 TWINRIX...... 50 thioridazine hcl...... 21 treprostinil...... 57 tyblume...... 45 thiothixene...... 21 TRESIBA...... 26 TYBOST...... 22 THROMBATE III...... 27 TRESIBA FLEXTOUCH...... 26 tydemy...... 45 THYMOGLOBULIN...... 49 tretinoin...... 20, 34 TYKERB...... 19 THYROGEN...... 52 tretinoin microsphere...... 34 TYSABRI...... 33 tiadylt er...... 29 tretinoin microsphere pump...... 34 TYVASO...... 57 tiagabine hcl...... 12 TREXALL...... 48 TYVASO REFILL...... 58 tilia fe...... 45 tri femynor...... 45 TYVASO STARTER...... 58 timolol maleate...... 29, 54 triamcinolone acetonide...... 33, 42 ULTIGUARD SAFEPACK timolol maleate pf...... 54 triamterene...... 31 SYR/NEEDLE...... 53 tinidazole...... 9 triamterene-hctz...... 30 ULTOMIRIS...... 49 TIVICAY...... 22 triazolam...... 24 unithroid...... 47 TIVICAY PD...... 22 triderm...... 42 UNITUXIN...... 20 tizanidine hcl...... 58 trientine hcl...... 36 UPTRAVI...... 58 tl-hem 150...... 35 tri-estarylla...... 45 urin ds...... 39 TOBRADEX...... 53 trifluoperazine hcl...... 21 ursodiol...... 37 TOBRADEX ST...... 53 trifluridine...... 53 valacyclovir hcl...... 22 tobramycin...... 53, 57 trihexyphenidyl hcl...... 20 valganciclovir hcl...... 22 tobramycin sulfate...... 8 tri-legest fe...... 45 valproate sodium...... 12 tobramycin-dexamethasone...... 53 tri-linyah...... 45 valproic acid...... 12 TOBREX...... 53 tri-lo-estarylla...... 45 valsartan...... 28 TODAY SPONGE...... 40 tri-lo-marzia...... 45 valsartan-hydrochlorothiazide... 30 tolcapone...... 20 tri-lo-mili...... 45 vancomycin hcl...... 9
73 vancomycin hcl in dextrose...... 9 vp-vite rx...... 37 zidovudine...... 23 vancomycin hcl in nacl...... 9 vyfemla...... 45 zileuton er...... 56 VANCOMYCIN HCL IN NACL.... 9 vylibra...... 45 ZIOPTAN...... 55 VAQTA...... 50 VYNDAMAX...... 30 ziprasidone hcl...... 22 VARIVAX...... 50 VYVANSE...... 32 ziprasidone mesylate...... 22 VAXELIS...... 50 VYXEOS...... 18 ZIRABEV...... 20 v-c forte...... 36 warfarin sodium...... 27 ZIRGAN...... 53 VCF VAGINAL water for irrigation, sterile...... 53 ZITHROMAX...... 11 CONTRACEPTIVE...... 40 wera...... 45 ZOKINVY...... 53 vcf vaginal contraceptive...... 40 westab mini...... 37 zoledronic acid...... 51 VELCADE...... 18 westab one...... 37 ZOLINZA...... 18 VELETRI...... 58 WIDE-SEAL DIAPHRAGM 60.. 53 ZOLMITRIPTAN...... 16 velivet...... 45 WIDE-SEAL DIAPHRAGM 65.. 53 zolmitriptan...... 16 VELTASSA...... 36 WIDE-SEAL DIAPHRAGM 70.. 53 zolpidem tartrate...... 58 VEMLIDY...... 22 WIDE-SEAL DIAPHRAGM 75.. 53 zolpidem tartrate er...... 58 VENCLEXTA...... 19 WIDE-SEAL DIAPHRAGM 80.. 53 ZOMIG...... 16 VENCLEXTA STARTING WIDE-SEAL DIAPHRAGM 85.. 53 zonisamide...... 11 PACK...... 19 WIDE-SEAL DIAPHRAGM 90.. 53 ZONTIVITY...... 27 venlafaxine hcl...... 13 WIDE-SEAL DIAPHRAGM 95.. 53 ZORTRESS...... 48 venlafaxine hcl er...... 14 WINRHO SDF...... 49 zovia 1/35 (28)...... 46 VENTAVIS...... 58 wixela inhub...... 56 zovia 1/35e (28)...... 46 VENTOLIN HFA...... 57 wymzya fe...... 45 zumandimine...... 46 verapamil hcl...... 29 XALKORI...... 19 ZYDELIG...... 19 verapamil hcl er...... 29 XARELTO...... 27 ZYKADIA...... 19 vestura...... 45 XARELTO STARTER PACK.....27 ZYPREXA RELPREVV...... 22 VICTOZA...... 25 XELJANZ...... 48 ZYVOX...... 9 vienva...... 45 XELJANZ XR...... 48 VIIBRYD...... 14 XGEVA...... 51 VIIBRYD STARTER PACK...... 14 XIAFLEX...... 53 VIMIZIM...... 39 XIFAXAN...... 9 VIMPAT...... 12 XIGDUO XR...... 25 vinblastine sulfate...... 18 XIIDRA...... 54 vincristine sulfate...... 18 XOLAIR...... 49 vinorelbine tartrate...... 18 XTAMPZA ER...... 6 viorele...... 45 XTANDI...... 17 VIRACEPT...... 23 xulane...... 45 VIREAD...... 23 XYNTHA...... 27 virt-caps...... 37 XYNTHA SOLOFUSE...... 27 virt-gard...... 37 YERVOY...... 20 virt-phos 250 neutral...... 35 yuvafem...... 45 VISTOGARD...... 53 zafemy...... 46 vita s forte...... 37 zafirlukast...... 56 vitacel...... 37 zaleplon...... 58 vita-min...... 37 ZALTRAP...... 18 vitamin d (ergocalciferol)...... 37 ZANOSAR...... 17 vitamin k1...... 37 zarah...... 46 vitamins acd-fluoride...... 37 ZELBORAF...... 19 VIVITROL...... 8 ZEMAIRA...... 39 volnea...... 45 zenatane...... 34 VONVENDI...... 27 ZENPEP...... 39 voriconazole...... 15 ZEPATIER...... 22 VOTRIENT...... 19 ZEPZELCA...... 17 vp-pnv-dha...... 37 ZERVIATE...... 54
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