Abilify (aripiprazole) Abilify oral solution
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- Sheena Hodges
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1 Responsible Quantity Program* (Programa Responsible Quantity*) Current (Corriente) 10/1/15 Quantity Limit Authorization Form (Formulario de límite de Responsible Quantity) Responsible Quantity program limits apply to generic versions of drugs where applicable. (Los límites del programa de cantidad responsable aplican a las versiones de medicinas genéricas). Brand/Generic name Abilify (aripiprazole) Abilify Discmelt Abilify oral solution 750 ml Abstral Accolate (zafirlukast) Aciphex (rabeprazole) Aciphex sprinkles Actiq (fentanyl citrate) 120 units Actonel (risedronate) 5 mg, 30 mg Actonel (risedronate) 35 mg 4 tabs Actonel (risedronate) 150 mg 1 tab Adcirca Adderall (amphetamine-dextroamphetamine) 5 mg, 7.5 mg, 10 mg, 12.5 mg, 15 mg, 30 mg Adderall (amphetamine-dextroamphetamine) 20 mg 90 tabs Adderall XR Advair Diskus 60 blisters Advair HFA 1 canister Advicor , , Advicor Aerospan 2 canisters Afinitor Afinitor Disperz 2 mg, 5 mg Afinitor Disperz 3 mg 90 tabs Afrezza 1080 units Aknyzeo 2 tabs / 30 days Alora 8 patches / 28 days Alsuma 8 doses Altoprev Alvesco 80 mcg 1 inhaler Alvesco 160 mcg 2 inhalers Ambien (zolpidem) Page 1 of 21
2 Ambien CR (zolpidem ER) Amerge (naratriptan) 1 mg 18 tabs Amerge (naratriptan) 2.5 mg 9 tabs Ampyra Amturnide Alagesic LQ elixir 2700 ml Androderm patch 60 patches AndroGel packet 60 packets AndroGel pump 4 pumps AndroGel 1.62 packet 60 packets AndroGel 1.62 pump 2 pumps Anoro Ellipta 60 blisters Antara 30 mg 60 caps Antara 90 mg Anzemet 50 mg 14 tabs Anzemet 100 mg 7 tabs Aplenzin Aptivus 100 mg/ml 380 ml Aptivus 250 mg 120 caps Aptensio XR Arcalyst 4 vials / 28 days Arcapta Neohaler 30 blisters Arixtra (fondaparinux) 30 syringes / 3 months Arnuity Ellipta 30 blisters Asmanex HFA 1 inhaler Astelin (azelastine) 2 inhalers Astepro 2 bottles Atacand 4 mg, 8 mg, 16 mg Atacand 32 mg Atacand HCT (candesartan/hydrochlorothiazide) Atelvia (risedronate) 4 tabs / 28 days Atripla Atrovent (ipratropium) 0.03% 2 inhalers Atrovent (ipratropium) 0.06% 3 inhalers Atrovent HFA 2 inhalers Aubagio Avalide (irbesartan/hydrochlorothiazide) Avapro (irbesartan) Page 2 of 21
3 Avinza (morphine ext release) 60 caps Avonex 4 vials/syringes / 28 days Axert (almotriptan) 6.25 mg 24 tabs Axert (almotriptan) 12.5 mg 12 tabs Axiron 2 pumps Azor Beconase AQ 2 inhalers Belsomra Benicar 5 mg Benicar 20 mg, 40 mg Benicar HCT Betaseron 14 vials/syringes / 28 days Binosto 4 tabs / 28 days Boniva (ibandronate) 2.5 mg 30 tablets Boniva (ibandronate) 150 mg 1 tablet Bosulif Breo Elipta 100 mcg/25 mcg 30 actuations Breo Elipta 