1 de abril de 2018 Introducción Programa de farmacia · Listamos todos los medicamentos según su...

Tufts Health Together Organizacion Responsible por el Cuidado de la Salud

Programa de farmacia y

Lista de Medicamentos Preferidos

1 de junio de 2018

Introducción

Programa de farmacia

Tratamos de proporcionar opciones de alta calidad y bajo costo para la terapia con medicamentos. Trabajamos con sus proveedores médicos y farmacéuticos para estar seguros de que cubrimos los medicamentos más útiles e importantes para una variedad

de enfermedades y condiciones. Cubrimos ambas, las primeras recetas de medicamentos y recetas adicionales. También cubrimos algunos medicamentos de venta libre (OTC, por sus siglas en inglés) si su proveedor le entrega una receta y la

compra en una farmacia. Nuestro programa de farmacia no cubre todos los medicamentos y recetas. Algunos

medicamentos deben cumplir algunas pautas clínicas antes de que los podamos cubrir. Su proveedor debe solicitarnos la autorización previa antes de que cubramos estos medicamentos.

Lista de Medicamentos Preferidos (PDL, por sus siglas en inglés)

Listamos todos los medicamentos según su categoría terapéutica y clase de droga, seguido por el nombre genérico o de marca. Use el índice para encontrar un medicamento según su nombre genérico o de marca. Cubrimos medicamentos de

marca solamente cuando un medicamento genérico no esté disponible o si brindamos la autorización previa para usar el medicamento de marca.

Con la receta de un médico, los medicamentos cubiertos están a disposición de los miembros menores de 21 años de edad gratis y de los miembros de 21 años o mayores por un pequeño copago. Algunos miembros de 21 años o más no necesitan pagar el

copago. Para determinar si no necesita pagar un copago, consulte su Manual del Miembro.

Copagos:

La mayoría de los miembros que tienen 21 años de edad o más deben pagar los siguientes copagos de farmacia:

• $1 por ciertos medicamentos genéricos cubiertos usados principalmente para la

diabetes, la hipertensión arterial y el alto nivel de colesterol. Estos

medicamentos se llaman antihiperglicémicos (como metaformina), antihipertensivos (como lisinopril) y antihiperlipidémicos (como simvastatin)

• $3.65 por ciertos medicamentos de venta libre (OTC, por sus siglas en inglés)

para los cuales tiene una receta del medico

• $3.65 por la primera receta y recetas adicionales de ciertos medicamentos genéricos cubiertos y de venta libre

• $3.65 por la primera receta y recetas adicionales de medicamentos cubiertos de

marca

La PDL se aplica solamente a medicamentos que recibe en farmacias minoristas y de especialidades. La PDL no se aplica a medicamentos que recibe si está en el hospital.

Los medicamentos que usted recibe mientras está en el hospital están cubiertos como parte de su estadía.

Para obtener la información más actualizada sobre la PDL, por favor visite tuftshealthplan.com o llámenos al 888.257.1985 (TTY: 888.391.5535).

Autorización previa

Algunos medicamentos siempre requieren autorización previa, lo que quiere decir que su proveedor debe solicitarnos la aprobación antes de que nosotros paguemos por el

medicamento. Uno de nuestros clínicos evaluará esta solicitud. Nosotros cubriremos el medicamento de acuerdo a nuestras directrices clínicas si:

Existe una justificación médica por la que necesita un medicamento en particular

Dependiendo del medicamento, otros medicamentos de la PDL no han sido útiles

Si no aprobamos la solicitud de autorización previa, usted o su representante autorizado, si identifica a uno, puede apelar la decisión. Vea su Manual del Miembro para obtener información sobre las quejas y apelaciones.

Programa de terapia escalonada Cubrimos algunos tipos de medicamentos solamente a través de nuestro programa de

terapia escalonada. Nuestro programa de terapia escalonada requiere que usted pruebe medicamentos de primer nivel antes de que cubramos otro medicamento de dicho tipo.

Si usted y su proveedor piensan que cierto medicamento no es apropiado para tratar su enfermedad, su proveedor puede solicitarnos la autorización previa para usar el otro medicamento. Uno de nuestros clínicos evaluará la solicitud. Nosotros cubriremos el

medicamento de acuerdo a nuestras directrices clínicas. Si no aprobamos la solicitud de autorización previa, usted o su representante autorizado, si identifica a uno, puede apelar la decisión. Vea su Manual del Miembro para obtener información sobre las

quejas y apelaciones. Límite a la cantidad

Para asegurar que los medicamentos que toma son seguros y que recibe la cantidad apropiada, podríamos limitar cuánto recibe en cada oportunidad. Su proveedor puede pedirnos la autorización previa si usted necesita más de lo que cubrimos. Uno de nuestros clínicos evaluará la solicitud. Nosotros cubriremos el medicamento de acuerdo

a nuestras directrices clínicas si existe una razón médica por la que se necesita esta cantidad en particular. Si no aprobamos la solicitud de autorización previa, usted o su representante autorizado, si identifica a uno, puede apelar la decisión. Vea su Manual

del Miembro para obtener información sobre las quejas y apelaciones.

Medicamentos genéricos

Los medicamentos genéricos tienen los mismos ingredientes activos y funcionan de la misma manera que los medicamentos de marca. Cuando hay medicamentos genéricos

disponibles, no cubrimos el medicamento de marca sin autorización previa. Si usted y su proveedor piensan que un medicamento genérico no es apropiado para tratar su enfermedad y que un medicamento de marca es médicamente necesario, su proveedor

puede solicitarnos la autorización previa. Uno de nuestros clínicos evaluará la solicitud. Si no aprobamos la solicitud de autorización previa, usted o su representante autorizado, si identifica a uno, puede apelar la decisión. Vea su Manual del Miembro

para obtener información sobre las quejas y apelaciones.

Medicamentos nuevos en el mercado

Nosotros evaluamos nuevos medicamentos para determinar su eficacia y seguridad antes de agregarlos a nuestra PDL. Un proveedor que piensa que un medicamento

nuevo en el mercado es médicamente necesario para usted antes de que lo hayamos evaluado, puede presentar una solicitud de autorización previa. Uno de nuestros clínicos evaluará esta solicitud. Si aprobamos la solicitud, cubriremos el medicamento

de acuerdo a nuestras directrices clínicas. Si no aprobamos la solicitud, usted o su representante autorizado, si identifica a uno, puede apelar la decisión. Vea su Manual del Miembro para obtener información sobre las quejas y apelaciones.

Límites a la cobertura

La columna Requisitos/Límites en la PDL indica cuando un medicamento tiene un cierto requisito o límite para la cobertura. Los límites a la cobertura incluyen:

AGE (edad, en inglés) — Se puede aplicar restricción a la edad Este medicamento requiere autorización previa, si el medicamento no está

cubierto basado en la edad del miembro. Su proveedor deberá solicitarnos la autorización previa si el medicamento es médicamente necesario.

PA (por sus siglas en inglés) — Autorización previa Este medicamento requiere autorización previa. Su proveedor puede recetar un medicamento diferente de la PDL o enviarnos una solicitud de autorización previa.

QL (por sus siglas en inglés) — Límite a la cantidad Este medicamento se limita a una cantidad específica. Si una mayor cantidad es

médicamente necesaria, su proveedor deberá enviar una solicitud de autorización previa.

SP (por sus siglas en inglés) — Medicamento de especialidad Este medicamento está disponible solamente a través de nuestro proveedor de farmacia de especialidades, CVS/specialty.

ST (por sus siglas en inglés) — Terapia escalonada Este medicamento requiere una autorización previa si todavía no ha usado un medicamento de primera línea de la PDL. Su proveedor puede recetar otro medicamento de la PDL o enviarnos una solicitud de autorización previa.

Medicare Parte D

Si tiene la cobertura de Medicare, su cobertura de medicamentos recetados de Medicare (Parte D) cubrirá gran parte de sus medicamentos recetados. Debería tener

una tarjeta de identificación adicional para su cobertura de medicamentos recetados de Medicare. Por favor, muéstrele a su farmacéutico su tarjeta de identificación de Medicare Parte D cuando compra un medicamento recetado.

Aunque tenga Medicare Parte D, nosotros cubriremos algunos medicamentos, tales como ciertos medicamentos OTC. Los montos del copago y las excepciones se siguen

aplicando a estos medicamentos cubiertos. Para más información, por favor llámenos al 888.257.1985 (TTY: 888.391.5535). También puede encontrar más información sobre su cobertura de medicamentos recetados de Medicare llamando a Medicare al

800.633.4227 (TTY: 877.486.2048), visitando el sitio web de Medicare en medicare.gov o consultando su manual Medicare y Usted. Recuerde llevar todas sus tarjetas de identificación con

usted cuando visita la farmacia. Cuando compra un medicamento recetado, por favor muestre su tarjeta de identificación como miembro de Tufts Health Together y MassHealth así como sus tarjetas de identificación para medicamentos recetados de

Medicare.

Programa de farmacia de especialidades

Una farmacia de especialidades necesita entregarle ciertos medicamentos, como medicamentos inyectables y por vía intravenosa (IV, por sus siglas en inglés), que a menudo se usan para tratar enfermedades crónicas como la hepatitis C o la esclerosis

múltiple. Estos tipos de medicamentos necesitan apoyo y conocimiento adicional. Las farmacias de especialidades tienen conocimientos en estos campos. Estas farmacias pueden brindar apoyo adicional a miembros y proveedores.

CVS/specialty es nuestra farmacia de especialidades y puede entregarle estos medicamentos. Además de proporcionar medicamentos específicos de especialidad,

CVS/specialty:

Entregará los medicamentos a su domicilio, consultorio de su proveedor o

cualquier dirección que elija (excepto una casilla de correos)

Responderá sus respuestas y ofrecerá ayuda con sus medicamentos

Le brindará información, materiales y apoyo continuo para ayudarle a atender su enfermedad y a tomar los medicamentos de la manera correcta

Tendrá farmacéuticos que pueden ayudarle las 24 horas al día, siete días a la

semana, en el 800.237.2767

Synagis

Cada año, desde el 1 de noviembre al 31 de marzo, CVS/specialty proporcionará a los

miembros de Tufts Health Together con Synagis, que se usa para prevenir una enfermedad respiratoria seria causada por el virus respiratorio sincitial (RSV, por sus siglas en inglés). Evaluaremos las solicitudes de Synagis según las directrices más

recientes de la American Academy of Pediatrics.

Tufts Health Plan cumple con las leyes federales de derechos civiles aplicables y no discrimina

por motivos de raza, color, nacionalidad, edad, discapacidad o sexo. Tufts Health Plan no excluye

a las personas ni las trata de forma diferente debido a su raza, color, nacionalidad, edad,

discapacidad o sexo.

Tufts Health Plan:

Proporciona asistencia y servicios gratuitos a las personas con discapacidades para que se comuniquen de manera

eficaz con nosotros, como los siguientes:

— Información escrita en otros formatos (letra grande, audio, formatos electrónicos accesibles, otros formatos)

Proporciona servicios lingüísticos gratuitos a personas cuya lengua materna no es el inglés, como los siguientes:

— Intérpretes capacitados

— Información escrita en otros idiomas

Si necesita recibir estos servicios, comuníquese con Servicios para Miembros de Tufts Health Plan a 888.257.1985.

Si considera que Tufts Health Plan no le proporcionó estos servicios o lo discriminó de otra manera por motivos de raza,

color, nacionalidad, edad, discapacidad o sexo, puede presentar un reclamo a la siguiente persona:

Tufts Health Plan

Attention: Civil Rights Coordinator, Legal Dept.

705 Mount Auburn St.

Watertown, MA 02472

Phone: 888.880.8699 ext. 48000, [TTY number— 866-930-9252]

Fax: 617.972.9048

Email: [email protected]

Puede presentar el reclamo en persona o por correo postal, fax o correo electrónico. Si necesita ayuda para hacerlo, el

coordinador de derechos civiles con Tufts Health Plan está a su disposición para brindársela.

También puede presentar un reclamo de derechos civiles ante la Office for Civil Rights (Oficina de Derechos Civiles) del

Department of Health and Human Services (Departamento de Salud y Servicios Humanos) de EE. UU. de manera

electrónica a través de Office for Civil Rights Complaint Portal, disponible en

https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, o bien, por correo postal a la siguiente dirección o por teléfono a los

números que figuran a continuación:

U.S. Department of Health and Human Services

200 Independence Avenue, SW

Room 509F, HHH Building

Washington, D.C. 20201

Phone: 800.368.1019, 800.537.7697 (TDD)

Puede obtener los formularios de reclamo en el sitio web http://www.hhs.gov/ocr/office/file/index.html.

tuftshealthplan.com | 888.257.1985

For no cost translation in English, call the number on your ID card.

Arabic .للحصول على خدمة الترجمة المجانية باللغة العربية، يرجى االتصال على الرقم المدون على بطاقة الهوية الخاصة بك

Chinese 若需免費的中文版本，請撥打ID卡上的電話號碼。

French Pour demander une traduction gratuite en français, composez le numéro indiqué sur votre carte d’identité.

German Um eine kostenlose deutsche Übersetzung zu erhalten, rufen Sie bitte die Telefonnummer auf Ihrer Ausweiskarte an.

Greek Για δωρεάν μετάφραση στα Ελληνικά, καλέστε τον αριθμό που αναγράφεται στην αναγνωριστική κάρτας σας.

Haitian Creole Pou jwenn tradiksyon gratis nan lang Kreyòl Ayisyen, rele nimewo ki sou kat ID ou.

Italian Per la traduzione in italiano senza costi aggiuntivi, è possibile chiamare il numero indicato sulla tessera identificativa.

Japanese 日本語の無料翻訳についてはIDカードに書いてある番号に電話してください。

Khmer (Cambodian) សម្រាបស់សវាបកប្ម្របសោយឥតគតិថ្លៃជា ភាសាប្មែរ សមូទរូសព័្ទសៅកានស់េមប្ែេានសៅសេើបណ័្ណសាា េ់សាជកិរបសអ់្នក។

Korean 한국어로 무료 통역을 원하시면, ID 카드에 있는 번호로 연락하십시오.

Laotian ສໍ າລັບການແປພາສາເປັນພາສາລາວທ ີ່ ບໍີ່ ໄດ້ເສຍຄີ່ າໃຊ້ຈີ່ າຍ, ໃຫ້ໂທຫາເບ ທ ີ່ ຢ ີ່ ເທິ ງບັດປະຈໍ າຕົວຂອງທີ່ ານ.

Navajo

naisrePبه شماره تلفن مندرج در کارت شناسائی تان زنگ بزنید. فارسی برای ترجمه رایگا

Polish Aby uzyskać bezpłatne tłumaczenie w języku polskim, należy zadzwonić na numer znajdujący się na Pana/i dowodzie tożsamości.

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Vietnamese Để có bản dịch tiếng Việt không phải trả phí, gọi theo số trên thẻ căn cước của bạn.

Table of Contents

BLOOD DISORDER................................................................................................................................................. 3CALORIC UNDERNUTRITION..............................................................................................................................7CHRONIC LUNG OR BREATHING PASSAGE PROBLEM................................................................................ 9COLD SYMPTOMS................................................................................................................................................13COLLAGEN VASCULAR DISEASE.................................................................................................................... 15CONDITION RESULTING FROM A DEFECTIVE IMMUNE SYSTEM...........................................................17DISEASE AFFECTING THE BODY'S METABOLISM.......................................................................................26DISEASE OF THE HEART AND BLOOD VESSELS..........................................................................................35DISEASE OF THE URINARY TRACT................................................................................................................. 46DISORDER OF NERVE......................................................................................................................................... 50DISORDER OF NERVOUS SYSTEM................................................................................................................... 68DISORDER OF REPRODUCTIVE SYSTEM....................................................................................................... 86DISORDER OF RESPIRATORY SYSTEM...........................................................................................................94DISORDER OF THE DIGESTIVE SYSTEM...................................................................................................... 100DISORDER OF THE ENDOCRINE GLANDS....................................................................................................109EAR PROBLEM....................................................................................................................................................117EYE DISORDER................................................................................................................................................... 117FEVER................................................................................................................................................................... 120INFECTION...........................................................................................................................................................121INFLAMMATION OF THE SEROUS MEMBRANES IN THE BODY.............................................................131INFLAMMATORY DISORDER.......................................................................................................................... 131INJURY TO A MUCOUS MEMBRANE............................................................................................................. 149LUNG DISEASE................................................................................................................................................... 150MAJOR TRAUMATIC INJURY.......................................................................................................................... 156MARGINAL ZONE LYMPHOMA...................................................................................................................... 156MUSCLE OR BONE DISORDER........................................................................................................................ 156NEUROPSYCHIATRIC DISORDER...................................................................................................................170NOT FEELING WELL..........................................................................................................................................191NUTRITIONAL DISORDER................................................................................................................................191OTHER OVER-THE-COUNTER DRUGS...........................................................................................................193OTHER PRESCRIPTION DRUGS.......................................................................................................................198OVERDOSE...........................................................................................................................................................222PAIN.......................................................................................................................................................................223PATIENT DEMOGRAPHICS...............................................................................................................................234PREGNANCY....................................................................................................................................................... 235PROCEDURE........................................................................................................................................................ 236REACTION DUE TO AN ALLERGEN............................................................................................................... 240RECENT OPERATION.........................................................................................................................................242SKIN CONDITION............................................................................................................................................... 244SLOW DRUG ELIMINATION BY KIDNEY......................................................................................................255TUMOR................................................................................................................................................................. 255

1

Drug Status NotesBLOOD DISORDER

ACTIMMUNE SUBCUTANEOUS SOLUTION $3.65 PA; SP

ADEMPAS ORAL TABLET $3.65 PA; SP

Advate Intravenous Solution Reconstituted MB/RX SP

Adynovate Intravenous Solution Reconstituted MB/RX SP

Afstyla Intravenous Kit MB/RX SP

Alphanate/VWF Complex/Human Intravenous Solution Reconstituted

MB/RX SP

AlphaNine SD Intravenous Solution Reconstituted

MB/RX SP

Alprolix Intravenous Solution Reconstituted MB/RX SP

ANADROL-50 ORAL TABLET $3.65 PA

anagrelide hcl oral capsule $3.65

ARANESP (ALBUMIN FREE) INJECTION SOLUTION 100 MCG/ML, 200 MCG/ML, 25 MCG/ML, 300 MCG/ML, 40 MCG/ML, 60 MCG/ML

$3.65 SP; QL (4 ML per 30 days)

ARANESP (ALBUMIN FREE) INJECTION SOLUTION PREFILLED SYRINGE 100 MCG/0.5ML, 150 MCG/0.3ML, 200 MCG/0.4ML, 25 MCG/0.42ML, 300 MCG/0.6ML, 40 MCG/0.4ML, 500 MCG/ML, 60 MCG/0.3ML


Arzerra Intravenous Concentrate MB/RX SP

aspirin-dipyridamole er oral capsule extended release 12 hour

$3.65 PA; QL (60 EA per 30 days)

AURYXIA ORAL TABLET $3.65 PA

Bebulin Intravenous Solution Reconstituted MB/RX SP

BeneFIX Intravenous Kit MB/RX SP

BRILINTA ORAL TABLET 60 MG $3.65 QL (60 EA per 30 days)

BRILINTA ORAL TABLET 90 MG $3.65 PA; QL (60 EA per 30 days)

Carimune NF Intravenous Solution Reconstituted 12 GM, 6 GM

MB/RX PA; SP

Coagadex Intravenous Solution Reconstituted MB/RX

Corifact Intravenous Kit MB/RX SP

DARZALEX INTRAVENOUS SOLUTION Medical Benefit

^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsPBHMI = Pediatric Behavioral Health Medication Initiative

3

Drug Status Notesdipyridamole oral tablet $3.65

DROXIA ORAL CAPSULE $3.65

ELIQUIS ORAL TABLET $3.65 QL (60 EA per 30 days)

Eloctate Intravenous Solution Reconstituted MB/RX SP

ENDARI ORAL PACKET $3.65 PA

enoxaparin sodium injection solution $3.65

enoxaparin sodium subcutaneous solution $3.65

EPOGEN INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML

$3.65 SP

EXJADE ORAL TABLET SOLUBLE $3.65 SP

FARYDAK ORAL CAPSULE $3.65 PA; SP

Feiba Intravenous Solution Reconstituted MB/RX SP

folic acid oral tablet 1 mg $3.65

fondaparinux sodium subcutaneous solution $3.65

FRAGMIN SUBCUTANEOUS SOLUTION10000 UNIT/ML, 12500 UNIT/0.5ML, 15000 UNIT/0.6ML, 18000 UNT/0.72ML, 2500 UNIT/0.2ML, 5000 UNIT/0.2ML, 7500 UNIT/0.3ML

$3.65

Gammagard S/D Less IgA Intravenous Solution Reconstituted

MB/RX PA; SP

Gamunex-C Injection Solution MB/RX PA; SP

Gazyva Intravenous Solution MB/RX SP

GRANIX SUBCUTANEOUS SOLUTION PREFILLED SYRINGE $3.65 PA; SP

Helixate FS Intravenous Kit MB/RX PA; SP

Hemofil M Intravenous Solution Reconstituted 1000 UNIT, 1700 UNIT, 250 UNIT, 500 UNIT

MB/RX SP

heparin sodium (porcine) injection solution10000 unit/ml, 20000 unit/ml, 5000 unit/ml

$3.65

Humate-P Intravenous Solution Reconstituted 1000-2400 UNIT, 250-600 UNIT, 500-1200 UNIT

MB/RX SP

Idelvion Intravenous Solution Reconstituted MB/RX SP

IMBRUVICA ORAL CAPSULE 70 MG $3.65 PA

IMBRUVICA ORAL TABLET $3.65 PA


4

Drug Status NotesIPRIVASK SUBCUTANEOUS SOLUTION RECONSTITUTED $3.65 QL (24 vials per 12 days)

Ixinity Intravenous Solution Reconstituted MB/RX SP

JADENU ORAL TABLET $3.65 SP

JADENU SPRINKLE ORAL PACKET $3.65 SP

JAKAFI ORAL TABLET $3.65 PA; SP

JANTOVEN ORAL TABLET $3.65

Koate-DVI Intravenous Solution Reconstituted MB/RX SP

Kogenate FS Bio-Set Intravenous Kit MB/RX SP

Kogenate FS Intravenous Kit MB/RX SP

Kovaltry Intravenous Solution Reconstituted MB/RX SP

leucovorin calcium oral tablet $3.65

LEUKERAN ORAL TABLET $3.65

Lucentis Intravitreal Solution Prefilled Syringe 0.5 MG/0.05ML

MB/RX SP

Lupron Depot (1-Month) Intramuscular Kit 3.75 MG

MB/RX PA; SP


MB/RX PA; SP

MEPHYTON ORAL TABLET $3.65

MIRCERA INJECTION SOLUTION PREFILLED SYRINGE 100 MCG/0.3ML, 200 MCG/0.3ML, 50 MCG/0.3ML, 75 MCG/0.3ML

$3.65 QL (2 Syringes per 28 days)

MIRCERA INJECTION SOLUTION PREFILLED SYRINGE 150 MCG/0.3ML, 30 MCG/0.3ML


Mitoxantrone HCl Intravenous Concentrate MB/RX SP

Monoclate-P Intravenous Kit 1000 UNIT, 1500 UNIT

MB/RX SP

Mononine Intravenous Solution Reconstituted 1000 UNIT

MB/RX SP

MOZOBIL SUBCUTANEOUS SOLUTION Medical Benefit SP

NEULASTA ONPRO SUBCUTANEOUS PREFILLED SYRINGE KIT $3.65 SP

NEULASTA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE $3.65 SP


5

Drug Status NotesNEUPOGEN INJECTION SOLUTION 300 MCG/ML, 480 MCG/1.6ML $3.65 PA; SP

NEUPOGEN INJECTION SOLUTION PREFILLED SYRINGE $3.65 PA; SP

NINLARO ORAL CAPSULE $3.65 PA; SP

Novoeight Intravenous Solution Reconstituted MB/RX SP

NovoSeven RT Intravenous Solution Reconstituted

MB/RX SP

Nplate Subcutaneous Solution Reconstituted MB/RX PA; SP

Nuwiq Intravenous Kit MB/RX SP

Nuwiq Intravenous Solution Reconstituted MB/RX SP

Obizur Intravenous Solution Reconstituted MB/RX SP

Octagam Intravenous Solution 10 GM/100ML, 2 GM/20ML, 20 GM/200ML, 5 GM/50ML

MB/RX PA; SP

Oncaspar Injection Solution MB/RX SP

prasugrel hcl oral tablet $3.65

Privigen Intravenous Solution MB/RX PA; SP

PROCRIT INJECTION SOLUTION $3.65 SP

Profilnine Intravenous Solution Reconstituted MB/RX SP

Profilnine SD Intravenous Solution Reconstituted MB/RX SP

PROMACTA ORAL TABLET $3.65 PA; SP

Rebinyn Intravenous Solution Reconstituted MB/RX SP

Recombinate Intravenous Solution Reconstituted MB/RX SP

Rhophylac Injection Solution Prefilled Syringe MB/RX SP

RiaSTAP Intravenous Solution Reconstituted MB/RX SP

Rixubis Intravenous Solution Reconstituted MB/RX SP

STIMATE NASAL SOLUTION $3.65 SP

Synribo Subcutaneous Solution Reconstituted MB/RX SP

TABLOID ORAL TABLET $3.65

THALOMID ORAL CAPSULE $3.65 SP

Tretten Intravenous Solution Reconstituted MB/RX SP

VENCLEXTA ORAL TABLET $3.65 PA

VENCLEXTA STARTING PACK ORAL TABLET THERAPY PACK $3.65 PA

Vonvendi Intravenous Solution Reconstituted MB/RX SP


6

Drug Status Noteswarfarin sodium oral tablet $3.65

Wilate Intravenous Kit MB/RX SP

WinRho SDF Injection Solution MB/RX SP

XARELTO ORAL TABLET $3.65 QL (30 EA per 30 days)

XARELTO STARTER PACK ORAL TABLET THERAPY PACK $3.65

¥ (1 Fill per life of plan); QL (51 EA per 21 days)

XATMEP ORAL SOLUTION $3.65 PA

Xyntha Intravenous Kit 1000 UNIT, 2000 UNIT, 250 UNIT, 500 UNIT

MB/RX SP

Xyntha Solofuse Intravenous Kit MB/RX SP

ZARXIO INJECTION SOLUTION PREFILLED SYRINGE $3.65 SP

Zoledronic Acid Intravenous Concentrate MB/RX

Zoledronic Acid Intravenous Solution 4 MG/100ML

MB/RX

ZONTIVITY ORAL TABLET $3.65

CALORIC UNDERNUTRITION


calcium acetate (phos binder) oral capsule $3.65

calcium acetate (phos binder) oral tablet $3.65

cyanocobalamin injection solution $3.65

ergocalciferol oral capsule $3.65

ESCAVITE D ORAL TABLET CHEWABLE $3.65 Age Limit (Max 6 Years)

ESCAVITE ORAL TABLET CHEWABLE $3.65 Age Limit (Max 6 Years)

folbee oral tablet $3.65


FOSRENOL ORAL PACKET $3.65

GENOTROPIN MINIQUICK SUBCUTANEOUS SOLUTION RECONSTITUTED

$3.65 PA; SP

GENOTROPIN SUBCUTANEOUS SOLUTION RECONSTITUTED $3.65 PA; SP

HUMATROPE INJECTION SOLUTION RECONSTITUTED $3.65 PA; SP

lanthanum carbonate oral tablet chewable $3.65



7

Drug Status Noteslevocarnitine oral solution $3.65

levocarnitine oral tablet $3.65

megestrol acetate oral suspension 40 mg/ml, 400 mg/10ml, 625 mg/5ml

$3.65

multi vitamin/minerals oral tablet $3.65

multi-vit/fluoride oral solution $3.65

multi-vit/fluoride/iron oral solution $3.65

multivitamin/fluoride oral tablet chewable 1 mg $3.65

mynephrocaps oral capsule $3.65

NORDITROPIN FLEXPRO SUBCUTANEOUS SOLUTION $3.65 PA; SP

NUTROPIN AQ NUSPIN 10 SUBCUTANEOUS SOLUTION $3.65 PA; SP



OMNITROPE SUBCUTANEOUS SOLUTION $3.65 PA; SP

OMNITROPE SUBCUTANEOUS SOLUTION RECONSTITUTED $3.65 PA; SP

PHOSLYRA ORAL SOLUTION $3.65

POLY-VI-FLOR ORAL SUSPENSION $3.65

RENAGEL ORAL TABLET $3.65

RENAL ORAL CAPSULE $3.65

SAIZEN CLICK.EASY INJECTION SOLUTION RECONSTITUTED $3.65 PA; SP

SAIZEN INJECTION SOLUTION RECONSTITUTED $3.65 PA; SP

SAIZENPREP INJECTION SOLUTION RECONSTITUTED $3.65 PA; SP

SEROSTIM SUBCUTANEOUS SOLUTION RECONSTITUTED 4 MG, 5 MG, 6 MG $3.65 PA; SP

sevelamer carbonate oral packet $3.65

tri-vit/fluoride/iron oral solution $3.65

tri-vitamin/fluoride oral solution $3.65

vitamin d (ergocalciferol) oral capsule 50000 unit $3.65


8

Drug Status NotesZOMACTON SUBCUTANEOUS SOLUTION RECONSTITUTED $3.65 PA; SP

ZORBTIVE SUBCUTANEOUS SOLUTION RECONSTITUTED $3.65 PA; SP

CHRONIC LUNG OR BREATHING PASSAGE PROBLEM

ADCIRCA ORAL TABLET $3.65 PA; SP; QL (60 EA per 30 days)


ADVAIR DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 100-50 MCG/DOSE

$3.65PA; Age Limit (Min 4 Years and Max 11 Years)

ADVAIR DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 250-50 MCG/DOSE, 500-50 MCG/DOSE

$3.65 PA

ADVAIR HFA INHALATION AEROSOL $3.65 PA

AEROSPAN INHALATION AEROSOL SOLUTION $3.65

albuterol sulfate er oral tablet extended release 12 hour

$3.65

albuterol sulfate inhalation nebulization solution $3.65

albuterol sulfate oral syrup $3.65

albuterol sulfate oral tablet $3.65

ALVESCO INHALATION AEROSOL SOLUTION $3.65

ANORO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED

$3.65 PA

Aralast NP Intravenous Solution Reconstituted 1000 MG, 500 MG

MB/RX SP

ARCAPTA NEOHALER INHALATION CAPSULE $3.65 QL (1 EA per 30 days)

ASMANEX 120 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED

$3.65


$3.65


9

Drug Status NotesASMANEX 30 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED

$3.65


$3.65


$3.65

ASMANEX HFA INHALATION AEROSOL $3.65

ATROVENT HFA INHALATION AEROSOL SOLUTION $3.65

azelastine hcl nasal solution 0.1 % $3.65

BECONASE AQ NASAL SUSPENSION $3.65 PA

BREO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED $3.65 PA; QL (1 EA per 30 days)

budesonide inhalation suspension $3.65

CAYSTON INHALATION SOLUTION RECONSTITUTED $3.65

CLARINEX-D 12 HOUR ORAL TABLET EXTENDED RELEASE 12 HOUR $3.65 PA

COMBIVENT RESPIMAT INHALATION AEROSOL SOLUTION $3.65

cromolyn sodium inhalation nebulization solution $3.65

DALIRESP ORAL TABLET $3.65 PA; STPA

DULERA INHALATION AEROSOL $3.65 PA

ELIXOPHYLLIN ORAL ELIXIR $3.65

Epoprostenol Sodium Intravenous Solution Reconstituted 0.5 MG

MB/RX PA; SP; QL (4 EA per 30 days)



ESBRIET ORAL CAPSULE $3.65 PA; SP; QL (270 EA per 30 days)

ESBRIET ORAL TABLET $3.65 PA; SP; QL (270 EA per 30 days)

Fasenra Subcutaneous Solution Prefilled Syringe MB/RX PA; SP

FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED

$3.65

FLOVENT HFA INHALATION AEROSOL $3.65


10

Drug Status Notesfluticasone propionate nasal suspension $3.65

fluticasone-salmeterol inhalation aerosol powder breath activated

$3.65

Glassia Intravenous Solution MB/RX SP

INCRUSE ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED

$3.65

ipratropium bromide inhalation solution $3.65

ipratropium bromide nasal solution $3.65

ipratropium-albuterol inhalation solution $3.65

KALYDECO ORAL PACKET $3.65 PA; QL (60 EA per 30 days)

KALYDECO ORAL TABLET $3.65 PA; QL (60 EA per 30 days)

LETAIRIS ORAL TABLET $3.65 PA; SP; QL (30 EA per 30 days)

levalbuterol hcl inhalation nebulization solution0.31 mg/3ml, 0.63 mg/3ml, 1.25 mg/3ml

$3.65

levalbuterol tartrate inhalation aerosol $3.65 PA

metaproterenol sulfate oral syrup $3.65

metaproterenol sulfate oral tablet $3.65

montelukast sodium oral packet $3.65 STPA; QL (30 EA per 30 days)

montelukast sodium oral tablet $3.65 QL (30 EA per 30 days)

montelukast sodium oral tablet chewable $3.65 QL (30 EA per 30 days)

NEBUPENT INHALATION SOLUTION RECONSTITUTED $3.65

NUCALA SUBCUTANEOUS SOLUTION RECONSTITUTED Medical Benefit PA

OFEV ORAL CAPSULE $3.65 PA; QL (60 EA per 30 days)

OMNARIS NASAL SUSPENSION $3.65 PA

OPSUMIT ORAL TABLET $3.65 PA; SP

ORALAIR SUBLINGUAL TABLET SUBLINGUAL $3.65 PA; QL (30 EA per 30 days)

ORENITRAM ORAL TABLET EXTENDED RELEASE $3.65 PA; SP

ORKAMBI ORAL TABLET $3.65 PA; QL (120 EA per 30 days)

PERFOROMIST INHALATION NEBULIZATION SOLUTION $3.65


11

Drug Status NotesPROAIR HFA INHALATION AEROSOL SOLUTION $3.65 PA

PROAIR RESPICLICK INHALATION AEROSOL POWDER BREATH ACTIVATED

$3.65 PA

PROVENTIL HFA INHALATION AEROSOL SOLUTION $3.65 PA

PULMICORT FLEXHALER INHALATION AEROSOL POWDER BREATH ACTIVATED

$3.65

PULMOZYME INHALATION SOLUTION $3.65 SP

QVAR INHALATION AEROSOL SOLUTION $3.65

QVAR REDIHALER INHALATION AEROSOL BREATH ACTIVATED $3.65 QL (10.6 GM per 30 days)

REMODULIN INJECTION SOLUTION $3.65 PA; SP

REVATIO ORAL SUSPENSION RECONSTITUTED $3.65 PA; SP

SEREVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED

$3.65

sildenafil citrate oral tablet 20 mg $3.65 PA; SP; QL (90 EA per 30 days)

SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION $3.65

STRIVERDI RESPIMAT INHALATION AEROSOL SOLUTION $3.65

SYMBICORT INHALATION AEROSOL160-4.5 MCG/ACT $3.65 PA

SYMBICORT INHALATION AEROSOL 80-4.5 MCG/ACT $3.65

PA; ¥ (PA applies to members 0-5 years of age and members 12 years of age and older (no PA required for members 6 through 11 years of age))

terbutaline sulfate oral tablet $3.65

THEO-24 ORAL CAPSULE EXTENDED RELEASE 24 HOUR 300 MG, 400 MG $3.65

THEOCHRON ORAL TABLET EXTENDED RELEASE 12 HOUR 100 MG, 200 MG, 300 MG

$3.65


12

Drug Status Notestheophylline er oral tablet extended release 12 hour

$3.65

theophylline er oral tablet extended release 24 hour

$3.65

theophylline oral solution $3.65

TOBI PODHALER INHALATION CAPSULE $3.65 PA; SP; QL (1 EA per 60 days)

tobramycin inhalation nebulization solution $3.65 SP

TRACLEER ORAL TABLET $3.65 PA; SP; QL (60 EA per 30 days)

TRACLEER ORAL TABLET SOLUBLE $3.65 PA; SP; QL (120 EA per 30 days)

TYVASO INHALATION SOLUTION $3.65 PA; SP

TYVASO REFILL INHALATION SOLUTION $3.65 PA; SP

TYVASO STARTER INHALATION SOLUTION $3.65 PA; SP

UPTRAVI ORAL TABLET $3.65 PA; SP

UPTRAVI ORAL TABLET THERAPY PACK $3.65 PA; SP

Veletri Intravenous Solution Reconstituted MB/RX SP

VENTAVIS INHALATION SOLUTION $3.65 PA; SP; QL (9 Vials per 1 day)

VENTOLIN HFA INHALATION AEROSOL SOLUTION $3.65

Xolair Subcutaneous Solution Reconstituted MB/RX PA; SP; QL (6 vials per 28 days)

zafirlukast oral tablet $3.65

ZETONNA NASAL AEROSOL SOLUTION $3.65 PA

COLD SYMPTOMS



benzonatate oral capsule 100 mg, 200 mg $3.65

budesonide nasal suspension $3.65 PA

cetirizine hcl oral solution 1 mg/ml $3.65 PA

cetirizine hcl oral syrup 1 mg/ml $3.65 PA

CLARINEX ORAL SYRUP $3.65 PA


clemastine fumarate oral tablet 2.68 mg $3.65

cyproheptadine hcl oral syrup $3.65


13

Drug Status Notescyproheptadine hcl oral tablet $3.65

desloratadine oral tablet $3.65 PA

flunisolide nasal solution 25 mcg/act (0.025%) $3.65

fluticasone propionate nasal suspension $3.65

GILPHEX TR ORAL TABLET $3.65

guaifenesin er oral tablet extended release 12 hour 600 mg

$3.65

hydrocod polst-cpm polst er oral suspension extended release

$3.65

hydrocodone-homatropine oral syrup $3.65

hydrocodone-homatropine oral tablet $3.65

hydromet oral syrup $3.65


levocetirizine dihydrochloride oral solution $3.65 PA

levocetirizine dihydrochloride oral tablet $3.65 PA

mometasone furoate nasal suspension $3.65 PA




ODACTRA SUBLINGUAL TABLET SUBLINGUAL $3.65 PA; QL (30 EA per 30 days)



promethazine vc/codeine oral syrup $3.65

promethazine-codeine oral syrup $3.65

promethazine-dm oral syrup $3.65

promethazine-phenylephrine oral syrup $3.65

pseudoephedrine hcl oral tablet 60 mg $3.65

QNASL CHILDRENS NASAL AEROSOL SOLUTION $3.65 PA

QNASL NASAL AEROSOL SOLUTION $3.65 PA

SEMPREX-D ORAL CAPSULE $3.65 PA

triamcinolone acetonide nasal aerosol $3.65

TUSSIGON ORAL TABLET $3.65


14

Drug Status NotesZETONNA NASAL AEROSOL SOLUTION $3.65 PA

COLLAGEN VASCULAR DISEASE

Actemra Intravenous Solution 200 MG/10ML MB/RX PA; SP; QL (4 vials per 28 days)



ACTEMRA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE $3.65

PA; SP; QL (4 syringes per 28 days)

azathioprine oral tablet $3.65

Benlysta Intravenous Solution Reconstituted MB/RX PA; SP

BENLYSTA SUBCUTANEOUS SOLUTION AUTO-INJECTOR $3.65 PA; SP

BENLYSTA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE $3.65 PA; SP

celecoxib oral capsule $3.65 STPA; QL (60 EA per 30 days)

cevimeline hcl oral capsule $3.65

CIMZIA PREFILLED SUBCUTANEOUS KIT $3.65 PA; SP; QL (2 EA per 28 days)

CIMZIA STARTER KIT SUBCUTANEOUS KIT $3.65

PA; SP; ¥ (For first 4 weeks of treatment); QL (6 Syringes per 28 days)

CIMZIA SUBCUTANEOUS KIT 2 X 200 MG $3.65 PA; SP; QL (2 EA per 28 days)

COSENTYX SENSOREADY PEN SUBCUTANEOUS SOLUTION AUTO-INJECTOR 150 MG/ML

$3.65 PA; SP

COSENTYX SUBCUTANEOUS SOLUTION PREFILLED SYRINGE $3.65 PA; SP

diclofenac sodium er oral tablet extended release 24 hour

$3.65

EGRIFTA SUBCUTANEOUS SOLUTION RECONSTITUTED 1 MG $3.65 PA; SP

ENBREL MINI SUBCUTANEOUS SOLUTION CARTRIDGE $3.65 PA; SP; QL (4 ea per 28 days)

ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 25 MG/0.5ML $3.65


ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 50 MG/ML $3.65


ENBREL SUBCUTANEOUS SOLUTION RECONSTITUTED $3.65



15

Drug Status NotesENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR $3.65


etodolac er oral tablet extended release 24 hour $3.65

flurbiprofen oral tablet $3.65

HP Acthar Injection Gel MB/RX SP

HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 40 MG/0.8ML, 80 MG/0.8ML, 80 MG/0.8ML & 40MG/0.4ML

$3.65 PA; SP; ¥ (1 Fill per life of plan)

HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT $3.65 PA; SP; QL (2 EA per 28 days)

HUMIRA PEN-CROHNS STARTER SUBCUTANEOUS PEN-INJECTOR KIT $3.65 PA; SP; ¥ (1 Fill per life of plan)

HUMIRA PEN-PSORIASIS STARTER SUBCUTANEOUS PEN-INJECTOR KIT $3.65 PA; SP; ¥ (1 Fill per life of plan)

HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT $3.65 PA; SP; QL (2 EA per 28 days)

hydroxychloroquine sulfate oral tablet $3.65

Inflectra Intravenous Solution Reconstituted MB/RX PA

KENALOG INJECTION SUSPENSION 10 MG/ML $3.65

ketoprofen er oral capsule extended release 24 hour

$3.65

KEVZARA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE $3.65 PA; SP; QL (2.28 ML per 30 days)

KINERET SUBCUTANEOUS SOLUTION PREFILLED SYRINGE $3.65 PA; QL (28 Syringes per 28 days)

Lartruvo Intravenous Solution MB/RX

leflunomide oral tablet $3.65

meloxicam oral tablet $3.65

methotrexate oral tablet $3.65

MYALEPT SUBCUTANEOUS SOLUTION RECONSTITUTED $3.65 PA; QL (30 Vials per 30 days)

nabumetone oral tablet $3.65

ORENCIA CLICKJECT SUBCUTANEOUS SOLUTION AUTO-INJECTOR $3.65 PA; SP; QL (4 ML per 28 days)

Orencia Intravenous Solution Reconstituted MB/RXPA; SP; QL (4 VIALS per 28 days)


16

Drug Status NotesORENCIA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE $3.65 PA; SP; QL (4 ML per 28 days)

oxaprozin oral tablet $3.65

PANRETIN EXTERNAL GEL $3.65 PA

pilocarpine hcl oral tablet $3.65

piroxicam oral capsule $3.65

Remicade Intravenous Solution Reconstituted MB/RX PA; SP

Renflexis Intravenous Solution Reconstituted MB/RX PA; SP

Rituxan Intravenous Solution MB/RX PA; SP

salsalate oral tablet $3.65

Simponi Aria Intravenous Solution MB/RX PA; SP; QL (5 vials per 8 Weeks)

SIMPONI SUBCUTANEOUS SOLUTION AUTO-INJECTOR $3.65

PA; SP; QL (1 syringe per 28 days)

SIMPONI SUBCUTANEOUS SOLUTION PREFILLED SYRINGE $3.65


sulfasalazine oral tablet delayed release $3.65

tolmetin sodium oral capsule $3.65

tolmetin sodium oral tablet $3.65

TREXALL ORAL TABLET $3.65

XELJANZ ORAL TABLET $3.65 PA; SP; QL (60 EA per 30 days)

XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HOUR $3.65 PA; SP; QL (30 EA per 30 days)

YONDELIS INTRAVENOUS SOLUTION RECONSTITUTED Medical Benefit

CONDITION RESULTING FROM A DEFECTIVE IMMUNE SYSTEM

abacavir sulfate oral solution $3.65

abacavir sulfate oral tablet $3.65

abacavir sulfate-lamivudine oral tablet $3.65

abacavir-lamivudine-zidovudine oral tablet $3.65







17

Drug Status NotesACTIMMUNE SUBCUTANEOUS SOLUTION $3.65 PA; SP


MB/RX SP

ANADROL-50 ORAL TABLET $3.65 PA

APTIVUS ORAL CAPSULE $3.65

APTIVUS ORAL SOLUTION $3.65

ARCALYST SUBCUTANEOUS SOLUTION RECONSTITUTED $3.65 PA; SP; QL (4 Vials per 28 days)

ASTAGRAF XL ORAL CAPSULE EXTENDED RELEASE 24 HOUR $3.65

atazanavir sulfate oral capsule $3.65

ATRIPLA ORAL TABLET $3.65





Berinert Intravenous Kit MB/RX SP

BIKTARVY ORAL TABLET $3.65


MB/RX PA; SP



CIMDUO ORAL TABLET $3.65





COMPLERA ORAL TABLET $3.65

cortisone acetate oral tablet $3.65


$3.65 PA; SP


18

Drug Status NotesCOSENTYX SUBCUTANEOUS SOLUTION PREFILLED SYRINGE $3.65 PA; SP

CRIXIVAN ORAL CAPSULE 200 MG, 400 MG $3.65

cromolyn sodium oral concentrate $3.65

cyclosporine modified oral capsule $3.65

cyclosporine modified oral solution $3.65

cyclosporine oral capsule $3.65

Cytogam Intravenous Injectable MB/RX PA; SP

DESCOVY ORAL TABLET $3.65 # (Preferred product)


$3.65

didanosine oral capsule delayed release 200 mg, 250 mg, 400 mg

$3.65

dronabinol oral capsule $3.65

EDURANT ORAL TABLET $3.65

efavirenz oral capsule $3.65

efavirenz oral tablet $3.65


EMTRIVA ORAL CAPSULE $3.65

EMTRIVA ORAL SOLUTION $3.65








ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR $3.65



EVOTAZ ORAL TABLET $3.65

FIRAZYR SUBCUTANEOUS SOLUTION $3.65 PA; SP; QL (3 ML per 1 Fill)

Flebogamma DIF Intravenous Solution MB/RX PA; SP


19

Drug Status Notesflurbiprofen oral tablet $3.65

fosamprenavir calcium oral tablet $3.65

FUZEON SUBCUTANEOUS SOLUTION RECONSTITUTED $3.65 SP

GAMMAGARD INJECTION SOLUTION Medical Benefit PA; SP


MB/RX PA; SP


GENGRAF ORAL CAPSULE 100 MG, 25 MG $3.65

GENGRAF ORAL SOLUTION $3.65


$3.65 PA; SP


GENVOYA ORAL TABLET $3.65 # (Preferred product)


guanidine hcl oral tablet $3.65 PA

Hizentra Subcutaneous Solution 1 GM/5ML, 10 GM/50ML, 2 GM/10ML, 4 GM/20ML

MB/RX PA; SP



MB/RX SP


HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 40 MG/0.8ML


HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 80 MG/0.8ML, 80 MG/0.8ML & 40MG/0.4ML




20

Drug Status NotesHUMIRA PEN-CROHNS STARTER SUBCUTANEOUS PEN-INJECTOR KIT $3.65 PA; SP; ¥ (1 Fill per life of plan)



hydrocortisone oral tablet $3.65


Hyqvia Subcutaneous Kit MB/RX PA; SP

Ilaris Subcutaneous Solution MB/RX PA; SP


INTELENCE ORAL TABLET $3.65

INVIRASE ORAL CAPSULE $3.65

INVIRASE ORAL TABLET $3.65

ISENTRESS HD ORAL TABLET $3.65 QL (60 EA per 30 days)

ISENTRESS ORAL PACKET $3.65 QL (60 EA per 30 days)

ISENTRESS ORAL TABLET $3.65

ISENTRESS ORAL TABLET CHEWABLE $3.65

JULUCA ORAL TABLET $3.65

KALETRA ORAL TABLET $3.65

KENALOG INJECTION SUSPENSION $3.65


$3.65



lamivudine oral solution $3.65

lamivudine oral tablet 150 mg, 300 mg $3.65

lamivudine-zidovudine oral tablet $3.65



LEXIVA ORAL SUSPENSION $3.65

lopinavir-ritonavir oral solution $3.65

MEDROL ORAL TABLET 2 MG $3.65


21

Drug Status Notesmegestrol acetate oral suspension 40 mg/ml, 400 mg/10ml, 625 mg/5ml

$3.65


MESTINON ORAL SYRUP $3.65


methylprednisolone oral tablet $3.65

methylprednisolone oral tablet therapy pack $3.65

methylprednisolone sodium succ injection solution reconstituted 125 mg, 40 mg

$3.65

MILLIPRED DP ORAL TABLET THERAPY PACK $3.65

MILLIPRED ORAL TABLET $3.65



mycophenolate mofetil oral capsule $3.65

mycophenolate mofetil oral suspension reconstituted

$3.65

mycophenolate mofetil oral tablet $3.65





NEUPOGEN INJECTION SOLUTION 300 MCG/ML, 480 MCG/1.6ML $3.65 PA; SP


nevirapine er oral tablet extended release 24 hour $3.65

nevirapine oral tablet $3.65


NORVIR ORAL CAPSULE $3.65 # (Preferred product)

NORVIR ORAL SOLUTION $3.65 # (Preferred product)

NORVIR ORAL TABLET $3.65 # (Preferred product)


22

Drug Status NotesNOXAFIL ORAL SUSPENSION $3.65 PA

NOXAFIL ORAL TABLET DELAYED RELEASE $3.65 PA






Octagam Intravenous Solution MB/RX PA; SP

ODEFSEY ORAL TABLET $3.65 # (Preferred product)





ORENCIA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE $3.65 PA; SP; QL (4 ML per 28 days)





prednisolone oral solution $3.65

prednisolone oral syrup 15 mg/5ml $3.65

prednisolone sodium phosphate oral solution 15 mg/5ml, 25 mg/5ml, 6.7 (5 base) mg/5ml

$3.65

prednisolone sodium phosphate oral tablet dispersible

$3.65

Prevymis Intravenous Solution MB/RX PA

PREVYMIS ORAL TABLET $3.65 PA

PREZCOBIX ORAL TABLET $3.65

PREZISTA ORAL SUSPENSION $3.65


23

Drug Status NotesPREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG, 800 MG $3.65



pyridostigmine bromide er oral tablet extended release

$3.65

pyridostigmine bromide oral tablet $3.65

RAPAMUNE ORAL SOLUTION $3.65



RESCRIPTOR ORAL TABLET $3.65

REYATAZ ORAL PACKET $3.65



Ruconest Intravenous Solution Reconstituted MB/RX SP





SANDIMMUNE ORAL SOLUTION $3.65

SELZENTRY ORAL SOLUTION $3.65 QL (1800 ML per 30 days)

SELZENTRY ORAL TABLET $3.65







sirolimus oral tablet $3.65

SOLU-CORTEF INJECTION SOLUTION RECONSTITUTED 100 MG, 1000 MG $3.65

stavudine oral capsule $3.65


24

Drug Status NotesSTRIBILD ORAL TABLET $3.65


SYMFI LO ORAL TABLET $3.65

SYMFI ORAL TABLET $3.65

SYNDROS ORAL SOLUTION $3.65 PA

tacrolimus oral capsule $3.65

tenofovir disoproxil fumarate oral tablet $3.65

TIVICAY ORAL TABLET $3.65




TRIUMEQ ORAL TABLET $3.65

TRUVADA ORAL TABLET 200-300 MG $3.65

TYBOST ORAL TABLET $3.65

VIDEX ORAL SOLUTION RECONSTITUTED $3.65

VIRACEPT ORAL TABLET $3.65

VIREAD ORAL POWDER $3.65

VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG $3.65







zidovudine oral capsule $3.65

zidovudine oral syrup $3.65

zidovudine oral tablet $3.65

ZOMACTON SUBCUTANEOUS SOLUTION RECONSTITUTED $3.65 PA; SP



25

Drug Status NotesZORTRESS ORAL TABLET $3.65 SP

DISEASE AFFECTING THE BODY'S METABOLISM

acarbose oral tablet $1

acetazolamide oral tablet $3.65

ACTOPLUS MET XR ORAL TABLET EXTENDED RELEASE 24 HOUR $1

ALDACTAZIDE ORAL TABLET 50-50 MG $1

Aldurazyme Intravenous Solution MB/RX PA; SP

alendronate sodium oral tablet 40 mg $3.65 QL (1 EA per 6 Months)

allopurinol oral tablet $3.65

alogliptin benzoate oral tablet $1 PA; QL (30 EA per 30 days)

alogliptin-metformin hcl oral tablet $1 PA; QL (60 EA per 30 days)

alogliptin-pioglitazone oral tablet $1 PA; QL (30 EA per 30 days)

ALTOPREV ORAL TABLET EXTENDED RELEASE 24 HOUR $1

amiloride hcl oral tablet $1

amlodipine-atorvastatin oral tablet $1 PA; QL (30 EA per 30 days)

ANTARA ORAL CAPSULE 30 MG, 90 MG $1 PA; QL (30 EA per 30 days)


MB/RX SP


atorvastatin calcium oral tablet $1


AVANDIA ORAL TABLET 2 MG, 4 MG $1


Brineura Solution MB/RX PA

bumetanide oral tablet $1

calcitriol oral capsule $3.65

calcitriol oral solution $3.65



captopril oral tablet $1

CARBAGLU ORAL TABLET $3.65 PA


26

Drug Status NotesCAYSTON INHALATION SOLUTION RECONSTITUTED $3.65

CERDELGA ORAL CAPSULE $3.65 PA; SP

Cerezyme Intravenous Solution Reconstituted 400 UNIT

MB/RX PA; SP



chlorothiazide oral tablet $1

chlorpropamide oral tablet $1

chlorthalidone oral tablet 25 mg, 50 mg $1

CHOLBAM ORAL CAPSULE $3.65 PA

cholestyramine light oral packet $1

cholestyramine light oral powder $1

cholestyramine oral packet $1

cholestyramine oral powder $1

Cinryze Intravenous Solution Reconstituted MB/RX PA; SP

colchicine oral tablet $3.65

colchicine-probenecid oral tablet $3.65

colestipol hcl oral packet $1

colestipol hcl oral tablet $1

constulose oral solution $3.65

CUPRIMINE ORAL CAPSULE 250 MG $3.65

CYSTAGON ORAL CAPSULE $3.65 PA; SP

danazol oral capsule $3.65

DEPEN TITRATABS ORAL TABLET $3.65

desmopressin ace rhinal tube nasal solution $3.65

desmopressin ace spray refrig nasal solution $3.65

desmopressin acetate oral tablet $3.65

desmopressin acetate spray nasal solution $3.65

DIURIL ORAL SUSPENSION $1


DUZALLO ORAL TABLET $3.65 PA

DYRENIUM ORAL CAPSULE $1



27

Drug Status NotesElaprase Intravenous Solution MB/RX SP

enulose oral solution $3.65

Ethacrynate Sodium Intravenous Solution Reconstituted

MB/RX

ethacrynic acid oral tablet $1 PA

etidronate disodium oral tablet $3.65

ezetimibe-simvastatin oral tablet $1 PA; QL (30 EA per 30 days)

FARXIGA ORAL TABLET $3.65 PA; QL (30 EA per 30 days)

fenofibrate micronized oral capsule 130 mg, 43 mg

$1 PA; QL (30 EA per 30 days)

fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg

$1 QL (30 EA per 30 days)

fenofibrate oral capsule $1 PA; QL (30 EA per 30 days)

fenofibrate oral tablet 120 mg, 145 mg, 40 mg, 48 mg


fenofibrate oral tablet 160 mg, 54 mg $1 QL (30 EA per 30 days)

fenofibric acid oral capsule delayed release $1 PA; QL (30 EA per 30 days)

fenofibric acid oral tablet $1 PA; QL (30 EA per 30 days)

FIBRICOR ORAL TABLET $3.65 QL (30 EA per 30 days)


flolipid oral suspension $3.65 PA

fluvastatin sodium er oral tablet extended release 24 hour


fluvastatin sodium oral capsule 20 mg $1 PA; QL (30 EA per 30 days)

fluvastatin sodium oral capsule 40 mg $3.65 PA; QL (30 EA per 30 days)


furosemide injection solution 10 mg/ml $1

furosemide oral solution 10 mg/ml, 8 mg/ml $1

furosemide oral tablet $1

gemfibrozil oral tablet $1

generlac oral solution $3.65


$3.65 PA; SP



28

Drug Status NotesGlassia Intravenous Solution MB/RX SP

glimepiride oral tablet $1

glipizide er oral tablet extended release 24 hour $1

glipizide oral tablet $1

glipizide xl oral tablet extended release 24 hour $1

glipizide-metformin hcl oral tablet $1

GLUCAGEN HYPOKIT INJECTION SOLUTION RECONSTITUTED $3.65

GLUCAGON EMERGENCY INJECTION KIT $3.65

glyburide micronized oral tablet $1

glyburide oral tablet $1

glyburide-metformin oral tablet $1

HAEGARDA SUBCUTANEOUS SOLUTION RECONSTITUTED $3.65 PA; SP


HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS SOLUTION $1

HUMULIN R U-500 KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR

$1


indapamide oral tablet $1

INDOCIN ORAL SUSPENSION $3.65

indomethacin er oral capsule extended release $3.65

indomethacin oral capsule $3.65

INVOKAMET ORAL TABLET $3.65 STPA; QL (60 EA per 30 days)

INVOKAMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR $3.65

STPA; QL (60 Tablets per 30 days)

INVOKANA ORAL TABLET 100 MG $3.65 STPA; QL (30 EA per 30 days)


JARDIANCE ORAL TABLET $3.65 STPA; QL (30 EA per 30 days)

JUXTAPID ORAL CAPSULE $3.65 PA; QL (30 EA per 30 days)




29

Drug Status NotesKANUMA INTRAVENOUS SOLUTION Medical Benefit PA

KEVEYIS ORAL TABLET $3.65 PA

KIONEX ORAL POWDER $3.65

KIONEX ORAL SUSPENSION $3.65

KLOR-CON M15 ORAL TABLET EXTENDED RELEASE $3.65

KORLYM ORAL TABLET $3.65 PA

Krystexxa Intravenous Solution MB/RX PA; SP

KUVAN ORAL TABLET SOLUBLE $3.65 PA; SP

KYNAMRO SUBCUTANEOUS SOLUTION PREFILLED SYRINGE $3.65 PA; SP; QL (4 EA per 28 days)

lactulose encephalopathy oral solution $3.65

lactulose oral solution $3.65




LIVALO ORAL TABLET $1 PA; QL (30 EA per 30 days)

lovastatin oral tablet $1


MB/RX SP

Lumizyme Intravenous Solution Reconstituted MB/RX SP

LYRICA CR ORAL TABLET EXTENDED RELEASE 24 HOUR $3.65

PA; ¥ (Additional PA requirements for members 5 years and under; PBHMI polypharmacy for members less than 18 years of age); QL (30 EA per 30 days)

LYRICA ORAL CAPSULE $3.65


LYRICA ORAL SOLUTION $3.65

PA; ¥ (Additional PA requirements for members 5 years and under; PBHMI polypharmacy for members less than 18 years of age); QL (900 ML per 30 days)

magdelay oral tablet delayed release $3.65


30

Drug Status Notesmegestrol acetate oral suspension 40 mg/ml, 400 mg/10ml, 625 mg/5ml

$3.65

metformin hcl er (mod) oral tablet extended release 24 hour

$1 PA

metformin hcl er (osm) oral tablet extended release 24 hour 1000 mg, 500 mg

$1 PA

metformin hcl er oral tablet extended release 24 hour

$1

metformin hcl oral tablet $1

methamphetamine hcl oral tablet $3.65

PA; ¥ (PA applies to members 2 years and under and 25 years and older; PBHMI polypharmacy for members less than 18 years of age); QL (150 EA per 30 days)

methyclothiazide oral tablet $1

metoclopramide hcl oral solution 10 mg/10ml, 5 mg/5ml

$3.65

metoclopramide hcl oral tablet $3.65

metolazone oral tablet $3.65

miglitol oral tablet $1


Naglazyme Intravenous Solution MB/RX SP

nateglinide oral tablet $1

NATPARA SUBCUTANEOUS CARTRIDGE $3.65PA; SP; QL (2 Cartridges per 21 days)

niacin er (antihyperlipidemic) oral tablet extended release

$1

niacin er oral capsule extended release $1

NIACOR ORAL TABLET $1

NITYR ORAL TABLET $3.65 PA


NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HOUR $3.65 PA



31

Drug Status NotesNUTROPIN AQ NUSPIN 20 SUBCUTANEOUS SOLUTION $3.65 PA; SP


octreotide acetate injection solution 100 mcg/ml, 1000 mcg/ml, 200 mcg/ml, 50 mcg/ml, 500 mcg/ml

$3.65 PA; SP; QL (30 ML per 30 days)



ORFADIN ORAL CAPSULE $3.65 PA

ORFADIN ORAL SUSPENSION $3.65 PA


oxandrolone oral tablet 10 mg $3.65 PA; QL (60 EA per 30 days)

oxandrolone oral tablet 2.5 mg $3.65 PA; QL (240 EA per 30 days)

Pamidronate Disodium Intravenous Solution MB/RX

Pamidronate Disodium Intravenous Solution Reconstituted

MB/RX


PHOSPHA 250 NEUTRAL ORAL TABLET $3.65

pioglitazone hcl oral tablet $1

pioglitazone hcl-glimepiride oral tablet $1

pioglitazone hcl-metformin hcl oral tablet $1

pot bicarb-pot chloride oral tablet effervescent $3.65

potassium bicarbonate oral tablet effervescent $3.65

potassium chloride crys er oral tablet extended release

$3.65

potassium chloride er oral capsule extended release

$3.65

potassium chloride er oral tablet extended release $3.65

potassium chloride oral packet $3.65

potassium chloride oral solution 20 meq/15ml (10%), 40 meq/15ml (20%)

$3.65

PRALUENT SUBCUTANEOUS SOLUTION PEN-INJECTOR $3.65 PA; SP; QL (2 ML per 28 days)

pravastatin sodium oral tablet $1


32

Drug Status Notesprobenecid oral tablet $3.65

PROGLYCEM ORAL SUSPENSION $3.65


RAVICTI ORAL LIQUID $3.65 PA; SP

REGRANEX EXTERNAL GEL $3.65


repaglinide oral tablet $1

repaglinide-metformin hcl oral tablet $1

REPATHA PUSHTRONEX SYSTEM SUBCUTANEOUS SOLUTION CARTRIDGE $3.65

PA; SP; # (Preferred product); QL (3.5 ML per 28 days)

REPATHA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE $3.65

PA; SP; # (Preferred product); QL (2 ML per 28 days)

REPATHA SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR $3.65


RIOMET ORAL SOLUTION $1

risedronate sodium oral tablet 30 mg $3.65 PA; QL (30 EA per 30 days)

rosuvastatin calcium oral tablet $1 PA; QL (30 EA per 30 days)





SAMSCA ORAL TABLET 15 MG $3.65 SP; QL (30 EA per 30 days)


SandoSTATIN LAR Depot Intramuscular Kit MB/RX PA; SP; QL (1 vial per 28 days)



simvastatin oral tablet $1

sodium polystyrene sulfonate oral powder $3.65

sodium polystyrene sulfonate oral suspension $3.65

sodium polystyrene sulfonate rectal suspension $3.65

Somatuline Depot Subcutaneous Solution MB/RX SP; QL (1 ML per 28 days)


33

Drug Status NotesSOMAVERT SUBCUTANEOUS SOLUTION RECONSTITUTED $3.65 PA; SP; QL (30 EA per 30 days)

spironolactone oral tablet $3.65

spironolactone-hctz oral tablet $3.65

SPS ORAL SUSPENSION $3.65

STRENSIQ SUBCUTANEOUS SOLUTION $3.65 PA; QL (24 Vials per 28 days)

SYMLINPEN 120 SUBCUTANEOUS SOLUTION PEN-INJECTOR $3.65



SYNJARDY ORAL TABLET $3.65 STPA; QL (60 EA per 30 days)

SYNJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR 10-1000 MG, 25-1000 MG

$3.65 STPA; QL (30 EA per 30 days)

SYNJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR 12.5-1000 MG, 5-1000 MG




tolazamide oral tablet $1

tolbutamide oral tablet $1

torsemide oral tablet $3.65

triamterene-hctz oral capsule $1

triamterene-hctz oral tablet $3.65

trientine hcl oral capsule $3.65 PA

TRIGLIDE ORAL TABLET 160 MG $3.65 PA; QL (30 EA per 30 days)

TRULICITY SUBCUTANEOUS SOLUTION PEN-INJECTOR $3.65 QL (4 pens per 28 days)

ULORIC ORAL TABLET $3.65STPA; QL (30 Tablets per 30 days)

VELTASSA ORAL PACKET $3.65

VICTOZA SUBCUTANEOUS SOLUTION PEN-INJECTOR $3.65 QL (3 pens per 28 days)

Vpriv Intravenous Solution Reconstituted MB/RX PA; SP

WELCHOL ORAL TABLET $3.65 PA


34

Drug Status NotesXgeva Subcutaneous Solution MB/RX PA; SP; QL (1 vial per 30 days)

XIFAXAN ORAL TABLET 200 MG $3.65 QL (9 EA per 30 days)


XIGDUO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 10-1000 MG, 10-500 MG, 2.5-1000 MG


XIGDUO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 5-1000 MG, 5-500 MG $3.65 PA; QL (60 EA per 30 days)


XURIDEN ORAL PACKET $3.65 PA; QL (120 Packets per 30 days)

ZETIA ORAL TABLET $1 PA; QL (30 EA per 30 days)



MB/RX



ZURAMPIC ORAL TABLET $3.65 PA

ZYPITAMAG ORAL TABLET $3.65 PA

DISEASE OF THE HEART AND BLOOD VESSELS

acebutolol hcl oral capsule $1



ADRENALIN INJECTION SOLUTION $3.65

AFEDITAB CR ORAL TABLET EXTENDED RELEASE 24 HOUR $1

ALDACTAZIDE ORAL TABLET 50-50 MG $1

almotriptan malate oral tablet $3.65 PA; QL (9 EA per 30 days)


MB/RX SP

AMICAR ORAL SOLUTION $3.65

AMICAR ORAL TABLET $3.65

amiloride hcl oral tablet $1

amiloride-hydrochlorothiazide oral tablet $1


35

Drug Status Notesamiodarone hcl oral tablet $3.65

amlodipine besy-benazepril hcl oral capsule $1 QL (30 EA per 30 days)

amlodipine besylate oral tablet $1

amlodipine besylate-valsartan oral tablet $1 PA; QL (30 EA per 30 days)


amlodipine-valsartan-hctz oral tablet $1 PA; QL (30 EA per 30 days)


anucort-hc rectal suppository $3.65

ANUSOL-HC RECTAL SUPPOSITORY $3.65



atenolol oral tablet $1

atenolol-chlorthalidone oral tablet $1

AZOR ORAL TABLET $1 PA

benazepril hcl oral tablet $1

benazepril-hydrochlorothiazide oral tablet $1

BENICAR HCT ORAL TABLET $1 STPA

BENICAR ORAL TABLET $1 STPA

betaxolol hcl oral tablet $1

BIDIL ORAL TABLET $3.65 PA

bisoprolol fumarate oral tablet $1

bisoprolol-hydrochlorothiazide oral tablet $1

Botox Injection Solution Reconstituted MB/RX PA; SP



bumetanide oral tablet $1

BYSTOLIC ORAL TABLET $1 STPA; QL (30 EA per 30 days)

CAFERGOT ORAL TABLET $3.65

candesartan cilexetil oral tablet $1 PA


captopril-hydrochlorothiazide oral tablet $1

CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 HOUR 120 MG $1 PA


MB/RX PA; SP


36

Drug Status NotesCARTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR $1

carvedilol oral tablet $1

carvedilol phosphate er oral capsule extended release 24 hour

$1PA; STPA; QL (30 EA per 30 days)

cilostazol oral tablet $3.65

clonidine hcl oral tablet $1

PA; ¥ (PA applies to members 2 years and under; PBHMI polypharmacy for members less than 18 years of age)

clonidine hcl transdermal patch weekly $1


clopidogrel bisulfate oral tablet $3.65

CLORPRES ORAL TABLET $1

CORLANOR ORAL TABLET $3.65 PA

DEMSER ORAL CAPSULE $1

DIGITEK ORAL TABLET $3.65

DIGOX ORAL TABLET $3.65

digoxin oral solution $3.65

digoxin oral tablet $3.65

dihydroergotamine mesylate nasal solution $3.65

DILATRATE-SR ORAL CAPSULE EXTENDED RELEASE $3.65

diltiazem cd oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg

$1

diltiazem hcl er beads oral capsule extended release 24 hour

$1

diltiazem hcl er coated beads oral capsule extended release 24 hour

$1

diltiazem hcl er coated beads oral tablet extended release 24 hour

$1

diltiazem hcl er oral capsule extended release 12 hour

$1

diltiazem hcl er oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg

$1

diltiazem hcl oral tablet $1


37

Drug Status Notesdilt-xr oral capsule extended release 24 hour $1

disopyramide phosphate oral capsule $3.65

divalproex sodium er oral tablet extended release 24 hour

$3.65

PA; ¥ (PA applies to members 5 years of age and under; PBHMI polypharmacy for members less than 18 years of age)

divalproex sodium oral capsule delayed release sprinkle

$3.65


divalproex sodium oral tablet delayed release $3.65


dofetilide oral capsule $3.65 SP

doxazosin mesylate oral tablet $1

EDARBI ORAL TABLET $3.65 PA

eletriptan hydrobromide oral tablet $3.65 PA; QL (9 EA per 30 days)


enalapril maleate oral tablet $1

enalapril-hydrochlorothiazide oral tablet $1



ENTRESTO ORAL TABLET $3.65 PA

eplerenone oral tablet $1 PA; QL (60 EA per 30 days)





eprosartan mesylate oral tablet $1 PA

ERGOMAR SUBLINGUAL TABLET SUBLINGUAL $3.65


MB/RX


Feiba Intravenous Solution Reconstituted MB/RX SP

felodipine er oral tablet extended release 24 hour $1


38

Drug Status Notesflecainide acetate oral tablet $3.65


fosinopril sodium oral tablet $1

fosinopril sodium-hctz oral tablet $1


$3.65

frovatriptan succinate oral tablet $3.65 PA; QL (9 EA per 30 days)

furosemide oral solution 10 mg/ml, 8 mg/ml $1

furosemide oral tablet $1


MB/RX PA; SP


guanfacine hcl oral tablet $1


HEMMOREX-HC RECTAL SUPPOSITORY25 MG $3.65

heparin (porcine) in nacl intravenous solution5000-0.9 ut/500ml-%

$3.65


$3.65


MB/RX SP

hydralazine hcl oral tablet $1

hydrochlorothiazide oral capsule $1

hydrochlorothiazide oral tablet $1

hydrocortisone ace-pramoxine external cream2.5-1 %

$3.65

hydrocortisone ace-pramoxine rectal cream $3.65

hydrocortisone acetate rectal suppository $3.65

Hydroxyprogesterone Caproate Intramuscular Solution

MB/RX

indapamide oral tablet $1


39

Drug Status NotesIPRIVASK SUBCUTANEOUS SOLUTION RECONSTITUTED $3.65 QL (24 vials per 12 days)

irbesartan oral tablet $1 STPA

irbesartan-hydrochlorothiazide oral tablet $1 STPA

ISORDIL TITRADOSE ORAL TABLET 40 MG $3.65

isosorbide dinitrate er oral tablet extended release

$3.65

isosorbide dinitrate oral tablet $3.65

isosorbide mononitrate er oral tablet extended release 24 hour

$3.65

isosorbide mononitrate oral tablet $3.65

isradipine oral capsule $1 PA

JANTOVEN ORAL TABLET $3.65

labetalol hcl oral tablet $1

LANOXIN ORAL TABLET 187.5 MCG, 62.5 MCG $3.65


lisinopril oral tablet $1

lisinopril-hydrochlorothiazide oral tablet $1

losartan potassium oral tablet $1

losartan potassium-hctz oral tablet $1


MB/RX SP



MB/RX PA; SP


MB/RX PA; SP

MATZIM LA ORAL TABLET EXTENDED RELEASE 24 HOUR $1 PA

meclizine hcl oral tablet $3.65

medroxyprogesterone acetate oral tablet $3.65

MESNEX ORAL TABLET $3.65

methyldopa oral tablet $1

methyldopa-hydrochlorothiazide oral tablet $1


40

Drug Status Notesmetoprolol succinate er oral tablet extended release 24 hour

$1

metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg

$1

metoprolol tartrate oral tablet 37.5 mg, 75 mg $3.65 PA

metoprolol-hydrochlorothiazide oral tablet $1

mexiletine hcl oral capsule $3.65

midodrine hcl oral tablet $3.65

MIGERGOT RECTAL SUPPOSITORY $3.65

MIGRANAL NASAL SOLUTION $3.65 QL (8 Units per 30 days)

MINITRAN TRANSDERMAL PATCH 24 HOUR $3.65

minoxidil oral tablet $1

moexipril hcl oral tablet $1

moexipril-hydrochlorothiazide oral tablet $1

MULTAQ ORAL TABLET $3.65

nadolol oral tablet 20 mg, 40 mg, 80 mg $1

nadolol-bendroflumethiazide oral tablet $1

naratriptan hcl oral tablet $3.65 STPA; QL (9 EA per 30 days)

NATAZIA ORAL TABLET $0

nicardipine hcl oral capsule $1

NIFEDICAL XL ORAL TABLET EXTENDED RELEASE 24 HOUR 60 MG $1

nifedipine er oral tablet extended release 24 hour30 mg, 60 mg

$1

nifedipine er oral tablet extended release 24 hour90 mg

$3.65

nifedipine er osmotic release oral tablet extended release 24 hour

$1

nifedipine oral capsule $1

nimodipine oral capsule $1 PA

nisoldipine er oral tablet extended release 24 hour

$1

NITRO-BID TRANSDERMAL OINTMENT $3.65

NITRO-DUR TRANSDERMAL PATCH 24 HOUR 0.3 MG/HR, 0.8 MG/HR $3.65


41

Drug Status Notesnitroglycerin sublingual tablet sublingual $3.65

nitroglycerin transdermal patch 24 hour $3.65

nitroglycerin translingual aerosol solution $3.65

nitroglycerin translingual solution $3.65

norepinephrine bitartrate intravenous solution Medical Benefit

norepinephrine-dextrose intravenous solution 4-5 mg/250ml-%, 8-5 mg/250ml-%

Medical Benefit

norepinephrine-sodium chloride intravenous solution 4-0.9 mg/250ml-%, 8-0.9 mg/250ml-%

Medical Benefit

norethindrone acetate oral tablet $3.65

NORPACE CR ORAL CAPSULE EXTENDED RELEASE 12 HOUR $3.65

NORTHERA ORAL CAPSULE $3.65 PA

NovoSeven RT Intravenous Solution Reconstituted

MB/RX SP





MB/RX PA; SP

omeprazole-sodium bicarbonate oral packet $3.65 PA



PACERONE ORAL TABLET 100 MG, 200 MG, 400 MG $3.65

pentoxifylline er oral tablet extended release $3.65

perindopril erbumine oral tablet $1

phenoxybenzamine hcl oral capsule $1

pindolol oral tablet $1

PRALUENT SUBCUTANEOUS SOLUTION PEN-INJECTOR $3.65 PA; SP; QL (2 ML per 28 days)

pramcort rectal cream $3.65


prazosin hcl oral capsule $1


42

Drug Status NotesPrivigen Intravenous Solution MB/RX PA; SP

PROCTOFOAM HC RECTAL FOAM $3.65

progesterone intramuscular oil $3.65 PA


propafenone hcl er oral capsule extended release 12 hour

$3.65

propafenone hcl oral tablet $3.65

propranolol hcl er oral capsule extended release 24 hour

$1

propranolol hcl oral solution 40 mg/5ml $1

propranolol hcl oral tablet $1

propranolol-hctz oral tablet $1

quinapril hcl oral tablet $1

quinapril-hydrochlorothiazide oral tablet $1

quinidine gluconate er oral tablet extended release

$3.65

quinidine sulfate oral tablet $3.65

ramipril oral capsule $1

RANEXA ORAL TABLET EXTENDED RELEASE 12 HOUR $3.65 PA; QL (60 EA per 30 days)

ranitidine hcl oral capsule $3.65

ranitidine hcl oral syrup $3.65

ranitidine hcl oral tablet 150 mg, 300 mg $3.65


REPATHA PUSHTRONEX SYSTEM SUBCUTANEOUS SOLUTION CARTRIDGE $3.65

PA; SP; # (Preferred product); QL (3.5 ML per 28 days)

REPATHA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE $3.65


REPATHA SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR $3.65




rizatriptan benzoate oral tablet $3.65 STPA; QL (9 EA per 30 days)

rizatriptan benzoate oral tablet dispersible $3.65 STPA; QL (9 EA per 30 days)



43

Drug Status NotesSORINE ORAL TABLET $1

sotalol hcl (af) oral tablet 120 mg, 80 mg $1

sotalol hcl oral tablet $1

SOTYLIZE ORAL SOLUTION $3.65


spironolactone-hctz oral tablet $3.65

sumatriptan nasal solution $3.65 QL (6 Units per 30 days)

sumatriptan succinate oral tablet $3.65 QL (9 EA per 30 days)

sumatriptan succinate refill subcutaneous solution cartridge

$3.65 QL (4 EA per 30 days)

sumatriptan succinate subcutaneous solution 6 mg/0.5ml


sumatriptan succinate subcutaneous solution auto-injector 4 mg/0.5ml, 6 mg/0.5ml


TAZTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR $1

TEKTURNA HCT ORAL TABLET $1 PA; QL (30 EA per 30 days)

TEKTURNA ORAL TABLET $1 PA; QL (30 EA per 30 days)

telmisartan oral tablet $1 PA

telmisartan-hctz oral tablet $1 PA

terazosin hcl oral capsule $1

timolol maleate oral tablet $1

topiramate er oral capsule er 24 hour sprinkle $3.65

PA; ¥ (Additional PA requirements for members 5 years and under; PBHMI polypharmacy for members less than 18 years of age)

topiramate oral capsule sprinkle $3.65

PA; ¥ (PA applies to members 5 years of age and under; PBHMI polypharmacy for members less than 18 years of age); QL (180 EA per 30 days)

topiramate oral tablet 100 mg, 50 mg $3.65



44

Drug Status Notes

topiramate oral tablet 200 mg $3.65




torsemide oral tablet $3.65



trandolapril oral tablet $1

trandolapril-verapamil hcl er oral tablet extended release

$1

tranexamic acid oral tablet $3.65 PA

triamterene-hctz oral capsule $1

triamterene-hctz oral tablet $3.65

TROKENDI XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR $3.65 PA






valsartan oral tablet $1 STPA

valsartan-hydrochlorothiazide oral tablet $1 STPA



verapamil hcl er oral capsule extended release 24 hour

$1

verapamil hcl er oral tablet extended release 120 mg, 180 mg, 240 mg

$1

verapamil hcl oral tablet $1


45

Drug Status NotesVonvendi Intravenous Solution Reconstituted MB/RX SP

warfarin sodium oral tablet $3.65






zolmitriptan oral tablet $3.65 STPA; QL (9 EA per 30 days)

zolmitriptan oral tablet dispersible $3.65 STPA; QL (9 EA per 30 days)

ZOMIG NASAL SOLUTION $3.65 STPA; QL (6 Units per 30 days)


DISEASE OF THE URINARY TRACT

AFINITOR ORAL TABLET $3.65 PA; SP; QL (30 EA per 30 days)

alfuzosin hcl er oral tablet extended release 24 hour

$3.65








Avastin Intravenous Solution MB/RX SP

AVC VAGINAL VAGINAL CREAM $3.65


bethanechol chloride oral tablet $3.65





46

Drug Status NotesCARDURA XL ORAL TABLET EXTENDED RELEASE 24 HOUR $1

CLEOCIN VAGINAL SUPPOSITORY $3.65

clindamycin phosphate vaginal cream $3.65




darifenacin hydrobromide er oral tablet extended release 24 hour

$3.65 PA

DEPO-PROVERA INTRAMUSCULAR SUSPENSION 400 MG/ML $3.65


DIVIGEL TRANSDERMAL GEL $3.65

doxazosin mesylate oral tablet $1

doxercalciferol oral capsule $3.65

dutasteride oral capsule $3.65 PA; QL (30 EA per 30 days)

dutasteride-tamsulosin hcl oral capsule $3.65 PA; QL (30 EA per 30 days)

ELESTRIN TRANSDERMAL GEL $3.65

Eligard Subcutaneous Kit MB/RX PA; SP

ELMIRON ORAL CAPSULE $3.65

EMCYT ORAL CAPSULE $3.65


$3.65 SP

estradiol vaginal cream $3.65

estradiol vaginal tablet $3.65

ESTRING VAGINAL RING $3.65

ESTROGEL TRANSDERMAL GEL $3.65

FEMRING VAGINAL RING $3.65

finasteride oral tablet 5 mg $3.65

flavoxate hcl oral tablet $3.65


GELNIQUE TRANSDERMAL GEL 10 % $3.65 PA



47

Drug Status NotesGENGRAF ORAL SOLUTION $3.65

GLYDO EXTERNAL GEL $3.65

GYNAZOLE-1 VAGINAL CREAM $3.65


MB/RX

imipramine hcl oral tablet $3.65


INTRAROSA VAGINAL INSERT $3.65 PA; QL (28 EA per 28 days)


Leuprolide Acetate Injection Kit MB/RX PA; SP

lidocaine hcl external gel 2 % $3.65


MB/RX PA; SP


MB/RX PA; SP

Lupron Depot (4-Month) Intramuscular Kit MB/RX PA; SP




methenamine hippurate oral tablet $3.65

methenamine mandelate oral tablet $3.65

metolazone oral tablet $3.65

metronidazole vaginal gel $3.65

miconazole 3 vaginal suppository $3.65

MIRCERA INJECTION SOLUTION PREFILLED SYRINGE 100 MCG/0.3ML, 200 MCG/0.3ML, 50 MCG/0.3ML, 75 MCG/0.3ML


MIRCERA INJECTION SOLUTION PREFILLED SYRINGE 150 MCG/0.3ML, 30 MCG/0.3ML



MONUROL ORAL PACKET $3.65



48

Drug Status Notesmycophenolate mofetil oral suspension reconstituted

$3.65


MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HOUR $3.65 PA



OSPHENA ORAL TABLET $3.65 PA

oxybutynin chloride er oral tablet extended release 24 hour

$3.65

oxybutynin chloride oral syrup $3.65

oxybutynin chloride oral tablet $3.65

OXYTROL TRANSDERMAL PATCH TWICE WEEKLY $3.65 PA

paricalcitol oral capsule $3.65 PA

phenazopyridine hcl oral tablet 100 mg, 200 mg $3.65


PREMARIN VAGINAL CREAM $3.65

PREMPHASE ORAL TABLET $3.65

PREMPRO ORAL TABLET $3.65



RAPAFLO ORAL CAPSULE $3.65 PA




SENSIPAR ORAL TABLET $3.65 STPA; SP




tamsulosin hcl oral capsule $3.65


terconazole vaginal cream $3.65

terconazole vaginal suppository $3.65

tinidazole oral tablet $3.65


49

Drug Status Notestolterodine tartrate er oral capsule extended release 24 hour

$3.65

tolterodine tartrate oral tablet $3.65

Torisel Intravenous Solution MB/RX SP

TOVIAZ ORAL TABLET EXTENDED RELEASE 24 HOUR $3.65


TRELSTAR MIXJECT INTRAMUSCULAR SUSPENSION RECONSTITUTED Medical Benefit SP

trimethoprim oral tablet $3.65

trospium chloride er oral capsule extended release 24 hour

$3.65

trospium chloride oral tablet $3.65

VANDAZOLE VAGINAL GEL $3.65

Vantas Subcutaneous Kit MB/RX SP

VESICARE ORAL TABLET $3.65 PA

Zoladex Subcutaneous Implant 10.8 MG MB/RX SP; QL (1 EA per 84 days)


ZORTRESS ORAL TABLET $3.65 SP

DISORDER OF NERVE

ADDERALL XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR $3.65


ADZENYS XR-ODT ORAL TABLET EXTENDED RELEASE DISPERSIBLE $3.65


AFINITOR DISPERZ ORAL TABLET SOLUBLE $3.65 PA; SP; QL (60 EA per 30 days)


amantadine hcl oral capsule $3.65

amantadine hcl oral syrup $3.65

amantadine hcl oral tablet $3.65



50

Drug Status Notes

amphetamine-dextroamphetamine oral tablet $3.65


AMPYRA ORAL TABLET EXTENDED RELEASE 12 HOUR $3.65

PA; SP; QL (60 Tablets per 30 days)

APTENSIO XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR $3.65


APTIOM ORAL TABLET $3.65


armodafinil oral tablet 150 mg, 200 mg, 250 mg $3.65 PA; QL (30 Tablets per 30 days)

armodafinil oral tablet 50 mg $3.65 PA; QL (60 Tablets per 30 days)



atomoxetine hcl oral capsule $3.65


atropine sulfate ophthalmic ointment $3.65

atropine sulfate ophthalmic solution $3.65

AUBAGIO ORAL TABLET $3.65 PA; SP; QL (30 EA per 30 days)

AUSTEDO ORAL TABLET $3.65 PA; QL (60 EA per 30 days)

AVONEX INTRAMUSCULAR KIT $3.65 SP

AVONEX PEN INTRAMUSCULAR AUTO-INJECTOR KIT $3.65 SP

AVONEX PREFILLED INTRAMUSCULAR PREFILLED SYRINGE KIT $3.65 SP

baclofen oral tablet 10 mg, 20 mg $3.65

BELSOMRA ORAL TABLET $3.65



51

Drug Status Notesbenztropine mesylate oral tablet $3.65

BETASERON SUBCUTANEOUS KIT $3.65 SP


BRIVIACT INTRAVENOUS SOLUTION Medical Benefit


BRIVIACT ORAL SOLUTION $3.65


BRIVIACT ORAL TABLET $3.65


bromocriptine mesylate oral capsule $3.65

bromocriptine mesylate oral tablet $3.65


caffeine citrate oral solution $3.65

carbamazepine er oral capsule extended release 12 hour

$3.65


carbamazepine er oral tablet extended release 12 hour

$3.65


carbamazepine oral suspension $3.65


carbamazepine oral tablet $3.65


carbamazepine oral tablet chewable $3.65


carbidopa oral tablet $3.65


52

Drug Status Notescarbidopa-levodopa er oral tablet extended release 25-100 mg, 50-200 mg

