Choice Care Advantage (HMO MedStar Medicare Choice (HMO) SNP) 017 018 Formulary Formulary (List of Covered Drugs) (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN. ABOUT PLEASE THE READ: DRUGS THIS DOCUMENT WE COVER IN CONTAINS THIS PLAN. INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN. HPMS Approved Formulary File Submission ID: 00017198, Version Number 7. HPMS Approved Formulary File File Submission ID: ID: 00017198, 000187, Version Version Number Number 7. 6. This formulary was updated on 08//016. For more recent information or other questions, please This formulary contact was MedStar updated on Medicare on 08//016. 09/08/017. For Choice Member For more Services recent at information or other questions, 855--101 or other please contact MedStar Medicare Choice Member Services at 855--101 or, questions, for TTY users, please 855-50-560 contact MedStar seven Medicare days Choice week from (HMO) a.m. Member to p.m., Services, * or visit at or, for TTY users, 855-50-560 seven days a week from 8 a.m. to 8 p.m., MedStarMedicareChoice.com. 855--101 or, for TTY users, 855-50-560. Our hours of operation * or change visit MedStarMedicareChoice.com. twice a year. You can call us October 1 through February 1 seven days a week from 8 a.m. to 8 p.m. From February 15 through September 0, you can call us Monday through Friday from 8 a.m. to 8 p.m., and Saturday from 8 a.m. to p.m. or visit MedStarMedicareChoice.com. H9915_17_007 H9915_18_017a Accepted H9915_17_007 Accepted
Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. When this drug list (formulary) refers to we, us, or our, it means MedStar Family Choice, Inc. When it refers to plan or our plan, it means MedStar Medicare Choice (HMO). This document includes a list of the drugs (formulary) for our plan which is current as of 09/08/017. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 019, and from time to time during the year. MedStar Medicare Choice (HMO) has a contract with Medicare. Enrollment in MedStar Medicare Choice depends on contract renewal. This document may be available in an alternative format such as Braille or large print; please call Member Services, at 855--101 or, for TTY users, 855-50-560, or visit MedStarMedicareChoice.com. The Formulary may change at any time. You will receive notice when necessary. i
What is the MedStar Medicare Choice (HMO) Formulary? A formulary is a list of covered drugs selected by our Plan in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. We will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a MedStar Medicare Choice (HMO) network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Can the Formulary (drug list) change? Generally, if you are taking a drug on our 018 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 018 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug, or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of 09/08/017. To get updated information about the drugs covered by MedStar Medicare Choice (HMO), please contact us. Our contact information appears on the front and back cover pages. If our plan makes non-maintenance drug changes to this formulary that were approved by the Centers for Medicare & Medicaid Services (CMS), we will notify members by mailing errata sheets that list the prescription drug, change made and the effective date. This will enable members to have the most up-todate information regarding the covered drugs on the plan s formulary. ii
How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, Cardiovascular. If you know what your drug is used for, look for the category name in the list that begins on page. Then look under the category name for your drug. Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page 119. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. What are generic drugs? Our Plan covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs. Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: Prior Authorization: Our Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from our Plan before you fill your prescriptions. If you don t get approval, our Plan may not cover the drug. Quantity Limits: For certain drugs, our Plan limits the amount of the drug that our Plan will cover. For example, our Plan provides 0 capsules per month per prescription for Lansoprazole. This may be in addition to a standard one-month or three-month supply. Step Therapy: In some cases, our Plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, our Plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, our Plan will then cover Drug B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted on line documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask our Plan to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, How do I request an exception to the MedStar Medicare Choice (HMO) formulary? on page iv for information about how to request an exception. iii