200 mcg/ 25 mcg 60 actuations Brintellix Bunavail 2.1/0.3 mg 90 films Bunavail 4.2/0.7 mg, 6.3/1 mg 60 films buprenorphine 2 mg, 8 mg 15 tabs / 90 days bupropion 75 mg bupropion 100 mg bupropion SR 100 mg, 150 mg, 200 mg bupropion ER 150 mg, 300 mg Butalbital Compound (butalbital-acetaminophen) Butalbital Compound (butalbital-aspirin-caffeine) Butrans All strengths 4 systems / 28 days Bydureon 4 syringes / 28 days Byetta pre-filled pen (60 doses) 1 pen Cambia 9 packets Capital and Codeine (acetaminophen/codeine 2700 ml solution) Caprelsa 100 mg Caprelsa 300 mg Celebrex (celecoxib) 50 mg, 100 mg, 200 mg 60 caps Celebrex (celecoxib) 400 mg Celexa (citalopram) tablets Page 3 of 21
4 Celexa (citalopram) oral solution 600 ml Cesamet 56 caps Cialis 2.5 mg, 5 mg Cimzia Starter kit 1 kit/year Cimzia 200mg syringe 2 syringes / 28 days Climara (estradiol) 4 patches Climara Pro 4 patches Clozaril (clozapine) 25 mg, 50mg 90 tabs Clozaril (clozapine) 100 mg 270 tabs Clozaril (clozapine) 200 mg Codeine tablets Combivent 2 inhalers Combivent Respimat 2 inhalers Combivent Respimat 2 bottles Combivir Cometriq 1 carton / 28 days Complera Concerta (methylphenidate ER) 18 mg, 27 mg, 54 mg Concerta (methylphenidate ER) 36 mg Conzip Copaxone (glatiramer) 30 syringes Copaxone syringes / 28 days Cozaar (losartan) 25 mg, 50 mg Cozaar (losartan) 100 mg Crestor 5 mg, 10 mg, 20 mg 45 tabs Crestor 40 mg Crixivan 100 mg 90 caps Crixivan 200 mg 270 caps Crixivan 400 mg 180 caps Cymbalta 20 mg, 30 mg 60 caps Cymbalta 60 mg Daliresp Daytrana 30 patches Delatestryl (testosterone enanthate) 200 mg/5 ml 1 vial / 28 days Demerol (meperidine) tablets 240 tabs Demerol (meperidine) liquid 2,400 ml Depo Testosterone (testosterone cypionate) 10 ml vials 1 vial / 28 days Depo Testosterone (testosterone cypionate) 1 ml vials 4 vials / 28 days Page 4 of 21
5 Desoxyn (methamphetamine) 150 tabs Detrol Detrol LA dextroamphetamine 5 mg dextroamphetamine 10 mg Dexedrine extended release capsule 5 mg 90 caps Dexedrine extended release capsule 10 mg, 15 mg 120 caps Dexedrine Spansule (dextroamphetamine sulfate 90 caps ext-release) Dexilant DHE 24 vials / 28 days Diabetic test strips (all brands) 204 strips/discs Dificid 40 tabs / 180 days Diclegis Dilaudid (hydromorphone) tablets Dilaudid (hydromorphone) liquid 1,440 ml Diovan (valsartan) 40 mg, 80 mg, 160 mg Diovan (valsartan) 320 mg Diovan HCT (valsartan-hydrochlorothiazide) Ditropan XL (oxybutynin ext-release) 5 mg Ditropan XL (oxybutynin ext-release) 10 mg, 15 mg Divigel 30 packets Dolgic Plus 150 tabs Dovonex cream 120 grams Dovonex (calcipotriene) solution 120 ml Duexis 90 tabs Dulera 1 canister Duragesic (fentanyl transdermal patch) 15 patches Dymista 1 bottle Edarbi Edarbyclor Edluar Edurant Effexor (venlafaxine) 90 tabs Effexor XR (venlafaxine ER) 37.5 mg, 150 mg Effexor XR (venlafaxine ER) 75 mg 90 caps Elestrin 1 pump Eliquis 2.5 mg Eliquis 5 mg Page 5 of 21
