National Preferred Formulary January 2021
How to Use the Formulary The Formulary is a list of medications available to members under their pharmacy benefit. All drugs are listed by their generic names or most common proprietary (branded) name. Any drugs not found in this formulary listing or any formulary updates published by Express Scripts are considered non-formulary drugs and require prior authorization.
All drugs are listed in each category in alphabetical order by generic or brand name. If the generic drug is FDA approved, it will appear italicized in the formulary listing. Covered brand drugs appear in CAPITALIZED font.
Benefit Coverage and Limitations The Formulary applies only to outpatient drugs provided to members and does not apply to medications used in inpatient settings. If a member has any specific questions regarding their coverage, they should contact Wellfleet or Express Scripts at the phone numbers listed on their ID card.
Excluded Agents Any drugs not listed in this print formulary are considered excluded from the drug benefit and are not covered. As new drugs become available, they will be considered for coverage under the Formulary.
Non-Formulary and Step Therapy Exception Requests A member (or their appointed representative, prescribing physician, or authorized prescriber) may request a standard/non-urgent or expedited/urgent preservice/prior and current authorization for a drug that is subjected to utilization management tools such as step therapy. To initiate an exception request, contact 800-417-8164. Prior authorization guidelines will be made available to the member, member’s authorization representative, prescribing physician and other authorized prescriber upon request.
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Table of Contents
ANTI - INFECTIVES ...... 3 ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ...... 22 AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH ...... 36 CARDIOVASCULAR, HYPERTENSION / LIPIDS ...... 65 DERMATOLOGICALS/TOPICAL THERAPY ...... 85 DIAGNOSTICS / MISCELLANEOUS AGENTS ...... 102 EAR, NOSE / THROAT MEDICATIONS ...... 113 ENDOCRINE/DIABETES ...... 115 GASTROENTEROLOGY ...... 151 IMMUNOLOGY, VACCINES / BIOTECHNOLOGY ...... 161 MUSCULOSKELETAL / RHEUMATOLOGY ...... 170 OBSTETRICS / GYNECOLOGY ...... 173 OPHTHALMOLOGY ...... 185 RESPIRATORY AND ALLERGY ...... 191 UROLOGICALS ...... 202 VITAMINS, HEMATINICS / ELECTROLYTES ...... 204 Index ...... 224
1 List of Abbreviations
ACA: Affordable Care Act.
OTC: Over the Counter. An OTC drug is a non-prescription drug.
PA: Prior Authorization. The Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval before you fill your prescriptions. If you don’t get approval, we may not cover the drug.
QL: Quantity Limit. For certain drugs, the Plan limits the amount of the drug that we will cover.
SP: Specialty
ST: Step Therapy. In some cases, the Plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B.
2 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits ANTI - INFECTIVES fluconazole in nacl 1 PA (iso-osm) ANTIFUNGAL AGENTS intravenous ABELCET 2 piggyback 100 INTRAVENOUS mg/50 ml, 200 SUSPENSION 5 mg/100 ml, 400 MG/ML mg/200 ml AMBISOME 2 fluconazole oral 1 INTRAVENOUS suspension for SUSPENSION FOR reconstitution 10 RECONSTITUTIO mg/ml, 40 mg/ml N 50 MG fluconazole oral 1 AMPHOTERICIN B 2 tablet 100 mg, 200 (BULK) POWDER mg, 50 mg amphotericin b 1 fluconazole oral 1 QL injection recon soln tablet 150 mg 50 mg FLUCYTOSINE 2 caspofungin 1 (BULK) POWDER intravenous recon 100 % soln 50 mg, 70 mg flucytosine oral 1 clotrimazole mucous 1 capsule 250 mg, 500 membrane troche 10 mg mg griseofulvin 1 CRESEMBA 2 PA microsize oral INTRAVENOUS suspension 125 mg/5 RECON SOLN 372 ml MG griseofulvin 1 CRESEMBA ORAL 2 PA microsize oral tablet CAPSULE 186 MG 500 mg ERAXIS(WATER 2 griseofulvin 1 DILUENT) ultramicrosize oral INTRAVENOUS tablet 125 mg, 250 RECON SOLN 100 mg MG, 50 MG ITRACONAZOLE 2 FLUCONAZOLE 2 (BULK) POWDER (BULK) POWDER itraconazole oral 1 QL 100 % capsule 100 mg itraconazole oral 1 solution 10 mg/ml
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 3 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits KETOCONAZOLE 2 posaconazole oral 1 PA (BULK) POWDER tablet,delayed release (dr/ec) 100 ketoconazole oral 1 mg tablet 200 mg TERBINAFINE 2 micafungin 1 (BULK) POWDER intravenous recon 100 % soln 100 mg, 50 mg terbinafine hcl oral 1 MICONAZOLE 2 tablet 250 mg (BULK) POWDER VORICONAZOLE 2 MYCAMINE 2 (BULK) POWDER INTRAVENOUS 100 % RECON SOLN 100 MG, 50 MG voriconazole 1 PA intravenous recon NOXAFIL 2 PA soln 200 mg INTRAVENOUS SOLUTION 300 voriconazole oral 1 PA MG/16.7 ML suspension for reconstitution 200 NOXAFIL ORAL 2 PA mg/5 ml (40 mg/ml) SUSPENSION 200 MG/5 ML (40 voriconazole oral 1 PA MG/ML) tablet 200 mg, 50 mg NYSTATIN 2 ANTIVIRALS (BULK) POWDER abacavir oral 1 SP 1 BILLION UNIT, 1 solution 20 mg/ml MILLION UNIT, 10 BILLION UNIT, 15 abacavir oral tablet 1 SP BILLION UNIT, 300 mg 150 MILLION abacavir-lamivudine 1 SP UNIT, 2 BILLION oral tablet 600-300 UNIT, 5 BILLION mg UNIT, 50 MILLION UNIT, 500 abacavir- 1 SP MILLION UNIT lamivudine- zidovudine oral nystatin oral 1 tablet 300-150-300 suspension 100,000 mg unit/ml ACYCLOVIR 2 nystatin oral tablet 1 (BULK) POWDER 500,000 unit 100 % acyclovir oral 1 capsule 200 mg
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 4 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits acyclovir oral 1 cidofovir 1 suspension 200 mg/5 intravenous solution ml 75 mg/ml acyclovir oral tablet 1 CIMDUO ORAL 2 SP 400 mg, 800 mg TABLET 300-300 MG acyclovir sodium 1 intravenous recon CRIXIVAN ORAL 2 SP soln 1,000 mg, 500 CAPSULE 200 MG mg DESCOVY ORAL 2 SP acyclovir sodium 1 TABLET 200-25 intravenous solution MG 50 mg/ml didanosine oral 1 SP adefovir oral tablet 1 capsule,delayed 10 mg release(dr/ec) 250 mg, 400 mg AMANTADINE 2 HCL (BULK) DOVATO ORAL 2 SP POWDER TABLET 50-300 MG amantadine hcl oral 1 capsule 100 mg EDURANT ORAL 2 SP TABLET 25 MG amantadine hcl oral 1 solution 50 mg/5 ml efavirenz oral 1 SP capsule 200 mg, 50 amantadine hcl oral 1 mg tablet 100 mg efavirenz oral tablet 1 SP APTIVUS (WITH 2 SP 600 mg VITAMIN E) ORAL SOLUTION 100 efavirenz- 1 SP MG/ML emtricitabin-tenofov oral tablet 600-200- APTIVUS ORAL 2 SP 300 mg CAPSULE 250 MG efavirenz-lamivu- 1 SP atazanavir oral 1 SP tenofov disop oral capsule 150 mg, 200 tablet 400-300-300 mg, 300 mg mg, 600-300-300 mg BARACLUDE 2 emtricitabine oral 1 SP ORAL SOLUTION capsule 200 mg 0.05 MG/ML emtricitabine- 1 SP; ACA BIKTARVY ORAL 2 SP tenofovir (tdf) oral TABLET 50-200-25 tablet 200-300 mg MG
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 5 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits EMTRIVA ORAL 2 SP INTELENCE ORAL 2 SP SOLUTION 10 TABLET 100 MG, MG/ML 200 MG, 25 MG entecavir oral tablet 1 INVIRASE ORAL 2 SP 0.5 mg, 1 mg TABLET 500 MG EPCLUSA ORAL 2 PA; SP; QL ISENTRESS HD 2 SP TABLET 200-50 ORAL TABLET MG, 400-100 MG 600 MG EPIVIR HBV 2 ISENTRESS ORAL 2 SP ORAL SOLUTION POWDER IN 25 MG/5 ML (5 PACKET 100 MG MG/ML) ISENTRESS ORAL 2 SP famciclovir oral 1 QL TABLET 400 MG tablet 125 mg, 250 ISENTRESS ORAL 2 SP mg, 500 mg TABLET,CHEWAB fosamprenavir oral 1 SP LE 100 MG, 25 MG tablet 700 mg JULUCA ORAL 2 SP FUZEON 2 SP TABLET 50-25 MG SUBCUTANEOUS KALETRA ORAL 2 SP; QL RECON SOLN 90 TABLET 100-25 MG MG, 200-50 MG ganciclovir sodium 1 lamivudine oral 1 SP intravenous recon solution 10 mg/ml soln 500 mg lamivudine oral 1 ganciclovir sodium 1 tablet 100 mg intravenous solution 50 mg/ml lamivudine oral 1 SP tablet 150 mg, 300 GENVOYA ORAL 2 SP mg TABLET 150-150- 200-10 MG lamivudine- 1 SP zidovudine oral HARVONI ORAL 2 PA; SP; QL tablet 150-300 mg PELLETS IN PACKET 33.75-150 LEXIVA ORAL 2 SP MG, 45-200 MG SUSPENSION 50 MG/ML HARVONI ORAL 2 PA; SP; QL TABLET 45-200 lopinavir-ritonavir 1 SP; QL MG, 90-400 MG oral solution 400- 100 mg/5 ml IDOXURIDINE 2 (BULK) POWDER 100 % You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 6 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits nevirapine oral 1 SP RAPIVAB (PF) 2 suspension 50 mg/5 INTRAVENOUS ml SOLUTION 200 MG/20 ML (10 nevirapine oral 1 SP MG/ML) tablet 200 mg RETROVIR 2 SP nevirapine oral 1 SP INTRAVENOUS tablet extended SOLUTION 10 release 24 hr 100 MG/ML mg, 400 mg REYATAZ ORAL 2 SP NORVIR ORAL 2 SP POWDER IN POWDER IN PACKET 50 MG PACKET 100 MG ribavirin inhalation 1 NORVIR ORAL 2 SP recon soln 6 gram SOLUTION 80 MG/ML ribavirin oral 1 ST; SP capsule 200 mg ODEFSEY ORAL 2 SP TABLET 200-25-25 ribavirin oral tablet 1 ST; SP MG 200 mg oseltamivir oral 1 QL rimantadine oral 1 capsule 30 mg, 45 tablet 100 mg mg, 75 mg ritonavir oral tablet 1 SP oseltamivir oral 1 QL 100 mg suspension for SELZENTRY 2 SP reconstitution 6 ORAL SOLUTION mg/ml 20 MG/ML PREVYMIS 2 SELZENTRY 2 SP INTRAVENOUS ORAL TABLET SOLUTION 240 150 MG, 25 MG, MG/12 ML, 480 300 MG, 75 MG MG/24 ML stavudine oral 1 SP PREVYMIS ORAL 2 QL capsule 15 mg, 20 TABLET 240 MG, mg, 30 mg, 40 mg 480 MG SYMFI LO ORAL 2 SP PREZISTA ORAL 2 SP TABLET 400-300- SUSPENSION 100 300 MG MG/ML SYMFI ORAL 2 SP PREZISTA ORAL 2 SP TABLET 600-300- TABLET 150 MG, 300 MG 600 MG, 75 MG, 800 MG
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 7 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits SYMTUZA ORAL 2 SP valganciclovir oral 1 TABLET 800-150- recon soln 50 mg/ml 200-10 MG valganciclovir oral 1 SYNAGIS 2 PA; SP tablet 450 mg INTRAMUSCULA VEMLIDY ORAL 2 R SOLUTION 100 TABLET 25 MG MG/ML, 50 MG/0.5 ML VIRACEPT ORAL 2 SP TABLET 250 MG, TEMIXYS ORAL 2 SP 625 MG TABLET 300-300 MG VIREAD ORAL 2 SP POWDER 40 tenofovir disoproxil 1 SP MG/SCOOP (40 fumarate oral tablet MG/GRAM) 300 mg VIREAD ORAL 2 SP TIVICAY ORAL 2 SP TABLET 150 MG, TABLET 10 MG, 25 200 MG, 250 MG MG, 50 MG VOSEVI ORAL 2 PA; SP; QL TIVICAY PD 2 SP TABLET 400-100- ORAL TABLET 100 MG FOR SUSPENSION 5 MG ZEPATIER ORAL 2 PA; SP; QL TABLET 50-100 TRIUMEQ ORAL 2 SP MG TABLET 600-50- 300 MG zidovudine oral 1 SP capsule 100 mg TROGARZO 2 PA; SP INTRAVENOUS zidovudine oral 1 SP SOLUTION 200 syrup 10 mg/ml MG/1.33 ML (150 zidovudine oral 1 SP MG/ML) tablet 300 mg TRUVADA ORAL 2 SP CEPHALOSPORINS TABLET 100-150 MG, 133-200 MG, AVYCAZ 2 ST 167-250 MG, 200- INTRAVENOUS 300 MG RECON SOLN 2.5 GRAM VALACYCLOVIR 2 (BULK) POWDER cefaclor oral capsule 1 100 % 250 mg, 500 mg valacyclovir oral 1 QL tablet 1 gram, 500 mg
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 8 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits cefaclor oral 1 cefepime in 1 ST suspension for dextrose,iso-osm reconstitution 125 intravenous mg/5 ml, 250 mg/5 piggyback 1 gram/50 ml, 375 mg/5 ml ml, 2 gram/100 ml cefaclor oral tablet 1 cefepime injection 1 ST extended release 12 recon soln 1 gram, 2 hr 500 mg gram cefadroxil oral 1 cefixime oral 1 capsule 500 mg capsule 400 mg cefadroxil oral 1 cefixime oral 1 suspension for suspension for reconstitution 250 reconstitution 100 mg/5 ml, 500 mg/5 mg/5 ml, 200 mg/5 ml ml cefadroxil oral tablet 1 cefotaxime injection 1 ST 1 gram recon soln 1 gram cefazolin in dextrose 1 ST cefotetan injection 1 ST (iso-os) intravenous recon soln 1 gram, 2 piggyback 1 gram/50 gram ml, 2 gram/50 ml cefotetan 1 ST cefazolin injection 1 ST intravenous recon recon soln 1 gram, soln 10 gram 10 gram, 100 gram, cefoxitin in dextrose, 1 ST 20 gram, 300 g, 500 iso-osm intravenous mg piggyback 1 gram/50 cefazolin 1 ST ml, 2 gram/50 ml intravenous recon cefoxitin intravenous 1 ST soln 1 gram recon soln 1 gram, cefdinir oral capsule 1 10 gram, 2 gram 300 mg cefpodoxime oral 1 cefdinir oral 1 suspension for suspension for reconstitution 100 reconstitution 125 mg/5 ml, 50 mg/5 ml mg/5 ml, 250 mg/5 cefpodoxime oral 1 ml tablet 100 mg, 200 cefditoren pivoxil 1 mg oral tablet 200 mg, 400 mg
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 9 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits cefprozil oral 1 cefuroxime sodium 1 ST suspension for intravenous recon reconstitution 125 soln 1.5 gram, 7.5 mg/5 ml, 250 mg/5 gram ml cephalexin oral 1 cefprozil oral tablet 1 capsule 250 mg, 500 250 mg, 500 mg mg, 750 mg CEFTAZIDIME 2 cephalexin oral 1 (BULK) POWDER suspension for 100 % reconstitution 125 mg/5 ml, 250 mg/5 CEFTAZIDIME IN 2 ST ml D5W INTRAVENOUS cephalexin oral 1 PIGGYBACK 1 tablet 250 mg, 500 GRAM/50 ML, 2 mg GRAM/50 ML tazicef injection 1 ST ceftazidime injection 1 ST recon soln 1 gram, 2 recon soln 1 gram, 2 gram, 6 gram gram, 6 gram tazicef intravenous 1 ST ceftriaxone in 1 ST recon soln 1 gram, 2 dextrose,iso-os gram intravenous TEFLARO 2 ST piggyback 1 gram/50 INTRAVENOUS ml, 2 gram/50 ml RECON SOLN 400 ceftriaxone injection 1 ST MG, 600 MG recon soln 1 gram, ZERBAXA 2 ST 10 gram, 2 gram, INTRAVENOUS 250 mg, 500 mg RECON SOLN 1.5 ceftriaxone 1 ST GRAM intravenous recon ERYTHROMYCINS / OTHER soln 1 gram, 2 gram MACROLIDES CEFTRIAXONE 2 SODIUM (BULK) AZITHROMYCIN 2 POWDER (BULK) POWDER 100 % cefuroxime axetil 1 oral tablet 250 mg, azithromycin 1 ST 500 mg intravenous recon soln 500 mg cefuroxime sodium 1 ST injection recon soln azithromycin oral 1 QL 750 mg packet 1 gram
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 10 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits azithromycin oral 1 QL ERYTHROMYCIN 2 suspension for ESTOLATE reconstitution 100 (BULK) POWDER mg/5 ml, 200 mg/5 100 % ml ERYTHROMYCIN 2 azithromycin oral 1 QL ETHYLSUCCIN(B tablet 250 mg, 500 ULK) POWDER mg, 600 mg erythromycin 1 CLARITHROMYCI 2 ethylsuccinate oral N (BULK) suspension for POWDER 100 % reconstitution 200 mg/5 ml, 400 mg/5 clarithromycin oral 1 ml suspension for reconstitution 125 erythromycin 1 mg/5 ml, 250 mg/5 ethylsuccinate oral ml tablet 400 mg clarithromycin oral 1 erythromycin oral 1 tablet 250 mg, 500 capsule,delayed mg release(dr/ec) 250 mg clarithromycin oral 1 tablet extended erythromycin oral 1 release 24 hr 500 mg tablet 250 mg, 500 mg e.e.s. 400 oral tablet 1 400 mg erythromycin oral 1 tablet,delayed ery-tab oral 1 release (dr/ec) 250 tablet,delayed mg, 333 mg, 500 mg release (dr/ec) 250 mg, 333 mg MISCELLANEOUS
erythrocin (as 1 ANTIINFECTIVES stearate) oral tablet ALBENDAZOLE 2 250 mg (BULK) POWDER ERYTHROCIN 2 ST 100 % INTRAVENOUS albendazole oral 1 QL RECON SOLN tablet 200 mg 1,000 MG, 500 MG ALINIA ORAL 2 QL ERYTHROMYCIN 2 SUSPENSION FOR (BULK) POWDER RECONSTITUTIO N 100 MG/5 ML ALINIA ORAL 2 QL TABLET 500 MG
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 11 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits amikacin injection 1 ST BENZNIDAZOLE 2 QL solution 1,000 mg/4 ORAL TABLET ml, 500 mg/2 ml 100 MG, 12.5 MG AMIKACIN 2 BETHKIS 2 PA; SP; QL SULFATE (BULK) INHALATION POWDER SOLUTION FOR NEBULIZATION AMINOSALICYLA 2 300 MG/4 ML TE SODIUM (BULK) POWDER CAPASTAT 2 100 % INJECTION RECON SOLN 1 AMINOSALICYLI 2 GRAM C ACID (BULK) POWDER CAYSTON 2 PA; SP; QL INHALATION ARIKAYCE 2 PA; SP SOLUTION FOR INHALATION NEBULIZATION SUSPENSION FOR 75 MG/ML NEBULIZATION 590 MG/8.4 ML CHLORAMPHENI 2 COL (BULK) atovaquone oral 1 POWDER 100 % suspension 750 mg/5 ml CHLORAMPHENI 2 COL atovaquone- 1 QL PALMITAT(BULK) proguanil oral tablet POWDER 250-100 mg, 62.5-25 mg chloramphenicol sod 1 succinate aztreonam injection 1 ST intravenous recon recon soln 1 gram, 2 soln 1 gram gram CHLOROQUINE 2 bacitracin (bulk) 1 PHOSPHATE powder 5 million (BULK) POWDER unit chloroquine 1 QL bacitracin 1 phosphate oral intramuscular recon tablet 250 mg, 500 soln 50,000 unit mg BACITRACIN, 2 CLINDAMYCIN 2 MICRONIZED HCL (BULK) (BULK) POWDER POWDER 100 % clindamycin hcl oral 1 capsule 150 mg, 300 mg, 75 mg You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 12 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits clindamycin in 5 % 1 ST DALVANCE 2 ST dextrose intravenous INTRAVENOUS piggyback 300 SOLUTION 500 mg/50 ml, 600 mg/50 MG ml, 900 mg/50 ml DAPSONE (BULK) 2 clindamycin 1 POWDER 98 % pediatric oral recon dapsone oral tablet 1 soln 75 mg/5 ml 100 mg, 25 mg CLINDAMYCIN 2 daptomycin 1 ST PHOSPHATE intravenous recon (BULK) soln 500 mg CRYSTALS EMVERM ORAL 2 QL CLINDAMYCIN 2 TABLET,CHEWAB PHOSPHATE LE 100 MG (BULK) POWDER ertapenem injection 1 ST clindamycin 1 ST recon soln 1 gram phosphate injection solution 150 mg/ml ethambutol oral 1 tablet 100 mg, 400 CLIOQUINOL 2 mg (BULK) POWDER FURAZOLIDONE 2 CLOFAZIMINE 2 (BULK) POWDER (BULK) POWDER 100 % COARTEM ORAL 2 QL GENTAMICIN 2 TABLET 20-120 (BULK) POWDER MG 590 MCG/MG COLISTIMETHAT 2 gentamicin in nacl 1 ST E SODIUM (BULK) (iso-osm) POWDER 390 intravenous MCG/MG piggyback 100 colistin 1 ST mg/100 ml, 60 mg/50 (colistimethate na) ml, 70 mg/50 ml, 80 injection recon soln mg/100 ml, 80 mg/50 150 mg ml, 90 mg/100 ml COLISTIN 2 GENTAMICIN IN 2 ST SULFATE (BULK) NACL (ISO-OSM) POWDER 1 INTRAVENOUS BILLION UNIT PIGGYBACK 100 MG/50 ML CYCLOSERINE 2 (BULK) POWDER
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 13 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits gentamicin injection 1 ST KITABIS PAK 2 PA; SP; QL solution 20 mg/2 ml, INHALATION 40 mg/ml SOLUTION FOR NEBULIZATION gentamicin sulfate 1 ST 300 MG/5 ML (ped) (pf) injection solution 20 mg/2 ml LINCOMYCIN 2 HCL (BULK) gentamicin sulfate 1 ST POWDER (pf) intravenous solution 100 mg/10 lincomycin injection 1 ST ml solution 300 mg/ml hydroxychloroquine 1 QL linezolid in dextrose 1 ST oral tablet 200 mg 5% intravenous piggyback 600 HYDROXYCHLOR 2 mg/300 ml OQUINE SULF (BULK) POWDER linezolid oral 1 PA suspension for imipenem-cilastatin 1 ST reconstitution 100 intravenous recon mg/5 ml soln 250 mg, 500 mg linezolid oral tablet 1 PA IMPAVIDO ORAL 2 PA; QL 600 mg CAPSULE 50 MG linezolid-0.9% 1 ST IODOQUINOL 2 sodium chloride (BULK) POWDER intravenous 100 % parenteral solution ISONIAZID 2 600 mg/300 ml (BULK) POWDER MEBENDAZOLE 2 isoniazid injection 1 (BULK) POWDER solution 100 mg/ml mefloquine oral 1 QL isoniazid oral 1 tablet 250 mg solution 50 mg/5 ml meropenem 1 ST isoniazid oral tablet 1 intravenous recon 100 mg, 300 mg soln 1 gram, 500 mg IVERMECTIN 2 MEROPENEM- 2 ST (BULK) POWDER 0.9% SODIUM ivermectin oral 1 QL CHLORIDE tablet 3 mg INTRAVENOUS PIGGYBACK 1 KANAMYCIN 2 GRAM/50 ML, 500 (BULK) POWDER MG/50 ML
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 14 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits metro i.v. 1 ST pentamidine 1 QL intravenous inhalation recon piggyback 500 soln 300 mg mg/100 ml pentamidine 1 METRONIDAZOL 2 injection recon soln E (BULK) 300 mg POWDER POLYMYXIN B 2 METRONIDAZOL 2 SULF,MICRON.(B E BENZOATE ULK) POWDER (BULK) POWDER 100 MILLION UNIT, 50 MILLION metronidazole in 1 ST UNIT, 6,000 nacl (iso-os) UNIT/MG intravenous piggyback 500 polymyxin b sulfate 1 ST mg/100 ml injection recon soln 500,000 unit metronidazole oral 1 capsule 375 mg PRAZIQUANTEL 2 (BULK) POWDER metronidazole oral 1 98.5-101 % tablet 250 mg, 500 mg praziquantel oral 1 tablet 600 mg neomycin oral tablet 1 500 mg PRIFTIN ORAL 2 TABLET 150 MG NEOMYCIN 2 SULFATE (BULK) PRIMAQUINE 2 QL POWDER ORAL TABLET 26.3 MG NICLOSAMIDE 2 (BULK) POWDER PYRANTEL 2 100 % PAMOATE (BULK) POWDER 100 % ORBACTIV 2 ST INTRAVENOUS pyrazinamide oral 1 RECON SOLN 400 tablet 500 mg MG PYRIMETHAMINE 2 PA paromomycin oral 1 (BULK) POWDER capsule 250 mg pyrimethamine oral 1 PA; SP PAROMOMYCIN 2 tablet 25 mg SULFATE (BULK) QUINACRINE 2 POWDER 675 (BULK) POWDER MCG/MG
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 15 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits QUININE HCL 2 tigecycline 1 ST DIHYDRATE intravenous recon (BULK) POWDER soln 50 mg 100 % TINIDAZOLE 2 QUININE 2 (BULK) POWDER SULFATE (BULK) 100 % POWDER tinidazole oral tablet 1 QL quinine sulfate oral 1 QL 250 mg, 500 mg capsule 324 mg TOBI PODHALER 2 PA; SP; QL rifabutin oral 1 INHALATION capsule 150 mg CAPSULE, W/INHALATION RIFAMPIN (BULK) 2 DEVICE 28 MG POWDER TOBRAMYCIN 2 rifampin intravenous 1 (BULK) POWDER recon soln 600 mg 900 MCG/MG rifampin oral 1 (NOT LESS THAN, capsule 150 mg, 300 USP) mg tobramycin in 0.225 1 PA; SP; QL SIRTURO ORAL 2 PA % nacl inhalation TABLET 100 MG, solution for 20 MG nebulization 300 SOLOSEC ORAL 2 QL mg/5 ml GRANULES DEL tobramycin in 0.9 % 1 ST RELEASE IN nacl intravenous PACKET 2 GRAM piggyback 60 mg/50 STREPTOMYCIN 2 ST ml INTRAMUSCULA tobramycin 1 PA; SP; QL R RECON SOLN 1 inhalation solution GRAM for nebulization 300 STREPTOMYCIN 2 mg/4 ml SULFATE (BULK) TOBRAMYCIN 2 POWDER SULFATE (BULK) SYNERCID 2 ST POWDER 634 INTRAVENOUS MCG/MG (NOT RECON SOLN 500 LESS THAN, USP) MG tobramycin sulfate 1 ST THIABENDAZOLE 2 injection recon soln (BULK) POWDER 1.2 gram
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 16 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits tobramycin sulfate 1 ST amoxicillin-pot 1 injection solution 10 clavulanate oral mg/ml, 40 mg/ml tablet extended release 12 hr 1,000- XIFAXAN ORAL 2 QL 62.5 mg TABLET 200 MG, 550 MG amoxicillin-pot 1 clavulanate oral PENICILLINS tablet,chewable 200- AMOXICILLIN 2 28.5 mg, 400-57 mg (BULK) POWDER ampicillin oral 1 100 % capsule 250 mg, 500 amoxicillin oral 1 mg capsule 250 mg, 500 ampicillin sodium 1 ST mg injection recon soln amoxicillin oral 1 1 gram, 10 gram, suspension for 125 mg, 2 gram, 250 reconstitution 125 mg, 500 mg mg/5 ml, 200 mg/5 ampicillin sodium 1 ST ml, 250 mg/5 ml, 400 intravenous recon mg/5 ml soln 1 gram, 2 gram amoxicillin oral 1 ampicillin-sulbactam 1 ST tablet 500 mg, 875 injection recon soln mg 1.5 gram, 15 gram, 3 amoxicillin oral 1 gram tablet,chewable 125 ampicillin-sulbactam 1 ST mg, 250 mg intravenous recon amoxicillin-pot 1 soln 1.5 gram, 3 clavulanate oral gram suspension for AUGMENTIN 2 reconstitution 200- ORAL 28.5 mg/5 ml, 250- SUSPENSION FOR 62.5 mg/5 ml, 400- RECONSTITUTIO 57 mg/5 ml, 600- N 125-31.25 MG/5 42.9 mg/5 ml ML amoxicillin-pot 1 BICILLIN C-R 2 ST clavulanate oral INTRAMUSCULA tablet 250-125 mg, R SYRINGE 500-125 mg, 875- 1,200,000 UNIT/ 2 125 mg ML(600K/600K), 1,200,000 UNIT/ 2 ML(900K/300K)
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 17 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits BICILLIN L-A 2 ST penicillin g 1 ST INTRAMUSCULA potassium injection R SYRINGE recon soln 20 1,200,000 UNIT/2 million unit, 5 ML, 2,400,000 million unit UNIT/4 ML, penicillin g procaine 1 ST 600,000 UNIT/ML intramuscular dicloxacillin oral 1 syringe 1.2 million capsule 250 mg, 500 unit/2 ml, 600,000 mg unit/ml nafcillin in dextrose 1 ST penicillin g sodium 1 ST iso-osm intravenous injection recon soln piggyback 1 gram/50 5 million unit ml, 2 gram/100 ml penicillin v 1 nafcillin injection 1 ST potassium oral recon recon soln 1 gram, soln 125 mg/5 ml, 10 gram, 2 gram 250 mg/5 ml nafcillin intravenous 1 ST penicillin v 1 recon soln 1 gram, 2 potassium oral tablet gram 250 mg, 500 mg oxacillin in 1 ST pfizerpen-g injection 1 ST dextrose(iso-osm) recon soln 20 intravenous million unit, 5 piggyback 1 gram/50 million unit ml, 2 gram/50 ml piperacillin- 1 ST oxacillin injection 1 ST tazobactam recon soln 1 gram, intravenous recon 10 gram, 2 gram soln 13.5 gram, 2.25 gram, 3.375 gram, oxacillin intravenous 1 ST 4.5 gram, 40.5 gram recon soln 1 gram, 2 gram ZOSYN IN 2 ST DEXTROSE (ISO- PENICILLIN G 2 ST OSM) POT IN INTRAVENOUS DEXTROSE PIGGYBACK 2.25 INTRAVENOUS GRAM/50 ML, PIGGYBACK 1 3.375 GRAM/50 MILLION UNIT/50 ML, 4.5 GRAM/100 ML, 2 MILLION ML UNIT/50 ML, 3 MILLION UNIT/50 QUINOLONES ML
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 18 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits BAXDELA 2 ST levofloxacin oral 1 INTRAVENOUS tablet 250 mg, 500 RECON SOLN 300 mg, 750 mg MG moxifloxacin oral 1 BAXDELA ORAL 2 QL tablet 400 mg TABLET 450 MG MOXIFLOXACIN- 2 ST CIPROFLOXACIN 2 SOD.ACE,SUL- (BULK) WATER CRYSTALS 100 % INTRAVENOUS PIGGYBACK 400 CIPROFLOXACIN 2 MG/250 ML (BULK) POWDER 100 % moxifloxacin- 1 ST sod.chloride(iso) ciprofloxacin hcl 1 intravenous oral tablet 100 mg, piggyback 400 250 mg, 500 mg, 750 mg/250 ml mg ofloxacin oral tablet 1 ciprofloxacin in 5 % 1 ST 300 mg, 400 mg dextrose intravenous piggyback 200 SULFA'S / RELATED AGENTS mg/100 ml, 400 SULFACETAMIDE 2 mg/200 ml (BULK) POWDER ciprofloxacin oral 1 SULFADIAZINE 2 suspension,microcap (BULK) POWDER sule recon 250 mg/5 ml, 500 mg/5 ml sulfadiazine oral 1 tablet 500 mg LEVOFLOXACIN 2 (BULK) POWDER SULFAMERAZINE 2 100 % (BULK) CRYSTALS levofloxacin in d5w 1 ST intravenous SULFAMETHOXA 2 piggyback 250 ZOLE (BULK) mg/50 ml, 500 POWDER mg/100 ml, 750 sulfamethoxazole- 1 ST mg/150 ml trimethoprim levofloxacin 1 ST intravenous solution intravenous solution 400-80 mg/5 ml 25 mg/ml sulfamethoxazole- 1 levofloxacin oral 1 trimethoprim oral solution 250 mg/10 suspension 200-40 ml mg/5 ml
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 19 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits sulfamethoxazole- 1 doxycycline hyclate 1 trimethoprim oral oral tablet,delayed tablet 400-80 mg, release (dr/ec) 100 800-160 mg mg, 150 mg, 200 mg, 50 mg, 75 mg SULFAPYRIDINE 2 (BULK) POWDER doxycycline 1 monohydrate oral sulfatrim oral 1 capsule 100 mg, 150 suspension 200-40 mg, 50 mg, 75 mg mg/5 ml doxycycline 1 SULFISOXAZOLE 2 monohydrate oral (BULK) suspension for CRYSTALS reconstitution 25 TETRACYCLINES mg/5 ml avidoxy oral tablet 1 doxycycline 1 100 mg monohydrate oral tablet 100 mg, 150 coremino oral tablet 1 mg, 50 mg, 75 mg extended release 24 hr 135 mg, 45 mg, MINOCIN 2 ST 90 mg INTRAVENOUS RECON SOLN 100 demeclocycline oral 1 MG tablet 150 mg, 300 mg MINOCYCLINE 2 HCL (BULK) doxy-100 1 ST POWDER intravenous recon soln 100 mg minocycline oral 1 capsule 100 mg, 50 DOXYCYCLINE 2 mg, 75 mg HYCLATE (BULK) POWDER minocycline oral 1 tablet 100 mg, 50 doxycycline hyclate 1 ST mg, 75 mg intravenous recon soln 100 mg minocycline oral 1 PA tablet extended doxycycline hyclate 1 release 24 hr 105 oral capsule 100 mg, mg, 115 mg, 135 mg, 50 mg 45 mg, 55 mg, 65 doxycycline hyclate 1 mg, 80 mg, 90 mg oral tablet 100 mg, mondoxyne nl oral 1 150 mg, 20 mg, 50 capsule 100 mg, 75 mg, 75 mg mg
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 20 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits morgidox oral 1 NITROFURAN 2 capsule 100 mg, 50 MACROCRYSTAL mg (BULK) POWDER 100 % ORACEA ORAL 2 PA CAPSULE,IR - NITROFURANTOI 2 DELAY N (BULK) REL,BIPHASE 40 POWDER MG nitrofurantoin 1 OXYTETRACYCLI 2 macrocrystal oral NE (BULK) capsule 100 mg, 25 POWDER mg, 50 mg TETRACYCLINE 2 nitrofurantoin 1 HCL (BULK) monohyd/m-cryst POWDER oral capsule 100 mg tetracycline oral 1 nitrofurantoin oral 1 capsule 250 mg, 500 suspension 25 mg/5 mg ml URINARY TRACT AGENTS TRIMETHOPRIM 2 (BULK) POWDER fosfomycin 1 100 % tromethamine oral packet 3 gram trimethoprim oral 1 tablet 100 mg METHENAMINE 2 (BULK) POWDER TRIMETHOPRIM, 2 100 % MICRO (BULK) POWDER 100 % methenamine 1 hippurate oral tablet VANCOMYCIN 1 gram VANCOMYCIN 2 METHENAMINE 2 (BULK) POWDER MANDELATE 900 MCG/MG (BULK) POWDER (NOT LESS THAN) methenamine 1 VANCOMYCIN IN 2 ST mandelate oral 0.9 % SODIUM tablet 0.5 g, 1 gram CHL INTRAVENOUS methylene blue 1 PIGGYBACK 1 (antidote) GRAM/200 ML, intravenous solution 500 MG/100 ML, 1 % (10 mg/ml) 750 MG/150 ML NALIDIXIC ACID 2 (BULK) POWDER
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 21 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits VANCOMYCIN IN 2 ST VIBATIV 2 ST 0.9 % SODIUM INTRAVENOUS CHL RECON SOLN 750 INTRAVENOUS MG SOLUTION 1 GRAM/250 ML, ANTINEOPLASTIC / 1.25 GRAM/250 IMMUNOSUPPRESSANT ML, 1.5 GRAM/250 DRUGS ML, 1.5 GRAM/500 ML, 1.75 ADJUNCTIVE AGENTS GRAM/250 ML, dexrazoxane hcl 1 1.75 GRAM/500 intravenous recon ML, 2 GRAM/500 soln 250 mg, 500 mg ML, 750 MG/150 ML, 750 MG/250 ELITEK 2 ML INTRAVENOUS RECON SOLN 1.5 VANCOMYCIN IN 2 ST MG, 7.5 MG DEXTROSE 5 % INTRAVENOUS KEPIVANCE 2 SP PIGGYBACK 1 INTRAVENOUS GRAM/200 ML, RECON SOLN 6.25 500 MG/100 ML, MG 750 MG/150 ML LEUCOVORIN 2 VANCOMYCIN IN 2 ST CALCIUM (BULK) DEXTROSE 5 % POWDER INTRAVENOUS leucovorin calcium 1 SOLUTION 1 injection recon soln GRAM/250 ML, 100 mg, 200 mg, 350 1.25 GRAM/250 mg, 50 mg, 500 mg ML, 1.5 GRAM/250 ML leucovorin calcium 1 injection solution 10 vancomycin 1 ST mg/ml intravenous recon soln 1,000 mg, 10 leucovorin calcium 1 gram, 5 gram, 500 oral tablet 10 mg, 15 mg, 750 mg mg, 25 mg, 5 mg vancomycin oral 1 ST; QL levoleucovorin 1 PA capsule 125 mg, 250 calcium intravenous mg recon soln 50 mg vancomycin oral 1 QL levoleucovorin 1 PA recon soln 50 mg/ml calcium intravenous solution 10 mg/ml
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 22 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits mesna intravenous 1 adriamycin 1 solution 100 mg/ml intravenous solution 10 mg/5 ml, 2 mg/ml, MESNEX ORAL 2 20 mg/10 ml, 50 TABLET 400 MG mg/25 ml VISTOGARD 2 PA; SP adrucil intravenous 1 ORAL GRANULES solution 2.5 gram/50 IN PACKET 10 ml GRAM AFINITOR 2 PA; SP VORAXAZE 2 DISPERZ ORAL INTRAVENOUS TABLET FOR RECON SOLN SUSPENSION 2 1,000 UNIT MG, 3 MG, 5 MG XGEVA 2 PA; SP AFINITOR ORAL 2 PA; SP SUBCUTANEOUS TABLET 10 MG SOLUTION 120 MG/1.7 ML (70 ALECENSA ORAL 2 PA; SP MG/ML) CAPSULE 150 MG ANTINEOPLASTIC / ALIMTA 2
IMMUNOSUPPRESSANT DRUGS INTRAVENOUS RECON SOLN 100 abiraterone oral 1 PA; SP MG, 500 MG tablet 250 mg ALIQOPA 2 PA; SP ABRAXANE 2 SP INTRAVENOUS INTRAVENOUS RECON SOLN 60 SUSPENSION FOR MG RECONSTITUTIO N 100 MG ALUNBRIG ORAL 2 PA; SP TABLET 180 MG, ADAKVEO 2 PA; SP 30 MG, 90 MG INTRAVENOUS SOLUTION 10 ALUNBRIG ORAL 2 PA; SP MG/ML TABLETS,DOSE PACK 90 MG (7)- ADCETRIS 2 PA; SP 180 MG (23) INTRAVENOUS RECON SOLN 50 ANASTROZOLE 2 MG (BULK) POWDER 100 % adriamycin 1 intravenous recon anastrozole oral 1 ACA soln 10 mg tablet 1 mg
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 23 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits ARRANON 2 SP BENDEKA 2 PA; SP INTRAVENOUS INTRAVENOUS SOLUTION 250 SOLUTION 25 MG/50 ML MG/ML arsenic trioxide 1 PA BESPONSA 2 PA; SP intravenous solution INTRAVENOUS 2 mg/ml RECON SOLN 0.9 MG (0.25 MG/ML AVASTIN 2 PA; SP INITIAL) INTRAVENOUS SOLUTION 25 bexarotene oral 1 PA; SP MG/ML capsule 75 mg azacitidine injection 1 SP bicalutamide oral 1 recon soln 100 mg tablet 50 mg AZATHIOPRINE 2 bleomycin injection 1 (BULK) POWDER recon soln 15 unit, 30 unit azathioprine oral 1 SP tablet 50 mg BLINCYTO 2 PA; SP INTRAVENOUS azathioprine sodium 1 SP KIT 35 MCG injection recon soln 100 mg BOSULIF ORAL 2 PA; SP TABLET 100 MG, AZEDRA 2 PA; SP 400 MG, 500 MG DOSIMETRIC INTRAVENOUS busulfan intravenous 1 SOLUTION 30 solution 60 mg/10 ml MCI/2 ML CABOMETYX 2 PA; SP AZEDRA 2 PA; SP ORAL TABLET 20 THERAPEUTIC MG, 40 MG, 60 MG INTRAVENOUS capecitabine oral 1 SP SOLUTION 337.5 tablet 150 mg, 500 MCI/22.5 ML mg BALVERSA ORAL 2 PA; SP CAPRELSA ORAL 2 PA; SP TABLET 3 MG, 4 TABLET 100 MG, MG, 5 MG 300 MG BAVENCIO 2 PA; SP carboplatin 1 INTRAVENOUS intravenous recon SOLUTION 20 soln 150 mg MG/ML carboplatin 1 intravenous solution 10 mg/ml
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 24 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits carmustine 1 PA cyclosporine 1 SP intravenous recon modified oral soln 100 mg capsule 100 mg, 25 mg, 50 mg CHLORAMBUCIL 2 (BULK) POWDER cyclosporine 1 SP modified oral cisplatin intravenous 1 solution 100 mg/ml solution 1 mg/ml cyclosporine oral 1 SP cladribine 1 capsule 100 mg, 25 intravenous solution mg 10 mg/10 ml CYRAMZA 2 PA; SP clofarabine 1 INTRAVENOUS intravenous solution SOLUTION 10 20 mg/20 ml MG/ML COMETRIQ ORAL 2 PA; SP cytarabine (pf) 1 CAPSULE 100 injection solution MG/DAY(80 MG 100 mg/5 ml (20 X1-20 MG X1), 140 mg/ml), 2 gram/20 MG/DAY(80 MG ml (100 mg/ml), 20 X1-20 MG X3), 60 mg/ml MG/DAY (20 MG X 3/DAY) cytarabine injection 1 solution 20 mg/ml COTELLIC ORAL 2 PA; SP TABLET 20 MG dacarbazine 1 intravenous recon CYCLOPHOSPHA 2 soln 100 mg, 200 mg MIDE (BULK) POWDER 100 % dactinomycin 1 intravenous recon cyclophosphamide 1 soln 0.5 mg intravenous recon soln 1 gram, 2 gram, DARZALEX 2 PA; SP 500 mg INTRAVENOUS SOLUTION 20 cyclophosphamide 1 MG/ML oral capsule 25 mg, 50 mg daunorubicin 1 intravenous recon CYCLOSPORINE 2 soln 20 mg (BULK) POWDER daunorubicin 1 cyclosporine 1 SP intravenous solution intravenous solution 5 mg/ml 250 mg/5 ml
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 25 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits decitabine 1 PA; SP ELIGARD (6 2 PA; SP intravenous recon MONTH) soln 50 mg SUBCUTANEOUS SYRINGE 45 MG DOCEFREZ 2 INTRAVENOUS ELIGARD 2 PA; SP RECON SOLN 20 SUBCUTANEOUS MG, 80 MG SYRINGE 7.5 MG (1 MONTH) docetaxel 1 intravenous solution ELZONRIS 2 PA; SP 160 mg/16 ml (10 INTRAVENOUS mg/ml), 160 mg/8 ml SOLUTION 1,000 (20 mg/ml), 20 mg/2 MCG/ML ml (10 mg/ml), 20 EMCYT ORAL 2 mg/ml (1 ml), 80 CAPSULE 140 MG mg/4 ml (20 mg/ml), 80 mg/8 ml (10 ENSPRYNG 2 PA; SP mg/ml) SUBCUTANEOUS SYRINGE 120 doxorubicin 1 MG/ML intravenous recon soln 50 mg epirubicin 1 intravenous recon doxorubicin 1 soln 200 mg, 50 mg intravenous solution 10 mg/5 ml, 2 mg/ml, epirubicin 1 20 mg/10 ml, 50 intravenous solution mg/25 ml 200 mg/100 ml, 50 mg/25 ml doxorubicin, peg- 1 liposomal ERBITUX 2 PA; SP intravenous INTRAVENOUS suspension 2 mg/ml SOLUTION 100 MG/50 ML, 200 DROXIA ORAL 2 MG/100 ML CAPSULE 200 MG, 300 MG, 400 MG ERIVEDGE ORAL 2 PA; SP CAPSULE 150 MG ELIGARD (3 2 PA; SP MONTH) ERLEADA ORAL 2 PA; SP SUBCUTANEOUS TABLET 60 MG SYRINGE 22.5 MG erlotinib oral tablet 1 PA; SP ELIGARD (4 2 PA; SP 100 mg, 150 mg, 25 MONTH) mg SUBCUTANEOUS SYRINGE 30 MG
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 26 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits ETOPOPHOS 2 FLUOROURACIL 2 INTRAVENOUS (BULK) POWDER RECON SOLN 100 100 % MG fluorouracil 1 ETOPOSIDE 2 intravenous solution (BULK) POWDER 1 gram/20 ml, 2.5 100 % gram/50 ml, 5 gram/100 ml, 500 etoposide 1 mg/10 ml intravenous solution 20 mg/ml flutamide oral 1 capsule 125 mg etoposide oral 1 capsule 50 mg FOLOTYN 2 PA; SP INTRAVENOUS everolimus 1 PA; SP SOLUTION 20 (antineoplastic) oral MG/ML (1 ML), 40 tablet 2.5 mg, 5 mg, MG/2 ML (20 7.5 mg MG/ML) everolimus 1 SP fulvestrant 1 PA (immunosuppressive intramuscular ) oral tablet 0.25 mg, syringe 250 mg/5 ml 0.5 mg, 0.75 mg GAMIFANT 2 PA; SP exemestane oral 1 ACA INTRAVENOUS tablet 25 mg SOLUTION 5 FIRMAGON KIT W 2 PA; SP MG/ML DILUENT GAZYVA 2 PA; SP SYRINGE INTRAVENOUS SUBCUTANEOUS SOLUTION 1,000 RECON SOLN 120 MG/40 ML MG, 80 MG gemcitabine 1 FLOXURIDINE 2 intravenous recon (BULK) POWDER soln 1 gram, 2 gram, 100 % 200 mg floxuridine injection 1 gemcitabine 1 recon soln 0.5 gram intravenous solution fludarabine 1 1 gram/26.3 ml (38 intravenous recon mg/ml), 2 gram/52.6 soln 50 mg ml (38 mg/ml), 200 fludarabine 1 mg/5.26 ml (38 intravenous solution mg/ml) 50 mg/2 ml gengraf oral capsule 1 SP 100 mg, 25 mg
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 27 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits gengraf oral solution 1 SP ifosfamide 1 100 mg/ml intravenous recon soln 1 gram, 3 gram GILOTRIF ORAL 2 PA; SP TABLET 20 MG, 30 ifosfamide 1 MG, 40 MG intravenous solution 1 gram/20 ml, 3 GLEOSTINE ORAL 2 gram/60 ml CAPSULE 10 MG, 100 MG, 40 MG imatinib oral tablet 1 PA; SP 100 mg, 400 mg HALAVEN 2 PA; SP INTRAVENOUS IMBRUVICA 2 PA; SP SOLUTION 1 MG/2 ORAL CAPSULE ML (0.5 MG/ML) 140 MG, 70 MG HERCEPTIN 2 PA; SP IMBRUVICA 2 PA; SP INTRAVENOUS ORAL TABLET RECON SOLN 150 140 MG, 280 MG, MG 420 MG, 560 MG HYCAMTIN ORAL 2 PA; SP IMFINZI 2 PA; SP CAPSULE 0.25 INTRAVENOUS MG, 1 MG SOLUTION 50 MG/ML HYDROXYUREA 2 (BULK) POWDER INLYTA ORAL 2 PA; SP 100 % TABLET 1 MG, 5 MG hydroxyurea oral 1 capsule 500 mg IODOPEN 2 INTRAVENOUS IBRANCE ORAL 2 PA; SP SOLUTION 100 CAPSULE 100 MG, MCG/ML 125 MG, 75 MG IRESSA ORAL 2 PA; SP IBRANCE ORAL 2 PA; SP TABLET 250 MG TABLET 100 MG, 125 MG, 75 MG irinotecan 1 intravenous solution ICLUSIG ORAL 2 PA; SP 100 mg/5 ml, 300 TABLET 15 MG, 45 mg/15 ml, 40 mg/2 MG ml, 500 mg/25 ml idarubicin 1 ISTODAX 2 PA; SP intravenous solution INTRAVENOUS 1 mg/ml RECON SOLN 10 IDHIFA ORAL 2 PA; SP MG/2 ML TABLET 100 MG, 50 MG
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 28 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits IXEMPRA 2 PA; SP LENVIMA ORAL 2 PA; SP INTRAVENOUS CAPSULE 10 RECON SOLN 15 MG/DAY (10 MG X MG, 45 MG 1), 12 MG/DAY (4 MG X 3), 14 JAKAFI ORAL 2 ST; SP MG/DAY(10 MG X TABLET 10 MG, 15 1-4 MG X 1), 18 MG, 20 MG, 25 MG/DAY (10 MG X MG, 5 MG 1-4 MG X2), 20 JEVTANA 2 PA; SP MG/DAY (10 MG X INTRAVENOUS 2), 24 MG/DAY(10 SOLUTION 10 MG X 2-4 MG X 1), MG/ML (FIRST 4 MG, 8 MG/DAY DILUTION) (4 MG X 2) KADCYLA 2 PA; SP LETROZOLE 2 INTRAVENOUS (BULK) POWDER RECON SOLN 100 100 % MG, 160 MG letrozole oral tablet 1 KANJINTI 2 PA; SP 2.5 mg INTRAVENOUS LEUKERAN ORAL 2 RECON SOLN 150 TABLET 2 MG MG, 420 MG LEUPROLIDE 2 KEYTRUDA 2 PA; SP (BULK) POWDER INTRAVENOUS 100 % SOLUTION 25 MG/ML leuprolide 1 PA; SP subcutaneous kit 1 KYMRIAH 2 PA; SP mg/0.2 ml INTRAVENOUS SUSPENSION LEVAMISOLE 2 0.2X10EXP6 TO (BULK) POWDER 2.5X10EXP8 CELL, LIBTAYO 2 PA; SP 0.6 TO 6 X 10EXP8 INTRAVENOUS CELL SOLUTION 50 KYPROLIS 2 PA; SP MG/ML INTRAVENOUS LONSURF ORAL 2 PA; SP RECON SOLN 10 TABLET 15-6.14 MG, 30 MG, 60 MG MG, 20-8.19 MG lapatinib oral tablet 1 PA; SP LORBRENA ORAL 2 PA; SP 250 mg TABLET 100 MG, 25 MG
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 29 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits LUPRON DEPOT 2 PA; SP MEGESTROL 2 (3 MONTH) ACETATE,MICRO INTRAMUSCULA (BULK) POWDER R SYRINGE KIT 100 % 11.25 MG megestrol oral 1 LUPRON DEPOT 2 PA; SP suspension 400 INTRAMUSCULA mg/10 ml (10 ml), R SYRINGE KIT 400 mg/10 ml (40 3.75 MG mg/ml), 625 mg/5 ml (125 mg/ml) LUPRON DEPOT- 2 PA; SP PED (3 MONTH) megestrol oral tablet 1 INTRAMUSCULA 20 mg, 40 mg R SYRINGE KIT MEKINIST ORAL 2 PA; SP 11.25 MG, 30 MG TABLET 0.5 MG, 2 LUPRON DEPOT- 2 PA; SP MG PED melphalan hcl 1 INTRAMUSCULA intravenous recon R KIT 11.25 MG, 15 soln 50 mg MG, 7.5 MG (PED) melphalan oral 1 LUTATHERA 2 SP tablet 2 mg INTRAVENOUS SOLUTION 10 MERCAPTOPURIN 2 MCI/ML (370 E (BULK) MBQ/ML) POWDER 100 % LYNPARZA ORAL 2 PA; SP mercaptopurine oral 1 TABLET 100 MG, tablet 50 mg 150 MG METHOTREXATE 2 LYSODREN ORAL 2 (BULK) POWDER TABLET 500 MG 100 % MARQIBO 2 SP methotrexate sodium 1 INTRAVENOUS (pf) injection recon KIT 5 MG/31 soln 1 gram ML(0.16 MG/ML) methotrexate sodium 1 FINAL (pf) injection MATULANE 2 SP solution 25 mg/ml ORAL CAPSULE methotrexate sodium 1 50 MG injection solution 25 MECHLORETHAM 2 mg/ml INE (BULK) methotrexate sodium 1 POWDER 98 % oral tablet 2.5 mg
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 30 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits MITOMYCIN 2 MYLOTARG 2 PA; SP (BULK) POWDER INTRAVENOUS RECON SOLN 4.5 mitomycin 1 MG (1 MG/ML intravenous recon INITIAL CONC) soln 20 mg, 40 mg, 5 mg NERLYNX ORAL 2 PA; SP TABLET 40 MG MITOTANE 2 (BULK) POWDER NEXAVAR ORAL 2 PA; SP 100 % TABLET 200 MG mitoxantrone 1 SP nilutamide oral 1 PA intravenous tablet 150 mg concentrate 2 mg/ml NINLARO ORAL 2 PA; SP MVASI 2 PA; SP CAPSULE 2.3 MG, INTRAVENOUS 3 MG, 4 MG SOLUTION 25 NUBEQA ORAL 2 PA; SP MG/ML TABLET 300 MG mycophenolate 1 SP NULOJIX 2 SP mofetil (hcl) INTRAVENOUS intravenous recon RECON SOLN 250 soln 500 mg MG mycophenolate 1 SP octreotide acetate 1 SP mofetil oral capsule injection solution 250 mg 1,000 mcg/ml, 100 mycophenolate 1 SP mcg/ml, 200 mcg/ml, mofetil oral 50 mcg/ml, 500 suspension for mcg/ml reconstitution 200 octreotide acetate 1 SP mg/ml injection syringe 100 mycophenolate 1 SP mcg/ml (1 ml), 50 mofetil oral tablet mcg/ml (1 ml), 500 500 mg mcg/ml (1 ml) mycophenolate 1 SP ODOMZO ORAL 2 PA; SP sodium oral CAPSULE 200 MG tablet,delayed OGIVRI 2 PA; SP release (dr/ec) 180 INTRAVENOUS mg, 360 mg RECON SOLN 150 MYLERAN ORAL 2 MG, 420 MG TABLET 2 MG
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 31 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits ONCASPAR 2 PA POTELIGEO 2 PA; SP INJECTION INTRAVENOUS SOLUTION 750 SOLUTION 4 UNIT/ML MG/ML ONIVYDE 2 PA; SP PROGRAF 2 SP INTRAVENOUS INTRAVENOUS DISPERSION 4.3 SOLUTION 5 MG/ML MG/ML OPDIVO 2 PA; SP PROGRAF ORAL 2 SP INTRAVENOUS GRANULES IN SOLUTION 100 PACKET 0.2 MG, 1 MG/10 ML, 240 MG MG/24 ML, 40 PURIXAN ORAL 2 SP MG/4 ML SUSPENSION 20 oxaliplatin 1 MG/ML intravenous recon REVLIMID ORAL 2 PA; SP soln 100 mg, 50 mg CAPSULE 10 MG, oxaliplatin 1 15 MG, 2.5 MG, 20 intravenous solution MG, 25 MG, 5 MG 100 mg/20 ml, 200 RITUXAN 2 PA; SP mg/40 ml, 50 mg/10 HYCELA ml (5 mg/ml) SUBCUTANEOUS paclitaxel 1 SOLUTION 1400 intravenous MG/11.7 ML (120 concentrate 6 mg/ml MG/ML), 1600 MG/13.4 ML (120 paraplatin 1 MG/ML) intravenous solution 10 mg/ml RITUXAN 2 PA; SP INTRAVENOUS PERJETA 2 PA; SP CONCENTRATE INTRAVENOUS 10 MG/ML SOLUTION 420 MG/14 ML (30 ROZLYTREK 2 PA; SP MG/ML) ORAL CAPSULE 100 MG, 200 MG PHOTOFRIN 2 INTRAVENOUS RUBRACA ORAL 2 PA; SP RECON SOLN 75 TABLET 200 MG, MG 250 MG, 300 MG POMALYST ORAL 2 PA; SP RUXIENCE 2 PA; SP CAPSULE 1 MG, 2 INTRAVENOUS MG, 3 MG, 4 MG CONCENTRATE 10 MG/ML
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 32 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits RYDAPT ORAL 2 PA; SP SYLVANT 2 PA; SP CAPSULE 25 MG INTRAVENOUS RECON SOLN 100 SANDIMMUNE 2 SP MG, 400 MG ORAL SOLUTION 100 MG/ML SYNRIBO 2 PA; SP SUBCUTANEOUS SIGNIFOR 2 PA; SP RECON SOLN 3.5 SUBCUTANEOUS MG SOLUTION 0.3 MG/ML (1 ML), 0.6 TACROLIMUS 2 MG/ML (1 ML), 0.9 ANHYDROUS MG/ML (1 ML) (BULK) POWDER 100 % SIMULECT 2 SP INTRAVENOUS TACROLIMUS 2 RECON SOLN 10 MICRONIZED MG, 20 MG (BULK) POWDER 100 % SIROLIMUS 2 (BULK) POWDER tacrolimus oral 1 SP 100 % capsule 0.5 mg, 1 mg, 5 mg sirolimus oral 1 SP solution 1 mg/ml TAFINLAR ORAL 2 PA; SP CAPSULE 50 MG, sirolimus oral tablet 1 SP 75 MG 0.5 mg, 1 mg, 2 mg TAGRISSO ORAL 2 PA; SP SOMATULINE 2 PA; SP TABLET 40 MG, 80 DEPOT MG SUBCUTANEOUS SYRINGE 120 TALZENNA ORAL 2 PA; SP MG/0.5 ML, 60 CAPSULE 0.25 MG/0.2 ML, 90 MG, 1 MG MG/0.3 ML TAMOXIFEN 2 SPRYCEL ORAL 2 PA; SP (BULK) POWDER TABLET 100 MG, tamoxifen oral tablet 1 ACA 140 MG, 20 MG, 50 10 mg, 20 mg MG, 70 MG, 80 MG TARGRETIN 2 PA; SP STIVARGA ORAL 2 PA; SP TOPICAL GEL 1 % TABLET 40 MG TASIGNA ORAL 2 PA; SP SUTENT ORAL 2 PA; SP CAPSULE 150 MG, CAPSULE 12.5 200 MG, 50 MG MG, 25 MG, 37.5 MG, 50 MG
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 33 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits TECENTRIQ 2 PA; SP topotecan 1 PA; SP INTRAVENOUS intravenous recon SOLUTION 1,200 soln 4 mg MG/20 ML (60 topotecan 1 PA; SP MG/ML), 840 intravenous solution MG/14 ML (60 4 mg/4 ml (1 mg/ml) MG/ML) toremifene oral 1 TEMODAR 2 SP tablet 60 mg INTRAVENOUS RECON SOLN 100 TRAZIMERA 2 PA; SP MG INTRAVENOUS RECON SOLN 420 temozolomide oral 1 PA; SP MG capsule 100 mg, 140 mg, 180 mg, 20 mg, TREANDA 2 PA; SP 250 mg, 5 mg INTRAVENOUS RECON SOLN 100 temsirolimus 1 PA; SP MG, 25 MG intravenous recon soln 30 mg/3 ml (10 tretinoin 1 mg/ml) (first) (antineoplastic) oral capsule 10 mg TENIPOSIDE 2 INTRAVENOUS TRIPTODUR 2 PA; SP SOLUTION 50 INTRAMUSCULA MG/5 ML R SUSPENSION FOR THALOMID ORAL 2 PA; SP RECONSTITUTIO CAPSULE 100 MG, N 22.5 MG 150 MG, 200 MG, 50 MG TRUXIMA 2 PA; SP INTRAVENOUS THIOGUANINE 2 CONCENTRATE (BULK) POWDER 10 MG/ML THIOTEPA 2 TYKERB ORAL 2 PA; SP (BULK) POWDER TABLET 250 MG 100 % UNITUXIN 2 SP thiotepa injection 1 PA INTRAVENOUS recon soln 100 mg, SOLUTION 3.5 15 mg MG/ML TIBSOVO ORAL 2 PA; SP valrubicin 1 PA; SP TABLET 250 MG intravesical solution toposar intravenous 1 40 mg/ml solution 20 mg/ml
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 34 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits VANTAS 2 PA; SP VITRAKVI ORAL 2 PA; SP IMPLANT KIT 50 CAPSULE 100 MG, MG (50 MCG/DAY) 25 MG VECTIBIX 2 PA; SP VITRAKVI ORAL 2 PA; SP INTRAVENOUS SOLUTION 20 SOLUTION 100 MG/ML MG/5 ML (20 VIZIMPRO ORAL 2 PA; SP MG/ML), 400 TABLET 15 MG, 30 MG/20 ML (20 MG, 45 MG MG/ML) VOTRIENT ORAL 2 PA; SP VELCADE 2 SP TABLET 200 MG INJECTION RECON SOLN 3.5 VYXEOS 2 PA; SP MG INTRAVENOUS RECON SOLN 44- VENCLEXTA 2 PA; SP 100 MG ORAL TABLET 10 MG, 100 MG, 50 XALKORI ORAL 2 PA; SP MG CAPSULE 200 MG, 250 MG VENCLEXTA 2 PA; SP STARTING PACK XERMELO ORAL 2 PA; SP ORAL TABLET 250 MG TABLETS,DOSE XOFIGO 2 SP PACK 10 MG-50 INTRAVENOUS MG- 100 MG SOLUTION 1,100 VERZENIO ORAL 2 PA; SP KBQ/ML(30 TABLET 100 MG, MICROCURIE/ML) 150 MG, 200 MG, XOSPATA ORAL 2 PA; SP 50 MG TABLET 40 MG vinblastine 1 XTANDI ORAL 2 PA; SP intravenous solution CAPSULE 40 MG 1 mg/ml YERVOY 2 PA; SP vincasar pfs 1 INTRAVENOUS intravenous solution SOLUTION 200 1 mg/ml, 2 mg/2 ml MG/40 ML (5 vincristine 1 MG/ML), 50 MG/10 intravenous solution ML (5 MG/ML) 1 mg/ml, 2 mg/2 ml YESCARTA 2 PA; SP vinorelbine 1 INTRAVENOUS intravenous solution SUSPENSION 10 mg/ml, 50 mg/5 ml
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 35 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits YONDELIS 2 SP ZYTIGA ORAL 2 PA; SP INTRAVENOUS TABLET 500 MG RECON SOLN 1 AUTONOMIC / CNS DRUGS, MG NEUROLOGY / PSYCH YONSA ORAL 2 PA; SP TABLET 125 MG ANTICONVULSANTS ZALTRAP 2 PA; SP BANZEL ORAL 2 PA INTRAVENOUS SUSPENSION 40 SOLUTION 100 MG/ML MG/4 ML (25 BANZEL ORAL 2 PA MG/ML), 200 MG/8 TABLET 200 MG, ML (25 MG/ML) 400 MG ZANOSAR 2 CARBAMAZEPINE 2 INTRAVENOUS (BULK) POWDER RECON SOLN 1 GRAM carbamazepine oral 1 capsule, er ZEJULA ORAL 2 PA; SP multiphase 12 hr CAPSULE 100 MG 100 mg, 200 mg, 300 ZELBORAF ORAL 2 PA; SP mg TABLET 240 MG carbamazepine oral 1 ZEVALIN (Y-90) 2 suspension 100 mg/5 INTRAVENOUS ml KIT 3.2 MG/2 ML carbamazepine oral 1 ZIRABEV 2 PA; SP tablet 200 mg INTRAVENOUS carbamazepine oral 1 SOLUTION 25 tablet extended MG/ML release 12 hr 100 ZOLADEX 2 PA; SP mg, 200 mg, 400 mg SUBCUTANEOUS carbamazepine oral 1 IMPLANT 10.8 tablet,chewable 100 MG, 3.6 MG mg ZOLINZA ORAL 2 PA; SP CELONTIN ORAL 2 CAPSULE 100 MG CAPSULE 300 MG ZORTRESS ORAL 2 SP clobazam oral 1 PA TABLET 1 MG suspension 2.5 ZYDELIG ORAL 2 PA; SP mg/ml TABLET 100 MG, clobazam oral tablet 1 PA 150 MG 10 mg, 20 mg ZYKADIA ORAL 2 PA; SP TABLET 150 MG You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 36 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits CLONAZEPAM 2 ETHOSUXIMIDE 2 (BULK) POWDER (BULK) POWDER 100 % 100 % clonazepam oral 1 ethosuximide oral 1 tablet 0.5 mg, 1 mg, capsule 250 mg 2 mg ethosuximide oral 1 clonazepam oral 1 solution 250 mg/5 ml tablet,disintegrating felbamate oral 1 0.125 mg, 0.25 mg, suspension 600 mg/5 0.5 mg, 1 mg, 2 mg ml DIACOMIT ORAL 2 PA; SP felbamate oral tablet 1 CAPSULE 250 MG, 400 mg, 600 mg 500 MG fosphenytoin 1 DIACOMIT ORAL 2 PA; SP injection solution POWDER IN 100 mg pe/2 ml, 500 PACKET 250 MG, mg pe/10 ml 500 MG FYCOMPA ORAL 2 diazepam rectal kit 1 SUSPENSION 0.5 12.5-15-17.5-20 mg, MG/ML 2.5 mg, 5-7.5-10 mg FYCOMPA ORAL 2 DILANTIN ORAL 2 TABLET 10 MG, 12 CAPSULE 30 MG MG, 2 MG, 4 MG, 6 divalproex oral 1 MG, 8 MG capsule, delayed rel GABAPENTIN 2 sprinkle 125 mg (BULK) POWDER divalproex oral 1 100 % tablet extended gabapentin oral 1 release 24 hr 250 capsule 100 mg, 300 mg, 500 mg mg, 400 mg divalproex oral 1 gabapentin oral 1 tablet,delayed solution 250 mg/5 release (dr/ec) 125 ml, 250 mg/5 ml (5 mg, 250 mg, 500 mg ml), 300 mg/6 ml (6 EPIDIOLEX ORAL 2 PA; SP ml) SOLUTION 100 gabapentin oral 1 MG/ML tablet 600 mg, 800 epitol oral tablet 200 1 mg mg LAMOTRIGINE 2 (BULK) POWDER 100 % You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 37 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits lamotrigine oral 1 levetiracetam oral 1 tablet 100 mg, 150 solution 100 mg/ml, mg, 200 mg, 25 mg 500 mg/5 ml (5 ml) lamotrigine oral 1 levetiracetam oral 1 tablet disintegrating, tablet 1,000 mg, 250 dose pk 25 mg (21) - mg, 500 mg, 750 mg 50 mg (7), 25 levetiracetam oral 1 mg(14)-50 mg (14)- tablet extended 100 mg (7), 50 mg release 24 hr 500 (42) -100 mg (14) mg, 750 mg lamotrigine oral 1 NAYZILAM 2 PA; QL tablet extended NASAL release 24hr 100 mg, SPRAY,NON- 200 mg, 25 mg, 250 AEROSOL 5 mg, 300 mg, 50 mg MG/SPRAY (0.1 lamotrigine oral 1 ML) tablet, chewable oxcarbazepine oral 1 dispersible 25 mg, 5 suspension 300 mg/5 mg ml (60 mg/ml) lamotrigine oral 1 oxcarbazepine oral 1 tablet,disintegrating tablet 150 mg, 300 100 mg, 200 mg, 25 mg, 600 mg mg, 50 mg PEGANONE ORAL 2 lamotrigine oral 1 TABLET 250 MG tablets,dose pack 25 mg (35), 25 mg (42) PHENOBARBITAL 2 -100 mg (7), 25 mg (BULK) POWDER (84) -100 mg (14) phenobarbital oral 1 LEVETIRACETAM 2 elixir 20 mg/5 ml (4 (BULK) POWDER mg/ml) 100 % phenobarbital oral 1 levetiracetam in nacl 1 tablet 100 mg, 15 (iso-os) intravenous mg, 16.2 mg, 30 mg, piggyback 1,000 32.4 mg, 60 mg, 64.8 mg/100 ml, 1,500 mg, 97.2 mg mg/100 ml, 500 phenobarbital 1 mg/100 ml sodium injection levetiracetam 1 solution 130 mg/ml, intravenous solution 65 mg/ml 500 mg/5 ml PHENYTOIN 2 (BULK) POWDER
