Blue Cross Blue Shield of North Carolina Open Basic 5 Tier

Transcription

July 2014
Blue Cross and Blue Shield of North Carolina
Open Basic 5 Tier Formulary
Contents
Therapeutic Class Drug List
Member guide to covered medications on the
Anti-Infective Drugs ..................................................... 1
Open Basic 5 Tier Formulary ...................................... I
Biologicals .................................................................. 12
Formulary tiers .............................................................. I
Antineoplastic Agents ................................................ 13
5-Tier formulary .............................................................. I
Endocrine And Metabolic Drugs ................................ 16
Generic drugs................................................................. I
Cardiovascular Agents............................................... 34
Compounded prescriptions ........................................... II
Respiratory Agents .................................................... 55
Prior review, quantity limitations and
Gastrointestinal Agents ............................................. 65
restricted-access drugs ................................................ II
Genitourinary Agents ................................................. 71
Specialty drugs.............................................................. II
Central Nervous System Drugs ................................. 75
Affordable Care Act ...................................................... II
Analgesics And Anesthetics ...................................... 92
Abbreviation/acronym key............................................ III
Neuromuscular Drugs .............................................. 107
Nutritional Products ................................................. 116
Hematological Agents .............................................. 127
Topical Products ...................................................... 133
Miscellaneous Products ........................................... 159
Index ....................................................................... 166
Please consider talking to your doctor about prescribing formulary medications, which may help reduce your
out-of-pocket costs. This list may help guide you and your doctor in selecting an appropriate medication for you.
The drug formulary is regularly updated. Please visit www.bcbsnc.com for the most up-to-date information.
To search for a drug name within this PDF document, use the Control and F keys on your keyboard, or go to
Edit in the drop-down menu and select Find/Search. Type in the word or phrase you are looking for and click
on Search.
5154-I NC IVL © Prime Therapeutics LLC 07/14
Member guide to covered medications on the Open Basic 5 Tier Formulary
This guide lists the approved brand name and generic prescription drugs that have been reviewed by Blue
Cross and Blue Shield of North Carolina (BCBSNC). Please refer to this formulary guide for information about
medications covered by this formulary, and present this guide to your doctor if you require a prescription. This
guide was current at the time of printing and is subject to change. For a more complete listing of drug
coverage and costs, you may use our drug search at www.bcbsnc.com. You may also call BCBSNC
Customer Service at the number listed on the back of your ID card to verify prescription drug benefits.
A formulary is a list of prescription drugs covered by a health plan. BCBSNC Pharmacy & Therapeutics (P&T)
Committee reviews medications at least quarterly. This includes ongoing reviews of clinical information about new
drugs and reviews of new safety and efficacy information about older drugs. The majority of BCBSNC’s P&T
Committee is composed of practicing physicians and pharmacists independent of BCBSNC.
Please refer to your member guide for detailed information regarding your pharmacy benefits, including your benefit
design, out-of-pocket costs, prior review and restricted access drug requests, and applicable exclusions.
Formulary tiers
The Open Basic 5 Tier Formulary covers medications approved by the United States Food & Drug Administration
(FDA), within existing benefits. The plan design determines the member’s payment obligation. Note: Drugs listed as
covered on Tier 1 and Tier 2 are generics. Brand names listed for Tier 1 and Tier 2 drugs are for reference only.
Brands for which generic equivalents are available are listed on Tier 4 unless indicated otherwise.
Here are the definitions of each tier for the five-tiered benefit structure:
•
Tier 1: Generic medications. Medications listed in Tier 1 have the lowest co-payment.
•
Tier 2: Non-preferred generic medications. Medications listed in Tier 2 have the second-lowest
co-payment.
•
Tier 3: Includes select brand-name drugs recommended by the BCBSNC P&T Committee as
preferred brand-name products based on safety, efficacy, and cost.
•
Tier 4: Contains 1) brand-name products that, as recommended by the P&T Committee, usually
have preferred and often less costly therapeutic alternatives at a lower tier, 2) some brands with
therapeutically equivalent generics, and 3) selected biosimilar specialty drugs. Medications
listed in Tier 4 have the second-highest co-payment.
•
Tier 5: Specialty drugs. Those medications, as classified by the P&T Committee, that generally
have unique uses, require special dosing or administration, are typically prescribed by a specialist
provider and are significantly more costly than alternative drugs or therapies. This may include
biosimilar specialty drugs. Medications listed in Tier 5 generally have the highest co-payment
or co-insurance amount.
Generic drugs
In most cases choosing a generic drug equivalent, when available, will mean significant savings to you. We
encourage you to discuss with your physician whether a generic alternative is available as these drugs represent
safe, effective treatment options. Especially for drugs that are taken daily and refilled frequently, you will experience
the long-term savings of a lower drug payment month after month. If you choose a brand name prescription drug
and a generic equivalent is available, you may be subject to a reduced benefit and a higher out-of-pocket
expense.
I
Blue Cross and Blue Shield of North Carolina (BCBSNC) July 2014 Open Basic 5 Tier Formulary
Compounded prescriptions
Compounded prescriptions contain two or more drugs mixed together. Compounded prescriptions are processed
according to member benefits. To be eligible for coverage, compounded medications must contain at least one
FDA-approved prescription ingredient and must not be a copy of a commercially available product. Compounded
medications may be subject to prior review.
Prior review, quantity limitations and restricted-access drugs
Certain medications may be subject to prior review, quantity limitations, or restricted-access programs. BCBSNC’s
P&T Committee reviews the clinical criteria for these programs.
•
Drugs that have prior review requirements must be reviewed by BCBSNC before coverage can be
authorized.
•
Certain medications may also have limitations on the quantity and days’ supply coverage. Quantities in
excess of the coverage limit must be reviewed and approved by BCBSNC before coverage can be
authorized for amounts in excess of the limits.
•
For coverage of restricted-access drugs, BCBSNC requires that the member has tried preferred formulary
drugs first. Coverage for restricted-access drugs may be provided without the use of
a preferred drug if the provider certifies in writing that the member has previously used preferred drugs
and the preferred drugs have been detrimental to the member's health or have been ineffective in treating
the same condition and, in the opinion of the provider, are likely to be detrimental to the member's health
or ineffective in treating the condition in the future. Clinical rationale and documentation for exception
requests may be required.
The FDA is responsible for approving medications for use based on clinical data proving the medication is safe and
effective for that specific use. BCBSNC’s prior review and quantity limitations programs follow FDA-approved uses
for these drugs. However, BCBSNC recognizes that in many cases, “off-label” (non-FDA approved) uses of
prescription drugs may be acceptable. In determining the acceptability of off-label uses, BCBSNC utilizes several
sources of clinical information including but not limited to 1) nationally recognized clinical references including
American Hospital Formulary Service Drug Information; 2) the results of at least two randomized controlled clinical
studies that support a specific off-label use, and that are published in peer-reviewed professional medical journals;
and 3) consultations with internal and external physician experts regarding community standards. Additional
searches for current supporting medical literature may be performed utilizing standard electronic databases.
Specialty drugs
These medications, as classified by BCBSNC, generally have unique uses, require special dosing or administration,
are typically prescribed by a specialist provider and are significantly more costly than alternative drugs or therapies.
Most specialty drugs can be found on Tier 5, but some may be found on a lower tier.
Some of these specialty drugs will need to be filled at a participating specialty pharmacy in our network. These
drugs are identified in the specialty column of the formulary guide. Call the customer service number on the back of
your ID card to determine which pharmacy can fill your specialty drug prescription.
Affordable Care Act
Please note, some drugs may have limited or $0 cost-sharing under the Affordable Care Act; examples of
categories of drugs that may be subject to limited or $0 cost share include aspirin, breast cancer preventive,
fluoride supplements, folic acid supplements, gonorrhea prophylaxis (newborn), iron supplements, tobacco
cessation, vaccines, vitamin D supplements, and some contraceptive drugs and devices. If you do not find the
drug you are searching for, consult or contact the customer service number on the back of your ID card to find
out if the drug is available over the counter or is covered under your medical benefit.
II
Abbreviation/acronym key
cap .............................................................. capsules
chew .......................................................... chewable
conc ........................................................concentrate
cr ................................................... controlled release
dr ...................................................... delayed release
ec ......................................................... enteric coated
effe ......................................................... effervescent
equiv ......................................................... equivalent
er ....................................................extended release
inhal ........................................................... inhalation