6 Embeda 20 mg, 30 mg, 50 mg, 60 mg, 80 mg 60 caps Embeda 100 mg 120 caps Emend 80 mg 4 caps Emend 125 mg 2 caps Emend Therapy Pack 2 Therapy Packs Emtriva 10 mg/ml 24 ml Emtriva Enablex Enbrel 25 mg 8 injections / 28 days Enbrel 50mg (months 1-3) 8 injections / 28 days Enbrel 50mg (months 4 and beyond) 4 injections / 28 days Endodan (oxycodone-aspirin) 3 Epivir (lamivudine) 10 mg/ml 960 ml Epivir (lamivudine) Epzicom Erivedge Esgic (butalbital-acetaminophen-caffeine) caps or tabs Esgic Plus (butalbital-acetaminophen-caffeine) caps or tabs Estraderm 8 patches / 28 days Estrasorb 56 pouches Estring 1 ring Estrogel 1 pump EvaMist 1 canister Evekeo 5 mg 90 tabs Evekeo 10 mg Evotaz Exalgo all strengths 30 tablets Exforge (amlodipine-valsartan) Exforge HCT (amlodipine-valsartanhydroclorothiazide) Extavia 15 vials / syringes Fanapt all strengths Fanapt titration pack 7 kits Farxiga FazaClo (clozapine) 12.5 mg, 100 mg 90 tabs FazaClo (clozapine) 25 mg 270 tabs FazaClo (clozapine) 150 mg FazaClo (clozapine) 200 mg Femring 1 ring / 90 days Page 6 of 21
7 Fenoglide 40 mg Fenoglide 120 mg fentanyl citrate transmucosal 120 units Fentora Fetzima Fetzima Titration pack 1 pack Fibricor 35 mg Fibricor 105 mg Fioricet (butalbital-acetaminophen-caffeine) Fioricet w/codeine (butalbital-acetaminophencaffeine-codeine) 180 caps Fiorinal (butalbital-aspirin-caffeine) 360 caps or tabs Fiorinal w/codeine (butalbital-aspirin-caffeinecodeine) 180 caps Flector patch 60 patches Flonase (fluticasone) 1 inhaler Flovent Diskus 50 mcg, 100 mcg 1 carton Flovent Diskus 250 mcg 4 cartons Flovent HFA 44 mcg, 110 mcg 1 inhaler Flovent HFA 220 mcg 2 inhalers Flunisolide nasal soln 25 mcg /spray, 29 mcg /spray 3 inhalers Fluoxetine 60 mg flu vaccines 1 injection / 90 days fluvoxamine 25 mg, 50 mg fluvoxamine 100 mg 90 caps Focalin (dexmethylphenidate) Focalin XR Foradil Aerolizer 1 blister pack (12 or 60) Forfivo Fortesta 2 canisters Fosamax (alendronate) 5 mg, 10 mg, 40 mg Fosamax (alendronate) 35 mg, 70 mg 4 tabs Fosamax (alendronate) oral solution 300 ml/28 days Fosamax Plus D 4 tabs Fragmin syringe, all strengths 30 syringes / 3 months Fragmin vial, all strengths 10 vials / 3 months Fulzyaq Frova 12 tabs Fuzeon 60 vials Page 7 of 21
