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ADAP Quarterly NDC Special Review ADAP Formulary Report Current List Of Specified Drug Classes and Drugs Effective Between 04/01/2017 and 06/30/2017 DRUG CLASS DRUG NAME PRODUCT DESCRIPTION EFF DATE TERM DATE PA RQRD BRAND *ANDROGENS-ANABOLIC* Nandrolone Decanoate ANABOLIN LA INJ 100MG/ML 06/11/2010 12/31/2029 NO NO ANDROLONE-D INJ 100MG/ML 06/11/2010 12/31/2029 NO NO ANDROLONE-D INJ 200MG/ML 06/11/2010 12/31/2029 NO NO DECA-DURABOL INJ 100MG/ML 06/11/2010 12/31/2029 NO YES DECA-DURABOL INJ 200MG/ML 06/11/2010 12/31/2029 NO YES DECA-DURABOL INJ 50MG/ML 06/11/2010 12/31/2029 NO YES HYBOLIN DECA INJ 100MG/ML 06/11/2010 12/31/2029 NO NO HYBOLIN DECA INJ 50MG/ML 06/11/2010 12/31/2029 NO NO KABOLIN INJ 50MG/ML 06/11/2010 12/31/2029 NO NO NANDROL DEC INJ 100MG/ML 06/11/2010 12/31/2029 NO NO NANDROL DEC INJ 200MG/ML 06/11/2010 12/31/2029 NO NO NANDROL DEC INJ 50MG/ML 06/11/2010 12/31/2029 NO NO NANDROLATE INJ 100MG/ML 06/11/2010 12/31/2029 NO NO NANDROLATE INJ 50MG/ML 06/11/2010 12/31/2029 NO NO NEO-DURABOL INJ 200MG/ML 06/11/2010 12/31/2029 NO NO NEO-DURABOL INJ 50MG/ML 06/11/2010 12/31/2029 NO NO NEO-DURABOLI INJ 100MG/ML 06/11/2010 12/31/2029 NO NO Nandrolone Phenpropionate ANABOLIN INJ 50MG/ML 06/11/2010 12/31/2029 NO NO ANDROLONE INJ 25MG/ML 06/11/2010 12/31/2029 NO NO ANDROLONE 50 INJ 50MG/ML 06/11/2010 12/31/2029 NO NO DURABOLIN INJ 25MG/ML 06/11/2010 12/31/2029 NO YES DURABOLIN INJ 50MG/ML 06/11/2010 12/31/2029 NO YES HYBOLIN INJ 50MG/ML 06/11/2010 12/31/2029 NO NO HYBOLIN IMPR INJ 25MG/ML 06/11/2010 12/31/2029 NO NO HYBOLIN IMPR INJ 50MG/ML 06/11/2010 12/31/2029 NO YES NANDROBOLIC INJ 25MG/ML 06/11/2010 12/31/2029 NO NO NANDROL PHEN INJ 25MG/ML 06/11/2010 12/31/2029 NO NO NANDROL PHEN INJ 50MG/ML 06/11/2010 12/31/2029 NO NO Testosterone ANDRO 100 INJ 100MG/ML 06/11/2010 12/31/2029 NO NO ANDRODERM DIS 2.5MG/24 06/11/2010 12/31/2029 NO YES ANDRODERM DIS 4MG/24HR 06/11/2010 12/31/2029 NO YES ANDRODERM DIS 5MG/24HR 06/11/2010 12/31/2029 NO YES ANDROGEL GEL 1%(25MG) 06/11/2010 12/31/2029 NO YES ANDROGEL GEL 1%(50MG) 01/01/2012 12/31/2029 NO YES ANDROGEL GEL 1.62% 09/30/2011 12/31/2029 NO YES ANDROLAN INJ 100MG/ML 06/11/2010 12/31/2029 NO NO ANDROLAN INJ 25MG/ML 06/11/2010 12/31/2029 NO NO ANDROLAN INJ 50MG/ML 06/11/2010 12/31/2029 NO NO DURA TESTOST INJ 200/ML 06/11/2010 12/31/2029 NO YES HISTERONE INJ 100MG/ML 06/11/2010 12/31/2029 NO NO HISTERONE