[["N","G","CELECOXIB CAP 100MG","CELECOXIB CAP 100 MG","1","0","0","0","","","ANALGESICS","COX-2 INHIBITORS"],["N","G","CELECOXIB CAP 200MG","CELECOXIB CAP 200 MG","1","0","0","0","","","ANALGESICS","COX-2 INHIBITORS"],["N","G","CELECOXIB CAP 400MG","CELECOXIB CAP 400 MG","1","0","0","0","","","ANALGESICS","COX-2 INHIBITORS"],["N","G","CELECOXIB CAP 50MG","CELECOXIB CAP 50 MG","1","0","0","0","","","ANALGESICS","COX-2 INHIBITORS"],["N","G","ALLOPURINOL INJ 500MG","ALLOPURINOL SODIUM FOR INJ 500 MG","1","0","0","0","","","ANALGESICS","GOUT"],["N","G","ALLOPURINOL TAB 100MG","ALLOPURINOL TAB 100 MG","1","0","0","0","","","ANALGESICS","GOUT"],["N","G","ALLOPURINOL TAB 300MG","ALLOPURINOL TAB 300 MG","1","0","0","0","","","ANALGESICS","GOUT"],["N","G","COLCHICINE TAB 0.6MG","COLCHICINE TAB 0.6 MG","1","0","0","0","","","ANALGESICS","GOUT"],["N","G","FEBUXOSTAT TAB 40MG","FEBUXOSTAT TAB 40 MG","1","0","1","0","","PA**","ANALGESICS","GOUT"],["N","G","FEBUXOSTAT TAB 80MG","FEBUXOSTAT TAB 80 MG","1","0","1","0","","PA**","ANALGESICS","GOUT"],["N","G","PROBEN/COLCH TAB 500-0.5","COLCHICINE W/ PROBENECID TAB 0.5-500 MG","1","0","0","0","","","ANALGESICS","GOUT"],["N","G","PROBENECID TAB 500MG","PROBENECID TAB 500 MG","1","0","0","0","","","ANALGESICS","GOUT"],["N","G","ULORIC TAB 40MG","FEBUXOSTAT TAB 40 MG","3","0","1","0","","PA**","ANALGESICS","GOUT"],["N","G","ULORIC TAB 80MG","FEBUXOSTAT TAB 80 MG","3","0","1","0","","PA**","ANALGESICS","GOUT"],["N","G","BUT/APAP/CAF CAP","BUTALBITAL-ACETAMINOPHEN-CAFFEINE CAP 50-300-40 MG","1","0","0","1","48 caps every 25 days","","ANALGESICS","NON-OPIOID ANALGESICS§"],["N","G","BUT/APAP/CAF CAP","BUTALBITAL-ACETAMINOPHEN-CAFFEINE CAP 50-325-40 MG","1","0","0","1","48 caps every 25 days","","ANALGESICS","NON-OPIOID ANALGESICS§"],["N","G","BUT/APAP/CAF TAB","BUTALBITAL-ACETAMINOPHEN-CAFFEINE TAB 50-325-40 MG","1","0","0","1","48 tabs every 25 days","","ANALGESICS","NON-OPIOID ANALGESICS§"],["N","G","BUT/ASA/CAFF CAP","BUTALBITAL-ASPIRIN-CAFFEINE CAP 50-325-40 MG","1","0","0","1","48 caps every 25 days","","ANALGESICS","NON-OPIOID ANALGESICS§"],["N","G","TENCON TAB 50-325MG","BUTALBITAL-ACETAMINOPHEN TAB 50-325 MG","1","0","0","1","48 tabs every 25 days","","ANALGESICS","NON-OPIOID ANALGESICS§"],["N","G","DICLO/MISOPR TAB 50-0.2MG","DICLOFENAC W/ MISOPROSTOL TAB DELAYED RELEASE 50-0.2 MG","1","0","0","0","","","ANALGESICS","NSAIDS, COMBINATIONS§"],["N","G","DICLO/MISOPR TAB 75-0.2MG","DICLOFENAC W/ MISOPROSTOL TAB DELAYED RELEASE 75-0.2 MG","1","0","0","0","","","ANALGESICS","NSAIDS, COMBINATIONS§"],["N","G","DICLOFEN POT TAB 50MG","DICLOFENAC POTASSIUM TAB 50 MG","1","0","0","0","","","ANALGESICS","NSAIDS§"],["N","G","DICLOFENAC TAB 100MG ER","DICLOFENAC SODIUM TAB ER 24HR 100 MG","1","0","0","0","","","ANALGESICS","NSAIDS§"],["N","G","DICLOFENAC TAB 25MG DR","DICLOFENAC SODIUM TAB DELAYED RELEASE 25 MG","1","0","0","0","","","ANALGESICS","NSAIDS§"],["N","G","DICLOFENAC TAB 50MG DR","DICLOFENAC SODIUM TAB DELAYED RELEASE 50 MG","1","0","0","0","","","ANALGESICS","NSAIDS§"],["N","G","DICLOFENAC TAB 75MG DR","DICLOFENAC SODIUM TAB DELAYED RELEASE 75 MG","1","0","0","0","","","ANALGESICS","NSAIDS§"],["N","G","ETODOLAC CAP 200MG","ETODOLAC CAP 200 MG","1","0","0","0","","","ANALGESICS","NSAIDS§"],["N","G","ETODOLAC CAP 300MG","ETODOLAC CAP 300 MG","1","0","0","0","","","ANALGESICS","NSAIDS§"],["N","G","ETODOLAC ER TAB 400MG","ETODOLAC TAB ER 24HR 400 MG","1","0","0","0","","","ANALGESICS","NSAIDS§"],["N","G","ETODOLAC ER TAB 500MG","ETODOLAC TAB ER 24HR 500 MG","1","0","0","0","","","ANALGESICS","NSAIDS§"],["N","G","ETODOLAC ER TAB 600MG","ETODOLAC TAB ER 24HR 600 MG","1","0","0","0","","","ANALGESICS","NSAIDS§"],["N","G","ETODOLAC TAB 400MG","ETODOLAC TAB 400 MG","1","0","0","0","","","ANALGESICS","NSAIDS§"],["N","G","ETODOLAC TAB 500MG","ETODOLAC TAB 500 MG","1","0","0","0","","","ANALGESICS","NSAIDS§"],["N","G","FENOPROFEN CAP 400MG","FENOPROFEN CALCIUM CAP 400 MG","1","0","0","0","","","ANALGESICS","NSAIDS§"],["N","G","FENOPROFEN TAB 600MG","FENOPROFEN CALCIUM TAB 600 MG","1","0","0","0","","","ANALGESICS","NSAIDS§"],["N","G","FLURBIPROFEN TAB 100MG","FLURBIPROFEN TAB 100 MG","1","0","0","0","","","ANALGESICS","NSAIDS§"],["N","G","FLURBIPROFEN TAB 50MG","FLURBIPROFEN TAB 50 MG","1","0","0","0","","","ANALGESICS","NSAIDS§"],["N","G","IBUPROFEN SUS 100/5ML","IBUPROFEN SUSP 100 MG/5ML","1","0","0","0","","","ANALGESICS","NSAIDS§"],["N","G","IBUPROFEN TAB 400MG","IBUPROFEN TAB 400 MG","1","0","0","0","","","ANALGESICS","NSAIDS§"],["N","G","IBUPROFEN TAB 600MG","IBUPROFEN TAB 600 MG","1","0","0","0","","","ANALGESICS","NSAIDS§"],["N","G","IBUPROFEN TAB 800MG","IBUPROFEN TAB 800 MG","1","0","0","0","","","ANALGESICS","NSAIDS§"],["N","G","KETOPROFEN CAP 200MG ER","KETOPROFEN CAP ER 24HR 200 MG","1","0","0","0","","","ANALGESICS","NSAIDS§"],["N","G","KETOROLAC INJ 15MG/ML","KETOROLAC TROMETHAMINE INJ 15 MG/ML","1","0","0","0","","","ANALGESICS","NSAIDS§"],["N","G","KETOROLAC INJ 30MG/ML","KETOROLAC TROMETHAMINE INJ 30 MG/ML","1","0","0","0","","","ANALGESICS","NSAIDS§"],["N","G","KETOROLAC INJ 30MG/ML","KETOROLAC TROMETHAMINE INJ 30 MG/ML","1","0","0","0","","","ANALGESICS","NSAIDS§"],["N","G","KETOROLAC INJ 60MG/2ML","KETOROLAC TROMETHAMINE IM INJ 60 MG/2ML (30 MG/ML)","1","0","0","0","","","ANALGESICS","NSAIDS§"],["N","G","KETOROLAC INJ 60MG/2ML","KETOROLAC TROMETHAMINE IM INJ 60 MG/2ML (30 MG/ML)","1","0","0","0","","","ANALGESICS","NSAIDS§"],["N","G","KETOROLAC TAB 10MG","KETOROLAC TROMETHAMINE TAB 10 MG","1","0","0","1","20 tabs every 25 days","","ANALGESICS","NSAIDS§"],["N","G","MECLOFEN SOD CAP 100MG","MECLOFENAMATE SODIUM CAP 100 MG","1","0","0","0","","","ANALGESICS","NSAIDS§"],["N","G","MECLOFEN SOD CAP 50MG","MECLOFENAMATE SODIUM CAP 50 MG","1","0","0","0","","","ANALGESICS","NSAIDS§"],["N","G","MEFENAM ACID CAP 250MG","MEFENAMIC ACID CAP 250 MG","1","0","0","0","","","ANALGESICS","NSAIDS§"],["N","G","MELOXICAM TAB 15MG","MELOXICAM TAB 15 MG","1","0","0","0","","","ANALGESICS","NSAIDS§"],["N","G","MELOXICAM TAB 7.5MG","MELOXICAM TAB 7.5 MG","1","0","0","0","","","ANALGESICS","NSAIDS§"],["N","G","NABUMETONE TAB 500MG","NABUMETONE TAB 500 MG","1","0","0","0","","","ANALGESICS","NSAIDS§"],["N","G","NABUMETONE TAB 750MG","NABUMETONE TAB 750 MG","1","0","0","0","","","ANALGESICS","NSAIDS§"],["N","G","NAPROXEN DR TAB 375MG","NAPROXEN TAB EC 375 MG","1","0","0","0","","","ANALGESICS","NSAIDS§"],["N","G","NAPROXEN DR TAB 500MG","NAPROXEN TAB EC 500 MG","1","0","0","0","","","ANALGESICS","NSAIDS§"],["N","G","NAPROXEN TAB 250MG","NAPROXEN TAB 250 MG","1","0","0","0","","","ANALGESICS","NSAIDS§"],["N","G","NAPROXEN TAB 375MG","NAPROXEN TAB 375 MG","1","0","0","0","","","ANALGESICS","NSAIDS§"],["N","G","NAPROXEN TAB 500MG","NAPROXEN TAB 500 MG","1","0","0","0","","","ANALGESICS","NSAIDS§"],["N","G","OXAPROZIN TAB 600MG","OXAPROZIN TAB 600 MG","1","0","0","0","","","ANALGESICS","NSAIDS§"],["N","G","PIROXICAM CAP 10MG","PIROXICAM CAP 10 MG","1","0","0","0","","","ANALGESICS","NSAIDS§"],["N","G","PIROXICAM CAP 20MG","PIROXICAM CAP 20 MG","1","0","0","0","","","ANALGESICS","NSAIDS§"],["N","G","SULINDAC TAB 150MG","SULINDAC TAB 150 MG","1","0","0","0","","","ANALGESICS","NSAIDS§"],["N","G","SULINDAC TAB 200MG","SULINDAC TAB 200 MG","1","0","0","0","","","ANALGESICS","NSAIDS§"],["N","G","TOLMETIN SOD CAP 400MG","TOLMETIN SODIUM CAP 400 MG","1","0","0","0","","","ANALGESICS","NSAIDS§"],["N","G","TOLMETIN SOD TAB 200MG","TOLMETIN SODIUM TAB 200 MG","1","0","0","0","","","ANALGESICS","NSAIDS§"],["N","G","TOLMETIN SOD TAB 600MG","TOLMETIN SODIUM TAB 600 MG","1","0","0","0","","","ANALGESICS","NSAIDS§"],["N","G","BUPREN/NALOX MIS 12-3MG","BUPRENORPHINE HCL-NALOXONE HCL SL FILM 12-3 MG (BASE EQUIV)","1","0","0","1","60 units every 25 days","","ANALGESICS","OPIOID AGONIST/ANTAGONIST§"],["N","G","BUPREN/NALOX MIS 2-0.5MG","BUPRENORPHINE HCL-NALOXONE HCL SL FILM 2-0.5 MG (BASE EQUIV)","1","0","0","1","90 units every 25 days","","ANALGESICS","OPIOID AGONIST/ANTAGONIST§"],["N","G","BUPREN/NALOX MIS 4-1MG","BUPRENORPHINE HCL-NALOXONE HCL SL FILM 4-1 MG (BASE EQUIV)","1","0","0","1","90 units every 25 days","","ANALGESICS","OPIOID AGONIST/ANTAGONIST§"],["N","G","BUPREN/NALOX MIS 8-2MG","BUPRENORPHINE HCL-NALOXONE HCL SL FILM 8-2 MG (BASE EQUIV)","1","0","0","1","90 units every 25 days","","ANALGESICS","OPIOID AGONIST/ANTAGONIST§"],["N","G","BUPREN/NALOX SUB 2-0.5MG","BUPRENORPHINE HCL-NALOXONE HCL SL TAB 2-0.5 MG (BASE EQUIV)","0","0","0","1","90 tabs every 25 days","$0 copay","ANALGESICS","OPIOID AGONIST/ANTAGONIST§"],["N","G","BUPREN/NALOX SUB 8-2MG","BUPRENORPHINE HCL-NALOXONE HCL SL TAB 8-2 MG (BASE EQUIV)","0","0","0","1","90 tabs every 25 days","$0 copay","ANALGESICS","OPIOID AGONIST/ANTAGONIST§"],["N","G","ZUBSOLV SUB 0.7-0.18","BUPRENORPHINE HCL-NALOXONE HCL SL TAB 0.7-0.18 MG (BASE EQ)","2","0","0","1","90 units every 25 days","","ANALGESICS","OPIOID AGONIST/ANTAGONIST§"],["N","G","ZUBSOLV SUB 1.4-0.36","BUPRENORPHINE HCL-NALOXONE HCL SL TAB 1.4-0.36 MG (BASE EQ)","2","0","0","1","90 units every 25 days","","ANALGESICS","OPIOID AGONIST/ANTAGONIST§"],["N","G","ZUBSOLV SUB 11.4-2.9","BUPRENORPHINE HCL-NALOXONE HCL SL TAB 11.4-2.9 MG (BASE EQ)","2","0","0","1","30 units every 25 days","","ANALGESICS","OPIOID AGONIST/ANTAGONIST§"],["N","G","ZUBSOLV SUB 2.9-0.71","BUPRENORPHINE HCL-NALOXONE HCL SL TAB 2.9-0.71 MG (BASE EQ)","2","0","0","1","90 units every 25 days","","ANALGESICS","OPIOID AGONIST/ANTAGONIST§"],["N","G","ZUBSOLV SUB 5.7-1.4","BUPRENORPHINE HCL-NALOXONE HCL SL TAB 5.7-1.4 MG (BASE EQ)","2","0","0","1","90 units every 25 days","","ANALGESICS","OPIOID AGONIST/ANTAGONIST§"],["N","G","ZUBSOLV SUB 8.6-2.1","BUPRENORPHINE HCL-NALOXONE HCL SL TAB 8.6-2.1 MG (BASE EQ)","2","0","0","1","60 units every 25 days","","ANALGESICS","OPIOID AGONIST/ANTAGONIST§"],["N","G","APAP/CODEINE SOL 120-12/5","ACETAMINOPHEN W/ CODEINE SOLN 120-12 MG/5ML","1","0","1","1","2700 ml every 25 days","Subject to initial 7-day limit","ANALGESICS","OPIOID ANALGESICS§"],["N","G","APAP/CODEINE TAB 300-15MG","ACETAMINOPHEN W/ CODEINE TAB 300-15 MG","1","0","1","1","400 tabs every 25 days","Subject to initial 7-day limit","ANALGESICS","OPIOID ANALGESICS§"],["N","G","APAP/CODEINE TAB 300-30MG","ACETAMINOPHEN W/ CODEINE TAB 300-30 MG","1","0","1","1","360 tabs every 25 days","Subject to initial 7-day limit","ANALGESICS","OPIOID ANALGESICS§"],["N","G","APAP/CODEINE TAB 300-60MG","ACETAMINOPHEN W/ CODEINE TAB 300-60 MG","1","0","1","1","180 tabs every 25 days","Subject to initial 7-day limit","ANALGESICS","OPIOID ANALGESICS§"],["N","G","BUT/APAP/CAF CAP CODEINE","BUTALBITAL-ACETAMINOPHEN-CAFF W/ COD CAP 50-300-40-30 MG","1","0","0","1","48 caps every 25 days","","ANALGESICS","OPIOID ANALGESICS§"],["N","G","BUTORPHANOL SOL 10MG/ML","BUTORPHANOL TARTRATE NASAL SOLN 10 MG/ML","1","0","0","1","2 bottles every 25 days","","ANALGESICS","OPIOID ANALGESICS§"],["N","G","CAPITAL/COD SUS 120-12/5","ACETAMINOPHEN W/ CODEINE SUSP 120-12 MG/5ML","3","0","1","1","2700 ml every 25 days","Subject to initial 7-day limit","ANALGESICS","OPIOID ANALGESICS§"],["N","G","CODEINE SULF TAB 15MG","CODEINE SULFATE TAB 15 MG","1","0","1","1","42 tabs every 25 days","Subject to initial 7-day limit","ANALGESICS","OPIOID ANALGESICS§"],["N","G","CODEINE SULF TAB 30MG","CODEINE SULFATE TAB 30 MG","1","0","1","1","42 tabs every 25 days","Subject to initial 7-day limit","ANALGESICS","OPIOID ANALGESICS§"],["N","G","CODEINE SULF TAB 60MG","CODEINE SULFATE TAB 60 MG","1","0","1","1","42 tabs every 25 days","Subject to initial 7-day limit","ANALGESICS","OPIOID ANALGESICS§"],["N","G","EMBEDA CAP 100-4MG","MORPHINE-NALTREXONE CAP ER 100-4 MG","2","1","1","0","","High Strength Requires PA","ANALGESICS","OPIOID ANALGESICS§"],["N","G","EMBEDA CAP 20-0.8MG","MORPHINE-NALTREXONE CAP ER 20-0.8 MG","2","0","1","1","60 caps every 25 days","","ANALGESICS","OPIOID ANALGESICS§"],["N","G","EMBEDA CAP 30-1.2MG","MORPHINE-NALTREXONE CAP ER 30-1.2 MG","2","0","1","1","60 caps every 25 days","","ANALGESICS","OPIOID ANALGESICS§"],["N","G","EMBEDA CAP 50-2MG","MORPHINE-NALTREXONE CAP ER 50-2 MG","2","0","1","1","30 caps every 25 days","","ANALGESICS","OPIOID ANALGESICS§"],["N","G","EMBEDA CAP 60-2.4MG","MORPHINE-NALTREXONE CAP ER 60-2.4 MG","2","0","1","1","30 caps every 25 days","","ANALGESICS","OPIOID ANALGESICS§"],["N","G","EMBEDA CAP 80-3.2MG","MORPHINE-NALTREXONE CAP ER 80-3.2 MG","2","0","1","1","30 caps every 25 days","","ANALGESICS","OPIOID ANALGESICS§"],["N","G","ENDOCET TAB 10-325MG","OXYCODONE W/ ACETAMINOPHEN TAB 10-325 MG","1","0","1","1","180 tabs every 25 days","Subject to initial 7-day limit","ANALGESICS","OPIOID ANALGESICS§"],["N","G","ENDOCET TAB 2.5-325","OXYCODONE W/ ACETAMINOPHEN TAB 2.5-325 MG","1","0","1","1","360 tabs every 25 days","Subject to initial 7-day limit","ANALGESICS","OPIOID ANALGESICS§"],["N","G","ENDOCET TAB 5-325MG","OXYCODONE W/ ACETAMINOPHEN TAB 5-325 MG","1","0","1","1","360 tabs every 25 days","Subject to initial 7-day limit","ANALGESICS","OPIOID ANALGESICS§"],["N","G","ENDOCET TAB 7.5-325","OXYCODONE W/ ACETAMINOPHEN TAB 7.5-325 MG","1","0","1","1","240 tabs every 25 days","Subject to initial 7-day limit","ANALGESICS","OPIOID ANALGESICS§"],["N","G","FENTANYL DIS 100MCG/H","FENTANYL TD PATCH 72HR 100 MCG/HR","1","1","1","0","","High Strength Requires PA","ANALGESICS","OPIOID ANALGESICS§"],["N","G","FENTANYL DIS 12MCG/HR","FENTANYL TD PATCH 72HR 12 MCG/HR","1","0","1","1","10 patches every 25 days","","ANALGESICS","OPIOID ANALGESICS§"],["N","G","FENTANYL DIS 25MCG/HR","FENTANYL TD PATCH 72HR 25 MCG/HR","1","0","1","1","10 patches every 25 days","","ANALGESICS","OPIOID ANALGESICS§"],["N","G","FENTANYL DIS 50MCG/HR","FENTANYL TD PATCH 72HR 50 MCG/HR","1","1","1","0","","High Strength Requires PA","ANALGESICS","OPIOID ANALGESICS§"],["N","G","FENTANYL DIS 75MCG/HR","FENTANYL TD PATCH 72HR 75 MCG/HR","1","1","1","0","","High Strength Requires PA","ANALGESICS","OPIOID ANALGESICS§"],["N","G","FENTANYL OT LOZ 1200MCG","FENTANYL CITRATE LOZENGE ON A HANDLE 1200 MCG","1","1","0","1","120 lozenges every 25 days","","ANALGESICS","OPIOID ANALGESICS§"],["N","G","FENTANYL OT LOZ 1600MCG","FENTANYL CITRATE LOZENGE ON A HANDLE 1600 MCG","1","1","0","1","120 lozenges every 25 days","","ANALGESICS","OPIOID ANALGESICS§"],["N","G","FENTANYL OT LOZ 200MCG","FENTANYL CITRATE LOZENGE ON A HANDLE 200 MCG","1","1","0","1","120 lozenges every 25 days","","ANALGESICS","OPIOID ANALGESICS§"],["N","G","FENTANYL OT LOZ 400MCG","FENTANYL CITRATE LOZENGE ON A HANDLE 400 MCG","1","1","0","1","120 lozenges every 25 days","","ANALGESICS","OPIOID ANALGESICS§"],["N","G","FENTANYL OT LOZ 600MCG","FENTANYL CITRATE LOZENGE ON A HANDLE 600 MCG","1","1","0","1","120 lozenges every 25 days","","ANALGESICS","OPIOID ANALGESICS§"],["N","G","FENTANYL OT LOZ 800MCG","FENTANYL CITRATE LOZENGE ON A HANDLE 800 MCG","1","1","0","1","120 lozenges every 25 days","","ANALGESICS","OPIOID ANALGESICS§"],["N","G","HYDROCO/APAP SOL 7.5-325","HYDROCODONE-ACETAMINOPHEN SOLN 7.5-325 MG/15ML","1","0","1","1","2700 ml every 25 days","Subject to initial 7-day limit","ANALGESICS","OPIOID ANALGESICS§"],["N","G","HYDROCO/APAP TAB 10-325MG","HYDROCODONE-ACETAMINOPHEN TAB 10-325 MG","1","0","1","1","180 tabs every 25 days","Subject to initial 7-day limit","ANALGESICS","OPIOID ANALGESICS§"],["N","G","HYDROCO/APAP TAB 5-325MG","HYDROCODONE-ACETAMINOPHEN TAB 5-325 MG","1","0","1","1","240 tabs every 25 days","Subject to initial 7-day limit","ANALGESICS","OPIOID ANALGESICS§"],["N","G","HYDROCO/APAP TAB 7.5-325","HYDROCODONE-ACETAMINOPHEN TAB 7.5-325 MG","1","0","1","1","180 tabs every 25 days","Subject to initial 7-day limit","ANALGESICS","OPIOID ANALGESICS§"],["N","G","HYDROCOD/IBU TAB 10-200MG","HYDROCODONE-IBUPROFEN TAB 10-200 MG","1","0","1","1","50 tabs every 25 days","Subject to initial 7-day limit","ANALGESICS","OPIOID ANALGESICS§"],["N","G","HYDROMORPHON LIQ 1MG/ML","HYDROMORPHONE HCL LIQD 1 MG/ML","1","0","1","1","600 ml every 25 days","Subject to initial 7-day limit","ANALGESICS","OPIOID ANALGESICS§"],["N","G","HYDROMORPHON SUP 3MG","HYDROMORPHONE HCL SUPPOS 3 MG","3","0","1","1","120 suppositories every 25 days","Subject to initial 7-day limit","ANALGESICS","OPIOID ANALGESICS§"],["N","G","HYDROMORPHON TAB 12MG ER","HYDROMORPHONE HCL TAB ER 24HR DETER 12 MG","1","0","1","1","30 tabs every 25 days","","ANALGESICS","OPIOID ANALGESICS§"],["N","G","HYDROMORPHON TAB 16MG ER","HYDROMORPHONE HCL TAB ER 24HR DETER 16 MG","1","0","1","1","30 tabs every 25 days","","ANALGESICS","OPIOID ANALGESICS§"],["N","G","HYDROMORPHON TAB 2MG","HYDROMORPHONE HCL TAB 2 MG","1","0","1","1","180 tabs every 25 days","Subject to initial 7-day limit","ANALGESICS","OPIOID ANALGESICS§"],["N","G","HYDROMORPHON TAB 32MG ER","HYDROMORPHONE HCL TAB ER 24HR DETER 32 MG","1","1","1","0","","High Strength Requires PA","ANALGESICS","OPIOID ANALGESICS§"],["N","G","HYDROMORPHON TAB 4MG","HYDROMORPHONE HCL TAB 4 MG","1","0","1","1","150 tabs every 25 days","Subject to initial 7-day limit","ANALGESICS","OPIOID ANALGESICS§"],["N","G","HYDROMORPHON TAB 8MG","HYDROMORPHONE HCL TAB 8 MG","1","0","1","1","60 tabs every 25 days","Subject to initial 7-day limit","ANALGESICS","OPIOID ANALGESICS§"],["N","G","HYDROMORPHON TAB 8MG ER","HYDROMORPHONE HCL TAB ER 24HR DETER 8 MG","1","0","1","1","30 tabs every 25 days","","ANALGESICS","OPIOID ANALGESICS§"],["N","G","HYSINGLA ER TAB 100 MG","HYDROCODONE BITARTRATE TAB ER 24HR DETER 100 MG","2","1","1","0","","High Strength Requires PA","ANALGESICS","OPIOID ANALGESICS§"],["N","G","HYSINGLA ER TAB 120 MG","HYDROCODONE BITARTRATE TAB ER 24HR DETER 120 MG","2","1","1","0","","High Strength Requires PA","ANALGESICS","OPIOID ANALGESICS§"],["N","G","HYSINGLA ER TAB 20 MG","HYDROCODONE BITARTRATE TAB ER 24HR DETER 20 MG","2","0","1","1","30 tabs every 25 days","","ANALGESICS","OPIOID ANALGESICS§"],["N","G","HYSINGLA ER TAB 30 MG","HYDROCODONE BITARTRATE TAB ER 24HR DETER 30 MG","2","0","1","1","30 tabs every 25 days","","ANALGESICS","OPIOID ANALGESICS§"],["N","G","HYSINGLA ER TAB 40 MG","HYDROCODONE BITARTRATE TAB ER 24HR DETER 40 MG","2","0","1","1","30 tabs every 25 days","","ANALGESICS","OPIOID ANALGESICS§"],["N","G","HYSINGLA ER TAB 60 MG","HYDROCODONE BITARTRATE TAB ER 24HR DETER 60 MG","2","0","1","1","30 tabs every 25 days","","ANALGESICS","OPIOID ANALGESICS§"],["N","G","HYSINGLA ER TAB 80 MG","HYDROCODONE BITARTRATE TAB ER 24HR DETER 80 MG","2","0","1","1","30 tabs every 25 days","","ANALGESICS","OPIOID ANALGESICS§"],["N","G","LORTAB TAB 10-325MG","HYDROCODONE-ACETAMINOPHEN TAB 10-325 MG","1","0","1","1","180 tabs every 25 days","Subject to initial 7-day limit","ANALGESICS","OPIOID ANALGESICS§"],["N","G","METHADONE CON 10MG/ML","METHADONE HCL CONC 10 MG/ML","1","0","0","1","30 ml every 25 days","(indicated for opioid addiction)","ANALGESICS","OPIOID ANALGESICS§"],["N","G","METHADONE CON 10MG/ML","METHADONE HCL CONC 10 MG/ML","1","0","1","1","60 mL every 25 days","(generic of Methadone Intensol, indicated for pain)","ANALGESICS","OPIOID ANALGESICS§"],["N","G","METHADONE INJ 10MG/ML","METHADONE HCL INJ 10 MG/ML","1","0","1","1","20 ml every 25 days","","ANALGESICS","OPIOID ANALGESICS§"],["N","G","METHADONE SOL 10MG/5ML","METHADONE HCL SOLN 10 MG/5ML","1","0","1","1","300 mL every 25 days","","ANALGESICS","OPIOID ANALGESICS§"],["N","G","METHADONE SOL 5MG/5ML","METHADONE HCL SOLN 5 MG/5ML","1","0","1","1","450 ml every 25 days","","ANALGESICS","OPIOID ANALGESICS§"],["N","G","METHADONE TAB 10MG","METHADONE HCL TAB 10 MG","1","0","1","1","60 tabs every 25 days","","ANALGESICS","OPIOID ANALGESICS§"],["N","G","METHADONE TAB 40MG","METHADONE HCL TAB FOR ORAL SUSP 40 MG","1","0","0","1","9 tabs every 25 days","","ANALGESICS","OPIOID ANALGESICS§"],["N","G","METHADONE TAB 5MG","METHADONE HCL TAB 5 MG","1","0","1","1","90 tabs every 25 days","","ANALGESICS","OPIOID ANALGESICS§"],["N","G","METHADOSE TAB 40MG","METHADONE HCL TAB FOR ORAL SUSP 40 MG","1","0","0","1","9 tabs every 25 days","","ANALGESICS","OPIOID ANALGESICS§"],["N","G","MORPHINE SUL CAP 100MG ER","MORPHINE SULFATE CAP ER 24HR 100 MG","1","1","1","0","","High Strength Requires PA","ANALGESICS","OPIOID ANALGESICS§"],["N","G","MORPHINE SUL CAP 10MG ER","MORPHINE SULFATE CAP ER 24HR 10 MG","1","0","1","1","60 caps every 25 days","","ANALGESICS","OPIOID ANALGESICS§"],["N","G","MORPHINE SUL CAP 120MG ER","MORPHINE SULFATE BEADS CAP ER 24HR 120 MG","1","1","1","0","","High Strength Requires PA","ANALGESICS","OPIOID ANALGESICS§"],["N","G","MORPHINE SUL CAP 20MG ER","MORPHINE SULFATE CAP ER 24HR 20 MG","1","0","1","1","60 caps every 25 days","","ANALGESICS","OPIOID ANALGESICS§"],["N","G","MORPHINE SUL CAP 30MG ER","MORPHINE SULFATE BEADS CAP ER 24HR 30 MG","1","0","1","1","30 caps every 25 days","","ANALGESICS","OPIOID ANALGESICS§"],["N","G","MORPHINE SUL CAP 30MG ER","MORPHINE SULFATE CAP ER 24HR 30 MG","1","0","1","1","60 caps every 25 days","","ANALGESICS","OPIOID ANALGESICS§"],["N","G","MORPHINE SUL CAP 45MG ER","MORPHINE SULFATE BEADS CAP ER 24HR 45 MG","1","0","1","1","30 caps every 25 days","","ANALGESICS","OPIOID ANALGESICS§"],["N","G","MORPHINE SUL CAP 50MG ER","MORPHINE SULFATE CAP ER 24HR 50 MG","1","0","1","1","30 caps every 25 days","","ANALGESICS","OPIOID ANALGESICS§"],["N","G","MORPHINE SUL CAP 60MG ER","MORPHINE SULFATE BEADS CAP ER 24HR 60 MG","1","0","1","1","30 caps every 25 days","","ANALGESICS","OPIOID ANALGESICS§"],["N","G","MORPHINE SUL CAP 60MG ER","MORPHINE SULFATE CAP ER 24HR 60 MG","1","0","1","1","30 caps every 25 days","","ANALGESICS","OPIOID ANALGESICS§"],["N","G","MORPHINE SUL CAP 75MG ER","MORPHINE SULFATE BEADS CAP ER 24HR 75 MG","1","0","1","1","30 caps every 25 days","","ANALGESICS","OPIOID ANALGESICS§"],["N","G","MORPHINE SUL CAP 80MG ER","MORPHINE SULFATE CAP ER 24HR 80 MG","1","0","1","1","30 caps every 25 days","","ANALGESICS","OPIOID ANALGESICS§"],["N","G","MORPHINE SUL CAP 90MG ER","MORPHINE SULFATE BEADS CAP ER 24HR 90 MG","1","0","1","1","30 caps every 25 days","","ANALGESICS","OPIOID ANALGESICS§"],["N","G","MORPHINE SUL INJ 0.5MG/ML","MORPHINE SULFATE INJ PF 0.5 MG/ML","1","0","0","0","","","ANALGESICS","OPIOID ANALGESICS§"],["N","G","MORPHINE SUL INJ 10MG/ML","MORPHINE SULFATE IV SOLN PF 10 MG/ML","1","0","0","0","","","ANALGESICS","OPIOID ANALGESICS§"],["N","G","MORPHINE SUL INJ 10MG/ML","MORPHINE SULFATE INJ 10 MG/ML","1","0","0","0","","","ANALGESICS","OPIOID ANALGESICS§"],["N","G","MORPHINE SUL INJ 150/30ML","MORPHINE SULFATE IV SOLN 5 MG/ML","3","0","0","0","","","ANALGESICS","OPIOID ANALGESICS§"],["N","G","MORPHINE SUL INJ 15MG/ML","MORPHINE SULFATE IV SOLN PF 15 MG/ML","1","0","0","0","","","ANALGESICS","OPIOID ANALGESICS§"],["N","G","MORPHINE SUL INJ 1MG/ML","MORPHINE SULFATE INJ PF 1 MG/ML","1","0","0","0","","","ANALGESICS","OPIOID ANALGESICS§"],["N","G","MORPHINE SUL INJ 1MG/ML","MORPHINE SULFATE IV SOLN 1 MG/ML","1","0","0","0","","","ANALGESICS","OPIOID ANALGESICS§"],["N","G","MORPHINE SUL INJ 2MG/ML","MORPHINE SULFATE IV SOLN PF 2 MG/ML","3","0","0","0","","","ANALGESICS","OPIOID ANALGESICS§"],["N","G","MORPHINE SUL INJ 4MG/ML","MORPHINE SULFATE INJ 4 MG/ML","3","0","0","0","","","ANALGESICS","OPIOID ANALGESICS§"],["N","G","MORPHINE SUL INJ 4MG/ML","MORPHINE SULFATE IV SOLN PF 4 MG/ML","1","0","0","0","","","ANALGESICS","OPIOID ANALGESICS§"],["N","G","MORPHINE SUL INJ 5MG/ML","MORPHINE SULFATE INJ 5 MG/ML","3","0","0","0","","","ANALGESICS","OPIOID ANALGESICS§"],["N","G","MORPHINE SUL INJ 8MG/ML","MORPHINE SULFATE IV SOLN PF 8 MG/ML","1","0","0","0","","","ANALGESICS","OPIOID ANALGESICS§"],["N","G","MORPHINE SUL INJ 8MG/ML","MORPHINE SULFATE INJ 8 MG/ML","1","0","0","0","","","ANALGESICS","OPIOID ANALGESICS§"],["N","G","MORPHINE SUL SOL 100/5ML","MORPHINE SULFATE ORAL SOLN 100 MG/5ML (20 MG/ML)","1","0","1","1","135 mL every 25 days","Subject to initial 7-day limit","ANALGESICS","OPIOID ANALGESICS§"],["N","G","MORPHINE SUL SOL 10MG/5ML","MORPHINE SULFATE ORAL SOLN 10 MG/5ML","1","0","1","1","900 ml every 25 days","Subject to initial 7-day limit","ANALGESICS","OPIOID ANALGESICS§"],["N","G","MORPHINE SUL SOL 20MG/5ML","MORPHINE SULFATE ORAL SOLN 20 MG/5ML","1","0","1","1","675 mL every 25 days","Subject to initial 7-day limit","ANALGESICS","OPIOID ANALGESICS§"],["N","G","MORPHINE SUL SUP 10MG","MORPHINE SULFATE SUPPOS 10 MG","1","0","1","1","180 suppositories every 25 days","Subject to initial 7-day limit","ANALGESICS","OPIOID ANALGESICS§"],["N","G","MORPHINE SUL SUP 20MG","MORPHINE SULFATE SUPPOS 20 MG","1","0","1","1","120 supp every 25 days","Subject to initial 7-day limit","ANALGESICS","OPIOID ANALGESICS§"],["N","G","MORPHINE SUL SUP 30MG","MORPHINE SULFATE SUPPOS 30 MG","1","0","1","1","90 supp every 25 days","Subject to initial 7-day limit","ANALGESICS","OPIOID ANALGESICS§"],["N","G","MORPHINE SUL SUP 5MG","MORPHINE SULFATE SUPPOS 5 MG","1","0","1","1","180 suppositories every 25 days","Subject to initial 7-day limit","ANALGESICS","OPIOID ANALGESICS§"],["N","G","MORPHINE SUL TAB 100MG ER","MORPHINE SULFATE TAB ER 100 MG","1","1","1","0","","High Strength Requires PA","ANALGESICS","OPIOID ANALGESICS§"],["N","G","MORPHINE SUL TAB 15MG","MORPHINE SULFATE TAB 15 MG","1","0","1","1","180 tabs every 25 days","Subject to initial 7-day limit","ANALGESICS","OPIOID ANALGESICS§"],["N","G","MORPHINE SUL TAB 15MG ER","MORPHINE SULFATE TAB ER 15 MG","1","0","1","1","90 tabs every 25 days","","ANALGESICS","OPIOID ANALGESICS§"],["N","G","MORPHINE SUL TAB 200MG ER","MORPHINE SULFATE TAB ER 200 MG","1","1","1","0","","High Strength Requires PA","ANALGESICS","OPIOID ANALGESICS§"],["N","G","MORPHINE SUL TAB 30MG","MORPHINE SULFATE TAB 30 MG","1","0","1","1","90 tabs every 25 days","Subject to initial 7-day limit","ANALGESICS","OPIOID ANALGESICS§"],["N","G","MORPHINE SUL TAB 30MG ER","MORPHINE SULFATE TAB ER 30 MG","1","0","1","1","90 tabs every 25 days","","ANALGESICS","OPIOID ANALGESICS§"],["N","G","MORPHINE SUL TAB 60MG ER","MORPHINE SULFATE TAB ER 60 MG","1","1","1","0","","High Strength Requires PA","ANALGESICS","OPIOID ANALGESICS§"],["N","G","NALBUPHINE INJ 10MG/ML","NALBUPHINE HCL INJ 10 MG/ML","1","0","0","0","","","ANALGESICS","OPIOID ANALGESICS§"],["N","G","NALBUPHINE INJ 20MG/ML","NALBUPHINE HCL INJ 20 MG/ML","1","0","0","0","","","ANALGESICS","OPIOID ANALGESICS§"],["N","G","NUCYNTA ER TAB 100MG","TAPENTADOL HCL TAB ER 12HR 100 MG","2","0","1","1","60 tabs every 25 days","","ANALGESICS","OPIOID ANALGESICS§"],["N","G","NUCYNTA ER TAB 150MG","TAPENTADOL HCL TAB ER 12HR 150 MG","2","1","1","0","","High Strength Requires PA","ANALGESICS","OPIOID ANALGESICS§"],["N","G","NUCYNTA ER TAB 200MG","TAPENTADOL HCL TAB ER 12HR 200 MG","2","1","1","0","","High Strength Requires PA","ANALGESICS","OPIOID ANALGESICS§"],["N","G","NUCYNTA ER TAB 250MG","TAPENTADOL HCL TAB ER 12HR 250 MG","2","1","1","0","","High Strength Requires PA","ANALGESICS","OPIOID ANALGESICS§"],["N","G","NUCYNTA ER TAB 50MG","TAPENTADOL HCL TAB ER 12HR 50 MG","2","0","1","1","60 tabs every 25 days","","ANALGESICS","OPIOID ANALGESICS§"],["N","G","NUCYNTA TAB 100MG","TAPENTADOL HCL TAB 100 MG","2","0","1","1","60 tabs every 25 days","Subject to initial 7-day limit","ANALGESICS","OPIOID ANALGESICS§"],["N","G","NUCYNTA TAB 50MG","TAPENTADOL HCL TAB 50 MG","2","0","1","1","120 tabs every 25 days","Subject to initial 7-day limit","ANALGESICS","OPIOID ANALGESICS§"],["N","G","NUCYNTA TAB 75MG","TAPENTADOL HCL TAB 75 MG","2","0","1","1","90 tabs every 25 days","Subject to initial 7-day limit","ANALGESICS","OPIOID ANALGESICS§"],["N","G","OXYCOD/APAP TAB 10-325MG","OXYCODONE W/ ACETAMINOPHEN TAB 10-325 MG","1","0","1","1","180 tabs every 25 days","Subject to initial 7-day limit","ANALGESICS","OPIOID ANALGESICS§"],["N","G","OXYCOD/APAP TAB 2.5-325","OXYCODONE W/ ACETAMINOPHEN TAB 2.5-325 MG","1","0","1","1","360 tabs every 25 days","Subject to initial 7-day limit","ANALGESICS","OPIOID ANALGESICS§"],["N","G","OXYCOD/APAP TAB 5-325MG","OXYCODONE W/ ACETAMINOPHEN TAB 5-325 MG","1","0","1","1","360 tabs every 25 days","Subject to initial 7-day limit","ANALGESICS","OPIOID ANALGESICS§"],["N","G","OXYCOD/APAP TAB 5-325MG","OXYCODONE W/ ACETAMINOPHEN TAB 5-325 MG","1","0","1","1","360 tabs every 25 days","Subject to initial 7-day limit","ANALGESICS","OPIOID ANALGESICS§"],["N","G","OXYCOD/APAP TAB 7.5-325","OXYCODONE W/ ACETAMINOPHEN TAB 7.5-325 MG","1","0","1","1","240 tabs every 25 days","Subject to initial 7-day limit","ANALGESICS","OPIOID ANALGESICS§"],["N","G","OXYCOD/ASA TAB","OXYCODONE-ASPIRIN TAB 4.8355-325 MG","1","0","1","1","360 tabs every 25 days","Subject to initial 7-day limit","ANALGESICS","OPIOID ANALGESICS§"],["N","G","OXYCOD/IBU TAB 5-400MG","OXYCODONE-IBUPROFEN TAB 5-400 MG","1","0","1","1","28 tabs every 25 days","Subject to initial 7-day limit","ANALGESICS","OPIOID ANALGESICS§"],["N","G","OXYCODONE CAP 5MG","OXYCODONE HCL CAP 5 MG","1","0","1","1","180 caps every 25 days","Subject to initial 7-day limit","ANALGESICS","OPIOID ANALGESICS§"],["N","G","OXYCODONE CON 20MG/ML","OXYCODONE HCL CONC 100 MG/5ML (20 MG/ML)","1","0","1","1","90 mL every 25 days","Subject to initial 7-day limit","ANALGESICS","OPIOID ANALGESICS§"],["N","G","OXYCODONE SOL 5MG/5ML","OXYCODONE HCL SOLN 5 MG/5ML","1","0","1","1","900 ml every 25 days","Subject to initial 7-day limit","ANALGESICS","OPIOID ANALGESICS§"],["N","G","OXYCODONE TAB 10MG","OXYCODONE HCL TAB 10 MG","1","0","1","1","180 tabs every 25 days","Subject to initial 7-day limit","ANALGESICS","OPIOID ANALGESICS§"],["N","G","OXYCODONE TAB 10MG ER","OXYCODONE HCL TAB ER 12HR DETER 10 MG","1","0","1","1","60 tabs every 25 days","","ANALGESICS","OPIOID ANALGESICS§"],["N","G","OXYCODONE TAB 15MG","OXYCODONE HCL TAB 15 MG","1","0","1","1","120 tabs every 25 days","Subject to initial 7-day limit","ANALGESICS","OPIOID ANALGESICS§"],["N","G","OXYCODONE TAB 15MG ER","OXYCODONE HCL TAB ER 12HR DETER 15 MG","1","0","1","1","60 tabs every 25 days","","ANALGESICS","OPIOID ANALGESICS§"],["N","G","OXYCODONE TAB 20MG","OXYCODONE HCL TAB 20 MG","1","0","1","1","90 tabs every 25 days","Subject to initial 7-day limit","ANALGESICS","OPIOID ANALGESICS§"],["N","G","OXYCODONE TAB 20MG ER","OXYCODONE HCL TAB ER 12HR DETER 20 MG","1","0","1","1","60 tabs every 25 days","","ANALGESICS","OPIOID ANALGESICS§"],["N","G","OXYCODONE TAB 30MG","OXYCODONE HCL TAB 30 MG","1","0","1","1","60 tabs every 25 days","Subject to initial 7-day limit","ANALGESICS","OPIOID ANALGESICS§"],["N","G","OXYCODONE TAB 30MG ER","OXYCODONE HCL TAB ER 12HR DETER 30 MG","1","0","1","1","60 tabs every 25 days","","ANALGESICS","OPIOID ANALGESICS§"],["N","G","OXYCODONE TAB 40MG ER","OXYCODONE HCL TAB ER 12HR DETER 40 MG","1","1","1","0","","High Strength Requires PA","ANALGESICS","OPIOID ANALGESICS§"],["N","G","OXYCODONE TAB 5MG","OXYCODONE HCL TAB 5 MG","1","0","1","1","180 tabs every 25 days","Subject to initial 7-day limit","ANALGESICS","OPIOID ANALGESICS§"],["N","G","OXYCODONE TAB 60MG ER","OXYCODONE HCL TAB ER 12HR DETER 60 MG","1","1","1","0","","High Strength Requires PA","ANALGESICS","OPIOID ANALGESICS§"],["N","G","OXYCODONE TAB 80MG ER","OXYCODONE HCL TAB ER 12HR DETER 80 MG","1","1","1","0","","High Strength Requires PA","ANALGESICS","OPIOID ANALGESICS§"],["N","G","OXYCODONE/ SOL APAP","OXYCODONE W/ ACETAMINOPHEN SOLN 5-325 MG/5ML","1","0","1","1","1800 ml every 25 days","Subject to initial 7-day limit","ANALGESICS","OPIOID ANALGESICS§"],["N","G","OXYCONTIN TAB 10MG CR","OXYCODONE HCL TAB ER 12HR DETER 10 MG","2","0","1","1","60 tabs every 25 days","","ANALGESICS","OPIOID ANALGESICS§"],["N","G","OXYCONTIN TAB 15MG CR","OXYCODONE HCL TAB ER 12HR DETER 15 MG","2","0","1","1","60 tabs every 25 days","","ANALGESICS","OPIOID ANALGESICS§"],["N","G","OXYCONTIN TAB 20MG CR","OXYCODONE HCL TAB ER 12HR DETER 20 MG","2","0","1","1","60 tabs every 25 days","","ANALGESICS","OPIOID ANALGESICS§"],["N","G","OXYCONTIN TAB 30MG CR","OXYCODONE HCL TAB ER 12HR DETER 30 MG","2","0","1","1","60 tabs every 25 days","","ANALGESICS","OPIOID ANALGESICS§"],["N","G","OXYCONTIN TAB 40MG CR","OXYCODONE HCL TAB ER 12HR DETER 40 MG","2","1","1","0","","High Strength Requires PA","ANALGESICS","OPIOID ANALGESICS§"],["N","G","OXYCONTIN TAB 60MG CR","OXYCODONE HCL TAB ER 12HR DETER 60 MG","2","1","1","0","","High Strength Requires PA","ANALGESICS","OPIOID ANALGESICS§"],["N","G","OXYCONTIN TAB 80MG CR","OXYCODONE HCL TAB ER 12HR DETER 80 MG","2","1","1","0","","High Strength Requires PA","ANALGESICS","OPIOID ANALGESICS§"],["N","G","OXYMORPHONE TAB 10MG ER","OXYMORPHONE HCL TAB ER 12HR 10 MG","1","0","1","1","60 tabs every 25 days","","ANALGESICS","OPIOID ANALGESICS§"],["N","G","OXYMORPHONE TAB 15MG ER","OXYMORPHONE HCL TAB ER 12HR 15 MG","1","0","1","1","60 tabs every 25 days","","ANALGESICS","OPIOID ANALGESICS§"],["N","G","OXYMORPHONE TAB 20MG ER","OXYMORPHONE HCL TAB ER 12HR 20 MG","1","1","1","0","","High Strength Requires PA","ANALGESICS","OPIOID ANALGESICS§"],["N","G","OXYMORPHONE TAB 30MG ER","OXYMORPHONE HCL TAB ER 12HR 30 MG","1","1","1","0","","High Strength Requires PA","ANALGESICS","OPIOID ANALGESICS§"],["N","G","OXYMORPHONE TAB 40MG ER","OXYMORPHONE HCL TAB ER 12HR 40 MG","1","1","1","0","","High Strength Requires PA","ANALGESICS","OPIOID ANALGESICS§"],["N","G","OXYMORPHONE TAB 5MG ER","OXYMORPHONE HCL TAB ER 12HR 5 MG","1","0","1","1","60 tabs every 25 days","","ANALGESICS","OPIOID ANALGESICS§"],["N","G","OXYMORPHONE TAB 7.5MG ER","OXYMORPHONE HCL TAB ER 12HR 7.5 MG","1","0","1","1","60 tabs every 25 days","","ANALGESICS","OPIOID ANALGESICS§"],["N","G","OXYMORPHONE TAB HCL 10MG","OXYMORPHONE HCL TAB 10 MG","1","0","1","1","90 tabs every 25 days","Subject to initial 7-day limit","ANALGESICS","OPIOID ANALGESICS§"],["N","G","OXYMORPHONE TAB HCL 5MG","OXYMORPHONE HCL TAB 5 MG","1","0","1","1","180 tabs every 25 days","Subject to initial 7-day limit","ANALGESICS","OPIOID ANALGESICS§"],["N","G","TRAMADOL HCL TAB 100MG ER","TRAMADOL HCL TAB ER 24HR 100 MG","1","0","1","1","30 tabs every 25 days","","ANALGESICS","OPIOID ANALGESICS§"],["N","G","TRAMADOL HCL TAB 200MG ER","TRAMADOL HCL TAB ER 24HR 200 MG","1","1","1","0","","High Strength Requires PA","ANALGESICS","OPIOID ANALGESICS§"],["N","G","TRAMADOL HCL TAB 300MG ER","TRAMADOL HCL TAB ER 24HR 300 MG","1","1","1","0","","High Strength Requires PA","ANALGESICS","OPIOID ANALGESICS§"],["N","G","TRAMADOL HCL TAB 50MG","TRAMADOL HCL TAB 50 MG","1","0","1","1","180 tabs every 25 days","Subject to initial 7-day limit","ANALGESICS","OPIOID ANALGESICS§"],["N","G","XARTEMIS XR TAB 7.5-325","OXYCODONE W/ ACETAMINOPHEN TAB ER 7.5-325 MG","3","0","0","1","120 tabs every 25 days","","ANALGESICS","OPIOID ANALGESICS§"],["N","G","XYLON TAB 10-200MG","HYDROCODONE-IBUPROFEN TAB 10-200 MG","1","0","1","1","50 tabs every 25 days","Subject to initial 7-day limit","ANALGESICS","OPIOID ANALGESICS§"],["N","G","BELBUCA MIS 150MCG","BUPRENORPHINE HCL BUCCAL FILM 150 MCG (BASE EQUIVALENT)","2","0","1","1","60 films every 25 days","","ANALGESICS","OPIOID PARTIAL AGONISTS§"],["N","G","BELBUCA MIS 300MCG","BUPRENORPHINE HCL BUCCAL FILM 300 MCG (BASE EQUIVALENT)","2","0","1","1","60 films every 25 days","","ANALGESICS","OPIOID PARTIAL AGONISTS§"],["N","G","BELBUCA MIS 450MCG","BUPRENORPHINE HCL BUCCAL FILM 450 MCG (BASE EQUIVALENT)","2","0","1","1","60 films every 25 days","","ANALGESICS","OPIOID PARTIAL AGONISTS§"],["N","G","BELBUCA MIS 600MCG","BUPRENORPHINE HCL BUCCAL FILM 600 MCG (BASE EQUIVALENT)","2","1","1","0","","High Strength Requires Prior Auth","ANALGESICS","OPIOID PARTIAL AGONISTS§"],["N","G","BELBUCA MIS 750MCG","BUPRENORPHINE HCL BUCCAL FILM 750 MCG (BASE EQUIVALENT)","2","1","1","0","","High Strength Requires Prior Auth","ANALGESICS","OPIOID PARTIAL AGONISTS§"],["N","G","BELBUCA MIS 75MCG","BUPRENORPHINE HCL BUCCAL FILM 75 MCG (BASE EQUIVALENT)","2","0","1","1","60 films every 25 days","","ANALGESICS","OPIOID PARTIAL AGONISTS§"],["N","G","BELBUCA MIS 900MCG","BUPRENORPHINE HCL BUCCAL FILM 900 MCG (BASE EQUIVALENT)","2","1","1","0","","High Strength Requires Prior Auth","ANALGESICS","OPIOID PARTIAL AGONISTS§"],["N","G","BUPRENORPHIN INJ 0.3MG/ML","BUPRENORPHINE HCL INJ 0.3 MG/ML (BASE EQUIV)","1","0","0","0","","","ANALGESICS","OPIOID PARTIAL AGONISTS§"],["N","G","BUPRENORPHIN SUB 2MG","BUPRENORPHINE HCL SL TAB 2 MG (BASE EQUIV)","0","0","0","1","90 tabs every 25 days","$0 copay; Must obtain approval after the first 30 day supply","ANALGESICS","OPIOID PARTIAL AGONISTS§"],["N","G","BUPRENORPHIN SUB 8MG","BUPRENORPHINE HCL SL TAB 8 MG (BASE EQUIV)","0","0","0","1","90 tabs every 25 days","$0 copay; Must obtain approval after the first 30 day supply","ANALGESICS","OPIOID PARTIAL AGONISTS§"],["N","G","ASPIRIN CHW 81MG","ASPIRIN CHEW TAB 81 MG","0","0","0","1","100 tabs every 30 days","$0 copay for members age 50-59 or members at risk for preeclampsia, otherwise not covered","ANALGESICS","SALICYLATES"],["N","G","ASPIRIN LOW TAB 81MG EC","ASPIRIN TAB DELAYED RELEASE 81 MG","0","0","0","1","100 tabs every 30 days","$0 copay for members age 50-59 or members at risk for preeclampsia, otherwise not covered","ANALGESICS","SALICYLATES"],["N","G","DIFLUNISAL TAB 500MG","DIFLUNISAL TAB 500 MG","1","0","0","0","","","ANALGESICS","SALICYLATES"],["N","G","LIDO/DEXTROS INJ 5-7.5%","LIDOCAINE 5% IN 7.5% DEXTROSE INTRASPINAL SOLN","3","0","0","0","","","ANESTHETICS","LOCAL ANESTHETICS"],["N","G","LIDOCAINE INJ 0.5%","LIDOCAINE HCL LOCAL INJ 0.5%","1","0","0","0","","","ANESTHETICS","LOCAL ANESTHETICS"],["N","G","LIDOCAINE INJ 0.5%","LIDOCAINE HCL LOCAL PRESERVATIVE FREE (PF) INJ 0.5%","1","0","0","0","","","ANESTHETICS","LOCAL ANESTHETICS"],["N","G","LIDOCAINE INJ 1%","LIDOCAINE HCL LOCAL INJ 1%","1","0","0","0","","","ANESTHETICS","LOCAL ANESTHETICS"],["N","G","LIDOCAINE INJ 1%","LIDOCAINE HCL LOCAL PRESERVATIVE FREE (PF) INJ 1%","1","0","0","0","","","ANESTHETICS","LOCAL ANESTHETICS"],["N","G","LIDOCAINE INJ 1.5%","LIDOCAINE HCL LOCAL PRESERVATIVE FREE (PF) INJ 1.5%","1","0","0","0","","","ANESTHETICS","LOCAL ANESTHETICS"],["N","G","LIDOCAINE INJ 2%","LIDOCAINE HCL LOCAL INJ 2%","1","0","0","0","","","ANESTHETICS","LOCAL ANESTHETICS"],["N","G","LIDOCAINE INJ 2%","LIDOCAINE HCL LOCAL PRESERVATIVE FREE (PF) INJ 2%","1","0","0","0","","","ANESTHETICS","LOCAL ANESTHETICS"],["N","G","LIDOCAINE INJ 4%","LIDOCAINE HCL LOCAL PRESERVATIVE FREE (PF) INJ 4%","1","0","0","0","","","ANESTHETICS","LOCAL ANESTHETICS"],["N","G","AMIKACIN INJ 1GM/4ML","AMIKACIN SULFATE INJ 1 GM/4ML (250 MG/ML)","1","0","0","0","","","ANTI-INFECTIVES","ANTI-BACTERIALS - MISCELLANEOUS"],["N","G","AMIKACIN INJ 500/2ML","AMIKACIN SULFATE INJ 500 MG/2ML (250 MG/ML)","1","0","0","0","","","ANTI-INFECTIVES","ANTI-BACTERIALS - MISCELLANEOUS"],["N","G","CHLORAMPHEN INJ 1GM","CHLORAMPHENICOL SODIUM SUCCINATE FOR IV INJ 1 GM","1","0","0","0","","","ANTI-INFECTIVES","ANTI-BACTERIALS - MISCELLANEOUS"],["N","G","GENTAM/NACL INJ 0.9MG/ML","GENTAMICIN IN SALINE INJ 0.9 MG/ML","3","0","0","0","","","ANTI-INFECTIVES","ANTI-BACTERIALS - MISCELLANEOUS"],["N","G","GENTAM/NACL INJ 1.4MG/ML","GENTAMICIN IN SALINE INJ 1.4 MG/ML","3","0","0","0","","","ANTI-INFECTIVES","ANTI-BACTERIALS - MISCELLANEOUS"],["N","G","GENTAM/NACL INJ 100MG","GENTAMICIN IN SALINE INJ 1 MG/ML","1","0","0","0","","","ANTI-INFECTIVES","ANTI-BACTERIALS - MISCELLANEOUS"],["N","G","GENTAM/NACL INJ 100MG","GENTAMICIN IN SALINE INJ 2 MG/ML","1","0","0","0","","","ANTI-INFECTIVES","ANTI-BACTERIALS - MISCELLANEOUS"],["N","G","GENTAM/NACL INJ 60MG","GENTAMICIN IN SALINE INJ 1.2 MG/ML","1","0","0","0","","","ANTI-INFECTIVES","ANTI-BACTERIALS - MISCELLANEOUS"],["N","G","GENTAM/NACL INJ 80MG","GENTAMICIN IN SALINE INJ 1.6 MG/ML","1","0","0","0","","","ANTI-INFECTIVES","ANTI-BACTERIALS - MISCELLANEOUS"],["N","G","GENTAM/NACL INJ 80MG PB","GENTAMICIN IN SALINE INJ 0.8 MG/ML","1","0","0","0","","","ANTI-INFECTIVES","ANTI-BACTERIALS - MISCELLANEOUS"],["N","G","GENTAMICIN INJ 10MG/ML","GENTAMICIN SULFATE INJ 10 MG/ML","1","0","0","0","","","ANTI-INFECTIVES","ANTI-BACTERIALS - MISCELLANEOUS"],["N","G","GENTAMICIN INJ 40MG/ML","GENTAMICIN SULFATE INJ 40 MG/ML","1","0","0","0","","","ANTI-INFECTIVES","ANTI-BACTERIALS - MISCELLANEOUS"],["N","G","MONUROL PAK GRANULES","FOSFOMYCIN TROMETHAMINE POWD PACK 3 GM (BASE EQUIVALENT)","3","0","0","0","","","ANTI-INFECTIVES","ANTI-BACTERIALS - MISCELLANEOUS"],["N","G","NEOMYCIN TAB 500MG","NEOMYCIN SULFATE TAB 500 MG","1","0","0","0","","","ANTI-INFECTIVES","ANTI-BACTERIALS - MISCELLANEOUS"],["N","G","PAROMOMYCIN CAP 250MG","PAROMOMYCIN SULFATE CAP 250 MG","1","0","0","0","","","ANTI-INFECTIVES","ANTI-BACTERIALS - MISCELLANEOUS"],["N","G","STREPTOMYCIN INJ 1GM","STREPTOMYCIN SULFATE FOR INJ 1 GM","1","0","0","0","","","ANTI-INFECTIVES","ANTI-BACTERIALS - MISCELLANEOUS"],["N","G","SULFADIAZINE TAB 500MG","SULFADIAZINE TAB 500 MG","3","0","0","0","","","ANTI-INFECTIVES","ANTI-BACTERIALS - MISCELLANEOUS"],["N","G","TINIDAZOLE TAB 250MG","TINIDAZOLE TAB 250 MG","1","0","0","0","","","ANTI-INFECTIVES","ANTI-BACTERIALS - MISCELLANEOUS"],["N","G","TINIDAZOLE TAB 500MG","TINIDAZOLE TAB 500 MG","1","0","0","0","","","ANTI-INFECTIVES","ANTI-BACTERIALS - MISCELLANEOUS"],["N","G","TOBRAMYCIN INJ 1.2/30ML","TOBRAMYCIN SULFATE INJ 1.2 GM/30ML (40 MG/ML) (BASE EQUIV)","1","0","0","0","","","ANTI-INFECTIVES","ANTI-BACTERIALS - MISCELLANEOUS"],["N","G","TOBRAMYCIN INJ 1.2GM","TOBRAMYCIN SULFATE FOR INJ 1.2 GM","1","0","0","0","","","ANTI-INFECTIVES","ANTI-BACTERIALS - MISCELLANEOUS"],["N","G","TOBRAMYCIN INJ 10MG/ML","TOBRAMYCIN SULFATE INJ 10 MG/ML (BASE EQUIVALENT)","1","0","0","0","","","ANTI-INFECTIVES","ANTI-BACTERIALS - MISCELLANEOUS"],["N","G","TOBRAMYCIN INJ 40MG/ML","TOBRAMYCIN SULFATE INJ 1.2 GM/30ML (40 MG/ML) (BASE EQUIV)","1","0","0","0","","","ANTI-INFECTIVES","ANTI-BACTERIALS - MISCELLANEOUS"],["N","G","TOBRAMYCIN INJ 40MG/ML","TOBRAMYCIN SULFATE INJ 2 GM/50ML (40 MG/ML) (BASE EQUIV)","1","0","0","0","","","ANTI-INFECTIVES","ANTI-BACTERIALS - MISCELLANEOUS"],["N","G","TOBRAMYCIN INJ 80MG/2ML","TOBRAMYCIN SULFATE INJ 80 MG/2ML (40 MG/ML) (BASE EQUIV)","1","0","0","0","","","ANTI-INFECTIVES","ANTI-BACTERIALS - MISCELLANEOUS"],["N","G","TOBRAMYCIN NEB 300/5ML","TOBRAMYCIN NEBU SOLN 300 MG/5ML","4","1","0","1","280 mL every 28 days","SP","ANTI-INFECTIVES","ANTI-BACTERIALS - MISCELLANEOUS"],["N","G","ALINIA SUS 100/5ML","NITAZOXANIDE FOR SUSP 100 MG/5ML","2","0","0","0","","","ANTI-INFECTIVES","ANTI-INFECTIVES - MISCELLANEOUS"],["N","G","ALINIA TAB 500MG","NITAZOXANIDE TAB 500 MG","2","0","0","0","","","ANTI-INFECTIVES","ANTI-INFECTIVES - MISCELLANEOUS"],["N","G","ATOVAQUONE SUS 750/5ML","ATOVAQUONE SUSP 750 MG/5ML","1","0","0","0","","","ANTI-INFECTIVES","ANTI-INFECTIVES - MISCELLANEOUS"],["N","G","AZACTAM/DEX INJ 1GM","AZTREONAM IN DEXTROSE INJ 1 GM/50ML","3","0","0","0","","","ANTI-INFECTIVES","ANTI-INFECTIVES - MISCELLANEOUS"],["N","G","AZACTAM/DEX INJ 2GM","AZTREONAM IN DEXTROSE INJ 2 GM/50ML","3","0","0","0","","","ANTI-INFECTIVES","ANTI-INFECTIVES - MISCELLANEOUS"],["N","G","AZTREONAM INJ 1GM","AZTREONAM FOR INJ 1 GM","1","0","0","0","","","ANTI-INFECTIVES","ANTI-INFECTIVES - MISCELLANEOUS"],["N","G","AZTREONAM INJ 2GM","AZTREONAM FOR INJ 2 GM","1","0","0","0","","","ANTI-INFECTIVES","ANTI-INFECTIVES - MISCELLANEOUS"],["N","G","CAYSTON INH 75MG","AZTREONAM LYSINE FOR INHAL SOLN 75 MG (BASE EQUIVALENT)","4","1","0","1","84 vials every 28 days","SP","ANTI-INFECTIVES","ANTI-INFECTIVES - MISCELLANEOUS"],["N","G","CLINDAMYCIN CAP 150MG","CLINDAMYCIN HCL CAP 150 MG","1","0","0","0","","","ANTI-INFECTIVES","ANTI-INFECTIVES - MISCELLANEOUS"],["N","G","CLINDAMYCIN CAP 300MG","CLINDAMYCIN HCL CAP 300 MG","1","0","0","0","","","ANTI-INFECTIVES","ANTI-INFECTIVES - MISCELLANEOUS"],["N","G","CLINDAMYCIN CAP 75MG","CLINDAMYCIN HCL CAP 75 MG","1","0","0","0","","","ANTI-INFECTIVES","ANTI-INFECTIVES - MISCELLANEOUS"],["N","G","CLINDAMYCIN INJ 300/2ML","CLINDAMYCIN PHOSPHATE IV SOLN 300 MG/2ML","1","0","0","0","","","ANTI-INFECTIVES","ANTI-INFECTIVES - MISCELLANEOUS"],["N","G","CLINDAMYCIN INJ 300/2ML","CLINDAMYCIN PHOSPHATE INJ 300 MG/2ML","1","0","0","0","","","ANTI-INFECTIVES","ANTI-INFECTIVES - MISCELLANEOUS"],["N","G","CLINDAMYCIN INJ 600/4ML","CLINDAMYCIN PHOSPHATE INJ 600 MG/4ML","1","0","0","0","","","ANTI-INFECTIVES","ANTI-INFECTIVES - MISCELLANEOUS"],["N","G","CLINDAMYCIN INJ 600/4ML","CLINDAMYCIN PHOSPHATE INJ 600 MG/4ML","1","0","0","0","","","ANTI-INFECTIVES","ANTI-INFECTIVES - MISCELLANEOUS"],["N","G","CLINDAMYCIN INJ 600/4ML","CLINDAMYCIN PHOSPHATE INJ 600 MG/4ML","1","0","0","0","","","ANTI-INFECTIVES","ANTI-INFECTIVES - MISCELLANEOUS"],["N","G","CLINDAMYCIN INJ 900/6ML","CLINDAMYCIN PHOSPHATE INJ 900 MG/6ML","1","0","0","0","","","ANTI-INFECTIVES","ANTI-INFECTIVES - MISCELLANEOUS"],["N","G","CLINDAMYCIN INJ 900/6ML","CLINDAMYCIN PHOSPHATE IV SOLN 900 MG/6ML","1","0","0","0","","","ANTI-INFECTIVES","ANTI-INFECTIVES - MISCELLANEOUS"],["N","G","CLINDAMYCIN INJ 900/6ML","CLINDAMYCIN PHOSPHATE INJ 900 MG/6ML","1","0","0","0","","","ANTI-INFECTIVES","ANTI-INFECTIVES - MISCELLANEOUS"],["N","G","CLINDAMYCIN INJ 900/6ML","CLINDAMYCIN PHOSPHATE INJ 900 MG/6ML","1","0","0","0","","","ANTI-INFECTIVES","ANTI-INFECTIVES - MISCELLANEOUS"],["N","G","CLINDAMYCIN INJ 9GM/60ML","CLINDAMYCIN PHOSPHATE INJ 9 GM/60ML","1","0","0","0","","","ANTI-INFECTIVES","ANTI-INFECTIVES - MISCELLANEOUS"],["N","G","CLINDAMYCIN INJ 9GM/60ML","CLINDAMYCIN PHOSPHATE INJ 9 GM/60ML","1","0","0","0","","","ANTI-INFECTIVES","ANTI-INFECTIVES - MISCELLANEOUS"],["N","G","CLINDAMYCIN SOL 75MG/5ML","CLINDAMYCIN PALMITATE HCL FOR SOLN 75 MG/5ML (BASE EQUIV)","1","0","0","0","","","ANTI-INFECTIVES","ANTI-INFECTIVES - MISCELLANEOUS"],["N","G","DAPSONE TAB 100MG","DAPSONE TAB 100 MG","1","0","0","0","","","ANTI-INFECTIVES","ANTI-INFECTIVES - MISCELLANEOUS"],["N","G","DAPSONE TAB 25MG","DAPSONE TAB 25 MG","1","0","0","0","","","ANTI-INFECTIVES","ANTI-INFECTIVES - MISCELLANEOUS"],["N","G","DAPTOMYCIN INJ 500MG","DAPTOMYCIN FOR IV SOLN 500 MG","1","0","0","0","","","ANTI-INFECTIVES","ANTI-INFECTIVES - MISCELLANEOUS"],["N","G","DARAPRIM TAB 25MG","PYRIMETHAMINE TAB 25 MG","3","0","0","0","","","ANTI-INFECTIVES","ANTI-INFECTIVES - MISCELLANEOUS"],["N","G","DORIPENEM INJ 250MG","DORIPENEM FOR IV INFUSION 250 MG","1","0","0","0","","","ANTI-INFECTIVES","ANTI-INFECTIVES - MISCELLANEOUS"],["N","G","DORIPENEM INJ 500MG","DORIPENEM FOR IV INFUSION 500 MG","1","0","0","0","","","ANTI-INFECTIVES","ANTI-INFECTIVES - MISCELLANEOUS"],["N","G","EMVERM CHW 100MG","MEBENDAZOLE CHEW TAB 100 MG","3","0","0","1","12 tabs every 365 days","","ANTI-INFECTIVES","ANTI-INFECTIVES - MISCELLANEOUS"],["N","G","ERTAPENEM INJ 1GM","ERTAPENEM SODIUM FOR INJ 1 GM (BASE EQUIVALENT)","1","0","0","0","","","ANTI-INFECTIVES","ANTI-INFECTIVES - MISCELLANEOUS"],["N","G","IMIPENEM/CIL INJ 250MG","IMIPENEM-CILASTATIN INTRAVENOUS FOR SOLN 250 MG","1","0","0","0","","","ANTI-INFECTIVES","ANTI-INFECTIVES - MISCELLANEOUS"],["N","G","IMIPENEM/CIL INJ 500MG","IMIPENEM-CILASTATIN INTRAVENOUS FOR SOLN 500 MG","1","0","0","0","","","ANTI-INFECTIVES","ANTI-INFECTIVES - MISCELLANEOUS"],["N","G","IMPAVIDO CAP 50MG","MILTEFOSINE CAP 50 MG","3","0","0","0","","","ANTI-INFECTIVES","ANTI-INFECTIVES - MISCELLANEOUS"],["N","G","INVANZ INJ 1GM","ERTAPENEM SODIUM FOR IV INJ 1 GM (BASE EQUIVALENT)","3","0","0","0","","","ANTI-INFECTIVES","ANTI-INFECTIVES - MISCELLANEOUS"],["N","G","IVERMECTIN TAB 3MG","IVERMECTIN TAB 3 MG","1","0","0","0","","","ANTI-INFECTIVES","ANTI-INFECTIVES - MISCELLANEOUS"],["N","G","LINEZOLID SUS 100/5ML","LINEZOLID FOR SUSP 100 MG/5ML","1","0","0","0","","","ANTI-INFECTIVES","ANTI-INFECTIVES - MISCELLANEOUS"],["N","G","LINEZOLID TAB 600MG","LINEZOLID TAB 600 MG","1","0","0","0","","","ANTI-INFECTIVES","ANTI-INFECTIVES - MISCELLANEOUS"],["N","G","MEROPENEM INJ 1GM","MEROPENEM IV FOR SOLN 1 GM","1","0","0","0","","","ANTI-INFECTIVES","ANTI-INFECTIVES - MISCELLANEOUS"],["N","G","MEROPENEM INJ 500MG","MEROPENEM IV FOR SOLN 500 MG","1","0","0","0","","","ANTI-INFECTIVES","ANTI-INFECTIVES - MISCELLANEOUS"],["N","G","METHENAM HIP TAB 1GM","METHENAMINE HIPPURATE TAB 1 GM","1","0","0","0","","","ANTI-INFECTIVES","ANTI-INFECTIVES - MISCELLANEOUS"],["N","G","METRON/NACL INJ 500MG","METRONIDAZOLE IN NACL 0.79% IV SOLN 500 MG/100ML","1","0","0","0","","","ANTI-INFECTIVES","ANTI-INFECTIVES - MISCELLANEOUS"],["N","G","METRONIDAZOL CAP 375MG","METRONIDAZOLE CAP 375 MG","1","0","0","0","","","ANTI-INFECTIVES","ANTI-INFECTIVES - MISCELLANEOUS"],["N","G","METRONIDAZOL TAB 250MG","METRONIDAZOLE TAB 250 MG","1","0","0","0","","","ANTI-INFECTIVES","ANTI-INFECTIVES - MISCELLANEOUS"],["N","G","METRONIDAZOL TAB 500MG","METRONIDAZOLE TAB 500 MG","1","0","0","0","","","ANTI-INFECTIVES","ANTI-INFECTIVES - MISCELLANEOUS"],["N","G","NEBUPENT INH 300MG","PENTAMIDINE ISETHIONATE FOR NEBULIZATION SOLN 300 MG","3","0","0","0","","","ANTI-INFECTIVES","ANTI-INFECTIVES - MISCELLANEOUS"],["N","G","NITROFUR MAC CAP 100MG","NITROFURANTOIN MACROCRYSTALLINE CAP 100 MG","1","1","0","0","","High Risk Medications require PA for members age 70 and older","ANTI-INFECTIVES","ANTI-INFECTIVES - MISCELLANEOUS"],["N","G","NITROFUR MAC CAP 25MG","NITROFURANTOIN MACROCRYSTALLINE CAP 25 MG","1","1","0","0","","High Risk Medications require PA for members age 70 and older","ANTI-INFECTIVES","ANTI-INFECTIVES - MISCELLANEOUS"],["N","G","NITROFUR MAC CAP 50MG","NITROFURANTOIN MACROCRYSTALLINE CAP 50 MG","1","1","0","0","","High Risk Medications require PA for members age 70 and older","ANTI-INFECTIVES","ANTI-INFECTIVES - MISCELLANEOUS"],["N","G","NITROFURANTN CAP 100MG","NITROFURANTOIN MONOHYDRATE MACROCRYSTALLINE CAP 100 MG","1","1","0","0","","High Risk Medications require PA for members age 70 and older","ANTI-INFECTIVES","ANTI-INFECTIVES - MISCELLANEOUS"],["N","G","NITROFURANTN SUS 25MG/5ML","NITROFURANTOIN SUSP 25 MG/5ML","1","1","0","0","","High Risk Medications require PA for members age 70 and older","ANTI-INFECTIVES","ANTI-INFECTIVES - MISCELLANEOUS"],["N","G","PENTAMIDINE INJ 300MG","PENTAMIDINE ISETHIONATE FOR SOLN 300 MG","1","0","0","0","","","ANTI-INFECTIVES","ANTI-INFECTIVES - MISCELLANEOUS"],["N","G","POLYMYXIN B INJ 500000","POLYMYXIN B SULFATE FOR INJ 500000 UNIT","1","0","0","0","","","ANTI-INFECTIVES","ANTI-INFECTIVES - MISCELLANEOUS"],["N","G","PRAZIQUANTEL TAB 600MG","PRAZIQUANTEL TAB 600 MG","1","0","0","1","24 tabs every 365 days","","ANTI-INFECTIVES","ANTI-INFECTIVES - MISCELLANEOUS"],["N","G","PRIMSOL SOL 50MG/5ML","TRIMETHOPRIM HCL ORAL SOLN 50 MG/5ML (BASE EQUIV)","2","0","0","0","","","ANTI-INFECTIVES","ANTI-INFECTIVES - MISCELLANEOUS"],["N","G","SIVEXTRO INJ 200MG","TEDIZOLID PHOSPHATE FOR IV SOLN 200 MG","3","0","0","0","","","ANTI-INFECTIVES","ANTI-INFECTIVES - MISCELLANEOUS"],["N","G","SIVEXTRO TAB 200MG","TEDIZOLID PHOSPHATE TAB 200 MG","3","0","0","0","","","ANTI-INFECTIVES","ANTI-INFECTIVES - MISCELLANEOUS"],["N","G","SMZ-TMP INJ 400-80/5","SULFAMETHOXAZOLE-TRIMETHOPRIM IV SOLN 400-80 MG/5ML","1","0","0","0","","","ANTI-INFECTIVES","ANTI-INFECTIVES - MISCELLANEOUS"],["N","G","SMZ-TMP SUS 200-40/5","SULFAMETHOXAZOLE-TRIMETHOPRIM SUSP 200-40 MG/5ML","1","0","0","0","","","ANTI-INFECTIVES","ANTI-INFECTIVES - MISCELLANEOUS"],["N","G","SMZ-TMP TAB 400-80MG","SULFAMETHOXAZOLE-TRIMETHOPRIM TAB 400-80 MG","1","0","0","0","","","ANTI-INFECTIVES","ANTI-INFECTIVES - MISCELLANEOUS"],["N","G","SMZ/TMP DS TAB 800-160","SULFAMETHOXAZOLE-TRIMETHOPRIM TAB 800-160 MG","1","0","0","0","","","ANTI-INFECTIVES","ANTI-INFECTIVES - MISCELLANEOUS"],["N","G","TRIMETHOPRIM TAB 100MG","TRIMETHOPRIM TAB 100 MG","1","0","0","0","","","ANTI-INFECTIVES","ANTI-INFECTIVES - MISCELLANEOUS"],["N","G","VANCOMYCIN CAP 125MG","VANCOMYCIN HCL CAP 125 MG (BASE EQUIVALENT)","1","0","0","1","80 caps every 10 days","","ANTI-INFECTIVES","ANTI-INFECTIVES - MISCELLANEOUS"],["N","G","VANCOMYCIN CAP 250MG","VANCOMYCIN HCL CAP 250 MG (BASE EQUIVALENT)","1","0","0","1","80 caps every 10 days","","ANTI-INFECTIVES","ANTI-INFECTIVES - MISCELLANEOUS"],["N","G","VANCOMYCIN INJ 1000MG","VANCOMYCIN HCL FOR IV SOLN 1 GM (BASE EQUIVALENT)","1","0","0","0","","","ANTI-INFECTIVES","ANTI-INFECTIVES - MISCELLANEOUS"],["N","G","VANCOMYCIN INJ 10GM","VANCOMYCIN HCL FOR IV SOLN 10 GM (BASE EQUIVALENT)","1","0","0","0","","","ANTI-INFECTIVES","ANTI-INFECTIVES - MISCELLANEOUS"],["N","G","VANCOMYCIN INJ 500MG","VANCOMYCIN HCL FOR IV SOLN 500 MG (BASE EQUIVALENT)","1","0","0","0","","","ANTI-INFECTIVES","ANTI-INFECTIVES - MISCELLANEOUS"],["N","G","VANCOMYCIN INJ 500MG","VANCOMYCIN HCL FOR IV SOLN 500 MG (BASE EQUIVALENT)","1","0","0","0","","","ANTI-INFECTIVES","ANTI-INFECTIVES - MISCELLANEOUS"],["N","G","VANCOMYCIN INJ 5GM","VANCOMYCIN HCL FOR IV SOLN 5 GM (BASE EQUIVALENT)","1","0","0","0","","","ANTI-INFECTIVES","ANTI-INFECTIVES - MISCELLANEOUS"],["N","G","VANCOMYCIN INJ 750MG","VANCOMYCIN HCL FOR IV SOLN 750 MG (BASE EQUIVALENT)","1","0","0","0","","","ANTI-INFECTIVES","ANTI-INFECTIVES - MISCELLANEOUS"],["N","G","XIFAXAN TAB 200MG","RIFAXIMIN TAB 200 MG","2","0","0","0","","","ANTI-INFECTIVES","ANTI-INFECTIVES - MISCELLANEOUS"],["N","G","XIFAXAN TAB 550MG","RIFAXIMIN TAB 550 MG","2","1","0","0","","","ANTI-INFECTIVES","ANTI-INFECTIVES - MISCELLANEOUS"],["N","G","AMPHOTERICIN INJ 50MG","AMPHOTERICIN B FOR IV SOLN 50 MG","1","0","0","0","","","ANTI-INFECTIVES","ANTIFUNGALS"],["N","G","BIO-STATIN CAP 1000000","NYSTATIN CAP 1000000 UNIT","2","0","0","0","","","ANTI-INFECTIVES","ANTIFUNGALS"],["N","G","BIO-STATIN CAP 500000","NYSTATIN CAP 500000 UNIT","2","0","0","0","","","ANTI-INFECTIVES","ANTIFUNGALS"],["N","G","BIO-STATIN POW","*NYSTATIN ORAL POWDER*","1","0","0","0","","","ANTI-INFECTIVES","ANTIFUNGALS"],["N","G","CRESEMBA CAP 186 MG","ISAVUCONAZONIUM SULFATE CAP 186 MG","3","0","0","0","","","ANTI-INFECTIVES","ANTIFUNGALS"],["N","G","FLUCONAZOLE SUS 10MG/ML","FLUCONAZOLE FOR SUSP 10 MG/ML","1","0","0","0","","","ANTI-INFECTIVES","ANTIFUNGALS"],["N","G","FLUCONAZOLE SUS 40MG/ML","FLUCONAZOLE FOR SUSP 40 MG/ML","1","0","0","0","","","ANTI-INFECTIVES","ANTIFUNGALS"],["N","G","FLUCONAZOLE TAB 100MG","FLUCONAZOLE TAB 100 MG","1","0","0","0","","","ANTI-INFECTIVES","ANTIFUNGALS"],["N","G","FLUCONAZOLE TAB 150MG","FLUCONAZOLE TAB 150 MG","1","0","0","0","","","ANTI-INFECTIVES","ANTIFUNGALS"],["N","G","FLUCONAZOLE TAB 200MG","FLUCONAZOLE TAB 200 MG","1","0","0","0","","","ANTI-INFECTIVES","ANTIFUNGALS"],["N","G","FLUCONAZOLE TAB 50MG","FLUCONAZOLE TAB 50 MG","1","0","0","0","","","ANTI-INFECTIVES","ANTIFUNGALS"],["N","G","GRISEOFULVIN SUS 125/5ML","GRISEOFULVIN MICROSIZE SUSP 125 MG/5ML","1","0","0","0","","","ANTI-INFECTIVES","ANTIFUNGALS"],["N","G","GRISEOFULVIN TAB MICR 500","GRISEOFULVIN MICROSIZE TAB 500 MG","1","0","0","0","","","ANTI-INFECTIVES","ANTIFUNGALS"],["N","G","GRISEOFULVIN TAB ULTR 125","GRISEOFULVIN ULTRAMICROSIZE TAB 125 MG","1","0","0","0","","","ANTI-INFECTIVES","ANTIFUNGALS"],["N","G","GRISEOFULVIN TAB ULTR 250","GRISEOFULVIN ULTRAMICROSIZE TAB 250 MG","1","0","0","0","","","ANTI-INFECTIVES","ANTIFUNGALS"],["N","G","ITRACONAZOLE CAP 100MG","ITRACONAZOLE CAP 100 MG","1","1","0","0","","","ANTI-INFECTIVES","ANTIFUNGALS"],["N","G","ITRACONAZOLE SOL 10MG/ML","ITRACONAZOLE ORAL SOLN 10 MG/ML","1","1","0","0","","","ANTI-INFECTIVES","ANTIFUNGALS"],["N","G","NOXAFIL SUS 40MG/ML","POSACONAZOLE SUSP 40 MG/ML","2","0","0","0","","","ANTI-INFECTIVES","ANTIFUNGALS"],["N","G","NOXAFIL TAB 100MG","POSACONAZOLE TAB DELAYED RELEASE 100 MG","2","0","0","0","","","ANTI-INFECTIVES","ANTIFUNGALS"],["N","G","NYSTATIN TAB 500000","NYSTATIN TAB 500000 UNIT","1","0","0","0","","","ANTI-INFECTIVES","ANTIFUNGALS"],["N","G","POSACONAZOLE TAB 100MG DR","POSACONAZOLE TAB DELAYED RELEASE 100 MG","1","0","0","0","","","ANTI-INFECTIVES","ANTIFUNGALS"],["N","G","TERBINAFINE TAB 250MG","TERBINAFINE HCL TAB 250 MG","1","1","0","0","","","ANTI-INFECTIVES","ANTIFUNGALS"],["N","G","VORICONAZOLE SUS 40MG/ML","VORICONAZOLE FOR SUSP 40 MG/ML","3","1","0","0","","","ANTI-INFECTIVES","ANTIFUNGALS"],["N","G","VORICONAZOLE TAB 200MG","VORICONAZOLE TAB 200 MG","3","1","0","0","","","ANTI-INFECTIVES","ANTIFUNGALS"],["N","G","VORICONAZOLE TAB 50MG","VORICONAZOLE TAB 50 MG","3","1","0","0","","","ANTI-INFECTIVES","ANTIFUNGALS"],["N","G","ATOVAQ/PROGU TAB 250-100","ATOVAQUONE-PROGUANIL HCL TAB 250-100 MG","1","0","0","0","","","ANTI-INFECTIVES","ANTIMALARIALS"],["N","G","ATOVAQ/PROGU TAB 62.5-25","ATOVAQUONE-PROGUANIL HCL TAB 62.5-25 MG","1","0","0","0","","","ANTI-INFECTIVES","ANTIMALARIALS"],["N","G","CHLOROQUINE TAB 250MG","CHLOROQUINE PHOSPHATE TAB 250 MG","1","0","0","0","","","ANTI-INFECTIVES","ANTIMALARIALS"],["N","G","CHLOROQUINE TAB 500MG","CHLOROQUINE PHOSPHATE TAB 500 MG","1","0","0","0","","","ANTI-INFECTIVES","ANTIMALARIALS"],["N","G","COARTEM TAB 20-120MG","ARTEMETHER-LUMEFANTRINE TAB 20-120 MG","3","0","0","0","","","ANTI-INFECTIVES","ANTIMALARIALS"],["N","G","MEFLOQUINE TAB 250MG","MEFLOQUINE HCL TAB 250 MG","1","0","0","0","","","ANTI-INFECTIVES","ANTIMALARIALS"],["N","G","PRIMAQUINE TAB 26.3MG","PRIMAQUINE PHOSPHATE TAB 26.3 MG (15 MG BASE)","1","0","0","0","","","ANTI-INFECTIVES","ANTIMALARIALS"],["N","G","QUININE SULF CAP 324MG","QUININE SULFATE CAP 324 MG","1","0","0","0","","","ANTI-INFECTIVES","ANTIMALARIALS"],["N","G","ABACAVIR SOL 20MG/ML","ABACAVIR SULFATE SOLN 20 MG/ML (BASE EQUIV)","1","0","0","1","900 mL every 30 days","","ANTI-INFECTIVES","ANTIRETROVIRAL AGENTS"],["N","G","ABACAVIR TAB 300MG","ABACAVIR SULFATE TAB 300 MG (BASE EQUIV)","1","0","0","1","60 tabs every 30 days","","ANTI-INFECTIVES","ANTIRETROVIRAL AGENTS"],["N","G","APTIVUS CAP 250MG","TIPRANAVIR CAP 250 MG","2","0","0","1","120 caps every 30 days","","ANTI-INFECTIVES","ANTIRETROVIRAL AGENTS"],["N","G","APTIVUS SOL","TIPRANAVIR ORAL SOLN 100 MG/ML","2","0","0","1","285 mL every 28 days","","ANTI-INFECTIVES","ANTIRETROVIRAL AGENTS"],["N","G","ATAZANAVIR CAP 150MG","ATAZANAVIR SULFATE CAP 150 MG (BASE EQUIV)","1","0","0","1","30 caps every 30 days","","ANTI-INFECTIVES","ANTIRETROVIRAL AGENTS"],["N","G","ATAZANAVIR CAP 200MG","ATAZANAVIR SULFATE CAP 200 MG (BASE EQUIV)","1","0","0","1","60 caps every 30 days","","ANTI-INFECTIVES","ANTIRETROVIRAL AGENTS"],["N","G","ATAZANAVIR CAP 300MG","ATAZANAVIR SULFATE CAP 300 MG (BASE EQUIV)","1","0","0","1","30 caps every 30 days","","ANTI-INFECTIVES","ANTIRETROVIRAL AGENTS"],["N","G","CRIXIVAN CAP 200MG","INDINAVIR SULFATE CAP 200 MG","2","0","0","1","450 caps every 30 days","","ANTI-INFECTIVES","ANTIRETROVIRAL AGENTS"],["N","G","CRIXIVAN CAP 400MG","INDINAVIR SULFATE CAP 400 MG","2","0","0","1","180 caps every 30 days","","ANTI-INFECTIVES","ANTIRETROVIRAL AGENTS"],["N","G","DIDANOSINE CAP 200MG","DIDANOSINE DELAYED RELEASE CAPSULE 200 MG","1","0","0","1","30 caps every 30 days","","ANTI-INFECTIVES","ANTIRETROVIRAL AGENTS"],["N","G","DIDANOSINE CAP 250MG","DIDANOSINE DELAYED RELEASE CAPSULE 250 MG","1","0","0","1","30 caps every 30 days","","ANTI-INFECTIVES","ANTIRETROVIRAL AGENTS"],["N","G","DIDANOSINE CAP 400MG","DIDANOSINE DELAYED RELEASE CAPSULE 400 MG","1","0","0","1","30 caps every 30 days","","ANTI-INFECTIVES","ANTIRETROVIRAL AGENTS"],["N","G","EDURANT TAB 25MG","RILPIVIRINE HCL TAB 25 MG (BASE EQUIVALENT)","2","0","0","1","60 tabs every 30 days","","ANTI-INFECTIVES","ANTIRETROVIRAL AGENTS"],["N","G","EFAVIRENZ CAP 200MG","EFAVIRENZ CAP 200 MG","1","0","0","1","90 caps every 30 days","","ANTI-INFECTIVES","ANTIRETROVIRAL AGENTS"],["N","G","EFAVIRENZ CAP 50MG","EFAVIRENZ CAP 50 MG","1","0","0","1","90 caps every 30 days","","ANTI-INFECTIVES","ANTIRETROVIRAL AGENTS"],["N","G","EFAVIRENZ TAB 600MG","EFAVIRENZ TAB 600 MG","1","0","0","1","30 tabs every 30 days","","ANTI-INFECTIVES","ANTIRETROVIRAL AGENTS"],["N","G","EMTRIVA CAP 200MG","EMTRICITABINE CAPS 200 MG","2","0","0","1","30 caps every 30 days","","ANTI-INFECTIVES","ANTIRETROVIRAL AGENTS"],["N","G","EMTRIVA SOL 10MG/ML","EMTRICITABINE SOLN 10 MG/ML","2","0","0","1","680 ml every 28 days","","ANTI-INFECTIVES","ANTIRETROVIRAL AGENTS"],["N","G","FOSAMPRENAVI TAB 700MG","FOSAMPRENAVIR CALCIUM TAB 700 MG (BASE EQUIV)","1","0","0","1","120 tabs every 30 days","","ANTI-INFECTIVES","ANTIRETROVIRAL AGENTS"],["N","G","FUZEON INJ 90MG","ENFUVIRTIDE FOR INJ 90 MG","4","0","0","1","60 vials every 30 days","","ANTI-INFECTIVES","ANTIRETROVIRAL AGENTS"],["N","G","INTELENCE TAB 100MG","ETRAVIRINE TAB 100 MG","2","0","0","1","120 tabs every 30 days","","ANTI-INFECTIVES","ANTIRETROVIRAL AGENTS"],["N","G","INTELENCE TAB 200MG","ETRAVIRINE TAB 200 MG","2","0","0","1","60 tabs every 30 days","","ANTI-INFECTIVES","ANTIRETROVIRAL AGENTS"],["N","G","INTELENCE TAB 25MG","ETRAVIRINE TAB 25 MG","2","0","0","1","120 tabs every 30 days","","ANTI-INFECTIVES","ANTIRETROVIRAL AGENTS"],["N","G","INVIRASE CAP 200MG","SAQUINAVIR MESYLATE CAP 200 MG","2","0","0","1","300 caps every 30 days","","ANTI-INFECTIVES","ANTIRETROVIRAL AGENTS"],["N","G","INVIRASE TAB 500MG","SAQUINAVIR MESYLATE TAB 500 MG","2","0","0","1","120 tabs every 30 days","","ANTI-INFECTIVES","ANTIRETROVIRAL AGENTS"],["N","G","ISENTRESS CHW 100MG","RALTEGRAVIR POTASSIUM CHEW TAB 100 MG (BASE EQUIV)","2","0","0","1","180 tabs every 30 days","","ANTI-INFECTIVES","ANTIRETROVIRAL AGENTS"],["N","G","ISENTRESS CHW 25MG","RALTEGRAVIR POTASSIUM CHEW TAB 25 MG (BASE EQUIV)","2","0","0","1","180 tabs every 30 days","","ANTI-INFECTIVES","ANTIRETROVIRAL AGENTS"],["N","G","ISENTRESS HD TAB 600MG","RALTEGRAVIR POTASSIUM TAB 600 MG (BASE EQUIV)","2","0","0","1","60 tabs every 30 days","","ANTI-INFECTIVES","ANTIRETROVIRAL AGENTS"],["N","G","ISENTRESS POW 100MG","RALTEGRAVIR POTASSIUM PACKET FOR SUSP 100 MG (BASE EQUIV)","2","0","0","1","60 packets every 30 days","","ANTI-INFECTIVES","ANTIRETROVIRAL AGENTS"],["N","G","ISENTRESS TAB 400MG","RALTEGRAVIR POTASSIUM TAB 400 MG (BASE EQUIV)","2","0","0","1","120 tabs every 30 days","","ANTI-INFECTIVES","ANTIRETROVIRAL AGENTS"],["N","G","LAMIVUDINE SOL 10MG/ML","LAMIVUDINE ORAL SOLN 10 MG/ML","1","0","0","1","900 ml every 30 days","","ANTI-INFECTIVES","ANTIRETROVIRAL AGENTS"],["N","G","LAMIVUDINE TAB 150MG","LAMIVUDINE TAB 150 MG","1","0","0","1","60 tabs every 30 days","","ANTI-INFECTIVES","ANTIRETROVIRAL AGENTS"],["N","G","LAMIVUDINE TAB 300MG","LAMIVUDINE TAB 300 MG","1","0","0","1","30 tabs every 30 days","","ANTI-INFECTIVES","ANTIRETROVIRAL AGENTS"],["N","G","LEXIVA SUS 50MG/ML","FOSAMPRENAVIR CALCIUM SUSP 50 MG/ML (BASE EQUIV)","2","0","0","1","1575 mL every 28 days","","ANTI-INFECTIVES","ANTIRETROVIRAL AGENTS"],["N","G","NEVIRAPINE SUS 50MG/5ML","NEVIRAPINE SUSP 50 MG/5ML","1","0","0","1","1200 mL every 30 days","","ANTI-INFECTIVES","ANTIRETROVIRAL AGENTS"],["N","G","NEVIRAPINE TAB 100MG","NEVIRAPINE TAB ER 24HR 100 MG","1","0","0","1","90 tabs every 30 days","","ANTI-INFECTIVES","ANTIRETROVIRAL AGENTS"],["N","G","NEVIRAPINE TAB 200MG","NEVIRAPINE TAB 200 MG","1","0","0","1","60 tabs every 30 days","","ANTI-INFECTIVES","ANTIRETROVIRAL AGENTS"],["N","G","NEVIRAPINE TAB 400MG ER","NEVIRAPINE TAB ER 24HR 400 MG","1","0","0","1","30 tabs every 30 days","","ANTI-INFECTIVES","ANTIRETROVIRAL AGENTS"],["N","G","NORVIR CAP 100MG","RITONAVIR CAP 100 MG","2","0","0","1","360 caps every 30 days","","ANTI-INFECTIVES","ANTIRETROVIRAL AGENTS"],["N","G","NORVIR POW 100MG","RITONAVIR POWDER PACKET 100 MG","2","0","0","1","360 packets every 30 days","","ANTI-INFECTIVES","ANTIRETROVIRAL AGENTS"],["N","G","NORVIR SOL 80MG/ML","RITONAVIR ORAL SOLN 80 MG/ML","2","0","0","1","480 mL every 30 days","","ANTI-INFECTIVES","ANTIRETROVIRAL AGENTS"],["N","G","PREZISTA SUS 100MG/ML","DARUNAVIR ETHANOLATE SUSP 100 MG/ML (BASE EQUIV)","2","0","0","1","400 ml every 30 days","","ANTI-INFECTIVES","ANTIRETROVIRAL AGENTS"],["N","G","PREZISTA TAB 150MG","DARUNAVIR ETHANOLATE TAB 150 MG (BASE EQUIV)","2","0","0","1","180 tabs every 30 days","","ANTI-INFECTIVES","ANTIRETROVIRAL AGENTS"],["N","G","PREZISTA TAB 600MG","DARUNAVIR ETHANOLATE TAB 600 MG (BASE EQUIV)","2","0","0","1","60 tabs every 30 days","","ANTI-INFECTIVES","ANTIRETROVIRAL AGENTS"],["N","G","PREZISTA TAB 75MG","DARUNAVIR ETHANOLATE TAB 75 MG (BASE EQUIV)","2","0","0","1","300 tabs every 30 days","","ANTI-INFECTIVES","ANTIRETROVIRAL AGENTS"],["N","G","PREZISTA TAB 800MG","DARUNAVIR ETHANOLATE TAB 800 MG (BASE EQUIV)","2","0","0","1","30 tabs every 30 days","","ANTI-INFECTIVES","ANTIRETROVIRAL AGENTS"],["N","G","RETROVIR INJ 10MG/ML","ZIDOVUDINE IV SOLN 10 MG/ML","2","0","0","0","","","ANTI-INFECTIVES","ANTIRETROVIRAL AGENTS"],["N","G","REYATAZ POW 50MG","ATAZANAVIR SULFATE ORAL POWDER PACKET 50 MG (BASE EQUIV)","2","0","0","1","180 packets every 30 days","","ANTI-INFECTIVES","ANTIRETROVIRAL AGENTS"],["N","G","RITONAVIR TAB 100MG","RITONAVIR TAB 100 MG","1","0","0","1","360 tabs every 30 days","","ANTI-INFECTIVES","ANTIRETROVIRAL AGENTS"],["N","G","SELZENTRY SOL 20MG/ML","MARAVIROC ORAL SOLN 20 MG/ML","2","0","0","1","1840 mL every 30 days","","ANTI-INFECTIVES","ANTIRETROVIRAL AGENTS"],["N","G","SELZENTRY TAB 150MG","MARAVIROC TAB 150 MG","2","0","0","1","60 tabs every 30 days","","ANTI-INFECTIVES","ANTIRETROVIRAL AGENTS"],["N","G","SELZENTRY TAB 25MG","MARAVIROC TAB 25 MG","2","0","0","1","240 tabs every 30 days","","ANTI-INFECTIVES","ANTIRETROVIRAL AGENTS"],["N","G","SELZENTRY TAB 300MG","MARAVIROC TAB 300 MG","2","0","0","1","120 tabs every 30 days","","ANTI-INFECTIVES","ANTIRETROVIRAL AGENTS"],["N","G","SELZENTRY TAB 75MG","MARAVIROC TAB 75 MG","2","0","0","1","60 tabs every 30 days","","ANTI-INFECTIVES","ANTIRETROVIRAL AGENTS"],["N","G","STAVUDINE CAP 15MG","STAVUDINE CAP 15 MG","1","0","0","1","60 caps every 30 days","","ANTI-INFECTIVES","ANTIRETROVIRAL AGENTS"],["N","G","STAVUDINE CAP 20MG","STAVUDINE CAP 20 MG","1","0","0","1","60 caps every 30 days","","ANTI-INFECTIVES","ANTIRETROVIRAL AGENTS"],["N","G","STAVUDINE CAP 30MG","STAVUDINE CAP 30 MG","1","0","0","1","60 caps every 30 days","","ANTI-INFECTIVES","ANTIRETROVIRAL AGENTS"],["N","G","STAVUDINE CAP 40MG","STAVUDINE CAP 40 MG","1","0","0","1","60 caps every 30 days","","ANTI-INFECTIVES","ANTIRETROVIRAL AGENTS"],["N","G","TENOFOVIR TAB 300MG","TENOFOVIR DISOPROXIL FUMARATE TAB 300 MG","1","0","0","1","30 tabs every 30 days","","ANTI-INFECTIVES","ANTIRETROVIRAL AGENTS"],["N","G","TIVICAY TAB 10MG","DOLUTEGRAVIR SODIUM TAB 10 MG (BASE EQUIV)","2","0","0","1","60 tabs every 30 days","","ANTI-INFECTIVES","ANTIRETROVIRAL AGENTS"],["N","G","TIVICAY TAB 25MG","DOLUTEGRAVIR SODIUM TAB 25 MG (BASE EQUIV)","2","0","0","1","60 tabs every 30 days","","ANTI-INFECTIVES","ANTIRETROVIRAL AGENTS"],["N","G","TIVICAY TAB 50MG","DOLUTEGRAVIR SODIUM TAB 50 MG (BASE EQUIV)","2","0","0","1","60 tabs every 30 days","","ANTI-INFECTIVES","ANTIRETROVIRAL AGENTS"],["N","G","TROGARZO INJ 150MG/ML","IBALIZUMAB-UIYK IV SOLN 200 MG/1.33ML (150 MG/ML)","4","0","0","0","","","ANTI-INFECTIVES","ANTIRETROVIRAL AGENTS"],["N","G","TYBOST TAB 150MG","COBICISTAT TAB 150 MG","2","0","0","1","30 tabs every 30 days","","ANTI-INFECTIVES","ANTIRETROVIRAL AGENTS"],["N","G","VIDEX EC CAP 125MG","DIDANOSINE DELAYED RELEASE CAPSULE 125 MG","2","0","0","1","30 caps every 30 days","","ANTI-INFECTIVES","ANTIRETROVIRAL AGENTS"],["N","G","VIDEX SOL 2GM","DIDANOSINE FOR SOLN 2 GM","2","0","0","1","1200 ml every 30 days","","ANTI-INFECTIVES","ANTIRETROVIRAL AGENTS"],["N","G","VIDEX SOL 4GM","DIDANOSINE FOR SOLN 4 GM","2","0","0","1","1200 ml every 30 days","","ANTI-INFECTIVES","ANTIRETROVIRAL AGENTS"],["N","G","VIRACEPT TAB 250MG","NELFINAVIR MESYLATE TAB 250 MG","2","0","0","1","300 tabs every 30 days","","ANTI-INFECTIVES","ANTIRETROVIRAL AGENTS"],["N","G","VIRACEPT TAB 625MG","NELFINAVIR MESYLATE TAB 625 MG","2","0","0","1","120 tabs every 30 days","","ANTI-INFECTIVES","ANTIRETROVIRAL AGENTS"],["N","G","VIREAD POW 40MG/GM","TENOFOVIR DISOPROXIL FUMARATE ORAL POWDER 40 MG/GM","2","0","0","1","240 gm every 30 days","","ANTI-INFECTIVES","ANTIRETROVIRAL AGENTS"],["N","G","VIREAD TAB 150MG","TENOFOVIR DISOPROXIL FUMARATE TAB 150 MG","2","0","0","1","30 tabs every 30 days","","ANTI-INFECTIVES","ANTIRETROVIRAL AGENTS"],["N","G","VIREAD TAB 200MG","TENOFOVIR DISOPROXIL FUMARATE TAB 200 MG","2","0","0","1","30 tabs every 30 days","","ANTI-INFECTIVES","ANTIRETROVIRAL AGENTS"],["N","G","VIREAD TAB 250MG","TENOFOVIR DISOPROXIL FUMARATE TAB 250 MG","2","0","0","1","30 tabs every 30 days","","ANTI-INFECTIVES","ANTIRETROVIRAL AGENTS"],["N","G","ZERIT SOL 1MG/ML","STAVUDINE FOR ORAL SOLN 1 MG/ML","2","0","0","1","2400 ml every 30 days","","ANTI-INFECTIVES","ANTIRETROVIRAL AGENTS"],["N","G","ZIDOVUDINE CAP 100MG","ZIDOVUDINE CAP 100 MG","1","0","0","1","180 caps every 30 days","","ANTI-INFECTIVES","ANTIRETROVIRAL AGENTS"],["N","G","ZIDOVUDINE SYP 50MG/5ML","ZIDOVUDINE SYRUP 10 MG/ML","1","0","0","1","1800 ml every 30 days","","ANTI-INFECTIVES","ANTIRETROVIRAL AGENTS"],["N","G","ZIDOVUDINE TAB 300MG","ZIDOVUDINE TAB 300 MG","1","0","0","1","60 tabs every 30 days","","ANTI-INFECTIVES","ANTIRETROVIRAL AGENTS"],["N","G","ABACA/LAMIVU TAB 600-300","ABACAVIR SULFATE-LAMIVUDINE TAB 600-300 MG","1","0","0","1","30 tabs every 30 days","","ANTI-INFECTIVES","ANTIRETROVIRAL COMBINATION AGENTS"],["N","G","ABACAV/LAMIV TAB /ZIDOVUD","ABACAVIR SULFATE-LAMIVUDINE-ZIDOVUDINE TAB 300-150-300 MG","1","0","0","1","60 tabs every 30 days","","ANTI-INFECTIVES","ANTIRETROVIRAL COMBINATION AGENTS"],["N","G","BIKTARVY TAB","BICTEGRAVIR-EMTRICITABINE-TENOFOVIR AF TAB 50-200-25 MG","2","0","0","1","30 tabs every 30 days","","ANTI-INFECTIVES","ANTIRETROVIRAL COMBINATION AGENTS"],["N","G","CIMDUO TAB 300-300","LAMIVUDINE-TENOFOVIR DISOPROXIL FUMARATE TAB 300-300 MG","2","0","0","1","30 tabs every 30 days","","ANTI-INFECTIVES","ANTIRETROVIRAL COMBINATION AGENTS"],["N","G","COMPLERA TAB","EMTRICITABINE-RILPIVIRINE-TENOFOVIR DF TAB 200-25-300 MG","2","0","0","1","30 tabs every 30 days","","ANTI-INFECTIVES","ANTIRETROVIRAL COMBINATION AGENTS"],["N","G","DESCOVY TAB 200/25","EMTRICITABINE-TENOFOVIR ALAFENAMIDE FUMARATE TAB 200-25 MG","2","0","0","1","30 tabs every 30 days","","ANTI-INFECTIVES","ANTIRETROVIRAL COMBINATION AGENTS"],["N","G","EVOTAZ TAB 300-150","ATAZANAVIR SULFATE-COBICISTAT TAB 300-150 MG (BASE EQUIV)","2","0","0","1","30 tabs every 30 days","","ANTI-INFECTIVES","ANTIRETROVIRAL COMBINATION AGENTS"],["N","G","GENVOYA TAB","ELVITEGRAV-COBIC-EMTRICITAB-TENOFOV AF TAB 150-150-200-10 MG","2","0","0","1","30 tabs every 30 days","","ANTI-INFECTIVES","ANTIRETROVIRAL COMBINATION AGENTS"],["N","G","KALETRA TAB 100-25MG","LOPINAVIR-RITONAVIR TAB 100-25 MG","2","0","0","1","240 tabs every 30 days","","ANTI-INFECTIVES","ANTIRETROVIRAL COMBINATION AGENTS"],["N","G","KALETRA TAB 200-50MG","LOPINAVIR-RITONAVIR TAB 200-50 MG","2","0","0","1","120 tabs every 30 days","","ANTI-INFECTIVES","ANTIRETROVIRAL COMBINATION AGENTS"],["N","G","LAMIVUD/ZIDO TAB 150-300","LAMIVUDINE-ZIDOVUDINE TAB 150-300 MG","1","0","0","1","60 tabs every 30 days","","ANTI-INFECTIVES","ANTIRETROVIRAL COMBINATION AGENTS"],["N","G","LOPIN/RITON SOL 80-20/ML","LOPINAVIR-RITONAVIR SOLN 400-100 MG/5ML (80-20 MG/ML)","1","0","0","1","390 mL every 30 days","","ANTI-INFECTIVES","ANTIRETROVIRAL COMBINATION AGENTS"],["N","G","ODEFSEY TAB","EMTRICITABINE-RILPIVIRINE-TENOFOVIR AF TAB 200-25-25 MG","2","0","0","1","30 tabs every 30 days","","ANTI-INFECTIVES","ANTIRETROVIRAL COMBINATION AGENTS"],["N","G","PREZCOBIX TAB 800-150","DARUNAVIR-COBICISTAT TAB 800-150 MG","2","0","0","1","30 tabs every 30 days","","ANTI-INFECTIVES","ANTIRETROVIRAL COMBINATION AGENTS"],["N","G","STRIBILD TAB","ELVITEGRAV-COBIC-EMTRICITAB-TENOFOVDF TAB 150-150-200-300 MG","2","0","0","1","30 tabs every 30 days","","ANTI-INFECTIVES","ANTIRETROVIRAL COMBINATION AGENTS"],["N","G","SYMFI LO TAB","EFAVIRENZ-LAMIVUDINE-TENOFOVIR DF TAB 400-300-300 MG","2","0","0","1","30 tabs every 30 days","","ANTI-INFECTIVES","ANTIRETROVIRAL COMBINATION AGENTS"],["N","G","SYMFI TAB","EFAVIRENZ-LAMIVUDINE-TENOFOVIR DF TAB 600-300-300 MG","2","0","0","1","30 tabs every 30 days","","ANTI-INFECTIVES","ANTIRETROVIRAL COMBINATION AGENTS"],["N","G","TRIUMEQ TAB","ABACAVIR-DOLUTEGRAVIR-LAMIVUDINE TAB 600-50-300 MG","2","0","0","1","30 tabs every 30 days","","ANTI-INFECTIVES","ANTIRETROVIRAL COMBINATION AGENTS"],["N","G","TRUVADA TAB 100-150","EMTRICITABINE-TENOFOVIR DISOPROXIL FUMARATE TAB 100-150 MG","2","0","0","1","30 tabs every 30 days","","ANTI-INFECTIVES","ANTIRETROVIRAL COMBINATION AGENTS"],["N","G","TRUVADA TAB 133-200","EMTRICITABINE-TENOFOVIR DISOPROXIL FUMARATE TAB 133-200 MG","2","0","0","1","30 tabs every 30 days","","ANTI-INFECTIVES","ANTIRETROVIRAL COMBINATION AGENTS"],["N","G","TRUVADA TAB 167-250","EMTRICITABINE-TENOFOVIR DISOPROXIL FUMARATE TAB 167-250 MG","2","0","0","1","30 tabs every 30 days","","ANTI-INFECTIVES","ANTIRETROVIRAL COMBINATION AGENTS"],["N","G","TRUVADA TAB 200-300","EMTRICITABINE-TENOFOVIR DISOPROXIL FUMARATE TAB 200-300 MG","2","0","1","1","30 tabs every 30 days","PA**; (coverage for pre and post-exposure prophylaxis only)","ANTI-INFECTIVES","ANTIRETROVIRAL COMBINATION AGENTS"],["N","G","CYCLOSERINE CAP 250MG","CYCLOSERINE CAP 250 MG","1","0","0","0","","","ANTI-INFECTIVES","ANTITUBERCULAR AGENTS"],["N","G","ETHAMBUTOL TAB 100MG","ETHAMBUTOL HCL TAB 100 MG","1","0","0","0","","","ANTI-INFECTIVES","ANTITUBERCULAR AGENTS"],["N","G","ETHAMBUTOL TAB 400MG","ETHAMBUTOL HCL TAB 400 MG","1","0","0","0","","","ANTI-INFECTIVES","ANTITUBERCULAR AGENTS"],["N","G","ISONIAZID INJ 100MG/ML","ISONIAZID INJ 100 MG/ML","1","0","0","0","","","ANTI-INFECTIVES","ANTITUBERCULAR AGENTS"],["N","G","ISONIAZID SYP 50MG/5ML","ISONIAZID SYRUP 50 MG/5ML","1","0","0","0","","","ANTI-INFECTIVES","ANTITUBERCULAR AGENTS"],["N","G","ISONIAZID TAB 100MG","ISONIAZID TAB 100 MG","1","0","0","0","","","ANTI-INFECTIVES","ANTITUBERCULAR AGENTS"],["N","G","ISONIAZID TAB 300MG","ISONIAZID TAB 300 MG","1","0","0","0","","","ANTI-INFECTIVES","ANTITUBERCULAR AGENTS"],["N","G","PASER GRA 4GM","AMINOSALICYLIC ACID ER GRANULES PACKET 4 GM","3","0","0","0","","","ANTI-INFECTIVES","ANTITUBERCULAR AGENTS"],["N","G","PRIFTIN TAB 150MG","RIFAPENTINE TAB 150 MG","2","0","0","0","","","ANTI-INFECTIVES","ANTITUBERCULAR AGENTS"],["N","G","PYRAZINAMIDE TAB 500MG","PYRAZINAMIDE TAB 500 MG","1","0","0","0","","","ANTI-INFECTIVES","ANTITUBERCULAR AGENTS"],["N","G","RIFABUTIN