8 Gattex 30 vials Gelnique 10% 30 sachets Gelnique 3% 1 pump gemfibrozil Geodon (ziprasidone) Gilenya Gilotrif All strengths Glatopa 1 kit Gleevec 100 mg 90 tabs Gleevec 400 mg Glucose Test Strips (all brands) 204 strips / discs Glyxambi granisetron 14 tabs Granisol 60 ml Grastek HP Acthar gel 7 vials/21 days Humira 10 mg, 20 mg, 40 mg 2 injections / 28 days Humira Starter pack 1 pack / year Humira pediatric Crohn s kit 1 kit / 180 days Hycet (hydrocodone-acetaminophen) 3600 ml hydrocodone-acetaminophen 2.5 mg-325mg 3 hydrocodone-acetaminophen 2.5 mg-500mg 240 tabs Hysingla ER 300 tabs Hyzaar (losartan/hydrochlorothiazide) Ibudone (hydrocodone-ibuprofen) tabs Iclusig 15 mg Iclusig 45 mg Imitrex nasal soln, 5 mg 6 units Imitrex nasal soln, 20 mg 2 units Imitrex (sumatriptan) 25 mg 36 tabs Imitrex (sumatriptan) 50 mg 18 tabs Imitrex (sumatriptan) 100 mg 9 tabs Imitrex (sumatriptan) syringe, vial 4 mg/0.5 ml 6 ml (12 inj) Imitrex (sumatriptan) syringe, vial 6 mg/0.5 ml 4 ml (8 inj) Incivek 168 tabs / 28 days Incruse Ellipta 30 blisters Inlyta 1 mg Inlyta 5 mg Page 8 of 21
9 Intelence 25 mg Intelence 100 mg, 200 mg Intermezzo Intuniv (guanfacine ER) Invega 1.5mg, 3 mg, 9 mg Invega 6 mg Invirase 200 mg 300 caps Invirase 500 mg Invokamet Invokana Iprivask 30 vials / 3 months Irenka 90 caps Isentress 25 mg, 100 mg Isentress 400 mg Isentress Powder 60 packets Jakafi 60 caps Janumet Janumet XR , Janumet XR Januvia Jardiance Juvisync Juxtapid 28 caps / 28 days Kadian (morphine once daily) 10 mg, 20 mg, 30 mg, 40 mg, 50 mg 60 caps Kadian (morphine once daily) 60 mg, 70 mg, 80 mg, 130 mg, caps mg Kadian (morphine once daily) 100 mg, 200 mg 120 caps Kaletra 80 mg/20 ml 320 ml Kaletra 100 mg/25 mg 300 tabs Kaletra 200 mg/50 mg Kalydeco Kapvay Kazano ketorolac 21 tabs Khedzela Kineret 30 syringes Kombiglyze XR 5-500, Kombiglyze XR Korlym Page 9 of 21
10 Kynamro 4 vials / 28 days Latuda 20 mg, 40 mg, 60 mg, 120 mg Latuda 80 mg Lazanda 150 ml Lescol (fluvastatin) 60 caps Lescol XL Letairis Levodromoran (levorphanol) tablets Lexapro (escitalopram) tablets Lexapro (escitalopram) oral solution 600mL Lexiva 50 mg/ml 1800 ml Lexiva 700 mg Lipitor 10 mg, 20 mg, 40 mg 45 tabs Lipitor 80 mg Lipofen 50 mg 60 caps Lipofen 150 mg Liptruzet Livalo 1 mg, 2 mg 45 tabs Livalo 4 mg Lofibra 54 mg Lofibra 160 mg Lofibra micronized Lopid (gemfibrozil) Lorcet (hydrocodone-acetaminophen) caps Lorcet Plus (hydrocodone-acetaminophen) Lortab (hydrocodone-acetaminophen) 5 mg/500 mg 240 tabs Lortab (hydrocodone-acetaminophen) 7.5 mg/500 mg, 10 mg/500 mg Lortab elixir (hydrocodone-acetaminophen) 7.5 mg/500 mg/15 ml 2700ml Lortab elixir (hydrocodone-acetaminophen) 10 mg/500 mg/15 ml 2025ml Lovenox (enoxaparin) syringe, all strengths 30 syringes / 3 months Lovenox (enoxaparin) vial, 300 mg/3 ml 10 vials / 3 months Lumigan 2.5 ml Lunesta (epszopiclone) Luvox CR 60 caps Lyrica 25 mg, 50 mg, 75 mg, 100 mg, 90 caps 150 mg, 200 mg Lyrica 225 mg, 300 mg 60 caps Lyrica 20mg/ml 900 ml Magnacet 5 mg/400 mg, 7.5 mg/400 mg 300 tabs Page 10 of 21