inj.................................................................. injection
liq....................................................................... liquid
lotn .................................................................... lotion
nebu ............................................................ nebulizer
III
odt ...................................... orally disintegrating tabs
oint ..............................................................ointment
ophth.......................................................... opthalmic
osm .................................................. osmotic release
powd ..............................................................powder
sa ..................................................... sustained action
sl ............................................................... sublingual
soln ............................................................... solution
sr ................................................... sustained release
suppose .............................................. suppositories
susp ....................................................... suspension
tab…................................................................ tablets
td… ......................................................... transdermal
ANTI-INFECTIVE AGENTS
PENICILLINS
AMPICILLIN - ampicillin for susp 125
mg/5ml
1
AMOXICILLIN - amoxicillin (trihydrate)
chew tab 125 mg
1
AMPICILLIN - ampicillin for susp 250
mg/5ml
1
AMOXICILLIN - amoxicillin (trihydrate)
chew tab 250 mg
1
ampicillin cap 250 mg
1
ampicillin cap 500 mg
1
amoxicillin (trihydrate) cap 250 mg
1
4
amoxicillin (trihydrate) cap 500 mg
1
AUGMENTIN - amoxicillin & k
clavulanate tab 500-125 mg
amoxicillin (trihydrate) for susp
125 mg/5ml
1
clavulanate tab 875-125 mg
4
200 mg/5ml
1
3
250 mg/5ml
1
clavulanate for susp 125-31.25
mg/5ml
4
400 mg/5ml
1
clavulanate for susp 250-62.5 mg/5ml
4
amoxicillin (trihydrate) tab 500 mg
1
AUGMENTIN ES-600 - amoxicillin & k
clavulanate for susp 600-42.9 mg/5ml
1
AUGMENTIN XR - amoxicillin & k
clavulanate tab sr 12hr 1000-62.5 mg
4
amoxicillin (trihydrate) tab 875 mg
amoxicillin & k clavulanate chew tab
200-28.5 mg
2
dicloxacillin sodium cap 250 mg
1
1
dicloxacillin sodium cap 500 mg
1
amoxicillin & k clavulanate chew tab
400-57 mg
4
amoxicillin & k clavulanate for susp
200-28.5 mg/5ml
1
MOXATAG - amoxicillin (trihydrate) tab
sr 24hr 775 mg
1
250-62.5 mg/5ml (Augmentin)
1
penicillin v potassium for soln
125 mg/5ml
1
400-57 mg/5ml
1
penicillin v potassium for soln
250 mg/5ml
penicillin v potassium tab 250 mg
1
penicillin v potassium tab 500 mg
1
1
600-42.9 mg/5ml (Augmentin es-600)
2
amoxicillin & k clavulanate tab sr
12hr 1000-62.5 mg (Augmentin xr)
1
amoxicillin & k clavulanate tab
250-125 mg
1
500-125 mg (Augmentin)
1
875-125 mg (Augmentin)
Quantity Limits
Restricted Access
Prior Review
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Drug Tier
2014
CEPHALOSPORINS
CEDAX - ceftibuten cap 400 mg
4
CEDAX - ceftibuten for susp 90 mg/5ml
4
CEDAX - ceftibuten for susp 180
mg/5ml
4
CEFACLOR - cefaclor for susp 125
mg/5ml
3
mg/5ml
3
1
cefuroxime axetil tab 500 mg (Ceftin)
1
CEPHALEXIN - cephalexin tab 250 mg
4
CEPHALEXIN - cephalexin tab 500 mg
4
cephalexin cap 250 mg (Keflex)
1
1
2
cephalexin for susp 125 mg/5ml
1
cephalexin for susp 250 mg/5ml
1
KEFLEX - cephalexin cap 250 mg
4
4
4
cefaclor cap 250 mg
2
cefaclor cap 500 mg
2
CEFACLOR ER - cefaclor monohydrate
tab sr 12hr 500 mg
4
cefadroxil cap 500 mg
1
cefadroxil for susp 250 mg/5ml
2
cefadroxil for susp 500 mg/5ml
2
cefadroxil tab 1 gm
2
cefdinir cap 300 mg
1
cefdinir for susp 125 mg/5ml
1
cefdinir for susp 250 mg/5ml
1
4
SPECTRACEF - cefditoren pivoxil tab
200 mg (base equivalent)
4
CEFDITOREN PIVOXIL - cefditoren
pivoxil tab 200 mg (base equivalent)
4
SPECTRACEF - cefditoren pivoxil tab
4
CEFDITOREN PIVOXIL - cefditoren
pivoxil tab 400 mg (base equivalent)
2
SUPRAX - cefixime cap 400 mg
4
cefpodoxime proxetil for susp
100 mg/5ml
SUPRAX - cefixime tab 400 mg
4
cefpodoxime proxetil for susp
50 mg/5ml
2
SUPRAX - cefixime chew tab 100 mg
4
SUPRAX - cefixime chew tab 200 mg
4
cefpodoxime proxetil tab 100 mg
2
4
cefpodoxime proxetil tab 200 mg
2
SUPRAX - cefixime for susp 100
mg/5ml
cefprozil for susp 125 mg/5ml
1
4
cefprozil for susp 250 mg/5ml
1
mg/5ml
1
mg/5ml
4
cefprozil tab 250 mg
cefprozil tab 500 mg
1
CEFTIBUTEN - ceftibuten cap 400 mg
4
CEFTIBUTEN - ceftibuten for susp 180
mg/5ml
AZITHROMYCIN - azithromycin powd
pack for susp 1 gm
4
4
4
azithromycin for susp 100 mg/5ml
(Zithromax)
1
CEFTIN - cefuroxime axetil tab 250 mg
CEFTIN - cefuroxime axetil tab 500 mg
4
1
CEFTIN - cefuroxime axetil for susp 125
mg/5ml
4
azithromycin for susp 200 mg/5ml
(Zithromax)
azithromycin tab 250 mg (Zithromax)
1
CEFTIN - cefuroxime axetil for susp 250
mg/5ml
3
1
1
cefuroxime axetil for susp
125 mg/5ml (Ceftin)
1
BIAXIN - clarithromycin tab 250 mg
4
2
MACROLIDES
Quantity Limits
1
3
Restricted Access
cefuroxime axetil tab 250 mg (Ceftin)
mg/5ml
Prior Review
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Drug Name
Prior Review
Drug Tier
2014
1
4
erythromycin ethylsuccinate tab
400 mg
1
BIAXIN XL - clarithromycin tab sr 24hr
500 mg
4
erythromycin w/ delayed release
particles cap 250 mg
4
BIAXIN XL PAC - clarithromycin tab sr
24hr 500 mg
4
PCE - erythromycin w/ enteric coated
particles tab 333 mg
4
clarithromycin for susp 125 mg/5ml
2
PCE - erythromycin w/ enteric coated
particles tab 500 mg
clarithromycin for susp 250 mg/5ml
(Biaxin)
2
ZITHROMAX - azithromycin tab 250 mg
4
4
clarithromycin tab sr 24hr 500 mg
(Biaxin xl pac)
2
4
clarithromycin tab 250 mg (Biaxin)
ZITHROMAX - azithromycin for susp
100 mg/5ml
4
2
clarithromycin tab 500 mg (Biaxin)
2
4
DIFICID - fidaxomicin tab 200 mg
5
ZITHROMAX - azithromycin for susp
200 mg/5ml
E.E.S. GRANULES - erythromycin
ethylsuccinate for susp 200 mg/5ml
4
ZITHROMAX - azithromycin powd pack
for susp 1 gm
4
E.E.S. 400 - erythromycin
ethylsuccinate tab 400 mg
1
ZITHROMAX TRI-PAK - azithromycin
tab 500 mg
4
ERY-TAB - erythromycin tab delayed
release 250 mg
1
ZITHROMAX Z-PAK - azithromycin tab
250 mg
4
release 333 mg
1
ZMAX - azithromycin extended release
for oral susp 2 gm
4
release 500 mg
1
TETRACYCLINES
4
ERYPED 200 - erythromycin
4
ADOXA - doxycycline monohydrate cap
150 mg
4
ERYPED 400 - erythromycin
4
ADOXA - doxycycline monohydrate tab
50 mg
4
ERYTHROCIN STEARATE erythromycin stearate tab 250 mg
3
75 mg
4
ERYTHROMYCIN - erythromycin w/
delayed release particles cap 250 mg
1
100 mg
4
ERYTHROMYCIN BASE - erythromycin
tab 250 mg
4
ADOXA PAK 1/100 - doxycycline
monohydrate tab 100 mg
4
ERYTHROMYCIN BASE - erythromycin
tab 500 mg
4
4
ERYTHROMYCIN ETHYLSUCCINA erythromycin ethylsuccinate tab 400
mg
1
•
•
Quantity Limits
Restricted Access
Prior Review
Drug Name
Drug Tier
BIAXIN - clarithromycin for susp 250
mg/5ml
Quantity Limits
4
Restricted Access
BIAXIN - clarithromycin tab 500 mg
Prior Review
Drug Name
Drug Tier
2014
• •
3
demeclocycline hcl tab 150 mg
2
demeclocycline hcl tab 300 mg
2
DORYX - doxycycline hyclate tab
delayed release 150 mg
4
DORYX - doxycycline hyclate tab
4
DOXYCYCLINE HYCLATE doxycycline hyclate cap dr particles
100 mg
4
doxycycline monohydrate tab 50 mg
(Adoxa)
2
doxycycline monohydrate tab 75 mg
(Adoxa)
2
DYNACIN - minocycline hcl tab 50 mg
4
4
4
MINOCIN - minocycline hcl cap 50 mg
4
4
4
MINOCIN KIT - minocycline hcl cap 50
mg w/ acne care products kit
4
• •
4
• •
doxycycline hyclate cap 100 mg
(Vibramycin)
1
MINOCIN KIT - minocycline hcl cap 100
mg w/ acne care products kit
(Vibramycin)
2
minocycline hcl cap 100 mg (Minocin) 1
minocycline hcl cap 50 mg (Minocin) 1
1
doxycycline hyclate tab delayed
release 100 mg
2
release 150 mg (Doryx)
2
release 75 mg
2
doxycycline hyclate tab 100 mg
1
doxycycline hyclate tab 20 mg
1
doxycycline monohydrate cap
100 mg (Monodox)
• •
•
minocycline hcl cap 75 mg (Minocin)
1
minocycline hcl tab sr 24hr 135 mg
2
2
2
minocycline hcl tab 100 mg
2
2
2
MONODOX - doxycycline monohydrate
cap 50 mg
4
2
cap 75 mg
4
doxycycline monohydrate cap
150 mg (Adoxa)
2
cap 100 mg
4
doxycycline monohydrate cap 50 mg
2
4
• •
doxycycline monohydrate cap 75 mg
(Monodox)
2
MORGIDOX 1X100MG - doxycycline
hyclate cap 1 x 100 mg w/ cleanser
kit
2
• •
doxycycline monohydrate tab
100 mg (Adoxa pak 1/100)
2
MORGIDOX 2X100MG - doxycycline
hyclate cap 2 x 100 mg w/ cleanser
kit
4
doxycycline monohydrate for susp
25 mg/5ml (Vibramycin)
4
doxycycline monohydrate tab
150 mg (Adoxa pak 1/150)
2
NICAZELDOXY 30 KIT - doxycycline
monohyd tab 100 mg &multivit/
minerals tab kit
4
Quantity Limits
AVIDOXY DK - doxycycline tab 100 mg
& suncreen & sal acid wash 2% kit
4
Restricted Access
• •
Prior Review
4
Drug Name
Drug Tier
Prior Review
ALODOX CONVENIENCE KIT doxycycline hyclate tab 20 mg w/
eyelid cleansers kit
Drug Name
Quantity Limits
Drug Tier
Restricted Access
2014
NICAZELDOXY 60 KIT - doxycycline
monohyd tab 100 mg &multivit/
minerals tab kit
4
NUTRIDOX - doxycycline monohyd cap
75 mg w/ omega 3-vit e cap kit
4
AVELOX ABC PACK - moxifloxacin hcl
tab 400 mg (base equiv)
4
4
• •
CIPRO - ciprofloxacin for oral susp 250
mg/5ml (5%) (5 gm/100ml)
OCUDOX - doxycycline hyclate cap 50
mg & eyelid cleans & spray kit
• •
CIPRO - ciprofloxacin for oral susp 500
mg/5ml (10%) (10 gm/100ml)
4
4
4
• •
CIPRO - ciprofloxacin hcl tab 250 mg
(base equiv)
4
ORAXYL - doxycycline hyclate cap 20
mg
SOLODYN - minocycline hcl tab sr 24hr
45 mg
CIPRO - ciprofloxacin hcl tab 500 mg
(base equiv)
4
4
55 mg
• •
CIPRO XR - ciprofloxacin-ciprofloxacin
hcl tab sr 24hr 500 mg (base eq)
4
4
65 mg
• •
CIPRO XR - ciprofloxacin-ciprofloxacin
hcl tab sr 24hr 1000 mg(base eq)
4
4
1
80 mg
4
• •
ciprofloxacin hcl tab 100 mg (base
equiv)
4
equiv) (Cipro)
1
90 mg
105 mg
• •
equiv) (Cipro)
1
4
115 mg
• •
equiv)
1
4
135 mg
ciprofloxacin-ciprofloxacin hcl tab sr
24hr 1000 mg(base eq) (Cipro xr)
1
4
1
ciprofloxacin-ciprofloxacin hcl tab sr
24hr 500 mg (base eq) (Cipro xr)
2
TETRACYCLINE HCL - tetracycline hcl
cap 250 mg
1
FACTIVE - gemifloxacin mesylate tab
320 mg (base equiv)
4
TETRACYCLINE HCL - tetracycline hcl
cap 500 mg
LEVAQUIN - levofloxacin tab 250 mg
4
tetracycline hcl cap 250 mg
1
4
tetracycline hcl cap 500 mg
1
4
VIBRAMYCIN - doxycycline
monohydrate for susp 25 mg/5ml
4
LEVAQUIN - levofloxacin oral soln 25
mg/ml
4
VIBRAMYCIN - doxycycline hyclate cap
100 mg
4
levofloxacin oral soln 25 mg/ml
(Levaquin)
2
VIBRAMYCIN - doxycycline calcium
syrup 50 mg/5ml
4
levofloxacin tab 250 mg (Levaquin)
1
1
1
FLUOROQUINOLONES
AVELOX - moxifloxacin hcl tab 400 mg
(base equiv)
4
• •
Quantity Limits
Restricted Access
Prior Review
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Drug Tier
2014
5
PASER - aminosalicylic acid cr granules
packet 4 gm
4
• •
NOROXIN - norfloxacin tab 400 mg
4
PRIFTIN - rifapentine tab 150 mg
4
ofloxacin tab 200 mg
2
pyrazinamide tab 500 mg
2
2
rifabutin cap 150 mg (Mycobutin)
2
2
RIFADIN - rifampin cap 150 mg
4
RIFADIN - rifampin cap 300 mg
4
AMINOGLYCOSIDES
Drug Name
BETHKIS - tobramycin nebu soln 300
mg/4ml
5
RIFAMATE - isoniazid & rifampin cap
150-300 mg
4
NEO-FRADIN - neomycin sulfate soln
25 mg/ml
4
rifampin cap 150 mg (Rifadin)
2
rifampin cap 300 mg (Rifadin)