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 38 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits phenytoin oral 1 roweepra xr oral 1 suspension 100 mg/4 tablet extended ml, 125 mg/5 ml release 24 hr 500 mg, 750 mg phenytoin oral 1 tablet,chewable 50 subvenite oral tablet 1 mg 100 mg, 150 mg, 200 mg, 25 mg PHENYTOIN 2 SODIUM (BULK) subvenite starter 1 POWDER (blue) kit oral tablets,dose pack 25 phenytoin sodium 1 mg (35) extended oral capsule 100 mg, 200 subvenite starter 1 mg, 300 mg (green) kit oral tablets,dose pack 25 phenytoin sodium 1 mg (84) -100 mg intravenous solution (14) 50 mg/ml subvenite starter 1 phenytoin sodium 1 (orange) kit oral intravenous syringe tablets,dose pack 25 50 mg/ml mg (42) -100 mg (7) pregabalin oral 1 tiagabine oral tablet 1 capsule 100 mg, 150 12 mg, 16 mg, 2 mg, mg, 200 mg, 225 mg, 4 mg 25 mg, 300 mg, 50 mg, 75 mg TOPIRAMATE 2 (BULK) POWDER pregabalin oral 1 99.7 % solution 20 mg/ml topiramate oral 1 PRIMIDONE 2 capsule, sprinkle 15 (BULK) POWDER mg, 25 mg 100 % topiramate oral 1 primidone oral 1 tablet 100 mg, 200 tablet 250 mg, 50 mg mg, 25 mg, 50 mg QUDEXY XR 2 ST VALPROATE 2 ORAL SODIUM (BULK) CAPSULE,SPRINK POWDER 100 % LE,ER 24HR 100 MG, 150 MG, 200 valproate sodium 1 MG, 25 MG, 50 MG intravenous solution 500 mg/5 ml (100 roweepra oral tablet 1 mg/ml) 1,000 mg, 500 mg, 750 mg
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 39 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits valproic acid (as 1 benztropine oral 1 sodium salt) oral tablet 0.5 mg, 1 mg, solution 250 mg/5 2 mg ml, 250 mg/5 ml (5 BROMOCRIPTINE 2 ml), 500 mg/10 ml (BULK) POWDER (10 ml) bromocriptine oral 1 VALPROIC ACID 2 capsule 5 mg (BULK) LIQUID 100 % bromocriptine oral 1 tablet 2.5 mg valproic acid oral 1 capsule 250 mg CARBIDOPA 2 (BULK) POWDER vigabatrin oral 1 PA; SP powder in packet carbidopa oral 1 PA 500 mg tablet 25 mg vigabatrin oral 1 PA; SP carbidopa-levodopa 1 tablet 500 mg oral tablet 10-100 mg, 25-100 mg, 25- vigadrone oral 1 PA; SP 250 mg powder in packet 500 mg carbidopa-levodopa 1 oral tablet extended VIMPAT 2 release 25-100 mg, INTRAVENOUS 50-200 mg SOLUTION 200 MG/20 ML carbidopa-levodopa 1 oral VIMPAT ORAL 2 tablet,disintegrating SOLUTION 10 10-100 mg, 25-100 MG/ML mg, 25-250 mg VIMPAT ORAL 2 carbidopa-levodopa- 1 TABLET 100 MG, entacapone oral 150 MG, 200 MG, tablet 12.5-50-200 50 MG mg, 18.75-75-200 zonisamide oral 1 mg, 25-100-200 mg, capsule 100 mg, 25 31.25-125-200 mg, mg, 50 mg 37.5-150-200 mg, 50-200-200 mg ANTIPARKINSONISM AGENTS entacapone oral 1 APOKYN 2 PA; SP tablet 200 mg SUBCUTANEOUS CARTRIDGE 10 MG/ML benztropine injection 1 solution 1 mg/ml You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 40 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits INBRIJA 2 PA; SP trihexyphenidyl oral 1 INHALATION elixir 0.4 mg/ml CAPSULE, trihexyphenidyl oral 1 W/INHALATION tablet 2 mg, 5 mg DEVICE 42 MG MIGRAINE / CLUSTER HEADACHE KYNMOBI 2 PA SUBLINGUAL THERAPY FILM 10 MG, 15 AIMOVIG 2 PA; QL MG, 20 MG, 25 AUTOINJECTOR MG, 30 MG SUBCUTANEOUS LEVODOPA 2 AUTO-INJECTOR (BULK) POWDER 140 MG/ML, 70 MG/ML pramipexole oral 1 tablet 0.125 mg, 0.25 AJOVY 2 PA mg, 0.5 mg, 0.75 mg, AUTOINJECTOR 1 mg, 1.5 mg SUBCUTANEOUS AUTO-INJECTOR pramipexole oral 1 225 MG/1.5 ML tablet extended release 24 hr 0.375 AJOVY SYRINGE 2 PA; QL mg, 0.75 mg, 1.5 mg, SUBCUTANEOUS 2.25 mg, 3 mg, 3.75 SYRINGE 225 mg, 4.5 mg MG/1.5 ML rasagiline oral tablet 1 almotriptan malate 1 QL 0.5 mg, 1 mg oral tablet 12.5 mg, 6.25 mg ropinirole oral tablet 1 0.25 mg, 0.5 mg, 1 dihydroergotamine 1 mg, 2 mg, 3 mg, 4 injection solution 1 mg, 5 mg mg/ml ropinirole oral tablet 1 DIHYDROERGOT 2 extended release 24 AMINE hr 12 mg, 2 mg, 4 MESYLT(BULK) mg, 6 mg, 8 mg POWDER SELEGILINE HCL 2 dihydroergotamine 1 ST; QL (BULK) POWDER nasal spray,non- aerosol 0.5 mg/pump selegiline hcl oral 1 act. (4 mg/ml) capsule 5 mg eletriptan oral tablet 1 QL selegiline hcl oral 1 20 mg, 40 mg tablet 5 mg tolcapone oral tablet 1 PA 100 mg
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 41 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits EMGALITY PEN 2 PA; QL SUMATRIPTAN 2 SUBCUTANEOUS (BULK) POWDER PEN INJECTOR 100 % 120 MG/ML sumatriptan nasal 1 QL EMGALITY 2 PA; QL spray,non-aerosol SYRINGE 20 mg/actuation, 5 SUBCUTANEOUS mg/actuation SYRINGE 120 SUMATRIPTAN 2 MG/ML, 300 MG/3 SUCCINATE ML (100 MG/ML X (BULK) POWDER 3) 100 % ERGOTAMINE 2 sumatriptan 1 QL TARTRATE succinate oral tablet (BULK) POWDER 100 mg, 25 mg, 50 ergotamine-caffeine 1 mg oral tablet 1-100 mg sumatriptan 1 QL frovatriptan oral 1 QL succinate tablet 2.5 mg subcutaneous cartridge 4 mg/0.5 isometh-dichloral- 1 ml, 6 mg/0.5 ml acetaminophn oral capsule 65-100-325 sumatriptan 1 QL mg succinate subcutaneous pen ISOMETHEPTENE 2 injector 4 mg/0.5 ml, MUCATE (BULK) 6 mg/0.5 ml POWDER 100 % sumatriptan 1 QL METHYSERGIDE 2 succinate (BULK) POWDER subcutaneous 100 % solution 6 mg/0.5 ml migergot rectal 1 sumatriptan 1 QL suppository 2-100 succinate mg subcutaneous naratriptan oral 1 QL syringe 6 mg/0.5 ml tablet 1 mg, 2.5 mg sumatriptan- 1 ST; QL rizatriptan oral 1 QL naproxen oral tablet tablet 10 mg, 5 mg 85-500 mg rizatriptan oral 1 QL zolmitriptan oral 1 QL tablet,disintegrating tablet 2.5 mg, 5 mg 10 mg, 5 mg zolmitriptan oral 1 QL tablet,disintegrating 2.5 mg, 5 mg You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 42 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits ZOMIG NASAL 2 ST; QL glatopa 1 PA; SP; QL SPRAY,NON- subcutaneous AEROSOL 2.5 MG, syringe 20 mg/ml, 40 5 MG mg/ml MISCELLANEOUS MAYZENT ORAL 2 PA; SP; QL
NEUROLOGICAL THERAPY TABLET 0.25 MG, 2 MG AUSTEDO ORAL 2 PA; SP; QL TABLET 12 MG, 6 memantine oral 1 MG, 9 MG capsule,sprinkle,er 24hr 14 mg, 21 mg, dalfampridine oral 1 PA; SP 28 mg, 7 mg tablet extended release 12 hr 10 mg memantine oral 1 solution 2 mg/ml dimethyl fumarate 1 PA; SP oral capsule,delayed memantine oral 1 release(dr/ec) 120 tablet 10 mg, 5 mg mg, 120 mg (14)- NAMZARIC ORAL 2 PA 240 mg (46), 240 mg CAP,SPRINKLE,ER donepezil oral tablet 1 24HR DOSE PACK 10 mg, 5 mg 7/14/21/28 MG-10 MG donepezil oral tablet 1 PA 23 mg NAMZARIC ORAL 2 PA CAPSULE,SPRINK donepezil oral 1 LE,ER 24HR 14-10 tablet,disintegrating MG, 21-10 MG, 28- 10 mg, 5 mg 10 MG, 7-10 MG galantamine oral 1 NUEDEXTA ORAL 2 PA capsule,ext rel. CAPSULE 20-10 pellets 24 hr 16 mg, MG 24 mg, 8 mg OCREVUS 2 PA; SP galantamine oral 1 INTRAVENOUS solution 4 mg/ml SOLUTION 30 galantamine oral 1 MG/ML tablet 12 mg, 4 mg, 8 RADICAVA 2 PA; SP mg INTRAVENOUS GILENYA ORAL 2 PA; SP PIGGYBACK 30 CAPSULE 0.5 MG MG/100 ML glatiramer 1 PA; SP; QL rivastigmine tartrate 1 subcutaneous oral capsule 1.5 mg, syringe 20 mg/ml, 40 3 mg, 4.5 mg, 6 mg mg/ml
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 43 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits rivastigmine 1 ZEPOSIA 2 PA; SP transdermal patch STARTER KIT 24 hour 13.3 mg/24 ORAL hour, 4.6 mg/24 hr, CAPSULE,DOSE 9.5 mg/24 hr PACK 0.23-0.46- 0.92 MG RUZURGI ORAL 2 PA; SP TABLET 10 MG ZEPOSIA 2 PA; SP STARTER PACK SPINRAZA (PF) 2 PA; SP; QL ORAL INTRATHECAL CAPSULE,DOSE SOLUTION 12 PACK 0.23 MG (4)- MG/5 ML 0.46 MG (3) TECFIDERA ORAL 2 PA; SP MUSCLE RELAXANTS / CAPSULE,DELAY ED ANTISPASMODIC THERAPY RELEASE(DR/EC) anectine injection 1 120 MG, 120 MG solution 20 mg/ml (14)- 240 MG (46), 240 MG atracurium 1 intravenous solution TEGSEDI 2 PA; SP 10 mg/ml SUBCUTANEOUS SYRINGE 284 BACLOFEN 2 MG/1.5 ML (BULK) POWDER 100 % tetrabenazine oral 1 PA; SP; QL tablet 12.5 mg, 25 baclofen intrathecal 1 mg solution 10,000 mcg/20ml (500 TYSABRI 2 PA; SP mcg/ml), 20,000 INTRAVENOUS mcg/20ml (1,000 SOLUTION 300 mcg/ml), 40,000 MG/15 ML mcg/20ml (2,000 VUMERITY ORAL 2 PA; SP mcg/ml) CAPSULE,DELAY baclofen oral tablet 1 ED 10 mg, 20 mg, 5 mg RELEASE(DR/EC) 231 MG CARISOPRODOL 2 (BULK) POWDER ZEPOSIA ORAL 2 PA; SP CAPSULE 0.92 MG chlorzoxazone oral 1 tablet 250 mg, 375 mg, 500 mg, 750 mg cisatracurium 1 intravenous solution 10 mg/ml conc. (icu use only), 2 mg/ml You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 44 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits CYCLOBENZAPRI 2 metaxalone oral 1 NE (BULK) tablet 400 mg, 800 POWDER 100 % mg cyclobenzaprine oral 1 METHOCARBAM 2 capsule,extended OL (BULK) release 24hr 15 mg, POWDER 100 % 30 mg methocarbamol 1 cyclobenzaprine oral 1 injection solution tablet 10 mg, 5 mg, 100 mg/ml 7.5 mg methocarbamol oral 1 DANTROLENE 2 tablet 500 mg, 750 (BULK) POWDER mg dantrolene 1 NEOSTIGMINE 2 intravenous recon METHYLSULF soln 20 mg (BULK) POWDER 100 % dantrolene oral 1 capsule 100 mg, 25 neostigmine 1 mg, 50 mg methylsulfate intravenous solution EDROPHONIUM 2 0.5 mg/ml, 1 mg/ml CHLORIDE (BULK) POWDER neostigmine 1 methylsulfate GABLOFEN 2 intravenous syringe INTRATHECAL 5 mg/5 ml (1 mg/ml) SYRINGE 10,000 MCG/20ML (500 ORPHENADRINE 2 MCG/ML), 20,000 CITRATE (BULK) MCG/20ML (1,000 POWDER MCG/ML), 40,000 orphenadrine citrate 1 MCG/20ML (2,000 injection solution 30 MCG/ML), 50 mg/ml MCG/ML (1 ML) orphenadrine citrate 1 LIORESAL 2 oral tablet extended INTRATHECAL release 100 mg SOLUTION 2,000 MCG/ML, 50 orphenadrine-asa- 1 MCG/ML, 500 caffeine oral tablet MCG/ML 50-770-60 mg metaxall oral tablet 1 orphengesic forte 1 800 mg oral tablet 50-770- 60 mg
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 45 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits pancuronium 1 tizanidine oral 1 intravenous solution capsule 2 mg, 4 mg, 1 mg/ml, 2 mg/ml 6 mg PYRIDOSTIGMINE 2 tizanidine oral tablet 1 BROMIDE (BULK) 2 mg, 4 mg POWDER 100 % vecuronium bromide 1 pyridostigmine 1 intravenous recon bromide oral syrup soln 10 mg, 20 mg 60 mg/5 ml NARCOTIC ANALGESICS pyridostigmine 1 acetaminophen-caff- 1 bromide oral tablet dihydrocod oral 60 mg capsule 320.5-30-16 pyridostigmine 1 mg bromide oral tablet acetaminophen-caff- 1 extended release 180 dihydrocod oral mg tablet 325-30-16 mg regonol injection 1 acetaminophen- 1 solution 5 mg/ml codeine oral solution revonto intravenous 1 120 mg-12 mg /5 ml recon soln 20 mg (5 ml), 120-12 mg/5 rocuronium 1 ml, 300 mg-30 mg intravenous solution /12.5 ml 10 mg/ml acetaminophen- 1 rocuronium 1 codeine oral tablet intravenous syringe 300-15 mg, 300-30 50 mg/5 ml (10 mg, 300-60 mg mg/ml) alfentanil injection 1 succinylcholine 1 solution 500 mcg/ml chloride injection ascomp with codeine 1 solution 20 mg/ml oral capsule 30-50- succinylcholine 1 325-40 mg chloride intravenous BELBUCA 2 ST; QL syringe 100 mg/5 ml BUCCAL FILM 150 (20 mg/ml) MCG, 300 MCG, SUCCINYLCHOLI 2 450 MCG, 600 NE CL (BULK) MCG, 75 MCG, 750 POWDER 100 % MCG, 900 MCG TIZANIDINE 2 BUPRENORPHINE 2 (BULK) POWDER HCL (BULK) 100 % POWDER You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 46 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits buprenorphine hcl 1 butalbital- 1 injection solution 0.3 acetaminophen-caff mg/ml oral tablet 50-325- 40 mg buprenorphine hcl 1 injection syringe 0.3 butalbital-aspirin- 1 mg/ml caffeine oral capsule 50-325-40 mg buprenorphine hcl 1 sublingual tablet 2 butalbital-aspirin- 1 mg, 8 mg caffeine oral tablet 50-325-40 mg buprenorphine 1 ST transdermal patch CODEINE 2 weekly 10 mcg/hour, PHOSPHATE 15 mcg/hour, 20 (BULK) POWDER mcg/hour, 5 100 % mcg/hour, 7.5 codeine sulfate oral 1 mcg/hour tablet 15 mg, 30 mg, butalbital compound 1 60 mg w/codeine oral codeine-butalbital- 1 capsule 30-50-325- asa-caff oral capsule 40 mg 30-50-325-40 mg butalbital- 1 diskets oral 1 ST acetaminop-caf-cod tablet,soluble 40 mg oral capsule 50-300- 40-30 mg, 50-325- duramorph (pf) 1 40-30 mg injection solution 0.5 mg/ml, 1 mg/ml butalbital- 1 acetaminophen oral dvorah oral tablet 1 capsule 50-300 mg 325-30-16 mg butalbital- 1 endocet oral tablet 1 acetaminophen oral 10-325 mg, 2.5-325 tablet 25-325 mg, mg, 5-325 mg, 7.5- 50-300 mg, 50-325 325 mg mg FENTANYL 2 butalbital- 1 CITRATE (BULK) acetaminophen-caff POWDER 100 % oral capsule 50-300- fentanyl citrate (pf) 1 40 mg, 50-325-40 injection solution 50 mg mcg/ml
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 47 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits fentanyl citrate (pf) 1 hydrocodone- 1 intravenous syringe acetaminophen oral 100 mcg/2 ml (50 solution 10-325 mcg/ml) mg/15 ml(15 ml), 7.5-325 mg/15 ml fentanyl citrate (pf)- 1 0.9%nacl hydrocodone- 1 intravenous solution acetaminophen oral 5 mcg/ml tablet 10-300 mg, 10-325 mg, 2.5-325 fentanyl citrate (pf)- 1 mg, 5-300 mg, 5-325 0.9%nacl mg, 7.5-300 mg, 7.5- intravenous syringe 325 mg 10 mcg/ml hydrocodone- 1 fentanyl citrate 1 ST; QL ibuprofen oral tablet buccal lozenge on a 10-200 mg, 5-200 handle 1,200 mcg, mg, 7.5-200 mg 1,600 mcg, 200 mcg, 400 mcg, 600 mcg, HYDROMORPHO 2 800 mcg NE (BULK) POWDER 100 % fentanyl transdermal 1 ST; QL patch 72 hour 100 hydromorphone (pf) 1 mcg/hr, 12 mcg/hr, injection solution 10 25 mcg/hr, 37.5 mg/ml, 2 mg/ml mcg/hour, 50 hydromorphone (pf)- 1 mcg/hr, 62.5 0.9 % nacl mcg/hour, 75 intravenous pt mcg/hr, 87.5 controlled analgesia mcg/hour syring 10 mg/50 ml HYDROCODONE 2 (0.2 mg/ml) BITARTRATE hydromorphone 1 (BULK) injection solution 1 CRYSTALS mg/ml, 2 mg/ml HYDROCODONE 2 hydromorphone 1 BITARTRATE injection syringe 1 (BULK) POWDER mg/ml, 2 mg/ml, 4 100 % mg/ml hydrocodone 1 ST; QL hydromorphone oral 1 bitartrate oral liquid 1 mg/ml capsule, oral only, er 12hr 10 mg, 15 hydromorphone oral 1 mg, 20 mg, 30 mg, tablet 2 mg, 4 mg, 8 40 mg, 50 mg mg
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 48 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits hydromorphone oral 1 ST; QL methadone intensol 1 ST tablet extended oral concentrate 10 release 24 hr 12 mg, mg/ml 16 mg, 32 mg, 8 mg methadone oral 1 ST hydromorphone 1 concentrate 10 rectal suppository 3 mg/ml mg methadone oral 1 ST HYSINGLA ER 2 ST; QL solution 10 mg/5 ml, ORAL 5 mg/5 ml TABLET,ORAL methadone oral 1 ST ONLY,EXT.REL.24 tablet 10 mg, 5 mg HR 100 MG, 120 MG, 20 MG, 30 methadone oral 1 ST MG, 40 MG, 60 tablet,soluble 40 mg MG, 80 MG methadose oral 1 ST ibuprofen-oxycodone 1 concentrate 10 oral tablet 400-5 mg mg/ml INFUMORPH P/F 2 methadose oral 1 ST INJECTION tablet,soluble 40 mg SOLUTION 10 MORPHINE 2 MG/ML, 25 (BULK) POWDER MG/ML 100 % LEVORPHANOL 2 morphine (pf) in 0.9 1 TARTRATE % sod chl (BULK) POWDER intravenous pt 100 % controlled analgesia levorphanol tartrate 1 syring 30 mg/30 ml oral tablet 2 mg (1 mg/ml) lorcet hd oral tablet 1 morphine (pf) in 0.9 1 10-325 mg % sod chl intravenous solution MEPERIDINE 2 1 mg/ml (BULK) POWDER 100 % morphine (pf) in 0.9 1 % sod chl METHADONE 2 intravenous syringe (BULK) POWDER 2 mg/2 ml (1 mg/ml), 100 % 5 mg/5 ml (1 mg/ml) methadone injection 1 morphine (pf) 1 solution 10 mg/ml injection solution 0.5 mg/ml, 1 mg/ml
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 49 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits morphine 1 morphine oral 1 ST; QL concentrate oral capsule,extend.relea solution 100 mg/5 ml se pellets 10 mg, 100 (20 mg/ml) mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 morphine in 0.9 % 1 mg, 80 mg sodium chlor intravenous pt morphine oral 1 controlled analgesia solution 10 mg/5 ml, syring 30 mg/30 ml 20 mg/5 ml (4 (1 mg/ml), 50 mg/50 mg/ml) ml (1 mg/ml) morphine oral tablet 1 morphine injection 1 15 mg, 30 mg solution 10 mg/ml, 8 morphine oral tablet 1 ST; QL mg/ml extended release 100 morphine injection 1 mg, 15 mg, 200 mg, syringe 10 mg/ml, 2 30 mg, 60 mg mg/ml, 4 mg/ml, 5 morphine rectal 1 mg/ml, 8 mg/ml suppository 10 mg, morphine 1 20 mg, 30 mg, 5 mg intravenous pt OXYCODONE 2 controlled analgesia (BULK) POWDER syring 30 mg/30 ml 100 % (1 mg/ml) oxycodone oral 1 morphine 1 capsule 5 mg intravenous solution 10 mg/ml, 4 mg/ml, oxycodone oral 1 50 mg/ml concentrate 20 mg/ml morphine 1 intravenous syringe oxycodone oral 1 10 mg/ml, 2 mg/ml, 4 solution 5 mg/5 ml mg/ml oxycodone oral 1 morphine oral 1 ST; QL tablet 10 mg, 15 mg, capsule, er 20 mg, 30 mg, 5 mg multiphase 24 hr oxycodone- 1 120 mg, 30 mg, 45 acetaminophen oral mg, 60 mg, 75 mg, tablet 10-325 mg, 90 mg 2.5-300 mg, 2.5-325 mg, 5-325 mg, 7.5- 325 mg
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 50 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits oxycodone-aspirin 1 vicodin hp oral 1 oral tablet 4.8355- tablet 10-300 mg 325 mg vtol lq oral solution 1 OXYCONTIN 2 ST; QL 50-325-40 mg/15 ml ORAL zebutal oral capsule 1 TABLET,ORAL 50-325-40 mg ONLY,EXT.REL.12 HR 10 MG, 15 MG, NON-NARCOTIC ANALGESICS 20 MG, 30 MG, 40 ACETAMINOPHE 2 MG, 60 MG, 80 MG N (BULK) oxymorphone oral 1 POWDER 100 % tablet 10 mg, 5 mg ASPIRIN (BULK) 2 oxymorphone oral 1 ST; QL POWDER 100 % tablet extended aspirin childrens 1 ACA; OTC release 12 hr 10 mg, oral tablet,chewable 15 mg, 20 mg, 30 81 mg mg, 40 mg, 5 mg, 7.5 mg aspirin low dose 1 ACA; OTC oral tablet,delayed prolate oral tablet 1 release (dr/ec) 81 10-300 mg, 5-300 mg mg, 7.5-300 mg aspirin oral tablet 1 ACA; OTC remifentanil 1 325 mg intravenous recon soln 1 mg, 2 mg, 5 aspirin oral 1 ACA; OTC mg tablet,chewable 81 mg SUBLOCADE 2 SP SUBCUTANEOUS aspirin oral 1 ACA; OTC SOLUTION, tablet,delayed EXTENDED REL release (dr/ec) 325 SYRINGE 100 mg, 81 mg MG/0.5 ML, 300 aspirin,buffd- 1 ACA; OTC MG/1.5 ML calcium carb-mag SUFENTANIL 2 oral tablet 325 mg CITRATE (BULK) aspir-trin oral 1 ACA; OTC POWDER tablet,delayed sufentanil citrate 1 release (dr/ec) 325 intravenous solution mg 50 mcg/ml bayer aspirin oral 1 ACA; OTC tencon oral tablet 1 tablet 325 mg 50-325 mg bufferin oral tablet 1 ACA; OTC 325 mg You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 51 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits buprenorphine- 1 choline,magnesium 1 naloxone sublingual salicylate oral liquid film 12-3 mg 500 mg/5 ml buprenorphine- 1 QL clonidine (pf) 1 naloxone sublingual epidural solution film 2-0.5 mg, 4-1 5,000 mcg/10 ml mg, 8-2 mg diclofenac potassium 1 buprenorphine- 1 QL oral tablet 50 mg naloxone sublingual DICLOFENAC 2 tablet 2-0.5 mg SODIUM (BULK) buprenorphine- 1 POWDER 100 % naloxone sublingual diclofenac sodium 1 tablet 8-2 mg oral tablet extended butorphanol 1 release 24 hr 100 mg injection solution 1 diclofenac sodium 1 mg/ml, 2 mg/ml oral tablet,delayed butorphanol nasal 1 QL release (dr/ec) 25 spray,non-aerosol mg, 50 mg, 75 mg 10 mg/ml diclofenac sodium 1 QL BUTORPHANOL 2 topical drops 1.5 % TARTRATE diclofenac sodium 1 ST; QL (BULK) POWDER topical gel 1 % 100 % diclofenac- 1 CALDOLOR 2 misoprostol oral INTRAVENOUS tablet,ir,delayed RECON SOLN 800 rel,biphasic 50-200 MG/8 ML (100 mg-mcg, 75-200 mg- MG/ML) mcg CELECOXIB 2 diflunisal oral tablet 1 (BULK) POWDER 500 mg 100 % e.c. prin oral 1 ACA; OTC celecoxib oral 1 PA tablet,delayed capsule 100 mg, 200 release (dr/ec) 325 mg, 400 mg, 50 mg mg children's aspirin 1 ACA; OTC ec-naproxen oral 1 oral tablet,chewable tablet,delayed 81 mg release (dr/ec) 375 CHOLIN AND MG 2 mg, 500 mg SALICYLATE(BUL K) POWDER
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 52 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits ecotrin low strength 1 ACA; OTC ibuprofen lysine (pf) 1 oral tablet,delayed intravenous solution release (dr/ec) 81 20 mg/2 ml mg ibuprofen oral tablet 1 ecotrin oral 1 ACA; OTC 400 mg, 600 mg, 800 tablet,delayed mg release (dr/ec) 325 INDOMETHACIN 2 mg (BULK) POWDER etodolac oral 1 indomethacin oral 1 capsule 200 mg, 300 capsule 25 mg, 50 mg mg etodolac oral tablet 1 indomethacin oral 1 400 mg, 500 mg capsule, extended etodolac oral tablet 1 release 75 mg extended release 24 indomethacin 1 hr 400 mg, 500 mg, sodium intravenous 600 mg recon soln 1 mg EUFLEXXA 2 PA; SP KETOPROFEN 2 INTRA- (BULK) POWDER ARTICULAR 100 % SYRINGE 10 MG/ML(MW 2.4 - ketoprofen oral 1 ST 3.6 MILLION) capsule 25 mg fenoprofen oral 1 ST ketoprofen oral 1 tablet 600 mg capsule 50 mg, 75 mg FLECTOR 2 ST; QL TRANSDERMAL ketoprofen oral 1 ST PATCH 12 HOUR capsule,ext rel. 1.3 % pellets 24 hr 200 mg FLURBIPROFEN 2 KETOPROFEN, 2 (BULK) POWDER MICRONIZED (BULK) POWDER flurbiprofen oral 1 100 % tablet 100 mg KETOROLAC 2 ibu oral tablet 400 1 (BULK) POWDER mg, 600 mg, 800 mg 100 % IBUPROFEN 2 ketorolac injection 1 (BULK) POWDER cartridge 15 mg/ml, 100 % 30 mg/ml
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 53 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits ketorolac injection 1 meloxicam oral 1 solution 15 mg/ml, tablet 15 mg 30 mg/ml, 30 mg/ml meloxicam oral 1 QL (1 ml) tablet 7.5 mg ketorolac injection 1 MONOVISC 2 PA; SP syringe 15 mg/ml, 30 INTRA- mg/ml ARTICULAR ketorolac 1 SYRINGE 88 MG/4 intramuscular ML cartridge 60 mg/2 ml nabumetone oral 1 ketorolac 1 tablet 500 mg, 750 intramuscular mg solution 60 mg/2 ml NABUMETONE, 2 ketorolac 1 MICRONIZED intramuscular (BULK) POWDER syringe 60 mg/2 ml 100 % ketorolac oral tablet 1 QL NALBUPHINE 2 10 mg (BULK) POWDER 100 % LICART 2 ST; QL TRANSDERMAL nalbuphine injection 1 PATCH 24 HOUR solution 10 mg/ml, 1.3 % 20 mg/ml lite coat aspirin oral 1 ACA; OTC NALOXONE 2 tablet 325 mg (BULK) POWDER meclofenamate oral 1 naloxone injection 1 capsule 100 mg, 50 solution 0.4 mg/ml mg naloxone injection 1 MECLOFENAMAT 2 syringe 0.4 mg/ml, 1 E SODIUM (BULK) mg/ml POWDER NALTREXONE 2 MEFENAMIC 2 HCL (BULK) ACID (BULK) POWDER 100 % POWDER 100 % NALTREXONE 2 mefenamic acid oral 1 HCL capsule 250 mg DIHYDRATE(BUL K) POWDER 100 % MELOXICAM 2 (BULK) POWDER naltrexone oral 1 100 % tablet 50 mg
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 54 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits NAPROXEN 2 OFIRMEV 2 (BULK) POWDER INTRAVENOUS SOLUTION 1,000 naproxen oral 1 ST MG/100 ML (10 suspension 125 mg/5 MG/ML) ml ORTHOVISC 2 PA; SP naproxen oral tablet 1 INTRA- 250 mg, 375 mg, 500 ARTICULAR mg SYRINGE 30 MG/2 naproxen oral 1 ML tablet,delayed oxaprozin oral tablet 1 release (dr/ec) 375 600 mg mg, 500 mg PIROXICAM 2 NAPROXEN 2 (BULK) POWDER SODIUM (BULK) 100 % POWDER piroxicam oral 1 naproxen sodium 1 capsule 10 mg, 20 oral tablet 275 mg, mg 550 mg PRIALT 2 SP naproxen sodium 1 ST INTRATHECAL oral tablet, er SOLUTION 100 multiphase 24 hr MCG/ML, 25 375 mg, 500 mg MCG/ML naproxen- 1 ST SALSALATE 2 esomeprazole oral (BULK) POWDER tablet,ir,delayed 100 % rel,biphasic 375-20 mg, 500-20 mg salsalate oral tablet 1 500 mg, 750 mg NARCAN NASAL 2 QL SPRAY,NON- SODIUM 2 AEROSOL 4 SALICYLATE MG/ACTUATION (BULK) POWDER NUCYNTA ER 2 ST; QL st joseph aspirin 1 ACA; OTC ORAL TABLET oral tablet,chewable EXTENDED 81 mg RELEASE 12 HR SULINDAC 2 100 MG, 150 MG, (BULK) POWDER 200 MG, 250 MG, 50 MG sulindac oral tablet 1 150 mg, 200 mg NUCYNTA ORAL 2 QL TABLET 100 MG, tolmetin oral capsule 1 ST 50 MG, 75 MG 400 mg You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 55 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits tolmetin oral tablet 1 ABILIFY 2 200 mg MAINTENA INTRAMUSCULA tolmetin oral tablet 1 ST R 600 mg SUSPENSION,EXT TRAMADOL 2 ENDED REL HYDROCHLORID RECON 300 MG, E (BULK) 400 MG POWDER 100 % ABILIFY 2 tramadol oral tablet 1 QL MAINTENA 50 mg INTRAMUSCULA tramadol oral tablet 1 ST; QL R extended release 24 SUSPENSION,EXT hr 100 mg, 200 mg, ENDED REL 300 mg SYRING 300 MG, 400 MG tramadol oral tablet, 1 ST; QL er multiphase 24 hr ALPRAZOLAM 2 100 mg, 200 mg, 300 (BULK) POWDER mg 100 % tramadol- 1 QL alprazolam intensol 1 acetaminophen oral oral concentrate 1 tablet 37.5-325 mg mg/ml tri-buffered aspirin 1 ACA; OTC alprazolam oral 1 oral tablet 325 mg tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg VIVITROL 2 SP INTRAMUSCULA alprazolam oral 1 R tablet extended SUSPENSION,EXT release 24 hr 0.5 mg, ENDED REL 1 mg, 2 mg, 3 mg RECON 380 MG alprazolam oral 1 ZUBSOLV 2 QL tablet,disintegrating SUBLINGUAL 0.25 mg, 0.5 mg, 1 TABLET 0.7-0.18 mg, 2 mg MG, 1.4-0.36 MG, AMITRIPTYLINE 2 2.9-0.71 MG, 5.7- (BULK) POWDER 1.4 MG, 8.6-2.1 MG amitriptyline oral 1 ZUBSOLV 2 tablet 10 mg, 100 SUBLINGUAL mg, 150 mg, 25 mg, TABLET 11.4-2.9 50 mg, 75 mg MG PSYCHOTHERAPEUTIC DRUGS
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 56 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits amitriptyline- 1 armodafinil oral 1 PA; QL chlordiazepoxide tablet 150 mg, 200 oral tablet 12.5-5 mg, 250 mg, 50 mg mg, 25-10 mg atomoxetine oral 1 PA amoxapine oral 1 capsule 10 mg, 100 tablet 100 mg, 150 mg, 18 mg, 25 mg, mg, 25 mg, 50 mg 40 mg, 60 mg, 80 mg amphetamine sulfate 1 PA BUPROPION HCL 2 oral tablet 10 mg, 5 (BULK) POWDER mg 100 % AMYTAL 2 bupropion hcl oral 1 INJECTION tablet 100 mg, 75 mg RECON SOLN 500 bupropion hcl oral 1 QL MG tablet extended aripiprazole oral 1 release 24 hr 150 solution 1 mg/ml mg, 300 mg aripiprazole oral 1 QL bupropion hcl oral 1 QL tablet 10 mg, 15 mg, tablet sustained- 2 mg, 20 mg, 30 mg, release 12 hr 100 5 mg mg, 150 mg, 200 mg aripiprazole oral 1 QL BUSPIRONE 2 tablet,disintegrating (BULK) POWDER 10 mg, 15 mg 100 % ARISTADA INITIO 2 buspirone oral tablet 1 INTRAMUSCULA 10 mg, 15 mg, 30 R mg, 5 mg, 7.5 mg SUSPENSION,EXT BUTALBITAL 2 ENDED REL (BULK) POWDER SYRING 675 MG/2.4 ML CHLORAL 2 HYDRATE (BULK) ARISTADA 2 CRYSTALS INTRAMUSCULA R chlordiazepoxide hcl 1 SUSPENSION,EXT oral capsule 10 mg, ENDED REL 25 mg, 5 mg SYRING 1,064 CHLORPROMAZI 2 MG/3.9 ML, 441 NE (BULK) MG/1.6 ML, 662 POWDER 100 % MG/2.4 ML, 882 MG/3.2 ML chlorpromazine 1 injection solution 25 mg/ml You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 57 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits chlorpromazine oral 1 desipramine oral 1 tablet 10 mg, 100 tablet 10 mg, 100 mg, 200 mg, 25 mg, mg, 150 mg, 25 mg, 50 mg 50 mg, 75 mg citalopram oral 1 desvenlafaxine 1 ST; QL solution 10 mg/5 ml succinate oral tablet extended release 24 citalopram oral 1 QL hr 100 mg, 25 mg, tablet 10 mg, 20 mg, 50 mg 40 mg dexmedetomidine in 1 CLOMIPRAMINE 2 0.9 % nacl (BULK) POWDER intravenous solution 100 % 200 mcg/50 ml (4 clomipramine oral 1 mcg/ml), 400 capsule 25 mg, 50 mcg/100 ml (4 mg, 75 mg mcg/ml), 80 mcg/20 clonidine hcl oral 1 PA ml (4 mcg/ml) tablet extended dexmedetomidine 1 release 12 hr 0.1 mg intravenous solution clorazepate 1 100 mcg/ml dipotassium oral dexmethylphenidate 1 PA tablet 15 mg, 3.75 oral capsule,er mg, 7.5 mg biphasic 50-50 10 clozapine oral tablet 1 mg, 15 mg, 20 mg, 100 mg, 200 mg, 25 25 mg, 30 mg, 35 mg, 50 mg mg, 40 mg, 5 mg clozapine oral 1 dexmethylphenidate 1 PA tablet,disintegrating oral tablet 10 mg, 100 mg, 12.5 mg, 2.5 mg, 5 mg 150 mg, 200 mg, 25 dextroamphetamine 1 PA mg oral capsule, DAYTRANA 2 PA extended release 10 TRANSDERMAL mg, 15 mg, 5 mg PATCH 24 HOUR dextroamphetamine 1 PA 10 MG/9 HR, 15 oral solution 5 mg/5 MG/9 HR, 20 MG/9 ml HR, 30 MG/9 HR dextroamphetamine 1 PA DESIPRAMINE 2 oral tablet 10 mg, 5 HCL (BULK) mg POWDER
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 58 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits dextroamphetamine- 1 PA DOXYLAMINE 2 amphetamine oral SUCCINATE capsule,extended (BULK) POWDER release 24hr 10 mg, duloxetine oral 1 QL 15 mg, 20 mg, 25 capsule,delayed mg, 30 mg, 5 mg release(dr/ec) 20 dextroamphetamine- 1 PA mg, 30 mg, 60 mg amphetamine oral duloxetine oral 1 ST; QL tablet 10 mg, 12.5 capsule,delayed mg, 15 mg, 20 mg, release(dr/ec) 40 mg 30 mg, 5 mg, 7.5 mg DYANAVEL XR 2 PA DIAZEPAM 2 ORAL SUSPEN, IR (BULK) POWDER - ER, BIPHASIC 100 % 24HR 2.5 MG/ML diazepam injection 1 ERGOLOID 2 solution 5 mg/ml (BULK) POWDER diazepam injection 1 100 % syringe 5 mg/ml ergoloid oral tablet 1 diazepam intensol 1 1 mg oral concentrate 5 escitalopram oxalate 1 mg/ml oral solution 5 mg/5 diazepam oral 1 ml solution 5 mg/5 ml escitalopram oxalate 1 QL (1 mg/ml) oral tablet 10 mg, 20 diazepam oral tablet 1 mg, 5 mg 10 mg, 2 mg, 5 mg estazolam oral tablet 1 doxapram 1 1 mg, 2 mg intravenous solution eszopiclone oral 1 QL 20 mg/ml tablet 1 mg, 2 mg, 3 DOXEPIN HCL 2 mg (BULK) POWDER FETZIMA ORAL 2 ST; QL doxepin oral capsule 1 CAPSULE,EXT 10 mg, 100 mg, 150 REL 24HR DOSE mg, 25 mg, 50 mg, PACK 20 MG (2)- 75 mg 40 MG (26) doxepin oral 1 FETZIMA ORAL 2 ST; QL concentrate 10 CAPSULE,EXTEN mg/ml DED RELEASE 24 HR 120 MG, 20 doxepin oral tablet 3 1 PA; QL MG, 40 MG, 80 MG mg, 6 mg You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 59 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits flumazenil 1 flurazepam oral 1 intravenous solution capsule 15 mg, 30 0.1 mg/ml mg FLUOXETINE 2 fluvoxamine oral 1 PA; QL (BULK) POWDER capsule,extended 100 % release 24hr 100 mg, 150 mg fluoxetine oral 1 QL capsule 10 mg, 40 fluvoxamine oral 1 QL mg tablet 100 mg, 25 mg, 50 mg fluoxetine oral 1 capsule 20 mg guanfacine oral 1 PA tablet extended fluoxetine oral 1 QL release 24 hr 1 mg, 2 capsule,delayed mg, 3 mg, 4 mg release(dr/ec) 90 mg guanidine oral tablet 1 fluoxetine oral 1 125 mg solution 20 mg/5 ml (4 mg/ml) HALOPERIDOL 2 (BULK) POWDER fluoxetine oral tablet 1 PA; QL 10 mg HALOPERIDOL 2 DECANOATE fluoxetine oral tablet 1 PA (BULK) POWDER 20 mg, 60 mg 100 % FLUPHENAZINE 2 haloperidol 1 DECANOATE decanoate (BULK) OIL 2.5 % intramuscular (W/W) solution 100 mg/ml, fluphenazine 1 50 mg/ml decanoate injection haloperidol lactate 1 solution 25 mg/ml injection solution 5 fluphenazine hcl 1 mg/ml injection solution 2.5 haloperidol lactate 1 mg/ml intramuscular fluphenazine hcl oral 1 syringe 5 mg/ml concentrate 5 mg/ml haloperidol lactate 1 fluphenazine hcl oral 1 oral concentrate 2 elixir 2.5 mg/5 ml mg/ml fluphenazine hcl oral 1 haloperidol oral 1 tablet 1 mg, 10 mg, tablet 0.5 mg, 1 mg, 2.5 mg, 5 mg 10 mg, 2 mg, 20 mg, 5 mg
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 60 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits IMIPRAMINE 2 lorazepam injection 1 (BULK) POWDER syringe 2 mg/ml, 4 100 % mg/ml imipramine hcl oral 1 lorazepam intensol 1 tablet 10 mg, 25 mg, oral concentrate 2 50 mg mg/ml imipramine pamoate 1 lorazepam oral 1 oral capsule 100 mg, concentrate 2 mg/ml 125 mg, 150 mg, 75 lorazepam oral 1 mg tablet 0.5 mg, 1 mg, LATUDA ORAL 2 QL 2 mg TABLET 120 MG, loxapine succinate 1 20 MG, 40 MG, 60 oral capsule 10 mg, MG, 80 MG 25 mg, 5 mg, 50 mg LITHIUM 2 maprotiline oral 1 CARBONATE tablet 25 mg, 50 mg, (BULK) POWDER 75 mg 99 % metadate er oral 1 PA lithium carbonate 1 tablet extended oral capsule 150 mg, release 20 mg 300 mg, 600 mg methamphetamine 1 PA lithium carbonate 1 oral tablet 5 mg oral tablet 300 mg METHYLPHENID 2 lithium carbonate 1 ATE HCL (BULK) oral tablet extended POWDER release 300 mg, 450 mg methylphenidate hcl 1 PA oral cap,er lithium citrate oral 1 sprinkle,biphasic 40- solution 8 meq/5 ml 60 10 mg, 15 mg, 20 LITHIUM 2 mg, 30 mg, 40 mg, CITRATE 50 mg, 60 mg TETRAHYD(BULK methylphenidate hcl 1 PA ) POWDER 100 % oral capsule, er LORAZEPAM 2 biphasic 30-70 10 (BULK) POWDER mg, 20 mg, 30 mg, 100 % 40 mg, 50 mg, 60 mg lorazepam injection 1 solution 2 mg/ml, 4 mg/ml
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 61 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits methylphenidate hcl 1 PA midazolam oral 1 oral capsule,er syrup 2 mg/ml biphasic 50-50 10 mirtazapine oral 1 mg, 20 mg, 30 mg, tablet 15 mg, 30 mg, 40 mg, 60 mg 45 mg, 7.5 mg methylphenidate hcl 1 PA mirtazapine oral 1 oral solution 10 tablet,disintegrating mg/5 ml, 5 mg/5 ml 15 mg, 30 mg, 45 mg methylphenidate hcl 1 PA modafinil oral tablet 1 PA; QL oral tablet 10 mg, 20 100 mg, 200 mg mg, 5 mg molindone oral 1 methylphenidate hcl 1 PA tablet 10 mg, 25 mg, oral tablet extended 5 mg release 10 mg, 20 mg MYDAYIS ORAL 2 PA CAPSULE, ER methylphenidate hcl 1 PA TRIPHASIC 24 HR oral tablet extended 12.5 MG, 25 MG, release 24hr 18 mg, 37.5 MG, 50 MG 27 mg, 36 mg, 54 mg NORTRIPTYLINE 2 methylphenidate hcl 1 PA (BULK) POWDER oral tablet,chewable 10 mg, 2.5 mg, 5 mg nortriptyline oral 1 capsule 10 mg, 25 MIDAZOLAM 2 mg, 50 mg, 75 mg (BULK) POWDER 100 % nortriptyline oral 1 solution 10 mg/5 ml midazolam (pf) in 1 0.9 % nacl olanzapine 1 intravenous solution intramuscular recon 1 mg/ml soln 10 mg midazolam (pf) 1 olanzapine oral 1 QL injection cartridge 2 tablet 10 mg, 15 mg, mg/2 ml (1 mg/ml), 5 2.5 mg, 20 mg, 5 mg, mg/ml 7.5 mg midazolam (pf) 1 olanzapine oral 1 QL injection syringe 2 tablet,disintegrating mg/2 ml (1 mg/ml), 5 10 mg, 15 mg, 20 mg/ml mg, 5 mg midazolam injection 1 solution 1 mg/ml, 5 mg/ml
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 62 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits olanzapine- 1 pimozide oral tablet 1 fluoxetine oral 1 mg, 2 mg capsule 12-25 mg, procentra oral 1 PA 12-50 mg, 3-25 mg, solution 5 mg/5 ml 6-25 mg, 6-50 mg protriptyline oral 1 paliperidone oral 1 QL tablet 10 mg, 5 mg tablet extended release 24hr 1.5 mg, quazepam oral tablet 1 3 mg, 6 mg, 9 mg 15 mg paroxetine hcl oral 1 QL quetiapine oral 1 QL tablet 10 mg, 20 mg, tablet 100 mg, 200 30 mg, 40 mg mg, 25 mg, 300 mg, 400 mg, 50 mg paroxetine hcl oral 1 PA; QL tablet extended quetiapine oral 1 QL release 24 hr 12.5 tablet extended mg, 25 mg, 37.5 mg release 24 hr 150 mg, 200 mg, 300 mg, paroxetine 1 PA; QL 400 mg, 50 mg mesylate(menop.sym ) oral capsule 7.5 QUILLICHEW ER 2 PA mg ORAL TABLET,CHEW,IR PENTOBARBITAL 2 - SODIUM (BULK) ER.BIPHASIC24HR POWDER 100 % 20 MG, 30 MG, 40 pentobarbital 1 MG sodium injection QUILLIVANT XR 2 PA solution 50 mg/ml ORAL perphenazine oral 1 SUSPENSION,EXT tablet 16 mg, 2 mg, 4 REL 24HR,RECON mg, 8 mg 5 MG/ML (25 MG/5 ML) perphenazine- 1 amitriptyline oral ramelteon oral tablet 1 QL tablet 2-10 mg, 2-25 8 mg mg, 4-10 mg, 4-25 mg, 4-50 mg PHENELZINE 2 (BULK) POWDER 100 % phenelzine oral 1 tablet 15 mg
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 63 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits RISPERDAL 2 thiothixene oral 1 CONSTA capsule 1 mg, 10 mg, INTRAMUSCULA 2 mg, 5 mg R tranylcypromine 1 SUSPENSION,EXT oral tablet 10 mg ENDED REL RECON 12.5 MG/2 TRAZODONE 2 ML, 25 MG/2 ML, (BULK) POWDER 37.5 MG/2 ML, 50 trazodone oral tablet 1 MG/2 ML 100 mg, 150 mg, 300 risperidone oral 1 mg, 50 mg solution 1 mg/ml triazolam oral tablet 1 risperidone oral 1 QL 0.125 mg, 0.25 mg tablet 0.25 mg, 0.5 trifluoperazine oral 1 mg, 1 mg, 2 mg, 3 tablet 1 mg, 10 mg, 2 mg, 4 mg mg, 5 mg risperidone oral 1 QL trimipramine oral 1 tablet,disintegrating capsule 100 mg, 25 0.25 mg, 0.5 mg, 1 mg, 50 mg mg, 2 mg, 3 mg, 4 mg venlafaxine oral 1 QL capsule,extended seconal sodium oral 1 QL release 24hr 150 mg, capsule 100 mg 37.5 mg, 75 mg SERTRALINE 2 venlafaxine oral 1 QL (BULK) POWDER tablet 100 mg, 25 100 % mg, 37.5 mg, 50 mg, sertraline oral 1 75 mg concentrate 20 venlafaxine oral 1 ST; QL mg/ml tablet extended sertraline oral tablet 1 QL release 24hr 150 mg, 100 mg, 25 mg, 50 225 mg, 37.5 mg, 75 mg mg SUNOSI ORAL 2 PA; QL VIIBRYD ORAL 2 PA; QL TABLET 150 MG, TABLET 10 MG, 20 75 MG MG, 40 MG THIORIDAZINE 2 VIIBRYD ORAL 2 PA; QL (BULK) POWDER TABLETS,DOSE 100 % PACK 10 MG (7)- 20 MG (23) thioridazine oral 1 tablet 10 mg, 100 mg, 25 mg, 50 mg You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 64 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits VYVANSE ORAL 2 PA ANTIARRHYTHMIC AGENTS CAPSULE 10 MG, adenosine 1 20 MG, 30 MG, 40 (diagnostic) MG, 50 MG, 60 intravenous solution MG, 70 MG 3 mg/ml VYVANSE ORAL 2 PA adenosine 1 TABLET,CHEWAB intravenous solution LE 10 MG, 20 MG, 3 mg/ml 30 MG, 40 MG, 50 MG, 60 MG adenosine 1 intravenous syringe XYREM ORAL 2 ST; SP 3 mg/ml SOLUTION 500 MG/ML amiodarone 1 intravenous solution zaleplon oral 1 QL 50 mg/ml capsule 10 mg, 5 mg amiodarone 1 zenzedi oral tablet 1 PA intravenous syringe 10 mg, 5 mg 150 mg/3 ml ziprasidone hcl oral 1 QL amiodarone oral 1 capsule 20 mg, 40 tablet 100 mg, 200 mg, 60 mg, 80 mg mg, 400 mg ziprasidone mesylate 1 bretylium tosylate 1 intramuscular recon injection solution 50 soln 20 mg/ml (final mg/ml conc.) dofetilide oral 1 zolpidem oral tablet 1 QL capsule 125 mcg, 10 mg, 5 mg 250 mcg, 500 mcg zolpidem oral 1 QL flecainide oral tablet 1 tablet,ext release 100 mg, 150 mg, 50 multiphase 12.5 mg, mg 6.25 mg ibutilide fumarate 1 zolpidem sublingual 1 QL intravenous solution tablet 1.75 mg, 3.5 0.1 mg/ml mg lidocaine (pf) in 1 ZULRESSO 2 PA; SP d7.5w intrathecal INTRAVENOUS solution 50 mg/ml (5 SOLUTION 5 %) MG/ML lidocaine (pf) 1 CARDIOVASCULAR, intravenous solution HYPERTENSION / LIPIDS 20 mg/ml (2 %)
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 65 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits lidocaine (pf) 1 quinidine gluconate 1 intravenous syringe oral tablet extended 100 mg/5 ml (2 %), release 324 mg 50 mg/5 ml (1 %) QUINIDINE 2 lidocaine in 5 % 1 SULFATE (BULK) dextrose (pf) CRYSTALS intravenous QUINIDINE 2 parenteral solution 4 SULFATE (BULK) mg/ml (0.4 %), 8 POWDER 100 % mg/ml (0.8 %) quinidine sulfate 1 MEXILETINE 2 oral tablet 200 mg, (BULK) POWDER 300 mg 100 % sorine oral tablet 1 mexiletine oral 1 120 mg, 160 mg, 240 capsule 150 mg, 200 mg, 80 mg mg, 250 mg sotalol af oral tablet 1 NEXTERONE 2 120 mg, 160 mg, 80 INTRAVENOUS mg SOLUTION 150 MG/100 ML (1.5 SOTALOL 2 MG/ML), 360 INTRAVENOUS MG/200 ML (1.8 SOLUTION 150 MG/ML) MG/10 ML (15 MG/ML) pacerone oral tablet 1 100 mg, 200 mg, 400 sotalol oral tablet 1 mg 120 mg, 160 mg, 240 mg, 80 mg PROCAINAMIDE 2 HCL (BULK) SOTYLIZE ORAL 2 POWDER SOLUTION 5 MG/ML procainamide 1 injection solution ANTIHYPERTENSIVE THERAPY 100 mg/ml, 500 ACEBUTOLOL 2 mg/ml (BULK) POWDER propafenone oral 1 acebutolol oral 1 capsule,extended capsule 200 mg, 400 release 12 hr 225 mg mg, 325 mg, 425 mg aliskiren oral tablet 1 propafenone oral 1 150 mg, 300 mg tablet 150 mg, 225 mg, 300 mg amiloride oral tablet 1 5 mg
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 66 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits amiloride- 1 atenolol- 1 hydrochlorothiazide chlorthalidone oral oral tablet 5-50 mg tablet 100-25 mg, 50-25 mg AMLODIPINE 2 BESYLATE BENAZEPRIL HCL 2 (BULK) POWDER (BULK) POWDER 100 % 100 % amlodipine oral 1 benazepril oral 1 tablet 10 mg, 2.5 mg, tablet 10 mg, 20 mg, 5 mg 40 mg, 5 mg amlodipine- 1 benazepril- 1 benazepril oral hydrochlorothiazide capsule 10-20 mg, oral tablet 10-12.5 10-40 mg, 2.5-10 mg, 20-12.5 mg, 20- mg, 5-10 mg, 5-20 25 mg, 5-6.25 mg mg, 5-40 mg BETAHISTINE 2 amlodipine- 1 (BULK) POWDER olmesartan oral 100 % tablet 10-20 mg, 10- betaxolol oral tablet 1 40 mg, 5-20 mg, 5- 10 mg, 20 mg 40 mg bisoprolol fumarate 1 amlodipine- 1 oral tablet 10 mg, 5 valsartan oral tablet mg 10-160 mg, 10-320 mg, 5-160 mg, 5-320 bisoprolol- 1 mg hydrochlorothiazide oral tablet 10-6.25 amlodipine- 1 mg, 2.5-6.25 mg, 5- valsartan-hcthiazid 6.25 mg oral tablet 10-160- 12.5 mg, 10-160-25 bumetanide injection 1 mg, 10-320-25 mg, solution 0.25 mg/ml 5-160-12.5 mg, 5- bumetanide oral 1 160-25 mg tablet 0.5 mg, 1 mg, ATENOLOL 2 2 mg (BULK) POWDER BYSTOLIC ORAL 2 PA 100 % TABLET 10 MG, atenolol oral tablet 1 2.5 MG, 20 MG, 5 100 mg, 25 mg, 50 MG mg candesartan oral 1 tablet 16 mg, 32 mg, 4 mg, 8 mg
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 67 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits candesartan- 1 CLONIDINE HCL 2 hydrochlorothiazid (BULK) POWDER oral tablet 16-12.5 clonidine hcl oral 1 mg, 32-12.5 mg, 32- tablet 0.1 mg, 0.2 25 mg mg, 0.3 mg CAPTOPRIL 2 clonidine 1 QL (BULK) POWDER transdermal patch 100 % weekly 0.1 mg/24 hr, captopril oral tablet 1 0.2 mg/24 hr, 0.3 100 mg, 12.5 mg, 25 mg/24 hr mg, 50 mg corlopam 1 captopril- 1 intravenous solution hydrochlorothiazide 10 mg/ml oral tablet 25-15 mg, CYCLANDELATE 2 25-25 mg, 50-15 mg, (BULK) POWDER 50-25 mg DILTIAZEM HCL 2 cartia xt oral 1 (BULK) POWDER capsule,extended release 24hr 120 mg, diltiazem hcl 1 180 mg, 240 mg, 300 intravenous recon mg soln 100 mg carvedilol oral tablet 1 diltiazem hcl 1 12.5 mg, 25 mg, intravenous solution 3.125 mg, 6.25 mg 5 mg/ml carvedilol phosphate 1 diltiazem hcl oral 1 oral capsule, er capsule,ext.rel 24h multiphase 24 hr 10 degradable 120 mg, mg, 20 mg, 40 mg, 180 mg, 240 mg 80 mg diltiazem hcl oral 1 chlorothiazide oral 1 capsule,extended tablet 500 mg release 12 hr 120 mg, 60 mg, 90 mg chlorothiazide 1 sodium intravenous diltiazem hcl oral 1 recon soln 500 mg capsule,extended release 24 hr 120 chlorthalidone oral 1 mg, 180 mg, 240 mg, tablet 25 mg, 50 mg 300 mg, 360 mg, 420 clonidine (pf) 1 mg epidural solution 1,000 mcg/10 ml (100 mcg/ml)
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 68 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits diltiazem hcl oral 1 eplerenone oral 1 capsule,extended tablet 25 mg, 50 mg release 24hr 120 mg, epoprostenol 1 PA; SP 180 mg, 240 mg, 300 (glycine) mg, 360 mg intravenous recon diltiazem hcl oral 1 soln 0.5 mg, 1.5 mg tablet 120 mg, 30 eprosartan oral 1 mg, 60 mg, 90 mg tablet 600 mg diltiazem hcl oral 1 esmolol in nacl (iso- 1 tablet extended osm) intravenous release 24 hr 180 parenteral solution mg, 240 mg, 300 mg, 2,000 mg/100 ml, 360 mg, 420 mg 2,500 mg/250 ml (10 dilt-xr oral 1 mg/ml) capsule,ext.rel 24h esmolol intravenous 1 degradable 120 mg, solution 100 mg/10 180 mg, 240 mg ml (10 mg/ml) doxazosin oral tablet 1 QL esmolol intravenous 1 1 mg, 2 mg, 4 mg, 8 syringe 100 mg/10 mg ml (10 mg/ml) EDARBI ORAL 2 PA ethacrynate sodium 1 TABLET 40 MG, 80 intravenous recon MG soln 50 mg EDARBYCLOR 2 PA ethacrynic acid oral 1 ORAL TABLET 40- tablet 25 mg 12.5 MG, 40-25 MG felodipine oral tablet 1 ENALAPRIL 2 extended release 24 MALEATE (BULK) hr 10 mg, 2.5 mg, 5 POWDER 100 % mg enalapril maleate 1 FLOLAN 2 PA; SP oral tablet 10 mg, INTRAVENOUS 2.5 mg, 20 mg, 5 mg RECON SOLN 0.5 enalaprilat 1 MG, 1.5 MG intravenous solution fosinopril oral tablet 1 1.25 mg/ml 10 mg, 20 mg, 40 mg enalapril- 1 fosinopril- 1 hydrochlorothiazide hydrochlorothiazide oral tablet 10-25 mg, oral tablet 10-12.5 5-12.5 mg mg, 20-12.5 mg
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 69 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits FUROSEMIDE 2 indapamide oral 1 (BULK) POWDER tablet 1.25 mg, 2.5 mg furosemide injection 1 solution 10 mg/ml irbesartan oral 1 tablet 150 mg, 300 furosemide injection 1 mg, 75 mg syringe 10 mg/ml irbesartan- 1 furosemide oral 1 hydrochlorothiazide solution 10 mg/ml, oral tablet 150-12.5 40 mg/5 ml (8 mg, 300-12.5 mg mg/ml) isradipine oral 1 furosemide oral 1 capsule 2.5 mg, 5 mg tablet 20 mg, 40 mg, 80 mg LABETALOL 2 (BULK) POWDER GUANABENZ 2 (BULK) POWDER labetalol 1 100 % intravenous solution 5 mg/ml GUANETHIDINE 2 SULFATE (BULK) labetalol 1 POWDER intravenous syringe 20 mg/4 ml (5 guanfacine oral 1 mg/ml), 25 mg/5 ml tablet 1 mg, 2 mg (5 mg/ml) HYDRALAZINE 2 labetalol oral tablet 1 HCL (BULK) 100 mg, 200 mg, 300 POWDER mg hydralazine injection 1 LISINOPRIL 2 solution 20 mg/ml (BULK) POWDER hydralazine oral 1 100 % tablet 10 mg, 100 lisinopril oral tablet 1 mg, 25 mg, 50 mg 10 mg, 2.5 mg, 20 HYDROCHLOROT 2 mg, 30 mg, 40 mg, 5 HIAZIDE (BULK) mg POWDER 100 % lisinopril- 1 hydrochlorothiazide 1 hydrochlorothiazide oral capsule 12.5 mg oral tablet 10-12.5 hydrochlorothiazide 1 mg, 20-12.5 mg, 20- oral tablet 12.5 mg, 25 mg 25 mg, 50 mg losartan oral tablet 1 100 mg, 25 mg, 50 mg
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 70 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits losartan- 1 metoprolol succinate 1 hydrochlorothiazide oral tablet extended oral tablet 100-12.5 release 24 hr 100 mg, 100-25 mg, 50- mg, 200 mg, 25 mg, 12.5 mg 50 mg MANNITOL 2 metoprolol ta- 1 (BULK) POWDER hydrochlorothiaz oral tablet 100-25 mannitol 10 % 1 mg, 100-50 mg, 50- intravenous 25 mg parenteral solution 10 % METOPROLOL 2 TARTRATE mannitol 20 % 1 (BULK) POWDER intravenous 100 % parenteral solution 20 % metoprolol tartrate 1 intravenous solution mannitol 25 % 1 5 mg/5 ml intravenous solution 25 % metoprolol tartrate 1 oral tablet 100 mg, mannitol 5 % 1 25 mg, 37.5 mg, 50 intravenous mg, 75 mg parenteral solution 5 % metyrosine oral 1 PA capsule 250 mg matzim la oral tablet 1 extended release 24 MINOXIDIL 2 hr 180 mg, 240 mg, (BULK) POWDER 300 mg, 360 mg, 420 minoxidil oral tablet 1 mg 10 mg, 2.5 mg methyldopa oral 1 moexipril oral tablet 1 tablet 250 mg, 500 15 mg, 7.5 mg mg NADOLOL (BULK) 2 methyldopa- 1 POWDER hydrochlorothiazide oral tablet 250-15 nadolol oral tablet 1 mg, 250-25 mg 20 mg, 40 mg, 80 mg methyldopate 1 nadolol- 1 intravenous solution bendroflumethiazide 250 mg/5 ml oral tablet 80-5 mg metolazone oral 1 nicardipine 1 tablet 10 mg, 2.5 mg, intravenous solution 5 mg 25 mg/10 ml
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 71 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits nicardipine oral 1 osmitrol 20 % 1 capsule 20 mg, 30 intravenous mg parenteral solution 20 % NIFEDIPINE 2 (BULK) POWDER PAPAVERINE 2 (BULK) POWDER nifedipine oral tablet 1 extended release papaverine injection 1 24hr 30 mg, 60 mg, solution 30 mg/ml 90 mg perindopril 1 nifedipine oral tablet 1 erbumine oral tablet extended release 30 2 mg, 4 mg, 8 mg mg, 60 mg, 90 mg PHENOXYBENZA 2 nimodipine oral 1 MINE (BULK) capsule 30 mg POWDER nisoldipine oral 1 phenoxybenzamine 1 PA tablet extended oral capsule 10 mg release 24 hr 17 mg, phentolamine 1 20 mg, 25.5 mg, 30 injection recon soln mg, 34 mg, 40 mg, 5 mg 8.5 mg PHENTOLAMINE 2 NYLIDRIN (BULK) 2 MESYLATE POWDER 100 % (BULK) POWDER olmesartan oral 1 pindolol oral tablet 1 tablet 20 mg, 40 mg, 10 mg, 5 mg 5 mg prazosin oral 1 olmesartan- 1 capsule 1 mg, 2 mg, amlodipin-hcthiazid 5 mg oral tablet 20-5-12.5 mg, 40-10-12.5 mg, PROPRANOLOL 2 40-10-25 mg, 40-5- (BULK) POWDER 12.5 mg, 40-5-25 mg propranolol 1 olmesartan- 1 intravenous solution hydrochlorothiazide 1 mg/ml oral tablet 20-12.5 propranolol oral 1 mg, 40-12.5 mg, 40- capsule,extended 25 mg release 24 hr 120 osmitrol 15 % 1 mg, 160 mg, 60 mg, intravenous 80 mg parenteral solution 15 %
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 72 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits propranolol oral 1 taztia xt oral 1 solution 20 mg/5 ml capsule,extended (4 mg/ml), 40 mg/5 release 24 hr 120 ml (8 mg/ml) mg, 180 mg, 240 mg, 300 mg, 360 mg propranolol oral 1 tablet 10 mg, 20 mg, TEKTURNA HCT 2 40 mg, 60 mg, 80 mg ORAL TABLET 150-12.5 MG, 150- propranolol- 1 25 MG, 300-12.5 hydrochlorothiazid MG, 300-25 MG oral tablet 40-25 mg, 80-25 mg telmisartan oral 1 tablet 20 mg, 40 mg, quinapril oral tablet 1 80 mg 10 mg, 20 mg, 40 mg, 5 mg telmisartan- 1 amlodipine oral quinapril- 1 tablet 40-10 mg, 40- hydrochlorothiazide 5 mg, 80-10 mg, 80- oral tablet 10-12.5 5 mg mg, 20-12.5 mg, 20- 25 mg telmisartan- 1 hydrochlorothiazid ramipril oral 1 oral tablet 40-12.5 capsule 1.25 mg, 10 mg, 80-12.5 mg, 80- mg, 2.5 mg, 5 mg 25 mg RESERPINE 2 terazosin oral 1 QL (BULK) POWDER capsule 1 mg, 10 mg, 100 % 2 mg, 5 mg SODIUM NITRITE 2 tiadylt er oral 1 (BULK) capsule,extended GRANULES release 24 hr 120 SPIRONOLACTON 2 mg, 180 mg, 240 mg, E (BULK) 300 mg, 360 mg, 420 POWDER 100 % mg SPIRONOLACTON 2 TIMOLOL 2 E MICRO (BULK) MALEATE (BULK) POWDER 100 % POWDER 100 % spironolactone oral 1 timolol maleate oral 1 tablet 100 mg, 25 tablet 10 mg, 20 mg, mg, 50 mg 5 mg spironolacton- 1 TOLAZOLINE 2 hydrochlorothiaz (BULK) POWDER oral tablet 25-25 mg 100 %
