NDC GPI ILLNESS DRUG LABEL PK 85185853015

Transcription

NDC
85185853015
85185852010
85185852030
85400462010
00025152031
85625257920
00025152531
85625258030
85472243010
85553232002
85553232460
85553232410
77131313980
85585284012
85585284060
85585285015
85585286001
85585286012
85585282020
85585283010
85585283050
85869216510
85423274010
85515284809
85515284810
85515285009
85515285010
85553295020
85738116007
77131300253
77131300254
77131300256
77131300257
77131306003
77131306006
77131305452
GPI
66100004000130
66100004000120
66100004000120
99406010000305
66100525000120
66100525000120
66100525000130
66100525000130
66100007300820
66109904200330
66109904200440
66109904200440
66100007100330
66100007100805
66100007100805
66100007102005
66100007101810
66100007101810
66100007100315
66100007100330
66100007100330
66100007100330
66100007100330
66100007100315
66100007100315
66100007100330
66100007100330
66100007101805
66100007000430
66100007000610
66100007000610
66100007000620
66100007000620
66100007000420
66100007000420
66100007000415
Release Date March 1, 2012
Rev. 75
ILLNESS
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
DRUG
ACEMETACIN
ACEMETACIN
ACEMETACIN
AZATHIOPRINE
CELECOXIB
CELECOXIB
CELECOXIB
CELECOXIB
DICLOFENAC POTASSIUM
DICLOFENAC + VIT. B1, B6, B12
DICLOFENAC SODIUM
DICLOFENAC SODIUM
DICLOFENAC SODIUM
DICLOFENAC SODIUM
DICLOFENAC SODIUM
DICLOFENAC SODIUM
DICLOFENAC SODIUM
DICLOFENAC SODIUM
NATIONAL HEALTH FUND
INDIVIDUAL BENEFITS
LABEL
RANTUDIL RET. TAB 90mg
RANTUDIL TAB 60mg
RANTUDIL TAB 60mg
IMURAN TAB 50mg
CELEBREX CAP 100mg
CELEBREX CAP 100mg
CELEBREX CAP 200mg
CELEBREX CAP 200mg
DICLOFENAC-LAS DISP.TAB 50 mg
DOLO-NEUROBION N TAB 50mg/50mg/50mg/1mg
DOLO-NEUROBION XR TAB 100mg/100mg/100mg/1mg
DOLO-NEUROBION XR TAB 100mg/100mg/100mg/1mg
APO-DICLO TAB RAPIDE 50mg
CATAFLAM DISP. TAB 46.5mg
CATAFLAM DISP. TAB 46.5mg
CATAFLAM DROPS
CATAFLAM SUS 9mg/5ml
CATAFLAM SUS 9mg/5ml
CATAFLAM TAB 25mg
CATAFLAM TAB 50mg
CATAFLAM TAB 50mg
DICLO- K 50mg TABS
DICLOFENAC-H2K TAB 50 mg
DICLOFENAC-P TAB 25mg
FLOGOZAN DROPS 1.5%
ACTERIC TAB 150mg ER
APO-DICLO EC TAB 25mg
APO-DICLO TAB SR 100mg
PK
30
10
30
100
100
20
100
30
100
120
60
10
100
12
60
15ml
1ml
120ml
20
10
50
100
100
100
100
100
100
20ml
7
100
500
100
500
100
250
500
PRSNTN
SUBSIDY
TAB/CAP
$67.45
$44.97
$44.97
$63.72
$39.52
$39.52
$79.04
$79.04
$13.99
$23.32
$55.63
$55.63
$13.99
$12.97
$12.97
$510.80
$4.09
$490.36
$7.01
$13.99
$13.99
$13.99
$13.99
$7.01
$7.01
$13.99
$13.99
$680.90
$41.99
$7.01
$7.01
$13.99
$13.99
$27.97
$27.97
$20.99
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
LIQ
LIQ
LIQ
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
LIQ
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
Page 1 of 39
85140302010
85335284010
85335284009
85335282010
85335283010
85335283020
85335283011
85566212515
85423212110
85423207010
85472243510
85515287810
85515288009
85515288010
85515288040
85515289010
85515289040
85852217010
85595345010
85595344010
85585935010
85585934020
85585934010
85585932010
85585933010
85894252004
85894252001
85894252204
85894252201
85560163407
85560163414
85560163007
85560163014
85560163207
85560163214
85640153010
85640152010
66100007000415
66100007000420
66100007000420
66100007000610
66100007000620
66100007000620
66100007000620
66100007021805
66100007000415
66100007000420
66100007000420
66100007000610
66100007000620
66100007000620
66100007000620
66100007000415
66100007000415
66100007000620
66100007000320
66100007000315
66100007000420
66100007000415
66100007000415
66100007000610
66100007000620
66290030006420
66290030006420
66290030002025
66290030002025
66100535000140
66100535000140
66100535000120
66100535000120
66100535000130
66100535000130
66100012000315
66100012000310
Rev. 75
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
DICLOFENAC SODIUM
DICLOFENAC SODIUM
DICLOFENAC SODIUM
DICLOFENAC SODIUM
DICLOFENAC SODIUM
DICLOFENAC SODIUM
DICLOFENAC SODIUM
DICLOFENAC SODIUM
DICLOFENAC SODIUM
DICLOFENAC SODIUM
DICLOFENAC SODIUM
DICLOFENAC SODIUM
DICLOFENAC SODIUM
DICLOFENAC SODIUM
DICLOFENAC SODIUM
DICLOFENAC SODIUM
DICLOFENAC SODIUM
DICLOFENAC SODIUM
DICLOFENAC SODIUM
DICLOFENAC SODIUM
DICLOFENAC SODIUM
DICLOFENAC SODIUM
DICLOFENAC SODIUM
DICLOFENAC SODIUM
DICLOFENAC SODIUM
ETANERCEPT
ETANERCEPT
ETANERCEPT
ETANERCEPT
ETORICOXIB
ETORICOXIB
ETORICOXIB
ETORICOXIB
ETORICOXIB
ETORICOXIB
FLURBIPROFEN
FLURBIPROFEN
INDIVIDUAL BENEFITS
DICLO DENK RETD TAB 100mg
DICLO DENK RETD TAB 100mg
DICLO DENK TAB 25mg
DICLO DENK TAB 50 mg
DICLOFENAC- MK DROPS 1.5%
DICLOFENAC-H2K SR TAB 75 mg
DICLOFENAC-H2K TAB 100 mg
DICLOFENAC-LAS SR TAB 100mg
DICLOFENAC-S EC- MAC TAB 25mg
DICLOFENAC-S EC- MAC TAB 50mg ( Bottle)
DICLOFENAC-S EC- MAC TAB 50mg (Box)
DICLOFENAC-S EC- MAC TAB 50mg
DICLOFENAC-S EC- MAC SR TAB 75mg
DICLOFENAC-S EC- MAC SR TAB 75mg
DICLOMAX-50 EC TAB
NOVO-DIFENAC TAB 100mg
NOVO-DIFENAC TAB 75mg
VOLTAREN RETARD TAB 100mg
VOLTAREN SR TAB 75mg
VOLTAREN SR TAB 75mg
VOLTAREN TAB 25mg EC
VOLTAREN TAB 50mg EC
ENBREL INJ. 25mg KIT
ENBREL INJ. 25mg -Single Vial
ENBREL INJ. 50mg -Pack of 4 Prefilled Syringes
ENBREL INJ. 50mg -Single Syringe
ARCOXIA TAB 120mg
ARCOXIA TAB 120mg
ARCOXIA TAB 60mg
ARCOXIA TAB 60mg
ARCOXIA TAB 90mg
ARCOXIA TAB 90mg
ANSAID TAB 100mg
ANSAID TAB 50mg
100
100
10
100
100
20
1000
15ml
10
100
100
100
100
100
400
100
400
100
100
100
10
20
100
100
100
4 vials
1 vial
4 Syr
1 Syr
7
14
7
14
7
14
100
100
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
LIQ
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
INJ
INJ
INJ
INJ
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
$20.99
$27.97
$27.97
$7.01
$13.99
$13.99
$13.99
$510.80
$20.99
$27.97
$27.97
$7.01
$13.99
$13.99
$13.99
$20.99
$20.99
$13.99
$27.97
$20.99
$27.97
$20.99
$20.99
$7.01
$13.99
$37,747.24
$9,436.81
$75,494.48
$18,873.62
$122.30
$122.30
$61.15
$61.15
$91.73
$91.73
$14.94
$7.47
Page 2 of 39
77131300367
77131300370
77131315845
85451343030
00024156210
77131300479
85140422010
77131300480
77131300482
77131315881
85465182050
85465183050
85780242596
85124332284
85423372010
85423373010
85472376510
85472377010
77131300501
85560442011
85560442030
85285462011
57894003001
85741126010
85695584028
85425182030
85852471050
85270515010
85270514510
85423519010
85423519210
85515562010
85515562040
85515561509
85515561510
85515561512
85515561540
66100012000310
66100012000315
13000020100305
13000020100305
13000020100305
66100020000320
66100020000320
66100020000330
66100020000330
66100020000330
66100020000320
66100020000330
66100020000320
66100020000320
66100020000320
66100020000330
66100020000320
66100020000330
66100030000105
66100030000105
66100030000105
66100030000105
52505040002120
66100035000407
66100035000210
66280050000320
66280050000320
66100052000320
66100052000310
66100052000310
66100052000320
66100052000320
66100052000320
66100052000310
66100052000310
66100052000310
66100052000310
Rev. 75
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
FLURBIPROFEN
FLURBIPROFEN
HYDROXYCHLOROQUINE SULFATE
IBUPROFEN
IBUPROFEN
IBUPROFEN
IBUPROFEN
IBUPROFEN
IBUPROFEN
IBUPROFEN
IBUPROFEN
IBUPROFEN
IBUPROFEN
IBUPROFEN
IBUPROFEN
IBUPROFEN
INDOMETHACIN
INDOMETHACIN
INDOMETHACIN
INDOMETHACIN
INFLIXIMAB
KETOPROFEN CR
KETOPROFEN CR
LEFLUNOMIDE
LEFLUNOMIDE
MELOXICAM
MELOXICAM
MELOXICAM
MELOXICAM
MELOXICAM
MELOXICAM
MELOXICAM
MELOXICAM
MELOXICAM
MELOXICAM
INDIVIDUAL BENEFITS
APO-FLURBIPROFEN TAB 50mg
APO-FLURBIPROFEN TAB100mg
APO-HYDROXYQUINE TAB 200MG
HCQS TAB 200mg
PLAQUENIL TAB 200mg
APO-IBUPROFEN TAB 400mg
BRUFEN TAB 400mg
BRUFEN TAB 600mg
CUPROFEN TABS 400mg
IBUPROFEN-ALP TAB 400MG
IBUPROFEN-H2K TAB 400MG
IBUPROFEN-H2K TAB 600MG
IBUPROFEN-LAS TAB 400mg
IBUPROFEN-LAS TAB 600mg
APO-INDOMETHACIN CAP 25mg
INDOCID CAP 25mg
INDOCID CAP 25mg
INDOMETHACIN-COX CAP 25mg
REMICADE 100mg INJECTION
BI-PROFENID TABS 150mg
ORUVAIL CAP 200mg ER
ARAVA TAB 20mg
LEFRA TAB 20mg
MELFLAM TAB 15MG
MELFLAM TAB 7.5MG
MELOXICAM-H2K TAB 7.5mg
MELOXICAM-H2K TAB 15mg
MELOXICAM-MAC TAB 15mg
MELOXICAM-MAC TAB 15mg
MELOXICAM-MAC TAB 7.5mg
100
100
100
30
100
1000
100
100
1000
500
50
50
96
84
100
100
100
100
1000
1000
30
1000
1 vial
10
28
30
50
100
100
10
10
100
400
10
100
100
400
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
INJ.
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
$7.47
$14.94
$32.61
$32.61
$32.61
$3.23
$3.23
$4.84
$4.84
$4.84
$3.23
$4.84
$3.23
$3.23
$3.23
$4.84
$3.23
$4.84
$1.97
$1.97
$1.97
$1.97
$31,929.75
$69.34
$92.43
$200.93
$200.93
$26.06
$13.03
$13.03
$26.06
$26.06
$26.06
$13.03
$13.03
$13.03
$13.03
Page 3 of 39
85650507010
85650507210
85220552510
85220552010
85220552030
85818535010
85818535210
77131300634
85710573056
85472642010
85140602010
77131300707
77131300708
85355352020
85355353020
85560242010
85181174010
85181174510
85245622012
85245622030
85365702050
85650637012
85160652012
85160652060
77131300719
77131300720
85595642010
85595642011
85350502050
85472538020
85480502010
85350501050
85480501005
85480503002
85296954002
85403804020
85403804210
66100052000310
66100052000320
66100052000320
66100052000310
66100052000310
66100052000310
66100052000320
66100060000315
66100060000615
66100070000110
66100070000105
66100070000110
66100070000110
66100070000105
66100070000110
66100080000310
22100018000310
22100018000330
22100040001204
22100040001204
22100040000305
22100040000910
22100040001205
22100040001205
22100045000315
22100045000315
22100045000315
22100045000315
21300050000320
21300050000305
21300050000305
21300050000305
21300050102015
21300050102030
21300050102030
65100095100120
65100095100420
Rev. 75
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis
Arthritis/Asthma
Arthritis/Asthma
Arthritis/Asthma/RHD
Arthritis/BCancer
Arthritis/BCancer
Arthritis/BCancer
Arthritis/BCancer
Arthritis/BCancer
Arthritis/BCancer
Arthritis/BCancer
Arthritis/Breast/Prostate Cancer
MELOXICAM
MELOXICAM
MELOXICAM
MELOXICAM
MELOXICAM
MELOXICAM
MELOXICAM
NAPROXEN
NAPROXEN
PIROXICAM
PIROXICAM
PIROXICAM
PIROXICAM
PIROXICAM
PIROXICAM
SULINDAC
DEFLAZACORT
DEFLAZACORT
PREDNISOLONE
PREDNISOLONE
PREDNISOLONE
PREDNISOLONE
PREDNISOLONE
PREDNISOLONE
PREDNISONE
PREDNISONE
PREDNISONE
PREDNISONE
METHOTREXATE
METHOTREXATE
METHOTREXATE
METHOTREXATE
METHOTREXATE SODIUM
METHOTREXATE SODIUM
METHOTREXATE SODIUM
TRAMADOL
TRAMADOL
INDIVIDUAL BENEFITS
MELOXICAM-PMS TAB 7.5mg
MELOXICAM-PMS TAB 15mg
MOBIC TAB 15mg
MOBIC TAB 7.5mg
MOBIC TAB 7.5mg
MUVERA TAB 7.5mg
MUVERA TAB 15mg
APO-NAPROXEN TAB 500mg
NAPROSYN EC TAB 500mg
PIROXICAM-LAS CAP 20mg
APO-PIROXICAM CAP 10mg
HOTEMIN CAP 10mg
HOTEMIN CAP 20mg
CLINORIL TAB 200mg
CALCORT TAB 6mg
CALCORT TAB 30mg
PREDCORT DS SYRUP 10mg/5ml
PREDCORT DS SYRUP 10mg/5ml
PREDNISOLONE-FP TAB 5mg
PREDNISOLONE-PMS 5mg/5ml
PRELONE SYP 15mg/5ml 120ml
PRELONE SYP 15mg/5ml 60ml
APO-PREDNISONE TAB 5mg
APO-PREDNISONE TAB 5mg
NOVO-PREDNISONE TAB 5mg
NOVO-PREDNISONE TAB 5mg
METHOTREX SOD-EBW TAB10mg
METHOTREXATE-LAS TAB2.5mg
METHOTREXATE-LDL TAB2.5mg
METHOTREX-EBW TAB 2.5mg
METHOTREXATE-EBW INJ 50mg/5ml
METHOTREX-LDL INJ50mg/2ml
ZEXATE INJ. 25mg/ml- 2ml
TRAMAL CAP 50mg
TRAMAL L.A. TAB 100mg
100
100
30
10
30
100
100
100
56
10
100
100
500
20
20
100
10
10
125ml
30ml
500
120ml
120ml
60ml
100
1000
100
1000
50
20
100
50
1 vial
1 vial
1 vial
20
10
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
LIQ
LIQ
TAB/CAP
LIQ
LIQ
LIQ
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
INJ
INJ
INJ
TAB/CAP
TAB/CAP
Page 4 of 39
$13.03
$26.06
$26.06
$13.03
$13.03
$13.03
$26.06
$20.30
$20.30
$10.30
$5.16
$10.30
$10.30
$5.16
$10.30
$31.68
$60.38
$301.90
$555.28
$133.27
$2.56
$266.65
$800.97
$400.48
$2.56
$2.56
$2.56
$2.56
$42.26
$10.57
$10.57
$10.57
$335.84
$335.84
$335.84
$36.40
$72.80
85403804510
85160155010
85160154010
77131319222
85455794020
85455794040
85580222001
85446442401
85446442001
85548143001
85400203001
85472152001
85472152501
85472153001
85423142001
85203145001
85203145201
85400202001
85585607030
85585607001
85585607330
85585607301
85165582001
85165583001
85165583520
85165583501
85165582501
85165582112
85220204001
85220203012
85400434060
85400436060
85400432012
85400432060
85472274001
85165562001
85585438030
65100095100920
65100095100120
65100095100920
65995002700320
65995002700320
65995002700320
44400010103410
44400010103440
44400010103410
44400010103230
44400010103440
44400010103410
44400010103235
44400010103240
44400010103410
44400010103210
44400010103230
44400010103410
44400015000120
44400015000120
44400015000140
44400015000140
44400015003220
44400015002515
44400015002520
44400015002520
44400015002920
44400015003220
44201025103410
44201025101205
44400033203230
44400033203240
44400033203220
44400033203220
44400033203220
44201027103320
44201027100120
Rev. 75
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
TRAMADOL
TRAMADOL
TRAMADOL
TRAMADOL & PARACETAMOL
BECLOMETHASONE DIPROPIONATE
BUDESONIDE
BUDESONIDE
BUDESONIDE
BUDESONIDE
BUDESONIDE
BUDESONIDE
BUDESONIDE
BUDESONIDE
BUDESONIDE
BUDESONIDE
FENOTEROL HYDROBROM
FENOTEROL HYDROBROM
FLUTICASONE PROPIONATE
FORMOTEROL FUMARATE
FORMOTEROL FUMARATE
INDIVIDUAL BENEFITS
TRAMAL DROPS 100mg/ml
ADAMON CAP 50mg
ADAMON DROPS 100mg/ml
APO-TRAMADOL& ACETAMINOPHEN TABS 37.5mg/325mg
TRAMACET TABS 37.5mg/325mg
TRAMACET TABS 37.5mg/325mg
BECLAZONE INH AER 50mcg
BECLAZONE-IVAX INH AER 250mcg
BECLAZONE-IVAX INH AER 50mcg
BECLOCIP HFA AER. 100mcg
BECLOFORTE AER 250mcg
BECLOMETHAS-LAS AER 50mcg
BECLOMETHAS-LAS AER200mcg
BECLOMETHAS-LAS AER250mcg
BECLOMETHASONE-H2K AER 50mcg
BECLOVAIRE 50 HFA AER
BECLOVAIRE 100 HFA AER
BECOTIDE AER 50mcg
MIFLONIDE INHL CAP 200MCG -PACK
MIFLONIDE INHL CAP 200MCG-SINGLE CAP
MIFLONIDE INHL CAP 400MCG - PACK
MIFLONIDE INHL CAP 400MCG-SINGLE CAP
PULMICORT INH 200MCG
PULMICORT NEB. 0.25mg/2ml-SINGLE AMP.
PULMICORT NEB. 0.5mg/2ml- PACK
PULMICORT NEB. 0.5mg/2ml-SINGLE AMP.