11 Magnacet 10 mg/400 mg Maprotiline 90 tabs Margesic-H (hydrocodone-acetaminophen) 240 caps Maxair Autohaler 1 canister Maxalt, Maxalt-MLT (rizatriptan) 5 mg 24 tabs Maxalt, Maxalt-MLT (rizatriptan) 10 mg 12 tabs Maxidone (hydrocodone-acetaminophen) tabs Mekinist 0.5 mg 90 tabs Mekinist 2 mg Menostar 4 patches Metadate CD (methylphenidate ext-release) Metadate ER (methylphenidate ext-release) 90 caps methadone tablets all strengths 90 tabs methadone liquid 5mg / 5 ml 900 ml methadone liquid 10mg / 5 ml 450 ml methadone liquid 10mg / ml 90 ml Methylin 2.5 mg, 5 mg 90 tabs Methylin 10 mg Methylin 5 mg/5 ml 450 ml Methylin 10 mg/5 ml 900 ml Methylin ER 90 tabs Mevacor (lovastatin) Micardis (telmisartan) Micardis HCT (telmisartan/hydrochlorothiazide) 40 mg/12.5 mg, 80 mg/25 mg Micardis HCT (telmisartan/hydrochlorothiazide) 80 mg/12.5 mg Migranal 8 ampules Minivelle 8 patches / 28 days Mirtazapine 7.5 mg, 15 mg, 30 mg, 45 mg morphine tablets 15mg 240 tabs morphine tablets 30mg morphine liquid 10mg / 5ml 2,700 ml morphine liquid 20mg / 5ml 1,350 ml morphine liquid 20mg / ml 270 ml MS Contin (morphine sulfate ext-release) 15 mg, 30 mg, 60 mg MS Contin (morphine sulfate ext-release) 100 mg, 200 mg Myrbetriq Nasacort AQ (triamcinolone) 1 inhaler Nasonex 2 inhalers Page 11 of 21
12 Nesina Neulasta 2 syringes/28 days Nexavar Nexium Nexium granules 30 packets Norco (hydrocodone-acetaminophen) 5 mg/325 mg, 10 mg/325 mg 3 Norco (hydrocodone-acetaminophen) 7.5 mg/325 mg Northera 100 mg 450 caps Northera 200 mg, 300 mg 180 caps Norvir 80 mg/ml 480 ml Norvir 100 mg 360 caps or tabs Nucynta Nucynta ER Nuvigil Oleptro 150 mg 45 tabs Oleptro 300 mg Omnaris 1 inhaler ondansetron 24 mg 7 tabs One Touch combo pack 1000 pouches Onglyza Onsolis 120 films Opana (oxymorphone IR) Opana ER (oxymorphone ER) Oralair Oralair starter pack 3 tabs/180 days Oramorph SR 15 mg, 30 mg, 60 mg Oramorph SR 100 mg Orbivan 180 caps Orbivan CF Orencia subcutaneous 4 syringes / 28 days Oseni Oxecta oxybutynin ER 5 mg oxybutynin ER 10 mg, 15 mg oxybutynin syrup 600 ml oxybutynin tabs 5 mg oxycodone liquid 5mg / 5ml 5,400 ml oxycodone liquid 20mg / ml 270 ml Page 12 of 21
13 oxycodone/ibuprofen oxycodone immediate release OxyContin (oxycodone ext-release) 90 tabs Oxytrol 8 patches Panlor SS 150 tabs Patanase 1 inhaler Paxil (paroxetine) 10 mg, 20 mg, 40mg Paxil (paroxetine) 30 mg Paxil (paroxetine) oral suspension 900 ml Paxil CR (paroxetine ER) 12.5 mg Paxil CR (paroxetine ER) 25 mg, 37.5 mg Pennsaid 1.5% 150 ml Pennsaid 2% 224 ml Percocet (oxycodone-acetaminophen) , Percocet (oxycodone-acetaminophen) , tabs Percocet (oxycodone-acetaminophen) , Pexeva (paroxetine) 10 mg, 20 mg, 40 mg Pexeva (paroxetine) 30 