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 73 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits torsemide oral tablet 1 UPTRAVI ORAL 2 PA; SP 10 mg, 100 mg, 20 TABLETS,DOSE mg, 5 mg PACK 200 MCG (140)- 800 MCG trandolapril oral 1 (60) tablet 1 mg, 2 mg, 4 mg valsartan oral tablet 1 160 mg, 320 mg, 40 trandolapril- 1 mg, 80 mg verapamil oral tablet, ir - er, valsartan- 1 biphasic 24hr 1-240 hydrochlorothiazide mg, 2-180 mg, 2-240 oral tablet 160-12.5 mg, 4-240 mg mg, 160-25 mg, 320- 12.5 mg, 320-25 mg, treprostinil sodium 1 PA; SP 80-12.5 mg injection solution 1 mg/ml, 10 mg/ml, 2.5 veletri intravenous 1 PA; SP mg/ml, 5 mg/ml recon soln 0.5 mg, 1.5 mg TRIAMTERENE 2 (BULK) POWDER VERAPAMIL 2 (BULK) POWDER triamterene oral 1 100 % capsule 100 mg, 50 mg verapamil 1 intravenous solution triamterene- 1 2.5 mg/ml hydrochlorothiazid oral capsule 37.5-25 verapamil 1 mg intravenous syringe 2.5 mg/ml triamterene- 1 hydrochlorothiazid verapamil oral 1 oral tablet 37.5-25 capsule, 24 hr er mg, 75-50 mg pellet ct 100 mg, 200 mg, 300 mg TRICHLORMETHI 2 AZIDE (BULK) verapamil oral 1 POWDER 100 % capsule,ext rel. pellets 24 hr 120 mg, UPTRAVI ORAL 2 PA; SP 180 mg, 240 mg, 360 TABLET 1,000 mg MCG, 1,200 MCG, 1,400 MCG, 1,600 verapamil oral tablet 1 MCG, 200 MCG, 120 mg, 40 mg, 80 400 MCG, 600 mg MCG, 800 MCG verapamil oral tablet 1 extended release 120 mg, 180 mg, 240 mg You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 74 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits CARDIAC GLYCOSIDES ADYNOVATE 2 PA; SP INTRAVENOUS digitek oral tablet 1 SOLUTION 1,000 125 mcg (0.125 mg), (+/-) UNIT, 1,500 250 mcg (0.25 mg) (+/-) UNIT, 2,000 digox oral tablet 125 1 (+/-) UNIT, 250 (+/- mcg (0.125 mg), 250 ) UNIT, 3,000 (+/-) mcg (0.25 mg) UNIT, 500 (+/-) UNIT, 750 (+/-) digoxin injection 1 UNIT solution 250 mcg/ml (0.25 mg/ml) AFSTYLA 2 PA; SP INTRAVENOUS digoxin injection 1 RECON SOLN syringe 250 mcg/ml 1,000 (+/-) UNIT (0.25 mg/ml) RANGE, 1,500 (+/-) digoxin oral solution 1 UNIT RANGE, 50 mcg/ml (0.05 2,000 (+/-) UNIT mg/ml) RANGE, 2,500 (+/-) digoxin oral tablet 1 UNIT RANGE, 250 125 mcg (0.125 mg), (+/-) UNIT RANGE, 250 mcg (0.25 mg) 3,000 (+/-) UNIT RANGE, 500 (+/-) LANOXIN 2 UNIT RANGE PEDIATRIC INJECTION ALPHANATE 2 PA; SP SOLUTION 100 INTRAVENOUS MCG/ML (0.1 RECON SOLN MG/ML) 1,000 (400 VWF) UNIT/10 ML, 1,500 COAGULATION THERAPY (600 VWF) ADVATE 2 PA; SP UNIT/10 ML, 2,000 INTRAVENOUS (800 VWF) RECON SOLN UNIT/10 ML, 250 1,000 (+/-) UNIT, (100 VWF) UNIT/5 1,500 (+/-) UNIT, ML, 500 (200 VWF) 2,000 (+/-) UNIT, UNIT/5 ML 250 (+/-) UNIT, ALPHANINE SD 2 PA; SP 3,000 (+/-) UNIT, INTRAVENOUS 4,000 (+/-) UNIT, RECON SOLN 500 (+/-) UNIT 1,000 (+/-) UNIT, 1,500 (+/-) UNIT, 500 (+/-) UNIT
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 75 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits ALPROLIX 2 PA; SP CEPROTIN (BLUE 2 PA; SP INTRAVENOUS BAR) RECON SOLN INTRAVENOUS 1,000 UNIT, 2,000 RECON SOLN 500 UNIT, 250 UNIT, UNIT 3,000 UNIT, 4,000 CEPROTIN 2 PA; SP UNIT, 500 UNIT (GREEN BAR) AMINOCAPROIC 2 INTRAVENOUS ACID (BULK) RECON SOLN POWDER 100 % 1,000 UNIT aminocaproic acid 1 cilostazol oral tablet 1 intravenous solution 100 mg, 50 mg 250 mg/ml clopidogrel oral 1 aminocaproic acid 1 tablet 300 mg, 75 mg oral solution 250 COAGADEX 2 PA; SP mg/ml (25 %) INTRAVENOUS aminocaproic acid 1 RECON SOLN 250 oral tablet 1,000 mg, (+/-) UNIT RANGE, 500 mg 500 (+/-) UNIT RANGE aspirin-dipyridamole 1 oral capsule, er CORIFACT 2 PA; SP multiphase 12 hr 25- INTRAVENOUS 200 mg RECON SOLN 1,000-1,600 UNIT BENEFIX 2 PA; SP INTRAVENOUS DICUMAROL 2 RECON SOLN (BULK) POWDER 1,000 UNIT, 2,000 DIPYRIDAMOLE 2 UNIT, 250 UNIT, (BULK) POWDER 3,000 UNIT, 500 100 % UNIT dipyridamole 1 bivalirudin 1 intravenous solution intravenous recon 5 mg/ml soln 250 mg dipyridamole oral 1 BRILINTA ORAL 2 tablet 25 mg, 50 mg, TABLET 60 MG, 90 75 mg MG DOPTELET (10 2 PA; SP; QL CABLIVI 2 PA; SP TAB PACK) ORAL INJECTION KIT 11 TABLET 20 MG MG
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 76 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits DOPTELET (15 2 PA; SP; QL ESPEROCT 2 PA; SP TAB PACK) ORAL INTRAVENOUS TABLET 20 MG RECON SOLN 1,000 (+/-) UNIT, DOPTELET (30 2 PA; SP; QL 1,500 (+/-) UNIT, TAB PACK) ORAL 2,000 (+/-) UNIT, TABLET 20 MG 3,000 (+/-) UNIT, ELIQUIS DVT-PE 2 PA 500 (+/-) UNIT TREAT 30D FEIBA NF 2 PA; SP START ORAL INTRAVENOUS TABLETS,DOSE RECON SOLN PACK 5 MG (74 1,750-3,250 UNIT, TABS) 350-650 UNIT, 700- ELIQUIS ORAL 2 PA 1,300 UNIT TABLET 2.5 MG, 5 fondaparinux 1 SP MG subcutaneous ELOCTATE 2 PA; SP syringe 10 mg/0.8 INTRAVENOUS ml, 2.5 mg/0.5 ml, 5 RECON SOLN mg/0.4 ml, 7.5 1,000 UNIT, 1,500 mg/0.6 ml UNIT, 2,000 UNIT, FRAGMIN 2 SP 250 UNIT, 3,000 SUBCUTANEOUS UNIT, 4,000 UNIT, SOLUTION 25,000 5,000 UNIT, 500 ANTI-XA UNIT, 6,000 UNIT, UNIT/ML 750 UNIT FRAGMIN 2 SP enoxaparin 1 SP SUBCUTANEOUS subcutaneous SYRINGE 10,000 solution 300 mg/3 ml ANTI-XA enoxaparin 1 SP UNIT/ML, 12,500 subcutaneous ANTI-XA UNIT/0.5 syringe 100 mg/ml, ML, 15,000 ANTI- 120 mg/0.8 ml, 150 XA UNIT/0.6 ML, mg/ml, 30 mg/0.3 ml, 18,000 ANTI-XA 40 mg/0.4 ml, 60 UNIT/0.72 ML, mg/0.6 ml, 80 mg/0.8 2,500 ANTI-XA ml UNIT/0.2 ML, 5,000 eptifibatide 1 ANTI-XA UNIT/0.2 intravenous solution ML, 7,500 ANTI- 0.75 mg/ml, 2 mg/ml XA UNIT/0.3 ML
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 77 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits HEMLIBRA 2 PA; SP heparin (porcine) in 1 SUBCUTANEOUS nacl (pf) intravenous SOLUTION 105 parenteral solution MG/0.7 ML, 150 1,000 unit/500 ml, MG/ML, 30 2,000 unit/1,000 ml MG/ML, 60 MG/0.4 heparin (porcine) 1 ML injection cartridge HEMOFIL M HIGH 2 PA; SP 5,000 unit/ml (1 ml) INTRAVENOUS heparin (porcine) 1 RECON SOLN 801- injection solution 1,500 UNIT 1,000 unit/ml, HEMOFIL M LOW 2 PA; SP 10,000 unit/ml, INTRAVENOUS 20,000 unit/ml, RECON SOLN 220- 5,000 unit/ml 400 UNIT heparin (porcine) 1 HEMOFIL M MID 2 PA; SP injection syringe INTRAVENOUS 5,000 unit/ml RECON SOLN 401- heparin 1 800 UNIT flush(porcine)- HEMOFIL M 2 PA; SP 0.9nacl intravenous SUPER HIGH kit 100 unit/ml INTRAVENOUS heparin lock flush 1 RECON SOLN (porcine) 1,501-2,000 UNIT intravenous solution hep flush-10 (pf) 1 10 unit/ml, 100 intravenous solution unit/ml 10 unit/ml heparin lock flush 1 HEPARIN 2 intravenous solution (PORCINE) 10 unit/ml (BULK) POWDER heparin lock flush 1 180 UNIT/MG intravenous syringe (USP) 10 unit/ml heparin (porcine) in 1 heparin 1 5 % dex intravenous lockflush(porcine)(pf parenteral solution ) intravenous syringe 20,000 unit/500 ml 10 unit/ml, 100 (40 unit/ml), 25,000 unit/ml unit/250 ml(100 unit/ml), 25,000 unit/500 ml (50 unit/ml)
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 78 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits heparin(porcine) in 1 JIVI 2 PA; SP 0.45% nacl INTRAVENOUS intravenous RECON SOLN parenteral solution 1,000 (+/-) UNIT, 25,000 unit/250 ml, 2,000 (+/-) UNIT, 25,000 unit/500 ml 3,000 (+/-) UNIT, 500 (+/-) UNIT heparin, porcine (pf) 1 injection solution KOGENATE FS 2 PA; SP 1,000 unit/ml INTRAVENOUS RECON SOLN HEPARIN, 2 1,000 (+/-) UNIT, PORCINE (PF) 2,000 (+/-) UNIT, INJECTION 250 (+/-) UNIT, SOLUTION 5,000 3,000 (+/-) UNIT, UNIT/0.5 ML 500 (+/-) UNIT heparin, porcine (pf) 1 KOVALTRY 2 PA; SP injection syringe INTRAVENOUS 5,000 unit/0.5 ml RECON SOLN heparin, porcine (pf) 1 1,000 (+/-) UNIT, intravenous solution 2,000 (+/-) UNIT, 100 unit/ml (1 ml) 250 (+/-) UNIT, heparin, porcine (pf) 1 3,000 (+/-) UNIT, intravenous syringe 500 (+/-) UNIT 1 unit/ml, 10 unit/ml, MONONINE 2 PA; SP 100 unit/ml INTRAVENOUS HUMATE-P 2 PA; SP RECON SOLN INTRAVENOUS 1,000 (+/-) UNIT RECON SOLN NOVOEIGHT 2 PA; SP 1,000-2,400 UNIT, INTRAVENOUS 250-600 UNIT, 500- RECON SOLN 1,200 UNIT 1,000 (+/-) UNIT, IXINITY 2 PA; SP 1,500 (+/-) UNIT, INTRAVENOUS 2,000 (+/-) UNIT, RECON SOLN 250 (+/-) UNIT, 1,000 UNIT, 1,500 3,000 (+/-) UNIT, UNIT, 2,000 UNIT, 500 (+/-) UNIT 250 UNIT, 3,000 NOVOSEVEN RT 2 PA; SP UNIT, 500 UNIT INTRAVENOUS jantoven oral tablet 1 RECON SOLN 1 1 mg, 10 mg, 2 mg, MG (1,000 MCG), 2 2.5 mg, 3 mg, 4 mg, MG (2,000 MCG), 5 5 mg, 6 mg, 7.5 mg MG (5,000 MCG), 8 MG (8,000 MCG)
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 79 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits NPLATE 2 PA; SP PROMACTA 2 PA; SP SUBCUTANEOUS ORAL POWDER IN RECON SOLN 125 PACKET 12.5 MG, MCG, 250 MCG, 25 MG 500 MCG PROMACTA 2 PA; SP OBIZUR 2 SP ORAL TABLET INTRAVENOUS 12.5 MG, 25 MG, 50 RECON SOLN 500 MG, 75 MG (+/-) UNIT RANGE protamine 1 PENTOXIFYLLINE 2 intravenous solution (BULK) POWDER 10 mg/ml 100 % PROTAMINE 2 pentoxifylline oral 1 SULFATE (BULK) tablet extended POWDER 100 % release 400 mg RIASTAP 2 PA; SP PHYTONADIONE 2 INTRAVENOUS (VIT K1) (BULK) RECON SOLN 1 LIQUID 100 % GRAM (900MG- 1,300MG) phytonadione 1 (vitamin k1) surgifoam topical 1 injection solution 10 sponge 12-7 mm mg/ml THROMBATE III 2 PHYTONADIONE 2 INTRAVENOUS (VITAMIN K1) RECON SOLN 500 INJECTION (+/-) UNIT SYRINGE 1 MG/0.5 TRANEXAMIC 2 ML ACID (BULK) phytonadione 1 QL POWDER (vitamin k1) oral tranexamic acid 1 tablet 5 mg intravenous solution prasugrel oral tablet 1 1,000 mg/10 ml (100 10 mg, 5 mg mg/ml) PROFILNINE 2 PA; SP TRETTEN 2 PA; SP INTRAVENOUS INTRAVENOUS RECON SOLN RECON SOLN 1,000 (+/-) UNIT, 2,500 UNIT 1,500 (+/-) UNIT, vitamin k injection 1 500 (+/-) UNIT solution 1 mg/0.5 ml vitamin k1 injection 1 solution 10 mg/ml
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 80 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits VITAMIN K1 2 atorvastatin oral 1 ACA; QL LIQUID 100 % tablet 10 mg, 20 mg VONVENDI 2 PA; SP atorvastatin oral 1 QL INTRAVENOUS tablet 40 mg, 80 mg RECON SOLN CHOLESTYRAMI 2 1,300 (+/-) UNIT NE (BULK) RANGE, 650 (+/-) POWDER UNIT RANGE cholestyramine (with 1 WARFARIN 2 sugar) oral powder (BULK) POWDER 4 gram 100 % cholestyramine (with 1 warfarin oral tablet 1 sugar) oral powder 1 mg, 10 mg, 2 mg, in packet 4 gram 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg cholestyramine light 1 oral powder 4 gram WILATE 2 PA; SP INTRAVENOUS cholestyramine light 1 RECON SOLN oral powder in 1,000-1,000 UNIT, packet 4 gram 500-500 UNIT colesevelam oral 1 XARELTO DVT-PE 2 PA powder in packet TREAT 30D 3.75 gram START ORAL colesevelam oral 1 TABLETS,DOSE tablet 625 mg PACK 15 MG (42)- 20 MG (9) colestipol oral 1 granules 5 gram XARELTO ORAL 2 PA TABLET 10 MG, 15 colestipol oral 1 MG, 2.5 MG, 20 packet 5 gram MG colestipol oral tablet 1 LIPID/CHOLESTEROL LOWERING 1 gram
AGENTS ezetimibe oral tablet 1 PA amlodipine- 1 QL 10 mg atorvastatin oral ezetimibe- 1 QL tablet 10-10 mg, 10- simvastatin oral 20 mg, 10-40 mg, tablet 10-10 mg, 10- 10-80 mg, 2.5-10 20 mg, 10-40 mg, mg, 2.5-20 mg, 2.5- 10-80 mg 40 mg, 5-10 mg, 5- 20 mg, 5-40 mg, 5- 80 mg
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 81 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits fenofibrate 1 lovastatin oral tablet 1 ACA; QL micronized oral 10 mg, 20 mg, 40 mg capsule 130 mg, 134 NEXLETOL ORAL 2 PA mg, 200 mg, 43 mg, TABLET 180 MG 67 mg NEXLIZET ORAL 2 PA fenofibrate 1 TABLET 180-10 nanocrystallized MG oral tablet 145 mg, 48 mg NIACIN (BULK) 2 POWDER fenofibrate oral 1 tablet 120 mg, 160 niacin oral tablet 1 mg, 40 mg, 54 mg 500 mg fenofibric acid 1 niacin oral tablet 1 (choline) oral extended release 24 capsule,delayed hr 1,000 mg, 500 release(dr/ec) 135 mg, 750 mg mg, 45 mg NIACINAMIDE 2 fenofibric acid oral 1 (BULK) POWDER tablet 105 mg, 35 mg 100 % fluvastatin oral 1 ACA; QL omega-3 acid ethyl 1 PA capsule 20 mg, 40 esters oral capsule 1 mg gram fluvastatin oral 1 ACA; QL PRALUENT PEN 2 PA tablet extended SUBCUTANEOUS release 24 hr 80 mg PEN INJECTOR 150 MG/ML, 75 GEMFIBROZIL 2 MG/ML (BULK) POWDER pravastatin oral 1 ACA; QL gemfibrozil oral 1 tablet 10 mg, 20 mg, tablet 600 mg 40 mg, 80 mg JUXTAPID ORAL 2 PA; SP prevalite oral 1 CAPSULE 10 MG, powder 4 gram 20 MG, 30 MG, 40 MG, 5 MG, 60 MG prevalite oral 1 powder in packet 4 LIPOFEN ORAL 2 gram CAPSULE 150 MG, 50 MG REPATHA 2 PA PUSHTRONEX LIVALO ORAL 2 ST; QL SUBCUTANEOUS TABLET 1 MG, 2 WEARABLE MG, 4 MG INJECTOR 420 MG/3.5 ML You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 82 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits REPATHA 2 PA CORLANOR ORAL 2 PA SURECLICK SOLUTION 5 MG/5 SUBCUTANEOUS ML PEN INJECTOR CORLANOR ORAL 2 PA 140 MG/ML TABLET 5 MG, 7.5 REPATHA 2 PA MG SYRINGE dobutamine in d5w 1 SUBCUTANEOUS intravenous SYRINGE 140 parenteral solution MG/ML 1,000 mg/250 ml rosuvastatin oral 1 ACA; QL (4,000 mcg/ml), 250 tablet 10 mg, 5 mg mg/250 ml (1 mg/ml), 500 mg/250 rosuvastatin oral 1 QL ml (2,000 mcg/ml) tablet 20 mg, 40 mg dobutamine 1 SIMVASTATIN 2 intravenous solution (BULK) POWDER 250 mg/20 ml (12.5 100 % mg/ml) simvastatin oral 1 ACA; QL DOPAMINE 2 tablet 10 mg, 20 mg, (BULK) POWDER 40 mg, 5 mg dopamine in 5 % 1 simvastatin oral 1 QL dextrose intravenous tablet 80 mg solution 200 mg/250 VASCEPA ORAL 2 PA ml (800 mcg/ml), CAPSULE 0.5 400 mg/250 ml GRAM, 1 GRAM (1,600 mcg/ml), 400 MISCELLANEOUS mg/500 ml (800 mcg/ml), 800 CARDIOVASCULAR AGENTS mg/250 ml (3,200 ACTIVASE 2 mcg/ml), 800 INTRAVENOUS mg/500 ml (1,600 RECON SOLN 100 mcg/ml) MG, 50 MG dopamine 1 cardioplegic soln 1 intravenous solution perfusion solution 16 200 mg/5 ml (40 meq/l (= k+) mg/ml), 400 mg/10 ml (40 mg/ml), 400 CATHFLO 2 mg/5 ml (80 mg/ml), ACTIVASE 800 mg/10 ml (80 INTRA- mg/ml), 800 mg/5 ml CATHETER (160 mg/ml) RECON SOLN 2 MG
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 83 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits ENTRESTO ORAL 2 QL phenylephrine hcl in 1 TABLET 24-26 0.9% nacl MG, 49-51 MG, 97- intravenous solution 103 MG 100 mg/250 ml (400 mcg/ml), 20 mg/250 ephedrine sulfate 1 ml (80 mcg/ml), 25 intravenous solution mg/250 ml (100 50 mg/ml mcg/ml), 40 mg/250 isoproterenol hcl 1 ml (160 mcg/ml), 50 injection solution 0.2 mg/250 ml (200 mg/ml mcg/ml), 80 mg/250 milrinone in 5 % 1 ml (320 mcg/ml) dextrose intravenous phenylephrine hcl in 1 piggyback 20 0.9% nacl mg/100 ml (200 intravenous syringe mcg/ml), 40 mg/200 20 mg/50 ml (400 ml (200 mcg/ml) mcg/ml) milrinone 1 phenylephrine hcl 1 intravenous solution injection solution 10 1 mg/ml mg/ml norepinephrine 1 ranolazine oral 1 bitartrate tablet extended intravenous solution release 12 hr 1,000 1 mg/ml mg, 500 mg norepinephrine 1 sodium nitroprusside 1 bitartrate-d5w intravenous solution intravenous solution 25 mg/ml 16 mg/250 ml (64 VYNDAMAX 2 PA; SP mcg/ml), 4 mg/250 ORAL CAPSULE ml (16 mcg/ml), 8 61 MG mg/250 ml (32 mcg/ml) VYNDAQEL 2 PA; SP ORAL CAPSULE norepinephrine 1 20 MG bitartrate-nacl intravenous solution NITRATES 16 mg/250 ml (64 DILATRATE-SR 2 mcg/ml), 4 mg/250 ORAL CAPSULE, ml (16 mcg/ml) EXTENDED RELEASE 40 MG ISOSORBIDE 2 (BULK) POWDER 98 %
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 84 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits isosorbide dinitrate 1 nitroglycerin 1 oral tablet 10 mg, 20 transdermal patch mg, 30 mg, 40 mg, 5 24 hour 0.1 mg/hr, mg 0.2 mg/hr, 0.4 mg/hr, 0.6 mg/hr isosorbide dinitrate 1 oral tablet extended nitroglycerin 1 release 40 mg translingual spray,non-aerosol isosorbide 1 400 mcg/spray mononitrate oral tablet 10 mg, 20 mg nitro-time oral 1 capsule, extended isosorbide 1 release 2.5 mg, 6.5 mononitrate oral mg, 9 mg tablet extended release 24 hr 120 DERMATOLOGICALS/TOPICA mg, 30 mg, 60 mg L THERAPY nitro-bid 1 ANTIPSORIATIC / transdermal ointment 2 % ANTISEBORRHEIC nitroglycerin in 5 % 1 acitretin oral 1 dextrose intravenous capsule 10 mg, 17.5 solution 100 mg/250 mg, 25 mg ml (400 mcg/ml), ANTHRALIN 2 200 mg/500 ml (400 (BULK) POWDER mcg/ml), 25 mg/250 ml (100 mcg/ml), 50 calcipotriene scalp 1 QL mg/250 ml (200 solution 0.005 % mcg/ml), 50 mg/500 calcipotriene topical 1 QL ml (100 mcg/ml) cream 0.005 % nitroglycerin 1 calcipotriene topical 1 QL intravenous solution ointment 0.005 % 50 mg/10 ml (5 calcipotriene- 1 QL mg/ml) betamethasone nitroglycerin oral 1 topical ointment capsule, extended 0.005-0.064 % release 2.5 mg, 6.5 calcipotriene- 1 QL mg, 9 mg betamethasone nitroglycerin 1 topical suspension sublingual tablet 0.3 0.005-0.064 % mg, 0.4 mg, 0.6 mg calcitriol topical 1 ointment 3 mcg/gram
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 85 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits CHLOROXINE 2 SELENIUM 2 (BULK) POWDER SULFIDE (BULK) 100 % POWDER 52-55.5 % COAL TAR 2 (BULK) TOPICAL selenium sulfide 1 SOLUTION 20 % topical lotion 2.5 % COAL TAR 2 selenium sulfide 1 (CRUDE) (BULK) topical shampoo SOLUTION 2.25 %, 2.3 % COAL TAR 2 SKYRIZI 2 PA; SP; QL (CRUDE) (BULK) SUBCUTANEOUS TAR SYRINGE KIT 150MG/1.66ML(75 COSENTYX (2 2 PA; SP; QL MG/0.83 ML X2) SYRINGES) SUBCUTANEOUS STELARA 2 PA; SP; QL SYRINGE 150 SUBCUTANEOUS MG/ML SOLUTION 45 MG/0.5 ML COSENTYX PEN 2 PA; SP; QL (2 PENS) STELARA 2 PA; SP; QL SUBCUTANEOUS SUBCUTANEOUS PEN INJECTOR SYRINGE 45 150 MG/ML MG/0.5 ML, 90 MG/ML COSENTYX PEN 2 PA; SP; QL SUBCUTANEOUS sulfacetamide 1 PEN INJECTOR sodium topical 150 MG/ML cleanser 10 % COSENTYX 2 PA; SP; QL sulfacetamide 1 SUBCUTANEOUS sodium topical SYRINGE 150 cleanser, gel 10 % MG/ML sulfacetamide 1 drithocreme hp 1 sodium topical topical cream 1 % shampoo 10 % ENSTILAR 2 QL TREMFYA 2 PA; SP; QL TOPICAL FOAM SUBCUTANEOUS 0.005-0.064 % AUTO-INJECTOR 100 MG/ML hydrocortisone- 1 pramoxine topical TREMFYA 2 PA; SP; QL cream 2.5-1 % SUBCUTANEOUS SYRINGE 100 MG/ML
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 86 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits BURN THERAPY salicylic acid topical 1 foam 6 % SILVER 2 SULFADIAZINE salicylic acid topical 1 (BULK) POWDER gel 6 % 100 % salicylic acid topical 1 silver sulfadiazine 1 liquid 26 % topical cream 1 % salicylic acid topical 1 ssd topical cream 1 1 lotion 6 % % salicylic acid topical 1 KERATOLYTICS lotion,extended release 6 % PODOPHYLLUM 2 RESIN (BULK) salicylic acid topical 1 POWDER shampoo 6 % POTASSIUM 2 salicylic acid- 1 HYDROXIDE ceramides no.1 (BULK) PELLET topical kit,cleanser and cream er 6 % RESORCINOL 2 (BULK) salimez topical 1 CRYSTALS cream 6 % RESORCINOL 2 salvax topical foam 1 (BULK) POWDER 6 % SALICYLIC ACID 2 SODIUM 2 (BULK) HYDROXIDE CRYSTALS (BULK) SOLUTION 10 % SALICYLIC ACID 2 (BULK) POWDER SULFUR 2 SUBLIMED salicylic acid topical 1 (BULK) POWDER cream 6 % 100 % salicylic acid topical 1 MISCELLANEOUS cream,extended DERMATOLOGICALS release 6 % ALLANTOIN 2 salicylic acid topical 1 (BULK) POWDER film forming liquid w/appl 27.5 % ALUMINUM 2 CHLORIDE salicylic acid topical 1 (BULK) POWDER film-forming soln er w/ appl 28.5 % AMINOBENZOIC 2 ACID (BULK) POWDER You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 87 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits AMMONIUM 2 cem-urea topical gel 1 LACTATE (BULK) 45 % SOLUTION 70 % CHLORHEXIDINE 2 ammonium lactate 1 OTC GLUCONATE topical cream 12 % (BULK) SOLUTION 20 % ammonium lactate 1 OTC topical lotion 12 % DICHLORACETIC 2 ACID (BULK) atopavo topical 1 LIQUID 99 % emulsion diclofenac sodium 1 PA; QL avo cream topical 1 topical gel 3 % emulsion doxepin topical 1 ST; QL BALSAM PERU 2 cream 5 % (BULK) LIQUID DUPIXENT PEN 2 PA; SP; QL BENZALKONIUM 2 SUBCUTANEOUS CHLORIDE PEN INJECTOR (BULK) 300 MG/2 ML SOLUTION 50 % DUPIXENT 2 PA; SP; QL BENZETHONIUM 2 SYRINGE CHLORIDE SUBCUTANEOUS (BULK) POWDER SYRINGE 200 bpco topical 1 MG/1.14 ML, 300 ointment in packet MG/2 ML CALAMINE 2 eletone topical 1 (BULK) POWDER cream CAMPHOR 2 emulsion sb topical 1 (BULK) emulsion CRYSTALS fluorouracil topical 1 CANTHARIDIN 2 cream 5 % (BULK) POWDER fluorouracil topical 1 CAPSAICIN 2 solution 2 %, 5 % (BULK) POWDER geri-hydrolac 1 OTC CAPSICUM 2 topical cream 12 % OLEORESIN GUAIACOL 2 (BULK) LIQUID 15 LIQUID % hpr plus hydrogel 1 CARAC TOPICAL 2 topical kit,cream CREAM 0.5 % and gel celacyn topical gel 1 with pump You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 88 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits hpr plus topical 1 methoxsalen oral 1 cream capsule,liqd- filled,rapid rel 10 hpr plus topical 1 mg foam methyl salicylate oil 1 hpr topical foam 1 MONOBENZONE 2 HYDROQUINONE 2 (BULK) POWDER (BULK) 100 % CRYSTALS 100 % MONSEL'S 2 ICHTHAMMOL 2 TOPICAL (BULK) LIQUID SOLUTION 0.2 TO 100 % 0.22 GRAM/ML ICHTHAMMOL 2 IRON (BULK) POWDER MONSEL'S 2 IMIQUIMOD 2 TOPICAL (BULK) POWDER SOLUTION WITH 100 % APPLICATOR 0.2 imiquimod topical 1 TO 0.22 GRAM/ML cream in packet 5 % nivatopic plus 1 IODOFORM 2 topical cream (BULK) POWDER PICATO TOPICAL 2 100 % GEL 0.015 %, 0.05 luxamend topical 1 % cream pimecrolimus topical 1 PA; QL mb hydrogel 1 cream 1 % (cyclomethicone) podofilox topical 1 topical kit,cream solution 0.5 % and gel pr cream topical 1 mb hydrogel topical 1 cream kit,cream and gel prosilk gel topical 1 96.53-3-0.4 -0.066 gel % pruclair topical 1 MENTHOL 2 cream (BULK) CRYSTALS prudoxin topical 1 ST; QL cream 5 % METHOXSALEN 2 (BULK) prumyx topical 1 CRYSTALS cream METHOXSALEN 2 (BULK) POWDER You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 89 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits QBREXZA 2 PA TANNIC ACID 2 TOPICAL (BULK) POWDER TOWELETTE 2.4 TITANIUM 2 % DIOXIDE (BULK) recedo topical gel 1 LIQUID 30 % REGRANEX 2 QL tri-chlor topical 1 TOPICAL GEL 0.01 solution 80 % % TRICHLOROACET 2 SAF-CLENS AF 2 IC ACID (BULK) DERMAL WOUND CRYSTALS TOPICAL TRICHLOROACET 2 CLEANSER IC ACID TOPICAL SILVER NITRATE 2 RECON SOLN 20 (BULK) %, 30 %, 35 %, 40 CRYSTALS %, 50 %, 80 %, 85 %, 90 % silver nitrate 1 applicators topical umecta topical foam 1 stick 75-25 % 40 % silver nitrate topical 1 UREA (BULK) 2 solution 0.5 %, 10 BEADS 100 % %, 25 %, 50 % UREA (BULK) 2 SILVER PROTEIN 2 POWDER 100 % MILD (BULK) urea nail stick 1 POWDER topical solution 50 skin treatment 1 OTC % topical lotion 12 % urea topical cream 1 SODIUM 2 39 %, 40 %, 41 %, HYALURONATE 45 %, 47 %, 50 % (BULK) POWDER urea topical foam 35 1 94 % % sonafine topical 1 urea topical gel 45 1 emulsion % TACROLIMUS 2 ure-k topical cream 1 (BULK) POWDER 50 % 100 % UVADEX 2 tacrolimus topical 1 PA; QL INJECTION ointment 0.03 %, 0.1 SOLUTION 20 % MCG/ML
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 90 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits VALCHLOR 2 PA; SP avar topical cleanser 1 TOPICAL GEL 10-5 % (w/w) 0.016 % avita topical cream 1 VASELINE WHITE 2 0.025 % PETROLEUM AZELAIC ACID 2 TOPICAL (BULK) FLAKES OINTMENT IN 100 %, 85 %, 88 % PACKET AZELAIC ACID 2 wintergreen oil oil 1 (BULK) POWDER WITCH HAZEL 2 100 % EXTRACT (BULK) azelaic acid topical 1 LIQUID gel 15 % ZINC OXIDE 2 benzepro topical 1 (BULK) POWDER towelette 6 % ZINC OXIDE 2 BENZOYL 2 TOPICAL PASTE PEROXIDE 25 % (BULK) POWDER THERAPY FOR ACNE 65 TO 82 % adapalene topical 1 benzoyl peroxide 1 cream 0.1 % topical cleanser 7 % adapalene topical 1 benzoyl peroxide 1 gel 0.3 % topical foam 5.3 %, 9.8 % adapalene topical 1 gel with pump 0.3 % bp 10-1 topical 1 ST cleanser 10-1 % adapalene topical 1 solution 0.1 % bpo topical gel 4 %, 1 8 % adapalene topical 1 swab 0.1 % bpo topical towelette 1 6 % adapalene-benzoyl 1 peroxide topical gel claravis oral capsule 1 with pump 0.1-2.5 % 10 mg, 20 mg, 30 mg, 40 mg amnesteem oral 1 capsule 10 mg, 20 cleansing wash 1 ST mg, 40 mg topical cleanser 10- 4-10 % AMZEEQ 2 ST TOPICAL FOAM 4 clindacin etz topical 1 % swab 1 % clindacin p topical 1 swab 1 % You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 91 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits clindamycin 1 QL erythromycin with 1 phosphate topical ethanol topical gel 2 foam 1 % % clindamycin 1 QL erythromycin with 1 phosphate topical ethanol topical gel 1 % solution 2 % clindamycin 1 QL erythromycin- 1 phosphate topical benzoyl peroxide lotion 1 % topical gel 3-5 % clindamycin 1 QL FINACEA 2 ST phosphate topical TOPICAL FOAM solution 1 % 15 % clindamycin 1 isotretinoin oral 1 phosphate topical capsule 10 mg, 20 swab 1 % mg, 30 mg, 40 mg clindamycin-benzoyl 1 metronidazole 1 peroxide topical gel topical cream 0.75 1-5 %, 1.2 %(1 % % base) -5 % metronidazole 1 clindamycin-benzoyl 1 topical gel 0.75 %, 1 peroxide topical gel % with pump 1-5 %, metronidazole 1 1.2-2.5 % topical gel with clindamycin- 1 pump 1 % tretinoin topical gel metronidazole 1 1.2-0.025 % topical lotion 0.75 % dapsone topical gel 1 MIRVASO 2 PA 5 % TOPICAL GEL dapsone topical gel 1 WITH PUMP 0.33 with pump 7.5 % % EPIDUO FORTE 2 ST myorisan oral 1 TOPICAL GEL capsule 10 mg, 20 WITH PUMP 0.3- mg, 30 mg, 40 mg 2.5 % neuac topical gel 1.2 1 ery pads topical 1 %(1 % base) -5 % swab 2 % ONEXTON 2 ST erygel topical gel 2 1 TOPICAL GEL % WITH PUMP 1.2 %(1 % BASE) -3.75 % You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 92 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits RETINOIC ACID 2 sulfacetamide- 1 POWDER sulfur-cleansr23 topical kit 9-4.5 % rosadan topical 1 cream 0.75 % sulfacleanse 8-4 1 ST topical suspension 8- rosadan topical gel 1 4 % 0.75 % tazarotene topical 1 PA rosula cleansing 1 cream 0.1 % cloths topical pads, medicated 10-5 % TAZORAC 2 PA TOPICAL CREAM sss 10-5 topical 1 0.05 % cream 10-5 % (w/w) TAZORAC 2 PA sss 10-5 topical 1 TOPICAL GEL 0.05 foam 10-5 % %, 0.1 % sulfacetamide 1 TRETINOIN 2 sodium-sulfur (BULK) POWDER topical cleanser 10-2 %, 10-5 % (w/w), 9- tretinoin 1 4 %, 9-4.5 %, 9.8- microspheres topical 4.8 % gel 0.04 %, 0.1 % sulfacetamide 1 tretinoin 1 sodium-sulfur microspheres topical topical cream 10-2 gel with pump 0.04 %, 10-5 % (w/w), %, 0.1 % 9.8-4.8 % tretinoin topical 1 sulfacetamide 1 cream 0.025 %, 0.05 sodium-sulfur %, 0.1 % topical lotion 10-5 tretinoin topical gel 1 % (w/v), 10-5 % 0.01 %, 0.025 %, (w/w), 9.8-4.8 % 0.05 % sulfacetamide 1 zenatane oral 1 sodium-sulfur capsule 10 mg, 20 topical pads, mg, 30 mg, 40 mg medicated 10-4 % TOPICAL ANESTHETICS sulfacetamide 1 sodium-sulfur BENZOCAINE 2 topical suspension (BULK) POWDER 10-5 %, 8-4 % BENZOCAINE 2 sulfacetamide sod- 1 MICRONIZED sulfur-urea topical (BULK) POWDER cleanser 10-5-10 % 100 %
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 93 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits BUPIVACAINE 2 ethyl chloride 1 (BULK) POWDER topical aerosol,spray 100 % 100 % bupivacaine (pf) 1 glydo mucous 1 QL injection solution membrane jelly in 0.25 % (2.5 mg/ml), applicator 2 % 0.5 % (5 mg/ml), LIDOCAINE 2 0.75 % (7.5 mg/ml) (BULK) POWDER bupivacaine 1 lidocaine (pf) 1 injection solution injection solution 10 0.25 % (2.5 mg/ml), mg/ml (1 %), 15 0.5 % (5 mg/ml) mg/ml (1.5 %), 20 bupivacaine- 1 mg/ml (2 %), 40 epinephrine (pf) mg/ml (4 %), 5 injection solution mg/ml (0.5 %) 0.25 %-1:200,000, lidocaine (pf) 1 0.5 %-1:200,000 injection syringe 50 bupivacaine- 1 mg/5 ml (1 %) epinephrine LIDOCAINE HCL 2 injection solution (BULK) POWDER 0.25 %-1:200,000, 100 % 0.5 %-1:200,000 lidocaine hcl 1 carbocaine (pf) 1 injection solution 10 injection solution 15 mg/ml (1 %), 20 mg/ml (1.5 %) mg/ml (2 %), 5 chloroprocaine (pf) 1 mg/ml (0.5 %) injection solution 20 lidocaine hcl 1 mg/ml (2 %), 30 laryngotracheal mg/ml (3 %) solution 4 % COCAINE (BULK) 2 lidocaine hcl mucous 1 QL CRYSTALS 100 % membrane jelly 2 % dermacinrx prizopak 1 lidocaine hcl mucous 1 QL topical kit 2.5-2.5 % membrane jelly in DIBUCAINE HCL 2 applicator 2 % (BULK) POWDER lidocaine hcl mucous 1 100 % membrane solution 4 DYCLONINE HCL 2 % (40 mg/ml) (BULK) POWDER lidocaine hcl topical 1 100 % cream 3 %
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 94 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits lidocaine hcl topical 1 lido-sorb topical 1 lotion 3 % lotion 3 % lidocaine hcl- 1 lidozion topical 1 hydrocortison ac lotion 3 % topical cream 3-0.5 lta pre-attached 1 % laryngotracheal lidocaine in nacl,iso- 1 solution 4 % osmo(pf) injection marcaine (pf) 1 syringe 100 mg/10 injection solution ml (1 %) 0.75 % (7.5 mg/ml) lidocaine topical 1 PA polocaine injection 1 adhesive solution 1 % (10 patch,medicated 5 % mg/ml) lidocaine topical 1 QL POLOCAINE 2 ointment 5 % INJECTION lidocaine viscous 1 SOLUTION 2 % mucous membrane polocaine-mpf 1 solution 2 % injection solution 10 lidocaine- 1 mg/ml (1 %), 15 epinephrine (pf) mg/ml (1.5 %), 20 injection solution 1.5 mg/ml (2 %) %-1:200,000, 2 %- PRILOCAINE 2 1:200,000 (BULK) POWDER lidocaine- 1 pro dna collection 1 epinephrine mucous membrane injection solution 0.5 kit 2 % %-1:200,000, 1 %- 1:100,000, 2 %- PROCAINE 2 1:100,000 (BULK) CRYSTALS lidocaine-prilocaine 1 QL topical cream 2.5- relador pak plus 1 2.5 % topical kit 2.5-2.5 % lidocaine-prilocaine 1 relador pak topical 1 topical kit 2.5-2.5 % kit 2.5-2.5 % lido-k topical lotion 1 ropivacaine (pf) 1 3 % injection solution 10 mg/ml (1 %), 2 lidopin topical 1 mg/ml (0.2 %), 5 cream 3 % mg/ml (0.5 %), 7.5 lidopril topical kit 1 mg/ml (0.75 %) 2.5-2.5 % You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 95 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits ROPIVACAINE 2 BACITRACIN ZN 2 HCL (BULK) MICRONIZED(BU POWDER 100 % LK) POWDER 40 UNIT/MG sensorcaine 1 injection solution 0.5 gentamicin topical 1 % (5 mg/ml) cream 0.1 % sensorcaine- 1 gentamicin topical 1 epinephrine ointment 0.1 % injection solution hydrocortisone- 1 0.25 %-1:200,000, iodoquinl-aloe2 0.5 %-1:200,000 topical gel 2-1-1 % sensorcaine-mpf 1 hydrocortisone- 1 injection solution 0.5 iodoquinol topical % (5 mg/ml) cream 1-1 % SENSORCAINE- 2 hydrocortisone- 1 MPF/EPINEPHRIN iodoquinol-aloe E INJECTION topical cream in SOLUTION 0.75 %- packet 1.9-1 % 1:200,000 lugols topical 1 TETRACAINE 2 solution 5-10 % (BULK) WAX 100 % mafenide acetate 1 topical packet 50 TETRACAINE 2 gram HCL (BULK) POWDER MUPIROCIN 2 (BULK) POWDER tetracaine hcl (pf) 1 100 % injection solution 1 % (10 mg/ml) mupirocin calcium 1 ST; QL topical cream 2 % xylocaine dental- 1 epinephrine mupirocin topical 1 QL injection cartridge 2 ointment 2 % %-1:100,000, 2 %- NITROFURAZONE 2 1:50,000 (BULK) POWDER zionodil topical 1 POVIDONE- 2 lotion 3 % IODINE (BULK) ZTLIDO TOPICAL 2 PA POWDER 100 % ADHESIVE strong iodine topical 1 PATCH,MEDICAT solution 5-10 % ED 1.8 % TOPICAL ANTIBACTERIALS
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 96 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits sulfacetamide 1 clotrimazole- 1 QL sodium (acne) betamethasone topical suspension topical lotion 1-0.05 10 % % SULFAMYLON 2 ECONAZOLE 2 TOPICAL CREAM NITRATE (BULK) 85 MG/G POWDER TRICLOSAN 2 econazole topical 1 QL (BULK) POWDER cream 1 % 100 % GENTIAN VIOLET 2 TOPICAL ANTIFUNGALS (BULK) CRYSTALS ciclodan topical 1 QL cream 0.77 % ketoconazole topical 1 QL cream 2 % ciclodan topical 1 solution 8 % ketoconazole topical 1 QL foam 2 % CICLOPIROX 2 OLAMINE (BULK) ketoconazole topical 1 QL POWDER shampoo 2 % ciclopirox topical 1 QL ketodan kit topical 1 cream 0.77 % combo pack 2 % ciclopirox topical 1 QL ketodan topical foam 1 QL gel 0.77 % 2 % ciclopirox topical 1 QL MICONAZOLE 2 shampoo 1 % NITRATE (BULK) POWDER ciclopirox topical 1 solution 8 % naftifine topical 1 QL cream 1 %, 2 % ciclopirox topical 1 QL suspension 0.77 % naftifine topical gel 1 QL 1 % ciclopirox-ure- 1 camph-menth-euc nyamyc topical 1 QL topical solution 8 % powder 100,000 unit/gram CLOTRIMAZOLE 2 (BULK) POWDER nystatin topical 1 QL cream 100,000 clotrimazole- 1 QL unit/gram betamethasone topical cream 1-0.05 nystatin topical 1 QL % ointment 100,000 unit/gram
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 97 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits nystatin topical 1 QL amcinonide topical 1 ST powder 100,000 cream 0.1 % unit/gram amcinonide topical 1 ST nystatin- 1 QL lotion 0.1 % triamcinolone apexicon e topical 1 ST topical cream cream 0.05 % 100,000-0.1 unit/g- % beser topical lotion 1 ST 0.05 % nystatin- 1 QL triamcinolone BETAMETHASON 2 topical ointment E DIPROPION 100,000-0.1 (BULK) POWDER unit/gram-% betamethasone 1 nystop topical 1 QL dipropionate topical powder 100,000 cream 0.05 % unit/gram betamethasone 1 oxiconazole topical 1 QL dipropionate topical cream 1 % lotion 0.05 % tavaborole topical 1 betamethasone 1 solution with dipropionate topical applicator 5 % ointment 0.05 % TOLNAFTATE 2 BETAMETHASON 2 (BULK) POWDER E VALERATE (BULK) POWDER UNDECYLENIC 2 ACID (BULK) betamethasone 1 LIQUID 100 % valerate topical cream 0.1 % TOPICAL ANTIVIRALS betamethasone 1 ST acyclovir topical 1 PA; QL valerate topical cream 5 % foam 0.12 % acyclovir topical 1 PA; QL betamethasone 1 ointment 5 % valerate topical TOPICAL CORTICOSTEROIDS lotion 0.1 % alclometasone 1 betamethasone 1 topical cream 0.05 valerate topical % ointment 0.1 % alclometasone 1 betamethasone, 1 topical ointment augmented topical 0.05 % cream 0.05 %
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 98 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits betamethasone, 1 desonide topical gel 1 ST augmented topical 0.05 % gel 0.05 % desonide topical 1 ST betamethasone, 1 lotion 0.05 % augmented topical desonide topical 1 lotion 0.05 % ointment 0.05 % betamethasone, 1 DESONIDE, 2 augmented topical MICRONIZED ointment 0.05 % (BULK) POWDER CLOBETASOL 2 desoximetasone 1 ST PROPIONATE topical cream 0.05 (BULK) POWDER %, 0.25 % clobetasol scalp 1 QL desoximetasone 1 ST solution 0.05 % topical gel 0.05 % clobetasol topical 1 QL desoximetasone 1 ST cream 0.05 % topical ointment clobetasol topical 1 ST; QL 0.05 %, 0.25 % foam 0.05 % desoximetasone 1 ST clobetasol topical 1 QL topical spray,non- gel 0.05 % aerosol 0.25 % clobetasol topical 1 ST; QL diflorasone topical 1 ST; QL lotion 0.05 % cream 0.05 % clobetasol topical 1 QL diflorasone topical 1 ST; QL ointment 0.05 % ointment 0.05 % clobetasol topical 1 ST; QL FLUOCINOLONE 2 shampoo 0.05 % ACETONIDE (BULK) POWDER clobetasol topical 1 ST; QL spray,non-aerosol fluocinolone and 1 0.05 % shower cap scalp oil 0.01 % clobetasol-emollient 1 QL topical cream 0.05 fluocinolone topical 1 % cream 0.01 %, 0.025 % clobetasol-emollient 1 ST; QL topical foam 0.05 % fluocinolone topical 1 oil 0.01 % clodan topical 1 ST; QL shampoo 0.05 % fluocinolone topical 1 ointment 0.025 % desonide topical 1 cream 0.05 % fluocinolone topical 1 solution 0.01 % You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 99 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits fluocinonide topical 1 QL fluticasone 1 cream 0.05 % propionate topical ointment 0.005 % fluocinonide topical 1 ST; QL cream 0.1 % halcinonide topical 1 ST cream 0.1 % fluocinonide topical 1 QL gel 0.05 % halobetasol 1 propionate topical fluocinonide topical 1 QL cream 0.05 % ointment 0.05 % halobetasol 1 fluocinonide topical 1 QL propionate topical solution 0.05 % ointment 0.05 % FLUOCINONIDE, 2 HYDROCORTISO 2 MICRONIZED(BU NE (BULK) LK) POWDER 100 POWDER % HYDROCORTISO 2 fluocinonide-e 1 QL NE ACETATE topical cream 0.05 (BULK) POWDER % hydrocortisone 1 QL flurandrenolide 1 ST; QL butyrate topical topical cream 0.05 cream 0.1 % % hydrocortisone 1 ST; QL flurandrenolide 1 ST; QL butyrate topical topical lotion 0.05 % lotion 0.1 % flurandrenolide 1 ST; QL hydrocortisone 1 ST topical ointment butyrate topical 0.05 % ointment 0.1 % FLUTICASONE 2 hydrocortisone 1 ST; QL PROP, MICRO butyrate topical (BULK) POWDER solution 0.1 % 100 % hydrocortisone 1 QL FLUTICASONE 2 butyr-emollient PROPIONATE topical cream 0.1 % (BULK) POWDER 100 % hydrocortisone 1 topical cream 2.5 % fluticasone 1 propionate topical hydrocortisone 1 cream 0.05 % topical lotion 2.5 % fluticasone 1 ST hydrocortisone 1 propionate topical topical ointment 2.5 lotion 0.05 % %
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 100 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits hydrocortisone 1 triamcinolone 1 valerate topical acetonide topical cream 0.2 % cream 0.025 %, 0.1 %, 0.5 % hydrocortisone 1 valerate topical triamcinolone 1 ointment 0.2 % acetonide topical lotion 0.025 %, 0.1 MOMETASONE 2 % FUROATE (BULK) POWDER 100 % triamcinolone 1 acetonide topical mometasone topical 1 ointment 0.025 %, cream 0.1 % 0.1 %, 0.5 % mometasone topical 1 triamcinolone 1 ST ointment 0.1 % acetonide topical mometasone topical 1 ointment 0.05 % solution 0.1 % trianex topical 1 ST nolix topical cream 1 ST; QL ointment 0.05 % 0.05 % triderm topical 1 nolix topical lotion 1 ST; QL cream 0.1 % 0.05 % triderm topical 1 ST prednicarbate 1 cream 0.5 % topical cream 0.1 % TOPICAL ENZYMES prednicarbate 1 topical ointment 0.1 COLLAGENASE 2 % CLOS HIST. (BULK) POWDER scalacort topical 1 lotion 2 % SANTYL TOPICAL 2 QL OINTMENT 250 tovet emollient 1 ST; QL UNIT/GRAM topical foam 0.05 % TOPICAL SCABICIDES /
TRIAMCINOLONE 2 PEDICULICIDES ACETONIDE (BULK) POWDER crotan topical lotion 1 100 % 10 % triamcinolone 1 ST; QL lindane topical 1 acetonide topical shampoo 1 % aerosol 0.147 malathion topical 1 mg/gram lotion 0.5 % PERMETHRIN 2 (BULK) LIQUID 92 % You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 101 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits permethrin topical 1 neomycin-polymyxin 1 cream 5 % b gu irrigation solution 40 mg- PYRITHIONE 2 200,000 unit/ml ZINC (BULK) LIQUID 48 % ringer's irrigation 1 solution spinosad topical 1 suspension 0.9 % tis-u-sol pentalyte 1 irrigation irrigation DIAGNOSTICS / solution 800-40-20- MISCELLANEOUS AGENTS 8.75- 6.25 mg/100 ml ANOREXIANTS
DIETHYLPROPIO 2 MISCELLANEOUS AGENTS N HCL (BULK) 2-DEOXY-D- 2 POWDER 100 % GLUCOSE (BULK) PHENTERMINE 2 POWDER HCL (BULK) 2- 2 POWDER 100 % METHOXYESTRA DIOL (BULK) ANTIDOTES POWDER 100 % acetylcysteine 1 3,5- 2 intravenous solution DIIODOTHYRONI 200 mg/ml (20 %) NE (BULK) EDETATE 2 POWDER 100 % DISODIUM acamprosate oral 1 (BULK) POWDER tablet,delayed 100 % release (dr/ec) 333 PROTOPAM 2 mg CHLORIDE ACD SOLUTION A 2 INJECTION SOLUTION 2.45- RECON SOLN 1 2.2 GRAM- 800 GRAM MG/100 ML
ENZYMES acetic acid irrigation 1 CHYMOTRYPSIN 2 solution 0.25 % (BULK) POWDER ALPHA PINENE 2 IRRIGATING SOLUTIONS (BULK) LIQUID lactated ringers 1 ALUMINUM, 2 irrigation solution (ACETATO- O)DIH(BULK) POWDER
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 102 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits AMMONIUM 2 BETANAPHTHOL 2 SULFATE (BULK) (BULK) POWDER GRANULES 99 % anagrelide oral 1 BISMUTH 2 capsule 0.5 mg, 1 mg CITRATE (BULK) POWDER ANISINDIONE 2 (BULK) POWDER BISMUTH 2 100 % SUBNITRATE (BULK) POWDER ANTICOAG 2 100 % CITRATE PHOS DEXTROSE BREVITAL 2 SOLUTION 2.63- INJECTION 222 GRAM- RECON SOLN 500 MG/100ML MG ANTIPYRINE 2 BROMHEXINE 2 (BULK) POWDER HCL (BULK) 100 % POWDER aqua care sodium 1 BUFLOMEDIL 2 chloride irrigation (BULK) POWDER solution 0.9 % 100 % aqua care sterile 1 bupivacaine- 1 water irrigation dextrose-water(pf) solution injection solution 0.75 % (7.5 mg/ml) ARALAST NP 2 PA; SP INTRAVENOUS CAFFEINE (BULK) 2 RECON SOLN POWDER 100 % 1,000 MG, 500 MG caffeine citrate 1 bacteriostatic 1 intravenous solution water(parabens) 60 mg/3 ml (20 injection solution mg/ml) BARIUM 2 caffeine citrate oral 1 SULFATE (BULK) solution 60 mg/3 ml POWDER (20 mg/ml) bd pre-filled normal 1 CALCITRIOL- 2 saline injection ALMOND OIL syringe (BULK) LIQUID 1 MCG/ML BENZYL 2 BENZOATE (BULK) LIQUID
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 103 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits CARBAGLU ORAL 2 PA; SP CLINIMIX E 2 TABLET, 2.75%/D5W SULF DISPERSIBLE 200 FREE MG INTRAVENOUS PARENTERAL CARBAZOCHROM 2 SOLUTION 2.75 % E (BULK) POWDER 100 % clovique oral 1 PA capsule 250 mg CESIUM 2 CHLORIDE COUMARIN 2 (BULK) (BULK) POWDER CRYSTALS 100 % cryoserv solution 99 1 cevimeline oral 1 % capsule 30 mg CYSTEAMINE 2 CHEMET ORAL 2 PA HCL (BULK) CAPSULE 100 MG POWDER 100 % CHLORHEXIDINE 2 d10 %-0.45 % 1 ACETATE (BULK) sodium chloride POWDER 100 % intravenous parenteral solution citric acid 1 anhydrous (bulk) d2.5 %-0.45 % 1 granules 100 % sodium chloride intravenous citric acid 1 parenteral solution monohydrate (bulk) granules 100 % d5 % and 0.9 % 1 sodium chloride clariscan 1 intravenous (meglumine) parenteral solution intravenous solution 0.5 mmol/ml (376.9 d5 %-0.45 % sodium 1 mg/ml) chloride intravenous parenteral solution CLEMIZOLE HCL 2 (BULK) POWDER DEANOL 2 BITARTRATE CLINIMIX 2 (BULK) POWDER 4.25%/D5W 100 % SULFIT FREE INTRAVENOUS deferasirox oral 1 PA; SP PARENTERAL granules in packet SOLUTION 4.25 % 180 mg, 360 mg, 90 mg
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 104 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits deferasirox oral 1 PA; SP DEXTROSE 2 tablet 180 mg, 360 (BULK) POWDER mg, 90 mg dextrose 10 % and 1 deferasirox oral 1 PA; SP 0.2 % nacl tablet, dispersible intravenous 125 mg, 250 mg, 500 parenteral solution mg dextrose 10 % in 1 deferiprone oral 1 PA; SP water (d10w) tablet 500 mg intravenous parenteral solution deferoxamine 1 10 % injection recon soln 2 gram, 500 mg dextrose 20 % in 1 water (d20w) delflex-lc/1.5% 1 intravenous dextrose parenteral solution intraperitoneal 20 % solution ca 2.5 meq/l- mg 0.5 meq/l dextrose 25 % in 1 water (d25w) delflex-lc/2.5% 1 intravenous syringe dextrose intraperitoneal dextrose 30 % in 1 solution ca 2.5 water (d30w) meq/l- mg 0.5 meq/l intravenous parenteral solution delflex-lc/4.25% 1 dextrose dextrose 40 % in 1 intraperitoneal water (d40w) solution ca 2.5 intravenous meq/l- mg 0.5 meq/l parenteral solution 40 % DEOXYCHOLIC 2 ACID (BULK) dextrose 5 % in 1 POWDER 98 % ringer's intravenous parenteral solution 5 desflurane 1 % inhalation liquid 100 % dextrose 5 % in 1 water (d5w) DESOXIMETASON 2 intravenous E, MICRO (BULK) parenteral solution POWDER 100 % dextrose 5 % in 1 DEXTROSE 2 water (d5w) (BULK) intravenous GRANULES piggyback 5 %
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 105 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits dextrose 5 %- 1 DIMETHYL 2 lactated ringers SULFOXIDE intravenous (BULK) LIQUID parenteral solution 99.99 % dextrose 5%-0.2 % 1 DINITROCHLORO 2 sod chloride BENZEN(2,4)(BUL intravenous K) CRYSTALS 100 parenteral solution % dextrose 5%-0.3 % 1 DIOSGENIN 2 sod.chloride (BULK) POWDER intravenous DIPHENCYPRONE 2 parenteral solution (BULK) POWDER dextrose 50 % in 1 98 % water (d50w) DISULFIRAM 2 intravenous (BULK) POWDER parenteral solution 100 % dextrose 50 % in 1 disulfiram oral 1 water (d50w) tablet 250 mg, 500 intravenous syringe mg dextrose 70 % in 1 DMPS CRYSTALS 2 water (d70w) intravenous DMSA (BULK) 2 parenteral solution POWDER 98 % DICHLORALPHEN 2 D-XYLOSE 2 AZONE (BULK) (BULK) POWDER POWDER 100 % ENFAMIL 2 OTC DILUENT FOR 2 SP GLUCOSE ORAL EPOPROSTENOL/F SOLUTION 5 % LOLA EOVIST 2 INTRAVENOUS INTRAVENOUS SOLUTION SOLUTION 0.25 diluent for 1 SP MMOL/ML (181.43 treprostinil (gly) MG/ML) intravenous solution ETHAMOLIN 2 DIMERCAPTOPRO 2 INTRAVENOUS PANESULFONATE SOLUTION 5 % SOD POWDER 97 ETHYL ALCOHOL 2 % (BULK) LIQUID 95 %
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 106 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits etidronate disodium 1 HISTAMINE 2 oral tablet 200 mg PHOSPHATE (BULK) ETOMIDATE 2 CRYSTALS 100 % (BULK) POWDER HYDRAZINE 2 etomidate 1 SULFATE (BULK) intravenous solution CRYSTALS 100 % 2 mg/ml HYDROXYPROPY 2 EXTRANEAL 7.5 2 L CELLULOSE % POWDER INTRAPERITONE AL SOLUTION CA ic green injection 1 3.5 MEQ/L- MG 0.5 recon soln 25 mg MEQ/L INCRELEX 2 PA; SP FERRIPROX (2 2 PA; SP SUBCUTANEOUS TIMES A DAY) SOLUTION 10 ORAL TABLET MG/ML 1,000 MG indigo carmine 1 FERRIPROX ORAL 2 PA; SP injection solution 8 SOLUTION 100 mg/ml (0.8 %) MG/ML INDOCYANINE 2 FERRIPROX ORAL 2 PA; SP GREEN (BULK) TABLET 1,000 MG, POWDER 100 % 500 MG indocyanine green 1 forane inhalation 1 injection recon soln liquid 99.9 % 25 mg GLASSIA 2 PA; SP IODINE (BULK) 2 INTRAVENOUS CRYSTALS SOLUTION 1 IODINE (BULK) 2 GRAM/50 ML (2 GRANULES 100 % %) IOPANOIC ACID 2 GLUTOL GEL 2 OTC (BULK) POWDER ORAL LIQUID 100 100 % GRAM/180 ML isoflurane inhalation 1 GRAMICIDIN D 2 liquid 99.9 % (BULK) POWDER isopropyl alcohol 1 OTC GRISEOFULVIN 2 solution 91 %, 99 % (BULK) POWDER isosulfan blue 1 HEXTEND 2 subcutaneous INTRAVENOUS solution 1 % SOLUTION 6 % You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 107 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits KAOLIN (BULK) 2 lmd 10 % in 0.9 % 1 POWDER sodium chlor intravenous KETAMINE 2 parenteral solution (BULK) POWDER 10 % 100 % lmd 10 % in 5 % 1 ketamine in 0.9 % 1 dextrose intravenous sod chloride parenteral solution intravenous syringe 10 % 50 mg/5 ml (10 mg/ml) LOKELMA ORAL 2 QL POWDER IN ketamine injection 1 PACKET 10 solution 10 mg/ml, GRAM, 5 GRAM 100 mg/ml, 50 mg/ml M-CRESOL 2 kionex (with 1 ACETATE (BULK) sorbitol) oral LIQUID 100 % suspension 15-19.3 gram/60 ml md-76 r injection 1 solution 66-10 % L-ALANINE 2 POWDER md-gastroview oral 1 solution 66-10 % lanthanum oral 1 tablet,chewable MECAMYLAMINE 2 1,000 mg, 500 mg, HCL (BULK) 750 mg POWDER LEUCINE (BULK) 2 MECLOFENOXAT 2 POWDER E HCL (BULK) POWDER 100 % LEVOCARNITINE 2 (BULK) POWDER MENADIONE 2 (BULK) POWDER levocarnitine (with 1 sugar) oral solution MEQUINOL 2 100 mg/ml (BULK) CRYSTALS 100 % levocarnitine oral 1 solution 100 mg/ml META-CRESOL 2 (BULK) LIQUID levocarnitine oral 1 100 % tablet 330 mg METHACHOLINE 2 LEXISCAN 2 CHLORIDE INTRAVENOUS (BULK) POWDER SYRINGE 0.4 MG/5 100 % ML
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 108 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits midodrine oral 1 OMNIPAQUE 300 2 tablet 10 mg, 2.5 mg, INTRAVENOUS 5 mg SOLUTION 300 MG IODINE/ML monoject 0.9% 1 sodium chloride OMNIPAQUE 350 2 injection syringe INTRAVENOUS SOLUTION 350 monoject prefill 1 MG IODINE/ML advanced ns injection syringe OXYQUINOLINE 2 SULFATE (BULK) MOXISYLYTE 2 POWDER 100 % (BULK) POWDER 100 % PARACHLOROPH 2 ENOL (BULK) MURI-LUBE OIL 2 POWDER 100 % NH4 2 PENTYLENETETR 2 TETRATHIOMOL AZOL (BULK) YBDATE (BULK) CRYSTALS POWDER 100 % PHENINDIONE 2 nitisinone oral 1 PA; SP (BULK) POWDER capsule 10 mg, 2 mg, 5 mg PHENOL (BULK) 2 LIQUID 89 % NITYR ORAL 2 PA; SP TABLET 10 MG, 2 PHENYLMERCURI 2 MG, 5 MG C NITRATE (BULK) normal saline flush 1 CRYSTALS injection syringe pilocarpine hcl oral 1 OMNIPAQUE 140 2 tablet 5 mg, 7.5 mg INTRAVENOUS SOLUTION 140 POLYETHYLENE 2 MG IODINE/ML GLYCOL 3350(BULK) OMNIPAQUE 180 2 POWDER INTRATHECAL SOLUTION 180 POTASSIUM 2 MG IODINE/ML CITRATE M- HYD(BULK) OMNIPAQUE 240 2 POWDER 100 % INTRAVENOUS SOLUTION 240 POVIDONE 2 MG IODINE/ML (BULK) POWDER K-30 PREGNENOLONE 2 (BULK) POWDER You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 109 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits PREGNENOLONE, 2 sodium benzoate-sod 1 MICRONIZED(BU phenylacet LK) POWDER 100 intravenous solution % 10-10 % PROLASTIN-C 2 PA; SP SODIUM BORATE 2 INTRAVENOUS (BULK) POWDER RECON SOLN SODIUM 2 1,000 MG BROMIDE (BULK) PROLASTIN-C 2 PA; SP GRANULES INTRAVENOUS SODIUM 2 SOLUTION 1,000 BUTYRATE MG (+/-)/20 ML (BULK) POWDER propofol intravenous 1 100 % emulsion 10 mg/ml sodium chlor 0.9% 1 RAVICTI ORAL 2 PA; SP bacteriostat LIQUID 1.1 injection solution 0.9 GRAM/ML % REVCOVI 2 PA; SP sodium chloride 0.9 1 INTRAMUSCULA % (flush) injection R SOLUTION 2.4 syringe MG/1.5 ML (1.6 sodium chloride 0.9 1 MG/ML) % injection solution riluzole oral tablet 1 PA sodium chloride 0.9 1 50 mg % intravenous risedronate oral 1 QL parenteral solution tablet 30 mg sodium chloride 0.9 1 SEROTONIN HCL 2 % intravenous (BULK) POWDER piggyback 97 % sodium chloride 1 sevelamer carbonate 1 injection syringe 0.9 oral powder in % packet 0.8 gram, 2.4 sodium chloride 1 gram irrigation solution sevelamer carbonate 1 0.9 % oral tablet 800 mg SODIUM CITRATE 2 sevelamer hcl oral 1 DIHYDRATE(BUL tablet 400 mg, 800 K) GRANULES mg sevoflurane 1 inhalation liquid You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 110 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits sodium ferric 1 PA SOTRADECOL 2 gluconat-sucrose INTRAVENOUS intravenous solution SOLUTION 1 % (10 62.5 mg/5 ml MG/ML) SODIUM 2 sps (with sorbitol) 1 PHENYLBUTYRA oral suspension 15- TE (BULK) 20 gram/60 ml POWDER 100 % sps (with sorbitol) 1 sodium 1 PA rectal enema 30-40 phenylbutyrate oral gram/120 ml powder 0.94 SQUARIC ACID 2 gram/gram (BULK) POWDER sodium 1 PA 100 % phenylbutyrate oral SQUARIC ACID 2 tablet 500 mg DIBUTYLEST.(BU sodium polystyrene 1 LK) LIQUID 100 % (sorb free) oral SQUARIC ACID 2 suspension 15 DIBUTYLEST.(BU gram/60 ml LK) POWDER sodium polystyrene 1 SQUARIC ACID IN 2 sulfonate oral BUTANOL LIQUID powder 150 MG SODIUM 2 SULFADIAZINE 2 TETRADECYL SODIUM (BULK) SULF (BULK) POWDER 100 % POWDER terrell inhalation 1 sodium tetradecyl 1 liquid 99.9 % sulfate intravenous solution 3 % (30 THEOBROMINE 2 mg/ml) (BULK) POWDER 100 % sodium thiosulfate 1 intravenous solution THYMOL (BULK) 2 12.5 gram/50 ml CRYSTALS (250 mg/ml) THYROGEN 2 SP SOLIRIS 2 PA; SP INTRAMUSCULA INTRAVENOUS R RECON SOLN SOLUTION 300 1.1 MG (0.9 MG/ MG/30 ML ML FINAL CONC.)
