Trusted Health Plan Formulary

Transcription

1 2015 Trusted Health Plan Formulary

2 Introduction... 6 The Trusted Health Plan Pharmacy and Therapeutics Committee (P&T)... 6 Notice... 6 Preface... 6 Product Selection Criteria... 6 Formulary Components... 6 Generic Substitution... 6 Covered Medications without Authorization... 6 Non-Covered Benefits... 7 Prior Authorization... 7 Step Therapy...7 Specialty Medications... 7 Quantity Limits...7 Benefit Exception... 7 Pharmacy Benefit Management... 7 Prior Authorization Information... 8 Acne Therapy Agents for Narcotic Withdrawal Alcoholism Treatment Agents Analgesic, Anti-inflammatory or Antipyretic - Non-Narcotic Analgesics - Narcotic Angina Therapy Anorectal - Glucocorticoids Anorectal Combinations Anterior Pituitary Hormones and Hormone Antagonists Anti-Infective - Immunologic Adjuvants Antianxiety Agents Antiarrhythmics Antibacterial Agents Anticoagulants Anticonvulsant Antidepressants Antidiarrheals...16 Antiemetics...16 Antifungals...17 Antihemophilic Factor Agents Antihistamines Antihyperlipidemics Antihypertensive Therapy Agents Antineoplastic - Alkylating Agents Antineoplastic - Antibody/Antibody-Drug Complexes Antineoplastic - Antimetabolites Antineoplastic - Hedgehog Pathway Inhibitor Antineoplastic - Hormone/Hormone Antagonist Agents Antineoplastic - Immunomodulators Antineoplastic - Mast Cell Stabilizers Antineoplastic - Metal Complexes Antineoplastic - Retinoids and Retinoid Receptor Agonists Antineoplastic - Systemic Enzyme Inhibitors Antineoplastic - Topoisomerase Inhibitors Antiparasitics...20 Antiparkinson Therapy Antiprotozoal-Antibacterial Agents Antipsychotics (Neuroleptics) Antitussives...21 Antivirals Appetite Stimulants Asthma/COPD Therapy Agents Attention Deficit-Hyperact Disorder (ADHD) Therapy Beta Adrenergic Blockers Bipolar Therapy Agents Blood Albumin and Plasma Proteins Bradykinin B2 Receptor Antagonists Calcium & Bone Metabolism Regulators Calcium Channel Blockers and Combinations Cardiac Inotropes Cardiovascular Sympathomimetics and Combinations

3 Chelating Agents Chemotherapy Rescue-Antidote Agents CNS Stimulants Cognitive Disorder Therapy - Antidementia Colonic Acidifier (Ammonia Inhibitor) Contraceptives Implant Contraceptives Injectable Contraceptives Intravaginal Contraceptives Oral Contraceptives Transdermal Corticosteroids Cystic Fibrosis Therapy Agents Dental-Periodontal Products Dermatological - Anti-infectives Dermatological - Antineoplastic or Premalignant Lesions Dermatological - Antiparasitics and Combinations Dermatological - Antipsoriatics Dermatological - Antiseborrheic Products and Combinations Dermatological - Burn Products Dermatological - Emollients and Combinations Dermatological - Glucocorticoids and Combinations Dermatological - Immunomodulating Agents Dermatological - Immunosuppressive Agents Dermatological - Keratolytics-Antimitotics Dermatological - NSAID s Dermatological - Topical Local Anesthetics and Combinations Diabetic Therapy Diagnostic Drugs - In Vivo Digestive Aids Diuretics Emergency Contraceptives and Combinations Estrogens and Combinations Gallstone Solubilizing (Litholysis) Agents and Combinations Gastrointestinal Antispasmodics Gastrointestinal Prokinetic Agents General Anesthetics General Injectable Solutions and Diluents Genitourinary Irrigants Hematopoietic Agents Hepatic Hormones (Hormones Secreted by the Liver) Hyperuricemia Therapy Immunosuppressive - Calcineurin Inhibitors Immunosuppressive - Inosine Monophosphate Dehydrogenase Inhibitors Immunosuppressive - Mammalian Target of Rapamycin (mtor) Inhibitors Immunosuppressive - Purine Analogs Inflammatory Bowel Agents Interstitial Cystitis Agents Irritable Bowel Syndrome (IBS) Agents Laxatives Local Anesthetics - Parenteral Medical Supplies & DME - Diabetic Supplies Medical Supplies & DME - Respiratory Therapy Metabolic Disease Enzyme Replacement, Gaucher s Disease Migraine Therapy Minerals & Electrolytes Mouth and Throat - Anti-infectives Mouth and Throat - Glucocorticoids Mouth and Throat - Local Anesthetics Mouth and Throat - Xerostomia Therapy Mucolytics...32 Multiple Sclerosis Agent - Interferons Multiple Sclerosis Agent - Potassium Channel Blocker Musculoskeletal Therapy Agents Narcolepsy and Cataplexy Therapy Agents Nasal Preparations Neuromuscular Therapy Agents Ophthalmic - Anti-allergy

4 Ophthalmic - Anti-infectives Ophthalmic - Anti-inflammatory Ophthalmic - Decongestants and Combinations Ophthalmic - Intraocular Pressure Reducing Agents Ophthalmic - Mydriatics and Cycloplegics Ophthalmic Combinations Otic - Anti-infectives Otic Combinations Oxytocics...34 Passive Immunizing Agents Peptic Ulcer Therapy Pharmaceutical Adjuvants Phosphate Binders Platelet Aggregation Inhibitors & Combinations Posterior Pituitary Hormones Progestins...35 Prostatic Hypertrophy Agents Pseudobulbar Affect (PBA) Agents Respiratory Combinations Sedative-Hypnotics Sickle Cell Anemia Agents Smoking Deterrents and Combinations Thyroid Therapy Urinary Analgesics Urinary Anti-infectives Urinary Antispasmodics Urinary Ph Modifiers Urinary Retention Therapy Vaginal Anti-infectives Vaginal Estrogens Vitamin Combinations Vitamins Wound Care Therapy Acne Therapy Analgesic, Anti-inflammatory or Antipyretic - Non-Narcotic Anorectal - Hemorrhoidal Single Agents Other Anorectal Combinations Antacids and Combinations Antidiarrheals...46 Antiemetics...46 Antihistamines Antiseptic - Biguanides Antitussives...47 Artificial Tears and Lubricants Bulk Chemicals Chemicals - Solvents Dermatological - Anti-infectives Dermatological - Antiparasitics and Combinations Dermatological - Antipruritics Dermatological - Antiseborrheic Products and Combinations Dermatological - Astringents and Combinations Dermatological - Emollients and Combinations Dermatological - Glucocorticoids and Combinations Dermatological - Irritants-Counter-Irritants Dermatological - Keratolytics-Antimitotics Dermatological - Soaps and Cleansers Diabetic Therapy Diagnostic Test Reagents Dietary Products Digestive Aids Emergency Contraceptives and Combinations Expectorants Gastrointestinal Antiflatulents and Combinations Irrigation Solutions Laxatives Medical Supplies & DME - Diabetic Supplies Medical Supplies & DME - GI-GU Ostomy & Irrigation Supplies

5 Medical Supplies & DME - Respiratory Therapy Medical Supplies & DME - Thermometers Minerals & Electrolytes Mouth and Throat - Non-Narcotic Antitussive - Local Anesthetic Combos Nasal Preparations Ophthalmic - Anti-allergy Ophthalmic - Hyperosmolar Agents Peptic Ulcer Therapy Respiratory Combinations Sedative-Hypnotics Smoking Deterrents and Combinations Urinary Analgesics Vaginal Anti-infectives Vitamin Combinations Vitamins

6 Introduction Trusted Health Plan is pleased to provide an updated 2015 Medicaid Formulary as a reference and informational tool for physicians, pharmacists and patients. The Trusted Health Plan Formulary is designed to assist practitioners in selecting clinically appropriate and cost-effective products for their patients. The Trusted Health Plan Pharmacy and Therapeutics Committee (P&T) The medications on this formulary have been reviewed by the Trusted Health Plan Pharmacy P&T Committee. The Committee includes physicians, pharmacists and health professionals. The clinical information within the formulary is primarily derived from medical literature and is reviewed and approved by the P&T Committee. Notice The information contained in this formulary is provided by Trusted Health Plan, solely for the convenience of medical providers. This formulary is not intended to be a substitute for the knowledge, expertise, skill and judgment of the medical provider in their choice of prescription drugs. Trusted Health Plan assumes no responsibility for the actions or omissions of any medical provider based upon reliance, in whole or in part, on the information contained herein. The medical provider should consult the drug manufacturer s product literature or standard references for more detailed information. Preface The Trusted Health Plan formulary is organized by sections. Each section includes therapeutic groups identified by either drug class or disease state. Products are listed by generic name. Brand and common names are included as a reference to assist in product recognition. Trusted Health Plan will not cover prescription drugs that are prescribed for experimental, investigational or non FDA approved indications, dosages, or routes of administration. Trusted Health Plan does not cover any medication excluded by District of Columbia Medicaid ( downloads/providers/dcrx_pdl_listing.pdf). Product Selection Criteria The MeridianRx P&T Committee considers clinical information on new to market drugs that are typically included in an outpatient pharmacy benefit. The primary goal of the MeridianRx P&T Committee is to preserve and evaluate the Trusted Health Plan formulary based upon an objective analysis of the safety, efficacy, approved indications, adverse effects, contraindications, patient administration/compliance considerations and cost effectiveness. When a new drug is considered for formulary inclusion, it will be reviewed relative to similar drugs currently included in the Trusted Health Plan Formulary. Formulary decisions are communicated quarterly on the Trusted Health Plan website. Therapeutic substitution occurs when a preferred drug is approved for use because it has similar treatment effects but is not identical to a nonpreferred drug. Formulary Components The Trusted Health Plan Formulary contains the following components: Covered medications without authorization, medications that must meet Step Therapy Protocol, medications that require Prior Authorization, Specialty medications and medications that are subject to Quantity Limits. Members will not be charged a co-pay when Trusted Health Plan covers a medication. Generic Substitution Trusted Health Plan is a mandatory generic plan. The brand and common names listed in the formulary are for reference only. Generic medication will be dispensed where available. Covered Medications without Authorization Trusted Health Plan covers many medications without any authorization required. These medications include many prescription and over-the-counter medications (when ordered by a physician). 6

