2015 List of Covered Drugs (Formulary)

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www.lacare.org

H8258_15160_2015Formulary Accepted

(Medicare-Medicaid Plan)

2015

List of Covered Drugs

(Formulary)

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN.

This Formulary was updated on September 19, 2014. If you have questions, please call

L.A. Care Cal MediConnect Plan Member Services at 1-888-522-1298 (TTY: 1-888-212-4460), 24 hours a day, 7 days a week, including holidays. For more information, visit www.calmediconnectla.org.

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i If you have questions, please call L.A. Care Cal MediConnect Plan at 1-888-522-1298 (TTY: 1-888-212-4460),

24 hours a day, 7 days a week, including holidays. The call is free. For more information, visit www.calmediconnectla.org.

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• Benefits, List of Covered Drugs, and pharmacy and provider networks and/or copayments may change from time to time throughout the year and on January 1 of each year.

• You can always check L.A. Care Cal MediConnect Plan’s up-to-date List of Covered Drugs online at www.calmediconnectla.org or by calling 1-888-522-1298 (TTY: 1-888-212-4460). • You can ask for this information in other formats, such as Braille or large print.

Call 1-888-522-1298 (TTY: 1-888-212-4460). The call is free.

• Limitations and restrictions may apply. For more information, call L.A. Care Cal MediConnect Plan Member Services or read the L.A. Care Cal MediConnect Plan Member Handbook.

• Co-pays for prescription drugs may vary based on the level of Extra Help you receive. Please contact the plan for more details.

• You can get this information for free in other languages. Call 1-888-522-1298 (TTY: 1-888-212-4460). The call is free.

• Puede obtener esta información gratis en otros idiomas. Llame al 1-888-522-1298 (TTY: 1-888-212-4460). La llamada es gratis.

• Այս տեղեկությունները անվճար կարող եք ստանալ այլ լեզուներով: Զանգահարեք 1-888-522-1298 հեռախոսահամարով (TTY` 1-888-212-4460): Զանգն անվճար է: •_{អ្នកអាចទទួលព័ត៌មានននះជាភាសាន្សេងៗនោយឥតគិតថ្លៃ។ សូមនៅនលខ}1-888-522-1298 (TTY: 1-888-212-4460)_{។ ការនៅននះគឺឥតគិតថ្លៃន�ើយ។} • 이 정보는 다른 언어로도 무료로 구하실 수 있습니다._{1-888-522-1298} (TTY: 1-888-212-4460)로 전화하시면 되며 통화료는 무료입니다. • Вы можете бесплатно получить эту информацию на других языках. Позвоните по номеру телефона 1-888-522-1298 (TTY: 1-888-212-4460). Звонок бесплатный.

• Makukuha ninyo ang impormasyong ito nang libre sa ibang mga wika. Tumawag sa 1-888-522-1298 (TTY: 1-888-212-4460). Ang tawag ay libre.

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If you have questions, please call L.A. Care Cal MediConnect Plan at 1-888-522-1298 (TTY: 1-888-212-4460), 24 hours a day, 7 days a week, including holidays. The call is free. For more information, visit www.calmediconnectla.org.

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) :ﻲﺼﻨﻟﺍ ﻒﺗﺎﻬﻟﺍ ﻢﻗﺭ 1-888-212-4460 .( ﻩﺬﻫ ﺔﻤﻟﺎﻜﻤﻟﺍ ﺔﻴﻧﺎﺠﻣ .

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iii If you have questions, please call L.A. Care Cal MediConnect Plan at 1-888-522-1298 (TTY: 1-888-212-4460),

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1. What prescription drugs are on the List of Covered Drugs? (We call the List of Covered Drugs the “Drug List” for short.)

The drugs on the Drug List are the drugs covered by L.A. Care Cal MediConnect Plan. The drugs are available at pharmacies within our network. A pharmacy is in our network if we have an agreement with them to work with us and provide you services. We refer to these pharmacies as “network pharmacies.”

L.A. Care Cal MediConnect Plan will cover all medically necessary drugs on the Drug List if: • your doctor or other prescriber says you need them to get better or stay healthy, and • you fill the prescription at an L.A. Care Cal MediConnect Plan network pharmacy. In some cases, you have to do something before you can get a drug (see Question 5).

You can also see an up-to-date list of drugs that we cover on our website at www.calmediconnectla.org or call Member Services at 1-888-522-1298 (TTY: 1-888-212-4460).

2. Does the Drug List ever change?

Yes. L.A. Care Cal MediConnect Plan may add or remove drugs on the Drug List during the year. Generally, the Drug List will only change if:

• a cheaper drug comes along that works as well as a drug on the Drug List now, or • we learn that a drug is not safe.

We may also change our rules about drugs. For example, we could:

• Decide to require or not require prior approval for a drug. (Prior approval is permission from L.A. Care Cal MediConnect Plan before you can get a drug.)

• Add or change the amount of a drug you can get (called “quantity limits”).

• Add or change step therapy restrictions on a drug. (Step therapy means you must try one drug before we will cover another drug.)

(For more information on these drug rules, see page iv.)

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www.calmediconnectla.org. You can also call Member Services to check the current Drug List at 1-888-522-1298 (TTY: 1-888-212-4460).

3. What happens when a cheaper drug comes along that works as well as a drug on the Drug List now?

If you are taking a drug that is removed because a cheaper drug that works just as well comes along, we will tell you. We will tell you at least 60 days before we remove it from the Drug List or when you ask for a refill. You will be notified of this change in a document called the

Explanation of Benefits which shows drugs to be removed from the Drug List in 60 days. The list of drugs to be removed is also posted on L.A. Care Cal MediConnect Plan’s website, www.calmediconnectla.org.

4. What happens when we find out a drug is not safe?

If the Food and Drug Administration (FDA) says a drug you are taking is not safe, we will take it off the Drug List right away. We will also send you a letter telling you that. We will also notify your provider so you can consult him/her to change to a drug on the Drug List that is safe to use. 5. Are there any restrictions or limits on drug coverage? Or are there any required

actions to take in order to get certain drugs?

Yes, some drugs have coverage rules or have limits on the amount you can get. In some cases, you must do something before you can get the drug. For example:

• Prior approval (or prior authorization): For some drugs, you or your doctor must get approval from L.A. Care Cal MediConnect Plan before you fill your prescription. If you don’t get approval, L.A. Care Cal MediConnect Plan may not cover the drug.

• Quantity limits: Sometimes L.A. Care Cal MediConnect Plan limits the amount of a drug you can get.

• Step therapy: Sometimes L.A. Care Cal MediConnect Plan requires you to do step therapy. This means you will have to try drugs in a certain order for your medical condition. You might have to try one drug before we will cover another drug. If your doctor thinks the first drug doesn’t work for you, then we will cover the second.

You can find out if your drug has any additional requirements or limits by looking in the tables on pages 1-61. You can also get more information by visiting our website at www.calmediconnectla.org. We have posted online a document that explains our prior authorization and step therapy restrictions. You may also ask us to send you a copy.

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v If you have questions, please call L.A. Care Cal MediConnect Plan at 1-888-522-1298 (TTY: 1-888-212-4460),

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Drug List, or if you cannot easily get the drug you need, we can help. We will cover a 31-day emergency supply of the drug you need (unless you have a prescription for fewer days), whether or not you are a new L.A. Care Cal MediConnect Plan member. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to request an exception. Please see Question 11 for more information about exceptions.

6. How will you know if the drug you want has limitations or if there are required actions to take to get the drug?

The List of Covered Drugs on page 1 has a column labeled “Necessary actions, restrictions, or limits on use.”

7. What happens if we change our rules on how we cover some of the drugs? For example, if we add prior authorization (approval), quantity limits, and/or step therapy restrictions on a drug.

We will tell you if we add prior approval, quantity limits, and/or step therapy restrictions on a drug. We will tell you at least 60 days before the restriction is added or when you next ask your pharmacy for a refill. Then, you can get a 60-day supply of the drug before the change to the coverage rules is made. This gives you time to talk to your doctor about what to do next. 8. How can you find a drug on the Drug List?

There are two ways to find a drug:

• You can search alphabetically (if you know how to spell the drug), or • You can search by medical condition.

To search alphabetically, go to the Alphabetical Listing section. You can find it by looking at the index at the end of the list. The medications are listed in alphabetical order.

To search by medical condition, find the section labeled “List of drugs by medical condition” on page 1. Then find your medical condition. For example, if you have a heart condition, you should look in that category. That is where you will find drugs that treat heart conditions.

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• Ask Member Services for a list of drugs like the one you want to take. Then show the list to your doctor or other prescriber. He or she can prescribe a drug on the Drug List that is like the one you want to take. Or

• You can ask the health plan to make an exception to cover your drug. Please see Question 11 for more information about exceptions.

10. What if you are a new L.A. Care Cal MediConnect Plan member and can’t find your drug on the Drug List or have a problem getting your drug?

We can help. We may cover a temporary 30-day supply of your drug during the first 90 days you are a member of L.A. Care Cal MediConnectPlan. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to request an exception.

We will cover a 30-day supply of your drug if:

• you are taking a drug that is not on our Drug List, or

• health plan rules do not let you get the amount ordered by your prescriber, or • the drug requires prior approval by L.A. Care Cal MediConnect Plan, or • you are taking a drug that is part of a step therapy restriction.

If you live in a nursing home or other long-term care facility, you may refill your prescription for as long as 98 days. You may refill the drug multiple times during the 90 days. This gives your prescriber time to change your drugs to those on the Drug List or ask for an exception. Level of Care Changes

We will provide a transition supply of your drugs when you experience a change in level of care. Examples of level of care changes may include the following:

1. Members who enter long-term care facilities from hospitals 2. Members who are discharged from a hospital to a home

3. Members who end their skilled nursing facility Medicare Part A stay and who need to revert to their Part D plan formulary

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vii If you have questions, please call L.A. Care Cal MediConnect Plan at 1-888-522-1298 (TTY: 1-888-212-4460),

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Pharmacies may contact L.A. Care Cal MediConnect Plan Pharmacy Services at 1-866-270-3877 to process point-of-sale overrides to ensure members receive access to their medications without any delays.

