Western Health Advandage

PREFERRED DRUG LIST
3-TIER PRESCRIPTION DRUG PLAN

FOR LARGE GROUP PLANS AND
SMALL GROUP NON-ACA COMPLIANT PLANS
Note: The copayment for specialty medication is plan dependent and is

specified in your Copayment Summary. Most specialty medications require
a Prior Authorization and may be limited to a 30-day supply.

Western Health Advantage complies with applicable Federal civil rights laws and does not discriminate on the basis
of race, color, national origin, age, disability, or sex.
Western Health Advantage does not exclude people or treat them differently because of race, color, national origin,
age, disability, or sex.
Western Health Advantage:
Provides free aids and services to people with disabilities to communicate effectively with us, such as:
• Qualified sign language interpreters
• Written information in other formats (large print, audio, accessible electronic formats, other formats)
Provides free language services to people whose primary language is not English, such as:
• Qualified interpreters
• Information written in other languages
If you need these services, contact the Member Services Manager.
If you believe that Western Health Advantage has failed to provide these services or discriminated in another way on
the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Member Services
Manager, 2349 Gateway Oaks Drive, Suite 100, Sacramento, CA 95833, 888.563.2250 or 916.563.2250, 888.877.5378
(TTY), 916.568.0126 (fax), memberservices@westernhealth.com. You can file a grievance in person or by mail, fax, or
email. If you need help filing a grievance, the Member Services Manager is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil
Rights, electronically through the Office for Civil Rights Complaint Portal, available at:
Website: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf
Mail: U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
Phone: 800.368.1019 or 800.537.7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
ENGLISH
If you, or someone you’re helping, have questions about Western Health Advantage, you have the right to get help
and information in your language at no cost. To talk to an interpreter, call 888.563.2250 or TTY 888.877.5378.
SPANISH
Si usted, o alguien a quien usted está ayudando, tiene preguntas acerca de Western Health Advantage, tiene
derecho a obtener ayuda e información en su idioma sin costo alguno. Para hablar con un intérprete, llame al
888.563.2250, o al TTY 888.877.5378 si tiene dificultades auditivas.
CHINESE
如果您，或是您正在協助的對象，有關於Western Health Advantage方面的問題，您有權利免費以您的母語得到幫助和
訊息。洽詢一位翻譯員，請撥電話888.563.2250或聽障人士專線(TTY) 888.877.5378。
VIETNAMESE
Nếu quý vị, hay người mà quý vị đang giúp đỡ, có câu hỏi về Western Health Advantage, quý vị sẽ có quyền được
giúp và có thêm thông tin bằng ngôn ngữ của mình miễn phí. Để nói chuyện với một thông dịch viên, xin gọi số
888.563.2250, hoặc gọi đường dây TTY dành cho người khiếm thính tại số 888.877.5378.
TAGALOG
Kung ikaw, o ang iyong tinutulangan, ay may mga katanungan tungkol sa Western Health Advantage, may
karapatan ka na makakuha ng tulong at impormasyon sa iyong wika ng walang gastos. Upang makausap ang isang
tagasalin, tumawag sa 888.563.2250 o TTY para sa may kapansanan sa pandinig sa 888.877.5378.

KOREAN
만약 귀하 또는 귀하가 돕고 있는 어떤 사람이 Western Health Advantage에 관해서 질문이 있다면 귀하는 그러한 도움과
정보를 귀하의 언어로 비용 부담 없이 얻을 수 있는 권리가 있습니다. 그렇게 통역사와 얘기하기 위해서는
888.563.2250이나 청각 장애인용 TTY 888.877.5378로 연락하십시오.
ARMENIAN
Եթե Դուք կամ Ձեր կողմից օգնություն ստացող անձը հարցեր ունի Western Health Advantage-ի մասին, Դուք
իրավունք ունեք անվճար օգնություն և տեղեկություններ ստանալու Ձեր նախընտրած լեզվով։ Թարգմանչի հետ
խոսելու համար զանգահարե՛ք 888.563.2250 համարով կամ TTY 888.877.5378՝ լսողության հետ խնդիրներ
ունեցողների համար։
PERSIAN-FARSI
‫ )وﺳﺗرن ھﻠث اَدوﻧﺗﯾﺞ( داﺷﺗﮫ ﺑﺎﺷﯾد ﺣق اﯾن را دارﯾد ﮐﮫ ﮐﻣﮏ و‬Western Health Advantage ‫ ﺳوال در ﻣورد‬، ‫ ﯾﺎ ﮐﺳﯽ ﮐﮫ ﺷﻣﺎ ﺑﮫ او ﮐﻣﮏ ﻣﯾﮑﻧﯾد‬،‫اﮔر ﺷﻣﺎ‬
888.877.5378 ‫ اﻓراد ﻧﺎﺷﻧوا ﻣﯽ ﺗواﻧﻧد ﺑﮫ ﺷﻣﺎره‬.‫ ﺗﻣﺎس ﺑﮕﯾرﯾد‬888.563.2250 ‫ ﻟطﻔﺎ ﺑﺎ ﺷﻣﺎره ﺗﻠﻔن‬.‫اطﻼﻋﺎت ﺑﮫ زﺑﺎن ﺧود را ﺑﮫ طور راﯾﮕﺎن درﯾﺎﻓت ﻧﻣﺎﯾﯾد‬
.‫ﭘﯾﺎم ﺗﺎﯾﭘﯽ ارﺳﺎل ﮐﻧﻧد‬
RUSSIAN
Если у вас или лица, которому вы помогаете, имеются вопросы по поводу Western Health Advantage, то вы имеете
право на бесплатное получение помощи и информации на вашем языке. Для разговора с переводчиком позвоните по
телефону 888.563.2250 или воспользуйтесь линией TTY для лиц с нарушениями слуха по номеру 888.877.5378.
JAPANESE
ご本人様、またはお客様の身の回りの方でも、Western Health Advantageについてご質問がございましたら、ご希望
の言語でサポートを受けたり、情報を入手したりすることができます。料金はかかりません。通訳とお話される場
合、888.563.2250までお電話ください。聴覚障がい者用TTYをご利用の場合は、888.877.5378までお電話ください。
ARABIC
‫ ﻓﻠدﯾك اﻟﺣق ﻓﻲ اﻟﺣﺻول ﻋﻠﻰ اﻟﻣﺳﺎﻋدة واﻟﻣﻌﻠوﻣﺎت‬،Western Health Advantage ‫إن ﻛﺎن ﻟدﯾك أو ﻟدى ﺷﺧص ﺗﺳﺎﻋده أﺳﺋﻠﺔ ﺑﺧﺻوص‬
.888.877.5378 ‫( ﻟﺿﻌﺎف اﻟﺳﻣﻊ‬TTY ) ‫ أو ﺑرﻗم اﻟﮭﺎﺗف اﻟﻧﺻﻲ‬،888.563.2250 ‫ ﻟﻠﺗﺣدث ﻣﻊ ﻣﺗرﺟم اﺗﺻل ﺑـ‬.‫اﻟﺿرورﯾﺔ ﺑﻠﻐﺗك ﻣن دون اﯾﺔ ﺗﻛﻠﻔﺔ‬
PUNJABI
ਜੇਕਰ ਤੁਸ(, ਜ" ਿਜਸ ਿਕਸੇ ਦੀ ਤੁਸ+ ਮਦਦ ਕਰ ਰਹੇ ਹੋ, ਦੇ Western Health Advantage ਬਾਰੇ ਸਵਾਲ ਹਨ ਤ+, ਤੁਹਾਨੂੰ ਆਪਣੀ ਭਾਸ਼ਾ ਿਵੱ ਚ
ਮਦਦ ਅਤੇ ਜਾਣਕਾਰੀ ਹਾਸਲ ਕਰਨ ਦਾ ਅਿਧਕਾਰ ਹੈ। ਦੁਭਾਸੀਏ ਨਾਲ ਗੱ ਲ ਕਰਨ ਲਈ, 888.563.2250 ‘ਤੇ ਜ$ ਪੂਰੀ ਤਰ)$ ਸੁਣਨ ਿਵੱ ਚ ਅਸਮਰਥ
ਟੀਟੀਵਾਈ ਲਈ 888.877.5378 ‘ਤੇ ਕਾਲ ਕਰੋ।
CAMBODIAN-MON-KHMER
!បសិនេបើអ)ក ឬនរ./0ក់ែដលកំពុងជួយអ)ក /នសំណ=រអំពី Western Health Advantage េទ, អ"ក$នសិទ)ិទទួលជំនួយនឹងព័ត៌$ន
េ"ក$%ង'(របស់អ$ក េ"យមិនអស់*+ក់។ េដើម%&ីនិ*យ,មួយអ/កបកែ3ប សូមទូរស័ព( 888.563.2250 ឬ TTY ស"#ប់អ"ក$តេចៀកធ*ន់ !មេលខ
888.877.5378។
HMONG
Yog koj, los yog tej tus neeg uas koj pab ntawd, muaj lus nug txog Western Health Advantage, koj muaj cai kom
lawv muab cov ntshiab lus qhia uas tau muab sau ua koj hom lus pub dawb rau koj. Yog koj xav nrog ib tug neeg
txhais lus tham, hu rau 888.563.2250 los sis TTY rau cov neeg uas tsis hnov lus zoo nyob ntawm 888.877.5378.
HINDI
य"द आप, या िजस &कसी क) आप मदद कर रहे हो, के Western Health Advantage के बारे म' ()न ह, तो, आपको अपनी भाषा
म" मदद तथा जानकार+ ,ा-त करने का अ0धकार है । दभ
ु ा7शए के साथ बात करने के 7लए, 888.563.2250 पर या परू & तरह
!वण म% असमथ) ट+ट+वाई के 0लए 888.877.5378 पर कॉल करो।
THAI
หากคุ ณ หรื อคนที) คุ ณกํ าลั งช่ วยเหลื อมี คํ าถามเกี' ยวกั บ Western Health Advantage
คุ ณมี สิ ทธิ ที'จะได้ รั บความช่ วยเหลื อและข้ อมู ลในภาษาของคุ ณได้ โดยไม่ มี ค่ าใช้ จ่ าย เพื# อพู ดคุ ยกั บล่ าม โทร 888.563.2250 หรื อใช้ TTY
สํ าหรั บคนหู หนวกโดยโทร 888.877.5378
Western Health Advantage Preferred Drug List
5-Alpha-Reductase Inhibitors / UROLOGICALS
Tier Generic Name Brand Name Notes
1 FINASTERIDE
2 DUTASTERIDE AVODART
3 DUTASTERIDE/TAMSULOSIN HCL JALYN
3 FINASTERIDE PROSCAR
5-HT2C Receptor Antagonist / AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH
3 LORCASERIN BELVIQ 5
5-HT3 Receptor Antagonists / ANTIEMETICS

1 GRANISETRON HCL
1 ONDANSETRON ONDANSETRON ODT
3 DOLASETRON ANZEMET
3 GRANISETRON SANCUSO
3 ONDANSETRON ZOFRAN ODT
4 GRANISETRON EXTENDED-RELEASE INJECTION SUSTOL 4
5-HT3 Receptor Antagonists / GASTROINTESTINAL OTHER

3 NETUPITANT/PALONOSETRON AKYNZEO 5
ADHD Amphetamines / CNS AGENTS

1 AMPHET ASP/AMPHET/D-AMPHET DEXTROAMPHETAMINE-AMPHETAMINE
1 AMPHET ASP/AMPHET/D-AMPHET AMPHETAMINE SALT COMBO
1 DEXTROAMPHETAMINE SULFATE
1 METHAMPHETAMINE HCL
3 AMPHET ASP/AMPHET/D-AMPHET ADDERALL
3 AMPHET ASP/AMPHET/D-AMPHET ADDERALL XR
3 DEXTROAMPHETAMINE SULFATE DEXEDRINE
ADHD Non-Amphetamine / CNS AGENTS

2 ATOMOXETINE HCL STRATTERA
3 CLONIDINE KAPVAY
3 GUANFACINE HCL INTUNIV
AMPA Receptor Antagonist / ANTICONVULSANTS

2 PERAMPANEL FYCOMPA
ANTILEISHMAIAL / ANTIPARASITICS
2 MILTEFOSINE CAPSULES IMPAVIDO
4 - Office/Clinic Administration
5 - Prior Authorization
4 of 104
Acidifying Agents / UROLOGICALS
3 POTASSIUM PHOSPHATE,MONOBASIC K-PHOS ORIGINAL
Adrenals / ENDOCRINE/DIABETES
1 CORTISONE ACETATE
1 DEXAMETHASONE
1 FLUDROCORTISONE ACETATE
1 METHYLPREDNISOLONE
1 PREDNISOLONE
1 PREDNISOLONE MILLIPRED
2 PREDNISOLONE SOD PHOSPHATE ORAPRED ODT
3 HYDROCORTISONE CORTEF
3 METHYLPREDNISOLONE MEDROL
3 PREDNISOLONE ACETATE FLO-PRED
Adrenals / GI AGENTS
1 BUDESONIDE BUDESONIDE EC
3 BUDESONIDE ENTOCORT EC
Adrenals / HORMONE: GLUCOCORTICOIDS/MINERALOCORTICOIDS

1 BETAMETHASONE DIPROPIONATE
1 BETAMETHASONE VALERATE BETA-VAL
1 BETAMETHASONE VALERATE
1 CLOTRIMAZOLE/BETAMETHASONE DIP CLOTRIMAZOLE-BETAMETHASONE
1 DEXAMETHASONE
1 HYDROCORTISONE VALERATE
1 PREDNISONE
2 DEXAMETHASONE DEXAMETHASONE INTENSOL
3 BENZOYL PEROXIDE/HYDROCORTISON VANOXIDE-HC
3 BETAMETHASONE VALERATE LUXIQ
3 CALCIPOTRIENE/BETAMETHASONE TACLONEX
3 DEXAMETHASONE MAXIDEX
3 HYDROCORTISONE BUTYRATE LOCOID
3 HYDROCORTISONE BUTYRATE/EMOLL LOCOID LIPOCREAM
3 HYDROCORTISONE/PRAMOXINE PRAMOSONE
3 HYDROCORTISONE/PRAMOXINE EPIFOAM
3 HYDROCORTISONE/PRAMOXINE/ALOE NOVACORT
Adrenocortical Insufficiency / ENDOCRINE/DIABETES

4 CORTICOTROPIN H.P. ACTHAR 5
Alcohol Deterrents / ANTI-ADDICTION/SUBSTANCE ABUSE

1 DISULFIRAM
3 ACAMPROSATE CALCIUM CAMPRAL
3 DISULFIRAM ANTABUSE
5 of 104
Alcohol Deterrents / ANTI-ADDICTION/SUBSTANCE ABUSE (cont.)
4 NALTREXONE HCL VIVITROL 5
Alkalinizing Agents / UROLOGICALS

1 CITRIC ACID/SODIUM CITRATE SODIUM CITRATE & CITRIC ACID
1 CITRIC ACID/SODIUM CITRATE CYTRA-2
1 POTASSIUM CITRATE
1 POTASSIUM CITRATE/CITRIC ACID CYTRA-K
1 POTASSIUM CITRATE/CITRIC ACID POTASSIUM CITRATE-CITRIC ACID
3 POTASSIUM CITRATE UROCIT-K
Alkylating Agent / ANTINEOPLASTICS

1 BUSULFAN
1 CARMUSTINE
1 CHLORAMBUCIL
1 CYCLOPHOSPHAMIDE
1 MECHLORETHAMINE
1 MELPHALAN
1 PROCARBAZINE
1 THIOTEPA
2 LOMUSTINE CEENU
3 MECHLORETHAMINE VALCHLOR 5
4 BENDAMUSTINE TREANDA 4
4 CISPLATIN 4
Allergen / IMMUNOLOGICAL AGENTS

3 GRASS POLLEN GRASTEK
3 GRASS POLLEN ORALAIR
3 RAGWEEK POLLEN RAGWITEK
Allylamines / ANTIFUNGALS
1 TERBINAFINE HCL
3 TERBINAFINE HCL LAMISIL
Alpha- And Beta-Adrenergic Agonists / CARDIOVASCULAR

3 DROXIDOPA NORTHERA 5
Alpha- And Beta-Adrenergic Agonists / RESPIRATORY AGENTS

3 EPINEPHRINE TWINJECT
Alpha-Adrenergic Agonists / CARDIOVASCULAR

1 CLONIDINE
6 of 104
Alpha-Adrenergic Agonists / CARDIOVASCULAR (cont.)
1 DIHYDROERGOTAMINE MESYLATE
2 EPINEPHRINE EPIPEN
2 EPINEPHRINE EPIPEN 2-PAK
2 EPINEPHRINE EPIPEN JR
2 EPINEPHRINE EPIPEN JR 2-PAK
3 CLONIDINE HCL KAPVAY
3 CLONIDINE HCL NEXICLON XR
Alpha-Adrenergic Agonists / DERMATOLOGICAL AGENTS

3 BRIMONIDINE TOPICAL MIRVASO
3 OXYMETAZOLINE HCL 1% CREAM RHOFADE 5
Alpha-Adrenergic Agonists (Eent) / OPHTHALMOLOGY

1 BRIMONIDINE TARTRATE
2 BRIMONIDINE TARTRATE ALPHAGAN P
3 BRIMONIDINE TARTRATE/TIMOLOL COMBIGAN
Alpha-Adrenergic Blocking Agents / ANTIMIGRAINE

1 ERGOTAMINE TARTRATE/CAFFEINE MIGERGOT
3 DIHYDROERGOTAMINE MESYLATE MIGRANAL
Alpha-Adrenergic Blocking Agents / CARDIOVASCULAR

1 ALFUZOSIN HCL
1 DOXAZOSIN MESYLATE
1 PRAZOSIN HCL
1 TAMSULOSIN HCL
1 TERAZOSIN HCL
2 DOXAZOSIN MESYLATE CARDURA XL
3 ALFUZOSIN HCL UROXATRAL
3 PRAZOSIN HCL MINIPRESS
3 SILODOSIN RAPAFLO
3 TAMSULOSIN HCL FLOMAX
Alpha-Glucosidase Inhibitors / BLOOD GLUCOSE REGULATORS

1 ACARBOSE
3 MIGLITOL GLYSET
Amebicides / ANTI - INFECTIVES

1 PAROMOMYCIN SULFATE
1 TINIDAZOLE
Aminoglycosides / ANTIBACTERIALS
1 NEOMYCIN SULFATE
7 of 104
Aminoglycosides / ANTIBACTERIALS (cont.)
3 TOBRAMYCIN IN 0.225% NACL TOBI 5
4 AMIKACIN 4
4 GENTAMICIN 4
4 KANAMYCIN 4
4 NETILMICIN NETROMYCIN 4
4 TOBRAMYCIN 4
Aminoglycosides / ANTIMYCOBACTERIALS - OTHER

4 CAPREOMYCIN CAPASTAT 4
Aminosalicylates / INFLAMMATORY BOWEL AGENTS

2 MESALAMINE ASACOL HD
2 MESALAMINE ASACOL
2 MESALAMINE PENTASA
3 MESALAMINE W/CLEANSING WIPES ROWASA
Ammonia Detoxicants / GI AGENTS

1 LACTULOSE
1 LACTULOSE ENULOSE
1 LACTULOSE GENERLAC
2 LACTULOSE KRISTALOSE
Amphetamines / AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH

3 LISDEXAMFETAMINE DIMESYLATE VYVANSE
Amylinomimetics / BLOOD GLUCOSE REGULATORS

4 PRAMLINTIDE ACETATE SYMLINPEN 120 5
4 PRAMLINTIDE ACETATE SYMLINPEN 60 5
Analgesics And Antipyretics- Misc. / ANTIMIGRAINE

1 ISOMETHEPT/ACETAMINOP/DICHLPHN EPIDRIN
1 ISOMETHEPT/ACETAMINOP/DICHLPHN ISOMETHEPT-DICHLORALP-ACETAMIN
Analgesics And Antipyretics- Misc. / AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH
1 BUTALB/ACETAMINOPHEN/CAFFEINE ZEBUTAL
1 BUTALB/ACETAMINOPHEN/CAFFEINE BUTALBITAL-ACETAMINOPHEN-CAFFE
3 BUTALB/ACETAMINOPHEN/CAFFEINE FIORICET
3 BUTALBITAL/ACETAMINOPHEN PHRENILIN FORTE
8 of 104
Androgens / ENDOCRINE/DIABETES
1 DANAZOL
Androgens / HORMONE: PITUITARY

2 TESTOSTERONE ANDROGEL
3 TESTOSTERONE
3 TESTOSTERONE ANDRODERM
3 TESTOSTERONE NASAL GEL NATESTO
4 TESTOSTERONE CYPIONATE DEPO-TESTOSTERONE 5
Angiotensin Ii Receptor Antagonists / CARDIOVASCULAR

1 CANDESARTAN 7
1 CANDESARTAN/HYDROCHLOROTHIAZID CANDESARTAN-HYDROCHLOROTHIAZID 7
1 IRBESARTAN
1 IRBESARTAN/HYDROCHLOROTHIAZIDE IRBESARTAN-HYDROCHLOROTHIAZIDE
1 LOSARTAN POTASSIUM
1 LOSARTAN/HYDROCHLOROTHIAZIDE LOSARTAN-HYDROCHLOROTHIAZIDE
1 TELMISARTAN/AMLODIPINE 7
1 VALSARTAN
1 VALSARTAN/HYDROCHLOROTHIAZIDE VALSARTAN-HYDROCHLOROTHIAZIDE
2 CANDESARTAN CILEXETIL ATACAND 7
2 CANDESARTAN/HYDROCHLOROTHIAZID ATACAND HCT 7
2 OLMESARTAN MEDOXOMIL BENICAR 7
2 OLMESARTAN/HYDROCHLOROTHIAZIDE BENICAR HCT 7
2 TELMISARTAN MICARDIS 7
2 TELMISARTAN/HYDROCHLOROTHIAZID MICARDIS HCT 7
3 AZILSARTAN MED/CHLORTHALIDONE EDARBYCLOR 7
3 AZILSARTAN MEDOXOMIL EDARBI 7
3 IRBESARTAN AVAPRO
3 IRBESARTAN/HYDROCHLOROTHIAZIDE AVALIDE
3 LOSARTAN POTASSIUM COZAAR
3 OLMESARTAN MED/AMLODIPINE/HCTZ TRIBENZOR 7
3 TELMISARTAN/AMLODIPINE TWYNSTA 7
3 VALSARTAN DIOVAN
3 VALSARTAN/HYDROCHLOROTHIAZIDE DIOVAN HCTZ
Angiotensin-Converting Enzyme Inhibitors / CARDIOVASCULAR

1 BENAZEPRIL HCL
1 BENAZEPRIL/HYDROCHLOROTHIAZIDE BENAZEPRIL-HYDROCHLOROTHIAZIDE
1 CAPTOPRIL
1 CAPTOPRIL/HYDROCHLOROTHIAZIDE CAPTOPRIL-HYDROCHLOROTHIAZIDE
1 ENALAPRIL MALEATE
1 ENALAPRIL/HYDROCHLOROTHIAZIDE ENALAPRIL-HYDROCHLOROTHIAZIDE
1 FOSINOPRIL SODIUM
1 FOSINOPRIL/HYDROCHLOROTHIAZIDE FOSINOPRIL-HYDROCHLOROTHIAZIDE
1 LISINOPRIL
1 LISINOPRIL/HYDROCHLOROTHIAZIDE LISINOPRIL-HYDROCHLOROTHIAZIDE
7 - Step Therapy
9 of 104
Angiotensin-Converting Enzyme Inhibitors / CARDIOVASCULAR (cont.)
1 PERINDOPRIL ERBUMINE
1 QUINAPRIL HCL
1 RAMIPRIL
3 ENALAPRIL MALEATE VASOTEC
3 LISINOPRIL ZESTRIL
3 QUINAPRIL HCL ACCUPRIL
3 QUINAPRIL/HYDROCHLOROTHIAZIDE ACCURETIC
3 RAMIPRIL ALTACE
3 TRANDOLAPRIL/VERAPAMIL HCL TARKA
Anorex.-Respir.-Cerebral Stimulants-Misc / AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH

1 METHYLPHENIDATE HCL METHYLPHENIDATE ER
1 METHYLPHENIDATE HCL METADATE ER
1 METHYLPHENIDATE HCL
1 METHYLPHENIDATE HCL METHYLPHENIDATE SR
1 MODAFINIL
2 METHYLPHENIDATE HCL RITALIN CAPSULE 10, 60 MG
3 ARMODAFINIL NUVIGIL
3 DEXMETHYLPHENIDATE HCL FOCALIN XR
3 DEXMETHYLPHENIDATE HCL FOCALIN
3 METHYLPHENIDATE DAYTRANA
3 METHYLPHENIDATE HCL CONCERTA
3 METHYLPHENIDATE HCL METHYLIN ER
3 METHYLPHENIDATE HCL METADATE CD
3 METHYLPHENIDATE HCL RITALIN
3 METHYLPHENIDATE HCL RITALIN LA CAPSULES 20, 30, 40 MG
3 METHYLPHENIDATE HCL METHYLIN
3 MODAFINIL PROVIGIL
Anthelmintics / ANTIPARASITICS
1 MEBENDAZOLE
2 IVERMECTIN STROMECTOL
3 ALBENDAZOLE ALBENZA
3 PRAZIQUANTEL BILTRICIDE
Anti HIV Other / ANTIVIRALS

2 COBICISTAT TYBOST
2 ELVITEGRAVIR/COBIC/EMT/TENOFOVIR STRIBILD
Anti-Cytomegalovirus / ANTIVIRALS
3 GANCICLOVIR ZIRGAN
3 VALGANCICLOVIR VALCYTE
4 CIDOFOVIR 4
Anti-HIV Other / ANTIVIRALS

2 DOLUTEGRAVIR TIVICAY
10 of 104
Anti-HIV Other / ANTIVIRALS (cont.)
2 ELVITEGRAVIR/COBICISTAT/EMTRICITABINE/TEN GENVOYA
OFOVIR ALAFENAMIDE
2 RALTEGRAVIR POTASSIUM ISENTRESS
2 RITONAVIR NORVIR
4 ENFUVIRTIDE FUZEON 5
Anti-Inflammatory Agents (Gi Drugs) / GI AGENTS

1 BALSALAZIDE DISODIUM
1 MESALAMINE
2 MESALAMINE CANASA
2 MESALAMINE LIALDA
3 MESALAMINE APRISO
Anti-Inflammatory Agents (Skin & Mucous) / DERMATOLOGICAL AGENTS

1 ALCLOMETASONE DIPROPIONATE
1 CLOBETASOL PROPIONATE CORMAX
1 CLOBETASOL PROPIONATE
1 CLOBETASOL PROPIONATE/EMOLL CLOBETASOL EMOLLIENT
1 DESONIDE
1 DESOXIMETASONE
1 FLUOCINOLONE ACETONIDE
1 FLUOCINONIDE/EMOLLIENT FLUOCINONIDE EMOLLIENT
1 FLUOCINONIDE/EMOLLIENT FLUOCINONIDE-E
1 HALOBETASOL PROPIONATE CREAM AND HALOBETASOL PROPIONATE
OINTMENT
1 MOMETASONE FUROATE
1 PREDNICARBATE
1 TRIAMCINOLONE ACETONIDE
2 DESONIDE DESONATE
2 DESONIDE VERDESO
2 FLURANDRENOLIDE CORDRAN
2 FLUTICASONE PROPIONATE CUTIVATE
3 CLOBETASOL PROPIONATE OLUX
3 CLOBETASOL PROPIONATE CLOBEX
3 CLOBETASOL PROPIONATE/EMOLL OLUX-E
3 CLOCORTOLONE PIVALATE CLODERM
3 DESOXIMETASONE TOPICORT
3 FLUOCINOLONE ACETONIDE CAPEX SHAMPOO
3 FLUOCINOLONE ACETONIDE DERMA-SMOOTHE-FS
3 FLUOCINONIDE VANOS
3 FLURANDRENOLIDE CORDRAN SP
3 HALCINONIDE HALOG
3 HALOBETASOL PROPIONATE CREAM AND ULTRAVATE
OINTMENT
3 HALOBETASOL PROPIONATE LOTION ULTRAVATE 5
3 MOMETASONE FUROATE ELOCON
3 TRIAMCINOLONE ACETONIDE KENALOG
Anti-Inflammatory Agents (Skin & Mucous) / GI AGENTS

1 HYDROCORTISONE COLOCORT
11 of 104
Anti-Inflammatory Agents (Skin & Mucous) / GI AGENTS (cont.)
1 HYDROCORTISONE
1 HYDROCORTISONE PROCTOZONE-HC
1 HYDROCORTISONE PROCTOSOL-HC
1 HYDROCORTISONE PROCTOCORT
1 HYDROCORTISONE ACETATE
1 HYDROCORTISONE ACETATE HEMRIL
1 HYDROCORTISONE ACETATE SUPPOSITORIES ANUCORT-HC 5
1 HYDROCORTISONE/PRAMOXINE HYDROCORTISONE-PRAMOXINE
2 HYDROCORTISONE ACETATE CORTIFOAM
2 HYDROCORTISONE/PRAMOXINE PROCTOFOAM-HC
3 HYDROCORTISONE ACETATE SUPPOSITORIES ANUSOL-HC 5
3 HYDROCORTISONE/PRAMOXINE ANALPRAM HC
Anti-Influenza / ANTIVIRALS
1 AMANTADINE HCL AMANTADINE
2 OSELTAMIVIR PHOSPHATE TAMIFLU 6
3 ZANAMIVIR RELENZA
4 INFLUENZA VACCINE FLUZONE 4
Antiallergic Agents / NASAL STEROID

1 OLOPATADINE HCL OLOPATADINE NASAL
3 OLOPATADINE HCL PATANASE
Antiallergic Agents / OPHTHALMOLOGY

1 AZELASTINE HCL
1 EPINASTINE HCL
2 LODOXAMIDE TROMETHAMINE ALOMIDE
3 ALCAFTADINE LASTACAFT
3 AZELASTINE HCL OPTIVAR
3 BEPOTASTINE BESILATE BEPREVE
3 EPINASTINE HCL ELESTAT
3 OLOPATADINE HCL PATADAY
3 OLOPATADINE HCL PATANOL
3 PEMIROLAST POTASSIUM ALAMAST
Antiallergic Agents / RESPIRATORY AGENTS

1 AZELASTINE
1 AZELASTINE HCL
3 AZELASTINE HCL ASTELIN
3 AZELASTINE HCL ASTEPRO
3 AZELASTINE/FLUTICASONE DYMISTA
Antiandrogen / ANTINEOPLASTICS
3 ENZALUTAMIDE XTANDI 5
6 - Quantity Limit
12 of 104
Antiangiogenic Agent / ANTINEOPLASTICS
3 PAZOPANIB VOTRIENT 5
3 SORAFENIB NEXAVAR 5
3 SUNITINIB MALATE SUTENT
4 BEVACIZUMAB AVASTIN 4
Antiarrhythmics / CARDIOVASCULAR
1 AMIODARONE HCL
1 DIGOXIN
1 FLECAINIDE ACETATE
1 MEXILETINE HCL
1 PROPAFENONE HCL
1 QUINIDINE GLUCONATE
1 QUINIDINE SULFATE
2 AMIODARONE HCL PACERONE
2 DISOPYRAMIDE PHOSPHATE NORPACE CR
3 DIGOXIN LANOXIN
3 DOFETILIDE TIKOSYN
3 DRONEDARONE HCL MULTAQ
3 PROPAFENONE HCL RYTHMOL SR
4 ADENOSINE ADENOCARD 4
Antibacterials (Eent) / ANTIBACTERIALS

1 NEOMYCIN/POLYMYXIN B SULF/HC NEOMYCIN-POLYMYXIN-HC
1 NEOMYCIN/POLYMYXIN B SULF/HC NEOMYCIN-POLYMYXIN-HYDROCORT
3 CIPROFLOXACIN HCL/DEXAMETH CIPRODEX
3 CIPROFLOXACIN/FLUOCINOLONE ACETONIDE OTOVEL
3 CIPROFLOXACIN/HYDROCORTISONE CIPRO HC
3 NEOMY SULF/COLIST SUL/HC/THONZ COLY-MYCIN S
3 NEOMY SULF/COLIST SUL/HC/THONZ CORTISPORIN-TC
Antibacterials (Eent) / DENTAL AGENT

3 MINOCYCLINE HCL MICROSPHERES ARESTIN 4
Antibacterials (Eent) / OPHTHALMOLOGY

1 BACITRACIN
1 BACITRACIN/POLYMYXIN B SULFATE AK-POLY-BAC
1 CIPROFLOXACIN HCL
1 GENTAMICIN SULFATE
1 GENTAMICIN SULFATE GENTAK
1 LEVOFLOXACIN
1 NEO/POLYMYX B SULF/DEXAMETH NEOMYCIN-POLYMYXIN-DEXAMETH
1 NEOMY SULF/BACITRA/POLYMYXIN B NEO-POLYCIN
1 NEOMY SULF/BACITRA/POLYMYXIN B NEOMYCIN-BACITRACIN-POLYMYXIN
1 NEOMY SULF/BACITRAC ZN/POLY/HC NEO-POLYCIN HC
13 of 104
Antibacterials (Eent) / OPHTHALMOLOGY (cont.)
1 NEOMY SULF/BACITRAC ZN/POLY/HC NEOMYCIN-BACITRACIN-POLY-HC
1 NEOMYCIN/POLYMYXN B/GRAMICIDIN NEOMYCIN-POLYMYXIN-GRAMICIDIN
1 OFLOXACIN
1 POLYMYXIN B SULF/TRIMETHOPRIM POLYMYXIN B SUL-TRIMETHOPRIM
1 SULFACETAMIDE SODIUM SULFAMIDE
1 SULFACETAMIDE SODIUM
1 SULFACETAMIDE/PREDNISOLONE SP SULFACETAMIDE-PREDNISOLONE
1 TOBRAMYCIN
1 TOBRAMYCIN/DEXAMETHASONE TOBRAMYCIN-DEXAMETHASONE
2 SULFACETAMIDE SODIUM BLEPH-10
2 TOBRAMYCIN TOBREX
2 TOBRAMYCIN/DEXAMETHASONE TOBRADEX ST
2 TOBRAMYCIN/DEXAMETHASONE TOBRADEX OPTHALMIC OINTMENT
3 AZITHROMYCIN AZASITE
3 BESIFLOXACIN HCL BESIVANCE
3 CIPROFLOXACIN HCL CILOXAN
3 GATIFLOXACIN ZYMAXID
3 GATIFLOXACIN ZYMAR
3 MOXIFLOXACIN HCL VIGAMOX
3 MOXIFLOXACIN HCL MOXEZA
3 NEO/POLYMYX B SULF/DEXAMETH MAXITROL
3 POLYMYXIN B SULF/TRIMETHOPRIM POLYTRIM
3 SULFACETM NA/PREDNISOL AC BLEPHAMIDE S.O.P.
3 SULFACETM NA/PREDNISOL AC BLEPHAMIDE
3 TOBRAMYCIN/DEXAMETHASONE TOBRADEX
3 TOBRAMYCIN/LOTEPRED ETAB ZYLET
Antibacterials (Eent) / RESPIRATORY AGENTS