7 Non-Covered Benefits The following categories are not covered benefits: Medications used for cosmetic purposes, to promote fertility, for sexual dysfunction, for experimental or investigational purposes, or medications that are not licensed for use in the United States. Prior Authorization Drugs indicated with "PA" require Prior Authorization for coverage. Details of the PA criteria are listed next to the drug name. Please call the MeridianRx Help Desk at or fax a completed Prior Authorization form to All requests must be accompanied by pertinent clinical information and are reviewed within 72 hours. Step Therapy Drugs indicated with a "ST" require Step Therapy for coverage. The required step is listed next to the drug name. Step Therapy ensures clinically appropriate and cost-effective drugs are used before other alternatives. Specialty Medications All specialty medications noted as "SP" are handled by MeridianRx. To order a specialty medication by fax, send the prescription and a completed prior authorization form to or call MeridianRx s Help Desk at Quantity Limits Drugs indicated with a "QL" have a set quantity limit imposed. These limits are based on FDA recommended dosing guidelines. The quantity limit is listed next to the drug name. All medications are subject to a maximum of 30 days per prescription. Benefit Exception The process for requesting non formulary medication(s) requires faxing of a completed Formulary Exception form indicating the request for an exception to the formulary. This request will need to include pertinent clinical documentation showing trial and failure of all formulary agents. It should also contain information showing the medication is the standard of care for the indication provided (Peer reviewed journal articles may be required). Please call the MeridianRx Help Desk at or fax a completed Formulary Exception form to Pharmacy Benefit Management Trusted Health Plan utilizes MeridianRx to manage each member s pharmacy benefit. MeridianRx provides Trusted Health Plan with a pharmacy network, pharmacy claims management services, and claims adjudication. MeridianRx s Help Desk can be contacted at

8 Prior Authorization Information Agents for Narcotic Withdrawal BUPRENORPHINE HCL/NALOXONE HCL SUBOXONE Analgesic, Anti-inflammatory or Antipyretic - Non-Narcotic ADALIMUMAB HUMIRA PA ANAKINRA KINERET PA BELIMUMAB BENLYSTA PA ETANERCEPT ENBREL PA PA Anterior Pituitary Hormones and Hormone Antagonists LEUPROLIDE ACETATE LUPRON DEPOT-PED PA OCTREOTIDE ACETATE, MICROSPHERES SANDOSTATIN LAR PA Anti-Infective - Immunologic Adjuvants INTERFERON GAMMA-1B,RECOMB. ACTIMMUNE PA,SP Antibacterial Agents THALIDOMIDE THALOMID PA TOBRAMYCIN TOBI PODHALER PA TOBRAMYCIN IN % SODIUM CHLORIDE TOBI Anticonvulsant CLOBAZAM ONFI PA Antidepressants DULOXETINE HCL CYMBALTA PA,QL PA Antihemophilic Factor Agents ANTI-INHIBITOR COAGULANT COMPLEX ANTIHEMOPHILIC FACTOR (FVIII) RECOMB,FULL LENGTH (ALB-FREE) ANTIHEMOPHILIC FACTOR VIII, HUMAN RECOMBINANT FEIBA NF KOGENATE FS RECOMBINATE ANTIHEMOPHILIC FACTOR, HUMAN MONOCLATE-P PA ANTIHEMOPHILIC FACTOR, HUMAN/ VON WILLEBRAND FACTOR,HUMAN COAGULATION FACTOR VIIA (RECOMBINANT) HUMATE-P NOVOSEVEN RT FACTOR IX ALPHANINE SD PA FACTOR IX HUMAN RECOMBINANT BENEFIX PA PA PA PA PA PA 8

9 Prior Authorization Information Antihyperlipidemics LOMITAPIDE MESYLATE JUXTAPID PA Antihypertensive Therapy Agents AMBRISENTAN LETAIRIS PA Antineoplastic - Alkylating Agents TEMOZOLOMIDE TEMODAR PA,QL Antineoplastic - Antibody/Antibody-Drug Complexes PERTUZUMAB PERJETA PA Antineoplastic - Antimetabolites CAPECITABINE XELODA PA Antineoplastic - Hedgehog Pathway Inhibitor VISMODEGIB ERIVEDGE PA Antineoplastic - Hormone/Hormone Antagonist Agents ENZALUTAMIDE XTANDI PA GOSERELIN ACETATE ZOLADEX PA LEUPROLIDE ACETATE ELIGARD PA TRIPTORELIN PAMOATE TRELSTAR PA Antineoplastic - Systemic Enzyme Inhibitors BOSUTINIB BOSULIF PA CABOZANTINIB S-MALATE COMETRIQ PA CRIZOTINIB XALKORI PA IMATINIB MESYLATE GLEEVEC PA,QL PONATINIB HCL ICLUSIG PA RUXOLITINIB PHOSPHATE JAKAFI PA VEMURAFENIB ZELBORAF PA Antineoplastic - Topoisomerase Inhibitors TOPOTECAN HCL HYCAMTIN PA Antivirals ADEFOVIR DIPIVOXIL ADEFOVIR DIPIVOXIL PA LEDIPASVIR/SOFOSBUVIR HARVONI PA,SP PEGINTERFERON ALFA-2A PEGASYS PA PEGINTERFERON ALFA-2B PEGINTRON REDIPEN PA RIBAVIRIN REBETOL PA TIPRANAVIR APTIVUS PA TIPRANAVIR/VITAMIN E TPGS APTIVUS PA 9

10 Prior Authorization Information Asthma/COPD Therapy Agents OMALIZUMAB XOLAIR PA Bipolar Therapy Agents ARIPIPRAZOLE ABILIFY PA Blood Albumin and Plasma Proteins C1 ESTERASE INHIBITOR CINRYZE PA Bradykinin B2 Receptor Antagonists ICATIBANT ACETATE FIRAZYR PA Calcium & Bone Metabolism Regulators TERIPARATIDE FORTEO PA Chelating Agents DEFERASIROX EXJADE PA Cystic Fibrosis Therapy Agents IVACAFTOR KALYDECO PA Diabetic Therapy EXENATIDE MICROSPHERES BYDUREON PA Diagnostic Drugs - In Vivo THYROTROPIN ALFA THYROGEN PA DARBEPOETIN ALFA IN POLYSORBATE 80 Hematopoietic Agents ARANESP EPOETIN ALFA PROCRIT PA FILGRASTIM NEUPOGEN PA PEGFILGRASTIM NEULASTA PA ROMIPLOSTIM NPLATE PA PA Hepatic Hormones (Hormones Secreted by the Liver) MECASERMIN INCRELEX PA Inflammatory Bowel Agents ADALIMUMAB HUMIRA PA INFLIXIMAB REMICADE PA 10

11 Prior Authorization Information Metabolic Disease Enzyme Replacement, Gaucher s Disease IMIGLUCERASE CEREZYME PA Mucolytics DORNASE ALFA PULMOZYME PA Multiple Sclerosis Agent - Interferons INTERFERON BETA-1A/ALBUMIN HUMAN REBIF INTERFERON BETA-1B EXTAVIA PA PA Multiple Sclerosis Agent - Potassium Channel Blocker DALFAMPRIDINE AMPYRA PA Musculoskeletal Therapy Agents HYALURONATE SODIUM EUFLEXXA PA HYLAN G-F 20 SYNVISC PA Passive Immunizing Agents CYTOMEGALOVIRUS IMMUNE GLOBULN CYTOGAM PALIVIZUMAB SYNAGIS PA RHO(D) IMMUNE GLOBULIN RHOGAM ULTRA-FILTERED PLUS PA PA Pseudobulbar Affect (PBA) Agents DEXTROMETHORPHAN HBR/ QUINIDINE SULFATE NUEDEXTA PA 11