$3.65

carbidopa-levodopa oral tablet $3.65

carbidopa-levodopa oral tablet dispersible $3.65

carbidopa-levodopa-entacapone oral tablet $3.65

CELONTIN ORAL CAPSULE $3.65


chlordiazepoxide hcl oral capsule $3.65


clonazepam oral tablet $3.65


clonidine hcl er oral tablet extended release 12 hour

$3.65


clorazepate dipotassium oral tablet $3.65


CONCERTA ORAL TABLET EXTENDED RELEASE 18 MG, 27 MG, 54 MG $3.65


CONCERTA ORAL TABLET EXTENDED RELEASE 36 MG $3.65




53

Drug Status Notes

COTEMPLA XR-ODT ORAL TABLET EXTENDED RELEASE DISPERSIBLE $3.65



dantrolene sodium oral capsule $3.65

DAYTRANA TRANSDERMAL PATCH $3.65

PA; ¥ (Additional PA requirements for members 2 years and under; PBHMI polypharmacy for members less than 18 years of age); QL (30 patches per 30 days)


dexmethylphenidate hcl oral tablet $3.65


dextroamphetamine sulfate er oral capsule extended release 24 hour

$3.65


dextroamphetamine sulfate oral solution $3.65

PA; ¥ (PA applies to members 2 years and under and 25 years and older; PBHMI polypharmacy for members less than 18 years of age); QL (1200 mL per 30 days)

dextroamphetamine sulfate oral tablet $3.65


DIAZEPAM INTENSOL ORAL CONCENTRATE $3.65


diazepam oral concentrate $3.65



54

Drug Status Notes

diazepam oral solution 1 mg/ml $3.65


diazepam oral tablet $3.65


diazepam rectal gel $3.65 QL (1 System per 1 Rx)


DILANTIN ORAL CAPSULE 30 MG $3.65


diphenhydramine hcl oral capsule $3.65

diphenhydramine hcl oral elixir $3.65


$3.65



$3.65




donepezil hcl oral tablet 10 mg, 5 mg $3.65

donepezil hcl oral tablet dispersible $3.65

DYANAVEL XR ORAL SUSPENSION EXTENDED RELEASE $3.65


Dysport Intramuscular Solution Reconstituted MB/RX PA; SP

EDLUAR SUBLINGUAL TABLET SUBLINGUAL $3.65 PA; QL (30 EA per 30 days)


EMFLAZA ORAL SUSPENSION $3.65 PA; QL (26 ML per 30 days)


55

Drug Status NotesEMFLAZA ORAL TABLET $3.65 PA; QL (30 EA per 30 days)

entacapone oral tablet $3.65


EPITOL ORAL TABLET $3.65PA; ¥ (PA applies to members 6 years and under)

ergoloid mesylates oral tablet $3.65


estazolam oral tablet 1 mg $3.65


eszopiclone oral tablet $3.65


ethosuximide oral capsule $3.65


ethosuximide oral solution $3.65


Exondys 51 Intravenous Solution MB/RX PA

EXTAVIA SUBCUTANEOUS KIT $3.65 SP

flurazepam hcl oral capsule $3.65


FOCALIN XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR $3.65




56

Drug Status Notes

FYCOMPA ORAL SUSPENSION $3.65


FYCOMPA ORAL TABLET $3.65


gabapentin oral capsule $3.65


gabapentin oral solution 250 mg/5ml $3.65


gabapentin oral tablet $3.65


GABITRIL ORAL TABLET 12 MG, 16 MG $3.65


galantamine hydrobromide er oral capsule extended release 24 hour

$3.65

galantamine hydrobromide oral solution $3.65

galantamine hydrobromide oral tablet $3.65



GILENYA ORAL CAPSULE $3.65STPA; SP; QL (30 EA per 30 days)

glatiramer acetate subcutaneous solution prefilled syringe

$3.65 SP

GLATOPA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 20 MG/ML $3.65 SP

GOCOVRI ORAL CAPSULE EXTENDED RELEASE 24 HOUR $3.65 PA


57

Drug Status Notes

GRALISE ORAL TABLET $3.65


GRALISE STARTER ORAL $3.65


guanfacine hcl er oral tablet extended release 24 hour

$3.65

PA; STPA; ¥ (Additional PA requirements for members 2 years and under; PBHMI polypharmacy for members less than 18 years of age); QL (30 EA per 30 days)


HETLIOZ ORAL CAPSULE $3.65 PA; QL (30 EA per 30 days)

HORIZANT ORAL TABLET EXTENDED RELEASE $3.65



hydroxyzine hcl oral syrup $3.65

hydroxyzine hcl oral tablet $3.65

hydroxyzine pamoate oral capsule $3.65

INCRELEX SUBCUTANEOUS SOLUTION $3.65 PA; SP

INGREZZA ORAL CAPSULE $3.65 PA




lamotrigine er oral tablet extended release 24 hour

$3.65


lamotrigine oral kit 25 & 50 & 100 mg, 25 (21)-50 (7) mg, 50 (42)-100(14) mg

$3.65



58

Drug Status Notes

lamotrigine oral tablet 100 mg, 150 mg $3.65


lamotrigine oral tablet 200 mg $3.65


lamotrigine oral tablet 25 mg $3.65PA; ¥ (PA applies to members 6 years and under); QL (180 EA per 30 days)

lamotrigine oral tablet chewable $3.65PA; ¥ (PA applies to members 6 years and under); QL (180 EA per 30 days)

lamotrigine oral tablet dispersible $3.65PA; ¥ (PA applies to members 6 years and under)

lamotrigine starter kit-blue oral kit $3.65


lamotrigine starter kit-green oral kit $3.65


lamotrigine starter kit-orange oral kit $3.65


levetiracetam er oral tablet extended release 24 hour 500 mg

$3.65



$3.65



59

Drug Status Notes

levetiracetam oral solution $3.65


levetiracetam oral tablet $3.65


lidocaine external patch 5 % $3.65








memantine hcl oral solution $3.65

memantine hcl oral tablet $3.65




methylphenidate hcl er (cd) oral capsule extended release

$3.65



60

Drug Status Notes

methylphenidate hcl er (la) oral capsule extended release 24 hour 10 mg, 20 mg, 40 mg, 60 mg

$3.65


methylphenidate hcl er (la) oral capsule extended release 24 hour 30 mg

$3.65


methylphenidate hcl er oral tablet extended release 10 mg, 20 mg

$3.65PA; ¥ (PA applies to members less than 3 years old or 25 and older); QL (30 EA per 30 days)

methylphenidate hcl er oral tablet extended release 24 hour


methylphenidate hcl oral solution $3.65PA; ¥ (PA applies to members less than 3 years old or 25 and older); QL (900 mL per 30 days)

methylphenidate hcl oral tablet $3.65PA; ¥ (PA applies to members less than 3 years old or 25 and older); QL (90 EA per 30 days)

methylphenidate hcl oral tablet chewable $3.65PA; ¥ (PA applies to members less than 3 years old or 25 and older); QL (90 EA per 30 days)



MIRAPEX ER ORAL TABLET EXTENDED RELEASE 24 HOUR 3.75 MG $3.65


modafinil oral tablet $3.65 PA; QL (30 EA per 30 days)

MYDAYIS ORAL CAPSULE EXTENDED RELEASE 24 HOUR $3.65


Myobloc Intramuscular Solution MB/RX PA; SP

NAMENDA XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR $3.65


61

Drug Status NotesNAMENDA XR TITRATION PACK ORAL CAPSULE EXTENDED RELEASE 24 HOUR $3.65


NEUPRO TRANSDERMAL PATCH 24 HOUR $3.65 PA; QL (30 EA per 30 days)



NUPLAZID ORAL TABLET $3.65PA; SP; QL (60 Tablets per 30 days)

Ocrevus Intravenous Solution MB/RX PA; SP



ONFI ORAL SUSPENSION $3.65


ONFI ORAL TABLET 10 MG, 20 MG $3.65


oxazepam oral capsule $3.65


oxcarbazepine oral suspension $3.65


oxcarbazepine oral tablet $3.65


OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HOUR 150 MG, 300 MG

$3.65



62

Drug Status Notes

OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HOUR 600 MG $3.65


PEGANONE ORAL TABLET $3.65


PHENYTOIN INFATABS ORAL TABLET CHEWABLE $3.65


phenytoin oral suspension 125 mg/5ml $3.65


phenytoin oral tablet chewable $3.65


phenytoin sodium extended oral capsule $3.65


pimozide oral tablet $3.65


pramipexole dihydrochloride er oral tablet extended release 24 hour 0.375 mg, 0.75 mg, 1.5 mg, 2.25 mg, 3 mg, 4.5 mg

$3.65

pramipexole dihydrochloride oral tablet $3.65


$1

propranolol hcl oral solution $1



$3.65



63

Drug Status Notes

QUILLICHEW ER ORAL TABLET CHEWABLE EXTENDED RELEASE $3.65


QUILLIVANT XR ORAL SUSPENSION RECONSTITUTED $3.65

PA; ¥ (Additional PA requirements for members 2 years and under; PBHMI polypharmacy for members less than 18 years of age); QL (360 mL per 30 days)

Radicava Intravenous Solution MB/RX PA

rasagiline mesylate oral tablet $3.65

REBIF REBIDOSE SUBCUTANEOUS SOLUTION AUTO-INJECTOR $3.65 SP

REBIF REBIDOSE TITRATION PACK SUBCUTANEOUS SOLUTION AUTO-INJECTOR

$3.65 SP

REBIF SUBCUTANEOUS SOLUTION PREFILLED SYRINGE $3.65 SP

REBIF TITRATION PACK SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

$3.65 SP


riluzole oral tablet $3.65

rivastigmine tartrate oral capsule $3.65

rivastigmine transdermal patch 24 hour $3.65



ropinirole hcl er oral tablet extended release 24 hour

$3.65

ropinirole hcl oral tablet $3.65

ROZEREM ORAL TABLET $3.65 PA; QL (30 EA per 30 days)

SABRIL ORAL TABLET $3.65



selegiline hcl oral capsule $3.65


64

Drug Status Notesselegiline hcl oral tablet $3.65


SOMAVERT SUBCUTANEOUS SOLUTION RECONSTITUTED $3.65 PA; SP; QL (30 EA per 30 days)

Spinraza Intrathecal Solution MB/RX PA

SPRITAM ORAL TABLET DISINTEGRATING SOLUBLE $3.65










TECFIDERA ORAL $3.65 PA; SP; QL (60 EA per 30 days)

TECFIDERA ORAL CAPSULE DELAYED RELEASE $3.65 PA; SP; QL (60 EA per 30 days)

temazepam oral capsule $3.65


tetrabenazine oral tablet 12.5 mg $3.65 PA; SP; QL (240 EA per 30 days)

tetrabenazine oral tablet 25 mg $3.65 PA; SP; QL (120 EA per 30 days)

tiagabine hcl oral tablet 2 mg, 4 mg $3.65


tolcapone oral tablet $3.65 PA; QL (180 EA per 30 days)




65

Drug Status Notes










trihexyphenidyl hcl oral elixir $3.65

trihexyphenidyl hcl oral tablet $3.65


Tysabri Intravenous Concentrate MB/RX PA; SP; QL (1 vial per 28 days)

valproic acid oral capsule $3.65


valproic acid oral solution $3.65


vigabatrin oral packet $3.65



66

Drug Status Notes

VIMPAT ORAL SOLUTION $3.65


VIMPAT ORAL TABLET $3.65


VYVANSE ORAL CAPSULE $3.65


VYVANSE ORAL TABLET CHEWABLE $3.65


XADAGO ORAL TABLET $3.65 PA

Xeomin Intramuscular Solution Reconstituted MB/RX PA; SP



XYREM ORAL SOLUTION $3.65 PA

zaleplon oral capsule $3.65


ZELAPAR ORAL TABLET DISPERSIBLE $3.65 PA; QL (60 EA per 30 days)

ZENZEDI ORAL TABLET 10 MG, 5 MG $3.65PA; ¥ (PA applies to members less than 3 years old or 25 and older); QL (90 EA per 30 days)

ZINBRYTA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE $3.65

PA; SP; QL (1 Injection per 30 days)




67

Drug Status Notes

zolpidem tartrate er oral tablet extended release $3.65


zolpidem tartrate oral tablet $3.65


zolpidem tartrate sublingual tablet sublingual $3.65



zonisamide oral capsule $3.65



DISORDER OF NERVOUS SYSTEM












68

Drug Status Notes

















AUBAGIO ORAL TABLET $3.65 PA; SP; QL (30 EA per 30 days)


AVONEX INTRAMUSCULAR KIT $3.65 SP

AVONEX PEN INTRAMUSCULAR AUTO-INJECTOR KIT $3.65 SP

AVONEX PREFILLED INTRAMUSCULAR PREFILLED SYRINGE KIT $3.65 SP


BELSOMRA ORAL TABLET $3.65



69

Drug Status Notesbenztropine mesylate oral tablet $3.65

BETASERON SUBCUTANEOUS KIT $3.65 SP


BRIVIACT INTRAVENOUS SOLUTION Medical Benefit


BRIVIACT ORAL SOLUTION $3.65


BRIVIACT ORAL TABLET $3.65







$3.65



$3.65










70

Drug Status Notescarbidopa-levodopa er oral tablet extended release 25-100 mg, 50-200 mg

$3.65

carbidopa-levodopa oral tablet $3.65

carbidopa-levodopa oral tablet dispersible $3.65

carbidopa-levodopa-entacapone oral tablet $3.65

CELONTIN ORAL CAPSULE $3.65







$3.65










71

Drug Status Notes











$3.65











72

Drug Status Notes





diazepam rectal gel $3.65 QL (1 System per 1 Rx)


DILANTIN ORAL CAPSULE 30 MG $3.65





$3.65



$3.65









EDLUAR SUBLINGUAL TABLET SUBLINGUAL $3.65 PA; QL (30 EA per 30 days)




73

Drug Status NotesEMFLAZA ORAL TABLET $3.65 PA; QL (30 EA per 30 days)

entacapone oral tablet $3.65





estazolam oral tablet 1 mg $3.65


eszopiclone oral tablet $3.65


ethosuximide oral capsule $3.65


ethosuximide oral solution $3.65



EXTAVIA SUBCUTANEOUS KIT $3.65 SP

flurazepam hcl oral capsule $3.65






74

Drug Status Notes











GABITRIL ORAL TABLET 12 MG, 16 MG $3.65



$3.65





GILENYA ORAL CAPSULE $3.65STPA; SP; QL (30 EA per 30 days)

glatiramer acetate subcutaneous solution prefilled syringe

$3.65 SP

GLATOPA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 20 MG/ML $3.65 SP

GOCOVRI ORAL CAPSULE EXTENDED RELEASE 24 HOUR $3.65 PA


75

Drug Status Notes






$3.65



HETLIOZ ORAL CAPSULE $3.65 PA; QL (30 EA per 30 days)

HORIZANT ORAL TABLET EXTENDED RELEASE $3.65











lamotrigine er oral tablet extended release 24 hour

$3.65



$3.65



76

Drug Status Notes















$3.65



$3.65



77

Drug Status Notes



















$3.65



78

Drug Status Notes


$3.65



$3.65











MIRAPEX ER ORAL TABLET EXTENDED RELEASE 24 HOUR 3.75 MG $3.65








79

Drug Status NotesNAMENDA XR TITRATION PACK ORAL CAPSULE EXTENDED RELEASE 24 HOUR $3.65


NEUPRO TRANSDERMAL PATCH 24 HOUR $3.65 PA; QL (30 EA per 30 days)




Ocrevus Intravenous Solution MB/RX PA; SP









oxcarbazepine oral suspension $3.65


oxcarbazepine oral tablet $3.65


OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HOUR 150 MG, 300 MG

$3.65



80

Drug Status Notes

OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HOUR 600 MG $3.65




PHENYTOIN INFATABS ORAL TABLET CHEWABLE $3.65


phenytoin oral suspension 125 mg/5ml $3.65


phenytoin oral tablet chewable $3.65


phenytoin sodium extended oral capsule $3.65





$3.65

pramipexole dihydrochloride oral tablet $3.65


$1




$3.65



81

Drug Status Notes







REBIF REBIDOSE SUBCUTANEOUS SOLUTION AUTO-INJECTOR $3.65 SP

REBIF REBIDOSE TITRATION PACK SUBCUTANEOUS SOLUTION AUTO-INJECTOR

$3.65 SP

REBIF SUBCUTANEOUS SOLUTION PREFILLED SYRINGE $3.65 SP

REBIF TITRATION PACK SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

$3.65 SP



rivastigmine tartrate oral capsule $3.65




ropinirole hcl er oral tablet extended release 24 hour

$3.65

ropinirole hcl oral tablet $3.65

ROZEREM ORAL TABLET $3.65 PA; QL (30 EA per 30 days)




selegiline hcl oral capsule $3.65


82

Drug Status Notesselegiline hcl oral tablet $3.65



Spinraza Intrathecal Solution MB/RX PA











TECFIDERA ORAL $3.65 PA; SP; QL (60 EA per 30 days)

TECFIDERA ORAL CAPSULE DELAYED RELEASE $3.65 PA; SP; QL (60 EA per 30 days)

temazepam oral capsule $3.65




tiagabine hcl oral tablet 2 mg, 4 mg $3.65






83

Drug Status Notes










trihexyphenidyl hcl oral elixir $3.65

trihexyphenidyl hcl oral tablet $3.65



valproic acid oral capsule $3.65


valproic acid oral solution $3.65





84

Drug Status Notes

VIMPAT ORAL SOLUTION $3.65


VIMPAT ORAL TABLET $3.65






XADAGO ORAL TABLET $3.65 PA





zaleplon oral capsule $3.65


ZELAPAR ORAL TABLET DISPERSIBLE $3.65 PA; QL (60 EA per 30 days)


ZINBRYTA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE $3.65

PA; SP; QL (1 Injection per 30 days)




85

Drug Status Notes

zolpidem tartrate er oral tablet extended release $3.65


zolpidem tartrate oral tablet $3.65


zolpidem tartrate sublingual tablet sublingual $3.65



zonisamide oral capsule $3.65



DISORDER OF REPRODUCTIVE SYSTEM


alendronate sodium oral tablet 10 mg, 5 mg $3.65 QL (30 EA per 30 days)


ALTAVERA ORAL TABLET $0

alyacen 1/35 oral tablet $0

alyacen 7/7/7 oral tablet $0

AMETHIA LO ORAL TABLET $0

AMETHIA ORAL TABLET $0

AMETHYST ORAL TABLET $0

ANDRODERM TRANSDERMAL PATCH 24 HOUR $3.65 PA

ANDROGEL PUMP TRANSDERMAL GEL20.25 MG/ACT (1.62%) $3.65 PA

ANDROGEL TRANSDERMAL GEL 20.25 MG/1.25GM (1.62%), 40.5 MG/2.5GM (1.62%), 50 MG/5GM (1%)

$3.65 PA

APRI ORAL TABLET $0


86

Drug Status NotesARANELLE ORAL TABLET $0

ASHLYNA ORAL TABLET $0

AUBRA ORAL TABLET $0


AVIANE ORAL TABLET $0

AZURETTE ORAL TABLET $0

BALZIVA ORAL TABLET $0

BEKYREE ORAL TABLET $0

BEYAZ ORAL TABLET $0

BLISOVI 24 FE ORAL TABLET $0

BLISOVI FE 1.5/30 ORAL TABLET $0

BLISOVI FE 1/20 ORAL TABLET $0

briellyn oral tablet $0

calcitonin (salmon) nasal solution $3.65

CAMILA ORAL TABLET $0

CAMRESE LO ORAL TABLET $0

CAMRESE ORAL TABLET $0

CAZIANT ORAL TABLET $0

CHATEAL ORAL TABLET $0

CIALIS ORAL TABLET 5 MG $3.65 PA; QL (30 EA per 30 days)


CLIMARA PRO TRANSDERMAL PATCH WEEKLY $3.65


COMBIPATCH TRANSDERMAL PATCH TWICE WEEKLY $3.65

CRINONE VAGINAL GEL 8 % $3.65 PA

CRYSELLE-28 ORAL TABLET $0

CYCLAFEM 1/35 ORAL TABLET $0

CYCLAFEM 7/7/7 ORAL TABLET $0

CYRED ORAL TABLET $0

danazol oral capsule $3.65

DASETTA 1/35 ORAL TABLET $0

DASETTA 7/7/7 ORAL TABLET $0


87

Drug Status NotesDAYSEE ORAL TABLET $0

DEBLITANE ORAL TABLET $0

DELYLA ORAL TABLET $0


DEPO-TESTOSTERONE INTRAMUSCULAR SOLUTION 100 MG/ML $3.65 PA

desogestrel-ethinyl estradiol oral tablet $0


drospirenone-ethinyl estradiol oral tablet $0

DUAVEE ORAL TABLET $3.65 PA


ELINEST ORAL TABLET $0

ELLA ORAL TABLET $0

EMOQUETTE ORAL TABLET $0

ENPRESSE-28 ORAL TABLET $0

ENSKYCE ORAL TABLET $0

ERRIN ORAL TABLET $0

estradiol oral tablet $3.65

estradiol transdermal patch twice weekly $3.65

estradiol transdermal patch weekly $3.65





estropipate oral tablet $3.65

EVAMIST TRANSDERMAL SOLUTION $3.65

exemestane oral tablet $3.65

FALMINA ORAL TABLET $0

FAYOSIM ORAL TABLET $0


FORTEO SUBCUTANEOUS SOLUTION 600 MCG/2.4ML $3.65 PA; SP; QL (1 vial per 30 days)

FOSAMAX PLUS D ORAL TABLET $3.65 PA; QL (4 EA per 28 days)

GIANVI ORAL TABLET $0


88

Drug Status NotesGILDAGIA ORAL TABLET $0

GILDESS FE 1.5/30 ORAL TABLET $0

GILDESS FE 1/20 ORAL TABLET $0


HEATHER ORAL TABLET $0


MB/RX

Ibandronate Sodium Intravenous Solution 3 MG/3ML

MB/RX QL (3 ML per 90 days)

ibandronate sodium oral tablet $3.65 PA; QL (1 EA per 28 days)


INTROVALE ORAL TABLET $0

JENCYCLA ORAL TABLET $0

JOLESSA ORAL TABLET $0

JOLIVETTE ORAL TABLET $0

JULEBER ORAL TABLET $0

JUNEL 1.5/30 ORAL TABLET $0

JUNEL 1/20 ORAL TABLET $0

JUNEL FE 1.5/30 ORAL TABLET $0

JUNEL FE 1/20 ORAL TABLET $0

JUNEL FE 24 ORAL TABLET $0

KAITLIB FE ORAL TABLET CHEWABLE $0

KARIVA ORAL TABLET $0

KELNOR 1/35 ORAL TABLET $0

KIMIDESS ORAL TABLET $0

KURVELO ORAL TABLET $0

KYLEENA INTRAUTERINE INTRAUTERINE DEVICE Medical Benefit

LARIN 1.5/30 ORAL TABLET $0

LARIN 1/20 ORAL TABLET $0

LARIN 24 FE ORAL TABLET $0

LARIN FE 1.5/30 ORAL TABLET $0

LARIN FE 1/20 ORAL TABLET $0

LAYOLIS FE ORAL TABLET CHEWABLE $0

LEENA ORAL TABLET $0


89

Drug Status NotesLESSINA ORAL TABLET $0

letrozole oral tablet $3.65

LEVONEST ORAL TABLET $0

levonorgest-eth estrad 91-day oral tablet $0

levonorgestrel oral tablet 1.5 mg $0

levonorgestrel-ethinyl estrad oral tablet $0

levonorg-eth estrad triphasic oral tablet $0

LEVORA 0.15/30 (28) ORAL TABLET $0

LO LOESTRIN FE ORAL TABLET $0

LOW-OGESTREL ORAL TABLET $0


MB/RX PA; SP


MB/RX PA; SP

LUTERA ORAL TABLET $0

LYNPARZA ORAL CAPSULE $3.65 PA

LYZA ORAL TABLET $0

marlissa oral tablet $0


mefenamic acid oral capsule $3.65 PA

MENEST ORAL TABLET 0.3 MG, 0.625 MG, 1.25 MG $3.65


methitest oral tablet $3.65 PA

methyltestosterone oral capsule $3.65


MIACALCIN INJECTION SOLUTION $3.65


MICROGESTIN 1.5/30 ORAL TABLET $0

MICROGESTIN 1/20 ORAL TABLET $0

MICROGESTIN FE 1.5/30 ORAL TABLET $0

MICROGESTIN FE 1/20 ORAL TABLET $0

MONO-LINYAH ORAL TABLET $0

MONONESSA ORAL TABLET $0

MY WAY ORAL TABLET $0


90

Drug Status NotesMYZILRA ORAL TABLET $0


NECON 0.5/35 (28) ORAL TABLET $0

NECON 1/35 (28) ORAL TABLET $0

NECON 7/7/7 ORAL TABLET $0

NEXT CHOICE ONE DOSE ORAL TABLET $0

NIKKI ORAL TABLET $0

NORA-BE ORAL TABLET $0

norethin ace-eth estrad-fe oral tablet $0

norethin ace-eth estrad-fe oral tablet chewable $0


norethindrone acet-ethinyl est oral tablet $0

norethindrone oral tablet $0

norethindrone-eth estradiol oral tablet $3.65

norethin-eth estradiol-fe oral tablet chewable 0.8-25 mg-mcg

$0

norgestimate-eth estradiol oral tablet 0.25-35 mg-mcg

$0

norgestim-eth estrad triphasic oral tablet $0

NORLYROC ORAL TABLET $0

NORTREL 0.5/35 (28) ORAL TABLET $0

NORTREL 1/35 (21) ORAL TABLET $0

NORTREL 1/35 (28) ORAL TABLET $0

NORTREL 7/7/7 ORAL TABLET $0

NUVARING VAGINAL RING $0

OCELLA ORAL TABLET $0

OGESTREL ORAL TABLET $0

ORSYTHIA ORAL TABLET $0


PHILITH ORAL TABLET $0

PIMTREA ORAL TABLET $0

PIRMELLA 1/35 ORAL TABLET $0

PIRMELLA 7/7/7 ORAL TABLET $0

PORTIA-28 ORAL TABLET $0


91

Drug Status NotesPREMARIN ORAL TABLET $3.65




PREVIFEM ORAL TABLET $0


progesterone micronized oral capsule $3.65

Prolia Subcutaneous Solution MB/RXPA; SP; QL (1 syringe per 180 days)

QUASENSE ORAL TABLET $0

raloxifene hcl oral tablet $3.65

RECLIPSEN ORAL TABLET $0




risedronate sodium oral tablet delayed release $3.65 PA; QL (4 EA per 28 days)

SETLAKIN ORAL TABLET $0

SHAROBEL ORAL TABLET $0

SOLTAMOX ORAL SOLUTION $3.65

SPRINTEC 28 ORAL TABLET $0

SRONYX ORAL TABLET $0

STRIANT BUCCAL $3.65 PA

SYEDA ORAL TABLET $0

SYNAREL NASAL SOLUTION $3.65 PA

tamoxifen citrate oral tablet $3.65

TARINA FE 1/20 ORAL TABLET $0



TESTOPEL IMPLANT PELLET $3.65 PA

testosterone cypionate intramuscular solution 100 mg/ml, 200 mg/ml

$3.65 PA

testosterone enanthate intramuscular solution $3.65 PA

testosterone transdermal gel 10 mg/act (2%), 12.5 mg/act (1%), 25 mg/2.5gm (1%), 50 mg/5gm (1%)

$3.65 PA

testosterone transdermal solution $3.65 PA


92

Drug Status NotesTILIA FE ORAL TABLET $0



TRI-ESTARYLLA ORAL TABLET $0

TRI-LEGEST FE ORAL TABLET $0

TRI-LINYAH ORAL TABLET $0

TRI-LO-ESTARYLLA ORAL TABLET $0

TRI-LO-MARZIA ORAL TABLET $0

TRI-LO-SPRINTEC ORAL TABLET $0

TRINESSA (28) ORAL TABLET $0

TRINESSA LO ORAL TABLET $0

TRI-PREVIFEM ORAL TABLET $0

TRI-SPRINTEC ORAL TABLET $0

TRIVORA (28) ORAL TABLET $0

TYMLOS SUBCUTANEOUS SOLUTION PEN-INJECTOR $3.65 PA; SP; QL (2 ML per 30 days)


VELIVET ORAL TABLET $0

VESTURA ORAL TABLET $0

VIENVA ORAL TABLET $0

viorele oral tablet $0

VYFEMLA ORAL TABLET $0

WERA ORAL TABLET $0

WYMZYA FE ORAL TABLET CHEWABLE $0

Xiaflex Injection Solution Reconstituted MB/RX PA

XULANE TRANSDERMAL PATCH WEEKLY $0

ZARAH ORAL TABLET $0

ZENCHENT ORAL TABLET $0



MB/RX

ZOVIA 1/35E (28) ORAL TABLET $0

ZOVIA 1/50E (28) ORAL TABLET $0


93

Drug Status NotesDISORDER OF RESPIRATORY SYSTEM


acetylcysteine inhalation solution $3.65





ADVAIR DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 250-50 MCG/DOSE, 500-50 MCG/DOSE

$3.65 PA




$3.65






$3.65 PA


MB/RX SP





$3.65


$3.65


94


$3.65


$3.65


$3.65


ATROVENT HFA INHALATION AEROSOL SOLUTION $3.65












chlorpromazine hcl oral tablet $3.65





clotrimazole mouth/throat lozenge $3.65

clotrimazole mouth/throat troche $3.65



95

Drug Status Notescromolyn sodium inhalation nebulization solution $3.65


cyproheptadine hcl oral tablet $3.65













MB/RX




$3.65





$3.65

furosemide injection solution 10 mg/ml $1





$3.65


$3.65




96

Drug Status Noteshydromet oral syrup $3.65


$3.65








$3.65




lidocaine external ointment $3.65 QL (50 GM per 30 days)











NOXAFIL ORAL SUSPENSION $3.65 PA







97

Drug Status NotesOPSUMIT ORAL TABLET $3.65 PA; SP




PASER ORAL PACKET $3.65 PA


PORTRAZZA INTRAVENOUS SOLUTION Medical Benefit

PRIFTIN ORAL TABLET $3.65

PROAIR HFA INHALATION AEROSOL SOLUTION $3.65 PA


$3.65 PA








$3.65









98

Drug Status NotesREVATIO ORAL SUSPENSION RECONSTITUTED $3.65 PA; SP



$3.65



SIRTURO ORAL TABLET $3.65 PA






Synagis Intramuscular Solution MB/RX PA; SP




$3.65


$3.65


$3.65









99

Drug Status NotesTYVASO INHALATION SOLUTION $3.65 PA; SP








VIRAZOLE INHALATION SOLUTION RECONSTITUTED $3.65







DISORDER OF THE DIGESTIVE SYSTEM

ACIPHEX SPRINKLE ORAL CAPSULE SPRINKLE $3.65 PA

adefovir dipivoxil oral tablet $3.65


AKYNZEO ORAL CAPSULE $3.65 QL (1 EA per 1 Fill)

ALINIA ORAL SUSPENSION RECONSTITUTED $3.65

ALINIA ORAL TABLET $3.65

alosetron hcl oral tablet $3.65

Aloxi Intravenous Solution 0.25 MG/5ML MB/RX QL (20 ML per 1 Rx)

AMITIZA ORAL CAPSULE $3.65 PA; QL (60 EA per 30 days)

amoxicill-clarithro-lansopraz oral $3.65



ANZEMET ORAL TABLET 100 MG $3.65 QL (10 EA per 1 fill)


100

Drug Status NotesANZEMET ORAL TABLET 50 MG $3.65 QL (5 EA per 1 fill)

APRISO ORAL CAPSULE EXTENDED RELEASE 24 HOUR $3.65


balsalazide disodium oral capsule $3.65

BARACLUDE ORAL SOLUTION $3.65

BILTRICIDE ORAL TABLET $3.65

BONJESTA ORAL TABLET EXTENDED RELEASE $3.65 PA

budesonide oral capsule delayed release particles $3.65

CANASA RECTAL SUPPOSITORY $3.65

CARAFATE ORAL SUSPENSION $3.65PA; ¥ (PA applies to members 12 years and older)

CESAMET ORAL CAPSULE $3.65 PA


chlordiazepoxide-clidinium oral capsule $3.65


chlorhexidine gluconate mouth/throat solution $3.65

CHOLBAM ORAL CAPSULE $3.65 PA

cimetidine hcl oral solution $3.65

cimetidine oral tablet $3.65





Cinvanti Intravenous Emulsion MB/RX QL (18 ML per 1 Fill)

CLINPRO 5000 DENTAL PASTE $3.65

COLOCORT RECTAL ENEMA $3.65

COMPRO RECTAL SUPPOSITORY $3.65


CORTIFOAM RECTAL FOAM $3.65


101

Drug Status NotesCREON ORAL CAPSULE DELAYED RELEASE PARTICLES $3.65


CUVPOSA ORAL SOLUTION $3.65




DAKLINZA ORAL TABLET $3.65 PA; SP

DELZICOL ORAL CAPSULE DELAYED RELEASE $3.65

DENAVIR EXTERNAL CREAM $3.65 PA; QL (5 GM per 1 Fill)

DENTA 5000 PLUS DENTAL CREAM $3.65

DENTAGEL DENTAL GEL $3.65


DEXILANT ORAL CAPSULE DELAYED RELEASE 60 MG $3.65 PA

DICLEGIS ORAL TABLET DELAYED RELEASE $3.65 PA

dicyclomine hcl oral capsule $3.65

dicyclomine hcl oral solution $3.65

dicyclomine hcl oral tablet $3.65

DIFICID ORAL TABLET $3.65 QL (20 EA per 1 Fill)

dimenhydrinate oral tablet $3.65

DIPENTUM ORAL CAPSULE $3.65

diphenoxylate-atropine oral liquid $3.65

diphenoxylate-atropine oral tablet $3.65


Elaprase Intravenous Solution MB/RX SP

Emend Intravenous Solution Reconstituted 150 MG

MB/RX QL (2 vials per 1 Rx)

EMEND ORAL CAPSULE 125 MG, 40 MG, 80 MG $3.65 QL (6 EA per 1 Rx)

EMEND ORAL SUSPENSION RECONSTITUTED $3.65 QL (3 Units per 7 days)

entecavir oral tablet $3.65

Entyvio Intravenous Solution Reconstituted MB/RX PA; SP


102

Drug Status Notesenulose oral solution $3.65

EPCLUSA ORAL TABLET $3.65 PA; SP



famotidine oral suspension reconstituted $3.65

famotidine oral tablet 20 mg, 40 mg $3.65

FLUORABON ORAL SOLUTION $3.65

FLUORIDEX SENSITIVITY RELIEF DENTAL PASTE $3.65

FLURA-DROPS ORAL SOLUTION 0.55 (0.25 F) MG/DROP $3.65

GamaSTAN S/D Intramuscular Injectable MB/RX PA; SP


MB/RX PA; SP

GATTEX SUBCUTANEOUS KIT $3.65 PA; SP; QL (1 Kit per 1 day)

GAVILYTE-C ORAL SOLUTION RECONSTITUTED $3.65

GAVILYTE-G ORAL SOLUTION RECONSTITUTED $3.65

GAVILYTE-H ORAL KIT $3.65




GIAZO ORAL TABLET $3.65 PA

GOLYTELY ORAL SOLUTION RECONSTITUTED 227.1 GM $3.65

granisetron hcl oral tablet $3.65 QL (14 EA per 1 Fill)

HARVONI ORAL TABLET $3.65 PA; SP






103

Drug Status NotesHUMIRA PEN-CROHNS STARTER SUBCUTANEOUS PEN-INJECTOR KIT $3.65 PA; SP; ¥ (1 Fill per life of plan)




$3.65

hydrocortisone ace-pramoxine rectal cream $3.65


hydrocortisone rectal enema $3.65


Intron A Injection Solution MB/RX SP

Intron A Injection Solution Reconstituted MB/RX SP

ivermectin oral tablet $3.65



lamivudine oral tablet 100 mg $3.65

lansoprazole oral capsule delayed release $3.65 PA

LINZESS ORAL CAPSULE $3.65 PA; QL (30 EA per 30 days)

LONSURF ORAL TABLET $3.65 PA; SP

loperamide hcl oral capsule $3.65

MAVYRET ORAL TABLET $3.65 PA; SP

mesalamine oral tablet delayed release 1.2 gm $3.65 STPA; QL (120 EA per 30 days)

mesalamine oral tablet delayed release 800 mg $3.65

mesalamine rectal enema $3.65


$3.65


misoprostol oral tablet $3.65

MODERIBA ORAL TABLET 200 MG $3.65 QL (210 EA per 30 days)

MOVANTIK ORAL TABLET $3.65 PA

MOVIPREP ORAL SOLUTION RECONSTITUTED $3.65



104

Drug Status Notesmulti-vit/fluoride/iron oral solution $3.65




$3.65


NAFRINSE DAILY/NEUTRAL MOUTH/THROAT SOLUTION RECONSTITUTED

$3.65

neomycin sulfate oral tablet $3.65

neutral sodium fluoride mouth/throat solution $3.65

NEXIUM 24HR ORAL CAPSULE DELAYED RELEASE $3.65 PA

NEXIUM ORAL PACKET $3.65 PA

nizatidine oral capsule $3.65

nizatidine oral solution $3.65

NUTRESTORE ORAL PACKET $3.65 PA

OCALIVA ORAL TABLET $3.65PA; SP; QL (30 TABS per 30 days)



omeprazole oral capsule delayed release $3.65


ondansetron hcl injection solution 4 mg/2ml, 40 mg/20ml

$3.65

ondansetron hcl oral solution $3.65 QL (105 ML per 1 Fill)

ondansetron hcl oral tablet $3.65 QL (21 EA per 1 Fill)

ondansetron oral tablet dispersible $3.65 QL (21 EA per 1 Fill)

OSMOPREP ORAL TABLET $3.65 QL (32 EA per 1 Fill)

PANCREAZE ORAL CAPSULE DELAYED RELEASE PARTICLES 10500 UNIT, 16800 UNIT, 21000 UNIT, 4200 UNIT

$3.65

paregoric oral tincture $3.65

PAROEX MOUTH/THROAT SOLUTION $3.65

paromomycin sulfate oral capsule $3.65


105

Drug Status Notespeg 3350/electrolytes oral solution reconstituted $3.65

peg 3350-kcl-na bicarb-nacl oral solution reconstituted

$3.65

peg-3350/electrolytes oral solution reconstituted $3.65

PEGASYS PROCLICK SUBCUTANEOUS SOLUTION $3.65 SP; QL (4 ML per 28 days)

PEGASYS SUBCUTANEOUS SOLUTION $3.65 SP; QL (4 ML per 28 days)

PEGINTRON SUBCUTANEOUS KIT $3.65 SP; QL (4 EA per 28 days)

PENTASA ORAL CAPSULE EXTENDED RELEASE $3.65

PERIOGARD MOUTH/THROAT SOLUTION $3.65

PERTZYE ORAL CAPSULE DELAYED RELEASE PARTICLES $3.65

PHENADOZ RECTAL SUPPOSITORY $3.65

PHENERGAN RECTAL SUPPOSITORY $3.65


polyethylene glycol 3350 oral powder $3.65


pramcort rectal cream $3.65

PREPOPIK ORAL PACKET $3.65

PREVACID SOLUTAB ORAL TABLET DISPERSIBLE $3.65 PA; Age Limit (Max 2 Years)

PRILOSEC ORAL PACKET $3.65 PA

prochlorperazine edisylate injection solution $3.65

prochlorperazine maleate oral tablet $3.65

prochlorperazine rectal suppository $3.65

PROCTOFOAM HC RECTAL FOAM $3.65



promethazine hcl oral solution $3.65

promethazine hcl oral syrup $3.65

promethazine hcl oral tablet $3.65

promethazine hcl rectal suppository $3.65

PROMETHEGAN RECTAL SUPPOSITORY $3.65


106

Drug Status NotesPYLERA ORAL CAPSULE $3.65

rabeprazole sodium oral tablet delayed release $3.65 PA




REBETOL ORAL SOLUTION $3.65 SP; QL (35 ML per 1 day)

RELISTOR ORAL TABLET $3.65 PA; QL (90 Tablets per 30 days)

RELISTOR SUBCUTANEOUS SOLUTION12 MG/0.6ML, 8 MG/0.4ML $3.65 PA



RIBASPHERE ORAL CAPSULE $3.65 QL (210 EA per 30 days)

RIBASPHERE ORAL TABLET 200 MG $3.65 QL (210 EA per 30 days)

ribavirin oral capsule $3.65 SP; QL (210 EA per 30 days)

ribavirin oral tablet 200 mg $3.65 SP; QL (210 EA per 30 days)

SANCUSO TRANSDERMAL PATCH $3.65 PA; QL (4 EA per 28 days)



scopolamine transdermal patch 72 hour $3.65

sf 5000 plus dental cream $3.65

sf dental gel $3.65

SFROWASA RECTAL ENEMA $3.65

sodium fluoride oral solution $3.65

sodium fluoride oral tablet 1.1 (0.5 f) mg $3.65

sodium fluoride oral tablet chewable $3.65

SOVALDI ORAL TABLET $3.65 PA; SP


Stelara Intravenous Solution MB/RXPA; SP; ¥ (1 Fill per life of plan); QL (4 VIALS per 1 Fill)

Stelara Subcutaneous Solution 45 MG/0.5ML MB/RX PA; QL (4 Vials per 1 Lifetime)

STELARA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE $3.65

PA; SP; QL (1 Syringe per 84 days)

sucralfate oral tablet $3.65

sulfasalazine oral tablet $3.65



107

Drug Status NotesSUPREP BOWEL PREP KIT ORAL SOLUTION $3.65

SUSTOL SUBCUTANEOUS PREFILLED SYRINGE Medical Benefit

SYMPROIC ORAL TABLET $3.65 PA






TRILYTE ORAL SOLUTION RECONSTITUTED $3.65

trimethobenzamide hcl oral capsule $3.65




UCERIS ORAL TABLET EXTENDED RELEASE 24 HOUR $3.65 PA

UCERIS RECTAL FOAM $3.65 PA

ursodiol oral capsule $3.65

ursodiol oral tablet $3.65

Varubi Intravenous Emulsion MB/RX

VARUBI ORAL TABLET $3.65¥ (Max of 6 tablets per 30 days); QL (2 Tablets per 1 Fill)

VEMLIDY ORAL TABLET $3.65

VIBERZI ORAL TABLET $3.65



VOSEVI ORAL TABLET $3.65 PA; SP

XERMELO ORAL TABLET $3.65 PA




108

Drug Status NotesZENPEP ORAL CAPSULE DELAYED RELEASE PARTICLES 10000 UNIT, 15000-51000 UNIT, 20000-63000 UNIT, 20000-68000 UNIT, 25000 UNIT, 25000-79000 UNIT, 3000-10000 UNIT, 40000-126000 UNIT, 40000-136000 UNIT, 5000 UNIT, 5000-24000 UNIT

$3.65

ZEPATIER ORAL TABLET $3.65 PA; SP

Zinplava Intravenous Solution MB/RX PA


DISORDER OF THE ENDOCRINE GLANDS

acarbose oral tablet $1

ACTOPLUS MET XR ORAL TABLET EXTENDED RELEASE 24 HOUR $1

Aldurazyme Intravenous Solution MB/RX PA; SP



alogliptin benzoate oral tablet $1 PA; QL (30 EA per 30 days)


alogliptin-pioglitazone oral tablet $1 PA; QL (30 EA per 30 days)

ANDRODERM TRANSDERMAL PATCH 24 HOUR $3.65 PA

ANDROGEL PUMP TRANSDERMAL GEL20.25 MG/ACT (1.62%) $3.65 PA

ANDROGEL TRANSDERMAL GEL 20.25 MG/1.25GM (1.62%), 40.5 MG/2.5GM (1.62%), 50 MG/5GM (1%)