INJ 50MG/ML 06/11/2010 12/31/2029 NO NO SHOTEST 100 INJ 100MG/ML 06/11/2010 12/31/2029 NO NO SHOTEST 50 INJ 50MG/ML 06/11/2010 12/31/2029 NO NO STRIANT MIS 30MG 06/11/2010 12/31/2029 NO YES TESAMORE 100 INJ 100MG/ML 06/11/2010 12/31/2029 NO NO TESONE 100 INJ 100MG/ML 06/11/2010 12/31/2029 NO NO TESTIM GEL 1%(50MG) 01/01/2012 12/31/2029 NO YES TESTODERM DIS 4MG/24HR 06/11/2010 12/31/2029 NO YES TESTODERM DIS 6MG/24HR 06/11/2010 12/31/2029 NO YES TESTODERM DIS TTS 06/11/2010 12/31/2029 NO YES TESTOJECT-50 INJ 50MG/ML 06/11/2010 12/31/2029 NO NO RT18100 Saturday, July 8, 2017 Page 1 of 279 Confidentiality Notice: This report is for the sole use of the intended recipient(s) and may contain confidential and privileged information. Any unauthorized review, use, disclosure or distribution is strictly prohibited. ADAP Formulary Report Current List Of Specified Drug Classes and Drugs Effective Between 04/01/2017 and 06/30/2017 DRUG CLASS DRUG NAME PRODUCT DESCRIPTION EFF DATE TERM DATE PA RQRD BRAND *ANDROGENS-ANABOLIC* Testosterone TESTOLIN INJ 100MG/ML 06/11/2010 12/31/2029 NO NO TESTONE POW 06/11/2010 12/31/2029 NO NO TESTONE/AQ INJ 100MG/ML 06/11/2010 12/31/2029 NO NO TESTONE/AQ INJ 50MG/ML 06/11/2010 12/31/2029 NO NO TESTOPEL MIS PELLETS 06/11/2010 12/31/2029 NO YES TESTOSTERONE GEL 1%(50MG) 01/01/2012 12/31/2029 NO YES TESTOSTERONE INJ 100MG/ML 06/11/2010 12/31/2029 NO NO TESTOSTERONE INJ 25MG/ML 06/11/2010 12/31/2029 NO NO TESTOSTERONE INJ 50MG/ML 06/11/2010 12/31/2029 NO NO TESTOSTERONE POW 06/11/2010 12/31/2029 NO YES TESTOSTERONE POW MICRONIZ 06/11/2010 12/31/2029 NO YES TESTRO INJ 100MG/ML 06/11/2010 12/31/2029 NO NO TESTRO INJ 50MG/ML 06/11/2010 12/31/2029 NO NO VOGELXO GEL 1%(50MG) 01/01/2012 12/31/2029 NO YES Testosterone Cypionate ANDRO-CYP200 INJ 200MG/ML 06/11/2010 12/31/2029 NO NO DEPANDRO 200 INJ 200MG/ML 06/11/2010 12/31/2029 NO NO DEPOTEST INJ 200MG/ML 06/11/2010 12/31/2029 NO NO DEPO-TESTOST INJ 200MG/ML 06/11/2010 12/31/2029 NO YES D-TES 200 INJ 200MG/ML 06/11/2010 12/31/2029 NO NO DURATEST INJ 200MG/ML 06/11/2010 12/31/2029 NO NO LA TEST 200 INJ 200MG/ML 06/11/2010 12/31/2029 NO NO RU-ANDROSPAN INJ 200MG/ML 06/11/2010 12/31/2029 NO NO TESTOJECT LA INJ 200MG/ML 06/11/2010 12/31/2029 NO NO TESTONE/CYP INJ 200MG/ML 06/11/2010 12/31/2029 NO YES TESTOST CYP INJ 200MG/ML 06/11/2010 12/31/2029 NO NO TESTRED INJ 200MG/ML 06/11/2010 12/31/2029 NO NO VIRILON INJ 200MG/ML 06/11/2010 