What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Member Services and ask if your drug is covered. If you learn that our Plan does not cover your drug, you have two options: You can ask Member Services for a list of similar drugs that are covered by our Plan. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by our Plan. You can ask our Plan to make an exception and cover your drug. See below for information about how to request an exception. How do I request an exception to the MedStar Medicare Choice (HMO) Formulary? You can ask our Plan to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level. You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, our Plan limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. Generally, our Plan will only approve your request for an exception if the alternative drugs included on the plan s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, tiering, or utilization restriction exception. When you request a formulary, tiering, or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 7 hours of getting your prescriber s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 7 hours for a decision. If your request to expedite is granted, we must give you a decision no later than hours after we get a supporting statement from your doctor or other prescriber. iv
What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 0- day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 0-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with up to a 98-day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 1-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception. In addition, all members who experience a level-of-care change are eligible for a transition supply. A level-of-care change is when a member changes from one treatment setting to another. For example, if a member is discharged from an inpatient facility to home on a non-formulary medication, the member will be eligible for a transition supply of that non-formulary medication. You can receive up to a 1-day supply of the medication (unless you have a prescription written for fewer days) after being discharged, to allow time for you and your physician to switch to a formulary alternative or request an exception. After your first 1-day supply, we will not pay for the drug, unless an exception was approved. Our transition policy applies only to those drugs that are Part D drugs. The transition policy cannot be used to cover non-part D drugs. For more information For more detailed information about your MedStar Medicare Choice (HMO) prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about our Plan, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE (1-800-6-7) hours a day/7 days a week. TTY users should call 1-877-86-08. Or, visit http://www.medicare.gov. v
MedStar Medicare Choice (HMO) Formulary The formulary that begins on page provides coverage information about the drugs covered by our Plan. If you have trouble finding your drug in the list, turn to the Index that begins on page 119. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., VENTOLIN HFA) and generic drugs are listed in lower-case italics (e.g., bupropion). The information in the Requirements/Limits column tells you if our Plan has any special requirements for coverage of your drug. Formulary Drug Tiers The formulary drug tier table provides the tier number (e.g., Tier ) and member cost-sharing for prescription drugs on each drug tier. Please refer to the tables on the next page based on the plan you are a member of, MedStar Medicare Choice (HMO). For additional information on your plan, please refer to the Evidence of Coverage or contact Member Services at 855--101 or, for TTY users, 855-50-560, seven days a week from 8 a.m. to 8 p.m.*, or visit MedStarMedicareChoice.com. vi
MedStar Medicare Choice (HMO) drug tiers and cost-sharing amounts after the annual deductible of $05 (Excludes Tiers 1,, & 6) for 018: MedStar Medicare Choice (HMO) Drug Tier Number Drug Tier Description 1 Preferred Generic drug tier Member Cost-Sharing (0-60 or 90-day supply) Retail $ copayment for a 0-day retail supply $8 copayment for a 60-day retail supply $1 copayment for a 90-day retail supply Generic drug tier $15 copayment for a 0-day retail supply $0 copayment for a 60-day retail supply $5 copayment for a 90-day retail supply Preferred Brand drug tier Non-Preferred Brand drug tier $7 copayment for a 0-day retail supply $9 copayment for a 60-day retail supply $11 copayment for a 90-day retail supply $100 copayment for a 0-day retail supply $00 copayment for a 60-day retail supply $00 copayment for a 90-day retail supply 5 Specialty drug tier 5% coinsurance for a 0-day retail supply (only) Member Cost-Sharing (0-60 or 90-day supply) Mail-order $ copayment for a 0-day mail-order supply $8 copayment for a 60-day mail-order supply $10 copayment for a 90-day mail-order supply $15 copayment for a 0-day mail-order supply $0 copayment for a 60-day mail-order supply $7.50 copayment for a 90-day mail-order supply $7 copayment for a 0-day mail-order supply $9 copayment for a 60-day mail-order supply $117.50 for a 90-day mail-order supply $100 copayment for a 0-day mail-order supply $00 copayment for a 60-day mail-order supply $50 copayment for a 90-day mail-order supply 5% coinsurance for a 0-day mail-order supply (only) 6 Select Care drug tier $ copayment for a 0-day retail supply $6 copayment for a 60-day retail supply $9 copayment for a 90-day retail supply $ copayment for a 0-day mail-order supply $6 copayment for a 60-day mail-order supply $7.50 copayment for a 90-day mail-order supply NOTE: Drugs are provided in a Long-term Care Facility for up to a 1-day supply. vii