2 MUPIROCIN CALCIUM BACTROBAN NASAL
Antibacterials (Skin & Mucous Membrane) / DERMATOLOGICAL AGENTS

1 CLINDAMYCIN PHOS/BENZOYL PEROX CLINDAMYCIN PHOS-BENZOYL PEROX
1 CLINDAMYCIN PHOS/BENZOYL PEROX CLINDAMYCIN-BENZOYL PEROXIDE
1 CLINDAMYCIN PHOSPHATE
1 ERYTHROMYCIN BASE/ETHANOL ERY
1 ERYTHROMYCIN/BENZOYL PEROXIDE ERYTHROMYCIN-BENZOYL PEROXIDE
1 MUPIROCIN
2 CLINDAMYCIN PHOS/BENZOYL PEROX ACANYA
2 ERYTHROMYCIN/BENZOYL PEROXIDE BENZAMYCINPAK
2 METRONIDAZOLE METROGEL
2 METRONIDAZOLE NORITATE
3 CLINDAMYCIN PHOS/BENZOYL PEROX DUAC
3 CLINDAMYCIN PHOS/BENZOYL PEROX BENZACLIN
3 CLINDAMYCIN PHOSPHATE CLINDAGEL
3 CLINDAMYCIN/TRETINOIN ZIANA 5
3 CLINDAMYCIN/TRETINOIN VELTIN 5
3 ERYTHROMYCIN BASE AKNE-MYCIN
3 METRONIDAZOLE METROLOTION
3 MUPIROCIN BACTROBAN
3 RETAPAMULIN ALTABAX
14 of 104
Antibacterials (Skin & Mucous Membrane) / DIAGNOSTICS & MISCELLANEOUS AGENTS
3 NEOMY SULF/POLYMYXIN B SULFATE NEOSPORIN G.U. IRRIGANT
Antibacterials (Skin & Mucous Membrane) / OBSTETRICS & GYNECOLOGY

1 CLINDAMYCIN PHOSPHATE
1 METRONIDAZOLE VANDAZOLE
2 CLINDAMYCIN PHOSPHATE CLEOCIN
3 METRONIDAZOLE METROGEL-VAGINAL
Antibacterials- Miscellaneous / ANTI - INFECTIVES

1 CLINDAMYCIN HCL
1 CLINDAMYCIN PALMITATE HCL
1 CLINDAMYCIN PALMITATE HCL CLEOCIN PALMITATE
1 VANCOMYCIN HCL
3 CLINDAMYCIN HCL CLEOCIN HCL
3 LINEZOLID ZYVOX 5
3 RIFAXIMIN XIFAXAN 5
3 VANCOMYCIN HCL VANCOCIN HCL
Antibacterials- Miscellaneous / GI AGENTS

3 BISMUTH SAL/METRONID/TETRACYC HELIDAC
3 BISMUTH/METRONID/TETRACYCLINE PYLERA
Antibacterials- Miscellaneous / OFFICE ADMINISTERED

4 BEZLOTOXUMAB INJECTION ZINPLAVA 4
Anticholinergics / ANTIPARKINSON AGENTS

1 BENZTROPINE MESYLATE
1 TRIHEXYPHENIDYL HCL
3 TRIHEXYPHENIDYL HCL ARTANE
Anticoagulants / BLOOD PRODUCT/MODIFIERS

1 WARFARIN SODIUM
2 DABIGATRAN ETEXILATE MESYLATE PRADAXA
3 WARFARIN SODIUM COUMADIN
4 DALTEPARIN SODIUM,PORCINE FRAGMIN 5
4 DARBEPOETIN ALFA ARANESP 5
4 ENOXAPARIN SODIUM LOVENOX 5
4 ENOXAPARIN SODIUM 5
4 FONDAPARINUX SODIUM 5
Anticonvulsants- Miscellaneous / ANTICONVULSANTS

1 FELBAMATE
15 of 104
Anticonvulsants- Miscellaneous / ANTICONVULSANTS (cont.)
1 LEVETIRACETAM
2 TIAGABINE HCL GABITRIL
3 BRIVARACETAM ORAL SOLUTION BRIVIACT
3 BRIVARACETAM TABLETS BRIVIACT
4 BRIVARACETAM FOR INJECTION BRIVIACT 4
Anticonvulsants- Other / ANTICONVULSANTS

1 CARBAMAZEPINE EPITOL
2 EZOGABINE POTIGA
2 METHSUXIMIDE CELONTIN
3 CARBAMAZEPINE EQUETRO
3 LACOSAMIDE VIMPAT
Antidepressants / AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH

1 DESVENLAFAXINE SUCCINATE
1 MIRTAZAPINE
1 NEFAZODONE HCL
1 OLANZAPINE/FLUOXETINE HCL OLANZAPINE-FLUOXETINE HCL
3 DESVENLAFAXINE SUCCINATE PRISTIQ ER
3 DOXEPIN HCL SILENOR
3 MIRTAZAPINE REMERON
3 OLANZAPINE/FLUOXETINE HCL SYMBYAX
3 VILAZODONE HYDROCHLORIDE VIIBRYD
Antidiarrhea Agents / GI AGENTS

1 DIPHENOXYLATE HCL/ATROPINE DIPHENOXYLATE-ATROPINE
1 LOPERAMIDE HCL LOPERAMIDE
3 CROFELEMER FULYZAQ 5
3 DIPHENOXYLATE HCL/ATROPINE LOMOTIL
3 OPIUM TINCTURE OPIUM
Antidotes / IMMUNOLOGICAL AGENTS

2 LEUCOVORIN CALCIUM
Antiemetics- Miscellaneous / GI AGENTS

3 SCOPOLAMINE TRANSDERM-SCOP
3 SCOPOLAMINE HYDROBROMIDE SCOPACE
Antiemetics- Miscellaneous / OBSTETRICS & GYNECOLOGY

3 DOXYLAMINE/PYRIDOXINE DICLEGIS
16 of 104
Antiestrogen / ANTINEOPLASTICS
1 TAMOXIFEN CITRATE
Antifungal Antibiotics / ANTIFUNGALS

1 FLUCYTOSINE
1 GRISEOFULVIN ULTRAMICROSIZE
1 GRISEOFULVIN,MICROSIZE GRISEOFULVIN
1 NYSTATIN
3 GRISEOFULVIN ULTRAMICROSIZE GRIS-PEG
3 GRISEOFULVIN,MICROSIZE GRIFULVIN V
Antifungals (Eent) / OPHTHALMOLOGY

3 NATAMYCIN NATACYN
Antifungals (Skin & Mucous Membrane) / DERMATOLOGICAL AGENTS

1 CICLOPIROX
1 CLOTRIMAZOLE
1 ECONAZOLE NITRATE
1 KETOCONAZOLE KETODAN
1 NYSTATIN NYSTOP
1 NYSTATIN NYAMYC
1 NYSTATIN/TRIAMCIN NYSTATIN-TRIAMCINOLONE
2 SULCONAZOLE NITRATE EXELDERM
3 CICLOPIROX/NAIL LACQ/FT DEOD#4 PEDIPIROX-4
3 KETOCONAZOLE NIZORAL
3 KETOCONAZOLE XOLEGEL
3 MICONAZOLE NITRATE/ZINC OX/PET VUSION
3 NAFTIFINE HCL NAFTIN
3 OXICONAZOLE NITRATE OXISTAT
3 SERTACONAZOLE NITRATE ERTACZO
Antifungals (Skin & Mucous Membrane) / OBSTETRICS & GYNECOLOGY

1 TERCONAZOLE
Antihemophilic / OFFICE ADMINISTERED

3 COAGULATION FACTOR IX RECOMBINANT FOR IDELVION 4
INJ
4 ANTIHEMOPHILIC FACTOR ELOCTATE 4
4 ANTIHEMOPHILIC FACTOR RECOMBINANT NUWIQ 4
4 ANTIHEMOPHYLIC FACTOR VIII, RECOMBINANT AFSTYLA 4
4 ANTIHEMOPHYLIC FACTOR [RECOMBINANT] ADYNOVATE 4
PEGYLATED INJECTION
4 COAGULATION FACTOR IX, RECOMBINANT IXINITY 4
4 COAGULATION FACTOR VIII, RECOMBINANT KOVALTRY 4
4 COAGULATION FACTOR X [HUMAN] FOR COAGADEX 4
INJECTION
17 of 104
Antihemophilic / OFFICE ADMINISTERED (cont.)
4 VON WILLEBRAND FACTOR RECOMBINANT FOR VONVENDI 4
INJ
Antihepatitis / ANTIVIRALS
1 RIBAVIRIN RIBASPHERE 5
1 RIBAVIRIN RIBAPAK 5
1 RIBAVIRIN 5
2 LEDIPASVIR/SOFOSBUVIR HARVONI 5
2 SOFOSBUVIR/VELPATASVIR EPCLUSA 5
2 SOFOSBUVIR/VELPATASVIR/VOXILAPREVIR VOSEVI 5
3 BOCEPREVIR VICTRELIS 5
3 GLECAPREVIR/PIBRENTASVIR MAVYRET 5
3 GRAZOPREVIR/ELBASVIR ZEPATIER 5
3 PARITAPREVIR;/RITON/OMBITAS/DASA VIEKIRA PAK 5
3 RIBAVIRIN REBETOL 5
3 RIBAVIRIN COPEGUS 5
3 SIMEPREVIR OLYSIO 5
3 SOFOSBUVIR SOLVALDI 5
3 TELAPREVIR INCIVEK 5
4 DACLATASVIR DAKLINZA 5
4 OMBITASVIR/PARITAPREVIR/RITONAVIR TECHNIVIE 5
4 PEGINTERFERON ALFA-2A PEGASYS PROCLICK 5
4 PEGINTERFERON ALFA-2A PEGASYS 5
4 PEGINTERFERON ALFA-2B PEGINTRON REDIPEN 5
Antiherpetic / ANTIVIRALS
1 ACYCLOVIR 6
1 VALACYCLOVIR HCL VALACYCLOVIR 6
3 ACYCLOVIR ZOVIRAX 6
3 ACYCLOVIR SITAVIG
3 VALACYCLOVIR HCL VALTREX 6
Antihistamines (Gi Drugs) / GI AGENTS

1 MECLIZINE HCL
1 PROCHLORPERAZINE MALEATE COMPRO
1 PROCHLORPERAZINE MALEATE
1 TRIMETHOBENZAMIDE HCL
3 MECLIZINE HCL ANTIVERT
Antimalarial Agents / ANTI - INFECTIVES

1 CHLOROQUINE PHOSPHATE
1 HYDROXYCHLOROQUINE SULFATE
6 - Quantity Limit
18 of 104
Antimalarial Agents / ANTI - INFECTIVES (cont.)
1 MEFLOQUINE HCL
2 PRIMAQUINE PHOSPHATE PRIMAQUINE
2 PYRIMETHAMINE DARAPRIM
3 HYDROXYCHLOROQUINE SULFATE PLAQUENIL
Antimalarials / ANTI - INFECTIVES

1 ATOVAQUONE/PROGUANIL HCL ATOVAQUONE-PROGUANIL HCL
1 QUININE SULFATE
3 ATOVAQUONE/PROGUANIL HCL MALARONE
Antimetabolite / ANTINEOPLASTICS
1 MERCAPTOPURINE
1 THIOGUANINE
2 METHOTREXATE SODIUM TREXALL
4 METHOTREXATE SODIUM METHOTREXATE 5
Antimuscarinic/Beta Agonist / RESPIRATORY AGENTS

2 UMECLIDINIUM/VILANTEROL ANORO ELLIPTA
Antimuscarinics/Antispasmodics / GI AGENTS
1 CHLORDIAZEPOXIDE/CLIDINIUM BR CHLORDIAZEPOXIDE-CLIDINIUM
1 DICYCLOMINE HCL
1 GLYCOPYRROLATE
1 PROPANTHELINE BROMIDE
Antimuscarinics/Antispasmodics / RESPIRATORY AGENTS

1 IPRATROPIUM BROMIDE 6
1 IPRATROPIUM/ALBUTEROL SULFATE IPRATROPIUM-ALBUTEROL 6
2 IPRATROPIUM BROMIDE ATROVENT HFA 6
2 TIOTROPIUM BROMIDE SPIRIVA 6
3 ACLIDINIUM BROMIDE TUDORZA PRESSAIR
3 GLYCOPYRROLATE INHALATION POWDER SEEBRI NEOHALER
3 IPRATROPIUM/ALBUTEROL SULFATE COMBIVENT 6
3 IPRATROPIUM/ALBUTEROL SULFATE COMBIVENT RESPIMAT 6
Antineoplastic Agents / ANTINEOPLASTICS

1 BICALUTAMIDE
1 HYDROXYUREA
1 IMATINIB MESYLATE 5
1 MEGESTROL ACETATE
6 - Quantity Limit
19 of 104
Antineoplastic Agents / ANTINEOPLASTICS (cont.)
2 MEGESTROL ACETATE MEGACE ES
2 THIOGUANINE TABLOID
2 TOREMIFENE CITRATE FARESTON
3 ABIRATERONE ACETATE ZYTIGA
3 CABOZANTINIB COMETRIQ 5
3 CABOZANTINIB CABOMETYX 5
3 CAPECITABINE XELODA
3 CRIZOTINIB XALKORI
3 DASATINIB SPRYCEL
3 ERLOTINIB HCL TARCEVA 5
3 EVEROLIMUS AFINITOR
3 IMATINIB MESYLATE GLEEVEC 5
3 LAPATINIB DITOSYLATE TYKERB
3 LETROZOLE FEMARA
3 NIRAPARIB CAPSULES ZEJULA 5
3 REGORAFENIB STIVARGA
3 TEMOZOLOMIDE TEMODAR
3 VISMODEGIB ERIVEDGE 5
4 LEUPROLIDE ACETATE 5
4 PONATINIB ICLUSIG 5
4 RADIUM RA 223 XOFIGO 5
4 TRIFLURIDINE/TIPIRACIL LONSURF 5
Antineoplastic Agents / OFFICE ADMINISTERED

4 LEUPROLIDE ACETATE LUPRON DEPOT 4
Antineoplastic Other / ANTINEOPLASTICS

4 DINUTUXIMAB FOR INJECTION UNITUXIN 4
4 OMACETAXINE MEPESUCCINATE FOR INJECTION SYNRIBO 4
4 SONIDEGIB CAPSULES ODOMZO 5
4 TRABECTEDIN FOR INJECTION YONDELIS 4
4 VINBLASTINE VELBAN 4
4 VINCRISTINE ONCOVIN 4
4 VINORELBINE NAVELBINE 4
Antiparkinsonian Agents / AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH

1 CARBIDOPA
3 CARBIDOPA LODOSYN
Antiprotozoals / ANTIPARASITICS
1 CHLOROQUINE
1 METRONIDAZOLE
1 TINIDAZOLE
3 NITAZOXANIDE ALINIA
20 of 104
Antiprotozoals / ANTIPARASITICS (cont.)
3 TINIDAZOLE TINDAMAX
Antipruritics And Local Anesthetics / DERMATOLOGICAL AGENTS

3 DOXEPIN HCL ZONALON
3 NORFLURANE/HFC 245FA PAIN EASE
3 TETRACAINE/BENZOCAINE/BUTAMBEN CETACAINE
Antipruritics And Local Anesthetics / UROLOGICALS

1 PHENAZOPYRIDINE HCL
Antiretrovirals / ANTIVIRALS
1 DIDANOSINE
1 LAMIVUDINE
1 LAMIVUDINE/ZIDOVUDINE LAMIVUDINE-ZIDOVUDINE
1 NEVIRAPINE
2 EFAVIRENZ SUSTIVA
2 EFAVIRENZ/EMTRICITAB/TENOFOVIR ATRIPLA
2 EMTRICITAB/RILPIVIRINE/TENOFOV COMPLERA
2 EMTRICITABINE EMTRIVA
2 ETRAVIRINE INTELENCE
2 MARAVIROC SELZENTRY
2 NEVIRAPINE VIRAMUNE
2 TENOFOVIR ALAFENAMIDE TABLETS VEMLIDY 5
2 TENOFOVIR DISOPROXIL FUMARATE VIREAD
3 NEVIRAPINE VIRAMUNE XR
Antisense Oligonucleotide / OFFICE ADMINISTERED

4 ETEPLIRSEN INJECTION EXONDYS 51 4
4 NUSINERSEN INJECTION SPINRAZA 4
Antispasmodics / GI AGENTS
1 HYOSCYAMINE SULFATE HYOMAX-SR
1 HYOSCYAMINE SULFATE
1 HYOSCYAMINE SULFATE OSCIMIN
1 HYOSCYAMINE SULFATE OSCIMIN SR
1 HYOSCYAMINE SULFATE HYOMAX-SL
1 HYOSCYAMINE SULFATE HYOMAX-FT
1 HYOSCYAMINE SULFATE OSCIMIN SL
1 PHENOBARB/HYOSCY/ATROPINE/SCOP BELLADONNA-PHENOBARBITAL
1 PHENOBARB/HYOSCY/ATROPINE/SCOP QUADRAPAX
1 PHENOBARB/HYOSCY/ATROPINE/SCOP SE-DONNA PB HYOS
3 PHENOBARB/HYOSCY/ATROPINE/SCOP DONNATAL
21 of 104
Antithyroid Agents / ENDOCRINE/DIABETES
1 METHIMAZOLE
1 PROPYLTHIOURACIL
3 POTASSIUM IODIDE SSKI
Antituberculosis Agents / ANTIMYCOBACTERIALS

1 ETHAMBUTOL HCL MYAMBUTOL
1 ETHAMBUTOL HCL
1 ISONIAZID
1 PYRAZINAMIDE
1 RIFAMPIN
2 BEDAQUILINE SIRTURO 5
2 RIFABUTIN MYCOBUTIN
3 RIFAPENTINE PRIFTIN
Antitussives / RESPIRATORY AGENTS

1 BENZONATATE
1 BROMPHENIRAMIN/PE/DEXTROMETHOR LOHIST-DM
1 CODEINE/PROMETHAZINE HCL PROMETHAZINE-CODEINE
1 D-METHORPHAN HB/PROMETH HCL PROMETHAZINE-DM
1 GUAIFENESIN/CODEINE PHOSPHATE IOPHEN-C NR
1 GUAIFENESIN/CODEINE PHOSPHATE CHERATUSSIN AC
1 GUAIFENESIN/CODEINE PHOSPHATE GUAIFENESIN AC
1 GUAIFENESIN/CODEINE PHOSPHATE GUAIFENESIN-CODEINE
1 GUAIFENESIN/CODEINE PHOSPHATE DEX-TUSS
1 HYDROCODONE BIT/HOMATROP ME-BR HYDROCODONE-HOMATROPINE MBR
1 HYDROCODONE BIT/HOMATROP ME-BR HYDROMET
1 HYDROCODONE/CHLORPHEN POLIS HYDROCODONE-CHLORPHENIRAMINE
1 P-EPHED HCL/CODEINE/GUAIFEN CHERATUSSIN DAC
1 P-EPHED HCL/CODEINE/GUAIFEN MYTUSSIN DAC
1 P-EPHED HCL/CODEINE/GUAIFEN GUAIFENESIN DAC
1 PHENYLEPHRINE HCL/COD/PROMETH PROMETHAZINE VC-CODEINE
3 D-METHORPHAN HB/P-EPD HCL/BPM BROMFED DM
3 HYDROCODONE/CHLORPHEN POLIS TUSSICAPS
Antivirals (Eent) / ANTIVIRALS

1 TRIFLURIDINE
Antivirals (Skin & Mucous Membrane) / DERMATOLOGICAL AGENTS

3 ACYCLOVIR/HYDROCORTISONE XERESE
3 PENCICLOVIR DENAVIR
Antivirals- Miscellaneous / OFFICE ADMINISTERED

4 HUMAN PAPILLOMAVIRUS GARDASIL/CERVARIX 4
22 of 104
Anxiolytics- Sedatives & Hypnotics-Misc. / AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH
1 BUSPIRONE HCL
1 CHLORAL HYDRATE
1 ESZOPICLONE 6
1 ZALEPLON 6
1 ZOLPIDEM TARTRATE 6
1 ZOLPIDEM TARTRATE ZOLPIDEM TARTRATE ER 6
2 CHLORAL HYDRATE SOMNOTE
3 ESZOPICLONE LUNESTA 6
3 RAMELTEON ROZEREM
3 ZALEPLON SONATA 6
3 ZOLPIDEM TARTRATE EDLUAR 6
3 ZOLPIDEM TARTRATE AMBIEN 6
3 ZOLPIDEM TARTRATE INTERMEZZO 6
3 ZOLPIDEM TARTRATE AMBIEN CR 6
Anxiolytics- Sedatives & Hypnotics-Misc. / DIAGNOSTICS & MISCELLANEOUS AGENTS

3 DICHLORALPHENAZONE
Anxiolytics- Sedatives & Hypnotics-Misc. / RESPIRATORY AGENTS

1 HYDROXYZINE HCL
1 HYDROXYZINE PAMOATE
Aromatase Inhibitor / ANTINEOPLASTICS

1 ANASTROZOLE
1 EXEMESTANE
1 LETROZOLE
3 ANASTROZOLE ARIMIDEX
Astringents / DERMATOLOGICAL AGENTS

1 ALUMINUM CHLORIDE HYPERCARE
3 ALUMINUM CHLORIDE XERAC AC
3 ALUMINUM CHLORIDE DRYSOL
Atypical/2nd Generation / ANTIPSYCHOTICS

1 OLANZAPINE OLANZAPINE ODT
1 OLANZAPINE
1 QUETIAPINE FUMARATE
1 RISPERIDONE RISPERIDONE ODT
1 RISPERIDONE
1 RISPERIDONE RISPERIDONE M-TAB
1 ZIPRASIDONE HCL
2 ARIPIPRAZOLE ABILIFY DISCMELT
2 ARIPIPRAZOLE ABILIFY
3 ASENAPINE MALEATE SAPHRIS
6 - Quantity Limit
23 of 104
Atypical/2nd Generation / ANTIPSYCHOTICS (cont.)
3 BREXPIPRAZOLE REXULTI
3 CARIPRAZINE VRAYLAR 7
3 ILOPERIDONE FANAPT
3 LURASIDONE HCL LATUDA
3 OLANZAPINE ZYPREXA
3 OLANZAPINE ZYPREXA ZYDIS
3 PALIPERIDONE INVEGA
3 PIMAVANSERIN TABLETS NUPLAZID 5
3 QUETIAPINE FUMARATE SEROQUEL
3 QUETIAPINE FUMARATE SEROQUEL XR
3 ZIPRASIDONE HCL GEODON
4 PALIPERIDONE PALMITATE INVEGA SUSTENNA 5
Azoles / ANTIFUNGALS
1 CLOTRIMAZOLE
1 FLUCONAZOLE
1 ITRACONAZOLE
1 KETOCONAZOLE
1 VORICONAZOLE 5
3 EFINACONAZOLE JUBLIA 5
3 FLUCONAZOLE DIFLUCAN
3 ISAVUCONAZOMIUN CRESEMBA 5
3 LULICONAZOLE LUZU
3 POSACONAZOLE NOXAFIL
B-lymphocyte stimulator / MUSCULOSKELETAL & RHEUMATOLOGY

4 BELIMUMAB BENLYSTA 5
BCL-2 INHIBITOR / ANTINEOPLASTICS

3 VENETOCLAX TABLETS VENCLEXTA 5
BILE ACID SYNTHESIS DISORDER / ENDOCRINE

4 CHOLIC ACID CAPSULES CHOLBAM 5
BPH / GI AGENTS
1 ALFUZOSIN
1 DOXAZOSIN MESYLATE DOXAZOSIN
1 TAMSULOSIN
1 TERAZOSIN HCL TERAZOSIN
3 SILODOSIN RAPAFLO
3 TAMSULOSIN FLOMAX
BRAF Inhibitor / ANTINEOPLASTICS

3 DABRAFENIB TAFINLAR 5
7 - Step Therapy
24 of 104
BRAF Inhibitor / ANTINEOPLASTICS (cont.)
3 VEMURAFENIB ZELBORAF 5
Barbiturates (Anticonvulsants) / ANTICONVULSANTS

1 PRIMIDONE
Barbiturates (Anxiolytic- Sedative/Hyp) / ANTICONVULSANTS

1 PHENOBARBITAL
Basic Lotions And Liniments / DERMATOLOGICAL AGENTS

1 AMMONIUM LACTATE
Basic Ointments And Protectants / DERMATOLOGICAL AGENTS

1 AMMONIUM LACTATE LAC-HYDRIN
Benzodiazepines (Anticonvulsants) / ANTICONVULSANTS

1 CLONAZEPAM
3 CLOBAZAM ONFI
3 CLONAZEPAM KLONOPIN
3 DIAZEPAM DIASTAT ACUDIAL
Benzodiazepines (Anxiolytic) / ANXIOLYTICS

1 ALPRAZOLAM ALPRAZOLAM ER
1 ALPRAZOLAM
1 ALPRAZOLAM ALPRAZOLAM ODT
1 ALPRAZOLAM ALPRAZOLAM XR
1 CHLORDIAZEPOXIDE HCL
1 CLORAZEPATE DIPOTASSIUM
1 DIAZEPAM
1 LORAZEPAM LORAZEPAM INTENSOL
1 LORAZEPAM
1 OXAZEPAM
3 ALPRAZOLAM XANAX
3 DIAZEPAM VALIUM
3 LORAZEPAM ATIVAN
Benzodiazepines (Sedative/Hyp) / SLEEP DISORDERS

1 ESTAZOLAM
1 FLURAZEPAM HCL 6
6 - Quantity Limit
25 of 104
Benzodiazepines (Sedative/Hyp) / SLEEP DISORDERS (cont.)
1 TEMAZEPAM 6
1 TRIAZOLAM 6
Beta-Adrenergic Agonists / RESPIRATORY AGENTS

1 LEVALBUTEROL HCL LEVALBUTEROL 6
2 ALBUTEROL SULFATE VENTOLIN HFA 6
2 ALBUTEROL SULFATE PROVENTIL HFA 6
2 ALBUTEROL SULFATE PROAIR HFA 6
3 ARFORMOTEROL TARTRATE BROVANA
3 INDACATEROL MALEATE ARCAPTA NEOHALER
3 LEVALBUTEROL TARTRATE XOPENEX HFA 6
Beta-Adrenergic Blocking Agents / ANTIMIGRAINE PHOPHYLACTIC

1 PROPRANOLOL HCL
Beta-Adrenergic Blocking Agents / CARDIOVASCULAR

1 ATENOLOL
1 ATENOLOL/CHLORTHALIDONE ATENOLOL-CHLORTHALIDONE
1 BISOPROLOL FUMARATE
1 BISOPROLOL FUMARATE/HCTZ BISOPROLOL-HYDROCHLOROTHIAZIDE
1 CARVEDILOL
1 LABETALOL HCL
1 METOPROLOL SUCCINATE
1 METOPROLOL TARTRATE
1 METOPROLOL/HYDROCHLOROTHIAZIDE METOPROLOL-HYDROCHLOROTHIAZIDE
1 NADOLOL
1 PINDOLOL
1 PROPRANOLOL HCL
1 SOTALOL HCL SOTALOL
1 SOTALOL HCL SOTALOL AF
2 CARVEDILOL PHOSPHATE COREG CR
3 ATENOLOL TENORMIN
3 CARVEDILOL COREG
3 METOPROLOL SUCCINATE TOPROL XL
3 NADOLOL CORGARD
3 NEBIVOLOL HCL BYSTOLIC
3 PROPRANOLOL HCL HEMANGEOL
3 PROPRANOLOL HCL INDERAL LA
3 PROPRANOLOL HCL INNOPRAN XL
Beta-Adrenergic Blocking Agents (Eent) / OPHTHALMOLOGY

1 BETAXOLOL HCL
1 LEVOBUNOLOL HCL
1 TIMOLOL MALEATE
2 BETAXOLOL HCL BETOPTIC S
2 TIMOLOL MALEATE ISTALOL
6 - Quantity Limit
26 of 104
Beta-Adrenergic Blocking Agents (Eent) / OPHTHALMOLOGY (cont.)
2 TIMOLOL MALEATE/PF TIMOPTIC OCUDOSE
3 TIMOLOL BETIMOL
3 TIMOLOL MALEATE TIMOPTIC
Beta-Lactam, Other / ANTIBACTERIALS

4 AZTREONAM AZACTAM 4
4 IMIPENEM PRIMAXIN 4
4 IMIPENEM/CILASTATN IMIPENEM/CILASTATIN 4
4 MEROPENEM 4
Biguanides / BLOOD GLUCOSE REGULATORS

1 METFORMIN HCL METFORMIN HCL ER
1 METFORMIN HCL
1 METFORMIN HCL ER (MOD) METFORMIN ER (MOD) 5
1 METFORMIN HCL ER (OSM)
2 METFORMIN HCL METFORMIN HYDROCHLORIDE
2 METFORMIN HCL RIOMET
3 METFORMIN HCL GLUCOPHAGE
3 METFORMIN HCL ER GLUCOPHAGE XR
3 METFORMIN HCL ER (MOD) GLUMETZA 5
3 METFORMIN HCL ER (OSM) FORTAMET
Bile Acid Sequestrants / CARDIOVASCULAR

1 CHOLESTYRAMINE (WITH SUGAR) CHOLESTYRAMINE
1 CHOLESTYRAMINE/ASPARTAME PREVALITE
1 CHOLESTYRAMINE/ASPARTAME CHOLESTYRAMINE LIGHT
1 COLESTIPOL HCL
3 COLESEVELAM HCL WELCHOL
Bipolar - Other / BIPOLAR AGENTS

1 ALPRAZOLAM
1 DIAZEPAM
1 OLANZAPINE
3 ARIPIPRAZOLE ABILIFY
3 LURASIDONE HCL LATUDA
Blood Formation Modifiers / ANTICONVULSANTS

3 EDOXABAN SAVAYSA
Blood Formation Modifiers / BLOOD PRODUCT/MODIFIERS

2 APIXABAN ELIQUIS 5
27 of 104
Blood Formation Modifiers / BLOOD PRODUCT/MODIFIERS (cont.)
2 RIVAROXABAN XARELTO
3 CLOPIDOGREL BISULFATE PLAVIX
4 FONDAPARINUX SODIUM ARIXTRA 5
4 HEPARIN 4
Bone Resorption Inhibitors / MUSCULOSKELETAL & RHEUMATOLOGY

1 ALENDRONATE SODIUM
1 IBANDRONATE SODIUM
1 RISEDRONATE
2 ALENDRONATE SODIUM/VITAMIN D3 FOSAMAX PLUS D
3 ALENDRONATE SODIUM FOSAMAX
3 ALENDRONATE SODIUM BINOSTO
3 IBANDRONATE SODIUM BONIVA
3 RISEDRONATE SODIUM ATELVIA
3 RISEDRONATE SODIUM ACTONEL
C1 Esterase Inhibitor / OFFICE ADMINISTERED

4 C1 ESTERASE INHIBITOR RUCONEST 4
CYSTIC FIBROSIS TRANSMEMBRANE REGULATOR PROTEIN / RESPIRATORY AGENTS

4 LUMACAFTOR/IVACAFTOR ORKAMBI 5
Calcium Channel Agents / ANTICONVULSANTS

1 ETHOSUXIMIDE
1 LAMOTRIGINE
2 LAMOTRIGINE LAMICTAL (GREEN)
2 LAMOTRIGINE LAMICTAL (ORANGE)
3 LAMOTRIGINE LAMICTAL ODT (ORANGE)
3 LAMOTRIGINE LAMICTAL
3 LAMOTRIGINE LAMICTAL ODT
3 LAMOTRIGINE LAMICTAL XR
3 LEVETIRACETAM KEPPRA XR
3 LEVETIRACETAM KEPPRA
Calcium Channel Blocker/ARB / CARDIOVASCULAR

1 AMLODIPINE/VALSARTAN 7
3 AMLODIPINE/VALSARTAN EXFORGE 7
3 AMLODIPINE/VALSARTAN/HCTZ EXFORGE HCT 7
Calcium-Channel Blocking Agents- Misc. / CARDIOVASCULAR

1 DILTIAZEM HCL TAZTIA XT
7 - Step Therapy
28 of 104
Calcium-Channel Blocking Agents- Misc. / CARDIOVASCULAR (cont.)
1 DILTIAZEM HCL CARTIA XT
1 DILTIAZEM HCL DILTIAZEM 24HR CD
1 DILTIAZEM HCL DILT-XR
1 DILTIAZEM HCL MATZIM LA
1 DILTIAZEM HCL DILTIAZEM 24HR ER
1 DILTIAZEM HCL DILTIAZEM ER
1 DILTIAZEM HCL
1 VERAPAMIL HCL
1 VERAPAMIL HCL VERAPAMIL ER
1 VERAPAMIL HCL VERAPAMIL ER PM
3 DILTIAZEM HCL CARDIZEM CD
3 DILTIAZEM HCL CARDIZEM LA
3 DILTIAZEM HCL TIAZAC
3 VERAPAMIL HCL CALAN SR
Carbonic Anhydrase Inhibitors / CARDIOVASCULAR

1 ACETAZOLAMIDE
3 ACETAZOLAMIDE DIAMOX SEQUELS
Carbonic Anhydrase Inhibitors (Eent) / OPHTHALMOLOGY

1 ACETAZOLAMIDE
1 DORZOLAMIDE HCL
1 DORZOLAMIDE HCL/TIMOLOL MALEAT DORZOLAMIDE-TIMOLOL
1 METHAZOLAMIDE
2 BRINZOLAMIDE AZOPT
3 DORZOLAMIDE HCL/TIMOLOL MALEAT COSOPT
3 DORZOLAMIDE/TIMOLOL/PF COSOPT PF
Cardiac Drugs- Miscellaneous / CARDIOVASCULAR

2 Ivabradine HCL Corlanor
3 RANOLAZINE RANEXA
3 SACUBITRIL/VALSARTAN ENTRESTO 5
Cariostatic Agents / VITAMINS, HEMATINICS & ELECTROLYTES

1 SODIUM FLUORIDE RENAF
1 SODIUM FLUORIDE FLUORITAB
1 SODIUM FLUORIDE FLUORIDE
1 SODIUM FLUORIDE EPIFLUR
1 SODIUM FLUORIDE
1 SODIUM FLUORIDE LUDENT FLUORIDE
2 SODIUM FLUORIDE FLURA-DROPS
2 SODIUM FLUORIDE FLUORABON
2 SODIUM FLUORIDE FLUOR-A-DAY
Catechol-O-Methyltransferase(Comt)Inhib. / AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH