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 111 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits TRICITRASOL 2 ZINC SULFATE 2 INJECTION HEPTAHYDRAT(B CONCENTRATE ULK) POWDER 46.7 % 100 % trientine oral 1 PA zoledronic acid- 1 PA; SP capsule 250 mg mannitol-water intravenous TRIOXSALEN 2 piggyback 5 mg/100 (BULK) ml CRYSTALS 100 %
VELPHORO ORAL 2 MISCELLANEOUS DEVICES TABLET,CHEWAB alcohol, rubbing 1 OTC LE 500 MG solution 70 % water for inject, 1 dy-o-derm solution 1 OTC bacteriostat INSTACLEAN 2 OTC injection solution SOLUTION water for injection, 1 ISOPROPYL 2 OTC sterile injection ALCOHOL solution SOLUTION 70 % water for injection, 1
sterile injection SMOKING DETERRENTS syringe bupropion hcl 1 ACA water for injection, 1 (smoking deter) oral sterile intravenous tablet extended parenteral solution release 12 hr 150 mg water for irrigation, 1 CHANTIX 2 ACA sterile irrigation CONTINUING solution MONTH BOX ORAL TABLET 1 XIAFLEX 2 PA; SP MG INJECTION RECON SOLN 0.9 CHANTIX ORAL 2 ACA MG TABLET 0.5 MG, 1 MG XURIDEN ORAL 2 PA; SP GRANULES IN CHANTIX 2 ACA PACKET 2 GRAM STARTING MONTH BOX YOHIMBINE HCL 2 ORAL (BULK) POWDER TABLETS,DOSE ZEMAIRA 2 PA; SP PACK 0.5 MG (11)- INTRAVENOUS 1 MG (42) RECON SOLN 1,000 MG You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 112 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits NICODERM CQ 2 ACA; OTC NICOTINE 2 TRANSDERMAL TARTRATE PATCH 24 HOUR POWDER 100 % 14 MG/24 HR, 21 nicotine transdermal 1 ACA; OTC MG/24 HR, 7 patch 24 hour 14 MG/24 HR mg/24 hr, 21 mg/24 nicorelief buccal 1 ACA; OTC hr, 7 mg/24 hr gum 2 mg nicotine transdermal 1 ACA; OTC NICORETTE 2 ACA; OTC patch, td daily, BUCCAL GUM 2 sequential 21-14-7 MG, 4 MG mg/24 hr NICORETTE 2 ACA; OTC quit 2 buccal gum 2 1 ACA; OTC BUCCAL mg LOZENGE 2 MG, 4 QUIT 2 BUCCAL 2 ACA; OTC MG LOZENGE 2 MG NICORETTE 2 ACA; OTC quit 4 buccal gum 4 1 ACA; OTC BUCCAL MINI mg LOZENGE 2 MG, 4 MG quit 4 buccal 1 ACA; OTC lozenge 4 mg nicotine (polacrilex) 1 ACA; OTC buccal gum 2 mg, 4 stop smoking aid 1 ACA; OTC mg buccal lozenge 2 mg, 4 mg NICOTINE 2 ACA; OTC (POLACRILEX) EAR, NOSE / THROAT
BUCCAL MEDICATIONS LOZENGE 2 MG MISCELLANEOUS AGENTS nicotine (polacrilex) 1 ACA; OTC buccal lozenge 4 mg azelastine nasal 1 QL aerosol,spray 137 nicotine (polacrilex) 1 ACA; OTC mcg (0.1 %) buccal mini lozenge 2 mg azelastine nasal 1 spray,non-aerosol NICOTINE 2 ACA; OTC 0.15 % (205.5 mcg) (POLACRILEX) BUCCAL MINI BECLOMETHASO 2 LOZENGE 4 MG NE DIPROP (BULK) POWDER NICOTINE 2 POLACRILEX CETYLPYRIDINIU 2 (BULK) POWDER M 15 %, 20 % CHLORIDE(BULK) CRYSTALS
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 113 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits chlorhexidine 1 sodium fluoride 1 gluconate mucous 5000 plus dental membrane cream 1.1 % mouthwash 0.12 % sodium fluoride-pot 1 denta 5000 plus 1 nitrate dental paste dental cream 1.1 % 1.1-5 % dentagel dental gel 1 triamcinolone 1 1.1 % acetonide dental paste 0.1 % EUGENOL (BULK) 2 LIQUID XYLOMETAZOLI 2 NE (BULK) fluoride (sodium) 1 POWDER 100 % dental cream 1.1 % MISCELLANEOUS OTIC fluoride (sodium) 1 dental gel 1.1 % PREPARATIONS fluoride (sodium) 1 acetic acid otic (ear) 1 dental paste 1.1 % solution 2 % ipratropium bromide 1 QL CARBAMIDE 2 nasal spray,non- PEROXIDE aerosol 0.03 %, 42 (BULK) POWDER mcg (0.06 %) 100 % olopatadine nasal 1 QL ciprofloxacin hcl 1 spray,non-aerosol otic (ear) 0.6 % dropperette 0.2 % oralone dental paste 1 flac otic oil otic 1 0.1 % (ear) drops 0.01 % OXYMETAZOLIN 2 fluocinolone 1 E (BULK) acetonide oil otic POWDER 100 % (ear) drops 0.01 % paroex oral rinse 1 hydrocortisone- 1 mucous membrane acetic acid otic (ear) mouthwash 0.12 % drops 1-2 % periogard mucous 1 ofloxacin otic (ear) 1 membrane drops 0.3 % mouthwash 0.12 % OTIC STEROID / ANTIBIOTIC sf 5000 plus dental 1 ciprofloxacin- 1 cream 1.1 % dexamethasone otic sf dental gel 1.1 % 1 (ear) drops,suspension 0.3-0.1 %
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 114 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits neomycin- 1 betamethasone 1 polymyxin-hc otic acet,sod phos (ear) injection suspension drops,suspension 6 mg/ml 3.5-10,000-1 mg/ml- BETAMETHASON 2 unit/ml-% E SOD PHOS neomycin- 1 (BULK) POWDER polymyxin-hc otic CORTICOTROPIN 2 (ear) solution 3.5- (BULK) POWDER 10,000-1 mg/ml- unit/ml-% CORTISONE 2 (BULK) POWDER OTOVEL OTIC 2 (EAR) SOLUTION cortisone oral tablet 1 0.3-0.025 % (0.25 25 mg ML) cosyntropin injection 1 ENDOCRINE/DIABETES recon soln 0.25 mg ADRENAL HORMONES decadron oral tablet 1 0.5 mg, 0.75 mg, 4 a-hydrocort 1 mg, 6 mg injection recon soln 100 mg DESOXYCORTICO 2 STERONE AC ALDOSTERONE 2 (BULK) POWDER (BULK) POWDER 100 % 97.5 % dexabliss oral 1 PA ARISTOSPAN 2 tablets,dose pack 1.5 INTRA- mg (39 tabs) ARTICULAR INJECTION DEXAMETHASON 2 SUSPENSION 20 E AC, MICRO MG/ML (BULK) POWDER 100 % ARISTOSPAN 2 INTRALESIONAL DEXAMETHASON 2 INJECTION E ACETATE SUSPENSION 5 (BULK) POWDER MG/ML dexamethasone 1 BETAMETHASON 2 intensol oral drops 1 E mg/ml ACET,MICRO(BUL DEXAMETHASON 2 K) POWDER 100 % E ISONIC (BULK) POWDER
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 115 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits dexamethasone oral 1 fludrocortisone oral 1 elixir 0.5 mg/5 ml tablet 0.1 mg dexamethasone oral 1 hidex oral 1 PA solution 0.5 mg/5 ml tablets,dose pack 1.5 mg (21 tabs) dexamethasone oral 1 tablet 0.5 mg, 0.75 hydrocortisone oral 1 mg, 1 mg, 1.5 mg, 2 tablet 10 mg, 20 mg, mg, 4 mg, 6 mg 5 mg dexamethasone oral 1 PA METHYLPREDNIS 2 tablets,dose pack 1.5 OLON mg (21 tabs), 1.5 mg AC,MIC(BULK) (35 tabs), 1.5 mg (51 POWDER 100 % tabs) methylprednisolone 1 DEXAMETHASON 2 acetate injection E SOD PHOS suspension 40 (BULK) POWDER mg/ml, 80 mg/ml 100 % methylprednisolone 1 dexamethasone 1 oral tablet 16 mg, 32 sodium phos (pf) mg, 4 mg, 8 mg injection solution 10 methylprednisolone 1 mg/ml oral tablets,dose dexamethasone 1 pack 4 mg sodium phosphate methylprednisolone 1 injection solution 10 sodium succ mg/ml, 4 mg/ml injection recon soln dexamethasone 1 125 mg, 40 mg sodium phosphate methylprednisolone 1 injection syringe 4 sodium succ mg/ml intravenous recon DEXAMETHASON 2 soln 1,000 mg, 500 E,MICRONIZED(B mg ULK) POWDER METHYLPREDNIS 2 100 % OLONE, MIC dexamethasone-0.9 1 (BULK) POWDER % sod. chlor 100 % intravenous millipred dp oral 1 piggyback 10 mg/50 tablets,dose pack 5 ml mg (21 tabs), 5 mg FLUDROCORTISO 2 (48 tabs) NE (BULK) POWDER You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 116 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits millipred oral tablet 1 prednisone oral 1 5 mg solution 5 mg/5 ml PREDNISOLONE 2 prednisone oral 1 (BULK) POWDER tablet 1 mg, 10 mg, 2.5 mg, 20 mg, 5 mg, PREDNISOLONE 2 50 mg AC, MICRO (BULK) POWDER prednisone oral 1 100 % tablets,dose pack 10 mg, 5 mg prednisolone oral 1 solution 15 mg/5 ml SOLU-CORTEF 2 ACT-O-VIAL (PF) PREDNISOLONE 2 INJECTION SOD PHOS (BULK) RECON SOLN POWDER 1,000 MG/8 ML, prednisolone sodium 1 100 MG/2 ML, 250 phosphate oral MG/2 ML, 500 solution 10 mg/5 ml, MG/4 ML 15 mg/5 ml (3 SOLU-CORTEF 2 mg/ml), 15 mg/5 ml INJECTION (5 ml), 20 mg/5 ml (4 RECON SOLN 100 mg/ml), 25 mg/5 ml MG (5 mg/ml), 5 mg base/5 ml (6.7 mg/5 TRIAMCIN 2 ml) DIACET, MICRO (BULK) POWDER prednisolone sodium 1 100 % phosphate oral tablet,disintegrating TRIAMCINOLONE 2 10 mg, 15 mg, 30 mg (BULK) POWDER PREDNISOLONE, 2 triamcinolone 1 MICRO (BULK) acetonide injection POWDER 100 % suspension 10 mg/ml, 40 mg/ml PREDNISONE 2 (BULK) POWDER TRIAMCINOLONE 2 DIACETATE prednisone intensol 1 (BULK) POWDER oral concentrate 5 mg/ml veripred 20 oral 1 solution 20 mg/5 ml PREDNISONE 2 (4 mg/ml) MICRONIZED (BULK) POWDER ANTITHYROID AGENTS 100 %
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 117 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits METHIMAZOLE 2 ACCU-CHEK 2 OTC (BULK) POWDER FASTCLIX 100 % LANCING DEV KIT methimazole oral 1 tablet 10 mg, 5 mg ACCU-CHEK 2 OTC MULTICLIX POTASSIUM 2 LANCET IODIDE (BULK) CRYSTALS 100 % ACCU-CHEK 2 OTC MULTICLIX POTASSIUM 2 LANCET KIT IODIDE (BULK) GRANULES ACCU-CHEK 2 RAPID D POTASSIUM 2 INFUSION IODIDE (BULK) SUBCUTANEOUS POWDER INFUSION SET 10 PROPYLTHIOURA 2 X 70 MM-CM, 6 X CIL (BULK) 50 MM-CM, 8 X 50 POWDER 100 % MM-CM, 8 X 70 propylthiouracil oral 1 MM-CM tablet 50 mg ACCU-CHEK 2 OTC SAFE-T-PRO 23 DIABETES THERAPY GAUGE 1ST TIER UNILET 2 OTC ACCU-CHEK 2 OTC COMFORTOUCH SAFE-T-PRO PLUS 28 GAUGE, 30 23 GAUGE GAUGE ACCU-CHEK 2 OTC 2-IN-1 LANCET 2 OTC SOFT DEV DEVICE 30 LANCETS KIT GAUGE ACCU-CHEK 2 OTC acarbose oral tablet 1 SOFTCLIX 100 mg, 25 mg, 50 LANCETS mg ACCU-CHEK 2 ACCU-CHEK 2 SPIRIT ADAPTER COMBO SYSTEM KIT ACCU-CHEK 2 SPIRIT ACCU-CHEK 2 OTC CARTRIDGE SYS FASTCLIX LANCET DRUM
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 118 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits ACCU-CHEK 2 ADVOCATE 2 OTC TENDER LANCET 26 SUBCUTANEOUS GAUGE, 30 INFUSION SET 13 GAUGE X 110 MM-CM, 13 ADVOCATE 2 OTC X 60 MM-CM, 13 X LANCING DEVICE 80 MM-CM, 17 X 110 MM-CM, 17 X ADVOCATE 2 OTC 60 MM-CM, 17 X RAPID-SAFE 80 MM-CM LANCING ACCU-CHEK 2 AEROCHAMBER 2 ULTRAFLEX MINI SPACER SUBCUTANEOUS AEROCHAMBER 2 INFUSION SET 10 MV SPACER X 110 MM-CM, 10 X 60 MM-CM, 10 X AEROCHAMBER 2 80 MM-CM, 8 X PLUS FLOW-VU 110 MM-CM, 8 X SPACER 60 MM-CM, 8 X 80 AEROCHAMBER 2 MM-CM PLUS FLOW-VU,L ACD-A SOLUTION 2 MSK SPACER ACE AEROSOL 2 AEROCHAMBER 2 CLOUD PLUS FLOW-VU,M ENHANCER MSK SPACER SPACER AEROCHAMBER 2 acti-lance lancets 17 1 OTC PLUS FLOW-VU,S gauge, 28 gauge MSK SPACER ACTI-LANCE 2 OTC AEROCHAMBER 2 LANCETS 23 PLUS Z STAT LG GAUGE MSK SPACER ADJUSTABLE 2 OTC AEROCHAMBER 2 LANCING DEVICE PLUS Z STAT MD MSK SPACER ADVANCED 2 OTC LANCING DEVICE AEROCHAMBER 2 KIT PLUS Z STAT SM MSK SPACER ADVANCED 2 OTC TRAVEL AEROCHAMBER 2 LANCETS 28 WITH GAUGE, 30 FLOWSIGNAL GAUGE SPACER
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 119 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits AEROCHAMBER 2 AUTOJECT 2 2 OTC Z-STAT PLUS- INJECTION FLW SG SPACER DEVICE SUBCUTANEOUS AEROTRACH 2 INSULIN PEN PLUS SPACER AUTO-LANCET 2 OTC AEROVENT PLUS 2 MINI SPACER AUTOLET 2 OTC alcohol pads topical 1 OTC IMPRESSION pads, medicated LANC DEV KIT ALCOHOL PREP 2 OTC AUTOLET 2 OTC PADS TOPICAL LANCING DEVICE PADS, MEDICATED AUTOLET PLUS 2 OTC LANCING DEVICE ALCOHOL SWABS 2 OTC TOPICAL PADS, AUTOPEN 1 TO 21 2 OTC MEDICATED UNITS SUBCUTANEOUS ALCOHOL WIPES 2 OTC INSULIN PEN TOPICAL PADS, MEDICATED AUTOPEN 2 TO 42 2 OTC UNITS ALTERNATE SITE 2 OTC SUBCUTANEOUS LANCET 26 INSULIN PEN GAUGE AUTOSOFT 30 2 ALTERNATE SITE 2 OTC INFUSION SET LANCING DEVICE AUTOSOFT 90 2 AQUA LANCE 2 OTC INFUSION SET LANCING DEVICE AUTOSOFT XC 2 ASSURE 2 OTC INFUSION SET 23" HAEMOLANCE INFUSION SET PLUS 1.2 MM, 18 GAUGE, 21 AUTOSOFT XC 2 GAUGE, 25 INFUSION SET 32" GAUGE, 28 INFUSION SET GAUGE AUTOSOFT XC 2 ASSURE LANCE 2 OTC INFUSION SET 43" 25 GAUGE, 28 INFUSION SET GAUGE BAQSIMI NASAL 2 QL ASSURE LANCE 2 OTC SPRAY,NON- PLUS 21 GAUGE, AEROSOL 3 25 GAUGE, 30 MG/ACTUATION GAUGE You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 120 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits BD ALCOHOL 2 OTC BD INSULIN 2 SWABS TOPICAL SYRINGE SLIP TIP PADS, SYRINGE 1 ML MEDICATED BD INSULIN 2 BD AUTOSHIELD 2 OTC SYRINGE DUO PEN NEEDLE SYRINGE 0.3 ML NEEDLE 30 29 GAUGE X 1/2", GAUGE X 3/16" 0.5 ML 29 GAUGE X 1/2", 1 ML 25 BD ECLIPSE 2 GAUGE X 5/8", 1 LUER-LOK ML 25 X 1", 1 ML NEEDLE 21 26 X 1/2", 1 ML 27 GAUGE X 1 1/2", GAUGE X 1/2", 1 22 GAUGE X 1", 25 ML 29 GAUGE X GAUGE X 1 1/2", 1/2" 30 X 1/2 " BD INSULIN 2 BD ECLIPSE 2 SYRINGE U-500 LUER-LOK SYRINGE 1/2 ML SYRINGE 1 ML 30 31 GAUGE X GAUGE X 1/2" 15/64" BD ECLIPSE 2 BD INSULIN 2 NEEDLE 21 SYRINGE ULTRA- GAUGE X 1", 25 FINE SYRINGE 0.3 GAUGE X 1" ML 30 GAUGE X BD FILTER 2 1/2", 0.3 ML 31 NEEDLE 5- GAUGE X 5/16", MICRON NOKO 0.5 ML 30 GAUGE NEEDLE 18 X 1/2", 0.5 ML 31 GAUGE X 1 1/2" GAUGE X 5/16", 1 BD FILTER 2 ML 30 GAUGE X NEEDLE-5 1/2", 1 ML 31 MICRON NEEDLE GAUGE X 5/16 19 X 1 1/2 " BD INTEGRA 2 BD INSULIN 2 NEEDLE NEEDLE SYRINGE HALF 23 GAUGE X 1" UNIT SYRINGE 0.3 BD 2 ML 31 GAUGE X INTRADERMAL 5/16" BEVEL NEEDLES BD INSULIN 2 NEEDLE 26 SYRINGE GAUGE X 3/8" SAFETY-LOK SYRINGE 1 ML 29 GAUGE X 1/2" You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 121 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits BD LO-DOSE 2 BD Q-SYTE MDV 2 OTC MICRO-FINE IV ADAPTER SYRINGE 1/2 ML INFUSION SET 28 GAUGE X 1/2" BD Q-SYTE SPLIT- 2 OTC BD LO-DOSE 2 SEPT DEVICE ULTRA-FINE INFUSION SET SYRINGE 0.5 ML BD REGULAR 2 29 GAUGE X 1/2" BEVEL NEEDLES BD MAGNI-GUIDE 2 OTC NEEDLE 18 SYRINGE GAUGE X 1 1/2", MAGNIFI 18 GAUGE X 1", 19 GAUGE X 1 1/2", BD 2 OTC 19 GAUGE X 1", 20 MICROTAINER GAUGE X 1 1/2", LANCET 1.5 X 2 20 GAUGE X 1", 21 MM, 21 GAUGE, GAUGE X 1 1/2", 30 GAUGE 21 GAUGE X 1", 22 BD NANO 2ND 2 OTC GAUGE X 1 1/2", GEN PEN NEEDLE 22 GAUGE X 1", 23 NEEDLE 32 GAUGE X 3/4", 25 GAUGE X 5/32" GAUGE X 1 1/2", BD NOKOR 2 25 GAUGE X 5/8", ADMIX NEEDLE 26 GAUGE X 1/2", NEEDLE 18 27 GAUGE X 1/2" GAUGE X 1 1/2" BD SAFETYGLIDE 2 BD 2 INSULIN PRECISIONGLIDE SYRINGE NEEDLE 25 SYRINGE 0.3 ML GAUGE X 1", 27 29 GAUGE X 1/2", GAUGE X 1 1/2" 0.3 ML 31 GAUGE X 15/64", 0.3 ML 31 BD 2 GAUGE X 5/16", PRECISIONGLIDE 0.5 ML 30 GAUGE NON-STERILE X 5/16", 0.5 ML 31 NEEDLE 18 GAUGE X 15/64", 1 GAUGE X 1 1/2", ML 29 GAUGE X 19 GAUGE X 1 1/2", 1 ML 31 1/2", 20 GAUGE X GAUGE X 15/64" 1 1/2", 21 GAUGE X 1 1/2", 22 GAUGE X 1 1/2", 23 GAUGE X 1", 25 GAUGE X 1", 25 GAUGE X 5/8"
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 122 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits BD SAFETYGLIDE 2 BD ULTRA-FINE 2 OTC NEEDLE NEEDLE NANO PEN 18 GAUGE X 1 NEEDLE NEEDLE 1/2", 21 GAUGE X 32 GAUGE X 5/32" 1 1/2", 21 GAUGE BD ULTRA-FINE 2 OTC X 1", 22 GAUGE X ORIG PEN 1 1/2", 25 GAUGE NEEDLE NEEDLE X 1", 25 X 5/8 ", 27 29 GAUGE X 1/2" X 5/8 " BD ULTRA-FINE 2 BD SAFETYGLIDE 2 SHORT PEN SYRINGE NEEDLE NEEDLE SYRINGE 1 ML 27 31 GAUGE X 5/16" GAUGE X 5/8" BD VEO INSULIN 2 BD SPECIALTY 2 SYR HALF UNIT USE NEEDLES SYRINGE 0.3 ML NEEDLE 16 31 GAUGE X GAUGE X 1 1/2", 15/64" 16 GAUGE X 1", 21 GAUGE X 2", 23 BD VEO INSULIN 2 GAUGE X 1 1/4", SYRINGE UF 25 GAUGE X 7/8", SYRINGE 0.3 ML 27 GAUGE X 1 31 GAUGE X 1/4", 30 GAUGE X 15/64", 1 ML 31 1", 30 GAUGE X GAUGE X 15/64", 1/2" 1/2 ML 31 GAUGE X 15/64" BD ULTRA FINE 2 OTC LANCETS 33 BD YALE 2 GAUGE REGULAR BEVEL NEEDLE 27 BD ULTRA-FINE II 2 OTC GAUGE X 1" LANCETS 30 GAUGE BLUNT NEEDLE, 2 DISPOSABLE BD ULTRA-FINE 2 OTC NEEDLE 18 X 1 1/2 MICRO PEN ", 22 X 1 1/2 " NEEDLE NEEDLE 32 GAUGE X 1/4" BREATHERITE 2 MDI SPACER BD ULTRA-FINE 2 OTC SPACER MINI PEN NEEDLE NEEDLE BREATHERITE 2 31 GAUGE X 3/16" SPACER-MASK, NEO. SPACER
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 123 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits BREATHERITE 2 BYETTA 2 PA; QL SPACER- SUBCUTANEOUS MASK,ADULT PEN INJECTOR 10 SPACER MCG/DOSE(250 MCG/ML) 2.4 ML, BREATHERITE 2 5 MCG/DOSE (250 SPACER- MCG/ML) 1.2 ML MASK,CHILD SPACER CAREONE 2 OTC LANCING DEVICE BREATHERITE 2 SPACER- CAREONE ULTRA 2 OTC MASK,INFANT THIN LANCET SPACER CARETOUCH 2 OTC BREATHERITE 2 ALCOHOL PREP SPACER- PAD TOPICAL MASK,S.CHLD PADS, SPACER MEDICATED BREATHERITE 2 CARETOUCH 2 OTC VALVED MDI LANCING DEVICE CHAMBER CARETOUCH 2 OTC SPACER TWIST LANCET 28 BREATHERITE 2 GAUGE, 30 VALVED MDI GAUGE, 33 SPACER SPACER GAUGE BULLSEYE MINI 2 OTC CLEO 90 2 SAFETY INFUSION SET 24" LANCETS 21 INFUSION SET GAUGE, 25 CLEO 90 2 GAUGE, 28 INFUSION SET 31" GAUGE INFUSION SET BYDUREON 2 PA; QL CLEVER CHEK 2 OTC BCISE LANCETS 30 SUBCUTANEOUS GAUGE AUTO-INJECTOR 2 MG/0.85 ML CLEVER CHOICE 2 CHAMBER-LRG BYDUREON 2 PA; QL MASK SPACER SUBCUTANEOUS PEN INJECTOR 2 CLEVER CHOICE 2 MG/0.65 ML CHAMBER-MED MASK SPACER
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 124 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits CLEVER CHOICE 2 CONTACT 2 CHAMBER-SM DETACH INFUS MASK SPACER SET 23" INFUSION SET COAGUCHEK 2 OTC LANCETS CONTACT 2 DETACH INFUS COLOR LANCETS 2 OTC SET 32" INFUSION 21 GAUGE SET COMFORT EZ 2 OTC CURITY 2 OTC LANCETS 23 ALCOHOL SWABS GAUGE, 28 TOPICAL PADS, GAUGE MEDICATED COMFORT 2 DERMAVIEW II 2 OTC INFUSION SET 23" TOPICAL INFUSION SET BANDAGE 2 3/8 X COMFORT 2 2 3/4 ", 4 X 4 1/2 " INFUSION SET 32" DERMAVIEW 2 OTC INFUSION SET TOPICAL COMFORT 2 BANDAGE 4 X 5 " INFUSION SET 43" DEXCOM G4 2 INFUSION SET RECEIVER COMFORT 2 OTC DEXCOM G4 2 LANCETS RECEIVER COMFORT SHORT 2 PEDIATRIC INSULIN PUMP DEXCOM G4 2 32" INFUSION SET RECEIVER-SHARE COMPACT SPACE 2 (PED) CHAMBER DEXCOM G4 2 SPACER RECEIVER-SHARE COMPACT SPACE 2 KIT CHAMBER-LRG DEXCOM G4 2 QL MASK SPACER TRANSMITTER COMPACT SPACE 2 DEVICE CHAMBER-MED DEXCOM G5 2 MASK SPACER RECEIVER COMPACT SPACE 2 DEXCOM G5 2 QL CHAMBER-SM TRANSMITTER MASK SPACER DEVICE DEXCOM G5-G4 2 QL SENSOR DEVICE You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 125 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits DEXCOM G6 2 EASY COMFORT 2 OTC RECEIVER LANCETS 30 GAUGE DEXCOM G6 2 QL SENSOR DEVICE EASY MINI EJECT 2 OTC LANCING DEVICE DEXCOM G6 2 QL TRANSMITTER EASY TOUCH 2 OTC DEVICE ALCOHOL PREP PADS TOPICAL DEXCOM 2 PADS, RECEIVER MEDICATED DIAZOXIDE 2 EASY TOUCH 2 OTC (BULK) POWDER LANCETS 26 100 % GAUGE, 28 diazoxide oral 1 GAUGE, 30 suspension 50 mg/ml GAUGE, 32 DISPOSABLE 2 GAUGE NEEDLES EASY TOUCH 2 OTC NEEDLE 22 LANCING DEVICE GAUGE X 3/4" EASY TOUCH 2 OTC DISPOSABLE 2 OTC SAFETY POWER LANCETS 21 DROPLET 2 OTC GAUGE, 23 LANCETS 30 GAUGE, 26 GAUGE GAUGE, 28 GAUGE, 30 DROPLET 2 OTC GAUGE, 32 LANCING DEVICE GAUGE EASIVENT 2 EASY TOUCH 2 OTC HOLDING TWIST LANCETS CHAMBER 26 GAUGE, 28 SPACER GAUGE, 30 EASIVENT MASK 2 GAUGE, 32 LARGE DEVICE GAUGE, 33 GAUGE EASIVENT MASK 2 MEDIUM DEVICE EASY TWIST AND 2 OTC CAP LANCETS 28 EASIVENT MASK 2 GAUGE SMALL DEVICE EMBRACE 2 OTC EASY COMFORT 2 OTC LANCETS 30 ALCOHOL PAD GAUGE TOPICAL PADS, MEDICATED You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 126 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits EXEL 2 FEMCAP 2 ACA HYPODERMIC VAGINAL DEVICE NEEDLES 22 MM, 26 MM, 30 NEEDLE 18 MM GAUGE X 1 1/2", FIFTY50 SAFETY 2 OTC 19 GAUGE X 1", 20 SEAL LANCETS 30 GAUGE X 1 1/2", GAUGE, 32 20 GAUGE X 1", 20 GAUGE X 3/4 ", 21 GAUGE X 1 1/2", 21 FILTER NEEDLES 2 GAUGE X 1", 22 NEEDLE 18 GAUGE X 1 1/2", GAUGE X 1 1/2" 22 GAUGE X 1", 22 FINE 30 2 OTC GAUGE X 3/4", 23 UNIVERSAL GAUGE X 3/4", 25 LANCETS 30 GAUGE X 1 1/2", GAUGE 25 GAUGE X 1", 25 GAUGE X 3/4", 25 FINGERSTIX 2 OTC GAUGE X 5/8", 26 LANCETS GAUGE X 1 1/2", FLEXICHAMBER 2 26 GAUGE X 1/2", SPACER 26 GAUGE X 3/8", 26 GAUGE X 5/8", FLEXICHAMBER- 2 27 GAUGE X 1/2", LG CHILD MASK 30 GAUGE X 1/2" DEVICE e-z ject lancets , 26 1 OTC FLEXICHAMBER- 2 gauge, 30 gauge, 32 SM ADULT MASK gauge, 33 gauge DEVICE e-z ject thin lancets 1 OTC FLEXICHAMBER- 2 28 gauge SM CHILD MASK DEVICE EZ SMART 2 OTC LANCETS 28 FLOW-EZE 2 GAUGE VENTED NEEDLE NEEDLE EZ-LETS 26 2 OTC GAUGE FORA LANCING 2 OTC DEVICE FARXIGA ORAL 2 ST; QL TABLET 10 MG, 5 FORACARE 2 OTC MG LANCETS 30 GAUGE FC2 FEMALE 2 ACA; OTC CONDOM FREESTYLE 2 OTC CONTROL SOLUTION
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 127 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits FREESTYLE 2 OTC glipizide oral tablet 1 FREEDOM KIT 10 mg, 5 mg FREESTYLE 2 OTC glipizide oral tablet 1 FREEDOM LITE extended release KIT 24hr 10 mg, 2.5 mg, 5 mg FREESTYLE 2 OTC INSULINX glipizide-metformin 1 oral tablet 2.5-250 FREESTYLE 2 OTC mg, 2.5-500 mg, 5- INSULINX STRIP 500 mg FREESTYLE 2 OTC GLUCAGEN 2 INSULINX TEST DIAGNOSTIC KIT STRIPS STRIP INJECTION FREESTYLE 2 OTC RECON SOLN 1 LANCETS 28 MG/ML GAUGE GLUCAGEN 2 QL FREESTYLE 2 HYPOKIT LIBRE 14 DAY INJECTION READER RECON SOLN 1 FREESTYLE 2 QL MG LIBRE 14 DAY GLUCAGON 2 QL SENSOR KIT (HCL) FREESTYLE 2 EMERGENCY KIT LIBRE 2 READER INJECTION RECON SOLN 1 FREESTYLE 2 MG LIBRE 2 SENSOR KIT GLUCAGON 2 QL EMERGENCY KIT FREESTYLE LITE 2 OTC (HUMAN) METER KIT INJECTION FREESTYLE LITE 2 OTC RECON SOLN 1 STRIPS STRIP MG FREESTYLE TEST 2 OTC GLUCOCOM 2 OTC STRIP LANCETS 28 GAUGE, 30 FREESTYLE 2 OTC GAUGE, 33 UNISTIK 2 GAUGE glimepiride oral 1 GLUCOSE 2 OTC tablet 1 mg, 2 mg, 4 KETONE mg CONTROL SOLN GLIPIZIDE (BULK) 2 SOLUTION POWDER 100 % You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 128 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits GLYBURIDE 2 GVOKE PFS 2- 2 QL (BULK) POWDER PACK SYRINGE SUBCUTANEOUS glyburide 1 SYRINGE 0.5 micronized oral MG/0.1 ML, 1 tablet 1.5 mg, 3 mg, MG/0.2 ML 6 mg HEALTHY 2 OTC glyburide oral tablet 1 ACCENTS 1.25 mg, 2.5 mg, 5 AUTOLET mg HEALTHY 2 OTC glyburide-metformin 1 ACCENTS UNILET oral tablet 1.25-250 LANCET 30 mg, 2.5-500 mg, 5- GAUGE 500 mg huber safety needles 1 GLYXAMBI ORAL 2 ST; QL (disp.) needle 22 x TABLET 10-5 MG, 3/4 " 25-5 MG HUMALOG 2 GOJJI LANCETS 2 OTC JUNIOR KWIKPEN 30 GAUGE U-100 GOJJI LANCING 2 OTC SUBCUTANEOUS DEVICE INSULIN PEN, GVOKE HYPOPEN 2 QL HALF-UNIT 100 1-PACK UNIT/ML SUBCUTANEOUS HUMALOG 2 AUTO-INJECTOR KWIKPEN 0.5 MG/0.1 ML, 1 INSULIN MG/0.2 ML SUBCUTANEOUS GVOKE HYPOPEN 2 QL INSULIN PEN 100 2-PACK UNIT/ML, 200 SUBCUTANEOUS UNIT/ML (3 ML) AUTO-INJECTOR HUMALOG MIX 2 0.5 MG/0.1 ML, 1 50-50 INSULN U- MG/0.2 ML 100 GVOKE PFS 1- 2 QL SUBCUTANEOUS PACK SYRINGE SUSPENSION 100 SUBCUTANEOUS UNIT/ML (50-50) SYRINGE 0.5 HUMALOG MIX 2 MG/0.1 ML, 1 50-50 KWIKPEN MG/0.2 ML SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (50-50)
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 129 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits HUMALOG MIX 2 HUMULIN R 2 75-25 KWIKPEN REGULAR U-100 SUBCUTANEOUS INSULN INSULIN PEN 100 INJECTION UNIT/ML (75-25) SOLUTION 100 UNIT/ML HUMALOG MIX 2 75-25(U- HUMULIN R U-500 2 100)INSULN (CONC) INSULIN SUBCUTANEOUS SUBCUTANEOUS SUSPENSION 100 SOLUTION 500 UNIT/ML (75-25) UNIT/ML HUMALOG U-100 2 HUMULIN R U-500 2 INSULIN (CONC) KWIKPEN SUBCUTANEOUS SUBCUTANEOUS CARTRIDGE 100 INSULIN PEN 500 UNIT/ML UNIT/ML (3 ML) HUMALOG U-100 2 HYPODERMIC 2 INSULIN NEEDLES SUBCUTANEOUS NEEDLE 21 SOLUTION 100 GAUGE X 1", 23 UNIT/ML GAUGE X 1 1/2", 26 GAUGE X 5/8" HUMULIN 70/30 2 U-100 INSULIN HYPOLANCE AST 2 OTC SUBCUTANEOUS LANCING KIT SUSPENSION 100 INCONTROL 2 OTC UNIT/ML (70-30) ALCOHOL PADS HUMULIN 70/30 2 TOPICAL PADS, U-100 KWIKPEN MEDICATED SUBCUTANEOUS INCONTROL 2 OTC INSULIN PEN 100 LANCING DEVICE UNIT/ML (70-30) INCONTROL 2 OTC HUMULIN N NPH 2 SUPER THIN INSULIN LANCETS 30 KWIKPEN GAUGE SUBCUTANEOUS INSULIN PEN 100 INCONTROL 2 OTC UNIT/ML (3 ML) ULTRA THIN LANCETS 28 HUMULIN N NPH 2 GAUGE U-100 INSULIN SUBCUTANEOUS SUSPENSION 100 UNIT/ML
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 130 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits INJECT EASE 2 OTC INVOKAMET 2 ST; QL LANCETS 28 ORAL TABLET GAUGE, 30 150-1,000 MG, 150- GAUGE 500 MG, 50-1,000 MG, 50-500 MG INSPIRACHAMBE 2 R SPACER INVOKAMET XR 2 ST; QL ORAL TABLET, IR INSPIRACHAMBE 2 - ER, BIPHASIC R WITH MASK- 24HR 150-1,000 LARGE SPACER MG, 150-500 MG, INSPIRACHAMBE 2 50-1,000 MG, 50- R WITH MASK- 500 MG MED SPACER INVOKANA ORAL 2 ST; QL INSPIRACHAMBE 2 TABLET 100 MG, R WITH MASK- 300 MG SMALL SPACER IV 2 OTC INSULIN 2 ADMINISTRATIO SYRINGE N SET INFUSION MICROFINE SET SYRINGE 1 ML 27 IV PREP WIPES 2 OTC GAUGE X 5/8" TOPICAL PADS, INSULIN 2 MEDICATED SYRINGE JANUMET ORAL 2 PA; QL NEEDLELESS TABLET 50-1,000 SYRINGE 1 ML MG, 50-500 MG INSULIN 2 JANUMET XR 2 PA; QL SYRINGE ORAL TABLET, SYRINGE 0.5 ML ER MULTIPHASE 29 GAUGE X 1/2" 24 HR 100-1,000 INSULIN 2 MG, 50-1,000 MG, SYRINGE- 50-500 MG NEEDLE U-100 JANUVIA ORAL 2 PA; QL SYRINGE 1 ML 28 TABLET 100 MG, GAUGE X 1/2", 1 25 MG, 50 MG ML 30 GAUGE X 1/2" JARDIANCE 2 ST; QL ORAL TABLET 10 INVACARE 2 OTC MG, 25 MG LANCETS 30 GAUGE
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 131 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits JENTADUETO 2 PA; QL LANTUS 2 ORAL TABLET SOLOSTAR U-100 2.5-1,000 MG, 2.5- INSULIN 500 MG, 2.5-850 SUBCUTANEOUS MG INSULIN PEN 100 UNIT/ML (3 ML) JENTADUETO XR 2 PA; QL ORAL TABLET, IR LANTUS U-100 2 - ER, BIPHASIC INSULIN 24HR 2.5-1,000 SUBCUTANEOUS MG, 5-1,000 MG SOLUTION 100 UNIT/ML KENDALL 2 OTC TOPICAL LANZO LANCING 2 OTC BANDAGE 2 X 2 DEVICE KIT 3/4 " LEVEMIR 2 LANCETS , 21 2 OTC FLEXTOUCH U- GAUGE, 26 100 INSULN GAUGE, 28 SUBCUTANEOUS GAUGE, 30 INSULIN PEN 100 GAUGE, 33 UNIT/ML (3 ML) GAUGE LEVEMIR U-100 2 LANCETS, SUPER 2 OTC INSULIN THIN SUBCUTANEOUS SOLUTION 100 LANCETS,THIN , 2 OTC UNIT/ML 23 GAUGE, 28 GAUGE LIFESHIELD 2 BLUNT CANNULA LANCETS,ULTRA 2 OTC NEEDLE 18 THIN , 26 GAUGE GAUGE X 1" LANCING DEVICE 2 OTC LITE TOUCH 2 OTC LANCING DEVICE 2 OTC LANCETS 28 WITH LANCETS GAUGE, 30 LANCING DEVICE 2 OTC GAUGE, 33 WITH LANCETS GAUGE KIT LITE TOUCH 2 OTC LANCING 2 OTC LANCING DEVICE SYSTEM LITE TOUCH- 2 MEDIUM MASK DEVICE LITEAIRE MDI 2 CHAMBER SPACER
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 132 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits LITETOUCH- 2 MEDLANCE PLUS 2 OTC LARGE MASK SPECIAL BLADE DEVICE 0.8 X 2 MM LITETOUCH- 2 MEDTRONIC 2 OTC SMALL MASK REMOTE DEVICE CONTROL LYUMJEV 2 METFORMIN 2 KWIKPEN U-100 (BULK) POWDER INSULIN 100 % SUBCUTANEOUS metformin oral 1 INSULIN PEN 100 solution 500 mg/5 ml UNIT/ML metformin oral 1 LYUMJEV 2 tablet 1,000 mg, 500 KWIKPEN U-200 mg, 850 mg INSULIN SUBCUTANEOUS metformin oral 1 QL INSULIN PEN 200 tablet extended UNIT/ML (3 ML) release 24 hr 500 mg, 750 mg LYUMJEV U-100 2 INSULIN metformin oral 1 ST; QL SUBCUTANEOUS tablet extended SOLUTION 100 release 24hr 1,000 UNIT/ML mg, 500 mg MEDISENSE 2 OTC metformin oral 1 PA; QL COMBO PACK tablet,er gast.retention 24 hr MEDISENSE 2 OTC 1,000 mg, 500 mg GLUCOSE KETONE COMBO MICRO THIN 2 OTC PACK LANCETS 33 GAUGE MEDISENSE MID 2 OTC CONTROL MICROCHAMBER 2 SOLUTION SPACER MEDISENSE THIN 2 OTC MICROLET 2 2 OTC LANCETS 28 LANCING DEVICE GAUGE KIT MEDLANCE PLUS 2 OTC MICROLET 2 OTC LANCETS 21 LANCET GAUGE, 25 MICROLET NEXT 2 OTC GAUGE, 30 LANCING DEVICE GAUGE KIT
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 133 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits MICROSPACER 2 MINIMED QUICK 2 SPACER SET 43" INFUSION SET miglitol oral tablet 1 100 mg, 25 mg, 50 MINIMED 2 mg SILHOUETTE 18" INFUSION SET MINI LANCING 2 OTC DEVICE MINIMED 2 SILHOUETTE 23" MINIMED 530G 2 INFUSION SET INSULIN PUMP MINIMED 2 MINIMED 630G 2 SILHOUETTE 32" INSULIN PUMP INFUSION SET MINIMED 670G 2 MINIMED 2 INSULIN PUMP SILHOUETTE 43" MINIMED 770G 2 INFUSION SET INSULIN PUMP MINIMED SURE T 2 MINIMED 2 18" INFUSION SET INFUSION SET- MINIMED SURE T 2 MMT 390 23" INFUSION SET INFUSION SET MINIMED SURE T 2 MINIMED MIO 18" 2 32" INFUSION SET INFUSION SET MINIMED 2 MINIMED MIO 23" 2 SYRINGE INFUSION SET RESERVOIR 3 ML MINIMED MIO 32" 2 MIO INFUSION 2 INFUSION SET SET INFUSION MINIMED MIO 2 OTC SET ADVANCE INF MONOJECT 2 SET23" INFUSION BLOOD SET COLLECTION MINIMED QUICK 2 NEEDLE 20 SET 18" INFUSION GAUGE X 1", 20 X SET 1 1/2 ", 21 GAUGE MINIMED QUICK 2 X 1", 22 GAUGE X SET 23" INFUSION 1" SET MONOJECT 2 MINIMED QUICK 2 FILTER SET 32" INFUSION ASPIRATOR SET NEEDLE 18 X 3 "
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 134 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits MONOJECT 2 MONOLET THIN 2 OTC FILTER NEEDLE LANCETS 28 NEEDLE 5 GAUGE MICRON 20 X 1 MOUTHPIECE 2 OTC 1/2" DEVICE MONOJECT 2 MULTI-DRAW 2 HYPODERMIC NEEDLE NEEDLE NEEDLES 20 GAUGE X 1", 21 NEEDLE 14 GAUGE X 1", 22 GAUGE X 1 1/2", GAUGE X 1" 18 GAUGE X 1 1/2", 18 GAUGE X MULTI-LANCET 2 OTC 1", 19 GAUGE X 1 DEVICE 2 KIT 1/2", 19 GAUGE X MYGLUCOHEALT 2 OTC 1", 20 GAUGE X 1 H LANCETS 30 1/2", 20 GAUGE X GAUGE 1", 21 GAUGE X 1 1/2", 21 GAUGE X nateglinide oral 1 1", 22 GAUGE X 1 tablet 120 mg, 60 mg 1/2", 22 GAUGE X NEEDLE (DISP) 16 2 1", 23 GAUGE X G NEEDLE 16 1", 25 GAUGE X 1 GAUGE X 1" 1/2", 25 GAUGE X 1", 25 GAUGE X NEEDLE (DISP) 18 2 5/8", 26 GAUGE X G NEEDLE 18 1 1/2", 27 GAUGE GAUGE X 1" X 1 1/2", 27 NEEDLE (DISP) 19 2 GAUGE X 1/2", 30 G NEEDLE 19 GAUGE X 3/4" GAUGE X 1 1/2" MONOJECT 2 NEEDLE (DISP) 23 2 HYPODERMIC GAUGE NEEDLE POLYPROPYL 23 GAUGE X 1" NEEDLE 18 GAUGE X 1 1/2" NEEDLES, HUBER 2 DISPOSABLE MONOJECT 2 NEEDLE 22 X 1 " MEDICATION TRANSF NDL NEXCARE 2 OTC NEEDLE 20 X 1 " TEGADERM TOPICAL MONOLET 2 OTC BANDAGE 4 X 4 LANCETS 21 3/4 " GAUGE
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 135 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits NOKOR NEEDLE 2 ON CALL PLUS 2 OTC NEEDLE 16 LANCET 30 GAUGE X 1", 18 GAUGE GAUGE X 1" ON CALL PLUS 2 OTC NOVA SAFETY 2 OTC LANCING DEVICE LANCETS 23 ONE WAY 2 OTC GAUGE, 28 VALVED GAUGE MOUTHPIECE NOVA SUREFLEX 2 OTC DEVICE LANCETS ONETOUCH 2 OTC NOVAMAX PLUS 2 OTC DELICA LANC KETONE STRIP DEVICE KIT NOVOFINE 32 2 OTC ONETOUCH 2 OTC NEEDLE 32 DELICA LANCETS GAUGE X 1/4" 30 GAUGE, 33 GAUGE NOVOFINE 2 OTC AUTOCOVER ONETOUCH 2 OTC NEEDLE 30 DELICA PLUS GAUGE X 1/3" LANC DEV KIT NOVOFINE PLUS 2 OTC ONETOUCH 2 OTC NEEDLE 32 DELICA PLUS GAUGE X 1/6" LANCET 30 GAUGE, 33 NOVOTWIST 2 OTC GAUGE NEEDLE 32 GAUGE X 1/5" ONETOUCH 2 OTC SURESOFT OMNIPOD DASH 5 2 LANCING DEV 18 PACK POD GAUGE, 21 SUBCUTANEOUS GAUGE, 28 CARTRIDGE GAUGE OMNIPOD 2 ONETOUCH 2 OTC INSULIN ULTRA BLUE MANAGEMENT TEST STRIP STRIP OMNIPOD 2 ONETOUCH 2 OTC INSULIN REFILL ULTRA CONTROL SUBCUTANEOUS SOLUTION CARTRIDGE ONETOUCH 2 OTC ON CALL LANCET 2 OTC ULTRA2 METER 30 GAUGE ONETOUCH 2 OTC ON CALL 2 OTC ULTRAMINI KIT LANCING DEVICE You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 136 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits ONETOUCH 2 OTC OPTICHAMBER 2 ULTRASOFT DIAMOND-SML LANCETS MASK SPACER ONETOUCH 2 OTC OZEMPIC 2 PA; QL VERIO FLEX SUBCUTANEOUS METER PEN INJECTOR 0.25 MG OR 0.5 ONETOUCH 2 OTC MG(2 MG/1.5 ML), VERIO HIGH 1 MG/DOSE (2 CONTROL MG/1.5 ML) SOLUTION PANDA MASK 2 OTC ONETOUCH 2 OTC DEVICE VERIO IQ METER PARADIGM 2 ONETOUCH 2 OTC RESERVOIR 1.8 VERIO METER ML, 3 ML ONETOUCH 2 OTC PARADIGM 2 VERIO MID SILHOUETTE CONTROL INFUS SET SOLUTION PEDIATRIC 2 OTC ONETOUCH 2 OTC MEDIUM MASK VERIO REFLECT DEVICE METER PEDIATRIC 2 OTC ONETOUCH 2 OTC PANDA MASK VERIO TEST DEVICE STRIPS STRIP PEDIATRIC 2 OTC ON-THE-GO 2 OTC SMALL MASK LANCETS 30 DEVICE GAUGE pioglitazone oral 1 QL OPTICHAMBER 2 tablet 15 mg, 30 mg, ADULT MASK- 45 mg LARGE DEVICE pioglitazone- 1 QL OPTICHAMBER 2 glimepiride oral DIAMOND LG tablet 30-2 mg, 30-4 MASK SPACER mg OPTICHAMBER 2 pioglitazone- 1 QL DIAMOND VHC metformin oral SPACER tablet 15-500 mg, OPTICHAMBER 2 15-850 mg DIAMOND-MED MSK SPACER
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 137 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits PIP LANCET 28 2 OTC PRIMEAIRE 2 GAUGE, 30 SPACER GAUGE PRO COMFORT 2 OTC POCKET 2 ALCOHOL PADS CHAMBER TOPICAL PADS, SPACER MEDICATED POLY HUB 2 PRO COMFORT 2 OTC NEEDLE NEEDLE LANCET 30 18 GAUGE X 1 GAUGE, 31 1/2", 18 GAUGE X GAUGE 1", 21 GAUGE X 1 PRO COMFORT 2 1/2", 21 GAUGE X SPACER-ADULT 1", 22 GAUGE X 1 MASK SPACER 1/2", 22 GAUGE X 1", 23 GAUGE X 1 PRO COMFORT 2 1/2", 23 GAUGE X SPACER-CHILD 1", 25 GAUGE X 1 MASK SPACER 1/2", 25 GAUGE X PROCARE 2 1", 25 GAUGE X SPACER WITH 5/8", 27 GAUGE X ADULT MASK 1 1/4", 27 GAUGE SPACER X 1/2", 30 GAUGE X 1/2" PROCARE 2 SPACER WITH POLYSKIN II 2 OTC CHILD MASK TOPICAL SPACER BANDAGE 4 X 4 3/4 " PROCHAMBER 2 SPACER PRECISION XTRA 2 OTC B-KETONE STRIP PRODIGY 2 OTC LANCETS 26 PRECISION XTRA 2 OTC GAUGE, 28 KETONE- GAUGE GLUCOSE KIT PRODIGY 2 OTC PRECISION XTRA 2 OTC LANCING DEVICE MONITOR PRODIGY TWIST 2 OTC PRECISION XTRA 2 OTC TOP LANCET 28 TEST STRIP GAUGE PRESSURE 2 OTC PURE COMFORT 2 OTC ACTIVATED ALCOHOL PADS LANCETS 21 TOPICAL PADS, GAUGE, 28 MEDICATED GAUGE
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 138 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits PURE COMFORT 2 OTC repaglinide oral 1 LANCETS 30 tablet 0.5 mg, 1 mg, GAUGE 2 mg PURE COMFORT 2 OTC repaglinide- 1 QL SAFETY metformin oral LANCETS 30 tablet 1-500 mg, 2- GAUGE 500 mg PUSH BUTTON 2 OTC REVEL 2 SAFETY PEDIATRIC LANCETS 28 PROGRAM PUMP GAUGE REVEL 2 QUICK-SET 2 PROGRAMMABLE PARADIGM PUMP INFUSION SET RIGHTEST GD500 2 OTC READYLANCE 2 OTC LANCING DEVICE SAFETY RIGHTEST GL300 2 OTC LANCETS 21 LANCETS 30 GAUGE, 23 GAUGE GAUGE, 26 GAUGE, 28 RITEFLO 2 GAUGE, 30 AEROCHAMBER GAUGE SPACER RELIAMED 2 OTC RYBELSUS ORAL 2 PA; QL LANCET 28 TABLET 14 MG, 3 GAUGE, 30 MG, 7 MG GAUGE SAFE-CLIP BY 2 OTC RELIAMED MINI 2 OTC MAIL DEVICE LANCING DEVICE SAFE-CLIP 2 OTC RELIAMED 2 OTC NEEDLE SAFETY SEAL STORAGE DEV LANCETS 28 DEVICE GAUGE, 30 SAFETY 2 OTC GAUGE LANCETS 21 RELION THIN 2 OTC GAUGE, 26 LANCETS 26 GAUGE, 28 GAUGE GAUGE RELION ULTRA 2 OTC SAFETY NEEDLES 2 THIN PLUS NEEDLE 18 LANCETS GAUGE X 1 1/2"
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 139 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits SAFETY SEAL 2 OTC SOLIQUA 100/33 2 QL LANCETS 28 SUBCUTANEOUS GAUGE, 30 INSULIN PEN 100 GAUGE UNIT-33 MCG/ML SAFETY-LET 2 OTC SOLUS V2 2 OTC LANCETS 30 LANCETS 28 GAUGE GAUGE, 30 GAUGE SEGLUROMET 2 ST; QL ORAL TABLET SOLUS V2 2 OTC 2.5-1,000 MG, 2.5- LANCING DEVICE 500 MG, 7.5-1,000 KIT MG, 7.5-500 MG SPACE CHAMBER 2 SIDESTREAM 2 OTC SPACER PEDIATRIC FACE SPACE CHAMBER 2 MASK DEVICE WITH LARGE SILHOUETTE 23"- 2 MASK SPACER FULL SET SPACE CHAMBER 2 INFUSION SET WITH MEDIUM SILHOUETTE 43"- 2 MASK SPACER FULL SET SPACE CHAMBER 2 INFUSION SET WITH SMALL SILICONE MASK - 2 MASK SPACER INFANT DEVICE STEGLATRO 2 ST; QL SILICONE MASK - 2 OTC ORAL TABLET 15 PEDIATRIC MG, 5 MG DEVICE STERILANCE TL 2 OTC SIL-SERTER 2 OTC 30 GAUGE, 32 GAUGE SINGLE-LET 2 OTC SUPER THIN 2 OTC SMART SENSE 2 OTC LANCETS 28 LANCETS 21 GAUGE, 30 GAUGE, 26 GAUGE GAUGE, 33 GAUGE SURE COMFORT 2 OTC ALCOHOL PREP SMARTDIABETES 2 OTC PADS TOPICAL VANTAGE PADS, SMARTEST 2 OTC MEDICATED LANCET SOFT TOUCH 2 OTC LANCETS
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 140 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits SURE COMFORT 2 OTC SURE-TOUCH 2 OTC LANCETS 18 LANCET GAUGE, 21 SURGUARD2 2 GAUGE, 23 SAFETY NEEDLE GAUGE, 28 18 GAUGE X 1 GAUGE, 30 1/2", 18 GAUGE X GAUGE 1", 19 GAUGE X 1 SURE COMFORT 2 OTC 1/2", 19 GAUGE X LANCING PEN 1", 20 GAUGE X 1 1/2", 20 GAUGE X SUREFLEX 2 OTC 1", 21 GAUGE X 1 DEVICE WITH 1/2", 21 GAUGE X LANCETS KIT 1", 22 GAUGE X 1 SUREFLEX 2 OTC 1/2", 22 GAUGE X LANCING DEVICE 1", 23 GAUGE X 1 SURE-LANCE , 26 2 OTC 1/2", 23 GAUGE X GAUGE, 28 1", 25 GAUGE X 1 GAUGE 1/2", 25 GAUGE X 1", 25 X 5/8 ", 26 SURE-LANCE 2 OTC GAUGE X 1/2", 27 ULTRA THIN 30 GAUGE X 1/2", 30 GAUGE GAUGE X 1 1/2" SURE-PEN 2 OTC SYMLINPEN 120 2 ST; QL LANCING DEVICE SUBCUTANEOUS SURE-PREP 2 OTC PEN INJECTOR ALCOHOL PREP 2,700 MCG/2.7 ML PADS TOPICAL SYMLINPEN 60 2 ST; QL PADS, SUBCUTANEOUS MEDICATED PEN INJECTOR SURESITE 2 OTC 1,500 MCG/1.5 ML MATRIX TOPICAL SYNJARDY ORAL 2 ST; QL BANDAGE 6 X 8 " TABLET 12.5-1,000 SURESITE 2 OTC MG, 12.5-500 MG, WINDOW 5-1,000 MG, 5-500 TOPICAL MG BANDAGE 4 X 4 SYNJARDY XR 2 ST; QL 1/2 " ORAL TABLET, IR SURE-T INFUSION 2 - ER, BIPHASIC SET 24HR 10-1,000 MG, 12.5-1,000 MG, 25- SURE-T 2 1,000 MG, 5-1,000 PARADIGM MG INFUSION SET
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 141 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits T:30 INFUSION 2 TEGADERM HP 2 OTC SET INFUSION FRAME STYLE SET TOPICAL BANDAGE 2 3/8 X T:90 INFUSION 2 2 3/4 ", 4 1/2 X 4 3/4 SET 23" INFUSION ", 4 X 4 1/2 " SET TEGADERM 2 OTC T:90 INFUSION 2 TOPICAL SET 43" INFUSION BANDAGE 2 X 2 SET 3/4 ", 2.375 X 4 ", 3 T:FLEX 2 1/2 X 4 ", 4 X 4 3/4 SUBCUTANEOUS " CARTRIDGE TELCARE 2 OTC T:SLIM G4 2 LANCETS 30 SUBCUTANEOUS GAUGE CARTRIDGE THIN LANCETS 26 2 OTC T:SLIM INSULIN 2 GAUGE DELIVERY TOPCARE 2 OTC SYSTEM UNIVERSAL1 T:SLIM 2 LANCET , 33 SUBCUTANEOUS GAUGE CARTRIDGE TOUJEO MAX U- 2 T:SLIM X2 2 300 SOLOSTAR SUBCUTANEOUS SUBCUTANEOUS CARTRIDGE INSULIN PEN 300 TECHLITE 2 OTC UNIT/ML (3 ML) LANCETS 25 TOUJEO 2 GAUGE, 28 SOLOSTAR U-300 GAUGE, 30 INSULIN GAUGE SUBCUTANEOUS TEGADERM 2 OTC INSULIN PEN 300 FIRST AID STYLE UNIT/ML (1.5 ML) TOPICAL TRADJENTA 2 PA; QL BANDAGE 2 3/8 X ORAL TABLET 5 2 3/4 ", 4 X 4 3/4 " MG TEGADERM 2 OTC TRANSPARENT 2 OTC FRAME STYLE DRESSINGS TOPICAL TOPICAL BANDAGE 2 3/8 X BANDAGE 2 X 2 2 3/4 ", 4 X 10 ", 4 3/4 ", 4 X 4 3/4 " X 4 3/4 ", 6 X 8 ", 8 X 12 " You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 142 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits TRANSPARENT 2 OTC TRUEPLUS 2 OTC THIN FILM LANCETS 26 DRESSING GAUGE, 28 TOPICAL GAUGE, 30 BANDAGE 2 3/8 X GAUGE, 33 2 3/4 " GAUGE TRESIBA 2 TRULICITY 2 PA; QL FLEXTOUCH U- SUBCUTANEOUS 100 PEN INJECTOR SUBCUTANEOUS 0.75 MG/0.5 ML, INSULIN PEN 100 1.5 MG/0.5 ML, 3 UNIT/ML (3 ML) MG/0.5 ML, 4.5 MG/0.5 ML TRESIBA 2 FLEXTOUCH U- TRUSTEEL 2 200 INFUSION SET 23" SUBCUTANEOUS INFUSION SET INSULIN PEN 200 TRUSTEEL 2 UNIT/ML (3 ML) INFUSION SET 32" TRESIBA U-100 2 INFUSION SET INSULIN TWIST LANCETS 2 OTC SUBCUTANEOUS 30 GAUGE, 32 SOLUTION 100 GAUGE UNIT/ML ULTI-LANCE 2 OTC TRIJARDY XR 2 ST ORAL TABLET, IR ULTI-LANCE KIT 2 OTC - ER, BIPHASIC ULTILET 2 OTC 24HR 10-5-1,000 ALCOHOL SWAB MG, 12.5-2.5-1,000 TOPICAL PADS, MG, 25-5-1,000 MEDICATED MG, 5-2.5-1,000 MG ULTILET BASIC 2 OTC LANCETS 30 TRUE COMFORT 2 OTC GAUGE ALCOHOL PADS TOPICAL PADS, ULTILET CLASSIC 2 OTC MEDICATED LANCETS , 28 GAUGE, 30 TRUE COMFORT 2 OTC GAUGE, 33 LANCET 30 GAUGE GAUGE ULTILET 2 OTC TRUEDRAW 2 OTC LANCETS 28 LANCING DEVICE GAUGE, 30 GAUGE, 33 GAUGE You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 143 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits ULTILET SAFETY 2 OTC UNILET LANCET 2 OTC LANCETS 23 28 GAUGE, 33 GAUGE GAUGE ULTRA THIN II 2 OTC UNILET LANCETS 2 OTC LANCETS 30 30 GAUGE GAUGE UNILET SUPER 2 OTC ULTRA THIN 2 OTC THIN LANCETS 30 LANCETS , 28 GAUGE GAUGE, 30 UNISTIK 2 2 OTC GAUGE, 31 DEVICE KIT GAUGE, 33 GAUGE UNISTIK 2 2 OTC NORMAL ULTRA THIN 2 OTC LANCET,DEVICE PLUS LANCETS 33 KIT GAUGE UNISTIK 3 2 OTC ULTRA TLC 2 OTC COMFORT LANCETS DEVICE KIT ULTRA-CARE 2 OTC UNISTIK 3 2 OTC LANCETS 30 COMFORT GAUGE LANCET ULTRALANCE 2 OTC UNISTIK 3 EXTRA 2 OTC LANCETS 26 LANCET 21 GAUGE, 28 GAUGE GAUGE UNISTIK 3 2 OTC ULTRA-THIN II 2 OTC GENTLE 30 LANCETS 28 GAUGE GAUGE UNISTIK 3 KIT 2 OTC UNILET 2 OTC COMFORTOUCH UNISTIK 3 2 OTC LANCET , 26 LANCETS 21 GAUGE GAUGE UNILET 2 OTC UNISTIK 3 2 OTC EXCELITE II NEONATAL LANCET DEVICE KIT UNILET 2 OTC UNISTIK 3 2 OTC EXCELITE NORMAL LANCET LANCET 23 GAUGE UNILET GP 2 OTC LANCET
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 144 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits UNISTIK CZT 2 OTC VIVAGUARD 2 OTC LANCET 23 LANCING DEVICE GAUGE, 28 WEBCOL 2 OTC GAUGE TOPICAL PADS, UNISTIK PRO 2 OTC MEDICATED LANCET 21 XIGDUO XR 2 ST; QL GAUGE, 25 ORAL TABLET, IR GAUGE, 28 - ER, BIPHASIC GAUGE 24HR 10-1,000 MG, UNISTIK SAFETY 2 OTC 10-500 MG, 2.5- 28 GAUGE, 30 1,000 MG, 5-1,000 GAUGE MG, 5-500 MG UNISTIK TOUCH 2 OTC XULTOPHY 2 QL LANCETS 21 100/3.6 GAUGE, 23 SUBCUTANEOUS GAUGE, 28 INSULIN PEN 100 GAUGE, 30 UNIT-3.6 MG /ML GAUGE (3 ML) UNIVERSAL 1 2 OTC YALE 2 LANCETS 21 DISPOSABLE GAUGE, 26 NEEDLES GAUGE, 30 NEEDLE 21 GAUGE, 33 GAUGE X 1 1/4" GAUGE MISCELLANEOUS HORMONES VARISOFT 2 ACTHREL 2 INFUSION SET 23" INTRAVENOUS INFUSION SET RECON SOLN 100 VARISOFT 2 MCG INFUSION SET 32" ALDURAZYME 2 PA; SP INFUSION SET INTRAVENOUS VARISOFT 2 SOLUTION 2.9 INFUSION SET 43" MG/5 ML INFUSION SET ANDRODERM 2 PA; QL V-GO 20 DEVICE 2 TRANSDERMAL V-GO 30 DEVICE 2 PATCH 24 HOUR 2 MG/24 HOUR, 4 V-GO 40 DEVICE 2 MG/24 HR VIVAGUARD 2 OTC LANCET 30 GAUGE
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 145 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits BRINEURA 2 PA; SP CLOMIPHENE 2 INTRAVENTRICU CITRATE (BULK) LAR KIT 300 POWDER 100 % MG/10 ML clomiphene citrate 1 (150MG/5ML X2) oral tablet 50 mg cabergoline oral 1 QL CRYSVITA 2 PA; SP; QL tablet 0.5 mg SUBCUTANEOUS calcitonin (salmon) 1 SOLUTION 10 nasal spray,non- MG/ML, 20 aerosol 200 MG/ML, 30 unit/actuation MG/ML calcitriol 1 DANAZOL (BULK) 2 intravenous solution POWDER 1 mcg/ml danazol oral capsule 1 calcitriol oral 1 100 mg, 200 mg, 50 capsule 0.25 mcg, mg 0.5 mcg DDAVP NASAL 2 calcitriol oral 1 SOLUTION 0.1 solution 1 mcg/ml MG/ML (REFRIGERATE) CERDELGA ORAL 2 PA; SP CAPSULE 84 MG DEHYDROEPIAN 2 DROSTERONE CEREZYME 2 PA; SP (MICRO) POWDER INTRAVENOUS 100 % RECON SOLN 400 UNIT DESMOPRESSIN 2 ACETATE (BULK) CETROTIDE 2 SP POWDER SUBCUTANEOUS KIT 0.25 MG desmopressin 1 SP injection solution 4 CHOR 2 mcg/ml GONADOTROPIN, HUM (BULK) desmopressin nasal 1 POWDER 1 spray with pump 10 MILLION UNIT, 10 mcg/spray (0.1 ml) MILLION UNIT, 2 desmopressin nasal 1 MILLION UNIT, 5 spray,non-aerosol MILLION UNIT 10 mcg/spray (0.1 cinacalcet oral 1 ST ml) tablet 30 mg, 60 mg, desmopressin oral 1 90 mg tablet 0.1 mg, 0.2 mg
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 146 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits doxercalciferol 1 KUVAN ORAL 2 PA; SP intravenous solution POWDER IN 4 mcg/2 ml PACKET 100 MG, 500 MG doxercalciferol oral 1 ST capsule 0.5 mcg, 1 KUVAN ORAL 2 PA; SP mcg, 2.5 mcg TABLET,SOLUBL E 100 MG ELAPRASE 2 PA; SP INTRAVENOUS LUMIZYME 2 PA; SP SOLUTION 6 MG/3 INTRAVENOUS ML RECON SOLN 50 MG FABRAZYME 2 PA; SP INTRAVENOUS MENOPUR 2 SP RECON SOLN 35 SUBCUTANEOUS MG, 5 MG RECON SOLN 75 UNIT ganirelix 1 SP subcutaneous MEPSEVII 2 PA; SP syringe 250 mcg/0.5 INTRAVENOUS ml SOLUTION 2 MG/ML GONAL-F RFF 2 ST; SP REDI-JECT METHITEST 2 SUBCUTANEOUS ORAL TABLET 10 PEN INJECTOR MG 300/0.5 UNIT/ML, METHYLTESTOST 2 450/0.75 UNIT/ML, ERONE (BULK) 900/1.5 UNIT/ML POWDER GONAL-F RFF 2 ST; SP methyltestosterone 1 SUBCUTANEOUS oral capsule 10 mg RECON SOLN 75 UNIT METHYLTESTOST 2 ERONE,MICRO(B GONAL-F 2 ST; SP ULK) POWDER SUBCUTANEOUS 100 % RECON SOLN 1,050 UNIT, 450 MIACALCIN 2 UNIT INJECTION SOLUTION 200 KANUMA 2 PA; SP UNIT/ML INTRAVENOUS SOLUTION 2 miglustat oral 1 PA; SP MG/ML capsule 100 mg
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 147 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits MYALEPT 2 PA; SP oxandrolone oral 1 SUBCUTANEOUS tablet 10 mg, 2.5 mg RECON SOLN 5 PALYNZIQ 2 PA; SP; QL MG/ML (FINAL SUBCUTANEOUS CONC.) SYRINGE 10 NAGLAZYME 2 PA; SP MG/0.5 ML, 2.5 INTRAVENOUS MG/0.5 ML, 20 SOLUTION 5 MG/5 MG/ML ML pamidronate 1 NANDROLONE 2 intravenous recon DECANOATE soln 30 mg, 90 mg (BULK) POWDER pamidronate 1 100 % intravenous solution NATESTO NASAL 2 PA; QL 30 mg/10 ml (3 GEL IN mg/ml), 60 mg/10 ml METERED-DOSE (6 mg/ml), 90 mg/10 PUMP 5.5 ml (9 mg/ml) MG/0.122 paricalcitol 1 GRAM/ACTUATIO intravenous solution N 2 mcg/ml, 5 mcg/ml NATPARA 2 PA; SP paricalcitol oral 1 ST SUBCUTANEOUS capsule 1 mcg, 2 CARTRIDGE 100 mcg, 4 mcg MCG/DOSE, 25 MCG/DOSE, 50 SAMSCA ORAL 2 PA; SP; QL MCG/DOSE, 75 TABLET 15 MG MCG/DOSE sapropterin oral 1 PA; SP NOVAREL 2 SP; QL powder in packet INTRAMUSCULA 100 mg, 500 mg R RECON SOLN sapropterin oral 1 PA; SP 10,000 UNIT, 5,000 tablet,soluble 100 UNIT mg ORILISSA ORAL 2 ST; QL serophene oral 1 TABLET 150 MG, tablet 50 mg 200 MG SOMAVERT 2 PA; SP OVIDREL 2 SP SUBCUTANEOUS SUBCUTANEOUS RECON SOLN 10 SYRINGE 250 MG, 15 MG, 20 MCG/0.5 ML MG, 25 MG, 30 MG OXANDROLONE 2 (BULK) POWDER 100 % You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 148 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits STANOZOLOL 2 TESTOSTERONE 2 (BULK) POWDER MICRONIZED 100 % (BULK) POWDER 100 % STANOZOLOL 2 MICRONIZED TESTOSTERONE 2 (BULK) POWDER PROPIONATE 100 % (BULK) POWDER STRENSIQ 2 PA; SP testosterone 1 PA; QL SUBCUTANEOUS transdermal gel 50 SOLUTION 18 mg/5 gram (1 %) MG/0.45 ML, 28 testosterone 1 PA; QL MG/0.7 ML, 40 transdermal gel in MG/ML, 80 MG/0.8 metered-dose pump ML 10 mg/0.5 gram SYNAREL NASAL 2 /actuation, 12.5 mg/ SPRAY,NON- 1.25 gram (1 %), AEROSOL 2 20.25 mg/1.25 gram MG/ML (1.62 %) TESTOSTERONE 2 testosterone 1 PA; QL (BULK) POWDER transdermal gel in packet 1 % (25 TESTOSTERONE 2 mg/2.5gram), 1 % CYP, MICRO (50 mg/5 gram), (BULK) POWDER 1.62 % (20.25 100 % mg/1.25 gram), 1.62 TESTOSTERONE 2 % (40.5 mg/2.5 CYPIONATE gram) (BULK) POWDER testosterone 1 PA; QL 100 % transdermal solution testosterone 1 PA in metered pump cypionate w/app 30 intramuscular oil mg/actuation (1.5 100 mg/ml, 200 ml) mg/ml TETRAHYDROBIO 2 TESTOSTERONE 2 PTERIN DI-HCL ENANTHATE POWDER , 100 % (BULK) POWDER tolvaptan oral tablet 1 PA; SP; QL 100 % 30 mg testosterone 1 PA VIMIZIM 2 PA; SP enanthate INTRAVENOUS intramuscular oil SOLUTION 5 MG/5 200 mg/ml ML (1 MG/ML) You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 149 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits zoledronic acid 1 SP levothyroxine oral 1 intravenous recon tablet 100 mcg, 112 soln 4 mg mcg, 125 mcg, 137 mcg, 150 mcg, 175 zoledronic acid 1 SP mcg, 200 mcg, 25 intravenous solution mcg, 300 mcg, 50 4 mg/5 ml mcg, 75 mcg, 88 mcg zoledronic acid- 1 SP levoxyl oral tablet 1 mannitol-water 100 mcg, 112 mcg, intravenous 125 mcg, 137 mcg, piggyback 4 mg/100 150 mcg, 175 mcg, ml 200 mcg, 25 mcg, 50 THYROID HORMONES mcg, 75 mcg, 88 mcg ARMOUR 2 LIOTHYRONINE 2 THYROID ORAL (BULK) POWDER TABLET 120 MG, 1 MG/GRAM, 100 15 MG, 180 MG, % 240 MG, 30 MG, liothyronine 1 300 MG, 60 MG, 90 intravenous solution MG 10 mcg/ml euthyrox oral tablet 1 liothyronine oral 1 100 mcg, 112 mcg, tablet 25 mcg, 5 125 mcg, 137 mcg, mcg, 50 mcg 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 np thyroid oral 1 mcg, 75 mcg, 88 mcg tablet 120 mg, 15 mg, 30 mg, 60 mg, levo-t oral tablet 100 1 90 mg mcg, 112 mcg, 125 mcg, 137 mcg, 150 PCCA T3 SODIUM 2 mcg, 175 mcg, 200 DILUTION mcg, 25 mcg, 300 POWDER 1 mcg, 50 mcg, 75 MG/GRAM mcg, 88 mcg PCCA T4 SODIUM 2 LEVOTHYROXINE 2 DILUTION (BULK) POWDER POWDER 1 1 MG/GRAM, 100 MG/GRAM % PROTIRELIN 2 levothyroxine 1 (BULK) POWDER intravenous recon 98 % soln 100 mcg, 200 THYROID, PORK 2 mcg, 500 mcg (BULK) POWDER 100 % USP
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 150 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits unithroid oral tablet 1 BISMUTH 2 100 mcg, 112 mcg, SUBCARBONATE 125 mcg, 137 mcg, (BULK) POWDER 150 mcg, 175 mcg, BISMUTH 2 200 mcg, 25 mcg, SUBGALLATE 300 mcg, 50 mcg, 75 (BULK) POWDER mcg, 88 mcg BISMUTH 2 westhroid oral tablet 1 SUBSALICYLATE 130 mg, 195 mg, (BULK) POWDER 32.5 mg, 65 mg, 97.5 mg chlordiazepoxide- 1 clidinium oral GASTROENTEROLOGY capsule 5-2.5 mg ANTIDIARRHEALS / CLIDINIUM 2 ANTISPASMODICS BROMIDE (BULK) anaspaz oral 1 POWDER 100 % tablet,disintegrating DICYCLOMINE 2 0.125 mg (BULK) POWDER atropine injection 1 100 % solution 0.4 mg/ml, 1 dicyclomine 1 mg/ml intramuscular atropine injection 1 solution 10 mg/ml syringe 0.05 mg/ml, dicyclomine oral 1 0.1 mg/ml capsule 10 mg ATTAPULGITE 2 dicyclomine oral 1 (BULK) POWDER solution 10 mg/5 ml BELLADONNA 2 dicyclomine oral 1 ALK LEAF EXT tablet 20 mg (BULK) POWDER diphenoxylate- 1 1.15 TO 1.35 % atropine oral liquid belladonna 1 2.5-0.025 mg/5 ml alkaloids-opium diphenoxylate- 1 rectal suppository atropine oral tablet 16.2-30 mg, 16.2-60 2.5-0.025 mg mg ed-spaz oral 1 BELLADONNA 2 tablet,disintegrating TINCTURE 0.125 mg (BULK) LIQUID 30 MG/100 ML GLYCOPYRROLA 2 TE (BULK) POWDER 100 %
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 151 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits glycopyrrolate (pf) 1 hyosyne oral elixir 1 in water intravenous 0.125 mg/5 ml syringe 0.4 mg/2 ml ISOPROPAMIDE 2 (0.2 mg/ml), 1 mg/5 IODIDE (BULK) ml (0.2 mg/ml) POWDER glycopyrrolate 1 LEVSIN 2 injection solution 0.2 INJECTION mg/ml SOLUTION 0.5 glycopyrrolate oral 1 MG/ML tablet 1 mg, 1.5 mg, LOPERAMIDE 2 2 mg (BULK) POWDER HOMATROPINE 2 METHSCOPOLAM 2 METHYLBROM INE BROMIDE (BULK) POWDER (BULK) POWDER 100 % METHSCOPOLAM 2 HYOSCYAMINE 2 INE NITRATE SULFATE (BULK) (BULK) POWDER POWDER 100 % hyoscyamine sulfate 1 opium tincture oral 1 oral drops 0.125 tincture 10 mg/ml mg/ml (morphine) hyoscyamine sulfate 1 oscimin oral tablet 1 oral elixir 0.125 0.125 mg mg/5 ml oscimin sl sublingual 1 hyoscyamine sulfate 1 tablet 0.125 mg oral tablet 0.125 mg oscimin sr oral 1 hyoscyamine sulfate 1 tablet extended oral tablet extended release 12 hr 0.375 release 12 hr 0.375 mg mg phenobarb-hyoscy- 1 hyoscyamine sulfate 1 atropine-scop oral oral elixir 16.2 mg- tablet,disintegrating 0.1037 mg/5 ml (5 0.125 mg ml), 16.2-0.1037 - hyoscyamine sulfate 1 0.0194 mg/5 ml sublingual tablet phenobarb-hyoscy- 1 0.125 mg atropine-scop oral hyosyne oral drops 1 tablet 16.2-0.1037 - 0.125 mg/ml 0.0194 mg
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 152 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits phenohytro oral 1 aprepitant oral 1 QL elixir 16.2-0.1037 - capsule,dose pack 0.0194 mg/5 ml 125 mg (1)- 80 mg (2) phenohytro oral 1 tablet 16.2-0.1037 - balsalazide oral 1 0.0194 mg capsule 750 mg PROPANTHELINE 2 BISACODYL 2 (BULK) POWDER (BULK) POWDER symax fastabs oral 1 bisacodyl oral 1 ACA; OTC tablet,disintegrating tablet,delayed 0.125 mg release (dr/ec) 5 mg symax-sl sublingual 1 bisa-lax (bisacodyl) 1 ACA; OTC tablet 0.125 mg oral tablet,delayed release (dr/ec) 5 mg symax-sr oral tablet 1 extended release 12 budesonide oral 1 hr 0.375 mg capsule,delayed,exte nd.release 3 mg MISCELLANEOUS