12 ADAPALENE BENZOYL PEROXIDE Acne Therapy CLINDAMYCIN PHOSPHATE ERYTHROMYCIN BASE/ETHYL ALCOHOL ISOTRETINOIN METRONIDAZOLE SULFACETAMIDE SODIUM SULFACETAMIDE SODIUM/SULFUR TRETINOIN ADAPALENE BENZOYL PEROXIDE CLINDAMYCIN PHOSPHATE ERYTHROMYCIN AMNESTEEM METRONIDAZOLE SULFACETAMIDE SODIUM SODIUM SULFACETAMIDE- SULFUR TRETINOIN Agents for Narcotic Withdrawal BUPRENORPHINE HCL/NALOXONE HCL DISULFIRAM SUBOXONE PA Alcoholism Treatment Agents DISULFIRAM Analgesic, Anti-inflammatory or Antipyretic - Non-Narcotic ADALIMUMAB HUMIRA PA ANAKINRA KINERET PA BELIMUMAB BENLYSTA PA BUTALBITAL/ASPIRIN/CAFFEINE CELECOXIB DICLOFENAC SODIUM DIFLUNISAL BUTALBITAL-ASPIRIN- CAFFEINE CELEBREX DICLOFENAC SODIUM ER DIFLUNISAL ETANERCEPT ENBREL PA IBUPROFEN KETOPROFEN KETOROLAC TROMETHAMINE LEFLUNOMIDE MELOXICAM METHOTREXATE SODIUM NABUMETONE NAPROXEN NAPROXEN SODIUM OXAPROZIN SULINDAC IBUPROFEN KETOPROFEN KETOROLAC TROMETHAMINE LEFLUNOMIDE MELOXICAM METHOTREXATE NABUMETONE NAPROXEN NAPROXEN SODIUM OXAPROZIN SULINDAC QL 12

13 Analgesics - Narcotic ACETAMINOPHEN WITH CODEINE PHOSPHATE CODEINE PHOSPHATE/BUTALBITAL/ ASPIRIN/CAFFEINE ACETAMINOPHEN-CODEINE BUTALBITAL COMPOUND- CODEINE FENTANYL FENTANYL QL HYDROCODONE BITARTRATE/ ACETAMINOPHEN HYDROMORPHONE HCL MEPERIDINE HCL/PF MORPHINE SULFATE MORPHINE SULFATE IN SODIUM CHLORIDE, ISO-OSMOTIC/PF VICODIN HYDROMORPHONE HCL MEPERIDINE HCL MORPHINE SULFATE MORPHINE SULFATE-NACL,ISO- OSM OXYCODONE HCL OXYCODONE HCL QL OXYCODONE HCL/ACETAMINOPHEN OXYCODONE HCL/ASPIRIN OXYCODONE- ACETAMINOPHEN OXYCODONE HCL-ASPIRIN TRAMADOL HCL TRAMADOL HCL QL TRAMADOL HCL/ACETAMINOPHEN TRAMADOL HCL- ACETAMINOPHEN Angina Therapy ISOSORBIDE DINITRATE ISOSORBIDE MONONITRATE NITROGLYCERIN HYDROCORTISONE ISOSORBIDE DINITRATE ISOSORBIDE MONONITRATE NITROGLYCERIN PATCH QL QL QL QL QL Anorectal - Glucocorticoids HYDROCORTISONE ACETATE HYDROCORTISONE ANUCORT-HC Anorectal Combinations LIDOCAINE HCL/HYDROCORTISONE ACETATE DANAZOL LIDOCAINE-HYDROCORTISONE Anterior Pituitary Hormones and Hormone Antagonists DANAZOL LEUPROLIDE ACETATE LUPRON DEPOT-PED PA OCTREOTIDE ACETATE OCTREOTIDE ACETATE, MICROSPHERES SANDOSTATIN SANDOSTATIN LAR PA Anti-Infective - Immunologic Adjuvants INTERFERON GAMMA-1B,RECOMB. ACTIMMUNE PA,SP 13

14 ALPRAZOLAM BUSPIRONE HCL Antianxiety Agents CHLORDIAZEPOXIDE HCL CLONAZEPAM DIAZEPAM HYDROXYZINE HCL LORAZEPAM OXAZEPAM AMIODARONE HCL DILTIAZEM HCL ALPRAZOLAM BUSPIRONE HCL CHLORDIAZEPOXIDE HCL CLONAZEPAM DIAZEPAM HYDROXYZINE HCL LORAZEPAM OXAZEPAM Antiarrhythmics DISOPYRAMIDE PHOSPHATE FLECAINIDE ACETATE LIDOCAINE HCL/PF PHENYTOIN SODIUM PROPAFENONE HCL SOTALOL HCL VERAPAMIL HCL AMOXICILLIN AMIODARONE HCL DILTIAZEM HCL DISOPYRAMIDE PHOSPHATE FLECAINIDE ACETATE LIDOCAINE HCL PHENYTOIN SODIUM PROPAFENONE HCL SOTALOL VERAPAMIL HCL Antibacterial Agents AMOXICILLIN/POTASSIUM CLAVULANATE AMPICILLIN TRIHYDRATE AMOXICILLIN AMOX TR-POTASSIUM CLAVULANATE AMPICILLIN TRIHYDRATE AZITHROMYCIN ZITHROMAX QL BACITRACIN CEFACLOR CEFADROXIL CEFDINIR CEFPROZIL CEFUROXIME AXETIL CEPHALEXIN CIPROFLOXACIN CIPROFLOXACIN HCL CLARITHROMYCIN CLINDAMYCIN HCL CLINDAMYCIN PALMITATE HCL DAPSONE DICLOXACILLIN SODIUM DOXYCYCLINE HYCLATE ERYTHROMYCIN BASE ERYTHROMYCIN ETHYLSUCCINATE BACITRACIN CEFACLOR CEFADROXIL CEFDINIR CEFPROZIL CEFUROXIME CEPHALEXIN CIPRO CIPROFLOXACIN HCL CLARITHROMYCIN CLINDAMYCIN HCL CLINDAMYCIN PALMITATE HCL DAPSONE DICLOXACILLIN SODIUM DOXYCYCLINE HYCLATE ERYTHROMYCIN ERYTHROMYCIN ETHYLSUCCINATE 14

15 Antibacterial Agents ERYTHROMYCIN STEARATE ETHAMBUTOL HCL GENTAMICIN SULFATE GENTAMICIN SULFATE/PF ISONIAZID LEVOFLOXACIN MINOCYCLINE HCL OFLOXACIN PENICILLIN G POTASSIUM PENICILLIN G PROCAINE PENICILLIN G SODIUM PENICILLIN V POTASSIUM PYRAZINAMIDE RIFAMPIN SULFAMETHOXAZOLE/ TRIMETHOPRIM TETRACYCLINE HCL ERYTHROMYCIN STEARATE ETHAMBUTOL HCL GENTAMICIN SULFATE GENTAMICIN SULFATE ISONIAZID LEVOFLOXACIN MINOCYCLINE HCL OFLOXACIN PENICILLIN G POTASSIUM PENICILLIN G PROCAINE PENICILLIN G SODIUM PENICILLIN V POTASSIUM PYRAZINAMIDE RIFAMPIN SULFAMETHOXAZOLE- TRIMETHOPRIM TETRACYCLINE HCL THALIDOMIDE THALOMID PA TOBRAMYCIN TOBI PODHALER PA TOBRAMYCIN IN % SODIUM CHLORIDE TRIMETHOPRIM VANCOMYCIN HCL TOBI TRIMETHOPRIM VANCOMYCIN HCL Anticoagulants DABIGATRAN ETEXILATE MESYLATE PRADAXA ENOXAPARIN SODIUM ENOXAPARIN SODIUM QL RIVAROXABAN XARELTO QL WARFARIN SODIUM CARBAMAZEPINE WARFARIN SODIUM Anticonvulsant CARBAMAZEPINE CLOBAZAM ONFI PA DIAZEPAM DIVALPROEX SODIUM ETHOSUXIMIDE GABAPENTIN LAMOTRIGINE LEVETIRACETAM OXCARBAZEPINE PHENYTOIN PHENYTOIN SODIUM EXTENDED DIAZEPAM DIVALPROEX SODIUM ETHOSUXIMIDE GABAPENTIN LAMOTRIGINE LEVETIRACETAM OXCARBAZEPINE PHENYTOIN PHENYTOIN SODIUM EXTENDED PREGABALIN LYRICA QL PA 15

16 PRIMIDONE TIAGABINE HCL TOPIRAMATE VALPROIC ACID Anticonvulsant VALPROIC ACID (AS SODIUM SALT) (VALPROATE SODIUM) ZONISAMIDE AMITRIPTYLINE HCL BUPROPION HCL PRIMIDONE TIAGABINE HCL TOPIRAMATE VALPROIC ACID VALPROIC ACID ZONISAMIDE Antidepressants CITALOPRAM HYDROBROMIDE CLOMIPRAMINE HCL DOXEPIN HCL AMITRIPTYLINE HCL BUPROPION XL CITALOPRAM HBR CLOMIPRAMINE HCL DOXEPIN HCL DULOXETINE HCL CYMBALTA PA,QL ESCITALOPRAM OXALATE FLUOXETINE HCL FLUVOXAMINE MALEATE IMIPRAMINE HCL IMIPRAMINE PAMOATE MIRTAZAPINE NORTRIPTYLINE HCL PAROXETINE HCL PHENELZINE SULFATE SERTRALINE HCL TRANYLCYPROMINE SULFATE TRAZODONE HCL VENLAFAXINE HCL ESCITALOPRAM OXALATE FLUOXETINE HCL FLUVOXAMINE MALEATE IMIPRAMINE HCL IMIPRAMINE PAMOATE MIRTAZAPINE NORTRIPTYLINE HCL PAROXETINE HCL PHENELZINE SULFATE SERTRALINE HCL TRANYLCYPROMINE SULFATE TRAZODONE HCL VENLAFAXINE HCL Antidiarrheals DIPHENOXYLATE HCL/ATROPINE SULFATE DRONABINOL GRANISETRON HCL MECLIZINE HCL DIPHENOXYLATE-ATROPINE Antiemetics DRONABINOL GRANISETRON HCL MECLIZINE HCL ONDANSETRON HCL ONDANSETRON HCL QL PROCHLORPERAZINE PROCHLORPERAZINE EDISYLATE PROCHLORPERAZINE MALEATE TRIMETHOBENZAMIDE HCL PROCHLORPERAZINE PROCHLORPERAZINE EDISYLATE PROCHLORPERAZINE MALEATE TRIMETHOBENZAMIDE HCL 16