2
neomycin sulfate tab 500 mg
1
paromomycin sulfate cap 250 mg
RIFATER - isoniazid-rifampin w/
pyrazinamide tab 50-120-300 mg
4
2
TOBI - tobramycin nebu soln 300
mg/5ml
5
SEROMYCIN - cycloserine cap 250 mg
4
5
SIRTURO - bedaquiline fumarate tab
100 mg (base equiv)
4
TOBI PODHALER - tobramycin inhal
cap 28 mg
TRECATOR - ethionamide tab 250 mg
4
tobramycin nebu soln 300 mg/5ml
(Tobi)
5
4
ANTIMYCOBACTERIAL AGENTS
nystatin oral powder
2
ANCOBON - flucytosine cap 250 mg
4
ANCOBON - flucytosine cap 500 mg
4
BIO-STATIN - nystatin cap 500000 unit
4
CYCLOSERINE - cycloserine cap 250
mg
4
BIO-STATIN - nystatin cap 1000000 unit 4
4
DIFLUCAN - fluconazole tab 50 mg
ethambutol hcl tab 100 mg
(Myambutol)
2
4
4
ethambutol hcl tab 400 mg
(Myambutol)
2
4
4
isoniazid & rifampin cap 150-300 mg
2
DIFLUCAN - fluconazole for susp 10
mg/ml
4
ISONIAZID - isoniazid syrup 50 mg/5ml
1
DIFLUCAN - fluconazole for susp 40
mg/ml
4
isoniazid tab 100 mg
isoniazid tab 300 mg
1
1
MYAMBUTOL - ethambutol hcl tab 100
mg
4
fluconazole for susp 10 mg/ml
(Diflucan)
1
MYAMBUTOL - ethambutol hcl tab 400
mg
4
fluconazole for susp 40 mg/ml
(Diflucan)
fluconazole tab 100 mg (Diflucan)
1
MYCOBUTIN - rifabutin cap 150 mg
4
1
6
• •
ANTIFUNGALS
SULFONAMIDES
SULFADIAZINE - sulfadiazine tab 500
mg
• •
• •
• •
• •
Quantity Limits
Prior Review
Restricted Access
Drug Tier
Quantity Limits
Restricted Access
2
Drug Tier
moxifloxacin hcl tab 400 mg (base
equiv) (Avelox)
Drug Name
Prior Review
2014
5
1
VFEND - voriconazole tab 200 mg
5
flucytosine cap 250 mg (Ancobon)
2
5
flucytosine cap 500 mg (Ancobon)
2
VFEND - voriconazole for susp 40 mg/
ml
GRIFULVIN V - griseofulvin microsize
tab 500 mg
4
voriconazole for susp 40 mg/ml
(Vfend)
5
GRIS-PEG - griseofulvin ultramicrosize
tab 125 mg
4
voriconazole tab 200 mg (Vfend)
2
voriconazole tab 50 mg (Vfend)
2
GRIS-PEG - griseofulvin ultramicrosize
tab 250 mg
4
ANTIVIRALS
griseofulvin microsize susp
125 mg/5ml
abacavir sulfate tab 300 mg (base
equiv) (Ziagen)
2
2
griseofulvin microsize tab 500 mg
(Grifulvin v)
abacavir sulfate-lamivudinezidovudine tab 300-150-300 mg
(Trizivir)
5
2
griseofulvin ultramicrosize tab
125 mg (Gris-peg)
2
acyclovir cap 200 mg (Zovirax)
1
acyclovir susp 200 mg/5ml (Zovirax)
1
griseofulvin ultramicrosize tab
250 mg (Gris-peg)
2
acyclovir tab 400 mg (Zovirax)
1
2
acyclovir tab 800 mg (Zovirax)
1
itraconazole cap 100 mg (Sporanox)
1
adefovir dipivoxil tab 10 mg
(Hepsera)
5
ketoconazole tab 200 mg
LAMISIL - terbinafine hcl tab 250 mg
4
4
LAMISIL - terbinafine hcl oral granules
packet 125 mg
• •
APTIVUS - tipranavir cap 250 mg
4
4
LAMISIL - terbinafine hcl oral granules
packet 187.5 mg
4
• •
APTIVUS - tipranavir oral soln 100 mg/
ml
ATRIPLA - efavirenz-emtricitabinetenofovir df tab 600-200-300 mg
5
NOXAFIL - posaconazole tab delayed
release 100 mg
5
BARACLUDE - entecavir tab 0.5 mg
5
5
BARACLUDE - entecavir tab 1 mg
5
NOXAFIL - posaconazole susp 40 mg/
ml
5
nystatin tab 500000 unit
1
BARACLUDE - entecavir oral soln 0.05
mg/ml
4
COMBIVIR - lamivudine-zidovudine tab
150-300 mg
SPORANOX - itraconazole cap 100 mg
4
4
COMPLERA - emtricitabine-rilpivirinetenofovir df tab 200-25-300 mg
5
SPORANOX - itraconazole oral soln 10
mg/ml
•
•
•
5
ONMEL - itraconazole tab 200 mg
5
SPORANOX PULSEPAK - itraconazole
cap 100 mg
•
COPEGUS - ribavirin tab 200 mg
4
CRIXIVAN - indinavir sulfate cap 200
mg
5
terbinafine hcl tab 250 mg (Lamisil)
1
TERBINEX - terbinafine oral tab 250 mg
& hydrxyprop chitosan liq 1% kit
CRIXIVAN - indinavir sulfate cap 400
mg
5
4
•
• •
Quantity Limits
VFEND - voriconazole tab 50 mg
Restricted Access
1
Prior Review
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Drug Tier
2014
7
INFERGEN - interferon alfacon-1 inj 15
mcg/0.5ml
5
• •
didanosine delayed release capsule
125 mg (Videx ec)
5
INTELENCE - etravirine tab 25 mg
5
5
200 mg (Videx ec)
5
5
5
INVIRASE - saquinavir mesylate cap
200 mg
5
250 mg (Videx ec)
5
INVIRASE - saquinavir mesylate tab
500 mg
5
400 mg (Videx ec)
4
ISENTRESS - raltegravir potassium tab
400 mg (base equiv)
5
EDURANT - rilpivirine hcl tab 25 mg
(base equivalent)
5
ISENTRESS - raltegravir potassium
chew tab 25 mg (base equiv)
5
EMTRIVA - emtricitabine caps 200 mg
EMTRIVA - emtricitabine soln 10 mg/ml
5
5
EPIVIR - lamivudine tab 150 mg
5
ISENTRESS - raltegravir potassium
chew tab 100 mg (base equiv)
EPIVIR - lamivudine tab 300 mg
5
5
EPIVIR - lamivudine oral soln 10 mg/ml
5
KALETRA - lopinavir-ritonavir tab
100-25 mg
EPIVIR HBV - lamivudine tab 100 mg
4
5
EPIVIR HBV - lamivudine oral soln 5
mg/ml
4
KALETRA - lopinavir-ritonavir tab
200-50 mg
5
EPZICOM - abacavir sulfate-lamivudine
tab 600-300 mg
5
KALETRA - lopinavir-ritonavir soln
400-100 mg/5ml (80-20 mg/ml)
lamivudine tab 100 mg (Epivir hbv)
5
famciclovir tab 125 mg (Famvir)
2
lamivudine tab 150 mg (Epivir)
5
2
lamivudine tab 300 mg (Epivir)
5
2
5
FAMVIR - famciclovir tab 125 mg
4
lamivudine-zidovudine tab
150-300 mg (Combivir)
4
LEXIVA - fosamprenavir calcium tab
700 mg (base equiv)
5
4
FLUMADINE - rimantadine
hydrochloride tab 100 mg
LEXIVA - fosamprenavir calcium susp
50 mg/ml (base equiv)
5
4
MODERIBA - ribavirin tab 400 mg
5
FUZEON - enfuvirtide for inj 90 mg
5
MODERIBA - ribavirin tab 600 mg
5
ganciclovir sodium for inj 500 mg
(Cytovene)
4
MODERIBA - ribavirin tab 200 mg &
ribavirin tab 400 mg dose pack
5
HEPSERA - adefovir dipivoxil tab 10 mg
5
INCIVEK - telaprevir tab 375 mg
MODERIBA - ribavirin tab 400 mg &
5
5
INFERGEN - interferon alfacon-1 inj 9
mcg/0.3ml
5
NEVIRAPINE - nevirapine susp 50
mg/5ml
4
8
•
•
• •
Drug Name
Quantity Limits
Prior Review
Restricted Access
Drug Tier
Quantity Limits
Restricted Access
5
Drug Tier
CYTOVENE - ganciclovir sodium for inj
500 mg
Drug Name
Prior Review
2014
5
•
nevirapine tab 200 mg (Viramune)
2
5
•
NORVIR - ritonavir cap 100 mg
5
PEGASYS PROCLICK - peginterferon
alfa-2a inj 135 mcg/0.5ml
NORVIR - ritonavir tab 100 mg
5
5
•
NORVIR - ritonavir oral soln 80 mg/ml
5
PEGASYS PROCLICK - peginterferon
alfa-2a inj 180 mcg/0.5ml
OLYSIO - simeprevir sodium cap 150
mg (base equivalent)
5
•
PEG-INTRON - peginterferon alfa-2b for 5
inj kit 50 mcg/0.5ml
PEG-INTRON REDIPEN - peginterferon 5
alfa-2b for inj kit 50 mcg/0.5ml
5
PEG-INTRON REDIPEN PAK 4 peginterferon alfa-2b for inj kit 50
mcg/0.5ml
5
mcg/0.5ml
5
mcg/0.5ml
5
mcg/0.5ml
5
PEGASYS - peginterferon alfa-2a inj
180 mcg/ml
5
PEGASYS - peginterferon alfa-2a inj
180 mcg/0.5ml
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Quantity Limits
Prior Review
PEGASYS - peginterferon alfa-2a inj kit
180 mcg/0.5ml
Drug Name
Restricted Access
Drug Tier
Quantity Limits
Restricted Access
5
Drug Tier
nevirapine tab sr 24hr 400 mg
(Viramune xr)
Drug Name
Prior Review
2014
PREZISTA - darunavir ethanolate tab 75 5
mg (base equiv)
5
PREZISTA - darunavir ethanolate tab
150 mg (base equiv)
5
400 mg (base equiv)
5
600 mg (base equiv)
5
800 mg (base equiv)
5
PREZISTA - darunavir ethanolate susp
100 mg/ml (base equiv)
5
REBETOL - ribavirin cap 200 mg
REBETOL - ribavirin soln 40 mg/ml
5
RELENZA DISKHALER - zanamivir
aero powder breath activated 5 mg/
blister
4
RESCRIPTOR - delavirdine mesylate
tab 100 mg
5
RESCRIPTOR - delavirdine mesylate
tab 200 mg
5
RETROVIR - zidovudine cap 100 mg
5
RETROVIR - zidovudine tab 300 mg
5
• •
RETROVIR - zidovudine syrup 10 mg/ml 5
5
REYATAZ - atazanavir sulfate cap 100
mg (base equiv)
5
mg (base equiv)
5
mg (base equiv)
5
mg (base equiv)
5
RIBASPHERE - ribavirin tab 400 mg
9
4
5
TAMIFLU - oseltamivir phosphate cap
45 mg (base equiv)
4
RIBASPHERE RIBAPAK - ribavirin tab
600 mg
5
75 mg (base equiv)
4
200 mg & ribavirin tab 400 mg dose
pack
5
TAMIFLU - oseltamivir phosphate for
susp 6 mg/ml (base equiv)
TAMIFLU - oseltamivir phosphate for
susp 12 mg/ml (base equiv)
4
400 mg & ribavirin tab 600 mg dose
pack
5
TIVICAY - dolutegravir sodium tab 50
mg (base equiv)
5
RIBATAB - ribavirin tab 400 mg
TRIZIVIR - abacavir sulfate-lamivudinezidovudine tab 300-150-300 mg
5
5
RIBATAB - ribavirin tab 600 mg
5
5
RIBATAB - ribavirin tab 400 mg &
5
TRUVADA - emtricitabine-tenofovir
disoproxil fumarate tab 200-300 mg
TYZEKA - telbivudine tab 600 mg
5
ribavirin cap 200 mg (Rebetol)
5
valacyclovir hcl tab 1 gm (Valtrex)
2
ribavirin tab 200 mg (Copegus)
5
valacyclovir hcl tab 500 mg (Valtrex)
2
rimantadine hydrochloride tab
100 mg (Flumadine)
2
VALCYTE - valganciclovir hcl tab 450
mg
5
SELZENTRY - maraviroc tab 150 mg
5
SELZENTRY - maraviroc tab 300 mg
5
SITAVIG - acyclovir buccal tab 50 mg
4
VALCYTE - valganciclovir hcl for soln 50 5
mg/ml (base equiv)
VALTREX - valacyclovir hcl tab 500 mg 4
SOVALDI - sofosbuvir tab 400 mg
5
stavudine cap 15 mg (Zerit)
VALTREX - valacyclovir hcl tab 1 gm
4
5
VICTRELIS - boceprevir cap 200 mg
5
5
VIDEX - didanosine for soln 2 gm
5
5
VIDEX - didanosine for soln 4 gm
5
5
5
stavudine for oral soln 1 mg/ml
(Zerit)
5
VIDEX EC - didanosine delayed release
capsule 125 mg
5
STRIBILD - elvitegrav-cobicisemtricitab-tenofov tab
150-150-200-300 mg
5
capsule 200 mg
capsule 250 mg
5
SUSTIVA - efavirenz cap 50 mg
5
5
SUSTIVA - efavirenz cap 200 mg
5
capsule 400 mg
5
VIRACEPT - nelfinavir mesylate tab 250
mg
5
SUSTIVA - efavirenz tab 600 mg
30 mg (base equiv)
4
VIRACEPT - nelfinavir mesylate tab 625
mg
5
VIRAMUNE - nevirapine tab 200 mg
5
10
•
•
Quantity Limits
Restricted Access
Prior Review
Drug Name
Drug Tier
400 mg
Quantity Limits
5
Restricted Access
RIBASPHERE - ribavirin tab 600 mg
Prior Review
Drug Name
Drug Tier
2014
VIRAMUNE - nevirapine susp 50
mg/5ml
5
VIRAMUNE XR - nevirapine tab sr 24hr
100 mg
5
VIRAMUNE XR - nevirapine tab sr 24hr
400 mg
5
VIRAZOLE - ribavirin for inhal soln 6 gm
5
VIREAD - tenofovir disoproxil fumarate
tab 150 mg
5
tab 200 mg
ATOVAQUONE/PROGUANIL HCL atovaquone-proguanil hcl tab 62.5-25
mg
4
chloroquine phosphate tab 250 mg
1
chloroquine phosphate tab 500 mg
(Aralen)
1
COARTEM - artemether-lumefantrine
tab 20-120 mg
3
DARAPRIM - pyrimethamine tab 25 mg
4
5
hydroxychloroquine sulfate tab
200 mg (Plaquenil)
1
tab 250 mg
5
MALARONE - atovaquone-proguanil hcl
tab 62.5-25 mg
4
tab 300 mg
5
MALARONE - atovaquone-proguanil hcl
tab 250-100 mg
4
oral powder 40 mg/gm
5
mefloquine hcl tab 250 mg
1
5
PLAQUENIL - hydroxychloroquine
sulfate tab 200 mg
4
ZERIT - stavudine cap 15 mg
5
3
5
PRIMAQUINE PHOSPHATE primaquine phosphate tab 26.3 mg
5
4
ZERIT - stavudine for oral soln 1 mg/ml
5
QUALAQUIN - quinine sulfate cap 324
mg
5
quinine sulfate cap 324 mg
(Qualaquin)
2
ZIAGEN - abacavir sulfate tab 300 mg
(base equiv)
ZIAGEN - abacavir sulfate soln 20 mg/
ml (base equiv)
5
zidovudine cap 100 mg (Retrovir)
• •
2
5
YODOXIN - iodoquinol tab 650 mg
2
zidovudine syrup 10 mg/ml (Retrovir)
5
ANTHELMINTICS
zidovudine tab 300 mg
5
ALBENZA - albendazole tab 200 mg
4
ZOVIRAX - acyclovir cap 200 mg
4
BILTRICIDE - praziquantel tab 600 mg
4
MEBENDAZOLE - mebendazole chew
tab 100 mg
4
STROMECTOL - ivermectin tab 3 mg
4
4
ZOVIRAX - acyclovir tab 800 mg
4
ZOVIRAX - acyclovir susp 200 mg/5ml
4
Quantity Limits
Restricted Access
AMEBICIDES
YODOXIN - iodoquinol tab 210 mg
ZOVIRAX - acyclovir tab 400 mg
Prior Review
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Drug Tier
2014
• •
• •
ANTI-INFECTIVE AGENTS - MISC.
