|
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)
|