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Below is a list of abbreviations that may appear on the following pages in the Requirements/Limits column that tell you if there are any special requirements for coverage of your drug. List of Abbreviations B/D: This prescription drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination. DL: Day Supply Limit. For certain drugs, we will only cover up to a 0-day supply at a time. LA: Limited Availability. This prescription may be available only at certain pharmacies. For more information, please call Member Services. NM: Not Available at Mail-Order. This prescription drug is not available through our mail-order service. Consider using mail order for your long-term (maintenance) medications (such as high blood pressure medications). Retail network pharmacies may be more appropriate for short-term prescriptions (such as antibiotics). PA: Prior Authorization. The Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval before you fill your prescriptions. If you don t get approval, we may not cover the drug. QL: Quantity Limit. For certain drugs, the Plan limits the amount of the drug that we will cover. ST: Step Therapy. In some cases, the Plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B. 1
ANALGESICS GOUT allopurinol sodium for inj 500 mg allopurinol tab 100 mg allopurinol tab 00 mg colchicine w/ probenecid tab 0.5-500 mg COLCRYS TAB 0.6MG probenecid tab 500 mg ULORIC TAB 0MG QL (0 tabs / 0 days), ST ULORIC TAB 80MG QL (0 tabs / 0 days), ST ZURAMPIC TAB 00MG PA MISCELLANEOUS clonidine hcl inj (for epidural infusion) 100 B/D mcg/ml clonidine hcl inj (for epidural infusion) 500 B/D mcg/ml PRIALT INJ 5MCG/ML NM PRIALT INJ 100MCG NM NSAIDS celecoxib cap 50 mg celecoxib cap 100 mg celecoxib cap 00 mg celecoxib cap 00 mg diclofenac potassium tab 50 mg diclofenac sodium tab delayed release 5 mg diclofenac sodium tab delayed release 50 mg diclofenac sodium tab delayed release 75 mg diclofenac sodium tab er hr 100 mg diflunisal tab 500 mg etodolac cap 00 mg etodolac cap 00 mg etodolac tab 00 mg etodolac tab 500 mg fenoprofen calcium tab 600 mg flurbiprofen tab 50 mg flurbiprofen tab 100 mg ibuprofen susp 100 mg/5ml 1 ibuprofen tab 00 mg 1 ibuprofen tab 600 mg 1 ibuprofen tab 800 mg 1
ketoprofen cap 50 mg ketoprofen cap 75 mg meclofenamate sodium cap 50 mg meclofenamate sodium cap 100 mg meloxicam tab 7.5 mg 1 meloxicam tab 15 mg 1 nabumetone tab 500 mg nabumetone tab 750 mg naproxen dr tab 75mg naproxen dr tab 500mg naproxen sodium tab 75 mg 1 naproxen sodium tab 550 mg 1 naproxen susp 15 mg/5ml 1 naproxen tab 50 mg 1 naproxen tab 75 mg 1 naproxen tab 500 mg 1 piroxicam cap 10 mg piroxicam cap 0 mg salsalate tab 500 mg salsalate tab 750 mg sulindac tab 150 mg sulindac tab 00 mg tolmetin sodium cap 00 mg tolmetin sodium tab 00 mg tolmetin sodium tab 600 mg OPIOID ANALGESICS acetaminophen w/ codeine soln 10-1 QL (500 ml / 0 days) mg/5ml acetaminophen w/ codeine tab 00-15 mg QL (90 tabs / 0 days) acetaminophen w/ codeine tab 00-0 mg QL (90 tabs / 0 days) acetaminophen w/ codeine tab 00-60 mg QL (180 tabs / 0 days) ascomp/cod cap 0mg QL (180 caps / 0 days) butalbital-acetaminophen-caff w/ cod cap 50- QL (180 caps / 0 days) 5-0-0 mg butalbital-aspirin-caff w/ codeine cap 50-5- QL (180 caps / 0 days) 0-0 mg butorphanol tartrate inj 1 mg/ml QL (70 ml / 0 days) butorphanol tartrate inj mg/ml QL (60 ml / 0 days) butorphanol tartrate nasal soln 10 mg/ml QL (0 ml / 0 days) nalbuphine hcl inj 10 mg/ml QL (00 ml / 0 days) nalbuphine hcl inj 0 mg/ml QL (100 ml / 0 days) tramadol hcl tab 50 mg QL (0 tabs / 0 days)
tramadol-acetaminophen tab 7.5-5 mg QL (0 tabs / 5 days) OPIOID ANALGESICS, CII ABSTRAL SUB 100MCG 5 QL (10 tabs / 0 days), PA; DL ABSTRAL SUB 00MCG 5 QL (10 tabs / 0 days), PA; DL ABSTRAL SUB 00MCG 5 QL (10 tabs / 0 days), PA; DL ABSTRAL SUB 00MCG 5 QL (116 tabs / 0 days), PA; DL ABSTRAL SUB 600MCG 5 QL (77 tabs / 0 days), PA; DL ABSTRAL SUB 800MCG 5 QL (58 tabs / 0 days), PA; DL codeine sulfate tab 15 mg QL (180 tabs / 0 days) codeine sulfate tab 0 mg QL (180 tabs / 0 days) codeine sulfate tab 60 mg QL (180 tabs / 0 days) duramorph inj 0.5mg/ml QL (00 ampules / 0 days) duramorph inj 1mg/ml QL (00 ampules / 0 days) endocet tab.5-5 QL (60 tabs / 0 days) endocet tab 5-5mg QL (60 tabs / 0 days) endocet tab 7.5-5 QL (60 tabs / 0 days) endocet tab 10-5mg QL (60 tabs / 0 days) FENTANYL CIT INJ 100MCG fentanyl citrate inj 0.05 mg/ml fentanyl citrate lozenge on a handle 00 mcg 5 QL (10 lozenges / 0 days), PA; DL fentanyl citrate lozenge on a handle 00 mcg 5 QL (116 lozenges / 0 days), PA; DL fentanyl citrate lozenge on a handle 600 mcg 5 QL (77 lozenges / 0 days), PA; DL fentanyl citrate lozenge on a handle 800 mcg 5 QL (58 lozenges / 0 days), PA; DL fentanyl citrate lozenge on a handle 100 5 QL (9 lozenges / 0 mcg days), PA; DL fentanyl citrate lozenge on a handle 1600 5 QL (9 lozenges / 0 mcg days), PA; DL fentanyl citrate pf soln cartridge 100 mcg/ml fentanyl citrate preservative free (pf) inj 100 mcg/ml fentanyl td patch 7hr 1 mcg/hr QL (10 patches / 0 days)
