QUALIFIED HEALTH PLAN FORMULARY Effective December 2016
Provided by EnvisionRx Introduction The Total Health Care (THC) Qualified Health Plan Formulary was developed to serve as a guide for physicians, pharmacists, health care professionals and members in the selection of cost-effective drug therapy. Total Health Care recognizes that drug therapy is an integral part of effective health management. Total Health Care continually reviews new and existing medications to ensure the Formulary remains responsive to the needs of our members and health professionals. Criteria used to evaluate drug selection for the formulary includes, but is not limited to: safety, efficacy and cost-effectiveness data, as well as comparison of relevant benefits of similar prescription or over-the counter (OTC) agents while minimizing potential duplications. Notice The information contained in this formulary is provided by THC & EnvisionRxOptions, solely for the convenience of medical providers and members. THC does not warrant or assure accuracy of this information, nor is it intended to be comprehensive in nature. This formulary is not intended to be a substitute for the knowledge, expertise, skill or judgment of the medical provider in their choice of prescription drugs. Total Health Care assumes no responsibility for the actions or omissions of any medical provider based upon reliance, in whole or in part, on the information contained herein. The medical provider should consult the drug manufacturer’s product literature or standard references for more detailed information. How to Read the Formulary All formulary drugs are listed either by their generic names (in lowercase) or by their brand names (in uppercase). Drugs are grouped together by their therapeutic drug category. Specific drug listings may be accessed by using the index, using the covered generic name or the covered brand name of the drug. Any drug not found in this Formulary listing shall be considered a non-formulary drug.
i
Tier Guidelines Generic
Tier 1
Preferred Brand
Tier 2
Non-Preferred Brand Non- Preferred Generic Specialty
Tier 3
Preventive
Tier 5 $0 co-pay at in-network pharmacies
Tier 4
The Certificate of Coverage provided upon enrollment has specific information regarding co-payments, coinsurance, annual deductible requirements and maximum out of pocket limits associated with the corresponding pharmacy benefit. Prescribing Guidelines Prescribing guidelines may apply to select drugs on the THC formulary. Prescribing guidelines may vary by benefit design but may include: Prior Authorization Required (PA)
Drug requires prior authorization through a specific physician request process.
Over the Counter Drugs (OTC)
Drug coverage is available for drugs that are available OTC with an authorized prescription from your provider.
Specialty Drugs (SP)
Drug requires processing through THC’s contracted specialty pharmacy, Diplomat Specialty Pharmacy.
Quantity Limit (QL)
Drug coverage may be limited to specific quantities per prescription and/or time period.
Age Limit (AL)
Drug coverage may depend on patient age.
Gender Restriction (GR) Step Therapy Required (ST)
Drug coverage may depend on patient gender.
Custom (C)
Drug coverage has unique restrictions.
Drug coverage requires that an alternative or trial of another drug be used before the medication is covered.
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Saving on Out-Of-Pocket Costs Total Health Care has designed its prescription drug plan to encourage the use of generic and preferred brand name drugs. Choosing non-preferred drugs may mean paying higher out-of-pocket expenses (such as coinsurance and co-payments) or not receiving coverage at all. Members may also pay less for generic drugs or they may be asked to pay the cost difference between brand name drugs and their generic alternatives, which are preferred by the plan. Benefit Coverage and Limitations This formulary does not define benefit coverage and limitations. Many members have specific benefit inclusions, exclusions, copayments, coinsurance or a lack of coverage, which are not reflected in the THC Qualified Health Plan Formulary. Members should contact Total Health Care at 1-800-826-2862 if they have questions regarding their coverage. Please note that the formulary process is evolutionary and changes can occur throughout the year. Preventive Medications Total Health Care covers certain preventive services for $0 co-pay when delivered by in-network pharmacies. These drugs are indicated on the THC Qualified Health Plan Formulary under Drug Tier 5. Examples of preventive medications include aspirin, contraceptives, iron supplementations, smoking cessation products and Vitamin D drugs. These drugs are available with standard drug coverage recommendations and are only available for certain populations. Prior Authorization (PA) Drugs indicated with a “PA” require Prior Authorization for coverage. A prescriber may complete a Prior Authorization form that can be found on the Total Health Care website at www.THCmi.com. You may also request a form by calling Total Health Care at 1-844-222-5584. Completed prior authorization forms should be faxed to 1-866-414-3453. Prior Authorization review of prescribing guidelines will be evaluated utilizing the established drug review criteria approved by Total Health Care. If the request does not meet the approved criteria, the request will not be approved and alternative therapy may be recommended along with the proper course of alternative action. The requesting provider will be provided written notification of Total Health Care review decisions. THC’s website has a contact link where members can contact THC’s Pharmacy Department to ask for an exception request. Non-Formulary Agents Drugs not located on the Total Health Care Qualified Health Plan Formulary, or any updates published by Total Health Care, shall be considered a non-formulary drug. Requests for coverage of non-formulary agents may be requested by the health professional depending on specific coverage parameters. Review for nonformulary drug requests will require a Prior Authorization request with documentation of medical necessity. Generally, the following basic medical necessity guidelines are used in conducting a review:
The patient has failed an appropriate trial of formulary or preferred agents. The use of preferred or formulary agent is contraindicated in the patient. iii
The formulary drug or preferred agents are not suited for the present patient care need, and the drug selected is required for patient safety.
If the request does not meet the established guidelines request, it will not be approved and alternative therapy may be recommended along with the proper course of alternative action. Common Drug Exclusions The member’s plan design may exclude certain drug classes. Prior authorization is generally not available for drugs that are specifically excluded by benefit design. Common excluded coverages may include, but are not limited to:
OTC medications or their equivalents unless otherwise specified in the Formulary listing. Drug products used for cosmetic purposes. Experimental drug products, or any drug product used in an experimental manner. Foreign drugs or drugs not approved by the United States Food & Drug Administration (FDA).
Mandated Generic Substitution Total Health Care advocates the use of cost-effective generic drugs where FDA-approved generic equivalent drugs are available. Generic products are listed in the Formulary and noted in lowercase lettering wherever an FDA-approved generic drug product is available. If a member or physician requests a brand name product in lieu of an approved generic, the member, based upon their coverage, will be required to pay the difference in cost between the brand/non-preferred brand and the generic drug, plus the brand/non-preferred brand copay. Total Health Care Pharmacy and Therapeutics (P&T) Committee Total Health Care’s Pharmacy & Therapeutics Committee meets quarterly to review and recommend medications for formulary consideration. The Committee considers clinical information on drugs that are new to the market and drugs that are typically included in an outpatient pharmacy benefit. This assures that the formulary remains responsive to patient and physician needs. The Committee is composed of physicians, pharmacists, and health care professionals. The Committee also uses reference materials from our Pharmacy Benefits Manager's Pharmacy and Therapeutics Advisory Panel. Product Selection Criteria The primary goal of the THC Pharmacy & Therapeutics Committee is to maintain and update the formulary based upon an objective analysis of the safety, efficacy, approved indications, adverse effects, contraindications, patient administration/compliance considerations and cost effectiveness of available drugs. When a drug is considered for formulary inclusion, it will be reviewed relative to similar drugs including those currently in the THC Formulary. Physicians may request a copy of THC’s drug criteria by calling the Pharmacy Department at 1-800-826-2862. Diabetic Testing Supplies Total Health Care works with J&B Medical Supply to provide diabetic testing supplies to our members. Covered diabetic testing supplies include Glucocard Vital glucometer, Glucocard Expression glucometer, and SD Biosensor GlucoNavii glucometer, Glucocard Vital test strips, Glucocard Expression test strips, SD Biosensor GlucoNavii test strips, lancets, insulin syringes, alcohol swabs and ketone strips. These supplies iv
are to be filled through J&B Medical Supply. If you have any questions about our diabetic supply program, please contact J&B Medical Supply at 1-844-236-7933. Specialty Bio-Pharmaceutical Pharmacy Program Total Health Care works with Diplomat Specialty Pharmacy to provide Specialty Bio-Pharmaceutical Pharmacy products to our members. These medications are to be filled exclusively through Diplomat Specialty Pharmacy. A Specialty Drug Prior Authorization Request form must be completed and faxed to EnvisionRx at 1-866414-3453 with supporting documentation and the prescription. A prescriber may obtain a Specialty Drug Prior Authorization Request form found on the Total Health Care website at www.THCmi.com. Once the order is received, EnvisionRx obtains authorization from Total Health Care. If the specialty prior authorization is approved, Total Health Care notifies Diplomat Specialty Pharmacy. Then the Diplomat Specialty Pharmacy staff ships the medication directly to the physician's office or the patient’s home. All packages are individually marked for each patient and refrigerated items are shipped in insulated containers. Where appropriate, each shipment includes needles, syringes and alcohol swabs. If you have any questions about our Specialty Bio-Pharmaceutical Pharmacy program, please contact EnvisionRx at 1-844-222-5584 or Diplomat Specialty Pharmacy at 1-877-977-9118. Contact Information The Total Health Care Qualified Health Plan Formulary is designed to assist physicians, members and other health care professionals in the selection of cost-effective agents. Total Health Care encourages your input and feedback on how we can assist in improving this document and the formulary management process. You may contact THC at 1-800-826-2862. Medication Limitations Quantity Limitations Quantity Limitations are on medications throughout the formulary and are indicated with a "QL" notation. These are medications that have a daily dose restriction, quantity/days’ supply limitation, and/or a limitation on the duration of therapy. Age Limitations Age Limitations are on medications throughout the formulary and are indicated with an "AL" notation. Coverage for a medication is indicated by the age limitation. This could be a minimum age, maximum age, and/or the combination of a minimum and maximum age edit. Gender Restrictions Gender restrictionss are indicated with a “GR” on the formulary and require the member to be a specific gender for coverage. Step Therapy Criteria v
Step Therapy medications are indicated with a “ST” on the formulary and require that an alternative, first line medication be tried and failed before the requested medication can be covered. The online claims adjudication system will automatically allow for the requested medication to be filled based on electronic claims history indicating that the first line medication was filled.
Step Therapy Criteria Therapy Class First Line Acetylcholinesterase Inhibitors
Aminosalicylic Acid Derivative Agents Analgesic Combination Agents
Second Line
donepezil, galantamine immediaterelease APRISO, DELZICOL
galantamine extendedrelease
hydrocodoneapap, ibuprofen
REPREXAIN, hydrocodoneibuprofen
PENTASA, ASACOL HD
Angiotensin Receptor losartan, Blocker losartan-hctz, ibesartan, ibesartan-hctz
telmisartan, telmisartanhctz
Angiotensintrandolapril, Converting Enzyme verapamil and Calcium Channel Blocker Antidiabetic Agents JANUVIA
trandolaprilverapamil
Antiemetic Agents
ANZEMET
ondansetron, granisetron
Antiglaucoma Agents latanoprost
Antihemorrhoidal Agents
hydrocortisone suppository
TRADJENTA ONGLYZA
LUMIGAN, bimatoprost, TRAVATANZ, ZIOPTAN CORTIFOAM
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Third Line Step Therapy Criteria Prior use of donepezil or galantamine immediate-release in the last 90 days. Prior use of APRISO or DELZICOL in the last 90 days. Prior use of hydrocodone-apap and ibuprofen in the last 90 days. BENICAR, Second Line: Prior BENICAR- use of losartan or HCT irbesartan-hctz in the last 90 days. Third Line: Prior use of telmisartan-hctz in the last 90 days. Prior use of trandolapril and verapamil in the last 90 days. Prior use of JANUVIA in the last 90 days. Prior use of ondansetron or granisetron in the last 90 days. Prior use of latanoprost in the last 90 days. Prior use of hydrocortisone suppository in the last 90 days.
Antimigraine
sumatriptan, rizatriptan
naratriptan
Anti-Parkinson's Agents
selegiline tablet
EMSAM
Anti-Parkinson's Agents
ropinirole immediaterelease
ropinirole extendedrelease
Antiprotozoal Antibiotic
metronidazole immediaterelease
FLAGYL ER
Antipsychotic Agents quetiapine immediaterelease, risperidone, ziprasidone, olanzapine
SEROQUEL XR
Antiviral Agents
valacyclovir
famciclovir
Benign Prostatic Hyperplasia agents
doxazosin immediaterelease, finasteride, tamsulosin, terazosin
AVODART, dutasteride
Angiotensin Receptor amlodipine, Blocker and Calcium losartan Channel Blocker
AZOR, amlodipinevalsartan
Beta2 Agonist
levalbuterol nebulizer solution XOPENEX HFA
Beta2 Agonist
albuterol nebulizer solution VENTOLIN HFA, PROAIR HFA, PROVENTIL
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AXERT, FROVA, frovatriptan, RELPAX
SAPHRIS
Second Line: Prior use of sumatriptan or rizatriptan in the last 90 days Third Line: Prior use of naratriptan in the last 90 days. Prior use of selegiline tablet in the last 90 days. Prior use of ropinirole immediaterelease in the last 90 days. Prior use of metronidazole immediate-release in the last 90 days. Second Line: Prior use of two first line agents within the last 90 days. Third Line: Prior use of SEROQUEL XR in the last 90 days. Prior use of valacyclovir in the last 90 days. Prior use of doxazosin immediate-release, finasteride, tamsulosin, or terazosin in the last 90 days (Member must have paid claims for two first line drugs). Prior use of amlodipine and losartan in the last 90 days. Prior use of albuterol nebulizer solution in the last 90 days. Prior use of VENTOLIN HFA, PROAIR HFA, or PROVENTIL HFA in
HFA
the last 90 days.
Beta Blocker
carvedilol immediaterelease
COREG CR, BYSTOLIC
Glucocorticoid Inhaler
AEROSPAN, DULERA
SYMBICORT ADVAIR DISKUS, ADVAIR HFA
Beta Blocker
propranolol immediaterelease
propranolol extendedrelease
HMG-CoA Reductase atorvastatin, Inhibitor simvastatin
Insulin Combination
NOVOLOG MIX 70/30
Melatonin Receptor Agonists
temazepam, zaleplon, zolpidem immediaterelease
Nasal Corticosteriods flunisolide, fluticasone, NASACORT OTC
Osteoporosis
alendronate
CRESTOR, rosuvastatin, LIVALO, VYTORIN HUMALOG MIX 75/25 ROZEREM
Prior use of carvedilol immediaterelease in the last 90 days. Second Line: Prior use of AEROSPAN or DULERA within the last 90 days. Third Line: Prior use of SYMBICORT in the last 90 days. Prior use of propranolol immediate-release in the last 90 days. Prior use of atorvastatin and simvastatin in the last 90 days. Prior use of HUMALOG MIX in the last 90 days. Prior use of temazepam, zaleplon or zolpidem immediate-release in the last 90 days (Member must have paid claims for two first line drugs). Prior use of flunisolide, fluticasone, or NASACORT OTC in the last 180 days (Member must have paid claims for two first line drugs).
ASTEPRO, azelastine, BECONASE AQ, NASONEX, mometasone, PATANASE, QNASL, RHINOCORT , budesonide, VERAMYST ACTONEL, MIACALCIN, Second Line: Prior calcitonin risedronate, use of alendronate ATELVIA, within the last 90 risedronate days. dr, Third Line: Prior use ibandronate of ACTONEL, viii
risedronate/dr, ATELVIA, or ibandronate in the last 90 days (Member must have paid claims for two first line drugs). Pleuromutilin mupirocin ALTABAX Prior use of Antibiotic mupirocin in the last 90 days. Rapid-Acting Insulin APIDRA HUMALOG Prior use of APIDRA VIALS, VIALS or NOVOLOG NOVOLOG VIALS in the last 90 VIALS days. Retinoic Acid tretinoin 0.025%, ATRALIN Prior use of tretinoin Derivatives tretinoin 0.05%, GEL, 0.025%, tretinoin tretinoin 0.1% tretinoin 0.05%, or tretinoin 0.04% gel 0.1% in the last 90 days. Scabicidal Agent permethrin 5% NATROBA Prior use of 0.9% permethrin 5% in the last 90 days. Short-Acting Insulin NOVOLIN N, HUMULIN Prior use of NOVOLIN R N, NOVOLIN in the last HUMULIN R 90 days. Tetracycline doxycycline minocycline doxycycline Second Line: Prior Antibiotics hyclate, tablets, 75mg, use of doxycycline doxycycline minocycline doxycycline hyclate, doxycycline monohydrate, capsules 150mg monohydrate, or doxycycline doxycycline suspension suspension in the last 90 days. Third Line: Prior use of minocycline tablets or capsules in the last 90 days. Topical ketoconazole 2% CAPEX Prior use of Corticosteroids shampoo SHAMPOO ketoconazole 2% shampoo in the last 90 days. Topical clobetasol, calcip-beta, Prior use of Corticosteroids desonide, TACLONEX clobetasol, desonide, betamethasone, SUSP, betamethasone, flucinolone, TACLONEX flucinolone, flucinonide, OINTMENT flucinonide, hydrocortisone, hydrocortisone, or triamcinolone triamcinolone in the last 90 days (Member must have paid claims ix
Urinary Antispasmodics
oxybutynin, tolterodine, ENABLEX, oxybutynin er, tolterodine er, darifenacin, OXYTROL trospium TOVIAZ, OTC, oxybutynin VESICARE, syrup trospium er
for two first line drugs). Second Line: Prior use of OXYTROL OTC, oxybutynin, oxybutynin er, or oxybutynin syrup in the last 90 days. Third Line: Prior use of tolterodine, tolterodine er, or trospium in the last 90 days.
*Formulary Disclaimer: Coverage for some drugs may be limited to specific dosage forms and/or strengths. The benefit design determines what is covered and the applicable co-payment. The medications listed on this formulary are subject to change pursuant to the formulary management activities of EnvisionRx. The presence of a medication on this formulary list does not guarantee coverage.
x
lowercase italics = Generic drugs UPPERCASE BOLD = Brand name drugs
Drug *Adhd/Anti-Narcolepsy/Anti-Obesity/A norexiants*
Status T1 = Tier 1 T2 = Tier 2 T3 = Tier 3 T4 = Tier 4 T5 = Tier 5
Status
Notes AL = Age Limit GR-F = Female Only GR-M = Male Only PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
Notes
amphetamine-dextroamphet er oral capsule extended release 24 hour 10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 5 mg
T3
amphetamine-dextroamphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 30 mg, 5 mg, 7.5 mg
T1
armodafinil oral tablet 150 mg, 200 mg, 50 mg
T4
caffeine citrate intravenous* solution 60 mg/3ml
T1
caffeine citrate oral solution 20 mg/ml
T1
caffeine-sodium benzoate injection solution 125-125 mg/ml
T1
DAYTRANA TRANSDERMAL PATCH 10 MG/9HR, 15 MG/9HR, 20 MG/9HR, 30 MG/9HR
T3
PA; QL (30 EA per 30 days); AL (Min 6 Years and Max 17 Years)
dexmethylphenidate hcl er oral capsule extended release 24 hour 10 mg, 20 mg
T3
PA; QL (30 EA per 30 days); AL (Min 6 Years and Max 17 Years)
dexmethylphenidate hcl er oral capsule extended release 24 hour 15 mg, 30 mg, 40 mg
T3
PA; QL (30 EA per 30 days)
dexmethylphenidate hcl oral tablet 10 mg, 2.5 mg, 5 mg
T1
AL (Min 6 Years and Max 17 Years)
dextroamphetamine sulfate er oral capsule extended release 24 hour 10 mg, 15 mg, 5 mg
T1
dextroamphetamine sulfate oral tablet 10 mg, 5 mg
T1
QL (30 EA per 30 days)
PA
1
Drug
Status
Notes
diethylpropion hcl er oral tablet extended release 24 hr* 75 mg
T1
diethylpropion hcl oral tablet 25 mg
T1
doxapram hcl intravenous* solution 20 mg/ml
T1
FOCALIN XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG, 15 MG, 20 MG, 25 MG, 30 MG, 35 MG, 40 MG
T3
PA; QL (30 EA per 30 days); AL (Min 6 Years and Max 17 Years)
guanfacine hcl er oral tablet extended release 24 hr* 1 mg, 2 mg, 3 mg, 4 mg
T3
PA
methamphetamine hcl oral tablet 5 mg
T1
methylphenidate hcl er (cd) oral capsule extended release* 10 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg
T1
QL (30 EA per 30 days); AL (Min 6 Years and Max 17 Years)
methylphenidate hcl er (la) oral capsule extended release 24 hour 20 mg, 30 mg, 40 mg
T1
QL (30 EA per 30 days); AL (Min 6 Years and Max 17 Years)
methylphenidate hcl er oral tablet extended release 24 hr* 18 mg, 27 mg, 36 mg, 54 mg
T3
QL (30 EA per 30 days); AL (Min 6 Years and Max 17 Years)
methylphenidate hcl er oral tablet extendedrelease* 10 mg, 20 mg
T1
QL (30 EA per 30 days); AL (Min 6 Years and Max 17 Years)
methylphenidate hcl er oral tablet extendedrelease* 18 mg, 27 mg, 36 mg, 54 mg
T3
QL (30 EA per 30 days); AL (Min 6 Years and Max 17 Years)
methylphenidate hcl oral solution 10 mg/5ml, 5 mg/5ml
T1
PA
methylphenidate hcl oral tablet 10 mg, 20 mg, 5 mg
T1
modafinil oral tablet 100 mg, 200 mg
T4
PA
NUVIGIL ORAL TABLET 150 MG
T4
PA
phendimetrazine tartrate er oral capsule extended release 24 hour 105 mg
T1
phendimetrazine tartrate oral tablet 35 mg
T1
phentermine hcl oral capsule 15 mg, 30 mg, 37.5 mg
T1
phentermine hcl oral tablet 37.5 mg
T1
STRATTERA ORAL CAPSULE 10 MG, 100 MG, 18 MG, 25 MG, 40 MG, 60 MG, 80 MG
T3
PA; AL (Min 6 Years and Max 17 Years)
*Aminoglycosides* neomycin sulfate oral tablet 500 mg
T1
*Analgesics - Anti-Inflammatory* ACTEMRA SUBCUTANEOUS* 162 MG/0.9ML
T4
PA
ARCALYST SUBCUTANEOUS* SOLUTION RECONSTITUTED 220 MG
T4
PA
2
Drug
Status
Notes
celecoxib oral capsule 100 mg, 200 mg, 50 mg
T1
QL (30 EA per 30 days)
diclofenac potassium oral tablet 50 mg
T1
diclofenac sodium er oral tablet extended release 24 hr* 100 mg
T1
diclofenac sodium oral tablet delayed release 25 mg, 50 mg, 75 mg
T1
diclofenac-misoprostol oral tablet delayed release 50-0.2 mg, 75-0.2 mg
T3
ENBREL SUBCUTANEOUS* SOLUTION RECONSTITUTED 25 MG
T4
etodolac er oral tablet extended release 24 hr* 400 mg, 500 mg, 600 mg
T1
etodolac oral capsule 200 mg, 300 mg
T1
etodolac oral tablet 400 mg, 500 mg
T1
flurbiprofen oral tablet 100 mg, 50 mg
T1
HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS* 40 MG/0.8ML
T4
PA
HUMIRA PEN SUBCUTANEOUS* 40 MG/0.8ML
T4
PA
HUMIRA PEN-CROHNS STARTER SUBCUTANEOUS* 40 MG/0.8ML
T4
PA
HUMIRA PEN-PSORIASIS STARTER SUBCUTANEOUS* 40 MG/0.8ML
T4
PA
HUMIRA SUBCUTANEOUS* 20 MG/0.4ML, 40 MG/0.8ML
T4
PA
IBUPROFEN COMFORT PAC COMBINATION KIT 800 MG
T1
ibuprofen oral suspension 100 mg/5ml
T1
ibuprofen oral tablet 400 mg, 600 mg, 800 mg
T1
indomethacin er oral capsule extended release* 75 mg
T1
indomethacin oral capsule 25 mg, 50 mg
T1
AL (Max 64 Years)
ketoprofen er oral capsule extended release 24 hour 200 mg
T1
QL (30 EA per 30 days)
ketoprofen oral capsule 50 mg
T1
QL (180 EA per 30 days)
ketoprofen oral capsule 75 mg
T1
QL (120 EA per 30 days)
ketorolac tromethamine oral tablet 10 mg
T1
QL (20 EA per 5 days)
KINERET SUBCUTANEOUS* 100 MG/0.67ML
T4
PA
leflunomide oral tablet 10 mg, 20 mg
T1
meclofenamate sodium oral capsule 100 mg, 50 mg
T3
PA
3
Drug
Status
Notes
MELOXICAM COMFORT PAC COMBINATION KIT 15 MG
T1
meloxicam oral suspension 7.5 mg/5ml
T3
meloxicam oral tablet 15 mg, 7.5 mg
T1
nabumetone oral tablet 500 mg
T1
QL (120 EA per 30 days)
nabumetone oral tablet 750 mg
T1
QL (60 EA per 30 days)
NAPROXEN COMFORT PAC COMBINATION KIT 500 MG
T1
naproxen dr oral tablet delayed release 375 mg, 500 mg
T1
naproxen kit oral tablet 500 mg
T1
naproxen oral suspension 125 mg/5ml
T1
naproxen oral tablet 250 mg, 375 mg, 500 mg
T1
naproxen sodium oral tablet 275 mg, 550 mg
T1
oxaprozin oral tablet 600 mg
T3
piroxicam oral capsule 10 mg, 20 mg
T1
RIDAURA ORAL CAPSULE 3 MG
T4
sulindac oral tablet 150 mg, 200 mg
T1
tolmetin sodium oral capsule 400 mg
T1
tolmetin sodium oral tablet 200 mg, 600 mg
T3
PA
*Analgesics - Nonnarcotic* adult aspirin ec low strength oral tablet delayed release 81 mg
T5
QL (60 EA per 30 days); AL (Min 40 Years and Max 79 Years)
adult aspirin low strength oral tablet dispersible 81 mg
T5
QL (60 EA per 30 days)
aspirin low dose oral tablet chewable 81 mg
T5
QL (60 EA per 30 days); AL (Min 40 Years and Max 79 Years)
aspirin oral tablet delayed release 325 mg
T5
QL (30 EA per 30 days); AL (Min 40 Years and Max 79 Years)
BAYER ADVANCED ASPIRIN EX ST ORAL TABLET 500 MG
T5
QL (30 EA per 30 days)
buffered aspirin oral tablet 325 mg
T5
QL (30 EA per 30 days); AL (Min 40 Years and Max 79 Years)
butalbital-acetaminophen oral tablet 50-325 mg
T1
butalbital-apap-caffeine oral capsule 50-300-40 mg, 50-325-40 mg
T1
butalbital-apap-caffeine oral tablet 50-325-40 mg
T1
butalbital-aspirin-caffeine oral capsule 50-325-40 mg
T1
choline-mag trisalicylate oral liquid† 500 mg/5ml
T1
diflunisal oral tablet 500 mg
T1
4
Drug
Status
Notes
salsalate oral tablet 500 mg, 750 mg
T1
sm aspirin oral tablet 325 mg
T5
QL (30 EA per 30 days); AL (Min 40 Years and Max 79 Years)
acetaminophen-codeine #2 oral tablet 300-15 mg
T1
QL (390 EA per 30 days)
acetaminophen-codeine #3 oral tablet 300-30 mg
T1
QL (390 EA per 30 days)
acetaminophen-codeine #4 oral tablet 300-60 mg
T1
QL (390 EA per 30 days)
acetaminophen-codeine oral solution 120-12 mg/5ml
T1
acetaminophen-codeine oral tablet 300-15 mg, 300-30 mg, 300-60 mg
T1
ASCOMP-CODEINE ORAL CAPSULE 50-325-40-30 MG
T1
ASTRAMORPH INJECTION SOLUTION 0.5 MG/ML, 1 MG/ML
T3
PA
buprenorphine hcl injection solution 0.3 mg/ml
T3
PA
buprenorphine hcl sublingual tablet sublingual 2 mg, 8 mg
T3
PA
buprenorphine hcl-naloxone hcl sublingual tablet sublingual 2-0.5 mg, 8-2 mg
T3
PA; QL (90 EA per 30 days)
butalbital-apap-caff-cod oral capsule 50-300-40-30 mg, 50-325-40-30 mg
T1
butalbital-asa-caff-codeine oral capsule 50-325-40-30 mg
T1
butorphanol tartrate injection solution 1 mg/ml, 2 mg/ml
T3
butorphanol tartrate nasal solution 10 mg/ml
T3
BUTRANS TRANSDERMAL PATCH WEEKLY 10 MCG/HR, 20 MCG/HR, 5 MCG/HR
T3
codeine sulfate oral solution 30 mg/5ml
T1
codeine sulfate oral tablet 15 mg, 30 mg
T1
duramorph injection solution 0.5 mg/ml, 1 mg/ml
T3
PA
ENDOCET ORAL TABLET 10-325 MG, 7.5-325 MG
T1
QL (180 EA per 30 days)
ENDOCET ORAL TABLET 5-325 MG
T1
QL (360 EA per 30 days)
ENDODAN ORAL TABLET 4.8355-325 MG
T1
fentanyl transdermal patch 72 hr 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr
T1
hydrocodone-acetaminophen oral solution 10-325 mg/15ml, 2.5-108 mg/5ml, 5-217 mg/10ml, 7.5-325 mg/15ml
T1
*Analgesics - Opioid*
QL (390 EA per 30 days)
PA
PA; QL (10 EA per 30 days)
5
Drug
Status
Notes
hydrocodone-acetaminophen oral tablet 10-300 mg, 7.5-300 mg
T3
QL (180 EA per 30 days)
hydrocodone-acetaminophen oral tablet 10-325 mg, 7.5-325 mg
T1
QL (180 EA per 30 days)
hydrocodone-acetaminophen oral tablet 2.5-325 mg
T1
hydrocodone-acetaminophen oral tablet 5-300 mg
T3
hydrocodone-acetaminophen oral tablet 5-325 mg
T1
QL (360 EA per 30 days)
hydrocodone-ibuprofen oral tablet 10-200 mg
T1
ST
hydrocodone-ibuprofen oral tablet 2.5-200 mg, 5-200 mg, 7.5-200 mg
T1
hydromorphone hcl oral liquid† 1 mg/ml
T3
hydromorphone hcl oral tablet 2 mg, 4 mg, 8 mg
T1
hydromorphone hcl suppository 3 mg
T3
IBUDONE ORAL TABLET 5-200 MG
T1
levorphanol tartrate oral tablet 2 mg
T1
LORCET PLUS ORAL TABLET 7.5-325 MG
T1
QL (180 EA per 30 days)
LORTAB ORAL TABLET 7.5-325 MG
T1
QL (180 EA per 30 days)
meperidine hcl injection solution 10 mg/ml, 100 mg/ml, 25 mg/ml, 50 mg/ml
T3
meperidine hcl oral solution 50 mg/5ml
T1
meperidine hcl oral tablet 100 mg, 50 mg
T1
methadone hcl injection solution 10 mg/ml
T3
methadone hcl oral concentrate 10 mg/ml
T1
methadone hcl oral solution 10 mg/5ml, 5 mg/5ml
T1
methadone hcl oral tablet 10 mg
T1
methadone hcl oral tablet 5 mg
T1
methadone hcl oral tablet soluble 40 mg
T1
morphine sulfate (concentrate) oral solution 20 mg/ml
T1
morphine sulfate (pf) injection solution 0.5 mg/ml, 1 mg/ml
T3
morphine sulfate (pf) intravenous* solution 10 mg/ml, 15 mg/ml, 2 mg/ml, 4 mg/ml, 8 mg/ml
T3
morphine sulfate er oral tablet extendedrelease* 100 mg, 15 mg, 30 mg, 60 mg
T1
morphine sulfate in dextrose intravenous* solution 1-5 mg/ml-%
T3
morphine sulfate injection solution 10 mg/ml, 15 mg/ml, 2 mg/ml, 4 mg/ml, 5 mg/ml, 8 mg/ml
T3
6
QL (240 EA per 30 days)
QL (240 EA per 30 days)
QL (90 EA per 30 days)
Drug
Status
Notes
morphine sulfate intramuscular* device 10 mg/0.7ml
T3
morphine sulfate intravenous* solution 1 mg/ml, 150 mg/30ml, 25 mg/ml, 50 mg/ml
T3
morphine sulfate oral solution 10 mg/5ml, 20 mg/5ml
T1
morphine sulfate oral tablet 15 mg, 30 mg
T3
morphine sulfate suppository 10 mg, 20 mg, 30 mg, 5 mg
T3
nalbuphine hcl injection solution 10 mg/ml, 20 mg/ml
T3
NORCO ORAL TABLET 7.5-325 MG
T1
NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HR* 100 MG, 150 MG, 200 MG, 250 MG, 50 MG
T3
PA
OPANA ER ORAL 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 5 MG, 7.5 MG
T3
PA
OPANA ER ORAL TABLET EXTENDED RELEASE 12 HR* 10 MG, 20 MG, 30 MG, 40 MG, 5 MG
T3
PA
oxycodone hcl oral capsule 5 mg
T1
QL (180 EA per 30 days)
oxycodone hcl oral concentrate 100 mg/5ml
T3
oxycodone hcl oral solution 5 mg/5ml
T1
oxycodone hcl oral tablet 10 mg, 15 mg, 20 mg, 30 mg, 5 mg
T1
QL (180 EA per 30 days)
oxycodone-acetaminophen oral tablet 10-325 mg, 7.5-325 mg
T1
QL (180 EA per 30 days)
oxycodone-acetaminophen oral tablet 2.5-325 mg
T1
oxycodone-acetaminophen oral tablet 5-325 mg
T1
oxycodone-aspirin oral tablet 4.8355-325 mg
T1
oxycodone-ibuprofen oral tablet 5-400 mg
T1
QL (240 EA per 30 days)
oxymorphone hcl er oral tablet extended release 12 hr* 10 mg
T3
PA; QL (90 EA per 30 days)
oxymorphone hcl er oral tablet extended release 12 hr* 15 mg, 20 mg, 30 mg, 40 mg, 7.5 mg
T3
PA
oxymorphone hcl er oral tablet extended release 12 hr* 5 mg
T3
pentazocine-naloxone hcl oral tablet 50-0.5 mg
T1
REPREXAIN ORAL TABLET 10-200 MG
T1
ST
ROXICET ORAL TABLET 5-325 MG
T1
QL (360 EA per 30 days)
SUBOXONE SUBLINGUAL FILM 12-3 MG
T3
PA; QL (30 EA per 30 days)
QL (180 EA per 30 days)
QL (360 EA per 30 days)
7
Drug
Status
Notes
SUBOXONE SUBLINGUAL FILM 2-0.5 MG, 4-1 MG
T3
PA; QL (90 EA per 30 days)
SUBOXONE SUBLINGUAL FILM 8-2 MG
T3
PA; QL (60 EA per 30 days)
tramadol hcl er (biphasic) oral tablet extended release 24 hr* 100 mg, 200 mg, 300 mg
T3
tramadol hcl er oral capsule extended release 24 hour 150 mg
T3
tramadol hcl er oral tablet extended release 24 hr* 100 mg, 200 mg, 300 mg
T3
tramadol hcl oral tablet 50 mg
T1
tramadol-acetaminophen oral tablet 37.5-325 mg
T1
VICODIN ES ORAL TABLET 7.5-300 MG
T3
VICODIN ORAL TABLET 5-300 MG
T3
QL (240 EA per 30 days) QL (180 EA per 30 days)
*Androgens-Anabolic* ANADROL-50 ORAL TABLET 50 MG
T4
ANDRODERM TRANSDERMAL PATCH 24 HR 2 MG/24HR, 4 MG/24HR
T3
PA
ANDROGEL PUMP TRANSDERMAL GEL 20.25 MG/ACT (1.62%)
T3
PA
ANDROGEL TRANSDERMAL GEL 20.25 MG/1.25GM (1.62%), 25 MG/2.5GM (1%), 40.5 MG/2.5GM (1.62%)
T3
PA
ANDROXY ORAL TABLET 10 MG
T3
PA
AXIRON TRANSDERMAL SOLUTION 30 MG/ACT
T3
PA
methitest oral tablet 10 mg
T3
testosterone transdermal gel 25 mg/2.5gm (1%)
T3
PA
*Anorectal Agents* ANALPRAM-HC LOTION 1-2.5 %
T3
COLOCORT ENEMA 100 MG/60ML
T1
CORTIFOAM FOAM 10 %
T3
hydrocortisone ace-pramoxine cream 1-1 %, 2.5-1 %
T3
hydrocortisone ace-pramoxine kit 2.5-1 & 1 %
T1
hydrocortisone acetate suppository 25 mg, 30 mg
T1
hydrocortisone enema 100 mg/60ml
T1
lidocaine-hydrocortisone ace cream 3-0.5 %
T1
lidocaine-hydrocortisone ace gel 2.8-0.55 %
T3
lidocaine-hydrocortisone ace kit 2-2 %
T3
lidocaine-hydrocortisone ace kit 3-0.5 %, 3-1 %, 3-2.5 %
T1
8
ST
PA
Drug
Status
pramcort cream 1-1 %
T1
PROCTOFOAM HC FOAM 1-1 %
T3
PROCTOZONE-HC CREAM 2.5 %
T1
RECTIV OINTMENT 0.4 %
T3
Notes QL (60 GM per 23 days)
*Anthelmintics* ALBENZA ORAL TABLET 200 MG
T2
PIN-X ORAL SUSPENSION 50 MG/ML
T1
PIN-X ORAL TABLET CHEWABLE 720.5 MG
T1
reeses pinworm medicine oral suspension 144 mg/ml
T1
*Antianginal Agents* DILATRATE-SR ORAL CAPSULE EXTENDED RELEASE* 40 MG
T3
isosorbide dinitrate er oral tablet extendedrelease* 40 mg
T1
isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 mg, 5 mg
T1
isosorbide mononitrate er oral tablet extended release 24 hr* 120 mg, 30 mg, 60 mg
T1
isosorbide mononitrate oral tablet 10 mg, 20 mg
T1
MINITRAN TRANSDERMAL PATCH 24 HR 0.1 MG/HR, 0.2 MG/HR, 0.4 MG/HR, 0.6 MG/HR
T1
NITRO-BID TRANSDERMAL OINTMENT 2 %
T3
NITRO-DUR TRANSDERMAL PATCH 24 HR 0.3 MG/HR, 0.8 MG/HR
T3
nitroglycerin er oral capsule extended release* 2.5 mg, 6.5 mg, 9 mg
T1
nitroglycerin sublingual tablet sublingual 0.3 mg, 0.4 mg, 0.6 mg
T1
nitroglycerin transdermal patch 24 hr 0.1 mg/hr, 0.2 mg/hr, 0.4 mg/hr, 0.6 mg/hr
T1
nitroglycerin translingual aerosol, solution 400 mcg/spray
T3
nitroglycerin translingual solution 0.4 mg/spray
T3
NITROLINGUAL TRANSLINGUAL SOLUTION 0.4 MG/SPRAY
T3
NITROSTAT SUBLINGUAL TABLET SUBLINGUAL 0.3 MG, 0.4 MG, 0.6 MG
T2
9
Drug RANEXA ORAL TABLET EXTENDED RELEASE 12 HR* 1000 MG, 500 MG
Status
Notes
T3
PA
alprazolam er oral tablet extended release 24 hr* 0.5 mg, 1 mg, 2 mg, 3 mg
T3
AL (Max 64 Years)
alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg
T1
alprazolam oral tablet dispersible 0.25 mg, 0.5 mg, 1 mg, 2 mg
T3
buspirone hcl oral tablet 10 mg, 15 mg, 30 mg, 5 mg, 7.5 mg
T1
chlordiazepoxide hcl oral capsule 10 mg, 25 mg, 5 mg
T1
clorazepate dipotassium oral tablet 15 mg, 3.75 mg, 7.5 mg
T1
diazepam injection solution 5 mg/ml
T1
diazepam intramuscular* 10 mg/2ml
T1
diazepam oral solution 1 mg/ml
T1
diazepam oral tablet 10 mg, 2 mg, 5 mg
T1
droperidol injection solution 2.5 mg/ml
T1
hydroxyzine hcl intramuscular* solution 25 mg/ml, 50 mg/ml
T1
hydroxyzine hcl oral solution 10 mg/5ml
T1
hydroxyzine hcl oral syrup 10 mg/5ml
T1
hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg
T1
hydroxyzine pamoate oral capsule 100 mg, 25 mg, 50 mg
T1
lorazepam injection solution 2 mg/ml, 4 mg/ml
T1
LORAZEPAM INTENSOL ORAL CONCENTRATE 2 MG/ML
T1
lorazepam oral concentrate 2 mg/ml
T1
lorazepam oral tablet 0.5 mg, 1 mg, 2 mg
T1
meprobamate oral tablet 200 mg, 400 mg
T1
oxazepam oral capsule 10 mg, 15 mg, 30 mg
T1
*Antianxiety Agents*
*Antiarrhythmics* amiodarone hcl oral tablet 200 mg, 400 mg
T1
disopyramide phosphate oral capsule 100 mg, 150 mg
T1
flecainide acetate oral tablet 100 mg, 150 mg, 50 mg
T1
10
AL (Max 64 Years)
AL (Max 64 Years) AL (Max 64 Years)
AL (Max 64 Years)
AL (Max 64 Years)
Drug
Status
mexiletine hcl oral capsule 150 mg, 200 mg, 250 mg
T1
MULTAQ ORAL TABLET 400 MG
T3
NORPACE CR ORAL CAPSULE EXTENDED RELEASE 12 HOUR 100 MG
T3
PACERONE ORAL TABLET 100 MG
T3
propafenone hcl er oral capsule extended release 12 hour 225 mg, 325 mg, 425 mg
T3
propafenone hcl oral tablet 150 mg, 225 mg, 300 mg
T1
quinidine gluconate er oral tablet extendedrelease* 324 mg
T1
quinidine sulfate er oral tablet extendedrelease* 300 mg
T1
quinidine sulfate oral tablet 200 mg, 300 mg
T1
Notes
PA
PA
*Antiasthmatic And Bronchodilator Agents* ADVAIR DISKUS INHALATION AEROSOL POWDER, BREATH ACTIVATED 100-50 MCG/DOSE
T2
QL (60 EA per 30 days)
ADVAIR DISKUS INHALATION AEROSOL POWDER, BREATH ACTIVATED 250-50 MCG/DOSE, 500-50 MCG/DOSE
T3
ST
ADVAIR HFA INHALATION AEROSOL† 115-21 MCG/ACT, 230-21 MCG/ACT, 45-21 MCG/ACT
T3
ST
AEROSPAN INHALATION AEROSOL, SOLUTION 80 MCG/ACT
T2
QL (8.9 GM per 30 days)
albuterol sulfate er oral tablet extended release 12 hr* 4 mg, 8 mg
T1
albuterol sulfate inhalation nebulization solution (2.5 mg/3ml) 0.083%, (5 mg/ml) 0.5%, 0.63 mg/3ml, 1.25 mg/3ml
T1
albuterol sulfate oral syrup 2 mg/5ml
T1
aminophylline intravenous* solution 25 mg/ml
T1
ARCAPTA NEOHALER INHALATION CAPSULE 75 MCG
T3
QL (30 EA per 30 days)
ASMANEX 120 METERED DOSES INHALATION AEROSOL POWDER, BREATH ACTIVATED 220 MCG/INH
T3
QL (2 EA per 30 days)
ASMANEX 14 METERED DOSES INHALATION AEROSOL POWDER, BREATH ACTIVATED 220 MCG/INH
T3
QL (2 EA per 30 days)
11
Drug
Status
Notes
ASMANEX 30 METERED DOSES INHALATION AEROSOL POWDER, BREATH ACTIVATED 110 MCG/INH, 220 MCG/INH
