MDwise Medicare
Quantity Limits List

Quantity Limits List

Drug Name

Quantity Limits

Analgesics

 

 

Analgesics, Miscellaneous

 

 

acetaminophen-codeine oral solution 120-12 mg/5 ml

 

QL (4500 per 30 days)

acetaminophen-codeine oral tablet 300-15 mg, 300-30 mg

 

QL (360 per 30 days)

acetaminophen-codeine oral tablet 300-60 mg

 

QL (180 per 30 days)

butalbital-acetaminophen-caff oral tablet50-325-40 mg

(Esgic)

QL (180 per 30 days)

butalbital-aspirin-caffeine oral capsule50-325-40 mg

 

QL (180 per 30 days)

butalbital-aspirin-caffeine oral tablet 50-325-40 mg

 

QL (180 per 30 days)

codeine sulfate oral tablet 30 mg, 60 mg

 

QL (180 per 30 days)

endocet oral tablet 10-325 mg

 

QL (180 per 30 days)

endocet oral tablet 2.5-325 mg, 5-325 mg

 

QL (360 per 30 days)

endocet oral tablet 7.5-325 mg

 

QL (240 per 30 days)

fentanyl citrate buccal lozenge on a handle 1,200 mcg, 1,600 mcg, 400 mcg, 600 mcg, 800 mcg

(Actiq)

QL (120 per 30 days)

fentanyl citrate buccal lozenge on a handle 200 mcg

(Actiq)

QL (120 per 30 days)

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

 

QL (10 per 30 days)

fentanyl transdermal patch 72 hour 25 mcg/hr

 

QL (10 per 30 days)

hydrocodone-acetaminophen oral solution7.5-325 mg/15 ml

 

QL (2700 per 30 days)

hydrocodone-acetaminophen oral tablet10-325 mg, 7.5-325 mg

 

QL (180 per 30 days)

hydrocodone-acetaminophen oral tablet2.5-325 mg, 5-325 mg

 

QL (240 per 30 days)

hydrocodone-ibuprofen oral tablet 7.5-200 mg

 

QL (150 per 30 days)

hydromorphone oral liquid 1 mg/ml

(Dilaudid)

QL (1200 per 30 days)

hydromorphone oral tablet 2 mg, 4 mg, 8 mg

(Dilaudid)

QL (180 per 30 days)

LAZANDA NASAL SPRAY,NON-AEROSOL 100 MCG/SPRAY, 300 MCG/SPRAY, 400 MCG/SPRAY

 

QL (30 per 30 days)

methadone injection solution 10 mg/ml

 

QL (120 per 30 days)

methadone oral solution 10 mg/5 ml

 

QL (600 per 30 days)

methadone oral solution 5 mg/5 ml

 

QL (1200 per 30 days)

methadone oral tablet 10 mg

 

QL (120 per 30 days)

methadone oral tablet 5 mg

 

QL (180 per 30 days)

methadose oral tablet,soluble 40 mg

 

QL (30 per 30 days)

morphine concentrate oral solution 100 mg/5 ml (20 mg/ml)

 

QL (180 per 30 days)

morphine oral solution 10 mg/5 ml

 

QL (700 per 30 days)

morphine oral solution 20 mg/5 ml (4 mg/ml)

 

QL (300 per 30 days)

MORPHINE ORAL TABLET 15 MG

 

QL (180 per 30 days)

MORPHINE ORAL TABLET 30 MG

 

QL (120 per 30 days)

morphine oral tablet extended release 100 mg, 200 mg, 60 mg

(MS Contin)

QL (60 per 30 days)

morphine oral tablet extended release 15 mg, 30 mg

(MS Contin)

QL (90 per 30 days)

oxycodone oral solution 5 mg/5 ml

 

QL (1300 per 30 days)

oxycodone oral tablet 10 mg

 

QL (180 per 30 days)

oxycodone oral tablet 15 mg, 30 mg

(Roxicodone)

QL (120 per 30 days)

oxycodone oral tablet 20 mg

 

QL (120 per 30 days)

oxycodone oral tablet 5 mg

(Roxicodone)

QL (180 per 30 days)

oxycodone oral tablet,oral only,ext.rel.12 hr 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 60 mg, 80 mg

(OxyContin)

QL (60 per 30 days)

oxycodone-acetaminophen oral tablet 10-325 mg

(Endocet)

QL (180 per 30 days)

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

(Endocet)

QL (360 per 30 days)

oxycodone-acetaminophen oral tablet 7.5-325 mg

(Endocet)

QL (240 per 30 days)

oxycodone-aspirin oral tablet 4.8355-325 mg

 

QL (360 per 30 days)

OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 60 MG, 80 MG

 

QL (60 per 30 days)

tramadol oral tablet 50 mg

(Ultram)

QL (240 per 30 days)

tramadol-acetaminophen oral tablet 37.5-325 mg

(Ultracet)

QL (300 per 30 days)

XTAMPZA ER ORAL CAP,SPRINKL,ER12HR(DONT CRUSH) 13.5 MG, 18 MG, 9 MG

 

QL (60 per 30 days)

XTAMPZA ER ORAL CAP,SPRINKL,ER12HR(DONT CRUSH) 27 MG

 

QL (120 per 30 days)

XTAMPZA ER ORAL CAP,SPRINKL,ER12HR(DONT CRUSH) 36 MG

 

QL (240 per 30 days)

Nonsteroidal Anti-Inflammatory Agents

 

 

celecoxib oral capsule 100 mg, 200 mg, 50 mg

(Celebrex)

QL (60 per 30 days)

diclofenac epolamine transdermal patch 12 hour 1.3 %

(Flector)

QL (60 per 30 days)

diclofenac potassium oral tablet 50 mg

(Cataflam)

QL (120 per 30 days)

diclofenac sodium oral tablet extended release 24 hr 100 mg

 

QL (60 per 30 days)

diclofenac sodium oral tablet,delayed release (dr/ec) 25 mg

 

QL (150 per 30 days)

diclofenac sodium oral tablet,delayed release (dr/ec) 50 mg

 

QL (120 per 30 days)

diclofenac sodium oral tablet,delayed release (dr/ec) 75 mg

 

QL (60 per 30 days)

diclofenac sodium topical drops 1.5 %

 

QL (300 per 30 days)

diclofenac sodium topical gel 1 %

(Arthritis Pain (diclofenac))

QL (1000 per 30 days)

diclofenac sodium topical gel 3 %

(Solaraze)

QL (100 per 28 days)

indomethacin oral capsule 25 mg

 

QL (240 per 30 days)

indomethacin oral capsule 50 mg

 

QL (120 per 30 days)

ketorolac oral tablet 10 mg

 

QL (20 per 30 days)

PENNSAID TOPICAL SOLUTION IN METERED-DOSE PUMP 20 MG/GRAM /ACTUATION(2 %)

 

QL (224 per 28 days)

Anesthetics

 

 

Local Anesthetics

 

 

glydo mucous membrane jelly in applicator 2 %

 

QL (30 per 30 days)

lidocaine hcl mucous membrane jelly 2 %

 

QL (30 per 30 days)

lidocaine topical adhesive patch,medicated 5 %

(Lidoderm)

QL (90 per 30 days)

lidocaine topical ointment 5 %

 

QL (90 per 30 days)

lidocaine-prilocaine topical cream 2.5-2.5 %

 

QL (30 per 30 days)

ZTLIDO TOPICAL ADHESIVE PATCH,MEDICATED 1.8 %

 

QL (90 per 30 days)

Anti-Addiction/Substance Abuse Treatment Agents

 

 

Anti-Addiction/Substance Abuse Treatment Agents

 

 

buprenorphine hcl sublingual tablet 2 mg, 8 mg

 

QL (90 per 30 days)

buprenorphine-naloxone sublingual film12-3 mg, 8-2 mg

(Suboxone)

QL (60 per 30 days)

buprenorphine-naloxone sublingual film2-0.5 mg, 4-1 mg

(Suboxone)

QL (30 per 30 days)

buprenorphine-naloxone sublingual tablet2-0.5 mg, 8-2 mg

 

QL (90 per 30 days)

CHANTIX CONTINUING MONTH BOX ORAL TABLET 1 MG

 

QL (336 per 365 days)

CHANTIX ORAL TABLET 0.5 MG, 1 MG

 

QL (336 per 365 days)

KLOXXADO NASAL SPRAY,NON-AEROSOL 8 MG/ACTUATION

 

QL (4 per 30 days)

LUCEMYRA ORAL TABLET 0.18 MG

 

QL (228 per 14 days)

NARCAN NASAL SPRAY,NON-AEROSOL 4 MG/ACTUATION

 

QL (4 per 30 days)

NICOTROL INHALATION CARTRIDGE 10 MG

 

QL (1008 per 90 days)

SUBLOCADE SUBCUTANEOUS SOLUTION, EXTENDED REL SYRINGE 100 MG/0.5 ML

 

QL (0.5 per 30 days)

SUBLOCADE SUBCUTANEOUS SOLUTION, EXTENDED REL SYRINGE 300 MG/1.5 ML

 

QL (1.5 per 30 days)

Antianxiety Agents

 

 

Benzodiazepines

 

 

alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg

(Xanax)

QL (120 per 30 days)

alprazolam oral tablet 2 mg

(Xanax)

QL (150 per 30 days)

chlordiazepoxide hcl oral capsule 10 mg, 25 mg, 5 mg

 

QL (120 per 30 days)

clonazepam oral tablet 0.5 mg, 1 mg

(Klonopin)

QL (90 per 30 days)

clonazepam oral tablet 2 mg

(Klonopin)

QL (300 per 30 days)

clonazepam oral tablet,disintegrating0.125 mg, 0.25 mg, 0.5 mg, 1 mg

 

QL (90 per 30 days)

clonazepam oral tablet,disintegrating 2 mg

 

QL (300 per 30 days)

clorazepate dipotassium oral tablet 15 mg, 3.75 mg

 

QL (180 per 30 days)

clorazepate dipotassium oral tablet 7.5 mg

(Tranxene T-Tab)

QL (180 per 30 days)

diazepam injection solution 5 mg/ml

 

QL (10 per 28 days)

diazepam injection syringe 5 mg/ml

 

QL (10 per 28 days)

diazepam oral concentrate 5 mg/ml

(Diazepam Intensol)

QL (1200 per 30 days)

diazepam oral solution 5 mg/5 ml (1 mg/ml)

 

QL (1200 per 30 days)

diazepam oral tablet 10 mg, 2 mg, 5 mg

(Valium)

QL (120 per 30 days)

lorazepam injection solution 2 mg/ml, 4 mg/ml

(Ativan)

QL (2 per 30 days)

lorazepam injection syringe 2 mg/ml, 4 mg/ml

 

QL (2 per 30 days)

lorazepam oral tablet 0.5 mg, 1 mg

(Ativan)

QL (90 per 30 days)

lorazepam oral tablet 2 mg

(Ativan)

QL (150 per 30 days)

temazepam oral capsule 15 mg, 30 mg

(Restoril)

QL (30 per 30 days)

Antibacterials

 

 

Aminoglycosides

 

 

TOBI PODHALER INHALATION CAPSULE, W/INHALATION DEVICE 28 MG

 

QL (224 per 28 days)

Antibacterials, Miscellaneous

 

 

nitrofurantoin macrocrystal oral capsule100 mg, 50 mg

(Macrodantin)

QL (120 per 30 days)

nitrofurantoin macrocrystal oral capsule25 mg

(Macrodantin)

QL (120 per 30 days)

nitrofurantoin monohyd/m-cryst oral capsule 100 mg

(Macrobid)

QL (60 per 30 days)

vancomycin oral capsule 125 mg

(Vancocin)

QL (56 per 14 days)

vancomycin oral capsule 250 mg

(Vancocin)

QL (112 per 14 days)

XIFAXAN ORAL TABLET 200 MG

 

QL (9 per 30 days)

XIFAXAN ORAL TABLET 550 MG

 

QL (90 per 30 days)

Macrolides

 

 

DIFICID ORAL SUSPENSION FOR RECONSTITUTION 40 MG/ML

 

QL (136 per 10 days)