$3.65 PA


AVANDIA ORAL TABLET 2 MG, 4 MG $1



cabergoline oral tablet $3.65





chlorpropamide oral tablet $1


109

Drug Status NotesCLIMARA PRO TRANSDERMAL PATCH WEEKLY $3.65

COMBIPATCH TRANSDERMAL PATCH TWICE WEEKLY $3.65


CRINONE VAGINAL GEL 8 % $3.65 PA

DEPO-TESTOSTERONE INTRAMUSCULAR SOLUTION 100 MG/ML $3.65 PA

desmopressin ace rhinal tube nasal solution $3.65

desmopressin ace spray refrig nasal solution $3.65


desmopressin acetate spray nasal solution $3.65

DEXAMETHASONE INTENSOL ORAL CONCENTRATE $3.65

dexamethasone oral elixir $3.65

dexamethasone oral solution $3.65

dexamethasone oral tablet $3.65

DEXPAK 10 DAY ORAL TABLET THERAPY PACK $3.65






Elaprase Intravenous Solution MB/RX SP



estradiol transdermal patch weekly $3.65





estropipate oral tablet $3.65



110

Drug Status NotesFEMRING VAGINAL RING $3.65

fludrocortisone acetate oral tablet $3.65





$3.65 PA; SP


glimepiride oral tablet $1

glipizide er oral tablet extended release 24 hour $1

glipizide oral tablet $1

glipizide xl oral tablet extended release 24 hour $1

glipizide-metformin hcl oral tablet $1

GLUCAGEN HYPOKIT INJECTION SOLUTION RECONSTITUTED $3.65

GLUCAGON EMERGENCY INJECTION KIT $3.65

glyburide micronized oral tablet $1

glyburide oral tablet $1

glyburide-metformin oral tablet $1


HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS SOLUTION $1

HUMULIN R U-500 KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR

$1



MB/RX






111

Drug Status NotesINTRAROSA VAGINAL INSERT $3.65 PA; QL (28 EA per 28 days)

INVOKAMET ORAL TABLET $3.65 STPA; QL (60 EA per 30 days)

INVOKAMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR $3.65

STPA; QL (60 Tablets per 30 days)



JARDIANCE ORAL TABLET $3.65 STPA; QL (30 EA per 30 days)


KORLYM ORAL TABLET $3.65 PA



LEVO-T ORAL TABLET $3.65

levothyroxine sodium oral tablet $3.65

LEVOXYL ORAL TABLET $3.65

liothyronine sodium oral tablet $3.65


MB/RX SP

Lupron Depot-Ped (1-Month) Intramuscular Kit MB/RX PA; SP

Lupron Depot-Ped (3-Month) Intramuscular Kit MB/RX PA; SP







LYSODREN ORAL TABLET $3.65




112

Drug Status NotesMENEST ORAL TABLET 0.3 MG, 0.625 MG, 1.25 MG $3.65


$1 PA

metformin hcl er (osm) oral tablet extended release 24 hour 1000 mg, 500 mg

$1 PA

metformin hcl er oral tablet extended release 24 hour

$1

metformin hcl oral tablet $1

methimazole oral tablet $3.65

methitest oral tablet $3.65 PA

methylprednisolone oral tablet $3.65



$3.65



$3.65






Naglazyme Intravenous Solution MB/RX SP

nateglinide oral tablet $1

NATPARA SUBCUTANEOUS CARTRIDGE $3.65PA; SP; QL (2 Cartridges per 21 days)







113

Drug Status NotesNUTROPIN AQ NUSPIN 20 SUBCUTANEOUS SOLUTION $3.65 PA; SP









pioglitazone hcl oral tablet $1

pioglitazone hcl-glimepiride oral tablet $1

pioglitazone hcl-metformin hcl oral tablet $1




$3.65


$3.65

PREMARIN ORAL TABLET $3.65







propylthiouracil oral tablet $3.65






114

Drug Status Notesrepaglinide-metformin hcl oral tablet $1

RIOMET ORAL SOLUTION $1














SIGNIFOR SUBCUTANEOUS SOLUTION $3.65 PA; QL (60 ML per 30 days)




STRIANT BUCCAL $3.65 PA

Supprelin LA Subcutaneous Kit MB/RX SP



SYNAREL NASAL SOLUTION $3.65 PA

SYNJARDY ORAL TABLET $3.65 STPA; QL (60 EA per 30 days)

SYNJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR 10-1000 MG, 25-1000 MG



115

Drug Status NotesSYNJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR 12.5-1000 MG, 5-1000 MG


TESTOPEL IMPLANT PELLET $3.65 PA

testosterone cypionate intramuscular solution 100 mg/ml, 200 mg/ml

$3.65 PA

testosterone enanthate intramuscular solution $3.65 PA

testosterone transdermal gel 10 mg/act (2%), 12.5 mg/act (1%), 25 mg/2.5gm (1%), 50 mg/5gm (1%)

$3.65 PA


Thyrogen Intramuscular Solution Reconstituted MB/RX SP

THYROLAR-1 ORAL TABLET $3.65

THYROLAR-1/2 ORAL TABLET $3.65

THYROLAR-1/4 ORAL TABLET $3.65



tolazamide oral tablet $1

tolbutamide oral tablet $1

Triptodur Intramuscular Suspension Reconstituted ER

MB/RX

TRULICITY SUBCUTANEOUS SOLUTION PEN-INJECTOR $3.65 QL (4 pens per 28 days)


UNITHROID ORAL TABLET $3.65

VICTOZA SUBCUTANEOUS SOLUTION PEN-INJECTOR $3.65 QL (3 pens per 28 days)

XIGDUO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 10-1000 MG, 10-500 MG, 2.5-1000 MG


XIGDUO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 5-1000 MG, 5-500 MG $3.65 PA; QL (60 EA per 30 days)


MB/RX



116

Drug Status NotesZORBTIVE SUBCUTANEOUS SOLUTION RECONSTITUTED $3.65 PA; SP

EAR PROBLEM

ACETASOL HC OTIC SOLUTION $3.65

acetic acid otic solution $3.65


CIPRO HC OTIC SUSPENSION $3.65

CIPRODEX OTIC SUSPENSION $3.65

dexamethasone sodium phosphate ophthalmic solution

$3.65

fluocinolone acetonide otic oil $3.65

hydrocortisone-acetic acid otic solution $3.65


neomycin-polymyxin-hc otic solution $3.65

neomycin-polymyxin-hc otic suspension $3.65

ofloxacin otic solution $3.65

OTIPRIO INTRATYMPANIC SUSPENSION Medical Benefit

EYE DISORDER


ADRENALIN INJECTION SOLUTION 1 MG/ML $3.65

ALOCRIL OPHTHALMIC SOLUTION $3.65 PA

ALPHAGAN P OPHTHALMIC SOLUTION0.1 % $3.65 PA

ALREX OPHTHALMIC SUSPENSION $3.65



AZASITE OPHTHALMIC SOLUTION $3.65 QL (2.5 mL per 1 fill)

azelastine hcl ophthalmic solution $3.65 PA

AZOPT OPHTHALMIC SUSPENSION $3.65 PA

bacitracin ophthalmic ointment $3.65

bacitracin-polymyxin b ophthalmic ointment 500-10000 unit/gm

$3.65

BEPREVE OPHTHALMIC SOLUTION $3.65 PA


117

Drug Status Notesbetaxolol hcl ophthalmic solution $3.65

BETIMOL OPHTHALMIC SOLUTION $3.65

BETOPTIC-S OPHTHALMIC SUSPENSION $3.65

bimatoprost ophthalmic solution $3.65 PA

BLEPHAMIDE OPHTHALMIC SUSPENSION $3.65

BLEPHAMIDE S.O.P. OPHTHALMIC OINTMENT $3.65

brimonidine tartrate ophthalmic solution 0.15 % $3.65 PA

brimonidine tartrate ophthalmic solution 0.2 % $3.65

bromfenac sodium (once-daily) ophthalmic solution

$3.65

carteolol hcl ophthalmic solution $3.65


COMBIGAN OPHTHALMIC SOLUTION $3.65 PA

COSOPT PF OPHTHALMIC SOLUTION $3.65

cromolyn sodium ophthalmic solution $3.65

cyclopentolate hcl ophthalmic solution $3.65 QL (2 ML per 30 days)


$3.65

diclofenac sodium ophthalmic solution $3.65

dorzolamide hcl ophthalmic solution $3.65

dorzolamide hcl-timolol mal ophthalmic solution $3.65

DUREZOL OPHTHALMIC EMULSION $3.65

EMADINE OPHTHALMIC SOLUTION $3.65 PA

epinastine hcl ophthalmic solution $3.65 PA

erythromycin ophthalmic ointment $3.65

FLAREX OPHTHALMIC SUSPENSION $3.65

fluorometholone ophthalmic suspension $3.65

flurbiprofen sodium ophthalmic solution $3.65

FML FORTE OPHTHALMIC SUSPENSION $3.65

FML OPHTHALMIC OINTMENT $3.65


MB/RX PA; SP


118

Drug Status NotesHOMATROPAIRE OPHTHALMIC SOLUTION $3.65

homatropine hbr ophthalmic solution $3.65

ILEVRO OPHTHALMIC SUSPENSION $3.65

ketorolac tromethamine ophthalmic solution $3.65

ketotifen fumarate ophthalmic solution $3.65

LASTACAFT OPHTHALMIC SOLUTION $3.65 PA

latanoprost ophthalmic solution $3.65

levobunolol hcl ophthalmic solution 0.5 % $3.65

LOTEMAX OPHTHALMIC GEL $3.65

LOTEMAX OPHTHALMIC OINTMENT $3.65

LOTEMAX OPHTHALMIC SUSPENSION $3.65


MB/RX SP

LUMIGAN OPHTHALMIC SOLUTION 0.01 % $3.65 PA

Macugen Intraocular Solution MB/RX SP

MAXIDEX OPHTHALMIC SUSPENSION $3.65

methazolamide oral tablet $3.65

metipranolol ophthalmic solution $3.65

NATACYN OPHTHALMIC SUSPENSION $3.65 PA

neomycin-bacitracin zn-polymyx ophthalmic ointment 5-400-10000

$3.65

neomycin-polymyxin-gramicidin ophthalmic solution 1.75-10000-.025

$3.65

neomycin-polymyxin-hc ophthalmic suspension3.5-10000-1

$3.65

NEO-POLYCIN OPHTHALMIC OINTMENT $3.65

NEVANAC OPHTHALMIC SUSPENSION $3.65

olopatadine hcl ophthalmic solution $3.65 PA

PHOSPHOLINE IODIDE OPHTHALMIC SOLUTION RECONSTITUTED $3.65

pilocarpine hcl ophthalmic solution 1 %, 2 %, 4 %

$3.65



119

Drug Status NotesPOLYCIN OPHTHALMIC OINTMENT $3.65

polymyxin b-trimethoprim ophthalmic solution $3.65

polyvinyl alcohol ophthalmic solution $3.65

PRED MILD OPHTHALMIC SUSPENSION $3.65

prednisolone acetate ophthalmic suspension $3.65

prednisolone sodium phosphate ophthalmic solution

$3.65

proparacaine hcl ophthalmic solution $3.65

RESCULA OPHTHALMIC SOLUTION $3.65 PA

RESTASIS OPHTHALMIC EMULSION $3.65 PA; QL (60 EA per 30 days)

SIMBRINZA OPHTHALMIC SUSPENSION $3.65 PA

sulfacetamide sodium ophthalmic ointment $3.65

sulfacetamide sodium ophthalmic solution $3.65

sulfacetamide-prednisolone ophthalmic solution $3.65

timolol maleate ophthalmic gel forming solution $3.65

timolol maleate ophthalmic solution 0.25 %, 0.5 %

$3.65

TIMOPTIC OCUDOSE OPHTHALMIC SOLUTION 0.25 % $3.65

TOBRADEX OPHTHALMIC OINTMENT $3.65

tobramycin-dexamethasone ophthalmic suspension

$3.65

TRAVATAN Z OPHTHALMIC SOLUTION $3.65 PA

TRIESENCE INTRAOCULAR SUSPENSION $3.65

trifluridine ophthalmic solution $3.65

tropicamide ophthalmic solution $3.65

Visudyne Intravenous Solution Reconstituted MB/RX SP

VYZULTA OPHTHALMIC SOLUTION $3.65 PA


ZIOPTAN OPHTHALMIC SOLUTION $3.65 PA

ZIRGAN OPHTHALMIC GEL $3.65 PA

ZYLET OPHTHALMIC SUSPENSION $3.65 QL (5 mL per 30 days)

FEVER



120

Drug Status NotesGammagard S/D Less IgA Intravenous Solution Reconstituted

MB/RX PA; SP

INFECTION


abacavir sulfate oral tablet $3.65



acyclovir external ointment $3.65



Alferon N Injection Solution MB/RX SP

ALINIA ORAL SUSPENSION RECONSTITUTED $3.65

ALINIA ORAL TABLET $3.65

ALTABAX EXTERNAL OINTMENT $3.65 STPA; QL (15 GM per 1 Fill)





APTIVUS ORAL CAPSULE $3.65

APTIVUS ORAL SOLUTION $3.65


atovaquone-proguanil hcl oral tablet $3.65

ATRIPLA ORAL TABLET $3.65




bacitracin ophthalmic ointment $3.65

bacitracin-polymyxin b ophthalmic ointment 500-10000 unit/gm

$3.65

BACTROBAN NASAL NASAL OINTMENT $3.65




BIKTARVY ORAL TABLET $3.65


121

Drug Status NotesBILTRICIDE ORAL TABLET $3.65


CENTANY EXTERNAL OINTMENT $3.65




chloroquine phosphate oral tablet $3.65

CICLODAN EXTERNAL CREAM $3.65

CICLODAN EXTERNAL SOLUTION $3.65

ciclopirox external gel $3.65

ciclopirox external solution $3.65

ciclopirox olamine external cream $3.65

ciclopirox olamine external suspension $3.65 PA

CIMDUO ORAL TABLET $3.65

CIPRODEX OTIC SUSPENSION $3.65






clotrimazole anti-fungal external cream $3.65

clotrimazole external cream $3.65

clotrimazole external solution $3.65



clotrimazole-betamethasone external cream $3.65

clotrimazole-betamethasone external lotion $3.65

COARTEM ORAL TABLET $3.65 QL (24 EA per 30 days)

COMPLERA ORAL TABLET $3.65

CONDYLOX EXTERNAL GEL $3.65

CORTISPORIN EXTERNAL CREAM $3.65

CRESEMBA ORAL CAPSULE $3.65


122

Drug Status NotesCRIXIVAN ORAL CAPSULE 200 MG, 400 MG $3.65





dapsone oral tablet $3.65

DENAVIR EXTERNAL CREAM $3.65 PA; QL (5 GM per 1 Fill)

DESCOVY ORAL TABLET $3.65 # (Preferred product)


didanosine oral capsule delayed release 200 mg, 250 mg, 400 mg

$3.65



econazole nitrate external cream $3.65

ECOZA EXTERNAL FOAM $3.65 PA

EDURANT ORAL TABLET $3.65




EMTRIVA ORAL CAPSULE $3.65

EMTRIVA ORAL SOLUTION $3.65



erythromycin ophthalmic ointment $3.65

EURAX EXTERNAL CREAM $3.65

EURAX EXTERNAL LOTION $3.65

EVOTAZ ORAL TABLET $3.65

EXELDERM EXTERNAL CREAM $3.65 PA

EXELDERM EXTERNAL SOLUTION $3.65 PA





123

Drug Status NotesFUZEON SUBCUTANEOUS SOLUTION RECONSTITUTED $3.65 SP









$3.65 PA; SP


gentamicin sulfate external cream $3.65

gentamicin sulfate external ointment $3.65

GENVOYA ORAL TABLET $3.65 # (Preferred product)






griseofulvin microsize oral suspension $3.65

griseofulvin microsize oral tablet $3.65

griseofulvin ultramicrosize oral tablet $3.65


$3.65



124

Drug Status NotesHARVONI ORAL TABLET $3.65 PA; SP



$3.65




imiquimod external cream $3.65

IMPAVIDO ORAL CAPSULE $3.65

INTELENCE ORAL TABLET $3.65



INVIRASE ORAL CAPSULE $3.65

INVIRASE ORAL TABLET $3.65


ISENTRESS HD ORAL TABLET $3.65 QL (60 EA per 30 days)

ISENTRESS ORAL PACKET $3.65 QL (60 EA per 30 days)

ISENTRESS ORAL TABLET $3.65

ISENTRESS ORAL TABLET CHEWABLE $3.65

isoniazid oral syrup $3.65

isoniazid oral tablet $3.65


JUBLIA EXTERNAL SOLUTION $3.65 PA

JULUCA ORAL TABLET $3.65

KALETRA ORAL TABLET $3.65

ketoconazole external cream $3.65

ketoconazole external shampoo $3.65

kp clotrimazole external cream $3.65


lamivudine oral tablet $3.65

lamivudine-zidovudine oral tablet $3.65




125

Drug Status NotesLEXIVA ORAL SUSPENSION $3.65


lindane external shampoo $3.65


LUZU EXTERNAL CREAM $3.65 PA



malathion external lotion $3.65


mefloquine hcl oral tablet $3.65


$3.65

methenamine hippurate oral tablet $3.65

methenamine mandelate oral tablet $3.65








MONUROL ORAL PACKET $3.65

mupirocin calcium external cream $3.65 PA

mupirocin external ointment $3.65

naftifine hcl external cream $3.65 PA

NAFTIN EXTERNAL GEL 1 % $3.65 PA



neomycin-bacitracin zn-polymyx ophthalmic ointment 5-400-10000

$3.65

neomycin-polymyxin-gramicidin ophthalmic solution 1.75-10000-.025

$3.65


126

Drug Status Notesneomycin-polymyxin-hc ophthalmic suspension3.5-10000-1

$3.65

NEO-POLYCIN OPHTHALMIC OINTMENT $3.65

nevirapine er oral tablet extended release 24 hour $3.65

nevirapine oral tablet $3.65


NORVIR ORAL CAPSULE $3.65 # (Preferred product)

NORVIR ORAL SOLUTION $3.65 # (Preferred product)

NORVIR ORAL TABLET $3.65 # (Preferred product)






NYAMYC EXTERNAL POWDER $3.65

nystatin external cream $3.65

nystatin external ointment $3.65

nystatin external powder $3.65

nystatin mouth/throat suspension $3.65

nystatin oral tablet $3.65

nystatin-triamcinolone external cream $3.65

nystatin-triamcinolone external ointment $3.65

NYSTOP EXTERNAL POWDER $3.65


ODEFSEY ORAL TABLET $3.65 # (Preferred product)




127

Drug Status NotesOMNITROPE SUBCUTANEOUS SOLUTION RECONSTITUTED $3.65 PA; SP


oseltamivir phosphate oral capsule 30 mg $3.65¥ (Max of 2 fills per year); QL (20 EA per 1 Fill)

oseltamivir phosphate oral capsule 45 mg, 75 mg $3.65¥ (Max of 2 fills per year); QL (10 EA per 1 Fill)

oseltamivir phosphate oral suspension reconstituted

$3.65¥ (Max of 2 fills per year); QL (180 ML per 1 Fill)

OTIPRIO INTRATYMPANIC SUSPENSION Medical Benefit

oxiconazole nitrate external cream $3.65 PA

OXISTAT EXTERNAL LOTION $3.65 PA


paromomycin sulfate oral capsule $3.65






permethrin external cream $3.65

podofilox external solution $3.65

POLYCIN OPHTHALMIC OINTMENT $3.65




PREZCOBIX ORAL TABLET $3.65

PREZISTA ORAL SUSPENSION $3.65

PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG, 800 MG $3.65


primaquine phosphate oral tablet $3.65




128

Drug Status Notespromethazine-codeine oral syrup $3.65




PYLERA ORAL CAPSULE $3.65




RELENZA DISKHALER INHALATION AEROSOL POWDER BREATH ACTIVATED

$3.65¥ (Max of 2 fills per year); QL (20 Blisters per 1 Rx)

RESCRIPTOR ORAL TABLET $3.65

REYATAZ ORAL PACKET $3.65





rimantadine hcl oral tablet $3.65




SELZENTRY ORAL SOLUTION $3.65 QL (1800 ML per 30 days)

SELZENTRY ORAL TABLET $3.65



silver sulfadiazine external cream $3.65


SKLICE EXTERNAL LOTION $3.65 STPA; QL (117 GM per 1 day)


spinosad external suspension $3.65 STPA; QL (120 ML per 1 Fill)

SSD EXTERNAL CREAM $3.65


129

Drug Status Notesstavudine oral capsule $3.65

STRIBILD ORAL TABLET $3.65



SULFAMYLON EXTERNAL CREAM $3.65 PA

SYMFI LO ORAL TABLET $3.65

SYMFI ORAL TABLET $3.65







TIVICAY ORAL TABLET $3.65





$3.65

TRECATOR ORAL TABLET $3.65 PA



trimethoprim oral tablet $3.65

TRIUMEQ ORAL TABLET $3.65

TRUVADA ORAL TABLET 200-300 MG $3.65


TYBOST ORAL TABLET $3.65

ULESFIA EXTERNAL LOTION $3.65 PA; QL (12 Bottles per 1 Rx)



VEREGEN EXTERNAL OINTMENT $3.65 PA

VIDEX ORAL SOLUTION RECONSTITUTED $3.65

VIRACEPT ORAL TABLET $3.65


130

Drug Status NotesVIRAZOLE INHALATION SOLUTION RECONSTITUTED $3.65








zidovudine oral capsule $3.65

zidovudine oral syrup $3.65

zidovudine oral tablet $3.65






INFLAMMATION OF THE SEROUS MEMBRANES IN THE BODY


INFLAMMATORY DISORDER











131

Drug Status NotesADVAIR DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 250-50 MCG/DOSE, 500-50 MCG/DOSE

$3.65 PA



ala-cort external cream 1 % $3.65

alclometasone dipropionate external cream $3.65

alclometasone dipropionate external ointment $3.65




MB/RX SP




amcinonide external cream $3.65 PA

amcinonide external lotion $3.65 PA

amcinonide external ointment $3.65 PA


ANALPRAM-HC RECTAL LOTION 2.5-1 % $3.65


$3.65 PA



APEXICON E EXTERNAL CREAM $3.65 PA

APRISO ORAL CAPSULE EXTENDED RELEASE 24 HOUR $3.65




$3.65


132


$3.65


$3.65


$3.65


$3.65






balsalazide disodium oral capsule $3.65








betamethasone dipropionate aug external cream $3.65

betamethasone dipropionate aug external gel $3.65

betamethasone dipropionate aug external lotion $3.65

betamethasone dipropionate aug external ointment

$3.65

betamethasone dipropionate external cream $3.65

betamethasone dipropionate external lotion $3.65

betamethasone dipropionate external ointment $3.65

betamethasone valerate external cream $3.65

betamethasone valerate external lotion $3.65


133

Drug Status Notesbetamethasone valerate external ointment $3.65

BLEPHAMIDE OPHTHALMIC SUSPENSION $3.65

BLEPHAMIDE S.O.P. OPHTHALMIC OINTMENT $3.65



$3.65



budesonide oral capsule delayed release particles $3.65

CANASA RECTAL SUPPOSITORY $3.65

CAPEX EXTERNAL SHAMPOO $3.65 PA

CARAFATE ORAL SUSPENSION $3.65PA; ¥ (PA applies to members 12 years and older)


MB/RX PA; SP






chlordiazepoxide-clidinium oral capsule $3.65


choline-mag trisalicylate oral liquid $3.65



ciclopirox external shampoo $3.65 PA



cimetidine hcl oral solution $3.65

cimetidine oral tablet 300 mg, 400 mg, 800 mg $3.65


134

Drug Status NotesCIMZIA PREFILLED SUBCUTANEOUS KIT $3.65 PA; SP; QL (2 EA per 28 days)







clobetasol propionate e external cream $3.65

clobetasol propionate external cream $3.65 PA

clobetasol propionate external foam $3.65

clobetasol propionate external gel $3.65 PA

clobetasol propionate external lotion $3.65

clobetasol propionate external ointment $3.65 PA

clocortolone pivalate external cream $3.65 PA

clocortolone pivalate pump external cream $3.65 PA










COLOCORT RECTAL ENEMA $3.65


CORDRAN EXTERNAL OINTMENT $3.65 PA

CORDRAN EXTERNAL TAPE $3.65 PA

CORTIFOAM RECTAL FOAM $3.65




135

Drug Status NotesCOSENTYX SENSOREADY PEN SUBCUTANEOUS SOLUTION AUTO-INJECTOR 150 MG/ML

$3.65 PA; SP








DELZICOL ORAL CAPSULE DELAYED RELEASE $3.65


desonide external cream $3.65 PA

desonide external lotion $3.65 PA

desonide external ointment $3.65 PA

desoximetasone external cream 0.05 % $3.65 PA

desoximetasone external cream 0.25 % $3.65

desoximetasone external gel $3.65

desoximetasone external ointment 0.05 % $3.65 PA

desoximetasone external ointment 0.25 % $3.65


$3.65

diclofenac potassium oral tablet $3.65


$3.65


diclofenac sodium transdermal gel 1 % $3.65 STPA

diclofenac sodium transdermal solution $3.65 PA


diflorasone diacetate external cream $3.65 PA

diflorasone diacetate external ointment $3.65 PA

DIPENTUM ORAL CAPSULE $3.65



136

Drug Status NotesDUPIXENT SUBCUTANEOUS SOLUTION PREFILLED SYRINGE $3.65 PA; SP; QL (4 ML per 28 days)






ELIDEL EXTERNAL CREAM $3.65 PA




EMFLAZA ORAL TABLET $3.65 PA; QL (30 EA per 30 days)











Entyvio Intravenous Solution Reconstituted MB/RX PA; SP


EPIFOAM EXTERNAL FOAM $3.65



etodolac oral capsule $3.65

etodolac oral tablet $3.65

EUCRISA EXTERNAL OINTMENT $3.65 PA

EUFLEXXA INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE Medical Benefit PA; SP




137

Drug Status NotesExondys 51 Intravenous Solution MB/RX PA


FINACEA EXTERNAL FOAM $3.65 QL (50 GM per 1 Rx)

FINACEA EXTERNAL GEL $3.65 QL (50 GM per 1 Rx)

FLAREX OPHTHALMIC SUSPENSION $3.65


$3.65



fluocinolone acetonide body external oil $3.65

fluocinolone acetonide external cream $3.65

fluocinolone acetonide external ointment $3.65

fluocinolone acetonide external solution $3.65


fluocinolone acetonide scalp external oil $3.65

fluocinonide external cream 0.05 % $3.65 QL (60 GM per 30 days)

fluocinonide external cream 0.1 % $3.65 PA; QL (120 GM per 30 days)

fluocinonide external gel $3.65 QL (60 GM per 30 days)

fluocinonide external ointment $3.65 QL (60 GM per 30 days)

fluocinonide external solution $3.65 QL (60 ML per 30 days)

fluorometholone ophthalmic suspension $3.65

flurandrenolide external cream $3.65 PA

flurandrenolide external lotion $3.65 PA


fluticasone propionate external cream $3.65

fluticasone propionate external lotion $3.65

fluticasone propionate external ointment $3.65



$3.65

FML FORTE OPHTHALMIC SUSPENSION $3.65

FML OPHTHALMIC OINTMENT $3.65




138

Drug Status NotesGammagard S/D Less IgA Intravenous Solution Reconstituted

MB/RX PA; SP


GIAZO ORAL TABLET $3.65 PA



$3.65


halobetasol propionate external cream $3.65 PA

halobetasol propionate external ointment $3.65 PA

HALOG EXTERNAL CREAM $3.65 PA

HALOG EXTERNAL OINTMENT $3.65 PA

HARVONI ORAL TABLET $3.65 PA; SP


HOMATROPAIRE OPHTHALMIC SOLUTION $3.65

homatropine hbr ophthalmic solution $3.65



MB/RX SP








$3.65



139

Drug Status Noteshydrocodone-homatropine oral tablet $3.65


$3.65


hydrocortisone butyrate external cream $3.65 PA

hydrocortisone butyrate external lotion $3.65

hydrocortisone butyrate external ointment $3.65 PA

hydrocortisone butyrate external solution $3.65 PA

hydrocortisone external cream 1 %, 2.5 % $3.65

hydrocortisone external lotion $3.65

hydrocortisone external ointment 1 %, 2.5 % $3.65


hydrocortisone rectal cream $3.65

hydrocortisone rectal enema $3.65

hydrocortisone valerate external cream $3.65

hydrocortisone valerate external ointment $3.65



ibuprofen oral suspension $3.65

ibuprofen oral tablet 400 mg, 600 mg, 800 mg $3.65





$3.65









KENALOG INJECTION SUSPENSION $3.65


140

Drug Status Notesketoconazole external cream $3.65

ketoconazole external foam $3.65



$3.65

ketoprofen oral capsule $3.65








lansoprazole oral capsule delayed release $3.65 PA






LOTEMAX OPHTHALMIC GEL $3.65

LOTEMAX OPHTHALMIC OINTMENT $3.65

LOTEMAX OPHTHALMIC SUSPENSION $3.65



MAXIDEX OPHTHALMIC SUSPENSION $3.65

meclofenamate sodium oral capsule $3.65




mesalamine oral tablet delayed release 800 mg $3.65

mesalamine rectal enema $3.65




141

Drug Status Notesmethylprednisolone oral tablet $3.65



$3.65

metronidazole external cream $3.65

metronidazole external gel 0.75 % $3.65

metronidazole external gel 1 % $3.65 PA

metronidazole external lotion $3.65



MIRVASO EXTERNAL GEL $3.65 PA


mometasone furoate external cream $3.65

mometasone furoate external ointment $3.65

mometasone furoate external solution $3.65











naproxen dr oral tablet delayed release $3.65

naproxen oral suspension $3.65

naproxen oral tablet $3.65

naproxen sodium oral tablet $3.65





142

Drug Status Notesnizatidine oral capsule $3.65

nizatidine oral solution $3.65

NORITATE EXTERNAL CREAM $3.65 PA














MB/RX PA; SP



omeprazole oral capsule delayed release $3.65







OTEZLA ORAL TABLET $3.65 PA; SP; QL (60 EA per 30 days)

OTEZLA ORAL TABLET THERAPY PACK $3.65 PA; SP; QL (60 EA per 30 days)



143

Drug Status Notesoxiconazole nitrate external cream $3.65 PA


PANDEL EXTERNAL CREAM $3.65






PENNSAID TRANSDERMAL SOLUTION 2 % $3.65 PA

PENTASA ORAL CAPSULE EXTENDED RELEASE $3.65






PRAMOSONE E EXTERNAL CREAM $3.65

PRAMOSONE EXTERNAL CREAM 1-1 % $3.65

PRAMOSONE EXTERNAL LOTION $3.65

PRAMOSONE EXTERNAL OINTMENT $3.65

PRED MILD OPHTHALMIC SUSPENSION $3.65

prednicarbate external cream $3.65

prednisolone acetate ophthalmic suspension $3.65



prednisolone sodium phosphate ophthalmic solution

$3.65


$3.65


$3.65

PREVACID SOLUTAB ORAL TABLET DISPERSIBLE $3.65 PA; Age Limit (Max 2 Years)


144

Drug Status NotesPRIFTIN ORAL TABLET $3.65

PRILOSEC ORAL PACKET $3.65 PA


probenecid oral tablet $3.65

PROCTO-PAK RECTAL CREAM $3.65

PROCTOSOL HC RECTAL CREAM $3.65

PROCTOZONE-HC RECTAL CREAM $3.65







psorcon external cream $3.65 PA


$3.65

PYLERA ORAL CAPSULE $3.65


$3.65














145

Drug Status NotesRESTASIS OPHTHALMIC EMULSION $3.65 PA; QL (60 EA per 30 days)







ROSADAN EXTERNAL CREAM $3.65

ROSADAN EXTERNAL GEL $3.65


SAVELLA ORAL TABLET $3.65 STPA; QL (60 EA per 30 days)

SAVELLA TITRATION PACK ORAL $3.65 STPA; QL (60 EA per 30 days)

selenium sulfide external lotion $3.65

selenium sulfide external shampoo 2.25 % $3.65

selenium sulf-pyrithione-urea external shampoo $3.65

SELRX EXTERNAL SHAMPOO $3.65



$3.65

SFROWASA RECTAL ENEMA $3.65








SOOLANTRA EXTERNAL CREAM $3.65 PA






146

Drug Status NotesSTELARA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE $3.65



sucralfate oral tablet $3.65



sulfacetamide-prednisolone ophthalmic solution $3.65

sulfasalazine oral tablet $3.65


sulindac oral tablet $3.65





SYNALAR (CREAM) EXTERNAL KIT $3.65 PA

SYNALAR (OINTMENT) EXTERNAL KIT $3.65 PA

tacrolimus external ointment $3.65 PA

TALTZ SUBCUTANEOUS SOLUTION AUTO-INJECTOR $3.65

PA; SP; ¥ (One 80 mg auto-injector/syringe per 28 days); QL (1 Injection per 28 days)

TALTZ SUBCUTANEOUS SOLUTION PREFILLED SYRINGE $3.65





$3.65


$3.65


$3.65


147

Drug Status Notestheophylline oral solution $3.65





$3.65




triamcinolone acetonide external aerosol solution $3.65 PA

triamcinolone acetonide external cream $3.65

triamcinolone acetonide external lotion $3.65

triamcinolone acetonide external ointment $3.65


TRIDERM EXTERNAL CREAM 0.1 % $3.65





UCERIS ORAL TABLET EXTENDED RELEASE 24 HOUR $3.65 PA

UCERIS RECTAL FOAM $3.65 PA







VOLTAREN TRANSDERMAL GEL $3.65 STPA; QL (32 GM per 1 day)





148

Drug Status NotesXATMEP ORAL SOLUTION $3.65 PA




XOLEGEL EXTERNAL GEL $3.65









INJURY TO A MUCOUS MEMBRANE












doxycycline hyclate oral tablet 20 mg $3.65








149

Drug Status NotesESTROGEL TRANSDERMAL GEL $3.65



MB/RX PA; SP






nystatin mouth/throat suspension $3.65

nystatin oral tablet $3.65


ORALONE MOUTH/THROAT PASTE $3.65








RESTASIS OPHTHALMIC EMULSION $3.65 PA; QL (60 EA per 30 days)



triamcinolone acetonide mouth/throat paste $3.65


LUNG DISEASE








150

Drug Status NotesADVAIR DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 250-50 MCG/DOSE, 500-50 MCG/DOSE

$3.65 PA




$3.65






$3.65 PA


MB/RX SP





$3.65


$3.65


$3.65


$3.65


$3.65



151

Drug Status NotesATROVENT HFA INHALATION AEROSOL SOLUTION $3.65






















MB/RX




$3.65



$3.65


152

Drug Status Notesfurosemide injection solution 10 mg/ml $1




$3.65


$3.65





$3.65







$3.65















153

Drug Status NotesNUCALA SUBCUTANEOUS SOLUTION RECONSTITUTED Medical Benefit PA









PROAIR HFA INHALATION AEROSOL SOLUTION $3.65 PA


$3.65 PA






$3.65








$3.65


154

Drug Status Notessildenafil citrate oral tablet 20 mg $3.65 PA; SP; QL (90 EA per 30 days)












$3.65


$3.65


$3.65












155

Drug Status NotesUPTRAVI ORAL TABLET THERAPY PACK $3.65 PA; SP










MAJOR TRAUMATIC INJURY

FLECTOR TRANSDERMAL PATCH $3.65PA; ¥ (Max of 3 months); QL (60 Patches per 30 days)

lidocaine hcl external cream 3 % $3.65

lidocaine hcl external lotion $3.65

lidopin external cream 3 % $3.65


SANTYL EXTERNAL OINTMENT $3.65 QL (30 GM per 1 Rx)




MARGINAL ZONE LYMPHOMA




MUSCLE OR BONE DISORDER






ACTIMMUNE SUBCUTANEOUS SOLUTION $3.65 PA; SP


156

Drug Status Notes







alendronate sodium oral tablet 40 mg $3.65 QL (1 EA per 6 Months)















Brineura Solution MB/RX PA




157

Drug Status Notescalcium acetate (phos binder) oral tablet $3.65







carisoprodol oral tablet 350 mg $3.65

carisoprodol-aspirin oral tablet $3.65


chlorzoxazone oral tablet 500 mg $3.65

choline-mag trisalicylate oral liquid $3.65






CLIMARA PRO TRANSDERMAL PATCH WEEKLY $3.65




$3.65





158

Drug Status Notes






$3.65 PA; SP





cyclobenzaprine hcl oral tablet 10 mg, 5 mg $3.65



$3.65 PA







$3.65



159

Drug Status Notes















$3.65




duloxetine hcl oral capsule delayed release particles 20 mg, 60 mg

$3.65



160

Drug Status Notes

duloxetine hcl oral capsule delayed release particles 30 mg

$3.65







EMFLAZA ORAL TABLET $3.65 PA; QL (30 EA per 30 days)











etidronate disodium oral tablet $3.65




EUFLEXXA INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE Medical Benefit PA; SP


FLECTOR TRANSDERMAL PATCH $3.65PA; ¥ (Max of 3 months); QL (60 Patches per 30 days)



161

Drug Status Notes











GELNIQUE TRANSDERMAL GEL 10 % $3.65 PA



$3.65











162

Drug Status Noteshydroxychloroquine sulfate oral tablet $3.65














$3.65







$3.65







163

Drug Status Notes




















metaxalone oral tablet 800 mg $3.65 STPA; QL (120 EA per 30 days)




164

Drug Status Notesmethocarbamol oral tablet $3.65



$3.65



$3.65



$3.65













MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HOUR $3.65 PA


165

Drug Status Notesnabumetone oral tablet $3.65

naproxen dr oral tablet delayed release $3.65










orphenadrine citrate er oral tablet extended release 12 hour

$3.65




oxybutynin chloride er oral tablet extended release 24 hour

$3.65

oxybutynin chloride oral syrup $3.65

oxybutynin chloride oral tablet $3.65

OXYTROL TRANSDERMAL PATCH TWICE WEEKLY $3.65 PA









166

Drug Status Notespiroxicam oral capsule $3.65






$3.65













risedronate sodium oral tablet 30 mg, 5 mg $3.65 PA; QL (30 EA per 30 days)









167

Drug Status NotesSAVELLA ORAL TABLET $3.65 STPA; QL (60 EA per 30 days)

















sulindac oral tablet $3.65







tizanidine hcl oral tablet $3.65



tolterodine tartrate er oral capsule extended release 24 hour

$3.65

tolterodine tartrate oral tablet $3.65


168

Drug Status NotesTOVIAZ ORAL TABLET EXTENDED RELEASE 24 HOUR $3.65



trospium chloride er oral capsule extended release 24 hour

$3.65

trospium chloride oral tablet $3.65



VESICARE ORAL TABLET $3.65 PA



VOLTAREN TRANSDERMAL GEL $3.65 STPA; QL (32 GM per 1 day)









Xgeva Subcutaneous Solution MB/RX PA; SP; QL (1 vial per 30 days)

Xiaflex Injection Solution Reconstituted MB/RX PA




169

Drug Status NotesZoledronic Acid Intravenous Concentrate MB/RX

Zoledronic Acid Intravenous Solution MB/RX


NEUROPSYCHIATRIC DISORDER

Abilify Maintena Intramuscular Suspension Reconstituted 300 MG, 400 MG

MB/RX

PA; ¥ (Additional PA requirements for members 5 years and under; PBHMI polypharmacy for members less than 18 years of age); QL (1 Syringe per 28 days)

acamprosate calcium oral tablet delayed release $3.65 QL (180 EA per 30 days)





alprazolam er oral tablet extended release 24 hour

$3.65


ALPRAZOLAM INTENSOL ORAL CONCENTRATE $3.65


alprazolam oral tablet $3.65


alprazolam oral tablet dispersible $3.65


alprazolam xr oral tablet extended release 24 hour

$3.65



170

Drug Status Notes

amoxapine oral tablet $3.65






aripiprazole oral solution $3.65


aripiprazole oral tablet $3.65


aripiprazole oral tablet dispersible $3.65


Aristada Intramuscular Prefilled Syringe MB/RX


ASCOMP-CODEINE ORAL CAPSULE $3.65 QL (180 EA per 30 days)






171

Drug Status Notes

BUNAVAIL BUCCAL FILM 2.1-0.3 MG, 6.3-1 MG $3.65

PA; ¥ (Max of 32 mg/day for the first 6 months); QL (30 EA per 30 days)

BUNAVAIL BUCCAL FILM 4.2-0.7 MG $3.65PA; ¥ (Max of 32 mg/day for the first 6 months); QL (60 EA per 30 days)

buprenorphine hcl sublingual tablet sublingual $3.65 PA

buprenorphine hcl-naloxone hcl sublingual tablet sublingual 2-0.5 mg

$3.65PA; ¥ (Max of 32 mg/day for the first 6 months); QL (90 EA per 30 days)

buprenorphine hcl-naloxone hcl sublingual tablet sublingual 8-2 mg


bupropion hcl er (smoking det) oral tablet extended release 12 hour

$3.65

bupropion hcl er (sr) oral tablet extended release 12 hour

$3.65


bupropion hcl er (xl) oral tablet extended release 24 hour

$3.65


bupropion hcl oral tablet $3.65


buspirone hcl oral tablet 10 mg, 15 mg, 5 mg, 7.5 mg

$3.65


buspirone hcl oral tablet 30 mg $3.65


butalbital-acetaminophen oral tablet 50-325 mg $3.65 QL (180 EA per 30 days)

butalbital-apap-caffeine oral capsule 50-325-40 mg

$3.65 QL (180 EA per 30 days)

butalbital-apap-caffeine oral tablet 50-325-40 mg $3.65 QL (180 EA per 30 days)

butalbital-asa-caff-codeine oral capsule $3.65 QL (180 EA per 30 days)


172

Drug Status Notesbutalbital-aspirin-caffeine oral capsule $3.65 QL (180 EA per 30 days)


$3.65



$3.65




CHANTIX CONTINUING MONTH PAK ORAL TABLET $3.65 QL (60 EA per 30 days)

CHANTIX ORAL TABLET $3.65 QL (60 EA per 30 days)