CAP 150MG","RIFABUTIN CAP 150 MG","1","0","0","0","","","ANTI-INFECTIVES","ANTITUBERCULAR AGENTS"],["N","G","RIFAMATE CAP","ISONIAZID & RIFAMPIN CAP 150-300 MG","2","0","0","0","","","ANTI-INFECTIVES","ANTITUBERCULAR AGENTS"],["N","G","RIFAMPIN CAP 150MG","RIFAMPIN CAP 150 MG","1","0","0","0","","","ANTI-INFECTIVES","ANTITUBERCULAR AGENTS"],["N","G","RIFAMPIN CAP 300MG","RIFAMPIN CAP 300 MG","1","0","0","0","","","ANTI-INFECTIVES","ANTITUBERCULAR AGENTS"],["N","G","RIFAMPIN INJ 600 MG","RIFAMPIN FOR INJ 600 MG","1","0","0","0","","","ANTI-INFECTIVES","ANTITUBERCULAR AGENTS"],["N","G","RIFATER TAB","ISONIAZID-RIFAMPIN W/ PYRAZINAMIDE TAB 50-120-300 MG","2","0","0","0","","","ANTI-INFECTIVES","ANTITUBERCULAR AGENTS"],["N","G","SIRTURO TAB 100MG","BEDAQUILINE FUMARATE TAB 100 MG (BASE EQUIV)","3","0","0","0","","","ANTI-INFECTIVES","ANTITUBERCULAR AGENTS"],["N","G","TRECATOR TAB 250MG","ETHIONAMIDE TAB 250 MG","2","0","0","0","","","ANTI-INFECTIVES","ANTITUBERCULAR AGENTS"],["N","G","ACYCLOVIR CAP 200MG","ACYCLOVIR CAP 200 MG","1","0","0","0","","","ANTI-INFECTIVES","ANTIVIRALS§"],["N","G","ACYCLOVIR NA INJ 500MG","ACYCLOVIR SODIUM FOR INJ 500 MG","1","0","0","0","","","ANTI-INFECTIVES","ANTIVIRALS§"],["N","G","ACYCLOVIR NA INJ 50MG/ML","ACYCLOVIR SODIUM IV SOLN 50 MG/ML","1","0","0","0","","","ANTI-INFECTIVES","ANTIVIRALS§"],["N","G","ACYCLOVIR SUS 200/5ML","ACYCLOVIR SUSP 200 MG/5ML","1","0","0","0","","","ANTI-INFECTIVES","ANTIVIRALS§"],["N","G","ACYCLOVIR TAB 400MG","ACYCLOVIR TAB 400 MG","1","0","0","0","","","ANTI-INFECTIVES","ANTIVIRALS§"],["N","G","ACYCLOVIR TAB 800MG","ACYCLOVIR TAB 800 MG","1","0","0","0","","","ANTI-INFECTIVES","ANTIVIRALS§"],["N","G","ADEFOV DIPIV TAB 10MG","ADEFOVIR DIPIVOXIL TAB 10 MG","4","0","0","0","","SP","ANTI-INFECTIVES","ANTIVIRALS§"],["N","G","BARACLUDE SOL .05MG/ML","ENTECAVIR ORAL SOLN 0.05 MG/ML","3","0","0","0","","SP","ANTI-INFECTIVES","ANTIVIRALS§"],["N","G","CIDOFOVIR INJ 75MG/ML","CIDOFOVIR IV INJ 75 MG/ML","1","0","0","0","","","ANTI-INFECTIVES","ANTIVIRALS§"],["N","G","ENTECAVIR TAB 0.5MG","ENTECAVIR TAB 0.5 MG","4","0","0","0","","SP","ANTI-INFECTIVES","ANTIVIRALS§"],["N","G","ENTECAVIR TAB 1MG","ENTECAVIR TAB 1 MG","4","0","0","0","","SP","ANTI-INFECTIVES","ANTIVIRALS§"],["N","G","EPIVIR HBV SOL 5MG/ML","LAMIVUDINE ORAL SOLN 5 MG/ML (HBV)","2","0","0","0","","SP","ANTI-INFECTIVES","ANTIVIRALS§"],["N","G","FAMCICLOVIR TAB 125MG","FAMCICLOVIR TAB 125 MG","1","0","0","0","","","ANTI-INFECTIVES","ANTIVIRALS§"],["N","G","FAMCICLOVIR TAB 250MG","FAMCICLOVIR TAB 250 MG","1","0","0","0","","","ANTI-INFECTIVES","ANTIVIRALS§"],["N","G","FAMCICLOVIR TAB 500MG","FAMCICLOVIR TAB 500 MG","1","0","0","0","","","ANTI-INFECTIVES","ANTIVIRALS§"],["N","G","LAMIVUDINE TAB 100MG","LAMIVUDINE TAB 100 MG (HBV)","1","0","0","0","","SP","ANTI-INFECTIVES","ANTIVIRALS§"],["N","G","OSELTAMIVIR CAP 30MG","OSELTAMIVIR PHOSPHATE CAP 30 MG (BASE EQUIV)","1","0","0","1","40 caps every 90 days","","ANTI-INFECTIVES","ANTIVIRALS§"],["N","G","OSELTAMIVIR CAP 45MG","OSELTAMIVIR PHOSPHATE CAP 45 MG (BASE EQUIV)","1","0","0","1","20 caps every 90 days","","ANTI-INFECTIVES","ANTIVIRALS§"],["N","G","OSELTAMIVIR CAP 75MG","OSELTAMIVIR PHOSPHATE CAP 75 MG (BASE EQUIV)","1","0","0","1","20 caps every 90 days","","ANTI-INFECTIVES","ANTIVIRALS§"],["N","G","OSELTAMIVIR SUS 6MG/ML","OSELTAMIVIR PHOSPHATE FOR SUSP 6 MG/ML (BASE EQUIV)","1","0","0","1","360 mL every 90 days","","ANTI-INFECTIVES","ANTIVIRALS§"],["N","G","RELENZA MIS DISKHALE","ZANAMIVIR AERO POWDER BREATH ACTIVATED 5 MG/BLISTER","2","0","0","1","2 inhalers every 90 days","","ANTI-INFECTIVES","ANTIVIRALS§"],["N","G","RIBAVIRIN INH 6GM","RIBAVIRIN FOR INHAL SOLN 6 GM","1","0","0","0","","","ANTI-INFECTIVES","ANTIVIRALS§"],["N","G","RIMANTADINE TAB 100MG","RIMANTADINE HYDROCHLORIDE TAB 100 MG","1","0","0","0","","","ANTI-INFECTIVES","ANTIVIRALS§"],["N","G","VALACYCLOVIR TAB 1GM","VALACYCLOVIR HCL TAB 1 GM","1","0","0","0","","","ANTI-INFECTIVES","ANTIVIRALS§"],["N","G","VALACYCLOVIR TAB 500MG","VALACYCLOVIR HCL TAB 500 MG","1","0","0","0","","","ANTI-INFECTIVES","ANTIVIRALS§"],["N","G","VALGANCICLOV SOL 50MG/ML","VALGANCICLOVIR HCL FOR SOLN 50 MG/ML (BASE EQUIV)","1","0","0","0","","","ANTI-INFECTIVES","ANTIVIRALS§"],["N","G","VALGANCICLOV TAB 450MG","VALGANCICLOVIR HCL TAB 450 MG (BASE EQUIVALENT)","1","0","0","0","","","ANTI-INFECTIVES","ANTIVIRALS§"],["N","G","VEMLIDY TAB 25MG","TENOFOVIR ALAFENAMIDE FUMARATE TAB 25 MG","3","0","0","0","","","ANTI-INFECTIVES","ANTIVIRALS§"],["N","G","CEFACLOR CAP 250MG","CEFACLOR CAP 250 MG","1","0","0","0","","","ANTI-INFECTIVES","CEPHALOSPORINS"],["N","G","CEFACLOR CAP 500MG","CEFACLOR CAP 500 MG","1","0","0","0","","","ANTI-INFECTIVES","CEPHALOSPORINS"],["N","G","CEFACLOR ER TAB 500MG","CEFACLOR MONOHYDRATE TAB ER 12HR 500 MG","2","0","0","0","","","ANTI-INFECTIVES","CEPHALOSPORINS"],["N","G","CEFACLOR SUS 125/5ML","CEFACLOR FOR SUSP 125 MG/5ML","1","0","0","0","","","ANTI-INFECTIVES","CEPHALOSPORINS"],["N","G","CEFACLOR SUS 250/5ML","CEFACLOR FOR SUSP 250 MG/5ML","1","0","0","0","","","ANTI-INFECTIVES","CEPHALOSPORINS"],["N","G","CEFACLOR SUS 375/5ML","CEFACLOR FOR SUSP 375 MG/5ML","1","0","0","0","","","ANTI-INFECTIVES","CEPHALOSPORINS"],["N","G","CEFADROXIL CAP 500MG","CEFADROXIL CAP 500 MG","1","0","0","0","","","ANTI-INFECTIVES","CEPHALOSPORINS"],["N","G","CEFADROXIL SUS 250/5ML","CEFADROXIL FOR SUSP 250 MG/5ML","1","0","0","0","","","ANTI-INFECTIVES","CEPHALOSPORINS"],["N","G","CEFADROXIL SUS 500/5ML","CEFADROXIL FOR SUSP 500 MG/5ML","1","0","0","0","","","ANTI-INFECTIVES","CEPHALOSPORINS"],["N","G","CEFADROXIL TAB 1GM","CEFADROXIL TAB 1 GM","1","0","0","0","","","ANTI-INFECTIVES","CEPHALOSPORINS"],["N","G","CEFAZOLIN INJ 10GM","CEFAZOLIN SODIUM FOR INJ 10 GM","1","0","0","0","","","ANTI-INFECTIVES","CEPHALOSPORINS"],["N","G","CEFAZOLIN INJ 1GM","CEFAZOLIN SODIUM FOR IV SOLN 1 GM","1","0","0","0","","","ANTI-INFECTIVES","CEPHALOSPORINS"],["N","G","CEFAZOLIN INJ 1GM","CEFAZOLIN SODIUM FOR INJ 1 GM","1","0","0","0","","","ANTI-INFECTIVES","CEPHALOSPORINS"],["N","G","CEFAZOLIN INJ 20GM","CEFAZOLIN SODIUM FOR INJ 20 GM","1","0","0","0","","","ANTI-INFECTIVES","CEPHALOSPORINS"],["N","G","CEFAZOLIN INJ 500MG","CEFAZOLIN SODIUM FOR INJ 500 MG","1","0","0","0","","","ANTI-INFECTIVES","CEPHALOSPORINS"],["N","G","CEFDINIR CAP 300MG","CEFDINIR CAP 300 MG","1","0","0","0","","","ANTI-INFECTIVES","CEPHALOSPORINS"],["N","G","CEFDINIR SUS 125/5ML","CEFDINIR FOR SUSP 125 MG/5ML","1","0","0","0","","","ANTI-INFECTIVES","CEPHALOSPORINS"],["N","G","CEFDINIR SUS 250/5ML","CEFDINIR FOR SUSP 250 MG/5ML","1","0","0","0","","","ANTI-INFECTIVES","CEPHALOSPORINS"],["N","G","CEFDITOREN TAB 200MG","CEFDITOREN PIVOXIL TAB 200 MG (BASE EQUIVALENT)","1","0","0","0","","","ANTI-INFECTIVES","CEPHALOSPORINS"],["N","G","CEFDITOREN TAB 400MG","CEFDITOREN PIVOXIL TAB 400 MG (BASE EQUIVALENT)","1","0","0","0","","","ANTI-INFECTIVES","CEPHALOSPORINS"],["N","G","CEFEPIME INJ 1GM","CEFEPIME HCL FOR INJ 1 GM","1","0","0","0","","","ANTI-INFECTIVES","CEPHALOSPORINS"],["N","G","CEFEPIME INJ 2GM","CEFEPIME HCL FOR INJ 2 GM","1","0","0","0","","","ANTI-INFECTIVES","CEPHALOSPORINS"],["N","G","CEFIXIME CAP 400MG","CEFIXIME CAP 400 MG","1","0","0","0","","","ANTI-INFECTIVES","CEPHALOSPORINS"],["N","G","CEFIXIME SUS 100/5ML","CEFIXIME FOR SUSP 100 MG/5ML","1","0","0","0","","","ANTI-INFECTIVES","CEPHALOSPORINS"],["N","G","CEFIXIME SUS 200/5ML","CEFIXIME FOR SUSP 200 MG/5ML","1","0","0","0","","","ANTI-INFECTIVES","CEPHALOSPORINS"],["N","G","CEFOTAXIME INJ 10GM","CEFOTAXIME SODIUM FOR INJ 10 GM","1","0","0","0","","","ANTI-INFECTIVES","CEPHALOSPORINS"],["N","G","CEFOTAXIME INJ 1GM","CEFOTAXIME SODIUM FOR INJ 1 GM","1","0","0","0","","","ANTI-INFECTIVES","CEPHALOSPORINS"],["N","G","CEFOTAXIME INJ 2GM","CEFOTAXIME SODIUM FOR INJ 2 GM","1","0","0","0","","","ANTI-INFECTIVES","CEPHALOSPORINS"],["N","G","CEFOTAXIME INJ 500MG","CEFOTAXIME SODIUM FOR INJ 500 MG","1","0","0","0","","","ANTI-INFECTIVES","CEPHALOSPORINS"],["N","G","CEFOTETAN INJ 10G","CEFOTETAN DISODIUM FOR INJ 10 GM","1","0","0","0","","","ANTI-INFECTIVES","CEPHALOSPORINS"],["N","G","CEFOTETAN INJ 1GM/10ML","CEFOTETAN DISODIUM FOR INJ 1 GM","1","0","0","0","","","ANTI-INFECTIVES","CEPHALOSPORINS"],["N","G","CEFOTETAN INJ 2GM/20ML","CEFOTETAN DISODIUM FOR INJ 2 GM","1","0","0","0","","","ANTI-INFECTIVES","CEPHALOSPORINS"],["N","G","CEFOXITIN INJ 10GM","CEFOXITIN SODIUM FOR INJ 10 GM","1","0","0","0","","","ANTI-INFECTIVES","CEPHALOSPORINS"],["N","G","CEFOXITIN INJ 1GM","CEFOXITIN SODIUM FOR IV SOLN 1 GM","1","0","0","0","","","ANTI-INFECTIVES","CEPHALOSPORINS"],["N","G","CEFOXITIN INJ 2GM","CEFOXITIN SODIUM FOR IV SOLN 2 GM","1","0","0","0","","","ANTI-INFECTIVES","CEPHALOSPORINS"],["N","G","CEFPODO PROX SUS 100/5ML","CEFPODOXIME PROXETIL FOR SUSP 100 MG/5ML","1","0","0","0","","","ANTI-INFECTIVES","CEPHALOSPORINS"],["N","G","CEFPODO PROX SUS 50MG/5ML","CEFPODOXIME PROXETIL FOR SUSP 50 MG/5ML","1","0","0","0","","","ANTI-INFECTIVES","CEPHALOSPORINS"],["N","G","CEFPODOXIME TAB 100MG","CEFPODOXIME PROXETIL TAB 100 MG","1","0","0","0","","","ANTI-INFECTIVES","CEPHALOSPORINS"],["N","G","CEFPODOXIME TAB 200MG","CEFPODOXIME PROXETIL TAB 200 MG","1","0","0","0","","","ANTI-INFECTIVES","CEPHALOSPORINS"],["N","G","CEFPROZIL SUS 125/5ML","CEFPROZIL FOR SUSP 125 MG/5ML","1","0","0","0","","","ANTI-INFECTIVES","CEPHALOSPORINS"],["N","G","CEFPROZIL SUS 250/5ML","CEFPROZIL FOR SUSP 250 MG/5ML","1","0","0","0","","","ANTI-INFECTIVES","CEPHALOSPORINS"],["N","G","CEFPROZIL TAB 250MG","CEFPROZIL TAB 250 MG","1","0","0","0","","","ANTI-INFECTIVES","CEPHALOSPORINS"],["N","G","CEFPROZIL TAB 500MG","CEFPROZIL TAB 500 MG","1","0","0","0","","","ANTI-INFECTIVES","CEPHALOSPORINS"],["N","G","CEFTAZIDIME INJ 2GM","CEFTAZIDIME FOR INJ 2 GM","1","0","0","0","","","ANTI-INFECTIVES","CEPHALOSPORINS"],["N","G","CEFTIBUTEN CAP 400MG","CEFTIBUTEN CAP 400 MG","1","0","0","0","","","ANTI-INFECTIVES","CEPHALOSPORINS"],["N","G","CEFTIBUTEN SUS 180/5ML","CEFTIBUTEN FOR SUSP 180 MG/5ML","1","0","0","0","","","ANTI-INFECTIVES","CEPHALOSPORINS"],["N","G","CEFTIN SUS 125/5ML","CEFUROXIME AXETIL FOR SUSP 125 MG/5ML","2","0","0","0","","","ANTI-INFECTIVES","CEPHALOSPORINS"],["N","G","CEFTIN SUS 250/5ML","CEFUROXIME AXETIL FOR SUSP 250 MG/5ML","2","0","0","0","","","ANTI-INFECTIVES","CEPHALOSPORINS"],["N","G","CEFTRIAXONE INJ 10GM","CEFTRIAXONE SODIUM FOR INJ 10 GM","1","0","0","0","","","ANTI-INFECTIVES","CEPHALOSPORINS"],["N","G","CEFTRIAXONE INJ 1GM","CEFTRIAXONE SODIUM FOR INJ 1 GM","1","0","0","0","","","ANTI-INFECTIVES","CEPHALOSPORINS"],["N","G","CEFTRIAXONE INJ 1GM","CEFTRIAXONE SODIUM FOR IV SOLN 1 GM","1","0","0","0","","","ANTI-INFECTIVES","CEPHALOSPORINS"],["N","G","CEFTRIAXONE INJ 250MG","CEFTRIAXONE SODIUM FOR INJ 250 MG","1","0","0","0","","","ANTI-INFECTIVES","CEPHALOSPORINS"],["N","G","CEFTRIAXONE INJ 2GM","CEFTRIAXONE SODIUM FOR IV SOLN 2 GM","1","0","0","0","","","ANTI-INFECTIVES","CEPHALOSPORINS"],["N","G","CEFTRIAXONE INJ 2GM","CEFTRIAXONE SODIUM FOR INJ 2 GM","1","0","0","0","","","ANTI-INFECTIVES","CEPHALOSPORINS"],["N","G","CEFTRIAXONE INJ 500MG","CEFTRIAXONE SODIUM FOR INJ 500 MG","1","0","0","0","","","ANTI-INFECTIVES","CEPHALOSPORINS"],["N","G","CEFUROXIME INJ 1.5GM","CEFUROXIME SODIUM FOR IV SOLN 1.5 GM","1","0","0","0","","","ANTI-INFECTIVES","CEPHALOSPORINS"],["N","G","CEFUROXIME INJ 1.5GM","CEFUROXIME SODIUM FOR IV SOLN 1.5 GM","1","0","0","0","","","ANTI-INFECTIVES","CEPHALOSPORINS"],["N","G","CEFUROXIME INJ 7.5GM","CEFUROXIME SODIUM FOR INJ 7.5 GM","1","0","0","0","","","ANTI-INFECTIVES","CEPHALOSPORINS"],["N","G","CEFUROXIME INJ 750MG","CEFUROXIME SODIUM FOR INJ 750 MG","1","0","0","0","","","ANTI-INFECTIVES","CEPHALOSPORINS"],["N","G","CEFUROXIME TAB 250MG","CEFUROXIME AXETIL TAB 250 MG","1","0","0","0","","","ANTI-INFECTIVES","CEPHALOSPORINS"],["N","G","CEFUROXIME TAB 500MG","CEFUROXIME AXETIL TAB 500 MG","1","0","0","0","","","ANTI-INFECTIVES","CEPHALOSPORINS"],["N","G","CEPHALEXIN CAP 250MG","CEPHALEXIN CAP 250 MG","1","0","0","0","","","ANTI-INFECTIVES","CEPHALOSPORINS"],["N","G","CEPHALEXIN CAP 500MG","CEPHALEXIN CAP 500 MG","1","0","0","0","","","ANTI-INFECTIVES","CEPHALOSPORINS"],["N","G","CEPHALEXIN CAP 750MG","CEPHALEXIN CAP 750 MG","1","0","0","0","","","ANTI-INFECTIVES","CEPHALOSPORINS"],["N","G","CEPHALEXIN SUS 125/5ML","CEPHALEXIN FOR SUSP 125 MG/5ML","1","0","0","0","","","ANTI-INFECTIVES","CEPHALOSPORINS"],["N","G","CEPHALEXIN SUS 250/5ML","CEPHALEXIN FOR SUSP 250 MG/5ML","1","0","0","0","","","ANTI-INFECTIVES","CEPHALOSPORINS"],["N","G","CEPHALEXIN TAB 250MG","CEPHALEXIN TAB 250 MG","1","0","0","0","","","ANTI-INFECTIVES","CEPHALOSPORINS"],["N","G","CEPHALEXIN TAB 500MG","CEPHALEXIN TAB 500 MG","1","0","0","0","","","ANTI-INFECTIVES","CEPHALOSPORINS"],["N","G","SUPRAX CHW 100MG","CEFIXIME CHEW TAB 100 MG","2","0","0","0","","","ANTI-INFECTIVES","CEPHALOSPORINS"],["N","G","SUPRAX CHW 200MG","CEFIXIME CHEW TAB 200 MG","2","0","0","0","","","ANTI-INFECTIVES","CEPHALOSPORINS"],["N","G","SUPRAX SUS 500/5ML","CEFIXIME FOR SUSP 500 MG/5ML","2","0","0","0","","","ANTI-INFECTIVES","CEPHALOSPORINS"],["N","G","TAZICEF INJ 1GM","CEFTAZIDIME FOR INJ 1 GM","1","0","0","0","","","ANTI-INFECTIVES","CEPHALOSPORINS"],["N","G","TAZICEF INJ 1GM","CEFTAZIDIME FOR IV SOLN 1 GM","1","0","0","0","","","ANTI-INFECTIVES","CEPHALOSPORINS"],["N","G","TAZICEF INJ 2GM","CEFTAZIDIME FOR IV SOLN 2 GM","1","0","0","0","","","ANTI-INFECTIVES","CEPHALOSPORINS"],["N","G","TAZICEF INJ 6GM","CEFTAZIDIME FOR INJ 6 GM","1","0","0","0","","","ANTI-INFECTIVES","CEPHALOSPORINS"],["N","G","ZINACEF INJ 750MG","CEFUROXIME SODIUM FOR IV SOLN 750 MG","3","0","0","0","","","ANTI-INFECTIVES","CEPHALOSPORINS"],["N","G","ZINACEF/H20 INJ 1.5GM PB","CEFUROXIME IN STERILE WATER INJ 1.5 GM/50ML","3","0","0","0","","","ANTI-INFECTIVES","CEPHALOSPORINS"],["N","G","AZITHROMYCIN INJ 500MG","AZITHROMYCIN IV FOR SOLN 500 MG","1","0","0","0","","","ANTI-INFECTIVES","ERYTHROMYCINS/MACROLIDES"],["N","G","AZITHROMYCIN POW 1GM PAK","AZITHROMYCIN POWD PACK FOR SUSP 1 GM","1","0","0","0","","","ANTI-INFECTIVES","ERYTHROMYCINS/MACROLIDES"],["N","G","AZITHROMYCIN SUS 100/5ML","AZITHROMYCIN FOR SUSP 100 MG/5ML","1","0","0","0","","","ANTI-INFECTIVES","ERYTHROMYCINS/MACROLIDES"],["N","G","AZITHROMYCIN SUS 200/5ML","AZITHROMYCIN FOR SUSP 200 MG/5ML","1","0","0","0","","","ANTI-INFECTIVES","ERYTHROMYCINS/MACROLIDES"],["N","G","AZITHROMYCIN TAB 250MG","AZITHROMYCIN TAB 250 MG","1","0","0","0","","","ANTI-INFECTIVES","ERYTHROMYCINS/MACROLIDES"],["N","G","AZITHROMYCIN TAB 500MG","AZITHROMYCIN TAB 500 MG","1","0","0","0","","","ANTI-INFECTIVES","ERYTHROMYCINS/MACROLIDES"],["N","G","AZITHROMYCIN TAB 600MG","AZITHROMYCIN TAB 600 MG","1","0","0","0","","","ANTI-INFECTIVES","ERYTHROMYCINS/MACROLIDES"],["N","G","CLARITHROMYC SUS 125/5ML","CLARITHROMYCIN FOR SUSP 125 MG/5ML","1","0","0","0","","","ANTI-INFECTIVES","ERYTHROMYCINS/MACROLIDES"],["N","G","CLARITHROMYC SUS 250/5ML","CLARITHROMYCIN FOR SUSP 250 MG/5ML","1","0","0","0","","","ANTI-INFECTIVES","ERYTHROMYCINS/MACROLIDES"],["N","G","CLARITHROMYC TAB 250MG","CLARITHROMYCIN TAB 250 MG","1","0","0","0","","","ANTI-INFECTIVES","ERYTHROMYCINS/MACROLIDES"],["N","G","CLARITHROMYC TAB 500MG","CLARITHROMYCIN TAB 500 MG","1","0","0","0","","","ANTI-INFECTIVES","ERYTHROMYCINS/MACROLIDES"],["N","G","CLARITHROMYC TAB 500MG ER","CLARITHROMYCIN TAB ER 24HR 500 MG","1","0","0","0","","","ANTI-INFECTIVES","ERYTHROMYCINS/MACROLIDES"],["N","G","DIFICID TAB 200MG","FIDAXOMICIN TAB 200 MG","2","1","0","0","","","ANTI-INFECTIVES","ERYTHROMYCINS/MACROLIDES"],["N","G","E.E.S. 400 TAB 400MG","ERYTHROMYCIN ETHYLSUCCINATE TAB 400 MG","1","0","0","0","","","ANTI-INFECTIVES","ERYTHROMYCINS/MACROLIDES"],["N","G","ERY-TAB TAB 250MG EC","ERYTHROMYCIN TAB DELAYED RELEASE 250 MG","1","0","0","0","","","ANTI-INFECTIVES","ERYTHROMYCINS/MACROLIDES"],["N","G","ERY-TAB TAB 333MG EC","ERYTHROMYCIN TAB DELAYED RELEASE 333 MG","1","0","0","0","","","ANTI-INFECTIVES","ERYTHROMYCINS/MACROLIDES"],["N","G","ERY-TAB TAB 500MG EC","ERYTHROMYCIN TAB DELAYED RELEASE 500 MG","1","0","0","0","","","ANTI-INFECTIVES","ERYTHROMYCINS/MACROLIDES"],["N","G","ERYTHROCIN INJ 500MG","ERYTHROMYCIN LACTOBIONATE FOR INJ 500 MG","3","0","0","0","","","ANTI-INFECTIVES","ERYTHROMYCINS/MACROLIDES"],["N","G","ERYTHROCIN INJ 500MG","ERYTHROMYCIN LACTOBIONATE FOR INJ 500 MG","3","0","0","0","","","ANTI-INFECTIVES","ERYTHROMYCINS/MACROLIDES"],["N","G","ERYTHROCIN TAB 250MG","ERYTHROMYCIN STEARATE TAB 250 MG","1","0","0","0","","","ANTI-INFECTIVES","ERYTHROMYCINS/MACROLIDES"],["N","G","ERYTHROM ETH SUS 200/5ML","ERYTHROMYCIN ETHYLSUCCINATE FOR SUSP 200 MG/5ML","1","0","0","0","","","ANTI-INFECTIVES","ERYTHROMYCINS/MACROLIDES"],["N","G","ERYTHROM ETH SUS 400/5ML","ERYTHROMYCIN ETHYLSUCCINATE FOR SUSP 400 MG/5ML","1","0","0","0","","","ANTI-INFECTIVES","ERYTHROMYCINS/MACROLIDES"],["N","G","ERYTHROM ETH TAB 400MG","ERYTHROMYCIN ETHYLSUCCINATE TAB 400 MG","1","0","0","0","","","ANTI-INFECTIVES","ERYTHROMYCINS/MACROLIDES"],["N","G","ERYTHROMYCIN CAP 250MG EC","ERYTHROMYCIN W/ DELAYED RELEASE PARTICLES CAP 250 MG","1","0","0","0","","","ANTI-INFECTIVES","ERYTHROMYCINS/MACROLIDES"],["N","G","ERYTHROMYCIN TAB 250MG BS","ERYTHROMYCIN TAB 250 MG","1","0","0","0","","","ANTI-INFECTIVES","ERYTHROMYCINS/MACROLIDES"],["N","G","ERYTHROMYCIN TAB 500MG BS","ERYTHROMYCIN TAB 500 MG","1","0","0","0","","","ANTI-INFECTIVES","ERYTHROMYCINS/MACROLIDES"],["N","G","PCE TAB 333MG EC","ERYTHROMYCIN W/ ENTERIC COATED PARTICLES TAB 333 MG","3","0","0","0","","","ANTI-INFECTIVES","ERYTHROMYCINS/MACROLIDES"],["N","G","PCE TAB 500MG EC","ERYTHROMYCIN W/ ENTERIC COATED PARTICLES TAB 500 MG","3","0","0","0","","","ANTI-INFECTIVES","ERYTHROMYCINS/MACROLIDES"],["N","G","ZMAX SUS 2GM","AZITHROMYCIN EXTENDED RELEASE FOR ORAL SUSP 2 GM","3","0","0","0","","","ANTI-INFECTIVES","ERYTHROMYCINS/MACROLIDES"],["N","G","CIPROFLOXACN INJ 200MG","CIPROFLOXACIN IV SOLN 200 MG/20ML (1%)","1","0","0","0","","","ANTI-INFECTIVES","FLUOROQUINOLONES"],["N","G","CIPROFLOXACN INJ 200MG","CIPROFLOXACIN 200 MG/100ML IN D5W","1","0","0","0","","","ANTI-INFECTIVES","FLUOROQUINOLONES"],["N","G","CIPROFLOXACN INJ 400MG","CIPROFLOXACIN IV SOLN 400 MG/40ML (1%)","1","0","0","0","","","ANTI-INFECTIVES","FLUOROQUINOLONES"],["N","G","CIPROFLOXACN INJ 400MG","CIPROFLOXACIN 400 MG/200ML IN D5W","1","0","0","0","","","ANTI-INFECTIVES","FLUOROQUINOLONES"],["N","G","CIPROFLOXACN SUS 250MG/5","CIPROFLOXACIN FOR ORAL SUSP 250 MG/5ML (5%) (5 GM/100ML)","1","0","0","0","","","ANTI-INFECTIVES","FLUOROQUINOLONES"],["N","G","CIPROFLOXACN SUS 500MG/5","CIPROFLOXACIN FOR ORAL SUSP 500 MG/5ML (10%) (10 GM/100ML)","1","0","0","0","","","ANTI-INFECTIVES","FLUOROQUINOLONES"],["N","G","CIPROFLOXACN TAB 1000MG","CIPROFLOXACIN-CIPROFLOXACIN HCL TAB ER 24HR 1000 MG(BASE EQ)","1","0","0","0","","","ANTI-INFECTIVES","FLUOROQUINOLONES"],["N","G","CIPROFLOXACN TAB 100MG","CIPROFLOXACIN HCL TAB 100 MG (BASE EQUIV)","1","0","0","0","","","ANTI-INFECTIVES","FLUOROQUINOLONES"],["N","G","CIPROFLOXACN TAB 250MG","CIPROFLOXACIN HCL TAB 250 MG (BASE EQUIV)","1","0","0","0","","","ANTI-INFECTIVES","FLUOROQUINOLONES"],["N","G","CIPROFLOXACN TAB 500MG","CIPROFLOXACIN HCL TAB 500 MG (BASE EQUIV)","1","0","0","0","","","ANTI-INFECTIVES","FLUOROQUINOLONES"],["N","G","CIPROFLOXACN TAB 500MG ER","CIPROFLOXACIN-CIPROFLOXACIN HCL TAB ER 24HR 500 MG (BASE EQ)","1","0","0","0","","","ANTI-INFECTIVES","FLUOROQUINOLONES"],["N","G","CIPROFLOXACN TAB 750MG","CIPROFLOXACIN HCL TAB 750 MG (BASE EQUIV)","1","0","0","0","","","ANTI-INFECTIVES","FLUOROQUINOLONES"],["N","G","FACTIVE TAB 320MG","GEMIFLOXACIN MESYLATE TAB 320 MG (BASE EQUIV)","3","0","0","0","","","ANTI-INFECTIVES","FLUOROQUINOLONES"],["N","G","LEVOFLOX/D5W INJ 250/50ML","LEVOFLOXACIN IN D5W IV SOLN 250 MG/50ML","1","0","0","0","","","ANTI-INFECTIVES","FLUOROQUINOLONES"],["N","G","LEVOFLOX/D5W INJ 500/100M","LEVOFLOXACIN IN D5W IV SOLN 500 MG/100ML","1","0","0","0","","","ANTI-INFECTIVES","FLUOROQUINOLONES"],["N","G","LEVOFLOX/D5W INJ 750/150","LEVOFLOXACIN IN D5W IV SOLN 750 MG/150ML","1","0","0","0","","","ANTI-INFECTIVES","FLUOROQUINOLONES"],["N","G","LEVOFLOXACIN INJ 25MG/ML","LEVOFLOXACIN IV SOLN 25 MG/ML","1","0","0","0","","","ANTI-INFECTIVES","FLUOROQUINOLONES"],["N","G","LEVOFLOXACIN SOL 25MG/ML","LEVOFLOXACIN ORAL SOLN 25 MG/ML","1","0","0","0","","","ANTI-INFECTIVES","FLUOROQUINOLONES"],["N","G","LEVOFLOXACIN TAB 250MG","LEVOFLOXACIN TAB 250 MG","1","0","0","0","","","ANTI-INFECTIVES","FLUOROQUINOLONES"],["N","G","LEVOFLOXACIN TAB 500MG","LEVOFLOXACIN TAB 500 MG","1","0","0","0","","","ANTI-INFECTIVES","FLUOROQUINOLONES"],["N","G","LEVOFLOXACIN TAB 750MG","LEVOFLOXACIN TAB 750 MG","1","0","0","0","","","ANTI-INFECTIVES","FLUOROQUINOLONES"],["N","G","MOXIFLOXACIN INJ 400/250","MOXIFLOXACIN HCL 400 MG/250ML IN SODIUM CHLORIDE 0.8% INJ","1","0","0","0","","","ANTI-INFECTIVES","FLUOROQUINOLONES"],["N","G","MOXIFLOXACIN TAB 400MG","MOXIFLOXACIN HCL TAB 400 MG (BASE EQUIV)","1","0","0","0","","","ANTI-INFECTIVES","FLUOROQUINOLONES"],["N","G","OFLOXACIN TAB 300MG","OFLOXACIN TAB 300 MG","1","0","0","0","","","ANTI-INFECTIVES","FLUOROQUINOLONES"],["N","G","OFLOXACIN TAB 400MG","OFLOXACIN TAB 400 MG","1","0","0","0","","","ANTI-INFECTIVES","FLUOROQUINOLONES"],["N","G","EPCLUSA TAB 400-100","SOFOSBUVIR-VELPATASVIR TAB 400-100 MG","4","1","0","1","28 tabs every 28 days","SP","ANTI-INFECTIVES","HEPATITIS C"],["N","G","HARVONI TAB 90-400MG","LEDIPASVIR-SOFOSBUVIR TAB 90-400 MG","4","1","0","1","28 tabs every 28 days","SP","ANTI-INFECTIVES","HEPATITIS C"],["N","G","PEGASYS INJ","PEGINTERFERON ALFA-2A INJ 180 MCG/0.5ML","4","1","0","0","","SP","ANTI-INFECTIVES","HEPATITIS C"],["N","G","PEGASYS INJ 180MCG/M","PEGINTERFERON ALFA-2A INJ 180 MCG/ML","4","1","0","0","","SP","ANTI-INFECTIVES","HEPATITIS C"],["N","G","PEGASYS INJ PROCLICK","PEGINTERFERON ALFA-2A INJ 135 MCG/0.5ML","4","1","0","0","","SP","ANTI-INFECTIVES","HEPATITIS C"],["N","G","REBETOL SOL 40MG/ML","RIBAVIRIN SOLN 40 MG/ML","4","1","0","0","","SP","ANTI-INFECTIVES","HEPATITIS C"],["N","G","RIBASPHERE CAP 200MG","RIBAVIRIN CAP 200 MG","1","1","0","0","","SP","ANTI-INFECTIVES","HEPATITIS C"],["N","G","RIBASPHERE TAB 200MG","RIBAVIRIN TAB 200 MG","1","1","0","0","","SP","ANTI-INFECTIVES","HEPATITIS C"],["N","G","RIBASPHERE TAB 400MG","RIBAVIRIN TAB 400 MG","1","1","0","0","","SP","ANTI-INFECTIVES","HEPATITIS C"],["N","G","RIBASPHERE TAB 600MG","RIBAVIRIN TAB 600 MG","1","1","0","0","","SP","ANTI-INFECTIVES","HEPATITIS C"],["N","G","RIBAVIRIN CAP 200MG","RIBAVIRIN CAP 200 MG","1","1","0","0","","SP","ANTI-INFECTIVES","HEPATITIS C"],["N","G","RIBAVIRIN TAB 200MG","RIBAVIRIN TAB 200 MG","1","1","0","0","","SP","ANTI-INFECTIVES","HEPATITIS C"],["N","G","SOVALDI TAB 400MG","SOFOSBUVIR TAB 400 MG","4","1","1","1","28 tabs every 28 days","SP","ANTI-INFECTIVES","HEPATITIS C"],["N","G","VOSEVI TAB","SOFOSBUVIR-VELPATASVIR-VOXILAPREVIR TAB 400-100-100 MG","4","1","0","1","28 tabs every 28 days","SP","ANTI-INFECTIVES","HEPATITIS C"],["N","G","ZEPATIER TAB 50-100MG","ELBASVIR-GRAZOPREVIR TAB 50-100 MG","4","1","1","1","28 tabs every 28 days","SP","ANTI-INFECTIVES","HEPATITIS C"],["N","G","AMOX-POT CLA TAB ER","AMOXICILLIN & K CLAVULANATE TAB ER 12HR 1000-62.5 MG","1","0","0","0","","","ANTI-INFECTIVES","PENICILLINS"],["N","G","AMOX/K CLAV CHW 200MG","AMOXICILLIN & K CLAVULANATE CHEW TAB 200-28.5 MG","1","0","0","0","","","ANTI-INFECTIVES","PENICILLINS"],["N","G","AMOX/K CLAV CHW 400MG","AMOXICILLIN & K CLAVULANATE CHEW TAB 400-57 MG","1","0","0","0","","","ANTI-INFECTIVES","PENICILLINS"],["N","G","AMOX/K CLAV SUS 200/5ML","AMOXICILLIN & K CLAVULANATE FOR SUSP 200-28.5 MG/5ML","1","0","0","0","","","ANTI-INFECTIVES","PENICILLINS"],["N","G","AMOX/K CLAV SUS 250/5ML","AMOXICILLIN & K CLAVULANATE FOR SUSP 250-62.5 MG/5ML","1","0","0","0","","","ANTI-INFECTIVES","PENICILLINS"],["N","G","AMOX/K CLAV SUS 400/5ML","AMOXICILLIN & K CLAVULANATE FOR SUSP 400-57 MG/5ML","1","0","0","0","","","ANTI-INFECTIVES","PENICILLINS"],["N","G","AMOX/K CLAV SUS 600/5ML","AMOXICILLIN & K CLAVULANATE FOR SUSP 600-42.9 MG/5ML","1","0","0","0","","","ANTI-INFECTIVES","PENICILLINS"],["N","G","AMOX/K CLAV TAB 250-125","AMOXICILLIN & K CLAVULANATE TAB 250-125 MG","1","0","0","0","","","ANTI-INFECTIVES","PENICILLINS"],["N","G","AMOX/K CLAV TAB 500-125","AMOXICILLIN & K CLAVULANATE TAB 500-125 MG","1","0","0","0","","","ANTI-INFECTIVES","PENICILLINS"],["N","G","AMOX/K CLAV TAB 875-125","AMOXICILLIN & K CLAVULANATE TAB 875-125 MG","1","0","0","0","","","ANTI-INFECTIVES","PENICILLINS"],["N","G","AMOXICILLIN CAP 250MG","AMOXICILLIN (TRIHYDRATE) CAP 250 MG","1","0","0","0","","","ANTI-INFECTIVES","PENICILLINS"],["N","G","AMOXICILLIN CAP 500MG","AMOXICILLIN (TRIHYDRATE) CAP 500 MG","1","0","0","0","","","ANTI-INFECTIVES","PENICILLINS"],["N","G","AMOXICILLIN CHW 125MG","AMOXICILLIN (TRIHYDRATE) CHEW TAB 125 MG","1","0","0","0","","","ANTI-INFECTIVES","PENICILLINS"],["N","G","AMOXICILLIN CHW 250MG","AMOXICILLIN (TRIHYDRATE) CHEW TAB 250 MG","1","0","0","0","","","ANTI-INFECTIVES","PENICILLINS"],["N","G","AMOXICILLIN SUS 125/5ML","AMOXICILLIN (TRIHYDRATE) FOR SUSP 125 MG/5ML","1","0","0","0","","","ANTI-INFECTIVES","PENICILLINS"],["N","G","AMOXICILLIN SUS 200/5ML","AMOXICILLIN (TRIHYDRATE) FOR SUSP 200 MG/5ML","1","0","0","0","","","ANTI-INFECTIVES","PENICILLINS"],["N","G","AMOXICILLIN SUS 250/5ML","AMOXICILLIN (TRIHYDRATE) FOR SUSP 250 MG/5ML","1","0","0","0","","","ANTI-INFECTIVES","PENICILLINS"],["N","G","AMOXICILLIN SUS 400/5ML","AMOXICILLIN (TRIHYDRATE) FOR SUSP 400 MG/5ML","1","0","0","0","","","ANTI-INFECTIVES","PENICILLINS"],["N","G","AMOXICILLIN TAB 500MG","AMOXICILLIN (TRIHYDRATE) TAB 500 MG","1","0","0","0","","","ANTI-INFECTIVES","PENICILLINS"],["N","G","AMOXICILLIN TAB 875MG","AMOXICILLIN (TRIHYDRATE) TAB 875 MG","1","0","0","0","","","ANTI-INFECTIVES","PENICILLINS"],["N","G","AMP-SULBACTA INJ 1.5GM","AMPICILLIN & SULBACTAM SODIUM FOR INJ 1.5 (1-0.5) GM","1","0","0","0","","","ANTI-INFECTIVES","PENICILLINS"],["N","G","AMP-SULBACTA INJ 10-5GM","AMPICILLIN & SULBACTAM SODIUM FOR IV SOLN 15 (10-5) GM","1","0","0","0","","","ANTI-INFECTIVES","PENICILLINS"],["N","G","AMP-SULBACTA INJ 15GM","AMPICILLIN & SULBACTAM SODIUM FOR IV SOLN 15 (10-5) GM","1","0","0","0","","","ANTI-INFECTIVES","PENICILLINS"],["N","G","AMP-SULBACTA INJ 2-1GM","AMPICILLIN & SULBACTAM SODIUM FOR INJ 3 (2-1) GM","1","0","0","0","","","ANTI-INFECTIVES","PENICILLINS"],["N","G","AMP-SULBACTA INJ 3GM","AMPICILLIN & SULBACTAM SODIUM FOR INJ 3 (2-1) GM","1","0","0","0","","","ANTI-INFECTIVES","PENICILLINS"],["N","G","AMPICILLIN CAP 250MG","AMPICILLIN CAP 250 MG","1","0","0","0","","","ANTI-INFECTIVES","PENICILLINS"],["N","G","AMPICILLIN CAP 500MG","AMPICILLIN CAP 500 MG","1","0","0","0","","","ANTI-INFECTIVES","PENICILLINS"],["N","G","AMPICILLIN INJ 10GM","AMPICILLIN SODIUM FOR IV SOLN 10 GM","1","0","0","0","","","ANTI-INFECTIVES","PENICILLINS"],["N","G","AMPICILLIN INJ 10GM","AMPICILLIN SODIUM FOR IV SOLN 10 GM","1","0","0","0","","","ANTI-INFECTIVES","PENICILLINS"],["N","G","AMPICILLIN INJ 125MG","AMPICILLIN SODIUM FOR INJ 125 MG","1","0","0","0","","","ANTI-INFECTIVES","PENICILLINS"],["N","G","AMPICILLIN INJ 1GM","AMPICILLIN SODIUM FOR IV SOLN 1 GM","1","0","0","0","","","ANTI-INFECTIVES","PENICILLINS"],["N","G","AMPICILLIN INJ 1GM","AMPICILLIN SODIUM FOR INJ 1 GM","1","0","0","0","","","ANTI-INFECTIVES","PENICILLINS"],["N","G","AMPICILLIN INJ 250MG","AMPICILLIN SODIUM FOR INJ 250 MG","1","0","0","0","","","ANTI-INFECTIVES","PENICILLINS"],["N","G","AMPICILLIN INJ 2GM","AMPICILLIN SODIUM FOR INJ 2 GM","1","0","0","0","","","ANTI-INFECTIVES","PENICILLINS"],["N","G","AMPICILLIN INJ 2GM","AMPICILLIN SODIUM FOR IV SOLN 2 GM","1","0","0","0","","","ANTI-INFECTIVES","PENICILLINS"],["N","G","AMPICILLIN INJ 500MG","AMPICILLIN SODIUM FOR INJ 500 MG","1","0","0","0","","","ANTI-INFECTIVES","PENICILLINS"],["N","G","AMPICILLIN SUS 125/5ML","AMPICILLIN FOR SUSP 125 MG/5ML","1","0","0","0","","","ANTI-INFECTIVES","PENICILLINS"],["N","G","AMPICILLIN SUS 250/5ML","AMPICILLIN FOR SUSP 250 MG/5ML","1","0","0","0","","","ANTI-INFECTIVES","PENICILLINS"],["N","G","AUGMENTIN SUS 125/5ML","AMOXICILLIN & K CLAVULANATE FOR SUSP 125-31.25 MG/5ML","2","0","0","0","","","ANTI-INFECTIVES","PENICILLINS"],["N","G","DICLOXACILL CAP 250MG","DICLOXACILLIN SODIUM CAP 250 MG","1","0","0","0","","","ANTI-INFECTIVES","PENICILLINS"],["N","G","DICLOXACILL CAP 500MG","DICLOXACILLIN SODIUM CAP 500 MG","1","0","0","0","","","ANTI-INFECTIVES","PENICILLINS"],["N","G","NAFCILLIN INJ 10GM","NAFCILLIN SODIUM FOR IV SOLN 10 GM","1","0","0","0","","","ANTI-INFECTIVES","PENICILLINS"],["N","G","NAFCILLIN INJ 1GM","NAFCILLIN SODIUM FOR IV SOLN 1 GM","1","0","0","0","","","ANTI-INFECTIVES","PENICILLINS"],["N","G","NAFCILLIN INJ 1GM","NAFCILLIN SODIUM FOR INJ 1 GM","1","0","0","0","","","ANTI-INFECTIVES","PENICILLINS"],["N","G","NAFCILLIN INJ 2GM","NAFCILLIN SODIUM FOR IV SOLN 2 GM","1","0","0","0","","","ANTI-INFECTIVES","PENICILLINS"],["N","G","NAFCILLIN INJ 2GM","NAFCILLIN SODIUM FOR INJ 2 GM","1","0","0","0","","","ANTI-INFECTIVES","PENICILLINS"],["N","G","OXACILLIN INJ 10GM","OXACILLIN SODIUM FOR INJ 10 GM (BASE EQUIVALENT)","1","0","0","0","","","ANTI-INFECTIVES","PENICILLINS"],["N","G","OXACILLIN INJ 1GM","OXACILLIN SODIUM FOR INJ 1 GM (BASE EQUIVALENT)","1","0","0","0","","","ANTI-INFECTIVES","PENICILLINS"],["N","G","OXACILLIN INJ 2GM","OXACILLIN SODIUM FOR INJ 2 GM (BASE EQUIVALENT)","1","0","0","0","","","ANTI-INFECTIVES","PENICILLINS"],["N","G","PEN G SOD INJ 5000000","PENICILLIN G SODIUM FOR INJ 5000000 UNIT","1","0","0","0","","","ANTI-INFECTIVES","PENICILLINS"],["N","G","PENICILLN GK INJ 20MU","PENICILLIN G POTASSIUM FOR INJ 20000000 UNIT","1","0","0","0","","","ANTI-INFECTIVES","PENICILLINS"],["N","G","PENICILLN GK INJ 5MU","PENICILLIN G POTASSIUM FOR INJ 5000000 UNIT","1","0","0","0","","","ANTI-INFECTIVES","PENICILLINS"],["N","G","PENICILLN VK SOL 125/5ML","PENICILLIN V POTASSIUM FOR SOLN 125 MG/5ML","1","0","0","0","","","ANTI-INFECTIVES","PENICILLINS"],["N","G","PENICILLN VK SOL 250/5ML","PENICILLIN V POTASSIUM FOR SOLN 250 MG/5ML","1","0","0","0","","","ANTI-INFECTIVES","PENICILLINS"],["N","G","PENICILLN VK TAB 250MG","PENICILLIN V POTASSIUM TAB 250 MG","1","0","0","0","","","ANTI-INFECTIVES","PENICILLINS"],["N","G","PENICILLN VK TAB 500MG","PENICILLIN V POTASSIUM TAB 500 MG","1","0","0","0","","","ANTI-INFECTIVES","PENICILLINS"],["N","G","PFIZERPEN INJ 20000000","PENICILLIN G POTASSIUM FOR INJ 20000000 UNIT","1","0","0","0","","","ANTI-INFECTIVES","PENICILLINS"],["N","G","PIPER/TAZOBA INJ 2-0.25GM","PIPERACILLIN SOD-TAZOBACTAM SOD FOR INJ 2.25 GM (2-0.25 GM)","1","0","0","0","","","ANTI-INFECTIVES","PENICILLINS"],["N","G","PIPER/TAZOBA INJ 2-0.25GM","PIPERACILLIN SOD-TAZOBACTAM SOD FOR INJ 2.25 GM (2-0.25 GM)","1","0","0","0","","","ANTI-INFECTIVES","PENICILLINS"],["N","G","PIPER/TAZOBA INJ 3-0.375G","PIPERACILLIN SOD-TAZOBACTAM NA FOR INJ 3.375 GM (3-0.375 GM)","1","0","0","0","","","ANTI-INFECTIVES","PENICILLINS"],["N","G","PIPER/TAZOBA INJ 36-4.5GM","PIPERACILLIN SOD-TAZOBACTAM SOD FOR INJ 40.5 GM (36-4.5 GM)","1","0","0","0","","","ANTI-INFECTIVES","PENICILLINS"],["N","G","PIPER/TAZOBA INJ 4-0.5GM","PIPERACILLIN SOD-TAZOBACTAM SOD FOR INJ 4.5 GM (4-0.5 GM)","1","0","0","0","","","ANTI-INFECTIVES","PENICILLINS"],["N","G","AVIDOXY TAB 100MG","DOXYCYCLINE MONOHYDRATE TAB 100 MG","1","0","0","0","","","ANTI-INFECTIVES","TETRACYCLINES"],["N","G","DEMECLOCYCL TAB 150MG","DEMECLOCYCLINE HCL TAB 150 MG","1","0","0","0","","","ANTI-INFECTIVES","TETRACYCLINES"],["N","G","DEMECLOCYCL TAB 300MG","DEMECLOCYCLINE HCL TAB 300 MG","1","0","0","0","","","ANTI-INFECTIVES","TETRACYCLINES"],["N","G","DOXY 100 INJ 100MG","DOXYCYCLINE HYCLATE FOR INJ 100 MG","1","0","0","0","","","ANTI-INFECTIVES","TETRACYCLINES"],["N","G","DOXYCYC MONO CAP 100MG","DOXYCYCLINE MONOHYDRATE CAP 100 MG","1","0","0","0","","","ANTI-INFECTIVES","TETRACYCLINES"],["N","G","DOXYCYC MONO CAP 150MG","DOXYCYCLINE MONOHYDRATE CAP 150 MG","1","0","0","0","","","ANTI-INFECTIVES","TETRACYCLINES"],["N","G","DOXYCYC MONO CAP 50MG","DOXYCYCLINE MONOHYDRATE CAP 50 MG","1","0","0","0","","","ANTI-INFECTIVES","TETRACYCLINES"],["N","G","DOXYCYC MONO CAP 75MG","DOXYCYCLINE MONOHYDRATE CAP 75 MG","1","0","0","0","","","ANTI-INFECTIVES","TETRACYCLINES"],["N","G","DOXYCYC MONO TAB 150MG","DOXYCYCLINE MONOHYDRATE TAB 150 MG","1","0","0","0","","","ANTI-INFECTIVES","TETRACYCLINES"],["N","G","DOXYCYC MONO TAB 50MG","DOXYCYCLINE MONOHYDRATE TAB 50 MG","1","0","0","0","","","ANTI-INFECTIVES","TETRACYCLINES"],["N","G","DOXYCYC MONO TAB 75MG","DOXYCYCLINE MONOHYDRATE TAB 75 MG","1","0","0","0","","","ANTI-INFECTIVES","TETRACYCLINES"],["N","G","DOXYCYCL HYC CAP 100MG","DOXYCYCLINE HYCLATE CAP 100 MG","1","0","0","0","","","ANTI-INFECTIVES","TETRACYCLINES"],["N","G","DOXYCYCL HYC CAP 50MG","DOXYCYCLINE HYCLATE CAP 50 MG","1","0","0","0","","","ANTI-INFECTIVES","TETRACYCLINES"],["N","G","DOXYCYCL HYC INJ 100MG","DOXYCYCLINE HYCLATE FOR INJ 100 MG","1","0","0","0","","","ANTI-INFECTIVES","TETRACYCLINES"],["N","G","DOXYCYCL HYC TAB 100MG","DOXYCYCLINE HYCLATE TAB 100 MG","1","0","0","0","","","ANTI-INFECTIVES","TETRACYCLINES"],["N","G","DOXYCYCL HYC TAB 100MG DR","DOXYCYCLINE HYCLATE TAB DELAYED RELEASE 100 MG","1","0","0","0","","","ANTI-INFECTIVES","TETRACYCLINES"],["N","G","DOXYCYCL HYC TAB 150MG DR","DOXYCYCLINE HYCLATE TAB DELAYED RELEASE 150 MG","1","0","0","0","","","ANTI-INFECTIVES","TETRACYCLINES"],["N","G","DOXYCYCL HYC TAB 75MG DR","DOXYCYCLINE HYCLATE TAB DELAYED RELEASE 75 MG","1","0","0","0","","","ANTI-INFECTIVES","TETRACYCLINES"],["N","G","DOXYCYCLINE SUS 25MG/5ML","DOXYCYCLINE MONOHYDRATE FOR SUSP 25 MG/5ML","1","0","0","0","","","ANTI-INFECTIVES","TETRACYCLINES"],["N","G","DOXYCYCLINE TAB 20MG","DOXYCYCLINE HYCLATE TAB 20 MG","1","0","0","0","","","ANTI-INFECTIVES","TETRACYCLINES"],["N","G","MINOCYCLINE CAP 100MG","MINOCYCLINE HCL CAP 100 MG","1","0","0","0","","","ANTI-INFECTIVES","TETRACYCLINES"],["N","G","MINOCYCLINE CAP 50MG","MINOCYCLINE HCL CAP 50 MG","1","0","0","0","","","ANTI-INFECTIVES","TETRACYCLINES"],["N","G","MINOCYCLINE CAP 75MG","MINOCYCLINE HCL CAP 75 MG","1","0","0","0","","","ANTI-INFECTIVES","TETRACYCLINES"],["N","G","MINOCYCLINE TAB 100MG","MINOCYCLINE HCL TAB 100 MG","1","0","0","0","","","ANTI-INFECTIVES","TETRACYCLINES"],["N","G","MINOCYCLINE TAB 50MG","MINOCYCLINE HCL TAB 50 MG","1","0","0","0","","","ANTI-INFECTIVES","TETRACYCLINES"],["N","G","MINOCYCLINE TAB 75MG","MINOCYCLINE HCL TAB 75 MG","1","0","0","0","","","ANTI-INFECTIVES","TETRACYCLINES"],["N","G","MORGIDOX CAP 1X100MG","DOXYCYCLINE HYCLATE CAP 100 MG","1","0","0","0","","","ANTI-INFECTIVES","TETRACYCLINES"],["N","G","TETRACYCLINE CAP 250MG","TETRACYCLINE HCL CAP 250 MG","1","0","0","0","","","ANTI-INFECTIVES","TETRACYCLINES"],["N","G","TETRACYCLINE CAP 500MG","TETRACYCLINE HCL CAP 500 MG","1","0","0","0","","","ANTI-INFECTIVES","TETRACYCLINES"],["N","G","VIBRAMYCIN SYP 50MG/5ML","DOXYCYCLINE CALCIUM SYRUP 50 MG/5ML","3","0","0","0","","","ANTI-INFECTIVES","TETRACYCLINES"],["N","G","BUSULFAN INJ 6MG/ML","BUSULFAN INJ 6 MG/ML","1","0","0","0","","","ANTINEOPLASTIC AGENTS","ALKYLATING AGENTS"],["N","G","CARMUSTINE INJ 100MG","CARMUSTINE FOR INJ 100 MG","1","0","0","0","","","ANTINEOPLASTIC AGENTS","ALKYLATING AGENTS"],["N","G","CYCLOPHOSPH CAP 25MG","CYCLOPHOSPHAMIDE CAP 25 MG","1","0","0","0","","","ANTINEOPLASTIC AGENTS","ALKYLATING AGENTS"],["N","G","CYCLOPHOSPH CAP 50MG","CYCLOPHOSPHAMIDE CAP 50 MG","1","0","0","0","","","ANTINEOPLASTIC AGENTS","ALKYLATING AGENTS"],["N","G","CYCLOPHOSPH INJ 1GM","CYCLOPHOSPHAMIDE FOR INJ 1 GM","4","0","0","0","","","ANTINEOPLASTIC AGENTS","ALKYLATING AGENTS"],["N","G","CYCLOPHOSPH INJ 2GM","CYCLOPHOSPHAMIDE FOR INJ 2 GM","4","0","0","0","","","ANTINEOPLASTIC AGENTS","ALKYLATING AGENTS"],["N","G","CYCLOPHOSPH INJ 500MG","CYCLOPHOSPHAMIDE FOR INJ 500 MG","4","0","0","0","","","ANTINEOPLASTIC AGENTS","ALKYLATING AGENTS"],["N","G","DACARBAZINE INJ 100MG","DACARBAZINE FOR INJ 100 MG","1","0","0","0","","","ANTINEOPLASTIC AGENTS","ALKYLATING AGENTS"],["N","G","DACARBAZINE INJ 200MG","DACARBAZINE FOR INJ 200 MG","1","0","0","0","","","ANTINEOPLASTIC AGENTS","ALKYLATING AGENTS"],["N","G","EMCYT CAP 140MG","ESTRAMUSTINE PHOSPHATE SODIUM CAP 140 MG","4","0","0","0","","","ANTINEOPLASTIC AGENTS","ALKYLATING AGENTS"],["N","G","GLEOSTINE CAP 100MG","LOMUSTINE CAP 100 MG","4","0","0","0","","","ANTINEOPLASTIC AGENTS","ALKYLATING AGENTS"],["N","G","GLEOSTINE CAP 10MG","LOMUSTINE CAP 10 MG","4","0","0","0","","","ANTINEOPLASTIC AGENTS","ALKYLATING AGENTS"],["N","G","GLEOSTINE CAP 40MG","LOMUSTINE CAP 40 MG","4","0","0","0","","","ANTINEOPLASTIC AGENTS","ALKYLATING AGENTS"],["N","G","GLEOSTINE CAP 5MG","LOMUSTINE CAP 5 MG","4","0","0","0","","","ANTINEOPLASTIC AGENTS","ALKYLATING AGENTS"],["N","G","GLIADEL WAF 7.7MG","CARMUSTINE IN POLIFEPROSAN INTRACRANIAL IMPLANT WAFER 7.7 MG","2","0","0","0","","","ANTINEOPLASTIC AGENTS","ALKYLATING AGENTS"],["N","G","HEXALEN CAP 50MG","ALTRETAMINE CAP 50 MG","2","0","0","0","","","ANTINEOPLASTIC AGENTS","ALKYLATING AGENTS"],["N","G","IFOSFAMIDE INJ 1GM","IFOSFAMIDE FOR INJ 1 GM","1","0","0","0","","","ANTINEOPLASTIC AGENTS","ALKYLATING AGENTS"],["N","G","IFOSFAMIDE INJ 1GM/20ML","IFOSFAMIDE IV INJ 1 GM/20ML (50 MG/ML)","1","0","0","0","","","ANTINEOPLASTIC AGENTS","ALKYLATING AGENTS"],["N","G","IFOSFAMIDE INJ 3GM/60ML","IFOSFAMIDE IV INJ 3 GM/60ML (50 MG/ML)","1","0","0","0","","","ANTINEOPLASTIC AGENTS","ALKYLATING AGENTS"],["N","G","LEUKERAN TAB 2MG","CHLORAMBUCIL TAB 2 MG","2","0","0","0","","","ANTINEOPLASTIC AGENTS","ALKYLATING AGENTS"],["N","G","MELPHALAN INJ 50MG","MELPHALAN HCL FOR INJ 50 MG (BASE EQUIV)","1","0","0","0","","","ANTINEOPLASTIC AGENTS","ALKYLATING AGENTS"],["N","G","MELPHALAN TAB 2MG","MELPHALAN TAB 2 MG","1","0","0","0","","","ANTINEOPLASTIC AGENTS","ALKYLATING AGENTS"],["N","G","TEMODAR INJ 100MG","TEMOZOLOMIDE FOR IV SOLN 100 MG","4","1","0","0","","SP","ANTINEOPLASTIC AGENTS","ALKYLATING AGENTS"],["N","G","TEMOZOLOMIDE CAP 100MG","TEMOZOLOMIDE CAP 100 MG","4","1","0","0","","SP","ANTINEOPLASTIC AGENTS","ALKYLATING AGENTS"],["N","G","TEMOZOLOMIDE CAP 140MG","TEMOZOLOMIDE CAP 140 MG","4","1","0","0","","SP","ANTINEOPLASTIC AGENTS","ALKYLATING AGENTS"],["N","G","TEMOZOLOMIDE CAP 180MG","TEMOZOLOMIDE CAP 180 MG","4","1","0","0","","SP","ANTINEOPLASTIC AGENTS","ALKYLATING AGENTS"],["N","G","TEMOZOLOMIDE CAP 20MG","TEMOZOLOMIDE CAP 20 MG","4","1","0","0","","SP","ANTINEOPLASTIC AGENTS","ALKYLATING AGENTS"],["N","G","TEMOZOLOMIDE CAP 250MG","TEMOZOLOMIDE CAP 250 MG","4","1","0","0","","SP","ANTINEOPLASTIC AGENTS","ALKYLATING AGENTS"],["N","G","TEMOZOLOMIDE CAP 5MG","TEMOZOLOMIDE CAP 5 MG","4","1","0","0","","SP","ANTINEOPLASTIC AGENTS","ALKYLATING AGENTS"],["N","G","DAUNORUBICIN INJ 5MG/ML","DAUNORUBICIN HCL IV SOLN 20 MG/4ML (BASE EQUIV)","1","0","0","0","","","ANTINEOPLASTIC AGENTS","ANTHRACYCLINES"],["N","G","DOXORUBICIN INJ 10MG","DOXORUBICIN HCL FOR INJ 10 MG","1","0","0","0","","","ANTINEOPLASTIC AGENTS","ANTHRACYCLINES"],["N","G","DOXORUBICIN INJ 2MG/ML","DOXORUBICIN HCL LIPOSOMAL INJ (FOR IV INFUSION) 2 MG/ML","1","0","0","0","","","ANTINEOPLASTIC AGENTS","ANTHRACYCLINES"],["N","G","DOXORUBICIN INJ 2MG/ML","DOXORUBICIN HCL INJ 2 MG/ML","1","0","0","0","","","ANTINEOPLASTIC AGENTS","ANTHRACYCLINES"],["N","G","DOXORUBICIN INJ 50MG","DOXORUBICIN HCL FOR INJ 50 MG","1","0","0","0","","","ANTINEOPLASTIC AGENTS","ANTHRACYCLINES"],["N","G","EPIRUBICIN INJ 200MG","EPIRUBICIN HCL IV SOLN 200 MG/100ML (2 MG/ML)","1","0","0","0","","","ANTINEOPLASTIC AGENTS","ANTHRACYCLINES"],["N","G","EPIRUBICIN INJ 50/25ML","EPIRUBICIN HCL IV SOLN 50 MG/25ML (2 MG/ML)","1","0","0","0","","","ANTINEOPLASTIC AGENTS","ANTHRACYCLINES"],["N","G","IDARUBICIN INJ 10/10ML","IDARUBICIN HCL IV INJ 10 MG/10ML (1 MG/ML)","1","0","0","0","","","ANTINEOPLASTIC AGENTS","ANTHRACYCLINES"],["N","G","IDARUBICIN INJ 20/20ML","IDARUBICIN HCL IV INJ 20 MG/20ML (1 MG/ML)","1","0","0","0","","","ANTINEOPLASTIC AGENTS","ANTHRACYCLINES"],["N","G","IDARUBICIN INJ 5MG/5ML","IDARUBICIN HCL IV INJ 5 MG/5ML (1 MG/ML)","1","0","0","0","","","ANTINEOPLASTIC AGENTS","ANTHRACYCLINES"],["N","G","BLEOMYCIN INJ 15UNIT","BLEOMYCIN SULFATE FOR INJ 15 UNIT","1","0","0","0","","","ANTINEOPLASTIC AGENTS","ANTIBIOTICS"],["N","G","BLEOMYCIN INJ 30UNIT","BLEOMYCIN SULFATE FOR INJ 30 UNIT","1","0","0","0","","","ANTINEOPLASTIC AGENTS","ANTIBIOTICS"],["N","G","MITOMYCIN INJ 20MG","MITOMYCIN FOR IV SOLN 20 MG","1","0","0","0","","","ANTINEOPLASTIC AGENTS","ANTIBIOTICS"],["N","G","MITOMYCIN INJ 40MG","MITOMYCIN FOR IV SOLN 40 MG","1","0","0","0","","","ANTINEOPLASTIC AGENTS","ANTIBIOTICS"],["N","G","MITOMYCIN INJ 5MG","MITOMYCIN FOR IV SOLN 5 MG","1","0","0","0","","","ANTINEOPLASTIC AGENTS","ANTIBIOTICS"],["N","G","ADRUCIL INJ 500/10ML","FLUOROURACIL IV SOLN 500 MG/10ML (50 MG/ML)","1","0","0","0","","","ANTINEOPLASTIC AGENTS","ANTIMETABOLITES"],["N","G","ALIMTA INJ 100MG","PEMETREXED DISODIUM FOR IV SOLN 100 MG (BASE EQUIV)","4","0","0","0","","","ANTINEOPLASTIC AGENTS","ANTIMETABOLITES"],["N","G","ALIMTA INJ 500MG","PEMETREXED DISODIUM FOR IV SOLN 500 MG (BASE EQUIV)","4","0","0","0","","","ANTINEOPLASTIC AGENTS","ANTIMETABOLITES"],["N","G","ARRANON INJ 5MG/ML","NELARABINE IV SOLN 5 MG/ML","2","0","0","0","","","ANTINEOPLASTIC AGENTS","ANTIMETABOLITES"],["N","G","AZACITIDINE INJ 100MG","AZACITIDINE FOR INJ 100 MG","4","1","0","0","","SP","ANTINEOPLASTIC AGENTS","ANTIMETABOLITES"],["N","G","CAPECITABINE TAB 150MG","CAPECITABINE TAB 150 MG","4","1","0","1","120 tabs every 30 days","SP","ANTINEOPLASTIC AGENTS","ANTIMETABOLITES"],["N","G","CAPECITABINE TAB 500MG","CAPECITABINE TAB 500 MG","4","1","0","1","300 tabs every 30 days","SP","ANTINEOPLASTIC AGENTS","ANTIMETABOLITES"],["N","G","CLADRIBINE INJ 1MG/ML","CLADRIBINE IV SOLN 10 MG/10ML (1 MG/ML)","1","0","0","0","","","ANTINEOPLASTIC AGENTS","ANTIMETABOLITES"],["N","G","CLOFARABINE INJ 20/20ML","CLOFARABINE IV SOLN 1 MG/ML","1","0","0","0","","","ANTINEOPLASTIC AGENTS","ANTIMETABOLITES"],["N","G","CYTARABINE INJ 100MG/ML","CYTARABINE INJ PF 100 MG/ML","1","0","0","0","","","ANTINEOPLASTIC AGENTS","ANTIMETABOLITES"],["N","G","CYTARABINE INJ 20MG/ML","CYTARABINE INJ PF 20 MG/ML","1","0","0","0","","","ANTINEOPLASTIC AGENTS","ANTIMETABOLITES"],["N","G","CYTARABINE INJ 20MG/ML","CYTARABINE INJ 20 MG/ML","1","0","0","0","","","ANTINEOPLASTIC AGENTS","ANTIMETABOLITES"],["N","G","DECITABINE INJ 50MG","DECITABINE FOR INJ 50 MG","4","1","0","0","","SP","ANTINEOPLASTIC AGENTS","ANTIMETABOLITES"],["N","G","FLOXURIDINE INJ 0.5GM","FLOXURIDINE FOR INJ 0.5 GM","1","0","0","0","","","ANTINEOPLASTIC AGENTS","ANTIMETABOLITES"],["N","G","FLUDARABINE INJ 50MG","FLUDARABINE PHOSPHATE FOR INJ 50 MG","1","0","0","0","","","ANTINEOPLASTIC AGENTS","ANTIMETABOLITES"],["N","G","FLUDARABINE INJ 50MG/2ML","FLUDARABINE PHOSPHATE INJ 25 MG/ML","1","0","0","0","","","ANTINEOPLASTIC AGENTS","ANTIMETABOLITES"],["N","G","FLUOROURACIL INJ 1GM/20ML","FLUOROURACIL IV SOLN 1 GM/20ML (50 MG/ML)","1","0","0","0","","","ANTINEOPLASTIC AGENTS","ANTIMETABOLITES"],["N","G","FLUOROURACIL INJ 2.5G/50M","FLUOROURACIL IV SOLN 2.5 GM/50ML (50 MG/ML)","1","0","0","0","","","ANTINEOPLASTIC AGENTS","ANTIMETABOLITES"],["N","G","FLUOROURACIL INJ 500/10ML","FLUOROURACIL IV SOLN 500 MG/10ML (50 MG/ML)","1","0","0","0","","","ANTINEOPLASTIC AGENTS","ANTIMETABOLITES"],["N","G","FLUOROURACIL INJ 5GM/100M","FLUOROURACIL IV SOLN 5 GM/100ML (50 MG/ML)","1","0","0","0","","","ANTINEOPLASTIC AGENTS","ANTIMETABOLITES"],["N","G","GEMCITABINE INJ 1GM","GEMCITABINE HCL FOR INJ 1 GM","4","0","0","0","","","ANTINEOPLASTIC AGENTS","ANTIMETABOLITES"],["N","G","GEMCITABINE INJ 1GM","GEMCITABINE HCL INJ 1 GM/26.3ML (38 MG/ML) (BASE EQUIV)","4","0","0","0","","","ANTINEOPLASTIC AGENTS","ANTIMETABOLITES"],["N","G","GEMCITABINE INJ 200MG","GEMCITABINE HCL FOR INJ 200 MG","4","0","0","0","","","ANTINEOPLASTIC AGENTS","ANTIMETABOLITES"],["N","G","GEMCITABINE INJ 200MG","GEMCITABINE HCL INJ 200 MG/5.26ML (38 MG/ML) (BASE EQUIV)","4","0","0","0","","","ANTINEOPLASTIC AGENTS","ANTIMETABOLITES"],["N","G","GEMCITABINE INJ 2GM","GEMCITABINE HCL INJ 2 GM/52.6ML (38 MG/ML) (BASE EQUIV)","4","0","0","0","","","ANTINEOPLASTIC AGENTS","ANTIMETABOLITES"],["N","G","GEMCITABINE INJ 2GM","GEMCITABINE HCL FOR INJ 2 GM","4","0","0","0","","","ANTINEOPLASTIC AGENTS","ANTIMETABOLITES"],["N","G","MERCAPTOPUR TAB 50MG","MERCAPTOPURINE TAB 50 MG","1","0","0","0","","","ANTINEOPLASTIC AGENTS","ANTIMETABOLITES"],["N","G","METHOTREXATE INJ 1GM","METHOTREXATE SODIUM FOR INJ 1 GM","1","0","0","0","","","ANTINEOPLASTIC AGENTS","ANTIMETABOLITES"],["N","G","METHOTREXATE INJ 250/10ML","METHOTREXATE SODIUM INJ PF 250 MG/10ML (25 MG/ML)","1","0","0","0","","","ANTINEOPLASTIC AGENTS","ANTIMETABOLITES"],["N","G","METHOTREXATE INJ 25MG/ML","METHOTREXATE SODIUM INJ 50 MG/2ML (25 MG/ML)","1","0","0","0","","","ANTINEOPLASTIC AGENTS","ANTIMETABOLITES"],["N","G","METHOTREXATE INJ 25MG/ML","METHOTREXATE SODIUM INJ PF 1000 MG/40ML (25 MG/ML)","1","0","0","0","","","ANTINEOPLASTIC AGENTS","ANTIMETABOLITES"],["N","G","METHOTREXATE INJ 25MG/ML","METHOTREXATE SODIUM INJ 250 MG/10ML (25 MG/ML)","1","0","0","0","","","ANTINEOPLASTIC AGENTS","ANTIMETABOLITES"],["N","G","METHOTREXATE INJ 50MG/2ML","METHOTREXATE SODIUM INJ PF 50 MG/2ML (25 MG/ML)","1","0","0","0","","","ANTINEOPLASTIC AGENTS","ANTIMETABOLITES"],["N","G","NIPENT INJ 10MG","PENTOSTATIN FOR INJ 10 MG","2","0","0","0","","","ANTINEOPLASTIC AGENTS","ANTIMETABOLITES"],["N","G","TABLOID TAB 40MG","THIOGUANINE TAB 40 MG","2","0","0","0","","","ANTINEOPLASTIC AGENTS","ANTIMETABOLITES"],["N","G","ABRAXANE INJ 100MG","PACLITAXEL PROTEIN-BOUND PARTICLES FOR IV SUSP 100 MG","2","0","0","0","","","ANTINEOPLASTIC AGENTS","ANTIMITOTIC, TAXOIDS"],["N","G","DOCEFREZ INJ 20MG","DOCETAXEL FOR INJ 20 MG","2","0","0","0","","","ANTINEOPLASTIC AGENTS","ANTIMITOTIC, TAXOIDS"],["N","G","DOCETAXEL INJ 140/7ML","DOCETAXEL FOR INJ CONC 140 MG/7ML (20 MG/ML)","2","0","0","0","","","ANTINEOPLASTIC AGENTS","ANTIMITOTIC, TAXOIDS"],["N","G","DOCETAXEL INJ 160/16ML","DOCETAXEL SOLN FOR IV INFUSION 160 MG/16ML","1","0","0","0","","","ANTINEOPLASTIC AGENTS","ANTIMITOTIC, TAXOIDS"],["N","G","DOCETAXEL INJ 160/8ML","DOCETAXEL FOR INJ CONC 160 MG/8ML (20 MG/ML)","2","0","0","0","","","ANTINEOPLASTIC AGENTS","ANTIMITOTIC, TAXOIDS"],["N","G","DOCETAXEL INJ 160/8ML","DOCETAXEL FOR INJ CONC 160 MG/8ML (20 MG/ML)","1","0","0","0","","","ANTINEOPLASTIC AGENTS","ANTIMITOTIC, TAXOIDS"],["N","G","DOCETAXEL INJ 20/0.5ML","DOCETAXEL FOR INJ CONC 20 MG/0.5ML (40 MG/ML)","2","0","0","0","","","ANTINEOPLASTIC AGENTS","ANTIMITOTIC, TAXOIDS"],["N","G","DOCETAXEL INJ 20MG/2ML","DOCETAXEL SOLN FOR IV INFUSION 20 MG/2ML","1","0","0","0","","","ANTINEOPLASTIC AGENTS","ANTIMITOTIC, TAXOIDS"],["N","G","DOCETAXEL INJ 20MG/ML","DOCETAXEL FOR INJ CONC 20 MG/ML","1","0","0","0","","","ANTINEOPLASTIC AGENTS","ANTIMITOTIC, TAXOIDS"],["N","G","DOCETAXEL INJ 80MG/2ML","DOCETAXEL FOR INJ CONC 80 MG/2ML (40 MG/ML)","2","0","0","0","","","ANTINEOPLASTIC AGENTS","ANTIMITOTIC, TAXOIDS"],["N","G","DOCETAXEL INJ 80MG/4ML","DOCETAXEL FOR INJ CONC 80 MG/4ML (20 MG/ML)","1","0","0","0","","","ANTINEOPLASTIC AGENTS","ANTIMITOTIC, TAXOIDS"],["N","G","DOCETAXEL INJ 80MG/8ML","DOCETAXEL SOLN FOR IV INFUSION 80 MG/8ML","1","0","0","0","","","ANTINEOPLASTIC AGENTS","ANTIMITOTIC, TAXOIDS"],["N","G","DOCETAXEL INJ NON-ALCO","DOCETAXEL (NON-ALCOHOL FORMULA) IV SOLN 80 MG/4ML","2","0","0","0","","","ANTINEOPLASTIC AGENTS","ANTIMITOTIC, TAXOIDS"],["N","G","DOCETAXEL INJ NON-ALCO","DOCETAXEL (NON-ALCOHOL FORMULA) IV SOLN 160 MG/8ML","2","0","0","0","","","ANTINEOPLASTIC AGENTS","ANTIMITOTIC, TAXOIDS"],["N","G","DOCETAXEL INJ NON-ALCO","DOCETAXEL (NON-ALCOHOL FORMULA) IV SOLN 20 MG/ML","2","0","0","0","","","ANTINEOPLASTIC AGENTS","ANTIMITOTIC, TAXOIDS"],["N","G","PACLITAXEL INJ 100MG","PACLITAXEL IV CONC 100 MG/16.7ML (6 MG/ML)","1","0","0","0","","","ANTINEOPLASTIC AGENTS","ANTIMITOTIC, TAXOIDS"],["N","G","PACLITAXEL INJ 150/25ML","PACLITAXEL IV CONC 150 MG/25ML (6 MG/ML)","1","0","0","0","","","ANTINEOPLASTIC AGENTS","ANTIMITOTIC, TAXOIDS"],["N","G","PACLITAXEL INJ 300/50ML","PACLITAXEL IV CONC 300 MG/50ML (6 MG/ML)","1","0","0","0","","","ANTINEOPLASTIC AGENTS","ANTIMITOTIC, TAXOIDS"],["N","G","PACLITAXEL INJ 30MG/5ML","PACLITAXEL IV CONC 30 MG/5ML (6 MG/ML)","1","0","0","0","","","ANTINEOPLASTIC AGENTS","ANTIMITOTIC, TAXOIDS"],["N","G","VINBLASTINE INJ 1MG/ML","VINBLASTINE SULFATE INJ 1 MG/ML","1","0","0","0","","","ANTINEOPLASTIC AGENTS","ANTIMITOTIC, VINCA ALKALOIDS"],["N","G","VINCASAR PFS INJ 1MG/ML","VINCRISTINE SULFATE IV SOLN 1 MG/ML","1","0","0","0","","","ANTINEOPLASTIC AGENTS","ANTIMITOTIC, VINCA ALKALOIDS"],["N","G","VINCRISTINE INJ 1MG/ML","VINCRISTINE SULFATE IV SOLN 1 MG/ML","1","0","0","0","","","ANTINEOPLASTIC AGENTS","ANTIMITOTIC, VINCA ALKALOIDS"],["N","G","VINORELBINE INJ 10MG/ML","VINORELBINE TARTRATE INJ 10 MG/ML (BASE EQUIV)","1","0","0","0","","","ANTINEOPLASTIC AGENTS","ANTIMITOTIC, VINCA ALKALOIDS"],["N","G","VINORELBINE INJ 50MG/5ML","VINORELBINE TARTRATE INJ 50 MG/5ML (10 MG/ML) (BASE EQUIV)","1","0","0","0","","","ANTINEOPLASTIC AGENTS","ANTIMITOTIC, VINCA ALKALOIDS"],["N","G","ERBITUX INJ 100MG","CETUXIMAB IV SOLN 100 MG/50ML (2 MG/ML)","4","1","0","0","","SP","ANTINEOPLASTIC AGENTS","BIOLOGIC RESPONSE MODIFIERS"],["N","G","ERBITUX INJ 200MG","CETUXIMAB IV SOLN 200 MG/100ML (2 MG/ML)","4","1","0","0","","SP","ANTINEOPLASTIC AGENTS","BIOLOGIC RESPONSE MODIFIERS"],["N","G","ERIVEDGE CAP 150MG","VISMODEGIB CAP 150 MG","4","1","0","1","30 caps every 30 days","SP","ANTINEOPLASTIC AGENTS","BIOLOGIC RESPONSE MODIFIERS"],["N","G","FARYDAK CAP 10MG","PANOBINOSTAT LACTATE CAP 10 MG (BASE EQUIVALENT)","4","1","0","0","","SP","ANTINEOPLASTIC AGENTS","BIOLOGIC RESPONSE MODIFIERS"],["N","G","FARYDAK CAP 15MG","PANOBINOSTAT LACTATE CAP 15 MG (BASE EQUIVALENT)","4","1","0","0","","SP","ANTINEOPLASTIC AGENTS","BIOLOGIC RESPONSE MODIFIERS"],["N","G","FARYDAK CAP 20MG","PANOBINOSTAT LACTATE CAP 20 MG (BASE EQUIVALENT)","4","1","0","0","","SP","ANTINEOPLASTIC AGENTS","BIOLOGIC RESPONSE MODIFIERS"],["N","G","GAZYVA INJ 25MG/ML","OBINUTUZUMAB SOLN FOR IV INFUSION 1000 MG/40ML (25 MG/ML)","4","1","0","0","","SP","ANTINEOPLASTIC AGENTS","BIOLOGIC RESPONSE MODIFIERS"],["N","G","IBRANCE CAP 100MG","PALBOCICLIB CAP 100 MG","4","1","0","1","21 caps every 28 days","SP","ANTINEOPLASTIC AGENTS","BIOLOGIC RESPONSE MODIFIERS"],["N","G","IBRANCE CAP 125MG","PALBOCICLIB CAP 125 MG","4","1","0","1","21 caps every 28 days","SP","ANTINEOPLASTIC AGENTS","BIOLOGIC RESPONSE MODIFIERS"],["N","G","IBRANCE CAP 75MG","PALBOCICLIB CAP 75 MG","4","1","0","1","21 caps every 28 days","SP","ANTINEOPLASTIC AGENTS","BIOLOGIC RESPONSE MODIFIERS"],["N","G","KADCYLA INJ 100MG","ADO-TRASTUZUMAB EMTANSINE FOR IV SOLN 100 MG","4","1","0","0","","SP","ANTINEOPLASTIC AGENTS","BIOLOGIC RESPONSE MODIFIERS"],["N","G","KADCYLA INJ 160MG","ADO-TRASTUZUMAB EMTANSINE FOR IV SOLN 160 MG","4","1","0","0","","SP","ANTINEOPLASTIC AGENTS","BIOLOGIC RESPONSE MODIFIERS"],["N","G","KEYTRUDA INJ 100MG/4M","PEMBROLIZUMAB IV SOLN 100 MG/4ML (25 MG/ML)","4","1","0","0","","SP","ANTINEOPLASTIC AGENTS","BIOLOGIC RESPONSE MODIFIERS"],["N","G","KISQALI TAB 200DOSE","RIBOCICLIB SUCCINATE TAB PACK 200 MG DAILY DOSE","4","1","0","1","63 tabs every 28 days","SP","ANTINEOPLASTIC AGENTS","BIOLOGIC RESPONSE MODIFIERS"],["N","G","KISQALI TAB 400DOSE","RIBOCICLIB SUCCINATE TAB PACK 400 MG DAILY DOSE (200 MG TAB)","4","1","0","1","63 tabs every 28 days","SP","ANTINEOPLASTIC AGENTS","BIOLOGIC RESPONSE MODIFIERS"],["N","G","KISQALI TAB 600DOSE","RIBOCICLIB SUCCINATE TAB PACK 600 MG DAILY DOSE (200 MG TAB)","4","1","0","1","63 tabs every 28 days","SP","ANTINEOPLASTIC AGENTS","BIOLOGIC RESPONSE MODIFIERS"],["N","G","LYNPARZA CAP 50MG","OLAPARIB CAP 50 MG","4","1","0","1","480 caps every 30 days","SP","ANTINEOPLASTIC AGENTS","BIOLOGIC RESPONSE MODIFIERS"],["N","G","LYNPARZA TAB 100MG","OLAPARIB TAB 100 MG","4","1","0","1","180 tabs every 30 days","SP","ANTINEOPLASTIC AGENTS","BIOLOGIC RESPONSE MODIFIERS"],["N","G","LYNPARZA TAB 150MG","OLAPARIB TAB 150 MG","4","1","0","1","120 tabs every 30 days","SP","ANTINEOPLASTIC AGENTS","BIOLOGIC RESPONSE MODIFIERS"],["N","G","RYDAPT CAP 25MG","MIDOSTAURIN CAP 25 MG","4","1","0","1","224 caps every 28 days","SP","ANTINEOPLASTIC AGENTS","BIOLOGIC RESPONSE MODIFIERS"],["N","G","ZEJULA CAP 100MG","NIRAPARIB TOSYLATE CAP 100 MG (BASE EQUIVALENT)","4","1","0","1","90 caps every 30 days","SP","ANTINEOPLASTIC AGENTS","BIOLOGIC RESPONSE MODIFIERS"],["N","G","ZOLINZA CAP 100MG","VORINOSTAT CAP 100 MG","4","1","0","1","120 caps every 30 days","SP","ANTINEOPLASTIC AGENTS","BIOLOGIC RESPONSE MODIFIERS"],["N","G","ABIRATERONE TAB 250MG","ABIRATERONE ACETATE TAB 250 MG","4","1","0","1","120 tabs every 30 days","SP","ANTINEOPLASTIC AGENTS","HORMONAL ANTINEOPLASTIC AGENTS"],["N","G","ANASTROZOLE TAB 1MG","ANASTROZOLE TAB 1 MG","1","0","0","0","","","ANTINEOPLASTIC AGENTS","HORMONAL ANTINEOPLASTIC AGENTS"],["N","G","BICALUTAMIDE TAB 50MG","BICALUTAMIDE TAB 50 MG","1","0","0","0","","","ANTINEOPLASTIC AGENTS","HORMONAL ANTINEOPLASTIC AGENTS"],["N","G","DEPO-PROVERA INJ 400/ML","MEDROXYPROGESTERONE ACETATE IM SUSP 400 MG/ML","3","0","0","0","","","ANTINEOPLASTIC AGENTS","HORMONAL ANTINEOPLASTIC AGENTS"],["N","G","ELIGARD INJ 22.5MG","LEUPROLIDE ACETATE (3 MONTH) FOR SUBCUTANEOUS INJ KIT 22.5MG","4","1","0","0","","SP","ANTINEOPLASTIC AGENTS","HORMONAL ANTINEOPLASTIC AGENTS"],["N","G","ELIGARD INJ 30MG","LEUPROLIDE ACETATE (4 MONTH) FOR SUBCUTANEOUS INJ KIT 30 MG","4","1","0","0","","SP","ANTINEOPLASTIC AGENTS","HORMONAL ANTINEOPLASTIC AGENTS"],["N","G","ELIGARD INJ 45MG","LEUPROLIDE ACETATE (6 MONTH) FOR SUBCUTANEOUS INJ KIT 45 MG","4","1","0","0","","SP","ANTINEOPLASTIC AGENTS","HORMONAL ANTINEOPLASTIC AGENTS"],["N","G","ELIGARD INJ 7.5MG","LEUPROLIDE ACETATE FOR SUBCUTANEOUS INJ KIT 7.5 MG","4","1","0","0","","SP","ANTINEOPLASTIC AGENTS","HORMONAL ANTINEOPLASTIC AGENTS"],["N","G","EXEMESTANE TAB 25MG","EXEMESTANE TAB 25 MG","1","0","0","0","","","ANTINEOPLASTIC AGENTS","HORMONAL ANTINEOPLASTIC AGENTS"],["N","G","FLUTAMIDE CAP 125MG","FLUTAMIDE CAP 125 MG","1","0","0","0","","","ANTINEOPLASTIC AGENTS","HORMONAL ANTINEOPLASTIC AGENTS"],["N","G","FULVESTRANT INJ 250/5ML","FULVESTRANT INJ 250 MG/5ML","1","0","0","0","","","ANTINEOPLASTIC AGENTS","HORMONAL ANTINEOPLASTIC AGENTS"],["N","G","LETROZOLE TAB 2.5MG","LETROZOLE TAB 2.5 MG","1","0","0","0","","","ANTINEOPLASTIC AGENTS","HORMONAL ANTINEOPLASTIC AGENTS"],["N","G","LEUPROLIDE INJ 1MG/0.2","LEUPROLIDE ACETATE INJ KIT 5 MG/ML","4","1","0","0","","SP","ANTINEOPLASTIC AGENTS","HORMONAL ANTINEOPLASTIC AGENTS"],["N","G","LUPR DEP-PED INJ 11.25MG","LEUPROLIDE ACETATE FOR INJ PEDIATRIC KIT 11.25 MG","4","1","0","0","","SP","ANTINEOPLASTIC AGENTS","HORMONAL ANTINEOPLASTIC AGENTS"],["N","G","LUPR DEP-PED INJ 11.25MG","LEUPROLIDE ACETATE (3 MONTH) FOR INJ PEDIATRIC KIT 11.25 MG","4","1","0","0","","SP","ANTINEOPLASTIC AGENTS","HORMONAL ANTINEOPLASTIC AGENTS"],["N","G","LUPR DEP-PED INJ 15MG","LEUPROLIDE ACETATE FOR INJ PEDIATRIC KIT 15 MG","4","1","0","0","","SP","ANTINEOPLASTIC AGENTS","HORMONAL ANTINEOPLASTIC AGENTS"],["N","G","LUPR DEP-PED INJ 3M 30MG","LEUPROLIDE ACETATE (3 MONTH) FOR INJ PEDIATRIC KIT 30 MG","4","1","0","0","","SP","ANTINEOPLASTIC AGENTS","HORMONAL ANTINEOPLASTIC AGENTS"],["N","G","LUPR DEP-PED INJ 7.5MG","LEUPROLIDE ACETATE FOR INJ PEDIATRIC KIT 7.5 MG","4","1","0","0","","SP","ANTINEOPLASTIC AGENTS","HORMONAL ANTINEOPLASTIC AGENTS"],["N","G","LYSODREN TAB 500MG","MITOTANE TAB 500 MG","2","0","0","0","","","ANTINEOPLASTIC AGENTS","HORMONAL ANTINEOPLASTIC AGENTS"],["N","G","MEGESTROL AC SUS 40MG/ML","MEGESTROL ACETATE SUSP 40 MG/ML","1","0","0","0","","","ANTINEOPLASTIC AGENTS","HORMONAL ANTINEOPLASTIC AGENTS"],["N","G","MEGESTROL AC TAB 20MG","MEGESTROL ACETATE TAB 20 MG","1","0","0","0","","","ANTINEOPLASTIC AGENTS","HORMONAL ANTINEOPLASTIC AGENTS"],["N","G","MEGESTROL AC TAB 40MG","MEGESTROL ACETATE TAB 40 MG","1","0","0","0","","","ANTINEOPLASTIC AGENTS","HORMONAL ANTINEOPLASTIC AGENTS"],["N","G","MEGESTROL SUS 625MG/5M","MEGESTROL ACETATE SUSP 625 MG/5ML","1","0","0","0","","","ANTINEOPLASTIC AGENTS","HORMONAL ANTINEOPLASTIC AGENTS"],["N","G","NILUTAMIDE TAB 150MG","NILUTAMIDE TAB 150 MG","1","0","0","0","","","ANTINEOPLASTIC AGENTS","HORMONAL ANTINEOPLASTIC AGENTS"],["N","G","TAMOXIFEN TAB 10MG","TAMOXIFEN CITRATE TAB 10 MG (BASE EQUIVALENT)","1","0","0","0","","$0 copay for women ages 35 and older for the primary prevention of breast cancer","ANTINEOPLASTIC AGENTS","HORMONAL ANTINEOPLASTIC AGENTS"],["N","G","TAMOXIFEN TAB 20MG","TAMOXIFEN CITRATE TAB 20 MG (BASE EQUIVALENT)","1","0","0","0","","$0 copay for women ages 35 and older for the primary prevention of breast cancer","ANTINEOPLASTIC AGENTS","HORMONAL ANTINEOPLASTIC AGENTS"],["N","G","TOREMIFENE TAB 60MG","TOREMIFENE CITRATE TAB 60 MG (BASE EQUIVALENT)","1","0","0","0","","","ANTINEOPLASTIC AGENTS","HORMONAL ANTINEOPLASTIC AGENTS"],["N","G","XTANDI CAP 40MG","ENZALUTAMIDE CAP 40 MG","4","1","0","1","120 caps every 30 days","SP","ANTINEOPLASTIC AGENTS","HORMONAL ANTINEOPLASTIC AGENTS"],["N","G","ZYTIGA TAB 500MG","ABIRATERONE ACETATE TAB 500 MG","4","1","0","1","60 tabs every 30 days","SP","ANTINEOPLASTIC AGENTS","HORMONAL ANTINEOPLASTIC AGENTS"],["N","G","AFINITOR DIS TAB 2MG","EVEROLIMUS TAB FOR ORAL SUSP 2 MG","4","1","0","1","60 tabs every 30 days","SP","ANTINEOPLASTIC AGENTS","KINASE INHIBITORS"],["N","G","AFINITOR DIS TAB 3MG","EVEROLIMUS TAB FOR ORAL SUSP 3 MG","4","1","0","1","90 tabs every 30 days","SP","ANTINEOPLASTIC AGENTS","KINASE INHIBITORS"],["N","G","AFINITOR DIS TAB 5MG","EVEROLIMUS TAB FOR ORAL SUSP 5 MG","4","1","0","1","60 tabs every 30 days","SP","ANTINEOPLASTIC AGENTS","KINASE INHIBITORS"],["N","G","AFINITOR TAB 10MG","EVEROLIMUS TAB 10 MG","4","1","0","1","30 tabs every 30 days","SP","ANTINEOPLASTIC AGENTS","KINASE INHIBITORS"],["N","G","AFINITOR TAB 2.5MG","EVEROLIMUS TAB 2.5 MG","4","1","0","1","30 tabs every 30 days","SP","ANTINEOPLASTIC AGENTS","KINASE INHIBITORS"],["N","G","AFINITOR TAB 5MG","EVEROLIMUS TAB 5 MG","4","1","0","1","30 tabs every 30 days","SP","ANTINEOPLASTIC AGENTS","KINASE INHIBITORS"],["N","G","AFINITOR TAB 7.5MG","EVEROLIMUS TAB 7.5 MG","4","1","0","1","30 tabs every 30 days","SP","ANTINEOPLASTIC AGENTS","KINASE INHIBITORS"],["N","G","ALECENSA CAP 150MG","ALECTINIB HCL CAP 150 MG (BASE EQUIVALENT)","4","1","0","1","240 caps every 30 days","SP","ANTINEOPLASTIC AGENTS","KINASE INHIBITORS"],["N","G","BOSULIF TAB 100MG","BOSUTINIB TAB 100 MG","4","1","0","1","90 tabs every 30 days","SP","ANTINEOPLASTIC AGENTS","KINASE INHIBITORS"],["N","G","BOSULIF TAB 400MG","BOSUTINIB TAB 400 MG","4","1","0","1","30 tabs every 30 days","SP","ANTINEOPLASTIC AGENTS","KINASE INHIBITORS"],["N","G","BOSULIF TAB 500MG","BOSUTINIB TAB 500 MG","4","1","0","1","30 tabs every 30 days","SP","ANTINEOPLASTIC AGENTS","KINASE INHIBITORS"],["N","G","CALQUENCE CAP 100MG","ACALABRUTINIB CAP 100 MG","4","1","0","1","60 caps every 30 days","SP","ANTINEOPLASTIC AGENTS","KINASE INHIBITORS"],["N","G","CAPRELSA TAB 100MG","VANDETANIB TAB 100 MG","4","1","0","1","60 tabs every 30 days","SP","ANTINEOPLASTIC AGENTS","KINASE INHIBITORS"],["N","G","CAPRELSA TAB 300MG","VANDETANIB TAB 300 MG","4","1","0","1","30 tabs every 30 days","SP","ANTINEOPLASTIC AGENTS","KINASE INHIBITORS"],["N","G","COMETRIQ KIT 100MG","CABOZANTINIB S-MAL CAP 1 X 80 MG & 1 X 20 MG (100 DOSE) KIT","4","1","0","1","1 kit every 28 days","SP","ANTINEOPLASTIC AGENTS","KINASE INHIBITORS"],["N","G","COMETRIQ KIT 140MG","CABOZANTINIB S-MAL CAP 1 X 80 MG & 3 X 20 MG (140 DOSE) KIT","4","1","0","1","1 kit every 28 days","SP","ANTINEOPLASTIC AGENTS","KINASE INHIBITORS"],["N","G","COMETRIQ KIT 60MG","CABOZANTINIB S-MALATE CAP 3 X 20 MG (60 MG DOSE) KIT","4","1","0","1","1 kit every 28 days","SP","ANTINEOPLASTIC AGENTS","KINASE INHIBITORS"],["N","G","ERLOTINIB TAB 100MG","ERLOTINIB HCL TAB 100 MG (BASE EQUIVALENT)","4","1","0","1","30 tabs every 30 days","SP","ANTINEOPLASTIC AGENTS","KINASE INHIBITORS"],["N","G","ERLOTINIB TAB 150MG","ERLOTINIB HCL TAB 150 MG (BASE EQUIVALENT)","4","1","0","1","30 tabs every 30 days","SP","ANTINEOPLASTIC AGENTS","KINASE INHIBITORS"],["N","G","ERLOTINIB TAB 25MG","ERLOTINIB HCL TAB 25 MG (BASE EQUIVALENT)","4","1","0","1","60 tabs every 30 days","SP","ANTINEOPLASTIC AGENTS","KINASE INHIBITORS"],["N","G","ICLUSIG TAB 15MG","PONATINIB HCL TAB 15 MG (BASE EQUIV)","4","1","0","1","60 tabs every 30 days","SP","ANTINEOPLASTIC AGENTS","KINASE INHIBITORS"],["N","G","ICLUSIG TAB 45MG","PONATINIB HCL TAB 45 MG (BASE EQUIV)","4","1","0","1","30 tabs every 30 days","SP","ANTINEOPLASTIC AGENTS","KINASE INHIBITORS"],["N","G","IDHIFA TAB 100MG","ENASIDENIB MESYLATE TAB 100 MG (BASE EQUIVALENT)","4","1","0","1","30 tabs every 30 days","SP","ANTINEOPLASTIC AGENTS","KINASE INHIBITORS"],["N","G","IDHIFA TAB 50MG","ENASIDENIB MESYLATE TAB 50 MG (BASE EQUIVALENT)","4","1","0","1","30 tabs every 30 days","SP","ANTINEOPLASTIC AGENTS","KINASE INHIBITORS"],["N","G","IMATINIB MES TAB 100MG","IMATINIB MESYLATE TAB 100 MG (BASE EQUIVALENT)","4","1","0","1","90 tabs every 30 days","SP","ANTINEOPLASTIC AGENTS","KINASE INHIBITORS"],["N","G","IMATINIB MES TAB 400MG","IMATINIB MESYLATE TAB 400 MG (BASE EQUIVALENT)","4","1","0","1","60 tabs every 30 days","SP","ANTINEOPLASTIC AGENTS","KINASE INHIBITORS"],["N","G","IMBRUVICA CAP 140MG","IBRUTINIB CAP 140 MG","4","1","0","1","90 caps every 30 days","SP","ANTINEOPLASTIC AGENTS","KINASE INHIBITORS"],["N","G","IMBRUVICA CAP 70MG","IBRUTINIB CAP 70 MG","4","1","0","1","30 caps every 30 days","SP","ANTINEOPLASTIC AGENTS","KINASE INHIBITORS"],["N","G","IMBRUVICA TAB 140MG","IBRUTINIB TAB 140 MG","4","1","0","1","30 tabs every 30 days","SP","ANTINEOPLASTIC AGENTS","KINASE INHIBITORS"],["N","G","IMBRUVICA TAB 280MG","IBRUTINIB TAB 280 MG","4","1","0","1","30 tabs every 30 days","SP","ANTINEOPLASTIC AGENTS","KINASE INHIBITORS"],["N","G","IMBRUVICA TAB 420MG","IBRUTINIB TAB 420 MG","4","1","0","1","30 tabs every 30 days","SP","ANTINEOPLASTIC AGENTS","KINASE INHIBITORS"],["N","G","IMBRUVICA TAB 560MG","IBRUTINIB TAB 560 MG","4","1","0","1","30 tabs every 30 days","SP","ANTINEOPLASTIC AGENTS","KINASE INHIBITORS"],["N","G","INLYTA TAB 1MG","AXITINIB TAB 1 MG","4","1","0","1","180 tabs every 30 days","SP","ANTINEOPLASTIC AGENTS","KINASE INHIBITORS"],["N","G","INLYTA TAB 5MG","AXITINIB TAB 5 MG","4","1","0","1","120 tabs every 30 days","SP","ANTINEOPLASTIC AGENTS","KINASE INHIBITORS"],["N","G","JAKAFI TAB 10MG","RUXOLITINIB PHOSPHATE TAB 10 MG (BASE EQUIVALENT)","4","1","0","1","60 tabs every 30 days","SP","ANTINEOPLASTIC AGENTS","KINASE INHIBITORS"],["N","G","JAKAFI TAB 15MG","RUXOLITINIB PHOSPHATE TAB 15 MG (BASE EQUIVALENT)","4","1","0","1","60 tabs every 30 days","SP","ANTINEOPLASTIC AGENTS","KINASE INHIBITORS"],["N","G","JAKAFI TAB 20MG","RUXOLITINIB PHOSPHATE TAB 20 MG (BASE EQUIVALENT)","4","1","0","1","60 tabs every 30 days","SP","ANTINEOPLASTIC AGENTS","KINASE INHIBITORS"],["N","G","JAKAFI TAB 25MG","RUXOLITINIB PHOSPHATE TAB 25 MG (BASE EQUIVALENT)","4","1","0","1","60 tabs every 30 days","SP","ANTINEOPLASTIC AGENTS","KINASE INHIBITORS"],["N","G","JAKAFI TAB 5MG","RUXOLITINIB PHOSPHATE TAB 5 MG (BASE EQUIVALENT)","4","1","0","1","60 tabs every 30 days","SP","ANTINEOPLASTIC AGENTS","KINASE INHIBITORS"],["N","G","LENVIMA CAP 10 MG","LENVATINIB CAP THERAPY PACK 10 MG (10 MG DAILY DOSE)","4","1","0","1","30 caps every 30 days","SP","ANTINEOPLASTIC AGENTS","KINASE INHIBITORS"],["N","G","LENVIMA CAP 12MG","LENVATINIB CAP THERAPY PACK 4 (3) MG (12 MG DAILY DOSE)","4","1","0","1","90 caps every 30 days","SP","ANTINEOPLASTIC AGENTS","KINASE INHIBITORS"],["N","G","LENVIMA CAP 14 MG","LENVATINIB CAP THERAPY PACK 10 & 4 MG (14 MG DAILY DOSE)","4","1","0","1","60 caps every 30 days","SP","ANTINEOPLASTIC AGENTS","KINASE INHIBITORS"],["N","G","LENVIMA CAP 18 MG","LENVATINIB CAP THERAPY PACK 10 & 4 (2) MG (18 MG DAILY DOSE)","4","1","0","1","90 caps every 30 days","SP","ANTINEOPLASTIC AGENTS","KINASE INHIBITORS"],["N","G","LENVIMA CAP 20 MG","LENVATINIB CAP THERAPY PACK 10 (2) MG (20 MG DAILY DOSE)","4","1","0","1","60 caps every 30 days","SP","ANTINEOPLASTIC AGENTS","KINASE INHIBITORS"],["N","G","LENVIMA CAP 24 MG","LENVATINIB CAP THERAPY PACK 10 (2) & 4 MG (24 MG DAILY DOSE)","4","1","0","1","90 caps every 30 days","SP","ANTINEOPLASTIC AGENTS","KINASE INHIBITORS"],["N","G","LENVIMA CAP 4MG","LENVATINIB CAP THERAPY PACK 4 MG (4 MG DAILY DOSE)","4","1","0","1","30 caps every 30 days","SP","ANTINEOPLASTIC AGENTS","KINASE INHIBITORS"],["N","G","LENVIMA CAP 8 MG","LENVATINIB CAP THERAPY PACK 4 (2) MG (8 MG DAILY DOSE)","4","1","0","1","60 caps every 30 days","SP","ANTINEOPLASTIC AGENTS","KINASE INHIBITORS"],["N","G","LORBRENA TAB 100MG","LORLATINIB TAB 100 MG","4","1","0","1","30 tabs every 30 days","SP","ANTINEOPLASTIC AGENTS","KINASE INHIBITORS"],["N","G","LORBRENA TAB 25MG","LORLATINIB TAB 25 MG","4","1","0","1","90 tabs every 30 days","SP","ANTINEOPLASTIC AGENTS","KINASE INHIBITORS"],["N","G","MEKINIST TAB 0.5MG","TRAMETINIB DIMETHYL SULFOXIDE TAB 0.5 MG (BASE EQUIVALENT)","4","1","0","1","90 tabs every 30 days","SP","ANTINEOPLASTIC AGENTS","KINASE INHIBITORS"],["N","G","MEKINIST TAB 2MG","TRAMETINIB DIMETHYL SULFOXIDE TAB 2 MG (BASE EQUIVALENT)","4","1","0","1","30 tabs every 30 days","SP","ANTINEOPLASTIC AGENTS","KINASE INHIBITORS"],["N","G","NEXAVAR TAB 200MG","SORAFENIB TOSYLATE TAB 200 MG (BASE EQUIVALENT)","4","1","0","1","120 tabs every 30 days","SP","ANTINEOPLASTIC AGENTS","KINASE INHIBITORS"],["N","G","SPRYCEL TAB 100MG","DASATINIB TAB 100 MG","4","1","0","1","30 tabs every 30 days","SP","ANTINEOPLASTIC AGENTS","KINASE INHIBITORS"],["N","G","SPRYCEL TAB 140MG","DASATINIB TAB 140 MG","4","1","0","1","30 tabs every 30 days","SP","ANTINEOPLASTIC AGENTS","KINASE INHIBITORS"],["N","G","SPRYCEL TAB 20MG","DASATINIB TAB 20 MG","4","1","0","1","90 tabs every 30 days","SP","ANTINEOPLASTIC AGENTS","KINASE INHIBITORS"],["N","G","SPRYCEL TAB 50MG","DASATINIB TAB 50 MG","4","1","0","1","30 tabs every 30 days","SP","ANTINEOPLASTIC AGENTS","KINASE INHIBITORS"],["N","G","SPRYCEL TAB 70MG","DASATINIB TAB 70 MG","4","1","0","1","30 tabs every 30 days","SP","ANTINEOPLASTIC AGENTS","KINASE INHIBITORS"],["N","G","SPRYCEL TAB 80MG","DASATINIB TAB 80 MG","4","1","0","1","30 tabs every 30 days","SP","ANTINEOPLASTIC AGENTS","KINASE INHIBITORS"],["N","G","STIVARGA TAB 40MG","REGORAFENIB TAB 40 MG","4","1","0","1","84 tabs every 28 days","SP","ANTINEOPLASTIC AGENTS","KINASE INHIBITORS"],["N","G","SUTENT CAP 12.5MG","SUNITINIB MALATE CAP 12.5 MG (BASE EQUIVALENT)","4","1","0","1","30 caps every 30 days","SP","ANTINEOPLASTIC AGENTS","KINASE INHIBITORS"],["N","G","SUTENT CAP 25MG","SUNITINIB MALATE CAP 25 MG (BASE EQUIVALENT)","4","1","0","1","30 caps every 30 days","SP","ANTINEOPLASTIC AGENTS","KINASE INHIBITORS"],["N","G","SUTENT CAP 37.5MG","SUNITINIB MALATE CAP 37.5 MG (BASE EQUIVALENT)","4","1","0","1","30 caps every 30 days","SP","ANTINEOPLASTIC AGENTS","KINASE INHIBITORS"],["N","G","SUTENT CAP 50MG","SUNITINIB MALATE CAP 50 MG (BASE EQUIVALENT)","4","1","0","1","30 caps every 30 days","SP","ANTINEOPLASTIC AGENTS","KINASE INHIBITORS"],["N","G","TAFINLAR CAP 50MG","DABRAFENIB MESYLATE CAP 50 MG (BASE EQUIVALENT)","4","1","0","1","120 caps every 30 days","SP","ANTINEOPLASTIC AGENTS","KINASE INHIBITORS"],["N","G","TAFINLAR CAP 75MG","DABRAFENIB MESYLATE CAP 75 MG (BASE EQUIVALENT)","4","1","0","1","120 caps every 30 days","SP","ANTINEOPLASTIC AGENTS","KINASE INHIBITORS"],["N","G","TYKERB TAB 250MG","LAPATINIB DITOSYLATE TAB 250 MG (BASE EQUIV)","4","1","0","1","180 tabs every 30 days","SP","ANTINEOPLASTIC AGENTS","KINASE INHIBITORS"],["N","G","VITRAKVI CAP 100MG","LAROTRECTINIB SULFATE CAP 100 MG (BASE EQUIVALENT)","4","1","0","1","60 caps every 30 days","SP","ANTINEOPLASTIC AGENTS","KINASE INHIBITORS"],["N","G","VITRAKVI CAP 25MG","LAROTRECTINIB SULFATE CAP 25 MG (BASE EQUIVALENT)","4","1","0","1","180 caps every 30 days","SP","ANTINEOPLASTIC AGENTS","KINASE INHIBITORS"],["N","G","VITRAKVI SOL 20MG/ML","LAROTRECTINIB SULFATE ORAL SOLN 20 MG/ML (BASE EQUIVALENT)","4","1","0","1","300 mL every 30 days","SP","ANTINEOPLASTIC AGENTS","KINASE INHIBITORS"],["N","G","VOTRIENT TAB 200MG","PAZOPANIB HCL TAB 200 MG (BASE EQUIV)","4","1","0","1","120 tabs every 30 days","SP","ANTINEOPLASTIC AGENTS","KINASE INHIBITORS"],["N","G","XALKORI CAP 200MG","CRIZOTINIB CAP 200 MG","4","1","0","1","60 caps every 30 days","SP","ANTINEOPLASTIC AGENTS","KINASE INHIBITORS"],["N","G","XALKORI CAP 250MG","CRIZOTINIB CAP 250 MG","4","1","0","1","60 caps every 30 days","SP","ANTINEOPLASTIC AGENTS","KINASE INHIBITORS"],["N","G","ZELBORAF TAB 240MG","VEMURAFENIB TAB 240 MG","4","1","0","1","240 tabs every 30 days","SP","ANTINEOPLASTIC AGENTS","KINASE INHIBITORS"],["N","G","ZYDELIG TAB 100MG","IDELALISIB TAB 100 MG","4","1","0","1","60 tabs every 30 days","SP","ANTINEOPLASTIC AGENTS","KINASE INHIBITORS"],["N","G","ZYDELIG TAB 150MG","IDELALISIB TAB 150 MG","4","1","0","1","60 tabs every 30 days","SP","ANTINEOPLASTIC AGENTS","KINASE INHIBITORS"],["N","G","ZYKADIA CAP 150MG","CERITINIB CAP 150 MG","4","1","0","1","90 caps every 30 days","SP","ANTINEOPLASTIC AGENTS","KINASE INHIBITORS"],["N","G","ZYKADIA TAB 150MG","CERITINIB TAB 150 MG","4","1","0","1","90 tabs every 30 days","SP","ANTINEOPLASTIC AGENTS","KINASE INHIBITORS"],["N","G","ARSENIC TRIO INJ 10/10ML","ARSENIC TRIOXIDE IV SOLN 10 MG/10ML (1 MG/ML)","1","0","0","0","","","ANTINEOPLASTIC AGENTS","MISCELLANEOUS"],["N","G","BEXAROTENE CAP 75MG","BEXAROTENE CAP 75 MG","4","1","0","0","","SP","ANTINEOPLASTIC AGENTS","MISCELLANEOUS"],["N","G","DROXIA CAP 200MG","HYDROXYUREA CAP 200 MG","2","0","0","0","","","ANTINEOPLASTIC AGENTS","MISCELLANEOUS"],["N","G","DROXIA CAP 300MG","HYDROXYUREA CAP 300 MG","2","0","0","0","","","ANTINEOPLASTIC AGENTS","MISCELLANEOUS"],["N","G","DROXIA CAP 400MG","HYDROXYUREA CAP 400 MG","2","0","0","0","","","ANTINEOPLASTIC AGENTS","MISCELLANEOUS"],["N","G","HYDROXYUREA CAP 500MG","HYDROXYUREA CAP 500 MG","1","0","0","0","","","ANTINEOPLASTIC AGENTS","MISCELLANEOUS"],["N","G","MATULANE CAP 50MG","PROCARBAZINE HCL CAP 50 MG","2","0","0","0","","","ANTINEOPLASTIC AGENTS","MISCELLANEOUS"],["N","G","MITOXANTRON INJ 2MG/ML","MITOXANTRONE HCL INJ CONC 30 MG/15ML (2 MG/ML)","4","1","0","0","","SP","ANTINEOPLASTIC AGENTS","MISCELLANEOUS"],["N","G","MITOXANTRON INJ 2MG/ML","MITOXANTRONE HCL INJ CONC 20 MG/10ML (2 MG/ML)","4","1","0","0","","SP","ANTINEOPLASTIC AGENTS","MISCELLANEOUS"],["N","G","MITOXANTRON INJ 2MG/ML","MITOXANTRONE HCL INJ CONC 25 MG/12.5ML (2 MG/ML)","4","1","0","0","","SP","ANTINEOPLASTIC AGENTS","MISCELLANEOUS"],["N","G","ODOMZO CAP 200MG","SONIDEGIB PHOSPHATE CAP 200 MG (BASE EQUIVALENT)","4","1","0","1","30 caps every 30 days","SP","ANTINEOPLASTIC AGENTS","MISCELLANEOUS"],["N","G","ONCASPAR INJ 750/ML","PEGASPARGASE INJ 750 UNIT/ML","4","1","0","0","","SP","ANTINEOPLASTIC AGENTS","MISCELLANEOUS"],["N","G","PHOTOFRIN INJ 75MG","PORFIMER SODIUM FOR INJ 75 MG","2","0","0","0","","","ANTINEOPLASTIC AGENTS","MISCELLANEOUS"],["N","G","QUADRAMET INJ","SAMARIUM SM 153 LEXIDRONAM INJ 1850 MBQ/ML (50 MCI/ML)","2","0","0","0","","","ANTINEOPLASTIC AGENTS","MISCELLANEOUS"],["N","G","THERACYS INJ","BCG LIVE INTRAVESICAL FOR SUSP 81 MG/VIAL","2","0","0","0","","","ANTINEOPLASTIC AGENTS","MISCELLANEOUS"],["N","G","TICE BCG INJ","BCG LIVE INTRAVESICAL FOR SUSP 50 MG","2","0","0","0","","","ANTINEOPLASTIC AGENTS","MISCELLANEOUS"],["N","G","TRETINOIN CAP 10MG","TRETINOIN CAP 10 MG","1","0","0","0","","","ANTINEOPLASTIC AGENTS","MISCELLANEOUS"],["N","G","TRISENOX INJ 12MG/6ML","ARSENIC TRIOXIDE IV SOLN 12 MG/6ML (2 MG/ML)","2","0","0","0","","","ANTINEOPLASTIC AGENTS","MISCELLANEOUS"],["N","G","UVADEX INJ 20MCG/ML","METHOXSALEN (PHOTOPHERESIS) SOLN 20 MCG/ML","2","0","0","0","","","ANTINEOPLASTIC AGENTS","MISCELLANEOUS"],["N","G","VISTOGARD PAK 10GM","URIDINE TRIACETATE ORAL GRANULES PACKET 10 GM","2","0","0","0","","","ANTINEOPLASTIC AGENTS","MISCELLANEOUS"],["N","G","CARBOPLATIN INJ 150/15ML","CARBOPLATIN IV SOLN 150 MG/15ML","1","0","0","0","","","ANTINEOPLASTIC AGENTS","PLATINUM-BASED AGENTS"],["N","G","CARBOPLATIN INJ 450/45ML","CARBOPLATIN IV SOLN 450 MG/45ML","1","0","0","0","","","ANTINEOPLASTIC AGENTS","PLATINUM-BASED AGENTS"],["N","G","CARBOPLATIN INJ 50MG/5ML","CARBOPLATIN IV SOLN 50 MG/5ML","1","0","0","0","","","ANTINEOPLASTIC AGENTS","PLATINUM-BASED AGENTS"],["N","G","CARBOPLATIN INJ 600/60ML","CARBOPLATIN IV SOLN 600 MG/60ML","1","0","0","0","","","ANTINEOPLASTIC AGENTS","PLATINUM-BASED AGENTS"],["N","G","CISPLATIN INJ 100MG","CISPLATIN INJ 100 MG/100ML (1 MG/ML)","1","0","0","0","","","ANTINEOPLASTIC AGENTS","PLATINUM-BASED AGENTS"],["N","G","CISPLATIN INJ 200MG","CISPLATIN INJ 200 MG/200ML (1 MG/ML)","1","0","0","0","","","ANTINEOPLASTIC AGENTS","PLATINUM-BASED AGENTS"],["N","G","CISPLATIN INJ 50/50ML","CISPLATIN INJ 50 MG/50ML (1 MG/ML)","1","0","0","0","","","ANTINEOPLASTIC AGENTS","PLATINUM-BASED AGENTS"],["N","G","OXALIPLATIN INJ 100MG","OXALIPLATIN FOR IV INJ 100 MG","4","0","0","0","","","ANTINEOPLASTIC AGENTS","PLATINUM-BASED AGENTS"],["N","G","OXALIPLATIN INJ 100MG","OXALIPLATIN IV SOLN 100 MG/20ML","4","0","0","0","","","ANTINEOPLASTIC AGENTS","PLATINUM-BASED AGENTS"],["N","G","OXALIPLATIN INJ 50/10ML","OXALIPLATIN IV SOLN 50 MG/10ML","4","0","0","0","","","ANTINEOPLASTIC AGENTS","PLATINUM-BASED AGENTS"],["N","G","OXALIPLATIN INJ 50MG","OXALIPLATIN FOR IV INJ 50 MG","4","0","0","0","","","ANTINEOPLASTIC AGENTS","PLATINUM-BASED AGENTS"],["N","G","AMIFOSTINE INJ 500MG","AMIFOSTINE FOR INJ 500 MG","1","0","0","0","","","ANTINEOPLASTIC AGENTS","PROTECTIVE AGENTS"],["N","G","DEXRAZOXANE INJ 250MG","DEXRAZOXANE HCL FOR INJ 250 MG (BASE EQUIVALENT)","1","0","0","0","","","ANTINEOPLASTIC AGENTS","PROTECTIVE AGENTS"],["N","G","DEXRAZOXANE INJ 500MG","DEXRAZOXANE