fentanyl td patch 7hr 5 mcg/hr QL (10 patches / 0 days) fentanyl td patch 7hr 50 mcg/hr QL (10 patches / 0 days) fentanyl td patch 7hr 75 mcg/hr QL (10 patches / 0 days) fentanyl td patch 7hr 100 mcg/hr QL (10 patches / 0 days) FENTORA TAB 100MCG 5 QL (10 tabs / 0 days), PA; DL FENTORA TAB 00MCG 5 QL (10 tabs / 0 days), PA; DL FENTORA TAB 00MCG 5 QL (116 tabs / 0 days), PA; DL FENTORA TAB 600MCG 5 QL (77 tabs / 0 days), PA; DL FENTORA TAB 800MCG 5 QL (58 tabs / 0 days), PA; DL hydrocodone-acetaminophen soln 7.5-5 QL (600 ml / 0 days) mg/15ml hydrocodone-acetaminophen soln 10-5 mg/15ml hydrocodone-acetaminophen tab.5-5 mg QL (60 tabs / 0 days) hydrocodone-acetaminophen tab 5-00 mg QL (90 tabs / 0 days) hydrocodone-acetaminophen tab 5-5 mg QL (60 tabs / 0 days) hydrocodone-acetaminophen tab 7.5-00 mg QL (90 tabs / 0 days) hydrocodone-acetaminophen tab 7.5-5 mg QL (60 tabs / 0 days) hydrocodone-acetaminophen tab 10-00 mg QL (90 tabs / 0 days) hydrocodone-acetaminophen tab 10-5 mg QL (60 tabs / 0 days) hydrocodone-ibuprofen tab 7.5-00 mg QL (150 tabs / 0 days) hydromorphone hcl inj 1 mg/ml hydromorphone hcl inj mg/ml QL (150 ml / 0 days) hydromorphone hcl inj mg/ml hydromorphone hcl preservative free (pf) inj QL (150 vials / 0 days) 10 mg/ml hydromorphone hcl preservative free (pf) inj QL (0 vials / 0 days) 10 mg/ml hydromorphone hcl tab mg QL (180 tabs / 0 days) hydromorphone hcl tab mg QL (180 tabs / 0 days) hydromorphone hcl tab 8 mg QL (180 tabs / 0 days) LAZANDA SPR 100MCG 5 QL (5 units / 0 days), PA; DL LAZANDA SPR 00MCG 5 QL (16 units / 0 days), PA; DL LAZANDA SPR 00MCG 5 QL (0 units / 0 days), PA; DL 5
levorphanol tartrate tab mg 5 QL (0 tabs / 0 days); DL lorcet hd tab 10-5mg QL (60 tabs / 0 days) lorcet plus tab 7.5-5 QL (60 tabs / 0 days) lorcet tab 5-5mg QL (60 tabs / 0 days) lortab tab 5-5mg QL (60 tabs / 0 days) lortab tab 7.5-5 QL (60 tabs / 0 days) lortab tab 10-5mg QL (60 tabs / 0 days) methadone hcl conc 10 mg/ml methadone hcl soln 5 mg/5ml QL (000 ml / 0 days) methadone hcl soln 10 mg/5ml QL (1000 ml / 0 days) methadone hcl tab 5 mg QL (90 tabs / 0 days) methadone hcl tab 10 mg QL (00 tabs / 0 days) methadone hcl tab for oral susp 0 mg METHADONE INJ 10MG/ML QL (160 ml / 0 days) METHADOSE CON 10MG/ML MORPHINE SUL INJ MG/ML QL (1000 ml / 0 days) MORPHINE SUL INJ MG/ML QL (500 ml / 0 days) MORPHINE SUL INJ 150/0ML morphine sulfate iv soln 1 mg/ml morphine sulfate iv soln pf 10 mg/ml morphine sulfate iv soln pf 15 mg/ml morphine sulfate oral soln 10 mg/5ml QL (900 ml / 0 days) morphine sulfate oral soln 0 mg/5ml QL (900 ml / 0 days) morphine sulfate oral soln 100 mg/5ml (0 QL (00 ml / 0 days) mg/ml) morphine sulfate tab 15 mg QL (180 tabs / 0 days) morphine sulfate tab 0 mg QL (180 tabs / 0 days) morphine sulfate tab er 15 mg QL (90 tabs / 0 days) morphine sulfate tab er 0 mg QL (90 tabs / 0 days) morphine sulfate tab er 60 mg QL (90 tabs / 0 days) morphine sulfate tab er 100 mg QL (60 tabs / 0 days) morphine sulfate tab er 00 mg QL (0 tabs / 0 days) OPANA ER TAB 5MG QL (60 tabs / 0 days) OPANA ER TAB 7.5MG QL (60 tabs / 0 days) OPANA ER TAB 10MG QL (60 tabs / 0 days) OPANA ER TAB 15MG QL (60 tabs / 0 days) OPANA ER TAB 0MG QL (60 tabs / 0 days) OPANA ER TAB 0MG QL (60 tabs / 0 days) OPANA ER TAB 0MG QL (50 tabs / 0 days) oxycodone hcl cap 5 mg QL (180 caps / 0 days) oxycodone hcl conc 100 mg/5ml (0 mg/ml) QL (180 ml / 0 days) 6
oxycodone hcl soln 5 mg/5ml QL (900 ml / 0 days) oxycodone hcl tab 5 mg QL (180 tabs / 0 days) oxycodone hcl tab 10 mg QL (180 tabs / 0 days) oxycodone hcl tab 15 mg QL (180 tabs / 0 days) oxycodone hcl tab 0 mg QL (180 tabs / 0 days) oxycodone hcl tab 0 mg QL (1 tabs / 0 days) oxycodone w/ acetaminophen soln 5-5 QL (1800 ml / 0 days) mg/5ml oxycodone w/ acetaminophen tab.5-5 QL (60 tabs / 0 days) mg oxycodone w/ acetaminophen tab 5-5 mg QL (60 tabs / 0 days) oxycodone w/ acetaminophen tab 7.5-5 QL (60 tabs / 0 days) mg oxycodone w/ acetaminophen tab 10-5 mg QL (60 tabs / 0 days) oxycodone-aspirin tab.855-5 mg QL (60 tabs / 0 days) oxycodone-ibuprofen tab 5-00 mg QL (10 tabs / 0 days) oxymorphone hcl tab 5 mg QL (180 tabs / 0 days) oxymorphone hcl tab 10 mg QL (180 tabs / 0 days) oxymorphone hcl tab er 1hr 5 mg QL (60 tabs / 0 days) oxymorphone hcl tab er 1hr 7.5 mg QL (60 tabs / 0 days) oxymorphone hcl tab er 1hr 10 mg QL (60 tabs / 0 days) oxymorphone hcl tab er 1hr 15 mg QL (60 tabs / 0 days) oxymorphone hcl tab er 1hr 0 mg QL (60 tabs / 0 days) oxymorphone hcl tab er 1hr 0 mg QL (60 tabs / 0 days) oxymorphone hcl tab er 1hr 0 mg QL (50 tabs / 0 days) SUBSYS SPR 100MCG 5 QL (10 sprays / 0 days), PA; DL SUBSYS SPR 00MCG 5 QL (10 sprays / 0 days), PA; DL SUBSYS SPR 00MCG 5 QL (8 sprays / 0 days), PA; DL SUBSYS SPR 600MCG 5 QL (56 sprays / 0 days), PA; DL SUBSYS SPR 800MCG 5 QL ( sprays / 0 days), PA; DL SUBSYS SPR 100MCG 5 QL (77 sprays / 0 days), PA; DL SUBSYS SPR 1600MCG 5 QL (58 sprays / 0 days), PA; DL PSYCHOTHERAPEUTIC-MISC buprenorphine hcl inj 0. mg/ml (base equiv) QL (67 ml / 0 days) TALWIN INJ 0MG/ML 7
ANESTHETICS LOCAL ANESTHETICS lidocaine hcl local inj 1% lidocaine hcl local inj 1.5% lidocaine hcl local inj % lidocaine hcl local preservative free (pf) inj 0.5% lidocaine hcl local preservative free (pf) inj 1% lidocaine hcl local preservative free (pf) inj % lidocaine hcl local preservative free (pf) inj % ropivacaine hcl inj mg/ml ropivacaine hcl inj 5 mg/ml ropivacaine hcl inj 7.5 mg/ml ropivacaine hcl inj 10 mg/ml ANTI-INFECTIVES ANTI-BACTERIALS - MISCELLANEOUS amikacin sulfate inj 1 gm/ml (50 mg/ml) amikacin sulfate inj 500 mg/ml (50 mg/ml) BETHKIS NEB 00/ML 5 B/D, QL ( ml / 56 days), NM; DL gentamicin in saline inj 0.8 mg/ml gentamicin in saline inj 1 mg/ml gentamicin in saline inj 1. mg/ml gentamicin in saline inj 1.6 mg/ml gentamicin sulfate inj 0 mg/ml neomycin sulfate tab 500 mg paromomycin sulfate cap 50 mg streptomycin sulfate for inj 1 gm SULFADIAZINE TAB 500MG TOBI PODHALR CAP 8MG 5 QL ( caps / 56 days), NM; DL tobramycin nebu soln 00 mg/5ml 5 B/D, QL (80 ml / 56 days), NM; DL tobramycin sulfate inj 10 mg/ml (base equivalent) tobramycin sulfate inj 80 mg/ml (0 mg/ml) (base equiv) ANTI-INFECTIVES - MISCELLANEOUS ALBENZA TAB 00MG 8
