Miscellaneous
PDL Status Values
Y = preferred
N = non-preferred. Non-preferred drugs listed as N but without clinical drug use criteria are subject to the
Non-Preferred Drugs in Select PDL Classes prior authorization criteria.
New drugs will be listed as N until reviewed by the P&T Committee and are subject to the
New Drug Policy.
V = voluntary non-preferred. Non-preferred mental health drugs are listed as V and prior authorization is not required.
Null (i.e. blank) = indicates the class or specific drug has not been reviewed for PDL placement.
To request a Prior Authorization, please use this form.
| Generic Name | Brand Name | Form | PDL Status |
Current Drug Use Criteria | Carveout ‐ Bill FFS |
New Drug Evaluation & Updates |
|---|---|---|---|---|---|---|
| vit C/E/zinc/lutein/zeaxanthin | OCUVITE EYE HEALTH | TAB CHEW | Y | |||
| dextromethorphan Hbr/quinidine | NUEDEXTA | CAPSULE | N | Pharmacy PA | Jun 05, 2025 | |
| diazoxide choline | VYKAT XR | TAB ER 24H | N | Pharmacy PA | BILL FFS | Aug 07, 2025 |
| etranacogene dezaparvovec-drlb | HEMGENIX | KIT | N | Pharmacy PA | BILL FFS | Oct 05, 2023 |
| etranacogene dezaparvovec-drlb | HEMGENIX | VIAL | N | Pharmacy PA | BILL FFS | Oct 05, 2023 |
| palovarotene | SOHONOS | CAPSULE | N | Pharmacy PA | BILL FFS | Dec 04, 2025 |
| paroxetine mesylate | PAROXETINE MESYLATE | CAPSULE | N | |||
| trofinetide | DAYBUE STIX | POWD PACK | N | Pharmacy PA | BILL FFS | Aug 03, 2023 |
| trofinetide | DAYBUE | SOLUTION | N | Pharmacy PA | BILL FFS | Aug 03, 2023 |
| valoctocogene roxaparvovc-rvox | ROCTAVIAN | VIAL | N | Pharmacy PA | BILL FFS | Oct 05, 2023 |
| zopapogene imadenovec-drba | PAPZIMEOS | VIAL | N | Pharmacy PA | BILL FFS | Dec 04, 2025 |
| AA/prot/arginine/C/zinc/copper | PROTEINEX WC | LIQUID | Pharmacy PA | |||
| acetic acid | ACETIC ACID | IRRIG SOLN | ||||
| acetohydroxamic acid | LITHOSTAT | TABLET | ||||
| acetylcysteine | ACETYLCYSTEINE | VIAL | ||||
| albumin human | FLEXBUMIN | IV SOLN | ||||
| albumin human | BUMINATE | IV SOLN | ||||
| albumin human | ALBUTEIN | IV SOLN | ||||
| albumin human | ALBUMIN (HUMAN) | IV SOLN | ||||
| albumin human | ALBUMINAR-5 | IV SOLN | ||||
| albumin human | ALBUKED-5 | VIAL | ||||
| albumin human | ALBUTEIN | VIAL | ||||
| albumin human | ALBURX | VIAL | ||||
| albumin human | ALBUKED-25 | VIAL | ||||
| albumin human-kjda | ALBUMINEX | VIAL | ||||
| albumin human/sodium chloride | ALBUMIN-SALINE | VIAL | ||||
| aloe vera | ALOE VERA | CAPSULE | ||||
| alpha-1-proteinase inhibitor | ZEMAIRA | VIAL | ||||
| alpha-1-proteinase inhibitor | PROLASTIN C | VIAL | ||||
| alpha-1-proteinase inhibitor | GLASSIA | VIAL | ||||
| alpha-1-proteinase inhibitor | ARALAST NP | VIAL | ||||
| alprostadil | CAVERJECT | AMPUL | ||||
| alprostadil | EDEX | KIT | ||||
| alprostadil | CAVERJECT | KIT | ||||
| alprostadil | CAVERJECT | SYRINGE | ||||
| alprostadil | CAVERJECT | VIAL | ||||