T3
QL (2 EA per 30 days)
ASMANEX 60 METERED DOSES INHALATION AEROSOL POWDER, BREATH ACTIVATED 220 MCG/INH
T3
QL (2 EA per 30 days)
ASMANEX 7 METERED DOSES INHALATION AEROSOL POWDER, BREATH ACTIVATED 110 MCG/INH
T3
QL (2 EA per 30 days)
ATROVENT HFA INHALATION AEROSOL, SOLUTION 17 MCG/ACT
T2
QL (26 GM per 25 days)
BREO ELLIPTA INHALATION AEROSOL POWDER, BREATH ACTIVATED 100-25 MCG/INH
T3
BREO ELLIPTA INHALATION AEROSOL POWDER, BREATH ACTIVATED 200-25 MCG/INH
T3
QL (60 EA per 30 days)
BROVANA INHALATION NEBULIZATION SOLUTION 15 MCG/2ML
T3
PA
budesonide inhalation suspension 0.25 mg/2ml, 0.5 mg/2ml
T1
QL (120 ML per 30 days)
budesonide inhalation suspension 1 mg/2ml
T4
QL (120 ML per 30 days)
COMBIVENT RESPIMAT INHALATION AEROSOL, SOLUTION 20-100 MCG/ACT
T3
QL (4 GM per 25 days)
DULERA INHALATION AEROSOL† 100-5 MCG/ACT, 200-5 MCG/ACT
T2
QL (13 GM per 25 days)
ELIXOPHYLLIN ORAL ELIXIR 80 MG/15ML
T2
epinephrine hcl injection 0.1 mg/ml
T1
epinephrine hcl injection solution 1 mg/ml
T1
FLOVENT DISKUS INHALATION AEROSOL POWDER, BREATH ACTIVATED 100 MCG/BLIST
T3
QL (60 EA per 30 days)
FORADIL AEROLIZER INHALATION CAPSULE 12 MCG
T2
QL (60 EA per 30 days)
INCRUSE ELLIPTA INHALATION AEROSOL POWDER, BREATH ACTIVATED 62.5 MCG/INH
T2
QL (30 EA per 30 days)
ipratropium bromide inhalation solution 0.02 %
T1
ipratropium-albuterol inhalation solution 0.5-2.5 (3) mg/3ml
T1
12
Drug
Status
Notes
levalbuterol hcl inhalation nebulization solution 0.31 mg/3ml, 0.63 mg/3ml, 1.25 mg/0.5ml, 1.25 mg/3ml
T1
ST
levalbuterol tartrate hfa inhalation aerosol† 45 mcg/act
T3
ST; QL (15 GM per 30 days)
metaproterenol sulfate oral syrup 10 mg/5ml
T1
metaproterenol sulfate oral tablet 10 mg, 20 mg
T1
montelukast sodium oral packet 4 mg
T1
montelukast sodium oral tablet 10 mg
T1
montelukast sodium oral tablet chewable 4 mg, 5 mg
T1
PERFOROMIST INHALATION NEBULIZATION SOLUTION 20 MCG/2ML
T3
PROAIR HFA INHALATION AEROSOL, SOLUTION 108 (90 BASE) MCG/ACT
T3
PROVENTIL HFA INHALATION AEROSOL, SOLUTION 108 (90 BASE) MCG/ACT
T3
QL (6.7 GM per 30 days)
PULMICORT FLEXHALER INHALATION AEROSOL POWDER, BREATH ACTIVATED 180 MCG/ACT, 90 MCG/ACT
T3
QL (1 EA per 30 days)
QVAR INHALATION AEROSOL, SOLUTION 40 MCG/ACT, 80 MCG/ACT
T2
QL (8.7 GM per 30 days)
SEREVENT DISKUS INHALATION AEROSOL POWDER, BREATH ACTIVATED 50 MCG/DOSE
T2
SPIRIVA HANDIHALER INHALATION CAPSULE 18 MCG
T2
QL (30 EA per 30 days)
STRIVERDI RESPIMAT INHALATION AEROSOL, SOLUTION 2.5 MCG/ACT
T2
QL (4 GM per 30 days)
SYMBICORT INHALATION AEROSOL† 160-4.5 MCG/ACT, 80-4.5 MCG/ACT
T2
ST; QL (10.2 GM per 25 days)
terbutaline sulfate injection solution 1 mg/ml
T1
terbutaline sulfate oral tablet 2.5 mg, 5 mg
T1
theophylline er oral tablet extended release 12 hr* 100 mg, 200 mg, 300 mg, 450 mg
T1
theophylline er oral tablet extended release 24 hr* 400 mg, 600 mg
T1
theophylline oral solution 80 mg/15ml
T1
TUDORZA PRESSAIR INHALATION AEROSOL POWDER, BREATH ACTIVATED 400 MCG/ACT
T2
PA
QL (60 EA per 30 days)
13
Drug
Status
Notes
VENTOLIN HFA INHALATION AEROSOL, SOLUTION 108 (90 BASE) MCG/ACT
T2
XOLAIR SUBCUTANEOUS* SOLUTION RECONSTITUTED 150 MG
T4
PA
XOPENEX HFA INHALATION AEROSOL† 45 MCG/ACT
T3
ST; QL (60 GM per 30 days)
zafirlukast oral tablet 10 mg, 20 mg
T3
ZYFLO CR ORAL TABLET EXTENDED RELEASE 12 HR* 600 MG
T4
PA
ZYFLO ORAL TABLET 600 MG
T4
PA
*Anticoagulants* enoxaparin sodium injection solution 300 mg/3ml
T4
enoxaparin sodium subcutaneous* solution 100 mg/ml, 120 mg/0.8ml, 150 mg/ml, 30 mg/0.3ml, 40 mg/0.4ml, 60 mg/0.6ml, 80 mg/0.8ml
T4
fondaparinux sodium subcutaneous* solution 10 mg/0.8ml, 2.5 mg/0.5ml, 5 mg/0.4ml, 7.5 mg/0.6ml
T4
FRAGMIN SUBCUTANEOUS* SOLUTION 10000 UNIT/ML, 12500 UNIT/0.5ML, 15000 UNIT/0.6ML, 18000 UNT/0.72ML, 2500 UNIT/0.2ML, 5000 UNIT/0.2ML, 7500 UNIT/0.3ML
T4
heparin (porcine) in nacl injection solution 100-0.45 unit/ml-%
T1
heparin lock flush intravenous* solution 1 unit/ml, 10 unit/ml, 100 unit/ml
T1
heparin sod (porcine) in d5w intravenous* solution 100 unit/ml
T1
heparin sodium (porcine) injection solution 1000 unit/ml, 10000 unit/ml, 20000 unit/ml, 5000 unit/ml
T1
heparin sodium (porcine) pf injection solution 5000 unit/0.5ml
T1
heparin sodium lock flush intravenous* solution 10 unit/ml, 100 unit/ml
T1
JANTOVEN ORAL TABLET 1 MG, 10 MG, 2 MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG
T1
MONOJECT FLUSH SYR/HEP LOCK INTRAVENOUS* SOLUTION 10 UNIT/ML, 100 UNIT/ML
T1
PRADAXA ORAL CAPSULE 150 MG, 75 MG
T3
14
PA
PA
Drug
Status
sash kit intravenous* kit 100-0.9 unit/ml-%
T1
warfarin sodium oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg
T1
XARELTO ORAL TABLET 10 MG, 15 MG, 20 MG
T3
Notes
PA
*Anticonvulsants* BANZEL ORAL SUSPENSION 40 MG/ML
T3
carbamazepine er oral capsule extended release 12 hour 100 mg, 200 mg, 300 mg
T1
carbamazepine er oral tablet extended release 12 hr* 200 mg, 400 mg
T1
carbamazepine oral suspension 100 mg/5ml
T1
carbamazepine oral tablet 200 mg
T1
carbamazepine oral tablet chewable 100 mg
T1
CELONTIN ORAL CAPSULE 300 MG
T2
clonazepam oral tablet 0.5 mg, 1 mg, 2 mg
T1
clonazepam oral tablet dispersible 0.125 mg, 0.25 mg, 0.5 mg, 1 mg, 2 mg
T1
DILANTIN ORAL CAPSULE 100 MG, 30 MG
T2
divalproex sodium er oral tablet extended release 24 hr* 250 mg, 500 mg
T1
divalproex sodium oral 125 mg
T1
divalproex sodium oral tablet delayed release 125 mg, 250 mg, 500 mg
T1
EPITOL ORAL TABLET 200 MG
T1
ethosuximide oral capsule 250 mg
T1
ethosuximide oral solution 250 mg/5ml
T3
felbamate oral suspension 600 mg/5ml
T4
felbamate oral tablet 400 mg, 600 mg
T3
gabapentin oral capsule 100 mg, 300 mg, 400 mg
T1
gabapentin oral solution 250 mg/5ml
T1
gabapentin oral tablet 600 mg, 800 mg
T1
GABITRIL ORAL TABLET 12 MG, 16 MG
T3
LAMICTAL ODT ORAL KIT 25 & 50 & 100 MG, 25 (21)-50 (7) MG, 50 (42)-100(14) MG
T3
lamotrigine er oral tablet extended release 24 hr* 100 mg, 200 mg, 25 mg, 250 mg, 300 mg, 50 mg
T3
lamotrigine oral kit 25 & 50 & 100 mg, 25 (21)-50 (7) mg, 50 (42)-100(14) mg
T3
15
Drug
Status
Notes
lamotrigine oral tablet 100 mg, 150 mg, 200 mg, 25 mg
T1
lamotrigine oral tablet chewable 25 mg, 5 mg
T1
levetiracetam er oral tablet extended release 24 hr* 500 mg, 750 mg
T3
levetiracetam intravenous* solution 500 mg/5ml
T1
levetiracetam oral solution 100 mg/ml
T1
levetiracetam oral tablet 1000 mg
T1
QL (90 EA per 30 days)
levetiracetam oral tablet 250 mg
T1
QL (360 EA per 30 days)
levetiracetam oral tablet 500 mg
T1
QL (180 EA per 30 days)
levetiracetam oral tablet 750 mg
T1
QL (120 EA per 30 days)
LYRICA ORAL CAPSULE 100 MG, 150 MG, 200 MG, 225 MG, 25 MG, 300 MG, 50 MG, 75 MG
T3
PA
LYRICA ORAL SOLUTION 20 MG/ML
T3
PA
oxcarbazepine oral suspension 300 mg/5ml
T1
oxcarbazepine oral tablet 150 mg, 300 mg, 600 mg
T1
PEGANONE ORAL TABLET 250 MG
T3
PHENYTOIN INFATABS ORAL TABLET CHEWABLE 50 MG
T1
phenytoin oral suspension 125 mg/5ml
T1
phenytoin oral tablet chewable 50 mg
T1
phenytoin sodium extended oral capsule 100 mg, 200 mg, 300 mg
T1
phenytoin sodium injection solution 50 mg/ml
T1
POTIGA ORAL TABLET 200 MG, 300 MG, 400 MG, 50 MG
T3
primidone oral tablet 250 mg, 50 mg
T1
SABRIL ORAL PACKET 500 MG
T4
TEGRETOL-XR ORAL TABLET EXTENDED RELEASE 12 HR* 100 MG
T2
tiagabine hcl oral tablet 2 mg, 4 mg
T3
topiramate oral capsule sprinkle 15 mg, 25 mg
T1
topiramate oral tablet 100 mg, 200 mg, 25 mg, 50 mg
T1
valproic acid oral capsule 250 mg
T1
valproic acid oral solution 250 mg/5ml
T1
valproic acid oral syrup 250 mg/5ml
T1
zonisamide oral capsule 100 mg
T1
QL (180 EA per 30 days)
zonisamide oral capsule 25 mg, 50 mg
T1
QL (360 EA per 30 days)
16
PA
Drug *Antidepressants*
Status
Notes
amitriptyline hcl oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg
T1
amoxapine oral tablet 100 mg, 150 mg, 25 mg, 50 mg
T1
bupropion hcl er (sr) oral tablet extended release 12 hr* 100 mg, 200 mg
T1
bupropion hcl er (sr) oral tablet extended release 12 hr* 150 mg
T5
bupropion hcl er (xl) oral tablet extended release 24 hr* 150 mg, 300 mg
T1
bupropion hcl oral tablet 100 mg, 75 mg
T1
citalopram hydrobromide oral solution 10 mg/5ml
T1
citalopram hydrobromide oral tablet 10 mg, 20 mg, 40 mg
T1
clomipramine hcl oral capsule 25 mg, 50 mg, 75 mg
T1
CYMBALTA ORAL CAPSULE DELAYED RELEASE PARTICLES 20 MG, 30 MG, 60 MG
T3
desipramine hcl oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg
T1
desvenlafaxine er oral tablet extended release 24 hr* 100 mg, 50 mg
T1
desvenlafaxine fumarate er oral tablet extended release 24 hr* 100 mg, 50 mg
T1
doxepin hcl oral capsule 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg
T1
doxepin hcl oral concentrate 10 mg/ml
T1
duloxetine hcl oral capsule delayed release particles 20 mg, 30 mg, 60 mg
T3
QL (30 EA per 30 days)
EMSAM TRANSDERMAL PATCH 24 HR 12 MG/24HR, 6 MG/24HR, 9 MG/24HR
T3
ST
escitalopram oxalate oral solution 5 mg/5ml
T1
escitalopram oxalate oral tablet 10 mg, 5 mg
T1
QL (45 EA per 30 days)
escitalopram oxalate oral tablet 20 mg
T1
QL (30 EA per 30 days)
fluoxetine hcl oral capsule 10 mg, 20 mg, 40 mg
T1
fluoxetine hcl oral capsule delayed release 90 mg
T1
fluoxetine hcl oral solution 20 mg/5ml
T1
fluoxetine hcl oral tablet 10 mg, 20 mg
T1
QL (60 EA per 30 days)
QL (4 EA per 28 days)
17
Drug
Status
Notes
fluvoxamine maleate oral tablet 100 mg, 25 mg, 50 mg
T1
imipramine hcl oral tablet 10 mg, 25 mg, 50 mg
T1
imipramine pamoate oral capsule 100 mg, 125 mg, 150 mg, 75 mg
T3
maprotiline hcl oral tablet 25 mg, 50 mg, 75 mg
T1
MARPLAN ORAL TABLET 10 MG
T3
mirtazapine oral tablet 15 mg, 30 mg, 45 mg, 7.5 mg
T1
mirtazapine oral tablet dispersible 15 mg, 30 mg, 45 mg
T3
nefazodone hcl oral tablet 100 mg, 150 mg, 200 mg, 250 mg, 50 mg
T1
nortriptyline hcl oral capsule 10 mg, 25 mg, 50 mg, 75 mg
T1
nortriptyline hcl oral solution 10 mg/5ml
T1
paroxetine hcl er oral tablet extended release 24 hr* 12.5 mg, 25 mg, 37.5 mg
T3
paroxetine hcl oral tablet 10 mg, 20 mg, 30 mg, 40 mg
T1
PAXIL ORAL SUSPENSION 10 MG/5ML
T2
phenelzine sulfate oral tablet 15 mg
T1
PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR* 100 MG, 25 MG, 50 MG
T3
PA
sertraline hcl oral concentrate 20 mg/ml
T1
PA
sertraline hcl oral tablet 100 mg, 25 mg, 50 mg
T1
tranylcypromine sulfate oral tablet 10 mg
T1
trazodone hcl oral tablet 100 mg, 150 mg, 300 mg, 50 mg
T1
trimipramine maleate oral capsule 100 mg, 25 mg, 50 mg
T1
venlafaxine hcl er oral capsule extended release 24 hour 150 mg, 37.5 mg, 75 mg
T1
venlafaxine hcl er oral tablet extended release 24 hr* 150 mg, 225 mg, 37.5 mg, 75 mg
T3
venlafaxine hcl oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 75 mg
T1
VIIBRYD ORAL KIT 10 & 20 & 40 MG
T3
PA
VIIBRYD ORAL TABLET 10 MG, 20 MG, 40 MG
T3
PA
*Antidiabetics* acarbose oral tablet 100 mg, 25 mg, 50 mg 18
T1
AL (Max 64 Years)
PA
Drug
Status
Notes
alogliptin benzoate oral tablet 12.5 mg, 25 mg, 6.25 mg
T3
QL (30 EA per 30 days)
alogliptin-metformin hcl oral tablet 12.5-1000 mg, 12.5-500 mg
T3
QL (30 EA per 30 days)
alogliptin-pioglitazone oral tablet 12.5-15 mg, 12.5-30 mg, 12.5-45 mg, 25-15 mg, 25-30 mg, 25-45 mg
T3
QL (30 EA per 30 days)
APIDRA INJECTION SOLUTION 100 UNIT/ML
T2
APIDRA SOLOSTAR SUBCUTANEOUS* 100 UNIT/ML
T2
AVANDIA ORAL TABLET 2 MG
T3
PA
BYDUREON SUBCUTANEOUS* 2 MG
T3
PA; QL (4 EA per 30 days)
BYETTA 10 MCG PEN SUBCUTANEOUS* 10 MCG/0.04ML
T3
PA; QL (2.4 ML per 30 days)
BYETTA 5 MCG PEN SUBCUTANEOUS* 5 MCG/0.02ML
T3
PA; QL (1.2 ML per 1 day)
chlorpropamide oral tablet 100 mg, 250 mg
T1
CYCLOSET ORAL TABLET 0.8 MG
T3
glimepiride oral tablet 1 mg, 2 mg, 4 mg
T1
glipizide er oral tablet extended release 24 hr* 10 mg, 2.5 mg, 5 mg
T1
glipizide oral tablet 10 mg, 5 mg
T1
glipizide xl oral tablet extended release 24 hr* 10 mg, 2.5 mg, 5 mg
T1
glipizide-metformin hcl oral tablet 2.5-250 mg, 2.5-500 mg, 5-500 mg
T1
GLUCAGEN HYPOKIT INJECTION SOLUTION RECONSTITUTED 1 MG
T3
QL (2 EA per 30 days)
GLUCAGON EMERGENCY INJECTION KIT 1 MG
T3
QL (2 EA per 30 days)
glucose oral tablet chewable 4 gm
T1
GLUMETZA ORAL TABLET EXTENDED RELEASE 24 HR* 500 MG
T3
glyburide micronized oral tablet 1.5 mg, 3 mg, 6 mg
T1
glyburide oral tablet 1.25 mg, 2.5 mg, 5 mg
T1
glyburide-metformin oral tablet 1.25-250 mg, 2.5-500 mg, 5-500 mg
T1
GLYSET ORAL TABLET 25 MG
T3
HUMALOG KWIKPEN SUBCUTANEOUS* 100 UNIT/ML
T3
QL (60 EA per 30 days)
QL (60 EA per 30 days)
ST
19
Drug
Status
Notes
HUMALOG MIX 50/50 KWIKPEN SUBCUTANEOUS* (50-50) 100 UNIT/ML
T3
HUMALOG MIX 50/50 SUBCUTANEOUS* SUSPENSION (50-50) 100 UNIT/ML
T3
HUMALOG MIX 75/25 KWIKPEN SUBCUTANEOUS* (75-25) 100 UNIT/ML
T3
PA
HUMALOG MIX 75/25 SUBCUTANEOUS* SUSPENSION (75-25) 100 UNIT/ML
T3
ST
HUMALOG SUBCUTANEOUS* 100 UNIT/ML
T3
ST
HUMALOG SUBCUTANEOUS* SOLUTION 100 UNIT/ML
T3
ST
HUMULIN N SUBCUTANEOUS* SUSPENSION 100 UNIT/ML
T3
ST
HUMULIN R INJECTION SOLUTION 100 UNIT/ML
T3
ST
HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS* SOLUTION 500 UNIT/ML
T4
PA
INVOKANA ORAL TABLET 100 MG, 300 MG
T3
JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG
T3
QL (30 EA per 30 days)
JENTADUETO ORAL TABLET 2.5-1000 MG, 2.5-500 MG, 2.5-850 MG
T3
PA; QL (60 EA per 30 days)
LANTUS SOLOSTAR SUBCUTANEOUS* 100 UNIT/ML
T3
LANTUS SUBCUTANEOUS* SOLUTION 100 UNIT/ML
T2
LEVEMIR FLEXPEN SUBCUTANEOUS* 100 UNIT/ML
T3
LEVEMIR FLEXTOUCH SUBCUTANEOUS* 100 UNIT/ML
T3
LEVEMIR SUBCUTANEOUS* SOLUTION 100 UNIT/ML
T2
metformin hcl er (mod) oral tablet extended release 24 hr* 500 mg
T3
metformin hcl er (osm) oral tablet extended release 24 hr* 1000 mg, 500 mg
T1
metformin hcl er oral tablet extended release 24 hr* 500 mg, 750 mg
T1
metformin hcl oral tablet 1000 mg, 500 mg, 850 mg
T1
miglitol oral tablet 25 mg
T3
20
PA
Drug
Status
Notes
nateglinide oral tablet 120 mg, 60 mg
T1
NOVOLIN 70/30 RELION SUBCUTANEOUS* SUSPENSION (70-30) 100 UNIT/ML
T2
NOVOLIN 70/30 SUBCUTANEOUS* SUSPENSION (70-30) 100 UNIT/ML
T2
NOVOLIN N RELION SUBCUTANEOUS* SUSPENSION 100 UNIT/ML
T2
ST
NOVOLIN N SUBCUTANEOUS* SUSPENSION 100 UNIT/ML
T2
ST
NOVOLIN R INJECTION SOLUTION 100 UNIT/ML
T2
ST
NOVOLIN R RELION INJECTION SOLUTION 100 UNIT/ML
T2
ST
NOVOLOG FLEXPEN SUBCUTANEOUS* 100 UNIT/ML
T3
NOVOLOG MIX 70/30 FLEXPEN SUBCUTANEOUS* (70-30) 100 UNIT/ML
T3
NOVOLOG MIX 70/30 SUBCUTANEOUS* SUSPENSION (70-30) 100 UNIT/ML
T3
NOVOLOG PENFILL SUBCUTANEOUS* 100 UNIT/ML
T3
NOVOLOG SUBCUTANEOUS* SOLUTION 100 UNIT/ML
T3
ONGLYZA ORAL TABLET 2.5 MG, 5 MG
T3
ST; QL (30 EA per 30 days)
pioglitazone hcl oral tablet 15 mg, 30 mg, 45 mg
T1
QL (30 EA per 30 days)
pioglitazone hcl-glimepiride oral tablet 30-2 mg, 30-4 mg
T3
pioglitazone hcl-metformin hcl oral tablet 15-500 mg, 15-850 mg
T3
PRANDIN ORAL TABLET 0.5 MG, 1 MG, 2 MG
T2
ra glucose oral tablet chewable 6-4 mg-gm
T1
repaglinide oral tablet 0.5 mg, 1 mg, 2 mg
T2
SYMLINPEN 120 SUBCUTANEOUS* 2700 MCG/2.7ML
T3
PA
SYMLINPEN 60 SUBCUTANEOUS* 1500 MCG/1.5ML
T3
PA
TANZEUM SUBCUTANEOUS* 30 MG, 50 MG
T3
PA
tolazamide oral tablet 250 mg, 500 mg
T1
tolbutamide oral tablet 500 mg
T1
TRADJENTA ORAL TABLET 5 MG
T3
PA
ST; QL (30 EA per 30 days) 21
Drug VICTOZA SUBCUTANEOUS* 18 MG/3ML
Status T3
Notes PA; QL (6 ML per 30 days)
*Antidiarrheals* diphenoxylate-atropine oral liquid† 2.5-0.025 mg/5ml
T1
diphenoxylate-atropine oral tablet 2.5-0.025 mg
T1
loperamide hcl oral capsule 2 mg
T1
loperamide hcl oral liquid† 1 mg/5ml
T1
loperamide hcl oral tablet 2 mg
T1
*Antidotes And Specific Antagonists* acetylcysteine intravenous* solution 200 mg/ml
T1
deferoxamine mesylate injection solution reconstituted 2 gm, 500 mg
T1
fomepizole intravenous* solution 1 gm/ml, 1.5 gm/1.5ml
T1
physostigmine salicylate injection solution 1 mg/ml
T1
*Antidotes* acetylcysteine intravenous* solution 200 mg/ml
T1
CHEMET ORAL CAPSULE 100 MG
T3
deferoxamine mesylate injection solution reconstituted 2 gm, 500 mg
T1
FERRIPROX ORAL TABLET 500 MG
T4
fomepizole intravenous* solution 1 gm/ml, 1.5 gm/1.5ml
T1
naloxone hcl injection solution 0.4 mg/ml
T1
QL (2 ML per 90 days)
naloxone hcl injection solution 1 mg/ml
T2
QL (2 ML per 90 days)
naltrexone hcl oral tablet 50 mg
T1
pentetate calcium trisodium combination solution 200 mg/ml
T1
pentetate zinc trisodium combination solution 200 mg/ml
T1
physostigmine salicylate injection solution 1 mg/ml
T1
VIVITROL INTRAMUSCULAR* SUSPENSION RECONSTITUTED 380 MG
T4
PA
ANZEMET ORAL TABLET 100 MG, 50 MG
T3
ST
CESAMET ORAL CAPSULE 1 MG
T3
PA
dimenhydrinate injection solution 50 mg/ml
T3
dronabinol oral capsule 10 mg
T4
PA
*Antiemetics*
22
PA
Drug
Status
Notes
dronabinol oral capsule 2.5 mg, 5 mg
T3
PA
granisetron hcl oral tablet 1 mg
T3
QL (10 EA per 23 days)
meclizine hcl oral tablet 12.5 mg, 25 mg
T1
ondansetron hcl oral solution 4 mg/5ml
T1
ondansetron hcl oral tablet 24 mg
T1
QL (5 EA per 23 days)
ondansetron hcl oral tablet 4 mg, 8 mg
T1
QL (15 EA per 23 days)
ondansetron oral tablet dispersible 4 mg, 8 mg
T1
QL (10 EA per 23 days)
trimethobenzamide hcl oral capsule 300 mg
T1
*Antifungals* fluconazole oral suspension reconstituted 10 mg/ml, 40 mg/ml
T1
QL (105 ML per 30 days)
fluconazole oral tablet 100 mg, 150 mg, 200 mg, 50 mg
T1
QL (30 EA per 30 days)
griseofulvin microsize oral suspension 125 mg/5ml
T1
griseofulvin microsize oral tablet 500 mg
T1
griseofulvin ultramicrosize oral tablet 125 mg, 250 mg
T1
ketoconazole oral tablet 200 mg
T1
nystatin oral powder
T1
nystatin oral tablet 500000 unit
T1
terbinafine hcl oral tablet 250 mg
T1
*Antihistamines* ALLEGRA ALLERGY CHILDRENS ORAL TABLET 30 MG
T1
QL (50 EA per 30 days)
carbinoxamine maleate oral tablet 4 mg
T1
AL (Max 64 Years)
cetirizine hcl allergy child oral solution 5 mg/5ml
T1
cetirizine hcl oral tablet 10 mg, 5 mg
T1
QL (50 EA per 30 days)
clemastine fumarate oral syrup 0.67 mg/5ml
T1
AL (Max 64 Years)
clemastine fumarate oral tablet 2.68 mg
T1
AL (Max 64 Years)
cyproheptadine hcl oral syrup 2 mg/5ml
T1
cyproheptadine hcl oral tablet 4 mg
T1
diphenhydramine hcl injection solution 50 mg/ml
T1
diphenhydramine hcl oral capsule 50 mg
T1
diphenhydramine hcl oral elixir 12.5 mg/5ml
T1
AL (Max 64 Years)
diphenhydramine hcl oral liquid† 12.5 mg/5ml
T1
AL (Max 64 Years)
fexofenadine hcl oral tablet 180 mg, 60 mg
T1
QL (50 EA per 30 days)
levocetirizine dihydrochloride oral tablet 5 mg
T1
QL (30 EA per 30 days)
loratadine childrens oral solution 5 mg/5ml
T1
QL (50 ML per 30 days)
AL (Max 64 Years)
23
Drug
Status
Notes
loratadine oral tablet 10 mg
T1
QL (50 EA per 30 days)
promethazine hcl injection solution 25 mg/ml, 50 mg/ml
T1
promethazine hcl oral solution 6.25 mg/5ml
T1
promethazine hcl oral tablet 12.5 mg, 25 mg, 50 mg
T1
promethazine hcl suppository 12.5 mg, 25 mg, 50 mg
T1
silphen cough oral syrup 12.5 mg/5ml
T1
AL (Max 64 Years)
sm loratadine oral tablet dispersible 10 mg
T1
QL (50 EA per 30 days)
atorvastatin calcium oral tablet 10 mg, 20 mg, 40 mg, 80 mg
T1
QL (30 EA per 30 days)
cholestyramine light oral packet 4 gm
T1
cholestyramine light oral powder 4 gm/dose
T1
cholestyramine oral packet 4 gm
T1
cholestyramine oral powder 4 gm/dose
T1
colestipol hcl oral granules 5 gm
T1
colestipol hcl oral packet 5 gm
T1
colestipol hcl oral tablet 1 gm
T1
CRESTOR ORAL TABLET 10 MG, 20 MG, 40 MG, 5 MG
T3
fenofibrate micronized oral capsule 130 mg, 134 mg, 200 mg, 43 mg, 67 mg
T1
fenofibrate oral tablet 145 mg, 48 mg
T1
fenofibrate oral tablet 160 mg, 54 mg
T1
fenofibric acid oral capsule delayed release 135 mg, 45 mg
T3
fenofibric acid oral tablet 105 mg, 35 mg
T1
fluvastatin sodium oral capsule 20 mg, 40 mg
T3
gemfibrozil oral tablet 600 mg
T1
LIPOFEN ORAL CAPSULE 150 MG, 50 MG
T3
PA
LIVALO ORAL TABLET 1 MG, 2 MG, 4 MG
T3
ST
lovastatin oral tablet 10 mg, 20 mg, 40 mg
T1
LOVAZA ORAL CAPSULE 1 GM
T3
niacin er (antihyperlipidemic) oral tablet extendedrelease* 1000 mg, 500 mg, 750 mg
T3
NIACOR ORAL TABLET 500 MG
T1
AL (Max 64 Years)
*Antihyperlipidemics*
24
ST; QL (30 EA per 30 days)
PA
PA
PA
Drug
Status
Notes
NIASPAN ORAL TABLET EXTENDEDRELEASE* 1000 MG, 500 MG, 750 MG
T3
omega-3-acid ethyl esters oral capsule 1 gm
T3
pravastatin sodium oral tablet 10 mg, 20 mg, 40 mg, 80 mg
T1
PREVALITE ORAL PACKET 4 GM
T1
PREVALITE ORAL POWDER 4 GM/DOSE
T1
rosuvastatin calcium oral tablet 10 mg, 20 mg, 40 mg, 5 mg
T3
simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg
T1
simvastatin oral tablet 80 mg
T1
PA
TRIGLIDE ORAL TABLET 160 MG
T3
PA
TRILIPIX ORAL CAPSULE DELAYED RELEASE 135 MG, 45 MG
T3
PA
VYTORIN ORAL TABLET 10-10 MG, 10-20 MG, 10-40 MG, 10-80 MG
T3
ST
WELCHOL ORAL PACKET 3.75 GM
T3
PA
WELCHOL ORAL TABLET 625 MG
T3
PA
ZETIA ORAL TABLET 10 MG
T3
PA
PA
ST; QL (30 EA per 30 days)
*Antihypertensives* amlodipine besy-benazepril hcl oral capsule 10-20 mg, 10-40 mg, 2.5-10 mg, 5-10 mg, 5-20 mg, 5-40 mg
T1
amlodipine besylate-valsartan oral tablet 10-160 mg, 10-320 mg, 5-160 mg, 5-320 mg
T3
ST
amlodipine-olmesartan oral tablet 10-20 mg, 10-40 mg, 5-20 mg, 5-40 mg
T3
ST
atenolol-chlorthalidone oral tablet 100-25 mg, 50-25 mg
T1
AZOR ORAL TABLET 10-20 MG, 10-40 MG, 5-20 MG, 5-40 MG
T3
benazepril hcl oral tablet 10 mg, 20 mg, 40 mg, 5 mg
T1
benazepril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg, 5-6.25 mg
T1
BENICAR HCT ORAL TABLET 20-12.5 MG, 40-12.5 MG, 40-25 MG
T3
ST
BENICAR ORAL TABLET 20 MG, 40 MG, 5 MG
T3
ST
bisoprolol-hydrochlorothiazide oral tablet 10-6.25 mg, 2.5-6.25 mg, 5-6.25 mg
T1
ST
25
Drug
Status
Notes
candesartan cilexetil oral tablet 16 mg, 32 mg
T1
candesartan cilexetil-hctz oral tablet 16-12.5 mg, 32-12.5 mg, 32-25 mg
T1
captopril oral tablet 100 mg, 12.5 mg, 25 mg, 50 mg
T1
captopril-hydrochlorothiazide oral tablet 25-15 mg, 25-25 mg, 50-15 mg, 50-25 mg
T1
clonidine hcl oral tablet 0.1 mg, 0.2 mg, 0.3 mg
T1
clonidine hcl transdermal patch weekly 0.1 mg/24hr, 0.2 mg/24hr, 0.3 mg/24hr
T3
DIBENZYLINE ORAL CAPSULE 10 MG
T3
DIOVAN ORAL TABLET 160 MG, 320 MG, 40 MG, 80 MG
T2
doxazosin mesylate oral tablet 1 mg, 2 mg, 4 mg, 8 mg
T1
AL (Max 64 Years)
EDARBI ORAL TABLET 40 MG, 80 MG
T3
PA
enalapril maleate oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg
T1
enalapril-hydrochlorothiazide oral tablet 10-25 mg, 5-12.5 mg
T1
eplerenone oral tablet 25 mg, 50 mg
T3
eprosartan mesylate oral tablet 600 mg
T1
fosinopril sodium oral tablet 10 mg, 20 mg, 40 mg
T1
fosinopril sodium-hctz oral tablet 10-12.5 mg, 20-12.5 mg
T1
guanfacine hcl oral tablet 1 mg, 2 mg
T1
hydralazine hcl oral tablet 10 mg, 100 mg, 25 mg, 50 mg
T1
irbesartan oral tablet 150 mg, 300 mg, 75 mg
T3
irbesartan-hydrochlorothiazide oral tablet 150-12.5 mg, 300-12.5 mg
T1
lisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 30 mg, 40 mg, 5 mg
T1
lisinopril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg
T1
losartan potassium oral tablet 100 mg, 25 mg, 50 mg
T1
QL (30 EA per 30 days)
losartan potassium-hctz oral tablet 100-12.5 mg, 100-25 mg, 50-12.5 mg
T1
QL (30 EA per 30 days)
methyldopa oral tablet 250 mg, 500 mg
T1
metoprolol-hydrochlorothiazide oral tablet 100-25 mg, 100-50 mg, 50-25 mg
T1
26
PA
PA
QL (30 EA per 30 days)
Drug
Status
Notes
MICARDIS HCT ORAL TABLET 40-12.5 MG, 80-12.5 MG, 80-25 MG
T3
MICARDIS ORAL TABLET 20 MG, 40 MG, 80 MG
T3
minoxidil oral tablet 10 mg, 2.5 mg
T1
moexipril hcl oral tablet 15 mg, 7.5 mg
T1
moexipril-hydrochlorothiazide oral tablet 15-12.5 mg, 15-25 mg, 7.5-12.5 mg
T1
nadolol-bendroflumethiazide oral tablet 40-5 mg, 80-5 mg
T1
olmesartan medoxomil oral tablet 20 mg, 40 mg, 5 mg
T3
ST
olmesartan medoxomil-hctz oral tablet 20-12.5 mg, 40-12.5 mg, 40-25 mg
T3
ST
perindopril erbumine oral tablet 2 mg, 4 mg, 8 mg
T1
phenoxybenzamine hcl oral capsule 10 mg
T3
prazosin hcl oral capsule 1 mg, 2 mg, 5 mg
T1
propranolol-hctz oral tablet 40-25 mg, 80-25 mg
T1
quinapril hcl oral tablet 10 mg, 20 mg, 40 mg, 5 mg
T1
quinapril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg
T1
ramipril oral capsule 1.25 mg, 10 mg, 2.5 mg, 5 mg
T1
reserpine oral tablet 0.1 mg, 0.25 mg
T1
TARKA ORAL TABLET EXTENDEDRELEASE* 1-240 MG, 2-180 MG, 2-240 MG, 4-240 MG
T3
TEKTURNA HCT ORAL TABLET 150-12.5 MG, 150-25 MG, 300-12.5 MG, 300-25 MG
T3
TEKTURNA ORAL TABLET 150 MG, 300 MG
T3
telmisartan oral tablet 20 mg, 40 mg, 80 mg
T1
telmisartan-hctz oral tablet 40-12.5 mg, 80-12.5 mg, 80-25 mg
T3
ST
terazosin hcl oral capsule 1 mg, 10 mg, 2 mg, 5 mg
T1
AL (Max 64 Years)
trandolapril oral tablet 1 mg, 2 mg, 4 mg
T1
QL (30 EA per 30 days)
trandolapril-verapamil hcl er oral tablet extendedrelease* 1-240 mg, 2-180 mg, 2-240 mg, 4-240 mg
T3
ST
ST
PA
ST
27
Drug
Status
valsartan oral tablet 160 mg, 320 mg, 40 mg, 80 mg
T2
valsartan-hydrochlorothiazide oral tablet 160-12.5 mg, 160-25 mg, 320-12.5 mg, 320-25 mg, 80-12.5 mg
T1
Notes
*Anti-Infective Agents - Misc.* ALINIA ORAL SUSPENSION RECONSTITUTED 100 MG/5ML
T4
PA
ALINIA ORAL TABLET 500 MG
T4
PA
atovaquone oral suspension 750 mg/5ml
T2
QL (210 ML per 18 days)
clindamycin hcl oral capsule 150 mg, 300 mg, 75 mg
T1
clindamycin palmitate hcl oral solution reconstituted 75 mg/5ml
T1
dapsone oral tablet 100 mg, 25 mg
T1
FLAGYL ER ORAL TABLET EXTENDED RELEASE 24 HR* 750 MG
T3
ST
KETEK ORAL TABLET 400 MG
T3
PA
linezolid in sodium chloride intravenous* solution 600-0.9 mg/300ml-%
T3
PA
linezolid intravenous* solution 600 mg/300ml
T3
PA
linezolid oral tablet 600 mg
T3
PA
MEPRON ORAL SUSPENSION 750 MG/5ML
T2
QL (210 ML per 18 days)
metronidazole oral capsule 375 mg
T1
metronidazole oral tablet 250 mg, 500 mg
T1
PENTAM INJECTION SOLUTION RECONSTITUTED 300 MG
T3
sulfamethoxazole-trimethoprim oral suspension 200-40 mg/5ml
T1
sulfamethoxazole-trimethoprim oral tablet 400-80 mg, 800-160 mg
T1
tinidazole oral tablet 250 mg, 500 mg
T3
trimethoprim oral tablet 100 mg
T1
vancomycin hcl in dextrose intravenous* solution 1 gm/200ml, 500 mg/100ml, 750 mg/150ml
T1
vancomycin hcl intravenous* solution reconstituted 10 gm
T3
vancomycin hcl intravenous* solution reconstituted 1000 mg, 500 mg, 5000 mg, 750 mg
T1
ZYVOX INTRAVENOUS* SOLUTION 200 MG/100ML, 600 MG/300ML
T3
28
PA
Drug
Status
Notes
ZYVOX ORAL SUSPENSION RECONSTITUTED 100 MG/5ML
T3
PA
ZYVOX ORAL TABLET 600 MG
T3
PA
atovaquone-proguanil hcl oral tablet 250-100 mg, 62.5-25 mg
T1
QL (30 EA per 30 days)
chloroquine phosphate oral tablet 250 mg, 500 mg
T1
COARTEM ORAL TABLET 20-120 MG
T3
DARAPRIM ORAL TABLET 25 MG
T2
hydroxychloroquine sulfate oral tablet 200 mg
T1
mefloquine hcl oral tablet 250 mg
T1
primaquine phosphate oral tablet 26.3 mg
T1
QUALAQUIN ORAL CAPSULE 324 MG
T1
quinine sulfate oral capsule 324 mg
T1
*Antimalarials*
*Antimyasthenic Agents* MESTINON ORAL SYRUP 60 MG/5ML
T2
PA
MESTINON ORAL TABLET EXTENDEDRELEASE* 180 MG
T2
PA
pyridostigmine bromide er oral tablet extendedrelease* 180 mg
T2
PA
pyridostigmine bromide oral tablet 60 mg
T1
*Antimyasthenic/Cholinergic Agents* MESTINON ORAL SYRUP 60 MG/5ML
T2
PA
MESTINON ORAL TABLET EXTENDEDRELEASE* 180 MG
T2
PA
pyridostigmine bromide er oral tablet extendedrelease* 180 mg
T2
PA
pyridostigmine bromide oral tablet 60 mg
T1
*Antimycobacterial Agents* ethambutol hcl oral tablet 100 mg, 400 mg
T1
isoniazid oral syrup 50 mg/5ml
T1
isoniazid oral tablet 100 mg, 300 mg
T1
MYCOBUTIN ORAL CAPSULE 150 MG
T2
pyrazinamide oral tablet 500 mg
T3
rifabutin oral capsule 150 mg
T2
RIFAMATE ORAL CAPSULE 150-300 MG
T3
rifampin oral capsule 150 mg, 300 mg
T1
RIFATER ORAL TABLET 50-120-300 MG
T3
PA PA
29
Drug *Antineoplastics And Adjunctive Therapies*
Status
Notes
ACTIMMUNE SUBCUTANEOUS* SOLUTION 2000000 UNIT/0.5ML
T4
PA
AFINITOR ORAL TABLET 10 MG, 2.5 MG, 5 MG, 7.5 MG
T4
PA
anastrozole oral tablet 1 mg
T1
bexarotene oral capsule 75 mg
T4
bicalutamide oral tablet 50 mg
T1
BOSULIF ORAL TABLET 100 MG, 500 MG
T4
PA
capecitabine oral tablet 150 mg, 500 mg
T4
PA
CAPRELSA ORAL TABLET 100 MG, 300 MG
T4
PA
COMETRIQ (100 MG DAILY DOSE) ORAL KIT 1 X 80 & 1 X 20 MG
T4
PA
COMETRIQ (140 MG DAILY DOSE) ORAL KIT 1 X 80 & 3 X 20 MG
T4
PA
COMETRIQ (60 MG DAILY DOSE) ORAL KIT 20 MG
T4
PA
DEPO-PROVERA INTRAMUSCULAR* SUSPENSION 400 MG/ML
T3
ELIGARD SUBCUTANEOUS* KIT 22.5 MG, 30 MG, 45 MG, 7.5 MG
T4
EMCYT ORAL CAPSULE 140 MG
T3
exemestane oral tablet 25 mg
T1
FARESTON ORAL TABLET 60 MG
T4
PA
FASLODEX INTRAMUSCULAR* SOLUTION 250 MG/5ML
T4
PA
FIRMAGON SUBCUTANEOUS* SOLUTION RECONSTITUTED 120 MG, 80 MG
T4
PA
flutamide oral capsule 125 mg
T3
GLEEVEC ORAL TABLET 100 MG, 400 MG
T4
hydroxyurea oral capsule 500 mg
T1
imatinib mesylate oral tablet 100 mg, 400 mg
T4
PA
INLYTA ORAL TABLET 1 MG, 5 MG
T4
PA
INTRON A INJECTION SOLUTION 10000000 UNIT/ML, 6000000 UNIT/ML
T4
PA
INTRON A INJECTION SOLUTION RECONSTITUTED 10000000 UNIT, 18000000 UNIT, 50000000 UNIT
T4
PA
30
PA
PA
PA
Drug
Status
Notes
JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 25 MG, 5 MG
T4
PA
KYPROLIS INTRAVENOUS* SOLUTION RECONSTITUTED 60 MG
T4
PA
letrozole oral tablet 2.5 mg
T1
GR-F; QL (30 EA per 30 days); AL (Min 18 Years)
leucovorin calcium oral tablet 10 mg, 15 mg, 25 mg, 5 mg
T4
PA
LEUKERAN ORAL TABLET 2 MG
T4
leuprolide acetate injection kit 1 mg/0.2ml
T4
PA
LUPRON DEPOT INTRAMUSCULAR* KIT 11.25 MG, 22.5 MG, 3.75 MG, 30 MG, 45 MG
T4
PA
LYSODREN ORAL TABLET 500 MG
T2
MATULANE ORAL CAPSULE 50 MG
T4
megestrol acetate oral suspension 40 mg/ml, 400 mg/10ml
T1
megestrol acetate oral tablet 20 mg, 40 mg
T1
mercaptopurine oral tablet 50 mg
T1
MESNEX ORAL TABLET 400 MG
T4
methotrexate oral tablet 2.5 mg
T1
methotrexate sodium (pf) injection solution 1 gm/40ml, 100 mg/4ml, 200 mg/8ml, 250 mg/10ml, 50 mg/2ml
T1
methotrexate sodium injection solution 25 mg/ml, 250 mg/10ml, 50 mg/2ml
T1
methotrexate sodium injection solution reconstituted 1 gm
T1
MYLERAN ORAL TABLET 2 MG
T4
PA
NEXAVAR ORAL TABLET 200 MG
T4
PA
POMALYST ORAL CAPSULE 1 MG, 2 MG, 3 MG, 4 MG
T4
PA
SPRYCEL ORAL TABLET 100 MG, 140 MG, 20 MG, 50 MG, 70 MG, 80 MG
T4
PA
STIVARGA ORAL TABLET 40 MG
T4
PA
SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 50 MG
T4
PA
SYLATRON SUBCUTANEOUS* KIT 200 MCG, 300 MCG, 4 X 200 MCG, 4 X 300 MCG, 600 MCG
T4
PA
TABLOID ORAL TABLET 40 MG
T4
PA
tamoxifen citrate oral tablet 10 mg, 20 mg
T5
PA
PA
31
Drug
Status
Notes
TARCEVA ORAL TABLET 100 MG, 150 MG, 25 MG
T4
PA
TARGRETIN ORAL CAPSULE 75 MG
T4
PA
TASIGNA ORAL CAPSULE 150 MG, 200 MG
T4
PA
TRELSTAR INTRAMUSCULAR* SUSPENSION RECONSTITUTED 11.25 MG, 3.75 MG
T4
PA
TRELSTAR MIXJECT INTRAMUSCULAR* SUSPENSION RECONSTITUTED 11.25 MG, 22.5 MG, 3.75 MG
T4
PA
tretinoin oral capsule 10 mg
T4
PA
TREXALL ORAL TABLET 10 MG, 15 MG, 5 MG, 7.5 MG
T3
PA
TYKERB ORAL TABLET 250 MG
T4
PA
VALSTAR INTRAVESICAL SOLUTION 40 MG/ML
T4
PA
VANTAS SUBCUTANEOUS* KIT 50 MG
T4
PA
VOTRIENT ORAL TABLET 200 MG
T4
PA
XALKORI ORAL CAPSULE 200 MG, 250 MG
T4
PA
XELODA ORAL TABLET 150 MG, 500 MG
T4
PA
ZOLADEX SUBCUTANEOUS* IMPLANT 10.8 MG, 3.6 MG
T3
PA
ZYTIGA ORAL TABLET 250 MG
T4
PA
*Antiparkinson Agents* amantadine hcl oral capsule 100 mg
T1
amantadine hcl oral syrup 50 mg/5ml
T1
amantadine hcl oral tablet 100 mg
T1
AZILECT ORAL TABLET 0.5 MG, 1 MG
T3
benztropine mesylate injection solution 1 mg/ml
T3
benztropine mesylate oral tablet 0.5 mg, 1 mg, 2 mg
T1
bromocriptine mesylate oral capsule 5 mg
T3
bromocriptine mesylate oral tablet 2.5 mg
T1
carbidopa oral tablet 25 mg
T3
carbidopa-levodopa er oral tablet extendedrelease* 25-100 mg, 50-200 mg
T1
carbidopa-levodopa oral tablet 10-100 mg, 25-100 mg, 25-250 mg
T1
32
Drug
Status
Notes
carbidopa-levodopa oral tablet dispersible 10-100 mg, 25-100 mg, 25-250 mg
T1
entacapone oral tablet 200 mg
T3
LODOSYN ORAL TABLET 25 MG
T3
MIRAPEX ER ORAL TABLET EXTENDED RELEASE 24 HR* 0.375 MG, 0.75 MG, 1.5 MG, 2.25 MG, 3 MG, 3.75 MG, 4.5 MG
T3
PA
NEUPRO TRANSDERMAL PATCH 24 HR 1 MG/24HR, 2 MG/24HR, 3 MG/24HR, 4 MG/24HR, 6 MG/24HR, 8 MG/24HR
T3
PA
pramipexole dihydrochloride er oral tablet extended release 24 hr* 0.375 mg, 0.75 mg, 1.5 mg, 2.25 mg, 3 mg, 3.75 mg, 4.5 mg
T3
PA
pramipexole dihydrochloride oral tablet 0.125 mg, 0.25 mg, 0.5 mg, 0.75 mg, 1 mg, 1.5 mg
T1
ropinirole hcl er oral tablet extended release 24 hr* 12 mg, 2 mg, 4 mg, 6 mg, 8 mg
T1
ropinirole hcl oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg, 5 mg
T1
selegiline hcl oral capsule 5 mg
T1
selegiline hcl oral tablet 5 mg
T1
TASMAR ORAL TABLET 100 MG
T4
PA
tolcapone oral tablet 100 mg
T4
PA
ABILIFY DISCMELT ORAL TABLET DISPERSIBLE 10 MG, 15 MG
T4
PA
ABILIFY INTRAMUSCULAR* SOLUTION 9.75 MG/1.3ML
T4
PA
ABILIFY MAINTENA INTRAMUSCULAR* SUSPENSION RECONSTITUTED 300 MG, 400 MG
T4
PA
ABILIFY ORAL SOLUTION 1 MG/ML
T4
PA
ABILIFY ORAL TABLET 10 MG, 15 MG, 2 MG, 20 MG, 30 MG, 5 MG
T4
PA
aripiprazole oral solution 1 mg/ml
T4
PA
aripiprazole oral tablet 10 mg, 15 mg, 2 mg, 20 mg, 30 mg, 5 mg
T4
PA
chlorpromazine hcl oral tablet 10 mg, 100 mg, 200 mg, 25 mg, 50 mg
T1
clozapine oral tablet 100 mg, 200 mg, 25 mg, 50 mg
T1
clozapine oral tablet dispersible 100 mg, 12.5 mg, 25 mg
T3
ST
*Antipsychotics/Antimanic Agents*
33
Drug
Status
Notes
COMPRO SUPPOSITORY 25 MG
T1
FANAPT ORAL TABLET 1 MG, 10 MG, 12 MG, 2 MG, 4 MG, 6 MG, 8 MG
T4
fluphenazine decanoate injection solution 25 mg/ml
T3
fluphenazine hcl injection solution 2.5 mg/ml
T3
fluphenazine hcl oral concentrate 5 mg/ml
T3
fluphenazine hcl oral elixir 2.5 mg/5ml
T1
fluphenazine hcl oral tablet 1 mg, 10 mg, 2.5 mg, 5 mg
T1
haloperidol decanoate intramuscular* solution 100 mg/ml, 50 mg/ml
T3
haloperidol lactate injection solution 5 mg/ml
T3
haloperidol lactate oral concentrate 2 mg/ml
T1
haloperidol oral tablet 0.5 mg, 1 mg, 10 mg, 2 mg, 20 mg, 5 mg
T1
INVEGA ORAL TABLET EXTENDED RELEASE 24 HR* 1.5 MG, 3 MG, 6 MG, 9 MG
T4
PA
INVEGA SUSTENNA INTRAMUSCULAR* SUSPENSION 117 MG/0.75ML, 156 MG/ML, 234 MG/1.5ML, 39 MG/0.25ML, 78 MG/0.5ML
T4
PA
LATUDA ORAL TABLET 120 MG, 20 MG, 40 MG, 80 MG
T3
PA
lithium carbonate er oral tablet extendedrelease* 300 mg, 450 mg
T1
lithium carbonate oral capsule 150 mg, 300 mg, 600 mg
T1
lithium carbonate oral tablet 300 mg
T1
lithium oral solution 8 meq/5ml
T1
loxapine succinate oral capsule 10 mg, 25 mg, 5 mg, 50 mg
T1
olanzapine intramuscular* solution reconstituted 10 mg
T3
olanzapine oral tablet 10 mg, 15 mg, 2.5 mg, 20 mg, 5 mg, 7.5 mg
T3
olanzapine oral tablet dispersible 10 mg, 15 mg, 20 mg, 5 mg
T3
paliperidone er oral tablet extended release 24 hr* 1.5 mg, 3 mg, 6 mg, 9 mg
T4
perphenazine oral tablet 16 mg, 2 mg, 4 mg, 8 mg
T1
34
PA
PA
Drug
Status
prochlorperazine edisylate injection solution 5 mg/ml
T3
prochlorperazine maleate oral tablet 10 mg, 5 mg
T1
prochlorperazine suppository 25 mg
T1
quetiapine fumarate er oral tablet extended release 24 hr* 150 mg, 200 mg, 300 mg, 400 mg, 50 mg
T3
quetiapine fumarate oral tablet 100 mg, 200 mg, 25 mg, 300 mg, 400 mg, 50 mg
T1
risperidone oral solution 1 mg/ml
T3
risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg
T1
risperidone oral tablet dispersible 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg
T3
SAPHRIS SUBLINGUAL TABLET SUBLINGUAL 10 MG, 5 MG
T3
SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR* 150 MG, 200 MG, 300 MG, 400 MG, 50 MG
T3
thiothixene oral capsule 1 mg, 10 mg, 2 mg, 5 mg
T1
trifluoperazine hcl oral tablet 1 mg, 10 mg, 2 mg, 5 mg
T1
ziprasidone hcl oral capsule 20 mg, 40 mg, 60 mg, 80 mg
T3
Notes
ST
ST
*Antiseptics & Disinfectants* chlorhexidine gluconate solution 20 %
T3
iodine strong external tincture 7-5 %
T1
lugols external solution
T1
*Antivirals* abacavir sulfate oral tablet 300 mg
T3
QL (60 EA per 30 days)
abacavir-lamivudine-zidovudine oral tablet 300-150-300 mg
T2
QL (60 EA per 30 days)
acyclovir oral capsule 200 mg
T1
acyclovir oral suspension 200 mg/5ml
T1
acyclovir oral tablet 400 mg, 800 mg
T1
adefovir dipivoxil oral tablet 10 mg
T4
PA
APTIVUS ORAL CAPSULE 250 MG
T3
QL (120 EA per 30 days)
APTIVUS ORAL SOLUTION 100 MG/ML
T3
QL (300 ML per 30 days)
ATRIPLA ORAL TABLET 600-200-300 MG
T2
QL (30 EA per 30 days)
BARACLUDE ORAL SOLUTION 0.05 MG/ML
T4
PA 35
Drug
Status
Notes
COMPLERA ORAL TABLET 200-25-300 MG
T2
QL (30 EA per 30 days)
CRIXIVAN ORAL CAPSULE 200 MG
T2
QL (360 EA per 30 days)
CRIXIVAN ORAL CAPSULE 400 MG
T2
QL (180 EA per 30 days)
didanosine oral capsule delayed release 125 mg, 200 mg
T3
QL (60 EA per 30 days)
didanosine oral capsule delayed release 250 mg, 400 mg
T3
QL (30 EA per 30 days)
EDURANT ORAL TABLET 25 MG
T2
QL (30 EA per 30 days)
EMTRIVA ORAL CAPSULE 200 MG
T2
QL (30 EA per 30 days)
EMTRIVA ORAL SOLUTION 10 MG/ML
T2
EPIVIR HBV ORAL SOLUTION 5 MG/ML
T3
QL (1800 ML per 30 days)
EPIVIR HBV ORAL TABLET 100 MG
T2
QL (90 EA per 30 days)
EPIVIR ORAL SOLUTION 10 MG/ML
T3
QL (900 ML per 30 days)
EPZICOM ORAL TABLET 600-300 MG
T2
QL (30 EA per 30 days)
famciclovir oral tablet 125 mg, 250 mg, 500 mg
T3
ST; QL (90 EA per 30 days)
HEPSERA ORAL TABLET 10 MG
T4
PA
INCIVEK ORAL TABLET 375 MG
T4
PA
INFERGEN SUBCUTANEOUS* INJECTABLE 15 MCG/0.5ML, 9 MCG/0.3ML
T4
PA
INTELENCE ORAL TABLET 100 MG
T3
QL (120 EA per 30 days)
INTELENCE ORAL TABLET 200 MG
T3
QL (60 EA per 30 days)
INTELENCE ORAL TABLET 25 MG
T3
QL (480 EA per 30 days)
INVIRASE ORAL CAPSULE 200 MG
T2
QL (300 EA per 30 days)
INVIRASE ORAL TABLET 500 MG
T2
QL (120 EA per 30 days)
ISENTRESS ORAL TABLET 400 MG
T2
QL (60 EA per 30 days)
ISENTRESS ORAL TABLET CHEWABLE 100 MG, 25 MG
T3
QL (60 EA per 30 days)
KALETRA ORAL SOLUTION 400-100 MG/5ML
T2
QL (450 ML per 23 days)
KALETRA ORAL TABLET 100-25 MG
T2
QL (360 EA per 30 days)
KALETRA ORAL TABLET 200-50 MG
T2
QL (180 EA per 30 days)
lamivudine oral solution 10 mg/ml
T3
QL (900 ML per 30 days)