1 ENTACAPONE
29 of 104
Catechol-O-Methyltransferase(Comt)Inhib. / AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH (cont.)
2 ENTACAPONE COMTAN
Cell Stimulants And Proliferants / DERMATOLOGICAL AGENTS

1 TRETINOIN 5
2 TRETINOIN AVITA 5
2 TRETINOIN ATRALIN 5
2 TRETINOIN MICROSPHERES RETIN-A MICRO PUMP 5
2 TRETINOIN MICROSPHERES RETIN-A MICRO 5
Central Alpha-Agonists / CARDIOVASCULAR

1 GUANFACINE HCL
1 METHYLDOPA
Central Monoamine-Depleting Agent / CNS AGENTS

3 VALBENAZINE CAPSULES INGREZZA 5
4 DEUTETRABENAZINE TABLETS AUSTEDO 5
Central Nervous System Agents- Misc. / AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH
3 DEXTROMETHORPHAN HBR/QUINIDINE NUEDEXTA 5
Central Nervous System Agents- Misc. / DIAGNOSTICS & MISCELLANEOUS AGENTS

3 RILUZOLE RILUTEK
Centrally Acting Skeletal Muscle Relaxnt / ANTISPASTICITY AGENTS

1 CARISOPRODOL
1 CHLORZOXAZONE
1 CYCLOBENZAPRINE HCL
1 METAXALONE
1 METHOCARBAMOL
1 TIZANIDINE HCL
3 CARISOPRODOL SOMA
3 CYCLOBENZAPRINE HCL AMRIX
3 METAXALONE SKELAXIN
Cephalosporins / ANTIBACTERIALS
1 CEFACLOR
1 CEFADROXIL HYDRATE CEFADROXIL
1 CEFAZOLIN
1 CEFDINIR
1 CEFPROZIL
30 of 104
Cephalosporins / ANTIBACTERIALS (cont.)
1 CEFUROXIME AXETIL CEFUROXIME
1 CEPHALEXIN
3 CEFIXIME SUPRAX
3 CEFRADINE VELOSEF
3 CEFTIBUTEN CEDAX
3 CEFTIBUTEN DIHYDRATE CEDAX
3 CEFUROXIME AXETIL CEFTIN
3 CEPHALEXIN KEFLEX
4 CEFEPIME MAXIPIME 4
4 CEFOTAXIME CLAFORAN 4
4 CEFOTETAN CEFOTAN 4
4 CEFOXITAN MEFOXIN 4
Chelator / CARDIOVASCULAR
3 DEFERASIROX EXJADE 5
Cholelitholytic Agents / GI AGENTS

1 URSODIOL
3 URSODIOL ACTIGALL
Cholesterol Absorption Inhibitors / CARDIOVASCULAR

3 LOMITAPIDE JUXTAPID 5
4 MIPOMERSEN KYNAMRO 5
Cholinesterase Inhibitors / ANTIDEMENTIA AGENTS

1 DONEPEZIL HCL
1 GALANTAMINE
1 RIVASTIGMINE
3 RIVASTIGMINE EXELON PATCH
Coagulant - Vitamin K / BLOOD PRODUCT/MODIFIERS

2 PHYTONADIONE MEPHYTON
Complement Inhibitors / RESPIRATORY AGENTS

4 ICATIBANT ACETATE FIRAZYR 5
Contraceptives / OBSTETRICS & GYNECOLOGY

1 DESOG-ET ESTRA/ETHIN ESTRA KARIVA 3
3 - No copay
31 of 104
Contraceptives / OBSTETRICS & GYNECOLOGY (cont.)
1 DESOG-ET ESTRA/ETHIN ESTRA VIORELE
1 DESOG-ET ESTRA/ETHIN ESTRA AZURETTE 3
1 DESOGESTREL-ETHINYL ESTRADIOL RECLIPSEN 3
1 DESOGESTREL-ETHINYL ESTRADIOL APRI 3
1 DESOGESTREL-ETHINYL ESTRADIOL VELIVET
1 DESOGESTREL-ETHINYL ESTRADIOL CAZIANT 3
1 DESOGESTREL-ETHINYL ESTRADIOL EMOQUETTE 3
1 ETHYNODIOL D-ETHINYL ESTRADIOL ZOVIA 1-35E 3
1 ETHYNODIOL D-ETHINYL ESTRADIOL ZOVIA 1-50E 3
1 ETHYNODIOL D-ETHINYL ESTRADIOL KELNOR 1-35 3
1 L-NORGEST-ETH ESTR/ETHIN ESTRA AMETHIA 3
1 L-NORGEST-ETH ESTR/ETHIN ESTRA AMETHIA LO 3
1 L-NORGEST-ETH ESTR/ETHIN ESTRA LEVONORG-ETH ESTRAD ETH ESTRAD 3
1 L-NORGEST-ETH ESTR/ETHIN ESTRA CAMRESE LO 3
1 L-NORGEST-ETH ESTR/ETHIN ESTRA CAMRESE 3
1 LEVONORGESTREL NEXT CHOICE 3
1 LEVONORGESTREL-ETH ESTRADIOL LESSINA 3
1 LEVONORGESTREL-ETH ESTRADIOL AVIANE 3
1 LEVONORGESTREL-ETH ESTRADIOL MYZILRA 3
1 LEVONORGESTREL-ETH ESTRADIOL AMETHYST 3
1 LEVONORGESTREL-ETH ESTRADIOL ENPRESSE 3
1 LEVONORGESTREL-ETH ESTRADIOL ALTAVERA
1 LEVONORGESTREL-ETH ESTRADIOL JOLESSA 3
1 LEVONORGESTREL-ETH ESTRADIOL TRIVORA-28 3
1 LEVONORGESTREL-ETH ESTRADIOL SRONYX 3
1 LEVONORGESTREL-ETH ESTRADIOL QUASENSE 3
1 LEVONORGESTREL-ETH ESTRADIOL PORTIA 3
1 LEVONORGESTREL-ETH ESTRADIOL LUTERA 3
1 LEVONORGESTREL-ETH ESTRADIOL ORSYTHIA 3
1 LEVONORGESTREL-ETH ESTRADIOL INTROVALE 3
1 LEVONORGESTREL-ETH ESTRADIOL LEVORA-28 3
1 NORELGESTROMIN/ETHIN.ESTRADIOL NORELGESTROMIN/ETH ESTRADIOL 3
1 NORETH A-ET ESTRA/FE FUMARATE JUNEL FE 3
1 NORETH A-ET ESTRA/FE FUMARATE GILDESS FE 3
1 NORETH A-ET ESTRA/FE FUMARATE TILIA FE 3
1 NORETH A-ET ESTRA/FE FUMARATE MICROGESTIN FE 3
1 NORETH A-ET ESTRA/FE FUMARATE TRI-LEGEST FE 3
1 NORETH-ETHINYL ESTRADIOL/IRON WYMZYA FE 3
1 NORETH-ETHINYL ESTRADIOL/IRON ZENCHENT FE 3
1 NORETH-ETHINYL ESTRADIOL/IRON ZEOSA 3
1 NORETHINDRONE CAMILA
1 NORETHINDRONE HEATHER
1 NORETHINDRONE JOLIVETTE 3
1 NORETHINDRONE NORA-BE 3
1 NORETHINDRONE
1 NORETHINDRONE ERRIN
1 NORETHINDRONE A-E ESTRADIOL MICROGESTIN 3
1 NORETHINDRONE A-E ESTRADIOL GILDESS 3
1 NORETHINDRONE A-E ESTRADIOL JUNEL 3
1 NORETHINDRONE-ETHINYL ESTRAD BRIELLYN 3
1 NORETHINDRONE-ETHINYL ESTRAD ARANELLE 3
1 NORETHINDRONE-ETHINYL ESTRAD LEENA 3
1 NORETHINDRONE-ETHINYL ESTRAD CYCLAFEM 3
1 NORETHINDRONE-ETHINYL ESTRAD ZENCHENT 3
3 - No copay
32 of 104
Contraceptives / OBSTETRICS & GYNECOLOGY (cont.)
1 NORETHINDRONE-ETHINYL ESTRAD NECON 3
1 NORETHINDRONE-ETHINYL ESTRAD NORTREL 3
1 NORETHINDRONE-ETHINYL ESTRAD ALYACEN
1 NORETHINDRONE-ETHINYL ESTRAD DASETTA 3
1 NORETHINDRONE-ETHINYL ESTRAD BALZIVA 3
1 NORGESTIMATE-ETHINYL ESTRADIOL TRI-SPRINTEC 3
1 NORGESTIMATE-ETHINYL ESTRADIOL TRI-PREVIFEM 3
1 NORGESTIMATE-ETHINYL ESTRADIOL TRINESSA 3
1 NORGESTIMATE-ETHINYL ESTRADIOL SPRINTEC 3
1 NORGESTIMATE-ETHINYL ESTRADIOL PREVIFEM 3
1 NORGESTIMATE-ETHINYL ESTRADIOL 3
1 NORGESTIMATE-ETHINYL ESTRADIOL MONONESSA 3
1 NORGESTREL-ETHINYL ESTRADIOL LOW-OGESTREL 3
1 NORGESTREL-ETHINYL ESTRADIOL NORGESTREL-ETHINY ESTRA 3
1 NORGESTREL-ETHINYL ESTRADIOL CRYSELLE 3
1 NORGESTREL-ETHINYL ESTRADIOL ELINEST 3
1 NORGESTREL-ETHINYL ESTRADIOL OGESTREL 3
2 DESOGESTREL-ETHINYL ESTRADIOL ORTHO-CEPT
2 ETONOGESTREL/ETHINYL ESTRADIOL NUVARING
2 NORETH A-ET ESTRA/FE FUMARATE LO LOESTRIN FE
2 NORETH A-ET ESTRA/FE FUMARATE LOESTRIN 24 FE
2 NORETH-ETHINYL ESTRADIOL/IRON GENERESS FE
2 NORGESTIMATE-ETHINYL ESTRADIOL ORTHO TRI-CYCLEN LO
3 DESOG-ET ESTRA/ETHIN ESTRA MIRCETTE
3 DESOGESTREL-ETHINYL ESTRADIOL DESOGEN
3 DROSPIR/ETH ESTRA/LEVOMEFOL CA BEYAZ
3 DROSPIR/ETH ESTRA/LEVOMEFOL CA SAFYRAL
3 ESTRADIOL VALERATE/DIENOGEST NATAZIA
3 ETHINYL ESTRADIOL/DROSPIRENONE YAZ
3 ETHINYL ESTRADIOL/DROSPIRENONE YASMIN 28
3 L-NORGEST-ETH ESTR/ETHIN ESTRA SEASONIQUE
3 LEVONORGESTREL-ETH ESTRADIOL SEASONALE
3 LEVONORGESTREL-ETH ESTRADIOL LYBREL
3 LEVONORGESTREL-ETH ESTRADIOL NORDETTE-28
3 NORELGESTROMIN/ETHIN.ESTRADIOL ORTHO EVRA
3 NORETH A-ET ESTRA/FE FUMARATE ESTROSTEP FE
3 NORETH A-ET ESTRA/FE FUMARATE LOESTRIN FE
3 NORETH-ETHINYL ESTRADIOL/IRON FEMCON FE
3 NORETHINDRONE MICRONOR
3 NORETHINDRONE A-E ESTRADIOL LOESTRIN
3 NORETHINDRONE-ETHINYL ESTRAD OVCON-35
3 NORETHINDRONE-ETHINYL ESTRAD ORTHO-NOVUM
3 NORETHINDRONE-ETHINYL ESTRAD BREVICON
3 NORGESTIMATE-ETHINYL ESTRADIOL ORTHO-CYCLEN
3 NORGESTIMATE-ETHINYL ESTRADIOL ORTHO TRI-CYCLEN
3 NORGESTREL-ETHINYL ESTRADIOL LO-OVRAL-28
3 ULIPRISTAL ACETATE ELLA
4 LEVONORGESTREL-RELEASING INTRAUTERINE KYLEENA 4
SYSTEM
Contraceptives (E.G. Foams- Devices) / ENDOCRINE/DIABETES

3 DIAPHRAGMS, ARC-SPRING ORTHO ALL-FLEX
3 - No copay
33 of 104
Corticosteroids / AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH
3 DEFLAZACORT EMFLAZA 5
4 CORTICOTROPIN ACTHAR H.P. 5
Corticosteroids (Eent) / EAR, NOSE & THROAT MEDICATIONS

3 FLUOCINOLONE ACETONIDE OIL DERMOTIC
Corticosteroids (Eent) / GI AGENTS

3 BUDESONIDE UCERIS 5
Corticosteroids (Eent) / OPHTHALMOLOGY

1 FLUOROMETHOLONE
1 PREDNISOLONE ACETATE
1 PREDNISOLONE SOD PHOSPHATE PREDNISOLONE SODIUM PHOSPHATE
2 FLUOROMETHOLONE FML FORTE
2 FLUOROMETHOLONE FML S.O.P.
2 PREDNISOLONE ACETATE PRED MILD
3 DIFLUPREDNATE DUREZOL
3 FLUOROMETHOLONE ACETATE FLAREX
3 LOTEPREDNOL ETABONATE ALREX
3 LOTEPREDNOL ETABONATE LOTEMAX
3 PREDNISOLONE ACETATE PRED FORTE
3 RIMEXOLONE VEXOL
Corticosteroids (Eent) / RESPIRATORY AGENTS

1 FLUNISOLIDE
1 FLUTICASONE PROPIONATE
2 BECLOMETHASONE DIPROPIONATE BECONASE AQ
3 BECLOMETHASONE DIPROPIONATE QNASL
3 BUDESONIDE RHINOCORT AQUA
3 CICLESONIDE OMNARIS
3 CICLESONIDE ZETONNA
3 FLUTICASONE FUROATE VERAMYST
3 FLUTICASONE PROPIONATE FLONASE
3 MOMETASONE FUROATE NASONEX
3 TRIAMCINOLONE ACETONIDE NASACORT AQ
Corticosteroids (Respiratory Tract) / RESPIRATORY AGENTS

1 BUDESONIDE
2 BECLOMETHASONE DIPROPIONATE QVAR
2 BUDESONIDE PULMICORT FLEXHALER
2 BUDESONIDE/FORMOTEROL FUMARATE SYMBICORT
2 FLUTICASONE FUROATE ARNUITY ELLIPTA
2 FLUTICASONE PROPIONATE FLOVENT HFA
2 FLUTICASONE PROPIONATE FLOVENT DISKUS
34 of 104
Corticosteroids (Respiratory Tract) / RESPIRATORY AGENTS (cont.)
2 FLUTICASONE/SALMETEROL ADVAIR HFA 6
2 FLUTICASONE/VILANTEROL BREO ELLIPTA
2 MOMETASONE FUROATE ASMANEX
3 BUDESONIDE PULMICORT
3 CICLESONIDE ALVESCO
3 MOMETASONE/FORMOTEROL DULERA
Cystine depleting agent / GENETIC DISORDERS

3 CYSTEAMINE PROCYSBI 5
Cystine depleting agent / OPHTHALMOLOGY

3 CYSTEAMINE CYSTARAN 5
Devices / BLOOD GLUCOSE REGULATORS

2 NEEDLES, INSULIN DISPOSABLE NOVOTWIST
2 SYR W-NDL,INS 0.3 ML HALF MARK INSULIN SYRINGE
2 SYRING W-NDL,DISP,INSUL,0.3ML ULTICARE
2 SYRING W-NDL,DISP,INSUL,0.3ML INSULIN SYRINGE
2 SYRING W-NDL,DISP,INSUL,0.5ML INSULIN SYRINGE
2 SYRING W-NDL,DISP,INSUL,0.5ML ULTRA COMFORT
2 SYRINGE & NEEDLE,INSULIN,1 ML INSULIN SYRINGE
3 INSULIN ADMIN. SUPPLIES HUMAPEN LUXURA HD
3 SYRINGE & NEEDLE,INSULIN,1 ML INSULIN SYRINGE
Devices / DIAGNOSTICS & MISCELLANEOUS AGENTS

3 SALIVA SUBSTITUTION COMBO NO.2 CAPHOSOL
Devices / EAR, NOSE & THROAT MEDICATIONS

3 GLY/CARB HOMOPOLY A/POT HYDROX MUGARD
Devices / ENDOCRINE/DIABETES
2 INHALER, ASSIST DEVICES BREATHERITE
2 INHALER, ASSIST DEVICES OPTICHAMBER
2 INHALER, ASSIST DEVICES OPTIHALER
2 INHALER, ASSIST DEVICES EASIVENT
2 INHALER, ASSIST DEVICES MICROCHAMBER
2 INHALER, ASSIST DEVICES VORTEX
2 INHALER, ASSIST DEVICES E-Z SPACER
2 INHALER, ASSIST DEVICES PROCHAMBER
2 INHALER,ASSIST DEVICE,ACCESORY OPTICHAMBER DIAMOND
6 - Quantity Limit
35 of 104
Devices / ENDOCRINE/DIABETES (cont.)
2 NEEDLES, INSULIN DISPOSABLE PEN NEEDLE
2 SYRING W-NDL,DISP,INSUL,0.3ML SURE COMFORT
2 SYRING W-NDL,DISP,INSUL,0.5ML EASY TOUCH
2 SYRINGE & NEEDLE,INSULIN,1 ML PRECISION
2 SYRINGE & NEEDLE,INSULIN,1 ML MONOJECT INSULIN SYRINGE
3 BISMUTH TRIBROMOPH/PETROLATUM XEROFORM PETROLATUM DRESSING
3 NEEDLES, DISPOSABLE SPECIALTY USE NEEDLES
3 NEEDLES, DISPOSABLE REGULAR BEVEL NEEDLES
3 NEEDLES, DISPOSABLE NEEDLE
3 NEEDLES, DISPOSABLE NEEDLES
Devices / RESPIRATORY AGENTS

2 INHALER, ASSIST DEVICES AEROCHAMBER Z-STAT PLUS
2 INHALER, ASSIST DEVICES AEROCHAMBER MAX
2 INHALER, ASSIST DEVICES AEROCHAMBER
2 INHALER, ASSIST DEVICES AEROCHAMBER MV
2 INHALER, ASSIST DEVICES AEROCHAMBER PLUS
2 INHALER, ASSIST DEVICES AEROCHAMBER WITH FLOWSIGNAL
Digestants / GI AGENTS
1 LIPASE/PROTEASE/AMYLASE PANCRELIPASE 5,000
2 LIPASE/PROTEASE/AMYLASE ZENPEP
2 LIPASE/PROTEASE/AMYLASE CREON 5
2 LIPASE/PROTEASE/AMYLASE PANCREAZE
Dihydropyridines / CARDIOVASCULAR
1 AMLODIPINE BESYLATE
1 AMLODIPINE BESYLATE/BENAZEPRIL AMLODIPINE BESYLATE-BENAZEPRIL
1 FELODIPINE FELODIPINE ER
1 NIFEDIPINE NIFEDIPINE ER
1 NIFEDIPINE AFEDITAB CR
1 NIFEDIPINE NIFEDIAC CC
1 NIFEDIPINE NIFEDICAL XL
1 NIFEDIPINE
1 NISOLDIPINE
3 AMLODIPINE BES/OLMESARTAN MED AZOR 7
3 AMLODIPINE BESYLATE NORVASC
3 AMLODIPINE BESYLATE/BENAZEPRIL LOTREL
3 NICARDIPINE HCL CARDENE SR
3 NIFEDIPINE ADALAT CC
3 NISOLDIPINE SULAR
Dipeptidyl Peptidase-4(Dpp-4) Inhibitors / BLOOD GLUCOSE REGULATORS

2 SAXAGLIPTIN HCL ONGLYZA
7 - Step Therapy
36 of 104
Dipeptidyl Peptidase-4(Dpp-4) Inhibitors / BLOOD GLUCOSE REGULATORS (cont.)
2 SAXAGLIPTIN HCL/METFORMIN HCL KOMBIGLYZE XR
2 SITAGLIPTIN PHOS/METFORMIN HCL JANUMET
2 SITAGLIPTIN PHOS/METFORMIN HCL JANUMET XR
2 SITAGLIPTIN PHOSPHATE JANUVIA
3 ALOGLIPTIN NESINA
3 LINAGLIPTIN TRADJENTA
3 LINAGLIPTIN/METFORMIN HCL JENTADUETO
Direct Vasodilators / CARDIOVASCULAR

1 HYDRALAZINE HCL
1 MINOXIDIL
Direct-Acting Skeletal Muscle Relaxants / AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH
1 DANTROLENE SODIUM
Disease-Modifying Antirheumatic Agents / MUSCULOSKELETAL & RHEUMATOLOGY

1 LEFLUNOMIDE
3 ANAKINRA KINERET
3 LEFLUNOMIDE ARAVA
4 ABATACEPT ORENCIA 5
4 ADALIMUMAB HUMIRA 5
4 ADALIMUMAB HUMIRA PEDIATRIC CROHNS 5
4 ETANERCEPT ENBREL 5
4 GOLIMUMAB SIMPONI 5
Disease-Modifying Antirheumatic Agents / OFFICE ADMINISTERED

4 INFLIXIMAB FOR INJECTION REMICADE 4
Dopamine Agonists / ANTIPARKINSON AGENTS

1 AMANTADINE HCL AMANTADINE
1 BROMOCRIPTINE MESYLATE
1 PRAMIPEXOLE DI-HCL PRAMIPEXOLE DIHYDROCHLORIDE
1 ROPINIROLE HCL
3 AMANTADINE HCL SYMMETREL
3 BROMOCRIPTINE MESYLATE CYCLOSET
3 PRAMIPEXOLE DI-HCL MIRAPEX ER
3 PRAMIPEXOLE DI-HCL MIRAPEX
3 ROPINIROLE HCL REQUIP
3 ROPINIROLE HCL REQUIP XL
3 ROTIGOTINE NEUPRO
Dopamine Antagonist / ANTIEMETICS

1 PROCLORPERAZINE
37 of 104
Dopamine Antagonist / ANTIEMETICS (cont.)
1 PROMETHAZINE HCL PROMETHEGAN
4 DROPERIDOL INAPSINE 4
Dopamine Precursors/AA Decarbox Inhibitor / ANTIPARKINSON AGENTS

1 CARBIDOPA/LEVODOPA CARBIDOPA-LEVODOPA
1 CARBIDOPA/LEVODOPA/ENTACAPONE CARBIDOPA-LEVODOPA-ENTACAPONE
3 CARBIDOPA/LEVODOPA RYTARY
3 CARBIDOPA/LEVODOPA/ENTACAPONE STALEVO
4 CARBIDOPA/LEVODOPA DUOPA 1
Dopamine Receptor Agonists / EMETOGENIC THERAPY

4 APOMORPHINE APOKYN 4
Dopamine Receptor Agonists / ENDOCRINE/DIABETES

1 CABERGOLINE
Dopamine Reuptake Blocker / AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH
1 METHYLPHENIDATE HCL METHYLPHENIDATE HCL CD
Dyslipidemics, Other / CARDIOVASCULAR

1 EZETIMIBE
1 EZETIMIBE/SIMVASTATIN
2 NIACIN NIASPAN
2 NIACIN/LOVASTATIN ADVICOR
2 NIACIN/SIMVASTATIN SIMCOR
3 EZETIMIBE ZETIA
3 EZETIMIBE/SIMVASTATIN VYTORIN
3 NIACIN NIACOR
3 OMEGA-3 ACID ETHYL ESTERS LOVAZA
Eent Anti-Infectives- Miscellaneous / EAR, NOSE & THROAT MEDICATIONS

1 CHLORHEXIDINE GLUCONATE
Eent Anti-Inflammatory Agents- Misc. / OPHTHALMOLOGY

3 CYCLOSPORINE RESTASIS
3 LIFITEGRAST OPTH SOLUTION XIIDRA 5
1 - Home Health
38 of 104
Eent Drugs- Miscellaneous / EAR, NOSE & THROAT MEDICATIONS
3 AMLEXANOX APHTHASOL
Eent Drugs- Miscellaneous / OPHTHALMOLOGY

3 EYE LUBRICANT COMBINATION NO.1 FRESHKOTE
3 HYDROXYPROPYL CELLULOSE LACRISERT
Eent Nonsteroidal Anti-Inflam. Agents / OPHTHALMOLOGY

1 BROMFENAC SODIUM
2 BROMFENAC SODIUM BROMDAY
2 KETOROLAC TROMETHAMINE/PF ACUVAIL
2 NEPAFENAC NEVANAC
3 BROMFENAC SODIUM XIBROM
3 KETOROLAC TROMETHAMINE ACULAR LS
3 KETOROLAC TROMETHAMINE ACULAR
Emollients / DERMATOLOGICAL AGENTS

1 EMOLLIENT COMBINATION NO.53 HPR PLUS
3 EMOLLIENT COMBINATION NO.10 BIAFINE
3 EMOLLIENT COMBINATION NO.32 EPICERAM
3 EMOLLIENT COMBINATION NO.35 MIMYX
3 EMOLLIENT COMBINATION NO.43 PROMISEB
3 EMOLLIENT COMBINATION NO.44 HYLATOPIC
3 EMOLLIENT COMBINATION NO.53 HYLATOPIC PLUS
3 EMOLLIENT COMBINATION NO.60 ATRAPRO HYDROGEL
3 VITE AC/GRAPE/HYALURONIC ACID ATOPICLAIR
Endothelin Receptor Antagonist / OFFICE ADMINISTERED

4 RAMUCIRUMAB CYRAMZA 4
Endothelin Receptor Antagonist / RESPIRATORY AGENTS

3 MACITENTAN OPSUMIT 5
Enzyme Replacement / ENZYME REPLACEMENT

3 ELIGLUSTAT CERDELGA 5
4 AGALSIDASE BETA FABRAZYME 4
Enzyme Replacement / OFFICE ADMINISTERED

4 ELOSULFASE ALFA VIMIZIM 4
39 of 104
Enzymes / RESPIRATORY AGENTS
3 DORNASE ALFA PULMOZYME 5
Ergot Alkaloids / ANTIMIGRAINE

1 DIHYDROERGOTAMINE MESYLATE
2 ERGOTAMINE TARTRATE ERGOMAR
2 ERGOTAMINE TARTRATE/CAFFEINE CAFERGOT
Estrogen Agonist-Antagonists / HORMONE: ER RECEPTOR MODIFIER

1 RALOXIFENE
3 ESTROGEN/BAZEDOXIFENE DUAVEE
3 OSPEMIFENE OSPHENA
3 RALOXIFENE EVISTA
4 CLOMIPHENE CITRATE 2
Estrogens / HORMONE: ESTROGENS

1 ESTRADIOL
1 ESTRADIOL/NORETHINDRONE ACET ESTRADIOL-NORETHINDRONE ACETAT
1 ESTROPIPATE
2 ESTRADIOL ALORA
2 ESTRADIOL ESTRACE 0.01% CREAM
2 ESTRADIOL MICRONIZED ESTRADIOL
3 ESTRADIOL DIVIGEL
3 ESTRADIOL EVAMIST
3 ESTRADIOL ESTROGEL
3 ESTRADIOL ELESTRIN
3 ESTRADIOL ESTRING
3 ESTRADIOL CLIMARA
3 ESTRADIOL ESTRACE TABLETS
3 ESTRADIOL ACETATE FEMRING
3 ESTRADIOL/NORETHINDRONE ACET ACTIVELLA
3 ESTROGENS,CONJ.,SYNTHETIC A CENESTIN
3 ESTROGENS,CONJ.,SYNTHETIC B ENJUVIA
3 NORETHIND AC/ETHINYL ESTRADIOL FEMHRT
Estrogens / OBSTETRICS & GYNECOLOGY

1 ESTRADIOL/NORETHINDRONE ACET MIMVEY
1 NORETHIND AC/ETHINYL ESTRADIOL JINTELI
1 NORETHIND AC/ETHINYL ESTRADIOL JEVANTIQUE
2 ESTRADIOL VAGIFEM
2 ESTRADIOL/LEVONORGESTREL CLIMARA PRO
2 ESTRADIOL/NORGESTIMATE PREFEST
2 ESTROGEN,CON/M-PROGEST ACET PREMPRO
2 ESTROGEN,CON/M-PROGEST ACET PREMPHASE
2 ESTROGENS, CONJUGATED PREMARIN
2 - Infertility
40 of 104
Estrogens / OBSTETRICS & GYNECOLOGY (cont.)
3 DROSPIRENONE/ESTRADIOL ANGELIQ
3 ESTRADIOL MENOSTAR
3 ESTRADIOL VIVELLE-DOT
3 ESTRADIOL/NORETHINDRONE ACET COMBIPATCH
3 ESTROGENS,ESTERIFIED MENEST
4 ESTRADIOL CYPIONATE DEPO-ESTRADIOL 5
Ethanolamine Derivatives / RESPIRATORY AGENTS

1 DIPHENHYDRAMINE HCL
Farnesoid X Receptor Agonists / GI AGENTS

3 OBETICHOLIC ACID TABLETS OCALIVA 5
Fibric Acid Derivatives / CARDIOVASCULAR

1 FENOFIBRATE NANOCRYSTALLIZED FENOFIBRATE
1 FENOFIBRIC ACID (CHOLINE) FENOFIBRIC ACID
1 GEMFIBROZIL
3 FENOFIBRATE FENOGLIDE
3 FENOFIBRATE LIPOFEN
3 FENOFIBRATE NANOCRYSTALLIZED TRIGLIDE
3 FENOFIBRATE NANOCRYSTALLIZED TRICOR
3 FENOFIBRATE,MICRONIZED ANTARA
3 FENOFIBRIC ACID (CHOLINE) TRILIPIX
Fibromyalgia Agents / CNS AGENTS

1 GABAPENTIN
3 MILNACIPRAN HCL SAVELLA
3 PREGABALIN LYRICA
First Gen. Antihist. Derivatives- Misc. / RESPIRATORY AGENTS

1 CYPROHEPTADINE HCL
Folic Acid Reductase Inhibitor / MUSCULOSKELETAL & RHEUMATOLOGY

4 METHOTREXATE OTREXUP 5
GABA Augmenting Agents / AANTICONVULSANTS

3 GABAPENTIN ENACARBIL HORIZANT
GABA Augmenting Agents / ANTICONVULSANTS

1 DIVALPROEX SODIUM
41 of 104
GABA Augmenting Agents / ANTICONVULSANTS (cont.)
1 DIVALPROEX SODIUM DIVALPROEX SODIUM ER
1 VALPROATE SODIUM VALPROIC ACID
3 DIVALPROEX SODIUM DEPAKOTE
3 DIVALPROEX SODIUM DEPAKOTE ER
3 DIVALPROEX SODIUM DEPAKOTE SPRINKLE
3 GABAPENTIN GRALISE
3 TIAGABINE GABITRIL
3 VIGABATRIN SABRIL 5
GLP-2 analog / GI AGENTS

4 TEDUGLUTIDE GATTEX 5
Gaba-Derivative Skeletal Muscle Relaxant / AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH
1 BACLOFEN
Genitourinary Smooth Muscle Relaxants / UROLOGICALS

1 FLAVOXATE HCL
1 OXYBUTYNIN CHLORIDE
1 OXYBUTYNIN CHLORIDE OXYBUTYNIN CHLORIDE ER
1 TOLTERODINE TARTRATE
3 DARIFENACIN HYDROBROMIDE ENABLEX
3 FESOTERODINE FUMARATE TOVIAZ
3 MIRABEGRON MYRBETRIQ
3 OXYBUTYNIN GELNIQUE
3 SOLIFENACIN SUCCINATE VESICARE
3 TOLTERODINE TARTRATE DETROL LA
3 TOLTERODINE TARTRATE DETROL
3 TROSPIUM CHLORIDE SANCTURA XR
Gi Drugs- Miscellaneous / GI AGENTS

3 CERTOLIZUMAB PEGOL CIMZIA 5
3 ELUXADOLINE TABLETS VIBERZI
3 LINACLOTIDE LINZESS
3 PLECANATIDE TABLETS TRULANCE 5
Glutamate Reducing Agents / ANTICONVULSANTS

1 GABAPENTIN
3 GABAPENTIN NEURONTIN
Glycogenolytic Agents / BLOOD GLUCOSE REGULATORS

3 GLUCAGON,HUMAN RECOMBINANT GLUCAGON EMERGENCY KIT
3 GLUCAGON,HUMAN RECOMBINANT GLUCAGEN
42 of 104
Gonadotropin-Releasing Hormone Antagnts / ENDOCRINE/DIABETES
4 CETRORELIX ACETATE CETROTIDE 2
4 GANIRELIX ACETATE 2
Gonadotropins / ENDOCRINE/DIABETES
4 CHORIONIC GONADOTROPIN, HUMAN CHORIONIC GONADOTROPIN 2
4 CHORIONIC GONADOTROPIN, HUMAN PREGNYL 2
4 FOLLITROPIN ALFA, RECOMB GONAL-F RFF 2
4 FOLLITROPIN ALFA, RECOMB GONAL-F 2
4 FOLLITROPIN BETA,RECOMB FOLLISTIM AQ 2
4 HCG ALPHA,RECOMBINANT OVIDREL 2
4 MENOTROPINS MENOPUR 2
4 UROFOLLITROPIN BRAVELLE 2
Gonadotropins / OBSTETRICS & GYNECOLOGY

4 CHORIONIC GONADOTROPIN NOVAREL 2
Growth Hormone Releasing Factor / DIAGNOSTICS & MISCELLANEOUS AGENTS

4 TESAMORELIN EGRIFTA 5
HER2 Targeted Antibody / ANTINEOPLASTICS

4 ADO-TRASTUZUMAB KADCYLA 5
4 TRASTUZUMAB HERCEPTIN 5
HYPOPHOSPHATASIA / ENDOCRINE
4 ASFOTASE ALFA INJECTION STRENSIQ 5
Hematopoietic Agents / ANTINEOPLASTICS

4 TBO-FILGRASTIM GRANIX 5
Hematopoietic Agents / CARDIOVASCULAR

3 ELTROMBOPAG OLAMINE PROMACTA 5
4 ROMIPLOSTIM NPLATE 5
Hematopoietic Agents / IMMUNOLOGICAL AGENTS

4 EPOETIN ALFA PROCRIT 5
4 PEGFILGRASTIM NEULASTA 5
2 - Infertility
43 of 104
Hematopoietic Agents / IMMUNOLOGICAL AGENTS (cont.)
4 PLERIXAFOR MOZOBIL 5
Hematopoietic Agents / OFFICE ADMINISTERED

4 EPOETIN ALFA EPOGEN 4
4 FILGRASTIM NEUPOGEN 4
Hemorrheologic Agents / CARDIOVASCULAR

1 PENTOXIFYLLINE
Hemostatic / OFFICE ADMINISTERED

4 COAGULATION FACTOR IX ALPROLIX 4
4 COAGULATION FACTOR IX RIXUBIS 4
4 COAGULATION FACTOR XIII TRETTEN 4
Hemostatics / CARDIOVASCULAR
3 AMINOCAPROIC ACID
4 ANTIHEMOPH.FVIII PLAS/ALB FREE ADVATE 5
Hemostatics / OBSTETRICS & GYNECOLOGY