| amino acids/protein hydrolys | PROTEINEX-18 | LIQUID | Pharmacy PA | |||
| anagrelide HCl | ANAGRELIDE HCL | CAPSULE | ||||
| anagrelide HCl | AGRYLIN | CAPSULE | ||||
| anise oil | ANISE OIL | OIL | ||||
| anti-thymocyte globulin,rabbit | THYMOGLOBULIN | VIAL | ||||
| antithrombin III (plasma der) | THROMBATE III | VIAL | ||||
| avanafil | AVANAFIL | TABLET | Pharmacy PA | |||
| azathioprine sodium | AZATHIOPRINE SODIUM | VIAL | ||||
| B3/B6/C/FA/coppr/Mg/Zn/alip ac | NICADAN | TABLET | Pharmacy PA | |||
| B3/B6/folic/zinc/copper/co-Q10 | NICADAN ZX | TABLET | Pharmacy PA | |||
| B3/lmfol/turm/blk pep/garl/hrb | INFLAMEX | CAPSULE | Pharmacy PA | |||
| bacteriostatic sodium chloride | SODIUM CHLORIDE | VIAL | ||||
| balsam peru/castor oil | BALSAM PERU-CASTOR OIL | OINT PACK | ||||
| balsam peru/castor oil | BPCO | OINT. (G) | ||||
| balsam peru/castor oil | BALSAM PERU-CASTOR OIL | OINT. (G) | ||||
| basiliximab | SIMULECT | VIAL | ||||
| belatacept | NULOJIX | VIAL | ||||
| beractant | SURVANTA | VIAL | ||||
| betaine | CYSTADANE | POWDER | ||||
| betaine | BETAINE ANHYDROUS | POWDER | ||||
| bremelanotide acetate | VYLEESI | AUTO INJCT | Feb 06, 2020 | |||
| brensocatib | BRINSUPRI | TABLET | Pharmacy PA | |||
| C/rut/hes/bioflav,cit/Butch br | TROMBONEX | CAPSULE | Pharmacy PA | |||
| C/rut/hesp/bio/dio/Arn/brom/zn | BRUSELIX | TABLET | Pharmacy PA | |||
| calc/D3/magnes/L-mefol/B6/rhub | MENATROL | CAPSULE | Pharmacy PA | |||
| caplacizumab-yhdp | CABLIVI | KIT | ||||
| caplacizumab-yhdp | CABLIVI | VIAL | ||||
| chlorhexidine gluconate | CHLORHEXIDINE GLUCONATE | MOUTHWASH | ||||
| cinacalcet HCl | SENSIPAR | TABLET | ||||
| cinacalcet HCl | CINACALCET HCL | TABLET | ||||
| citric acid/sodium citrate | SODIUM CITRATE-CITRIC ACID | SOLUTION | ||||
| citric acid/sodium citrate | ORAL CITRATE | SOLUTION | ||||
| citric acid/sodium citrate | ORACIT | SOLUTION | ||||
| coagulation factor X | COAGADEX | VIAL | ||||
| collagen, hydrolysate (bovine) | LIQUID COLLAGEN | LIQUID | Pharmacy PA | |||
| concizumab-mtci | ALHEMO PEN | PEN INJCTR | ||||
| cranberry fruit extract | CRANBERRY FRUIT | CAPSULE | ||||
| cromolyn sodium | GASTROCROM | ORAL CONC | ||||
| cromolyn sodium | CROMOLYN SODIUM | ORAL CONC | ||||
| cyclosporine | SANDIMMUNE | AMPUL | ||||
| D3/FA/aloe/cascara/inulin/elm | SYNVERA | TABLET | Pharmacy PA | |||
| D3/FA/aloe/cascara/inulin/elm | METAVEX | TABLET | Pharmacy PA | |||
| deoxycholic acid | KYBELLA | VIAL | ||||
| deuruxolitinib phosphate | LEQSELVI | TABLET | Pharmacy PA | |||
| dextran 40 in 0.9 % NaCl | LMD 10% WITH 0.9% SOD CHLORIDE | IV SOLN | ||||
| dextran 40 in 0.9 % NaCl | GENTRAN 40 IN NORMAL SALINE | IV SOLN | ||||
| dextran 40 in dextrose 5 % | LMD 10% WITH 5% DEXTROSE | IV SOLN | ||||
| dextran 40 in dextrose 5 % | GENTRAN 40 IN DEXTROSE 5% | IV SOLN | ||||
| dextran 75 in 0.9 % NaCl | GENTRAN 75 IN NORMAL SALINE | IV SOLN | ||||