lamivudine oral tablet 100 mg
T2
QL (90 EA per 30 days)
lamivudine oral tablet 150 mg
T3
QL (60 EA per 30 days)
lamivudine oral tablet 300 mg
T3
QL (30 EA per 30 days)
lamivudine-zidovudine oral tablet 150-300 mg
T3
QL (60 EA per 30 days)
LEXIVA ORAL SUSPENSION 50 MG/ML
T2
QL (180 ML per 30 days)
LEXIVA ORAL TABLET 700 MG
T2
QL (120 EA per 30 days)
36
Drug
Status
Notes
MODERIBA 800 DOSE PACK ORAL TABLET 400 MG
T4
PA
nevirapine er oral tablet extended release 24 hr* 400 mg
T2
QL (30 EA per 30 days)
nevirapine oral suspension 50 mg/5ml
T1
PA
nevirapine oral tablet 200 mg
T1
QL (60 EA per 30 days)
NORVIR ORAL CAPSULE 100 MG
T2
QL (360 EA per 30 days)
NORVIR ORAL SOLUTION 80 MG/ML
T2
QL (450 ML per 23 days)
NORVIR ORAL TABLET 100 MG
T2
QL (360 EA per 30 days)
PEGASYS PROCLICK SUBCUTANEOUS* SOLUTION 135 MCG/0.5ML
T4
PA
PEGASYS SUBCUTANEOUS* SOLUTION 180 MCG/ML
T4
PA
PEG-INTRON REDIPEN PAK 4 SUBCUTANEOUS* KIT 120 MCG/0.5ML, 150 MCG/0.5ML, 50 MCG/0.5ML, 80 MCG/0.5ML
T4
PA
PEG-INTRON REDIPEN SUBCUTANEOUS* KIT 120 MCG/0.5ML, 150 MCG/0.5ML, 50 MCG/0.5ML, 80 MCG/0.5ML
T4
PA
PEGINTRON SUBCUTANEOUS* KIT 120 MCG/0.5ML, 150 MCG/0.5ML, 50 MCG/0.5ML, 80 MCG/0.5ML
T4
PA
PEG-INTRON SUBCUTANEOUS* KIT 120 MCG/0.5ML, 150 MCG/0.5ML, 50 MCG/0.5ML, 80 MCG/0.5ML
T4
PA
PREZISTA ORAL SUSPENSION 100 MG/ML
T3
QL (480 ML per 30 days)
PREZISTA ORAL TABLET 150 MG
T2
QL (240 EA per 30 days)
PREZISTA ORAL TABLET 600 MG
T2
QL (60 EA per 30 days)
PREZISTA ORAL TABLET 75 MG
T2
QL (480 EA per 30 days)
PREZISTA ORAL TABLET 800 MG
T3
QL (60 EA per 30 days)
REBETOL ORAL SOLUTION 40 MG/ML
T4
PA
RELENZA DISKHALER INHALATION AEROSOL POWDER, BREATH ACTIVATED 5 MG/BLISTER
T2
PA; QL (20 EA per 5 days)
RESCRIPTOR ORAL TABLET 100 MG
T2
QL (360 EA per 30 days)
RESCRIPTOR ORAL TABLET 200 MG
T2
QL (180 EA per 30 days)
REYATAZ ORAL CAPSULE 150 MG, 200 MG
T2
QL (60 EA per 30 days)
REYATAZ ORAL CAPSULE 300 MG
T2
QL (30 EA per 30 days)
RIBAPAK ORAL TABLET 400 & 600 MG, 400 MG, 600 MG
T4
PA 37
Drug
Status
Notes
RIBASPHERE ORAL CAPSULE 200 MG
T4
PA
RIBASPHERE ORAL TABLET 200 MG, 400 MG, 600 MG
T4
PA
RIBASPHERE RIBAPAK ORAL TABLET 400 & 600 MG, 400 MG, 600 MG
T4
PA
RIBATAB ORAL 400 & 600 MG
T4
PA
RIBATAB ORAL TABLET 400 MG, 600 MG
T4
PA
ribavirin oral capsule 200 mg
T4
PA
ribavirin oral tablet 200 mg
T4
PA
rimantadine hcl oral tablet 100 mg
T1
SELZENTRY ORAL TABLET 150 MG, 300 MG
T3
QL (120 EA per 30 days)
stavudine oral capsule 15 mg, 20 mg, 30 mg, 40 mg
T1
QL (60 EA per 30 days)
stavudine oral solution reconstituted 1 mg/ml
T1
QL (1200 ML per 30 days)
STRIBILD ORAL TABLET 150-150-200-300 MG
T2
QL (30 EA per 30 days)
SUSTIVA ORAL CAPSULE 200 MG
T2
QL (90 EA per 30 days)
SUSTIVA ORAL CAPSULE 50 MG
T2
QL (360 EA per 30 days)
SUSTIVA ORAL TABLET 600 MG
T2
QL (30 EA per 30 days)
TAMIFLU ORAL CAPSULE 30 MG, 45 MG, 75 MG
T2
QL (10 EA per 5 days)
TAMIFLU ORAL SUSPENSION RECONSTITUTED 6 MG/ML
T2
QL (120 ML per 10 days); AL (Max 6 Years)
TIVICAY ORAL TABLET 50 MG
T3
QL (30 EA per 30 days)
TRIUMEQ ORAL TABLET 600-50-300 MG
T3
QL (30 EA per 30 days)
TRIZIVIR ORAL TABLET 300-150-300 MG
T2
QL (60 EA per 30 days)
TRUVADA ORAL TABLET 100-150 MG, 133-200 MG, 167-250 MG, 200-300 MG
T2
QL (30 EA per 30 days)
TYZEKA ORAL TABLET 600 MG
T4
PA
valacyclovir hcl oral tablet 1 gm, 500 mg
T1
VALCYTE ORAL SOLUTION RECONSTITUTED 50 MG/ML
T4
PA
VICTRELIS ORAL CAPSULE 200 MG
T4
PA
VIDEX ORAL SOLUTION RECONSTITUTED 2 GM, 4 GM
T2
QL (603 ML per 30 days)
VIRACEPT ORAL TABLET 250 MG
T2
QL (300 EA per 30 days)
VIRACEPT ORAL TABLET 625 MG
T2
QL (120 EA per 30 days)
VIRAMUNE ORAL SUSPENSION 50 MG/5ML
T2
QL (1200 ML per 30 days)
38
Drug
Status
Notes
VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 HR* 400 MG
T2
QL (30 EA per 30 days)
VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG, 300 MG
T2
QL (30 EA per 30 days)
ZIAGEN ORAL SOLUTION 20 MG/ML
T2
QL (900 ML per 30 days)
zidovudine oral capsule 100 mg
T1
QL (180 EA per 30 days)
zidovudine oral syrup 50 mg/5ml
T1
QL (1800 ML per 30 days)
zidovudine oral tablet 300 mg
T1
QL (60 EA per 30 days)
*Assorted Classes* alprostadil injection solution 500 mcg/ml
T1
AZASAN ORAL TABLET 100 MG, 75 MG
T3
azathioprine oral tablet 50 mg
T1
CELLCEPT ORAL SUSPENSION RECONSTITUTED 200 MG/ML
T4
cyclosporine modified oral capsule 100 mg
T3
cyclosporine modified oral capsule 25 mg, 50 mg
T1
cyclosporine modified oral solution 100 mg/ml
T3
cyclosporine oral capsule 100 mg, 25 mg
T3
DEPEN TITRATABS ORAL TABLET 250 MG
T4
GENGRAF ORAL CAPSULE 100 MG
T3
GENGRAF ORAL CAPSULE 25 MG
T1
GENGRAF ORAL SOLUTION 100 MG/ML
T3
KIONEX ORAL POWDER
T1
KIONEX ORAL SUSPENSION 15 GM/60ML
T1
mycophenolate mofetil oral capsule 250 mg
T1
mycophenolate mofetil oral suspension reconstituted 200 mg/ml
T4
mycophenolate mofetil oral tablet 500 mg
T1
mycophenolic acid oral tablet delayed release 180 mg, 360 mg
T3
PA
MYFORTIC ORAL TABLET DELAYED RELEASE 180 MG, 360 MG
T3
PA
RAPAMUNE ORAL SOLUTION 1 MG/ML
T4
PA
RAPAMUNE ORAL TABLET 0.5 MG
T4
PA
REVLIMID ORAL CAPSULE 10 MG, 15 MG, 2.5 MG, 25 MG, 5 MG
T4
PA
SANDIMMUNE ORAL SOLUTION 100 MG/ML
T4
PA
sirolimus oral tablet 0.5 mg
T4
PA
PA
39
Drug
Status
Notes
sodium polystyrene sulfonate oral powder
T1
sodium polystyrene sulfonate oral suspension 15 gm/60ml
T1
sodium polystyrene sulfonate suspension 30 gm/120ml, 50 gm/200ml
T1
SPS ORAL SUSPENSION 15 GM/60ML
T1
SYPRINE ORAL CAPSULE 250 MG
T4
tacrolimus oral capsule 0.5 mg, 1 mg
T1
tacrolimus oral capsule 5 mg
T3
THALOMID ORAL CAPSULE 100 MG, 150 MG, 200 MG, 50 MG
T4
PA
ZORTRESS ORAL TABLET 0.25 MG, 0.5 MG, 0.75 MG
T4
PA
*Beta Blockers* acebutolol hcl oral capsule 200 mg, 400 mg
T1
atenolol oral tablet 100 mg, 25 mg, 50 mg
T1
betaxolol hcl oral tablet 10 mg, 20 mg
T1
bisoprolol fumarate oral tablet 10 mg, 5 mg
T1
BYSTOLIC ORAL TABLET 10 MG, 2.5 MG, 20 MG, 5 MG
T3
carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg, 6.25 mg
T1
COREG CR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG, 20 MG, 40 MG, 80 MG
T3
labetalol hcl oral tablet 100 mg, 200 mg, 300 mg
T1
LEVATOL ORAL TABLET 20 MG
T3
PA
metoprolol succinate er oral tablet extended release 24 hr* 100 mg, 200 mg, 25 mg, 50 mg
T1
QL (30 EA per 30 days)
metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg
T1
nadolol oral tablet 20 mg, 40 mg, 80 mg
T1
pindolol oral tablet 10 mg, 5 mg
T1
propranolol hcl er oral capsule extended release 24 hour 120 mg, 160 mg, 60 mg, 80 mg
T1
propranolol hcl oral solution 20 mg/5ml, 40 mg/5ml
T1
propranolol hcl oral tablet 10 mg, 20 mg, 40 mg, 60 mg, 80 mg
T1
sotalol hcl (af) oral tablet 120 mg, 160 mg, 80 mg
T1
40
ST
ST
ST
Drug
Status
sotalol hcl oral tablet 120 mg, 160 mg, 240 mg, 80 mg
T1
timolol maleate oral tablet 10 mg, 20 mg, 5 mg
T1
Notes
*Calcium Channel Blockers* AFEDITAB CR ORAL TABLET EXTENDED RELEASE 24 HR* 30 MG, 60 MG
T1
QL (30 EA per 30 days)
amlodipine besylate oral tablet 10 mg, 2.5 mg, 5 mg
T1
QL (30 EA per 30 days)
CARTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG
T1
QL (30 EA per 30 days)
dilt-cd oral capsule extended release 24 hour 120 mg
T1
QL (30 EA per 30 days)
diltiazem cd oral capsule extended release 24 hour 120 mg
T1
QL (60 EA per 30 days)
diltiazem cd oral capsule extended release 24 hour 180 mg, 240 mg
T1
QL (30 EA per 30 days)
diltiazem hcl cd oral capsule extended release 24 hour 360 mg
T1
QL (30 EA per 30 days)
diltiazem hcl er beads oral capsule extended release 24 hour 120 mg
T1
QL (60 EA per 30 days)
diltiazem hcl er beads oral capsule extended release 24 hour 180 mg, 240 mg, 300 mg, 360 mg, 420 mg
T1
QL (30 EA per 30 days)
diltiazem hcl er coated beads oral capsule extended release 24 hour 120 mg
T1
QL (60 EA per 30 days)
diltiazem hcl er coated beads oral capsule extended release 24 hour 180 mg, 240 mg, 300 mg, 360 mg
T1
QL (30 EA per 30 days)
diltiazem hcl er oral capsule extended release 12 hour 120 mg, 60 mg, 90 mg
T1
QL (60 EA per 30 days)
diltiazem hcl er oral capsule extended release 24 hour 120 mg
T1
QL (60 EA per 30 days)
diltiazem hcl er oral capsule extended release 24 hour 180 mg, 240 mg
T1
QL (30 EA per 30 days)
diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg, 90 mg
T1
dilt-xr oral capsule extended release 24 hour 120 mg
T1
QL (30 EA per 30 days)
felodipine er oral tablet extended release 24 hr* 10 mg, 2.5 mg, 5 mg
T1
QL (30 EA per 30 days)
isradipine oral capsule 2.5 mg, 5 mg
T1
nicardipine hcl oral capsule 20 mg, 30 mg
T1 41
Drug
Status
Notes
NIFEDICAL XL ORAL TABLET EXTENDED RELEASE 24 HR* 30 MG, 60 MG
T1
QL (30 EA per 30 days)
nifedipine er oral tablet extended release 24 hr* 30 mg, 60 mg, 90 mg
T1
QL (30 EA per 30 days)
nifedipine er osmotic release oral tablet extended release 24 hr* 30 mg, 60 mg, 90 mg
T1
QL (30 EA per 30 days)
nifedipine oral capsule 10 mg, 20 mg
T1
nimodipine oral capsule 30 mg
T1
nisoldipine er oral tablet extended release 24 hr* 17 mg, 20 mg, 25.5 mg, 30 mg, 34 mg, 40 mg, 8.5 mg
T1
TAZTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG
T1
verapamil hcl er oral capsule extended release 24 hour 100 mg, 120 mg, 180 mg, 200 mg, 240 mg, 300 mg, 360 mg
T1
verapamil hcl er oral tablet extendedrelease* 120 mg, 180 mg, 240 mg
T1
verapamil hcl oral tablet 120 mg, 40 mg, 80 mg
T1
QL (30 EA per 30 days)
QL (30 EA per 30 days)
*Cardiotonics* DIGITEK ORAL TABLET 250 MCG
T1
DIGOX ORAL TABLET 250 MCG
T1
digoxin oral solution 0.05 mg/ml
T1
digoxin oral tablet 125 mcg, 250 mcg
T1
LANOXIN ORAL TABLET 250 MCG
T1
*Cardiovascular Agents - Misc.* ADCIRCA ORAL TABLET 20 MG
T4
PA
CAVERJECT IMPULSE INTRACAVERNOSAL * KIT 10 MCG, 20 MCG
T3
PA
CAVERJECT INTRACAVERNOSAL * SOLUTION RECONSTITUTED 20 MCG, 40 MCG
T3
PA
CIALIS ORAL TABLET 2.5 MG, 20 MG, 5 MG
T3
PA
EDEX INTRACAVERNOSAL * KIT 10 MCG, 20 MCG
T3
PA
isoxsuprine hcl oral tablet 10 mg
T1
LETAIRIS ORAL TABLET 10 MG, 5 MG
T4
42
PA
Drug
Status
Notes
MUSE URETHRAL PELLET 1000 MCG, 125 MCG, 250 MCG, 500 MCG
T3
PA
papaverine hcl injection solution 30 mg/ml
T1
PA
sildenafil citrate oral tablet 20 mg
T4
PA
TYVASO INHALATION SOLUTION 0.6 MG/ML
T4
PA
TYVASO REFILL INHALATION SOLUTION 0.6 MG/ML
T4
PA
TYVASO STARTER INHALATION SOLUTION 0.6 MG/ML
T4
PA
VENTAVIS INHALATION SOLUTION 10 MCG/ML, 20 MCG/ML
T4
PA
*Cephalosporins* cefaclor er oral tablet extended release 12 hr* 500 mg
T1
cefaclor oral capsule 250 mg, 500 mg
T1
cefaclor oral suspension reconstituted 125 mg/5ml, 250 mg/5ml, 375 mg/5ml
T1
cefadroxil oral capsule 500 mg
T1
cefadroxil oral suspension reconstituted 250 mg/5ml, 500 mg/5ml
T1
cefadroxil oral tablet 1 gm
T1
cefdinir oral capsule 300 mg
T1
cefdinir oral suspension reconstituted 125 mg/5ml, 250 mg/5ml
T1
cefpodoxime proxetil oral suspension reconstituted 100 mg/5ml, 50 mg/5ml
T1
cefpodoxime proxetil oral tablet 100 mg, 200 mg
T1
cefprozil oral suspension reconstituted 125 mg/5ml, 250 mg/5ml
T1
cefprozil oral tablet 250 mg, 500 mg
T1
ceftriaxone sodium in dextrose intravenous* solution 40 mg/ml
T1
ceftriaxone sodium injection solution reconstituted 1 gm, 100 gm, 2 gm, 250 mg, 500 mg
T1
ceftriaxone sodium intravenous* solution reconstituted 10 gm, 2 gm
T1
ceftriaxone sodium-dextrose intravenous* solution reconstituted 2-2.22 gm-%
T1
cefuroxime axetil oral tablet 250 mg, 500 mg
T1
cephalexin oral capsule 250 mg, 500 mg
T1
AL (Max 11 Years)
43
Drug
Status
cephalexin oral capsule 750 mg
T3
cephalexin oral suspension reconstituted 125 mg/5ml, 250 mg/5ml
T1
cephalexin oral tablet 250 mg, 500 mg
T1
KEFLEX ORAL CAPSULE 750 MG
T3
SUPRAX ORAL SUSPENSION RECONSTITUTED 500 MG/5ML
T3
Notes PA
PA
*Chemicals* chlorhexidine gluconate solution
T3
coal tar solution , 20 %
T1
iodine strong (lugol's) solution
T1
*Contraceptives* ALTAVERA ORAL TABLET 0.15-30 MG-MCG
T5
GR-F; QL (28 EA per 28 days)
alyacen 1/35 oral tablet 1-35 mg-mcg
T5
GR-F; QL (28 EA per 28 days)
alyacen 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg
T5
GR-F; QL (28 EA per 28 days)
APRI ORAL TABLET 0.15-30 MG-MCG
T5
GR-F; QL (28 EA per 28 days)
AVIANE ORAL TABLET 0.1-20 MG-MCG
T5
GR-F; QL (28 EA per 28 days)
CAMILA ORAL TABLET 0.35 MG
T5
GR-F; QL (28 EA per 28 days)
CAZIANT ORAL TABLET 0.1/0.125/0.15 -0.025 MG
T5
GR-F; QL (28 EA per 28 days)
CHATEAL ORAL TABLET 0.15-30 MG-MCG
T5
GR-F; QL (28 EA per 28 days)
CRYSELLE-28 ORAL TABLET 0.3-30 MG-MCG
T5
GR-F; QL (28 EA per 28 days)
CYCLAFEM 1/35 ORAL TABLET 1-35 MG-MCG
T5
GR-F; QL (28 EA per 28 days)
CYCLAFEM 7/7/7 ORAL TABLET 0.5/0.75/1-35 MG-MCG
T5
GR-F; QL (28 EA per 28 days)
DASETTA 1/35 ORAL TABLET 1-35 MG-MCG
T5
GR-F; QL (28 EA per 28 days)
DASETTA 7/7/7 ORAL TABLET 0.5/0.75/1-35 MG-MCG
T5
GR-F; QL (28 EA per 28 days)
DEPO-SUBQ PROVERA 104 SUBCUTANEOUS* SUSPENSION 104 MG/0.65ML
T3
GR-F; QL (1 ML per 90 days)
ELINEST ORAL TABLET 0.3-30 MG-MCG
T5
GR-F; QL (28 EA per 28 days)
ELLA ORAL TABLET 30 MG
T3
GR-F
EMOQUETTE ORAL TABLET 0.15-30 MG-MCG
T5
GR-F; QL (28 EA per 28 days)
ENPRESSE-28 ORAL TABLET
T5
GR-F; QL (28 EA per 28 days)
44
Drug
Status
Notes
ERRIN ORAL TABLET 0.35 MG
T5
GR-F; QL (28 EA per 28 days)
ESTARYLLA ORAL TABLET 0.25-35 MG-MCG
T5
GR-F; QL (28 EA per 28 days)
FALMINA ORAL TABLET 0.1-20 MG-MCG
T5
GR-F; QL (28 EA per 28 days)
GILDESS 1.5/30 ORAL TABLET 1.5-30 MG-MCG
T5
GR-F
GILDESS 1/20 ORAL TABLET 1-20 MG-MCG
T5
GR-F
GILDESS 24 FE ORAL TABLET 1-20 MG-MCG(24)
T5
GILDESS FE 1.5/30 ORAL TABLET 1.5-30 MG-MCG
T5
GR-F; QL (28 EA per 28 days)
GILDESS FE 1/20 ORAL TABLET 1-20 MG-MCG
T5
GR-F; QL (28 EA per 28 days)
HEATHER ORAL TABLET 0.35 MG
T5
GR-F; QL (28 EA per 28 days)
JOLIVETTE ORAL TABLET 0.35 MG
T5
GR-F; QL (28 EA per 28 days)
JUNEL 1.5/30 ORAL TABLET 1.5-30 MG-MCG
T5
GR-F; QL (28 EA per 28 days)
JUNEL 1/20 ORAL TABLET 1-20 MG-MCG
T5
GR-F; QL (28 EA per 28 days)
JUNEL FE 1.5/30 ORAL TABLET 1.5-30 MG-MCG
T5
GR-F; QL (28 EA per 28 days)
JUNEL FE 1/20 ORAL TABLET 1-20 MG-MCG
T5
GR-F; QL (28 EA per 28 days)
JUNEL FE 24 ORAL TABLET 1-20 MG-MCG(24)
T5
KELNOR 1/35 ORAL TABLET 1-35 MG-MCG
T5
GR-F; QL (28 EA per 28 days)
KURVELO ORAL TABLET 0.15-30 MG-MCG
T5
GR-F; QL (28 EA per 28 days)
LARIN 24 FE ORAL TABLET 1-20 MG-MCG(24)
T5
LARIN FE 1/20 ORAL TABLET 1-20 MG-MCG
T5
LESSINA ORAL TABLET 0.1-20 MG-MCG
T5
GR-F; QL (28 EA per 28 days)
LEVONEST ORAL TABLET
T5
GR-F; QL (28 EA per 28 days)
levonorgest-eth estrad 91-day oral tablet 0.1-0.02 & 0.01 mg, 0.15-0.03 mg
T5
GR-F; QL (28 EA per 28 days)
levonorgestrel oral tablet 0.75 mg
T5
GR-F; QL (2 EA per 30 days)
levonorgestrel-ethinyl estrad oral tablet 0.15-30 mg-mcg
T5
GR-F; QL (28 EA per 28 days)
LEVORA 0.15/30 (28) ORAL TABLET 0.15-30 MG-MCG
T5
GR-F; QL (28 EA per 28 days)
45
Drug
Status
Notes
LOMEDIA 24 FE ORAL TABLET 1-20 MG-MCG(24)
T5
LOW-OGESTREL ORAL TABLET 0.3-30 MG-MCG
T5
GR-F; QL (28 EA per 28 days)
LUTERA ORAL TABLET 0.1-20 MG-MCG
T5
GR-F; QL (28 EA per 28 days)
marlissa oral tablet 0.15-30 mg-mcg
T5
GR-F; QL (28 EA per 28 days)
medroxyprogesterone acetate intramuscular* suspension 150 mg/ml
T5
GR-F; QL (1 ML per 90 days)
MICROGESTIN FE 1/20 ORAL TABLET 1-20 MG-MCG
T5
GR-F
MONO-LINYAH ORAL TABLET 0.25-35 MG-MCG
T5
GR-F; QL (28 EA per 28 days)
MONONESSA ORAL TABLET 0.25-35 MG-MCG
T5
GR-F; QL (28 EA per 28 days)
MYZILRA ORAL TABLET
T5
GR-F; QL (28 EA per 28 days)
NECON 0.5/35 (28) ORAL TABLET 0.5-35 MG-MCG
T5
GR-F; QL (28 EA per 28 days)
NECON 1/35 (28) ORAL TABLET 1-35 MG-MCG
T5
GR-F; QL (28 EA per 28 days)
NECON 1/50 (28) ORAL TABLET 1-50 MG-MCG
T5
GR-F; QL (28 EA per 21 days)
NECON 7/7/7 ORAL TABLET 0.5/0.75/1-35 MG-MCG
T5
GR-F; QL (28 EA per 28 days)
NORA-BE ORAL TABLET 0.35 MG
T5
GR-F; QL (28 EA per 28 days)
norethin ace-eth estrad-fe oral tablet 1-20 mg-mcg, 1-20 mg-mcg(24)
T5
norethindrone oral tablet 0.35 mg
T5
GR-F; QL (28 EA per 28 days)
norgestimate-eth estradiol oral tablet 0.25-35 mg-mcg
T5
GR-F; QL (28 EA per 28 days)
norgestim-eth estrad triphasic oral tablet 0.18/0.215/0.25 mg-35 mcg
T5
GR-F; QL (28 EA per 28 days)
NORTREL 0.5/35 (28) ORAL TABLET 0.5-35 MG-MCG
T5
GR-F; QL (28 EA per 28 days)
NORTREL 1/35 (21) ORAL TABLET 1-35 MG-MCG
T5
GR-F; QL (28 EA per 28 days)
NORTREL 1/35 (28) ORAL TABLET 1-35 MG-MCG
T5
GR-F; QL (28 EA per 28 days)
NORTREL 7/7/7 ORAL TABLET 0.5/0.75/1-35 MG-MCG
T5
GR-F; QL (28 EA per 28 days)
NUVARING VAGINAL RING 0.12-0.015 MG/24HR
T5
PA
ORSYTHIA ORAL TABLET 0.1-20 MG-MCG
T5
GR-F; QL (28 EA per 28 days)
46
Drug
Status
Notes
ORTHO EVRA TRANSDERMAL PATCH WEEKLY 150-35 MCG/24HR
T5
PA
PORTIA-28 ORAL TABLET 0.15-30 MG-MCG
T5
GR-F; QL (28 EA per 28 days)
PREVIFEM ORAL TABLET 0.25-35 MG-MCG
T5
GR-F; QL (28 EA per 28 days)
RECLIPSEN ORAL TABLET 0.15-30 MG-MCG
T5
GR-F; QL (28 EA per 28 days)
SPRINTEC 28 ORAL TABLET 0.25-35 MG-MCG
T5
GR-F; QL (28 EA per 28 days)
SRONYX ORAL TABLET 0.1-20 MG-MCG
T5
GR-F; QL (28 EA per 28 days)
TARINA FE 1/20 ORAL TABLET 1-20 MG-MCG
T5
TRI-ESTARYLLA ORAL TABLET 0.18/0.215/0.25 MG-35 MCG
T5
GR-F; QL (28 EA per 28 days)
TRI-LINYAH ORAL TABLET 0.18/0.215/0.25 MG-35 MCG
T5
GR-F; QL (28 EA per 28 days)
TRINESSA (28) ORAL TABLET 0.18/0.215/0.25 MG-35 MCG
T5
GR-F; QL (28 EA per 28 days)
TRI-PREVIFEM ORAL TABLET 0.18/0.215/0.25 MG-35 MCG
T5
GR-F; QL (28 EA per 28 days)
TRI-SPRINTEC ORAL TABLET 0.18/0.215/0.25 MG-35 MCG
T5
GR-F; QL (28 EA per 28 days)
TRIVORA (28) ORAL TABLET
T5
GR-F; QL (28 EA per 28 days)
VELIVET ORAL TABLET 0.1/0.125/0.15 -0.025 MG
T5
GR-F; QL (28 EA per 28 days)
WERA ORAL TABLET 0.5-35 MG-MCG
T5
GR-F; QL (28 EA per 28 days)
XULANE TRANSDERMAL PATCH WEEKLY 150-35 MCG/24HR
T5
PA
ZOVIA 1/35E (28) ORAL TABLET 1-35 MG-MCG
T5
GR-F; QL (28 EA per 28 days)
*Corticosteroids* A-HYDROCORT INJECTION SOLUTION RECONSTITUTED 100 MG
T1
betamethasone sod phos & acet injection suspension 6 (3-3) mg/ml
T1
budesonide oral capsule delayed release particles 3 mg
T4
cortisone acetate oral tablet 25 mg
T1
DEPO-MEDROL INJECTION SUSPENSION 20 MG/ML
T3
DEXAMETHASONE INTENSOL ORAL CONCENTRATE 1 MG/ML
T3 47
Drug
Status
dexamethasone oral elixir 0.5 mg/5ml
T1
dexamethasone oral solution 0.5 mg/5ml
T1
dexamethasone oral tablet 0.5 mg, 0.75 mg, 1 mg, 1.5 mg, 2 mg, 4 mg, 6 mg
T1
dexamethasone sod phosphate pf injection solution 10 mg/ml
T1
dexamethasone sodium phosphate injection solution 10 mg/ml, 100 mg/10ml, 120 mg/30ml, 20 mg/5ml, 4 mg/ml
T1
DEXPAK 10 DAY ORAL 1.5 MG (35)
T3
DEXPAK 13 DAY ORAL 1.5 MG (51)
T3
DEXPAK 6 DAY ORAL 1.5 MG (21)
T3
fludrocortisone acetate oral tablet 0.1 mg
T1
hydrocortisone oral tablet 10 mg, 20 mg, 5 mg
T1
methylprednisolone oral 4 mg
T1
methylprednisolone oral tablet 16 mg, 32 mg, 4 mg, 8 mg
T1
MILLIPRED DP ORAL 5 MG (21), 5 MG (48)
T3
MILLIPRED ORAL TABLET 5 MG
T3
prednisolone oral solution 15 mg/5ml
T1
prednisolone oral syrup 15 mg/5ml
T1
prednisolone sodium phosphate oral solution 15 mg/5ml, 25 mg/5ml, 6.7 (5 base) mg/5ml
T1
PREDNISONE INTENSOL ORAL CONCENTRATE 5 MG/ML
T3
prednisone oral 10 mg (21), 10 mg (48), 5 mg (21), 5 mg (48)
T1
prednisone oral solution 5 mg/5ml
T1
prednisone oral tablet 1 mg, 10 mg, 2.5 mg, 20 mg, 5 mg, 50 mg
T1
*Cough/Cold/Allergy* acetylcysteine inhalation solution 10 %, 20 %
T1
benzonatate oral capsule 100 mg, 200 mg
T1
BROMFED DM ORAL SYRUP 30-2-10 MG/5ML
T1
hydrocod polst-cpm polst er oral 10-8 mg/5ml
T1
hydrocodone-homatropine oral syrup 5-1.5 mg/5ml
T1
hydromet oral syrup 5-1.5 mg/5ml
T1
promethazine vc plain oral syrup 6.25-5 mg/5ml
T1
48
Notes
Drug
Status
promethazine vc/codeine oral syrup 6.25-5-10 mg/5ml
T1
promethazine-codeine oral syrup 6.25-10 mg/5ml
T1
promethazine-dm oral syrup 6.25-15 mg/5ml
T1
sodium chloride inhalation nebulization solution 0.9 %, 10 %, 3 %, 7 %
T1
tgq 15dm/5peh/2cpm oral syrup 15-5-2 mg/5ml
T1
tgq 30pse/150gfn/15dm oral syrup 30-150-15 mg/5ml
T1
WAL-TAP CHILDRENS ORAL ELIXIR 1-2.5 MG/5ML
T1
Notes
*Dermatologicals* acitretin oral capsule 10 mg, 17.5 mg, 25 mg
T4
PA
acne medication 10 external gel 10 %
T1
acne medication 5 external gel 5 %
T1
acne medication 5 external lotion 5 %
T1
acyclovir external ointment 5 %
T4
alclometasone dipropionate external cream 0.05 %
T1
alclometasone dipropionate external ointment 0.05 %
T1
ALPHAQUIN HP EXTERNAL CREAM 4 %
T1
ALTABAX EXTERNAL OINTMENT 1 %
T3
amcinonide external cream 0.1 %
T3
amcinonide external lotion 0.1 %
T3
amcinonide external ointment 0.1 %
T3
ammonium lactate external cream 12 %
T1
PA
ammonium lactate external lotion 12 %
T1
PA
ATRALIN EXTERNAL GEL 0.05 %
T3
ST; QL (45 GM per 23 days)
AVITA EXTERNAL GEL 0.025 %
T1
BAZA EXTERNAL KIT
T1
BENZEPRO EXTERNAL FOAM 5.3 %
T3
BENZEPRO SHORT CONTACT EXTERNAL FOAM 9.8 %
T3
benzoyl peroxide cleanser external lotion 6 %
T1
benzoyl peroxide external foam 5.3 %
T3
benzoyl peroxide external gel 10 %, 5 %
T1
benzoyl peroxide wash external kit 4 & 5 %, 8 & 5%
T1
benzoyl peroxide-erythromycin external gel 5-3 %
T1
PA
ST
49
Drug
Status
Notes
betamethasone dipropionate aug external cream 0.05 %
T1
QL (100 GM per 23 days)
betamethasone dipropionate aug external gel 0.05 %
T1
QL (100 GM per 23 days)
betamethasone dipropionate aug external lotion 0.05 %
T1
QL (120 ML per 23 days)
betamethasone dipropionate aug external ointment 0.05 %
T1
QL (100 GM per 23 days)
betamethasone dipropionate external cream 0.05 %
T1
QL (90 GM per 23 days)
betamethasone dipropionate external lotion 0.05 %
T1
QL (120 ML per 23 days)
betamethasone dipropionate external ointment 0.05 %
T1
QL (90 GM per 23 days)
betamethasone valerate external cream 0.1 %
T1
QL (90 GM per 23 days)
betamethasone valerate external foam 0.12 %
T3
betamethasone valerate external lotion 0.1 %
T1
QL (120 ML per 23 days)
betamethasone valerate external ointment 0.1 %
T1
QL (90 GM per 23 days)
bp cleansing external lotion 4 %
T1
bp foam external foam 5.3 %
T3
bp gel external gel 10 %, 5 %
T1
bp wash external liquid† 7 %
T3
bpo creamy wash external kit 4 & 5 %, 8 & 5 %
T1
calcipotriene external cream 0.005 %
T3
calcipotriene external ointment 0.005 %
T3
calcipotriene external solution 0.005 %
T3
calcipotriene-betameth diprop external ointment 0.005-0.064 %
T3
ST
calcitriol external ointment 3 mcg/gm
T3
PA
CAPEX EXTERNAL SHAMPOO 0.01 %
T3
ST; QL (120 ML per 23 days)
CEM-UREA EXTERNAL SOLUTION 45 %
T3
ciclopirox external solution 8 %
T3
ciclopirox treatment external kit 8 %
T3
ciclopirox-vitamin e external kit 8 & 5 %
T3
CLINDACIN ETZ EXTERNAL KIT 1 %
T1
CLINDACIN ETZ EXTERNAL SWAB 1 %
T1
CLINDACIN PAC EXTERNAL KIT 1 %
T1
CLINDACIN-P EXTERNAL SWAB 1 %
T1
clindamycin phos-benzoyl perox external gel 1-5 %, 1.2-5 %
T3
50
Drug
Status
Notes
clindamycin phosphate external foam 1 %
T3
clindamycin phosphate external gel 1 %
T3
clindamycin phosphate external lotion 1 %
T1
clindamycin phosphate external solution 1 %
T1
clindamycin phosphate external swab 1 %
T1
clobetasol propionate e external cream 0.05 %
T1
clobetasol propionate emulsion external foam 0.05 %
T3
clobetasol propionate external foam 0.05 %
T3
clobetasol propionate external gel 0.05 %
T1
clobetasol propionate external lotion 0.05 %
T3
clobetasol propionate external ointment 0.05 %
T1
clobetasol propionate external shampoo 0.05 %
T3
clobetasol propionate external solution 0.05 %
T1
CLODERM EXTERNAL CREAM 0.1 %
T3
CLODERM PUMP EXTERNAL CREAM 0.1 %
T3
clotrimazole external cream 1 %
T1
clotrimazole external solution 1 %
T1
clotrimazole-betamethasone external cream 1-0.05 %
T1
QL (90 GM per 23 days)
clotrimazole-betamethasone external lotion 1-0.05 %
T3
QL (60 ML per 23 days)
CONDYLOX EXTERNAL GEL 0.5 %
T3
PA
CORDRAN EXTERNAL CREAM 0.05 %
T3
PA
CORDRAN EXTERNAL LOTION 0.05 %
T3
PA
CORDRAN EXTERNAL TAPE 4 MCG/SQCM
T3
PA; QL (1 EA per 23 days)
CORMAX SCALP APPLICATION EXTERNAL SOLUTION 0.05 %
T1
QL (100 ML per 23 days)
CORTISPORIN EXTERNAL CREAM 3.5-10000-0.5
T1
CORTISPORIN EXTERNAL OINTMENT 1 %
T3
DENAVIR EXTERNAL CREAM 1 %
T3
desonide external cream 0.05 %
T3
desonide external lotion 0.05 %
T3
desonide external ointment 0.05 %
T1
QL (120 GM per 23 days)
desoximetasone external cream 0.05 %, 0.25 %
T1
QL (200 GM per 23 days)
desoximetasone external gel 0.05 %
T1
QL (120 GM per 23 days)
QL (120 GM per 23 days)
QL (120 GM per 23 days) QL (120 GM per 23 days)
QL (50 GM per 30 days)
QL (120 GM per 23 days)
51
Drug
Status
Notes
desoximetasone external ointment 0.05 %
T3
QL (120 GM per 23 days)
desoximetasone external ointment 0.25 %
T1
QL (200 GM per 23 days)
diclofenac sodium transdermal gel 1 %
T3
QL (200 GM per 30 days)
diflorasone diacetate external cream 0.05 %
T1
QL (120 GM per 23 days)
diflorasone diacetate external ointment 0.05 %
T1
QL (120 GM per 23 days)
DRITHO-CREME HP EXTERNAL CREAM 1%
T3
DYSPORT (GLABELLAR LINES) INTRAMUSCULAR* SOLUTION RECONSTITUTED 300 UNIT
T4
PA
econazole nitrate external cream 1 %
T1
QL (85 GM per 23 days)
ELIDEL EXTERNAL CREAM 1 %
T3
QL (100 GM per 23 days)
EPIDUO EXTERNAL GEL 0.1-2.5 %
T3
ERTACZO EXTERNAL CREAM 2 %
T3
ery external pad 2 %
T1
erythromycin external gel 2 %
T1
erythromycin external pad 2 %
T1
erythromycin external solution 2 %
T1
ethyl chloride external aerosol†
T1
EURAX EXTERNAL CREAM 10 %
T2
PA
EURAX EXTERNAL LOTION 10 %
T2
PA
EXODERM EXTERNAL LOTION 25-1 %
T1
finasteride oral tablet 1 mg
T1
fluocinolone acetonide external cream 0.01 %, 0.025 %
T1
QL (120 GM per 23 days)
fluocinolone acetonide external ointment 0.025 %
T1
QL (120 GM per 23 days)
fluocinolone acetonide external solution 0.01 %
T3
QL (120 ML per 23 days)
fluocinonide external gel 0.05 %
T1
QL (120 GM per 23 days)
fluocinonide external ointment 0.05 %
T1
QL (120 GM per 23 days)
fluocinonide external solution 0.05 %
T1
QL (120 ML per 23 days)
fluocinonide-e external cream 0.05 %
T1
QL (120 GM per 23 days)
fluorouracil external cream 5 %
T3
fluorouracil external solution 2 %, 5 %
T1
flurandrenolide external cream 0.05 %
T3
PA
fluticasone propionate external cream 0.05 %
T1
QL (120 GM per 23 days)
fluticasone propionate external lotion 0.05 %
T3
fluticasone propionate external ointment 0.005 %
T1
gentamicin sulfate external cream 0.1 %
T1
gentamicin sulfate external ointment 0.1 %
T1
52
QL (120 GM per 23 days)
Drug
Status
Notes
GLYDO EXTERNAL GEL 2 %
T1
QL (90 ML per 23 days)
gnp hydrocortisone/aloe external cream 1 %
T1
QL (120 GM per 23 days)
halobetasol propionate external cream 0.05 %
T1
QL (100 GM per 23 days)
halobetasol propionate external ointment 0.05 %
T1
QL (100 GM per 23 days)
HALOG EXTERNAL CREAM 0.1 %
T3
QL (100 GM per 23 days)
HALOG EXTERNAL OINTMENT 0.1 %
T3
QL (100 GM per 23 days)
hm hydrocortisone plus external cream 1 %
T1
QL (120 GM per 23 days)
hm hydrocortisone-aloe max st external cream 1 %
T1
QL (120 GM per 23 days)
hydrocortisone ace-pramoxine external cream 2.5-1 %
T1
QL (60 GM per 23 days)
hydrocortisone butyr lipo base external cream 0.1 %
T1
hydrocortisone butyrate external cream 0.1 %
T1
hydrocortisone butyrate external ointment 0.1 %
T1
hydrocortisone butyrate external solution 0.1 %
T1
hydrocortisone external cream 2.5 %
T3
QL (90 GM per 23 days)
hydrocortisone external lotion 1 %
T1
QL (240 GM per 23 days)
hydrocortisone external lotion 2.5 %
T1
QL (120 ML per 23 days)
hydrocortisone external ointment 1 %, 2.5 %
T1
QL (90 GM per 23 days)
hydrocortisone valerate external cream 0.2 %
T1
QL (120 GM per 23 days)
hydrocortisone valerate external ointment 0.2 %
T1
QL (120 GM per 23 days)
hydrocortisone-aloe external cream 1 %
T1
QL (120 GM per 23 days)
hydroquinone external cream 4 %
T1
hydroquinone time release external cream 4 %
T1
HYPERCARE EXTERNAL SOLUTION 20 %
T1
imiquimod external cream 5 %
T4
QL (60 EA per 30 days)
KENALOG EXTERNAL AEROSOL, SOLUTION 0.147 MG/GM
T3
PA
ketoconazole external cream 2 %
T1
ketoconazole external shampoo 2 %
T1
KETODAN EXTERNAL FOAM 2 %
T3
KETODAN EXTERNAL KIT 2 %
T3
kls hydrocortisone plus external cream 1 %
T1
kp benzoyl peroxide external gel 10 %, 5 %
T1
lactic acid e external cream 10-3500 %-unt/30gm
T1
PA
lactic acid external lotion 10 %
T1
PA
LATRIX EXTERNAL SUSPENSION 50 %
T1
QL (120 GM per 23 days)
53
Drug
Status
Notes
lidocaine external cream 4 %
T1
QL (90 GM per 30 days)
lidocaine external ointment 5 %
T1
QL (70.8 GM per 23 days)
lidocaine external patch 5 %
T3
PA
lidocaine hcl external cream 3 %
T1
QL (85 GM per 30 days)
lidocaine hcl external gel 2 %
T1
lidocaine hcl external lotion 3 %
T1
QL (100 ML per 23 days)
lidocaine hcl external solution 4 %
T1
QL (100 ML per 23 days)
lidocaine-prilocaine external cream 2.5-2.5 %
T1
lidocaine-prilocaine external kit 2.5-2.5 %
T1
LIDODERM EXTERNAL PATCH 5 %
T3
lindane external lotion 1 %
T3
lindane external shampoo 1 %
T3
mafenide acetate external packet 5 %
T3
malathion external lotion 0.5 %
T2
medi-first hydrocortisone external cream 1 %
T1
melpaque hp external cream 4 %
T1
MELQUIN 3 EXTERNAL SOLUTION 3 %
T1
melquin hp external cream 4 %
T1
MENTAX EXTERNAL CREAM 1 %
T3
methoxsalen rapid oral capsule 10 mg
T3
metronidazole external cream 0.75 %
T3
metronidazole external gel 0.75 %
T3
metronidazole external lotion 0.75 %
T1
miconazole nitrate external cream 2 %
T1
mometasone furoate external cream 0.1 %
T1
mometasone furoate external ointment 0.1 %
T1
mometasone furoate external solution 0.1 %
T1
mupirocin calcium external cream 2 %
T3
mupirocin external ointment 2 %
T1
NATROBA EXTERNAL SUSPENSION 0.9 %
T3
NYAMYC EXTERNAL POWDER 100000 UNIT/GM
T1
nystatin external cream 100000 unit/gm
T1
nystatin external ointment 100000 unit/gm
T1
nystatin external powder , 100000 unit/gm
T1
nystatin powder
T1
nystatin-triamcinolone external cream 100000-0.1 unit/gm-%
T3
54
PA
QL (120 EA per 23 days)
PA
Drug
Status
Notes
nystatin-triamcinolone external ointment 100000-0.1 unit/gm-%
T1
NYSTOP EXTERNAL POWDER 100000 UNIT/GM
T1
oxiconazole nitrate external cream 1 %
T3
OXISTAT EXTERNAL CREAM 1 %
T3
OXSORALEN EXTERNAL LOTION 1 %
T4
OXSORALEN ULTRA ORAL CAPSULE 10 MG
T3
PA
permethrin external cream 5 %
T1
QL (120 GM per 30 days)
podocon external solution 25 %
T3
podofilox external solution 0.5 %
T1
PR BENZOYL PEROXIDE WASH EXTERNAL LIQUID† 7 %
T3
prednicarbate external cream 0.1 %
T1
QL (120 GM per 23 days)
prednicarbate external ointment 0.1 %
T1
QL (120 GM per 23 days)
PRUDOXIN EXTERNAL CREAM 5 %
T3
pyrogallic acid external ointment 25-2 %
T1
REA LO 39 EXTERNAL CREAM 39 %
T3
REGENECARE EXTERNAL GEL 2 %
T1
QL (90 GM per 23 days)
REGENECARE HA EXTERNAL GEL 2 %
T1
QL (90 GM per 23 days)
REMEVEN EXTERNAL CREAM 50 %
T1
ROSADAN EXTERNAL CREAM 0.75 %
T3
ROSADAN EXTERNAL GEL 0.75 %
T3
ROSADAN EXTERNAL KIT 0.75 % (CREAM), 0.75 % (GEL)
T3
SALACYN EXTERNAL CREAM 6 %
T1
SALACYN EXTERNAL LOTION 6 %
T1
salicylic acid external cream 6 %
T3
salicylic acid external foam 6 %
T3
salicylic acid external gel 6 %
T1
salicylic acid external liquid† 26 %, 27.5 %
T1
salicylic acid external lotion 6 %
T3
salicylic acid external shampoo 6 %
T1
salicylic acid wart remover external liquid† 27.5 %
T1
salicylic acid-cleanser external kit 6 % (cream), 6 % (lotion)
T3
SALVAX EXTERNAL FOAM 6 %
T3
55
Drug
Status
Notes
SANTYL EXTERNAL OINTMENT 250 UNIT/GM
T3
sb hydrocortisone external cream 1 %
T1
QL (120 GM per 23 days)
scalacort external lotion 2 %
T3
QL (120 ML per 23 days)
se bpo wash external liquid† 7 %
T3
SEB-PREV WASH EXTERNAL LIQUID† 10 %
T3
selenium sulfide external lotion 2.5 %
T1
selenium sulf-pyrithione-urea external shampoo 2.25 %
T3
silver nitrate external ointment 10 %
T1
silver nitrate external solution 0.5 %, 10 %, 25 %, 50 %
T1
SKLICE EXTERNAL LOTION 0.5 %
T3
sm hydrocortisone plus external cream 1 %
T1
QL (120 GM per 23 days)
sm hydrocortisone-aloe max st external cream 1 %
T1
QL (120 GM per 23 days)
sodium sulfacetamide wash external liquid† 10 %
T3
SORIATANE CK COMBINATION KIT 10 MG, 25 MG
T4
PA
SORIATANE ORAL CAPSULE 10 MG, 17.5 MG, 25 MG
T4
PA
STELARA SUBCUTANEOUS* 45 MG/0.5ML
T4
PA
sulfacetamide sodium (acne) external lotion 10 %
T3
sulfacetamide sodium external gel 10 % (cleans)
T3
sulfacetamide sodium external liquid† 10 %
T3
sulfacetamide sodium external suspension 10 %
T3
sulfacetamide sodium-sulfur external lotion 10-5 %
T3
sulfacetamide sodium-sulfur external suspension 10-5 %
T3
SYNALAR (CREAM) EXTERNAL KIT 0.025 %
T3
SYNALAR (OINTMENT) EXTERNAL KIT 0.025 %
T3
SYNALAR EXTERNAL CREAM 0.025 %
T3
SYNALAR EXTERNAL OINTMENT 0.025 %
T3
TACLONEX EXTERNAL OINTMENT 0.005-0.064 %
T3
ST
TACLONEX EXTERNAL SUSPENSION 0.005-0.064 %
T3
ST
56
Drug
Status
Notes
TACLONEX SCALP EXTERNAL SUSPENSION 0.005-0.064 %
T3
ST
TAZORAC EXTERNAL CREAM 0.05 %, 0.1 %
T4
PA
TAZORAC EXTERNAL GEL 0.05 %, 0.1 %
T4
PA
tgt anti-itch/aloe max st external cream 1 %
T1
QL (120 GM per 23 days)
tl hydroquinone external cream 4 %
T1
tretinoin (emollient) external cream 0.05 %
T1
QL (45 GM per 23 days); AL (Max 28 Years)
tretinoin external cream 0.025 %, 0.05 %, 0.1 %
T1
QL (45 GM per 23 days)
tretinoin external gel 0.01 %
T1
QL (45 GM per 23 days)
tretinoin external gel 0.025 %
T1
ST
tretinoin microsphere external gel 0.04 %
T3
ST
tretinoin microsphere pump external gel 0.04 %
T3
ST
triamcinolone acetonide external aerosol, solution 0.147 mg/gm
T3
PA
triamcinolone acetonide external cream 0.025 %, 0.1 %
T1
QL (160 GM per 23 days)
triamcinolone acetonide external cream 0.5 %
T1
QL (60 GM per 23 days)
triamcinolone acetonide external lotion 0.025 %, 0.1 %
T1
QL (120 ML per 23 days)
triamcinolone acetonide external ointment 0.025 %, 0.1 %
T1
QL (160 GM per 23 days)
triamcinolone acetonide external ointment 0.5 %
T1
QL (60 GM per 23 days)
TRIANEX EXTERNAL OINTMENT 0.05 %
T3
QL (60 GM per 23 days)
UMECTA MOUSSE EXTERNAL FOAM 40 %
T3
URAMAXIN EXTERNAL FOAM 20 %
T3
urea external cream 39 %, 45 %, 50 %
T3
urea external emulsion 50 %
T3
urea external gel 40 %
T3
urea external lotion 40 %, 45 %
T3
urea external suspension 50 %
T3
urea in zn undecyl-lactic acid external emulsion 50 %
T3
urea nail external gel 45 %
T3
urea nail external kit 40 & 0.2 %
T3
urea nail film external suspension 40 %
T3
VASOLEX EXTERNAL OINTMENT
T1
VELTIN EXTERNAL GEL 1.2-0.025 %
T3 57
Drug
Status
Notes
VEREGEN EXTERNAL OINTMENT 15 %
T3
PA
VITAZOL EXTERNAL CREAM 0.75 %
T3
VOLTAREN TRANSDERMAL GEL 1 %
T3
WOUND WASH SALINE EXTERNAL SOLUTION 0.9 %
T1
X-VIATE EXTERNAL CREAM 40 %
T1
X-VIATE EXTERNAL GEL 40 %
T1
ZOVIRAX EXTERNAL CREAM 5 %
T3
PA
GLUCAGEN DIAGNOSTIC INJECTION SOLUTION RECONSTITUTED 1 MG
T3
QL (2 EA per 30 days)
SODIUM CHLORIDE THERMOJECT SYS INJECTION SOLUTION 0.9 %
T3
THYROGEN INTRAMUSCULAR* SOLUTION RECONSTITUTED 1.1 MG
T4
QL (200 GM per 30 days)
*Diagnostic Products*
PA
*Digestive Aids* CREON ORAL CAPSULE DELAYED RELEASE PARTICLES 12000 UNIT, 24000 UNIT, 3000-9500 UNIT, 36000 UNIT, 6000 UNIT
T2
ZENPEP ORAL CAPSULE DELAYED RELEASE PARTICLES 25000 UNIT
T2
*Direct-Acting P2y12 Inhibitors*** BRILINTA ORAL TABLET 60 MG, 90 MG
T3
*Diuretics* acetazolamide er oral capsule extended release 12 hour 500 mg
T1
acetazolamide oral tablet 125 mg, 250 mg
T1
amiloride hcl oral tablet 5 mg
T1
amiloride-hydrochlorothiazide oral tablet 5-50 mg
T1
bumetanide injection solution 0.25 mg/ml
T1
bumetanide oral tablet 0.5 mg, 1 mg, 2 mg
T1
chlorothiazide oral tablet 250 mg, 500 mg
T1
chlorthalidone oral tablet 25 mg, 50 mg
T1
DYRENIUM ORAL CAPSULE 100 MG
T3
EDECRIN ORAL TABLET 25 MG
T3
furosemide oral solution 10 mg/ml, 8 mg/ml
T1
furosemide oral tablet 20 mg, 40 mg, 80 mg
T1
hydrochlorothiazide oral capsule 12.5 mg
T1
58
QL (60 EA per 30 days)
Drug
Status
hydrochlorothiazide oral tablet 12.5 mg, 25 mg, 50 mg
T1
indapamide oral tablet 1.25 mg, 2.5 mg
T1
methyclothiazide oral tablet 5 mg
T1
metolazone oral tablet 10 mg, 2.5 mg, 5 mg
T1
spironolactone oral tablet 100 mg, 25 mg, 50 mg
T1
spironolactone-hctz oral tablet 25-25 mg
T1
torsemide oral tablet 10 mg, 100 mg, 20 mg, 5 mg
T1
triamterene-hctz oral capsule 37.5-25 mg
T1
triamterene-hctz oral tablet 37.5-25 mg, 75-50 mg
T1
Notes
*Endocrine And Metabolic Agents Misc.* ACTONEL ORAL TABLET 150 MG
T2
ST; QL (1 EA per 30 days)
ACTONEL ORAL TABLET 30 MG, 5 MG
T2
ST; QL (30 EA per 30 days)
ACTONEL ORAL TABLET 35 MG
T2
ST
alendronate sodium oral tablet 10 mg, 35 mg, 5 mg, 70 mg
T1
QL (4 EA per 28 days)
alendronate sodium oral tablet 40 mg
T1
PA; QL (4 EA per 28 days)
ATELVIA ORAL TABLET DELAYED RELEASE 35 MG
T3
ST; QL (4 EA per 30 days)
cabergoline oral tablet 0.5 mg
T1
calcitonin (salmon) nasal solution 200 unit/act
T1
calcitriol oral capsule 0.25 mcg, 0.5 mcg
T1
calcitriol oral solution 1 mcg/ml
T3
chorionic gonadotropin intramuscular* solution reconstituted 10000 unit
T4
CYSTADANE ORAL POWDER
T4
desmopressin ace rhinal tube nasal solution 0.01 %
T1
desmopressin ace spray refrig nasal solution 0.01 %
T3
desmopressin acetate injection solution 4 mcg/ml
T4
desmopressin acetate oral tablet 0.1 mg, 0.2 mg
T1
desmopressin acetate spray nasal solution 0.01 %
T3
doxercalciferol oral capsule 0.5 mcg, 1 mcg, 2.5 mcg
T3
etidronate disodium oral tablet 200 mg, 400 mg
T3
EVISTA ORAL TABLET 60 MG
T5
FORTEO SUBCUTANEOUS* SOLUTION 600 MCG/2.4ML
T4
PA
PA
PA
PA 59
Drug
Status
Notes
FOSAMAX PLUS D ORAL TABLET 70-2800 MG-UNIT, 70-5600 MG-UNIT
T3
PA
ganirelix acetate subcutaneous* solution 250 mcg/0.5ml
T4
PA
GENOTROPIN MINIQUICK SUBCUTANEOUS* SOLUTION RECONSTITUTED 0.2 MG, 0.4 MG, 0.6 MG, 0.8 MG, 1 MG, 1.2 MG, 1.4 MG, 1.6 MG, 1.8 MG, 2 MG
T4
PA
GENOTROPIN SUBCUTANEOUS* SOLUTION RECONSTITUTED 12 MG, 5 MG
T4
PA
HECTOROL ORAL CAPSULE 0.5 MCG, 1 MCG, 2.5 MCG
T3
PA
ibandronate sodium oral tablet 150 mg
T3
ST