DIFICID ORAL TABLET 200 MG

 

QL (20 per 10 days)

Quinolones

 

 

BAXDELA ORAL TABLET 450 MG

 

QL (28 per 14 days)

Tetracyclines

 

 

doxycycline monohydrate oral capsule 100 mg

(Mondoxyne NL)

QL (60 per 30 days)

doxycycline monohydrate oral capsule 50 mg

(Monodox)

QL (60 per 30 days)

doxycycline monohydrate oral tablet 100 mg

(Avidoxy)

QL (60 per 30 days)

doxycycline monohydrate oral tablet 50 mg

 

QL (60 per 30 days)

mondoxyne nl oral capsule 100 mg

 

QL (60 per 30 days)

Anticancer Agents

 

 

Anticancer Agents

 

 

AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION 2 MG, 3 MG, 5 MG

 

QL (112 per 28 days)

AFINITOR ORAL TABLET 10 MG

 

QL (56 per 28 days)

ALECENSA ORAL CAPSULE 150 MG

 

QL (240 per 30 days)

ALIQOPA INTRAVENOUS RECON SOLN 60 MG

 

QL (3 per 28 days)

ALUNBRIG ORAL TABLET 180 MG, 90 MG

 

QL (30 per 30 days)

ALUNBRIG ORAL TABLET 30 MG

 

QL (120 per 30 days)

AYVAKIT ORAL TABLET 100 MG, 200 MG, 25 MG, 300 MG, 50 MG

 

QL (30 per 30 days)

BALVERSA ORAL TABLET 3 MG

 

QL (84 per 28 days)

BALVERSA ORAL TABLET 4 MG

 

QL (56 per 28 days)

BALVERSA ORAL TABLET 5 MG

 

QL (28 per 28 days)

BOSULIF ORAL TABLET 100 MG

 

QL (90 per 30 days)

BOSULIF ORAL TABLET 400 MG, 500 MG

 

QL (30 per 30 days)

BRAFTOVI ORAL CAPSULE 75 MG

 

QL (180 per 30 days)

BRUKINSA ORAL CAPSULE 80 MG

 

QL (120 per 30 days)

CABOMETYX ORAL TABLET 20 MG, 60 MG

 

QL (30 per 30 days)

CABOMETYX ORAL TABLET 40 MG

 

QL (60 per 30 days)

CALQUENCE ORAL CAPSULE 100 MG

 

QL (60 per 30 days)

CAPRELSA ORAL TABLET 100 MG

 

QL (60 per 30 days)

CAPRELSA ORAL TABLET 300 MG

 

QL (30 per 30 days)

COMETRIQ ORAL CAPSULE 100 MG/DAY(80 MG X1-20 MG X1), 140 MG/DAY(80 MG X1-20 MG X3), 60 MG/DAY (20 MG X 3/DAY)

 

QL (112 per 28 days)

COPIKTRA ORAL CAPSULE 15 MG, 25 MG

 

QL (56 per 28 days)

COTELLIC ORAL TABLET 20 MG

 

QL (63 per 28 days)

DANYELZA INTRAVENOUS SOLUTION 4 MG/ML

 

QL (120 per 28 days)

DAURISMO ORAL TABLET 100 MG

 

QL (30 per 30 days)

DAURISMO ORAL TABLET 25 MG

 

QL (60 per 30 days)

ERIVEDGE ORAL CAPSULE 150 MG

 

QL (30 per 30 days)

ERLEADA ORAL TABLET 60 MG

 

QL (120 per 30 days)

erlotinib oral tablet 100 mg, 25 mg

(Tarceva)

QL (60 per 30 days)

erlotinib oral tablet 150 mg

(Tarceva)

QL (90 per 30 days)

everolimus (antineoplastic) oral tablet 2.5 mg, 5 mg, 7.5 mg

(Afinitor)

QL (28 per 28 days)

FOTIVDA ORAL CAPSULE 0.89 MG, 1.34 MG

 

QL (21 per 28 days)

GAVRETO ORAL CAPSULE 100 MG

 

QL (120 per 30 days)

GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG

 

QL (30 per 30 days)

HERCEPTIN HYLECTA SUBCUTANEOUS SOLUTION 600 MG-10,000 UNIT/5 ML

 

QL (5 per 21 days)

IBRANCE ORAL CAPSULE 100 MG, 125 MG, 75 MG

 

QL (21 per 28 days)

IBRANCE ORAL TABLET 100 MG, 125 MG, 75 MG

 

QL (21 per 28 days)

ICLUSIG ORAL TABLET 10 MG, 15 MG, 30 MG, 45 MG

 

QL (30 per 30 days)

IDHIFA ORAL TABLET 100 MG, 50 MG

 

QL (30 per 30 days)

imatinib oral tablet 100 mg

(Gleevec)

QL (180 per 30 days)

imatinib oral tablet 400 mg

(Gleevec)

QL (60 per 30 days)

IMBRUVICA ORAL CAPSULE 140 MG

 

QL (120 per 30 days)

IMBRUVICA ORAL CAPSULE 70 MG

 

QL (28 per 28 days)

IMBRUVICA ORAL TABLET 140 MG, 280 MG, 420 MG, 560 MG

 

QL (28 per 28 days)

IMLYGIC INJECTION SUSPENSION 10EXP6 (1 MILLION) PFU/ML

 

QL (4 per 365 days)

IMLYGIC INJECTION SUSPENSION 10EXP8 (100 MILLION) PFU/ML

 

QL (8 per 28 days)

INLYTA ORAL TABLET 1 MG

 

QL (180 per 30 days)

INLYTA ORAL TABLET 5 MG

 

QL (120 per 30 days)

INQOVI ORAL TABLET 35-100 MG

 

QL (5 per 28 days)

INREBIC ORAL CAPSULE 100 MG

 

QL (120 per 30 days)

IRESSA ORAL TABLET 250 MG

 

QL (60 per 30 days)

JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 25 MG, 5 MG

 

QL (60 per 30 days)

KEYTRUDA INTRAVENOUS SOLUTION 25 MG/ML

 

QL (8 per 21 days)

KISQALI FEMARA CO-PACK ORAL TABLET 200 MG/DAY(200 MG X 1)-2.5 MG

 

QL (49 per 28 days)

KISQALI FEMARA CO-PACK ORAL TABLET 400 MG/DAY(200 MG X 2)-2.5 MG

 

QL (70 per 28 days)

KISQALI FEMARA CO-PACK ORAL TABLET 600 MG/DAY(200 MG X 3)-2.5 MG

 

QL (91 per 28 days)

KISQALI ORAL TABLET 200 MG/DAY (200 MG X 1)

 

QL (21 per 28 days)

KISQALI ORAL TABLET 400 MG/DAY (200 MG X 2)

 

QL (42 per 28 days)

KISQALI ORAL TABLET 600 MG/DAY (200 MG X 3)

 

QL (63 per 28 days)

KOSELUGO ORAL CAPSULE 10 MG

 

QL (300 per 30 days)

KOSELUGO ORAL CAPSULE 25 MG

 

QL (120 per 30 days)

LIBTAYO INTRAVENOUS SOLUTION 50 MG/ML

 

QL (7 per 21 days)

LONSURF ORAL TABLET 15-6.14 MG

 

QL (100 per 28 days)

LONSURF ORAL TABLET 20-8.19 MG

 

QL (80 per 28 days)

LORBRENA ORAL TABLET 100 MG

 

QL (30 per 30 days)

LORBRENA ORAL TABLET 25 MG

 

QL (90 per 30 days)

LUMAKRAS ORAL TABLET 120 MG

 

QL (240 per 30 days)

LYNPARZA ORAL TABLET 100 MG, 150 MG

 

QL (120 per 30 days)

MEKINIST ORAL TABLET 0.5 MG

 

QL (90 per 30 days)

MEKINIST ORAL TABLET 2 MG

 

QL (30 per 30 days)

MEKTOVI ORAL TABLET 15 MG

 

QL (180 per 30 days)

NERLYNX ORAL TABLET 40 MG

 

QL (180 per 30 days)

NEXAVAR ORAL TABLET 200 MG

 

QL (120 per 30 days)

NINLARO ORAL CAPSULE 2.3 MG, 3 MG, 4 MG

 

QL (3 per 28 days)

NUBEQA ORAL TABLET 300 MG

 

QL (120 per 30 days)

ONUREG ORAL TABLET 200 MG, 300 MG

 

QL (14 per 28 days)

PEMAZYRE ORAL TABLET 13.5 MG, 4.5 MG, 9 MG

 

QL (14 per 21 days)

PEPAXTO INTRAVENOUS RECON SOLN 20 MG

 

QL (2 per 28 days)

PHESGO SUBCUTANEOUS SOLUTION 1,200 MG-600MG- 30000 UNIT/15ML

 

QL (15 per 21 days)

PHESGO SUBCUTANEOUS SOLUTION 600 MG-600 MG- 20000 UNIT/10ML

 

QL (10 per 21 days)

PIQRAY ORAL TABLET 200 MG/DAY (200 MG X 1)

 

QL (28 per 28 days)

PIQRAY ORAL TABLET 250 MG/DAY (200 MG X1-50 MG X1), 300 MG/DAY (150 MG X 2)

 

QL (56 per 28 days)

POMALYST ORAL CAPSULE 1 MG, 2 MG, 3 MG, 4 MG

 

QL (21 per 28 days)

PORTRAZZA INTRAVENOUS SOLUTION 800 MG/50 ML (16 MG/ML)

 

QL (100 per 21 days)

QINLOCK ORAL TABLET 50 MG

 

QL (90 per 30 days)

RETEVMO ORAL CAPSULE 40 MG

 

QL (180 per 30 days)

RETEVMO ORAL CAPSULE 80 MG

 

QL (120 per 30 days)

REVLIMID ORAL CAPSULE 10 MG, 15 MG, 2.5 MG, 20 MG, 25 MG, 5 MG

 

QL (28 per 28 days)

ROZLYTREK ORAL CAPSULE 100 MG

 

QL (180 per 30 days)

ROZLYTREK ORAL CAPSULE 200 MG

 

QL (90 per 30 days)

RUBRACA ORAL TABLET 200 MG, 250 MG, 300 MG

 

QL (120 per 30 days)

RYDAPT ORAL CAPSULE 25 MG

 

QL (224 per 28 days)

SPRYCEL ORAL TABLET 100 MG, 140 MG, 50 MG, 70 MG, 80 MG

 

QL (30 per 30 days)

SPRYCEL ORAL TABLET 20 MG

 

QL (90 per 30 days)

STIVARGA ORAL TABLET 40 MG

 

QL (84 per 28 days)

SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 37.5 MG, 50 MG

 

QL (30 per 30 days)

TABRECTA ORAL TABLET 150 MG, 200 MG

 

QL (120 per 30 days)

TAFINLAR ORAL CAPSULE 50 MG, 75 MG

 

QL (120 per 30 days)

TAGRISSO ORAL TABLET 40 MG, 80 MG

 

QL (30 per 30 days)

TALZENNA ORAL CAPSULE 0.25 MG

 

QL (90 per 30 days)

TALZENNA ORAL CAPSULE 1 MG

 

QL (30 per 30 days)

TASIGNA ORAL CAPSULE 150 MG, 200 MG

 

QL (112 per 28 days)

TASIGNA ORAL CAPSULE 50 MG

 

QL (120 per 30 days)

TAZVERIK ORAL TABLET 200 MG

 

QL (240 per 30 days)

TEPMETKO ORAL TABLET 225 MG

 

QL (60 per 30 days)

TIBSOVO ORAL TABLET 250 MG

 

QL (60 per 30 days)

TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 11.25 MG

 

QL (1 per 84 days)

TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 22.5 MG

 

QL (1 per 168 days)

TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 3.75 MG

 

QL (1 per 28 days)

TUKYSA ORAL TABLET 150 MG

 

QL (120 per 30 days)

TUKYSA ORAL TABLET 50 MG

 

QL (300 per 30 days)

TURALIO ORAL CAPSULE 200 MG

 

QL (120 per 30 days)

UKONIQ ORAL TABLET 200 MG

 

QL (120 per 30 days)