| dextran 75 in 0.9 % NaCl | DEXTRAN 75 IN NORMAL SALINE | IV SOLN | ||||
| dextran 75/inverted sugar 10 % | GENTRAN 75 IN TRAVERT 10% | IV SOLN | ||||
| dichlorphenamide | KEVEYIS | TABLET | Pharmacy PA | Mar 22, 2018 | ||
| dichlorphenamide | DICHLORPHENAMIDE | TABLET | Pharmacy PA | Mar 22, 2018 | ||
| dichlorphenamide | ORMALVI | TABLET | Pharmacy PA | Mar 22, 2018 | ||
| diluent 1,live virus vac(swfi) | DILUENT-MERCK LIVE VIRUS VACC | SYRINGE | ||||
| diluent 1,live virus vac(swfi) | DILUENT-MERCK LIVE VIRUS VACC | VIAL | ||||
| diluent for artesunate | DILUENT FOR ARTESUNATE | VIAL | ||||
| diluent for coag factor Vlla | DILUENT FOR NOVOSEVEN RT | SYRINGE | ||||
| diluent for decitabine | DILUENT FOR DECITABINE | VIAL | ||||
| diluent for epoprostenol(glyc) | PH 12 DILUENT FOR FLOLAN | VIAL | ||||
| diluent for ixabepilone | DILUENT FOR IXEMPRA | VIAL | ||||
| diluent for leuprolide | DILUENT FOR ELIGARD | SYRINGE | ||||
| diluent for melphalan | DILUENT FOR MELPHALAN | VIAL | ||||
| diluent for mitomycin | STERILE HYDROGEL FOR ZUSDURI | VIAL | ||||
| diluent for mitomycin | STERILE HYDROGEL FOR JELMYTO | VIAL | ||||
| diluent for rasburicase (pol) | DILUENT FOR ELITEK | AMPUL | ||||
| diluent for treprostinil (gly) | DILUENT FOR TREPROSTINIL | VIAL | ||||
| diluent for treprostinil (gly) | DILUENT FOR REMODULIN | VIAL | ||||
| diluent, cabazitaxel (ethanol) | DILUENT FOR JEVTANA | VIAL | ||||
| diluent, carmustine (ethanol) | DILUENT FOR BICNU | VIAL | ||||
| diluent, carmustine (ethanol) | DILUENT FOR CARMUSTINE | VIAL | ||||
| diluent, dexrazoxane (sod lac) | DEXRAZOXANE DILUENT-SODIUM LAC | VIAL | ||||
| diluent, glucagon (glycerin) | DILUENT FOR GLUCAGON EMERG KIT | SYRINGE | ||||
| diluent, insulin aspart | DILUTING MEDIUM FOR NOVOLOG | VIAL | ||||
| diluent, insulin aspart | DILUTING MEDIUM FOR KIRSTY VL | VIAL | ||||
| diluent, romidepsin (prop gly) | DILUENT FOR ROMIDEPSIN | VIAL | ||||
| diluent, romidepsin (prop gly) | DILUENT FOR ISTODAX | VIAL | ||||
| diluent,caplacizumab-yhdp | STERILE WATER DILUENT-CABLIVI | SYRINGE | ||||
| diluent,insulin lispro,regular | STERILE DILUENT FOR HUMALOG | VIAL | ||||
| diluent,naltrexone microsphere | DILUENT FOR VIVITROL | VIAL | ||||
| diluent,omeprazole(sod bicarb) | DILUENT FOR KONVOMEP | SOLUTION | ||||
| diluent,temsirolimus (ethanol) | DILUENT FOR TORISEL | VIAL | ||||
| diluent,temsirolimus (ethanol) | DILUENT FOR TEMSIROLIMUS | VIAL | ||||
| diluent,voretigene neparvovec | DILUENT-VORETIGENE NEPARVOVEC | VIAL | ||||
| dimethyl sulfoxide | CRYOSERV | VIAL | ||||
| dong quai | DONG QUAI | CAPSULE | ||||
| doxecitine/doxribtimine | KYGEVVI | POWD PACK | BILL FFS | |||
| elamipretide HCl | FORZINITY | VIAL | Pharmacy PA | BILL FFS | Feb 05, 2026 | |
| emicizumab-kxwh | HEMLIBRA | VIAL | ||||
| etelcalcetide hydrochloride | PARSABIV | VIAL | ||||