INCRELEX SUBCUTANEOUS* SOLUTION 40 MG/4ML
T4
PA
levocarnitine oral solution 1 gm/10ml
T3
levocarnitine oral tablet 330 mg
T3
LUPRON DEPOT-PED INTRAMUSCULAR* KIT 11.25 MG (PED), 30 MG (PED)
T4
PA
MIACALCIN INJECTION SOLUTION 200 UNIT/ML
T3
ST
NORDITROPIN FLEXPRO SUBCUTANEOUS* SOLUTION 10 MG/1.5ML, 15 MG/1.5ML, 5 MG/1.5ML
T4
PA
NORDITROPIN NORDIFLEX PEN SUBCUTANEOUS* SOLUTION 15 MG/1.5ML, 30 MG/3ML, 5 MG/1.5ML
T4
PA
NUTROPIN AQ NUSPIN 10 SUBCUTANEOUS* SOLUTION 10 MG/2ML
T4
PA
NUTROPIN AQ NUSPIN 20 SUBCUTANEOUS* SOLUTION 20 MG/2ML
T4
PA
NUTROPIN AQ NUSPIN 5 SUBCUTANEOUS* SOLUTION 5 MG/2ML
T4
PA
NUTROPIN AQ PEN SUBCUTANEOUS* SOLUTION 10 MG/2ML, 20 MG/2ML
T4
PA
octreotide acetate injection solution 100 mcg/ml, 1000 mcg/ml, 200 mcg/ml, 50 mcg/ml, 500 mcg/ml
T4
PA
ORFADIN ORAL CAPSULE 10 MG, 2 MG, 5 MG
T4
PA
paricalcitol oral capsule 1 mcg, 2 mcg, 4 mcg
T3
PA
60
Drug
Status
Notes
PROLIA SUBCUTANEOUS* SOLUTION 60 MG/ML
T4
raloxifene hcl oral tablet 60 mg
T5
risedronate sodium oral tablet 150 mg
T2
ST; QL (1 EA per 30 days)
risedronate sodium oral tablet 30 mg, 5 mg
T2
ST; QL (30 EA per 30 days)
risedronate sodium oral tablet 35 mg
T2
ST
risedronate sodium oral tablet delayed release 35 mg
T3
ST; QL (4 EA per 30 days)
SAMSCA ORAL TABLET 15 MG, 30 MG
T4
PA
SANDOSTATIN LAR DEPOT INTRAMUSCULAR* KIT 10 MG, 20 MG, 30 MG
T4
PA
SENSIPAR ORAL TABLET 30 MG, 60 MG, 90 MG
T4
PA
SOMATULINE DEPOT SUBCUTANEOUS* SOLUTION 120 MG/0.5ML, 60 MG/0.2ML, 90 MG/0.3ML
T4
PA
SOMAVERT SUBCUTANEOUS* SOLUTION RECONSTITUTED 10 MG, 15 MG, 20 MG
T4
PA
STIMATE NASAL SOLUTION 1.5 MG/ML
T4
PA
TEV-TROPIN SUBCUTANEOUS* SOLUTION RECONSTITUTED 5 MG
T4
PA
ZEMPLAR ORAL CAPSULE 1 MCG, 2 MCG, 4 MCG
T3
PA
PA
*Estrogens* ALORA TRANSDERMAL PATCH BIWEEKLY 0.075 MG/24HR
T2
COMBIPATCH TRANSDERMAL PATCH BIWEEKLY 0.05-0.14 MG/DAY, 0.05-0.25 MG/DAY
T3
COVARYX HS ORAL TABLET 0.625-1.25 MG
T1
COVARYX ORAL TABLET 1.25-2.5 MG
T1
ENJUVIA ORAL TABLET 0.3 MG, 0.45 MG, 0.625 MG, 0.9 MG, 1.25 MG
T2
GR-F
estradiol oral tablet 0.5 mg, 1 mg, 2 mg
T1
GR-F
estradiol transdermal patch biweekly 0.025 mg/24hr, 0.0375 mg/24hr, 0.05 mg/24hr, 0.075 mg/24hr, 0.1 mg/24hr
T2
GR-F; QL (8 EA per 28 days)
estradiol transdermal patch weekly 0.025 mg/24hr, 0.0375 mg/24hr, 0.05 mg/24hr, 0.06 mg/24hr, 0.075 mg/24hr, 0.1 mg/24hr
T1
GR-F; QL (4 EA per 28 days)
61
Drug
Status
Notes
estradiol valerate intramuscular* oil 20 mg/ml, 40 mg/ml
T1
GR-F
estradiol-norethindrone acet oral tablet 0.5-0.1 mg, 1-0.5 mg
T1
ESTROGEL TRANSDERMAL GEL 0.75 MG/1.25 GM (0.06%)
T3
GR-F
estropipate oral tablet 0.75 mg, 1.5 mg, 3 mg
T1
GR-F
EVAMIST TRANSDERMAL SOLUTION 1.53 MG/SPRAY
T3
GR-F
JINTELI ORAL TABLET 1-5 MG-MCG
T1
GR-F; QL (28 EA per 28 days)
MENEST ORAL TABLET 0.3 MG, 0.625 MG, 1.25 MG, 2.5 MG
T3
GR-F
MIMVEY ORAL TABLET 1-0.5 MG
T1
MINIVELLE TRANSDERMAL PATCH BIWEEKLY 0.1 MG/24HR
T2
PREMARIN ORAL TABLET 0.3 MG
T2
GR-F
PREMARIN ORAL TABLET 0.45 MG, 0.625 MG, 0.9 MG, 1.25 MG
T3
GR-F
PREMPHASE ORAL TABLET 0.625-5 MG
T2
PREMPRO ORAL TABLET 0.3-1.5 MG, 0.45-1.5 MG, 0.625-2.5 MG, 0.625-5 MG
T2
VIVELLE-DOT TRANSDERMAL PATCH BIWEEKLY 0.025 MG/24HR, 0.0375 MG/24HR, 0.05 MG/24HR, 0.075 MG/24HR, 0.1 MG/24HR
T2
*Fluoroquinolones* AVELOX ORAL TABLET 400 MG
T3
CIPRO ORAL SUSPENSION RECONSTITUTED 250 MG/5ML (5%), 500 MG/5ML (10%)
T3
ciprofloxacin hcl oral tablet 100 mg, 250 mg, 500 mg, 750 mg
T1
ciprofloxacin oral suspension reconstituted 250 mg/5ml (5%), 500 mg/5ml (10%)
T3
ciprofloxacin-ciproflox hcl er oral tablet extended release 24 hr* 1000 mg, 500 mg
T1
FACTIVE ORAL TABLET 320 MG
T3
levofloxacin oral tablet 250 mg, 500 mg, 750 mg
T1
moxifloxacin hcl oral tablet 400 mg
T3
NOROXIN ORAL TABLET 400 MG
T3
ofloxacin oral tablet 400 mg
T1
62
Drug *Gastrointestinal Agents - Misc.*
Status
Notes
AMITIZA ORAL CAPSULE 24 MCG, 8 MCG
T3
APRISO ORAL CAPSULE EXTENDED RELEASE 24 HOUR 0.375 GM
T3
ASACOL HD ORAL TABLET DELAYED RELEASE 800 MG
T3
balsalazide disodium oral capsule 750 mg
T1
calcium acetate (phos binder) oral capsule 667 mg
T1
calcium acetate (phos binder) oral tablet 667 mg
T1
CANASA SUPPOSITORY 1000 MG
T4
CIMZIA PREFILLED SUBCUTANEOUS* KIT 2 X 200 MG/ML
T4
PA
CIMZIA STARTER KIT SUBCUTANEOUS* KIT 6 X 200 MG/ML
T4
PA
CIMZIA SUBCUTANEOUS* KIT 2 X 200 MG
T4
PA
cromolyn sodium oral concentrate 100 mg/5ml
T1
DELZICOL ORAL CAPSULE DELAYED RELEASE 400 MG
T2
DIPENTUM ORAL CAPSULE 250 MG
T3
PA
FOSRENOL ORAL TABLET CHEWABLE 1000 MG, 500 MG, 750 MG
T3
PA
lactulose encephalopathy oral solution 10 gm/15ml
T1
LINZESS ORAL CAPSULE 145 MCG, 290 MCG
T3
mesalamine enema 4 gm
T1
mesalamine-cleanser kit 4 gm
T1
metoclopramide hcl oral solution 5 mg/5ml
T1
metoclopramide hcl oral tablet 10 mg, 5 mg
T1
PENTASA ORAL CAPSULE EXTENDED RELEASE* 250 MG, 500 MG
T3
PHOSLYRA ORAL SOLUTION 667 MG/5ML
T3
RENAGEL ORAL TABLET 400 MG, 800 MG
T3
PA
RENVELA ORAL PACKET 0.8 GM, 2.4 GM
T3
PA
RENVELA ORAL TABLET 800 MG
T3
PA
sulfasalazine oral tablet 500 mg
T1
sulfasalazine oral tablet delayed release 500 mg
T1
PA
ST
PA
ST
63
Drug
Status
ursodiol oral capsule 300 mg
T1
ursodiol oral tablet 250 mg, 500 mg
T3
Notes
*Genitourinary Agents - Miscellaneous* acetic acid irrigation solution 0.25 %
T1
alfuzosin hcl er oral tablet extended release 24 hr* 10 mg
T3
aminoacetic acid irrigation solution 1.5 %
T1
AVODART ORAL CAPSULE 0.5 MG
T3
CARDURA XL ORAL TABLET EXTENDED RELEASE 24 HR* 4 MG
T3
citric acid-sodium citrate oral solution 334-500 mg/5ml
T1
cytra-2 oral solution 500-334 mg/5ml
T1
CYTRA-3 ORAL SYRUP 550-500-334 MG/5ML
T1
cytra-k oral solution 1100-334 mg/5ml
T1
dutasteride oral capsule 0.5 mg
T3
ST
ELMIRON ORAL CAPSULE 100 MG
T4
PA
finasteride oral tablet 5 mg
T1
glycine irrigation solution 1.5 %
T1
glycine urologic irrigation solution 1.5 %
T1
neomycin-polymyxin b gu irrigation solution 40-200000
T1
phenazopyridine hcl oral tablet 100 mg, 200 mg
T1
potassium citrate er oral tablet extendedrelease* 10 meq (1080 mg), 5 meq (540 mg)
T1
potassium citrate er oral tablet extendedrelease* 15 meq (1620 mg)
T3
potassium citrate-citric acid oral solution 1100-334 mg/5ml
T1
RAPAFLO ORAL CAPSULE 4 MG, 8 MG
T3
sodium chloride irrigation solution 0.9 %
T1
sorbitol irrigation solution 3 %, 3.3 %
T1
sorbitol-mannitol irrigation solution 2.7-0.54 gm/100ml
T1
tamsulosin hcl oral capsule 0.4 mg
T1
UROCIT-K 10 ORAL TABLET EXTENDEDRELEASE* 10 MEQ (1080 MG)
T2
UROCIT-K 15 ORAL TABLET EXTENDEDRELEASE* 15 MEQ (1620 MG)
T3
64
ST
PA
QL (60 EA per 30 days)
Drug
Status
UROCIT-K 5 ORAL TABLET EXTENDEDRELEASE* 5 MEQ (540 MG)
T2
virtrate-k oral solution 1100-334 mg/5ml
T1
Notes
*Gout Agents* allopurinol oral tablet 100 mg, 300 mg
T1
colchicine oral tablet 0.6 mg
T3
colchicine-probenecid oral tablet 0.5-500 mg
T1
COLCRYS ORAL TABLET 0.6 MG
T3
probenecid oral tablet 500 mg
T1
QL (20 EA per 30 days) QL (20 EA per 30 days)
*Hematological Agents - Misc.* AGGRENOX ORAL CAPSULE EXTENDED RELEASE 12 HOUR 25-200 MG
T3
anagrelide hcl oral capsule 0.5 mg, 1 mg
T1
aspirin-dipyridamole er oral capsule extended release 12 hour 25-200 mg
T3
BERINERT INTRAVENOUS* KIT 500 UNIT
T4
PA
BRILINTA ORAL TABLET 60 MG, 90 MG
T3
QL (60 EA per 30 days)
CEPROTIN INTRAVENOUS* SOLUTION RECONSTITUTED 1000 UNIT, 500 UNIT
T4
PA
cilostazol oral tablet 100 mg, 50 mg
T1
clopidogrel bisulfate oral tablet 300 mg, 75 mg
T1
dipyridamole oral tablet 25 mg, 50 mg, 75 mg
T1
FIRAZYR SUBCUTANEOUS* SOLUTION 30 MG/3ML
T4
PA
KALBITOR SUBCUTANEOUS* SOLUTION 10 MG/ML
T4
PA
pentoxifylline er oral tablet extendedrelease* 400 mg
T1
QL (90 EA per 30 days)
ticlopidine hcl oral tablet 250 mg
T1
QL (30 EA per 30 days)
*Hematopoietic Agents* ARANESP (ALBUMIN FREE) INJECTION 100 MCG/0.5ML, 150 MCG/0.3ML, 200 MCG/0.4ML, 25 MCG/0.42ML, 300 MCG/0.6ML, 40 MCG/0.4ML, 500 MCG/ML, 60 MCG/0.3ML
T4
PA
ARANESP (ALBUMIN FREE) INJECTION SOLUTION 100 MCG/ML, 150 MCG/0.75ML, 200 MCG/ML, 25 MCG/ML, 300 MCG/ML, 40 MCG/ML, 60 MCG/ML
T4
PA
b-6 folic acid oral capsule 400-1000-50 mcg-mcg-mg
T1
65
Drug
Status
Notes
cyanocobalamin injection solution 1000 mcg/ml
T1
DEXFERRUM INJECTION SOLUTION 50 MG/ML
T1
DROXIA ORAL CAPSULE 200 MG, 300 MG, 400 MG
T2
EPOGEN INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML
T4
ferraplus 90 oral tablet 90-1 mg
T1
ferrous gluconate oral tablet 240 (27 fe) mg
T5
ferrous sulfate oral elixir 220 (44 fe) mg/5ml
T5
ferrous sulfate oral liquid† 220 (44 fe) mg/5ml
T5
ferrous sulfate oral tablet 325 (65 fe) mg
T5
ferrous sulfate oral tablet delayed release 324 (65 fe) mg, 325 (65 fe) mg
T5
folic acid injection solution 5 mg/ml
T1
folic acid oral tablet 1 mg, 400 mcg, 800 mcg
T5
gnp iron oral tablet 200 (65 fe) mg
T5
HEMATOGEN FA ORAL CAPSULE 200-250-0.01-1 MG
T1
HEMATOGEN FORTE ORAL CAPSULE 460-60-0.01-1 MG
T1
HEMOCYTE-F ORAL TABLET 324-1 MG
T1
hydroxocobalamin intramuscular* solution 1000 mcg/ml
T1
INFED INJECTION SOLUTION 50 MG/ML
T4
PA
LEUKINE INTRAVENOUS* SOLUTION RECONSTITUTED 250 MCG
T4
PA
NEUMEGA SUBCUTANEOUS* SOLUTION RECONSTITUTED 5 MG
T4
PA
NEUPOGEN INJECTION 300 MCG/0.5ML, 480 MCG/0.8ML
T4
PA
NEUPOGEN INJECTION SOLUTION 300 MCG/ML, 480 MCG/1.6ML
T4
PA
physicians ez use b-12 injection kit 1000 mcg/ml
T1
poly-iron 150 forte oral capsule 150-25-1 mg-mcg-mg
T1
PROCRIT INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML, 40000 UNIT/ML
T4
tl gard rx oral tablet 2.2-25-1 mg
T1
66
PA
PA
QL (30 EA per 30 days)
PA
Drug
Status
tl icon oral capsule
T1
ZARXIO INJECTION 300 MCG/0.5ML, 480 MCG/0.8ML
T4
Notes PA
*Hemostatics* aminocaproic acid oral tablet 1000 mg, 500 mg
T3
*Hypnotics* estazolam oral tablet 1 mg, 2 mg
T1
eszopiclone oral tablet 1 mg, 2 mg, 3 mg
T3
flurazepam hcl oral capsule 15 mg, 30 mg
T1
LUNESTA ORAL TABLET 1 MG, 2 MG, 3 MG
T3
phenobarbital oral elixir 20 mg/5ml
T1
phenobarbital oral solution 20 mg/5ml
T1
phenobarbital oral tablet 100 mg, 15 mg, 16.2 mg, 30 mg, 32.4 mg, 60 mg, 64.8 mg, 97.2 mg
T1
ROZEREM ORAL TABLET 8 MG
T3
ST; QL (30 EA per 30 days)
sm sleep aid maximum strength oral capsule 50 mg
T1
AL (Max 64 Years)
temazepam oral capsule 15 mg, 30 mg
T1
temazepam oral capsule 22.5 mg, 7.5 mg
T3
triazolam oral tablet 0.125 mg, 0.25 mg
T1
AL (Max 64 Years)
zaleplon oral capsule 10 mg, 5 mg
T1
AL (Max 64 Years)
zolpidem tartrate er oral tablet extendedrelease* 12.5 mg, 6.25 mg
T3
QL (30 EA per 30 days)
zolpidem tartrate oral tablet 10 mg, 5 mg
T1
QL (30 EA per 30 days)
PA; AL (Max 64 Years)
PA; AL (Max 64 Years)
*Laxatives* COLYTE WITH FLAVOR PACKS ORAL SOLUTION RECONSTITUTED 227.1 GM, 240 GM
T3
GAVILYTE-C ORAL SOLUTION RECONSTITUTED 240 GM
T1
GAVILYTE-G ORAL SOLUTION RECONSTITUTED 236 GM
T1
GAVILYTE-N WITH FLAVOR PACK ORAL SOLUTION RECONSTITUTED 420 GM
T1
GOLYTELY ORAL SOLUTION RECONSTITUTED 227.1 GM
T1
QL (1 EA per 365 days)
KRISTALOSE ORAL PACKET 10 GM, 20 GM
T3
PA
lactulose oral solution 10 gm/15ml
T1 67
Drug
Status
OSMOPREP ORAL TABLET 1.102-0.398 GM
T3
peg 3350/electrolytes oral solution reconstituted 240 gm
T1
peg 3350-kcl-na bicarb-nacl oral solution reconstituted 420 gm
T1
peg-3350/electrolytes oral solution reconstituted 236 gm
T1
polyethylene glycol 3350 oral packet
T1
polyethylene glycol 3350 oral powder
T1
PREPOPIK ORAL PACKET 10-3.5-12 MG-GM-GM
T3
SUPREP BOWEL PREP ORAL SOLUTION
T3
TRILYTE ORAL SOLUTION RECONSTITUTED 420 GM
T1
Notes
PA
*Macrolides* azithromycin hydrogencitrate intravenous* solution reconstituted 2.5 gm
T1
azithromycin intravenous* solution reconstituted 500 mg
T1
azithromycin oral packet 1 gm
T1
azithromycin oral suspension reconstituted 100 mg/5ml, 200 mg/5ml
T1
azithromycin oral tablet 250 mg
T1
azithromycin oral tablet 500 mg
T1
azithromycin oral tablet 600 mg
T1
clarithromycin er oral tablet extended release 24 hr* 500 mg
T1
clarithromycin oral suspension reconstituted 125 mg/5ml, 250 mg/5ml
T1
clarithromycin oral tablet 250 mg, 500 mg
T1
DIFICID ORAL TABLET 200 MG
T3
ERY-TAB ORAL TABLET DELAYED RELEASE 333 MG
T3
ERYTHROCIN STEARATE ORAL TABLET 250 MG
T1
erythromycin base oral capsule delayed release particles 250 mg
T1
erythromycin base oral tablet 250 mg, 500 mg
T1
erythromycin ethylsuccinate oral tablet 400 mg
T1
ZITHROMAX ORAL PACKET 1 GM
T3
68
QL (30 EA per 30 days)
QL (12 EA per 30 days) QL (60 EA per 30 days)
PA
Drug *Medical Devices*
Status
Notes
1st tier unifine pentips 29g x 12mm , 31g x 5 mm , 31g x 6 mm , 31g x 8 mm , 32g x 4 mm
T1
QL (200 EA per 30 days)
1st tier unifine pentips plus 29g x 12mm , 31g x 5 mm , 31g x 6 mm , 31g x 8 mm , 32g x 4 mm
T1
QL (200 EA per 30 days)
ADVOCATE INSULIN PEN NEEDLES 31G X 5 MM , 31G X 8 MM
T1
QL (200 EA per 30 days)
ADVOCATE INSULIN SYRINGE 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML
T1
QL (200 EA per 30 days)
anti-stick insulin syringe 29g x 1/2" 1 ml
T1
QL (200 EA per 30 days)
ASSURE ID INSULIN SAFETY SYR 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML
T1
QL (200 EA per 30 days)
aurora pen needles 29g x 12mm , 31g x 6 mm , 31g x 8 mm
T1
QL (200 EA per 30 days)
aurora unifine pentips 31g x 5 mm , 32g x 4 mm
T1
QL (200 EA per 30 days)
BD AUTOSHIELD 29G X 12MM
T1
QL (200 EA per 30 days)
BD INSULIN SYR ULTRAFINE II 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML
T1
QL (200 EA per 30 days)
BD INSULIN SYRINGE 28G X 1/2" 1 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 1/2" 0.5 ML, 31G X 5/16" 0.3 ML
T1
QL (200 EA per 30 days)
BD INSULIN SYRINGE HALF-UNIT 31G X 5/16" 0.3 ML
T1
QL (200 EA per 30 days)
BD INSULIN SYRINGE MICROFINE 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML
T1
QL (200 EA per 30 days)
BD INSULIN SYRINGE ULTRAFINE 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 1/2" 0.3 ML, 30G X 1/2" 0.5 ML, 30G X 1/2" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML
T1
QL (200 EA per 30 days)
BD INTEGRA INSULIN SYRINGE 29G X 1/2" 1 ML
T1
QL (200 EA per 30 days)
BD PEN NEEDLE MINI U/F 31G X 5 MM
T1
QL (200 EA per 30 days)
BD PEN NEEDLE NANO U/F 32G X 4 MM
T1
QL (200 EA per 30 days)
BD PEN NEEDLE SHORT U/F 31G X 8 MM
T1
QL (200 EA per 30 days)
BD SAFETYGLIDE INSULIN SYRINGE 29G X 1/2" 0.5 ML, 30G X 5/16" 0.5 ML
T1
QL (200 EA per 30 days)
BD SAFETY-LOK INSULIN SYRINGE 29G X 1/2" 1 ML
T1
QL (200 EA per 30 days)
69
Drug
Status
Notes
CAREFINE PEN NEEDLES 29G X 12MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 MM , 32G X 6 MM
T1
QL (200 EA per 30 days)
careone insulin syringe 30g x 1/2" 0.3 ml, 30g x 1/2" 0.5 ml, 30g x 1/2" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml
T1
QL (200 EA per 30 days)
careone unifine pentips 29g x 12mm , 31g x 5 mm , 31g x 6 mm , 31g x 8 mm , 32g x 4 mm
T1
QL (200 EA per 30 days)
careone unifine pentips plus 29g x 12mm , 31g x 5 mm , 31g x 6 mm , 31g x 8 mm , 32g x 4 mm
T1
QL (200 EA per 30 days)
CLEVER CHOICE COMFORT EZ 29G X 12MM
T1
QL (200 EA per 30 days)
clickfine pen needles 31g x 6 mm , 31g x 8 mm , 32g x 4 mm
T1
QL (200 EA per 30 days)
COMFORT ASSIST INSULIN SYRINGE 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML
T1
QL (200 EA per 30 days)
COMFORT EZ INSULIN SYRINGE 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 1/2" 0.3 ML, 30G X 1/2" 0.5 ML, 30G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML
T1
QL (200 EA per 30 days)
COMFORT EZ PEN NEEDLES 31G X 5 MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 MM , 32G X 6 MM
T1
QL (200 EA per 30 days)
cvs insulin syringe 29g x 1/2" 0.5 ml, 30g x 1/2" 0.3 ml, 30g x 1/2" 0.5 ml
T1
QL (200 EA per 30 days)
cvs lancing device
T1
drug mart ultra comfort syr 29g x 1/2" 0.3 ml, 29g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml
T1
QL (200 EA per 30 days)
drug mart unifine pentips 29g x 12mm , 31g x 5 mm , 31g x 6 mm , 31g x 8 mm , 32g x 4 mm
T1
QL (200 EA per 30 days)
drug mart unifine pentips plus 32g x 4 mm
T1
QL (200 EA per 30 days)
duane reade unifine pentips 29g x 12mm , 31g x 6 mm , 31g x 8 mm
T1
QL (200 EA per 30 days)
easy comfort insulin syringe 30g x 1/2" 0.5 ml, 30g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml
T1
QL (200 EA per 30 days)
70
Drug
Status
Notes
easy comfort pen needles 31g x 5 mm , 31g x 6 mm , 31g x 8 mm , 32g x 4 mm
T1
QL (200 EA per 30 days)
EASY TOUCH INSULIN SAFETY SYR 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 1/2" 1 ML, 30G X 5/16" 0.5 ML
T1
QL (200 EA per 30 days)
EASY TOUCH INSULIN SYRINGE 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 1/2" 0.3 ML, 30G X 1/2" 0.5 ML, 30G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML
T1
QL (200 EA per 30 days)
EASY TOUCH PEN NEEDLES 29G X 12MM , 31G X 5 MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 MM , 32G X 6 MM
T1
QL (200 EA per 30 days)
eql insulin syringe 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml
T1
QL (200 EA per 30 days)
eql short pen needle 31g x 8 mm
T1
QL (200 EA per 30 days)
eql ultra comfort insulin syr 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml
T1
QL (200 EA per 30 days)
eql ultra short pen needle 31g x 6 mm
T1
QL (200 EA per 30 days)
EXCEL COMFORT POINT PEN NEEDLE 29G X 12MM , 31G X 6 MM , 31G X 8 MM
T1
QL (200 EA per 30 days)
EXEL COMFORT POINT INSULIN SYR 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML
T1
QL (200 EA per 30 days)
FIFTY50 PEN NEEDLES 31G X 5 MM , 31G X 8 MM
T1
QL (200 EA per 30 days)
FIFTY50 SUPERIOR COMFORT SYR 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML
T1
QL (200 EA per 30 days)
freds pharmacy unifine pentip+ 31g x 5 mm , 31g x 8 mm
T1
QL (200 EA per 30 days)
freds pharmacy unifine pentips 32g x 4 mm
T1
QL (200 EA per 30 days)
FREESTYLE PRECISION INS SYR 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML
T1
QL (200 EA per 30 days)
global ease inject pen needles 29g x 12mm , 31g x 5 mm , 31g x 8 mm , 32g x 4 mm
T1
QL (200 EA per 30 days)
71
Drug
Status
Notes
global inject ease insulin syr 28g x 1/2" 0.5 ml, 28g x 1/2" 1 ml, 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 1/2" 0.3 ml, 30g x 1/2" 0.5 ml, 30g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml
T1
QL (200 EA per 30 days)
GLUCOPRO INSULIN SYRINGE 30G X 1/2" 0.3 ML, 30G X 1/2" 0.5 ML, 30G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML
T1
QL (200 EA per 30 days)
gnp clickfine pen needles 31g x 6 mm , 31g x 8 mm
T1
QL (200 EA per 30 days)
gnp insulin syringe 28g x 1/2" 0.5 ml, 28g x 1/2" 1 ml, 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml
T1
QL (200 EA per 30 days)
gnp ultra com insulin syringe 28g x 1/2" 0.5 ml, 28g x 1/2" 1 ml, 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml
T1
QL (200 EA per 30 days)
healthwise mini pen needles 31g x 6 mm
T1
QL (200 EA per 30 days)
healthwise pen needles 29g x 12mm
T1
QL (200 EA per 30 days)
healthwise short pen needles 31g x 8 mm
T1
QL (200 EA per 30 days)
healthwise unifine pentips 32g x 4 mm
T1
QL (200 EA per 30 days)
healthy accents unifine pentip 29g x 12mm , 31g x 5 mm , 31g x 6 mm , 31g x 8 mm , 32g x 4 mm
T1
QL (200 EA per 30 days)
h-e-b incontrol pen needles 29g x 12mm , 31g x 5 mm , 31g x 6 mm , 31g x 8 mm , 32g x 4 mm
T1
QL (200 EA per 30 days)
insulin syringe 28g x 1/2" 0.5 ml, 28g x 1/2" 1 ml, 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 1/2" 0.5 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml
T1
QL (200 EA per 30 days)
insulin syringe/needle 28g x 1/2" 0.5 ml, 28g x 1/2" 1 ml
T1
QL (200 EA per 30 days)
insupen pen needles 32g x 4 mm
T1
QL (200 EA per 30 days)
INSUPEN SENSITIVE 32G X 6 MM
T1
QL (200 EA per 30 days)
INSUPEN ULTRAFIN 29G X 12MM , 31G X 6 MM , 31G X 8 MM
T1
QL (200 EA per 30 days)
kinray insulin syringe 29g x 1/2" 0.5 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml
T1
QL (200 EA per 30 days)
72
Drug
Status
Notes
kroger insulin syringe 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml
T1
QL (200 EA per 30 days)
kroger pen needles 29g x 12mm , 31g x 6 mm , 31g x 8 mm
T1
QL (200 EA per 30 days)
leader insulin syringe 28g x 1/2" 0.5 ml, 28g x 1/2" 1 ml, 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml
T1
QL (200 EA per 30 days)
LEADER UNIFINE PENTIPS 31G X 5 MM , 32G X 4 MM
T1
QL (200 EA per 30 days)
LEADER UNIFINE PENTIPS PLUS 31G X 5 MM , 31G X 8 MM , 32G X 4 MM
T1
QL (200 EA per 30 days)
LITE TOUCH PEN NEEDLES 31G X 5 MM
T1
QL (200 EA per 30 days)
LITETOUCH INSULIN SYRINGE 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML
T1
QL (200 EA per 30 days)
LITETOUCH PEN NEEDLES 31G X 6 MM , 31G X 8 MM
T1
QL (200 EA per 30 days)
live better pen needles 29g x 12mm , 31g x 6 mm , 31g x 8 mm
T1
QL (200 EA per 30 days)
longs insulin syringe 31g x 5/16" 0.5 ml
T1
QL (200 EA per 30 days)
MAGELLAN INSULIN SAFETY SYR 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML
T1
QL (200 EA per 30 days)
MAXI-COMFORT INSULIN SYRINGE 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML
T1
QL (200 EA per 30 days)
medic insulin syringe 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml
T1
QL (200 EA per 30 days)
medicine shoppe pen needles 29g x 12mm , 31g x 6 mm , 31g x 8 mm
T1
QL (200 EA per 30 days)
meijer pen needles 29g x 12mm , 31g x 6 mm , 31g x 8 mm
T1
QL (200 EA per 30 days)
MONOJECT INSULIN SYRINGE 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 1 ML
T1
QL (200 EA per 30 days)
73
Drug
Status
Notes
MONOJECT ULTRA COMFORT SYRINGE 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML
T1
QL (200 EA per 30 days)
MOORE MONO INSULIN SYRINGE 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML
T1
QL (200 EA per 30 days)
ms insulin syringe 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml
T1
QL (200 EA per 30 days)
NOVOFINE 32G X 6 MM
T1
QL (200 EA per 30 days)
NOVOFINE PLUS 32G X 4 MM
T1
QL (200 EA per 30 days)
pc unifine pentips 29g x 12mm , 31g x 5 mm , 31g x 6 mm , 31g x 8 mm
T1
QL (200 EA per 30 days)
pen needles 1/2" 29g x 12mm
T1
QL (200 EA per 30 days)
pen needles 29g x 12mm , 31g x 6 mm
T1
QL (200 EA per 30 days)
pen needles 3/16" 31g x 5 mm
T1
QL (200 EA per 30 days)
pen needles 5/16" 31g x 8 mm
T1
QL (200 EA per 30 days)
PENTIPS 31G X 5 MM , 31G X 8 MM , 32G X 4 MM
T1
QL (200 EA per 30 days)
PRECISION SUREDOSE PLUS SYR 29G X 1/2" 0.3 ML, 29G X 1/2" 1 ML
T1
QL (200 EA per 30 days)
PRECISION SURE-DOSE SYRINGE 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.5 ML
T1
QL (200 EA per 30 days)
preferred plus insulin syringe 28g x 1/2" 0.5 ml, 28g x 1/2" 1 ml, 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml
T1
QL (200 EA per 30 days)
preferred plus unifine pentips 29g x 12mm , 31g x 5 mm , 31g x 6 mm , 31g x 8 mm , 32g x 4 mm
T1
QL (200 EA per 30 days)
PRODIGY INSULIN SYRINGE 28G X 1/2" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML
T1
QL (200 EA per 30 days)
px extra short pen needles 31g x 6 mm
T1
QL (200 EA per 30 days)
px insulin syringe 30g x 1/2" 0.3 ml, 30g x 1/2" 0.5 ml, 30g x 1/2" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml
T1
QL (200 EA per 30 days)
px mini pen needles 31g x 5 mm
T1
QL (200 EA per 30 days)
px pen needle 29g x 12mm , 31g x 8 mm
T1
QL (200 EA per 30 days)
qc pen needles 29g x 12mm , 31g x 6 mm , 31g x 8 mm
T1
QL (200 EA per 30 days)
qc unifine pentips 32g x 4 mm
T1
QL (200 EA per 30 days)
74
Drug
Status
Notes
ra insulin syringe 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml
T1
QL (200 EA per 30 days)
ra pen needles 31g x 5 mm , 31g x 8 mm
T1
QL (200 EA per 30 days)
RELION INSULIN SYRINGE 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML
T1
QL (200 EA per 30 days)
RELI-ON INSULIN SYRINGE 29G X 1/2" 1 ML
T1
QL (200 EA per 30 days)
RELION MINI PEN NEEDLES 31G X 6 MM
T1
QL (200 EA per 30 days)
RELION PEN NEEDLES 29G X 12MM , 31G X 8 MM , 32G X 4 MM
T1
QL (200 EA per 30 days)
RELION SHORT PEN NEEDLES 31G X 8 MM
T1
QL (200 EA per 30 days)
SAFESNAP INSULIN SYRINGE 28G X 1/2" 1 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML
T1
QL (200 EA per 30 days)
SAFETY-GLIDE SYRINGE 29G X 1/2" 0.3 ML
T1
QL (200 EA per 30 days)
sb insulin syringe 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 1 ml
T1
QL (200 EA per 30 days)
schnucks insulin syringe 29g x 1/2" 0.5 ml, 30g x 5/16" 0.5 ml
T1
QL (200 EA per 30 days)
SHOPKO UNIFINE PENTIPS 29G X 12MM , 31G X 5 MM , 31G X 8 MM , 32G X 4 MM
T1
QL (200 EA per 30 days)
sm insulin syringe 28g x 1/2" 0.5 ml, 28g x 1/2" 1 ml, 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml
T1
QL (200 EA per 30 days)
sure comfort insulin syringe 28g x 1/2" 0.5 ml, 28g x 1/2" 1 ml, 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 1/2" 0.3 ml, 30g x 1/2" 0.5 ml, 30g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml
T1
QL (200 EA per 30 days)
sure comfort pen needles 31g x 5 mm , 31g x 8 mm , 32g x 4 mm , 32g x 6 mm
T1
QL (200 EA per 30 days)
SURE-FINE PEN NEEDLES 31G X 5 MM , 31G X 8 MM
T1
QL (200 EA per 30 days)
75
Drug
Status
Notes
SURE-JECT INSULIN SYRINGE 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML
T1
QL (200 EA per 30 days)
TERUMO INSULIN SYRINGE 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML
T1
QL (200 EA per 30 days)
TERUMO SURGUARD INSULIN SYR 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML
T1
QL (200 EA per 30 days)
THINPRO INSULIN SYRINGE 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML
T1
QL (200 EA per 30 days)
todays health mini pen needles 31g x 6 mm
T1
QL (200 EA per 30 days)
todays health pen needles 29g x 12mm
T1
QL (200 EA per 30 days)
todays health short pen needle 31g x 8 mm
T1
QL (200 EA per 30 days)
topcare clickfine pen needles 31g x 6 mm , 31g x 8 mm
T1
QL (200 EA per 30 days)
topcare ultra comfort ins syr 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml
T1
QL (200 EA per 30 days)
TRUEPLUS INSULIN SYRINGE 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML
T1
QL (200 EA per 30 days)
ULTICARE INSULIN SAFETY SYR 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML
T1
QL (200 EA per 30 days)
ULTICARE INSULIN SYRINGE 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 1/2" 0.3 ML, 30G X 1/2" 0.5 ML, 30G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML
T1
QL (200 EA per 30 days)
ULTICARE MICRO PEN NEEDLES 32G X 4 MM
T1
QL (200 EA per 30 days)
ULTICARE MINI PEN NEEDLES 31G X 6 MM
T1
QL (200 EA per 30 days)
ULTICARE PEN NEEDLES 29G X 12MM
T1
QL (200 EA per 30 days)
76
Drug
Status
Notes
ULTICARE SHORT PEN NEEDLES 31G X 8 MM
T1
QL (200 EA per 30 days)
ULTILET INSULIN SYRINGE SHORT 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML
T1
QL (200 EA per 30 days)
ULTILET PEN NEEDLE 31G X 8 MM
T1
QL (200 EA per 30 days)
ultra comfort insulin syringe 30g x 5/16" 0.3 ml
T1
QL (200 EA per 30 days)
ultra-comfort insulin syringe 28g x 1/2" 0.5 ml, 28g x 1/2" 1 ml, 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml
T1
QL (200 EA per 30 days)
ULTRA-THIN II INS SYR SHORT 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML
T1
QL (200 EA per 30 days)
ULTRA-THIN II INSULIN SYRINGE 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML
T1
QL (200 EA per 30 days)
ULTRA-THIN II MINI PEN NEEDLE 31G X 5 MM
T1
QL (200 EA per 30 days)
ULTRA-THIN II PEN NEEDLE SHORT 31G X 8 MM
T1
QL (200 EA per 30 days)
UNIFINE PENTIPS 29G X 12MM , 31G X 5 MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 MM
T1
QL (200 EA per 30 days)
unifine pentips plus 29g x 12mm , 31g x 5 mm , 31g x 6 mm , 31g x 8 mm , 32g x 4 mm
T1
QL (200 EA per 30 days)
value health insulin syringe 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml
T1
QL (200 EA per 30 days)
valumark pen needles 29g x 12mm , 31g x 6 mm , 31g x 8 mm
T1
QL (200 EA per 30 days)
VANISHPOINT INSULIN SYRINGE 29G X 1/2" 1 ML, 30G X 1/2" 0.5 ML
T1
QL (200 EA per 30 days)
VIDA MIA UNIFINE PENTIPS 29G X 12MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 MM
T1
QL (200 EA per 30 days)
vp insulin syringe 29g x 1/2" 0.3 ml
T1
QL (200 EA per 30 days)
V-R MONO INSULIN SYRINGE 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML
T1
QL (200 EA per 30 days)
wegmans unifine pentips plus 31g x 5 mm , 31g x 6 mm , 31g x 8 mm , 32g x 4 mm
T1
QL (200 EA per 30 days)
77
Drug *Migraine Products*
Status
Notes
almotriptan malate oral tablet 12.5 mg, 6.25 mg
T3
ST; QL (9 EA per 23 days)
AXERT ORAL TABLET 12.5 MG, 6.25 MG
T3
ST; QL (9 EA per 23 days)
CAFERGOT ORAL TABLET 1-100 MG
T2
dihydroergotamine mesylate nasal solution 4 mg/ml
T3
FROVA ORAL TABLET 2.5 MG
T3
ST; QL (9 EA per 23 days)
frovatriptan succinate oral tablet 2.5 mg
T3
ST; QL (9 EA per 23 days)
isometheptene-caffeine-apap oral tablet 65-20-325 mg
T1
MIGRANAL NASAL SOLUTION 4 MG/ML
T3
naratriptan hcl oral tablet 1 mg, 2.5 mg
T1
ST; QL (9 EA per 23 days)
RELPAX ORAL TABLET 20 MG, 40 MG
T3
ST; QL (9 EA per 23 days)
rizatriptan benzoate oral tablet 10 mg, 5 mg
T1
sumatriptan nasal solution 20 mg/act, 5 mg/act
T3
sumatriptan succinate oral tablet 100 mg, 25 mg, 50 mg
T1
QL (9 EA per 23 days)
sumatriptan succinate refill subcutaneous* 4 mg/0.5ml, 6 mg/0.5ml
T3
PA; QL (10 ML per 23 days)
sumatriptan succinate subcutaneous* 4 mg/0.5ml, 6 mg/0.5ml
T3
PA; QL (10 ML per 23 days)
sumatriptan succinate subcutaneous* solution 4 mg/0.5ml, 6 mg/0.5ml
T3
PA; QL (10 ML per 23 days)
zolmitriptan oral tablet 2.5 mg, 5 mg
T3
*Minerals & Electrolytes* EFFER-K ORAL TABLET EFFERVESCENT 10 MEQ, 20 MEQ
T3
effervescent pot chloride oral tablet effervescent 25 meq
T1
fluoritab oral tablet chewable 1.1 (0.5 f) mg
T5
gnp vitamin d-400 oral tablet 90-400 mg-unit
T5
iodine strong oral solution 5 %
T1
KLOR-CON M15 ORAL TABLET EXTENDEDRELEASE* 15 MEQ
T3
KLOR-CON ORAL PACKET 25 MEQ
T1
PHOSPHA 250 NEUTRAL ORAL TABLET 155-852-130 MG
T1
potassium bicarbonate oral tablet effervescent 25 meq
T1
potassium chloride crys er oral tablet extendedrelease* 10 meq, 20 meq
T1
78
PA
Drug
Status
potassium chloride er oral capsule extended release* 10 meq, 8 meq
T1
potassium chloride er oral tablet extendedrelease* 10 meq, 20 meq, 8 meq
T1
potassium chloride oral packet 20 meq
T1
potassium chloride oral solution 20 meq/15ml (10%), 40 meq/15ml (20%)
T1
sodium chloride flush intravenous* solution 0.9 %
T3
sodium chloride injection solution 0.9 %
T3
sodium chloride intravenous* solution 0.9 %
T3
sodium fluoride oral solution 1.1 (0.5 f) mg/ml
T5
sodium fluoride oral tablet chewable 2.2 (1 f) mg
T5
zinc sulfate oral capsule 220 mg
T1
Notes
*Mouth/Throat/Dental Agents* chlorhexidine gluconate mouth/throat solution 0.12 %
T1
CLINPRO 5000 DENTAL PASTE 1.1 %
T1
clotrimazole mouth/throat lozenge 10 mg
T1
cold sore treatment external liquid†
T5
DENTA 5000 PLUS DENTAL CREAM 1.1 %
T1
DENTAGEL DENTAL GEL 1.1 %
T1
lidocaine hcl mouth/throat solution 4 %
T1
nystatin mouth/throat suspension 100000 unit/ml
T1
ORAVIG BUCCAL TABLET 50 MG
T1
PERIOMED MOUTH/THROAT CONCENTRATE 0.63 %
T1
pilocarpine hcl oral tablet 5 mg, 7.5 mg
T1
sf 5000 plus dental cream 1.1 %
T1
sf dental gel 1.1 %
T1
stannous fluoride mouth/throat concentrate 0.63 %
T1
triamcinolone acetonide mouth/throat paste 0.1 %
T3
QL (810 EA per 365 days)
QL (100 ML per 23 days)
*Multivitamins* bp folinatal plus b oral tablet 1 mg
T1
multi-vit/fluoride oral solution 0.25 mg/ml, 0.5 mg/ml
T1
prenatal oral tablet 27-0.8 mg
T5
se-natal 19 oral tablet 29-1 mg
T1
79
Drug
Status
TARON-PREX ORAL CAPSULE 30-1.2-265 MG
T1
tri-vit/fluoride oral solution 0.25 mg/ml
T1
tri-vitamin/fluoride oral solution 0.5 mg/ml
T1
Notes
*Musculoskeletal Therapy Agents* baclofen oral tablet 10 mg, 20 mg
T1
carisoprodol oral tablet 350 mg
T1
chlorzoxazone oral tablet 500 mg
T1
CYCLOBENZAPRINE COMFORT PAC COMBINATION KIT 10 MG
T1
cyclobenzaprine hcl oral tablet 10 mg, 5 mg
T1
dantrolene sodium oral capsule 100 mg, 25 mg, 50 mg
T1
LORZONE ORAL TABLET 375 MG
T3
metaxalone oral tablet 800 mg
T3
methocarbamol oral tablet 500 mg, 750 mg
T1
orphenadrine citrate er oral tablet extended release 12 hr* 100 mg
T1
TIZANIDINE COMFORT PAC COMBINATION 4 MG
T1
QL (90 EA per 30 days)
tizanidine hcl oral capsule 2 mg, 4 mg, 6 mg
T3
QL (90 EA per 30 days)
tizanidine hcl oral tablet 2 mg, 4 mg
T1
QL (90 EA per 30 days)
ASTEPRO NASAL SOLUTION 0.15 %
T3
ST
azelastine hcl nasal solution 0.1 %
T1
ST
azelastine hcl nasal solution 0.15 %
T3
ST
BACTROBAN NASAL NASAL OINTMENT 2%
T3
BECONASE AQ NASAL SUSPENSION 42 MCG/SPRAY
T3
ST
budesonide nasal suspension 32 mcg/act
T3
ST
cvs nasal allergy spray nasal aerosol† 55 mcg/act
T1
QL (16.9 ML per 30 days)
flunisolide nasal solution 25 mcg/act (0.025%)
T1
QL (50 ML per 25 days)
fluticasone propionate nasal suspension 50 mcg/act
T1
QL (16 GM per 25 days)
ipratropium bromide nasal solution 0.03 %
T1
QL (30 ML per 25 days)
ipratropium bromide nasal solution 0.06 %
T1
QL (15 ML per 25 days)
mometasone furoate nasal suspension 50 mcg/act
T3
ST
NASACORT ALLERGY 24HR NASAL AEROSOL† 55 MCG/ACT
T1
AL (Max 64 Years)
PA
*Nasal Agents - Systemic And Topical*
80
Drug
Status
Notes
nasal allergy 24 hour nasal aerosol† 55 mcg/act
T1
QL (16.9 ML per 30 days)
NASONEX NASAL SUSPENSION 50 MCG/ACT
T3
ST
QNASL NASAL AEROSOL, SOLUTION 80 MCG/ACT
T3
ST
RHINOCORT ALLERGY NASAL SUSPENSION 32 MCG/ACT
T1
RHINOCORT AQUA NASAL SUSPENSION 32 MCG/ACT
T3
ST
triamcinolone acetonide nasal aerosol† 55 mcg/act
T1
QL (16.9 GM per 30 days)
VERAMYST NASAL SUSPENSION 27.5 MCG/SPRAY
T3
ST
DYSPORT INTRAMUSCULAR* SOLUTION RECONSTITUTED 300 UNIT, 500 UNIT
T4
PA
RILUTEK ORAL TABLET 50 MG
T4
riluzole oral tablet 50 mg
T4
*Neuromuscular Agents*
*Nutrients* nac oral capsule 600 mg
T1
*Ophthalmic Agents* ACUVAIL OPHTHALMIC SOLUTION 0.45 %
T3
ALOCRIL OPHTHALMIC SOLUTION 2 %
T3
PA
ALOMIDE OPHTHALMIC SOLUTION 0.1 %
T3
PA
ALPHAGAN P OPHTHALMIC SOLUTION 0.1 %
T3
apraclonidine hcl ophthalmic solution 0.5 %
T3
atropine sulfate ophthalmic ointment 1 %
T1
atropine sulfate ophthalmic solution 1 %
T1
AZASITE OPHTHALMIC SOLUTION 1 %
T3
azelastine hcl ophthalmic solution 0.05 %
T3
bacitracin ophthalmic ointment 500 unit/gm
T1
bacitracin-polymyxin b ophthalmic ointment 500-10000 unit/gm
T1
bacitra-neomycin-polymyxin-hc ophthalmic ointment 1 %
T1
balanced salt intraocular solution
T1
BEPREVE OPHTHALMIC SOLUTION 1.5 %
T3
PA
PA 81
Drug
Status
Notes
BESIVANCE OPHTHALMIC SUSPENSION 0.6 %
T3
betaxolol hcl ophthalmic solution 0.5 %
T1
BETOPTIC-S OPHTHALMIC SUSPENSION 0.25 %
T2
PA
bimatoprost ophthalmic solution 0.03 %
T1
ST; QL (5 ML per 30 days)
BLEPHAMIDE S.O.P. OPHTHALMIC OINTMENT 10-0.2 %
T2
brimonidine tartrate ophthalmic solution 0.15 %
T3
brimonidine tartrate ophthalmic solution 0.2 %
T1
bromfenac sodium (once-daily) ophthalmic solution 0.09 %
T3
bromfenac sodium ophthalmic solution 0.09 %
T3
carteolol hcl ophthalmic solution 1 %
T1
CILOXAN OPHTHALMIC OINTMENT 0.3 %
T3
ciprofloxacin hcl ophthalmic solution 0.3 %
T1
COMBIGAN OPHTHALMIC SOLUTION 0.2-0.5 %
T3
cromolyn sodium ophthalmic solution 4 %
T1
cyclopentolate hcl ophthalmic solution 1 %, 2 %
T1
CYSTARAN OPHTHALMIC SOLUTION 0.44 %
T4
dexamethasone sodium phosphate ophthalmic solution 0.1 %
T1
diclofenac sodium ophthalmic solution 0.1 %
T1
dorzolamide hcl ophthalmic solution 2 %
T1
dorzolamide hcl-timolol mal ophthalmic solution 22.3-6.8 mg/ml
T3
DUREZOL OPHTHALMIC EMULSION 0.05 %
T3
EMADINE OPHTHALMIC SOLUTION 0.05 %
T3
epinastine hcl ophthalmic solution 0.05 %
T3
erythromycin ophthalmic ointment 5 mg/gm
T1
FLAREX OPHTHALMIC SUSPENSION 0.1 %
T3
FLUCAINE OPHTHALMIC SOLUTION 0.25-0.5 %
T1
fluorometholone ophthalmic suspension 0.1 %
T1
flurbiprofen sodium ophthalmic solution 0.03 %
T1
82
Drug
Status
Notes
FML OPHTHALMIC OINTMENT 0.1 %
T2
gatifloxacin ophthalmic solution 0.5 %
T3
gentamicin sulfate ophthalmic ointment 0.3 %
T1
gentamicin sulfate ophthalmic solution 0.3 %
T1
homatropine hbr ophthalmic solution 5 %
T1
IOPIDINE OPHTHALMIC SOLUTION 1 %
T3
ketorolac tromethamine ophthalmic solution 0.4 %, 0.5 %
T1
LACRISERT OPHTHALMIC INSERT 5 MG
T3
PA
LASTACAFT OPHTHALMIC SOLUTION 0.25 %
T3
PA
latanoprost ophthalmic solution 0.005 %
T1
QL (5 ML per 23 days)
levobunolol hcl ophthalmic solution 0.5 %
T1
levofloxacin ophthalmic solution 0.5 %
T1
LOTEMAX OPHTHALMIC OINTMENT 0.5 %
T3
LOTEMAX OPHTHALMIC SUSPENSION 0.5 %
T3
LUMIGAN OPHTHALMIC SOLUTION 0.01 %
T3
metipranolol ophthalmic solution 0.3 %
T1
MOXEZA OPHTHALMIC SOLUTION 0.5 %
T3
naphazoline hcl ophthalmic solution 0.1 %
T1
NATACYN OPHTHALMIC SUSPENSION 5 %
T3
neomycin-bacitracin zn-polymyx ophthalmic ointment 5-400-10000
T1
neomycin-polymyxin-dexameth ophthalmic ointment 3.5-10000-0.1
T1
neomycin-polymyxin-dexameth ophthalmic suspension 3.5-10000-0.1
T1
neomycin-polymyxin-gramicidin ophthalmic solution 1.75-10000-.025
T1
neomycin-polymyxin-hc ophthalmic suspension 3.5-10000-1
T1
NEVANAC OPHTHALMIC SUSPENSION 0.1 %
T3
ofloxacin ophthalmic solution 0.3 %
T1
olopatadine hcl ophthalmic solution 0.1 %
T3
PA
PATADAY OPHTHALMIC SOLUTION 0.2 %
T3
PA
PA
ST
PA
83
Drug
Status
Notes
PATANOL OPHTHALMIC SOLUTION 0.1 %
T3
PA
PHOSPHOLINE IODIDE OPHTHALMIC SOLUTION RECONSTITUTED 0.125 %
T2
PA
pilocarpine hcl ophthalmic solution 1 %, 2 %, 4 %
T1
polymyxin b-trimethoprim ophthalmic solution 10000-0.1 unit/ml-%
T1
PRED MILD OPHTHALMIC SUSPENSION 0.12 %
T2
prednisolone acetate ophthalmic suspension 1 %
T1
prednisolone sodium phosphate ophthalmic solution 1 %
T1
proparacaine hcl ophthalmic solution 0.5 %
T1
sulfacetamide sodium ophthalmic solution 10 %
T1
sulfacetamide-prednisolone ophthalmic solution 10-0.23 %
T1
tetracaine hcl ophthalmic solution 0.5 %
T1
timolol maleate ophthalmic gel forming solution 0.25 %, 0.5 %
T3
timolol maleate ophthalmic solution 0.25 %, 0.5 %
T1