ANTIMALARIALS
ARALEN - chloroquine phosphate tab
500 mg
4
atovaquone-proguanil hcl tab
250-100 mg (Malarone)
2
ALINIA - nitazoxanide tab 500 mg
4
ALINIA - nitazoxanide for susp 100
mg/5ml
4
atovaquone susp 750 mg/5ml
(Mepron)
2
11
BACTRIM - sulfamethoxazoletrimethoprim tab 400-80 mg
4
NEBUPENT - pentamidine isethionate
for nebulization soln 300 mg
BACTRIM DS - sulfamethoxazoletrimethoprim tab 800-160 mg
4
CAYSTON - aztreonam lysine for inhal
soln 75 mg (base equivalent)
5
CLEOCIN - clindamycin hcl cap 75 mg
4
4
4
CLEOCIN PEDIATRIC GRANULE clindamycin palmitate hcl for soln 75
mg/5ml (base equiv)
4
clindamycin hcl cap 150 mg (Cleocin)
1
PRIMSOL - trimethoprim hcl oral soln 50 4
mg/5ml (base equiv)
4
SEPTRA DS - sulfamethoxazoletrimethoprim tab 800-160 mg
sulfamethoxazole-trimethoprim susp 1
200-40 mg/5ml
1
sulfamethoxazole-trimethoprim tab
400-80 mg (Bactrim)
1
sulfamethoxazole-trimethoprim tab
800-160 mg (Bactrim ds)
4
TINDAMAX - tinidazole tab 250 mg
1
TINDAMAX - tinidazole tab 500 mg
4
1
tinidazole tab 250 mg (Tindamax)
2
clindamycin palmitate hcl for soln
75 mg/5ml (base equiv) (Cleocin
pediatric gr)
2
tinidazole tab 500 mg (Tindamax)
2
trimethoprim tab 100 mg
1
DAPSONE - dapsone tab 25 mg
VANCOCIN HCL - vancomycin hcl cap
125 mg
4
3
DAPSONE - dapsone tab 100 mg
3
4
erythromycin-sulfisoxazole for susp
200-600 mg/5ml
2
VANCOCIN HCL - vancomycin hcl cap
250 mg
2
FIRST-VANCOMYCIN 25 - vancomycin
hcl oral soln 25 mg/ml (compound kit)
4
vancomycin hcl cap 125 mg
(Vancocin hcl)
2
FIRST-VANCOMYCIN 50 - vancomycin
hcl oral soln 50 mg/ml (compound kit)
4
vancomycin hcl cap 250 mg
(Vancocin hcl)
XIFAXAN - rifaximin tab 200 mg
4
FLAGYL - metronidazole cap 375 mg
4
XIFAXAN - rifaximin tab 550 mg
4
FLAGYL - metronidazole tab 250 mg
4
ZYVOX - linezolid tab 600 mg
4
FLAGYL - metronidazole tab 500 mg
4
ZYVOX - linezolid for susp 100 mg/5ml
4
FLAGYL ER - metronidazole tab sr 24hr
750 mg
4
KETEK - telithromycin tab 300 mg
4
KETEK - telithromycin tab 400 mg
4
MEPRON - atovaquone susp 750
mg/5ml
• •
• •
BIOLOGICALS
BIOLOGICALS MISC
5
4
GRASTEK - timothy grass pollen
allergen ext tab sl 2800 bau
4
metronidazole cap 375 mg (Flagyl)
2
metronidazole tab 250 mg (Flagyl)
1
metronidazole tab 500 mg (Flagyl)
1
ORALAIR - grass mixed pollen ext tab sl 4
300 ir (index of reactivity)
4
RAGWITEK - short ragweed pollen
allergen extract tab sl 12 amb a 1-u
• •
Quantity Limits
Restricted Access
4
ADAGEN - pegademase bovine inj 250
unit/ml
12
Prior Review
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Drug Name
Prior Review
Drug Tier
2014
ANTINEOPLASTIC AGENTS
ANTINEOPLASTICS
• •
CYCLOPHOSPHAMIDE cyclophosphamide tab 25 mg
5
CYCLOPHOSPHAMIDE cyclophosphamide tab 50 mg
5
ELIGARD - leuprolide acetate for
subcutaneous inj kit 7.5 mg
5
ELIGARD - leuprolide acetate (3 month)
for subcutaneous inj kit 22.5mg
5
ACTIMMUNE - interferon gamma-1b inj
100 mcg/0.5ml (2000000 unit/0.5ml)
5
AFINITOR - everolimus tab 2.5 mg
5
AFINITOR - everolimus tab 5 mg
5
AFINITOR - everolimus tab 7.5 mg
5
AFINITOR - everolimus tab 10 mg
5
AFINITOR DISPERZ - everolimus tab
for oral susp 2 mg
for subcutaneous inj kit 30 mg
5
5
for oral susp 3 mg
for subcutaneous inj kit 45 mg
5
5
for oral susp 5 mg
EMCYT - estramustine phosphate
sodium cap 140 mg
4
5
ERIVEDGE - vismodegib cap 150 mg
5
ALKERAN - melphalan tab 2 mg
5
ETOPOSIDE - etoposide cap 50 mg
5
anastrozole tab 1 mg (Arimidex)
1
exemestane tab 25 mg (Aromasin)
2
ARIMIDEX - anastrozole tab 1 mg
4
AROMASIN - exemestane tab 25 mg
FARESTON - toremifene citrate tab 60
4
4
azacitidine for inj 100 mg (Vidaza)
2
FASLODEX - fulvestrant inj 250 mg/5ml
5
bicalutamide tab 50 mg (Casodex)
1
FEMARA - letrozole tab 2.5 mg
4
BOSULIF - bosutinib tab 100 mg
5
flutamide cap 125 mg
5
BOSULIF - bosutinib tab 500 mg
5
5
capecitabine tab 150 mg (Xeloda)
5
GILOTRIF - afatinib dimaleate tab 20
capecitabine tab 500 mg (Xeloda)
5
5
CAPRELSA - vandetanib tab 100 mg
5
5
5
CAPRELSA - vandetanib tab 300 mg
CASODEX - bicalutamide tab 50 mg
4
CEENU - lomustine cap 10 mg
GLEEVEC - imatinib mesylate tab 100
5
5
5
5
5
GLEEVEC - imatinib mesylate tab 400
HEXALEN - altretamine cap 50 mg
4
COMETRIQ - cabozantinib s-malate cap 5
3 x 20 mg (60 mg dose) kit
COMETRIQ - cabozantinib s-mal cap 1 5
x 80 mg & 1 x 20 mg (100 dose) kit
COMETRIQ - cabozantinib s-mal cap 1 5
x 80 mg & 3 x 20 mg (140 dose) kit
Quantity Limits
Restricted Access
Prior Review
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Drug Tier
2014
HYCAMTIN - topotecan hcl cap 0.25 mg 5
(base equiv)
5
HYCAMTIN - topotecan hcl cap 1 mg
(base equiv)
5
HYDREA - hydroxyurea cap 500 mg
hydroxyurea cap 500 mg (Hydrea)
5
13
ICLUSIG - ponatinib hcl tab 15 mg
(base equiv)
5
LUPRON DEPOT - leuprolide acetate
for inj kit 3.75 mg
5
ICLUSIG - ponatinib hcl tab 45 mg
(base equiv)
5
LUPRON DEPOT - leuprolide acetate
for inj kit 7.5 mg
5
IMBRUVICA - ibrutinib cap 140 mg
5
INLYTA - axitinib tab 1 mg
5
INLYTA - axitinib tab 5 mg
5
INTRON-A - interferon alfa-2b inj
6000000 unit/ml
5
• •
INTRON-A - interferon alfa-2b inj
10000000 unit/ml
5
• •
INTRON-A W/DILUENT - interferon
alfa-2b for inj 10000000 unit
5
• •
LUPRON DEPOT - leuprolide acetate (3 5
month) for inj kit 11.25 mg
month) for inj kit 22.5 mg
month) for inj kit 30 mg
month) for inj kit 45 mg
5
LYSODREN - mitotane tab 500 mg
5
• •
MATULANE - procarbazine hcl cap 50
mg
5
5
• •
MEGACE ORAL - megestrol acetate
susp 40 mg/ml
4
IRESSA - gefitinib tab 250 mg
5
2
JAKAFI - ruxolitinib phosphate tab 5 mg
(base equivalent)
5
megestrol acetate susp 40 mg/ml
(Megace oral)
megestrol acetate tab 20 mg
1
JAKAFI - ruxolitinib phosphate tab 10
5
megestrol acetate tab 40 mg
1
5
•
5
MEKINIST - trametinib dimethyl
sulfoxide tab 0.5 mg (base
equivalent)
5
MEKINIST - trametinib dimethyl
sulfoxide tab 2 mg (base equivalent)
5
•
5
mercaptopurine tab 50 mg
(Purinethol)
1
letrozole tab 2.5 mg (Femara)
1
MESNEX - mesna tab 400 mg
5
LEUCOVORIN CALCIUM - leucovorin
calcium tab 10 mg
2
methotrexate sodium for inj 1 gm
2
methotrexate sodium inj pf 25 mg/ml
1
LEUCOVORIN CALCIUM - leucovorin
calcium tab 15 mg
2
methotrexate sodium inj 25 mg/ml
1
2
methotrexate sodium tab 2.5 mg
(base equiv)
1
leucovorin calcium tab 25 mg
leucovorin calcium tab 5 mg
2
MYLERAN - busulfan tab 2 mg
4
LEUKERAN - chlorambucil tab 2 mg
5
5
LOMUSTINE - lomustine cap 10 mg
4
NEXAVAR - sorafenib tosylate tab 200
4
NILANDRON - nilutamide tab 150 mg
4
4
POMALYST - pomalidomide cap 1 mg
5
14
• •
Quantity Limits
Restricted Access
Prior Review
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Drug Name
Prior Review
Drug Tier
2014
PURINETHOL - mercaptopurine tab 50
mg
4
SOLTAMOX - tamoxifen citrate oral soln 4
10 mg/5ml (base equivalent)
5
SPRYCEL - dasatinib tab 20 mg
5
5
5
5
5
STIVARGA - regorafenib tab 40 mg
5
SUTENT - sunitinib malate cap 12.5 mg
(base equivalent)
5
SUTENT - sunitinib malate cap 25 mg
(base equivalent)
5
SUTENT - sunitinib malate cap 50 mg
(base equivalent)
5
SYLATRON - peginterferon alfa-2b for
inj kit 296 mcg
5
inj kit 444 mcg
5
inj kit 888 mcg
5
inj kit 4 x 296 mcg
5
inj kit 4 x 444 mcg
5
inj kit 4 x 888 mcg
5
TABLOID - thioguanine tab 40 mg
5
TAFINLAR - dabrafenib mesylate cap
5
•
TAFINLAR - dabrafenib mesylate cap
5
•
tamoxifen citrate tab 10 mg (base
equivalent)
1
TARCEVA - erlotinib tab 25 mg
5
5
5
TARGRETIN - bexarotene cap 75 mg
5
TASIGNA - nilotinib cap 150 mg
5
TASIGNA - nilotinib cap 200 mg
5
TEMODAR - temozolomide cap 5 mg
5
5
5
5
5
5
temozolomide cap 100 mg (Temodar)
5
5
5
5
5
5
tretinoin cap 10 mg
5
TREXALL - methotrexate sodium tab 5
mg (base equiv)
4
TREXALL - methotrexate sodium tab
7.5 mg (base equiv)
4
mg (base equiv)
4
mg (base equiv)
4
TYKERB - lapatinib ditosylate tab 250
mg (base equiv)
5
VANDETANIB - vandetanib tab 100 mg
5
VANDETANIB - vandetanib tab 300 mg
5
VIDAZA - azacitidine for inj 100 mg
5
VOTRIENT - pazopanib hcl tab 200 mg
(base equiv)
5
XALKORI - crizotinib cap 200 mg
5
Quantity Limits
5
1
Restricted Access
tamoxifen citrate tab 20 mg (base
equivalent)
Prior Review
5
Drug Name
Drug Tier
• •
• •
• •
Quantity Limits
5
Restricted Access
Prior Review
Drug Name
Drug Tier
2014
15
XTANDI - enzalutamide cap 40 mg
5
ZELBORAF - vemurafenib tab 240 mg
(base equivalent)
5
ZOLINZA - vorinostat cap 100 mg
5
ZYKADIA - ceritinib cap 150 mg
5
ZYTIGA - abiraterone acetate tab 250
mg
5
• •
•
•
ENDOCRINE AND METABOLIC DRUGS
CORTICOSTEROIDS
DEXPAK 6 DAY - dexamethasone tab
1.5 mg taper pack
4
ENTOCORT EC - budesonide cap sr
24hr 3 mg
4
FLO-PRED - prednisolone acetate oral
susp 16.7 mg/5ml (15 mg/5ml base)
4
fludrocortisone acetate tab 0.1 mg
1
hydrocortisone tab 10 mg (Cortef)
1
1
1