17 Antifungals FLUCONAZOLE FLUCONAZOLE QL GRISEOFULVIN ULTRAMICROSIZE GRISEOFULVIN, MICROSIZE ITRACONAZOLE KETOCONAZOLE NYSTATIN TERBINAFINE HCL GRISEOFULVIN ULTRAMICROSIZE GRISEOFULVIN ITRACONAZOLE KETOCONAZOLE NYSTATIN TERBINAFINE HCL Antihemophilic Factor Agents ANTI-INHIBITOR COAGULANT COMPLEX ANTIHEMOPHILIC FACTOR (FVIII) RECOMB,FULL LENGTH (ALB-FREE) ANTIHEMOPHILIC FACTOR VIII, HUMAN RECOMBINANT FEIBA NF KOGENATE FS RECOMBINATE ANTIHEMOPHILIC FACTOR, HUMAN MONOCLATE-P PA ANTIHEMOPHILIC FACTOR, HUMAN/ VON WILLEBRAND FACTOR,HUMAN COAGULATION FACTOR VIIA (RECOMBINANT) HUMATE-P NOVOSEVEN RT FACTOR IX ALPHANINE SD PA FACTOR IX HUMAN RECOMBINANT BENEFIX PA CETIRIZINE HCL Antihistamines CLEMASTINE FUMARATE CYPROHEPTADINE HCL DIPHENHYDRAMINE HCL FEXOFENADINE HCL PROMETHAZINE HCL CETIRIZINE HCL CLEMASTINE FUMARATE CYPROHEPTADINE HCL DIPHENHYDRAMINE HCL FEXOFENADINE HCL PROMETHAZINE HCL Antihyperlipidemics ATORVASTATIN CALCIUM CHOLESTYRAMINE/ASPARTAME COLESTIPOL HCL EZETIMIBE FENOFIBRATE FENOFIBRATE NANOCRYSTALLIZED FENOFIBRATE,MICRONIZED GEMFIBROZIL ATORVASTATIN CALCIUM CHOLESTYRAMINE LIGHT COLESTIPOL HCL ZETIA FENOFIBRATE FENOFIBRATE FENOFIBRATE GEMFIBROZIL LOMITAPIDE MESYLATE JUXTAPID PA LOVASTATIN NIACIN PRAVASTATIN SODIUM LOVASTATIN NIACIN ER PRAVASTATIN SODIUM PA PA PA PA PA 17

18 SIMVASTATIN Antihyperlipidemics SIMVASTATIN Antihypertensive Therapy Agents ALISKIREN HEMIFUMARATE ALISKIREN HEMIFUMARATE/ HYDROCHLOROTHIAZIDE TEKTURNA TEKTURNA HCT AMBRISENTAN LETAIRIS PA AMLODIPINE BESYLATE/ OLMESARTAN MEDOXOMIL ATENOLOL/CHLORTHALIDONE BENAZEPRIL HCL BENAZEPRIL HCL/ HYDROCHLOROTHIAZIDE BISOPROLOL FUMARATE/ HYDROCHLOROTHIAZIDE CAPTOPRIL CAPTOPRIL/ HYDROCHLOROTHIAZIDE AZOR ATENOLOL-CHLORTHALIDONE BENAZEPRIL HCL BENAZEPRIL- HYDROCHLOROTHIAZIDE BISOPROLOL- HYDROCHLOROTHIAZIDE CAPTOPRIL CAPTOPRIL- HYDROCHLOROTHIAZIDE CLONIDINE CLONIDINE QL CLONIDINE HCL DOXAZOSIN MESYLATE ENALAPRIL MALEATE ENALAPRIL MALEATE/ HYDROCHLOROTHIAZIDE EPOPROSTENOL SODIUM (GLYCINE) FOSINOPRIL SODIUM FOSINOPRIL SODIUM/ HYDROCHLOROTHIAZIDE GUANFACINE HCL HYDRALAZINE HCL CLONIDINE HCL DOXAZOSIN MESYLATE ENALAPRIL MALEATE ENALAPRIL- HYDROCHLOROTHIAZIDE FLOLAN FOSINOPRIL SODIUM FOSINOPRIL- HYDROCHLOROTHIAZIDE GUANFACINE HCL HYDRALAZINE HCL IRBESARTAN IRBESARTAN QL ISOSORBIDE DINITRATE/ HYDRALAZINE HCL LISINOPRIL LISINOPRIL/HYDROCHLOROTHIAZIDE BIDIL LISINOPRIL LISINOPRIL- HYDROCHLOROTHIAZIDE LOSARTAN POTASSIUM LOSARTAN POTASSIUM QL LOSARTAN POTASSIUM/ HYDROCHLOROTHIAZIDE METHYLDOPA METOPROLOL TARTRATE/ HYDROCHLOROTHIAZIDE PRAZOSIN HCL PROPRANOLOL HCL/ HYDROCHLOROTHIAZIDE QUINAPRIL HCL LOSARTAN- HYDROCHLOROTHIAZIDE METHYLDOPA METOPROLOL- HYDROCHLOROTHIAZIDE PRAZOSIN HCL PROPRANOLOL- HYDROCHLOROTHIAZID QUINAPRIL HCL QL QL 18

19 Antihypertensive Therapy Agents QUINAPRIL HCL/ HYDROCHLOROTHIAZIDE RAMIPRIL QUINAPRIL- HYDROCHLOROTHIAZIDE RAMIPRIL SILDENAFIL CITRATE SILDENAFIL QL TERAZOSIN HCL ALTRETAMINE BUSULFAN CHLORAMBUCIL CYCLOPHOSPHAMIDE LOMUSTINE MELPHALAN PROCARBAZINE HCL TERAZOSIN HCL Antineoplastic - Alkylating Agents HEXALEN MYLERAN LEUKERAN CYCLOPHOSPHAMIDE LOMUSTINE ALKERAN MATULANE TEMOZOLOMIDE TEMODAR PA,QL Antineoplastic - Antibody/Antibody-Drug Complexes PERTUZUMAB PERJETA PA Antineoplastic - Antimetabolites CAPECITABINE XELODA PA FLUOROURACIL HYDROXYUREA MERCAPTOPURINE THIOGUANINE FLUOROURACIL HYDREA MERCAPTOPURINE TABLOID Antineoplastic - Hedgehog Pathway Inhibitor VISMODEGIB ERIVEDGE PA ANASTROZOLE BICALUTAMIDE Antineoplastic - Hormone/Hormone Antagonist Agents ANASTROZOLE BICALUTAMIDE ENZALUTAMIDE XTANDI PA ESTRAMUSTINE PHOSPHATE SODIUM EXEMESTANE FLUTAMIDE EMCYT EXEMESTANE FLUTAMIDE GOSERELIN ACETATE ZOLADEX PA LETROZOLE LETROZOLE LEUPROLIDE ACETATE ELIGARD PA MEGESTROL ACETATE MITOTANE TAMOXIFEN CITRATE MEGESTROL ACETATE LYSODREN TAMOXIFEN CITRATE 19

20 TOREMIFENE CITRATE Antineoplastic - Hormone/Hormone Antagonist Agents FARESTON TRIPTORELIN PAMOATE TRELSTAR PA Antineoplastic - Immunomodulators INTERFERON ALFA-2B,RECOMB. CROMOLYN SODIUM OXALIPLATIN BEXAROTENE INTRON A Antineoplastic - Mast Cell Stabilizers CROMOLYN SODIUM Antineoplastic - Metal Complexes OXALIPLATIN Antineoplastic - Retinoids and Retinoid Receptor Agonists TARGRETIN Antineoplastic - Systemic Enzyme Inhibitors BOSUTINIB BOSULIF PA CABOZANTINIB S-MALATE COMETRIQ PA CRIZOTINIB XALKORI PA ERLOTINIB HCL TARCEVA QL IMATINIB MESYLATE GLEEVEC PA,QL PONATINIB HCL ICLUSIG PA RUXOLITINIB PHOSPHATE JAKAFI PA VEMURAFENIB ZELBORAF PA ETOPOSIDE Antineoplastic - Topoisomerase Inhibitors ETOPOSIDE TOPOTECAN HCL HYCAMTIN PA Antiparasitics ATOVAQUONE/PROGUANIL HCL CHLOROQUINE PHOSPHATE HYDROXYCHLOROQUINE SULFATE MEFLOQUINE HCL AMANTADINE HCL ATOVAQUONE-PROGUANIL HCL CHLOROQUINE PHOSPHATE HYDROXYCHLOROQUINE SULFATE MEFLOQUINE HCL Antiparkinson Therapy BENZTROPINE MESYLATE BROMOCRIPTINE MESYLATE CARBIDOPA/LEVODOPA CARBIDOPA/LEVODOPA/ ENTACAPONE AMANTADINE BENZTROPINE MESYLATE BROMOCRIPTINE MESYLATE CARBIDOPA-LEVODOPA CARBIDOPA-LEVODOPA- ENTACAPONE 20