GASTROINTESTINAL AGENTS budesonide oral 1 tablet,delayed and 5- 2 ext.release 9 mg AMINOSALICYLI C ACID POWDER CHENODAL ORAL 2 PA; SP TABLET 250 MG alophen (bisacodyl) 1 ACA; OTC oral tablet,delayed CHOLBAM ORAL 2 PA; SP release (dr/ec) 5 mg CAPSULE 250 MG alosetron oral tablet 1 CHOLBAM ORAL 2 PA; SP; QL 0.5 mg, 1 mg CAPSULE 50 MG ALUMINUM 2 CINVANTI 2 HYDROXIDE GEL INTRAVENOUS (BULK) POWDER EMULSION 7.2 MG/ML AMINOSALICYLI 2 C ACID-5 citrate of magnesia 1 ACA; OTC POWDER oral solution anucort-hc rectal 1 citroma oral solution 1 ACA; OTC suppository 25 mg clearlax oral powder 1 ACA; OTC APOMORPHINE 2 17 gram/dose (BULK) POWDER clearlax oral powder 1 ACA; OTC aprepitant oral 1 QL in packet 17 gram capsule 125 mg, 40 mg, 80 mg You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 153 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits CLENPIQ ORAL 2 ACA doxylamine- 1 QL SOLUTION 10 MG- pyridoxine (vit b6) 3.5 GRAM -12 oral tablet,delayed GRAM/160 ML release (dr/ec) 10-10 mg compro rectal 1 suppository 25 mg dronabinol oral 1 PA capsule 10 mg, 2.5 constulose oral 1 mg, 5 mg solution 10 gram/15 ml DROPERIDOL 2 (BULK) POWDER CREON ORAL 2 CAPSULE,DELAY droperidol injection 1 ED solution 2.5 mg/ml RELEASE(DR/EC) ducodyl (bisacodyl) 1 ACA; OTC 12,000-38,000 - oral tablet,delayed 60,000 UNIT, release (dr/ec) 5 mg 24,000-76,000 - 120,000 UNIT, dulcolax 1 ACA; OTC 3,000-9,500- 15,000 (magnesium UNIT, 36,000- hydroxide) oral 114,000- 180,000 suspension 400 mg/5 UNIT, 6,000-19,000 ml -30,000 UNIT ENTYVIO 2 PA; SP cromolyn oral 1 INTRAVENOUS concentrate 100 RECON SOLN 300 mg/5 ml MG CYSTADANE 2 SP enulose oral solution 1 ORAL POWDER 1 10 gram/15 ml GRAM/1.7 ML fleet laxative 1 ACA; OTC DIMENHYDRINAT 2 (bisacodyl) oral E (BULK) tablet,delayed POWDER 100 % release (dr/ec) 5 mg dimenhydrinate 1 fosaprepitant 1 injection solution 50 intravenous recon mg/ml soln 150 mg DIPHENIDOL 2 gavilax oral powder 1 ACA; OTC (BULK) POWDER 17 gram/dose DOCUSATE 2 gavilyte-c oral recon 1 ACA SODIUM (BULK) soln 240-22.72-6.72 POWDER , 85 % -5.84 gram
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 154 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits gavilyte-g oral recon 1 ACA hydrocortisone 1 soln 236-22.74-6.74 topical cream with -5.86 gram perineal applicator 1 %, 2.5 % gavilyte-n oral recon 1 ACA soln 420 gram hydrocortisone- 1 pramoxine rectal generlac oral 1 cream 1-1 %, 2.5-1 solution 10 gram/15 % (4g) ml hydrocortisone- 1 ST gentle laxative 1 ACA; OTC pramoxine rectal (bisacodyl) oral cream 2.5-1 % tablet,delayed release (dr/ec) 5 mg KINEVAC 2 INJECTION gentlelax oral 1 ACA; OTC RECON SOLN 5 powder 17 MCG gram/dose lactulose oral packet 1 glycolax oral 1 ACA; OTC 10 gram powder 17 gram/dose lactulose oral 1 solution 10 gram/15 granisetron (pf) 1 ml, 10 gram/15 ml intravenous solution (15 ml), 20 gram/30 1 mg/ml (1 ml), 100 ml mcg/ml laxaclear oral 1 ACA; OTC granisetron hcl 1 powder 17 intravenous solution gram/dose 1 mg/ml, 1 mg/ml (1 ml) laxative (bisacodyl) 1 ACA; OTC oral tablet 5 mg granisetron hcl oral 1 QL tablet 1 mg laxative (bisacodyl) 1 ACA; OTC oral tablet,delayed healthylax oral 1 ACA; OTC release (dr/ec) 5 mg powder in packet 17 gram laxative peg 3350 1 ACA; OTC oral powder 17 hemmorex-hc rectal 1 gram/dose suppository 25 mg lidocaine hcl- 1 hydrocortisone 1 hydrocortison ac acetate rectal rectal cream 3-0.5 % suppository 25 mg, 30 mg hydrocortisone 1 rectal enema 100 mg/60 ml You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 155 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits lidocaine hcl- 1 mesalamine rectal 1 hydrocortison ac enema 4 gram/60 ml rectal kit 2 %-2 % (7 mesalamine rectal 1 gram), 3-0.5 %, 3-1 suppository 1,000 % (7 gram) mg lidocaine- 1 mesalamine with 1 hydrocortisone-aloe cleansing wipe rectal gel 2.8-0.55 % rectal enema kit 4 lidocaine- 1 gram/60 ml hydrocortisone-aloe METOCLOPRAMI 2 rectal kit 3-2.5 % (7 DE (BULK) gram) POWDER LINZESS ORAL 2 QL metoclopramide hcl 1 CAPSULE 145 injection solution 5 MCG, 290 MCG, 72 mg/ml MCG metoclopramide hcl 1 MAGNESIUM 2 injection syringe 5 CITRATE (BULK) mg/ml POWDER metoclopramide hcl 1 magnesium citrate 1 ACA; OTC oral solution 5 mg/5 oral solution ml MAGNESIUM 2 metoclopramide hcl 1 SULFATE (BULK) oral tablet 10 mg, 5 CRYSTALS 100 % mg MECLIZINE HCL 2 metoclopramide hcl 1 (BULK) POWDER oral MESALAMINE 2 tablet,disintegrating (BULK) POWDER 10 mg, 5 mg mesalamine oral 1 milk of magnesia 1 ACA; OTC capsule (with del rel concentrated oral tablets) 400 mg suspension 2,400 mg/10 ml mesalamine oral 1 capsule,extended milk of magnesia 1 ACA; OTC release 24hr 0.375 oral suspension 400 gram mg/5 ml mesalamine oral 1 miralax oral powder 1 ACA; OTC tablet,delayed in packet 17 gram release (dr/ec) 1.2 MOVANTIK ORAL 2 QL gram, 800 mg TABLET 12.5 MG, 25 MG You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 156 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits natura-lax oral 1 ACA; OTC peg 3350- 1 ACA powder 17 electrolytes oral gram/dose recon soln 236- 22.74-6.74 -5.86 OCALIVA ORAL 2 PA; SP; QL gram TABLET 10 MG, 5 MG peg3350-sod sul- 1 ACA nacl-kcl-asb-c oral ONDANSETRON 2 powder in packet HCL (BULK) 100-7.5-2.691 gram POWDER 100 % peg-electrolyte soln 1 ACA ondansetron hcl (pf) 1 oral recon soln 420 injection solution 4 gram mg/2 ml peg-prep oral kit 5- 1 ACA ondansetron hcl (pf) 1 210 mg-gram injection syringe 4 mg/2 ml PENTASA ORAL 2 CAPSULE, ondansetron hcl 1 EXTENDED intravenous solution RELEASE 250 MG, 2 mg/ml 500 MG ondansetron hcl oral 1 QL phosphate laxative 1 ACA; OTC solution 4 mg/5 ml oral liquid 7.2-2.7 ondansetron hcl oral 1 QL gram/15 ml tablet 24 mg, 4 mg, 8 polyethylene glycol 1 ACA; OTC mg 3350 oral powder 17 ondansetron oral 1 QL gram/dose tablet,disintegrating polyethylene glycol 1 ACA 4 mg, 8 mg 3350 oral powder in oral saline laxative 1 ACA; OTC packet 17 gram oral liquid 7.2-2.7 powderlax oral 1 ACA; OTC gram/15 ml powder 17 palonosetron 1 gram/dose intravenous solution powderlax oral 1 ACA; OTC 0.25 mg/5 ml powder in packet 17 palonosetron 1 gram intravenous syringe PRAMOXINE HCL 2 0.25 mg/5 ml (BULK) POWDER PANCREATIN 2 (BULK) POWDER
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 157 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits PREPOPIK ORAL 2 ACA purelax oral powder 1 ACA; OTC POWDER IN in packet 17 gram PACKET 10 MG- RECTIV RECTAL 2 3.5 GRAM-12 OINTMENT 0.4 % GRAM (W/W) prochlorperazine 1 RELISTOR ORAL 2 ST edisylate injection TABLET 150 MG solution 10 mg/2 ml (5 mg/ml), 5 mg/ml RELISTOR 2 ST SUBCUTANEOUS PROCHLORPERAZ 2 SOLUTION 12 INE MG/0.6 ML EDISYLT(BULK) POWDER 100 % RELISTOR 2 ST SUBCUTANEOUS prochlorperazine 1 SYRINGE 12 maleate oral tablet MG/0.6 ML, 8 10 mg, 5 mg MG/0.4 ML PROCHLORPERAZ 2 REMICADE 2 PA; SP INE INTRAVENOUS MALEATE(BULK) RECON SOLN 100 POWDER MG prochlorperazine 1 scopolamine base 1 rectal suppository 25 transdermal patch 3 mg day 1 mg over 3 procto-med hc 1 days topical cream with SCOPOLAMINE 2 perineal applicator HBR (BULK) 2.5 % POWDER procto-pak topical 1 SIMETHICONE 2 cream with perineal (BULK) LIQUID applicator 1 % smoothlax oral 1 ACA; OTC proctosol hc topical 1 powder 17 cream with perineal gram/dose applicator 2.5 % smoothlax oral 1 ACA; OTC proctozone-hc 1 powder in packet 17 topical cream with gram perineal applicator 2.5 % SODIUM 2 PHOSPHATE,DIBA purelax oral powder 1 ACA; OTC SIC(BULK) 17 gram/dose POWDER
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 158 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits SUCRAID ORAL 2 PA; SP VARUBI ORAL 2 QL SOLUTION 8,500 TABLET 90 MG UNIT/ML VIBERZI ORAL 2 SULFASALAZINE 2 TABLET 100 MG, (BULK) POWDER 75 MG sulfasalazine oral 1 VIOKACE ORAL 2 tablet 500 mg TABLET 10,440- 39,150- 39,150 sulfasalazine oral 1 UNIT, 20,880- tablet,delayed 78,300- 78,300 release (dr/ec) 500 UNIT mg woman's laxative 1 ACA; OTC SUPREP BOWEL 2 ACA (bisacodyl) oral PREP KIT ORAL tablet 5 mg RECON SOLN 17.5-3.13-1.6 women's gentle 1 ACA; OTC GRAM laxative(bisac) oral tablet,delayed SYMPROIC ORAL 2 release (dr/ec) 5 mg TABLET 0.2 MG women's laxative 1 ACA; OTC trilyte with flavor 1 ACA (bisacodyl) oral packets oral recon tablet 5 mg soln 420 gram women's laxative 1 ACA; OTC TRIMETHOBENZA 2 (bisacodyl) oral MIDE (BULK) tablet,delayed POWDER 100 % release (dr/ec) 5 mg trimethobenzamide 1 oral capsule 300 mg TRULANCE ORAL 2 TABLET 3 MG UCERIS RECTAL 2 FOAM 2 MG/ACTUATION URSODIOL 2 (BULK) POWDER 100 % ursodiol oral 1 capsule 300 mg ursodiol oral tablet 1 250 mg, 500 mg
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 159 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits ZENPEP ORAL 2 esomeprazole 1 ST; QL CAPSULE,DELAY magnesium oral ED granules dr for susp RELEASE(DR/EC) in packet 10 mg, 20 10,000-32,000 - mg 42,000 UNIT, esomeprazole 1 ST 15,000-47,000 - magnesium oral 63,000 UNIT, granules dr for susp 20,000-63,000- in packet 40 mg 84,000 UNIT, 25,000-79,000- esomeprazole 1 105,000 UNIT, sodium intravenous 3,000-10,000 - recon soln 20 mg, 40 14,000-UNIT, mg 40,000-126,000- FAMOTIDINE 2 168,000 UNIT, (BULK) POWDER 5,000-17,000- 100 % 24,000 UNIT famotidine (pf) 1 ULCER THERAPY intravenous solution amoxicil- 1 QL 20 mg/2 ml clarithromy- famotidine (pf)-nacl 1 lansopraz oral (iso-os) intravenous combo pack 500- piggyback 20 mg/50 500-30 mg ml CIMETIDINE 2 famotidine 1 (BULK) POWDER intravenous solution cimetidine hcl oral 1 10 mg/ml solution 300 mg/5 ml famotidine oral 1 cimetidine oral 1 suspension 40 mg/5 tablet 300 mg, 400 ml (8 mg/ml) mg, 800 mg famotidine oral 1 esomeprazole 1 QL tablet 40 mg magnesium oral LANSOPRAZOLE 2 capsule,delayed (BULK) POWDER release(dr/ec) 20 mg 100 % esomeprazole 1 lansoprazole oral 1 magnesium oral capsule,delayed capsule,delayed release(dr/ec) 30 mg release(dr/ec) 40 mg lansoprazole oral 1 QL tablet,disintegrat, delay rel 15 mg
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 160 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits lansoprazole oral 1 pantoprazole 1 tablet,disintegrat, intravenous recon delay rel 30 mg soln 40 mg MISOPROSTOL 2 pantoprazole oral 1 (BULK) POWDER granules dr for susp 1 % in packet 40 mg misoprostol oral 1 pantoprazole oral 1 QL tablet 100 mcg, 200 tablet,delayed mcg release (dr/ec) 20 mg NEXIUM PACKET 2 ST; QL ORAL GRANULES pantoprazole oral 1 DR FOR SUSP IN tablet,delayed PACKET 2.5 MG, 5 release (dr/ec) 40 MG mg nizatidine oral 1 PYLERA ORAL 2 capsule 150 mg, 300 CAPSULE 140-125- mg 125 MG nizatidine oral 1 rabeprazole oral 1 solution 150 mg/10 tablet,delayed ml release (dr/ec) 20 mg OMEPRAZOLE 2 (BULK) POWDER ranitidine hcl oral 1 100 % syrup 15 mg/ml omeprazole oral 1 QL ranitidine hcl oral 1 capsule,delayed tablet 300 mg release(dr/ec) 10 mg SUCRALFATE 2 omeprazole oral 1 (BULK) POWDER capsule,delayed sucralfate oral 1 release(dr/ec) 20 suspension 100 mg, 40 mg mg/ml omeprazole-sodium 1 PA sucralfate oral tablet 1 bicarbonate oral 1 gram capsule 40-1.1 mg- gram TALICIA ORAL 2 QL CAPSULE,IR - omeprazole-sodium 1 PA; QL DELAY bicarbonate oral REL,BIPHASE 10- packet 20-1,680 mg 250-12.5 MG omeprazole-sodium 1 PA IMMUNOLOGY, VACCINES / bicarbonate oral packet 40-1,680 mg BIOTECHNOLOGY
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 161 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits BIOTECHNOLOGY DRUGS GENOTROPIN 2 PA; SP MINIQUICK ACTIMMUNE 2 PA; SP SUBCUTANEOUS SUBCUTANEOUS SYRINGE 0.2 SOLUTION 100 MG/0.25 ML, 0.4 MCG/0.5 ML MG/0.25 ML, 0.6 ALFERON N 2 MG/0.25 ML, 0.8 INJECTION MG/0.25 ML, 1 SOLUTION 5 MG/0.25 ML, 1.2 MILLION MG/0.25 ML, 1.4 UNIT/ML MG/0.25 ML, 1.6 MG/0.25 ML, 1.8 AVONEX 2 PA; SP; QL MG/0.25 ML, 2 INTRAMUSCULA MG/0.25 ML R PEN INJECTOR KIT 30 MCG/0.5 GENOTROPIN 2 PA; SP ML SUBCUTANEOUS CARTRIDGE 12 AVONEX 2 PA; SP; QL MG/ML (36 INTRAMUSCULA UNIT/ML), 5 R SYRINGE KIT 30 MG/ML (15 MCG/0.5 ML UNIT/ML) BETASERON 2 PA; SP; QL ILARIS (PF) 2 SP SUBCUTANEOUS SUBCUTANEOUS KIT 0.3 MG SOLUTION 150 EGRIFTA SV 2 PA; SP MG/ML SUBCUTANEOUS INTRON A 2 SP RECON SOLN 2 INJECTION MG RECON SOLN 10 FULPHILA 2 PA; SP; QL MILLION UNIT (1 SUBCUTANEOUS ML), 18 MILLION SYRINGE 6 MG/0.6 UNIT (1 ML), 50 ML MILLION UNIT (1 ML) INTRON A 2 SP INJECTION SOLUTION 10 MILLION UNIT/ML, 6 MILLION UNIT/ML
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 162 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits LEUKINE 2 PA; SP PEGASYS 2 PA; SP; QL INJECTION SUBCUTANEOUS RECON SOLN 250 SOLUTION 180 MCG MCG/ML MOZOBIL 2 SP PEGASYS 2 PA; SP; QL SUBCUTANEOUS SUBCUTANEOUS SOLUTION 24 SYRINGE 180 MG/1.2 ML (20 MCG/0.5 ML MG/ML) PLEGRIDY 2 PA; SP; QL NEULASTA 2 PA; SP; QL SUBCUTANEOUS SUBCUTANEOUS PEN INJECTOR SYRINGE 6 MG/0.6 125 MCG/0.5 ML, ML 63 MCG/0.5 ML- 94 MCG/0.5 ML NEULASTA 2 PA; SP; QL SUBCUTANEOUS PLEGRIDY 2 PA; SP; QL SYRINGE, W/ SUBCUTANEOUS WEARABLE SYRINGE 125 INJECTOR 6 MCG/0.5 ML, 63 MG/0.6 ML MCG/0.5 ML- 94 MCG/0.5 ML NIVESTYM 2 PA; SP INJECTION PROCRIT 2 PA; SP SOLUTION 300 INJECTION MCG/ML, 480 SOLUTION 10,000 MCG/1.6 ML UNIT/ML, 2,000 UNIT/ML, 20,000 NIVESTYM 2 PA; SP UNIT/2 ML, 20,000 SUBCUTANEOUS UNIT/ML, 3,000 SYRINGE 300 UNIT/ML, 4,000 MCG/0.5 ML, 480 UNIT/ML, 40,000 MCG/0.8 ML UNIT/ML NORDITROPIN 2 PA; SP PROLEUKIN 2 PA; SP FLEXPRO INTRAVENOUS SUBCUTANEOUS RECON SOLN 22 PEN INJECTOR 10 MILLION UNIT MG/1.5 ML (6.7 MG/ML), 15 REBIF (WITH 2 PA; SP; QL MG/1.5 ML (10 ALBUMIN) MG/ML), 30 MG/3 SUBCUTANEOUS ML (10 MG/ML), 5 SYRINGE 22 MG/1.5 ML (3.3 MCG/0.5 ML, 44 MG/ML) MCG/0.5 ML
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 163 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits REBIF REBIDOSE 2 PA; SP; QL ZIEXTENZO 2 PA; SP SUBCUTANEOUS SUBCUTANEOUS PEN INJECTOR 22 SYRINGE 6 MG/0.6 MCG/0.5 ML, 44 ML MCG/0.5 ML, VACCINES / MISCELLANEOUS 8.8MCG/0.2ML-22 MCG/0.5ML (6) IMMUNOLOGICALS REBIF TITRATION 2 PA; SP; QL ACTHIB (PF) 2 ACA PACK INTRAMUSCULA SUBCUTANEOUS R RECON SOLN 10 SYRINGE MCG/0.5 ML 8.8MCG/0.2ML-22 ADACEL(TDAP 2 ACA MCG/0.5ML (6) ADOLESN/ADULT RETACRIT 2 PA; SP )(PF) INJECTION INTRAMUSCULA SOLUTION 10,000 R SUSPENSION 2 UNIT/ML, 2,000 LF-(2.5-5-3-5 UNIT/ML, 3,000 MCG)-5LF/0.5 ML UNIT/ML, 4,000 ADACEL(TDAP 2 ACA UNIT/ML, 40,000 ADOLESN/ADULT UNIT/ML )(PF) SERMORELIN 2 INTRAMUSCULA ACETATE (BULK) R SYRINGE 2 LF- POWDER 100 % (2.5-5-3-5 MCG)- 5LF/0.5 ML SEROSTIM 2 PA; SP SUBCUTANEOUS AFLURIA QD 2 ACA RECON SOLN 4 2020-21(3YR MG, 5 MG, 6 MG UP)(PF) INTRAMUSCULA SYLATRON 2 PA; SP R SYRINGE 60 SUBCUTANEOUS MCG (15 MCG X KIT 200 MCG, 300 4)/0.5 ML MCG AFLURIA QD 2 ACA UDENYCA 2 PA; SP; QL 2020-21(6- SUBCUTANEOUS 35MO)(PF) SYRINGE 6 MG/0.6 INTRAMUSCULA ML R SYRINGE 30 ZARXIO 2 PA; SP MCG (7.5 MCG X INJECTION 4)/0.25 ML SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 164 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits AFLURIA QUAD 2 ACA candin intradermal 1 2020-2021(6MO allergen fda UP) standard INTRAMUSCULA CROFAB 2 R SUSPENSION 60 INJECTION MCG (15 MCG X RECON SOLN 4)/0.5 ML CYTOGAM 2 PA; SP APLISOL 2 INTRAVENOUS INTRADERMAL SOLUTION 50 SOLUTION 5 TUB. MG/ML UNIT /0.1 ML DAPTACEL (DTAP 2 ACA ATGAM 2 PA PEDIATRIC) (PF) INTRAVENOUS INTRAMUSCULA SOLUTION 50 R SUSPENSION MG/ML 15-10-5 LF-MCG- BCG VACCINE, 2 ACA LF/0.5ML LIVE (PF) ENGERIX-B (PF) 2 ACA PERCUTANEOUS INTRAMUSCULA SUSPENSION FOR R SUSPENSION 20 RECONSTITUTIO MCG/ML N 50 MG ENGERIX-B (PF) 2 ACA BEXSERO 2 ACA INTRAMUSCULA INTRAMUSCULA R SYRINGE 20 R SYRINGE 50-50- MCG/ML 50-25 MCG/0.5 ML ENGERIX-B 2 ACA BIOTHRAX 2 ACA PEDIATRIC (PF) INTRAMUSCULA INTRAMUSCULA R SUSPENSION 0.5 R SYRINGE 10 ML/DOSE MCG/0.5 ML BOOSTRIX TDAP 2 ACA FLUAD 2020-2021 2 ACA INTRAMUSCULA (65 YR UP)(PF) R SUSPENSION INTRAMUSCULA 2.5-8-5 LF-MCG- R SYRINGE 45 LF/0.5ML MCG (15 MCG X BOOSTRIX TDAP 2 ACA 3)/0.5 ML INTRAMUSCULA FLUAD QUAD 2 ACA R SYRINGE 2.5-8-5 2020-21(65Y LF-MCG-LF/0.5ML UP)(PF) BOTOX 2 PA; SP INTRAMUSCULA INJECTION R SYRINGE 60 RECON SOLN 100 MCG (15 MCG X UNIT, 200 UNIT 4)/0.5 ML You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 165 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits FLUARIX QUAD 2 ACA FLUZONE QUAD 2 ACA 2020-2021 (PF) 2020-2021 (PF) INTRAMUSCULA INTRAMUSCULA R SYRINGE 60 R SYRINGE 60 MCG (15 MCG X MCG (15 MCG X 4)/0.5 ML 4)/0.5 ML FLUBLOK QUAD 2 ACA FLUZONE QUAD 2 ACA 2020-2021 (PF) 2020-2021 INTRAMUSCULA INTRAMUSCULA R SYRINGE 180 R SUSPENSION 60 MCG (45 MCG X MCG (15 MCG X 4)/0.5 ML 4)/0.5 ML FLUCELVAX 2 ACA fomepizole 1 QUAD 2020-2021 intravenous solution (PF) 1 gram/ml INTRAMUSCULA GAMASTAN 2 SP R SYRINGE 60 INTRAMUSCULA MCG (15 MCG X R SOLUTION 15-18 4)/0.5 ML % RANGE FLUCELVAX 2 ACA GAMASTAN S/D 2 SP QUAD 2020-2021 INTRAMUSCULA INTRAMUSCULA R SOLUTION 15-18 R SUSPENSION 60 % RANGE MCG (15 MCG X 4)/0.5 ML GAMMAGARD 2 PA; SP LIQUID FLULAVAL QUAD 2 ACA INJECTION 2020-2021 (PF) SOLUTION 10 % INTRAMUSCULA R SYRINGE 60 GAMMAGARD S- 2 PA; SP MCG (15 MCG X D (IGA < 1 4)/0.5 ML MCG/ML) INTRAVENOUS FLUZONE 2 ACA RECON SOLN 10 HIGHDOSE QUAD GRAM, 5 GRAM 20-21 PF INTRAMUSCULA R SYRINGE 240 MCG/0.7 ML FLUZONE QUAD 2 ACA 2020-2021 (PF) INTRAMUSCULA R SUSPENSION 60 MCG (15 MCG X 4)/0.5 ML You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 166 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits GAMUNEX-C 2 PA; SP HISTATROL 2 INJECTION INTRADERMAL SOLUTION 1 SOLUTION 0.1 GRAM/10 ML (10 (0.275) MG/ML %), 10 GRAM/100 HIZENTRA 2 PA; SP ML (10 %), 2.5 SUBCUTANEOUS GRAM/25 ML (10 SOLUTION 1 %), 20 GRAM/200 GRAM/5 ML (20 ML (10 %), 40 %), 10 GRAM/50 GRAM/400 ML (10 ML (20 %), 2 %), 5 GRAM/50 ML GRAM/10 ML (20 (10 %) %), 4 GRAM/20 ML GARDASIL 9 (PF) 2 ACA (20 %) INTRAMUSCULA HYPERHEP B S/D 2 R SUSPENSION 0.5 INTRAMUSCULA ML R SOLUTION 220 GARDASIL 9 (PF) 2 ACA UNIT/ML, 220 INTRAMUSCULA UNIT/ML (5 ML) R SYRINGE 0.5 ML HYPERHEP B S/D 2 HAVRIX (PF) 2 ACA INTRAMUSCULA INTRAMUSCULA R SYRINGE 220 R SUSPENSION UNIT/ML 1,440 ELISA HYPERHEP B S-D 2 UNIT/ML NEONATAL HAVRIX (PF) 2 ACA INTRAMUSCULA INTRAMUSCULA R SYRINGE 110 R SYRINGE 1,440 UNIT/0.5 ML ELISA UNIT/ML, HYPERRAB (PF) 2 720 ELISA INTRAMUSCULA UNIT/0.5 ML R SOLUTION 300 HEPAGAM B 2 UNIT/ML INJECTION HYPERRAB S/D 2 SOLUTION >312 (PF) UNIT/ML, INTRAMUSCULA GREATR THAN R SOLUTION 150 312 UNIT/ML (5 UNIT/ML ML) HYPERRHO S/D 2 HIBERIX (PF) 2 ACA INTRAMUSCULA INTRAMUSCULA R SYRINGE 1,500 R RECON SOLN 10 UNIT (300 MCG), MCG/0.5 ML 250 UNIT (50 MCG)
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 167 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits HYPERTET S/D 2 M-M-R II (PF) 2 ACA (PF) SUBCUTANEOUS INTRAMUSCULA RECON SOLN R SYRINGE 250 1,000-12,500 UNIT TCID50/0.5 ML IMOGAM RABIES- 2 MYOBLOC 2 PA; SP HT (PF) INTRAMUSCULA INTRAMUSCULA R SOLUTION R SOLUTION 150 10,000 UNIT/2 ML, UNIT/ML 2,500 UNIT/0.5 ML, 5,000 UNIT/ML IMOVAX RABIES 2 ACA VACCINE (PF) PEDIARIX (PF) 2 ACA INTRAMUSCULA INTRAMUSCULA R RECON SOLN R SYRINGE 10 2.5 UNIT MCG-25LF-25 MCG-10LF/0.5 ML INFANRIX (DTAP) 2 ACA (PF) PEDVAX HIB (PF) 2 ACA INTRAMUSCULA INTRAMUSCULA R SUSPENSION R SOLUTION 7.5 25-58-10 LF-MCG- MCG/0.5 ML LF/0.5ML PENTACEL (PF) 2 ACA INFANRIX (DTAP) 2 ACA INTRAMUSCULA (PF) R KIT 15 LF UNIT- INTRAMUSCULA 20 MCG-5 LF/0.5 R SYRINGE 25-58- ML, 15LF-48MCG- 10 LF-MCG- 62DU -10 LF/0.5ML MCG/0.5ML IPOL INJECTION 2 ACA PENTACEL 2 ACA SUSPENSION 40-8- ACTHIB 32 UNIT/0.5 ML COMPONENT (PF) INTRAMUSCULA IXIARO (PF) 2 ACA R RECON SOLN 10 INTRAMUSCULA MCG/0.5 ML R SYRINGE 6 MCG/0.5 ML PNEUMOVAX-23 2 ACA INJECTION MENACTRA (PF) 2 ACA SOLUTION 25 INTRAMUSCULA MCG/0.5 ML R SOLUTION 4 MCG/0.5 ML PNEUMOVAX-23 2 ACA INJECTION SYRINGE 25 MCG/0.5 ML
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 168 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits PREVNAR 13 (PF) 2 ACA ROTATEQ 2 ACA INTRAMUSCULA VACCINE ORAL R SYRINGE 0.5 ML SOLUTION 2 ML PRIVIGEN 2 PA; SP SHINGRIX (PF) 2 ACA INTRAVENOUS INTRAMUSCULA SOLUTION 10 % R SUSPENSION FOR PROQUAD (PF) 2 ACA RECONSTITUTIO SUBCUTANEOUS N 50 MCG/0.5 ML SUSPENSION FOR RECONSTITUTIO STAMARIL (PF) 2 ACA N 10EXP3-4.3-3- SUBCUTANEOUS 3.99 TCID50/0.5 SUSPENSION FOR RECONSTITUTIO PROVENGE 2 SP N 1,000 UNIT/0.5 INTRAVENOUS ML SUSPENSION 50 MILLION TDVAX 2 ACA CELL/250 ML INTRAMUSCULA R SUSPENSION 2- QUADRACEL (PF) 2 ACA 2 LF UNIT/0.5 ML INTRAMUSCULA R SUSPENSION 15 TETANUS,DIPHTH 2 ACA LF-48 MCG- 5 LF ERIA TOX UNIT/0.5ML PED(PF) INTRAMUSCULA RABAVERT (PF) 2 ACA R SUSPENSION 5- INTRAMUSCULA 25 LF UNIT/0.5 ML R SUSPENSION FOR THYMOGLOBULI 2 SP RECONSTITUTIO N INTRAVENOUS N 2.5 UNIT RECON SOLN 25 MG RECOMBIVAX HB 2 ACA (PF) TICE BCG 2 INTRAMUSCULA INTRAVESICAL R SUSPENSION 10 SUSPENSION FOR MCG/ML, 40 RECONSTITUTIO MCG/ML, 5 N 50 MG MCG/0.5 ML TRUMENBA 2 ACA RECOMBIVAX HB 2 ACA INTRAMUSCULA (PF) R SYRINGE 120 INTRAMUSCULA MCG/0.5 ML R SYRINGE 10 TUBERSOL 2 MCG/ML, 5 INTRADERMAL MCG/0.5 ML SOLUTION 5 TUB. UNIT /0.1 ML You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 169 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits TWINRIX (PF) 2 ACA XEMBIFY 2 PA; SP INTRAMUSCULA SUBCUTANEOUS R SYRINGE 720 SOLUTION 1 ELISA UNIT- 20 GRAM/5 ML (20 MCG/ML %), 10 GRAM/50 ML (20 %), 2 TYPHIM VI 2 ACA GRAM/10 ML (20 INTRAMUSCULA %), 4 GRAM/20 ML R SOLUTION 25 (20 %) MCG/0.5 ML YF-VAX (PF) 2 ACA TYPHIM VI 2 ACA SUBCUTANEOUS INTRAMUSCULA SUSPENSION FOR R SYRINGE 25 RECONSTITUTIO MCG/0.5 ML N 10 EXP4.74 VARIVAX (PF) 2 ACA UNIT/0.5 ML SUBCUTANEOUS MUSCULOSKELETAL / SUSPENSION FOR RECONSTITUTIO RHEUMATOLOGY N 1,350 UNIT/0.5
ML GOUT THERAPY VARIZIG 2 ACA ALLOPURINOL 2 INTRAMUSCULA (BULK) POWDER R SOLUTION 125 allopurinol oral 1 UNIT/1.2 ML tablet 100 mg, 300 VAXCHORA 2 ACA mg VACCINE ORAL allopurinol sodium 1 SUSPENSION FOR intravenous recon RECONSTITUTIO soln 500 mg N 4X10EXP8 TO aloprim intravenous 1 2X 10EXP9 CF recon soln 500 mg UNIT COLCHICINE 2 VIVOTIF ORAL 2 ACA (BULK) POWDER CAPSULE,DELAY ED colchicine oral 1 RELEASE(DR/EC) tablet 0.6 mg 2 BILLION UNIT febuxostat oral 1 ST tablet 40 mg, 80 mg KRYSTEXXA 2 PA; SP INTRAVENOUS SOLUTION 8 MG/ML
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 170 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits MITIGARE ORAL 2 TYMLOS 2 PA; SP; QL CAPSULE 0.6 MG SUBCUTANEOUS PEN INJECTOR 80 probenecid oral 1 MCG (3,120 tablet 500 mg MCG/1.56 ML) probenecid- 1
colchicine oral OTHER RHEUMATOLOGICALS tablet 500-0.5 mg ACTEMRA 2 PA; SP; QL ACTPEN OSTEOPOROSIS THERAPY SUBCUTANEOUS alendronate oral 1 QL PEN INJECTOR solution 70 mg/75 ml 162 MG/0.9 ML alendronate oral 1 QL ACTEMRA 2 PA; SP tablet 10 mg, 35 mg, INTRAVENOUS 5 mg, 70 mg SOLUTION 200 FORTEO 2 PA; SP; QL MG/10 ML (20 SUBCUTANEOUS MG/ML), 400 PEN INJECTOR 20 MG/20 ML (20 MCG/DOSE MG/ML), 80 MG/4 (600MCG/2.4ML) ML (20 MG/ML) ibandronate 1 PA; SP ACTEMRA 2 PA; SP; QL intravenous solution SUBCUTANEOUS 3 mg/3 ml SYRINGE 162 MG/0.9 ML ibandronate 1 PA; SP intravenous syringe BENLYSTA 2 PA; SP 3 mg/3 ml INTRAVENOUS RECON SOLN 120 ibandronate oral 1 QL MG, 400 MG tablet 150 mg BENLYSTA 2 PA; SP; QL raloxifene oral tablet 1 ACA SUBCUTANEOUS 60 mg AUTO-INJECTOR risedronate oral 1 QL 200 MG/ML tablet 150 mg, 35 BENLYSTA 2 PA; SP; QL mg, 5 mg SUBCUTANEOUS risedronate oral 1 QL SYRINGE 200 tablet,delayed MG/ML release (dr/ec) 35 D-PENAMINE 2 PA mg ORAL TABLET 125 MG
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 171 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits ENBREL MINI 2 PA; SP; QL HUMIRA 2 PA; SP; QL SUBCUTANEOUS SUBCUTANEOUS CARTRIDGE 50 SYRINGE KIT 10 MG/ML (1 ML) MG/0.2 ML, 20 MG/0.4 ML, 40 ENBREL 2 PA; SP; QL MG/0.8 ML SUBCUTANEOUS RECON SOLN 25 HUMIRA(CF) PEDI 2 PA; SP; QL MG (1 ML) CROHNS STARTER ENBREL 2 PA; SP; QL SUBCUTANEOUS SUBCUTANEOUS SYRINGE KIT 80 SOLUTION 25 MG/0.8 ML, 80 MG/0.5 ML MG/0.8 ML-40 ENBREL 2 PA; SP; QL MG/0.4 ML SUBCUTANEOUS HUMIRA(CF) PEN 2 PA; SP; QL SYRINGE 25 CROHNS-UC-HS MG/0.5 ML (0.5), SUBCUTANEOUS 50 MG/ML (1 ML) PEN INJECTOR ENBREL 2 PA; SP; QL KIT 80 MG/0.8 ML SURECLICK HUMIRA(CF) PEN 2 PA; SP; QL SUBCUTANEOUS PSOR-UV-ADOL PEN INJECTOR 50 HS MG/ML (1 ML) SUBCUTANEOUS GOLD SODIUM 2 PEN INJECTOR THIOMALATE KIT 80 MG/0.8 ML- (BULK) POWDER 40 MG/0.4 ML HUMIRA PEN 2 PA; SP; QL HUMIRA(CF) PEN 2 PA; SP; QL CROHNS-UC-HS SUBCUTANEOUS START PEN INJECTOR SUBCUTANEOUS KIT 40 MG/0.4 ML PEN INJECTOR HUMIRA(CF) 2 PA; SP; QL KIT 40 MG/0.8 ML SUBCUTANEOUS HUMIRA PEN 2 PA; SP; QL SYRINGE KIT 10 PSOR-UVEITS- MG/0.1 ML, 20 ADOL HS MG/0.2 ML, 40 SUBCUTANEOUS MG/0.4 ML PEN INJECTOR leflunomide oral 1 QL KIT 40 MG/0.8 ML tablet 10 mg, 20 mg HUMIRA PEN 2 PA; SP; QL OTEZLA ORAL 2 PA; SP; QL SUBCUTANEOUS TABLET 30 MG PEN INJECTOR KIT 40 MG/0.8 ML
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 172 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits OTEZLA 2 PA; SP; QL RINVOQ ORAL 2 PA; SP; QL STARTER ORAL TABLET TABLETS,DOSE EXTENDED PACK 10 MG (4)- RELEASE 24 HR 20 MG (4)-30 MG 15 MG (47), 10 MG (4)-20 SAVELLA ORAL 2 ST; QL MG (4)-30 MG(19) TABLET 100 MG, OTREXUP (PF) 2 ST 12.5 MG, 25 MG, 50 SUBCUTANEOUS MG AUTO-INJECTOR SAVELLA ORAL 2 ST; QL 10 MG/0.4 ML, 12.5 TABLETS,DOSE MG/0.4 ML, 15 PACK 12.5 MG (5)- MG/0.4 ML, 17.5 25 MG(8)-50 MG/0.4 ML, 20 MG(42) MG/0.4 ML, 22.5 MG/0.4 ML, 25 SIMPONI 2 PA; SP; QL MG/0.4 ML SUBCUTANEOUS PEN INJECTOR PENICILLAMINE 2 100 MG/ML (BULK) POWDER SIMPONI 2 PA; SP; QL penicillamine oral 1 PA SUBCUTANEOUS capsule 250 mg SYRINGE 100 penicillamine oral 1 PA MG/ML tablet 250 mg XELJANZ ORAL 2 PA; SP; QL PENICILLAMINE( 2 TABLET 10 MG, 5 D-) POWDER MG RASUVO (PF) 2 ST XELJANZ XR 2 PA; SP; QL SUBCUTANEOUS ORAL TABLET AUTO-INJECTOR EXTENDED 10 MG/0.2 ML, 12.5 RELEASE 24 HR MG/0.25 ML, 15 11 MG, 22 MG MG/0.3 ML, 17.5 MG/0.35 ML, 20 OBSTETRICS / GYNECOLOGY MG/0.4 ML, 22.5 ESTROGENS / PROGESTINS MG/0.45 ML, 25 MG/0.5 ML, 30 amabelz oral tablet 1 MG/0.6 ML, 7.5 0.5-0.1 mg, 1-0.5 mg MG/0.15 ML camila oral tablet 1 ACA RIDAURA ORAL 2 0.35 mg CAPSULE 3 MG
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 173 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits COMBIPATCH 2 dotti transdermal 1 QL TRANSDERMAL patch semiweekly PATCH 0.025 mg/24 hr, SEMIWEEKLY 0.0375 mg/24 hr, 0.05-0.14 MG/24 0.05 mg/24 hr, 0.075 HR, 0.05-0.25 mg/24 hr, 0.1 mg/24 MG/24 HR hr covaryx h.s. oral 1 DUAVEE ORAL 2 tablet 0.625-1.25 mg TABLET 0.45-20 MG covaryx oral tablet 1 1.25-2.5 mg eemt hs oral tablet 1 0.625-1.25 mg CRINONE 2 VAGINAL GEL 4 eemt oral tablet 1 % 1.25-2.5 mg CRINONE 2 SP ENDOMETRIN 2 SP VAGINAL GEL 8 VAGINAL INSERT % 100 MG deblitane oral tablet 1 ACA errin oral tablet 0.35 1 ACA 0.35 mg mg DEPO-ESTRADIOL 2 ESTRADIOL 2 INTRAMUSCULA (BULK) POWDER R OIL 5 MG/ML 100 % DIVIGEL 2 QL ESTRADIOL 2 TRANSDERMAL BENZOATE GEL IN PACKET (BULK) POWDER 0.25 MG/0.25 ESTRADIOL 2 GRAM (0.1 %), 0.5 CYPIONATE MG/0.5 GRAM (0.1 (BULK) POWDER %), 0.75 MG/0.75 GRAM (0.1%), 1 ESTRADIOL 2 MG/GRAM (0.1 %) HEMIHYD,MICRO (BULK) POWDER DIVIGEL 2 100 % TRANSDERMAL GEL IN PACKET ESTRADIOL 2 1.25 MG/1.25 MICRONIZED GRAM (0.1 %) (BULK) POWDER 100 % estradiol oral tablet 1 0.5 mg, 1 mg, 2 mg
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 174 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits estradiol 1 QL ESTRONE (BULK) 2 transdermal patch CRYSTALS semiweekly 0.025 ESTRONE (BULK) 2 mg/24 hr, 0.0375 POWDER 100 % mg/24 hr, 0.05 mg/24 hr, 0.075 ETHINYL 2 mg/24 hr, 0.1 mg/24 ESTRADIOL hr (BULK) POWDER estradiol 1 QL fyavolv oral tablet 1 transdermal patch 0.5-2.5 mg-mcg, 1-5 weekly 0.025 mg/24 mg-mcg hr, 0.0375 mg/24 hr, heather oral tablet 1 ACA 0.05 mg/24 hr, 0.06 0.35 mg mg/24 hr, 0.075 mg/24 hr, 0.1 mg/24 hydroxyprogest(pf)(p 1 PA; SP hr reg presv) intramuscular oil estradiol vaginal 1 250 mg/ml (1 ml) cream 0.01 % (0.1 mg/gram) hydroxyprogesterone 1 PA; SP cap(ppres) estradiol vaginal 1 intramuscular oil tablet 10 mcg 250 mg/ml ESTRADIOL 2 HYDROXYPROGE 2 VALERATE STERONE (BULK) POWDER CAPR(BULK) estradiol valerate 1 POWDER 100 % intramuscular oil 20 hydroxyprogesterone 1 mg/ml, 40 mg/ml caproate estradiol- 1 intramuscular oil norethindrone acet 250 mg/ml oral tablet 0.5-0.1 incassia oral tablet 1 ACA mg, 1-0.5 mg 0.35 mg ESTRING 2 jencycla oral tablet 1 ACA VAGINAL RING 2 0.35 mg MG (7.5 MCG /24 HOUR) jinteli oral tablet 1-5 1 mg-mcg estrogens- 1 methyltestosterone lyza oral tablet 0.35 1 ACA oral tablet 0.625- mg 1.25 mg, 1.25-2.5 mg
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 175 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits MEDROXYPROGE 2 PREMARIN ORAL 2 ST, AC TABLET 0.3 MG, MICRO(BULK) 0.45 MG, 0.625 MG, POWDER 100 % 0.9 MG, 1.25 MG medroxyprogesteron 1 ACA; QL PREMARIN 2 e intramuscular VAGINAL CREAM suspension 150 0.625 MG/GRAM mg/ml PREMPHASE 2 medroxyprogesteron 1 ACA; QL ORAL TABLET e intramuscular 0.625 MG (14)/ syringe 150 mg/ml 0.625MG-5MG(14) medroxyprogesteron 1 PREMPRO ORAL 2 e oral tablet 10 mg, TABLET 0.3-1.5 2.5 mg, 5 mg MG, 0.45-1.5 MG, 0.625-2.5 MG, mimvey oral tablet 1 0.625-5 MG 1-0.5 mg PROGESTERONE 2 nora-be oral tablet 1 ACA (BULK) POWDER 0.35 mg 100 % NORETHINDRON 2 progesterone 1 SP E (BULK) intramuscular oil 50 POWDER 100 % mg/ml norethindrone 1 ACA PROGESTERONE 2 (contraceptive) oral MICRONIZED tablet 0.35 mg (BULK) POWDER NORETHINDRON 2 100 % E ACETATE progesterone 1 (BULK) POWDER micronized oral norethindrone 1 capsule 100 mg, 200 acetate oral tablet 5 mg mg sharobel oral tablet 1 ACA norethindrone ac-eth 1 0.35 mg estradiol oral tablet tulana oral tablet 1 ACA 0.5-2.5 mg-mcg, 1-5 0.35 mg mg-mcg yuvafem vaginal 1 norlyda oral tablet 1 ACA tablet 10 mcg 0.35 mg
PREMARIN 2 MISCELLANEOUS OB/GYN INJECTION clindamycin 1 RECON SOLN 25 phosphate vaginal MG cream 2 % You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 176 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits eluryng vaginal ring 1 ACA MIRENA 2 SP; ACA 0.12-0.015 mg/24 hr INTRAUTERINE INTRAUTERINE etonogestrel-ethinyl 1 ACA DEVICE 20 estradiol vaginal MCG/24 HOURS (6 ring 0.12-0.015 YRS) 52 MG mg/24 hr NEXPLANON 2 SP; ACA fem ph vaginal gel 1 SUBDERMAL 0.9-0.025 % IMPLANT 68 MG gynol ii vaginal gel 3 1 ACA; OTC ORIAHNN ORAL 2 PA % CAPSULE, ISOXSUPRINE 2 SEQUENTIAL 300- HCL (BULK) 1-0.5MG(AM) /300 POWDER 100 % MG(PM) isoxsuprine oral 1 SKYLA 2 SP; ACA tablet 10 mg, 20 mg INTRAUTERINE KYLEENA 2 SP; ACA INTRAUTERINE INTRAUTERINE DEVICE 14 INTRAUTERINE MCG/24 HRS (3 DEVICE 17.5 YRS) 13.5 MG MCG/24 HRS (5 SULFANILAMIDE 2 YRS) 19.5 MG (BULK) POWDER LUPANETA PACK 2 PA; SP SULFATHIAZOLE 2 (1 MONTH) KIT. (BULK) POWDER SYRINGE AND terconazole vaginal 1 TABLET 3.75 MG - cream 0.4 %, 0.8 % 5 MG (30) terconazole vaginal 1 LUPANETA PACK 2 PA; SP suppository 80 mg (3 MONTH) KIT. SYRINGE AND TODAY 2 ACA; OTC TABLET 11.25 MG CONTRACEPTIVE -5 MG (90) SPONGE VAGINAL metronidazole 1 CONTRACEPTIVE vaginal gel 0.75 % SPONGE 1,000 MG miconazole-3 1 tranexamic acid oral 1 vaginal suppository tablet 650 mg 200 mg TRIMO-SAN 2 JELLY VAGINAL GEL 0.025-0.01 %
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 177 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits VAGINAL 2 ACA; OTC apri oral tablet 0.15- 1 ACA CONTRACEPTIVE 0.03 mg FILM VAGINAL aranelle (28) oral 1 ACA FILM 28 % tablet 0.5/1/0.5-35 vaginal 1 ACA; OTC mg-mcg contraceptive foam ashlyna oral 1 ACA vaginal foam 12.5 % tablets,dose pack,3 vandazole vaginal 1 month 0.15 mg-30 gel 0.75 % mcg (84)/10 mcg (7) VCF 2 ACA; OTC aubra eq oral tablet 1 ACA CONTRACEPTIVE 0.1-20 mg-mcg GEL VAGINAL aubra oral tablet 1 ACA GEL 4 % 0.1-20 mg-mcg xulane transdermal 1 ACA aurovela 1.5/30 (21) 1 ACA patch weekly 150-35 oral tablet 1.5-30 mcg/24 hr mg-mcg ORAL CONTRACEPTIVES / aurovela 1/20 (21) 1 ACA RELATED AGENTS oral tablet 1-20 mg- afirmelle oral tablet 1 ACA mcg 0.1-20 mg-mcg aurovela 24 fe oral 1 ACA altavera (28) oral 1 ACA tablet 1 mg-20 mcg tablet 0.15-0.03 mg (24)/75 mg (4) alyacen 1/35 (28) 1 ACA aurovela fe 1.5/30 1 ACA oral tablet 1-35 mg- (28) oral tablet 1.5 mcg mg-30 mcg (21)/75 mg (7) alyacen 7/7/7 (28) 1 ACA oral tablet 0.5/0.75/1 aurovela fe 1-20 1 ACA mg- 35 mcg (28) oral tablet 1 mg-20 mcg (21)/75 amethia lo oral 1 ACA mg (7) tablets,dose pack,3 month 0.10 mg-20 aviane oral tablet 1 ACA mcg (84)/10 mcg (7) 0.1-20 mg-mcg amethia oral 1 ACA ayuna oral tablet 1 ACA tablets,dose pack,3 0.15-0.03 mg month 0.15 mg-30 azurette (28) oral 1 ACA mcg (84)/10 mcg (7) tablet 0.15-0.02 amethyst (28) oral 1 ACA mgx21 /0.01 mg x 5 tablet 90-20 mcg (28)
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 178 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits balziva (28) oral 1 ACA cyclafem 1/35 (28) 1 ACA tablet 0.4-35 mg- oral tablet 1-35 mg- mcg mcg bekyree (28) oral 1 ACA cyclafem 7/7/7 (28) 1 ACA tablet 0.15-0.02 oral tablet 0.5/0.75/1 mgx21 /0.01 mg x 5 mg- 35 mcg blisovi 24 fe oral 1 ACA cyred eq oral tablet 1 ACA tablet 1 mg-20 mcg 0.15-0.03 mg (24)/75 mg (4) cyred oral tablet 1 ACA blisovi fe 1.5/30 (28) 1 ACA 0.15-0.03 mg oral tablet 1.5 mg-30 dasetta 1/35 (28) 1 ACA mcg (21)/75 mg (7) oral tablet 1-35 mg- blisovi fe 1/20 (28) 1 ACA mcg oral tablet 1 mg-20 dasetta 7/7/7 (28) 1 ACA mcg (21)/75 mg (7) oral tablet 0.5/0.75/1 briellyn oral tablet 1 ACA mg- 35 mcg 0.4-35 mg-mcg daysee oral 1 ACA camrese lo oral 1 ACA tablets,dose pack,3 tablets,dose pack,3 month 0.15 mg-30 month 0.10 mg-20 mcg (84)/10 mcg (7) mcg (84)/10 mcg (7) desog- 1 ACA camrese oral 1 ACA e.estradiol/e.estradio tablets,dose pack,3 l oral tablet 0.15- month 0.15 mg-30 0.02 mgx21 /0.01 mg mcg (84)/10 mcg (7) x 5 caziant (28) oral 1 ACA drospirenone- 1 ACA tablet 0.1/.125/.15- e.estradiol-lm.fa 25 mg-mcg oral tablet 3-0.02- 0.451 mg (24) (4), 3- charlotte 24 fe oral 1 ACA 0.03-0.451 mg (21) tablet,chewable 1 (7) mg-20 mcg(24) /75 mg (4) drospirenone-ethinyl 1 ACA estradiol oral tablet chateal (28) oral 1 ACA 3-0.02 mg, 3-0.03 tablet 0.15-0.03 mg mg chateal eq (28) oral 1 ACA econtra ez oral 1 ACA; OTC; tablet 0.15-0.03 mg tablet 1.5 mg QL cryselle (28) oral 1 ACA econtra one-step 1 ACA; OTC; tablet 0.3-30 mg- oral tablet 1.5 mg QL mcg
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 179 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits elinest oral tablet 1 ACA introvale oral 1 ACA 0.3-30 mg-mcg tablets,dose pack,3 month 0.15 mg-30 emoquette oral 1 ACA mcg (91) tablet 0.15-0.03 mg isibloom oral tablet 1 ACA enpresse oral tablet 1 ACA 0.15-0.03 mg 50-30 (6)/75-40 (5)/125-30(10) jaimiess oral 1 ACA tablets,dose pack,3 enskyce oral tablet 1 ACA month 0.15 mg-30 0.15-0.03 mg mcg (84)/10 mcg (7) estarylla oral tablet 1 ACA jasmiel (28) oral 1 ACA 0.25-35 mg-mcg tablet 3-0.02 mg ethynodiol diac-eth 1 ACA jolessa oral 1 ACA estradiol oral tablet tablets,dose pack,3 1-35 mg-mcg, 1-50 month 0.15 mg-30 mg-mcg mcg (91) falmina (28) oral 1 ACA juleber oral tablet 1 ACA tablet 0.1-20 mg- 0.15-0.03 mg mcg junel 1.5/30 (21) 1 ACA fayosim oral 1 ACA oral tablet 1.5-30 tablets,dose pack,3 mg-mcg month 0.15 mg-20 mcg/ 0.15 mg-25 junel 1/20 (21) oral 1 ACA mcg tablet 1-20 mg-mcg femynor oral tablet 1 ACA junel fe 1.5/30 (28) 1 ACA 0.25-35 mg-mcg oral tablet 1.5 mg-30 mcg (21)/75 mg (7) gianvi (28) oral 1 ACA tablet 3-0.02 mg junel fe 1/20 (28) 1 ACA oral tablet 1 mg-20 hailey 24 fe oral 1 ACA mcg (21)/75 mg (7) tablet 1 mg-20 mcg (24)/75 mg (4) junel fe 24 oral 1 ACA tablet 1 mg-20 mcg hailey fe 1.5/30 (28) 1 ACA (24)/75 mg (4) oral tablet 1.5 mg-30 mcg (21)/75 mg (7) kaitlib fe oral 1 ACA tablet,chewable hailey fe 1/20 (28) 1 ACA 0.8mg-25mcg(24) oral tablet 1 mg-20 and 75 mg (4) mcg (21)/75 mg (7) kalliga oral tablet 1 ACA hailey oral tablet 1 ACA 0.15-0.03 mg 1.5-30 mg-mcg
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 180 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits kariva (28) oral 1 ACA lessina oral tablet 1 ACA tablet 0.15-0.02 0.1-20 mg-mcg mgx21 /0.01 mg x 5 levonest (28) oral 1 ACA kelnor 1/35 (28) oral 1 ACA tablet 50-30 (6)/75- tablet 1-35 mg-mcg 40 (5)/125-30(10) kelnor 1-50 oral 1 ACA levonorgestrel oral 1 ACA; OTC; tablet 1-50 mg-mcg tablet 1.5 mg QL kurvelo (28) oral 1 ACA levonorgestrel- 1 ACA tablet 0.15-0.03 mg ethinyl estrad oral tablet 0.1-20 mg- l norgest/e.estradiol- 1 ACA mcg, 0.15-0.03 mg, e.estrad oral 90-20 mcg (28) tablets,dose pack,3 month 0.10 mg-20 levonorgestrel- 1 ACA mcg (84)/10 mcg (7), ethinyl estrad oral 0.15 mg-20 mcg/ tablets,dose pack,3 0.15 mg-25 mcg, month 0.15 mg-30 0.15 mg-30 mcg mcg (91) (84)/10 mcg (7) levonorg-eth estrad 1 ACA larin 1.5/30 (21) 1 ACA triphasic oral tablet oral tablet 1.5-30 50-30 (6)/75-40 mg-mcg (5)/125-30(10) larin 1/20 (21) oral 1 ACA levora-28 oral tablet 1 ACA tablet 1-20 mg-mcg 0.15-0.03 mg larin 24 fe oral 1 ACA lillow (28) oral 1 ACA tablet 1 mg-20 mcg tablet 0.15-0.03 mg (24)/75 mg (4) LO LOESTRIN FE 2 ST; ACA larin fe 1.5/30 (28) 1 ACA ORAL TABLET 1 oral tablet 1.5 mg-30 MG-10 MCG mcg (21)/75 mg (7) (24)/10 MCG (2) larin fe 1/20 (28) 1 ACA lojaimiess oral 1 ACA oral tablet 1 mg-20 tablets,dose pack,3 mcg (21)/75 mg (7) month 0.10 mg-20 mcg (84)/10 mcg (7) larissia oral tablet 1 ACA 0.1-20 mg-mcg loryna (28) oral 1 ACA tablet 3-0.02 mg layolis fe oral 1 ACA tablet,chewable low-ogestrel (28) 1 ACA 0.8mg-25mcg(24) oral tablet 0.3-30 and 75 mg (4) mg-mcg leena 28 oral tablet 1 ACA lo-zumandimine (28) 1 ACA 0.5/1/0.5-35 mg-mcg oral tablet 3-0.02 mg You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 181 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits lutera (28) oral 1 ACA new day oral tablet 1 ACA; OTC; tablet 0.1-20 mg- 1.5 mg QL mcg nikki (28) oral tablet 1 ACA marlissa (28) oral 1 ACA 3-0.02 mg tablet 0.15-0.03 mg noreth-ethinyl 1 ACA melodetta 24 fe oral 1 ACA estradiol-iron oral tablet,chewable 1 tablet,chewable mg-20 mcg(24) /75 0.4mg-35mcg(21) mg (4) and 75 mg (7), 0.8mg-25mcg(24) mibelas 24 fe oral 1 ACA and 75 mg (4) tablet,chewable 1 mg-20 mcg(24) /75 norethindrone ac-eth 1 ACA mg (4) estradiol oral tablet 1-20 mg-mcg, 1.5-30 microgestin 1.5/30 1 ACA mg-mcg (21) oral tablet 1.5- 30 mg-mcg norethindrone- 1 ACA e.estradiol-iron oral microgestin 1/20 1 ACA tablet 1 mg-20 mcg (21) oral tablet 1-20 (21)/75 mg (7), 1.5 mg-mcg mg-30 mcg (21)/75 microgestin fe 1.5/30 1 ACA mg (7) (28) oral tablet 1.5 norethindrone- 1 ACA mg-30 mcg (21)/75 e.estradiol-iron oral mg (7) tablet,chewable 1 microgestin fe 1/20 1 ACA mg-20 mcg(24) /75 (28) oral tablet 1 mg (4) mg-20 mcg (21)/75 norgestimate-ethinyl 1 ACA mg (7) estradiol oral tablet mili oral tablet 0.25- 1 ACA 0.18/0.215/0.25 mg- 35 mg-mcg 25 mcg, mono-linyah oral 1 ACA 0.18/0.215/0.25 mg- tablet 0.25-35 mg- 35 mcg (28), 0.25-35 mcg mg-mcg my choice oral tablet 1 ACA; OTC; nortrel 0.5/35 (28) 1 ACA 1.5 mg QL oral tablet 0.5-35 mg-mcg my way oral tablet 1 ACA; OTC; 1.5 mg QL nortrel 1/35 (21) 1 ACA oral tablet 1-35 mg- necon 0.5/35 (28) 1 ACA mcg (21) oral tablet 0.5-35 mg-mcg
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 182 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits nortrel 1/35 (28) 1 ACA setlakin oral 1 ACA oral tablet 1-35 mg- tablets,dose pack,3 mcg month 0.15 mg-30 mcg (91) nortrel 7/7/7 (28) 1 ACA oral tablet 0.5/0.75/1 simliya (28) oral 1 ACA mg- 35 mcg tablet 0.15-0.02 mgx21 /0.01 mg x 5 ocella oral tablet 3- 1 ACA 0.03 mg simpesse oral 1 ACA tablets,dose pack,3 opcicon one-step 1 ACA; OTC; month 0.15 mg-30 oral tablet 1.5 mg QL mcg (84)/10 mcg (7) option-2 oral tablet 1 ACA; OTC; sprintec (28) oral 1 ACA 1.5 mg QL tablet 0.25-35 mg- orsythia oral tablet 1 ACA mcg 0.1-20 mg-mcg sronyx oral tablet 1 ACA philith oral tablet 1 ACA 0.1-20 mg-mcg 0.4-35 mg-mcg syeda oral tablet 3- 1 ACA pimtrea (28) oral 1 ACA 0.03 mg tablet 0.15-0.02 tarina 24 fe oral 1 ACA mgx21 /0.01 mg x 5 tablet 1 mg-20 mcg pirmella oral tablet 1 ACA (24)/75 mg (4) 0.5/0.75/1 mg- 35 tarina fe 1/20 (28) 1 ACA mcg, 1-35 mg-mcg oral tablet 1 mg-20 PLAN B ONE-STEP 2 ACA; OTC; mcg (21)/75 mg (7) ORAL TABLET 1.5 QL tarina fe 1-20 eq 1 ACA MG (28) oral tablet 1 portia 28 oral tablet 1 ACA mg-20 mcg (21)/75 0.15-0.03 mg mg (7) previfem oral tablet 1 ACA TAYTULLA ORAL 2 ST; ACA 0.25-35 mg-mcg CAPSULE 1 MG-20 reclipsen (28) oral 1 ACA MCG (24)/75 MG tablet 0.15-0.03 mg (4) rivelsa oral 1 ACA tilia fe oral tablet 1- 1 ACA tablets,dose pack,3 20(5)/1-30(7) /1mg- month 0.15 mg-20 35mcg (9) mcg/ 0.15 mg-25 tri femynor oral 1 ACA mcg tablet 0.18/0.215/0.25 mg- 35 mcg (28)
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 183 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits tri-estarylla oral 1 ACA tri-vylibra lo oral 1 ACA tablet tablet 0.18/0.215/0.25 mg- 0.18/0.215/0.25 mg- 35 mcg (28) 25 mcg tri-legest fe oral 1 ACA tri-vylibra oral 1 ACA tablet 1-20(5)/1- tablet 30(7) /1mg-35mcg 0.18/0.215/0.25 mg- (9) 35 mcg (28) tri-linyah oral tablet 1 ACA tydemy oral tablet 3- 1 ACA 0.18/0.215/0.25 mg- 0.03-0.451 mg (21) 35 mcg (28) (7) tri-lo-estarylla oral 1 ACA velivet triphasic 1 ACA tablet regimen (28) oral 0.18/0.215/0.25 mg- tablet 0.1/.125/.15- 25 mcg 25 mg-mcg tri-lo-marzia oral 1 ACA vienva oral tablet 1 ACA tablet 0.1-20 mg-mcg 0.18/0.215/0.25 mg- viorele (28) oral 1 ACA 25 mcg tablet 0.15-0.02 tri-lo-mili oral tablet 1 ACA mgx21 /0.01 mg x 5 0.18/0.215/0.25 mg- volnea (28) oral 1 ACA 25 mcg tablet 0.15-0.02 tri-lo-sprintec oral 1 ACA mgx21 /0.01 mg x 5 tablet vyfemla (28) oral 1 ACA 0.18/0.215/0.25 mg- tablet 0.4-35 mg- 25 mcg mcg tri-mili oral tablet 1 ACA vylibra oral tablet 1 ACA 0.18/0.215/0.25 mg- 0.25-35 mg-mcg 35 mcg (28) wera (28) oral tablet 1 ACA tri-previfem (28) 1 ACA 0.5-35 mg-mcg oral tablet 0.18/0.215/0.25 mg- wymzya fe oral 1 ACA 35 mcg (28) tablet,chewable 0.4mg-35mcg(21) tri-sprintec (28) oral 1 ACA and 75 mg (7) tablet 0.18/0.215/0.25 mg- zarah oral tablet 3- 1 ACA 35 mcg (28) 0.03 mg trivora (28) oral 1 ACA zovia 1/35e (28) oral 1 ACA tablet 50-30 (6)/75- tablet 1-35 mg-mcg 40 (5)/125-30(10)
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 184 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits zumandimine (28) 1 ACA bacitracin- 1 oral tablet 3-0.03 mg polymyxin b ophthalmic (eye) OXYTOCICS ointment 500-10,000 HEMABATE 2 unit/gram INTRAMUSCULA ciprofloxacin hcl 1 R SOLUTION 250 ophthalmic (eye) MCG/ML drops 0.3 % methergine oral 1 QL erythromycin 1 tablet 0.2 mg ophthalmic (eye) methylergonovine 1 ointment 5 mg/gram injection solution 0.2 (0.5 %) mg/ml (1 ml) gatifloxacin 1 methylergonovine 1 QL ophthalmic (eye) oral tablet 0.2 mg drops 0.5 % OXYTOCIN 2 gentak ophthalmic 1 (BULK) POWDER (eye) ointment 0.3 % (3 mg/gram) oxytocin in 0.9 % 1 sod chloride gentamicin 1 intravenous solution ophthalmic (eye) 20 unit/1000 ml drops 0.3 % oxytocin injection 1 levofloxacin 1 solution 10 unit/ml ophthalmic (eye) drops 0.5 % OPHTHALMOLOGY moxifloxacin 1 ANTIBIOTICS ophthalmic (eye) ak-poly-bac 1 drops 0.5 % ophthalmic (eye) moxifloxacin 1 ointment 500-10,000 ophthalmic (eye) unit/gram drops, viscous 0.5 % AZASITE 2 NATACYN 2 OPHTHALMIC OPHTHALMIC (EYE) DROPS 1 % (EYE) bacitracin 1 DROPS,SUSPENSI ophthalmic (eye) ON 5 % ointment 500 unit/gram
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 185 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits neomycin- 1 VIDARABINE 2 bacitracin- (BULK) POWDER polymyxin 100 % ophthalmic (eye) VIDARABINE 2 ointment 3.5-400- MONOHYDRATE 10,000 mg-unit- (BULK) POWDER unit/g 91.5 % (84.5-98.5%) neomycin- 1 BETA-BLOCKERS polymyxin- gramicidin betaxolol ophthalmic 1 ophthalmic (eye) (eye) drops 0.5 % drops 1.75 mg- carteolol ophthalmic 1 10,000 unit- (eye) drops 1 % 0.025mg/ml levobunolol 1 neo-polycin 1 ophthalmic (eye) ophthalmic (eye) drops 0.5 % ointment 3.5-400- 10,000 mg-unit- metipranolol 1 unit/g ophthalmic (eye) drops 0.3 % ofloxacin ophthalmic 1 (eye) drops 0.3 % timolol maleate 1 ophthalmic (eye) polycin ophthalmic 1 drops 0.25 %, 0.5 % (eye) ointment 500- 10,000 unit/gram timolol maleate 1 ophthalmic (eye) polymyxin b sulf- 1 drops, once daily 0.5 trimethoprim % ophthalmic (eye) drops 10,000 unit- 1 timolol maleate 1 mg/ml ophthalmic (eye) gel forming solution tobramycin 1 0.25 %, 0.5 % ophthalmic (eye) drops 0.3 % CHOLINESTERASE INHIBITOR
MIOTICS ANTIVIRALS PHOSPHOLINE 2 TRIFLURIDINE 2 IODIDE (BULK) POWDER OPHTHALMIC 100 % (EYE) DROPS trifluridine 1 0.125 % ophthalmic (eye)
drops 1 % CYCLOPLEGIC MYDRIATICS ATROPINE 2 (BULK) POWDER
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 186 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits atropine ophthalmic 1 azelastine 1 (eye) drops 1 % ophthalmic (eye) drops 0.05 % atropine ophthalmic 1 (eye) ointment 1 % balanced salt 1 intraocular solution CYCLOPENTOLA 2 TE (BULK) BEPREVE 2 ST POWDER 100 % OPHTHALMIC (EYE) DROPS 1.5 cyclopentolate 1 % ophthalmic (eye) drops 0.5 %, 1 %, 2 bioglo ophthalmic 1 % (eye) strip 1 mg homatropaire 1 biolon intraocular 1 ophthalmic (eye) syringe 10 mg/ml drops 5 % bss intraocular 1 TROPICAMIDE 2 solution (BULK) POWDER cromolyn 1 tropicamide 1 ophthalmic (eye) ophthalmic (eye) drops 4 % drops 0.5 %, 1 % CYSTARAN 2 PA; SP DIRECT ACTING MIOTICS OPHTHALMIC (EYE) DROPS 0.44 ACETYLCHOLINE 2 % CHLORIDE (BULK) POWDER DAPIPRAZOLE 2 (BULK) POWDER PILOCARPINE 2 HCL (BULK) epinastine 1 POWDER ophthalmic (eye) drops 0.05 % pilocarpine hcl 1 ophthalmic (eye) EYLEA 2 PA; SP drops 1 %, 2 %, 4 % INTRAVITREAL SOLUTION 2 PILOCARPINE 2 MG/0.05 ML NITRATE (BULK) POWDER EYLEA 2 PA; SP INTRAVITREAL MISCELLANEOUS SYRINGE 2 OPHTHALMOLOGICS MG/0.05 ML acuicyn topical 1 FLUORESCEIN 2 spray,non-aerosol (BULK) POWDER 0.01 % 100 % altacaine ophthalmic 1 (eye) drops 0.5 % You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 187 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits fluorescein- 1 OXERVATE 2 PA; SP proparacaine OPHTHALMIC ophthalmic (eye) (EYE) DROPS drops 0.25-0.5 % 0.002 % fluorescite 1 PAZEO 2 ST intravenous solution OPHTHALMIC 500 mg/5 ml (10 %) (EYE) DROPS 0.7 % ful-glo ophthalmic 1 (eye) strip 1 mg POLYVINYL 2 ALCOHOL (BULK) glostrips ophthalmic 1 POWDER 100 % (eye) strip 1 mg PROPARACAINE 2 green glo 1 (BULK) POWDER ophthalmic (eye) 100 % strip 1.5 mg proparacaine 1 HYALURONIDAS 2 ophthalmic (eye) E, BOVINE drops 0.5 % (BULK) POWDER 1 MILLION UNIT RESTASIS 2 PA; QL MULTIDOSE hypocyn topical 1 OPHTHALMIC spray,non-aerosol (EYE) DROPS 0.05 0.01 % % KETOTIFEN 2 RESTASIS 2 PA; QL FUMARATE OPHTHALMIC (BULK) POWDER (EYE) 100 % DROPPERETTE lidocaine- 1 0.05 % phenylephrn in tetracaine hcl 1 water intraocular ophthalmic (eye) solution 1-1.5 % drops 0.5 % LUXTURNA 2 PA; SP VISUDYNE 2 SP SUBRETINAL INTRAVENOUS SUSPENSION 1.5 RECON SOLN 15 X 10EXP11 VG/0.3 MG ML (FNL) XIIDRA 2 PA; QL ocucoat intraocular 1 OPHTHALMIC syringe 2 % (EYE) olopatadine 1 DROPPERETTE 5 ophthalmic (eye) % drops 0.1 %, 0.2 % NON-STEROIDAL ANTI-
INFLAMMATORY AGENTS You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 188 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits bromfenac 1 OTHER GLAUCOMA DRUGS ophthalmic (eye) bimatoprost 1 ST drops 0.09 % ophthalmic (eye) diclofenac sodium 1 drops 0.03 % ophthalmic (eye) CARBACHOL 2 drops 0.1 % (BULK) POWDER flurbiprofen sodium 1 99 % ophthalmic (eye) COMBIGAN 2 drops 0.03 % OPHTHALMIC ILEVRO 2 (EYE) DROPS 0.2- OPHTHALMIC 0.5 % (EYE) DEMECARIUM 2 DROPS,SUSPENSI BROMIDE (BULK) ON 0.3 % POWDER 100 % ketorolac 1 dorzolamide 1 ophthalmic (eye) ophthalmic (eye) drops 0.4 %, 0.5 % drops 2 % PROLENSA 2 dorzolamide-timolol 1 OPHTHALMIC (pf) ophthalmic (eye) (EYE) DROPS 0.07 dropperette 2-0.5 % % dorzolamide-timolol 1 ORAL DRUGS FOR GLAUCOMA ophthalmic (eye) ACETAZOLAMID 2 drops 22.3-6.8 E (BULK) mg/ml POWDER latanoprost 1 ST acetazolamide oral 1 ophthalmic (eye) capsule, extended drops 0.005 % release 500 mg LUMIGAN 2 ST acetazolamide oral 1 OPHTHALMIC tablet 125 mg, 250 (EYE) DROPS 0.01 mg % acetazolamide 1 miostat intraocular 1 sodium injection solution 0.01 % recon soln 500 mg physostigmine 1 METHAZOLAMID 2 salicylate injection E (BULK) solution 1 mg/ml POWDER RHOPRESSA 2 methazolamide oral 1 OPHTHALMIC tablet 25 mg, 50 mg (EYE) DROPS 0.02 % You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 189 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits travoprost 1 ST TOBRADEX ST 2 ophthalmic (eye) OPHTHALMIC drops 0.004 % (EYE) DROPS,SUSPENSI ZIOPTAN (PF) 2 ST ON 0.3-0.05 % OPHTHALMIC (EYE) tobramycin- 1 DROPPERETTE dexamethasone 0.0015 % ophthalmic (eye) drops,suspension STEROID-ANTIBIOTIC 0.3-0.1 % COMBINATIONS ZYLET 2 neomycin- 1 OPHTHALMIC bacitracin-poly-hc (EYE) ophthalmic (eye) DROPS,SUSPENSI ointment 3.5-400- ON 0.3-0.5 % 10,000 mg-unit/g- 1% STEROIDS neomycin-polymyxin 1 ALREX 2 ST b-dexameth OPHTHALMIC ophthalmic (eye) (EYE) drops,suspension DROPS,SUSPENSI 3.5mg/ml-10,000 ON 0.2 % unit/ml-0.1 % dexamethasone 1 neomycin-polymyxin 1 sodium phosphate b-dexameth ophthalmic (eye) ophthalmic (eye) drops 0.1 % ointment 3.5 mg/g- fluorometholone 1 10,000 unit/g-0.1 % ophthalmic (eye) neomycin- 1 drops,suspension 0.1 polymyxin-hc % ophthalmic (eye) INVELTYS 2 drops,suspension OPHTHALMIC 3.5-10,000-10 mg- (EYE) unit-mg/ml DROPS,SUSPENSI neo-polycin hc 1 ON 1 % ophthalmic (eye) LOTEMAX 2 ointment 3.5-400- OPHTHALMIC 10,000 mg-unit/g- (EYE) DROPS,GEL 1% 0.5 % TOBRADEX 2 OPHTHALMIC (EYE) OINTMENT 0.3-0.1 % You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 190 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits LOTEMAX 2 sulfacetamide 1 OPHTHALMIC sodium ophthalmic (EYE) OINTMENT (eye) drops 10 % 0.5 % sulfacetamide 1 LOTEMAX SM 2 sodium ophthalmic OPHTHALMIC (eye) ointment 10 % (EYE) DROPS,GEL SYMPATHOMIMETICS 0.38 % ALPHAGAN P 2 loteprednol 1 OPHTHALMIC etabonate (EYE) DROPS 0.1 ophthalmic (eye) % drops,suspension 0.5 % apraclonidine 1 ophthalmic (eye) OZURDEX 2 SP drops 0.5 % INTRAVITREAL IMPLANT 0.7 MG brimonidine 1 ophthalmic (eye) prednisolone acetate 1 drops 0.15 %, 0.2 % ophthalmic (eye) drops,suspension 1 BRIMONIDINE 2 % TARTRATE (BULK) POWDER prednisolone sodium 1 100 % phosphate ophthalmic (eye) VASOCONSTRICTOR
drops 1 % DECONGESTANTS STEROID-SULFONAMIDE PHENYLEPHRINE 2 COMBINATIONS HCL (BULK) POWDER 100 % sulfacetamide- 1 prednisolone phenylephrine hcl 1 ophthalmic (eye) ophthalmic (eye) drops 10 %-0.23 % drops 10 %, 2.5 % (0.25 %) TETRAHYDROZO 2 SULFONAMIDES LINE HCL (BULK) POWDER SULFACETAMIDE 2 SOD, MONO RESPIRATORY AND
(BULK) POWDER ALLERGY 100 % ANTIHISTAMINE / SULFACETAMIDE 2 SODIUM (BULK) ANTIALLERGENIC AGENTS POWDER adrenalin injection 1 solution 1 mg/ml, 1 mg/ml (1 ml) You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 191 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits benzonatate oral 1 desloratadine oral 1 QL capsule 100 mg, 150 tablet 5 mg mg, 200 mg desloratadine oral 1 QL BROMPHENIRAMI 2 tablet,disintegrating NE MALEATE 2.5 mg, 5 mg (BULK) POWDER dexchlorpheniramin 1 brompheniramine- 1 e maleate oral pseudoeph-dm oral solution 2 mg/5 ml syrup 2-30-10 mg/5 DEXTROMETHOR 2 ml PHAN HBR carbinoxamine 1 (BULK) POWDER maleate oral liquid 4 DIPHENHYDRAMI 2 mg/5 ml NE (BULK) carbinoxamine 1 POWDER maleate oral tablet 4 diphenhydramine hcl 1 mg injection solution 50 carbinoxamine 1 ST mg/ml maleate oral tablet 6 diphenhydramine hcl 1 mg injection syringe 50 CHLORPHENIRA 2 mg/ml MINE EPINEPHRINE 2 MALEATE(BULK) (BULK) POWDER POWDER EPINEPHRINE 2 CLEMASTINE 2 BITARTRATE FUMARATE (BULK) POWDER (BULK) POWDER epinephrine hcl in 1 clemastine oral 1 0.9 % nacl tablet 2.68 mg intravenous solution codeine-guaifenesin 1 2 mg/250 ml (8 oral liquid 10-100 mcg/ml), 8 mg/250 mg/5 ml ml (32 mcg/ml) CYPROHEPTADIN 2 epinephrine hcl in 1 E (BULK) 0.9 % nacl POWDER 100 % intravenous syringe 1 mg/10 ml (100 cyproheptadine oral 1 mcg/ml), 100 mcg/10 syrup 2 mg/5 ml ml (10 mcg/ml) cyproheptadine oral 1 tablet 4 mg