VENCLEXTA ORAL TABLET 10 MG

 

PA NSO; LA; QL (60 per 30 days)

VENCLEXTA ORAL TABLET 100 MG

 

QL (180 per 30 days)

VENCLEXTA ORAL TABLET 50 MG

 

PA NSO; LA; QL (30 per 30 days)

VERZENIO ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG

 

QL (56 per 28 days)

VITRAKVI ORAL CAPSULE 100 MG

 

QL (60 per 30 days)

VITRAKVI ORAL CAPSULE 25 MG

 

QL (180 per 30 days)

VITRAKVI ORAL SOLUTION 20 MG/ML

 

QL (300 per 30 days)

VIZIMPRO ORAL TABLET 15 MG, 30 MG, 45 MG

 

QL (30 per 30 days)

VOTRIENT ORAL TABLET 200 MG

 

QL (120 per 30 days)

XALKORI ORAL CAPSULE 200 MG, 250 MG

 

QL (120 per 30 days)

XOSPATA ORAL TABLET 40 MG

 

QL (90 per 30 days)

XPOVIO ORAL TABLET 100 MG/WEEK (20 MG X 5)

 

QL (20 per 28 days)

XPOVIO ORAL TABLET 100 MG/WEEK (50 MG X 2), 40 MG/WEEK (20 MG X 2), 40MG TWICE WEEK (40 MG X 2), 80 MG/WEEK (40 MG X 2)

 

QL (8 per 28 days)

XPOVIO ORAL TABLET 40 MG/WEEK (40 MG X 1), 60 MG/WEEK (60 MG X 1)

 

QL (4 per 28 days)

XPOVIO ORAL TABLET 40MG TWICE WEEK (80 MG/WEEK), 80 MG/WEEK (20 MG X 4)

 

QL (16 per 28 days)

XPOVIO ORAL TABLET 60 MG/WEEK (20 MG X 3)

 

QL (12 per 28 days)

XPOVIO ORAL TABLET 60MG TWICE WEEK (120 MG/WEEK)

 

QL (24 per 28 days)

XPOVIO ORAL TABLET 80MG TWICE WEEK (160 MG/WEEK)

 

QL (32 per 28 days)

XTANDI ORAL CAPSULE 40 MG

 

QL (120 per 30 days)

XTANDI ORAL TABLET 40 MG

 

QL (120 per 30 days)

XTANDI ORAL TABLET 80 MG

 

QL (60 per 30 days)

YONSA ORAL TABLET 125 MG

 

QL (120 per 30 days)

ZEJULA ORAL CAPSULE 100 MG

 

QL (90 per 30 days)

ZELBORAF ORAL TABLET 240 MG

 

QL (240 per 30 days)

ZOLADEX SUBCUTANEOUS IMPLANT 10.8 MG

 

QL (1 per 84 days)

ZOLADEX SUBCUTANEOUS IMPLANT 3.6 MG

 

QL (1 per 28 days)

ZYDELIG ORAL TABLET 100 MG, 150 MG

 

QL (60 per 30 days)

ZYKADIA ORAL TABLET 150 MG

 

QL (84 per 28 days)

ZYTIGA ORAL TABLET 250 MG, 500 MG

 

QL (120 per 30 days)

Anticonvulsants

 

 

Anticonvulsants

 

 

APTIOM ORAL TABLET 200 MG, 400 MG

 

QL (30 per 30 days)

APTIOM ORAL TABLET 600 MG, 800 MG

 

QL (60 per 30 days)

BRIVIACT INTRAVENOUS SOLUTION 50 MG/5 ML

 

QL (80 per 30 days)

BRIVIACT ORAL SOLUTION 10 MG/ML

 

QL (600 per 30 days)

BRIVIACT ORAL TABLET 10 MG, 100 MG, 25 MG, 50 MG, 75 MG

 

QL (60 per 30 days)

clobazam oral suspension 2.5 mg/ml

(Onfi)

QL (480 per 30 days)

clobazam oral tablet 10 mg, 20 mg

(Onfi)

QL (60 per 30 days)

DIACOMIT ORAL CAPSULE 250 MG

 

QL (360 per 30 days)

DIACOMIT ORAL CAPSULE 500 MG

 

QL (180 per 30 days)

DIACOMIT ORAL POWDER IN PACKET 250 MG

 

QL (360 per 30 days)

DIACOMIT ORAL POWDER IN PACKET 500 MG

 

QL (180 per 30 days)

FYCOMPA ORAL SUSPENSION 0.5 MG/ML

 

QL (720 per 30 days)

FYCOMPA ORAL TABLET 10 MG, 12 MG, 8 MG

 

QL (30 per 30 days)

FYCOMPA ORAL TABLET 2 MG

 

QL (30 per 30 days)

FYCOMPA ORAL TABLET 4 MG, 6 MG

 

QL (60 per 30 days)

gabapentin oral capsule 100 mg, 300 mg

(Neurontin)

QL (360 per 30 days)

gabapentin oral capsule 400 mg

(Neurontin)

QL (270 per 30 days)

gabapentin oral solution 250 mg/5 ml

(Neurontin)

QL (2160 per 30 days)

gabapentin oral tablet 600 mg

(Neurontin)

QL (180 per 30 days)

gabapentin oral tablet 800 mg

(Neurontin)

QL (120 per 30 days)

NAYZILAM NASAL SPRAY,NON-AEROSOL 5 MG/SPRAY (0.1 ML)

 

QL (10 per 30 days)

pregabalin oral capsule 100 mg, 150 mg, 200 mg, 25 mg, 50 mg, 75 mg

(Lyrica)

QL (90 per 30 days)

pregabalin oral capsule 225 mg, 300 mg

(Lyrica)

QL (60 per 30 days)

pregabalin oral solution 20 mg/ml

(Lyrica)

QL (900 per 30 days)

SPRITAM ORAL TABLET FOR SUSPENSION 1,000 MG

 

QL (60 per 30 days)

SPRITAM ORAL TABLET FOR SUSPENSION 250 MG, 500 MG, 750 MG

 

QL (120 per 30 days)

SYMPAZAN ORAL FILM 10 MG, 20 MG

 

QL (60 per 30 days)

SYMPAZAN ORAL FILM 5 MG

 

QL (60 per 30 days)

vigabatrin oral powder in packet 500 mg

(Vigadrone)

QL (180 per 30 days)

vigabatrin oral tablet 500 mg

(Sabril)

QL (180 per 30 days)

vigadrone oral powder in packet 500 mg

 

QL (180 per 30 days)

VIMPAT INTRAVENOUS SOLUTION 200 MG/20 ML

 

QL (200 per 5 days)

VIMPAT ORAL SOLUTION 10 MG/ML

 

QL (1200 per 30 days)

VIMPAT ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG

 

QL (60 per 30 days)

XCOPRI MAINTENANCE PACK ORAL TABLET 250 MG/DAY (200 MG X1-50 MG X1), 250MG/DAY(150 MG X1-100MG X1), 350 MG/DAY (200 MG X1-150MG X1)

 

QL (56 per 28 days)

XCOPRI ORAL TABLET 100 MG, 50 MG

 

QL (30 per 30 days)

XCOPRI ORAL TABLET 150 MG, 200 MG

 

QL (60 per 30 days)

Antidementia Agents

 

 

Antidementia Agents

 

 

donepezil oral tablet 10 mg, 5 mg

(Aricept)

QL (30 per 30 days)

donepezil oral tablet,disintegrating 10 mg, 5 mg

 

QL (30 per 30 days)

galantamine oral capsule,ext rel. pellets 24 hr 16 mg, 24 mg, 8 mg

(Razadyne ER)

QL (30 per 30 days)

galantamine oral solution 4 mg/ml

 

QL (200 per 30 days)

galantamine oral tablet 12 mg, 4 mg, 8 mg

 

QL (60 per 30 days)

memantine oral capsule,sprinkle,er 24hr14 mg, 21 mg, 28 mg, 7 mg

(Namenda XR)

QL (30 per 30 days)

memantine oral solution 2 mg/ml

 

QL (300 per 30 days)

memantine oral tablet 10 mg, 5 mg

(Namenda)

QL (60 per 30 days)

NAMZARIC ORAL CAPSULE,SPRINKLE,ER 24HR 14-10 MG, 21-10 MG, 28-10 MG, 7-10 MG

 

QL (30 per 30 days)

rivastigmine tartrate oral capsule 1.5 mg, 3 mg, 4.5 mg, 6 mg

 

QL (60 per 30 days)

rivastigmine transdermal patch 24 hour13.3 mg/24 hour, 4.6 mg/24 hour, 9.5 mg/24 hour

(Exelon Patch)

QL (30 per 30 days)

Antidepressants

 

 

Antidepressants

 

 

citalopram oral solution 10 mg/5 ml

 

QL (600 per 30 days)

citalopram oral tablet 10 mg, 20 mg, 40 mg

(Celexa)

QL (30 per 30 days)

desvenlafaxine succinate oral tablet extended release 24 hr 100 mg, 25 mg, 50 mg

(Pristiq)

QL (30 per 30 days)

DRIZALMA SPRINKLE ORAL CAPSULE, DELAYED REL SPRINKLE 20 MG, 30 MG, 60 MG

 

QL (60 per 30 days)

DRIZALMA SPRINKLE ORAL CAPSULE, DELAYED REL SPRINKLE 40 MG

 

QL (30 per 30 days)

duloxetine oral capsule,delayed release(dr/ec) 20 mg, 30 mg, 60 mg

(Cymbalta)

QL (60 per 30 days)

EMSAM TRANSDERMAL PATCH 24 HOUR 12 MG/24 HR, 6 MG/24 HR, 9 MG/24 HR

 

QL (30 per 30 days)

FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR 120 MG, 20 MG, 40 MG, 80 MG

 

QL (30 per 30 days)

TRINTELLIX ORAL TABLET 10 MG, 20 MG, 5 MG

 

QL (30 per 30 days)

venlafaxine oral capsule,extended release 24hr 150 mg

(Effexor XR)

QL (30 per 30 days)

venlafaxine oral capsule,extended release 24hr 37.5 mg, 75 mg

(Effexor XR)

QL (90 per 30 days)

VIIBRYD ORAL TABLET 10 MG, 20 MG, 40 MG

 

QL (30 per 30 days)

Antidiabetic Agents

 

 

Antidiabetic Agents, Miscellaneous

 

 

acarbose oral tablet 100 mg, 25 mg, 50 mg

(Precose)

QL (90 per 30 days)

FARXIGA ORAL TABLET 10 MG, 5 MG

 

QL (30 per 30 days)

JARDIANCE ORAL TABLET 10 MG, 25 MG

 

QL (30 per 30 days)

JENTADUETO ORAL TABLET 2.5-1,000 MG, 2.5-500 MG, 2.5-850 MG

 

QL (60 per 30 days)

JENTADUETO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 2.5-1,000 MG

 

QL (60 per 30 days)

JENTADUETO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 5-1,000 MG

 

QL (30 per 30 days)

KORLYM ORAL TABLET 300 MG

 

QL (112 per 28 days)

metformin oral tablet 1,000 mg

 

QL (75 per 30 days)

metformin oral tablet 500 mg

 

QL (150 per 30 days)

metformin oral tablet 850 mg

 

QL (90 per 30 days)

metformin oral tablet extended release 24 hr 500 mg

 

QL (120 per 30 days)

metformin oral tablet extended release 24 hr 750 mg

 

QL (60 per 30 days)

OZEMPIC SUBCUTANEOUS PEN INJECTOR 0.25 MG OR 0.5 MG(2 MG/1.5 ML)

 

QL (1.5 per 28 days)

OZEMPIC SUBCUTANEOUS PEN INJECTOR 1 MG/DOSE (2 MG/1.5 ML), 1 MG/DOSE (4 MG/3 ML)

 

QL (3 per 28 days)

pioglitazone oral tablet 15 mg, 30 mg, 45 mg

(Actos)

QL (30 per 30 days)

repaglinide oral tablet 0.5 mg, 1 mg

 

QL (120 per 30 days)

repaglinide oral tablet 2 mg

 

QL (240 per 30 days)