INTERARTICULAR JOINT KIT triamcinolone inj 40 mg/ml & lidocaine
1% & ammonia inh kit
4
MEDROL - methylprednisolone tab 2
mg
4
mg
4
4
budesonide cap sr 24hr 3 mg
(Entocort ec)
2
CELESTONE - betamethasone soln 0.6
mg/5ml
4
CORTEF - hydrocortisone tab 5 mg
4
4
4
CORTISONE ACETATE - cortisone
acetate tab 25 mg
3
mg
4
DEXAMETHASONE - dexamethasone
tab 1 mg
1
mg
4
tab 2 mg
1
mg
4
soln 0.5 mg/5ml
4
MEDROL DOSEPAK methylprednisolone tab 4 mg dose
pack
dexamethasone elixir 0.5 mg/5ml
1
1
DEXAMETHASONE INTENSOL dexamethasone conc 1 mg/ml
4
methylprednisolone tab 16 mg
(Medrol)
1
dexamethasone tab 0.5 mg
1
(Medrol)
1
(Medrol)
1
1
dexamethasone tab 4 mg
methylprednisolone tab 4 mg dose
pack (Medrol dosepak)
1
1
dexamethasone tab 6 mg
1
1
1.5 mg taper pack
4
(Medrol)
MILLIPRED - prednisolone tab 5 mg
1
16
• •
Quantity Limits
5
4
Restricted Access
XELODA - capecitabine tab 500 mg
1.5 mg taper pack
Prior Review
5
Drug Name
Drug Tier
XELODA - capecitabine tab 150 mg
Quantity Limits
5
Restricted Access
XALKORI - crizotinib cap 250 mg
Prior Review
Drug Name
Drug Tier
2014
4
MILLIPRED DP - prednisolone tab 5 mg
dose pack
4
ORAPRED - prednisolone sod
phosphate oral soln 15 mg/5ml (base
equiv)
4
ORAPRED ODT - prednisolone sod
phos orally disintegr tab 10 mg (base
eq)
4
eq)
4
eq)
4
PEDIAPRED - prednisolone sod phosph 4
oral soln 6.7 mg/5ml (5 mg/5ml base)
4
PHYSICIANS EZ USE JOINT T triamcinolone inj 40 mg/ml & lidocaine
1% & ammonia inh kit
1
prednisolone sod phosph oral
soln 6.7 mg/5ml (5 mg/5ml base)
(Pediapred)
1
prednisolone sod phosphate oral
soln 15 mg/5ml (base equiv)
4
PREDNISOLONE SODIUM PHOSP prednisolone sodium phosphate oral
soln 25 mg/5ml (base eq)
1
prednisolone syrup 15 mg/5ml (usp
solution equivalent) (Prelone)
1
PREDNISONE - prednisone tab 50 mg
prednisone tab 1 mg
1
prednisone tab 10 mg
1
prednisone tab 10 mg dose pack
1
prednisone tab 2.5 mg
1
prednisone tab 20 mg
1
prednisone tab 5 mg
1
prednisone tab 5 mg dose pack
1
PRELONE - prednisolone syrup 15
mg/5ml (usp solution equivalent)
4
RAYOS - prednisone tab delayed
release 1 mg
4
• •
release 2 mg
4
• •
release 5 mg
4
• •
UCERIS - budesonide tab sr 24hr 9 mg
4
• •
VERIPRED 20 - prednisolone sod
equiv)
4
Quantity Limits
Restricted Access
Prior Review
Quantity Limits
Restricted Access
Drug Name
Drug Tier
MILLIPRED - prednisolone sod
equiv)
Prior Review
Drug Name
Drug Tier
2014
ANDROGEN-ANABOLIC
ANADROL-50 - oxymetholone tab 50
mg
4
•
ANDRODERM - testosterone td patch
24hr 2 mg/24hr
3
•
ANDRODERM - testosterone td patch
24hr 4 mg/24hr
3
•
ANDROGEL - testosterone td gel 25
mg/2.5gm (1%)
3
•
ANDROGEL - testosterone td gel 50
mg/5gm (1%)
3
•
•
PREDNISONE - prednisone oral soln 5
mg/5ml
ANDROGEL - testosterone td gel 20.25
mg/1.25gm (1.62%)
3
3
1
ANDROGEL - testosterone td gel 40.5
mg/2.5gm (1.62%)
3
•
dose pack
1
PREDNISONE INTENSOL - prednisone
conc 5 mg/ml
4
ANDROGEL PUMP - testosterone td gel 3
12.5 mg/act (1%)
ANDROGEL PUMP - testosterone td gel 3
20.25 mg/act (1.62%)
•
dose pack
•
17
TESTRED - methyltestosterone cap 10
mg
•
•
• •
ESTROGENS
ACTIVELLA - estradiol & norethindrone
acetate tab 0.5-0.1 mg
4
• •
ACTIVELLA - estradiol & norethindrone
acetate tab 1-0.5 mg
4
ALORA - estradiol td patch biweekly
0.025 mg/24hr
4
• •
0.05 mg/24hr
4
• •
0.075 mg/24hr
4
• •
ALORA - estradiol td patch biweekly 0.1
mg/24hr
4
• •
ANGELIQ - drospirenone-estradiol tab
0.25-0.5 mg
4
• •
ANGELIQ - drospirenone-estradiol tab
0.5-1 mg
4
• •
CENESTIN - estrogens, conjugated
synthetic a tab 0.3 mg
4
• •
4
• •
4
• •
4
• •
4
• •
CLIMARA - estradiol td patch weekly
0.025 mg/24hr
4
danazol cap 200 mg
2
danazol cap 50 mg
2
DELATESTRYL - testosterone
enanthate im in oil 200 mg/ml
4
DEPO-TESTOSTERONE - testosterone
cypionate im in oil 100 mg/ml
4
DEPO-TESTOSTERONE - testosterone
4
FIRST-TESTOSTERONE - testosterone
propionate td ointment 2%
4
FIRST-TESTOSTERONE MC COM testosterone propionate td cream 2%
4
FORTESTA - testosterone td gel 10mg/
act (2%)
4
METHITEST - methyltestosterone oral
tab 10 mg
4
OXANDRIN - oxandrolone tab 2.5 mg
4
OXANDRIN - oxandrolone tab 10 mg
4
oxandrolone tab 10 mg (Oxandrin)
2
oxandrolone tab 2.5 mg (Oxandrin)
2
STRIANT - testosterone buccal
mucoadhesive system 30 mg
4
•
•
•
•
•
TESTIM - testosterone td gel 50
mg/5gm (1%)
4
• •
0.0375 mg/24hr (37.5 mcg/24hr)
4
testosterone cypionate im in oil
100 mg/ml (Depo-testosterone)
1
•
0.05 mg/24hr
4
testosterone cypionate im in oil
200 mg/ml (Depo-testosterone)
1
•
0.06 mg/24hr
4
testosterone enanthate im in oil
200 mg/ml
1
•
0.075 mg/24hr
4
18
•
•
•
• •
• •
• •
•
Quantity Limits
4
Restricted Access
•
ANDROXY - fluoxymesterone tab 10 mg 4
4
AVEED - testosterone undecanoate im
inj in oil 750 mg/3ml (250mg/ml)
4
AXIRON - testosterone td soln 30 mg/
act
2
danazol cap 100 mg
Prior Review
4
Drug Name
Drug Tier
Quantity Limits
Prior Review
ANDROID - methyltestosterone cap 10
mg
Drug Tier
Drug Name
Restricted Access
2014
CLIMARA - estradiol td patch weekly 0.1 4
mg/24hr
4
CLIMARA PRO - estradiollevonorgestrel td patch weekly
0.045-0.015 mg/day
COMBIPATCH - estradiol-norethindrone 4
ace td pttw 0.05-0.14 mg/day
COMBIPATCH - estradiol-norethindrone 4
ace td pttw 0.05-0.25 mg/day
DELESTROGEN - estradiol valerate im 4
in oil 10 mg/ml
in oil 20 mg/ml
in oil 40 mg/ml
4
DEPO-ESTRADIOL - estradiol
4
DIVIGEL - estradiol td gel 0.25
mg/0.25gm (0.1%)
DIVIGEL - estradiol td gel 0.5 mg/0.5gm 4
(0.1%)
4
DIVIGEL - estradiol td gel 1 mg/gm
(0.1%)
4
DUAVEE - conjugated estrogensbazedoxifene tab 0.45-20 mg
4
ELESTRIN - estradiol gel 0.06% (0.52
mg/0.87 gm metered-dose pump)
4
ENJUVIA - estrogens, conjugated
synthetic b tab 0.3 mg
4
4
4
4
1
esterified estrogens &
methyltestosterone tab
0.625-1.25 mg
esterified estrogens &
methyltestosterone tab 1.25-2.5 mg
1
ESTRACE - estradiol tab 0.5 mg
4
ESTRACE - estradiol tab 1 mg
4
ESTRACE - estradiol tab 2 mg
4
estradiol & norethindrone acetate
tab 0.5-0.1 mg (Activella)
2
estradiol & norethindrone acetate
tab 1-0.5 mg (Activella)
2
estradiol tab 0.5 mg (Estrace)
1
estradiol tab 1 mg (Estrace)
1
estradiol tab 2 mg (Estrace)
1
estradiol td patch weekly
0.025 mg/24hr (Climara)
1
0.0375 mg/24hr (37.5 mcg/24hr)
(Climara)
1
1
1
1
• •
1
• •
2
• •
estradiol valerate im in oil 10 mg/ml
(Delestrogen)
2
• •
(Delestrogen)
2
• •
(Delestrogen)
4
• •
• •
ESTRASORB - estradiol transdermal
emulsion 4.35 mg/1.74gm
4
• •
• •
ESTROGEL - estradiol gel 0.06% (0.75
mg/1.25 gm metered-dose pump)
ESTROPIPATE - estropipate tab 3 mg
1
estropipate tab 0.75 mg
1
estropipate tab 1.5 mg
1
• •
• •
• •
• •
Quantity Limits
Restricted Access
Prior Review
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Drug Tier
2014
19
4
• •
FEMTRACE - estradiol acetate tab 0.9
mg
4
• •
MENEST - esterified estrogens tab 0.3
mg
4
• •
MENEST - esterified estrogens tab
0.625 mg
4
• •
mg
4
mg
MENOSTAR - estradiol td patch weekly
14 mcg/24hr
PREMPRO - conjugated estrogenmedroxyprogest acetate tab 0.3-1.5
mg
3
PREMPRO - conjugated estrogenmedroxyprogest acetate tab 0.45-1.5
mg
3
PREMPRO - conjugated estrogenmedroxyprogest acetate tab
0.625-2.5 mg
3
3
• •
PREMPRO - conjugated estrogenmedroxyprogest acetate tab 0.625-5
mg
4
• •
VIVELLE-DOT - estradiol td patch
biweekly 0.025 mg/24hr
4
• •
4
• •
4
• •
MINIVELLE - estradiol td patch biweekly 4
0.0375 mg/24hr
0.05 mg/24hr
0.075 mg/24hr
0.1 mg/24hr
4
PREFEST - estradiol tab 1
mg(15)/estrad-norgestimate tab
1-0.09mg(15)
PREMARIN - estrogens, conjugated tab 3
0.3 mg
0.45 mg
0.625 mg
0.9 mg
1.25 mg
3
PREMPHASE - conj est 0.625(14)/conj
est-medroxypro ac tab 0.625-5mg(14)
• •
4
• •
• •
4
• •
• •
4
• •
• •
CONTRACEPTIVES
AMETHYST - levonorgestrel-ethinyl
estradiol (continuous) tab 90-20 mcg
4
• •
BEYAZ - drospirenone-ethinyl estradlevomefolate tab 3-0.02-0.451 mg
4
• •
20
• •
BREVICON-28 - norethindrone & ethinyl 4
estradiol tab 0.5 mg-35 mcg
4
CYCLESSA - desogest-ethin est tab
0.1-0.025/0.125-0.025/0.15-0.025mgmg
3
DEPO-PROVERA CONTRACEPTIV medroxyprogesterone acetate im
susp 150 mg/ml
3
DEPO-SUBQ PROVERA 104 medroxyprogesterone acetate
subcutaneous susp 104 mg/0.65ml
4
DESOGEN - desogestrel & ethinyl
• •
• •
Quantity Limits
FEMTRACE - estradiol acetate tab 0.45
mg
Restricted Access
• •
Prior Review
4
Drug Name
Drug Tier
Prior Review
EVAMIST - estradiol transdermal spray
1.53 mg/spray
Drug Name
Quantity Limits
Drug Tier
Restricted Access
2014
desogest-eth estrad & eth estrad tab
0.15-0.02/0.01 mg(21/5) (Mircette)
1
levonorgestrel & ethinyl estradiol tab
0.15 mg-30 mcg
1
desogest-ethin est tab
0.1-0.025/0.125-0.025/0.15-0.025mgmg (Cyclessa)
1
levonorgestrel tab 0.75 mg (Plan b)
1
levonorgestrel tab 1.5 mg (Plan b
one-step)
1
desogestrel & ethinyl estradiol tab
0.15 mg-30 mcg (Desogen)