11. Can you ask for an exception to cover your drug?

Yes. You can ask L.A. Care Cal MediConnect Plan to make an exception to cover a drug that is not on the Drug List.

You can also ask us to change the rules on your drug.

• For example, L.A. Care Cal MediConnect Plan may limit the amount of a drug we will cover. If your drug has a limit, you can ask us to change the limit and cover more.

• Other examples: You can ask us to drop step therapy restrictions or prior approval requirements. 12. How long does it take to get an exception?

First, we must receive a statement from your prescriber supporting your request for an exception. After we receive the statement, we will give you a decision on your exception request within 72 hours. If you or your prescriber think your health may be harmed if you have to wait 72 hours for a decision, you can ask for an expedited exception. This is a faster decision. If your prescriber supports your request, we will give you a decision within 24 hours of receiving your prescriber’s supporting statement.

13. How can you ask for an exception?

To ask for an exception, call Member Services or our Pharmacy Department. Your care team will work with you and your provider to help you ask for an exception.

14. What are generic drugs?

Generic drugs are made up of the same ingredients as brand-name drugs. They usually cost less than the brand-name drug and their names are less commonly known. Generic drugs are approved by the Food and Drug Administration (FDA).

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You can read the L.A. Care Cal MediConnect Plan Drug List to see what OTC drugs are covered.

16. Does L.A. Care Cal MediConnect Plan cover OTC non-drug products?

L.A. Care Cal MediConnect Plan covers some OTC non-drug products. You can read the L.A. Care Cal MediConnect Plan Drug List to see what OTC non-drug products are covered. 17. What is your co-pay?

You can read the L.A. Care Cal MediConnect Plan Drug List to learn about the co-pay for each drug. L.A. Care Cal MediConnect Plan members living in nursing homes or other long-term care facilities will have no co-pays. Some members getting long-term care in the community will also have no co-pays.

Co-pays are listed by tiers. Tiers are groups of drugs with the same co-pay.

• Tier 1 drugs are generic drugs. The co-pay will be from $0 to $2.65, depending on your level of Medicaid eligibility.

• Tier 2 drugs are brand name drugs. The co-pay will be from $0 to $6.60, depending on your level of Medicaid eligibility.

• Tier 3 drugs are Non-Medicare Rx Generic drugs. For Tier 3 drugs you pay nothing. • Tier 4 drugs are Non-Medicare OTC drugs. For Tier 4 drugs you pay nothing.

List of Covered Drugs

The list of covered drugs below or that begins on the next page gives you information about the drugs covered by L.A. Care Cal MediConnect Plan. If you have trouble finding your drug in the list, turn to the Index that begins on page 1.

The first column of the chart lists the name of the drug. Brand-name drugs are capitalized (e.g., CYMBALTA) and generic drugs are listed in lowercase italics (e.g., metformin).

The information in the “Necessary actions, restrictions, or limits on use” column tells you if L.A. Care Cal MediConnect Plan has any rules for covering your drug.

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ix If you have questions, please call L.A. Care Cal MediConnect Plan at 1-888-522-1298 (TTY: 1-888-212-4460),

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Utilization Management Restrictions

PA Prior Authorization

Restriction You (or your physician) are required to get prior authorization from L.A. Care Cal MediConnect Plan before you fill your prescription for this drug. Without prior approval, L.A. Care Cal MediConnect Plan may not cover this drug.

PA BvD Prior Authorization Restriction for Part B vs Part D Determination

This drug may be eligible for payment under Medicare Part B or Part D. You (or your physician) are required to get prior authorization from L.A. Care Cal MediConnect Plan to determine that this drug is covered under Medicare Part D before you fill your prescription for this drug. Without prior approval, L.A. Care Cal MediConnect Plan may not cover this drug.

PA NSO Prior Authorization Restriction for New Starts Only

If this is a new prescription for you, i.e., the first time this drug is prescribed for you, you (or your physician) are required to get prior authorization from L.A. Care Cal MediConnect Plan before you fill your prescription for this drug. Without prior approval, L.A. Care Cal MediConnect Plan may not cover this drug. QL Quantity Limit Restriction L.A. Care Cal MediConnect Plan limits the quantity to be covered within a

specific time frame for this drug.

ST Step Therapy Restriction Before L.A. Care Cal MediConnect Plan will provide coverage for this drug, you must first try another drug(s) on the formulary to treat your medical condition. This drug may only be covered if the other drug(s) does not work for you.

Other Special Requirements for Coverage

LD Limited Distribution Drug This prescription may be available only at certain pharmacies. For more information, consult your Provider/Pharmacy Directory or call Member Services at 1-888-522-1298 (TTY: 1-888-212-4460), 24 hours a day, 7 days a week, including holidays.

Note: The asterisk (*) next to a drug means the drug is not a “Part D drug.” The amount you pay when you fill a prescription for this drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify for catastrophic coverage). These drugs also have different rules for appeals. An appeal is a formal way of asking us to review a decision we made about your coverage and to change it if you think we made a mistake. For example, we might decide that a drug that you want is not covered or is no longer covered by Medicare or Medi-Cal. If you or your doctor disagrees with our decision, you can appeal. If you ever have a question, call Member Services at 1-822-522-1298 (TTY: 1-888-212-4460). You can also read the Member Handbook to learn how to appeal a decision.

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ADHD/ ANTI-NARCOLEPSY/ ANTI-OBESITY/ ANOREXIANTS AMPHETAMINES

1 ADDERALL XR CAP

1 amphetamine/ dextroamphetamine tab

1 dextroamphetamine ER cap 1 dextroamphetamine tab 1 methamphetamine tab 2 VYVANSE CAP ANOREXIANTS NON-AMPHETAMINE 3 phentermine cap 15mg* PA 3 phentermine cap 30mg* PA 3 phentermine tab 37.5mg* PA 3 QSYMIA CAP* PA ANTI-OBESITY AGENTS 3 XENICAL CAP 120MG* PA

ATTENTION-DEFICIT/ HYPERACTIVITY DISORDER (ADHD) AGENTS 2

INTUNIV TAB 1MG, 2MG PA ST

2

INTUNIV TAB 3MG, 4MG PA NSO ST

2

STRATTERA CAP QL=60 Caps/30 Days

STIMULANTS - MISC. 1 dexmethylphenidate ER cap 1 dexmethylphenidate tab 1 metadate ER tab 1 methylphenidate CD cap 1 methylphenidate ER cap 1 methylphenidate ER tab 1 methylphenidate soln. 1 methylphenidate tab 2

NUVIGIL TAB PA QL=30 Tabs/30 Days

AMINOGLYCOSIDES AMINOGLYCOSIDES 1 amikacin inj. PA BvD 1 gentamicin inj. PA BvD 1

gentamicin/ nacl inj. PA BvD

1 gentamicin/ nacl inj. 1.6mg/ ml

1 gentamycin/ nacl inj.

1 isotonic gentamicin 1 neomycin tab 1 paromomycin cap 2 STREPTOMYCIN INJ. PA BvD 2 TOBI NEB NM PA 2 TOBI PODHALER NM PA 1 tobramycin inj PA BvD 2

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ANALGESICS - ANTI-INFLAMMATORY ANTI-TNF-ALPHA - MONOCLONAL ANTIBODIES

2 HUMIRA KIT NM PA 2 SIMPONI INJ. NM PA GOLD COMPOUNDS 2 RIDAURA CAP INTERLEUKIN-1 BLOCKERS 2 ARCALYST INJ. NM PA INTERLEUKIN-1BETA BLOCKERS 2 ILARIS INJ. NM PA

NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS) 2

CELEBREX CAP QL=60 Caps/30 Days

1 diclofenac ec tab

1 diclofenac potassium tab

1 diclofenac XR tab

1 diclofenac/ misoprostol tab

1 etodolac cap 1 etodolac ER tab 1 etodolac tab 1 fenoprofen tab 1 flurbiprofen tab 4 ibuprofen cap 200mg* 4 ibuprofen chew tab 100mg*

1 ibuprofen susp. 1 ibuprofen tab 4 ibuprofen tab 100mg* 4

ibuprofen tab 200mg* QL=100 Tabs/100 Days

2 INDOCIN SUSP. PA 1 indomethacin cap PA 1 indomethacin ER cap PA 1 ketoprofen cap 1 ketorolac inj. PA 1

ketorolac tab PA QL=20 Tabs/5 Days

2 MECLOFENAMATE SODIUM CAP

1 mefenamic acid cap

2 MELOXICAM SUSP 1 meloxicam tab 1 nabumetone tab 1 naproxen dr tab 1 naproxen sodium tab

1 naproxen susp. 1 naproxen tab 1 oxaprozin tab 1 piroxicam cap

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1 sulindac tab 1 tolmetin cap 1 tolmetin tab 2 TOLMETIN TAB 200MG

PYRIMIDINE SYNTHESIS INHIBITORS

1 leflunomide tab

SELECTIVE COSTIMULATION MODULATORS

2

ORENCIA INJ. PA

2

ORENCIA SUB-Q INJ. PA

SOLUBLE TUMOR NECROSIS FACTOR RECEPTOR AGENTS 2

ENBREL INJ. NM PA

ANALGESICS - NONNARCOTIC ANALGESIC COMBINATIONS

4 aspirin/ acetaminophen/ caffeine tab 250-250-65mg*

ANALGESICS OTHER

4 acetaminophen cap 500mg*

4 acetaminophen chew tab 160mg*

4 acetaminophen CR tab 650mg* 4 acetaminophen elixir 160mg/ 5ml* 4 acetaminophen liquid 160mg/ 5ml* 4 ACETAMINOPHEN LIQUID 500MG/ 5ML* 4 acetaminophen soln. 160mg/ 5ml* 4 acetaminophen suppository 120mg* 4 acetaminophen suppository 325mg* 4 acetaminophen suppository 650mg* 4 acetaminophen suppository 80mg* 4 acetaminophen susp. 160mg/ 5ml* 4 acetaminophen susp. 80mg/ 0.8ml* 4 acetaminophen tab 325mg* 4 acetaminophen tab 500mg* SALICYLATES 4 ASCRIPTIN TAB 325MG* 4

aspirin 81mg tab* QL=100 Tabs/100 Days

4

aspirin DR tab 325mg* QL=100 Tabs/100 Days

4

aspirin DR tab 81mg* QL=100 Tabs/100 Days

4

aspirin tab 325mg* QL=100 Tabs/100 Days

4 aspirin tab 500mg* 1 diflunisal tab ANALGESICS - OPIOID OPIOID AGONISTS 1 codeine sulfate tab