RYBELSUS ORAL TABLET 14 MG, 3 MG, 7 MG

 

QL (30 per 30 days)

SYMLINPEN 120 SUBCUTANEOUS PEN INJECTOR 2,700 MCG/2.7 ML

 

QL (10.8 per 28 days)

SYMLINPEN 60 SUBCUTANEOUS PEN INJECTOR 1,500 MCG/1.5 ML

 

QL (10.8 per 28 days)

SYNJARDY ORAL TABLET 12.5-1,000 MG, 12.5-500 MG, 5-1,000 MG, 5-500 MG

 

QL (60 per 30 days)

SYNJARDY XR ORAL TABLET, IR - ER, BIPHASIC 24HR 10-1,000 MG, 25-1,000 MG

 

QL (30 per 30 days)

SYNJARDY XR ORAL TABLET, IR - ER, BIPHASIC 24HR 12.5-1,000 MG, 5-1,000 MG

 

QL (60 per 30 days)

TRADJENTA ORAL TABLET 5 MG

 

QL (30 per 30 days)

TRULICITY SUBCUTANEOUS PEN INJECTOR 0.75 MG/0.5 ML, 1.5 MG/0.5 ML, 3 MG/0.5 ML, 4.5 MG/0.5 ML

 

QL (2 per 28 days)

VICTOZA 3-PAK SUBCUTANEOUS PEN INJECTOR 0.6 MG/0.1 ML (18 MG/3 ML)

 

QL (9 per 30 days)

XIGDUO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 10-1,000 MG, 10-500 MG

 

QL (30 per 30 days)

XIGDUO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 2.5-1,000 MG, 5-1,000 MG, 5-500 MG

 

QL (60 per 30 days)

Insulins

 

 

FIASP FLEXTOUCH U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML)

 

QL (30 per 28 days)

FIASP PENFILL U-100 INSULIN SUBCUTANEOUS CARTRIDGE 100 UNIT/ML (3 ML)

 

QL (30 per 28 days)

FIASP U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNIT/ML

 

QL (40 per 28 days)

HUMULIN R U-500 (CONC) INSULIN SUBCUTANEOUS SOLUTION 500 UNIT/ML

 

QL (40 per 28 days)

HUMULIN R U-500 (CONC) KWIKPEN SUBCUTANEOUS INSULIN PEN 500 UNIT/ML (3 ML)

 

QL (24 per 28 days)

LANTUS SOLOSTAR U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML)

 

QL (30 per 28 days)

LANTUS U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNIT/ML

 

QL (40 per 28 days)

NOVOLIN 70/30 U-100 INSULIN SUBCUTANEOUS SUSPENSION 100 UNIT/ML (70-30)

 

QL (40 per 28 days)

NOVOLIN 70-30 FLEXPEN U-100 SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (70-30)

 

QL (30 per 28 days)

NOVOLIN N FLEXPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML)

 

QL (30 per 28 days)

NOVOLIN N NPH U-100 INSULIN SUBCUTANEOUS SUSPENSION 100 UNIT/ML

 

QL (40 per 28 days)

NOVOLIN R FLEXPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML)

 

QL (30 per 28 days)

NOVOLIN R REGULAR U-100 INSULN INJECTION SOLUTION 100 UNIT/ML

 

QL (40 per 28 days)

NOVOLOG FLEXPEN U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML)

 

QL (30 per 28 days)

NOVOLOG MIX 70-30 U-100 INSULN SUBCUTANEOUS SOLUTION 100 UNIT/ML (70-30)

 

QL (40 per 28 days)

NOVOLOG MIX 70-30FLEXPEN U-100 SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (70-30)

 

QL (30 per 28 days)

NOVOLOG PENFILL U-100 INSULIN SUBCUTANEOUS CARTRIDGE 100 UNIT/ML

 

QL (30 per 28 days)

NOVOLOG U-100 INSULIN ASPART SUBCUTANEOUS SOLUTION 100 UNIT/ML

 

QL (40 per 28 days)

SOLIQUA 100/33 SUBCUTANEOUS INSULIN PEN 100 UNIT-33 MCG/ML

 

QL (30 per 30 days)

TOUJEO MAX U-300 SOLOSTAR SUBCUTANEOUS INSULIN PEN 300 UNIT/ML (3 ML)

 

QL (18 per 28 days)

TOUJEO SOLOSTAR U-300 INSULIN SUBCUTANEOUS INSULIN PEN 300 UNIT/ML (1.5 ML)

 

QL (13.5 per 28 days)

XULTOPHY 100/3.6 SUBCUTANEOUS INSULIN PEN 100 UNIT-3.6 MG /ML (3 ML)

 

QL (15 per 28 days)

Sulfonylureas

 

 

glimepiride oral tablet 1 mg, 2 mg

(Amaryl)

QL (30 per 30 days)

glimepiride oral tablet 4 mg

(Amaryl)

QL (60 per 30 days)

glipizide oral tablet 10 mg

(Glucotrol)

QL (120 per 30 days)

glipizide oral tablet 5 mg

 

QL (60 per 30 days)

glipizide oral tablet extended release 24hr10 mg

(Glucotrol XL)

QL (60 per 30 days)

glipizide oral tablet extended release 24hr2.5 mg, 5 mg

(Glucotrol XL)

QL (30 per 30 days)

glipizide-metformin oral tablet 2.5-250 mg

 

QL (240 per 30 days)

glipizide-metformin oral tablet 2.5-500 mg, 5-500 mg

 

QL (120 per 30 days)

Antifungals

 

 

Antifungals

 

 

ciclopirox topical cream 0.77 %

(Ciclodan)

QL (180 per 30 days)

ciclopirox topical solution 8 %

(Ciclodan)

QL (19.8 per 30 days)

clotrimazole-betamethasone topical cream1-0.05 %

 

QL (90 per 30 days)

econazole topical cream 1 %

 

QL (170 per 30 days)

ketoconazole topical cream 2 %

 

QL (180 per 30 days)

ketoconazole topical shampoo 2 %

 

QL (360 per 30 days)

nyamyc topical powder 100,000 unit/gram

 

QL (60 per 30 days)

nystatin oral suspension 100,000 unit/ml

 

QL (900 per 30 days)

nystatin topical cream 100,000 unit/gram

 

QL (60 per 30 days)

nystatin topical ointment 100,000 unit/gram

 

QL (60 per 30 days)

nystatin topical powder 100,000 unit/gram

(Nyamyc)

QL (60 per 30 days)

nystop topical powder 100,000 unit/gram

 

QL (60 per 30 days)

Antigout Agents

 

 

Antigout Agents, Other

 

 

colchicine oral tablet 0.6 mg

(Colcrys)

QL (120 per 30 days)

febuxostat oral tablet 40 mg, 80 mg

(Uloric)

QL (30 per 30 days)

MITIGARE ORAL CAPSULE 0.6 MG

 

QL (60 per 30 days)

Antimigraine Agents

 

 

Antimigraine Agents

 

 

dihydroergotamine injection solution 1 mg/ml

(D.H.E.45)

QL (24 per 28 days)

dihydroergotamine nasal spray,non-aerosol 0.5 mg/pump act. (4 mg/ml)

(Migranal)

QL (8 per 28 days)

EMGALITY PEN SUBCUTANEOUS PEN INJECTOR 120 MG/ML

 

QL (2 per 30 days)

EMGALITY SYRINGE SUBCUTANEOUS SYRINGE 120 MG/ML

 

QL (2 per 30 days)

EMGALITY SYRINGE SUBCUTANEOUS SYRINGE 300 MG/3 ML (100 MG/ML X 3)

 

QL (3 per 30 days)

rizatriptan oral tablet 10 mg

(Maxalt)

QL (12 per 30 days)

rizatriptan oral tablet 5 mg

 

QL (12 per 30 days)

rizatriptan oral tablet,disintegrating 10 mg

(Maxalt-MLT)

QL (12 per 30 days)

rizatriptan oral tablet,disintegrating 5 mg

 

QL (12 per 30 days)

sumatriptan nasal spray,non-aerosol 20 mg/actuation

(Imitrex)

QL (12 per 30 days)

sumatriptan nasal spray,non-aerosol 5 mg/actuation

(Imitrex)

QL (18 per 30 days)

sumatriptan succinate oral tablet 100 mg

(Imitrex)

QL (9 per 30 days)

sumatriptan succinate oral tablet 25 mg, 50 mg

(Imitrex)

QL (18 per 30 days)

sumatriptan succinate subcutaneous cartridge 4 mg/0.5 ml

(Imitrex STATdose Refill)

QL (4 per 28 days)

sumatriptan succinate subcutaneous cartridge 6 mg/0.5 ml

(Imitrex STATdose Refill)

QL (4 per 28 days)

sumatriptan succinate subcutaneous pen injector 4 mg/0.5 ml, 6 mg/0.5 ml

(Imitrex STATdose Pen)

QL (4 per 28 days)

sumatriptan succinate subcutaneous solution 6 mg/0.5 ml

(Imitrex)

QL (4 per 28 days)

sumatriptan succinate subcutaneous syringe 6 mg/0.5 ml

 

QL (4 per 28 days)

UBRELVY ORAL TABLET 100 MG, 50 MG

 

QL (16 per 30 days)

Antimycobacterials

 

 

Antimycobacterials

 

 

PRETOMANID ORAL TABLET 200 MG

 

QL (30 per 30 days)

Antinausea Agents

 

 

Antinausea Agents

 

 

aprepitant oral capsule 125 mg

 

QL (2 per 28 days)

aprepitant oral capsule 40 mg

 

QL (1 per 28 days)

aprepitant oral capsule 80 mg

(Emend)

QL (4 per 28 days)

aprepitant oral capsule,dose pack 125 mg (1)- 80 mg (2)

(Emend)

QL (6 per 28 days)

dronabinol oral capsule 10 mg, 2.5 mg, 5 mg

(Marinol)

QL (60 per 30 days)

EMEND ORAL SUSPENSION FOR RECONSTITUTION 125 MG (25 MG/ ML FINAL CONC.)

 

QL (6 per 28 days)

fosaprepitant intravenous recon soln 150 mg

(Emend (fosaprepitant))

QL (2 per 28 days)

scopolamine base transdermal patch 3 day1 mg over 3 days

(Transderm-Scop)

QL (10 per 30 days)

Antiparasite Agents

 

 

Antiparasite Agents

 

 

chloroquine phosphate oral tablet 250 mg

 

QL (50 per 30 days)

chloroquine phosphate oral tablet 500 mg

 

QL (25 per 30 days)

hydroxychloroquine oral tablet 200 mg

(Plaquenil)

QL (90 per 30 days)

IMPAVIDO ORAL CAPSULE 50 MG

 

QL (84 per 28 days)

quinine sulfate oral capsule 324 mg

(Qualaquin)

QL (42 per 7 days)

Antiparkinsonian Agents

 

 

Antiparkinsonian Agents

 

 

APOKYN SUBCUTANEOUS CARTRIDGE 10 MG/ML

 

QL (60 per 30 days)

INBRIJA INHALATION CAPSULE, W/INHALATION DEVICE 42 MG

 

QL (300 per 30 days)

KYNMOBI SUBLINGUAL FILM 10 MG, 15 MG, 20 MG, 25 MG, 30 MG

 

QL (150 per 30 days)

NEUPRO TRANSDERMAL PATCH 24 HOUR 1 MG/24 HOUR, 2 MG/24 HOUR, 3 MG/24 HOUR, 4 MG/24 HOUR, 6 MG/24 HOUR, 8 MG/24 HOUR

 

QL (30 per 30 days)

OSMOLEX ER ORAL TABLET, IR - ER, BIPHASIC 24HR 129 MG, 193 MG, 258 MG

 

QL (30 per 30 days)

OSMOLEX ER ORAL TABLET, IR - ER, BIPHASIC 24HR 322 MG/DAY(129 MG X1-193MG X1)

 

QL (60 per 30 days)

XADAGO ORAL TABLET 100 MG

 

QL (30 per 30 days)

XADAGO ORAL TABLET 50 MG

 

QL (30 per 30 days)

Antipsychotic Agents

 