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 192 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits epinephrine hcl in 1 GUAIFENESIN 2 5% dextrose (BULK) POWDER intravenous solution 100 % 2 mg/250 ml (8 guaifenesin ac oral 1 mcg/ml), 4 mg/250 liquid 10-100 mg/5 ml (16 mcg/ml) ml epinephrine 1 QL guaifenesin dac oral 1 injection auto- syrup 30-10-100 injector 0.15 mg/0.3 mg/5 ml ml, 0.3 mg/0.3 ml hydrocodone- 1 epinephrine 1 chlorpheniramine injection solution 1 oral mg/ml, 1 mg/ml (1 suspension,extended ml) rel 12 hr 10-8 mg/5 epinephrine 1 ml injection syringe 0.1 hydrocodone- 1 mg/ml homatropine oral EPIPEN 2-PAK 2 PA; QL syrup 5-1.5 mg/5 ml INJECTION AUTO- hydrocodone- 1 INJECTOR 0.3 homatropine oral MG/0.3 ML tablet 5-1.5 mg EPIPEN 2 PA; QL hydromet oral syrup 1 INJECTION AUTO- 5-1.5 mg/5 ml INJECTOR 0.3 MG/0.3 ML HYDROXYZINE 2 HCL (BULK) EPIPEN JR 2-PAK 2 PA; QL POWDER INJECTION AUTO- INJECTOR 0.15 hydroxyzine hcl 1 MG/0.3 ML intramuscular solution 25 mg/ml, EPIPEN JR 2 PA; QL 50 mg/ml INJECTION AUTO- INJECTOR 0.15 hydroxyzine hcl oral 1 MG/0.3 ML solution 10 mg/5 ml g tussin ac oral 1 hydroxyzine hcl oral 1 liquid 10-100 mg/5 tablet 10 mg, 25 mg, ml 50 mg guaiatussin ac oral 1 HYDROXYZINE 2 liquid 10-100 mg/5 PAMOATE (BULK) ml POWDER
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 193 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits hydroxyzine 1 promethazine-dm 1 pamoate oral oral syrup 6.25-15 capsule 100 mg, 25 mg/5 ml mg, 50 mg promethazine- 1 LEVOCETIRIZINE 2 phenyleph-codeine (BULK) POWDER oral syrup 6.25-5-10 mg/5 ml LORATADINE 2 (BULK) POWDER promethazine- 1 100 % phenylephrine oral syrup 6.25-5 mg/5 maxi-tuss ac oral 1 ml liquid 10-100 mg/5 ml promethegan rectal 1 suppository 12.5 mg, m-clear wc oral 1 25 mg, 50 mg liquid 6.3-100 mg/5 ml PSEUDOEPHEDRI 2 NE HCL (BULK) phenadoz rectal 1 POWDER 100 % suppository 25 mg PYRILAMINE 2 PROMETHAZINE 2 MALEATE (BULK) (BULK) POWDER POWDER 100 % rydex oral liquid 1 promethazine 1 1.3-10-6.3 mg/5 ml injection solution 25 mg/ml, 50 mg/ml SYMJEPI 2 QL INJECTION promethazine oral 1 SYRINGE 0.15 syrup 6.25 mg/5 ml MG/0.3 ML, 0.3 promethazine oral 1 MG/0.3 ML tablet 12.5 mg, 25 TRIPELENNAMIN 2 mg, 50 mg E (BULK) promethazine rectal 1 POWDER 100 % suppository 12.5 mg, TRIPROLIDINE 2 25 mg, 50 mg HCL (BULK) promethazine vc oral 1 POWDER 100 % syrup 6.25-5 mg/5 virtussin ac oral 1 ml liquid 10-100 mg/5 promethazine- 1 ml codeine oral syrup virtussin dac oral 1 6.25-10 mg/5 ml syrup 30-10-100 mg/5 ml PULMONARY AGENTS You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 194 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits ACETYLCYSTEIN 2 albuterol sulfate oral 1 E (BULK) tablet extended POWDER release 12 hr 4 mg, 8 mg acetylcysteine 1 solution 100 mg/ml alyq oral tablet 20 1 PA; SP; QL (10 %), 200 mg/ml mg (20 %) ambrisentan oral 1 PA; SP ADEMPAS ORAL 2 PA; SP tablet 10 mg, 5 mg TABLET 0.5 MG, 1 AMINOPHYLLINE 2 MG, 1.5 MG, 2 MG, (BULK) POWDER 2.5 MG aminophylline 1 ADVAIR HFA 2 PA; QL intravenous solution INHALATION HFA 250 mg/10 ml, 500 AEROSOL mg/20 ml INHALER 115-21 MCG/ACTUATION ANORO ELLIPTA 2 QL , 230-21 INHALATION MCG/ACTUATION BLISTER WITH , 45-21 DEVICE 62.5-25 MCG/ACTUATION MCG/ACTUATION ALBUTEROL 2 ARNUITY 2 QL SULFATE (BULK) ELLIPTA POWDER INHALATION BLISTER WITH albuterol sulfate 1 QL DEVICE 100 inhalation hfa MCG/ACTUATION aerosol inhaler 90 , 200 mcg/actuation MCG/ACTUATION albuterol sulfate 1 , 50 inhalation solution MCG/ACTUATION for nebulization 0.63 ASMANEX HFA 2 QL mg/3 ml, 1.25 mg/3 INHALATION HFA ml, 2.5 mg /3 ml AEROSOL (0.083 %), 2.5 INHALER 100 mg/0.5 ml, 5 mg/ml MCG/ACTUATION albuterol sulfate oral 1 , 200 syrup 2 mg/5 ml MCG/ACTUATION , 50 albuterol sulfate oral 1 MCG/ACTUATION tablet 2 mg, 4 mg
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 195 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits ASMANEX 2 QL budesonide 1 QL TWISTHALER inhalation INHALATION suspension for AEROSOL POWDR nebulization 0.25 BREATH mg/2 ml, 0.5 mg/2 ACTIVATED 110 ml, 1 mg/2 ml MCG/ budesonide nasal 1 QL ACTUATION (30), spray,non-aerosol 220 MCG/ 32 mcg/actuation ACTUATION (120), 220 MCG/ BUDESONIDE, 2 ACTUATION (14), MICRONIZED 220 MCG/ (BULK) POWDER ACTUATION (30), 100 % 220 MCG/ caffeine-sodium 1 ACTUATION (60) benzoate injection azelastine- 1 QL solution 250 mg/ml fluticasone nasal (125 mg/ml caffeine) spray,non-aerosol CINRYZE 2 PA; SP 137-50 mcg/spray INTRAVENOUS BEVESPI 2 QL RECON SOLN 500 AEROSPHERE UNIT (5 ML) INHALATION HFA COMBIVENT 2 QL AEROSOL RESPIMAT INHALER 9-4.8 INHALATION MCG MIST 20-100 bosentan oral tablet 1 PA; SP MCG/ACTUATION 125 mg, 62.5 mg CROMOLYN 2 BREO ELLIPTA 2 PA; QL (BULK) POWDER INHALATION cromolyn inhalation 1 BLISTER WITH solution for DEVICE 100-25 nebulization 20 mg/2 MCG/DOSE, 200-25 ml MCG/DOSE DALIRESP ORAL 2 PA; QL BREZTRI 2 QL TABLET 250 MCG AEROSPHERE INHALATION HFA DALIRESP ORAL 2 PA AEROSOL TABLET 500 MCG INHALER 160-9- 4.8 MCG/ACTUATION
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 196 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits DULERA 2 PA; QL FASENRA 2 PA; SP INHALATION HFA SUBCUTANEOUS AEROSOL SYRINGE 30 INHALER 100-5 MG/ML MCG/ACTUATION FLOVENT DISKUS 2 QL , 200-5 INHALATION MCG/ACTUATION BLISTER WITH , 50-5 DEVICE 100 MCG/ACTUATION MCG/ACTUATION DYMISTA NASAL 2 QL , 250 SPRAY,NON- MCG/ACTUATION AEROSOL 137-50 , 50 MCG/SPRAY MCG/ACTUATION DYPHYLLINE 2 FLOVENT HFA 2 QL (BULK) POWDER INHALATION HFA 100 % AEROSOL INHALER 110 EPHEDRINE HCL 2 MCG/ACTUATION (BULK) POWDER , 220 EPHEDRINE 2 MCG/ACTUATION SULFATE (BULK) , 44 POWDER MCG/ACTUATION ephedrine sulfate 1 FLUNISOLIDE 2 injection solution 50 (BULK) POWDER mg/ml 100 % epinephrine hcl 1 flunisolide nasal 1 QL nasal solution 1 spray,non-aerosol mg/ml 25 mcg (0.025 %) ESBRIET ORAL 2 PA; SP; QL fluticasone 1 QL CAPSULE 267 MG propionate nasal ESBRIET ORAL 2 PA; SP; QL spray,suspension 50 TABLET 267 MG mcg/actuation ESBRIET ORAL 2 PA; SP TABLET 801 MG FASENRA PEN 2 PA; SP SUBCUTANEOUS AUTO-INJECTOR 30 MG/ML
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 197 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits FLUTICASONE 2 PA; QL ipratropium- 1 QL PROPION- albuterol inhalation SALMETEROL solution for INHALATION nebulization 0.5 mg- AEROSOL POWDR 3 mg(2.5 mg base)/3 BREATH ml ACTIVATED 113- ISOPROTERENOL 2 14 HCL (BULK) MCG/ACTUATION POWDER , 232-14 MCG/ACTUATION KALYDECO ORAL 2 PA; SP , 55-14 GRANULES IN MCG/ACTUATION PACKET 25 MG fluticasone propion- 1 PA; QL KALYDECO ORAL 2 PA; SP; QL salmeterol GRANULES IN inhalation blister PACKET 50 MG, 75 with device 100-50 MG mcg/dose, 250-50 KALYDECO ORAL 2 PA; SP; QL mcg/dose, 500-50 TABLET 150 MG mcg/dose levalbuterol hcl 1 FORMOTEROL 2 inhalation solution FUMARATE for nebulization 0.31 (BULK) POWDER mg/3 ml, 0.63 mg/3 100 % ml, 1.25 mg/0.5 ml, icatibant 1 PA; SP 1.25 mg/3 ml subcutaneous metaproterenol oral 1 syringe 30 mg/3 ml syrup 10 mg/5 ml INCRUSE 2 QL METAPROTEREN 2 ELLIPTA OL SULFATE INHALATION (BULK) POWDER BLISTER WITH DEVICE 62.5 mometasone nasal 1 QL MCG/ACTUATION spray,non-aerosol 50 mcg/actuation IPRATROPIUM 2 BROMIDE (BULK) MONTELUKAST 2 POWDER (BULK) POWDER ipratropium bromide 1 montelukast oral 1 inhalation solution granules in packet 4 0.02 % mg montelukast oral 1 tablet 10 mg
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 198 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits montelukast oral 1 PROAIR 2 QL tablet,chewable 4 RESPICLICK mg, 5 mg INHALATION AEROSOL POWDR nebusal inhalation 1 BREATH solution for ACTIVATED 90 nebulization 3 % MCG/ACTUATION NUCALA 2 PA; SP; QL PULMICORT 2 QL SUBCUTANEOUS FLEXHALER AUTO-INJECTOR INHALATION 100 MG/ML AEROSOL POWDR NUCALA 2 PA; SP; QL BREATH SUBCUTANEOUS ACTIVATED 180 RECON SOLN 100 MCG/ACTUATION MG , 90 NUCALA 2 PA; SP; QL MCG/ACTUATION SUBCUTANEOUS pulmosal inhalation 1 SYRINGE 100 solution for MG/ML nebulization 7 % OFEV ORAL 2 PA; SP; QL PULMOZYME 2 PA; SP CAPSULE 100 MG, INHALATION 150 MG SOLUTION 1 OPSUMIT ORAL 2 PA; SP MG/ML TABLET 10 MG QNASL NASAL 2 QL ORKAMBI ORAL 2 PA; SP; QL HFA AEROSOL GRANULES IN INHALER 40 PACKET 100-125 MCG/ACTUATION MG, 150-188 MG , 80 MCG/ACTUATION ORKAMBI ORAL 2 PA; SP; QL TABLET 100-125 QVAR 2 QL MG, 200-125 MG REDIHALER INHALATION HFA PERFOROMIST 2 QL AEROSOL INHALATION BREATH SOLUTION FOR ACTIVATED 40 NEBULIZATION MCG/ACTUATION 20 MCG/2 ML , 80 PROAIR HFA 2 QL MCG/ACTUATION INHALATION HFA RACEPINEPHRINE 2 AEROSOL (BULK) POWDER INHALER 90 100 % MCG/ACTUATION
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 199 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits RUCONEST 2 PA; SP STIOLTO 2 QL INTRAVENOUS RESPIMAT RECON SOLN INHALATION 2,100 UNIT MIST 2.5-2.5 MCG/ACTUATION SEREVENT 2 QL DISKUS SYMBICORT 2 PA; QL INHALATION INHALATION HFA BLISTER WITH AEROSOL DEVICE 50 INHALER 160-4.5 MCG/DOSE MCG/ACTUATION , 80-4.5 sildenafil 1 PA; SP MCG/ACTUATION (pulm.hypertension) intravenous solution SYMDEKO ORAL 2 PA; SP; QL 10 mg/12.5 ml TABLETS, SEQUENTIAL 100- sildenafil 1 PA; SP; QL 150 MG (D)/ 150 (pulm.hypertension) MG (N), 50-75 MG oral suspension for (D)/ 75 MG (N) reconstitution 10 mg/ml tadalafil (pulm. 1 PA; SP; QL hypertension) oral sildenafil 1 PA; SP; QL tablet 20 mg (pulm.hypertension) oral tablet 20 mg terbutaline oral 1 tablet 2.5 mg, 5 mg sodium chloride 1 inhalation solution terbutaline 1 for nebulization 0.9 subcutaneous %, 10 %, 3 %, 7 % solution 1 mg/ml SPIRIVA 2 QL TERBUTALINE 2 RESPIMAT SULFATE (BULK) INHALATION POWDER MIST 1.25 theochron oral tablet 1 MCG/ACTUATION extended release 12 , 2.5 hr 100 mg, 200 mg MCG/ACTUATION THEOPHYLLINE 2 SPIRIVA WITH 2 QL (BULK) POWDER HANDIHALER INHALATION CAPSULE, W/INHALATION DEVICE 18 MCG
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 200 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits theophylline in 1 TYVASO 2 PA; SP dextrose 5 % INHALATION intravenous SOLUTION FOR parenteral solution NEBULIZATION 200 mg/100 ml, 200 1.74 MG/2.9 ML mg/50 ml, 400 (0.6 MG/ML) mg/250 ml, 800 TYVASO 2 PA; SP mg/250 ml INSTITUTIONAL theophylline oral 1 START KIT elixir 80 mg/15 ml INHALATION SOLUTION FOR theophylline oral 1 NEBULIZATION solution 80 mg/15 ml 1.74 MG/2.9 ML theophylline oral 1 TYVASO REFILL 2 PA; SP tablet extended KIT INHALATION release 12 hr 300 SOLUTION FOR mg, 450 mg NEBULIZATION theophylline oral 1 1.74 MG/2.9 ML tablet extended (0.6 MG/ML) release 24 hr 400 TYVASO 2 PA; SP mg, 600 mg STARTER KIT TRACLEER ORAL 2 PA; SP INHALATION TABLET FOR SOLUTION FOR SUSPENSION 32 NEBULIZATION MG 1.74 MG/2.9 ML TRELEGY 2 QL VENTOLIN HFA 2 QL ELLIPTA INHALATION HFA INHALATION AEROSOL BLISTER WITH INHALER 90 DEVICE 100-62.5- MCG/ACTUATION 25 MCG wixela inhub 1 PA; QL TRELEGY 2 inhalation blister ELLIPTA with device 100-50 INHALATION mcg/dose, 250-50 BLISTER WITH mcg/dose, 500-50 DEVICE 200-62.5- mcg/dose 25 MCG XOLAIR 2 PA; SP; QL TRIKAFTA ORAL 2 PA; SP SUBCUTANEOUS TABLETS, RECON SOLN 150 SEQUENTIAL 100- MG 50-75 MG(D) /150 MG (N)
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 201 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits XOLAIR 2 PA; SP; QL oxybutynin chloride 1 SUBCUTANEOUS oral tablet 5 mg SYRINGE 150 oxybutynin chloride 1 MG/ML, 75 MG/0.5 oral tablet extended ML release 24hr 10 mg, YUPELRI 2 QL 15 mg, 5 mg INHALATION solifenacin oral 1 SOLUTION FOR tablet 10 mg, 5 mg NEBULIZATION 175 MCG/3 ML tolterodine oral 1 capsule,extended zafirlukast oral 1 release 24hr 2 mg, 4 tablet 10 mg, 20 mg mg zileuton oral tablet, 1 PA tolterodine oral 1 er multiphase 12 hr tablet 1 mg, 2 mg 600 mg TOVIAZ ORAL 2 UROLOGICALS TABLET ANTICHOLINERGICS / EXTENDED
ANTISPASMODICS RELEASE 24 HR 4 MG, 8 MG darifenacin oral 1 tablet extended trospium oral 1 release 24 hr 15 mg, capsule,extended 7.5 mg release 24hr 60 mg flavoxate oral tablet 1 trospium oral tablet 1 100 mg 20 mg BENIGN PROSTATIC GELNIQUE 2 QL TRANSDERMAL HYPERPLASIA(BPH) THERAPY GEL IN PACKET alfuzosin oral tablet 1 10 % (100 extended release 24 MG/GRAM) hr 10 mg MYRBETRIQ 2 dutasteride oral 1 PA ORAL TABLET capsule 0.5 mg EXTENDED RELEASE 24 HR dutasteride- 1 PA 25 MG, 50 MG tamsulosin oral capsule, er OXYBUTYNIN 2 multiphase 24 hr CHLORIDE 0.5-0.4 mg (BULK) POWDER FINASTERIDE 2 oxybutynin chloride 1 (BULK) POWDER oral syrup 5 mg/5 ml 100 %
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 202 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits finasteride oral 1 ELMIRON ORAL 2 tablet 5 mg CAPSULE 100 MG silodosin oral 1 glycine urologic 1 capsule 4 mg, 8 mg irrigation solution 1.5 % tamsulosin oral 1 capsule 0.4 mg glycine urologic 1 solution irrigation CHOLINERGIC STIMULANTS solution 1.5 % BETHANECHOL 2 hyophen oral tablet 1 CHLORIDE 81.6-0.12-10.8 mg (BULK) POWDER K-PHOS 2 bethanechol chloride 1 ORIGINAL ORAL oral tablet 10 mg, 25 TABLET,SOLUBL mg, 5 mg, 50 mg E 500 MG
MISCELLANEOUS UROLOGICALS methen-sod phos- 1 ALPROSTADIL 2 meth blue-hyos oral (BULK) POWDER tablet 81.6-40.8-0.12 100 % mg alprostadil injection 1 METHIONINE 2 solution 500 mcg/ml (BULK) POWDER AMMONIUM 2 MUSE INTRA- 2 PA; QL CHLORIDE URETHRAL (BULK) SUPPOSITORY GRANULES 1,000 MCG, 125 MCG, 250 MCG, CAVERJECT 2 PA; QL 500 MCG IMPULSE INTRACAVERNOS PENTOSAN 2 AL KIT 10 MCG, POLYSULFATE 20 MCG NA (BULK) POWDER 100 % CAVERJECT 2 PA; QL INTRACAVERNOS phosphasal oral 1 AL RECON SOLN tablet 81.6-10.8-40.8 20 MCG, 40 MCG mg CAVERJECT 2 PA; QL potassium citrate 1 INTRACAVERNOS oral tablet extended AL SYRINGE 10 release 10 meq MCG, 20 MCG (1,080 mg), 15 meq, 5 meq (540 mg) CYSTAGON ORAL 2 PA; SP CAPSULE 150 MG, 50 MG
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 203 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits RENACIDIN 2 vardenafil oral 1 ST; QL IRRIGATION tablet,disintegrating SOLUTION 1980.6 10 mg MG-59.4 MG- URINARY ANESTHETICS 980.4MG/30ML PHENAZOPYRIDI 2 SILDENAFIL 2 NE (BULK) (BULK) POWDER POWDER 100 % 100 % phenazopyridine 1 sildenafil oral tablet 1 ST; QL oral tablet 100 mg, 100 mg, 25 mg, 50 200 mg mg VITAMINS, HEMATINICS / tadalafil oral tablet 1 ST; QL 10 mg, 2.5 mg, 20 ELECTROLYTES mg, 5 mg BLOOD DERIVATIVES uretron d-s oral 1 tablet 81.6-10.8-40.8 albumin, human 25 1 mg % intravenous parenteral solution urimar-t oral tablet 1 25 % 120-0.12-10.8 mg albumin, human 5 % 1 urin ds oral tablet 1 intravenous 81.6-10.8-40.8 mg parenteral solution 5 uro-458 oral tablet 1 % 81-10.8-40.8 mg albuminar 25 % 1 urogesic-blue oral 1 intravenous tablet 81.6-40.8-0.12 parenteral solution mg 25 % uro-mp oral capsule 1 alburx (human) 25 1 118-10-40.8-36 mg % intravenous parenteral solution uryl oral tablet 81.6- 1 25 % 40.8-0.12 mg alburx (human) 5 % 1 ustell oral capsule 1 intravenous 120-0.12 mg parenteral solution 5 utira-c oral tablet 1 % 81.6-10.8-40.8 mg albutein 25 % 1 vardenafil oral 1 ST; QL intravenous tablet 10 mg, 2.5 mg, parenteral solution 20 mg, 5 mg 25 %
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 204 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits albutein 5 % 1 CALCIUM 2 intravenous GLUCON parenteral solution 5 MONOHYD % (BULK) POWDER 100 % buminate 25 % 1 intravenous calcium gluconate in 1 parenteral solution 0.9% nacl 25 % intravenous solution 1 gram/100 ml buminate 5 % 1 intravenous calcium gluconate 1 parenteral solution 5 intravenous solution % 100 mg/ml (10%) plasbumin 25 % 1 chromium chloride 1 intravenous intravenous solution parenteral solution 4 mcg/ml 25 % copper chloride 1 plasbumin 5 % 1 intravenous solution intravenous 0.4 mg/ml parenteral solution 5 effer-k oral tablet, 1 % effervescent 25 meq
ELECTROLYTES GLYCOPHOS 2 ADDAMEL N 2 INTRAVENOUS INTRAVENOUS SOLUTION 1 SOLUTION 5.33- MMOL/ML 0.34-0.54 MCG- klor-con 10 oral 1 MG-MG/ML tablet extended calcium 1 release 10 meq acetate(phosphat klor-con 8 oral 1 bind) oral capsule tablet extended 667 mg release 8 meq calcium 1 klor-con m10 oral 1 acetate(phosphat tablet,er bind) oral tablet 667 particles/crystals 10 mg meq calcium chloride 1 klor-con m15 oral 1 intravenous solution tablet,er 100 mg/ml (10 %) particles/crystals 15 calcium chloride 1 meq intravenous syringe 100 mg/ml (10 %)
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 205 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits klor-con m20 oral 1 magnesium sulfate in 1 tablet,er water intravenous particles/crystals 20 piggyback 2 gram/50 meq ml (4 %), 4 gram/100 ml (4 %), klor-con oral packet 1 4 gram/50 ml (8 %) 20 meq magnesium sulfate 1 klor-con/ef oral 1 injection solution 4 tablet, effervescent meq/ml (50 %) 25 meq magnesium sulfate 1 k-tab oral tablet 1 injection syringe 4 extended release 8 meq/ml meq MANGANESE 2 lactated ringers 1 CHLORIDE intravenous (BULK) POWDER parenteral solution 100 % lugols oral solution 1 manganese chloride 1 5 % intravenous solution MAGNESIUM 2 0.1 mg/ml CHLORIDE MANGANESE 2 (BULK) SULFATE (BULK) CRYSTALS POWDER magnesium chloride 1 manganese sulfate 1 injection solution intravenous solution 200 mg/ml (20 %) 0.1 mg/ml MAGNESIUM 2 MULTITRACE-4 2 OXIDE (BULK) CONCENTRATE POWDER 100 % INTRAVENOUS MAGNESIUM 2 SOLUTION 10 SULFATE IN D5W MCG-1 MG- 0.5 INTRAVENOUS MG-5 MG/ML PIGGYBACK 1 MULTITRACE-4 2 GRAM/100 ML INTRAVENOUS magnesium sulfate in 1 SOLUTION 4 water intravenous MCG-0.4 MG- 0.1 parenteral solution MG-1 MG/ML 20 gram/500 ml (4 %), 40 gram/1,000 ml (4 %)
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 206 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits MULTITRACE-4 2 potassium acetate 1 NEONATAL intravenous solution INTRAVENOUS 2 meq/ml SOLUTION 0.85 potassium chlorid- 1 MCG-0.1 MG - d5-0.45%nacl 25MCG-1.5MG/ML intravenous multitrace-4 1 parenteral solution pediatric 10 meq/l, 20 meq/l, intravenous solution 30 meq/l, 40 meq/l 1 mcg-0.1 mg-25 POTASSIUM 2 mcg-1 mg/ml CHLORIDE MULTITRACE-5 2 (BULK) POWDER CONCENTRATE potassium chloride 1 INTRAVENOUS in 0.9%nacl SOLUTION 10 intravenous MCG-1 MG-0.5 parenteral solution MG-60MCG- 20 meq/l, 40 meq/l 5MG/ML potassium chloride 1 MULTITRACE-5 2 in 5 % dex INTRAVENOUS intravenous SOLUTION 4-400- parenteral solution 100-20 -1000 20 meq/l, 30 meq/l, MCG/ML 40 meq/l NORMOSOL-R IN 2 potassium chloride 1 5 % DEXTROSE in lr-d5 intravenous INTRAVENOUS parenteral solution PARENTERAL 20 meq/l, 40 meq/l SOLUTION 5 % potassium chloride 1 nutrilyte intravenous 1 in water intravenous solution 25-40.6-5 piggyback 10 meq/20 ml meq/100 ml, 10 PEDITRACE 2 meq/50 ml, 20 INTRAVENOUS meq/100 ml, 20 SOLUTION 521- meq/50 ml, 30 53.7-3.6 MCG/ML meq/100 ml, 40 meq/100 ml PHOSLYRA ORAL 2 SOLUTION 667 potassium chloride 1 MG (169 MG intravenous solution CALCIUM)/5 ML 2 meq/ml POTASSIUM 2 ACETATE (BULK) POWDER 100 % You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 207 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits potassium chloride 1 POTASSIUM 2 oral capsule, GLUCONATE extended release 10 (BULK) POWDER meq, 8 meq POTASSIUM 2 potassium chloride 1 PERMANGANATE oral liquid 20 (BULK) meq/15 ml, 40 GRANULES meq/15 ml potassium phosphate 1 potassium chloride 1 m-/d-basic oral packet 20 meq intravenous solution 3 mmol/ml potassium chloride 1 oral tablet extended ringer's intravenous 1 release 10 meq, 20 parenteral solution meq, 8 meq selenium 1 potassium chloride 1 intravenous solution oral tablet,er 40 mcg/ml particles/crystals 10 SODIUM 2 meq, 20 meq ACETATE (BULK) potassium chloride- 1 POWDER 0.45 % nacl sodium acetate 1 intravenous intravenous solution parenteral solution 2 meq/ml, 4 meq/ml 20 meq/l sodium bicarbonate 1 potassium chloride- 1 in d5w intravenous d5-0.2%nacl solution 150 intravenous meq/1,000 ml parenteral solution 10 meq/l, 20 meq/l, sodium bicarbonate 1 30 meq/l, 40 meq/l intravenous solution 1 meq/ml (8.4 %), potassium chloride- 1 4.2 % d5-0.3%nacl intravenous sodium bicarbonate 1 parenteral solution intravenous syringe 20 meq/l 10 meq/10 ml (8.4 %), 4.2 % (0.5 potassium chloride- 1 meq/ml), 7.5 % (0.9 d5-0.9%nacl meq/ml), 8.4 % (1 intravenous meq/ml) parenteral solution 20 meq/l, 40 meq/l SODIUM 2 CHLORIDE (BULK) GRANULES You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 208 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits SODIUM 2 ZINC ACETATE 2 CHLORIDE DIHYDRATE (BULK) POWDER (BULK) CRYSTALS 100 % sodium chloride 0.45 1 % intravenous ZINC CHLORIDE 2 parenteral solution (BULK) 0.45 % GRANULES sodium chloride 3 % 1 zinc chloride 1 intravenous intravenous solution parenteral solution 3 1 mg/ml % ZINC SULFATE 2 sodium chloride 5 % 1 (BULK) POWDER intravenous , 100 % parenteral solution 5 zinc sulfate 1 % intravenous solution sodium chloride 1 1 mg/ml, 5 mg/ml intravenous MISCELLANEOUS NUTRITION parenteral solution 2.5 meq/ml, 4 PRODUCTS meq/ml ADVANTAGE 2 OTC SODIUM 2 WITH IRON ORAL LACTATE (BULK) POWDER 2.07-5.6 SOLUTION 60 % GRAM/100 KCAL sodium phosphate 1 AMINOSYN 10 % 2 intravenous solution INTRAVENOUS 3 mmol/ml PARENTERAL SOLUTION 10 % strong iodine oral 1 solution 5 % AMINOSYN 7 % 2 WITH TPN 2 ELECTROLYTES ELECTROLYTES INTRAVENOUS II INTRAVENOUS PARENTERAL SOLUTION 18-18- SOLUTION 7 % 5-4.5-35 MEQ/20 ML AMINOSYN 8.5 % 2 INTRAVENOUS TRACE 2 PARENTERAL ELEMENTS SOLUTION 8.5 % 4/PEDIATRIC INTRAVENOUS AMINOSYN 8.5 %- 2 SOLUTION 1 ELECTROLYTES MCG-0.1 MG-30 INTRAVENOUS MCG-0.5 MG/ML PARENTERAL SOLUTION 8.5 % You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 209 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits AMINOSYN II 10 2 AMINOSYN-RF 5.2 2 % INTRAVENOUS % INTRAVENOUS PARENTERAL PARENTERAL SOLUTION 10 % SOLUTION 5.2 % AMINOSYN II 15 2 ARGININE (L- 2 % INTRAVENOUS ARGININE) PARENTERAL (BULK) POWDER SOLUTION 15 % 100 % AMINOSYN II 7 % 2 ARGININE HCL(L- 2 INTRAVENOUS ARGININE)(BULK PARENTERAL ) POWDER 100 % SOLUTION 7 % BAL IN OIL 2 AMINOSYN II 8.5 2 INTRAMUSCULA % INTRAVENOUS R SOLUTION 100 PARENTERAL MG/ML SOLUTION 8.5 % BCAD 1 ORAL 2 OTC AMINOSYN II 8.5 2 POWDER 16.2-500 %- GRAM-KCAL/100 ELECTROLYTES G INTRAVENOUS CALCILO XD 2 OTC PARENTERAL ORAL POWDER SOLUTION 8.5 % CALCIUM 2 AMINOSYN M 3.5 2 DISODIUM % INTRAVENOUS VERSENATE PARENTERAL INJECTION SOLUTION 3.5 % SOLUTION 200 AMINOSYN-HBC 2 MG/ML 7% CLINIMIX 2 INTRAVENOUS 5%/D15W PARENTERAL SULFITE FREE SOLUTION 7 % INTRAVENOUS AMINOSYN-PF 10 2 PARENTERAL % INTRAVENOUS SOLUTION 5 % PARENTERAL CLINIMIX 2 SOLUTION 10 % 5%/D25W AMINOSYN-PF 7 2 SULFITE-FREE % (SULFITE- INTRAVENOUS FREE) PARENTERAL INTRAVENOUS SOLUTION 5 % PARENTERAL SOLUTION 7 %
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 210 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits CLINIMIX 2 CYCLINEX-1 2 OTC 4.25%/D10W SULF ORAL POWDER FREE 7.5-510 G- INTRAVENOUS KCAL/100 G PARENTERAL CYSTEINE HCL(L- 2 SOLUTION 4.25 % CYSTEINE)(BULK CLINIMIX 4.25%- 2 ) POWDER D25W SULF-FREE EDETATE 2 INTRAVENOUS CALCIUM PARENTERAL DISODIUM(BULK) SOLUTION 4.25 % POWDER 100 % CLINIMIX 5%- 2 ELECARE INFANT 2 OTC D20W(SULFITE- FORMULA ORAL FREE) POWDER 3.1-4.8- INTRAVENOUS 10.7 GRAM/100 PARENTERAL KCAL SOLUTION 5 % electrolyte-48 in d5w 1 CLINIMIX E 2 intravenous 4.25%/D10W SUL parenteral solution FREE INTRAVENOUS ENFAGROW 2 OTC PARENTERAL TODDLR SOLUTION 4.25 % TRANSITION SOY ORAL POWDER CLINIMIX E 2 3.3-4.4 GRAM/100 4.25%/D5W SULF KCAL FREE INTRAVENOUS enfamil a.r. oral 1 OTC PARENTERAL powder 2.5-5.1-11.3 SOLUTION 4.25 % gram/100 kcal CLINIMIX E 2 ENFAMIL 2 OTC 5%/D15W SULFIT ENFACARE ORAL FREE POWDER 2.8-5.3 INTRAVENOUS GRAM/100 KCAL PARENTERAL ENFAMIL 2 OTC SOLUTION 5 % GENTLEASE CLINIMIX E 2 NON-GMO ORAL 5%/D20W SULFIT POWDER 2.3-5.3 FREE GRAM/100 KCAL INTRAVENOUS PARENTERAL SOLUTION 5 %
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 211 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits ENFAMIL 2 OTC ENFAMIL 2 OTC GENTLEASE NEWBORN ORAL ORAL LIQUID 2.3- POWDER 2.1-5.3 5.3 GRAM/100 GRAM/100 KCAL KCAL ENFAMIL 2 OTC ENFAMIL 2 OTC PROSOBEE LIPIL GENTLEASE ORAL ORAL POWDER CONCENTRATE 2.3-5.3 GRAM/100 ENFAMIL 2 OTC KCAL PROSOBEE LIPIL ENFAMIL INFANT 2 OTC ORAL LIQUID NON-GMO ORAL ENFAMIL 2 OTC POWDER 2-5.3 PROSOBEE ORAL GRAM/100 KCAL POWDER 2.5-5.3 ENFAMIL INFANT 2 OTC GRAM/100 KCAL ORAL ENFAPORT ORAL 2 OTC CONCENTRATE 2- LIQUID 3.5-5.5-10 5.3 GRAM/100 GRAM/100 KCAL KCAL freamine iii 10 % 1 ENFAMIL INFANT 2 OTC intravenous ORAL LIQUID 2- parenteral solution 5.3 GRAM/100 10 % KCAL GERBER GOOD 2 OTC ENFAMIL INFANT 2 OTC START GENTLE ORAL POWDER 2- NOGMO ORAL 5.3 GRAM/100 POWDER 2.1-5.1- KCAL 11.4 GRAM/100 ENFAMIL INFANT 2 OTC KCAL ORAL POWDER IN GERBER GOOD 2 OTC PACKET 2-5.3 START GENTLE GRAM/100 KCAL ORAL LIQUID 2.2- ENFAMIL 2 OTC 5.1-11.6 GRAM/100 NEWBORN NON- KCAL GMO ORAL GERBER GOOD 2 OTC POWDER 2.1-5.3 START SOY ORAL GRAM/100 KCAL LIQUID 2.5-5.1 ENFAMIL 2 OTC GRAM/100 KCAL NEWBORN ORAL GERBER GOOD 2 OTC LIQUID 2.1-5.3 START SOY ORAL GRAM/100 KCAL POWDER 2.5-5.1 GRAM/100 KCAL
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 212 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits GERBER GS 2 OTC IONOSOL-B IN 2 GENTLEPRO 2 D5W NO-GMO ORAL INTRAVENOUS POWDER 1.9-5.1- PARENTERAL 11.9 GRAM/100 SOLUTION 5 % KCAL IONOSOL-MB IN 2 GERBER GS 2 OTC D5W GNTLPR INTRAVENOUS NOGMO(B.LACT) PARENTERAL ORAL POWDER SOLUTION 5 % 2.2-5.1-11.2 G/100 ISOLYTE S PH 7.4 2 KCAL INTRAVENOUS GLUTAREX-1 2 OTC PARENTERAL ORAL POWDER SOLUTION 15-480 G- ISOLYTE-P IN 5 % 2 KCAL/100 G DEXTROSE HCY 1 POWDER 2 OTC INTRAVENOUS ORAL POWDER PARENTERAL 16.2-500 GRAM- SOLUTION 5 % KCAL/100 G ISOLYTE-S 2 HEPATAMINE 8% 2 INTRAVENOUS INTRAVENOUS PARENTERAL PARENTERAL SOLUTION SOLUTION 8 % ISOMIL 2 OTC hetastarch 6 % in 1 ADVANCE ORAL 0.9 % nacl LIQUID intravenous solution ISOMIL DF ORAL 2 OTC 6 % LIQUID HISTIDINE HCL(L- 2 ISOMIL/IRON 2 OTC HISTID)(BULK) ORAL LIQUID POWDER I-VALEX-1 ORAL 2 OTC HOMINEX-1 2 OTC POWDER 15 ORAL POWDER GRAM-480 15-480 GRAM- KCAL/100 GRAM KCAL KETONEX-1 2 OTC intralipid 1 ORAL POWDER intravenous 15-480 G-KCAL emulsion 20 % MSUD ANALOG 2 OTC ORAL POWDER 13-475 GRAM- KCAL/100 G You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 213 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits NEPHRAMINE 5.4 2 ORNITHINE 2 % INTRAVENOUS HYDROCHLORID PARENTERAL E (BULK) SOLUTION 5.4 % POWDER 100 % NORMOSOL-M IN 2 PFD TODDLER 2 OTC 5 % DEXTROSE ORAL POWDER INTRAVENOUS 530 KCAL/100 PARENTERAL GRAM SOLUTION PLASMA-LYTE 2 NORMOSOL-R PH 2 148 7.4 INTRAVENOUS INTRAVENOUS PARENTERAL PARENTERAL SOLUTION SOLUTION PLASMA-LYTE A 2 NUTRAMIGEN 2 OTC INTRAVENOUS DHA-ARA ORAL PARENTERAL CONCENTRATE SOLUTION 2.8-5.3-10.3 plasmanate 1 GRAM/100 KCAL intravenous NUTRAMIGEN 2 OTC parenteral solution 5 DHA-ARA ORAL % LIQUID 2.8-5.3- plenamine 1 10.3 GRAM/100 intravenous KCAL parenteral solution NUTRAMIGEN 2 OTC 15 % TODDLER PREGESTIMIL 2 OTC ENFLORA-LGG ORAL LIQUID 2.8- ORAL POWDER 5.6 GRAM/ 100 2.5-4.3 GRAM/100 KCAL (5 OZ), 2.8- KCAL 5.6 GRAM/ 100 NUTRAMIGEN 2 OTC KCAL(4.2OZ) WITH ENFLORA PREGESTIMIL 2 OTC LGG ORAL ORAL POWDER POWDER 2.8-5.3- 10.3 GRAM/100 premasol 10 % 1 KCAL intravenous parenteral solution OA 1 POWDER 2 OTC 10 % ORAL POWDER 15.7-500 G- KCAL/100 G
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 214 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits PREMIUM 2 OTC SIMILAC 2 OTC INFANT ADVANCE ORAL FORMULA ORAL LIQUID 2.07-5.40- POWDER 2.1-5.3 11.2 GRAM/100 GRAM/100 KCAL KCAL PROCALAMINE 2 SIMILAC 2 OTC 3% ADVANCE ORAL INTRAVENOUS POWDER IN PARENTERAL PACKET 2.07 SOLUTION 3 % GRAM/100 KCAL(17.4 GRAM) PRODUCT 3232A 2 OTC ORAL POWDER SIMILAC 2 OTC 22-33-14.8 G-G- ADVANCE MG/100 G ORGANIC ORAL LIQUID 2.07 PRO-PHREE ORAL 2 OTC GRAM-5.4 POWDER 5.5-12.7 GRAM/100 KCAL GRAM/100 KCAL similac advance 1 OTC PROPIMEX-1 2 OTC organic oral powder ORAL POWDER 2.07 gram-5.63 15-480 G- gram/100 kcal KCAL/100 G SIMILAC 2 OTC PROSOL 20 % 2 ADVANCE WITH INTRAVENOUS IRON ORAL PARENTERAL POWDER 2.07-5.6 SOLUTION GRAM/100 KCAL RCF SOY 2 OTC similac alimentum 1 OTC PROTEIN oral powder 2.75- FORMULA BASE 5.54-10.2 gram/100 ORAL kcal CONCENTRATE SIMILAC EXPERT 2 OTC R-GENE 10 2 CARE INTRAVENOUS ALIMENTUM PARENTERAL ORAL POWDER SOLUTION 10 % 2.75-5.54-10.2 SIMILAC 2 OTC GRAM/100 KCAL ADVANCE ORAL CONCENTRATE
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 215 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits SIMILAC EXPERT 2 OTC SIMILAC 2 OTC CARE NEOSURE ORAL ALIMENTUM LIQUID 2.8-5.5- ORAL 10.1 GRAM/100 SUSPENSION 2.75- KCAL 5.54-10.2 SIMILAC PM 2 OTC GRAM/100 KCAL ORAL POWDER SIMILAC EXPERT 2 OTC SIMILAC PRO- 2 OTC CARE NEOSURE ADVANCE NON- ORAL POWDER GMO ORAL 2.8-5.5 GRAM/100 LIQUID 2.07-5.4-11 KCAL GRAM/100 KCAL SIMILAC EXPERT 2 OTC SIMILAC PRO- 2 OTC CARE ORAL SENSITIVE NON- LIQUID GMO ORAL SIMILAC FOR 2 OTC LIQUID 2.1-5.4- SPIT-UP ORAL 10.9 GRAM/100 LIQUID 2.14-5.4-11 KCAL GRAM/100 KCAL similac sensitive fuss 1 OTC SIMILAC FOR 2 OTC and gas oral SPIT-UP ORAL concentrate 2.1-5.4- POWDER 2.14-5.4- 11.1 gram/100 kcal 11 GRAM/100 SIMILAC 2 OTC KCAL SENSITIVE FUSS SIMILAC HUMAN 2 OTC AND GAS ORAL MILK FORTIFIER LIQUID 2.14-5.4- ORAL LIQUID IN 11.1 GRAM/100 PACKET 0.349-6.85 KCAL GRAM-KCAL/5 SIMILAC 2 OTC ML SENSITIVE FUSS SIMILAC HUMAN 2 OTC AND GAS ORAL MILK FORTIFIER POWDER 2.1-5.4- ORAL POWDER IN 11.1 GRAM/100 PACKET 0.25 KCAL, 2.2-5.4-11 GRAM-3.5 GRAM/100 KCAL KCAL/0.9 GRAM SIMILAC 2 OTC SIMILAC LOW- 2 OTC SENSITIVE IRON ORAL ISOMIL SOY LIQUID ORAL POWDER IN PACKET 2.45 GRAM/100 KCAL(17.6 GRAM)
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 216 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits SIMILAC 2 OTC SIMILAC TOTAL 2 OTC SENSITIVE ORAL COMFORT ORAL SUSPENSION 2.14- POWDER 2.32-5.4 5.4-10.7 G/100 GRAM/100 KCAL KCAL travasol 10 % 1 SIMILAC SOY 2 OTC intravenous ISOMIL ORAL parenteral solution LIQUID 2.45-5.46 10 % GRAM/100 KCAL TROMETHAMINE 2 SIMILAC SOY 2 OTC (BULK) POWDER ISOMIL ORAL 100 % POWDER 2.45-5.46 TROPHAMINE 10 2 GRAM/100 KCAL % INTRAVENOUS SIMILAC SPECIAL 2 OTC PARENTERAL CARE 24 ORAL SOLUTION 10 % LIQUID 3-5.43 TYREX-1 ORAL 2 OTC GRAM/100 KCAL POWDER 15-480 SIMILAC SPECIAL 2 OTC GRAM-KCAL CARE 30 ORAL TYROS 1 ORAL 2 OTC SUSPENSION 3- POWDER 16.7-500 6.61 GRAM/100 G-KCAL KCAL XLEU ANALOG 2 OTC SIMILAC 2 OTC ORAL POWDER 13 SUPPLEMENTATI GRAM-475 ON ORAL LIQUID KCAL/100 GRAM 2.07-5.4-11.3 GRAM/100 KCAL XLYS- XTRP 2 OTC ANALOG ORAL SIMILAC 2 OTC POWDER 13-475 SUPPLEMENTATI GRAM-KCAL/100 ON ORAL G POWDER 2.07-5.6- 10.8 GRAM/100 XMET ANALOG 2 OTC KCAL ORAL POWDER 13-475 G- SIMILAC TOTAL 2 OTC KCAL/100 G COMFORT NON- GMO ORAL XMTVI ANALOG 2 OTC POWDER 2.32-5.4 ORAL POWDER GRAM/100 KCAL 13-475 G- KCAL/100 G SIMILAC TOTAL 2 OTC COMFORT ORAL LIQUID 2.32-5.4 GRAM/100 KCAL You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 217 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits XPHE, XTYR 2 OTC balance b-50 (with 1 ACA; OTC ANALOG ORAL folic acid) oral POWDER 13-475 tablet 0.4 mg G-KCAL balanced b-100 1 ACA; OTC XPTM ANALOG 2 OTC complex oral tablet ORAL POWDER extended release 100 13-475 G-KCAL mg VITAMINS / HEMATINICS balanced b-100 oral 1 ACA; OTC tablet 0.4 mg AQUASOL A 2 INTRAMUSCULA balanced b-50 oral 1 ACA; OTC R SOLUTION tablet 50,000 UNIT/ML bal-care dha oral 1 ascorbic acid 1 combo pack,tablet (vitamin c) injection and cap,dr 27-1-430 solution 500 mg/ml mg ASCORBIC 2 b-complex injection 1 ACID(VITAMIN injection solution C)(BULK) 100-2-100-2-2 GRANULES 100 % mg/ml b complex 1 (with 1 ACA; OTC b-complex with 1 ACA; OTC folic acid) oral vitamin c oral tablet tablet 0.4 mg , 400-500 mcg-mg b complex 100 1 classic prenatal oral 1 ACA; OTC injection solution tablet 28 mg iron- 100-2-100-2-2 800 mcg mg/ml c-nate dha oral 1 b complex 100 oral 1 ACA; OTC capsule 28 mg iron- tablet 0.4 mg 1 mg -200 mg b complex-vitamin 1 ACA; OTC complete natal dha 1 b12 oral tablet oral combo pack 29- 1-250-200 mg b complex-vitamin c- 1 ACA; OTC folic acid oral tablet complex b-100 oral 1 ACA; OTC 400 mcg tablet extended release b-100 complex oral 1 ACA; OTC tablet extended cyanocobalamin 1 release 100 mg (vitamin b-12) injection solution balance b-100 (folic 1 ACA; OTC 1,000 mcg/ml acid) oral tablet 0.4 mg
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 218 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits CYANOCOBALA 2 fluoride (sodium) 1 ACA; OTC MIN(VIT B- oral tablet,chewable 12)(BULK) 0.25 mg(0.55 mg POWDER sod. fluoride), 0.5 mg (1.1 mg sodium daily prenatal oral 1 ACA; OTC fluorid), 1 mg (2.2 combo pack 28-800- mg sod. fluoride) 440 mg-mcg-mg fluoritab oral 1 ACA; OTC dialyvite 800 oral 1 ACA; OTC tablet,chewable 0.5 tablet 0.8 mg mg (1.1 mg sodium elite-ob oral tablet 1 fluorid), 1 mg (2.2 50 mg iron- 1.25 mg mg sod. fluoride) ERGOCALCIFERO 2 folic acid injection 1 L (VIT D2) (BULK) solution 5 mg/ml POWDER folic acid oral tablet 1 ergocalciferol 1 1 mg (vitamin d2) oral folic acid oral tablet 1 ACA; OTC capsule 1,250 mcg 400 mcg, 800 mcg (50,000 unit) folivane-ob oral 1 FERAHEME 2 PA capsule 85-1 mg INTRAVENOUS SOLUTION 510 foltabs 800 oral 1 ACA; OTC MG/17 ML (30 tablet 0.8-10-115 MG/ML) mg-mg-mcg FERRIC 2 full spectrum b- 1 ACA; OTC SUBSULFATE vitamin c oral tablet (BULK) POWDER 0.8 mg FERRIC 2 hydroxocobalamin 1 SUBSULFATE intramuscular (BULK) solution 1,000 SOLUTION 20 TO mcg/ml 22 GRAM/100 ML INFED INJECTION 2 PA fluoride (sodium) 1 ACA; OTC SOLUTION 50 oral drops 0.5 mg MG/ML (1.1 mg INFUVITE 2 sod.fluorid)/ml PEDIATRIC INTRAVENOUS SOLUTION 80 MG- 400 UNIT- 200 MCG/5 ML
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 219 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits kobee oral tablet 0.4 1 ACA; OTC multivitamin with 1 ACA; OTC mg fluoride oral tablet,chewable 0.5 kpn oral tablet 1 ACA; OTC mg ludent fluoride oral 1 ACA; OTC multivitamins with 1 ACA; OTC tablet,chewable 0.25 fluoride oral mg(0.55 mg sod. tablet,chewable 0.25 fluoride), 0.5 mg mg, 0.5 mg, 1 mg (1.1 mg sodium fluorid), 1 mg (2.2 mvc-fluoride oral 1 ACA; OTC mg sod. fluoride) tablet,chewable 0.25 mg, 0.5 mg, 1 mg m.v.i. adult 1 intravenous solution mynatal advance 1 3,300 unit- 150 oral tablet 90-1-50 mcg/10 ml mg M.V.I. PEDIATRIC 2 mynatal oral capsule 1 INTRAVENOUS 65 mg iron- 1 mg RECON SOLN 80- mynatal oral tablet 1 400-200 MG-UNIT- 90-1-50 mg MCG mynatal plus oral 1 M.V.I.-12 2 tablet 65 mg iron- 1 (WITHOUT mg VITAMIN K) INTRAVENOUS mynatal-z oral tablet 1 SOLUTION 3,300 65 mg iron- 1 mg UNIT-200 UNIT/10 mynate 90 plus oral 1 ML tablet extended m-natal plus oral 1 release 90 mg iron-1 tablet 27 mg iron- 1 mg mg NASCOBAL 2 multi-vit with 1 OTC NASAL fluoride-iron oral SPRAY,NON- drops 0.25mg AEROSOL 500 fluoride -10 mg MCG/SPRAY iron/ml natural b-100 1 ACA; OTC multi-vitamin with 1 ACA; OTC complex oral tablet fluoride oral drops 100 mg 0.25 mg/ml, 0.5 newgen oral tablet 1 mg/ml 32-1,000 mg-mcg
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 220 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits obstetrix dha oral 1 prena1 pearl oral 1 combo pack,tablet capsule,ir - delay and cap,dr 29 mg rel,biphase 30-1.4- iron-1 mg -50 mg 200 mg one daily prenatal 1 ACA; OTC prena1 true oral 1 oral combo pack 28- combo pack 30 mg 800-440 mg-mcg-mg iron- 1.4 mg-300 mg perry prenatal oral 1 ACA; OTC prenaissance oral 1 capsule 13.5-0.4 mg capsule 29-1.25-55- 325 mg pnv 29-1 oral tablet 1 29 mg iron- 1 mg prenaissance plus 1 oral capsule 28-1- pnv-dha + docusate 1 50-250 mg oral capsule 27- 1.25-55-300 mg prenatabs fa oral 1 tablet 29-1 mg pnv-dha oral capsule 1 27 mg iron-1 mg - prenatabs rx oral 1 300 mg tablet 29 mg iron- 1 mg pnv-omega oral 1 capsule 28-1-300 mg prenatal complete 1 ACA; OTC oral tablet 14 mg pnv-select oral tablet 1 iron- 400 mcg 27-1 mg prenatal formula 1 ACA; OTC pr natal 400 ec oral 1 oral tablet 28 mg combo pack,tablet iron- 800 mcg and cap,dr 29-1-400 mg prenatal low iron 1 oral tablet 27 mg pr natal 400 oral 1 iron- 1 mg combo pack 29-1- 400 mg prenatal multi-dha 1 ACA; OTC (algal oil) oral pr natal 430 ec oral 1 capsule 27mg iron- combo pack,tablet 800 mcg-250 mg and cap,dr 29-1-430 mg prenatal 1 ACA; OTC multivitamins oral pr natal 430 oral 1 tablet 28 mg iron- combo pack 29 mg 800 mcg iron-1 mg -430 mg prenatal one daily 1 ACA; OTC prena1 chew oral 1 oral tablet 27 mg tablet,chew,ir - iron- 800 mcg dr,biphase 1.4 mg prenatal oral tablet 1 ACA; OTC 28 mg iron- 800 mcg You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 221 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits prenatal plus 1 RIBOFLAVIN 2 (calcium carb) oral (VITAMIN B2) tablet 27 mg iron- 1 (BULK) POWDER mg RIBOFLAVIN 2 prenatal plus oral 1 5PHOSPHAT tablet 29 mg iron- 1 SOD(BULK) mg POWDER prenatal tablet oral 1 ACA; OTC se-natal 19 chewable 1 tablet 28 mg iron- oral tablet,chewable 800 mcg 29 mg iron- 1 mg prenatal vitamin 1 ACA; OTC se-natal-19 oral 1 oral tablet 27 mg tablet 29 mg iron- 1 iron- 0.8 mg mg prenatal vitamin 1 stress formula 600 c 1 ACA; OTC plus low iron oral oral tablet tablet 27 mg iron- 1 stress formula oral 1 ACA; OTC mg tablet prenatal vit-iron 1 ACA; OTC stress formula with 1 ACA; OTC fum-folic ac oral iron oral tablet 500 tablet 28 mg iron- mg-400 mcg- 18 mg 800 mcg iron prenatal vits96-iron 1 ACA; OTC stress formula with 1 ACA; OTC fum-folic oral tablet iron(sulf) oral tablet 27 mg iron- 800 mcg 500 mg-400 mcg- 27 prenatal-u oral 1 mg iron capsule 106.5-1 mg super b complex- 1 ACA; OTC preplus oral tablet 1 vitamin c oral tablet 27 mg iron- 1 mg super b maxi 1 ACA; OTC pretab oral tablet 1 complex oral tablet 29-1 mg 0.4 mg PYRIDOXINE 2 super quints b-50 1 ACA; OTC (BULK) POWDER oral tablet 100 % super quints oral 1 ACA; OTC pyridoxine (vitamin 1 tablet 0.4 mg b6) injection taron-c dha oral 1 solution 100 mg/ml capsule 35-1-200 mg rena-vite oral tablet 1 ACA; OTC 0.8 mg
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 222 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits taron-prex prenatal- 1 virt-nate dha oral 1 dha oral capsule 30 capsule 28 mg iron- mg iron-1.2 mg-55 1 mg -200 mg mg-265 mg virt-pn dha oral 1 thiamine hcl 1 capsule 27 mg iron- (vitamin b1) 1 mg -300 mg injection solution virt-pn plus oral 1 100 mg/ml capsule 28-1-300 mg trinatal rx 1 oral 1 vitamin b complex 1 ACA; OTC tablet 60 mg iron-1 oral tablet mg vitamin b complex- 1 ACA; OTC trinate oral tablet 28 1 folic acid oral tablet mg iron- 1 mg 0.4 mg triveen-duo dha oral 1 vitamins a,c,d and 1 ACA; OTC combo pack 29-1- fluoride oral drops 400 mg 0.25 mg fluor. (0.55 tri-vitamin with 1 ACA; OTC mg)/ml, 0.5 mg fluoride oral drops fluoride (1.1 mg)/ml 0.25 mg fluor. (0.55 vitamins b complex 1 ACA; OTC mg)/ml, 0.5 mg oral tablet fluoride (1.1 mg)/ml vp-ch-pnv oral 1 tri-vite with fluoride 1 ACA; OTC capsule 30 mg iron- oral drops 0.25 mg 1 mg -50 mg-260 mg fluor. (0.55 mg)/ml, 0.5 mg fluoride (1.1 zatean-pn dha oral 1 mg)/ml capsule 27 mg iron- 1 mg -300 mg VENOFER 2 PA INTRAVENOUS zatean-pn plus oral 1 SOLUTION 100 capsule 28-1-300 mg MG IRON/5 ML, zingiber oral tablet 1 200 MG IRON/10 1.2 mg-40 mg- 124.1 ML, 50 MG mg-100 mg IRON/2.5 ML virt-c dha oral 1 capsule 35-1-200 mg
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 223 Index
1 ACCU-CHEK SPIRIT ADDAMEL N ...... 205 1ST TIER UNILET CARTRIDGE SYS ...... 118 adefovir ...... 5 COMFORTOUCH ...... 118 ACCU-CHEK TENDER .... 119 ADEMPAS ...... 195 2 ACCU-CHEK ULTRAFLEX adenosine ...... 65 2-DEOXY-D-GLUCOSE ...... 119 adenosine (diagnostic) ...... 65 (BULK) ...... 102 ACD SOLUTION A ...... 102 ADJUSTABLE LANCING 2-IN-1 LANCET DEVICE. 118 ACD-A ...... 119 DEVICE ...... 119 2-METHOXYESTRADIOL ACE AEROSOL CLOUD adrenalin ...... 191 (BULK) ...... 102 ENHANCER ...... 119 adriamycin ...... 23 3 acebutolol ...... 66 adrucil ...... 23 3,5-DIIODOTHYRONINE ACEBUTOLOL (BULK) ..... 66 ADVAIR HFA ...... 195 (BULK) ...... 102 ACETAMINOPHEN (BULK) ADVANCED LANCING 5 ...... 51 DEVICE ...... 119 5-AMINOSALICYLIC ACID acetaminophen-caff- ADVANCED TRAVEL ...... 153 dihydrocod ...... 46 LANCETS ...... 119 A acetaminophen-codeine ...... 46 ADVANTAGE WITH IRON abacavir ...... 4 acetazolamide ...... 189 ...... 209 abacavir-lamivudine ...... 4 ACETAZOLAMIDE (BULK) ADVATE ...... 75 abacavir-lamivudine- ...... 189 ADVOCATE LANCET ..... 119 zidovudine ...... 4 acetazolamide sodium ...... 189 ADVOCATE LANCING ABELCET ...... 3 acetic acid ...... 102, 114 DEVICE ...... 119 ABILIFY MAINTENA ...... 56 ACETYLCHOLINE ADVOCATE RAPID-SAFE abiraterone ...... 23 CHLORIDE (BULK) ..... 187 LANCING ...... 119 ABRAXANE ...... 23 acetylcysteine ...... 102, 195 ADYNOVATE ...... 75 acamprosate ...... 102 ACETYLCYSTEINE (BULK) AEROCHAMBER MINI ... 119 acarbose ...... 118 ...... 195 AEROCHAMBER MV ...... 119 ACCU-CHEK COMBO acitretin ...... 85 AEROCHAMBER PLUS SYSTEM ...... 118 ACTEMRA ...... 171 FLOW-VU ...... 119 ACCU-CHEK FASTCLIX ACTEMRA ACTPEN ...... 171 AEROCHAMBER PLUS LANCET DRUM ...... 118 ACTHIB (PF) ...... 164 FLOW-VU,L MSK ...... 119 ACCU-CHEK FASTCLIX ACTHREL...... 145 AEROCHAMBER PLUS LANCING DEV ...... 118 acti-lance lancets ...... 119 FLOW-VU,M MSK ...... 119 ACCU-CHEK MULTICLIX ACTI-LANCE LANCETS . 119 AEROCHAMBER PLUS LANCET ...... 118 ACTIMMUNE ...... 162 FLOW-VU,S MSK ...... 119 ACCU-CHEK RAPID D ACTIVASE ...... 83 AEROCHAMBER PLUS Z INFUSION ...... 118 acuicyn...... 187 STAT LG MSK ...... 119 ACCU-CHEK SAFE-T-PRO acyclovir ...... 4, 5, 98 AEROCHAMBER PLUS Z ...... 118 ACYCLOVIR (BULK) ...... 4 STAT MD MSK ...... 119 ACCU-CHEK SAFE-T-PRO acyclovir sodium ...... 5 AEROCHAMBER PLUS Z PLUS ...... 118 ADACEL(TDAP STAT SM MSK ...... 119 ACCU-CHEK SOFT DEV ADOLESN/ADULT)(PF) AEROCHAMBER WITH LANCETS ...... 118 ...... 164 FLOWSIGNAL ...... 119 ACCU-CHEK SOFTCLIX ADAKVEO ...... 23 AEROCHAMBER Z-STAT LANCETS ...... 118 adapalene ...... 91 PLUS-FLW SG ...... 120 ACCU-CHEK SPIRIT adapalene-benzoyl peroxide . 91 AEROTRACH PLUS ...... 120 ADAPTER ...... 118 ADCETRIS ...... 23 AEROVENT PLUS ...... 120 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 224 AFINITOR ...... 23 allopurinol sodium ...... 170 AMINOBENZOIC ACID AFINITOR DISPERZ ...... 23 almotriptan malate ...... 41 (BULK) ...... 87 afirmelle ...... 178 alophen (bisacodyl) ...... 153 aminocaproic acid ...... 76 AFLURIA QD 2020-21(3YR aloprim...... 170 AMINOCAPROIC ACID UP)(PF) ...... 164 alosetron ...... 153 (BULK) ...... 76 AFLURIA QD 2020-21(6- ALPHA PINENE (BULK) . 102 aminophylline ...... 195 35MO)(PF) ...... 164 ALPHAGAN P ...... 191 AMINOPHYLLINE (BULK) AFLURIA QUAD 2020- ALPHANATE ...... 75 ...... 195 2021(6MO UP) ...... 165 ALPHANINE SD ...... 75 AMINOSALICYLATE AFSTYLA ...... 75 alprazolam ...... 56 SODIUM (BULK) ...... 12 a-hydrocort ...... 115 ALPRAZOLAM (BULK) .... 56 AMINOSALICYLIC ACID AIMOVIG AUTOINJECTOR alprazolam intensol...... 56 (BULK) ...... 12 ...... 41 ALPROLIX ...... 76 AMINOSALICYLIC ACID-5 AJOVY AUTOINJECTOR .. 41 alprostadil ...... 203 ...... 153 AJOVY SYRINGE ...... 41 ALPROSTADIL (BULK) .. 203 AMINOSYN 10 % ...... 209 ak-poly-bac ...... 185 ALREX ...... 190 AMINOSYN 7 % WITH albendazole ...... 11 altacaine ...... 187 ELECTROLYTES ...... 209 ALBENDAZOLE (BULK) .. 11 altavera (28) ...... 178 AMINOSYN 8.5 % ...... 209 albumin, human 25 %...... 204 ALTERNATE SITE LANCET AMINOSYN 8.5 %- albumin, human 5 %...... 204 ...... 120 ELECTROLYTES ...... 209 albuminar 25 % ...... 204 ALTERNATE SITE AMINOSYN II 10 % ...... 210 alburx (human) 25 % ...... 204 LANCING DEVICE ...... 120 AMINOSYN II 15 % ...... 210 alburx (human) 5 % ...... 204 ALUMINUM CHLORIDE AMINOSYN II 7 % ...... 210 albutein 25 % ...... 204 (BULK) ...... 87 AMINOSYN II 8.5 % ...... 210 albutein 5 % ...... 205 ALUMINUM HYDROXIDE AMINOSYN II 8.5 %- albuterol sulfate ...... 195 GEL (BULK) ...... 153 ELECTROLYTES ...... 210 ALBUTEROL SULFATE ALUMINUM, (ACETATO- AMINOSYN M 3.5 % ...... 210 (BULK) ...... 195 O)DIH(BULK) ...... 102 AMINOSYN-HBC 7% ...... 210 alclometasone ...... 98 ALUNBRIG ...... 23 AMINOSYN-PF 10 % ...... 210 alcohol pads ...... 120 alyacen 1/35 (28) ...... 178 AMINOSYN-PF 7 % ALCOHOL PREP PADS ... 120 alyacen 7/7/7 (28) ...... 178 (SULFITE-FREE) ...... 210 ALCOHOL SWABS ...... 120 alyq ...... 195 AMINOSYN-RF 5.2 % ...... 210 ALCOHOL WIPES ...... 120 amabelz ...... 173 amiodarone ...... 65 alcohol, rubbing ...... 112 amantadine hcl ...... 5 amitriptyline ...... 56 ALDOSTERONE (BULK) 115 AMANTADINE HCL (BULK) AMITRIPTYLINE (BULK) . 56 ALDURAZYME ...... 145 ...... 5 amitriptyline-chlordiazepoxide ALECENSA ...... 23 AMBISOME ...... 3 ...... 57 alendronate ...... 171 ambrisentan ...... 195 amlodipine ...... 67 alfentanil ...... 46 amcinonide ...... 98 AMLODIPINE BESYLATE ALFERON N...... 162 amethia ...... 178 (BULK) ...... 67 alfuzosin ...... 202 amethia lo ...... 178 amlodipine-atorvastatin ...... 81 ALIMTA ...... 23 amethyst (28) ...... 178 amlodipine-benazepril ...... 67 ALINIA ...... 11 amikacin ...... 12 amlodipine-olmesartan ...... 67 ALIQOPA ...... 23 AMIKACIN SULFATE amlodipine-valsartan ...... 67 aliskiren ...... 66 (BULK) ...... 12 amlodipine-valsartan-hcthiazid ALLANTOIN (BULK) ...... 87 amiloride ...... 66 ...... 67 allopurinol ...... 170 amiloride-hydrochlorothiazide AMMONIUM CHLORIDE ALLOPURINOL (BULK) . 170 ...... 67 (BULK) ...... 203
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 225 ammonium lactate ...... 88 ARALAST NP ...... 103 atovaquone-proguanil ...... 12 AMMONIUM LACTATE aranelle (28) ...... 178 atracurium ...... 44 (BULK) ...... 88 ARGININE (L-ARGININE) atropine ...... 151, 187 AMMONIUM SULFATE (BULK) ...... 210 ATROPINE (BULK) ...... 186 (BULK) ...... 103 ARGININE HCL(L- ATTAPULGITE (BULK) .. 151 amnesteem ...... 91 ARGININE)(BULK) ...... 210 aubra ...... 178 amoxapine ...... 57 ARIKAYCE ...... 12 aubra eq ...... 178 amoxicil-clarithromy-lansopraz aripiprazole ...... 57 AUGMENTIN ...... 17 ...... 160 ARISTADA ...... 57 aurovela 1.5/30 (21) ...... 178 amoxicillin ...... 17 ARISTADA INITIO...... 57 aurovela 1/20 (21) ...... 178 AMOXICILLIN (BULK) ..... 17 ARISTOSPAN INTRA- aurovela 24 fe ...... 178 amoxicillin-pot clavulanate .. 17 ARTICULAR ...... 115 aurovela fe 1.5/30 (28) ...... 178 amphetamine sulfate ...... 57 ARISTOSPAN aurovela fe 1-20 (28) ...... 178 amphotericin b ...... 3 INTRALESIONAL ...... 115 AUSTEDO ...... 43 AMPHOTERICIN B (BULK) 3 armodafinil ...... 57 AUTOJECT 2 INJECTION ampicillin ...... 17 ARMOUR THYROID ...... 150 DEVICE ...... 120 ampicillin sodium ...... 17 ARNUITY ELLIPTA ...... 195 AUTO-LANCET MINI ...... 120 ampicillin-sulbactam ...... 17 ARRANON ...... 24 AUTOLET IMPRESSION AMYTAL ...... 57 arsenic trioxide ...... 24 LANC DEV ...... 120 AMZEEQ ...... 91 ascomp with codeine ...... 46 AUTOLET LANCING anagrelide ...... 103 ascorbic acid (vitamin c) .... 218 DEVICE ...... 120 anaspaz ...... 151 ASCORBIC ACID(VITAMIN AUTOLET PLUS LANCING anastrozole ...... 23 C)(BULK) ...... 218 DEVICE ...... 120 ANASTROZOLE (BULK) .. 23 ashlyna ...... 178 AUTOPEN 1 TO 21 UNITS ANDRODERM ...... 145 ASMANEX HFA ...... 195 ...... 120 anectine...... 44 ASMANEX TWISTHALER AUTOPEN 2 TO 42 UNITS ANISINDIONE (BULK) ... 103 ...... 196 ...... 120 ANORO ELLIPTA ...... 195 aspirin ...... 51 AUTOSOFT 30 ...... 120 ANTHRALIN (BULK) ...... 85 ASPIRIN (BULK) ...... 51 AUTOSOFT 90 ...... 120 ANTICOAG CITRATE PHOS aspirin childrens ...... 51 AUTOSOFT XC INFUSION DEXTROSE ...... 103 aspirin low dose ...... 51 SET 23 ...... 120 ANTIPYRINE (BULK) ..... 103 aspirin,buffd-calcium carb-mag AUTOSOFT XC INFUSION anucort-hc ...... 153 ...... 51 SET 32 ...... 120 apexicon e ...... 98 aspirin-dipyridamole ...... 76 AUTOSOFT XC INFUSION APLISOL ...... 165 aspir-trin ...... 51 SET 43 ...... 120 APOKYN ...... 40 ASSURE HAEMOLANCE avar ...... 91 APOMORPHINE (BULK) 153 PLUS ...... 120 AVASTIN ...... 24 apraclonidine ...... 191 ASSURE LANCE ...... 120 aviane ...... 178 aprepitant ...... 153 ASSURE LANCE PLUS.... 120 avidoxy ...... 20 apri ...... 178 atazanavir...... 5 avita ...... 91 APTIVUS ...... 5 atenolol ...... 67 avo cream ...... 88 APTIVUS (WITH VITAMIN ATENOLOL (BULK) ...... 67 AVONEX ...... 162 E) ...... 5 atenolol-chlorthalidone ...... 67 AVYCAZ ...... 8 aqua care sodium chloride .. 103 ATGAM ...... 165 ayuna ...... 178 aqua care sterile water ...... 103 atomoxetine ...... 57 azacitidine ...... 24 AQUA LANCE LANCING atopavo ...... 88 AZASITE ...... 185 DEVICE ...... 120 atorvastatin ...... 81 azathioprine ...... 24 AQUASOL A ...... 218 atovaquone...... 12 AZATHIOPRINE (BULK) .. 24