1 TRANEXAMIC ACID
3 TRANEXAMIC ACID LYSTEDA
Hereditary Tyrosinemia / ENDOCRINE

3 NITISINONE ORFADIN 5
Heterocyclic Antidepressants / ANTIDEPRESSANTS, OTHER

1 AMOXAPINE
1 MAPROTILINE HCL
1 MIRTAZAPINE
Histamine H2-Antagonists / GI AGENTS

1 CIMETIDINE
1 FAMOTIDINE
1 NIZATIDINE
1 RANITIDINE HCL
3 FAMOTIDINE PEPCID
44 of 104
Histamine H2-Antagonists / GI AGENTS (cont.)
3 RANITIDINE HCL ZANTAC 25
Histone inhibitor / ANTINEOPLASTICS

3 PANOBINOSTAT FARYDAK 5
3 VORINOSTAT ZOLINZA 5
Histone inhibitor / OFFICE ADMINISTERED

4 BELINOSTAT BELEODAQ 4
Hmg-Coa Reductase Inhibitors / CARDIOVASCULAR

1 AMLODIPINE/ATORVASTATIN AMLODIPINE-ATORVASTATIN
1 ATORVASTATIN CALCIUM
1 FLUVASTATIN SODIUM
1 LOVASTATIN
1 PRAVASTATIN SODIUM
1 SIMVASTATIN
3 ATORVASTATIN CALCIUM LIPITOR
3 FLUVASTATIN SODIUM LESCOL XL
3 FLUVASTATIN SODIUM LESCOL
3 LOVASTATIN ALTOPREV
3 PITAVASTATIN CALCIUM LIVALO
3 PRAVASTATIN SODIUM PRAVACHOL
3 ROSUVASTATIN CALCIUM CRESTOR
3 SIMVASTATIN ZOCOR
Human Leptin / GENETIC DISORDERS

4 METRELEPTN MYALEPT 5
INTERLEUKIN-17A RECEPTOR ANTAGONIST / DERMATOLOGICAL AGENTS

4 IXEKIZUMAB FOR SUBCUTANEOUS INJ TALTZ 5
Immunomodulator / IMMUNOLOGICAL AGENTS

3 APREMILAST OTEZLA 5
3 LENALIDOMIDE REVLIMID 5
3 POMALIDOMIDE POMALYST 5
3 THALIDOMIDE THALOMID 5
3 TOFACITINIB XELJANZ 5
4 INTERFERON ALFACON 1 INFERGEN 5
Immunosuppressive Agents / IMMUNOLOGICAL AGENTS

1 AZATHIOPRINE
45 of 104
Immunosuppressive Agents / IMMUNOLOGICAL AGENTS (cont.)
1 CYCLOSPORINE
1 CYCLOSPORINE, MODIFIED GENGRAF
1 CYCLOSPORINE, MODIFIED CYCLOSPORINE MODIFIED
1 MYCOPHENOLATE MOFETIL
1 TACROLIMUS
2 CYCLOSPORINE SANDIMMUNE
2 CYCLOSPORINE, MODIFIED NEORAL
2 MYCOPHENOLATE SODIUM MYFORTIC
2 SIROLIMUS RAPAMUNE
3 MYCOPHENOLATE MOFETIL CELLCEPT
3 TACROLIMUS PROGRAF
4 TOCILIZUMAB ACTEMRA SQ 5
4 TOCILIZUMAB ACTEMRA 5
Incretin Mimetics / BLOOD GLUCOSE REGULATORS

2 EXENATIDE BYETTA 5
2 EXENATIDE EXTENDED RELEASE BYDUREON BCISE 5
2 EXENATIDE MICROSPHERES BYDUREON 5
2 LIRAGLUTIDE VICTOZA 2-PAK 5
2 LIRAGLUTIDE VICTOZA 3-PAK 5
3 ALBIGLUTIDE TANZEUM 5
3 DULAGLUTIDE TRULICITY 5
3 LIXISENATIDE INJECTION ADLYXIN 5
Incretin Mimetics / OBESITY

4 LIRAGLUTIDE SAXENDA 5
Inhibit DNA polymerases / ANTINEOPLASTICS

1 TEMOZOLOMIDE
Inhibit DNA polymerases / ANTIVIRALS

3 GANCICLOVIR CYTOVENE 5
Inhibit Protein Synthesis / ANTIFUNGALS

3 TAVABOROLE KERYDIN 5
Inhibit Protein Synthesis / ANTINEOPLASTICS

4 OMACETAXINE SYNRIBO 5
Inhibit Protein Synthesis / GENETIC DISORDERS

3 MIGLUSTAT ZAVESCA 5
46 of 104
Insulins / BLOOD GLUCOSE REGULATORS
2 HUM INSULIN NPH/REG INSULIN HM HUMULIN 70-30
2 HUM INSULIN NPH/REG INSULIN HM NOVOLIN 70-30
2 INSULIN GLARGINE,HUM.REC.ANLOG LANTUS
2 INSULIN GLARGINE,HUM.REC.ANLOG LANTUS SOLOSTAR
2 INSULIN GLARGINE,HUM.REC.ANLOG TOUJEO
2 INSULIN LISPRO HUMALOG
2 INSULIN NPL/INSULIN LISPRO HUMALOG MIX 50-50
2 INSULIN NPL/INSULIN LISPRO HUMALOG MIX 75-25
2 INSULIN REGULAR, HUMAN HUMULIN R
2 INSULIN REGULAR, HUMAN NOVOLIN R
2 NPH, HUMAN INSULIN ISOPHANE HUMULIN N
2 NPH, HUMAN INSULIN ISOPHANE NOVOLIN N
3 INSULIN ASPART NOVOLOG 7
3 INSULIN ASPART NOVOLOG FLEXPEN 7
3 INSULIN DEGLUDEC INJECTION TRESIBA 7
3 INSULIN DETEMIR LEVEMIR FLEXTOUCH 7
3 INSULIN DETEMIR LEVEMIR 7
3 INSULIN GLARGINE,HUM.REC.ANLOG Basaglar KwikPen 7
3 INSULIN GLULISINE APIDRA SOLOSTAR
3 INSULIN GLULISINE APIDRA
3 INSULIN INHALED AFREZZA
3 INSULN ASP PRT/INSULIN ASPART NOVOLOG MIX 70-30 7
3 INSULN ASP PRT/INSULIN ASPART NOVOLOG MIX 70-30 FLEXPEN 7
Integrase Strand Inhibitor / ANTIVIRALS

2 ELVITEGRAVIR VITEKTA
Interferons / IMMUNOLOGICAL AGENTS

4 INTERFERON ALFA-2B,RECOMB. INTRON A 5
4 INTERFERON ALFA-2B,RECOMB. PEG-INTRON 5
4 INTERFERON ALFA-2B,RECOMB. SYLATRON 5
Interleukin / CARDIOVASCULAR
4 OPRELVEKIN NEUMEGA 5
Interleukin / DERMATOLOGICAL AGENTS

4 SECUKINUMAB COSENTYX 5
Interleukin / OFFICE ADMINISTERED

4 SILTUXIMAB SYLVANT 4
7 - Step Therapy
47 of 104
Intravitreal injection / OPHTHALMOLOGY
4 OCRIPLASMIN JETREA 5
Keratolytic Agents / DERMATOLOGICAL AGENTS

1 BENZOYL PEROXIDE LAVOCLEN-4
1 BENZOYL PEROXIDE BENZEPRO
1 BENZOYL PEROXIDE
1 BENZOYL PEROXIDE BP WASH
1 BENZOYL PEROXIDE BPO
1 BENZOYL PEROXIDE BP WASH ACNE TREATMENT
1 SALICYLIC ACID
1 SULFACET SOD/SULFUR/WITCH HAZ SE 10-5 SS
1 SULFACETAMIDE SODIUM/SULFUR ZENCIA
1 SULFACETAMIDE SODIUM/SULFUR SULFACETAMIDE SODIUM-SULFUR
1 SULFACETAMIDE SODIUM/SULFUR SODIUM SULFACETAMIDE-SULFUR
1 SULFACETAMIDE SODIUM/SULFUR PRASCION
1 SULFACETAMIDE SODIUM/SULFUR PRASCION FC
1 SULFACETAMIDE SODIUM/SULFUR BP 10-1
1 UREA
2 BENZOYL PEROXIDE BENZEFOAM ULTRA
2 BENZOYL PEROXIDE BENZAC AC
2 SULFACETAMIDE SODIUM/SULFUR CLARIFOAM EF
3 SALICYLIC ACID KERALYT
3 SALICYLIC ACID/CERAMIDE CMB #1 SALEX
3 SULFACETAMIDE SODIUM/SULFUR CLENIA
Keratoplastic Agents / DERMATOLOGICAL AGENTS

1 ANTHRALIN DRITHOCREME HP
3 COAL TAR
Kinase Inhibitor / ANTINEOPLASTICS

3 CERITINIB ZYKADIA 5
3 IDELALISIB ZYDELIG 5
3 LENVATINIB LENVIMA 5
3 RIBOCICLIB TABLETS KISQALI 5
3 RUXOLITINIB JAKAFI 5
3 TRAMETINIB MEKINIST 5
LIPOSOMAL ACID LIPASE DEFICIENCY / ENDOCRINE

4 SEBELIPASE ALFA INJECTION KANUMA 4
Laxatives / GI AGENTS
1 PEG 3350/NA SULF,BICARB,CL/KCL PEG 3350-ELECTROLYTE
48 of 104
Laxatives / GI AGENTS (cont.)
1 PEG 3350/NA SULF,BICARB,CL/KCL PEG-3350 AND ELECTROLYTES
1 PEG 3350/NA SULF,BICARB,CL/KCL GAVILYTE
1 POLYETHYLENE GLYCOL 3350
2 NAPHOS M-B M-H/NA PHOS,DI-BA OSMOPREP
2 PEG 3350/NA SULF,BICARB,CL/KCL GOLYTELY PACKETS
3 BISAC/NACL/NAHCO3/KCL/PEG 3350 HALFLYTELY-BISACODYL
3 LUBIPROSTONE AMITIZA
3 PEG 3350/NA SULF,BICARB,CL/KCL GOLYTELY
3 PEG 3350/NA SULF,BICARB,CL/KCL COLYTE WITH FLAVOR PACKETS
3 PEG3350/SOD SUL/NACL/ASB/C/KCL MOVIPREP
3 SOD PICOSULF/MAG OX/CITRIC AC PREPOPIK
3 SODIUM,POTASSIUM,&MAG SULFATES SUPREP
Leprosy / ANTIMYCOBACTERIALS - OTHER

2 DAPSONE
3 CLOFAZIMINE LAMPRENE
Leukotriene Modifiers / RESPIRATORY AGENTS

1 MONTELUKAST SODIUM
1 ZAFIRLUKAST
3 MONTELUKAST SODIUM SINGULAIR
3 ZAFIRLUKAST ACCOLATE
3 ZILEUTON ZYFLO CR 5
Local Anesthetics / ANESTHETICS

1 HYDROCORTISONE AC/LIDOCAINE LIDOCAINE-HYDROCORTISONE
1 LIDOCAINE HCL
1 LIDOCAINE HCL LIDOCAINE HCL VISCOUS
1 LIDOCAINE/PRILOCAINE LIDOCAINE-PRILOCAINE
3 LIDOCAINE LIDODERM
Local Anesthetics (Eent) / OTIC AGENTS

1 ANTIPYRINE/BENZOCAINE/GLYCERIN AURODEX
1 ANTIPYRINE/BENZOCAINE/GLYCERIN ANTIPYRINE-BENZOCAINE
3 ANTIPY/BENZOCAINE/POLICOS NO.1 OTIC CARE
3 ANTIPYRINE/BENZOCAINE AURAX
Local Anti-Infectives- Miscellaneous / DERMATOLOGICAL AGENTS

1 HYDROCORTISONE/IODOQUINOL HYDROCORTISONE-IODOQUINOL
1 SELENIUM SULFIDE
1 SILVER SULFADIAZINE SSD
1 SILVER SULFADIAZINE THERMAZENE
1 SILVER SULFADIAZINE
1 SULFACETAMIDE SOD/SULFUR/UREA CLEANSING WASH
49 of 104
Local Anti-Infectives- Miscellaneous / DERMATOLOGICAL AGENTS (cont.)
1 SULFACETAMIDE SOD/SULFUR/UREA SODIUM SULFACETAMIDE-SULFUR
1 SULFACETAMIDE SODIUM SEB-PREV
1 SULFACETAMIDE SODIUM SODIUM SULFACETAMIDE
1 SULFACETM NA/AVOBENZONE/SULFUR PRASCION RA
2 SELENIUM SULFIDE TERSI FOAM
3 HEXACHLOROPHENE PHISOHEX
3 SILVER SULFADIAZINE SILVADENE
Loop Diuretics / CARDIOVASCULAR

1 BUMETANIDE
1 FUROSEMIDE
1 TORSEMIDE
2 ETHACRYNIC ACID EDECRIN
3 FUROSEMIDE LASIX
MAO Inhibitor / ANTIDEPRESSANTS

1 PHENELZINE SULFATE
1 TRANYLCYPROMINE SULFATE
MEK Inhibitor / ANTINEOPLASTICS

4 COBIMETINIB TABLETS COTELLIC 5
MIXED 5HT1A AGONIST HT2A ANTAGONIST / CNS AGENTS

4 FLIBANSERIN ADDYI 5
MS / CNS AGENTS
2 GLATIRAMER ACETATE GLATOPA 5
3 DALFAMPRIDINE AMPYRA 5
3 DIMETHYL FUMARATE TECFIDERA 5
3 TERIFLUNOMIDE AUBAGIO 5
4 GLATIRAMER ACETATE COPAXONE 5
4 INTERFERON BETA-1A AVONEX 5
4 INTERFERON BETA-1A AVONEX PEN 5
4 INTERFERON BETA-1A/ALBUMIN REBIF 5
4 INTERFERON BETA-1A/ALBUMIN AVONEX ADMINISTRATION PACK 5
4 INTERFERON BETA-1B BETASERON 5
Macrolides / ANTIBACTERIALS
1 AZITHROMYCIN
1 CLARITHROMYCIN CLARITHROMYCIN ER
1 CLARITHROMYCIN
1 ERYTHROMYCIN BASE ERYTHROMYCIN
50 of 104
Macrolides / ANTIBACTERIALS (cont.)
1 ERYTHROMYCIN ETHYLSUCCINATE E.E.S. 400
1 ERYTHROMYCIN ETHYLSUCCINATE
1 ERYTHROMYCIN STEARATE ERYTHROCIN STEARATE
2 ERYTHROMYCIN BASE ERY-TAB
2 ERYTHROMYCIN ETHYLSUCCINATE E.E.S. 200
2 ERYTHROMYCIN ETHYLSUCCINATE ERYPED 400
2 ERYTHROMYCIN ETHYLSUCCINATE ERYPED 200
3 AZITHROMYCIN ZITHROMAX
3 AZITHROMYCIN ZMAX
Mast-Cell Stabilizers / OPHTHALMOLOGY

1 CROMOLYN SODIUM
3 NEDOCROMIL SODIUM ALOCRIL
Mast-Cell Stabilizers / RESPIRATORY AGENTS

1 CROMOLYN SODIUM
Meglitinides / BLOOD GLUCOSE REGULATORS

1 NATEGLINIDE
3 NATEGLINIDE STARLIX
Meglitinides / ENDOCRINE/DIABETES
1 REPAGLINIDE
3 REPAGLINIDE PRANDIN
Melatonin Receptor Agonist / AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH
3 TASIMELTEON HETLIOZ 5
Miotics / OPHTHALMOLOGY
1 PILOCARPINE HCL
Miscellaneous Anti-Infectives (Eent) / ANTIBACTERIALS

1 ACETIC ACID/HYDROCORTISONE HYDROCORTISONE-ACETIC ACID
Miscellaneous Anti-Infectives (Eent) / OTIC AGENTS

1 ACETIC ACID
1 ACETIC ACID/HYDROCORTISONE ACETASOL HC
Miscellaneous Anti-Infectives (Systemic) / ANTI - INFECTIVES

1 SULFAMETHOXAZOLE/TRIMETHOPRIM SULFAMETHOXAZOLE-TRIMETHOPRIM
51 of 104
Miscellaneous Anti-Infectives (Systemic) / ANTI - INFECTIVES (cont.)
3 METRONIDAZOLE FLAGYL ER
3 METRONIDAZOLE FLAGYL
Miscellaneous B-Lactam Antibiotics / ANTI - INFECTIVES

3 AZTREONAM LYSINE CAYSTON
Miscellaneous Gi Drugs / GI AGENTS

3 ALOSETRON HCL LOTRONEX
4 OCTREOTIDE ACETATE SANDOSTATIN 5
Monoamine Oxidase B Inhibitors / ANTIPARKINSON AGENTS

1 SELEGILINE HCL
3 SELEGILINE EMSAM
Monoamine Oxidase B Inhibitors / AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH
3 RASAGILINE MESYLATE AZILECT
Monoamine Transporter Inhibitor / AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH
3 TETRABENAZINE XENAZINE 5
Monoclonal Antibody / ANTINEOPLASTICS

4 ATEZOLIZUMAB FOR INJECTION TECENTRIQ 4
4 AVELUMAB INJECTION BAVENCIO 4
4 BRENTUXIMAB ADCETRIS 4
4 CANAKINUMAB ILARIS 5
4 DARATUMUMAB INJECTION DARZALEX 4
4 DENOSUMAB XGEVA 5
4 ELOTUZUMAB INJECTION EMPLICITI 4
4 NECITUMUMAB FOR INJECTION PORTRAZZA 4
4 OLARATUMAB INJECTION LARTRUVO 4
4 PEMBROLIZUMAB KEYTRUDA 4
Monoclonal Antibody / DERMATOLOGICAL AGENTS

4 DUPILUMAB SUBCUTANEOUS INJECTION DUPIXENT 5
Monoclonal Antibody / MUSCULOSKELETAL & RHEUMATOLOGY

4 DENOSUMAB PROLIA 4
52 of 104
Monoclonal Antibody / OFFICE ADMINISTERED
3 RESLIZUMAB INJECTION CINQAIR 4
4 MEPOLIZUMAB INJECTION NUCALA 4
4 OMALIZUMAB XOLAIR 4
4 RITUXIMAB RITUXAN 4
4 SYNAGIS PALIVIZUMAB 4
Mood Stabilizers / BIPOLAR AGENTS

1 CARBAMAZEPINE
1 LAMOTRIGINE
1 LITHIUM CARBONATE
1 LITHIUM CITRATE LITHIUM
1 VALPROATE SODIUM VALPROIC ACID
3 LITHIUM CARBONATE LITHOBID
Mucolytic Agents / RESPIRATORY AGENTS

1 ACETYLCYSTEINE
Multiple Sclerosis / CNS AGENTS

3 FINGOLIMOD HCL GILENYA 5
4 PEGINTERFERON ALFA-1A PLEGRIDY 5
Multiple Sclerosis / OFFICE ADMINISTERED

4 ALEMTUZUMAB LEMTRADA 4
4 NATALIZUMAB TYSABRI 4
4 OCRELIZUMAB INJECTION OCREVUS 4
Multivitamin Preparations / VITAMINS, HEMATINICS & ELECTROLYTES

1 FLUORIDE/IRON/VIT A,C TRI-VIT WITH FLUORIDE-IRON
1 FLUORIDE/VITAMINS A,C,AND D TRIPHLUORIVIT
1 MULTIVITAMINS WITH FLUORIDE MULTI-VITAMIN WITH FLUORIDE
1 MULTIVITAMINS WITH FLUORIDE PHLUORIVIT
1 MULTIVITS WITH IRON & FLUORIDE MULTI-VITAMIN W-FLUORIDE-IRON
1 PED MV A,C,D3 #21 W-FLUORIDE TRIPLE-VITAMIN W-FLUORIDE
1 PED MV A,C,D3 #21 W-FLUORIDE VITAMINS A,C,D & FLUORIDE
1 PED MV A,C,D3 #21 W-FLUORIDE TRI-VITAMIN WITH FLUORIDE
1 PEDI MVI NO.12/SODIUM FLUORIDE MVC-FLUORIDE
1 PNV COMBO #22/IRON/FA/OM3/DHA HEMENATAL OB + DHA
1 PNV NO.22/IRON CBN&GLUC/FA/DSS VINACAL
1 PNV W-O CA NO5/FE FUMARATE/FA PRENATAL-U 3
1 PNV WITH CA,NO.72/IRON,CARB/FA PRENATAL PLUS 3
3 - No copay
53 of 104
Multivitamin Preparations / VITAMINS, HEMATINICS & ELECTROLYTES (cont.)
1 PNV66/IRON FUMARATE/FA/DSS/DHA PNV-DHA + DOCUSATE
1 PNV66/IRON FUMARATE/FA/DSS/DHA FOLCAL DHA
1 PNV66/IRON FUMARATE/FA/DSS/DHA VEMAVITE-PRX 2
1 PNV77/SOD IRON EDTA& PS/FA/OM3 VENATAL COMPLETE DHA
1 PRENATAL NO.25/IRON/FA #6/DHA PRENA1
1 PRENATAL VIT 15/IRON CB/FA/DSS TRIADVANCE 3
1 PRENATAL VIT 15/IRON CB/FA/DSS PRENATAL AD 3
1 PRENATAL VIT 16/IRON CB/FA/DSS VINATE GT
1 PRENATAL VIT 18/IRON CB/FA/DSS VINATE ULTRA 3
1 PRENATAL VIT NO.78/IRON/FA PRENATABS FA 3
1 PRENATAL VIT/IRON FUMARATE/FA PRENATAL 19
1 PRENATAL VITAMINS#21, IRON, FA HEMENATAL OB
3 PED MV A,C,D3 #38 W-FLUORIDE TRI-VI-FLOR
3 PEDI MULTIVIT #37 W-FLUORIDE POLY-VI-FLOR
3 PN W-CA64/IRON CB&GL/FA/DSS/DH CITRANATAL 90 DHA
3 PNV #38/IRON FUM/FOLATE/DHA PRENATE DHA
3 PNV 18/FE,CARB/FA/DSS/UBI/DHA PREQUE 10
3 PNV COMBO #19/IRON/FOL AC/DHA PREFERA-OB ONE
3 PNV COMBO #22/IRON/FA/OM3/DHA PREFERA-OB PLUS DHA
3 PNV WITH CA,NO.71/IRON/FA VOL-PLUS
3 PNV WITH CA,NO63/IRON/FA/B6 CITRANATAL B-CALM
3 PNV#79/IRON/FA/LMFOLATE CA/DHA NEEVO DHA
3 PNV/FA/B6/CALCIUM PHOS/GINGER B-NEXA
3 PNV22/IRON CBN&GLUC/FA/DSS/DHA CITRANATAL DHA
3 PNV38/IRON CBN&GLUC/FA/DSS/DHA CITRANATAL ASSURE
3 PNV53/IRON FUM/FA/DOCUSATE/DHA NEXA PLUS
3 PNV66/IRON FUMARATE/FA/DSS/DHA PRENEXA
3 PNV69/IRON,CARBONYL/FA/DSS/DHA CITRANATAL HARMONY
3 PNV80/IRON FUMARATE/FA/DSS/DHA NEXA SELECT
3 PRENATAL NO.25/IRON/FA #6/DHA VITAMEDMD ONE RX
3 PRENATAL NO.39/IRON/FA #6/DHA VITAMEDMD PLUS RX
3 PRENATAL VIT #76/IRON,CARB/FA VOL-TAB RX
3 PRENATAL VIT NO.44/IRON/FA/DHA PRENATE MINI
3 PRENATAL VIT NO.78/IRON/FA VENATAL-FA
3 PRENATAL VIT#36/IRON/FA CMB#6 PRENATE ELITE
3 PRENATAL VIT#42/FA CMB#6 VITAMEDMD REDICHEW RX
3 PRENATAL VITAMINS#21, IRON, FA PREFERA OB
Mydriatics / OPHTHALMOLOGY
1 ATROPINE SULFATE ATROPINE CARE
1 ATROPINE SULFATE/PF ATROPINE SULFATE
1 CYCLOPENTOLATE HCL
1 HOMATROPINE HBR HOMATROPAIRE
2 CYCLOPENTOLATE HCL CYCLOGYL
2 SCOPOLAMINE HYDROBROMIDE ISOPTO HYOSCINE
3 HOMATROPINE HBR ISOPTO HOMATROPINE
NMDA Receptor Blocker / ANTIDEMENTIA AGENTS

3 MEMANTINE HCL NAMENDA
Nephropathic Cystinosis / ENDOCRINE

3 CYSTEAMINE PROCYSBI 5
3 - No copay
54 of 104
Neurotoxin / OFFICE ADMINISTERED
4 ONABOTULINUMTOXINA BOTOX 4
Nitrates And Nitrites / CARDIOVASCULAR

1 ISOSORBIDE DINITRATE
1 ISOSORBIDE MONONITRATE ISOSORBIDE MONONITRATE ER
1 NITROGLYCERIN NITRO-BID
2 NITROGLYCERIN NITROMIST
2 NITROGLYCERIN NITROSTAT
2 NITROGLYCERIN NITRO-DUR
3 ISOSORBIDE MONONITRATE IMDUR
Nitrogen Binding Agent / UROLOGICALS

3 GLYCEROL PHENYLBUTYRATE RAVICTI 5
Non-Nucleoside Reverse Transcriptase Inhibitor / ANTIVIRALS

1 NEVIRAPINE
2 DELAVIRDINE RESCRIPTOR
2 EFAVIRENZ SUSTIVA
2 ETRAVIRINE INTELENCE
2 RILPIVIRINE EDURANT
3 NEVIRAPINE VIRAMUNE
Nonsteroidal Anti-Inflammatory Agents / ANALGESICS/ANTI-INFLAMMATORY

1 BUTALBITAL/ASPIRIN/CAFFEINE BUTALBITAL-ASPIRIN-CAFFEINE
1 CELECOXIB 7
1 DICLOFENAC SODIUM
1 DICLOFENAC SODIUM/MISOPROSTOL DICLOFENAC SODIUM-MISOPROSTOL
1 ETODOLAC
1 IBUPROFEN
1 INDOMETHACIN
1 KETOPROFEN
1 KETOROLAC TROMETHAMINE
1 MELOXICAM
1 NABUMETONE
1 NAPROXEN
1 OXAPROZIN
1 PIROXICAM
1 SALSALATE
1 SULINDAC
2 NAPROXEN SODIUM NAPRELAN
3 ASPIRIN EXTENDED-RELEASE CAPSULES DURLAZA 5
3 BUTALBITAL/ASPIRIN/CAFFEINE FIORINAL
7 - Step Therapy
55 of 104
Nonsteroidal Anti-Inflammatory Agents / ANALGESICS/ANTI-INFLAMMATORY (cont.)
3 CELECOXIB CELEBREX 7
3 DICLOFENAC EPOLAMINE FLECTOR 5
3 DICLOFENAC POTASSIUM CAMBIA
3 DICLOFENAC POTASSIUM ZIPSOR
3 DICLOFENAC SODIUM PENNSAID 5
3 DICLOFENAC SODIUM VOLTAREN
3 DICLOFENAC SODIUM/MISOPROSTOL ARTHROTEC 75
3 DICLOFENAC SODIUM/MISOPROSTOL ARTHROTEC 50
3 INDOMETHACIN INDOCIN
3 KETOROLAC TROMETHAMINE SPRIX
3 MELOXICAM MOBIC
3 OXAPROZIN DAYPRO
Nucleoside/Nucleotide RT Inhibitors / ANTIVIRALS

1 ABACAVIR SULFATE ABACAVIR
1 LAMIVUDINE
1 ZIDOVUDINE
1 ZIDOVUDINE/LAMIVUDINE
2 ABACAVIR SULFATE/LAMIVUDINE EPZICOM
2 ABACAVIR/LAMIVUDINE/ZIDOVUDINE TRIZIVIR
2 EMTRICITABINE/RILPIVIRINE/TENOFOVIR ODFESEY
2 EMTRICITABINE/TENOFOVIR TRUVADA
2 LAMIVUDINE EPIVIR HBV
3 ABACAVIR SULFATE ZIAGEN
3 LAMIVUDINE/ZIDOVUDINE COMBIVIR
3 ZIDOVUDINE RETROVIR
Nucleosides And Nucleotides / ANTIVIRALS

1 ENTECAVIR
1 FAMCICLOVIR
2 ADEFOVIR DIPIVOXIL HEPSERA
2 TELBIVUDINE TYZEKA
3 ENTECAVIR BARACLUDE
3 FAMCICLOVIR FAMVIR
3 VALGANCICLOVIR HCL VALCYTE
ONCOLYTIC VIRUS / ANTINEOPLASTICS

4 TALIMOGENE LAHERPAREPVEC IMLYGIC 4
Ophthalmic Antiinflammatory / OPHTHALMOLOGY

4 DESAMETHASONE INTRAVITREAL OZURDEX 4
Opiate Agonists, Short Acting / ANALGESICS

1 ACETAMINOPHEN WITH CODEINE ACETAMINOPHEN-CODEINE
7 - Step Therapy
56 of 104
Opiate Agonists, Short Acting / ANALGESICS (cont.)
1 BUTALBIT/ACETAMIN/CAFF/CODEINE BUTALB-CAFF-ACETAMINOPH-CODEIN
1 CODEINE/BUTALBITAL/ASA/CAFFEIN BUTALBITAL COMPOUND-CODEINE
1 CODEINE/BUTALBITAL/ASA/CAFFEIN ASCOMP WITH CODEINE
1 HYDROCODONE BIT/ACETAMINOPHEN HYDROCODONE-ACETAMINOPHEN
1 HYDROCODONE/IBUPROFEN HYDROCODONE BIT-IBUPROFEN
1 HYDROCODONE/IBUPROFEN HYDROCODONE-IBUPROFEN
1 HYDROMORPHONE HCL
1 MEPERIDINE HCL
1 MORPHINE SULFATE
1 OXYCODONE HCL OXYCODONE CONCENTRATE
1 OXYCODONE HCL
1 OXYCODONE HCL/ACETAMINOPHEN OXYCODONE-ACETAMINOPHEN
1 OXYCODONE HCL/ACETAMINOPHEN ENDOCET
1 OXYCODONE HCL/ASPIRIN ENDODAN
1 OXYCODONE HCL/OXYCODON TER/ASA OXYCODONE-ASPIRIN
1 OXYMORPHONE HCL
1 TRAMADOL HCL
1 TRAMADOL HCL/ACETAMINOPHEN TRAMADOL HCL-ACETAMINOPHEN
2 HYDROMORPHONE HCL DILAUDID
2 METHADONE HCL
2 MORPHINE SULFATE AVINZA
2 MORPHINE SULFATE KADIAN
2 OXYCODONE HCL/ACETAMINOPHEN ROXICET
3 ACETAMINOPHEN WITH CODEINE TYLENOL-CODEINE NO.3
3 FENTANYL DURAGESIC
3 FENTANYL CITRATE FENTORA
3 FENTANYL CITRATE ABSTRAL
3 HYDROCODONE BIT/ACETAMINOPHEN VICODIN HP
3 HYDROCODONE BIT/ACETAMINOPHEN LORTAB
3 HYDROCODONE BIT/ACETAMINOPHEN NORCO
3 HYDROCODONE BIT/ACETAMINOPHEN VICODIN
3 HYDROCODONE BITARTRATE ZOHYDRO
3 HYDROCODONE BITARTRATE
3 HYDROCODONE/IBUPROFEN IBUDONE
3 HYDROCODONE/IBUPROFEN REPREXAIN
3 HYDROCODONE/IBUPROFEN VICOPROFEN
3 HYDROMORPHONE HCL EXALGO
3 OXYCODONE HCL/ACETAMINOPHEN PERCOCET
3 TAPENTADOL HCL NUCYNTA
3 TRAMADOL HCL RYBIX ODT
3 TRAMADOL HCL ULTRAM
Opiate Agonists,Long Acting / ANALGESICS

1 FENTANYL TRANSDERMAL FENTANYL
1 HYDROMORPHONE ER
1 MORPHINE SULFATE MORPHINE SULFATE ER
2 OXYCODONE HCL OXYCONTIN
3 HYDROCODONE BITARTRATE HYSINGLA ER
3 MORPHINE SULFATE MS CONTIN
3 OXYCODONE HCL XARTEMIS XR
3 OXYMORPHONE HCL OPANA ER
3 TAPENTADOL HCL NUCYNTA ER
3 TRAMADOL HCL ULTRAM ER
Opiate Antagonists / ANTI-ADDICTION/SUBSTANCE ABUSE

1 NALOXONE
57 of 104
Opiate Antagonists / ANTI-ADDICTION/SUBSTANCE ABUSE (cont.)
4 NALOXONE EVZIO 5
Opiate Antagonists / AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH

3 NALTREXONE HCL
Opiate Antagonists / GASTROINTESTINAL OTHER

3 METHYLNALTREXONE BROMIDE TABLETS RELISTOR 5
Opiate Antagonists / GI AGENTS

3 NALOXEGOL MOVANTIK 5
Opiate Antagonists / OBESITY

3 NALOXONE/BUPROPION CONTRAVE 5
Opiate Partial Agonists / ANALGESICS

3 BUPRENORPHINE BUTRANS
3 BUPRENORPHINE BUCCAL FILM BELBUCA
Opiate Partial Agonists / ANTI-ADDICTION/SUBSTANCE ABUSE

1 BUPRENORPHINE HCL/NALOXONE HCL BUPRENORPHINE/NALOXONE SL TABS 5
3 BUPRENORPHINE HCL/NALOXONE HCL SUBOXONE SL TABS 5
4 BUPRENORPHINE IMPLANT PROBUPHINE 4
Other Miscellaneous Therapeutic Agents / ANTINEOPLASTICS

4 OCTREOTIDE ACETATE 5
Other Miscellaneous Therapeutic Agents / DIAGNOSTICS & MISCELLANEOUS AGENTS

1 LEVOCARNITINE (WITH SUGAR) LEVOCARNITINE
3 LEVOCARNITINE CARNITOR SF
3 LEVOCARNITINE CARNITOR
Other Miscellaneous Therapeutic Agents / ENDOCRINE/DIABETES

3 CINACALCET HCL SENSIPAR 5
3 SAPROPTERIN DIHYDROCHLORIDE KUVAN
58 of 104
Other Miscellaneous Therapeutic Agents / UROLOGICALS
3 PENTOSAN POLYSULFATE SODIUM ELMIRON
Other Miscellaneous Therapeutic Agents / VITAMINS, HEMATINICS & ELECTROLYTES