| evening primrose oil | EVENING PRIMROSE | CAPSULE | ||||
| factor IX | ALPHANINE SD | VIAL | ||||
| factor IX complx no.4,3-factor | KONYNE 80 | VIAL | ||||
| factor IX complx no.4,3-factor | PROFILNINE | VIAL | ||||
| factor IX human rec,pegylated | REBINYN | VIAL | ||||
| factor IX human recomb,Thr 148 | IXINITY | VIAL | ||||
| factor IX human recombinant | RIXUBIS | VIAL | ||||
| factor IX human recombinant | BENEFIX | VIAL | ||||
| factor IX rec, Fc fusion protn | ALPROLIX | VIAL | ||||
| factor IX recom,albumin fusion | IDELVION | VIAL | ||||
| factor XIII | CORIFACT | VIAL | ||||
| factor XIII A-subunit,recomb | TRETTEN | VIAL | ||||
| fat emul/soy/mct/oliv/fish oil | SMOFLIPID | EMULSION | ||||
| fat emulsion/olive,soybean oil | CLINOLIPID | EMULSION | ||||
| fat emulsions | TRAVAMULSION | EMULSION | ||||
| fat emulsions | NUTRILIPID | EMULSION | ||||
| fat emulsions | LIPOSYN III | EMULSION | ||||
| fat emulsions | LIPOSYN II | EMULSION | ||||
| fat emulsions | INTRALIPID | EMULSION | ||||
| fatty acid6/fish oil/glycerin | OMEGAVEN | EMULSION | ||||
| fidanacogene elaparvovec-dzkt | BEQVEZ | KIT | ||||
| fidanacogene elaparvovec-dzkt | BEQVEZ | VIAL | ||||
| finasteride | FINASTERIDE | TABLET | ||||
| finasteride | PROPECIA | TABLET | ||||
| fitusiran sodium | QFITLIA PEN | PEN INJCTR | ||||
| fitusiran sodium | QFITLIA | VIAL | ||||
| flumazenil | FLUMAZENIL | VIAL | ||||
| fluoride (sodium) | SODIUM FLUORIDE 5000 PLUS | CREAM (G) | ||||
| fluoride (sodium) | DENTA 5000 PLUS | CREAM (G) | ||||
| fluoride (sodium) | SODIUM FLUORIDE | DROPS | ||||
| fluoride (sodium) | DENTAGEL | GEL (GRAM) | ||||
| fluoride (sodium) | SODIUM FLUORIDE | GEL (GRAM) | ||||
| fluoride (sodium) | SODIUM FLUORIDE 5000 DRY MOUTH | PASTE (ML) | ||||
| fluoride (sodium) | SODIUM FLUORIDE | PASTE (ML) | ||||
| fluoride (sodium) | SODIUM FLUORIDE | SOLUTION | ||||
| fluoride (sodium) | FLUORIDE | TAB CHEW | ||||
| fluoride (sodium) | SODIUM FLUORIDE | TAB CHEW | ||||
| folic acid/inositol | PREGNITUDE | POWD PACK | Pharmacy PA | |||
| garlic | GARLIC | CAPSULE | ||||
| garlic | GARLIC | TABLET | ||||
| garlic | GARLIN | TABLET | ||||
| garlic | GARLIC ONE-A-DAY | TABLET | ||||
| ginger root | GINGER ROOT | CAPSULE | ||||
| ginseng | GINSENG | CAPSULE | ||||
| goldenseal root | GOLDEN SEAL | CAPSULE | ||||
| grape seed extract | GRAPE SEED EXTRACT | CAPSULE | ||||
| green tea leaf extract | CARDIO TEA | CAPSULE | ||||
| hemin | PANHEMATIN | VIAL | ||||
| hetastarch in 0.9 % NaCl | HETASTARCH-0.9% NACL | PLAST. BAG | ||||
| hetastarch/electrolyt,lactated | HEXTEND LACTATED ELECTROLYTE | PLAST. BAG | ||||
| hum prothrombin cplx, 4-factor | KCENTRA | VIAL | ||||
| human prothrombin complex-lans | BALFAXAR | VIAL | ||||
| hydrocortisone acetate | HYDROCORTISONE ACETATE | SUPP.RECT | ||||
| hydrocortisone acetate | ANUDIL HC | SUPP.RECT | ||||
| isopropyl alcohol | ISOPROPYL ALCOHOL | SOLUTION | ||||