12/31/2029 NO NO *ANORECTAL AGENTS* Benzocaine (Rectal) AMERICAINE OIN 20% 07/01/2007 12/31/2029 NO YES ANOCAINE SUP 07/01/2007 12/31/2029 NO YES BISCOLAN SUP 07/01/2007 12/31/2029 NO NO HEMET HEMORR SUP 07/01/2007 12/31/2029 NO NO MEDICONE OIN 07/01/2007 12/31/2029 NO NO MEDICONE SUP 07/01/2007 12/31/2029 NO NO MEDICONE SUP 130MG 07/01/2007 12/31/2029 NO YES MEDICONE REC OIN 07/01/2007 12/31/2029 NO YES MEDICONE REC SUP 07/01/2007 12/31/2029 NO YES Benzocaine-Benzethonium (Rectal) AMERICAINE OIN 20% 07/01/2007 12/31/2029 NO YES Benzocaine-Ephedrine HEMOCAINE OIN 07/01/2007 12/31/2029 NO YES PAZO OIN 07/01/2007 12/31/2029 NO YES PAZO SUP 07/01/2007 12/31/2029 NO YES Benzocaine-Phenylephrine RECTAGENE SUP 07/01/2007 12/31/2029 NO YES Benz-Pyril-Phenyleph-Bismuth Subgallate-Zinc Oxide RECTAGENE OIN 07/01/2007 12/31/2029 NO NO Budesonide (Intrarectal) UCERIS AER 2MG/ACT 07/01/2007 12/31/2029 NO YES Calamine-Zinc Oxide (Rectal) VERSAL SUP HEMORRHO 07/01/2007 12/31/2029 NO YES Camphor-Phenol-Tannic Acid-Zinc Oxide (Rectal) MEDICONE OIN MAX ST 07/01/2007 12/31/2029 NO YES PETERSONS OIN HEMORRH 07/01/2007 12/31/2029 NO YES Cocoa Butter-Shark Liver Oil HCA HEMORRHO SUP 79-3% 07/01/2007 12/31/2029 NO NO HEMOR AID SUP 07/01/2007 12/31/2029 NO NO HEMORRHOID SUP PREP 07/01/2007 12/31/2029 NO NO HEMORRHOIDAL SUP 07/01/2007 12/31/2029 NO YES HEMORRHOIDAL SUP H 07/01/2007 12/31/2029 NO NO RT18100 Saturday, July 8, 2017 Page 2 of 279 Confidentiality Notice: This report is for the sole use of the intended recipient(s) and may contain confidential and privileged information. Any unauthorized review, use, disclosure or distribution is strictly prohibited. ADAP Formulary Report Current List Of Specified Drug Classes and Drugs Effective Between 04/01/2017 and 06/30/2017 DRUG CLASS DRUG NAME PRODUCT DESCRIPTION EFF DATE TERM DATE PA RQRD BRAND *ANORECTAL AGENTS* Cocoa Butter-Shark Liver Oil HEMORRHOIDAL SUP PREP 07/01/2007 12/31/2029 NO NO HEMORROID SUP 3% 07/01/2007 12/31/2029 NO YES OSCO HEMORRH SUP 3% 07/01/2007 12/31/2029 NO NO PREPARATION SUP H 07/01/2007 12/31/2029 NO YES PROMPT RELIE SUP 07/01/2007 12/31/2029 NO NO SAV-ON HEMOR SUP 07/01/2007 12/31/2029 NO NO WYANOIDS REL SUP FACTOR 07/01/2007 12/31/2029 NO YES Dibucaine (Rectal) DIBUCAINE OIN 1% 07/01/2007 12/31/2029 NO NO HEMMORHOIDAL OIN & TOP 1% 07/01/2007 12/31/2029 NO NO NUPERCAINAL OIN 1% 07/01/2007 12/31/2029 NO YES RECTACAINE OIN 1% 07/01/2007 12/31/2029 