PULMICORT TURBUHAL 200MCG
PULMICORT HFA pMDINHALER 200mcg 120DS
BEROTEC INH AER
BEROTEC SYR
FLIXOTIDE AER 125mcg 60DS
FLOHALE-LAS 50mcg INHALER
OXIS TURBUHALER 9MCG/DS
FORADIL DRY CAP PWD 12MCG - PACK
10ml
10
10ml
100
20
40
200Ds
200Ds
200Ds
200Ds
200Ds
200Ds
200Ds
200Ds
200Ds
200Ds
200Ds
200Ds
30
1
30
1
1
1
20
1
1
120D
1
125ml
60Ds
60Ds
120Ds
60Ds
120Ds
60Ds
30
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
INH
INH
INH
INH
INH
INH
INH
INH
INH
INH
INH
INH
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
INH
NEB
NEB
NEB
INH
INH
INH
LIQ
INH
INH
INH
INH
INH
INH
TAB/CAP
$650.00
$36.40
$650.00
$92.80
$92.80
$92.80
$274.93
$1,374.67
$274.93
$549.87
$1,374.67
$274.93
$1,099.73
$1,374.67
$274.93
$274.93
$549.87
$274.93
$545.99
$18.20
$1,091.99
$36.40
$707.77
$72.62
$2,904.96
$145.25
$707.77
$849.32
$591.76
$555.21
$1,057.19
$2,114.38
$845.74
$422.87
$845.74
$1,637.63
$1,025.86
Page 5 of 39
85585438001
85165561501
85548283001
85548283501
85165705012
85165705060
85165704560
85165704060
85165704012
85165843001
85165843501
77131307564
85220103001
85220102020
85423383001
85472382515
85472382001
85553713030
85560753030
85560751530
85560752030
77131300769
85315202001
85100902001
85472717001
85885725001
85400746001
77131302212
77131300774
85245304001
85245304012
85365454001
85365454012
85365454015
85365452050
85365453050
85446715001
44201027100120
44201027103315
44209902053215
44209902053225
44209902053320
44209902053320
44209902053330
44209902053310
44209902053310
44209902053210
44209902053220
44100030102520
44100030103415
44100030102515
44100030103215
44100030102520
44100030103415
44505050102720
44505050100330
44505050100515
44505050100520
44201010003410
44201010003410
44201010003410
44201010003410
44201010003410
44201010003410
44201010102520
44201010100310
44201010100905
44201010100905
44201010101205
44201010101205
44201010101205
44201010100305
44201010100310
44201010003410
Rev. 75
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
FORMOTEROL FUMARATE
FORMOTEROL FUMARATE
FORMOTEROL/BUDESONIDE
IPRATROPIUM BROMIDE
IPRATROPIUM BROMIDE
IPRATROPIUM BROMIDE
IPRATROPIUM BROMIDE
IPRATROPIUM BROMIDE
IPRATROPIUM BROMIDE
MONTELUKAST
MONTELUKAST
MONTELUKAST
MONTELUKAST
SALBUTAMOL
SALBUTAMOL
SALBUTAMOL
SALBUTAMOL
SALBUTAMOL
SALBUTAMOL
SALBUTAMOL SULFATE
SALBUTAMOL SULFATE
SALBUTAMOL SULFATE
SALBUTAMOL SULFATE
SALBUTAMOL SULFATE
SALBUTAMOL SULFATE
SALBUTAMOL SULFATE
SALBUTAMOL SULFATE
SALBUTAMOL SULFATE
SALBUTAMOL SULFATE
INDIVIDUAL BENEFITS
FORADIL DRY CAP PWD 12MCG-SINGLE CAP
OXIS TURBUHALER 4.5MCG/DS
FORMECORT 100 HFA INHALER
FORMECORT 200 HFA INHALER
SYMBICORT 4.5/160mcg TURBUHAL 120DS
SYMBICORT 4.5/160mcg TURBUHAL 60DS
SYMBICORT 9/320mcg TURBUHAL 60DS
SYMBICORT 4.5/80mcg TURBUHAL 60D
SYMBICORT 4.5/80mcg TURBUHAL 120D
VANNAIR 4.5/80mcg pMDInhaler 120DS
VANNAIR 4.5/160mcg pMDInhaler 120DS
APO-IPRAVENT NEB 0.025%
ATROVENT INH AER 20mcg
ATROVENT NEB 0.02%
IPRATROPIUM-H2K INH AER.20mcg
IPRATROPIUM-LAS NEB0.025%
IPRATROP-LAS INH AER.20mcg
SINGULAIR ORAL GRANULES 4mg- Single Packet
SINGULAIR TAB 10mg
SINGULAIR TAB 4mg
SINGULAIR TAB 5mg
APO-SALVENT AER 100mcg
BUTAHALE AER 100mcg
SALBULIN AER 100mcg
SALBUTAMOL-LAS AER 100mcg
SALOMOL AER 100mcg
VENTOLIN AER 100mcg
APO-SALBUTAMOL NEBULISING SOLN.
APO-SALVENT TAB 4mg
BRONCLAIR LIQUID
BRONCLAIR LIQUID
FEDBUTAMOL SYP 2mg/5ml
FEDBUTAMOL TAB 2mg
FEDBUTAMOL TAB 4mg
SALAMOL-IVAX AER 100mcg
1
60Ds
120Ds
120Ds
120Ds
60Ds
60Ds
60Ds
120Ds
120Ds
120Ds
20ml
200Ds
20ml
200Ds
15ml
200Ds
30
30
30
30
200Ds
200Ds
250Ds
200Ds
200Ds
200Ds
10ml
100
1ml
125ml
1ml
120ml
150ml
500
500
1
TAB/CAP
INH
INH
INH
INH
INH
INH
INH
INH
INH
INH
NEB
INH
NEB
INH
NEB
INH
GRANULE
TAB/CAP
TAB/CAP
TAB/CAP
INH
INH
INH
INH
INH
INH
NEB
TAB/CAP
LIQ
LIQ
LIQ
LIQ
LIQ
TAB/CAP
TAB/CAP
INH
$34.19
$818.82
$1,593.28
$1,951.88
$2,885.38
$1,442.69
$2,885.38
$1,144.21
$2,288.42
$2,288.42
$2,885.38
$1,081.89
$1,040.92
$865.51
$1,040.92
$811.41
$1,040.92
$48.83
$122.08
$48.83
$61.04
$260.87
$260.87
$326.08
$260.87
$260.87
$260.87
$316.14
$2.29
$1.86
$234.94
$1.86
$225.47
$281.82
$1.15
$2.29
$260.87
Page 6 of 39
85446715420
85446715820
85423722001
85423722101
85472717501
85472716501
85472716510
85472716010
85650723001
85738749001
85650723010
85830723050
85203713001
85548714001
85400747020
85400744001
85400744015
85548144001
85472718001
85423725001
85220322001
85220322520
85220322501
85548713001
85548713501
85400644501
85400643001
85400643501
85399716060
85400644001
85399717512
85399716512
85399717012
85472722001
85472722101
85400642001
85100707010
44201010102517
44201010102518
44201010003410
44201010003410
44201010102520
44201010101205
44201010101205
44201010100310
44201010101205
44201010003210
44201010101205
44201010100310
44201010003210
44201010003410
44201010102520
44201010101205
44201010101205
44990002103410
44990002103410
44990002103410
44209902013220
44209902012520
44209902012520
44209902503315
44209902503220
44209902503315
44209902503320
44209902503330
44209902503240
44209902503305
44209902503215
44209902503220
44209902503210
44209902503215
44209902503220
44201058103410
44300040000420
Rev. 75
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
SALBUTAMOL SULFATE
SALBUTAMOL SULFATE
SALBUTAMOL SULFATE
SALBUTAMOL SULFATE
SALBUTAMOL SULFATE
SALBUTAMOL SULFATE
SALBUTAMOL SULFATE
SALBUTAMOL SULFATE
SALBUTAMOL SULFATE
SALBUTAMOL SULFATE
SALBUTAMOL SULFATE
SALBUTAMOL SULFATE
SALBUTAMOL SULFATE
SALBUTAMOL SULFATE
SALBUTAMOL SULFATE
SALBUTAMOL SULFATE
SALBUTAMOL SULFATE
SALBUTAMOL-BECLOMETHASONE
SALBUTAMOL-IPRATROPIUM
SALMETEROL XINA-FLUTICASONE
SALMETEROL XINAFOATE
THEOPHYLLINE
INDIVIDUAL BENEFITS
SALAMOL-IVAX NEB. SOLN. 0.1%
20x2.5ml
SALAMOL-IVAX NEB. SOLN. 0.2%
20x2.5ml
SALBUTAMOL-H2K AER 100mcg
200Ds
SALBUTAMOL-H2K AER 100mcg- CFC FREE
200Ds
SALBUTAMOL-LAS NEB.SOLN.
15ml
SALBUTAMOL-LAS SYP2mg/5ml
1ml
SALBUTAMOL-LAS SYP2mg/5ml
100ml
SALBUTAMOL-LAS TAB 4mg
100
SALBUTAMOL-PMS SYP2mg/5ml
1ml
SALBUTAMOL-Sandoz AER 100mcg
200Ds
SALBUTAMOL-PMS SYP2mg/5ml
100ml
SALBUTAMOL-SPM TAB 4mg
500
SALBUTAVENT HFA AER 100mcg
200Ds
SALVENT HFA AER. 100mcg
200Ds
VENTOLIN NEB 0.5%
20ml
VENTOLIN SYP 2mg/5ml
1ml
VENTOLIN SYP 2mg/5ml
150ml
BECLOSAL HFA AER 100/50mcg
200Ds
LAS SALBUTAMOL & BECLOMETHAS. AER 100/50mcg 200Ds
SALBUTAMOL & BECLOMETHAS.-H2K AER 100/50mcg 200Ds
COMBIVENT AER
1
COMBIVENT INHALATION SOLUTION - 1 pack
20vials
COMBIVENT INHALATION SOLUTION- Single Vial
1 vial
SALMETIDE HFA Aer. 25mcg/125mcg
200Ds
SALMETIDE HFA Aer. 25mcg/250mcg
200Ds
SERETIDE AER 25/125mcg 120D (GLAXO WELL.)
120D
SERETIDE DISKUS AER 50/100mcg(GLAXO WELL.)
60Ds
SERETIDE DISKUS AER 50/250mcg (GLAXO WELL.)
60Ds
SERETIDE DISKUS AER 50/500mcg (GSK)
60Ds
SERETIDE EVOHALER 25/50mcg (GLAXO WELL.)
120Ds
SERETIDE EVOHALER 25/125mcg (GSK)
120Ds
SERETIDE EVOHALER 25/250mcg (GSK)
120Ds
SERETIDE EVOHALER-GSK 25mcg/50mcg-120D
120Ds
SEROFLO-LAS AER INHALER 25/125mcg -120D
120Ds
SEROFLO-LAS AER INHALER 25/250mcg -120D
120Ds
SEREVENT AER 25MCG/DS
120Ds
NUELIN SA TAB 250mg
100
NEB
NEB
INH
INH
NEB
LIQ
LIQ
TAB/CAP
LIQ
INH
LIQ
TAB/CAP
INH
INH
NEB
LIQ
LIQ
INH
INH
INH
INH
INH
INH
INH
INH
INH
INH
INH
INH
INH
INH
INH
INH
INH
INH
INH
TAB/CAP
$316.14
$632.28
$260.87
$260.87
$474.22
$1.86
$187.95
$2.29
$1.86
$260.87
$187.95
$2.29
$260.87
$260.87
$632.27
$1.85
$281.82
$450.42
$450.42
$450.42
$1,218.44
$3,835.96
$191.80
$2,636.00
$2,937.23
$2,636.00
$2,529.30
$2,636.00
$2,937.23
$2,529.30
$2,636.00
$2,937.23
$2,529.30
$2,636.00
$2,937.23
$1,791.05
$9.21
Page 7 of 39
85100705090
85220822030
85274118001
85857122001
85857122501
85857123001
85423732001
85124822001
85472052001
85270942001
85423140501
85472022001
85270191001
85274117401
85274117201
85274117001
85690185028
85165072028
85160304001
85160303001
85160302010
85183253001
85183252001
85183252501
85183255050
85640172030
85296276010
85710352005
85350402020
85350402005
85350402010
85585432030
85315592010
77131300814
85140682060
77131300818
77131300819
44300040000310
44100060200210
97100000006200
97100000006200
97100000006200
97100000006200
97100000006200
97100000006200
97100000006200
97100000006200
97100000006300
97100000006300
97100000006300
97100000006300
97100000006300
97100000006300
21402810000310
21402810000310
21101020002125
21101020002120
21101020000310
21101020002125
21101020002110
21101020002120
21101020000310
99900000000000
21300030002010
21300030002010
21300030002010
21300030002010
21300030002010
21402860000320
21402860000320
21402680100310
21402680100310
21402680100320
21402680100320
Rev. 75
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
Asthma
BCancer
BCancer
BCancer
BCancer
BCancer
BCancer
BCancer
BCancer
BCancer
BCancer
BCancer
BCancer
BCancer
BCancer
BCancer
BCancer
BCancer
BCancer
BCancer
BCancer
BCancer
THEOPHYLLINE
TIOTROPIUM
SPACER
SPACER & MASK
SPACER & MASK
SPACER
SPACER
SPACER
SPACER
SPACER
MASK
MASK
MASK
MASK
MASK
MASK
ANASTROZOLE
ANASTROZOLE
CYCLOPHOSPHAMIDE
CYCLOPHOSPHAMIDE
CYCLOPHOSPHAMIDE
CYCLOPHOSPHAMIDE
CYCLOPHOSPHAMIDE
CYCLOPHOSPHAMIDE
CYCLOPHOSPHAMIDE
EXEMESTANE
FLUOROURACIL
FLUOROURACIL
FLUOROURACIL
FLUOROURACIL
FLUOROURACIL
LETROZOLE
LETROZOLE
TAMOXIFEN CITRATE
TAMOXIFEN CITRATE
TAMOXIFEN CITRATE
TAMOXIFEN CITRATE
INDIVIDUAL BENEFITS
NUELIN TAB 125mg
SPIRIVA INH. PWD. CAPS 18mcg
ABLE SPACER
AEROCHAMBER PLUS SPACER AND MASK- INFANT
AEROCHAMBER PLUS SPACER AND MASK- PAED.
AEROCHAMBER PLUS SPACER AND MOUTHPIECE-ADULT
SPACER-H2K
VOLUMATIC SPACER
ZEROSTAT- LAS SPACER
ZEROSTAT VT SPACER
BABY MASK-H2K
BABY MASK-LAS
BABY MASK-CIPLA
ABLE SPACER MASK - INFANT
ABLE SPACER MASK - CHILD
ABLE SPACER MASK - ADULT
AREMED TAB 1mg
ARIMIDEX TAB 1mg
ENDOXAN-ASTA INJ 1GM
ENDOXAN-ASTA INJ 500mg
ENDOXAN-ASTA TAB 50mg
ENDOXAN-BXT INJ 1 GM
ENDOXAN-BXT INJ 200mg
ENDOXAN-BXT INJ 500mg
ENDOXAN-BXT TAB 50mg
AROMASIN TAB 25mg
FIVOFLU INJ. 500mg -10ml
FLUOROURACIL INJ250mg/5ml
FLUOROURACIL-EBW INJ1GM
FLUOROURACIL-EBW INJ250mg
FLUOROURACIL-EBW INJ500mg
FEMARA TAB 2.5mg
ORETA TAB 2.5mg
APO-TAMOX TAB 10mg
APO-TAMOX TAB 10mg
APO-TAMOX TAB 20mg
APO-TAMOX TAB 20mg
90
30
1
1
1
1
1
1
1
1
1
1
1
1
1
1
28
28
1 vial
1 vial
100
1vial
1vial
1vial
50
30
1 vial
1 vial
1 vial
1 vial
1 vial
30
10
100
60
30
100
TAB/CAP
INH
Device
Device
Device
Device
Device
Device
Device
Device
Device
Device
Device
Device
Device
Device
TAB/CAP
TAB/CAP
INJ
INJ
TAB/CAP
INJ
INJ
INJ
TAB/CAP
TAB/CAP
INJ
INJ
INJ
INJ
INJ
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
$4.60
$4,315.96
$604.66
$975.94
$975.94
$604.66
$604.66
$604.66
$604.66
$604.66
$371.28
$371.28
$371.28
$371.28
$371.28
$371.28
$434.11
$434.11
$1,031.75
$515.88
$54.04
$1,031.75
$206.35
$515.88
$54.04
$413.17
$219.56
$109.78
$439.11
$109.78
$219.56
$303.72
$303.72
$9.29
$9.29
$18.62
$18.62
Page 8 of 39
85165552030
85165552530
85350752020
85350752030
85355962025
85355962030
85296213001
85296214001
85270312005
85270312002
85350323008
85315332501
85315332502
85315332503
85181745001
85181745201
85165944001
85165942001
85738475001
85585459001
85738475201
85115522501
85115522001
85439192016
85439192050
85350362005
85350362017
85350362025
85350362050
85296384050
85296384017
85296384005
85315494005
85315494017
85315494041
85315494050
85472612005
21402680100310
21402680100320
21402680100320
21402680100320
21402680100310
21402680100310
21500005001320
21500005001330
21500005001320
21500005001330
21500005001305
21500005001320
21500005001330
21500005001340
21500005001320
21500005001330
21405005102330
21405005102310
21405010106410
21405010106405
21405010106420
21405010156420
21405010106405
21500012001310
21500012001330
21500012001320
21500012001310
21500012001315
21500012001330
21500012001330
21500012001310
21500012001320
21500012001320
21500012001310
21500012001325
21500012001330
21500012001320
Rev. 75
BCancer
BCancer
BCancer
BCancer
BCancer
BCancer
BCancer/PCancer
BCancer/PCancer
BCancer/PCancer
BCancer/PCancer
BCancer/PCancer
BCancer/PCancer
BCancer/PCancer
BCancer/PCancer
BCancer/PCancer
BCancer/PCancer
BCancer/PCancer
BCancer/PCancer
BCancer/PCancer
BCancer/PCancer
BCancer/PCancer
BCancer/PCancer
BCancer/PCancer
BCancer/PCancer
BCancer/PCancer
BCancer/PCancer
BCancer/PCancer
BCancer/PCancer
BCancer/PCancer
BCancer/PCancer
BCancer/PCancer
BCancer/PCancer
BCancer/PCancer
BCancer/PCancer
BCancer/PCancer
BCancer/PCancer
BCancer/PCancer
TAMOXIFEN CITRATE
TAMOXIFEN CITRATE
TAMOXIFEN CITRATE
TAMOXIFEN CITRATE
TAMOXIFEN CITRATE
TAMOXIFEN CITRATE
DOCETAXEL
DOCETAXEL
DOCETAXEL
DOCETAXEL
DOCETAXEL
DOCETAXEL
DOCETAXEL
DOCETAXEL
DOCETAXEL
DOCETAXEL
GOSERELIN
GOSERELIN
LEUPROLIDE
LEUPROLIDE
LEUPROLIDE
LEUPROLIDE
LEUPROLIDE
PACLITAXEL
PACLITAXEL
PACLITAXEL
PACLITAXEL
PACLITAXEL
PACLITAXEL
PACLITAXEL
PACLITAXEL
PACLITAXEL
PACLITAXEL
PACLITAXEL
PACLITAXEL
PACLITAXEL
PACLITAXEL
INDIVIDUAL BENEFITS
NOLVADEX TAB 10mg
NOLVADEX-D TAB 20mg
TAMOXIFEN-EBW TAB 20mg
TAMOXIFEN-EBW TAB 20mg
ZITAZONIUM TAB 10mg
ZITAZONIUM TAB 10mg
DAXOTEL INJ. 20mg/0.5ml
DAXOTEL INJ. 80mg/2ml
DOCETAX INJ. 20mg/0.5ml
DOCETAX INJ. 80mg/2ml
DOCETAXEL-EBWE INJ. 80mg/8ml
DOCETERE INJ. 20mg /0.5ml
DOCETERE INJ. 80mg /2ml
DOCETERE INJ. 120mg /3ml
TAXOTERE INJ. 20mg/0.5ml
TAXOTERE INJ. 80mg/2ml
ZOLADEX DEPOT INJ. 10.8mg- 1vial
ZOLADEX DEPOT INJ. 3.6mg- 1vial
LECTRUM DEPOT INJ. 7.5mg-1 vial
LUCRIN DEPOT INJ. 11.25mg- 1vial
LUCRIN DEPOT INJ. 3.75mg- 1vial
CYTAX Inj. 100mg /16.7ml
CYTAX Inj. 300mg /50ml
EBETAXEL (EBWE) Inj. 30mg /5ml
EBETAXEL (EBWE) Inj. 100mg /16.7ml
INTAXEL INJ.300mg /50ml
MITOTAX INJ.30mg/5ml
MITOTAX INJ.100mg/16.7ml
MITOTAX INJ.250mg/41.7ml
MITOTAX INJ.300mg/50ml
PACLITAXEL-LAS Inj. 30mg/5ml
30
30
20
30
250
30
1 vial
1 vial
1 vial
1 vial
2 vial
1 vial
1 vial
1 vial
1 vial
1 vial
1 vial
1 vial
1 vial
1 vial
2 vial
1 vial
1 vial
1 vial
1 vial
1 vial
1 vial
1 vial
1 vial
1 vial
1 vial
1 vial
1 vial
1 vial
1 vial
1 vial
1 vial
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
INJ
INJ
INJ
INJ
INJ
INJ
INJ
INJ
INJ
INJ
INJ
INJ
INJ
INJ
INJ
INJ
INJ
INJ
INJ
INJ
INJ
INJ
INJ
INJ
INJ
INJ
INJ
INJ
INJ
INJ
INJ
$9.29
$18.62
$18.62
$18.62
$9.29
$9.29
$5,267.47
$21,069.89
$5,267.47
$21,069.89
$21,069.89
$5,267.47
$21,069.89
$31,604.82
$5,267.47
$21,069.89
$47,539.18
$15,846.40
$15,810.55
$7,905.28
$23,715.83
$23,715.83
$7,905.28
$10,608.00
$31,824.00
$3,182.40
$10,608.00
$15,912.00
$31,824.00
$31,824.00
$10,608.00
$3,182.40
$3,182.40
$10,608.00
$26,520.00
$31,824.00
$3,182.40
Page 9 of 39
85472612116
00015347530
77131313650
77131313651
77131313652
85625252020
85625253020
85625254020
85399136030
85423280030
85423280010
85472272030
85270342010
85270342030
85560672028
85220402010
85220402530
85390695030
85423737510
85270792015
77131312807
77131312801
77131312803
77131312805
85115401014
85115406028
85115402028
85115404028
85355812030
85650811010
85650811510
85650812010
85185503030
85185503090
85185502084
77131300397
85140342010