1

duramorph inj. PA BvD

2 EXALGO TAB

1

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1 fentanyl patch 1 hydromorphone ER tab 1 hydromorphone inj. PA BvD 1 hydromorphone oral liquid

1 hydromorphone tab

2

LAZANDA SPRAY PA QL=30 Bottles/30 Days

2 LEVORPHANOL TAB 1 meperitab tab PA 1 methadone soln. 1 methadone tab 1

morphine sulfate ER cap QL=60 Caps/30 Days

1

morphine sulfate ER tab QL=120 Tabs/30 Days

2

MORPHINE SULFATE PF INJ. 2MG, 4MG PA BvD

1 morphine sulfate soln.

1 morphine sulfate tab

2

NUCYNTA ER TAB QL=60 Tabs/30 Days

1 oxycodone cap 1 oxycodone soln. 1 oxycodone tab 2

OXYCONTIN TAB QL=60 Tabs/30 Days

2

OXYCONTIN TAB 80MG QL=120 Tabs/30 Days

1

oxymorphone ER tab QL=60 Tabs/30 Days

1 oxymorphone tab 1 tramadol ER tab 1 tramadol hcl tab OPIOID COMBINATIONS 1 acetaminophen/ codeine soln.

1 acetaminophen/ codeine tab

1 endocet tab

1 endodan tab

1 hydrocodone/ acetaminophen soln. 7.5-325mg/ 15ml

1 hydrocodone/ acetaminophen tab 5-300mg, 7.5-300mg,

10-300mg

1 hydrocodone/ acetaminophen tab 5-325mg, 7.5-325mg,

10-325mg

1 hydrocodone/ ibuprofen tab

1 oxycodone / aspirin tab

1 oxycodone / ibuprofen tab

1 oxycodone/ acetaminophen tab

2 ROXICET SOLN

1 tramadol/ acetaminophen tab

OPIOID PARTIAL AGONISTS

1 buprenorphine inj. PA BvD 1 buprenorphine sl tab 1 butorphanol inj PA BvD

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1

butorphanol soln. QL=4 Bottles/30 Days

2

BUTRANS PATCH QL=4 Patches/28 Days

1

pentazocine/ naloxone tab PA

2 SUBOXONE SL FILM ANDROGENS-ANABOLIC ANABOLIC STEROIDS 2 ANADROL-50 TAB 1 oxandrolone tab ANDROGENS 2

ANDRODERM PATCH 2MG/ 24HR PA QL=60 Patches/30 Days

2

ANDRODERM PATCH 4MG/ 24HR PA QL=30 Patches/30 Days

2

ANDROGEL GEL 1%(50MG) PA QL=60 Patches/30 Days

2

ANDROGEL PUMP PA QL=2 Bottles/30 Days

2 ANDROXY TAB

1 danazol cap

1

testosterone cypionate inj. PA BvD

1

testosterone enanthate inj. PA BvD

ANORECTAL AGENTS INTRARECTAL STEROIDS 1 colocort enema 1 hydrocortisone enema RECTAL STEROIDS 1 procto-pak 1 proctozone-hc cream ANTACIDS ANTACID COMBINATIONS 4 aluminum hydroxide/ magnesium carbonate chew tab*

4 aluminum/ mag hydroxide/ simethicone susp.

225-20-25mg/ 5ml*

4 antacid susp.*

4 GELUSIL CHEW TAB*

4 MAALOX ADVANCED MAXIMUM STRENGTH

CHEW TAB*

4 maalox max susp*

ANTACIDS - ALUMINUM SALTS

4 ALUMINUM HYDROXIDE GEL SUSP. 320MG/

5ML*

4 aluminum hydroxide gel susp. 600mg/ 5ml*

ANTACIDS - BICARBONATE

4 sodium bicarbonate tab 650mg*

ANTACIDS - CALCIUM SALTS

4 calcium carbonate chew tab 1000mg*

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4 calcium carbonate tab 648mg*

ANTHELMINTICS ANTHELMINTICS 2 ALBENZA TAB 2 STROMECTOL TAB ANTIANGINAL AGENTS ANTIANGINALS-OTHER 2 RANEXA TAB NITRATES 1 isosorbide dinitrate ER tab

1 isosorbide dinitrate tab

1 isosorbide mononitrate ER tab

1 isosorbide mononitrate tab

1 minitran patch 2 NITRO-DUR PATCH 0.3MG/ HR, 0.8MG/ HR 1 nitroglycerin inj. PA BvD 1 nitroglycerin lingual spray

1 nitroglycerin patch

2 NITROSTAT SL TAB

ANTIANXIETY AGENTS ANTIANXIETY AGENTS - MISC.

1 buspirone tab

1

hydroxyzine inj. PA

1

hydroxyzine pamoate cap PA

1 hydroxyzine syrup PA 1 hydroxyzine tab PA 1 meprobamate tab PA BENZODIAZEPINES 1 alprazolam ER tab 1 alprazolam odt tab

1 alprazolam tab 1 chlordiazepoxide cap 1 clorazepate tab 1 DIAZEPAM INTENSOL 1 DIAZEPAM SOLN. 1 diazepam tab 1 lorazepam conc 1 lorazepam tab 1 oxazepam cap ANTIARRHYTHMICS ANTIARRHYTHMICS TYPE I-A

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1 disopyramide cap PA 2 NORPACE CR PA 2 PROCAINAMIDE INJ. PA BvD 1 quinidine gluconate CR tab

2

QUINIDINE GLUCONATE INJ. PA BvD

1 quinidine sulfate tab

ANTIARRHYTHMICS TYPE I-B

1 mexiletine cap

ANTIARRHYTHMICS TYPE I-C

1 flecainide tab 1 propafenone ER cap 1 propafenone tab

ANTIARRHYTHMICS TYPE III

1 amiodarone inj PA BvD 1 amiodarone tab 2 MULTAQ TAB 2 NEXTERONE INJ. PA BvD 2 TIKOSYN CAP

ANTIASTHMATIC AND BRONCHODILATOR AGENTS ANTIASTHMATIC - MONOCLONAL ANTIBODIES

2 XOLAIR INJ. NM PA ANTI-INFLAMMATORY AGENTS 1 cromolyn neb PA BvD BRONCHODILATORS - ANTICHOLINERGICS 2 ATROVENT HFA INHALER

1

ipratropium neb PA BvD

2 SPIRIVA CAP HANDIHALER

2 TUDORZA INHALER

LEUKOTRIENE MODULATORS

1 montelukast chew tab

1 montelukast granules 1 montelukast tab 1 zafirlukast tab

SELECTIVE PHOSPHODIESTERASE 4 (PDE4) INHIBITORS 2 DALIRESP TAB STEROID INHALANTS 2 ASMANEX INHALER 1

budesonide neb PA BvD QL=60 Neb/30 Days

2

FLOVENT DISKUS QL=1 Inhalers/30 Days

2

FLOVENT HFA INHALER 220MCG QL=2 Inhalers/30 Days

2

FLOVENT HFA INHALER 44MCG, 110MCG QL=1 Inhalers/30 Days 2

PULMICORT NEB 1MG/ 2ML PA BvD QL=60 Neb/30 Days

1

QVAR INHALER QL=4 Inhalers/30 Days

(19)

2

ADVAIR DISKUS QL=1 Inhalers/30 Days

2

ADVAIR HFA INHALER QL=1 Inhalers/30 Days

1

albuterol neb PA BvD

1 albuterol sulfate ER tab

1 albuterol syrup 1 albuterol tab 2 COMBIVENT RESPIMAT 2

DULERA INHALER QL=1 Inhalers/30 Days

4 EPHEDRINE SULFATE CAP 25MG*

2 FORADIL CAP

1

ipratropium/ albuterol neb. PA BvD

1 levalbuterol neb PA BvD 1 METAPROTERENOL SYRUP 2 SEREVENT INHALER 2

SYMBICORT INHALER QL=1 Inhalers/30 Days

1

terbutaline inj. PA BvD

1 terbutaline tab

2

VENTOLIN HFA INHALER QL=4 Inhalers/30 Days

XANTHINES 1 aminophylline inj. PA BvD 2 ELIXOPHYLLIN SOLN. 1 theophylline ER tab 1 theophylline soln. ANTICOAGULANTS COUMARIN ANTICOAGULANTS 2 COUMADIN INJ. PA BvD 1 jantoven tab 1 warfarin tab

DIRECT FACTOR XA INHIBITORS

2 ELIQUIS TAB

2 XARELTO TAB

HEPARINS AND HEPARINOID-LIKE AGENTS

1

enoxaparin inj. QL=35 Syringes/17 Days

1 fondaparinux inj. NM PA 2 FRAGMIN INJ. NM PA BvD 1 heparin inj. PA BvD 1 heparin/ d5w inj. PA BvD 1

heparin/ nacl inj. PA BvD

THROMBIN INHIBITORS 1 argatroban inj. 100mg/ ml PA BvD 2 ARGATROBAN INJ. 125MG/ 125ML PA BvD 2 PRADAXA CAP ANTICONVULSANTS AMPA GLUTAMATE RECEPTOR ANTAGONISTS

(20)

2

FYCOMPA TAB PA NSO

ANTICONVULSANTS - BENZODIAZEPINES

1 clonazepam odt tab

1 clonazepam tab

2 DIASTAT RECTAL GEL

2 DIAZEPAM RECTAL GEL

2

ONFI SUSPENSION PA NSO

2

ONFI TAB PA NSO

ANTICONVULSANTS - MISC.