21 ENTACAPONE PRAMIPEXOLE DI-HCL ROPINIROLE HCL SELEGILINE HCL TRIHEXYPHENIDYL HCL METRONIDAZOLE Antiparkinson Therapy ENTACAPONE PRAMIPEXOLE DIHYDROCHLORIDE ROPINIROLE HCL SELEGILINE HCL TRIHEXYPHENIDYL HCL Antiprotozoal-Antibacterial Agents METRONIDAZOLE IN SODIUM CHLORIDE METRONIDAZOLE METRONIDAZOLE Antipsychotics (Neuroleptics) CLOZAPINE CLOZAPINE ODT QL FLUPHENAZINE DECANOATE FLUPHENAZINE HCL HALOPERIDOL HALOPERIDOL DECANOATE HALOPERIDOL LACTATE FLUPHENAZINE DECANOATE FLUPHENAZINE HCL HALOPERIDOL HALOPERIDOL DECANOATE HALOPERIDOL LACTATE OLANZAPINE OLANZAPINE QL PALIPERIDONE PALMITATE PERPHENAZINE INVEGA SUSTENNA PERPHENAZINE QUETIAPINE FUMARATE QUETIAPINE FUMARATE QL RISPERIDONE THIOTHIXENE TRIFLUOPERAZINE HCL ZIPRASIDONE HCL BENZONATATE ACYCLOVIR RISPERIDONE THIOTHIXENE TRIFLUOPERAZINE HCL ZIPRASIDONE HCL Antitussives BENZONATATE Antivirals ACYCLOVIR ADEFOVIR DIPIVOXIL ADEFOVIR DIPIVOXIL PA FAMCICLOVIR GANCICLOVIR SODIUM LAMIVUDINE FAMCICLOVIR GANCICLOVIR SODIUM EPIVIR HBV LEDIPASVIR/SOFOSBUVIR HARVONI PA,SP OSELTAMIVIR PHOSPHATE TAMIFLU PEGINTERFERON ALFA-2A PEGASYS PA PEGINTERFERON ALFA-2B PEGINTRON REDIPEN PA RIBAVIRIN REBETOL PA RIMANTADINE HCL RIMANTADINE HCL 21

22 Antivirals TIPRANAVIR APTIVUS PA TIPRANAVIR/VITAMIN E TPGS APTIVUS PA VALACYCLOVIR HCL ZANAMIVIR MEGESTROL ACETATE ALBUTEROL SULFATE BUDESONIDE VALACYCLOVIR RELENZA Appetite Stimulants MEGESTROL ACETATE Asthma/COPD Therapy Agents BUDESONIDE/FORMOTEROL FUMARATE CROMOLYN SODIUM FLUTICASONE PROPIONATE FLUTICASONE PROPIONATE/ SALMETEROL XINAFOATE FORMOTEROL FUMARATE IPRATROPIUM BROMIDE LEVALBUTEROL HCL LEVALBUTEROL TARTRATE MONTELUKAST SODIUM PROVENTIL HFA BUDESONIDE SYMBICORT CROMOLYN SODIUM FLOVENT DISKUS ADVAIR DISKUS FORADIL IPRATROPIUM BROMIDE LEVALBUTEROL HCL XOPENEX HFA MONTELUKAST SODIUM OMALIZUMAB XOLAIR PA SALMETEROL XINAFOATE TERBUTALINE SULFATE THEOPHYLLINE ANHYDROUS THEOPHYLLINE/DEXTROSE 5 % IN WATER TIOTROPIUM BROMIDE ZAFIRLUKAST SEREVENT DISKUS TERBUTALINE SULFATE THEOPHYLLINE THEOPHYLLINE IN 5% DEXTROSE SPIRIVA ZAFIRLUKAST Attention Deficit-Hyperact Disorder (ADHD) Therapy DEXMETHYLPHENIDATE HCL GUANFACINE HCL METHYLPHENIDATE HCL ATENOLOL DEXMETHYLPHENIDATE HCL GUANFACINE HCL ER RITALIN LA Beta Adrenergic Blockers BISOPROLOL FUMARATE ATENOLOL BISOPROLOL FUMARATE CARVEDILOL CARVEDILOL QL LABETALOL HCL METOPROLOL SUCCINATE METOPROLOL TARTRATE NADOLOL LABETALOL HCL METOPROLOL SUCCINATE METOPROLOL TARTRATE NADOLOL 22

23 Beta Adrenergic Blockers PROPRANOLOL HCL PROPRANOLOL HCL TIMOLOL MALEATE TIMOLOL MALEATE Bipolar Therapy Agents ARIPIPRAZOLE ABILIFY PA LITHIUM CARBONATE LITHIUM CARBONATE ER Blood Albumin and Plasma Proteins C1 ESTERASE INHIBITOR CINRYZE PA Bradykinin B2 Receptor Antagonists ICATIBANT ACETATE FIRAZYR PA Calcium & Bone Metabolism Regulators ALENDRONATE SODIUM ALENDRONATE SODIUM QL CALCITONIN,SALMON,SYNTHETIC MIACALCIN RALOXIFENE HCL EVISTA TERIPARATIDE FORTEO PA Calcium Channel Blockers and Combinations AMLODIPINE BESYLATE AMLODIPINE BESYLATE QL DILTIAZEM HCL DILTIAZEM HCL NIFEDIPINE NIFEDIPINE ER VERAPAMIL HCL VERAPAMIL ER Cardiac Inotropes DIGOXIN DIGOXIN Cardiovascular Sympathomimetics and Combinations EPINEPHRINE AUVI-Q MIDODRINE HCL MIDODRINE HCL Chelating Agents DEFERASIROX EXJADE PA Chemotherapy Rescue-Antidote Agents LEUCOVORIN CALCIUM LEUCOVORIN CALCIUM MESNA MESNA 23

24 CNS Stimulants DEXTROAMPHETAMINE SULF- SACCHARATE/AMPHETAMINE SULF- ASPARTATE DEXTROAMPHETAMINE SULFATE DONEPEZIL HCL GALANTAMINE HBR RIVASTIGMINE DEXTROAMPHETAMINE- AMPHET ER DEXTROAMPHETAMINE SULFATE QL Cognitive Disorder Therapy - Antidementia RIVASTIGMINE TARTRATE LACTULOSE ETONOGESTREL DONEPEZIL HCL GALANTAMINE HYDROBROMIDE RIVASTIGMINE RIVASTIGMINE Colonic Acidifier (Ammonia Inhibitor) LACTULOSE Contraceptives Implant NEXPLANON Contraceptives Injectable MEDROXYPROGESTERONE ACETATE DEPO-PROVERA Contraceptives Intravaginal ETONOGESTREL/ETHINYL ESTRADIOL NUVARING Contraceptives Oral DESOGESTREL-ETHINYL ESTRADIOL DESOGESTREL-ETHINYL ESTRADIOL/ ETHINYL ESTRADIOL ETHINYL ESTRADIOL/ DROSPIRENONE ETHYNODIOL DIACETATE-ETHINYL ESTRADIOL LEVONORGESTREL-ETHINYL ESTRADIOL LEVONORGESTREL/ETHINYL ESTRADIOL AND ETHINYL ESTRADIOL NORETHINDRONE NORETHINDRONE ACETATE-ETHINYL ESTRADIOL NORETHINDRONE ACETATE-ETHINYL ESTRADIOL/FERROUS FUMARATE NORETHINDRONE-ETHINYL ESTRADIOL DESOGEN KARIVA GIANVI ZOVIA 1-50E LEVONORGESTREL-ETH ESTRADIOL CAMRESE NORETHINDRONE NORETHINDRON-ETHINYL ESTRADIOL NORETHIN-ETH ESTRA FERROUS FUM OVCON-35 QL 24

25 Contraceptives Oral NORETHINDRONE-MESTRANOL NORGESTIMATE-ETHINYL ESTRADIOL NORGESTREL-ETHINYL ESTRADIOL NECON SPRINTEC CRYSELLE Contraceptives Transdermal NORELGESTROMIN/ETHINYL ESTRADIOL DEXAMETHASONE XULANE Corticosteroids DEXAMETHASONE SOD PHOSPHATE FLUDROCORTISONE ACETATE HYDROCORTISONE METHYLPREDNISOLONE PREDNISOLONE SOD PHOSPHATE PREDNISONE DEXAMETHASONE DEXAMETHASONE SODIUM PHOSPHATE FLUDROCORTISONE ACETATE HYDROCORTISONE METHYLPREDNISOLONE PREDNISOLONE SODIUM PHOSPHATE PREDNISONE QL Cystic Fibrosis Therapy Agents IVACAFTOR KALYDECO PA Dental-Periodontal Products DOXYCYCLINE HYCLATE SODIUM FLUORIDE CICLOPIROX CICLOPIROX OLAMINE DOXYCYCLINE HYCLATE SODIUM FLUORIDE Dermatological - Anti-infectives CICLOPIROX/UREA/CAMPHOR/ MENTHOL/EUCALYPTOL ECONAZOLE NITRATE GENTAMICIN SULFATE KETOCONAZOLE MUPIROCIN MUPIROCIN CALCIUM NYSTATIN BEXAROTENE DICLOFENAC SODIUM FLUOROURACIL CICLOPIROX CICLOPIROX CICLOPIROX ECONAZOLE NITRATE GENTAMICIN SULFATE KETOCONAZOLE MUPIROCIN MUPIROCIN NYSTATIN Dermatological - Antineoplastic or Premalignant Lesions TARGRETIN DICLOFENAC SODIUM FLUOROURACIL 25