ALINIA SUS 100/5ML ALINIA TAB 500MG 5 QL (0 tabs / 0 days); DL atovaquone susp 750 mg/5ml 5 DL AZACTAM/DEX INJ GM aztreonam for inj 1 gm aztreonam for inj gm baciim inj 50000unt bacitracin intramuscular for soln 50000 unit BILTRICIDE TAB 600MG CAYSTON INH 75MG 5 QL (8 vials / 56 days), NM, LA; DL chloramphenicol sodium succinate for iv inj 1 gm clindamycin hcl cap 75 mg clindamycin hcl cap 150 mg clindamycin hcl cap 00 mg clindamycin palmitate hcl for soln 75 mg/5ml (base equiv) clindamycin phosphate in d5w iv soln 00 mg/50ml clindamycin phosphate in d5w iv soln 600 mg/50ml clindamycin phosphate in d5w iv soln 900 mg/50ml clindamycin phosphate iv soln 00 mg/ml clindamycin phosphate iv soln 900 mg/6ml colistimethate sodium for inj 150 mg DALVANCE SOL 500MG 5 DL dapsone tab 5 mg dapsone tab 100 mg daptomycin for iv soln 500 mg 5 DL DARAPRIM TAB 5MG DORIBAX INJ 500MG imipenem-cilastatin intravenous for soln 50 mg imipenem-cilastatin intravenous for soln 500 mg INVANZ INJ 1GM ivermectin tab mg LINCOCIN INJ 00MG/ML lincomycin hcl inj 00 mg/ml linezolid for susp 100 mg/5ml 5 DL 9
linezolid iv soln 600 mg/00ml ( mg/ml) 5 DL linezolid tab 600 mg 5 DL meropenem iv for soln 1 gm meropenem iv for soln 500 mg methenamine hippurate tab 1 gm methenamine mandelate tab 0.5 gm methenamine mandelate tab 1 gm metronidazole cap 75 mg metronidazole in nacl 0.79% iv soln 500 mg/100ml metronidazole tab 50 mg metronidazole tab 500 mg MONUROL PAK GRANULES NEBUPENT INH 00MG B/D nitrofurantoin macrocrystalline cap 50 mg nitrofurantoin macrocrystalline cap 100 mg nitrofurantoin monohydrate macrocrystalline cap 100 mg ORBACTIV SOL 00MG 5 DL PENTAM 00 INJ 00MG polymyxin b sulfate for inj 500000 unit SIVEXTRO INJ 00MG 5 QL (6 vials / 0 days); DL SIVEXTRO TAB 00MG 5 QL (6 tabs / 0 days); DL sulfamethoxazole-trimethoprim iv soln 00-80 mg/5ml sulfamethoxazole-trimethoprim susp 00-0 1 mg/5ml sulfamethoxazole-trimethoprim tab 00-80 1 mg sulfamethoxazole-trimethoprim tab 800-160 1 mg SYNERCID INJ 500MG 5 DL TIGECYCLINE INJ 50MG 5 DL tinidazole tab 50 mg tinidazole tab 500 mg trimethoprim tab 100 mg vancomycin hcl cap 15 mg 5 DL vancomycin hcl cap 50 mg 5 DL vancomycin hcl for inj 10 gm vancomycin hcl for inj 500 mg vancomycin hcl for inj 1000 mg XIFAXAN TAB 00MG QL (9 tabs / days) 10
ANTIFUNGALS ABELCET INJ 5MG/ML 5 B/D; DL AMBISOME INJ 50MG 5 B/D; DL amphotericin b for inj 50 mg B/D CANCIDAS INJ 50MG 5 B/D; DL CANCIDAS INJ 70MG 5 B/D; DL CRESEMBA CAP 186 MG 5 DL CRESEMBA INJ 7MG 5 DL ERAXIS INJ 50MG ERAXIS INJ 100MG fluconazole for susp 10 mg/ml fluconazole for susp 0 mg/ml fluconazole in nacl 0.9% inj 00 mg/100ml fluconazole in nacl 0.9% inj 00 mg/00ml fluconazole tab 50 mg fluconazole tab 100 mg fluconazole tab 150 mg fluconazole tab 00 mg flucytosine cap 50 mg 5 DL flucytosine cap 500 mg 5 DL griseofulvin microsize susp 15 mg/5ml griseofulvin microsize tab 500 mg griseofulvin ultramicrosize tab 15 mg griseofulvin ultramicrosize tab 50 mg itraconazole cap 100 mg QL (10 caps / 0 days), PA ketoconazole tab 00 mg MYCAMINE INJ 50MG 5 DL MYCAMINE INJ 100MG 5 DL NOXAFIL SUS 0MG/ML 5 PA; DL NOXAFIL TAB 100MG 5 QL (9 tabs / 0 days), PA; DL nystatin tab 500000 unit ONMEL TAB 00MG QL (0 tabs / 0 days), PA terbinafine hcl tab 50 mg 1 voriconazole for inj 00 mg voriconazole for susp 0 mg/ml 5 DL voriconazole tab 50 mg 5 DL voriconazole tab 00 mg 5 DL ANTIMALARIALS atovaquone-proguanil hcl tab 6.5-5 mg 11
atovaquone-proguanil hcl tab 50-100 mg chloroquine phosphate tab 50 mg chloroquine phosphate tab 500 mg COARTEM TAB 0-10MG mefloquine hcl tab 50 mg PRIMAQUINE TAB 6.MG quinine sulfate cap mg PA ANTIRETROVIRAL AGENTS abacavir sulfate tab 00 mg (base equiv) APTIVUS CAP 50MG 5 DL APTIVUS SOL 5 DL CRIXIVAN CAP 00MG CRIXIVAN CAP 00MG didanosine delayed release capsule 15 mg didanosine delayed release capsule 00 mg didanosine delayed release capsule 50 mg didanosine delayed release capsule 00 mg EDURANT TAB 5MG 5 DL EMTRIVA CAP 00MG EMTRIVA SOL 10MG/ML FUZEON INJ 90MG 5 NM; DL INTELENCE TAB 5MG INTELENCE TAB 100MG 5 DL INTELENCE TAB 00MG 5 DL INVIRASE CAP 00MG INVIRASE TAB 500MG 5 DL ISENTRESS CHW 5MG ISENTRESS CHW 100MG ISENTRESS POW 100MG ISENTRESS TAB 00MG 5 DL lamivudine oral soln 10 mg/ml lamivudine tab 150 mg lamivudine tab 00 mg LEXIVA SUS 50MG/ML LEXIVA TAB 700MG 5 DL nevirapine susp 50 mg/5ml nevirapine tab 00 mg nevirapine tab er hr 100 mg nevirapine tab er hr 00 mg NORVIR CAP 100MG NORVIR SOL 80MG/ML NORVIR TAB 100MG 1
PREZISTA SUS 100MG/ML PREZISTA TAB 75MG PREZISTA TAB 150MG PREZISTA TAB 600MG 5 DL PREZISTA TAB 800MG 5 DL RESCRIPTOR TAB 100 MG RESCRIPTOR TAB 00MG RETROVIR INJ 10MG/ML REYATAZ CAP 150MG 5 DL REYATAZ CAP 00MG 5 DL REYATAZ CAP 00MG 5 DL REYATAZ POW 50MG 5 DL SELZENTRY TAB 5MG SELZENTRY TAB 75MG 5 DL SELZENTRY TAB 150MG 5 DL SELZENTRY TAB 00MG 5 DL stavudine cap 15 mg stavudine cap 0 mg stavudine cap 0 mg stavudine cap 0 mg SUSTIVA CAP 50MG SUSTIVA CAP 00MG SUSTIVA TAB 600MG 5 DL TIVICAY TAB 10MG TIVICAY TAB 5MG 5 DL TIVICAY TAB 50MG 5 DL TYBOST TAB 150MG VIDEX SOL GM VIRACEPT TAB 50MG 5 DL VIRACEPT TAB 65MG 5 DL VIREAD POW 0MG/GM 5 DL VIREAD TAB 150MG 5 DL VIREAD TAB 00MG 5 DL VIREAD TAB 50MG 5 DL VIREAD TAB 00MG 5 DL ZERIT SOL 1MG/ML ZIAGEN SOL 0MG/ML zidovudine cap 100 mg zidovudine syrup 10 mg/ml zidovudine tab 00 mg ANTIRETROVIRAL COMBINATION AGENTS abacavir sulfate-lamivudine tab 600-00 mg 5 DL 1