HCL FOR INJ 500 MG (BASE EQUIVALENT)","1","0","0","0","","","ANTINEOPLASTIC AGENTS","PROTECTIVE AGENTS"],["N","G","LEUCOVOR CA INJ 100MG","LEUCOVORIN CALCIUM FOR INJ 100 MG","1","0","0","0","","","ANTINEOPLASTIC AGENTS","PROTECTIVE AGENTS"],["N","G","LEUCOVOR CA INJ 200MG","LEUCOVORIN CALCIUM FOR INJ 200 MG","1","0","0","0","","","ANTINEOPLASTIC AGENTS","PROTECTIVE AGENTS"],["N","G","LEUCOVOR CA INJ 350MG","LEUCOVORIN CALCIUM FOR INJ 350 MG","1","0","0","0","","","ANTINEOPLASTIC AGENTS","PROTECTIVE AGENTS"],["N","G","LEUCOVOR CA INJ 50MG","LEUCOVORIN CALCIUM FOR INJ 50 MG","1","0","0","0","","","ANTINEOPLASTIC AGENTS","PROTECTIVE AGENTS"],["N","G","LEUCOVOR CA TAB 10MG","LEUCOVORIN CALCIUM TAB 10 MG","1","0","0","0","","","ANTINEOPLASTIC AGENTS","PROTECTIVE AGENTS"],["N","G","LEUCOVOR CA TAB 15MG","LEUCOVORIN CALCIUM TAB 15 MG","1","0","0","0","","","ANTINEOPLASTIC AGENTS","PROTECTIVE AGENTS"],["N","G","LEUCOVOR CA TAB 25MG","LEUCOVORIN CALCIUM TAB 25 MG","1","0","0","0","","","ANTINEOPLASTIC AGENTS","PROTECTIVE AGENTS"],["N","G","LEUCOVOR CA TAB 5MG","LEUCOVORIN CALCIUM TAB 5 MG","1","0","0","0","","","ANTINEOPLASTIC AGENTS","PROTECTIVE AGENTS"],["N","G","LEUCOVORIN INJ CALCIUM","LEUCOVORIN CALCIUM FOR INJ 500 MG","1","0","0","0","","","ANTINEOPLASTIC AGENTS","PROTECTIVE AGENTS"],["N","G","MESNA INJ 1GM","MESNA INJ 100 MG/ML","1","0","0","0","","","ANTINEOPLASTIC AGENTS","PROTECTIVE AGENTS"],["N","G","MESNEX TAB 400MG","MESNA TAB 400 MG","4","0","0","0","","","ANTINEOPLASTIC AGENTS","PROTECTIVE AGENTS"],["N","G","CAMPTOSAR INJ 300/15ML","IRINOTECAN HCL INJ 300 MG/15ML (20 MG/ML)","2","0","0","0","","","ANTINEOPLASTIC AGENTS","TOPOISOMERASE INHIBITORS"],["N","G","ETOPOSIDE CAP 50MG","ETOPOSIDE CAP 50 MG","1","0","0","0","","","ANTINEOPLASTIC AGENTS","TOPOISOMERASE INHIBITORS"],["N","G","ETOPOSIDE INJ 20MG/ML","ETOPOSIDE INJ 100 MG/5ML (20 MG/ML)","1","0","0","0","","","ANTINEOPLASTIC AGENTS","TOPOISOMERASE INHIBITORS"],["N","G","IRINOTECAN INJ 100/5ML","IRINOTECAN HCL INJ 100 MG/5ML (20 MG/ML)","4","0","0","0","","","ANTINEOPLASTIC AGENTS","TOPOISOMERASE INHIBITORS"],["N","G","IRINOTECAN INJ 40MG/2ML","IRINOTECAN HCL INJ 40 MG/2ML (20 MG/ML)","4","0","0","0","","","ANTINEOPLASTIC AGENTS","TOPOISOMERASE INHIBITORS"],["N","G","IRINOTECAN INJ 500MG/25","IRINOTECAN HCL INJ 500 MG/25ML (20 MG/ML)","4","0","0","0","","","ANTINEOPLASTIC AGENTS","TOPOISOMERASE INHIBITORS"],["N","G","TENIPOSIDE INJ 50MG/5ML","TENIPOSIDE IV SOLN 10 MG/ML","2","0","0","0","","","ANTINEOPLASTIC AGENTS","TOPOISOMERASE INHIBITORS"],["N","G","TOPOSAR INJ 100/5ML","ETOPOSIDE INJ 100 MG/5ML (20 MG/ML)","1","0","0","0","","","ANTINEOPLASTIC AGENTS","TOPOISOMERASE INHIBITORS"],["N","G","TOPOSAR INJ 20MG/ML","ETOPOSIDE INJ 1 GM/50ML (20 MG/ML)","1","0","0","0","","","ANTINEOPLASTIC AGENTS","TOPOISOMERASE INHIBITORS"],["N","G","TOPOSAR INJ 20MG/ML","ETOPOSIDE INJ 500 MG/25ML (20 MG/ML)","1","0","0","0","","","ANTINEOPLASTIC AGENTS","TOPOISOMERASE INHIBITORS"],["N","G","TOPOTECAN INJ 4MG","TOPOTECAN HCL FOR INJ 4 MG (BASE EQUIV)","1","0","0","0","","","ANTINEOPLASTIC AGENTS","TOPOISOMERASE INHIBITORS"],["N","G","VENCLEXTA TAB 100MG","VENETOCLAX TAB 100 MG","4","1","0","0","","SP","ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","ANTINEOPLASTIC, BCL-2 INHIBITORS"],["N","G","VENCLEXTA TAB 10MG","VENETOCLAX TAB 10 MG","4","1","0","0","","SP","ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","ANTINEOPLASTIC, BCL-2 INHIBITORS"],["N","G","VENCLEXTA TAB 50MG","VENETOCLAX TAB 50 MG","4","1","0","0","","SP","ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","ANTINEOPLASTIC, BCL-2 INHIBITORS"],["N","G","VENCLEXTA TAB START PK","VENETOCLAX TAB THERAPY STARTER PACK 10 & 50 & 100 MG","4","1","0","0","","SP","ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES","ANTINEOPLASTIC, BCL-2 INHIBITORS"],["N","G","AMLOD/BENAZP CAP 10-20MG","AMLODIPINE BESYLATE-BENAZEPRIL HCL CAP 10-20 MG","1","0","0","0","","","CARDIOVASCULAR","ACE INHIBITOR COMBINATIONS"],["N","G","AMLOD/BENAZP CAP 10-40MG","AMLODIPINE BESYLATE-BENAZEPRIL HCL CAP 10-40 MG","1","0","0","0","","","CARDIOVASCULAR","ACE INHIBITOR COMBINATIONS"],["N","G","AMLOD/BENAZP CAP 2.5-10MG","AMLODIPINE BESYLATE-BENAZEPRIL HCL CAP 2.5-10 MG","1","0","0","0","","","CARDIOVASCULAR","ACE INHIBITOR COMBINATIONS"],["N","G","AMLOD/BENAZP CAP 5-10MG","AMLODIPINE BESYLATE-BENAZEPRIL HCL CAP 5-10 MG","1","0","0","0","","","CARDIOVASCULAR","ACE INHIBITOR COMBINATIONS"],["N","G","AMLOD/BENAZP CAP 5-20MG","AMLODIPINE BESYLATE-BENAZEPRIL HCL CAP 5-20 MG","1","0","0","0","","","CARDIOVASCULAR","ACE INHIBITOR COMBINATIONS"],["N","G","AMLOD/BENAZP CAP 5-40MG","AMLODIPINE BESYLATE-BENAZEPRIL HCL CAP 5-40 MG","1","0","0","0","","","CARDIOVASCULAR","ACE INHIBITOR COMBINATIONS"],["N","G","BENAZEP/HCTZ TAB 10-12.5","BENAZEPRIL & HYDROCHLOROTHIAZIDE TAB 10-12.5 MG","1","0","0","0","","","CARDIOVASCULAR","ACE INHIBITOR COMBINATIONS"],["N","G","BENAZEP/HCTZ TAB 20-12.5","BENAZEPRIL & HYDROCHLOROTHIAZIDE TAB 20-12.5 MG","1","0","0","0","","","CARDIOVASCULAR","ACE INHIBITOR COMBINATIONS"],["N","G","BENAZEP/HCTZ TAB 20-25MG","BENAZEPRIL & HYDROCHLOROTHIAZIDE TAB 20-25 MG","1","0","0","0","","","CARDIOVASCULAR","ACE INHIBITOR COMBINATIONS"],["N","G","BENAZEP/HCTZ TAB 5-6.25","BENAZEPRIL & HYDROCHLOROTHIAZIDE TAB 5-6.25 MG","1","0","0","0","","","CARDIOVASCULAR","ACE INHIBITOR COMBINATIONS"],["N","G","CAPTOPR/HCTZ TAB 25-15MG","CAPTOPRIL & HYDROCHLOROTHIAZIDE TAB 25-15 MG","1","0","0","0","","","CARDIOVASCULAR","ACE INHIBITOR COMBINATIONS"],["N","G","CAPTOPR/HCTZ TAB 25-25MG","CAPTOPRIL & HYDROCHLOROTHIAZIDE TAB 25-25 MG","1","0","0","0","","","CARDIOVASCULAR","ACE INHIBITOR COMBINATIONS"],["N","G","CAPTOPR/HCTZ TAB 50-15MG","CAPTOPRIL & HYDROCHLOROTHIAZIDE TAB 50-15 MG","1","0","0","0","","","CARDIOVASCULAR","ACE INHIBITOR COMBINATIONS"],["N","G","CAPTOPR/HCTZ TAB 50-25MG","CAPTOPRIL & HYDROCHLOROTHIAZIDE TAB 50-25 MG","1","0","0","0","","","CARDIOVASCULAR","ACE INHIBITOR COMBINATIONS"],["N","G","ENALAPR/HCTZ TAB 10-25MG","ENALAPRIL MALEATE & HYDROCHLOROTHIAZIDE TAB 10-25 MG","1","0","0","0","","","CARDIOVASCULAR","ACE INHIBITOR COMBINATIONS"],["N","G","ENALAPR/HCTZ TAB 5-12.5MG","ENALAPRIL MALEATE & HYDROCHLOROTHIAZIDE TAB 5-12.5 MG","1","0","0","0","","","CARDIOVASCULAR","ACE INHIBITOR COMBINATIONS"],["N","G","FOSINOP/HCTZ TAB 10/12.5","FOSINOPRIL SODIUM & HYDROCHLOROTHIAZIDE TAB 10-12.5 MG","1","0","0","0","","","CARDIOVASCULAR","ACE INHIBITOR COMBINATIONS"],["N","G","FOSINOP/HCTZ TAB 20/12.5","FOSINOPRIL SODIUM & HYDROCHLOROTHIAZIDE TAB 20-12.5 MG","1","0","0","0","","","CARDIOVASCULAR","ACE INHIBITOR COMBINATIONS"],["N","G","LISINOP/HCTZ TAB 10-12.5","LISINOPRIL & HYDROCHLOROTHIAZIDE TAB 10-12.5 MG","1","0","0","0","","","CARDIOVASCULAR","ACE INHIBITOR COMBINATIONS"],["N","G","LISINOP/HCTZ TAB 20-12.5","LISINOPRIL & HYDROCHLOROTHIAZIDE TAB 20-12.5 MG","1","0","0","0","","","CARDIOVASCULAR","ACE INHIBITOR COMBINATIONS"],["N","G","LISINOP/HCTZ TAB 20-25MG","LISINOPRIL & HYDROCHLOROTHIAZIDE TAB 20-25 MG","1","0","0","0","","","CARDIOVASCULAR","ACE INHIBITOR COMBINATIONS"],["N","G","MOEXIPR/HCTZ TAB 15-12.5","MOEXIPRIL-HYDROCHLOROTHIAZIDE TAB 15-12.5 MG","1","0","0","0","","","CARDIOVASCULAR","ACE INHIBITOR COMBINATIONS"],["N","G","MOEXIPR/HCTZ TAB 15-25MG","MOEXIPRIL-HYDROCHLOROTHIAZIDE TAB 15-25 MG","1","0","0","0","","","CARDIOVASCULAR","ACE INHIBITOR COMBINATIONS"],["N","G","MOEXIPR/HCTZ TAB 7.5-12.5","MOEXIPRIL-HYDROCHLOROTHIAZIDE TAB 7.5-12.5 MG","1","0","0","0","","","CARDIOVASCULAR","ACE INHIBITOR COMBINATIONS"],["N","G","QNAPRIL/HCTZ TAB 10-12.5","QUINAPRIL-HYDROCHLOROTHIAZIDE TAB 10-12.5 MG","1","0","0","0","","","CARDIOVASCULAR","ACE INHIBITOR COMBINATIONS"],["N","G","QNAPRIL/HCTZ TAB 20-12.5","QUINAPRIL-HYDROCHLOROTHIAZIDE TAB 20-12.5 MG","1","0","0","0","","","CARDIOVASCULAR","ACE INHIBITOR COMBINATIONS"],["N","G","QNAPRIL/HCTZ TAB 20-25MG","QUINAPRIL-HYDROCHLOROTHIAZIDE TAB 20-25 MG","1","0","0","0","","","CARDIOVASCULAR","ACE INHIBITOR COMBINATIONS"],["N","G","TRANDO/VERAP TAB 1-240 ER","TRANDOLAPRIL-VERAPAMIL HCL TAB ER 1-240 MG","1","0","0","0","","","CARDIOVASCULAR","ACE INHIBITOR COMBINATIONS"],["N","G","TRANDO/VERAP TAB 2-180 ER","TRANDOLAPRIL-VERAPAMIL HCL TAB ER 2-180 MG","1","0","0","0","","","CARDIOVASCULAR","ACE INHIBITOR COMBINATIONS"],["N","G","TRANDO/VERAP TAB 2-240 ER","TRANDOLAPRIL-VERAPAMIL HCL TAB ER 2-240 MG","1","0","0","0","","","CARDIOVASCULAR","ACE INHIBITOR COMBINATIONS"],["N","G","TRANDO/VERAP TAB 4-240 ER","TRANDOLAPRIL-VERAPAMIL HCL TAB ER 4-240 MG","1","0","0","0","","","CARDIOVASCULAR","ACE INHIBITOR COMBINATIONS"],["N","G","BENAZEPRIL TAB 10MG","BENAZEPRIL HCL TAB 10 MG","1","0","0","0","","","CARDIOVASCULAR","ACE INHIBITORS"],["N","G","BENAZEPRIL TAB 20MG","BENAZEPRIL HCL TAB 20 MG","1","0","0","0","","","CARDIOVASCULAR","ACE INHIBITORS"],["N","G","BENAZEPRIL TAB 40MG","BENAZEPRIL HCL TAB 40 MG","1","0","0","0","","","CARDIOVASCULAR","ACE INHIBITORS"],["N","G","BENAZEPRIL TAB 5MG","BENAZEPRIL HCL TAB 5 MG","1","0","0","0","","","CARDIOVASCULAR","ACE INHIBITORS"],["N","G","CAPTOPRIL TAB 100MG","CAPTOPRIL TAB 100 MG","1","0","0","0","","","CARDIOVASCULAR","ACE INHIBITORS"],["N","G","CAPTOPRIL TAB 12.5MG","CAPTOPRIL TAB 12.5 MG","1","0","0","0","","","CARDIOVASCULAR","ACE INHIBITORS"],["N","G","CAPTOPRIL TAB 25MG","CAPTOPRIL TAB 25 MG","1","0","0","0","","","CARDIOVASCULAR","ACE INHIBITORS"],["N","G","CAPTOPRIL TAB 50MG","CAPTOPRIL TAB 50 MG","1","0","0","0","","","CARDIOVASCULAR","ACE INHIBITORS"],["N","G","ENALAPRIL TAB 10MG","ENALAPRIL MALEATE TAB 10 MG","1","0","0","0","","","CARDIOVASCULAR","ACE INHIBITORS"],["N","G","ENALAPRIL TAB 2.5MG","ENALAPRIL MALEATE TAB 2.5 MG","1","0","0","0","","","CARDIOVASCULAR","ACE INHIBITORS"],["N","G","ENALAPRIL TAB 20MG","ENALAPRIL MALEATE TAB 20 MG","1","0","0","0","","","CARDIOVASCULAR","ACE INHIBITORS"],["N","G","ENALAPRIL TAB 5MG","ENALAPRIL MALEATE TAB 5 MG","1","0","0","0","","","CARDIOVASCULAR","ACE INHIBITORS"],["N","G","FOSINOPRIL TAB 10MG","FOSINOPRIL SODIUM TAB 10 MG","1","0","0","0","","","CARDIOVASCULAR","ACE INHIBITORS"],["N","G","FOSINOPRIL TAB 20MG","FOSINOPRIL SODIUM TAB 20 MG","1","0","0","0","","","CARDIOVASCULAR","ACE INHIBITORS"],["N","G","FOSINOPRIL TAB 40MG","FOSINOPRIL SODIUM TAB 40 MG","1","0","0","0","","","CARDIOVASCULAR","ACE INHIBITORS"],["N","G","LISINOPRIL TAB 10MG","LISINOPRIL TAB 10 MG","1","0","0","0","","","CARDIOVASCULAR","ACE INHIBITORS"],["N","G","LISINOPRIL TAB 2.5MG","LISINOPRIL TAB 2.5 MG","1","0","0","0","","","CARDIOVASCULAR","ACE INHIBITORS"],["N","G","LISINOPRIL TAB 20MG","LISINOPRIL TAB 20 MG","1","0","0","0","","","CARDIOVASCULAR","ACE INHIBITORS"],["N","G","LISINOPRIL TAB 30MG","LISINOPRIL TAB 30 MG","1","0","0","0","","","CARDIOVASCULAR","ACE INHIBITORS"],["N","G","LISINOPRIL TAB 40MG","LISINOPRIL TAB 40 MG","1","0","0","0","","","CARDIOVASCULAR","ACE INHIBITORS"],["N","G","LISINOPRIL TAB 5MG","LISINOPRIL TAB 5 MG","1","0","0","0","","","CARDIOVASCULAR","ACE INHIBITORS"],["N","G","MOEXIPRIL TAB 15MG","MOEXIPRIL HCL TAB 15 MG","1","0","0","0","","","CARDIOVASCULAR","ACE INHIBITORS"],["N","G","MOEXIPRIL TAB 7.5MG","MOEXIPRIL HCL TAB 7.5 MG","1","0","0","0","","","CARDIOVASCULAR","ACE INHIBITORS"],["N","G","PERINDOPRIL TAB 2MG","PERINDOPRIL ERBUMINE TAB 2 MG","1","0","0","0","","","CARDIOVASCULAR","ACE INHIBITORS"],["N","G","PERINDOPRIL TAB 4MG","PERINDOPRIL ERBUMINE TAB 4 MG","1","0","0","0","","","CARDIOVASCULAR","ACE INHIBITORS"],["N","G","PERINDOPRIL TAB 8MG","PERINDOPRIL ERBUMINE TAB 8 MG","1","0","0","0","","","CARDIOVASCULAR","ACE INHIBITORS"],["N","G","QUINAPRIL TAB 10MG","QUINAPRIL HCL TAB 10 MG","1","0","0","0","","","CARDIOVASCULAR","ACE INHIBITORS"],["N","G","QUINAPRIL TAB 20MG","QUINAPRIL HCL TAB 20 MG","1","0","0","0","","","CARDIOVASCULAR","ACE INHIBITORS"],["N","G","QUINAPRIL TAB 40MG","QUINAPRIL HCL TAB 40 MG","1","0","0","0","","","CARDIOVASCULAR","ACE INHIBITORS"],["N","G","QUINAPRIL TAB 5MG","QUINAPRIL HCL TAB 5 MG","1","0","0","0","","","CARDIOVASCULAR","ACE INHIBITORS"],["N","G","RAMIPRIL CAP 1.25MG","RAMIPRIL CAP 1.25 MG","1","0","0","0","","","CARDIOVASCULAR","ACE INHIBITORS"],["N","G","RAMIPRIL CAP 10MG","RAMIPRIL CAP 10 MG","1","0","0","0","","","CARDIOVASCULAR","ACE INHIBITORS"],["N","G","RAMIPRIL CAP 2.5MG","RAMIPRIL CAP 2.5 MG","1","0","0","0","","","CARDIOVASCULAR","ACE INHIBITORS"],["N","G","RAMIPRIL CAP 5MG","RAMIPRIL CAP 5 MG","1","0","0","0","","","CARDIOVASCULAR","ACE INHIBITORS"],["N","G","TRANDOLAPRIL TAB 1MG","TRANDOLAPRIL TAB 1 MG","1","0","0","0","","","CARDIOVASCULAR","ACE INHIBITORS"],["N","G","TRANDOLAPRIL TAB 2MG","TRANDOLAPRIL TAB 2 MG","1","0","0","0","","","CARDIOVASCULAR","ACE INHIBITORS"],["N","G","TRANDOLAPRIL TAB 4MG","TRANDOLAPRIL TAB 4 MG","1","0","0","0","","","CARDIOVASCULAR","ACE INHIBITORS"],["N","G","EPLERENONE TAB 25MG","EPLERENONE TAB 25 MG","1","0","0","0","","","CARDIOVASCULAR","ALDOSTERONE RECEPTOR ANTAGONISTS"],["N","G","EPLERENONE TAB 50MG","EPLERENONE TAB 50 MG","1","0","0","0","","","CARDIOVASCULAR","ALDOSTERONE RECEPTOR ANTAGONISTS"],["N","G","DOXAZOSIN TAB 1MG","DOXAZOSIN MESYLATE TAB 1 MG","1","0","0","0","","","CARDIOVASCULAR","ALPHA BLOCKERS"],["N","G","DOXAZOSIN TAB 2MG","DOXAZOSIN MESYLATE TAB 2 MG","1","0","0","0","","","CARDIOVASCULAR","ALPHA BLOCKERS"],["N","G","DOXAZOSIN TAB 4MG","DOXAZOSIN MESYLATE TAB 4 MG","1","0","0","0","","","CARDIOVASCULAR","ALPHA BLOCKERS"],["N","G","DOXAZOSIN TAB 8MG","DOXAZOSIN MESYLATE TAB 8 MG","1","0","0","0","","","CARDIOVASCULAR","ALPHA BLOCKERS"],["N","G","PRAZOSIN HCL CAP 1MG","PRAZOSIN HCL CAP 1 MG","1","0","0","0","","","CARDIOVASCULAR","ALPHA BLOCKERS"],["N","G","PRAZOSIN HCL CAP 2MG","PRAZOSIN HCL CAP 2 MG","1","0","0","0","","","CARDIOVASCULAR","ALPHA BLOCKERS"],["N","G","PRAZOSIN HCL CAP 5MG","PRAZOSIN HCL CAP 5 MG","1","0","0","0","","","CARDIOVASCULAR","ALPHA BLOCKERS"],["N","G","TERAZOSIN CAP 10MG","TERAZOSIN HCL CAP 10 MG (BASE EQUIVALENT)","1","0","0","0","","","CARDIOVASCULAR","ALPHA BLOCKERS"],["N","G","TERAZOSIN CAP 1MG","TERAZOSIN HCL CAP 1 MG (BASE EQUIVALENT)","1","0","0","0","","","CARDIOVASCULAR","ALPHA BLOCKERS"],["N","G","TERAZOSIN CAP 2MG","TERAZOSIN HCL CAP 2 MG (BASE EQUIVALENT)","1","0","0","0","","","CARDIOVASCULAR","ALPHA BLOCKERS"],["N","G","TERAZOSIN CAP 5MG","TERAZOSIN HCL CAP 5 MG (BASE EQUIVALENT)","1","0","0","0","","","CARDIOVASCULAR","ALPHA BLOCKERS"],["N","G","AMLOD/OLMESA TAB 10-20MG","AMLODIPINE BESYLATE-OLMESARTAN MEDOXOMIL TAB 10-20 MG","1","0","0","0","","","CARDIOVASCULAR","ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS"],["N","G","AMLOD/OLMESA TAB 10-40MG","AMLODIPINE BESYLATE-OLMESARTAN MEDOXOMIL TAB 10-40 MG","1","0","0","0","","","CARDIOVASCULAR","ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS"],["N","G","AMLOD/OLMESA TAB 5-20MG","AMLODIPINE BESYLATE-OLMESARTAN MEDOXOMIL TAB 5-20 MG","1","0","0","0","","","CARDIOVASCULAR","ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS"],["N","G","AMLOD/OLMESA TAB 5-40MG","AMLODIPINE BESYLATE-OLMESARTAN MEDOXOMIL TAB 5-40 MG","1","0","0","0","","","CARDIOVASCULAR","ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS"],["N","G","AMLOD/VALSAR TAB /HCTZ","AMLODIPINE-VALSARTAN-HYDROCHLOROTHIAZIDE TAB 10-160-12.5 MG","1","0","0","0","","","CARDIOVASCULAR","ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS"],["N","G","AMLOD/VALSAR TAB /HCTZ","AMLODIPINE-VALSARTAN-HYDROCHLOROTHIAZIDE TAB 5-160-25 MG","1","0","0","0","","","CARDIOVASCULAR","ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS"],["N","G","AMLOD/VALSAR TAB /HCTZ","AMLODIPINE-VALSARTAN-HYDROCHLOROTHIAZIDE TAB 10-160-25 MG","1","0","0","0","","","CARDIOVASCULAR","ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS"],["N","G","AMLOD/VALSAR TAB /HCTZ","AMLODIPINE-VALSARTAN-HYDROCHLOROTHIAZIDE TAB 10-320-25 MG","1","0","0","0","","","CARDIOVASCULAR","ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS"],["N","G","AMLOD/VALSAR TAB /HCTZ","AMLODIPINE-VALSARTAN-HYDROCHLOROTHIAZIDE TAB 5-160-12.5 MG","1","0","0","0","","","CARDIOVASCULAR","ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS"],["N","G","AMLOD/VALSAR TAB 10-160MG","AMLODIPINE BESYLATE-VALSARTAN TAB 10-160 MG","1","0","0","0","","","CARDIOVASCULAR","ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS"],["N","G","AMLOD/VALSAR TAB 10-320MG","AMLODIPINE BESYLATE-VALSARTAN TAB 10-320 MG","1","0","0","0","","","CARDIOVASCULAR","ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS"],["N","G","AMLOD/VALSAR TAB 5-160MG","AMLODIPINE BESYLATE-VALSARTAN TAB 5-160 MG","1","0","0","0","","","CARDIOVASCULAR","ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS"],["N","G","AMLOD/VALSAR TAB 5-320MG","AMLODIPINE BESYLATE-VALSARTAN TAB 5-320 MG","1","0","0","0","","","CARDIOVASCULAR","ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS"],["N","G","BYVALSON TAB 5-80MG","NEBIVOLOL-VALSARTAN TAB 5-80 MG","3","0","0","0","","","CARDIOVASCULAR","ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS"],["N","G","CANDESA/HCTZ TAB 16-12.5","CANDESARTAN CILEXETIL-HYDROCHLOROTHIAZIDE TAB 16-12.5 MG","1","0","0","0","","","CARDIOVASCULAR","ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS"],["N","G","CANDESA/HCTZ TAB 32-12.5","CANDESARTAN CILEXETIL-HYDROCHLOROTHIAZIDE TAB 32-12.5 MG","1","0","0","0","","","CARDIOVASCULAR","ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS"],["N","G","CANDESA/HCTZ TAB 32-25MG","CANDESARTAN CILEXETIL-HYDROCHLOROTHIAZIDE TAB 32-25 MG","1","0","0","0","","","CARDIOVASCULAR","ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS"],["N","G","IRBESAR/HCTZ TAB 150-12.5","IRBESARTAN-HYDROCHLOROTHIAZIDE TAB 150-12.5 MG","1","0","0","0","","","CARDIOVASCULAR","ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS"],["N","G","IRBESAR/HCTZ TAB 300-12.5","IRBESARTAN-HYDROCHLOROTHIAZIDE TAB 300-12.5 MG","1","0","0","0","","","CARDIOVASCULAR","ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS"],["N","G","LOSARTAN/HCT TAB 100-12.5","LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 100-12.5 MG","1","0","0","0","","","CARDIOVASCULAR","ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS"],["N","G","LOSARTAN/HCT TAB 100-25","LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 100-25 MG","1","0","0","0","","","CARDIOVASCULAR","ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS"],["N","G","LOSARTAN/HCT TAB 50-12.5","LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 50-12.5 MG","1","0","0","0","","","CARDIOVASCULAR","ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS"],["N","G","OLM MED/AMLO TAB /HCTZ","OLMESARTAN-AMLODIPINE-HYDROCHLOROTHIAZIDE TAB 40-10-25 MG","1","0","0","0","","","CARDIOVASCULAR","ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS"],["N","G","OLM MED/AMLO TAB /HCTZ","OLMESARTAN-AMLODIPINE-HYDROCHLOROTHIAZIDE TAB 20-5-12.5 MG","1","0","0","0","","","CARDIOVASCULAR","ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS"],["N","G","OLM MED/AMLO TAB /HCTZ","OLMESARTAN-AMLODIPINE-HYDROCHLOROTHIAZIDE TAB 40-5-12.5 MG","1","0","0","0","","","CARDIOVASCULAR","ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS"],["N","G","OLM MED/AMLO TAB /HCTZ","OLMESARTAN-AMLODIPINE-HYDROCHLOROTHIAZIDE TAB 40-5-25 MG","1","0","0","0","","","CARDIOVASCULAR","ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS"],["N","G","OLM MED/AMLO TAB /HCTZ","OLMESARTAN-AMLODIPINE-HYDROCHLOROTHIAZIDE TAB 40-10-12.5 MG","1","0","0","0","","","CARDIOVASCULAR","ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS"],["N","G","OLM MED/HCTZ TAB 20-12.5","OLMESARTAN MEDOXOMIL-HYDROCHLOROTHIAZIDE TAB 20-12.5 MG","1","0","0","0","","","CARDIOVASCULAR","ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS"],["N","G","OLM MED/HCTZ TAB 40-12.5","OLMESARTAN MEDOXOMIL-HYDROCHLOROTHIAZIDE TAB 40-12.5 MG","1","0","0","0","","","CARDIOVASCULAR","ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS"],["N","G","OLM MED/HCTZ TAB 40-25MG","OLMESARTAN MEDOXOMIL-HYDROCHLOROTHIAZIDE TAB 40-25 MG","1","0","0","0","","","CARDIOVASCULAR","ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS"],["N","G","TELMIS/AMLOD TAB 40-10MG","TELMISARTAN-AMLODIPINE TAB 40-10 MG","1","0","0","0","","","CARDIOVASCULAR","ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS"],["N","G","TELMIS/AMLOD TAB 40-5MG","TELMISARTAN-AMLODIPINE TAB 40-5 MG","1","0","0","0","","","CARDIOVASCULAR","ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS"],["N","G","TELMIS/AMLOD TAB 80-10MG","TELMISARTAN-AMLODIPINE TAB 80-10 MG","1","0","0","0","","","CARDIOVASCULAR","ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS"],["N","G","TELMIS/AMLOD TAB 80-5MG","TELMISARTAN-AMLODIPINE TAB 80-5 MG","1","0","0","0","","","CARDIOVASCULAR","ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS"],["N","G","TELMISA/HCTZ TAB 40-12.5","TELMISARTAN-HYDROCHLOROTHIAZIDE TAB 40-12.5 MG","1","0","0","0","","","CARDIOVASCULAR","ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS"],["N","G","TELMISA/HCTZ TAB 80-12.5","TELMISARTAN-HYDROCHLOROTHIAZIDE TAB 80-12.5 MG","1","0","0","0","","","CARDIOVASCULAR","ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS"],["N","G","TELMISA/HCTZ TAB 80-25MG","TELMISARTAN-HYDROCHLOROTHIAZIDE TAB 80-25 MG","1","0","0","0","","","CARDIOVASCULAR","ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS"],["N","G","VALSART/HCTZ TAB 160-12.5","VALSARTAN-HYDROCHLOROTHIAZIDE TAB 160-12.5 MG","1","0","0","0","","","CARDIOVASCULAR","ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS"],["N","G","VALSART/HCTZ TAB 160-25MG","VALSARTAN-HYDROCHLOROTHIAZIDE TAB 160-25 MG","1","0","0","0","","","CARDIOVASCULAR","ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS"],["N","G","VALSART/HCTZ TAB 320-12.5","VALSARTAN-HYDROCHLOROTHIAZIDE TAB 320-12.5 MG","1","0","0","0","","","CARDIOVASCULAR","ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS"],["N","G","VALSART/HCTZ TAB 320-25MG","VALSARTAN-HYDROCHLOROTHIAZIDE TAB 320-25 MG","1","0","0","0","","","CARDIOVASCULAR","ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS"],["N","G","VALSART/HCTZ TAB 80-12.5","VALSARTAN-HYDROCHLOROTHIAZIDE TAB 80-12.5 MG","1","0","0","0","","","CARDIOVASCULAR","ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS"],["N","G","CANDESARTAN TAB 16MG","CANDESARTAN CILEXETIL TAB 16 MG","1","0","0","0","","","CARDIOVASCULAR","ANGIOTENSIN II RECEPTOR ANTAGONISTS"],["N","G","CANDESARTAN TAB 32MG","CANDESARTAN CILEXETIL TAB 32 MG","1","0","0","0","","","CARDIOVASCULAR","ANGIOTENSIN II RECEPTOR ANTAGONISTS"],["N","G","CANDESARTAN TAB 4MG","CANDESARTAN CILEXETIL TAB 4 MG","1","0","0","0","","","CARDIOVASCULAR","ANGIOTENSIN II RECEPTOR ANTAGONISTS"],["N","G","CANDESARTAN TAB 8MG","CANDESARTAN CILEXETIL TAB 8 MG","1","0","0","0","","","CARDIOVASCULAR","ANGIOTENSIN II RECEPTOR ANTAGONISTS"],["N","G","EDARBI TAB 40MG","AZILSARTAN MEDOXOMIL TAB 40 MG","3","0","1","0","","PA**","CARDIOVASCULAR","ANGIOTENSIN II RECEPTOR ANTAGONISTS"],["N","G","EDARBI TAB 80MG","AZILSARTAN MEDOXOMIL TAB 80 MG","3","0","1","0","","PA**","CARDIOVASCULAR","ANGIOTENSIN II RECEPTOR ANTAGONISTS"],["N","G","EPROSART MES TAB 600MG","EPROSARTAN MESYLATE TAB 600 MG","1","0","0","0","","","CARDIOVASCULAR","ANGIOTENSIN II RECEPTOR ANTAGONISTS"],["N","G","IRBESARTAN TAB 150MG","IRBESARTAN TAB 150 MG","1","0","0","0","","","CARDIOVASCULAR","ANGIOTENSIN II RECEPTOR ANTAGONISTS"],["N","G","IRBESARTAN TAB 300MG","IRBESARTAN TAB 300 MG","1","0","0","0","","","CARDIOVASCULAR","ANGIOTENSIN II RECEPTOR ANTAGONISTS"],["N","G","IRBESARTAN TAB 75MG","IRBESARTAN TAB 75 MG","1","0","0","0","","","CARDIOVASCULAR","ANGIOTENSIN II RECEPTOR ANTAGONISTS"],["N","G","LOSARTAN POT TAB 100MG","LOSARTAN POTASSIUM TAB 100 MG","1","0","0","0","","","CARDIOVASCULAR","ANGIOTENSIN II RECEPTOR ANTAGONISTS"],["N","G","LOSARTAN POT TAB 25MG","LOSARTAN POTASSIUM TAB 25 MG","1","0","0","0","","","CARDIOVASCULAR","ANGIOTENSIN II RECEPTOR ANTAGONISTS"],["N","G","LOSARTAN POT TAB 50MG","LOSARTAN POTASSIUM TAB 50 MG","1","0","0","0","","","CARDIOVASCULAR","ANGIOTENSIN II RECEPTOR ANTAGONISTS"],["N","G","OLMESA MEDOX TAB 20MG","OLMESARTAN MEDOXOMIL TAB 20 MG","1","0","0","0","","","CARDIOVASCULAR","ANGIOTENSIN II RECEPTOR ANTAGONISTS"],["N","G","OLMESA MEDOX TAB 40MG","OLMESARTAN MEDOXOMIL TAB 40 MG","1","0","0","0","","","CARDIOVASCULAR","ANGIOTENSIN II RECEPTOR ANTAGONISTS"],["N","G","OLMESA MEDOX TAB 5MG","OLMESARTAN MEDOXOMIL TAB 5 MG","1","0","0","0","","","CARDIOVASCULAR","ANGIOTENSIN II RECEPTOR ANTAGONISTS"],["N","G","TELMISARTAN TAB 20MG","TELMISARTAN TAB 20 MG","1","0","0","0","","","CARDIOVASCULAR","ANGIOTENSIN II RECEPTOR ANTAGONISTS"],["N","G","TELMISARTAN TAB 40MG","TELMISARTAN TAB 40 MG","1","0","0","0","","","CARDIOVASCULAR","ANGIOTENSIN II RECEPTOR ANTAGONISTS"],["N","G","TELMISARTAN TAB 80MG","TELMISARTAN TAB 80 MG","1","0","0","0","","","CARDIOVASCULAR","ANGIOTENSIN II RECEPTOR ANTAGONISTS"],["N","G","VALSARTAN TAB 160MG","VALSARTAN TAB 160 MG","1","0","0","0","","","CARDIOVASCULAR","ANGIOTENSIN II RECEPTOR ANTAGONISTS"],["N","G","VALSARTAN TAB 320MG","VALSARTAN TAB 320 MG","1","0","0","0","","","CARDIOVASCULAR","ANGIOTENSIN II RECEPTOR ANTAGONISTS"],["N","G","VALSARTAN TAB 40MG","VALSARTAN TAB 40 MG","1","0","0","0","","","CARDIOVASCULAR","ANGIOTENSIN II RECEPTOR ANTAGONISTS"],["N","G","VALSARTAN TAB 80MG","VALSARTAN TAB 80 MG","1","0","0","0","","","CARDIOVASCULAR","ANGIOTENSIN II RECEPTOR ANTAGONISTS"],["N","G","AMIODARONE INJ 50MG/ML","AMIODARONE HCL INJ 450 MG/9ML (50 MG/ML)","1","0","0","0","","","CARDIOVASCULAR","ANTIARRHYTHMICS"],["N","G","AMIODARONE INJ 50MG/ML","AMIODARONE HCL INJ 900 MG/18ML (50 MG/ML)","1","0","0","0","","","CARDIOVASCULAR","ANTIARRHYTHMICS"],["N","G","AMIODARONE INJ 50MG/ML","AMIODARONE HCL INJ 150 MG/3ML (50 MG/ML)","1","0","0","0","","","CARDIOVASCULAR","ANTIARRHYTHMICS"],["N","G","AMIODARONE TAB 200MG","AMIODARONE HCL TAB 200 MG","1","0","0","0","","","CARDIOVASCULAR","ANTIARRHYTHMICS"],["N","G","AMIODARONE TAB 400MG","AMIODARONE HCL TAB 400 MG","1","0","0","0","","","CARDIOVASCULAR","ANTIARRHYTHMICS"],["N","G","DISOPYRAMIDE CAP 100MG","DISOPYRAMIDE PHOSPHATE CAP 100 MG","1","0","0","0","","","CARDIOVASCULAR","ANTIARRHYTHMICS"],["N","G","DISOPYRAMIDE CAP 150MG","DISOPYRAMIDE PHOSPHATE CAP 150 MG","1","0","0","0","","","CARDIOVASCULAR","ANTIARRHYTHMICS"],["N","G","DOFETILIDE CAP 125MCG","DOFETILIDE CAP 125 MCG (0.125 MG)","1","1","0","0","","SP","CARDIOVASCULAR","ANTIARRHYTHMICS"],["N","G","DOFETILIDE CAP 250MCG","DOFETILIDE CAP 250 MCG (0.25 MG)","1","1","0","0","","SP","CARDIOVASCULAR","ANTIARRHYTHMICS"],["N","G","DOFETILIDE CAP 500MCG","DOFETILIDE CAP 500 MCG (0.5 MG)","1","1","0","0","","SP","CARDIOVASCULAR","ANTIARRHYTHMICS"],["N","G","FLECAINIDE TAB 100MG","FLECAINIDE ACETATE TAB 100 MG","1","0","0","0","","","CARDIOVASCULAR","ANTIARRHYTHMICS"],["N","G","FLECAINIDE TAB 150MG","FLECAINIDE ACETATE TAB 150 MG","1","0","0","0","","","CARDIOVASCULAR","ANTIARRHYTHMICS"],["N","G","FLECAINIDE TAB 50MG","FLECAINIDE ACETATE TAB 50 MG","1","0","0","0","","","CARDIOVASCULAR","ANTIARRHYTHMICS"],["N","G","LIDOCAIN/D5W INJ 4MG/ML","LIDOCAINE IV INFUSION IN D5W INJ 4 MG/ML","1","0","0","0","","","CARDIOVASCULAR","ANTIARRHYTHMICS"],["N","G","LIDOCAIN/D5W INJ 8MG/ML","LIDOCAINE IV INFUSION IN D5W INJ 8 MG/ML","1","0","0","0","","","CARDIOVASCULAR","ANTIARRHYTHMICS"],["N","G","LIDOCAINE INJ 10MG/ML","LIDOCAINE HCL (CARDIAC) IV SOLN PREF SYR 50 MG/5ML (1%)","1","0","0","0","","","CARDIOVASCULAR","ANTIARRHYTHMICS"],["N","G","LIDOCAINE INJ 10MG/ML","LIDOCAINE HCL (CARDIAC) IV PF SOLN PREF SYR 50 MG/5ML(1%)","1","0","0","0","","","CARDIOVASCULAR","ANTIARRHYTHMICS"],["N","G","LIDOCAINE INJ 20MG/ML","LIDOCAINE HCL (CARDIAC) IV SOLN PREF SYR 100 MG/5ML (2%)","1","0","0","0","","","CARDIOVASCULAR","ANTIARRHYTHMICS"],["N","G","LIDOCAINE INJ 20MG/ML","LIDOCAINE HCL (CARDIAC) IV PF SOLN 100 MG/5ML (2%)","1","0","0","0","","","CARDIOVASCULAR","ANTIARRHYTHMICS"],["N","G","LIDOCAINE INJ 20MG/ML","LIDOCAINE HCL(CARDIAC) IV PF SOLN PREF SYR 100 MG/5ML (2%)","1","0","0","0","","","CARDIOVASCULAR","ANTIARRHYTHMICS"],["N","G","MEXILETINE CAP 150MG","MEXILETINE HCL CAP 150 MG","1","0","0","0","","","CARDIOVASCULAR","ANTIARRHYTHMICS"],["N","G","MEXILETINE CAP 200MG","MEXILETINE HCL CAP 200 MG","1","0","0","0","","","CARDIOVASCULAR","ANTIARRHYTHMICS"],["N","G","MEXILETINE CAP 250MG","MEXILETINE HCL CAP 250 MG","1","0","0","0","","","CARDIOVASCULAR","ANTIARRHYTHMICS"],["N","G","MULTAQ TAB 400MG","DRONEDARONE HCL TAB 400 MG (BASE EQUIVALENT)","3","1","0","0","","","CARDIOVASCULAR","ANTIARRHYTHMICS"],["N","G","NORPACE CAP 100MG CR","DISOPYRAMIDE PHOSPHATE CAP ER 12HR 100 MG","2","0","0","0","","","CARDIOVASCULAR","ANTIARRHYTHMICS"],["N","G","NORPACE CAP 150MG CR","DISOPYRAMIDE PHOSPHATE CAP ER 12HR 150 MG","2","0","0","0","","","CARDIOVASCULAR","ANTIARRHYTHMICS"],["N","G","PACERONE TAB 100MG","AMIODARONE HCL TAB 100 MG","1","0","0","0","","","CARDIOVASCULAR","ANTIARRHYTHMICS"],["N","G","PACERONE TAB 200MG","AMIODARONE HCL TAB 200 MG","1","0","0","0","","","CARDIOVASCULAR","ANTIARRHYTHMICS"],["N","G","PROCAINAMIDE INJ 100MG/ML","PROCAINAMIDE HCL INJ 100 MG/ML","1","0","0","0","","","CARDIOVASCULAR","ANTIARRHYTHMICS"],["N","G","PROPAFENONE CAP 225MG ER","PROPAFENONE HCL CAP ER 12HR 225 MG","1","0","0","0","","","CARDIOVASCULAR","ANTIARRHYTHMICS"],["N","G","PROPAFENONE CAP 325MG ER","PROPAFENONE HCL CAP ER 12HR 325 MG","1","0","0","0","","","CARDIOVASCULAR","ANTIARRHYTHMICS"],["N","G","PROPAFENONE CAP 425MG ER","PROPAFENONE HCL CAP ER 12HR 425 MG","1","0","0","0","","","CARDIOVASCULAR","ANTIARRHYTHMICS"],["N","G","PROPAFENONE TAB 150MG","PROPAFENONE HCL TAB 150 MG","1","0","0","0","","","CARDIOVASCULAR","ANTIARRHYTHMICS"],["N","G","PROPAFENONE TAB 225MG","PROPAFENONE HCL TAB 225 MG","1","0","0","0","","","CARDIOVASCULAR","ANTIARRHYTHMICS"],["N","G","PROPAFENONE TAB 300MG","PROPAFENONE HCL TAB 300 MG","1","0","0","0","","","CARDIOVASCULAR","ANTIARRHYTHMICS"],["N","G","SORINE TAB 120MG","SOTALOL HCL TAB 120 MG","1","0","0","0","","","CARDIOVASCULAR","ANTIARRHYTHMICS"],["N","G","SORINE TAB 160MG","SOTALOL HCL TAB 160 MG","1","0","0","0","","","CARDIOVASCULAR","ANTIARRHYTHMICS"],["N","G","SORINE TAB 240MG","SOTALOL HCL TAB 240 MG","1","0","0","0","","","CARDIOVASCULAR","ANTIARRHYTHMICS"],["N","G","SORINE TAB 80MG","SOTALOL HCL TAB 80 MG","1","0","0","0","","","CARDIOVASCULAR","ANTIARRHYTHMICS"],["N","G","SOTALOL AF TAB 120MG","SOTALOL HCL (AFIB/AFL) TAB 120 MG","1","0","0","0","","","CARDIOVASCULAR","ANTIARRHYTHMICS"],["N","G","SOTALOL AF TAB 160MG","SOTALOL HCL (AFIB/AFL) TAB 160 MG","1","0","0","0","","","CARDIOVASCULAR","ANTIARRHYTHMICS"],["N","G","SOTALOL AF TAB 80MG","SOTALOL HCL (AFIB/AFL) TAB 80 MG","1","0","0","0","","","CARDIOVASCULAR","ANTIARRHYTHMICS"],["N","G","SOTALOL HCL INJ 150/10ML","SOTALOL HCL INJ 150 MG/10ML (15 MG/ML)","3","0","0","0","","","CARDIOVASCULAR","ANTIARRHYTHMICS"],["N","G","SOTALOL HCL TAB 120MG","SOTALOL HCL TAB 120 MG","1","0","0","0","","","CARDIOVASCULAR","ANTIARRHYTHMICS"],["N","G","SOTALOL HCL TAB 160MG","SOTALOL HCL TAB 160 MG","1","0","0","0","","","CARDIOVASCULAR","ANTIARRHYTHMICS"],["N","G","SOTALOL HCL TAB 240MG","SOTALOL HCL TAB 240 MG","1","0","0","0","","","CARDIOVASCULAR","ANTIARRHYTHMICS"],["N","G","SOTALOL HCL TAB 80MG","SOTALOL HCL TAB 80 MG","1","0","0","0","","","CARDIOVASCULAR","ANTIARRHYTHMICS"],["N","G","CHOLESTYRAM POW 4GM","CHOLESTYRAMINE POWDER PACKETS 4 GM","1","0","0","0","","","CARDIOVASCULAR","ANTILIPEMICS, BILE ACID RESINS"],["N","G","CHOLESTYRAM POW 4GM","CHOLESTYRAMINE POWDER 4 GM/DOSE","1","0","0","0","","","CARDIOVASCULAR","ANTILIPEMICS, BILE ACID RESINS"],["N","G","CHOLESTYRAM POW 4GM LITE","CHOLESTYRAMINE LIGHT POWDER PACKETS 4 GM","1","0","0","0","","","CARDIOVASCULAR","ANTILIPEMICS, BILE ACID RESINS"],["N","G","CHOLESTYRAM POW 4GM LITE","CHOLESTYRAMINE LIGHT POWDER 4 GM/DOSE","1","0","0","0","","","CARDIOVASCULAR","ANTILIPEMICS, BILE ACID RESINS"],["N","G","COLESEVELAM PAK 3.75","COLESEVELAM HCL PACKET FOR SUSP 3.75 GM","1","0","0","0","","","CARDIOVASCULAR","ANTILIPEMICS, BILE ACID RESINS"],["N","G","COLESEVELAM TAB 625MG","COLESEVELAM HCL TAB 625 MG","1","0","0","0","","","CARDIOVASCULAR","ANTILIPEMICS, BILE ACID RESINS"],["N","G","COLESTIPOL GRA 5GM","COLESTIPOL HCL GRANULES 5 GM","1","0","0","0","","","CARDIOVASCULAR","ANTILIPEMICS, BILE ACID RESINS"],["N","G","COLESTIPOL GRA 5GM","COLESTIPOL HCL GRANULE PACKETS 5 GM","1","0","0","0","","","CARDIOVASCULAR","ANTILIPEMICS, BILE ACID RESINS"],["N","G","COLESTIPOL TAB 1GM","COLESTIPOL HCL TAB 1 GM","1","0","0","0","","","CARDIOVASCULAR","ANTILIPEMICS, BILE ACID RESINS"],["N","G","PREVALITE POW 4GM","CHOLESTYRAMINE LIGHT POWDER 4 GM/DOSE","1","0","0","0","","","CARDIOVASCULAR","ANTILIPEMICS, BILE ACID RESINS"],["N","G","EZETIMIBE TAB 10MG","EZETIMIBE TAB 10 MG","1","0","0","0","","","CARDIOVASCULAR","ANTILIPEMICS, CHOLESTEROL ABSORPTION INHIBITOR"],["N","G","FENOFIBRATE CAP 130MG","FENOFIBRATE MICRONIZED CAP 130 MG","1","0","0","0","","","CARDIOVASCULAR","ANTILIPEMICS, FIBRATES"],["N","G","FENOFIBRATE CAP 134MG","FENOFIBRATE MICRONIZED CAP 134 MG","1","0","0","0","","","CARDIOVASCULAR","ANTILIPEMICS, FIBRATES"],["N","G","FENOFIBRATE CAP 150MG","FENOFIBRATE CAP 150 MG","1","0","0","0","","","CARDIOVASCULAR","ANTILIPEMICS, FIBRATES"],["N","G","FENOFIBRATE CAP 200MG","FENOFIBRATE MICRONIZED CAP 200 MG","1","0","0","0","","","CARDIOVASCULAR","ANTILIPEMICS, FIBRATES"],["N","G","FENOFIBRATE CAP 43MG","FENOFIBRATE MICRONIZED CAP 43 MG","1","0","0","0","","","CARDIOVASCULAR","ANTILIPEMICS, FIBRATES"],["N","G","FENOFIBRATE CAP 50MG","FENOFIBRATE CAP 50 MG","1","0","0","0","","","CARDIOVASCULAR","ANTILIPEMICS, FIBRATES"],["N","G","FENOFIBRATE CAP 67MG","FENOFIBRATE MICRONIZED CAP 67 MG","1","0","0","0","","","CARDIOVASCULAR","ANTILIPEMICS, FIBRATES"],["N","G","FENOFIBRATE TAB 145MG","FENOFIBRATE TAB 145 MG","1","0","0","0","","","CARDIOVASCULAR","ANTILIPEMICS, FIBRATES"],["N","G","FENOFIBRATE TAB 160MG","FENOFIBRATE TAB 160 MG","1","0","0","0","","","CARDIOVASCULAR","ANTILIPEMICS, FIBRATES"],["N","G","FENOFIBRATE TAB 48MG","FENOFIBRATE TAB 48 MG","1","0","0","0","","","CARDIOVASCULAR","ANTILIPEMICS, FIBRATES"],["N","G","FENOFIBRATE TAB 54MG","FENOFIBRATE TAB 54 MG","1","0","0","0","","","CARDIOVASCULAR","ANTILIPEMICS, FIBRATES"],["N","G","FENOFIBRIC CAP 135MG DR","CHOLINE FENOFIBRATE CAP DR 135 MG (FENOFIBRIC ACID EQUIV)","1","0","0","0","","","CARDIOVASCULAR","ANTILIPEMICS, FIBRATES"],["N","G","FENOFIBRIC CAP 45MG DR","CHOLINE FENOFIBRATE CAP DR 45 MG (FENOFIBRIC ACID EQUIV)","1","0","0","0","","","CARDIOVASCULAR","ANTILIPEMICS, FIBRATES"],["N","G","FENOFIBRIC TAB 105MG","FENOFIBRIC ACID TAB 105 MG","1","0","0","0","","","CARDIOVASCULAR","ANTILIPEMICS, FIBRATES"],["N","G","FENOFIBRIC TAB 35MG","FENOFIBRIC ACID TAB 35 MG","1","0","0","0","","","CARDIOVASCULAR","ANTILIPEMICS, FIBRATES"],["N","G","GEMFIBROZIL TAB 600MG","GEMFIBROZIL TAB 600 MG","1","0","0","0","","","CARDIOVASCULAR","ANTILIPEMICS, FIBRATES"],["N","G","ATORVASTATIN TAB 10MG","ATORVASTATIN CALCIUM TAB 10 MG (BASE EQUIVALENT)","1","0","0","0","","$0 copay for members age 40 through 75","CARDIOVASCULAR","ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS"],["N","G","ATORVASTATIN TAB 20MG","ATORVASTATIN CALCIUM TAB 20 MG (BASE EQUIVALENT)","1","0","0","0","","$0 copay for members age 40 through 75","CARDIOVASCULAR","ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS"],["N","G","ATORVASTATIN TAB 40MG","ATORVASTATIN CALCIUM TAB 40 MG (BASE EQUIVALENT)","1","0","0","0","","","CARDIOVASCULAR","ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS"],["N","G","ATORVASTATIN TAB 80MG","ATORVASTATIN CALCIUM TAB 80 MG (BASE EQUIVALENT)","1","0","0","0","","","CARDIOVASCULAR","ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS"],["N","G","FLUVASTATIN CAP 20MG","FLUVASTATIN SODIUM CAP 20 MG (BASE EQUIVALENT)","1","0","0","0","","$0 copay for members age 40 through 75","CARDIOVASCULAR","ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS"],["N","G","FLUVASTATIN CAP 40MG","FLUVASTATIN SODIUM CAP 40 MG (BASE EQUIVALENT)","1","0","0","0","","$0 copay for members age 40 through 75","CARDIOVASCULAR","ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS"],["N","G","FLUVASTATIN TAB 80MG ER","FLUVASTATIN SODIUM TAB ER 24 HR 80 MG (BASE EQUIVALENT)","1","0","0","0","","$0 copay for members age 40 through 75","CARDIOVASCULAR","ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS"],["N","G","LIVALO TAB 1MG","PITAVASTATIN CALCIUM TAB 1 MG (BASE EQUIV)","3","0","1","0","","PA**","CARDIOVASCULAR","ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS"],["N","G","LIVALO TAB 2MG","PITAVASTATIN CALCIUM TAB 2 MG (BASE EQUIV)","3","0","1","0","","PA**","CARDIOVASCULAR","ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS"],["N","G","LIVALO TAB 4MG","PITAVASTATIN CALCIUM TAB 4 MG (BASE EQUIV)","3","0","1","0","","PA**","CARDIOVASCULAR","ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS"],["N","G","LOVASTATIN TAB 10MG","LOVASTATIN TAB 10 MG","1","0","0","0","","$0 copay for members age 40 through 75","CARDIOVASCULAR","ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS"],["N","G","LOVASTATIN TAB 20MG","LOVASTATIN TAB 20 MG","1","0","0","0","","$0 copay for members age 40 through 75","CARDIOVASCULAR","ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS"],["N","G","LOVASTATIN TAB 40MG","LOVASTATIN TAB 40 MG","1","0","0","0","","$0 copay for members age 40 through 75","CARDIOVASCULAR","ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS"],["N","G","PRAVASTATIN TAB 10MG","PRAVASTATIN SODIUM TAB 10 MG","1","0","0","0","","$0 copay for members age 40 through 75","CARDIOVASCULAR","ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS"],["N","G","PRAVASTATIN TAB 20MG","PRAVASTATIN SODIUM TAB 20 MG","1","0","0","0","","$0 copay for members age 40 through 75","CARDIOVASCULAR","ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS"],["N","G","PRAVASTATIN TAB 40MG","PRAVASTATIN SODIUM TAB 40 MG","1","0","0","0","","$0 copay for members age 40 through 75","CARDIOVASCULAR","ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS"],["N","G","PRAVASTATIN TAB 80MG","PRAVASTATIN SODIUM TAB 80 MG","1","0","0","0","","$0 copay for members age 40 through 75","CARDIOVASCULAR","ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS"],["N","G","ROSUVASTATIN TAB 10MG","ROSUVASTATIN CALCIUM TAB 10 MG","1","0","1","0","","$0 copay for members age 40 through 75; PA**","CARDIOVASCULAR","ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS"],["N","G","ROSUVASTATIN TAB 20MG","ROSUVASTATIN CALCIUM TAB 20 MG","1","0","0","0","","","CARDIOVASCULAR","ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS"],["N","G","ROSUVASTATIN TAB 40MG","ROSUVASTATIN CALCIUM TAB 40 MG","1","0","0","0","","","CARDIOVASCULAR","ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS"],["N","G","ROSUVASTATIN TAB 5MG","ROSUVASTATIN CALCIUM TAB 5 MG","1","0","1","0","","$0 copay for members age 40 through 75; PA**","CARDIOVASCULAR","ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS"],["N","G","SIMVASTATIN TAB 10MG","SIMVASTATIN TAB 10 MG","1","0","0","0","","$0 copay for members age 40 through 75","CARDIOVASCULAR","ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS"],["N","G","SIMVASTATIN TAB 20MG","SIMVASTATIN TAB 20 MG","1","0","0","0","","$0 copay for members age 40 through 75","CARDIOVASCULAR","ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS"],["N","G","SIMVASTATIN TAB 40MG","SIMVASTATIN TAB 40 MG","1","0","0","0","","$0 copay for members age 40 through 75","CARDIOVASCULAR","ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS"],["N","G","SIMVASTATIN TAB 5MG","SIMVASTATIN TAB 5 MG","1","0","0","0","","$0 copay for members age 40 through 75","CARDIOVASCULAR","ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS"],["N","G","SIMVASTATIN TAB 80MG","SIMVASTATIN TAB 80 MG","1","0","1","0","","PA**","CARDIOVASCULAR","ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS"],["N","G","EZETIM/SIMVA TAB 10-10MG","EZETIMIBE-SIMVASTATIN TAB 10-10 MG","1","0","0","0","","","CARDIOVASCULAR","ANTILIPEMICS, HMG-COA REDUCTASE INHIBITORS/COMBINATIONS"],["N","G","EZETIM/SIMVA TAB 10-20MG","EZETIMIBE-SIMVASTATIN TAB 10-20 MG","1","0","0","0","","","CARDIOVASCULAR","ANTILIPEMICS, HMG-COA REDUCTASE INHIBITORS/COMBINATIONS"],["N","G","EZETIM/SIMVA TAB 10-40MG","EZETIMIBE-SIMVASTATIN TAB 10-40 MG","1","0","0","0","","","CARDIOVASCULAR","ANTILIPEMICS, HMG-COA REDUCTASE INHIBITORS/COMBINATIONS"],["N","G","EZETIM/SIMVA TAB 10-80MG","EZETIMIBE-SIMVASTATIN TAB 10-80 MG","1","0","0","0","","","CARDIOVASCULAR","ANTILIPEMICS, HMG-COA REDUCTASE INHIBITORS/COMBINATIONS"],["N","G","NIACIN ER TAB 1000MG","NIACIN TAB ER 1000 MG (ANTIHYPERLIPIDEMIC)","1","0","0","0","","","CARDIOVASCULAR","ANTILIPEMICS, MISCELLANEOUS"],["N","G","NIACIN ER TAB 500MG","NIACIN TAB ER 500 MG (ANTIHYPERLIPIDEMIC)","1","0","0","0","","","CARDIOVASCULAR","ANTILIPEMICS, MISCELLANEOUS"],["N","G","NIACIN ER TAB 750MG","NIACIN TAB ER 750 MG (ANTIHYPERLIPIDEMIC)","1","0","0","0","","","CARDIOVASCULAR","ANTILIPEMICS, MISCELLANEOUS"],["N","G","OMEGA-3-ACID CAP 1GM","OMEGA-3-ACID ETHYL ESTERS CAP 1 GM","1","1","0","0","","","CARDIOVASCULAR","ANTILIPEMICS, OMEGA-3 FATTY ACIDS"],["N","G","VASCEPA CAP 0.5GM","ICOSAPENT ETHYL CAP 0.5 GM","2","0","0","0","","","CARDIOVASCULAR","ANTILIPEMICS, OMEGA-3 FATTY ACIDS"],["N","G","VASCEPA CAP 1GM","ICOSAPENT ETHYL CAP 1 GM","2","0","0","0","","","CARDIOVASCULAR","ANTILIPEMICS, OMEGA-3 FATTY ACIDS"],["N","G","REPATHA INJ 140MG/ML","EVOLOCUMAB SUBCUTANEOUS SOLN PREFILLED SYRINGE 140 MG/ML","4","1","0","1","2 syringes every 28 days","SP","CARDIOVASCULAR","ANTILIPEMICS, PCSK9 INHIBITORS"],["N","G","REPATHA PUSH INJ 420/3.5","EVOLOCUMAB SUBCUTANEOUS SOLN CARTRIDGE/INFUSOR 420 MG/3.5ML","4","1","0","1","1 cartridge every 28 days","SP","CARDIOVASCULAR","ANTILIPEMICS, PCSK9 INHIBITORS"],["N","G","REPATHA SURE INJ 140MG/ML","EVOLOCUMAB SUBCUTANEOUS SOLN AUTO-INJECTOR 140 MG/ML","4","1","0","1","2 pens every 28 days","SP","CARDIOVASCULAR","ANTILIPEMICS, PCSK9 INHIBITORS"],["N","G","ATENOL/CHLOR TAB 100-25MG","ATENOLOL & CHLORTHALIDONE TAB 100-25 MG","1","0","0","0","","","CARDIOVASCULAR","BETA-BLOCKER/DIURETIC COMBINATIONS"],["N","G","ATENOL/CHLOR TAB 50-25MG","ATENOLOL & CHLORTHALIDONE TAB 50-25 MG","1","0","0","0","","","CARDIOVASCULAR","BETA-BLOCKER/DIURETIC COMBINATIONS"],["N","G","BISOPRL/HCTZ TAB 10/6.25","BISOPROLOL & HYDROCHLOROTHIAZIDE TAB 10-6.25 MG","1","0","0","0","","","CARDIOVASCULAR","BETA-BLOCKER/DIURETIC COMBINATIONS"],["N","G","BISOPRL/HCTZ TAB 2.5/6.25","BISOPROLOL & HYDROCHLOROTHIAZIDE TAB 2.5-6.25 MG","1","0","0","0","","","CARDIOVASCULAR","BETA-BLOCKER/DIURETIC COMBINATIONS"],["N","G","BISOPRL/HCTZ TAB 5-6.25MG","BISOPROLOL & HYDROCHLOROTHIAZIDE TAB 5-6.25 MG","1","0","0","0","","","CARDIOVASCULAR","BETA-BLOCKER/DIURETIC COMBINATIONS"],["N","G","METOPRL/HCTZ TAB 100-25MG","METOPROLOL & HYDROCHLOROTHIAZIDE TAB 100-25 MG","1","0","0","0","","","CARDIOVASCULAR","BETA-BLOCKER/DIURETIC COMBINATIONS"],["N","G","METOPRL/HCTZ TAB 100-50MG","METOPROLOL & HYDROCHLOROTHIAZIDE TAB 100-50 MG","1","0","0","0","","","CARDIOVASCULAR","BETA-BLOCKER/DIURETIC COMBINATIONS"],["N","G","METOPRL/HCTZ TAB 50-25MG","METOPROLOL & HYDROCHLOROTHIAZIDE TAB 50-25 MG","1","0","0","0","","","CARDIOVASCULAR","BETA-BLOCKER/DIURETIC COMBINATIONS"],["N","G","NADOLOL/BEND TAB 40-5MG","NADOLOL & BENDROFLUMETHIAZIDE TAB 40-5 MG","1","0","0","0","","","CARDIOVASCULAR","BETA-BLOCKER/DIURETIC COMBINATIONS"],["N","G","PROPRAN/HCTZ TAB 40/25","PROPRANOLOL & HYDROCHLOROTHIAZIDE TAB 40-25 MG","1","0","0","0","","","CARDIOVASCULAR","BETA-BLOCKER/DIURETIC COMBINATIONS"],["N","G","PROPRAN/HCTZ TAB 80/25","PROPRANOLOL & HYDROCHLOROTHIAZIDE TAB 80-25 MG","1","0","0","0","","","CARDIOVASCULAR","BETA-BLOCKER/DIURETIC COMBINATIONS"],["N","G","ACEBUTOLOL CAP 200MG","ACEBUTOLOL HCL CAP 200 MG","1","0","0","0","","","CARDIOVASCULAR","BETA-BLOCKERS"],["N","G","ACEBUTOLOL CAP 400MG","ACEBUTOLOL HCL CAP 400 MG","1","0","0","0","","","CARDIOVASCULAR","BETA-BLOCKERS"],["N","G","ATENOLOL TAB 100MG","ATENOLOL TAB 100 MG","1","0","0","0","","","CARDIOVASCULAR","BETA-BLOCKERS"],["N","G","ATENOLOL TAB 25MG","ATENOLOL TAB 25 MG","1","0","0","0","","","CARDIOVASCULAR","BETA-BLOCKERS"],["N","G","ATENOLOL TAB 50MG","ATENOLOL TAB 50 MG","1","0","0","0","","","CARDIOVASCULAR","BETA-BLOCKERS"],["N","G","BETAXOLOL TAB 10MG","BETAXOLOL HCL TAB 10 MG","1","0","0","0","","","CARDIOVASCULAR","BETA-BLOCKERS"],["N","G","BETAXOLOL TAB 20MG","BETAXOLOL HCL TAB 20 MG","1","0","0","0","","","CARDIOVASCULAR","BETA-BLOCKERS"],["N","G","BISOPROL FUM TAB 10MG","BISOPROLOL FUMARATE TAB 10 MG","1","0","0","0","","","CARDIOVASCULAR","BETA-BLOCKERS"],["N","G","BISOPROL FUM TAB 5MG","BISOPROLOL FUMARATE TAB 5 MG","1","0","0","0","","","CARDIOVASCULAR","BETA-BLOCKERS"],["N","G","BYSTOLIC TAB 10MG","NEBIVOLOL HCL TAB 10 MG (BASE EQUIVALENT)","3","0","0","0","","","CARDIOVASCULAR","BETA-BLOCKERS"],["N","G","BYSTOLIC TAB 2.5MG","NEBIVOLOL HCL TAB 2.5 MG (BASE EQUIVALENT)","3","0","0","0","","","CARDIOVASCULAR","BETA-BLOCKERS"],["N","G","BYSTOLIC TAB 20MG","NEBIVOLOL HCL TAB 20 MG (BASE EQUIVALENT)","3","0","0","0","","","CARDIOVASCULAR","BETA-BLOCKERS"],["N","G","BYSTOLIC TAB 5MG","NEBIVOLOL HCL TAB 5 MG (BASE EQUIVALENT)","3","0","0","0","","","CARDIOVASCULAR","BETA-BLOCKERS"],["N","G","CARVEDILOL CAP 10MG ER","CARVEDILOL PHOSPHATE CAP ER 24HR 10 MG","1","0","0","0","","","CARDIOVASCULAR","BETA-BLOCKERS"],["N","G","CARVEDILOL CAP 20MG ER","CARVEDILOL PHOSPHATE CAP ER 24HR 20 MG","1","0","0","0","","","CARDIOVASCULAR","BETA-BLOCKERS"],["N","G","CARVEDILOL CAP 40MG ER","CARVEDILOL PHOSPHATE CAP ER 24HR 40 MG","1","0","0","0","","","CARDIOVASCULAR","BETA-BLOCKERS"],["N","G","CARVEDILOL CAP 80MG ER","CARVEDILOL PHOSPHATE CAP ER 24HR 80 MG","1","0","0","0","","","CARDIOVASCULAR","BETA-BLOCKERS"],["N","G","CARVEDILOL TAB 12.5MG","CARVEDILOL TAB 12.5 MG","1","0","0","0","","","CARDIOVASCULAR","BETA-BLOCKERS"],["N","G","CARVEDILOL TAB 25MG","CARVEDILOL TAB 25 MG","1","0","0","0","","","CARDIOVASCULAR","BETA-BLOCKERS"],["N","G","CARVEDILOL TAB 3.125MG","CARVEDILOL TAB 3.125 MG","1","0","0","0","","","CARDIOVASCULAR","BETA-BLOCKERS"],["N","G","CARVEDILOL TAB 6.25MG","CARVEDILOL TAB 6.25 MG","1","0","0","0","","","CARDIOVASCULAR","BETA-BLOCKERS"],["N","G","LABETALOL INJ 5MG/ML","LABETALOL HCL IV SOLN 5 MG/ML","1","0","0","0","","","CARDIOVASCULAR","BETA-BLOCKERS"],["N","G","LABETALOL TAB 100MG","LABETALOL HCL TAB 100 MG","1","0","0","0","","","CARDIOVASCULAR","BETA-BLOCKERS"],["N","G","LABETALOL TAB 200MG","LABETALOL HCL TAB 200 MG","1","0","0","0","","","CARDIOVASCULAR","BETA-BLOCKERS"],["N","G","LABETALOL TAB 300MG","LABETALOL HCL TAB 300 MG","1","0","0","0","","","CARDIOVASCULAR","BETA-BLOCKERS"],["N","G","METOPROL TAR TAB 100MG","METOPROLOL TARTRATE TAB 100 MG","1","0","0","0","","","CARDIOVASCULAR","BETA-BLOCKERS"],["N","G","METOPROL TAR TAB 25MG","METOPROLOL TARTRATE TAB 25 MG","1","0","0","0","","","CARDIOVASCULAR","BETA-BLOCKERS"],["N","G","METOPROL TAR TAB 50MG","METOPROLOL TARTRATE TAB 50 MG","1","0","0","0","","","CARDIOVASCULAR","BETA-BLOCKERS"],["N","G","METOPROLOL INJ 1MG/ML","METOPROLOL TARTRATE IV SOLN CART INJ 5 MG/5ML (1 MG/ML)","1","0","0","0","","","CARDIOVASCULAR","BETA-BLOCKERS"],["N","G","METOPROLOL INJ 5MG/5ML","METOPROLOL TARTRATE IV SOLN 5 MG/5ML","1","0","0","0","","","CARDIOVASCULAR","BETA-BLOCKERS"],["N","G","METOPROLOL TAB 100MG ER","METOPROLOL SUCCINATE TAB ER 24HR 100 MG (TARTRATE EQUIV)","1","0","0","0","","","CARDIOVASCULAR","BETA-BLOCKERS"],["N","G","METOPROLOL TAB 200MG ER","METOPROLOL SUCCINATE TAB ER 24HR 200 MG (TARTRATE EQUIV)","1","0","0","0","","","CARDIOVASCULAR","BETA-BLOCKERS"],["N","G","METOPROLOL TAB 25MG ER","METOPROLOL SUCCINATE TAB ER 24HR 25 MG (TARTRATE EQUIV)","1","0","0","0","","","CARDIOVASCULAR","BETA-BLOCKERS"],["N","G","METOPROLOL TAB 50MG ER","METOPROLOL SUCCINATE TAB ER 24HR 50 MG (TARTRATE EQUIV)","1","0","0","0","","","CARDIOVASCULAR","BETA-BLOCKERS"],["N","G","NADOLOL TAB 20MG","NADOLOL TAB 20 MG","1","0","0","0","","","CARDIOVASCULAR","BETA-BLOCKERS"],["N","G","NADOLOL TAB 40MG","NADOLOL TAB 40 MG","1","0","0","0","","","CARDIOVASCULAR","BETA-BLOCKERS"],["N","G","NADOLOL TAB 80MG","NADOLOL TAB 80 MG","1","0","0","0","","","CARDIOVASCULAR","BETA-BLOCKERS"],["N","G","PINDOLOL TAB 10MG","PINDOLOL TAB 10 MG","1","0","0","0","","","CARDIOVASCULAR","BETA-BLOCKERS"],["N","G","PINDOLOL TAB 5MG","PINDOLOL TAB 5 MG","1","0","0","0","","","CARDIOVASCULAR","BETA-BLOCKERS"],["N","G","PROPRANOLOL CAP 120MG ER","PROPRANOLOL HCL CAP ER 24HR 120 MG","1","0","0","0","","","CARDIOVASCULAR","BETA-BLOCKERS"],["N","G","PROPRANOLOL CAP 160MG ER","PROPRANOLOL HCL CAP ER 24HR 160 MG","1","0","0","0","","","CARDIOVASCULAR","BETA-BLOCKERS"],["N","G","PROPRANOLOL CAP 60MG ER","PROPRANOLOL HCL CAP ER 24HR 60 MG","1","0","0","0","","","CARDIOVASCULAR","BETA-BLOCKERS"],["N","G","PROPRANOLOL CAP 80MG ER","PROPRANOLOL HCL CAP ER 24HR 80 MG","1","0","0","0","","","CARDIOVASCULAR","BETA-BLOCKERS"],["N","G","PROPRANOLOL INJ 1MG/ML","PROPRANOLOL HCL INJ 1 MG/ML","1","0","0","0","","","CARDIOVASCULAR","BETA-BLOCKERS"],["N","G","PROPRANOLOL SOL 20MG/5ML","PROPRANOLOL HCL ORAL SOLN 20 MG/5ML","1","0","0","0","","","CARDIOVASCULAR","BETA-BLOCKERS"],["N","G","PROPRANOLOL SOL 40MG/5ML","PROPRANOLOL HCL ORAL SOLN 40 MG/5ML","1","0","0","0","","","CARDIOVASCULAR","BETA-BLOCKERS"],["N","G","PROPRANOLOL TAB 10MG","PROPRANOLOL HCL TAB 10 MG","1","0","0","0","","","CARDIOVASCULAR","BETA-BLOCKERS"],["N","G","PROPRANOLOL TAB 20MG","PROPRANOLOL HCL TAB 20 MG","1","0","0","0","","","CARDIOVASCULAR","BETA-BLOCKERS"],["N","G","PROPRANOLOL TAB 40MG","PROPRANOLOL HCL TAB 40 MG","1","0","0","0","","","CARDIOVASCULAR","BETA-BLOCKERS"],["N","G","PROPRANOLOL TAB 60MG","PROPRANOLOL HCL TAB 60 MG","1","0","0","0","","","CARDIOVASCULAR","BETA-BLOCKERS"],["N","G","PROPRANOLOL TAB 80MG","PROPRANOLOL HCL TAB 80 MG","1","0","0","0","","","CARDIOVASCULAR","BETA-BLOCKERS"],["N","G","TIMOLOL MAL TAB 10MG","TIMOLOL MALEATE TAB 10 MG","1","0","0","0","","","CARDIOVASCULAR","BETA-BLOCKERS"],["N","G","TIMOLOL MAL TAB 20MG","TIMOLOL MALEATE TAB 20 MG","1","0","0","0","","","CARDIOVASCULAR","BETA-BLOCKERS"],["N","G","TIMOLOL MAL TAB 5MG","TIMOLOL MALEATE TAB 5 MG","1","0","0","0","","","CARDIOVASCULAR","BETA-BLOCKERS"],["N","G","AMLOD/ATORVA TAB 10-10MG","AMLODIPINE BESYLATE-ATORVASTATIN CALCIUM TAB 10-10 MG","1","0","0","0","","","CARDIOVASCULAR","CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS"],["N","G","AMLOD/ATORVA TAB 10-20MG","AMLODIPINE BESYLATE-ATORVASTATIN CALCIUM TAB 10-20 MG","1","0","0","0","","","CARDIOVASCULAR","CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS"],["N","G","AMLOD/ATORVA TAB 10-40MG","AMLODIPINE BESYLATE-ATORVASTATIN CALCIUM TAB 10-40 MG","1","0","0","0","","","CARDIOVASCULAR","CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS"],["N","G","AMLOD/ATORVA TAB 10-80MG","AMLODIPINE BESYLATE-ATORVASTATIN CALCIUM TAB 10-80 MG","1","0","0","0","","","CARDIOVASCULAR","CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS"],["N","G","AMLOD/ATORVA TAB 2.5-10MG","AMLODIPINE BESYLATE-ATORVASTATIN CALCIUM TAB 2.5-10 MG","1","0","0","0","","","CARDIOVASCULAR","CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS"],["N","G","AMLOD/ATORVA TAB 2.5-20MG","AMLODIPINE BESYLATE-ATORVASTATIN CALCIUM TAB 2.5-20 MG","1","0","0","0","","","CARDIOVASCULAR","CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS"],["N","G","AMLOD/ATORVA TAB 2.5-40MG","AMLODIPINE BESYLATE-ATORVASTATIN CALCIUM TAB 2.5-40 MG","1","0","0","0","","","CARDIOVASCULAR","CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS"],["N","G","AMLOD/ATORVA TAB 5-10MG","AMLODIPINE BESYLATE-ATORVASTATIN CALCIUM TAB 5-10 MG","1","0","0","0","","","CARDIOVASCULAR","CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS"],["N","G","AMLOD/ATORVA TAB 5-20MG","AMLODIPINE BESYLATE-ATORVASTATIN CALCIUM TAB 5-20 MG","1","0","0","0","","","CARDIOVASCULAR","CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS"],["N","G","AMLOD/ATORVA TAB 5-40MG","AMLODIPINE BESYLATE-ATORVASTATIN CALCIUM TAB 5-40 MG","1","0","0","0","","","CARDIOVASCULAR","CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS"],["N","G","AMLOD/ATORVA TAB 5-80MG","AMLODIPINE BESYLATE-ATORVASTATIN CALCIUM TAB 5-80 MG","1","0","0","0","","","CARDIOVASCULAR","CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS"],["N","G","AFEDITAB TAB 30MG CR","NIFEDIPINE TAB ER 24HR 30 MG","1","0","0","0","","","CARDIOVASCULAR","CALCIUM CHANNEL BLOCKERS"],["N","G","AFEDITAB TAB 60MG CR","NIFEDIPINE TAB ER 24HR 60 MG","1","0","0","0","","","CARDIOVASCULAR","CALCIUM CHANNEL BLOCKERS"],["N","G","AMLODIPINE TAB 10MG","AMLODIPINE BESYLATE TAB 10 MG (BASE EQUIVALENT)","1","0","0","0","","","CARDIOVASCULAR","CALCIUM CHANNEL BLOCKERS"],["N","G","AMLODIPINE TAB 2.5MG","AMLODIPINE BESYLATE TAB 2.5 MG (BASE EQUIVALENT)","1","0","0","0","","","CARDIOVASCULAR","CALCIUM CHANNEL BLOCKERS"],["N","G","AMLODIPINE TAB 5MG","AMLODIPINE BESYLATE TAB 5 MG (BASE EQUIVALENT)","1","0","0","0","","","CARDIOVASCULAR","CALCIUM CHANNEL BLOCKERS"],["N","G","CARDENE IV INJ 40/200ML","NICARDIPINE HCL IV SOLN 40 MG/200ML IN DEXTROSE 5%","3","0","0","0","","","CARDIOVASCULAR","CALCIUM CHANNEL BLOCKERS"],["N","G","CARDENE IV SOL 20/200ML","NICARDIPINE HCL IV SOLN 20 MG/200ML IN DEXTROSE 4.8%","3","0","0","0","","","CARDIOVASCULAR","CALCIUM CHANNEL BLOCKERS"],["N","G","CARDIZEM LA TAB 120MG","DILTIAZEM HCL COATED BEADS TAB ER 24HR 120 MG","2","0","0","0","","","CARDIOVASCULAR","CALCIUM CHANNEL BLOCKERS"],["N","G","CARTIA XT CAP 120/24HR","DILTIAZEM HCL COATED BEADS CAP ER 24HR 120 MG","1","0","0","0","","","CARDIOVASCULAR","CALCIUM CHANNEL BLOCKERS"],["N","G","CARTIA XT CAP 180/24HR","DILTIAZEM HCL COATED BEADS CAP ER 24HR 180 MG","1","0","0","0","","","CARDIOVASCULAR","CALCIUM CHANNEL BLOCKERS"],["N","G","CARTIA XT CAP 240/24HR","DILTIAZEM HCL COATED BEADS CAP ER 24HR 240 MG","1","0","0","0","","","CARDIOVASCULAR","CALCIUM CHANNEL BLOCKERS"],["N","G","CARTIA XT CAP 300/24HR","DILTIAZEM HCL COATED BEADS CAP ER 24HR 300 MG","1","0","0","0","","","CARDIOVASCULAR","CALCIUM CHANNEL BLOCKERS"],["N","G","DILTIAZEM CAP 120MG ER","DILTIAZEM HCL CAP ER 12HR 120 MG","1","0","0","0","","","CARDIOVASCULAR","CALCIUM CHANNEL BLOCKERS"],["N","G","DILTIAZEM CAP 120MG ER","DILTIAZEM HCL CAP ER 24HR 120 MG","1","0","0","0","","","CARDIOVASCULAR","CALCIUM CHANNEL BLOCKERS"],["N","G","DILTIAZEM CAP 120MG ER","DILTIAZEM HCL COATED BEADS CAP ER 24HR 120 MG","1","0","0","0","","","CARDIOVASCULAR","CALCIUM CHANNEL BLOCKERS"],["N","G","DILTIAZEM CAP 120MG/24","DILTIAZEM HCL EXTENDED RELEASE BEADS CAP ER 24HR 120 MG","1","0","0","0","","","CARDIOVASCULAR","CALCIUM CHANNEL BLOCKERS"],["N","G","DILTIAZEM CAP 180MG ER","DILTIAZEM HCL COATED BEADS CAP ER 24HR 180 MG","1","0","0","0","","","CARDIOVASCULAR","CALCIUM CHANNEL BLOCKERS"],["N","G","DILTIAZEM CAP 180MG ER","DILTIAZEM HCL CAP ER 24HR 180 MG","1","0","0","0","","","CARDIOVASCULAR","CALCIUM CHANNEL BLOCKERS"],["N","G","DILTIAZEM CAP 180MG/24","DILTIAZEM HCL EXTENDED RELEASE BEADS CAP ER 24HR 180 MG","1","0","0","0","","","CARDIOVASCULAR","CALCIUM CHANNEL BLOCKERS"],["N","G","DILTIAZEM CAP 240MG ER","DILTIAZEM HCL CAP ER 24HR 240 MG","1","0","0","0","","","CARDIOVASCULAR","CALCIUM CHANNEL BLOCKERS"],["N","G","DILTIAZEM CAP 240MG ER","DILTIAZEM HCL COATED BEADS CAP ER 24HR 240 MG","1","0","0","0","","","CARDIOVASCULAR","CALCIUM CHANNEL BLOCKERS"],["N","G","DILTIAZEM CAP 240MG/24","DILTIAZEM HCL EXTENDED RELEASE BEADS CAP ER 24HR 240 MG","1","0","0","0","","","CARDIOVASCULAR","CALCIUM CHANNEL BLOCKERS"],["N","G","DILTIAZEM CAP 300MG ER","DILTIAZEM HCL EXTENDED RELEASE BEADS CAP ER 24HR 300 MG","1","0","0","0","","","CARDIOVASCULAR","CALCIUM CHANNEL BLOCKERS"],["N","G","DILTIAZEM CAP 300MG ER","DILTIAZEM HCL COATED BEADS CAP ER 24HR 300 MG","1","0","0","0","","","CARDIOVASCULAR","CALCIUM CHANNEL BLOCKERS"],["N","G","DILTIAZEM CAP 360MG ER","DILTIAZEM HCL COATED BEADS CAP ER 24HR 360 MG","1","0","0","0","","","CARDIOVASCULAR","CALCIUM CHANNEL BLOCKERS"],["N","G","DILTIAZEM CAP 360MG/24","DILTIAZEM HCL EXTENDED RELEASE BEADS CAP ER 24HR 360 MG","1","0","0","0","","","CARDIOVASCULAR","CALCIUM CHANNEL BLOCKERS"],["N","G","DILTIAZEM CAP 420MG/24","DILTIAZEM HCL EXTENDED RELEASE BEADS CAP ER 24HR 420 MG","1","0","0","0","","","CARDIOVASCULAR","CALCIUM CHANNEL BLOCKERS"],["N","G","DILTIAZEM CAP 60MG ER","DILTIAZEM HCL CAP ER 12HR 60 MG","1","0","0","0","","","CARDIOVASCULAR","CALCIUM CHANNEL BLOCKERS"],["N","G","DILTIAZEM CAP 90MG ER","DILTIAZEM HCL CAP ER 12HR 90 MG","1","0","0","0","","","CARDIOVASCULAR","CALCIUM CHANNEL BLOCKERS"],["N","G","DILTIAZEM INJ 100MG","DILTIAZEM HCL IV FOR SOLN 100 MG","3","0","0","0","","","CARDIOVASCULAR","CALCIUM CHANNEL BLOCKERS"],["N","G","DILTIAZEM INJ 125/25ML","DILTIAZEM HCL IV SOLN 125 MG/25ML (5 MG/ML)","1","0","0","0","","","CARDIOVASCULAR","CALCIUM CHANNEL BLOCKERS"],["N","G","DILTIAZEM INJ 25MG/5ML","DILTIAZEM HCL IV SOLN 25 MG/5ML (5 MG/ML)","1","0","0","0","","","CARDIOVASCULAR","CALCIUM CHANNEL BLOCKERS"],["N","G","DILTIAZEM INJ 50/10ML","DILTIAZEM HCL IV SOLN 50 MG/10ML (5 MG/ML)","1","0","0","0","","","CARDIOVASCULAR","CALCIUM CHANNEL BLOCKERS"],["N","G","DILTIAZEM TAB 120MG","DILTIAZEM HCL TAB 120 MG","1","0","0","0","","","CARDIOVASCULAR","CALCIUM CHANNEL BLOCKERS"],["N","G","DILTIAZEM TAB 30MG","DILTIAZEM HCL TAB 30 MG","1","0","0","0","","","CARDIOVASCULAR","CALCIUM CHANNEL BLOCKERS"],["N","G","DILTIAZEM TAB 60MG","DILTIAZEM HCL TAB 60 MG","1","0","0","0","","","CARDIOVASCULAR","CALCIUM CHANNEL BLOCKERS"],["N","G","DILTIAZEM TAB 90MG","DILTIAZEM HCL TAB 90 MG","1","0","0","0","","","CARDIOVASCULAR","CALCIUM CHANNEL BLOCKERS"],["N","G","FELODIPINE TAB 10MG ER","FELODIPINE TAB ER 24HR 10 MG","1","0","0","0","","","CARDIOVASCULAR","CALCIUM CHANNEL BLOCKERS"],["N","G","FELODIPINE TAB 2.5MG ER","FELODIPINE TAB ER 24HR 2.5 MG","1","0","0","0","","","CARDIOVASCULAR","CALCIUM CHANNEL BLOCKERS"],["N","G","FELODIPINE TAB 5MG ER","FELODIPINE TAB ER 24HR 5 MG","1","0","0","0","","","CARDIOVASCULAR","CALCIUM CHANNEL BLOCKERS"],["N","G","ISRADIPINE CAP 2.5MG","ISRADIPINE CAP 2.5 MG","1","0","0","0","","","CARDIOVASCULAR","CALCIUM CHANNEL BLOCKERS"],["N","G","ISRADIPINE CAP 5MG","ISRADIPINE CAP 5 MG","1","0","0","0","","","CARDIOVASCULAR","CALCIUM CHANNEL BLOCKERS"],["N","G","MATZIM LA TAB 180MG/24","DILTIAZEM HCL COATED BEADS TAB ER 24HR 180 MG","1","0","0","0","","","CARDIOVASCULAR","CALCIUM CHANNEL BLOCKERS"],["N","G","MATZIM LA TAB 240MG/24","DILTIAZEM HCL COATED BEADS TAB ER 24HR 240 MG","1","0","0","0","","","CARDIOVASCULAR","CALCIUM CHANNEL BLOCKERS"],["N","G","MATZIM LA TAB 300MG/24","DILTIAZEM HCL COATED BEADS TAB ER 24HR 300 MG","1","0","0","0","","","CARDIOVASCULAR","CALCIUM CHANNEL BLOCKERS"],["N","G","MATZIM LA TAB 360MG/24","DILTIAZEM HCL COATED BEADS TAB ER 24HR 360 MG","1","0","0","0","","","CARDIOVASCULAR","CALCIUM CHANNEL BLOCKERS"],["N","G","MATZIM LA TAB 420MG/24","DILTIAZEM HCL COATED BEADS TAB ER 24HR 420 MG","1","0","0","0","","","CARDIOVASCULAR","CALCIUM CHANNEL BLOCKERS"],["N","G","NICARDIPINE CAP 20MG","NICARDIPINE HCL CAP 20 MG","1","0","0","0","","","CARDIOVASCULAR","CALCIUM CHANNEL BLOCKERS"],["N","G","NICARDIPINE CAP 30MG","NICARDIPINE HCL CAP 30 MG","1","0","0","0","","","CARDIOVASCULAR","CALCIUM CHANNEL BLOCKERS"],["N","G","NICARDIPINE INJ 25/10ML","NICARDIPINE HCL IV SOLN 2.5 MG/ML","1","0","0","0","","","CARDIOVASCULAR","CALCIUM CHANNEL BLOCKERS"],["N","G","NIFEDIPINE TAB 30MG ER","NIFEDIPINE TAB ER 24HR 30 MG","1","0","0","0","","","CARDIOVASCULAR","CALCIUM CHANNEL BLOCKERS"],["N","G","NIFEDIPINE TAB 30MG ER","NIFEDIPINE TAB ER 24HR OSMOTIC RELEASE 30 MG","1","0","0","0","","","CARDIOVASCULAR","CALCIUM CHANNEL BLOCKERS"],["N","G","NIFEDIPINE TAB 60MG ER","NIFEDIPINE TAB ER 24HR 60 MG","1","0","0","0","","","CARDIOVASCULAR","CALCIUM CHANNEL BLOCKERS"],["N","G","NIFEDIPINE TAB 60MG ER","NIFEDIPINE TAB ER 24HR OSMOTIC RELEASE 60 MG","1","0","0","0","","","CARDIOVASCULAR","CALCIUM CHANNEL BLOCKERS"],["N","G","NIFEDIPINE TAB 90MG ER","NIFEDIPINE TAB ER 24HR 90 MG","1","0","0","0","","","CARDIOVASCULAR","CALCIUM CHANNEL BLOCKERS"],["N","G","NIFEDIPINE TAB 90MG ER","NIFEDIPINE TAB ER 24HR OSMOTIC RELEASE 90 MG","1","0","0","0","","","CARDIOVASCULAR","CALCIUM CHANNEL BLOCKERS"],["N","G","NIMODIPINE CAP 30MG","NIMODIPINE CAP 30 MG","1","0","0","0","","","CARDIOVASCULAR","CALCIUM CHANNEL BLOCKERS"],["N","G","NISOLDIPINE TAB 17MG ER","NISOLDIPINE TAB ER 24HR 17 MG","1","0","0","0","","","CARDIOVASCULAR","CALCIUM CHANNEL BLOCKERS"],["N","G","NISOLDIPINE TAB 20MG ER","NISOLDIPINE TAB ER 24HR 20 MG","1","0","0","0","","","CARDIOVASCULAR","CALCIUM CHANNEL BLOCKERS"],["N","G","NISOLDIPINE TAB 25.5MG","NISOLDIPINE TAB ER 24HR 25.5 MG","1","0","0","0","","","CARDIOVASCULAR","CALCIUM CHANNEL BLOCKERS"],["N","G","NISOLDIPINE TAB 30MG ER","NISOLDIPINE TAB ER 24HR 30 MG","1","0","0","0","","","CARDIOVASCULAR","CALCIUM CHANNEL BLOCKERS"],["N","G","NISOLDIPINE TAB 34MG ER","NISOLDIPINE TAB ER 24HR 34 MG","1","0","0","0","","","CARDIOVASCULAR","CALCIUM CHANNEL BLOCKERS"],["N","G","NISOLDIPINE TAB 40MG ER","NISOLDIPINE TAB ER 24HR 40 MG","1","0","0","0","","","CARDIOVASCULAR","CALCIUM CHANNEL BLOCKERS"],["N","G","NISOLDIPINE TAB 8.5MG ER","NISOLDIPINE TAB ER 24HR 8.5 MG","1","0","0","0","","","CARDIOVASCULAR","CALCIUM CHANNEL BLOCKERS"],["N","G","TAZTIA XT CAP 120MG/24","DILTIAZEM HCL EXTENDED RELEASE BEADS CAP ER 24HR 120 MG","1","0","0","0","","","CARDIOVASCULAR","CALCIUM CHANNEL BLOCKERS"],["N","G","TAZTIA XT CAP 180MG/24","DILTIAZEM HCL EXTENDED RELEASE BEADS CAP ER 24HR 180 MG","1","0","0","0","","","CARDIOVASCULAR","CALCIUM CHANNEL BLOCKERS"],["N","G","TAZTIA XT CAP 240MG/24","DILTIAZEM HCL EXTENDED RELEASE BEADS CAP ER 24HR 240 MG","1","0","0","0","","","CARDIOVASCULAR","CALCIUM CHANNEL BLOCKERS"],["N","G","TAZTIA XT CAP 300MG ER","DILTIAZEM HCL EXTENDED RELEASE BEADS CAP ER 24HR 300 MG","1","0","0","0","","","CARDIOVASCULAR","CALCIUM CHANNEL BLOCKERS"],["N","G","TAZTIA XT CAP 360MG/24","DILTIAZEM HCL EXTENDED RELEASE BEADS CAP ER 24HR 360 MG","1","0","0","0","","","CARDIOVASCULAR","CALCIUM CHANNEL BLOCKERS"],["N","G","VERAPAMIL CAP 100MG ER","VERAPAMIL HCL CAP ER 24HR 100 MG","1","0","0","0","","","CARDIOVASCULAR","CALCIUM CHANNEL BLOCKERS"],["N","G","VERAPAMIL CAP 120MG ER","VERAPAMIL HCL CAP ER 24HR 120 MG","1","0","0","0","","","CARDIOVASCULAR","CALCIUM CHANNEL BLOCKERS"],["N","G","VERAPAMIL CAP 180MG ER","VERAPAMIL HCL CAP ER 24HR 180 MG","1","0","0","0","","","CARDIOVASCULAR","CALCIUM CHANNEL BLOCKERS"],["N","G","VERAPAMIL CAP 200MG ER","VERAPAMIL HCL CAP ER 24HR 200 MG","1","0","0","0","","","CARDIOVASCULAR","CALCIUM CHANNEL BLOCKERS"],["N","G","VERAPAMIL CAP 240MG ER","VERAPAMIL HCL CAP ER 24HR 240 MG","1","0","0","0","","","CARDIOVASCULAR","CALCIUM CHANNEL BLOCKERS"],["N","G","VERAPAMIL CAP 300MG ER","VERAPAMIL HCL CAP ER 24HR 300 MG","1","0","0","0","","","CARDIOVASCULAR","CALCIUM CHANNEL BLOCKERS"],["N","G","VERAPAMIL CAP 360MG SR","VERAPAMIL HCL CAP ER 24HR 360 MG","1","0","0","0","","","CARDIOVASCULAR","CALCIUM CHANNEL BLOCKERS"],["N","G","VERAPAMIL INJ 2.5MG/ML","VERAPAMIL HCL IV SOLN 2.5 MG/ML","1","0","0","0","","","CARDIOVASCULAR","CALCIUM CHANNEL BLOCKERS"],["N","G","VERAPAMIL TAB 120MG","VERAPAMIL HCL TAB 120 MG","1","0","0","0","","","CARDIOVASCULAR","CALCIUM CHANNEL BLOCKERS"],["N","G","VERAPAMIL TAB 120MG ER","VERAPAMIL HCL TAB ER 120 MG","1","0","0","0","","","CARDIOVASCULAR","CALCIUM CHANNEL BLOCKERS"],["N","G","VERAPAMIL TAB 180MG ER","VERAPAMIL HCL TAB ER 180 MG","1","0","0","0","","","CARDIOVASCULAR","CALCIUM CHANNEL BLOCKERS"],["N","G","VERAPAMIL TAB 240MG ER","VERAPAMIL HCL TAB ER 240 MG","1","0","0","0","","","CARDIOVASCULAR","CALCIUM CHANNEL BLOCKERS"],["N","G","VERAPAMIL TAB 40MG","VERAPAMIL HCL TAB 40 MG","1","0","0","0","","","CARDIOVASCULAR","CALCIUM CHANNEL BLOCKERS"],["N","G","VERAPAMIL TAB 80MG","VERAPAMIL HCL TAB 80 MG","1","0","0","0","","","CARDIOVASCULAR","CALCIUM CHANNEL BLOCKERS"],["N","G","DIGOX TAB 0.125MG","DIGOXIN TAB 125 MCG (0.125 MG)","1","0","0","0","","","CARDIOVASCULAR","DIGITALIS GLYCOSIDES"],["N","G","DIGOX TAB 0.25MG","DIGOXIN TAB 250 MCG (0.25 MG)","1","0","0","0","","","CARDIOVASCULAR","DIGITALIS GLYCOSIDES"],["N","G","DIGOXIN INJ 0.25MG/1","DIGOXIN INJ 0.25 MG/ML","1","0","0","0","","","CARDIOVASCULAR","DIGITALIS GLYCOSIDES"],["N","G","DIGOXIN SOL 50MCG/ML","DIGOXIN ORAL SOLN 0.05 MG/ML","1","0","0","0","","","CARDIOVASCULAR","DIGITALIS GLYCOSIDES"],["N","G","DIGOXIN TAB 0.125MG","DIGOXIN TAB 125 MCG (0.125 MG)","1","0","0","0","","","CARDIOVASCULAR","DIGITALIS GLYCOSIDES"],["N","G","DIGOXIN TAB 0.25MG","DIGOXIN TAB 250 MCG (0.25 MG)","1","0","0","0","","","CARDIOVASCULAR","DIGITALIS GLYCOSIDES"],["N","G","LANOXIN PED INJ 0.1MG/ML","DIGOXIN INJ 0.1 MG/ML","3","0","0","0","","","CARDIOVASCULAR","DIGITALIS GLYCOSIDES"],["N","G","LANOXIN TAB 0.0625MG","DIGOXIN TAB 62.5 MCG (0.0625 MG)","2","0","0","0","","","CARDIOVASCULAR","DIGITALIS GLYCOSIDES"],["N","G","LANOXIN TAB 0.1875MG","DIGOXIN TAB 187.5 MCG (0.1875 MG)","2","0","0","0","","","CARDIOVASCULAR","DIGITALIS GLYCOSIDES"],["N","G","ALISKIREN TAB 150MG","ALISKIREN FUMARATE TAB 150 MG (BASE EQUIVALENT)","1","0","0","0","","","CARDIOVASCULAR","DIRECT RENIN INHIBITORS/COMBINATIONS"],["N","G","ALISKIREN TAB 300MG","ALISKIREN FUMARATE TAB 300 MG (BASE EQUIVALENT)","1","0","0","0","","","CARDIOVASCULAR","DIRECT RENIN INHIBITORS/COMBINATIONS"],["N","G","ACETAZOLAMID CAP 500MG ER","ACETAZOLAMIDE CAP ER 12HR 500 MG","1","0","0","0","","","CARDIOVASCULAR","DIURETICS"],["N","G","ACETAZOLAMID INJ 500MG","ACETAZOLAMIDE SODIUM FOR INJ 500 MG","1","0","0","0","","","CARDIOVASCULAR","DIURETICS"],["N","G","ACETAZOLAMID TAB 125MG","ACETAZOLAMIDE TAB 125 MG","1","0","0","0","","","CARDIOVASCULAR","DIURETICS"],["N","G","ACETAZOLAMID TAB 250MG","ACETAZOLAMIDE TAB 250 MG","1","0","0","0","","","CARDIOVASCULAR","DIURETICS"],["N","G","ALDACTAZIDE TAB 50/50","SPIRONOLACTONE & HYDROCHLOROTHIAZIDE TAB 50-50 MG","2","0","0","0","","","CARDIOVASCULAR","DIURETICS"],["N","G","AMILOR/HCTZ TAB 5-50","AMILORIDE & HYDROCHLOROTHIAZIDE TAB 5-50 MG","1","0","0","0","","","CARDIOVASCULAR","DIURETICS"],["N","G","AMILORIDE TAB 5MG","AMILORIDE HCL TAB 5 MG","1","0","0","0","","","CARDIOVASCULAR","DIURETICS"],["N","G","BUMETANIDE INJ 0.25/ML","BUMETANIDE INJ 0.25 MG/ML","1","0","0","0","","","CARDIOVASCULAR","DIURETICS"],["N","G","BUMETANIDE TAB 0.5MG","BUMETANIDE TAB 0.5 MG","1","0","0","0","","","CARDIOVASCULAR","DIURETICS"],["N","G","BUMETANIDE TAB 1MG","BUMETANIDE TAB 1 MG","1","0","0","0","","","CARDIOVASCULAR","DIURETICS"],["N","G","BUMETANIDE TAB 2MG","BUMETANIDE TAB 2 MG","1","0","0","0","","","CARDIOVASCULAR","DIURETICS"],["N","G","CHLOROTHIAZ INJ 500MG","CHLOROTHIAZIDE SODIUM FOR INJ 500 MG","1","0","0","0","","","CARDIOVASCULAR","DIURETICS"],["N","G","CHLOROTHIAZ TAB 250MG","CHLOROTHIAZIDE TAB 250 MG","1","0","0","0","","","CARDIOVASCULAR","DIURETICS"],["N","G","CHLOROTHIAZ TAB 500MG","CHLOROTHIAZIDE TAB 500 MG","1","0","0","0","","","CARDIOVASCULAR","DIURETICS"],["N","G","CHLORTHALID TAB 25MG","CHLORTHALIDONE TAB 25 MG","1","0","0","0","","","CARDIOVASCULAR","DIURETICS"],["N","G","CHLORTHALID TAB 50MG","CHLORTHALIDONE TAB 50 MG","1","0","0","0","","","CARDIOVASCULAR","DIURETICS"],["N","G","DIURIL SUS 250/5ML","CHLOROTHIAZIDE SUSP 250 MG/5ML","3","0","0","0","","","CARDIOVASCULAR","DIURETICS"],["N","G","DYRENIUM CAP 100MG","TRIAMTERENE CAP 100 MG","3","0","0","0","","","CARDIOVASCULAR","DIURETICS"],["N","G","DYRENIUM CAP 50MG","TRIAMTERENE CAP 50 MG","3","0","0","0","","","CARDIOVASCULAR","DIURETICS"],["N","G","ETHACRYNATE INJ 50MG","ETHACRYNATE SODIUM FOR INJ 50 MG","1","0","0","0","","","CARDIOVASCULAR","DIURETICS"],["N","G","ETHACRYNIC TAB ACD 25MG","ETHACRYNIC ACID TAB 25 MG","1","0","0","0","","","CARDIOVASCULAR","DIURETICS"],["N","G","FUROSEMIDE INJ 10MG/ML","FUROSEMIDE INJ 10 MG/ML","1","0","0","0","","","CARDIOVASCULAR","DIURETICS"],["N","G","FUROSEMIDE SOL 10MG/ML","FUROSEMIDE ORAL SOLN 10 MG/ML","1","0","0","0","","","CARDIOVASCULAR","DIURETICS"],["N","G","FUROSEMIDE SOL 8MG/ML","FUROSEMIDE ORAL SOLN 8 MG/ML","1","0","0","0","","","CARDIOVASCULAR","DIURETICS"],["N","G","FUROSEMIDE TAB 20MG","FUROSEMIDE TAB 20 MG","1","0","0","0","","","CARDIOVASCULAR","DIURETICS"],["N","G","FUROSEMIDE TAB 40MG","FUROSEMIDE TAB 40 MG","1","0","0","0","","","CARDIOVASCULAR","DIURETICS"],["N","G","FUROSEMIDE TAB 80MG","FUROSEMIDE TAB 80 MG","1","0","0","0","","","CARDIOVASCULAR","DIURETICS"],["N","G","HYDROCHLOROT CAP 12.5MG","HYDROCHLOROTHIAZIDE CAP 12.5 MG","1","0","0","0","","","CARDIOVASCULAR","DIURETICS"],["N","G","HYDROCHLOROT TAB 12.5MG","HYDROCHLOROTHIAZIDE TAB 12.5 MG","1","0","0","0","","","CARDIOVASCULAR","DIURETICS"],["N","G","HYDROCHLOROT TAB 25MG","HYDROCHLOROTHIAZIDE TAB 25 MG","1","0","0","0","","","CARDIOVASCULAR","DIURETICS"],["N","G","HYDROCHLOROT TAB 50MG","HYDROCHLOROTHIAZIDE TAB 50 MG","1","0","0","0","","","CARDIOVASCULAR","DIURETICS"],["N","G","INDAPAMIDE TAB 1.25MG","INDAPAMIDE TAB 1.25 MG","1","0","0","0","","","CARDIOVASCULAR","DIURETICS"],["N","G","INDAPAMIDE TAB 2.5MG","INDAPAMIDE TAB 2.5 MG","1","0","0","0","","","CARDIOVASCULAR","DIURETICS"],["N","G","METHAZOLAMID TAB 25MG","METHAZOLAMIDE TAB 25 MG","1","0","0","0","","","CARDIOVASCULAR","DIURETICS"],["N","G","METHAZOLAMID TAB 50MG","METHAZOLAMIDE TAB 50 MG","1","0","0","0","","","CARDIOVASCULAR","DIURETICS"],["N","G","METHYCLOTHIA TAB 5MG","METHYCLOTHIAZIDE TAB 5 MG","1","0","0","0","","","CARDIOVASCULAR","DIURETICS"],["N","G","METOLAZONE TAB 10MG","METOLAZONE TAB 10 MG","1","0","0","0","","","CARDIOVASCULAR","DIURETICS"],["N","G","METOLAZONE TAB 2.5MG","METOLAZONE TAB 2.5 MG","1","0","0","0","","","CARDIOVASCULAR","DIURETICS"],["N","G","METOLAZONE TAB 5MG","METOLAZONE TAB 5 MG","1","0","0","0","","","CARDIOVASCULAR","DIURETICS"],["N","G","SPIRONO/HCTZ TAB 25/25","SPIRONOLACTONE & HYDROCHLOROTHIAZIDE TAB 25-25 MG","1","0","0","0","","","CARDIOVASCULAR","DIURETICS"],["N","G","SPIRONOLACT TAB 100MG","SPIRONOLACTONE TAB 100 MG","1","0","0","0","","","CARDIOVASCULAR","DIURETICS"],["N","G","SPIRONOLACT TAB 25MG","SPIRONOLACTONE TAB 25 MG","1","0","0","0","","","CARDIOVASCULAR","DIURETICS"],["N","G","SPIRONOLACT TAB 50MG","SPIRONOLACTONE TAB 50 MG","1","0","0","0","","","CARDIOVASCULAR","DIURETICS"],["N","G","TORSEMIDE TAB 100MG","TORSEMIDE TAB 100 MG","1","0","0","0","","","CARDIOVASCULAR","DIURETICS"],["N","G","TORSEMIDE TAB 10MG","TORSEMIDE TAB 10 MG","1","0","0","0","","","CARDIOVASCULAR","DIURETICS"],["N","G","TORSEMIDE TAB 20MG","TORSEMIDE TAB 20 MG","1","0","0","0","","","CARDIOVASCULAR","DIURETICS"],["N","G","TORSEMIDE TAB 5MG","TORSEMIDE TAB 5 MG","1","0","0","0","","","CARDIOVASCULAR","DIURETICS"],["N","G","TRIAMT/HCTZ CAP 37.5-25","TRIAMTERENE & HYDROCHLOROTHIAZIDE CAP 37.5-25 MG","1","0","0","0","","","CARDIOVASCULAR","DIURETICS"],["N","G","TRIAMT/HCTZ CAP 50-25MG","TRIAMTERENE & HYDROCHLOROTHIAZIDE CAP 50-25 MG","1","0","0","0","","","CARDIOVASCULAR","DIURETICS"],["N","G","TRIAMT/HCTZ TAB 37.5-25","TRIAMTERENE & HYDROCHLOROTHIAZIDE TAB 37.5-25 MG","1","0","0","0","","","CARDIOVASCULAR","DIURETICS"],["N","G","TRIAMT/HCTZ TAB 75-50MG","TRIAMTERENE & HYDROCHLOROTHIAZIDE TAB 75-50 MG","1","0","0","0","","","CARDIOVASCULAR","DIURETICS"],["N","G","TRIAMTERENE CAP 100MG","TRIAMTERENE CAP 100 MG","1","0","0","0","","","CARDIOVASCULAR","DIURETICS"],["N","G","TRIAMTERENE CAP 50MG","TRIAMTERENE CAP 50 MG","1","0","0","0","","","CARDIOVASCULAR","DIURETICS"],["N","G","CLONIDINE DIS 0.1/24HR","CLONIDINE TD PATCH WEEKLY 0.1 MG/24HR","1","0","0","0","","","CARDIOVASCULAR","MISCELLANEOUS"],["N","G","CLONIDINE DIS 0.2/24HR","CLONIDINE TD PATCH WEEKLY 0.2 MG/24HR","1","0","0","0","","","CARDIOVASCULAR","MISCELLANEOUS"],["N","G","CLONIDINE DIS 0.3/24HR","CLONIDINE TD PATCH WEEKLY 0.3 MG/24HR","1","0","0","0","","","CARDIOVASCULAR","MISCELLANEOUS"],["N","G","CLONIDINE TAB 0.1MG","CLONIDINE HCL TAB 0.1 MG","1","0","0","0","","","CARDIOVASCULAR","MISCELLANEOUS"],["N","G","CLONIDINE TAB 0.2MG","CLONIDINE HCL TAB 0.2 MG","1","0","0","0","","","CARDIOVASCULAR","MISCELLANEOUS"],["N","G","CLONIDINE TAB 0.3MG","CLONIDINE HCL TAB 0.3 MG","1","0","0","0","","","CARDIOVASCULAR","MISCELLANEOUS"],["N","G","CORLANOR TAB 5MG","IVABRADINE HCL TAB 5 MG (BASE EQUIV)","2","0","0","0","","","CARDIOVASCULAR","MISCELLANEOUS"],["N","G","CORLANOR TAB 7.5MG","IVABRADINE HCL TAB 7.5 MG (BASE EQUIV)","2","0","0","0","","","CARDIOVASCULAR","MISCELLANEOUS"],["N","G","ENTRESTO TAB 24-26MG","SACUBITRIL-VALSARTAN TAB 24-26 MG","2","0","0","0","","","CARDIOVASCULAR","MISCELLANEOUS"],["N","G","ENTRESTO TAB 49-51MG","SACUBITRIL-VALSARTAN TAB 49-51 MG","2","0","0","0","","","CARDIOVASCULAR","MISCELLANEOUS"],["N","G","ENTRESTO TAB 97-103MG","SACUBITRIL-VALSARTAN TAB 97-103 MG","2","0","0","0","","","CARDIOVASCULAR","MISCELLANEOUS"],["N","G","GUANFACINE TAB 1MG","GUANFACINE HCL TAB 1 MG","1","0","0","0","","","CARDIOVASCULAR","MISCELLANEOUS"],["N","G","GUANFACINE TAB 2MG","GUANFACINE HCL TAB 2 MG","1","0","0","0","","","CARDIOVASCULAR","MISCELLANEOUS"],["N","G","HYDRALAZINE INJ 20MG/ML","HYDRALAZINE HCL INJ 20 MG/ML","1","0","0","0","","","CARDIOVASCULAR","MISCELLANEOUS"],["N","G","HYDRALAZINE TAB 100MG","HYDRALAZINE HCL TAB 100 MG","1","0","0","0","","","CARDIOVASCULAR","MISCELLANEOUS"],["N","G","HYDRALAZINE TAB 10MG","HYDRALAZINE HCL TAB 10 MG","1","0","0","0","","","CARDIOVASCULAR","MISCELLANEOUS"],["N","G","HYDRALAZINE TAB 25MG","HYDRALAZINE HCL TAB 25 MG","1","0","0","0","","","CARDIOVASCULAR","MISCELLANEOUS"],["N","G","HYDRALAZINE TAB 50MG","HYDRALAZINE HCL TAB 50 MG","1","0","0","0","","","CARDIOVASCULAR","MISCELLANEOUS"],["N","G","METHYLDOPA TAB 250MG","METHYLDOPA TAB 250 MG","1","0","0","0","","","CARDIOVASCULAR","MISCELLANEOUS"],["N","G","METHYLDOPA TAB 500MG","METHYLDOPA TAB 500 MG","1","0","0","0","","","CARDIOVASCULAR","MISCELLANEOUS"],["N","G","METHYLDOPATE INJ 250/5ML","METHYLDOPATE HCL INJ 250 MG/5ML","1","0","0","0","","","CARDIOVASCULAR","MISCELLANEOUS"],["N","G","MIDODRINE TAB 10MG","MIDODRINE HCL TAB 10 MG","1","0","0","0","","","CARDIOVASCULAR","MISCELLANEOUS"],["N","G","MIDODRINE