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 226 azathioprine sodium ...... 24 BAVENCIO ...... 24 BD Q-SYTE MDV ADAPTER AZEDRA DOSIMETRIC .... 24 BAXDELA ...... 19 ...... 122 AZEDRA THERAPEUTIC . 24 bayer aspirin ...... 51 BD Q-SYTE SPLIT-SEPT azelaic acid ...... 91 BCAD 1 ...... 210 DEVICE ...... 122 AZELAIC ACID (BULK) ... 91 BCG VACCINE, LIVE (PF) BD REGULAR BEVEL azelastine ...... 113, 187 ...... 165 NEEDLES ...... 122 azelastine-fluticasone ...... 196 b-complex injection ...... 218 BD SAFETYGLIDE INSULIN azithromycin ...... 10, 11 b-complex with vitamin c ... 218 SYRINGE ...... 122 AZITHROMYCIN (BULK) 10 BD ALCOHOL SWABS.... 121 BD SAFETYGLIDE NEEDLE aztreonam ...... 12 BD AUTOSHIELD DUO PEN ...... 123 azurette (28)...... 178 NEEDLE ...... 121 BD SAFETYGLIDE B BD ECLIPSE ...... 121 SYRINGE ...... 123 b complex 1 (with folic acid) BD ECLIPSE LUER-LOK . 121 BD SPECIALTY USE ...... 218 BD FILTER NEEDLE 5- NEEDLES ...... 123 b complex 100 ...... 218 MICRON NOKO ...... 121 BD ULTRA FINE LANCETS b complex-vitamin b12...... 218 BD FILTER NEEDLE-5 ...... 123 b complex-vitamin c-folic acid MICRON ...... 121 BD ULTRA-FINE II ...... 218 BD INSULIN SYRINGE ... 121 LANCETS ...... 123 b-100 complex ...... 218 BD INSULIN SYRINGE BD ULTRA-FINE MICRO bacitracin ...... 12, 185 HALF UNIT ...... 121 PEN NEEDLE ...... 123 bacitracin (bulk) ...... 12 BD INSULIN SYRINGE BD ULTRA-FINE MINI PEN BACITRACIN ZN SAFETY-LOK ...... 121 NEEDLE ...... 123 MICRONIZED(BULK) ... 96 BD INSULIN SYRINGE SLIP BD ULTRA-FINE NANO BACITRACIN, TIP ...... 121 PEN NEEDLE ...... 123 MICRONIZED (BULK) .. 12 BD INSULIN SYRINGE U- BD ULTRA-FINE ORIG PEN bacitracin-polymyxin b ...... 185 500 ...... 121 NEEDLE ...... 123 baclofen ...... 44 BD INSULIN SYRINGE BD ULTRA-FINE SHORT BACLOFEN (BULK) ...... 44 ULTRA-FINE ...... 121 PEN NEEDLE ...... 123 bacteriostatic water(parabens) BD INTEGRA NEEDLE ... 121 BD VEO INSULIN SYR ...... 103 BD INTRADERMAL BEVEL HALF UNIT ...... 123 BAL IN OIL ...... 210 NEEDLES ...... 121 BD VEO INSULIN SYRINGE balance b-100 (folic acid) ... 218 BD LO-DOSE MICRO-FINE UF ...... 123 balance b-50 (with folic acid) IV ...... 122 BD YALE REGULAR ...... 218 BD LO-DOSE ULTRA-FINE BEVEL ...... 123 balanced b-100 ...... 218 ...... 122 BECLOMETHASONE balanced b-100 complex..... 218 BD MAGNI-GUIDE DIPROP (BULK) ...... 113 balanced b-50 ...... 218 SYRINGE MAGNIFI..... 122 bekyree (28) ...... 179 balanced salt ...... 187 BD MICROTAINER BELBUCA ...... 46 bal-care dha ...... 218 LANCET ...... 122 BELLADONNA ALK LEAF balsalazide ...... 153 BD NANO 2ND GEN PEN EXT (BULK) ...... 151 BALSAM PERU (BULK) ... 88 NEEDLE ...... 122 belladonna alkaloids-opium 151 BALVERSA ...... 24 BD NOKOR ADMIX BELLADONNA TINCTURE balziva (28) ...... 179 NEEDLE ...... 122 (BULK) ...... 151 BANZEL ...... 36 BD PRECISIONGLIDE ..... 122 benazepril ...... 67 BAQSIMI ...... 120 BD PRECISIONGLIDE NON- BENAZEPRIL HCL (BULK) BARACLUDE ...... 5 STERILE ...... 122 ...... 67 BARIUM SULFATE (BULK) bd pre-filled normal saline . 103 benazepril-hydrochlorothiazide ...... 103 ...... 67
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 227 BENDEKA ...... 24 bicalutamide ...... 24 BREATHERITE SPACER- BENEFIX ...... 76 BICILLIN C-R ...... 17 MASK,CHILD ...... 124 BENLYSTA ...... 171 BICILLIN L-A ...... 18 BREATHERITE SPACER- BENZALKONIUM BIKTARVY ...... 5 MASK,INFANT ...... 124 CHLORIDE (BULK) ...... 88 bimatoprost ...... 189 BREATHERITE SPACER- benzepro ...... 91 bioglo ...... 187 MASK,S.CHLD ...... 124 BENZETHONIUM biolon ...... 187 BREATHERITE VALVED CHLORIDE (BULK) ...... 88 BIOTHRAX ...... 165 MDI CHAMBER ...... 124 BENZNIDAZOLE ...... 12 bisacodyl ...... 153 BREATHERITE VALVED BENZOCAINE (BULK) ...... 93 BISACODYL (BULK)...... 153 MDI SPACER ...... 124 BENZOCAINE bisa-lax (bisacodyl) ...... 153 BREO ELLIPTA ...... 196 MICRONIZED (BULK) .. 93 BISMUTH CITRATE (BULK) bretylium tosylate ...... 65 benzonatate ...... 192 ...... 103 BREVITAL ...... 103 benzoyl peroxide ...... 91 BISMUTH BREZTRI AEROSPHERE . 196 BENZOYL PEROXIDE SUBCARBONATE (BULK) briellyn ...... 179 (BULK) ...... 91 ...... 151 BRILINTA ...... 76 benztropine ...... 40 BISMUTH SUBGALLATE brimonidine ...... 191 BENZYL BENZOATE (BULK) ...... 151 BRIMONIDINE TARTRATE (BULK) ...... 103 BISMUTH SUBNITRATE (BULK) ...... 191 BEPREVE ...... 187 (BULK) ...... 103 BRINEURA ...... 146 beser ...... 98 BISMUTH bromfenac ...... 189 BESPONSA ...... 24 SUBSALICYLATE BROMHEXINE HCL (BULK) BETAHISTINE (BULK) ..... 67 (BULK) ...... 151 ...... 103 BETAMETHASONE bisoprolol fumarate...... 67 bromocriptine ...... 40 ACET,MICRO(BULK) .. 115 bisoprolol-hydrochlorothiazide BROMOCRIPTINE (BULK) betamethasone acet,sod phos ...... 67 ...... 40 ...... 115 bivalirudin ...... 76 BROMPHENIRAMINE BETAMETHASONE bleomycin ...... 24 MALEATE (BULK) ...... 192 DIPROPION (BULK) ...... 98 BLINCYTO ...... 24 brompheniramine-pseudoeph- betamethasone dipropionate . 98 blisovi 24 fe ...... 179 dm ...... 192 BETAMETHASONE SOD blisovi fe 1.5/30 (28) ...... 179 bss ...... 187 PHOS (BULK) ...... 115 blisovi fe 1/20 (28) ...... 179 budesonide ...... 153, 196 betamethasone valerate ...... 98 BLUNT NEEDLE, BUDESONIDE, BETAMETHASONE DISPOSABLE ...... 123 MICRONIZED (BULK) 196 VALERATE (BULK) ...... 98 BOOSTRIX TDAP...... 165 bufferin ...... 51 betamethasone, augmented.. 98, bosentan ...... 196 BUFLOMEDIL (BULK) .... 103 99 BOSULIF ...... 24 BULLSEYE MINI SAFETY BETANAPHTHOL (BULK) BOTOX ...... 165 LANCETS ...... 124 ...... 103 bp 10-1 ...... 91 bumetanide ...... 67 BETASERON ...... 162 bpco ...... 88 buminate 25 % ...... 205 betaxolol ...... 67, 186 bpo ...... 91 buminate 5 % ...... 205 bethanechol chloride ...... 203 BREATHERITE MDI bupivacaine ...... 94 BETHANECHOL CHLORIDE SPACER ...... 123 BUPIVACAINE (BULK) .... 94 (BULK) ...... 203 BREATHERITE SPACER- bupivacaine (pf) ...... 94 BETHKIS ...... 12 MASK, NEO...... 123 bupivacaine-dextrose-water(pf) BEVESPI AEROSPHERE . 196 BREATHERITE SPACER- ...... 103 bexarotene ...... 24 MASK,ADULT ...... 124 bupivacaine-epinephrine ...... 94 BEXSERO ...... 165 bupivacaine-epinephrine (pf) 94
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 228 buprenorphine...... 47 CALCIUM GLUCON CARETOUCH ALCOHOL buprenorphine hcl ...... 47 MONOHYD (BULK)..... 205 PREP PAD ...... 124 BUPRENORPHINE HCL calcium gluconate ...... 205 CARETOUCH LANCING (BULK) ...... 46 calcium gluconate in 0.9% nacl DEVICE ...... 124 buprenorphine-naloxone...... 52 ...... 205 CARETOUCH TWIST bupropion hcl...... 57 CALDOLOR ...... 52 LANCET ...... 124 BUPROPION HCL (BULK) 57 camila ...... 173 CARISOPRODOL (BULK) . 44 bupropion hcl (smoking deter) CAMPHOR (BULK) ...... 88 carmustine ...... 25 ...... 112 camrese ...... 179 carteolol ...... 186 buspirone ...... 57 camrese lo ...... 179 cartia xt ...... 68 BUSPIRONE (BULK) ...... 57 candesartan ...... 67 carvedilol ...... 68 busulfan ...... 24 candesartan-hydrochlorothiazid carvedilol phosphate ...... 68 BUTALBITAL (BULK) ...... 57 ...... 68 caspofungin ...... 3 butalbital compound w/codeine candin ...... 165 CATHFLO ACTIVASE ...... 83 ...... 47 CANTHARIDIN (BULK) .... 88 CAVERJECT ...... 203 butalbital-acetaminop-caf-cod CAPASTAT ...... 12 CAVERJECT IMPULSE ... 203 ...... 47 capecitabine ...... 24 CAYSTON ...... 12 butalbital-acetaminophen ..... 47 CAPRELSA...... 24 caziant (28) ...... 179 butalbital-acetaminophen-caff CAPSAICIN (BULK) ...... 88 cefaclor ...... 8, 9 ...... 47 CAPSICUM OLEORESIN cefadroxil ...... 9 butalbital-aspirin-caffeine .... 47 (BULK) ...... 88 cefazolin ...... 9 butorphanol...... 52 captopril ...... 68 cefazolin in dextrose (iso-os) .. 9 BUTORPHANOL CAPTOPRIL (BULK) ...... 68 cefdinir ...... 9 TARTRATE (BULK) ...... 52 captopril-hydrochlorothiazide cefditoren pivoxil ...... 9 BYDUREON ...... 124 ...... 68 cefepime ...... 9 BYDUREON BCISE ...... 124 CARAC ...... 88 cefepime in dextrose,iso-osm . 9 BYETTA ...... 124 CARBACHOL (BULK) ..... 189 cefixime ...... 9 BYSTOLIC ...... 67 CARBAGLU ...... 104 cefotaxime ...... 9 C carbamazepine ...... 36 cefotetan ...... 9 cabergoline ...... 146 CARBAMAZEPINE (BULK) cefoxitin ...... 9 CABLIVI ...... 76 ...... 36 cefoxitin in dextrose, iso-osm . 9 CABOMETYX...... 24 CARBAMIDE PEROXIDE cefpodoxime ...... 9 CAFFEINE (BULK) ...... 103 (BULK) ...... 114 cefprozil ...... 10 caffeine citrate ...... 103 CARBAZOCHROME (BULK) ceftazidime ...... 10 caffeine-sodium benzoate ... 196 ...... 104 CEFTAZIDIME (BULK) ..... 10 CALAMINE (BULK) ...... 88 carbidopa ...... 40 CEFTAZIDIME IN D5W ..... 10 CALCILO XD ...... 210 CARBIDOPA (BULK) ...... 40 ceftriaxone ...... 10 calcipotriene ...... 85 carbidopa-levodopa ...... 40 ceftriaxone in dextrose,iso-os calcipotriene-betamethasone 85 carbidopa-levodopa- ...... 10 calcitonin (salmon) ...... 146 entacapone ...... 40 CEFTRIAXONE SODIUM calcitriol ...... 85, 146 carbinoxamine maleate ...... 192 (BULK) ...... 10 CALCITRIOL-ALMOND OIL carbocaine (pf) ...... 94 cefuroxime axetil ...... 10 (BULK) ...... 103 carboplatin ...... 24 cefuroxime sodium ...... 10 calcium acetate(phosphat bind) cardioplegic soln...... 83 celacyn ...... 88 ...... 205 CAREONE LANCING celecoxib ...... 52 calcium chloride ...... 205 DEVICE ...... 124 CELECOXIB (BULK) ...... 52 CALCIUM DISODIUM CAREONE ULTRA THIN CELONTIN ...... 36 VERSENATE...... 210 LANCET ...... 124 cem-urea ...... 88
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 229 cephalexin...... 10 CHLORPROMAZINE cladribine ...... 25 CEPROTIN (BLUE BAR) ... 76 (BULK) ...... 57 claravis ...... 91 CEPROTIN (GREEN BAR) 76 chlorthalidone ...... 68 clariscan (meglumine) ...... 104 CERDELGA...... 146 chlorzoxazone ...... 44 clarithromycin ...... 11 CEREZYME ...... 146 CHOLBAM ...... 153 CLARITHROMYCIN (BULK) CESIUM CHLORIDE CHOLESTYRAMINE ...... 11 (BULK) ...... 104 (BULK) ...... 81 classic prenatal ...... 218 CETROTIDE ...... 146 cholestyramine (with sugar) . 81 cleansing wash ...... 91 CETYLPYRIDINIUM cholestyramine light ...... 81 clearlax ...... 153 CHLORIDE(BULK) ...... 113 CHOLIN AND MG clemastine ...... 192 cevimeline ...... 104 SALICYLATE(BULK) .... 52 CLEMASTINE FUMARATE CHANTIX ...... 112 choline,magnesium salicylate (BULK) ...... 192 CHANTIX CONTINUING ...... 52 CLEMIZOLE HCL (BULK) MONTH BOX ...... 112 CHOR GONADOTROPIN, ...... 104 CHANTIX STARTING HUM (BULK) ...... 146 CLENPIQ ...... 154 MONTH BOX ...... 112 chromium chloride ...... 205 CLEO 90 INFUSION SET 24 charlotte 24 fe ...... 179 CHYMOTRYPSIN (BULK) ...... 124 chateal (28) ...... 179 ...... 102 CLEO 90 INFUSION SET 31 chateal eq (28) ...... 179 ciclodan ...... 97 ...... 124 CHEMET ...... 104 ciclopirox ...... 97 CLEVER CHEK LANCETS CHENODAL ...... 153 CICLOPIROX OLAMINE ...... 124 children's aspirin ...... 52 (BULK) ...... 97 CLEVER CHOICE CHLORAL HYDRATE ciclopirox-ure-camph-menth- CHAMBER-LRG MASK (BULK) ...... 57 euc ...... 97 ...... 124 CHLORAMBUCIL (BULK) 25 cidofovir ...... 5 CLEVER CHOICE CHLORAMPHENICOL cilostazol ...... 76 CHAMBER-MED MASK (BULK) ...... 12 CIMDUO ...... 5 ...... 124 CHLORAMPHENICOL cimetidine ...... 160 CLEVER CHOICE PALMITAT(BULK) ...... 12 CIMETIDINE (BULK) ...... 160 CHAMBER-SM MASK . 125 chloramphenicol sod succinate cimetidine hcl ...... 160 CLIDINIUM BROMIDE ...... 12 cinacalcet ...... 146 (BULK) ...... 151 chlordiazepoxide hcl ...... 57 CINRYZE ...... 196 clindacin etz ...... 91 chlordiazepoxide-clidinium 151 CINVANTI ...... 153 clindacin p ...... 91 CHLORHEXIDINE ciprofloxacin ...... 19 clindamycin hcl ...... 12 ACETATE (BULK) ...... 104 CIPROFLOXACIN (BULK) 19 CLINDAMYCIN HCL chlorhexidine gluconate ..... 114 ciprofloxacin hcl ... 19, 114, 185 (BULK) ...... 12 CHLORHEXIDINE ciprofloxacin in 5 % dextrose clindamycin in 5 % dextrose 13 GLUCONATE (BULK) ... 88 ...... 19 clindamycin pediatric ...... 13 chloroprocaine (pf) ...... 94 ciprofloxacin-dexamethasone clindamycin phosphate .. 13, 92, chloroquine phosphate...... 12 ...... 114 176 CHLOROQUINE cisatracurium ...... 44 CLINDAMYCIN PHOSPHATE (BULK) .... 12 cisplatin ...... 25 PHOSPHATE (BULK) .... 13 chlorothiazide ...... 68 citalopram ...... 58 clindamycin-benzoyl peroxide chlorothiazide sodium ...... 68 citrate of magnesia...... 153 ...... 92 CHLOROXINE (BULK) ..... 86 citric acid anhydrous (bulk) 104 clindamycin-tretinoin ...... 92 CHLORPHENIRAMINE citric acid monohydrate (bulk) CLINIMIX 5%/D15W MALEATE(BULK) ...... 192 ...... 104 SULFITE FREE ...... 210 chlorpromazine ...... 57, 58 citroma ...... 153
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 230 CLINIMIX 5%/D25W COAGADEX...... 76 complete natal dha ...... 218 SULFITE-FREE ...... 210 COAGUCHEK LANCETS 125 complex b-100 ...... 218 CLINIMIX 4.25%/D10W COAL TAR (BULK)...... 86 compro ...... 154 SULF FREE ...... 211 COAL TAR (CRUDE) constulose ...... 154 CLINIMIX 4.25%/D5W (BULK) ...... 86 CONTACT DETACH INFUS SULFIT FREE...... 104 COARTEM ...... 13 SET 23 ...... 125 CLINIMIX 4.25%-D25W COCAINE (BULK) ...... 94 CONTACT DETACH INFUS SULF-FREE ...... 211 CODEINE PHOSPHATE SET 32 ...... 125 CLINIMIX 5%- (BULK) ...... 47 copper chloride ...... 205 D20W(SULFITE-FREE) 211 codeine sulfate ...... 47 coremino ...... 20 CLINIMIX E 2.75%/D5W codeine-butalbital-asa-caff ... 47 CORIFACT ...... 76 SULF FREE ...... 104 codeine-guaifenesin ...... 192 CORLANOR ...... 83 CLINIMIX E 4.25%/D10W colchicine...... 170 corlopam ...... 68 SUL FREE...... 211 COLCHICINE (BULK) ..... 170 CORTICOTROPIN (BULK) CLINIMIX E 4.25%/D5W colesevelam ...... 81 ...... 115 SULF FREE ...... 211 colestipol ...... 81 cortisone ...... 115 CLINIMIX E 5%/D15W COLISTIMETHATE CORTISONE (BULK) ...... 115 SULFIT FREE...... 211 SODIUM (BULK) ...... 13 COSENTYX ...... 86 CLINIMIX E 5%/D20W colistin (colistimethate na) ... 13 COSENTYX (2 SYRINGES) SULFIT FREE...... 211 COLISTIN SULFATE ...... 86 CLIOQUINOL (BULK) ...... 13 (BULK) ...... 13 COSENTYX PEN ...... 86 clobazam...... 36 COLLAGENASE CLOS COSENTYX PEN (2 PENS) 86 clobetasol ...... 99 HIST. (BULK)...... 101 cosyntropin ...... 115 CLOBETASOL COLOR LANCETS ...... 125 COTELLIC ...... 25 PROPIONATE (BULK) .. 99 COMBIGAN ...... 189 COUMARIN (BULK) ...... 104 clobetasol-emollient ...... 99 COMBIPATCH ...... 174 covaryx ...... 174 clodan ...... 99 COMBIVENT RESPIMAT 196 covaryx h.s...... 174 clofarabine ...... 25 COMETRIQ ...... 25 CREON ...... 154 CLOFAZIMINE (BULK) .... 13 COMFORT EZ LANCETS 125 CRESEMBA ...... 3 clomiphene citrate ...... 146 COMFORT INFUSION SET CRINONE ...... 174 CLOMIPHENE CITRATE 23 ...... 125 CRIXIVAN ...... 5 (BULK) ...... 146 COMFORT INFUSION SET CROFAB ...... 165 clomipramine ...... 58 32 ...... 125 cromolyn ...... 154, 187, 196 CLOMIPRAMINE (BULK) 58 COMFORT INFUSION SET CROMOLYN (BULK) ...... 196 clonazepam ...... 37 43 ...... 125 crotan ...... 101 CLONAZEPAM (BULK) .... 37 COMFORT LANCETS ...... 125 cryoserv ...... 104 clonidine ...... 68 COMFORT SHORT INSULIN cryselle (28) ...... 179 clonidine (pf) ...... 52, 68 PUMP 32 ...... 125 CRYSVITA ...... 146 clonidine hcl ...... 58, 68 COMPACT SPACE CURITY ALCOHOL SWABS CLONIDINE HCL (BULK) 68 CHAMBER ...... 125 ...... 125 clopidogrel ...... 76 COMPACT SPACE cyanocobalamin (vitamin b-12) clorazepate dipotassium ...... 58 CHAMBER-LRG MASK ...... 218 clotrimazole ...... 3 ...... 125 CYANOCOBALAMIN(VIT CLOTRIMAZOLE (BULK) 97 COMPACT SPACE B-12)(BULK) ...... 219 clotrimazole-betamethasone . 97 CHAMBER-MED MASK cyclafem 1/35 (28) ...... 179 clovique ...... 104 ...... 125 cyclafem 7/7/7 (28) ...... 179 clozapine...... 58 COMPACT SPACE CYCLANDELATE (BULK) 68 c-nate dha ...... 218 CHAMBER-SM MASK. 125 CYCLINEX-1 ...... 211
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 231 cyclobenzaprine ...... 45 DAPIPRAZOLE (BULK) .. 187 desog-e.estradiol/e.estradiol CYCLOBENZAPRINE dapsone ...... 13, 92 ...... 179 (BULK) ...... 45 DAPSONE (BULK) ...... 13 desonide ...... 99 cyclopentolate...... 187 DAPTACEL (DTAP DESONIDE, MICRONIZED CYCLOPENTOLATE PEDIATRIC) (PF) ...... 165 (BULK) ...... 99 (BULK) ...... 187 daptomycin ...... 13 desoximetasone ...... 99 cyclophosphamide ...... 25 darifenacin ...... 202 DESOXIMETASONE, CYCLOPHOSPHAMIDE DARZALEX ...... 25 MICRO (BULK) ...... 105 (BULK) ...... 25 dasetta 1/35 (28) ...... 179 DESOXYCORTICOSTERON CYCLOSERINE (BULK) .... 13 dasetta 7/7/7 (28) ...... 179 E AC (BULK) ...... 115 cyclosporine ...... 25 daunorubicin ...... 25 desvenlafaxine succinate ...... 58 CYCLOSPORINE (BULK) . 25 daysee ...... 179 dexabliss ...... 115 cyclosporine modified ...... 25 DAYTRANA...... 58 dexamethasone ...... 116 cyproheptadine ...... 192 DDAVP ...... 146 DEXAMETHASONE AC, CYPROHEPTADINE (BULK) DEANOL BITARTRATE MICRO (BULK) ...... 115 ...... 192 (BULK) ...... 104 DEXAMETHASONE CYRAMZA ...... 25 deblitane ...... 174 ACETATE (BULK) ...... 115 cyred ...... 179 decadron ...... 115 dexamethasone intensol ...... 115 cyred eq ...... 179 decitabine...... 26 DEXAMETHASONE ISONIC CYSTADANE ...... 154 deferasirox ...... 104, 105 (BULK) ...... 115 CYSTAGON ...... 203 deferiprone...... 105 DEXAMETHASONE SOD CYSTARAN ...... 187 deferoxamine ...... 105 PHOS (BULK) ...... 116 CYSTEAMINE HCL (BULK) DEHYDROEPIANDROSTER dexamethasone sodium phos ...... 104 ONE (MICRO) ...... 146 (pf) ...... 116 CYSTEINE HCL(L- delflex-lc/1.5% dextrose ..... 105 dexamethasone sodium CYSTEINE)(BULK) ...... 211 delflex-lc/2.5% dextrose ..... 105 phosphate ...... 116, 190 cytarabine ...... 25 delflex-lc/4.25% dextrose ... 105 DEXAMETHASONE,MICRO cytarabine (pf) ...... 25 DEMECARIUM BROMIDE NIZED(BULK) ...... 116 CYTOGAM ...... 165 (BULK) ...... 189 dexamethasone-0.9 % sod. D demeclocycline ...... 20 chlor ...... 116 d10 %-0.45 % sodium chloride denta 5000 plus ...... 114 dexchlorpheniramine maleate ...... 104 dentagel ...... 114 ...... 192 d2.5 %-0.45 % sodium DEOXYCHOLIC ACID DEXCOM G4 RECEIVER 125 chloride ...... 104 (BULK) ...... 105 DEXCOM G4 RECEIVER d5 % and 0.9 % sodium DEPO-ESTRADIOL ...... 174 PEDIATRIC ...... 125 chloride ...... 104 dermacinrx prizopak ...... 94 DEXCOM G4 RECEIVER- d5 %-0.45 % sodium chloride DERMAVIEW ...... 125 SHARE (PED) ...... 125 ...... 104 DERMAVIEW II ...... 125 DEXCOM G4 RECEIVER- dacarbazine ...... 25 DESCOVY ...... 5 SHARE KIT ...... 125 dactinomycin ...... 25 desflurane ...... 105 DEXCOM G4 daily prenatal ...... 219 desipramine ...... 58 TRANSMITTER ...... 125 dalfampridine ...... 43 DESIPRAMINE HCL (BULK) DEXCOM G5 RECEIVER 125 DALIRESP ...... 196 ...... 58 DEXCOM G5 DALVANCE ...... 13 desloratadine ...... 192 TRANSMITTER ...... 125 danazol ...... 146 desmopressin ...... 146 DEXCOM G5-G4 SENSOR DANAZOL (BULK) ...... 146 DESMOPRESSIN ACETATE ...... 125 dantrolene ...... 45 (BULK) ...... 146 DEXCOM G6 RECEIVER 126 DANTROLENE (BULK) .... 45 DEXCOM G6 SENSOR ..... 126
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 232 DEXCOM G6 DICHLORACETIC ACID diphenhydramine hcl ...... 192 TRANSMITTER ...... 126 (BULK) ...... 88 DIPHENIDOL (BULK) ..... 154 DEXCOM RECEIVER ...... 126 DICHLORALPHENAZONE diphenoxylate-atropine ...... 151 dexmedetomidine ...... 58 (BULK) ...... 106 dipyridamole ...... 76 dexmedetomidine in 0.9 % nacl diclofenac potassium ...... 52 DIPYRIDAMOLE (BULK) . 76 ...... 58 diclofenac sodium... 52, 88, 189 diskets ...... 47 dexmethylphenidate ...... 58 DICLOFENAC SODIUM DISPOSABLE NEEDLES . 126 dexrazoxane hcl ...... 22 (BULK) ...... 52 DISPOSABLE POWER ..... 126 dextroamphetamine ...... 58 diclofenac-misoprostol ...... 52 disulfiram ...... 106 dextroamphetamine- dicloxacillin ...... 18 DISULFIRAM (BULK) ..... 106 amphetamine ...... 59 DICUMAROL (BULK) ...... 76 divalproex ...... 37 DEXTROMETHORPHAN dicyclomine ...... 151 DIVIGEL ...... 174 HBR (BULK) ...... 192 DICYCLOMINE (BULK) . 151 DMPS ...... 106 DEXTROSE (BULK) ...... 105 didanosine ...... 5 DMSA (BULK) ...... 106 dextrose 10 % and 0.2 % nacl DIETHYLPROPION HCL dobutamine ...... 83 ...... 105 (BULK) ...... 102 dobutamine in d5w ...... 83 dextrose 10 % in water (d10w) diflorasone ...... 99 DOCEFREZ ...... 26 ...... 105 diflunisal ...... 52 docetaxel ...... 26 dextrose 20 % in water (d20w) digitek ...... 75 DOCUSATE SODIUM ...... 105 digox ...... 75 (BULK) ...... 154 dextrose 25 % in water (d25w) digoxin ...... 75 dofetilide ...... 65 ...... 105 dihydroergotamine...... 41 donepezil ...... 43 dextrose 30 % in water (d30w) DIHYDROERGOTAMINE dopamine ...... 83 ...... 105 MESYLT(BULK) ...... 41 DOPAMINE (BULK) ...... 83 dextrose 40 % in water (d40w) DILANTIN ...... 37 dopamine in 5 % dextrose .... 83 ...... 105 DILATRATE-SR ...... 84 DOPTELET (10 TAB PACK) dextrose 5 % in ringer's ...... 105 diltiazem hcl ...... 68, 69 ...... 76 dextrose 5 % in water (d5w) DILTIAZEM HCL (BULK) . 68 DOPTELET (15 TAB PACK) ...... 105 dilt-xr ...... 69 ...... 77 dextrose 5 %-lactated ringers DILUENT FOR DOPTELET (30 TAB PACK) ...... 106 EPOPROSTENOL/FLOLA ...... 77 dextrose 5%-0.2 % sod ...... 106 dorzolamide ...... 189 chloride ...... 106 diluent for treprostinil (gly) 106 dorzolamide-timolol ...... 189 dextrose 5%-0.3 % dimenhydrinate ...... 154 dorzolamide-timolol (pf) .... 189 sod.chloride ...... 106 DIMENHYDRINATE dotti ...... 174 dextrose 50 % in water (d50w) (BULK) ...... 154 DOVATO ...... 5 ...... 106 DIMERCAPTOPROPANESU doxapram ...... 59 dextrose 70 % in water (d70w) LFONATE SOD ...... 106 doxazosin ...... 69 ...... 106 dimethyl fumarate...... 43 doxepin ...... 59, 88 DIACOMIT ...... 37 DIMETHYL SULFOXIDE DOXEPIN HCL (BULK) ..... 59 dialyvite 800 ...... 219 (BULK) ...... 106 doxercalciferol ...... 147 diazepam...... 37, 59 DINITROCHLOROBENZEN( doxorubicin ...... 26 DIAZEPAM (BULK) ...... 59 2,4)(BULK) ...... 106 doxorubicin, peg-liposomal .. 26 diazepam intensol ...... 59 DIOSGENIN (BULK) ...... 106 doxy-100 ...... 20 diazoxide ...... 126 DIPHENCYPRONE (BULK) doxycycline hyclate ...... 20 DIAZOXIDE (BULK) ...... 126 ...... 106 DOXYCYCLINE HYCLATE DIBUCAINE HCL (BULK) 94 DIPHENHYDRAMINE (BULK) ...... 20 (BULK) ...... 192 doxycycline monohydrate .... 20
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 233 DOXYLAMINE SUCCINATE EASY COMFORT eletone ...... 88 (BULK) ...... 59 ALCOHOL PAD ...... 126 eletriptan ...... 41 doxylamine-pyridoxine (vit b6) EASY COMFORT LANCETS ELIGARD ...... 26 ...... 154 ...... 126 ELIGARD (3 MONTH) ...... 26 D-PENAMINE ...... 171 EASY MINI EJECT ELIGARD (4 MONTH) ...... 26 drithocreme hp...... 86 LANCING DEVICE ...... 126 ELIGARD (6 MONTH) ...... 26 dronabinol...... 154 EASY TOUCH ALCOHOL elinest ...... 180 droperidol ...... 154 PREP PADS ...... 126 ELIQUIS ...... 77 DROPERIDOL (BULK) .... 154 EASY TOUCH LANCETS 126 ELIQUIS DVT-PE TREAT DROPLET LANCETS ...... 126 EASY TOUCH LANCING 30D START ...... 77 DROPLET LANCING DEVICE ...... 126 ELITEK ...... 22 DEVICE ...... 126 EASY TOUCH SAFETY elite-ob ...... 219 drospirenone-e.estradiol-lm.fa LANCETS ...... 126 ELMIRON ...... 203 ...... 179 EASY TOUCH TWIST ELOCTATE ...... 77 drospirenone-ethinyl estradiol LANCETS ...... 126 eluryng ...... 177 ...... 179 EASY TWIST AND CAP ELZONRIS ...... 26 DROXIA ...... 26 LANCETS ...... 126 EMBRACE LANCETS ...... 126 DUAVEE ...... 174 ec-naproxen ...... 52 EMCYT ...... 26 ducodyl (bisacodyl) ...... 154 econazole ...... 97 EMGALITY PEN ...... 42 dulcolax (magnesium ECONAZOLE NITRATE EMGALITY SYRINGE ...... 42 hydroxide) ...... 154 (BULK) ...... 97 emoquette ...... 180 DULERA ...... 197 econtra ez ...... 179 emtricitabine ...... 5 duloxetine ...... 59 econtra one-step ...... 179 emtricitabine-tenofovir (tdf) ... 5 DUPIXENT PEN ...... 88 ecotrin ...... 53 EMTRIVA ...... 6 DUPIXENT SYRINGE...... 88 ecotrin low strength ...... 53 emulsion sb ...... 88 duramorph (pf) ...... 47 EDARBI ...... 69 EMVERM ...... 13 dutasteride ...... 202 EDARBYCLOR ...... 69 enalapril maleate ...... 69 dutasteride-tamsulosin ...... 202 EDETATE CALCIUM ENALAPRIL MALEATE dvorah ...... 47 DISODIUM(BULK) ...... 211 (BULK) ...... 69 D-XYLOSE (BULK) ...... 106 EDETATE DISODIUM enalaprilat ...... 69 DYANAVEL XR ...... 59 (BULK) ...... 102 enalapril-hydrochlorothiazide DYCLONINE HCL (BULK) EDROPHONIUM CHLORIDE ...... 69 ...... 94 (BULK) ...... 45 ENBREL ...... 172 DYMISTA ...... 197 ed-spaz ...... 151 ENBREL MINI ...... 172 dy-o-derm ...... 112 EDURANT ...... 5 ENBREL SURECLICK ..... 172 DYPHYLLINE (BULK) .... 197 eemt ...... 174 endocet ...... 47 E eemt hs ...... 174 ENDOMETRIN ...... 174 e.c. prin ...... 52 efavirenz ...... 5 ENFAGROW TODDLR e.e.s. 400 ...... 11 efavirenz-emtricitabin-tenofov TRANSITION SOY ...... 211 EASIVENT HOLDING ...... 5 enfamil a.r...... 211 CHAMBER ...... 126 efavirenz-lamivu-tenofov disop ENFAMIL ENFACARE .... 211 EASIVENT MASK LARGE ...... 5 ENFAMIL GENTLEASE .. 212 ...... 126 effer-k ...... 205 ENFAMIL GENTLEASE EASIVENT MASK MEDIUM EGRIFTA SV ...... 162 NON-GMO ...... 211 ...... 126 ELAPRASE ...... 147 ENFAMIL GLUCOSE ...... 106 EASIVENT MASK SMALL ELECARE INFANT ENFAMIL INFANT ...... 212 ...... 126 FORMULA ...... 211 ENFAMIL INFANT NON- electrolyte-48 in d5w ...... 211 GMO ...... 212
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 234 ENFAMIL NEWBORN ..... 212 eprosartan ...... 69 ESTRADIOL ENFAMIL NEWBORN NON- eptifibatide ...... 77 HEMIHYD,MICRO GMO...... 212 ERAXIS(WATER DILUENT) (BULK) ...... 174 ENFAMIL PROSOBEE ..... 212 ...... 3 ESTRADIOL MICRONIZED ENFAMIL PROSOBEE LIPIL ERBITUX ...... 26 (BULK) ...... 174 ...... 212 ERGOCALCIFEROL (VIT estradiol valerate ...... 175 ENFAPORT ...... 212 D2) (BULK) ...... 219 ESTRADIOL VALERATE ENGERIX-B (PF) ...... 165 ergocalciferol (vitamin d2) . 219 (BULK) ...... 175 ENGERIX-B PEDIATRIC ergoloid ...... 59 estradiol-norethindrone acet (PF) ...... 165 ERGOLOID (BULK) ...... 59 ...... 175 enoxaparin ...... 77 ERGOTAMINE TARTRATE ESTRING ...... 175 enpresse ...... 180 (BULK) ...... 42 estrogens-methyltestosterone enskyce ...... 180 ergotamine-caffeine ...... 42 ...... 175 ENSPRYNG ...... 26 ERIVEDGE ...... 26 ESTRONE (BULK) ...... 175 ENSTILAR...... 86 ERLEADA ...... 26 eszopiclone ...... 59 entacapone ...... 40 erlotinib ...... 26 ethacrynate sodium ...... 69 entecavir ...... 6 errin ...... 174 ethacrynic acid ...... 69 ENTRESTO ...... 84 ertapenem ...... 13 ethambutol ...... 13 ENTYVIO ...... 154 ery pads...... 92 ETHAMOLIN ...... 106 enulose ...... 154 erygel ...... 92 ETHINYL ESTRADIOL EOVIST ...... 106 ery-tab ...... 11 (BULK) ...... 175 EPCLUSA ...... 6 ERYTHROCIN ...... 11 ethosuximide ...... 37 EPHEDRINE HCL (BULK) erythrocin (as stearate) ...... 11 ETHOSUXIMIDE (BULK) . 37 ...... 197 erythromycin ...... 11, 185 ETHYL ALCOHOL (BULK) ephedrine sulfate ...... 84, 197 ERYTHROMYCIN (BULK)11 ...... 106 EPHEDRINE SULFATE ERYTHROMYCIN ethyl chloride ...... 94 (BULK) ...... 197 ESTOLATE (BULK) ...... 11 ethynodiol diac-eth estradiol EPIDIOLEX ...... 37 ERYTHROMYCIN ...... 180 EPIDUO FORTE...... 92 ETHYLSUCCIN(BULK) . 11 etidronate disodium ...... 107 epinastine ...... 187 erythromycin ethylsuccinate. 11 etodolac ...... 53 epinephrine ...... 193 erythromycin with ethanol.... 92 etomidate ...... 107 EPINEPHRINE (BULK).... 192 erythromycin-benzoyl peroxide ETOMIDATE (BULK) ...... 107 EPINEPHRINE ...... 92 etonogestrel-ethinyl estradiol BITARTRATE (BULK) 192 ESBRIET ...... 197 ...... 177 epinephrine hcl ...... 197 escitalopram oxalate ...... 59 ETOPOPHOS ...... 27 epinephrine hcl in 0.9 % nacl esmolol ...... 69 etoposide ...... 27 ...... 192 esmolol in nacl (iso-osm) ..... 69 ETOPOSIDE (BULK) ...... 27 epinephrine hcl in 5% dextrose esomeprazole magnesium... 160 EUFLEXXA ...... 53 ...... 193 esomeprazole sodium ...... 160 EUGENOL (BULK) ...... 114 EPIPEN ...... 193 ESPEROCT ...... 77 euthyrox ...... 150 EPIPEN 2-PAK ...... 193 estarylla ...... 180 everolimus (antineoplastic) .. 27 EPIPEN JR ...... 193 estazolam ...... 59 everolimus EPIPEN JR 2-PAK ...... 193 estradiol ...... 174, 175 (immunosuppressive) ...... 27 epirubicin ...... 26 ESTRADIOL (BULK) ...... 174 EXEL HYPODERMIC epitol ...... 37 ESTRADIOL BENZOATE NEEDLES ...... 127 EPIVIR HBV...... 6 (BULK) ...... 174 exemestane ...... 27 eplerenone ...... 69 ESTRADIOL CYPIONATE EXTRANEAL 7.5 % ...... 107 epoprostenol (glycine) ...... 69 (BULK) ...... 174 EYLEA ...... 187
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 235 e-z ject lancets ...... 127 FIFTY50 SAFETY SEAL fludrocortisone ...... 116 e-z ject thin lancets ...... 127 LANCETS ...... 127 FLUDROCORTISONE EZ SMART LANCETS ..... 127 FILTER NEEDLES ...... 127 (BULK) ...... 116 ezetimibe ...... 81 FINACEA ...... 92 FLULAVAL QUAD 2020- ezetimibe-simvastatin ...... 81 finasteride ...... 203 2021 (PF) ...... 166 EZ-LETS ...... 127 FINASTERIDE (BULK) .... 202 flumazenil ...... 60 F FINE 30 UNIVERSAL flunisolide ...... 197 FABRAZYME ...... 147 LANCETS ...... 127 FLUNISOLIDE (BULK) .... 197 falmina (28) ...... 180 FINGERSTIX LANCETS .. 127 fluocinolone ...... 99 famciclovir ...... 6 FIRMAGON KIT W FLUOCINOLONE famotidine...... 160 DILUENT SYRINGE ...... 27 ACETONIDE (BULK) ..... 99 FAMOTIDINE (BULK) .... 160 flac otic oil ...... 114 fluocinolone acetonide oil .. 114 famotidine (pf)...... 160 flavoxate ...... 202 fluocinolone and shower cap 99 famotidine (pf)-nacl (iso-os) flecainide ...... 65 fluocinonide ...... 100 ...... 160 FLECTOR ...... 53 FLUOCINONIDE, FARXIGA ...... 127 fleet laxative (bisacodyl) .... 154 MICRONIZED(BULK) . 100 FASENRA ...... 197 FLEXICHAMBER ...... 127 fluocinonide-e ...... 100 FASENRA PEN ...... 197 FLEXICHAMBER-LG FLUORESCEIN (BULK) .. 187 fayosim ...... 180 CHILD MASK ...... 127 fluorescein-proparacaine .... 188 FC2 FEMALE CONDOM . 127 FLEXICHAMBER-SM fluorescite ...... 188 febuxostat ...... 170 ADULT MASK ...... 127 fluoride (sodium) ...... 114, 219 FEIBA NF ...... 77 FLEXICHAMBER-SM fluoritab ...... 219 felbamate ...... 37 CHILD MASK ...... 127 fluorometholone ...... 190 felodipine ...... 69 FLOLAN ...... 69 fluorouracil ...... 27, 88 fem ph ...... 177 FLOVENT DISKUS ...... 197 FLUOROURACIL (BULK) . 27 FEMCAP ...... 127 FLOVENT HFA ...... 197 fluoxetine ...... 60 femynor ...... 180 FLOW-EZE VENTED FLUOXETINE (BULK) ...... 60 fenofibrate ...... 82 NEEDLE ...... 127 fluphenazine decanoate ...... 60 fenofibrate micronized ...... 82 floxuridine ...... 27 FLUPHENAZINE fenofibrate nanocrystallized . 82 FLOXURIDINE (BULK)..... 27 DECANOATE (BULK) ... 60 fenofibric acid ...... 82 FLUAD 2020-2021 (65 YR fluphenazine hcl ...... 60 fenofibric acid (choline) ...... 82 UP)(PF) ...... 165 flurandrenolide ...... 100 fenoprofen ...... 53 FLUAD QUAD 2020-21(65Y flurazepam ...... 60 fentanyl ...... 48 UP)(PF) ...... 165 flurbiprofen ...... 53 fentanyl citrate ...... 48 FLUARIX QUAD 2020-2021 FLURBIPROFEN (BULK) .. 53 FENTANYL CITRATE (PF) ...... 166 flurbiprofen sodium ...... 189 (BULK) ...... 47 FLUBLOK QUAD 2020-2021 flutamide ...... 27 fentanyl citrate (pf) ...... 47, 48 (PF) ...... 166 FLUTICASONE PROP, fentanyl citrate (pf)-0.9%nacl FLUCELVAX QUAD 2020- MICRO (BULK) ...... 100 ...... 48 2021 ...... 166 fluticasone propionate 100, 197 FERAHEME ...... 219 FLUCELVAX QUAD 2020- FLUTICASONE FERRIC SUBSULFATE 2021 (PF) ...... 166 PROPIONATE (BULK) . 100 (BULK) ...... 219 fluconazole ...... 3 fluticasone propion-salmeterol FERRIPROX ...... 107 FLUCONAZOLE (BULK) .... 3 ...... 198 FERRIPROX (2 TIMES A fluconazole in nacl (iso-osm) . 3 FLUTICASONE PROPION- DAY) ...... 107 flucytosine ...... 3 SALMETEROL ...... 198 FETZIMA...... 59 FLUCYTOSINE (BULK) ...... 3 fluvastatin ...... 82 fludarabine ...... 27 fluvoxamine ...... 60
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 236 FLUZONE HIGHDOSE FREESTYLE TEST ...... 128 GENTAMICIN IN NACL QUAD 20-21 PF...... 166 FREESTYLE UNISTIK 2 .. 128 (ISO-OSM) ...... 13 FLUZONE QUAD 2020-2021 frovatriptan ...... 42 gentamicin sulfate (ped) (pf) 14 ...... 166 ful-glo ...... 188 gentamicin sulfate (pf) ...... 14 FLUZONE QUAD 2020-2021 full spectrum b-vitamin c ... 219 GENTIAN VIOLET (BULK) (PF) ...... 166 FULPHILA ...... 162 ...... 97 folic acid ...... 219 fulvestrant ...... 27 gentle laxative (bisacodyl) .. 155 folivane-ob ...... 219 FURAZOLIDONE (BULK). 13 gentlelax ...... 155 FOLOTYN ...... 27 furosemide ...... 70 GENVOYA ...... 6 foltabs 800 ...... 219 FUROSEMIDE (BULK) ...... 70 GERBER GOOD START fomepizole ...... 166 FUZEON ...... 6 GENTLE ...... 212 fondaparinux...... 77 fyavolv ...... 175 GERBER GOOD START FORA LANCING DEVICE FYCOMPA ...... 37 GENTLE NOGMO ...... 212 ...... 127 G GERBER GOOD START FORACARE LANCETS ... 127 g tussin ac ...... 193 SOY ...... 212 forane ...... 107 gabapentin ...... 37 GERBER GS GENTLEPRO 2 FORMOTEROL FUMARATE GABAPENTIN (BULK) ...... 37 NO-GMO ...... 213 (BULK) ...... 198 GABLOFEN ...... 45 GERBER GS GNTLPR FORTEO ...... 171 galantamine ...... 43 NOGMO(B.LACT) ...... 213 fosamprenavir ...... 6 GAMASTAN ...... 166 geri-hydrolac ...... 88 fosaprepitant ...... 154 GAMASTAN S/D ...... 166 gianvi (28) ...... 180 fosfomycin tromethamine .... 21 GAMIFANT ...... 27 GILENYA ...... 43 fosinopril ...... 69 GAMMAGARD LIQUID .. 166 GILOTRIF ...... 28 fosinopril-hydrochlorothiazide GAMMAGARD S-D (IGA < 1 GLASSIA ...... 107 ...... 69 MCG/ML) ...... 166 glatiramer ...... 43 fosphenytoin ...... 37 GAMUNEX-C...... 167 glatopa ...... 43 FRAGMIN ...... 77 ganciclovir sodium ...... 6 GLEOSTINE ...... 28 freamine iii 10 % ...... 212 ganirelix ...... 147 glimepiride ...... 128 FREESTYLE CONTROL .. 127 GARDASIL 9 (PF) ...... 167 glipizide ...... 128 FREESTYLE FREEDOM . 128 gatifloxacin ...... 185 GLIPIZIDE (BULK) ...... 128 FREESTYLE FREEDOM gavilax ...... 154 glipizide-metformin ...... 128 LITE ...... 128 gavilyte-c ...... 154 glostrips ...... 188 FREESTYLE INSULINX .. 128 gavilyte-g ...... 155 GLUCAGEN DIAGNOSTIC FREESTYLE INSULINX gavilyte-n ...... 155 KIT ...... 128 TEST STRIPS ...... 128 GAZYVA ...... 27 GLUCAGEN HYPOKIT .... 128 FREESTYLE LANCETS ... 128 GELNIQUE ...... 202 GLUCAGON (HCL) FREESTYLE LIBRE 14 DAY gemcitabine ...... 27 EMERGENCY KIT ...... 128 READER ...... 128 gemfibrozil ...... 82 GLUCAGON EMERGENCY FREESTYLE LIBRE 14 DAY GEMFIBROZIL (BULK)..... 82 KIT (HUMAN) ...... 128 SENSOR...... 128 generlac ...... 155 GLUCOCOM LANCETS .. 128 FREESTYLE LIBRE 2 gengraf ...... 27, 28 GLUCOSE KETONE READER ...... 128 GENOTROPIN ...... 162 CONTROL SOLN ...... 128 FREESTYLE LIBRE 2 GENOTROPIN MINIQUICK GLUTAREX-1 ...... 213 SENSOR...... 128 ...... 162 GLUTOL GEL ...... 107 FREESTYLE LITE METER gentak ...... 185 glyburide ...... 129 ...... 128 gentamicin ...... 14, 96, 185 GLYBURIDE (BULK) ...... 129 FREESTYLE LITE STRIPS GENTAMICIN (BULK) ...... 13 glyburide micronized ...... 129 ...... 128 gentamicin in nacl (iso-osm) 13 glyburide-metformin ...... 129
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 237 glycine urologic ...... 203 hailey fe 1.5/30 (28) ...... 180 HEXTEND ...... 107 glycine urologic solution .... 203 hailey fe 1/20 (28) ...... 180 HIBERIX (PF) ...... 167 glycolax ...... 155 HALAVEN ...... 28 hidex ...... 116 GLYCOPHOS ...... 205 halcinonide ...... 100 HISTAMINE PHOSPHATE glycopyrrolate...... 152 halobetasol propionate ...... 100 (BULK) ...... 107 GLYCOPYRROLATE haloperidol ...... 60 HISTATROL ...... 167 (BULK) ...... 151 HALOPERIDOL (BULK) ... 60 HISTIDINE HCL(L- glycopyrrolate (pf) in water 152 haloperidol decanoate ...... 60 HISTID)(BULK) ...... 213 glydo ...... 94 HALOPERIDOL HIZENTRA ...... 167 GLYXAMBI ...... 129 DECANOATE (BULK) ... 60 homatropaire ...... 187 GOJJI LANCETS ...... 129 haloperidol lactate ...... 60 HOMATROPINE GOJJI LANCING DEVICE HARVONI...... 6 METHYLBROM (BULK) ...... 129 HAVRIX (PF) ...... 167 ...... 152 GOLD SODIUM HCY 1 POWDER ...... 213 HOMINEX-1 ...... 213 THIOMALATE (BULK)172 HEALTHY ACCENTS hpr ...... 89 GONAL-F ...... 147 AUTOLET...... 129 hpr plus ...... 89 GONAL-F RFF ...... 147 HEALTHY ACCENTS hpr plus hydrogel ...... 88 GONAL-F RFF REDI-JECT UNILET LANCET ...... 129 huber safety needles (disp.) 129 ...... 147 healthylax ...... 155 HUMALOG JUNIOR GRAMICIDIN D (BULK) . 107 heather ...... 175 KWIKPEN U-100 ...... 129 granisetron (pf) ...... 155 HEMABATE ...... 185 HUMALOG KWIKPEN granisetron hcl ...... 155 HEMLIBRA ...... 78 INSULIN ...... 129 green glo ...... 188 hemmorex-hc ...... 155 HUMALOG MIX 50-50 GRISEOFULVIN (BULK) 107 HEMOFIL M HIGH ...... 78 INSULN U-100 ...... 129 griseofulvin microsize ...... 3 HEMOFIL M LOW...... 78 HUMALOG MIX 50-50 griseofulvin ultramicrosize ..... 3 HEMOFIL M MID ...... 78 KWIKPEN ...... 129 GUAIACOL ...... 88 HEMOFIL M SUPER HIGH78 HUMALOG MIX 75-25 guaiatussin ac ...... 193 hep flush-10 (pf) ...... 78 KWIKPEN ...... 130 GUAIFENESIN (BULK) ... 193 HEPAGAM B...... 167 HUMALOG MIX 75-25(U- guaifenesin ac ...... 193 heparin (porcine) ...... 78 100)INSULN ...... 130 guaifenesin dac ...... 193 HEPARIN (PORCINE) HUMALOG U-100 INSULIN GUANABENZ (BULK) ...... 70 (BULK) ...... 78 ...... 130 GUANETHIDINE SULFATE heparin (porcine) in 5 % dex 78 HUMATE-P ...... 79 (BULK) ...... 70 heparin (porcine) in nacl (pf) 78 HUMIRA ...... 172 guanfacine ...... 60, 70 heparin flush(porcine)-0.9nacl HUMIRA PEN ...... 172 guanidine ...... 60 ...... 78 HUMIRA PEN CROHNS-UC- GVOKE HYPOPEN 1-PACK heparin lock flush ...... 78 HS START ...... 172 ...... 129 heparin lock flush (porcine) . 78 HUMIRA PEN PSOR- GVOKE HYPOPEN 2-PACK heparin lockflush(porcine)(pf) UVEITS-ADOL HS ...... 172 ...... 129 ...... 78 HUMIRA(CF) ...... 172 GVOKE PFS 1-PACK heparin(porcine) in 0.45% nacl HUMIRA(CF) PEDI SYRINGE...... 129 ...... 79 CROHNS STARTER ..... 172 GVOKE PFS 2-PACK heparin, porcine (pf) ...... 79 HUMIRA(CF) PEN ...... 172 SYRINGE...... 129 HEPARIN, PORCINE (PF) . 79 HUMIRA(CF) PEN gynol ii...... 177 HEPATAMINE 8% ...... 213 CROHNS-UC-HS ...... 172 H HERCEPTIN ...... 28 HUMIRA(CF) PEN PSOR- hailey ...... 180 hetastarch 6 % in 0.9 % nacl UV-ADOL HS ...... 172 hailey 24 fe ...... 180 ...... 213
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 238 HUMULIN 70/30 U-100 hydrocortisone-iodoquinol-aloe HYPODERMIC NEEDLES INSULIN ...... 130 ...... 96 ...... 130 HUMULIN 70/30 U-100 hydrocortisone-pramoxine ... 86, HYPOLANCE AST KWIKPEN ...... 130 155 LANCING ...... 130 HUMULIN N NPH INSULIN hydromet ...... 193 HYSINGLA ER ...... 49 KWIKPEN ...... 130 hydromorphone ...... 48, 49 I HUMULIN N NPH U-100 HYDROMORPHONE ibandronate ...... 171 INSULIN ...... 130 (BULK) ...... 48 IBRANCE ...... 28 HUMULIN R REGULAR U- hydromorphone (pf) ...... 48 ibu ...... 53 100 INSULN ...... 130 hydromorphone (pf)-0.9 % ibuprofen ...... 53 HUMULIN R U-500 (CONC) nacl ...... 48 IBUPROFEN (BULK) ...... 53 INSULIN ...... 130 HYDROQUINONE (BULK) ibuprofen lysine (pf) ...... 53 HUMULIN R U-500 (CONC) ...... 89 ibuprofen-oxycodone ...... 49 KWIKPEN ...... 130 hydroxocobalamin ...... 219 ibutilide fumarate ...... 65 HYALURONIDASE, hydroxychloroquine...... 14 ic green ...... 107 BOVINE (BULK) ...... 188 HYDROXYCHLOROQUINE icatibant ...... 198 HYCAMTIN ...... 28 SULF (BULK) ...... 14 ICHTHAMMOL (BULK) .... 89 hydralazine ...... 70 hydroxyprogest(pf)(preg presv) ICLUSIG ...... 28 HYDRALAZINE HCL ...... 175 idarubicin ...... 28 (BULK) ...... 70 hydroxyprogesterone IDHIFA ...... 28 HYDRAZINE SULFATE cap(ppres) ...... 175 IDOXURIDINE (BULK) ...... 6 (BULK) ...... 107 HYDROXYPROGESTERON ifosfamide ...... 28 hydrochlorothiazide ...... 70 E CAPR(BULK)...... 175 ILARIS (PF) ...... 162 HYDROCHLOROTHIAZIDE hydroxyprogesterone caproate ILEVRO ...... 189 (BULK) ...... 70 ...... 175 imatinib ...... 28 hydrocodone bitartrate...... 48 HYDROXYPROPYL IMBRUVICA ...... 28 HYDROCODONE CELLULOSE ...... 107 IMFINZI ...... 28 BITARTRATE (BULK) .. 48 hydroxyurea ...... 28 imipenem-cilastatin ...... 14 hydrocodone-acetaminophen 48 HYDROXYUREA (BULK) 28 IMIPRAMINE (BULK) ...... 61 hydrocodone-chlorpheniramine hydroxyzine hcl ...... 193 imipramine hcl ...... 61 ...... 193 HYDROXYZINE HCL imipramine pamoate ...... 61 hydrocodone-homatropine . 193 (BULK) ...... 193 imiquimod ...... 89 hydrocodone-ibuprofen ...... 48 hydroxyzine pamoate ...... 194 IMIQUIMOD (BULK) ...... 89 hydrocortisone .... 100, 116, 155 HYDROXYZINE PAMOATE IMOGAM RABIES-HT (PF) HYDROCORTISONE (BULK) ...... 193 ...... 168 (BULK) ...... 100 hyophen ...... 203 IMOVAX RABIES VACCINE hydrocortisone acetate ...... 155 hyoscyamine sulfate ...... 152 (PF) ...... 168 HYDROCORTISONE HYOSCYAMINE SULFATE IMPAVIDO ...... 14 ACETATE (BULK) ...... 100 (BULK) ...... 152 INBRIJA ...... 41 hydrocortisone butyrate ...... 100 hyosyne ...... 152 incassia ...... 175 hydrocortisone butyr-emollient HYPERHEP B S/D ...... 167 INCONTROL ALCOHOL ...... 100 HYPERHEP B S-D PADS ...... 130 hydrocortisone valerate ...... 101 NEONATAL ...... 167 INCONTROL LANCING hydrocortisone-acetic acid.. 114 HYPERRAB (PF)...... 167 DEVICE ...... 130 hydrocortisone-iodoquinl-aloe2 HYPERRAB S/D (PF) ...... 167 INCONTROL SUPER THIN ...... 96 HYPERRHO S/D ...... 167 LANCETS ...... 130 hydrocortisone-iodoquinol ... 96 HYPERTET S/D (PF) ...... 168 INCONTROL ULTRA THIN hypocyn ...... 188 LANCETS ...... 130
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 239 INCRELEX ...... 107 IPOL ...... 168 IV PREP WIPES ...... 131 INCRUSE ELLIPTA...... 198 ipratropium bromide ... 114, 198 I-VALEX-1 ...... 213 indapamide ...... 70 IPRATROPIUM BROMIDE ivermectin ...... 14 indigo carmine ...... 107 (BULK) ...... 198 IVERMECTIN (BULK) ...... 14 indocyanine green ...... 107 ipratropium-albuterol...... 198 IXEMPRA ...... 29 INDOCYANINE GREEN irbesartan ...... 70 IXIARO (PF) ...... 168 (BULK) ...... 107 irbesartan-hydrochlorothiazide IXINITY ...... 79 indomethacin ...... 53 ...... 70 J INDOMETHACIN (BULK) 53 IRESSA ...... 28 jaimiess ...... 180 indomethacin sodium ...... 53 irinotecan ...... 28 JAKAFI ...... 29 INFANRIX (DTAP) (PF)... 168 ISENTRESS ...... 6 jantoven ...... 79 INFED ...... 219 ISENTRESS HD ...... 6 JANUMET ...... 131 INFUMORPH P/F ...... 49 isibloom ...... 180 JANUMET XR ...... 131 INFUVITE PEDIATRIC.... 219 isoflurane ...... 107 JANUVIA ...... 131 INJECT EASE LANCETS 131 ISOLYTE S PH 7.4 ...... 213 JARDIANCE ...... 131 INLYTA ...... 28 ISOLYTE-P IN 5 % jasmiel (28) ...... 180 INSPIRACHAMBER ...... 131 DEXTROSE ...... 213 jencycla ...... 175 INSPIRACHAMBER WITH ISOLYTE-S ...... 213 JENTADUETO ...... 132 MASK-LARGE ...... 131 isometh-dichloral- JENTADUETO XR ...... 132 INSPIRACHAMBER WITH acetaminophn...... 42 JEVTANA ...... 29 MASK-MED ...... 131 ISOMETHEPTENE MUCATE jinteli ...... 175 INSPIRACHAMBER WITH (BULK) ...... 42 JIVI ...... 79 MASK-SMALL ...... 131 ISOMIL ADVANCE ...... 213 jolessa ...... 180 INSTACLEAN ...... 112 ISOMIL DF ...... 213 juleber ...... 180 INSULIN SYRINGE...... 131 ISOMIL/IRON ...... 213 JULUCA ...... 6 INSULIN SYRINGE isoniazid...... 14 junel 1.5/30 (21) ...... 180 MICROFINE ...... 131 ISONIAZID (BULK) ...... 14 junel 1/20 (21) ...... 180 INSULIN SYRINGE ISOPROPAMIDE IODIDE junel fe 1.5/30 (28) ...... 180 NEEDLELESS ...... 131 (BULK) ...... 152 junel fe 1/20 (28) ...... 180 INSULIN SYRINGE- isopropyl alcohol ...... 107 junel fe 24 ...... 180 NEEDLE U-100 ...... 131 ISOPROPYL ALCOHOL .. 112 JUXTAPID ...... 82 INTELENCE ...... 6 isoproterenol hcl ...... 84 K intralipid ...... 213 ISOPROTERENOL HCL KADCYLA ...... 29 INTRON A ...... 162 (BULK) ...... 198 kaitlib fe ...... 180 introvale ...... 180 ISOSORBIDE (BULK) ...... 84 KALETRA ...... 6 INVACARE LANCETS .... 131 isosorbide dinitrate ...... 85 kalliga ...... 180 INVELTYS ...... 190 isosorbide mononitrate ...... 85 KALYDECO ...... 198 INVIRASE ...... 6 isosulfan blue ...... 107 KANAMYCIN (BULK) ...... 14 INVOKAMET ...... 131 isotretinoin ...... 92 KANJINTI ...... 29 INVOKAMET XR ...... 131 isoxsuprine...... 177 KANUMA ...... 147 INVOKANA ...... 131 ISOXSUPRINE HCL (BULK) KAOLIN (BULK) ...... 108 IODINE (BULK)...... 107 ...... 177 kariva (28) ...... 181 IODOFORM (BULK) ...... 89 isradipine ...... 70 kelnor 1/35 (28) ...... 181 IODOPEN ...... 28 ISTODAX ...... 28 kelnor 1-50 ...... 181 IODOQUINOL (BULK) ...... 14 itraconazole ...... 3 KENDALL ...... 132 IONOSOL-B IN D5W ...... 213 ITRACONAZOLE (BULK)... 3 KEPIVANCE ...... 22 IONOSOL-MB IN D5W .... 213 IV ADMINISTRATION SET ketamine ...... 108 IOPANOIC ACID (BULK) 107 ...... 131 KETAMINE (BULK) ...... 108
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 240 ketamine in 0.9 % sod chloride lamivudine-zidovudine ...... 6 levalbuterol hcl ...... 198 ...... 108 lamotrigine...... 38 LEVAMISOLE (BULK) ...... 29 ketoconazole ...... 4, 97 LAMOTRIGINE (BULK) .... 37 LEVEMIR FLEXTOUCH U- KETOCONAZOLE (BULK) . 4 LANCETS ...... 132 100 INSULN ...... 132 ketodan ...... 97 LANCETS, SUPER THIN . 132 LEVEMIR U-100 INSULIN ketodan kit ...... 97 LANCETS,THIN ...... 132 ...... 132 KETONEX-1 ...... 213 LANCETS,ULTRA THIN . 132 levetiracetam ...... 38 ketoprofen...... 53 LANCING DEVICE ...... 132 LEVETIRACETAM (BULK) KETOPROFEN (BULK) ..... 53 LANCING DEVICE WITH ...... 38 KETOPROFEN, LANCETS ...... 132 levetiracetam in nacl (iso-os) 38 MICRONIZED (BULK) .. 53 LANCING SYSTEM ...... 132 levobunolol ...... 186 ketorolac ...... 53, 54, 189 LANOXIN PEDIATRIC ...... 75 levocarnitine ...... 108 KETOROLAC (BULK) ...... 53 lansoprazole ...... 160, 161 LEVOCARNITINE (BULK) KETOTIFEN FUMARATE LANSOPRAZOLE (BULK) ...... 108 (BULK) ...... 188 ...... 160 levocarnitine (with sugar) ... 108 KEYTRUDA ...... 29 lanthanum ...... 108 LEVOCETIRIZINE (BULK) KINEVAC ...... 155 LANTUS SOLOSTAR U-100 ...... 194 kionex (with sorbitol) ...... 108 INSULIN ...... 132 LEVODOPA (BULK) ...... 41 KITABIS PAK ...... 14 LANTUS U-100 INSULIN 132 levofloxacin ...... 19, 185 klor-con ...... 206 LANZO LANCING DEVICE LEVOFLOXACIN (BULK) . 19 klor-con 10 ...... 205 ...... 132 levofloxacin in d5w ...... 19 klor-con 8 ...... 205 lapatinib ...... 29 levoleucovorin calcium ...... 22 klor-con m10 ...... 205 larin 1.5/30 (21) ...... 181 levonest (28) ...... 181 klor-con m15 ...... 205 larin 1/20 (21) ...... 181 levonorgestrel ...... 181 klor-con m20 ...... 206 larin 24 fe...... 181 levonorgestrel-ethinyl estrad klor-con/ef ...... 206 larin fe 1.5/30 (28) ...... 181 ...... 181 kobee ...... 220 larin fe 1/20 (28) ...... 181 levonorg-eth estrad triphasic KOGENATE FS ...... 79 larissia ...... 181 ...... 181 KOVALTRY ...... 79 latanoprost ...... 189 levora-28 ...... 181 K-PHOS ORIGINAL ...... 203 LATUDA...... 61 levorphanol tartrate ...... 49 kpn ...... 220 laxaclear...... 155 LEVORPHANOL KRYSTEXXA ...... 170 laxative (bisacodyl) ...... 155 TARTRATE (BULK) ...... 49 k-tab ...... 206 laxative peg 3350...... 155 levo-t ...... 150 kurvelo (28) ...... 181 layolis fe ...... 181 levothyroxine ...... 150 KUVAN ...... 147 leena 28...... 181 LEVOTHYROXINE (BULK) KYLEENA ...... 177 leflunomide ...... 172 ...... 150 KYMRIAH ...... 29 LENVIMA...... 29 levoxyl ...... 150 KYNMOBI ...... 41 lessina ...... 181 LEVSIN ...... 152 KYPROLIS ...... 29 letrozole ...... 29 LEXISCAN ...... 108 L LETROZOLE (BULK) ...... 29 LEXIVA ...... 6 l norgest/e.estradiol-e.estrad LEUCINE (BULK) ...... 108 LIBTAYO ...... 29 ...... 181 leucovorin calcium ...... 22 LICART ...... 54 labetalol ...... 70 LEUCOVORIN CALCIUM lidocaine ...... 95 LABETALOL (BULK) ...... 70 (BULK) ...... 22 lidocaine (pf) in d7.5w ...... 65 lactated ringers ...... 102, 206 LEUKERAN ...... 29 LIDOCAINE (BULK) ...... 94 lactulose ...... 155 LEUKINE ...... 163 lidocaine (pf) ...... 65, 66, 94 L-ALANINE ...... 108 leuprolide ...... 29 lidocaine hcl ...... 94, 95 lamivudine ...... 6 LEUPROLIDE (BULK) ...... 29 LIDOCAINE HCL (BULK) . 94
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 241 lidocaine hcl-hydrocortison ac LITETOUCH-LARGE MASK LUPRON DEPOT-PED ...... 30 ...... 95, 155, 156 ...... 133 LUPRON DEPOT-PED (3 lidocaine in 5 % dextrose (pf) LITETOUCH-SMALL MASK MONTH) ...... 30 ...... 66 ...... 133 LUTATHERA ...... 30 lidocaine in nacl,iso-osmo(pf) lithium carbonate ...... 61 lutera (28) ...... 182 ...... 95 LITHIUM CARBONATE luxamend ...... 89 lidocaine viscous ...... 95 (BULK) ...... 61 LUXTURNA ...... 188 lidocaine-epinephrine ...... 95 lithium citrate ...... 61 LYNPARZA ...... 30 lidocaine-epinephrine (pf) .... 95 LITHIUM CITRATE LYSODREN ...... 30 lidocaine-hydrocortisone-aloe TETRAHYD(BULK) ...... 61 LYUMJEV KWIKPEN U-100 ...... 156 LIVALO ...... 82 INSULIN ...... 133 lidocaine-phenylephrn in water lmd 10 % in 0.9 % sodium LYUMJEV KWIKPEN U-200 ...... 188 chlor ...... 108 INSULIN ...... 133 lidocaine-prilocaine ...... 95 lmd 10 % in 5 % dextrose .. 108 LYUMJEV U-100 INSULIN lido-k ...... 95 LO LOESTRIN FE ...... 181 ...... 133 lidopin...... 95 lojaimiess ...... 181 lyza ...... 175 lidopril ...... 95 LOKELMA ...... 108 M lido-sorb ...... 95 LONSURF ...... 29 m.v.i. adult ...... 220 lidozion ...... 95 LOPERAMIDE (BULK) .... 152 M.V.I. PEDIATRIC ...... 220 LIFESHIELD BLUNT lopinavir-ritonavir ...... 6 M.V.I.-12 (WITHOUT CANNULA ...... 132 LORATADINE (BULK) .... 194 VITAMIN K) ...... 220 lillow (28) ...... 181 lorazepam ...... 61 mafenide acetate ...... 96 lincomycin ...... 14 LORAZEPAM (BULK) ...... 61 magnesium chloride ...... 206 LINCOMYCIN HCL (BULK) lorazepam intensol ...... 61 MAGNESIUM CHLORIDE ...... 14 LORBRENA ...... 29 (BULK) ...... 206 lindane ...... 101 lorcet hd ...... 49 magnesium citrate ...... 156 linezolid ...... 14 loryna (28) ...... 181 MAGNESIUM CITRATE linezolid in dextrose 5% ...... 14 losartan ...... 70 (BULK) ...... 156 linezolid-0.9% sodium chloride losartan-hydrochlorothiazide 71 MAGNESIUM OXIDE ...... 14 LOTEMAX ...... 190, 191 (BULK) ...... 206 LINZESS ...... 156 LOTEMAX SM ...... 191 magnesium sulfate ...... 206 LIORESAL...... 45 loteprednol etabonate ...... 191 MAGNESIUM SULFATE liothyronine ...... 150 lovastatin ...... 82 (BULK) ...... 156 LIOTHYRONINE (BULK) 150 low-ogestrel (28) ...... 181 MAGNESIUM SULFATE IN LIPOFEN ...... 82 loxapine succinate ...... 61 D5W ...... 206 lisinopril ...... 70 lo-zumandimine (28) ...... 181 magnesium sulfate in water 206 LISINOPRIL (BULK)...... 70 lta pre-attached ...... 95 malathion ...... 101 lisinopril-hydrochlorothiazide ludent fluoride ...... 220 manganese chloride ...... 206 ...... 70 lugols ...... 96, 206 MANGANESE CHLORIDE lite coat aspirin ...... 54 LUMIGAN ...... 189 (BULK) ...... 206 LITE TOUCH LANCETS . 132 LUMIZYME ...... 147 manganese sulfate ...... 206 LITE TOUCH LANCING LUPANETA PACK (1 MANGANESE SULFATE DEVICE ...... 132 MONTH) ...... 177 (BULK) ...... 206 LITE TOUCH-MEDIUM LUPANETA PACK (3 MANNITOL (BULK) ...... 71 MASK ...... 132 MONTH) ...... 177 mannitol 10 % ...... 71 LITEAIRE MDI CHAMBER LUPRON DEPOT ...... 30 mannitol 20 % ...... 71 ...... 132 LUPRON DEPOT (3 mannitol 25 % ...... 71 MONTH) ...... 30 mannitol 5 % ...... 71