abacavir sulfate-lamivudine-zidovudine tab 5 DL 00-150-00 mg ATRIPLA TAB 5 DL COMPLERA TAB 5 DL DESCOVY TAB 00/5 5 DL EVOTAZ TAB 00-150 5 DL GENVOYA TAB 5 DL KALETRA TAB 100-5MG KALETRA TAB 00-50MG 5 DL lamivudine-zidovudine tab 150-00 mg lopinavir-ritonavir soln 00-100 mg/5ml (80-0 mg/ml) ODEFSEY TAB 5 DL PREZCOBIX TAB 800-150 5 DL STRIBILD TAB 5 DL TRIUMEQ TAB 5 DL TRUVADA TAB 100-150 5 DL TRUVADA TAB 1-00 5 DL TRUVADA TAB 167-50 5 DL TRUVADA TAB 00-00 5 DL ANTITUBERCULAR AGENTS CAPASTAT SUL INJ 1GM ethambutol hcl tab 100 mg ethambutol hcl tab 00 mg isoniazid inj 100 mg/ml isoniazid syrup 50 mg/5ml 1 isoniazid tab 100 mg 1 isoniazid tab 00 mg 1 PASER GRA GM PRIFTIN TAB 150MG pyrazinamide tab 500 mg rifabutin cap 150 mg RIFAMATE CAP rifampin cap 150 mg rifampin cap 00 mg rifampin for inj 600 mg RIFATER TAB SIRTURO TAB 100MG 5 LA, PA; DL TRECATOR TAB 50MG ANTIVIRALS acyclovir cap 00 mg 1 acyclovir sodium iv soln 50 mg/ml B/D 1
acyclovir susp 00 mg/5ml acyclovir tab 00 mg acyclovir tab 800 mg adefovir dipivoxil tab 10 mg 5 PA; DL BARACLUDE SOL.05MG/ML PA cidofovir iv inj 75 mg/ml 5 B/D; DL entecavir tab 0.5 mg 5 PA; DL entecavir tab 1 mg 5 PA; DL EPIVIR HBV SOL 5MG/ML famciclovir tab 15 mg famciclovir tab 50 mg famciclovir tab 500 mg foscarnet sodium inj mg/ml B/D ganciclovir sodium for inj 500 mg B/D lamivudine tab 100 mg (hbv) MODERIBA PAK 600/DAY 5 NM; DL MODERIBA PAK 800/DAY 5 NM; DL MODERIBA PAK 1000/DAY 5 NM; DL MODERIBA PAK 100/DAY 5 NM; DL moderiba tab 00mg NM oseltamivir phosphate cap 0 mg (base QL (8 caps / 180 days) equiv) oseltamivir phosphate cap 5 mg (base QL ( caps / 180 days) equiv) oseltamivir phosphate cap 75 mg (base QL ( caps / 180 days) equiv) PEGASYS INJ 5 QL ( injections / 8 days), NM; DL PEGASYS INJ 180MCG/M 5 QL ( injections / 8 days), NM; DL PEGASYS INJ PROCLICK 5 QL ( injections / 8 days), NM; DL REBETOL SOL 0MG/ML 5 NM; DL RELENZA MIS DISKHALE QL (10 blisters / 65 days) ribasphere cap 00mg NM ribasphere tab 00mg NM ribasphere tab 00mg NM ribasphere tab 600mg 5 NM; DL ribavirin cap 00 mg NM ribavirin tab 00 mg NM rimantadine hydrochloride tab 100 mg 15
SOVALDI TAB 00MG 5 QL (0 tabs / 0 days), TAMIFLU SUS 6MG/ML QL (55 ml / 180 days) valacyclovir hcl tab 1 gm valacyclovir hcl tab 500 mg valganciclovir hcl for soln 50 mg/ml (base 5 DL equiv) valganciclovir hcl tab 50 mg (base 5 DL equivalent) VEMLIDY TAB 5MG 5 PA; DL CEPHALOSPORINS AVYCAZ INJ -0.5GM 5 DL cefaclor cap 50 mg cefaclor cap 500 mg CEFACLOR ER TAB 500MG cefadroxil cap 500 mg cefadroxil for susp 50 mg/5ml cefadroxil for susp 500 mg/5ml cefadroxil tab 1 gm cefazolin sodium for inj 1 gm cefazolin sodium for inj 10 gm cefazolin sodium for inj 500 mg cefdinir cap 00 mg cefdinir for susp 15 mg/5ml cefdinir for susp 50 mg/5ml cefepime hcl for inj 1 gm cefepime hcl for inj gm cefotaxime sodium for inj 1 gm cefotaxime sodium for inj gm cefotaxime sodium for inj 10 gm cefotaxime sodium for inj 500 mg cefotetan disodium for inj 1 gm cefotetan disodium for inj gm cefotetan disodium for inj 10 gm cefoxitin sodium for inj 10 gm cefoxitin sodium for iv soln 1 gm cefoxitin sodium for iv soln gm cefpodoxime proxetil for susp 50 mg/5ml cefpodoxime proxetil for susp 100 mg/5ml cefpodoxime proxetil tab 100 mg cefpodoxime proxetil tab 00 mg cefprozil for susp 15 mg/5ml 16
cefprozil for susp 50 mg/5ml cefprozil tab 50 mg cefprozil tab 500 mg ceftazidime for inj 1 gm ceftazidime for inj gm ceftazidime for inj 6 gm ceftibuten cap 00 mg ceftibuten for susp 180 mg/5ml ceftriaxone sodium for inj 10 gm ceftriaxone sodium for inj 50 mg ceftriaxone sodium for inj 500 mg ceftriaxone sodium for iv soln 1 gm ceftriaxone sodium for iv soln gm cefuroxime axetil tab 50 mg cefuroxime axetil tab 500 mg cefuroxime sodium for inj 1.5 gm cefuroxime sodium for inj 750 mg cephalexin cap 50 mg 1 cephalexin cap 500 mg 1 cephalexin cap 750 mg cephalexin for susp 15 mg/5ml 1 cephalexin for susp 50 mg/5ml 1 cephalexin tab 50 mg 1 cephalexin tab 500 mg 1 FORTAZ INJ 1GM FORTAZ INJ GM SUPRAX CAP 00MG SUPRAX CHW 100MG SUPRAX CHW 00MG TEFLARO INJ 00MG TEFLARO INJ 600MG 5 DL ZERBAXA INJ 1.5GM 5 DL ERYTHROMYCINS/MACROLIDES azithromycin for susp 100 mg/5ml azithromycin for susp 00 mg/5ml azithromycin iv for soln 500 mg azithromycin powd pack for susp 1 gm azithromycin tab 50 mg azithromycin tab 500 mg azithromycin tab 600 mg clarithromycin for susp 15 mg/5ml clarithromycin for susp 50 mg/5ml 17
clarithromycin tab 50 mg clarithromycin tab 500 mg clarithromycin tab er hr 500 mg DIFICID TAB 00MG 5 QL (0 tabs / 10 days), ST; DL e.e.s. 00 tab 00mg E.E.S. GRAN SUS 00/5ML ery-tab tab 50mg ec ery-tab tab mg ec ery-tab tab 500mg ec ERYTHROCIN INJ 500MG erythrocin tab 50mg erythromycin ethylsuccinate for susp 00 mg/5ml erythromycin ethylsuccinate tab 00 mg erythromycin tab 50 mg erythromycin tab 500 mg erythromycin w/ delayed release particles cap 50 mg FLUOROQUINOLONES AVELOX INJ ciprofloxacin 00 mg/100ml in d5w ciprofloxacin 00 mg/00ml in d5w ciprofloxacin hcl tab 100 mg (base equiv) 1 ciprofloxacin hcl tab 50 mg (base equiv) 1 ciprofloxacin hcl tab 500 mg (base equiv) 1 ciprofloxacin hcl tab 750 mg (base equiv) 1 ciprofloxacin iv soln 00 mg/0ml (1%) ciprofloxacin iv soln 00 mg/0ml (1%) ciprofloxacin-ciprofloxacin hcl tab er hr QL (8 tabs / 0 days) 500 mg (base eq) ciprofloxacin-ciprofloxacin hcl tab er hr QL (1 tabs / 0 days) 1000 mg(base eq) levofloxacin in d5w iv soln 50 mg/50ml levofloxacin in d5w iv soln 500 mg/100ml levofloxacin in d5w iv soln 750 mg/150ml levofloxacin iv soln 5 mg/ml levofloxacin oral soln 5 mg/ml levofloxacin tab 50 mg levofloxacin tab 500 mg levofloxacin tab 750 mg moxifloxacin hcl tab 00 mg (base equiv) 18