21500012001320
21500012001320
36202005100310
36202005100320
36202005100330
36202005100310
36202005100320
36202005100330
56851020000120
56851030000320
56851030000320
56851030000320
56851030000320
56851030000320
56851030000320
56852070100220
56852070100420
56852070100220
56852070100220
56852070100220
36202040100320
36202040100305
36202040100310
36202040100315
36202040100300
36202040100320
36202040100310
36202040100315
36202040100315
36202040100305
36202040100310
36202040100315
27500010000340
27500010000340
27500010000320
27200040000315
27200040000315
Rev. 75
BCancer/PCancer
BCancer/PCancer
Benign Prostatic Hyperplasia
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
PACLITAXEL
PACLITAXEL
DOXAZOSIN
DOXAZOSIN
DOXAZOSIN
DOXAZOSIN
DOXAZOSIN
DOXAZOSIN
DUTASTERIDE
FINASTERIDE
FINASTERIDE
FINASTERIDE
FINASTERIDE
FINASTERIDE
FINASTERIDE
TAMSULOSIN
TAMSULOSIN
TAMSULOSIN
TAMSULOSIN
TAMSULOSIN
TERAZOSIN
TERAZOSIN
TERAZOSIN
TERAZOSIN
TERAZOSIN
TERAZOSIN
TERAZOSIN
TERAZOSIN
TERAZOSIN
TERAZOSIN
TERAZOSIN
TERAZOSIN
ACARBOSE
ACARBOSE
ACARBOSE
GLIBENCLAMIDE
GLIBENCLAMIDE
INDIVIDUAL BENEFITS
PACLITAXEL-LAS Inj. 100mg/16.7ml
TAXOL Inj. 30mg/5ml
APO-DOXAZOSIN TAB 1mg
CARDURA TAB 1mg
CARDURA TAB 2mg
CARDURA TAB 4mg
AVODART CAP 0.5mg
FINASTERIDE-H2K TAB 5mg
FINASTERIDE-H2K TAB 5mg
FINASTERIDE-LAS TAB 5mg
FINCAR TAB 5MG
FINCAR TAB 5MG
PROSCAR TAB 5mg
FLOMAX TAB 0.4mg
FLOMAX CR TAB 0.4 mg
TAMSOL PR CAPSULES 0.4mg
TAMSULOSIN-H2K TAB 0.4mg
URIMAX MR TAB 0.4mg
APO-TERAZOSIN TAB 10mg
HYTRIN STARTER PACK
HYTRIN TAB 10mg
HYTRIN TAB 2mg
HYTRIN TAB 5mg
SETEGIS TAB 5mg
TERAZOSIN-PMS TAB 1mg
GLUCOBAY TAB 100mg
GLUCOBAY TAB 100mg
GLUCOBAY TAB 50mg
APO-GLYBURIDE TAB 5mg
APO-GLYBURIDE TAB 5mg
1 vial
1 vial
100
100
100
20
20
20
30
30
10
30
100
30
28
100
30
30
10
15
100
100
100
100
14
28
28
28
30
100
100
100
30
90
84
500
100
INJ
INJ
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
$10,608.00
$3,182.40
$14.46
$28.93
$57.86
$14.46
$28.93
$57.86
$108.09
$65.93
$65.93
$65.93
$65.93
$65.93
$65.93
$64.82
$64.82
$64.82
$64.82
$64.82
$67.50
$6.75
$13.50
$33.75
$559.60
$67.50
$13.50
$33.75
$33.75
$6.75
$13.50
$33.75
$32.47
$32.47
$16.24
$3.35
$3.35
Page 10 of 39
85237152011
85425302050
85472337010
85690352040
85690352010
85690352011
00009034101
00009035201
00009344901
00009344903
77131315644
77131317774
85775282530
85775282230
85178319510
85472342010
85423323010
85451326030
85315672010
85315672020
85315668020
85315668010
85315668520
85315668510
85425172020
85425173020
77131317360
77131317361
85335352030
85335352230
85423325010
85738314510
85738314010
85315368020
85315368120
85406292010
85178321030
27200040000315
27200040000315
27200040000315
27200040000315
27200040000315
27200040000315
27200040000307
27200040000312
27200040000320
27200040000320
27200025000320
27200025000420
27200025000420
27200025000430
27200025000320
27200025000320
27200025000320
27200025000320
27200025000320
27200025000320
27200025000420
27200025000420
27200025000430
27200025000430
27200027000320
27200027000340
27200027000320
27200027000340
27200027000320
27200027000330
27200027000320
27200027000340
27200027000320
27200027000320
27200027000340
27200027000320
27200027000320
Rev. 75
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
GLIBENCLAMIDE
GLIBENCLAMIDE
GLIBENCLAMIDE
GLIBENCLAMIDE
GLIBENCLAMIDE
GLIBENCLAMIDE
GLIBENCLAMIDE(MICRONISED)
GLICLAZIDE
GLICLAZIDE
GLICLAZIDE
GLICLAZIDE
GLICLAZIDE
GLICLAZIDE
GLICLAZIDE
GLICLAZIDE
GLICLAZIDE
GLICLAZIDE
GLICLAZIDE
GLICLAZIDE
GLICLAZIDE
GLICLAZIDE
GLIMEPIRIDE
GLIMEPIRIDE
GLIMEPIRIDE
GLIMEPIRIDE
GLIMEPIRIDE
GLIMEPIRIDE
GLIMEPIRIDE
GLIMEPIRIDE
GLIMEPIRIDE
GLIMEPIRIDE
GLIMEPIRIDE
GLIMEPIRIDE
GLIMEPIRIDE
INDIVIDUAL BENEFITS
BETANASE TAB 5mg
DAONIL TAB 5mg
GLIBENCLAMIDE- LAS TAB 5mg
GLITISOL TAB 5mg
GLITISOL TAB 5mg
GLITISOL TAB 5mg
GLYNASE TAB 1.5mg
GLYNASE TAB 3mg
GLYNASE TAB 6mg
GLYNASE TAB 6mg
APO-GLICLAZIDE TAB80mg
APO-GLICLAZIDE MR TAB 30mg
DIAMICRON MR TAB 30mg
DIAMICRON MR TAB 60mg
GLICLAZIDE-AUR TAB 80mg
GLICLAZIDE-LAS TAB 80mg
GLICLAZIDE-H2K TAB 80mg
GLYCINORM -80 TAB 80mg
RECLIDE TAB 80mg
RECLIDE TAB 80mg
RECLIDE MR TAB 30mg
RECLIDE MR TAB 30mg
RECLIDE MR TAB 60mg
RECLIDE MR TAB 60mg
AMARYL TAB 2mg
AMARYL TAB 4mg
APO-GLIMEPIRIDE TAB 2mg
APO-GLIMEPIRIDE TAB 4mg
GLIMEPIRIDE-DENK TAB 2mg
GLIMEPIRIDE-DENK TAB 3mg
GLIMEPIRIDE-H2K TAB 2mg
GLIMEPIRIDE (Sandoz)TAB 4mg
GLIMEPIRIDE(Sandoz) TAB 2mg
GLIMY TABLETS 2mg
GLIMY TABLETS 4mg
GLIMULIN -2 TAB
GLIRIDE -2 TAB
1000
500
100
40
100
1000
100
100
100
500
60
100
30
30
100
100
100
30
100
20
20
100
20
100
20
20
100
100
30
30
10
10
10
20
20
100
30
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
Page 11 of 39
$3.35
$3.35
$3.35
$3.35
$3.35
$3.35
$1.74
$3.50
$6.99
$6.99
$9.67
$9.67
$9.67
$19.34
$9.67
$9.67
$9.67
$9.67
$9.67
$9.67
$9.67
$9.67
$19.34
$19.34
$29.31
$58.62
$29.31
$58.62
$29.31
$43.97
$29.31
$58.62
$29.31
$29.31
$58.62
$29.31
$29.31
85178321010
85451327030
85451327230
85439952020
85439952220
85741121030
85741121216
85741121416
00049156066
00049155066
85590607003
85590607001
85590607105
85590607101
85590575003
85590575001
85590575105
85590575101
85590475015
85181442010
85741472003
85741472203
85741122003
85741122010
85741122001
85490404010
85490404003
85490404001
85590554010
85590554003
85590554001
85892854003
85892854010
85490401003
85490401001
85490401010
85490401503
27200027000320
27200027000320
27200027000340
27200027000320
27200027000340
27997002320330
27997002320335
27997002320340
27200030000420
27200030000410
27104092001820
27104092001820
27104092002020
27104092002020
27104093001820
27104093001820
27104093001820
27104093001820
27104094002020
27104095002010
27104095002010
27104095002010
27104097002010
27104097002010
27104097002010
27104020001805
27104020001805
27104020001805
27104020001805
27104020001805
27104020001805
27104020001805
27104020001805
27104005002020
27104005002020
27104005002020
27104007001820
Rev. 75
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
GLIMEPIRIDE
GLIMEPIRIDE
GLIMEPIRIDE
GLIMEPIRIDE
GLIMEPIRIDE
GLIMEPIRIDE & METFORMIN
GLIPIZIDE CR
GLIPIZIDE CR
INSULIN ASPART
INSULIN ASPART
INSULIN ASPART
INSULIN ASPART
INSULIN ASPART & ASPART PROTAMINE
INSULIN DETEMIR
INSULIN GLARGINE
INSULIN GLARGINE
INSULIN GLARGINE
INSULIN GLULISINE
INSULIN GLULISINE
INSULIN GLULISINE
INSULIN ISOPHANE
INSULIN ISOPHANE
INSULIN ISOPHANE
INSULIN ISOPHANE
INSULIN ISOPHANE
INSULIN ISOPHANE
INSULIN ISOPHANE
INSULIN ISOPHANE
INSULIN LISPRO
INSULIN LISPRO
INSULIN LISPRO
INSULIN LISPRO& LISPRO PROTAMINE
INDIVIDUAL BENEFITS
GLIRIDE -2 TAB
GLYREE-2 TAB
GLYREE-4 TAB
ZORYL TAB 2mg
ZORYL TAB 4mg
AMARYL-M TAB 2mg /500mg
GLUCOTROL XL TAB 10mg
GLUCOTROL XL TAB 5mg
NOVORAPID INJ. PENFILL 3ml x 5 cartridges
NOVORAPID INJ. PENFILL 3ml-Single cartridge
NOVORAPID FLEXPEN INJ. 3ml-Single Pen
NOVORAPID FLEXPEN INJ. 3ml x 5 Pens
NOVOMIX 30 INJ. PENFILL 3ml x 5 cartridges
NOVOMIX 30 INJ. PENFILL 3ml-Single cartridge
NOVOMIX 30 FLEXPEN INJ. 3ml x 5 Pens
NOVOMIX 30 FLEXPEN INJ. 3ml-Single Pen
LEVEMIR FLEXPEN INJ. 3ml x 5 pens
LANTUS INJ -10ml vial
LANTUS INJ -3ml Single cartridge
LANTUS SOLOSTAR PRE-FILLED PEN INJ -3ml
APIDRA INJ.3ml-Single cartridge
APIDRA INJ.3ml-10ml vial
APIDRA SOLOSTAR PRE-FILLED PEN INJ. -3ml
HUMULIN N INJ U-100
HUMULIN N INJ. PENFILL 3ml x 5 cartridges
HUMULIN N INJ. PENFILL 3ml-Single cartridge
NOVOLIN N INJ U-100
NOVOLIN N INJ PENFILL 3ml x 5 cartridges
NOVOLIN N INJ PENFILL 3ml Single cartridge
WOSULIN N INJ. PENFILL 3ml- Single cartridge
WOSULIN N INJ. U-100
HUMALOG INJ PENFILL 3ml x 5 cartridges
HUMALOG INJ PENFILL 3ml-Single cartridge
HUMALOG INJ U-100
HUMALOG MIX 25 PENFILL 3ml x 5 cartridges
100
30
30
20
20
30
16
16
100
100
15ml
3ml
3ml
15ml
15ml
3ml
15ml
3ml
15ml
10ml
3ml
3ml
3ml
10ml
3ml
10ml
15ml
3ml
10ml
15ml
3ml
3ml
10ml
15ml
3ml
10ml
15ml
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
INJ
INJ
INJ
INJ
INJ
INJ
INJ
INJ
INJ
INJ
INJ
INJ
INJ
INJ
INJ
INJ
INJ
INJ
INJ
INJ
INJ
INJ
INJ
INJ
INJ
INJ
INJ
$29.31
$29.31
$58.62
$29.31
$58.62
$35.81
$36.17
$65.48
$57.92
$28.96
$3,413.32
$682.64
$682.64
$3,413.32
$3,413.32
$682.64
$3,413.32
$682.64
$4,875.80
$3,250.56
$975.16
$975.16
$682.64
$2,275.40
$682.64
$800.17
$1,200.34
$240.06
$800.17
$1,200.34
$240.06
$240.06
$800.17
$3,413.32
$682.64
$2,275.40
$3,413.32
Page 12 of 39
85490401501
85490402010
85590552010
85590552005
85590552001
85892854410
85892854403
85490405003
85490405001
85490405010
85590555010
85590555003
85590555001
85892854203
85892854210
85490402003
85490402001
00169347718
85590552201
85178137011
77131307807
77131307808
77131316964
77131312615
77131313648
85365527050
85500504030
85556324430
85500502050
85556324030
85556324230
85500503010
85690382050
85869518010
85869518050
85124516051
85124516028
27104007001820
27104090001810
27104090001810
27104090001810
27104090001810
27104090001810
27104090001810
27104010002005
27104010002005
27104010002005
27104010002005
27104010002005
27104010002005
27104010002005
27104010002005
27104090001810
27104090001810
27104090001810
27104090001810
27250050000320
27250050000320
27250050000320
27250050000320
27250050000340
27250050000340
27250050000320
27250050000350
27250050000430
27250050000320
27250050000420
27250050000425
27250050000340
27250050000320
27250050000320
27250050000320
27250050000320
27250050000320
Rev. 75
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
INSULIN LISPRO& LISPRO PROTAMINE
INSULIN REGULAR & ISOPHANE (HUMAN)70/30
INSULIN REGULAR (HUMAN)
INSULIN REGULAR&ISOPHANE(HUMAN) 70/30
METFORMIN HCL
METFORMIN HCL
METFORMIN HCL
METFORMIN HCL
METFORMIN HCL
METFORMIN HCL
METFORMIN HCL
METFORMIN HCL
METFORMIN HCL
METFORMIN HCL
METFORMIN HCL
METFORMIN HCL
METFORMIN HCL
METFORMIN HCL
METFORMIN HCL
METFORMIN HCL
METFORMIN HCL
METFORMIN HCL
INDIVIDUAL BENEFITS
HUMALOG MIX 25 PENFILL 3ml (Single cartridge)
HUMULIN INJ 70/30
NOVOLIN INJ 70/30
NOVOLIN INJ 70/30 PENFILL 1.5ml x 5 cartridges
NOVOLIN INJ 70/30 PENFILL 1.5ml-Single cartridge
WOSULIN INJ.70/30 U-100
WOSULIN INJ.70/30 PENFILL 3ml- Single cartridge
HUMULIN R INJ PENFILL 3ml x 5 cartridges
HUMULIN R INJ PENFILL 3ml-Single cartridge
HUMULIN R INJ U-100
NOVOLIN R INJ U-100
NOVOLIN R INJ PENFILL 3ml x 5 cartridges
NOVOLIN R INJ PENFILL 3ml Single cartridge
WOSULIN R INJ. PENFILL 3ml- Single cartridge
WOSULIN R INJ. U-100
HUMULIN INJ 70/30 PENFILL 3ml x 5 cartridges
HUMULIN INJ 70/30PENFILL 3ml Single cartridge
NOVOLIN INJ 70/30 PENFILL 3ml x 5 cartridges
NOVOLIN INJ 70/30 PENFILL 3ml Single cartridge
AUROMET TAB 500mg
APO-METFORMIN TAB 500mg
FEDFORMIN TAB 500mg
GLUCOPHAGE 1000mg
GLUCOPHAGE XR TAB 1000mg
GLUCOPHAGE TAB 500mg
GLUCOPHAGE TAB 850mg
GLYFORMIN TAB 500mg
METFOR-500 TAB
METFOR-500 TAB
METFORMIN-ALP TAB 500mg
METFORMIN-ALP TAB 500mg
3ml
10ml
10ml
7.5ml
1.5ml
10ml
3ml
15ml
3ml
10ml
10ml
15ml
3ml
3ml
10ml
15ml
3ml
15ml
3ml
100
100
500
360
100
500
500
30
30
500
30
30
100
500
100
500
500
28
INJ
INJ
INJ
INJ
INJ
INJ
INJ
INJ
INJ
INJ
INJ
INJ
INJ
INJ
INJ
INJ
INJ
INJ
INJ
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
$682.64
$800.17
$800.17
$600.18
$120.03
$800.17
$240.06
$1,200.34
$240.06
$800.17
$800.17
$1,200.34
$240.06
$240.06
$800.17
$1,200.34
$240.06
$1,200.34
$240.06
$3.44
$3.44
$3.44
$3.44
$5.83
$5.83
$3.44
$6.86
$6.86
$3.44
$3.44
$5.16
$5.83
$3.44
$3.44
$3.44
$3.44
$3.44
Page 13 of 39
85423522010
85423521814
85423521810
85335511010
85335511050
85335511030
85335512030
85335512012
85335512230
85472532010
85472532510
85472533010
85650522050
85105602050
85406882050
85406882010
85439955030
85439955011
85553322030
85553323030
85553322530
85553323230
85490101530
85490102030
85490102530
85315332020
85315332010
85315332220
85315332210
85818616030
85818616230
85590602030
85590603030
85590604030
85560454028
85560454228
85560454428
27250050000420
27250050000320
27250050000320
27250050000320
27250050000320
27250050000320
27250050000340
27250050000340
27250050000350
27250050000320
27250050000420
27250050000340
27250050000320
27250050000320
27250050000320
27250050000320
27250050000320
27250050000320
27309902600320
27309902600330
27309902600325
27309902600335
27607050000315
27607050000320
27607050000325
27607050000315
27607050000315
27607050000320
27607050000320
27607050000315
27607050000320
27280060000310
27280060000320
27280060000330
27550071600325
27550071600330
27550071600335
Rev. 75
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
METFORMIN HCL
METFORMIN HCL
METFORMIN HCL
METFORMIN HCL
METFORMIN HCL
METFORMIN HCL
METFORMIN HCL
METFORMIN HCL
METFORMIN HCL
METFORMIN HCL
METFORMIN HCL
METFORMIN HCL
METFORMIN HCL
METFORMIN HCL
METFORMIN HCL
METFORMIN HCL
METFORMIN HCL
METFORMIN HCL
METFORMIN-GLIBENCLAMIDE
PIOGLITAZONE
PIOGLITAZONE
PIOGLITAZONE
PIOGLITAZONE
PIOGLITAZONE
PIOGLITAZONE
PIOGLITAZONE
PIOGLITAZONE
PIOGLITAZONE
REPAGLINIDE
REPAGLINIDE
REPAGLINIDE
SITAGLIPTIN
SITAGLIPTIN
SITAGLIPTIN
INDIVIDUAL BENEFITS
METFORMIN-H2K TAB XR 500mg
METFORMIN-H2K TAB 500mg
METFORMIN-H2K TAB 500mg
METFORMIN-DENK TAB 500mg
METFORMIN-LAS TAB 500mg
METFORMIN-LAS TAB XR 500mg
METFORMIN-LAS TAB 850mg
METFORMIN-PMS TAB 500mg
ORABET TAB 500mg
XMET TAB 500mg
XMET TAB 500mg
ZOMET TAB 500mg
ZOMET TAB 500mg
GLUCOVANCE TAB 250-1.25mg
GLUCOVANCE TAB 500-5mg
GLUCOVANCE TAB 500-2.5mg
GLUCOVANCE TAB 1000-5mg
ACTOS TAB 15mg
ACTOS TAB 30mg
ACTOS TAB 45mg
DIAVISTA 15 mg TAB
DIAVISTA 15 mg TAB
DIAVISTA 30 mg TAB
DIAVISTA 30 mg TAB
PIOGLIT TAB 15mg
PIOGLIT TAB 30mg
NOVONORM TAB 0.5 mg
NOVONORM TAB 1 mg
NOVONORM TAB 2 mg
JANUVIA TAB 25mg
JANUVIA TAB 50mg
JANUVIA TAB 100mg
100
140
100
100
500
30
30
120
30
100
100
100
500
500
500
100
30
1000
30
30
30
30
30
30
30
20
100
20
100
30
30
30
30
30
28
28
28
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
Page 14 of 39
$3.44
$3.44
$3.44
$3.44
$3.44
$3.44
$5.83
$5.83
$6.86
$3.44
$3.44
$5.83
$3.44
$3.44
$3.44
$3.44
$3.44
$3.44
$13.07
$31.89
$26.12
$52.24
$107.17
$214.32
$321.49
$107.17
$107.17
$214.32
$214.32
$107.17
$214.32
$8.57
$17.15
$34.30
$23.60
$47.20
$94.40
85560455056
85560455256
85713114050
85713112050
85713121150
85301123050
85301123150
85578147550
85866264050
85647243550
85846288450
85115288750
85441326550
85116586650
85116586630
85116586725
85116586610
85547583050
85547623050
85427611650
85302323050
85302323150
85804176250
85579726150
85427730550
85427731550
85713122020
85713122001
85713122025
85301124010
85301124001
85866264510
85866264501
85846288210
85846288201
85460276010
85460276001
27992502700320
27992502700330
94100030006000
94100030006000
94100030006000
94100030006000
94100030006000
94100030006000
94100030006000
94100030006000
94100030006000
94100030006000
94100030006000
94100030006000
94100030006000
94100030006000
94100030006000
94100030006000
94100030006000
94100030006000
94100030006000
94100030006000
94100030006000
94100030006000
94100030006000