TAB 2.5MG","MIDODRINE HCL TAB 2.5 MG","1","0","0","0","","","CARDIOVASCULAR","MISCELLANEOUS"],["N","G","MIDODRINE TAB 5MG","MIDODRINE HCL TAB 5 MG","1","0","0","0","","","CARDIOVASCULAR","MISCELLANEOUS"],["N","G","MINOXIDIL TAB 10MG","MINOXIDIL TAB 10 MG","1","0","0","0","","","CARDIOVASCULAR","MISCELLANEOUS"],["N","G","MINOXIDIL TAB 2.5MG","MINOXIDIL TAB 2.5 MG","1","0","0","0","","","CARDIOVASCULAR","MISCELLANEOUS"],["N","G","PHENOXYBENZA CAP 10MG","PHENOXYBENZAMINE HCL CAP 10 MG","1","0","0","0","","","CARDIOVASCULAR","MISCELLANEOUS"],["N","G","RANOLAZINE TAB 1000MG","RANOLAZINE TAB ER 12HR 1000 MG","1","0","1","0","","PA**","CARDIOVASCULAR","MISCELLANEOUS"],["N","G","RANOLAZINE TAB 500MG ER","RANOLAZINE TAB ER 12HR 500 MG","1","0","1","0","","PA**","CARDIOVASCULAR","MISCELLANEOUS"],["N","G","DILATRATE SR CAP 40MG","ISOSORBIDE DINITRATE CAP ER 40 MG","3","0","0","0","","","CARDIOVASCULAR","NITRATES"],["N","G","ISORDIL TAB 40MG","ISOSORBIDE DINITRATE TAB 40 MG","2","0","0","0","","","CARDIOVASCULAR","NITRATES"],["N","G","ISOSORB DIN TAB 10MG","ISOSORBIDE DINITRATE TAB 10 MG","1","0","0","0","","","CARDIOVASCULAR","NITRATES"],["N","G","ISOSORB DIN TAB 20MG","ISOSORBIDE DINITRATE TAB 20 MG","1","0","0","0","","","CARDIOVASCULAR","NITRATES"],["N","G","ISOSORB DIN TAB 30MG","ISOSORBIDE DINITRATE TAB 30 MG","1","0","0","0","","","CARDIOVASCULAR","NITRATES"],["N","G","ISOSORB DIN TAB 40MG ER","ISOSORBIDE DINITRATE TAB ER 40 MG","1","0","0","0","","","CARDIOVASCULAR","NITRATES"],["N","G","ISOSORB DIN TAB 5MG","ISOSORBIDE DINITRATE TAB 5 MG","1","0","0","0","","","CARDIOVASCULAR","NITRATES"],["N","G","ISOSORB MONO TAB 10MG","ISOSORBIDE MONONITRATE TAB 10 MG","1","0","0","0","","","CARDIOVASCULAR","NITRATES"],["N","G","ISOSORB MONO TAB 120MG ER","ISOSORBIDE MONONITRATE TAB ER 24HR 120 MG","1","0","0","0","","","CARDIOVASCULAR","NITRATES"],["N","G","ISOSORB MONO TAB 20MG","ISOSORBIDE MONONITRATE TAB 20 MG","1","0","0","0","","","CARDIOVASCULAR","NITRATES"],["N","G","ISOSORB MONO TAB 30MG ER","ISOSORBIDE MONONITRATE TAB ER 24HR 30 MG","1","0","0","0","","","CARDIOVASCULAR","NITRATES"],["N","G","ISOSORB MONO TAB 60MG ER","ISOSORBIDE MONONITRATE TAB ER 24HR 60 MG","1","0","0","0","","","CARDIOVASCULAR","NITRATES"],["N","G","MINITRAN DIS 0.1MG/HR","NITROGLYCERIN TD PATCH 24HR 0.1 MG/HR","1","0","0","0","","","CARDIOVASCULAR","NITRATES"],["N","G","MINITRAN DIS 0.2MG/HR","NITROGLYCERIN TD PATCH 24HR 0.2 MG/HR","1","0","0","0","","","CARDIOVASCULAR","NITRATES"],["N","G","MINITRAN DIS 0.4MG/HR","NITROGLYCERIN TD PATCH 24HR 0.4 MG/HR","1","0","0","0","","","CARDIOVASCULAR","NITRATES"],["N","G","MINITRAN DIS 0.6MG/HR","NITROGLYCERIN TD PATCH 24HR 0.6 MG/HR","1","0","0","0","","","CARDIOVASCULAR","NITRATES"],["N","G","NITRO-BID OIN 2%","NITROGLYCERIN OINT 2%","3","0","0","0","","","CARDIOVASCULAR","NITRATES"],["N","G","NITRO-DUR DIS 0.3MG/HR","NITROGLYCERIN TD PATCH 24HR 0.3 MG/HR","2","0","0","0","","","CARDIOVASCULAR","NITRATES"],["N","G","NITRO-DUR DIS 0.8MG/HR","NITROGLYCERIN TD PATCH 24HR 0.8 MG/HR","2","0","0","0","","","CARDIOVASCULAR","NITRATES"],["N","G","NITROGLY/D5W INJ 100MG","NITROGLYCERIN IV SOLN 400 MCG/ML IN D5W","1","0","0","0","","","CARDIOVASCULAR","NITRATES"],["N","G","NITROGLY/D5W INJ 25MG","NITROGLYCERIN IV SOLN 100 MCG/ML IN D5W","1","0","0","0","","","CARDIOVASCULAR","NITRATES"],["N","G","NITROGLY/D5W INJ 50MG","NITROGLYCERIN IV SOLN 200 MCG/ML IN D5W","1","0","0","0","","","CARDIOVASCULAR","NITRATES"],["N","G","NITROGLYCER DIS 0.1MG/HR","NITROGLYCERIN TD PATCH 24HR 0.1 MG/HR","1","0","0","0","","","CARDIOVASCULAR","NITRATES"],["N","G","NITROGLYCER DIS 0.2MG/HR","NITROGLYCERIN TD PATCH 24HR 0.2 MG/HR","1","0","0","0","","","CARDIOVASCULAR","NITRATES"],["N","G","NITROGLYCER DIS 0.4MG/HR","NITROGLYCERIN TD PATCH 24HR 0.4 MG/HR","1","0","0","0","","","CARDIOVASCULAR","NITRATES"],["N","G","NITROGLYCER DIS 0.6MG/HR","NITROGLYCERIN TD PATCH 24HR 0.6 MG/HR","1","0","0","0","","","CARDIOVASCULAR","NITRATES"],["N","G","NITROGLYCER INJ 5MG/ML","NITROGLYCERIN IV SOLN 5 MG/ML","3","0","0","0","","","CARDIOVASCULAR","NITRATES"],["N","G","NITROGLYCERI SUB 0.6MG","NITROGLYCERIN SL TAB 0.6 MG","1","0","0","0","","","CARDIOVASCULAR","NITRATES"],["N","G","NITROGLYCERN SUB 0.3MG","NITROGLYCERIN SL TAB 0.3 MG","1","0","0","0","","","CARDIOVASCULAR","NITRATES"],["N","G","NITROGLYCERN SUB 0.4MG","NITROGLYCERIN SL TAB 0.4 MG","1","0","0","0","","","CARDIOVASCULAR","NITRATES"],["N","G","NITROGLYCRN SPR 0.4MG","NITROGLYCERIN TL SOLN 0.4 MG/SPRAY (400 MCG/SPRAY)","1","0","0","0","","","CARDIOVASCULAR","NITRATES"],["N","G","ADEMPAS TAB 0.5MG","RIOCIGUAT TAB 0.5 MG","4","1","0","1","90 tabs every 30 days","SP","CARDIOVASCULAR","PULMONARY ARTERIAL HYPERTENSION"],["N","G","ADEMPAS TAB 1.5MG","RIOCIGUAT TAB 1.5 MG","4","1","0","1","90 tabs every 30 days","SP","CARDIOVASCULAR","PULMONARY ARTERIAL HYPERTENSION"],["N","G","ADEMPAS TAB 1MG","RIOCIGUAT TAB 1 MG","4","1","0","1","90 tabs every 30 days","SP","CARDIOVASCULAR","PULMONARY ARTERIAL HYPERTENSION"],["N","G","ADEMPAS TAB 2.5MG","RIOCIGUAT TAB 2.5 MG","4","1","0","1","90 tabs every 30 days","SP","CARDIOVASCULAR","PULMONARY ARTERIAL HYPERTENSION"],["N","G","ADEMPAS TAB 2MG","RIOCIGUAT TAB 2 MG","4","1","0","1","90 tabs every 30 days","SP","CARDIOVASCULAR","PULMONARY ARTERIAL HYPERTENSION"],["N","G","AMBRISENTAN TAB 10MG","AMBRISENTAN TAB 10 MG","4","1","0","1","30 tabs every 30 days","SP","CARDIOVASCULAR","PULMONARY ARTERIAL HYPERTENSION"],["N","G","AMBRISENTAN TAB 5MG","AMBRISENTAN TAB 5 MG","4","1","0","1","30 tabs every 30 days","SP","CARDIOVASCULAR","PULMONARY ARTERIAL HYPERTENSION"],["N","G","BOSENTAN TAB 125MG","BOSENTAN TAB 125 MG","4","1","0","1","60 tabs every 30 days","SP","CARDIOVASCULAR","PULMONARY ARTERIAL HYPERTENSION"],["N","G","BOSENTAN TAB 62.5MG","BOSENTAN TAB 62.5 MG","4","1","0","1","60 tabs every 30 days","SP","CARDIOVASCULAR","PULMONARY ARTERIAL HYPERTENSION"],["N","G","EPOPROSTENOL INJ 0.5MG","EPOPROSTENOL SODIUM FOR INJ 0.5 MG","4","1","0","0","","SP","CARDIOVASCULAR","PULMONARY ARTERIAL HYPERTENSION"],["N","G","EPOPROSTENOL INJ 1.5MG","EPOPROSTENOL SODIUM FOR INJ 1.5 MG","4","1","0","0","","SP","CARDIOVASCULAR","PULMONARY ARTERIAL HYPERTENSION"],["N","G","LETAIRIS TAB 10MG","AMBRISENTAN TAB 10 MG","4","1","0","1","30 tabs every 30 days","SP","CARDIOVASCULAR","PULMONARY ARTERIAL HYPERTENSION"],["N","G","LETAIRIS TAB 5MG","AMBRISENTAN TAB 5 MG","4","1","0","1","30 tabs every 30 days","SP","CARDIOVASCULAR","PULMONARY ARTERIAL HYPERTENSION"],["N","G","OPSUMIT TAB 10MG","MACITENTAN TAB 10 MG","4","1","0","1","30 tabs every 30 days","SP","CARDIOVASCULAR","PULMONARY ARTERIAL HYPERTENSION"],["N","G","ORENITRAM TAB 0.125MG","TREPROSTINIL DIOLAMINE TAB ER 0.125 MG (BASE EQUIV)","4","1","0","0","","SP","CARDIOVASCULAR","PULMONARY ARTERIAL HYPERTENSION"],["N","G","ORENITRAM TAB 0.25MG","TREPROSTINIL DIOLAMINE TAB ER 0.25 MG (BASE EQUIV)","4","1","0","0","","SP","CARDIOVASCULAR","PULMONARY ARTERIAL HYPERTENSION"],["N","G","ORENITRAM TAB 1MG","TREPROSTINIL DIOLAMINE TAB ER 1 MG (BASE EQUIV)","4","1","0","0","","SP","CARDIOVASCULAR","PULMONARY ARTERIAL HYPERTENSION"],["N","G","ORENITRAM TAB 2.5MG","TREPROSTINIL DIOLAMINE TAB ER 2.5 MG (BASE EQUIV)","4","1","0","0","","SP","CARDIOVASCULAR","PULMONARY ARTERIAL HYPERTENSION"],["N","G","ORENITRAM TAB 5MG","TREPROSTINIL DIOLAMINE TAB ER 5 MG (BASE EQUIV)","4","1","0","0","","SP","CARDIOVASCULAR","PULMONARY ARTERIAL HYPERTENSION"],["N","G","REMODULIN INJ 10MG/ML","TREPROSTINIL INJ SOLN 200 MG/20ML (10 MG/ML)","4","1","0","0","","SP","CARDIOVASCULAR","PULMONARY ARTERIAL HYPERTENSION"],["N","G","REMODULIN INJ 1MG/ML","TREPROSTINIL INJ SOLN 20 MG/20ML (1 MG/ML)","4","1","0","0","","SP","CARDIOVASCULAR","PULMONARY ARTERIAL HYPERTENSION"],["N","G","REMODULIN INJ 2.5MG/ML","TREPROSTINIL INJ SOLN 50 MG/20ML (2.5 MG/ML)","4","1","0","0","","SP","CARDIOVASCULAR","PULMONARY ARTERIAL HYPERTENSION"],["N","G","REMODULIN INJ 5MG/ML","TREPROSTINIL INJ SOLN 100 MG/20ML (5 MG/ML)","4","1","0","0","","SP","CARDIOVASCULAR","PULMONARY ARTERIAL HYPERTENSION"],["N","G","SILDENAFIL INJ","SILDENAFIL CITRATE IV SOLN 10 MG/12.5ML (BASE EQUIVALENT)","4","1","0","0","","SP","CARDIOVASCULAR","PULMONARY ARTERIAL HYPERTENSION"],["N","G","SILDENAFIL TAB 20MG","SILDENAFIL CITRATE TAB 20 MG","4","1","0","1","90 tabs every 30 days","SP","CARDIOVASCULAR","PULMONARY ARTERIAL HYPERTENSION"],["N","G","TADALAFIL TAB 20MG","TADALAFIL TAB 20 MG (PAH)","4","1","0","1","60 tabs every 30 days","SP","CARDIOVASCULAR","PULMONARY ARTERIAL HYPERTENSION"],["N","G","TRACLEER TAB 125MG","BOSENTAN TAB 125 MG","4","1","0","1","60 tabs every 30 days","SP","CARDIOVASCULAR","PULMONARY ARTERIAL HYPERTENSION"],["N","G","TRACLEER TAB 32MG","BOSENTAN TAB FOR ORAL SUSP 32 MG","4","1","0","1","112 tabs every 28 days","SP","CARDIOVASCULAR","PULMONARY ARTERIAL HYPERTENSION"],["N","G","TRACLEER TAB 62.5MG","BOSENTAN TAB 62.5 MG","4","1","0","1","60 tabs every 30 days","SP","CARDIOVASCULAR","PULMONARY ARTERIAL HYPERTENSION"],["N","G","TYVASO START SOL 0.6MG/ML","TREPROSTINIL INHALATION SOLUTION 0.6 MG/ML","4","1","0","1","28 ampules every 28 days","SP","CARDIOVASCULAR","PULMONARY ARTERIAL HYPERTENSION"],["N","G","UPTRAVI TAB 1000MCG","SELEXIPAG TAB 1000 MCG","4","1","0","0","","SP","CARDIOVASCULAR","PULMONARY ARTERIAL HYPERTENSION"],["N","G","UPTRAVI TAB 1200MCG","SELEXIPAG TAB 1200 MCG","4","1","0","0","","SP","CARDIOVASCULAR","PULMONARY ARTERIAL HYPERTENSION"],["N","G","UPTRAVI TAB 1400MCG","SELEXIPAG TAB 1400 MCG","4","1","0","0","","SP","CARDIOVASCULAR","PULMONARY ARTERIAL HYPERTENSION"],["N","G","UPTRAVI TAB 1600MCG","SELEXIPAG TAB 1600 MCG","4","1","0","0","","SP","CARDIOVASCULAR","PULMONARY ARTERIAL HYPERTENSION"],["N","G","UPTRAVI TAB 200/800","SELEXIPAG TAB THERAPY PACK 200 MCG (140) & 800 MCG (60)","4","1","0","0","","SP","CARDIOVASCULAR","PULMONARY ARTERIAL HYPERTENSION"],["N","G","UPTRAVI TAB 200MCG","SELEXIPAG TAB 200 MCG","4","1","0","0","","SP","CARDIOVASCULAR","PULMONARY ARTERIAL HYPERTENSION"],["N","G","UPTRAVI TAB 400MCG","SELEXIPAG TAB 400 MCG","4","1","0","0","","SP","CARDIOVASCULAR","PULMONARY ARTERIAL HYPERTENSION"],["N","G","UPTRAVI TAB 600MCG","SELEXIPAG TAB 600 MCG","4","1","0","0","","SP","CARDIOVASCULAR","PULMONARY ARTERIAL HYPERTENSION"],["N","G","UPTRAVI TAB 800MCG","SELEXIPAG TAB 800 MCG","4","1","0","0","","SP","CARDIOVASCULAR","PULMONARY ARTERIAL HYPERTENSION"],["N","G","VENTAVIS SOL 10MCG/ML","ILOPROST INHALATION SOLUTION 10 MCG/ML","4","1","0","1","270 ampules every 30 days","SP","CARDIOVASCULAR","PULMONARY ARTERIAL HYPERTENSION"],["N","G","VENTAVIS SOL 20MCG/ML","ILOPROST INHALATION SOLUTION 20 MCG/ML","4","1","0","1","270 ampules every 30 days","SP","CARDIOVASCULAR","PULMONARY ARTERIAL HYPERTENSION"],["N","G","ALPRAZOLAM CON 1 MG/ML","ALPRAZOLAM CONC 1 MG/ML","2","0","0","1","300 mL every 25 days","","CENTRAL NERVOUS SYSTEM","ANTIANXIETY§"],["N","G","ALPRAZOLAM TAB 0.25 ODT","ALPRAZOLAM ORALLY DISINTEGRATING TAB 0.25 MG","1","0","0","1","150 tabs every 25 days","","CENTRAL NERVOUS SYSTEM","ANTIANXIETY§"],["N","G","ALPRAZOLAM TAB 0.25MG","ALPRAZOLAM TAB 0.25 MG","1","0","0","1","150 tabs every 25 days","","CENTRAL NERVOUS SYSTEM","ANTIANXIETY§"],["N","G","ALPRAZOLAM TAB 0.5MG","ALPRAZOLAM TAB 0.5 MG","1","0","0","1","150 tabs every 25 days","","CENTRAL NERVOUS SYSTEM","ANTIANXIETY§"],["N","G","ALPRAZOLAM TAB 0.5MG OD","ALPRAZOLAM ORALLY DISINTEGRATING TAB 0.5 MG","1","0","0","1","150 tabs every 25 days","","CENTRAL NERVOUS SYSTEM","ANTIANXIETY§"],["N","G","ALPRAZOLAM TAB 1MG","ALPRAZOLAM TAB 1 MG","1","0","0","1","150 tabs every 25 days","","CENTRAL NERVOUS SYSTEM","ANTIANXIETY§"],["N","G","ALPRAZOLAM TAB 1MG ODT","ALPRAZOLAM ORALLY DISINTEGRATING TAB 1 MG","1","0","0","1","150 tabs every 25 days","","CENTRAL NERVOUS SYSTEM","ANTIANXIETY§"],["N","G","ALPRAZOLAM TAB 2MG","ALPRAZOLAM TAB 2 MG","1","0","0","1","150 tabs every 25 days","","CENTRAL NERVOUS SYSTEM","ANTIANXIETY§"],["N","G","ALPRAZOLAM TAB 2MG ODT","ALPRAZOLAM ORALLY DISINTEGRATING TAB 2 MG","1","0","0","1","150 tabs every 25 days","","CENTRAL NERVOUS SYSTEM","ANTIANXIETY§"],["N","G","LORAZEPAM CON 2MG/ML","LORAZEPAM CONC 2 MG/ML","1","0","0","1","150 mL every 25 days","","CENTRAL NERVOUS SYSTEM","ANTIANXIETY§"],["N","G","LORAZEPAM TAB 0.5MG","LORAZEPAM TAB 0.5 MG","1","0","0","1","150 tabs every 25 days","","CENTRAL NERVOUS SYSTEM","ANTIANXIETY§"],["N","G","LORAZEPAM TAB 1MG","LORAZEPAM TAB 1 MG","1","0","0","1","150 tabs every 25 days","","CENTRAL NERVOUS SYSTEM","ANTIANXIETY§"],["N","G","LORAZEPAM TAB 2MG","LORAZEPAM TAB 2 MG","1","0","0","1","150 tabs every 25 days","","CENTRAL NERVOUS SYSTEM","ANTIANXIETY§"],["N","G","MEPROBAMATE TAB 200MG","MEPROBAMATE TAB 200 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIANXIETY§"],["N","G","MEPROBAMATE TAB 400MG","MEPROBAMATE TAB 400 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIANXIETY§"],["N","G","OXAZEPAM CAP 10MG","OXAZEPAM CAP 10 MG","1","0","0","1","120 caps every 25 days","","CENTRAL NERVOUS SYSTEM","ANTIANXIETY§"],["N","G","OXAZEPAM CAP 15MG","OXAZEPAM CAP 15 MG","1","0","0","1","120 caps every 25 days","","CENTRAL NERVOUS SYSTEM","ANTIANXIETY§"],["N","G","OXAZEPAM CAP 30MG","OXAZEPAM CAP 30 MG","1","0","0","1","120 caps every 25 days","","CENTRAL NERVOUS SYSTEM","ANTIANXIETY§"],["N","G","APTIOM TAB 200MG","ESLICARBAZEPINE ACETATE TAB 200 MG","3","1","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","APTIOM TAB 400MG","ESLICARBAZEPINE ACETATE TAB 400 MG","3","1","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","APTIOM TAB 600MG","ESLICARBAZEPINE ACETATE TAB 600 MG","3","1","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","APTIOM TAB 800MG","ESLICARBAZEPINE ACETATE TAB 800 MG","3","1","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","BANZEL SUS 40MG/ML","RUFINAMIDE SUSP 40 MG/ML","3","1","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","BANZEL TAB 200MG","RUFINAMIDE TAB 200 MG","3","1","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","BANZEL TAB 400MG","RUFINAMIDE TAB 400 MG","3","1","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","BRIVIACT INJ 50MG/5ML","BRIVARACETAM IV SOLN 50 MG/5ML","3","1","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","BRIVIACT SOL 10MG/ML","BRIVARACETAM ORAL SOLN 10 MG/ML","3","1","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","BRIVIACT TAB 100MG","BRIVARACETAM TAB 100 MG","3","1","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","BRIVIACT TAB 10MG","BRIVARACETAM TAB 10 MG","3","1","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","BRIVIACT TAB 25MG","BRIVARACETAM TAB 25 MG","3","1","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","BRIVIACT TAB 50MG","BRIVARACETAM TAB 50 MG","3","1","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","BRIVIACT TAB 75MG","BRIVARACETAM TAB 75 MG","3","1","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","CARBAMAZEPIN CAP 100MG ER","CARBAMAZEPINE CAP ER 12HR 100 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","CARBAMAZEPIN CAP 200MG ER","CARBAMAZEPINE CAP ER 12HR 200 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","CARBAMAZEPIN CAP 300MG ER","CARBAMAZEPINE CAP ER 12HR 300 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","CARBAMAZEPIN CHW 100MG","CARBAMAZEPINE CHEW TAB 100 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","CARBAMAZEPIN SUS 100/5ML","CARBAMAZEPINE SUSP 100 MG/5ML","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","CARBAMAZEPIN TAB 100MGER","CARBAMAZEPINE TAB ER 12HR 100 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","CARBAMAZEPIN TAB 200MG","CARBAMAZEPINE TAB 200 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","CARBAMAZEPIN TAB 200MG ER","CARBAMAZEPINE TAB ER 12HR 200 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","CARBAMAZEPIN TAB 400MG ER","CARBAMAZEPINE TAB ER 12HR 400 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","CELONTIN CAP 300MG","METHSUXIMIDE CAP 300 MG","3","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","CLOBAZAM SUS 2.5MG/ML","CLOBAZAM SUSPENSION 2.5 MG/ML","1","1","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","CLOBAZAM TAB 10MG","CLOBAZAM TAB 10 MG","1","1","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","CLOBAZAM TAB 20MG","CLOBAZAM TAB 20 MG","1","1","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","CLONAZEPAM TAB 0.5MG","CLONAZEPAM TAB 0.5 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","CLONAZEPAM TAB 1MG","CLONAZEPAM TAB 1 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","CLONAZEPAM TAB 2MG","CLONAZEPAM TAB 2 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","CLORAZ DIPOT TAB 15MG","CLORAZEPATE DIPOTASSIUM TAB 15 MG","1","0","0","1","180 tabs every 25 days","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","CLORAZ DIPOT TAB 3.75MG","CLORAZEPATE DIPOTASSIUM TAB 3.75 MG","1","0","0","1","180 tabs every 25 days","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","CLORAZ DIPOT TAB 7.5MG","CLORAZEPATE DIPOTASSIUM TAB 7.5 MG","1","0","0","1","180 tabs every 25 days","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","DIAZEPAM CON 5MG/ML","DIAZEPAM CONC 5 MG/ML","1","0","0","1","240 mL every 25 days","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","DIAZEPAM INJ 5MG/ML","DIAZEPAM INJ 5 MG/ML","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","DIAZEPAM SOL 5MG/5ML","DIAZEPAM ORAL SOLN 1 MG/ML","1","0","0","1","1200 mL every 25 days","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","DIAZEPAM TAB 10MG","DIAZEPAM TAB 10 MG","1","0","0","1","120 tabs every 25 days","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","DIAZEPAM TAB 2MG","DIAZEPAM TAB 2 MG","1","0","0","1","120 tabs every 25 days","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","DIAZEPAM TAB 5MG","DIAZEPAM TAB 5 MG","1","0","0","1","120 tabs every 25 days","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","DILANTIN CAP 30MG","PHENYTOIN SODIUM EXTENDED CAP 30 MG","3","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","DIVALPROEX CAP 125MG","DIVALPROEX SODIUM CAP DELAYED RELEASE SPRINKLE 125 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","DIVALPROEX TAB 125MG DR","DIVALPROEX SODIUM TAB DELAYED RELEASE 125 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","DIVALPROEX TAB 250MG DR","DIVALPROEX SODIUM TAB DELAYED RELEASE 250 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","DIVALPROEX TAB 250MG ER","DIVALPROEX SODIUM TAB ER 24 HR 250 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","DIVALPROEX TAB 500MG DR","DIVALPROEX SODIUM TAB DELAYED RELEASE 500 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","DIVALPROEX TAB 500MG ER","DIVALPROEX SODIUM TAB ER 24 HR 500 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","EPITOL TAB 200MG","CARBAMAZEPINE TAB 200 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","ETHOSUXIMIDE CAP 250MG","ETHOSUXIMIDE CAP 250 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","ETHOSUXIMIDE SOL 250/5ML","ETHOSUXIMIDE SOLN 250 MG/5ML","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","FELBAMATE SUS 600/5ML","FELBAMATE SUSP 600 MG/5ML","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","FELBAMATE TAB 400MG","FELBAMATE TAB 400 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","FELBAMATE TAB 600MG","FELBAMATE TAB 600 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","FOSPHENYTOIN INJ 100/2ML","FOSPHENYTOIN SODIUM INJ 100 MG/2ML (PHENYTOIN EQUIV)","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","FOSPHENYTOIN INJ 500/10ML","FOSPHENYTOIN SODIUM INJ 500 MG/10ML (PHENYTOIN EQUIV)","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","FYCOMPA SUS 0.5MG/ML","PERAMPANEL SUSP 0.5 MG/ML","2","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","FYCOMPA TAB 10MG","PERAMPANEL TAB 10 MG","2","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","FYCOMPA TAB 12MG","PERAMPANEL TAB 12 MG","2","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","FYCOMPA TAB 2MG","PERAMPANEL TAB 2 MG","2","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","FYCOMPA TAB 4MG","PERAMPANEL TAB 4 MG","2","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","FYCOMPA TAB 6MG","PERAMPANEL TAB 6 MG","2","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","FYCOMPA TAB 8MG","PERAMPANEL TAB 8 MG","2","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","GABAPENTIN CAP 100MG","GABAPENTIN CAP 100 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","GABAPENTIN CAP 300MG","GABAPENTIN CAP 300 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","GABAPENTIN CAP 400MG","GABAPENTIN CAP 400 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","GABAPENTIN SOL 250/5ML","GABAPENTIN ORAL SOLN 250 MG/5ML","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","GABAPENTIN TAB 600MG","GABAPENTIN TAB 600 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","GABAPENTIN TAB 800MG","GABAPENTIN TAB 800 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","LAMOTRIGINE CHW 25MG","LAMOTRIGINE TAB CHEWABLE DISPERSIBLE 25 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","LAMOTRIGINE CHW 5MG","LAMOTRIGINE TAB CHEWABLE DISPERSIBLE 5 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","LAMOTRIGINE KIT START 35","LAMOTRIGINE TAB 25 MG (35) STARTER KIT","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","LAMOTRIGINE KIT START 49","LAMOTRIGINE TAB 25 MG (42) & 100 MG (7) STARTER KIT","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","LAMOTRIGINE KIT START 98","LAMOTRIGINE TAB 25 MG (84) & 100 MG (14) STARTER KIT","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","LAMOTRIGINE TAB 100MG","LAMOTRIGINE TAB 100 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","LAMOTRIGINE TAB 100MG","LAMOTRIGINE ORALLY DISINTEGRATING TAB 100 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","LAMOTRIGINE TAB 100MG ER","LAMOTRIGINE TAB ER 24HR 100 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","LAMOTRIGINE TAB 150MG","LAMOTRIGINE TAB 150 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","LAMOTRIGINE TAB 200MG","LAMOTRIGINE TAB 200 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","LAMOTRIGINE TAB 200MG","LAMOTRIGINE ORALLY DISINTEGRATING TAB 200 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","LAMOTRIGINE TAB 200MG ER","LAMOTRIGINE TAB ER 24HR 200 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","LAMOTRIGINE TAB 250MG ER","LAMOTRIGINE TAB ER 24HR 250 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","LAMOTRIGINE TAB 25MG","LAMOTRIGINE TAB 25 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","LAMOTRIGINE TAB 25MG ER","LAMOTRIGINE TAB ER 24HR 25 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","LAMOTRIGINE TAB 25MG ODT","LAMOTRIGINE ORALLY DISINTEGRATING TAB 25 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","LAMOTRIGINE TAB 300MG ER","LAMOTRIGINE TAB ER 24HR 300 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","LAMOTRIGINE TAB 50MG ER","LAMOTRIGINE TAB ER 24HR 50 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","LAMOTRIGINE TAB 50MG ODT","LAMOTRIGINE ORALLY DISINTEGRATING TAB 50 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","LEVETIRACETA INJ 10MG/ML","LEVETIRACETAM IN SODIUM CHLORIDE IV SOLN 1000 MG/100ML","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","LEVETIRACETA INJ 15MG/ML","LEVETIRACETAM IN SODIUM CHLORIDE IV SOLN 1500 MG/100ML","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","LEVETIRACETA INJ 5MG/ML","LEVETIRACETAM IN SODIUM CHLORIDE IV SOLN 500 MG/100ML","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","LEVETIRACETA SOL 100MG/ML","LEVETIRACETAM ORAL SOLN 100 MG/ML","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","LEVETIRACETA TAB 1000MG","LEVETIRACETAM TAB 1000 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","LEVETIRACETA TAB 250MG","LEVETIRACETAM TAB 250 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","LEVETIRACETA TAB 500MG","LEVETIRACETAM TAB 500 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","LEVETIRACETA TAB 500MG ER","LEVETIRACETAM TAB ER 24HR 500 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","LEVETIRACETA TAB 750MG","LEVETIRACETAM TAB 750 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","LEVETIRACETA TAB 750MG ER","LEVETIRACETAM TAB ER 24HR 750 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","LEVETIRACETM INJ 500/5ML","LEVETIRACETAM INJ 500 MG/5ML (100 MG/ML)","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","LYRICA CAP 100MG","PREGABALIN CAP 100 MG","3","0","1","0","","PA**","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","LYRICA CAP 150MG","PREGABALIN CAP 150 MG","3","0","1","0","","PA**","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","LYRICA CAP 200MG","PREGABALIN CAP 200 MG","3","0","1","0","","PA**","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","LYRICA CAP 225MG","PREGABALIN CAP 225 MG","3","0","1","0","","PA**","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","LYRICA CAP 25MG","PREGABALIN CAP 25 MG","3","0","1","0","","PA**","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","LYRICA CAP 300MG","PREGABALIN CAP 300 MG","3","0","1","0","","PA**","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","LYRICA CAP 50MG","PREGABALIN CAP 50 MG","3","0","1","0","","PA**","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","LYRICA CAP 75MG","PREGABALIN CAP 75 MG","3","0","1","0","","PA**","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","LYRICA SOL 20MG/ML","PREGABALIN SOLN 20 MG/ML","3","0","1","0","","PA**","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","OXCARBAZEPIN SUS 300MG/5M","OXCARBAZEPINE SUSP 300 MG/5ML (60 MG/ML)","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","OXCARBAZEPIN TAB 150MG","OXCARBAZEPINE TAB 150 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","OXCARBAZEPIN TAB 300MG","OXCARBAZEPINE TAB 300 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","OXCARBAZEPIN TAB 600MG","OXCARBAZEPINE TAB 600 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","PEGANONE TAB 250MG","ETHOTOIN TAB 250 MG","3","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","PHENOBARB ELX 20MG/5ML","PHENOBARBITAL ELIXIR 20 MG/5ML","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","PHENOBARB TAB 100MG","PHENOBARBITAL TAB 100 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","PHENOBARB TAB 15MG","PHENOBARBITAL TAB 15 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","PHENOBARB TAB 16.2MG","PHENOBARBITAL TAB 16.2 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","PHENOBARB TAB 30MG","PHENOBARBITAL TAB 30 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","PHENOBARB TAB 32.4MG","PHENOBARBITAL TAB 32.4 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","PHENOBARB TAB 60MG","PHENOBARBITAL TAB 60 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","PHENOBARB TAB 64.8MG","PHENOBARBITAL TAB 64.8 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","PHENOBARB TAB 97.2MG","PHENOBARBITAL TAB 97.2 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","PHENYTOIN CHW 50MG","PHENYTOIN CHEW TAB 50 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","PHENYTOIN EX CAP 100MG","PHENYTOIN SODIUM EXTENDED CAP 100 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","PHENYTOIN EX CAP 200MG","PHENYTOIN SODIUM EXTENDED CAP 200 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","PHENYTOIN EX CAP 300MG","PHENYTOIN SODIUM EXTENDED CAP 300 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","PHENYTOIN INJ 50MG/ML","PHENYTOIN SODIUM INJ 50 MG/ML","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","PHENYTOIN SUS 125/5ML","PHENYTOIN SUSP 125 MG/5ML","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","PREGABALIN CAP 100MG","PREGABALIN CAP 100 MG","1","0","1","0","","PA**","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","PREGABALIN CAP 150MG","PREGABALIN CAP 150 MG","1","0","1","0","","PA**","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","PREGABALIN CAP 200MG","PREGABALIN CAP 200 MG","1","0","1","0","","PA**","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","PREGABALIN CAP 225MG","PREGABALIN CAP 225 MG","1","0","1","0","","PA**","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","PREGABALIN CAP 25MG","PREGABALIN CAP 25 MG","1","0","1","0","","PA**","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","PREGABALIN CAP 300MG","PREGABALIN CAP 300 MG","1","0","1","0","","PA**","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","PREGABALIN CAP 50MG","PREGABALIN CAP 50 MG","1","0","1","0","","PA**","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","PREGABALIN CAP 75MG","PREGABALIN CAP 75 MG","1","0","1","0","","PA**","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","PREGABALIN SOL 20MG/ML","PREGABALIN SOLN 20 MG/ML","1","0","1","0","","PA**","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","PRIMIDONE TAB 250MG","PRIMIDONE TAB 250 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","PRIMIDONE TAB 50MG","PRIMIDONE TAB 50 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","TIAGABINE TAB 12MG","TIAGABINE HCL TAB 12 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","TIAGABINE TAB 16MG","TIAGABINE HCL TAB 16 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","TIAGABINE TAB 2MG","TIAGABINE HCL TAB 2 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","TIAGABINE TAB 4MG","TIAGABINE HCL TAB 4 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","TOPIRAMATE CAP 15MG","TOPIRAMATE SPRINKLE CAP 15 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","TOPIRAMATE CAP 25MG","TOPIRAMATE SPRINKLE CAP 25 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","TOPIRAMATE TAB 100MG","TOPIRAMATE TAB 100 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","TOPIRAMATE TAB 200MG","TOPIRAMATE TAB 200 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","TOPIRAMATE TAB 25MG","TOPIRAMATE TAB 25 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","TOPIRAMATE TAB 50MG","TOPIRAMATE TAB 50 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","VALPROATE INJ 100MG/ML","VALPROATE SODIUM INJ 100 MG/ML","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","VALPROIC ACD CAP 250MG","VALPROIC ACID CAP 250 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","VALPROIC ACD SOL 250/5ML","VALPROATE SODIUM ORAL SOLN 250 MG/5ML (BASE EQUIV)","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","VIGABATRIN PAK 500MG","VIGABATRIN POWD PACK 500 MG","4","1","0","1","180 packets every 30 days","SP","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","VIGABATRIN TAB 500MG","VIGABATRIN TAB 500 MG","4","1","0","1","180 tabs every 30 days","SP","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","VIMPAT INJ 200MG/20","LACOSAMIDE IV INJ 200 MG/20ML (10 MG/ML)","3","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","VIMPAT SOL 10MG/ML","LACOSAMIDE ORAL SOLUTION 10 MG/ML","3","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","VIMPAT TAB 100MG","LACOSAMIDE TAB 100 MG","3","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","VIMPAT TAB 150MG","LACOSAMIDE TAB 150 MG","3","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","VIMPAT TAB 200MG","LACOSAMIDE TAB 200 MG","3","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","VIMPAT TAB 50MG","LACOSAMIDE TAB 50 MG","3","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","ZONISAMIDE CAP 100MG","ZONISAMIDE CAP 100 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","ZONISAMIDE CAP 25MG","ZONISAMIDE CAP 25 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","ZONISAMIDE CAP 50MG","ZONISAMIDE CAP 50 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTICONVULSANTS§"],["N","G","DONEPEZIL TAB 10MG","DONEPEZIL HYDROCHLORIDE TAB 10 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIDEMENTIA"],["N","G","DONEPEZIL TAB 10MG ODT","DONEPEZIL HYDROCHLORIDE ORALLY DISINTEGRATING TAB 10 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIDEMENTIA"],["N","G","DONEPEZIL TAB 5MG","DONEPEZIL HYDROCHLORIDE TAB 5 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIDEMENTIA"],["N","G","DONEPEZIL TAB 5MG ODT","DONEPEZIL HYDROCHLORIDE ORALLY DISINTEGRATING TAB 5 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIDEMENTIA"],["N","G","DONEPEZIL TAB HCL 23MG","DONEPEZIL HYDROCHLORIDE TAB 23 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIDEMENTIA"],["N","G","ERGOLOID MES TAB 1MG ORAL","ERGOLOID MESYLATES TAB 1 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIDEMENTIA"],["N","G","GALANTAMINE CAP 16MG ER","GALANTAMINE HYDROBROMIDE CAP ER 24HR 16 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIDEMENTIA"],["N","G","GALANTAMINE CAP 24MG ER","GALANTAMINE HYDROBROMIDE CAP ER 24HR 24 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIDEMENTIA"],["N","G","GALANTAMINE CAP 8MG ER","GALANTAMINE HYDROBROMIDE CAP ER 24HR 8 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIDEMENTIA"],["N","G","GALANTAMINE SOL 4MG/ML","GALANTAMINE HYDROBROMIDE ORAL SOLN 4 MG/ML","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIDEMENTIA"],["N","G","GALANTAMINE TAB 12MG","GALANTAMINE HYDROBROMIDE TAB 12 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIDEMENTIA"],["N","G","GALANTAMINE TAB 4MG","GALANTAMINE HYDROBROMIDE TAB 4 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIDEMENTIA"],["N","G","GALANTAMINE TAB 8MG","GALANTAMINE HYDROBROMIDE TAB 8 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIDEMENTIA"],["N","G","MEMANT TITRA PAK 5-10MG","MEMANTINE HCL TAB 5 MG (28) & 10 MG (21) TITRATION PAK","1","1","0","0","","PA applies for members less than 30 years of age","CENTRAL NERVOUS SYSTEM","ANTIDEMENTIA"],["N","G","MEMANTINE HC CAP 14MG ER","MEMANTINE HCL CAP ER 24HR 14 MG","1","1","0","0","","PA applies for members less than 30 years of age","CENTRAL NERVOUS SYSTEM","ANTIDEMENTIA"],["N","G","MEMANTINE HC CAP 21MG ER","MEMANTINE HCL CAP ER 24HR 21 MG","1","1","0","0","","PA applies for members less than 30 years of age","CENTRAL NERVOUS SYSTEM","ANTIDEMENTIA"],["N","G","MEMANTINE HC CAP 28MG ER","MEMANTINE HCL CAP ER 24HR 28 MG","1","1","0","0","","PA applies for members less than 30 years of age","CENTRAL NERVOUS SYSTEM","ANTIDEMENTIA"],["N","G","MEMANTINE HC CAP 7MG ER","MEMANTINE HCL CAP ER 24HR 7 MG","1","1","0","0","","PA applies for members less than 30 years of age","CENTRAL NERVOUS SYSTEM","ANTIDEMENTIA"],["N","G","MEMANTINE HC SOL 2MG/ML","MEMANTINE HCL ORAL SOLUTION 2 MG/ML","1","1","0","0","","PA applies for members less than 30 years of age","CENTRAL NERVOUS SYSTEM","ANTIDEMENTIA"],["N","G","MEMANTINE TAB HCL 10MG","MEMANTINE HCL TAB 10 MG","1","1","0","0","","PA applies for members less than 30 years of age","CENTRAL NERVOUS SYSTEM","ANTIDEMENTIA"],["N","G","MEMANTINE TAB HCL 5MG","MEMANTINE HCL TAB 5 MG","1","1","0","0","","PA applies for members less than 30 years of age","CENTRAL NERVOUS SYSTEM","ANTIDEMENTIA"],["N","G","NAMENDA XR CAP TITRATIO","MEMANTINE HCL CAP ER 24HR 7 MG & 14 MG & 21 MG & 28 MG PACK","2","1","0","0","","PA applies for members less than 30 years of age","CENTRAL NERVOUS SYSTEM","ANTIDEMENTIA"],["N","G","RIVASTIGMINE CAP 1.5MG","RIVASTIGMINE TARTRATE CAP 1.5 MG (BASE EQUIVALENT)","1","1","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIDEMENTIA"],["N","G","RIVASTIGMINE CAP 3MG","RIVASTIGMINE TARTRATE CAP 3 MG (BASE EQUIVALENT)","1","1","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIDEMENTIA"],["N","G","RIVASTIGMINE CAP 4.5MG","RIVASTIGMINE TARTRATE CAP 4.5 MG (BASE EQUIVALENT)","1","1","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIDEMENTIA"],["N","G","RIVASTIGMINE CAP 6MG","RIVASTIGMINE TARTRATE CAP 6 MG (BASE EQUIVALENT)","1","1","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIDEMENTIA"],["N","G","RIVASTIGMINE DIS 13.3/24","RIVASTIGMINE TD PATCH 24HR 13.3 MG/24HR","1","1","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIDEMENTIA"],["N","G","RIVASTIGMINE DIS 4.6MG/24","RIVASTIGMINE TD PATCH 24HR 4.6 MG/24HR","1","1","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIDEMENTIA"],["N","G","RIVASTIGMINE DIS 9.5MG/24","RIVASTIGMINE TD PATCH 24HR 9.5 MG/24HR","1","1","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIDEMENTIA"],["N","G","AMITRIPTYLIN TAB 100MG","AMITRIPTYLINE HCL TAB 100 MG","1","1","0","0","","Members 70 and older subject to PA","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","AMITRIPTYLIN TAB 10MG","AMITRIPTYLINE HCL TAB 10 MG","1","0","0","1","150 tabs every 25 days","QL applies to members age 65 and older","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","AMITRIPTYLIN TAB 150MG","AMITRIPTYLINE HCL TAB 150 MG","1","1","0","0","","Members 70 and older subject to PA","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","AMITRIPTYLIN TAB 25MG","AMITRIPTYLINE HCL TAB 25 MG","1","0","0","1","60 tabs every 25 days","QL applies to members age 65 and older","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","AMITRIPTYLIN TAB 50MG","AMITRIPTYLINE HCL TAB 50 MG","1","0","0","1","30 tabs every 25 days","QL applies to members age 65 and older","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","AMITRIPTYLIN TAB 75MG","AMITRIPTYLINE HCL TAB 75 MG","1","1","0","0","","Members 70 and older subject to PA","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","AMOXAPINE TAB 100MG","AMOXAPINE TAB 100 MG","1","0","0","1","90 tabs every 25 days","QL applies to members age 65 and older","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","AMOXAPINE TAB 150MG","AMOXAPINE TAB 150 MG","1","0","0","1","60 tabs every 25 days","QL applies to members age 65 and older","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","AMOXAPINE TAB 25MG","AMOXAPINE TAB 25 MG","1","0","0","1","90 tabs every 25 days","QL applies to members age 65 and older","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","AMOXAPINE TAB 50MG","AMOXAPINE TAB 50 MG","1","0","0","1","90 tabs every 25 days","QL applies to members age 65 and older","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","BUPROPION TAB 100MG","BUPROPION HCL TAB 100 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","BUPROPION TAB 100MG SR","BUPROPION HCL TAB ER 12HR 100 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","BUPROPION TAB 150MG SR","BUPROPION HCL TAB ER 12HR 150 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","BUPROPION TAB 200MG SR","BUPROPION HCL TAB ER 12HR 200 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","BUPROPION TAB 75MG","BUPROPION HCL TAB 75 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","BUPROPN HCL TAB 150MG XL","BUPROPION HCL TAB ER 24HR 150 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","BUPROPN HCL TAB 300MG XL","BUPROPION HCL TAB ER 24HR 300 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","CITALOPRAM SOL 10MG/5ML","CITALOPRAM HYDROBROMIDE ORAL SOLN 10 MG/5ML","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","CITALOPRAM TAB 10MG","CITALOPRAM HYDROBROMIDE TAB 10 MG (BASE EQUIV)","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","CITALOPRAM TAB 20MG","CITALOPRAM HYDROBROMIDE TAB 20 MG (BASE EQUIV)","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","CITALOPRAM TAB 40MG","CITALOPRAM HYDROBROMIDE TAB 40 MG (BASE EQUIV)","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","DESIPRAMINE TAB 100MG","DESIPRAMINE HCL TAB 100 MG","1","0","0","1","30 tabs every 25 days","QL applies to members age 65 and older","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","DESIPRAMINE TAB 10MG","DESIPRAMINE HCL TAB 10 MG","1","0","0","1","90 tabs every 25 days","QL applies to members age 65 and older","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","DESIPRAMINE TAB 150MG","DESIPRAMINE HCL TAB 150 MG","1","0","0","1","30 tabs every 25 days","QL applies to members age 65 and older","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","DESIPRAMINE TAB 25MG","DESIPRAMINE HCL TAB 25 MG","1","0","0","1","90 tabs every 25 days","QL applies to members age 65 and older","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","DESIPRAMINE TAB 50MG","DESIPRAMINE HCL TAB 50 MG","1","0","0","1","90 tabs every 25 days","QL applies to members age 65 and older","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","DESIPRAMINE TAB 75MG","DESIPRAMINE HCL TAB 75 MG","1","0","0","1","60 tabs every 25 days","QL applies to members age 65 and older","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","DESVENLAFAX TAB 100MG ER","DESVENLAFAXINE SUCCINATE TAB ER 24HR 100 MG (BASE EQUIV)","1","0","1","0","","(generic of Pristiq) PA**","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","DESVENLAFAX TAB 25MG ER","DESVENLAFAXINE SUCCINATE TAB ER 24HR 25 MG (BASE EQUIV)","1","0","1","0","","(generic of Pristiq) PA**","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","DESVENLAFAX TAB 50MG ER","DESVENLAFAXINE SUCCINATE TAB ER 24HR 50 MG (BASE EQUIV)","1","0","1","0","","(generic of Pristiq) PA**","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","DOXEPIN HCL CAP 100MG","DOXEPIN HCL CAP 100 MG","1","0","0","1","30 caps every 25 days","QL applies to members age 65 and older","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","DOXEPIN HCL CAP 10MG","DOXEPIN HCL CAP 10 MG","1","0","0","1","90 caps every 25 days","QL applies to members age 65 and older","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","DOXEPIN HCL CAP 150MG","DOXEPIN HCL CAP 150 MG","1","0","0","1","30 caps every 25 days","QL applies to members age 65 and older","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","DOXEPIN HCL CAP 25MG","DOXEPIN HCL CAP 25 MG","1","0","0","1","90 caps every 25 days","QL applies to members age 65 and older","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","DOXEPIN HCL CAP 50MG","DOXEPIN HCL CAP 50 MG","1","0","0","1","90 caps every 25 days","QL applies to members age 65 and older","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","DOXEPIN HCL CAP 75MG","DOXEPIN HCL CAP 75 MG","1","0","0","1","60 caps every 25 days","QL applies to members age 65 and older","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","DOXEPIN HCL CON 10MG/ML","DOXEPIN HCL CONC 10 MG/ML","1","0","0","1","450 mL every 25 days","QL applies to members age 65 and older","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","DULOXETINE CAP 20MG","DULOXETINE HCL ENTERIC COATED PELLETS CAP 20 MG (BASE EQ)","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","DULOXETINE CAP 30MG","DULOXETINE HCL ENTERIC COATED PELLETS CAP 30 MG (BASE EQ)","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","DULOXETINE CAP 60MG","DULOXETINE HCL ENTERIC COATED PELLETS CAP 60 MG (BASE EQ)","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","EMSAM DIS 12MG/24H","SELEGILINE TD PATCH 24HR 12 MG/24HR","3","1","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","EMSAM DIS 6MG/24HR","SELEGILINE TD PATCH 24HR 6 MG/24HR","3","1","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","EMSAM DIS 9MG/24HR","SELEGILINE TD PATCH 24HR 9 MG/24HR","3","1","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","ESCITALOPRAM SOL 5MG/5ML","ESCITALOPRAM OXALATE SOLN 5 MG/5ML (BASE EQUIV)","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","ESCITALOPRAM TAB 10MG","ESCITALOPRAM OXALATE TAB 10 MG (BASE EQUIV)","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","ESCITALOPRAM TAB 20MG","ESCITALOPRAM OXALATE TAB 20 MG (BASE EQUIV)","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","ESCITALOPRAM TAB 5MG","ESCITALOPRAM OXALATE TAB 5 MG (BASE EQUIV)","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","FETZIMA CAP 120MG","LEVOMILNACIPRAN HCL CAP ER 24HR 120 MG (BASE EQUIVALENT)","3","0","1","0","","PA**","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","FETZIMA CAP 20MG","LEVOMILNACIPRAN HCL CAP ER 24HR 20 MG (BASE EQUIVALENT)","3","0","1","0","","PA**","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","FETZIMA CAP 40MG","LEVOMILNACIPRAN HCL CAP ER 24HR 40 MG (BASE EQUIVALENT)","3","0","1","0","","PA**","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","FETZIMA CAP 80MG","LEVOMILNACIPRAN HCL CAP ER 24HR 80 MG (BASE EQUIVALENT)","3","0","1","0","","PA**","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","FETZIMA CAP TITRATIO","LEVOMILNACIPRAN HCL CAP ER 24HR 20 & 40 MG THERAPY PACK","3","0","1","0","","PA**","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","FLUOXETINE CAP 10MG","FLUOXETINE HCL CAP 10 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","FLUOXETINE CAP 20MG","FLUOXETINE HCL CAP 20 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","FLUOXETINE CAP 40MG","FLUOXETINE HCL CAP 40 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","FLUOXETINE CAP 90MG DR","FLUOXETINE HCL CAP DELAYED RELEASE 90 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","FLUOXETINE SOL 20MG/5ML","FLUOXETINE HCL SOLUTION 20 MG/5ML","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","FLUOXETINE TAB 10MG","FLUOXETINE HCL TAB 10 MG","1","0","0","0","","(generic Sarafem not covered)","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","FLUOXETINE TAB 20MG","FLUOXETINE HCL TAB 20 MG","1","0","0","0","","(generic Sarafem not covered)","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","FLUOXETINE TAB 60MG","FLUOXETINE HCL TAB 60 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","IMIPRAM HCL TAB 10MG","IMIPRAMINE HCL TAB 10 MG","1","0","0","1","120 tabs every 25 days","QL applies to members age 65 and older","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","IMIPRAM HCL TAB 25MG","IMIPRAMINE HCL TAB 25 MG","1","0","0","1","120 tabs every 25 days","QL applies to members age 65 and older","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","IMIPRAM HCL TAB 50MG","IMIPRAMINE HCL TAB 50 MG","1","0","0","1","60 tabs every 25 days","QL applies to members age 65 and older","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","IMIPRAM PAM CAP 100MG","IMIPRAMINE PAMOATE CAP 100 MG","1","0","0","1","30 caps every 25 days","QL applies to members age 65 and older","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","IMIPRAM PAM CAP 125MG","IMIPRAMINE PAMOATE CAP 125 MG","1","1","0","0","","Members 70 and older subject to PA","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","IMIPRAM PAM CAP 150MG","IMIPRAMINE PAMOATE CAP 150 MG","1","1","0","0","","Members 70 and older subject to PA","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","IMIPRAM PAM CAP 75MG","IMIPRAMINE PAMOATE CAP 75 MG","1","0","0","1","30 caps every 25 days","QL applies to members age 65 and older","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","MAPROTILINE TAB 25MG","MAPROTILINE HCL TAB 25 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","MAPROTILINE TAB 50MG","MAPROTILINE HCL TAB 50 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","MAPROTILINE TAB 75MG","MAPROTILINE HCL TAB 75 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","MARPLAN TAB 10MG","ISOCARBOXAZID TAB 10 MG","3","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","MIRTAZAPINE TAB 15MG","MIRTAZAPINE TAB 15 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","MIRTAZAPINE TAB 15MG ODT","MIRTAZAPINE ORALLY DISINTEGRATING TAB 15 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","MIRTAZAPINE TAB 30MG","MIRTAZAPINE TAB 30 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","MIRTAZAPINE TAB 30MG ODT","MIRTAZAPINE ORALLY DISINTEGRATING TAB 30 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","MIRTAZAPINE TAB 45MG","MIRTAZAPINE TAB 45 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","MIRTAZAPINE TAB 45MG ODT","MIRTAZAPINE ORALLY DISINTEGRATING TAB 45 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","MIRTAZAPINE TAB 7.5MG","MIRTAZAPINE TAB 7.5 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","NEFAZODONE TAB 100MG","NEFAZODONE HCL TAB 100 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","NEFAZODONE TAB 150MG","NEFAZODONE HCL TAB 150 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","NEFAZODONE TAB 200MG","NEFAZODONE HCL TAB 200 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","NEFAZODONE TAB 250MG","NEFAZODONE HCL TAB 250 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","NEFAZODONE TAB 50MG","NEFAZODONE HCL TAB 50 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","NORTRIPTYLIN CAP 10MG","NORTRIPTYLINE HCL CAP 10 MG","1","0","0","1","150 caps every 25 days","QL applies to members age 65 and older","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","NORTRIPTYLIN CAP 25MG","NORTRIPTYLINE HCL CAP 25 MG","1","0","0","1","60 caps every 25 days","QL applies to members age 65 and older","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","NORTRIPTYLIN CAP 50MG","NORTRIPTYLINE HCL CAP 50 MG","1","0","0","1","30 caps every 25 days","QL applies to members age 65 and older","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","NORTRIPTYLIN CAP 75MG","NORTRIPTYLINE HCL CAP 75 MG","1","1","0","0","","Members 70 and older subject to PA","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","NORTRIPTYLIN SOL 10MG/5ML","NORTRIPTYLINE HCL SOLN 10 MG/5ML","1","0","0","1","750 mL every 25 days","QL applies to members age 65 and older","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","PAROXETIN ER TAB 12.5MG","PAROXETINE HCL TAB ER 24HR 12.5 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","PAROXETIN ER TAB 37.5MG","PAROXETINE HCL TAB ER 24HR 37.5 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","PAROXETINE TAB 10MG","PAROXETINE HCL TAB 10 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","PAROXETINE TAB 20MG","PAROXETINE HCL TAB 20 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","PAROXETINE TAB 25MG ER","PAROXETINE HCL TAB ER 24HR 25 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","PAROXETINE TAB 30MG","PAROXETINE HCL TAB 30 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","PAROXETINE TAB 40MG","PAROXETINE HCL TAB 40 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","PHENELZINE TAB 15MG","PHENELZINE SULFATE TAB 15 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","PROTRIPTYLIN TAB 10MG","PROTRIPTYLINE HCL TAB 10 MG","1","0","0","1","60 tabs every 25 days","QL applies to members age 65 and older","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","PROTRIPTYLIN TAB 5MG","PROTRIPTYLINE HCL TAB 5 MG","1","0","0","1","90 tabs every 25 days","QL applies to members age 65 and older","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","SERTRALINE CON 20MG/ML","SERTRALINE HCL ORAL CONCENTRATE FOR SOLUTION 20 MG/ML","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","SERTRALINE TAB 100MG","SERTRALINE HCL TAB 100 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","SERTRALINE TAB 25MG","SERTRALINE HCL TAB 25 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","SERTRALINE TAB 50MG","SERTRALINE HCL TAB 50 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","TRANYLCYPROM TAB 10MG","TRANYLCYPROMINE SULFATE TAB 10 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","TRAZODONE TAB 100MG","TRAZODONE HCL TAB 100 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","TRAZODONE TAB 150MG","TRAZODONE HCL TAB 150 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","TRAZODONE TAB 300MG","TRAZODONE HCL TAB 300 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","TRAZODONE TAB 50MG","TRAZODONE HCL TAB 50 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","TRIMIPRAMINE CAP 100MG","TRIMIPRAMINE MALEATE CAP 100 MG","1","0","0","1","30 caps every 25 days","QL applies to members age 65 and older","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","TRIMIPRAMINE CAP 25MG","TRIMIPRAMINE MALEATE CAP 25 MG","1","0","0","1","60 caps every 25 days","QL applies to members age 65 and older","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","TRIMIPRAMINE CAP 50MG","TRIMIPRAMINE MALEATE CAP 50 MG","1","0","0","1","60 caps every 25 days","QL applies to members age 65 and older","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","TRINTELLIX TAB 10MG","VORTIOXETINE HBR TAB 10 MG (BASE EQUIV)","3","0","1","0","","PA**","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","TRINTELLIX TAB 20MG","VORTIOXETINE HBR TAB 20 MG (BASE EQUIV)","3","0","1","0","","PA**","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","TRINTELLIX TAB 5MG","VORTIOXETINE HBR TAB 5 MG (BASE EQUIV)","3","0","1","0","","PA**","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","VENLAFAXINE CAP 150MG ER","VENLAFAXINE HCL CAP ER 24HR 150 MG (BASE EQUIVALENT)","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","VENLAFAXINE CAP 37.5 ER","VENLAFAXINE HCL CAP ER 24HR 37.5 MG (BASE EQUIVALENT)","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","VENLAFAXINE CAP 75MG ER","VENLAFAXINE HCL CAP ER 24HR 75 MG (BASE EQUIVALENT)","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","VENLAFAXINE TAB 100MG","VENLAFAXINE HCL TAB 100 MG (BASE EQUIVALENT)","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","VENLAFAXINE TAB 150MG ER","VENLAFAXINE HCL TAB ER 24HR 150 MG (BASE EQUIVALENT)","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","VENLAFAXINE TAB 25MG","VENLAFAXINE HCL TAB 25 MG (BASE EQUIVALENT)","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","VENLAFAXINE TAB 37.5 ER","VENLAFAXINE HCL TAB ER 24HR 37.5 MG (BASE EQUIVALENT)","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","VENLAFAXINE TAB 37.5MG","VENLAFAXINE HCL TAB 37.5 MG (BASE EQUIVALENT)","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","VENLAFAXINE TAB 50MG","VENLAFAXINE HCL TAB 50 MG (BASE EQUIVALENT)","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","VENLAFAXINE TAB 75MG","VENLAFAXINE HCL TAB 75 MG (BASE EQUIVALENT)","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","VENLAFAXINE TAB 75MG ER","VENLAFAXINE HCL TAB ER 24HR 75 MG (BASE EQUIVALENT)","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","VIIBRYD KIT STARTER","VILAZODONE HCL TAB STARTER KIT 10 (7) & 20 (23) MG","3","0","1","0","","PA**","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","VIIBRYD TAB 10MG","VILAZODONE HCL TAB 10 MG","3","0","1","0","","PA**","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","VIIBRYD TAB 20MG","VILAZODONE HCL TAB 20 MG","3","0","1","0","","PA**","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","VIIBRYD TAB 40MG","VILAZODONE HCL TAB 40 MG","3","0","1","0","","PA**","CENTRAL NERVOUS SYSTEM","ANTIDEPRESSANTS§"],["N","G","AMANTADINE CAP 100MG","AMANTADINE HCL CAP 100 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPARKINSONIAN AGENTS"],["N","G","AMANTADINE SYP 50MG/5ML","AMANTADINE HCL SYRUP 50 MG/5ML","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPARKINSONIAN AGENTS"],["N","G","AMANTADINE TAB 100MG","AMANTADINE HCL TAB 100 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPARKINSONIAN AGENTS"],["N","G","APOKYN INJ 10MG/ML","APOMORPHINE HCL SOLN CARTRIDGE 30 MG/3ML","4","1","0","0","","SP","CENTRAL NERVOUS SYSTEM","ANTIPARKINSONIAN AGENTS"],["N","G","BENZTROPINE INJ 1MG/ML","BENZTROPINE MESYLATE INJ 1 MG/ML","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPARKINSONIAN AGENTS"],["N","G","BENZTROPINE TAB 0.5MG","BENZTROPINE MESYLATE TAB 0.5 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPARKINSONIAN AGENTS"],["N","G","BENZTROPINE TAB 1MG","BENZTROPINE MESYLATE TAB 1 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPARKINSONIAN AGENTS"],["N","G","BENZTROPINE TAB 2MG","BENZTROPINE MESYLATE TAB 2 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPARKINSONIAN AGENTS"],["N","G","BROMOCRIPTIN CAP 5MG","BROMOCRIPTINE MESYLATE CAP 5 MG (BASE EQUIVALENT)","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPARKINSONIAN AGENTS"],["N","G","BROMOCRIPTIN TAB 2.5MG","BROMOCRIPTINE MESYLATE TAB 2.5 MG (BASE EQUIVALENT)","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPARKINSONIAN AGENTS"],["N","G","CARB/LEVO 50 TAB /ENTACAP","CARBIDOPA-LEVODOPA-ENTACAPONE TABS 12.5-50-200 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPARKINSONIAN AGENTS"],["N","G","CARB/LEVO 75 TAB /ENTACAP","CARBIDOPA-LEVODOPA-ENTACAPONE TABS 18.75-75-200 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPARKINSONIAN AGENTS"],["N","G","CARB/LEVO ER TAB 25-100MG","CARBIDOPA & LEVODOPA TAB ER 25-100 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPARKINSONIAN AGENTS"],["N","G","CARB/LEVO ER TAB 50-200MG","CARBIDOPA & LEVODOPA TAB ER 50-200 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPARKINSONIAN AGENTS"],["N","G","CARB/LEVO TAB 10-100MG","CARBIDOPA & LEVODOPA ORALLY DISINTEGRATING TAB 10-100 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPARKINSONIAN AGENTS"],["N","G","CARB/LEVO TAB 10-100MG","CARBIDOPA & LEVODOPA TAB 10-100 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPARKINSONIAN AGENTS"],["N","G","CARB/LEVO TAB 25-100MG","CARBIDOPA & LEVODOPA ORALLY DISINTEGRATING TAB 25-100 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPARKINSONIAN AGENTS"],["N","G","CARB/LEVO TAB 25-100MG","CARBIDOPA & LEVODOPA TAB 25-100 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPARKINSONIAN AGENTS"],["N","G","CARB/LEVO TAB 25-250MG","CARBIDOPA & LEVODOPA ORALLY DISINTEGRATING TAB 25-250 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPARKINSONIAN AGENTS"],["N","G","CARB/LEVO TAB 25-250MG","CARBIDOPA & LEVODOPA TAB 25-250 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPARKINSONIAN AGENTS"],["N","G","CARB/LEVO100 TAB /ENTACAP","CARBIDOPA-LEVODOPA-ENTACAPONE TABS 25-100-200 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPARKINSONIAN AGENTS"],["N","G","CARB/LEVO125 TAB /ENTACAP","CARBIDOPA-LEVODOPA-ENTACAPONE TABS 31.25-125-200 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPARKINSONIAN AGENTS"],["N","G","CARB/LEVO150 TAB /ENTACAP","CARBIDOPA-LEVODOPA-ENTACAPONE TABS 37.5-150-200 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPARKINSONIAN AGENTS"],["N","G","CARB/LEVO200 TAB /ENTACAP","CARBIDOPA-LEVODOPA-ENTACAPONE TABS 50-200-200 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPARKINSONIAN AGENTS"],["N","G","CARBIDOPA TAB 25MG","CARBIDOPA TAB 25 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPARKINSONIAN AGENTS"],["N","G","ENTACAPONE TAB 200MG","ENTACAPONE TAB 200 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPARKINSONIAN AGENTS"],["N","G","NEUPRO DIS 1MG/24HR","ROTIGOTINE TD PATCH 24HR 1 MG/24HR","2","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPARKINSONIAN AGENTS"],["N","G","NEUPRO DIS 2MG/24HR","ROTIGOTINE TD PATCH 24HR 2 MG/24HR","2","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPARKINSONIAN AGENTS"],["N","G","NEUPRO DIS 3MG/24HR","ROTIGOTINE TD PATCH 24HR 3 MG/24HR","2","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPARKINSONIAN AGENTS"],["N","G","NEUPRO DIS 4MG/24HR","ROTIGOTINE TD PATCH 24HR 4 MG/24HR","2","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPARKINSONIAN AGENTS"],["N","G","NEUPRO DIS 6MG/24HR","ROTIGOTINE TD PATCH 24HR 6 MG/24HR","2","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPARKINSONIAN AGENTS"],["N","G","NEUPRO DIS 8MG/24HR","ROTIGOTINE TD PATCH 24HR 8 MG/24HR","2","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPARKINSONIAN AGENTS"],["N","G","PRAMIPEXOLE TAB 0.125MG","PRAMIPEXOLE DIHYDROCHLORIDE TAB 0.125 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPARKINSONIAN AGENTS"],["N","G","PRAMIPEXOLE TAB 0.25MG","PRAMIPEXOLE DIHYDROCHLORIDE TAB 0.25 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPARKINSONIAN AGENTS"],["N","G","PRAMIPEXOLE TAB 0.375 ER","PRAMIPEXOLE DIHYDROCHLORIDE TAB ER 24HR 0.375 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPARKINSONIAN AGENTS"],["N","G","PRAMIPEXOLE TAB 0.5MG","PRAMIPEXOLE DIHYDROCHLORIDE TAB 0.5 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPARKINSONIAN AGENTS"],["N","G","PRAMIPEXOLE TAB 0.75 ER","PRAMIPEXOLE DIHYDROCHLORIDE TAB ER 24HR 0.75 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPARKINSONIAN AGENTS"],["N","G","PRAMIPEXOLE TAB 0.75MG","PRAMIPEXOLE DIHYDROCHLORIDE TAB 0.75 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPARKINSONIAN AGENTS"],["N","G","PRAMIPEXOLE TAB 1.5MG","PRAMIPEXOLE DIHYDROCHLORIDE TAB 1.5 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPARKINSONIAN AGENTS"],["N","G","PRAMIPEXOLE TAB 1.5MG ER","PRAMIPEXOLE DIHYDROCHLORIDE TAB ER 24HR 1.5 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPARKINSONIAN AGENTS"],["N","G","PRAMIPEXOLE TAB 1MG","PRAMIPEXOLE DIHYDROCHLORIDE TAB 1 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPARKINSONIAN AGENTS"],["N","G","PRAMIPEXOLE TAB 2.25 ER","PRAMIPEXOLE DIHYDROCHLORIDE TAB ER 24HR 2.25 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPARKINSONIAN AGENTS"],["N","G","PRAMIPEXOLE TAB 3.75 ER","PRAMIPEXOLE DIHYDROCHLORIDE TAB ER 24HR 3.75 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPARKINSONIAN AGENTS"],["N","G","PRAMIPEXOLE TAB 3MG ER","PRAMIPEXOLE DIHYDROCHLORIDE TAB ER 24HR 3 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPARKINSONIAN AGENTS"],["N","G","PRAMIPEXOLE TAB 4.5MG ER","PRAMIPEXOLE DIHYDROCHLORIDE TAB ER 24HR 4.5 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPARKINSONIAN AGENTS"],["N","G","RASAGILINE TAB 0.5MG","RASAGILINE MESYLATE TAB 0.5 MG (BASE EQUIV)","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPARKINSONIAN AGENTS"],["N","G","RASAGILINE TAB 1MG","RASAGILINE MESYLATE TAB 1 MG (BASE EQUIV)","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPARKINSONIAN AGENTS"],["N","G","ROPINIROLE TAB 0.25MG","ROPINIROLE HYDROCHLORIDE TAB 0.25 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPARKINSONIAN AGENTS"],["N","G","ROPINIROLE TAB 0.5MG","ROPINIROLE HYDROCHLORIDE TAB 0.5 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPARKINSONIAN AGENTS"],["N","G","ROPINIROLE TAB 1MG","ROPINIROLE HYDROCHLORIDE TAB 1 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPARKINSONIAN AGENTS"],["N","G","ROPINIROLE TAB 2MG","ROPINIROLE HYDROCHLORIDE TAB 2 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPARKINSONIAN AGENTS"],["N","G","ROPINIROLE TAB 3MG","ROPINIROLE HYDROCHLORIDE TAB 3 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPARKINSONIAN AGENTS"],["N","G","ROPINIROLE TAB 4MG","ROPINIROLE HYDROCHLORIDE TAB 4 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPARKINSONIAN AGENTS"],["N","G","ROPINIROLE TAB 5MG","ROPINIROLE HYDROCHLORIDE TAB 5 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPARKINSONIAN AGENTS"],["N","G","SELEGILINE CAP 5MG","SELEGILINE HCL CAP 5 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPARKINSONIAN AGENTS"],["N","G","SELEGILINE TAB 5MG","SELEGILINE HCL TAB 5 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPARKINSONIAN AGENTS"],["N","G","TOLCAPONE TAB 100MG","TOLCAPONE TAB 100 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPARKINSONIAN AGENTS"],["N","G","TRIHEXYPHEN SOL 0.4MG/ML","TRIHEXYPHENIDYL HCL ELIXIR 0.4 MG/ML","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPARKINSONIAN AGENTS"],["N","G","TRIHEXYPHEN TAB 2MG","TRIHEXYPHENIDYL HCL TAB 2 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPARKINSONIAN AGENTS"],["N","G","TRIHEXYPHEN TAB 5MG","TRIHEXYPHENIDYL HCL TAB 5 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPARKINSONIAN AGENTS"],["N","G","ARIPIPRAZOLE SOL 1MG/ML","ARIPIPRAZOLE ORAL SOLUTION 1 MG/ML","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","ARIPIPRAZOLE TAB 10MG","ARIPIPRAZOLE TAB 10 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","ARIPIPRAZOLE TAB 10MG ODT","ARIPIPRAZOLE ORALLY DISINTEGRATING TAB 10 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","ARIPIPRAZOLE TAB 15MG","ARIPIPRAZOLE TAB 15 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","ARIPIPRAZOLE TAB 15MG ODT","ARIPIPRAZOLE ORALLY DISINTEGRATING TAB 15 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","ARIPIPRAZOLE TAB 20MG","ARIPIPRAZOLE TAB 20 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","ARIPIPRAZOLE TAB 2MG","ARIPIPRAZOLE TAB 2 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","ARIPIPRAZOLE TAB 30MG","ARIPIPRAZOLE TAB 30 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","ARIPIPRAZOLE TAB 5MG","ARIPIPRAZOLE TAB 5 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","ARISTADA INJ 1064MG","ARIPIPRAZOLE LAUROXIL IM ER SUSP PREFILLED SYR 1064 MG/3.9ML","2","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","ARISTADA INJ 441MG/1.","ARIPIPRAZOLE LAUROXIL IM ER SUSP PREFILLED SYR 441 MG/1.6ML","2","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","ARISTADA INJ 662MG/2","ARIPIPRAZOLE LAUROXIL IM ER SUSP PREFILLED SYR 662 MG/2.4ML","2","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","ARISTADA INJ 882MG/3","ARIPIPRAZOLE LAUROXIL IM ER SUSP PREFILLED SYR 882 MG/3.2ML","2","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","ARISTADA INJ INITIO","ARIPIPRAZOLE LAUROXIL IM ER SUSP PREFILLED SYR 675 MG/2.4ML","2","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","CHLORPROMAZ INJ 25MG/ML","CHLORPROMAZINE HCL INJ 25 MG/ML","3","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","CHLORPROMAZ INJ 50MG/2ML","CHLORPROMAZINE HCL INJ 50 MG/2ML","3","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","CHLORPROMAZ TAB 100MG","CHLORPROMAZINE HCL TAB 100 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","CHLORPROMAZ TAB 10MG","CHLORPROMAZINE HCL TAB 10 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","CHLORPROMAZ TAB 200MG","CHLORPROMAZINE HCL TAB 200 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","CHLORPROMAZ TAB 25MG","CHLORPROMAZINE HCL TAB 25 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","CHLORPROMAZ TAB 50MG","CHLORPROMAZINE HCL TAB 50 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","CLOZAPINE TAB 100/ODT","CLOZAPINE ORALLY DISINTEGRATING TAB 100 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","CLOZAPINE TAB 100MG","CLOZAPINE TAB 100 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","CLOZAPINE TAB 12.5/ODT","CLOZAPINE ORALLY DISINTEGRATING TAB 12.5 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","CLOZAPINE TAB 150/ODT","CLOZAPINE ORALLY DISINTEGRATING TAB 150 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","CLOZAPINE TAB 200/ODT","CLOZAPINE ORALLY DISINTEGRATING TAB 200 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","CLOZAPINE TAB 200MG","CLOZAPINE TAB 200 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","CLOZAPINE TAB 25MG","CLOZAPINE TAB 25 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","CLOZAPINE TAB 25MG ODT","CLOZAPINE ORALLY DISINTEGRATING TAB 25 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","CLOZAPINE TAB 50MG","CLOZAPINE TAB 50 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","FLUPHENAZ DE INJ 25MG/ML","FLUPHENAZINE DECANOATE INJ 25 MG/ML","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","FLUPHENAZINE CON 5MG/ML","FLUPHENAZINE HCL ORAL CONC 5 MG/ML","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","FLUPHENAZINE ELX 2.5/5ML","FLUPHENAZINE HCL ELIXIR 2.5 MG/5ML","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","FLUPHENAZINE INJ 2.5MG/ML","FLUPHENAZINE HCL INJ 2.5 MG/ML","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","FLUPHENAZINE TAB 10MG","FLUPHENAZINE HCL TAB 10 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","FLUPHENAZINE TAB 1MG","FLUPHENAZINE HCL TAB 1 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","FLUPHENAZINE TAB 2.5MG","FLUPHENAZINE HCL TAB 2.5 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","FLUPHENAZINE TAB 5MG","FLUPHENAZINE HCL TAB 5 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","HALOPER DEC INJ 100MG/ML","HALOPERIDOL DECANOATE IM SOLN 100 MG/ML","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","HALOPER DEC INJ 50MG/ML","HALOPERIDOL DECANOATE IM SOLN 50 MG/ML","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","HALOPER LAC INJ 5MG/ML","HALOPERIDOL LACTATE INJ 5 MG/ML","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","HALOPERIDOL CON 2MG/ML","HALOPERIDOL LACTATE ORAL CONC 2 MG/ML","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","HALOPERIDOL TAB 0.5MG","HALOPERIDOL TAB 0.5 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","HALOPERIDOL TAB 10MG","HALOPERIDOL TAB 10 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","HALOPERIDOL TAB 1MG","HALOPERIDOL TAB 1 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","HALOPERIDOL TAB 20MG","HALOPERIDOL TAB 20 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","HALOPERIDOL TAB 2MG","HALOPERIDOL TAB 2 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","HALOPERIDOL TAB 5MG","HALOPERIDOL TAB 5 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","LATUDA TAB 120MG","LURASIDONE HCL TAB 120 MG","2","0","1","0","","PA**","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","LATUDA TAB 20MG","LURASIDONE HCL TAB 20 MG","2","0","1","0","","PA**","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","LATUDA TAB 40MG","LURASIDONE HCL TAB 40 MG","2","0","1","0","","PA**","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","LATUDA TAB 60MG","LURASIDONE HCL TAB 60 MG","2","0","1","0","","PA**","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","LATUDA TAB 80MG","LURASIDONE HCL TAB 80 MG","2","0","1","0","","PA**","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","LOXAPINE CAP 10MG","LOXAPINE SUCCINATE CAP 10 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","LOXAPINE CAP 25MG","LOXAPINE SUCCINATE CAP 25 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","LOXAPINE CAP 50MG","LOXAPINE SUCCINATE CAP 50 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","LOXAPINE CAP 5MG","LOXAPINE SUCCINATE CAP 5 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","NUPLAZID TAB 17MG","PIMAVANSERIN TARTRATE TAB 17 MG (BASE EQUIVALENT)","4","1","0","0","","SP","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","OLANZAPINE INJ 10MG","OLANZAPINE FOR IM INJ 10 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","OLANZAPINE TAB 10MG","OLANZAPINE TAB 10 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","OLANZAPINE TAB 10MG ODT","OLANZAPINE ORALLY DISINTEGRATING TAB 10 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","OLANZAPINE TAB 15MG","OLANZAPINE TAB 15 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","OLANZAPINE TAB 15MG ODT","OLANZAPINE ORALLY DISINTEGRATING TAB 15 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","OLANZAPINE TAB 2.5MG","OLANZAPINE TAB 2.5 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","OLANZAPINE TAB 20MG","OLANZAPINE TAB 20 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","OLANZAPINE TAB 20MG ODT","OLANZAPINE ORALLY DISINTEGRATING TAB 20 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","OLANZAPINE TAB 5MG","OLANZAPINE TAB 5 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","OLANZAPINE TAB 5MG ODT","OLANZAPINE ORALLY DISINTEGRATING TAB 5 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","OLANZAPINE TAB 7.5MG","OLANZAPINE TAB 7.5 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","PALIPERIDONE TAB ER 1.5MG","PALIPERIDONE TAB ER 24HR 1.5 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","PALIPERIDONE TAB ER 3MG","PALIPERIDONE TAB ER 24HR 3 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","PALIPERIDONE TAB ER 6MG","PALIPERIDONE TAB ER 24HR 6 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","PALIPERIDONE TAB ER 9MG","PALIPERIDONE TAB ER 24HR 9 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","PERPHENAZINE TAB 16MG","PERPHENAZINE TAB 16 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","PERPHENAZINE TAB 2MG","PERPHENAZINE TAB 2 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","PERPHENAZINE TAB 4MG","PERPHENAZINE TAB 4 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","PERPHENAZINE TAB 8MG","PERPHENAZINE TAB 8 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","QUETIAPINE TAB 100MG","QUETIAPINE FUMARATE TAB 100 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","QUETIAPINE TAB 150MG ER","QUETIAPINE FUMARATE TAB ER 24HR 150 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","QUETIAPINE TAB 200MG","QUETIAPINE FUMARATE TAB 200 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","QUETIAPINE TAB 200MG ER","QUETIAPINE FUMARATE TAB ER 24HR 200 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","QUETIAPINE TAB 25MG","QUETIAPINE FUMARATE TAB 25 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","QUETIAPINE TAB 300MG","QUETIAPINE FUMARATE TAB 300 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","QUETIAPINE TAB 300MG ER","QUETIAPINE FUMARATE TAB ER 24HR 300 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","QUETIAPINE TAB 400MG","QUETIAPINE FUMARATE TAB 400 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","QUETIAPINE TAB 400MG ER","QUETIAPINE FUMARATE TAB ER 24HR 400 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","QUETIAPINE TAB 50MG","QUETIAPINE FUMARATE TAB 50 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","QUETIAPINE TAB 50MG ER","QUETIAPINE FUMARATE TAB ER 24HR 50 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","REXULTI TAB 0.25MG","BREXPIPRAZOLE TAB 0.25 MG","3","0","1","0","","PA**","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","REXULTI TAB 0.5MG","BREXPIPRAZOLE TAB 0.5 MG","3","0","1","0","","PA**","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","REXULTI TAB 1MG","BREXPIPRAZOLE TAB 1 MG","3","0","1","0","","PA**","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","REXULTI TAB 2MG","BREXPIPRAZOLE TAB 2 MG","3","0","1","0","","PA**","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","REXULTI TAB 3MG","BREXPIPRAZOLE TAB 3 MG","3","0","1","0","","PA**","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","REXULTI TAB 4MG","BREXPIPRAZOLE TAB 4 MG","3","0","1","0","","PA**","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","RISPERIDONE SOL 1MG/ML","RISPERIDONE SOLN 1 MG/ML","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","RISPERIDONE TAB 0.25 ODT","RISPERIDONE ORALLY DISINTEGRATING TAB 0.25 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","RISPERIDONE TAB 0.25MG","RISPERIDONE TAB 0.25 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","RISPERIDONE TAB 0.5MG","RISPERIDONE TAB 0.5 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","RISPERIDONE TAB 0.5MG OD","RISPERIDONE ORALLY