MOXIFLOXACIN INJ ofloxacin tab 00 mg ofloxacin tab 00 mg PENICILLINS amoxicillin & k clavulanate chew tab 00-8.5 mg amoxicillin & k clavulanate chew tab 00-57 mg amoxicillin & k clavulanate for susp 00-8.5 mg/5ml amoxicillin & k clavulanate for susp 50-6.5 mg/5ml amoxicillin & k clavulanate for susp 00-57 mg/5ml amoxicillin & k clavulanate for susp 600-.9 mg/5ml amoxicillin & k clavulanate tab 50-15 mg amoxicillin & k clavulanate tab 500-15 mg amoxicillin & k clavulanate tab 875-15 mg amoxicillin & k clavulanate tab er 1hr 1000-6.5 mg amoxicillin (trihydrate) cap 50 mg 1 amoxicillin (trihydrate) cap 500 mg 1 amoxicillin (trihydrate) chew tab 15 mg 1 amoxicillin (trihydrate) chew tab 50 mg 1 amoxicillin (trihydrate) for susp 15 mg/5ml 1 amoxicillin (trihydrate) for susp 00 mg/5ml 1 amoxicillin (trihydrate) for susp 50 mg/5ml 1 amoxicillin (trihydrate) for susp 00 mg/5ml 1 amoxicillin (trihydrate) tab 500 mg 1 amoxicillin (trihydrate) tab 875 mg 1 ampicillin & sulbactam sodium for inj 1.5 (1-0.5) gm ampicillin & sulbactam sodium for inj (-1) gm ampicillin & sulbactam sodium for iv soln 15 (10-5) gm ampicillin cap 50 mg ampicillin cap 500 mg ampicillin for susp 15 mg/5ml ampicillin for susp 50 mg/5ml ampicillin sodium for inj 1 gm ampicillin sodium for inj gm 19
ampicillin sodium for inj 15 mg ampicillin sodium for inj 50 mg ampicillin sodium for inj 500 mg ampicillin sodium for iv soln gm ampicillin sodium for iv soln 10 gm BACTOCILL INJ DEX 1GM BACTOCILL INJ DEX GM 5 DL BICILLIN C-R INJ 900/00 BICILLIN C-R INJ 100000 BICILLIN L-A INJ 600000 BICILLIN L-A INJ 100000 BICILLIN L-A INJ 00000 dicloxacillin sodium cap 50 mg dicloxacillin sodium cap 500 mg nafcillin sodium for inj 1 gm nafcillin sodium for inj gm nafcillin sodium for inj 10 gm 5 DL nafcillin sodium for iv soln gm oxacillin sodium for inj 1 gm oxacillin sodium for inj gm oxacillin sodium for inj 10 gm 5 DL PEN G PROC INJ 600000 PENICILL GK/ INJ DEX MU PENICILL GK/ INJ DEX MU penicillin g potassium for inj 5000000 unit penicillin g sodium for inj 5000000 unit 5 DL penicillin v potassium for soln 15 mg/5ml 1 penicillin v potassium for soln 50 mg/5ml 1 penicillin v potassium tab 50 mg 1 penicillin v potassium tab 500 mg 1 pfizerpen-g inj 0mu piperacillin sod-tazobactam na for inj.75 gm (-0.75 gm) piperacillin sod-tazobactam sod for inj.5 gm (-0.5 gm) piperacillin sod-tazobactam sod for inj.5 gm (-0.5 gm) piperacillin sod-tazobactam sod for inj 0.5 gm (6-.5 gm) ZOSYN SOL -0.5GM ZOSYN SOL -0.75G ZOSYN SOL -0.50GM 0
TETRACYCLINES doxy 100 inj 100mg doxycycline hyclate cap 50 mg doxycycline hyclate cap 100 mg doxycycline hyclate tab 0 mg doxycycline hyclate tab 100 mg doxycycline monohydrate cap 50 mg doxycycline monohydrate cap 100 mg doxycycline monohydrate for susp 5 mg/5ml doxycycline monohydrate tab 50 mg doxycycline monohydrate tab 75 mg doxycycline monohydrate tab 100 mg doxycycline monohydrate tab 150 mg minocycline hcl cap 50 mg minocycline hcl cap 75 mg minocycline hcl cap 100 mg morgidox cap 1x50mg tetracycline hcl cap 50 mg tetracycline hcl cap 500 mg VIBRAMYCIN SYP 50MG/5ML ANTINEOPLASTIC AGENTS ALKYLATING AGENTS BENDEKA INJ 100/ML 5 NM; DL BICNU INJ 100MG busulfan inj 6 mg/ml 5 DL CYCLOPHOSPH CAP 5MG B/D CYCLOPHOSPH CAP 50MG B/D cyclophosphamide for inj 1 gm B/D cyclophosphamide for inj gm B/D cyclophosphamide for inj 500 mg B/D dacarbazine for inj 100 mg dacarbazine for inj 00 mg EMCYT CAP 10MG PA GLEOSTINE CAP 5MG PA GLEOSTINE CAP 10MG PA GLEOSTINE CAP 0MG PA GLEOSTINE CAP 100MG PA HEXALEN CAP 50MG 5 DL ifosfamide for inj 1 gm IFOSFAMIDE INJ GM ifosfamide iv inj 1 gm/0ml (50 mg/ml) 1
ifosfamide iv inj gm/60ml (50 mg/ml) LEUKERAN TAB MG melphalan hcl for inj 50 mg (base equiv) 5 DL MUSTARGEN INJ 10MG TEMODAR INJ 100MG 5 NM; DL thiotepa for inj 15 mg 5 NM; DL TREANDA INJ 100MG 5 NM; DL ZANOSAR INJ 1GM ANTHRACYCLINES adriamycin inj 0mg doxorubicin hcl for inj 10 mg doxorubicin hcl for inj 50 mg doxorubicin hcl inj mg/ml doxorubicin hcl liposomal inj (for iv infusion) 5 DL mg/ml epirubicin hcl iv soln 50 mg/5ml ( mg/ml) epirubicin hcl iv soln 00 mg/100ml ( mg/ml) ANTIBIOTICS bleomycin sulfate for inj 15 unit bleomycin sulfate for inj 0 unit B/D daunorubicin hcl inj 5 mg/ml (base equiv) idarubicin hcl iv inj 10 mg/10ml (1 mg/ml) 5 DL mitomycin for iv soln 5 mg 5 DL mitomycin for iv soln 0 mg 5 DL mitomycin for iv soln 0 mg 5 DL VALSTAR SOL 0MG/ML 5 NM; DL ANTIMETABOLITES adrucil inj 500/10ml B/D ALIMTA INJ 100MG 5 DL ALIMTA INJ 500MG 5 DL ARRANON INJ 5MG/ML 5 DL azacitidine for inj 100 mg 5 NM; DL cladribine iv soln 10 mg/10ml (1 mg/ml) 5 B/D; DL clofarabine iv soln 1 mg/ml 5 DL cytarabine inj 0 mg/ml B/D cytarabine inj pf 0 mg/ml B/D cytarabine inj pf 100 mg/ml B/D decitabine for inj 50 mg 5 NM; DL floxuridine for inj 0.5 gm fludarabine phosphate for inj 50 mg fludarabine phosphate inj 5 mg/ml