 

Antipsychotic Agents

 

 

aripiprazole oral solution 1 mg/ml

 

QL (900 per 30 days)

aripiprazole oral tablet 10 mg, 15 mg, 20 mg, 30 mg, 5 mg

(Abilify)

QL (30 per 30 days)

aripiprazole oral tablet 2 mg

(Abilify)

QL (60 per 30 days)

aripiprazole oral tablet,disintegrating 10 mg

 

QL (90 per 30 days)

aripiprazole oral tablet,disintegrating 15 mg

 

QL (60 per 30 days)

ARISTADA INITIO INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 675 MG/2.4 ML

 

QL (4.8 per 365 days)

ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 1,064 MG/3.9 ML

 

QL (3.9 per 56 days)

ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 441 MG/1.6 ML

 

QL (1.6 per 28 days)

ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 662 MG/2.4 ML

 

QL (2.4 per 28 days)

ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 882 MG/3.2 ML

 

QL (3.2 per 28 days)

asenapine maleate sublingual tablet 10 mg, 2.5 mg, 5 mg

(Saphris)

QL (60 per 30 days)

CAPLYTA ORAL CAPSULE 42 MG

 

QL (30 per 30 days)

clozapine oral tablet 100 mg

(Clozaril)

QL (270 per 30 days)

clozapine oral tablet 200 mg

(Clozaril)

QL (135 per 30 days)

clozapine oral tablet 25 mg

(Clozaril)

QL (90 per 30 days)

clozapine oral tablet 50 mg

(Clozaril)

QL (90 per 30 days)

clozapine oral tablet,disintegrating 100 mg, 12.5 mg, 25 mg

 

QL (90 per 30 days)

clozapine oral tablet,disintegrating 150 mg

 

QL (180 per 30 days)

clozapine oral tablet,disintegrating 200 mg

 

QL (120 per 30 days)

FANAPT ORAL TABLET 1 MG, 10 MG, 12 MG, 2 MG, 4 MG, 6 MG, 8 MG

 

QL (60 per 30 days)

INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 117 MG/0.75 ML

 

QL (0.75 per 28 days)

INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 156 MG/ML

 

QL (1 per 28 days)

INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 234 MG/1.5 ML

 

QL (1.5 per 28 days)

INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 39 MG/0.25 ML

 

QL (0.25 per 28 days)

INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 78 MG/0.5 ML

 

QL (0.5 per 28 days)

INVEGA TRINZA INTRAMUSCULAR SYRINGE 273 MG/0.875 ML

 

QL (0.875 per 84 days)

INVEGA TRINZA INTRAMUSCULAR SYRINGE 410 MG/1.315 ML

 

QL (1.315 per 84 days)

INVEGA TRINZA INTRAMUSCULAR SYRINGE 546 MG/1.75 ML

 

QL (1.75 per 84 days)

INVEGA TRINZA INTRAMUSCULAR SYRINGE 819 MG/2.625 ML

 

QL (2.625 per 84 days)

LATUDA ORAL TABLET 120 MG, 20 MG, 40 MG, 60 MG

 

QL (30 per 30 days)

LATUDA ORAL TABLET 80 MG

 

QL (60 per 30 days)

molindone oral tablet 10 mg

 

QL (240 per 30 days)

molindone oral tablet 25 mg

 

QL (270 per 30 days)

molindone oral tablet 5 mg

 

QL (120 per 30 days)

NUPLAZID ORAL CAPSULE 34 MG

 

QL (30 per 30 days)

NUPLAZID ORAL TABLET 10 MG

 

QL (30 per 30 days)

olanzapine intramuscular recon soln 10 mg

(Zyprexa)

QL (30 per 30 days)

olanzapine oral tablet 10 mg, 15 mg, 2.5 mg, 20 mg, 5 mg, 7.5 mg

(Zyprexa)

QL (30 per 30 days)

olanzapine oral tablet,disintegrating 10 mg, 15 mg, 20 mg, 5 mg

(Zyprexa Zydis)

QL (30 per 30 days)

paliperidone oral tablet extended release 24hr 1.5 mg, 3 mg, 9 mg

(Invega)

QL (30 per 30 days)

paliperidone oral tablet extended release 24hr 6 mg

(Invega)

QL (60 per 30 days)

PERSERIS ABDOMINAL SUBCUTANEOUS SUSPENSION,EXTENDED REL SYRING 120 MG, 90 MG

 

QL (1 per 30 days)

quetiapine oral tablet 100 mg, 200 mg, 25 mg, 50 mg

(Seroquel)

QL (90 per 30 days)

quetiapine oral tablet 300 mg, 400 mg

(Seroquel)

QL (60 per 30 days)

REXULTI ORAL TABLET 0.25 MG

 

QL (120 per 30 days)

REXULTI ORAL TABLET 0.5 MG

 

QL (60 per 30 days)

REXULTI ORAL TABLET 1 MG, 2 MG, 3 MG, 4 MG

 

QL (30 per 30 days)

RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 12.5 MG/2 ML, 25 MG/2 ML

 

QL (2 per 28 days)

RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 37.5 MG/2 ML, 50 MG/2 ML

 

QL (2 per 28 days)

risperidone oral solution 1 mg/ml

(Risperdal)

QL (480 per 30 days)

risperidone oral tablet 0.25 mg

 

QL (60 per 30 days)

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

(Risperdal)

QL (60 per 30 days)

risperidone oral tablet 4 mg

(Risperdal)

QL (120 per 30 days)

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

 

QL (60 per 30 days)

risperidone oral tablet,disintegrating 3 mg, 4 mg

 

QL (120 per 30 days)

SECUADO TRANSDERMAL PATCH 24 HOUR 3.8 MG/24 HOUR, 5.7 MG/24 HOUR, 7.6 MG/24 HOUR

 

QL (30 per 30 days)

VERSACLOZ ORAL SUSPENSION 50 MG/ML

 

QL (540 per 30 days)

VRAYLAR ORAL CAPSULE 1.5 MG, 3 MG, 4.5 MG, 6 MG

 

QL (30 per 30 days)

ziprasidone hcl oral capsule 20 mg, 40 mg, 60 mg, 80 mg

(Geodon)

QL (60 per 30 days)

ziprasidone mesylate intramuscular recon soln 20 mg/ml (final conc.)

(Geodon)

QL (6 per 28 days)

ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 210 MG

 

QL (2 per 28 days)

ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 300 MG

 

QL (2 per 28 days)

ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 405 MG

 

QL (1 per 28 days)

Antivirals (Systemic)

 

 

Antiretrovirals

 

 

KALETRA ORAL TABLET 100-25 MG

 

QL (300 per 30 days)

KALETRA ORAL TABLET 200-50 MG

 

QL (120 per 30 days)

lopinavir-ritonavir oral solution 400-100 mg/5 ml

(Kaletra)

QL (480 per 30 days)

lopinavir-ritonavir oral tablet 100-25 mg

(Kaletra)

QL (300 per 30 days)

lopinavir-ritonavir oral tablet 200-50 mg

(Kaletra)

QL (120 per 30 days)

VEMLIDY ORAL TABLET 25 MG

 

QL (30 per 30 days)

Antivirals, Miscellaneous

 

 

oseltamivir oral capsule 30 mg

(Tamiflu)

QL (84 per 180 days)

oseltamivir oral capsule 45 mg

(Tamiflu)

QL (48 per 180 days)

oseltamivir oral capsule 75 mg

(Tamiflu)

QL (42 per 180 days)

oseltamivir oral suspension for reconstitution 6 mg/ml

(Tamiflu)

QL (540 per 180 days)

PREVYMIS INTRAVENOUS SOLUTION 240 MG/12 ML

 

QL (336 per 28 days)

PREVYMIS INTRAVENOUS SOLUTION 480 MG/24 ML

 

QL (672 per 28 days)

PREVYMIS ORAL TABLET 240 MG, 480 MG

 

QL (28 per 28 days)

RELENZA DISKHALER INHALATION BLISTER WITH DEVICE 5 MG/ACTUATION

 

QL (60 per 180 days)

XOFLUZA ORAL TABLET 20 MG, 40 MG

 

QL (4 per 180 days)

XOFLUZA ORAL TABLET 80 MG

 

QL (2 per 180 days)

Hcv Antivirals

 

 

EPCLUSA ORAL TABLET 200-50 MG, 400-100 MG

 

QL (28 per 28 days)

HARVONI ORAL PELLETS IN PACKET 33.75-150 MG

 

QL (28 per 28 days)

HARVONI ORAL PELLETS IN PACKET 45-200 MG

 

QL (56 per 28 days)

HARVONI ORAL TABLET 45-200 MG, 90-400 MG

 

QL (28 per 28 days)

VOSEVI ORAL TABLET 400-100-100 MG

 

QL (28 per 28 days)

Blood Products/Modifiers/Volume Expanders

 

 

Anticoagulants

 

 

ELIQUIS ORAL TABLET 2.5 MG

 

QL (60 per 30 days)

ELIQUIS ORAL TABLET 5 MG

 

QL (74 per 30 days)

enoxaparin subcutaneous solution 300 mg/3 ml

(Lovenox)

QL (30 per 30 days)

enoxaparin subcutaneous syringe 100 mg/ml, 150 mg/ml

(Lovenox)

QL (60 per 30 days)

enoxaparin subcutaneous syringe 120 mg/0.8 ml, 80 mg/0.8 ml

(Lovenox)

QL (48 per 30 days)

enoxaparin subcutaneous syringe 30 mg/0.3 ml

(Lovenox)

QL (18 per 30 days)

enoxaparin subcutaneous syringe 40 mg/0.4 ml

(Lovenox)

QL (24 per 30 days)

enoxaparin subcutaneous syringe 60 mg/0.6 ml

(Lovenox)

QL (36 per 30 days)

fondaparinux subcutaneous syringe 10 mg/0.8 ml

(Arixtra)

QL (24 per 30 days)

fondaparinux subcutaneous syringe 2.5 mg/0.5 ml

(Arixtra)

QL (15 per 30 days)

fondaparinux subcutaneous syringe 5 mg/0.4 ml

(Arixtra)

QL (12 per 30 days)

fondaparinux subcutaneous syringe 7.5 mg/0.6 ml

(Arixtra)

QL (18 per 30 days)

XARELTO ORAL TABLET 10 MG, 20 MG

 

QL (30 per 30 days)

XARELTO ORAL TABLET 15 MG, 2.5 MG

 

QL (60 per 30 days)

Blood Formation Modifiers

 

 

CINRYZE INTRAVENOUS RECON SOLN 500 UNIT (5 ML)

 

QL (20 per 30 days)

DOPTELET (10 TAB PACK) ORAL TABLET 20 MG

 

QL (60 per 30 days)

DOPTELET (15 TAB PACK) ORAL TABLET 20 MG

 

QL (60 per 30 days)

DOPTELET (30 TAB PACK) ORAL TABLET 20 MG

 

QL (60 per 30 days)

HAEGARDA SUBCUTANEOUS RECON SOLN 2,000 UNIT

 

QL (30 per 30 days)

HAEGARDA SUBCUTANEOUS RECON SOLN 3,000 UNIT

 

QL (20 per 30 days)

MULPLETA ORAL TABLET 3 MG

 

QL (7 per 7 days)

ORLADEYO ORAL CAPSULE 110 MG, 150 MG

 

QL (30 per 30 days)

PROMACTA ORAL POWDER IN PACKET 12.5 MG

 

QL (90 per 30 days)

PROMACTA ORAL POWDER IN PACKET 25 MG

 

QL (180 per 30 days)

PROMACTA ORAL TABLET 12.5 MG

 

QL (90 per 30 days)

PROMACTA ORAL TABLET 25 MG

 

QL (30 per 30 days)

PROMACTA ORAL TABLET 50 MG, 75 MG

 

QL (60 per 30 days)

RETACRIT INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML

 

QL (12 per 28 days)

RETACRIT INJECTION SOLUTION 40,000 UNIT/ML

 

QL (4 per 28 days)

Hematologic Agents, Miscellaneous

 

 

CABLIVI INJECTION KIT 11 MG

 

QL (30 per 30 days)