DISINTEGRATING TAB 0.5 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","RISPERIDONE TAB 1MG","RISPERIDONE TAB 1 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","RISPERIDONE TAB 1MG ODT","RISPERIDONE ORALLY DISINTEGRATING TAB 1 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","RISPERIDONE TAB 2MG","RISPERIDONE TAB 2 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","RISPERIDONE TAB 2MG ODT","RISPERIDONE ORALLY DISINTEGRATING TAB 2 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","RISPERIDONE TAB 3MG","RISPERIDONE TAB 3 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","RISPERIDONE TAB 3MG ODT","RISPERIDONE ORALLY DISINTEGRATING TAB 3 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","RISPERIDONE TAB 4MG","RISPERIDONE TAB 4 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","RISPERIDONE TAB 4MG ODT","RISPERIDONE ORALLY DISINTEGRATING TAB 4 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","SAPHRIS SUB 10MG","ASENAPINE MALEATE SL TAB 10 MG (BASE EQUIV)","3","0","1","0","","PA**","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","SAPHRIS SUB 2.5MG","ASENAPINE MALEATE SL TAB 2.5 MG (BASE EQUIV)","3","0","1","0","","PA**","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","SAPHRIS SUB 5MG","ASENAPINE MALEATE SL TAB 5 MG (BASE EQUIV)","3","0","1","0","","PA**","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","THIORIDAZINE TAB 100MG","THIORIDAZINE HCL TAB 100 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","THIORIDAZINE TAB 10MG","THIORIDAZINE HCL TAB 10 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","THIORIDAZINE TAB 25MG","THIORIDAZINE HCL TAB 25 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","THIORIDAZINE TAB 50MG","THIORIDAZINE HCL TAB 50 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","THIOTHIXENE CAP 10MG","THIOTHIXENE CAP 10 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","THIOTHIXENE CAP 1MG","THIOTHIXENE CAP 1 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","THIOTHIXENE CAP 2MG","THIOTHIXENE CAP 2 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","THIOTHIXENE CAP 5MG","THIOTHIXENE CAP 5 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","TRIFLUOPERAZ TAB 10MG","TRIFLUOPERAZINE HCL TAB 10 MG (BASE EQUIVALENT)","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","TRIFLUOPERAZ TAB 1MG","TRIFLUOPERAZINE HCL TAB 1 MG (BASE EQUIVALENT)","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","TRIFLUOPERAZ TAB 2MG","TRIFLUOPERAZINE HCL TAB 2 MG (BASE EQUIVALENT)","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","TRIFLUOPERAZ TAB 5MG","TRIFLUOPERAZINE HCL TAB 5 MG (BASE EQUIVALENT)","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","ZIPRASIDONE CAP 20MG","ZIPRASIDONE HCL CAP 20 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","ZIPRASIDONE CAP 40MG","ZIPRASIDONE HCL CAP 40 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","ZIPRASIDONE CAP 60MG","ZIPRASIDONE HCL CAP 60 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","ZIPRASIDONE CAP 80MG","ZIPRASIDONE HCL CAP 80 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ANTIPSYCHOTICS"],["N","G","AMPHET/DEXTR CAP 10MG ER","AMPHETAMINE-DEXTROAMPHETAMINE CAP ER 24HR 10 MG","1","0","0","1","90 caps every 25 days","","CENTRAL NERVOUS SYSTEM","ATTENTION DEFICIT HYPERACTIVITY DISORDER§"],["N","G","AMPHET/DEXTR CAP 15MG ER","AMPHETAMINE-DEXTROAMPHETAMINE CAP ER 24HR 15 MG","1","0","0","1","30 caps every 25 days","","CENTRAL NERVOUS SYSTEM","ATTENTION DEFICIT HYPERACTIVITY DISORDER§"],["N","G","AMPHET/DEXTR CAP 20MG ER","AMPHETAMINE-DEXTROAMPHETAMINE CAP ER 24HR 20 MG","1","0","0","1","30 caps every 25 days","","CENTRAL NERVOUS SYSTEM","ATTENTION DEFICIT HYPERACTIVITY DISORDER§"],["N","G","AMPHET/DEXTR CAP 25MG ER","AMPHETAMINE-DEXTROAMPHETAMINE CAP ER 24HR 25 MG","1","0","0","1","30 caps every 25 days","","CENTRAL NERVOUS SYSTEM","ATTENTION DEFICIT HYPERACTIVITY DISORDER§"],["N","G","AMPHET/DEXTR CAP 30MG ER","AMPHETAMINE-DEXTROAMPHETAMINE CAP ER 24HR 30 MG","1","0","0","1","30 caps every 25 days","","CENTRAL NERVOUS SYSTEM","ATTENTION DEFICIT HYPERACTIVITY DISORDER§"],["N","G","AMPHET/DEXTR CAP 5MG ER","AMPHETAMINE-DEXTROAMPHETAMINE CAP ER 24HR 5 MG","1","0","0","1","90 caps every 25 days","","CENTRAL NERVOUS SYSTEM","ATTENTION DEFICIT HYPERACTIVITY DISORDER§"],["N","G","AMPHET/DEXTR TAB 10MG","AMPHETAMINE-DEXTROAMPHETAMINE TAB 10 MG","1","0","0","1","90 tabs every 25 days","","CENTRAL NERVOUS SYSTEM","ATTENTION DEFICIT HYPERACTIVITY DISORDER§"],["N","G","AMPHET/DEXTR TAB 12.5MG","AMPHETAMINE-DEXTROAMPHETAMINE TAB 12.5 MG","1","0","0","1","90 tabs every 25 days","","CENTRAL NERVOUS SYSTEM","ATTENTION DEFICIT HYPERACTIVITY DISORDER§"],["N","G","AMPHET/DEXTR TAB 15MG","AMPHETAMINE-DEXTROAMPHETAMINE TAB 15 MG","1","0","0","1","60 tabs every 25 days","","CENTRAL NERVOUS SYSTEM","ATTENTION DEFICIT HYPERACTIVITY DISORDER§"],["N","G","AMPHET/DEXTR TAB 20MG","AMPHETAMINE-DEXTROAMPHETAMINE TAB 20 MG","1","0","0","1","60 tabs every 25 days","","CENTRAL NERVOUS SYSTEM","ATTENTION DEFICIT HYPERACTIVITY DISORDER§"],["N","G","AMPHET/DEXTR TAB 30MG","AMPHETAMINE-DEXTROAMPHETAMINE TAB 30 MG","1","0","0","1","30 tabs every 25 days","","CENTRAL NERVOUS SYSTEM","ATTENTION DEFICIT HYPERACTIVITY DISORDER§"],["N","G","AMPHET/DEXTR TAB 5MG","AMPHETAMINE-DEXTROAMPHETAMINE TAB 5 MG","1","0","0","1","90 tabs every 25 days","","CENTRAL NERVOUS SYSTEM","ATTENTION DEFICIT HYPERACTIVITY DISORDER§"],["N","G","AMPHET/DEXTR TAB 7.5MG","AMPHETAMINE-DEXTROAMPHETAMINE TAB 7.5 MG","1","0","0","1","90 tabs every 25 days","","CENTRAL NERVOUS SYSTEM","ATTENTION DEFICIT HYPERACTIVITY DISORDER§"],["N","G","ATOMOXETINE CAP 100MG","ATOMOXETINE HCL CAP 100 MG (BASE EQUIV)","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ATTENTION DEFICIT HYPERACTIVITY DISORDER§"],["N","G","ATOMOXETINE CAP 10MG","ATOMOXETINE HCL CAP 10 MG (BASE EQUIV)","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ATTENTION DEFICIT HYPERACTIVITY DISORDER§"],["N","G","ATOMOXETINE CAP 18MG","ATOMOXETINE HCL CAP 18 MG (BASE EQUIV)","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ATTENTION DEFICIT HYPERACTIVITY DISORDER§"],["N","G","ATOMOXETINE CAP 25MG","ATOMOXETINE HCL CAP 25 MG (BASE EQUIV)","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ATTENTION DEFICIT HYPERACTIVITY DISORDER§"],["N","G","ATOMOXETINE CAP 40MG","ATOMOXETINE HCL CAP 40 MG (BASE EQUIV)","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ATTENTION DEFICIT HYPERACTIVITY DISORDER§"],["N","G","ATOMOXETINE CAP 60MG","ATOMOXETINE HCL CAP 60 MG (BASE EQUIV)","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ATTENTION DEFICIT HYPERACTIVITY DISORDER§"],["N","G","ATOMOXETINE CAP 80MG","ATOMOXETINE HCL CAP 80 MG (BASE EQUIV)","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","ATTENTION DEFICIT HYPERACTIVITY DISORDER§"],["N","G","DEXMETHYLPH CAP 15MG ER","DEXMETHYLPHENIDATE HCL CAP ER 24 HR 15 MG","1","0","0","1","60 caps every 25 days","","CENTRAL NERVOUS SYSTEM","ATTENTION DEFICIT HYPERACTIVITY DISORDER§"],["N","G","DEXMETHYLPH CAP 30MG ER","DEXMETHYLPHENIDATE HCL CAP ER 24 HR 30 MG","1","0","0","1","30 caps every 25 days","","CENTRAL NERVOUS SYSTEM","ATTENTION DEFICIT HYPERACTIVITY DISORDER§"],["N","G","DEXMETHYLPH CAP 40MG ER","DEXMETHYLPHENIDATE HCL CAP ER 24 HR 40 MG","1","0","0","1","30 caps every 25 days","","CENTRAL NERVOUS SYSTEM","ATTENTION DEFICIT HYPERACTIVITY DISORDER§"],["N","G","DEXMETHYLPH TAB 10MG","DEXMETHYLPHENIDATE HCL TAB 10 MG","1","0","0","1","60 tabs every 25 days","","CENTRAL NERVOUS SYSTEM","ATTENTION DEFICIT HYPERACTIVITY DISORDER§"],["N","G","DEXMETHYLPH TAB 2.5MG","DEXMETHYLPHENIDATE HCL TAB 2.5 MG","1","0","0","1","120 tabs every 25 days","","CENTRAL NERVOUS SYSTEM","ATTENTION DEFICIT HYPERACTIVITY DISORDER§"],["N","G","DEXMETHYLPH TAB 5MG","DEXMETHYLPHENIDATE HCL TAB 5 MG","1","0","0","1","120 tabs every 25 days","","CENTRAL NERVOUS SYSTEM","ATTENTION DEFICIT HYPERACTIVITY DISORDER§"],["N","G","DEXMETHYLPHE CAP 10MG ER","DEXMETHYLPHENIDATE HCL CAP ER 24 HR 10 MG","1","0","0","1","60 caps every 25 days","","CENTRAL NERVOUS SYSTEM","ATTENTION DEFICIT HYPERACTIVITY DISORDER§"],["N","G","DEXMETHYLPHE CAP 20MG ER","DEXMETHYLPHENIDATE HCL CAP ER 24 HR 20 MG","1","0","0","1","60 caps every 25 days","","CENTRAL NERVOUS SYSTEM","ATTENTION DEFICIT HYPERACTIVITY DISORDER§"],["N","G","DEXMETHYLPHE CAP 5MG ER","DEXMETHYLPHENIDATE HCL CAP ER 24 HR 5 MG","1","0","0","1","60 caps every 25 days","","CENTRAL NERVOUS SYSTEM","ATTENTION DEFICIT HYPERACTIVITY DISORDER§"],["N","G","DEXMETHYLPHE CAP ER 25MG","DEXMETHYLPHENIDATE HCL CAP ER 24 HR 25 MG","1","0","0","1","30 caps every 25 days","","CENTRAL NERVOUS SYSTEM","ATTENTION DEFICIT HYPERACTIVITY DISORDER§"],["N","G","DEXMETHYLPHE CAP ER 35MG","DEXMETHYLPHENIDATE HCL CAP ER 24 HR 35 MG","1","0","0","1","30 caps every 25 days","","CENTRAL NERVOUS SYSTEM","ATTENTION DEFICIT HYPERACTIVITY DISORDER§"],["N","G","DEXTROAMPHET CAP 10MG ER","DEXTROAMPHETAMINE SULFATE CAP ER 24HR 10 MG","1","0","0","1","120 caps every 25 days","","CENTRAL NERVOUS SYSTEM","ATTENTION DEFICIT HYPERACTIVITY DISORDER§"],["N","G","DEXTROAMPHET CAP 15MG ER","DEXTROAMPHETAMINE SULFATE CAP ER 24HR 15 MG","1","0","0","1","60 caps every 25 days","","CENTRAL NERVOUS SYSTEM","ATTENTION DEFICIT HYPERACTIVITY DISORDER§"],["N","G","DEXTROAMPHET CAP 5MG ER","DEXTROAMPHETAMINE SULFATE CAP ER 24HR 5 MG","1","0","0","1","120 caps every 25 days","","CENTRAL NERVOUS SYSTEM","ATTENTION DEFICIT HYPERACTIVITY DISORDER§"],["N","G","DEXTROAMPHET SOL 5MG/5ML","DEXTROAMPHETAMINE SULFATE ORAL SOLUTION 5 MG/5ML","1","0","0","1","1,200 mL every 25 days","","CENTRAL NERVOUS SYSTEM","ATTENTION DEFICIT HYPERACTIVITY DISORDER§"],["N","G","DEXTROAMPHET TAB 10MG","DEXTROAMPHETAMINE SULFATE TAB 10 MG","1","0","0","1","120 tabs every 25 days","","CENTRAL NERVOUS SYSTEM","ATTENTION DEFICIT HYPERACTIVITY DISORDER§"],["N","G","DEXTROAMPHET TAB 5MG","DEXTROAMPHETAMINE SULFATE TAB 5 MG","1","0","0","1","120 tabs every 25 days","","CENTRAL NERVOUS SYSTEM","ATTENTION DEFICIT HYPERACTIVITY DISORDER§"],["N","G","GUANFACINE TAB 1MG ER","GUANFACINE HCL TAB ER 24HR 1 MG (BASE EQUIV)","1","0","1","0","","PA**","CENTRAL NERVOUS SYSTEM","ATTENTION DEFICIT HYPERACTIVITY DISORDER§"],["N","G","GUANFACINE TAB 2MG ER","GUANFACINE HCL TAB ER 24HR 2 MG (BASE EQUIV)","1","0","1","0","","PA**","CENTRAL NERVOUS SYSTEM","ATTENTION DEFICIT HYPERACTIVITY DISORDER§"],["N","G","GUANFACINE TAB 3MG ER","GUANFACINE HCL TAB ER 24HR 3 MG (BASE EQUIV)","1","0","1","0","","PA**","CENTRAL NERVOUS SYSTEM","ATTENTION DEFICIT HYPERACTIVITY DISORDER§"],["N","G","GUANFACINE TAB 4MG ER","GUANFACINE HCL TAB ER 24HR 4 MG (BASE EQUIV)","1","0","1","0","","PA**","CENTRAL NERVOUS SYSTEM","ATTENTION DEFICIT HYPERACTIVITY DISORDER§"],["N","G","METHAMPHETAM TAB 5MG","METHAMPHETAMINE HCL TAB 5 MG","1","0","0","1","150 tabs every 25 days","","CENTRAL NERVOUS SYSTEM","ATTENTION DEFICIT HYPERACTIVITY DISORDER§"],["N","G","METHLPHENIDA CHW 2.5MG","METHYLPHENIDATE HCL CHEW TAB 2.5 MG","1","0","0","1","180 chew tabs every 25 days","","CENTRAL NERVOUS SYSTEM","ATTENTION DEFICIT HYPERACTIVITY DISORDER§"],["N","G","METHYLPHENID CAP 10MG","METHYLPHENIDATE HCL CAP ER 10 MG (CD)","1","0","0","1","60 caps every 25 days","","CENTRAL NERVOUS SYSTEM","ATTENTION DEFICIT HYPERACTIVITY DISORDER§"],["N","G","METHYLPHENID CAP 20MG","METHYLPHENIDATE HCL CAP ER 20 MG (CD)","1","0","0","1","60 caps every 25 days","","CENTRAL NERVOUS SYSTEM","ATTENTION DEFICIT HYPERACTIVITY DISORDER§"],["N","G","METHYLPHENID CAP 20MG ER","METHYLPHENIDATE HCL CAP ER 24HR 20 MG (LA)","1","0","0","1","60 caps every 25 days","","CENTRAL NERVOUS SYSTEM","ATTENTION DEFICIT HYPERACTIVITY DISORDER§"],["N","G","METHYLPHENID CAP 30MG","METHYLPHENIDATE HCL CAP ER 30 MG (CD)","1","0","0","1","60 caps every 25 days","","CENTRAL NERVOUS SYSTEM","ATTENTION DEFICIT HYPERACTIVITY DISORDER§"],["N","G","METHYLPHENID CAP 30MG ER","METHYLPHENIDATE HCL CAP ER 24HR 30 MG (LA)","1","0","0","1","60 caps every 25 days","","CENTRAL NERVOUS SYSTEM","ATTENTION DEFICIT HYPERACTIVITY DISORDER§"],["N","G","METHYLPHENID CAP 40MG","METHYLPHENIDATE HCL CAP ER 40 MG (CD)","1","0","0","1","30 caps every 25 days","","CENTRAL NERVOUS SYSTEM","ATTENTION DEFICIT HYPERACTIVITY DISORDER§"],["N","G","METHYLPHENID CAP 40MG ER","METHYLPHENIDATE HCL CAP ER 24HR 40 MG (LA)","1","0","0","1","30 caps every 25 days","","CENTRAL NERVOUS SYSTEM","ATTENTION DEFICIT HYPERACTIVITY DISORDER§"],["N","G","METHYLPHENID CAP 50MG","METHYLPHENIDATE HCL CAP ER 50 MG (CD)","1","0","0","1","30 caps every 25 days","","CENTRAL NERVOUS SYSTEM","ATTENTION DEFICIT HYPERACTIVITY DISORDER§"],["N","G","METHYLPHENID CAP 60MG","METHYLPHENIDATE HCL CAP ER 60 MG (CD)","1","0","0","1","30 caps every 25 days","","CENTRAL NERVOUS SYSTEM","ATTENTION DEFICIT HYPERACTIVITY DISORDER§"],["N","G","METHYLPHENID CAP 60MG LA","METHYLPHENIDATE HCL CAP ER 24HR 60 MG (LA)","1","0","0","1","30 caps every 25 days","","CENTRAL NERVOUS SYSTEM","ATTENTION DEFICIT HYPERACTIVITY DISORDER§"],["N","G","METHYLPHENID CHW 10MG","METHYLPHENIDATE HCL CHEW TAB 10 MG","1","0","0","1","180 chew tabs every 25 days","","CENTRAL NERVOUS SYSTEM","ATTENTION DEFICIT HYPERACTIVITY DISORDER§"],["N","G","METHYLPHENID CHW 5MG","METHYLPHENIDATE HCL CHEW TAB 5 MG","1","0","0","1","180 chew tabs every 25 days","","CENTRAL NERVOUS SYSTEM","ATTENTION DEFICIT HYPERACTIVITY DISORDER§"],["N","G","METHYLPHENID SOL 10MG/5ML","METHYLPHENIDATE HCL SOLN 10 MG/5ML","1","0","0","1","900 mL every 25 days","","CENTRAL NERVOUS SYSTEM","ATTENTION DEFICIT HYPERACTIVITY DISORDER§"],["N","G","METHYLPHENID SOL 5MG/5ML","METHYLPHENIDATE HCL SOLN 5 MG/5ML","1","0","0","1","1800 mL every 25 days","","CENTRAL NERVOUS SYSTEM","ATTENTION DEFICIT HYPERACTIVITY DISORDER§"],["N","G","METHYLPHENID TAB 10MG","METHYLPHENIDATE HCL TAB 10 MG","1","0","0","1","180 tabs every 25 days","","CENTRAL NERVOUS SYSTEM","ATTENTION DEFICIT HYPERACTIVITY DISORDER§"],["N","G","METHYLPHENID TAB 10MG ER","METHYLPHENIDATE HCL TAB ER 10 MG","1","0","0","1","90 tabs every 25 days","","CENTRAL NERVOUS SYSTEM","ATTENTION DEFICIT HYPERACTIVITY DISORDER§"],["N","G","METHYLPHENID TAB 18MG ER","METHYLPHENIDATE HCL TAB ER OSMOTIC RELEASE (OSM) 18 MG","1","0","0","1","60 tabs every 25 days","","CENTRAL NERVOUS SYSTEM","ATTENTION DEFICIT HYPERACTIVITY DISORDER§"],["N","G","METHYLPHENID TAB 18MG ER","METHYLPHENIDATE HCL TAB ER 24HR 18 MG","1","0","0","1","60 tabs every 25 days","","CENTRAL NERVOUS SYSTEM","ATTENTION DEFICIT HYPERACTIVITY DISORDER§"],["N","G","METHYLPHENID TAB 20MG","METHYLPHENIDATE HCL TAB 20 MG","1","0","0","1","90 tabs every 25 days","","CENTRAL NERVOUS SYSTEM","ATTENTION DEFICIT HYPERACTIVITY DISORDER§"],["N","G","METHYLPHENID TAB 20MG ER","METHYLPHENIDATE HCL TAB ER 20 MG","1","0","0","1","90 tabs every 25 days","","CENTRAL NERVOUS SYSTEM","ATTENTION DEFICIT HYPERACTIVITY DISORDER§"],["N","G","METHYLPHENID TAB 27MG ER","METHYLPHENIDATE HCL TAB ER 24HR 27 MG","1","0","0","1","60 tabs every 25 days","","CENTRAL NERVOUS SYSTEM","ATTENTION DEFICIT HYPERACTIVITY DISORDER§"],["N","G","METHYLPHENID TAB 27MG ER","METHYLPHENIDATE HCL TAB ER OSMOTIC RELEASE (OSM) 27 MG","1","0","0","1","60 tabs every 25 days","","CENTRAL NERVOUS SYSTEM","ATTENTION DEFICIT HYPERACTIVITY DISORDER§"],["N","G","METHYLPHENID TAB 36MG ER","METHYLPHENIDATE HCL TAB ER OSMOTIC RELEASE (OSM) 36 MG","1","0","0","1","60 tabs every 25 days","","CENTRAL NERVOUS SYSTEM","ATTENTION DEFICIT HYPERACTIVITY DISORDER§"],["N","G","METHYLPHENID TAB 36MG ER","METHYLPHENIDATE HCL TAB ER 24HR 36 MG","1","0","0","1","60 tabs every 25 days","","CENTRAL NERVOUS SYSTEM","ATTENTION DEFICIT HYPERACTIVITY DISORDER§"],["N","G","METHYLPHENID TAB 54MG ER","METHYLPHENIDATE HCL TAB ER OSMOTIC RELEASE (OSM) 54 MG","1","0","0","1","30 tabs every 25 days","","CENTRAL NERVOUS SYSTEM","ATTENTION DEFICIT HYPERACTIVITY DISORDER§"],["N","G","METHYLPHENID TAB 54MG ER","METHYLPHENIDATE HCL TAB ER 24HR 54 MG","1","0","0","1","30 tabs every 25 days","","CENTRAL NERVOUS SYSTEM","ATTENTION DEFICIT HYPERACTIVITY DISORDER§"],["N","G","METHYLPHENID TAB 5MG","METHYLPHENIDATE HCL TAB 5 MG","1","0","0","1","180 tabs every 25 days","","CENTRAL NERVOUS SYSTEM","ATTENTION DEFICIT HYPERACTIVITY DISORDER§"],["N","G","VYVANSE CAP 10MG","LISDEXAMFETAMINE DIMESYLATE CAP 10 MG","2","0","0","0","","","CENTRAL NERVOUS SYSTEM","ATTENTION DEFICIT HYPERACTIVITY DISORDER§"],["N","G","VYVANSE CAP 20MG","LISDEXAMFETAMINE DIMESYLATE CAP 20 MG","2","0","0","0","","","CENTRAL NERVOUS SYSTEM","ATTENTION DEFICIT HYPERACTIVITY DISORDER§"],["N","G","VYVANSE CAP 30MG","LISDEXAMFETAMINE DIMESYLATE CAP 30 MG","2","0","0","0","","","CENTRAL NERVOUS SYSTEM","ATTENTION DEFICIT HYPERACTIVITY DISORDER§"],["N","G","VYVANSE CAP 40MG","LISDEXAMFETAMINE DIMESYLATE CAP 40 MG","2","0","0","0","","","CENTRAL NERVOUS SYSTEM","ATTENTION DEFICIT HYPERACTIVITY DISORDER§"],["N","G","VYVANSE CAP 50MG","LISDEXAMFETAMINE DIMESYLATE CAP 50 MG","2","0","0","0","","","CENTRAL NERVOUS SYSTEM","ATTENTION DEFICIT HYPERACTIVITY DISORDER§"],["N","G","VYVANSE CAP 60MG","LISDEXAMFETAMINE DIMESYLATE CAP 60 MG","2","0","0","0","","","CENTRAL NERVOUS SYSTEM","ATTENTION DEFICIT HYPERACTIVITY DISORDER§"],["N","G","VYVANSE CAP 70MG","LISDEXAMFETAMINE DIMESYLATE CAP 70 MG","2","0","0","0","","","CENTRAL NERVOUS SYSTEM","ATTENTION DEFICIT HYPERACTIVITY DISORDER§"],["N","G","VYVANSE CHW 10MG","LISDEXAMFETAMINE DIMESYLATE CHEW TAB 10 MG","2","0","0","0","","","CENTRAL NERVOUS SYSTEM","ATTENTION DEFICIT HYPERACTIVITY DISORDER§"],["N","G","VYVANSE CHW 20MG","LISDEXAMFETAMINE DIMESYLATE CHEW TAB 20 MG","2","0","0","0","","","CENTRAL NERVOUS SYSTEM","ATTENTION DEFICIT HYPERACTIVITY DISORDER§"],["N","G","VYVANSE CHW 30MG","LISDEXAMFETAMINE DIMESYLATE CHEW TAB 30 MG","2","0","0","0","","","CENTRAL NERVOUS SYSTEM","ATTENTION DEFICIT HYPERACTIVITY DISORDER§"],["N","G","VYVANSE CHW 40MG","LISDEXAMFETAMINE DIMESYLATE CHEW TAB 40 MG","2","0","0","0","","","CENTRAL NERVOUS SYSTEM","ATTENTION DEFICIT HYPERACTIVITY DISORDER§"],["N","G","VYVANSE CHW 50MG","LISDEXAMFETAMINE DIMESYLATE CHEW TAB 50 MG","2","0","0","0","","","CENTRAL NERVOUS SYSTEM","ATTENTION DEFICIT HYPERACTIVITY DISORDER§"],["N","G","VYVANSE CHW 60MG","LISDEXAMFETAMINE DIMESYLATE CHEW TAB 60 MG","2","0","0","0","","","CENTRAL NERVOUS SYSTEM","ATTENTION DEFICIT HYPERACTIVITY DISORDER§"],["N","G","ZENZEDI TAB 15MG","DEXTROAMPHETAMINE SULFATE TAB 15 MG","1","0","0","1","60 tabs every 25 days","","CENTRAL NERVOUS SYSTEM","ATTENTION DEFICIT HYPERACTIVITY DISORDER§"],["N","G","ZENZEDI TAB 2.5MG","DEXTROAMPHETAMINE SULFATE TAB 2.5 MG","1","0","0","1","120 tabs every 25 days","","CENTRAL NERVOUS SYSTEM","ATTENTION DEFICIT HYPERACTIVITY DISORDER§"],["N","G","ZENZEDI TAB 20MG","DEXTROAMPHETAMINE SULFATE TAB 20 MG","1","0","0","1","60 tabs every 25 days","","CENTRAL NERVOUS SYSTEM","ATTENTION DEFICIT HYPERACTIVITY DISORDER§"],["N","G","ZENZEDI TAB 30MG","DEXTROAMPHETAMINE SULFATE TAB 30 MG","1","0","0","1","30 tabs every 25 days","","CENTRAL NERVOUS SYSTEM","ATTENTION DEFICIT HYPERACTIVITY DISORDER§"],["N","G","ZENZEDI TAB 7.5MG","DEXTROAMPHETAMINE SULFATE TAB 7.5 MG","1","0","0","1","120 tabs every 25 days","","CENTRAL NERVOUS SYSTEM","ATTENTION DEFICIT HYPERACTIVITY DISORDER§"],["N","G","BELSOMRA TAB 10MG","SUVOREXANT TAB 10 MG","2","0","1","0","","PA**","CENTRAL NERVOUS SYSTEM","HYPNOTICS§"],["N","G","BELSOMRA TAB 15MG","SUVOREXANT TAB 15 MG","2","0","1","0","","PA**","CENTRAL NERVOUS SYSTEM","HYPNOTICS§"],["N","G","BELSOMRA TAB 20MG","SUVOREXANT TAB 20 MG","2","0","1","0","","PA**","CENTRAL NERVOUS SYSTEM","HYPNOTICS§"],["N","G","BELSOMRA TAB 5MG","SUVOREXANT TAB 5 MG","2","0","1","0","","PA**","CENTRAL NERVOUS SYSTEM","HYPNOTICS§"],["N","G","ESZOPICLONE TAB 1MG","ESZOPICLONE TAB 1 MG","1","0","0","1","15 tabs every 25 days","","CENTRAL NERVOUS SYSTEM","HYPNOTICS§"],["N","G","ESZOPICLONE TAB 2MG","ESZOPICLONE TAB 2 MG","1","0","0","1","15 tabs every 25 days","","CENTRAL NERVOUS SYSTEM","HYPNOTICS§"],["N","G","ESZOPICLONE TAB 3MG","ESZOPICLONE TAB 3 MG","1","0","0","1","15 tabs every 25 days","","CENTRAL NERVOUS SYSTEM","HYPNOTICS§"],["N","G","HETLIOZ CAP 20MG","TASIMELTEON CAPSULE 20 MG","4","1","0","1","30 caps every 30 days","SP","CENTRAL NERVOUS SYSTEM","HYPNOTICS§"],["N","G","RAMELTEON TAB 8MG","RAMELTEON TAB 8 MG","1","0","0","1","15 tabs every 25 days","","CENTRAL NERVOUS SYSTEM","HYPNOTICS§"],["N","G","ROZEREM TAB 8MG","RAMELTEON TAB 8 MG","3","0","1","1","15 tabs every 25 days","PA**","CENTRAL NERVOUS SYSTEM","HYPNOTICS§"],["N","G","SILENOR TAB 3MG","DOXEPIN HCL (SLEEP) TAB 3 MG (BASE EQUIV)","2","0","1","1","30 tabs every 25 days","QL applies to members age 65 and older; PA**","CENTRAL NERVOUS SYSTEM","HYPNOTICS§"],["N","G","SILENOR TAB 6MG","DOXEPIN HCL (SLEEP) TAB 6 MG (BASE EQUIV)","2","0","1","1","30 tabs every 25 days","QL applies to members age 65 and older; PA**","CENTRAL NERVOUS SYSTEM","HYPNOTICS§"],["N","G","SLEEP-AID TAB 25MG","DOXYLAMINE SUCCINATE (SLEEP) TAB 25 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","HYPNOTICS§"],["N","G","TEMAZEPAM CAP 15MG","TEMAZEPAM CAP 15 MG","1","0","0","1","15 caps every 25 days","","CENTRAL NERVOUS SYSTEM","HYPNOTICS§"],["N","G","TEMAZEPAM CAP 22.5MG","TEMAZEPAM CAP 22.5 MG","1","0","0","1","15 caps every 25 days","","CENTRAL NERVOUS SYSTEM","HYPNOTICS§"],["N","G","TEMAZEPAM CAP 30MG","TEMAZEPAM CAP 30 MG","1","0","0","1","15 caps every 25 days","","CENTRAL NERVOUS SYSTEM","HYPNOTICS§"],["N","G","TEMAZEPAM CAP 7.5MG","TEMAZEPAM CAP 7.5 MG","1","0","0","1","15 caps every 25 days","","CENTRAL NERVOUS SYSTEM","HYPNOTICS§"],["N","G","ZALEPLON CAP 10MG","ZALEPLON CAP 10 MG","1","0","0","1","15 caps every 25 days","","CENTRAL NERVOUS SYSTEM","HYPNOTICS§"],["N","G","ZALEPLON CAP 5MG","ZALEPLON CAP 5 MG","1","0","0","1","15 caps every 25 days","","CENTRAL NERVOUS SYSTEM","HYPNOTICS§"],["N","G","ZOLPIDEM ER TAB 12.5MG","ZOLPIDEM TARTRATE TAB ER 12.5 MG","1","0","0","1","15 tabs every 25 days","","CENTRAL NERVOUS SYSTEM","HYPNOTICS§"],["N","G","ZOLPIDEM ER TAB 6.25MG","ZOLPIDEM TARTRATE TAB ER 6.25 MG","1","0","0","1","15 tabs every 25 days","","CENTRAL NERVOUS SYSTEM","HYPNOTICS§"],["N","G","ZOLPIDEM TAB 10MG","ZOLPIDEM TARTRATE TAB 10 MG","1","0","0","1","15 tabs every 25 days","","CENTRAL NERVOUS SYSTEM","HYPNOTICS§"],["N","G","ZOLPIDEM TAB 5MG","ZOLPIDEM TARTRATE TAB 5 MG","1","0","0","1","15 tabs every 25 days","","CENTRAL NERVOUS SYSTEM","HYPNOTICS§"],["N","G","ALMOTRIPTAN TAB 12.5MG","ALMOTRIPTAN MALATE TAB 12.5 MG","1","0","0","1","12 tabs every 25 days","","CENTRAL NERVOUS SYSTEM","MIGRAINE§"],["N","G","ALMOTRIPTAN TAB 6.25MG","ALMOTRIPTAN MALATE TAB 6.25 MG","1","0","0","1","12 tabs every 25 days","","CENTRAL NERVOUS SYSTEM","MIGRAINE§"],["N","G","DIHYDROERGOT INJ 1MG/ML","DIHYDROERGOTAMINE MESYLATE INJ 1 MG/ML","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","MIGRAINE§"],["N","G","DIHYDROERGOT SPR 4MG/ML","DIHYDROERGOTAMINE MESYLATE NASAL SPRAY 4 MG/ML","1","0","0","1","8 units every 25 days","","CENTRAL NERVOUS SYSTEM","MIGRAINE§"],["N","G","ELETRIPTAN TAB 20MG","ELETRIPTAN HYDROBROMIDE TAB 20 MG (BASE EQUIVALENT)","1","0","0","1","12 tabs every 25 days","","CENTRAL NERVOUS SYSTEM","MIGRAINE§"],["N","G","ELETRIPTAN TAB 40MG","ELETRIPTAN HYDROBROMIDE TAB 40 MG (BASE EQUIVALENT)","1","0","0","1","12 tabs every 25 days","","CENTRAL NERVOUS SYSTEM","MIGRAINE§"],["N","G","ERGOT/CAFFEN TAB 1-100MG","ERGOTAMINE W/ CAFFEINE TAB 1-100 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","MIGRAINE§"],["N","G","FROVATRIPTAN TAB 2.5MG","FROVATRIPTAN SUCCINATE TAB 2.5 MG (BASE EQUIVALENT)","1","0","0","1","18 tabs every 25 days","","CENTRAL NERVOUS SYSTEM","MIGRAINE§"],["N","G","NARATRIPTAN TAB 1MG","NARATRIPTAN HCL TAB 1 MG (BASE EQUIV)","1","0","0","1","12 tabs every 25 days","","CENTRAL NERVOUS SYSTEM","MIGRAINE§"],["N","G","NARATRIPTAN TAB 2.5MG","NARATRIPTAN HCL TAB 2.5 MG (BASE EQUIV)","1","0","0","1","12 tabs every 25 days","","CENTRAL NERVOUS SYSTEM","MIGRAINE§"],["N","G","RIZATRIPTAN TAB 10MG","RIZATRIPTAN BENZOATE TAB 10 MG (BASE EQUIVALENT)","1","0","0","1","18 tabs every 25 days","","CENTRAL NERVOUS SYSTEM","MIGRAINE§"],["N","G","RIZATRIPTAN TAB 10MG ODT","RIZATRIPTAN BENZOATE ORAL DISINTEGRATING TAB 10 MG (BASE EQ)","1","0","0","1","18 tabs every 25 days","","CENTRAL NERVOUS SYSTEM","MIGRAINE§"],["N","G","RIZATRIPTAN TAB 5MG","RIZATRIPTAN BENZOATE TAB 5 MG (BASE EQUIVALENT)","1","0","0","1","18 tabs every 25 days","","CENTRAL NERVOUS SYSTEM","MIGRAINE§"],["N","G","RIZATRIPTAN TAB 5MG ODT","RIZATRIPTAN BENZOATE ORAL DISINTEGRATING TAB 5 MG (BASE EQ)","1","0","0","1","18 tabs every 25 days","","CENTRAL NERVOUS SYSTEM","MIGRAINE§"],["N","G","SUMATRIPTAN INJ 4MG/0.5","SUMATRIPTAN SUCCINATE SOLUTION CARTRIDGE 4 MG/0.5ML","1","0","0","1","18 syringes every 25 days","","CENTRAL NERVOUS SYSTEM","MIGRAINE§"],["N","G","SUMATRIPTAN INJ 4MG/0.5","SUMATRIPTAN SUCCINATE SOLUTION AUTO-INJECTOR 4 MG/0.5ML","1","0","0","1","18 syringes every 25 days","","CENTRAL NERVOUS SYSTEM","MIGRAINE§"],["N","G","SUMATRIPTAN INJ 6MG/0.5","SUMATRIPTAN SUCCINATE INJ 6 MG/0.5ML","1","0","0","1","12 vials every 25 days","","CENTRAL NERVOUS SYSTEM","MIGRAINE§"],["N","G","SUMATRIPTAN INJ 6MG/0.5","SUMATRIPTAN SUCCINATE SOLUTION CARTRIDGE 6 MG/0.5ML","1","0","0","1","12 units every 25 days","","CENTRAL NERVOUS SYSTEM","MIGRAINE§"],["N","G","SUMATRIPTAN INJ 6MG/0.5","SUMATRIPTAN SUCCINATE SOLUTION PREFILLED SYRINGE 6 MG/0.5ML","1","0","0","1","12 units every 25 days","","CENTRAL NERVOUS SYSTEM","MIGRAINE§"],["N","G","SUMATRIPTAN INJ 6MG/0.5","SUMATRIPTAN SUCCINATE SOLUTION AUTO-INJECTOR 6 MG/0.5ML","1","0","0","1","12 units every 25 days","","CENTRAL NERVOUS SYSTEM","MIGRAINE§"],["N","G","SUMATRIPTAN SPR 20MG/ACT","SUMATRIPTAN NASAL SPRAY 20 MG/ACT","1","0","0","1","12 sprays every 25 days","","CENTRAL NERVOUS SYSTEM","MIGRAINE§"],["N","G","SUMATRIPTAN SPR 5MG/ACT","SUMATRIPTAN NASAL SPRAY 5 MG/ACT","1","0","0","1","24 sprays every 25 days","","CENTRAL NERVOUS SYSTEM","MIGRAINE§"],["N","G","SUMATRIPTAN TAB 100MG","SUMATRIPTAN SUCCINATE TAB 100 MG","1","0","0","1","12 tabs every 25 days","","CENTRAL NERVOUS SYSTEM","MIGRAINE§"],["N","G","SUMATRIPTAN TAB 25MG","SUMATRIPTAN SUCCINATE TAB 25 MG","1","0","0","1","12 tabs every 25 days","","CENTRAL NERVOUS SYSTEM","MIGRAINE§"],["N","G","SUMATRIPTAN TAB 50MG","SUMATRIPTAN SUCCINATE TAB 50 MG","1","0","0","1","12 tabs every 25 days","","CENTRAL NERVOUS SYSTEM","MIGRAINE§"],["N","G","ZOLMITRIPTAN TAB 2.5 MG","ZOLMITRIPTAN ORALLY DISINTEGRATING TAB 2.5 MG","1","0","0","1","12 tabs every 25 days","","CENTRAL NERVOUS SYSTEM","MIGRAINE§"],["N","G","ZOLMITRIPTAN TAB 2.5MG","ZOLMITRIPTAN TAB 2.5 MG","1","0","0","1","12 tabs every 25 days","","CENTRAL NERVOUS SYSTEM","MIGRAINE§"],["N","G","ZOLMITRIPTAN TAB 5MG","ZOLMITRIPTAN TAB 5 MG","1","0","0","1","12 tabs every 25 days","","CENTRAL NERVOUS SYSTEM","MIGRAINE§"],["N","G","ZOLMITRIPTAN TAB 5MG ODT","ZOLMITRIPTAN ORALLY DISINTEGRATING TAB 5 MG","1","0","0","1","12 tabs every 25 days","","CENTRAL NERVOUS SYSTEM","MIGRAINE§"],["N","G","ZOMIG SPR 2.5MG","ZOLMITRIPTAN NASAL SPRAY 2.5 MG/SPRAY UNIT","3","0","0","1","12 sprays every 25 days","","CENTRAL NERVOUS SYSTEM","MIGRAINE§"],["N","G","ZOMIG SPR 5MG","ZOLMITRIPTAN NASAL SPRAY 5 MG/SPRAY UNIT","3","0","0","1","12 sprays every 25 days","","CENTRAL NERVOUS SYSTEM","MIGRAINE§"],["N","G","BUSPIRONE TAB 10MG","BUSPIRONE HCL TAB 10 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","MISCELLANEOUS"],["N","G","BUSPIRONE TAB 15MG","BUSPIRONE HCL TAB 15 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","MISCELLANEOUS"],["N","G","BUSPIRONE TAB 30MG","BUSPIRONE HCL TAB 30 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","MISCELLANEOUS"],["N","G","BUSPIRONE TAB 5MG","BUSPIRONE HCL TAB 5 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","MISCELLANEOUS"],["N","G","BUSPIRONE TAB 7.5MG","BUSPIRONE HCL TAB 7.5 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","MISCELLANEOUS"],["N","G","CLOMIPRAMINE CAP 25MG","CLOMIPRAMINE HCL CAP 25 MG","1","0","0","1","150 caps every 25 days","QL applies to members age 65 and older","CENTRAL NERVOUS SYSTEM","MISCELLANEOUS"],["N","G","CLOMIPRAMINE CAP 50MG","CLOMIPRAMINE HCL CAP 50 MG","1","0","0","1","150 caps every 25 days","QL applies to members age 65 and older","CENTRAL NERVOUS SYSTEM","MISCELLANEOUS"],["N","G","CLOMIPRAMINE CAP 75MG","CLOMIPRAMINE HCL CAP 75 MG","1","0","0","1","90 caps every 25 days","QL applies to members age 65 and older","CENTRAL NERVOUS SYSTEM","MISCELLANEOUS"],["N","G","FLUVOXAMINE CAP 100MG ER","FLUVOXAMINE MALEATE CAP ER 24HR 100 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","MISCELLANEOUS"],["N","G","FLUVOXAMINE CAP 150MG ER","FLUVOXAMINE MALEATE CAP ER 24HR 150 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","MISCELLANEOUS"],["N","G","FLUVOXAMINE TAB 100MG","FLUVOXAMINE MALEATE TAB 100 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","MISCELLANEOUS"],["N","G","FLUVOXAMINE TAB 25MG","FLUVOXAMINE MALEATE TAB 25 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","MISCELLANEOUS"],["N","G","FLUVOXAMINE TAB 50MG","FLUVOXAMINE MALEATE TAB 50 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","MISCELLANEOUS"],["N","G","GUANIDINE TAB 125MG","GUANIDINE HCL TAB 125 MG","3","0","0","0","","","CENTRAL NERVOUS SYSTEM","MISCELLANEOUS"],["N","G","LITHIUM CARB CAP 150MG","LITHIUM CARBONATE CAP 150 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","MISCELLANEOUS"],["N","G","LITHIUM CARB CAP 300MG","LITHIUM CARBONATE CAP 300 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","MISCELLANEOUS"],["N","G","LITHIUM CARB CAP 600MG","LITHIUM CARBONATE CAP 600 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","MISCELLANEOUS"],["N","G","LITHIUM CARB TAB 300MG","LITHIUM CARBONATE TAB 300 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","MISCELLANEOUS"],["N","G","LITHIUM CARB TAB 300MG ER","LITHIUM CARBONATE TAB ER 300 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","MISCELLANEOUS"],["N","G","LITHIUM CARB TAB 450MG ER","LITHIUM CARBONATE TAB ER 450 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","MISCELLANEOUS"],["N","G","LITHIUM SOL 8MEQ/5ML","LITHIUM ORAL SOLUTION 8 MEQ/5ML","3","0","0","0","","","CENTRAL NERVOUS SYSTEM","MISCELLANEOUS"],["N","G","NUEDEXTA CAP 20-10MG","DEXTROMETHORPHAN HBR-QUINIDINE SULFATE CAP 20-10 MG","2","1","0","0","","","CENTRAL NERVOUS SYSTEM","MISCELLANEOUS"],["N","G","PIMOZIDE TAB 1MG","PIMOZIDE TAB 1 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","MISCELLANEOUS"],["N","G","PIMOZIDE TAB 2MG","PIMOZIDE TAB 2 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","MISCELLANEOUS"],["N","G","PYRIDOSTIGM TAB 60MG","PYRIDOSTIGMINE BROMIDE TAB 60 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","MISCELLANEOUS"],["N","G","PYRIDOSTIGMI SOL 60MG/5ML","PYRIDOSTIGMINE BROMIDE ORAL SOLN 60 MG/5ML","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","MISCELLANEOUS"],["N","G","PYRIDOSTIGMI SOL 60MG/5ML","PYRIDOSTIGMINE BROMIDE ORAL SOLN 60 MG/5ML","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","MISCELLANEOUS"],["N","G","PYRIDOSTIGMI TAB ER 180MG","PYRIDOSTIGMINE BROMIDE TAB ER 180 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","MISCELLANEOUS"],["N","G","REGONOL INJ 5MG/ML","PYRIDOSTIGMINE BROMIDE IV SOLN 10 MG/2ML (5 MG/ML)","3","0","0","0","","","CENTRAL NERVOUS SYSTEM","MISCELLANEOUS"],["N","G","RILUZOLE TAB 50MG","RILUZOLE TAB 50 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","MISCELLANEOUS"],["N","G","SAVELLA MIS TITR PAK","MILNACIPRAN HCL TAB 12.5 MG (5) & 25 MG (8) & 50 MG (42) PAK","3","0","1","0","","PA**","CENTRAL NERVOUS SYSTEM","MISCELLANEOUS"],["N","G","SAVELLA TAB 100MG","MILNACIPRAN HCL TAB 100 MG","3","0","1","0","","PA**","CENTRAL NERVOUS SYSTEM","MISCELLANEOUS"],["N","G","SAVELLA TAB 12.5MG","MILNACIPRAN HCL TAB 12.5 MG","3","0","1","0","","PA**","CENTRAL NERVOUS SYSTEM","MISCELLANEOUS"],["N","G","SAVELLA TAB 25MG","MILNACIPRAN HCL TAB 25 MG","3","0","1","0","","PA**","CENTRAL NERVOUS SYSTEM","MISCELLANEOUS"],["N","G","SAVELLA TAB 50MG","MILNACIPRAN HCL TAB 50 MG","3","0","1","0","","PA**","CENTRAL NERVOUS SYSTEM","MISCELLANEOUS"],["N","G","TETRABENAZIN TAB 12.5MG","TETRABENAZINE TAB 12.5 MG","4","1","0","1","240 tabs every 30 days","SP","CENTRAL NERVOUS SYSTEM","MISCELLANEOUS"],["N","G","TETRABENAZIN TAB 25MG","TETRABENAZINE TAB 25 MG","4","1","0","1","120 tabs every 30 days","SP","CENTRAL NERVOUS SYSTEM","MISCELLANEOUS"],["N","G","AUBAGIO TAB 14MG","TERIFLUNOMIDE TAB 14 MG","4","1","0","1","30 tabs every 30 days","SP","CENTRAL NERVOUS SYSTEM","MULTIPLE SCLEROSIS AGENTS"],["N","G","AUBAGIO TAB 7MG","TERIFLUNOMIDE TAB 7 MG","4","1","0","1","30 tabs every 30 days","SP","CENTRAL NERVOUS SYSTEM","MULTIPLE SCLEROSIS AGENTS"],["N","G","AVONEX KIT 30MCG","INTERFERON BETA-1A FOR IM INJ KIT 30MCG (33MCG(6.6 MU)/VIAL)","4","1","1","1","4 injections every 28 days","SP","CENTRAL NERVOUS SYSTEM","MULTIPLE SCLEROSIS AGENTS"],["N","G","AVONEX PEN KIT 30MCG","INTERFERON BETA-1A IM AUTO-INJECTOR KIT 30 MCG/0.5ML","4","1","1","1","4 injections every 28 days","SP","CENTRAL NERVOUS SYSTEM","MULTIPLE SCLEROSIS AGENTS"],["N","G","AVONEX PREFL KIT 30MCG","INTERFERON BETA-1A IM PREFILLED SYRINGE KIT 30 MCG/0.5ML","4","1","1","1","4 injections every 28 days","SP","CENTRAL NERVOUS SYSTEM","MULTIPLE SCLEROSIS AGENTS"],["N","G","BETASERON INJ 0.3MG","INTERFERON BETA-1B FOR INJ KIT 0.3 MG","4","1","0","1","14 injections every 28 days","SP","CENTRAL NERVOUS SYSTEM","MULTIPLE SCLEROSIS AGENTS"],["N","G","COPAXONE INJ 20MG/ML","GLATIRAMER ACETATE SOLN PREFILLED SYRINGE 20 MG/ML","4","1","0","1","30 injections every 30 days","SP","CENTRAL NERVOUS SYSTEM","MULTIPLE SCLEROSIS AGENTS"],["N","G","COPAXONE INJ 40MG/ML","GLATIRAMER ACETATE SOLN PREFILLED SYRINGE 40 MG/ML","4","1","0","1","12 syringes every 28 days","SP","CENTRAL NERVOUS SYSTEM","MULTIPLE SCLEROSIS AGENTS"],["N","G","DALFAMPRIDIN TAB 10MG ER","DALFAMPRIDINE TAB ER 12HR 10 MG","4","1","0","1","60 tabs every 30 days","SP","CENTRAL NERVOUS SYSTEM","MULTIPLE SCLEROSIS AGENTS"],["N","G","GILENYA CAP 0.5MG","FINGOLIMOD HCL CAP 0.5 MG (BASE EQUIV)","4","1","0","1","30 caps every 30 days","SP","CENTRAL NERVOUS SYSTEM","MULTIPLE SCLEROSIS AGENTS"],["N","G","GLATIRAMER INJ 40MG/ML","GLATIRAMER ACETATE SOLN PREFILLED SYRINGE 40 MG/ML","2","1","0","1","12 syringes every 28 days","SP","CENTRAL NERVOUS SYSTEM","MULTIPLE SCLEROSIS AGENTS"],["N","G","GLATOPA INJ 20MG/ML","GLATIRAMER ACETATE SOLN PREFILLED SYRINGE 20 MG/ML","2","1","0","1","30 injections every 30 days","SP","CENTRAL NERVOUS SYSTEM","MULTIPLE SCLEROSIS AGENTS"],["N","G","PLEGRIDY INJ","PEGINTERFERON BETA-1A SOLN PREFILLED SYRINGE 125 MCG/0.5ML","4","1","1","1","1 carton every 28 days","SP","CENTRAL NERVOUS SYSTEM","MULTIPLE SCLEROSIS AGENTS"],["N","G","PLEGRIDY INJ PEN","PEGINTERFERON BETA-1A SOLN PEN-INJECTOR 125 MCG/0.5ML","4","1","1","1","1 carton every 28 days","SP","CENTRAL NERVOUS SYSTEM","MULTIPLE SCLEROSIS AGENTS"],["N","G","PLEGRIDY INJ STARTER","PEGINTERFERON BETA-1A SOLN PREF SYR 63 & 94 MCG/0.5ML PACK","4","1","1","1","1 kit every 28 days","SP","CENTRAL NERVOUS SYSTEM","MULTIPLE SCLEROSIS AGENTS"],["N","G","PLEGRIDY PEN INJ STARTER","PEGINTERFERON BETA-1A SOLN PEN-INJ 63 & 94 MCG/0.5ML PACK","4","1","1","1","1 pack every 28 days","SP","CENTRAL NERVOUS SYSTEM","MULTIPLE SCLEROSIS AGENTS"],["N","G","REBIF INJ 22/0.5","INTERFERON BETA-1A SOLN PREF SYR 22 MCG/0.5ML (12MU/ML)","4","1","0","1","12 syringes every 28 days","SP","CENTRAL NERVOUS SYSTEM","MULTIPLE SCLEROSIS AGENTS"],["N","G","REBIF INJ 44/0.5","INTERFERON BETA-1A SOLN PREF SYR 44 MCG/0.5ML (24MU/ML)","4","1","0","1","12 syringes every 28 days","SP","CENTRAL NERVOUS SYSTEM","MULTIPLE SCLEROSIS AGENTS"],["N","G","REBIF REBIDO INJ 22/0.5","INTERFERON BETA-1A SOLN AUTO-INJ 22 MCG/0.5ML (12MU/ML)","4","1","0","1","12 syringes every 28 days","SP","CENTRAL NERVOUS SYSTEM","MULTIPLE SCLEROSIS AGENTS"],["N","G","REBIF REBIDO INJ 44/0.5","INTERFERON BETA-1A SOLN AUTO-INJ 44 MCG/0.5ML (24MU/ML)","4","1","0","1","12 syringes every 28 days","SP","CENTRAL NERVOUS SYSTEM","MULTIPLE SCLEROSIS AGENTS"],["N","G","REBIF REBIDO INJ TITRATN","INTERFERON BETA-1A AUTO-INJ 6X8.8 MCG/0.2ML & 6X22 MCG/0.5ML","4","1","0","1","1 box every 28 days","SP","CENTRAL NERVOUS SYSTEM","MULTIPLE SCLEROSIS AGENTS"],["N","G","REBIF TITRTN INJ PACK","INTERFERON BETA-1A PREF SYR 6X8.8 MCG/0.2ML & 6X22 MCG/0.5ML","4","1","0","1","1 box every 28 days","SP","CENTRAL NERVOUS SYSTEM","MULTIPLE SCLEROSIS AGENTS"],["N","G","TECFIDERA CAP 120MG","DIMETHYL FUMARATE CAPSULE DELAYED RELEASE 120 MG","4","1","0","1","14 caps every 28 days","SP","CENTRAL NERVOUS SYSTEM","MULTIPLE SCLEROSIS AGENTS"],["N","G","TECFIDERA CAP 240MG","DIMETHYL FUMARATE CAPSULE DELAYED RELEASE 240 MG","4","1","0","1","60 caps every 30 days","SP","CENTRAL NERVOUS SYSTEM","MULTIPLE SCLEROSIS AGENTS"],["N","G","TECFIDERA MIS STARTER","DIMETHYL FUMARATE CAPSULE DR STARTER PACK 120 MG & 240 MG","4","1","0","1","1 kit every 30 days","SP","CENTRAL NERVOUS SYSTEM","MULTIPLE SCLEROSIS AGENTS"],["N","G","TYSABRI INJ 300/15ML","NATALIZUMAB FOR IV INJ CONC 300 MG/15ML","4","1","0","1","1 vial every 28 days","SP","CENTRAL NERVOUS SYSTEM","MULTIPLE SCLEROSIS AGENTS"],["N","G","BACLOFEN TAB 10MG","BACLOFEN TAB 10 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","MUSCULOSKELETAL THERAPY AGENTS"],["N","G","BACLOFEN TAB 20MG","BACLOFEN TAB 20 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","MUSCULOSKELETAL THERAPY AGENTS"],["N","G","BACLOFEN TAB 5MG","BACLOFEN TAB 5 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","MUSCULOSKELETAL THERAPY AGENTS"],["N","G","CARISOPRODOL TAB 250MG","CARISOPRODOL TAB 250 MG","1","1","0","0","","High Risk Medications require PA for members age 70 and older","CENTRAL NERVOUS SYSTEM","MUSCULOSKELETAL THERAPY AGENTS"],["N","G","CARISOPRODOL TAB 350MG","CARISOPRODOL TAB 350 MG","1","1","0","0","","High Risk Medications require PA for members age 70 and older","CENTRAL NERVOUS SYSTEM","MUSCULOSKELETAL THERAPY AGENTS"],["N","G","CHLORZOXAZON TAB 500MG","CHLORZOXAZONE TAB 500 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","MUSCULOSKELETAL THERAPY AGENTS"],["N","G","CYCLOBENZAPR TAB 10MG","CYCLOBENZAPRINE HCL TAB 10 MG","1","1","0","0","","High Risk Medications require PA for members age 70 and older","CENTRAL NERVOUS SYSTEM","MUSCULOSKELETAL THERAPY AGENTS"],["N","G","CYCLOBENZAPR TAB 5MG","CYCLOBENZAPRINE HCL TAB 5 MG","1","1","0","0","","High Risk Medications require PA for members age 70 and older","CENTRAL NERVOUS SYSTEM","MUSCULOSKELETAL THERAPY AGENTS"],["N","G","CYCLOBENZAPR TAB 7.5MG","CYCLOBENZAPRINE HCL TAB 7.5 MG","1","1","0","0","","High Risk Medications require PA for members age 70 and older","CENTRAL NERVOUS SYSTEM","MUSCULOSKELETAL THERAPY AGENTS"],["N","G","DANTROLENE CAP 100MG","DANTROLENE SODIUM CAP 100 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","MUSCULOSKELETAL THERAPY AGENTS"],["N","G","DANTROLENE CAP 25MG","DANTROLENE SODIUM CAP 25 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","MUSCULOSKELETAL THERAPY AGENTS"],["N","G","DANTROLENE CAP 50MG","DANTROLENE SODIUM CAP 50 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","MUSCULOSKELETAL THERAPY AGENTS"],["N","G","METAXALONE TAB 400MG","METAXALONE TAB 400 MG","1","1","0","0","","High Risk Medications require PA for members age 70 and older","CENTRAL NERVOUS SYSTEM","MUSCULOSKELETAL THERAPY AGENTS"],["N","G","METAXALONE TAB 800MG","METAXALONE TAB 800 MG","1","1","0","0","","High Risk Medications require PA for members age 70 and older","CENTRAL NERVOUS SYSTEM","MUSCULOSKELETAL THERAPY AGENTS"],["N","G","METHOCARBAM TAB 500MG","METHOCARBAMOL TAB 500 MG","1","1","0","0","","High Risk Medications require PA for members age 70 and older","CENTRAL NERVOUS SYSTEM","MUSCULOSKELETAL THERAPY AGENTS"],["N","G","METHOCARBAM TAB 750MG","METHOCARBAMOL TAB 750 MG","1","1","0","0","","High Risk Medications require PA for members age 70 and older","CENTRAL NERVOUS SYSTEM","MUSCULOSKELETAL THERAPY AGENTS"],["N","G","ORPHENADRINE INJ 30MG/ML","ORPHENADRINE CITRATE INJ 30 MG/ML","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","MUSCULOSKELETAL THERAPY AGENTS"],["N","G","ORPHENADRINE TAB 100MG ER","ORPHENADRINE CITRATE TAB ER 12HR 100 MG","1","1","0","0","","High Risk Medications require PA for members age 70 and older","CENTRAL NERVOUS SYSTEM","MUSCULOSKELETAL THERAPY AGENTS"],["N","G","TIZANIDINE TAB 2MG","TIZANIDINE HCL TAB 2 MG (BASE EQUIVALENT)","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","MUSCULOSKELETAL THERAPY AGENTS"],["N","G","TIZANIDINE TAB 4MG","TIZANIDINE HCL TAB 4 MG (BASE EQUIVALENT)","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","MUSCULOSKELETAL THERAPY AGENTS"],["N","G","ARMODAFINIL TAB 150MG","ARMODAFINIL TAB 150 MG","1","1","0","0","","","CENTRAL NERVOUS SYSTEM","NARCOLEPSY/CATAPLEXY"],["N","G","ARMODAFINIL TAB 200MG","ARMODAFINIL TAB 200 MG","1","1","0","0","","","CENTRAL NERVOUS SYSTEM","NARCOLEPSY/CATAPLEXY"],["N","G","ARMODAFINIL TAB 250MG","ARMODAFINIL TAB 250 MG","1","1","0","0","","","CENTRAL NERVOUS SYSTEM","NARCOLEPSY/CATAPLEXY"],["N","G","ARMODAFINIL TAB 50MG","ARMODAFINIL TAB 50 MG","1","1","0","0","","","CENTRAL NERVOUS SYSTEM","NARCOLEPSY/CATAPLEXY"],["N","G","MODAFINIL TAB 100MG","MODAFINIL TAB 100 MG","1","1","0","0","","","CENTRAL NERVOUS SYSTEM","NARCOLEPSY/CATAPLEXY"],["N","G","MODAFINIL TAB 200MG","MODAFINIL TAB 200 MG","1","1","0","0","","","CENTRAL NERVOUS SYSTEM","NARCOLEPSY/CATAPLEXY"],["N","G","XYREM SOL 500MG/ML","SODIUM OXYBATE ORAL SOLUTION 500 MG/ML","4","1","0","0","","","CENTRAL NERVOUS SYSTEM","NARCOLEPSY/CATAPLEXY"],["N","G","ACAMPRO CAL TAB 333MG","ACAMPROSATE CALCIUM TAB DELAYED RELEASE 333 MG","1","1","0","0","","","CENTRAL NERVOUS SYSTEM","PSYCHOTHERAPEUTIC-MISC"],["N","G","BUPROPION TAB 150MG SR","BUPROPION HCL (SMOKING DETERRENT) TAB ER 12HR 150 MG","0","0","0","0","","$0 limited to 2 treatment cycles/year","CENTRAL NERVOUS SYSTEM","PSYCHOTHERAPEUTIC-MISC"],["N","G","CHANTIX PAK 0.5& 1MG","VARENICLINE TARTRATE TAB 0.5 MG X 11 & TAB 1 MG X 42 PACK","0","0","0","0","","$0 limited to 2 treatment cycles/year","CENTRAL NERVOUS SYSTEM","PSYCHOTHERAPEUTIC-MISC"],["N","G","CHANTIX PAK 1MG","VARENICLINE TARTRATE TAB 1 MG (BASE EQUIV)","0","0","0","0","","$0 limited to 2 treatment cycles/year","CENTRAL NERVOUS SYSTEM","PSYCHOTHERAPEUTIC-MISC"],["N","G","CHANTIX TAB 0.5MG","VARENICLINE TARTRATE TAB 0.5 MG (BASE EQUIV)","0","0","0","0","","$0 limited to 2 treatment cycles/year","CENTRAL NERVOUS SYSTEM","PSYCHOTHERAPEUTIC-MISC"],["N","G","CHANTIX TAB 1MG","VARENICLINE TARTRATE TAB 1 MG (BASE EQUIV)","0","0","0","0","","$0 limited to 2 treatment cycles/year","CENTRAL NERVOUS SYSTEM","PSYCHOTHERAPEUTIC-MISC"],["N","G","DISULFIRAM TAB 250MG","DISULFIRAM TAB 250 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","PSYCHOTHERAPEUTIC-MISC"],["N","G","DISULFIRAM TAB 500MG","DISULFIRAM TAB 500 MG","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","PSYCHOTHERAPEUTIC-MISC"],["N","G","NALOXONE INJ 0.4MG/ML","NALOXONE HCL SOLN CARTRIDGE 0.4 MG/ML","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","PSYCHOTHERAPEUTIC-MISC"],["N","G","NALOXONE INJ 0.4MG/ML","NALOXONE HCL INJ 4 MG/10ML","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","PSYCHOTHERAPEUTIC-MISC"],["N","G","NALOXONE INJ 0.4MG/ML","NALOXONE HCL INJ 0.4 MG/ML","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","PSYCHOTHERAPEUTIC-MISC"],["N","G","NALOXONE INJ 1MG/ML","NALOXONE HCL SOLN PREFILLED SYRINGE 2 MG/2ML","1","0","0","0","","","CENTRAL NERVOUS SYSTEM","PSYCHOTHERAPEUTIC-MISC"],["N","G","NALTREXONE TAB 50MG","NALTREXONE HCL TAB 50 MG","0","0","0","0","","$0 copay","CENTRAL NERVOUS SYSTEM","PSYCHOTHERAPEUTIC-MISC"],["N","G","NARCAN SPR","NALOXONE HCL NASAL SPRAY 4 MG/0.1ML","2","0","0","0","","","CENTRAL NERVOUS SYSTEM","PSYCHOTHERAPEUTIC-MISC"],["N","G","NICORELIEF GUM 4MG MINT","NICOTINE POLACRILEX GUM 4 MG","0","0","0","0","","$0 limited to 2 treatment cycles/year","CENTRAL NERVOUS SYSTEM","PSYCHOTHERAPEUTIC-MISC"],["N","G","NICOTINE DIS 14MG/24H","NICOTINE TD PATCH 24HR 14 MG/24HR","0","0","0","0","","$0 limited to 2 treatment cycles/year","CENTRAL NERVOUS SYSTEM","PSYCHOTHERAPEUTIC-MISC"],["N","G","NICOTINE DIS 21MG/24H","NICOTINE TD PATCH 24HR 21 MG/24HR","0","0","0","0","","$0 limited to 2 treatment cycles/year","CENTRAL NERVOUS SYSTEM","PSYCHOTHERAPEUTIC-MISC"],["N","G","NICOTINE DIS 7MG/24HR","NICOTINE TD PATCH 24HR 7 MG/24HR","0","0","0","0","","$0 limited to 2 treatment cycles/year","CENTRAL NERVOUS SYSTEM","PSYCHOTHERAPEUTIC-MISC"],["N","G","NICOTINE GUM 4MG","NICOTINE POLACRILEX GUM 4 MG","0","0","0","0","","$0 limited to 2 treatment cycles/year","CENTRAL NERVOUS SYSTEM","PSYCHOTHERAPEUTIC-MISC"],["N","G","NICOTINE LOZ 2MG MINT","NICOTINE POLACRILEX LOZENGE 2 MG","0","0","0","0","","$0 limited to 2 treatment cycles/year","CENTRAL NERVOUS SYSTEM","PSYCHOTHERAPEUTIC-MISC"],["N","G","NICOTINE POL GUM 2MG","NICOTINE POLACRILEX GUM 2 MG","0","0","0","0","","$0 limited to 2 treatment cycles/year","CENTRAL NERVOUS SYSTEM","PSYCHOTHERAPEUTIC-MISC"],["N","G","NICOTINE POL LOZ 4MG MINT","NICOTINE POLACRILEX LOZENGE 4 MG","0","0","0","0","","$0 limited to 2 treatment cycles/year","CENTRAL NERVOUS SYSTEM","PSYCHOTHERAPEUTIC-MISC"],["N","G","NICOTINE TD DIS 14MG/24H","NICOTINE TD PATCH 24HR 14 MG/24HR","0","0","0","0","","$0 limited to 2 treatment cycles/year","CENTRAL NERVOUS SYSTEM","PSYCHOTHERAPEUTIC-MISC"],["N","G","NICOTINE TD DIS 21MG/24H","NICOTINE TD PATCH 24HR 21 MG/24HR","0","0","0","0","","$0 limited to 2 treatment cycles/year","CENTRAL NERVOUS SYSTEM","PSYCHOTHERAPEUTIC-MISC"],["N","G","NICOTINE TD DIS 7MG/24HR","NICOTINE TD PATCH 24HR 7 MG/24HR","0","0","0","0","","$0 limited to 2 treatment cycles/year","CENTRAL NERVOUS SYSTEM","PSYCHOTHERAPEUTIC-MISC"],["N","G","NICOTROL INH","NICOTINE INHALER SYSTEM 10 MG (4 MG DELIVERED)","0","0","0","1","max 168 days every year","$0 limited to 2 treatment cycles/year","CENTRAL NERVOUS SYSTEM","PSYCHOTHERAPEUTIC-MISC"],["N","G","NICOTROL NS SPR 10MG/ML","NICOTINE NASAL SPRAY 10 MG/ML (0.5 MG/SPRAY)","0","0","0","1","max 168 days every year","$0 limited to 2 treatment cycles/year","CENTRAL NERVOUS SYSTEM","PSYCHOTHERAPEUTIC-MISC"],["N","G","SM NICOTINE DIS 14MG/24H","NICOTINE TD PATCH 24HR 14 MG/24HR","0","0","0","0","","$0 limited to 2 treatment cycles/year","CENTRAL NERVOUS SYSTEM","PSYCHOTHERAPEUTIC-MISC"],["N","G","SM NICOTINE DIS 21MG","NICOTINE TD PATCH 24HR 21 MG/24HR","0","0","0","0","","$0 limited to 2 treatment cycles/year","CENTRAL NERVOUS SYSTEM","PSYCHOTHERAPEUTIC-MISC"],["N","G","SM NICOTINE DIS 7MG/24HR","NICOTINE TD PATCH 24HR 7 MG/24HR","0","0","0","0","","$0 limited to 2 treatment cycles/year","CENTRAL NERVOUS SYSTEM","PSYCHOTHERAPEUTIC-MISC"],["N","G","VIVITROL INJ 380MG","NALTREXONE FOR IM EXTENDED RELEASE SUSP 380 MG","4","1","0","1","1 vial every 30 days","SP","CENTRAL NERVOUS SYSTEM","PSYCHOTHERAPEUTIC-MISC"],["N","G","INTRAROSA SUP 6.5MG","PRASTERONE VAGINAL INSERT 6.5 MG","3","0","0","0","","","ENDOCRINE AND METABOLIC","ANDROGENS"],["N","G","METHYLTESTOS CAP 10MG","METHYLTESTOSTERONE CAP 10 MG","1","1","0","0","","","ENDOCRINE AND METABOLIC","ANDROGENS"],["N","G","TESTOST CYP INJ 100MG/ML","TESTOSTERONE CYPIONATE IM INJ IN OIL 100 MG/ML","1","1","0","0","","","ENDOCRINE AND METABOLIC","ANDROGENS"],["N","G","TESTOST CYP INJ 200MG/ML","TESTOSTERONE CYPIONATE IM INJ IN OIL 200 MG/ML","1","1","0","0","","","ENDOCRINE AND METABOLIC","ANDROGENS"],["N","G","TESTOST ENAN INJ 200MG/ML","TESTOSTERONE ENANTHATE IM INJ IN OIL 200 MG/ML","1","1","0","0","","","ENDOCRINE AND METABOLIC","ANDROGENS"],["N","G","TESTOSTERONE GEL 1%(25MG)","TESTOSTERONE TD GEL 25 MG/2.5GM (1%)","1","1","0","0","","","ENDOCRINE AND METABOLIC","ANDROGENS"],["N","G","TESTOSTERONE GEL 10MG/ACT","TESTOSTERONE TD GEL 10MG/ACT (2%)","1","1","0","0","","","ENDOCRINE AND METABOLIC","ANDROGENS"],["N","G","ACARBOSE TAB 100MG","ACARBOSE TAB 100 MG","1","0","0","0","","","ENDOCRINE AND METABOLIC","ANTIDIABETICS, ALPHA-GLUCOSIDASE INHIBITORS"],["N","G","ACARBOSE TAB 25MG","ACARBOSE TAB 25 MG","1","0","0","0","","","ENDOCRINE AND METABOLIC","ANTIDIABETICS, ALPHA-GLUCOSIDASE INHIBITORS"],["N","G","ACARBOSE TAB 50MG","ACARBOSE TAB 50 MG","1","0","0","0","","","ENDOCRINE AND METABOLIC","ANTIDIABETICS, ALPHA-GLUCOSIDASE INHIBITORS"],["N","G","MIGLITOL TAB 100MG","MIGLITOL TAB 100 MG","1","0","0","0","","","ENDOCRINE AND METABOLIC","ANTIDIABETICS, ALPHA-GLUCOSIDASE INHIBITORS"],["N","G","MIGLITOL TAB 25MG","MIGLITOL TAB 25 MG","1","0","0","0","","","ENDOCRINE AND METABOLIC","ANTIDIABETICS, ALPHA-GLUCOSIDASE INHIBITORS"],["N","G","MIGLITOL TAB 50MG","MIGLITOL TAB 50 MG","1","0","0","0","","","ENDOCRINE AND METABOLIC","ANTIDIABETICS, ALPHA-GLUCOSIDASE INHIBITORS"],["N","G","SYMLINPEN 60 INJ 1000MCG","PRAMLINTIDE ACETATE PEN-INJ 1500 MCG/1.5ML (1000 MCG/ML)","3","0","1","0","","PA**","ENDOCRINE AND METABOLIC","ANTIDIABETICS, AMYLIN ANALOGS"],["N","G","SYMLNPEN 120 INJ 1000MCG","PRAMLINTIDE ACETATE PEN-INJ 2700 MCG/2.7ML (1000 MCG/ML)","3","0","1","0","","PA**","ENDOCRINE AND METABOLIC","ANTIDIABETICS, AMYLIN ANALOGS"],["N","G","METFORMIN TAB 1000MG","METFORMIN HCL TAB 1000 MG","1","0","0","0","","","ENDOCRINE AND METABOLIC","ANTIDIABETICS, BIGUANIDE"],["N","G","METFORMIN TAB 500MG","METFORMIN HCL TAB 500 MG","1","0","0","0","","","ENDOCRINE AND METABOLIC","ANTIDIABETICS, BIGUANIDE"],["N","G","METFORMIN TAB 500MG ER","METFORMIN HCL TAB ER 24HR 500 MG","1","0","0","0","","","ENDOCRINE AND METABOLIC","ANTIDIABETICS, BIGUANIDE"],["N","G","METFORMIN TAB 750MG ER","METFORMIN HCL TAB ER 24HR 750 MG","1","0","0","0","","","ENDOCRINE AND METABOLIC","ANTIDIABETICS, BIGUANIDE"],["N","G","METFORMIN TAB 850MG","METFORMIN HCL TAB 850 MG","1","0","0","0","","","ENDOCRINE AND METABOLIC","ANTIDIABETICS, BIGUANIDE"],["N","G","GLIP/METFORM TAB 2.5-250M","GLIPIZIDE-METFORMIN HCL TAB 2.5-250 MG","1","0","0","0","","","ENDOCRINE AND METABOLIC","ANTIDIABETICS, BIGUANIDE/ SULFONYLUREA COMBINATIONS"],["N","G","GLIP/METFORM TAB 2.5-500M","GLIPIZIDE-METFORMIN HCL TAB 2.5-500 MG","1","0","0","0","","","ENDOCRINE AND METABOLIC","ANTIDIABETICS, BIGUANIDE/ SULFONYLUREA COMBINATIONS"],["N","G","GLIP/METFORM TAB 5-500MG","GLIPIZIDE-METFORMIN HCL TAB 5-500 MG","1","0","0","0","","","ENDOCRINE AND METABOLIC","ANTIDIABETICS, BIGUANIDE/ SULFONYLUREA COMBINATIONS"],["N","G","GLYB/METFORM TAB 1.25-250","GLYBURIDE-METFORMIN TAB 1.25-250 MG","1","1","0","0","","High Risk Medications require PA for members age 70 and older","ENDOCRINE AND METABOLIC","ANTIDIABETICS, BIGUANIDE/ SULFONYLUREA COMBINATIONS"],["N","G","GLYB/METFORM TAB 2.5-500","GLYBURIDE-METFORMIN TAB 2.5-500 MG","1","1","0","0","","High Risk Medications require PA for members age 70 and older","ENDOCRINE AND METABOLIC","ANTIDIABETICS, BIGUANIDE/ SULFONYLUREA COMBINATIONS"],["N","G","GLYB/METFORM TAB 5-500MG","GLYBURIDE-METFORMIN TAB 5-500 MG","1","1","0","0","","High Risk Medications require PA for members age 70 and older","ENDOCRINE AND METABOLIC","ANTIDIABETICS, BIGUANIDE/ SULFONYLUREA COMBINATIONS"],["N","G","ALOGLIPTIN TAB 12.5MG","ALOGLIPTIN BENZOATE TAB 12.5 MG (BASE EQUIV)","1","0","0","0","","","ENDOCRINE AND METABOLIC","ANTIDIABETICS, DIPEPTIDYL PEPTIDASE-4 INHIBITORS"],["N","G","ALOGLIPTIN TAB 25MG","ALOGLIPTIN BENZOATE TAB 25 MG (BASE EQUIV)","1","0","0","0","","","ENDOCRINE AND METABOLIC","ANTIDIABETICS, DIPEPTIDYL PEPTIDASE-4 INHIBITORS"],["N","G","ALOGLIPTIN TAB 6.25MG","ALOGLIPTIN BENZOATE TAB 6.25 MG (BASE EQUIV)","1","0","0","0","","","ENDOCRINE AND METABOLIC","ANTIDIABETICS, DIPEPTIDYL PEPTIDASE-4 INHIBITORS"],["N","G","JANUVIA TAB 100MG","SITAGLIPTIN PHOSPHATE TAB 100 MG (BASE EQUIV)","2","0","1","0","","PA**","ENDOCRINE AND METABOLIC","ANTIDIABETICS, DIPEPTIDYL PEPTIDASE-4 INHIBITORS"],["N","G","JANUVIA TAB 25MG","SITAGLIPTIN PHOSPHATE TAB 25 MG (BASE EQUIV)","2","0","1","0","","PA**","ENDOCRINE AND METABOLIC","ANTIDIABETICS, DIPEPTIDYL PEPTIDASE-4 INHIBITORS"],["N","G","JANUVIA TAB 50MG","SITAGLIPTIN PHOSPHATE TAB 50 MG (BASE EQUIV)","2","0","1","0","","PA**","ENDOCRINE AND METABOLIC","ANTIDIABETICS, DIPEPTIDYL PEPTIDASE-4 INHIBITORS"],["N","G","TRADJENTA TAB 5MG","LINAGLIPTIN TAB 5 MG","2","0","1","0","","PA**","ENDOCRINE AND METABOLIC","ANTIDIABETICS, DIPEPTIDYL PEPTIDASE-4 INHIBITORS"],["N","G","CYCLOSET TAB 0.8MG","BROMOCRIPTINE MESYLATE TAB 0.8 MG (BASE EQUIVALENT)","3","0","0","0","","","ENDOCRINE AND METABOLIC","ANTIDIABETICS, DOPAMINE RECEPTOR AGONISTS"],["N","G","JANUMET TAB 50-1000","SITAGLIPTIN-METFORMIN HCL TAB 50-1000 MG","2","0","1","0","","PA**","ENDOCRINE AND METABOLIC","ANTIDIABETICS, DPP-4 INHIBITOR COMBINATIONS"],["N","G","JANUMET TAB 50-500MG","SITAGLIPTIN-METFORMIN HCL TAB 50-500 MG","2","0","1","0","","PA**","ENDOCRINE AND METABOLIC","ANTIDIABETICS, DPP-4 INHIBITOR COMBINATIONS"],["N","G","JANUMET XR TAB 100-1000","SITAGLIPTIN-METFORMIN HCL TAB ER 24HR 100-1000 MG","2","0","1","0","","PA**","ENDOCRINE AND METABOLIC","ANTIDIABETICS, DPP-4 INHIBITOR COMBINATIONS"],["N","G","JANUMET XR TAB 50-1000","SITAGLIPTIN-METFORMIN HCL TAB ER 24HR 50-1000 MG","2","0","1","0","","PA**","ENDOCRINE AND METABOLIC","ANTIDIABETICS, DPP-4 INHIBITOR COMBINATIONS"],["N","G","JANUMET XR TAB 50-500MG","SITAGLIPTIN-METFORMIN HCL TAB ER 24HR 50-500 MG","2","0","1","0","","PA**","ENDOCRINE AND METABOLIC","ANTIDIABETICS, DPP-4 INHIBITOR COMBINATIONS"],["N","G","JENTADUETO TAB XR","LINAGLIPTIN-METFORMIN HCL TAB ER 24HR 5-1000 MG","3","0","1","0","","PA**","ENDOCRINE AND METABOLIC","ANTIDIABETICS, DPP-4 INHIBITOR COMBINATIONS"],["N","G","JENTADUETO TAB XR","LINAGLIPTIN-METFORMIN HCL TAB ER 24HR 2.5-1000 MG","3","0","1","0","","PA**","ENDOCRINE AND METABOLIC","ANTIDIABETICS, DPP-4 INHIBITOR COMBINATIONS"],["N","G","OZEMPIC INJ 2/1.5ML","SEMAGLUTIDE SOLN PEN-INJ 1 MG/DOSE (2 MG/1.5ML)","2","0","1","0","","PA**","ENDOCRINE AND METABOLIC","ANTIDIABETICS, INCRETIN MIMETIC AGENTS"],["N","G","OZEMPIC INJ 2/1.5ML","SEMAGLUTIDE SOLN PEN-INJ 0.25 OR 0.5 MG/DOSE (2 MG/1.5ML)","2","0","1","0","","PA**","ENDOCRINE AND METABOLIC","ANTIDIABETICS, INCRETIN MIMETIC AGENTS"],["N","G","TRULICITY INJ 0.75/0.5","DULAGLUTIDE SOLN PEN-INJECTOR 0.75 MG/0.5ML","2","0","1","0","","PA**","ENDOCRINE AND METABOLIC","ANTIDIABETICS, INCRETIN MIMETIC AGENTS"],["N","G","TRULICITY INJ 1.5/0.5","DULAGLUTIDE SOLN PEN-INJECTOR 1.5 MG/0.5ML","2","0","1","0","","PA**","ENDOCRINE AND METABOLIC","ANTIDIABETICS, INCRETIN MIMETIC AGENTS"],["N","G","VICTOZA INJ 18MG/3ML","LIRAGLUTIDE SOLN PEN-INJECTOR 18 MG/3ML (6 MG/ML)","2","0","1","0","","PA**","ENDOCRINE AND METABOLIC","ANTIDIABETICS, INCRETIN MIMETIC AGENTS"],["N","G","SOLIQUA INJ 100/33","INSULIN GLARGINE-LIXISENATIDE SOL PEN-INJ 100-33 UNIT-MCG/ML","2","0","1","0","","PA**","ENDOCRINE AND METABOLIC","ANTIDIABETICS, INCRETIN MIMETIC COMBINATION AGENTS"],["N","G","XULTOPHY INJ 100/3.6","INSULIN DEGLUDEC-LIRAGLUTIDE SOL PEN-INJ 100-3.6 UNIT-MG/ML","3","0","1","0","","PA**","ENDOCRINE AND METABOLIC","ANTIDIABETICS, INCRETIN MIMETIC COMBINATION AGENTS"],["N","G","BASAGLAR INJ 100UNIT","INSULIN GLARGINE SOLN PEN-INJECTOR 100 UNIT/ML","2","0","0","0","","","ENDOCRINE AND METABOLIC","ANTIDIABETICS, INSULIN"],["N","G","FIASP FLEX INJ TOUCH","INSULIN ASPART (WITH NIACINAMIDE) SOL PEN-INJ 100 UNIT/ML","2","0","0","0","","","ENDOCRINE AND METABOLIC","ANTIDIABETICS, INSULIN"],["N","G","FIASP INJ 100/ML","INSULIN ASPART (WITH NIACINAMIDE) INJ 100 UNIT/ML","2","0","0","0","","","ENDOCRINE AND METABOLIC","ANTIDIABETICS, INSULIN"],["N","G","HUMULIN INJ 70/30","INSULIN NPH ISOPHANE & REGULAR HUMAN INJ 100 UNIT/ML (70-30)","3","0","0","0","","","ENDOCRINE AND METABOLIC","ANTIDIABETICS, INSULIN"],["N","G","HUMULIN INJ 70/30KWP","INSULIN NPH & REGULAR SUSP PEN-INJ 100 UNIT/ML (70-30)","3","0","0","0","","","ENDOCRINE AND METABOLIC","ANTIDIABETICS, INSULIN"],["N","G","HUMULIN N INJ U-100","INSULIN NPH (HUMAN) (ISOPHANE) INJ 100 UNIT/ML","3","0","0","0","","","ENDOCRINE AND METABOLIC","ANTIDIABETICS, INSULIN"],["N","G","HUMULIN N INJ U-100KWP","INSULIN NPH (HUMAN) (ISOPHANE) SUSP PEN-INJECTOR 100 UNIT/ML","3","0","0","0","","","ENDOCRINE AND METABOLIC","ANTIDIABETICS, INSULIN"],["N","G","HUMULIN R INJ U-100","INSULIN REGULAR (HUMAN) INJ 100 UNIT/ML","3","0","0","0","","","ENDOCRINE AND METABOLIC","ANTIDIABETICS, INSULIN"],["N","G","HUMULIN R INJ U-500","INSULIN REGULAR (HUMAN) INJ 500 UNIT/ML","2","0","0","0","","","ENDOCRINE AND METABOLIC","ANTIDIABETICS, INSULIN"],["N","G","HUMULIN R INJ U-500","INSULIN REGULAR (HUMAN) SOLN PEN-INJECTOR 500 UNIT/ML","2","0","0","0","","","ENDOCRINE AND METABOLIC","ANTIDIABETICS, INSULIN"],["N","G","LEVEMIR INJ","INSULIN DETEMIR INJ 100 UNIT/ML","2","0","0","0","","","ENDOCRINE AND METABOLIC","ANTIDIABETICS, INSULIN"],["N","G","LEVEMIR INJ FLEXTOUC","INSULIN DETEMIR SOLN PEN-INJECTOR 100 UNIT/ML","2","0","0","0","","","ENDOCRINE AND METABOLIC","ANTIDIABETICS, INSULIN"],["N","G","NOVOLIN INJ 70/30","INSULIN NPH ISOPHANE & REGULAR HUMAN INJ 100 UNIT/ML (70-30)","2","0","0","0","","RELION not covered","ENDOCRINE AND METABOLIC","ANTIDIABETICS, INSULIN"],["N","G","NOVOLIN INJ FLEXPEN","INSULIN NPH & REGULAR SUSP PEN-INJ 100 UNIT/ML (70-30)","2","0","0","0","","RELION not covered","ENDOCRINE AND METABOLIC","ANTIDIABETICS, INSULIN"],["N","G","NOVOLIN N INJ U-100","INSULIN NPH (HUMAN) (ISOPHANE) INJ 100 UNIT/ML","2","0","0","0","","RELION not covered","ENDOCRINE AND METABOLIC","ANTIDIABETICS, INSULIN"],["N","G","NOVOLIN R INJ U-100","INSULIN REGULAR (HUMAN) INJ 100 UNIT/ML","2","0","0","0","","RELION not covered","ENDOCRINE AND METABOLIC","ANTIDIABETICS, INSULIN"],["N","G","NOVOLOG INJ 100/ML","INSULIN ASPART INJ 100 UNIT/ML","2","0","0","0","","","ENDOCRINE AND METABOLIC","ANTIDIABETICS, INSULIN"],["N","G","NOVOLOG INJ FLEXPEN","INSULIN ASPART SOLN PEN-INJECTOR 100 UNIT/ML","2","0","0","0","","","ENDOCRINE AND METABOLIC","ANTIDIABETICS, INSULIN"],["N","G","NOVOLOG INJ PENFILL","INSULIN ASPART SOLN CARTRIDGE 100 UNIT/ML","2","0","0","0","","","ENDOCRINE AND METABOLIC","ANTIDIABETICS, INSULIN"],["N","G","NOVOLOG MIX INJ 70/30","INSULIN ASPART PROT & ASPART (HUMAN) INJ 100 UNIT/ML (70-30)","2","0","0","0","","","ENDOCRINE AND METABOLIC","ANTIDIABETICS, INSULIN"],["N","G","NOVOLOG MIX INJ FLEXPEN","INSULIN ASPART PROT & ASPART SUS PEN-INJ 100 UNIT/ML (70-30)","2","0","0","0","","","ENDOCRINE AND METABOLIC","ANTIDIABETICS, INSULIN"],["N","G","TRESIBA FLEX INJ 100UNIT","INSULIN DEGLUDEC SOLN PEN-INJECTOR 100 UNIT/ML","2","0","0","0","","","ENDOCRINE AND METABOLIC","ANTIDIABETICS, INSULIN"],["N","G","TRESIBA FLEX INJ 200UNIT","INSULIN DEGLUDEC SOLN PEN-INJECTOR 200 UNIT/ML","2","0","0","0","","","ENDOCRINE AND METABOLIC","ANTIDIABETICS, INSULIN"],["N","G","TRESIBA INJ 100UNIT","INSULIN DEGLUDEC INJ 100 UNIT/ML","2","0","0","0","","","ENDOCRINE AND METABOLIC","ANTIDIABETICS, INSULIN"],["N","G","PIOGLITAZONE TAB 15MG","PIOGLITAZONE HCL TAB 15 MG (BASE EQUIV)","1","0","0","0","","","ENDOCRINE AND METABOLIC","ANTIDIABETICS, INSULIN SENSITIZER"],["N","G","PIOGLITAZONE TAB 30MG","PIOGLITAZONE HCL TAB 30 MG (BASE EQUIV)","1","0","0","0","","","ENDOCRINE AND METABOLIC","ANTIDIABETICS, INSULIN SENSITIZER"],["N","G","PIOGLITAZONE TAB 45MG","PIOGLITAZONE HCL TAB 45 MG (BASE EQUIV)","1","0","0","0","","","ENDOCRINE AND METABOLIC","ANTIDIABETICS, INSULIN SENSITIZER"],["N","G","PIOGLITA/MET TAB 15-500MG","PIOGLITAZONE HCL-METFORMIN HCL TAB 15-500 MG","1","0","0","0","","","ENDOCRINE AND METABOLIC","ANTIDIABETICS, INSULIN SENSITIZER/BIGUANIDE COMBINATION"],["N","G","PIOGLITA/MET TAB 15-850MG","PIOGLITAZONE HCL-METFORMIN HCL TAB 15-850 MG","1","0","0","0","","","ENDOCRINE AND METABOLIC","ANTIDIABETICS, INSULIN SENSITIZER/BIGUANIDE COMBINATION"],["N","G","PIOGLIT/GLIM TAB 30-2MG","PIOGLITAZONE HCL-GLIMEPIRIDE TAB 30-2 MG","1","0","0","0","","","ENDOCRINE AND METABOLIC","ANTIDIABETICS, INSULIN SENSITIZER/SULFONYLUREA COMBINATION"],["N","G","PIOGLIT/GLIM TAB 30-4MG","PIOGLITAZONE HCL-GLIMEPIRIDE TAB 30-4 MG","1","0","0","0","","","ENDOCRINE AND METABOLIC","ANTIDIABETICS, INSULIN SENSITIZER/SULFONYLUREA COMBINATION"],["N","G","NATEGLINIDE TAB 120MG","NATEGLINIDE TAB 120 MG","1","0","0","0","","","ENDOCRINE AND METABOLIC","ANTIDIABETICS, MEGLITINIDE"],["N","G","NATEGLINIDE TAB 60MG","NATEGLINIDE TAB 60 MG","1","0","0","0","","","ENDOCRINE AND METABOLIC","ANTIDIABETICS, MEGLITINIDE"],["N","G","REPAGLINIDE TAB 0.5MG","REPAGLINIDE TAB 0.5 MG","1","0","0","0","","","ENDOCRINE AND METABOLIC","ANTIDIABETICS, MEGLITINIDE"],["N","G","REPAGLINIDE TAB 1MG","REPAGLINIDE TAB 1 MG","1","0","0","0","","","ENDOCRINE AND METABOLIC","ANTIDIABETICS, MEGLITINIDE"],["N","G","REPAGLINIDE TAB 2MG","REPAGLINIDE TAB 2 MG","1","0","0","0","","","ENDOCRINE AND METABOLIC","ANTIDIABETICS, MEGLITINIDE"],["N","G","REPAGLINIDE TAB 1-500MG","REPAGLINIDE-METFORMIN HCL TAB 1-500 MG","1","0","0","0","","","ENDOCRINE AND METABOLIC","ANTIDIABETICS, MEGLITINIDE/BIGUANIDE COMBINATION"],["N","G","REPAGLINIDE TAB 2-500MG","REPAGLINIDE-METFORMIN HCL TAB 2-500 MG","1","0","0","0","","","ENDOCRINE AND METABOLIC","ANTIDIABETICS, MEGLITINIDE/BIGUANIDE COMBINATION"],["N","G","SYNJARDY TAB","EMPAGLIFLOZIN-METFORMIN HCL TAB 12.5-1000 MG","2","0","1","0","","PA**","ENDOCRINE AND METABOLIC","ANTIDIABETICS, SODIUM-GLUC CO-TRANSPOR2 INHIB (SGLT2) COMBO"],["N","G","SYNJARDY TAB 12.5-500","EMPAGLIFLOZIN-METFORMIN HCL TAB 12.5-500 MG","2","0","1","0","","PA**","ENDOCRINE AND METABOLIC","ANTIDIABETICS, SODIUM-GLUC CO-TRANSPOR2 INHIB (SGLT2) COMBO"],["N","G","SYNJARDY TAB 5-1000MG","EMPAGLIFLOZIN-METFORMIN HCL TAB 5-1000 MG","2","0","1","0","","PA**","ENDOCRINE AND METABOLIC","ANTIDIABETICS, SODIUM-GLUC CO-TRANSPOR2 INHIB (SGLT2) COMBO"],["N","G","SYNJARDY TAB 5-500MG","EMPAGLIFLOZIN-METFORMIN HCL TAB 5-500 MG","2","0","1","0","","PA**","ENDOCRINE AND METABOLIC","ANTIDIABETICS, SODIUM-GLUC CO-TRANSPOR2 INHIB (SGLT2) COMBO"],["N","G","SYNJARDY XR TAB","EMPAGLIFLOZIN-METFORMIN HCL TAB ER 24HR 12.5-1000 MG","2","0","1","0","","PA**","ENDOCRINE AND METABOLIC","ANTIDIABETICS, SODIUM-GLUC CO-TRANSPOR2 INHIB (SGLT2) COMBO"],["N","G","SYNJARDY XR TAB 10-1000","EMPAGLIFLOZIN-METFORMIN HCL TAB ER 24HR 10-1000 MG","2","0","1","0","","PA**","ENDOCRINE AND METABOLIC","ANTIDIABETICS, SODIUM-GLUC CO-TRANSPOR2 INHIB (SGLT2) COMBO"],["N","G","SYNJARDY XR TAB 25-1000","EMPAGLIFLOZIN-METFORMIN HCL TAB ER 24HR 25-1000 MG","2","0","1","0","","PA**","ENDOCRINE AND METABOLIC","ANTIDIABETICS, SODIUM-GLUC CO-TRANSPOR2 INHIB (SGLT2) COMBO"],["N","G","SYNJARDY XR TAB 5-1000MG","EMPAGLIFLOZIN-METFORMIN HCL TAB ER 24HR 5-1000 MG","2","0","1","0","","PA**","ENDOCRINE AND METABOLIC","ANTIDIABETICS, SODIUM-GLUC CO-TRANSPOR2 INHIB (SGLT2) COMBO"],["N","G","XIGDUO XR TAB 10-1000","DAPAGLIFLOZIN-METFORMIN HCL TAB ER 24HR 10-1000 MG","2","0","1","0","","PA**","ENDOCRINE AND METABOLIC","ANTIDIABETICS, SODIUM-GLUC CO-TRANSPOR2 INHIB (SGLT2) COMBO"],["N","G","XIGDUO XR TAB 10-500MG","DAPAGLIFLOZIN-METFORMIN HCL TAB ER 24HR 10-500 MG","2","0","1","0","","PA**","ENDOCRINE AND METABOLIC","ANTIDIABETICS, SODIUM-GLUC CO-TRANSPOR2 INHIB (SGLT2) COMBO"],["N","G","XIGDUO XR TAB 2.5-1000","DAPAGLIFLOZIN-METFORMIN HCL TAB ER 24HR 2.5-1000 MG","2","0","1","0","","PA**","ENDOCRINE AND METABOLIC","ANTIDIABETICS, SODIUM-GLUC CO-TRANSPOR2 INHIB (SGLT2) COMBO"],["N","G","XIGDUO XR TAB 5-1000MG","DAPAGLIFLOZIN-METFORMIN HCL TAB ER 24HR 5-1000 MG","2","0","1","0","","PA**","ENDOCRINE AND METABOLIC","ANTIDIABETICS, SODIUM-GLUC CO-TRANSPOR2 INHIB (SGLT2) COMBO"],["N","G","XIGDUO XR TAB 5-500MG","DAPAGLIFLOZIN-METFORMIN HCL TAB ER 24HR 5-500 MG","2","0","1","0","","PA**","ENDOCRINE AND METABOLIC","ANTIDIABETICS, SODIUM-GLUC CO-TRANSPOR2 INHIB (SGLT2) COMBO"],["N","G","GLYXAMBI TAB 10-5 MG","EMPAGLIFLOZIN-LINAGLIPTIN TAB 10-5 MG","2","0","1","0","","PA**","ENDOCRINE AND METABOLIC","ANTIDIABETICS, SODIUM-GLUC CO-TRANSPOR2 INHIB (SGLT2)/DPP-4 INHIBITOR COMBINATIONS"],["N","G","GLYXAMBI TAB 25-5 MG","EMPAGLIFLOZIN-LINAGLIPTIN TAB 25-5 MG","2","0","1","0","","PA**","ENDOCRINE AND METABOLIC","ANTIDIABETICS, SODIUM-GLUC CO-TRANSPOR2 INHIB (SGLT2)/DPP-4 INHIBITOR COMBINATIONS"],["N","G","QTERN TAB 10MG/5MG","DAPAGLIFLOZIN-SAXAGLIPTIN TAB 10-5 MG","2","0","1","0","","PA**","ENDOCRINE AND METABOLIC","ANTIDIABETICS, SODIUM-GLUC CO-TRANSPOR2 INHIB (SGLT2)/DPP-4 INHIBITOR COMBINATIONS"],["N","G","QTERN TAB 5-5MG","DAPAGLIFLOZIN-SAXAGLIPTIN TAB 5-5 MG","2","0","1","0","","PA**","ENDOCRINE AND METABOLIC","ANTIDIABETICS, SODIUM-GLUC CO-TRANSPOR2 INHIB (SGLT2)/DPP-4 INHIBITOR COMBINATIONS"],["N","G","FARXIGA TAB 10MG","DAPAGLIFLOZIN PROPANEDIOL TAB 10 MG (BASE EQUIVALENT)","2","0","1","0","","PA**","ENDOCRINE AND METABOLIC","ANTIDIABETICS, SODIUM-GLUCOSE COTRANSPORTER2(SGLT2) INHIB"],["N","G","FARXIGA TAB 5MG","DAPAGLIFLOZIN PROPANEDIOL TAB 5 MG (BASE EQUIVALENT)","2","0","1","0","","PA**","ENDOCRINE AND METABOLIC","ANTIDIABETICS, SODIUM-GLUCOSE COTRANSPORTER2(SGLT2) INHIB"],["N","G","JARDIANCE TAB 10MG","EMPAGLIFLOZIN TAB 10 MG","2","0","1","0","","PA**","ENDOCRINE AND METABOLIC","ANTIDIABETICS, SODIUM-GLUCOSE COTRANSPORTER2(SGLT2) INHIB"],["N","G","JARDIANCE TAB 25MG","EMPAGLIFLOZIN TAB 25 MG","2","0","1","0","","PA**","ENDOCRINE AND METABOLIC","ANTIDIABETICS, SODIUM-GLUCOSE COTRANSPORTER2(SGLT2) INHIB"],["N","G","GLIMEPIRIDE TAB 1MG","GLIMEPIRIDE TAB 1 MG","1","0","0","0","","","ENDOCRINE AND METABOLIC","ANTIDIABETICS, SULFONYLUREA"],["N","G","GLIMEPIRIDE TAB 2MG","GLIMEPIRIDE TAB 2 MG","1","0","0","0","","","ENDOCRINE AND METABOLIC","ANTIDIABETICS, SULFONYLUREA"],["N","G","GLIMEPIRIDE TAB 4MG","GLIMEPIRIDE TAB 4 MG","1","0","0","0","","","ENDOCRINE AND METABOLIC","ANTIDIABETICS, SULFONYLUREA"],["N","G","GLIPIZIDE ER TAB 10MG","GLIPIZIDE TAB ER 24HR 10 MG","1","0","0","0","","","ENDOCRINE AND METABOLIC","ANTIDIABETICS, SULFONYLUREA"],["N","G","GLIPIZIDE ER TAB 2.5MG","GLIPIZIDE TAB ER 24HR 2.5 MG","1","0","0","0","","","ENDOCRINE AND METABOLIC","ANTIDIABETICS, SULFONYLUREA"],["N","G","GLIPIZIDE ER TAB 5MG","GLIPIZIDE TAB ER 24HR 5 MG","1","0","0","0","","","ENDOCRINE AND METABOLIC","ANTIDIABETICS, SULFONYLUREA"],["N","G","GLIPIZIDE TAB 10MG","GLIPIZIDE TAB 10 MG","1","0","0","0","","","ENDOCRINE AND METABOLIC","ANTIDIABETICS, SULFONYLUREA"],["N","G","GLIPIZIDE TAB 5MG","GLIPIZIDE TAB 5 MG","1","0","0","0","","","ENDOCRINE AND METABOLIC","ANTIDIABETICS, SULFONYLUREA"],["N","G","GLYBURID MCR TAB 1.5MG","GLYBURIDE MICRONIZED TAB 1.5 MG","1","1","0","0","","High Risk Medications require PA for members age 70 and older","ENDOCRINE AND METABOLIC","ANTIDIABETICS, SULFONYLUREA"],["N","G","GLYBURID MCR TAB 3MG","GLYBURIDE MICRONIZED TAB 3 MG","1","1","0","0","","High Risk Medications require PA for members age 70 and older","ENDOCRINE AND METABOLIC","ANTIDIABETICS, SULFONYLUREA"],["N","G","GLYBURID MCR TAB 6MG","GLYBURIDE MICRONIZED TAB 6 MG","1","1","0","0","","High Risk Medications require PA for members age 70 and older","ENDOCRINE AND METABOLIC","ANTIDIABETICS, SULFONYLUREA"],["N","G","GLYBURIDE TAB 1.25MG","GLYBURIDE TAB 1.25 MG","1","1","0","0","","High Risk Medications require PA for members age 70 and older","ENDOCRINE AND METABOLIC","ANTIDIABETICS, SULFONYLUREA"],["N","G","GLYBURIDE TAB 2.5MG","GLYBURIDE TAB 2.5 MG","1","1","0","0","","High Risk Medications require PA for members age 70 and older","ENDOCRINE AND METABOLIC","ANTIDIABETICS, SULFONYLUREA"],["N","G","GLYBURIDE TAB 5MG","GLYBURIDE TAB 5 MG","1","1","0","0","","High Risk Medications require PA for members age 70 and older","ENDOCRINE AND METABOLIC","ANTIDIABETICS, SULFONYLUREA"],["N","G","ALENDRONATE SOL 70/75ML","ALENDRONATE SODIUM ORAL SOLN 70 MG/75ML","1","0","0","0","","","ENDOCRINE AND METABOLIC","BISPHOSPHONATES"],["N","G","ALENDRONATE TAB 10MG","ALENDRONATE SODIUM TAB 10 MG","1","0","0","0","","","ENDOCRINE AND METABOLIC","BISPHOSPHONATES"],["N","G","ALENDRONATE TAB 35MG","ALENDRONATE SODIUM TAB 35 MG","1","0","0","0","","","ENDOCRINE AND METABOLIC","BISPHOSPHONATES"],["N","G","ALENDRONATE TAB 40MG","ALENDRONATE SODIUM TAB 40 MG","1","0","0","0","","","ENDOCRINE AND METABOLIC","BISPHOSPHONATES"],["N","G","ALENDRONATE TAB 5MG","ALENDRONATE SODIUM TAB 5 MG","1","0","0","0","","","ENDOCRINE AND METABOLIC","BISPHOSPHONATES"],["N","G","ALENDRONATE TAB 70MG","ALENDRONATE SODIUM TAB 70 MG","1","0","0","0","","","ENDOCRINE AND METABOLIC","BISPHOSPHONATES"],["N","G","FOSAMAX + D TAB 70-2800","ALENDRONATE SODIUM-CHOLECALCIFEROL TAB 70-2800 MG-UNIT","3","0","1","0","","PA**","ENDOCRINE AND METABOLIC","BISPHOSPHONATES"],["N","G","FOSAMAX + D TAB 70-5600","ALENDRONATE SODIUM-CHOLECALCIFEROL TAB 70-5600 MG-UNIT","3","0","1","0","","PA**","ENDOCRINE AND METABOLIC","BISPHOSPHONATES"],["N","G","IBANDRONATE INJ 3MG/3ML","IBANDRONATE SODIUM IV SOLN 3 MG/3ML (BASE EQUIVALENT)","1","0","0","0","","","ENDOCRINE AND METABOLIC","BISPHOSPHONATES"],["N","G","IBANDRONATE TAB 150MG","IBANDRONATE SODIUM TAB 150 MG (BASE EQUIVALENT)","1","0","0","0","","","ENDOCRINE AND METABOLIC","BISPHOSPHONATES"],["N","G","PAMIDRONATE INJ 30/10ML","PAMIDRONATE DISODIUM IV SOLN 3 MG/ML","1","0","0","0","","","ENDOCRINE AND METABOLIC","BISPHOSPHONATES"],["N","G","PAMIDRONATE INJ 30MG","PAMIDRONATE DISODIUM FOR INJ 30 MG","1","0","0","0","","","ENDOCRINE AND METABOLIC","BISPHOSPHONATES"],["N","G","PAMIDRONATE INJ 90/10ML","PAMIDRONATE DISODIUM IV SOLN 9 MG/ML","1","0","0","0","","","ENDOCRINE AND METABOLIC","BISPHOSPHONATES"],["N","G","PAMIDRONATE INJ 90MG","PAMIDRONATE DISODIUM FOR INJ 90 MG","1","0","0","0","","","ENDOCRINE AND METABOLIC","BISPHOSPHONATES"],["N","G","RISEDRON SOD TAB 35MG DR","RISEDRONATE SODIUM TAB DELAYED RELEASE 35 MG","1","0","0","0","","","ENDOCRINE AND METABOLIC","BISPHOSPHONATES"],["N","G","RISEDRONATE TAB 150MG","RISEDRONATE SODIUM TAB 150 MG","1","0","0","0","","","ENDOCRINE AND METABOLIC","BISPHOSPHONATES"],["N","G","RISEDRONATE TAB 30MG","RISEDRONATE SODIUM TAB 30 MG","1","0","0","0","","","ENDOCRINE AND METABOLIC","BISPHOSPHONATES"],["N","G","RISEDRONATE TAB 35MG","RISEDRONATE SODIUM TAB 35 MG","1","0","0","0","","","ENDOCRINE AND METABOLIC","BISPHOSPHONATES"],["N","G","RISEDRONATE TAB 5MG","RISEDRONATE SODIUM TAB 5 MG","1","0","0","0","","","ENDOCRINE AND METABOLIC","BISPHOSPHONATES"],["N","G","ZOLEDRONIC INJ 4MG/5ML","ZOLEDRONIC ACID INJ CONC FOR IV INFUSION 4 MG/5ML","4","1","0","0","","SP","ENDOCRINE AND METABOLIC","BISPHOSPHONATES"],["N","G","ZOLEDRONIC INJ 5/100ML","ZOLEDRONIC ACID IV SOLN 5 MG/100ML","4","1","0","0","","SP","ENDOCRINE AND METABOLIC","BISPHOSPHONATES"],["N","G","SENSIPAR TAB 30MG","CINACALCET HCL TAB 30 MG (BASE EQUIV)","4","1","0","1","60 tabs every 30 days","SP","ENDOCRINE AND METABOLIC","CALCIUM RECEPTOR AGONISTS"],["N","G","SENSIPAR TAB 60MG","CINACALCET HCL TAB 60 MG (BASE EQUIV)","4","1","0","1","60 tabs every 30 days","SP","ENDOCRINE AND METABOLIC","CALCIUM RECEPTOR AGONISTS"],["N","G","SENSIPAR TAB 90MG","CINACALCET HCL TAB 90 MG (BASE EQUIV)","4","1","0","1","120 tabs every 30 days","SP","ENDOCRINE AND METABOLIC","CALCIUM RECEPTOR AGONISTS"],["N","G","CHEMET CAP 100MG","SUCCIMER CAP 100 MG","3","0","0","0","","","ENDOCRINE AND METABOLIC","CHELATING AGENTS"],["N","G","DEPEN TITRA TAB 250MG","PENICILLAMINE TAB 250 MG","3","0","0","0","","","ENDOCRINE AND METABOLIC","CHELATING AGENTS"],["N","G","FERRIPROX SOL 100MG/ML","DEFERIPRONE ORAL SOLN 100 MG/ML","4","1","0","0","","SP","ENDOCRINE AND METABOLIC","CHELATING AGENTS"],["N","G","FERRIPROX TAB 1000MG","DEFERIPRONE TAB 1000 MG","4","1","0","0","","SP","ENDOCRINE AND METABOLIC","CHELATING AGENTS"],["N","G","FERRIPROX TAB 500MG","DEFERIPRONE TAB 500 MG","4","1","0","0","","SP","ENDOCRINE AND METABOLIC","CHELATING AGENTS"],["N","G","KIONEX SUS 15GM/60","SODIUM POLYSTYRENE SULFONATE ORAL SUSP 15 GM/60ML","1","0","0","0","","","ENDOCRINE AND METABOLIC","CHELATING AGENTS"],["N","G","SOD POLY SUL SUS 15GM/60","SODIUM POLYSTYRENE SULFONATE ORAL SUSP 15 GM/60ML","1","0","0","0","","","ENDOCRINE AND METABOLIC","CHELATING AGENTS"],["N","G","SOD POLY SUL SUS 30/120ML","SODIUM POLYSTYRENE SULFONATE RECTAL SUSP 30 GM/120ML","1","0","0","0","","","ENDOCRINE AND METABOLIC","CHELATING AGENTS"],["N","G","TRIENTINE CAP 250MG","TRIENTINE HCL CAP 250 MG","1","0","0","0","","","ENDOCRINE AND METABOLIC","CHELATING AGENTS"],["N","G","ALTAVERA TAB","LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","ALYACEN TAB 1/35","NORETHINDRONE & ETHINYL ESTRADIOL TAB 1 MG-35 MCG","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","ALYACEN TAB 7/7/7","NORETHINDRONE-ETH ESTRADIOL TAB 0.5-35/0.75-35/1-35 MG-MCG","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","AMETHIA TAB","LEVONORG-ETH EST TAB 0.15-0.03MG(84) & ETH EST TAB 0.01MG(7)","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","AMETHYST TAB 90-20MCG","LEVONORGESTREL-ETHINYL ESTRADIOL (CONTINUOUS) TAB 90-20 MCG","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","ANNOVERA MIS","SEGESTERONE ACE-ETHINYL ESTRADIOL VA RING 0.15-0.013 MG/24HR","0","0","0","1","1 every 300 days","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","APRI TAB","DESOGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","ARANELLE TAB","NORETHINDRONE-ETH ESTRADIOL TAB 0.5-35/1-35/0.5-35 MG-MCG","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","ASHLYNA TAB","LEVONORG-ETH EST TAB 0.15-0.03MG(84) & ETH EST TAB 0.01MG(7)","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","AVIANE TAB","LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.1 MG-20 MCG","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","AZURETTE TAB 28 DAY","DESOGEST-ETH ESTRAD & ETH ESTRAD TAB 0.15-0.02/0.01 MG(21/5)","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","BALCOLTRA TAB 0.1-20","LEVONORGESTREL-ETHINYL ESTRADIOL-FE TAB 0.1 MG-20 MCG (21)","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","CAMILA TAB 0.35MG","NORETHINDRONE TAB 0.35 MG","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","CAZIANT PAK","DESOGEST-ETHIN EST TAB 0.1-0.025/0.125-0.025/0.15-0.025MG-MG","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","CHATEAL TAB 0.15/30","LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","CRYSELLE-28 TAB 28 TABS","NORGESTREL & ETHINYL