fluorouracil inj 1 gm/0ml (50 mg/ml) fluorouracil inj.5 gm/50ml (50 mg/ml) B/D FOLOTYN INJ 0MG/ML 5 NM; DL gemcitabine hcl for inj 1 gm 5 DL gemcitabine hcl for inj gm 5 DL gemcitabine hcl for inj 00 mg 5 DL gemcitabine hcl inj 1 gm/6.ml (8 mg/ml) 5 DL (base equiv) gemcitabine hcl inj gm/5.6ml (8 mg/ml) 5 DL (base equiv) gemcitabine hcl inj 00 mg/5.6ml (8 5 DL mg/ml) (base equiv) mercaptopurine tab 50 mg methotrexate sodium for inj 1 gm B/D methotrexate sodium inj 50 mg/10ml (5 B/D mg/ml) methotrexate sodium inj pf 50 mg/ml (5 B/D mg/ml) methotrexate sodium inj pf 1000 mg/0ml B/D (5 mg/ml) NIPENT INJ 10MG 5 DL PURIXAN SUS 0MG/ML 5 TABLOID TAB 0MG PA ANTIMITOTIC, TAXOIDS ABRAXANE INJ 100MG 5 DL DOCETAXEL INJ 80MG/ML 5 DL DOCETAXEL INJ 80MG/8ML 5 DL JEVTANA INJ 60/1.5ML 5 NM; DL paclitaxel iv conc 00 mg/50ml (6 mg/ml) ANTIMITOTIC, VINCA ALKALOIDS vinblastine sulfate inj 1 mg/ml B/D vincasar pfs inj 1mg/ml B/D vincristine sulfate iv soln 1 mg/ml B/D vinorelbine tartrate inj 10 mg/ml (base equiv) vinorelbine tartrate inj 50 mg/5ml (10 mg/ml) (base equiv) BIOLOGIC RESPONSE MODIFIERS ARZERRA CON 100/5ML 5 B/D, NM; DL AVASTIN INJ 5 NM; DL AVASTIN INJ 00/16ML 5 NM; DL BAVENCIO INJ 0MG/ML 5
BELEODAQ INJ 500MG 5 NM; DL BLINCYTO INJ 5MCG 5 NM; DL CAMPATH INJ 0MG/ML 5 DL CYRAMZA INJ 100/10ML 5 B/D, NM; DL CYRAMZA INJ 500/50ML 5 B/D, NM; DL DARZALEX SOL 100MG/5M 5 NM, LA; DL DARZALEX SOL 00MG/0 5 NM, LA; DL EMPLICITI INJ 00MG 5 B/D, NM; DL EMPLICITI INJ 00MG 5 B/D, NM; DL ERBITUX INJ 100MG 5 NM; DL ERBITUX INJ 00MG 5 NM; DL ERIVEDGE CAP 150MG 5 QL (0 caps / 0 days), FARYDAK CAP 10MG 5 QL (1 caps / 1 days), FARYDAK CAP 15MG 5 QL (1 caps / 1 days), FARYDAK CAP 0MG 5 QL (6 caps / 1 days), GAZYVA INJ 5MG/ML 5 NM; DL HERCEPTIN INJ 0MG 5 NM; DL IBRANCE CAP 75MG 5 QL ( caps / 8 days), IBRANCE CAP 100MG 5 QL ( caps / 8 days), IBRANCE CAP 15MG 5 QL (1 caps / 8 days), IMFINZI INJ 10/. 5 NM; DL IMFINZI INJ 500/10 5 NM; DL ISTODAX OVR INJ 10MG 5 NM; DL KADCYLA INJ 100MG 5 NM; DL KADCYLA INJ 160MG 5 NM; DL KEYTRUDA INJ 100MG/M 5 NM; DL KEYTRUDA SOL 50MG 5 NM; DL KISQALI 00 PAK FEMARA 5 QL (9 tabs / 8 days), KISQALI 00 PAK FEMARA 5 QL (70 tabs / 8 days), KISQALI 600 PAK FEMARA 5 QL (91 tabs / 8 days), KISQALI TAB 00DOSE 5 QL (6 tabs / 8 days),
KISQALI TAB 00DOSE 5 QL (6 tabs / 8 days), KISQALI TAB 600DOSE 5 QL (6 tabs / 8 days), KYPROLIS SOL 0MG 5 NM; DL KYPROLIS SOL 60MG 5 NM; DL LARTRUVO INJ 10MG/ML 5 NM, LA; DL LYNPARZA CAP 50MG 5 QL (80 caps / 0 days), NINLARO CAP.MG 5 QL (6 caps / 8 days), NINLARO CAP MG 5 QL (6 caps / 8 days), NINLARO CAP MG 5 QL ( caps / 8 days), ODOMZO CAP 00MG 5 QL (0 caps / 0 days), NM, LA, PA; DL OPDIVO INJ 0MG/ML 5 NM; DL OPDIVO INJ 100MG/10 5 NM; DL PERJETA INJ 0/1ML 5 NM; DL PORTRAZZA INJ 800/50ML 5 B/D, NM; DL RITUXAN INJ 500MG 5 RUBRACA TAB 00MG 5 NM, LA, PA; DL RUBRACA TAB 00MG 5 NM, LA, PA; DL TECENTRIQ INJ 100/0 5 NM, LA; DL TORISEL SOL 5MG/ML 5 NM; DL UNITUXIN INJ 5 NM; DL VECTIBIX INJ 100MG 5 B/D, NM; DL VECTIBIX INJ 00MG 5 B/D, NM; DL VELCADE INJ.5MG 5 NM; DL VENCLEXTA TAB 10MG QL (100 tabs / 0 days), NM, LA, PA VENCLEXTA TAB 50MG QL (0 tabs / 0 days), NM, LA, PA VENCLEXTA TAB 100MG 5 QL (10 tabs / 0 days), NM, LA, PA; DL VENCLEXTA TAB START PK 5 QL ( tabs / 0 days), NM, LA, PA; DL YERVOY INJ 50MG 5 NM; DL YERVOY INJ 00MG 5 NM; DL ZALTRAP INJ 100/ML 5 NM; DL ZALTRAP INJ 00/8ML 5 NM; DL 5
ZEJULA CAP 100MG 5 QL (90 caps / 0 days), ZOLINZA CAP 100MG 5 QL (10 caps / 0 days), DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS (DMARDS) methotrexate sodium inj 5 mg/ml B/D HORMONAL ANTINEOPLASTIC AGENTS anastrozole tab 1 mg bicalutamide tab 50 mg DEPO-PROVERA INJ 00/ML ELIGARD INJ 7.5MG QL (1 kit / 8 days), NM, PA ELIGARD INJ.5MG QL (1 kit / 8 days), NM, PA ELIGARD INJ 0MG QL (1 kit / 11 days), NM, PA ELIGARD INJ 5MG QL (1 kit / 168 days), NM, PA exemestane tab 5 mg FARESTON TAB 60MG 5 PA; DL FASLODEX INJ 50MG 5 DL FIRMAGON INJ 80MG QL (1 vials / 8 days), NM, PA FIRMAGON INJ 10MG 5 QL ( vials / 65 days), flutamide cap 15 mg hydroxyprogesterone caproate im in oil 1.5 5 PA; DL gm/5ml letrozole tab.5 mg leuprolide acetate inj kit 5 mg/ml NM, PA LUPRON DEPOT INJ.75MG 5 QL (1 kit / 8 days), NM, PA; DL LUPRON DEPOT INJ 7.5MG 5 QL (1 kit / 8 days), NM, PA; DL LUPRON DEPOT INJ 11.5MG 5 QL (1 kit / 8 days), NM, PA; DL LUPRON DEPOT INJ.5MG 5 QL (1 kit / 8 days), NM, PA; DL LUPRON DEPOT INJ 0MG 5 QL (1 kit / 8 days), NM, PA; DL LUPRON DEPOT INJ 5MG 5 QL (1 kit / 168 days), NM, PA; DL LYSODREN TAB 500MG 5 DL 6
megestrol acetate susp 0 mg/ml PA megestrol acetate tab 0 mg PA megestrol acetate tab 0 mg PA nilutamide tab 150 mg 5 DL SOLTAMOX SOL 10MG/5ML tamoxifen citrate tab 10 mg (base equivalent) tamoxifen citrate tab 0 mg (base equivalent) TRELSTAR MIX INJ.75MG 5 QL (1 injection / 8 days), TRELSTAR MIX INJ 11.5MG 5 QL (1 injection / 8 days), TRELSTAR MIX INJ.5MG 5 QL (1 injection / 168 days), XTANDI CAP 0MG 5 QL (10 caps / 0 days), ZYTIGA TAB 50MG 5 QL (10 tabs / 0 days), IMMUNOMODULATORS POMALYST CAP 1MG 5 QL (8 caps / 8 days), POMALYST CAP MG 5 QL ( caps / 8 days), POMALYST CAP MG 5 QL ( caps / 8 days), POMALYST CAP MG 5 QL (1 caps / 8 days), REVLIMID CAP.5MG 5 QL (10 caps / 8 days), NM, LA, PA; DL REVLIMID CAP 5MG 5 QL (105 caps / 8 days), NM, LA, PA; DL REVLIMID CAP 10MG 5 QL (6 caps / 8 days), NM, LA, PA; DL REVLIMID CAP 15MG 5 QL ( caps / 8 days), NM, LA, PA; DL REVLIMID CAP 0MG 5 QL ( caps / 8 days), NM, LA, PA; DL REVLIMID CAP 5MG 5 QL (1 caps / 8 days), NM, LA, PA; DL SYLVANT SOL 100MG 5 SYLVANT SOL 00MG 5 THALOMID CAP 50MG 5 THALOMID CAP 100MG 5 7