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 242 maprotiline ...... 61 megestrol ...... 30 METHAZOLAMIDE (BULK) marcaine (pf) ...... 95 MEGESTROL ...... 189 marlissa (28) ...... 182 ACETATE,MICRO METHENAMINE (BULK) .. 21 MARQIBO ...... 30 (BULK) ...... 30 methenamine hippurate ...... 21 MATULANE ...... 30 MEKINIST ...... 30 methenamine mandelate ...... 21 matzim la ...... 71 melodetta 24 fe ...... 182 METHENAMINE maxi-tuss ac ...... 194 meloxicam ...... 54 MANDELATE (BULK) ... 21 MAYZENT ...... 43 MELOXICAM (BULK) ...... 54 methen-sod phos-meth blue- mb hydrogel...... 89 melphalan ...... 30 hyos ...... 203 mb hydrogel (cyclomethicone) melphalan hcl ...... 30 methergine ...... 185 ...... 89 memantine ...... 43 methimazole ...... 118 m-clear wc ...... 194 MENACTRA (PF) ...... 168 METHIMAZOLE (BULK) 118 M-CRESOL ACETATE MENADIONE (BULK) ..... 108 METHIONINE (BULK) .... 203 (BULK) ...... 108 MENOPUR ...... 147 METHITEST ...... 147 md-76 r ...... 108 MENTHOL (BULK) ...... 89 methocarbamol ...... 45 md-gastroview ...... 108 MEPERIDINE (BULK) ...... 49 METHOCARBAMOL MEBENDAZOLE (BULK) . 14 MEPSEVII...... 147 (BULK) ...... 45 MECAMYLAMINE HCL MEQUINOL (BULK) ...... 108 METHOTREXATE (BULK) (BULK) ...... 108 mercaptopurine ...... 30 ...... 30 MECHLORETHAMINE MERCAPTOPURINE (BULK) methotrexate sodium ...... 30 (BULK) ...... 30 ...... 30 methotrexate sodium (pf) ..... 30 MECLIZINE HCL (BULK) meropenem ...... 14 methoxsalen ...... 89 ...... 156 MEROPENEM-0.9% METHOXSALEN (BULK) .. 89 meclofenamate ...... 54 SODIUM CHLORIDE ..... 14 METHSCOPOLAMINE MECLOFENAMATE mesalamine ...... 156 BROMIDE (BULK) ...... 152 SODIUM (BULK)...... 54 MESALAMINE (BULK) ... 156 METHSCOPOLAMINE MECLOFENOXATE HCL mesalamine with cleansing NITRATE (BULK) ...... 152 (BULK) ...... 108 wipe ...... 156 methyl salicylate ...... 89 MEDISENSE ...... 133 mesna ...... 23 methyldopa ...... 71 MEDISENSE GLUCOSE MESNEX...... 23 methyldopa- KETONE ...... 133 META-CRESOL (BULK) . 108 hydrochlorothiazide ...... 71 MEDISENSE MID metadate er ...... 61 methyldopate ...... 71 CONTROL ...... 133 metaproterenol ...... 198 methylene blue (antidote) ..... 21 MEDISENSE THIN METAPROTERENOL methylergonovine ...... 185 LANCETS ...... 133 SULFATE (BULK) ...... 198 methylphenidate hcl ...... 61, 62 MEDLANCE PLUS metaxall ...... 45 METHYLPHENIDATE HCL LANCETS ...... 133 metaxalone...... 45 (BULK) ...... 61 MEDLANCE PLUS SPECIAL metformin ...... 133 METHYLPREDNISOLON BLADE...... 133 METFORMIN (BULK) ..... 133 AC,MIC(BULK) ...... 116 MEDROXYPROGEST, AC METHACHOLINE methylprednisolone ...... 116 MICRO(BULK) ...... 176 CHLORIDE (BULK) ..... 108 methylprednisolone acetate 116 medroxyprogesterone ...... 176 methadone ...... 49 methylprednisolone sodium MEDTRONIC REMOTE METHADONE (BULK) ...... 49 succ ...... 116 CONTROL ...... 133 methadone intensol ...... 49 METHYLPREDNISOLONE, mefenamic acid ...... 54 methadose ...... 49 MIC (BULK) ...... 116 MEFENAMIC ACID (BULK) methamphetamine ...... 61 methyltestosterone ...... 147 ...... 54 methazolamide...... 189 METHYLTESTOSTERONE mefloquine ...... 14 (BULK) ...... 147
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 243 METHYLTESTOSTERONE, midazolam (pf) in 0.9 % nacl MINOCIN ...... 20 MICRO(BULK) ...... 147 ...... 62 minocycline ...... 20 METHYSERGIDE (BULK) 42 midodrine...... 109 MINOCYCLINE HCL metipranolol ...... 186 migergot...... 42 (BULK) ...... 20 METOCLOPRAMIDE miglitol ...... 134 minoxidil ...... 71 (BULK) ...... 156 miglustat ...... 147 MINOXIDIL (BULK) ...... 71 metoclopramide hcl ...... 156 mili...... 182 MIO INFUSION SET ...... 134 metolazone ...... 71 milk of magnesia ...... 156 miostat ...... 189 metoprolol succinate ...... 71 milk of magnesia concentrated miralax ...... 156 metoprolol ta-hydrochlorothiaz ...... 156 MIRENA ...... 177 ...... 71 millipred ...... 117 mirtazapine ...... 62 metoprolol tartrate ...... 71 millipred dp ...... 116 MIRVASO ...... 92 METOPROLOL TARTRATE milrinone ...... 84 misoprostol ...... 161 (BULK) ...... 71 milrinone in 5 % dextrose .... 84 MISOPROSTOL (BULK) .. 161 metro i.v...... 15 mimvey ...... 176 MITIGARE ...... 171 metronidazole ...... 15, 92, 177 MINI LANCING DEVICE 134 mitomycin ...... 31 METRONIDAZOLE (BULK) MINIMED 530G INSULIN MITOMYCIN (BULK) ...... 31 ...... 15 PUMP ...... 134 MITOTANE (BULK) ...... 31 METRONIDAZOLE MINIMED 630G INSULIN mitoxantrone ...... 31 BENZOATE (BULK) ...... 15 PUMP ...... 134 M-M-R II (PF) ...... 168 metronidazole in nacl (iso-os) MINIMED 670G INSULIN m-natal plus ...... 220 ...... 15 PUMP ...... 134 modafinil ...... 62 metyrosine ...... 71 MINIMED 770G INSULIN moexipril ...... 71 mexiletine ...... 66 PUMP ...... 134 molindone ...... 62 MEXILETINE (BULK) ...... 66 MINIMED INFUSION SET- mometasone ...... 101, 198 MIACALCIN ...... 147 MMT 390 ...... 134 MOMETASONE FUROATE mibelas 24 fe ...... 182 MINIMED MIO 18 ...... 134 (BULK) ...... 101 micafungin ...... 4 MINIMED MIO 23 ...... 134 mondoxyne nl ...... 20 MICONAZOLE (BULK) ...... 4 MINIMED MIO 32 ...... 134 MONOBENZONE (BULK) . 89 MICONAZOLE NITRATE MINIMED MIO ADVANCE monoject 0.9% sodium (BULK) ...... 97 INF SET23 ...... 134 chloride ...... 109 miconazole-3 ...... 177 MINIMED QUICK SET 18134 MONOJECT BLOOD MICRO THIN LANCETS . 133 MINIMED QUICK SET 23134 COLLECTION ...... 134 MICROCHAMBER ...... 133 MINIMED QUICK SET 32134 MONOJECT FILTER microgestin 1.5/30 (21) ...... 182 MINIMED QUICK SET 43134 ASPIRATOR ...... 134 microgestin 1/20 (21) ...... 182 MINIMED SILHOUETTE 18 MONOJECT FILTER microgestin fe 1.5/30 (28) .. 182 ...... 134 NEEDLE ...... 135 microgestin fe 1/20 (28) ..... 182 MINIMED SILHOUETTE 23 MONOJECT HYPODERMIC MICROLET 2 LANCING ...... 134 NEEDLES ...... 135 DEVICE ...... 133 MINIMED SILHOUETTE 32 MONOJECT HYPODERMIC MICROLET LANCET ...... 133 ...... 134 POLYPROPYL ...... 135 MICROLET NEXT MINIMED SILHOUETTE 43 MONOJECT MEDICATION LANCING DEVICE ...... 133 ...... 134 TRANSF NDL ...... 135 MICROSPACER ...... 134 MINIMED SURE T 18 ...... 134 monoject prefill advanced ns midazolam ...... 62 MINIMED SURE T 23 ...... 134 ...... 109 MIDAZOLAM (BULK) ...... 62 MINIMED SURE T 32 ...... 134 MONOLET LANCETS ...... 135 midazolam (pf) ...... 62 MINIMED SYRINGE MONOLET THIN LANCETS RESERVOIR ...... 134 ...... 135
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 244 mono-linyah ...... 182 my choice ...... 182 NAPROXEN SODIUM MONONINE ...... 79 my way ...... 182 (BULK) ...... 55 MONOVISC...... 54 MYALEPT ...... 148 naproxen-esomeprazole ...... 55 MONSEL'S ...... 89 MYCAMINE ...... 4 naratriptan ...... 42 montelukast ...... 198, 199 mycophenolate mofetil ...... 31 NARCAN ...... 55 MONTELUKAST (BULK) 198 mycophenolate mofetil (hcl) 31 NASCOBAL ...... 220 morgidox ...... 21 mycophenolate sodium ...... 31 NATACYN ...... 185 morphine...... 50 MYDAYIS ...... 62 nateglinide ...... 135 MORPHINE (BULK) ...... 49 MYGLUCOHEALTH NATESTO ...... 148 morphine (pf)...... 49 LANCETS ...... 135 NATPARA ...... 148 morphine (pf) in 0.9 % sod chl MYLERAN ...... 31 natural b-100 complex ...... 220 ...... 49 MYLOTARG ...... 31 natura-lax ...... 157 morphine concentrate ...... 50 mynatal ...... 220 NAYZILAM ...... 38 morphine in 0.9 % sodium mynatal advance ...... 220 nebusal ...... 199 chlor ...... 50 mynatal plus ...... 220 necon 0.5/35 (28) ...... 182 MOUTHPIECE ...... 135 mynatal-z ...... 220 NEEDLE (DISP) 16 G ...... 135 MOVANTIK ...... 156 mynate 90 plus...... 220 NEEDLE (DISP) 18 G ...... 135 moxifloxacin...... 19, 185 MYOBLOC ...... 168 NEEDLE (DISP) 19 G ...... 135 MOXIFLOXACIN- myorisan ...... 92 NEEDLE (DISP) 23 GAUGE SOD.ACE,SUL-WATER . 19 MYRBETRIQ ...... 202 ...... 135 moxifloxacin-sod.chloride(iso) N NEEDLES, HUBER ...... 19 nabumetone ...... 54 DISPOSABLE ...... 135 MOXISYLYTE (BULK) ... 109 NABUMETONE, neomycin ...... 15 MOZOBIL ...... 163 MICRONIZED (BULK) .. 54 NEOMYCIN SULFATE MSUD ANALOG ...... 213 nadolol ...... 71 (BULK) ...... 15 MULTI-DRAW NEEDLE . 135 NADOLOL (BULK) ...... 71 neomycin-bacitracin-poly-hc MULTI-LANCET DEVICE 2 nadolol-bendroflumethiazide 71 ...... 190 ...... 135 nafcillin ...... 18 neomycin-bacitracin- MULTITRACE-4 ...... 206 nafcillin in dextrose iso-osm 18 polymyxin ...... 186 MULTITRACE-4 naftifine ...... 97 neomycin-polymyxin b gu .. 102 CONCENTRATE...... 206 NAGLAZYME ...... 148 neomycin-polymyxin b- MULTITRACE-4 nalbuphine ...... 54 dexameth ...... 190 NEONATAL ...... 207 NALBUPHINE (BULK) ...... 54 neomycin-polymyxin- multitrace-4 pediatric ...... 207 NALIDIXIC ACID (BULK) 21 gramicidin ...... 186 MULTITRACE-5 ...... 207 naloxone ...... 54 neomycin-polymyxin-hc .... 115, MULTITRACE-5 NALOXONE (BULK) ...... 54 190 CONCENTRATE...... 207 naltrexone ...... 54 neo-polycin ...... 186 multi-vit with fluoride-iron 220 NALTREXONE HCL (BULK) neo-polycin hc ...... 190 multivitamin with fluoride . 220 ...... 54 NEOSTIGMINE multi-vitamin with fluoride 220 NALTREXONE HCL METHYLSULF (BULK) . 45 multivitamins with fluoride 220 DIHYDRATE(BULK) ..... 54 neostigmine methylsulfate .... 45 mupirocin ...... 96 NAMZARIC ...... 43 NEPHRAMINE 5.4 % ...... 214 MUPIROCIN (BULK) ...... 96 NANDROLONE NERLYNX ...... 31 mupirocin calcium ...... 96 DECANOATE (BULK) . 148 neuac ...... 92 MURI-LUBE ...... 109 naproxen ...... 55 NEULASTA ...... 163 MUSE ...... 203 NAPROXEN (BULK) ...... 55 nevirapine ...... 7 MVASI ...... 31 naproxen sodium ...... 55 new day ...... 182 mvc-fluoride ...... 220 newgen ...... 220
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 245 NEXAVAR ...... 31 NITYR ...... 109 NOVAMAX PLUS KETONE NEXCARE TEGADERM .. 135 nivatopic plus ...... 89 ...... 136 NEXIUM PACKET ...... 161 NIVESTYM ...... 163 NOVAREL ...... 148 NEXLETOL ...... 82 nizatidine ...... 161 NOVOEIGHT ...... 79 NEXLIZET...... 82 NOKOR NEEDLE ...... 136 NOVOFINE 32 ...... 136 NEXPLANON ...... 177 nolix ...... 101 NOVOFINE AUTOCOVER NEXTERONE ...... 66 nora-be ...... 176 ...... 136 NH4 NORDITROPIN FLEXPRO NOVOFINE PLUS ...... 136 TETRATHIOMOLYBDAT ...... 163 NOVOSEVEN RT ...... 79 E (BULK) ...... 109 norepinephrine bitartrate ...... 84 NOVOTWIST ...... 136 niacin ...... 82 norepinephrine bitartrate-d5w NOXAFIL ...... 4 NIACIN (BULK) ...... 82 ...... 84 np thyroid ...... 150 NIACINAMIDE (BULK) .... 82 norepinephrine bitartrate-nacl NPLATE ...... 80 nicardipine ...... 71, 72 ...... 84 NUBEQA ...... 31 NICLOSAMIDE (BULK) .... 15 noreth-ethinyl estradiol-iron NUCALA ...... 199 NICODERM CQ ...... 113 ...... 182 NUCYNTA ...... 55 nicorelief...... 113 NORETHINDRONE (BULK) NUCYNTA ER ...... 55 NICORETTE ...... 113 ...... 176 NUEDEXTA ...... 43 nicotine ...... 113 norethindrone (contraceptive) NULOJIX ...... 31 nicotine (polacrilex) ...... 113 ...... 176 NUTRAMIGEN DHA-ARA NICOTINE (POLACRILEX) norethindrone acetate ...... 176 ...... 214 ...... 113 NORETHINDRONE NUTRAMIGEN TODDLER NICOTINE POLACRILEX ACETATE (BULK) ...... 176 ENFLORA-LGG ...... 214 (BULK) ...... 113 norethindrone ac-eth estradiol NUTRAMIGEN WITH NICOTINE TARTRATE ... 113 ...... 176, 182 ENFLORA LGG ...... 214 nifedipine ...... 72 norethindrone-e.estradiol-iron nutrilyte ...... 207 NIFEDIPINE (BULK) ...... 72 ...... 182 nyamyc ...... 97 nikki (28) ...... 182 norgestimate-ethinyl estradiol NYLIDRIN (BULK) ...... 72 nilutamide ...... 31 ...... 182 nystatin ...... 4, 97, 98 nimodipine ...... 72 norlyda ...... 176 NYSTATIN (BULK) ...... 4 NINLARO ...... 31 normal saline flush ...... 109 nystatin-triamcinolone ...... 98 nisoldipine ...... 72 NORMOSOL-M IN 5 % nystop ...... 98 nitisinone ...... 109 DEXTROSE ...... 214 O nitro-bid ...... 85 NORMOSOL-R IN 5 % OA 1 POWDER ...... 214 NITROFURAN DEXTROSE ...... 207 OBIZUR ...... 80 MACROCRYSTAL NORMOSOL-R PH 7.4 ..... 214 obstetrix dha ...... 221 (BULK) ...... 21 nortrel 0.5/35 (28)...... 182 OCALIVA ...... 157 nitrofurantoin ...... 21 nortrel 1/35 (21)...... 182 ocella ...... 183 NITROFURANTOIN (BULK) nortrel 1/35 (28)...... 183 OCREVUS ...... 43 ...... 21 nortrel 7/7/7 (28) ...... 183 octreotide acetate ...... 31 nitrofurantoin macrocrystal .. 21 nortriptyline ...... 62 ocucoat ...... 188 nitrofurantoin monohyd/m- NORTRIPTYLINE (BULK) 62 ODEFSEY ...... 7 cryst ...... 21 NORVIR ...... 7 ODOMZO ...... 31 NITROFURAZONE (BULK) NOVA SAFETY LANCETS OFEV ...... 199 ...... 96 ...... 136 OFIRMEV ...... 55 nitroglycerin ...... 85 NOVA SUREFLEX ofloxacin ...... 19, 114, 186 nitroglycerin in 5 % dextrose 85 LANCETS ...... 136 OGIVRI ...... 31 nitro-time ...... 85 olanzapine ...... 62
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 246 olanzapine-fluoxetine ...... 63 ONETOUCH ULTRA BLUE ORKAMBI ...... 199 olmesartan ...... 72 TEST STRIP...... 136 ORNITHINE olmesartan-amlodipin- ONETOUCH ULTRA HYDROCHLORIDE hcthiazid ...... 72 CONTROL ...... 136 (BULK) ...... 214 olmesartan- ONETOUCH ULTRA2 orphenadrine citrate ...... 45 hydrochlorothiazide ...... 72 METER ...... 136 ORPHENADRINE CITRATE olopatadine ...... 114, 188 ONETOUCH ULTRAMINI (BULK) ...... 45 omega-3 acid ethyl esters ..... 82 ...... 136 orphenadrine-asa-caffeine .... 45 omeprazole ...... 161 ONETOUCH ULTRASOFT orphengesic forte ...... 45 OMEPRAZOLE (BULK) .. 161 LANCETS ...... 137 orsythia ...... 183 omeprazole-sodium ONETOUCH VERIO FLEX ORTHOVISC ...... 55 bicarbonate ...... 161 METER ...... 137 oscimin ...... 152 OMNIPAQUE 140 ...... 109 ONETOUCH VERIO HIGH oscimin sl ...... 152 OMNIPAQUE 180 ...... 109 CONTROL ...... 137 oscimin sr ...... 152 OMNIPAQUE 240 ...... 109 ONETOUCH VERIO IQ oseltamivir ...... 7 OMNIPAQUE 300 ...... 109 METER ...... 137 osmitrol 15 % ...... 72 OMNIPAQUE 350 ...... 109 ONETOUCH VERIO METER osmitrol 20 % ...... 72 OMNIPOD DASH 5 PACK ...... 137 OTEZLA ...... 172 POD ...... 136 ONETOUCH VERIO MID OTEZLA STARTER ...... 173 OMNIPOD INSULIN CONTROL ...... 137 OTOVEL ...... 115 MANAGEMENT ...... 136 ONETOUCH VERIO OTREXUP (PF) ...... 173 OMNIPOD INSULIN REFILL REFLECT METER ...... 137 OVIDREL ...... 148 ...... 136 ONETOUCH VERIO TEST oxacillin ...... 18 ON CALL LANCET ...... 136 STRIPS ...... 137 oxacillin in dextrose(iso-osm) ON CALL LANCING ONEXTON ...... 92 ...... 18 DEVICE ...... 136 ONIVYDE ...... 32 oxaliplatin ...... 32 ON CALL PLUS LANCET136 ON-THE-GO LANCETS ... 137 oxandrolone ...... 148 ON CALL PLUS LANCING opcicon one-step ...... 183 OXANDROLONE (BULK) DEVICE ...... 136 OPDIVO ...... 32 ...... 148 ONCASPAR ...... 32 opium tincture...... 152 oxaprozin ...... 55 ondansetron ...... 157 OPSUMIT ...... 199 oxcarbazepine ...... 38 ondansetron hcl ...... 157 OPTICHAMBER ADULT OXERVATE ...... 188 ONDANSETRON HCL MASK-LARGE ...... 137 oxiconazole ...... 98 (BULK) ...... 157 OPTICHAMBER DIAMOND oxybutynin chloride ...... 202 ondansetron hcl (pf) ...... 157 LG MASK ...... 137 OXYBUTYNIN CHLORIDE one daily prenatal ...... 221 OPTICHAMBER DIAMOND (BULK) ...... 202 ONE WAY VALVED VHC...... 137 oxycodone ...... 50 MOUTHPIECE ...... 136 OPTICHAMBER DIAMOND- OXYCODONE (BULK) ...... 50 ONETOUCH DELICA LANC MED MSK ...... 137 oxycodone-acetaminophen ... 50 DEVICE ...... 136 OPTICHAMBER DIAMOND- oxycodone-aspirin ...... 51 ONETOUCH DELICA SML MASK ...... 137 OXYCONTIN ...... 51 LANCETS ...... 136 option-2 ...... 183 OXYMETAZOLINE (BULK) ONETOUCH DELICA PLUS ORACEA...... 21 ...... 114 LANC DEV ...... 136 oral saline laxative ...... 157 oxymorphone ...... 51 ONETOUCH DELICA PLUS oralone ...... 114 OXYQUINOLINE SULFATE LANCET ...... 136 ORBACTIV...... 15 (BULK) ...... 109 ONETOUCH SURESOFT ORIAHNN...... 177 OXYTETRACYCLINE LANCING DEV ...... 136 ORILISSA ...... 148 (BULK) ...... 21
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 247 oxytocin ...... 185 peg3350-sod sul-nacl-kcl-asb-c PHENINDIONE (BULK) .. 109 OXYTOCIN (BULK) ...... 185 ...... 157 phenobarb-hyoscy-atropine- oxytocin in 0.9 % sod chloride PEGANONE ...... 38 scop ...... 152 ...... 185 PEGASYS ...... 163 phenobarbital ...... 38 OZEMPIC ...... 137 peg-electrolyte soln ...... 157 PHENOBARBITAL (BULK) OZURDEX ...... 191 peg-prep ...... 157 ...... 38 P penicillamine ...... 173 phenobarbital sodium ...... 38 pacerone ...... 66 PENICILLAMINE (BULK) phenohytro ...... 153 paclitaxel ...... 32 ...... 173 PHENOL (BULK) ...... 109 paliperidone ...... 63 PENICILLAMINE(D-) ...... 173 phenoxybenzamine ...... 72 palonosetron ...... 157 PENICILLIN G POT IN PHENOXYBENZAMINE PALYNZIQ ...... 148 DEXTROSE ...... 18 (BULK) ...... 72 pamidronate ...... 148 penicillin g potassium ...... 18 PHENTERMINE HCL PANCREATIN (BULK) .... 157 penicillin g procaine ...... 18 (BULK) ...... 102 pancuronium ...... 46 penicillin g sodium ...... 18 phentolamine ...... 72 PANDA MASK...... 137 penicillin v potassium ...... 18 PHENTOLAMINE pantoprazole ...... 161 PENTACEL (PF) ...... 168 MESYLATE (BULK) ...... 72 papaverine ...... 72 PENTACEL ACTHIB phenylephrine hcl ...... 84, 191 PAPAVERINE (BULK) ...... 72 COMPONENT (PF) ...... 168 PHENYLEPHRINE HCL PARACHLOROPHENOL pentamidine ...... 15 (BULK) ...... 191 (BULK) ...... 109 PENTASA ...... 157 phenylephrine hcl in 0.9% nacl PARADIGM RESERVOIR 137 pentobarbital sodium ...... 63 ...... 84 PARADIGM SILHOUETTE PENTOBARBITAL SODIUM PHENYLMERCURIC INFUS SET ...... 137 (BULK) ...... 63 NITRATE (BULK) ...... 109 paraplatin ...... 32 PENTOSAN POLYSULFATE phenytoin ...... 39 paricalcitol ...... 148 NA (BULK) ...... 203 PHENYTOIN (BULK) ...... 38 paroex oral rinse ...... 114 pentoxifylline...... 80 phenytoin sodium ...... 39 paromomycin ...... 15 PENTOXIFYLLINE (BULK) PHENYTOIN SODIUM PAROMOMYCIN SULFATE ...... 80 (BULK) ...... 39 (BULK) ...... 15 PENTYLENETETRAZOL phenytoin sodium extended .. 39 paroxetine hcl ...... 63 (BULK) ...... 109 philith ...... 183 paroxetine PERFOROMIST ...... 199 PHOSLYRA ...... 207 mesylate(menop.sym) ...... 63 perindopril erbumine ...... 72 phosphasal ...... 203 PAZEO ...... 188 periogard ...... 114 phosphate laxative ...... 157 PCCA T3 SODIUM PERJETA ...... 32 PHOSPHOLINE IODIDE .. 186 DILUTION ...... 150 permethrin ...... 102 PHOTOFRIN ...... 32 PCCA T4 SODIUM PERMETHRIN (BULK) .... 101 physostigmine salicylate ..... 189 DILUTION ...... 150 perphenazine ...... 63 PHYTONADIONE (VIT K1) PEDIARIX (PF) ...... 168 perphenazine-amitriptyline ... 63 (BULK) ...... 80 PEDIATRIC MEDIUM perry prenatal ...... 221 phytonadione (vitamin k1) ... 80 MASK ...... 137 PFD TODDLER ...... 214 PHYTONADIONE PEDIATRIC PANDA MASK pfizerpen-g...... 18 (VITAMIN K1) ...... 80 ...... 137 phenadoz ...... 194 PICATO ...... 89 PEDIATRIC SMALL MASK phenazopyridine ...... 204 pilocarpine hcl ...... 109, 187 ...... 137 PHENAZOPYRIDINE PILOCARPINE HCL (BULK) PEDITRACE ...... 207 (BULK) ...... 204 ...... 187 PEDVAX HIB (PF) ...... 168 phenelzine ...... 63 PILOCARPINE NITRATE peg 3350-electrolytes ...... 157 PHENELZINE (BULK) ...... 63 (BULK) ...... 187
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 248 pimecrolimus ...... 89 posaconazole ...... 4 pramipexole ...... 41 pimozide ...... 63 potassium acetate ...... 207 PRAMOXINE HCL (BULK) pimtrea (28) ...... 183 POTASSIUM ACETATE ...... 157 pindolol...... 72 (BULK) ...... 207 prasugrel ...... 80 pioglitazone ...... 137 potassium chlorid-d5- pravastatin ...... 82 pioglitazone-glimepiride .... 137 0.45%nacl ...... 207 praziquantel ...... 15 pioglitazone-metformin ...... 137 potassium chloride ...... 207, 208 PRAZIQUANTEL (BULK) . 15 PIP LANCET ...... 138 POTASSIUM CHLORIDE prazosin ...... 72 piperacillin-tazobactam ...... 18 (BULK) ...... 207 PRECISION XTRA B- pirmella...... 183 potassium chloride in 0.9%nacl KETONE ...... 138 piroxicam ...... 55 ...... 207 PRECISION XTRA PIROXICAM (BULK) ...... 55 potassium chloride in 5 % dex KETONE-GLUCOSE .... 138 PLAN B ONE-STEP ...... 183 ...... 207 PRECISION XTRA plasbumin 25 % ...... 205 potassium chloride in lr-d5 . 207 MONITOR ...... 138 plasbumin 5 % ...... 205 potassium chloride in water 207 PRECISION XTRA TEST . 138 PLASMA-LYTE 148 ...... 214 potassium chloride-0.45 % nacl prednicarbate ...... 101 PLASMA-LYTE A ...... 214 ...... 208 prednisolone ...... 117 plasmanate ...... 214 potassium chloride-d5- PREDNISOLONE (BULK)117 PLEGRIDY ...... 163 0.2%nacl ...... 208 PREDNISOLONE AC, plenamine ...... 214 potassium chloride-d5- MICRO (BULK) ...... 117 PNEUMOVAX-23 ...... 168 0.3%nacl ...... 208 prednisolone acetate ...... 191 pnv 29-1...... 221 potassium chloride-d5- PREDNISOLONE SOD PHOS pnv-dha ...... 221 0.9%nacl ...... 208 (BULK) ...... 117 pnv-dha + docusate ...... 221 potassium citrate ...... 203 prednisolone sodium phosphate pnv-omega ...... 221 POTASSIUM CITRATE M- ...... 117, 191 pnv-select ...... 221 HYD(BULK) ...... 109 PREDNISOLONE, MICRO POCKET CHAMBER ...... 138 POTASSIUM GLUCONATE (BULK) ...... 117 podofilox ...... 89 (BULK) ...... 208 prednisone ...... 117 PODOPHYLLUM RESIN POTASSIUM HYDROXIDE PREDNISONE (BULK) ..... 117 (BULK) ...... 87 (BULK) ...... 87 prednisone intensol ...... 117 polocaine ...... 95 POTASSIUM IODIDE PREDNISONE POLOCAINE ...... 95 (BULK) ...... 118 MICRONIZED (BULK) 117 polocaine-mpf...... 95 POTASSIUM pregabalin ...... 39 POLY HUB NEEDLE ...... 138 PERMANGANATE PREGESTIMIL ...... 214 polycin ...... 186 (BULK) ...... 208 PREGNENOLONE (BULK) polyethylene glycol 3350 ... 157 potassium phosphate m-/d- ...... 109 POLYETHYLENE GLYCOL basic ...... 208 PREGNENOLONE, 3350(BULK) ...... 109 POTELIGEO ...... 32 MICRONIZED(BULK) . 110 POLYMYXIN B POVIDONE (BULK) ...... 109 PREMARIN ...... 176 SULF,MICRON.(BULK). 15 POVIDONE-IODINE (BULK) premasol 10 % ...... 214 polymyxin b sulfate ...... 15 ...... 96 PREMIUM INFANT polymyxin b sulf-trimethoprim powderlax ...... 157 FORMULA ...... 215 ...... 186 pr cream ...... 89 PREMPHASE ...... 176 POLYSKIN II ...... 138 pr natal 400 ...... 221 PREMPRO ...... 176 POLYVINYL ALCOHOL pr natal 400 ec ...... 221 prena1 chew ...... 221 (BULK) ...... 188 pr natal 430 ...... 221 prena1 pearl ...... 221 POMALYST ...... 32 pr natal 430 ec ...... 221 prena1 true ...... 221 portia 28...... 183 PRALUENT PEN...... 82 prenaissance ...... 221
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 249 prenaissance plus ...... 221 pro dna collection ...... 95 PROMETHAZINE (BULK) prenatabs fa ...... 221 PROAIR HFA ...... 199 ...... 194 prenatabs rx ...... 221 PROAIR RESPICLICK ..... 199 promethazine vc ...... 194 prenatal ...... 221 probenecid ...... 171 promethazine-codeine ...... 194 prenatal complete ...... 221 probenecid-colchicine ...... 171 promethazine-dm ...... 194 prenatal formula ...... 221 procainamide ...... 66 promethazine-phenyleph- prenatal low iron...... 221 PROCAINAMIDE HCL codeine ...... 194 prenatal multi-dha (algal oil) (BULK) ...... 66 promethazine-phenylephrine ...... 221 PROCAINE (BULK) ...... 95 ...... 194 prenatal multivitamins ...... 221 PROCALAMINE 3% ...... 215 promethegan ...... 194 prenatal one daily ...... 221 PROCARE SPACER WITH propafenone ...... 66 prenatal plus ...... 222 ADULT MASK ...... 138 PROPANTHELINE (BULK) prenatal plus (calcium carb)222 PROCARE SPACER WITH ...... 153 prenatal tablet ...... 222 CHILD MASK ...... 138 proparacaine ...... 188 prenatal vitamin ...... 222 procentra ...... 63 PROPARACAINE (BULK) prenatal vitamin plus low iron PROCHAMBER ...... 138 ...... 188 ...... 222 prochlorperazine ...... 158 PRO-PHREE ...... 215 prenatal vit-iron fum-folic ac prochlorperazine edisylate .. 158 PROPIMEX-1 ...... 215 ...... 222 PROCHLORPERAZINE propofol ...... 110 prenatal vits96-iron fum-folic EDISYLT(BULK) ...... 158 propranolol ...... 72, 73 ...... 222 prochlorperazine maleate ... 158 PROPRANOLOL (BULK) .. 72 prenatal-u ...... 222 PROCHLORPERAZINE propranolol-hydrochlorothiazid preplus ...... 222 MALEATE(BULK) ...... 158 ...... 73 PREPOPIK ...... 158 PROCRIT ...... 163 propylthiouracil ...... 118 PRESSURE ACTIVATED procto-med hc ...... 158 PROPYLTHIOURACIL LANCETS ...... 138 procto-pak ...... 158 (BULK) ...... 118 pretab ...... 222 proctosol hc ...... 158 PROQUAD (PF) ...... 169 prevalite ...... 82 proctozone-hc ...... 158 prosilk gel ...... 89 previfem ...... 183 PRODIGY LANCETS ...... 138 PROSOL 20 % ...... 215 PREVNAR 13 (PF) ...... 169 PRODIGY LANCING protamine ...... 80 PREVYMIS ...... 7 DEVICE ...... 138 PROTAMINE SULFATE PREZISTA ...... 7 PRODIGY TWIST TOP (BULK) ...... 80 PRIALT ...... 55 LANCET ...... 138 PROTIRELIN (BULK) ...... 150 PRIFTIN ...... 15 PRODUCT 3232A ...... 215 PROTOPAM CHLORIDE . 102 PRILOCAINE (BULK)...... 95 PROFILNINE ...... 80 protriptyline ...... 63 PRIMAQUINE ...... 15 progesterone ...... 176 PROVENGE ...... 169 PRIMEAIRE ...... 138 PROGESTERONE (BULK) pruclair ...... 89 primidone ...... 39 ...... 176 prudoxin ...... 89 PRIMIDONE (BULK) ...... 39 progesterone micronized .... 176 prumyx ...... 89 PRIVIGEN ...... 169 PROGESTERONE PSEUDOEPHEDRINE HCL PRO COMFORT ALCOHOL MICRONIZED (BULK) 176 (BULK) ...... 194 PADS ...... 138 PROGRAF...... 32 PULMICORT FLEXHALER PRO COMFORT LANCET PROLASTIN-C ...... 110 ...... 199 ...... 138 prolate ...... 51 pulmosal ...... 199 PRO COMFORT SPACER- PROLENSA ...... 189 PULMOZYME ...... 199 ADULT MASK ...... 138 PROLEUKIN ...... 163 PURE COMFORT ALCOHOL PRO COMFORT SPACER- PROMACTA ...... 80 PADS ...... 138 CHILD MASK ...... 138 promethazine ...... 194
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 250 PURE COMFORT LANCETS QUIT 2 ...... 113 repaglinide ...... 139 ...... 139 quit 4 ...... 113 repaglinide-metformin ...... 139 PURE COMFORT SAFETY QVAR REDIHALER ...... 199 REPATHA PUSHTRONEX 82 LANCETS ...... 139 R REPATHA SURECLICK .... 83 purelax ...... 158 RABAVERT (PF) ...... 169 REPATHA SYRINGE ...... 83 PURIXAN ...... 32 rabeprazole ...... 161 RESERPINE (BULK) ...... 73 PUSH BUTTON SAFETY RACEPINEPHRINE (BULK) RESORCINOL (BULK) ...... 87 LANCETS ...... 139 ...... 199 RESTASIS ...... 188 PYLERA ...... 161 RADICAVA ...... 43 RESTASIS MULTIDOSE .. 188 PYRANTEL PAMOATE raloxifene ...... 171 RETACRIT ...... 164 (BULK) ...... 15 ramelteon ...... 63 RETINOIC ACID ...... 93 pyrazinamide ...... 15 ramipril ...... 73 RETROVIR ...... 7 pyridostigmine bromide ...... 46 ranitidine hcl ...... 161 REVCOVI ...... 110 PYRIDOSTIGMINE ranolazine ...... 84 REVEL PEDIATRIC BROMIDE (BULK) ...... 46 RAPIVAB (PF) ...... 7 PROGRAM PUMP ...... 139 PYRIDOXINE (BULK) ..... 222 rasagiline ...... 41 REVEL PROGRAMMABLE pyridoxine (vitamin b6) ...... 222 RASUVO (PF) ...... 173 PUMP ...... 139 PYRILAMINE MALEATE RAVICTI ...... 110 REVLIMID ...... 32 (BULK) ...... 194 RCF SOY PROTEIN revonto ...... 46 pyrimethamine ...... 15 FORMULA BASE ...... 215 REYATAZ ...... 7 PYRIMETHAMINE (BULK) READYLANCE SAFETY R-GENE 10 ...... 215 ...... 15 LANCETS ...... 139 RHOPRESSA ...... 189 PYRITHIONE ZINC (BULK) REBIF (WITH ALBUMIN) RIASTAP ...... 80 ...... 102 ...... 163 ribavirin ...... 7 Q REBIF REBIDOSE ...... 164 RIBOFLAVIN (VITAMIN QBREXZA ...... 90 REBIF TITRATION PACK B2) (BULK) ...... 222 QNASL...... 199 ...... 164 RIBOFLAVIN 5PHOSPHAT QUADRACEL (PF) ...... 169 recedo ...... 90 SOD(BULK) ...... 222 quazepam ...... 63 reclipsen (28) ...... 183 RIDAURA ...... 173 QUDEXY XR ...... 39 RECOMBIVAX HB (PF) .. 169 rifabutin ...... 16 quetiapine ...... 63 RECTIV...... 158 rifampin ...... 16 QUICK-SET PARADIGM 139 regonol ...... 46 RIFAMPIN (BULK) ...... 16 QUILLICHEW ER ...... 63 REGRANEX ...... 90 RIGHTEST GD500 QUILLIVANT XR ...... 63 relador pak ...... 95 LANCING DEVICE ...... 139 QUINACRINE (BULK) ...... 15 relador pak plus ...... 95 RIGHTEST GL300 LANCETS quinapril ...... 73 RELIAMED LANCET...... 139 ...... 139 quinapril-hydrochlorothiazide RELIAMED MINI LANCING riluzole ...... 110 ...... 73 DEVICE ...... 139 rimantadine ...... 7 quinidine gluconate ...... 66 RELIAMED SAFETY SEAL ringer's ...... 102, 208 quinidine sulfate ...... 66 LANCETS ...... 139 RINVOQ ...... 173 QUINIDINE SULFATE RELION THIN LANCETS 139 risedronate ...... 110, 171 (BULK) ...... 66 RELION ULTRA THIN PLUS RISPERDAL CONSTA ...... 64 QUININE HCL DIHYDRATE LANCETS ...... 139 risperidone ...... 64 (BULK) ...... 16 RELISTOR ...... 158 RITEFLO AEROCHAMBER quinine sulfate ...... 16 REMICADE ...... 158 ...... 139 QUININE SULFATE (BULK) remifentanil ...... 51 ritonavir ...... 7 ...... 16 RENACIDIN ...... 204 RITUXAN ...... 32 quit 2 ...... 113 rena-vite ...... 222 RITUXAN HYCELA ...... 32
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 251 rivastigmine ...... 44 SCOPOLAMINE HBR silodosin ...... 203 rivastigmine tartrate...... 43 (BULK) ...... 158 SIL-SERTER ...... 140 rivelsa ...... 183 seconal sodium ...... 64 silver nitrate ...... 90 rizatriptan ...... 42 SEGLUROMET ...... 140 SILVER NITRATE (BULK) 90 rocuronium ...... 46 selegiline hcl ...... 41 silver nitrate applicators ...... 90 ropinirole ...... 41 SELEGILINE HCL (BULK) 41 SILVER PROTEIN MILD ropivacaine (pf) ...... 95 selenium...... 208 (BULK) ...... 90 ROPIVACAINE HCL (BULK) selenium sulfide ...... 86 silver sulfadiazine ...... 87 ...... 96 SELENIUM SULFIDE SILVER SULFADIAZINE rosadan ...... 93 (BULK) ...... 86 (BULK) ...... 87 rosula cleansing cloths ...... 93 SELZENTRY ...... 7 SIMETHICONE (BULK) .. 158 rosuvastatin...... 83 se-natal 19 chewable ...... 222 SIMILAC ADVANCE ...... 215 ROTATEQ VACCINE ...... 169 se-natal-19 ...... 222 similac advance organic ..... 215 roweepra ...... 39 sensorcaine ...... 96 SIMILAC ADVANCE roweepra xr ...... 39 sensorcaine-epinephrine ...... 96 ORGANIC ...... 215 ROZLYTREK ...... 32 sensorcaine-mpf...... 96 SIMILAC ADVANCE WITH RUBRACA...... 32 SENSORCAINE- IRON ...... 215 RUCONEST ...... 200 MPF/EPINEPHRINE ...... 96 similac alimentum ...... 215 RUXIENCE ...... 32 SEREVENT DISKUS ...... 200 SIMILAC EXPERT CARE 216 RUZURGI ...... 44 SERMORELIN ACETATE SIMILAC EXPERT CARE RYBELSUS ...... 139 (BULK) ...... 164 ALIMENTUM ...... 215, 216 RYDAPT ...... 33 serophene ...... 148 SIMILAC EXPERT CARE rydex ...... 194 SEROSTIM ...... 164 NEOSURE ...... 216 S SEROTONIN HCL (BULK) SIMILAC FOR SPIT-UP ... 216 SAF-CLENS AF DERMAL ...... 110 SIMILAC HUMAN MILK WOUND...... 90 sertraline ...... 64 FORTIFIER ...... 216 SAFE-CLIP BY MAIL ...... 139 SERTRALINE (BULK) ...... 64 SIMILAC LOW-IRON ...... 216 SAFE-CLIP NEEDLE setlakin...... 183 SIMILAC NEOSURE ...... 216 STORAGE DEV ...... 139 sevelamer carbonate ...... 110 SIMILAC PM ...... 216 SAFETY LANCETS ...... 139 sevelamer hcl ...... 110 SIMILAC PRO-ADVANCE SAFETY NEEDLES ...... 139 sevoflurane ...... 110 NON-GMO ...... 216 SAFETY SEAL LANCETS sf 114 SIMILAC PRO-SENSITIVE ...... 140 sf 5000 plus ...... 114 NON-GMO ...... 216 SAFETY-LET LANCETS . 140 sharobel ...... 176 SIMILAC SENSITIVE ...... 217 salicylic acid ...... 87 SHINGRIX (PF) ...... 169 similac sensitive fuss and gas SALICYLIC ACID (BULK) 87 SIDESTREAM PEDIATRIC ...... 216 salicylic acid-ceramides no.1 87 FACE MASK ...... 140 SIMILAC SENSITIVE FUSS salimez ...... 87 SIGNIFOR...... 33 AND GAS ...... 216 salsalate ...... 55 sildenafil ...... 204 SIMILAC SENSITIVE SALSALATE (BULK) ...... 55 SILDENAFIL (BULK) ...... 204 ISOMIL SOY ...... 216 salvax ...... 87 sildenafil (pulm.hypertension) SIMILAC SOY ISOMIL .... 217 SAMSCA ...... 148 ...... 200 SIMILAC SPECIAL CARE 24 SANDIMMUNE ...... 33 SILHOUETTE 23...... 140 ...... 217 SANTYL ...... 101 SILHOUETTE 43...... 140 SIMILAC SPECIAL CARE 30 sapropterin ...... 148 SILICONE MASK - INFANT ...... 217 SAVELLA ...... 173 ...... 140 SIMILAC scalacort ...... 101 SILICONE MASK - SUPPLEMENTATION .. 217 scopolamine base...... 158 PEDIATRIC ...... 140
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 252 SIMILAC TOTAL SODIUM CITRATE sotalol ...... 66 COMFORT...... 217 DIHYDRATE(BULK) ... 110 SOTALOL ...... 66 SIMILAC TOTAL sodium ferric gluconat-sucrose sotalol af ...... 66 COMFORT NON-GMO 217 ...... 111 SOTRADECOL ...... 111 simliya (28) ...... 183 sodium fluoride 5000 plus .. 114 SOTYLIZE ...... 66 simpesse ...... 183 sodium fluoride-pot nitrate . 114 SPACE CHAMBER ...... 140 SIMPONI ...... 173 SODIUM HYALURONATE SPACE CHAMBER WITH SIMULECT ...... 33 (BULK) ...... 90 LARGE MASK ...... 140 simvastatin ...... 83 SODIUM HYDROXIDE SPACE CHAMBER WITH SIMVASTATIN (BULK) .... 83 (BULK) ...... 87 MEDIUM MASK ...... 140 SINGLE-LET ...... 140 SODIUM LACTATE (BULK) SPACE CHAMBER WITH sirolimus ...... 33 ...... 209 SMALL MASK ...... 140 SIROLIMUS (BULK) ...... 33 SODIUM NITRITE (BULK) spinosad ...... 102 SIRTURO ...... 16 ...... 73 SPINRAZA (PF) ...... 44 skin treatment ...... 90 sodium nitroprusside ...... 84 SPIRIVA RESPIMAT ...... 200 SKYLA...... 177 sodium phenylbutyrate ...... 111 SPIRIVA WITH SKYRIZI ...... 86 SODIUM HANDIHALER ...... 200 SMART SENSE LANCETS PHENYLBUTYRATE spironolactone ...... 73 ...... 140 (BULK) ...... 111 SPIRONOLACTONE (BULK) SMARTDIABETES sodium phosphate ...... 209 ...... 73 VANTAGE...... 140 SODIUM SPIRONOLACTONE MICRO SMARTEST LANCET ...... 140 PHOSPHATE,DIBASIC(B (BULK) ...... 73 smoothlax ...... 158 ULK) ...... 158 spironolacton-hydrochlorothiaz sodium acetate ...... 208 sodium polystyrene (sorb free) ...... 73 SODIUM ACETATE (BULK) ...... 111 sprintec (28) ...... 183 ...... 208 sodium polystyrene sulfonate SPRYCEL ...... 33 sodium benzoate-sod ...... 111 sps (with sorbitol) ...... 111 phenylacet...... 110 SODIUM SALICYLATE SQUARIC ACID (BULK) . 111 sodium bicarbonate ...... 208 (BULK) ...... 55 SQUARIC ACID sodium bicarbonate in d5w 208 SODIUM TETRADECYL DIBUTYLEST.(BULK) . 111 SODIUM BORATE (BULK) SULF (BULK) ...... 111 SQUARIC ACID IN ...... 110 sodium tetradecyl sulfate .... 111 BUTANOL ...... 111 SODIUM BROMIDE (BULK) sodium thiosulfate ...... 111 sronyx ...... 183 ...... 110 SOFT TOUCH LANCETS 140 ssd ...... 87 SODIUM BUTYRATE solifenacin ...... 202 sss 10-5 ...... 93 (BULK) ...... 110 SOLIQUA 100/33 ...... 140 st joseph aspirin ...... 55 sodium chlor 0.9% bacteriostat SOLIRIS ...... 111 STAMARIL (PF) ...... 169 ...... 110 SOLOSEC ...... 16 STANOZOLOL (BULK) ... 149 sodium chloride .. 110, 200, 209 SOLU-CORTEF ...... 117 STANOZOLOL SODIUM CHLORIDE SOLU-CORTEF ACT-O- MICRONIZED (BULK) 149 (BULK) ...... 208, 209 VIAL (PF) ...... 117 stavudine ...... 7 sodium chloride 0.45 % ...... 209 SOLUS V2 LANCETS ...... 140 STEGLATRO ...... 140 sodium chloride 0.9 % ...... 110 SOLUS V2 LANCING STELARA ...... 86 sodium chloride 0.9 % (flush) DEVICE ...... 140 STERILANCE TL ...... 140 ...... 110 SOMATULINE DEPOT ...... 33 STIOLTO RESPIMAT ...... 200 sodium chloride 3 % ...... 209 SOMAVERT ...... 148 STIVARGA ...... 33 sodium chloride 5 % ...... 209 sonafine ...... 90 stop smoking aid ...... 113 sorine ...... 66 STRENSIQ ...... 149
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 253 STREPTOMYCIN ...... 16 SULFAMYLON ...... 97 SURE-T INFUSION SET .. 141 STREPTOMYCIN SULFATE SULFANILAMIDE (BULK) SURE-T PARADIGM ...... 141 (BULK) ...... 16 ...... 177 SURE-TOUCH LANCET .. 141 stress formula ...... 222 SULFAPYRIDINE (BULK) 20 surgifoam ...... 80 stress formula 600 c...... 222 sulfasalazine ...... 159 SURGUARD2 SAFETY .... 141 stress formula with iron ...... 222 SULFASALAZINE (BULK) SUTENT ...... 33 stress formula with iron(sulf) ...... 159 syeda ...... 183 ...... 222 SULFATHIAZOLE (BULK) SYLATRON ...... 164 strong iodine ...... 96, 209 ...... 177 SYLVANT ...... 33 SUBLOCADE ...... 51 sulfatrim...... 20 symax fastabs ...... 153 subvenite...... 39 SULFISOXAZOLE (BULK)20 symax-sl ...... 153 subvenite starter (blue) kit .... 39 SULFUR SUBLIMED symax-sr ...... 153 subvenite starter (green) kit .. 39 (BULK) ...... 87 SYMBICORT ...... 200 subvenite starter (orange) kit 39 sulindac ...... 55 SYMDEKO ...... 200 succinylcholine chloride ...... 46 SULINDAC (BULK) ...... 55 SYMFI ...... 7 SUCCINYLCHOLINE CL sumatriptan ...... 42 SYMFI LO ...... 7 (BULK) ...... 46 SUMATRIPTAN (BULK) ... 42 SYMJEPI ...... 194 SUCRAID ...... 159 sumatriptan succinate ...... 42 SYMLINPEN 120 ...... 141 sucralfate ...... 161 SUMATRIPTAN SYMLINPEN 60 ...... 141 SUCRALFATE (BULK).... 161 SUCCINATE (BULK) ..... 42 SYMPROIC ...... 159 sufentanil citrate ...... 51 sumatriptan-naproxen ...... 42 SYMTUZA ...... 8 SUFENTANIL CITRATE SUNOSI...... 64 SYNAGIS ...... 8 (BULK) ...... 51 super b complex-vitamin c . 222 SYNAREL ...... 149 SULFACETAMIDE (BULK) super b maxi complex...... 222 SYNERCID ...... 16 ...... 19 super quints...... 222 SYNJARDY ...... 141 SULFACETAMIDE SOD, super quints b-50 ...... 222 SYNJARDY XR ...... 141 MONO (BULK) ...... 191 SUPER THIN LANCETS .. 140 SYNRIBO ...... 33 sulfacetamide sodium ... 86, 191 SUPREP BOWEL PREP KIT T sulfacetamide sodium (acne) 97 ...... 159 T SULFACETAMIDE SODIUM SURE COMFORT ALCOHOL 30 INFUSION SET ...... 142 (BULK) ...... 191 PREP PADS ...... 140 90 INFUSION SET 23 ... 142 sulfacetamide sodium-sulfur 93 SURE COMFORT LANCETS 90 INFUSION SET 43 ... 142 sulfacetamide sod-sulfur-urea ...... 141 FLEX ...... 142 ...... 93 SURE COMFORT LANCING SLIM ...... 142 sulfacetamide-prednisolone 191 PEN ...... 141 SLIM G4 ...... 142 sulfacetamide-sulfur-cleansr23 SUREFLEX DEVICE WITH SLIM INSULIN ...... 93 LANCETS ...... 141 DELIVERY SYSTEM142 sulfacleanse 8-4 ...... 93 SUREFLEX LANCING SLIM X2 ...... 142 sulfadiazine...... 19 DEVICE ...... 141 tacrolimus ...... 33, 90 SULFADIAZINE (BULK) .. 19 SURE-LANCE ...... 141 TACROLIMUS (BULK) ...... 90 SULFADIAZINE SODIUM SURE-LANCE ULTRA THIN TACROLIMUS (BULK) ...... 111 ...... 141 ANHYDROUS (BULK) .. 33 SULFAMERAZINE (BULK) SURE-PEN LANCING TACROLIMUS ...... 19 DEVICE ...... 141 MICRONIZED (BULK) .. 33 SULFAMETHOXAZOLE SURE-PREP ALCOHOL tadalafil ...... 204 (BULK) ...... 19 PREP PADS ...... 141 tadalafil (pulm. hypertension) sulfamethoxazole-trimethoprim SURESITE MATRIX...... 141 ...... 200 ...... 19, 20 SURESITE WINDOW ...... 141 TAFINLAR ...... 33
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 254 TAGRISSO ...... 33 terbinafine hcl ...... 4 thioridazine ...... 64 TALICIA ...... 161 terbutaline ...... 200 THIORIDAZINE (BULK) ... 64 TALZENNA...... 33 TERBUTALINE SULFATE thiotepa ...... 34 tamoxifen ...... 33 (BULK) ...... 200 THIOTEPA (BULK) ...... 34 TAMOXIFEN (BULK) ...... 33 terconazole...... 177 thiothixene ...... 64 tamsulosin...... 203 terrell ...... 111 THROMBATE III ...... 80 TANNIC ACID (BULK) ..... 90 testosterone ...... 149 THYMOGLOBULIN ...... 169 TARGRETIN ...... 33 TESTOSTERONE (BULK) THYMOL (BULK) ...... 111 tarina 24 fe ...... 183 ...... 149 THYROGEN ...... 111 tarina fe 1/20 (28) ...... 183 TESTOSTERONE CYP, THYROID, PORK (BULK) tarina fe 1-20 eq (28) ...... 183 MICRO (BULK) ...... 149 ...... 150 taron-c dha ...... 222 testosterone cypionate ...... 149 tiadylt er ...... 73 taron-prex prenatal-dha ...... 223 TESTOSTERONE tiagabine ...... 39 TASIGNA ...... 33 CYPIONATE (BULK) ... 149 TIBSOVO ...... 34 tavaborole ...... 98 testosterone enanthate...... 149 TICE BCG ...... 169 TAYTULLA...... 183 TESTOSTERONE tigecycline ...... 16 tazarotene ...... 93 ENANTHATE (BULK) . 149 tilia fe ...... 183 tazicef ...... 10 TESTOSTERONE timolol maleate ...... 73, 186 TAZORAC ...... 93 MICRONIZED (BULK) 149 TIMOLOL MALEATE taztia xt ...... 73 TESTOSTERONE (BULK) ...... 73 TDVAX ...... 169 PROPIONATE (BULK). 149 tinidazole ...... 16 TECENTRIQ ...... 34 TETANUS,DIPHTHERIA TINIDAZOLE (BULK) ...... 16 TECFIDERA ...... 44 TOX PED(PF) ...... 169 tis-u-sol pentalyte ...... 102 TECHLITE LANCETS ...... 142 tetrabenazine ...... 44 TITANIUM DIOXIDE TEFLARO ...... 10 TETRACAINE (BULK) ...... 96 (BULK) ...... 90 TEGADERM ...... 142 tetracaine hcl...... 188 TIVICAY ...... 8 TEGADERM FIRST AID TETRACAINE HCL (BULK) TIVICAY PD ...... 8 STYLE ...... 142 ...... 96 tizanidine ...... 46 TEGADERM FRAME STYLE tetracaine hcl (pf)...... 96 TIZANIDINE (BULK) ...... 46 ...... 142 tetracycline ...... 21 TOBI PODHALER ...... 16 TEGADERM HP FRAME TETRACYCLINE HCL TOBRADEX ...... 190 STYLE ...... 142 (BULK) ...... 21 TOBRADEX ST ...... 190 TEGSEDI ...... 44 TETRAHYDROBIOPTERIN tobramycin ...... 16, 186 TEKTURNA HCT ...... 73 DI-HCL ...... 149 TOBRAMYCIN (BULK) ..... 16 TELCARE LANCETS ...... 142 TETRAHYDROZOLINE HCL tobramycin in 0.225 % nacl .. 16 telmisartan ...... 73 (BULK) ...... 191 tobramycin in 0.9 % nacl ...... 16 telmisartan-amlodipine ...... 73 THALOMID ...... 34 tobramycin sulfate ...... 16, 17 telmisartan-hydrochlorothiazid THEOBROMINE (BULK) 111 TOBRAMYCIN SULFATE ...... 73 theochron ...... 200 (BULK) ...... 16 TEMIXYS ...... 8 theophylline ...... 201 tobramycin-dexamethasone 190 TEMODAR ...... 34 THEOPHYLLINE (BULK)200 TODAY CONTRACEPTIVE temozolomide ...... 34 theophylline in dextrose 5 % SPONGE ...... 177 temsirolimus ...... 34 ...... 201 TOLAZOLINE (BULK) ...... 73 tencon ...... 51 THIABENDAZOLE (BULK) tolcapone ...... 41 TENIPOSIDE ...... 34 ...... 16 tolmetin ...... 55, 56 tenofovir disoproxil fumarate . 8 thiamine hcl (vitamin b1) ... 223 TOLNAFTATE (BULK) ...... 98 terazosin ...... 73 THIN LANCETS ...... 142 tolterodine ...... 202 TERBINAFINE (BULK) ...... 4 THIOGUANINE (BULK) .... 34 tolvaptan ...... 149
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 255 TOPCARE UNIVERSAL1 TRESIBA U-100 INSULIN tri-lo-sprintec ...... 184 LANCET ...... 142 ...... 143 trilyte with flavor packets ... 159 topiramate ...... 39 tretinoin ...... 93 trimethobenzamide ...... 159 TOPIRAMATE (BULK)...... 39 tretinoin (antineoplastic)...... 34 TRIMETHOBENZAMIDE toposar ...... 34 TRETINOIN (BULK) ...... 93 (BULK) ...... 159 topotecan ...... 34 tretinoin microspheres ...... 93 trimethoprim ...... 21 toremifene...... 34 TRETTEN ...... 80 TRIMETHOPRIM (BULK) . 21 torsemide ...... 74 tri femynor ...... 183 TRIMETHOPRIM, MICRO TOUJEO MAX U-300 TRIAMCIN DIACET, MICRO (BULK) ...... 21 SOLOSTAR ...... 142 (BULK) ...... 117 tri-mili ...... 184 TOUJEO SOLOSTAR U-300 TRIAMCINOLONE (BULK) trimipramine ...... 64 INSULIN ...... 142 ...... 117 TRIMO-SAN JELLY ...... 177 tovet emollient ...... 101 triamcinolone acetonide .... 101, trinatal rx 1 ...... 223 TOVIAZ ...... 202 114, 117 trinate ...... 223 TPN ELECTROLYTES II . 209 TRIAMCINOLONE TRIOXSALEN (BULK) .... 112 TRACE ELEMENTS ACETONIDE (BULK)... 101 TRIPELENNAMINE (BULK) 4/PEDIATRIC ...... 209 TRIAMCINOLONE ...... 194 TRACLEER ...... 201 DIACETATE (BULK) ... 117 tri-previfem (28) ...... 184 TRADJENTA ...... 142 triamterene ...... 74 TRIPROLIDINE HCL tramadol ...... 56 TRIAMTERENE (BULK) ... 74 (BULK) ...... 194 TRAMADOL triamterene-hydrochlorothiazid TRIPTODUR ...... 34 HYDROCHLORIDE ...... 74 tri-sprintec (28) ...... 184 (BULK) ...... 56 trianex ...... 101 TRIUMEQ ...... 8 tramadol-acetaminophen ...... 56 triazolam ...... 64 triveen-duo dha ...... 223 trandolapril ...... 74 tri-buffered aspirin ...... 56 tri-vitamin with fluoride ..... 223 trandolapril-verapamil ...... 74 tri-chlor ...... 90 tri-vite with fluoride ...... 223 tranexamic acid ...... 80, 177 TRICHLORMETHIAZIDE trivora (28) ...... 184 TRANEXAMIC ACID (BULK) ...... 74 tri-vylibra ...... 184 (BULK) ...... 80 TRICHLOROACETIC ACID tri-vylibra lo ...... 184 TRANSPARENT ...... 90 TROGARZO ...... 8 DRESSINGS ...... 142 TRICHLOROACETIC ACID TROMETHAMINE (BULK) TRANSPARENT THIN FILM (BULK) ...... 90 ...... 217 DRESSING ...... 143 TRICITRASOL ...... 112 TROPHAMINE 10 % ...... 217 tranylcypromine ...... 64 TRICLOSAN (BULK) ...... 97 tropicamide ...... 187 travasol 10 % ...... 217 triderm ...... 101 TROPICAMIDE (BULK) .. 187 travoprost ...... 190 trientine ...... 112 trospium ...... 202 TRAZIMERA...... 34 tri-estarylla...... 184 TRUE COMFORT trazodone ...... 64 trifluoperazine ...... 64 ALCOHOL PADS ...... 143 TRAZODONE (BULK) ...... 64 trifluridine ...... 186 TRUE COMFORT LANCET TREANDA ...... 34 TRIFLURIDINE (BULK) .. 186 ...... 143 TRELEGY ELLIPTA ...... 201 trihexyphenidyl ...... 41 TRUEDRAW LANCING TREMFYA ...... 86 TRIJARDY XR ...... 143 DEVICE ...... 143 treprostinil sodium...... 74 TRIKAFTA ...... 201 TRUEPLUS LANCETS ..... 143 TRESIBA FLEXTOUCH U- tri-legest fe ...... 184 TRULANCE ...... 159 100 ...... 143 tri-linyah ...... 184 TRULICITY ...... 143 TRESIBA FLEXTOUCH U- tri-lo-estarylla ...... 184 TRUMENBA ...... 169 200 ...... 143 tri-lo-marzia ...... 184 TRUSTEEL INFUSION SET tri-lo-mili ...... 184 23 ...... 143
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 256 TRUSTEEL INFUSION SET UNILET COMFORTOUCH uryl ...... 204 32 ...... 143 LANCET ...... 144 ustell ...... 204 TRUVADA ...... 8 UNILET EXCELITE II utira-c ...... 204 TRUXIMA ...... 34 LANCET ...... 144 UVADEX ...... 90 TUBERSOL ...... 169 UNILET EXCELITE V tulana ...... 176 LANCET ...... 144 VAGINAL TWINRIX (PF) ...... 170 UNILET GP LANCET ...... 144 CONTRACEPTIVE FILM TWIST LANCETS ...... 143 UNILET LANCET ...... 144 ...... 178 tydemy ...... 184 UNILET LANCETS...... 144 vaginal contraceptive foam . 178 TYKERB ...... 34 UNILET SUPER THIN valacyclovir ...... 8 TYMLOS ...... 171 LANCETS ...... 144 VALACYCLOVIR (BULK) .. 8 TYPHIM VI ...... 170 UNISTIK 2 DEVICE ...... 144 VALCHLOR ...... 91 TYREX-1 ...... 217 UNISTIK 2 NORMAL valganciclovir ...... 8 TYROS 1 ...... 217 LANCET,DEVICE...... 144 valproate sodium ...... 39 TYSABRI ...... 44 UNISTIK 3 ...... 144 VALPROATE SODIUM TYVASO ...... 201 UNISTIK 3 COMFORT (BULK) ...... 39 TYVASO INSTITUTIONAL DEVICE ...... 144 valproic acid ...... 40 START KIT...... 201 UNISTIK 3 COMFORT valproic acid (as sodium salt) TYVASO REFILL KIT ..... 201 LANCET ...... 144 ...... 40 TYVASO STARTER KIT . 201 UNISTIK 3 EXTRA LANCET VALPROIC ACID (BULK) . 40 U ...... 144 valrubicin ...... 34 UCERIS ...... 159 UNISTIK 3 GENTLE ...... 144 valsartan ...... 74 UDENYCA ...... 164 UNISTIK 3 LANCETS ...... 144 valsartan-hydrochlorothiazide ULTI-LANCE ...... 143 UNISTIK 3 NEONATAL ...... 74 ULTILET ALCOHOL SWAB DEVICE ...... 144 vancomycin ...... 22 ...... 143 UNISTIK 3 NORMAL VANCOMYCIN (BULK) .... 21 ULTILET BASIC LANCETS LANCET ...... 144 VANCOMYCIN IN 0.9 % ...... 143 UNISTIK CZT LANCET ... 145 SODIUM CHL ...... 21, 22 ULTILET CLASSIC UNISTIK PRO LANCET .. 145 VANCOMYCIN IN LANCETS ...... 143 UNISTIK SAFETY ...... 145 DEXTROSE 5 % ...... 22 ULTILET LANCETS ...... 143 UNISTIK TOUCH LANCETS vandazole ...... 178 ULTILET SAFETY ...... 145 VANTAS ...... 35 LANCETS ...... 144 unithroid ...... 151 vardenafil ...... 204 ULTRA THIN II LANCETS UNITUXIN ...... 34 VARISOFT INFUSION SET ...... 144 UNIVERSAL 1 LANCETS 145 23 ...... 145 ULTRA THIN LANCETS . 144 UPTRAVI ...... 74 VARISOFT INFUSION SET ULTRA THIN PLUS urea ...... 90 32 ...... 145 LANCETS ...... 144 UREA (BULK)...... 90 VARISOFT INFUSION SET ULTRA TLC LANCETS ... 144 urea nail stick...... 90 43 ...... 145 ULTRA-CARE LANCETS 144 ure-k...... 90 VARIVAX (PF) ...... 170 ULTRALANCE LANCETS uretron d-s...... 204 VARIZIG ...... 170 ...... 144 urimar-t ...... 204 VARUBI ...... 159 ULTRA-THIN II LANCETS urin ds ...... 204 VASCEPA ...... 83 ...... 144 uro-458 ...... 204 VASELINE WHITE umecta ...... 90 urogesic-blue ...... 204 PETROLEUM ...... 91 UNDECYLENIC ACID uro-mp ...... 204 VAXCHORA VACCINE ... 170 (BULK) ...... 98 ursodiol ...... 159 VCF CONTRACEPTIVE GEL URSODIOL (BULK) ...... 159 ...... 178
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 257 VECTIBIX ...... 35 VISTOGARD ...... 23 woman's laxative (bisacodyl) vecuronium bromide ...... 46 VISUDYNE...... 188 ...... 159 VELCADE ...... 35 vitamin b complex ...... 223 women's gentle laxative(bisac) veletri ...... 74 vitamin b complex-folic acid ...... 159 velivet triphasic regimen (28) ...... 223 women's laxative (bisacodyl) ...... 184 vitamin k ...... 80 ...... 159 VELPHORO...... 112 vitamin k1 ...... 80 wymzya fe ...... 184 VEMLIDY ...... 8 VITAMIN K1 ...... 81 X VENCLEXTA ...... 35 vitamins a,c,d and fluoride . 223 XALKORI ...... 35 VENCLEXTA STARTING vitamins b complex ...... 223 XARELTO ...... 81 PACK ...... 35 VITRAKVI ...... 35 XARELTO DVT-PE TREAT venlafaxine ...... 64 VIVAGUARD LANCET ... 145 30D START ...... 81 VENOFER ...... 223 VIVAGUARD LANCING XELJANZ ...... 173 VENTOLIN HFA ...... 201 DEVICE ...... 145 XELJANZ XR ...... 173 verapamil ...... 74 VIVITROL ...... 56 XEMBIFY ...... 170 VERAPAMIL (BULK) ...... 74 VIVOTIF ...... 170 XERMELO ...... 35 veripred 20...... 117 VIZIMPRO ...... 35 XGEVA ...... 23 VERZENIO ...... 35 volnea (28) ...... 184 XIAFLEX ...... 112 V-GO 20 ...... 145 VONVENDI ...... 81 XIFAXAN ...... 17 V-GO 30 ...... 145 VORAXAZE ...... 23 XIGDUO XR ...... 145 V-GO 40 ...... 145 voriconazole ...... 4 XIIDRA ...... 188 VIBATIV ...... 22 VORICONAZOLE (BULK) .. 4 XLEU ANALOG ...... 217 VIBERZI ...... 159 VOSEVI ...... 8 XLYS- XTRP ANALOG ... 217 vicodin hp ...... 51 VOTRIENT ...... 35 XMET ANALOG ...... 217 VIDARABINE (BULK) .... 186 vp-ch-pnv...... 223 XMTVI ANALOG ...... 217 VIDARABINE vtol lq ...... 51 XOFIGO ...... 35 MONOHYDRATE (BULK) VUMERITY ...... 44 XOLAIR ...... 201, 202 ...... 186 vyfemla (28) ...... 184 XOSPATA ...... 35 vienva ...... 184 vylibra ...... 184 XPHE, XTYR ANALOG ... 218 vigabatrin ...... 40 VYNDAMAX ...... 84 XPTM ANALOG ...... 218 vigadrone ...... 40 VYNDAQEL ...... 84 XTANDI ...... 35 VIIBRYD ...... 64 VYVANSE ...... 65 xulane ...... 178 VIMIZIM ...... 149 VYXEOS ...... 35 XULTOPHY 100/3.6 ...... 145 VIMPAT...... 40 W XURIDEN ...... 112 vinblastine ...... 35 warfarin ...... 81 xylocaine dental-epinephrine 96 vincasar pfs ...... 35 WARFARIN (BULK) ...... 81 XYLOMETAZOLINE vincristine ...... 35 water for inject, bacteriostat (BULK) ...... 114 vinorelbine ...... 35 ...... 112 XYREM ...... 65 VIOKACE ...... 159 water for injection, sterile ... 112 Y viorele (28) ...... 184 water for irrigation, sterile .. 112 YALE DISPOSABLE VIRACEPT ...... 8 WEBCOL ...... 145 NEEDLES ...... 145 VIREAD ...... 8 wera (28)...... 184 YERVOY ...... 35 virt-c dha ...... 223 westhroid ...... 151 YESCARTA ...... 35 virt-nate dha...... 223 WILATE ...... 81 YF-VAX (PF) ...... 170 virt-pn dha ...... 223 wintergreen oil ...... 91 YOHIMBINE HCL (BULK) virt-pn plus ...... 223 WITCH HAZEL EXTRACT ...... 112 virtussin ac...... 194 (BULK) ...... 91 YONDELIS ...... 36 virtussin dac...... 194 wixela inhub ...... 201 YONSA ...... 36
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 258 YUPELRI ...... 202 ZERBAXA ...... 10 ZOLADEX ...... 36 yuvafem ...... 176 ZEVALIN (Y-90) ...... 36 zoledronic acid ...... 150 Z zidovudine ...... 8 zoledronic acid-mannitol-water zafirlukast ...... 202 ZIEXTENZO ...... 164 ...... 112, 150 zaleplon ...... 65 zileuton ...... 202 ZOLINZA ...... 36 ZALTRAP ...... 36 ZINC ACETATE zolmitriptan ...... 42 ZANOSAR ...... 36 DIHYDRATE (BULK) .. 209 zolpidem ...... 65 zarah ...... 184 zinc chloride ...... 209 ZOMIG ...... 43 ZARXIO ...... 164 ZINC CHLORIDE (BULK) zonisamide ...... 40 zatean-pn dha...... 223 ...... 209 ZORTRESS ...... 36 zatean-pn plus ...... 223 ZINC OXIDE ...... 91 ZOSYN IN DEXTROSE (ISO- zebutal ...... 51 ZINC OXIDE (BULK) ...... 91 OSM) ...... 18 ZEJULA ...... 36 zinc sulfate ...... 209 zovia 1/35e (28) ...... 184 ZELBORAF ...... 36 ZINC SULFATE (BULK) . 209 ZTLIDO ...... 96 ZEMAIRA ...... 112 ZINC SULFATE ZUBSOLV ...... 56 zenatane ...... 93 HEPTAHYDRAT(BULK) ZULRESSO ...... 65 ZENPEP ...... 160 ...... 112 zumandimine (28) ...... 185 zenzedi ...... 65 zingiber ...... 223 ZYDELIG ...... 36 ZEPATIER ...... 8 zionodil ...... 96 ZYKADIA ...... 36 ZEPOSIA ...... 44 ZIOPTAN (PF) ...... 190 ZYLET ...... 190 ZEPOSIA STARTER KIT ... 44 ziprasidone hcl ...... 65 ZYTIGA ...... 36 ZEPOSIA STARTER PACK ziprasidone mesylate ...... 65 ...... 44 ZIRABEV ...... 36
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 259