94100030006000
97202025006300
97202025006300
97202025006300
97202025006300
97202025006300
97202025006300
97202025006300
97202025006300
97202025006300
97202025006300
97202025006300
Rev. 75
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
SITAGLIPTIN & METFORMIN
SITAGLIPTIN & METFORMIN
GLUCOMETER BLOOD GLUCOSE TEST STRIP
LANCET
LANCET
LANCET
LANCET
LANCET
LANCET
LANCET
LANCET
LANCET
LANCET
LANCET
INDIVIDUAL BENEFITS
JANUMET TAB 50mg /500mg
56
JANUMET TAB 50mg /1000mg
56
Accu-Chek Advantage Blood Glucose Test Strips
50
Accu-Chek Active Blood Glucose Test Strips
50
Accu-Chek Performa Blood Glucose Test Strips
50
Advocate Blood Glucose Test Strips
50
Advocate Redi-Code Blood Glucose Test Strips
50
Betachek Blood Glucose Test Strips
50
Ez Smart Blood Glucose Test Strips
50
Easi Check Precise Glucose Test Strips
50
Freestyle Blood Glucose Test Strips
50
Freestyle Lite Blood Glucose Test Strips
50
Glucolab Blood Glucose Test Strips
50
ON-Call Plus Blood Glucose Test Strips
50
30
25
100
Optium Blood Glucose Test Strips
50
Precision Xtra Blood Glucose Test Strips
50
Prestige Blood Glucose Test Strips
50
Prodigy Blood Glucose Test Strips
50
Prodigy Autocode Blood Glucose Test Strips #52800
50
Standard Diagnostics(SD) Code Free Blood Glucose Test Strips 50
TRUEbalance Blood Glucose Test Strips
50
TRUEread Blood Glucose Test Strips
50
Truetrack Blood Glucose Test Strips
50
Accu-Chek Softclix 11 Lancets
200
1
25
Advocate Lancets- 30G
100
Advocate Lancets- 30G
1
Ez Smart Lancets
100
Ez Smart Lancets
1
Freestyle Lancets
100
Freestyle Lancets
1
JT Fine Lancets
100
JT Fine Lancets
1
TAB/CAP
TAB/CAP
Strip
Strip
Strip
Strip
Strip
Strip
Strip
Strip
Strip
Strip
Strip
Strip
Strip
Strip
Strip
Strip
Strip
Strip
Strip
Strip
Strip
Strip
Strip
Strip
Lancet
Lancet
Lancet
Lancet
Lancet
Lancet
Lancet
Lancet
Lancet
Lancet
Lancet
$49.40
$51.60
$1,693.01
$1,693.01
$1,693.01
$1,693.01
$1,693.01
$1,693.01
$1,693.01
$1,693.01
$1,693.01
$1,693.01
$1,693.01
$1,693.01
$1,015.81
$846.50
$3,386.02
$1,693.01
$1,693.01
$1,693.01
$1,693.01
$1,693.01
$1,693.01
$1,693.01
$1,693.01
$1,693.01
$468.22
$2.34
$58.46
$234.11
$2.34
$234.11
$2.34
$234.11
$2.34
$234.11
$2.34
Page 15 of 39
85537472010
85537472001
85547512010
85547512001
85116585510
85116585610
85116585601
85129733010
85129733001
85867411910
85867411901
85867412010
85867412001
85867412210
85867412201
85196162010
85196162001
85590551010
85590551001
85129733110
85129733101
85196140501
85196141001
85196141701
85196142001
85196141501
85557242101
85557242201
85557243001
85557243101
85844384501
85844384001
85844383501
85539472801
85539473001
85539473101
85539472501
97202025006300
97202025006300
97202025006300
97202025006300
97202025006300
97202025006300
97202025006300
97202025006300
97202025006300
97202025006300
97202025006300
97202025006300
97202025006300
97202025006300
97202025006300
97051020316315
97051020316315
97051020316320
97051020316320
97051020316315
97051020316315
97051030906320
97051030906327
97051030906380
97051030906384
97051030906370
97051030906328
97051030906325
97051030906384
97051030906386
97051030906327
97051030906380
97051030906370
97051030906328
97051030906327
97051030906325
97051030906308
Rev. 75
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
LANCET
LANCET
LANCET
LANCET
LANCET
LANCET
LANCET
LANCET
LANCET
LANCET
LANCET
LANCET
LANCET
LANCET
LANCET
PENFILL NEEDLE
PENFILL NEEDLE
PENFILL NEEDLE
PENFILL NEEDLE
PENFILL NEEDLE
PENFILL NEEDLE
INSULIN SYRINGE
INSULIN SYRINGE
INSULIN SYRINGE
INSULIN SYRINGE
INSULIN SYRINGE
INSULIN SYRINGE
INSULIN SYRINGE
INSULIN SYRINGE
INSULIN SYRINGE
INSULIN SYRINGE
INSULIN SYRINGE
INSULIN SYRINGE
INSULIN SYRINGE
INSULIN SYRINGE
INSULIN SYRINGE
INSULIN SYRINGE
INDIVIDUAL BENEFITS
MPD Ultra Thin Lancets
MPD Ultra Thin Lancets
Medisense Lancets
Medisense Lancets
On-Call Now Lancets
On- Call Plus Lancets
On- Call Plus Lancets
SURE COMFORT 30G LANCETS
SURE COMFORT 30G LANCETS
Vitalcare Safety Lancets 26G
Vitalcare Safety Lancets 26G
Vitalcare Lancets 28G
Insulin Pen Needle(For use with Humapens) 31G
Insulin Pen Needle(For use with Humapens) 31G
Novofine Needle 31G
Novofine Needle 31G
Sure Comfort Pen Needle 31G
Sure Comfort Pen Needle 31G
B-D Insulin Syringes 1/2cc /28G / I/2 ins
B-D Insulin Syringes 1/2cc /29G / I/2 ins
B-D Insulin Syringes 1cc /29G / I/2 ins
B-D Insulin Syringes 1cc 30Gx 8mm
B-D Insulin Syringes 1cc/ 28G / 1/2 ins
Easy Touch Insulin Syringes- .5cc x 30G x 5/16 ins
Easy Touch Insulin Syringes- .5cc x 31G x 5/16 ins
Easy Touch Insulin Syringes- 1cc x 30G x 5/16 ins
Easy Touch Insulin Syringes- 1cc x 31G x 5/16 ins
Insulin Syringes-Terumo 1cc/ 29G / 1/2 ins
Insulin Syringes-Terumo 1/2 cc /29G/ 1/2ins
Insulin Syringes-Terumo 1/2cc /28G / 1/2ins
Lite Touch Insulin Syringes 1/2cc /30G/8mm
Lite Touch Insulin Syringes 1/2cc/ 29 G/ I/2ins
Lite Touch Insulin Syringes 1/2cc/ 31 G/ 8mm
Lite Touch Insulin Syringes 0.3cc/ 31 G/ 8mm
100
1
100
1
100
100
1
100
1
100
1
100
1
100
1
100
1
100
1
100
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Lancet
Lancet
Lancet
Lancet
Lancet
Lancet
Lancet
Lancet
Lancet
Lancet
Lancet
Lancet
Lancet
Lancet
Lancet
Needle
Needle
Needle
Needle
Needle
Needle
Syringe
Syringe
Syringe
Syringe
Syringe
Syringe
Syringe
Syringe
Syringe
Syringe
Syringe
Syringe
Syringe
Syringe
Syringe
Syringe
$234.11
$2.34
$234.11
$2.34
$234.11
$234.11
$2.34
$234.11
$2.34
$234.11
$2.34
$234.11
$2.34
$234.11
$2.34
$1,442.30
$14.42
$1,442.30
$14.42
$1,442.30
$14.42
$11.78
$11.78
$11.78
$11.78
$11.78
$11.78
$11.78
$11.78
$11.78
$11.78
$11.78
$11.78
$11.78
$11.78
$11.78
$11.78
Page 16 of 39
85539474001
85539475001
85547622401
85547622201
85129731801
85129731901
85129730501
85129731201
85129732001
85129731501
00193284450
85186323050
00193218121
85513511210
85513511610
85116114010
85116114910
85116115010
85116115510
85842794010
85842793010
00193218421
N/A
85860414030
85860414230
85860413830
85365183011
85365183050
00071000724
00071036224
85625373020
85213257510
85595612010
77131313793
77131313794
77131313795
85650352810
97051030906380
97051030906384
97051030906328
97051030906380
97051030906380
97051030906385
97051030906308
97051030906323
97051030906386
97051030906325
94100035106000
94100035106000
94109900006100
94109900006100
94109900006100
94109900006100
94109900006100
94109900006100
94109900006100
94109900006100
94109900006100
94109900006100
N/A
72600042000320
72600042000330
72600042002020
60100060000315
60100060000315
72200030000505
72200030200110
72200030200110
72200030100210
72200030100110
72600030000110
72600030000130
72600030000140
72600030000110
Rev. 75
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
Epilepsy
Epilepsy
Epilepsy
Epilepsy
Epilepsy
Epilepsy
Epilepsy
Epilepsy
Epilepsy
Epilepsy
Epilepsy/Diabetes
Epilepsy/Diabetes
Epilepsy/Diabetes
Epilepsy/Diabetes
INSULIN SYRINGE
INSULIN SYRINGE
INSULIN SYRINGE
INSULIN SYRINGE
INSULIN SYRINGE
INSULIN SYRINGE
INSULIN SYRINGE
INSULIN SYRINGE
INSULIN SYRINGE
INSULIN SYRINGE
URINE TEST STRIP
URINE TEST STRIP
URINE TEST STRIP
URINE TEST STRIP
URINE TEST STRIP
URINE TEST STRIP
URINE TEST STRIP
URINE TEST STRIP
URINE TEST STRIP
URINE TEST STRIP
URINE TEST STRIP
URINE TEST STRIP
TEST REAGENT
LEVETIRACETAM
LEVETIRACETAM
LEVETIRACETAM
PHENOBARBITAL
PHENOBARBITAL
PHENYTOIN
PHENYTOIN SODIUM
PHENYTOIN SODIUM
PHENYTOIN SODIUM
PHENYTOIN SODIUM
GABAPENTIN
GABAPENTIN
GABAPENTIN
GABAPENTIN
INDIVIDUAL BENEFITS
Lite Touch Insulin Syringes 1cc / 29 G/1/2ins
Lite Touch Insulin Syringes 1cc / 30 G/8mm
Precision Insulin Syringes 1/2 cc / 30G/ 5/16.
Precision Insulin Syringes 1cc/29G/ 1/2ins
Sure Comfort Insulin Syringes 1cc/29G/ 1/2ins
Sure Comfort Insulin Syringes 1cc/30G/ 1/2ins
Sure Comfort Insulin Syringes .3cc/31G/ 5/16 ins
Sure Comfort Insulin Syringes 1cc/31G/ 5/16 ins
Clinistix Reagent Strips
Glucostix
Labstix
MEDI-TEST COMBI 2 STRIPS
MEDI-TEST COMBI 6 A STRIPS
Mission 3 (2+) Urinalysis Reagent Test Strips
Mission 5 Urinalysis Reagent Test Strips
TC URS-2P Urine Reagent Test Strips
TC URS-10 Urine Reagent Test Strips
Uristix
NycoHbA1c Blood Glucose Test
KEPPRA TAB 500mg
KEPPRA TAB 1000mg
KEPPRA 10% SOLUTION
BARBIFED TAB 30mg
BARBIFED TAB 30mg
DILANTIN CHW 50mg
DILANTIN CAP 100mg
DILANTIN CAP 100mg
EPILANTIN TAB 100mg
NOVO-PHENYTOIN CAP 100mg
APO-GABAPENTIN CAP 100mg
GABAPENTIN- PMS CAP 100mg
1
1
1
1
1
1
1
1
1
1
50
50
100
100
100
100
100
100
100
100
100
100
1
30
30
300ml
1000
500
100
100
200
100
1000
100
100
100
100
Syringe
Syringe
Syringe
Syringe
Syringe
Syringe
Syringe
Syringe
Syringe
Syringe
Strip
Strip
Strip
Strip
Strip
Strip
Strip
Strip
Strip
Strip
Strip
Strip
Liquid
TAB/CAP
TAB/CAP
Liquid
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
$11.78
$11.78
$11.78
$11.78
$11.78
$11.78
$11.78
$11.78
$11.78
$11.78
$391.26
$391.26
$1,740.39
$1,052.12
$1,740.39
$1,052.12
$1,731.62
$1,740.39
$1,377.63
$1,052.12
$1,377.63
$1,052.12
$400.00
$64.00
$128.00
$3,796.00
$2.69
$2.69
$10.92
$21.83
$21.83
$21.83
$21.83
$17.60
$52.80
$70.40
$17.60
Page 17 of 39
85650363010
85650363210
85738296010
85738296110
00071080324
00071080524
00071080624
85625512028
85625512228
85625512428
85625512628
00074621413
00074621513
85115263810
85115264010
85400478030
85400478530
85400479030
85650461010
85650461015
00074568216
85115263001
85740362210
85740362510
85740362810
85740363001
85740363030
85740362010
85852813010
85852814010
85852814510
85852813510
85455785560
85455786520
85455786020
85455786220
85439755020
72600030000130
72600030000140
72600030000130
72600030000140
72600030000110
72600030000130
72600030000140
72600055000130
72600055000132
72600055000135
72600055000140
72500010100610
72500010100615
72500010100410
72500010100415
72600040000560
72600040000565
72600040000570
72600040000310
72600040000330
72500020101205
72500020101205
72500020100420
72500020100430
72500020100440
72500020101202
72500020101202
72500020100325
72500020100625
72500020100430
72500020100440
72500020101202
72600075000120
72600075000330
72600075000310
72600075000320
72600075000310
Rev. 75
Epilepsy/Diabetes
Epilepsy/Diabetes
Epilepsy/Diabetes
Epilepsy/Diabetes
Epilepsy/Diabetes
Epilepsy/Diabetes
Epilepsy/Diabetes
Epilepsy/Diabetes
Epilepsy/Diabetes
Epilepsy/Diabetes
Epilepsy/Diabetes
Epilepsy/Major Depression
GABAPENTIN
GABAPENTIN
GABAPENTIN
GABAPENTIN
GABAPENTIN
GABAPENTIN
GABAPENTIN
PREGABALIN
PREGABALIN
PREGABALIN
PREGABALIN
DIVALPROEX SODIUM
DIVALPROEX SODIUM
DIVALPROEX SODIUM
DIVALPROEX SODIUM
LAMOTRIGINE
LAMOTRIGINE
LAMOTRIGINE
LAMOTRIGINE
LAMOTRIGINE
SODIUM VALPROATE
SODIUM VALPROATE
SODIUM VALPROATE
SODIUM VALPROATE
SODIUM VALPROATE
SODIUM VALPROATE
SODIUM VALPROATE
SODIUM VALPROATE
SODIUM VALPROATE
SODIUM VALPROATE
SODIUM VALPROATE
SODIUM VALPROATE
TOPIRAMATE
TOPIRAMATE
TOPIRAMATE
TOPIRAMATE
TOPIRAMATE
INDIVIDUAL BENEFITS
GABAPENTIN (Sandoz) CAP 300mg
GABAPENTIN(Sandoz) CAP 400mg
NEURONTIN CAP 100mg
NEURONTIN CAP 300mg
NEURONTIN CAP 400mg
LYRICA CAP 50mg
LYRICA CAP 75mg
LYRICA CAP 150mg
LYRICA CAP 300mg
DEPAKOTE TAB 250mg
DEPAKOTE TAB 500mg
DEPAKOTE ER TAB 250mg
DEPAKOTE ER TAB 500mg
LAMICTAL CHW. DISP. TAB 25mg
LAMICTAL CHW. DISP. TAB 50mg
LAMICTAL CHW. DISP. TAB 100 mg
LAMOTRIGINE -PMS TAB 25mg
LAMOTRIGINE -PMS TAB 100mg
DEPAKENE SYP 250/5ml
DEPAKENE SYP 250/5ml
EPILIM CHRONO TAB 200mg
EPILIM SYP 200mg/5ml
EPILIM SYP 200mg/5ml
EPILIM TAB 200mg
VALPARIN 200mg EC TAB
VALPARIN CHRONO TAB 300mg
VALPARIN CHRONO TAB 500mg
VALPARIN- 200 ORAL SOLN.
TOPAMAX SPRINKLES 15mg
TOPAMAX TAB 100mg
TOPAMAX TAB 25mg
TOPAMAX TAB 50mg
TOPAZ TAB 25mg
100
100
10
10
100
100
100
28
28
28
28
100
100
100
100
30
30
30
100
100
480ml
1ml
100
100
100
1ml
300ml
100
100
100
100
100ml
60
20
20
20
20
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
LIQ
LIQ
TAB/CAP
TAB/CAP
TAB/CAP
LIQ
LIQ
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
LIQ
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
$52.80
$70.40
$52.80
$70.40
$17.60
$52.80
$70.40
$50.48
$75.72
$151.44
$302.88
$14.79
$29.58
$14.79
$29.58
$18.09
$36.19
$72.38
$18.09
$72.38
$1,615.66
$3.36
$12.34
$18.51
$30.85
$4.53
$1,357.16
$12.34
$12.34
$18.51
$30.85
$452.39
$15.43
$102.83
$25.71
$51.42
$25.71
Page 18 of 39
85439755220
85439755420
85738767620
85738767820
85738768020
00074568113
77131300145
77131300146
85852178010
85852179510
85852179010
85595262050
85585836010
85585832050
85392746084
85585833010
85585833020
85585834020
85585835030
85585835020
85585834050
85840784050
85840784530
85840783011
85840783050
85439945030
85585884010
85585882020
85585882030
85585883020
85585883030
77131300011
77131300012
85159116005
00065024605
00065024610
85122482025
72600075000320
72600075000330
72600075000310
72600075000320
72600075000330
72500030000105
72600020000305
72600020000305
72600020000305
72600020000420
72600020000410
72600020000305
72600020001810
72600020000303
72600020000303
72600020000305
72600020000305
72600020000410
72600020000420
72600020000420
72600020000410
72600020000410
72600020000420
72600020000305
72600020000305
72600020000420
72600045001810
72600045000310
72600045000310
72600045000320
72600045000320
37100010000310
37100010000310
86250010100910
86250010101810
86250010101810
86330016002020
Rev. 75
Epilepsy/Major Depression/Diabetes Adjunct
Glaucoma
Glaucoma
Glaucoma
Glaucoma
Glaucoma
Glaucoma
TOPIRAMATE
TOPIRAMATE
TOPIRAMATE
TOPIRAMATE
TOPIRAMATE
VALPROIC ACID
CARBAMAZEPINE
CARBAMAZEPINE
CARBAMAZEPINE
CARBAMAZEPINE CR
CARBAMAZEPINE CR
CARBAMAZEPINE
CARBAMAZEPINE
CARBAMAZEPINE
CARBAMAZEPINE
CARBAMAZEPINE
CARBAMAZEPINE
CARBAMAZEPINE CR
CARBAMAZEPINE CR
CARBAMAZEPINE CR
CARBAMAZEPINE CR
CARBAMAZEPINE CR
CARBAMAZEPINE CR
CARBAMAZEPINE
CARBAMAZEPINE
CARBAMAZEPINE CR
OXCARBAZEPINE
OXCARBAZEPINE
OXCARBAZEPINE
OXCARBAZEPINE
OXCARBAZEPINE
ACETAZOLAMIDE
ACETAZOLAMIDE
BETAXOLOL HCL
BETAXOLOL HCL
BETAXOLOL HCL
BIMATOPROST
INDIVIDUAL BENEFITS
TOPAZ TAB 50mg
TOPAZ TAB 100mg
TOPIRAMATE (Sandoz) TAB 25mg
DEPAKENE CAP 250mg
APO-CARBAMAZEP TAB 200mg
APO-CARBAMAZEP TAB 200mg
CARBATOL 200mg TAB
CARBATOL CR 400mg TAB
CARBATOL CR 200mg TAB
NOVO-CARBAMAZEPINE TAB 200mg
TEGRETOL SUSP. 100mg/5ml
TEGRETOL TAB 100mg
TEGRETOL TAB 100mg
TEGRETOL TAB 200mg
TEGRETOL TAB 200mg
TEGRETOL CR TAB 200mg
TEGRETOL CR TAB TAB 200mg
TERIL CR TAB 200mg
TERIL CR TAB 400mg
TERIL TAB 200mg
TERIL TAB 200mg
ZEN RETARD ER TAB 400mg
TRILEPTAL SUSP 300mg/5ML
TRILEPTAL TAB 300mg
TRILEPTAL TAB 300mg
TRILEPTAL TAB 600mg
TRILEPTAL TAB 600mg
APO-ACETAZOLAM TAB 250mg
APO-ACETAZOLAM TAB 250mg
ACCULOL SOL 0.5% OP
BETOPTIC-S SUS 0.25% OP
BETOPTIC-S SUS 0.25% OP
LUMIGAN SOL 0.03% OP
20
20
20
20
20
100
100
500
100
100
100
500
100ml
50
84
100
20
20
30
20
50
50
30
1000
50
30
100ml
20
30
20
30
100
500
5ml
5ml
10ml
2.5ml
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
LIQ
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
LIQ.