ESTRADIOL TAB 0.3 MG-30 MCG","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","CYCLAFEM TAB 1/35","NORETHINDRONE & ETHINYL ESTRADIOL TAB 1 MG-35 MCG","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","CYCLAFEM TAB 7/7/7","NORETHINDRONE-ETH ESTRADIOL TAB 0.5-35/0.75-35/1-35 MG-MCG","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","DASETTA TAB 1/35","NORETHINDRONE & ETHINYL ESTRADIOL TAB 1 MG-35 MCG","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","DASETTA TAB 7/7/7","NORETHINDRONE-ETH ESTRADIOL TAB 0.5-35/0.75-35/1-35 MG-MCG","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","DELYLA TAB 0.1-0.02","LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.1 MG-20 MCG","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","DEPO-SQ PROV INJ 104","MEDROXYPROGESTERONE ACETATE SUSP PREF SYR 104 MG/0.65ML","0","0","0","1","4 inj every 300 days","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","DROS/ETH EST TAB LEVOMEFO","DROSPIRENONE-ETHINYL ESTRAD-LEVOMEFOLATE TAB 3-0.03-0.451 MG","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","DROSPIR/ETHI TAB 3-0.03MG","DROSPIRENONE-ETHINYL ESTRADIOL TAB 3-0.03 MG","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","DROSPIRE/ETH TAB ESTR/LEV","DROSPIRENONE-ETHINYL ESTRAD-LEVOMEFOLATE TAB 3-0.02-0.451 MG","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","ELINEST TAB","NORGESTREL & ETHINYL ESTRADIOL TAB 0.3 MG-30 MCG","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","ELLA TAB 30MG","ULIPRISTAL ACETATE TAB 30 MG","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","EMOQUETTE TAB","DESOGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","ENPRESSE-28 TAB","LEVONORGESTREL-ETH ESTRA TAB 0.05-30/0.075-40/0.125-30MG-MCG","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","ENSKYCE TAB","DESOGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","ERRIN TAB 0.35MG","NORETHINDRONE TAB 0.35 MG","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","ETHYNODIOL TAB 1-50","ETHYNODIOL DIACETATE & ETHINYL ESTRADIOL TAB 1 MG-50 MCG","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","FALMINA TAB","LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.1 MG-20 MCG","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","FAYOSIM TAB","LEVONOR-ETH EST TAB 0.15-0.02/0.025/0.03 MG &ETH EST 0.01 MG","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","GIANVI TAB 3-0.02MG","DROSPIRENONE-ETHINYL ESTRADIOL TAB 3-0.02 MG","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","GILDESS FE TAB 1.5/30","NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1.5 MG-30 MCG","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","GILDESS FE TAB 1/20","NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1 MG-20 MCG","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","HEATHER TAB 0.35MG","NORETHINDRONE TAB 0.35 MG","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","INTROVALE TAB","LEVONORGESTREL & ETHINYL ESTRADIOL (91-DAY) TAB 0.15-0.03 MG","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","JOLESSA TAB","LEVONORGESTREL & ETHINYL ESTRADIOL (91-DAY) TAB 0.15-0.03 MG","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","JOLIVETTE TAB 0.35MG","NORETHINDRONE TAB 0.35 MG","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","JUNEL 1.5/30 TAB","NORETHINDRONE ACE & ETHINYL ESTRADIOL TAB 1.5 MG-30 MCG","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","JUNEL 1/20 TAB","NORETHINDRONE ACE & ETHINYL ESTRADIOL TAB 1 MG-20 MCG","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","JUNEL FE TAB 1.5/30","NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1.5 MG-30 MCG","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","JUNEL FE TAB 1/20","NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1 MG-20 MCG","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","KARIVA TAB 28 DAY","DESOGEST-ETH ESTRAD & ETH ESTRAD TAB 0.15-0.02/0.01 MG(21/5)","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","KELNOR TAB 1/35","ETHYNODIOL DIACETATE & ETHINYL ESTRADIOL TAB 1 MG-35 MCG","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","KURVELO TAB 0.15/30","LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","KYLEENA IUD 19.5MG","LEVONORGESTREL RELEASING IUD 17.5 MCG/DAY (19.5 MG TOTAL)","0","0","0","1","1 every 300 days","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","LARIN TAB 1.5/30","NORETHINDRONE ACE & ETHINYL ESTRADIOL TAB 1.5 MG-30 MCG","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","LEENA TAB","NORETHINDRONE-ETH ESTRADIOL TAB 0.5-35/1-35/0.5-35 MG-MCG","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","LESSINA TAB","LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.1 MG-20 MCG","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","LEVONEST TAB","LEVONORGESTREL-ETH ESTRA TAB 0.05-30/0.075-40/0.125-30MG-MCG","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","LEVONOR/ETHI TAB ESTRADIO","LEVONORGESTREL & ETHINYL ESTRADIOL (91-DAY) TAB 0.15-0.03 MG","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","LEVONOR/ETHI TAB ESTRADIO","LEVONORG-ETH EST TAB 0.1-0.02MG(84) & ETH EST TAB 0.01MG(7)","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","LEVONOR/ETHI TAB ESTRADIO","LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","LEVORA-28 TAB 0.15/30","LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","LILETTA IUD 52MG","LEVONORGESTREL RELEASING IUD 19.5 MCG/DAY (52 MG TOTAL)","0","0","0","1","1 every 300 days","SP","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","LO LOESTRIN TAB 1-10-10","NORETHIN-ETH ESTRADIOL-FE TAB 1 MG-10 MCG (24)/10 MCG (2)","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","LORYNA TAB 3-0.02MG","DROSPIRENONE-ETHINYL ESTRADIOL TAB 3-0.02 MG","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","LOW-OGESTREL TAB","NORGESTREL & ETHINYL ESTRADIOL TAB 0.3 MG-30 MCG","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","LUTERA TAB","LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.1 MG-20 MCG","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","MARLISSA TAB 0.15/30","LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","MEDROXYPR AC INJ 150MG/ML","MEDROXYPROGESTERONE ACETATE IM SUSP PREFILLED SYR 150 MG/ML","0","0","0","1","4 inj every 300 days","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","MEDROXYPR AC INJ 150MG/ML","MEDROXYPROGESTERONE ACETATE IM SUSP 150 MG/ML","0","0","0","1","4 inj every 300 days","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","MIBELAS 24 CHW FE","NORETHINDRONE ACE-ETH ESTRADIOL-FE CHEW TAB 1 MG-20 MCG (24)","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","MICROGESTIN TAB 1.5/30","NORETHINDRONE ACE & ETHINYL ESTRADIOL TAB 1.5 MG-30 MCG","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","MIRENA IUD SYSTEM","LEVONORGESTREL RELEASING IUD 20 MCG/DAY (52 MG TOTAL)","0","0","0","1","1 every 300 days","SP","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","MONO-LINYAH TAB 0.25-35","NORGESTIMATE & ETHINYL ESTRADIOL TAB 0.25 MG-35 MCG","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","MONONESSA TAB","NORGESTIMATE & ETHINYL ESTRADIOL TAB 0.25 MG-35 MCG","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","MYZILRA TAB","LEVONORGESTREL-ETH ESTRA TAB 0.05-30/0.075-40/0.125-30MG-MCG","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","NATAZIA TAB","ESTRADIOL VALERATE-DIENOGEST TAB 3 MG /2-2 MG/2-3 MG/1 MG","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","NECON TAB 0.5/35","NORETHINDRONE & ETHINYL ESTRADIOL TAB 0.5 MG-35 MCG","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","NECON TAB 1/35","NORETHINDRONE & ETHINYL ESTRADIOL TAB 1 MG-35 MCG","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","NECON TAB 1/50-28","NORETHINDRONE & MESTRANOL TAB 1 MG-50 MCG","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","NECON TAB 10/11-28","NORETHINDRONE-ETH ESTRADIOL TAB 0.5-35/1-35 MG-MCG (10/11)","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","NEXPLANON IMP 68MG","ETONOGESTREL SUBDERMAL IMPLANT 68 MG","0","0","0","1","1 every 300 days","SP","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","NIKKI TAB 3-0.02MG","DROSPIRENONE-ETHINYL ESTRADIOL TAB 3-0.02 MG","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","NORA-BE TAB 0.35MG","NORETHINDRONE TAB 0.35 MG","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","NORETH/ETHIN CHW FE","NORETHINDRONE & ETHINYL ESTRADIOL-FE CHEW TAB 0.8 MG-25 MCG","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","NORETH/ETHIN TAB 1/20","NORETHINDRONE ACE & ETHINYL ESTRADIOL TAB 1 MG-20 MCG","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","NORETH/ETHIN TAB FE 1/20","NORETHINDRONE ACE-ETHINYL ESTRADIOL-FE TAB 1 MG-20 MCG (24)","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","NORETHINDRON TAB 0.35MG","NORETHINDRONE TAB 0.35 MG","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","NORGEST/ETHI TAB 0.25/35","NORGESTIMATE & ETHINYL ESTRADIOL TAB 0.25 MG-35 MCG","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","NORGEST/ETHI TAB ESTRADIO","NORGESTIMATE-ETH ESTRAD TAB 0.18-35/0.215-35/0.25-35 MG-MCG","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","NORGEST/ETHI TAB ESTRADIO","NORGESTIMATE-ETH ESTRAD TAB 0.18-25/0.215-25/0.25-25 MG-MCG","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","NORTREL TAB 0.5/35","NORETHINDRONE & ETHINYL ESTRADIOL TAB 0.5 MG-35 MCG","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","NORTREL TAB 1/35","NORETHINDRONE & ETHINYL ESTRADIOL TAB 1 MG-35 MCG","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","NORTREL TAB 7/7/7","NORETHINDRONE-ETH ESTRADIOL TAB 0.5-35/0.75-35/1-35 MG-MCG","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","NUVARING MIS","ETONOGESTREL-ETHINYL ESTRADIOL VA RING 0.120-0.015 MG/24HR","0","0","0","1","13 every 300 days","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","OCELLA TAB 3-0.03MG","DROSPIRENONE-ETHINYL ESTRADIOL TAB 3-0.03 MG","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","OGESTREL TAB","NORGESTREL & ETHINYL ESTRADIOL TAB 0.5 MG-50 MCG","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","ORSYTHIA TAB","LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.1 MG-20 MCG","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","PARAGARD IUD T380A","*COPPER IUD**","0","0","0","1","1 unit every 300 days","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","PIRMELLA TAB 1/35","NORETHINDRONE & ETHINYL ESTRADIOL TAB 1 MG-35 MCG","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","PIRMELLA TAB 7/7/7","NORETHINDRONE-ETH ESTRADIOL TAB 0.5-35/0.75-35/1-35 MG-MCG","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","PORTIA-28 TAB","LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","PREVIFEM TAB","NORGESTIMATE & ETHINYL ESTRADIOL TAB 0.25 MG-35 MCG","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","QUASENSE TAB","LEVONORGESTREL & ETHINYL ESTRADIOL (91-DAY) TAB 0.15-0.03 MG","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","RECLIPSEN TAB","DESOGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","RIVELSA TAB","LEVONOR-ETH EST TAB 0.15-0.02/0.025/0.03 MG &ETH EST 0.01 MG","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","SKYLA IUD 13.5MG","LEVONORGESTREL RELEASING IUD 14 MCG/DAY (13.5 MG TOTAL)","0","0","0","1","1 every 300 days","SP","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","SLYND TAB 4MG","DROSPIRENONE TAB 4 MG","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","SPRINTEC 28 TAB 28 DAY","NORGESTIMATE & ETHINYL ESTRADIOL TAB 0.25 MG-35 MCG","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","SRONYX TAB","LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.1 MG-20 MCG","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","SYEDA TAB 3-0.03MG","DROSPIRENONE-ETHINYL ESTRADIOL TAB 3-0.03 MG","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","TAKE ACTION TAB 1.5MG","LEVONORGESTREL TAB 1.5 MG","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","TAYTULLA CAP 1MG/20MC","NORETHINDRONE ACE-ETHINYL ESTRADIOL-FE CAP 1 MG-20 MCG (24)","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","TILIA FE TAB","NORETHINDRONE AC-ETHINYL ESTRAD-FE TAB 1-20/1-30/1-35 MG-MCG","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","TRI-LINYAH TAB","NORGESTIMATE-ETH ESTRAD TAB 0.18-35/0.215-35/0.25-35 MG-MCG","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","TRI-SPRINTEC TAB","NORGESTIMATE-ETH ESTRAD TAB 0.18-35/0.215-35/0.25-35 MG-MCG","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","TRINESSA TAB","NORGESTIMATE-ETH ESTRAD TAB 0.18-35/0.215-35/0.25-35 MG-MCG","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","TRIVORA-28 TAB","LEVONORGESTREL-ETH ESTRA TAB 0.05-30/0.075-40/0.125-30MG-MCG","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","VELIVET PAK","DESOGEST-ETHIN EST TAB 0.1-0.025/0.125-0.025/0.15-0.025MG-MG","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","VESTURA TAB 3-0.02MG","DROSPIRENONE-ETHINYL ESTRADIOL TAB 3-0.02 MG","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","VIORELE TAB","DESOGEST-ETH ESTRAD & ETH ESTRAD TAB 0.15-0.02/0.01 MG(21/5)","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","VIORELE TAB","DESOGEST-ETH ESTRAD & ETH ESTRAD TAB 0.15-0.02/0.01 MG(21/5)","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","WERA TAB 0.5/35","NORETHINDRONE & ETHINYL ESTRADIOL TAB 0.5 MG-35 MCG","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","XULANE DIS 150-35","NORELGESTROMIN-ETHINYL ESTRADIOL TD PTWK 150-35 MCG/24HR","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","ZARAH TAB 3-0.03MG","DROSPIRENONE-ETHINYL ESTRADIOL TAB 3-0.03 MG","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","ZENCHENT FE CHW 0.4MG-35","NORETHINDRONE & ETHINYL ESTRADIOL-FE CHEW TAB 0.4 MG-35 MCG","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","ZENCHENT TAB","NORETHINDRONE & ETHINYL ESTRADIOL TAB 0.4 MG-35 MCG","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","ZOVIA 1/35E TAB","ETHYNODIOL DIACETATE & ETHINYL ESTRADIOL TAB 1 MG-35 MCG","0","0","0","0","","","ENDOCRINE AND METABOLIC","CONTRACEPTIVES"],["N","G","DANAZOL CAP 100MG","DANAZOL CAP 100 MG","1","0","0","0","","","ENDOCRINE AND METABOLIC","ENDOMETRIOSIS"],["N","G","DANAZOL CAP 200MG","DANAZOL CAP 200 MG","1","0","0","0","","","ENDOCRINE AND METABOLIC","ENDOMETRIOSIS"],["N","G","DANAZOL CAP 50MG","DANAZOL CAP 50 MG","1","0","0","0","","","ENDOCRINE AND METABOLIC","ENDOMETRIOSIS"],["N","G","SYNAREL SOL 2MG/ML","NAFARELIN ACETATE NASAL SOLN 2 MG/ML (200 MCG/ACT) (BASE EQ)","2","0","0","0","","","ENDOCRINE AND METABOLIC","ENDOMETRIOSIS"],["N","G","CARBAGLU TAB 200MG","CARGLUMIC ACID TAB 200 MG","4","1","0","0","","SP","ENDOCRINE AND METABOLIC","ENZYME REPLACEMENTS"],["N","G","CERDELGA CAP 84MG","ELIGLUSTAT TARTRATE CAP 84 MG (BASE EQUIVALENT)","4","1","0","1","60 caps every 30 days","SP","ENDOCRINE AND METABOLIC","ENZYME REPLACEMENTS"],["N","G","CYSTADANE POW","*BETAINE POWDER FOR ORAL SOLUTION***","4","0","0","0","","SP","ENDOCRINE AND METABOLIC","ENZYME REPLACEMENTS"],["N","G","CYSTAGON CAP 150MG","CYSTEAMINE BITARTRATE CAP 150 MG","4","1","0","0","","SP","ENDOCRINE AND METABOLIC","ENZYME REPLACEMENTS"],["N","G","CYSTAGON CAP 50MG","CYSTEAMINE BITARTRATE CAP 50 MG","4","1","0","0","","SP","ENDOCRINE AND METABOLIC","ENZYME REPLACEMENTS"],["N","G","KUVAN POW 100MG","SAPROPTERIN DIHYDROCHLORIDE POWDER PACKET 100 MG","4","1","0","0","","SP","ENDOCRINE AND METABOLIC","ENZYME REPLACEMENTS"],["N","G","KUVAN POW 500MG","SAPROPTERIN DIHYDROCHLORIDE POWDER PACKET 500 MG","4","1","0","0","","SP","ENDOCRINE AND METABOLIC","ENZYME REPLACEMENTS"],["N","G","KUVAN TAB 100MG","SAPROPTERIN DIHYDROCHLORIDE SOLUBLE TAB 100 MG","4","1","0","0","","SP","ENDOCRINE AND METABOLIC","ENZYME REPLACEMENTS"],["N","G","MYALEPT INJ 11.3MG","METRELEPTIN FOR SUBCUTANEOUS INJ 11.3 MG","4","1","0","0","","SP","ENDOCRINE AND METABOLIC","ENZYME REPLACEMENTS"],["N","G","ORFADIN CAP 10MG","NITISINONE CAP 10 MG","4","1","0","0","","SP","ENDOCRINE AND METABOLIC","ENZYME REPLACEMENTS"],["N","G","ORFADIN CAP 20MG","NITISINONE CAP 20 MG","4","1","0","0","","SP","ENDOCRINE AND METABOLIC","ENZYME REPLACEMENTS"],["N","G","ORFADIN CAP 2MG","NITISINONE CAP 2 MG","4","1","0","0","","SP","ENDOCRINE AND METABOLIC","ENZYME REPLACEMENTS"],["N","G","ORFADIN CAP 5MG","NITISINONE CAP 5 MG","4","1","0","0","","SP","ENDOCRINE AND METABOLIC","ENZYME REPLACEMENTS"],["N","G","ORFADIN SUS 4MG/ML","NITISINONE SUSP 4 MG/ML","4","1","0","0","","SP","ENDOCRINE AND METABOLIC","ENZYME REPLACEMENTS"],["N","G","PHENYLBUTYRA POW SODIUM","SODIUM PHENYLBUTYRATE ORAL POWDER 3 GM/TEASPOONFUL","1","1","0","0","","SP","ENDOCRINE AND METABOLIC","ENZYME REPLACEMENTS"],["N","G","SODIUM PHENY TAB 500MG","SODIUM PHENYLBUTYRATE TAB 500 MG","4","1","0","0","","SP","ENDOCRINE AND METABOLIC","ENZYME REPLACEMENTS"],["N","G","CLIMARA PRO DIS WEEKLY","ESTRADIOL-LEVONORGESTREL TD PATCH WEEKLY 0.045-0.015 MG/DAY","2","0","0","0","","","ENDOCRINE AND METABOLIC","ESTROGENS"],["N","G","DEPO-ESTRADI INJ 5MG/ML","ESTRADIOL CYPIONATE IM IN OIL 5 MG/ML","3","0","0","0","","","ENDOCRINE AND METABOLIC","ESTROGENS"],["N","G","DIVIGEL GEL 0.25MG","ESTRADIOL TD GEL 0.25 MG/0.25GM (0.1%)","3","1","0","0","","High Risk Medications require PA for members age 70 and older","ENDOCRINE AND METABOLIC","ESTROGENS"],["N","G","DIVIGEL GEL 0.5MG","ESTRADIOL TD GEL 0.5 MG/0.5GM (0.1%)","3","1","0","0","","High Risk Medications require PA for members age 70 and older","ENDOCRINE AND METABOLIC","ESTROGENS"],["N","G","DIVIGEL GEL 0.75MG","ESTRADIOL TD GEL 0.75 MG/0.75GM (0.1%)","3","1","0","0","","High Risk Medications require PA for members age 70 and older","ENDOCRINE AND METABOLIC","ESTROGENS"],["N","G","DIVIGEL GEL 1MG/GM","ESTRADIOL TD GEL 1 MG/GM (0.1%)","3","1","0","0","","High Risk Medications require PA for members age 70 and older","ENDOCRINE AND METABOLIC","ESTROGENS"],["N","G","DUAVEE TAB 0.45-20","CONJUGATED ESTROGENS-BAZEDOXIFENE TAB 0.45-20 MG","2","0","0","0","","","ENDOCRINE AND METABOLIC","ESTROGENS"],["N","G","ELESTRIN GEL 0.06%","ESTRADIOL GEL 0.06% (0.52 MG/0.87 GM METERED-DOSE PUMP)","3","1","0","0","","High Risk Medications require PA for members age 70 and older","ENDOCRINE AND METABOLIC","ESTROGENS"],["N","G","ESTRA/NORETH TAB 0.5-0.1","ESTRADIOL & NORETHINDRONE ACETATE TAB 0.5-0.1 MG","1","0","0","0","","","ENDOCRINE AND METABOLIC","ESTROGENS"],["N","G","ESTRA/NORETH TAB 1-0.5MG","ESTRADIOL & NORETHINDRONE ACETATE TAB 1-0.5 MG","1","0","0","0","","","ENDOCRINE AND METABOLIC","ESTROGENS"],["N","G","ESTRAD VAL INJ 200MG/5","ESTRADIOL VALERATE IM IN OIL 40 MG/ML","1","0","0","0","","","ENDOCRINE AND METABOLIC","ESTROGENS"],["N","G","ESTRAD VAL INJ 20MG/ML","ESTRADIOL VALERATE IM IN OIL 20 MG/ML","1","0","0","0","","","ENDOCRINE AND METABOLIC","ESTROGENS"],["N","G","ESTRADIOL CRE 0.01%","ESTRADIOL VAGINAL CREAM 0.1 MG/GM","1","0","0","0","","","ENDOCRINE AND METABOLIC","ESTROGENS"],["N","G","ESTRADIOL DIS 0.025MG","ESTRADIOL TD PATCH WEEKLY 0.025 MG/24HR","1","1","0","0","","High Risk Medications require PA for members age 70 and older","ENDOCRINE AND METABOLIC","ESTROGENS"],["N","G","ESTRADIOL DIS 0.025MG","ESTRADIOL TD PATCH TWICE WEEKLY 0.025 MG/24HR","1","1","0","0","","High Risk Medications require PA for members age 70 and older","ENDOCRINE AND METABOLIC","ESTROGENS"],["N","G","ESTRADIOL DIS 0.0375MG","ESTRADIOL TD PATCH TWICE WEEKLY 0.0375 MG/24HR","1","1","0","0","","High Risk Medications require PA for members age 70 and older","ENDOCRINE AND METABOLIC","ESTROGENS"],["N","G","ESTRADIOL DIS 0.0375MG","ESTRADIOL TD PATCH WEEKLY 0.0375 MG/24HR (37.5 MCG/24HR)","1","1","0","0","","High Risk Medications require PA for members age 70 and older","ENDOCRINE AND METABOLIC","ESTROGENS"],["N","G","ESTRADIOL DIS 0.05MG","ESTRADIOL TD PATCH WEEKLY 0.05 MG/24HR","1","1","0","0","","High Risk Medications require PA for members age 70 and older","ENDOCRINE AND METABOLIC","ESTROGENS"],["N","G","ESTRADIOL DIS 0.05MG","ESTRADIOL TD PATCH WEEKLY 0.05 MG/24HR","1","1","0","0","","High Risk Medications require PA for members age 70 and older","ENDOCRINE AND METABOLIC","ESTROGENS"],["N","G","ESTRADIOL DIS 0.05MG","ESTRADIOL TD PATCH TWICE WEEKLY 0.05 MG/24HR","1","1","0","0","","High Risk Medications require PA for members age 70 and older","ENDOCRINE AND METABOLIC","ESTROGENS"],["N","G","ESTRADIOL DIS 0.06MG","ESTRADIOL TD PATCH WEEKLY 0.06 MG/24HR","1","1","0","0","","High Risk Medications require PA for members age 70 and older","ENDOCRINE AND METABOLIC","ESTROGENS"],["N","G","ESTRADIOL DIS 0.075MG","ESTRADIOL TD PATCH WEEKLY 0.075 MG/24HR","1","1","0","0","","High Risk Medications require PA for members age 70 and older","ENDOCRINE AND METABOLIC","ESTROGENS"],["N","G","ESTRADIOL DIS 0.075MG","ESTRADIOL TD PATCH TWICE WEEKLY 0.075 MG/24HR","1","1","0","0","","High Risk Medications require PA for members age 70 and older","ENDOCRINE AND METABOLIC","ESTROGENS"],["N","G","ESTRADIOL DIS 0.1MG","ESTRADIOL TD PATCH WEEKLY 0.1 MG/24HR","1","1","0","0","","High Risk Medications require PA for members age 70 and older","ENDOCRINE AND METABOLIC","ESTROGENS"],["N","G","ESTRADIOL DIS 0.1MG","ESTRADIOL TD PATCH WEEKLY 0.1 MG/24HR","1","1","0","0","","High Risk Medications require PA for members age 70 and older","ENDOCRINE AND METABOLIC","ESTROGENS"],["N","G","ESTRADIOL DIS 0.1MG","ESTRADIOL TD PATCH TWICE WEEKLY 0.1 MG/24HR","1","1","0","0","","High Risk Medications require PA for members age 70 and older","ENDOCRINE AND METABOLIC","ESTROGENS"],["N","G","ESTRADIOL TAB 0.5MG","ESTRADIOL TAB 0.5 MG","1","1","0","0","","High Risk Medications require PA for members age 70 and older","ENDOCRINE AND METABOLIC","ESTROGENS"],["N","G","ESTRADIOL TAB 1MG","ESTRADIOL TAB 1 MG","1","1","0","0","","High Risk Medications require PA for members age 70 and older","ENDOCRINE AND METABOLIC","ESTROGENS"],["N","G","ESTRADIOL TAB 2MG","ESTRADIOL TAB 2 MG","1","1","0","0","","High Risk Medications require PA for members age 70 and older","ENDOCRINE AND METABOLIC","ESTROGENS"],["N","G","ESTROGEL GEL","ESTRADIOL GEL 0.06% (0.75 MG/1.25 GM METERED-DOSE PUMP)","3","1","0","0","","High Risk Medications require PA for members age 70 and older","ENDOCRINE AND METABOLIC","ESTROGENS"],["N","G","ESTROPIPATE TAB 0.75MG","ESTROPIPATE TAB 0.75 MG","1","1","0","0","","High Risk Medications require PA for members age 70 and older","ENDOCRINE AND METABOLIC","ESTROGENS"],["N","G","ESTROPIPATE TAB 1.5MG","ESTROPIPATE TAB 1.5 MG","1","1","0","0","","High Risk Medications require PA for members age 70 and older","ENDOCRINE AND METABOLIC","ESTROGENS"],["N","G","ESTROPIPATE TAB 3MG","ESTROPIPATE TAB 3 MG","1","1","0","0","","High Risk Medications require PA for members age 70 and older","ENDOCRINE AND METABOLIC","ESTROGENS"],["N","G","EVAMIST SPR 1.53MG","ESTRADIOL TRANSDERMAL SPRAY 1.53 MG/SPRAY","3","1","0","0","","High Risk Medications require PA for members age 70 and older","ENDOCRINE AND METABOLIC","ESTROGENS"],["N","G","JINTELI TAB 1MG-5MCG","NORETHINDRONE ACETATE-ETHINYL ESTRADIOL TAB 1 MG-5 MCG","1","0","0","0","","","ENDOCRINE AND METABOLIC","ESTROGENS"],["N","G","MENEST TAB 0.3MG","ESTERIFIED ESTROGENS TAB 0.3 MG","3","1","0","0","","High Risk Medications require PA for members age 70 and older","ENDOCRINE AND METABOLIC","ESTROGENS"],["N","G","MENEST TAB 0.625MG","ESTERIFIED ESTROGENS TAB 0.625 MG","3","1","0","0","","High Risk Medications require PA for members age 70 and older","ENDOCRINE AND METABOLIC","ESTROGENS"],["N","G","MENEST TAB 1.25MG","ESTERIFIED ESTROGENS TAB 1.25 MG","3","1","0","0","","High Risk Medications require PA for members age 70 and older","ENDOCRINE AND METABOLIC","ESTROGENS"],["N","G","MENEST TAB 2.5MG","ESTERIFIED ESTROGENS TAB 2.5 MG","3","1","0","0","","High Risk Medications require PA for members age 70 and older","ENDOCRINE AND METABOLIC","ESTROGENS"],["N","G","MIMVEY LO TAB 0.5-0.1","ESTRADIOL & NORETHINDRONE ACETATE TAB 0.5-0.1 MG","1","0","0","0","","","ENDOCRINE AND METABOLIC","ESTROGENS"],["N","G","MIMVEY TAB 1-0.5MG","ESTRADIOL & NORETHINDRONE ACETATE TAB 1-0.5 MG","1","0","0","0","","","ENDOCRINE AND METABOLIC","ESTROGENS"],["N","G","NORETH/ETHIN TAB 0.5-2.5","NORETHINDRONE ACETATE-ETHINYL ESTRADIOL TAB 0.5 MG-2.5 MCG","1","0","0","0","","","ENDOCRINE AND METABOLIC","ESTROGENS"],["N","G","PREMARIN TAB 0.3MG","ESTROGENS, CONJUGATED TAB 0.3 MG","3","1","0","0","","High Risk Medications require PA for members age 70 and older","ENDOCRINE AND METABOLIC","ESTROGENS"],["N","G","PREMARIN TAB 0.45MG","ESTROGENS, CONJUGATED TAB 0.45 MG","3","1","0","0","","High Risk Medications require PA for members age 70 and older","ENDOCRINE AND METABOLIC","ESTROGENS"],["N","G","PREMARIN TAB 0.625MG","ESTROGENS, CONJUGATED TAB 0.625 MG","3","1","0","0","","High Risk Medications require PA for members age 70 and older","ENDOCRINE AND METABOLIC","ESTROGENS"],["N","G","PREMARIN TAB 0.9MG","ESTROGENS, CONJUGATED TAB 0.9 MG","3","1","0","0","","High Risk Medications require PA for members age 70 and older","ENDOCRINE AND METABOLIC","ESTROGENS"],["N","G","PREMARIN TAB 1.25MG","ESTROGENS, CONJUGATED TAB 1.25 MG","3","1","0","0","","High Risk Medications require PA for members age 70 and older","ENDOCRINE AND METABOLIC","ESTROGENS"],["N","G","PREMARIN VAG CRE 0.625MG","ESTROGENS, CONJUGATED VAGINAL CREAM 0.625 MG/GM","3","0","0","0","","","ENDOCRINE AND METABOLIC","ESTROGENS"],["N","G","YUVAFEM TAB 10MCG","ESTRADIOL VAGINAL TAB 10 MCG","1","0","0","0","","","ENDOCRINE AND METABOLIC","ESTROGENS"],["N","G","CORTISONE AC TAB 25MG","CORTISONE ACETATE TAB 25 MG","1","0","0","0","","","ENDOCRINE AND METABOLIC","GLUCOCORTICOIDS"],["N","G","DEPO-MEDROL INJ 20MG/ML","METHYLPREDNISOLONE ACETATE INJ SUSP 20 MG/ML","3","0","0","0","","","ENDOCRINE AND METABOLIC","GLUCOCORTICOIDS"],["N","G","DEXAMETH PHO INJ 10MG/ML","DEXAMETHASONE SOD PHOSPHATE PRESERVATIVE FREE INJ 10 MG/ML","1","0","0","0","","","ENDOCRINE AND METABOLIC","GLUCOCORTICOIDS"],["N","G","DEXAMETH PHO INJ 10MG/ML","DEXAMETHASONE SODIUM PHOSPHATE INJ 100 MG/10ML","1","0","0","0","","","ENDOCRINE AND METABOLIC","GLUCOCORTICOIDS"],["N","G","DEXAMETH PHO INJ 10MG/ML","DEXAMETHASONE SODIUM PHOSPHATE INJ 10 MG/ML","1","0","0","0","","","ENDOCRINE AND METABOLIC","GLUCOCORTICOIDS"],["N","G","DEXAMETH PHO INJ 120MG/30","DEXAMETHASONE SODIUM PHOSPHATE INJ 120 MG/30ML","1","0","0","0","","","ENDOCRINE AND METABOLIC","GLUCOCORTICOIDS"],["N","G","DEXAMETH PHO INJ 4MG/ML","DEXAMETHASONE SODIUM PHOSPHATE INJ 20 MG/5ML","1","0","0","0","","","ENDOCRINE AND METABOLIC","GLUCOCORTICOIDS"],["N","G","DEXAMETH PHO INJ 4MG/ML","DEXAMETHASONE SODIUM PHOSPHATE INJ 4 MG/ML","1","0","0","0","","","ENDOCRINE AND METABOLIC","GLUCOCORTICOIDS"],["N","G","DEXAMETHASON CON 1MG/ML","DEXAMETHASONE CONC 1 MG/ML","2","0","0","0","","","ENDOCRINE AND METABOLIC","GLUCOCORTICOIDS"],["N","G","DEXAMETHASON ELX 0.5/5ML","DEXAMETHASONE ELIXIR 0.5 MG/5ML","1","0","0","0","","","ENDOCRINE AND METABOLIC","GLUCOCORTICOIDS"],["N","G","DEXAMETHASON SOL 0.5/5ML","DEXAMETHASONE SOLN 0.5 MG/5ML","1","0","0","0","","","ENDOCRINE AND METABOLIC","GLUCOCORTICOIDS"],["N","G","DEXAMETHASON TAB 0.5MG","DEXAMETHASONE TAB 0.5 MG","1","0","0","0","","","ENDOCRINE AND METABOLIC","GLUCOCORTICOIDS"],["N","G","DEXAMETHASON TAB 0.75MG","DEXAMETHASONE TAB 0.75 MG","1","0","0","0","","","ENDOCRINE AND METABOLIC","GLUCOCORTICOIDS"],["N","G","DEXAMETHASON TAB 1.5MG","DEXAMETHASONE TAB 1.5 MG","1","0","0","0","","","ENDOCRINE AND METABOLIC","GLUCOCORTICOIDS"],["N","G","DEXAMETHASON TAB 1MG","DEXAMETHASONE TAB 1 MG","1","0","0","0","","","ENDOCRINE AND METABOLIC","GLUCOCORTICOIDS"],["N","G","DEXAMETHASON TAB 2MG","DEXAMETHASONE TAB 2 MG","1","0","0","0","","","ENDOCRINE AND METABOLIC","GLUCOCORTICOIDS"],["N","G","DEXAMETHASON TAB 4MG","DEXAMETHASONE TAB 4 MG","1","0","0","0","","","ENDOCRINE AND METABOLIC","GLUCOCORTICOIDS"],["N","G","DEXAMETHASON TAB 6MG","DEXAMETHASONE TAB 6 MG","1","0","0","0","","","ENDOCRINE AND METABOLIC","GLUCOCORTICOIDS"],["N","G","FLUDROCORT TAB 0.1MG","FLUDROCORTISONE ACETATE TAB 0.1 MG","1","0","0","0","","","ENDOCRINE AND METABOLIC","GLUCOCORTICOIDS"],["N","G","HYDROCORT TAB 10MG","HYDROCORTISONE TAB 10 MG","1","0","0","0","","","ENDOCRINE AND METABOLIC","GLUCOCORTICOIDS"],["N","G","HYDROCORT TAB 20MG","HYDROCORTISONE TAB 20 MG","1","0","0","0","","","ENDOCRINE AND METABOLIC","GLUCOCORTICOIDS"],["N","G","HYDROCORT TAB 5MG","HYDROCORTISONE TAB 5 MG","1","0","0","0","","","ENDOCRINE AND METABOLIC","GLUCOCORTICOIDS"],["N","G","MEDROL TAB 2MG","METHYLPREDNISOLONE TAB 2 MG","2","0","0","0","","","ENDOCRINE AND METABOLIC","GLUCOCORTICOIDS"],["N","G","METHYLPR ACE INJ 40MG/ML","METHYLPREDNISOLONE ACETATE INJ SUSP 40 MG/ML","1","0","0","0","","","ENDOCRINE AND METABOLIC","GLUCOCORTICOIDS"],["N","G","METHYLPR ACE INJ 80MG/ML","METHYLPREDNISOLONE ACETATE INJ SUSP 80 MG/ML","1","0","0","0","","","ENDOCRINE AND METABOLIC","GLUCOCORTICOIDS"],["N","G","METHYLPR SS INJ 1000MG","METHYLPREDNISOLONE SOD SUCC FOR INJ 1000 MG (BASE EQUIV)","1","0","0","0","","","ENDOCRINE AND METABOLIC","GLUCOCORTICOIDS"],["N","G","METHYLPR SS INJ 125MG","METHYLPREDNISOLONE SOD SUCC FOR INJ 125 MG (BASE EQUIV)","1","0","0","0","","","ENDOCRINE AND METABOLIC","GLUCOCORTICOIDS"],["N","G","METHYLPR SS INJ 125MG","METHYLPREDNISOLONE SOD SUCC FOR INJ 125 MG (BASE EQUIV)","1","0","0","0","","","ENDOCRINE AND METABOLIC","GLUCOCORTICOIDS"],["N","G","METHYLPR SS INJ 40MG","METHYLPREDNISOLONE SOD SUCC FOR INJ 40 MG (BASE EQUIV)","1","0","0","0","","","ENDOCRINE AND METABOLIC","GLUCOCORTICOIDS"],["N","G","METHYLPR SS INJ 40MG","METHYLPREDNISOLONE SOD SUCC FOR INJ 40 MG (BASE EQUIV)","1","0","0","0","","","ENDOCRINE AND METABOLIC","GLUCOCORTICOIDS"],["N","G","METHYLPRED TAB 16MG","METHYLPREDNISOLONE TAB 16 MG","1","0","0","0","","","ENDOCRINE AND METABOLIC","GLUCOCORTICOIDS"],["N","G","METHYLPRED TAB 32MG","METHYLPREDNISOLONE TAB 32 MG","1","0","0","0","","","ENDOCRINE AND METABOLIC","GLUCOCORTICOIDS"],["N","G","METHYLPRED TAB 4MG","METHYLPREDNISOLONE TAB THERAPY PACK 4 MG (21)","1","0","0","0","","","ENDOCRINE AND METABOLIC","GLUCOCORTICOIDS"],["N","G","METHYLPRED TAB 4MG","METHYLPREDNISOLONE TAB 4 MG","1","0","0","0","","","ENDOCRINE AND METABOLIC","GLUCOCORTICOIDS"],["N","G","METHYLPRED TAB 8MG","METHYLPREDNISOLONE TAB 8 MG","1","0","0","0","","","ENDOCRINE AND METABOLIC","GLUCOCORTICOIDS"],["N","G","PRED SOD PHO SOL 5MG/5ML","PREDNISOLONE SOD PHOSPH ORAL SOLN 6.7 MG/5ML (5 MG/5ML BASE)","1","0","0","0","","","ENDOCRINE AND METABOLIC","GLUCOCORTICOIDS"],["N","G","PREDNISOLONE SOL 10MG/5ML","PREDNISOLONE SOD PHOSPHATE ORAL SOLN 10 MG/5ML (BASE EQUIV)","1","0","0","0","","","ENDOCRINE AND METABOLIC","GLUCOCORTICOIDS"],["N","G","PREDNISOLONE SOL 15MG/5ML","PREDNISOLONE SYRUP 15 MG/5ML (USP SOLUTION EQUIVALENT)","1","0","0","0","","","ENDOCRINE AND METABOLIC","GLUCOCORTICOIDS"],["N","G","PREDNISOLONE SOL 15MG/5ML","PREDNISOLONE SOD PHOSPHATE ORAL SOLN 15 MG/5ML (BASE EQUIV)","1","0","0","0","","","ENDOCRINE AND METABOLIC","GLUCOCORTICOIDS"],["N","G","PREDNISOLONE SOL 20MG/5ML","PREDNISOLONE SOD PHOSPHATE ORAL SOLN 20 MG/5ML (BASE EQUIV)","1","0","0","0","","","ENDOCRINE AND METABOLIC","GLUCOCORTICOIDS"],["N","G","PREDNISOLONE SOL 25MG/5ML","PREDNISOLONE SODIUM PHOSPHATE ORAL SOLN 25 MG/5ML (BASE EQ)","1","0","0","0","","","ENDOCRINE AND METABOLIC","GLUCOCORTICOIDS"],["N","G","PREDNISOLONE TAB 10MG ODT","PREDNISOLONE SOD PHOS ORALLY DISINTEGR TAB 10 MG (BASE EQ)","1","0","0","0","","","ENDOCRINE AND METABOLIC","GLUCOCORTICOIDS"],["N","G","PREDNISOLONE TAB 15MG ODT","PREDNISOLONE SOD PHOS ORALLY DISINTEGR TAB 15 MG (BASE EQ)","1","0","0","0","","","ENDOCRINE AND METABOLIC","GLUCOCORTICOIDS"],["N","G","PREDNISOLONE TAB 30MG ODT","PREDNISOLONE SOD PHOS ORALLY DISINTEGR TAB 30 MG (BASE EQ)","1","0","0","0","","","ENDOCRINE AND METABOLIC","GLUCOCORTICOIDS"],["N","G","PREDNISONE CON 5MG/ML","PREDNISONE CONC 5 MG/ML","2","0","0","0","","","ENDOCRINE AND METABOLIC","GLUCOCORTICOIDS"],["N","G","PREDNISONE PAK 10MG","PREDNISONE TAB THERAPY PACK 10 MG (48)","1","0","0","0","","","ENDOCRINE AND METABOLIC","GLUCOCORTICOIDS"],["N","G","PREDNISONE PAK 10MG","PREDNISONE TAB THERAPY PACK 10 MG (21)","1","0","0","0","","","ENDOCRINE AND METABOLIC","GLUCOCORTICOIDS"],["N","G","PREDNISONE PAK 5MG","PREDNISONE TAB THERAPY PACK 5 MG (48)","1","0","0","0","","","ENDOCRINE AND METABOLIC","GLUCOCORTICOIDS"],["N","G","PREDNISONE PAK 5MG","PREDNISONE TAB THERAPY PACK 5 MG (21)","1","0","0","0","","","ENDOCRINE AND METABOLIC","GLUCOCORTICOIDS"],["N","G","PREDNISONE SOL 5MG/5ML","PREDNISONE ORAL SOLN 5 MG/5ML","1","0","0","0","","","ENDOCRINE AND METABOLIC","GLUCOCORTICOIDS"],["N","G","PREDNISONE TAB 10MG","PREDNISONE TAB 10 MG","1","0","0","0","","","ENDOCRINE AND METABOLIC","GLUCOCORTICOIDS"],["N","G","PREDNISONE TAB 10MG","PREDNISONE TAB 10 MG","1","0","0","0","","","ENDOCRINE AND METABOLIC","GLUCOCORTICOIDS"],["N","G","PREDNISONE TAB 1MG","PREDNISONE TAB 1 MG","1","0","0","0","","","ENDOCRINE AND METABOLIC","GLUCOCORTICOIDS"],["N","G","PREDNISONE TAB 2.5MG","PREDNISONE TAB 2.5 MG","1","0","0","0","","","ENDOCRINE AND METABOLIC","GLUCOCORTICOIDS"],["N","G","PREDNISONE TAB 20MG","PREDNISONE TAB 20 MG","1","0","0","0","","","ENDOCRINE AND METABOLIC","GLUCOCORTICOIDS"],["N","G","PREDNISONE TAB 50MG","PREDNISONE TAB 50 MG","1","0","0","0","","","ENDOCRINE AND METABOLIC","GLUCOCORTICOIDS"],["N","G","PREDNISONE TAB 5MG","PREDNISONE TAB 5 MG","1","0","0","0","","","ENDOCRINE AND METABOLIC","GLUCOCORTICOIDS"],["N","G","SOLU-MEDROL INJ 2GM","METHYLPREDNISOLONE SOD SUCC FOR INJ 2000 MG (BASE EQUIV)","3","0","0","0","","","ENDOCRINE AND METABOLIC","GLUCOCORTICOIDS"],["N","G","GLUCAGON KIT 1MG","GLUCAGON (RDNA) FOR INJ KIT 1 MG","2","0","0","0","","","ENDOCRINE AND METABOLIC","GLUCOSE ELEVATING AGENTS"],["N","G","INSTA-GLUCOS GEL 77.4%","GLUCOSE GEL 77.4%","2","0","0","0","","","ENDOCRINE AND METABOLIC","GLUCOSE ELEVATING AGENTS"],["N","G","HUMATROPE INJ 12MG","SOMATROPIN FOR INJ 12 MG (36 UNIT)","4","1","0","0","","SP","ENDOCRINE AND METABOLIC","HUMAN GROWTH HORMONES"],["N","G","HUMATROPE INJ 24MG","SOMATROPIN FOR INJ 24 MG","4","1","0","0","","SP","ENDOCRINE AND METABOLIC","HUMAN GROWTH HORMONES"],["N","G","HUMATROPE INJ 5MG","SOMATROPIN FOR INJ 5 MG","4","1","0","0","","SP","ENDOCRINE AND METABOLIC","HUMAN GROWTH HORMONES"],["N","G","HUMATROPE INJ 6MG","SOMATROPIN FOR INJ 6 MG (18 UNIT)","4","1","0","0","","SP","ENDOCRINE AND METABOLIC","HUMAN GROWTH HORMONES"],["N","G","CABERGOLINE TAB 0.5MG","CABERGOLINE TAB 0.5 MG","1","0","0","0","","","ENDOCRINE AND METABOLIC","MISCELLANEOUS"],["N","G","CALCITONIN SPR 200/ACT","CALCITONIN (SALMON) NASAL SOLN 200 UNIT/ACT","1","0","0","0","","","ENDOCRINE AND METABOLIC","MISCELLANEOUS"],["N","G","CHOR GONADOT INJ 10000UNT","CHORIONIC GONADOTROPIN FOR IM INJ 10000 UNIT","4","1","0","0","","SP","ENDOCRINE AND METABOLIC","MISCELLANEOUS"],["N","G","INCRELEX INJ 40MG/4ML","MECASERMIN INJ 40 MG/4ML (10 MG/ML)","4","1","0","0","","SP","ENDOCRINE AND METABOLIC","MISCELLANEOUS"],["N","G","MIACALCIN INJ 200/ML","CALCITONIN (SALMON) INJ 200 UNIT/ML","3","0","0","0","","","ENDOCRINE AND METABOLIC","MISCELLANEOUS"],["N","G","OCTREOTIDE INJ 1000MCG","OCTREOTIDE ACETATE INJ 1000 MCG/ML (1 MG/ML)","4","1","0","1","45 ml every 30 days","SP","ENDOCRINE AND METABOLIC","MISCELLANEOUS"],["N","G","OCTREOTIDE INJ 100MCG","OCTREOTIDE ACETATE INJ 100 MCG/ML (0.1 MG/ML)","4","1","0","1","90 ml every 30 days","SP","ENDOCRINE AND METABOLIC","MISCELLANEOUS"],["N","G","OCTREOTIDE INJ 200MCG","OCTREOTIDE ACETATE INJ 200 MCG/ML (0.2 MG/ML)","4","1","0","1","225 ml every 30 days","SP","ENDOCRINE AND METABOLIC","MISCELLANEOUS"],["N","G","OCTREOTIDE INJ 500MCG","OCTREOTIDE ACETATE INJ 500 MCG/ML (0.5 MG/ML)","4","1","0","1","90 ml every 30 days","SP","ENDOCRINE AND METABOLIC","MISCELLANEOUS"],["N","G","OCTREOTIDE INJ 50MCG/ML","OCTREOTIDE ACETATE INJ 50 MCG/ML (0.05 MG/ML)","4","1","0","1","90 ml every 30 days","SP","ENDOCRINE AND METABOLIC","MISCELLANEOUS"],["N","G","OSPHENA TAB 60MG","OSPEMIFENE TAB 60 MG","2","0","0","0","","","ENDOCRINE AND METABOLIC","MISCELLANEOUS"],["N","G","PROLIA SOL 60MG/ML","DENOSUMAB INJ SOLN PREFILLED SYRINGE 60 MG/ML","4","1","0","1","60mg every 24 weeks","SP","ENDOCRINE AND METABOLIC","MISCELLANEOUS"],["N","G","RALOXIFENE TAB 60MG","RALOXIFENE HCL TAB 60 MG","1","0","0","0","","$0 copay for women ages 35 and older for the primary prevention of breast cancer","ENDOCRINE AND METABOLIC","MISCELLANEOUS"],["N","G","SAMSCA TAB 15MG","TOLVAPTAN TAB 15 MG","4","1","0","0","","SP","ENDOCRINE AND METABOLIC","MISCELLANEOUS"],["N","G","SAMSCA TAB 30MG","TOLVAPTAN TAB 30 MG","4","1","0","0","","SP","ENDOCRINE AND METABOLIC","MISCELLANEOUS"],["N","G","SIGNIFOR INJ 0.3MG/ML","PASIREOTIDE DIASPARTATE INJ 0.3 MG/ML (BASE EQUIV)","4","1","0","1","60 ampules every 30 days","SP","ENDOCRINE AND METABOLIC","MISCELLANEOUS"],["N","G","SIGNIFOR INJ 0.6MG/ML","PASIREOTIDE DIASPARTATE INJ 0.6 MG/ML (BASE EQUIV)","4","1","0","1","60 ampules every 30 days","SP","ENDOCRINE AND METABOLIC","MISCELLANEOUS"],["N","G","SIGNIFOR INJ 0.9MG/ML","PASIREOTIDE DIASPARTATE INJ 0.9 MG/ML (BASE EQUIV)","4","1","0","1","60 ampules every 30 days","SP","ENDOCRINE AND METABOLIC","MISCELLANEOUS"],["N","G","SOMATULINE INJ 120/.5ML","LANREOTIDE ACETATE EXTENDED RELEASE INJ 120 MG/0.5ML","4","1","0","1","1 injection every 28 days","SP","ENDOCRINE AND METABOLIC","MISCELLANEOUS"],["N","G","SOMATULINE INJ 60/0.2ML","LANREOTIDE ACETATE EXTENDED RELEASE INJ 60 MG/0.2ML","4","1","0","1","1 injection every 28 days","SP","ENDOCRINE AND METABOLIC","MISCELLANEOUS"],["N","G","SOMATULINE INJ 90/0.3ML","LANREOTIDE ACETATE EXTENDED RELEASE INJ 90 MG/0.3ML","4","1","0","1","1 injection every 28 days","SP","ENDOCRINE AND METABOLIC","MISCELLANEOUS"],["N","G","SOMAVERT INJ 10MG","PEGVISOMANT FOR INJ 10 MG (AS PROTEIN)","4","1","0","1","30 vials every 30 days","SP","ENDOCRINE AND METABOLIC","MISCELLANEOUS"],["N","G","SOMAVERT INJ 15MG","PEGVISOMANT FOR INJ 15 MG (AS PROTEIN)","4","1","0","1","30 vials every 30 days","SP","ENDOCRINE AND METABOLIC","MISCELLANEOUS"],["N","G","SOMAVERT INJ 20MG","PEGVISOMANT FOR INJ 20 MG (AS PROTEIN)","4","1","0","1","30 vials every 30 days","SP","ENDOCRINE AND METABOLIC","MISCELLANEOUS"],["N","G","SOMAVERT INJ 25MG","PEGVISOMANT FOR INJ 25 MG (AS PROTEIN)","4","1","0","1","30 vials every 30 days","SP","ENDOCRINE AND METABOLIC","MISCELLANEOUS"],["N","G","SOMAVERT INJ 30MG","PEGVISOMANT FOR INJ 30 MG (AS PROTEIN)","4","1","0","1","30 vials every 30 days","SP","ENDOCRINE AND METABOLIC","MISCELLANEOUS"],["N","G","TYMLOS INJ","ABALOPARATIDE SUBCUTANEOUS SOLN PEN-INJECTOR 3120 MCG/1.56ML","4","1","0","1","1 pen every 30 days","SP","ENDOCRINE AND METABOLIC","MISCELLANEOUS"],["N","G","CALC ACETATE CAP 667MG","CALCIUM ACETATE (PHOSPHATE BINDER) CAP 667 MG (169 MG CA)","1","0","0","0","","","ENDOCRINE AND METABOLIC","PHOSPHATE BINDER AGENTS"],["N","G","CALC ACETATE TAB 667MG","CALCIUM ACETATE (PHOSPHATE BINDER) TAB 667 MG","1","0","0","0","","","ENDOCRINE AND METABOLIC","PHOSPHATE BINDER AGENTS"],["N","G","FOSRENOL POW 1000MG","LANTHANUM CARBONATE ORAL POWDER PACK 1000 MG (ELEMENTAL)","3","0","0","0","","","ENDOCRINE AND METABOLIC","PHOSPHATE BINDER AGENTS"],["N","G","FOSRENOL POW 750MG","LANTHANUM CARBONATE ORAL POWDER PACK 750 MG (ELEMENTAL)","3","0","0","0","","","ENDOCRINE AND METABOLIC","PHOSPHATE BINDER AGENTS"],["N","G","LANTHANUM CHW 1000MG","LANTHANUM CARBONATE CHEW TAB 1000 MG (ELEMENTAL)","1","0","0","0","","","ENDOCRINE AND METABOLIC","PHOSPHATE BINDER AGENTS"],["N","G","LANTHANUM CHW 500MG","LANTHANUM CARBONATE CHEW TAB 500 MG (ELEMENTAL)","1","0","0","0","","","ENDOCRINE AND METABOLIC","PHOSPHATE BINDER AGENTS"],["N","G","LANTHANUM CHW 750MG","LANTHANUM CARBONATE CHEW TAB 750 MG (ELEMENTAL)","1","0","0","0","","","ENDOCRINE AND METABOLIC","PHOSPHATE BINDER AGENTS"],["N","G","PHOSLYRA SOL","CALCIUM ACETATE (PHOSPHATE BINDER) ORAL SOLN 667 MG/5ML","2","0","0","0","","","ENDOCRINE AND METABOLIC","PHOSPHATE BINDER AGENTS"],["N","G","SEVELAMER POW 0.8GM","SEVELAMER CARBONATE PACKET 0.8 GM","1","0","0","0","","","ENDOCRINE AND METABOLIC","PHOSPHATE BINDER AGENTS"],["N","G","SEVELAMER POW 2.4GM","SEVELAMER CARBONATE PACKET 2.4 GM","1","0","0","0","","","ENDOCRINE AND METABOLIC","PHOSPHATE BINDER AGENTS"],["N","G","SEVELAMER TAB 400MG","SEVELAMER HCL TAB 400 MG","1","0","0","0","","","ENDOCRINE AND METABOLIC","PHOSPHATE BINDER AGENTS"],["N","G","SEVELAMER TAB 800MG","SEVELAMER HCL TAB 800 MG","1","0","0","0","","","ENDOCRINE AND METABOLIC","PHOSPHATE BINDER AGENTS"],["N","G","SEVELAMER TAB 800MG","SEVELAMER CARBONATE TAB 800 MG","1","0","0","0","","","ENDOCRINE AND METABOLIC","PHOSPHATE BINDER AGENTS"],["N","G","VELPHORO CHW 500MG","SUCROFERRIC OXYHYDROXIDE CHEW TAB 500 MG","3","0","0","0","","","ENDOCRINE AND METABOLIC","PHOSPHATE BINDER AGENTS"],["N","G","CRINONE GEL 4% VAG","PROGESTERONE VAGINAL GEL 4%","2","0","0","0","","","ENDOCRINE AND METABOLIC","PROGESTINS"],["N","G","CRINONE GEL 8% VAG","PROGESTERONE VAGINAL GEL 8%","2","0","0","0","","","ENDOCRINE AND METABOLIC","PROGESTINS"],["N","G","LUPANETA KIT 11.25-5","LEUPROLIDE (3 MON) INJ 11.25 MG & NORETHINDRONE TAB 5 MG KIT","4","1","0","0","","SP","ENDOCRINE AND METABOLIC","PROGESTINS"],["N","G","LUPANETA KIT 3.75-5","LEUPROLIDE (1 MON) INJ 3.75 MG & NORETHINDRONE TAB 5 MG KIT","4","1","0","0","","SP","ENDOCRINE AND METABOLIC","PROGESTINS"],["N","G","MEDROXYPR AC TAB 10MG","MEDROXYPROGESTERONE ACETATE TAB 10 MG","1","0","0","0","","","ENDOCRINE AND METABOLIC","PROGESTINS"],["N","G","MEDROXYPR AC TAB 2.5MG","MEDROXYPROGESTERONE ACETATE TAB 2.5 MG","1","0","0","0","","","ENDOCRINE AND METABOLIC","PROGESTINS"],["N","G","MEDROXYPR AC TAB 5MG","MEDROXYPROGESTERONE ACETATE TAB 5 MG","1","0","0","0","","","ENDOCRINE AND METABOLIC","PROGESTINS"],["N","G","NORETHIN ACE TAB 5MG","NORETHINDRONE ACETATE TAB 5 MG","1","0","0","0","","","ENDOCRINE AND METABOLIC","PROGESTINS"],["N","G","PROGESTERONE CAP 100MG","PROGESTERONE MICRONIZED CAP 100 MG","1","0","0","0","","","ENDOCRINE AND METABOLIC","PROGESTINS"],["N","G","PROGESTERONE CAP 200MG","PROGESTERONE MICRONIZED CAP 200 MG","1","0","0","0","","","ENDOCRINE AND METABOLIC","PROGESTINS"],["N","G","LEVOTHYROXIN TAB 100MCG","LEVOTHYROXINE SODIUM TAB 100 MCG","1","0","0","0","","","ENDOCRINE AND METABOLIC","THYROID AGENTS"],["N","G","LEVOTHYROXIN TAB 112MCG","LEVOTHYROXINE SODIUM TAB 112 MCG","1","0","0","0","","","ENDOCRINE AND METABOLIC","THYROID AGENTS"],["N","G","LEVOTHYROXIN TAB 125MCG","LEVOTHYROXINE SODIUM TAB 125 MCG","1","0","0","0","","","ENDOCRINE AND METABOLIC","THYROID AGENTS"],["N","G","LEVOTHYROXIN TAB 137MCG","LEVOTHYROXINE SODIUM TAB 137 MCG","1","0","0","0","","","ENDOCRINE AND METABOLIC","THYROID AGENTS"],["N","G","LEVOTHYROXIN TAB 150MCG","LEVOTHYROXINE SODIUM TAB 150 MCG","1","0","0","0","","","ENDOCRINE AND METABOLIC","THYROID AGENTS"],["N","G","LEVOTHYROXIN TAB 175MCG","LEVOTHYROXINE SODIUM TAB 175 MCG","1","0","0","0","","","ENDOCRINE AND METABOLIC","THYROID AGENTS"],["N","G","LEVOTHYROXIN TAB 200MCG","LEVOTHYROXINE SODIUM TAB 200 MCG","1","0","0","0","","","ENDOCRINE AND METABOLIC","THYROID AGENTS"],["N","G","LEVOTHYROXIN TAB 25MCG","LEVOTHYROXINE SODIUM TAB 25 MCG","1","0","0","0","","","ENDOCRINE AND METABOLIC","THYROID AGENTS"],["N","G","LEVOTHYROXIN TAB 300MCG","LEVOTHYROXINE SODIUM TAB 300 MCG","1","0","0","0","","","ENDOCRINE AND METABOLIC","THYROID AGENTS"],["N","G","LEVOTHYROXIN TAB 50MCG","LEVOTHYROXINE SODIUM TAB 50 MCG","1","0","0","0","","","ENDOCRINE AND METABOLIC","THYROID AGENTS"],["N","G","LEVOTHYROXIN TAB 75MCG","LEVOTHYROXINE SODIUM TAB 75 MCG","1","0","0","0","","","ENDOCRINE AND METABOLIC","THYROID AGENTS"],["N","G","LEVOTHYROXIN TAB 88MCG","LEVOTHYROXINE SODIUM TAB 88 MCG","1","0","0","0","","","ENDOCRINE AND METABOLIC","THYROID AGENTS"],["N","G","LEVOXYL TAB 100MCG","LEVOTHYROXINE SODIUM TAB 100 MCG","1","0","0","0","","","ENDOCRINE AND METABOLIC","THYROID AGENTS"],["N","G","LEVOXYL TAB 112MCG","LEVOTHYROXINE SODIUM TAB 112 MCG","1","0","0","0","","","ENDOCRINE AND METABOLIC","THYROID AGENTS"],["N","G","LEVOXYL TAB 125MCG","LEVOTHYROXINE SODIUM TAB 125 MCG","1","0","0","0","","","ENDOCRINE AND METABOLIC","THYROID AGENTS"],["N","G","LEVOXYL TAB 137MCG","LEVOTHYROXINE SODIUM TAB 137 MCG","1","0","0","0","","","ENDOCRINE AND METABOLIC","THYROID AGENTS"],["N","G","LEVOXYL TAB 150MCG","LEVOTHYROXINE SODIUM TAB 150 MCG","1","0","0","0","","","ENDOCRINE AND METABOLIC","THYROID AGENTS"],["N","G","LEVOXYL TAB 175MCG","LEVOTHYROXINE SODIUM TAB 175 MCG","1","0","0","0","","","ENDOCRINE AND METABOLIC","THYROID AGENTS"],["N","G","LEVOXYL TAB 200MCG","LEVOTHYROXINE SODIUM TAB 200 MCG","1","0","0","0","","","ENDOCRINE AND METABOLIC","THYROID AGENTS"],["N","G","LEVOXYL TAB 25MCG","LEVOTHYROXINE SODIUM TAB 25 MCG","1","0","0","0","","","ENDOCRINE AND METABOLIC","THYROID AGENTS"],["N","G","LEVOXYL TAB 50MCG","LEVOTHYROXINE SODIUM TAB 50 MCG","1","0","0","0","","","ENDOCRINE AND METABOLIC","THYROID AGENTS"],["N","G","LEVOXYL TAB 75MCG","LEVOTHYROXINE SODIUM TAB 75 MCG","1","0","0","0","","","ENDOCRINE AND METABOLIC","THYROID AGENTS"],["N","G","LEVOXYL TAB 88MCG","LEVOTHYROXINE SODIUM TAB 88 MCG","1","0","0","0","","","ENDOCRINE AND METABOLIC","THYROID AGENTS"],["N","G","LIOTHYRONINE INJ 10MCG/ML","LIOTHYRONINE SODIUM IV SOLN 10 MCG/ML","1","0","0","0","","","ENDOCRINE AND METABOLIC","THYROID AGENTS"],["N","G","LIOTHYRONINE TAB 25MCG","LIOTHYRONINE SODIUM TAB 25 MCG","1","0","0","0","","","ENDOCRINE AND METABOLIC","THYROID AGENTS"],["N","G","LIOTHYRONINE TAB 50MCG","LIOTHYRONINE SODIUM TAB 50 MCG","1","0","0","0","","","ENDOCRINE AND METABOLIC","THYROID AGENTS"],["N","G","LIOTHYRONINE TAB 5MCG","LIOTHYRONINE SODIUM TAB 5 MCG","1","0","0","0","","","ENDOCRINE AND METABOLIC","THYROID AGENTS"],["N","G","METHIMAZOLE TAB 10MG","METHIMAZOLE TAB 10 MG","1","0","0","0","","","ENDOCRINE AND METABOLIC","THYROID AGENTS"],["N","G","METHIMAZOLE TAB 5MG","METHIMAZOLE TAB 5 MG","1","0","0","0","","","ENDOCRINE AND METABOLIC","THYROID AGENTS"],["N","G","PROPYLTHIOUR TAB 50MG","PROPYLTHIOURACIL TAB 50 MG","1","0","0","0","","","ENDOCRINE AND METABOLIC","THYROID AGENTS"],["N","G","SYNTHROID TAB 100MCG","LEVOTHYROXINE SODIUM TAB 100 MCG","2","0","0","0","","","ENDOCRINE AND METABOLIC","THYROID AGENTS"],["N","G","SYNTHROID TAB 112MCG","LEVOTHYROXINE SODIUM TAB 112 MCG","2","0","0","0","","","ENDOCRINE AND METABOLIC","THYROID AGENTS"],["N","G","SYNTHROID TAB 125MCG","LEVOTHYROXINE SODIUM TAB 125 MCG","2","0","0","0","","","ENDOCRINE AND METABOLIC","THYROID AGENTS"],["N","G","SYNTHROID TAB 137MCG","LEVOTHYROXINE SODIUM TAB 137 MCG","2","0","0","0","","","ENDOCRINE AND METABOLIC","THYROID AGENTS"],["N","G","SYNTHROID TAB 150MCG","LEVOTHYROXINE SODIUM TAB 150 MCG","2","0","0","0","","","ENDOCRINE AND METABOLIC","THYROID AGENTS"],["N","G","SYNTHROID TAB 175MCG","LEVOTHYROXINE SODIUM TAB 175 MCG","2","0","0","0","","","ENDOCRINE AND METABOLIC","THYROID AGENTS"],["N","G","SYNTHROID TAB 200MCG","LEVOTHYROXINE SODIUM TAB 200 MCG","2","0","0","0","","","ENDOCRINE AND METABOLIC","THYROID AGENTS"],["N","G","SYNTHROID TAB 25MCG","LEVOTHYROXINE SODIUM TAB 25 MCG","2","0","0","0","","","ENDOCRINE AND METABOLIC","THYROID AGENTS"],["N","G","SYNTHROID TAB 300MCG","LEVOTHYROXINE SODIUM TAB 300 MCG","2","0","0","0","","","ENDOCRINE AND METABOLIC","THYROID AGENTS"],["N","G","SYNTHROID TAB 50MCG","LEVOTHYROXINE SODIUM TAB 50 MCG","2","0","0","0","","","ENDOCRINE AND METABOLIC","THYROID AGENTS"],["N","G","SYNTHROID TAB 75MCG","LEVOTHYROXINE SODIUM TAB 75 MCG","2","0","0","0","","","ENDOCRINE AND METABOLIC","THYROID AGENTS"],["N","G","SYNTHROID TAB 88MCG","LEVOTHYROXINE SODIUM TAB 88 MCG","2","0","0","0","","","ENDOCRINE AND METABOLIC","THYROID AGENTS"],["N","G","THYROLAR-1 TAB 60MG","LIOTRIX (T3-T4) TAB 60 MG (12.5-50 MCG)","3","0","0","0","","","ENDOCRINE AND METABOLIC","THYROID AGENTS"],["N","G","THYROLAR-1/2 TAB 30MG","LIOTRIX (T3-T4) TAB 30 MG (6.25-25 MCG)","3","0","0","0","","","ENDOCRINE AND METABOLIC","THYROID AGENTS"],["N","G","THYROLAR-1/4 TAB 15MG","LIOTRIX (T3-T4) TAB 15 MG (3.1-12.5 MCG)","3","0","0","0","","","ENDOCRINE AND METABOLIC","THYROID AGENTS"],["N","G","THYROLAR-2 TAB 120MG","LIOTRIX (T3-T4) TAB 120 MG (25-100 MCG)","3","0","0","0","","","ENDOCRINE AND METABOLIC","THYROID AGENTS"],["N","G","THYROLAR-3 TAB 180MG","LIOTRIX (T3-T4) TAB 180 MG (37.5-150 MCG)","3","0","0","0","","","ENDOCRINE AND METABOLIC","THYROID AGENTS"],["N","G","UNITHROID TAB 100MCG","LEVOTHYROXINE SODIUM TAB 100 MCG","1","0","0","0","","","ENDOCRINE AND METABOLIC","THYROID AGENTS"],["N","G","UNITHROID TAB 112MCG","LEVOTHYROXINE SODIUM TAB 112 MCG","1","0","0","0","","","ENDOCRINE AND METABOLIC","THYROID AGENTS"],["N","G","UNITHROID TAB 125MCG","LEVOTHYROXINE SODIUM TAB 125 MCG","1","0","0","0","","","ENDOCRINE AND METABOLIC","THYROID AGENTS"],["N","G","UNITHROID TAB 200MCG","LEVOTHYROXINE SODIUM TAB 200 MCG","1","0","0","0","","","ENDOCRINE AND METABOLIC","THYROID AGENTS"],["N","G","UNITHROID TAB 25MCG","LEVOTHYROXINE SODIUM TAB 25 MCG","1","0","0","0","","","ENDOCRINE AND METABOLIC","THYROID AGENTS"],["N","G","UNITHROID TAB 300MCG","LEVOTHYROXINE SODIUM TAB 300 MCG","1","0","0","0","","","ENDOCRINE AND METABOLIC","THYROID AGENTS"],["N","G","UNITHROID TAB 50MCG","LEVOTHYROXINE SODIUM TAB 50 MCG","1","0","0","0","","","ENDOCRINE AND METABOLIC","THYROID AGENTS"],["N","G","UNITHROID TAB 75MCG","LEVOTHYROXINE SODIUM TAB 75 MCG","1","0","0","0","","","ENDOCRINE AND METABOLIC","THYROID AGENTS"],["N","G","UNITHROID TAB 88MCG","LEVOTHYROXINE SODIUM TAB 88 MCG","1","0","0","0","","","ENDOCRINE AND METABOLIC","THYROID AGENTS"],["N","G","DESMOPRESSIN INJ 4MCG/ML","DESMOPRESSIN ACETATE INJ 4 MCG/ML","1","0","0","0","","","ENDOCRINE AND METABOLIC","VASOPRESSINS"],["N","G","DESMOPRESSIN SPR 0.01%","DESMOPRESSIN ACETATE NASAL SPRAY SOLN 0.01%","1","0","0","0","","","ENDOCRINE AND METABOLIC","VASOPRESSINS"],["N","G","DESMOPRESSIN SPR 0.01%","DESMOPRESSIN ACETATE NASAL SPRAY SOLN 0.01% (REFRIGERATED)","1","0","0","0","","","ENDOCRINE AND METABOLIC","VASOPRESSINS"],["N","G","DESMOPRESSIN TAB 0.1MG","DESMOPRESSIN ACETATE TAB 0.1 MG","1","0","0","0","","","ENDOCRINE AND METABOLIC","VASOPRESSINS"],["N","G","DESMOPRESSIN TAB 0.2MG","DESMOPRESSIN ACETATE TAB 0.2 MG","1","0","0","0","","","ENDOCRINE AND METABOLIC","VASOPRESSINS"],["N","G","ATROPINE SUL INJ 0.05MG/1","ATROPINE SULFATE SOLN PREFILL SYR 0.25 MG/5ML (0.05 MG/ML)","1","0","0","0","","","GASTROINTESTINAL","ANTICHOLINERGICS"],["N","G","ATROPINE SUL INJ 0.1MG/ML","ATROPINE SULFATE SOLN PREFILL SYR 1 MG/10ML (0.1 MG/ML)","1","0","0","0","","","GASTROINTESTINAL","ANTICHOLINERGICS"],["N","G","CUVPOSA SOL 1MG/5ML","GLYCOPYRROLATE ORAL SOLN 1 MG/5ML","2","0","0","0","","","GASTROINTESTINAL","ANTICHOLINERGICS"],["N","G","DICYCLOMINE CAP 10MG","DICYCLOMINE HCL CAP 10 MG","1","0","0","0","","","GASTROINTESTINAL","ANTICHOLINERGICS"],["N","G","DICYCLOMINE INJ 10MG/ML","DICYCLOMINE HCL INJ 10 MG/ML","1","0","0","0","","","GASTROINTESTINAL","ANTICHOLINERGICS"],["N","G","DICYCLOMINE SOL 10MG/5ML","DICYCLOMINE HCL ORAL SOLN 10 MG/5ML","1","0","0","0","","","GASTROINTESTINAL","ANTICHOLINERGICS"],["N","G","DICYCLOMINE TAB 20MG","DICYCLOMINE HCL TAB 20 MG","1","0","0","0","","","GASTROINTESTINAL","ANTICHOLINERGICS"],["N","G","ED-SPAZ TAB 0.125MG","HYOSCYAMINE SULFATE TAB DISINT 0.125 MG","1","0","0","0","","","GASTROINTESTINAL","ANTICHOLINERGICS"],["N","G","GLYCOPYRROL INJ 0.2MG/ML","GLYCOPYRROLATE INJ 4 MG/20ML (0.2 MG/ML)","1","0","0","0","","","GASTROINTESTINAL","ANTICHOLINERGICS"],["N","G","GLYCOPYRROL INJ 0.2MG/ML","GLYCOPYRROLATE INJ 0.2 MG/ML","1","0","0","0","","","GASTROINTESTINAL","ANTICHOLINERGICS"],["N","G","GLYCOPYRROL INJ 0.4/2ML","GLYCOPYRROLATE INJ 0.4 MG/2ML (0.2 MG/ML)","1","0","0","0","","","GASTROINTESTINAL","ANTICHOLINERGICS"],["N","G","GLYCOPYRROL INJ 1MG/5ML","GLYCOPYRROLATE INJ 1 MG/5ML (0.2 MG/ML)","1","0","0","0","","","GASTROINTESTINAL","ANTICHOLINERGICS"],["N","G","GLYCOPYRROL INJ 1MG/5ML","GLYCOPYRROLATE INJ 1 MG/5ML (0.2 MG/ML)","1","0","0","0","","","GASTROINTESTINAL","ANTICHOLINERGICS"],["N","G","GLYCOPYRROL INJ 4MG/20ML","GLYCOPYRROLATE INJ 4 MG/20ML (0.2 MG/ML)","1","0","0","0","","","GASTROINTESTINAL","ANTICHOLINERGICS"],["N","G","GLYCOPYRROL TAB 1MG","GLYCOPYRROLATE TAB 1 MG","1","0","0","0","","","GASTROINTESTINAL","ANTICHOLINERGICS"],["N","G","GLYCOPYRROL TAB 2MG","GLYCOPYRROLATE TAB 2 MG","1","0","0","0","","","GASTROINTESTINAL","ANTICHOLINERGICS"],["N","G","HYOSCYAMINE SUB 0.125MG","HYOSCYAMINE SULFATE SL TAB 0.125 MG","1","0","0","0","","","GASTROINTESTINAL","ANTICHOLINERGICS"],["N","G","HYOSCYAMINE TAB 0.125MG","HYOSCYAMINE SULFATE TAB 0.125 MG","1","0","0","0","","","GASTROINTESTINAL","ANTICHOLINERGICS"],["N","G","HYOSCYAMINE TAB 0.125MG","HYOSCYAMINE SULFATE TAB DISINT 0.125 MG","1","0","0","0","","","GASTROINTESTINAL","ANTICHOLINERGICS"],["N","G","HYOSCYAMINE TAB 0.375 ER","HYOSCYAMINE SULFATE TAB ER 12HR 0.375 MG","1","0","0","0","","","GASTROINTESTINAL","ANTICHOLINERGICS"],["N","G","METHSCOPOLAM TAB 2.5MG","METHSCOPOLAMINE BROMIDE TAB 2.5 MG","1","0","0","0","","","GASTROINTESTINAL","ANTICHOLINERGICS"],["N","G","METHSCOPOLAM TAB 5MG","METHSCOPOLAMINE BROMIDE TAB 5 MG","1","0","0","0","","","GASTROINTESTINAL","ANTICHOLINERGICS"],["N","G","NULEV TAB 0.125MG","HYOSCYAMINE SULFATE TAB DISINT 0.125 MG","1","0","0","0","","","GASTROINTESTINAL","ANTICHOLINERGICS"],["N","G","OSCIMIN SR TAB 0.375MG","HYOSCYAMINE SULFATE TAB ER 12HR 0.375 MG","1","0","0","0","","","GASTROINTESTINAL","ANTICHOLINERGICS"],["N","G","OSCIMIN SUB 0.125MG","HYOSCYAMINE SULFATE SL TAB 0.125 MG","1","0","0","0","","","GASTROINTESTINAL","ANTICHOLINERGICS"],["N","G","OSCIMIN TAB 0.125MG","HYOSCYAMINE SULFATE TAB 0.125 MG","1","0","0","0","","","GASTROINTESTINAL","ANTICHOLINERGICS"],["N","G","SYMAX-SL SUB 0.125MG","HYOSCYAMINE SULFATE SL TAB 0.125 MG","1","0","0","0","","","GASTROINTESTINAL","ANTICHOLINERGICS"],["N","G","AKYNZEO CAP 300-0.5","NETUPITANT-PALONOSETRON CAP 300-0.5 MG","3","0","0","1","2 caps every 21 days","","GASTROINTESTINAL","ANTIEMETICS§"],["N","G","APREPITANT CAP 125MG","APREPITANT CAPSULE 125 MG","1","0","0","1","2 caps every 21 days","","GASTROINTESTINAL","ANTIEMETICS§"],["N","G","APREPITANT CAP 40MG","APREPITANT CAPSULE 40 MG","1","0","0","1","3 caps every 180 days","","GASTROINTESTINAL","ANTIEMETICS§"],["N","G","APREPITANT CAP 80MG","APREPITANT CAPSULE 80 MG","1","0","0","1","4 caps every 21 days","","GASTROINTESTINAL","ANTIEMETICS§"],["N","G","APREPITANT PAK 80 & 125","APREPITANT CAPSULE THERAPY PACK 80 & 125 MG","1","0","0","1","2 packs every 21 days","","GASTROINTESTINAL","ANTIEMETICS§"],["N","G","CESAMET CAP 1MG","NABILONE CAP 1 MG","3","0","0","1","18 caps every 21 days","","GASTROINTESTINAL","ANTIEMETICS§"],["N","G","COMPRO SUP 25MG","PROCHLORPERAZINE SUPPOS 25 MG","1","0","0","0","","","GASTROINTESTINAL","ANTIEMETICS§"],["N","G","DRONABINOL CAP 10MG","DRONABINOL CAP 10 MG","1","0","0","1","60 caps every 25 days","","GASTROINTESTINAL","ANTIEMETICS§"],["N","G","DRONABINOL CAP 2.5MG","DRONABINOL CAP 2.5 MG","1","0","0","1","60 caps every 25 days","","GASTROINTESTINAL","ANTIEMETICS§"],["N","G","DRONABINOL CAP 5MG","DRONABINOL CAP 5 MG","1","0","0","1","60 caps every 25 days","","GASTROINTESTINAL","ANTIEMETICS§"],["N","G","GRANISETRON INJ 0.1MG/ML","GRANISETRON HCL INJ 0.1 MG/ML","1","0","0","1","2 mL every 21 days","","GASTROINTESTINAL","ANTIEMETICS§"],["N","G","GRANISETRON INJ 1MG/ML","GRANISETRON HCL INJ 1 MG/ML","1","0","0","1","2 mL every 21 days","","GASTROINTESTINAL","ANTIEMETICS§"],["N","G","GRANISETRON INJ 4MG/4ML","GRANISETRON HCL INJ 4 MG/4ML (1 MG/ML)","1","0","0","1","2 mL every 21 days","","GASTROINTESTINAL","ANTIEMETICS§"],["N","G","GRANISETRON TAB 1MG","GRANISETRON HCL TAB 1 MG","1","0","0","1","12 tabs every 21 days","","GASTROINTESTINAL","ANTIEMETICS§"],["N","G","MECLIZINE TAB 12.5MG","MECLIZINE HCL TAB 12.5 MG","1","0","0","0","","","GASTROINTESTINAL","ANTIEMETICS§"],["N","G","MECLIZINE TAB 25MG","MECLIZINE HCL TAB 25 MG","1","0","0","0","","","GASTROINTESTINAL","ANTIEMETICS§"],["N","G","METOCLOPRAM INJ 5MG/ML","METOCLOPRAMIDE HCL INJ 5 MG/ML (BASE EQUIVALENT)","1","0","0","0","","","GASTROINTESTINAL","ANTIEMETICS§"],["N","G","METOCLOPRAM SOL 5MG/5ML","METOCLOPRAMIDE HCL SOLN 5 MG/5ML (10 MG/10ML) (BASE EQUIV)","1","0","0","0","","","GASTROINTESTINAL","ANTIEMETICS§"],["N","G","METOCLOPRAM TAB 10MG","METOCLOPRAMIDE HCL TAB 10 MG (BASE EQUIVALENT)","1","0","0","0","","","GASTROINTESTINAL","ANTIEMETICS§"],["N","G","METOCLOPRAM TAB 5MG","METOCLOPRAMIDE HCL TAB 5 MG (BASE EQUIVALENT)","1","0","0","0","","","GASTROINTESTINAL","ANTIEMETICS§"],["N","G","METOCLOPRAM TAB 5MG ODT","METOCLOPRAMIDE HCL ORALLY DISINTEGRATING TAB 5 MG (BASE EQ)","1","0","0","0","","","GASTROINTESTINAL","ANTIEMETICS§"],["N","G","ONDANSETRON INJ 40/20ML","ONDANSETRON HCL INJ 40 MG/20ML (2 MG/ML)","1","0","0","1","20 mL every 21 days","","GASTROINTESTINAL","ANTIEMETICS§"],["N","G","ONDANSETRON INJ 4MG/2ML","ONDANSETRON HCL INJ 4 MG/2ML (2 MG/ML)","1","0","0","1","20 mL every 21 days","","GASTROINTESTINAL","ANTIEMETICS§"],["N","G","ONDANSETRON SOL 4MG/5ML","ONDANSETRON HCL ORAL SOLN 4 MG/5ML","1","0","0","1","200 mL every 21 days","","GASTROINTESTINAL","ANTIEMETICS§"],["N","G","ONDANSETRON TAB 24MG","ONDANSETRON HCL TAB 24 MG","1","0","0","1","2 tabs every 21 days","","GASTROINTESTINAL","ANTIEMETICS§"],["N","G","ONDANSETRON TAB 4MG","ONDANSETRON HCL TAB 4 MG","1","0","0","1","18 tabs every 21 days","","GASTROINTESTINAL","ANTIEMETICS§"],["N","G","ONDANSETRON TAB 4MG ODT","ONDANSETRON ORALLY DISINTEGRATING TAB 4 MG","1","0","0","1","18 tabs every 21 days","","GASTROINTESTINAL","ANTIEMETICS§"],["N","G","ONDANSETRON TAB 8MG","ONDANSETRON HCL TAB 8 MG","1","0","0","1","18 tabs every 21 days","","GASTROINTESTINAL","ANTIEMETICS§"],["N","G","ONDANSETRON TAB 8MG ODT","ONDANSETRON ORALLY DISINTEGRATING TAB 8 MG","1","0","0","1","18 tabs every 21 days","","GASTROINTESTINAL","ANTIEMETICS§"],["N","G","PHENADOZ SUP 25MG","PROMETHAZINE HCL SUPPOS 25 MG","1","0","0","0","","","GASTROINTESTINAL","ANTIEMETICS§"],["N","G","PROCHLORPER SUP 25MG","PROCHLORPERAZINE SUPPOS 25 MG","1","0","0","0","","","GASTROINTESTINAL","ANTIEMETICS§"],["N","G","PROCHLORPER TAB 10MG","PROCHLORPERAZINE MALEATE TAB 10 MG (BASE EQUIVALENT)","1","0","0","0","","","GASTROINTESTINAL","ANTIEMETICS§"],["N","G","PROCHLORPER TAB 5MG","PROCHLORPERAZINE MALEATE TAB 5 MG (BASE EQUIVALENT)","1","0","0","0","","","GASTROINTESTINAL","ANTIEMETICS§"],["N","G","PROMETHAZINE INJ 25MG/ML","PROMETHAZINE HCL INJ 25 MG/ML","1","0","0","0","","","GASTROINTESTINAL","ANTIEMETICS§"],["N","G","PROMETHAZINE INJ 50MG/ML","PROMETHAZINE HCL INJ 50 MG/ML","1","0","0","0","","","GASTROINTESTINAL","ANTIEMETICS§"],["N","G","PROMETHAZINE SUP 12.5MG","PROMETHAZINE HCL SUPPOS 12.5 MG","1","0","0","0","","","GASTROINTESTINAL","ANTIEMETICS§"],["N","G","PROMETHAZINE SUP 25MG","PROMETHAZINE HCL SUPPOS 25 MG","1","0","0","0","","","GASTROINTESTINAL","ANTIEMETICS§"],["N","G","PROMETHAZINE SYP 6.25/5ML","PROMETHAZINE HCL SYRUP 6.25 MG/5ML","1","1","0","0","","High Risk Medications require PA for members age 70 and older","GASTROINTESTINAL","ANTIEMETICS§"],["N","G","PROMETHAZINE TAB 12.5MG","PROMETHAZINE HCL TAB 12.5 MG","1","1","0","0","","High Risk Medications require PA for members age 70 and older","GASTROINTESTINAL","ANTIEMETICS§"],["N","G","PROMETHAZINE TAB 25MG","PROMETHAZINE HCL TAB 25 MG","1","1","0","0","","High Risk Medications require PA for members age 70 and older","GASTROINTESTINAL","ANTIEMETICS§"],["N","G","PROMETHAZINE TAB 50MG","PROMETHAZINE HCL TAB 50 MG","1","1","0","0","","High Risk Medications require PA for members age 70 and older","GASTROINTESTINAL","ANTIEMETICS§"],["N","G","PROMETHEGAN SUP 12.5MG","PROMETHAZINE HCL SUPPOS 12.5 MG","1","0","0","0","","","GASTROINTESTINAL","ANTIEMETICS§"],["N","G","PROMETHEGAN SUP 25MG","PROMETHAZINE HCL SUPPOS 25 MG","1","0","0","0","","","GASTROINTESTINAL","ANTIEMETICS§"],["N","G","PROMETHEGAN SUP 50MG","PROMETHAZINE HCL SUPPOS 50 MG","1","0","0","0","","","GASTROINTESTINAL","ANTIEMETICS§"],["N","G","SANCUSO DIS 3.1MG","GRANISETRON TD PATCH 3.1 MG/24HR (CONTAINS 34.3 MG)","2","0","0","1","2 patches every 21 days","","GASTROINTESTINAL","ANTIEMETICS§"],["N","G","SCOPOLAMINE DIS 1MG/3DAY","SCOPOLAMINE TD PATCH 72HR 1 MG/3DAYS","1","0","0","0","","","GASTROINTESTINAL","ANTIEMETICS§"],["N","G","TRANSDERM-SC DIS 1.5MG","SCOPOLAMINE TD PATCH 72HR 1 MG/3DAYS","3","0","0","0","","","GASTROINTESTINAL","ANTIEMETICS§"],["N","G","TRIMETHOBENZ CAP 300MG","TRIMETHOBENZAMIDE HCL CAP 300 MG","1","0","0","0","","","GASTROINTESTINAL","ANTIEMETICS§"],["N","G","VARUBI INJ","ROLAPITANT HCL IV EMUL 166.5 MG/92.5ML (1.8 MG/ML) (BASE EQ)","2","0","0","0","","","GASTROINTESTINAL","ANTIEMETICS§"],["N","G","VARUBI TAB 90MG","ROLAPITANT HCL TAB 90 MG (BASE EQUIV)","2","0","0","0","","","GASTROINTESTINAL","ANTIEMETICS§"],["N","G","CIMETIDINE SOL 300/5ML","CIMETIDINE HCL SOLN 300 MG/5ML","1","0","0","0","","","GASTROINTESTINAL","H2-RECEPTOR ANTAGONISTS"],["N","G","CIMETIDINE TAB 200MG","CIMETIDINE TAB 200 MG","1","0","0","0","","","GASTROINTESTINAL","H2-RECEPTOR ANTAGONISTS"],["N","G","CIMETIDINE TAB 300MG","CIMETIDINE TAB 300 MG","1","0","0","0","","","GASTROINTESTINAL","H2-RECEPTOR ANTAGONISTS"],["N","G","CIMETIDINE TAB 400MG","CIMETIDINE TAB 400 MG","1","0","0","0","","","GASTROINTESTINAL","H2-RECEPTOR ANTAGONISTS"],["N","G","CIMETIDINE TAB 800MG","CIMETIDINE TAB 800 MG","1","0","0","0","","","GASTROINTESTINAL","H2-RECEPTOR ANTAGONISTS"],["N","G","FAMOTIDINE INJ 10MG/ML","FAMOTIDINE INJ 20 MG/2ML","1","0","0","0","","","GASTROINTESTINAL","H2-RECEPTOR ANTAGONISTS"],["N","G","FAMOTIDINE INJ 200/20ML","FAMOTIDINE INJ 200 MG/20ML","1","0","0","0","","","GASTROINTESTINAL","H2-RECEPTOR ANTAGONISTS"],["N","G","FAMOTIDINE INJ 20MG/2ML","FAMOTIDINE INJ 20 MG/2ML","1","0","0","0","","","GASTROINTESTINAL","H2-RECEPTOR ANTAGONISTS"],["N","G","FAMOTIDINE INJ 20MG/50M","FAMOTIDINE IN NACL 0.9% IV SOLN 20 MG/50ML","1","0","0","0","","","GASTROINTESTINAL","H2-RECEPTOR ANTAGONISTS"],["N","G","FAMOTIDINE INJ 40MG/4ML","FAMOTIDINE INJ 40 MG/4ML","1","0","0","0","","","GASTROINTESTINAL","H2-RECEPTOR ANTAGONISTS"],["N","G","FAMOTIDINE SUS 40MG/5ML","FAMOTIDINE FOR SUSP 40 MG/5ML","1","0","0","0","","","GASTROINTESTINAL","H2-RECEPTOR ANTAGONISTS"],["N","G","FAMOTIDINE TAB 20MG","FAMOTIDINE TAB 20 MG","1","0","0","0","","","GASTROINTESTINAL","H2-RECEPTOR ANTAGONISTS"],["N","G","FAMOTIDINE TAB 40MG","FAMOTIDINE TAB 40 MG","1","0","0","0","","","GASTROINTESTINAL","H2-RECEPTOR ANTAGONISTS"],["N","G","NIZATIDINE CAP 150MG","NIZATIDINE CAP 150 MG","1","0","0","0","","","GASTROINTESTINAL","H2-RECEPTOR ANTAGONISTS"],["N","G","NIZATIDINE CAP 300MG","NIZATIDINE CAP 300 MG","1","0","0","0","","","GASTROINTESTINAL","H2-RECEPTOR ANTAGONISTS"],["N","G","NIZATIDINE SOL 15MG/ML","NIZATIDINE ORAL SOLN 15 MG/ML","1","0","0","0","","","GASTROINTESTINAL","H2-RECEPTOR ANTAGONISTS"],["N","G","RANITIDINE CAP 150MG","RANITIDINE HCL CAP 150 MG","1","0","0","0","","","GASTROINTESTINAL","H2-RECEPTOR ANTAGONISTS"],["N","G","RANITIDINE CAP 300MG","RANITIDINE HCL CAP 300 MG","1","0","0","0","","","GASTROINTESTINAL","H2-RECEPTOR ANTAGONISTS"],["N","G","RANITIDINE INJ 150/6ML","RANITIDINE HCL INJ 150 MG/6ML (25 MG/ML)","1","0","0","0","","","GASTROINTESTINAL","H2-RECEPTOR ANTAGONISTS"],["N","G","RANITIDINE INJ 50MG/2ML","RANITIDINE HCL INJ 50 MG/2ML (25 MG/ML)","1","0","0","0","","","GASTROINTESTINAL","H2-RECEPTOR ANTAGONISTS"],["N","G","RANITIDINE SYP 75MG/5ML","RANITIDINE HCL SYRUP 15 MG/ML (75 MG/5ML)","1","0","0","0","","","GASTROINTESTINAL","H2-RECEPTOR ANTAGONISTS"],["N","G","RANITIDINE TAB 150MG","RANITIDINE HCL TAB 150 MG","1","0","0","0","","","GASTROINTESTINAL","H2-RECEPTOR ANTAGONISTS"],["N","G","RANITIDINE TAB 300MG","RANITIDINE HCL TAB 300 MG","1","0","0","0","","","GASTROINTESTINAL","H2-RECEPTOR ANTAGONISTS"],["N","G","APRISO CAP 0.375GM","MESALAMINE CAP ER 24HR 0.375 GM","2","0","0","0","","","GASTROINTESTINAL","INFLAMMATORY BOWEL DISEASE"],["N","G","BALSALAZIDE CAP 750MG","BALSALAZIDE DISODIUM CAP 750 MG","1","0","0","0","","","GASTROINTESTINAL","INFLAMMATORY BOWEL DISEASE"],["N","G","BUDESONIDE CAP 3MG DR","BUDESONIDE DELAYED RELEASE PARTICLES CAP 3 MG","1","0","0","0","","","GASTROINTESTINAL","INFLAMMATORY BOWEL DISEASE"],["N","G","COLOCORT ENE 100MG","HYDROCORTISONE ENEMA 100 MG/60ML","1","0","0","0","","","GASTROINTESTINAL","INFLAMMATORY BOWEL DISEASE"],["N","G","DIPENTUM CAP 250MG","OLSALAZINE SODIUM CAP 250 MG","3","0","0","0","","","GASTROINTESTINAL","INFLAMMATORY BOWEL DISEASE"],["N","G","MESALAMINE ENE 4GM","MESALAMINE ENEMA 4 GM","1","0","0","0","","","GASTROINTESTINAL","INFLAMMATORY BOWEL DISEASE"],["N","G","MESALAMINE KIT 4GM","*MESALAMINE RECTAL ENEMA 4 GM & CLEANSER WIPE KIT**","1","0","0","0","","","GASTROINTESTINAL","INFLAMMATORY BOWEL DISEASE"],["N","G","MESALAMINE SUP 1000MG","MESALAMINE SUPPOS 1000 MG","1","0","0","0","","","GASTROINTESTINAL","INFLAMMATORY BOWEL DISEASE"],["N","G","SULFASALAZIN TAB 500MG","SULFASALAZINE TAB 500 MG","1","0","0","0","","","GASTROINTESTINAL","INFLAMMATORY BOWEL DISEASE"],["N","G","SULFASALAZIN TAB 500MG DR","SULFASALAZINE TAB DELAYED RELEASE 500 MG","1","0","0","0","","","GASTROINTESTINAL","INFLAMMATORY BOWEL DISEASE"],["N","G","AMITIZA CAP 24MCG","LUBIPROSTONE CAP 24 MCG","2","0","0","0","","","GASTROINTESTINAL","IRRITABLE BOWEL SYNDROME WITH CONSTIPATION"],["N","G","AMITIZA CAP 8MCG","LUBIPROSTONE CAP 8 MCG","2","0","0","0","","","GASTROINTESTINAL","IRRITABLE BOWEL SYNDROME WITH CONSTIPATION"],["N","G","LINZESS CAP 145MCG","LINACLOTIDE CAP 145 MCG","2","0","0","0","","","GASTROINTESTINAL","IRRITABLE BOWEL SYNDROME WITH CONSTIPATION"],["N","G","LINZESS CAP 290MCG","LINACLOTIDE CAP 290 MCG","2","0","0","0","","","GASTROINTESTINAL","IRRITABLE BOWEL SYNDROME WITH CONSTIPATION"],["N","G","LINZESS CAP 72MCG","LINACLOTIDE CAP 72 MCG","2","0","0","0","","","GASTROINTESTINAL","IRRITABLE BOWEL SYNDROME WITH CONSTIPATION"],["N","G","ALOSETRON TAB 0.5MG","ALOSETRON HCL TAB 0.5 MG (BASE EQUIV)","1","1","0","0","","","GASTROINTESTINAL","IRRITABLE BOWEL SYNDROME WITH DIARRHEA"],["N","G","ALOSETRON TAB 1MG","ALOSETRON HCL TAB 1 MG (BASE EQUIV)","1","1","0","0","","","GASTROINTESTINAL","IRRITABLE BOWEL SYNDROME WITH DIARRHEA"],["N","G","CLENPIQ SOL","SOD PICOSULFATE-MG OX-CITRIC AC SOL 10 MG-3.5 GM-12 GM/160ML","0","0","0","0","","$0 copay for members age 50 through 74, otherwise not covered","GASTROINTESTINAL","LAXATIVES"],["N","G","ENULOSE SOL 10GM/15","LACTULOSE (ENCEPHALOPATHY) SOLUTION 10 GM/15ML","1","0","0","0","","","GASTROINTESTINAL","LAXATIVES"],["N","G","GAVILYTE-C SOL","PEG 3350-KCL-NA BICARB-NACL-NA SULFATE FOR SOLN 240 GM","1","0","0","0","","","GASTROINTESTINAL","LAXATIVES"],["N","G","GAVILYTE-G SOL","PEG 3350-KCL-NA BICARB-NACL-NA SULFATE FOR SOLN 236 GM","1","0","0","0","","","GASTROINTESTINAL","LAXATIVES"],["N","G","GAVILYTE-H KIT","BISACODYL TAB & PEG 3350-KCL-SOD BICARB-NACL FOR SOLN KIT","0","0","0","0","","$0 copay for members age 50 through 74, otherwise not covered","GASTROINTESTINAL","LAXATIVES"],["N","G","GAVILYTE-N SOL FLAV PK","PEG 3350-KCL-SOD BICARB-NACL FOR SOLN 420 GM","1","0","0","0","","","GASTROINTESTINAL","LAXATIVES"],["N","G","GENERLAC SOL 10GM/15","LACTULOSE (ENCEPHALOPATHY) SOLUTION 10 GM/15ML","1","0","0","0","","","GASTROINTESTINAL","LAXATIVES"],["N","G","GOLYTELY SOL","PEG 3350-KCL-NA BICARB-NACL-NA SULFATE PACKET 227.1 GM","2","0","0","0","","","GASTROINTESTINAL","LAXATIVES"],["N","G","LACTULOSE SOL 10GM/15","LACTULOSE SOLUTION 10 GM/15ML","1","0","0","0","","","GASTROINTESTINAL","LAXATIVES"],["N","G","MOVIPREP SOL","PEG 3350-KCL-NACL-NA SULFATE-NA ASCORBATE-C FOR SOLN 100 GM","0","0","0","0","","$0 copay for members age 50 through 74; Tier 3 for all others","GASTROINTESTINAL","LAXATIVES"],["N","G","OSMOPREP TAB 1.5GM","SOD PHOS MONO-SOD PHOS DI TABS 1.102-0.398 GM(1.5GM NA PHOS)","3","0","0","0","","","GASTROINTESTINAL","LAXATIVES"],["N","G","PEG 3350 SOL ELECTROL","PEG 3350-KCL-NA BICARB-NACL-NA SULFATE FOR SOLN 240 GM","1","0","0","0","","","GASTROINTESTINAL","LAXATIVES"],["N","G","PEG-3350 SOL ELECTROL","PEG 3350-KCL-NA BICARB-NACL-NA SULFATE FOR SOLN 236 GM","1","0","0","0","","","GASTROINTESTINAL","LAXATIVES"],["N","G","PEG-3350/KCL SOL /SODIUM","PEG 3350-KCL-SOD BICARB-NACL FOR SOLN 420 GM","1","0","0","0","","","GASTROINTESTINAL","LAXATIVES"],["N","G","PLENVU SOL","PEG 3350-KCL-NACL-NA SULFATE-NA ASCORBATE-C FOR SOLN 140 GM","0","0","0","0","","$0 copay for members age 50 through 74, otherwise not covered","GASTROINTESTINAL","LAXATIVES"],["N","G","POLYETH GLYC POW 3350 NF","POLYETHYLENE GLYCOL 3350 ORAL POWDER","1","0","0","0","","","GASTROINTESTINAL","LAXATIVES"],["N","G","PREPOPIK PAK","SOD PICOSULFATE-MG OXIDE-CITRIC ACID PACK 10 MG-3.5 GM-12 GM","0","0","0","0","","$0 copay for members age 50 through 74, otherwise not covered","GASTROINTESTINAL","LAXATIVES"],["N","G","SUPREP BOWEL SOL PREP KIT","SOD SULFATE-POT SULF-MG SULF ORAL SOL 17.5-3.13-1.6 GM/177ML","0","0","0","0","","$0 copay for members age 50 through 74; Tier 3 for all others","GASTROINTESTINAL","LAXATIVES"],["N","G","CARAFATE SUS 1GM/10ML","SUCRALFATE SUSP 1 GM/10ML","3","0","0","0","","","GASTROINTESTINAL","MISCELLANEOUS"],["N","G","CROMOLYN SOD CON 100/5ML","CROMOLYN SODIUM ORAL CONC 100 MG/5ML","1","0","0","0","","","GASTROINTESTINAL","MISCELLANEOUS"],["N","G","DIPHEN/ATROP LIQ 2.5/5","DIPHENOXYLATE W/ ATROPINE LIQ 2.5-0.025 MG/5ML","1","0","0","0","","","GASTROINTESTINAL","MISCELLANEOUS"],["N","G","DIPHEN/ATROP TAB 2.5MG","DIPHENOXYLATE W/ ATROPINE TAB 2.5-0.025 MG","1","0","0","0","","","GASTROINTESTINAL","MISCELLANEOUS"],["N","G","LOPERAMIDE CAP 2MG","LOPERAMIDE HCL CAP 2 MG","1","0","0","0","","","GASTROINTESTINAL","MISCELLANEOUS"],["N","G","MISOPROSTOL TAB 100MCG","MISOPROSTOL TAB 100 MCG","1","0","0","0","","","GASTROINTESTINAL","MISCELLANEOUS"],["N","G","MISOPROSTOL TAB 200MCG","MISOPROSTOL TAB 200 MCG","1","0","0","0","","","GASTROINTESTINAL","MISCELLANEOUS"],["N","G","MOTOFEN TAB 1-0.025","DIFENOXIN W/ ATROPINE TAB 1-0.025 MG","3","0","0","0","","","GASTROINTESTINAL","MISCELLANEOUS"],["N","G","MOVANTIK TAB 12.5MG","NALOXEGOL OXALATE TAB 12.5 MG (BASE EQUIVALENT)","2","0","0","0","","","GASTROINTESTINAL","MISCELLANEOUS"],["N","G","MOVANTIK TAB 25MG","NALOXEGOL OXALATE TAB 25 MG (BASE EQUIVALENT)","2","0","0","0","","","GASTROINTESTINAL","MISCELLANEOUS"],["N","G","SUCRAID SOL 8500/ML","SACROSIDASE SOLN 8500 UNIT/ML","3","0","0","0","","","GASTROINTESTINAL","MISCELLANEOUS"],["N","G","SUCRALFATE TAB 1GM","SUCRALFATE TAB 1 GM","1","0","0","0","","","GASTROINTESTINAL","MISCELLANEOUS"],["N","G","URSODIOL CAP 300MG","URSODIOL CAP 300 MG","1","0","0","0","","","GASTROINTESTINAL","MISCELLANEOUS"],["N","G","URSODIOL TAB 250MG","URSODIOL TAB 250 MG","1","0","0","0","","","GASTROINTESTINAL","MISCELLANEOUS"],["N","G","URSODIOL TAB 500MG","URSODIOL TAB 500 MG","1","0","0","0","","","GASTROINTESTINAL","MISCELLANEOUS"],["N","G","CREON CAP 12000UNT","PANCRELIPASE (LIP-PROT-AMYL) DR CAP 12000-38000-60000 UNIT","2","0","0","0","","","GASTROINTESTINAL","PANCREATIC ENZYMES"],["N","G","CREON CAP 24000UNT","PANCRELIPASE (LIP-PROT-AMYL) DR CAP 24000-76000-120000 UNIT","2","0","0","0","","","GASTROINTESTINAL","PANCREATIC ENZYMES"],["N","G","CREON CAP 3000UNIT","PANCRELIPASE (LIP-PROT-AMYL) DR CAP 3000-9500-15000 UNIT","2","0","0","0","","","GASTROINTESTINAL","PANCREATIC ENZYMES"],["N","G","CREON CAP 36000UNT","PANCRELIPASE (LIP-PROT-AMYL) DR CAP 36000-114000-180000 UNIT","2","0","0","0","","","GASTROINTESTINAL","PANCREATIC ENZYMES"],["N","G","CREON CAP 6000UNIT","PANCRELIPASE (LIP-PROT-AMYL) DR CAP 6000-19000-30000 UNIT","2","0","0","0","","","GASTROINTESTINAL","PANCREATIC ENZYMES"],["N","G","VIOKACE TAB 10440","PANCRELIPASE (LIP-PROT-AMYL) TAB 10440-39150-39150 UNIT","2","0","0","0","","","GASTROINTESTINAL","PANCREATIC ENZYMES"],["N","G","VIOKACE TAB 20880","PANCRELIPASE (LIP-PROT-AMYL) TAB 20880-78300-78300 UNIT","2","0","0","0","","","GASTROINTESTINAL","PANCREATIC ENZYMES"],["N","G","ZENPEP CAP 10000UNT","PANCRELIPASE (LIP-PROT-AMYL) DR CAP 10000-32000-42000 UNIT","2","0","0","0","","","GASTROINTESTINAL","PANCREATIC ENZYMES"],["N","G","ZENPEP CAP 15000UNT","PANCRELIPASE (LIP-PROT-AMYL) DR CAP 15000-47000-63000 UNIT","2","0","0","0","","","GASTROINTESTINAL","PANCREATIC ENZYMES"],["N","G","ZENPEP CAP 20000UNT","PANCRELIPASE (LIP-PROT-AMYL) DR CAP 20000-63000-84000 UNIT","2","0","0","0","","","GASTROINTESTINAL","PANCREATIC ENZYMES"],["N","G","ZENPEP CAP 25000","PANCRELIPASE (LIP-PROT-AMYL) DR CAP 25000-79000-105000 UNIT","2","0","0","0","","","GASTROINTESTINAL","PANCREATIC ENZYMES"],["N","G","ZENPEP CAP 3000UNIT","PANCRELIPASE (LIP-PROT-AMYL) DR CAP 3000-10000-14000 UNIT","2","0","0","0","","","GASTROINTESTINAL","PANCREATIC ENZYMES"],["N","G","ZENPEP CAP 40000","PANCRELIPASE (LIP-PROT-AMYL) DR CAP 40000-126000-168000 UNIT","2","0","0","0","","","GASTROINTESTINAL","PANCREATIC ENZYMES"],["N","G","ZENPEP CAP 5000UNIT","PANCRELIPASE (LIP-PROT-AMYL) DR CAP 5000-17000-24000 UNIT","2","0","0","0","","","GASTROINTESTINAL","PANCREATIC ENZYMES"],["N","G","DEXILANT CAP 30MG DR","DEXLANSOPRAZOLE CAP DELAYED RELEASE 30 MG","3","0","1","1","90 caps every 365 days","PA**","GASTROINTESTINAL","PROTON PUMP INHIBITORS§"],["N","G","DEXILANT CAP 60MG DR","DEXLANSOPRAZOLE CAP DELAYED RELEASE 60 MG","3","0","1","1","90 caps every 365 days","PA**","GASTROINTESTINAL","PROTON PUMP INHIBITORS§"],["N","G","ESOMEPRA MAG CAP 20MG DR","ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ)","1","0","0","1","90 caps every 365 days","","GASTROINTESTINAL","PROTON PUMP INHIBITORS§"],["N","G","ESOMEPRA MAG CAP 40MG DR","ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 40 MG (BASE EQ)","1","0","0","1","90 caps every 365 days","","GASTROINTESTINAL","PROTON PUMP INHIBITORS§"],["N","G","ESOMEPRAZOLE INJ 20MG","ESOMEPRAZOLE SODIUM FOR INTRAVENOUS SOLN 20 MG (BASE EQUIV)","1","0","0","0","","","GASTROINTESTINAL","PROTON PUMP INHIBITORS§"],["N","G","ESOMEPRAZOLE INJ 40MG","ESOMEPRAZOLE SODIUM FOR INTRAVENOUS SOLN 