2

APTIOM TAB PA NSO

2 BANZEL SUSP.

2 BANZEL TAB

1 carbamazepine chew tab

1 carbamazepine ER cap 1 carbamazepine ER tab 1 carbamazepine susp. 1 carbamazepine tab 1 epitol tab 1 gabapentin cap 1 gabapentin soln. 1 gabapentin tab 2 LAMICTAL ODT 2 LAMICTAL STARTER KIT

2 LAMICTAL XR KIT

1 lamotrigine chew tab

1 lamotrigine ER tab 1 lamotrigine tab 1 levetiracetam ER tab 1 levetiracetam inj PA BvD 1 levetiracetam soln. 1 levetiracetam tab 2 LYRICA CAP 2 LYRICA SOLN. 1 oxcarbazepine oral susp.

1 oxcarbazepine tab

2 OXTELLAR XR TAB

2

POTIGA TAB PA NSO QL=90 Tabs/30 Days

1 primidone tab

2 TEGRETOL-XR TAB

1 topiramate sprinkle cap

1 topiramate tab

2

TROKENDI XR CAP PA NSO

2

VIMPAT INJ. PA BvD

2 VIMPAT SOLN.

2

(21)

1 zonisamide cap CARBAMATES 1 felbamate susp. 1 felbamate tab GABA MODULATORS 2 GABITRIL TAB 2 SABRIL POWDER NM 2 SABRIL TAB NM 1 tiagabine tab HYDANTOINS 2 DILANTIN CAP 1 fosphenytoin inj. PA BvD 2 PEGANONE TAB 1 phenytoin cap 1 phenytoin chew tab

1 phenytoin inj. PA BvD 1 phenytoin susp. SUCCINIMIDES 2 CELONTIN CAP 1 ethosuximide cap 1 ethosuximide soln. VALPROIC ACID 1 divalproex dr tab 1 divalproex ER tab 1 divalproex sprinkle cap

1

valproate sodium inj. PA BvD

1 valproic acid cap

1 valproic acid syrup

ANTIDEPRESSANTS ALPHA-2 RECEPTOR ANTAGONISTS (TETRACYCLICS)

1 mirtazapine odt tab

1 mirtazapine tab ANTIDEPRESSANTS - MISC. 2 APLENZIN TAB ST 1 bupropion SR tab 1 bupropion tab 1 bupropion XL tab 1 maprotiline tab MODIFIED CYCLICS 2 BRINTELLIX TAB ST 2 NEFAZODONE TAB 1 trazodone tab 2

VIIBRYD STARTER PACK PA NSO

2

(22)

MONOAMINE OXIDASE INHIBITORS (MAOIS) 2 EMSAM PATCH 2 MARPLAN TAB 1 phenelzine tab 1 tranylcypromine tab

SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIS) 1 citalopram soln. 1 citalopram tab 1 escitalopram soln. 1 escitalopram tab 1 fluoxetine cap 1 fluoxetine soln. 1 fluoxetine tab 1 fluvoxamine ER cap ST 1 fluvoxamine tab 1 paroxetine ER tab 1 paroxetine tab 2 PAXIL SUSP. 2 PEXEVA TAB ST 1 sertraline conc. 1 sertraline tab

SEROTONIN-NOREPINEPHRINE REUPTAKE INHIBITORS (SNRIS) 2

DESVENLAFAXINE ER TAB ST

1

duloxetine cap QL=60 Caps/30 Days

2 FETZIMA CAP ST 2 FETZIMA PACK ST 2 KHEDEZYLA TAB ST 2 PRISTIQ TAB ST 1 venlafaxine ER cap 1 venlafaxine ER tab 2 VENLAFAXINE ER TAB 225MG 1 venlafaxine tab TRICYCLIC AGENTS 1

amitriptyline tab PA NSO

1 amoxapine tab

1

clomipramine cap PA NSO

1 desipramine tab

1

doxepin conc. PA NSO

1

doxepine cap PA NSO

1

imipramine pamoate PA NSO

1

imipramine tab PA NSO

1 nortriptyline cap 1 nortriptyline soln. 1 protriptyline tab 2

(23)

ANTIDIABETICS ALPHA-GLUCOSIDASE INHIBITORS 1 acarbose tab 2 GLYSET TAB

ANTIDIABETIC - AMYLIN ANALOGS

2 SYMLINPEN ANTIDIABETIC COMBINATIONS 2 AVANDAMET TAB 2 AVANDARYL TAB 1 glipizide/ metformin tab

1

glyburide/ metformin tab PA

2 JANUMET TAB

2 JANUMET XR TAB

1 pioglitazone/ glimepiride tab

1 pioglitazone/ metformin tab

BIGUANIDES

1 metformin ER osmotic tab 1000mg

1 metformin ER tab 1 metformin tab DIABETIC OTHER 2 GLUCAGEN HYPOKIT 2 GLUCAGON KIT 2 KORLYM TAB NM PA 2 PROGLYCEM SUSP.

DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS

2

JANUVIA TAB QL=30 Tabs/30 Days

2

ONGLYZA TAB QL=30 Tabs/30 Days

2

TRADJENTA TAB QL=30 Tabs/30 Days

INCRETIN MIMETIC AGENTS (GLP-1 RECEPTOR AGONISTS) 2 BYDUREON INJ. 2 VICTOZA INJ. INSULIN 2 HUMALOG PEN ST 2 HUMALOG VIAL ST 2 HUMULIN 70/ 30 PEN 2 HUMULIN N PEN 2 HUMULIN R U-500 VIAL

2 LANTUS SOLOSTAR 2 LANTUS VIAL 2 LEVEMIR FLEXPEN 2 LEVEMIR INJ. 2 NOVOLIN 70/ 30 VIAL 2 NOVOLIN N VIAL 2 NOVOLIN R VIAL

(24)

2 NOVOLOG FLEXPEN

2 NOVOLOG MIX 70/ 30 PEN

2 NOVOLOG MIX 70/ 30 VIAL

2 NOVOLOG VIAL

INSULIN SENSITIZING AGENTS

2 AVANDIA TAB 1 pioglitazone tab MEGLITINIDE ANALOGUES 1 nateglinide tab 1 repaglinide tab

SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITORS 2

FARXIGA TAB ST

2

INVOKANA TAB QL=30 Tabs/30 Days

SULFONYLUREAS 1 chlorpropamide tab PA 1 glimepiride tab 1 glipizide ER tab 1 glipizide tab 1

glyburide micronized tab PA

1 glyburide tab PA 1 tolazamide tab 2 TOLBUTAMIDE TAB ANTIDIARRHEALS ANTIDIARRHEAL AGENTS - MISC.

4 bismuth subsalicylate chew tab 262mg*

4 bismuth subsalicylate susp 262mg/ 15ml*

4 bismuth subsalicylate susp 525mg/ 15ml*

4 bismuth subsalicylate tab 262mg*

ANTIPERISTALTIC AGENTS

1 diphenoxylate/ atropine liquid

1 diphenoxylate/ atropine tab

1 loperamide cap 4 loperamide tab 2mg* ANTIDOTES ANTIDOTES 1 fomepizole inj. PA BvD

ANTIDOTES - CHELATING AGENTS

2 CHEMET CAP

2

EXJADE ORAL SUSP. NM

2 FERRIPROX LD PA OPIOID ANTAGONISTS 1 naloxone inj. 1 naltrexone tab

(25)

ANTIEMETICS 5-HT3 RECEPTOR ANTAGONISTS

1

granisetron inj. PA BvD

1

granisetron tab PA BvD QL=9 Tabs/2 Days

1

ondansetron inj. PA BvD

1

ondansetron odt tab PA BvD

1 ondansetron soln. PA BvD 1 ondansetron tab PA BvD ANTIEMETICS - ANTICHOLINERGIC 4 BONINE CHEW TAB 25MG*

4 dimenhydrinate tab 50mg* 1 meclizine tab 2 TRANSDERM SCOP 1 trimethobenzamide cap PA ANTIEMETICS - MISCELLANEOUS 2 CESAMET CAP 1 dronabinol cap

SUBSTANCE P/ NEUROKININ 1 (NK1) RECEPTOR ANTAGONISTS 2

EMEND CAP PA BvD QL=3 Caps/2 Days

2

EMEND PACK PA BvD QL=3 Caps/2 Days

ANTIFUNGALS

ANTIFUNGAL - GLUCAN SYNTHESIS INHIBITORS (ECHINOCANDINS) 2 CANCIDAS INJ. NM PA BvD 2 ERAXIS INJ. PA BvD 2 MYCAMINE INJ. PA BvD ANTIFUNGALS 2 ABELCET INJ. PA BvD 2 AMBISOME INJ. PA BvD 2 AMPHOTERICIN B INJ. PA BvD 1 flucytosine cap 1 griseofulvin microsize susp.