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
OPT
OPT
OPT
OPT
$51.42
$102.83
$25.71
$51.42
$102.83
$17.30
$12.63
$12.63
$12.63
$25.27
$12.63
$12.63
$240.00
$6.32
$6.32
$12.63
$12.63
$12.63
$25.27
$25.27
$12.63
$12.63
$25.27
$12.63
$12.63
$25.27
$663.22
$49.92
$49.92
$99.84
$99.84
$3.04
$3.04
$780.55
$780.55
$1,561.10
$1,352.00
Page 19 of 39
85122125005
85122125010
85361152005
85658162005
85122183005
00065027505
85123135010
85130202005
85423225005
85658327005
85560852005
85560275005
85658327205
85640842025
85658483025
85658483225
85641874025
11980025265
11980025220
00998020415
00998020615
85363614505
85363614005
85361614015
85525642010
85525643010
85525644010
85525645010
00364713272
00364713472
77131300854
77131300856
85140744010
85363382005
85585632505
85237576505
85270622005
86602020102008
86602020102008
86602020102010
86602020102010
86259902102020
86802320001820
86802320001820
86807011002020
86802340102020
86802340102020
86802340102020
86259902202020
86259902202020
86330050002020
86330050002020
86259902502020
86259902502020
86250020102005
86250020102005
86501030102020
86501030102030
86501030102030
86501030102020
86501030102030
86501030102015
86501030102020
86501030102025
86501030102030
86501030102020
86501030102030
86250030102005
86250030102010
86250030102010
86250030102010
86250030104010
86250030102010
86250030102005
Rev. 75
Glaucoma
Glaucoma
Glaucoma
Glaucoma
Glaucoma
Glaucoma
Glaucoma
Glaucoma
Glaucoma
Glaucoma
Glaucoma
Glaucoma
Glaucoma
Glaucoma
Glaucoma
Glaucoma
Glaucoma
Glaucoma
Glaucoma
Glaucoma
Glaucoma
Glaucoma
Glaucoma
Glaucoma
Glaucoma
Glaucoma
Glaucoma
Glaucoma
Glaucoma
Glaucoma
Glaucoma
Glaucoma
Glaucoma
Glaucoma
Glaucoma
Glaucoma
Glaucoma
BRIMONIDINE
BRIMONIDINE
BRIMONIDINE
BRIMONIDINE
BRIMONIDINE & TIMOLOL
BRINZOLAMIDE
BRINZOLAMIDE
CANABIS SATIVA
DORZOLAMIDE HCL
DORZOLAMIDE HCL
DORZOLAMIDE HCL
DORZOLAMIDE-TIMOLOL
DORZOLAMIDE-TIMOLOL
LATANOPROST
LATANOPROST
LATANOPROST & TIMOLOL
LATANOPROST & TIMOLOL
LEVOBUNOLOL
LEVOBUNOLOL
PILOCARPINE HCL
PILOCARPINE HCL
PILOCARPINE HCL
PILOCARPINE HCL
PILOCARPINE HCL
PILOCARPINE HCL
PILOCARPINE HCL
PILOCARPINE HCL
PILOCARPINE HCL
PILOCARPINE HCL
PILOCARPINE HCL
TIMOLOL MALEATE
TIMOLOL MALEATE
TIMOLOL MALEATE
TIMOLOL MALEATE
TIMOLOL MALEATE
TIMOLOL MALEATE
TIMOLOL MALEATE
INDIVIDUAL BENEFITS
ALPHAGAN P SOL 0.15% OP
ALPHAGAN P SOL 0.15% OP
BRIMONIDINE TARTRATE SOL 0.2% OP
BRIMOPRESS SOL 0.2% OP
COMBIGAN SOL 0.2% / 0.5% OP
AZOPT SUS 1% OP
AZOPT SUS 1% OP
CANASOL DROPS OP
DORZOLAMIDE -H2K SOL 2% OP
GLAUCOTENSIL D SOL 2% OP
TRUSOPT SOL 2% OP
COSOPT SOL 2.5% OP
GLAUCOTENSIL TD SOL 2% & 0.5% OP
XALATAN SOL 0.005% OP
LOUTEN SOL 0.005% OP
LOUTEN-T SOL 0.005%/0.5% OP
XALACOM SOL 0.005%/0.5% OP
BETAGAN SOL 0.5% OP
BETAGAN SOL 0.5% OP
ISOPTO CARP SOL 2% OP
ISOPTO CARP SOL 4% OP
PILOCAR OP 4% SOL
PILOCAR OP 2% SOL
PILOCARPINE-FLC OP 4% SOL
PILOCARPINE-MTD OP 1% SOL
PILOCARPINE-SHN SOL 2% OP
PILOCARPINE-SHN SOL 4% OP
APO-TIMOP SOL 0.25% OP
IOTIM SOL 0.5% OP
NYOLOL GEL 0.1% OP
OCUPRES-E SOL 0.5% OP
OCUTIM SOL 0.25% OP
5ml
10ml
5ml
5ml
5ml
5ml
10ml
5ml
5ml
5ml
5ml
5ml
5ml
2.5ml
2.5ml
2.5ml
2.5ml
2.5ml
10ml
15ml
15ml
5ml
5ml
15ml
10ml
10ml
10ml
10ml
15ml
15ml
5ml
5ml
10ml
5ml
5ml
5ml
5ml
OPT
OPT
OPT
OPT
OPT
OPT
OPT
OPT
OPT
OPT
OPT
OPT
OPT
OPT
OPT
OPT
OPT
OPT
OPT
OPT
OPT
OPT
OPT
OPT
OPT
OPT
OPT
OPT
OPT
OPT
OPT
OPT
OPT
OPT
OPT
OPT
OPT
$878.80
$1,757.60
$878.80
$878.80
$1,225.64
$1,110.83
$2,221.65
$279.07
$1,147.54
$1,147.54
$1,147.54
$1,930.24
$1,930.24
$1,852.50
$1,852.50
$1,434.24
$1,434.24
$956.80
$1,913.60
$199.99
$399.97
$133.32
$66.67
$399.97
$66.67
$133.32
$199.99
$266.64
$199.99
$399.97
$173.43
$346.84
$693.68
$346.84
$346.84
$346.84
$173.43
Page 20 of 39
85270623005
85159584005
85658624005
85658624505
85423742005
85472761005
85472762005
85525781005
85525782005
00006336603
00006336703
85560802025
85560803025
85869745005
85658322003
85123752025
85123752125
85123232025
85265652005
77131318950
77131318969
77131318971
85423132030
85423132230
85213478030
85213478130
85213478230
85615462020
85615463020
85615464040
85560342010
85560342020
85755952007
85755952014
85560945014
85560945214
85560945414
86250030102010
86250030102010
86250030102005
86250030102010
86250030102010
86250030102005
86250030102010
86250030102005
86250030102010
86250030102005
86250030102010
86250030102050
86250030102055
86250030102010
86330065002020
86330065002020
86330065002020
86339902742020
86330070302020
39400010100310
39400010100320
39400010100330
39400010100310
39400010100320
39400010100310
39400010100320
39400010100330
39400010100310
39400010100320
39400010100330
39500030000310
39500030000310
39500030000310
39500030000310
39509902260310
39509902260320
39509902260340
Rev. 75
Glaucoma
Glaucoma
Glaucoma
Glaucoma
Glaucoma
Glaucoma
Glaucoma
Glaucoma
Glaucoma
Glaucoma
Glaucoma
Glaucoma
Glaucoma
Glaucoma
Glaucoma
Glaucoma
Glaucoma
Glaucoma
Glaucoma
H.Cholest./Diabetes/Hypertension/ IHD Adjunct
TIMOLOL MALEATE
TIMOLOL MALEATE
TIMOLOL MALEATE
TIMOLOL MALEATE
TIMOLOL MALEATE
TIMOLOL MALEATE
TIMOLOL MALEATE
TIMOLOL MALEATE
TIMOLOL MALEATE
TIMOLOL MALEATE
TIMOLOL MALEATE
TIMOLOL MALEATE
TIMOLOL MALEATE
TIMOLOL MALEATE
TRAVOPROST
TRAVOPROST
TRAVOPROST
TRAVOPROST & TIMOLOL
UNOPROSTONE ISOPROPYL
ATORVASTATIN CALCIUM
EZETIMIBE
EZETIMIBE
EZETIMIBE
EZETIMIBE
EZETIMIBE & SIMVASTATIN
INDIVIDUAL BENEFITS
OCUTIM SOL 0.5% OP
OPTIMOL SOL 0.5% OP
POENTIMOL SOL 0.25% OP
POENTIMOL SOL 0.5% OP
TIMOLOL-H2K SOL 0.5% OP
TIMOLOL-LAS SOL 0.25% OP
TIMOLOL-LAS SOL 0.5% OP
TIMOLOL-MTD SOL 0.25% OP
TIMOLOL-MTD SOL 0.5% OP
TIMOPTIC SOL 0.25% OP
TIMOPTIC SOL 0.5% OP
TIMOPTIC-XE SOL 0.25% OP
TIMOPTIC-XE SOL 0.5% OP
VYTIM SOL 0.5% OP
GLAUCOPROST SOL .004% OP
TRAVATAN SOL. .004% OP
TRAVATAN BAK-FREE SOL. .004% OP
DUOTRAV SOL. .004% / 0.5%
RESCULA SOL. .12% OP
APO- ATORVASTATIN TAB 10mg
ATORVASTATIN-H2K TAB 10mg
ATORVASTATIN-H2K TAB 20mg
LIPIREST TAB 10mg
LIPIREST TAB 20mg
LIPIREST TAB 40mg
LIPITOR TAB 10mg
LIPITOR TAB 20mg
LIPITOR TAB 40mg
EZETROL TAB 10mg
EZETROL TAB 10mg
ZETIA TAB 10mg
ZETIA TAB 10mg
VYTORIN TAB 10mg/10mg
5ml
5ml
5ml
5ml
5ml
5ml
5ml
5ml
5ml
5ml
5ml
2.5ml
2.5ml
5ml
2.5ml
2.5ml
2.5ml
2.5ml
5ml
100
100
100
30
30
30
30
30
20
20
20
10
20
7
14
14
14
14
OPT
OPT
OPT
OPT
OPT
OPT
OPT
OPT
OPT
OPT
OPT
OPT
OPT
OPT
OPT
OPT
OPT
OPT
OPT
OPT
OPT
OPT
OPT
OPT
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
$346.84
$346.84
$173.43
$346.84
$346.84
$173.43
$346.84
$173.43
$346.84
$173.43
$346.84
$173.43
$346.84
$346.84
$1,418.56
$1,418.56
$1,418.56
$1,639.02
$1,433.25
$69.88
$139.77
$139.77
$69.88
$139.77
$69.88
$139.77
$139.77
$69.88
$139.77
$139.77
$83.20
$83.20
$83.20
$83.20
$92.49
$92.49
$139.66
Page 21 of 39
85560945614
85585482028
85585483028
85585484028
77131301350
00071073720
77131307557
85315472010
85650492010
85650492510
85560502030
85115562090
85115562290
85115562490
77131313946
77131313947
77131313948
00003515405
00003517805
00003519410
85680632010
85650631510
85650632010
85650632510
85165221528
85165222028
85165222030
85165222528
85165222328
77131315833
77131315835
77131315838
85451716028
85451716128
85451716228
85205812030
85205813030
39509902260380
39400030100120
39400030100140
39400030100340
39200030000310
39200030000310
39400050000310
39400050000310
39400050000310
39400050000320
39400050000310
39450050000450
39450050000460
39450050000470
39400065100320
39400065100330
39400065100340
39400065100320
39400065100330
39400065100340
39400065100330
39400065100320
39400065100330
39400065100340
39400070000310
39400070000320
39400070000320
39400070000330
39400070000340
39400075000320
39400075000330
39400075000340
39400075000320
39400075000330
39400075000340
39400075000320
39400075000330
Rev. 75
FLUVASTATIN SODIUM
FLUVASTATIN SODIUM
FLUVASTATIN SODIUM
GEMFIBROZIL
GEMFIBROZIL
LOVASTATIN
LOVASTATIN
LOVASTATIN
LOVASTATIN
LOVASTATIN
NICOTINIC ACID (NIACIN) CR
PRAVASTATIN SODIUM
PRAVASTATIN SODIUM
PRAVASTATIN SODIUM
PRAVASTATIN SODIUM
PRAVASTATIN SODIUM
PRAVASTATIN SODIUM
PRAVASTATIN SODIUM
PRAVASTATIN SODIUM
PRAVASTATIN SODIUM
PRAVASTATIN SODIUM
ROSUVASTATIN
ROSUVASTATIN
ROSUVASTATIN
ROSUVASTATIN
ROSUVASTATIN
SIMVASTATIN
SIMVASTATIN
SIMVASTATIN
SIMVASTATIN
SIMVASTATIN
SIMVASTATIN
SIMVASTATIN
SIMVASTATIN
INDIVIDUAL BENEFITS
LESCOL CAP 20mg
LESCOL CAP 40mg
LESCOL XL TAB 80mg
APO-GEMFIBROZIL TAB 600mg
LOPID TAB 600mg
APO-LOVASTATIN TAB 20mg
LOSTATIN TAB 20mg
LOVASTATIN-PMS TABS 20mg
LOVASTATIN-PMS TABS 40mg
MEVACOR TAB 20mg
NIASPAN ER TABS 500mg
APO-PRAVASTATIN TAB 10mg
PRAVACHOL TAB 10mg
PRAVACHOL TAB 20mg
PRAVACHOL TAB 40mg
PRAVATOR TAB 20mg
PRAVASTATIN-PMS TAB 10mg
CRESTOR TAB 5mg
CRESTOR TAB 10mg
CRESTOR TAB 10mg
CRESTOR TAB 20mg
CRESTOR TAB 40mg
APO-SIMVASTATIN TABLETS 10mg
SIMLO TAB 10mg
SIMLO TAB 20mg
SIMLO TAB 40mg
SIMPLAQOR TAB 10mg
SIMPLAQOR TAB 20mg
14
28
28
28
100
60
100
10
100
100
30
90
90
90
30
30
30
90
90
90
10
100
100
100
28
28
30
28
28
30
30
30
28
28
28
30
30
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
Page 22 of 39
$139.66
$41.76
$83.49
$167.03
$30.44
$30.44
$42.31
$42.31
$42.31
$84.61
$42.31
$99.00
$148.50
$198.00
$21.29
$42.59
$85.18
$21.29
$42.59
$85.18
$42.59
$21.29
$42.59
$85.18
$40.80
$81.60
$81.60
$163.20
$163.20
$24.87
$49.74
$99.47
$24.87
$49.74
$99.47
$24.87
$49.74
85738752030
85178718030
85178718230
85869717030
85869717230
85869717430
85335708030
85335708230
85423729010
85423729210
85472732010
85472732030
85472732530
85472732510
85650736830
85650737010
85439717030
85680732010
85680733010
85680734010
85680734050
85560972030
85560973030
85560974030
77131300028
77131300031
85245272011
85245272050
85245274011
85245274022
85124144012
85245372025
85245372020
77131300441
77131300442
77131300446
85124314056
39400075000340
39400075000330
39400075000340
39400075000320
39400075000330
39400075000340
39400075000330
39400075000340
39400075000330
39400075000340
39400075000320
39400075000320
39400075000330
39400075000330
39400075000330
39400075000340
39400075000330
39400075000320
39400075000330
39400075000340
39400075000340
39400075000320
39400075000330
39400075000340
37990002100310
37990002100310
37600010000305
37600010000305
37600010000310
37600010000310
37600010000310
36991002280305
36991002280305
36400010100310
36400010100310
36400010100315
36400010100310
Rev. 75
Hypertension
Hypertension
Hypertension
Hypertension
Hypertension
Hypertension
Hypertension
Hypertension
Hypertension
Hypertension
Hypertension
Hypertension
Hypertension
SIMVASTATIN
SIMVASTATIN
SIMVASTATIN
SIMVASTATIN
SIMVASTATIN
SIMVASTATIN
SIMVASTATIN
SIMVASTATIN
SIMVASTATIN
SIMVASTATIN
SIMVASTATIN
SIMVASTATIN
SIMVASTATIN
SIMVASTATIN
SIMVASTATIN
SIMVASTATIN
SIMVASTATIN
SIMVASTATIN
SIMVASTATIN
SIMVASTATIN
SIMVASTATIN
SIMVASTATIN
SIMVASTATIN
SIMVASTATIN
AMILORIDE & HYDROCHLOROTHIAZIDE
AMILORIDE & HYDROCHLOROTHIAZIDE
BENDROFLUAZIDE
BENDROFLUAZIDE
BENDROFLUAZIDE
BENDROFLUAZIDE
BENDROFLUMETHIAZIDE
BENDROFLUAZIDE & RESERPINE
BENDROFLUAZIDE & RESERPINE
HYDRALAZINE HCL
HYDRALAZINE HCL
HYDRALAZINE HCL
HYDRALAZINE HCL
INDIVIDUAL BENEFITS
SIMPLAQOR TAB 40mg
SIMSTATIN TAB 20mg
SIMSTATIN TAB 40mg
SIMVA TAB 10mg
SIMVA TAB 20mg
SIMVA TAB 40mg
SIMVA-DENK 20mg TABLETS
SIMVA-DENK 40mg TABLETS
SIMVASTATIN-H2K TAB 20mg
SIMVASTATIN-H2K TAB 40mg
SIMVASTATIN-LAS TAB 10mg
SIMVASTATIN-PMS TAB 20mg
SIMVASTATIN-PMS TAB 40mg
SIMTAS TAB 20mg
SIMVOR TAB 10mg
SIMVOR TAB 20mg
SIMVOR TAB 40mg
SIMVOR TAB 40mg
ZOCOR TAB 10mg
ZOCOR TAB 20mg
ZOCOR TAB 40mg
APO-AMILZIDE TAB 5mg/50mg
APO-AMILZIDE TAB 5mg/50mg
BEZIDE HS TAB 2.5mg
BEZIDE HS TAB 2.5mg
BEZIDE TAB 5mg
BEZIDE TAB 5mg
BENDROFLUMETHIAZIDE -ALP TAB 5mg
COMBEZIDE B TAB
COMBEZIDE B TAB
APO-HYDRALAZINE TAB 25mg
HYDRALAZINE-ALP TAB 25mg
30
30
30
30
30
30
30
30
100
100
10
30
30
10
30
100
30
10
10
10
50
30
30
30
100
1000
1000
500
1000
2000
1000
250
200
100
500
100
56
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
Page 23 of 39
$99.47
$49.74
$99.47
$24.87
$49.74
$99.47
$49.74
$99.47
$49.74
$99.47
$24.87
$24.87
$49.74
$49.74
$49.74
$99.47
$49.74
$24.87
$49.74
$99.47
$99.47
$24.87
$49.74
$99.47
$4.59
$4.59
$1.44
$1.44
$2.87
$2.87
$2.87
$4.22
$4.22
$2.52
$2.52
$5.03
$2.52
77131300451
85140402050
77131300456
85140403010
85285392010
85830442011
85830442050
85852483010
85852482530
85775572030
85560152030
85560153030
85355302050
85355303050
85178515010
85124532056
85733518050
77131300531
77131300533
85585792010
85585792050
85585202010
85770152010
85852124010
77131300136
77131300139
85215202090
85215203090
59772704501
59772704601
59772704701
85335152010
85423148810
85423149210
85472173030
85595252010
85595252011
37600040000305
37600040000305
37600040000310
37600040000310
37600040000305
37600040000310
37600040000310
37600050000305
37600050000404
37600050000404
36201030000310
36201030000315
36201030000310
36201030000315
36201030000310
36201030000310
36201030000310
79700030000420
79700030000420
79700030000420
79700030000420
36991003300320
37500020000305
36100010000310
36100010000310
36100010000315
36100010000310
36100010000315
36100010000305
36100010000310
36100010000315
36100010000310
36100010000310
36100010000315
36100010000310
36100010000310
36100010000310
Rev. 75
Hypertension
Hypertension
Hypertension
Hypertension
Hypertension
Hypertension
Hypertension
Hypertension
Hypertension
Hypertension
Hypertension
Hypertension
Hypertension
Hypertension
Hypertension
Hypertension
Hypertension
Hypertension
Hypertension
Hypertension
Hypertension
Hypertension
Hypertension
Hypertension/ IHD /Diabetes Adjunct
HYDROCHLOROTHIAZIDE
HYDROCHLOROTHIAZIDE
HYDROCHLOROTHIAZIDE
HYDROCHLOROTHIAZIDE
HYDROCHLOROTHIAZIDE
HYDROCHLOROTHIAZIDE
HYDROCHLOROTHIAZIDE
INDAPAMIDE
INDAPAMIDE
INDAPAMIDE
METHYLDOPA
METHYLDOPA
METHYLDOPA
METHYLDOPA
METHYLDOPA
METHYLDOPA
METHYLDOPA
POTASSIUM CHLORIDE
POTASSIUM CHLORIDE
POTASSIUM CHLORIDE
POTASSIUM CHLORIDE
RESERPINE/CLOPAMIDE/DIHYDROERGOCRISTINE
SPIRONOLACTONE
CAPTOPRIL
CAPTOPRIL
CAPTOPRIL
CAPTOPRIL
CAPTOPRIL
CAPTOPRIL
CAPTOPRIL