40 MG (BASE EQUIV)","1","0","0","0","","","GASTROINTESTINAL","PROTON PUMP INHIBITORS§"],["N","G","LANSOPRAZOLE CAP 15MG DR","LANSOPRAZOLE CAP DELAYED RELEASE 15 MG","1","0","0","1","90 caps every 365 days","","GASTROINTESTINAL","PROTON PUMP INHIBITORS§"],["N","G","LANSOPRAZOLE CAP 30MG DR","LANSOPRAZOLE CAP DELAYED RELEASE 30 MG","1","0","0","1","90 caps every 365 days","","GASTROINTESTINAL","PROTON PUMP INHIBITORS§"],["N","G","OMEPRAZOLE CAP 10MG","OMEPRAZOLE CAP DELAYED RELEASE 10 MG","1","0","0","1","90 caps every 365 days","","GASTROINTESTINAL","PROTON PUMP INHIBITORS§"],["N","G","OMEPRAZOLE CAP 20MG","OMEPRAZOLE CAP DELAYED RELEASE 20 MG","1","0","0","1","90 caps every 365 days","","GASTROINTESTINAL","PROTON PUMP INHIBITORS§"],["N","G","OMEPRAZOLE CAP 40MG","OMEPRAZOLE CAP DELAYED RELEASE 40 MG","1","0","0","1","90 caps every 365 days","","GASTROINTESTINAL","PROTON PUMP INHIBITORS§"],["N","G","PANTOPRAZOLE TAB 20MG","PANTOPRAZOLE SODIUM EC TAB 20 MG (BASE EQUIV)","1","0","0","1","90 tabs every 365 days","","GASTROINTESTINAL","PROTON PUMP INHIBITORS§"],["N","G","PANTOPRAZOLE TAB 40MG","PANTOPRAZOLE SODIUM EC TAB 40 MG (BASE EQUIV)","1","0","0","1","90 tabs every 365 days","","GASTROINTESTINAL","PROTON PUMP INHIBITORS§"],["N","G","RABEPRAZOLE TAB 20MG","RABEPRAZOLE SODIUM EC TAB 20 MG","1","0","0","1","90 tabs every 365 days","","GASTROINTESTINAL","PROTON PUMP INHIBITORS§"],["N","G","PROCTO-PAK CRE 1%","HYDROCORTISONE RECTAL CREAM 1%","1","0","0","0","","","GASTROINTESTINAL","RECTAL,CORTICOSTEROIDS"],["N","G","PROCTOSOL HC CRE 2.5%","HYDROCORTISONE RECTAL CREAM 2.5%","1","0","0","0","","","GASTROINTESTINAL","RECTAL,CORTICOSTEROIDS"],["N","G","PROCTOZONE CRE -HC 2.5%","HYDROCORTISONE RECTAL CREAM 2.5%","1","0","0","0","","","GASTROINTESTINAL","RECTAL,CORTICOSTEROIDS"],["N","G","ALFUZOSIN TAB 10MG ER","ALFUZOSIN HCL TAB ER 24HR 10 MG","1","0","0","0","","","GENITOURINARY","BENIGN PROSTATIC HYPERPLASIA"],["N","G","CARDURA XL TAB 4MG","DOXAZOSIN MESYLATE TAB ER 24 HR 4 MG (BASE EQUIV)","3","0","1","0","","PA**","GENITOURINARY","BENIGN PROSTATIC HYPERPLASIA"],["N","G","CARDURA XL TAB 8MG","DOXAZOSIN MESYLATE TAB ER 24 HR 8 MG (BASE EQUIV)","3","0","1","0","","PA**","GENITOURINARY","BENIGN PROSTATIC HYPERPLASIA"],["N","G","DUTAST/TAMSU CAP 0.5-0.4","DUTASTERIDE-TAMSULOSIN HCL CAP 0.5-0.4 MG","1","0","0","0","","","GENITOURINARY","BENIGN PROSTATIC HYPERPLASIA"],["N","G","DUTASTERIDE CAP 0.5MG","DUTASTERIDE CAP 0.5 MG","1","0","0","0","","","GENITOURINARY","BENIGN PROSTATIC HYPERPLASIA"],["N","G","FINASTERIDE TAB 5MG","FINASTERIDE TAB 5 MG","1","0","0","0","","","GENITOURINARY","BENIGN PROSTATIC HYPERPLASIA"],["N","G","SILODOSIN CAP 4MG","SILODOSIN CAP 4 MG","1","0","0","0","","","GENITOURINARY","BENIGN PROSTATIC HYPERPLASIA"],["N","G","SILODOSIN CAP 8MG","SILODOSIN CAP 8 MG","1","0","0","0","","","GENITOURINARY","BENIGN PROSTATIC HYPERPLASIA"],["N","G","TADALAFIL TAB 2.5MG","TADALAFIL TAB 2.5 MG","1","1","0","1","30 tabs every 25 days","","GENITOURINARY","BENIGN PROSTATIC HYPERPLASIA"],["N","G","TADALAFIL TAB 5MG","TADALAFIL TAB 5 MG","1","1","0","1","30 tabs every 25 days","","GENITOURINARY","BENIGN PROSTATIC HYPERPLASIA"],["N","G","TAMSULOSIN CAP 0.4MG","TAMSULOSIN HCL CAP 0.4 MG","1","0","0","0","","","GENITOURINARY","BENIGN PROSTATIC HYPERPLASIA"],["N","G","CONCEPTROL GEL 4%","NONOXYNOL-9 GEL 4%","0","0","0","0","","","GENITOURINARY","CONTRACEPTIVES"],["N","G","ENCARE SUP 100MG","NONOXYNOL-9 VAGINAL SUPPOS 100 MG","0","0","0","0","","","GENITOURINARY","CONTRACEPTIVES"],["N","G","GYNOL II GEL 3%","NONOXYNOL-9 GEL 3%","0","0","0","0","","","GENITOURINARY","CONTRACEPTIVES"],["N","G","SHUR-SEAL GEL 2%","NONOXYNOL-9 GEL 2%","0","0","0","0","","","GENITOURINARY","CONTRACEPTIVES"],["N","G","TODAY SPONGE MIS","NONOXYNOL-9 VAGINAL SPONGE 1000 MG","0","0","0","0","","","GENITOURINARY","CONTRACEPTIVES"],["N","G","VCF VAGINAL AER CONTRACP","NONOXYNOL-9 FOAM 12.5%","0","0","0","0","","","GENITOURINARY","CONTRACEPTIVES"],["N","G","VCF VAGINAL MIS CONTRACP","NONOXYNOL-9 FILM 28%","0","0","0","0","","","GENITOURINARY","CONTRACEPTIVES"],["N","G","BETHANECHOL TAB 10MG","BETHANECHOL CHLORIDE TAB 10 MG","1","0","0","0","","","GENITOURINARY","MISCELLANEOUS"],["N","G","BETHANECHOL TAB 25MG","BETHANECHOL CHLORIDE TAB 25 MG","1","0","0","0","","","GENITOURINARY","MISCELLANEOUS"],["N","G","BETHANECHOL TAB 50MG","BETHANECHOL CHLORIDE TAB 50 MG","1","0","0","0","","","GENITOURINARY","MISCELLANEOUS"],["N","G","BETHANECHOL TAB 5MG","BETHANECHOL CHLORIDE TAB 5 MG","1","0","0","0","","","GENITOURINARY","MISCELLANEOUS"],["N","G","ELMIRON CAP 100MG","PENTOSAN POLYSULFATE SODIUM CAPS 100 MG","3","0","0","0","","","GENITOURINARY","MISCELLANEOUS"],["N","G","FLAVOXATE TAB 100MG","FLAVOXATE HCL TAB 100 MG","1","0","0","0","","","GENITOURINARY","MISCELLANEOUS"],["N","G","POT CITRATE TAB 1080MG","POTASSIUM CITRATE TAB ER 10 MEQ (1080 MG)","1","0","0","0","","","GENITOURINARY","MISCELLANEOUS"],["N","G","POT CITRATE TAB 1620MG","POTASSIUM CITRATE TAB ER 15 MEQ (1620 MG)","1","0","0","0","","","GENITOURINARY","MISCELLANEOUS"],["N","G","POT CITRATE TAB 540MG ER","POTASSIUM CITRATE TAB ER 5 MEQ (540 MG)","1","0","0","0","","","GENITOURINARY","MISCELLANEOUS"],["N","G","URINARY PAIN TAB 95MG","PHENAZOPYRIDINE HCL TAB 95 MG","1","0","0","0","","","GENITOURINARY","MISCELLANEOUS"],["N","G","DARIFENACIN TAB 15MG","DARIFENACIN HYDROBROMIDE TAB ER 24HR 15 MG (BASE EQUIV)","1","0","0","0","","","GENITOURINARY","URINARY ANTISPASMODICS"],["N","G","DARIFENACIN TAB 7.5MG","DARIFENACIN HYDROBROMIDE TAB ER 24HR 7.5 MG (BASE EQUIV)","1","0","0","0","","","GENITOURINARY","URINARY ANTISPASMODICS"],["N","G","MYRBETRIQ TAB 25MG","MIRABEGRON TAB ER 24 HR 25 MG","3","0","1","0","","PA**","GENITOURINARY","URINARY ANTISPASMODICS"],["N","G","MYRBETRIQ TAB 50MG","MIRABEGRON TAB ER 24 HR 50 MG","3","0","1","0","","PA**","GENITOURINARY","URINARY ANTISPASMODICS"],["N","G","OXYBUTYNIN SYP 5MG/5ML","OXYBUTYNIN CHLORIDE SYRUP 5 MG/5ML","1","0","0","0","","","GENITOURINARY","URINARY ANTISPASMODICS"],["N","G","OXYBUTYNIN TAB 10MG ER","OXYBUTYNIN CHLORIDE TAB ER 24HR 10 MG","1","0","0","0","","","GENITOURINARY","URINARY ANTISPASMODICS"],["N","G","OXYBUTYNIN TAB 15MG ER","OXYBUTYNIN CHLORIDE TAB ER 24HR 15 MG","1","0","0","0","","","GENITOURINARY","URINARY ANTISPASMODICS"],["N","G","OXYBUTYNIN TAB 5MG","OXYBUTYNIN CHLORIDE TAB 5 MG","1","0","0","0","","","GENITOURINARY","URINARY ANTISPASMODICS"],["N","G","OXYBUTYNIN TAB 5MG ER","OXYBUTYNIN CHLORIDE TAB ER 24HR 5 MG","1","0","0","0","","","GENITOURINARY","URINARY ANTISPASMODICS"],["N","G","SOLIFENACIN TAB 10MG","SOLIFENACIN SUCCINATE TAB 10 MG","1","0","0","0","","","GENITOURINARY","URINARY ANTISPASMODICS"],["N","G","SOLIFENACIN TAB 5MG","SOLIFENACIN SUCCINATE TAB 5 MG","1","0","0","0","","","GENITOURINARY","URINARY ANTISPASMODICS"],["N","G","TOLTERODINE CAP 2MG ER","TOLTERODINE TARTRATE CAP ER 24HR 2 MG","1","0","0","0","","","GENITOURINARY","URINARY ANTISPASMODICS"],["N","G","TOLTERODINE CAP 4MG ER","TOLTERODINE TARTRATE CAP ER 24HR 4 MG","1","0","0","0","","","GENITOURINARY","URINARY ANTISPASMODICS"],["N","G","TOLTERODINE TAB 1MG","TOLTERODINE TARTRATE TAB 1 MG","1","0","0","0","","","GENITOURINARY","URINARY ANTISPASMODICS"],["N","G","TOLTERODINE TAB 2MG","TOLTERODINE TARTRATE TAB 2 MG","1","0","0","0","","","GENITOURINARY","URINARY ANTISPASMODICS"],["N","G","TOVIAZ TAB 4MG","FESOTERODINE FUMARATE TAB ER 24HR 4 MG","2","0","0","0","","","GENITOURINARY","URINARY ANTISPASMODICS"],["N","G","TOVIAZ TAB 8MG","FESOTERODINE FUMARATE TAB ER 24HR 8 MG","2","0","0","0","","","GENITOURINARY","URINARY ANTISPASMODICS"],["N","G","TROSPIUM CHL CAP 60MG ER","TROSPIUM CHLORIDE CAP ER 24HR 60 MG","1","0","0","0","","","GENITOURINARY","URINARY ANTISPASMODICS"],["N","G","TROSPIUM CL TAB 20MG","TROSPIUM CHLORIDE TAB 20 MG","1","0","0","0","","","GENITOURINARY","URINARY ANTISPASMODICS"],["N","G","CLEOCIN SUP 100MG","CLINDAMYCIN PHOSPHATE VAGINAL SUPPOS 100 MG","2","0","0","0","","","GENITOURINARY","VAGINAL ANTI-INFECTIVES"],["N","G","CLINDAMYCIN CRE 2% VAG","CLINDAMYCIN PHOSPHATE VAGINAL CREAM 2%","1","0","0","0","","","GENITOURINARY","VAGINAL ANTI-INFECTIVES"],["N","G","GYNAZOLE-1 CRE 2%","BUTOCONAZOLE NITRATE (ONE DOSE) VAGINAL CREAM 2%","3","0","0","0","","","GENITOURINARY","VAGINAL ANTI-INFECTIVES"],["N","G","METRONIDAZOL GEL 0.75%VAG","METRONIDAZOLE VAGINAL GEL 0.75%","1","0","0","0","","","GENITOURINARY","VAGINAL ANTI-INFECTIVES"],["N","G","MICONAZOLE 3 SUP 200MG","MICONAZOLE NITRATE VAGINAL SUPPOS 200 MG","1","0","0","0","","","GENITOURINARY","VAGINAL ANTI-INFECTIVES"],["N","G","TERCONAZOLE CRE 0.4%","TERCONAZOLE VAGINAL CREAM 0.4%","1","0","0","0","","","GENITOURINARY","VAGINAL ANTI-INFECTIVES"],["N","G","TERCONAZOLE SUP 80MG","TERCONAZOLE VAGINAL SUPPOS 80 MG","1","0","0","0","","","GENITOURINARY","VAGINAL ANTI-INFECTIVES"],["N","G","VANDAZOLE GEL 0.75%","METRONIDAZOLE VAGINAL GEL 0.75%","1","0","0","0","","","GENITOURINARY","VAGINAL ANTI-INFECTIVES"],["N","G","ZAZOLE CRE 0.8%","TERCONAZOLE VAGINAL CREAM 0.8%","1","0","0","0","","","GENITOURINARY","VAGINAL ANTI-INFECTIVES"],["N","G","ZAZOLE SUP 80MG","TERCONAZOLE VAGINAL SUPPOS 80 MG","1","0","0","0","","","GENITOURINARY","VAGINAL ANTI-INFECTIVES"],["N","G","ARGATRB/NACL INJ 50MG/50","ARGATROBAN IN SODIUM CHLORIDE 0.9% IV SOLN 50 MG/50ML","3","0","0","0","","","HEMATOLOGIC","ANTICOAGULANTS"],["N","G","ARGATROBAN INJ 100MG/ML","ARGATROBAN INJ 250 MG/2.5ML (CONCENTRATE FOR IV INFUSION)","1","0","0","0","","","HEMATOLOGIC","ANTICOAGULANTS"],["N","G","ARGATROBAN INJ 125/125","ARGATROBAN IN SODIUM CHLORIDE 0.9% IV SOLN 125 MG/125ML","3","0","0","0","","","HEMATOLOGIC","ANTICOAGULANTS"],["N","G","ARGATROBAN INJ 250/250","ARGATROBAN IN SODIUM CHLORIDE 0.9% IV SOLN 250 MG/250ML","3","0","0","0","","","HEMATOLOGIC","ANTICOAGULANTS"],["N","G","ELIQUIS TAB 2.5MG","APIXABAN TAB 2.5 MG","2","0","0","0","","","HEMATOLOGIC","ANTICOAGULANTS"],["N","G","ELIQUIS TAB 5MG","APIXABAN TAB 5 MG","2","0","0","0","","","HEMATOLOGIC","ANTICOAGULANTS"],["N","G","ENOXAPARIN INJ 100MG/ML","ENOXAPARIN SODIUM INJ 100 MG/ML","1","0","0","0","","","HEMATOLOGIC","ANTICOAGULANTS"],["N","G","ENOXAPARIN INJ 120/0.8","ENOXAPARIN SODIUM INJ 120 MG/0.8ML","1","0","0","0","","","HEMATOLOGIC","ANTICOAGULANTS"],["N","G","ENOXAPARIN INJ 150MG/ML","ENOXAPARIN SODIUM INJ 150 MG/ML","1","0","0","0","","","HEMATOLOGIC","ANTICOAGULANTS"],["N","G","ENOXAPARIN INJ 30/0.3ML","ENOXAPARIN SODIUM INJ 30 MG/0.3ML","1","0","0","0","","","HEMATOLOGIC","ANTICOAGULANTS"],["N","G","ENOXAPARIN INJ 300/3ML","ENOXAPARIN SODIUM INJ 300 MG/3ML","1","0","0","0","","","HEMATOLOGIC","ANTICOAGULANTS"],["N","G","ENOXAPARIN INJ 40/0.4ML","ENOXAPARIN SODIUM INJ 40 MG/0.4ML","1","0","0","0","","","HEMATOLOGIC","ANTICOAGULANTS"],["N","G","ENOXAPARIN INJ 60/0.6ML","ENOXAPARIN SODIUM INJ 60 MG/0.6ML","1","0","0","0","","","HEMATOLOGIC","ANTICOAGULANTS"],["N","G","ENOXAPARIN INJ 80/0.8ML","ENOXAPARIN SODIUM INJ 80 MG/0.8ML","1","0","0","0","","","HEMATOLOGIC","ANTICOAGULANTS"],["N","G","FONDAPARINUX INJ 10/0.8ML","FONDAPARINUX SODIUM SUBCUTANEOUS INJ 10 MG/0.8ML","1","0","0","0","","","HEMATOLOGIC","ANTICOAGULANTS"],["N","G","FONDAPARINUX INJ 2.5/0.5","FONDAPARINUX SODIUM SUBCUTANEOUS INJ 2.5 MG/0.5ML","1","0","0","0","","","HEMATOLOGIC","ANTICOAGULANTS"],["N","G","FONDAPARINUX INJ 5/0.4ML","FONDAPARINUX SODIUM SUBCUTANEOUS INJ 5 MG/0.4ML","1","0","0","0","","","HEMATOLOGIC","ANTICOAGULANTS"],["N","G","FONDAPARINUX INJ 7.5/0.6","FONDAPARINUX SODIUM SUBCUTANEOUS INJ 7.5 MG/0.6ML","1","0","0","0","","","HEMATOLOGIC","ANTICOAGULANTS"],["N","G","FRAGMIN INJ 10000/ML","DALTEPARIN SODIUM INJ 10000 UNIT/ML","3","0","0","0","","","HEMATOLOGIC","ANTICOAGULANTS"],["N","G","FRAGMIN INJ 12500UNT","DALTEPARIN SODIUM INJ 12500 UNIT/0.5ML","3","0","0","0","","","HEMATOLOGIC","ANTICOAGULANTS"],["N","G","FRAGMIN INJ 15000UNT","DALTEPARIN SODIUM INJ 15000 UNIT/0.6ML","3","0","0","0","","","HEMATOLOGIC","ANTICOAGULANTS"],["N","G","FRAGMIN INJ 18000UNT","DALTEPARIN SODIUM INJ 18000 UNIT/0.72ML","3","0","0","0","","","HEMATOLOGIC","ANTICOAGULANTS"],["N","G","FRAGMIN INJ 2500/0.2","DALTEPARIN SODIUM INJ 2500 UNIT/0.2ML","3","0","0","0","","","HEMATOLOGIC","ANTICOAGULANTS"],["N","G","FRAGMIN INJ 5000/0.2","DALTEPARIN SODIUM INJ 5000 UNIT/0.2ML","3","0","0","0","","","HEMATOLOGIC","ANTICOAGULANTS"],["N","G","FRAGMIN INJ 7500/0.3","DALTEPARIN SODIUM INJ 7500 UNIT/0.3ML","3","0","0","0","","","HEMATOLOGIC","ANTICOAGULANTS"],["N","G","FRAGMIN INJ 95000UNT","DALTEPARIN SODIUM INJ 95000 UNIT/3.8ML","3","0","0","0","","","HEMATOLOGIC","ANTICOAGULANTS"],["N","G","HEPARIN SOD INJ 1000/ML","HEPARIN SODIUM (PORCINE) INJ 1000 UNIT/ML","1","0","0","0","","","HEMATOLOGIC","ANTICOAGULANTS"],["N","G","HEPARIN SOD INJ 10000/ML","HEPARIN SODIUM (PORCINE) PF INJ 5000 UNIT/0.5ML","1","0","0","0","","","HEMATOLOGIC","ANTICOAGULANTS"],["N","G","HEPARIN SOD INJ 10000/ML","HEPARIN SODIUM (PORCINE) INJ 10000 UNIT/ML","1","0","0","0","","","HEMATOLOGIC","ANTICOAGULANTS"],["N","G","HEPARIN SOD INJ 20000/ML","HEPARIN SODIUM (PORCINE) INJ 20000 UNIT/ML","1","0","0","0","","","HEMATOLOGIC","ANTICOAGULANTS"],["N","G","HEPARIN SOD INJ 5000/0.5","HEPARIN SODIUM (PORCINE) PF INJ 5000 UNIT/0.5ML","1","0","0","0","","","HEMATOLOGIC","ANTICOAGULANTS"],["N","G","HEPARIN SOD INJ 5000/ML","HEPARIN SODIUM (PORCINE) INJ 5000 UNIT/ML","1","0","0","0","","","HEMATOLOGIC","ANTICOAGULANTS"],["N","G","JANTOVEN TAB 10MG","WARFARIN SODIUM TAB 10 MG","1","0","0","0","","","HEMATOLOGIC","ANTICOAGULANTS"],["N","G","JANTOVEN TAB 1MG","WARFARIN SODIUM TAB 1 MG","1","0","0","0","","","HEMATOLOGIC","ANTICOAGULANTS"],["N","G","JANTOVEN TAB 2.5MG","WARFARIN SODIUM TAB 2.5 MG","1","0","0","0","","","HEMATOLOGIC","ANTICOAGULANTS"],["N","G","JANTOVEN TAB 2MG","WARFARIN SODIUM TAB 2 MG","1","0","0","0","","","HEMATOLOGIC","ANTICOAGULANTS"],["N","G","JANTOVEN TAB 3MG","WARFARIN SODIUM TAB 3 MG","1","0","0","0","","","HEMATOLOGIC","ANTICOAGULANTS"],["N","G","JANTOVEN TAB 4MG","WARFARIN SODIUM TAB 4 MG","1","0","0","0","","","HEMATOLOGIC","ANTICOAGULANTS"],["N","G","JANTOVEN TAB 5MG","WARFARIN SODIUM TAB 5 MG","1","0","0","0","","","HEMATOLOGIC","ANTICOAGULANTS"],["N","G","JANTOVEN TAB 6MG","WARFARIN SODIUM TAB 6 MG","1","0","0","0","","","HEMATOLOGIC","ANTICOAGULANTS"],["N","G","JANTOVEN TAB 7.5MG","WARFARIN SODIUM TAB 7.5 MG","1","0","0","0","","","HEMATOLOGIC","ANTICOAGULANTS"],["N","G","PRADAXA CAP 110MG","DABIGATRAN ETEXILATE MESYLATE CAP 110 MG (ETEXILATE BASE EQ)","3","0","0","0","","","HEMATOLOGIC","ANTICOAGULANTS"],["N","G","PRADAXA CAP 150MG","DABIGATRAN ETEXILATE MESYLATE CAP 150 MG (ETEXILATE BASE EQ)","3","0","0","0","","","HEMATOLOGIC","ANTICOAGULANTS"],["N","G","PRADAXA CAP 75MG","DABIGATRAN ETEXILATE MESYLATE CAP 75 MG (ETEXILATE BASE EQ)","3","0","0","0","","","HEMATOLOGIC","ANTICOAGULANTS"],["N","G","WARFARIN TAB 10MG","WARFARIN SODIUM TAB 10 MG","1","0","0","0","","","HEMATOLOGIC","ANTICOAGULANTS"],["N","G","WARFARIN TAB 1MG","WARFARIN SODIUM TAB 1 MG","1","0","0","0","","","HEMATOLOGIC","ANTICOAGULANTS"],["N","G","WARFARIN TAB 2.5MG","WARFARIN SODIUM TAB 2.5 MG","1","0","0","0","","","HEMATOLOGIC","ANTICOAGULANTS"],["N","G","WARFARIN TAB 2MG","WARFARIN SODIUM TAB 2 MG","1","0","0","0","","","HEMATOLOGIC","ANTICOAGULANTS"],["N","G","WARFARIN TAB 3MG","WARFARIN SODIUM TAB 3 MG","1","0","0","0","","","HEMATOLOGIC","ANTICOAGULANTS"],["N","G","WARFARIN TAB 4MG","WARFARIN SODIUM TAB 4 MG","1","0","0","0","","","HEMATOLOGIC","ANTICOAGULANTS"],["N","G","WARFARIN TAB 5MG","WARFARIN SODIUM TAB 5 MG","1","0","0","0","","","HEMATOLOGIC","ANTICOAGULANTS"],["N","G","WARFARIN TAB 6MG","WARFARIN SODIUM TAB 6 MG","1","0","0","0","","","HEMATOLOGIC","ANTICOAGULANTS"],["N","G","WARFARIN TAB 7.5MG","WARFARIN SODIUM TAB 7.5 MG","1","0","0","0","","","HEMATOLOGIC","ANTICOAGULANTS"],["N","G","XARELTO STAR TAB 15/20MG","RIVAROXABAN TAB STARTER THERAPY PACK 15 MG & 20 MG","2","0","0","0","","","HEMATOLOGIC","ANTICOAGULANTS"],["N","G","XARELTO TAB 10MG","RIVAROXABAN TAB 10 MG","2","0","0","0","","","HEMATOLOGIC","ANTICOAGULANTS"],["N","G","XARELTO TAB 15MG","RIVAROXABAN TAB 15 MG","2","0","0","0","","","HEMATOLOGIC","ANTICOAGULANTS"],["N","G","XARELTO TAB 2.5MG","RIVAROXABAN TAB 2.5 MG","2","0","0","0","","","HEMATOLOGIC","ANTICOAGULANTS"],["N","G","XARELTO TAB 20MG","RIVAROXABAN TAB 20 MG","2","0","0","0","","","HEMATOLOGIC","ANTICOAGULANTS"],["N","G","ARANESP INJ 100MCG","DARBEPOETIN ALFA SOLN PREFILLED SYRINGE 100 MCG/0.5ML","4","1","0","0","","SP","HEMATOLOGIC","HEMATOPOIETIC GROWTH FACTORS"],["N","G","ARANESP INJ 100MCG","DARBEPOETIN ALFA SOLN INJ 100 MCG/ML","4","1","0","0","","SP","HEMATOLOGIC","HEMATOPOIETIC GROWTH FACTORS"],["N","G","ARANESP INJ 10MCG","DARBEPOETIN ALFA SOLN PREFILLED SYRINGE 10 MCG/0.4ML","4","1","0","0","","SP","HEMATOLOGIC","HEMATOPOIETIC GROWTH FACTORS"],["N","G","ARANESP INJ 150MCG","DARBEPOETIN ALFA SOLN PREFILLED SYRINGE 150 MCG/0.3ML","4","1","0","0","","SP","HEMATOLOGIC","HEMATOPOIETIC GROWTH FACTORS"],["N","G","ARANESP INJ 200MCG","DARBEPOETIN ALFA SOLN PREFILLED SYRINGE 200 MCG/0.4ML","4","1","0","0","","SP","HEMATOLOGIC","HEMATOPOIETIC GROWTH FACTORS"],["N","G","ARANESP INJ 200MCG","DARBEPOETIN ALFA SOLN INJ 200 MCG/ML","4","1","0","0","","SP","HEMATOLOGIC","HEMATOPOIETIC GROWTH FACTORS"],["N","G","ARANESP INJ 25MCG","DARBEPOETIN ALFA SOLN INJ 25 MCG/ML","4","1","0","0","","SP","HEMATOLOGIC","HEMATOPOIETIC GROWTH FACTORS"],["N","G","ARANESP INJ 25MCG","DARBEPOETIN ALFA SOLN PREFILLED SYRINGE 25 MCG/0.42ML","4","1","0","0","","SP","HEMATOLOGIC","HEMATOPOIETIC GROWTH FACTORS"],["N","G","ARANESP INJ 300MCG","DARBEPOETIN ALFA SOLN PREFILLED SYRINGE 300 MCG/0.6ML","4","1","0","0","","SP","HEMATOLOGIC","HEMATOPOIETIC GROWTH FACTORS"],["N","G","ARANESP INJ 300MCG","DARBEPOETIN ALFA SOLN INJ 300 MCG/ML","4","1","0","0","","SP","HEMATOLOGIC","HEMATOPOIETIC GROWTH FACTORS"],["N","G","ARANESP INJ 40MCG","DARBEPOETIN ALFA SOLN INJ 40 MCG/ML","4","1","0","0","","SP","HEMATOLOGIC","HEMATOPOIETIC GROWTH FACTORS"],["N","G","ARANESP INJ 40MCG","DARBEPOETIN ALFA SOLN PREFILLED SYRINGE 40 MCG/0.4ML","4","1","0","0","","SP","HEMATOLOGIC","HEMATOPOIETIC GROWTH FACTORS"],["N","G","ARANESP INJ 500MCG","DARBEPOETIN ALFA SOLN PREFILLED SYRINGE 500 MCG/ML","4","1","0","0","","SP","HEMATOLOGIC","HEMATOPOIETIC GROWTH FACTORS"],["N","G","ARANESP INJ 60MCG","DARBEPOETIN ALFA SOLN INJ 60 MCG/ML","4","1","0","0","","SP","HEMATOLOGIC","HEMATOPOIETIC GROWTH FACTORS"],["N","G","ARANESP INJ 60MCG","DARBEPOETIN ALFA SOLN PREFILLED SYRINGE 60 MCG/0.3ML","4","1","0","0","","SP","HEMATOLOGIC","HEMATOPOIETIC GROWTH FACTORS"],["N","G","FULPHILA INJ 6/0.6ML","PEGFILGRASTIM-JMDB SOLN PREFILLED SYRINGE 6 MG/0.6ML","4","1","0","1","2 injections every 28 days","SP","HEMATOLOGIC","HEMATOPOIETIC GROWTH FACTORS"],["N","G","MIRCERA INJ 100MCG","METHOXY PEG-EPOETIN BETA SOLN PREFILLED SYR 100 MCG/0.3ML","4","1","0","0","","SP","HEMATOLOGIC","HEMATOPOIETIC GROWTH FACTORS"],["N","G","MIRCERA INJ 200MCG","METHOXY PEG-EPOETIN BETA SOLN PREFILLED SYR 200 MCG/0.3ML","4","1","0","0","","SP","HEMATOLOGIC","HEMATOPOIETIC GROWTH FACTORS"],["N","G","MIRCERA INJ 50MCG","METHOXY PEG-EPOETIN BETA SOLN PREFILLED SYR 50 MCG/0.3ML","4","1","0","0","","SP","HEMATOLOGIC","HEMATOPOIETIC GROWTH FACTORS"],["N","G","MIRCERA INJ 75MCG","METHOXY PEG-EPOETIN BETA SOLN PREFILLED SYR 75 MCG/0.3ML","4","1","0","0","","SP","HEMATOLOGIC","HEMATOPOIETIC GROWTH FACTORS"],["N","G","MIRCERA SOL 150/0.3","METHOXY PEG-EPOETIN BETA SOLN PREFILLED SYR 150 MCG/0.3ML","4","1","0","0","","SP","HEMATOLOGIC","HEMATOPOIETIC GROWTH FACTORS"],["N","G","MIRCERA SOL 30/0.3ML","METHOXY PEG-EPOETIN BETA SOLN PREFILLED SYR 30 MCG/0.3ML","4","1","0","0","","SP","HEMATOLOGIC","HEMATOPOIETIC GROWTH FACTORS"],["N","G","PROMACTA TAB 12.5MG","ELTROMBOPAG OLAMINE TAB 12.5 MG (BASE EQUIV)","4","1","0","1","30 tabs every 30 days","SP","HEMATOLOGIC","HEMATOPOIETIC GROWTH FACTORS"],["N","G","PROMACTA TAB 25MG","ELTROMBOPAG OLAMINE TAB 25 MG (BASE EQUIV)","4","1","0","1","30 tabs every 30 days","SP","HEMATOLOGIC","HEMATOPOIETIC GROWTH FACTORS"],["N","G","PROMACTA TAB 50MG","ELTROMBOPAG OLAMINE TAB 50 MG (BASE EQUIV)","4","1","0","1","60 tabs every 30 days","SP","HEMATOLOGIC","HEMATOPOIETIC GROWTH FACTORS"],["N","G","PROMACTA TAB 75MG","ELTROMBOPAG OLAMINE TAB 75 MG (BASE EQUIV)","4","1","0","1","60 tabs every 30 days","SP","HEMATOLOGIC","HEMATOPOIETIC GROWTH FACTORS"],["N","G","RETACRIT INJ 10000UNT","EPOETIN ALFA-EPBX INJ 10000 UNIT/ML","4","1","0","0","","SP","HEMATOLOGIC","HEMATOPOIETIC GROWTH FACTORS"],["N","G","RETACRIT INJ 2000UNIT","EPOETIN ALFA-EPBX INJ 2000 UNIT/ML","4","1","0","0","","SP","HEMATOLOGIC","HEMATOPOIETIC GROWTH FACTORS"],["N","G","RETACRIT INJ 3000UNIT","EPOETIN ALFA-EPBX INJ 3000 UNIT/ML","4","1","0","0","","SP","HEMATOLOGIC","HEMATOPOIETIC GROWTH FACTORS"],["N","G","RETACRIT INJ 40000UNT","EPOETIN ALFA-EPBX INJ 40000 UNIT/ML","4","1","0","0","","SP","HEMATOLOGIC","HEMATOPOIETIC GROWTH FACTORS"],["N","G","RETACRIT INJ 4000UNIT","EPOETIN ALFA-EPBX INJ 4000 UNIT/ML","4","1","0","0","","SP","HEMATOLOGIC","HEMATOPOIETIC GROWTH FACTORS"],["N","G","ZARXIO INJ 300/0.5","FILGRASTIM-SNDZ SOLN PREFILLED SYRINGE 300 MCG/0.5ML","4","1","0","0","","SP","HEMATOLOGIC","HEMATOPOIETIC GROWTH FACTORS"],["N","G","ZARXIO INJ 480/0.8","FILGRASTIM-SNDZ SOLN PREFILLED SYRINGE 480 MCG/0.8ML","4","1","0","0","","SP","HEMATOLOGIC","HEMATOPOIETIC GROWTH FACTORS"],["N","G","ANAGRELIDE CAP 0.5MG","ANAGRELIDE HCL CAP 0.5 MG","1","0","0","0","","","HEMATOLOGIC","MISCELLANEOUS"],["N","G","ANAGRELIDE CAP 1MG","ANAGRELIDE HCL CAP 1 MG","1","0","0","0","","","HEMATOLOGIC","MISCELLANEOUS"],["N","G","CILOSTAZOL TAB 100MG","CILOSTAZOL TAB 100 MG","1","0","0","0","","","HEMATOLOGIC","MISCELLANEOUS"],["N","G","CILOSTAZOL TAB 50MG","CILOSTAZOL TAB 50 MG","1","0","0","0","","","HEMATOLOGIC","MISCELLANEOUS"],["N","G","FIRAZYR INJ 30MG/3ML","ICATIBANT ACETATE INJ 30 MG/3ML (BASE EQUIVALENT)","4","1","0","0","","SP","HEMATOLOGIC","MISCELLANEOUS"],["N","G","HEMLIBRA INJ 105/0.7","EMICIZUMAB-KXWH SUBCUTANEOUS SOLN 105 MG/0.7ML (150 MG/ML)","4","1","0","0","","SP","HEMATOLOGIC","MISCELLANEOUS"],["N","G","HEMLIBRA INJ 150/ML","EMICIZUMAB-KXWH SUBCUTANEOUS SOLN 150 MG/ML","4","1","0","0","","SP","HEMATOLOGIC","MISCELLANEOUS"],["N","G","HEMLIBRA INJ 30MG/ML","EMICIZUMAB-KXWH SUBCUTANEOUS SOLN 30 MG/ML","4","1","0","0","","SP","HEMATOLOGIC","MISCELLANEOUS"],["N","G","HEMLIBRA INJ 60/0.4","EMICIZUMAB-KXWH SUBCUTANEOUS SOLN 60 MG/0.4ML (150 MG/ML)","4","1","0","0","","SP","HEMATOLOGIC","MISCELLANEOUS"],["N","G","ICATIBANT INJ 30MG/3ML","ICATIBANT ACETATE INJ 30 MG/3ML (BASE EQUIVALENT)","4","1","0","0","","SP","HEMATOLOGIC","MISCELLANEOUS"],["N","G","PENTOXIFYLLI TAB 400MG ER","PENTOXIFYLLINE TAB ER 400 MG","1","0","0","0","","","HEMATOLOGIC","MISCELLANEOUS"],["N","G","TRANEX ACID INJ 100MG/ML","TRANEXAMIC ACID IV SOLN 1000 MG/10ML (100 MG/ML)","1","0","0","0","","","HEMATOLOGIC","MISCELLANEOUS"],["N","G","TRANEX ACID TAB 650MG","TRANEXAMIC ACID TAB 650 MG","1","0","0","0","","","HEMATOLOGIC","MISCELLANEOUS"],["N","G","ASA/DIPYRIDA CAP 25-200MG","ASPIRIN-DIPYRIDAMOLE CAP ER 12HR 25-200 MG","1","0","0","0","","","HEMATOLOGIC","PLATELET AGGREGATION INHIBITORS"],["N","G","BRILINTA TAB 60MG","TICAGRELOR TAB 60 MG","2","0","0","0","","","HEMATOLOGIC","PLATELET AGGREGATION INHIBITORS"],["N","G","BRILINTA TAB 90MG","TICAGRELOR TAB 90 MG","2","0","0","0","","","HEMATOLOGIC","PLATELET AGGREGATION INHIBITORS"],["N","G","CLOPIDOGREL TAB 300MG","CLOPIDOGREL BISULFATE TAB 300 MG (BASE EQUIV)","1","0","0","0","","","HEMATOLOGIC","PLATELET AGGREGATION INHIBITORS"],["N","G","CLOPIDOGREL TAB 75MG","CLOPIDOGREL BISULFATE TAB 75 MG (BASE EQUIV)","1","0","0","0","","","HEMATOLOGIC","PLATELET AGGREGATION INHIBITORS"],["N","G","DIPYRIDAMOLE TAB 25MG","DIPYRIDAMOLE TAB 25 MG","1","1","0","0","","High Risk Medications require PA for members age 70 and older","HEMATOLOGIC","PLATELET AGGREGATION INHIBITORS"],["N","G","DIPYRIDAMOLE TAB 50MG","DIPYRIDAMOLE TAB 50 MG","1","1","0","0","","High Risk Medications require PA for members age 70 and older","HEMATOLOGIC","PLATELET AGGREGATION INHIBITORS"],["N","G","DIPYRIDAMOLE TAB 75MG","DIPYRIDAMOLE TAB 75 MG","1","1","0","0","","High Risk Medications require PA for members age 70 and older","HEMATOLOGIC","PLATELET AGGREGATION INHIBITORS"],["N","G","PRASUGREL TAB 10MG","PRASUGREL HCL TAB 10 MG (BASE EQUIV)","1","0","0","0","","","HEMATOLOGIC","PLATELET AGGREGATION INHIBITORS"],["N","G","PRASUGREL TAB 5MG","PRASUGREL HCL TAB 5 MG (BASE EQUIV)","1","0","0","0","","","HEMATOLOGIC","PLATELET AGGREGATION INHIBITORS"],["N","G","YOSPRALA TAB 325-40MG","ASPIRIN-OMEPRAZOLE TAB DELAYED RELEASE 325-40 MG","3","0","0","0","","","HEMATOLOGIC","PLATELET AGGREGATION INHIBITORS"],["N","G","YOSPRALA TAB 81-40MG","ASPIRIN-OMEPRAZOLE TAB DELAYED RELEASE 81-40 MG","3","0","0","0","","","HEMATOLOGIC","PLATELET AGGREGATION INHIBITORS"],["N","G","ZONTIVITY TAB 2.08MG","VORAPAXAR SULFATE TAB 2.08 MG (BASE EQUIVALENT)","2","0","0","0","","","HEMATOLOGIC","PLATELET AGGREGATION INHIBITORS"],["N","G","ACTEMRA INJ 162/0.9","TOCILIZUMAB SUBCUTANEOUS SOLN PREFILLED SYRINGE 162 MG/0.9ML","4","1","1","1","4 syringes every 28 days","SP","IMMUNOLOGIC AGENTS","BIOLOGIC DISEASE-MODIFYING AGENTS"],["N","G","ACTEMRA INJ 200/10ML","TOCILIZUMAB IV INJ 200 MG/10ML","4","1","1","1","4 vials every 14 days","SP","IMMUNOLOGIC AGENTS","BIOLOGIC DISEASE-MODIFYING AGENTS"],["N","G","ACTEMRA INJ 400/20ML","TOCILIZUMAB IV INJ 400 MG/20ML","4","1","1","1","2 vials every 14 days","SP","IMMUNOLOGIC AGENTS","BIOLOGIC DISEASE-MODIFYING AGENTS"],["N","G","ACTEMRA INJ 80MG/4ML","TOCILIZUMAB IV INJ 80 MG/4ML","4","1","1","1","5 vials every 28 days","SP","IMMUNOLOGIC AGENTS","BIOLOGIC DISEASE-MODIFYING AGENTS"],["N","G","ENBREL INJ 25/0.5ML","ETANERCEPT SUBCUTANEOUS SOLN PREFILLED SYRINGE 25 MG/0.5ML","4","1","0","1","8 syringes every 28 days","SP; Preferred agent for Ankylosing Spondylitis, Psoriatic Arthritis, and Rheumatoid Arthritis","IMMUNOLOGIC AGENTS","BIOLOGIC DISEASE-MODIFYING AGENTS"],["N","G","ENBREL INJ 25MG","ETANERCEPT FOR SUBCUTANEOUS INJ 25 MG","4","1","0","1","8 syringes every 28 days","SP; Preferred agent for Ankylosing Spondylitis, Psoriatic Arthritis, and Rheumatoid Arthritis","IMMUNOLOGIC AGENTS","BIOLOGIC DISEASE-MODIFYING AGENTS"],["N","G","ENBREL INJ 50MG/ML","ETANERCEPT SUBCUTANEOUS SOLN PREFILLED SYRINGE 50 MG/ML","4","1","0","1","8 syringes every 28 days","SP; Preferred agent for Ankylosing Spondylitis, Psoriatic Arthritis, and Rheumatoid Arthritis","IMMUNOLOGIC AGENTS","BIOLOGIC DISEASE-MODIFYING AGENTS"],["N","G","ENBREL MINI INJ 50MG/ML","ETANERCEPT SUBCUTANEOUS SOLUTION CARTRIDGE 50 MG/ML","4","1","0","1","8 cartridges every 28 days","SP; Preferred agent for Ankylosing Spondylitis, Psoriatic Arthritis, and Rheumatoid Arthritis","IMMUNOLOGIC AGENTS","BIOLOGIC DISEASE-MODIFYING AGENTS"],["N","G","ENBREL SRCLK INJ 50MG/ML","ETANERCEPT SUBCUTANEOUS SOLUTION AUTO-INJECTOR 50 MG/ML","4","1","0","1","8 syringes every 28 days","SP; Preferred agent for Ankylosing Spondylitis, Psoriatic Arthritis, and Rheumatoid Arthritis","IMMUNOLOGIC AGENTS","BIOLOGIC DISEASE-MODIFYING AGENTS"],["N","G","HUMIRA INJ 10/0.1ML","ADALIMUMAB PREFILLED SYRINGE KIT 10 MG/0.1ML","4","1","0","1","2 injections every 28 days","SP","IMMUNOLOGIC AGENTS","BIOLOGIC DISEASE-MODIFYING AGENTS"],["N","G","HUMIRA INJ 10MG/0.2","ADALIMUMAB PREFILLED SYRINGE KIT 10 MG/0.2ML","4","1","0","1","2 injections every 28 days","SP","IMMUNOLOGIC AGENTS","BIOLOGIC DISEASE-MODIFYING AGENTS"],["N","G","HUMIRA INJ 20/0.2ML","ADALIMUMAB PREFILLED SYRINGE KIT 20 MG/0.2ML","4","1","0","1","2 injections every 28 days","SP","IMMUNOLOGIC AGENTS","BIOLOGIC DISEASE-MODIFYING AGENTS"],["N","G","HUMIRA INJ 40/0.4ML","ADALIMUMAB PREFILLED SYRINGE KIT 40 MG/0.4ML","4","1","0","1","4 injections every 28 days","SP","IMMUNOLOGIC AGENTS","BIOLOGIC DISEASE-MODIFYING AGENTS"],["N","G","HUMIRA KIT 20MG/0.4","ADALIMUMAB PREFILLED SYRINGE KIT 20 MG/0.4ML","4","1","0","1","2 injections every 28 days","SP","IMMUNOLOGIC AGENTS","BIOLOGIC DISEASE-MODIFYING AGENTS"],["N","G","HUMIRA KIT 40MG/0.8","ADALIMUMAB PREFILLED SYRINGE KIT 40 MG/0.8ML","4","1","0","1","4 injections every 28 days","SP","IMMUNOLOGIC AGENTS","BIOLOGIC DISEASE-MODIFYING AGENTS"],["N","G","HUMIRA PEDIA INJ CROHNS","ADALIMUMAB PREFILLED SYRINGE KIT 80 MG/0.8ML & 40 MG/0.4ML","4","1","0","1","2 injections every 28 days","SP; (80mg and 40mg dual strength kit)","IMMUNOLOGIC AGENTS","BIOLOGIC DISEASE-MODIFYING AGENTS"],["N","G","HUMIRA PEDIA INJ CROHNS","ADALIMUMAB PREFILLED SYRINGE KIT 80 MG/0.8ML","4","1","0","1","3 injections every 28 days","SP; (80mg single strength kit)","IMMUNOLOGIC AGENTS","BIOLOGIC DISEASE-MODIFYING AGENTS"],["N","G","HUMIRA PEN INJ 40/0.4ML","ADALIMUMAB PEN-INJECTOR KIT 40 MG/0.4ML","4","1","0","1","4 injections every 28 days","SP","IMMUNOLOGIC AGENTS","BIOLOGIC DISEASE-MODIFYING AGENTS"],["N","G","HUMIRA PEN INJ CD/UC/HS","ADALIMUMAB PEN-INJECTOR KIT 40 MG/0.8ML","4","1","0","1","6 pens every 28 days","SP","IMMUNOLOGIC AGENTS","BIOLOGIC DISEASE-MODIFYING AGENTS"],["N","G","HUMIRA PEN INJ PS/UV","ADALIMUMAB PEN-INJECTOR KIT 40 MG/0.8ML","4","1","0","1","4 pens every 28 days","SP","IMMUNOLOGIC AGENTS","BIOLOGIC DISEASE-MODIFYING AGENTS"],["N","G","HUMIRA PEN KIT CD/UC/HS","ADALIMUMAB PEN-INJECTOR KIT 80 MG/0.8ML","4","1","0","1","1 kit every 28 days","SP","IMMUNOLOGIC AGENTS","BIOLOGIC DISEASE-MODIFYING AGENTS"],["N","G","HUMIRA PEN KIT PS/UV","ADALIMUMAB PEN-INJECTOR KIT 80 MG/0.8ML & 40 MG/0.4ML","4","1","0","1","1 kit every 28 days","SP","IMMUNOLOGIC AGENTS","BIOLOGIC DISEASE-MODIFYING AGENTS"],["N","G","KEVZARA INJ 150/1.14","SARILUMAB SUBCUTANEOUS SOLN PREFILLED SYRINGE 150 MG/1.14ML","4","1","0","1","2 syringes every 4 weeks","SP; Preferred agent for Rheumatoid Arthritis","IMMUNOLOGIC AGENTS","BIOLOGIC DISEASE-MODIFYING AGENTS"],["N","G","KEVZARA INJ 150/1.14","SARILUMAB SUBCUTANEOUS SOLUTION AUTO-INJECTOR 150 MG/1.14ML","4","1","0","1","2 pens every 28 days","SP; Preferred agent for Rheumatoid Arthritis","IMMUNOLOGIC AGENTS","BIOLOGIC DISEASE-MODIFYING AGENTS"],["N","G","KEVZARA INJ 200/1.14","SARILUMAB SUBCUTANEOUS SOLN PREFILLED SYRINGE 200 MG/1.14ML","4","1","0","1","2 syringes every 4 weeks","SP; Preferred agent for Rheumatoid Arthritis","IMMUNOLOGIC AGENTS","BIOLOGIC DISEASE-MODIFYING AGENTS"],["N","G","KEVZARA INJ 200/1.14","SARILUMAB SUBCUTANEOUS SOLUTION AUTO-INJECTOR 200 MG/1.14ML","4","1","0","1","2 pens every 28 days","SP; Preferred agent for Rheumatoid Arthritis","IMMUNOLOGIC AGENTS","BIOLOGIC DISEASE-MODIFYING AGENTS"],["N","G","SIMPONI ARIA SOL 50MG/4ML","GOLIMUMAB IV SOLN 50 MG/4ML","4","1","0","1","200 mg every 8 weeks","SP","IMMUNOLOGIC AGENTS","BIOLOGIC DISEASE-MODIFYING AGENTS"],["N","G","SIMPONI INJ 100MG/ML","GOLIMUMAB SUBCUTANEOUS SOLN PREFILLED SYRINGE 100 MG/ML","4","1","0","1","1 injection every 28 days","SP; Preferred agent for Ulcerative Colitis","IMMUNOLOGIC AGENTS","BIOLOGIC DISEASE-MODIFYING AGENTS"],["N","G","SIMPONI INJ 100MG/ML","GOLIMUMAB SUBCUTANEOUS SOLN AUTO-INJECTOR 100 MG/ML","4","1","0","1","1 injection every 28 days","SP; Preferred agent for Ulcerative Colitis","IMMUNOLOGIC AGENTS","BIOLOGIC DISEASE-MODIFYING AGENTS"],["N","G","SIMPONI INJ 50/0.5ML","GOLIMUMAB SUBCUTANEOUS SOLN PREFILLED SYRINGE 50 MG/0.5ML","4","1","0","1","1 injection every 28 days","SP; Preferred agent for Ulcerative Colitis","IMMUNOLOGIC AGENTS","BIOLOGIC DISEASE-MODIFYING AGENTS"],["N","G","SIMPONI INJ 50/0.5ML","GOLIMUMAB SUBCUTANEOUS SOLN AUTO-INJECTOR 50 MG/0.5ML","4","1","0","1","1 injection every 28 days","SP; Preferred agent for Ulcerative Colitis","IMMUNOLOGIC AGENTS","BIOLOGIC DISEASE-MODIFYING AGENTS"],["N","G","SKYRIZI INJ 150DOSE","RISANKIZUMAB-RZAA SOL PREFILLED SYRINGE 2 X 75 MG/0.83ML KIT","4","1","0","1","2 syringes every 12 weeks","SP; Preferred agent for Psoriasis","IMMUNOLOGIC AGENTS","BIOLOGIC DISEASE-MODIFYING AGENTS"],["N","G","STELARA INJ 45MG/0.5","USTEKINUMAB SOLN PREFILLED SYRINGE 45 MG/0.5ML","4","1","0","1","1 syringe every 84 days","SP; Preferred agent for Crohn's Disease (after failure of Humira) and Psoriasis","IMMUNOLOGIC AGENTS","BIOLOGIC DISEASE-MODIFYING AGENTS"],["N","G","STELARA INJ 90MG/ML","USTEKINUMAB SOLN PREFILLED SYRINGE 90 MG/ML","4","1","0","1","1 syringe every 56 days","SP; Preferred agent for Crohn's Disease (after failure of Humira) and Psoriasis","IMMUNOLOGIC AGENTS","BIOLOGIC DISEASE-MODIFYING AGENTS"],["N","G","TALTZ INJ 80MG/ML","IXEKIZUMAB SUBCUTANEOUS SOLN AUTO-INJECTOR 80 MG/ML","4","1","0","1","1 injection every 28 days","SP; Preferred agent for Psoriasis","IMMUNOLOGIC AGENTS","BIOLOGIC DISEASE-MODIFYING AGENTS"],["N","G","TALTZ INJ 80MG/ML","IXEKIZUMAB SUBCUTANEOUS SOLN PREFILLED SYRINGE 80 MG/ML","4","1","0","1","1 injection every 28 days","SP; Preferred agent for Psoriasis","IMMUNOLOGIC AGENTS","BIOLOGIC DISEASE-MODIFYING AGENTS"],["N","G","XELJANZ TAB 5MG","TOFACITINIB CITRATE TAB 5 MG (BASE EQUIVALENT)","4","1","0","1","60 tabs every 30 days","SP; Preferred agent for Rheumatoid Arthritis","IMMUNOLOGIC AGENTS","BIOLOGIC DISEASE-MODIFYING AGENTS"],["N","G","XELJANZ XR TAB 11MG","TOFACITINIB CITRATE TAB ER 24HR 11 MG (BASE EQUIVALENT)","4","1","0","1","30 tabs every 30 days","SP; Preferred agent for Rheumatoid Arthritis","IMMUNOLOGIC AGENTS","BIOLOGIC DISEASE-MODIFYING AGENTS"],["N","G","HYDROXYCHLOR TAB 200MG","HYDROXYCHLOROQUINE SULFATE TAB 200 MG","1","0","0","0","","","IMMUNOLOGIC AGENTS","DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS (DMARDS)"],["N","G","LEFLUNOMIDE TAB 10MG","LEFLUNOMIDE TAB 10 MG","1","0","0","0","","","IMMUNOLOGIC AGENTS","DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS (DMARDS)"],["N","G","LEFLUNOMIDE TAB 20MG","LEFLUNOMIDE TAB 20 MG","1","0","0","0","","","IMMUNOLOGIC AGENTS","DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS (DMARDS)"],["N","G","METHOTREXATE TAB 2.5MG","METHOTREXATE SODIUM TAB 2.5 MG (BASE EQUIV)","1","0","0","0","","","IMMUNOLOGIC AGENTS","DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS (DMARDS)"],["N","G","OTEZLA TAB 10/20/30","APREMILAST TAB STARTER THERAPY PACK 10 MG & 20 MG & 30 MG","4","1","0","1","55 tabs every 28 days","SP; Preferred agent for Psoriasis and Psoriatic Arthritis","IMMUNOLOGIC AGENTS","DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS (DMARDS)"],["N","G","OTEZLA TAB 30MG","APREMILAST TAB 30 MG","4","1","0","1","60 tabs every 30 days","SP; Preferred agent for Psoriasis and Psoriatic Arthritis","IMMUNOLOGIC AGENTS","DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS (DMARDS)"],["N","G","HYQVIA INJ 10-800","IMMUN GLOB INJ 10 GM/100ML-HYALURON INJ 800 UNT/5 ML KIT","4","1","0","0","","SP","IMMUNOLOGIC AGENTS","IMMUNOGLOBULIN"],["N","G","HYQVIA INJ 2.5-200","IMMUN GLOB INJ 2.5 GM/25ML-HYALURON INJ 200 UNT/1.25 ML KIT","4","1","0","0","","SP","IMMUNOLOGIC AGENTS","IMMUNOGLOBULIN"],["N","G","HYQVIA INJ 20-1600","IMMUN GLOB INJ 20 GM/200ML-HYALURON INJ 1600 UNT/10 ML KIT","4","1","0","0","","SP","IMMUNOLOGIC AGENTS","IMMUNOGLOBULIN"],["N","G","HYQVIA INJ 30-2400","IMMUN GLOB INJ 30 GM/300ML-HYALURON INJ 2400 UNT/15 ML KIT","4","1","0","0","","SP","IMMUNOLOGIC AGENTS","IMMUNOGLOBULIN"],["N","G","HYQVIA INJ 5-400","IMMUN GLOB INJ 5 GM/50ML-HYALURON INJ 400 UNT/2.5 ML KIT","4","1","0","0","","SP","IMMUNOLOGIC AGENTS","IMMUNOGLOBULIN"],["N","G","ACTIMMUNE INJ 2MU/0.5","INTERFERON GAMMA-1B INJ 100 MCG/0.5ML (2000000 UNIT/0.5ML)","4","1","0","0","","SP","IMMUNOLOGIC AGENTS","IMMUNOMODULATORS"],["N","G","ALFERON N INJ 5MU/ML","INTERFERON ALFA-N3 INJ 5000000 UNIT/ML","4","0","0","0","","SP","IMMUNOLOGIC AGENTS","IMMUNOMODULATORS"],["N","G","ARCALYST INJ 220MG","RILONACEPT FOR INJ 220 MG","4","1","0","1","4 vials every 28 days","SP","IMMUNOLOGIC AGENTS","IMMUNOMODULATORS"],["N","G","INTRON A INJ 10MU","INTERFERON ALFA-2B FOR INJ 10000000 UNIT","4","1","0","0","","SP","IMMUNOLOGIC AGENTS","IMMUNOMODULATORS"],["N","G","INTRON A INJ 18MU","INTERFERON ALFA-2B INJ 6000000 UNIT/ML","4","1","0","0","","SP","IMMUNOLOGIC AGENTS","IMMUNOMODULATORS"],["N","G","INTRON A INJ 18MU","INTERFERON ALFA-2B FOR INJ 18000000 UNIT","4","1","0","0","","SP","IMMUNOLOGIC AGENTS","IMMUNOMODULATORS"],["N","G","INTRON A INJ 25MU","INTERFERON ALFA-2B INJ 10000000 UNIT/ML","4","1","0","0","","SP","IMMUNOLOGIC AGENTS","IMMUNOMODULATORS"],["N","G","INTRON A INJ 50MU","INTERFERON ALFA-2B FOR INJ 50000000 UNIT","4","1","0","0","","SP","IMMUNOLOGIC AGENTS","IMMUNOMODULATORS"],["N","G","POMALYST CAP 1MG","POMALIDOMIDE CAP 1 MG","4","1","0","1","21 caps every 21 days","SP","IMMUNOLOGIC AGENTS","IMMUNOMODULATORS"],["N","G","POMALYST CAP 2MG","POMALIDOMIDE CAP 2 MG","4","1","0","1","21 caps every 21 days","SP","IMMUNOLOGIC AGENTS","IMMUNOMODULATORS"],["N","G","POMALYST CAP 3MG","POMALIDOMIDE CAP 3 MG","4","1","0","1","21 caps every 21 days","SP","IMMUNOLOGIC AGENTS","IMMUNOMODULATORS"],["N","G","POMALYST CAP 4MG","POMALIDOMIDE CAP 4 MG","4","1","0","1","21 caps every 21 days","SP","IMMUNOLOGIC AGENTS","IMMUNOMODULATORS"],["N","G","REVLIMID CAP 10MG","LENALIDOMIDE CAP 10 MG","4","1","0","1","28 caps every 28 days","SP","IMMUNOLOGIC AGENTS","IMMUNOMODULATORS"],["N","G","REVLIMID CAP 15MG","LENALIDOMIDE CAP 15 MG","4","1","0","1","28 caps every 28 days","SP","IMMUNOLOGIC AGENTS","IMMUNOMODULATORS"],["N","G","REVLIMID CAP 2.5MG","LENALIDOMIDE CAPS 2.5 MG","4","1","0","1","28 caps every 28 days","SP","IMMUNOLOGIC AGENTS","IMMUNOMODULATORS"],["N","G","REVLIMID CAP 20MG","LENALIDOMIDE CAP 20 MG","4","1","0","1","21 caps every 28 days","SP","IMMUNOLOGIC AGENTS","IMMUNOMODULATORS"],["N","G","REVLIMID CAP 25MG","LENALIDOMIDE CAP 25 MG","4","1","0","1","21 caps every 28 days","SP","IMMUNOLOGIC AGENTS","IMMUNOMODULATORS"],["N","G","REVLIMID CAP 5MG","LENALIDOMIDE CAP 5 MG","4","1","0","1","28 caps every 28 days","SP","IMMUNOLOGIC AGENTS","IMMUNOMODULATORS"],["N","G","THALOMID CAP 100MG","THALIDOMIDE CAP 100 MG","4","1","0","1","28 caps every 28 days","SP","IMMUNOLOGIC AGENTS","IMMUNOMODULATORS"],["N","G","THALOMID CAP 150MG","THALIDOMIDE CAP 150 MG","4","1","0","1","56 caps every 28 days","SP","IMMUNOLOGIC AGENTS","IMMUNOMODULATORS"],["N","G","THALOMID CAP 200MG","THALIDOMIDE CAP 200 MG","4","1","0","1","56 caps every 28 days","SP","IMMUNOLOGIC AGENTS","IMMUNOMODULATORS"],["N","G","THALOMID CAP 50MG","THALIDOMIDE CAP 50 MG","4","1","0","1","28 caps every 28 days","SP","IMMUNOLOGIC AGENTS","IMMUNOMODULATORS"],["N","G","AZASAN TAB 100MG","AZATHIOPRINE TAB 100 MG","3","0","0","0","","SP","IMMUNOLOGIC AGENTS","IMMUNOSUPPRESSANTS"],["N","G","AZASAN TAB 75 MG","AZATHIOPRINE TAB 75 MG","3","0","0","0","","SP","IMMUNOLOGIC AGENTS","IMMUNOSUPPRESSANTS"],["N","G","AZATHIOPRINE TAB 50MG","AZATHIOPRINE TAB 50 MG","1","0","0","0","","SP","IMMUNOLOGIC AGENTS","IMMUNOSUPPRESSANTS"],["N","G","CYCLOSPORINE CAP 100MG","CYCLOSPORINE CAP 100 MG","1","0","0","0","","SP","IMMUNOLOGIC AGENTS","IMMUNOSUPPRESSANTS"],["N","G","CYCLOSPORINE CAP 100MG MD","CYCLOSPORINE MODIFIED CAP 100 MG","1","0","0","0","","SP","IMMUNOLOGIC AGENTS","IMMUNOSUPPRESSANTS"],["N","G","CYCLOSPORINE CAP 25MG","CYCLOSPORINE CAP 25 MG","1","0","0","0","","SP","IMMUNOLOGIC AGENTS","IMMUNOSUPPRESSANTS"],["N","G","CYCLOSPORINE CAP 25MG MOD","CYCLOSPORINE MODIFIED CAP 25 MG","1","0","0","0","","SP","IMMUNOLOGIC AGENTS","IMMUNOSUPPRESSANTS"],["N","G","CYCLOSPORINE CAP 50MG MOD","CYCLOSPORINE MODIFIED CAP 50 MG","1","0","0","0","","SP","IMMUNOLOGIC AGENTS","IMMUNOSUPPRESSANTS"],["N","G","CYCLOSPORINE INJ 50MG/ML","CYCLOSPORINE IV SOLN 50 MG/ML","1","0","0","0","","SP","IMMUNOLOGIC AGENTS","IMMUNOSUPPRESSANTS"],["N","G","CYCLOSPORINE SOL MODIFIED","CYCLOSPORINE MODIFIED ORAL SOLN 100 MG/ML","1","0","0","0","","SP","IMMUNOLOGIC AGENTS","IMMUNOSUPPRESSANTS"],["N","G","GENGRAF CAP 100MG","CYCLOSPORINE MODIFIED CAP 100 MG","1","0","0","0","","SP","IMMUNOLOGIC AGENTS","IMMUNOSUPPRESSANTS"],["N","G","GENGRAF CAP 25MG","CYCLOSPORINE MODIFIED CAP 25 MG","1","0","0","0","","SP","IMMUNOLOGIC AGENTS","IMMUNOSUPPRESSANTS"],["N","G","GENGRAF SOL 100MG/ML","CYCLOSPORINE MODIFIED ORAL SOLN 100 MG/ML","1","0","0","0","","SP","IMMUNOLOGIC AGENTS","IMMUNOSUPPRESSANTS"],["N","G","MYCOPHENOLAT CAP 250MG","MYCOPHENOLATE MOFETIL CAP 250 MG","1","0","0","0","","SP","IMMUNOLOGIC AGENTS","IMMUNOSUPPRESSANTS"],["N","G","MYCOPHENOLAT INJ 500MG","MYCOPHENOLATE MOFETIL HCL FOR IV SOLN 500 MG (BASE EQUIV)","1","0","0","0","","SP","IMMUNOLOGIC AGENTS","IMMUNOSUPPRESSANTS"],["N","G","MYCOPHENOLAT SUS 200MG/ML","MYCOPHENOLATE MOFETIL FOR ORAL SUSP 200 MG/ML","1","0","0","0","","SP","IMMUNOLOGIC AGENTS","IMMUNOSUPPRESSANTS"],["N","G","MYCOPHENOLAT TAB 500MG","MYCOPHENOLATE MOFETIL TAB 500 MG","1","0","0","0","","SP","IMMUNOLOGIC AGENTS","IMMUNOSUPPRESSANTS"],["N","G","MYCOPHENOLIC TAB 180MG DR","MYCOPHENOLATE SODIUM TAB DR 180 MG (MYCOPHENOLIC ACID EQUIV)","1","0","0","0","","SP","IMMUNOLOGIC AGENTS","IMMUNOSUPPRESSANTS"],["N","G","MYCOPHENOLIC TAB 360MG DR","MYCOPHENOLATE SODIUM TAB DR 360 MG (MYCOPHENOLIC ACID EQUIV)","1","0","0","0","","SP","IMMUNOLOGIC AGENTS","IMMUNOSUPPRESSANTS"],["N","G","PROGRAF INJ 5MG/ML","TACROLIMUS INJ 5 MG/ML","3","0","0","0","","SP","IMMUNOLOGIC AGENTS","IMMUNOSUPPRESSANTS"],["N","G","SANDIMMUNE SOL 100MG/ML","CYCLOSPORINE ORAL SOLN 100 MG/ML","3","0","0","0","","SP","IMMUNOLOGIC AGENTS","IMMUNOSUPPRESSANTS"],["N","G","SIROLIMUS SOL 1MG/ML","SIROLIMUS ORAL SOLN 1 MG/ML","1","0","0","0","","SP","IMMUNOLOGIC AGENTS","IMMUNOSUPPRESSANTS"],["N","G","SIROLIMUS TAB 0.5MG","SIROLIMUS TAB 0.5 MG","1","0","0","0","","SP","IMMUNOLOGIC AGENTS","IMMUNOSUPPRESSANTS"],["N","G","SIROLIMUS TAB 1MG","SIROLIMUS TAB 1 MG","1","0","0","0","","SP","IMMUNOLOGIC AGENTS","IMMUNOSUPPRESSANTS"],["N","G","SIROLIMUS TAB 2MG","SIROLIMUS TAB 2 MG","1","0","0","0","","SP","IMMUNOLOGIC AGENTS","IMMUNOSUPPRESSANTS"],["N","G","TACROLIMUS CAP 0.5MG","TACROLIMUS CAP 0.5 MG","1","0","0","0","","SP","IMMUNOLOGIC AGENTS","IMMUNOSUPPRESSANTS"],["N","G","TACROLIMUS CAP 1MG","TACROLIMUS CAP 1 MG","1","0","0","0","","SP","IMMUNOLOGIC AGENTS","IMMUNOSUPPRESSANTS"],["N","G","TACROLIMUS CAP 5MG","TACROLIMUS CAP 5 MG","1","0","0","0","","SP","IMMUNOLOGIC AGENTS","IMMUNOSUPPRESSANTS"],["N","G","ZORTRESS TAB 0.25MG","EVEROLIMUS TAB 0.25 MG","2","0","0","0","","SP","IMMUNOLOGIC AGENTS","IMMUNOSUPPRESSANTS"],["N","G","ZORTRESS TAB 0.5MG","EVEROLIMUS TAB 0.5 MG","2","0","0","0","","SP","IMMUNOLOGIC AGENTS","IMMUNOSUPPRESSANTS"],["N","G","ZORTRESS TAB 0.75MG","EVEROLIMUS TAB 0.75 MG","2","0","0","0","","SP","IMMUNOLOGIC AGENTS","IMMUNOSUPPRESSANTS"],["N","G","ZORTRESS TAB 1MG","EVEROLIMUS TAB 1 MG","2","0","0","0","","SP","IMMUNOLOGIC AGENTS","IMMUNOSUPPRESSANTS"],["N","G","ACTHIB INJ","HAEMOPHILUS B POLYSACCHARIDE CONJUGATE VACCINE FOR INJ","0","0","0","0","","$0 copay for members age 18 and younger, otherwise not covered","IMMUNOLOGIC AGENTS","VACCINES"],["N","G","ADACEL INJ","TET TOX-DIPH-ACELL PERTUSS AD INJ 5-2-15.5 LF-LF-MCG/0.5ML","0","0","0","0","","","IMMUNOLOGIC AGENTS","VACCINES"],["N","G","AFLURIA QUAD INJ 2019-20","INFLUENZA VIRUS VAC SPLIT QUADRIVALENT SUSP PREF SYR 0.5ML","0","0","0","0","","","IMMUNOLOGIC AGENTS","VACCINES"],["N","G","AFLURIA QUAD INJ 2019-20","INFLUENZA VIRUS VAC SPLIT QUADRIVALENT SUSP PREF SYR 0.25 ML","0","0","0","0","","","IMMUNOLOGIC AGENTS","VACCINES"],["N","G","AFLURIA QUAD INJ 2019-20","INFLUENZA VIRUS VACCINE SPLIT QUADRIVALENT IM INJ","0","0","0","0","","","IMMUNOLOGIC AGENTS","VACCINES"],["N","G","BEXSERO INJ","MENINGOCOCCAL VAC B (RECOMB OMV ADJUV) INJ PREFILLED SYRINGE","0","0","0","0","","","IMMUNOLOGIC AGENTS","VACCINES"],["N","G","BOOSTRIX INJ","TET TOX-DIPH-ACELL PERTUSS AD INJ 5-2.5-18.5 LF-LF-MCG/0.5ML","0","0","0","0","","","IMMUNOLOGIC AGENTS","VACCINES"],["N","G","DAPTACEL INJ","DIPH, ACELLULAR PERT & TET TOX INJ 15 LF-23 MCG-5 LF/0.5ML","0","0","0","0","","$0 copay for members age 18 and younger, otherwise not covered","IMMUNOLOGIC AGENTS","VACCINES"],["N","G","DIP/TET PED INJ 25-5LFU","DIPHTHERIA-TETANUS TOX ADSORBED (DT) IM INJ 25-5 UNIT/0.5ML","0","0","0","0","","$0 copay for members age 18 and younger, otherwise not covered","IMMUNOLOGIC AGENTS","VACCINES"],["N","G","ENGERIX-B INJ 10/0.5ML","HEPATITIS B VACCINE (RECOMBINANT) 10 MCG/0.5ML","0","0","0","0","","","IMMUNOLOGIC AGENTS","VACCINES"],["N","G","ENGERIX-B INJ 10/0.5ML","HEPATITIS B VACCINE (RECOMBINANT) SUSP 10 MCG/0.5ML","0","0","0","0","","","IMMUNOLOGIC AGENTS","VACCINES"],["N","G","ENGERIX-B INJ 20MCG/ML","HEPATITIS B VACCINE (RECOMBINANT) 20 MCG/ML","0","0","0","0","","","IMMUNOLOGIC AGENTS","VACCINES"],["N","G","ENGERIX-B INJ 20MCG/ML","HEPATITIS B VACCINE (RECOMBINANT) SUSP 20 MCG/ML","0","0","0","0","","","IMMUNOLOGIC AGENTS","VACCINES"],["N","G","FLUAD INJ 2019-20","INFLUENZA VAC TYPE A&B SURFACE ANT ADJ SUSP PREF SYR 0.5 ML","0","0","0","0","","","IMMUNOLOGIC AGENTS","VACCINES"],["N","G","FLUARIX QUAD INJ 2019-20","INFLUENZA VIRUS VAC SPLIT QUADRIVALENT SUSP PREF SYR 0.5ML","0","0","0","0","","","IMMUNOLOGIC AGENTS","VACCINES"],["N","G","FLUBLOK QUAD INJ 2019-20","INFLUENZA VAC RECOMB HA QUAD PF SOLN PREF SYR 0.5 ML","0","0","0","0","","","IMMUNOLOGIC AGENTS","VACCINES"],["N","G","FLUCLVX QUAD INJ 2019-20","INFLUENZA VAC TISSUE-CULTURED SUBUNIT QUADRIVALENT IM SUSP","0","0","0","0","","","IMMUNOLOGIC AGENTS","VACCINES"],["N","G","FLUCLVX QUAD INJ 2019-20","INFLUENZA VAC TISS-CULT SUBUNT QUAD SUSP PREF SYR 0.5 ML","0","0","0","0","","","IMMUNOLOGIC AGENTS","VACCINES"],["N","G","FLULAVAL QUA INJ 2019-20","INFLUENZA VIRUS VAC SPLIT QUADRIVALENT SUSP PREF SYR 0.5ML","0","0","0","0","","","IMMUNOLOGIC AGENTS","VACCINES"],["N","G","FLULAVAL QUA INJ 2019-20","INFLUENZA VIRUS VACCINE SPLIT QUADRIVALENT IM INJ","0","0","0","0","","","IMMUNOLOGIC AGENTS","VACCINES"],["N","G","FLUMIST QUAD SUS 2019-20","INFLUENZA VIRUS VACCINE LIVE QUADRIVALENT INTRANASAL SUSP","0","0","0","0","","","IMMUNOLOGIC AGENTS","VACCINES"],["N","G","FLUZONE HD INJ PF 19-20","INFLUENZA VIRUS VAC SPLIT HIGH-DOSE PF SUSP PREF SYR 0.5ML","0","0","0","0","","","IMMUNOLOGIC AGENTS","VACCINES"],["N","G","FLUZONE QUAD INJ 2019-20","INFLUENZA VIRUS VAC SPLIT QUADRIVALENT SUSP PREF SYR 0.5ML","0","0","0","0","","","IMMUNOLOGIC AGENTS","VACCINES"],["N","G","FLUZONE QUAD INJ 2019-20","INFLUENZA VIRUS VACCINE SPLIT QUADRIVALENT INJ 0.5 ML","0","0","0","0","","","IMMUNOLOGIC AGENTS","VACCINES"],["N","G","FLUZONE QUAD INJ 2019-20","INFLUENZA VIRUS VAC SPLIT QUADRIVALENT SUSP PREF SYR 0.25 ML","0","0","0","0","","","IMMUNOLOGIC AGENTS","VACCINES"],["N","G","FLUZONE QUAD INJ 2019-20","INFLUENZA VIRUS VACCINE SPLIT QUADRIVALENT IM INJ","0","0","0","0","","","IMMUNOLOGIC AGENTS","VACCINES"],["N","G","GARDASIL 9 INJ","HUMAN PAPILLOMAVIRUS (HPV) 9-VALENT RECOMB VAC IM SUSP","0","0","0","0","","","IMMUNOLOGIC AGENTS","VACCINES"],["N","G","GARDASIL 9 INJ","HUMAN PAPILLOMAVIRUS (HPV) 9-VALENT RECOMB VAC SUSP PREF SYR","0","0","0","0","","","IMMUNOLOGIC AGENTS","VACCINES"],["N","G","GARDASIL INJ","HUMAN PAPILLOMAVIRUS (HPV) QUADRIVALENT RECOMBINANT VAC INJ","0","0","0","0","","","IMMUNOLOGIC AGENTS","VACCINES"],["N","G","HAVRIX INJ 1440UNIT","HEPATITIS A VACCINE INJ SUSP 1440 EL UNIT/ML","0","0","0","0","","","IMMUNOLOGIC AGENTS","VACCINES"],["N","G","HAVRIX INJ 720UNIT","HEPATITIS A VACCINE INJ SUSP 720 EL UNIT/0.5ML","0","0","0","0","","","IMMUNOLOGIC AGENTS","VACCINES"],["N","G","HEPLISAV-B INJ 20/0.5ML","HEPATITIS B VACCINE RECOMB ADJUVANTED PREF SYR 20 MCG/0.5ML","0","0","0","0","","","IMMUNOLOGIC AGENTS","VACCINES"],["N","G","HEPLISAV-B INJ 20MCG","HEPATITIS B VACCINE RECOMBINANT ADJUVANTED 20 MCG/0.5ML","0","0","0","0","","","IMMUNOLOGIC AGENTS","VACCINES"],["N","G","HIBERIX SOL 10MCG","HAEMOPHILUS B POLYSACCHARIDE CONJUGATE VAC FOR INJ 10 MCG","0","0","0","0","","$0 copay for members age 18 and younger, otherwise not covered","IMMUNOLOGIC AGENTS","VACCINES"],["N","G","INFANRIX INJ","DIPH, ACELLULAR PERT & TET TOX INJ 25 LF-58 MCG-10 LF/0.5ML","0","0","0","0","","$0 copay for members age 18 and younger, otherwise not covered","IMMUNOLOGIC AGENTS","VACCINES"],["N","G","IPOL INJ INACTIVE","POLIOVIRUS VACCINE, IPV INJECTION","0","0","0","0","","$0 copay for members age 18 and younger, otherwise not covered","IMMUNOLOGIC AGENTS","VACCINES"],["N","G","KINRIX INJ","DIPH-TETANUS TOX AD-ACELL PERT & POLIO VIRUS, IPV VAC INJ","0","0","0","0","","$0 copay for members age 18 and younger, otherwise not covered","IMMUNOLOGIC AGENTS","VACCINES"],["N","G","M-M-R II INJ","MEASLES-MUMPS-RUBELLA VIRUS VACCINES FOR INJ SOLN","0","0","0","0","","","IMMUNOLOGIC AGENTS","VACCINES"],["N","G","MENACTRA INJ","MENINGOCOCCAL (A, C, Y, AND W-135) CONJUGATE VACCINE INJ","0","0","0","0","","","IMMUNOLOGIC AGENTS","VACCINES"],["N","G","MENHIBRIX INJ","MENINGOCOCCAL (C & Y)-HAEMOPHILUS B TET TOX CONJ VAC FOR INJ","0","0","0","0","","$0 copay for members age 18 and younger, otherwise not covered","IMMUNOLOGIC AGENTS","VACCINES"],["N","G","MENOMUNE INJ A/C/Y/W","MENINGOCOCCAL (A, C, Y, AND W-135) POLYSACC VAC FOR INJ","0","0","0","0","","","IMMUNOLOGIC AGENTS","VACCINES"],["N","G","MENVEO INJ","MENINGOCOCCAL (A, C, Y, AND W-135) OLIGO CONJ VAC FOR INJ","0","0","0","0","","","IMMUNOLOGIC AGENTS","VACCINES"],["N","G","PEDIARIX INJ 0.5ML","DIPH-TETANUS TOX-ACELL PERT-HEPATITIS B-POLIO IPV VAC INJ","0","0","0","0","","$0 copay for members age 18 and younger, otherwise not covered","IMMUNOLOGIC AGENTS","VACCINES"],["N","G","PEDVAX HIB INJ","HAEMOPHILUS B POLYSACCHARIDE CONJ VAC IM SUSP 7.5 MCG/0.5 ML","0","0","0","0","","$0 copay for members age 18 and younger, otherwise not covered","IMMUNOLOGIC AGENTS","VACCINES"],["N","G","PENTACEL INJ","DIPH-AC PER-TET TOX AD-POLIOV-HAEMOPH B POLY VAC FOR IM SUSP","0","0","0","0","","$0 copay for members age 18 and younger, otherwise not covered","IMMUNOLOGIC AGENTS","VACCINES"],["N","G","PNEUMOVAX 23 INJ 25/0.5","PNEUMOCOCCAL VACCINE POLYVALENT INJ 25 MCG/0.5ML","0","0","0","0","","","IMMUNOLOGIC AGENTS","VACCINES"],["N","G","PREVNAR 13 INJ","PNEUMOCOCCAL 13-VALENT CONJUGATE VACCINE INJ","0","0","0","0","","","IMMUNOLOGIC AGENTS","VACCINES"],["N","G","PROQUAD INJ","MEASLES-MUMPS-RUBELLA-VARICELLA VIRUS VACCINES FOR SUSP","0","0","0","0","","$0 copay for members age 18 and younger, otherwise not covered","IMMUNOLOGIC AGENTS","VACCINES"],["N","G","RECOMBIVA HB INJ 10MCG/ML","HEPATITIS B VACCINE (RECOMBINANT) SUSP 10 MCG/ML","0","0","0","0","","","IMMUNOLOGIC AGENTS","VACCINES"],["N","G","RECOMBIVA HB INJ 5MCG/0.5","HEPATITIS B VACCINE (RECOMBINANT) SUSP 5 MCG/0.5ML","0","0","0","0","","","IMMUNOLOGIC AGENTS","VACCINES"],["N","G","RECOMBIVA-HB INJ 40MCG/ML","HEPATITIS B VACCINE (RECOMBINANT) SUSP 40 MCG/ML","0","0","0","0","","","IMMUNOLOGIC AGENTS","VACCINES"],["N","G","ROTARIX SUS","ROTAVIRUS VACCINE, LIVE FOR ORAL SUSP","0","0","0","0","","$0 copay for members age 18 and younger, otherwise not covered","IMMUNOLOGIC AGENTS","VACCINES"],["N","G","ROTATEQ SOL","ROTAVIRUS VACCINE, LIVE ORAL PENTAVALENT SOLN","0","0","0","0","","$0 copay for members age 18 and younger, otherwise not covered","IMMUNOLOGIC AGENTS","VACCINES"],["N","G","SHINGRIX INJ 50MCG","ZOSTER VAC RECOMBINANT ADJUVANTED FOR IM INJ 50 MCG/0.5ML","0","0","0","0","","$0 copay for members age 19 and older, otherwise not covered","IMMUNOLOGIC AGENTS","VACCINES"],["N","G","TDVAX INJ 2-2 LF","TETANUS-DIPHTHERIA TOXOIDS (TD) INJ 2-2 LF/0.5ML","0","0","0","0","","$0 copay for members age 19 and older, otherwise not covered","IMMUNOLOGIC AGENTS","VACCINES"],["N","G","TENIVAC INJ 5-2LF","TETANUS-DIPHTHERIA TOXOIDS (TD) INJ 5-2 LFU","0","0","0","0","","$0 copay for members age 19 and older, otherwise not covered","IMMUNOLOGIC AGENTS","VACCINES"],["N","G","TRUMENBA INJ","MENINGOCOCCAL GROUP B VAC (RECOMB) IM SUSP PREFILLED SYR","0","0","0","0","","","IMMUNOLOGIC AGENTS","VACCINES"],["N","G","TWINRIX INJ","HEP A-HEP B VACCINE SUSP PREF SYR 720-20 ELU-MCG/ML","0","0","0","0","","$0 copay for members age 19 and older, otherwise not covered","IMMUNOLOGIC AGENTS","VACCINES"],["N","G","VAQTA INJ 25/0.5ML","HEPATITIS A VACCINE INJ SUSP 25 UNIT/0.5ML","0","0","0","0","","","IMMUNOLOGIC AGENTS","VACCINES"],["N","G","VAQTA INJ 50UNT/ML","HEPATITIS A VACCINE INJ SUSP 50 UNIT/ML","0","0","0","0","","","IMMUNOLOGIC AGENTS","VACCINES"],["N","G","VARIVAX INJ","VARICELLA VIRUS VAC LIVE FOR SUBCUTANEOUS INJ 1350 PFU/0.5ML","0","0","0","0","","","IMMUNOLOGIC AGENTS","VACCINES"],["N","G","ZOSTAVAX INJ","ZOSTER VACCINE LIVE FOR SUBCUTANEOUS SUSP 19400 UNIT/0.65ML","0","0","0","0","","$0 copay for members age 19 and older, otherwise not covered","IMMUNOLOGIC AGENTS","VACCINES"],["N","G","CAYA DPR","*DIAPHRAGM ARC-SPRING***","0","0","0","1","1 every 300 days","","MEDICAL DEVICES","CONTRACEPTIVES"],["N","G","FC2 FEMALE MIS CONDOM","*CONDOMS - FEMALE***","0","0","0","0","","","MEDICAL DEVICES","CONTRACEPTIVES"],["N","G","FEMCAP MIS 22MM","CERVICAL CAP 22 MM","0","0","0","1","1 every 300 days","","MEDICAL DEVICES","CONTRACEPTIVES"],["N","G","FEMCAP MIS 26MM","CERVICAL CAP 26 MM","0","0","0","1","1 every 300 days","","MEDICAL DEVICES","CONTRACEPTIVES"],["N","G","FEMCAP MIS 30MM","CERVICAL CAP 30 MM","0","0","0","1","1 every 300 days","","MEDICAL DEVICES","CONTRACEPTIVES"],["N","G","OMNIFLEX DPR","*DIAPHRAGMS***","0","0","0","1","1 every 300 days","","MEDICAL DEVICES","CONTRACEPTIVES"],["N","G","WIDE-SEAL DPR KIT 60","DIAPHRAGM WIDE SEAL 60 MM","0","0","0","1","1 every 300 days","","MEDICAL DEVICES","CONTRACEPTIVES"],["N","G","WIDE-SEAL DPR KIT 65","DIAPHRAGM WIDE SEAL 65 MM","0","0","0","1","1 every 300 days","","MEDICAL DEVICES","CONTRACEPTIVES"],["N","G","WIDE-SEAL DPR KIT 70","DIAPHRAGM WIDE SEAL 70 MM","0","0","0","1","1 every 300 days","","MEDICAL DEVICES","CONTRACEPTIVES"],["N","G","WIDE-SEAL DPR KIT 75","DIAPHRAGM WIDE SEAL 75 MM","0","0","0","1","1 every 300 days","","MEDICAL DEVICES","CONTRACEPTIVES"],["N","G","WIDE-SEAL DPR KIT 80","DIAPHRAGM WIDE SEAL 80 MM","0","0","0","1","1 every 300 days","","MEDICAL DEVICES","CONTRACEPTIVES"],["N","G","WIDE-SEAL DPR KIT 85","DIAPHRAGM WIDE SEAL 85 MM","0","0","0","1","1 every 300 days","","MEDICAL DEVICES","CONTRACEPTIVES"],["N","G","WIDE-SEAL DPR KIT 90","DIAPHRAGM WIDE SEAL 90 MM","0","0","0","1","1 every 300 days","","MEDICAL DEVICES","CONTRACEPTIVES"],["N","G","WIDE-SEAL DPR KIT 95","DIAPHRAGM WIDE SEAL 95 MM","0","0","0","1","1 every 300 days","","MEDICAL DEVICES","CONTRACEPTIVES"],["N","G","ACCU-CHEK KIT AVA CONN","*BLOOD GLUCOSE MONITORING KIT W/ DEVICE***","2","0","0","0","","","MEDICAL DEVICES","DIABETIC SUPPLIES"],["N","G","ACCU-CHEK KIT AVIVA PL","*BLOOD GLUCOSE MONITORING KIT W/ DEVICE***","2","0","0","0","","","MEDICAL DEVICES","DIABETIC SUPPLIES"],["N","G","ACCU-CHEK KIT COMPACT","*BLOOD GLUCOSE MONITORING KIT***","2","0","0","0","","","MEDICAL DEVICES","DIABETIC SUPPLIES"],["N","G","ACCU-CHEK KIT GUIDE","*BLOOD GLUCOSE MONITORING KIT W/ DEVICE***","2","0","0","0","","","MEDICAL DEVICES","DIABETIC SUPPLIES"],["N","G","ACCU-CHEK KIT NANO","*BLOOD GLUCOSE MONITORING KIT W/ DEVICE***","2","0","0","0","","","MEDICAL DEVICES","DIABETIC SUPPLIES"],["N","G","ACCU-CHEK LIQ SMART","*BLOOD GLUCOSE CALIBRATION - LIQUID***","2","0","0","0","","","MEDICAL DEVICES","DIABETIC SUPPLIES"],["N","G","ACCU-CHEK MIS AVIVA","*BLOOD GLUCOSE MONITORING DEVICES***","2","0","0","0","","","MEDICAL DEVICES","DIABETIC SUPPLIES"],["N","G","ACCU-CHEK MIS MLTICLIX","*LANCETS***","2","0","0","0","","","MEDICAL DEVICES","DIABETIC SUPPLIES"],["N","G","ACCU-CHEK TES AVIVA PL","GLUCOSE BLOOD TEST STRIP","2","0","0","1","204 Test Strips every 25 days","","MEDICAL DEVICES","DIABETIC SUPPLIES"],["N","G","ACCU-CHEK TES COMPACT","GLUCOSE BLOOD TEST STRIP","2","0","0","1","204 Test Strips every 25 days","","MEDICAL DEVICES","DIABETIC SUPPLIES"],["N","G","ACCU-CHEK TES GUIDE","GLUCOSE BLOOD TEST STRIP","2","0","0","1","204 Test Strips every 25 days","","MEDICAL DEVICES","DIABETIC SUPPLIES"],["N","G","ACCU-CHEK TES SMART","GLUCOSE BLOOD TEST STRIP","2","0","0","1","204 Test Strips every 25 days","","MEDICAL DEVICES","DIABETIC SUPPLIES"],["N","G","ALCOH-WIPE MIS 12\"X12\"","*ALCOHOL SHEETS***","2","0","0","0","","","MEDICAL DEVICES","DIABETIC SUPPLIES"],["N","G","BD SWAB REG PAD SNGL USE","*ALCOHOL SWABS***","2","0","0","0","","","MEDICAL DEVICES","DIABETIC SUPPLIES"],["N","G","CHEMSTRIP 9 TES STRIPS","*MULTIPLE URINE TEST STRIPS***","2","0","0","0","","","MEDICAL DEVICES","DIABETIC SUPPLIES"],["N","G","DIASCREEN 10 MIS","*URINE GLUCOSE MONITORING SUPPLIES***","2","0","0","0","","","MEDICAL DEVICES","DIABETIC SUPPLIES"],["N","G","DIASTIX TES STRIPS","GLUCOSE URINE TEST-(GLUCOSE OXIDASE) STRIP","2","0","0","0","","","MEDICAL DEVICES","DIABETIC SUPPLIES"],["N","G","INSULIN SYRG MIS 1ML/31G","INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 15/64\"","2","0","0","0","","","MEDICAL DEVICES","DIABETIC SUPPLIES"],["N","G","KETO-DIASTIX TES","*URINE GLUCOSE-KETONES TEST STRIPS***","2","0","0","0","","","MEDICAL DEVICES","DIABETIC SUPPLIES"],["N","G","LANCING DEVI MIS","*LANCET DEVICES***","2","0","0","0","","","MEDICAL DEVICES","DIABETIC SUPPLIES"],["N","G","MONOJECTOR MIS END CAPS","*LANCETS MISC.***","2","0","0","0","","","MEDICAL DEVICES","DIABETIC SUPPLIES"],["N","G","NOVOFINE MIS 32GX6MM","INSULIN PEN NEEDLE 32 G X 6 MM (1/4\" OR 15/64\")","2","0","0","0","","","MEDICAL DEVICES","DIABETIC SUPPLIES"],["N","G","SHARPS CONT MIS 1/2 GAL","*SHARPS CONTAINER - MISC***","2","0","0","0","","","MEDICAL DEVICES","DIABETIC SUPPLIES"],["N","G","AEROCHAMBER MIS PLUS","*SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE***","2","0","0","0","","","MEDICAL DEVICES","MISCELLANEOUS"],["N","G","FLEXICHAMBER MIS MASK SM","*SPACER/AEROSOL-HOLDING CHAMBER SUPPLIES - MASKS***","2","0","0","0","","","MEDICAL DEVICES","MISCELLANEOUS"],["N","G","HUMATROPEN MIS FOR 12MG","*INJECTION DEVICE - MISC***","2","0","0","0","","","MEDICAL DEVICES","MISCELLANEOUS"],["N","G","HUMATROPEN MIS FOR 24MG","*INJECTION DEVICE - MISC***","2","0","0","0","","","MEDICAL DEVICES","MISCELLANEOUS"],["N","G","HUMATROPEN MIS FOR 6MG","*INJECTION DEVICE - MISC***","2","0","0","0","","","MEDICAL DEVICES","MISCELLANEOUS"],["N","G","OPTICHAMBER MIS FACE MAS","*SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE***","2","0","0","0","","","MEDICAL DEVICES","MISCELLANEOUS"],["N","G","PANDA MASK MIS PEDIATRI","*SPACER/AEROSOL-HOLDING CHAMBER SUPPLIES - MASKS***","2","0","0","0","","","MEDICAL DEVICES","MISCELLANEOUS"],["N","G","FLUOR-A-DAY DRO 0.125MG","SODIUM FLUORIDE SOLN 0.125 MG/DROP F (0.275 MG/DROP NAF)","0","0","0","0","","$0 applies for ages 5 and under, otherwise not covered","NUTRITIONAL/SUPPLEMENTS","ELECTROLYTES"],["N","G","FLUORABON DRO","SODIUM FLUORIDE SOLN 0.25 MG/0.6ML (FROM 0.55 MG/0.6ML NAF)","0","0","0","0","","$0 applies for ages 5 and under, otherwise not covered","NUTRITIONAL/SUPPLEMENTS","ELECTROLYTES"],["N","G","FLUORIDE CHW 0.25MG F","SODIUM FLUORIDE CHEW TAB 0.25 MG F (FROM 0.55 MG NAF)","0","0","0","0","","$0 applies for ages 5 and under, otherwise not covered","NUTRITIONAL/SUPPLEMENTS","ELECTROLYTES"],["N","G","FLUORIDE CHW 1MG F","SODIUM FLUORIDE CHEW TAB 1 MG F (FROM 2.2 MG NAF)","1","0","0","0","","","NUTRITIONAL/SUPPLEMENTS","ELECTROLYTES"],["N","G","FLUORITAB CHW 0.25MG F","SODIUM FLUORIDE CHEW TAB 0.25 MG F (FROM 0.55 MG NAF)","0","0","0","0","","$0 applies for ages 5 and under, otherwise not covered","NUTRITIONAL/SUPPLEMENTS","ELECTROLYTES"],["N","G","FLUORITAB CHW 0.5MG F","SODIUM FLUORIDE CHEW TAB 0.5 MG F (FROM 1.1 MG NAF)","0","0","0","0","","$0 applies for ages 5 and under, otherwise not covered","NUTRITIONAL/SUPPLEMENTS","ELECTROLYTES"],["N","G","FLUORITAB CHW 2.2MG","SODIUM FLUORIDE CHEW TAB 1 MG F (FROM 2.2 MG NAF)","1","0","0","0","","","NUTRITIONAL/SUPPLEMENTS","ELECTROLYTES"],["N","G","FLURA-DROPS DRO 0.25MG F","SODIUM FLUORIDE SOLN 0.25 MG/DROP F (FROM 0.55 MG/DROP NAF)","0","0","0","0","","$0 applies for ages 5 and under, otherwise not covered","NUTRITIONAL/SUPPLEMENTS","ELECTROLYTES"],["N","G","K-EFFERVESCE TAB 25MEQ EF","POTASSIUM BICARBONATE EFFER TAB 25 MEQ","1","0","0","0","","","NUTRITIONAL/SUPPLEMENTS","ELECTROLYTES"],["N","G","KLOR-CON 10 TAB 10MEQ ER","POTASSIUM CHLORIDE TAB ER 10 MEQ","1","0","0","0","","","NUTRITIONAL/SUPPLEMENTS","ELECTROLYTES"],["N","G","KLOR-CON 8 TAB 8MEQ ER","POTASSIUM CHLORIDE TAB ER 8 MEQ (600 MG)","1","0","0","0","","","NUTRITIONAL/SUPPLEMENTS","ELECTROLYTES"],["N","G","KLOR-CON M15 TAB 15MEQ ER","POTASSIUM CHLORIDE MICROENCAPSULATED CRYS ER TAB 15 MEQ","1","0","0","0","","","NUTRITIONAL/SUPPLEMENTS","ELECTROLYTES"],["N","G","KLOR-CON M20 TAB 20MEQ ER","POTASSIUM CHLORIDE MICROENCAPSULATED CRYS ER TAB 20 MEQ","1","0","0","0","","","NUTRITIONAL/SUPPLEMENTS","ELECTROLYTES"],["N","G","LUDENT CHW 0.25MG F","SODIUM FLUORIDE CHEW TAB 0.25 MG F (FROM 0.55 MG NAF)","0","0","0","0","","$0 applies for ages 5 and under, otherwise not covered","NUTRITIONAL/SUPPLEMENTS","ELECTROLYTES"],["N","G","LUDENT CHW 0.5MG F","SODIUM FLUORIDE CHEW TAB 0.5 MG F (FROM 1.1 MG NAF)","0","0","0","0","","$0 applies for ages 5 and under, otherwise not covered","NUTRITIONAL/SUPPLEMENTS","ELECTROLYTES"],["N","G","LUDENT CHW 1MG F","SODIUM FLUORIDE CHEW TAB 1 MG F (FROM 2.2 MG NAF)","1","0","0","0","","","NUTRITIONAL/SUPPLEMENTS","ELECTROLYTES"],["N","G","LURIDE DRO 0.5MG/ML","SODIUM FLUORIDE SOLN 0.5 MG/ML F (FROM 1.1 MG/ML NAF)","0","0","0","0","","$0 applies for ages 5 and under, otherwise not covered","NUTRITIONAL/SUPPLEMENTS","ELECTROLYTES"],["N","G","MAGNESIUM SU INJ 20/500ML","MAGNESIUM SULFATE IV SOLN 20 GM/500ML (40 MG/ML)","1","0","0","0","","","NUTRITIONAL/SUPPLEMENTS","ELECTROLYTES"],["N","G","MAGNESIUM SU INJ 2GM/50ML","MAGNESIUM SULFATE IV SOLN 2 GM/50ML (40 MG/ML)","1","0","0","0","","","NUTRITIONAL/SUPPLEMENTS","ELECTROLYTES"],["N","G","MAGNESIUM SU INJ 40G/1000","MAGNESIUM SULFATE IV SOLN 40 GM/1000ML (40 MG/ML)","1","0","0","0","","","NUTRITIONAL/SUPPLEMENTS","ELECTROLYTES"],["N","G","MAGNESIUM SU INJ 4G/100ML","MAGNESIUM SULFATE IV SOLN 4 GM/100ML (40 MG/ML)","1","0","0","0","","","NUTRITIONAL/SUPPLEMENTS","ELECTROLYTES"],["N","G","MAGNESIUM SU INJ 50%","MAGNESIUM SULFATE INJ 50%","1","0","0","0","","","NUTRITIONAL/SUPPLEMENTS","ELECTROLYTES"],["N","G","MAGNESIUM SU INJ 80MG/ML","MAGNESIUM SULFATE IV SOLN 4 GM/50ML (80 MG/ML)","1","0","0","0","","","NUTRITIONAL/SUPPLEMENTS","ELECTROLYTES"],["N","G","MG SO4/D5W INJ 10MG/ML","MAGNESIUM SULFATE IN DEXTROSE 5% IV SOLN 1 GM/100ML","1","0","0","0","","","NUTRITIONAL/SUPPLEMENTS","ELECTROLYTES"],["N","G","NAFRINSE CHW 1MG F","SODIUM FLUORIDE CHEW TAB 1 MG F (FROM 2.2 MG NAF)","1","0","0","0","","","NUTRITIONAL/SUPPLEMENTS","ELECTROLYTES"],["N","G","NAFRINSE DRO 0.125MG","SODIUM FLUORIDE SOLN 0.125 MG/DROP F (0.275 MG/DROP NAF)","0","0","0","0","","$0 applies for ages 5 and under, otherwise not covered","NUTRITIONAL/SUPPLEMENTS","ELECTROLYTES"],["N","G","NORMAL SALIN INJ 0.9%","SODIUM CHLORIDE FLUSH IV SOLN 0.9%","1","0","0","0","","","NUTRITIONAL/SUPPLEMENTS","ELECTROLYTES"],["N","G","POT CHLORIDE CAP 10MEQ ER","POTASSIUM CHLORIDE CAP ER 10 MEQ","1","0","0","0","","","NUTRITIONAL/SUPPLEMENTS","ELECTROLYTES"],["N","G","POT CHLORIDE CAP 8MEQ ER","POTASSIUM CHLORIDE CAP ER 8 MEQ","1","0","0","0","","","NUTRITIONAL/SUPPLEMENTS","ELECTROLYTES"],["N","G","POT CHLORIDE SOL 10% SF","POTASSIUM CHLORIDE ORAL SOLN 10% (20 MEQ/15ML)","1","0","0","0","","","NUTRITIONAL/SUPPLEMENTS","ELECTROLYTES"],["N","G","POT CHLORIDE SOL 20%","POTASSIUM CHLORIDE ORAL SOLN 20% (40 MEQ/15ML)","1","0","0","0","","","NUTRITIONAL/SUPPLEMENTS","ELECTROLYTES"],["N","G","POT CHLORIDE TAB 10MEQ ER","POTASSIUM CHLORIDE TAB ER 10 MEQ","1","0","0","0","","","NUTRITIONAL/SUPPLEMENTS","ELECTROLYTES"],["N","G","POT CHLORIDE TAB 20MEQ ER","POTASSIUM CHLORIDE TAB ER 20 MEQ (1500 MG)","1","0","0","0","","","NUTRITIONAL/SUPPLEMENTS","ELECTROLYTES"],["N","G","POT CHLORIDE TAB 8MEQ ER","POTASSIUM CHLORIDE TAB ER 8 MEQ (600 MG)","1","0","0","0","","","NUTRITIONAL/SUPPLEMENTS","ELECTROLYTES"],["N","G","POT CL MICRO TAB 10MEQ CR","POTASSIUM CHLORIDE MICROENCAPSULATED CRYS ER TAB 10 MEQ","1","0","0","0","","","NUTRITIONAL/SUPPLEMENTS","ELECTROLYTES"],["N","G","POT CL MICRO TAB 20MEQ ER","POTASSIUM CHLORIDE MICROENCAPSULATED CRYS ER TAB 20 MEQ","1","0","0","0","","","NUTRITIONAL/SUPPLEMENTS","ELECTROLYTES"],["N","G","SOD CHLORIDE INJ 2.5/ML","SODIUM CHLORIDE INJ 2.5 MEQ/ML (14.6%)","1","0","0","0","","","NUTRITIONAL/SUPPLEMENTS","ELECTROLYTES"],["N","G","SOD FLUORIDE CHW 0.25MG F","SODIUM FLUORIDE CHEW TAB 0.25 MG F (FROM 0.55 MG NAF)","0","0","0","0","","$0 applies for ages 5 and under, otherwise not covered","NUTRITIONAL/SUPPLEMENTS","ELECTROLYTES"],["N","G","SOD FLUORIDE CHW 0.5MG F","SODIUM FLUORIDE CHEW TAB 0.5 MG F (FROM 1.1 MG NAF)","0","0","0","0","","$0 applies for ages 5 and under, otherwise not covered","NUTRITIONAL/SUPPLEMENTS","ELECTROLYTES"],["N","G","SOD FLUORIDE CHW 1MG F","SODIUM FLUORIDE CHEW TAB 1 MG F (FROM 2.2 MG NAF)","1","0","0","0","","","NUTRITIONAL/SUPPLEMENTS","ELECTROLYTES"],["N","G","SOD FLUORIDE DRO 0.5MG/ML","SODIUM FLUORIDE SOLN 0.5 MG/ML F (FROM 1.1 MG/ML NAF)","0","0","0","0","","$0 applies for ages 5 and under, otherwise not covered","NUTRITIONAL/SUPPLEMENTS","ELECTROLYTES"],["N","G","SOD FLUORIDE TAB 0.5MG F","SODIUM FLUORIDE TAB 0.5 MG F (FROM 1.1 MG NAF)","0","0","0","0","","$0 applies for ages 5 and under, otherwise not covered","NUTRITIONAL/SUPPLEMENTS","ELECTROLYTES"],["N","G","SOD FLUORIDE TAB 1MG F","SODIUM FLUORIDE TAB 1 MG F (FROM 2.2 MG NAF)","1","0","0","0","","","NUTRITIONAL/SUPPLEMENTS","ELECTROLYTES"],["N","G","POT CHL/NACL INJ 20MEQ/L","KCL 20 MEQ/L (0.15%) IN NACL 0.45% INJ","1","0","0","0","","","NUTRITIONAL/SUPPLEMENTS","IV REPLACEMENT SOLUTIONS"],["N","G","POT CHL/NACL INJ 20MEQ/L","KCL 20 MEQ/L (0.15%) IN NACL 0.9% INJ","1","0","0","0","","","NUTRITIONAL/SUPPLEMENTS","IV REPLACEMENT SOLUTIONS"],["N","G","POT CHL/NACL INJ 40MEQ/L","KCL 40 MEQ/L (0.3%) IN NACL 0.9% INJ","1","0","0","0","","","NUTRITIONAL/SUPPLEMENTS","IV REPLACEMENT SOLUTIONS"],["N","G","POT CHLORIDE INJ 10MEQ","POTASSIUM CHLORIDE INJ 10 MEQ/50ML","1","0","0","0","","","NUTRITIONAL/SUPPLEMENTS","IV REPLACEMENT SOLUTIONS"],["N","G","POT CHLORIDE INJ 10MEQ","POTASSIUM CHLORIDE INJ 10 MEQ/100ML","1","0","0","0","","","NUTRITIONAL/SUPPLEMENTS","IV REPLACEMENT SOLUTIONS"],["N","G","POT CHLORIDE INJ 20MEQ","POTASSIUM CHLORIDE INJ 20 MEQ/100ML","1","0","0","0","","","NUTRITIONAL/SUPPLEMENTS","IV REPLACEMENT SOLUTIONS"],["N","G","POT CHLORIDE INJ 20MEQ","POTASSIUM CHLORIDE INJ 20 MEQ/50ML","1","0","0","0","","","NUTRITIONAL/SUPPLEMENTS","IV REPLACEMENT SOLUTIONS"],["N","G","POT CHLORIDE INJ 2MEQ/ML","POTASSIUM CHLORIDE INJ 2 MEQ/ML","1","0","0","0","","","NUTRITIONAL/SUPPLEMENTS","IV REPLACEMENT SOLUTIONS"],["N","G","POT CHLORIDE INJ 40MEQ","POTASSIUM CHLORIDE INJ 40 MEQ/100ML","1","0","0","0","","","NUTRITIONAL/SUPPLEMENTS","IV REPLACEMENT SOLUTIONS"],["N","G","SOD CHLORIDE INJ 0.45%","SODIUM CHLORIDE IV SOLN 0.45%","1","0","0","0","","","NUTRITIONAL/SUPPLEMENTS","IV REPLACEMENT SOLUTIONS"],["N","G","SOD CHLORIDE INJ 0.9%","SODIUM CHLORIDE PRESERVATIVE FREE (PF) INJ 0.9%","1","0","0","0","","","NUTRITIONAL/SUPPLEMENTS","IV REPLACEMENT SOLUTIONS"],["N","G","SOD CHLORIDE INJ 0.9%","SODIUM CHLORIDE PRESERVATIVE FREE (PF) INJ 0.9%","1","0","0","0","","","NUTRITIONAL/SUPPLEMENTS","IV REPLACEMENT SOLUTIONS"],["N","G","SOD CHLORIDE INJ 0.9%","SODIUM CHLORIDE IV SOLN 0.9%","1","0","0","0","","","NUTRITIONAL/SUPPLEMENTS","IV REPLACEMENT SOLUTIONS"],["N","G","SOD CHLORIDE INJ 3%","SODIUM CHLORIDE IV SOLN 3%","1","0","0","0","","","NUTRITIONAL/SUPPLEMENTS","IV REPLACEMENT SOLUTIONS"],["N","G","SOD CHLORIDE INJ 5%","SODIUM CHLORIDE IV SOLN 5%","1","0","0","0","","","NUTRITIONAL/SUPPLEMENTS","IV REPLACEMENT SOLUTIONS"],["N","G","CALCITRIOL CAP 0.25MCG","CALCITRIOL CAP 0.25 MCG","1","0","0","0","","","NUTRITIONAL/SUPPLEMENTS","VITAMINS"],["N","G","CALCITRIOL CAP 0.5MCG","CALCITRIOL CAP 0.5 MCG","1","0","0","0","","","NUTRITIONAL/SUPPLEMENTS","VITAMINS"],["N","G","CALCITRIOL INJ 1MCG/ML","CALCITRIOL INJ 1 MCG/ML","1","0","0","0","","","NUTRITIONAL/SUPPLEMENTS","VITAMINS"],["N","G","CALCITRIOL SOL 1MCG/ML","CALCITRIOL ORAL SOLN 1 MCG/ML","1","0","0","0","","","NUTRITIONAL/SUPPLEMENTS","VITAMINS"],["N","G","CITRANATAL CAP HARMONY","*PRENAT W/O A W/FE FUM-FE CBN-DSS-FA-DHA CAP 27-1-260 MG***","2","0","0","0","","","NUTRITIONAL/SUPPLEMENTS","VITAMINS"],["N","G","CITRANATAL CAP MEDLEY","*PRENAT W/O A W/FE FUM-FE CBN-FA-DHA CAP 27-1-200 MG***","2","0","0","0","","","NUTRITIONAL/SUPPLEMENTS","VITAMINS"],["N","G","CITRANATAL MIS","*PRENAT W/O A W/FECBN-FEGL-DSS-FA TAB 90 &DHA CAP 300MG PAK*","2","0","0","0","","","NUTRITIONAL/SUPPLEMENTS","VITAMINS"],["N","G","CITRANATAL MIS 90 DHA","*PRENAT W/O A W/FECBN-FEGL-DSS-FA TAB 90 &DHA CAP 300MG PAK*","2","0","0","0","","","NUTRITIONAL/SUPPLEMENTS","VITAMINS"],["N","G","CITRANATAL MIS B-CALM","*PRENAT W/O A W/FECBN-FEGLU-FA TAB 20-1 MG & VIT B6 TAB PAK*","2","0","0","0","","","NUTRITIONAL/SUPPLEMENTS","VITAMINS"],["N","G","CITRANATAL PAK ASSURE","*PRENAT W/O A W/FECBN-FEGL-DSS-FA TAB & DHA CAP 300 MG PACK*","2","0","0","0","","","NUTRITIONAL/SUPPLEMENTS","VITAMINS"],["N","G","CITRANATAL PAK DHA","*PRENAT W/O A W/FECBN-FEGL-DSS-FA TAB & DHA CAP 250 MG PACK*","2","0","0","0","","","NUTRITIONAL/SUPPLEMENTS","VITAMINS"],["N","G","CITRANATAL TAB BLOOM","*PRENATAL VIT W/ DSS-FE CBN-FE GLUC-FA TAB 90-1 MG***","2","0","0","0","","","NUTRITIONAL/SUPPLEMENTS","VITAMINS"],["N","G","CITRANATAL TAB RX","*PRENATAL W/O A W/ FE CARBONYL-FE GLUC-DSS-FA TAB 27-1MG***","2","0","0","0","","","NUTRITIONAL/SUPPLEMENTS","VITAMINS"],["N","G","CYANOCOBALAM INJ 1000MCG","CYANOCOBALAMIN INJ 1000 MCG/ML","1","0","0","0","","","NUTRITIONAL/SUPPLEMENTS","VITAMINS"],["N","G","DOXERCALCIF CAP 0.5MCG","DOXERCALCIFEROL CAP 0.5 MCG","1","0","0","0","","","NUTRITIONAL/SUPPLEMENTS","VITAMINS"],["N","G","DOXERCALCIF CAP 1MCG","DOXERCALCIFEROL CAP 1 MCG","1","0","0","0","","","NUTRITIONAL/SUPPLEMENTS","VITAMINS"],["N","G","DOXERCALCIF CAP 2.5MCG","DOXERCALCIFEROL CAP 2.5 MCG","1","0","0","0","","","NUTRITIONAL/SUPPLEMENTS","VITAMINS"],["N","G","DOXERCALCIF INJ 4MCG/2ML","DOXERCALCIFEROL INJ 4 MCG/2ML (2 MCG/ML)","1","0","0","0","","","NUTRITIONAL/SUPPLEMENTS","VITAMINS"],["N","G","ELITE-OB TAB","*PRENATAL VIT W/ IRON CARBONYL-FA TAB 50-1.25 MG***","1","0","0","0","","","NUTRITIONAL/SUPPLEMENTS","VITAMINS"],["N","G","FOLIC ACID CAP 800MCG","FOLIC ACID CAP 0.8 MG","0","0","0","1","100 caps every 30 days","$0 copay for women ages 55 and under, otherwise not covered","NUTRITIONAL/SUPPLEMENTS","VITAMINS"],["N","G","FOLIC ACID TAB 1MG","FOLIC ACID TAB 1 MG","1","0","0","0","","","NUTRITIONAL/SUPPLEMENTS","VITAMINS"],["N","G","FOLIC ACID TAB 400MCG","FOLIC ACID TAB 400 MCG","0","0","0","1","100 tabs every 30 days","$0 copay for women ages 55 and under, otherwise not covered","NUTRITIONAL/SUPPLEMENTS","VITAMINS"],["N","G","FOLIC ACID TAB 800MCG","FOLIC ACID TAB 800 MCG","0","0","0","1","100 tabs every 30 days","$0 copay for women ages 55 and under, otherwise not covered","NUTRITIONAL/SUPPLEMENTS","VITAMINS"],["N","G","MULTI-VIT/FE DRO /FL 0.25","*PEDIATRIC MULTIPLE VITAMINS W/ FL-FE DROPS 0.25-10 MG/ML**","1","0","0","0","","","NUTRITIONAL/SUPPLEMENTS","VITAMINS"],["N","G","MULTI-VIT/FL DRO /FE 0.25","*PEDIATRIC MULTIPLE VITAMINS W/ FL-FE DROPS 0.25-10 MG/ML**","1","0","0","0","","","NUTRITIONAL/SUPPLEMENTS","VITAMINS"],["N","G","MULTI-VIT/FL DRO 0.25MG","*PEDIATRIC MULTIPLE VITAMINS W/ FLUORIDE SOLN 0.25 MG/ML***","1","0","0","0","","","NUTRITIONAL/SUPPLEMENTS","VITAMINS"],["N","G","MULTI-VIT/FL DRO 0.5MG/ML","*PEDIATRIC MULTIPLE VITAMINS W/ FLUORIDE SOLN 0.5 MG/ML***","1","0","0","0","","","NUTRITIONAL/SUPPLEMENTS","VITAMINS"],["N","G","MULTIVIT/FL CHW 0.25MG","*PEDIATRIC MULTIPLE VITAMINS W/ FLUORIDE CHEW TAB 0.25 MG***","1","0","0","0","","","NUTRITIONAL/SUPPLEMENTS","VITAMINS"],["N","G","MULTIVIT/FL CHW 0.5MG","*PEDIATRIC MULTIPLE VITAMINS W/ FLUORIDE CHEW TAB 0.5 MG***","1","0","0","0","","","NUTRITIONAL/SUPPLEMENTS","VITAMINS"],["N","G","MULTIVIT/FL CHW 1MG","*PEDIATRIC MULTIPLE VITAMINS W/ FLUORIDE CHEW TAB 1 MG***","1","0","0","0","","","NUTRITIONAL/SUPPLEMENTS","VITAMINS"],["N","G","MVC-FLUORIDE CHW 1MG","*PEDIATRIC MULTIPLE VITAMINS W/ FLUORIDE CHEW TAB 1 MG***","1","0","0","0","","","NUTRITIONAL/SUPPLEMENTS","VITAMINS"],["N","G","PARICALCITOL CAP 1 MCG","PARICALCITOL CAP 1 MCG","1","0","0","0","","","NUTRITIONAL/SUPPLEMENTS","VITAMINS"],["N","G","PARICALCITOL CAP 2 MCG","PARICALCITOL CAP 2 MCG","1","0","0","0","","","NUTRITIONAL/SUPPLEMENTS","VITAMINS"],["N","G","PARICALCITOL CAP 4 MCG","PARICALCITOL CAP 4 MCG","1","0","0","0","","","NUTRITIONAL/SUPPLEMENTS","VITAMINS"],["N","G","PARICALCITOL INJ 2MCG/ML","PARICALCITOL IV SOLN 2 MCG/ML","1","0","0","0","","","NUTRITIONAL/SUPPLEMENTS","VITAMINS"],["N","G","PARICALCITOL INJ 5MCG/ML","PARICALCITOL IV SOLN 5 MCG/ML","1","0","0","0","","","NUTRITIONAL/SUPPLEMENTS","VITAMINS"],["N","G","PHYTONADIONE TAB 5MG","PHYTONADIONE TAB 5 MG","1","0","0","0","","","NUTRITIONAL/SUPPLEMENTS","VITAMINS"],["N","G","PRENATABS RX TAB","*PRENATAL VIT W/ IRON CARBONYL-FA TAB 29-1 MG***","1","0","0","0","","","NUTRITIONAL/SUPPLEMENTS","VITAMINS"],["N","G","PYRIDOXINE TAB 25MG","PYRIDOXINE HCL TAB 25 MG","1","0","0","0","","","NUTRITIONAL/SUPPLEMENTS","VITAMINS"],["N","G","PYRIDOXINE TAB 50MG","PYRIDOXINE HCL TAB 50 MG","1","0","0","0","","","NUTRITIONAL/SUPPLEMENTS","VITAMINS"],["N","G","TRI-VIT/FE DRO /FL 0.25","*PEDIATRIC VITAMINS ACD FLUORIDE & FE DROPS 0.25-10 MG/ML***","1","0","0","0","","","NUTRITIONAL/SUPPLEMENTS","VITAMINS"],["N","G","TRI-VIT/FL DRO 0.25MG","*PEDIATRIC VITAMINS ACD W/ FLUORIDE SOLN 0.25 MG/ML***","1","0","0","0","","","NUTRITIONAL/SUPPLEMENTS","VITAMINS"],["N","G","TRI-VIT/FL DRO 0.5MG","*PEDIATRIC VITAMINS ACD W/ FLUORIDE SOLN 0.5 MG/ML***","1","0","0","0","","","NUTRITIONAL/SUPPLEMENTS","VITAMINS"],["N","G","VIRT-VITE TAB FORTE","FOLIC ACID-PYRIDOXINE-CYANOCOBALAMIN TAB 2.5-25-2 MG","1","0","0","0","","","NUTRITIONAL/SUPPLEMENTS","VITAMINS"],["N","G","VIT A/C/D/FL DRO 0.25MG","*PEDIATRIC VITAMINS ACD W/ FLUORIDE SOLN 0.25 MG/ML***","1","0","0","0","","","NUTRITIONAL/SUPPLEMENTS","VITAMINS"],["N","G","VITAMIN