TOBRADEX OPHTHALMIC OINTMENT 0.3-0.1 %
T3
QL (3.5 GM per 10 days)
TOBRADEX ST OPHTHALMIC SUSPENSION 0.3-0.05 %
T2
QL (1 ML per 10 days)
tobramycin ophthalmic solution 0.3 %
T1
tobramycin-dexamethasone ophthalmic suspension 0.3-0.1 %
T1
TOBREX OPHTHALMIC OINTMENT 0.3 %
T2
TRAVATAN Z OPHTHALMIC SOLUTION 0.004 %
T3
ST
travoprost ophthalmic solution 0.004 %
T1
ST; QL (5 ML per 30 days)
trifluridine ophthalmic solution 1 %
T3
tropicamide ophthalmic solution 0.5 %, 1 %
T1
VEXOL OPHTHALMIC SUSPENSION 1 %
T3
VIGAMOX OPHTHALMIC SOLUTION 0.5 %
T3
ZIOPTAN OPHTHALMIC SOLUTION 0.0015 %
T3
ZIRGAN OPHTHALMIC GEL 0.15 %
T3
84
QL (5 ML per 10 days)
PA
ST
Drug ZYMAXID OPHTHALMIC SOLUTION 0.5 %
Status
Notes
T3
*Otic Agents* acetic acid otic solution 2 %
T1
acetic acid-aluminum acetate otic solution 2 %
T1
antipyrine-benzocaine otic solution 5.4-1.4 %
T1
CIPRO HC OTIC SUSPENSION 0.2-1 %
T3
CIPRODEX OTIC SUSPENSION 0.3-0.1 %
T3
ciprofloxacin hcl otic solution 0.2 %
T1
COLY-MYCIN S OTIC SUSPENSION 3.3-3-10-0.5 MG/ML
T3
fluocinolone acetonide otic oil 0.01 %
T3
hydrocortisone-acetic acid otic solution 1-2 %
T3
neomycin-polymyxin-hc otic solution 1 %
T1
neomycin-polymyxin-hc otic suspension 3.5-10000-1
T1
ofloxacin otic solution 0.3 %
T1
otic care otic solution 5.4-1.4-0.0097 %
T1
PA
*Oxytocics* methylergonovine maleate oral tablet 0.2 mg
T1
*Passive Immunizing Agents* SYNAGIS INTRAMUSCULAR* SOLUTION 100 MG/ML, 50 MG/0.5ML
T4
PA
*Penicillins* amoxicillin oral capsule 250 mg, 500 mg
T1
amoxicillin oral suspension reconstituted 125 mg/5ml, 200 mg/5ml, 250 mg/5ml, 400 mg/5ml
T1
amoxicillin oral tablet 500 mg, 875 mg
T1
amoxicillin oral tablet chewable 125 mg, 250 mg
T1
amoxicillin-pot clavulanate er oral tablet extended release 12 hr* 1000-62.5 mg
T3
amoxicillin-pot clavulanate oral suspension reconstituted 200-28.5 mg/5ml, 400-57 mg/5ml, 600-42.9 mg/5ml
T1
amoxicillin-pot clavulanate oral tablet 250-125 mg, 500-125 mg, 875-125 mg
T1
amoxicillin-pot clavulanate oral tablet chewable 200-28.5 mg, 400-57 mg
T1
ampicillin oral capsule 250 mg, 500 mg
T1
QL (28 EA per 14 days)
85
Drug
Status
ampicillin oral suspension reconstituted 125 mg/5ml, 250 mg/5ml
T1
AUGMENTIN ORAL SUSPENSION RECONSTITUTED 125-31.25 MG/5ML
T2
BICILLIN L-A INTRAMUSCULAR* SUSPENSION 1200000 UNIT/2ML
T2
BICILLIN L-A INTRAMUSCULAR* SUSPENSION 600000 UNIT/ML
T4
dicloxacillin sodium oral capsule 250 mg, 500 mg
T1
penicillin v potassium oral solution reconstituted 125 mg/5ml, 250 mg/5ml
T1
penicillin v potassium oral tablet 250 mg, 500 mg
T1
Notes
PA
*Pharmaceutical Adjuvants* saline bacteriostatic injection solution 0.9 %
T3
saline-benzyl alcohol injection solution 0.9 %
T3
sodium chloride bacteriostatic injection solution 0.9 %
T3
*Potassium Removing Agents*** KIONEX ORAL POWDER
T1
KIONEX ORAL SUSPENSION 15 GM/60ML
T1
sodium polystyrene sulfonate oral powder
T1
sodium polystyrene sulfonate oral suspension 15 gm/60ml
T1
sodium polystyrene sulfonate suspension 30 gm/120ml, 50 gm/200ml
T1
SPS ORAL SUSPENSION 15 GM/60ML
T1
*Progestins* medroxyprogesterone acetate oral tablet 10 mg, 2.5 mg, 5 mg
T1
norethindrone acetate oral tablet 5 mg
T1
*Psychotherapeutic And Neurological Agents - Misc.* acamprosate calcium oral tablet delayed release 333 mg
T3
AMPYRA ORAL TABLET EXTENDED RELEASE 12 HR* 10 MG
T4
PA
AVONEX INTRAMUSCULAR* KIT 30 MCG
T4
PA
AVONEX PEN INTRAMUSCULAR* 30 MCG/0.5ML
T4
PA
AVONEX PREFILLED INTRAMUSCULAR* 30 MCG/0.5ML
T4
PA
86
Drug
Status
Notes
BETASERON SUBCUTANEOUS* KIT 0.3 MG
T4
bupropion hcl er (smoking det) oral tablet extended release 12 hr* 150 mg
T5
CHANTIX CONTINUING MONTH PAK ORAL TABLET 1 MG
T5
QL (180 EA per 365 days)
CHANTIX ORAL TABLET 0.5 MG, 1 MG
T5
QL (180 EA per 365 days)
CHANTIX STARTING MONTH PAK ORAL TABLET 0.5 MG X 11 & 1 MG X 42
T5
QL (180 EA per 90 days)
chlordiazepoxide-amitriptyline oral tablet 10-25 mg, 5-12.5 mg
T1
COPAXONE SUBCUTANEOUS* 20 MG/ML
T4
disulfiram oral tablet 250 mg, 500 mg
T1
donepezil hcl oral tablet 10 mg, 5 mg
T1
donepezil hcl oral tablet 23 mg
T3
donepezil hcl oral tablet dispersible 10 mg
T1
donepezil hcl oral tablet dispersible 5 mg
T3
ergoloid mesylates oral tablet 1 mg
T3
EXELON TRANSDERMAL PATCH 24 HR 13.3 MG/24HR, 4.6 MG/24HR, 9.5 MG/24HR
T3
PA
EXTAVIA SUBCUTANEOUS* KIT 0.3 MG
T4
PA
fluoxetine hcl (pmdd) oral capsule 10 mg, 20 mg
T1
galantamine hydrobromide er oral capsule extended release 24 hour 16 mg, 24 mg, 8 mg
T1
galantamine hydrobromide oral tablet 12 mg, 4 mg, 8 mg
T1
GILENYA ORAL CAPSULE 0.5 MG
T4
PA
GLATOPA SUBCUTANEOUS* 20 MG/ML
T4
PA
memantine hcl oral solution 2 mg/ml
T3
memantine hcl oral tablet 10 mg, 5 (28)-10 (21) mg, 5 mg
T3
NAMENDA ORAL SOLUTION 10 MG/5ML
T3
NAMENDA ORAL TABLET 10 MG, 5 MG
T3
NAMENDA TITRATION PAK ORAL TABLET 5 (28)-10 (21) MG
T3
nicotine polacrilex mouth/throat gum 2 mg, 4 mg
T5
QL (810 EA per 365 days)
nicotine transdermal patch 24 hr 14 mg/24hr, 21 mg/24hr, 7 mg/24hr
T5
QL (90 EA per 365 days)
NICOTROL INHALATION INHALER 10 MG
T5
PA
PA
PA
ST
87
Drug
Status
Notes
NICOTROL NS NASAL SOLUTION 10 MG/ML
T5
NUEDEXTA ORAL CAPSULE 20-10 MG
T4
olanzapine-fluoxetine hcl oral capsule 12-25 mg, 12-50 mg, 3-25 mg, 6-25 mg, 6-50 mg
T3
ORAP ORAL TABLET 1 MG, 2 MG
T3
perphenazine-amitriptyline oral tablet 2-10 mg, 2-25 mg, 4-10 mg, 4-25 mg, 4-50 mg
T1
pimozide oral tablet 1 mg, 2 mg
T3
PA
REBIF REBIDOSE SUBCUTANEOUS* 22 MCG/0.5ML, 44 MCG/0.5ML
T4
PA
REBIF REBIDOSE TITRATION PACK SUBCUTANEOUS* 6X8.8 & 6X22 MCG
T4
PA
REBIF SUBCUTANEOUS* 22 MCG/0.5ML, 44 MCG/0.5ML
T4
PA
REBIF TITRATION PACK SUBCUTANEOUS* 6X8.8 & 6X22 MCG
T4
PA
rivastigmine tartrate oral capsule 1.5 mg, 3 mg, 4.5 mg
T3
rivastigmine tartrate oral capsule 6 mg
T3
PA
rivastigmine transdermal patch 24 hr 13.3 mg/24hr, 4.6 mg/24hr, 9.5 mg/24hr
T3
PA
SAVELLA ORAL TABLET 100 MG, 12.5 MG, 25 MG, 50 MG
T3
PA
tetrabenazine oral tablet 12.5 mg, 25 mg
T4
PA
XENAZINE ORAL TABLET 12.5 MG, 25 MG
T4
PA
XYREM ORAL SOLUTION 500 MG/ML
T4
PA
KALYDECO ORAL TABLET 150 MG
T4
PA
PULMOZYME INHALATION SOLUTION 1 MG/ML
T4
PA; QL (60 ML per 30 days)
PA
PA
*Respiratory Agents - Misc.*
*Serotonin Modulators*** nefazodone hcl oral tablet 100 mg, 150 mg, 200 mg, 250 mg, 50 mg
T1
trazodone hcl oral tablet 100 mg, 150 mg, 300 mg, 50 mg
T1
VIIBRYD ORAL KIT 10 & 20 & 40 MG
T3
PA
VIIBRYD ORAL TABLET 10 MG, 20 MG, 40 MG
T3
PA
88
Drug *Sulfonamides* sulfadiazine oral tablet 500 mg
Status
Notes
T3
*Tetracyclines* AVIDOXY DK COMBINATION KIT 100 MG
T1
demeclocycline hcl oral tablet 150 mg, 300 mg
T3
doxycycline hyclate oral capsule 100 mg, 50 mg
T1
doxycycline hyclate oral tablet 100 mg, 20 mg
T1
doxycycline hyclate oral tablet delayed release 150 mg, 75 mg
T3
doxycycline monohydrate oral capsule 100 mg, 50 mg
T1
doxycycline monohydrate oral capsule 150 mg, 75 mg
T3
doxycycline monohydrate oral suspension reconstituted 25 mg/5ml
T1
doxycycline monohydrate oral tablet 100 mg, 50 mg, 75 mg
T1
doxycycline monohydrate oral tablet 150 mg
T3
minocycline hcl er oral tablet extended release 24 hr* 135 mg, 45 mg
T4
ST
minocycline hcl er oral tablet extended release 24 hr* 90 mg
T3
ST
minocycline hcl oral capsule 100 mg, 75 mg
T1
ST
minocycline hcl oral capsule 50 mg
T1
minocycline hcl oral tablet 100 mg, 50 mg, 75 mg
T1
MORGIDOX COMBINATION KIT 1 X 100 MG, 2 X 100 MG
T1
NICAZELDOXY 30 ORAL KIT 100 MG
T1
NICAZELDOXY 60 ORAL KIT 100 MG
T1
tetracycline hcl oral capsule 250 mg, 500 mg
T1
ST
ST
*Thyroid Agents* levothyroxine sodium oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg
T1
LEVOXYL ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 50 MCG, 75 MCG, 88 MCG
T1
liothyronine sodium oral tablet 25 mcg, 5 mcg, 50 mcg
T1
methimazole oral tablet 10 mg, 5 mg
T1 89
Drug
Status
NATURE-THROID ORAL TABLET 130 MG, 16.25 MG, 195 MG, 32.5 MG, 65 MG
T1
propylthiouracil oral tablet 50 mg
T1
SYNTHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG
T2
THYROLAR-1 ORAL TABLET 60 (12.5-50) MG (MCG)
T3
THYROLAR-1/2 ORAL TABLET 30 (6.25-25) MG (MCG)
T3
THYROLAR-1/4 ORAL TABLET 15 (3.1-12.5) MG (MCG)
T3
THYROLAR-2 ORAL TABLET 120 (25-100) MG (MCG)
T3
THYROLAR-3 ORAL TABLET 180 (37.5-150) MG (MCG)
T3
UNITHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG
T1
WESTHROID ORAL TABLET 130 MG, 32.5 MG, 65 MG
T1
Notes
*Ulcer Drugs* belladonna alkaloids-opium suppository 16.2-60 mg
T1
belladonna-opium suppository 16.2-30 mg
T1
CARAFATE ORAL SUSPENSION 1 GM/10ML
T3
chlordiazepoxide-clidinium oral capsule 5-2.5 mg
T1
cimetidine hcl oral solution 300 mg/5ml
T1
cimetidine oral tablet 200 mg, 300 mg, 400 mg, 800 mg
T1
dicyclomine hcl oral capsule 10 mg
T1
dicyclomine hcl oral solution 10 mg/5ml
T1
dicyclomine hcl oral tablet 20 mg
T1
famotidine oral suspension reconstituted 40 mg/5ml
T1
famotidine oral tablet 20 mg, 40 mg
T1
FIRST-LANSOPRAZOLE ORAL SUSPENSION 3 MG/ML
T3
glycopyrrolate oral tablet 1 mg, 2 mg
T1
90
PA
QL (150 ML per 30 days)
Drug
Status
Notes
hyoscyamine sulfate er oral tablet extended release 12 hr* 0.375 mg
T1
AL (Max 64 Years)
hyoscyamine sulfate oral elixir 0.125 mg/5ml
T1
AL (Max 64 Years)
hyoscyamine sulfate oral solution 0.125 mg/ml
T1
AL (Max 64 Years)
hyoscyamine sulfate oral tablet 0.125 mg
T1
AL (Max 64 Years)
hyoscyamine sulfate oral tablet dispersible 0.125 mg
T1
AL (Max 64 Years)
hyoscyamine sulfate sublingual tablet sublingual 0.125 mg
T1
AL (Max 64 Years)
lansoprazole oral capsule delayed release 30 mg
T3
QL (30 EA per 30 days)
methscopolamine bromide oral tablet 2.5 mg, 5 mg
T3
misoprostol oral tablet 100 mcg, 200 mcg
T1
NEXIUM 24HR ORAL CAPSULE DELAYED RELEASE 20 MG
T1
nizatidine oral capsule 150 mg, 300 mg
T1
nizatidine oral solution 15 mg/ml
T1
omeprazole magnesium oral capsule delayed release 20.6 (20 base) mg
T1
QL (60 EA per 30 days)
omeprazole oral capsule delayed release 10 mg, 20 mg, 40 mg
T1
QL (60 EA per 30 days)
omeprazole-sodium bicarbonate oral capsule 20-1100 mg
T3
QL (30 EA per 30 days)
omeprazole-sodium bicarbonate oral capsule 40-1100 mg
T3
PA; QL (30 EA per 30 days)
pantoprazole sodium oral tablet delayed release 20 mg, 40 mg
T1
QL (60 EA per 30 days)
propantheline bromide oral tablet 15 mg
T1
ranitidine hcl oral capsule 150 mg, 300 mg
T3
ranitidine hcl oral syrup 75 mg/5ml
T1
ranitidine hcl oral tablet 150 mg, 300 mg
T1
sucralfate oral tablet 1 gm
T1
SYMAX DUOTAB ORAL TABLET EXTENDEDRELEASE* 0.375 MG
T1
QL (60 EA per 30 days)
AL (Max 64 Years)
*Urinary Anti-Infectives* HYOPHEN ORAL TABLET 81.6 MG
T1
methenamine hippurate oral tablet 1 gm
T1
methenamine mandelate oral tablet 0.5 gm, 1 gm
T1
MONUROL ORAL PACKET 3 GM
T3
nitrofurantoin macrocrystal oral capsule 100 mg, 50 mg
T1 91
Drug
Status
nitrofurantoin monohyd macro oral capsule 100 mg
T1
nitrofurantoin oral suspension 25 mg/5ml
T3
PHOSPHASAL ORAL TABLET 81.6 MG
T1
URETRON D/S ORAL TABLET
T1
USTELL ORAL CAPSULE 120 MG
T1
Notes
*Urinary Antispasmodics* bethanechol chloride oral tablet 10 mg, 25 mg, 5 mg, 50 mg
T1
darifenacin hydrobromide er oral tablet extended release 24 hr* 15 mg, 7.5 mg
T2
DETROL LA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 2 MG, 4 MG
T2
ENABLEX ORAL TABLET EXTENDED RELEASE 24 HR* 15 MG, 7.5 MG
T2
flavoxate hcl oral tablet 100 mg
T1
GELNIQUE TRANSDERMAL GEL 3 (28) % (MG/ACT)
T3
oxybutynin chloride er oral tablet extended release 24 hr* 10 mg, 15 mg, 5 mg
T1
oxybutynin chloride oral syrup 5 mg/5ml
T1
oxybutynin chloride oral tablet 5 mg
T1
OXYTROL FOR WOMEN TRANSDERMAL PATCH BIWEEKLY 3.9 MG/24HR
T3
OXYTROL TRANSDERMAL PATCH BIWEEKLY 3.9 MG/24HR
T3
tolterodine tartrate er oral capsule extended release 24 hour 2 mg, 4 mg
T2
tolterodine tartrate oral tablet 1 mg, 2 mg
T1
ST
TOVIAZ ORAL TABLET EXTENDED RELEASE 24 HR* 4 MG, 8 MG
T2
ST
trospium chloride er oral capsule extended release 24 hour 60 mg
T1
ST
trospium chloride oral tablet 20 mg
T1
ST
VESICARE ORAL TABLET 10 MG, 5 MG
T3
ST
AFLURIA INTRAMUSCULAR* SUSPENSION
T5
QL (0.5 ML per 365 days); AL (Min 9 Years)
AFLURIA PRESERVATIVE FREE INTRAMUSCULAR* 0.5 ML
T5
QL (0.5 ML per 365 days); AL (Min 9 Years)
FLUARIX QUADRIVALENT INTRAMUSCULAR* 0.5 ML
T5
QL (0.5 ML per 365 days); AL (Min 3 Years)
ST
ST
ST
*Vaccines*
92
Drug
Status
Notes
FLUCELVAX INTRAMUSCULAR* 0.5 ML
T5
FLULAVAL QUADRIVALENT INTRAMUSCULAR* 0.5 ML
T5
QL (0.5 ML per 365 days); AL (Min 9 Years)
FLULAVAL QUADRIVALENT INTRAMUSCULAR* SUSPENSION
T5
QL (0.5 ML per 365 days); AL (Min 6 Months)
FLUVIRIN INTRAMUSCULAR* SUSPENSION
T5
QL (0.5 ML per 365 days); AL (Min 4 Years)
FLUVIRIN PRESERVATIVE FREE INTRAMUSCULAR* 0.5 ML
T5
QL (0.5 ML per 365 days); AL (Min 4 Years)
FLUZONE QUADRIVALENT INTRAMUSCULAR* 0.25 ML
T5
QL (0.25 ML per 365 days); AL (Min 6 Months and Max 35 Months)
FLUZONE QUADRIVALENT INTRAMUSCULAR* 0.5 ML
T5
QL (0.5 ML per 365 days); AL (Min 3 Years)
FLUZONE QUADRIVALENT INTRAMUSCULAR* SUSPENSION
T5
QL (0.5 ML per 365 days); AL (Min 6 Months)
FLUZONE QUADRIVALENT INTRAMUSCULAR* SUSPENSION 0.5 ML
T5
QL (0.5 ML per 365 days); AL (Min 3 Years)
MEDICAL PROVIDER EZ FLU INTRAMUSCULAR* 0.5 ML
T5
medical provider ez flu pf intramuscular* 0.5 ml
T5
ZOSTAVAX SUBCUTANEOUS* SOLUTION RECONSTITUTED 19400 UNT/0.65ML
T5
*Vaginal Products* CLEOCIN VAGINAL SUPPOSITORY 100 MG
T3
clindamycin phosphate vaginal cream 2 %
T1
clotrimazole vaginal cream 1 %
T1
QL (50 GM per 30 days)
CRINONE VAGINAL GEL 4 %, 8 %
T4
PA
ENDOMETRIN VAGINAL INSERT 100 MG
T3
ESTRACE VAGINAL CREAM 0.1 MG/GM
T2
ESTRING VAGINAL RING 2 MG
T3
GYNAZOLE-1 VAGINAL CREAM 2 %
T3
metronidazole vaginal gel 0.75 %
T1
miconazole 3 applicator vaginal kit 200 & 2 mg-% (9gm)
T1
miconazole 3 combo pack vaginal kit 200 & 2 mg-% (9gm)
T1
terconazole vaginal cream 0.4 %, 0.8 %
T1
terconazole vaginal suppository 80 mg
T3
VAGIFEM VAGINAL TABLET 10 MCG
T3 93
Drug YUVAFEM VAGINAL TABLET 10 MCG
Status
Notes
T3
*Vasopressors* ADRENACLICK INJECTION 0.15 MG/0.15ML
T3
AUVI-Q INJECTION 0.15 MG/0.15ML
T3
epinephrine hcl pf intravenous* solution 1 mg/ml
T1
epinephrine injection 0.15 mg/0.15ml
T1
epinephrine injection 0.3 mg/0.3ml
T1
EPIPEN 2-PAK INJECTION 0.3 MG/0.3ML
T2
EPIPEN INJECTION 0.3 MG/0.3ML
T2
EPIPEN JR 2-PAK INJECTION 0.15 MG/0.3ML
T2
QL (2 EA per 90 days)
EPIPEN JR INJECTION 0.15 MG/0.3ML
T2
QL (2 EA per 90 days)
midodrine hcl oral tablet 10 mg, 2.5 mg, 5 mg
T1
QL (2 EA per 90 days)
*Vitamins* ascorbic acid injection solution 500 mg/ml
T1
d 1000 oral tablet chewable 1000 unit
T5
d3 maximum strength oral liquid† 5000 unit/ml
T5
D3-50 ORAL CAPSULE 50000 UNIT
T5
QL (60 EA per 30 days)
MEPHYTON ORAL TABLET 5 MG
T2
PA
niacin oral tablet 500 mg
T1
POTABA ORAL CAPSULE 500 MG
T3
pyridoxine hcl injection solution 100 mg/ml
T3
REPLESTA NX ORAL WAFER 14000 UNIT
T5
THERA-D 4000 ORAL TABLET 4000 UNIT
T5
vitamin d (cholecalciferol) oral capsule 1000 unit, 400 unit
T5
vitamin d (cholecalciferol) oral tablet 400 unit
T5
vitamin d (ergocalciferol) oral capsule 50000 unit
T1
vitamin d oral tablet 2000 unit
T5
vitamin d3 oral capsule 10000 unit, 2000 unit, 5000 unit
T5
vitamin d3 oral liquid† 400 unit/ml
T5
vitamin d3 oral tablet 1000 unit, 5000 unit
T5
94
QL (60 EA per 30 days)
QL (60 EA per 30 days)
Index
Index
Index
Index
1st tier unifine pentips .............................. 69 1st tier unifine pentips plus ............... 69 abacavir sulfate ................................................... 35 abacavir-lamivudine-zidovudine ....................................................................................................... 35 ABILIFY ..................................................................... 33 ABILIFY DISCMELT ........................ 33 ABILIFY MAINTENA ....................... 33 acamprosate calcium .................................. 86 acarbose ......................................................................... 18 acebutolol hcl ......................................................... 40 acetaminophen-codeine .............................. 5 acetaminophen-codeine #2 .................... 5 acetaminophen-codeine #3 .................... 5 acetaminophen-codeine #4 .................... 5 acetazolamide ........................................................ 58 acetazolamide er ............................................... 58 acetic acid ....................................................... 64, 85 acetic acid-aluminum acetate ........ 85 acetylcysteine ............................................. 22, 48 acitretin ........................................................................... 49 acne medication 10 ........................................ 49 acne medication 5 ............................................ 49 ACTEMRA ................................................................. 2 ACTIMMUNE .................................................. 30 ACTONEL ............................................................... 59 ACUVAIL ................................................................. 81 acyclovir ............................................................. 35, 49 ADCIRCA ................................................................. 42 adefovir dipivoxil .............................................. 35 ADRENACLICK .......................................... 94 adult aspirin ec low strength .............. 4 adult aspirin low strength ....................... 4 ADVAIR DISKUS ....................................... 11 ADVAIR HFA ................................................... 11 ADVOCATE INSULIN PEN NEEDLES ................................................................. 69 ADVOCATE INSULIN SYRINGE .................................................................. 69 AEROSPAN .......................................................... 11 AFEDITAB CR ............................................... 41 AFINITOR .............................................................. 30 AFLURIA .................................................................. 92 AFLURIA PRESERVATIVE FREE ................................................................................. 92 AGGRENOX ....................................................... 65 A-HYDROCORT ......................................... 47 ALBENZA .................................................................... 9 albuterol sulfate .................................................. 11 albuterol sulfate er ......................................... 11 alclometasone dipropionate ............. 49 alendronate sodium ....................................... 59 alfuzosin hcl er ..................................................... 64 ALINIA ......................................................................... 28
ALLEGRA ALLERGY CHILDRENS ....................................................... 23 allopurinol .................................................................. 65 almotriptan malate ......................................... 78 ALOCRIL ................................................................. 81 alogliptin benzoate ......................................... 19 alogliptin-metformin hcl ........................ 19 alogliptin-pioglitazone ............................. 19 ALOMIDE ............................................................... 81 ALORA ......................................................................... 61 ALPHAGAN P .................................................. 81 ALPHAQUIN HP ........................................ 49 alprazolam .................................................................. 10 alprazolam er ......................................................... 10 alprostadil ................................................................... 39 ALTABAX ............................................................... 49 ALTAVERA ......................................................... 44 alyacen 1/35 ............................................................. 44 alyacen 7/7/7 ........................................................... 44 amantadine hcl ..................................................... 32 amcinonide ................................................................. 49 amiloride hcl ........................................................... 58 amiloride-hydrochlorothiazide .... 58 aminoacetic acid ............................................... 64 aminocaproic acid .......................................... 67 aminophylline ......................................................... 11 amiodarone hcl .................................................... 10 AMITIZA .................................................................. 63 amitriptyline hcl ................................................. 17 amlodipine besy-benazepril hcl ....................................................................................................... 25 amlodipine besylate ...................................... 41 amlodipine besylate-valsartan ..... 25 amlodipine-olmesartan ............................ 25 ammonium lactate ........................................... 49 amoxapine ................................................................... 17 amoxicillin .................................................................. 85 amoxicillin-pot clavulanate .............. 85 amoxicillin-pot clavulanate er ..... 85 amphetamine-dextroamphet er ........ 1 amphetamine-dextroamphetamine ........................................................................................................... 1 ampicillin .......................................................... 85, 86 AMPYRA ................................................................... 86 ANADROL-50 ....................................................... 8 anagrelide hcl ........................................................ 65 ANALPRAM-HC ............................................. 8 anastrozole ................................................................. 30 ANDRODERM ..................................................... 8 ANDROGEL ............................................................ 8 ANDROGEL PUMP ................................... 8 ANDROXY ................................................................. 8 antipyrine-benzocaine ............................... 85 anti-stick insulin syringe ....................... 69
ANZEMET .............................................................. 22 APIDRA ....................................................................... 19 APIDRA SOLOSTAR .......................... 19 apraclonidine hcl .............................................. 81 APRI ................................................................................... 44 APRISO ........................................................................ 63 APTIVUS ................................................................... 35 ARANESP (ALBUMIN FREE) ....................................................................................................... 65 ARCALYST .............................................................. 2 ARCAPTA NEOHALER ............... 11 aripiprazole ............................................................... 33 armodafinil .................................................................... 1 ASACOL HD ....................................................... 63 ASCOMP-CODEINE ................................ 5 ascorbic acid ........................................................... 94 ASMANEX 120 METERED DOSES ............................................................................ 11 ASMANEX 14 METERED DOSES ............................................................................ 11 ASMANEX 30 METERED DOSES ............................................................................ 12 ASMANEX 60 METERED DOSES ............................................................................ 12 ASMANEX 7 METERED DOSES ............................................................................ 12 aspirin .................................................................................... 4 aspirin low dose ..................................................... 4 aspirin-dipyridamole er .......................... 65 ASSURE ID INSULIN SAFETY SYR ...................................................................................... 69 ASTEPRO ................................................................ 80 ASTRAMORPH ................................................. 5 ATELVIA .................................................................. 59 atenolol ............................................................................ 40 atenolol-chlorthalidone .......................... 25 atorvastatin calcium .................................... 24 atovaquone ................................................................. 28 atovaquone-proguanil hcl ................... 29 ATRALIN ................................................................. 49 ATRIPLA .................................................................. 35 atropine sulfate .................................................... 81 ATROVENT HFA ...................................... 12 AUGMENTIN .................................................... 86 aurora pen needles ......................................... 69 aurora unifine pentips ............................... 69 AUVI-Q ......................................................................... 94 AVANDIA ................................................................. 19 AVELOX .................................................................... 62 AVIANE ....................................................................... 44 AVIDOXY DK .................................................. 89 AVITA ............................................................................. 49 AVODART .............................................................. 64 AVONEX .................................................................... 86 95
Index
Index
Index
AVONEX PEN .................................................. 86 AVONEX PREFILLED .................... 86 AXERT .......................................................................... 78 AXIRON .......................................................................... 8 AZASAN ..................................................................... 39 AZASITE ................................................................... 81 azathioprine .............................................................. 39 azelastine hcl ............................................... 80, 81 AZILECT .................................................................. 32 azithromycin ............................................................. 68 azithromycin hydrogencitrate ....... 68 AZOR ............................................................................... 25 b-6 folic acid ............................................................ 65 bacitracin ..................................................................... 81 bacitracin-polymyxin b ............................ 81 bacitra-neomycin-polymyxin-hc ....................................................................................................... 81 baclofen ........................................................................... 80 BACTROBAN NASAL ...................... 80 balanced salt ........................................................... 81 balsalazide disodium .................................. 63 BANZEL ..................................................................... 15 BARACLUDE .................................................... 35 BAYER ADVANCED ASPIRIN EX ST ................................................................................... 4 BAZA ................................................................................ 49 BD AUTOSHIELD .................................... 69 BD INSULIN SYR ULTRAFINE II ................................................................................................ 69 BD INSULIN SYRINGE ................. 69 BD INSULIN SYRINGE HALF-UNIT ......................................................... 69 BD INSULIN SYRINGE MICROFINE ....................................................... 69 BD INSULIN SYRINGE ULTRAFINE ....................................................... 69 BD INTEGRA INSULIN SYRINGE .................................................................. 69 BD PEN NEEDLE MINI U/F ....................................................................................................... 69 BD PEN NEEDLE NANO U/F ....................................................................................................... 69 BD PEN NEEDLE SHORT U/F ....................................................................................................... 69 BD SAFETYGLIDE INSULIN SYRINGE .................................................................. 69 BD SAFETY-LOK INSULIN SYRINGE .................................................................. 69 BECONASE AQ ............................................ 80 belladonna alkaloids-opium ............ 90 belladonna-opium ............................................ 90 benazepril hcl ......................................................... 25 benazepril-hydrochlorothiazide ....................................................................................................... 25 BENICAR ................................................................. 25
BENICAR HCT .............................................. 25 BENZEPRO .......................................................... 49 BENZEPRO SHORT CONTACT .............................................................. 49 benzonatate ................................................................ 48 benzoyl peroxide ................................................ 49 benzoyl peroxide cleanser ................... 49 benzoyl peroxide wash ............................. 49 benzoyl peroxide-erythromycin ... 49 benztropine mesylate ................................... 32 BEPREVE ................................................................ 81 BERINERT ............................................................ 65 BESIVANCE ........................................................ 82 betamethasone dipropionate ........... 50 betamethasone dipropionate aug ....................................................................................................... 50 betamethasone sod phos & acet ....................................................................................................... 47 betamethasone valerate .......................... 50 BETASERON ..................................................... 87 betaxolol hcl ................................................. 40, 82 bethanechol chloride ................................... 92 BETOPTIC-S ...................................................... 82 bexarotene ................................................................... 30 bicalutamide ............................................................. 30 BICILLIN L-A .................................................. 86 bimatoprost ................................................................ 82 bisoprolol fumarate ...................................... 40 bisoprolol-hydrochlorothiazide ....................................................................................................... 25 BLEPHAMIDE S.O.P. ........................ 82 BOSULIF ................................................................... 30 bp cleansing .............................................................. 50 bp foam ............................................................................ 50 bp folinatal plus b ............................................ 79 bp gel ................................................................................... 50 bp wash ............................................................................ 50 bpo creamy wash .............................................. 50 BREO ELLIPTA .......................................... 12 BRILINTA ................................................... 58, 65 brimonidine tartrate ..................................... 82 BROMFED DM .............................................. 48 bromfenac sodium ........................................... 82 bromfenac sodium (once-daily) ....................................................................................................... 82 bromocriptine mesylate ........................... 32 BROVANA .............................................................. 12 budesonide .......................................... 12, 47, 80 buffered aspirin ....................................................... 4 bumetanide ................................................................. 58 buprenorphine hcl ............................................... 5 buprenorphine hcl-naloxone hcl ... 5 bupropion hcl ......................................................... 17 bupropion hcl er (smoking det) ... 87 bupropion hcl er (sr) ................................... 17
bupropion hcl er (xl) ................................... 17 buspirone hcl ........................................................... 10 butalbital-acetaminophen ........................ 4 butalbital-apap-caff-cod ............................ 5 butalbital-apap-caffeine ............................. 4 butalbital-asa-caff-codeine ................... 5 butalbital-aspirin-caffeine ...................... 4 butorphanol tartrate ........................................ 5 BUTRANS .................................................................... 5 BYDUREON ......................................................... 19 BYETTA 10 MCG PEN .................... 19 BYETTA 5 MCG PEN ........................ 19 BYSTOLIC ............................................................. 40 cabergoline ................................................................ 59 CAFERGOT ......................................................... 78 caffeine citrate .......................................................... 1 caffeine-sodium benzoate ......................... 1 calcipotriene ............................................................ 50 calcipotriene-betameth diprop ..... 50 calcitonin (salmon) ........................................ 59 calcitriol ............................................................. 50, 59 calcium acetate (phos binder) ....... 63 CAMILA ..................................................................... 44 CANASA ..................................................................... 63 candesartan cilexetil ................................... 26 candesartan cilexetil-hctz .................... 26 capecitabine ............................................................. 30 CAPEX ........................................................................... 50 CAPRELSA ........................................................... 30 captopril ......................................................................... 26 captopril-hydrochlorothiazide ..... 26 CARAFATE .......................................................... 90 carbamazepine ..................................................... 15 carbamazepine er ............................................. 15 carbidopa ..................................................................... 32 carbidopa-levodopa ......................... 32, 33 carbidopa-levodopa er ............................. 32 carbinoxamine maleate ........................... 23 CARDURA XL ................................................. 64 CAREFINE PEN NEEDLES ... 70 careone insulin syringe ........................... 70 careone unifine pentips ........................... 70 careone unifine pentips plus ............ 70 carisoprodol ............................................................. 80 carteolol hcl .............................................................. 82 CARTIA XT .......................................................... 41 carvedilol ...................................................................... 40 CAVERJECT ..................................................... 42 CAVERJECT IMPULSE ............... 42 CAZIANT ................................................................. 44 cefaclor ............................................................................ 43 cefaclor er ................................................................... 43 cefadroxil ...................................................................... 43 cefdinir ............................................................................. 43 cefpodoxime proxetil ................................... 43
96
Index
Index
Index