CHANTIX STARTING MONTH PAK ORAL TABLET $3.65 QL (60 EA per 30 days)





citalopram hydrobromide oral solution $3.65


citalopram hydrobromide oral tablet $3.65


clomipramine hcl oral capsule $3.65



173

Drug Status Notes




$3.65




clozapine oral tablet $3.65


clozapine oral tablet dispersible $3.65











174

Drug Status Notes

desipramine hcl oral tablet $3.65


desvenlafaxine er oral tablet extended release 24 hour

$3.65

PA; STPA; ¥ (Additional PA requirements for members 5 years and under; PBHMI polypharmacy for members less than 18 years of age)

desvenlafaxine succinate er oral tablet extended release 24 hour 100 mg, 50 mg

$3.65





$3.65











175

Drug Status Notes





disulfiram oral tablet $3.65


$3.65



$3.65






doxepin hcl oral capsule $3.65


doxepin hcl oral concentrate $3.65


drospirenone-ethinyl estradiol oral tablet 3-0.02 mg

$0


$3.65



176

Drug Status Notes


$3.65




EMSAM TRANSDERMAL PATCH 24 HOUR $3.65


eq nicotine mouth/throat lozenge $3.65

eq nicotine polacrilex mouth/throat gum $3.65

eq nicotine polacrilex mouth/throat lozenge $3.65

eq nicotine step 3 transdermal patch 24 hour $3.65

eq nicotine transdermal patch 24 hour 14 mg/24hr, 21 mg/24hr

$3.65

eql nicotine polacrilex mouth/throat gum $3.65

eql nicotine polacrilex mouth/throat lozenge $3.65


escitalopram oxalate oral solution $3.65


escitalopram oxalate oral tablet $3.65


FANAPT ORAL TABLET $3.65



177

Drug Status Notes

FANAPT TITRATION PACK ORAL TABLET $3.65


FETZIMA ORAL CAPSULE EXTENDED RELEASE 24 HOUR $3.65


FETZIMA TITRATION ORAL CAPSULE ER 24 HOUR THERAPY PACK $3.65


fluoxetine hcl (pmdd) oral tablet $3.65 PA

fluoxetine hcl oral capsule $3.65


fluoxetine hcl oral solution $3.65


fluoxetine hcl oral tablet 10 mg, 20 mg $3.65


fluphenazine decanoate injection solution $3.65


fluphenazine hcl oral concentrate $3.65


fluphenazine hcl oral elixir $3.65



178

Drug Status Notes

fluphenazine hcl oral tablet $3.65


fluvoxamine maleate er oral capsule extended release 24 hour

$3.65


fluvoxamine maleate oral tablet $3.65





$3.65



Geodon Intramuscular Solution Reconstituted MB/RX



gnp nicotine mini mouth/throat lozenge $3.65

gnp nicotine polacrilex mouth/throat gum $3.65

gnp nicotine polacrilex mouth/throat lozenge $3.65


$3.65


haloperidol decanoate intramuscular solution100 mg/ml, 50 mg/ml

$3.65



179

Drug Status Notes

haloperidol lactate injection solution 5 mg/ml $3.65


haloperidol lactate oral concentrate $3.65


haloperidol oral tablet $3.65


hm nicotine polacrilex mouth/throat gum $3.65

hm nicotine polacrilex mouth/throat lozenge $3.65

hm nicotine transdermal patch 24 hour $3.65




imipramine hcl oral tablet $3.65


imipramine pamoate oral capsule $3.65


Invega Sustenna Intramuscular Suspension MB/RX

PA; ¥ (Additional PA requirements for members 5 years and under; PBHMI polypharmacy for members less than 18 years of age); 2 vials first month; QL (1 syringe per 30 days)

Invega Trinza Intramuscular Suspension MB/RX



$3.65



180

Drug Status Notes














LATUDA ORAL TABLET $3.65


lithium carbonate er oral tablet extended release $3.65


lithium carbonate oral capsule $3.65



181

Drug Status Notes

lithium carbonate oral tablet $3.65


lithium oral solution $3.65


LORAZEPAM INTENSOL ORAL CONCENTRATE $3.65


lorazepam oral concentrate $3.65


lorazepam oral tablet $3.65


loxapine succinate oral capsule $3.65


maprotiline hcl oral tablet $3.65




meprobamate oral tablet $3.65


METHADONE HCL INTENSOL ORAL CONCENTRATE $3.65 QL (6 ML per 1 day)

methadone hcl oral concentrate $3.65 QL (6 ML per 1 day)

methadone hcl oral solution 10 mg/5ml $3.65 QL (30 ML per 1 day)


methadone hcl oral tablet 10 mg $3.65 QL (6 EA per 1 day)


182

Drug Status Notesmethadone hcl oral tablet 5 mg $3.65 QL (12 EA per 1 day)

methadone hcl oral tablet soluble Medical Benefit

METHADOSE ORAL TABLET SOLUBLE Medical Benefit




$3.65



$3.65



$3.65










183

Drug Status Notes

mirtazapine oral tablet $3.65


mirtazapine oral tablet dispersible $3.65




naltrexone hcl oral tablet $3.65


NAMENDA XR TITRATION PACK ORAL CAPSULE EXTENDED RELEASE 24 HOUR $3.65

nefazodone hcl oral tablet $3.65


NICORELIEF MOUTH/THROAT GUM $3.65

nicotine mini mouth/throat lozenge $3.65

nicotine polacrilex mouth/throat gum $3.65

nicotine polacrilex mouth/throat lozenge $3.65

nicotine step 1 transdermal patch 24 hour $3.65



nicotine transdermal patch 24 hour $3.65

NICOTROL INHALATION INHALER $3.65

NICOTROL NS NASAL SOLUTION $3.65


nortriptyline hcl oral capsule $3.65



184

Drug Status Notes

nortriptyline hcl oral solution $3.65


NUEDEXTA ORAL CAPSULE $3.65 PA


OLANZapine Intramuscular Solution Reconstituted

MB/RX


olanzapine oral tablet $3.65


olanzapine oral tablet dispersible $3.65


olanzapine-fluoxetine hcl oral capsule $3.65




paliperidone er oral tablet extended release 24 hour

$3.65


paroxetine hcl er oral tablet extended release 24 hour

$3.65



185

Drug Status Notes

paroxetine hcl oral tablet $3.65


PAXIL ORAL SUSPENSION $3.65


perphenazine oral tablet $3.65


phenelzine sulfate oral tablet $3.65




PROBUPHINE IMPLANT KIT SUBCUTANEOUS IMPLANT Medical Benefit PA

protriptyline hcl oral tablet $3.65


quetiapine fumarate er oral tablet extended release 24 hour

$3.65


quetiapine fumarate oral tablet $3.65





186

Drug Status Notes



ra mini nicotine mouth/throat lozenge $3.65

ra nicotine mouth/throat gum $3.65

ra nicotine polacrilex mouth/throat gum $3.65

ra nicotine polacrilex mouth/throat lozenge $3.65

ra nicotine transdermal patch 24 hour $3.65

REXULTI ORAL TABLET $3.65


RisperDAL Consta Intramuscular Suspension Reconstituted

MB/RX

PA; ¥ (PA applies to members 5 years of age and under; PBHMI polypharmacy for members less than 18 years of age); QL (2 injections per 28 days)

RISPERIDONE M-TAB ORAL TABLET DISPERSIBLE 0.5 MG, 1 MG, 2 MG $3.65


risperidone oral solution $3.65


risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg

$3.65


risperidone oral tablet 4 mg $3.65


risperidone oral tablet dispersible $3.65



187

Drug Status Notesrivastigmine tartrate oral capsule $3.65


SAPHRIS SUBLINGUAL TABLET SUBLINGUAL $3.65


SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HOUR $3.65 PA

sertraline hcl oral concentrate $3.65


sertraline hcl oral tablet $3.65


sm nicotine mouth/throat gum $3.65

sm nicotine mouth/throat lozenge $3.65

sm nicotine polacrilex mouth/throat gum $3.65

sm nicotine polacrilex mouth/throat lozenge $3.65

sm nicotine transdermal patch 24 hour $3.65

SUBOXONE SUBLINGUAL FILM 12-3 MG, 4-1 MG $3.65

¥ (Max of 32 mg/day for the first 6 months); QL (30 EA per 30 days)

SUBOXONE SUBLINGUAL FILM 2-0.5 MG $3.65¥ (Max of 32 mg/day for the first 6 months); QL (90 EA per 30 days)

SUBOXONE SUBLINGUAL FILM 8-2 MG $3.65¥ (Max of 32 mg/day for the first 6 months); QL (60 EA per 30 days)

TENCON ORAL TABLET 50-325 MG $3.65 QL (180 EA per 30 days)



tgt nicotine mouth/throat gum 4 mg $3.65

tgt nicotine polacrilex mouth/throat gum $3.65

tgt nicotine polacrilex mouth/throat lozenge $3.65

tgt nicotine step one transdermal patch 24 hour $3.65

tgt nicotine step three transdermal patch 24 hour $3.65

tgt nicotine step two transdermal patch 24 hour $3.65


188

Drug Status Notes

thioridazine hcl oral tablet $3.65


thiothixene oral capsule $3.65


tranylcypromine sulfate oral tablet $3.65


trazodone hcl oral tablet $3.65


trifluoperazine hcl oral tablet $3.65


trimipramine maleate oral capsule $3.65


TRINTELLIX ORAL TABLET $3.65


venlafaxine hcl er oral capsule extended release 24 hour

$3.65


venlafaxine hcl er oral tablet extended release 24 hour

$3.65


venlafaxine hcl oral tablet $3.65



189

Drug Status Notes

VERSACLOZ ORAL SUSPENSION $3.65



VIIBRYD ORAL TABLET $3.65


VIIBRYD STARTER PACK ORAL KIT $3.65


VIVITROL INTRAMUSCULAR SUSPENSION RECONSTITUTED $3.65

VRAYLAR ORAL CAPSULE $3.65


VRAYLAR ORAL CAPSULE THERAPY PACK $3.65






ZEBUTAL ORAL CAPSULE 50-325-40 MG $3.65 QL (180 EA per 30 days)



190

Drug Status Notes

ziprasidone hcl oral capsule $3.65


ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL 1.4-0.36 MG, 2.9-0.71 MG, 5.7-1.4 MG


ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL 11.4-2.9 MG, 8.6-2.1 MG $3.65


ZyPREXA Relprevv Intramuscular Suspension Reconstituted 210 MG, 300 MG

MB/RX

PA; ¥ (PA applies to members 5 years of age and under; PBHMI polypharmacy for members less than 18 years of age); QL (2 vials per 28 days)

ZyPREXA Relprevv Intramuscular Suspension Reconstituted 405 MG

MB/RX

PA; ¥ (PA applies to members 5 years of age and under; PBHMI polypharmacy for members less than 18 years of age); QL (1 vial per 28 days)

NOT FEELING WELL


NUTRITIONAL DISORDER




cyanocobalamin injection solution $3.65

ergocalciferol oral capsule $3.65



folbee oral tablet $3.65




$3.65 PA; SP



191

Drug Status NotesHUMATROPE INJECTION SOLUTION RECONSTITUTED $3.65 PA; SP



levocarnitine oral solution $3.65

levocarnitine oral tablet $3.65


$3.65

multi vitamin/minerals oral tablet $3.65




mynephrocaps oral capsule $3.65










RENAL ORAL CAPSULE $3.65






192

Drug Status Notessevelamer carbonate oral packet $3.65



vitamin d (ergocalciferol) oral capsule 50000 unit $3.65



OTHER OVER-THE-COUNTER DRUGS

ACCU-CHEK SAFE-T PRO LANCETS $3.65

ACCU-CHEK SOFT TOUCH LANCETS $3.65

ACCU-CHEK SOFTCLIX LANCETS $3.65

BD INSULIN SYRINGE 25G X 1" 1 ML, 25G X 5/8" 1 ML, 26G X 1/2" 1 ML, 27.5G X 5/8" 2 ML, 27G X 1/2" 1 ML, 29G X 1/2" 1 ML, U-100 1 ML

$3.65

BD INSULIN SYRINGE MICROFINE 27G X 5/8" 1 ML, 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML

$3.65

BD INSULIN SYRINGE ULTRAFINE 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 1/2" 0.3 ML, 30G X 1/2" 0.5 ML, 30G X 1/2" 1 ML

$3.65

BD LANCET ULTRAFINE 33G $3.65

BD SAFETY-LOK INSULIN SYRINGE $3.65

BD SYRINGE SLIP TIP 3 ML $3.65

CLEANLET LANCETS 28G $3.65


comfort lancets $3.65

COPASIL EXTERNAL GEL $3.65

daily multi oral tablet $3.65

diphenhydramine hcl oral capsule 25 mg $3.65

eq nicotine mouth/throat gum 4 mg $3.65



eq nicotine transdermal patch 24 hour 7 mg/24hr $3.65


193

Drug Status NotesEZ-LETS LANCETS 26G $3.65

ferrous sulfate granules $3.65

FINGERSTIX LANCETS $3.65

FREESTYLE INSULINX TEST IN VITRO STRIP $0 QL (150 strips per 30 days)

FREESTYLE LANCETS $3.65

FREESTYLE LITE TEST IN VITRO STRIP $0 QL (150 strips per 30 days)

FREESTYLE PRECISION NEO TEST IN VITRO STRIP $0 QL (150 strips per 30 days)

FREESTYLE TEST IN VITRO STRIP $0 QL (150 strips per 30 days)

GEBAUERS PAIN EASE EXTERNAL AEROSOL $3.65

GENTLE-LET GP LANCETS $3.65

GENTLE-LET LANCETS $3.65

gnp lancets $3.65

gnp ultra com insulin syringe 28g x 1/2" 0.5 ml, 28g x 1/2" 1 ml, 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml

$3.65

HAEMOLANCE LOW FLOW LANCETS $3.65

hm nicotine transdermal patch 24 hour 7 mg/24hr $3.65

HUMULIN 70/30 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR

$1

HUMULIN 70/30 SUBCUTANEOUS SUSPENSION $1

HUMULIN N KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR $1

HUMULIN N SUBCUTANEOUS SUSPENSION $1

HUMULIN R INJECTION SOLUTION $1

HY-VEE LANCETS $3.65

hy-vee thin lancets $3.65

insulin syringe 28g x 1/2" 0.5 ml, 28g x 1/2" 1 ml, 29g x 1" 0.3 ml, 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml

$3.65

insulin syringe 29g x 1/2" 1 ml, 30g x 5/16" 1 ml $3.65


194

Drug Status Notesinsulin syringe/needle $3.65

kinney lancets $3.65

kinney thin lancets $3.65

kinray insulin syringe 29g x 1/2" 0.5 ml $3.65

lancets $3.65

lancets thin $3.65

lavare wound wash external gel $3.65

levocarnitine oral solution $3.65

LIFESCAN UNISTIK II LANCETS $3.65

lite touch lancets $3.65

longs lancets thin $3.65

MEDISENSE THIN LANCETS $3.65

MEIJER LANCETS $3.65

MICROTAINER SAFETY FLOW LANCET $3.65

MONOJECT FILTER ASPIRATOR $3.65

MONOJECT INSULIN SYRINGE 25G X 5/8" 1 ML, 27G X 1/2" 1 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 30G X 5/16" 1 ML, U-100 1 ML

$3.65

MONOJECT INSULIN SYRINGE 28G X 1/2" 0.5 ML $3.65

MONOJECT PHARMACY TRAY 20 ML , 3 ML , 35 ML , 6 ML , 60 ML $3.65

MONOJECT PISTON SYRINGE $3.65

MONOJECT SYRINGE 12 ML , 18G X 1" 12 ML, 20G X 1" 3 ML, 20G X 1-1/2" 12 ML, 20G X 1-1/2" 3 ML, 20G X 1-1/2" 6 ML, 20G X 3/4" 3 ML, 21G X 1" 12 ML, 21G X 1" 3 ML, 21G X 1" 6 ML, 21G X 1-1/2" 12 ML, 21G X 1-1/2" 3 ML, 21G X 1-1/2" 6 ML, 22G X 1" 3 ML, 22G X 1-1/2" 3 ML, 23G X 1" 3 ML, 25G X 1" 3 ML, 25G X 1-1/4" 3 ML, 25G X 5/8" 3 ML, 27G X 1-1/4" 3 ML, 3 ML

$3.65

MONOJECT SYRINGE CATH TIP $3.65

MONOJECT SYRINGE ECC LUER 35 ML $3.65

MONOJECT SYRINGE LUER LOCK $3.65


195

Drug Status NotesMONOJECT SYRINGE REG LUER 12 ML , 20 ML , 3 ML , 35 ML , 6 ML $3.65

MONOJECT TB SAFETY SYRINGE 28G X 1/2" 1 ML $3.65

MONOJECT TB SYRINGE 25G X 5/8" 1 ML, 26G X 3/8" 1 ML, 28G X 1/2" 1 ML $3.65

MONOJECT ULTRA COMFORT SYRINGE28G X 1/2" 0.5 ML $3.65

MONOLET LANCETS $3.65

MULTI COMPLETE ORAL CAPSULE $3.65

n-acetyl-l-cysteine oral capsule $3.65

NEXIUM 24HR ORAL CAPSULE DELAYED RELEASE $3.65 PA

NOVOLIN 70/30 RELION SUBCUTANEOUS SUSPENSION $1

NOVOLIN 70/30 SUBCUTANEOUS SUSPENSION $1

NOVOLIN N RELION SUBCUTANEOUS SUSPENSION $1

NOVOLIN N SUBCUTANEOUS SUSPENSION $1

NOVOLIN R INJECTION SOLUTION $1

NOVOLIN R RELION INJECTION SOLUTION $1

ONETOUCH CLUB LANCETS FINE PT $3.65

ONETOUCH FINEPOINT LANCETS $3.65

ONETOUCH ULTRASOFT LANCETS $3.65

potassium bicarbonate granules $3.65

potassium chloride granules $3.65

potassium citrate monohydrate granules $3.65

PRECISION SURE-DOSE SYRINGE 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.5 ML

$3.65

PRECISION THIN LANCETS $3.65

PRECISION THINS GP LANCETS $3.65

PRECISION ULTRA LANCET $3.65


196

Drug Status NotesPRECISION XTRA BLOOD GLUCOSE IN VITRO STRIP $0 QL (150 strips per 30 days)

preferred plus lancets colored $3.65

preferred plus lancets thin $3.65

prenatal 19 oral tablet $3.65

prenatal 19 oral tablet chewable $3.65

PSS SELECT GP LANCETS $3.65

PSS SELECT SAFETY LANCETS $3.65

qc nicotine polacrilex mouth/throat gum $3.65

reality lancets $3.65

reality trigger lancets $3.65

sb lancets thin $3.65

sb lancets ultra thin $3.65

sr nicotine mouth/throat gum $3.65

super thin lancets $3.65

sure comfort insulin syringe 28g x 1/2" 0.5 ml, 28g x 1/2" 1 ml, 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml

$3.65

SURELITE LANCETS $3.65

tb syringe 1 ml $3.65

TECHLITE LANCETS $3.65

tgt nicotine mouth/throat gum $3.65

THINLETS GP LANCETS $3.65

THINLETS LANCET $3.65

ULTICARE TUBERCULIN SAFETY SYR28G X 1/2" 1 ML $3.65

ULTILET CLASSIC LANCETS $3.65

ULTILET LANCETS $3.65

ULTRA-THIN II AUTO LANCET $3.65

ULTRA-THIN II LANCETS $3.65

UNILET COMFORTOUCH LANCET $3.65

UNILET G.P. LANCET $3.65

UNILET G.P. SUPERLITE LANCET $3.65

UNILET LANCET $3.65


197

Drug Status NotesUNILET SUPERLITE LANCET $3.65

UNISTIK 1 $3.65

VITALET PRO LANCETS $3.65

VITALET PRO PLUS LANCETS $3.65

W&F LANCETS 26G $3.65

W&F LANCETS COLORED 21G $3.65

OTHER PRESCRIPTION DRUGS




acamprosate calcium oral tablet delayed release $3.65 QL (180 EA per 30 days)

acetaminophen-codeine oral tablet $3.65¥ (Max of 4 g of acetaminophen or 360 mg of codeine)

acetazolamide er oral capsule extended release 12 hour

$3.65


acitretin oral capsule $3.65 QL (60 EA per 30 days)



acyclovir oral capsule $3.65

acyclovir oral suspension $3.65

acyclovir oral tablet $3.65



ADMELOG SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR $3.65

ADMELOG SUBCUTANEOUS SOLUTION $3.65

ADRENALIN NASAL SOLUTION $3.65


ALBENZA ORAL TABLET $3.65

ALECENSA ORAL CAPSULE $3.65 PA; SP

Aliqopa Intravenous Solution Reconstituted MB/RX PA



198

Drug Status Notesalogliptin benzoate oral tablet $1 PA; QL (30 EA per 30 days)


alogliptin-pioglitazone oral tablet 12.5-15 mg, 12.5-30 mg, 25-30 mg, 25-45 mg


ALOMIDE OPHTHALMIC SOLUTION $3.65 PA

alosetron hcl oral tablet 0.5 mg $3.65

ALUNBRIG ORAL TABLET $3.65 PA; SP

amiodarone hcl oral tablet 100 mg $3.65

amitriptyline hcl oral tablet $3.65


amlodipine besylate-valsartan oral tablet $1 PA; QL (30 EA per 30 days)

amlodipine-valsartan-hctz oral tablet $1 PA; QL (30 EA per 30 days)


amoxicillin oral capsule $3.65

amoxicillin oral suspension reconstituted $3.65

amoxicillin oral tablet $3.65

amoxicillin oral tablet chewable 125 mg, 250 mg $3.65

amoxicillin-pot clavulanate er oral tablet extended release 12 hour

$3.65

amoxicillin-pot clavulanate oral suspension reconstituted

$3.65

amoxicillin-pot clavulanate oral tablet $3.65

amoxicillin-pot clavulanate oral tablet chewable $3.65

amphetamine-dextroamphetamine oral tablet 12.5 mg, 15 mg, 7.5 mg

$3.65


ampicillin oral capsule 500 mg $3.65

anastrozole oral tablet $3.65


$3.65 PA

ANTARA ORAL CAPSULE 30 MG, 90 MG $1 PA; QL (30 EA per 30 days)

APIDRA INJECTION SOLUTION $1


199

Drug Status NotesAPIDRA SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR $1



aripiprazole oral tablet 2 mg $3.65


aripiprazole oral tablet dispersible $3.65


ARMOUR THYROID ORAL TABLET $3.65







atovaquone oral suspension $3.65

AUBRA ORAL TABLET $0

AUGMENTIN ORAL SUSPENSION RECONSTITUTED 125-31.25 MG/5ML $3.65


AVAR CLEANSER EXTERNAL EMULSION $3.65

avidoxy oral tablet $3.65

AzaCITIDine Injection Suspension Reconstituted MB/RX

azithromycin oral packet $3.65

azithromycin oral suspension reconstituted $3.65

azithromycin oral tablet 250 mg, 500 mg, 600 mg $3.65


200

Drug Status Notesbacitra-neomycin-polymyxin-hc ophthalmic ointment

$3.65

BANZEL ORAL SUSPENSION $3.65


BANZEL ORAL TABLET $3.65


BASAGLAR KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR $3.65

Bavencio Intravenous Solution MB/RX

BAXDELA ORAL TABLET $3.65

Beleodaq Intravenous Solution Reconstituted MB/RX SP

BENDEKA INTRAVENOUS SOLUTION Medical Benefit

BESIVANCE OPHTHALMIC SUSPENSION $3.65

Besponsa Intravenous Solution Reconstituted MB/RX

bexarotene oral capsule $3.65 SP

bicalutamide oral tablet $3.65

bimatoprost ophthalmic solution $3.65 PA

BOSULIF ORAL TABLET 100 MG $3.65 PA; SP; QL (120 EA per 30 days)

BOSULIF ORAL TABLET 500 MG $3.65 PA; SP; QL (30 EA per 30 days)

bp multinatal plus oral tablet $3.65

bp multinatal plus oral tablet chewable $3.65


$3.65

budesonide inhalation suspension 1 mg/2ml $3.65

buprenorphine transdermal patch weekly 10 mcg/hr, 20 mcg/hr, 5 mcg/hr


butalbital-aspirin-caffeine oral capsule $3.65 QL (180 EA per 30 days)

CABOMETYX ORAL TABLET $3.65 PA; SP

calcipotriene-betameth diprop external ointment $3.65 PA

CALQUENCE ORAL CAPSULE $3.65 PA

capecitabine oral tablet 150 mg $3.65 SP; QL (84 EA per 14 days)

capecitabine oral tablet 500 mg $3.65 SP; QL (168 EA per 14 days)


201

Drug Status NotesCAPRELSA ORAL TABLET 100 MG $3.65 PA; QL (60 EA per 30 days)

CAPRELSA ORAL TABLET 300 MG $3.65 PA; QL (30 EA per 30 days)

carbamazepine er oral tablet extended release 12 hour 100 mg

$3.65



carvedilol phosphate er oral capsule extended release 24 hour

$1PA; STPA; QL (30 EA per 30 days)

CAVAREST DENTAL GEL $3.65

cefaclor er oral tablet extended release 12 hour $3.65

cefaclor oral capsule $3.65

cefaclor oral suspension reconstituted 125 mg/5ml, 250 mg/5ml

$3.65

cefadroxil oral capsule $3.65

cefadroxil oral suspension reconstituted $3.65

cefadroxil oral tablet $3.65

cefdinir oral capsule $3.65

cefdinir oral suspension reconstituted $3.65

cefditoren pivoxil oral tablet $3.65

cefixime oral suspension reconstituted $3.65

cefpodoxime proxetil oral suspension reconstituted

$3.65

cefpodoxime proxetil oral tablet $3.65

cefprozil oral suspension reconstituted $3.65

cefprozil oral tablet $3.65

CEFTIN ORAL SUSPENSION RECONSTITUTED $3.65

CefTRIAXone Sodium Intravenous Solution Reconstituted 1 GM, 2 GM

MB/RX

cefuroxime axetil oral tablet $3.65


cephalexin oral capsule $3.65

cephalexin oral suspension reconstituted $3.65

cephalexin oral tablet $3.65

CEROVEL EXTERNAL LOTION $3.65


202

Drug Status NotesCILOXAN OPHTHALMIC OINTMENT $3.65

ciprofloxacin hcl ophthalmic solution $3.65

ciprofloxacin hcl oral tablet $3.65

ciprofloxacin oral suspension reconstituted 500 mg/5ml (10%)

$3.65

ciprofloxacin-ciproflox hcl er oral tablet extended release 24 hour

$3.65

clarithromycin er oral tablet extended release 24 hour

$3.65

clarithromycin oral suspension reconstituted $3.65

clarithromycin oral tablet $3.65

clindamycin hcl oral capsule $3.65

clindamycin palmitate hcl oral solution reconstituted

$3.65

clobetasol propionate external liquid $3.65 PA




$3.65


clozapine oral tablet dispersible 150 mg, 200 mg $3.65


COMETRIQ (100 MG DAILY DOSE) ORAL KIT $3.65 PA



COTELLIC ORAL TABLET $3.65 PA; SP

cyclopentolate hcl ophthalmic solution 0.5 % $3.65 QL (2 ML per 30 days)

cyclophosphamide injection solution reconstituted $1 SP

cyclophosphamide oral capsule $3.65 SP

cycloserine oral capsule $3.65


203

Drug Status Notescytra-2 oral solution $3.65


$3.65 PA

Decitabine Intravenous Solution Reconstituted MB/RX SP

DELTASONE ORAL TABLET $3.65

DEPRIZINE FUSEPAQ ORAL SUSPENSION RECONSTITUTED $3.65

desogestrel-ethinyl estradiol oral tablet $0

desvenlafaxine succinate er oral tablet extended release 24 hour 100 mg, 50 mg

$3.65




diazepam oral solution 5 mg/5ml $3.65


diclofenac sodium oral tablet delayed release $3.65


diclofenac sodium transdermal gel 3 % $3.65¥ (Max of 90 days per year); QL (200 GM per 30 days)


dicloxacillin sodium oral capsule $3.65

DICOPANOL FUSEPAQ ORAL SUSPENSION RECONSTITUTED $3.65

dicyclomine hcl oral solution $3.65


$1


DONNATAL ORAL ELIXIR $3.65

DONNATAL ORAL TABLET $3.65

doxepin hcl external cream $3.65 QL (45 grams per 1 Fill)


doxycycline hyclate oral capsule $3.65


204

Drug Status Notesdoxycycline hyclate oral tablet 100 mg $3.65

doxycycline monohydrate oral capsule 100 mg, 50 mg

$3.65

doxycycline monohydrate oral suspension reconstituted

$3.65

doxycycline monohydrate oral tablet 100 mg, 50 mg

$3.65

DRITHO-CREME HP EXTERNAL CREAM $3.65


$0



$3.65



$3.65




E.E.S. 400 ORAL TABLET $3.65

EASYGEL DENTAL GEL $3.65







EMPLICITI INTRAVENOUS SOLUTION RECONSTITUTED Medical Benefit


Epirubicin HCl Intravenous Solution 200 MG/100ML, 50 MG/25ML

MB/RX

Erbitux Intravenous Solution MB/RX SP

ERLEADA ORAL TABLET $3.65 PA; SP


205

Drug Status NotesERYPED 400 ORAL SUSPENSION RECONSTITUTED $3.65

ERY-TAB ORAL TABLET DELAYED RELEASE $3.65

ERYTHROCIN STEARATE ORAL TABLET250 MG $3.65

erythromycin base oral capsule delayed release particles

$3.65

erythromycin base oral tablet $3.65

erythromycin ethylsuccinate oral suspension reconstituted

$3.65

erythromycin ethylsuccinate oral tablet $3.65

est estrogens-methyltest hs oral tablet $3.65

est estrogens-methyltest oral tablet $3.65

ESTARYLLA ORAL TABLET $0




estradiol-norethindrone acet oral tablet $3.65


MB/RX


ethambutol hcl oral tablet $3.65

etoposide oral capsule $3.65

ezetimibe-simvastatin oral tablet $1 PA; QL (30 EA per 30 days)

FABIOR EXTERNAL FOAM $3.65 PA

famciclovir oral tablet $3.65

FARESTON ORAL TABLET $3.65


felbamate oral suspension $3.65


felbamate oral tablet $3.65



206

Drug Status Notesfenofibrate oral capsule $1 PA; QL (30 EA per 30 days)

fenofibrate oral tablet 120 mg, 40 mg $1 PA; QL (30 EA per 30 days)

fenofibric acid oral capsule delayed release $1 PA; QL (30 EA per 30 days)

FETZIMA ORAL CAPSULE EXTENDED RELEASE 24 HOUR $3.65


FETZIMA TITRATION ORAL CAPSULE ER 24 HOUR THERAPY PACK $3.65


FIASP FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR $3.65

FIASP SUBCUTANEOUS SOLUTION $3.65

Firmagon Subcutaneous Solution Reconstituted MB/RX SP

FIRST-HYDROCORTISONE EXTERNAL GEL $3.65

FIRST-LANSOPRAZOLE ORAL SUSPENSION $3.65 PA

FIRST-MOUTHWASH BLM MOUTH/THROAT SUSPENSION $3.65

FIRST-OMEPRAZOLE ORAL SUSPENSION $3.65 PA

FIRST-PROGESTERONE VGS 100 VAGINAL SUPPOSITORY $3.65

FIRST-PROGESTERONE VGS 200 VAGINAL SUPPOSITORY $3.65

FIRST-VANCOMYCIN 25 ORAL SOLUTION $3.65

FIRST-VANCOMYCIN 50 ORAL SOLUTION $3.65

FIRVANQ ORAL SOLUTION RECONSTITUTED $3.65 QL (2 ML per 10 days)

fluconazole oral suspension reconstituted $3.65

fluconazole oral tablet $3.65

flucytosine oral capsule $3.65 PA


207

Drug Status Notesfluocinonide external cream 0.1 % $3.65 PA; QL (120 GM per 30 days)

fluoxetine hcl (pmdd) oral tablet $3.65 PA



flutamide oral capsule $3.65

fluvastatin sodium er oral tablet extended release 24 hour






gatifloxacin ophthalmic solution $3.65


GEBAUERS SPRAY AND STRETCH EXTERNAL AEROSOL $3.65

GENTAK OPHTHALMIC OINTMENT $3.65

gentamicin sulfate ophthalmic solution $3.65

GILOTRIF ORAL TABLET $3.65 PA

GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG $3.65

glycopyrrolate oral tablet 1 mg, 2 mg $3.65

GORDONS UREA EXTERNAL OINTMENT40 % $3.65


Halaven Intravenous Solution MB/RX SP

Hemofil M Intravenous Solution Reconstituted 1000 UNIT, 1700 UNIT, 250 UNIT, 500 UNIT

MB/RX SP

Herceptin Intravenous Solution Reconstituted MB/RX SP

HEXALEN ORAL CAPSULE $3.65

Hizentra Subcutaneous Solution 10 GM/50ML MB/RX PA; SP

HUMALOG KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML $1

HUMALOG KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 200 UNIT/ML $3.65


208

Drug Status NotesHUMALOG MIX 50/50 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR

$1

HUMALOG MIX 50/50 SUBCUTANEOUS SUSPENSION $1

HUMALOG MIX 75/25 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR

$1

HUMALOG MIX 75/25 SUBCUTANEOUS SUSPENSION $1

HUMALOG SUBCUTANEOUS SOLUTION $1

HUMALOG SUBCUTANEOUS SOLUTION CARTRIDGE $1

HYCAMTIN ORAL CAPSULE 0.25 MG $3.65 PA; SP; QL (15 EA per 21 days)

HYCAMTIN ORAL CAPSULE 1 MG $3.65 PA; SP; QL (25 EA per 21 days)

hydrocodone-acetaminophen oral solution 2.5-108 mg/5ml, 5-217 mg/10ml

$3.65 QL (480 ML per 1 day)



HYOPHEN ORAL TABLET $3.65

hyoscyamine sulfate er oral tablet extended release 12 hour

$3.65

hyoscyamine sulfate oral elixir $3.65

hyoscyamine sulfate oral solution $3.65

hyoscyamine sulfate oral tablet $3.65

hyoscyamine sulfate oral tablet dispersible $3.65

hyoscyamine sulfate sublingual tablet sublingual $3.65

hyosyne oral elixir $3.65

hyosyne oral solution $3.65

HYPERSAL INHALATION NEBULIZATION SOLUTION 3.5 % $3.65



IBRANCE ORAL CAPSULE $3.65 PA; SP

ICLUSIG ORAL TABLET $3.65 PA

IDHIFA ORAL TABLET $3.65 PA; SP; QL (30 EA per 30 days)

imatinib mesylate oral tablet $3.65


209

Drug Status NotesIMBRUVICA ORAL TABLET 140 MG $3.65 PA

Imfinzi Intravenous Solution MB/RX

INLYTA ORAL TABLET $3.65 PA; SP

IRESSA ORAL TABLET $3.65 PA

isometheptene-dichloral-apap oral capsule $3.65 QL (300 EA per 30 days)

itraconazole oral capsule $3.65


Ixempra Kit Intravenous Solution Reconstituted MB/RX SP

Jevtana Intravenous Solution MB/RX SP

K.B.G.L IN TERODERM EXTERNAL CREAM $3.65

Kadcyla Intravenous Solution Reconstituted MB/RX SP

ketoconazole oral tablet $3.65

KISQALI 200 DOSE ORAL TABLET $3.65 PA



Kogenate FS Intravenous Kit MB/RX SP

K-PHOS NO 2 ORAL TABLET $3.65

K-PHOS ORAL TABLET $3.65



LANOXIN ORAL TABLET 187.5 MCG, 62.5 MCG $3.65


LARIN FE 1.5/30 ORAL TABLET $0

LARIN FE 1/20 ORAL TABLET $0

LATUDA ORAL TABLET 60 MG $3.65


LENVIMA 10 MG DAILY DOSE ORAL CAPSULE THERAPY PACK $3.65 PA



210

Drug Status NotesLENVIMA 20 MG DAILY DOSE ORAL CAPSULE THERAPY PACK $3.65 PA


Leukine Intravenous Solution Reconstituted MB/RX SP


levofloxacin ophthalmic solution $3.65

levofloxacin oral solution $3.65

levofloxacin oral tablet $3.65

levonorgest-eth estrad 91-day oral tablet 0.15-0.03 &0.01 mg

$0

levonorgestrel oral tablet 1.5 mg $0

levonorgestrel-ethinyl estrad oral tablet 90-20 mcg

$0

levonorg-eth estrad triphasic oral tablet $0


LIDOPROFEN EXTERNAL CREAM $3.65

linezolid oral suspension reconstituted $3.65 QL (840 ML per 14 days)

linezolid oral tablet $3.65 QL (28 EA per 14 days)


LORYNA ORAL TABLET $0


LYNPARZA ORAL TABLET $3.65 PA

LYZA ORAL TABLET $0

MATULANE ORAL CAPSULE $3.65

me/naphos/mb/hyo1 oral tablet $3.65

megestrol acetate oral suspension 625 mg/5ml $3.65

megestrol acetate oral tablet $3.65

MEKINIST ORAL TABLET $3.65 PA; SP

melphalan oral tablet $3.65



meperidine hcl oral tablet 100 mg $3.65 QL (12 EA per 1 day)

mercaptopurine oral tablet $3.65



211

Drug Status Notesmesalamine oral tablet delayed release 800 mg $3.65


$1 PA

methoxsalen rapid oral capsule $3.65


$3.65




metronidazole oral capsule $3.65

metronidazole oral tablet $3.65

MICROCYN EXTERNAL GEL $3.65

MICROCYN SKIN AND WOUND EXTERNAL GEL $3.65


MILLIPRED DP 12-DAY ORAL TABLET THERAPY PACK $3.65

minocycline hcl oral capsule $3.65




MONDOXYNE NL ORAL CAPSULE 100 MG, 50 MG $3.65

Monoclate-P Intravenous Kit 1500 UNIT MB/RX SP

MONOJECT CONTROL SYRINGE $3.65

MONOJECT INSULIN SYRINGE 28G X 1/2" 0.5 ML, 29G X 1/2" 0.5 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML

$3.65

MONOJECT SYRINGE 22G X 1-1/2" 6 ML, 3 ML , 6 ML $3.65

MONOJECT SYRINGE LUER LOCK 6 ML , 60 ML $3.65

MONOJECT SYRINGE REG LUER 12 ML $3.65


212

Drug Status NotesMononine Intravenous Solution Reconstituted 1000 UNIT

MB/RX SP

MORGIDOX ORAL CAPSULE 100 MG $3.65

morphine sulfate er beads oral capsule extended release 24 hour 120 mg, 90 mg

$3.65 PA; QL (2 EA per 1 day)

morphine sulfate er beads oral capsule extended release 24 hour 30 mg








morphine sulfate er oral capsule extended release 24 hour 10 mg


MOXEZA OPHTHALMIC SOLUTION $3.65

moxifloxacin hcl ophthalmic solution $3.65

moxifloxacin hcl oral tablet $3.65






$3.65

MYLERAN ORAL TABLET $3.65

Mylotarg Intravenous Solution Reconstituted 4.5 MG

MB/RX

NAFRINSE DAILY ACIDULATED MOUTH/THROAT SOLUTION RECONSTITUTED

$3.65

NAFRINSE WEEKLY MOUTH/THROAT SOLUTION RECONSTITUTED $3.65


napro external cream $3.65

NATURE-THROID ORAL TABLET $3.65

NEBUSAL INHALATION NEBULIZATION SOLUTION 6 % $3.65


213

Drug Status Notesneomycin-polymyxin-dexameth ophthalmic ointment

$3.65

neomycin-polymyxin-dexameth ophthalmic suspension 3.5-10000-0.1

$3.65

neomycin-polymyxin-hc otic solution 1 % $3.65

NEO-POLYCIN HC OPHTHALMIC OINTMENT $3.65

NERLYNX ORAL TABLET $3.65 PA; SP

NEUTRAGARD ADVANCED DENTAL GEL $3.65

nevirapine er oral tablet extended release 24 hour400 mg

$3.65

NEXAVAR ORAL TABLET $3.65 PA; SP; QL (120 EA per 30 days)

niacin er (antihyperlipidemic) oral tablet extended release

$1

NIFEDIAC CC ORAL TABLET EXTENDED RELEASE 24 HOUR 30 MG $3.65

nilutamide oral tablet $3.65

nitrofurantoin macrocrystal oral capsule $3.65

nitrofurantoin monohyd macro oral capsule $3.65

nitrofurantoin oral suspension $3.65

norepinephrine-dextrose intravenous solution 4-5 mg/500ml-%

Medical Benefit

norepinephrine-sodium chloride intravenous solution prefilled syringe 0.08-0.9 mg/10ml-%, 0.16-0.9 mg/10ml-%

Medical Benefit

norethin ace-eth estrad-fe oral tablet $0

norethin ace-eth estrad-fe oral tablet chewable $0

norethindrone acet-ethinyl est oral tablet $0


norethin-eth estradiol-fe oral tablet chewable 0.8-25 mg-mcg

$0

norgestim-eth estrad triphasic oral tablet0.18/0.215/0.25 mg-25 mcg

$0

nortuss-ex oral liquid $3.65

NOVOLOG FLEXPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR $1


214

Drug Status NotesNOVOLOG MIX 70/30 FLEXPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR

$1

NOVOLOG MIX 70/30 SUBCUTANEOUS SUSPENSION $1

NOVOLOG PENFILL SUBCUTANEOUS SOLUTION CARTRIDGE $1

NOVOLOG SUBCUTANEOUS SOLUTION $1


np thyroid oral tablet 30 mg, 60 mg, 90 mg $3.65

ofloxacin ophthalmic solution $3.65

ofloxacin oral tablet 400 mg $3.65


OMEPRAZOLE+SYRSPEND SF ALKA ORAL SUSPENSION $3.65






Opdivo Intravenous Solution MB/RX

opium oral tincture $3.65


OSCION CLEANSER EXTERNAL LOTION6 % $3.65 PA

oseltamivir phosphate oral capsule 30 mg $3.65¥ (Max of 2 fills per year); QL (20 EA per 1 Fill)

oseltamivir phosphate oral capsule 45 mg, 75 mg $3.65¥ (Max of 2 fills per year); QL (10 EA per 1 Fill)

oseltamivir phosphate oral suspension reconstituted

$3.65¥ (Max of 2 fills per year); QL (180 ML per 1 Fill)



215

Drug Status Notesoxycodone hcl er oral tablet er 12 hour abuse-deterrent 10 mg, 20 mg, 40 mg, 80 mg

$3.65 QL (90 EA per 30 days)

oxycodone-acetaminophen oral solution $3.65¥ (Max of 4 g of acetaminophen or 160 mg of oxycodone )

OXYCONTIN ORAL TABLET ER 12 HOUR ABUSE-DETERRENT 15 MG $3.65 QL (90 EA per 30 days)

PACLitaxel Intravenous Concentrate MB/RX

paliperidone er oral tablet extended release 24 hour

$3.65


PANCREAZE ORAL CAPSULE DELAYED RELEASE PARTICLES 10500 UNIT, 16800 UNIT, 21000 UNIT, 4200 UNIT

$3.65

pantoprazole sodium oral tablet delayed release $3.65


PCE ORAL TABLET DELAYED RELEASE $3.65



penicillin g procaine intramuscular suspension $3.65

penicillin v potassium oral solution reconstituted $3.65

penicillin v potassium oral tablet $3.65


Perjeta Intravenous Solution MB/RX SP

phenobarbital oral elixir $3.65

phenobarbital oral solution $3.65

phenobarbital oral tablet $3.65

PHENOHYTRO ORAL TABLET $3.65


phenylephrine-guaifenesin oral liquid $3.65

PHOS-FLUR DENTAL GEL $3.65

PHOSPHASAL ORAL TABLET $3.65


216

Drug Status Notes

pimozide oral tablet 2 mg $3.65


PIMTREA ORAL TABLET $0

PIRMELLA 7/7/7 ORAL TABLET $0

POMALYST ORAL CAPSULE $3.65 PA; SP

potassium chloride er oral tablet extended release20 meq

$3.65

potassium chloride oral packet $3.65

potassium citrate er oral tablet extended release $3.65


$3.65


PRED-G OPHTHALMIC SUSPENSION $3.65

PRED-G S.O.P. OPHTHALMIC OINTMENT $3.65


$3.65

PREDNISONE INTENSOL ORAL CONCENTRATE $3.65

prednisone oral solution $3.65

prednisone oral tablet $3.65

prednisone oral tablet therapy pack $3.65

premium lidocaine external ointment $3.65 QL (50 GM per 30 days)

primidone oral tablet $3.65


PRIMSOL ORAL SOLUTION $3.65



progesterone micronized transdermal cream $3.65

Proleukin Intravenous Solution Reconstituted MB/RX SP

promethazine hcl rectal suppository 50 mg $3.65


PROTONIX ORAL PACKET $3.65 PA


217

Drug Status NotesPULMOSAL INHALATION NEBULIZATION SOLUTION $3.65

PURIXAN ORAL SUSPENSION $3.65

pyrazinamide oral tablet $3.65


$3.65

quetiapine fumarate er oral tablet extended release 24 hour

$3.65


quinine sulfate oral capsule $3.65 PA




REA LO 40 EXTERNAL CREAM $3.65

REA LO 40 EXTERNAL LOTION $3.65



repaglinide-metformin hcl oral tablet $1

REVLIMID ORAL CAPSULE $3.65 PA; SP

rexaphenac transdermal cream $3.65

rifabutin oral capsule $3.65

RIFAMATE ORAL CAPSULE $3.65

rifampin oral capsule $3.65

RIFATER ORAL TABLET $3.65


risedronate sodium oral tablet 30 mg, 5 mg $3.65 PA; QL (30 EA per 30 days)