TAVALISSE ORAL TABLET 100 MG, 150 MG

 

QL (60 per 30 days)

tranexamic acid oral tablet 650 mg

(Lysteda)

QL (30 per 30 days)

Platelet-Aggregation Inhibitors

 

 

aspirin-dipyridamole oral capsule, er multiphase 12 hr 25-200 mg

 

QL (60 per 30 days)

prasugrel oral tablet 10 mg, 5 mg

(Effient)

QL (30 per 30 days)

Cardiovascular Agents

 

 

Alpha-Adrenergic Agents

 

 

clonidine transdermal patch weekly 0.1 mg/24 hr

(Catapres-TTS-1)

QL (4 per 28 days)

clonidine transdermal patch weekly 0.2 mg/24 hr

(Catapres-TTS-2)

QL (4 per 28 days)

clonidine transdermal patch weekly 0.3 mg/24 hr

(Catapres-TTS-3)

QL (8 per 28 days)

droxidopa oral capsule 100 mg, 200 mg, 300 mg

(Northera)

QL (180 per 30 days)

Angiotensin Ii Receptor Antagonists

 

 

ENTRESTO ORAL TABLET 24-26 MG, 49-51 MG, 97-103 MG

 

QL (60 per 30 days)

Cardiovascular Agents, Miscellaneous

 

 

CORLANOR ORAL SOLUTION 5 MG/5 ML

 

QL (600 per 30 days)

CORLANOR ORAL TABLET 5 MG, 7.5 MG

 

QL (60 per 30 days)

epinephrine injection auto-injector 0.15 mg/0.3 ml

(EpiPen Jr)

QL (4 per 30 days)

epinephrine injection auto-injector 0.3 mg/0.3 ml

 

QL (4 per 30 days)

epinephrine injection auto-injector 0.3 mg/0.3 ml

(Auvi-Q)

QL (4 per 30 days)

icatibant subcutaneous syringe 30 mg/3 ml

(Firazyr)

QL (18 per 30 days)

ranolazine oral tablet extended release 12 hr 1,000 mg

(Ranexa)

QL (60 per 30 days)

ranolazine oral tablet extended release 12 hr 500 mg

(Ranexa)

QL (120 per 30 days)

VYNDAMAX ORAL CAPSULE 61 MG

 

QL (30 per 30 days)

VYNDAQEL ORAL CAPSULE 20 MG

 

QL (120 per 30 days)

Diuretics

 

 

JYNARQUE ORAL TABLET 15 MG, 30 MG

 

QL (120 per 30 days)

JYNARQUE ORAL TABLETS, SEQUENTIAL 15 MG (AM)/ 15 MG (PM), 30 MG (AM)/ 15 MG (PM), 45 MG (AM)/ 15 MG (PM), 60 MG (AM)/ 30 MG (PM), 90 MG (AM)/ 30 MG (PM)

 

QL (56 per 28 days)

Dyslipidemics

 

 

atorvastatin oral tablet 10 mg, 20 mg, 40 mg, 80 mg

(Lipitor)

QL (30 per 30 days)

ezetimibe oral tablet 10 mg

(Zetia)

QL (30 per 30 days)

JUXTAPID ORAL CAPSULE 10 MG, 30 MG, 40 MG, 60 MG

 

QL (30 per 30 days)

JUXTAPID ORAL CAPSULE 20 MG

 

QL (90 per 30 days)

JUXTAPID ORAL CAPSULE 5 MG

 

QL (45 per 30 days)

LIVALO ORAL TABLET 1 MG, 2 MG, 4 MG

 

QL (30 per 30 days)

NEXLETOL ORAL TABLET 180 MG

 

QL (30 per 30 days)

NEXLIZET ORAL TABLET 180-10 MG

 

QL (30 per 30 days)

omega-3 acid ethyl esters oral capsule 1 gram

(Lovaza)

QL (120 per 30 days)

PRALUENT PEN SUBCUTANEOUS PEN INJECTOR 150 MG/ML, 75 MG/ML

 

QL (2 per 28 days)

pravastatin oral tablet 20 mg, 40 mg

 

QL (30 per 30 days)

rosuvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg

(Crestor)

QL (30 per 30 days)

simvastatin oral tablet 10 mg, 20 mg, 40 mg, 80 mg

(Zocor)

QL (30 per 30 days)

simvastatin oral tablet 5 mg

 

QL (30 per 30 days)

VASCEPA ORAL CAPSULE 0.5 GRAM

 

QL (240 per 30 days)

VASCEPA ORAL CAPSULE 1 GRAM

 

QL (120 per 30 days)

Central Nervous System Agents

 

 

Central Nervous System Agents

 

 

atomoxetine oral capsule 10 mg, 18 mg, 25 mg, 40 mg

(Strattera)

QL (60 per 30 days)

atomoxetine oral capsule 100 mg, 60 mg, 80 mg

(Strattera)

QL (30 per 30 days)

AUBAGIO ORAL TABLET 14 MG, 7 MG

 

QL (30 per 30 days)

AUSTEDO ORAL TABLET 12 MG, 9 MG

 

QL (120 per 30 days)

AUSTEDO ORAL TABLET 6 MG

 

QL (60 per 30 days)

AVONEX INTRAMUSCULAR PEN INJECTOR KIT 30 MCG/0.5 ML

 

QL (1 per 28 days)

AVONEX INTRAMUSCULAR SYRINGE KIT 30 MCG/0.5 ML

 

QL (1 per 28 days)

BETASERON SUBCUTANEOUS KIT 0.3 MG

 

QL (15 per 30 days)

COPAXONE SUBCUTANEOUS SYRINGE 20 MG/ML

 

QL (30 per 30 days)

COPAXONE SUBCUTANEOUS SYRINGE 40 MG/ML

 

QL (12 per 28 days)

dalfampridine oral tablet extended release 12 hr 10 mg

(Ampyra)

QL (60 per 30 days)

dexmethylphenidate oral tablet 10 mg, 2.5 mg

(Focalin)

QL (60 per 30 days)

dexmethylphenidate oral tablet 5 mg

(Focalin)

QL (60 per 30 days)

dextroamphetamine oral tablet 10 mg

(Zenzedi)

QL (180 per 30 days)

dextroamphetamine oral tablet 5 mg

(Zenzedi)

QL (90 per 30 days)

dextroamphetamine-amphetamine oral capsule,extended release 24hr 10 mg, 15 mg, 5 mg

(Adderall XR)

QL (30 per 30 days)

dextroamphetamine-amphetamine oral capsule,extended release 24hr 20 mg, 25 mg, 30 mg

(Adderall XR)

QL (60 per 30 days)

dextroamphetamine-amphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 30 mg, 5 mg, 7.5 mg

(Adderall)

QL (60 per 30 days)

dimethyl fumarate oral capsule,delayed release(dr/ec) 120 mg

(Tecfidera)

QL (14 per 7 days)

dimethyl fumarate oral capsule,delayed release(dr/ec) 240 mg

(Tecfidera)

QL (60 per 30 days)

GILENYA ORAL CAPSULE 0.25 MG, 0.5 MG

 

QL (30 per 30 days)

glatiramer subcutaneous syringe 20 mg/ml

(Copaxone)

QL (30 per 30 days)

glatiramer subcutaneous syringe 40 mg/ml

(Copaxone)

QL (12 per 28 days)

glatopa subcutaneous syringe 20 mg/ml

 

QL (30 per 30 days)

glatopa subcutaneous syringe 40 mg/ml

 

QL (12 per 28 days)

guanfacine oral tablet extended release 24 hr 1 mg, 2 mg, 3 mg, 4 mg

(Intuniv ER)

QL (30 per 30 days)

KESIMPTA PEN SUBCUTANEOUS PEN INJECTOR 20 MG/0.4 ML

 

QL (1.2 per 28 days)

MAYZENT ORAL TABLET 0.25 MG

 

QL (112 per 28 days)

MAYZENT ORAL TABLET 2 MG

 

QL (30 per 30 days)

methylphenidate hcl oral capsule, er biphasic 30-70 10 mg, 20 mg, 40 mg, 50 mg, 60 mg

 

QL (30 per 30 days)

methylphenidate hcl oral capsule, er biphasic 30-70 30 mg

 

QL (60 per 30 days)

methylphenidate hcl oral capsule,er biphasic 50-50 10 mg, 20 mg, 40 mg

(Ritalin LA)

QL (30 per 30 days)

methylphenidate hcl oral capsule,er biphasic 50-50 30 mg

(Ritalin LA)

QL (60 per 30 days)

methylphenidate hcl oral capsule,er biphasic 50-50 60 mg

 

QL (30 per 30 days)

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

(Methylin)

QL (900 per 30 days)

methylphenidate hcl oral tablet 10 mg, 20 mg, 5 mg

(Ritalin)

QL (90 per 30 days)

PLEGRIDY SUBCUTANEOUS PEN INJECTOR 125 MCG/0.5 ML

 

QL (1 per 28 days)

PLEGRIDY SUBCUTANEOUS SYRINGE 125 MCG/0.5 ML

 

QL (1 per 28 days)

RADICAVA INTRAVENOUS SOLUTION 30 MG/100 ML

 

QL (2800 per 28 days)

riluzole oral tablet 50 mg

(Rilutek)

QL (60 per 30 days)

SAVELLA ORAL TABLET 100 MG, 12.5 MG, 25 MG, 50 MG

 

QL (60 per 30 days)

tetrabenazine oral tablet 12.5 mg, 25 mg

(Xenazine)

QL (112 per 28 days)

VUMERITY ORAL CAPSULE,DELAYED RELEASE(DR/EC) 231 MG

 

QL (120 per 30 days)

Contraceptives

 

 

Contraceptives

 

 

amethia oral tablets,dose pack,3 month0.15 mg-30 mcg (84)/10 mcg (7)

 

QL (91 per 84 days)

ashlyna oral tablets,dose pack,3 month0.15 mg-30 mcg (84)/10 mcg (7)

 

QL (91 per 84 days)

daysee oral tablets,dose pack,3 month0.15 mg-30 mcg (84)/10 mcg (7)

 

QL (91 per 84 days)

ELLA ORAL TABLET 30 MG

 

QL (6 per 365 days)

eluryng vaginal ring 0.12-0.015 mg/24 hr

 

QL (1 per 28 days)

etonogestrel-ethinyl estradiol vaginal ring0.12-0.015 mg/24 hr

(EluRyng)

QL (1 per 28 days)

iclevia oral tablets,dose pack,3 month 0.15 mg-30 mcg (91)

 

QL (91 per 84 days)

introvale oral tablets,dose pack,3 month0.15 mg-30 mcg (91)

 

QL (91 per 84 days)

jaimiess oral tablets,dose pack,3 month0.15 mg-30 mcg (84)/10 mcg (7)

 

QL (91 per 84 days)

l norgest/e.estradiol-e.estrad oral tablets,dose pack,3 month 0.10 mg-20 mcg (84)/10 mcg (7)

(LoJaimiess)

QL (91 per 84 days)

l norgest/e.estradiol-e.estrad oral tablets,dose pack,3 month 0.15 mg-30 mcg (84)/10 mcg (7)

(Amethia)

QL (91 per 84 days)

levonorgestrel-ethinyl estrad oral tablets,dose pack,3 month 0.15 mg-30 mcg (91)

(Iclevia)

QL (91 per 84 days)

lojaimiess oral tablets,dose pack,3 month0.10 mg-20 mcg (84)/10 mcg (7)

 

QL (91 per 84 days)

setlakin oral tablets,dose pack,3 month0.15 mg-30 mcg (91)

 

QL (91 per 84 days)

simpesse oral tablets,dose pack,3 month0.15 mg-30 mcg (84)/10 mcg (7)

 

QL (91 per 84 days)

xulane transdermal patch weekly 150-35 mcg/24 hr

 

QL (3 per 28 days)

zafemy transdermal patch weekly 150-35 mcg/24 hr

 

QL (3 per 28 days)

Dental And Oral Agents

 

 

Dermatological Agents

 

 

Dermatological Agents, Other

 

 

acyclovir topical ointment 5 %

(Zovirax)