26 MALATHION PERMETHRIN SPINOSAD CALCIPOTRIENE CALCITRIOL TAZAROTENE SELENIUM SULFIDE Dermatological - Antiparasitics and Combinations MALATHION PERMETHRIN SPINOSAD Dermatological - Antipsoriatics CALCIPOTRIENE CALCITRIOL TAZORAC Dermatological - Antiseborrheic Products and Combinations SULFACETAMIDE SODIUM SILVER SULFADIAZINE AMMONIUM LACTATE SELENIUM SULFIDE SODIUM SULFACETAMIDE Dermatological - Burn Products SILVER SULFADIAZINE Dermatological - Emollients and Combinations AMMONIUM LACTATE Dermatological - Glucocorticoids and Combinations ALCLOMETASONE DIPROPIONATE BETAMETHASONE DIPROPIONATE BETAMETHASONE DIPROPIONATE/ PROPYLENE GLYCOL BETAMETHASONE VALERATE CLOBETASOL PROPIONATE CLOBETASOL PROPIONATE/ EMOLLIENT BASE DESONIDE DESOXIMETASONE DIFLORASONE DIACETATE FLUOCINOLONE ACETONIDE FLUOCINOLONE ACETONIDE/ SHOWER CAP FLUOCINONIDE FLUTICASONE PROPIONATE HALOBETASOL PROPIONATE HYDROCORTISONE HYDROCORTISONE BUTYRATE MOMETASONE FUROATE TRIAMCINOLONE ACETONIDE ALCLOMETASONE DIPROPIONATE BETAMETHASONE DIPROPIONATE BETAMETHASONE DIPROPIONATE BETAMETHASONE VALERATE CLOBETASOL PROPIONATE CLOBETASOL EMOLLIENT DESONIDE DESOXIMETASONE DIFLORASONE DIACETATE FLUOCINOLONE ACETONIDE FLUOCINOLONE ACETONIDE FLUOCINONIDE FLUTICASONE PROPIONATE HALOBETASOL PROPIONATE HYDROCORTISONE HYDROCORTISONE BUTYRATE MOMETASONE FUROATE TRIAMCINOLONE ACETONIDE 26

27 IMIQUIMOD TACROLIMUS PODOFILOX DICLOFENAC SODIUM LIDOCAINE HCL LIDOCAINE/PRILOCAINE ACARBOSE Dermatological - Immunomodulating Agents IMIQUIMOD Dermatological - Immunosuppressive Agents TACROLIMUS Dermatological - Keratolytics-Antimitotics PODOFILOX Dermatological - NSAID s DICLOFENAC SODIUM Dermatological - Topical Local Anesthetics and Combinations LIDOCAINE HCL LIDOCAINE-PRILOCAINE Diabetic Therapy ACARBOSE EXENATIDE BYETTA QL EXENATIDE MICROSPHERES BYDUREON PA GLIMEPIRIDE GLIPIZIDE GLIPIZIDE/METFORMIN HCL GLUCAGON,HUMAN RECOMBINANT GLYBURIDE GLYBURIDE,MICRONIZED GLYBURIDE/METFORMIN HCL INSULIN ASPART INSULIN ASPART PROTAMINE HUMAN/INSULIN ASPART INSULIN GLARGINE,HUMAN RECOMBINANT ANALOG INSULIN GLULISINE INSULIN LISPRO INSULIN LISPRO PROTAMINE & INSULIN LISPRO GLIMEPIRIDE GLIPIZIDE GLIPIZIDE-METFORMIN GLUCAGON EMERGENCY KIT GLYBURIDE GLYBURIDE MICRONIZED GLYBURIDE-METFORMIN HCL NOVOLOG NOVOLOG MIX LANTUS SOLOSTAR APIDRA HUMALOG HUMALOG MIX INSULIN REGULAR, HUMAN HUMULIN R U-500 METFORMIN HCL MIFEPRISTONE NATEGLINIDE PIOGLITAZONE HCL PIOGLITAZONE HCL/GLIMEPIRIDE PIOGLITAZONE HCL/METFORMIN HCL METFORMIN HCL KORLYM NATEGLINIDE PIOGLITAZONE HCL PIOGLITAZONE-GLIMEPIRIDE PIOGLITAZONE-METFORMIN PRAMLINTIDE ACETATE SYMLINPEN 60 REPAGLINIDE PRANDIN 27

28 SAXAGLIPTIN HCL Diabetic Therapy SITAGLIPTIN PHOSPHATE SITAGLIPTIN PHOSPHATE/ METFORMIN HCL DIPYRIDAMOLE ONGLYZA JANUVIA JANUMET XR Diagnostic Drugs - In Vivo DIPYRIDAMOLE THYROTROPIN ALFA THYROGEN PA Digestive Aids LIPASE/PROTEASE/AMYLASE ACETAZOLAMIDE AMILORIDE HCL CREON Diuretics AMILORIDE HCL/ HYDROCHLOROTHIAZIDE BUMETANIDE CHLORTHALIDONE EPLERENONE FUROSEMIDE HYDROCHLOROTHIAZIDE INDAPAMIDE METHAZOLAMIDE METOLAZONE SPIRONOLACTONE TORSEMIDE TRIAMTERENE/ HYDROCHLOROTHIAZIDE LEVONORGESTREL ULIPRISTAL ACETATE ESTRADIOL ACETAZOLAMIDE AMILORIDE HCL AMILORIDE- HYDROCHLOROTHIAZIDE BUMETANIDE CHLORTHALIDONE INSPRA FUROSEMIDE HYDROCHLOROTHIAZIDE INDAPAMIDE METHAZOLAMIDE METOLAZONE SPIRONOLACTONE TORSEMIDE TRIAMTERENE- HYDROCHLOROTHIAZID Emergency Contraceptives and Combinations LEVONORGESTREL ELLA Estrogens and Combinations ESTROGENS, CONJUGATED ESTROGENS, CONJUGATED/ MEDROXYPROGESTERONE ACETATE URSODIOL ESTRADIOL PREMARIN PREMPRO Gallstone Solubilizing (Litholysis) Agents and Combinations URSODIOL 28

29 Gastrointestinal Antispasmodics CHLORDIAZEPOXIDE/CLIDINIUM BROMIDE DICYCLOMINE HCL HYOSCYAMINE SULFATE CHLORDIAZEPOXIDE- CLIDINIUM DICYCLOMINE HCL HYOSCYAMINE SULFATE Gastrointestinal Prokinetic Agents METOCLOPRAMIDE HCL METOCLOPRAMIDE HCL General Anesthetics METHOHEXITAL SODIUM IN STERILE WATER FOR INJECTION/PF MIDAZOLAM HCL IN 0.9 % SODIUM CHLORIDE SODIUM CHLORIDE METHOHEXITAL-STERILE WATER MIDAZOLAM HCL-0.9% NACL General Injectable Solutions and Diluents SODIUM CHLORIDE 0.45 % SODIUM CHLORIDE 3 % SODIUM CHLORIDE 5 % ACETIC ACID SODIUM CHLORIDE SODIUM CHLORIDE SODIUM CHLORIDE SODIUM CHLORIDE Genitourinary Irrigants SODIUM CHLORIDE IRRIGATING SOLUTION DARBEPOETIN ALFA IN POLYSORBATE 80 ACETIC ACID SODIUM CHLORIDE Hematopoietic Agents ARANESP EPOETIN ALFA PROCRIT PA FILGRASTIM NEUPOGEN PA PEGFILGRASTIM NEULASTA PA ROMIPLOSTIM NPLATE PA SARGRAMOSTIM LEUKINE PA Hepatic Hormones (Hormones Secreted by the Liver) MECASERMIN INCRELEX PA ALLOPURINOL PROBENECID CYCLOSPORINE Hyperuricemia Therapy ALLOPURINOL PROBENECID Immunosuppressive - Calcineurin Inhibitors CYCLOSPORINE, MODIFIED CYCLOSPORINE CYCLOSPORINE MODIFIED 29

30 TACROLIMUS Immunosuppressive - Calcineurin Inhibitors TACROLIMUS Immunosuppressive - Inosine Monophosphate Dehydrogenase Inhibitors MYCOPHENOLATE MOFETIL SIROLIMUS AZATHIOPRINE MYCOPHENOLATE MOFETIL Immunosuppressive - Mammalian Target of Rapamycin (mtor) Inhibitors RAPAMUNE Immunosuppressive - Purine Analogs AZATHIOPRINE Inflammatory Bowel Agents ADALIMUMAB HUMIRA PA BUDESONIDE HYDROCORTISONE HYDROCORTISONE ACETATE BUDESONIDE EC HYDROCORTISONE CORTIFOAM INFLIXIMAB REMICADE PA MESALAMINE SULFASALAZINE CANASA SULFASALAZINE Interstitial Cystitis Agents PENTOSAN POLYSULFATE SODIUM LUBIPROSTONE ELMIRON Irritable Bowel Syndrome (IBS) Agents AMITIZA Laxatives PEG 3350/SOD SULF/SOD BICARBONATE/SOD CHLORIDE/ POTASSIUM CHL COLYTE WITH FLAVOR PACKETS POLYETHYLENE GLYCOL 3350 POLYETHYLENE GLYCOL 3350 SODIUM CHLORIDE/SODIUM BICARBONATE/POTASSIUM CHLORIDE/PEG LIDOCAINE HCL PEG 3350-ELECTROLYTE Local Anesthetics - Parenteral LIDOCAINE HCL IN 0.9 % SODIUM CHLORIDE/PF LIDOCAINE HCL/PF LIDOCAINE HCL LIDOCAINE HCL LIDOCAINE HCL Medical Supplies & DME - Diabetic Supplies INSULIN ADMIN. SUPPLIES INSULIN PUMP CONTROLLER HUMAPEN LUXURA HD SNAP INSULIN PUMP CONTROLLER 30