1
levonorgestrel-eth estra tab
0.05-30/0.075-40/0.125-30mg-mcg
1
drospirenone-ethinyl estradiol tab
3-0.02 mg (Yaz)
2
4
drospirenone-ethinyl estradiol tab
3-0.03 mg (Yasmin 28)
2
LO LOESTRIN FE - norethin-eth
estradiol-fe tab 1 mg-10 mcg (24)/10
mcg (2)
ELLA - ulipristal acetate tab 30 mg
ESTROSTEP FE - norethindrone acethinyl estrad-fe tab 1-20/1-30/1-35
mg-mcg
4
LO MINASTRIN FE - norethin-eth
estrad-fe chew/tab 1 mg-10 mcg/10
mcg ther pack
4
3
4
ethynodiol diacetate & ethinyl
estradiol tab 1 mg-35 mcg
1
LOESTRIN FE 1.5/30 - norethindrone
ace & ethinyl estradiol-fe tab 1.5
mg-30 mcg
4
FALESSA - levonorgest-eth estrad tab
0.1 mg-20 mcg & fa tab 1 mg kit
4
LOESTRIN FE 1/20 - norethindrone
ace & ethinyl estradiol-fe tab 1 mg-20
mcg
FEMCON FE - norethindrone & ethinyl
estradiol-fe chew tab 0.4 mg-35 mcg
4
4
FEMHRT LOW DOSE - norethindrone
acetate-ethinyl estradiol tab 0.5
mg-2.5 mcg
4
LOESTRIN 1.5/30-21 - norethindrone
ace & ethinyl estradiol tab 1.5 mg-30
mcg
LOESTRIN 1/20-21 - norethindrone ace
& ethinyl estradiol tab 1 mg-20 mcg
4
FEMHRT 1/5 - norethindrone acetateethinyl estradiol tab 1 mg-5 mcg
4
• •
4
• •
GENERESS FE - norethindrone &
ethinyl estradiol-fe chew tab 0.8
mg-25 mcg
4
• •
LOESTRIN 24 FE - norethindrone aceethinyl estradiol-fe tab 1 mg-20 mcg
(24)
4
• •
JINTELI - norethindrone acetate-ethinyl
4
LOMEDIA 24 FE - norethindrone aceethinyl estradiol-fe tab 1 mg-20 mcg
(24)
4
levonorg-eth est tab 0.1-0.02mg(84)
& eth est tab 0.01mg(7)
(Loseasonique)
2
LOSEASONIQUE - levonorg-eth est
tab 0.1-0.02mg(84) & eth est tab
0.01mg(7)
1
levonorg-eth est tab 0.15-0.03mg(84)
& eth est tab 0.01mg(7)
(Seasonique)
2
medroxyprogesterone acetate im
susp 150 mg/ml (Depo-provera
contrac)
4
levonorgestrel & ethinyl estradiol
(91-day) tab 0.15-0.03 mg
1
MINASTRIN 24 FE - norethindrone aceeth estradiol-fe chew tab 1 mg-20
mcg (24)
1
MIRCETTE - desogest-eth estrad & eth
estrad tab 0.15-0.02/0.01 mg(21/5)
4
levonorgestrel & ethinyl estradiol tab
0.1 mg-20 mcg
• •
• •
Quantity Limits
Restricted Access
Prior Review
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Drug Tier
2014
• •
21
MODICON - norethindrone & ethinyl
4
NATAZIA - estradiol valerate-dienogest
tab 3 mg /2-2 mg/2-3 mg/1 mg
4
NECON 1/50-28 - norethindrone &
mestranol tab 1 mg-50 mcg
4
NECON 10/11-28 - norethindrone-eth
estradiol tab 0.5-35/1-35 mg-mcg
(10/11)
4
NOR-QD - norethindrone tab 0.35 mg
4
NORDETTE-28 - levonorgestrel &
ethinyl estradiol tab 0.15 mg-30 mcg
4
norelgestromin-ethinyl estradiol td
ptwk 150-35 mcg/24hr (Ortho evra)
2
norethindrone & ethinyl estradiol tab
0.4 mg-35 mcg (Ovcon-35)
1
0.5 mg-35 mcg (Brevicon-28)
1
1 mg-35 mcg (Norinyl 1+35)
1
norethindrone & ethinyl estradiol-fe
chew tab 0.4 mg-35 mcg (Femcon
fe)
2
norethindrone ac-ethinyl estradfe tab 1-20/1-30/1-35 mg-mcg
(Estrostep fe)
norethindrone-eth estradiol tab
0.5-35/0.75-35/1-35 mg-mcg (Orthonovum 7/7/7)
1
1
• •
norethindrone-eth estradiol tab
0.5-35/1-35/0.5-35 mg-mcg (Trinorinyl 28)
• •
norgestimate & ethinyl estradiol tab
0.25 mg-35 mcg (Ortho-cyclen)
1
norgestimate-eth estrad tab
0.18-35/0.215-35/0.25-35 mg-mcg
(Ortho tri-cyclen)
1
norgestrel & ethinyl estradiol tab
0.3 mg-30 mcg
1
NORINYL 1+35 - norethindrone &
ethinyl estradiol tab 1 mg-35 mcg
4
NORINYL 1+50 - norethindrone &
mestranol tab 1 mg-50 mcg
4
NUVARING - etonogestrel-ethinyl
estradiol va ring 0.120-0.015 mg/24hr
3
OGESTREL - norgestrel & ethinyl
4
ORTHO EVRA - norelgestromin-ethinyl
estradiol td ptwk 150-35 mcg/24hr
4
1
ORTHO MICRONOR - norethindrone
tab 0.35 mg
4
4
norethindrone ace & ethinyl estradiol
tab 1 mg-20 mcg (Loestrin 1/20-21)
1
ORTHO TRI-CYCLEN norgestimate-eth estrad tab
0.18-35/0.215-35/0.25-35 mg-mcg
norethindrone ace & ethinyl estradiol
tab 1.5 mg-30 mcg (Loestrin
1.5/30-21)
1
ORTHO TRI-CYCLEN LO norgestimate-eth estrad tab
0.18-25/0.215-25/0.25-25 mg-mcg
4
norethindrone ace & ethinyl
estradiol-fe tab 1 mg-20 mcg
(Loestrin fe 1/20)
1
ORTHO-CEPT - desogestrel & ethinyl
4
4
norethindrone ace & ethinyl
estradiol-fe tab 1.5 mg-30 mcg
(Loestrin fe 1.5/30)
1
ORTHO-CYCLEN - norgestimate &
ethinyl estradiol tab 0.25 mg-35 mcg
norethindrone acetate-ethinyl
2
norethindrone tab 0.35 mg (Nor-qd)
1
22
• •
• •
• •
• •
ORTHO-NOVUM 1/35 - norethindrone & 4
ORTHO-NOVUM 7/7/7 - norethindrone- 4
eth estradiol tab 0.5-35/0.75-35/1-35
mg-mcg
Quantity Limits
Restricted Access
Prior Review
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Drug Name
Prior Review
Drug Tier
2014
OVCON-35 - norethindrone & ethinyl
4
PROMETRIUM - progesterone
micronized cap 100 mg
4
PLAN B - levonorgestrel tab 0.75 mg
4
4
PLAN B ONE-STEP - levonorgestrel tab
1.5 mg
4
PROMETRIUM - progesterone
micronized cap 200 mg
4
QUARTETTE - levonor-eth est tab
0.15-0.02/0.025/0.03 mg &eth est
0.01 mg
4
PROVERA - medroxyprogesterone
acetate tab 2.5 mg
acetate tab 5 mg
4
acetate tab 10 mg
4
SAFYRAL - drospirenone-ethinyl estrad- 4
levomefolate tab 3-0.03-0.451 mg
4
SEASONIQUE - levonorg-eth est
tab 0.15-0.03mg(84) & eth est tab
0.01mg(7)
4
TRI-NORINYL 28 - norethindrone-eth
estradiol tab 0.5-35/1-35/0.5-35 mgmcg
4
YASMIN 28 - drospirenone-ethinyl
estradiol tab 3-0.03 mg
YAZ - drospirenone-ethinyl estradiol tab 4
3-0.02 mg
4
ZOVIA 1/50E - ethynodiol diacetate &
• •
Quantity Limits
Restricted Access
Prior Review
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Drug Tier
2014
ANTIDIABETICS
ANTIDIABETICS
acarbose tab 100 mg (Precose)
2
2
2
ACTOPLUS MET - pioglitazone hclmetformin hcl tab 15-500 mg
4
ACTOPLUS MET - pioglitazone hclmetformin hcl tab 15-850 mg
4
ACTOPLUS MET XR - pioglitazone hclmetformin hcl tab sr 24hr 15-1000 mg
4
• •
4
• •
AYGESTIN - norethindrone acetate tab
5 mg
4
ACTOPLUS MET XR - pioglitazone hclmetformin hcl tab sr 24hr 30-1000 mg
4
medroxyprogesterone acetate tab
10 mg (Provera)
1
ACTOS - pioglitazone hcl tab 15 mg
(base equiv)
4
2.5 mg (Provera)
1
(base equiv)
4
5 mg (Provera)
1
(base equiv)
AMARYL - glimepiride tab 1 mg
4
MEGACE ES - megestrol acetate susp
625 mg/5ml
4
4
4
norethindrone acetate tab 5 mg
(Aygestin)
2
4
• •
progesterone im in oil 50 mg/ml
2
AVANDAMET - rosiglitazone maleatemetformin hcl tab 2-500 mg
• •
2
4
progesterone micronized cap 100 mg
(Prometrium)
• •
(Prometrium)
4
2
• •
PROGESTINS
• •
23
Prior Review
4
• •
FARXIGA - dapagliflozin propanediol
tab 5 mg (base equivalent)
4
• •
AVANDARYL - rosiglitazone maleateglimepiride tab 4-1 mg
4
• •
FARXIGA - dapagliflozin propanediol
tab 10 mg (base equivalent)
4
• •
4
• •
FORTAMET - metformin hcl tab sr 24hr
osmotic 500 mg
4
4
• •
FORTAMET - metformin hcl tab sr 24hr
osmotic 1000 mg
4
4
• •
glimepiride tab 1 mg (Amaryl)
1
1
• •
4
1
4
• •
glipizide tab sr 24hr 10 mg (Glucotrol
xl)
1
AVANDIA - rosiglitazone maleate tab 2
mg (base equiv)
4
• •
glipizide tab sr 24hr 2.5 mg (Glucotrol
xl)
1
mg (base equiv)
4
• •
glipizide tab sr 24hr 5 mg (Glucotrol
xl)
1
mg (base equiv)
4
• •
glipizide tab 10 mg (Glucotrol)
1
BYDUREON - exenatide extended
release for inj susp 2 mg
glipizide tab 5 mg (Glucotrol)
1
BYETTA - exenatide soln pen-injector 5
mcg/0.02ml
4
• •
glipizide-metformin hcl tab
2.5-250 mg
2
BYETTA - exenatide soln pen-injector
10 mcg/0.04ml
4
• •
glipizide-metformin hcl tab
2.5-500 mg
2
CHLORPROPAMIDE - chlorpropamide
tab 100 mg
4
glipizide-metformin hcl tab 5-500 mg
2
3
CHLORPROPAMIDE - chlorpropamide
tab 250 mg
4
GLUCAGEN - glucagon hcl (rdna) for inj
1 mg (base equiv)
3
CYCLOSET - bromocriptine mesylate
tab 0.8 mg (base equivalent)
4
GLUCAGEN HYPOKIT - glucagon hcl
(rdna) for inj 1 mg (base equiv)
3
DEX4 GLUCOSE - glucose oral liquid
15 gm/59ml
4
GLUCAGON EMERGENCY KIT glucagon (rdna) for inj kit 1 mg
4
DIABETA - glyburide tab 1.25 mg
4
GLUCOPHAGE - metformin hcl tab 500
mg
DIABETA - glyburide tab 2.5 mg
4
4
DIABETA - glyburide tab 5 mg
4
GLUCOPHAGE - metformin hcl tab 850
mg
4
GLUCOPHAGE - metformin hcl tab
1000 mg
4
DUETACT - pioglitazone hcl-glimepiride
tab 30-2 mg
4
GLUCOPHAGE XR - metformin hcl tab
sr 24hr 500 mg
4
DUETACT - pioglitazone hcl-glimepiride
tab 30-4 mg
Drug Name
24
Drug Name
Quantity Limits
Drug Tier
Restricted Access
Prior Review
Quantity Limits
Drug Tier
Restricted Access
2014
GLUCOPHAGE XR - metformin hcl tab
sr 24hr 750 mg
4
glyburide-metformin tab 5-500 mg
(Glucovance)
1
glucose gel 40%
2
4
glucose oral liquid 15 gm/59ml
2
GLYNASE - glyburide micronized tab
1.5 mg
GLUCOTROL - glipizide tab 5 mg
4
4
GLUCOTROL - glipizide tab 10 mg
4
GLYNASE - glyburide micronized tab 3
mg
4
GLYNASE - glyburide micronized tab 6
mg
4
GLUCOTROL XL - glipizide tab sr 24hr
2.5 mg
4
GLYSET - miglitol tab 25 mg
4
5 mg
4
10 mg
4
4
INVOKANA - canagliflozin tab 100 mg
3
GLUCOVANCE - glyburide-metformin