| isopropyl alcohol | DY-O-DERM | SOLUTION | ||||
| isopropyl alcohol | ISOPROPYL RUBBING ALCOHOL | SOLUTION | ||||
| kava | KAVA KAVA | CAPSULE | ||||
| kit prep Tc-99m/exametazime | CERETEC | KIT | ||||
| L. acidophilus/B. coagulans | ACIDOPHILUS-BACILLUS COAGULANS | TABLET | ||||
| L. acidophilus/Bifid. animalis | DERMACINRX LACTEROL | CAPSULE | ||||
| L. acidophilus/Bifid. animalis | LUMIVA | CAPSULE | ||||
| L. acidophilus/Bifid. animalis | LACTOVIVE | CAPSULE | ||||
| L. acidophilus/Bifid. animalis | DERMACINRX PROMEROL | CAPSULE | ||||
| L. acidophilus/Bifid. animalis | DERMACINRX PROBITROL | CAPSULE | ||||
| L. acidophilus/Bifid. animalis | DERMACINRX PROBITRAN | CAPSULE | ||||
| L. acidophilus/Bifid. animalis | DERMACINRX PROBINATE | CAPSULE | ||||
| L. acidophilus/Bifid. animalis | NEXIVA | CAPSULE | ||||
| L. acidophilus/Bifid. animalis | BIOSTORA | CAPSULE | ||||
| L. acidophilus/Bifid. animalis | BIOCORE RESTORE | CAPSULE | ||||
| L. acidophilus/Bifid. animalis | BIOCORE IMMUNE PLUS | CAPSULE | ||||
| L. acidophilus/Bifid. animalis | BIOCORE DAILY | CAPSULE | ||||
| L. acidophilus/Bifid. animalis | DERMACINRX PROBISOL | CAPSULE | ||||
| L. acidophilus/Bifid. animalis | MICROBALANCE | CAPSULE | ||||
| L. acidophilus/Bifid. animalis | MICROFLOR 33 | CAPSULE | ||||
| L. acidophilus/Bifid. animalis | WELLPRO-31 | CAPSULE | ||||
| L. acidophilus/Bifid. animalis | SUREBIOTIC | CAPSULE | ||||
| L. acidophilus/Bifid. animalis | RELIBIOTIC | CAPSULE | ||||
| L. acidophilus/Bifid. animalis | PRORIVA | CAPSULE | ||||
| L. acidophilus/Bifid. animalis | NOVORA | CAPSULE | ||||
| L. acidophilus/Bifid. animalis | DIALYVITE CHEWABLE PROBIOTIC | TAB CHEW | ||||
| L. acidophilus/L.bulgaricus | FLORANEX | GRAN PACK | ||||
| L. acidophilus/L.bulgaricus | FLORANEX | TABLET | ||||
| L. acidophilus/L.bulgaricus | LACTOBACILLUS | TABLET | ||||
| L. acidophilus/L.bulgaricus | MICROVERA | TABLET | ||||
| L. acidophilus/pectin, citrus | ACIDOPHILUS-PECTIN | TABLET | ||||
| L.acid,casei/B.animal/S.thermo | RISAQUAD-2 | CAPSULE | ||||
| L.acid,para/B.bifidum/S.therm | RISAQUAD | CAPSULE | ||||
| L.acid,parac,plant/B.anim/FOS | PROBENTRA | CAPSULE DR | ||||
| L.acid,parac,plant/B.anim/FOS | BIONARA ULTRA | CAPSULE DR | ||||
| L.acidop,ferm,plant,reut,rhamn | MICROVARA | CAPSULE DR | ||||
| L.acidoph/L.bulg/B.bif/S.therm | PROBIOTIC ACIDOPHILUS | TABLET | ||||
| L.acidoph/L.bulg/B.bif/S.therm | RISA-BID | TABLET | ||||
| Lactobacil 2/Bifido 1/S.thermo | VSL#3 DS | PACKET | ||||
| Lactobacillus acidophilus | ACIDOPHILUS LACTOBACILLI | CAPSULE | ||||
| Lactobacillus acidophilus | DERMACINRX BACILLEX | CAPSULE | ||||
| Lactobacillus acidophilus | GUTSTOR | CAPSULE | ||||
| Lactobacillus acidophilus | MICROWELL | CAPSULE | ||||
| Lactobacillus acidophilus | MOVYRA | CAPSULE | ||||
| Lactobacillus acidophilus | SYMBIARA | CAPSULE | ||||