RISPERIDONE M-TAB ORAL TABLET DISPERSIBLE 0.5 MG, 1 MG, 2 MG $3.65


Rituxan Hycela Subcutaneous Solution MB/RX PA; SP

rivastigmine transdermal patch 24 hour 4.6 mg/24hr, 9.5 mg/24hr

$3.65


218

Drug Status NotesRixubis Intravenous Solution Reconstituted MB/RX SP

ropivacaine hcl-nacl injection solution 0.1-0.9 % Medical Benefit

ROSANIL CLEANSER EXTERNAL EMULSION $3.65

rosuvastatin calcium oral tablet $1 PA; QL (30 EA per 30 days)

RUBRACA ORAL TABLET $3.65 PA; SP; QL (120 EA per 30 days)

RYDAPT ORAL CAPSULE $3.65 PA; SP






SIVEXTRO ORAL TABLET $3.65 QL (6 EA per 365 days)

sodium chloride irrigation solution 0.9 % $3.65 PA

sodium fluoride oral tablet 2.2 (1 f) mg $3.65

sodium polystyrene sulfonate oral powder $3.65


SPORANOX ORAL SOLUTION $3.65

SPRYCEL ORAL TABLET 100 MG, 140 MG $3.65 PA; SP; QL (30 EA per 30 days)

SPRYCEL ORAL TABLET 20 MG, 50 MG, 70 MG, 80 MG $3.65 PA; SP; QL (60 EA per 30 days)

STIVARGA ORAL TABLET $3.65 PA; SP; QL (84 EA per 28 days)

sulfacetamide sodium-sulfur external emulsion $3.65

sulfacetamide sodium-sulfur external lotion 10-5 %

$3.65

sulfadiazine oral tablet $3.65

sulfamethoxazole-trimethoprim oral suspension200-40 mg/5ml

$3.65

sulfamethoxazole-trimethoprim oral tablet $3.65


SULFATRIM PEDIATRIC ORAL SUSPENSION $3.65

SUPRAX ORAL CAPSULE $3.65

SUPRAX ORAL SUSPENSION RECONSTITUTED 500 MG/5ML $3.65


219

Drug Status NotesSUPRAX ORAL TABLET CHEWABLE $3.65

SUTENT ORAL CAPSULE $3.65 PA; SP


TAFINLAR ORAL CAPSULE $3.65 PA; SP

TAGRISSO ORAL TABLET 40 MG $3.65 PA; QL (30 Tablets per 30 days)

TAGRISSO ORAL TABLET 80 MG $3.65 PA

TARCEVA ORAL TABLET 100 MG, 150 MG $3.65 SP; QL (30 EA per 30 days)

TARCEVA ORAL TABLET 25 MG $3.65 SP; QL (90 EA per 30 days)

TASIGNA ORAL CAPSULE 150 MG, 200 MG $3.65 PA; SP

Tecentriq Intravenous Solution MB/RX


telmisartan-hctz oral tablet $1 PA

Temodar Intravenous Solution Reconstituted MB/RX SP

temozolomide oral capsule $3.65 SP


terbinafine hcl oral tablet $3.65¥ (Max of 90 tablets per 365 days); QL (30 EA per 30 days)

testosterone transdermal gel 10 mg/act (2%), 25 mg/2.5gm (1%), 50 mg/5gm (1%)

$3.65 PA




tetracycline hcl oral capsule $3.65

TIVICAY ORAL TABLET 50 MG $3.65


tobramycin ophthalmic solution $3.65

TOBREX OPHTHALMIC OINTMENT $3.65


tolterodine tartrate er oral capsule extended release 24 hour

$3.65

Treanda Intravenous Solution Reconstituted MB/RX SP

TRESIBA FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR $3.65

tretinoin external gel 0.05 % $3.65 PA


220

Drug Status Notestretinoin oral capsule $3.65



TRI-LO-SPRINTEC ORAL TABLET $0



TYKERB ORAL TABLET $3.65 PA; SP; QL (180 EA per 30 days)

UNITHROID DIRECT ORAL TABLET $3.65

UNITHROID ORAL TABLET 137 MCG $3.65

urea external cream 40 %, 50 % $3.65

urea external lotion 40 % $3.65

urea external suspension 40 % $3.65

urea-c40 external lotion $3.65

ure-k external cream $3.65

URETRON D/S ORAL TABLET $3.65

URIMAR-T ORAL TABLET $3.65

URYL ORAL TABLET $3.65

Vabomere Intravenous Solution Reconstituted MB/RX

valacyclovir hcl oral tablet $3.65

VALCHLOR EXTERNAL GEL $3.65

valganciclovir hcl oral solution reconstituted $3.65

valganciclovir hcl oral tablet $3.65

valsartan oral tablet $1 STPA

Valstar Intravesical Solution MB/RX SP

vancomycin hcl oral capsule $3.65 QL (40 EA per 10 days)

Vectibix Intravenous Solution 100 MG/5ML, 400 MG/20ML

MB/RX SP

Velcade Injection Solution Reconstituted MB/RX SP

VERSACLOZ ORAL SUSPENSION $3.65


VERZENIO ORAL TABLET $3.65 PA; SP


221

Drug Status NotesVidaza Injection Suspension Reconstituted MB/RX SP



voriconazole oral suspension reconstituted $3.65 PA

voriconazole oral tablet $3.65 PA; QL (180 EA per 30 days)

VOTRIENT ORAL TABLET $3.65 PA; SP; QL (120 EA per 30 days)

VYFEMLA ORAL TABLET $0

Vyxeos Intravenous Suspension Reconstituted 100-44 MG

MB/RX

WESTHROID ORAL TABLET 130 MG, 195 MG, 32.5 MG, 65 MG, 97.5 MG $3.65

WP THYROID ORAL TABLET $3.65

XALKORI ORAL CAPSULE $3.65 PA; SP

XTANDI ORAL CAPSULE $3.65 PA; SP; QL (120 EA per 30 days)

Yervoy Intravenous Solution MB/RX SP

Zaltrap Intravenous Solution MB/RX SP


ZEJULA ORAL CAPSULE $3.65 PA

ZELBORAF ORAL TABLET $3.65 PA; SP

ZMAX ORAL SUSPENSION RECONSTITUTED $3.65

Zoledronic Acid Intravenous Solution MB/RX

ZOMIG NASAL SOLUTION 2.5 MG $3.65 STPA; QL (6 Units per 30 days)

ZOVIRAX EXTERNAL CREAM $3.65 PA; QL (5 GM per 1 Rx)

ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL 1.4-0.36 MG, 5.7-1.4 MG $3.65


ZYDELIG ORAL TABLET $3.65

ZYKADIA ORAL CAPSULE $3.65 PA; SP

ZYTIGA ORAL TABLET 250 MG $3.65 PA; SP; QL (120 EA per 30 days)

ZYTIGA ORAL TABLET 500 MG $3.65 PA; SP; QL (60 EA per 30 days)

OVERDOSE



222

Drug Status NotesAMITIZA ORAL CAPSULE $3.65 PA; QL (60 EA per 30 days)

CHEMET ORAL CAPSULE $3.65



EVZIO INJECTION SOLUTION AUTO-INJECTOR $3.65

PA; ¥ (Max of 4 units per 30 days); QL (2 Units per 1 Rx)


FERRIPROX ORAL SOLUTION $3.65 PA

FERRIPROX ORAL TABLET $3.65 PA




MOVANTIK ORAL TABLET $3.65 PA

naloxone hcl injection solution 0.4 mg/ml $3.65

NARCAN NASAL LIQUID $3.65¥ (Max of 4 units per 30 days); QL (2 Units per 1 Rx)

RELISTOR ORAL TABLET $3.65 PA; QL (90 Tablets per 30 days)

RELISTOR SUBCUTANEOUS SOLUTION12 MG/0.6ML, 8 MG/0.4ML $3.65 PA

SYMPROIC ORAL TABLET $3.65 PA


VISTOGARD ORAL PACKET $3.65 QL (20 EA per 30 days)

PAIN

ABSTRAL SUBLINGUAL TABLET SUBLINGUAL $3.65 PA

acetaminophen-codeine #2 oral tablet $3.65¥ (Max of 4 g of acetaminophen or 360 mg of codeine)



acetaminophen-codeine oral solution $3.65¥ (Max of 4 g of acetaminophen or 360 mg of codeine)

acetaminophen-codeine oral tablet $3.65¥ (Max of 4 g of acetaminophen or 360 mg of codeine)


223

Drug Status NotesAFEDITAB CR ORAL TABLET EXTENDED RELEASE 24 HOUR $1


amlodipine besylate oral tablet $1

ASCOMP-CODEINE ORAL CAPSULE $3.65 QL (180 EA per 30 days)

atenolol oral tablet $1

BELBUCA BUCCAL FILM $3.65 PA; QL (60 Films per 30 days)





$3.65

buprenorphine transdermal patch weekly $3.65 PA; QL (4 EA per 28 days)

butalbital-acetaminophen oral tablet 50-325 mg $3.65 QL (180 EA per 30 days)

butalbital-apap-caffeine oral capsule 50-325-40 mg

$3.65 QL (180 EA per 30 days)

butalbital-apap-caffeine oral tablet 50-325-40 mg $3.65 QL (180 EA per 30 days)

butalbital-asa-caff-codeine oral capsule $3.65 QL (180 EA per 30 days)

butalbital-aspirin-caffeine oral capsule $3.65 QL (180 EA per 30 days)

butorphanol tartrate injection solution $3.65

butorphanol tartrate nasal solution $3.65


CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 HOUR 120 MG $1 PA

CARTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR $1


cimetidine oral tablet 200 mg $3.65

clopidogrel bisulfate oral tablet $3.65

codeine sulfate oral tablet $3.65 QL (360 mg per 1 day)



diflunisal oral tablet $3.65



224

Drug Status NotesDILATRATE-SR ORAL CAPSULE EXTENDED RELEASE $3.65

diltiazem cd oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg

$1

diltiazem hcl er beads oral capsule extended release 24 hour

$1

diltiazem hcl er coated beads oral capsule extended release 24 hour

$1


$1

diltiazem hcl er oral capsule extended release 12 hour

$1

diltiazem hcl er oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg

$1

diltiazem hcl oral tablet $1

dilt-xr oral capsule extended release 24 hour $1


$3.65



$3.65





$3.65



$3.65





225

Drug Status NotesEMBEDA ORAL CAPSULE EXTENDED RELEASE 100-4 MG $3.65 PA; QL (2 EA per 1 day)

EMBEDA ORAL CAPSULE EXTENDED RELEASE 20-0.8 MG $3.65 PA; QL (12 EA per 1 day)


EMBEDA ORAL CAPSULE EXTENDED RELEASE 50-2 MG, 60-2.4 MG $3.65 PA; QL (4 EA per 1 day)


ENDOCET ORAL TABLET 10-325 MG, 2.5-325 MG, 5-325 MG, 7.5-325 MG $3.65

¥ (Max of 4 g of acetaminophen or 160 mg of oxycodone )



eplerenone oral tablet $1 PA; QL (60 EA per 30 days)




famotidine oral suspension reconstituted $3.65

famotidine oral tablet 20 mg, 40 mg $3.65

fenoprofen calcium oral tablet $3.65

fentanyl citrate buccal lozenge on a handle $3.65 PA; QL (120 EA per 30 days)

fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr

$3.65 QL (10 EA per 30 days)

fentanyl transdermal patch 72 hour 37.5 mcg/hr, 62.5 mcg/hr, 87.5 mcg/hr


FENTORA BUCCAL TABLET 100 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG $3.65 PA; QL (4 EA per 1 day)

flavoxate hcl oral tablet $3.65


$3.65



226

Drug Status Notes












hydrocodone-acetaminophen oral solution 2.5-108 mg/5ml, 5-217 mg/10ml, 7.5-325 mg/15ml

$3.65 QL (480 ML per 1 day)

hydrocodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg

$3.65 QL (12 EA per 1 day)

hydrocodone-ibuprofen oral tablet 10-200 mg, 5-200 mg, 7.5-200 mg

$3.65 QL (5 EA per 1 day)

hydromorphone hcl er oral tablet er 24 hour abuse-deterrent

$3.65 PA; QL (64 mg per 1 day)

hydromorphone hcl oral liquid $3.65 QL (64 mg per 1 day)

hydromorphone hcl oral tablet $3.65 QL (64 mg per 1 day)

hydromorphone hcl rectal suppository $3.65

IBUDONE ORAL TABLET $3.65 QL (5 EA per 1 day)






227

Drug Status NotesISORDIL TITRADOSE ORAL TABLET 40 MG $3.65

isosorbide dinitrate er oral tablet extended release

$3.65

isosorbide dinitrate oral tablet $3.65

isosorbide mononitrate er oral tablet extended release 24 hour

$3.65

isosorbide mononitrate oral tablet $3.65

KADIAN ORAL CAPSULE EXTENDED RELEASE 24 HOUR 200 MG $3.65 PA; QL (1 EA per 1 day)

KADIAN ORAL CAPSULE EXTENDED RELEASE 24 HOUR 40 MG $3.65 PA; QL (6 EA per 1 day)


ketorolac tromethamine injection solution 15 mg/ml, 30 mg/ml

$3.65¥ (Max of 5 days per Rx); QL (120 mg per 1 day)

ketorolac tromethamine intramuscular solution60 mg/2ml



ketorolac tromethamine oral tablet $3.65 QL (20 EA per 30 days)






LORCET HD ORAL TABLET $3.65 QL (12 EA per 1 day)

LORCET ORAL TABLET $3.65 QL (12 EA per 1 day)

LORCET PLUS ORAL TABLET 7.5-325 MG $3.65 QL (12 EA per 1 day)



MATZIM LA ORAL TABLET EXTENDED RELEASE 24 HOUR $1 PA


mefenamic acid oral capsule $3.65 PA

meperidine hcl oral solution $3.65 QL (120 ML per 1 day)


228

Drug Status Notesmeperidine hcl oral tablet 100 mg $3.65 QL (12 EA per 1 day)

meperidine hcl oral tablet 50 mg $3.65 QL (24 EA per 1 day)

METHADONE HCL INTENSOL ORAL CONCENTRATE $3.65 QL (6 ML per 1 day)

methadone hcl oral concentrate $3.65 QL (6 ML per 1 day)





methadone hcl oral tablet soluble Medical Benefit

METHADOSE ORAL TABLET SOLUBLE Medical Benefit

metoprolol succinate er oral tablet extended release 24 hour

$1

metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg

$1

metoprolol tartrate oral tablet 37.5 mg, 75 mg $3.65 PA



MINITRAN TRANSDERMAL PATCH 24 HOUR $3.65

morphine sulfate (concentrate) oral solution 100 mg/5ml

$3.65 QL (12 ML per 1 day)

morphine sulfate er beads oral capsule extended release 24 hour 120 mg, 90 mg















229

Drug Status Notesmorphine sulfate er oral capsule extended release 24 hour 20 mg




morphine sulfate er oral capsule extended release 24 hour 50 mg, 60 mg




morphine sulfate er oral tablet extended release100 mg



$3.65 QL (16 EA per 1 day)







morphine sulfate oral solution 10 mg/5ml $3.65 QL (120 ML per 1 day)

morphine sulfate oral solution 20 mg/5ml $3.65 QL (60 ML per 1 day)

morphine sulfate oral tablet 15 mg $3.65 QL (16 EA per 1 day)

morphine sulfate oral tablet 30 mg $3.65 QL (8 EA per 1 day)

nadolol oral tablet 20 mg, 40 mg, 80 mg $1






nicardipine hcl oral capsule $1

NIFEDICAL XL ORAL TABLET EXTENDED RELEASE 24 HOUR 60 MG $1

nifedipine er oral tablet extended release 24 hour30 mg, 60 mg

$1

nifedipine er oral tablet extended release 24 hour90 mg

$3.65

nifedipine er osmotic release oral tablet extended release 24 hour

$1


230

Drug Status Notesnifedipine oral capsule $1

NITRO-BID TRANSDERMAL OINTMENT $3.65

NITRO-DUR TRANSDERMAL PATCH 24 HOUR 0.3 MG/HR, 0.8 MG/HR $3.65

nitroglycerin sublingual tablet sublingual $3.65

nitroglycerin transdermal patch 24 hour $3.65

nitroglycerin translingual aerosol solution $3.65

nitroglycerin translingual solution $3.65


NUCYNTA ORAL TABLET $3.65 PA

OPANA ER ORAL TABLET ER 12 HOUR ABUSE-DETERRENT $3.65 PA; QL (80 mg per 1 day)


oxycodone hcl er oral tablet er 12 hour abuse-deterrent

$3.65 QL (90 EA per 30 days)

oxycodone hcl oral capsule $3.65 QL (160 mg per 1 day)

oxycodone hcl oral concentrate 100 mg/5ml $3.65 QL (160 mg per 1 day)

oxycodone hcl oral solution $3.65

oxycodone hcl oral tablet $3.65 QL (160 mg per 1 day)

oxycodone-acetaminophen oral solution $3.65¥ (Max of 4 g of acetaminophen or 160 mg of oxycodone )

oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg

$3.65¥ (Max of 4 g of acetaminophen or 160 mg of oxycodone )

oxycodone-aspirin oral tablet 4.8355-325 mg $3.65

oxycodone-ibuprofen oral tablet $3.65 PA

OXYCONTIN ORAL TABLET ER 12 HOUR ABUSE-DETERRENT $3.65 QL (90 EA per 30 days)

oxymorphone hcl er oral tablet extended release 12 hour

$3.65 PA; QL (80 mg per 1 day)

oxymorphone hcl oral tablet $3.65 PA; QL (80 mg per 1 day)


perindopril erbumine oral tablet $1


phenazopyridine hcl oral tablet 100 mg, 200 mg $3.65



231

Drug Status Notesprasugrel hcl oral tablet $3.65








$1

propranolol hcl oral solution 40 mg/5ml $1


RANEXA ORAL TABLET EXTENDED RELEASE 12 HOUR $3.65 PA; QL (60 EA per 30 days)



SAVELLA ORAL TABLET $3.65 STPA; QL (60 EA per 30 days)


SPRIX NASAL SOLUTION $3.65PA; ¥ (Max of 5 days per Rx); QL (4 units per 1 day)









TAZTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR $1


TENCON ORAL TABLET 50-325 MG $3.65 QL (180 EA per 30 days)

timolol maleate oral tablet $1




232

Drug Status Notes









tramadol hcl er (biphasic) oral tablet extended release 24 hour 100 mg, 300 mg

$3.65 PA

tramadol hcl er oral tablet extended release 24 hour


tramadol hcl oral tablet $3.65 QL (240 EA per 30 days)

tramadol-acetaminophen oral tablet $3.65 QL (240 EA per 30 days)

trandolapril oral tablet $1


verapamil hcl oral tablet $1

VERDROCET ORAL TABLET $3.65 QL (12 EA per 1 day)


ZOHYDRO ER ORAL CAPSULE ER 12 HOUR ABUSE-DETERRENT $3.65 PA; QL (120 mg per 1 day)






233

Drug Status NotesPATIENT DEMOGRAPHICS

bupropion hcl er (smoking det) oral tablet extended release 12 hour

$3.65

CHANTIX CONTINUING MONTH PAK ORAL TABLET $3.65 QL (60 EA per 30 days)

CHANTIX ORAL TABLET $3.65 QL (60 EA per 30 days)

CHANTIX STARTING MONTH PAK ORAL TABLET $3.65 QL (60 EA per 30 days)

eq nicotine mouth/throat lozenge $3.65

eq nicotine polacrilex mouth/throat gum $3.65



eq nicotine transdermal patch 24 hour 14 mg/24hr, 21 mg/24hr

$3.65

eql nicotine polacrilex mouth/throat gum $3.65

eql nicotine polacrilex mouth/throat lozenge $3.65

gnp nicotine mini mouth/throat lozenge $3.65

gnp nicotine polacrilex mouth/throat gum $3.65

gnp nicotine polacrilex mouth/throat lozenge $3.65

hm nicotine polacrilex mouth/throat gum $3.65

hm nicotine polacrilex mouth/throat lozenge $3.65

hm nicotine transdermal patch 24 hour $3.65

NICORELIEF MOUTH/THROAT GUM $3.65

nicotine mini mouth/throat lozenge $3.65

nicotine polacrilex mouth/throat gum $3.65

nicotine polacrilex mouth/throat lozenge $3.65




nicotine transdermal patch 24 hour $3.65

NICOTROL INHALATION INHALER $3.65

NICOTROL NS NASAL SOLUTION $3.65

ra mini nicotine mouth/throat lozenge $3.65

ra nicotine mouth/throat gum $3.65

ra nicotine polacrilex mouth/throat gum $3.65


234

Drug Status Notesra nicotine polacrilex mouth/throat lozenge $3.65

ra nicotine transdermal patch 24 hour $3.65

sm nicotine mouth/throat gum $3.65

sm nicotine mouth/throat lozenge $3.65

sm nicotine polacrilex mouth/throat gum $3.65

sm nicotine polacrilex mouth/throat lozenge $3.65

sm nicotine transdermal patch 24 hour $3.65

tgt nicotine mouth/throat gum 4 mg $3.65

tgt nicotine polacrilex mouth/throat gum $3.65

tgt nicotine polacrilex mouth/throat lozenge $3.65

tgt nicotine step one transdermal patch 24 hour $3.65

tgt nicotine step three transdermal patch 24 hour $3.65

tgt nicotine step two transdermal patch 24 hour $3.65

PREGNANCY

BONJESTA ORAL TABLET EXTENDED RELEASE $3.65 PA

bp folinatal plus b oral tablet $3.65


DICLEGIS ORAL TABLET DELAYED RELEASE $3.65 PA

ELITE-OB ORAL TABLET $3.65

INATAL ADVANCE ORAL TABLET $3.65

Makena Intramuscular Oil MB/RX QL (1 ML per 7 days)

Makena Subcutaneous Solution Auto-Injector MB/RX QL (2 ML per 7 days)

OBSTETRIX EC ORAL TABLET $3.65

pnv folic acid + iron oral tablet $3.65

PRENATABS RX ORAL TABLET $3.65

prenatal 19 oral tablet $3.65

prenatal 19 oral tablet chewable $3.65

prenatal oral tablet 27-0.8 mg $3.65


TRINATE ORAL TABLET $3.65



235

Drug Status NotesPROCEDURE




MB/RX SP










$3.65






$3.65










FERRIPROX ORAL SOLUTION $3.65 PA

FERRIPROX ORAL TABLET $3.65 PA



236

Drug Status Notesfondaparinux sodium subcutaneous solution $3.65


$3.65


GAVILYTE-C ORAL SOLUTION RECONSTITUTED $3.65

GAVILYTE-G ORAL SOLUTION RECONSTITUTED $3.65




GOLYTELY ORAL SOLUTION RECONSTITUTED 227.1 GM $3.65


$3.65


$3.65


MB/RX SP





IPRIVASK SUBCUTANEOUS SOLUTION RECONSTITUTED $3.65 QL (24 vials per 12 days)










237

Drug Status Noteslidocaine external ointment $3.65 QL (50 GM per 30 days)

lidocaine hcl (pf) injection solution 4 % $3.65




lidocaine hcl external solution $3.65

lidocaine hcl injection solution 0.5 %, 1 %, 2 % $3.65

lidocaine viscous mouth/throat solution $3.65

lidocaine-prilocaine external cream $3.65

lidocaine-prilocaine external kit $3.65


liothyronine sodium oral tablet $3.65

MOVIPREP ORAL SOLUTION RECONSTITUTED $3.65




$3.65








$3.65

OSMOPREP ORAL TABLET $3.65 QL (32 EA per 1 Fill)


peg 3350/electrolytes oral solution reconstituted $3.65

peg 3350-kcl-na bicarb-nacl oral solution reconstituted

$3.65

peg-3350/electrolytes oral solution reconstituted $3.65



238

Drug Status NotesPHENERGAN RECTAL SUPPOSITORY $3.65


$3.65



PREPOPIK ORAL PACKET $3.65










quinidine gluconate er oral tablet extended release

$3.65

quinidine sulfate oral tablet $3.65









SUPREP BOWEL PREP KIT ORAL SOLUTION $3.65







239

Drug Status NotesVonvendi Intravenous Solution Reconstituted MB/RX SP







REACTION DUE TO AN ALLERGEN

ADRENACLICK INJECTION DEVICE $3.65 PA; QL (2 EA per 1 day)

ADRENACLICK INJECTION SOLUTION AUTO-INJECTOR $3.65 PA; QL (2 EA per 1 day)
























240

Drug Status Notesepinephrine injection solution auto-injector 0.15 mg/0.15ml, 0.3 mg/0.3ml

$3.65 QL (2 EA per 1 Fill)

EPIPEN 2-PAK INJECTION SOLUTION AUTO-INJECTOR $3.65 PA; QL (2 EA per 1 Fill)

EPIPEN JR 2-PAK INJECTION SOLUTION AUTO-INJECTOR $3.65 PA; QL (2 EA per 1 Fill)




$3.65
























241

Drug Status NotesXolair Subcutaneous Solution Reconstituted MB/RX PA; SP; QL (6 vials per 28 days)


RECENT OPERATION




MB/RX SP








$3.65






$3.65











$3.65


242

Drug Status NotesHumate-P Intravenous Solution Reconstituted 1000-2400 UNIT, 250-600 UNIT, 500-1200 UNIT

MB/RX SP





IPRIVASK SUBCUTANEOUS SOLUTION RECONSTITUTED $3.65 QL (24 vials per 12 days)








lidocaine hcl (pf) injection solution 4 % $3.65




lidocaine hcl external solution $3.65

lidocaine hcl injection solution 0.5 %, 1 %, 2 % $3.65

lidocaine viscous mouth/throat solution $3.65

lidocaine-prilocaine external cream $3.65

lidocaine-prilocaine external kit $3.65




$3.65






$3.65



243

Drug Status NotesPHENADOZ RECTAL SUPPOSITORY $3.65



$3.65




















Vonvendi Intravenous Solution Reconstituted MB/RX SP




SKIN CONDITION

ABSORICA ORAL CAPSULE $3.65 PA

acitretin oral capsule $3.65 QL (60 EA per 30 days)

acne medication 5 external gel $3.65

acyclovir external ointment $3.65

ACZONE EXTERNAL GEL 7.5 % $3.65 PA; QL (60 GM per 30 days)


244

Drug Status Notesadapalene external cream $3.65 STPA

adapalene external gel $3.65 STPA

adapalene external lotion $3.65 STPA

ala-cort external cream 1 % $3.65

alclometasone dipropionate external cream $3.65

alclometasone dipropionate external ointment $3.65



amcinonide external cream $3.65 PA

amcinonide external lotion $3.65 PA

amcinonide external ointment $3.65 PA

ammonium lactate external cream $3.65

ammonium lactate external lotion $3.65

ANALPRAM-HC RECTAL LOTION 2.5-1 % $3.65

APEXICON E EXTERNAL CREAM $3.65 PA

AVITA EXTERNAL CREAM $3.65 PA

AVITA EXTERNAL GEL $3.65 PA

AZELEX EXTERNAL CREAM $3.65 QL (30 grams per 1 fill)




benzoyl peroxide external gel 10 %, 5 % $3.65

benzoyl peroxide wash external liquid 10 % $3.65

benzoyl peroxide-erythromycin external gel $3.65 QL (23 GM per 30 days)


betamethasone dipropionate aug external cream $3.65

betamethasone dipropionate aug external gel $3.65

betamethasone dipropionate aug external lotion $3.65

betamethasone dipropionate aug external ointment

$3.65

betamethasone dipropionate external cream $3.65

betamethasone dipropionate external lotion $3.65

betamethasone dipropionate external ointment $3.65


245

Drug Status Notesbetamethasone valerate external cream $3.65

betamethasone valerate external foam $3.65

betamethasone valerate external lotion $3.65

betamethasone valerate external ointment $3.65




bp foaming wash external liquid $3.65

bp wash external liquid 2.5 % $3.65

calcipotriene external cream $3.65

calcipotriene external ointment $3.65

calcipotriene external solution $3.65

calcipotriene-betameth diprop external ointment $3.65 PA

CALCITRENE EXTERNAL OINTMENT $3.65

calcitriol external ointment $3.65

CAPEX EXTERNAL SHAMPOO $3.65 PA





CICLODAN EXTERNAL SOLUTION $3.65


ciclopirox external shampoo $3.65 PA

ciclopirox external solution $3.65







CLARAVIS ORAL CAPSULE $3.65PA; ¥ (Max of 5 months); QL (60 EA per 30 days)



246

Drug Status Notesclindamycin phos-benzoyl perox external gel $3.65 PA; QL (50 GM per 30 days)

clindamycin phosphate external foam $3.65 PA

clindamycin phosphate external gel $3.65

clindamycin phosphate external lotion $3.65

clindamycin phosphate external solution $3.65

clobetasol propionate e external cream $3.65

clobetasol propionate external cream $3.65 PA

clobetasol propionate external foam $3.65

clobetasol propionate external gel $3.65 PA

clobetasol propionate external liquid $3.65 PA

clobetasol propionate external lotion $3.65

clobetasol propionate external ointment $3.65 PA

clobetasol propionate external shampoo $3.65

clobetasol propionate external solution $3.65 PA



CLODAN EXTERNAL SHAMPOO $3.65







CORDRAN EXTERNAL OINTMENT $3.65 PA

CORDRAN EXTERNAL TAPE $3.65 PA



$3.65 PA; SP




dapsone external gel $3.65 PA; QL (60 GM per 30 days)

dapsone oral tablet $3.65


247

Drug Status NotesDENAVIR EXTERNAL CREAM $3.65 PA; QL (5 GM per 1 Fill)

desonide external cream $3.65 PA

desonide external lotion $3.65 PA

desonide external ointment $3.65 PA

desoximetasone external cream 0.05 % $3.65 PA

desoximetasone external cream 0.25 % $3.65

desoximetasone external gel $3.65

desoximetasone external ointment 0.05 % $3.65 PA

desoximetasone external ointment 0.25 % $3.65

diclofenac sodium transdermal gel 3 % $3.65¥ (Max of 90 days per year); QL (200 GM per 30 days)

DIFFERIN EXTERNAL GEL 0.1 % $3.65 ^ (OTC only)

diflorasone diacetate external cream $3.65 PA

diflorasone diacetate external ointment $3.65 PA


$0

DRYSOL EXTERNAL SOLUTION $3.65

DUPIXENT SUBCUTANEOUS SOLUTION PREFILLED SYRINGE $3.65 PA; SP; QL (4 ML per 28 days)




ELIDEL EXTERNAL CREAM $3.65 PA










EPIFOAM EXTERNAL FOAM $3.65

ERIVEDGE ORAL CAPSULE $3.65 PA; SP

erythromycin external gel $3.65


248

Drug Status Noteserythromycin external solution $3.65

EUCRISA EXTERNAL OINTMENT $3.65 PA

EURAX EXTERNAL CREAM $3.65

EURAX EXTERNAL LOTION $3.65



FABIOR EXTERNAL FOAM $3.65 PA

FINACEA EXTERNAL FOAM $3.65 QL (50 GM per 1 Rx)

FINACEA EXTERNAL GEL $3.65 QL (50 GM per 1 Rx)


fluocinolone acetonide body external oil $3.65

fluocinolone acetonide external cream $3.65

fluocinolone acetonide external ointment $3.65

fluocinolone acetonide external solution $3.65


fluocinolone acetonide scalp external oil $3.65

fluocinonide external cream 0.05 % $3.65 QL (60 GM per 30 days)

fluocinonide external cream 0.1 % $3.65 PA; QL (120 GM per 30 days)

fluocinonide external gel $3.65 QL (60 GM per 30 days)

fluocinonide external ointment $3.65 QL (60 GM per 30 days)

fluocinonide external solution $3.65 QL (60 ML per 30 days)

FLUOROPLEX EXTERNAL CREAM $3.65

fluorouracil external cream $3.65

fluorouracil external solution $3.65



fluticasone propionate external cream $3.65

fluticasone propionate external lotion $3.65

fluticasone propionate external ointment $3.65


MB/RX PA; SP

gentamicin sulfate external cream $3.65

gentamicin sulfate external ointment $3.65



249

Drug Status Notesgriseofulvin microsize oral suspension $3.65

griseofulvin microsize oral tablet $3.65

griseofulvin ultramicrosize oral tablet $3.65

halobetasol propionate external cream $3.65 PA

halobetasol propionate external ointment $3.65 PA

HALOG EXTERNAL CREAM $3.65 PA

HALOG EXTERNAL OINTMENT $3.65 PA








$3.65

hydrocortisone butyrate external cream $3.65 PA


hydrocortisone butyrate external ointment $3.65 PA

hydrocortisone butyrate external solution $3.65 PA

hydrocortisone external cream 1 %, 2.5 % $3.65

hydrocortisone external lotion $3.65

hydrocortisone external ointment 1 %, 2.5 % $3.65


hydrocortisone valerate external cream $3.65

hydrocortisone valerate external ointment $3.65


hydroxyurea oral capsule $3.65


IMLYGIC INTRALESIONAL SUSPENSION Medical Benefit

IMPAVIDO ORAL CAPSULE $3.65


250

Drug Status NotesInflectra Intravenous Solution Reconstituted MB/RX PA




ketoconazole external cream $3.65

ketoconazole external foam $3.65









lindane external shampoo $3.65


malathion external lotion $3.65


methoxsalen rapid oral capsule $3.65

metronidazole external cream $3.65

metronidazole external gel 0.75 % $3.65

metronidazole external gel 1 % $3.65 PA

metronidazole external lotion $3.65


mometasone furoate external cream $3.65

mometasone furoate external ointment $3.65

mometasone furoate external solution $3.65



MYORISAN ORAL CAPSULE $3.65 PA



NEUAC EXTERNAL GEL $3.65 PA



251

Drug Status NotesNORITATE EXTERNAL CREAM $3.65 PA








ODOMZO ORAL CAPSULE $3.65 PA








PANDEL EXTERNAL CREAM $3.65


permethrin external cream $3.65

PICATO EXTERNAL GEL $3.65 PA; QL (1 Box per 1 Rx)



PRAMOSONE E EXTERNAL CREAM $3.65

PRAMOSONE EXTERNAL CREAM 1-1 % $3.65

PRAMOSONE EXTERNAL LOTION $3.65

PRAMOSONE EXTERNAL OINTMENT $3.65

prednicarbate external cream $3.65

PROCTO-PAK RECTAL CREAM $3.65



psorcon external cream $3.65 PA



252

Drug Status NotesRemicade Intravenous Solution Reconstituted MB/RX PA; SP


RETIN-A MICRO PUMP EXTERNAL GEL0.08 % $3.65 PA

ROSADAN EXTERNAL CREAM $3.65

ROSADAN EXTERNAL GEL $3.65


SANTYL EXTERNAL OINTMENT $3.65 QL (30 GM per 1 Rx)


selenium sulfide external shampoo 2.25 % $3.65

selenium sulf-pyrithione-urea external shampoo $3.65


SILIQ SUBCUTANEOUS SOLUTION PREFILLED SYRINGE $3.65 PA; SP; QL (3 ML per 28 days)


SOLARAZE TRANSDERMAL GEL $3.65¥ (Max of 90 days per year); QL (200 GM per 30 days)

SOOLANTRA EXTERNAL CREAM $3.65 PA

spinosad external suspension $3.65 STPA; QL (120 ML per 1 Fill)





sulfacetamide sodium (acne) external lotion $3.65

sulfacetamide sodium external suspension $3.65

SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 MCG, 600 MCG $3.65 SP

SYNALAR (CREAM) EXTERNAL KIT $3.65 PA

SYNALAR (OINTMENT) EXTERNAL KIT $3.65 PA

TACLONEX EXTERNAL SUSPENSION $3.65 PA





253

Drug Status Notes



TARGRETIN EXTERNAL GEL $3.65

tazarotene external cream $3.65 PA; STPA

TAZORAC EXTERNAL CREAM 0.05 % $3.65 STPA

TAZORAC EXTERNAL GEL $3.65 STPA

TILIA FE ORAL TABLET $0

TREMFYA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE $3.65 PA; SP; QL (1 ML per 54 days)

tretinoin external cream $3.65 PA

tretinoin external gel $3.65 PA

tretinoin microsphere external gel $3.65 PA

tretinoin microsphere pump external gel $3.65 PA



triamcinolone acetonide external cream $3.65

triamcinolone acetonide external lotion $3.65

triamcinolone acetonide external ointment $3.65

TRIDERM EXTERNAL CREAM 0.1 % $3.65

TRI-LEGEST FE ORAL TABLET $0

ULESFIA EXTERNAL LOTION $3.65 PA; QL (12 Bottles per 1 Rx)








XOLEGEL EXTERNAL GEL $3.65

ZENATANE ORAL CAPSULE $3.65 PA

ZOLINZA ORAL CAPSULE $3.65 PA; SP

ZYCLARA EXTERNAL CREAM $3.65 PA; QL (28 EA per 14 days)

ZYCLARA PUMP EXTERNAL CREAM $3.65 PA; QL (2 Pumps per 1 day)


254

Drug Status NotesSLOW DRUG ELIMINATION BY KIDNEY


TUMOR

ABSTRAL SUBLINGUAL TABLET SUBLINGUAL $3.65 PA



AKYNZEO ORAL CAPSULE $3.65 QL (1 EA per 1 Fill)

alfuzosin hcl er oral tablet extended release 24 hour

$3.65










Arzerra Intravenous Concentrate MB/RX SP



CARDURA XL ORAL TABLET EXTENDED RELEASE 24 HOUR $1

CESAMET ORAL CAPSULE $3.65 PA

Cinvanti Intravenous Emulsion MB/RX QL (18 ML per 1 Fill)

DARZALEX INTRAVENOUS SOLUTION Medical Benefit

DEMSER ORAL CAPSULE $1



255

Drug Status Notesdoxazosin mesylate oral tablet $1




Eligard Subcutaneous Kit MB/RX PA; SP

EMCYT ORAL CAPSULE $3.65




EMEND ORAL SUSPENSION RECONSTITUTED $3.65 QL (3 Units per 7 days)


$3.65 SP

ERIVEDGE ORAL CAPSULE $3.65 PA; SP

exemestane oral tablet $3.65

FARYDAK ORAL CAPSULE $3.65 PA; SP

fentanyl citrate buccal lozenge on a handle $3.65 PA; QL (120 EA per 30 days)

FENTORA BUCCAL TABLET 100 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG $3.65 PA; QL (4 EA per 1 day)

finasteride oral tablet 5 mg $3.65

fluorouracil external cream 5 % $3.65

fluorouracil external solution 5 % $3.65


granisetron hcl oral tablet $3.65 QL (14 EA per 1 Fill)



MB/RX

hydroxyurea oral capsule $3.65




IMLYGIC INTRALESIONAL SUSPENSION Medical Benefit



256

Drug Status NotesIntron A Injection Solution Reconstituted MB/RX SP

JAKAFI ORAL TABLET $3.65 PA; SP


letrozole oral tablet $3.65

LEUKERAN ORAL TABLET $3.65


LONSURF ORAL TABLET $3.65 PA; SP





LYNPARZA ORAL CAPSULE $3.65 PA

LYSODREN ORAL TABLET $3.65






NEUPOGEN INJECTION SOLUTION 300 MCG/ML, 480 MCG/1.6ML $3.65 PA; SP


NINLARO ORAL CAPSULE $3.65 PA; SP



ODOMZO ORAL CAPSULE $3.65 PA

Oncaspar Injection Solution MB/RX SP


$3.65

ondansetron hcl oral solution $3.65 QL (105 ML per 1 Fill)

ondansetron hcl oral tablet $3.65 QL (21 EA per 1 Fill)

ondansetron oral tablet dispersible $3.65 QL (21 EA per 1 Fill)

Pamidronate Disodium Intravenous Solution MB/RX


257

Drug Status NotesPamidronate Disodium Intravenous Solution Reconstituted

MB/RX








RAPAFLO ORAL CAPSULE $3.65 PA


SANCUSO TRANSDERMAL PATCH $3.65 PA; QL (4 EA per 28 days)


SOLTAMOX ORAL SOLUTION $3.65


SUSTOL SUBCUTANEOUS PREFILLED SYRINGE Medical Benefit

SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 MCG, 600 MCG $3.65 SP


Synribo Subcutaneous Solution Reconstituted MB/RX SP

TABLOID ORAL TABLET $3.65

tamoxifen citrate oral tablet $3.65

tamsulosin hcl oral capsule $3.65

TARGRETIN EXTERNAL GEL $3.65


THALOMID ORAL CAPSULE $3.65 SP


Torisel Intravenous Solution MB/RX SP

TRELSTAR MIXJECT INTRAMUSCULAR SUSPENSION RECONSTITUTED Medical Benefit SP


Vantas Subcutaneous Kit MB/RX SP

Varubi Intravenous Emulsion MB/RX


258

Drug Status Notes

VARUBI ORAL TABLET $3.65¥ (Max of 6 tablets per 30 days); QL (2 Tablets per 1 Fill)

VENCLEXTA ORAL TABLET $3.65 PA

VENCLEXTA STARTING PACK ORAL TABLET THERAPY PACK $3.65 PA


XERMELO ORAL TABLET $3.65 PA

Xgeva Subcutaneous Solution MB/RX PA; SP; QL (1 vial per 30 days)







MB/RX

ZOLINZA ORAL CAPSULE $3.65 PA; SP


259


260

Indexabacavir sulfate .......... 17, 121, 198abacavir sulfate-lamivudine.....................................17, 121, 198abacavir-lamivudine-zidovudine.....................................17, 121, 198Abilify Maintena.......................170ABSORICA ............................. 244ABSTRAL ....................... 223, 255acamprosate calcium ........ 170, 198acarbose ..............................26, 109ACCU-CHEK SAFE-T PRO LANCETS ............................... 193ACCU-CHEK SOFT TOUCH LANCETS ............................... 193ACCU-CHEK SOFTCLIX LANCETS ............................... 193acebutolol hcl ..............................35acetaminophen-codeine .... 198, 223acetaminophen-codeine #2 ....... 223acetaminophen-codeine #3 ....... 223acetaminophen-codeine #4 ....... 223ACETASOL HC ..................... 117acetazolamide ....... 26, 94, 117, 150acetazolamide er .......................198acetic acid .................................117acetylcysteine .............. 94, 150, 222ACIPHEX SPRINKLE...................................100, 131, 198acitretin .............................198, 244acne medication 5 ..................... 244Actemra.................15, 17, 131, 156ACTEMRA ..15, 17, 131, 156, 198ACTIMMUNE .............. 3, 18, 156ACTOPLUS MET XR ......26, 109acyclovir ....................121, 198, 244ACZONE ................................. 244adapalene ..................................245ADCIRCA ................9, 35, 94, 150ADDERALL XR . 50, 68, 157, 170adefovir dipivoxil...........................100, 121, 131, 198ADEMPAS ...3, 9, 35, 94, 150, 198ADMELOG ............................. 198ADMELOG SOLOSTAR ...... 198ADRENACLICK .................... 240