31 Medical Supplies & DME - Diabetic Supplies INSULIN PUMP SYRINGE, 1.8 ML INSULIN PUMP SYRINGE, 3 ML NEEDLES, INSULIN DISPOSABLE PEN NEEDLE, DIABETIC SYRINGE WITH NEEDLE, INSULIN, SAFETY, 0.3 ML SYRINGE WITH NEEDLE, INSULIN, SAFETY, 0.5 ML SYRINGE WITH NEEDLE, INSULIN, SAFETY, 1 ML SYRINGE WITH NEEDLE,DISPOSABLE, INSULIN 1 ML SYRINGE WITH NEEDLE,INSULIN DISPOSABLE,0.3 ML SYRINGE WITH NEEDLE,INSULIN DISPOSABLE,0.5 ML THINSET THINSET PEN NEEDLE PEN NEEDLE MAGELLAN INSULIN SAFETY SYRNG MAGELLAN INSULIN SAFETY SYRNG MAGELLAN INSULIN SAFETY SYRNG MONOJECT INSULIN SYRINGE MONOJECT INSULIN SYRINGE MONOJECT Medical Supplies & DME - Respiratory Therapy INHALER, ASSIST DEVICES AEROCHAMBER PLUS FLOW- VU Metabolic Disease Enzyme Replacement, Gaucher s Disease IMIGLUCERASE CEREZYME PA Migraine Therapy DIHYDROERGOTAMINE MESYLATE DIHYDROERGOTAMINE MESYLATE RIZATRIPTAN BENZOATE RIZATRIPTAN QL SUMATRIPTAN SUMATRIPTAN SUMATRIPTAN SUCCINATE SUMATRIPTAN SUCCINATE QL ZOLMITRIPTAN ZOLMITRIPTAN QL Minerals & Electrolytes IRON ASPGLY/ASCORB.CAL/VIT B12/ CALCIUM THR/SUCC.ACID/STOMACH IRON FUMARTE &ASP GLY/ ASCORB.CAL/VIT B12/FA/CA-THR/ SUCC.ACID POTASSIUM BICARBONATE/CITRIC ACID POTASSIUM CHLORIDE MV-IRON-ASC-B12-THRE-SUC- STOM MV-IRON FUM-ASP-ASC-B12-FA- SUC KLOR-CON-EF POTASSIUM CHLORIDE QL Mouth and Throat - Anti-infectives CHLORHEXIDINE GLUCONATE CLOTRIMAZOLE NYSTATIN CHLORHEXIDINE GLUCONATE CLOTRIMAZOLE NYSTATIN 31

32 Mouth and Throat - Glucocorticoids TRIAMCINOLONE ACETONIDE LIDOCAINE HCL PILOCARPINE HCL TRIAMCINOLONE ACETONIDE Mouth and Throat - Local Anesthetics LIDOCAINE HCL Mouth and Throat - Xerostomia Therapy SALIVA SUBSTITUTION COMBO NO.3 PILOCARPINE HCL AQUORAL Mucolytics DORNASE ALFA PULMOZYME PA INTERFERON BETA-1A Multiple Sclerosis Agent - Interferons INTERFERON BETA-1A/ALBUMIN HUMAN AVONEX REBIF INTERFERON BETA-1B EXTAVIA PA PA Multiple Sclerosis Agent - Potassium Channel Blocker DALFAMPRIDINE AMPYRA PA BACLOFEN CARISOPRODOL Musculoskeletal Therapy Agents BACLOFEN CARISOPRODOL CYCLOBENZAPRINE HCL CYCLOBENZAPRINE HCL QL DANTROLENE SODIUM DANTROLENE SODIUM HYALURONATE SODIUM EUFLEXXA PA HYLAN G-F 20 SYNVISC PA METAXALONE METHOCARBAMOL ORPHENADRINE CITRATE TIZANIDINE HCL MODAFINIL AZELASTINE HCL FLUNISOLIDE METAXALONE METHOCARBAMOL ORPHENADRINE CITRATE TIZANIDINE HCL Narcolepsy and Cataplexy Therapy Agents MODAFINIL Nasal Preparations FLUTICASONE PROPIONATE IPRATROPIUM BROMIDE TRIAMCINOLONE ACETONIDE AZELASTINE HCL FLUNISOLIDE FLUTICASONE PROPIONATE IPRATROPIUM BROMIDE TRIAMCINOLONE ACETONIDE 32

33 Neuromuscular Therapy Agents PYRIDOSTIGMINE BROMIDE AZELASTINE HCL CROMOLYN SODIUM BACITRACIN PYRIDOSTIGMINE BROMIDE Ophthalmic - Anti-allergy AZELASTINE HCL CROMOLYN SODIUM Ophthalmic - Anti-infectives BACITRACIN/POLYMYXIN B SULFATE CIPROFLOXACIN HCL ERYTHROMYCIN BASE GENTAMICIN SULFATE LEVOFLOXACIN NEOMYCIN SULFATE/BACITRACIN/ POLYMYXIN B NEOMYCIN SULFATE/POLYMYXIN B SULFATE/GRAMICIDIN D OFLOXACIN POLYMYXIN B SULFATE/ TRIMETHOPRIM SULFACETAMIDE SODIUM TOBRAMYCIN TRIFLURIDINE DICLOFENAC SODIUM FLUOROMETHOLONE BACITRACIN BACITRACIN-POLYMYXIN CIPROFLOXACIN HCL ERYTHROMYCIN GENTAMICIN SULFATE LEVOFLOXACIN NEO-POLYCIN NEOMYCIN-POLYMYXIN- GRAMICIDIN OFLOXACIN POLYMYXIN B SUL- TRIMETHOPRIM SULFACETAMIDE SODIUM TOBRAMYCIN TRIFLURIDINE Ophthalmic - Anti-inflammatory KETOROLAC TROMETHAMINE LOTEPREDNOL ETABONATE PREDNISOLONE ACETATE PREDNISOLONE SOD PHOSPHATE NAPHAZOLINE HCL BIMATOPROST DICLOFENAC SODIUM FML FORTE KETOROLAC TROMETHAMINE LOTEMAX PREDNISOLONE ACETATE PREDNISOLONE SODIUM PHOSPHATE Ophthalmic - Decongestants and Combinations NAPHAZOLINE HCL Ophthalmic - Intraocular Pressure Reducing Agents BRIMONIDINE TARTRATE BRINZOLAMIDE DORZOLAMIDE HCL DORZOLAMIDE HCL/TIMOLOL MALEATE LATANOPROST BIMATOPROST ALPHAGAN P AZOPT DORZOLAMIDE HCL DORZOLAMIDE-TIMOLOL LATANOPROST 33

34 LEVOBUNOLOL HCL METIPRANOLOL PILOCARPINE HCL TIMOLOL MALEATE ATROPINE SULFATE Ophthalmic - Intraocular Pressure Reducing Agents LEVOBUNOLOL HCL METIPRANOLOL PILOCARPINE HCL TIMOLOL MALEATE Ophthalmic - Mydriatics and Cycloplegics ATROPINE SULFATE Ophthalmic Combinations NEOMYCIN SULFATE/BACITRACIN ZINC/POLYMYXIN B/ HYDROCORTISONE NEOMYCIN SULFATE/POLYMYXIN B SULFATE/HYDROCORTISONE NEOMYCIN/POLYMYXIN B SULFATE/ DEXAMETHASONE TOBRAMYCIN/DEXAMETHASONE ACETIC ACID OFLOXACIN NEO-POLYCIN HC NEOMYCIN-POLYMYXIN-HC NEOMYCIN-POLYMYXIN- DEXAMETH TOBRAMYCIN- DEXAMETHASONE Otic - Anti-infectives ACETIC ACID OFLOXACIN Otic Combinations ACETIC ACID/ALUMINUM ACETATE NEOMYCIN SULFATE/POLYMYXIN B SULFATE/HYDROCORTISONE ACETIC ACID-ALUMINUM NEOMYCIN-POLYMYXIN- HYDROCORT Oxytocics METHYLERGONOVINE MALEATE METHYLERGONOVINE MALEATE Passive Immunizing Agents CYTOMEGALOVIRUS IMMUNE GLOBULN IMMUNE GLOBULIN,GAMM(IGG)/ GLYCINE/IGA GREATER THAN 50 MCG/ML CYTOGAM GAMUNEX-C PALIVIZUMAB SYNAGIS PA RHO(D) IMMUNE GLOBULIN CIMETIDINE CIMETIDINE HCL LANSOPRAZOLE RHOGAM ULTRA-FILTERED PLUS Peptic Ulcer Therapy CIMETIDINE CIMETIDINE LANSOPRAZOLE PA PA 34