3 BAICALIN/CATECHIN/CITRATED ZNC LIMBREL250
Oxazolidinone / ANTI - INFECTIVES

3 TEDIZOLID SIVEXTRO
Oxytocics / OBSTETRICS & GYNECOLOGY

1 METHYLERGONOVINE MALEATE
3 METHYLERGONOVINE MALEATE METHERGINE
PCSK9 INHIBITOR / CARDIOVASCULAR

4 ALIROCUMAB PRALUENT 5
4 EVOLOCUMAB REPATHA 5
PO4 scavengers / GENETIC DISORDERS

3 CARGLUMIC ACID CARBAGLU 5
Parasympathomimetic (Cholinergic Agents) / AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH
1 PYRIDOSTIGMINE BROMIDE
2 PYRIDOSTIGMINE BROMIDE MESTINON
Parasympathomimetic (Cholinergic Agents) / DIAGNOSTICS & MISCELLANEOUS AGENTS

1 CEVIMELINE HCL
2 CEVIMELINE HCL EVOXAC
Parasympathomimetic (Cholinergic Agents) / UROLOGICALS

1 BETHANECHOL CHLORIDE
Parasympathomimetics / ANTIMYASTHENIC AGNETS

1 NEOSTIGMINE
1 PYRIDOSTIGMINE
Parathyroid / ENDOCRINE
4 PARATHYROID HORMONE FOR INJECTION NATPARA 5
59 of 104
Parathyroid / ENDOCRINE/DIABETES
1 CALCITONIN,SALMON,SYNTHETIC CALCITONIN-SALMON
1 CALCITONIN,SALMON,SYNTHETIC FORTICAL
Parathyroid / MUSCULOSKELETAL & RHEUMATOLOGY

4 TERIPARATIDE FORTEO 5
Pediculicides/Scabicides / ANTIPARASITICS
3 NITAZOXANIDE ALINIA
Penicillins / ANTIBACTERIALS
1 AMOXICILLIN
1 AMOXICILLIN/POTASSIUM CLAV AMOXICILLIN-CLAVULANATE ER
1 AMOXICILLIN/POTASSIUM CLAV AMOX TR-POTASSIUM CLAVULANATE
1 AMPICILLIN TRIHYDRATE
1 CARBENICILLIN
1 DICLOXACILLIN SODIUM
1 PENICILLIN V POTASSIUM
2 AMOXICILLIN/POTASSIUM CLAV AUGMENTIN
4 NAFCILLIN NAFCIL 4
4 OXACILLIN 4
4 PENICILLIN G BICILLIN LA 4
4 PIPERACILLIN PIPRACIL 4
Pharmaceutical Aids / DERMATOLOGICAL AGENTS

3 PYRITHIONE ZINC ZINC PYRITHIONE
Pharmaceutical Aids / DIAGNOSTICS & MISCELLANEOUS AGENTS

2 PREGNENOLONE, MICRONIZED PREGNENOLONE MICRONIZED
3 PREGNENOLONE
Pharmaceutical Aids / ENDOCRINE/DIABETES

3 7-OXODEHYDROEPIANDROSTERONE,MC 7-KETO DHEA
Phenothiazine Derivatives / RESPIRATORY AGENTS

1 PHENYLEPHRINE HCL/PROMETH HCL PROMETHAZINE VC
1 PROMETHAZINE HCL PHENADOZ
1 PROMETHAZINE HCL
Phosphate-Removing Agents / CARDIOVASCULAR

3 FERRIC CITRATE AURYXIA
60 of 104
Phosphate-Removing Agents / GI AGENTS
1 CALCIUM ACETATE
1 SAVELAMER
2 SEVELAMER HCL RENAGEL
3 FERRIC CITRATE
3 LANTHANUM CARBONATE FOSRENOL
3 SEVELAMER CARBONATE RENVELA
3 SUCROFERRIC OXYHYDROXIDE VELPHORO
Phosphodiesterase Type 5 Inhibitors / CARDIOVASCULAR

ED AVANAFIL STENDRA 6
Phosphodiesterase Type 5 Inhibitors / RESPIRATORY AGENTS

1 SILDENAFIL CITRATE SILDENAFIL 5
3 SILDENAFIL CITRATE REVATIO 5
3 TADALAFIL ADCIRCA
Phosphodiesterase Type 5 Inhibitors / UROLOGICALS

ED SILDENAFIL CITRATE VIAGRA 6
ED TADALAFIL CIALIS 6
ED VARDENAFIL HCL STAXYN 6
ED VARDENAFIL HCL LEVITRA 6
Photosensitizer / DERMATOLOGICAL AGENTS

3 METHOXSALEN, RAPID OXSORALEN-ULTRA
Pituitary / ENDOCRINE/DIABETES
1 DESMOPRESSIN (NONREFRIGERATED) DESMOPRESSIN ACETATE
3 DESMOPRESSIN (NONREFRIGERATED) DDAVP
3 DESMOPRESSIN ACETATE STIMATE
Pituitary / IMMUNOLOGICAL AGENTS

4 SOMATROPIN HUMATROPE 5
4 SOMATROPIN NORDITROPIN FLEXPRO 5
4 SOMATROPIN GENOTROPIN 5
4 SOMATROPIN NUTROPIN AQ NUSPIN 5
4 SOMATROPIN NORDITROPIN NORDIFLEX 5
4 SOMATROPIN OMNITROPE 5
4 SOMATROPIN NUTROPIN AQ 5
Pituitary - Androgens / HORMONE: PITUITARY

1 ESTROGEN,ESTER/ME-TESTOSTERONE COVARYX H.S.
6 - Quantity Limit
61 of 104
Pituitary - Androgens / HORMONE: PITUITARY (cont.)
1 ESTROGEN,ESTER/ME-TESTOSTERONE EEMT H.S.
1 ESTROGEN,ESTER/ME-TESTOSTERONE ESTROGEN & METHYLTESTOSTERONE
1 ESTROGEN,ESTER/ME-TESTOSTERONE EEMT
3 METHYLTESTOSTERONE ANDROID
3 METHYLTESTOSTERONE
3 METHYLTESTOSTERONE METHITEST
3 TESTOSTERONE TESTIM
3 TESTOSTERONE AXIRON
3 TESTOSTERONE FORTESTA
4 TESTOSTERONE CYPIONATE 5
4 TESTOSTERONE ENANTHATE DELATESTRYL 5
Platelet Modifying Agents / BLOOD PRODUCT/MODIFIERS

1 ANAGRELIDE HCL
1 CILOSTAZOL
1 CLOPIDOGREL BISULFATE CLOPIDOGREL
1 TICLOPIDINE HCL
2 CLOPIDOGREL BISULFATE PLAVIX
3 ASPIRIN/DIPYRIDAMOLE AGGRENOX
3 PRASUGREL HCL EFFIENT
3 TICAGRELOR BRILINTA
Potassium Sparing Diuretic / CARDIOVASCULAR

1 SPIRONOLACT/HYDROCHLOROTHIAZID SPIRONOLACTONE-HCTZ
1 SPIRONOLACTONE
3 SPIRONOLACT/HYDROCHLOROTHIAZID ALDACTAZIDE
Potassium-Removing Agents / CARDIOVASCULAR

3 PATIROMER ORAL SUSPENSION VELTASSA
Potassium-Removing Agents / DIAGNOSTICS & MISCELLANEOUS AGENTS

1 SODIUM POLYSTYRENE SULFONATE KALEXATE
1 SODIUM POLYSTYRENE SULFONATE KIONEX
Potassium-Sparing Diuretics / CARDIOVASCULAR

1 AMILORIDE HCL
1 AMILORIDE/HYDROCHLOROTHIAZIDE AMILORIDE-HYDROCHLOROTHIAZIDE
1 TRIAMTERENE/HYDROCHLOROTHIAZID TRIAMTERENE-HCTZ
1 TRIAMTERENE/HYDROCHLOROTHIAZID TRIAMTERENE-HYDROCHLOROTHIAZID
3 TRIAMTERENE DYRENIUM
3 TRIAMTERENE/HYDROCHLOROTHIAZID DYAZIDE
3 TRIAMTERENE/HYDROCHLOROTHIAZID MAXZIDE-25 MG
Progestins / HORMONE: PROGESTINS

1 MEDROXYPROGESTERONE ACETATE
62 of 104
Progestins / HORMONE: PROGESTINS (cont.)
1 NORETHINDRONE ACETATE
1 PROGESTERONE
3 MEDROXYPROGESTERONE ACETATE PROVERA
3 PROGESTERONE,MICRONIZED ENDOMETRIN
3 PROGESTERONE,MICRONIZED PROGESTERONE
3 PROGESTERONE,MICRONIZED CRINONE
3 PROGESTERONE,MICRONIZED PROMETRIUM
4 HYDROXYPROGESTERONE CAPROATE MAKENA 5
4 PROGESTERONE PROGESTERONE IN OIL 2
Prokinetic Agents / GI AGENTS

1 METOCLOPRAMIDE HCL
3 METOCLOPRAMIDE HCL METOZOLV ODT
Prostacyclin Vasodilator / RESPIRATORY AGENTS

3 TREPROSTINIL ORENITRAM 5
Prostaglandins / GI AGENTS
1 MISOPROSTOL
Prostaglandins / HORMONE: PROSTAGLANDINS

1 LATANOPROST
2 BIMATOPROST LUMIGAN
2 TRAVOPROST TRAVATAN Z
3 ILOPROST VENTAVIS 5
3 LATANOPROST XALATAN
3 TAFLUPROST/PF ZIOPTAN
3 UNOPROSTONE RESCULA
Protease Inhibitors / ANTIVIRALS

2 ATAZANAVIR SULFATE REYATAZ
2 DARUNAVIR ETHANOLATE PREZISTA
2 FOSAMPRENAVIR CALCIUM LEXIVA
2 INDINAVIR CRIXIVAN
2 LOPINAVIR/RITONAVIR KALETRA
2 RITONAVIR NORVIR
2 SAQUINAVIR INVIRASE
2 TIPRANAVIR APTIVUS
Protease Inhibitors / CARDIOVASCULAR

3 VORAPAXAR ZONTIVITY
2 - Infertility
63 of 104
Proteasome Inhibitor / ANTINEOPLASTICS
4 BORTEZOMIB VELCADE 5
4 IXAZOMIB CAPSULES NINLARO 5
Protectants / GI AGENTS
1 SUCRALFATE
3 SUCRALFATE CARAFATE
Proteinase / OFFICE ADMINISTERED

4 COLLAGENASE CLOSTRIDIUM XIAFLEX 4
Proton-Pump Inhibitors / GI AGENTS

1 ESOMEPRAZOLE MAGNESIUM
1 LANSOPRAZOLE
1 OMEPRAZOLE
1 OMEPRAZOLE/SODIUM BICARBONATE OMEPRAZOLE-SODIUM BICARBONATE 5
1 PANTOPRAZOLE SODIUM
1 RABEPRAZOLE SODIUM RABEPRAZOLE
2 ESOMEPRAZOLE MAGNESIUM NEXIUM PACKETS
3 DEXLANSOPRAZOLE DEXILANT
3 ESOMEPRAZOLE MAGNESIUM NEXIUM
3 LANSOPRAZOLE PREVACID
3 LANSOPRAZOLE/AMOXICILN/CLARITH PREVPAC
3 OMEPRAZOLE PRILOSEC
3 OMEPRAZOLE/CLARITH/AMOXICILLIN OMECLAMOX-PAK
3 OMEPRAZOLE/SODIUM BICARBONATE ZEGERID 5
3 PANTOPRAZOLE SODIUM PROTONIX
3 RABEPRAZOLE SODIUM ACIPHEX
Quinolones / ANTIBACTERIALS
1 CIPROFLOXACIN HCL
1 LEVOFLOXACIN
1 OFLOXACIN
2 MOXIFLOXACIN HCL AVELOX
2 MOXIFLOXACIN HCL AVELOX ABC PACK
3 CIPROFLOXACIN HCL CIPRO
3 LEVOFLOXACIN LEVAQUIN
3 NORFLOXACIN NOROXIN
RESPIRATORY INHALANT COMBINATIONS / RESPIRATORY AGENTS

3 GLYCOPYRROLATE/FORMOTEROL FUMARATE BEVESPI AEROSPHERE
INHALATION
3 INDACATEROL/GLYCOPYRROLATE INHALATION UTIBRON NEOHALER
POWDER
64 of 104
Renin Inhibitors / CARDIOVASCULAR
2 ALISKIREN HEMIFUMARATE TEKTURNA
3 ALISKIREN/HYDROCHLOROTHIAZIDE TEKTURNA HCT
3 ALISKIREN/VALSARTAN VALTURNA 7
Replacement Preparations / RESPIRATORY AGENTS

1 SODIUM CHLORIDE FOR INHALATION SODIUM CHLORIDE
3 SODIUM CHLORIDE FOR INHALATION HYPER-SAL
Replacement Preparations / VITAMINS, HEMATINICS & ELECTROLYTES

1 POTASSIUM BICARBONATE/CIT AC POTASSIUM BICARBONATE
1 POTASSIUM BICARBONATE/CIT AC KLOR-CON-EF
1 POTASSIUM CHLORIDE KLOR-CON
1 POTASSIUM CHLORIDE
1 POTASSIUM CHLORIDE EPIKLOR
1 ZINC SULFATE
2 POTASSIUM BICARBONATE/CIT AC EFFER-K
2 POTASSIUM CHLORIDE K-TAB
Respiratory Smooth Muscle Relaxants / RESPIRATORY AGENTS

1 THEOPHYLLINE ANHYDROUS
2 THEOPHYLLINE ANHYDROUS THEO-24
Respiratory Tract Agents- Miscellaneous / RESPIRATORY AGENTS

2 TIOTROPIUM BROMIDE/OLODATEROL STIOLTO RESPIMAT
INHALATION SPRAY
3 ROFLUMILAST DALIRESP
Retinoids / ANTINEOPLASTICS
3 ALITRETINOIN PANRETIN 5
3 TRETINOIN VESANOID 5
Ribose Polymerase Inhibitor / ANTINEOPLASTICS

3 OLAPARIB LYNPARZA 5
3 RUCAPARIB TABLETS RUBRACA 5
Scabicides And Pediculicides / DERMATOLOGICAL AGENTS

1 PERMETHRIN
2 CROTAMITON EURAX
7 - Step Therapy
65 of 104
Scabicides And Pediculicides / DERMATOLOGICAL AGENTS (cont.)
3 BENZYL ALCOHOL ULESFIA
3 IVERMECTIN SOOLANTRA
3 SPINOSAD NATROBA
Second Generation Antihistamines / RESPIRATORY AGENTS

1 DESLORATADINE
1 FEXOFENADINE HCL
1 FEXOFENADINE/PSEUDOEPHEDRINE FEXOFENADINE-PSE ER
1 LEVOCETIRIZINE DIHYDROCHLORIDE
3 DESLORATADINE CLARINEX
3 DESLORATADINE/PSEUDOEPHEDRINE CLARINEX-D 12 HOUR
3 DESLORATADINE/PSEUDOEPHEDRINE CLARINEX-D 24 HOUR
3 FEXOFENADINE HCL ALLEGRA
3 FEXOFENADINE/PSEUDOEPHEDRINE ALLEGRA-D 24 HOUR
3 FEXOFENADINE/PSEUDOEPHEDRINE ALLEGRA-D 12 HOUR
3 LEVOCETIRIZINE DIHYDROCHLORIDE XYZAL
Selective Serotonin Agonists / ANTIMIGRAINE

1 NARATRIPTAN HCL 6
1 RIZATRIPTAN BENZOATE RIZATRIPTAN 6
1 RIZATRIPTAN MLT 6
1 SUMATRIPTAN 6
1 ZOLMITRIPTAN 6
2 ALMOTRIPTAN MALATE AXERT 6
2 ELETRIPTAN HBR RELPAX 6
2 ZOLMITRIPTAN ZOMIG SPRAY 6
3 FROVATRIPTAN SUCCINATE FROVA 6
3 NARATRIPTAN HCL AMERGE 6
3 RIZATRIPTAN BENZOATE MAXALT MLT 6
3 RIZATRIPTAN BENZOATE MAXALT 6
3 SUMATRIPTAN NASAL POWDER ONZETRA XSAIL 5
3 SUMATRIPTAN SUCC/NAPROXEN SOD TREXIMET 6
3 SUMATRIPTAN SUCCINATE SUMAVEL DOSEPRO 6
3 SUMATRIPTAN SUCCINATE IMITREX 6
3 ZOLMITRIPTAN ZOMIG ZMT TABLETS 6
3 ZOLMITRIPTAN ZOMIG TABLETS 6
Selective Serotonin Agonists / AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH
3 PAROXETINE HCL BRISDELLE
3 VORTIOXETINE BRINTELLIX
Selective Serotonin Reuptake Inhibitor / ANTIDEPRESSANTS

1 CITALOPRAM HYDROBROMIDE CITALOPRAM HBR
1 ESCITALOPRAM OXALATE
6 - Quantity Limit
66 of 104
Selective Serotonin Reuptake Inhibitor / ANTIDEPRESSANTS (cont.)
1 FLUOXETINE HCL CAPSULE FLUOXETINE HCL
1 FLUOXETINE HCL DR CAPSULE FLUOXETINE DR
1 FLUOXETINE HCL TABLETS FLUOXETINE HCL 5
1 PAROXETINE HCL
1 SERTRALINE HCL
3 CITALOPRAM HYDROBROMIDE CELEXA
3 ESCITALOPRAM OXALATE LEXAPRO
3 FLUOXETINE HCL CAPSULE PROZAC
3 FLUOXETINE HCL TABLETS SARAFEM 5
3 PAROXETINE HCL PAXIL CR
3 PAROXETINE HCL PAXIL
3 SERTRALINE HCL ZOLOFT
Serotonin Norepinephrine Reuptake Inhibitor / ANTI-ADDICTION/SUBSTANCE ABUSE

1 BUPROPION HCL BUPROPION HCL SR
Serotonin Norepinephrine Reuptake Inhibitor / ANTIDEPRESSANTS

1 BUPROPION HCL BUPROPION XL
1 BUPROPION HCL BUDEPRION XL
1 BUPROPION HCL
1 BUPROPION HCL BUDEPRION SR
1 DULOXETINE HCL DULOXETINE
1 VENLAFAXINE HCL
1 VENLAFAXINE HCL VENLAFAXINE HCL ER
2 BUPROPION HCL FORFIVO XL
3 BUPROPION HBR APLENZIN
3 BUPROPION HCL WELLBUTRIN XL
3 BUPROPION HCL WELLBUTRIN SR
3 BUPROPION HCL WELLBUTRIN
3 DULOXETINE HCL CYMBALTA
3 LEVOMILNACIPRAN FETZIMA
3 VENLAFAXINE HCL EFFEXOR XR
Serotonin Reptake Blocker / ANTIDEPRESSANTS, OTHER

1 TRAZODONE HCL
3 TRAZODONE HCL OLEPTRO ER
Serums / IMMUNOLOGICAL AGENTS

4 IMMUNE GLOBULIN,GAMMA(IGG) HIZENTRA 5
Skin And Mucous Membrane Agents- Misc. / DERMATOLOGICAL AGENTS

1 ADAPALENE
1 ADAPALENE 5
1 CALCIPOTRIENE CALCITRENE
67 of 104
Skin And Mucous Membrane Agents- Misc. / DERMATOLOGICAL AGENTS (cont.)
1 CALCIPOTRIENE
1 FLUOROURACIL
1 IMIQUIMOD
1 ISOTRETINOIN CLARAVIS 5
1 ISOTRETINOIN AMNESTEEM 5
1 ISOTRETINOIN ZENATANE 5
1 ISOTRETINOIN MYORISAN 5
1 PODOFILOX
1 TAZAROTENE TAZAROTENE 0.1% CREAM 5
2 AZELAIC ACID FINACEA
2 BECAPLERMIN REGRANEX 5
2 FLUOROURACIL CARAC
2 ISOTRETINOIN ABSORICA 5
2 PODOFILOX CONDYLOX
3 ACITRETIN SORIATANE
3 ADAPALENE DIFFERIN 5
3 ADAPALENE/BENZOYL PEROXIDE EPIDUO
3 AZELAIC ACID AZELEX
3 CALCIPOTRIENE DOVONEX
3 CALCIPOTRIENE SORILUX
3 CALCITRIOL VECTICAL
3 COLLAGENASE CLOSTRIDIUM HIST. SANTYL
3 DAPSONE ACZONE 5
3 DICLOFENAC SODIUM SOLARAZE 5
3 IMIQUIMOD ALDARA
3 IMIQUIMOD ZYCLARA
3 INGENOL MEBUTATE PICATO
3 PIMECROLIMUS ELIDEL
3 PODOPHYLLUM RESIN PODOCON-25
3 TACROLIMUS PROTOPIC
3 TAZAROTENE TAZORAC 0.05% 5
3 TAZAROTENE TAZORAC 0.1% CREAM 5
3 TAZAROTENE TAZORAC 0.1% GEL 5
3 TRYPSIN/BALSAM PERU/CASTOR OIL XENADERM
Skin And Mucous Membrane Agents- Misc. / DIAGNOSTICS & MISCELLANEOUS AGENTS
3 FORMALDEHYDE LAZERFORMALYDE
Skin And Mucous Membrane Agents- Misc. / GI AGENTS

3 NITROGLYCERIN RECTIV
Smoking Cessation / ANTI-ADDICTION/SUBSTANCE ABUSE

1 BUPROPION SR BUPROBAN 3
1 BUPROPION SR BUPROPION HCL SR 3
2 VARENICLINE TARTRATE CHANTIX 3
3 BUPROPION SR ZYBAN 3
3 - No copay
68 of 104
Sodium Channel Agents / AANTICONVULSANTS
3 CARBAMAZEPINE TEGRETOL
Sodium Channel Agents / ANTICONVULSANTS

1 CARBAMAZEPINE CARBAMAZEPINE ER
1 CARBAMAZEPINE CARBAMAZEPINE XR
1 CARBAMAZEPINE
1 OXCARBAZEPINE
1 PHENYTOIN
1 PHENYTOIN SODIUM EXTENDED
1 TOPIRAMATE
1 ZONISAMIDE
3 CARBAMAZEPINE CARBATROL
3 CARBAMAZEPINE TEGRETOL XR
3 OXCARBAZEPINE TRILEPTAL
3 PHENYTOIN SODIUM EXTENDED PHENYTEK
3 TOPIRAMATE TOPAMAX
Sodium Channel Agents / ANTIMIGRAINE PHOPHYLACTIC

1 TOPIRAMATE
Sodium Channel Inhibitor / AANTICONVULSANTS

3 PHENYTOIN SODIUM EXTENDED DILANTIN
Sodium Channel Inhibitor / ANTICONVULSANTS

3 ESLICARBAZEPINE APTIOM
3 RUFINAMIDE BANZEL 5
Sodium Glucose Transporter 2 / BLOOD GLUCOSE REGULATORS

2 CANAGLIFLOZIN INVOKANA
2 EMPAGLIFLOZIN JARDIANCE
Sodium Glucose Transporter 2 / ENDOCRINE/DIABETES

3 DAPAGLIFLOZIN FARXIGA
Somatostatin Analogue / ENDOCRINE

3 PASIREOTIDE SIGNIFOR 5
Stimulant guanylate cyclase / RESPIRATORY AGENTS

3 RIOCIGUAT ADEMPAS 5
69 of 104
Substance P Antagonist / ANTIEMETICS
3 APREPITANT EMEND
3 ROLAPITANT TABLETS VARUBI 6
Sulfonamides (Systemic) / ANTIBACTERIALS

1 SULFASALAZINE SULFAZINE
1 SULFASALAZINE SULFAZINE EC
Sulfonamides (Systemic) / INFLAMMATORY BOWEL AGENTS

1 SULFASALAZINE SULFASALAZINE DR
1 SULFASALAZINE
Sulfonylureas / BLOOD GLUCOSE REGULATORS

1 GLIMEPIRIDE
1 GLIPIZIDE GLIPIZIDE ER
1 GLIPIZIDE
1 GLIPIZIDE GLIPIZIDE XL
1 GLIPIZIDE/METFORMIN HCL GLIPIZIDE-METFORMIN
1 GLYBURIDE
1 GLYBURIDE/METFORMIN HCL GLYBURIDE-METFORMIN HCL
1 TOLAZAMIDE
1 TOLBUTAMIDE
3 GLIPIZIDE GLUCOTROL XL
3 GLYBURIDE/METFORMIN HCL GLUCOVANCE
Sympathomimetic (Adrenergic) Agents / DIAGNOSTICS & MISCELLANEOUS AGENTS

1 MIDODRINE HCL
Sympathomimetic (Adrenergic) Agents / RESPIRATORY AGENTS

1 ALBUTEROL SULFATE 6
1 EPINEPHRINE
1 TERBUTALINE SULFATE
2 FLUTICASONE/SALMETEROL ADVAIR DISKUS 6
2 FORMOTEROL FUMARATE FORADIL
2 SALMETEROL XINAFOATE SEREVENT DISKUS
3 LEVALBUTEROL HCL XOPENEX 6
3 PIRBUTEROL ACETATE MAXAIR AUTOHALER
T Cell Blocker / ANTINEOPLASTICS

4 BELATACEPT NULOJIX 5
TNF Inhibitor / RESPIRATORY AGENTS OTHER

3 PIRFENIDONE ESBRIET 5
6 - Quantity Limit
70 of 104
Tetracyclines / ANTIBACTERIALS
1 DEMECLOCYCLINE HCL
1 DOXYCYCLINE HYCLATE DR TABLETS DOXYCYCLINE HYCLATE 5
1 DOXYCYCLINE HYCLATE IR TABLETS DOXYCYCLINE HYCLATE
1 DOXYCYCLINE MONOHYDRATE
1 MINOCYCLINE HCL CAPSULES MINOCYCLINE HCL
1 MINOCYCLINE HCL TABLETS MINOCYCLINE HCL 5
1 TETRACYCLINE HCL
3 DOXYCYCLINE HYCLATE CAPSULE VIBRAMYCIN
3 DOXYCYCLINE HYCLATE DR TABLETS DORYX 5
3 DOXYCYCLINE MONOHYDRATE MONODOX
3 DOXYCYCLINE MONOHYDRATE ORACEA 5
3 MINOCYCLINE HCL CAPSULES MINOCIN
3 MINOCYCLINE HCL TABLET EXTENDED RELEASE SOLODYN 5
Thiazide Diuretics / CARDIOVASCULAR

1 CHLOROTHIAZIDE
1 CHLORTHALIDONE
1 HYDROCHLOROTHIAZIDE
1 INDAPAMIDE
1 METOLAZONE
3 CHLOROTHIAZIDE DIURIL
Thiazolidinediones / BLOOD GLUCOSE REGULATORS

1 PIOGLITAZONE HCL
1 PIOGLITAZONE HCL/METFORMIN HCL PIOGLITAZONE-METFORMIN
3 PIOGLITAZONE HCL ACTOS
3 PIOGLITAZONE HCL/METFORMIN HCL ACTOPLUS MET
3 PIOGLITAZONE HCL/METFORMIN HCL ACTOPLUS MET XR
Thyroid Agents / HORMONE: THYROID

1 LEVOTHYROXINE SODIUM LEVOXYL
1 LEVOTHYROXINE SODIUM
1 THYROID,PORK WESTHROID
1 THYROID,PORK NATURE-THROID
2 LIOTHYRONINE SODIUM
2 LIOTHYRONINE SODIUM PCCA T3 SODIUM DILUTION
2 THYROID,PORK ARMOUR THYROID
2 THYROID,PORK THYROID
2 THYROID,PORK NATURE-THROID
3 LEVOTHYROXINE SODIUM SYNTHROID
3 LEVOTHYROXINE SODIUM LEVOTHROID
3 LEVOTHYROXINE SODIUM TIROSINT
3 LIOTHYRONINE SODIUM CYTOMEL
Topical Analgesic / DERMATOLOGICAL AGENTS

3 CAPSAICIN QUTENZA 5
71 of 104
Treatment Resistant / ANTIPSYCHOTICS
1 CLOZAPINE
Tricyclic Antidepressants / ANTIDEPRESSANTS

1 AMITRIPTYLINE HCL
1 CLOMIPRAMINE HCL
1 DESIPRAMINE HCL
1 DOXEPIN HCL
1 IMIPRAMINE HCL
1 NORTRIPTYLINE HCL
3 CLOMIPRAMINE HCL ANAFRANIL
3 TRIMIPRAMINE MALEATE SURMONTIL
Tricyclic Antidepressants / ANTIMIGRAINE PHOPHYLACTIC

1 AMITRIPTYLINE HCL
Tryptophan Hydroxylase Inhibitor / GI AGENTS

3 TELOTRISTAT ETHYL TABLETS XERMELO 5
Typical/1st Generation / ANTIPSYCHOTICS

1 CHLORPROMAZINE HCL
1 FLUPHENAZINE HCL
1 HALOPERIDOL
1 LOXAPINE
1 PERPHENAZINE
1 PROLIXIN
1 STELAZINE
1 THIORIDAZINE HCL
1 THIOTHIXENE
4 HALOPERIDOL LACTATE 5
Tyrosine Kinase / ANTINEOPLASTICS

3 AFATINIB GILOTRIF 5
3 IRBRUTINIB IMBRUVICA 5
3 NILOTINIB TASIGNA 5
3 OSIMERTINIB TABLETS TAGRISSO 5
3 PALBOCICLIB IBRANCE 5
4 ALECTINIB CAPSULES ALECENSA 5
Tyrosine Kinase / DERMATOLOGICAL AGENTS

4 USTEKINUMAB STELARA 5
Tyrosine Kinase / RESPIRATORY AGENTS OTHER

3 NINTEDANIB OFEV 5
72 of 104
Uric Acid Synthesis Inhibitor / ANTIGOUT
1 ALLOPURINOL
Uric Acid Transporter 1 Inhibitor / ANTIGOUT

3 LESINURAD TABLETS ZURAMPIC 5
Uricosuric Agents / ANTIGOUT

1 COLCHICINE/PROBENECID PROBENECID-COLCHICINE
2 COLCHICINE COLCRYS
Uricosuric Agents / MUSCULOSKELETAL & RHEUMATOLOGY

1 PROBENECID
Uridine Triacetate / ENDOCRINE

4 URIDINE TRIACETATE XURIDEN 5
Urinary Anti-Infectives / ANTI - INFECTIVES

1 NITROFURANTOIN
1 NITROFURANTOIN MACROCRYSTAL NITROFURANTOIN
1 NITROFURANTOIN MONOHYD/M-CRYST NITROFURANTOIN MONO-MACRO
1 TRIMETHOPRIM
2 NITROFURANTOIN MACROCRYSTAL MACRODANTIN
3 FOSFOMYCIN TROMETHAMINE MONUROL
3 NITROFURANTOIN MONOHYD/M-CRYST MACROBID
Urinary Anti-Infectives / UROLOGICALS

3 MTH/ME BLUE/SOD PHOS/PHEN/HYOS URIBEL
Vaccines / ANTIBACTERIALS
4 MENINGOCOCCAL GR B VACCINE BEXSERO 4
Vaccines / IMMUNOLOGICAL AGENTS

3 CHOLERA VACCINE, LIVE, ORAL SUSPENSION VAXCHORA
3 TYPHOID VACC,LIVE,ATTENUATED VIVOTIF BERNA
Vascular Endothelial Growth Factor / OFFICE ADMINISTERED

4 AFLIBERCEPT EYLEA 4
73 of 104
Vasoconstrictors / OPHTHALMOLOGY
1 NAPHAZOLINE HCL
1 PHENYLEPHRINE HCL
Vasodilating Agents- Miscellaneous / RESPIRATORY AGENTS

3 AMBRISENTAN LETAIRIS 5
3 BOSENTAN TRACLEER 5
4 TREPROSTINIL REMODULIN 5
4 TREPROSTINIL TYVASO 5
Vasodilating Agents- Miscellaneous / UROLOGICALS

ED ALPROSTADIL EDEX 6
ED ALPROSTADIL MUSE 6
Vasodilator, Arterial/Venous / CARDIOVASCULAR

1 NITROGLYCERIN
1 NITROGLYCERIN NITROGLYCERIN PATCH
3 NITROGLYCERIN NITROLINGUAL
Vasopressin Related / CARDIOVASCULAR

3 TOLVAPTAN SAMSCA 5
Vitamin B Complex / VITAMINS, HEMATINICS & ELECTROLYTES

1 FOLIC ACID
3 ACETYL/METHYL-B12/LMEFOLATE CA CEREFOLIN NAC
3 CYANOCOBALAMIN (VITAMIN B-12) NASCOBAL
3 CYANOCOBALAMIN/FA/PYRIDOXINE FOLGARD RX
3 VIT B CMPLX 3/FA/VIT C/BIOTIN NEPHRO-VITE RX
4 CYANOCOBALAMIN (VITAMIN B-12) CYANOCOBALAMIN INJECTION 5
Vitamin D / ENDOCRINE/DIABETES
1 CALCITRIOL
2 PARICALCITOL ZEMPLAR
3 CALCIFEDIOL EXTENDED-RELEASE CAPSULES RAYALDEE
3 DOXERCALCIFEROL HECTOROL
Vitamin D / VITAMINS, HEMATINICS & ELECTROLYTES