cefprozil .......................................................................... 43 ceftriaxone sodium ......................................... 43 ceftriaxone sodium in dextrose .... 43 ceftriaxone sodium-dextrose ........... 43 cefuroxime axetil ............................................... 43 celecoxib ............................................................................ 3 CELLCEPT ........................................................... 39 CELONTIN ............................................................ 15 CEM-UREA .......................................................... 50 cephalexin ........................................................ 43, 44 CEPROTIN ............................................................ 65 CESAMET ............................................................... 22 cetirizine hcl ............................................................. 23 cetirizine hcl allergy child .................. 23 CHANTIX ................................................................. 87 CHANTIX CONTINUING MONTH PAK .................................................... 87 CHANTIX STARTING MONTH PAK .................................................... 87 CHATEAL ............................................................... 44 CHEMET ................................................................... 22 chlordiazepoxide hcl ................................... 10 chlordiazepoxide-amitriptyline ... 87 chlordiazepoxide-clidinium .............. 90 chlorhexidine gluconate ............................................................................... 35, 44, 79 chloroquine phosphate ............................. 29 chlorothiazide ........................................................ 58 chlorpromazine hcl ........................................ 33 chlorpropamide ................................................... 19 chlorthalidone ....................................................... 58 chlorzoxazone ........................................................ 80 cholestyramine ..................................................... 24 cholestyramine light ..................................... 24 choline-mag trisalicylate .......................... 4 chorionic gonadotropin .......................... 59 CIALIS ........................................................................... 42 ciclopirox ...................................................................... 50 ciclopirox treatment ..................................... 50 ciclopirox-vitamin e ...................................... 50 cilostazol ........................................................................ 65 CILOXAN ................................................................. 82 cimetidine ..................................................................... 90 cimetidine hcl ......................................................... 90 CIMZIA ........................................................................ 63 CIMZIA PREFILLED ........................ 63 CIMZIA STARTER KIT ............... 63 CIPRO ............................................................................. 62 CIPRO HC ............................................................... 85 CIPRODEX ............................................................ 85 ciprofloxacin ............................................................ 62 ciprofloxacin hcl ........................ 62, 82, 85 ciprofloxacin-ciproflox hcl er ........ 62 citalopram hydrobromide .................... 17 citric acid-sodium citrate ..................... 64
clarithromycin ....................................................... 68 clarithromycin er .............................................. 68 clemastine fumarate ..................................... 23 CLEOCIN ................................................................. 93 CLEVER CHOICE COMFORT EZ ............................................................................................ 70 clickfine pen needles .................................... 70 CLINDACIN ETZ ...................................... 50 CLINDACIN PAC ...................................... 50 CLINDACIN-P ................................................. 50 clindamycin hcl ................................................... 28 clindamycin palmitate hcl ................... 28 clindamycin phos-benzoyl perox ....................................................................................................... 50 clindamycin phosphate ................ 51, 93 CLINPRO 5000 ............................................... 79 clobetasol propionate ................................ 51 clobetasol propionate e ........................... 51 clobetasol propionate emulsion ....................................................................................................... 51 CLODERM ............................................................. 51 CLODERM PUMP ................................... 51 clomipramine hcl .............................................. 17 clonazepam ................................................................ 15 clonidine hcl ............................................................. 26 clopidogrel bisulfate .................................... 65 clorazepate dipotassium ........................ 10 clotrimazole ...................................... 51, 79, 93 clotrimazole-betamethasone ............ 51 clozapine ........................................................................ 33 coal tar ............................................................................. 44 COARTEM ............................................................. 29 codeine sulfate .......................................................... 5 colchicine ..................................................................... 65 colchicine-probenecid ............................... 65 COLCRYS ............................................................... 65 cold sore treatment ........................................ 79 colestipol hcl ........................................................... 24 COLOCORT ............................................................ 8 COLY-MYCIN S .......................................... 85 COLYTE WITH FLAVOR PACKS ........................................................................... 67 COMBIGAN ......................................................... 82 COMBIPATCH .............................................. 61 COMBIVENT RESPIMAT ........ 12 COMETRIQ (100 MG DAILY DOSE) .............................................................................. 30 COMETRIQ (140 MG DAILY DOSE) .............................................................................. 30 COMETRIQ (60 MG DAILY DOSE) .............................................................................. 30 COMFORT ASSIST INSULIN SYRINGE .................................................................. 70 COMFORT EZ INSULIN SYRINGE .................................................................. 70
COMFORT EZ PEN NEEDLES ....................................................................................................... 70 COMPLERA ........................................................ 36 COMPRO .................................................................. 34 CONDYLOX ........................................................ 51 COPAXONE ......................................................... 87 CORDRAN ............................................................. 51 COREG CR ........................................................... 40 CORMAX SCALP APPLICATION .............................................. 51 CORTIFOAM ........................................................ 8 cortisone acetate ............................................... 47 CORTISPORIN .............................................. 51 COVARYX ............................................................. 61 COVARYX HS ................................................. 61 CREON ......................................................................... 58 CRESTOR ................................................................ 24 CRINONE ................................................................. 93 CRIXIVAN ............................................................. 36 cromolyn sodium ................................... 63, 82 CRYSELLE-28 ................................................ 44 cvs insulin syringe ........................................... 70 cvs lancing device ............................................ 70 cvs nasal allergy spray ............................ 80 cyanocobalamin ................................................. 66 CYCLAFEM 1/35 ........................................ 44 CYCLAFEM 7/7/7 ...................................... 44 CYCLOBENZAPRINE COMFORT PAC .......................................... 80 cyclobenzaprine hcl ...................................... 80 cyclopentolate hcl ............................................ 82 CYCLOSET .......................................................... 19 cyclosporine ............................................................. 39 cyclosporine modified ............................... 39 CYMBALTA ........................................................ 17 cyproheptadine hcl ......................................... 23 CYSTADANE ..................................................... 59 CYSTARAN .......................................................... 82 cytra-2 ............................................................................... 64 CYTRA-3 ................................................................... 64 cytra-k ................................................................................ 64 d 1000 ................................................................................ 94 d3 maximum strength ................................. 94 D3-50 .................................................................................. 94 dantrolene sodium ........................................... 80 dapsone ............................................................................ 28 DARAPRIM .......................................................... 29 darifenacin hydrobromide er ......... 92 DASETTA 1/35 ................................................ 44 DASETTA 7/7/7 .............................................. 44 DAYTRANA ............................................................. 1 deferoxamine mesylate ............................. 22 DELZICOL ............................................................ 63 demeclocycline hcl ......................................... 89 DENAVIR ................................................................. 51 97
Index
Index
Index
DENTA 5000 PLUS .................................. 79 DENTAGEL ......................................................... 79 DEPEN TITRATABS ........................... 39 DEPO-MEDROL ......................................... 47 DEPO-PROVERA ...................................... 30 DEPO-SUBQ PROVERA 104 ....................................................................................................... 44 desipramine hcl ................................................... 17 desmopressin ace rhinal tube ........ 59 desmopressin ace spray refrig ...... 59 desmopressin acetate .................................. 59 desmopressin acetate spray .............. 59 desonide .......................................................................... 51 desoximetasone ........................................ 51, 52 desvenlafaxine er .............................................. 17 desvenlafaxine fumarate er ............... 17 DETROL LA ....................................................... 92 dexamethasone ..................................................... 48 DEXAMETHASONE INTENSOL ............................................................. 47 dexamethasone sod phosphate pf ....................................................................................................... 48 dexamethasone sodium phosphate ........................................................................................... 48, 82 DEXFERRUM .................................................. 66 dexmethylphenidate hcl ............................... 1 dexmethylphenidate hcl er ...................... 1 DEXPAK 10 DAY ....................................... 48 DEXPAK 13 DAY ....................................... 48 DEXPAK 6 DAY ........................................... 48 dextroamphetamine sulfate ................... 1 dextroamphetamine sulfate er ........... 1 diazepam ........................................................................ 10 DIBENZYLINE .............................................. 26 diclofenac potassium ....................................... 3 diclofenac sodium ........................ 3, 52, 82 diclofenac sodium er ....................................... 3 diclofenac-misoprostol ................................. 3 dicloxacillin sodium ..................................... 86 dicyclomine hcl .................................................... 90 didanosine ................................................................... 36 diethylpropion hcl ............................................... 2 diethylpropion hcl er ....................................... 2 DIFICID ....................................................................... 68 diflorasone diacetate ................................... 52 diflunisal ............................................................................ 4 DIGITEK ................................................................... 42 DIGOX ........................................................................... 42 digoxin .............................................................................. 42 dihydroergotamine mesylate ........... 78 DILANTIN .............................................................. 15 DILATRATE-SR .............................................. 9 dilt-cd ................................................................................. 41 diltiazem cd ............................................................... 41 diltiazem hcl ............................................................. 41
diltiazem hcl cd .................................................... 41 diltiazem hcl er ..................................................... 41 diltiazem hcl er beads ................................ 41 diltiazem hcl er coated beads ......... 41 dilt-xr .................................................................................. 41 dimenhydrinate .................................................... 22 DIOVAN ...................................................................... 26 DIPENTUM ........................................................... 63 diphenhydramine hcl ................................... 23 diphenoxylate-atropine ............................ 22 dipyridamole ............................................................ 65 disopyramide phosphate ........................ 10 disulfiram ..................................................................... 87 divalproex sodium ........................................... 15 divalproex sodium er .................................. 15 donepezil hcl ............................................................ 87 dorzolamide hcl ................................................... 82 dorzolamide hcl-timolol mal ........... 82 doxapram hcl .............................................................. 2 doxazosin mesylate ........................................ 26 doxepin hcl ................................................................. 17 doxercalciferol ..................................................... 59 doxycycline hyclate ....................................... 89 doxycycline monohydrate .................... 89 DRITHO-CREME HP ........................ 52 dronabinol ....................................................... 22, 23 droperidol .................................................................... 10 DROXIA ...................................................................... 66 drug mart ultra comfort syr .............. 70 drug mart unifine pentips ..................... 70 drug mart unifine pentips plus ..... 70 duane reade unifine pentips ............. 70 DULERA ..................................................................... 12 duloxetine hcl ......................................................... 17 duramorph ...................................................................... 5 DUREZOL ............................................................... 82 dutasteride .................................................................. 64 DYRENIUM ......................................................... 58 DYSPORT ................................................................ 81 DYSPORT (GLABELLAR LINES) ............................................................................ 52 easy comfort insulin syringe ............ 70 easy comfort pen needles ...................... 71 EASY TOUCH INSULIN SAFETY SYR ..................................................... 71 EASY TOUCH INSULIN SYRINGE .................................................................. 71 EASY TOUCH PEN NEEDLES ....................................................................................................... 71 econazole nitrate ............................................... 52 EDARBI ....................................................................... 26 EDECRIN ................................................................. 58 EDEX ................................................................................ 42 EDURANT ............................................................... 36 EFFER-K ................................................................... 78
effervescent pot chloride ....................... 78 ELIDEL ........................................................................ 52 ELIGARD ................................................................. 30 ELINEST .................................................................... 44 ELIXOPHYLLIN ........................................ 12 ELLA ................................................................................ 44 ELMIRON ............................................................... 64 EMADINE ................................................................ 82 EMCYT ......................................................................... 30 EMOQUETTE .................................................. 44 EMSAM ........................................................................ 17 EMTRIVA ................................................................ 36 ENABLEX ................................................................ 92 enalapril maleate .............................................. 26 enalapril-hydrochlorothiazide ..... 26 ENBREL ......................................................................... 3 ENDOCET ................................................................... 5 ENDODAN .................................................................. 5 ENDOMETRIN .............................................. 93 ENJUVIA ................................................................... 61 enoxaparin sodium ......................................... 14 ENPRESSE-28 .................................................. 44 entacapone ................................................................. 33 EPIDUO ....................................................................... 52 epinastine hcl .......................................................... 82 epinephrine ................................................................ 94 epinephrine hcl .................................................... 12 epinephrine hcl pf ............................................ 94 EPIPEN ......................................................................... 94 EPIPEN 2-PAK ............................................... 94 EPIPEN JR ............................................................. 94 EPIPEN JR 2-PAK .................................... 94 EPITOL ........................................................................ 15 EPIVIR .......................................................................... 36 EPIVIR HBV ....................................................... 36 eplerenone ................................................................... 26 EPOGEN .................................................................... 66 eprosartan mesylate ..................................... 26 EPZICOM ................................................................ 36 eql insulin syringe ........................................... 71 eql short pen needle ...................................... 71 eql ultra comfort insulin syr ............ 71 eql ultra short pen needle .................... 71 ergoloid mesylates .......................................... 87 ERRIN ............................................................................. 45 ERTACZO ............................................................... 52 ery ............................................................................................ 52 ERY-TAB .................................................................. 68 ERYTHROCIN STEARATE ....................................................................................................... 68 erythromycin ................................................ 52, 82 erythromycin base ........................................... 68 erythromycin ethylsuccinate ............ 68 escitalopram oxalate ................................... 17 ESTARYLLA ..................................................... 45
98
Index
Index
Index
estazolam ...................................................................... 67 ESTRACE ................................................................ 93 estradiol .......................................................................... 61 estradiol valerate .............................................. 62 estradiol-norethindrone acet .......... 62 ESTRING .................................................................. 93 ESTROGEL .......................................................... 62 estropipate .................................................................. 62 eszopiclone ................................................................. 67 ethambutol hcl ....................................................... 29 ethosuximide ............................................................ 15 ethyl chloride .......................................................... 52 etidronate disodium ...................................... 59 etodolac ............................................................................... 3 etodolac er ...................................................................... 3 EURAX .......................................................................... 52 EVAMIST ................................................................. 62 EVISTA ........................................................................ 59 EXCEL COMFORT POINT PEN NEEDLE ................................................... 71 EXEL COMFORT POINT INSULIN SYR ................................................... 71 EXELON .................................................................... 87 exemestane ................................................................. 30 EXODERM ............................................................. 52 EXTAVIA ................................................................. 87 FACTIVE .................................................................. 62 FALMINA ................................................................ 45 famciclovir .................................................................. 36 famotidine .................................................................... 90 FANAPT ...................................................................... 34 FARESTON ........................................................... 30 FASLODEX ........................................................... 30 felbamate ....................................................................... 15 felodipine er .............................................................. 41 fenofibrate ................................................................... 24 fenofibrate micronized .............................. 24 fenofibric acid ....................................................... 24 fentanyl ................................................................................. 5 ferraplus 90 ............................................................... 66 FERRIPROX ....................................................... 22 ferrous gluconate .............................................. 66 ferrous sulfate ........................................................ 66 fexofenadine hcl .................................................. 23 FIFTY50 PEN NEEDLES ............. 71 FIFTY50 SUPERIOR COMFORT SYR ........................................... 71 finasteride ........................................................ 52, 64 FIRAZYR .................................................................. 65 FIRMAGON ......................................................... 30 FIRST-LANSOPRAZOLE .......... 90 FLAGYL ER ........................................................ 28 FLAREX ..................................................................... 82 flavoxate hcl ............................................................. 92 flecainide acetate .............................................. 10
FLOVENT DISKUS ................................ 12 FLUARIX QUADRIVALENT ....................................................................................................... 92 FLUCAINE ............................................................. 82 FLUCELVAX ..................................................... 93 fluconazole ................................................................. 23 fludrocortisone acetate ............................ 48 FLULAVAL QUADRIVALENT ....................................................................................................... 93 flunisolide .................................................................... 80 fluocinolone acetonide ................. 52, 85 fluocinonide .............................................................. 52 fluocinonide-e ........................................................ 52 fluoritab .......................................................................... 78 fluorometholone ................................................. 82 fluorouracil ................................................................ 52 fluoxetine hcl ........................................................... 17 fluoxetine hcl (pmdd) .................................. 87 fluphenazine decanoate ........................... 34 fluphenazine hcl .................................................. 34 flurandrenolide .................................................... 52 flurazepam hcl ....................................................... 67 flurbiprofen .................................................................... 3 flurbiprofen sodium ...................................... 82 flutamide ........................................................................ 30 fluticasone propionate .................. 52, 80 fluvastatin sodium ........................................... 24 FLUVIRIN ............................................................... 93 FLUVIRIN PRESERVATIVE FREE ................................................................................. 93 fluvoxamine maleate .................................... 18 FLUZONE QUADRIVALENT ....................................................................................................... 93 FML ..................................................................................... 83 FOCALIN XR ........................................................ 2 folic acid ........................................................................ 66 fomepizole .................................................................... 22 fondaparinux sodium .................................. 14 FORADIL AEROLIZER ............... 12 FORTEO .................................................................... 59 FOSAMAX PLUS D ................................ 60 fosinopril sodium .............................................. 26 fosinopril sodium-hctz .............................. 26 FOSRENOL .......................................................... 63 FRAGMIN ............................................................... 14 freds pharmacy unifine pentip+ ....................................................................................................... 71 freds pharmacy unifine pentips ... 71 FREESTYLE PRECISION INS SYR ...................................................................................... 71 FROVA .......................................................................... 78 frovatriptan succinate ............................... 78 furosemide ................................................................... 58 gabapentin .................................................................. 15 GABITRIL .............................................................. 15
galantamine hydrobromide ............... 87 galantamine hydrobromide er ...... 87 ganirelix acetate ................................................ 60 gatifloxacin ................................................................ 83 GAVILYTE-C ................................................... 67 GAVILYTE-G ................................................... 67 GAVILYTE-N WITH FLAVOR PACK ................................................................................ 67 GELNIQUE ........................................................... 92 gemfibrozil .................................................................. 24 GENGRAF .............................................................. 39 GENOTROPIN ................................................ 60 GENOTROPIN MINIQUICK ....................................................................................................... 60 gentamicin sulfate ............................... 52, 83 GILDESS 1.5/30 ............................................. 45 GILDESS 1/20 ................................................... 45 GILDESS 24 FE ............................................. 45 GILDESS FE 1.5/30 ................................. 45 GILDESS FE 1/20 ....................................... 45 GILENYA ................................................................. 87 GLATOPA ............................................................... 87 GLEEVEC ............................................................... 30 glimepiride ................................................................. 19 glipizide ........................................................................... 19 glipizide er .................................................................. 19 glipizide xl ................................................................... 19 glipizide-metformin hcl ........................... 19 global ease inject pen needles ...... 71 global inject ease insulin syr .......... 72 GLUCAGEN DIAGNOSTIC ....................................................................................................... 58 GLUCAGEN HYPOKIT ................ 19 GLUCAGON EMERGENCY ....................................................................................................... 19 GLUCOPRO INSULIN SYRINGE .................................................................. 72 glucose .............................................................................. 19 GLUMETZA ........................................................ 19 glyburide ........................................................................ 19 glyburide micronized .................................. 19 glyburide-metformin .................................... 19 glycine ............................................................................... 64 glycine urologic .................................................. 64 glycopyrrolate ....................................................... 90 GLYDO ......................................................................... 53 GLYSET ...................................................................... 19 gnp clickfine pen needles ...................... 72 gnp hydrocortisone/aloe ........................ 53 gnp insulin syringe ......................................... 72 gnp iron ........................................................................... 66 gnp ultra com insulin syringe ........ 72 gnp vitamin d-400 ............................................ 78 GOLYTELY ......................................................... 67 granisetron hcl ..................................................... 23 99
Index
Index
Index
griseofulvin microsize ............................... 23 griseofulvin ultramicrosize ................ 23 guanfacine hcl ....................................................... 26 guanfacine hcl er .................................................. 2 GYNAZOLE-1 .................................................. 93 halobetasol propionate ............................ 53 HALOG ........................................................................ 53 haloperidol ................................................................. 34 haloperidol decanoate .............................. 34 haloperidol lactate ......................................... 34 healthwise mini pen needles ............ 72 healthwise pen needles ............................. 72 healthwise short pen needles .......... 72 healthwise unifine pentips ................... 72 healthy accents unifine pentip ....... 72 HEATHER .............................................................. 45 h-e-b incontrol pen needles ............... 72 HECTOROL ........................................................ 60 HEMATOGEN FA .................................... 66 HEMATOGEN FORTE ................... 66 HEMOCYTE-F ............................................... 66 heparin (porcine) in nacl ...................... 14 heparin lock flush ............................................. 14 heparin sod (porcine) in d5w ......... 14 heparin sodium (porcine) ..................... 14 heparin sodium (porcine) pf ............ 14 heparin sodium lock flush ................... 14 HEPSERA ................................................................ 36 hm hydrocortisone plus ........................... 53 hm hydrocortisone-aloe max st ... 53 homatropine hbr ................................................ 83 HUMALOG ........................................................... 20 HUMALOG KWIKPEN .................. 19 HUMALOG MIX 50/50 ..................... 20 HUMALOG MIX 50/50 KWIKPEN ............................................................... 20 HUMALOG MIX 75/25 ..................... 20 HUMALOG MIX 75/25 KWIKPEN ............................................................... 20 HUMIRA ........................................................................ 3 HUMIRA PEDIATRIC CROHNS START ........................................... 3 HUMIRA PEN ...................................................... 3 HUMIRA PEN-CROHNS STARTER .................................................................... 3 HUMIRA PEN-PSORIASIS STARTER .................................................................... 3 HUMULIN N ....................................................... 20 HUMULIN R ....................................................... 20 HUMULIN R U-500 (CONCENTRATED) ............................. 20 hydralazine hcl ..................................................... 26 hydrochlorothiazide ......................... 58, 59 hydrocod polst-cpm polst er ............ 48 hydrocodone-acetaminophen ..... 5, 6