QL (30 per 30 days)

calcipotriene scalp solution 0.005 %

 

QL (120 per 30 days)

calcipotriene topical cream 0.005 %

(Dovonex)

QL (120 per 30 days)

imiquimod topical cream in packet 5 %

(Aldara)

QL (24 per 30 days)

PANRETIN TOPICAL GEL 0.1 %

 

QL (180 per 30 days)

SANTYL TOPICAL OINTMENT 250 UNIT/GRAM

 

QL (180 per 30 days)

Dermatological Antibacterials

 

 

clindamycin phosphate topical solution 1 %

(Cleocin T)

QL (180 per 30 days)

erythromycin with ethanol topical gel 2 %

(Erygel)

QL (180 per 30 days)

erythromycin with ethanol topical solution2 %

 

QL (180 per 30 days)

gentamicin topical cream 0.1 %

 

QL (120 per 30 days)

gentamicin topical ointment 0.1 %

 

QL (120 per 30 days)

mupirocin topical ointment 2 %

(Centany)

QL (220 per 30 days)

Dermatological Anti-Inflammatory Agents

 

 

desoximetasone topical cream 0.25 %

(Topicort)

QL (120 per 30 days)

pimecrolimus topical cream 1 %

(Elidel)

QL (100 per 30 days)

tacrolimus topical ointment 0.03 %, 0.1 %

(Protopic)

QL (100 per 30 days)

Enzyme Replacement/Modifiers

 

 

Enzyme Replacement/Modifiers

 

 

GALAFOLD ORAL CAPSULE 123 MG

 

QL (14 per 28 days)

miglustat oral capsule 100 mg

(Zavesca)

QL (90 per 30 days)

Eye, Ear, Nose, Throat Agents

 

 

Eye, Ear, Nose, Throat Agents, Miscellaneous

 

 

azelastine nasal aerosol,spray 137 mcg (0.1 %)

 

QL (30 per 25 days)

CYSTARAN OPHTHALMIC (EYE) DROPS 0.44 %

 

QL (60 per 28 days)

ipratropium bromide nasal spray,non-aerosol 21 mcg (0.03 %)

 

QL (30 per 28 days)

ipratropium bromide nasal spray,non-aerosol 42 mcg (0.06 %)

 

QL (15 per 10 days)

Eye, Ear, Nose, Throat Anti-Infectives Agents

 

 

ciprofloxacin-dexamethasone otic (ear) drops,suspension 0.3-0.1 %

(Ciprodex)

QL (7.5 per 7 days)

erythromycin ophthalmic (eye) ointment 5 mg/gram (0.5 %)

 

QL (3.5 per 4 days)

Eye, Ear, Nose, Throat Anti-Inflammatory Agents

 

 

EYSUVIS OPHTHALMIC (EYE) DROPS,SUSPENSION 0.25 %

 

QL (8.3 per 14 days)

flunisolide nasal spray,non-aerosol 25 mcg (0.025 %)

 

QL (50 per 25 days)

fluticasone propionate nasal spray,suspension 50 mcg/actuation

(24 Hour Allergy Relief)

QL (16 per 30 days)

ketorolac ophthalmic (eye) drops 0.5 %

(Acular)

QL (10 per 25 days)

mometasone nasal spray,non-aerosol 50 mcg/actuation

(Nasonex)

QL (34 per 30 days)

RESTASIS OPHTHALMIC (EYE) DROPPERETTE 0.05 %

 

QL (60 per 30 days)

XHANCE NASAL AEROSOL BREATH ACTIVATED 93 MCG/ACTUATION

 

QL (32 per 30 days)

Gastrointestinal Agents

 

 

Antiulcer Agents And Acid Suppressants

 

 

esomeprazole magnesium oral capsule,delayed release(dr/ec) 20 mg

(Nexium)

QL (30 per 30 days)

esomeprazole magnesium oral capsule,delayed release(dr/ec) 40 mg

(Nexium)

QL (60 per 30 days)

lansoprazole oral capsule,delayed release(dr/ec) 15 mg

(Prevacid 24Hr)

QL (30 per 30 days)

lansoprazole oral capsule,delayed release(dr/ec) 30 mg

(Prevacid)

QL (60 per 30 days)

omeprazole-sodium bicarbonate oral capsule 20-1.1 mg-gram, 40-1.1 mg-gram

(Zegerid)

QL (30 per 30 days)

pantoprazole oral tablet,delayed release (dr/ec) 20 mg

(Protonix)

QL (30 per 30 days)

pantoprazole oral tablet,delayed release (dr/ec) 40 mg

(Protonix)

QL (60 per 30 days)

rabeprazole oral tablet,delayed release (dr/ec) 20 mg

(AcipHex)

QL (30 per 30 days)

Gastrointestinal Agents, Other

 

 

LINZESS ORAL CAPSULE 145 MCG, 290 MCG, 72 MCG

 

QL (30 per 30 days)

LOKELMA ORAL POWDER IN PACKET 10 GRAM

 

QL (34 per 30 days)

LOKELMA ORAL POWDER IN PACKET 5 GRAM

 

QL (30 per 30 days)

lubiprostone oral capsule 24 mcg, 8 mcg

(Amitiza)

QL (60 per 30 days)

MOVANTIK ORAL TABLET 12.5 MG, 25 MG

 

QL (30 per 30 days)

OCALIVA ORAL TABLET 10 MG, 5 MG

 

QL (30 per 30 days)

XERMELO ORAL TABLET 250 MG

 

QL (90 per 30 days)

Genitourinary Agents

 

 

Genitourinary Agents, Miscellaneous

 

 

alfuzosin oral tablet extended release 24 hr 10 mg

(Uroxatral)

QL (30 per 30 days)

Heavy Metal Antagonists

 

 

Heavy Metal Antagonists

 

 

clovique oral capsule 250 mg

 

QL (240 per 30 days)

trientine oral capsule 250 mg

(Clovique)

QL (240 per 30 days)

Hormonal Agents, Stimulant/Replacement/Modifying

 

 

Androgens

 

 

testosterone enanthate intramuscular oil200 mg/ml

 

QL (5 per 28 days)

testosterone transdermal gel in metered-dose pump 12.5 mg/ 1.25 gram (1 %)

(Vogelxo)

QL (300 per 30 days)

testosterone transdermal gel in metered-dose pump 20.25 mg/1.25 gram (1.62 %)

(AndroGel)

QL (150 per 30 days)

testosterone transdermal gel in packet 1 % (25 mg/2.5gram), 1 % (50 mg/5 gram)

(AndroGel)

QL (300 per 30 days)

testosterone transdermal solution in metered pump w/app 30 mg/actuation (1.5 ml)

 

QL (180 per 30 days)

XYOSTED SUBCUTANEOUS AUTO-INJECTOR 100 MG/0.5 ML, 50 MG/0.5 ML, 75 MG/0.5 ML

 

QL (2 per 28 days)

Estrogens And Antiestrogens

 

 

dotti transdermal patch semiweekly 0.025 mg/24 hr, 0.0375 mg/24 hr, 0.05 mg/24 hr, 0.075 mg/24 hr, 0.1 mg/24 hr

 

QL (8 per 28 days)

estradiol transdermal patch semiweekly0.025 mg/24 hr, 0.0375 mg/24 hr, 0.05 mg/24 hr, 0.075 mg/24 hr, 0.1 mg/24 hr

(Dotti)

QL (8 per 28 days)

estradiol transdermal patch weekly 0.025 mg/24 hr, 0.0375 mg/24 hr, 0.05 mg/24 hr, 0.06 mg/24 hr, 0.075 mg/24 hr, 0.1 mg/24 hr

(Climara)

QL (4 per 28 days)

estradiol vaginal tablet 10 mcg

(Yuvafem)

QL (18 per 28 days)

FEMRING VAGINAL RING 0.05 MG/24 HR, 0.1 MG/24 HR

 

QL (1 per 84 days)

lyllana transdermal patch semiweekly0.025 mg/24 hr, 0.0375 mg/24 hr, 0.05 mg/24 hr, 0.075 mg/24 hr, 0.1 mg/24 hr

 

QL (8 per 28 days)

yuvafem vaginal tablet 10 mcg

 

QL (18 per 28 days)

Glucocorticoids/Mineralocorticoids

 

 

EMFLAZA ORAL SUSPENSION 22.75 MG/ML

 

QL (91 per 28 days)

EMFLAZA ORAL TABLET 18 MG

 

QL (30 per 30 days)

EMFLAZA ORAL TABLET 30 MG, 36 MG, 6 MG

 

QL (60 per 30 days)

Pituitary

 

 

EGRIFTA SUBCUTANEOUS RECON SOLN 2 MG

 

QL (30 per 30 days)

EGRIFTA SV SUBCUTANEOUS RECON SOLN 2 MG

 

QL (30 per 30 days)

ORILISSA ORAL TABLET 150 MG

 

QL (28 per 28 days)

ORILISSA ORAL TABLET 200 MG

 

QL (56 per 28 days)

SIGNIFOR SUBCUTANEOUS SOLUTION 0.3 MG/ML (1 ML), 0.6 MG/ML (1 ML), 0.9 MG/ML (1 ML)

 

QL (60 per 30 days)

SOMATULINE DEPOT SUBCUTANEOUS SYRINGE 120 MG/0.5 ML

 

QL (0.5 per 28 days)

SOMATULINE DEPOT SUBCUTANEOUS SYRINGE 60 MG/0.2 ML

 

QL (0.2 per 28 days)

SOMATULINE DEPOT SUBCUTANEOUS SYRINGE 90 MG/0.3 ML

 

QL (0.3 per 28 days)

SUPPRELIN LA IMPLANT KIT 50 MG (65 MCG/DAY)

 

QL (1 per 360 days)

TRIPTODUR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 22.5 MG

 

QL (1 per 168 days)

Progestins

 

 

medroxyprogesterone intramuscular suspension 150 mg/ml

(Depo-Provera)

QL (1 per 84 days)

medroxyprogesterone intramuscular syringe 150 mg/ml

(Depo-Provera)

QL (1 per 84 days)

Immunological Agents

 

 

Immunological Agents

 

 

BENLYSTA SUBCUTANEOUS AUTO-INJECTOR 200 MG/ML

 

QL (8 per 28 days)

BENLYSTA SUBCUTANEOUS SYRINGE 200 MG/ML

 

QL (8 per 28 days)

Vaccines

 

 

GARDASIL 9 (PF) INTRAMUSCULAR SUSPENSION 0.5 ML

 

QL (1.5 per 365 days)

GARDASIL 9 (PF) INTRAMUSCULAR SYRINGE 0.5 ML

 

QL (1.5 per 365 days)

SHINGRIX (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 50 MCG/0.5 ML

 

QL (2 per 365 days)

VARIVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 1,350 UNIT/0.5 ML

 

QL (2 per 365 days)

ZOSTAVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 19,400 UNIT/0.65 ML

 

QL (1 per 365 days)

Metabolic Bone Disease Agents

 

 

Metabolic Bone Disease Agents

 

 

alendronate oral tablet 10 mg, 5 mg

 

QL (30 per 30 days)

alendronate oral tablet 35 mg

 

QL (4 per 28 days)

alendronate oral tablet 70 mg

(Fosamax)

QL (4 per 28 days)

calcitonin (salmon) nasal spray,non-aerosol 200 unit/actuation

 

QL (3.7 per 28 days)

cinacalcet oral tablet 30 mg

(Sensipar)

QL (60 per 30 days)

cinacalcet oral tablet 60 mg

(Sensipar)

QL (60 per 30 days)

cinacalcet oral tablet 90 mg

(Sensipar)

QL (120 per 30 days)

EVENITY SUBCUTANEOUS SYRINGE 105 MG/1.17 ML, 210MG/2.34ML ( 105MG/1.17MLX2)

 

QL (2.34 per 30 days)

ibandronate intravenous solution 3 mg/3 ml

 

QL (3 per 84 days)

ibandronate intravenous syringe 3 mg/3 ml

 

QL (3 per 84 days)

ibandronate oral tablet 150 mg

(Boniva)

QL (1 per 28 days)