CAPTOPRIL
CAPTOPRIL
CAPTOPRIL
CAPTOPRIL
CAPTOPRIL
CAPTOPRIL
CAPTOPRIL
INDIVIDUAL BENEFITS
APO-HYDRO TAB 25mg
APO-HYDRO TAB 25mg
APO-HYDRO TAB 50mg
APO-HYDRO TAB 50mg
HYDROCHLORTHZ-COX TAB25mg
HYDROCHLORTHZ-SPM TAB50mg
HYDROCHLORTHZ-SPM TAB50mg
LORVAS TAB 2.5MG
LORVAS SR TAB 1.5MG
NATRILIX SR TAB 1.5mg
ALDOMET TAB 250mg
ALDOMET TAB 500mg
DOPEGYT TAB 250mg
DOPEGYT TAB 500mg
EMDOPA TAB 250mg
METHYLDOPA-ALP TAB 250mg
METHYLDOPA-SK H2K TAB 250mg
APO-K TAB 600mg
APO-K TAB 600mg
SLOW-K TAB 600mg CR
SLOW-K TAB 600mg CR
BRINERDIN TAB
ALDACTONE TAB 25mg
ANGIOPRIL TABS 25mg
APO-CAPTO TAB 25mg
APO-CAPTO TAB 50mg
CAPOTEN TAB 25mg
CAPOTEN TAB 50mg
CAPTOPRIL-APT TAB 12.5mg
CAPTOPRIL-APT TAB 25mg
CAPTOPRIL-APT TAB 50mg
CAPTOPRIL-DENK TAB 25mg
CAPTOPRIL-H2K TAB 25mg
CAPTOPRIL-H2K TAB 50mg
CAPTOPRIL-LAS TAB 25mg
NOVO-CAPTORIL TAB 25mg
1000
500
1000
100
100
1000
500
100
30
30
30
30
500
500
100
56
500
100
1000
100
500
100
100
100
100
100
90
90
100
100
100
100
100
100
30
100
1000
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
Page 24 of 39
$2.06
$2.06
$4.13
$4.13
$2.06
$4.13
$4.13
$17.31
$17.31
$17.31
$4.71
$9.43
$4.71
$9.43
$4.71
$4.71
$4.71
$3.34
$3.34
$3.34
$3.34
$12.68
$26.53
$6.17
$6.17
$12.33
$6.17
$12.33
$3.08
$6.17
$12.33
$6.17
$6.17
$12.33
$6.17
$6.17
$6.17
85595253010
85355902030
85355903020
85215204090
85335302330
00006072068
85560914530
85560915030
77131300314
77131300315
85140317030
77131300317
85140317530
77131300311
85140316530
85237163010
85237162010
85390384030
85390385030
85390383030
85335302030
85335302530
85423252210
85472255510
85472255010
85315344020
85315342020
85315343020
85423251510
85423252010
85213256210
85213256010
85237162011
85237163011
85680391510
85680392010
85680392020
36100010000315
36100010000310
36100010000315
36991802250340
36991802350315
36991802350310
36991802350310
36991802350315
36100020100310
36100020100310
36100020100310
36100020100315
36100020100315
36100020100305
36100020100305
36100020100310
36100020100305
36100020100310
36100020100315
36100020100305
36100020100310
36100020100315
36100020100315
36100020100310
36100020100305
36100020100310
36100020100303
36100020100305
36100020100305
36100020100310
36100020100305
36100020100310
36100020100305
36100020100310
36100020100310
36100020100315
36100020100315
Rev. 75
CAPTOPRIL
CAPTOPRIL
CAPTOPRIL
CAPTOPRIL & HYDROCHLOROTHIAZIDE
ENALAPRIL & HYDROCHLOROTHIAZIDE
ENALAPRIL MALEATE
ENALAPRIL MALEATE
ENALAPRIL MALEATE
ENALAPRIL MALEATE
ENALAPRIL MALEATE
ENALAPRIL MALEATE
ENALAPRIL MALEATE
ENALAPRIL MALEATE
ENALAPRIL MALEATE
ENALAPRIL MALEATE
ENALAPRIL MALEATE
ENALAPRIL MALEATE
ENALAPRIL MALEATE
ENALAPRIL MALEATE
ENALAPRIL MALEATE
ENALAPRIL MALEATE
ENALAPRIL MALEATE
ENALAPRIL MALEATE
ENALAPRIL MALEATE
ENALAPRIL MALEATE
ENALAPRIL MALEATE
ENALAPRIL MALEATE
ENALAPRIL MALEATE
ENALAPRIL MALEATE
ENALAPRIL MALEATE
ENALAPRIL MALEATE
ENALAPRIL MALEATE
ENALAPRIL MALEATE
ENALAPRIL MALEATE
INDIVIDUAL BENEFITS
TENSIOMIN TAB 25mg
TENSIOMIN TAB 50mg
CAPOZIDE TAB 50/25mg
ENA +HCTZ- DENK TAB 20mg/12.5mg
VASERETIC TAB 10-25mg
VASERETIC TAB 10-25mg
VASERETIC TAB 20-12.5mg
APO-ENALAPRIL TAB 10mg
BQL 10 TAB 10mg
BQL 5 TAB 5mg
EDNYT TAB 10mg
EDNYT TAB 20mg
EDNYT TAB 5mg
ENA-DENK TABLETS 10mg
ENA-DENK TABLETS 20mg
ENALAPRIL-H2K TAB 20mg
ENALAPRIL-LAS TAB 10mg
ENALAPRIL-LAS TAB 5mg
ENAM TAB 10mg
ENAM TAB 2.5mg
ENAM TAB 5mg
ENATEC TAB 5mg
ENATEC TAB 10mg
ENVAS TAB 5mg
ENVAS TAB 10mg
INVORIL TAB 10mg
INVORIL TAB 20mg
INVORIL TAB 20mg
100
30
20
90
30
100
30
30
100
500
30
100
30
100
30
100
100
30
30
30
30
30
100
100
100
20
20
20
100
100
100
100
100
100
100
100
20
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
Page 25 of 39
$12.33
$6.17
$12.33
$27.17
$67.45
$33.75
$33.75
$67.45
$8.66
$8.66
$8.66
$17.38
$17.38
$4.33
$4.33
$8.66
$4.33
$8.66
$17.38
$4.33
$8.66
$17.38
$17.38
$8.66
$4.33
$8.66
$2.19
$4.33
$4.33
$8.66
$4.33
$8.66
$4.33
$8.66
$8.66
$17.38
$17.38
85680391010
85738715220
85738715420
85738715020
85560913030
85560914030
85560912030
00087015846
00087060942
85215542010
85215543010
77131301377
77131301380
77131301374
85178479010
85738478830
85738478430
85738478030
85423474510
85423475010
85423475510
85390443028
85390444028
85390442028
85451473828
85451474028
85451474228
85852473510
85852473010
00006020758
85165904010
85165904028
85165905028
85165903010
85165903028
85165907028
85775242130
36100020100305
36100020100310
36100020100315
36100020100305
36100020100310
36100020100315
36100020100305
36100027100310
36100027100320
36991802400310
36991802400320
36100030000310
36100030000315
36100030000305
36100030000310
36100030000315
36100030000305
36100030000310
36100030000303
36100030000305
36100030000310
36100030000310
36100030000315
36100030000305
36100030000305
36100030000310
36100030000315
36100030000310
36100030000305
36100030000315
36100030000310
36100030000310
36100030000315
36100030000305
36100030000305
36991802550310
36100035050312
Rev. 75
ENALAPRIL MALEATE
ENALAPRIL MALEATE
ENALAPRIL MALEATE
ENALAPRIL MALEATE
ENALAPRIL MALEATE
ENALAPRIL MALEATE
ENALAPRIL MALEATE
FOSINOPRIL SODIUM
FOSINOPRIL SODIUM
FOSINOPRIL SOD.& HYDROCHLOROTHIAZIDE
FOSINOPRIL SOD. & HYDROCHLOROTHIAZIDE
LISINOPRIL
LISINOPRIL
LISINOPRIL
LISINOPRIL
LISINOPRIL
LISINOPRIL
LISINOPRIL
LISINOPRIL
LISINOPRIL
LISINOPRIL
LISINOPRIL
LISINOPRIL
LISINOPRIL
LISINOPRIL
LISINOPRIL
LISINOPRIL
LISINOPRIL
LISINOPRIL
LISINOPRIL
LISINOPRIL
LISINOPRIL
LISINOPRIL
LISINOPRIL
LISINOPRIL
LISINOPRIL & HYDROCHLOROTHIAZIDE
PERINDOPRIL ARGININE
INDIVIDUAL BENEFITS
INVORIL TAB 5mg
REDOPRIL TAB 10mg
REDOPRIL TAB 20mg
REDOPRIL TAB 5mg
VASOTEC TAB 10mg
VASOTEC TAB 20mg
VASOTEC TAB 5mg
MONOPRIL TAB 10mg
MONOPRIL TAB 20mg
MONOPRIL-HCT TAB 10/12.5
MONOPRIL-HCT TAB 20/12.5
APO-LISINOPRIL TAB 10mg
LINOTEN TAB 10mg
LISDENE TAB 20mg
LISDENE TAB 5mg
LISDENE TAB 10mg
LISINOPRIL -H2K TAB 2.5mg
LISINOPRIL- H2K TAB 5mg
LISINOPRIL- H2K TAB10mg
LISOPRESS TAB 10mg
LISOPRESS TAB 20mg
LISOPRESS TAB 5mg
LISORIL TAB 5mg
LISORIL TAB 10mg
LISORIL TAB 20mg
LISTRIL TAB 10mg
LISTRIL TAB 5mg
PRINIVIL TAB 20mg
ZESTRIL TAB 10mg
ZESTRIL TAB 10mg
ZESTRIL TAB 20mg
ZESTRIL TAB 5mg
ZESTRIL TAB 5mg
ZESTORETIC TAB 20-12.5mg
COVERSYL TAB 5mg
100
20
20
20
30
30
30
90
90
100
100
100
100
100
100
30
30
30
100
100
100
28
28
28
28
28
28
100
100
100
100
28
28
100
28
28
30
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
Page 26 of 39
$4.33
$8.66
$17.38
$4.33
$8.66
$17.38
$4.33
$23.32
$46.64
$32.43
$38.74
$12.82
$25.64
$6.41
$12.82
$25.64
$6.41
$12.82
$3.21
$6.41
$12.82
$12.82
$25.64
$6.41
$6.41
$12.82
$25.64
$12.82
$6.41
$25.64
$12.82
$12.82
$25.64
$6.41
$6.41
$46.91
$38.80
85775242630
85406611010
85406611210
85775622030
85775622430
85775622630
85775622230
85775202030
85615153030
85615154030
85615152030
77131317138
77131317141
77131317135
85451671128
85451671028
85270685010
85181752015
85741763015
85425852020
85425853020
85425854020
85165102028
85165102010
85165103028
85165103528
85115203030
85115202030
85165104028
85165104428
85165104628
85115204030
85741125014
85741125514
85740162030
85740163030
85741127014
36100035050322
36100035100305
36100035100310
36991802650320
36991802660310
36991802660315
36991802660320
36991802650330
36100040100310
36100040100320
36100040100305
36100050000120
36100050000130
36100050000140
36100050000130
36100050000140
36100050000330
36100050000140
36100050000340
36100050000320
36100050000330
36991802700310
36150020100320
36150020100320
36150020100330
36150020100340
36150020100330
36150020100320
36994002200320
36994002200325
36994002200330
36994002200320
36150030000320
36150030000340
36150030000320
36150030000340
36994002370320
Rev. 75
Hypertension/Diabetes Adjunct
PERINDOPRIL ARGININE
PERINDOPRIL ERBUMINE
PERINDOPRIL ERBUMINE
PERINDOPRIL TERTBUTYLAMINE & INDAPAMIDE
COVERSYL TAB 10mg
PERIGARD TAB 2mg
PERIGARD TAB 4mg
PRETERAX TAB 2mg/0.625mg (is being replaced by 2.5mg)
PERINDOPRIL TERTBUTYLAMINE & INDAPAMIDE
PRETERAX TAB 2.5mg/0.625mg
PRETERAX TAB 5mg/1.25mg
PRETERAX TAB 10mg/2.5mg
BIPRETERAX TAB 4mg/1.25mg (is being replaced by 5mg)
QUINAPRIL HCL
QUINAPRIL HCL
QUINAPRIL HCL
RAMIPRIL
RAMIPRIL
RAMIPRIL
RAMIPRIL
RAMIPRIL
RAMIPRIL
RAMIPRIL
RAMIPRIL
RAMIPRIL
RAMIPRIL
RAMIPRIL & HYDROCHLOROTHIAZIDE
CANDESARTAN CILEXETIL
CANDESARTAN & HYDROCHLOROTHIAZIDE
IRBESARTAN
IRBESARTAN
IRBESARTAN
IRBESARTAN
IRBESARTAN & HYDROCHLOROTHIAZIDE
ACCUPRIL TAB 10mg
ACCUPRIL TAB 20mg
ACCUPRIL TAB 5mg
APO-RAMIPRIL CAP 2.5mg
APO-RAMIPRIL CAP 5mg
APO-RAMIPRIL CAP 10mg
RAMCOR TABS 5mg
RAMCOR TABS 10mg
RAMIPRES-5 TABS
TRITACE PREVENT CAP 10mg
TRITACE TAB 10mg
TRITACE TAB 2.5mg
TRITACE TAB 5mg
TRITACE HCT TAB 2.5/12.5mg
ATACAND TAB 8mg
ATACAND TAB 8mg
ATACAND TAB 16mg
ATACAND TAB 32mg
BLOPRESS TAB 16mg
BLOPRESS TAB 8mg
ATACAND PLUS 16mg/12.5mg TAB
ATACAND PLUS 32mg/12.5mg TAB
ATACAND PLUS 32mg/25mg TAB
BLOPRESS PLUS 16mg/12.5mg TAB
APROVEL TAB 150mg
APROVEL TAB 300mg
AVAPRO TAB 150mg
AVAPRO TAB 300mg
CoAPROVEL TAB 300mg/12.5mg
PERINDOPRIL ARGININE & INDAPAMIDE
INDIVIDUAL BENEFITS
30
10
100
30
30
30
30
30
30
30
30
30
30
30
28
28
100
15
15
20
20
20
28
100
28
28
30
30
28
28
28
30
14
14
30
30
14
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
Page 27 of 39
$77.60
$19.40
$38.80
$47.42
$47.42
$61.02
$61.02
$61.02
$22.96
$45.90
$11.48
$18.72
$37.44
$74.88
$37.44
$74.88
$37.44
$74.88
$74.88
$18.72
$37.44
$36.30
$44.62
$44.62
$89.25
$89.25
$89.25
$44.62
$87.38
$87.38
$87.38
$87.38
$51.49
$102.98
$51.49
$102.98
$67.97
85741127514
85741126514
85680215010
85680215030
85560283015
85560282028
85560282030
85335470028
85335470228
85439481028
85423491810
85423491830
85423492010
85423492030
85178487010
85237508028
85237508228
85237508428
85451626228
85451626328
85451627028
85315682010
85315682020
85315683010
85315683020
85315682814
85852752028
85852752528
85560402528
85560402530
85560402330
85560402028
85560402030
85220502028
85220504028
85220504228
85585353014
36994002370340
36994002370315
36150040200330
36150040200330
36150040200340
36150040200330
36150040200330
36150040200330
36150040200340
36150040200330
36150040200320
36150040200320
36150040200330
36150040200330
36150040200330
36150040200320
36150040200330
36150040200340
36150040200320
36150040200330
36994002450320
36150040200320
36150040200320
36150040200330
36150040200330
36994002450320
36150040200320
36150040200330
36994002450340
36994002450340
36994002450330
36994002450320
36994002450320
36150070000340
36994002620320
36994002620325
36150080000130
Rev. 75
LOSARTAN POTASSIUM
LOSARTAN POTASSIUM
LOSARTAN POTASSIUM
LOSARTAN POTASSIUM
LOSARTAN POTASSIUM
LOSARTAN POTASSIUM
LOSARTAN POTASSIUM
LOSARTAN POTASSIUM
LOSARTAN POTASSIUM
LOSARTAN POTASSIUM
LOSARTAN POTASSIUM
LOSARTAN POTASSIUM
LOSARTAN POTASSIUM
LOSARTAN POTASSIUM
LOSARTAN POTASSIUM
LOSARTAN POTASSIUM
LOSARTAN POTASSIUM
LOSARTAN POTASSIUM
LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE
LOSARTAN POTASSIUM
LOSARTAN POTASSIUM
LOSARTAN POTASSIUM
LOSARTAN POTASSIUM
LOSARTAN POTASSIUM
LOSARTAN POTASSIUM
TELMISARTAN
TELMISARTAN & HYDROCHLOROTHIAZIDE
TELMISARTAN & HYDROCHLOROTHIAZIDE
VALSARTAN
INDIVIDUAL BENEFITS
CoAPROVEL TAB 300mg/25mg
CoAPROVEL TAB 150mg/12.5mg
COVANCE TAB 50mg
COVANCE TAB 50mg
COZAAR TAB 100mg
COZAAR TAB 50mg
COZAAR TAB 50mg
LOSAR-DENK TAB 50mg
LOSAR-DENK TAB 100mg
LOSARTAS TAB 50mg
LOSARTAN-H2K TAB 25mg
LOSATENSIL 50mg Tablets
LOSIUM TAB 25mg
LOSIUM TAB 50mg
LOSIUM TAB 100mg
PRESARTAN-25mg TABS
PRESARTAN-50mg TABS
PRESARTAN H TAB 50mg/12.5mg
RESILO TAB 25mg
RESILO TAB 25mg
RESILO TAB 50mg
RESILO TAB 50mg
RESILO-H TAB 50mg/12.5mg -14s
TOZAAR TAB 25mg
TOZAAR TAB 50mg
HYZAAR TAB 100/25mg
HYZAAR TAB 100/25mg
HYZAAR TAB 100/12.5mg
MICARDIS TAB 80mg
MICARDIS PLUS TAB 80mg / 12.5mg
MICARDIS PLUS TAB 80mg / 25mg
DIOVAN CAP 160mg
14
14
10
30
15
28
30
28
28
28
100
30
100
30
100
28
28
28
28
28
28
100
20
100
20
14
28
28
28
30
30
28
30
28
28
28
14
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
Page 28 of 39
$85.23
$67.97
$24.76
$24.76
$49.52
$24.76
$24.76
$24.76
$49.52
$24.76
$12.38
$12.38
$24.76
$24.76
$24.76
$12.38
$24.76
$49.52
$12.38
$24.76
$41.17
$12.38
$12.38
$24.76
$24.76
$41.17
$12.38
$24.76
$82.36
$82.36
$98.31
$41.17
$41.17
$65.97
$67.62
$66.24
$75.96
85585353528
85585352014
85585353514
85585353814
85585353828
85585352514
85585323014
85585323028
85585323214
85585323228
85585322014
85585324014
85585324214
77131300096
77131300092
85869132010
85869132050
85353132020
85353132520
85114133028
85114133228
85114133428
85124126528
85124126328
85124126128
85335127010
85335127030
85423132014
85423132514
00364251401
00364251301
85852146530
85852146510
85852146030
85205185528
85205185028
85670183030
36150080000330
36150080000120
36150080000330
36150080000340
36150080000340
36150080000320
36994002700340
36994002700340
36994002700350
36994002700350
36994002700320
36994002700355
36994002700360
33200020000310
33200020000305
33200020000310
33200020000310
33200020000305
33200020000310
33200020000303
33200020000305
33200020000310
33200020000310
33200020000305
33200020000303
33200020000305
33200020000305
33200020000305
33200020000310
33200020000310
33200020000305
33200020000310
33200020000310
33200020000305
33200020000310
33200020000305
33200020000310
Rev. 75
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
VALSARTAN
VALSARTAN
VALSARTAN
VALSARTAN
VALSARTAN
VALSARTAN
VALSARTAN-HYDROCHLOROTHIAZIDE
ATENOLOL
ATENOLOL
ATENOLOL
ATENOLOL
ATENOLOL
ATENOLOL
ATENOLOL
ATENOLOL
ATENOLOL
ATENOLOL
ATENOLOL
ATENOLOL
ATENOLOL
ATENOLOL
ATENOLOL
ATENOLOL
ATENOLOL
ATENOLOL
ATENOLOL
ATENOLOL
ATENOLOL
ATENOLOL
ATENOLOL
ATENOLOL
INDIVIDUAL BENEFITS
DIOVAN CAP 160mg
DIOVAN CAP 80mg
DIOVAN TAB 160mg
DIOVAN TAB 320mg
DIOVAN TAB 320mg
DIOVAN TAB 80mg
CO-DIOVAN TAB 160/12.5mg
CO-DIOVAN TAB 160/25mg
CO-DIOVAN TAB 160/25mg
CO-DIOVAN TAB 320mg/12.5mg
CO-DIOVAN TAB 320mg/25mg
APO-ATENOL TAB 100mg
APO-ATENOL TAB 50mg
ATEN TAB 100mg
ATEN TAB 100mg
ATENO TABS 50mg
ATENO TABS 100mg
ATENOLOL-ACT TAB 25mg