1 ERGOCALCIFEROL (VITAMIN D2) VITAMIN D2
Xanthine Oxidase Inhibitor / ANTIGOUT

3 FEBUXOSTAT ULORIC 5
6 - Quantity Limit
74 of 104
integrin receptor antagonist / OFFICE ADMINISTERED
4 VEDOLIZUMAB ENTYVIO 4
75 of 104
Index
7 A (cont.)
7-KETO DHEA 60 ADEFOVIR DIPIVOXIL 56
7-OXODEHYDROEPIANDROSTERONE,MC 60 ADEMPAS 69
ADENOCARD 13
A ADENOSINE 13
ABACAVIR 56 ADLYXIN 46
ABACAVIR SULFATE 56 ADO-TRASTUZUMAB 43
ABACAVIR SULFATE/LAMIVUDINE 56 ADVAIR DISKUS 70
ABACAVIR/LAMIVUDINE/ZIDOVUDINE 56 ADVAIR HFA 35
ABATACEPT 37 ADVATE 44
ABILIFY 23, 27 ADVICOR 38
ABILIFY DISCMELT 23 ADYNOVATE 17
ABIRATERONE ACETATE 20 AEROCHAMBER 36
ABSORICA 68 AEROCHAMBER MAX 36
ABSTRAL 57 AEROCHAMBER MV 36
ACAMPROSATE CALCIUM 5 AEROCHAMBER PLUS 36
ACANYA 14 AEROCHAMBER WITH FLOWSIGNAL 36
ACARBOSE 7 AEROCHAMBER Z-STAT PLUS 36
ACCOLATE 49 AFATINIB 72
ACCUPRIL 10 AFEDITAB CR 36
ACCURETIC 10 AFINITOR 20
ACETAMINOPHEN WITH CODEINE 56, 57 AFLIBERCEPT 73
ACETAMINOPHEN-CODEINE 56 AFREZZA 47
ACETASOL HC 51 AFSTYLA 17
ACETAZOLAMIDE 29 AGALSIDASE BETA 39
ACETIC ACID 51 AGGRENOX 62
ACETIC ACID/HYDROCORTISONE 51 AK-POLY-BAC 13
ACETYL/METHYL-B12/LMEFOLATE CA 74 AKNE-MYCIN 14
ACETYLCYSTEINE 53 AKYNZEO 4
ACIPHEX 64 ALAMAST 12
ACITRETIN 68 ALBENDAZOLE 10
ACLIDINIUM BROMIDE 19 ALBENZA 10
ACTEMRA 46 ALBIGLUTIDE 46
ACTEMRA SQ 46 ALBUTEROL SULFATE 26, 70
ACTHAR H.P. 34 ALCAFTADINE 12
ACTIGALL 31 ALCLOMETASONE DIPROPIONATE 11
ACTIVELLA 40 ALDACTAZIDE 62
ACTONEL 28 ALDARA 68
ACTOPLUS MET 71 ALECENSA 72
ACTOPLUS MET XR 71 ALECTINIB CAPSULES 72
ACTOS 71 ALEMTUZUMAB 53
ACULAR 39 ALENDRONATE SODIUM 28
ACULAR LS 39 ALENDRONATE SODIUM/VITAMIN D3 28
ACUVAIL 39 ALFUZOSIN 24
ACYCLOVIR 18 ALFUZOSIN HCL 7
ACYCLOVIR/HYDROCORTISONE 22 ALINIA 20, 60
ACZONE 68 ALIROCUMAB 59
ADALAT CC 36 ALISKIREN HEMIFUMARATE 65
ADALIMUMAB 37 ALISKIREN/HYDROCHLOROTHIAZIDE 65
ADAPALENE 67, 68 ALISKIREN/VALSARTAN 65
ADAPALENE/BENZOYL PEROXIDE 68 ALITRETINOIN 65
ADCETRIS 52 ALLEGRA 66
ADCIRCA 61 ALLEGRA-D 12 HOUR 66
ADDERALL 4 ALLEGRA-D 24 HOUR 66
ADDERALL XR 4 ALLOPURINOL 73
ADDYI 50 ALMOTRIPTAN MALATE 66
76 of 104
A (cont.) A (cont.)
ALOCRIL 51 AMRIX 30
ALOGLIPTIN 37 ANAFRANIL 72
ALOMIDE 12 ANAGRELIDE HCL 62
ALORA 40 ANAKINRA 37
ALOSETRON HCL 52 ANALPRAM HC 12
ALPHAGAN P 7 ANASTROZOLE 23
ALPRAZOLAM 25, 27 ANDRODERM 9
ALPRAZOLAM ER 25 ANDROGEL 9
ALPRAZOLAM ODT 25 ANDROID 62
ALPRAZOLAM XR 25 ANGELIQ 41
ALPROLIX 44 ANORO ELLIPTA 19
ALPROSTADIL 74 ANTABUSE 5
ALREX 34 ANTARA 41
ALTABAX 14 ANTHRALIN 48
ALTACE 10 ANTIHEMOPH.FVIII PLAS/ALB FREE 44
ALTAVERA 32 ANTIHEMOPHILIC FACTOR 17
ALTOPREV 45 ANTIHEMOPHILIC FACTOR RECOMBINANT 17
ALUMINUM CHLORIDE 23 ANTIHEMOPHYLIC FACTOR VIII, RECOMBINANT 17
ALVESCO 35 ANTIHEMOPHYLIC FACTOR [RECOMBINANT]
ALYACEN 33 PEGYLATED INJECTION 17
AMANTADINE 12, 37 ANTIPY/BENZOCAINE/POLICOS NO.1 49
AMANTADINE HCL 12, 37 ANTIPYRINE-BENZOCAINE 49
AMBIEN 23 ANTIPYRINE/BENZOCAINE 49
AMBIEN CR 23 ANTIPYRINE/BENZOCAINE/GLYCERIN 49
AMBRISENTAN 74 ANTIVERT 18
AMERGE 66 ANUCORT-HC 12
AMETHIA 32 ANUSOL-HC 12
AMETHIA LO 32 ANZEMET 4
AMETHYST 32 APHTHASOL 39
AMIKACIN 8 APIDRA 47
AMILORIDE HCL 62 APIDRA SOLOSTAR 47
AMILORIDE-HYDROCHLOROTHIAZIDE 62 APIXABAN 27
AMILORIDE/HYDROCHLOROTHIAZIDE 62 APLENZIN 67
AMINOCAPROIC ACID 44 APOKYN 38
AMIODARONE HCL 13 APOMORPHINE 38
AMITIZA 49 APREMILAST 45
AMITRIPTYLINE HCL 72 APREPITANT 70
AMLEXANOX 39 APRI 32
AMLODIPINE BES/OLMESARTAN MED 36 APRISO 11
AMLODIPINE BESYLATE 36 APTIOM 69
AMLODIPINE BESYLATE-BENAZEPRIL 36 APTIVUS 63
AMLODIPINE BESYLATE/BENAZEPRIL 36 ARANELLE 32
AMLODIPINE-ATORVASTATIN 45 ARANESP 15
AMLODIPINE/ATORVASTATIN 45 ARAVA 37
AMLODIPINE/VALSARTAN 28 ARCAPTA NEOHALER 26
AMLODIPINE/VALSARTAN/HCTZ 28 ARESTIN 13
AMMONIUM LACTATE 25 ARFORMOTEROL TARTRATE 26
AMNESTEEM 68 ARIMIDEX 23
AMOX TR-POTASSIUM CLAVULANATE 60 ARIPIPRAZOLE 23, 27
AMOXAPINE 44 ARIXTRA 28
AMOXICILLIN 60 ARMODAFINIL 10
AMOXICILLIN-CLAVULANATE ER 60 ARMOUR THYROID 71
AMOXICILLIN/POTASSIUM CLAV 60 ARNUITY ELLIPTA 34
AMPHET ASP/AMPHET/D-AMPHET 4 ARTANE 15
AMPHETAMINE SALT COMBO 4 ARTHROTEC 50 56
AMPICILLIN TRIHYDRATE 60 ARTHROTEC 75 56
AMPYRA 50 ASACOL 8
77 of 104
A (cont.) A (cont.)
ASACOL HD 8 AZELASTINE HCL 12
ASCOMP WITH CODEINE 57 AZELASTINE/FLUTICASONE 12
ASENAPINE MALEATE 23 AZELEX 68
ASFOTASE ALFA INJECTION 43 AZILECT 52
ASMANEX 35 AZILSARTAN MED/CHLORTHALIDONE 9
ASPIRIN EXTENDED-RELEASE CAPSULES 55 AZILSARTAN MEDOXOMIL 9
ASPIRIN/DIPYRIDAMOLE 62 AZITHROMYCIN 14, 50, 51
ASTELIN 12 AZOPT 29
ASTEPRO 12 AZOR 36
ATACAND 9 AZTREONAM 27
ATACAND HCT 9 AZTREONAM LYSINE 52
ATAZANAVIR SULFATE 63 AZURETTE 32
ATELVIA 28
ATENOLOL 26 B
ATENOLOL-CHLORTHALIDONE 26 B-NEXA 54
ATENOLOL/CHLORTHALIDONE 26 BACITRACIN 13
ATEZOLIZUMAB FOR INJECTION 52 BACITRACIN/POLYMYXIN B SULFATE 13
ATIVAN 25 BACLOFEN 42
ATOMOXETINE HCL 4 BACTROBAN 14
ATOPICLAIR 39 BACTROBAN NASAL 14
ATORVASTATIN CALCIUM 45 BAICALIN/CATECHIN/CITRATED ZNC 59
ATOVAQUONE-PROGUANIL HCL 19 BALSALAZIDE DISODIUM 11
ATOVAQUONE/PROGUANIL HCL 19 BALZIVA 33
ATRALIN 30 BANZEL 69
ATRAPRO HYDROGEL 39 BARACLUDE 56
ATRIPLA 21 BAVENCIO 52
ATROPINE CARE 54 BECAPLERMIN 68
ATROPINE SULFATE 54 BECLOMETHASONE DIPROPIONATE 34
ATROPINE SULFATE/PF 54 BECONASE AQ 34
ATROVENT HFA 19 BEDAQUILINE 22
AUBAGIO 50 BELATACEPT 70
AUGMENTIN 60 BELBUCA 58
AURAX 49 BELEODAQ 45
AURODEX 49 BELIMUMAB 24
AURYXIA 60 BELINOSTAT 45
AUSTEDO 30 BELLADONNA-PHENOBARBITAL 21
AVALIDE 9 BELVIQ 4
AVANAFIL 61 BENAZEPRIL HCL 9
AVAPRO 9 BENAZEPRIL-HYDROCHLOROTHIAZIDE 9
AVASTIN 13 BENAZEPRIL/HYDROCHLOROTHIAZIDE 9
AVELOX 64 BENDAMUSTINE 6
AVELOX ABC PACK 64 BENICAR 9
AVELUMAB INJECTION 52 BENICAR HCT 9
AVIANE 32 BENLYSTA 24
AVINZA 57 BENZAC AC 48
AVITA 30 BENZACLIN 14
AVODART 4 BENZAMYCINPAK 14
AVONEX 50 BENZEFOAM ULTRA 48
AVONEX ADMINISTRATION PACK 50 BENZEPRO 48
AVONEX PEN 50 BENZONATATE 22
AXERT 66 BENZOYL PEROXIDE 48
AXIRON 62 BENZOYL PEROXIDE/HYDROCORTISON 5
AZACTAM 27 BENZTROPINE MESYLATE 15
AZASITE 14 BENZYL ALCOHOL 66
AZATHIOPRINE 45 BEPOTASTINE BESILATE 12
AZELAIC ACID 68 BEPREVE 12
AZELASTINE 12 BESIFLOXACIN HCL 14
78 of 104
B (cont.) B (cont.)
BESIVANCE 14 BROMDAY 39
BETA-VAL 5 BROMFED DM 22
BETAMETHASONE DIPROPIONATE 5 BROMFENAC SODIUM 39
BETAMETHASONE VALERATE 5 BROMOCRIPTINE MESYLATE 37
BETASERON 50 BROMPHENIRAMIN/PE/DEXTROMETHOR 22
BETAXOLOL HCL 26 BROVANA 26
BETHANECHOL CHLORIDE 59 BUDEPRION SR 67
BETIMOL 27 BUDEPRION XL 67
BETOPTIC S 26 BUDESONIDE 5, 34, 35
BEVACIZUMAB 13 BUDESONIDE EC 5
BEVESPI AEROSPHERE 64 BUDESONIDE/FORMOTEROL FUMARATE 34
BEXSERO 73 BUMETANIDE 50
BEYAZ 33 BUPRENORPHINE 58
BEZLOTOXUMAB INJECTION 15 BUPRENORPHINE BUCCAL FILM 58
BIAFINE 39 BUPRENORPHINE HCL/NALOXONE HCL 58
BICALUTAMIDE 19 BUPRENORPHINE IMPLANT 58
BICILLIN LA 60 BUPRENORPHINE/NALOXONE SL TABS 58
BILTRICIDE 10 BUPROBAN 68
BIMATOPROST 63 BUPROPION HBR 67
BINOSTO 28 BUPROPION HCL 67
BISAC/NACL/NAHCO3/KCL/PEG 3350 49 BUPROPION HCL SR 67, 68
BISMUTH SAL/METRONID/TETRACYC 15 BUPROPION SR 68
BISMUTH TRIBROMOPH/PETROLATUM 36 BUPROPION XL 67
BISMUTH/METRONID/TETRACYCLINE 15 BUSPIRONE HCL 23
BISOPROLOL FUMARATE 26 BUSULFAN 6
BISOPROLOL FUMARATE/HCTZ 26 BUTALB-CAFF-ACETAMINOPH-CODEIN 57
BISOPROLOL-HYDROCHLOROTHIAZIDE 26 BUTALB/ACETAMINOPHEN/CAFFEINE 8
BLEPH-10 14 BUTALBIT/ACETAMIN/CAFF/CODEINE 57
BLEPHAMIDE 14 BUTALBITAL COMPOUND-CODEINE 57
BLEPHAMIDE S.O.P. 14 BUTALBITAL-ACETAMINOPHEN-CAFFE 8
BOCEPREVIR 18 BUTALBITAL-ASPIRIN-CAFFEINE 55
BONIVA 28 BUTALBITAL/ACETAMINOPHEN 8
BORTEZOMIB 64 BUTALBITAL/ASPIRIN/CAFFEINE 55
BOSENTAN 74 BUTRANS 58
BOTOX 55 BYDUREON 46
BP 10-1 48 BYDUREON BCISE 46
BP WASH 48 BYETTA 46
BP WASH ACNE TREATMENT 48 BYSTOLIC 26
BPO 48 Basaglar KwikPen 47
BRAVELLE 43
BREATHERITE 35 C
BRENTUXIMAB 52 C1 ESTERASE INHIBITOR 28
BREO ELLIPTA 35 CABERGOLINE 38
BREVICON 33 CABOMETYX 20
BREXPIPRAZOLE 24 CABOZANTINIB 20
BRIELLYN 32 CAFERGOT 40
BRILINTA 62 CALAN SR 29
BRIMONIDINE TARTRATE 7 CALCIFEDIOL EXTENDED-RELEASE CAPSULES 74
BRIMONIDINE TARTRATE/TIMOLOL 7 CALCIPOTRIENE 67, 68
BRIMONIDINE TOPICAL 7 CALCIPOTRIENE/BETAMETHASONE 5
BRINTELLIX 66 CALCITONIN,SALMON,SYNTHETIC 60
BRINZOLAMIDE 29 CALCITONIN-SALMON 60
BRISDELLE 66 CALCITRENE 67
BRIVARACETAM FOR INJECTION 16 CALCITRIOL 68, 74
BRIVARACETAM ORAL SOLUTION 16 CALCIUM ACETATE 61
BRIVARACETAM TABLETS 16 CAMBIA 56
BRIVIACT 16 CAMILA 32
79 of 104
C (cont.) C (cont.)
CAMPRAL 5 CEFOTAXIME 31
CAMRESE 32 CEFOTETAN 31
CAMRESE LO 32 CEFOXITAN 31
CANAGLIFLOZIN 69 CEFPROZIL 30
CANAKINUMAB 52 CEFRADINE 31
CANASA 11 CEFTIBUTEN 31
CANDESARTAN 9 CEFTIBUTEN DIHYDRATE 31
CANDESARTAN CILEXETIL 9 CEFTIN 31
CANDESARTAN-HYDROCHLOROTHIAZID 9 CEFUROXIME 31
CANDESARTAN/HYDROCHLOROTHIAZID 9 CEFUROXIME AXETIL 31
CAPASTAT 8 CELEBREX 56
CAPECITABINE 20 CELECOXIB 55, 56
CAPEX SHAMPOO 11 CELEXA 67
CAPHOSOL 35 CELLCEPT 46
CAPREOMYCIN 8 CELONTIN 16
CAPSAICIN 71 CENESTIN 40
CAPTOPRIL 9 CEPHALEXIN 31
CAPTOPRIL-HYDROCHLOROTHIAZIDE 9 CERDELGA 39
CAPTOPRIL/HYDROCHLOROTHIAZIDE 9 CEREFOLIN NAC 74
CARAC 68 CERITINIB 48
CARAFATE 64 CERTOLIZUMAB PEGOL 42
CARBAGLU 59 CETACAINE 21
CARBAMAZEPINE 16, 53, 69 CETRORELIX ACETATE 43
CARBAMAZEPINE ER 69 CETROTIDE 43
CARBAMAZEPINE XR 69 CEVIMELINE HCL 59
CARBATROL 69 CHANTIX 68
CARBENICILLIN 60 CHERATUSSIN AC 22
CARBIDOPA 20 CHERATUSSIN DAC 22
CARBIDOPA-LEVODOPA 38 CHLORAL HYDRATE 23
CARBIDOPA-LEVODOPA-ENTACAPONE 38 CHLORAMBUCIL 6
CARBIDOPA/LEVODOPA 38 CHLORDIAZEPOXIDE HCL 25
CARBIDOPA/LEVODOPA/ENTACAPONE 38 CHLORDIAZEPOXIDE-CLIDINIUM 19
CARDENE SR 36 CHLORDIAZEPOXIDE/CLIDINIUM BR 19
CARDIZEM CD 29 CHLORHEXIDINE GLUCONATE 38
CARDIZEM LA 29 CHLOROQUINE 20
CARDURA XL 7 CHLOROQUINE PHOSPHATE 18
CARGLUMIC ACID 59 CHLOROTHIAZIDE 71
CARIPRAZINE 24 CHLORPROMAZINE HCL 72
CARISOPRODOL 30 CHLORTHALIDONE 71
CARMUSTINE 6 CHLORZOXAZONE 30
CARNITOR 58 CHOLBAM 24
CARNITOR SF 58 CHOLERA VACCINE, LIVE, ORAL SUSPENSION 73
CARTIA XT 29 CHOLESTYRAMINE 27
CARVEDILOL 26 CHOLESTYRAMINE (WITH SUGAR) 27
CARVEDILOL PHOSPHATE 26 CHOLESTYRAMINE LIGHT 27
CAYSTON 52 CHOLESTYRAMINE/ASPARTAME 27
CAZIANT 32 CHOLIC ACID CAPSULES 24
CEDAX 31 CHORIONIC GONADOTROPIN 43
CEENU 6 CHORIONIC GONADOTROPIN, HUMAN 43
CEFACLOR 30 CIALIS 61
CEFADROXIL 30 CICLESONIDE 34, 35
CEFADROXIL HYDRATE 30 CICLOPIROX 17
CEFAZOLIN 30 CICLOPIROX/NAIL LACQ/FT DEOD#4 17
CEFDINIR 30 CIDOFOVIR 10
CEFEPIME 31 CILOSTAZOL 62
CEFIXIME 31 CILOXAN 14
CEFOTAN 31 CIMETIDINE 44
80 of 104
C (cont.) C (cont.)
CIMZIA 42 CLORAZEPATE DIPOTASSIUM 25
CINACALCET HCL 58 CLOTRIMAZOLE 17, 24
CINQAIR 53 CLOTRIMAZOLE-BETAMETHASONE 5
CIPRO 64 CLOTRIMAZOLE/BETAMETHASONE DIP 5
CIPRO HC 13 CLOZAPINE 72
CIPRODEX 13 COAGADEX 17
CIPROFLOXACIN HCL 13, 14, 64 COAGULATION FACTOR IX 44
CIPROFLOXACIN HCL/DEXAMETH 13 COAGULATION FACTOR IX RECOMBINANT FOR INJ
CIPROFLOXACIN/FLUOCINOLONE ACETONIDE 13 17
CIPROFLOXACIN/HYDROCORTISONE 13 COAGULATION FACTOR IX, RECOMBINANT 17
CISPLATIN 6 COAGULATION FACTOR VIII, RECOMBINANT 17
CITALOPRAM HBR 66 COAGULATION FACTOR X [HUMAN] FOR INJECTION
CITALOPRAM HYDROBROMIDE 66, 67 17
CITRANATAL 90 DHA 54 COAGULATION FACTOR XIII 44
CITRANATAL ASSURE 54 COAL TAR 48
CITRANATAL B-CALM 54 COBICISTAT 10
CITRANATAL DHA 54 COBIMETINIB TABLETS 50
CITRANATAL HARMONY 54 CODEINE/BUTALBITAL/ASA/CAFFEIN 57
CITRIC ACID/SODIUM CITRATE 6 CODEINE/PROMETHAZINE HCL 22
CLAFORAN 31 COLCHICINE 73
CLARAVIS 68 COLCHICINE/PROBENECID 73
CLARIFOAM EF 48 COLCRYS 73
CLARINEX 66 COLESEVELAM HCL 27
CLARINEX-D 12 HOUR 66 COLESTIPOL HCL 27
CLARINEX-D 24 HOUR 66 COLLAGENASE CLOSTRIDIUM 64
CLARITHROMYCIN 50 COLLAGENASE CLOSTRIDIUM HIST. 68
CLARITHROMYCIN ER 50 COLOCORT 11
CLEANSING WASH 49 COLY-MYCIN S 13
CLENIA 48 COLYTE WITH FLAVOR PACKETS 49
CLEOCIN 15 COMBIGAN 7
CLEOCIN HCL 15 COMBIPATCH 41
CLEOCIN PALMITATE 15 COMBIVENT 19
CLIMARA 40 COMBIVENT RESPIMAT 19
CLIMARA PRO 40 COMBIVIR 56
CLINDAGEL 14 COMETRIQ 20
CLINDAMYCIN HCL 15 COMPLERA 21
CLINDAMYCIN PALMITATE HCL 15 COMPRO 18
CLINDAMYCIN PHOS-BENZOYL PEROX 14 COMTAN 30
CLINDAMYCIN PHOS/BENZOYL PEROX 14 CONCERTA 10
CLINDAMYCIN PHOSPHATE 14, 15 CONDYLOX 68
CLINDAMYCIN-BENZOYL PEROXIDE 14 CONTRAVE 58
CLINDAMYCIN/TRETINOIN 14 COPAXONE 50
CLOBAZAM 25 COPEGUS 18
CLOBETASOL EMOLLIENT 11 CORDRAN 11
CLOBETASOL PROPIONATE 11 CORDRAN SP 11
CLOBETASOL PROPIONATE/EMOLL 11 COREG 26
CLOBEX 11 COREG CR 26
CLOCORTOLONE PIVALATE 11 CORGARD 26
CLODERM 11 CORMAX 11
CLOFAZIMINE 49 CORTEF 5
CLOMIPHENE CITRATE 40 CORTICOTROPIN 5, 34
CLOMIPRAMINE HCL 72 CORTIFOAM 12
CLONAZEPAM 25 CORTISONE ACETATE 5
CLONIDINE 4, 6 CORTISPORIN-TC 13
CLONIDINE HCL 7 COSENTYX 47
CLOPIDOGREL 62 COSOPT 29
CLOPIDOGREL BISULFATE 28, 62 COSOPT PF 29
81 of 104
C (cont.) D (cont.)
COTELLIC 50 DARZALEX 52
COUMADIN 15 DASATINIB 20
COVARYX H.S. 61 DASETTA 33
COZAAR 9 DAYPRO 56
CREON 36 DAYTRANA 10
CRESEMBA 24 DDAVP 61
CRESTOR 45 DEFERASIROX 31
CRINONE 63 DEFLAZACORT 34
CRIXIVAN 63 DELATESTRYL 62
CRIZOTINIB 20 DELAVIRDINE 55
CROFELEMER 16 DEMECLOCYCLINE HCL 71
CROMOLYN SODIUM 51 DENAVIR 22
CROTAMITON 65 DENOSUMAB 52
CRYSELLE 33 DEPAKOTE 42
CUTIVATE 11 DEPAKOTE ER 42
CYANOCOBALAMIN (VITAMIN B-12) 74 DEPAKOTE SPRINKLE 42
CYANOCOBALAMIN INJECTION 74 DEPO-ESTRADIOL 41
CYANOCOBALAMIN/FA/PYRIDOXINE 74 DEPO-TESTOSTERONE 9
CYCLAFEM 32 DERMA-SMOOTHE-FS 11
CYCLOBENZAPRINE HCL 30 DERMOTIC 34
CYCLOGYL 54 DESAMETHASONE INTRAVITREAL 56
CYCLOPENTOLATE HCL 54 DESIPRAMINE HCL 72
CYCLOPHOSPHAMIDE 6 DESLORATADINE 66
CYCLOSET 37 DESLORATADINE/PSEUDOEPHEDRINE 66
CYCLOSPORINE 38, 46 DESMOPRESSIN (NONREFRIGERATED) 61
CYCLOSPORINE MODIFIED 46 DESMOPRESSIN ACETATE 61
CYCLOSPORINE, MODIFIED 46 DESOG-ET ESTRA/ETHIN ESTRA 31, 32, 33
CYMBALTA 67 DESOGEN 33
CYPROHEPTADINE HCL 41 DESOGESTREL-ETHINYL ESTRADIOL 32, 33
CYRAMZA 39 DESONATE 11
CYSTARAN 35 DESONIDE 11
CYSTEAMINE 35, 54 DESOXIMETASONE 11
CYTOMEL 71 DESVENLAFAXINE SUCCINATE 16
CYTOVENE 46 DETROL 42
CYTRA-2 6 DETROL LA 42
CYTRA-K 6 DEUTETRABENAZINE TABLETS 30
Corlanor 29 DEX-TUSS 22
DEXAMETHASONE 5
D DEXAMETHASONE INTENSOL 5
D-METHORPHAN HB/P-EPD HCL/BPM 22 DEXEDRINE 4
D-METHORPHAN HB/PROMETH HCL 22 DEXILANT 64
DABIGATRAN ETEXILATE MESYLATE 15 DEXLANSOPRAZOLE 64
DABRAFENIB 24 DEXMETHYLPHENIDATE HCL 10
DACLATASVIR 18 DEXTROAMPHETAMINE SULFATE 4
DAKLINZA 18 DEXTROAMPHETAMINE-AMPHETAMINE 4
DALFAMPRIDINE 50 DEXTROMETHORPHAN HBR/QUINIDINE 30
DALIRESP 65 DIAMOX SEQUELS 29
DALTEPARIN SODIUM,PORCINE 15 DIAPHRAGMS, ARC-SPRING 33
DANAZOL 9 DIASTAT ACUDIAL 25
DANTROLENE SODIUM 37 DIAZEPAM 25, 27
DAPAGLIFLOZIN 69 DICHLORALPHENAZONE 23
DAPSONE 49, 68 DICLEGIS 16
DARAPRIM 19 DICLOFENAC EPOLAMINE 56
DARATUMUMAB INJECTION 52 DICLOFENAC POTASSIUM 56
DARBEPOETIN ALFA 15 DICLOFENAC SODIUM 55, 56, 68
DARIFENACIN HYDROBROMIDE 42 DICLOFENAC SODIUM-MISOPROSTOL 55
DARUNAVIR ETHANOLATE 63 DICLOFENAC SODIUM/MISOPROSTOL 55, 56
82 of 104
D (cont.) D (cont.)
DICLOXACILLIN SODIUM 60 DUAC 14
DICYCLOMINE HCL 19 DUAVEE 40
DIDANOSINE 21 DULAGLUTIDE 46
DIFFERIN 68 DULERA 35
DIFLUCAN 24 DULOXETINE 67
DIFLUPREDNATE 34 DULOXETINE HCL 67
DIGOXIN 13 DUOPA 38
DIHYDROERGOTAMINE MESYLATE 7, 40 DUPILUMAB SUBCUTANEOUS INJECTION 52
DILANTIN 69 DUPIXENT 52
DILAUDID 57 DURAGESIC 57
DILT-XR 29 DUREZOL 34
DILTIAZEM 24HR CD 29 DURLAZA 55
DILTIAZEM 24HR ER 29 DUTASTERIDE 4
DILTIAZEM ER 29 DUTASTERIDE/TAMSULOSIN HCL 4
DILTIAZEM HCL 28, 29 DYAZIDE 62
DIMETHYL FUMARATE 50 DYMISTA 12
DINUTUXIMAB FOR INJECTION 20 DYRENIUM 62
DIOVAN 9
DIOVAN HCTZ 9 E
DIPHENHYDRAMINE HCL 41 E-Z SPACER 35
DIPHENOXYLATE HCL/ATROPINE 16 E.E.S. 200 51
DIPHENOXYLATE-ATROPINE 16 E.E.S. 400 51
DISOPYRAMIDE PHOSPHATE 13 EASIVENT 35
DISULFIRAM 5 EASY TOUCH 36
DIURIL 71 ECONAZOLE NITRATE 17
DIVALPROEX SODIUM 41, 42 EDARBI 9
DIVALPROEX SODIUM ER 42 EDARBYCLOR 9
DIVIGEL 40 EDECRIN 50
DOFETILIDE 13 EDEX 74
DOLASETRON 4 EDLUAR 23
DOLUTEGRAVIR 10 EDOXABAN 27
DONEPEZIL HCL 31 EDURANT 55
DONNATAL 21 EEMT 62
DORNASE ALFA 40 EEMT H.S. 62
DORYX 71 EFAVIRENZ 21, 55
DORZOLAMIDE HCL 29 EFAVIRENZ/EMTRICITAB/TENOFOVIR 21
DORZOLAMIDE HCL/TIMOLOL MALEAT 29 EFFER-K 65
DORZOLAMIDE-TIMOLOL 29 EFFEXOR XR 67
DORZOLAMIDE/TIMOLOL/PF 29 EFFIENT 62
DOVONEX 68 EFINACONAZOLE 24
DOXAZOSIN 24 EGRIFTA 43
DOXAZOSIN MESYLATE 7, 24 ELESTAT 12
DOXEPIN HCL 16, 21, 72 ELESTRIN 40
DOXERCALCIFEROL 74 ELETRIPTAN HBR 66
DOXYCYCLINE HYCLATE 71 ELIDEL 68
DOXYCYCLINE HYCLATE CAPSULE 71 ELIGLUSTAT 39
DOXYCYCLINE HYCLATE DR TABLETS 71 ELINEST 33
DOXYCYCLINE HYCLATE IR TABLETS 71 ELIQUIS 27
DOXYCYCLINE MONOHYDRATE 71 ELLA 33
DOXYLAMINE/PYRIDOXINE 16 ELMIRON 59
DRITHOCREME HP 48 ELOCON 11
DRONEDARONE HCL 13 ELOCTATE 17
DROPERIDOL 38 ELOSULFASE ALFA 39
DROSPIR/ETH ESTRA/LEVOMEFOL CA 33 ELOTUZUMAB INJECTION 52
DROSPIRENONE/ESTRADIOL 41 ELTROMBOPAG OLAMINE 43
DROXIDOPA 6 ELUXADOLINE TABLETS 42
DRYSOL 23 ELVITEGRAVIR 47
83 of 104
E (cont.) E (cont.)
ELVITEGRAVIR/COBIC/EMT/TENOFOVIR 10 EPZICOM 56
ELVITEGRAVIR/COBICISTAT/EMTRICITABINE/TENOF EQUETRO 16
OVIR ALAFENAMIDE 11 ERGOCALCIFEROL (VITAMIN D2) 74
EMEND 70 ERGOMAR 40
EMFLAZA 34 ERGOTAMINE TARTRATE 40
EMOLLIENT COMBINATION NO.10 39 ERGOTAMINE TARTRATE/CAFFEINE 7, 40
EMOLLIENT COMBINATION NO.32 39 ERIVEDGE 20
EMOLLIENT COMBINATION NO.35 39 ERLOTINIB HCL 20
EMOLLIENT COMBINATION NO.43 39 ERRIN 32
EMOLLIENT COMBINATION NO.44 39 ERTACZO 17
EMOLLIENT COMBINATION NO.53 39 ERY 14
EMOLLIENT COMBINATION NO.60 39 ERY-TAB 51
EMOQUETTE 32 ERYPED 200 51
EMPAGLIFLOZIN 69 ERYPED 400 51
EMPLICITI 52 ERYTHROCIN STEARATE 51
EMSAM 52 ERYTHROMYCIN 50
EMTRICITAB/RILPIVIRINE/TENOFOV 21 ERYTHROMYCIN BASE 14, 50, 51
EMTRICITABINE 21 ERYTHROMYCIN BASE/ETHANOL 14
EMTRICITABINE/RILPIVIRINE/TENOFOVIR 56 ERYTHROMYCIN ETHYLSUCCINATE 51
EMTRICITABINE/TENOFOVIR 56 ERYTHROMYCIN STEARATE 51
EMTRIVA 21 ERYTHROMYCIN-BENZOYL PEROXIDE 14
ENABLEX 42 ERYTHROMYCIN/BENZOYL PEROXIDE 14
ENALAPRIL MALEATE 9, 10 ESBRIET 70
ENALAPRIL-HYDROCHLOROTHIAZIDE 9 ESCITALOPRAM OXALATE 66, 67
ENALAPRIL/HYDROCHLOROTHIAZIDE 9 ESLICARBAZEPINE 69
ENBREL 37 ESOMEPRAZOLE MAGNESIUM 64
ENDOCET 57 ESTAZOLAM 25
ENDODAN 57 ESTRACE 0.01% CREAM 40
ENDOMETRIN 63 ESTRACE TABLETS 40
ENFUVIRTIDE 11 ESTRADIOL 40, 41
ENJUVIA 40 ESTRADIOL ACETATE 40
ENOXAPARIN SODIUM 15 ESTRADIOL CYPIONATE 41
ENPRESSE 32 ESTRADIOL MICRONIZED 40
ENTACAPONE 29, 30 ESTRADIOL VALERATE/DIENOGEST 33
ENTECAVIR 56 ESTRADIOL-NORETHINDRONE ACETAT 40
ENTOCORT EC 5 ESTRADIOL/LEVONORGESTREL 40
ENTRESTO 29 ESTRADIOL/NORETHINDRONE ACET 40, 41
ENTYVIO 75 ESTRADIOL/NORGESTIMATE 40
ENULOSE 8 ESTRING 40
ENZALUTAMIDE 12 ESTROGEL 40
EPCLUSA 18 ESTROGEN & METHYLTESTOSTERONE 62
EPICERAM 39 ESTROGEN,CON/M-PROGEST ACET 40
EPIDRIN 8 ESTROGEN,ESTER/ME-TESTOSTERONE 61, 62
EPIDUO 68 ESTROGEN/BAZEDOXIFENE 40
EPIFLUR 29 ESTROGENS, CONJUGATED 40
EPIFOAM 5 ESTROGENS,CONJ.,SYNTHETIC A 40
EPIKLOR 65 ESTROGENS,CONJ.,SYNTHETIC B 40
EPINASTINE HCL 12 ESTROGENS,ESTERIFIED 41
EPINEPHRINE 6, 7, 70 ESTROPIPATE 40
EPIPEN 7 ESTROSTEP FE 33
EPIPEN 2-PAK 7 ESZOPICLONE 23
EPIPEN JR 7 ETANERCEPT 37
EPIPEN JR 2-PAK 7 ETEPLIRSEN INJECTION 21
EPITOL 16 ETHACRYNIC ACID 50
EPIVIR HBV 56 ETHAMBUTOL HCL 22
EPOETIN ALFA 43, 44 ETHINYL ESTRADIOL/DROSPIRENONE 33
EPOGEN 44 ETHOSUXIMIDE 28
84 of 104
E (cont.) F (cont.)
ETHYNODIOL D-ETHINYL ESTRADIOL 32 FETZIMA 67
ETODOLAC 55 FEXOFENADINE HCL 66
ETONOGESTREL/ETHINYL ESTRADIOL 33 FEXOFENADINE-PSE ER 66
ETRAVIRINE 21, 55 FEXOFENADINE/PSEUDOEPHEDRINE 66
EURAX 65 FILGRASTIM 44
EVAMIST 40 FINACEA 68
EVEROLIMUS 20 FINASTERIDE 4
EVISTA 40 FINGOLIMOD HCL 53
EVOLOCUMAB 59 FIORICET 8
EVOXAC 59 FIORINAL 55
EVZIO 58 FIRAZYR 31
EXALGO 57 FLAGYL 52
EXELDERM 17 FLAGYL ER 52
EXELON PATCH 31 FLAREX 34
EXEMESTANE 23 FLAVOXATE HCL 42
EXENATIDE 46 FLECAINIDE ACETATE 13
EXENATIDE EXTENDED RELEASE 46 FLECTOR 56
EXENATIDE MICROSPHERES 46 FLIBANSERIN 50
EXFORGE 28 FLO-PRED 5
EXFORGE HCT 28 FLOMAX 7, 24
EXJADE 31 FLONASE 34
EXONDYS 51 21 FLOVENT DISKUS 34
EYE LUBRICANT COMBINATION NO.1 39 FLOVENT HFA 34
EYLEA 73 FLUCONAZOLE 24
EZETIMIBE 38 FLUCYTOSINE 17
EZETIMIBE/SIMVASTATIN 38 FLUDROCORTISONE ACETATE 5
EZOGABINE 16 FLUNISOLIDE 34
FLUOCINOLONE ACETONIDE 11
F FLUOCINOLONE ACETONIDE OIL 34
FABRAZYME 39 FLUOCINONIDE 11
FAMCICLOVIR 56 FLUOCINONIDE EMOLLIENT 11
FAMOTIDINE 44 FLUOCINONIDE-E 11
FAMVIR 56 FLUOCINONIDE/EMOLLIENT 11
FANAPT 24 FLUOR-A-DAY 29
FARESTON 20 FLUORABON 29
FARXIGA 69 FLUORIDE 29
FARYDAK 45 FLUORIDE/IRON/VIT A,C
FEBUXOSTAT 74 FLUORIDE/VITAMINS A,C,AND D 53
FELBAMATE 15 FLUORITAB 29
FELODIPINE 36 FLUOROMETHOLONE 34
FELODIPINE ER 36 FLUOROMETHOLONE ACETATE 34
FEMARA 20 FLUOROURACIL 68
FEMCON FE 33 FLUOXETINE DR 67
FEMHRT 40 FLUOXETINE HCL 67
FEMRING 40 FLUOXETINE HCL CAPSULE 67
FENOFIBRATE 41 FLUOXETINE HCL DR CAPSULE 67
FENOFIBRATE NANOCRYSTALLIZED 41 FLUOXETINE HCL TABLETS 67
FENOFIBRATE,MICRONIZED 41 FLUPHENAZINE HCL 72
FENOFIBRIC ACID 41 FLURA-DROPS 29
FENOFIBRIC ACID (CHOLINE) 41 FLURANDRENOLIDE 11
FENOGLIDE 41 FLURAZEPAM HCL 25
FENTANYL 57 FLUTICASONE FUROATE 34
FENTANYL CITRATE 57 FLUTICASONE PROPIONATE 11, 34
FENTANYL TRANSDERMAL 57 FLUTICASONE/SALMETEROL 35, 70
FENTORA 57 FLUTICASONE/VILANTEROL 35
FERRIC CITRATE 60, 61 FLUVASTATIN SODIUM 45
FESOTERODINE FUMARATE 42 FLUZONE 12
85 of 104
F (cont.) G (cont.)
FML FORTE 34 GEODON 24
FML S.O.P. 34 GILDESS 32
FOCALIN 10 GILDESS FE 32
FOCALIN XR 10 GILENYA 53
FOLCAL DHA 54 GILOTRIF 72
FOLGARD RX 74 GLATIRAMER ACETATE 50
FOLIC ACID 74 GLATOPA 50
FOLLISTIM AQ 43 GLECAPREVIR/PIBRENTASVIR 18
FOLLITROPIN ALFA, RECOMB 43 GLEEVEC 20
FOLLITROPIN BETA,RECOMB 43 GLIMEPIRIDE 70
FONDAPARINUX SODIUM 15, 28 GLIPIZIDE 70
FORADIL 70 GLIPIZIDE ER 70
FORFIVO XL 67 GLIPIZIDE XL 70
FORMALDEHYDE 68 GLIPIZIDE-METFORMIN 70
FORMOTEROL FUMARATE 70 GLIPIZIDE/METFORMIN HCL 70
FORTAMET 27 GLUCAGEN 42
FORTEO 60 GLUCAGON EMERGENCY KIT 42
FORTESTA 62 GLUCAGON,HUMAN RECOMBINANT 42
FORTICAL 60 GLUCOPHAGE 27
FOSAMAX 28 GLUCOPHAGE XR 27
FOSAMAX PLUS D 28 GLUCOTROL XL 70
FOSAMPRENAVIR CALCIUM 63 GLUCOVANCE 70
FOSFOMYCIN TROMETHAMINE 73 GLUMETZA 27
FOSINOPRIL SODIUM 9 GLY/CARB HOMOPOLY A/POT HYDROX 35
FOSINOPRIL-HYDROCHLOROTHIAZIDE 9 GLYBURIDE 70
FOSINOPRIL/HYDROCHLOROTHIAZIDE 9 GLYBURIDE-METFORMIN HCL 70
FOSRENOL 61 GLYBURIDE/METFORMIN HCL 70
FRAGMIN 15 GLYCEROL PHENYLBUTYRATE 55
FRESHKOTE 39 GLYCOPYRROLATE 19
FROVA 66 GLYCOPYRROLATE INHALATION POWDER 19
FROVATRIPTAN SUCCINATE 66 GLYCOPYRROLATE/FORMOTEROL FUMARATE
FULYZAQ 16 INHALATION 64
FUROSEMIDE 50 GLYSET 7
FUZEON 11 GOLIMUMAB 37
FYCOMPA 4 GOLYTELY 49
GOLYTELY PACKETS 49
G GONAL-F 43
GABAPENTIN 41, 42 GONAL-F RFF 43
GABAPENTIN ENACARBIL 41 GRALISE 42
GABITRIL 16, 42 GRANISETRON 4
GALANTAMINE 31 GRANISETRON EXTENDED-RELEASE INJECTION 4
GANCICLOVIR 10, 46 GRANISETRON HCL 4
GANIRELIX ACETATE 43 GRANIX 43
GARDASIL/CERVARIX 22 GRASS POLLEN 6
GATIFLOXACIN 14 GRASTEK 6
GATTEX 42 GRAZOPREVIR/ELBASVIR 18
GAVILYTE 49 GRIFULVIN V 17
GELNIQUE 42 GRIS-PEG 17
GEMFIBROZIL 41 GRISEOFULVIN 17
GENERESS FE 33 GRISEOFULVIN ULTRAMICROSIZE 17
GENERLAC 8 GRISEOFULVIN,MICROSIZE 17
GENGRAF 46 GUAIFENESIN AC 22
GENOTROPIN 61 GUAIFENESIN DAC 22
GENTAK 13 GUAIFENESIN-CODEINE 22
GENTAMICIN 8 GUAIFENESIN/CODEINE PHOSPHATE 22
GENTAMICIN SULFATE 13 GUANFACINE HCL 4, 30
GENVOYA 11
H
H.P. ACTHAR 5
86 of 104
H (cont.) H (cont.)
HALCINONIDE 11 HYDROCORTISONE BUTYRATE/EMOLL 5
HALFLYTELY-BISACODYL 49 HYDROCORTISONE VALERATE 5
HALOBETASOL PROPIONATE 11 HYDROCORTISONE-ACETIC ACID 51
HALOBETASOL PROPIONATE CREAM AND HYDROCORTISONE-IODOQUINOL 49
OINTMENT 11 HYDROCORTISONE-PRAMOXINE 12
HALOBETASOL PROPIONATE LOTION 11 HYDROCORTISONE/IODOQUINOL 49
HALOG 11 HYDROCORTISONE/PRAMOXINE 5, 12
HALOPERIDOL 72 HYDROCORTISONE/PRAMOXINE/ALOE 5
HALOPERIDOL LACTATE 72 HYDROMET 22
HARVONI 18 HYDROMORPHONE ER 57
HCG ALPHA,RECOMBINANT 43 HYDROMORPHONE HCL 57
HEATHER 32 HYDROXYCHLOROQUINE SULFATE 18, 19
HECTOROL 74 HYDROXYPROGESTERONE CAPROATE 63
HELIDAC 15 HYDROXYPROPYL CELLULOSE 39
HEMANGEOL 26 HYDROXYUREA 19
HEMENATAL OB 54 HYDROXYZINE HCL 23
HEMENATAL OB + DHA 53 HYDROXYZINE PAMOATE 23
HEMRIL 12 HYLATOPIC 39
HEPARIN 28 HYLATOPIC PLUS 39
HEPSERA 56 HYOMAX-FT 21
HERCEPTIN 43 HYOMAX-SL 21
HETLIOZ 51 HYOMAX-SR 21
HEXACHLOROPHENE 50 HYOSCYAMINE SULFATE 21
HIZENTRA 67 HYPER-SAL 65
HOMATROPAIRE 54 HYPERCARE 23
HOMATROPINE HBR 54 HYSINGLA ER 57
HORIZANT 41
HPR PLUS 39 I
HUM INSULIN NPH/REG INSULIN HM 47 IBANDRONATE SODIUM 28
HUMALOG 47 IBRANCE 72
HUMALOG MIX 50-50 47 IBUDONE 57
HUMALOG MIX 75-25 47 IBUPROFEN 55
HUMAN PAPILLOMAVIRUS 22 ICATIBANT ACETATE 31
HUMAPEN LUXURA HD 35 ICLUSIG 20
HUMATROPE 61 IDELALISIB 48
HUMIRA 37 IDELVION 17
HUMIRA PEDIATRIC CROHNS 37 ILARIS 52
HUMULIN 70-30 47 ILOPERIDONE 24
HUMULIN N 47 ILOPROST 63
HUMULIN R 47 IMATINIB MESYLATE 19, 20
HYDRALAZINE HCL 37 IMBRUVICA 72
HYDROCHLOROTHIAZIDE 71 IMDUR 55
HYDROCODONE BIT-IBUPROFEN 57 IMIPENEM 27
HYDROCODONE BIT/ACETAMINOPHEN 57 IMIPENEM/CILASTATIN 27
HYDROCODONE BIT/HOMATROP ME-BR 22 IMIPENEM/CILASTATN 27
HYDROCODONE BITARTRATE 57 IMIPRAMINE HCL 72
HYDROCODONE-ACETAMINOPHEN 57 IMIQUIMOD 68
HYDROCODONE-CHLORPHENIRAMINE 22 IMITREX 66
HYDROCODONE-HOMATROPINE MBR 22 IMLYGIC 56
HYDROCODONE-IBUPROFEN 57 IMMUNE GLOBULIN,GAMMA(IGG) 67
HYDROCODONE/CHLORPHEN POLIS 22 IMPAVIDO 4
HYDROCODONE/IBUPROFEN 57 INAPSINE 38
HYDROCORTISONE 5, 11, 12 INCIVEK 18
HYDROCORTISONE AC/LIDOCAINE 49 INDACATEROL MALEATE 26
HYDROCORTISONE ACETATE 12 INDACATEROL/GLYCOPYRROLATE INHALATION
HYDROCORTISONE ACETATE SUPPOSITORIES 12 POWDER 64
HYDROCORTISONE BUTYRATE 5 INDAPAMIDE 71
87 of 104
I (cont.) I (cont.)
INDERAL LA 26 ISTALOL 26
INDINAVIR 63 ITRACONAZOLE 24
INDOCIN 56 IVERMECTIN 10, 66
INDOMETHACIN 55, 56 IXAZOMIB CAPSULES 64
INFERGEN 45 IXEKIZUMAB FOR SUBCUTANEOUS INJ 45
INFLIXIMAB FOR INJECTION 37 IXINITY 17
INFLUENZA VACCINE 12 Ivabradine HCL 29
INGENOL MEBUTATE 68
INGREZZA 30 J
INHALER, ASSIST DEVICES 35, 36 JAKAFI 48
INHALER,ASSIST DEVICE,ACCESORY 35 JALYN 4
INNOPRAN XL 26 JANUMET 37
INSULIN ADMIN. SUPPLIES 35 JANUMET XR 37
INSULIN ASPART 47 JANUVIA 37
INSULIN DEGLUDEC INJECTION 47 JARDIANCE 69
INSULIN DETEMIR 47 JENTADUETO 37
INSULIN GLARGINE,HUM.REC.ANLOG 47 JETREA 48
INSULIN GLULISINE 47 JEVANTIQUE 40
INSULIN INHALED 47 JINTELI 40
INSULIN LISPRO 47 JOLESSA 32
INSULIN NPL/INSULIN LISPRO 47 JOLIVETTE 32
INSULIN REGULAR, HUMAN 47 JUBLIA 24
INSULIN SYRINGE 35 JUNEL 32
INSULN ASP PRT/INSULIN ASPART 47 JUNEL FE 32
INTELENCE 21, 55 JUXTAPID 31
INTERFERON ALFA-2B,RECOMB. 47
INTERFERON ALFACON 1 45 K
INTERFERON BETA-1A 50 K-PHOS ORIGINAL 5
INTERFERON BETA-1A/ALBUMIN 50 K-TAB 65
INTERFERON BETA-1B 50 KADCYLA 43
INTERMEZZO 23 KADIAN 57
INTRON A 47 KALETRA 63
INTROVALE 32 KALEXATE 62
INTUNIV 4 KANAMYCIN 8
INVEGA 24 KANUMA 48
INVEGA SUSTENNA 24 KAPVAY 4, 7
INVIRASE 63 KARIVA 31
INVOKANA 69 KEFLEX 31
IOPHEN-C NR 22 KELNOR 1-35 32
IPRATROPIUM BROMIDE 19 KENALOG 11
IPRATROPIUM-ALBUTEROL 19 KEPPRA 28
IPRATROPIUM/ALBUTEROL SULFATE 19 KEPPRA XR 28
IRBESARTAN 9 KERALYT 48
IRBESARTAN-HYDROCHLOROTHIAZIDE 9 KERYDIN 46
IRBESARTAN/HYDROCHLOROTHIAZIDE 9 KETOCONAZOLE 17, 24
IRBRUTINIB 72 KETODAN 17
ISAVUCONAZOMIUN 24 KETOPROFEN 55
ISENTRESS 11 KETOROLAC TROMETHAMINE 39, 55, 56
ISOMETHEPT-DICHLORALP-ACETAMIN 8 KETOROLAC TROMETHAMINE/PF 39
ISOMETHEPT/ACETAMINOP/DICHLPHN 8 KEYTRUDA 52
ISONIAZID 22 KINERET 37
ISOPTO HOMATROPINE 54 KIONEX 62
ISOPTO HYOSCINE 54 KISQALI 48
ISOSORBIDE DINITRATE 55 KLONOPIN 25
ISOSORBIDE MONONITRATE 55 KLOR-CON 65
ISOSORBIDE MONONITRATE ER 55 KLOR-CON-EF 65
ISOTRETINOIN 68 KOMBIGLYZE XR 37
88 of 104
K (cont.) L (cont.)
KOVALTRY 17 LEVAQUIN 64
KRISTALOSE 8 LEVEMIR 47
KUVAN 58 LEVEMIR FLEXTOUCH 47
KYLEENA 33 LEVETIRACETAM 16, 28
KYNAMRO 31 LEVITRA 61
LEVOBUNOLOL HCL 26
L LEVOCARNITINE 58
L-NORGEST-ETH ESTR/ETHIN ESTRA 32, 33 LEVOCARNITINE (WITH SUGAR) 58