ADRENALIN.....35, 117, 121, 198, 236, 240, 242ADVAIR DISKUS.................9, 94, 131, 132, 150, 151ADVAIR HFA .......9, 94, 132, 151Advate...........................................3Adynovate.....................................3ADZENYS XR-ODT...............................50, 68, 157, 170AEROSPAN .. 9, 94, 132, 151, 198AFEDITAB CR .................35, 224AFINITOR .......... 46, 86, 100, 255AFINITOR DISPERZ 50, 68, 255Afstyla...........................................3AKYNZEO ...................... 100, 255ala-cort ............................. 132, 245ALBENZA ............................... 198albuterol sulfate .............. 9, 94, 151albuterol sulfate er ..........9, 94, 151alclometasone dipropionate...........................................132, 245ALDACTAZIDE .................26, 35Aldurazyme.........................26, 109ALECENSA .............................198alendronate sodium...............................26, 86, 109, 157Alferon N.................. 121, 132, 245alfuzosin hcl er ....................46, 255ALINIA ............................100, 121Aliqopa..................................... 198allopurinol .................... 26, 46, 255almotriptan malate.........................35, 50, 68, 198, 224ALOCRIL ........117, 132, 149, 240alogliptin benzoate ......26, 109, 199alogliptin-metformin hcl.....................................26, 109, 199alogliptin-pioglitazone 26, 109, 199ALOMIDE ...............................199alosetron hcl ..................... 100, 199Aloxi................. 100, 236, 242, 255ALPHAGAN P ........................ 117

Alphanate/VWF Complex/Human...................3, 18, 35, 132, 236, 242AlphaNine SD...............................3alprazolam ................................ 170alprazolam er ............................170ALPRAZOLAM INTENSOL 170alprazolam xr ............................170Alprolix.........................................3ALREX ............ 117, 132, 149, 240ALTABAX ...............121, 132, 245ALTAVERA ..............................86ALTOPREV .............................. 26ALUNBRIG .............................199ALVESCO ............. 9, 94, 132, 151alyacen 1/35 ................................86alyacen 7/7/7 ...............................86amantadine hcl ..............50, 68, 121amcinonide ........................132, 245AMETHIA .................................86AMETHIA LO .......................... 86AMETHYST ............................. 86AMICAR ....................35, 236, 242amiloride hcl .........................26, 35amiloride-hydrochlorothiazide ... 35amiodarone hcl ................... 36, 199AMITIZA ........................ 100, 223amitriptyline hcl ........................199amlodipine besy-benazepril hcl .. 36amlodipine besylate ............ 36, 224amlodipine besylate-valsartan.............................................36, 199amlodipine-atorvastatin...................................26, 36, 50, 68amlodipine-valsartan-hctz .. 36, 199ammonium lactate .....................245amoxapine .................................171amoxicill-clarithro-lansopraz...........................100, 121, 132, 199amoxicillin ................................ 199amoxicillin-pot clavulanate ...... 199amoxicillin-pot clavulanate er ..199


261

amphetamine-dextroamphetamine.......................51, 69, 157, 171, 199ampicillin .................................. 199AMPYRA .....................51, 69, 157ANADROL-50 .......................3, 18anagrelide hcl ................. 3, 36, 255ANALPRAM-HC ............132, 245anastrozole ................................199ANDRODERM ..................86, 109ANDROGEL ..................... 86, 109ANDROGEL PUMP .........86, 109ANORO ELLIPTA.........................9, 94, 132, 151, 199ANTARA ........................... 26, 199anucort-hc ...................36, 100, 132ANUSOL-HC ............ 36, 100, 132ANZEMET .............. 100, 101, 255APEXICON E ................. 132, 245APIDRA ...................................199APIDRA SOLOSTAR ............ 200APRI ...........................................86APRISO ........................... 101, 132APTENSIO XR ... 51, 69, 157, 171APTIOM ......................51, 69, 200APTIVUS ...........................18, 121Aralast NP.................9, 26, 94, 151ARANELLE .............................. 87ARANESP (ALBUMIN FREE) ............................ 3, 46, 255ARCALYST ........ 18, 26, 117, 132ARCAPTA NEOHALER.................................9, 94, 132, 151aripiprazole .......................171, 200Aristada.....................................171armodafinil ............. 51, 69, 94, 151ARMOUR THYROID ............200Arzerra.................................. 3, 255ASCOMP-CODEINE ..... 171, 224ASHLYNA .................................87ASMANEX 120 METERED DOSES ................... 9, 94, 132, 151ASMANEX 14 METERED DOSES ................... 9, 94, 133, 151ASMANEX 30 METERED DOSES ................. 10, 95, 133, 151

ASMANEX 60 METERED DOSES ................. 10, 95, 133, 151ASMANEX 7 METERED DOSES ................. 10, 95, 133, 151ASMANEX HFA .10, 95, 133, 151aspirin-dipyridamole er.....................3, 36, 51, 69, 200, 236ASTAGRAF XL.......................18, 46, 200, 236, 242atazanavir sulfate ........18, 121, 200atenolol ............................... 36, 224atenolol-chlorthalidone .............. 36atomoxetine hcl.......................51, 69, 157, 171, 200atorvastatin calcium ................... 26atovaquone ................................200atovaquone-proguanil hcl .........121ATRIPLA .......................... 18, 121atropine sulfate ..... 51, 69, 117, 157ATROVENT HFA ...... 10, 95, 152AUBAGIO ........................... 51, 69AUBRA .............................. 87, 200AUGMENTIN ......................... 200AURYXIA.......3, 7, 26, 46, 109, 157, 191, 200AUSTEDO ........... 51, 69, 157, 171AVANDIA ..........................26, 109AVAR CLEANSER ................ 200Avastin..........46, 95, 101, 152, 255AVC VAGINAL ..........46, 87, 121AVIANE .....................................87avidoxy ......................................200AVITA ..................................... 245AVONEX ............................. 51, 69AVONEX PEN .................... 51, 69AVONEX PREFILLED ..... 51, 69AzaCITIDine............................ 200AZASITE .........117, 121, 133, 149azathioprine.........15, 18, 46, 133, 157, 236, 242azelastine hcl.10, 13, 95, 117, 121, 133, 149, 240AZELEX ..................................245azithromycin ............................. 200AZOPT .....................................117AZOR .........................................36AZURETTE .............................. 87

bacitracin ..........................117, 121bacitracin-polymyxin b ..... 117, 121bacitra-neomycin-polymyxin-hc201baclofen .........................51, 69, 157BACTROBAN NASAL .......... 121balsalazide disodium ........ 101, 133BALZIVA .................................. 87BANZEL ..................................201BARACLUDE ......... 101, 121, 133BASAGLAR KWIKPEN ....... 201Bavencio................................... 201BAXDELA ...............................201BD INSULIN SYRINGE ........193BD INSULIN SYRINGE MICROFINE ...........................193BD INSULIN SYRINGE ULTRAFINE ...........................193BD LANCET ULTRAFINE 33G ........................................... 193BD SAFETY-LOK INSULIN SYRINGE ................................ 193BD SYRINGE SLIP TIP ........ 193Bebulin..........................................3BECONASE AQ.........10, 13, 95, 121, 133, 149, 240BEKYREE .................................87BELBUCA ............................... 224Beleodaq................................... 201BELSOMRA ....................... 51, 69benazepril hcl ..............................36benazepril-hydrochlorothiazide ..36BENDEKA ...............................201BeneFIX........................................3BENICAR ..................................36BENICAR HCT ........................ 36Benlysta................ 15, 18, 133, 245BENLYSTA .........15, 18, 133, 245benzonatate ... 13, 95, 121, 133, 152benzoyl peroxide ....................... 245benzoyl peroxide wash ..............245benzoyl peroxide-erythromycin .245benztropine mesylate .............52, 70BEPREVE ....... 117, 133, 149, 240Berinert................. 18, 26, 240, 245BESIVANCE ........................... 201Besponsa................................... 201


262

betamethasone dipropionate...........................................133, 245betamethasone dipropionate aug .................................... 133, 245betamethasone valerate...................................133, 134, 246BETASERON ......................52, 70betaxolol hcl ........................36, 118bethanechol chloride ...................46BETIMOL ............................... 118BETOPTIC-S .......................... 118bexarotene .................201, 246, 255BEYAZ .......................87, 171, 246bicalutamide ............................. 201BIDIL ......................................... 36BIKTARVY .......................18, 121BILTRICIDE .................. 101, 122bimatoprost ....................... 118, 201bisoprolol fumarate .................... 36bisoprolol-hydrochlorothiazide .. 36BLEPHAMIDE ............... 118, 134BLEPHAMIDE S.O.P. ... 118, 134BLISOVI 24 FE .........................87BLISOVI FE 1.5/30 .................. 87BLISOVI FE 1/20 ..................... 87BONJESTA ..................... 101, 235BOSULIF .................................201Botox...............36, 52, 70, 224, 246bp foaming wash ....................... 246bp folinatal plus b ..................... 235bp multinatal plus ..................... 201bp wash ..................................... 246BREO ELLIPTA 10, 95, 134, 152briellyn ........................................87BRILINTA .....3, 36, 224, 236, 242brimonidine tartrate ..................118Brineura.............................. 26, 157BRIVIACT .......................... 52, 70bromfenac sodium (once-daily)...........118, 134, 201, 224, 236, 242bromocriptine mesylate .52, 70, 109budesonide10, 13, 95, 101, 122, 134, 152, 201, 240bumetanide ............................26, 36BUNAVAIL ............................. 172buprenorphine ...................201, 224

buprenorphine hcl .....................172buprenorphine hcl-naloxone hcl...................................................172bupropion hcl ............................172bupropion hcl er (smoking det)...........................................172, 234bupropion hcl er (sr) .................172bupropion hcl er (xl) .................172buspirone hcl ............................ 172butalbital-acetaminophen . 172, 224butalbital-apap-caffeine ... 172, 224butalbital-asa-caff-codeine...........................................172, 224butalbital-aspirin-caffeine...................................173, 201, 224butorphanol tartrate ................. 224BYSTOLIC ................................36cabergoline ............................... 109CABOMETYX ........................201CAFERGOT ..........36, 52, 70, 224caffeine citrate.................52, 70, 95, 152, 191, 235calcipotriene ............................. 246calcipotriene-betameth diprop...........................................201, 246calcitonin (salmon) ..... 87, 109, 157CALCITRENE ........................246calcitriol ..............................26, 246calcium acetate (phos binder)...........7, 26, 46, 109, 157, 158, 191CALQUENCE .........................201CAMILA ....................................87CAMRESE ................................ 87CAMRESE LO ..........................87CANASA ..........................101, 134candesartan cilexetil ...................36capecitabine ..............................201CAPEX .............................134, 246CAPRELSA .............................202captopril ..................26, 36, 46, 109captopril-hydrochlorothiazide ....36CARAFATE .................... 101, 134CARBAGLU ............................. 26carbamazepine ......52, 70, 158, 173carbamazepine er ..52, 70, 173, 202carbidopa ......................52, 70, 202carbidopa-levodopa ..............53, 71

carbidopa-levodopa er ..........53, 71carbidopa-levodopa-entacapone...............................................53, 71CARDIZEM LA ................36, 224CARDURA XL ..................47, 255Carimune NF............ 3, 18, 36, 134carisoprodol ..............................158carisoprodol-aspirin ................. 158carteolol hcl .............................. 118CARTIA XT ...................... 37, 224carvedilol .................................... 37carvedilol phosphate er ...... 37, 202CAVAREST ............................ 202CAYSTON .............10, 27, 95, 152CAZIANT ..................................87cefaclor ..................................... 202cefaclor er .................................202cefadroxil .................................. 202cefdinir ......................................202cefditoren pivoxil ...................... 202cefixime ..................................... 202cefpodoxime proxetil .................202cefprozil .................................... 202CEFTIN ................................... 202CefTRIAXone Sodium............. 202cefuroxime axetil .......................202celecoxib ....... 15, 18, 134, 158, 202CELONTIN ......................... 53, 71CENTANY ...............122, 134, 246cephalexin ................................. 202CERDELGA ..............................27Cerezyme.................................... 27CEROVEL ...............................202CESAMET .......................101, 255cetirizine hcl.........13, 27, 95, 122, 134, 240, 246cevimeline hcl15, 18, 101, 118, 134CHANTIX ....................... 173, 234CHANTIX CONTINUING MONTH PAK ................. 173, 234CHANTIX STARTING MONTH PAK ................. 173, 234CHATEAL .................................87CHEMET .................................223chlordiazepoxide hcl .....53, 71, 173


263

chlordiazepoxide-clidinium...........................................101, 134chlorhexidine gluconate...................................101, 122, 149chloroquine phosphate ..............122chlorothiazide ............................. 27chlorpromazine hcl ..... 95, 152, 173chlorpropamide ...................27, 109chlorthalidone .............................27chlorzoxazone ........................... 158CHOLBAM ....................... 27, 101cholestyramine ............................27cholestyramine light ....................27choline-mag trisalicylate .. 134, 158CIALIS .......................................87CICLODAN .............122, 134, 246ciclopirox .................. 122, 134, 246ciclopirox olamine .... 122, 134, 246cilostazol ..................... 37, 158, 224CILOXAN ............................... 203CIMDUO ........................... 18, 122cimetidine ..................101, 134, 224cimetidine hcl ....................101, 134CIMZIA...............15, 18, 101, 135, 158, 246CIMZIA PREFILLED...............15, 18, 101, 135, 158, 246CIMZIA STARTER KIT...............15, 18, 101, 135, 158, 246Cinryze........................................27Cinvanti.............................101, 255CIPRO HC .............................. 117CIPRODEX ..................... 117, 122ciprofloxacin ............................. 203ciprofloxacin hcl ....................... 203ciprofloxacin-ciproflox hcl er ... 203citalopram hydrobromide ......... 173CLARAVIS ............................. 246CLARINEX . 13, 95, 122, 135, 240CLARINEX-D 12 HOUR.................10, 13, 95, 122, 135, 240clarithromycin ...........................203clarithromycin er ...................... 203CLEANLET LANCETS 28G 193clemastine fumarate...............13, 95, 122, 135, 240, 246CLEOCIN ....................47, 87, 122

CLIMARA PRO ....... 87, 110, 158clindamycin hcl .........................203clindamycin palmitate hcl .........203clindamycin phos-benzoyl perox...................................................247clindamycin phosphate...............................47, 87, 122, 247CLINPRO 5000 .......................101clobetasol propionate135, 203, 247clobetasol propionate e .....135, 247clocortolone pivalate 135, 203, 247clocortolone pivalate pump...................................135, 203, 247CLODAN ................................. 247clomipramine hcl ...................... 173clonazepam ........... 53, 71, 158, 174clonidine hcl ................................37clonidine hcl er.......................53, 71, 158, 174, 203clopidogrel bisulfate ........... 37, 224clorazepate dipotassium53, 71, 174CLORPRES ...............................37clotrimazole 95, 122, 135, 149, 247clotrimazole anti-fungal...........................122, 135, 193, 247clotrimazole-betamethasone...................................122, 135, 247clozapine ........................... 174, 203Coagadex...................................... 3COARTEM ............................. 122codeine sulfate .......................... 224colchicine ....................27, 135, 158colchicine-probenecid .27, 135, 158colestipol hcl ...............................27COLOCORT ................... 101, 135COMBIGAN ........................... 118COMBIPATCH ................ 87, 110COMBIVENT RESPIMAT.......................................10, 95, 152COMETRIQ (100 MG DAILY DOSE) ........................ 203COMETRIQ (140 MG DAILY DOSE) ........................ 203COMETRIQ (60 MG DAILY DOSE) ...................................... 203comfort lancets ..........................193COMPLERA ..................... 18, 122

COMPRO ................................ 101CONCERTA ....... 53, 71, 159, 174CONDYLOX ........... 122, 135, 247constulose ............... 27, 53, 71, 101COPASIL .................................193CORDRAN ......................135, 247Corifact......................................... 3CORLANOR ............................. 37CORTIFOAM ................. 101, 135cortisone acetate .........18, 110, 135CORTISPORIN ...... 122, 135, 247COSENTYX 15, 19, 136, 159, 247COSENTYX SENSOREADY PEN .............. 15, 18, 136, 159, 247COSOPT PF ............................ 118COTELLIC ............................. 203COTEMPLA XR-ODT...............................54, 72, 159, 174CREON ....................................102CRESEMBA ............................122CRINONE ......................... 87, 110CRIXIVAN ........................19, 123cromolyn sodium.10, 19, 96, 118, 136, 149, 152, 240CRYSELLE-28 ......................... 87CUPRIMINE.................27, 54, 72, 102, 159, 223CUVPOSA ............................... 102cyanocobalamin ....................7, 191CYCLAFEM 1/35 ..................... 87CYCLAFEM 7/7/7 .................... 87cyclobenzaprine hcl .................. 159cyclopentolate hcl ............. 118, 203cyclophosphamide .....................203cycloserine ................................ 203cyclosporine ..19, 47, 102, 236, 242cyclosporine modified.......................19, 47, 102, 236, 242cyproheptadine hcl.........13, 14, 96, 123, 136, 240, 247CYRED ...................................... 87CYSTAGON ..............................27Cytogam..............19, 123, 236, 242cytra-2 .......................................204daily multi ................................. 193DAKLINZA .............102, 123, 136DALIRESP .......... 10, 96, 136, 152


264

danazol ..................................27, 87dantrolene sodium 54, 72, 120, 159dapsone ............................. 123, 247darifenacin hydrobromide er.....................................47, 159, 204DARZALEX ........................3, 255DASETTA 1/35 ......................... 87DASETTA 7/7/7 ........................ 87DAYSEE .................................... 88DAYTRANA ........54, 72, 159, 174DEBLITANE .............................88Decitabine................................. 204DELTASONE ..........................204DELYLA ....................................88DELZICOL ..................... 102, 136DEMSER ........................... 37, 255DENAVIR ................102, 123, 248DENTA 5000 PLUS ................ 102DENTAGEL ............................102DEPEN TITRATABS.................27, 54, 72, 102, 159, 223DEPO-PROVERA ...... 47, 88, 255DEPO-TESTOSTERONE88, 110DEPRIZINE FUSEPAQ ........ 204DESCOVY .........................19, 123desipramine hcl .........................175desloratadine 14, 96, 123, 136, 240desmopressin ace rhinal tube.............................................27, 110desmopressin ace spray refrig.............................................27, 110desmopressin acetate .... 27, 47, 110desmopressin acetate spray 27, 110desogestrel-ethinyl estradiol.............................................88, 204desonide ............................ 136, 248desoximetasone ................. 136, 248desvenlafaxine er ...................... 175desvenlafaxine succinate er...........................................175, 204dexamethasone ..........................110DEXAMETHASONE INTENSOL ..............................110dexamethasone sodium phosphate ..117, 118, 136, 236, 242DEXILANT ............................. 102

dexmethylphenidate hcl...............................54, 72, 159, 175DEXPAK 10 DAY ...................110DEXPAK 13 DAY ...................110DEXPAK 6 DAY .....................110dextroamphetamine sulfate...............................54, 72, 160, 175dextroamphetamine sulfate er...............................54, 72, 159, 175diazepam...54, 55, 72, 73, 160, 175, 176, 204DIAZEPAM INTENSOL...............................54, 72, 160, 175DICLEGIS .......................102, 235diclofenac potassium 136, 160, 224diclofenac sodium118, 136, 160, 204, 224, 236, 242, 248diclofenac sodium er...............................15, 19, 136, 160dicloxacillin sodium ..................204DICOPANOL FUSEPAQ ...... 204dicyclomine hcl ................. 102, 204didanosine ...........................19, 123DIFFERIN ............................... 248DIFICID ...................102, 123, 136diflorasone diacetate ........ 136, 248diflunisal ................................... 224DIGITEK ...................................37DIGOX .......................................37digoxin ........................................ 37dihydroergotamine mesylate.................................37, 55, 73, 224DILANTIN .......................... 55, 73DILATRATE-SR .............. 37, 225diltiazem cd .........................37, 225diltiazem hcl ........................37, 225diltiazem hcl er ................... 37, 225diltiazem hcl er beads ......... 37, 225diltiazem hcl er coated beads.....................................37, 204, 225dilt-xr .................................. 38, 225dimenhydrinate ......................... 102DIPENTUM .....................102, 136diphenhydramine hcl...............................55, 73, 193, 240diphenoxylate-atropine ............. 102

dipyridamole ................................. 4disopyramide phosphate ............. 38disulfiram ..................................176DIURIL ......................................27divalproex sodium.........................38, 55, 73, 176, 225divalproex sodium er.........................38, 55, 73, 176, 225DIVIGEL ............. 47, 88, 110, 149dofetilide ..................... 38, 204, 236donepezil hcl ................. 55, 73, 176DONNATAL ........................... 204dorzolamide hcl ........................ 118dorzolamide hcl-timolol mal .....118doxazosin mesylate ....... 38, 47, 256doxepin hcl ........................176, 204doxercalciferol ....47, 110, 204, 236doxycycline hyclate ... 149, 204, 205doxycycline monohydrate ......... 205DRITHO-CREME HP ........... 205dronabinol .....19, 27, 102, 123, 256drospirenone-ethinyl estradiol.............................88, 176, 205, 248DROXIA ...................................... 4DRYSOL ..................................248DUAVEE ........... 88, 110, 160, 205DULERA ............. 10, 96, 136, 152duloxetine hcl...........160, 161, 176, 177, 205, 225DUPIXENT ..................... 137, 248DUREZOL...................118, 137, 225, 236, 242dutasteride .................. 47, 205, 256dutasteride-tamsulosin hcl.....................................47, 205, 256DUZALLO .................27, 137, 161DYANAVEL XR .55, 73, 161, 177DYRENIUM ..............................27Dysport................. 55, 73, 161, 248E.E.S. 400 .................................205EASYGEL ............................... 205econazole nitrate .......123, 137, 248ECOZA ............ 123, 137, 205, 248EDARBI .....................................38EDLUAR ............................. 55, 73EDURANT .........................19, 123efavirenz ......................19, 123, 205


265

EGRIFTA ...... 15, 19, 27, 123, 137Elaprase.......................28, 102, 110ELESTRIN .......... 47, 88, 110, 149eletriptan hydrobromide.........................38, 55, 73, 205, 225ELIDEL ........................... 137, 248Eligard.................................47, 256ELINEST ................................... 88ELIQUIS ..........4, 38, 96, 152, 236ELITE-OB ............................... 235ELIXOPHYLLIN10, 96, 137, 152ELLA ......................................... 88ELMIRON .................................47Eloctate......................................... 4EMADINE ....... 118, 137, 149, 240EMBEDA .................................226EMCYT ............................. 47, 256Emend....................... 102, 205, 256EMEND ........... 102, 236, 242, 256EMFLAZA...................55, 56, 73, 74, 137, 161EMOQUETTE .......................... 88EMPLICITI .............................205EMSAM ................................... 177EMTRIVA ......................... 19, 123enalapril maleate ........................ 38enalapril-hydrochlorothiazide ....38ENBREL ......15, 19, 137, 161, 248ENBREL MINI.......................15, 19, 137, 161, 248ENBREL SURECLICK.......................16, 19, 137, 161, 248ENDARI .......................................4ENDOCET ...............................226enoxaparin sodium ..4, 38, 226, 236ENPRESSE-28 .......................... 88ENSKYCE ................................. 88entacapone ............................56, 74entecavir ............102, 123, 137, 205ENTRESTO ...............................38Entyvio..............................102, 137enulose .................... 28, 56, 74, 103EPCLUSA ................103, 123, 137EPIFOAM ....................... 137, 248epinastine hcl .... 118, 137, 149, 240epinephrine ............................... 241EPIPEN 2-PAK .......................241

EPIPEN JR 2-PAK ................. 241Epirubicin HCl..........................205EPITOL ....................... 56, 74, 161eplerenone ...........................38, 226EPOGEN ....................... 4, 47, 256Epoprostenol Sodium.................................10, 38, 96, 152eprosartan mesylate ....................38eq nicotine .................177, 193, 234eq nicotine polacrilex177, 193, 234eq nicotine step 3 ...... 177, 193, 234eql nicotine polacrilex ...... 177, 234Erbitux...................................... 205ergocalciferol ........................7, 191ergoloid mesylates ........ 56, 74, 177ERGOMAR ........... 38, 56, 74, 226ERIVEDGE ..................... 248, 256ERLEADA ...............................205ERRIN ....................................... 88ERYPED 400 ...........................206ERY-TAB ................................ 206ERYTHROCIN STEARATE 206erythromycin ..... 118, 123, 248, 249erythromycin base .....................206erythromycin ethylsuccinate ..... 206ESBRIET ..................... 10, 96, 152ESCAVITE ..................7, 103, 191ESCAVITE D .............. 7, 103, 191escitalopram oxalate .................177est estrogens-methyltest ............ 206est estrogens-methyltest hs ........206ESTARYLLA ..........................206estazolam .............................. 56, 74estradiol ........ 47, 88, 110, 149, 206estradiol-norethindrone acet .... 206ESTRING ............ 47, 88, 110, 149ESTROGEL ........ 47, 88, 110, 150estropipate .......................... 88, 110eszopiclone ............................56, 74Ethacrynate Sodium.........................28, 38, 96, 152, 206ethacrynic acid28, 38, 96, 152, 206ethambutol hcl .......................... 206ethosuximide ......................... 56, 74etidronate disodium ............ 28, 161etodolac .....................137, 161, 226etodolac er ............ 16, 19, 137, 161

etoposide ................................... 206EUCRISA ........................ 137, 249EUFLEXXA .................... 137, 161EURAX ............................ 123, 249EVAMIST ..................................88EVOTAZ ........................... 19, 123EVZIO ..................................... 223EXELDERM ........... 123, 137, 249exemestane ..........................88, 256EXJADE ...................... 4, 223, 236Exondys 51........... 56, 74, 138, 161EXTAVIA ............................56, 74ezetimibe-simvastatin ..........28, 206EZ-LETS LANCETS 26G ..... 194FABIOR ...........................206, 249FALMINA ................................. 88famciclovir ................................ 206famotidine ......................... 103, 226FANAPT .................................. 177FANAPT TITRATION PACK ....................................... 178FARESTON .............................206FARXIGA ..................28, 110, 206FARYDAK .......................... 4, 256Fasenra..................10, 96, 138, 152FAYOSIM ................................. 88Feiba....................................... 4, 38felbamate ...................................206felodipine er ................................ 38FEMRING ........... 47, 88, 111, 150fenofibrate ...........................28, 207fenofibrate micronized ................ 28fenofibric acid .....................28, 207fenoprofen calcium ................... 226fentanyl ..................................... 226fentanyl citrate .................. 226, 256FENTORA .......................226, 256FERRIPROX ...................223, 236ferrous sulfate ........................... 194FETZIMA ........................178, 207FETZIMA TITRATION 178, 207FIASP .......................................207FIASP FLEXTOUCH ............ 207FIBRICOR ................................ 28FINACEA ........................ 138, 249finasteride ........................... 47, 256FINGERSTIX LANCETS ......194


266

FIRAZYR ............ 19, 28, 241, 249Firmagon...................................207FIRST-HYDROCORTISONE...................................................207FIRST-LANSOPRAZOLE .... 207FIRST-MOUTHWASH BLM207FIRST-OMEPRAZOLE ........ 207FIRST-PROGESTERONE VGS 100 ................................... 207FIRST-PROGESTERONE VGS 200 ................................... 207FIRST-VANCOMYCIN 25 ....207FIRST-VANCOMYCIN 50 ....207FIRVANQ ................................207FLAREX ..........................118, 138flavoxate hcl ........................47, 226Flebogamma DIF........................ 19flecainide acetate ........................ 39FLECTOR ....................... 156, 161flolipid .........................................28FLOVENT DISKUS...............................10, 96, 138, 152FLOVENT HFA ..10, 96, 138, 152fluconazole ................................207flucytosine ................................. 207fludrocortisone acetate ............. 111flunisolide ..... 14, 96, 123, 138, 241fluocinolone acetonide...................................117, 138, 249fluocinolone acetonide body...........................................138, 249fluocinolone acetonide scalp...........................................138, 249fluocinonide .............. 138, 208, 249FLUORABON .........................103FLUORIDEX SENSITIVITY RELIEF ................................... 103fluorometholone ................118, 138FLUOROPLEX .......................249fluorouracil ....................... 249, 256fluoxetine hcl .............................178fluoxetine hcl (pmdd) ........ 178, 208fluphenazine decanoate .............178fluphenazine hcl ................ 178, 179FLURA-DROPS ......................103flurandrenolide ......... 138, 208, 249flurazepam hcl ...................... 56, 74

flurbiprofen ........... 16, 20, 138, 161flurbiprofen sodium .. 118, 236, 242flutamide ................................... 208fluticasone propionate.................11, 14, 96, 123, 138, 249fluticasone-salmeterol...............................11, 96, 138, 152fluvastatin sodium .......................28fluvastatin sodium er ...........28, 208fluvoxamine maleate ................. 179fluvoxamine maleate er .............179FML ................................. 118, 138FML FORTE ...................118, 138FOCALIN XR ..... 56, 74, 162, 179folbee .....................................7, 191folic acid ........................... 4, 7, 191fondaparinux sodium.................................4, 39, 237, 242FORTEO ................... 88, 111, 162FOSAMAX PLUS D . 88, 111, 162fosamprenavir calcium20, 123, 208fosinopril sodium ........................ 39fosinopril sodium-hctz ................ 39FOSRENOL...................7, 28, 47, 111, 162, 191FRAGMIN .............4, 39, 226, 237FREESTYLE INSULINX TEST ........................................ 194FREESTYLE LANCETS .......194FREESTYLE LITE TEST .....194FREESTYLE PRECISION NEO TEST .............................. 194FREESTYLE TEST ............... 194frovatriptan succinate.........................39, 56, 74, 208, 226furosemide ...............28, 39, 96, 153FUZEON ............................20, 124FYCOMPA ..........57, 75, 162, 208gabapentin ............ 57, 75, 124, 227GABITRIL .......................... 57, 75galantamine hydrobromide.......................................57, 75, 179galantamine hydrobromide er.......................................57, 75, 179GamaSTAN S/D....... 103, 124, 138

GAMMAGARD.........................20, 57, 75, 138, 162Gammagard S/D Less IgA4, 20, 39, 103, 118, 121, 139, 150, 249Gamunex-C...............4, 20, 39, 139gatifloxacin ............................... 208GATTEX ................. 103, 237, 242GAVILYTE-C .................103, 237GAVILYTE-G .................103, 237GAVILYTE-H .........................103Gazyva.................. 4, 156, 208, 256GEBAUERS PAIN EASE ...... 194GEBAUERS SPRAY AND STRETCH ............................... 208GELNIQUE .......................47, 162gemfibrozil .................................. 28generlac .................. 28, 57, 75, 103GENGRAF.................20, 47, 48, 103, 237, 242GENOTROPIN...................7, 20, 28, 111, 124, 191GENOTROPIN MINIQUICK...................7, 20, 28, 111, 124, 191GENTAK ................................. 208gentamicin sulfate .....124, 208, 249GENTLE-LET GP LANCETS ............................... 194GENTLE-LET LANCETS .... 194GENVOYA ........................20, 124Geodon......................................179GIANVI ..................... 88, 179, 249GIAZO ............................. 103, 139GILDAGIA ................................89GILDESS FE 1.5/30 ..................89GILDESS FE 1/20 .....................89GILENYA ............................57, 75GILOTRIF .............................. 208GILPHEX TR ..... 14, 96, 124, 139Glassia.....................11, 29, 96, 153glatiramer acetate .................57, 75GLATOPA ...........................57, 75GLEOSTINE ...........................208glimepiride ..........................29, 111glipizide ...............................29, 111glipizide er .......................... 29, 111glipizide xl ...........................29, 111


267

glipizide-metformin hcl .......29, 111GLUCAGEN HYPOKIT . 29, 111GLUCAGON EMERGENCY.............................................29, 111glyburide ............................. 29, 111glyburide micronized .......... 29, 111glyburide-metformin ........... 29, 111glycopyrrolate ...........................208GLYDO.......48, 96, 153, 162, 227, 237, 242gnp lancets ................................ 194gnp nicotine mini .............. 179, 234gnp nicotine polacrilex ..... 179, 234gnp ultra com insulin syringe ... 194GOCOVRI ...........................57, 75GOLYTELY ....................103, 237GORDONS UREA ..................208GRALISE ............ 58, 76, 124, 227GRALISE STARTER...............................58, 76, 124, 227granisetron hcl ..................103, 256GRANIX ................ 4, 20, 208, 256griseofulvin microsize .......124, 250griseofulvin ultramicrosize...........................................124, 250guaifenesin er14, 96, 124, 139, 153guanfacine hcl .............................39guanfacine hcl er .. 58, 76, 162, 179guanidine hcl .. 20, 58, 76, 139, 162GYNAZOLE-1 ............ 48, 89, 124HAEGARDA ............................. 29HAEMOLANCE LOW FLOW LANCETS .................. 194Halaven..................................... 208halobetasol propionate ..... 139, 250HALOG ........................... 139, 250haloperidol ................................180haloperidol decanoate .............. 179haloperidol lactate ....................180HARVONI ............... 103, 125, 139HEATHER ................................ 89Helixate FS................................... 4HEMMOREX-HC .... 39, 103, 139Hemofil M............................ 4, 208heparin (porcine) in nacl.....................................39, 237, 242heparin sodium (porcine)4, 39, 237

Herceptin...................................208HETLIOZ ............................58, 76HEXALEN ...............................208Hizentra...............................20, 208hm nicotine ................180, 194, 234hm nicotine polacrilex ...... 180, 234HOMATROPAIRE ........ 119, 139homatropine hbr ............... 119, 139HORIZANT .........................58, 76HP Acthar. 16, 20, 58, 76, 139, 162HUMALOG .............................209HUMALOG KWIKPEN ........ 208HUMALOG MIX 50/50 ......... 209HUMALOG MIX 50/50 KWIKPEN ...............................209HUMALOG MIX 75/25 ......... 209HUMALOG MIX 75/25 KWIKPEN ...............................209Humate-P.. 4, 20, 39, 139, 237, 243HUMATROPE...................7, 20, 29, 111, 125, 192HUMIRA...............16, 21, 104, 139, 162, 250HUMIRA PEDIATRIC CROHNS START...............16, 20, 103, 139, 162, 250HUMIRA PEN...............16, 20, 103, 139, 162, 250HUMIRA PEN-CROHNS STARTER...............16, 21, 104, 139, 162, 250HUMIRA PEN-PSORIASIS STARTER...............16, 21, 104, 139, 162, 250HUMULIN 70/30 .................... 194HUMULIN 70/30 KWIKPEN 194HUMULIN N ...........................194HUMULIN N KWIKPEN ......194HUMULIN R ...........................194HUMULIN R U-500 (CONCENTRATED) ........29, 111HUMULIN R U-500 KWIKPEN .........................29, 111HYCAMTIN ............................209hydralazine hcl ............................39hydrochlorothiazide ....................39

hydrocod polst-cpm polst er...............14, 96, 125, 139, 153, 241hydrocodone-acetaminophen...........................................209, 227hydrocodone-homatropine...............14, 96, 125, 139, 140, 153hydrocodone-ibuprofen .............227hydrocortisone.............21, 104, 111, 140, 209, 250hydrocortisone ace-pramoxine.............................39, 104, 140, 250hydrocortisone acetate39, 104, 140hydrocortisone butyrate...................................140, 209, 250hydrocortisone valerate .... 140, 250hydrocortisone-acetic acid ....... 117hydromet ....... 14, 97, 125, 140, 153hydromorphone hcl ...................227hydromorphone hcl er ...............227hydroxychloroquine sulfate.......................16, 21, 140, 163, 250Hydroxyprogesterone Caproate.........................39, 48, 89, 111, 256hydroxyurea ...................... 250, 256hydroxyzine hcl.......................58, 76, 180, 237, 243hydroxyzine pamoate.......................58, 76, 180, 237, 243HYOPHEN .............................. 209hyoscyamine sulfate .................. 209hyoscyamine sulfate er ..............209hyosyne ......................................209HYPERSAL .............................209Hyqvia.........................................21HY-VEE LANCETS ...............194hy-vee thin lancets .................... 194Ibandronate Sodium.............................89, 111, 163, 209ibandronate sodium .... 89, 111, 163IBRANCE ................................209IBUDONE ................................227ibuprofen ...................140, 163, 227ICLUSIG ................................. 209Idelvion......................................... 4IDHIFA ....................................209Ilaris.............. 21, 29, 117, 140, 163ILEVRO ...119, 140, 227, 237, 243


268

imatinib mesylate ...................... 209IMBRUVICA ...... 4, 156, 210, 256Imfinzi.......................................210imipramine hcl .................... 48, 180imipramine pamoate ................. 180imiquimod ......... 125, 140, 250, 256IMLYGIC ........................250, 256IMPAVIDO ..................... 125, 250INATAL ADVANCE ..............235INCRELEX ................. 58, 76, 111INCRUSE ELLIPTA...............................11, 97, 140, 153indapamide ........................... 29, 39INDOCIN ...................29, 140, 163indomethacin ...............29, 140, 163indomethacin er .......... 29, 140, 163Inflectra.16, 21, 104, 140, 163, 251INGREZZA ................. 58, 76, 163INLYTA ...................................210insulin syringe ...........................194insulin syringe/needle ............... 195INTELENCE .....................21, 125INTRAROSA.......................48, 89, 112, 150, 227Intron A...........104, 125, 140, 251, 256, 257INTROVALE ............................ 89Invega Sustenna........................ 180Invega Trinza............................ 180INVIRASE .........................21, 125INVOKAMET ...................29, 112INVOKAMET XR ............ 29, 112INVOKANA ...................... 29, 112ipratropium bromide.........11, 14, 97, 125, 140, 153, 241ipratropium-albuterol ... 11, 97, 153IPRIVASK .............5, 40, 237, 243irbesartan ....................................40irbesartan-hydrochlorothiazide ..40IRESSA ....................................210ISENTRESS ...................... 21, 125ISENTRESS HD ............... 21, 125isometheptene-dichloral-apap .. 210isoniazid ....................................125ISORDIL TITRADOSE ...40, 228isosorbide dinitrate .............40, 228isosorbide dinitrate er .........40, 228

isosorbide mononitrate ....... 40, 228isosorbide mononitrate er ...40, 228isradipine .................................... 40itraconazole .............................. 210ivermectin ..................104, 125, 210Ixempra Kit...............................210Ixinity............................................5JADENU ...................... 5, 223, 237JADENU SPRINKLE .5, 223, 237JAKAFI ............................... 5, 257JANTOVEN .......................... 5, 40JARDIANCE .....................29, 112JENCYCLA ...............................89Jevtana...................................... 210JOLESSA ...................................89JOLIVETTE ............................. 89JUBLIA ....................125, 140, 251JULEBER ..................................89JULUCA ............................ 21, 125JUNEL 1.5/30 ............................ 89JUNEL 1/20 ............................... 89JUNEL FE 1.5/30 ...................... 89JUNEL FE 1/20 ......................... 89JUNEL FE 24 ............................ 89JUXTAPID ................................ 29K.B.G.L IN TERODERM ......210Kadcyla..................................... 210KADIAN .................................. 228KAITLIB FE ............................. 89KALETRA .........................21, 125KALYDECO ......... 11, 29, 97, 153KANUMA ..................................30KARIVA .................................... 89KELNOR 1/35 ...........................89KENALOG ..16, 21, 112, 140, 163ketoconazole ......125, 141, 210, 251ketoprofen ................. 141, 163, 228ketoprofen er .........16, 21, 141, 163ketorolac tromethamine...................119, 141, 228, 237, 243ketotifen fumarate...........................119, 141, 150, 241KEVEYIS .............. 30, 58, 76, 163KEVZARA .......... 16, 21, 141, 163KIMIDESS ................................ 89KINERET ............16, 21, 141, 163kinney lancets ............................195

kinney thin lancets .................... 195kinray insulin syringe ............... 195KIONEX .................................... 30KISQALI 200 DOSE .............. 210KISQALI 400 DOSE .............. 210KISQALI 600 DOSE .............. 210KLOR-CON M15 ......................30Koate-DVI.................................... 5Kogenate FS..........................5, 210Kogenate FS Bio-Set.................... 5KORLYM ..........................30, 112Kovaltry........................................ 5kp clotrimazole ..........125, 141, 251K-PHOS ................................... 210K-PHOS NO 2 ......................... 210Krystexxa....................30, 141, 163KURVELO ................................ 89KUVAN ......................................30KYLEENA .................................89KYNAMRO ...............................30labetalol hcl ................................ 40lactulose ..................30, 58, 76, 104lactulose encephalopathy.................................30, 58, 76, 104lamivudine ...21, 104, 125, 141, 210lamivudine-zidovudine ........21, 125lamotrigine...58, 59, 76, 77, 163, 164, 180, 181lamotrigine er ....................... 58, 76lamotrigine starter kit-blue...............................59, 77, 164, 181lamotrigine starter kit-green...............................59, 77, 164, 181lamotrigine starter kit-orange...............................59, 77, 164, 181lancets ....................................... 195lancets thin ................................195LANOXIN ......................... 40, 210lansoprazole ......................104, 141lanthanum carbonate...........7, 30, 48, 112, 164, 192, 210LARIN 1.5/30 ............................ 89LARIN 1/20 ............................... 89LARIN 24 FE ............................ 89LARIN FE 1.5/30 .............. 89, 210LARIN FE 1/20 ................. 89, 210Lartruvo................ 16, 21, 141, 257


269

LASTACAFT .. 119, 141, 150, 241latanoprost ................................119LATUDA ......................... 181, 210lavare wound wash ................... 195LAYOLIS FE ............................ 89LEENA .......................................89leflunomide ........... 16, 21, 141, 164LENVIMA 10 MG DAILY DOSE ....................................... 210LENVIMA 14 MG DAILY DOSE ....................................... 210LENVIMA 20 MG DAILY DOSE ....................................... 211LENVIMA 24 MG DAILY DOSE ....................................... 211LESSINA ................................... 90LETAIRIS ............. 11, 40, 97, 153letrozole .............................. 90, 257leucovorin calcium ....5, 7, 192, 223LEUKERAN ........................5, 257Leukine..................................... 211Leuprolide Acetate......48, 112, 257levalbuterol hcl ............. 11, 97, 153levalbuterol tartrate...............................11, 97, 153, 211levetiracetam .................60, 78, 164levetiracetam er .................... 59, 77levobunolol hcl ..........................119levocarnitine ................. 8, 192, 195levocetirizine dihydrochloride.........14, 30, 97, 125, 141, 241, 251levofloxacin ...............................211LEVONEST ...............................90levonorgest-eth estrad 91-day.............................................90, 211levonorgestrel ..................... 90, 211levonorgestrel-ethinyl estrad.............................................90, 211levonorg-eth estrad triphasic.............................................90, 211LEVORA 0.15/30 (28) .............. 90LEVO-T ................................... 112levothyroxine sodium ................ 112LEVOXYL ...............................112LEXIVA .............................21, 126

lidocaine60, 78, 97, 126, 153, 211, 228, 238, 243, 251lidocaine hcl48, 97, 153, 156, 164, 228, 238, 243, 251lidocaine hcl (pf) ...............238, 243lidocaine viscous ...............238, 243lidocaine-prilocaine ..........238, 243lidopin ....... 156, 228, 238, 243, 251LIDOPROFEN ........................211LIFESCAN UNISTIK II LANCETS ............................... 195lindane .............................. 126, 251linezolid .....................................211LINZESS ................................. 104liothyronine sodium .......... 112, 238lisinopril ......................................40lisinopril-hydrochlorothiazide ....40lite touch lancets ....................... 195lithium ....................................... 182lithium carbonate ..............181, 182lithium carbonate er ................. 181LIVALO .....................................30LO LOESTRIN FE ...................90longs lancets thin ...................... 195LONSURF ....................... 104, 257loperamide hcl .......................... 104lopinavir-ritonavir ...... 21, 126, 211lorazepam ................................. 182LORAZEPAM INTENSOL ...182LORCET ................................. 228LORCET HD .......................... 228LORCET PLUS ...................... 228LORYNA ................................. 211losartan potassium ......................40losartan potassium-hctz .............. 40LOTEMAX ......................119, 141lovastatin .....................................30LOW-OGESTREL ................... 90loxapine succinate .....................182Lucentis.............5, 30, 40, 112, 119LUMIGAN ...............................119Lumizyme............... 30, 40, 97, 153Lupron Depot (1-Month).............................5, 40, 48, 90, 257