1 griseofulvin tab 1 nystatin tab 1 terbinafine tab IMIDAZOLE-RELATED ANTIFUNGALS 1 fluconazole susp. 1 fluconazole tab 1

fluconazole/ dextrose inj. PA BvD

1 itraconazole cap PA 1 ketoconazole tab 2 NOXAFIL SUSP PA 2 NOXAFIL TAB NM PA 1 voriconazole inj. PA 1 voriconazole susp. PA

(26)

1 voriconazole tab NM PA ANTIHISTAMINES ANTIHISTAMINES - ALKYLAMINES 4 chlorpheniramine syrup 2mg/ 5ml* 4 chlorpheniramine tab 4mg* ANTIHISTAMINES - ETHANOLAMINES 4 BENADRYL CHEW TAB 12.5MG*

1 carbinoxamine soln. PA 1 carbinoxamine tab PA 2 CLEMASTINE SYRUP PA 1 clemastine tab PA 4 clemastine tab 1.34mg* 4 diphenhydramine cap 25mg* 4 diphenhydramine cap 50mg* 4 diphenhydramine elixir 12.5mg/ 5ml* 1 diphenhydramine inj. PA BvD 4 diphenhydramine liquid 12.5mg/ 5ml* 1

diphenhydramine oral soln (Rx only) PA

4 diphenhydramine tab 25mg* ANTIHISTAMINES - NON-SEDATING 3 ALLEGRA TAB 30MG* PA 4 cetirizine chew tab 10mg*

4 cetirizine chew tab 5mg*

1 cetirizine oral soln (Rx only)

4

cetirizine soln 1mg/ ml* QL=300 ml/30 Days

4

cetirizine tab 10mg* QL=30 Tabs/30 Days

4

cetirizine tab 5mg* QL=30 Tabs/30 Days

1 desloratadine ODT tab

1 desloratatine tab 3 fexofenadine tab 180mg* PA 3 fexofenadine tab 60mg* PA 1 levocetirizine soln. 1 levocetirizine tab 4

loratadine ODT tab 10mg* QL=30 Tabs/30 Days

4

loratadine syrup 5mg/ 5ml* QL=300 ml/30 Days

4

loratadine tab 10mg* QL=30 Tabs/30 Days

ANTIHISTAMINES - PHENOTHIAZINES 1 phenadoz supp. PA 1 promethazine inj. PA 1 promethazine supp. PA 1 promethazine syrup PA 1 promethazine tab PA 2 PROMETHAZINE VC CODEINE PA 1 promethegan supp. PA

(27)

2 PROMETHEGAN SUPP. 50MG PA ANTIHISTAMINES - PIPERIDINES 1 cyproheptadine syrup PA 1 cyproheptadine tab PA ANTIHYPERLIPIDEMICS ANTIHYPERLIPIDEMICS - COMBINATIONS 2 LIPTRUZET TAB ANTIHYPERLIPIDEMICS - MISC. 2 LOVAZA CAP 1 omega-3 acid cap

2

VASCEPA PA

BILE ACID SEQUESTRANTS

1 cholestyramine light powder

1 cholestyramine lite powder packet

1 colestipol granule 1 colestipol tab 2 WELCHOL TAB

FIBRIC ACID DERIVATIVES

1 fenofibrate micronized cap

1 fenofibrate tab 1 gemfibrozil tab 1 LOFIBRA CAP 1 LOFIBRA TAB 2 TRIGLIDE TAB 2 TRILIPIX CAP

HMG COA REDUCTASE INHIBITORS

1 atorvastatin tab

2

CRESTOR TAB QL=30 Tabs/30 Days

2

CRESTOR TAB 20MG QL=45 Tabs/30 Days

1 fluvastatin cap 2 LESCOL XL TAB 1 lovastatin tab 1 pravastatin tab 2 SIMCOR TAB 1 simvastatin tab

INTESTINAL CHOLESTEROL ABSORPTION INHIBITORS 2

ZETIA TAB QL=30 Tabs/30 Days

NICOTINIC ACID DERIVATIVES

1 NIACOR TAB 2 NIASPAN ER TAB ANTIHYPERTENSIVES ACE INHIBITORS 1 benazepril tab

(28)

1 captopril tab 1 enalapril tab 1 fosinopril tab 1 lisinopril tab 1 moexipril tab 1 perindopril tab 1 quinapril tab 1 ramipril cap 1 trandolapril tab

AGENTS FOR PHEOCHROMOCYTOMA

2 DEMSER CAP

2 DIBENZYLINE CAP

ANGIOTENSIN II RECEPTOR ANTAGONISTS

1 candesartan tab

2 DIOVAN TAB

1 eprosartan mesylate tab

1 irbesartan tab 1 losartan tab 1 telmisartan tab ANTIADRENERGIC ANTIHYPERTENSIVES 1 clonidine patch 1 clonidine tab 1 doxazosin tab 1 guanfacine IR tab PA 1 methyldopa tab PA 1 prazosin cap 1 terazosin cap ANTIHYPERTENSIVE COMBINATIONS 1 amlodipine/ benazepril cap

1 atenolol/ chlorthalidone tab

1 benazepril/ hctz tab 1 bisoprolol/ hctz tab 1 candesartan/ hctz tab 1 captopril/ hctz tab 2 DUTOPROL TAB 1 enalapril/ hctz tab 2 EXFORGE HCT TAB 2 EXFORGE TAB 1 fosinopril/ hctz tab 1 irbesartan/ hctz tab 1 lisinopril/ hctz tab 1 losartan/ hctz tab 1 methyldopa/ hctz tab PA 1 metoprolol/ hctz tab 1 moexipril/ hctz tab

(29)

1 nadolol/ bendroflumethiazide tab

1 propranolol/ hctz tab

1 quinapril/ hctz tab

1 telmisartan/ amlodipine tab

1 telmisartan/ hctz tab

1 valsartan/ hctz tab

SELECTIVE ALDOSTERONE RECEPTOR ANTAGONISTS (SARAS) 1 eplerenone tab VASODILATORS 1 hydralazine inj PA BvD 1 hydralazine tab 1 minoxidil tab

ANTI-INFECTIVE AGENTS - MISC. ANTI-INFECTIVE AGENTS - MISC.

2

AZACTAM/ DEXTROSE INJ. PA BvD

1 aztreonam inj. PA BvD 1 baciim inj PA BvD 1 colistimethate inj. PA BvD 1 metronidazole cap 1 metronidazole tab 1

metronidazole/ nacl inj. PA BvD

2 NEBUPENT NEB PA BvD 2 PENTAM INJ. PA BvD 1 tinidazole tab 1 trimethoprim tab 1

vancomycin cap ST QL=56 Caps/10 Days

1

vancomycin inj. PA BvD

ANTI-INFECTIVE MISC. - COMBINATIONS

1 e.s.p susp.

1 sulfamethoxazole/ trimethoprim DS tab

2

SULFAMETHOXAZOLE/ TRIMETHOPRIM INJ. PA BvD

1 sulfamethoxazole/ trimethoprim susp.

1 sulfamethoxazole/ trimethoprim tab

ANTIPROTOZOAL AGENTS 2 ALINIA SUSP. 2 ALINIA TAB 1 atovaquone susp CARBAPENEMS 2 DORIBAX INJ. PA BvD 1

imipenem/ cilastatin inj. PA BvD

2 INVANZ INJ. PA BvD 1 meropenem inj. PA BvD CHLORAMPHENICOLS 2 CHLORAMPHENICAL INJ. PA BvD

(30)

CYCLIC LIPOPEPTIDES 2 CUBICIN INJ. NM PA BvD GLYCYLCYCLINES 2 TYGACIL INJ. PA BvD LEPROSTATICS 1 dapsone tab LINCOSAMIDES 1 clindamycin cap 1 clindamycin inj PA BvD 1 clindamycin soln. 2 LINCOCIN PA BvD OXAZOLIDINONES 2 ZYVOX INJ. NM PA 2 ZYVOX SUSP. NM PA 2 ZYVOX TAB NM PA POLYMYXINS 1 polymyxin b inj. PA BvD STREPTOGRAMINS 2 SYNERCID INJ PA BvD ANTIMALARIALS ANTIMALARIAL COMBINATIONS 1 atovaquone/ proguanil tab

2 COARTEM TAB ANTIMALARIALS 1 chloroquine tab 2 DARAPRIM TAB 1 hydroxychloroquine tab 1 mefloquine tab 2 PRIMAQUINE TAB 1 quinine sulfate cap

ANTIMYASTHENIC AGENTS ANTIMYASTHENIC AGENTS

2 GUANIDINE TAB

2 MESTINON TIMESPAN TAB

1 pyridostigmine tab ANTIMYCOBACTERIAL AGENTS ANTI TB COMBINATIONS 2 RIFAMATE CAP 2 RIFATER TAB ANTIMYCOBACTERIAL AGENTS 2 CAPASTAT INJ. PA BvD 1 ethambutol tab 1 isoniazid inj.

(31)

1 isoniazid syrup 1 isoniazid tab 2 PASER GRANULE 2 PRIFTIN TAB 1 pyrazinamide tab 1 rifabutin cap 1 rifampin cap 1 rifampin inj. PA BvD 2 TRECATOR TAB

ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES ALKYLATING AGENTS 2 BICNU INJ. PA BvD 2 BUSULFEX INJ. PA BvD 1 carboplatin inj. PA BvD 1 cisplatin inj PA BvD 2 CYCLOPHOSPHAMIDE CAP 1 cyclophosphamide tab PA BvD 2 HEXALEN CAP NM 2 IFEX INJ. PA BvD 1 ifosfamide inj. PA BvD 2 LEUKERAN TAB 2 LOMUSTINE CAP 1 melphalan inj. PA BvD 2 MYSTARGEN INJ. PA BvD 1 oxaliplatin inj PA BvD 2

TREANDA INJ. NM PA NSO

2 ZANOSAR INJ PA BvD ANTIMETABOLITES 2 ALIMTA INJ. PA BvD 2 ARRANON INJ PA BvD 1 azacitidine inj. PA BvD 1 cladribine inj. PA BvD 2 CLOLAR INJ. PA BvD 1 cytarabine inj. PA BvD 1 decitabine inj. PA BvD 1 fludarabine inj. PA BvD 1 fluorouracil inj. PA BvD 2

FOLOTYN INJ. NM PA NSO

1 gemcitabine inj. PA BvD 1 mercaptopurine tab 1 methotrexate inj. PA BvD 1 methotrexate PF inj. PA BvD 1 methotrexate tab PA BvD 2 TABLOID TAB 2 TREXALL TAB PA BvD

(32)