mg Phrenilin Forte 180 caps Picato gel 0.015% gel 3 tubes / 90 days Picato gel 0.05% gel 2 tubes / 90 days Pomalyst 21 caps / 21 days Pradaxa 60 caps Pravachol (pravastatin) 10 mg, 20 mg, 40 mg 45 tabs Pravachol (pravastatin) 80 mg Prevacid (lansoprazole) 15 mg, 30mg 30 packets / caps Prevacid Solutab (lansoprazole) Prezcobix Prezista 75 mg 300 tabs Prezista 150 mg Prezista 600 mg Prezista oral suspension 400 ml Prilosec (omeprazole delayed-release ) 10 mg, 40mg Prilosec (omeprazole delayed-release ) 20 mg 60 caps Prilosec suspension packet 2.5 mg 60 packs Prilosec suspension packet 10 mg 30 packs Primlev 5 mg/300 mg 3 Primlev 7.5 mg/300 mg 240 tabs Page 13 of 21
14 Primlev 10 mg/300 mg Pristiq (desvenlafaxine ER) ProAir HFA 2 inhalers ProAir Respiclick 2 inhalers Procentra 1800 ml Promacta Protonix (pantoprazole delayed-release) 30 packets / tabs Proventil HFA 2 inhalers Provigil (modafinil) Prozac (fluoxetine) 10 mg / tabs Prozac (fluoxetine) 20 mg 120 caps / tabs Prozac (fluoxetine) 40mg 60 caps Prozac (fluoxetine) 60mg 60 caps Prozac (fluoxetine) oral solution 600 ml Prozac weekly (fluoxetine) 4 caps / 28 days Pulmicort Flexhaler 90 mcg 1 inhaler Pulmicort Flexhaler 180 mcg 2 inhalers Quillivant XR 360 ml Qnasl 1 inhaler Qualaquin (quinine) 42 capsules / 3 months Qvar 40 mcg 1 inhaler Qvar 80mcg 2 inhaler Ragwitek Rebif/Rebif Rebidose 12 syringes / 28 days Rebif Titration Pack 1 kit / 28 days Relenza 20 discs / 6 months Relpax 20 mg 12 tabs Relpax 40 mg 6 tabs Reprexain (hydrocodone-ibuprofen) tabs Rescriptor 100 mg 90 tabs Rescriptor 200 mg Rescula 5 ml Retrovir (zidovudine) 50 mg/5 ml 1920 ml Retrovir (zidovudine) 100 mg 180 caps Retrovir (zidovudine) 300 mg 60 caps Revatio (sildenafil) 90 tabs Revlimid 2.5mg, 5 mg, 10 mg Revlimid 15 mg, 25 mg 21 caps / 28 days Page 14 of 21
15 Reyataz 50mg 150 packets Reyataz 150 mg, 300 mg Reyataz 200 mg 60 caps Rexulti Rhinocort Aqua 2 inhalers Risperdal (risperidone) 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg Risperdal (risperidone) 4 mg Risperdal oral solution (risperidone) 480 ml Risperdal M-tab (risperidone) 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg Risperdal M-tab (risperidone) 4 mg Ritalin (methylphenidate) 90 tabs Ritalin LA (methylphenidate LA) All strengths Ritalin SR (methylphenidate ext-release) 90 tabs Roxicet (oxycodone-acetaminophen) Roxicet (oxycodone-acetaminophen) tabs Roxicet solution 1800 ml Rozerem Rybix ODT 240 tabs Ryzolt (tramadol) Samsca 15 mg / 365 days Samsca 30 mg / 365 days Sanctura (trospium) Sanctura XR (trospium ext-release) Sancuso 4 patches Saphris Savella Savella Dosepak 1 pack Savaysa Selzentry 150 mg Selzentry 300 mg Serevent Diskus 1 package Seroquel (quetiapine) 25 mg, 50 mg, 100 mg, 200 mg 90 tabs Seroquel (quetiapine) 300 mg, 400 mg Seroquel XR 50 mg, 300 mg, 400 mg Seroquel XR 150 mg, 200 mg Signifor 60 amps Silenor Simcor , , Page 15 of 21