ATENOLOL-ALP TAB 100mg
ATENOLOL-DENK TAB 50mg
ATENOLOL-DENK TAB 50mg
ATENOLOL- H2K TAB 50mg
ATENOLOL-H2K TAB 100mg
ATENOLOL-SHN TAB 100mg
ATENOLOL-SHN TAB 50mg
BETACARD TAB 100mg
BETACARD TAB 100mg
BETACARD TAB 50mg
BLOCOTENOL TAB 100mg
BLOCOTENOL TAB 50mg
BLOKIUM 100 TAB
28
14
14
14
28
14
14
28
14
28
14
14
14
100
100
100
500
20
20
28
28
28
28
28
28
100
30
140
140
100
100
30
100
30
28
28
30
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
Page 29 of 39
$75.96
$37.99
$75.96
$75.96
$75.96
$37.99
$83.98
$83.98
$90.27
$90.27
$83.98
$100.06
$100.06
$9.41
$4.71
$9.41
$9.41
$4.71
$9.41
$2.35
$4.71
$9.41
$9.41
$4.71
$2.35
$4.71
$4.71
$4.71
$9.41
$9.41
$4.71
$9.41
$9.41
$4.71
$9.41
$4.71
$9.41
85670182030
85595193050
85595193010
85165803028
85165802028
85235752028
85690822010
85670184020
85165805028
85165806028
85165542028
85553182030
85553182530
85553183030
85553953030
85553952030
85553952530
77131315841
77131315842
77131315843
85439174230
85439174030
85423149510
85423149610
85315252320
85315252420
85315252520
85710243028
85710243030
85710244028
85710244030
85710242028
85710242030
85355892530
85355893030
85355892030
77131300267
33200020000305
33200020000310
33200020000310
33200020000310
33200020000305
33200020000305
33200020000310
36992002100320
36992002100308
36992002100320
36992002150110
33200022100320
33200022100305
33200022100310
36992002130330
36992002130310
36992002130320
33100007000310
33100007000320
33100007000330
33100007000310
33100007000320
33100007000310
33100007000320
33100007000310
33100007000320
33100007000330
33100007000320
33100007000320
33100007000330
33100007000330
33100007000310
33100007000310
33100007000320
33100007000330
33100007000310
34000010100305
Rev. 75
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
ATENOLOL
ATENOLOL
ATENOLOL
ATENOLOL
ATENOLOL
ATENOLOL
ATENOLOL
ATENOLOL & CHLORTHALIDONE
ATENOLOL & NIFEDIPINE
BISOPROLOL
BISOPROLOL
BISOPROLOL
BISOPROLOL & HYDROCHLOROTHIAZIDE
CARVEDILOL
CARVEDILOL
CARVEDILOL
CARVEDILOL
CARVEDILOL
CARVEDILOL
CARVEDILOL
CARVEDILOL
CARVEDILOL
CARVEDILOL
CARVEDILOL
CARVEDILOL
CARVEDILOL
CARVEDILOL
CARVEDILOL
CARVEDILOL
CARVEDILOL
CARVEDILOL
CARVEDILOL
DILTIAZEM HCL
INDIVIDUAL BENEFITS
BLOKIUM 50 TAB
NOVO-ATENOL TAB 100mg
NOVO-ATENOMEL TAB 100mg
TENORMIN TAB 100mg
TENORMIN TAB 50mg
TOTAMOL TAB 50mg
VELORIN TAB 100mg
BLOKIUM DIU TAB 100mg/25mg
TENORET TAB 50mg/12.5mg
TENORETIC TAB 100mg/25mg
NIF-TEN TAB 50mg/20mg
CONCOR TAB 10mg
CONCOR TAB 2.5mg
CONCOR TAB 5mg
ZIAC TAB 10mg/6.25mg
ZIAC TAB 2.5mg/6.25mg
ZIAC TAB 5mg/6.25mg
APO-CARVEDILOL TAB 6.25mg
APO-CARVEDILOL TAB 12.5mg
APO-CARVEDILOL TAB 25mg
CARCA TAB 6.25mg
CARCA TAB 12.5mg
CARVEDILOL TAB 6.25mg
CARVEDILOL TAB 12.5mg
CARVIDEX TAB 6.25mg
CARVIDEX TAB 12.5mg
CARVIDEX TAB 25mg
COREG TAB 12.5mg
COREG TAB 12.5mg
COREG TAB 25mg
COREG TAB 25mg
COREG TAB 6.25mg
COREG TAB 6.25mg
TALLITON TAB 12.5mg
TALLITON TAB 25mg
TALLITON TAB 6.25mg
APO-DILTIAZ TAB 30mg
30
500
100
28
28
28
100
20
28
28
28
30
30
30
30
30
30
100
100
100
30
30
100
100
20
20
20
28
30
28
30
28
30
30
30
30
100
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
Page 30 of 39
$4.71
$9.41
$9.41
$9.41
$4.71
$4.71
$9.41
$32.94
$16.47
$32.94
$14.00
$118.87
$29.71
$59.42
$78.04
$51.79
$64.81
$9.20
$18.39
$36.77
$9.20
$18.39
$9.20
$18.39
$9.20
$18.39
$36.77
$18.39
$18.39
$36.77
$36.77
$9.20
$9.20
$18.39
$36.77
$9.20
$10.74
77131300270
85615324010
85615323010
85615322010
85165572530
85165572030
77131300381
77131300382
85140312010
85365532011
85365532020
85124291012
85124291028
85335336010
85425452025
85595762010
85585373030
85585372028
85585372056
85400472014
85585524010
85585523010
85585522010
85215322090
85852544030
85852545030
85185092010
85185102030
85185103010
85185103030
85185112028
85185112098
77131300640
77131300642
77131305997
77131307985
77131307914
34000010100310
34000010100430
34000010100415
34000010100310
34000013000420
34000013000410
37200030000310
37200030000310
37200030000310
37200030000310
37200030000310
37200030000310
37200030000310
37200030000310
37200030000310
37200030000310
34000015000220
34000015000310
34000015000310
34000016000305
33200030100320
33200030100315
33200030100310
33100010000310
33200040200320
33200040200325
34000020000105
34000020000430
34000020000440
34000020000440
34000020000420
34000020000420
34000020000105
34000020000105
34000020000410
34000020000410
34000020000420
Rev. 75
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
DILTIAZEM HCL
DILTIAZEM HCL
DILTIAZEM HCL
DILTIAZEM HCL
FELODIPINE
FELODIPINE
FUROSEMIDE
FUROSEMIDE
FUROSEMIDE
FUROSEMIDE
FUROSEMIDE
FUROSEMIDE
FUROSEMIDE
FUROSEMIDE
FUROSEMIDE
FUROSEMIDE
ISRADIPINE
ISRADIPINE
ISRADIPINE
LACIDIPINE
METOPROLOL TARTRATE
METOPROLOL TARTRATE
METOPROLOL TARTRATE
NADOLOL
NEBIVOLOL
NEBIVOLOL
NIFEDIPINE
NIFEDIPINE
NIFEDIPINE
NIFEDIPINE
NIFEDIPINE
NIFEDIPINE
NIFEDIPINE
NIFEDIPINE
NIFEDIPINE
NIFEDIPINE
NIFEDIPINE
INDIVIDUAL BENEFITS
APO-DILTIAZ TAB 60mg
DILZEM RETARD TAB 180mg
DILZEM RETARD TAB 90mg
DILZEM TAB 60mg
PLENDIL TAB 10mg
PLENDIL TAB 5mg
APO-FUROSEMIDE TAB 40mg
FEDFRUSEMIDE TAB 40mg
FEDFRUSEMIDE TAB 40mg
FRUSEMIDE-ALP TAB 40mg
FRUSEMIDE-ALP TAB 40mg
FURO-DENK TAB 40mg
LASIX TAB 40mg
NOVO-SEMIDE TAB 40mg
DYNACIRC SRO CAP 5mg
DYNACIRC TAB 2.5mg
DYNACIRC TAB 2.5mg
LACIPIL TAB 4mg
LOPRESSOR DIVITAB 200mg
LOPRESSOR TAB 100mg
LOPRESSOR TAB 50mg
CORGARD TAB 80mg
NEBICARD TAB 2.5mg
NEBICARD TAB 5mg
ADALAT CAP 10mg
ADALAT OROS TAB 30mg
ADALAT RETARD TAB 20mg
ADALAT RETARD TAB 20mg
APO-NIFED CAP 10mg
APO-NIFED CAP 10mg
APO-NIFED PA TAB 10mg
100
100
100
100
30
30
100
500
1000
1000
200
1000
28
100
250
100
30
28
56
14
14
100
100
90
30
30
100
30
10
30
28
28
100
500
100
60
100
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
Page 31 of 39
$21.46
$64.41
$32.20
$21.46
$45.62
$22.81
$6.49
$6.49
$6.49
$6.49
$6.49
$6.49
$6.49
$6.49
$6.49
$6.49
$51.33
$25.67
$25.67
$46.08
$49.93
$24.97
$12.49
$18.26
$15.85
$31.70
$5.49
$22.09
$44.19
$44.19
$11.05
$11.05
$5.49
$5.49
$5.49
$5.49
$11.05
77131307925
85852175010
85237175030
85355272060
85353253020
85335542010
85335543010
85335543030
85335544030
85335544010
85423552010
85472562010
85472561510
85472562510
77131300743
77131300739
77131300755
77131300748
77131300751
77131300750
85595633050
85124633012
85285601050
85285604050
85285608050
85830632011
85165403014
85165402014
85215702028
77131300909
85465402020
85255902050
85105404010
85115453020
85465403020
85465404020
85650882010
34000020000420
34000020000420
34000020000420
34000020000420
34000020000420
34000020000105
34000020000410
34000020000410
34000020000420
34000020000420
34000020000420
34000020000105
34000020000103
34000020000420
33100040100305
33100040100305
33100040100310
33100040100315
33100040100325
33100040100325
33100040100315
33100040100315
33100040100305
33100040100315
33100040100325
33100040100315
33100040100215
33100040100205
33100045100310
34000030100305
34000030100305
34000030100305
34000030100420
34000030100410
34000030100410
34000030100420
34000030100420
Rev. 75
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
Hypertension/IHD
NIFEDIPINE
NIFEDIPINE
NIFEDIPINE
NIFEDIPINE
NIFEDIPINE
NIFEDIPINE
NIFEDIPINE
NIFEDIPINE
NIFEDIPINE
NIFEDIPINE
NIFEDIPINE
NIFEDIPINE
NIFEDIPINE
NIFEDIPINE
PROPRANOLOL HCL
PROPRANOLOL HCL
PROPRANOLOL HCL
PROPRANOLOL HCL
PROPRANOLOL HCL
PROPRANOLOL HCL
PROPRANOLOL HCL
PROPRANOLOL HCL
PROPRANOLOL HCL
PROPRANOLOL HCL
PROPRANOLOL HCL
PROPRANOLOL HCL
PROPRANOLOL HCL CR
PROPRANOLOL HCL CR
SOTALOL HCL
VERAPAMIL HCL
VERAPAMIL HCL
VERAPAMIL HCL
VERAPAMIL HCL CR
VERAPAMIL HCL CR
VERAPAMIL HCL CR
VERAPAMIL HCL CR
VERAPAMIL HCL CR
INDIVIDUAL BENEFITS
CALCIGARD RET. TAB 20mg
CALNIF RETARD TAB 20mg
CORDAFLEX RETD TAB 20mg
EPILAT RETARD TAB 20mg
NIFEDI-DENK GEL CAP 10mg
NIFEDI-DENK RETD TAB 10mg
NIFEDIPINE SR-H2K TAB 20mg
NIFEDIPINE-LAS CAP 10mg
NIFEDIPINE-LAS CAP 5mg
NIFEDIPINE-LAS SR TAB20mg
APO-PROPRANOLOL TAB 10mg
NOVO-PRANOL TAB 40mg
PROPRANOLOL-ALP TAB 40mg
PROPRANOLOL-COX TAB 10mg
PROPRANOLOL-SPM TAB 40mg
INDERAL LA CAP 160mg
INDERAL LA CAP 80mg
SOTACOR TAB 80mg
APO-VERAP TAB 80mg
ISOPTIN TAB 80mg
VERAPAMIL-CHN TAB 80mg
GEANGIN TAB 240mg
ISOPTIN SR TAB 120mg
VERAPAMIL-PMS SR TAB 240mg
60
100
30
60
20
100
100
30
30
100
100
100
100
100
1000
100
1000
1000
1000
100
500
56
500
500
500
1000
14
14
28
100
20
50
100
20
20
20
100
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
Page 32 of 39
$11.05
$11.05
$11.05
$11.05
$11.05
$5.49
$5.49
$5.49
$11.05
$11.05
$11.05
$5.49
$2.76
$11.05
$0.57
$0.57
$1.13
$2.26
$4.53
$4.53
$2.26
$2.26
$0.57
$2.26
$4.53
$2.26
$9.05
$4.53
$14.10
$12.85
$12.85
$12.85
$38.50
$19.25
$19.25
$38.50
$38.50
77131300512
85895433010
85895432010
85585623010
85585622010
85355563010
85355562030
00071057124
85423752010
85775842530
85775842060
85582214011
85400484001
85400484060
85400482011
85887475050
85400483011
85887475550
85515142010
85515142040
12843010605
85186142040
85650312012
85650312030
85178136030
85451185030
85472100510
85423270010
85738183014
85852212030
85315642010
85315642020
85315642014
85315642028
63653117106
85743623028
85213761030
32100020000310
32100020000710
32100020000310
32100030005940
32100030005920
32100030003405
32100030000406
32100030000720
40170050100310
40170050100410
40170050100310
31200010000310
31200010001005
31200010001005
31200010000305
31200010000305
31200010000310
31200010000305
64100010000601
64100010000601
64100010000601
64100010000601
64100010000601
64100010000601
85150020100320
85150020100320
85150020100320
85150020100320
85150020100320
85150020100320
85150020100320
85150020100320
85150020100320
85150020100320
85150020100320
85150020100320
85150020100320
Rev. 75
IHD
IHD
IHD
IHD
IHD
IHD
IHD
IHD
IHD
IHD
IHD
IHD/RHD
IHD/RHD
IHD/RHD
IHD/RHD
IHD/RHD
IHD/RHD
IHD/RHD
IHD/Vascular Disease
ISOSORBIDE DINITRATE
NITROGLYCERIN
NITROGLYCERIN
NITROGLYCERIN
NITROGLYCERIN
NITROGLYCERIN
TRIMETAZIDINE DI-HCL
DIGOXIN
DIGOXIN
DIGOXIN
DIGOXIN
DIGOXIN
DIGOXIN
DIGOXIN
ASPIRIN
ASPIRIN
ASPIRIN
ASPIRIN
ASPIRIN
ASPIRIN
CLOPIDOGREL
CLOPIDOGREL
CLOPIDOGREL
CLOPIDOGREL
CLOPIDOGREL
CLOPIDOGREL
CLOPIDOGREL
CLOPIDOGREL
CLOPIDOGREL
CLOPIDOGREL
CLOPIDOGREL
CLOPIDOGREL
CLOPIDOGREL
INDIVIDUAL BENEFITS
APO-ISDN TAB 10mg
ISORDIL SUB 5mg
ISORDIL TAB 10mg
NITRODERM TTS PATCH 10 mg
NITRODERM TTS PATCH 5 mg
NITROMINT 0.4MG AEROSOL
NITROMINT RET. TAB 2.6mg
NITROSTAT SUBLINGUAL TAB0.6mg
TRIMETAZIDINE- H2K TAB 20mg
VASTAREL MR 35mg
VASTAREL TAB 20mg
DIGOXIN-NA TAB 0.25mg
LANOXIN PED ELX 0.05/ml
LANOXIN PED ELX 0.05/ml 60ml
LANOXIN TAB 0.125mg
LANOXIN TAB 0.125mg
LANOXIN TAB 0.25mg
LANOXIN TAB 0.25mg
ASPIRIN-MAC EC TAB 81mg
ASPIRIN-MAC EC TAB 81mg
BAYER ASPIRIN EC TAB 81mg
BAYER ASPIRIN EC TAB 81mg
ENTROPHEN EC TAB 81mg
ENTROPHEN EC TAB 81mg
AURIX TAB 75mg
CLOPACT -75 TAB -30s
CLOPIDOGREL-LAS TAB 75mg
CLOPIDOGREL-H2K TAB 75mg
CLOPIDOGREL(Sandoz) TAB 75mg
DE PLATT TAB 75mg
PLAGRIL TAB 75mg
PLAGRIL TAB 75mg
PLAGRIL TAB 75mg
PLAGRIL TAB 75mg
PLAVIX TAB 75mg
PLAVIX TAB 75mg
TROMBLATT TAB 75mg
100
100
100
10
10
1
30
100
100
30
60
1000
1ml
60ml
1000
500
1000
500
100
400
120
400
120
30
30
30
100
100
14
30
100
20
14
28
30
28
30
TAB/CAP
TAB/CAP
TAB/CAP
PATCH
PATCH
AER
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
LIQ
LIQ
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
$1.96
$0.98
$1.96
$1,487.91
$743.96
$390.01
$5.66
$9.07
$10.61
$15.92
$10.61
$7.61
$8.48
$508.74
$3.80
$3.80
$7.61
$7.61
$4.69
$4.69
$4.69
$4.69
$4.69
$4.69
$47.49
$47.49
$47.49
$47.49
$47.49
$47.49
$47.49
$47.49
$47.49
$47.49
$47.49
$47.49
$47.49
Page 33 of 39
77131300279
77131300286
77131300287
85220602010
85220603010
77131300042
85400772030
85399843530
85399844030
85110172020
85585302014
85355292028
85110552028
77131308040
85390322028
85439284030
85423284010
85472282010
85680278010
85205412014
85490602014
85490602056
77131300485
77131300489
85124362028
85124362228
85585851560
85585852050
85575282010
77131315191
00029321113
85399622030
85650592010
85738592010
85390652030
85399621530
85399622530
32200010000305
32200010000315
32200010000315
32200010000305
32200010000315
58200010100310
58300040100430
58300040100430
58300040100440
58160020100320
58160020100320
58160020100320
58160022200320
58160040000120
58160040000120
58160040000120
58160040000120
58160040000120
58160040000120
58160040000120
58160040000120
58160040000120
58200050100305
58200050100310
58200050100305
58200050100310
58200050100305
58200050100310
59500010100303
58160060000320
58160060000320
58160060000320
58160060000320
58160060000320
58160060000320
58160060000410
58160060000420
Rev. 75
IHD/Vascular Disease/RHD
Major Depression
Major Depression
Major Depression
Major Depression
Major Depression
Major Depression
Major Depression
Major Depression
Major Depression
Major Depression
Major Depression
Major Depression
Major Depression
Major Depression
Major Depression
Major Depression
Major Depression
Major Depression
Major Depression
Major Depression
Major Depression
Major Depression
Major Depression
Major Depression
Major Depression
Major Depression
Major Depression
Major Depression
Major Depression
Major Depression
Major Depression
Major Depression
DIPYRIDAMOLE
DIPYRIDAMOLE
DIPYRIDAMOLE
DIPYRIDAMOLE
DIPYRIDAMOLE
AMITRIPTYLINE HCL
BUPROPION
BUPROPION
BUPROPION
CITALOPRAM HYDROBROMIDE
ESCITALOPRAM OXALATE
FLUOXETINE HCL
FLUOXETINE HCL
FLUOXETINE HCL
FLUOXETINE HCL
FLUOXETINE HCL
FLUOXETINE HCL
FLUOXETINE HCL
FLUOXETINE HCL
FLUOXETINE HCL
IMIPRAMINE HCL
IMIPRAMINE HCL
IMIPRAMINE HCL
IMIPRAMINE HCL
IMIPRAMINE HCL
IMIPRAMINE HCL
LITHIUM CARBONATE
PAROXETINE HCL
PAROXETINE HCL
PAROXETINE HCL
PAROXETINE HCL
PAROXETINE HCL
PAROXETINE HCL
PAROXETINE HCL CR
PAROXETINE HCL CR
INDIVIDUAL BENEFITS
APO-DIPYRIDAMOLE TAB 25mg
PERSANTINE TAB 25mg
PERSANTINE TAB 75mg
APO-AMITRIPTYLIN TAB 25mg
WELLBUTRIN SR TAB 150mg
WELLBUTRIN XL TAB 150mg
WELLBUTRIN XL TAB 300mg
CIPRAMIL TAB 20mg
CIPRAMIL TAB 20mg
DALSAN TAB 20mg
LEXAPRO TAB 10mg