NO NO Diperodon HCl (Rectal) HEMORRHOID OIN 07/01/2007 12/31/2029 NO NO RECTOLATUM OIN 07/01/2007 12/31/2029 NO NO Diperodon-Pyrilamine-Phenylephrine EMEROID CRE 07/01/2007 12/31/2029 NO YES HEMET HEMORR OIN 07/01/2007 12/31/2029 NO NO RECTAL OIN 07/01/2007 12/31/2029 NO YES Ephedrine & Belladonna WYANOID SUP 07/01/2007 12/31/2029 NO YES Hamamelis Water-Glycerin TUCKS CLEAR GEL 07/01/2007 12/31/2029 NO YES Hydrocortisone (Intrarectal) COLOCORT ENE 100MG 07/01/2007 12/31/2029 NO NO CORTENEMA ENE 100MG 07/01/2007 12/31/2029 NO YES HYDROCORT ENE 100MG 07/01/2007 12/31/2029 NO NO Hydrocortisone (Rectal) ANUSOL-HC CRE 2.5% 07/01/2007 12/31/2029 NO YES HEMORRHOIDAL CRE HC 2.5% 07/01/2007 12/31/2029 NO NO HEMORRHOIDAL CRE -HC 2.5% 07/01/2007 12/31/2029 NO NO HYDROCORT CRE 1% 07/01/2007 12/31/2029 NO NO HYDROCORT CRE 2.5% 07/01/2007 12/31/2029 NO NO HYDROCORTISO CRE 2.5% 07/01/2007 12/31/2029 NO NO PROCTOCARE CRE -HC 2.5% 07/01/2007 12/31/2029 NO NO PROCTOCORT CRE 1% 07/01/2007 12/31/2029 NO YES PROCTOCREAM CRE HC 2.5% 07/01/2007 12/31/2029 NO NO PROCTOCREAM CRE -HC 2.5% 07/01/2007 12/31/2029 NO NO PROCTO-KIT CRE 2.5% 07/01/2007 12/31/2029 NO NO PROCTO-MED CRE HC 2.5% 07/01/2007 12/31/2029 NO NO PROCTO-PAK CRE 1% 07/01/2007 12/31/2029 NO NO PROCTOSOL HC CRE 2.5% 07/01/2007 12/31/2029 NO NO PROCTOZONE CRE -HC 2.5% 07/01/2007 12/31/2029 NO NO Hydrocortisone Ace-Pramoxine-Dietary Manage Prod-Cleans Wipe ANALPRAM KIT ADVANCED 07/01/2007 12/31/2029 NO YES Hydrocortisone Acetate (Intrarectal) CORTIFOAM AER 90MG 07/01/2007 12/31/2029 NO YES Hydrocortisone Acetate (Rectal) ANUCORT-HC SUP 10MG 07/01/2007 12/31/2029 NO NO ANUCORT-HC SUP 25MG 07/01/2007 12/31/2029 NO NO ANUGARD-HC SUP 07/01/2007 12/31/2029 NO NO ANU-MED HC SUP 25MG 07/01/2007 12/31/2029 NO NO ANUMED-HC SUP 25MG 07/01/2007 12/31/2029 NO NO ANU-MED-HC SUP 10MG 07/01/2007 12/31/2029 NO NO ANUPREP-HC SUP 10MG 07/01/2007 12/31/2029 NO NO ANUPREP-HC SUP 25MG 07/01/2007 12/31/2029 NO NO ANURX-HC SUP 25MG 07/01/2007 12/31/2029 NO NO ANUSOL-HC CRE 0.5% 07/01/2007 12/31/2029 NO YES ANUSOL-HC CRE 1% 07/01/2007 12/31/2029 NO YES ANUSOL-HC SUP 10MG 07/01/2007 12/31/2029 NO YES ANUSOL-HC SUP 25MG 07/01/2007 12/31/2029 NO NO RT18100 Saturday, July 8, 2017 Page 3 of 279 Confidentiality Notice: This report is for the sole use of the intended recipient(s) and may contain confidential and privileged information.
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