| Lactobacillus acidophilus/pect | ACIDOPHILUS-PECTIN | CAPSULE | ||||
| Lactobacillus casei/folic acid | RESTORA RX | CAPSULE | ||||
| Lactobacillus combo no.5 | PROVELLA | TABLET DR | ||||
| Lactobacillus plantarum | PROBIONYX | CAPSULE | ||||
| Lactobacillus plantarum | FLORESTA BOWEL SUPPORT PROBIO | CAPSULE | ||||
| Lactobacillus plantarum | PAXOTIN | CAPSULE | ||||
| Lactobacillus plantarum | MICROBIOTA | CAPSULE | ||||
| Lactobacillus plantarum | BOLSITOL | CAPSULE | ||||
| laronidase | ALDURAZYME | VIAL | ||||
| levocarnitine | CARNITOR SF | SOLUTION | ||||
| levocarnitine | LEVOCARNITINE | SOLUTION | Pharmacy PA | |||
| levocarnitine | LEVOCARNITINE SF | SOLUTION | ||||
| levocarnitine | CARNITOR | TABLET | ||||
| levocarnitine | LEVOCARNITINE | TABLET | Pharmacy PA | |||
| levocarnitine | CARNITOR | VIAL | ||||
| levocarnitine | LEVOCARNITINE | VIAL | ||||
| levocarnitine (with sugar) | CARNITOR | SOLUTION | ||||
| levocarnitine (with sugar) | LEVOCARNITINE | SOLUTION | ||||
| licorice root | LICORICE ROOT | CAPSULE | ||||
| lipase/protease/amylase (pork) | TRI-PASE 16 | TABLET | Pharmacy PA | |||
| lipase/protease/amylase (pork) | TRI-PASE 8 | TABLET | Pharmacy PA | |||
| Lu-177 vipivotide tetraxetan | PLUVICTO | VIAL | ||||
| lunsotogene parvec-cwha | OTARMENI | VIAL | ||||
| lutein/zeaxanthin | OCUVITE LUTEIN 25 | CAPSULE | ||||
| lutein/zeaxanthin | OCUVITE BLUE LIGHT | CAPSULE | ||||
| lymphocyte IG,antithymocyt,equ | ATGAM | AMPUL | ||||
| mannitol/sorbitol solution | SORBITOL-MANNITOL | IRRIG SOLN | ||||
| marstacimab-hncq | HYMPAVZI PEN | PEN INJCTR | ||||
| megestrol acetate | MEGESTROL ACETATE | ORAL SUSP | ||||
| mifepristone | MIFEPREX | TABLET | ||||
| mifepristone | MIFEPRISTONE | TABLET | ||||
| milnacipran HCl | MILNACIPRAN HCL | TAB DS PK | Pharmacy PA | |||
| milnacipran HCl | SAVELLA | TAB DS PK | Pharmacy PA | |||
| milnacipran HCl | MILNACIPRAN HCL | TABLET | Pharmacy PA | |||
| milnacipran HCl | SAVELLA | TABLET | Pharmacy PA | |||
| mv-mins/folic acid/guarana/caf | ONE DAILY | TABLET | Pharmacy PA | |||
| mycophenolate mofetil HCl | MYCOPHENOLATE MOFETIL | VIAL | ||||
| mycophenolate mofetil HCl | CELLCEPT | VIAL | ||||
| neomycin sulf/polymyxin B sulf | NEOMYCIN-POLYMYXIN B | AMPUL | ||||
| neomycin sulf/polymyxin B sulf | NEOMYCIN-POLYMYXIN B | VIAL | ||||
| niacin1/folic/B12/iron/zinc/Cr | DERMANIC | TAB IR DR | Pharmacy PA | |||
| nitisinone | ORFADIN | CAPSULE | ||||
| nitisinone | NITISINONE | CAPSULE | ||||
| nitisinone | ORFADIN | ORAL SUSP | ||||
| nitisinone | NITYR | TABLET | ||||
| nitisinone | HARLIKU | TABLET | ||||
| nitroglycerin | RECTIV | OINT. (G) | Jun 28, 2012 | |||
| nitroglycerin | NITROGLYCERIN | OINT. (G) | ||||
| omega-3/dha/epa/vit E | SYSTANE VITAMIN | CAPSULE | Pharmacy PA | |||
| ospemifene | OSPHENA | TABLET | Pharmacy PA | |||
| Panax ginseng root | KOREAN GINSENG | CAPSULE | ||||
| pegvisomant | SOMAVERT | VIAL | ||||