hydrocodone-homatropine ................. 48 hydrocodone-ibuprofen ............................... 6 hydrocortisone .................................. 8, 48, 53 hydrocortisone ace-pramoxine ............................................................................................... 8, 53 hydrocortisone acetate ................................. 8 hydrocortisone butyr lipo base .... 53 hydrocortisone butyrate ......................... 53 hydrocortisone valerate .......................... 53 hydrocortisone-acetic acid ................ 85 hydrocortisone-aloe ..................................... 53 hydromet ........................................................................ 48 hydromorphone hcl ........................................... 6 hydroquinone .......................................................... 53 hydroquinone time release ................. 53 hydroxocobalamin .......................................... 66 hydroxychloroquine sulfate ............... 29 hydroxyurea .............................................................. 30 hydroxyzine hcl .................................................... 10 hydroxyzine pamoate .................................. 10 HYOPHEN .............................................................. 91 hyoscyamine sulfate ...................................... 91 hyoscyamine sulfate er ............................. 91 HYPERCARE .................................................... 53 ibandronate sodium ...................................... 60 IBUDONE ..................................................................... 6 ibuprofen ........................................................................... 3 IBUPROFEN COMFORT PAC ........................................................................................................... 3 imatinib mesylate .............................................. 30 imipramine hcl ...................................................... 18 imipramine pamoate .................................... 18 imiquimod .................................................................... 53 INCIVEK ................................................................... 36 INCRELEX ............................................................ 60 INCRUSE ELLIPTA ............................. 12 indapamide ................................................................. 59 indomethacin ............................................................... 3 indomethacin er ...................................................... 3 INFED ............................................................................. 66 INFERGEN ............................................................ 36 INLYTA ....................................................................... 30 insulin syringe ....................................................... 72 insulin syringe/needle ................................ 72 insupen pen needles ...................................... 72 INSUPEN SENSITIVE ...................... 72 INSUPEN ULTRAFIN ....................... 72 INTELENCE ....................................................... 36 INTRON A ............................................................... 30 INVEGA ...................................................................... 34 INVEGA SUSTENNA .......................... 34 INVIRASE ............................................................... 36 INVOKANA .......................................................... 20 iodine strong ................................................ 35, 78 iodine strong (lugol's) ............................... 44
IOPIDINE ................................................................. 83 ipratropium bromide ....................... 12, 80 ipratropium-albuterol ................................ 12 irbesartan ..................................................................... 26 irbesartan-hydrochlorothiazide ....................................................................................................... 26 ISENTRESS .......................................................... 36 isometheptene-caffeine-apap .......... 78 isoniazid ......................................................................... 29 isosorbide dinitrate ........................................... 9 isosorbide dinitrate er ................................... 9 isosorbide mononitrate ................................ 9 isosorbide mononitrate er ....................... 9 isoxsuprine hcl ...................................................... 42 isradipine ...................................................................... 41 JAKAFI ......................................................................... 31 JANTOVEN .......................................................... 14 JANUVIA .................................................................. 20 JENTADUETO ................................................ 20 JINTELI ...................................................................... 62 JOLIVETTE ........................................................ 45 JUNEL 1.5/30 ...................................................... 45 JUNEL 1/20 ............................................................ 45 JUNEL FE 1.5/30 .......................................... 45 JUNEL FE 1/20 ................................................ 45 JUNEL FE 24 ...................................................... 45 KALBITOR ........................................................... 65 KALETRA ............................................................... 36 KALYDECO ........................................................ 88 KEFLEX ..................................................................... 44 KELNOR 1/35 ................................................... 45 KENALOG ............................................................. 53 KETEK .......................................................................... 28 ketoconazole ................................................. 23, 53 KETODAN .............................................................. 53 ketoprofen ........................................................................ 3 ketoprofen er ............................................................... 3 ketorolac tromethamine .................. 3, 83 KINERET ..................................................................... 3 kinray insulin syringe ................................. 72 KIONEX .......................................................... 39, 86 KLOR-CON .......................................................... 78 KLOR-CON M15 ......................................... 78 kls hydrocortisone plus ............................ 53 kp benzoyl peroxide ...................................... 53 KRISTALOSE .................................................. 67 kroger insulin syringe ................................ 73 kroger pen needles ......................................... 73 KURVELO .............................................................. 45 KYPROLIS ............................................................ 31 labetalol hcl .............................................................. 40 LACRISERT ........................................................ 83 lactic acid ..................................................................... 53 lactic acid e ............................................................... 53 lactulose ......................................................................... 67
100
Index
Index
Index
lactulose encephalopathy ..................... 63 LAMICTAL ODT ....................................... 15 lamivudine ................................................................... 36 lamivudine-zidovudine ............................. 36 lamotrigine ..................................................... 15, 16 lamotrigine er ........................................................ 15 LANOXIN ................................................................. 42 lansoprazole ............................................................. 91 LANTUS ...................................................................... 20 LANTUS SOLOSTAR ........................ 20 LARIN 24 FE ...................................................... 45 LARIN FE 1/20 ................................................ 45 LASTACAFT ...................................................... 83 latanoprost ................................................................. 83 LATRIX ....................................................................... 53 LATUDA ..................................................................... 34 leader insulin syringe ................................. 73 LEADER UNIFINE PENTIPS ....................................................................................................... 73 LEADER UNIFINE PENTIPS PLUS .................................................................................. 73 leflunomide ..................................................................... 3 LESSINA .................................................................... 45 LETAIRIS ................................................................ 42 letrozole .......................................................................... 31 leucovorin calcium ......................................... 31 LEUKERAN ......................................................... 31 LEUKINE ................................................................. 66 leuprolide acetate ............................................ 31 levalbuterol hcl .................................................... 13 levalbuterol tartrate hfa ......................... 13 LEVATOL ............................................................... 40 LEVEMIR ................................................................ 20 LEVEMIR FLEXPEN ......................... 20 LEVEMIR FLEXTOUCH ........... 20 levetiracetam ........................................................... 16 levetiracetam er .................................................. 16 levobunolol hcl ..................................................... 83 levocarnitine ............................................................ 60 levocetirizine dihydrochloride ...... 23 levofloxacin ................................................... 62, 83 LEVONEST ........................................................... 45 levonorgest-eth estrad 91-day ...... 45 levonorgestrel ........................................................ 45 levonorgestrel-ethinyl estrad .......... 45 LEVORA 0.15/30 (28) ........................... 45 levorphanol tartrate ......................................... 6 levothyroxine sodium .................................. 89 LEVOXYL ............................................................... 89 LEXIVA ....................................................................... 36 lidocaine ......................................................................... 54 lidocaine hcl ................................................. 54, 79 lidocaine-hydrocortisone ace ............ 8 lidocaine-prilocaine ..................................... 54 LIDODERM ......................................................... 54
lindane .............................................................................. 54 linezolid ........................................................................... 28 linezolid in sodium chloride ............. 28 LINZESS .................................................................... 63 liothyronine sodium ...................................... 89 LIPOFEN ................................................................... 24 lisinopril ......................................................................... 26 lisinopril-hydrochlorothiazide ..... 26 LITE TOUCH PEN NEEDLES ....................................................................................................... 73 LITETOUCH INSULIN SYRINGE .................................................................. 73 LITETOUCH PEN NEEDLES ....................................................................................................... 73 lithium ................................................................................ 34 lithium carbonate ............................................. 34 lithium carbonate er ..................................... 34 LIVALO ....................................................................... 24 live better pen needles ............................... 73 LODOSYN ............................................................... 33 LOMEDIA 24 FE ......................................... 46 longs insulin syringe .................................... 73 loperamide hcl ...................................................... 22 loratadine ..................................................................... 24 loratadine childrens ..................................... 23 lorazepam ..................................................................... 10 LORAZEPAM INTENSOL ....... 10 LORCET PLUS .................................................. 6 LORTAB ........................................................................ 6 LORZONE .............................................................. 80 losartan potassium ......................................... 26 losartan potassium-hctz .......................... 26 LOTEMAX ............................................................. 83 lovastatin ....................................................................... 24 LOVAZA .................................................................... 24 LOW-OGESTREL .................................... 46 loxapine succinate ........................................... 34 lugols ................................................................................... 35 LUMIGAN ............................................................... 83 LUNESTA ................................................................ 67 LUPRON DEPOT ....................................... 31 LUPRON DEPOT-PED .................... 60 LUTERA ..................................................................... 46 LYRICA ....................................................................... 16 LYSODREN .......................................................... 31 mafenide acetate ................................................ 54 MAGELLAN INSULIN SAFETY SYR ..................................................... 73 malathion ...................................................................... 54 maprotiline hcl ..................................................... 18 marlissa ........................................................................... 46 MARPLAN ............................................................. 18 MATULANE ........................................................ 31 MAXI-COMFORT INSULIN SYRINGE .................................................................. 73
meclizine hcl ............................................................ 23 meclofenamate sodium ................................. 3 medic insulin syringe .................................. 73 MEDICAL PROVIDER EZ FLU ...................................................................................... 93 medical provider ez flu pf .................... 93 medicine shoppe pen needles ......... 73 medi-first hydrocortisone ..................... 54 medroxyprogesterone acetate ........................................................................................... 46, 86 mefloquine hcl ....................................................... 29 megestrol acetate .............................................. 31 meijer pen needles .......................................... 73 meloxicam ........................................................................ 4 MELOXICAM COMFORT PAC .......................................................................................... 4 melpaque hp ............................................................. 54 MELQUIN 3 ......................................................... 54 melquin hp ................................................................... 54 memantine hcl ....................................................... 87 MENEST .................................................................... 62 MENTAX ................................................................... 54 meperidine hcl ........................................................... 6 MEPHYTON ....................................................... 94 meprobamate .......................................................... 10 MEPRON ................................................................... 28 mercaptopurine ................................................... 31 mesalamine ................................................................ 63 mesalamine-cleanser .................................. 63 MESNEX .................................................................... 31 MESTINON ........................................................... 29 metaproterenol sulfate .............................. 13 metaxalone ................................................................. 80 metformin hcl .......................................................... 20 metformin hcl er ................................................. 20 metformin hcl er (mod) ............................ 20 metformin hcl er (osm) ............................. 20 methadone hcl ........................................................... 6 methamphetamine hcl .................................... 2 methenamine hippurate ........................... 91 methenamine mandelate ........................ 91 methimazole .............................................................. 89 methitest ............................................................................. 8 methocarbamol .................................................... 80 methotrexate ............................................................. 31 methotrexate sodium ................................... 31 methotrexate sodium (pf) ...................... 31 methoxsalen rapid ........................................... 54 methscopolamine bromide .................. 91 methyclothiazide ................................................ 59 methyldopa ................................................................. 26 methylergonovine maleate .................. 85 methylphenidate hcl .......................................... 2 methylphenidate hcl er ................................. 2 methylphenidate hcl er (cd) .................. 2 101
Index
Index
Index
methylphenidate hcl er (la) ................... 2 methylprednisolone ....................................... 48 metipranolol ............................................................. 83 metoclopramide hcl ....................................... 63 metolazone .................................................................. 59 metoprolol succinate er .......................... 40 metoprolol tartrate ......................................... 40 metoprolol-hydrochlorothiazide ....................................................................................................... 26 metronidazole ................................. 28, 54, 93 mexiletine hcl .......................................................... 11 MIACALCIN ...................................................... 60 MICARDIS ............................................................. 27 MICARDIS HCT .......................................... 27 miconazole 3 applicator ......................... 93 miconazole 3 combo pack ................... 93 miconazole nitrate ........................................... 54 MICROGESTIN FE 1/20 ............... 46 midodrine hcl .......................................................... 94 miglitol ............................................................................. 20 MIGRANAL ......................................................... 78 MILLIPRED ........................................................ 48 MILLIPRED DP ........................................... 48 MIMVEY ................................................................... 62 MINITRAN ................................................................ 9 MINIVELLE ........................................................ 62 minocycline hcl .................................................... 89 minocycline hcl er ........................................... 89 minoxidil ........................................................................ 27 MIRAPEX ER ................................................... 33 mirtazapine ................................................................ 18 misoprostol ................................................................ 91 modafinil ............................................................................ 2 MODERIBA 800 DOSE PACK ....................................................................................................... 37 moexipril hcl ............................................................ 27 moexipril-hydrochlorothiazide .... 27 mometasone furoate ......................... 54, 80 MONOJECT FLUSH SYR/HEP LOCK ............................................................................... 14 MONOJECT INSULIN SYRINGE .................................................................. 73 MONOJECT ULTRA COMFORT SYRINGE ...................... 74 MONO-LINYAH .......................................... 46 MONONESSA ................................................... 46 montelukast sodium ....................................... 13 MONUROL ............................................................ 91 MOORE MONO INSULIN SYRINGE .................................................................. 74 MORGIDOX ........................................................ 89 morphine sulfate ............................................ 6, 7 morphine sulfate (concentrate) ....... 6 morphine sulfate (pf) ....................................... 6 morphine sulfate er ............................................ 6
morphine sulfate in dextrose ............... 6 MOXEZA .................................................................. 83 moxifloxacin hcl ................................................. 62 ms insulin syringe ............................................ 74 MULTAQ .................................................................. 11 multi-vit/fluoride ................................................ 79 mupirocin ..................................................................... 54 mupirocin calcium .......................................... 54 MUSE ............................................................................... 43 MYCOBUTIN .................................................... 29 mycophenolate mofetil .............................. 39 mycophenolic acid .......................................... 39 MYFORTIC .......................................................... 39 MYLERAN ............................................................. 31 MYZILRA ................................................................ 46 nabumetone ................................................................... 4 nac ........................................................................................... 81 nadolol .............................................................................. 40 nadolol-bendroflumethiazide ......... 27 nalbuphine hcl ........................................................... 7 naloxone hcl ............................................................. 22 naltrexone hcl ........................................................ 22 NAMENDA ............................................................. 87 NAMENDA TITRATION PAK ....................................................................................................... 87 naphazoline hcl ................................................... 83 naproxen ............................................................................ 4 NAPROXEN COMFORT PAC ........................................................................................................... 4 naproxen dr ................................................................... 4 naproxen kit .................................................................. 4 naproxen sodium ................................................... 4 naratriptan hcl ...................................................... 78 NASACORT ALLERGY 24HR ....................................................................................................... 80 nasal allergy 24 hour ................................. 81 NASONEX ............................................................... 81 NATACYN .............................................................. 83 nateglinide .................................................................. 21 NATROBA .............................................................. 54 NATURE-THROID ................................. 90 NECON 0.5/35 (28) .................................... 46 NECON 1/35 (28) .......................................... 46 NECON 1/50 (28) .......................................... 46 NECON 7/7/7 ....................................................... 46 nefazodone hcl .......................................... 18, 88 neomycin sulfate .................................................... 2 neomycin-bacitracin zn-polymyx ....................................................................................................... 83 neomycin-polymyxin b gu .................... 64 neomycin-polymyxin-dexameth ... 83 neomycin-polymyxin-gramicidin ....................................................................................................... 83 neomycin-polymyxin-hc .............. 83, 85 NEUMEGA ............................................................. 66
NEUPOGEN ......................................................... 66 NEUPRO ..................................................................... 33 NEVANAC .............................................................. 83 nevirapine .................................................................... 37 nevirapine er ........................................................... 37 NEXAVAR .............................................................. 31 NEXIUM 24HR ............................................... 91 niacin .................................................................................. 94 niacin er (antihyperlipidemic) ...... 24 NIACOR ...................................................................... 24 NIASPAN ................................................................... 25 nicardipine hcl ...................................................... 41 NICAZELDOXY 30 ................................ 89 NICAZELDOXY 60 ................................ 89 nicotine ............................................................................. 87 nicotine polacrilex .......................................... 87 NICOTROL ........................................................... 87 NICOTROL NS .............................................. 88 NIFEDICAL XL ............................................ 42 nifedipine ...................................................................... 42 nifedipine er .............................................................. 42 nifedipine er osmotic release .......... 42 nimodipine .................................................................. 42 nisoldipine er .......................................................... 42 NITRO-BID ............................................................... 9 NITRO-DUR ............................................................ 9 nitrofurantoin ......................................................... 92 nitrofurantoin macrocrystal ............. 91 nitrofurantoin monohyd macro ... 92 nitroglycerin ................................................................. 9 nitroglycerin er ........................................................ 9 NITROLINGUAL ........................................... 9 NITROSTAT ........................................................... 9 nizatidine ....................................................................... 91 NORA-BE ................................................................. 46 NORCO ............................................................................. 7 NORDITROPIN FLEXPRO .... 60 NORDITROPIN NORDIFLEX PEN ...................................................................................... 60 norethin ace-eth estrad-fe ................... 46 norethindrone ......................................................... 46 norethindrone acetate ............................... 86 norgestimate-eth estradiol .................. 46 norgestim-eth estrad triphasic ..... 46 NOROXIN ................................................................ 62 NORPACE CR ................................................. 11 NORTREL 0.5/35 (28) ......................... 46 NORTREL 1/35 (21) ............................... 46 NORTREL 1/35 (28) ............................... 46 NORTREL 7/7/7 ............................................ 46 nortriptyline hcl .................................................. 18 NORVIR ...................................................................... 37 NOVOFINE ........................................................... 74 NOVOFINE PLUS ..................................... 74 NOVOLIN 70/30 ............................................ 21
102
Index
Index
Index
NOVOLIN 70/30 RELION .......... 21 NOVOLIN N ........................................................ 21 NOVOLIN N RELION ....................... 21 NOVOLIN R ........................................................ 21 NOVOLIN R RELION ....................... 21 NOVOLOG ............................................................ 21 NOVOLOG FLEXPEN ..................... 21 NOVOLOG MIX 70/30 ...................... 21 NOVOLOG MIX 70/30 FLEXPEN ................................................................. 21 NOVOLOG PENFILL ........................ 21 NUCYNTA ER ..................................................... 7 NUEDEXTA ......................................................... 88 NUTROPIN AQ NUSPIN 10 .... 60 NUTROPIN AQ NUSPIN 20 .... 60 NUTROPIN AQ NUSPIN 5 ........ 60 NUTROPIN AQ PEN ............................ 60 NUVARING .......................................................... 46 NUVIGIL ....................................................................... 2 NYAMYC .................................................................. 54 nystatin ..................................................... 23, 54, 79 nystatin-triamcinolone ................. 54, 55 NYSTOP ...................................................................... 55 octreotide acetate ............................................. 60 ofloxacin ................................................. 62, 83, 85 olanzapine ................................................................... 34 olanzapine-fluoxetine hcl ..................... 88 olmesartan medoxomil ............................. 27 olmesartan medoxomil-hctz .............. 27 olopatadine hcl .................................................... 83 omega-3-acid ethyl esters .................... 25 omeprazole ................................................................. 91 omeprazole magnesium ........................... 91 omeprazole-sodium bicarbonate ....................................................................................................... 91 ondansetron .............................................................. 23 ondansetron hcl ................................................... 23 ONGLYZA .............................................................. 21 OPANA ER ................................................................. 7 ORAP ................................................................................ 88 ORAVIG ..................................................................... 79 ORFADIN ................................................................. 60 orphenadrine citrate er ........................... 80 ORSYTHIA ............................................................ 46 ORTHO EVRA ................................................ 47 OSMOPREP ......................................................... 68 otic care .......................................................................... 85 oxaprozin .......................................................................... 4 oxazepam ...................................................................... 10 oxcarbazepine ........................................................ 16 oxiconazole nitrate ......................................... 55 OXISTAT .................................................................. 55 OXSORALEN .................................................... 55 OXSORALEN ULTRA ...................... 55 oxybutynin chloride ....................................... 92
oxybutynin chloride er .............................. 92 oxycodone hcl ............................................................ 7 oxycodone-acetaminophen ..................... 7 oxycodone-aspirin ............................................... 7 oxycodone-ibuprofen ...................................... 7 oxymorphone hcl er .......................................... 7 OXYTROL .............................................................. 92 OXYTROL FOR WOMEN ........ 92 PACERONE ......................................................... 11 paliperidone er ..................................................... 34 pantoprazole sodium ................................... 91 papaverine hcl ....................................................... 43 paricalcitol ................................................................. 60 paroxetine hcl ........................................................ 18 paroxetine hcl er ................................................ 18 PATADAY ............................................................... 83 PATANOL ............................................................... 84 PAXIL ............................................................................. 18 pc unifine pentips ............................................. 74 peg 3350/electrolytes .................................. 68 peg 3350-kcl-na bicarb-nacl ........... 68 peg-3350/electrolytes ................................. 68 PEGANONE ......................................................... 16 PEGASYS ................................................................. 37 PEGASYS PROCLICK .................... 37 PEGINTRON ...................................................... 37 PEG-INTRON ................................................... 37 PEG-INTRON REDIPEN ............. 37 PEG-INTRON REDIPEN PAK 4 .................................................................................................. 37 pen needles ................................................................. 74 pen needles 1/2" ................................................. 74 pen needles 3/16" ............................................. 74 pen needles 5/16" ............................................. 74 penicillin v potassium ................................ 86 PENTAM .................................................................... 28 PENTASA ................................................................. 63 pentazocine-naloxone hcl ........................ 7 pentetate calcium trisodium ............. 22 pentetate zinc trisodium ......................... 22 PENTIPS .................................................................... 74 pentoxifylline er .................................................. 65 PERFOROMIST ........................................... 13 perindopril erbumine .................................. 27 PERIOMED .......................................................... 79 permethrin ................................................................... 55 perphenazine ........................................................... 34 perphenazine-amitriptyline ............... 88 phenazopyridine hcl ..................................... 64 phendimetrazine tartrate ........................... 2 phendimetrazine tartrate er .................. 2 phenelzine sulfate ............................................. 18 phenobarbital ......................................................... 67 phenoxybenzamine hcl .............................. 27 phentermine hcl ....................................................... 2
phenytoin ....................................................................... 16 PHENYTOIN INFATABS ........... 16 phenytoin sodium .............................................. 16 phenytoin sodium extended ............... 16 PHOSLYRA .......................................................... 63 PHOSPHA 250 NEUTRAL ........ 78 PHOSPHASAL ................................................ 92 PHOSPHOLINE IODIDE ............ 84 physicians ez use b-12 ............................... 66 physostigmine salicylate ........................ 22 pilocarpine hcl .......................................... 79, 84 pimozide ......................................................................... 88 pindolol ............................................................................ 40 PIN-X .................................................................................... 9 pioglitazone hcl ................................................... 21 pioglitazone hcl-glimepiride ........... 21 pioglitazone hcl-metformin hcl .... 21 piroxicam .......................................................................... 4 podocon ........................................................................... 55 podofilox ........................................................................ 55 polyethylene glycol 3350 ...................... 68 poly-iron 150 forte ......................................... 66 polymyxin b-trimethoprim ................... 84 POMALYST ......................................................... 31 PORTIA-28 ............................................................. 47 POTABA ..................................................................... 94 potassium bicarbonate ............................. 78 potassium chloride ......................................... 79 potassium chloride crys er ................. 78 potassium chloride er ................................. 79 potassium citrate er ...................................... 64 potassium citrate-citric acid ............ 64 POTIGA ....................................................................... 16 PR BENZOYL PEROXIDE WASH .............................................................................. 55 PRADAXA ............................................................... 14 pramcort ............................................................................. 9 pramipexole dihydrochloride ......... 33 pramipexole dihydrochloride er ....................................................................................................... 33 PRANDIN ................................................................. 21 pravastatin sodium ......................................... 25 prazosin hcl ............................................................... 27 PRECISION SUREDOSE PLUS SYR ...................................................................................... 74 PRECISION SURE-DOSE SYRINGE .................................................................. 74 PRED MILD ......................................................... 84 prednicarbate ......................................................... 55 prednisolone ............................................................. 48 prednisolone acetate ................................... 84 prednisolone sodium phosphate ........................................................................................... 48, 84 prednisone ................................................................... 48 PREDNISONE INTENSOL ...... 48 103