NATPARA SUBCUTANEOUS CARTRIDGE 100 MCG/DOSE, 25 MCG/DOSE, 50 MCG/DOSE, 75 MCG/DOSE

 

QL (2 per 28 days)

PROLIA SUBCUTANEOUS SYRINGE 60 MG/ML

 

QL (1 per 180 days)

RAYALDEE ORAL CAPSULE,EXTENDED RELEASE 24 HR 30 MCG

 

QL (60 per 30 days)

risedronate oral tablet 150 mg

(Actonel)

QL (1 per 28 days)

risedronate oral tablet 30 mg, 5 mg

 

QL (30 per 30 days)

risedronate oral tablet 35 mg

(Actonel)

QL (4 per 28 days)

risedronate oral tablet 35 mg (12 pack), 35 mg (4 pack)

 

QL (4 per 28 days)

risedronate oral tablet,delayed release (dr/ec) 35 mg

(Atelvia)

QL (4 per 28 days)

TYMLOS SUBCUTANEOUS PEN INJECTOR 80 MCG (3,120 MCG/1.56 ML)

 

QL (1.56 per 30 days)

zoledronic acid-mannitol-water intravenous piggyback 5 mg/100 ml

(Reclast)

QL (100 per 300 days)

Miscellaneous Therapeutic Agents

 

 

Miscellaneous Therapeutic Agents

 

 

ELMIRON ORAL CAPSULE 100 MG

 

QL (90 per 30 days)

ENDARI ORAL POWDER IN PACKET 5 GRAM

 

QL (180 per 30 days)

KEVEYIS ORAL TABLET 50 MG

 

QL (120 per 30 days)

RECTIV RECTAL OINTMENT 0.4 % (W/W)

 

QL (30 per 30 days)

TAKHZYRO SUBCUTANEOUS SOLUTION 300 MG/2 ML (150 MG/ML)

 

QL (4 per 28 days)

THALOMID ORAL CAPSULE 100 MG, 150 MG, 200 MG, 50 MG

 

QL (60 per 30 days)

TYBOST ORAL TABLET 150 MG

 

QL (30 per 30 days)

VISTOGARD ORAL GRANULES IN PACKET 10 GRAM

 

QL (24 per 14 days)

XURIDEN ORAL GRANULES IN PACKET 2 GRAM

 

QL (120 per 30 days)

Ophthalmic Agents

 

 

Antiglaucoma Agents

 

 

latanoprost ophthalmic (eye) drops 0.005 %

(Xalatan)

QL (2.5 per 25 days)

LUMIGAN OPHTHALMIC (EYE) DROPS 0.01 %

 

QL (2.5 per 25 days)

RHOPRESSA OPHTHALMIC (EYE) DROPS 0.02 %

 

QL (2.5 per 25 days)

ROCKLATAN OPHTHALMIC (EYE) DROPS 0.02-0.005 %

 

QL (2.5 per 25 days)

travoprost ophthalmic (eye) drops 0.004 %

(Travatan Z)

QL (2.5 per 25 days)

Respiratory Tract Agents

 

 

Anti-Inflammatories, Inhaled Corticosteroids

 

 

ADVAIR DISKUS INHALATION BLISTER WITH DEVICE 100-50 MCG/DOSE, 250-50 MCG/DOSE, 500-50 MCG/DOSE

 

QL (60 per 30 days)

ADVAIR HFA INHALATION HFA AEROSOL INHALER 115-21 MCG/ACTUATION, 230-21 MCG/ACTUATION, 45-21 MCG/ACTUATION

 

QL (12 per 30 days)

ARNUITY ELLIPTA INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 200 MCG/ACTUATION, 50 MCG/ACTUATION

 

QL (30 per 30 days)

BREO ELLIPTA INHALATION BLISTER WITH DEVICE 100-25 MCG/DOSE, 200-25 MCG/DOSE

 

QL (60 per 30 days)

budesonide inhalation suspension for nebulization 0.25 mg/2 ml, 0.5 mg/2 ml

(Pulmicort)

QL (120 per 30 days)

budesonide inhalation suspension for nebulization 1 mg/2 ml

(Pulmicort)

QL (60 per 30 days)

FLOVENT 100 MCG DISKUS 100 MCG/ACTUATION

 

QL (60 per 30 days)

FLOVENT 250 MCG DISKUS 250 MCG/ACTUATION

 

QL (120 per 30 days)

FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 50 MCG/ACTUATION

 

QL (60 per 30 days)

FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 250 MCG/ACTUATION

 

QL (120 per 30 days)

FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCG/ACTUATION

 

QL (12 per 30 days)

FLOVENT HFA INHALATION HFA AEROSOL INHALER 220 MCG/ACTUATION

 

QL (24 per 30 days)

FLOVENT HFA INHALATION HFA AEROSOL INHALER 44 MCG/ACTUATION

 

QL (21.2 per 30 days)

SYMBICORT INHALATION HFA AEROSOL INHALER 160-4.5 MCG/ACTUATION, 80-4.5 MCG/ACTUATION

 

QL (30.6 per 30 days)

Bronchodilators

 

 

albuterol 5 mg/ml solution 5 mg/ml

 

QL (120 per 30 days)

albuterol sulfate inhalation hfa aerosol inhaler 90 mcg/actuation

(ProAir HFA)

QL (17 per 30 days)

albuterol sulfate inhalation hfa aerosol inhaler 90 mcg/actuation (nda020503)

 

QL (13.4 per 30 days)

albuterol sulfate inhalation hfa aerosol inhaler 90 mcg/actuation (nda020983)

 

QL (36 per 30 days)

albuterol sulfate inhalation solution for nebulization 0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 mg /3 ml (0.083 %)

 

QL (360 per 30 days)

albuterol sulfate inhalation solution for nebulization 2.5 mg/0.5 ml

 

QL (120 per 30 days)

ANORO ELLIPTA INHALATION BLISTER WITH DEVICE 62.5-25 MCG/ACTUATION

 

QL (60 per 30 days)

ATROVENT HFA INHALATION HFA AEROSOL INHALER 17 MCG/ACTUATION

 

QL (25.8 per 28 days)

BREZTRI AEROSPHERE INHALATION HFA AEROSOL INHALER 160-9-4.8 MCG/ACTUATION

 

QL (10.7 per 30 days)

COMBIVENT RESPIMAT INHALATION MIST 20-100 MCG/ACTUATION

 

QL (8 per 30 days)

ipratropium bromide inhalation solution0.02 %

 

QL (312.5 per 30 days)

ipratropium-albuterol inhalation solution for nebulization 0.5 mg-3 mg(2.5 mg base)/3 ml

 

QL (540 per 30 days)

SEREVENT DISKUS INHALATION BLISTER WITH DEVICE 50 MCG/DOSE

 

QL (60 per 30 days)

SPIRIVA RESPIMAT INHALATION MIST 1.25 MCG/ACTUATION, 2.5 MCG/ACTUATION

 

QL (4 per 30 days)

SPIRIVA WITH HANDIHALER INHALATION CAPSULE, W/INHALATION DEVICE 18 MCG

 

QL (30 per 30 days)

STIOLTO RESPIMAT INHALATION MIST 2.5-2.5 MCG/ACTUATION

 

QL (4 per 30 days)

TRELEGY ELLIPTA INHALATION BLISTER WITH DEVICE 100-62.5-25 MCG, 200-62.5-25 MCG

 

QL (60 per 30 days)

Respiratory Tract Agents, Other

 

 

BRONCHITOL INHALATION CAPSULE, W/INHALATION DEVICE 40 MG

 

QL (560 per 28 days)

DALIRESP ORAL TABLET 250 MCG

 

QL (28 per 28 days)

DALIRESP ORAL TABLET 500 MCG

 

QL (30 per 30 days)

ESBRIET ORAL CAPSULE 267 MG

 

QL (270 per 30 days)

ESBRIET ORAL TABLET 267 MG

 

QL (270 per 30 days)

ESBRIET ORAL TABLET 801 MG

 

QL (90 per 30 days)

FASENRA PEN SUBCUTANEOUS AUTO-INJECTOR 30 MG/ML

 

QL (1 per 28 days)

FASENRA SUBCUTANEOUS SYRINGE 30 MG/ML

 

QL (1 per 28 days)

KALYDECO ORAL GRANULES IN PACKET 25 MG, 50 MG, 75 MG

 

QL (56 per 28 days)

KALYDECO ORAL TABLET 150 MG

 

QL (56 per 28 days)

NUCALA SUBCUTANEOUS AUTO-INJECTOR 100 MG/ML

 

QL (3 per 28 days)

NUCALA SUBCUTANEOUS RECON SOLN 100 MG

 

QL (3 per 28 days)

NUCALA SUBCUTANEOUS SYRINGE 100 MG/ML

 

QL (3 per 28 days)

OFEV ORAL CAPSULE 100 MG, 150 MG

 

QL (60 per 30 days)

ORKAMBI ORAL GRANULES IN PACKET 100-125 MG, 150-188 MG

 

QL (56 per 28 days)

ORKAMBI ORAL TABLET 100-125 MG, 200-125 MG

 

QL (120 per 30 days)

SYMDEKO ORAL TABLETS, SEQUENTIAL 100-150 MG (D)/ 150 MG (N), 50-75 MG (D)/ 75 MG (N)

 

QL (56 per 28 days)

TRIKAFTA ORAL TABLETS, SEQUENTIAL 100-50-75 MG(D) /150 MG (N), 50-25-37.5 MG (D)/75 MG (N)

 

QL (84 per 28 days)

Skeletal Muscle Relaxants

 

 

Skeletal Muscle Relaxants

 

 

chlorzoxazone oral tablet 250 mg

 

QL (120 per 30 days)

Sleep Disorder Agents

 

 

Sleep Disorder Agents

 

 

armodafinil oral tablet 150 mg, 200 mg, 250 mg, 50 mg

(Nuvigil)

QL (30 per 30 days)

BELSOMRA ORAL TABLET 10 MG, 15 MG, 20 MG, 5 MG

 

QL (30 per 30 days)

eszopiclone oral tablet 1 mg, 2 mg, 3 mg

(Lunesta)

QL (30 per 30 days)

HETLIOZ LQ ORAL SUSPENSION 4 MG/ML

 

QL (150 per 30 days)

HETLIOZ ORAL CAPSULE 20 MG

 

QL (30 per 30 days)

SUNOSI ORAL TABLET 150 MG, 75 MG

 

QL (30 per 30 days)

XYREM ORAL SOLUTION 500 MG/ML

 

QL (540 per 30 days)

zaleplon oral capsule 10 mg, 5 mg

 

QL (30 per 30 days)

zolpidem oral tablet 10 mg, 5 mg

(Ambien)

QL (30 per 30 days)

Vasodilating Agents

 

 

Vasodilating Agents

 

 

ADEMPAS ORAL TABLET 0.5 MG, 1 MG, 1.5 MG, 2 MG, 2.5 MG

 

QL (90 per 30 days)

alyq oral tablet 20 mg

 

QL (60 per 30 days)

ambrisentan oral tablet 10 mg, 5 mg

(Letairis)

QL (30 per 30 days)

OPSUMIT ORAL TABLET 10 MG

 

QL (30 per 30 days)

sildenafil (pulm.hypertension) intravenous solution 10 mg/12.5 ml

(Revatio)

QL (37.5 per 1 day)

sildenafil (pulm.hypertension) oral tablet20 mg

(Revatio)

QL (90 per 30 days)

tadalafil (pulm. hypertension) oral tablet20 mg

(Alyq)

QL (60 per 30 days)

TRACLEER ORAL TABLET 125 MG, 62.5 MG

 

QL (60 per 30 days)

TRACLEER ORAL TABLET FOR SUSPENSION 32 MG

 

QL (112 per 28 days)

UPTRAVI ORAL TABLET 1,000 MCG, 1,200 MCG, 1,400 MCG, 1,600 MCG, 400 MCG, 600 MCG, 800 MCG

 

QL (60 per 30 days)

UPTRAVI ORAL TABLET 200 MCG

 

QL (240 per 30 days)

CMS Material ID: H7746_MDwiseWebsite
Updated: 11/23/2021 12:51:21 PM