| pegzilarginase-nbln | LOARGYS | VIAL | BILL FFS | |||
| pentastarch/0.9 % sod chloride | PENTASPAN | INFUS. BTL | ||||
| pine bark ext (pycnogenols) | PYCNOGENOL | TABLET | Pharmacy PA | |||
| plasma human, blood group A | OCTAPLAS | PLAST. BAG | ||||
| plasma human, blood group AB | OCTAPLAS | PLAST. BAG | ||||
| plasma human, blood group B | OCTAPLAS | PLAST. BAG | ||||
| plasma human, blood group O | OCTAPLAS | PLAST. BAG | ||||
| poractant alfa | CUROSURF | VIAL | ||||
| potassium citrate | UROCIT-K | TABLET ER | ||||
| potassium citrate | POTASSIUM CITRATE ER | TABLET ER | ||||
| potassium citrate/citric acid | POTASSIUM CITRATE-CITRIC ACID | SOLUTION | ||||
| protein C, human | CEPROTIN | VIAL | ||||
| radium-223 dichloride | XOFIGO | VIAL | ||||
| red yeast rice | RED YEAST RICE | CAPSULE | ||||
| resmetirom | REZDIFFRA | TABLET | Pharmacy PA | Aug 01, 2024 | ||
| rilonacept | ARCALYST | VIAL | ||||
| Ringer's solution | TIS-U-SOL | IRRIG SOLN | ||||
| Ringer's solution | RINGERS IRRIGATION | IRRIG SOLN | ||||
| Ringer's solution,lactated | LACTATED RINGERS | IRRIG SOLN | ||||
| ritlecitinib tosylate | LITFULO | CAPSULE | Pharmacy PA | |||
| saccharin | DILUENT | ORAL SUSP | ||||
| Saccharomyces boulardii | SACCHAROMYCES BOULARDII | CAPSULE | ||||
| shark cartilage | SHARK FIN CARTILAGE | CAPSULE | Pharmacy PA | |||
| shark cartilage | SHARK CARTILAGE | CAPSULE | Pharmacy PA | |||
| sibeprenlimab-szsi | VOYXACT | SYRINGE | ||||
| Siberian ginseng root | SIBERIAN GINSENG | CAPSULE | ||||
| silver/povidone-iodin/alginate | RAYASORE KIT | KIT | ||||
| simethicone | PHAZYME | CAPSULE | ||||
| simethicone | GAS RELIEF | CAPSULE | ||||
| simethicone | SIMETHICONE | CAPSULE | ||||
| simethicone | ANTI-GAS | CAPSULE | ||||
| simethicone | INFANTS' SIMETHICONE | DROPS SUSP | ||||
| simethicone | INFANTS' GAS RELIEF | DROPS SUSP | ||||
| simethicone | INFANT'S GAS RELIEF | DROPS SUSP | ||||
| simethicone | INFANT GAS RELIEF | DROPS SUSP | ||||
| simethicone | COLIC | DROPS SUSP | ||||
| simethicone | SIMETHICONE | TAB CHEW | ||||
| simethicone | GAS RELIEF | TAB CHEW | ||||
| sod,pot chlor/mag/sod,pot phos | TIS-U-SOL PENTALYTE | IRRIG SOLN | ||||
| sod/pot/K cit/sod cit/cit acid | TRICITRATES | SOLUTION | ||||
| sod/pot/K cit/sod cit/cit acid | POTASS CIT-SOD CIT-CITRIC ACID | SOLUTION | ||||
| sodium benzoate/sod phenylacet | SODIUM PHENYLACET-SOD BENZOATE | VIAL | ||||
| sodium fluoride/potassium nit | DENTA 5000 PLUS SENSITIVE | PASTE (ML) | ||||
| sodium fluoride/potassium nit | SODIUM FLUORIDE-POTASSIUM NITR | PASTE (ML) | ||||
| sodium fluoride/potassium nit | SODIUM FLUORIDE ENAMEL PROTECT | PASTE (ML) | ||||
| sodium fluoride/potassium nit | SODIUM FLUORIDE SENSITIVE | PASTE (ML) | ||||
| sorbitol solution | SORBITOL | IRRIG SOLN | ||||
| sugammadex sodium | BRIDION | VIAL | ||||
| tacrolimus | PROGRAF | AMPUL | ||||