LABETALOL HCL 26 LEVOCETIRIZINE DIHYDROCHLORIDE 66
LAC-HYDRIN 25 LEVOFLOXACIN 13, 64
LACOSAMIDE 16 LEVOMILNACIPRAN 67
LACRISERT 39 LEVONORG-ETH ESTRAD ETH ESTRAD 32
LACTULOSE 8 LEVONORGESTREL 32
LAMICTAL 28 LEVONORGESTREL-ETH ESTRADIOL 32, 33
LAMICTAL (GREEN) 28 LEVONORGESTREL-RELEASING INTRAUTERINE
LAMICTAL (ORANGE) 28 SYSTEM 33
LAMICTAL ODT 28 LEVORA-28 32
LAMICTAL ODT (ORANGE) 28 LEVOTHROID 71
LAMICTAL XR 28 LEVOTHYROXINE SODIUM 71
LAMISIL 6 LEVOXYL 71
LAMIVUDINE 21, 56 LEXAPRO 67
LAMIVUDINE-ZIDOVUDINE 21 LEXIVA 63
LAMIVUDINE/ZIDOVUDINE 21, 56 LIALDA 11
LAMOTRIGINE 28, 53 LIDOCAINE 49
LAMPRENE 49 LIDOCAINE HCL 49
LANOXIN 13 LIDOCAINE HCL VISCOUS 49
LANSOPRAZOLE 64 LIDOCAINE-HYDROCORTISONE 49
LANSOPRAZOLE/AMOXICILN/CLARITH 64 LIDOCAINE-PRILOCAINE 49
LANTHANUM CARBONATE 61 LIDOCAINE/PRILOCAINE 49
LANTUS 47 LIDODERM 49
LANTUS SOLOSTAR 47 LIFITEGRAST OPTH SOLUTION 38
LAPATINIB DITOSYLATE 20 LIMBREL250 59
LARTRUVO 52 LINACLOTIDE 42
LASIX 50 LINAGLIPTIN 37
LASTACAFT 12 LINAGLIPTIN/METFORMIN HCL 37
LATANOPROST 63 LINEZOLID 15
LATUDA 24, 27 LINZESS 42
LAVOCLEN-4 48 LIOTHYRONINE SODIUM 71
LAZERFORMALYDE 68 LIPASE/PROTEASE/AMYLASE 36
LEDIPASVIR/SOFOSBUVIR 18 LIPITOR 45
LEENA 32 LIPOFEN 41
LEFLUNOMIDE 37 LIRAGLUTIDE 46
LEMTRADA 53 LISDEXAMFETAMINE DIMESYLATE 8
LENALIDOMIDE 45 LISINOPRIL 9, 10
LENVATINIB 48 LISINOPRIL-HYDROCHLOROTHIAZIDE 9
LENVIMA 48 LISINOPRIL/HYDROCHLOROTHIAZIDE 9
LESCOL 45 LITHIUM 53
LESCOL XL 45 LITHIUM CARBONATE 53
LESINURAD TABLETS 73 LITHIUM CITRATE 53
LESSINA 32 LITHOBID 53
LETAIRIS 74 LIVALO 45
LETROZOLE 20, 23 LIXISENATIDE INJECTION 46
LEUCOVORIN CALCIUM 16 LO LOESTRIN FE 33
LEUPROLIDE ACETATE 20 LO-OVRAL-28 33
LEVALBUTEROL 26 LOCOID 5
LEVALBUTEROL HCL 26, 70 LOCOID LIPOCREAM 5
LEVALBUTEROL TARTRATE 26 LODOSYN 20
89 of 104
L (cont.) M (cont.)
LODOXAMIDE TROMETHAMINE 12 MAXIDEX 5
LOESTRIN 33 MAXIPIME 31
LOESTRIN 24 FE 33 MAXITROL 14
LOESTRIN FE 33 MAXZIDE-25 MG 62
LOHIST-DM 22 MEBENDAZOLE 10
LOMITAPIDE 31 MECHLORETHAMINE 6
LOMOTIL 16 MECLIZINE HCL 18
LOMUSTINE 6 MEDROL 5
LONSURF 20 MEDROXYPROGESTERONE ACETATE 62, 63
LOPERAMIDE 16 MEFLOQUINE HCL 19
LOPERAMIDE HCL 16 MEFOXIN 31
LOPINAVIR/RITONAVIR 63 MEGACE ES 20
LORAZEPAM 25 MEGESTROL ACETATE 19, 20
LORAZEPAM INTENSOL 25 MEKINIST 48
LORCASERIN 4 MELOXICAM 55, 56
LORTAB 57 MELPHALAN 6
LOSARTAN POTASSIUM 9 MEMANTINE HCL 54
LOSARTAN-HYDROCHLOROTHIAZIDE 9 MENEST 41
LOSARTAN/HYDROCHLOROTHIAZIDE 9 MENINGOCOCCAL GR B VACCINE 73
LOTEMAX 34 MENOPUR 43
LOTEPREDNOL ETABONATE 34 MENOSTAR 41
LOTREL 36 MENOTROPINS 43
LOTRONEX 52 MEPERIDINE HCL 57
LOVASTATIN 45 MEPHYTON 31
LOVAZA 38 MEPOLIZUMAB INJECTION 53
LOVENOX 15 MERCAPTOPURINE 19
LOW-OGESTREL 33 MEROPENEM 27
LOXAPINE 72 MESALAMINE 8, 11
LUBIPROSTONE 49 MESALAMINE W/CLEANSING WIPES 8
LUDENT FLUORIDE 29 MESTINON 59
LULICONAZOLE 24 METADATE CD 10
LUMACAFTOR/IVACAFTOR 28 METADATE ER 10
LUMIGAN 63 METAXALONE 30
LUNESTA 23 METFORMIN ER (MOD) 27
LUPRON DEPOT 20 METFORMIN HCL 27
LURASIDONE HCL 24, 27 METFORMIN HCL ER 27
LUTERA 32 METFORMIN HCL ER (MOD) 27
LUXIQ 5 METFORMIN HCL ER (OSM) 27
LUZU 24 METFORMIN HYDROCHLORIDE 27
LYBREL 33 METHADONE HCL 57
LYNPARZA 65 METHAMPHETAMINE HCL 4
LYRICA 41 METHAZOLAMIDE 29
LYSTEDA 44 METHERGINE 59
METHIMAZOLE 22
M METHITEST 62
MACITENTAN 39 METHOCARBAMOL 30
MACROBID 73 METHOTREXATE 19, 41
MACRODANTIN 73 METHOTREXATE SODIUM 19
MAKENA 63 METHOXSALEN, RAPID 61
MALARONE 19 METHSUXIMIDE 16
MAPROTILINE HCL 44 METHYLDOPA 30
MARAVIROC 21 METHYLERGONOVINE MALEATE 59
MATZIM LA 29 METHYLIN 10
MAVYRET 18 METHYLIN ER 10
MAXAIR AUTOHALER 70 METHYLNALTREXONE BROMIDE TABLETS 58
MAXALT 66 METHYLPHENIDATE 10
MAXALT MLT 66 METHYLPHENIDATE ER 10
90 of 104
M (cont.) M (cont.)
METHYLPHENIDATE HCL 10, 38 MONONESSA 33
METHYLPHENIDATE HCL CD 38 MONTELUKAST SODIUM 49
METHYLPHENIDATE SR 10 MONUROL 73
METHYLPREDNISOLONE 5 MORPHINE SULFATE 57
METHYLTESTOSTERONE 62 MORPHINE SULFATE ER 57
METOCLOPRAMIDE HCL 63 MOVANTIK 58
METOLAZONE 71 MOVIPREP 49
METOPROLOL SUCCINATE 26 MOXEZA 14
METOPROLOL TARTRATE 26 MOXIFLOXACIN HCL 14, 64
METOPROLOL-HYDROCHLOROTHIAZIDE 26 MOZOBIL 44
METOPROLOL/HYDROCHLOROTHIAZIDE 26 MS CONTIN 57
METOZOLV ODT 63 MTH/ME BLUE/SOD PHOS/PHEN/HYOS 73
METRELEPTN 45 MUGARD 35
METROGEL 14 MULTAQ 13
METROGEL-VAGINAL 15 MULTI-VITAMIN W-FLUORIDE-IRON 53
METROLOTION 14 MULTI-VITAMIN WITH FLUORIDE 53
METRONIDAZOLE 14, 15, 20, 52 MULTIVITAMINS WITH FLUORIDE 53
MEXILETINE HCL 13 MULTIVITS WITH IRON & FLUORIDE 53
MICARDIS 9 MUPIROCIN 14
MICARDIS HCT 9 MUPIROCIN CALCIUM 14
MICONAZOLE NITRATE/ZINC OX/PET 17 MUSE 74
MICROCHAMBER 35 MVC-FLUORIDE 53
MICROGESTIN 32 MYALEPT 45
MICROGESTIN FE 32 MYAMBUTOL 22
MICRONOR 33 MYCOBUTIN 22
MIDODRINE HCL 70 MYCOPHENOLATE MOFETIL 46
MIGERGOT 7 MYCOPHENOLATE SODIUM 46
MIGLITOL 7 MYFORTIC 46
MIGLUSTAT 46 MYORISAN 68
MIGRANAL 7 MYRBETRIQ 42
MILLIPRED 5 MYTUSSIN DAC 22
MILNACIPRAN HCL 41 MYZILRA 32
MILTEFOSINE CAPSULES 4
MIMVEY 40 N
MIMYX 39 NABUMETONE 55
MINIPRESS 7 NADOLOL 26
MINOCIN 71 NAFCIL 60
MINOCYCLINE HCL 71 NAFCILLIN 60
MINOCYCLINE HCL CAPSULES 71 NAFTIFINE HCL 17
MINOCYCLINE HCL MICROSPHERES 13 NAFTIN 17
MINOCYCLINE HCL TABLET EXTENDED RELEASE 71 NALOXEGOL 58
MINOCYCLINE HCL TABLETS 71 NALOXONE 57, 58
MINOXIDIL 37 NALOXONE/BUPROPION 58
MIPOMERSEN 31 NALTREXONE HCL 6, 58
MIRABEGRON 42 NAMENDA 54
MIRAPEX 37 NAPHAZOLINE HCL 74
MIRAPEX ER 37 NAPHOS M-B M-H/NA PHOS,DI-BA 49
MIRCETTE 33 NAPRELAN 55
MIRTAZAPINE 16, 44 NAPROXEN 55
MIRVASO 7 NAPROXEN SODIUM 55
MISOPROSTOL 63 NARATRIPTAN HCL 66
MOBIC 56 NASACORT AQ 34
MODAFINIL 10 NASCOBAL 74
MOMETASONE FUROATE 11, 34, 35 NASONEX 34
MOMETASONE/FORMOTEROL 35 NATACYN 17
MONODOX 71 NATALIZUMAB 53
MONOJECT INSULIN SYRINGE 36 NATAMYCIN 17
91 of 104
N (cont.) N (cont.)
NATAZIA 33 NIACIN/LOVASTATIN 38
NATEGLINIDE 51 NIACIN/SIMVASTATIN 38
NATESTO 9 NIACOR 38
NATPARA 59 NIASPAN 38
NATROBA 66 NICARDIPINE HCL 36
NATURE-THROID 71 NIFEDIAC CC 36
NAVELBINE 20 NIFEDICAL XL 36
NEBIVOLOL HCL 26 NIFEDIPINE 36
NECITUMUMAB FOR INJECTION 52 NIFEDIPINE ER 36
NECON 33 NILOTINIB 72
NEDOCROMIL SODIUM 51 NINLARO 64
NEEDLE 36 NINTEDANIB 72
NEEDLES 36 NIRAPARIB CAPSULES 20
NEEDLES, DISPOSABLE 36 NISOLDIPINE 36
NEEDLES, INSULIN DISPOSABLE 35, 36 NITAZOXANIDE 20, 60
NEEVO DHA 54 NITISINONE 44
NEFAZODONE HCL 16 NITRO-BID 55
NEO-POLYCIN 13 NITRO-DUR 55
NEO-POLYCIN HC 13 NITROFURANTOIN 73
NEO/POLYMYX B SULF/DEXAMETH 13, 14 NITROFURANTOIN MACROCRYSTAL 73
NEOMY SULF/BACITRA/POLYMYXIN B 13 NITROFURANTOIN MONO-MACRO 73
NEOMY SULF/BACITRAC ZN/POLY/HC 13, 14 NITROFURANTOIN MONOHYD/M-CRYST 73
NEOMY SULF/COLIST SUL/HC/THONZ 13 NITROGLYCERIN 55, 68, 74
NEOMY SULF/POLYMYXIN B SULFATE 15 NITROGLYCERIN PATCH 74
NEOMYCIN SULFATE 7 NITROLINGUAL 74
NEOMYCIN-BACITRACIN-POLY-HC 14 NITROMIST 55
NEOMYCIN-BACITRACIN-POLYMYXIN 13 NITROSTAT 55
NEOMYCIN-POLYMYXIN-DEXAMETH 13 NIZATIDINE 44
NEOMYCIN-POLYMYXIN-GRAMICIDIN 14 NIZORAL 17
NEOMYCIN-POLYMYXIN-HC 13 NORA-BE 32
NEOMYCIN-POLYMYXIN-HYDROCORT 13 NORCO 57
NEOMYCIN/POLYMYXIN B SULF/HC 13 NORDETTE-28 33
NEOMYCIN/POLYMYXN B/GRAMICIDIN 14 NORDITROPIN FLEXPRO 61
NEORAL 46 NORDITROPIN NORDIFLEX 61
NEOSPORIN G.U. IRRIGANT 15 NORELGESTROMIN/ETH ESTRADIOL 32
NEOSTIGMINE 59 NORELGESTROMIN/ETHIN.ESTRADIOL 32, 33
NEPAFENAC 39 NORETH A-ET ESTRA/FE FUMARATE 32, 33
NEPHRO-VITE RX 74 NORETH-ETHINYL ESTRADIOL/IRON 32, 33
NESINA 37 NORETHIND AC/ETHINYL ESTRADIOL 40
NETILMICIN 8 NORETHINDRONE 32, 33
NETROMYCIN 8 NORETHINDRONE A-E ESTRADIOL 32, 33
NETUPITANT/PALONOSETRON 4 NORETHINDRONE ACETATE 63
NEULASTA 43 NORETHINDRONE-ETHINYL ESTRAD 32, 33
NEUMEGA 47 NORFLOXACIN 64
NEUPOGEN 44 NORFLURANE/HFC 245FA 21
NEUPRO 37 NORGESTIMATE-ETHINYL ESTRADIOL 33
NEURONTIN 42 NORGESTREL-ETHINY ESTRA 33
NEVANAC 39 NORGESTREL-ETHINYL ESTRADIOL 33
NEVIRAPINE 21, 55 NORITATE 14
NEXA PLUS 54 NOROXIN 64
NEXA SELECT 54 NORPACE CR 13
NEXAVAR 13 NORTHERA 6
NEXICLON XR 7 NORTREL 33
NEXIUM 64 NORTRIPTYLINE HCL 72
NEXIUM PACKETS 64 NORVASC 36
NEXT CHOICE 32 NORVIR 11, 63
NIACIN 38 NOVACORT 5
92 of 104
N (cont.) O (cont.)
NOVAREL 43 OMACETAXINE 46
NOVOLIN 70-30 47 OMACETAXINE MEPESUCCINATE FOR INJECTION 20
NOVOLIN N 47 OMALIZUMAB 53
NOVOLIN R 47 OMBITASVIR/PARITAPREVIR/RITONAVIR 18
NOVOLOG 47 OMECLAMOX-PAK 64
NOVOLOG FLEXPEN 47 OMEGA-3 ACID ETHYL ESTERS 38
NOVOLOG MIX 70-30 47 OMEPRAZOLE 64
NOVOLOG MIX 70-30 FLEXPEN 47 OMEPRAZOLE-SODIUM BICARBONATE 64
NOVOTWIST 35 OMEPRAZOLE/CLARITH/AMOXICILLIN 64
NOXAFIL 24 OMEPRAZOLE/SODIUM BICARBONATE 64
NPH, HUMAN INSULIN ISOPHANE 47 OMNARIS 34
NPLATE 43 OMNITROPE 61
NUCALA 53 ONABOTULINUMTOXINA 55
NUCYNTA 57 ONCOVIN 20
NUCYNTA ER 57 ONDANSETRON 4
NUEDEXTA 30 ONDANSETRON ODT 4
NULOJIX 70 ONFI 25
NUPLAZID 24 ONGLYZA 36
NUSINERSEN INJECTION 21 ONZETRA XSAIL 66
NUTROPIN AQ 61 OPANA ER 57
NUTROPIN AQ NUSPIN 61 OPIUM 16
NUVARING 33 OPIUM TINCTURE 16
NUVIGIL 10 OPRELVEKIN 47
NUWIQ 17 OPSUMIT 39
NYAMYC 17 OPTICHAMBER 35
NYSTATIN 17 OPTICHAMBER DIAMOND 35
NYSTATIN-TRIAMCINOLONE 17 OPTIHALER 35
NYSTATIN/TRIAMCIN 17 OPTIVAR 12
NYSTOP 17 ORACEA 71
ORALAIR 6
O ORAPRED ODT 5
OBETICHOLIC ACID TABLETS 41 ORENCIA 37
OCALIVA 41 ORENITRAM 63
OCRELIZUMAB INJECTION 53 ORFADIN 44
OCREVUS 53 ORKAMBI 28
OCRIPLASMIN 48 ORSYTHIA 32
OCTREOTIDE ACETATE 52, 58 ORTHO ALL-FLEX 33
ODFESEY 56 ORTHO EVRA 33
ODOMZO 20 ORTHO TRI-CYCLEN 33
OFEV 72 ORTHO TRI-CYCLEN LO 33
OFLOXACIN 14, 64 ORTHO-CEPT 33
OGESTREL 33 ORTHO-CYCLEN 33
OLANZAPINE 23, 24, 27 ORTHO-NOVUM 33
OLANZAPINE ODT 23 OSCIMIN 21
OLANZAPINE-FLUOXETINE HCL 16 OSCIMIN SL 21
OLANZAPINE/FLUOXETINE HCL 16 OSCIMIN SR 21
OLAPARIB 65 OSELTAMIVIR PHOSPHATE 12
OLARATUMAB INJECTION 52 OSIMERTINIB TABLETS 72
OLEPTRO ER 67 OSMOPREP 49
OLMESARTAN MED/AMLODIPINE/HCTZ 9 OSPEMIFENE 40
OLMESARTAN MEDOXOMIL 9 OSPHENA 40
OLMESARTAN/HYDROCHLOROTHIAZIDE 9 OTEZLA 45
OLOPATADINE HCL 12 OTIC CARE 49
OLOPATADINE NASAL 12 OTOVEL 13
OLUX 11 OTREXUP 41
OLUX-E 11 OVCON-35 33
OLYSIO 18 OVIDREL 43
93 of 104
O (cont.) P (cont.)
OXACILLIN 60 PEG-INTRON 47
OXAPROZIN 55, 56 PEG3350/SOD SUL/NACL/ASB/C/KCL 49
OXAZEPAM 25 PEGASYS 18
OXCARBAZEPINE 69 PEGASYS PROCLICK 18
OXICONAZOLE NITRATE 17 PEGFILGRASTIM 43
OXISTAT 17 PEGINTERFERON ALFA-1A 53
OXSORALEN-ULTRA 61 PEGINTERFERON ALFA-2A 18
OXYBUTYNIN 42 PEGINTERFERON ALFA-2B 18
OXYBUTYNIN CHLORIDE 42 PEGINTRON REDIPEN 18
OXYBUTYNIN CHLORIDE ER 42 PEMBROLIZUMAB 52
OXYCODONE CONCENTRATE 57 PEMIROLAST POTASSIUM 12
OXYCODONE HCL 57 PEN NEEDLE 36
OXYCODONE HCL/ACETAMINOPHEN 57 PENCICLOVIR 22
OXYCODONE HCL/ASPIRIN 57 PENICILLIN G 60
OXYCODONE HCL/OXYCODON TER/ASA 57 PENICILLIN V POTASSIUM 60
OXYCODONE-ACETAMINOPHEN 57 PENNSAID 56
OXYCODONE-ASPIRIN 57 PENTASA 8
OXYCONTIN 57 PENTOSAN POLYSULFATE SODIUM 59
OXYMETAZOLINE HCL 1% CREAM 7 PENTOXIFYLLINE 44
OXYMORPHONE HCL 57 PEPCID 44
OZURDEX 56 PERAMPANEL 4
PERCOCET 57
P PERINDOPRIL ERBUMINE 10
P-EPHED HCL/CODEINE/GUAIFEN 22 PERMETHRIN 65
PACERONE 13 PERPHENAZINE 72
PAIN EASE 21 PHENADOZ 60
PALBOCICLIB 72 PHENAZOPYRIDINE HCL 21
PALIPERIDONE 24 PHENELZINE SULFATE 50
PALIPERIDONE PALMITATE 24 PHENOBARB/HYOSCY/ATROPINE/SCOP 21
PALIVIZUMAB 53 PHENOBARBITAL 25
PANCREAZE 36 PHENYLEPHRINE HCL 74
PANCRELIPASE 5,000 36 PHENYLEPHRINE HCL/COD/PROMETH 22
PANOBINOSTAT 45 PHENYLEPHRINE HCL/PROMETH HCL 60
PANRETIN 65 PHENYTEK 69
PANTOPRAZOLE SODIUM 64 PHENYTOIN 69
PARATHYROID HORMONE FOR INJECTION 59 PHENYTOIN SODIUM EXTENDED 69
PARICALCITOL 74 PHISOHEX 50
PARITAPREVIR;/RITON/OMBITAS/DASA 18 PHLUORIVIT 53
PAROMOMYCIN SULFATE 7 PHRENILIN FORTE 8
PAROXETINE HCL 66, 67 PHYTONADIONE 31
PASIREOTIDE 69 PICATO 68
PATADAY 12 PILOCARPINE HCL 51
PATANASE 12 PIMAVANSERIN TABLETS 24
PATANOL 12 PIMECROLIMUS 68
PATIROMER ORAL SUSPENSION 62 PINDOLOL 26
PAXIL 67 PIOGLITAZONE HCL 71
PAXIL CR 67 PIOGLITAZONE HCL/METFORMIN HCL 71
PAZOPANIB 13 PIOGLITAZONE-METFORMIN 71
PCCA T3 SODIUM DILUTION 71 PIPERACILLIN 60
PED MV A,C,D3 #21 W-FLUORIDE 53 PIPRACIL 60
PED MV A,C,D3 #38 W-FLUORIDE 54 PIRBUTEROL ACETATE 70
PEDI MULTIVIT #37 W-FLUORIDE 54 PIRFENIDONE 70
PEDI MVI NO.12/SODIUM FLUORIDE 53 PIROXICAM 55
PEDIPIROX-4 17 PITAVASTATIN CALCIUM 45
PEG 3350-ELECTROLYTE 48 PLAQUENIL 19
PEG 3350/NA SULF,BICARB,CL/KCL 48, 49 PLAVIX 28, 62
PEG-3350 AND ELECTROLYTES 49 PLECANATIDE TABLETS 42
94 of 104
P (cont.) P (cont.)
PLEGRIDY 53 PRAVASTATIN SODIUM 45
PLERIXAFOR 44 PRAZIQUANTEL 10
PN W-CA64/IRON CB&GL/FA/DSS/DH 54 PRAZOSIN HCL 7
PNV #38/IRON FUM/FOLATE/DHA 54 PRECISION 36
PNV 18/FE,CARB/FA/DSS/UBI/DHA 54 PRED FORTE 34
PNV COMBO #19/IRON/FOL AC/DHA 54 PRED MILD 34
PNV COMBO #22/IRON/FA/OM3/DHA 53, 54 PREDNICARBATE 11
PNV NO.22/IRON CBN&GLUC/FA/DSS 53 PREDNISOLONE 5
PNV W-O CA NO5/FE FUMARATE/FA 53 PREDNISOLONE ACETATE 5, 34
PNV WITH CA,NO.71/IRON/FA 54 PREDNISOLONE SOD PHOSPHATE 5, 34
PNV WITH CA,NO.72/IRON,CARB/FA 53 PREDNISOLONE SODIUM PHOSPHATE 34
PNV WITH CA,NO63/IRON/FA/B6 54 PREDNISONE 5
PNV#79/IRON/FA/LMFOLATE CA/DHA 54 PREFERA OB 54
PNV-DHA + DOCUSATE 54 PREFERA-OB ONE 54
PNV/FA/B6/CALCIUM PHOS/GINGER 54 PREFERA-OB PLUS DHA 54
PNV22/IRON CBN&GLUC/FA/DSS/DHA 54 PREFEST 40
PNV38/IRON CBN&GLUC/FA/DSS/DHA 54 PREGABALIN 41
PNV53/IRON FUM/FA/DOCUSATE/DHA 54 PREGNENOLONE 60
PNV66/IRON FUMARATE/FA/DSS/DHA 54 PREGNENOLONE MICRONIZED 60
PNV69/IRON,CARBONYL/FA/DSS/DHA 54 PREGNENOLONE, MICRONIZED 60
PNV77/SOD IRON EDTA& PS/FA/OM3 54 PREGNYL 43
PNV80/IRON FUMARATE/FA/DSS/DHA 54 PREMARIN 40
PODOCON-25 68 PREMPHASE 40
PODOFILOX 68 PREMPRO 40
PODOPHYLLUM RESIN 68 PRENA1 54
POLY-VI-FLOR 54 PRENATABS FA 54
POLYETHYLENE GLYCOL 3350 49 PRENATAL 19 54
POLYMYXIN B SUL-TRIMETHOPRIM 14 PRENATAL AD 54
POLYMYXIN B SULF/TRIMETHOPRIM 14 PRENATAL NO.25/IRON/FA #6/DHA 54
POLYTRIM 14 PRENATAL NO.39/IRON/FA #6/DHA 54
POMALIDOMIDE 45 PRENATAL PLUS 53
POMALYST 45 PRENATAL VIT #76/IRON,CARB/FA 54
PONATINIB 20 PRENATAL VIT 15/IRON CB/FA/DSS 54
PORTIA 32 PRENATAL VIT 16/IRON CB/FA/DSS 54
PORTRAZZA 52 PRENATAL VIT 18/IRON CB/FA/DSS 54
POSACONAZOLE 24 PRENATAL VIT NO.44/IRON/FA/DHA 54
POTASSIUM BICARBONATE 65 PRENATAL VIT NO.78/IRON/FA 54
POTASSIUM BICARBONATE/CIT AC 65 PRENATAL VIT#36/IRON/FA CMB#6 54
POTASSIUM CHLORIDE 65 PRENATAL VIT#42/FA CMB#6 54
POTASSIUM CITRATE 6 PRENATAL VIT/IRON FUMARATE/FA 54
POTASSIUM CITRATE-CITRIC ACID 6 PRENATAL VITAMINS#21, IRON, FA 54
POTASSIUM CITRATE/CITRIC ACID 6 PRENATAL-U 53
POTASSIUM IODIDE 22 PRENATE DHA 54
POTASSIUM PHOSPHATE,MONOBASIC 5 PRENATE ELITE 54
POTIGA 16 PRENATE MINI 54
PRADAXA 15 PRENEXA 54
PRALUENT 59 PREPOPIK 49
PRAMIPEXOLE DI-HCL 37 PREQUE 10 54
PRAMIPEXOLE DIHYDROCHLORIDE 37 PREVACID 64
PRAMLINTIDE ACETATE 8 PREVALITE 27
PRAMOSONE 5 PREVIFEM 33
PRANDIN 51 PREVPAC 64
PRASCION 48 PREZISTA 63
PRASCION FC 48 PRIFTIN 22
PRASCION RA 50 PRILOSEC 64
PRASUGREL HCL 62 PRIMAQUINE 19
PRAVACHOL 45 PRIMAQUINE PHOSPHATE 19
95 of 104
P (cont.) Q (cont.)
PRIMAXIN 27 QUETIAPINE FUMARATE 23, 24
PRIMIDONE 25 QUINAPRIL HCL 10
PRISTIQ ER 16 QUINAPRIL/HYDROCHLOROTHIAZIDE 10
PROAIR HFA 26 QUINIDINE GLUCONATE 13
PROBENECID 73 QUINIDINE SULFATE 13
PROBENECID-COLCHICINE 73 QUININE SULFATE 19
PROBUPHINE 58 QUTENZA 71
PROCARBAZINE 6 QVAR 34
PROCHAMBER 35
PROCHLORPERAZINE MALEATE 18 R
PROCLORPERAZINE 37 RABEPRAZOLE 64
PROCRIT 43 RABEPRAZOLE SODIUM 64
PROCTOCORT 12 RADIUM RA 223 20
PROCTOFOAM-HC 12 RAGWEEK POLLEN 6
PROCTOSOL-HC 12 RAGWITEK 6
PROCTOZONE-HC 12 RALOXIFENE 40
PROCYSBI 35, 54 RALTEGRAVIR POTASSIUM 11
PROGESTERONE 63 RAMELTEON 23
PROGESTERONE IN OIL 63 RAMIPRIL 10
PROGESTERONE,MICRONIZED 63 RAMUCIRUMAB 39
PROGRAF 46 RANEXA 29
PROLIA 52 RANITIDINE HCL 44, 45
PROLIXIN 72 RANOLAZINE 29
PROMACTA 43 RAPAFLO 7, 24
PROMETHAZINE HCL 38, 60 RAPAMUNE 46
PROMETHAZINE VC 60 RASAGILINE MESYLATE 52
PROMETHAZINE VC-CODEINE 22 RAVICTI 55
PROMETHAZINE-CODEINE 22 RAYALDEE 74
PROMETHAZINE-DM 22 REBETOL 18
PROMETHEGAN 38 REBIF 50
PROMETRIUM 63 RECLIPSEN 32
PROMISEB 39 RECTIV 68
PROPAFENONE HCL 13 REGORAFENIB 20
PROPANTHELINE BROMIDE 19 REGRANEX 68
PROPRANOLOL HCL 26 REGULAR BEVEL NEEDLES 36
PROPYLTHIOURACIL 22 RELENZA 12
PROSCAR 4 RELISTOR 58
PROTONIX 64 RELPAX 66
PROTOPIC 68 REMERON 16
PROVENTIL HFA 26 REMICADE 37
PROVERA 63 REMODULIN 74
PROVIGIL 10 RENAF 29
PROZAC 67 RENAGEL 61
PULMICORT 35 RENVELA 61
PULMICORT FLEXHALER 34 REPAGLINIDE 51
PULMOZYME 40 REPATHA 59
PYLERA 15 REPREXAIN 57
PYRAZINAMIDE 22 REQUIP 37
PYRIDOSTIGMINE 59 REQUIP XL 37
PYRIDOSTIGMINE BROMIDE 59 RESCRIPTOR 55
PYRIMETHAMINE 19 RESCULA 63
PYRITHIONE ZINC 60 RESLIZUMAB INJECTION 53
RESTASIS 38
Q RETAPAMULIN 14
QNASL 34 RETIN-A MICRO 30
QUADRAPAX 21 RETIN-A MICRO PUMP 30
QUASENSE 32 RETROVIR 56
96 of 104
R (cont.) S (cont.)
REVATIO 61 SACUBITRIL/VALSARTAN 29
REVLIMID 45 SAFYRAL 33
REXULTI 24 SALEX 48
REYATAZ 63 SALICYLIC ACID 48
RHINOCORT AQUA 34 SALICYLIC ACID/CERAMIDE CMB #1 48
RHOFADE 7 SALIVA SUBSTITUTION COMBO NO.2 35
RIBAPAK 18 SALMETEROL XINAFOATE 70
RIBASPHERE 18 SALSALATE 55
RIBAVIRIN 18 SAMSCA 74
RIBOCICLIB TABLETS 48 SANCTURA XR 42
RIFABUTIN 22 SANCUSO 4
RIFAMPIN 22 SANDIMMUNE 46
RIFAPENTINE 22 SANDOSTATIN 52
RIFAXIMIN 15 SANTYL 68
RILPIVIRINE 55 SAPHRIS 23
RILUTEK 30 SAPROPTERIN DIHYDROCHLORIDE 58
RILUZOLE 30 SAQUINAVIR 63
RIMEXOLONE 34 SARAFEM 67
RIOCIGUAT 69 SAVAYSA 27
RIOMET 27 SAVELAMER 61
RISEDRONATE 28 SAVELLA 41
RISEDRONATE SODIUM 28 SAXAGLIPTIN HCL 36
RISPERIDONE 23 SAXAGLIPTIN HCL/METFORMIN HCL 37
RISPERIDONE M-TAB 23 SAXENDA 46
RISPERIDONE ODT 23 SCOPACE 16
RITALIN 10 SCOPOLAMINE 16
RITALIN CAPSULE 10, 60 MG 10 SCOPOLAMINE HYDROBROMIDE 16, 54
RITALIN LA CAPSULES 20, 30, 40 MG 10 SE 10-5 SS 48
RITONAVIR 11, 63 SE-DONNA PB HYOS 21
RITUXAN 53 SEASONALE 33
RITUXIMAB 53 SEASONIQUE 33
RIVAROXABAN 28 SEB-PREV 50
RIVASTIGMINE 31 SEBELIPASE ALFA INJECTION 48
RIXUBIS 44 SECUKINUMAB 47
RIZATRIPTAN 66 SEEBRI NEOHALER 19
RIZATRIPTAN BENZOATE 66 SELEGILINE 52
RIZATRIPTAN MLT 66 SELEGILINE HCL 52
ROFLUMILAST 65 SELENIUM SULFIDE 49, 50
ROLAPITANT TABLETS 70 SELZENTRY 21
ROMIPLOSTIM 43 SENSIPAR 58
ROPINIROLE HCL 37 SEREVENT DISKUS 70
ROSUVASTATIN CALCIUM 45 SEROQUEL 24
ROTIGOTINE 37 SEROQUEL XR 24
ROWASA 8 SERTACONAZOLE NITRATE 17
ROXICET 57 SERTRALINE HCL 67
ROZEREM 23 SEVELAMER CARBONATE 61
RUBRACA 65 SEVELAMER HCL 61
RUCAPARIB TABLETS 65 SIGNIFOR 69
RUCONEST 28 SILDENAFIL 61
RUFINAMIDE 69 SILDENAFIL CITRATE 61
RUXOLITINIB 48 SILENOR 16
RYBIX ODT 57 SILODOSIN 7, 24
RYTARY 38 SILTUXIMAB 47
RYTHMOL SR 13 SILVADENE 50
SILVER SULFADIAZINE 49, 50
S SIMCOR 38
SABRIL 42 SIMEPREVIR 18
97 of 104
S (cont.) S (cont.)
SIMPONI 37 STIMATE 61
SIMVASTATIN 45 STIOLTO RESPIMAT 65
SINGULAIR 49 STIVARGA 20
SIROLIMUS 46 STRATTERA 4
SIRTURO 22 STRENSIQ 43
SITAGLIPTIN PHOS/METFORMIN HCL 37 STRIBILD 10
SITAGLIPTIN PHOSPHATE 37 STROMECTOL 10
SITAVIG 18 SUBOXONE SL TABS 58
SIVEXTRO 59 SUCRALFATE 64
SKELAXIN 30 SUCROFERRIC OXYHYDROXIDE 61
SOD PICOSULF/MAG OX/CITRIC AC 49 SULAR 36
SODIUM CHLORIDE 65 SULCONAZOLE NITRATE 17
SODIUM CHLORIDE FOR INHALATION 65 SULFACET SOD/SULFUR/WITCH HAZ 48
SODIUM CITRATE & CITRIC ACID 6 SULFACETAMIDE SOD/SULFUR/UREA 49, 50
SODIUM FLUORIDE 29 SULFACETAMIDE SODIUM 14, 50
SODIUM POLYSTYRENE SULFONATE 62 SULFACETAMIDE SODIUM-SULFUR 48
SODIUM SULFACETAMIDE 50 SULFACETAMIDE SODIUM/SULFUR 48
SODIUM SULFACETAMIDE-SULFUR 48, 50 SULFACETAMIDE-PREDNISOLONE 14
SODIUM,POTASSIUM,&MAG SULFATES 49 SULFACETAMIDE/PREDNISOLONE SP 14
SOFOSBUVIR 18 SULFACETM NA/AVOBENZONE/SULFUR 50
SOFOSBUVIR/VELPATASVIR 18 SULFACETM NA/PREDNISOL AC 14
SOFOSBUVIR/VELPATASVIR/VOXILAPREVIR 18 SULFAMETHOXAZOLE-TRIMETHOPRIM 51
SOLARAZE 68 SULFAMETHOXAZOLE/TRIMETHOPRIM 51
SOLIFENACIN SUCCINATE 42 SULFAMIDE 14
SOLODYN 71 SULFASALAZINE 70
SOLVALDI 18 SULFASALAZINE DR 70
SOMA 30 SULFAZINE 70
SOMATROPIN 61 SULFAZINE EC 70
SOMNOTE 23 SULINDAC 55
SONATA 23 SUMATRIPTAN 66
SONIDEGIB CAPSULES 20 SUMATRIPTAN NASAL POWDER 66
SOOLANTRA 66 SUMATRIPTAN SUCC/NAPROXEN SOD 66
SORAFENIB 13 SUMATRIPTAN SUCCINATE 66
SORIATANE 68 SUMAVEL DOSEPRO 66
SORILUX 68 SUNITINIB MALATE 13
SOTALOL 26 SUPRAX 31
SOTALOL AF 26 SUPREP 49
SOTALOL HCL 26 SURE COMFORT 36
SPECIALTY USE NEEDLES 36 SURMONTIL 72
SPINOSAD 66 SUSTIVA 21, 55
SPINRAZA 21 SUSTOL 4
SPIRIVA 19 SUTENT 13
SPIRONOLACT/HYDROCHLOROTHIAZID 62 SYLATRON 47
SPIRONOLACTONE 62 SYLVANT 47
SPIRONOLACTONE-HCTZ 62 SYMBICORT 34
SPRINTEC 33 SYMBYAX 16
SPRIX 56 SYMLINPEN 120 8
SPRYCEL 20 SYMLINPEN 60 8
SRONYX 32 SYMMETREL 37
SSD 49 SYNAGIS 53
SSKI 22 SYNRIBO 20, 46
STALEVO 38 SYNTHROID 71
STARLIX 51 SYR W-NDL,INS 0.3 ML HALF MARK 35
STAXYN 61 SYRING W-NDL,DISP,INSUL,0.3ML 35, 36
STELARA 72 SYRING W-NDL,DISP,INSUL,0.5ML 35, 36
STELAZINE 72 SYRINGE & NEEDLE,INSULIN,1 ML 35, 36
STENDRA 61
T
TABLOID 20
98 of 104
T (cont.) T (cont.)
TACLONEX 5 TESTOSTERONE 9, 62
TACROLIMUS 46, 68 TESTOSTERONE CYPIONATE 9, 62
TADALAFIL 61 TESTOSTERONE ENANTHATE 62
TAFINLAR 24 TESTOSTERONE NASAL GEL 9
TAFLUPROST/PF 63 TETRABENAZINE 52
TAGRISSO 72 TETRACAINE/BENZOCAINE/BUTAMBEN 21
TALIMOGENE LAHERPAREPVEC 56 TETRACYCLINE HCL 71
TALTZ 45 THALIDOMIDE 45
TAMIFLU 12 THALOMID 45
TAMOXIFEN CITRATE 17 THEO-24 65
TAMSULOSIN 24 THEOPHYLLINE ANHYDROUS 65
TAMSULOSIN HCL 7 THERMAZENE 49
TANZEUM 46 THIOGUANINE 19, 20
TAPENTADOL HCL 57 THIORIDAZINE HCL 72
TARCEVA 20 THIOTEPA 6
TARKA 10 THIOTHIXENE 72
TASIGNA 72 THYROID 71
TASIMELTEON 51 THYROID,PORK 71
TAVABOROLE 46 TIAGABINE 42
TAZAROTENE 68 TIAGABINE HCL 16
TAZAROTENE 0.1% CREAM 68 TIAZAC 29
TAZORAC 0.05% 68 TICAGRELOR 62
TAZORAC 0.1% CREAM 68 TICLOPIDINE HCL 62
TAZORAC 0.1% GEL 68 TIKOSYN 13
TAZTIA XT 28 TILIA FE 32
TBO-FILGRASTIM 43 TIMOLOL 27
TECENTRIQ 52 TIMOLOL MALEATE 26, 27
TECFIDERA 50 TIMOLOL MALEATE/PF 27
TECHNIVIE 18 TIMOPTIC 27
TEDIZOLID 59 TIMOPTIC OCUDOSE 27
TEDUGLUTIDE 42 TINDAMAX 21
TEGRETOL 69 TINIDAZOLE 7, 20, 21
TEGRETOL XR 69 TIOTROPIUM BROMIDE 19
TEKTURNA 65 TIOTROPIUM BROMIDE/OLODATEROL INHALATION
TEKTURNA HCT 65 SPRAY 65
TELAPREVIR 18 TIPRANAVIR 63
TELBIVUDINE 56 TIROSINT 71
TELMISARTAN 9 TIVICAY 10
TELMISARTAN/AMLODIPINE 9 TIZANIDINE HCL 30
TELMISARTAN/HYDROCHLOROTHIAZID 9 TOBI 8
TELOTRISTAT ETHYL TABLETS 72 TOBRADEX 14
TEMAZEPAM 26 TOBRADEX OPTHALMIC OINTMENT 14
TEMODAR 20 TOBRADEX ST 14
TEMOZOLOMIDE 20, 46 TOBRAMYCIN 8, 14
TENOFOVIR ALAFENAMIDE TABLETS 21 TOBRAMYCIN IN 0.225% NACL 8
TENOFOVIR DISOPROXIL FUMARATE 21 TOBRAMYCIN-DEXAMETHASONE 14
TENORMIN 26 TOBRAMYCIN/DEXAMETHASONE 14
TERAZOSIN 24 TOBRAMYCIN/LOTEPRED ETAB 14
TERAZOSIN HCL 7, 24 TOBREX 14
TERBINAFINE HCL 6 TOCILIZUMAB 46
TERBUTALINE SULFATE 70 TOFACITINIB 45
TERCONAZOLE 17 TOLAZAMIDE 70
TERIFLUNOMIDE 50 TOLBUTAMIDE 70
TERIPARATIDE 60 TOLTERODINE TARTRATE 42
TERSI FOAM 50 TOLVAPTAN 74
TESAMORELIN 43 TOPAMAX 69
TESTIM 62 TOPICORT 11
99 of 104
T (cont.) T (cont.)
TOPIRAMATE 69 TRIZIVIR 56
TOPROL XL 26 TROSPIUM CHLORIDE 42
TOREMIFENE CITRATE 20 TRULANCE 42
TORSEMIDE 50 TRULICITY 46
TOUJEO 47 TRUVADA 56
TOVIAZ 42 TRYPSIN/BALSAM PERU/CASTOR OIL 68
TRABECTEDIN FOR INJECTION 20 TUDORZA PRESSAIR 19
TRACLEER 74 TUSSICAPS 22
TRADJENTA 37 TWINJECT 6
TRAMADOL HCL 57 TWYNSTA 9
TRAMADOL HCL-ACETAMINOPHEN 57 TYBOST 10
TRAMADOL HCL/ACETAMINOPHEN 57 TYKERB 20
TRAMETINIB 48 TYLENOL-CODEINE NO.3 57
TRANDOLAPRIL/VERAPAMIL HCL 10 TYPHOID VACC,LIVE,ATTENUATED 73
TRANEXAMIC ACID 44 TYSABRI 53
TRANSDERM-SCOP 16 TYVASO 74
TRANYLCYPROMINE SULFATE 50 TYZEKA 56
TRASTUZUMAB 43
TRAVATAN Z 63 U
TRAVOPROST 63 UCERIS 34
TRAZODONE HCL 67 ULESFIA 66
TREANDA 6 ULIPRISTAL ACETATE 33
TREPROSTINIL 63, 74 ULORIC 74
TRESIBA 47 ULTICARE 35
TRETINOIN 30, 65 ULTRA COMFORT 35
TRETINOIN MICROSPHERES 30 ULTRAM 57
TRETTEN 44 ULTRAM ER 57
TREXALL 19 ULTRAVATE 11
TREXIMET 66 UMECLIDINIUM/VILANTEROL 19
TRI-LEGEST FE 32 UNITUXIN 20
TRI-PREVIFEM 33 UNOPROSTONE 63
TRI-SPRINTEC 33 UREA 48
TRI-VI-FLOR 54 URIBEL 73
TRI-VIT WITH FLUORIDE-IRON 53 URIDINE TRIACETATE 73
TRI-VITAMIN WITH FLUORIDE 53 UROCIT-K 6
TRIADVANCE 54 UROFOLLITROPIN 43
TRIAMCINOLONE ACETONIDE 11, 34 UROXATRAL 7
TRIAMTERENE 62 URSODIOL 31
TRIAMTERENE-HCTZ 62 USTEKINUMAB 72
TRIAMTERENE-HYDROCHLOROTHIAZID 62 UTIBRON NEOHALER 64
TRIAMTERENE/HYDROCHLOROTHIAZID 62
TRIAZOLAM 26 V
TRIBENZOR 9 VAGIFEM 40
TRICOR 41 VALACYCLOVIR 18
TRIFLURIDINE 22 VALACYCLOVIR HCL 18
TRIFLURIDINE/TIPIRACIL 20 VALBENAZINE CAPSULES 30
TRIGLIDE 41 VALCHLOR 6
TRIHEXYPHENIDYL HCL 15 VALCYTE 10, 56
TRILEPTAL 69 VALGANCICLOVIR 10
TRILIPIX 41 VALGANCICLOVIR HCL 56
TRIMETHOBENZAMIDE HCL 18 VALIUM 25
TRIMETHOPRIM 73 VALPROATE SODIUM 42, 53
TRIMIPRAMINE MALEATE 72 VALPROIC ACID 42, 53
TRINESSA 33 VALSARTAN 9
TRIPHLUORIVIT 53 VALSARTAN-HYDROCHLOROTHIAZIDE 9
TRIPLE-VITAMIN W-FLUORIDE 53 VALSARTAN/HYDROCHLOROTHIAZIDE 9
TRIVORA-28 32 VALTREX 18
100 of 104
V (cont.) V (cont.)
VALTURNA 65 VINATE ULTRA 54
VANCOCIN HCL 15 VINBLASTINE 20
VANCOMYCIN HCL 15 VINCRISTINE 20
VANDAZOLE 15 VINORELBINE 20
VANOS 11 VIORELE 32
VANOXIDE-HC 5 VIRAMUNE 21, 55
VARDENAFIL HCL 61 VIRAMUNE XR 21
VARENICLINE TARTRATE 68 VIREAD 21
VARUBI 70 VISMODEGIB 20
VASOTEC 10 VIT B CMPLX 3/FA/VIT C/BIOTIN 74
VAXCHORA 73 VITAMEDMD ONE RX 54
VECTICAL 68 VITAMEDMD PLUS RX 54
VEDOLIZUMAB 75 VITAMEDMD REDICHEW RX 54
VELBAN 20 VITAMIN D2 74
VELCADE 64 VITAMINS A,C,D & FLUORIDE 53
VELIVET 32 VITE AC/GRAPE/HYALURONIC ACID 39
VELOSEF 31 VITEKTA 47
VELPHORO 61 VIVELLE-DOT 41
VELTASSA 62 VIVITROL 6
VELTIN 14 VIVOTIF BERNA 73
VEMAVITE-PRX 2 54 VOL-PLUS 54
VEMLIDY 21 VOL-TAB RX 54
VEMURAFENIB 25 VOLTAREN 56
VENATAL COMPLETE DHA 54 VON WILLEBRAND FACTOR RECOMBINANT FOR INJ
VENATAL-FA 54 18
VENCLEXTA 24 VONVENDI 18
VENETOCLAX TABLETS 24 VORAPAXAR 63
VENLAFAXINE HCL 67 VORICONAZOLE 24
VENLAFAXINE HCL ER 67 VORINOSTAT 45
VENTAVIS 63 VORTEX 35
VENTOLIN HFA 26 VORTIOXETINE 66
VERAMYST 34 VOSEVI 18
VERAPAMIL ER 29 VOTRIENT 13
VERAPAMIL ER PM 29 VRAYLAR 24
VERAPAMIL HCL 29 VUSION 17
VERDESO 11 VYTORIN 38
VESANOID 65 VYVANSE 8
VESICARE 42
VEXOL 34 W
VIAGRA 61 WARFARIN SODIUM 15
VIBERZI 42 WELCHOL 27
VIBRAMYCIN 71 WELLBUTRIN 67
VICODIN 57 WELLBUTRIN SR 67
VICODIN HP 57 WELLBUTRIN XL 67
VICOPROFEN 57 WESTHROID 71
VICTOZA 2-PAK 46 WYMZYA FE 32
VICTOZA 3-PAK 46
VICTRELIS 18 X
VIEKIRA PAK 18 XALATAN 63
VIGABATRIN 42 XALKORI 20
VIGAMOX 14 XANAX 25
VIIBRYD 16 XARELTO 28
VILAZODONE HYDROCHLORIDE 16 XARTEMIS XR 57
VIMIZIM 39 XELJANZ 45
VIMPAT 16 XELODA 20
VINACAL 53 XENADERM 68
VINATE GT 54 XENAZINE 52
101 of 104
X (cont.) Z (cont.)
XERAC AC 23 ZMAX 51
XERESE 22 ZOCOR 45
XERMELO 72 ZOFRAN ODT 4
XEROFORM PETROLATUM DRESSING 36 ZOHYDRO 57
XGEVA 52 ZOLINZA 45
XIAFLEX 64 ZOLMITRIPTAN 66
XIBROM 39 ZOLOFT 67
XIFAXAN 15 ZOLPIDEM TARTRATE 23
XIIDRA 38 ZOLPIDEM TARTRATE ER 23
XOFIGO 20 ZOMIG SPRAY 66
XOLAIR 53 ZOMIG TABLETS 66
XOLEGEL 17 ZOMIG ZMT TABLETS 66
XOPENEX 70 ZONALON 21
XOPENEX HFA 26 ZONISAMIDE 69
XTANDI 12 ZONTIVITY 63
XURIDEN 73 ZOVIA 1-35E 32
XYZAL 66 ZOVIA 1-50E 32
ZOVIRAX 18
Y ZURAMPIC 73
YASMIN 28 33 ZYBAN 68
YAZ 33 ZYCLARA 68
YONDELIS 20 ZYDELIG 48
ZYFLO CR 49
Z ZYKADIA 48
ZAFIRLUKAST 49 ZYLET 14
ZALEPLON 23 ZYMAR 14
ZANAMIVIR 12 ZYMAXID 14
ZANTAC 25 45 ZYPREXA 24
ZAVESCA 46 ZYPREXA ZYDIS 24
ZEBUTAL 8 ZYTIGA 20
ZEGERID 64 ZYVOX 15
ZEJULA 20
ZELBORAF 25
ZEMPLAR 74
ZENATANE 68
ZENCHENT 32
ZENCHENT FE 32
ZENCIA 48
ZENPEP 36
ZEOSA 32
ZEPATIER 18
ZESTRIL 10
ZETIA 38
ZETONNA 34
ZIAGEN 56
ZIANA 14
ZIDOVUDINE 56
ZIDOVUDINE/LAMIVUDINE 56
ZILEUTON 49
ZINC PYRITHIONE 60
ZINC SULFATE 65
ZINPLAVA 15
ZIOPTAN 63
ZIPRASIDONE HCL 23, 24
ZIPSOR 56
ZIRGAN 10
ZITHROMAX 51
102 of 104
Notes
1 - Home Health
2 - Infertility
3 - No copay
6 - Quantity Limit
7 - Step Therapy
103 of 104
2349 Gateway Oaks Drive, Suite 100
Sacramento, California 95833
916.563.2250
888.563.2250 toll-free
888.877.5378 tty
916.563.3182 fax
Published 03.18