tab 1.25-250 mg
4
INVOKANA - canagliflozin tab 300 mg
3
4
• •
tab 2.5-500 mg
4
JANUMET - sitagliptin-metformin hcl tab
50-500 mg
• •
4
JANUMET - sitagliptin-metformin hcl tab
50-1000 mg
4
tab 5-500 mg
• •
GLUMETZA - metformin hcl tab sr 24hr
modified release 500 mg
• •
JANUMET XR - sitagliptin-metformin hcl
tab sr 24hr 50-500 mg
4
4
• •
• •
GLUMETZA - metformin hcl tab sr 24hr
modified release 1000 mg
tab sr 24hr 50-1000 mg
4
4
• •
GLYBURIDE - glyburide tab 1.25 mg
tab sr 24hr 100-1000 mg
4
1
GLYBURIDE - glyburide tab 2.5 mg
1
4
• •
GLYBURIDE - glyburide tab 5 mg
1
JANUVIA - sitagliptin phosphate tab 25
mg (base equiv)
glyburide micronized tab 1.5 mg
(Glynase)
1
JANUVIA - sitagliptin phosphate tab 50
mg (base equiv)
4
• •
glyburide micronized tab 3 mg
(Glynase)
1
• •
glyburide micronized tab 6 mg
(Glynase)
1
glyburide tab 1.25 mg
1
glyburide tab 2.5 mg
1
glyburide tab 5 mg
1
glyburide-metformin tab 1.25-250 mg
(Glucovance)
1
(Glucovance)
1
JANUVIA - sitagliptin phosphate tab 100 4
mg (base equiv)
4
JENTADUETO - linagliptin-metformin
hcl tab 2.5-500 mg
4
hcl tab 2.5-850 mg
4
hcl tab 2.5-1000 mg
4
JUVISYNC - sitagliptin-simvastatin tab
50-10 mg
4
50-20 mg
Quantity Limits
Restricted Access
Prior Review
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Drug Tier
2014
• •
• •
• •
• •
• •
• •
• •
• •
25
Prior Review
50-40 mg
4
• •
NESINA - alogliptin benzoate tab 12.5
mg (base equiv)
4
• •
100-10 mg
4
• •
NESINA - alogliptin benzoate tab 25 mg
(base equiv)
4
• •
100-20 mg
4
• •
ONGLYZA - saxagliptin hcl tab 2.5 mg
(base equiv)
3
100-40 mg
4
• •
ONGLYZA - saxagliptin hcl tab 5 mg
(base equiv)
3
KAZANO - alogliptin-metformin hcl tab
12.5-500 mg
4
• •
OSENI - alogliptin-pioglitazone tab
12.5-15 mg
4
• •
KAZANO - alogliptin-metformin hcl tab
12.5-1000 mg
4
• •
12.5-30 mg
4
• •
KOMBIGLYZE XR - saxagliptinmetformin hcl tab sr 24hr 2.5-1000
mg
3
12.5-45 mg
4
• •
4
• •
KOMBIGLYZE XR - saxagliptinmetformin hcl tab sr 24hr 5-500 mg
3
25-15 mg
• •
3
25-30 mg
4
KOMBIGLYZE XR - saxagliptinmetformin hcl tab sr 24hr 5-1000 mg
• •
KORLYM - mifepristone tab 300 mg
25-45 mg
4
5
METAGLIP - glipizide-metformin hcl tab
2.5-250 mg
4
pioglitazone hcl tab 15 mg (base
equiv) (Actos)
2
metformin hcl tab sr 24hr osmotic
1000 mg (Fortamet)
2
equiv) (Actos)
2
metformin hcl tab sr 24hr osmotic
500 mg (Fortamet)
2
equiv) (Actos)
2
metformin hcl tab sr 24hr 500 mg
(Glucophage xr)
1
pioglitazone hcl-glimepiride tab
30-2 mg (Duetact)
2
metformin hcl tab sr 24hr 750 mg
(Glucophage xr)
1
pioglitazone hcl-glimepiride tab
30-4 mg (Duetact)
2
metformin hcl tab 1000 mg
(Glucophage)
1
pioglitazone hcl-metformin hcl tab
15-500 mg (Actoplus met)
2
(Glucophage)
1
pioglitazone hcl-metformin hcl tab
15-850 mg (Actoplus met)
2
(Glucophage)
1
PRANDIMET - repaglinide-metformin
hcl tab 1-500 mg
4
• •
nateglinide tab 120 mg (Starlix)
2
4
• •
nateglinide tab 60 mg (Starlix)
2
PRANDIMET - repaglinide-metformin
hcl tab 2-500 mg
NESINA - alogliptin benzoate tab 6.25
mg (base equiv)
4
PRANDIN - repaglinide tab 0.5 mg
4
PRANDIN - repaglinide tab 1 mg
4
Drug Name
26
•
• •
Drug Name
Quantity Limits
Drug Tier
Restricted Access
Prior Review
Quantity Limits
Drug Tier
Restricted Access
2014
PRECOSE - acarbose tab 100 mg
4
PROGLYCEM - diazoxide susp 50 mg/
ml
4
repaglinide tab 0.5 mg (Prandin)
2
repaglinide tab 1 mg (Prandin)
2
repaglinide tab 2 mg (Prandin)
2
RIOMET - metformin hcl oral soln 500
mg/5ml
4
STARLIX - nateglinide tab 60 mg
4
STARLIX - nateglinide tab 120 mg
4
SYMLINPEN 120 - pramlintide acetate
pen-inj 2700 mcg/2.7ml (1000 mcg/
ml)
4
SYMLINPEN 60 - pramlintide acetate
pen-inj 1500 mcg/1.5ml (1000 mcg/
ml)
4
TOLAZAMIDE - tolazamide tab 500 mg
1
tolazamide tab 250 mg
1
TOLBUTAMIDE - tolbutamide tab 500
mg
1
TRADJENTA - linagliptin tab 5 mg
4
VICTOZA - liraglutide soln pen-injector
18 mg/3ml (6 mg/ml)
3
4
APIDRA SOLOSTAR - insulin glulisine
soln pen-injector inj 100 unit/ml
4
HUMALOG - insulin lispro (human) soln
cartridge 100 unit/ml
3
HUMALOG - insulin lispro (human) inj
100 unit/ml
3
HUMALOG KWIKPEN - insulin lispro
(human) soln pen-injector 100 unit/ml
3
NOVOLOG - insulin aspart inj 100 unit/
ml
4
4
• •
NOVOLOG PENFILL - insulin aspart
soln cartridge 100 unit/ml
4
• •
NOVOLOG PENFILL - insulin aspart inj
100 unit/ml
4
• •
Short-Acting Insulins
• •
• •
• •
• •
Rapid-Acting Insulins
APIDRA - insulin glulisine inj 100 unit/ml
NOVOLOG FLEXPEN - insulin aspart
soln pen-injector 100 unit/ml
Drug Name
Quantity Limits
4
Restricted Access
Prior Review
4
Drug Tier
Quantity Limits
4
Restricted Access
PRANDIN - repaglinide tab 2 mg
Prior Review
Drug Name
Drug Tier
2014
• •
• •
• •
HUMULIN R - insulin regular (human) inj 3
100 unit/ml
3
HUMULIN R U-500 (CONCENTR insulin regular (human) inj 500 unit/ml
NOVOLIN R - insulin regular (human) inj 4
100 unit/ml
4
NOVOLIN R RELION - insulin regular
(human) inj 100 unit/ml
4
RELION R - insulin regular (human) inj
100 unit/ml
• •
• •
• •
Intermediate-Acting Insulins
HUMALOG MIX 50/50 - insulin lispro
prot & lispro (human) inj 100 unit/ml
(50-50)
3
HUMALOG MIX 50/50 KWIKPEN insulin lispro prot & lispro sus pen-inj
100 unit/ml (50-50)
3
HUMALOG MIX 75/25 - insulin lispro
prot & lispro (human) inj 100 unit/ml
(75-25)
3
HUMALOG MIX 75/25 KWIKPEN insulin lispro prot & lispro sus pen-inj
100 unit/ml (75-25)
3
HUMULIN N - insulin isophane (human)
inj 100 unit/ml
3
HUMULIN N KWIKPEN - insulin
isophane (human) susp pen-injector
100 unit/ml
3
HUMULIN N U-100 PEN - insulin
isophane (human) susp pen-injector
100 unit/ml
3
HUMULIN 70/30 - insulin isophane
& regular (human) inj 100 unit/ml
(70-30)
3
27
HUMULIN 70/30 KWIKPEN - insulin
isophane & regular susp pen-inj 100
unit/ml (70-30)
3
HUMULIN 70/30 PEN - insulin isophane
& regular susp pen-inj 100 unit/ml
(70-30)
3
NOVOLIN N - insulin isophane (human)
inj 100 unit/ml
4
• •
NOVOLIN N RELION - insulin isophane
(human) inj 100 unit/ml
4
• •
NOVOLIN 70/30 - insulin isophane
& regular (human) inj 100 unit/ml
(70-30)
4
• •
NOVOLIN 70/30 RELION - insulin
isophane & regular (human) inj 100
unit/ml (70-30)
4
• •
NOVOLOG MIX 70/30 - insulin aspart
prot & aspart (human) inj 100 unit/ml
(70-30)
4
NOVOLOG MIX 70/30 PREFILL - insulin 4
aspart prot & aspart sus pen-inj 100
unit/ml (70-30)
• •
• •
Basal Insulins
LANTUS - insulin glargine inj 100 unit/ml 3
3
LANTUS SOLOSTAR - insulin glargine
4
LEVEMIR - insulin detemir inj 100 unit/
ml
4
LEVEMIR FLEXPEN - insulin detemir
THYROID AGENTS
ARMOUR THYROID - thyroid tab 15 mg 4
(1/4 grain)
(1/2 grain)
(1 grain)
(1 1/2 grain)
4
ARMOUR THYROID - thyroid tab 120
mg (2 grain)
28
• •
• •
mg (3 grain)
4
mg (4 grain)
4
mg (5 grain)
4
CYTOMEL - liothyronine sodium tab 5
mcg
4
mcg
4
mcg
4
levothyroxine sodium tab 100 mcg
(Synthroid)
1
(Synthroid)
1
(Synthroid)
1
(Synthroid)
1
(Synthroid)
1
(Synthroid)
1
(Synthroid)
1
(Synthroid)
1
(Synthroid)
1
(Synthroid)
1
(Synthroid)
1
(Synthroid)
1
liothyronine sodium tab 25 mcg
(Cytomel)
1
(Cytomel)
1
Quantity Limits
Restricted Access
Prior Review
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Drug Name
Prior Review
Drug Tier
2014
(Cytomel)
1
methimazole tab 10 mg (Tapazole)
1
methimazole tab 5 mg (Tapazole)
1
NATURE-THROID - thyroid tab 16.25
mg
1
NATURE-THROID - thyroid tab 32.5 mg
1
mg (3/4 grain)
1
NATURE-THROID - thyroid tab 65 mg
1
mg
1
NATURE-THROID - thyroid tab 97.5 mg
1
mg
1
1
1
1
Quantity Limits
Restricted Access
SYNTHROID - levothyroxine sodium tab 4
137 mcg
150 mcg
175 mcg
200 mcg
300 mcg
4
TAPAZOLE - methimazole tab 5 mg
TAPAZOLE - methimazole tab 10 mg
4
thyroid tab 30 mg (1/2 grain) (Armour
thyroid)
1
thyroid tab 60 mg (1 grain) (Armour
thyroid)
1
thyroid tab 90 mg (1 1/2 grain)
(Armour thyroid)
1
(5 grain)
THYROLAR-1 - liotrix (t3-t4) tab 60 mg
(12.5-50 mcg)
4
1
mg
THYROLAR-1/2 - liotrix (t3-t4) tab 30
mg (6.25-25 mcg)
4
1
4
NATURE-THROID NT-2.5 - thyroid tab
162.5 mg (2 1/2 grain)
1
THYROLAR-1/4 - liotrix (t3-t4) tab 15
mg (3.1-12.5 mcg)
1
(25-100 mcg)
4
propylthiouracil tab 50 mg
(37.5-150 mcg)
4
TIROSINT - levothyroxine sodium cap
13 mcg
4
25 mcg
4
50 mcg
4
75 mcg
4
88 mcg
4
100 mcg
4
25 mcg
50 mcg
75 mcg
88 mcg
100 mcg
112 mcg
125 mcg
Prior Review
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Drug Tier
2014
29
WP THYROID - thyroid tab 113.75 mg
1
WP THYROID - thyroid tab 130 mg
1
112 mcg
4
125 mcg
4
137 mcg
4
150 mcg
4
WESTHROID - thyroid tab 16.25 mg
1
1
(3/4 grain)
1
WESTHROID - thyroid tab 65 mg
1
1
1
1
1
WESTHROID - thyroid tab 162.5 mg (2
1/2 grain)
1
1
1
WESTHROID - thyroid tab 325 mg (5
grain)
1
1
WESTHROID-P - thyroid tab 16.25 mg
1
1
(3/4 grain)
1
WESTHROID-P - thyroid tab 65 mg
1
ENDOCRINE and METABOLIC AGENTS - MISC.