Index
Index
Index
preferred plus insulin syringe ....... 74 preferred plus unifine pentips ....... 74 PREMARIN .......................................................... 62 PREMPHASE .................................................... 62 PREMPRO .............................................................. 62 prenatal ........................................................................... 79 PREPOPIK ............................................................. 68 PREVALITE ........................................................ 25 PREVIFEM ............................................................ 47 PREZISTA .............................................................. 37 primaquine phosphate ............................... 29 primidone ..................................................................... 16 PRISTIQ ..................................................................... 18 PROAIR HFA .................................................... 13 probenecid .................................................................. 65 prochlorperazine ............................................... 35 prochlorperazine edisylate ................ 35 prochlorperazine maleate ................... 35 PROCRIT ................................................................. 66 PROCTOFOAM HC .................................. 9 PROCTOZONE-HC ................................... 9 PRODIGY INSULIN SYRINGE ....................................................................................................... 74 PROLIA ....................................................................... 61 promethazine hcl ............................................... 24 promethazine vc plain ............................... 48 promethazine vc/codeine ....................... 49 promethazine-codeine ............................... 49 promethazine-dm .............................................. 49 propafenone hcl .................................................. 11 propafenone hcl er ......................................... 11 propantheline bromide ............................. 91 proparacaine hcl ............................................... 84 propranolol hcl .................................................... 40 propranolol hcl er ........................................... 40 propranolol-hctz ................................................ 27 propylthiouracil .................................................. 90 PROVENTIL HFA .................................... 13 PRUDOXIN ........................................................... 55 PULMICORT FLEXHALER ....................................................................................................... 13 PULMOZYME ................................................. 88 px extra short pen needles .................. 74 px insulin syringe ............................................. 74 px mini pen needles ....................................... 74 px pen needle .......................................................... 74 pyrazinamide ........................................................... 29 pyridostigmine bromide .......................... 29 pyridostigmine bromide er ................. 29 pyridoxine hcl ........................................................ 94 pyrogallic acid ...................................................... 55 qc pen needles ....................................................... 74 qc unifine pentips ............................................. 74 QNASL ........................................................................... 81 QUALAQUIN ..................................................... 29
quetiapine fumarate ...................................... 35 quetiapine fumarate er ............................. 35 quinapril hcl ............................................................. 27 quinapril-hydrochlorothiazide ..... 27 quinidine gluconate er .............................. 11 quinidine sulfate ................................................. 11 quinidine sulfate er ........................................ 11 quinine sulfate ....................................................... 29 QVAR ............................................................................... 13 ra glucose ..................................................................... 21 ra insulin syringe .............................................. 75 ra pen needles ........................................................ 75 raloxifene hcl .......................................................... 61 ramipril ............................................................................ 27 RANEXA .................................................................... 10 ranitidine hcl ........................................................... 91 RAPAFLO ................................................................ 64 RAPAMUNE ........................................................ 39 REA LO 39 .............................................................. 55 REBETOL ................................................................ 37 REBIF .............................................................................. 88 REBIF REBIDOSE .................................. 88 REBIF REBIDOSE TITRATION PACK ................................ 88 REBIF TITRATION PACK ..... 88 RECLIPSEN ........................................................ 47 RECTIV ........................................................................... 9 reeses pinworm medicine ......................... 9 REGENECARE .............................................. 55 REGENECARE HA ................................ 55 RELENZA DISKHALER .............. 37 RELION INSULIN SYRINGE ....................................................................................................... 75 RELI-ON INSULIN SYRINGE ....................................................................................................... 75 RELION MINI PEN NEEDLES ....................................................................................................... 75 RELION PEN NEEDLES ............. 75 RELION SHORT PEN NEEDLES ................................................................. 75 RELPAX ..................................................................... 78 REMEVEN ............................................................. 55 RENAGEL ............................................................... 63 RENVELA ............................................................... 63 repaglinide ................................................................. 21 REPLESTA NX .............................................. 94 REPREXAIN ........................................................... 7 RESCRIPTOR .................................................. 37 reserpine ........................................................................ 27 REVLIMID ............................................................. 39 REYATAZ ............................................................... 37 RHINOCORT ALLERGY .......... 81 RHINOCORT AQUA ........................... 81 RIBAPAK ................................................................. 37 RIBASPHERE .................................................. 38
RIBASPHERE RIBAPAK ........... 38 RIBATAB .................................................................. 38 ribavirin .......................................................................... 38 RIDAURA ..................................................................... 4 rifabutin .......................................................................... 29 RIFAMATE ........................................................... 29 rifampin ........................................................................... 29 RIFATER .................................................................. 29 RILUTEK ................................................................. 81 riluzole .............................................................................. 81 rimantadine hcl ................................................... 38 risedronate sodium ........................................ 61 risperidone ................................................................. 35 rivastigmine .............................................................. 88 rivastigmine tartrate .................................... 88 rizatriptan benzoate ...................................... 78 ropinirole hcl .......................................................... 33 ropinirole hcl er ................................................. 33 ROSADAN ............................................................... 55 rosuvastatin calcium ................................... 25 ROXICET ..................................................................... 7 ROZEREM ............................................................. 67 SABRIL ........................................................................ 16 SAFESNAP INSULIN SYRINGE .................................................................. 75 SAFETY-GLIDE SYRINGE .... 75 SALACYN ................................................................ 55 salicylic acid ............................................................ 55 salicylic acid wart remover ............... 55 salicylic acid-cleanser .............................. 55 saline bacteriostatic ..................................... 86 saline-benzyl alcohol .................................. 86 salsalate .............................................................................. 5 SALVAX ..................................................................... 55 SAMSCA ..................................................................... 61 SANDIMMUNE ............................................. 39 SANDOSTATIN LAR DEPOT ....................................................................................................... 61 SANTYL ...................................................................... 56 SAPHRIS .................................................................... 35 sash kit .............................................................................. 15 SAVELLA ................................................................ 88 sb hydrocortisone ............................................. 56 sb insulin syringe .............................................. 75 scalacort ......................................................................... 56 schnucks insulin syringe ........................ 75 se bpo wash ............................................................... 56 SEB-PREV WASH .................................... 56 selegiline hcl ............................................................ 33 selenium sulfide ................................................... 56 selenium sulf-pyrithione-urea ....... 56 SELZENTRY ...................................................... 38 se-natal 19 ................................................................... 79 SENSIPAR ............................................................... 61 SEREVENT DISKUS ........................... 13
104
Index
Index
Index
SEROQUEL XR ............................................ 35 sertraline hcl ........................................................... 18 sf ................................................................................................. 79 sf 5000 plus ................................................................ 79 SHOPKO UNIFINE PENTIPS ....................................................................................................... 75 sildenafil citrate .................................................. 43 silphen cough .......................................................... 24 silver nitrate ............................................................. 56 simvastatin .................................................................. 25 sirolimus ........................................................................ 39 SKLICE ........................................................................ 56 sm aspirin ......................................................................... 5 sm hydrocortisone plus ............................ 56 sm hydrocortisone-aloe max st .... 56 sm insulin syringe ............................................ 75 sm loratadine .......................................................... 24 sm sleep aid maximum strength ....................................................................................................... 67 sodium chloride ........................... 49, 64, 79 sodium chloride bacteriostatic ..... 86 sodium chloride flush ................................. 79 SODIUM CHLORIDE THERMOJECT SYS ............................. 58 sodium fluoride .................................................... 79 sodium polystyrene sulfonate ........................................................................................... 40, 86 sodium sulfacetamide wash .............. 56 SOMATULINE DEPOT .................. 61 SOMAVERT ........................................................ 61 sorbitol ............................................................................. 64 sorbitol-mannitol .............................................. 64 SORIATANE ....................................................... 56 SORIATANE CK ......................................... 56 sotalol hcl ..................................................................... 41 sotalol hcl (af) ....................................................... 40 SPIRIVA HANDIHALER ............ 13 spironolactone ...................................................... 59 spironolactone-hctz ....................................... 59 SPRINTEC 28 .................................................... 47 SPRYCEL ................................................................. 31 SPS ............................................................................ 40, 86 SRONYX ..................................................................... 47 stannous fluoride .............................................. 79 stavudine ........................................................................ 38 STELARA ................................................................ 56 STIMATE ................................................................. 61 STIVARGA ............................................................ 31 STRATTERA ......................................................... 2 STRIBILD ................................................................ 38 STRIVERDI RESPIMAT .............. 13 SUBOXONE ..................................................... 7, 8 sucralfate ...................................................................... 91 sulfacetamide sodium ..................... 56, 84 sulfacetamide sodium (acne) .......... 56
sulfacetamide sodium-sulfur ........... 56 sulfacetamide-prednisolone ............. 84 sulfadiazine ................................................................ 89 sulfamethoxazole-trimethoprim ....................................................................................................... 28 sulfasalazine ............................................................ 63 sulindac ............................................................................... 4 sumatriptan ................................................................ 78 sumatriptan succinate ............................... 78 sumatriptan succinate refill .............. 78 SUPRAX ...................................................................... 44 SUPREP BOWEL PREP ................ 68 sure comfort insulin syringe ............ 75 sure comfort pen needles ...................... 75 SURE-FINE PEN NEEDLES ....................................................................................................... 75 SURE-JECT INSULIN SYRINGE .................................................................. 76 SUSTIVA .................................................................... 38 SUTENT ...................................................................... 31 SYLATRON .......................................................... 31 SYMAX DUOTAB ..................................... 91 SYMBICORT ..................................................... 13 SYMLINPEN 120 ........................................ 21 SYMLINPEN 60 ............................................ 21 SYNAGIS ................................................................... 85 SYNALAR ................................................................ 56 SYNALAR (CREAM) .......................... 56 SYNALAR (OINTMENT) ............ 56 SYNTHROID ...................................................... 90 SYPRINE ................................................................... 40 TABLOID ................................................................. 31 TACLONEX ......................................................... 56 TACLONEX SCALP ............................. 57 tacrolimus .................................................................... 40 TAMIFLU ................................................................. 38 tamoxifen citrate ................................................ 31 tamsulosin hcl ........................................................ 64 TANZEUM ............................................................. 21 TARCEVA ............................................................... 32 TARGRETIN ...................................................... 32 TARINA FE 1/20 .......................................... 47 TARKA ......................................................................... 27 TARON-PREX ................................................. 80 TASIGNA .................................................................. 32 TASMAR .................................................................... 33 TAZORAC .............................................................. 57 TAZTIA XT .......................................................... 42 TEGRETOL-XR ........................................... 16 TEKTURNA ......................................................... 27 TEKTURNA HCT ...................................... 27 telmisartan .................................................................. 27 telmisartan-hctz .................................................. 27 temazepam .................................................................. 67 terazosin hcl ............................................................. 27
terbinafine hcl ....................................................... 23 terbutaline sulfate ............................................ 13 terconazole ................................................................. 93 TERUMO INSULIN SYRINGE ....................................................................................................... 76 TERUMO SURGUARD INSULIN SYR ................................................... 76 testosterone .................................................................... 8 tetrabenazine ........................................................... 88 tetracaine hcl .......................................................... 84 tetracycline hcl ..................................................... 89 TEV-TROPIN .................................................... 61 tgq 15dm/5peh/2cpm ................................... 49 tgq 30pse/150gfn/15dm ........................... 49 tgt anti-itch/aloe max st .......................... 57 THALOMID ......................................................... 40 theophylline ............................................................... 13 theophylline er ...................................................... 13 THERA-D 4000 ............................................... 94 THINPRO INSULIN SYRINGE ....................................................................................................... 76 thiothixene ................................................................... 35 THYROGEN ........................................................ 58 THYROLAR-1 ................................................. 90 THYROLAR-1/2 ........................................... 90 THYROLAR-1/4 ........................................... 90 THYROLAR-2 ................................................. 90 THYROLAR-3 ................................................. 90 tiagabine hcl ............................................................ 16 ticlopidine hcl ........................................................ 65 timolol maleate ........................................ 41, 84 tinidazole ....................................................................... 28 TIVICAY .................................................................... 38 TIZANIDINE COMFORT PAC ....................................................................................................... 80 tizanidine hcl ........................................................... 80 tl gard rx ........................................................................ 66 tl hydroquinone ................................................... 57 tl icon .................................................................................. 67 TOBRADEX ......................................................... 84 TOBRADEX ST ............................................. 84 tobramycin .................................................................. 84 tobramycin-dexamethasone .............. 84 TOBREX .................................................................... 84 todays health mini pen needles .... 76 todays health pen needles .................... 76 todays health short pen needle ..... 76 tolazamide ................................................................... 21 tolbutamide ................................................................ 21 tolcapone ....................................................................... 33 tolmetin sodium ....................................................... 4 tolterodine tartrate ......................................... 92 tolterodine tartrate er ................................ 92 topcare clickfine pen needles ......... 76 topcare ultra comfort ins syr .......... 76 105
Index
Index
Index
topiramate ................................................................... 16 torsemide ....................................................................... 59 TOVIAZ ....................................................................... 92 TRADJENTA ..................................................... 21 tramadol hcl ................................................................. 8 tramadol hcl er ......................................................... 8 tramadol hcl er (biphasic) ...................... 8 tramadol-acetaminophen ......................... 8 trandolapril ............................................................... 27 trandolapril-verapamil hcl er ........ 27 tranylcypromine sulfate .......................... 18 TRAVATAN Z .................................................. 84 travoprost ..................................................................... 84 trazodone hcl ............................................... 18, 88 TRELSTAR ........................................................... 32 TRELSTAR MIXJECT .................... 32 tretinoin ............................................................... 32, 57 tretinoin (emollient) ...................................... 57 tretinoin microsphere ................................. 57 tretinoin microsphere pump ............. 57 TREXALL ................................................................ 32 triamcinolone acetonide ............................................................................... 57, 79, 81 triamterene-hctz ................................................. 59 TRIANEX ................................................................. 57 triazolam ........................................................................ 67 TRI-ESTARYLLA .................................... 47 trifluoperazine hcl ........................................... 35 trifluridine ................................................................... 84 TRIGLIDE .............................................................. 25 TRI-LINYAH ..................................................... 47 TRILIPIX .................................................................. 25 TRILYTE .................................................................. 68 trimethobenzamide hcl ............................. 23 trimethoprim ............................................................ 28 trimipramine maleate ................................. 18 TRINESSA (28) ............................................... 47 TRI-PREVIFEM ........................................... 47 TRI-SPRINTEC ............................................. 47 TRIUMEQ ............................................................... 38 tri-vit/fluoride ........................................................ 80 tri-vitamin/fluoride ........................................ 80 TRIVORA (28) ................................................. 47 TRIZIVIR ................................................................. 38 tropicamide ................................................................ 84 trospium chloride ............................................. 92 trospium chloride er ..................................... 92 TRUEPLUS INSULIN SYRINGE .................................................................. 76 TRUVADA .............................................................. 38 TUDORZA PRESSAIR ..................... 13 TYKERB .................................................................... 32 TYVASO ..................................................................... 43 TYVASO REFILL ..................................... 43 TYVASO STARTER ............................. 43
TYZEKA .................................................................... 38 ULTICARE INSULIN SAFETY SYR ...................................................................................... 76 ULTICARE INSULIN SYRINGE .................................................................. 76 ULTICARE MICRO PEN NEEDLES ................................................................. 76 ULTICARE MINI PEN NEEDLES ................................................................. 76 ULTICARE PEN NEEDLES ... 76 ULTICARE SHORT PEN NEEDLES ................................................................. 77 ULTILET INSULIN SYRINGE SHORT .......................................................................... 77 ULTILET PEN NEEDLE .............. 77 ultra comfort insulin syringe .......... 77 ultra-comfort insulin syringe .......... 77 ULTRA-THIN II INS SYR SHORT .......................................................................... 77 ULTRA-THIN II INSULIN SYRINGE .................................................................. 77 ULTRA-THIN II MINI PEN NEEDLE ..................................................................... 77 ULTRA-THIN II PEN NEEDLE SHORT .......................................................................... 77 UMECTA MOUSSE ............................... 57 UNIFINE PENTIPS ................................. 77 unifine pentips plus ........................................ 77 UNITHROID ....................................................... 90 URAMAXIN ......................................................... 57 urea ........................................................................................ 57 urea in zn undecyl-lactic acid ....... 57 urea nail ......................................................................... 57 urea nail film ........................................................... 57 URETRON D/S ................................................ 92 UROCIT-K 10 ................................................... 64 UROCIT-K 15 ................................................... 64 UROCIT-K 5 ....................................................... 65 ursodiol ............................................................................ 64 USTELL ....................................................................... 92 VAGIFEM ................................................................ 93 valacyclovir hcl ................................................... 38 VALCYTE ............................................................... 38 valproic acid ............................................................ 16 valsartan ........................................................................ 28 valsartan-hydrochlorothiazide ..... 28 VALSTAR ................................................................ 32 value health insulin syringe .............. 77 valumark pen needles ................................. 77 vancomycin hcl .................................................... 28 vancomycin hcl in dextrose ............... 28 VANISHPOINT INSULIN SYRINGE .................................................................. 77 VANTAS ..................................................................... 32 VASOLEX ................................................................ 57
VELIVET .................................................................. 47 VELTIN ........................................................................ 57 venlafaxine hcl ...................................................... 18 venlafaxine hcl er ............................................. 18 VENTAVIS ............................................................. 43 VENTOLIN HFA ......................................... 14 VERAMYST ......................................................... 81 verapamil hcl .......................................................... 42 verapamil hcl er ................................................. 42 VEREGEN ............................................................... 58 VESICARE ............................................................. 92 VEXOL .......................................................................... 84 VICODIN ....................................................................... 8 VICODIN ES ........................................................... 8 VICTOZA ................................................................. 22 VICTRELIS .......................................................... 38 VIDA MIA UNIFINE PENTIPS ....................................................................................................... 77 VIDEX ............................................................................. 38 VIGAMOX .............................................................. 84 VIIBRYD ........................................................ 18, 88 VIRACEPT ............................................................. 38 VIRAMUNE ......................................................... 38 VIRAMUNE XR ............................................ 39 VIREAD ....................................................................... 39 virtrate-k ........................................................................ 65 vitamin d ........................................................................ 94 vitamin d (cholecalciferol) ................. 94 vitamin d (ergocalciferol) .................... 94 vitamin d3 .................................................................... 94 VITAZOL ................................................................. 58 VIVELLE-DOT .............................................. 62 VIVITROL .............................................................. 22 VOLTAREN ......................................................... 58 VOTRIENT ............................................................ 32 vp insulin syringe ............................................. 77 V-R MONO INSULIN SYRINGE .................................................................. 77 VYTORIN ................................................................. 25 WAL-TAP CHILDRENS ............... 49 warfarin sodium ................................................. 15 wegmans unifine pentips plus ........ 77 WELCHOL ............................................................ 25 WERA ............................................................................. 47 WESTHROID .................................................... 90 WOUND WASH SALINE ............ 58 XALKORI ................................................................ 32 XARELTO ............................................................... 15 XELODA .................................................................... 32 XENAZINE ............................................................ 88 XOLAIR ...................................................................... 14 XOPENEX HFA ............................................ 14 XULANE ..................................................................... 47 X-VIATE ..................................................................... 58 XYREM ........................................................................ 88
106
Index
YUVAFEM ............................................................. 94 zafirlukast .................................................................... 14 zaleplon ........................................................................... 67 ZARXIO ...................................................................... 67 ZEMPLAR .............................................................. 61 ZENPEP ....................................................................... 58 ZETIA ............................................................................. 25 ZIAGEN ....................................................................... 39 zidovudine .................................................................... 39 zinc sulfate .................................................................. 79 ZIOPTAN .................................................................. 84 ziprasidone hcl ..................................................... 35 ZIRGAN ...................................................................... 84 ZITHROMAX ................................................... 68 ZOLADEX ............................................................... 32 zolmitriptan ............................................................... 78 zolpidem tartrate ............................................... 67 zolpidem tartrate er ...................................... 67 zonisamide .................................................................. 16 ZORTRESS ............................................................ 40 ZOSTAVAX .......................................................... 93 ZOVIA 1/35E (28) ....................................... 47 ZOVIRAX ................................................................. 58 ZYFLO ........................................................................... 14 ZYFLO CR ............................................................. 14 ZYMAXID ............................................................... 85 ZYTIGA ....................................................................... 32 ZYVOX ............................................................. 28, 29
107