16 Simcor , Simponi 1 injection Singulair (montelukast) Singulair (montelukast) oral granules, 4mg 30 packets Sonata (zaleplon) Sorilux 120 grams Spiriva Handihaler Spiriva Respimat 1 canister Sprix 5 bottles Sprycel 20 mg Sprycel 50 mg, 70 mg, 80 mg, 100 mg, 140 mg Stagesic 240 caps Stelara 1 syringe / 12 weeks Strattera 10 mg, 18 mg, 25 mg, 40 mg 60 caps Strattera 60 mg, 80 mg, 100 mg Stiolto Respimat 4 grams Stivarga 84 tabs / 28 days Striant 60 systems Stribild Striverdi Respimat 1 canister Suboxone (buprenorphine/naloxone) 2mg / 0.5mg or films Suboxone (buprenorphine/naloxone) 4mg / 1mg 30 films Suboxone (buprenorphine/naloxone) 8mg / 2mg tablet 90 tablets Suboxone (buprenorphine/naloxone) 8mg / 2mg film, 12mg / 3 mg film 60 films Suboxone oral film 120 films Subsys 120 sprays Subutex (buprenorphine) 15 tabs / 3 months Sumatriptan nasal soln, 5 mg 6 units Sumatriptan nasal soln, 20 mg 2 units sumatriptan 25 mg 36 tabs sumatriptan 50 mg 18 tabs sumatriptan 100 mg 9 tabs sumatriptan vial, 4 mg/0.5 ml 6 ml / 12 injections sumatriptan vial, 6mg/0.5ml 4ml / 8 injections Sumavel DosePro 12 injections Sustiva 50 mg 90 tabs Sustiva 200 mg Sustiva 600 mg Page 16 of 21
17 Sutent 12.5 mg 90 caps Sutent 25 mg, 50 mg 60 caps Sutent 37.5 mg Symbicort 1 inhaler Symbyax Taclonex ointment 120 grams Taclonex suspension 120 ml Tafinlar 50 mg Tafinlar 75 mg Talacen (pentazocine-acetaminophen) Tamiflu susp, 6mg/ml 180 ml / 6 months Tamiflu susp, 12 mg/ml 75 ml / 6 months Tamiflu 30 mg 20 caps / 6 months Tamiflu 45 mg, 75 mg 10 caps / 6 months Tanzeum 4 syringes / 28 days Tarceva 25 mg Tarceva 100 mg, 150 mg Tasigna 120 caps Tazorac cream 120 grams Tazorac gel 100 grams Tecfidera starter pack 1/6 months Tecfidera 120 mg 14 caps/6 months Tecfidera 240 mg 60 caps Tekamlo Tekturna Tekturna HCT Temodar 140 mg, 250 mg 42 caps Temodar all other strengths 20 caps Tencon Testim 60 tubes Teveten 400 mg Teveten (eprosartan) 600 mg Teveten HCT Thalomid 50 mg, 100 mg Thalomid 150 mg, 200 mg 60 caps Toviaz Tracleer Tradjenta Page 17 of 21
18 tramadol ER Travatan Z 2.5 ml Travoprost 2.5 ml Treximet 18 tabs Trezix 300 caps Tribenzor Tricor 48 mg Tricor 145 mg Triglide 50 mg Triglide 160 mg Trilipix 45 mg Trilipix 135 mg Trizivir Trulicity 4 pens / 28 days Truvada Tudorza 1 canister Twynsta (telmisartan amlodipine) Tykerb Tylenol w/codeine (acetaminophen-codeine) 300 mg/15 mg, 300 mg/30 mg 3 Tylenol w/codeine (acetaminophen-codeine) 300 mg/60 mg Tylenol w/codeine elixir (acetaminophen-codeine) 2700 ml Tylox (oxycodone-acetaminophen) caps Tyvaso 