ANTINEOPLASTIC - ANGIOGENESIS INHIBITORS 2

AVASTIN INJ NM PA BvD

2

ZALTRAP INJ. NM PA NSO

ANTINEOPLASTIC - ANTIBODIES 2 ARZERRA INJ. PA BvD 2 ERBITUX SOLN PA BvD 2 HERCEPTIN INJ. NM PA BvD 2

KADCYLA INJ. NM PA NSO

2

PERJETA INJ. NM PA NSO

2

RITUXAN INJ. PA BvD

2

VECTIBIX INJ PA BvD

2

YERVOY INJ. PA NSO

ANTINEOPLASTIC - HEDGEHOG PATHWAY INHIBITORS 2

ERIVEDGE CAP NM PA NSO

ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS 1 anastrozole tab 1 bicalutamide tab 2 ELIGARD INJ. PA BvD 2 EMCYT CAP 1 exemestane tab 2 FARESTON TAB NM 2 FASLODEX INJ NM PA BvD 2

FIRMAGON INJ. NM PA NSO

1 flutamide cap 1 letrozole tab 1 leuprolide inj. PA BvD 2

LUPRON DEPOT (3 MONTH) KIT 11.25MG, 22.5MG NM PA BvD

2

LUPRON DEPOT (4 MONTH) KIT 30MG NM PA BvD

2

LUPRON DEPOT (6 MONTH) KIT 45MG NM PA BvD

2

LUPRON DEPOT INJ. PA BvD

2 LYSODREN TAB

1

megestrol acetate susp. PA NSO

1

megestrol acetate tab PA NSO

2 NILANDRON TAB

2

SOLTAMOX ORAL SOLN. PA NSO

1 tamoxifen citrate tab

2

TRELSTAR DEPOT MIXJECT INJ. PA BvD

2

TRELSTAR LA MIXJECT INJ. PA BvD

2

TRELSTAR MIXJECT INJ. PA BvD

2

XTANDI CAP NM PA NSO QL=120 Caps/30 Days

2

ZYTIGA TAB NM PA NSO

ANTINEOPLASTIC - IMMUNOMODULATORS

2

POMALYST CAP NM PA NSO

(33)

1

bleomycin sulfate inj. PA BvD

2 COSMEGEN INJ. 0.5MG PA BvD 1 daunorubicin inj PA BvD 1 doxorubicin inj. PA BvD 1 edirubicin inj PA BvD 1 idarubicin inj PA BvD 1 mitomycin inj. PA BvD 1 mitoxantrone inj PA BvD

ANTINEOPLASTIC ENZYME INHIBITORS

2

AFINITOR DISPERZ NM PA NSO

2

AFINITOR TAB NM PA NSO QL=30 Tabs/30 Days

2

BOSULIF TAB NM PA NSO

2

CAPRELSA TAB NM PA NSO

2

COMETRIQ PACK NM PA NSO

2

GILOTRIF TAB NM PA NSO QL=30 Tabs/30 Days

2

GLEEVEC TAB NM PA NSO

2

IMBRUVICA CAP NM PA NSO

2

INLYTA TAB NM PA NSO

2

ISTODAX INJ. NM PA NSO

2

JAKAFI TAB NM PA NSO QL=60 Tabs/30 Days

2

MEKINIST TAB NM PA NSO

2

NEXAVAR TAB LD NM PA NSO

2

SPRYCEL TAB NM PA NSO

2

STIVARGA TAB NM PA NSO QL=120 Tabs/30 Days

2

SUTENT CAP NM PA NSO

2

TAFINLAR CAP NM PA NSO

2

TARCEVA TAB NM PA NSO

2

TASIGNA CAP NM PA NSO

2

TORISEL SOLN PA BvD

2

TYKERB TAB LD NM PA NSO

2

VELCADE INJ. NM PA BvD

2

VOTRIENT TAB NM PA NSO

2

XALKORI CAP NM PA NSO

2

ZELBORAF TAB NM PA NSO

2

ZOLINZA CAP NM PA NSO

2

ZYKADIA CAP NM PA NSO

ANTINEOPLASTIC ENZYMES

2

ERWINAZE INJ. NM PA NSO

2 ONCASPAR INJ. PA BvD ANTINEOPLASTICS MISC. 2 ACTIMMUNE INJ. PA BvD 1 dacarbazine inj. PA BvD 1 hydroxyurea cap 2 INTRON-A INJ. PA BvD 2 MATULANE CAP

(34)

2

PROLEUKINE IV SOLN. NM PA BvD

2

SYLATRON INJ. NM PA NSO

2

SYNRIBO INJ. NM PA BvD

2

TARGRETIN CAP NM PA NSO

1 tretinoin cap 2 TRISENOX INJ. PA BvD 2 UVADEX SOLN PA BvD CHEMOTHERAPY ADJUNCTS 2 ELITEK INJ. NM PA BvD 2 KEPIVANCE INJ NM PA BvD

CHEMOTHERAPY RESCUE/ ANTIDOTE AGENTS

1 amifostine inj. PA BvD 1 dexrazoxane inj. PA BvD 2 FUSILEV INJ. PA BvD 1 leucovorin inj. PA BvD 1 leucovorin tab 1 mesna inj. PA BvD 2 MESNEX TAB MITOTIC INHIBITORS 2 ABRAXANE SUSP PA BvD 2 DOCEFREZ INJ. PA BvD 2 DOCETAXEL INJ. NM PA BvD 2 ETOPOPHOS INJ. PA BvD 1 etoposide inj. PA BvD 2 HALAVEN INJ. NM PA BvD 2 IXEMPRA INJ PA BvD 2 JEVTANA INJ. NM PA BvD 1 paclitaxel inj PA BvD 2 TAXOTERE INJ NM PA BvD 1 toposar inj. PA BvD 1 vinblastine inj. PA BvD 1 vincasar pfs inj. PA BvD 1 vincristine inj. PA BvD 1 vinorelbine inj PA BvD TOPOISOMERASE I INHIBITORS 1 irinotecan inj. PA BvD 1 topotecan inj. PA BvD ANTIPARKINSON AGENTS ANTIPARKINSON ADJUVANTS 1 carbidopa tab ANTIPARKINSON ANTICHOLINERGICS 1 benztropine inj. PA BvD 1 benztropine tab PA 1 trihexyphenidyl soln PA

(35)

1

trihexyphenidyl tab PA

ANTIPARKINSON COMT INHIBITORS

1 entacapone tab 2 TASMAR ANTIPARKINSON DOPAMINERGICS 1 amantadine cap 1 amantadine syrup 2 APOKYN INJ. PA BvD 1 bromocriptine cap 1 bromocriptine tab 2 CARBIDOPA/ ENTACAPONE/ LEVODOPA TAB

1 carbidopa/ levodopa ER tab

1 carbidopa/ levodopa ODT tab

1 carbidopa/ levodopa tab

2 NEUPRO PATCH 1 pramipexole tab 1 ropinirole ER tab 1 ropinirole tab 2 STALEVO TAB

ANTIPARKINSON MONOAMINE OXIDASE INHIBITORS 2 AZILECT TAB 1 selegiline cap 1 selegiline tab

ANTIPSYCHOTICS/ ANTIMANIC AGENTS ANTIMANIC AGENTS

1 lithium carbonate cap

1 lithium carbonate ER tab

1 lithium carbonate tab

1 lithium citrate soln.

ANTIPSYCHOTICS - MISC. 2 EQUETRO CAP 2 GEODON INJ. PA BvD 2

LATUDA TAB PA NSO QL=30 Tabs/30 Days

1 ziprasidone cap

BENZISOXAZOLES

2

FANAPT TAB PA NSO

2

FANAPT TITRATION PACK PA NSO

2

INVEGA SUSTENNA INJ. PA NSO

2

INVEGA TAB PA NSO

2

RISPERDAL CONSTA INJ. PA BvD

1 risperidone odt 1 risperidone soln. 1 risperidone tab BUTYROPHENONES

(36)

1

haloperidol decanoate inj. PA BvD

1

haloperidol inj. PA BvD

1 haloperidol oral conc.

1 haloperidol tab DIBENZAPINES 1 clozapine tab 2 FAZACLO TAB 1 loxapine cap 1 olanzapine inj. PA BvD 1 olanzapine ODT tab

1 olanzapine tab

1 quetiapine tab

2

SAPHRIS SL TAB PA NSO QL=60 Tabs/30 Days

2 SEROQUEL XR TAB 2 VERSACLOZ SUSP PHENOTHIAZINES 1 chlorpromazine inj. PA BvD 1 chlorpromazine tab 1 compro suppository 2

FLUPHENAZINE DECANOATE INJ. PA BvD

1 fluphenazine elixir

2

FLUPHENAZINE INJ. PA BvD

1 fluphenazine oral conc.