Lupron Depot (3-Month).............................5, 40, 48, 90, 257Lupron Depot (4-Month).... 48, 257Lupron Depot (6-Month).... 48, 257Lupron Depot-Ped (1-Month)...112Lupron Depot-Ped (3-Month)...112LUTERA ....................................90LUZU ............... 126, 141, 211, 251LYNPARZA .............. 90, 211, 257LYRICA .................30, 60, 78, 112LYRICA CR.................30, 60, 78, 112, 126, 228LYSODREN .................... 112, 257LYZA ................................. 90, 211Macugen....................................119magdelay .....................................30Makena......................................235malathion .......................... 126, 251maprotiline hcl ..........................182marlissa .......................................90MATULANE ........................... 211MATZIM LA .................... 40, 228MAVYRET ..............104, 126, 141MAXIDEX .......................119, 141me/naphos/mb/hyo1 .................. 211meclizine hcl ................... 40, 60, 78meclofenamate sodium...................................141, 164, 228MEDISENSE THIN LANCETS ............................... 195MEDROL .................. 21, 112, 141medroxyprogesterone acetate.................................40, 48, 90, 112mefenamic acid ................... 90, 228mefloquine hcl ...........................126megestrol acetate...................8, 22, 31, 126, 192, 211MEIJER LANCETS ...............195MEKINIST ..............................211meloxicam ............. 16, 22, 141, 164melphalan ................................. 211memantine hcl .......60, 78, 182, 211MENEST ........................... 90, 113meperidine hcl ...........211, 228, 229MEPHYTON ...............................5meprobamate ............................ 182mercaptopurine .........................211


270

mesalamine ....... 104, 141, 211, 212MESNEX ............... 40, 48, 90, 257MESTINON ...22, 60, 78, 141, 164metaproterenol sulfate .. 11, 97, 153metaxalone ................................164metformin hcl ...................... 31, 113metformin hcl er ..................31, 113metformin hcl er (mod)31, 113, 212metformin hcl er (osm) ........31, 113methadone hcl ...........182, 183, 229METHADONE HCL INTENSOL ......................182, 229METHADOSE ................ 183, 229methamphetamine hcl.........................31, 60, 78, 164, 183methazolamide .......................... 119methenamine hippurate .......48, 126methenamine mandelate ..... 48, 126methimazole .............................. 113methitest ..............................90, 113methocarbamol ......................... 165methotrexate ..16, 22, 141, 165, 251methoxsalen rapid .............212, 251methyclothiazide ......................... 31methyldopa ..................................40methyldopa-hydrochlorothiazide ....................40methylphenidate hcl.......................61, 79, 165, 183, 212methylphenidate hcl er...............................61, 79, 165, 183methylphenidate hcl er (cd)...............................60, 78, 165, 183methylphenidate hcl er (la).......................61, 79, 165, 183, 212methylprednisolone .....22, 113, 142methylprednisolone sodium succ.....................................22, 113, 142methyltestosterone ...... 90, 113, 212metipranolol ..............................119metoclopramide hcl .....31, 104, 113metolazone ............................ 31, 48metoprolol succinate er ...... 41, 229metoprolol tartrate ..............41, 229metoprolol-hydrochlorothiazide . 41

metronidazole...............48, 90, 126, 142, 212, 251mexiletine hcl .............................. 41MIACALCIN ............ 90, 113, 165miconazole 3 ................. 48, 90, 126MICROCYN ............................212MICROCYN SKIN AND WOUND ...................................212MICROGESTIN 1.5/30 ............90MICROGESTIN 1/20 ...............90MICROGESTIN FE 1.5/30 ......90MICROGESTIN FE 1/20 .........90MICROTAINER SAFETY FLOW LANCET .................... 195midodrine hcl .............................. 41MIGERGOT ......... 41, 61, 79, 229miglitol ........................31, 113, 212MIGRANAL ..........41, 61, 79, 229MILLIPRED ............. 22, 113, 142MILLIPRED DP .......22, 113, 142MILLIPRED DP 12-DAY ......212MINITRAN ....................... 41, 229minocycline hcl ......................... 212minoxidil ..................................... 41MIRAPEX ER .....................61, 79MIRCERA .............................5, 48mirtazapine ............................... 184MIRVASO ............... 142, 212, 251misoprostol ............................... 104Mitoxantrone HCl.............................5, 48, 61, 79, 257modafinil ................. 61, 79, 97, 153MODERIBA ....104, 126, 142, 212moexipril hcl ............................... 41moexipril-hydrochlorothiazide ... 41mometasone furoate.......14, 97, 126, 142, 212, 241, 251MONDOXYNE NL .................212Monoclate-P..........................5, 212MONOJECT CONTROL SYRINGE ................................ 212MONOJECT FILTER ASPIRATOR ...........................195MONOJECT INSULIN SYRINGE ........................ 195, 212MONOJECT PHARMACY TRAY ....................................... 195

MONOJECT PISTON SYRINGE ................................ 195MONOJECT SYRINGE 195, 212MONOJECT SYRINGE CATH TIP ............................... 195MONOJECT SYRINGE ECC LUER ....................................... 195MONOJECT SYRINGE LUER LOCK .................. 195, 212MONOJECT SYRINGE REG LUER ............................... 196, 212MONOJECT TB SAFETY SYRINGE ................................ 196MONOJECT TB SYRINGE ..196MONOJECT ULTRA COMFORT SYRINGE .......... 196MONOLET LANCETS ..........196MONO-LINYAH ...................... 90MONONESSA ...........................90Mononine..............................5, 213montelukast sodium.........11, 14, 97, 126, 142, 153, 241MONUROL ....................... 48, 126MORGIDOX ........................... 213morphine sulfate ....................... 230morphine sulfate (concentrate) .229morphine sulfate er ... 213, 229, 230morphine sulfate er beads .213, 229MOVANTIK ................... 104, 223MOVIPREP .....................104, 238MOXEZA ................................ 213moxifloxacin hcl ........................213MOZOBIL .....5, 22, 213, 238, 257MULTAQ .................................. 41MULTI COMPLETE .............196multi vitamin/minerals .......... 8, 192multi-vit/fluoride ... 8, 104, 192, 213multi-vit/fluoride/iron...............................8, 105, 192, 213multivitamin/fluoride...............................8, 105, 192, 213mupirocin ..................126, 142, 251mupirocin calcium .... 126, 142, 251MY WAY ...................................90MYALEPT ............ 16, 22, 31, 142


271

mycophenolate mofetil.........22, 48, 49, 105, 213, 238, 243MYDAYIS ........... 61, 79, 165, 184MYLERAN ..............................213Mylotarg................................... 213mynephrocaps ....................... 8, 192Myobloc........................61, 79, 165MYORISAN ............................ 251MYRBETRIQ ................... 49, 165MYZILRA ................................. 91nabumetone ...........16, 22, 142, 166n-acetyl-l-cysteine .....................196nadolol ................................ 41, 230nadolol-bendroflumethiazide ......41NAFRINSE DAILY ACIDULATED ....................... 213NAFRINSE DAILY/NEUTRAL .................105NAFRINSE WEEKLY ...........213naftifine hcl ....... 126, 142, 213, 251NAFTIN ................... 126, 142, 251Naglazyme.......................... 31, 113naloxone hcl ..............................223naltrexone hcl ........................... 184NAMENDA XR ...........61, 79, 184NAMENDA XR TITRATION PACK ........................... 62, 80, 184napro .........................................213naproxen ................... 142, 166, 230naproxen dr .......................142, 166naproxen sodium .......142, 166, 230naratriptan hcl ........ 41, 62, 80, 230NARCAN ................................. 223NATACYN ...... 119, 126, 142, 150NATAZIA ......................41, 49, 91nateglinide .......................... 31, 113NATPARA .........................31, 113NATURE-THROID ................213NEBUPENT.................11, 22, 97, 126, 142, 153NEBUSAL ............................... 213NECON 0.5/35 (28) ................... 91NECON 1/35 (28) ...................... 91NECON 7/7/7 .............................91nefazodone hcl .......................... 184neomycin sulfate ....... 105, 238, 243

neomycin-bacitracin zn-polymyx ............................. 119, 126neomycin-polymyxin-dexameth .214neomycin-polymyxin-gramicidin...........................................119, 126neomycin-polymyxin-hc...........................117, 119, 127, 214NEO-POLYCIN ..............119, 127NEO-POLYCIN HC ...............214NERLYNX ...............................214NEUAC .................................... 251NEULASTA ...........5, 22, 238, 257NEULASTA ONPRO.................................5, 22, 238, 257NEUPOGEN ..................6, 22, 257NEUPRO ............................. 62, 80NEUTRAGARD ADVANCED ............................214neutral sodium fluoride .............105NEVANAC...................119, 142, 230, 238, 243nevirapine ........................... 22, 127nevirapine er ...............22, 127, 214NEXAVAR .............................. 214NEXIUM ..................................105NEXIUM 24HR ...............105, 196NEXT CHOICE ONE DOSE .. 91niacin er ...................................... 31niacin er (antihyperlipidemic).............................................31, 214NIACOR .................................... 31nicardipine hcl .................... 41, 230NICORELIEF ................. 184, 234nicotine ............................. 184, 234nicotine mini ..................... 184, 234nicotine polacrilex ............ 184, 234nicotine step 1 ................... 184, 234nicotine step 2 ................... 184, 234nicotine step 3 ................... 184, 234NICOTROL .....................184, 234NICOTROL NS .............. 184, 234NIFEDIAC CC ........................214NIFEDICAL XL ............... 41, 230nifedipine ............................ 41, 231nifedipine er ........................ 41, 230

nifedipine er osmotic release.............................................41, 230NIKKI ........................ 91, 184, 251nilutamide ................................. 214nimodipine .............. 41, 62, 80, 156NINLARO ........................... 6, 257nisoldipine er .............................. 41NITRO-BID .......................41, 231NITRO-DUR ..................... 41, 231nitrofurantoin ............................214nitrofurantoin macrocrystal ......214nitrofurantoin monohyd macro .214nitroglycerin ....................... 42, 231NITYR ....................................... 31nizatidine ...........................105, 143NORA-BE ..................................91NORDITROPIN FLEXPRO...................8, 22, 31, 113, 127, 192norepinephrine bitartrate ........... 42norepinephrine-dextrose .....42, 214norepinephrine-sodium chloride.............................................42, 214norethin ace-eth estrad-fe ...91, 214norethindrone ............................. 91norethindrone acetate.................................42, 49, 91, 113norethindrone acet-ethinyl est.............................................91, 214norethindrone-eth estradiol.............................91, 113, 166, 214norethin-eth estradiol-fe ..... 91, 214norgestimate-eth estradiol .......... 91norgestim-eth estrad triphasic.............................................91, 214NORITATE ..................... 143, 252NORLYROC ............................. 91NORPACE CR ..........................42NORTHERA ............................. 42NORTREL 0.5/35 (28) ..............91NORTREL 1/35 (21) .................91NORTREL 1/35 (28) .................91NORTREL 7/7/7 ....................... 91nortriptyline hcl ................ 184, 185nortuss-ex ..................................214NORVIR ............................ 22, 127Novoeight..................................... 6NOVOLIN 70/30 ..................... 196


272

NOVOLIN 70/30 RELION .... 196NOVOLIN N ........................... 196NOVOLIN N RELION ...........196NOVOLIN R ........................... 196NOVOLIN R RELION ...........196NOVOLOG ............................. 215NOVOLOG FLEXPEN ..........214NOVOLOG MIX 70/30 .......... 215NOVOLOG MIX 70/30 FLEXPEN ................................215NOVOLOG PENFILL ........... 215NovoSeven RT........................6, 42NOXAFIL.......23, 97, 127, 143, 150, 153, 215np thyroid ..................................215Nplate........................6, 23, 42, 143NUCALA11, 42, 97, 143, 154, 241NUCYNTA .............................. 231NUCYNTA ER.........................31, 62, 80, 113, 231NUEDEXTA ............................185NUPLAZID ................. 62, 80, 185NUTRESTORE .......105, 238, 243NUTROPIN AQ NUSPIN 10...................8, 23, 31, 113, 127, 192NUTROPIN AQ NUSPIN 20...................8, 23, 32, 114, 127, 192NUTROPIN AQ NUSPIN 5...................8, 23, 32, 114, 127, 192NUVARING .............................. 91Nuwiq........................................... 6NYAMYC ................ 127, 143, 252nystatin ..............127, 143, 150, 252nystatin-triamcinolone...................................127, 143, 252NYSTOP .................. 127, 143, 252Obizur....................... 6, 23, 42, 143OBSTETRIX EC .................... 235OCALIVA ............................... 105OCELLA ................................... 91Ocrevus................................. 62, 80Octagam....................6, 23, 42, 143octreotide acetate.........32, 62, 80, 105, 114, 166, 257ODACTRA .. 14, 97, 127, 143, 241ODEFSEY ......................... 23, 127ODOMZO ........................252, 257

OFEV ........................... 11, 97, 154ofloxacin ........................... 117, 215OGESTREL .............................. 91OLANZapine............................ 185olanzapine .................................185olanzapine-fluoxetine hcl ..........185olopatadine hcl...................119, 143, 150, 215, 241omeprazole ........................105, 143OMEPRAZOLE+SYRSPEND SF ALKA ............................. 215omeprazole-sodium bicarbonate.............................42, 105, 143, 215OMNARIS.................11, 14, 97, 127, 143, 241OMNITROPE...........8, 23, 32, 114, 127, 128, 192Oncaspar............................... 6, 257ondansetron ...................... 105, 257ondansetron hcl 105, 238, 243, 257ONETOUCH CLUB LANCETS FINE PT ...............196ONETOUCH FINEPOINT LANCETS ............................... 196ONETOUCH ULTRASOFT LANCETS ............................... 196ONFI ............................ 62, 80, 215OPANA ER ..............................231Opdivo...................................... 215opium ........................................ 215OPSUMIT ......11, 42, 98, 154, 215ORALAIR.................11, 14, 98, 128, 143, 241ORALONE .............................. 150Orencia..........16, 23, 143, 166, 252ORENCIA ... 17, 23, 143, 166, 252ORENCIA CLICKJECT.......................16, 23, 143, 166, 252ORENITRAM ....... 11, 42, 98, 154ORFADIN ..................................32ORKAMBI ............ 11, 32, 98, 154orphenadrine citrate er .............166ORSYTHIA ............................... 91OSCION CLEANSER ............215oseltamivir phosphate .......128, 215OSMOPREP ....................105, 238OSPHENA ... 49, 91, 114, 150, 231

OTEZLA ..................143, 166, 252OTIPRIO ......................... 117, 128oxandrolone ................................ 32oxaprozin .............. 17, 23, 143, 166oxazepam ...................... 62, 80, 185oxcarbazepine ....................... 62, 80oxiconazole nitrate...........................128, 144, 215, 252OXISTAT ................ 128, 144, 252OXTELLAR XR ..... 62, 63, 80, 81oxybutynin chloride .............49, 166oxybutynin chloride er ........ 49, 166oxycodone hcl ........................... 231oxycodone hcl er ............... 216, 231oxycodone-acetaminophen216, 231oxycodone-aspirin .....................231oxycodone-ibuprofen 231, 238, 243OXYCONTIN ................. 216, 231oxymorphone hcl .......................231oxymorphone hcl er .................. 231OXYTROL ........................ 49, 166PACERONE ..............................42PACLitaxel............................... 216paliperidone er ..................185, 216Pamidronate Disodium32, 257, 258PANCREAZE ................. 105, 216PANDEL ..........................144, 252PANRETIN . 17, 23, 144, 252, 258pantoprazole sodium .................216paregoric ...................................105paricalcitol ..................49, 114, 216PAROEX ................. 105, 128, 150paromomycin sulfate .........105, 128paroxetine hcl ........................... 186paroxetine hcl er ....................... 185PASER ............... 98, 128, 144, 154PAXIL ......................................186PCE .......................................... 216peg 3350/electrolytes ........ 106, 238peg 3350-kcl-na bicarb-nacl...........................................106, 238peg-3350/electrolytes ........106, 238PEGANONE ........63, 81, 166, 216PEGASYS ................106, 128, 144PEGASYS PROCLICK...................................106, 128, 144PEGINTRON .......... 106, 128, 144


273

penicillin g procaine ................. 216penicillin v potassium ............... 216PENNSAID ..............144, 166, 216PENTASA ........................106, 144pentoxifylline er .......... 42, 166, 231PERFOROMIST .11, 98, 144, 154perindopril erbumine .......... 42, 231PERIOGARD ..........106, 128, 150Perjeta....................................... 216permethrin .........................128, 252perphenazine .............................186PERTZYE ............................... 106PHENADOZ ....106, 231, 238, 244phenazopyridine hcl ............49, 231phenelzine sulfate ......................186PHENERGAN .106, 231, 239, 244phenobarbital ............................216PHENOHYTRO ..................... 216phenoxybenzamine hcl 42, 216, 258phenylephrine-guaifenesin ........216phenytoin ...............................63, 81PHENYTOIN INFATABS .63, 81phenytoin sodium extended ...63, 81PHILITH ................................... 91PHOS-FLUR ........................... 216PHOSLYRA...................8, 32, 49, 114, 166, 192PHOSPHA 250 NEUTRAL ..... 32PHOSPHASAL ....................... 216PHOSPHOLINE IODIDE ..... 119PICATO ...................................252pilocarpine hcl17, 23, 106, 119, 144, 239, 244, 258pimozide ........63, 81, 166, 186, 217PIMTREA ......................... 91, 217pindolol ....................................... 42pioglitazone hcl ...................32, 114pioglitazone hcl-glimepiride.............................................32, 114pioglitazone hcl-metformin hcl.............................................32, 114PIRMELLA 1/35 .......................91PIRMELLA 7/7/7 ..............91, 217piroxicam .............. 17, 23, 144, 167pnv folic acid + iron ................. 235podofilox ................... 128, 144, 252POLYCIN ........................120, 128

polyethylene glycol 3350 .......... 106polymyxin b-trimethoprim...........................120, 128, 144, 150POLY-VI-FLOR ......... 8, 106, 192polyvinyl alcohol .......................120POMALYST ............................217PORTIA-28 ............................... 91PORTRAZZA ... 98, 154, 252, 258pot bicarb-pot chloride ............... 32potassium bicarbonate ........32, 196potassium chloride ......32, 196, 217potassium chloride crys er ..........32potassium chloride er ......... 32, 217potassium citrate er .................. 217potassium citrate monohydrate .196PRALUENT ........................ 32, 42pramcort ............................. 42, 106pramipexole dihydrochloride63, 81pramipexole dihydrochloride er.......................................63, 81, 217PRAMOSONE ................ 144, 252PRAMOSONE E .............144, 252prasugrel hcl.................6, 42, 217, 232, 239, 244pravastatin sodium ......................32prazosin hcl .................................42PRECISION SURE-DOSE SYRINGE ................................ 196PRECISION THIN LANCETS ............................... 196PRECISION THINS GP LANCETS ............................... 196PRECISION ULTRA LANCET ..................................196PRECISION XTRA BLOOD GLUCOSE ...............................197PRED MILD ....................120, 144PRED-G ................................... 217PRED-G S.O.P. ....................... 217prednicarbate ....................144, 252prednisolone ............... 23, 114, 144prednisolone acetate .........120, 144prednisolone sodium phosphate.....................23, 114, 120, 144, 217prednisone .................................217PREDNISONE INTENSOL .. 217preferred plus lancets colored .. 197

preferred plus lancets thin ........ 197PREMARIN 49, 92, 114, 150, 232premium lidocaine .................... 217PREMPHASE ..... 49, 92, 114, 150PREMPRO .......... 49, 92, 114, 150PRENATABS RX ................... 235prenatal .....................................235prenatal 19 ........................197, 235PREPOPIK ......................106, 239PREVACID SOLUTAB . 106, 144PREVIFEM ............................... 92Prevymis............. 23, 128, 239, 244PREVYMIS ....... 23, 128, 239, 244PREZCOBIX .....................23, 128PREZISTA .................. 23, 24, 128PRIFTIN ............98, 128, 145, 154PRILOSEC ......................106, 145primaquine phosphate .............. 128primidone ..................................217PRIMSOL ................................217Privigen.....................6, 24, 43, 145PROAIR HFA ............. 12, 98, 154PROAIR RESPICLICK.......................................12, 98, 154probenecid .. 33, 145, 167, 239, 255PROBUPHINE IMPLANT KIT ........................................... 186prochlorperazine .......................106prochlorperazine edisylate ....... 106prochlorperazine maleate .........106PROCRIT ......................6, 49, 258PROCTOFOAM HC ........ 43, 106PROCTO-PAK ............... 145, 252PROCTOSOL HC .. 145, 217, 252PROCTOZONE-HC...................................145, 217, 252Profilnine...................................... 6Profilnine SD................................ 6progesterone ........... 43, 49, 92, 114progesterone micronized .....92, 217PROGLYCEM ..33, 106, 114, 258Proleukin...................................217Prolia...........................92, 114, 167PROMACTA...................6, 24, 43, 106, 128, 145


274

promethazine hcl...................106, 217, 232, 239, 244promethazine vc/codeine.......................14, 98, 128, 145, 154promethazine-codeine...............14, 98, 129, 145, 154, 241promethazine-dm...............14, 98, 129, 145, 154, 241promethazine-phenylephrine...............14, 98, 129, 145, 217, 241PROMETHEGAN...........................106, 232, 239, 244propafenone hcl .......................... 43propafenone hcl er ......................43proparacaine hcl .......120, 239, 244propranolol hcl.........................43, 63, 81, 167, 232propranolol hcl er ...43, 63, 81, 232propranolol-hctz ......................... 43propylthiouracil ........................ 114PROTONIX .............................217protriptyline hcl ........................ 186PROVENTIL HFA ..... 12, 98, 154pseudoephedrine hcl...............................14, 98, 129, 145psorcon ............................. 145, 252PSS SELECT GP LANCETS 197PSS SELECT SAFETY LANCETS ............................... 197PULMICORT FLEXHALER...............................12, 98, 145, 154PULMOSAL ............................218PULMOZYME ..... 12, 33, 98, 154PURIXAN ................................218PYLERA ..................107, 129, 145pyrazinamide .............................218pyridostigmine bromide.........................24, 63, 81, 145, 167pyridostigmine bromide er.................24, 63, 81, 145, 167, 218qc nicotine polacrilex ................197QNASL .........14, 98, 129, 145, 241QNASL CHILDRENS.......................14, 98, 129, 145, 241QUASENSE ...............................92quetiapine fumarate .................. 186quetiapine fumarate er ......186, 218

QUILLICHEW ER...............................64, 82, 167, 186QUILLIVANT XR...............................64, 82, 167, 187quinapril hcl ................................43quinapril-hydrochlorothiazide ....43quinidine gluconate er ........ 43, 239quinidine sulfate ..................43, 239quinine sulfate ...........................218QVAR ...................12, 98, 145, 154QVAR REDIHALER...............................12, 98, 145, 154ra mini nicotine .................187, 234ra nicotine .................187, 234, 235ra nicotine polacrilex 187, 234, 235rabeprazole sodium .. 107, 145, 218Radicava........................64, 82, 167raloxifene hcl.....................92, 114, 167, 218, 258ramipril ....................................... 43RANEXA ........................... 43, 232ranitidine hcl ...............43, 107, 145RAPAFLO ......................... 49, 258RAPAMUNE.................24, 49, 98, 154, 239, 244rasagiline mesylate ....... 64, 82, 218RAVICTI ................................... 33REA LO 40 .............................. 218reality lancets ............................197reality trigger lancets ............... 197REBETOL ............... 107, 129, 145REBIF .................................. 64, 82REBIF REBIDOSE ............ 64, 82REBIF REBIDOSE TITRATION PACK ........... 64, 82REBIF TITRATION PACK...............................................64, 82Rebinyn.........................................6RECLIPSEN ............................. 92Recombinate................................. 6REGRANEX.................33, 64, 82, 114, 218, 252RELENZA DISKHALER ...... 129RELISTOR ......................107, 223Remicade...............17, 24, 107, 145, 167, 253REMODULIN ....... 12, 43, 98, 154

RENAGEL...................8, 33, 49, 114, 167, 192RENAL ................................ 8, 192Renflexis...............17, 24, 107, 145, 167, 253repaglinide ..................33, 114, 218repaglinide-metformin hcl.....................................33, 115, 218REPATHA ...........................33, 43REPATHA PUSHTRONEX SYSTEM ..............................33, 43REPATHA SURECLICK .. 33, 43RESCRIPTOR .................. 24, 129RESCULA ............................... 120RESTASIS ............... 120, 146, 150RETIN-A MICRO PUMP ......253REVATIO ..............12, 43, 99, 154REVLIMID ............................. 218rexaphenac ................................218REXULTI ................................ 187REYATAZ .........................24, 129Rhophylac......... 6, 24, 43, 146, 235RiaSTAP....................................... 6RIBASPHERE ........ 107, 129, 146ribavirin .................... 107, 129, 146rifabutin .................................... 218RIFAMATE .............................218rifampin .....................................218RIFATER ................................ 218riluzole .......................... 64, 82, 167rimantadine hcl .........................129RIOMET ............................33, 115risedronate sodium.......................33, 92, 115, 167, 218RisperDAL Consta....................187risperidone ................................187RISPERIDONE M-TAB 187, 218Rituxan..........17, 24, 146, 167, 258Rituxan Hycela......................... 218rivastigmine .......... 64, 82, 188, 218rivastigmine tartrate ..... 64, 82, 188Rixubis..................................6, 219rizatriptan benzoate 43, 64, 82, 232ropinirole hcl ........................ 64, 82ropinirole hcl er ....................64, 82ropivacaine hcl-nacl ................. 219ROSADAN .......................146, 253


275

ROSANIL CLEANSER ......... 219rosuvastatin calcium ...........33, 219ROZEREM ..........................64, 82RUBRACA .............................. 219Ruconest............... 24, 33, 241, 253RYDAPT ..................................219SABRIL ....................... 64, 82, 167SAIZEN ... 8, 24, 33, 115, 129, 192SAIZEN CLICK.EASY...................8, 24, 33, 115, 129, 192SAIZENPREP...................8, 24, 33, 115, 129, 192salsalate ................ 17, 24, 146, 167SAMSCA ........................... 33, 115SANCUSO ....................... 107, 258SANDIMMUNE.......................24, 49, 107, 239, 244SandoSTATIN LAR Depot.........33, 64, 82, 107, 115, 167, 258SANTYL .......................... 156, 253SAPHRIS ................................. 188SAVELLA ............... 146, 168, 232SAVELLA TITRATION PACK ....................... 146, 168, 232sb lancets thin ........................... 197sb lancets ultra thin .................. 197scopolamine .............................. 107selegiline hcl ............. 64, 65, 82, 83selenium sulfide ........ 146, 219, 253selenium sulf-pyrithione-urea...........................................146, 253SELRX ..................... 146, 219, 253SELZENTRY .................... 24, 129SEMPREX-D.......................14, 99, 129, 146, 241SENSIPAR .................49, 115, 239SEREVENT DISKUS...............................12, 99, 146, 154SEROQUEL XR ..................... 188SEROSTIM...................8, 24, 33, 115, 129, 192sertraline hcl .............................188SETLAKIN ................................92sevelamer carbonate...........8, 33, 49, 115, 168, 193, 219sf ................................................107sf 5000 plus ............................... 107

SFROWASA ....................107, 146SHAROBEL .............................. 92SIGNIFOR ...............................115sildenafil citrate ...... 12, 43, 99, 155SILIQ ....................................... 253silver sulfadiazine...........................129, 156, 239, 244SIMBRINZA ........................... 120SIMPONI .............17, 24, 146, 168Simponi Aria...............17, 24, 146, 168, 219, 253simvastatin .................................. 33sirolimus.........24, 49, 99, 155, 219, 239, 244SIRTURO .......... 99, 129, 146, 155SIVEXTRO ............................. 219SKLICE ................................... 129sm nicotine ........................ 188, 235sm nicotine polacrilex .......188, 235sodium chloride ........................ 219sodium fluoride ................. 107, 219sodium polystyrene sulfonate.............................................33, 219SOLARAZE ............................ 253SOLTAMOX ..................... 92, 258SOLU-CORTEF ....... 24, 115, 146Somatuline Depot.................33, 65, 83, 115, 168, 258SOMAVERT . 34, 65, 83, 115, 168SOOLANTRA ................. 146, 253SORINE ..................................... 44sotalol hcl ....................................44sotalol hcl (af) .............................44SOTYLIZE ................................44SOVALDI ........ 107, 129, 146, 219spinosad ............................ 129, 253Spinraza................................ 65, 83SPIRIVA RESPIMAT...............................12, 99, 146, 155spironolactone ...... 34, 44, 107, 131spironolactone-hctz ...............34, 44SPORANOX ............................219SPRINTEC 28 ........................... 92SPRITAM ....................65, 83, 168SPRIX ...................... 232, 239, 244SPRYCEL ................................219SPS ............................................. 34

sr nicotine ................................. 197SRONYX ................................... 92SSD ................... 129, 156, 239, 244stavudine ............................. 24, 130Stelara............... 107, 146, 168, 253STELARA ....... 107, 147, 168, 253STIMATE ....................................6STIVARGA ............................. 219STRENSIQ ................................ 34STRIANT ...........................92, 115STRIBILD ......................... 25, 130STRIVERDI RESPIMAT...............................12, 99, 147, 155SUBOXONE ............................188sucralfate .......................... 107, 147sulfacetamide sodium...................120, 130, 147, 150, 253sulfacetamide sodium (acne) .... 253sulfacetamide sodium-sulfur .....219sulfacetamide-prednisolone...........................................120, 147sulfadiazine ............................... 219sulfamethoxazole-trimethoprim 219SULFAMYLON...........................130, 156, 239, 244sulfasalazine...............17, 25, 107, 147, 168, 219SULFATRIM PEDIATRIC ...219sulindac .............................147, 168sumatriptan ............. 44, 65, 83, 232sumatriptan succinate.................................44, 65, 83, 232sumatriptan succinate refill.................................44, 65, 83, 232super thin lancets ......................197Supprelin LA............................ 115SUPRAX .......................... 219, 220SUPREP BOWEL PREP KIT...........................................108, 239sure comfort insulin syringe ..... 197SURELITE LANCETS .......... 197SUSTOL ...........................108, 258SUTENT .................................. 220SYEDA .......................................92SYLATRON .................... 253, 258SYMBICORT ......12, 99, 147, 155SYMFI ............................... 25, 130


276

SYMFI LO .........................25, 130SYMLINPEN 120 ............. 34, 115SYMLINPEN 60 ............... 34, 115SYMPROIC .....................108, 223Synagis................99, 130, 147, 155SYNALAR (CREAM) .... 147, 253SYNALAR (OINTMENT)...........................................147, 253SYNAREL ......................... 92, 115SYNDROS ... 25, 34, 108, 130, 258SYNJARDY .......................34, 115SYNJARDY XR ........ 34, 115, 116Synribo..................................6, 258TABLOID ............................6, 258TACLONEX ............................253tacrolimus25, 49, 108, 147, 220, 239, 244, 253TAFINLAR ............................. 220TAGRISSO ..............................220TALTZ .............147, 168, 253, 254tamoxifen citrate ................. 92, 258tamsulosin hcl ..................... 49, 258TARCEVA ...............................220TARGRETIN .................. 254, 258TARINA FE 1/20 ...................... 92TASIGNA ................................ 220tazarotene ................................. 254TAZORAC .............................. 254TAZTIA XT ...................... 44, 232tb syringe 1 ml .......................... 197Tecentriq................................... 220TECFIDERA .......................65, 83TECHLITE LANCETS ..........197TEKTURNA ..............................44TEKTURNA HCT .................... 44telmisartan .................. 44, 220, 232telmisartan-hctz .................. 44, 220temazepam ............................ 65, 83Temodar....................................220temozolomide ............................ 220TENCON ......................... 188, 232tenofovir disoproxil fumarate.....................25, 108, 130, 147, 220terazosin hcl ..................44, 49, 258terbinafine hcl ...........................220terbutaline sulfate ......... 12, 99, 155terconazole ....................49, 92, 130

TESTOPEL ....................... 92, 116testosterone ................. 92, 116, 220testosterone cypionate .........92, 116testosterone enanthate ........ 92, 116tetrabenazine .65, 83, 168, 188, 220tetracycline hcl ..........................220tgt nicotine ................ 188, 197, 235tgt nicotine polacrilex ....... 188, 235tgt nicotine step one .......... 188, 235tgt nicotine step three ........188, 235tgt nicotine step two .......... 188, 235THALOMID ........................6, 258THEO-24 ............. 12, 99, 147, 155THEOCHRON ....12, 99, 147, 155theophylline ...........13, 99, 148, 155theophylline er ...... 13, 99, 147, 155THINLETS GP LANCETS ... 197THINLETS LANCET ............ 197thioridazine hcl ......................... 189thiothixene .................................189Thyrogen...................116, 239, 258THYROLAR-1 ........................116THYROLAR-1/2 .....................116THYROLAR-1/4 .....................116THYROLAR-2 ........................116THYROLAR-3 ........................116tiagabine hcl ......................... 65, 83TILIA FE ...........................93, 254timolol maleate ........... 44, 120, 232TIMOPTIC OCUDOSE .........120tinidazole ...............49, 93, 108, 130TIVICAY ................... 25, 130, 220tizanidine hcl .............................168TOBI PODHALER.................13, 34, 99, 130, 148, 155TOBRADEX ............120, 130, 148tobramycin.........13, 34, 99, 130, 148, 155, 220tobramycin-dexamethasone...................................120, 130, 148TOBREX ................................. 220tolazamide ...........................34, 116tolbutamide ......................... 34, 116tolcapone .......................65, 83, 220tolmetin sodium .....17, 25, 148, 168tolterodine tartrate ..............50, 168tolterodine tartrate er . 50, 168, 220

topiramate .........44, 45, 66, 84, 233topiramate er .......... 44, 65, 83, 232Torisel................................. 50, 258torsemide ...............................34, 45TOVIAZ .............................50, 169TRACLEER .......... 13, 45, 99, 155tramadol hcl ..............................233tramadol hcl er ......................... 233tramadol hcl er (biphasic) ........ 233tramadol-acetaminophen ..........233trandolapril .........................45, 233trandolapril-verapamil hcl er ..... 45tranexamic acid ...............45, 50, 93tranylcypromine sulfate ............ 189TRAVATAN Z ........................ 120trazodone hcl ............................ 189Treanda..................................... 220TRECATOR ............................130TRELSTAR MIXJECT ... 50, 258TREMFYA .............................. 254TRESIBA FLEXTOUCH ...... 220tretinoin .....................220, 221, 254tretinoin microsphere ................254tretinoin microsphere pump ......254Tretten...........................................6TREXALL ... 17, 25, 148, 169, 254triamcinolone acetonide14, 99, 130, 148, 150, 221, 241, 254triamterene-hctz ....................34, 45TRIDERM ....................... 148, 254trientine hcl.........34, 66, 84, 108, 169, 221, 223TRIESENCE ... 120, 148, 239, 244TRI-ESTARYLLA ................... 93trifluoperazine hcl .....................189trifluridine .........120, 130, 148, 150TRIGLIDE ................................ 34trihexyphenidyl hcl ................66, 84TRI-LEGEST FE ..............93, 254TRI-LINYAH ............................93TRI-LO-ESTARYLLA ............ 93TRI-LO-MARZIA .................... 93TRI-LO-SPRINTEC .........93, 221TRILYTE ................ 108, 221, 239trimethobenzamide hcl...................................108, 239, 244trimethoprim ....................... 50, 130


277

trimipramine maleate ................189TRINATE ................................ 235TRINESSA (28) .........................93TRINESSA LO ..........................93TRINTELLIX ......................... 189TRI-PREVIFEM .......................93Triptodur................................... 116TRI-SPRINTEC ........................93TRIUMEQ .........................25, 130tri-vit/fluoride/iron ........8, 108, 193tri-vitamin/fluoride ....... 8, 108, 193TRIVORA (28) ..........................93TROKENDI XR.........................45, 66, 84, 221, 233tropicamide ............................... 120trospium chloride ................50, 169trospium chloride er ........... 50, 169TRULICITY ......................34, 116TRUVADA ........................ 25, 130TUSSIGON ..14, 99, 130, 148, 155TYBOST ............................ 25, 130TYKERB ................................. 221TYMLOS ................... 93, 116, 169Tysabri.................. 66, 84, 108, 148TYVASO ..............13, 45, 100, 155TYVASO REFILL...............................13, 45, 100, 155TYVASO STARTER...............................13, 45, 100, 155UCERIS ........................... 108, 148ULESFIA ......................... 130, 254ULORIC .................... 34, 148, 169ULTICARE TUBERCULIN SAFETY SYR ..........................197ULTILET CLASSIC LANCETS ............................... 197ULTILET LANCETS .............197ULTRA-THIN II AUTO LANCET ..................................197ULTRA-THIN II LANCETS .197UNILET COMFORTOUCH LANCET ..................................197UNILET G.P. LANCET .........197UNILET G.P. SUPERLITE LANCET ..................................197UNILET LANCET ................. 197

UNILET SUPERLITE LANCET ..................................198UNISTIK 1 .............................. 198UNITHROID ...................116, 221UNITHROID DIRECT .......... 221UPTRAVI .... 13, 45, 100, 155, 156urea ........................................... 221urea-c40 ....................................221ure-k ..........................................221URETRON D/S ....................... 221URIMAR-T ..............................221ursodiol ..................................... 108URYL ....................................... 221Vabomere..................................221valacyclovir hcl .........................221VALCHLOR ........... 221, 254, 258valganciclovir hcl ..................... 221valproic acid ......................... 66, 84valsartan ............................. 45, 221valsartan-hydrochlorothiazide ... 45Valstar.......................................221vancomycin hcl ......................... 221VANDAZOLE .............50, 93, 130Vantas................................. 50, 258Varubi............................... 108, 258VARUBI ...........................108, 259Vectibix.....................................221Velcade..................................... 221Veletri................... 13, 45, 100, 156VELIVET .................................. 93VELTASSA ............................... 34VEMLIDY ............... 108, 130, 148VENCLEXTA ..................... 6, 259VENCLEXTA STARTING PACK ................................... 6, 259venlafaxine hcl .......................... 189venlafaxine hcl er ......................189VENTAVIS ..........13, 45, 100, 156VENTOLIN HFA ......13, 100, 156verapamil hcl ...................... 45, 233verapamil hcl er ..........................45VERDROCET .........................233VEREGEN ...............130, 148, 254VERSACLOZ ................. 190, 221VERZENIO ............................. 221VESICARE ........................50, 169VESTURA ................. 93, 190, 254

VIBERZI ................................. 108VICTOZA ..........................34, 116Vidaza....................................... 222VIDEX ............................... 25, 130VIENVA .....................................93vigabatrin ..............66, 84, 169, 222VIIBRYD ................................. 190VIIBRYD STARTER PACK .190VIMPAT .............................. 67, 85viorele ......................................... 93VIRACEPT ....................... 25, 130VIRAZOLE ..... 100, 131, 148, 156VIREAD .............25, 108, 131, 148VISTOGARD .......................... 223Visudyne................................... 120VITALET PRO LANCETS ... 198VITALET PRO PLUS LANCETS ............................... 198vitamin d (ergocalciferol) ..... 8, 193VIVITROL .............................. 190VOLTAREN ....................148, 169Vonvendi.................6, 46, 240, 244voriconazole ..............................222VOSEVI ................... 108, 131, 148VOTRIENT ............................. 222Vpriv........................................... 34VRAYLAR .............................. 190VYFEMLA ........................ 93, 222VYVANSE ........... 67, 85, 169, 190Vyxeos...................................... 222VYZULTA ...............................120W&F LANCETS 26G .............198W&F LANCETS COLORED 21G ........................................... 198warfarin sodium ......................7, 46WELCHOL ............................... 34WERA ........................................93WESTHROID ......................... 222Wilate........7, 25, 46, 148, 240, 244WinRho SDF.... 7, 25, 46, 148, 235WP THYROID ........................222WYMZYA FE ........................... 93XADAGO .............................67, 85XALKORI ............................... 222XARELTO .....7, 46, 100, 156, 240


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XARELTO STARTER PACK.........................7, 46, 100, 156, 240XATMEP ............. 7, 149, 169, 259XELJANZ ....17, 25, 149, 169, 254XELJANZ XR.......................17, 25, 149, 169, 254Xeomin......... 67, 85, 120, 169, 254XERMELO ......................108, 259Xgeva..........................35, 169, 259Xiaflex................................ 93, 169XIFAXAN ......35, 67, 85, 108, 131XIGDUO XR ..................... 35, 116Xolair.......13, 35, 100, 149, 156, 242, 254XOLEGEL .......................149, 254XTANDI ...................................222XULANE ................................... 93XURIDEN ..................................35Xyntha...........................................7Xyntha Solofuse............................7XYREM ....................... 67, 85, 169Yervoy...................................... 222YONDELIS ......... 17, 25, 149, 259zafirlukast ........... 13, 100, 149, 156zaleplon .................................67, 85Zaltrap.......................................222ZARAH ......................................93ZARXIO ........................ 7, 25, 259ZEBUTAL ............... 190, 222, 233ZEJULA ...................................222ZELAPAR ........................... 67, 85ZELBORAF ............................ 222ZENATANE ............................ 254ZENCHENT ..............................93ZENPEP ...................................109ZENZEDI ............ 67, 85, 169, 190ZEPATIER ..............109, 131, 149ZETIA ........................................35ZETONNA...............13, 15, 100, 131, 149, 242zidovudine ........................... 25, 131ZINBRYTA ......................... 67, 85Zinplava.................... 109, 131, 149ZIOPTAN ................................ 120ziprasidone hcl ..........................191ZIRGAN .................. 120, 131, 149ZMAX ...................................... 222

ZOHYDRO ER ....................... 233Zoladex......................... 50, 93, 259Zoledronic Acid...........7, 35, 93, 116, 170, 222, 259ZOLINZA ........................254, 259zolmitriptan .............46, 67, 85, 233zolpidem tartrate ...................68, 86zolpidem tartrate er .............. 68, 86ZOMACTON...................9, 25, 35, 116, 131, 193ZOMIG .......... 46, 68, 86, 222, 233zonisamide ............................ 68, 86ZONTIVITY.............7, 46, 68, 86, 233, 240, 244ZORBTIVE...................9, 25, 35, 117, 131, 193ZORTRESS . 26, 50, 109, 240, 244ZOVIA 1/35E (28) .....................93ZOVIA 1/50E (28) .....................93ZOVIRAX ............................... 222ZUBSOLV ....................... 191, 222ZURAMPIC .............. 35, 149, 170ZYCLARA ...............................254ZYCLARA PUMP .................. 254ZYDELIG ................................222ZYKADIA ............................... 222ZYLET .....................120, 131, 149ZYPITAMAG ........................... 35ZyPREXA Relprevv................. 191ZYTIGA ...................................222


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1 de abril de 2018 Introducción Programa de farmacia · Listamos todos los medicamentos según su...

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