Western Health Advandage

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PREFERRED DRUG LIST

3-TIER PRESCRIPTION DRUG PLAN

Note: The copayment for specialty medication is plan dependent and is

5-HT3 Receptor Antagonists / ANTIEMETICS

5-HT3 Receptor Antagonists / GASTROINTESTINAL OTHER

ADHD Amphetamines / CNS AGENTS

ADHD Non-Amphetamine / CNS AGENTS

AMPA Receptor Antagonist / ANTICONVULSANTS

Adrenals / HORMONE: GLUCOCORTICOIDS/MINERALOCORTICOIDS

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Alpha-Adrenergic Agonists / DERMATOLOGICAL AGENTS

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Alpha-Adrenergic Blocking Agents / ANTIMIGRAINE

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Alpha-Glucosidase Inhibitors / BLOOD GLUCOSE REGULATORS

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Amphetamines / AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH

Amylinomimetics / BLOOD GLUCOSE REGULATORS

Analgesics And Antipyretics- Misc. / ANTIMIGRAINE

Androgens / HORMONE: PITUITARY

Angiotensin Ii Receptor Antagonists / CARDIOVASCULAR

Angiotensin-Converting Enzyme Inhibitors / CARDIOVASCULAR

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Anti-Inflammatory Agents (Gi Drugs) / GI AGENTS

Anti-Inflammatory Agents (Skin & Mucous) / DERMATOLOGICAL AGENTS

Anti-Inflammatory Agents (Skin & Mucous) / GI AGENTS

Antiallergic Agents / NASAL STEROID

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Antiallergic Agents / RESPIRATORY AGENTS

Antibacterials (Eent) / ANTIBACTERIALS

Antibacterials (Eent) / DENTAL AGENT

Antibacterials (Eent) / OPHTHALMOLOGY

Antibacterials (Eent) / RESPIRATORY AGENTS

Antibacterials (Skin & Mucous Membrane) / DERMATOLOGICAL AGENTS

Antibacterials (Skin & Mucous Membrane) / OBSTETRICS & GYNECOLOGY

Antibacterials- Miscellaneous / ANTI - INFECTIVES

Antibacterials- Miscellaneous / GI AGENTS

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Antidiarrhea Agents / GI AGENTS

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Antiemetics- Miscellaneous / GI AGENTS

Antiemetics- Miscellaneous / OBSTETRICS & GYNECOLOGY

Antifungal Antibiotics / ANTIFUNGALS

Antifungals (Eent) / OPHTHALMOLOGY

Antifungals (Skin & Mucous Membrane) / DERMATOLOGICAL AGENTS

Antifungals (Skin & Mucous Membrane) / OBSTETRICS & GYNECOLOGY

Antihemophilic / OFFICE ADMINISTERED