1 fluphenazine tab

1 perphenazine tab

1

prochlorperazine edisylate inj. PA BvD

1 prochlorperazine suppository

1 prochlorperazine tab

1

thioridazine tab PA NSO

1 trifluoperazine tab

QUINOLINONE DERIVATIVES

2

ABILIFY DISC TAB NM QL=60 Tabs/30 Days

2

ABILIFY INJ. PA BvD

2

ABILIFY MAINTENANCE INJ. PA BvD

2 ABILIFY SOLN.

2

ABILIFY TAB QL=60 Tabs/30 Days

THIOXANTHENES

1 thiothixene cap

ANTISEPTICS & DISINFECTANTS CHLORINE ANTISEPTICS

4

CHLORHEXIDINE GLUCONATE LIQUID 2%* QL=240 ml/365 Days

4

chlorhexidine gluconate liquid 4%* QL=120 ml/30 Days 4

CHLORHEXIDINE GLUCONATE PADS 2%*

3

(37)

ANTIVIRALS ANTIRETROVIRALS

1 abacavir tab

1 abacavir/ lamivudine/ zidovudine tab

2 APTIVUS CAP NM 2 APTIVUS SOLN. NM 2 ATRIPLA TAB NM 2 COMPLERA TAB NM 2 CRIXIVAN CAP 1 didanosine cap 2 EDURANT TAB NM 2 EMTRIVA CAP 2 EMTRIVA SOLN. 2 EPIVIR HBV SOLN. 2 EPIVIR SOLN. 2 EPZICOM TAB NM 2 FUZEON INJ. NM 2 INTELENCE TAB NM 2 INVIRASE CAP 2 INVIRASE TAB NM 2

ISENTRESS CHEW TAB NM

2 ISENTRESS POWDER PACK

2 ISENTRESS TAB NM 2 KALETRA SOLN. NM 2 KALETRA TAB NM 1 lamivudine tab 1

lamivudine/ zidovudine tab NM

2 LEXIVA SUSP. 2 LEXIVA TAB NM 1 nevirapine er tab 1 nevirapine tab 2 NORVIR CAP 2 NORVIR SOLN. 2 NORVIR TAB 2 PREZISTA SUSP. 2 PREZISTA TAB NM 2 RESCRIPTOR TAB 2 RETROVIR INJ. 2 REYATAZ CAP NM 2 SELZENTRY TAB NM 1 stavudine cap 1 stavudine soln. 2

STRIBILD TAB NM QL=30 Tabs/30 Days

2 SUSTIVA CAP

2 SUSTIVA TAB

(38)

2

TIVICAY TAB NM QL=60 Tabs/30 Days

2 TRUVADA TAB NM 2 VIDEX SOLN. 2 VIRACEPT TAB NM 2 VIRAMUNE SUSP. 2 VIRAMUNE XR TAB 2 VIREAD POWDER 2 VIREAD TAB NM 2 ZIAGEN SOLN. 1 zidovudine cap 1 zidovudine syrup 1 zidovudine tab CMV AGENTS 1 cidofovir inj. PA BvD 1 FOSCARNET INJ. PA BvD 1 ganciclovir inj. PA BvD 2 VALCYTE SOLN. NM 2 VALCYTE TAB NM HEPATITIS AGENTS 1 adefovir tab 2 BARACLUDE SOLN. 2 BARACLUDE TAB 1 moderiba tab 200mg 2 MODERIBA TAB 400MG, 600MG NM 2 OLYSIO TAB NM PA 2 PEG-INTRON INJ. NM 2 PEGASYS INJ. NM 2

PEGASYS PROCLICK INJ. NM

1 ribasphere cap 1 ribasphere tab 1 ribavirin cap 1 ribavirin tab 2

SOVALDI TAB NM PA QL=30 Tabs/30 Days

2 TYZEKA TAB HERPES AGENTS 1 acyclovir cap 1 acyclovir inj. PA BvD 1 acyclovir inj. PA BvD 1 acyclovir susp. 1 acyclovir tab 1 famciclovir tab 1 valacyclovir tab INFLUENZA AGENTS 2

RELENZA DISKHALER QL=56 Blisters/180 Days

1 rimantadine tab

(39)

2

TAMIFLU CAP 30MG QL=84 Caps/180 Days

2

TAMIFLU CAP 45MG, 75MG QL=28 Caps/180 Days

2

TAMIFLU SUSP. QL=6 Bottles/180 Days

RESPIRATORY SYNCYTIAL VIRUS (RSV) AGENTS 2 VIRAZOLE INH. PA BvD ASSORTED CLASSES CHELATING AGENTS 2 CUPRIMINE CAP ST 2 DEPEN TITRATABS 2 SYPRINE CAP IMMUNOMODULATORS 2

REVLIMID CAP LD NM PA NSO QL=30 Caps/30 Days

2

REVLIMID CAP 2.5MG, 20MG NM PA NSO QL=30 Caps/30 Days

2

THALOMID CAP NM PA NSO

IMMUNOSUPPRESSIVE AGENTS 2 ASTAGRAF XL CAP PA BvD 2 ATGAM INJ NM PA BvD 2 AZASAN TAB PA BvD 1 azathioprine tab PA BvD 2 CELLCEPT IV INJ PA BvD 2 CELLCEPT SUSP. PA BvD 1 cyclosporine cap PA BvD 1 cyclosporine inj. PA BvD 1

cyclosporine modified cap PA BvD

2

CYCLOSPORINE MODIFIED CAP 50MG PA BvD

1

cyclosporine modified soln. PA BvD

1 gengraf cap PA BvD 1 gengraf soln. PA BvD 1 mycophenolate cap PA BvD 1

mycophenolate sodium tab PA BvD

1 mycophenolate tab PA BvD 2 NULOJIX INJ. NM PA BvD 2 PROGRAF INJ PA BvD 2 RAPAMUNE SOLN. PA BvD 2 RAPAMUNE TAB PA BvD 2 SANDIMMUNE SOLN. PA BvD 2 SIMULECT INJ PA BvD 1 sirolimus cap PA BvD 1 tacrolimus cap PA BvD 2 THYMOGLOBULIN INJ. PA BvD 2

ZORTRESS TAB NM PA NSO

IRRIGATION SOLUTIONS

1

lactated ringers irrigation PA BvD

1

(40)

1

physiosol irrigation soln. PA BvD

1

ringers irrigation PA BvD

1

sterile water irrigation PA BvD

LYMPHATIC AGENTS

2

SYLVANT INJ. NM PA BvD

POTASSIUM REMOVING RESINS

1 kionex powder

1 sodium polystyrene sulfonate susp.

BETA BLOCKERS ALPHA-BETA BLOCKERS 1 carvedilol tab 1 labetalol inj. PA BvD 1 labetalol tab

BETA BLOCKERS CARDIO-SELECTIVE

1 acebutolol cap 1 atenolol tab 1 betaxolol tab 1 bisoprolol tab 2 BYSTOLIC TAB 1 metoprolol ER tab 1 metoprolol inj. PA BvD 1 metoprolol tab

BETA BLOCKERS NON-SELECTIVE

2 INNOPRAN XL CAP 1 nadolol tab 1 pindolol tab 1 propranolol ER cap 1 propranolol inj. PA BvD 1 propranolol oral soln.

1 propranolol tab 1 sorine tab 1 sotalol tab 1 timolol maleate tab

BIOLOGICALS MISC BIOLOGICALS MISC

2

ADAGEN INJ. NM PA BvD

CALCIUM CHANNEL BLOCKERS CALCIUM CHANNEL BLOCKERS

1 afeditab CR tab 1 amlodipine tab 2 CARDENE INJ. PA BvD 1 cartia xt cap 1 dilt-xr cap 1 diltiazem CD cap

(41)

1 diltiazem ER cap 1 diltiazem inj PA BvD 1 diltiazem tab 1 felodipine ER tab 1 isradipine cap 1 matzim la tab 1 nicardipine cap 1 nicardipine inj. PA BvD 1 nifedical XL tab 1 nifedipine cap PA 1 nifedipine ER tab 1 nimodipine cap 1 nisoldipine ER tab 1 taztia-xt cap 1 verapamil ER cap 1 verapamil ER tab 1 verapamil inj. PA BvD 1 verapamil tab CARDIOTONICS CARDIAC GLYCOSIDES 1 digoxin inj. PA 1

digoxin oral soln PA

1

digoxin tab 0.125mg QL=30 Tabs/30 Days

1

digoxin tab 0.25mg PA

CARDIOVASCULAR AGENTS - MISC. CARDIOVASCULAR AGENTS MISC. - COMBINATIONS

1 amlodipine/ atorvastatin tab

2 BIDIL TAB PROSTAGLANDIN VASODILATORS 2 REMODULIN INJ. NM PA BvD 2 TYVASO INH. NM PA 2 VENTAVIS INH. NM PA

PULMONARY HYPERTENSION - ENDOTHELIN RECEPTOR ANTAGONISTS 2

LETAIRIS TAB NM PA

2

TRACLEER TAB LD NM PA

PULMONARY HYPERTENSION - PHOSPHODIESTERASE INHIBITORS 2 ADCIRCA TAB NM PA 1 sildenafil tab PA CEPHALOSPORINS CEPHALOSPORINS - 1ST GENERATION 1 cefadroxil cap 1 cefadroxil susp. 1 cefadroxil tab 1 cefazolin inj. PA BvD

(42)

2 CEFAZOLIN/ D5W INJ. PA BvD 1 cephalexin cap 1 cephalexin susp 1 cephalexin tab CEPHALOSPORINS - 2ND GENERATION 1 cefaclor cap 2 CEFOTETAN INJ. PA BvD 1 cefoxitin inj. PA BvD 2

CEFOXITIN/ DEXTROSE INJ. PA BvD

1 cefprozil susp. 1 cefprozil tab 1 cefuroxime inj. PA BvD 1 cefuroxime tab CEPHALOSPORINS - 3RD GENERATION 2 CEDAX SUSP. 1 cefdinir cap 1 cefdinir susp. 1 cefotaxime inj. PA BvD 1 cefpodoxime susp. 1 cefpodoxime tab 1 ceftazidime inj. PA BvD 2

CEFTAZIDIME/ DEXTROSE INJ. PA BvD

1 ceftriaxone inj. PA BvD 2 SUPRAX CAP CEPHALOSPORINS - 4TH GENERATION 1 cefepime inj. PA BvD CEPHALOSPORINS - 5TH GENERATION 2 TEFLARO INJ. PA BvD CONTRACEPTIVES COMBINATION CONTRACEPTIVES - ORAL

1 amethia tab 1 apri tab 1 aranelle tab 1 aviane tab 1 balziva tab 2 BEYAZ TAB 1 briellyn tab 1 cryselle-28 tab 1 cyclafem tab 1 emoquette tab 1 enpresse-28 tab 1 gildagia tab 1 introvale tab 1 junel fe tab

(43)

1 junel tab 1 kariva tab 1 kelnor tab 1 larin fe tab 1 larin tab 1 leena tab 1 lessina 1 levonest tab 1 levonorgestrel/ ethinyl estradiol tab

1 levora-28 tab 2 LO MINASTRIN FE TAB 1 low-ogestrel tab 1 lutera tab 1 marlissa tab 1 microgestin tab 1 mononessa tab 2 NATAZIA TAB 1 necon tab 1 nortrel tab 1 orsythia tab 2 ORTHO-TRI CYCLEN LO 1 pimtrea tab 1 pirmella tab 1 portia-28 tab 1 previfem tab 2 QUARTETTE TAB 1 quasense tab 1 reclipsen tab 1 sprintec-28 tab 1 sronyx tab 1 tri-legest fe tab 1 tri-previfem tab 1 tri-sprintec tab 1 trinessa tab 1 trivora-28 tab 1 velivet tab 1 vyfemla tab 2 YASMIN TAB 1 zenchent fe tab 1 zenchent tab 1 zovia tab

COMBINATION CONTRACEPTIVES - TRANSDERMAL 1 xulane patch

COMBINATION CONTRACEPTIVES - VAGINAL

2 NUVARING

(44)

EMERGENCY CONTRACEPTIVES

2 ELLA

PROGESTIN CONTRACEPTIVES - INJECTABLE

1 medroxyprogesterone inj.