28 amps / 28 days Ultracet (tramadol-acetaminophen) 240 tabs Ultram (tramadol) 240 tabs Ultram ER (tramadol ER) Valturna Vectical 200 grams Venlafaxine ER 37.5 mg, 150 mg, 225 mg Venlafaxine ER 75 mg 90 tabs Ventavis 68 amps / 30 days Ventolin HFA 8 gm, 18 gm 2 canisters Veramyst 1 inhaler Versacloz 540 ml Vesicare Vicodin (hydrocodone-acetaminophen) 5-500, tabs Vicodin ES (hydrocodone-acetaminophen) tabs Vicodin HP (hydrocodone-acetaminophen) Page 18 of 21
19 Vicoprofen (hydrocodone-ibuprofen) 150 tabs Victoza 1 package Victrelis 336 caps / 28 days Videx (didanosine) powders 1200 ml Videx EC capsules Viibryd Viibryd 10 mg, 20 mg, 40 mg Viibryd Starter Kit 1 kit / 28 days Vimovo Viracept 250 mg 270 caps Viracept 625 mg Virammune 50 mg/5 ml 1200 ml Virammune 200 mg Virammune XR 100 mg 90 tabs Virammune XR 400 mg Viread Viread 40 mg/1 gm 240 grams Vitekta Vivelle Dot 8 patches / 28 days Voltaren gel 1000 grams Votrient Vogelxo 300 grams Vytorin all strengths Vyvanse Xalatan (latanoprost) 2.5 ml Xalkori 60 caps Xarelto 10 mg 35 tabs / 90 days Xarelto 15 mg Xarelto 20 mg Xartemis XR Xeljanz Xeloda 150 mg 120 caps Xeloda 500 mg 420 caps Xenazine 12.5 mg 240 tabs Xenazine 25 mg Xifaxan 200 mg 9 tabs / 3 days Xifaxan 550 mg Xigduo XR 5 mg/500 mg, 10 mg/500 mg, 10 mg/1000 mg Page 19 of 21
20 Xigduo XR 5 mg/1000 mg Xodol (hydrocodone/acetaminophen) 5 mg/300 mg 3 Xodol (hydrocodone/acetaminophen) 7.5 mg/300 mg, 10 mg/300 mg Xolox 240 tabs Xopenex HFA 2 canisters Xtandi 160 caps Xyrem 540 ml Zamicet 2700 ml Zegerid (omeprazole/sodium bicarbonate) 20 mg, 40 mg 30 packets / caps Zelboraf 240 tabs Zenzedi 2.5 mg, 15 mg, 20 mg 90 tabs Zenzedi 7.5 mg, 30 mg Zerit 1 mg/1 ml 2400 ml Zerit all capsules 60 caps Zetia Zetonna 1 bottle Ziagen 20 mg/ml 960 ml Ziagen Zipsor 120 caps Zocor (simvastatin) 5 mg, 10 mg, 40 mg 45 tabs Zocor (simvastatin) 20 mg Zocor (simvastatin) 80 mg Zofran (ondansetron) oral soln 100 ml (2 bottles) Zofran, Zofran ODT (ondansetron) 4 mg 42 tabs Zofran, Zofran ODT (ondansetron) 8 mg 21 tabs Zohydro ER 60 caps Zolinza 120 caps Zoloft (sertraline) 25 mg, 50 mg Zoloft (sertraline) 100 mg Zoloft (sertraline) oral concentrate 300 ml Zolpimist 1 canister Zolvit 2025 ml Zomig nasal soln 12 units Zomig, Zomig ZMT (zolmitriptan) 2.5 mg 18 tabs Zomig, Zomig ZMT (zolmitriptan) 5 mg 9 tabs Zorvolex 90 caps Zubsolv 1.4 mg/0.36 mg, 5.7mg/1.4mg 90 tabs Zubsolv 8.6 mg/2.1 mg Page 20 of 21
21 Zuplenz 4 mg 40 films Zuplenz 8 mg 20 films Zydone (hydrocodone/acetaminophen) 5 mg/400 mg 240 tabs Zydone (hydrocodone/acetaminophen) 7.5 mg/400 mg, 10 mg/400 mg Zyflo, Zyflo CR Zyprexa, Zyprexa Zydis (olanzapine, olanzapine ODT) Zytiga Page 21 of 21
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