APO-FLUOXETINE CAP 20mg
DEPREXIN CAP 20mg
FLUNIL 20 Capsules
FLUOXETINE-H2K CAP 20mg
FLUOXETINE-LAS CAP 20mg
FLURAN CAP 20mg
HAPILUX CAPS 20MG
PROZAC CAP 20mg
PROZAC CAP 20mg
APO-IMIPRAMINE TAB 10mg
APO-IMIPRAMINE TAB 25mg
IMIPRAMINE-ALP TAB 10mg
IMIPRAMINE-ALP TAB 25mg
TOFRANIL TAB 10mg
TOFRANIL TAB 25mg
CAMCOLIT TAB 250mg
APO-PAROXETINE 20mg TAB
PAXIL TAB 20mg
PAXIL TAB 20mg
PAROXETINE (PMS) TAB 20mg
PAROXETINE (Sandoz) TAB 20mg
REXETIN TAB 20mg
PAXIL TAB CR 12.5mg
PAXIL TAB CR 25mg
100
100
500
100
100
1000
30
100
30
28
14
28
28
100
28
30
100
100
100
14
14
56
100
100
28
28
60
50
100
30
30
30
100
10
30
30
30
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
Page 34 of 39
$1.39
$4.18
$4.18
$1.39
$4.18
$1.58
$74.92
$74.92
$126.46
$111.63
$111.63
$111.63
$104.97
$34.20
$34.20
$34.20
$34.20
$34.20
$34.20
$34.20
$34.20
$34.20
$1.29
$3.25
$1.29
$3.25
$1.29
$3.25
$7.16
$80.27
$80.27
$80.27
$80.27
$80.27
$80.27
$40.14
$80.27
77131312681
77131312676
85852715010
85205782014
85439714030
85472724010
85650731010
85650731510
85650732010
85355862030
85625963010
85625962010
85625965014
85625964014
00008083601
85894233915
85894233990
85894233930
00008083701
85894233590
85894233530
85894233515
00008083301
85894233730
85894233790
85894233715
85738819014
85738819214
85852825010
85852824810
85490952014
85490951514
85490951528
85490952028
85490952201
85455455007
85455455207
58160070100120
58160070100110
58160070100310
58160070100310
58160070100310
58160070100320
58160070100105
58160070100110
58160070100120
58160070100310
58160070100120
58160070100110
58160070100320
58160070100310
58300090100250
58300090100250
58300090100250
58300090100250
58300090100220
58300090100220
58300090100220
58300090100220
58300090100230
58300090100230
58300090100230
58300090100230
58300090100230
58300090100250
58300090100230
58300090100220
59150060000320
59150060000310
59150060000310
59150060000320
59150060002130
59070055000430
59070055000435
Rev. 75
Major Depression
Major Depression
Major Depression
Major Depression
Major Depression
Major Depression
Major Depression
Major Depression
Major Depression
Major Depression
Major Depression
Major Depression
Major Depression
Major Depression
Major Depression
Major Depression
Major Depression
Major Depression
Major Depression
Major Depression
Major Depression
Major Depression
Major Depression
Major Depression
Major Depression
Major Depression
Major Depression
Major Depression
Major Depression
Major Depression
Major Depression/Psychosis
SERTRALINE HCL
SERTRALINE HCL
SERTRALINE HCL
SERTRALINE HCL
SERTRALINE HCL
SERTRALINE HCL
SERTRALINE HCL
SERTRALINE HCL
SERTRALINE HCL
SERTRALINE HCL
SERTRALINE HCL
SERTRALINE HCL
SERTRALINE HCL
SERTRALINE HCL
VENLAFAXINE HCL XR
VENLAFAXINE HCL XR
VENLAFAXINE HCL XR
VENLAFAXINE HCL XR
VENLAFAXINE HCL XR
VENLAFAXINE HCL XR
VENLAFAXINE HCL XR
VENLAFAXINE HCL XR
VENLAFAXINE HCL XR
VENLAFAXINE HCL XR
VENLAFAXINE HCL XR
VENLAFAXINE HCL XR
VENLAFAXINE HCL XR
VENLAFAXINE HCL XR
VENLAFAXINE HCL XR
VENLAFAXINE HCL XR
OLANZAPINE
OLANZAPINE
OLANZAPINE
OLANZAPINE
OLANZAPINE
PALIPERIDONE
PALIPERIDONE
INDIVIDUAL BENEFITS
APO-SERTRALINE CAP 100mg
APO-SERTRALINE CAP 50mg
SERENATA TAB 50mg
SEROLUX TAB 50MG
SERTIMA TAB 50mg
SERTRALINE-LAS TAB 100mg
SERTRALINE-PMS TAB 25mg
STIMULOTON TAB 50mg
ZOLOFT CAP 100mg
ZOLOFT CAP 50mg
ZOLOFT TAB 100mg
ZOLOFT TAB 50mg
EFFEXOR XR CAP 150mg
EFFEXOR XR CAP 37.5mg
EFFEXOR XR CAP 75mg
EFFEXOR XR CAP 75mg
EFFEXOR XR CAP 75mg
EFFEXOR XR CAP 75mg
VENLAFAXINE (Sandoz) 75mg XR CAP
VENLAFAXINE (Sandoz) 150mg XR CAP
VENLIFT OD CAP 75mg
VENLIFT OD CAP 37.5mg
ZYPREXA TAB 10mg
ZYPREXA TAB 5mg
ZYPREXA TAB 5mg
ZYPREXA TAB 10mg
ZYPREXA 10mg IM Injection
INVEGA ER TAB 3mg
INVEGA ER TAB 6mg
100
100
100
14
30
10
100
100
100
30
100
100
14
14
100
15
90
30
100
90
30
15
100
30
90
15
14
14
100
100
14
14
28
28
1 vial
7
7
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
INJ
TAB/CAP
TAB/CAP
Page 35 of 39
$88.25
$44.14
$44.14
$44.14
$44.14
$88.25
$22.08
$44.14
$88.25
$44.14
$88.25
$44.14
$88.25
$44.14
$161.86
$161.86
$161.86
$161.86
$40.48
$40.48
$40.48
$40.48
$80.93
$80.93
$80.93
$80.93
$80.93
$161.86
$80.93
$40.48
$586.05
$293.02
$293.02
$586.05
$998.00
$258.77
$517.54
85455455228
85455455407
85455455428
77131319033
77131319035
85165682010
85165682510
85165683010
85165683530
85165682360
85165683260
85165683760
85165683960
77131317378
77131317379
77131317380
85852675510
85852675530
85353681020
85439617050
85455684501
85455685001
85455684201
85455680920
85455681920
85455681020
85455682020
85455683020
85455684060
85455684010
85650702010
85650702210
85738674020
85738673020
85738673520
85625452014
85625452514
59070055000435
59070055000440
59070055000440
59150070100310
59150070100330
59150070100310
59150070100320
59150070100330
59150070100340
59150070100410
59150070100420
59150070100430
59150070100440
59070070000310
59070070000320
59070070000330
59070070000320
59070070000320
59070070000320
59070070000320
59070070001920
59070070001925
59070070001930
59070070000310
59070070000320
59070070000310
59070070000320
59070070000330
59070070002010
59070070002010
59070070000310
59070070000320
59070070000330
59070070000310
59070070000320
59400090100120
59400090100130
Rev. 75
PALIPERIDONE
PALIPERIDONE
PALIPERIDONE
QUETIAPINE FUMARATE
QUETIAPINE FUMARATE
QUETIAPINE FUMARATE
QUETIAPINE FUMARATE
QUETIAPINE FUMARATE
QUETIAPINE FUMARATE
QUETIAPINE FUMARATE
QUETIAPINE FUMARATE
QUETIAPINE FUMARATE
QUETIAPINE FUMARATE
RISPERIDONE
RISPERIDONE
RISPERIDONE
RISPERIDONE
RISPERIDONE
RISPERIDONE
RISPERIDONE
RISPERIDONE
RISPERIDONE
RISPERIDONE
RISPERIDONE
RISPERIDONE
RISPERIDONE
RISPERIDONE
RISPERIDONE
RISPERIDONE
RISPERIDONE
RISPERIDONE
RISPERIDONE
RISPERIDONE
RISPERIDONE
RISPERIDONE
ZIPRASIDONE
ZIPRASIDONE
INDIVIDUAL BENEFITS
INVEGA ER TAB 6mg
INVEGA ER TAB 9mg
INVEGA ER TAB 9mg
APO-QUETIAPINE TAB 25mg
APO-QUETIAPINE TAB 200mg
SEROQUEL TAB 25mg
SEROQUEL TAB 100mg
SEROQUEL TAB 200mg
SEROQUEL TAB 300mg
SEROQUEL XR TAB 50mg
APO-RISPERIDONE TAB 1mg
RESPIDON -2mg TAB
RESPIDON -2mg TAB
RISDAL TAB 2mg
RISDONE TAB 2mg
RISPERDAL CONSTA 25mg DEPO INJ
RISPERDAL CONSTA 37.5mg DEPO INJ
RISPERDAL CONSTA 50mg DEPO INJ
RISPERDAL QUICKLET 1mg DISP. TAB
RISPERDAL QUICKLET TAB 2mg
RISPERDAL TAB 1mg
RISPERDAL TAB 2mg
RISPERDAL TAB 3mg
RISPERDAL SOLUTION 1mg/ml
RISPERDAL SOLUTION 1mg/ml
RISPERIDONE- PMS TAB 1mg
RISPERIDONE- PMS TAB 2mg
RISPOLUX TAB 3mg
RISPOLUX TABS 1mg
RISPOLUX TABS 2mg
GEODON TAB 40mg
GEODON TAB 60mg
28
7
28
100
100
30
30
30
30
60
60
60
60
100
100
100
100
30
20
50
1
1
1
20
20
20
20
20
60ml
100ml
100
100
20
20
20
14
14
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
INJ
INJ
INJ
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
LIQ
LIQ
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
$517.54
$776.34
$776.34
$23.33
$186.56
$23.33
$93.28
$186.56
$279.85
$46.66
$186.56
$279.85
$373.13
$33.13
$66.26
$99.39
$66.26
$66.26
$66.26
$66.26
$8,447.41
$12,671.12
$16,894.82
$33.13
$66.26
$33.13
$66.26
$99.39
$4,194.94
$6,991.57
$33.13
$66.26
$99.39
$33.13
$66.26
$121.14
$181.70
Page 36 of 39
85625453014
85625453501
85895654028
77131313991
85750086030
85750081015
85750085050
00085052506
85472288020
85160782004
85439147030
85165184028
85165182028
85895653028
85895652028
77131300099
85650182010
85595664010
85595662010
85840773011
85840773050
85840772011
85840772050
85585463050
85585462050
85730282025
85140365010
77131300414
77131300415
85455411020
85770732050
77131300834
77131300836
85140723011
85140724010
85840684030
85840683030
59400090100140
59400090302120
24000015000330
21402010100310
21402010100315
21402010100305
21402010100310
21402440000110
21402440000320
56800050002010
21402420000320
21402420000340
21402420000320
24000015000320
24000015000310
73100010100315
73100010100315
59200015100320
59200015100310
59200015100320
59200015100320
59200015100310
59200015100310
59150020000330
59150020000320
59200025302005
59100010100312
59100010100315
59100010100320
59100010100320
59100010100312
59200080100315
59200080100315
59200080100320
59200080100325
59200080100325
59200080100315
Rev. 75
PCancer
PCancer
PCancer
PCancer
PCancer
PCancer
PCancer
PCancer
PCancer
PCancer
PCancer
PCancer
PCancer
Psychosis
Psychosis
Psychosis
Psychosis
Psychosis
Psychosis
Psychosis
Psychosis
Psychosis
Psychosis
Psychosis
Psychosis
Psychosis
Psychosis
Psychosis
Psychosis
Psychosis
Psychosis
Psychosis
Psychosis
Psychosis
Psychosis
ZIPRASIDONE
ZIPRASIDONE
CONJUGATED OESTROGEN
CYPROTERONE ACETATE
CYPROTERONE ACETATE
CYPROTERONE ACETATE
CYPROTERONE ACETATE
FLUTAMIDE
FLUTAMIDE
MESNA
BICALUTAMIDE
BICALUTAMIDE
BICALUTAMIDE
BENZTROPINE MESYLATE
BENZTROPINE MESYLATE
CHLORPROMAZINE HCL
CHLORPROMAZINE HCL
CHLORPROMAZINE HCL
CHLORPROMAZINE HCL
CHLORPROMAZINE HCL
CHLORPROMAZINE HCL
CLOZAPINE
CLOZAPINE
FLUPHENAZINE DECANOATE
HALOPERIDOL
HALOPERIDOL
HALOPERIDOL
HALOPERIDOL
HALOPERIDOL
THIORIDAZINE HCL
THIORIDAZINE HCL
THIORIDAZINE HCL
THIORIDAZINE HCL
THIORIDAZINE HCL
THIORIDAZINE HCL
INDIVIDUAL BENEFITS
GEODON TAB 80mg
GEODON INJ.20mg
PREMARIN TAB 1.25mg
APO-CYPROTERONE TAB 50mg
ANDROCUR TAB 100mg
ANDROCUR TAB 10mg
ANDROCUR TAB 50mg
EULEXIN TAB 125mg
FLUTAMIDE-LAS TAB 250mg
UROMITEXAN INJ 400mg
BICAL 50 TAB
CASODEX TAB 150mg
CASODEX TAB 50mg
PREMARIN TAB 0.625mg
PREMARIN TAB 0.3mg
APO-BENZTROPINE TAB 2mg
BENZTROPINE-PMS TAB 2mg
NOVO-PROMAZINE TAB 100mg
NOVO-PROMAZINE TAB 25mg
TAROCTYL TAB 100mg
TAROCTYL TAB 100mg
TAROCTYL TAB 25mg
TAROCTYL TAB 25mg
LEPONEX TAB 100mg
LEPONEX TAB 25mg
FLUPHEN DEC-RM INJ25mg/ml
APO-HALOPERIDOL TAB 1.5mg
APO-HALOPERIDOL TAB 2mg
APO-HALOPERIDOL TAB 5mg
HALDOL TAB 5 mg
SERENACE TAB 1.5 mg
APO-THIORIDAZINE TAB 25mg
APO-THIORIDAZINE TAB100mg
RIDAZIN-TARO TAB 100mg
RIDAZIN-TARO TAB 25mg
14
1
28
100
30
15
50
180
20
2 vial
30
28
28
28
28
100
100
100
100
1000
50
1000
50
50
50
TAB/CAP
VIAL
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
INJ
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
INJ
100
1000
100
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
50
100
1000
1000
100
30
30
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
$242.27
$2,671.29
$41.44
$64.86
$129.73
$12.98
$64.86
$21.01
$42.02
$1,144.00
$568.03
$1,022.45
$568.03
$20.73
$10.37
$2.32
$2.32
$9.35
$2.33
$9.35
$9.35
$2.33
$2.33
$74.38
$18.60
$544.50
$0.99
$1.28
$3.26
$3.25
$0.99
$9.43
$9.43
$18.86
$37.72
$37.72
$9.43
Page 37 of 39
77131300882
77131300884
85795744010
77131300890
85140762050
77131300893
00005443423
00005443434
00005443623
85110205020
85110203010
85110204010
85110202010
85205722001
85115303001
85115323001
85830412001
85830412501
00074636902
85115303060
00074572913
00074630513
85830412010
85830412510
00074634620
00074634653
00074631613
85237262010
85237262110
85140582010
85666816030
85666816230
85775262030
85220095060
77131305456
85423599010
85472632010
59200085100315
59200085100315
59200085100315
73100070100310
73100070100310
73100070100320
73100070100310
73100070100310
73100070100320
59300080300920
59300080300310
59300080300325
59300080300305
01100020001830
03100030301910
03100030301915
03100030301910
03100030301915
03100030301910
03100030301910
03100030300305
03100030301915
03100030301910
03100030301915
03100010100305
03100010100305
03100010100310
3100010100305
3100010100310
01100040100313
85000021000320
85000021000330
85990020020320
32990002300220
85200010000410
85200010000410
85200010000410
Rev. 75
Psychosis
Psychosis
Psychosis
Psychosis
Psychosis
Psychosis
Psychosis
Psychosis
Psychosis
Psychosis
Psychosis
Psychosis
Psychosis
RHD
RHD
RHD
RHD
RHD
RHD
RHD
RHD
RHD
RHD
RHD
RHD
RHD
RHD
RHD
RHD
RHD
VASCULAR
VASCULAR
VASCULAR
VASCULAR
VASCULAR
VASCULAR
VASCULAR
TRIFLUOPERAZINE HCL
TRIFLUOPERAZINE HCL
TRIFLUOPERAZINE HCL
TRIHEXYPHENIDYL HCL
TRIHEXYPHENIDYL HCL
TRIHEXYPHENIDYL HCL
TRIHEXYPHENIDYL HCL
TRIHEXYPHENIDYL HCL
TRIHEXYPHENIDYL HCL
ZUCLOPENTHIXOL DIHCL
BENZATHINE BENZYL PENICILLIN
ERYTHROMYCIN ETHYL SUCCINATE
ERYTHROMYCIN STEARATE
PENICILLIN V POTASSIUM
DIOSMIN
DIOSMIN
DIOSMIN & HESPERIDIN
DIPYRIDAMOLE & ASPIRIN
PENTOXIFYLLINE
PENTOXIFYLLINE
PENTOXIFYLLINE
INDIVIDUAL BENEFITS
APO-TRIFLUOPERAZ TAB 5mg
APO-TRIFLUOPERAZ TAB 5mg
STELAZINE TAB 5mg
APO-TRIHEX TAB 2mg
APO-TRIHEX TAB 2mg
APO-TRIHEX TAB 5mg
ARTANE TAB 2mg
ARTANE TAB 2mg
ARTANE TAB 5mg
CLOPIXOL DROPS 20mg/ml
CLOPIXOL TAB 10mg
CLOPIXOL TAB 25mg
CLOPIXOL TAB 2mg
RETARPEN 2.4MU
E.E.S. Gran. SUSP 200mg/5ml
ERYPED SUSP.400mg/5ML
ERYTHROMYCIN-SPM SUSP 200mg
ERYTHROMYCIN-SPM SUSP400mg
E.E.S.GRAN.SUSP.200mg/5ML
E.E.S.GRAN.SUSP.200mg/5ML
E.E.S.TAB.400mg
ERYPED SUSP.400mg/5ML
ERYTHROCIN TAB 250mg
ETOCIN TAB 250mg
ETOCIN TAB 500mg
APO-PEN VK TAB 300mg
VENEX TAB 300mg
VENEX TAB 500mg
DAFLON TAB 500mg
AGGRENOX CAP 200mg/25mg
APO-PENTOX SR TAB 400mg
PENTOX-H2K SR TAB 400mg
PENTOX-LAS SR TAB 400mg
100
1000
100
100
500
100
100
1000
100
1 vial
100
100
100
1 vial
1ml
1ml
1ml
1ml
100ml
60ml
100
100ml
100ml
100
100
500
100
100
100
100
30
30
30
60
100
100
10
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
LIQ
TAB/CAP
TAB/CAP
TAB/CAP
INJ
LIQ
LIQ
LIQ
LIQ
LIQ
LIQ
TAB/CAP
LIQ
LIQ
LIQ
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
TAB/CAP
$1.85
$1.85
$1.85
$1.54
$1.54
$3.95
$1.54
$1.54
$3.95
$1,202.72
$15.57
$38.93
$3.09
$74.88
$1.12
$2.22
$1.12
$2.22
$111.15
$67.02
$17.52
$222.30
$111.15
$222.30
$10.95
$10.95
$21.91
$10.95
$21.91
$3.78
$11.36
$18.93
$18.93
$62.19
$12.09
$12.09
$12.09
Page 38 of 39
85425822010
85390282230
85390293015
85455768078
85200010000410
85200030000310
90970025004020
99900000000000
Rev. 75
VASCULAR
VASCULAR
VASCULAR /DIABETES
VASCULAR /DIABETES
PENTOXIFYLLINE
VINPOCETINE
ZINC HYALURONATE
KETANSERIN
INDIVIDUAL BENEFITS
TRENTAL TAB 400mg CR
CAVINTON FORTE TAB 10mg
CURIOSIN GEL
SUFREXAL GEL -78Gm
100
30
15g
78g
TAB/CAP
TAB/CAP
GEL
GEL
$12.09
$24.08
$847.60
$2,026.26
Page 39 of 39

NDC GPI ILLNESS DRUG LABEL PK 85185853015

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