35 MISOPROSTOL OMEPRAZOLE Peptic Ulcer Therapy PANTOPRAZOLE SODIUM RANITIDINE HCL SUCRALFATE MISOPROSTOL OMEPRAZOLE PANTOPRAZOLE SODIUM RANITIDINE HCL SUCRALFATE Pharmaceutical Adjuvants SODIUM CHLORIDE FOR INHALATION CALCIUM ACETATE ANAGRELIDE HCL CILOSTAZOL SODIUM CHLORIDE Phosphate Binders CALCIUM ACETATE Platelet Aggregation Inhibitors & Combinations CLOPIDOGREL BISULFATE DIPYRIDAMOLE ANAGRELIDE HCL CILOSTAZOL CLOPIDOGREL DIPYRIDAMOLE Posterior Pituitary Hormones DESMOPRESSIN ACETATE DESMOPRESSIN ACETATE (NON- REFRIGERATED) DESMOPRESSIN ACETATE DESMOPRESSIN ACETATE Progestins MEDROXYPROGESTERONE ACETATE NORETHINDRONE ACETATE ALFUZOSIN HCL DUTASTERIDE FINASTERIDE TAMSULOSIN HCL DEPO-PROVERA NORETHINDRONE ACETATE Prostatic Hypertrophy Agents ALFUZOSIN HCL ER AVODART FINASTERIDE TAMSULOSIN HCL Pseudobulbar Affect (PBA) Agents DEXTROMETHORPHAN HBR/ QUINIDINE SULFATE NUEDEXTA Respiratory Combinations CETIRIZINE HCL/PSEUDOEPHEDRINE HCL DEXTROMETHORPHAN HBR/ PSEUDOEPHEDRINE HCL/ BROMPHENIRAMINE FEXOFENADINE HCL/ PSEUDOEPHEDRINE HCL ZYRTEC-D BROMPHENIRAMINE- PSEUDOEPHED-DM FEXOFENADINE-PSE ER PA QL 35

36 Respiratory Combinations HYDROCODONE BITARTRATE/ HOMATROPINE METHYLBROMIDE PROMETHAZINE HCL/CODEINE PROMETHAZINE HCL/ DEXTROMETHORPHAN HBR PROMETHAZINE/PHENYLEPHRINE HCL/CODEINE FLURAZEPAM HCL LORAZEPAM HYDROCODONE- HOMATROPINE MBR PROMETHAZINE-CODEINE PROMETHAZINE-DM PROMETHAZINE VC-CODEINE Sedative-Hypnotics PENTOBARBITAL SODIUM PHENOBARBITAL TEMAZEPAM FLURAZEPAM HCL LORAZEPAM PENTOBARBITAL SODIUM PHENOBARBITAL TEMAZEPAM ZOLPIDEM TARTRATE ZOLPIDEM TARTRATE QL HYDROXYUREA Sickle Cell Anemia Agents DROXIA Smoking Deterrents and Combinations VARENICLINE TARTRATE CHANTIX QL Thyroid Therapy LEVOTHYROXINE SODIUM LIOTHYRONINE SODIUM METHIMAZOLE PROPYLTHIOURACIL SYNTHROID LIOTHYRONINE SODIUM METHIMAZOLE PROPYLTHIOURACIL Urinary Analgesics PHENAZOPYRIDINE HCL PHENAZOPYRIDINE HCL Urinary Anti-infectives CIPROFLOXACIN/CIPROFLOXACIN HCL NITROFURANTOIN NITROFURANTOIN MACROCRYSTAL NITROFURANTOIN MONOHYDRATE/ MACROCRYSTALS CIPROFLOXACIN ER NITROFURANTOIN NITROFURANTOIN NITROFURANTOIN MONO- MACRO Urinary Antispasmodics DARIFENACIN HYDROBROMIDE OXYBUTYNIN CHLORIDE TOLTERODINE TARTRATE TROSPIUM CHLORIDE ENABLEX OXYBUTYNIN CHLORIDE ER DETROL LA TROSPIUM CHLORIDE ER QL 36

37 Urinary Ph Modifiers CITRIC ACID/SODIUM CITRATE POTASSIUM CITRATE POTASSIUM CITRATE/CITRIC ACID SODIUM CITRATE & CITRIC ACID POTASSIUM CITRATE ER POTASSIUM CITRATE-CITRIC ACID Urinary Retention Therapy BETHANECHOL CHLORIDE BETHANECHOL CHLORIDE Vaginal Anti-infectives CLINDAMYCIN PHOSPHATE METRONIDAZOLE TERCONAZOLE CLEOCIN METRONIDAZOLE TERCONAZOLE Vaginal Estrogens ESTROGENS, CONJUGATED PREMARIN Vitamin Combinations FERROUS SULFATE/SODIUM FLUORIDE/VIT A PALM/VIT C/VITAMIN D3 FLUORIDE/IRON/VITAMINS A,C,AND D MVI, PEDI NO.1 WITH VIT K MVI, PEDI NO.2 WITH VIT K PEDIATRIC MULTIVIT #37/SODIUM FLUORIDE/IRON BISGLYCINATE HCL PEDIATRIC MULTIVIT COMB NO.90/ SODIUM FLUORIDE PEDIATRIC MULTIVITAMIN COMBINATION NO.2/SODIUM FLUORIDE PEDIATRIC MULTIVITAMIN COMBO NO.45/FLUORIDE/FERROUS SULFATE PEDIATRIC MULTIVITAMIN COMBO NO.75/FLUORIDE/FERROUS SULFATE PEDIATRIC MULTIVITAMIN NO.108/ IRON FUMARATE/SODIUM FLUORIDE PEDIATRIC MULTIVITAMIN NO.22/ CHOLECALCIFEROL/PHYTONADIONE PEDIATRIC MULTIVITAMIN NO.33 WITH SODIUM FLUORIDE PEDIATRIC MULTIVITAMIN NO.33/ SODIUM FLUORIDE/IRON CARBONYL PEDIATRIC MULTIVITAMIN NO.37 WITH SODIUM FLUORIDE PEDIATRIC MULTIVITAMIN NO.47 WITH IRON & SODIUM FLUORIDE MYKIDZ IRON FL TRI-VIT WITH FLUORIDE-IRON INFUVITE M.V.I. PEDIATRIC POLY-VI-FLOR WITH IRON POLY-VI-FLOR FS MULTI-VITAMIN W-FLUORIDE MULTI-VITAMIN-FLUOR-IRON MULTIVITAMINS W-FLUORIDE- IRON TEXAVITE LQ MULTIVITAMINS-A,B,D,E,K,ZN POLY-VI-FLOR POLY-VI-FLOR WITH IRON POLY-VI-FLOR TL-FLUORIVITE 37

38 Vitamin Combinations PEDIATRIC MULTIVITAMIN NO.61/ CHOLECALCIFEROL/PHYTONADIONE PEDIATRIC MULTIVITAMIN NO.63 WITH SODIUM FLUORIDE PEDIATRIC MULTIVITAMIN NO.65/ CHOLECALCIFEROL/PHYTONADIONE PEDIATRIC MULTIVITAMIN NO.77/ CHOLECALCIFEROL/PHYTONADIONE PEDIATRIC MULTIVITAMIN NO.78 WITH IRON & SODIUM FLUORIDE PEDIATRIC MULTIVITAMIN NO.83 WITH SODIUM FLUORIDE PEDIATRIC MULTIVITAMIN NO.84 WITH SODIUM FLUORIDE PEDIATRIC MULTIVITAMIN NO.85 WITH SODIUM FLUORIDE PEDIATRIC MULTIVITAMIN NO.86 WITH IRON & SODIUM FLUORIDE PEDIATRIC MULTIVITAMINS A,C,& D3 NO.21 WITH SODIUM FLUORIDE PEDIATRIC MULTIVITAMINS A,C,& D3 NO.38 WITH SODIUM FLUORIDE PEDIATRIC MULTIVITAMINS COMBINATION NO.12/SODIUM FLUORIDE PEDIATRIC MULTIVITAMINS NO.16 WITH SODIUM FLUORIDE PEDIATRIC MULTIVITAMINS NO.17 WITH SODIUM FLUORIDE PEDIATRIC MULTIVITAMINS NO.82 WITH SODIUM FLUORIDE PNV NO.20/IRON FUMARATE/FA/ DOCUSATE NA/FISH OIL CONC/DHA/ EPA PNV NO.35/IRON FUMARATE/FOLATE COMB. #6/DHA PNV NO17/IRON,CARB/IRON BISGLY/ FA/FISH OIL/DHA/OMEGA 3,6 #1 PNV NO18/IRON,CARBONYL/FOLIC ACID/DOCUSATE NA/UBIDECAR/DHA PNV WITH CA NO.37/IRON CARB & ASP GLY/FA/OMEGA-3 FATTY ACIDS PNV#85/IRON CARB./IRON ASP.GLYCINATE/FOLIC ACID/DHA/ FISH OIL PNV,CA,NO.35/IRON,CARBONYL & ASP GLY/FA/DSS/OMEGA-3 PRENATAL NO.30/IRON CARBONLY & ASPARTO GLYCINATE/FA/OMEGA3 PRENATAL NO.56/IRON CARBONYL & ASPARTO GLYCINATE/FA/DHA COMPLETE FORMULATION D3000 QUFLORA MULTIVITAMINS-A,B,D,E,K,ZN COMPLETE FORMULATION PEDIATRIC ESCAVITE D QUFLORA QUFLORA FLORIVA ESCAVITE LQ TRI-VITAMIN WITH FLUORIDE TRI-VI-FLORO MVC-FLUORIDE MULTIVITAMINS WITH FLUORIDE MULTIVITAMIN WITH FLUORIDE MULTIVITAMINS WITH FLUORIDE TL-CARE DHA PRENATE ESSENTIAL ELITE-OB 400 PREQUE 10 ULTIMATECARE ONE OB COMPLETE ONE ULTIMATECARE ONE NF OB COMPLETE WITH DHA OB COMPLETE PETITE 38