PROGESTIN CONTRACEPTIVES - ORAL

1 camila tab 1 errin tab 1 jolivette tab 1 lyza tab 1 nora-be tab 1 norethindrone tab CORTICOSTEROIDS GLUCOCORTICOSTEROIDS 1 A-HYDROCORT INJ. PA BvD 1 budesonide EC cap NM 1 CORTEF TAB 1 cortisone tab 1 dexamethasone conc. 1 dexamethasone elixir 1 dexamethasone inj. PA BvD 1 dexamethasone tab 1 hydrocortisone tab 2 MEDROL TAB 2MG 1

methylprednisolone acetate inj. PA BvD

1 methylprednisolone dose pak

1

methylprednisolone sodium succinate inj. PA BvD 1

methylprednisolone tab

2 ORAPRED ODT

1 prednisolone sodium phosphate soln.

2 PREDNISONE INTENSOL 1 prednisone soln. 1 prednisone tab 2 SOLU-CORTEF INJ. PA BvD 1 triamcinolone acetonide inj.

2

UCERIS TAB PA QL=30 Tabs/30 Days

MINERALOCORTICOIDS

1 fludrocortisone tab

COUGH/ COLD/ ALLERGY ANTITUSSIVES

4

benzonatate cap 100mg, 200mg* QL=90 Caps/30 Days 4 dextromethorphan liquid 15mg/ 5ml* 4 dextromethorphan syrup 10mg/ 5ml* 4 dextromethorphan syrup 15mg/ 5ml* 4 dextromethorphan syrup 7.5mg/ 5ml*

(45)

4 hydrocodone/ homatropine syrup 5-1.5mg/ 5ml*

4

ZONATUSS CAP 150MG* QL=90 Caps/30 Days

COUGH/ COLD/ ALLERGY COMBINATIONS

4 brompheniramine/ pseudoephedrine elixir 1-15mg/ 5ml*

4 chlorpheniramine DM liquid 2-15mg/ 5ml*

4 chlorpheniramine/ pseudoephedrine tab 4-60mg*

4 dextromethorphan/ guaifensen syrup 10-100mg/ 5ml*

4 dextromethorphan/ guaifensin liquid 10-100mg/ 5ml*

4 ED A-HIST LIQUID 4-10MG/ 5ML*

4 guaifensin/ codeine soln 100-10mg/ 5ml*

4 LOHIST-D LIQUID 2-30MG*

4

loratadine-d tab 10-240mg* QL=60 Tabs/30 Days 4

loratadine-d tab 5-120mg* QL=60 Tabs/30 Days 4

phenylephrine chlorpheniramine soln 10-2-15mg/ 5ml*

4 phenylephrine chlorpheniramine soln 10-4-15mg/ 5ml*

4 phenylephrine DM/ guaifenesin liquid 5-10-100mg/ 5ml*

4 phenylephrine/ guaifenesin liquid 5-100mg/ 5ml*

4 promethazine DM syrup 6.25-15mg/ 5ml*

4 promethazine/ codeine syrup 6.25-10mg/ 5ml*

4 pseudoephedrine DM/ guaifenesin liquid 30-10-100mg/

5ml*

4 pseudoephedrine/ brompheniramine DM elixir 15-1-5mg/

5ml*

4 pseudoephedrine/ chlorpheniramine DM liquid

15-2-15mg/ 5ml*

4 pseudoephedrine/ chlorpheniramine DM syrup

30-2-10mg/ 5ml*

4 pseudoephedrine/ doxylamine/ DM/ acetaminophen liquid

60-12.5-30-1000mg/ 30ml*

4 pseudoephedrine/ guaifensen liquid 7.5-50mg/ ml*

4 pseudoephedrine/ guaifensin syrup 30-100mg/ 5ml*

4 triprolidine/ pseudoephedrine syrup 1.25-30mg/ 5ml*

4 triprolidine/ pseudoephedrine tab 2.5-60mg*

EXPECTORANTS 4 guaifenesin liquid 100mg/ 5ml* 4 guaifenesin liquid 200mg/ 5ml* 4 guaifenesin tab 400mg* MUCOLYTICS 1 acetylcysteine soln. PA BvD DERMATOLOGICALS

(46)

ACNE PRODUCTS 1 adapalene cream PA 1 adapalene gel PA 1 amnesteem cap 1 avita cream PA 1 avita gel PA 4 benzoyl peroxide gel 10%*

4 BENZOYL PEROXIDE GEL 2.5%*

4 benzoyl peroxide liquid 10%*

4 benzoyl peroxide liquid 5%*

4 BENZOYL PEROXIDE LOTION 10%*

4 BENZOYL PEROXIDE LOTION 5%*

1 claravis cap

1 clindamycin foam

1 clindamycin phosphate gel

1 clindamycin phosphate lotion

1 clindamycin phosphate soln.

1 clindamycin phosphate swab

1 clindamycin/ benzoyl peroxide gel

2 DIFFERIN LOTION PA 2 EPIDUO GEL PA 1 ery pad 1 erythromycin topical gel

1 erythromycin topical soln.

1 erythromycin/ benzoyl peroxide gel

1 myorisan

2

RETIN-A MICRO GEL PA

1 sulfacetamide sodium lotion

1 tretinoin cream PA 1 tretinoin gel PA 1 zenatane cap ANTIBIOTICS - TOPICAL 4 bacitracin ointment 500unit/ gm*

4 bacitracin zinc ointment 500unit/ gm*

4 bacitracin/ polymyxin b oint.*

1 gentamicin sulfate cream

1 gentamicin sulfate oint.

1 mupirocin cream 1 mupirocin oint. ANTIFUNGALS - TOPICAL 1 ciclopirox cream 1 ciclopirox gel 1 ciclopirox nail lacquer

1 ciclopirox shampoo

1 ciclopirox susp.

(47)

1 clotrimazole cream

1 clotrimazole soln.

1 clotrimazole/ betamethasone cream

1 clotrimazole/ betamethasone lotion

1 econazole nitrate cream

2 ERTACZO CR 1 ketoconazole cream 1 ketoconazole shampoo 4 ketoconazole shampoo 1%* 4 miconazole cream 2%* 4 miconazole powder 2%* 2 NAFTIN CREAM 2 NAFTIN GEL 1 nyamyc powder 1 nystatin cream 1 nystatin oint. 1 nystatin topical powder

1 nystatin/ triamcinolone cream

1 nystatin/ triamcinolone oint.

1 nystop topical powder

2 OXISTAT CREAM

2 OXISTAT LOTION

1 pedi-dri topical powder

4 tolnaftate cream 1%* 4 tolnaftate soln 1%* ANTIHISTAMINES-TOPICAL 4 diphenhydramine cream 2%* 4 diphenhydramine gel 2%* 4 diphenhydramine soln. 2%* 4 diphenhydramine/ zinc acetate cream 2-0.1%*

ANTI-INFLAMMATORY AGENTS - TOPICAL

1 diclofenac sodium topical soln.

2 PENNSAID SOLN.

2

VOLTAREN GEL QL=5 Tubes/14 Days

ANTINEOPLASTIC OR PREMALIGNANT LESION AGENTS - TOPICAL 2 CARAC CREAM 1 diclofenac gel 1 fluorouracil cream 1 fluorouracil solution 2 PANRETIN GEL NM 2

PICATO GEL 0.015% QL=3 Tubes/10 Days

2

PICATO GEL 0.05% QL=2 Tubes/10 Days

2

TARGRETIN GEL 1% NM

ANTIPRURITICS - TOPICAL

1 prudoxin cream

(48)

ANTIPSORIATICS 2 8-MOP CAP 1 acitretin cap 1 calcipotriene cream 1 calcipotriene oint. 1 calcipotriene soln. 2 CALCITRIOL OINTMENT 1 methoxsalen cap 2 STELARA INJ. NM PA 2 TAZORAC CREAM 2 TAZORAC GEL 2 VECTICAL OINT. ANTISEBORRHEIC PRODUCTS 1 selenium sulfide shampoo

ANTIVIRALS - TOPICAL 2 DENAVIR CREAM 2 ZOVIRAX OINT. BURN PRODUCTS 1 mafenide topical solution

1 silver sulfadiazine cream

1 ssd cream 2 SULFAMYLON CREAM CORTICOSTEROIDS - TOPICAL 1 ala cort cream

1 alclometasone cream 1 alclometasone oint. 1 amcinonide cream 2 AMCINONIDE OINTMENT 1 augmented betamethasone cream

1 augmented betamethasone gel

1 augmented betamethasone lotion

1 augmented betamethasone oint

1 betamethasone dipropionate cream

1 betamethasone dipropionate gel

1 betamethasone dipropionate lotion

1 betamethasone valerate cream

1 betamethasone valerate foam

1 betamethasone valerate lotion

1 betamethasone valerate oint

1 calcipotriene/ betamethasone oint

1 clobetasol e cream 1 clobetasol gel 1 clobetasol lotion 1 clobetasol oint