D CAP 50000UNT","ERGOCALCIFEROL CAP 1.25 MG (50000 UNIT)","1","0","0","0","","","NUTRITIONAL/SUPPLEMENTS","VITAMINS"],["N","G","VITAMIN D3 CAP 50000UNT","CHOLECALCIFEROL CAP 1.25 MG (50000 UNIT)","1","0","0","0","","","NUTRITIONAL/SUPPLEMENTS","VITAMINS"],["N","G","BLEPHAMIDE OIN S.O.P.","SULFACETAMIDE SODIUM-PREDNISOLONE OPHTH OINT 10-0.2%","2","0","0","0","","","OPHTHALMIC","ANTI-INFECTIVE/ANTI-INFLAMMATORY"],["N","G","BLEPHAMIDE SUS OP","SULFACETAMIDE SODIUM-PREDNISOLONE OPHTH SUSP 10-0.2%","2","0","0","0","","","OPHTHALMIC","ANTI-INFECTIVE/ANTI-INFLAMMATORY"],["N","G","NEO/POLY/BAC OIN /HC 1%OP","BACITRACIN-POLYMYXIN-NEOMYCIN-HC OPHTH OINT 1%","1","0","0","0","","","OPHTHALMIC","ANTI-INFECTIVE/ANTI-INFLAMMATORY"],["N","G","NEO/POLY/DEX OIN 0.1% OP","NEOMYCIN-POLYMYXIN-DEXAMETHASONE OPHTH OINT 0.1%","1","0","0","0","","","OPHTHALMIC","ANTI-INFECTIVE/ANTI-INFLAMMATORY"],["N","G","NEO/POLY/DEX SUS 0.1% OP","NEOMYCIN-POLYMYXIN-DEXAMETHASONE OPHTH SUSP 0.1%","1","0","0","0","","","OPHTHALMIC","ANTI-INFECTIVE/ANTI-INFLAMMATORY"],["N","G","NEO/POLY/HC SUS OP","NEOMYCIN-POLYMYXIN-HC OPHTH SUSP","1","0","0","0","","","OPHTHALMIC","ANTI-INFECTIVE/ANTI-INFLAMMATORY"],["N","G","SULF/PRED NA SOL OP","SULFACETAMIDE SODIUM-PREDNISOLONE OPHTH SOLN 10-0.23(0.25)%","1","0","0","0","","","OPHTHALMIC","ANTI-INFECTIVE/ANTI-INFLAMMATORY"],["N","G","TOBRA/DEXAME SUS 0.3-0.1%","TOBRAMYCIN-DEXAMETHASONE OPHTH SUSP 0.3-0.1%","1","0","0","0","","","OPHTHALMIC","ANTI-INFECTIVE/ANTI-INFLAMMATORY"],["N","G","TOBRADEX OIN 0.3-0.1%","TOBRAMYCIN-DEXAMETHASONE OPHTH OINT 0.3-0.1%","2","0","0","0","","","OPHTHALMIC","ANTI-INFECTIVE/ANTI-INFLAMMATORY"],["N","G","TOBRADEX ST SUS 0.3-0.05","TOBRAMYCIN-DEXAMETHASONE OPHTH SUSP 0.3-0.05%","2","0","0","0","","","OPHTHALMIC","ANTI-INFECTIVE/ANTI-INFLAMMATORY"],["N","G","AZASITE SOL 1%","AZITHROMYCIN OPHTH SOLN 1%","2","0","0","0","","","OPHTHALMIC","ANTI-INFECTIVES"],["N","G","BACIT/POLYMY OIN OP","BACITRACIN-POLYMYXIN B OPHTH OINT","1","0","0","0","","","OPHTHALMIC","ANTI-INFECTIVES"],["N","G","BACITRACIN OIN OP","BACITRACIN OPHTH OINT 500 UNIT/GM","1","0","0","0","","","OPHTHALMIC","ANTI-INFECTIVES"],["N","G","BESIVANCE SUS 0.6%","BESIFLOXACIN HCL OPHTH SUSP 0.6% (BASE EQUIV)","3","0","0","0","","","OPHTHALMIC","ANTI-INFECTIVES"],["N","G","CIPROFLOXACN SOL 0.3% OP","CIPROFLOXACIN HCL OPHTH SOLN 0.3% (BASE EQUIVALENT)","1","0","0","0","","","OPHTHALMIC","ANTI-INFECTIVES"],["N","G","ERYTHROMYCIN OIN 5MG/GM","ERYTHROMYCIN OPHTH OINT 5 MG/GM","1","0","0","0","","","OPHTHALMIC","ANTI-INFECTIVES"],["N","G","ERYTHROMYCIN OIN OP","ERYTHROMYCIN OPHTH OINT 5 MG/GM","1","0","0","0","","","OPHTHALMIC","ANTI-INFECTIVES"],["N","G","GATIFLOXACIN SOL 0.5%","GATIFLOXACIN OPHTH SOLN 0.5%","1","0","0","0","","","OPHTHALMIC","ANTI-INFECTIVES"],["N","G","GENTAK OIN 0.3% OP","GENTAMICIN SULFATE OPHTH OINT 0.3%","1","0","0","0","","","OPHTHALMIC","ANTI-INFECTIVES"],["N","G","GENTAMICIN OIN 0.3% OP","GENTAMICIN SULFATE OPHTH OINT 0.3%","1","0","0","0","","","OPHTHALMIC","ANTI-INFECTIVES"],["N","G","GENTAMICIN SOL 0.3% OP","GENTAMICIN SULFATE OPHTH SOLN 0.3%","1","0","0","0","","","OPHTHALMIC","ANTI-INFECTIVES"],["N","G","GENTAMICIN SOL 0.3% OP","GENTAMICIN SULFATE OPHTH SOLN 0.3%","1","0","0","0","","","OPHTHALMIC","ANTI-INFECTIVES"],["N","G","LEVOFLOXACIN SOL 0.5%","LEVOFLOXACIN OPHTH SOLN 0.5%","1","0","0","0","","","OPHTHALMIC","ANTI-INFECTIVES"],["N","G","MOXEZA SOL 0.5%","MOXIFLOXACIN HCL OPHTH SOLN 0.5% (BASE EQ) (2 TIMES DAILY)","2","0","0","0","","","OPHTHALMIC","ANTI-INFECTIVES"],["N","G","MOXIFLOXACIN SOL HCL 0.5%","MOXIFLOXACIN HCL OPHTH SOLN 0.5% (BASE EQUIV)","1","0","0","0","","","OPHTHALMIC","ANTI-INFECTIVES"],["N","G","NATACYN SUS 5% OP","NATAMYCIN OPHTH SUSP 5%","2","0","0","0","","","OPHTHALMIC","ANTI-INFECTIVES"],["N","G","NEO/POLY/GRA SOL OP","NEOMYCIN-POLYMY-GRAMICID OP SOL 1.75-10000-0.025MG-UNT-MG/ML","1","0","0","0","","","OPHTHALMIC","ANTI-INFECTIVES"],["N","G","OFLOXACIN DRO 0.3% OP","OFLOXACIN OPHTH SOLN 0.3%","1","0","0","0","","","OPHTHALMIC","ANTI-INFECTIVES"],["N","G","POLYCIN OIN OP","BACITRACIN-POLYMYXIN B OPHTH OINT","1","0","0","0","","","OPHTHALMIC","ANTI-INFECTIVES"],["N","G","SOD SULFACET SOL 10% OP","SULFACETAMIDE SODIUM OPHTH SOLN 10%","1","0","0","0","","","OPHTHALMIC","ANTI-INFECTIVES"],["N","G","SULFACET SOD OIN 10% OP","SULFACETAMIDE SODIUM OPHTH OINT 10%","1","0","0","0","","","OPHTHALMIC","ANTI-INFECTIVES"],["N","G","TOBRAMYCIN SOL 0.3% OP","TOBRAMYCIN OPHTH SOLN 0.3%","1","0","0","0","","","OPHTHALMIC","ANTI-INFECTIVES"],["N","G","TRIFLURIDINE SOL 1% OP","TRIFLURIDINE OPHTH SOLN 1%","1","0","0","0","","","OPHTHALMIC","ANTI-INFECTIVES"],["N","G","TRIMETHOPRIM SOL POLYMYXN","POLYMYXIN B-TRIMETHOPRIM OPHTH SOLN 10000 UNIT/ML-0.1%","1","0","0","0","","","OPHTHALMIC","ANTI-INFECTIVES"],["N","G","ZIRGAN GEL 0.15%","GANCICLOVIR OPHTH GEL 0.15%","3","0","0","0","","","OPHTHALMIC","ANTI-INFECTIVES"],["N","G","ACUVAIL SOL 0.45%","KETOROLAC TROMETHAMINE (PF) OPHTH SOLN 0.45%","2","0","0","0","","","OPHTHALMIC","ANTI-INFLAMMATORIES"],["N","G","ALREX SUS 0.2%","LOTEPREDNOL ETABONATE OPHTH SUSP 0.2%","3","0","0","0","","","OPHTHALMIC","ANTI-INFLAMMATORIES"],["N","G","BROMFENAC SOL 0.09% OP","BROMFENAC SODIUM OPHTH SOLN 0.09% (BASE EQUIVALENT)","1","0","0","0","","","OPHTHALMIC","ANTI-INFLAMMATORIES"],["N","G","BROMFENAC SOL 0.09% OP","BROMFENAC SODIUM OPHTH SOLN 0.09% (BASE EQUIV) (ONCE-DAILY)","1","0","0","0","","","OPHTHALMIC","ANTI-INFLAMMATORIES"],["N","G","DEXAMETH PHO SOL 0.1% OP","DEXAMETHASONE SODIUM PHOSPHATE OPHTH SOLN 0.1%","1","0","0","0","","","OPHTHALMIC","ANTI-INFLAMMATORIES"],["N","G","DICLOFENAC SOL 0.1% OP","DICLOFENAC SODIUM OPHTH SOLN 0.1%","1","0","0","0","","","OPHTHALMIC","ANTI-INFLAMMATORIES"],["N","G","DUREZOL EMU 0.05%","DIFLUPREDNATE OPHTH EMULSION 0.05%","2","0","0","0","","","OPHTHALMIC","ANTI-INFLAMMATORIES"],["N","G","FLAREX SUS 0.1% OP","FLUOROMETHOLONE ACETATE OPHTH SUSP 0.1%","2","0","0","0","","","OPHTHALMIC","ANTI-INFLAMMATORIES"],["N","G","FLUOROMETHOL SUS 0.1% OP","FLUOROMETHOLONE OPHTH SUSP 0.1%","1","0","0","0","","","OPHTHALMIC","ANTI-INFLAMMATORIES"],["N","G","FLURBIPROFEN SOL 0.03% OP","FLURBIPROFEN SODIUM OPHTH SOLN 0.03%","1","0","0","0","","","OPHTHALMIC","ANTI-INFLAMMATORIES"],["N","G","FML FORTE SUS 0.25% OP","FLUOROMETHOLONE OPHTH SUSP 0.25%","2","0","0","0","","","OPHTHALMIC","ANTI-INFLAMMATORIES"],["N","G","FML OIN 0.1% OP","FLUOROMETHOLONE OPHTH OINT 0.1%","2","0","0","0","","","OPHTHALMIC","ANTI-INFLAMMATORIES"],["N","G","ILEVRO DRO 0.3% OP","NEPAFENAC OPHTH SUSP 0.3%","2","0","0","0","","","OPHTHALMIC","ANTI-INFLAMMATORIES"],["N","G","KETOROLAC SOL 0.4%","KETOROLAC TROMETHAMINE OPHTH SOLN 0.4%","1","0","0","0","","","OPHTHALMIC","ANTI-INFLAMMATORIES"],["N","G","KETOROLAC SOL 0.5%","KETOROLAC TROMETHAMINE OPHTH SOLN 0.5%","1","0","0","0","","","OPHTHALMIC","ANTI-INFLAMMATORIES"],["N","G","LOTEMAX GEL 0.5%","LOTEPREDNOL ETABONATE OPHTH GEL 0.5%","3","0","0","0","","","OPHTHALMIC","ANTI-INFLAMMATORIES"],["N","G","LOTEMAX OIN 0.5%","LOTEPREDNOL ETABONATE OPHTH OINT 0.5%","3","0","0","0","","","OPHTHALMIC","ANTI-INFLAMMATORIES"],["N","G","LOTEMAX SUS 0.5%","LOTEPREDNOL ETABONATE OPHTH SUSP 0.5%","3","0","0","0","","","OPHTHALMIC","ANTI-INFLAMMATORIES"],["N","G","LOTEPREDNOL SUS 0.5%","LOTEPREDNOL ETABONATE OPHTH SUSP 0.5%","1","0","0","0","","","OPHTHALMIC","ANTI-INFLAMMATORIES"],["N","G","MAXIDEX SUS 0.1% OP","DEXAMETHASONE OPHTH SUSP 0.1%","2","0","0","0","","","OPHTHALMIC","ANTI-INFLAMMATORIES"],["N","G","NEVANAC SUS 0.1%","NEPAFENAC OPHTH SUSP 0.1%","2","0","0","0","","","OPHTHALMIC","ANTI-INFLAMMATORIES"],["N","G","PRED MILD SUS 0.12% OP","PREDNISOLONE ACETATE OPHTH SUSP 0.12%","2","0","0","0","","","OPHTHALMIC","ANTI-INFLAMMATORIES"],["N","G","PRED SOD PHO SOL 1% OP","PREDNISOLONE SODIUM PHOSPHATE OPHTH SOLN 1%","2","0","0","0","","","OPHTHALMIC","ANTI-INFLAMMATORIES"],["N","G","PREDNISOLONE SUS 1% OP","PREDNISOLONE ACETATE OPHTH SUSP 1%","1","0","0","0","","","OPHTHALMIC","ANTI-INFLAMMATORIES"],["N","G","ALOCRIL SOL 2%","NEDOCROMIL SODIUM OPHTH SOLN 2%","3","0","0","0","","","OPHTHALMIC","ANTIALLERGICS"],["N","G","ALOMIDE SOL 0.1% OP","LODOXAMIDE TROMETHAMINE OPHTH SOLN 0.1%","3","0","0","0","","","OPHTHALMIC","ANTIALLERGICS"],["N","G","AZELASTINE DRO 0.05%","AZELASTINE HCL OPHTH SOLN 0.05%","1","0","0","0","","","OPHTHALMIC","ANTIALLERGICS"],["N","G","BEPREVE DRO 1.5%","BEPOTASTINE BESILATE OPHTH SOLN 1.5%","3","0","0","0","","","OPHTHALMIC","ANTIALLERGICS"],["N","G","CROMOLYN SOD SOL 4% OP","CROMOLYN SODIUM OPHTH SOLN 4%","1","0","0","0","","","OPHTHALMIC","ANTIALLERGICS"],["N","G","EMADINE SOL 0.05% OP","EMEDASTINE DIFUMARATE OPHTH SOLN 0.05% (BASE EQUIV)","3","0","0","0","","","OPHTHALMIC","ANTIALLERGICS"],["N","G","EPINASTINE DRO 0.05%","EPINASTINE HCL OPHTH SOLN 0.05%","1","0","0","0","","","OPHTHALMIC","ANTIALLERGICS"],["N","G","LASTACAFT SOL 0.25%","ALCAFTADINE OPHTH SOLN 0.25%","2","0","0","0","","","OPHTHALMIC","ANTIALLERGICS"],["N","G","OLOPATADINE DRO 0.1%","OLOPATADINE HCL OPHTH SOLN 0.1% (BASE EQUIVALENT)","1","0","0","0","","","OPHTHALMIC","ANTIALLERGICS"],["N","G","OLOPATADINE SOL 0.2%","OLOPATADINE HCL OPHTH SOLN 0.2% (BASE EQUIVALENT)","1","0","0","0","","","OPHTHALMIC","ANTIALLERGICS"],["N","G","PAZEO DRO 0.7%","OLOPATADINE HCL OPHTH SOLN 0.7% (BASE EQUIVALENT)","2","0","0","0","","","OPHTHALMIC","ANTIALLERGICS"],["N","G","ALPHAGAN P SOL 0.1%","BRIMONIDINE TARTRATE OPHTH SOLN 0.1%","3","0","0","0","","","OPHTHALMIC","ANTIGLAUCOMA"],["N","G","APRACLONIDIN SOL 0.5% OP","APRACLONIDINE HCL OPHTH SOLN 0.5% (BASE EQUIVALENT)","1","0","0","0","","","OPHTHALMIC","ANTIGLAUCOMA"],["N","G","AZOPT SUS 1% OP","BRINZOLAMIDE OPHTH SUSP 1%","2","0","0","0","","","OPHTHALMIC","ANTIGLAUCOMA"],["N","G","BETAXOLOL SOL 0.5% OP","BETAXOLOL HCL OPHTH SOLN 0.5%","1","0","0","0","","","OPHTHALMIC","ANTIGLAUCOMA"],["N","G","BETIMOL SOL 0.25%","TIMOLOL OPHTH SOLN 0.25%","3","0","0","0","","","OPHTHALMIC","ANTIGLAUCOMA"],["N","G","BETIMOL SOL 0.5%","TIMOLOL OPHTH SOLN 0.5%","3","0","0","0","","","OPHTHALMIC","ANTIGLAUCOMA"],["N","G","BETOPTIC-S SUS 0.25% OP","BETAXOLOL HCL OPHTH SUSP 0.25%","2","0","0","0","","","OPHTHALMIC","ANTIGLAUCOMA"],["N","G","BIMATOPROST SOL 0.03%","BIMATOPROST OPHTH SOLN 0.03%","1","0","0","0","","","OPHTHALMIC","ANTIGLAUCOMA"],["N","G","BRIMONIDINE SOL 0.15%","BRIMONIDINE TARTRATE OPHTH SOLN 0.15%","1","0","0","0","","","OPHTHALMIC","ANTIGLAUCOMA"],["N","G","BRIMONIDINE SOL 0.2% OP","BRIMONIDINE TARTRATE OPHTH SOLN 0.2%","1","0","0","0","","","OPHTHALMIC","ANTIGLAUCOMA"],["N","G","CARTEOLOL SOL 1% OP","CARTEOLOL HCL OPHTH SOLN 1%","1","0","0","0","","","OPHTHALMIC","ANTIGLAUCOMA"],["N","G","COMBIGAN SOL 0.2/0.5%","BRIMONIDINE TARTRATE-TIMOLOL MALEATE OPHTH SOLN 0.2-0.5%","2","0","0","0","","","OPHTHALMIC","ANTIGLAUCOMA"],["N","G","DORZOL/TIMOL SOL 22.3-6.8","DORZOLAMIDE HCL-TIMOLOL MALEATE OPHTH SOLN 22.3-6.8 MG/ML","1","0","0","0","","","OPHTHALMIC","ANTIGLAUCOMA"],["N","G","DORZOLAMIDE SOL 2% OP","DORZOLAMIDE HCL OPHTH SOLN 2%","1","0","0","0","","","OPHTHALMIC","ANTIGLAUCOMA"],["N","G","IOPIDINE SOL 1% OP","APRACLONIDINE HCL OPHTH SOLN 1% (BASE EQUIVALENT)","3","0","0","0","","","OPHTHALMIC","ANTIGLAUCOMA"],["N","G","LATANOPROST SOL 0.005%","LATANOPROST OPHTH SOLN 0.005%","1","0","0","0","","","OPHTHALMIC","ANTIGLAUCOMA"],["N","G","LEVOBUNOLOL SOL 0.5% OP","LEVOBUNOLOL HCL OPHTH SOLN 0.5%","1","0","0","0","","","OPHTHALMIC","ANTIGLAUCOMA"],["N","G","LUMIGAN SOL 0.01%","BIMATOPROST OPHTH SOLN 0.01%","2","0","1","0","","PA**","OPHTHALMIC","ANTIGLAUCOMA"],["N","G","METIPRANOLOL SOL 0.3% OPH","METIPRANOLOL OPHTH SOLN 0.3%","1","0","0","0","","","OPHTHALMIC","ANTIGLAUCOMA"],["N","G","PHOSPHOLINE SOL 0.125%OP","ECHOTHIOPHATE IODIDE OPHTH FOR SOLN 0.125%","3","0","0","0","","","OPHTHALMIC","ANTIGLAUCOMA"],["N","G","PILOCARPINE SOL 1% OP","PILOCARPINE HCL OPHTH SOLN 1%","1","0","0","0","","","OPHTHALMIC","ANTIGLAUCOMA"],["N","G","SIMBRINZA SUS 1-0.2%","BRINZOLAMIDE-BRIMONIDINE TARTRATE OPHTH SUSP 1-0.2%","2","0","0","0","","","OPHTHALMIC","ANTIGLAUCOMA"],["N","G","TIMOLOL GEL SOL 0.25% OP","TIMOLOL MALEATE OPHTH GEL FORMING SOLN 0.25%","1","0","0","0","","","OPHTHALMIC","ANTIGLAUCOMA"],["N","G","TIMOLOL GEL SOL 0.5% OP","TIMOLOL MALEATE OPHTH GEL FORMING SOLN 0.5%","1","0","0","0","","","OPHTHALMIC","ANTIGLAUCOMA"],["N","G","TIMOLOL MAL SOL 0.25% OP","TIMOLOL MALEATE OPHTH SOLN 0.25%","1","0","0","0","","","OPHTHALMIC","ANTIGLAUCOMA"],["N","G","TIMOLOL MAL SOL 0.5% OP","TIMOLOL MALEATE OPHTH SOLN 0.5%","1","0","0","0","","","OPHTHALMIC","ANTIGLAUCOMA"],["N","G","TIMOLOL MALE SOL 0.5%","TIMOLOL MALEATE OPHTH SOLN 0.5% (ONCE-DAILY)","1","0","0","0","","","OPHTHALMIC","ANTIGLAUCOMA"],["N","G","TIMOPTIC OCU SOL 0.25% OP","TIMOLOL MALEATE PRESERVATIVE FREE OPHTH SOLN 0.25%","2","0","0","0","","","OPHTHALMIC","ANTIGLAUCOMA"],["N","G","TIMOPTIC OCU SOL 0.5% OP","TIMOLOL MALEATE PRESERVATIVE FREE OPHTH SOLN 0.5%","2","0","0","0","","","OPHTHALMIC","ANTIGLAUCOMA"],["N","G","TRAVATAN Z DRO 0.004%","TRAVOPROST OPHTH SOLN 0.004% (BENZALKONIUM FREE) (BAK FREE)","2","0","0","0","","","OPHTHALMIC","ANTIGLAUCOMA"],["N","G","ZIOPTAN DRO 0.0015%","TAFLUPROST PRESERVATIVE FREE (PF) OPHTH SOLN 0.0015%","3","0","1","0","","PA**","OPHTHALMIC","ANTIGLAUCOMA"],["N","G","ATROPINE SUL SOL 1% OP","ATROPINE SULFATE OPHTH SOLN 1%","1","0","0","0","","","OPHTHALMIC","MISCELLANEOUS"],["N","G","CYSTARAN SOL 0.44%","CYSTEAMINE HCL OPHTH SOLN 0.44% (BASE EQUIVALENT)","4","1","0","0","","SP","OPHTHALMIC","MISCELLANEOUS"],["N","G","LACRISERT MIS 5MG OP","*ARTIFICIAL TEAR OPHTH INSERT***","3","0","0","0","","","OPHTHALMIC","MISCELLANEOUS"],["N","G","PHENYLEPHRIN SOL 10% OP","PHENYLEPHRINE HCL OPHTH SOLN 10%","1","0","0","0","","","OPHTHALMIC","MISCELLANEOUS"],["N","G","PHENYLEPHRIN SOL 2.5% OP","PHENYLEPHRINE HCL OPHTH SOLN 2.5%","1","0","0","0","","","OPHTHALMIC","MISCELLANEOUS"],["N","G","PROPARACAINE SOL 0.5% OP","PROPARACAINE HCL OPHTH SOLN 0.5%","1","0","0","0","","","OPHTHALMIC","MISCELLANEOUS"],["N","G","PROPARACAINE SOL 0.5% OP","PROPARACAINE HCL OPHTH SOLN 0.5%","1","0","0","0","","","OPHTHALMIC","MISCELLANEOUS"],["N","G","RESTASIS EMU 0.05%","CYCLOSPORINE (OPHTH) EMULSION 0.05%","2","0","0","0","","","OPHTHALMIC","MISCELLANEOUS"],["N","G","TROPICAMIDE SOL 0.5% OP","TROPICAMIDE OPHTH SOLN 0.5%","1","0","0","0","","","OPHTHALMIC","MISCELLANEOUS"],["N","G","TROPICAMIDE SOL 1% OP","TROPICAMIDE OPHTH SOLN 1%","1","0","0","0","","","OPHTHALMIC","MISCELLANEOUS"],["N","G","PHYSIOLYTE SOL","*IRRIGATION SOLUTION, PHYSIOLOGICAL**","1","0","0","0","","","OTHER","IRRIGATION SOLUTIONS"],["N","G","PHYSIOSOL SOL IRRIGAT","*IRRIGATION SOLUTION, PHYSIOLOGICAL**","1","0","0","0","","","OTHER","IRRIGATION SOLUTIONS"],["N","G","TIS-U-SOL SOL","RINGER'S SOLUTION FOR IRRIGATION","1","0","0","0","","","OTHER","IRRIGATION SOLUTIONS"],["N","G","EPINEPHRINE INJ 0.15MG","EPINEPHRINE SOLUTION AUTO-INJECTOR 0.15 MG/0.15ML (1:1000)","1","0","0","0","","(generic of Adrenaclick)","RESPIRATORY","ANAPHYLAXIS TREATMENT AGENTS"],["N","G","EPINEPHRINE INJ 0.15MG","EPINEPHRINE SOLUTION AUTO-INJECTOR 0.15 MG/0.3ML (1:2000)","1","0","0","0","","","RESPIRATORY","ANAPHYLAXIS TREATMENT AGENTS"],["N","G","EPINEPHRINE INJ 0.3MG","EPINEPHRINE SOLUTION AUTO-INJECTOR 0.3 MG/0.3ML (1:1000)","1","0","0","0","","(generics manufactured by Teva/Mylan)","RESPIRATORY","ANAPHYLAXIS TREATMENT AGENTS"],["N","G","EPINEPHRINE INJ 0.3MG","EPINEPHRINE SOLUTION AUTO-INJECTOR 0.3 MG/0.3ML (1:1000)","1","0","0","0","","(generic of Adrenaclick)","RESPIRATORY","ANAPHYLAXIS TREATMENT AGENTS"],["N","G","BEVESPI AER 9-4.8MCG","GLYCOPYRROLATE-FORMOTEROL FUMARATE AEROSOL 9-4.8 MCG/ACT","2","0","0","1","1 package every 25 days","","RESPIRATORY","ANTICHOLINERGIC/BETA AGONIST COMBINATIONS§"],["N","G","COMBIVENT AER 20-100","IPRATROPIUM-ALBUTEROL INHAL AEROSOL SOLN 20-100 MCG/ACT","2","0","0","1","2 inhalers every 25 days","","RESPIRATORY","ANTICHOLINERGIC/BETA AGONIST COMBINATIONS§"],["N","G","IPRATROPIUM/ SOL ALBUTER","IPRATROPIUM-ALBUTEROL NEBU SOLN 0.5-2.5(3) MG/3ML","1","0","0","1","6 boxes every 25 days","","RESPIRATORY","ANTICHOLINERGIC/BETA AGONIST COMBINATIONS§"],["N","G","INCRUSE ELPT INH 62.5MCG","UMECLIDINIUM BR AERO POWD BREATH ACT 62.5 MCG/INH (BASE EQ)","2","0","0","1","1 package every 25 days","","RESPIRATORY","ANTICHOLINERGICS§"],["N","G","IPRATROPIUM SOL 0.02%INH","IPRATROPIUM BROMIDE INHAL SOLN 0.02%","1","0","0","1","5 boxes every 25 days","","RESPIRATORY","ANTICHOLINERGICS§"],["N","G","IPRATROPIUM SPR 0.03%","IPRATROPIUM BROMIDE NASAL SOLN 0.03% (21 MCG/SPRAY)","1","0","0","0","","","RESPIRATORY","ANTICHOLINERGICS§"],["N","G","IPRATROPIUM SPR 0.06%","IPRATROPIUM BROMIDE NASAL SOLN 0.06% (42 MCG/SPRAY)","1","0","0","0","","","RESPIRATORY","ANTICHOLINERGICS§"],["N","G","SPIRIVA AER 1.25MCG","TIOTROPIUM BROMIDE MONOHYDRATE INHAL AEROSOL 1.25 MCG/ACT","2","0","0","1","1 package every 25 days","","RESPIRATORY","ANTICHOLINERGICS§"],["N","G","SPIRIVA CAP HANDIHLR","TIOTROPIUM BROMIDE MONOHYDRATE INHAL CAP 18 MCG (BASE EQUIV)","2","0","0","1","1 package every 25 days","","RESPIRATORY","ANTICHOLINERGICS§"],["N","G","SPIRIVA SPR 2.5MCG","TIOTROPIUM BROMIDE MONOHYDRATE INHAL AEROSOL 2.5 MCG/ACT","2","0","0","1","1 package every 25 days","","RESPIRATORY","ANTICHOLINERGICS§"],["N","G","DYMISTA SPR 137-50","AZELASTINE HCL-FLUTICASONE PROP NASAL SPRAY 137-50 MCG/ACT","2","0","0","1","1 package every 25 days","","RESPIRATORY","ANTIHISTAMINE COMBINATIONS"],["N","G","AZELASTINE SPR 0.1%","AZELASTINE HCL NASAL SPRAY 0.1% (137 MCG/SPRAY)","1","0","0","1","2 bottles every 25 days","","RESPIRATORY","ANTIHISTAMINES§"],["N","G","AZELASTINE SPR 0.15%","AZELASTINE HCL NASAL SPRAY 0.15% (205.5 MCG/SPRAY)","1","0","0","1","2 bottles every 25 days","","RESPIRATORY","ANTIHISTAMINES§"],["N","G","BROMPHENIRAM CHW 12MG","BROMPHENIRAMINE TANNATE CHEW TAB 12 MG","1","0","0","0","","","RESPIRATORY","ANTIHISTAMINES§"],["N","G","CARBINOXAMIN SOL 4MG/5ML","CARBINOXAMINE MALEATE SOLN 4 MG/5ML","1","0","0","0","","","RESPIRATORY","ANTIHISTAMINES§"],["N","G","CARBINOXAMIN TAB 4MG","CARBINOXAMINE MALEATE TAB 4 MG","1","0","0","0","","","RESPIRATORY","ANTIHISTAMINES§"],["N","G","CLARINEX SYP 0.5MG/ML","DESLORATADINE SYRUP 0.5 MG/ML","3","0","0","0","","","RESPIRATORY","ANTIHISTAMINES§"],["N","G","CLEMASTINE TAB 2.68MG","CLEMASTINE FUMARATE TAB 2.68 MG","1","1","0","0","","High Risk Medications require PA for members age 70 and older","RESPIRATORY","ANTIHISTAMINES§"],["N","G","CYPROHEPTAD SYP 2MG/5ML","CYPROHEPTADINE HCL SYRUP 2 MG/5ML","1","0","0","0","","","RESPIRATORY","ANTIHISTAMINES§"],["N","G","CYPROHEPTAD TAB 4MG","CYPROHEPTADINE HCL TAB 4 MG","1","0","0","0","","","RESPIRATORY","ANTIHISTAMINES§"],["N","G","DESLORATADIN TAB 2.5 ODT","DESLORATADINE TAB ORALLY DISINTEGRATING 2.5 MG","1","0","0","0","","","RESPIRATORY","ANTIHISTAMINES§"],["N","G","DESLORATADIN TAB 5MG","DESLORATADINE TAB 5 MG","1","0","0","0","","","RESPIRATORY","ANTIHISTAMINES§"],["N","G","DESLORATADIN TAB 5MG ODT","DESLORATADINE TAB ORALLY DISINTEGRATING 5 MG","1","0","0","0","","","RESPIRATORY","ANTIHISTAMINES§"],["N","G","DIPHENHYDRAM ELX 12.5/5ML","DIPHENHYDRAMINE HCL ELIXIR 12.5 MG/5ML","1","0","0","0","","","RESPIRATORY","ANTIHISTAMINES§"],["N","G","DIPHENHYDRAM INJ 50MG/ML","DIPHENHYDRAMINE HCL INJ 50 MG/ML","1","0","0","0","","","RESPIRATORY","ANTIHISTAMINES§"],["N","G","HYDROXYZ HCL INJ 25MG/ML","HYDROXYZINE HCL IM SOLN 25 MG/ML","1","1","0","0","","High Risk Medications require PA for members age 70 and older","RESPIRATORY","ANTIHISTAMINES§"],["N","G","HYDROXYZ HCL INJ 50MG/ML","HYDROXYZINE HCL IM SOLN 50 MG/ML","1","1","0","0","","High Risk Medications require PA for members age 70 and older","RESPIRATORY","ANTIHISTAMINES§"],["N","G","HYDROXYZ HCL SYP 10MG/5ML","HYDROXYZINE HCL SYRUP 10 MG/5ML","1","1","0","0","","High Risk Medications require PA for members age 70 and older","RESPIRATORY","ANTIHISTAMINES§"],["N","G","HYDROXYZ HCL TAB 10MG","HYDROXYZINE HCL TAB 10 MG","1","1","0","0","","High Risk Medications require PA for members age 70 and older","RESPIRATORY","ANTIHISTAMINES§"],["N","G","HYDROXYZ HCL TAB 25MG","HYDROXYZINE HCL TAB 25 MG","1","1","0","0","","High Risk Medications require PA for members age 70 and older","RESPIRATORY","ANTIHISTAMINES§"],["N","G","HYDROXYZ HCL TAB 50MG","HYDROXYZINE HCL TAB 50 MG","1","1","0","0","","High Risk Medications require PA for members age 70 and older","RESPIRATORY","ANTIHISTAMINES§"],["N","G","HYDROXYZ PAM CAP 100MG","HYDROXYZINE PAMOATE CAP 100 MG","1","1","0","0","","High Risk Medications require PA for members age 70 and older","RESPIRATORY","ANTIHISTAMINES§"],["N","G","HYDROXYZ PAM CAP 25MG","HYDROXYZINE PAMOATE CAP 25 MG","1","1","0","0","","High Risk Medications require PA for members age 70 and older","RESPIRATORY","ANTIHISTAMINES§"],["N","G","HYDROXYZ PAM CAP 50MG","HYDROXYZINE PAMOATE CAP 50 MG","1","1","0","0","","High Risk Medications require PA for members age 70 and older","RESPIRATORY","ANTIHISTAMINES§"],["N","G","LEVOCETIRIZI SOL 2.5/5ML","LEVOCETIRIZINE DIHYDROCHLORIDE SOLN 2.5 MG/5ML (0.5 MG/ML)","1","0","0","0","","","RESPIRATORY","ANTIHISTAMINES§"],["N","G","LEVOCETIRIZI TAB 5MG","LEVOCETIRIZINE DIHYDROCHLORIDE TAB 5 MG","1","0","0","0","","","RESPIRATORY","ANTIHISTAMINES§"],["N","G","OLOPATADINE SPR 0.6%","OLOPATADINE HCL NASAL SOLN 0.6%","1","0","0","1","1 container every 25 days","","RESPIRATORY","ANTIHISTAMINES§"],["N","G","ALBUTEROL AER HFA","ALBUTEROL SULFATE INHAL AERO 108 MCG/ACT (90MCG BASE EQUIV)","1","0","0","1","2 inhalers every 25 days","","RESPIRATORY","BETA AGONISTS§"],["N","G","ALBUTEROL NEB 0.083%","ALBUTEROL SULFATE SOLN NEBU 0.083% (2.5 MG/3ML)","1","0","0","1","5 boxes every 25 days","","RESPIRATORY","BETA AGONISTS§"],["N","G","ALBUTEROL NEB 0.5%","ALBUTEROL SULFATE SOLN NEBU 0.5% (5 MG/ML)","1","0","0","1","60 mL every 25 days","","RESPIRATORY","BETA AGONISTS§"],["N","G","ALBUTEROL NEB 0.63MG/3","ALBUTEROL SULFATE SOLN NEBU 0.63 MG/3ML (BASE EQUIV)","1","0","0","1","5 boxes every 25 days","","RESPIRATORY","BETA AGONISTS§"],["N","G","ALBUTEROL NEB 1.25MG/3","ALBUTEROL SULFATE SOLN NEBU 1.25 MG/3ML (BASE EQUIV)","1","0","0","1","5 boxes every 25 days","","RESPIRATORY","BETA AGONISTS§"],["N","G","ALBUTEROL SYP 2MG/5ML","ALBUTEROL SULFATE SYRUP 2 MG/5ML","1","0","0","0","","","RESPIRATORY","BETA AGONISTS§"],["N","G","ALBUTEROL TAB 2MG","ALBUTEROL SULFATE TAB 2 MG","1","0","0","0","","","RESPIRATORY","BETA AGONISTS§"],["N","G","ALBUTEROL TAB 4MG","ALBUTEROL SULFATE TAB 4 MG","1","0","0","0","","","RESPIRATORY","BETA AGONISTS§"],["N","G","ALBUTEROL TAB 4MG ER","ALBUTEROL SULFATE TAB ER 12HR 4 MG","1","0","0","0","","","RESPIRATORY","BETA AGONISTS§"],["N","G","ALBUTEROL TAB 8MG ER","ALBUTEROL SULFATE TAB ER 12HR 8 MG","1","0","0","0","","","RESPIRATORY","BETA AGONISTS§"],["N","G","LEVALBUTEROL AER 45/ACT","LEVALBUTEROL TARTRATE INHAL AEROSOL 45 MCG/ACT (BASE EQUIV)","1","0","0","1","2 inhalers every 25 days","","RESPIRATORY","BETA AGONISTS§"],["N","G","LEVALBUTEROL NEB 0.31MG","LEVALBUTEROL HCL SOLN NEBU 0.31 MG/3ML (BASE EQUIV)","1","0","0","1","300 mL every 25 days","","RESPIRATORY","BETA AGONISTS§"],["N","G","LEVALBUTEROL NEB 0.63MG","LEVALBUTEROL HCL SOLN NEBU 0.63 MG/3ML (BASE EQUIV)","1","0","0","1","300 mL every 25 days","","RESPIRATORY","BETA AGONISTS§"],["N","G","LEVALBUTEROL NEB 1.25/0.5","LEVALBUTEROL HCL SOLN NEBU CONC 1.25 MG/0.5ML (BASE EQUIV)","1","0","0","1","45 mL every 25 days","","RESPIRATORY","BETA AGONISTS§"],["N","G","LEVALBUTEROL NEB 1.25MG","LEVALBUTEROL HCL SOLN NEBU 1.25 MG/3ML (BASE EQUIV)","1","0","0","1","300 mL every 25 days","","RESPIRATORY","BETA AGONISTS§"],["N","G","METAPROTEREN SYP 10MG/5ML","METAPROTERENOL SULFATE SYRUP 10 MG/5ML","1","0","0","0","","","RESPIRATORY","BETA AGONISTS§"],["N","G","METAPROTEREN TAB 10MG","METAPROTERENOL SULFATE TAB 10 MG","1","0","0","0","","","RESPIRATORY","BETA AGONISTS§"],["N","G","METAPROTEREN TAB 20MG","METAPROTERENOL SULFATE TAB 20 MG","1","0","0","0","","","RESPIRATORY","BETA AGONISTS§"],["N","G","PERFOROMIST NEB 20MCG","FORMOTEROL FUMARATE SOLN NEBU 20 MCG/2ML","2","0","0","1","2 boxes every 25 days","","RESPIRATORY","BETA AGONISTS§"],["N","G","PROAIR HFA AER","ALBUTEROL SULFATE INHAL AERO 108 MCG/ACT (90MCG BASE EQUIV)","2","0","0","1","2 inhalers every 25 days","","RESPIRATORY","BETA AGONISTS§"],["N","G","PROAIR RESPI AER","ALBUTEROL SULFATE AER POW BA 108 MCG/ACT (90 MCG BASE EQUIV)","2","0","0","1","2 packages every 25 days","","RESPIRATORY","BETA AGONISTS§"],["N","G","STRIVERDI AER 2.5MCG","OLODATEROL HCL INHAL AEROSOL SOLN 2.5 MCG/ACT (BASE EQUIV)","2","0","0","1","1 package every 25 days","","RESPIRATORY","BETA AGONISTS§"],["N","G","TERBUTALINE TAB 2.5MG","TERBUTALINE SULFATE TAB 2.5 MG","1","0","0","0","","","RESPIRATORY","BETA AGONISTS§"],["N","G","TERBUTALINE TAB 5MG","TERBUTALINE SULFATE TAB 5 MG","1","0","0","0","","","RESPIRATORY","BETA AGONISTS§"],["N","G","NUCALA INJ 100MG","MEPOLIZUMAB FOR INJ 100 MG","4","1","0","1","3 injections every 28 days","SP","RESPIRATORY","BIOLOGIC RESPONSE MODIFIERS"],["N","G","NUCALA INJ 100MG/ML","MEPOLIZUMAB SUBCUTANEOUS SOLUTION AUTO-INJECTOR 100 MG/ML","4","1","0","1","3 injections every 28 days","SP","RESPIRATORY","BIOLOGIC RESPONSE MODIFIERS"],["N","G","NUCALA INJ 100MG/ML","MEPOLIZUMAB SUBCUTANEOUS SOLUTION PREF SYRINGE 100 MG/ML","4","1","0","1","3 injections every 28 days","SP","RESPIRATORY","BIOLOGIC RESPONSE MODIFIERS"],["N","G","XOLAIR INJ 150MG/ML","OMALIZUMAB SUBCUTANEOUS SOLN PREFILLED SYRINGE 150 MG/ML","4","1","0","1","4 syringes every 28 days","SP","RESPIRATORY","BIOLOGIC RESPONSE MODIFIERS"],["N","G","XOLAIR INJ 75/0.5","OMALIZUMAB SUBCUTANEOUS SOLN PREFILLED SYRINGE 75 MG/0.5ML","4","1","0","1","2 syringes every 28 days","SP","RESPIRATORY","BIOLOGIC RESPONSE MODIFIERS"],["N","G","XOLAIR SOL 150MG","OMALIZUMAB FOR INJ 150 MG","4","1","0","1","6 vials every 28 days","SP","RESPIRATORY","BIOLOGIC RESPONSE MODIFIERS"],["N","G","BENZONATATE CAP 100MG","BENZONATATE CAP 100 MG","1","0","0","0","","","RESPIRATORY","COLD/COUGH"],["N","G","BENZONATATE CAP 200MG","BENZONATATE CAP 200 MG","1","0","0","0","","","RESPIRATORY","COLD/COUGH"],["N","G","BROM/PSE/DM SYP","PSEUDOEPHED-BROMPHEN-DM SYRUP 30-2-10 MG/5ML","1","0","0","0","","","RESPIRATORY","COLD/COUGH"],["N","G","CHERATUSSIN SYP AC","GUAIFENESIN-CODEINE SOLN 100-10 MG/5ML","1","0","0","0","","","RESPIRATORY","COLD/COUGH"],["N","G","HYDROC/HOMAT TAB 5-1.5MG","HYDROCODONE W/ HOMATROPINE TAB 5-1.5 MG","1","0","0","0","","","RESPIRATORY","COLD/COUGH"],["N","G","HYDROCOD/HOM SYP 5-1.5/5","HYDROCODONE W/ HOMATROPINE SYRUP 5-1.5 MG/5ML","1","0","0","0","","","RESPIRATORY","COLD/COUGH"],["N","G","HYDROMET SYP 5-1.5/5","HYDROCODONE W/ HOMATROPINE SYRUP 5-1.5 MG/5ML","1","0","0","0","","","RESPIRATORY","COLD/COUGH"],["N","G","NORTUSS-EX LIQ 200-20/5","DEXTROMETHORPHAN-GUAIFENESIN LIQUID 20-200 MG/5ML","2","0","0","0","","","RESPIRATORY","COLD/COUGH"],["N","G","PROMETH VC SOL PLAIN","PROMETHAZINE & PHENYLEPHRINE SYRUP 6.25-5 MG/5ML","1","0","0","0","","","RESPIRATORY","COLD/COUGH"],["N","G","PROMETH VC/ SYP CODEINE","PROMETHAZINE-PHENYLEPHRINE-CODEINE SYRUP 6.25-5-10 MG/5ML","1","0","0","0","","","RESPIRATORY","COLD/COUGH"],["N","G","PROMETH/COD SOL 6.25-10","PROMETHAZINE W/ CODEINE SYRUP 6.25-10 MG/5ML","1","0","0","0","","","RESPIRATORY","COLD/COUGH"],["N","G","PROMETHAZINE SYP DM","PROMETHAZINE-DM SYRUP 6.25-15 MG/5ML","1","0","0","0","","","RESPIRATORY","COLD/COUGH"],["N","G","TUSSIGON TAB 5-1.5MG","HYDROCODONE W/ HOMATROPINE TAB 5-1.5 MG","1","0","0","0","","","RESPIRATORY","COLD/COUGH"],["N","G","TUZISTRA XR SUS","CODEINE POLIST-CHLORPHEN POLIST ER SUSP 14.7-2.8 MG/5ML","3","0","0","0","","","RESPIRATORY","COLD/COUGH"],["N","G","VITUZ SOL 5-4MG","HYDROCODONE-CHLORPHENIRAMINE SOLN 5-4 MG/5ML","3","0","0","0","","","RESPIRATORY","COLD/COUGH"],["N","G","ZILEUTON ER TAB 600MG","ZILEUTON TAB ER 12HR 600 MG","3","0","0","0","","","RESPIRATORY","LEUKOTRIENE MODIFIERS"],["N","G","MONTELUKAST CHW 4MG","MONTELUKAST SODIUM CHEW TAB 4 MG (BASE EQUIV)","1","0","0","0","","","RESPIRATORY","LEUKOTRIENE RECEPTOR ANTAGONISTS"],["N","G","MONTELUKAST CHW 5MG","MONTELUKAST SODIUM CHEW TAB 5 MG (BASE EQUIV)","1","0","0","0","","","RESPIRATORY","LEUKOTRIENE RECEPTOR ANTAGONISTS"],["N","G","MONTELUKAST GRA 4MG","MONTELUKAST SODIUM ORAL GRANULES PACKET 4 MG (BASE EQUIV)","1","0","0","0","","","RESPIRATORY","LEUKOTRIENE RECEPTOR ANTAGONISTS"],["N","G","MONTELUKAST TAB 10MG","MONTELUKAST SODIUM TAB 10 MG (BASE EQUIV)","1","0","0","0","","","RESPIRATORY","LEUKOTRIENE RECEPTOR ANTAGONISTS"],["N","G","ZAFIRLUKAST TAB 10MG","ZAFIRLUKAST TAB 10 MG","1","0","0","0","","","RESPIRATORY","LEUKOTRIENE RECEPTOR ANTAGONISTS"],["N","G","ZAFIRLUKAST TAB 20MG","ZAFIRLUKAST TAB 20 MG","1","0","0","0","","","RESPIRATORY","LEUKOTRIENE RECEPTOR ANTAGONISTS"],["N","G","CROMOLYN SOD NEB 20MG/2ML","CROMOLYN SODIUM SOLN NEBU 20 MG/2ML","1","0","0","1","2 boxes every 25 days","","RESPIRATORY","MAST CELL STABILIZERS§"],["N","G","ACETYLCYST SOL 10%","ACETYLCYSTEINE INHAL SOLN 10%","1","0","0","0","","","RESPIRATORY","MISCELLANEOUS"],["N","G","ACETYLCYST SOL 20%","ACETYLCYSTEINE INHAL SOLN 20%","1","0","0","0","","","RESPIRATORY","MISCELLANEOUS"],["N","G","DALIRESP TAB 250MCG","ROFLUMILAST TAB 250 MCG","3","1","0","0","","","RESPIRATORY","MISCELLANEOUS"],["N","G","DALIRESP TAB 500MCG","ROFLUMILAST TAB 500 MCG","3","1","0","0","","","RESPIRATORY","MISCELLANEOUS"],["N","G","ESBRIET CAP 267MG","PIRFENIDONE CAP 267 MG","4","1","0","1","270 caps every 30 days","SP","RESPIRATORY","MISCELLANEOUS"],["N","G","ESBRIET TAB 267MG","PIRFENIDONE TAB 267 MG","4","1","0","1","270 tabs every 30 days","SP","RESPIRATORY","MISCELLANEOUS"],["N","G","ESBRIET TAB 801MG","PIRFENIDONE TAB 801 MG","4","1","0","1","90 tabs every 30 days","SP","RESPIRATORY","MISCELLANEOUS"],["N","G","GLASSIA INJ","ALPHA1-PROTEINASE INHIBITOR (HUMAN) INJ 1000 MG/50ML","4","1","0","0","","SP","RESPIRATORY","MISCELLANEOUS"],["N","G","KALYDECO PAK 25MG","IVACAFTOR PACKET 25 MG","4","1","0","1","56 packets every 28 days","SP","RESPIRATORY","MISCELLANEOUS"],["N","G","KALYDECO PAK 50MG","IVACAFTOR PACKET 50 MG","4","1","0","1","56 packets every 28 days","SP","RESPIRATORY","MISCELLANEOUS"],["N","G","KALYDECO PAK 75MG","IVACAFTOR PACKET 75 MG","4","1","0","1","56 packets every 28 days","SP","RESPIRATORY","MISCELLANEOUS"],["N","G","KALYDECO TAB 150MG","IVACAFTOR TAB 150 MG","4","1","0","1","56 tabs every 28 days","SP","RESPIRATORY","MISCELLANEOUS"],["N","G","ORKAMBI GRA 100-125","LUMACAFTOR-IVACAFTOR GRANULES PACKET 100-125 MG","4","1","0","1","56 packets every 28 days","SP","RESPIRATORY","MISCELLANEOUS"],["N","G","ORKAMBI GRA 150-188","LUMACAFTOR-IVACAFTOR GRANULES PACKET 150-188 MG","4","1","0","1","56 packets every 28 days","SP","RESPIRATORY","MISCELLANEOUS"],["N","G","ORKAMBI TAB 100-125","LUMACAFTOR-IVACAFTOR TAB 100-125 MG","4","1","0","1","112 tabs every 28 days","SP","RESPIRATORY","MISCELLANEOUS"],["N","G","ORKAMBI TAB 200-125","LUMACAFTOR-IVACAFTOR TAB 200-125 MG","4","1","0","1","112 tabs every 28 days","SP","RESPIRATORY","MISCELLANEOUS"],["N","G","PROLASTIN-C INJ 1000MG","ALPHA1-PROTEINASE INHIBITOR (HUMAN) FOR IV SOLN 1000 MG","4","1","0","0","","SP","RESPIRATORY","MISCELLANEOUS"],["N","G","PROLASTIN-C INJ 1000MG","ALPHA1-PROTEINASE INHIBITOR (HUMAN) INJ 1000 MG/20ML","4","1","0","0","","SP","RESPIRATORY","MISCELLANEOUS"],["N","G","SOD CHLORIDE NEB 0.9%","SODIUM CHLORIDE SOLN NEBU 0.9%","1","0","0","0","","","RESPIRATORY","MISCELLANEOUS"],["N","G","SODIUM CHLOR NEB 10%","SODIUM CHLORIDE SOLN NEBU 10%","1","0","0","0","","","RESPIRATORY","MISCELLANEOUS"],["N","G","SODIUM CHLOR NEB 3%","SODIUM CHLORIDE SOLN NEBU 3%","1","0","0","0","","","RESPIRATORY","MISCELLANEOUS"],["N","G","SODIUM CHLOR NEB 7%","SODIUM CHLORIDE SOLN NEBU 7%","1","0","0","0","","","RESPIRATORY","MISCELLANEOUS"],["N","G","SYMDEKO TAB 100-150","TEZACAFTOR-IVACAFTOR 100-150 MG & IVACAFTOR 150 MG TAB TBPK","4","1","0","1","56 tabs every 28 days","SP","RESPIRATORY","MISCELLANEOUS"],["N","G","SYMDEKO TAB 50-75MG","TEZACAFTOR-IVACAFTOR 50-75 MG & IVACAFTOR 75 MG TAB TBPK","4","1","0","1","56 tabs every 28 days","SP","RESPIRATORY","MISCELLANEOUS"],["N","G","FLUNISOLIDE SPR 0.025%","FLUNISOLIDE NASAL SOLN 25 MCG/ACT (0.025%)","1","0","0","1","3 containers every 25 days","","RESPIRATORY","NASAL STEROIDS§"],["N","G","FLUTICASONE SPR 50MCG","FLUTICASONE PROPIONATE NASAL SUSP 50 MCG/ACT","1","0","0","1","1 container every 25 days","","RESPIRATORY","NASAL STEROIDS§"],["N","G","OMNARIS SPR","CICLESONIDE NASAL SUSP 50 MCG/ACT","3","0","1","1","1 package every 25 days","PA**","RESPIRATORY","NASAL STEROIDS§"],["N","G","TRIAMCINOLON AER 55MCG/AC","TRIAMCINOLONE ACETONIDE NASAL AEROSOL SUSPENSION 55 MCG/ACT","1","0","0","1","1 bottle every 25 days","","RESPIRATORY","NASAL STEROIDS§"],["N","G","ASMANEX 120 AER 220MCG","MOMETASONE FUROATE INHAL POWD 220 MCG/INH (BREATH ACTIVATED)","2","0","0","1","1 inhaler every 25 days","","RESPIRATORY","STEROID INHALANTS§"],["N","G","ASMANEX 30 AER 110MCG","MOMETASONE FUROATE INHAL POWD 110 MCG/INH (BREATH ACTIVATED)","2","0","0","1","2 inhalers every 25 days","","RESPIRATORY","STEROID INHALANTS§"],["N","G","ASMANEX 30 AER 220MCG","MOMETASONE FUROATE INHAL POWD 220 MCG/INH (BREATH ACTIVATED)","2","0","0","1","4 inhalers every 25 days","","RESPIRATORY","STEROID INHALANTS§"],["N","G","ASMANEX 60 AER 220MCG","MOMETASONE FUROATE INHAL POWD 220 MCG/INH (BREATH ACTIVATED)","2","0","0","1","2 inhalers every 25 days","","RESPIRATORY","STEROID INHALANTS§"],["N","G","ASMANEX HFA AER 100 MCG","MOMETASONE FUROATE INHAL AEROSOL SUSPENSION 100 MCG/ACT","2","0","0","1","1 inhaler every 25 days","","RESPIRATORY","STEROID INHALANTS§"],["N","G","ASMANEX HFA AER 200 MCG","MOMETASONE FUROATE INHAL AEROSOL SUSPENSION 200 MCG/ACT","2","0","0","1","1 inhaler every 25 days","","RESPIRATORY","STEROID INHALANTS§"],["N","G","BUDESONIDE SUS 0.25MG/2","BUDESONIDE INHALATION SUSP 0.25 MG/2ML","1","0","0","1","3 boxes every 25 days","","RESPIRATORY","STEROID INHALANTS§"],["N","G","BUDESONIDE SUS 0.5MG/2","BUDESONIDE INHALATION SUSP 0.5 MG/2ML","1","0","0","1","2 boxes every 25 days","","RESPIRATORY","STEROID INHALANTS§"],["N","G","BUDESONIDE SUS 1MG/2ML","BUDESONIDE INHALATION SUSP 1 MG/2ML","1","0","0","1","1 box every 25 days","","RESPIRATORY","STEROID INHALANTS§"],["N","G","QVAR REDIHA AER 80MCG","BECLOMETHASONE DIPROP HFA BREATH ACT INH AER 80 MCG/ACT","2","0","0","1","2 packages every 25 days","","RESPIRATORY","STEROID INHALANTS§"],["N","G","QVAR REDIHAL AER 40MCG","BECLOMETHASONE DIPROP HFA BREATH ACT INH AER 40 MCG/ACT","2","0","0","1","2 packages every 25 days","","RESPIRATORY","STEROID INHALANTS§"],["N","G","ADVAIR DISKU AER 100/50","FLUTICASONE-SALMETEROL AER POWDER BA 100-50 MCG/DOSE","1","0","0","1","1 package every 25 days","","RESPIRATORY","STEROID/BETA-AGONIST COMBINATIONS§"],["N","G","ADVAIR DISKU AER 250/50","FLUTICASONE-SALMETEROL AER POWDER BA 250-50 MCG/DOSE","1","0","0","1","1 package every 25 days","","RESPIRATORY","STEROID/BETA-AGONIST COMBINATIONS§"],["N","G","ADVAIR DISKU AER 500/50","FLUTICASONE-SALMETEROL AER POWDER BA 500-50 MCG/DOSE","1","0","0","1","1 package every 25 days","","RESPIRATORY","STEROID/BETA-AGONIST COMBINATIONS§"],["N","G","ADVAIR HFA AER 115/21","FLUTICASONE-SALMETEROL INHAL AEROSOL 115-21 MCG/ACT","2","0","0","1","1 package every 25 days","","RESPIRATORY","STEROID/BETA-AGONIST COMBINATIONS§"],["N","G","ADVAIR HFA AER 230/21","FLUTICASONE-SALMETEROL INHAL AEROSOL 230-21 MCG/ACT","2","0","0","1","1 package every 25 days","","RESPIRATORY","STEROID/BETA-AGONIST COMBINATIONS§"],["N","G","ADVAIR HFA AER 45/21","FLUTICASONE-SALMETEROL INHAL AEROSOL 45-21 MCG/ACT","2","0","0","1","1 package every 25 days","","RESPIRATORY","STEROID/BETA-AGONIST COMBINATIONS§"],["N","G","BREO ELLIPTA INH 100-25","FLUTICASONE FUROATE-VILANTEROL AERO POWD BA 100-25 MCG/INH","2","0","0","1","1 package every 25 days","","RESPIRATORY","STEROID/BETA-AGONIST COMBINATIONS§"],["N","G","BREO ELLIPTA INH 200-25","FLUTICASONE FUROATE-VILANTEROL AERO POWD BA 200-25 MCG/INH","2","0","0","1","1 package every 25 days","","RESPIRATORY","STEROID/BETA-AGONIST COMBINATIONS§"],["N","G","SYMBICORT AER 160-4.5","BUDESONIDE-FORMOTEROL FUMARATE DIHYD AEROSOL 160-4.5 MCG/ACT","2","0","0","1","1 package every 25 days","","RESPIRATORY","STEROID/BETA-AGONIST COMBINATIONS§"],["N","G","SYMBICORT AER 80-4.5","BUDESONIDE-FORMOTEROL FUMARATE DIHYD AEROSOL 80-4.5 MCG/ACT","2","0","0","1","1 package every 25 days","","RESPIRATORY","STEROID/BETA-AGONIST COMBINATIONS§"],["N","G","AMINOPHYLLIN INJ 25MG/ML","AMINOPHYLLINE INJ 25 MG/ML","1","0","0","0","","","RESPIRATORY","XANTHINES"],["N","G","ELIXOPHYLLIN ELX 80/15ML","THEOPHYLLINE ELIXIR 80 MG/15ML","3","0","0","0","","","RESPIRATORY","XANTHINES"],["N","G","THEO-24 CAP 100MG CR","THEOPHYLLINE CAP ER 24HR 100 MG","3","0","0","0","","","RESPIRATORY","XANTHINES"],["N","G","THEO-24 CAP 200MG CR","THEOPHYLLINE CAP ER 24HR 200 MG","3","0","0","0","","","RESPIRATORY","XANTHINES"],["N","G","THEO-24 CAP 300MG CR","THEOPHYLLINE CAP ER 24HR 300 MG","3","0","0","0","","","RESPIRATORY","XANTHINES"],["N","G","THEO-24 CAP 400MG ER","THEOPHYLLINE CAP ER 24HR 400 MG","3","0","0","0","","","RESPIRATORY","XANTHINES"],["N","G","THEOCHRON TAB 100MG CR","THEOPHYLLINE TAB ER 12HR 100 MG","1","0","0","0","","","RESPIRATORY","XANTHINES"],["N","G","THEOCHRON TAB 200MG CR","THEOPHYLLINE TAB ER 12HR 200 MG","1","0","0","0","","","RESPIRATORY","XANTHINES"],["N","G","THEOCHRON TAB 300MG CR","THEOPHYLLINE TAB ER 12HR 300 MG","1","0","0","0","","","RESPIRATORY","XANTHINES"],["N","G","THEOPHYLLINE SOL 80/15ML","THEOPHYLLINE SOLN 80 MG/15ML","1","0","0","0","","","RESPIRATORY","XANTHINES"],["N","G","THEOPHYLLINE TAB 400MG ER","THEOPHYLLINE TAB ER 24HR 400 MG","1","0","0","0","","","RESPIRATORY","XANTHINES"],["N","G","THEOPHYLLINE TAB 450MG ER","THEOPHYLLINE TAB ER 12HR 450 MG","1","0","0","0","","","RESPIRATORY","XANTHINES"],["N","G","THEOPHYLLINE TAB 600MG ER","THEOPHYLLINE TAB ER 24HR 600 MG","1","0","0","0","","","RESPIRATORY","XANTHINES"],["N","G","ADAPAL/BEN P GEL 0.1-2.5%","ADAPALENE-BENZOYL PEROXIDE GEL 0.1-2.5%","1","0","0","0","","","TOPICAL","DERMATOLOGY, ACNE"],["N","G","ADAPALENE CRE 0.1%","ADAPALENE CREAM 0.1%","1","1","0","0","","PA applies for members age 35 and older","TOPICAL","DERMATOLOGY, ACNE"],["N","G","ADAPALENE GEL 0.1%","ADAPALENE GEL 0.1%","1","1","0","0","","PA applies for members age 35 and older","TOPICAL","DERMATOLOGY, ACNE"],["N","G","ADAPALENE GEL 0.3%","ADAPALENE GEL 0.3%","1","1","0","0","","PA applies for members age 35 and older","TOPICAL","DERMATOLOGY, ACNE"],["N","G","ADAPALENE LOT 0.1%","ADAPALENE LOTION 0.1%","1","1","0","0","","PA applies for members age 35 and older","TOPICAL","DERMATOLOGY, ACNE"],["N","G","AMNESTEEM CAP 10MG","ISOTRETINOIN CAP 10 MG","1","1","0","0","","","TOPICAL","DERMATOLOGY, ACNE"],["N","G","AMNESTEEM CAP 20MG","ISOTRETINOIN CAP 20 MG","1","1","0","0","","","TOPICAL","DERMATOLOGY, ACNE"],["N","G","AMNESTEEM CAP 40MG","ISOTRETINOIN CAP 40 MG","1","1","0","0","","","TOPICAL","DERMATOLOGY, ACNE"],["N","G","AVITA CRE 0.025%","TRETINOIN CREAM 0.025%","1","1","0","0","","PA applies for members age 35 and older","TOPICAL","DERMATOLOGY, ACNE"],["N","G","AVITA GEL 0.025%","TRETINOIN GEL 0.025%","1","1","0","0","","PA applies for members age 35 and older","TOPICAL","DERMATOLOGY, ACNE"],["N","G","AZELEX CRE 20%","AZELAIC ACID CREAM 20%","3","0","1","0","","PA**","TOPICAL","DERMATOLOGY, ACNE"],["N","G","BENZIQ GEL 5.25%","BENZOYL PEROXIDE GEL 5.25 %","2","0","0","0","","","TOPICAL","DERMATOLOGY, ACNE"],["N","G","BENZIQ LS GEL 2.75%","BENZOYL PEROXIDE GEL 2.75%","2","0","0","0","","","TOPICAL","DERMATOLOGY, ACNE"],["N","G","BENZIQ WASH LIQ 5.25%","BENZOYL PEROXIDE LIQ 5.25%","1","0","0","0","","","TOPICAL","DERMATOLOGY, ACNE"],["N","G","BP WASH LIQ 2.5%","BENZOYL PEROXIDE LIQ 2.5%","1","0","0","0","","","TOPICAL","DERMATOLOGY, ACNE"],["N","G","CLARAVIS CAP 10MG","ISOTRETINOIN CAP 10 MG","1","1","0","0","","","TOPICAL","DERMATOLOGY, ACNE"],["N","G","CLARAVIS CAP 20MG","ISOTRETINOIN CAP 20 MG","1","1","0","0","","","TOPICAL","DERMATOLOGY, ACNE"],["N","G","CLARAVIS CAP 30MG","ISOTRETINOIN CAP 30 MG","1","1","0","0","","","TOPICAL","DERMATOLOGY, ACNE"],["N","G","CLARAVIS CAP 40MG","ISOTRETINOIN CAP 40 MG","1","1","0","0","","","TOPICAL","DERMATOLOGY, ACNE"],["N","G","CLEARPLEX X GEL 10%","BENZOYL PEROXIDE GEL 10%","1","0","0","0","","","TOPICAL","DERMATOLOGY, ACNE"],["N","G","CLINDAM/BENZ GEL 1.2-2.5%","CLINDAMYCIN PHOSPHATE-BENZOYL PEROXIDE GEL 1.2-2.5%","1","0","0","0","","","TOPICAL","DERMATOLOGY, ACNE"],["N","G","CLINDAMY/BEN GEL 1-5%","CLINDAMYCIN PHOSPHATE-BENZOYL PEROXIDE GEL 1-5%","1","0","0","0","","","TOPICAL","DERMATOLOGY, ACNE"],["N","G","CLINDAMY/BEN GEL 1.2-5%","CLINDAMYCIN PHOSPH-BENZOYL PEROXIDE (REFRIG) GEL 1.2 (1)-5%","1","0","0","0","","","TOPICAL","DERMATOLOGY, ACNE"],["N","G","CLINDAMYCIN AER 1%","CLINDAMYCIN PHOSPHATE FOAM 1%","1","0","0","0","","","TOPICAL","DERMATOLOGY, ACNE"],["N","G","CLINDAMYCIN GEL 1%","CLINDAMYCIN PHOSPHATE GEL 1%","1","0","0","0","","","TOPICAL","DERMATOLOGY, ACNE"],["N","G","CLINDAMYCIN LOT 1%","CLINDAMYCIN PHOSPHATE LOTION 1%","1","0","0","0","","","TOPICAL","DERMATOLOGY, ACNE"],["N","G","CLINDAMYCIN LOT 10MG/ML","CLINDAMYCIN PHOSPHATE LOTION 1%","1","0","0","0","","","TOPICAL","DERMATOLOGY, ACNE"],["N","G","CLINDAMYCIN PAD 1%","CLINDAMYCIN PHOSPHATE SWAB 1%","1","0","0","0","","","TOPICAL","DERMATOLOGY, ACNE"],["N","G","CLINDAMYCIN SOL 1%","CLINDAMYCIN PHOSPHATE SOLN 1%","1","0","0","0","","","TOPICAL","DERMATOLOGY, ACNE"],["N","G","EPIDUO FORTE GEL 0.3-2.5%","ADAPALENE-BENZOYL PEROXIDE GEL 0.3-2.5%","3","0","0","0","","","TOPICAL","DERMATOLOGY, ACNE"],["N","G","ERY PAD 2%","ERYTHROMYCIN PADS 2%","1","0","0","0","","","TOPICAL","DERMATOLOGY, ACNE"],["N","G","ERY/BENZOYL GEL 5-3%","BENZOYL PEROXIDE-ERYTHROMYCIN GEL 5-3%","1","0","0","0","","","TOPICAL","DERMATOLOGY, ACNE"],["N","G","ERYTHROMYCIN GEL 2%","ERYTHROMYCIN GEL 2%","1","0","0","0","","","TOPICAL","DERMATOLOGY, ACNE"],["N","G","ERYTHROMYCIN PAD 2%","ERYTHROMYCIN PADS 2%","1","0","0","0","","","TOPICAL","DERMATOLOGY, ACNE"],["N","G","ERYTHROMYCIN SOL 2%","ERYTHROMYCIN SOLN 2%","1","0","0","0","","","TOPICAL","DERMATOLOGY, ACNE"],["N","G","ISOTRETINOIN CAP 10MG","ISOTRETINOIN CAP 10 MG","1","1","0","0","","","TOPICAL","DERMATOLOGY, ACNE"],["N","G","MYORISAN CAP 20MG","ISOTRETINOIN CAP 20 MG","1","1","0","0","","","TOPICAL","DERMATOLOGY, ACNE"],["N","G","MYORISAN CAP 40MG","ISOTRETINOIN CAP 40 MG","1","1","0","0","","","TOPICAL","DERMATOLOGY, ACNE"],["N","G","SULFACETAMID LOT 10%","SULFACETAMIDE SODIUM LOTION 10% (ACNE)","1","0","0","0","","","TOPICAL","DERMATOLOGY, ACNE"],["N","G","TRETINOIN CRE 0.025%","TRETINOIN CREAM 0.025%","1","1","0","0","","PA applies for members age 35 and older","TOPICAL","DERMATOLOGY, ACNE"],["N","G","TRETINOIN CRE 0.05%","TRETINOIN CREAM 0.05%","1","1","0","0","","PA applies for members age 35 and older","TOPICAL","DERMATOLOGY, ACNE"],["N","G","TRETINOIN CRE 0.1%","TRETINOIN CREAM 0.1%","1","1","0","0","","PA applies for members age 35 and older","TOPICAL","DERMATOLOGY, ACNE"],["N","G","TRETINOIN GEL 0.01%","TRETINOIN GEL 0.01%","1","1","0","0","","PA applies for members age 35 and older","TOPICAL","DERMATOLOGY, ACNE"],["N","G","TRETINOIN GEL 0.025%","TRETINOIN GEL 0.025%","1","1","0","0","","PA applies for members age 35 and older","TOPICAL","DERMATOLOGY, ACNE"],["N","G","TRETINOIN GEL 0.04%PMP","TRETINOIN MICROSPHERE GEL 0.04%","1","1","0","0","","PA applies for members age 35 and older","TOPICAL","DERMATOLOGY, ACNE"],["N","G","TRETINOIN GEL 0.05%","TRETINOIN GEL 0.05%","1","1","0","0","","PA applies for members age 35 and older","TOPICAL","DERMATOLOGY, ACNE"],["N","G","TRETINOIN GEL 0.1%","TRETINOIN MICROSPHERE GEL 0.1%","1","1","0","0","","PA applies for members age 35 and older","TOPICAL","DERMATOLOGY, ACNE"],["N","G","ZENATANE CAP 30MG","ISOTRETINOIN CAP 30 MG","1","1","0","0","","","TOPICAL","DERMATOLOGY, ACNE"],["N","G","FLUOROPLEX CRE 1%","FLUOROURACIL CREAM 1%","3","0","0","0","","","TOPICAL","DERMATOLOGY, ACTINIC KERATOSIS"],["N","G","FLUOROURACIL CRE 0.5%","FLUOROURACIL CREAM 0.5%","1","0","0","0","","","TOPICAL","DERMATOLOGY, ACTINIC KERATOSIS"],["N","G","FLUOROURACIL CRE 5%","FLUOROURACIL CREAM 5%","1","0","0","0","","","TOPICAL","DERMATOLOGY, ACTINIC KERATOSIS"],["N","G","FLUOROURACIL SOL 2%","FLUOROURACIL SOLN 2%","1","0","0","0","","","TOPICAL","DERMATOLOGY, ACTINIC KERATOSIS"],["N","G","FLUOROURACIL SOL 5%","FLUOROURACIL SOLN 5%","1","0","0","0","","","TOPICAL","DERMATOLOGY, ACTINIC KERATOSIS"],["N","G","IMIQUIMOD CRE 5%","IMIQUIMOD CREAM 5%","1","0","0","0","","","TOPICAL","DERMATOLOGY, ACTINIC KERATOSIS"],["N","G","PICATO GEL 0.015%","INGENOL MEBUTATE GEL 0.015%","3","0","0","0","","","TOPICAL","DERMATOLOGY, ACTINIC KERATOSIS"],["N","G","PICATO GEL 0.05%","INGENOL MEBUTATE GEL 0.05%","3","0","0","0","","","TOPICAL","DERMATOLOGY, ACTINIC KERATOSIS"],["N","G","ALTABAX OIN 1%","RETAPAMULIN OINT 1%","3","0","0","0","","","TOPICAL","DERMATOLOGY, ANTIBIOTICS"],["N","G","BACTROBAN OIN NASAL 2%","MUPIROCIN CALCIUM NASAL OINT 2%","3","0","0","0","","","TOPICAL","DERMATOLOGY, ANTIBIOTICS"],["N","G","CORTISPORIN CRE 0.5%","NEOMYCIN-POLYMYXIN-HC CRM 3.5 MG/GM-10000 UNT/GM-0.5%","3","0","0","0","","","TOPICAL","DERMATOLOGY, ANTIBIOTICS"],["N","G","CORTISPORIN OIN 1%","BACITRACIN-POLYMYXIN-NEOMYCIN HC OINT 1%","3","0","0","0","","","TOPICAL","DERMATOLOGY, ANTIBIOTICS"],["N","G","GENTAMICIN CRE 0.1%","GENTAMICIN SULFATE CREAM 0.1%","1","0","0","0","","","TOPICAL","DERMATOLOGY, ANTIBIOTICS"],["N","G","GENTAMICIN OIN 0.1%","GENTAMICIN SULFATE OINT 0.1%","1","0","0","0","","","TOPICAL","DERMATOLOGY, ANTIBIOTICS"],["N","G","IV PREP WIPE PAD","*ANTISEPTIC PRODUCTS MISC - PADS**","2","0","0","0","","","TOPICAL","DERMATOLOGY, ANTIBIOTICS"],["N","G","MUPIROCIN OIN 2%","MUPIROCIN OINT 2%","1","0","0","0","","","TOPICAL","DERMATOLOGY, ANTIBIOTICS"],["N","G","SILVER SULFA CRE 1%","SILVER SULFADIAZINE CREAM 1%","1","0","0","0","","","TOPICAL","DERMATOLOGY, ANTIBIOTICS"],["N","G","SSD CRE 1%","SILVER SULFADIAZINE CREAM 1%","1","0","0","0","","","TOPICAL","DERMATOLOGY, ANTIBIOTICS"],["N","G","SULFAMYLON CRE 85MG/GM","MAFENIDE ACETATE CREAM 85 MG/GM","3","0","0","0","","","TOPICAL","DERMATOLOGY, ANTIBIOTICS"],["N","G","CICLOPIROX CRE 0.77%","CICLOPIROX OLAMINE CREAM 0.77% (BASE EQUIV)","1","0","0","0","","","TOPICAL","DERMATOLOGY, ANTIFUNGALS"],["N","G","CICLOPIROX GEL 0.77%","CICLOPIROX GEL 0.77%","1","0","0","0","","","TOPICAL","DERMATOLOGY, ANTIFUNGALS"],["N","G","CICLOPIROX SHA 1%","CICLOPIROX SHAMPOO 1%","1","0","0","0","","","TOPICAL","DERMATOLOGY, ANTIFUNGALS"],["N","G","CICLOPIROX SOL 8%","CICLOPIROX SOLUTION 8%","1","0","0","0","","","TOPICAL","DERMATOLOGY, ANTIFUNGALS"],["N","G","CICLOPIROX SUS 0.77%","CICLOPIROX OLAMINE SUSP 0.77% (BASE EQUIV)","1","0","0","0","","","TOPICAL","DERMATOLOGY, ANTIFUNGALS"],["N","G","CLOTRIM/BETA CRE DIPROP","CLOTRIMAZOLE W/ BETAMETHASONE CREAM 1-0.05%","1","0","0","0","","","TOPICAL","DERMATOLOGY, ANTIFUNGALS"],["N","G","CLOTRIM/BETA LOT DIPROP","CLOTRIMAZOLE W/ BETAMETHASONE LOTION 1-0.05%","1","0","0","0","","","TOPICAL","DERMATOLOGY, ANTIFUNGALS"],["N","G","CLOTRIMAZOLE CRE 1%","CLOTRIMAZOLE CREAM 1%","1","0","0","0","","","TOPICAL","DERMATOLOGY, ANTIFUNGALS"],["N","G","CLOTRIMAZOLE SOL 1%","CLOTRIMAZOLE SOLN 1%","1","0","0","0","","","TOPICAL","DERMATOLOGY, ANTIFUNGALS"],["N","G","ECONAZOLE CRE 1%","ECONAZOLE NITRATE CREAM 1%","1","0","0","0","","","TOPICAL","DERMATOLOGY, ANTIFUNGALS"],["N","G","ERTACZO CRE 2%","SERTACONAZOLE NITRATE CREAM 2%","3","0","0","0","","","TOPICAL","DERMATOLOGY, ANTIFUNGALS"],["N","G","EXELDERM CRE 1%","SULCONAZOLE NITRATE CREAM 1%","3","0","1","0","","PA**","TOPICAL","DERMATOLOGY, ANTIFUNGALS"],["N","G","EXELDERM SOL 1%","SULCONAZOLE NITRATE SOLUTION 1%","3","0","1","0","","PA**","TOPICAL","DERMATOLOGY, ANTIFUNGALS"],["N","G","JUBLIA SOL 10%","EFINACONAZOLE SOLN 10%","3","1","0","0","","","TOPICAL","DERMATOLOGY, ANTIFUNGALS"],["N","G","KETOCONAZOLE AER 2%","KETOCONAZOLE FOAM 2%","1","0","0","0","","","TOPICAL","DERMATOLOGY, ANTIFUNGALS"],["N","G","KETOCONAZOLE CRE 2%","KETOCONAZOLE CREAM 2%","1","0","0","0","","","TOPICAL","DERMATOLOGY, ANTIFUNGALS"],["N","G","MENTAX CRE 1%","BUTENAFINE HCL CREAM 1%","3","0","0","0","","","TOPICAL","DERMATOLOGY, ANTIFUNGALS"],["N","G","NAFTIFINE CRE HCL 1%","NAFTIFINE HCL CREAM 1%","1","0","0","0","","","TOPICAL","DERMATOLOGY, ANTIFUNGALS"],["N","G","NAFTIFINE CRE HCL 2%","NAFTIFINE HCL CREAM 2%","1","0","0","0","","","TOPICAL","DERMATOLOGY, ANTIFUNGALS"],["N","G","NYAMYC POW 100000","NYSTATIN TOPICAL POWDER 100000 UNIT/GM","1","0","0","0","","","TOPICAL","DERMATOLOGY, ANTIFUNGALS"],["N","G","NYAMYC POW 100000","NYSTATIN TOPICAL POWDER 100000 UNIT/GM","1","0","0","0","","","TOPICAL","DERMATOLOGY, ANTIFUNGALS"],["N","G","NYSTAT/TRIAM CRE","NYSTATIN-TRIAMCINOLONE CREAM 100000-0.1 UNIT/GM-%","1","0","0","0","","","TOPICAL","DERMATOLOGY, ANTIFUNGALS"],["N","G","NYSTAT/TRIAM OIN","NYSTATIN-TRIAMCINOLONE OINT 100000-0.1 UNIT/GM-%","1","0","0","0","","","TOPICAL","DERMATOLOGY, ANTIFUNGALS"],["N","G","NYSTATIN CRE 100000","NYSTATIN CREAM 100000 UNIT/GM","1","0","0","0","","","TOPICAL","DERMATOLOGY, ANTIFUNGALS"],["N","G","NYSTATIN OIN 100000","NYSTATIN OINT 100000 UNIT/GM","1","0","0","0","","","TOPICAL","DERMATOLOGY, ANTIFUNGALS"],["N","G","NYSTATIN POW 100000","NYSTATIN TOPICAL POWDER 100000 UNIT/GM","1","0","0","0","","","TOPICAL","DERMATOLOGY, ANTIFUNGALS"],["N","G","NYSTOP POW 100000","NYSTATIN TOPICAL POWDER 100000 UNIT/GM","1","0","0","0","","","TOPICAL","DERMATOLOGY, ANTIFUNGALS"],["N","G","NYSTOP POW 100000","NYSTATIN TOPICAL POWDER 100000 UNIT/GM","1","0","0","0","","","TOPICAL","DERMATOLOGY, ANTIFUNGALS"],["N","G","OXICONAZOLE CRE NITRATE","OXICONAZOLE NITRATE CREAM 1%","1","0","0","0","","","TOPICAL","DERMATOLOGY, ANTIFUNGALS"],["N","G","OXISTAT LOT 1%","OXICONAZOLE NITRATE LOTION 1%","3","0","0","0","","","TOPICAL","DERMATOLOGY, ANTIFUNGALS"],["N","G","DOXEPIN HCL CRE 5%","DOXEPIN HCL CREAM 5%","1","0","1","1","90 grams every 25 days","PA**","TOPICAL","DERMATOLOGY, ANTIPRURITIC"],["N","G","ACITRETIN CAP 10MG","ACITRETIN CAP 10 MG","1","0","0","0","","","TOPICAL","DERMATOLOGY, ANTIPSORIATICS"],["N","G","ACITRETIN CAP 17.5MG","ACITRETIN CAP 17.5 MG","1","0","0","0","","","TOPICAL","DERMATOLOGY, ANTIPSORIATICS"],["N","G","ACITRETIN CAP 25MG","ACITRETIN CAP 25 MG","1","0","0","0","","","TOPICAL","DERMATOLOGY, ANTIPSORIATICS"],["N","G","CALCIPOTRIEN CRE 0.005%","CALCIPOTRIENE CREAM 0.005%","3","0","0","0","","","TOPICAL","DERMATOLOGY, ANTIPSORIATICS"],["N","G","CALCIPOTRIEN OIN 0.005%","CALCIPOTRIENE OINT 0.005%","1","0","0","0","","","TOPICAL","DERMATOLOGY, ANTIPSORIATICS"],["N","G","CALCIPOTRIEN SOL 0.005%","CALCIPOTRIENE SOLN 0.005% (50 MCG/ML)","1","0","0","0","","","TOPICAL","DERMATOLOGY, ANTIPSORIATICS"],["N","G","CALCITRENE OIN 0.005%","CALCIPOTRIENE OINT 0.005%","1","0","0","0","","","TOPICAL","DERMATOLOGY, ANTIPSORIATICS"],["N","G","CALCITRIOL OIN 3MCG/GM","CALCITRIOL OINT 3 MCG/GM","1","0","0","0","","","TOPICAL","DERMATOLOGY, ANTIPSORIATICS"],["N","G","COSENTYX INJ 150MG/ML","SECUKINUMAB SUBCUTANEOUS SOLN PREFILLED SYRINGE 150 MG/ML","4","1","0","1","1 box every 28 days","SP; Preferred agent for Ankylosing Spondylitis and Psoriatic Arthritis","TOPICAL","DERMATOLOGY, ANTIPSORIATICS"],["N","G","COSENTYX INJ 300DOSE","SECUKINUMAB SUBCUTANEOUS PREF SYR 150 MG/ML (300 MG DOSE)","4","1","0","1","1 box every 28 days","SP; Preferred agent for Ankylosing Spondylitis and Psoriatic Arthritis","TOPICAL","DERMATOLOGY, ANTIPSORIATICS"],["N","G","COSENTYX PEN INJ 150MG/ML","SECUKINUMAB SUBCUTANEOUS SOLN AUTO-INJECTOR 150 MG/ML","4","1","0","1","1 box every 28 days","SP; Preferred agent for Ankylosing Spondylitis and Psoriatic Arthritis","TOPICAL","DERMATOLOGY, ANTIPSORIATICS"],["N","G","COSENTYX PEN INJ 300DOSE","SECUKINUMAB SUBCUTANEOUS AUTO-INJ 150 MG/ML (300 MG DOSE)","4","1","0","1","1 box every 28 days","SP; Preferred agent for Ankylosing Spondylitis and Psoriatic Arthritis","TOPICAL","DERMATOLOGY, ANTIPSORIATICS"],["N","G","METHOXSALEN CAP 10MG","METHOXSALEN RAPID CAP 10 MG","1","0","0","0","","","TOPICAL","DERMATOLOGY, ANTIPSORIATICS"],["N","G","TAZAROTENE CRE 0.1%","TAZAROTENE CREAM 0.1%","1","1","0","0","","","TOPICAL","DERMATOLOGY, ANTIPSORIATICS"],["N","G","TAZORAC CRE 0.05%","TAZAROTENE CREAM 0.05%","2","1","0","0","","","TOPICAL","DERMATOLOGY, ANTIPSORIATICS"],["N","G","TAZORAC GEL 0.05%","TAZAROTENE GEL 0.05%","2","1","0","0","","","TOPICAL","DERMATOLOGY, ANTIPSORIATICS"],["N","G","TAZORAC GEL 0.1%","TAZAROTENE GEL 0.1%","2","1","0","0","","","TOPICAL","DERMATOLOGY, ANTIPSORIATICS"],["N","G","KETOCONAZOLE SHA 2%","KETOCONAZOLE SHAMPOO 2%","1","0","0","0","","","TOPICAL","DERMATOLOGY, ANTISEBORRHEICS"],["N","G","SELENIUM SUL LOT 2.5%","SELENIUM SULFIDE LOTION 2.5%","1","0","0","0","","","TOPICAL","DERMATOLOGY, ANTISEBORRHEICS"],["N","G","ALA-CORT CRE 1%","HYDROCORTISONE CREAM 1%","1","0","0","0","","","TOPICAL","DERMATOLOGY, CORTICOSTEROIDS"],["N","G","ALCLOMETASON CRE 0.05%","ALCLOMETASONE DIPROPIONATE CREAM 0.05%","1","0","0","1","120g every 25 days","","TOPICAL","DERMATOLOGY, CORTICOSTEROIDS"],["N","G","ALCLOMETASON OIN 0.05%","ALCLOMETASONE DIPROPIONATE OINT 0.05%","1","0","0","1","120g every 25 days","","TOPICAL","DERMATOLOGY, CORTICOSTEROIDS"],["N","G","ALPHATREX GEL 0.05%","BETAMETHASONE DIPROPIONATE AUGMENTED GEL 0.05%","1","0","0","1","120g every 25 days","","TOPICAL","DERMATOLOGY, CORTICOSTEROIDS"],["N","G","AMCINONIDE CRE 0.1%","AMCINONIDE CREAM 0.1%","1","0","0","1","120g every 25 days","","TOPICAL","DERMATOLOGY, CORTICOSTEROIDS"],["N","G","AMCINONIDE LOT 0.1%","AMCINONIDE LOTION 0.1%","1","0","0","1","120mL every 25 days","","TOPICAL","DERMATOLOGY, CORTICOSTEROIDS"],["N","G","AMCINONIDE OIN 0.1%","AMCINONIDE OINT 0.1%","2","0","0","1","120g every 25 days","","TOPICAL","DERMATOLOGY, CORTICOSTEROIDS"],["N","G","AUG BETAMET CRE 0.05%","BETAMETHASONE DIPROPIONATE AUGMENTED CREAM 0.05%","1","0","0","1","120g every 25 days","","TOPICAL","DERMATOLOGY, CORTICOSTEROIDS"],["N","G","AUG BETAMET GEL 0.05%","BETAMETHASONE DIPROPIONATE AUGMENTED GEL 0.05%","1","0","0","1","120g every 25 days","","TOPICAL","DERMATOLOGY, CORTICOSTEROIDS"],["N","G","AUG BETAMET LOT 0.05%","BETAMETHASONE DIPROPIONATE AUGMENTED LOTION 0.05%","1","0","0","1","120mL every 25 days","","TOPICAL","DERMATOLOGY, CORTICOSTEROIDS"],["N","G","AUG BETAMET OIN 0.05%","BETAMETHASONE DIPROPIONATE AUGMENTED OINT 0.05%","1","0","0","1","120g every 25 days","","TOPICAL","DERMATOLOGY, CORTICOSTEROIDS"],["N","G","BETAMETH DIP CRE 0.05%","BETAMETHASONE DIPROPIONATE CREAM 0.05%","1","0","0","1","120g every 25 days","","TOPICAL","DERMATOLOGY, CORTICOSTEROIDS"],["N","G","BETAMETH DIP LOT 0.05%","BETAMETHASONE DIPROPIONATE LOTION 0.05%","1","0","0","1","120mL every 25 days","","TOPICAL","DERMATOLOGY, CORTICOSTEROIDS"],["N","G","BETAMETH DIP OIN 0.05%","BETAMETHASONE DIPROPIONATE OINT 0.05%","1","0","0","1","120g every 25 days","","TOPICAL","DERMATOLOGY, CORTICOSTEROIDS"],["N","G","BETAMETH VAL AER 0.12%","BETAMETHASONE VALERATE AEROSOL FOAM 0.12%","1","0","0","0","","","TOPICAL","DERMATOLOGY, CORTICOSTEROIDS"],["N","G","BETAMETH VAL CRE 0.1%","BETAMETHASONE VALERATE CREAM 0.1% (BASE EQUIVALENT)","1","0","0","1","120g every 25 days","","TOPICAL","DERMATOLOGY, CORTICOSTEROIDS"],["N","G","BETAMETH VAL LOT 0.1%","BETAMETHASONE VALERATE LOTION 0.1% (BASE EQUIVALENT)","1","0","0","1","120mL every 25 days","","TOPICAL","DERMATOLOGY, CORTICOSTEROIDS"],["N","G","BETAMETH VAL OIN 0.1%","BETAMETHASONE VALERATE OINT 0.1% (BASE EQUIVALENT)","1","0","0","1","120g every 25 days","","TOPICAL","DERMATOLOGY, CORTICOSTEROIDS"],["N","G","CALCIPOTRIEN OIN BETAMETH","CALCIPOTRIENE-BETAMETHASONE DIPROPIONATE OINT 0.005-0.064%","3","0","0","0","","","TOPICAL","DERMATOLOGY, CORTICOSTEROIDS"],["N","G","CLOBETASOL AER 0.05%","CLOBETASOL PROPIONATE FOAM 0.05%","1","0","0","0","","","TOPICAL","DERMATOLOGY, CORTICOSTEROIDS"],["N","G","CLOBETASOL CRE 0.05%","CLOBETASOL PROPIONATE CREAM 0.05%","1","0","0","1","120g every 25 days","","TOPICAL","DERMATOLOGY, CORTICOSTEROIDS"],["N","G","CLOBETASOL GEL 0.05%","CLOBETASOL PROPIONATE GEL 0.05%","1","0","0","1","120g every 25 days","","TOPICAL","DERMATOLOGY, CORTICOSTEROIDS"],["N","G","CLOBETASOL LOT 0.05%","CLOBETASOL PROPIONATE LOTION 0.05%","1","0","0","1","120mL every 25 days","","TOPICAL","DERMATOLOGY, CORTICOSTEROIDS"],["N","G","CLOBETASOL OIN 0.05%","CLOBETASOL PROPIONATE OINT 0.05%","1","0","0","1","120g every 25 days","","TOPICAL","DERMATOLOGY, CORTICOSTEROIDS"],["N","G","CLOBETASOL SHA 0.05%","CLOBETASOL PROPIONATE SHAMPOO 0.05%","1","0","0","0","","","TOPICAL","DERMATOLOGY, CORTICOSTEROIDS"],["N","G","CLOBETASOL SOL 0.05%","CLOBETASOL PROPIONATE SOLN 0.05%","1","0","0","0","","","TOPICAL","DERMATOLOGY, CORTICOSTEROIDS"],["N","G","CLOBETASOL SPR 0.05%","CLOBETASOL PROPIONATE SPRAY 0.05%","1","0","0","0","","","TOPICAL","DERMATOLOGY, CORTICOSTEROIDS"],["N","G","CLOCORTOLONE CRE PIV 0.1%","CLOCORTOLONE PIVALATE CREAM 0.1%","1","0","0","1","120g every 25 days","","TOPICAL","DERMATOLOGY, CORTICOSTEROIDS"],["N","G","DESONIDE CRE 0.05%","DESONIDE CREAM 0.05%","1","0","0","1","120g every 25 days","","TOPICAL","DERMATOLOGY, CORTICOSTEROIDS"],["N","G","DESONIDE LOT 0.05%","DESONIDE LOTION 0.05%","1","0","0","1","120mL every 25 days","","TOPICAL","DERMATOLOGY, CORTICOSTEROIDS"],["N","G","DESONIDE OIN 0.05%","DESONIDE OINT 0.05%","1","0","0","1","120g every 25 days","","TOPICAL","DERMATOLOGY, CORTICOSTEROIDS"],["N","G","DESOXIMETAS CRE 0.05%","DESOXIMETASONE CREAM 0.05%","1","0","0","1","120g every 25 days","","TOPICAL","DERMATOLOGY, CORTICOSTEROIDS"],["N","G","DESOXIMETAS CRE 0.25%","DESOXIMETASONE CREAM 0.25%","1","0","0","1","120g every 25 days","","TOPICAL","DERMATOLOGY, CORTICOSTEROIDS"],["N","G","DESOXIMETAS GEL 0.05%","DESOXIMETASONE GEL 0.05%","1","0","0","1","120g every 25 days","","TOPICAL","DERMATOLOGY, CORTICOSTEROIDS"],["N","G","DESOXIMETAS OIN 0.05%","DESOXIMETASONE OINT 0.05%","1","0","0","1","120g every 25 days","","TOPICAL","DERMATOLOGY, CORTICOSTEROIDS"],["N","G","DESOXIMETAS OIN 0.25%","DESOXIMETASONE OINT 0.25%","1","0","0","1","120g every 25 days","","TOPICAL","DERMATOLOGY, CORTICOSTEROIDS"],["N","G","DIFLORASONE CRE 0.05%","DIFLORASONE DIACETATE CREAM 0.05%","1","0","0","1","120g every 25 days","","TOPICAL","DERMATOLOGY, CORTICOSTEROIDS"],["N","G","DIFLORASONE OIN 0.05%","DIFLORASONE DIACETATE OINT 0.05%","1","0","0","1","120g every 25 days","","TOPICAL","DERMATOLOGY, CORTICOSTEROIDS"],["N","G","FLUOCIN ACET CRE 0.01%","FLUOCINOLONE ACETONIDE CREAM 0.01%","1","0","0","0","","","TOPICAL","DERMATOLOGY, CORTICOSTEROIDS"],["N","G","FLUOCIN ACET CRE 0.025%","FLUOCINOLONE ACETONIDE CREAM 0.025%","1","0","0","1","120g every 25 days","","TOPICAL","DERMATOLOGY, CORTICOSTEROIDS"],["N","G","FLUOCIN ACET OIL 0.01% SC","FLUOCINOLONE ACETONIDE OIL 0.01% (SCALP OIL)","1","0","0","0","","","TOPICAL","DERMATOLOGY, CORTICOSTEROIDS"],["N","G","FLUOCIN ACET OIL BODY","FLUOCINOLONE ACETONIDE OIL 0.01% (BODY OIL)","1","0","0","0","","","TOPICAL","DERMATOLOGY, CORTICOSTEROIDS"],["N","G","FLUOCIN ACET OIN 0.025%","FLUOCINOLONE ACETONIDE OINT 0.025%","1","0","0","1","120g every 25 days","","TOPICAL","DERMATOLOGY, CORTICOSTEROIDS"],["N","G","FLUOCIN ACET SOL 0.01%","FLUOCINOLONE ACETONIDE SOLN 0.01%","1","0","0","0","","","TOPICAL","DERMATOLOGY, CORTICOSTEROIDS"],["N","G","FLUOCINONIDE CRE 0.05%","FLUOCINONIDE CREAM 0.05%","1","0","0","1","120g every 25 days","","TOPICAL","DERMATOLOGY, CORTICOSTEROIDS"],["N","G","FLUOCINONIDE GEL 0.05%","FLUOCINONIDE GEL 0.05%","1","0","0","1","120g every 25 days","","TOPICAL","DERMATOLOGY, CORTICOSTEROIDS"],["N","G","FLUOCINONIDE OIN 0.05%","FLUOCINONIDE OINT 0.05%","1","0","0","1","120g every 25 days","","TOPICAL","DERMATOLOGY, CORTICOSTEROIDS"],["N","G","FLUOCINONIDE SOL 0.05%","FLUOCINONIDE SOLN 0.05%","1","0","0","0","","","TOPICAL","DERMATOLOGY, CORTICOSTEROIDS"],["N","G","FLURANDRENOL CRE 0.05%","FLURANDRENOLIDE CREAM 0.05%","1","0","0","1","120g every 25 days","","TOPICAL","DERMATOLOGY, CORTICOSTEROIDS"],["N","G","FLURANDRENOL LOT 0.05%","FLURANDRENOLIDE LOTION 0.05%","1","0","0","1","120mL every 25 days","","TOPICAL","DERMATOLOGY, CORTICOSTEROIDS"],["N","G","FLURANDRENOL OIN 0.05%","FLURANDRENOLIDE OINT 0.05%","1","0","0","1","120g every 25 days","","TOPICAL","DERMATOLOGY, CORTICOSTEROIDS"],["N","G","FLUTICASONE CRE 0.05%","FLUTICASONE PROPIONATE CREAM 0.05%","1","0","0","1","120g every 25 days","","TOPICAL","DERMATOLOGY, CORTICOSTEROIDS"],["N","G","FLUTICASONE LOT 0.05%","FLUTICASONE PROPIONATE LOTION 0.05%","1","0","0","1","120mL every 25 days","","TOPICAL","DERMATOLOGY, CORTICOSTEROIDS"],["N","G","FLUTICASONE OIN 0.005%","FLUTICASONE PROPIONATE OINT 0.005%","1","0","0","1","120g every 25 days","","TOPICAL","DERMATOLOGY, CORTICOSTEROIDS"],["N","G","HALCINONIDE CRE 0.1%","HALCINONIDE CREAM 0.1%","1","0","0","1","120g every 25 days","","TOPICAL","DERMATOLOGY, CORTICOSTEROIDS"],["N","G","HALOBETASOL CRE 0.05%","HALOBETASOL PROPIONATE CREAM 0.05%","1","0","0","1","120g every 25 days","","TOPICAL","DERMATOLOGY, CORTICOSTEROIDS"],["N","G","HALOBETASOL OIN 0.05%","HALOBETASOL PROPIONATE OINT 0.05%","1","0","0","1","120g every 25 days","","TOPICAL","DERMATOLOGY, CORTICOSTEROIDS"],["N","G","HALOG CRE 0.1%","HALCINONIDE CREAM 0.1%","3","0","0","1","120g every 25 days","","TOPICAL","DERMATOLOGY, CORTICOSTEROIDS"],["N","G","HALOG OIN 0.1%","HALCINONIDE OINT 0.1%","3","0","0","1","120g every 25 days","","TOPICAL","DERMATOLOGY, CORTICOSTEROIDS"],["N","G","HC BUTYRATE CRE 0.1%","HYDROCORTISONE BUTYRATE CREAM 0.1%","1","0","0","1","120g every 25 days","","TOPICAL","DERMATOLOGY, CORTICOSTEROIDS"],["N","G","HC BUTYRATE CRE 0.1%","HYDROCORTISONE BUTYRATE HYDROPHILIC LIPO BASE CREAM 0.1%","1","0","0","1","120g every 25 days","","TOPICAL","DERMATOLOGY, CORTICOSTEROIDS"],["N","G","HC BUTYRATE OIN 0.1%","HYDROCORTISONE BUTYRATE OINT 0.1%","1","0","0","1","120g every 25 days","","TOPICAL","DERMATOLOGY, CORTICOSTEROIDS"],["N","G","HC BUTYRATE SOL 0.1%","HYDROCORTISONE BUTYRATE SOLN 0.1%","1","0","0","0","","","TOPICAL","DERMATOLOGY, CORTICOSTEROIDS"],["N","G","HC VALERATE CRE 0.2%","HYDROCORTISONE VALERATE CREAM 0.2%","1","0","0","1","120g every 25 days","","TOPICAL","DERMATOLOGY, CORTICOSTEROIDS"],["N","G","HC VALERATE OIN 0.2%","HYDROCORTISONE VALERATE OINT 0.2%","1","0","0","1","120g every 25 days","","TOPICAL","DERMATOLOGY, CORTICOSTEROIDS"],["N","G","HYDROCORT CRE 1%","HYDROCORTISONE CREAM 1%","1","0","0","0","","","TOPICAL","DERMATOLOGY, CORTICOSTEROIDS"],["N","G","HYDROCORT CRE 2.5%","HYDROCORTISONE CREAM 2.5%","1","0","0","0","","","TOPICAL","DERMATOLOGY, CORTICOSTEROIDS"],["N","G","HYDROCORT LOT 2.5%","HYDROCORTISONE LOTION 2.5%","1","0","0","0","","","TOPICAL","DERMATOLOGY, CORTICOSTEROIDS"],["N","G","HYDROCORT OIN 1%","HYDROCORTISONE OINT 1%","1","0","0","0","","","TOPICAL","DERMATOLOGY, CORTICOSTEROIDS"],["N","G","HYDROCORT OIN 2.5%","HYDROCORTISONE OINT 2.5%","1","0","0","0","","","TOPICAL","DERMATOLOGY, CORTICOSTEROIDS"],["N","G","LOKARA LOT 0.05%","DESONIDE LOTION 0.05%","1","0","0","1","120mL every 25 days","","TOPICAL","DERMATOLOGY, CORTICOSTEROIDS"],["N","G","MOMETASONE CRE 0.1%","MOMETASONE FUROATE CREAM 0.1%","1","0","0","1","120g every 25 days","","TOPICAL","DERMATOLOGY, CORTICOSTEROIDS"],["N","G","MOMETASONE OIN 0.1%","MOMETASONE FUROATE OINT 0.1%","1","0","0","1","120g every 25 days","","TOPICAL","DERMATOLOGY, CORTICOSTEROIDS"],["N","G","MOMETASONE SOL 0.1%","MOMETASONE FUROATE SOLUTION 0.1% (LOTION)","1","0","0","1","120mL every 25 days","","TOPICAL","DERMATOLOGY, CORTICOSTEROIDS"],["N","G","PREDNICARBAT CRE 0.1%","PREDNICARBATE CREAM 0.1%","1","0","0","1","120g every 25 days","","TOPICAL","DERMATOLOGY, CORTICOSTEROIDS"],["N","G","PREDNICARBAT OIN 0.1%","PREDNICARBATE OINT 0.1%","1","0","0","1","120g every 25 days","","TOPICAL","DERMATOLOGY, CORTICOSTEROIDS"],["N","G","TRIAMCINOLON AER SPRAY","TRIAMCINOLONE ACETONIDE AEROSOL SOLN 0.147 MG/GM","1","0","0","0","","","TOPICAL","DERMATOLOGY, CORTICOSTEROIDS"],["N","G","TRIAMCINOLON CRE 0.025%","TRIAMCINOLONE ACETONIDE CREAM 0.025%","1","0","0","0","","","TOPICAL","DERMATOLOGY, CORTICOSTEROIDS"],["N","G","TRIAMCINOLON CRE 0.1%","TRIAMCINOLONE ACETONIDE CREAM 0.1%","1","0","0","0","","","TOPICAL","DERMATOLOGY, CORTICOSTEROIDS"],["N","G","TRIAMCINOLON CRE 0.5%","TRIAMCINOLONE ACETONIDE CREAM 0.5%","1","0","0","0","","","TOPICAL","DERMATOLOGY, CORTICOSTEROIDS"],["N","G","TRIAMCINOLON LOT 0.025%","TRIAMCINOLONE ACETONIDE LOTION 0.025%","1","0","0","0","","","TOPICAL","DERMATOLOGY, CORTICOSTEROIDS"],["N","G","TRIAMCINOLON LOT 0.1%","TRIAMCINOLONE ACETONIDE LOTION 0.1%","1","0","0","0","","","TOPICAL","DERMATOLOGY, CORTICOSTEROIDS"],["N","G","TRIAMCINOLON OIN 0.025%","TRIAMCINOLONE ACETONIDE OINT 0.025%","1","0","0","0","","","TOPICAL","DERMATOLOGY, CORTICOSTEROIDS"],["N","G","TRIAMCINOLON OIN 0.1%","TRIAMCINOLONE ACETONIDE OINT 0.1%","1","0","0","0","","","TOPICAL","DERMATOLOGY, CORTICOSTEROIDS"],["N","G","TRIAMCINOLON OIN 0.5%","TRIAMCINOLONE ACETONIDE OINT 0.5%","1","0","0","0","","","TOPICAL","DERMATOLOGY, CORTICOSTEROIDS"],["N","G","TRIDERM CRE 0.1%","TRIAMCINOLONE ACETONIDE CREAM 0.1%","1","0","0","0","","","TOPICAL","DERMATOLOGY, CORTICOSTEROIDS"],["N","G","7T LIDO GEL 2%","LIDOCAINE HCL GEL 2%","1","0","0","1","30gm every 25 days","","TOPICAL","DERMATOLOGY, LOCAL ANESTHETICS"],["N","G","LIDO/PRILOCN CRE 2.5-2.5%","LIDOCAINE-PRILOCAINE CREAM 2.5-2.5%","1","0","0","1","30gm every 25 days","","TOPICAL","DERMATOLOGY, LOCAL ANESTHETICS"],["N","G","LIDO/PRILOCN KIT 2.5-2.5%","LIDOCAINE-PRILOCAINE CREAM KIT 2.5-2.5%","1","0","0","0","","","TOPICAL","DERMATOLOGY, LOCAL ANESTHETICS"],["N","G","LIDOCAINE GEL 2%","LIDOCAINE HCL URETHRAL/MUCOSAL GEL PREFILLED SYRINGE 2%","1","0","0","1","30gm every 25 days","","TOPICAL","DERMATOLOGY, LOCAL ANESTHETICS"],["N","G","LIDOCAINE GEL 2% JELLY","LIDOCAINE HCL URETHRAL/MUCOSAL GEL 2%","1","0","0","1","30gm every 25 days","","TOPICAL","DERMATOLOGY, LOCAL ANESTHETICS"],["N","G","LIDOCAINE OIN 5%","LIDOCAINE OINT 5%","1","0","0","1","50gm every 25 days","","TOPICAL","DERMATOLOGY, LOCAL ANESTHETICS"],["N","G","LIDOCAINE PAD 5%","LIDOCAINE PATCH 5%","1","1","0","1","90 patches every 25 days","","TOPICAL","DERMATOLOGY, LOCAL ANESTHETICS"],["N","G","LIDOCAINE SOL 4%","LIDOCAINE HCL SOLN 4%","1","0","0","1","50mL every 25 days","","TOPICAL","DERMATOLOGY, LOCAL ANESTHETICS"],["N","G","PRAMOX GEL 1%","PRAMOXINE HCL GEL 1%","1","0","0","0","","","TOPICAL","DERMATOLOGY, LOCAL ANESTHETICS"],["N","G","SYNERA DIS 70-70MG","LIDOCAINE-TETRACAINE TOPICAL PATCH 70-70 MG","3","0","0","1","2 patches every 25 days","","TOPICAL","DERMATOLOGY, LOCAL ANESTHETICS"],["N","G","ACYCLOVIR OIN 5%","ACYCLOVIR OINT 5%","1","0","0","0","","","TOPICAL","DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE"],["N","G","AMMONIUM LAC CRE 12%","LACTIC ACID (AMMONIUM LACTATE) CREAM 12%","1","0","0","0","","","TOPICAL","DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE"],["N","G","AMMONIUM LAC LOT 12%","LACTIC ACID (AMMONIUM LACTATE) LOTION 12%","1","0","0","0","","","TOPICAL","DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE"],["N","G","CONDYLOX GEL 0.5%","PODOFILOX GEL 0.5%","3","0","0","0","","","TOPICAL","DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE"],["N","G","DENAVIR CRE 1%","PENCICLOVIR CREAM 1%","3","0","0","0","","","TOPICAL","DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE"],["N","G","DICLOFENAC GEL 1%","DICLOFENAC SODIUM GEL 1%","1","0","0","1","500g every 25 days","","TOPICAL","DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE"],["N","G","EUCRISA OIN 2%","CRISABOROLE OINT 2%","2","0","0","0","","","TOPICAL","DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE"],["N","G","LACTIC ACID LOT 10%","LACTIC ACID (AMMONIUM LACTATE) LOTION 10%","1","0","0","0","","","TOPICAL","DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE"],["N","G","PIMECROLIMUS CRE 1%","PIMECROLIMUS CREAM 1%","1","0","0","0","","","TOPICAL","DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE"],["N","G","PODOFILOX SOL 0.5%","PODOFILOX SOLN 0.5%","1","0","0","0","","","TOPICAL","DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE"],["N","G","RECTIV OIN 0.4%","NITROGLYCERIN OINT 0.4%","3","0","0","0","","","TOPICAL","DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE"],["N","G","TACROLIMUS OIN 0.03%","TACROLIMUS OINT 0.03%","1","0","0","0","","SP","TOPICAL","DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE"],["N","G","TACROLIMUS OIN 0.1%","TACROLIMUS OINT 0.1%","1","0","0","0","","SP","TOPICAL","DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE"],["N","G","TARGRETIN GEL 1%","BEXAROTENE GEL 1%","4","1","0","0","","SP","TOPICAL","DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE"],["N","G","VEREGEN OIN 15%","SINECATECHINS OINT 15%","3","0","0","0","","","TOPICAL","DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE"],["N","G","AZELAIC ACID GEL 15%","AZELAIC ACID GEL 15%","1","0","0","0","","","TOPICAL","DERMATOLOGY, ROSACEA"],["N","G","FINACEA AER 15%","AZELAIC ACID FOAM 15%","2","0","0","0","","","TOPICAL","DERMATOLOGY, ROSACEA"],["N","G","METRONIDAZOL CRE 0.75%","METRONIDAZOLE CREAM 0.75%","1","0","0","0","","","TOPICAL","DERMATOLOGY, ROSACEA"],["N","G","METRONIDAZOL GEL 0.75%","METRONIDAZOLE GEL 0.75%","1","0","0","0","","","TOPICAL","DERMATOLOGY, ROSACEA"],["N","G","METRONIDAZOL GEL 1%","METRONIDAZOLE GEL 1%","1","0","0","0","","","TOPICAL","DERMATOLOGY, ROSACEA"],["N","G","METRONIDAZOL LOT 0.75%","METRONIDAZOLE LOTION 0.75%","1","0","0","0","","","TOPICAL","DERMATOLOGY, ROSACEA"],["N","G","MIRVASO GEL 0.33%","BRIMONIDINE TARTRATE GEL 0.33% (BASE EQUIVALENT)","3","0","0","0","","","TOPICAL","DERMATOLOGY, ROSACEA"],["N","G","ROSADAN CRE 0.75%","METRONIDAZOLE CREAM 0.75%","1","0","0","0","","","TOPICAL","DERMATOLOGY, ROSACEA"],["N","G","CROTAN LOT 10%","CROTAMITON LOTION 10%","1","0","0","0","","","TOPICAL","DERMATOLOGY, SCABICIDES AND PEDICULIDES"],["N","G","EURAX CRE 10%","CROTAMITON CREAM 10%","3","0","0","0","","","TOPICAL","DERMATOLOGY, SCABICIDES AND PEDICULIDES"],["N","G","LINDANE SHA 1%","LINDANE SHAMPOO 1%","1","0","0","0","","","TOPICAL","DERMATOLOGY, SCABICIDES AND PEDICULIDES"],["N","G","MALATHION LOT 0.5%","MALATHION LOTION 0.5%","1","0","0","0","","","TOPICAL","DERMATOLOGY, SCABICIDES AND PEDICULIDES"],["N","G","PERMETHRIN CRE 5%","PERMETHRIN CREAM 5%","1","0","0","0","","","TOPICAL","DERMATOLOGY, SCABICIDES AND PEDICULIDES"],["N","G","SKLICE LOT 0.5%","IVERMECTIN LOTION 0.5%","3","0","0","0","","","TOPICAL","DERMATOLOGY, SCABICIDES AND PEDICULIDES"],["N","G","SPINOSAD SUS 0.9%","SPINOSAD SUSP 0.9%","1","0","0","0","","","TOPICAL","DERMATOLOGY, SCABICIDES AND PEDICULIDES"],["N","G","ULESFIA LOT 5%","BENZYL ALCOHOL LOTION 5%","3","0","0","0","","","TOPICAL","DERMATOLOGY, SCABICIDES AND PEDICULIDES"],["N","G","REGRANEX GEL 0.01%","BECAPLERMIN GEL 0.01%","3","1","0","0","","","TOPICAL","DERMATOLOGY, WOUND CARE AGENTS"],["N","G","SANTYL OIN 250/GM","COLLAGENASE OINT 250 UNIT/GM","3","1","0","0","","","TOPICAL","DERMATOLOGY, WOUND CARE AGENTS"],["N","G","SODIUM CHLOR SOL 0.9% IRR","SODIUM CHLORIDE IRRIGATION SOLN 0.9%","1","0","0","0","","","TOPICAL","DERMATOLOGY, WOUND CARE AGENTS"],["N","G","CEVIMELINE CAP 30MG","CEVIMELINE HCL CAP 30 MG","1","0","0","0","","","TOPICAL","MOUTH/THROAT/DENTAL AGENTS"],["N","G","CHLORHEX GLU SOL 0.12%","CHLORHEXIDINE GLUCONATE SOLN 0.12%","1","0","0","0","","","TOPICAL","MOUTH/THROAT/DENTAL AGENTS"],["N","G","CLOTRIMAZOLE TRO 10MG","CLOTRIMAZOLE TROCHE 10 MG","1","0","0","0","","","TOPICAL","MOUTH/THROAT/DENTAL AGENTS"],["N","G","LIDOCAINE SOL 2% VISC","LIDOCAINE HCL VISCOUS SOLN 2%","1","0","0","0","","","TOPICAL","MOUTH/THROAT/DENTAL AGENTS"],["N","G","LIDOCAINE SOL 4%","LIDOCAINE HCL LARYNGOTRACHEAL SOLN 4%","1","0","0","0","","","TOPICAL","MOUTH/THROAT/DENTAL AGENTS"],["N","G","NYSTATIN SUS 100000","NYSTATIN SUSP 100000 UNIT/ML","1","0","0","0","","","TOPICAL","MOUTH/THROAT/DENTAL AGENTS"],["N","G","ORALONE DENT PST 0.1%","TRIAMCINOLONE ACETONIDE DENTAL PASTE 0.1%","1","0","0","0","","","TOPICAL","MOUTH/THROAT/DENTAL AGENTS"],["N","G","ORAVIG TAB 50MG","MICONAZOLE BUCCAL TAB 50 MG (MOUTH-THROAT)","3","0","0","0","","","TOPICAL","MOUTH/THROAT/DENTAL AGENTS"],["N","G","PERIOGARD SOL 0.12%","CHLORHEXIDINE GLUCONATE SOLN 0.12%","1","0","0","0","","","TOPICAL","MOUTH/THROAT/DENTAL AGENTS"],["N","G","PILOCARPINE TAB 5MG","PILOCARPINE HCL TAB 5 MG","1","0","0","0","","","TOPICAL","MOUTH/THROAT/DENTAL AGENTS"],["N","G","PILOCARPINE TAB 7.5MG","PILOCARPINE HCL TAB 7.5 MG","1","0","0","0","","","TOPICAL","MOUTH/THROAT/DENTAL AGENTS"],["N","G","TRIAMCINOLON PST DEN 0.1%","TRIAMCINOLONE ACETONIDE DENTAL PASTE 0.1%","1","0","0","0","","","TOPICAL","MOUTH/THROAT/DENTAL AGENTS"],["N","G","ACE ACD/ALUM SOL 2% OTIC","ACETIC ACID 2% IN ALUMINUM ACETATE OTIC SOLN","1","0","0","0","","","TOPICAL","OTIC"],["N","G","ACETIC ACID SOL 2% OTIC","ACETIC ACID OTIC SOLN 2%","1","0","0","0","","","TOPICAL","OTIC"],["N","G","CIPRO HC SUS OTIC","CIPROFLOXACIN-HYDROCORTISONE OTIC SUSP 0.2-1%","3","0","0","0","","","TOPICAL","OTIC"],["N","G","CIPRODEX SUS 0.3-0.1%","CIPROFLOXACIN-DEXAMETHASONE OTIC SUSP 0.3-0.1%","2","0","0","0","","","TOPICAL","OTIC"],["N","G","COLY-MYCIN S SUS OTIC","NEOMYCIN-COLISTIN-HC-THONZONIUM OTIC SUSP 3.3-3-10-0.5 MG/ML","3","0","0","0","","","TOPICAL","OTIC"],["N","G","FLUOCIN ACET OIL 0.01%","FLUOCINOLONE ACETONIDE (OTIC) OIL 0.01%","1","0","0","0","","","TOPICAL","OTIC"],["N","G","HC/ACET ACID SOL OTIC","HYDROCORTISONE W/ ACETIC ACID OTIC SOLN 1-2%","1","0","0","0","","","TOPICAL","OTIC"],["N","G","NEO/POLY/HC SOL 1% OTIC","NEOMYCIN-POLYMYXIN-HC OTIC SOLN 1%","1","0","0","0","","","TOPICAL","OTIC"],["N","G","NEO/POLY/HC SUS 1% OTIC","NEOMYCIN-POLYMYXIN-HC OTIC SUSP 3.5 MG/ML-10000 UNIT/ML-1%","1","0","0","0","","","TOPICAL","OTIC"],["N","G","OFLOXACIN DRO 0.3%OTIC","OFLOXACIN OTIC SOLN 0.3%","1","0","0","0","","","TOPICAL","OTIC"]]