| taurolidine in heparin sodium | DEFENCATH | VIAL | ||||
| teduglutide | GATTEX | KIT | ||||
| tiopronin | TIOPRONIN | TABLET | ||||
| tiopronin | THIOLA | TABLET | ||||
| tiopronin | THIOLA EC | TABLET DR | ||||
| tiopronin | VENXXIVA | TABLET DR | ||||
| tiopronin | TIOPRONIN | TABLET DR | ||||
| triamcinolone acetonide | TRIAMCINOLONE ACETONIDE | PASTE (G) | ||||
| tryptophan/tyrosine/blueberry | BLUES AWAY POSTPARTUM SUPPORT | LIQUID SEQ | Pharmacy PA | |||
| ubidecarenone | COENZYME Q-10 | CAPSULE | Pharmacy PA | |||
| ubidecarenone | COENZYME Q10 | CAPSULE | Pharmacy PA | |||
| ubidecarenone | ULTRA COQ10 | CAPSULE | Pharmacy PA | |||
| ubidecarenone | CO Q-10 | CAPSULE | Pharmacy PA | |||
| valerian root | VALERIAN ROOT | CAPSULE | ||||
| vardenafil HCl | VARDENAFIL HCL | TAB RAPDIS | Pharmacy PA | |||
| vardenafil HCl | VARDENAFIL HCL | TABLET | Pharmacy PA | |||
| venom-wasp | VENOMIL MAINTENANCE | VIAL | ||||
| venom-wasp | ALBAY | VIAL | ||||
| venom-wasp protein | VENOMIL INDIVIDUAL DIAGNOSTIC | VIAL | ||||
| vit C/dios/rut/bioflav/butc br | TROMBONEX-D | CAPSULE | Pharmacy PA | |||
| vit C/E/Zn/coppr/lutein/zeaxan | PRESERVISION AREDS 2 | CAPSULE | ||||
| vit C/E/Zn/coppr/lutein/zeaxan | OCUVITE LUTEIN-ZEAXANTHIN | CAPSULE | ||||
| vit C/E/Zn/coppr/lutein/zeaxan | PRESERVISION AREDS 2 | TAB CHEW | ||||
| vit D3/lutein/zeaxant/turmeric | BLINK NUTRITEARS | CAPSULE | Pharmacy PA | |||
| von Willebrand factor | VONVENDI | VIAL | ||||
| water for inj.,bacteriostatic | BACTERIOSTATIC WATER-OGIVRI | VIAL | ||||
| water for inj.,bacteriostatic | BACTERIOSTATIC WATER-HERZUMA | VIAL | ||||
| water for inj.,bacteriostatic | BACTERIOSTATIC WATER-KANJINTI | VIAL | ||||
| water for inj.,bacteriostatic | WATER | VIAL | ||||
| water for inj.,bacteriostatic | BACTERIOSTATIC WATER-TRAZIMERA | VIAL | ||||
| water for inj.,bacteriostatic | BACTERIOSTATIC WATER-OMNITROPE | VIAL | ||||
| water for injection,sterile | WATER | IV SOLN | ||||
| water for injection,sterile | STERILE WATER DILUNT-WINREVAIR | SYRINGE | ||||
| water for injection,sterile | STERILE WATER DILUENT-ABRYSVO | SYRINGE | ||||
| water for injection,sterile | WATER | SYRINGE | ||||
| water for injection,sterile | STERILE WATER FOR ACTIVASE | VIAL | ||||
| water for injection,sterile | STERILE WATER FOR ZEMAIRA | VIAL | ||||
| water for injection,sterile | STERILE WATER FOR TRETTEN | VIAL | ||||
| water for injection,sterile | STERILE WATER FOR TNKASE | VIAL | ||||
| water for injection,sterile | STERILE WATER FOR PROLASTIN-C | VIAL | ||||
| water for injection,sterile | STERILE WATER FOR KCENTRA | VIAL | ||||
| water for injection,sterile | STERILE WATER FOR BERINERT | VIAL | ||||
| water for injection,sterile | STERILE WATER (GRIFOLS FACTOR) | VIAL | ||||
| water for injection,sterile | STERILE WATER FOR HUMATE-P | VIAL | ||||
| water for injection,sterile | WATER | VIAL | ||||
| yohimbe bark | YOHIMBE | TABLET |