5 •
ACTHAR HP - corticotropin inj gel 80
unit/ml
4 •
ACTONEL - risedronate sodium tab 5
mg
4 •
mg
4 •
mg
ACTONEL - risedronate sodium tab 150 4 •
mg
ALENDRONATE SODIUM - alendronate 1
sodium tab 40 mg
ALENDRONATE SODIUM - alendronate 4 •
sodium oral soln 70 mg/75ml
1
alendronate sodium tab 10 mg
1
1
WESTHROID-P - thyroid tab 130 mg
1
1
1
1
1
(Fosamax)
(3/4 grain)
1
ATELVIA - risedronate sodium tab
4
• •
WP THYROID - thyroid tab 65 mg
1
4
• •
1
BINOSTO - alendronate sodium
effervescent tab 70 mg
30
OXYTOCICS
CERVIDIL - dinoprostone vaginal inserts 4
10 mg
4
METHERGINE - methylergonovine
maleate tab 0.2 mg
1
methylergonovine maleate tab
0.2 mg
4
PREPIDIL - dinoprostone cervical gel
0.5 mg/3gm
4
PROSTIN E2 - dinoprostone vaginal
suppos 20 mg
•
•
•
•
•
•
Quantity Limits
1
Restricted Access
Prior Review
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Drug Name
Prior Review
Drug Tier
2014
BONIVA - ibandronate sodium tab 150
4
BRAVELLE - urofollitropin purified for inj
75 unit
5
BUPHENYL - sodium phenylbutyrate
tab 500 mg
5
BUPHENYL - sodium phenylbutyrate
oral powder 3 gm/teaspoonful
Quantity Limits
Restricted Access
Prior Review
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Drug Tier
2014
DDAVP - desmopressin acetate nasal
soln 0.01% (refrigerated)
4
DDAVP - desmopressin acetate nasal
spray soln 0.01%
4
desmopressin acetate inj 4 mcg/ml
(Ddavp)
2
5
desmopressin acetate nasal soln
0.01% (refrigerated) (Ddavp)
2
cabergoline tab 0.5 mg
2
2
calcitonin (salmon) nasal soln 200
unit/act (Miacalcin)
2
desmopressin acetate nasal spray
soln 0.01% (Ddavp)
2
calcitriol cap 0.25 mcg (Rocaltrol)
1
desmopressin acetate nasal spray
soln 0.01% (refrigerated)
calcitriol cap 0.5 mcg (Rocaltrol)
1
2
calcitriol oral soln 1 mcg/ml
(Rocaltrol)
2
desmopressin acetate tab 0.1 mg
(Ddavp)
2
CARBAGLU - carglumic acid tab 200
mg
5
desmopressin acetate tab 0.2 mg
(Ddavp)
4
CARNITOR - levocarnitine tab 330 mg
4
DIDRONEL - etidronate disodium tab
400 mg
4
doxercalciferol cap 0.5 mcg
(Hectorol)
2
CARNITOR - levocarnitine oral soln 1
gm/10ml (10%)
4
doxercalciferol cap 1 mcg (Hectorol)
2
CARNITOR SF - levocarnitine oral soln
1 gm/10ml (10%)
2
CETROTIDE - cetrorelix acetate for inj
kit 0.25 mg
5
doxercalciferol cap 2.5 mcg
(Hectorol)
5
•
CETROTIDE - cetrorelix acetate for inj
kit 3 mg
5
EGRIFTA - tesamorelin acetate for inj 1
mg (base equiv)
5
•
chorionic gonadotropin for inj 10000
unit
2
EGRIFTA - tesamorelin acetate for inj 2
mg (base equiv)
4
CLOMID - clomiphene citrate tab 50 mg
4
ETIDRONATE DISODIUM - etidronate
disodium tab 200 mg
1
ETIDRONATE DISODIUM - etidronate
disodium tab 400 mg
2
clomiphene citrate tab 50 mg
(Clomid)
5
EVISTA - raloxifene hcl tab 60 mg
4
CYSTADANE - betaine powder for oral
solution
5
•
DDAVP - desmopressin acetate tab 0.1
mg
4
FOLLISTIM AQ - follitropin beta inj 75
unit/0.5ml
5
•
DDAVP - desmopressin acetate tab 0.2
mg
4
unit/0.5ml
5
•
DDAVP - desmopressin acetate inj 4
mcg/ml
4
unit/0.36ml
unit/0.72ml
5
•
•
• •
•
•
•
•
•
• •
31
Quantity Limits
Prior Review
Restricted Access
Drug Tier
Quantity Limits
Restricted Access
5
• •
GONAL-F - follitropin alfa for inj 450 unit
5
5
FORTICAL - calcitonin (salmon) nasal
soln 200 unit/act
2
GONAL-F - follitropin alfa for inj 1050
unit
•
•
•
4
GONAL-F RFF - follitropin alfa for inj 75
unit
5
FOSAMAX - alendronate sodium tab 10
mg
•
4
GONAL-F RFF PEN - follitropin alfa inj
300 unit/0.5ml
5
FOSAMAX - alendronate sodium tab 70
mg
•
FOSAMAX PLUS D - alendronate
sodium-cholecalciferol tab 70-2800
mg-unit
450 unit/0.75ml
5
4
900 unit/1.5ml
5
•
FOSAMAX PLUS D - alendronate
sodium-cholecalciferol tab 70-5600
mg-unit
4
GONAL-F RFF REDIJECT - follitropin
alfa inj 300 unit/0.5ml
5
•
5
5
GANIRELIX ACETATE - ganirelix
acetate inj 250 mcg/0.5ml
•
5
• •
5
GENOTROPIN - somatropin for
subcutaneous inj 5 mg
•
5
• •
HECTOROL - doxercalciferol cap 0.5
mcg
4
GENOTROPIN - somatropin for inj 12
mg (13.8 mg overfill)
5
• •
HECTOROL - doxercalciferol cap 1 mcg
4
GENOTROPIN MINIQUICK somatropin for inj 0.2 mg
4
5
HECTOROL - doxercalciferol cap 2.5
mcg
HUMATROPE - somatropin for inj 5 mg
5
5
• •
HUMATROPE - somatropin for inj 6 mg
(18 unit)
5
• •
• •
5
• •
HUMATROPE - somatropin for inj 12
mg (36 unit)
5
• •
GENOTROPIN MINIQUICK somatropin for inj 1 mg
5
• •
HUMATROPE - somatropin for inj 24
mg
5
• •
5
• •
HUMATROPE COMBO PACK somatropin for inj 5 mg
5
• •
5
• •
ibandronate sodium tab 150 mg
(base equivalent) (Boniva)
2
5
• •
INCRELEX - mecasermin inj 40 mg/4ml
(10 mg/ml)
5
•
5
• •
KUVAN - sapropterin dihydrochloride
powder packet 100 mg
4
•
Drug Tier
GENOTROPIN MINIQUICK somatropin for inj 2 mg
Drug Name
unit/1.08ml
5
FORTEO - teriparatide (recombinant) inj
600 mcg/2.4ml
5
32
Prior Review
2014
•
•
• •
• •
•
• •
Drug Name
• •
NORDITROPIN NORDIFLEX PEN somatropin inj 10 mg/1.5ml
5
• •
levocarnitine oral soln 1 gm/10ml
(10%) (Carnitor)
2
5
• •
levocarnitine tab 330 mg (Carnitor)
2
5
• •
LUPANETA PACK - leuprolide (1 mon)
inj 3.75 mg & norethindrone tab 5 mg
kit
5
NORDITROPIN NORDIFLEX PEN somatropin inj 30 mg/3ml
NUTROPIN - somatropin for inj 10 mg
5
5
LUPANETA PACK - leuprolide (3 mon)
inj 11.25 mg & norethindrone tab 5
mg kit
5
NUTROPIN AQ - somatropin inj 10
mg/2ml
• •
• •
NUTROPIN AQ NUSPIN 10 somatropin inj 10 mg/2ml
5
• •
LUPRON DEPOT-PED - leuprolide
acetate for inj pediatric kit 7.5 mg
5
NUTROPIN AQ NUSPIN 20 somatropin inj 20 mg/2ml
5
• •
acetate for inj pediatric kit 11.25 mg
5
NUTROPIN AQ NUSPIN 5 - somatropin
inj 5 mg/2ml
5
• •
acetate for inj pediatric kit 15 mg
5
NUTROPIN AQ PEN - somatropin inj 10
mg/2ml
5
• •
acetate (3 month) for inj pediatric kit
11.25 mg
5
NUTROPIN AQ PEN - somatropin inj 20
mg/2ml
5
• •
5
octreotide acetate inj 100 mcg/ml
(0.1 mg/ml) (Sandostatin)
5
acetate (3 month) for inj pediatric kit
30 mg
5
LUVERIS - lutropin alfa for
subcutaneous inj 75 unit
5
(1 mg/ml) (Sandostatin)
5
MENOPUR - menotropins for
subcutaneous inj 75 unit
5
5
MIACALCIN - calcitonin (salmon) nasal
soln 200 unit/act
4
5
MYALEPT - metreleptin for
subcutaneous inj 11.3 mg
5
5
•
NORDITROPIN CARTRIDGE somatropin inj 5 mg/1.5ml
5
OMNITROPE - somatropin inj 5
mg/1.5ml
5
•
NORDITROPIN FLEXPRO - somatropin
inj 5 mg/1.5ml
5
• •
OMNITROPE - somatropin inj 10
mg/1.5ml
inj 10 mg/1.5ml
5
• •
OMNITROPE - somatropin for inj 5.8 mg 5
5
ORFADIN - nitisinone cap 2 mg
inj 15 mg/1.5ml
5
• •
5
• •
•
•
•
•
•
Drug Name
•
•
•
• •
Drug Name
5
5
OSPHENA - ospemifene tab 60 mg
4
Quantity Limits
Prior Review
5
Restricted Access
Drug Tier
Prior Review
KUVAN - sapropterin dihydrochloride
soluble tab 100 mg
Quantity Limits
Drug Tier
Restricted Access
2014
•
•
•
•
33
paricalcitol cap 1 mcg (Zemplar)
2
2
2
raloxifene hcl tab 60 mg (Evista)
2
RAVICTI - glycerol phenylbutyrate liquid
1.1 gm/ml
5
REPRONEX - menotropins for inj 75
unit
5
ROCALTROL - calcitriol cap 0.25 mcg
4
ROCALTROL - calcitriol cap 0.5 mcg
4
ROCALTROL - calcitriol oral soln 1 mcg/ 4
ml
SAIZEN - somatropin (non-refrigerated) 5
for inj 5 mg
SAIZEN - somatropin (non-refrigerated) 5
for inj 8.8 mg
5
SAIZEN CLICK.EASY - somatropin
(non-refrigerated) for inj 8.8 mg
5
SAMSCA - tolvaptan tab 15 mg
SAMSCA - tolvaptan tab 30 mg
5
SANDOSTATIN - octreotide acetate inj
50 mcg/ml (0.05 mg/ml)
5
5
5
5
1000 mcg/ml (1 mg/ml)
5
SENSIPAR - cinacalcet hcl tab 30 mg
(base equiv)
5
(base equiv)
5
(base equiv)
5
• •
•
• •
• •
• •
SEROSTIM - somatropin (nonrefrigerated) for subcutaneous inj 4
mg
5
• •
mg
5
• •
mg
5
• •
SKELID - tiludronate disodium tab 200
mg (tiludronic acid equivalent)
4
• •
sodium phenylbutyrate oral powder
3 gm/teaspoonful (Buphenyl)
2
SOMATULINE DEPOT - lanreotide
acetate extended release inj 60
mg/0.2ml
5
• •
mg/0.3ml
5
• •
mg/0.5ml
5
• •
SOMAVERT - pegvisomant for inj 10 mg 5
(as protein)
(as protein)
(as protein)
STIMATE - desmopressin acetate nasal 5
soln 1.5 mg/ml
SYNAREL - nafarelin acetate nasal soln 5
2 mg/ml
5
TEV-TROPIN - somatropin for
subcutaneous inj 5 mg
4
ZEMPLAR - paricalcitol cap 1 mcg
• •
Drug Name
4
4
ZORBTIVE - somatropin (nonrefrigerated) for subcutaneous inj 8.8
mg
5
• •
• •
• •
• •
CARDIOVASCULAR AGENTS
34
Quantity Limits
Restricted Access
Quantity Limits
•
Prior Review
5
Drug Tier
OVIDREL - choriogonadotropin alfa inj
250 mcg/0.5ml
Restricted Access
Drug Name
Prior Review
Drug Tier
2014
CARDIOTONICS
• •
isosorbide dinitrate tab 5 mg (Isordil
titradose)
1
DIGOXIN - digoxin oral soln 0.05 mg/ml
4
digoxin tab 125 mcg (0.125 mg)
(Lanoxin)
1
isosorbide mononitrate tab sr 24hr
120 mg (Imdur)
1
digoxin tab 250 mcg (0.25 mg)
(Lanoxin)
1
30 mg (Imdur)
1
LANOXIN - digoxin tab 62.5 mcg
(0.0625 mg)
4
60 mg (Imdur)
1
LANOXIN - digoxin tab 125 mcg (0.125
mg)
4
isosorbide mononitrate tab 10 mg
1
isosorbide mononitrate tab 20 mg
1
LANOXIN - digoxin tab 187.5 mcg
(0.1875 mg)
4
MONOKET - isosorbide mononitrate tab
10 mg
4
LANOXIN - digoxin tab 250 mcg (0.25
mg)
4
MONOKET - isosorbide mononitrate tab
20 mg
4
NITRO-BID - nitroglycerin oint 2%
1
ANTIANGINAL AGENTS
AMYL NITRITE - amyl nitrite inhal soln
0.3 ml
4
• •
NITRO-DUR - nitroglycerin td patch
24hr 0.1 mg/hr
4
DILATRATE SR - isosorbide dinitrate
cap cr 40 mg
4
• •
24hr 0.2 mg/hr
4
IMDUR - isosorbide mononitrate tab sr
24hr 30 mg
4
24hr 0.3 mg/hr
4
24hr 60 mg
4
24hr 0.4 mg/hr
4
24hr 120 mg
4
24hr 0.6 mg/hr
4
ISORDIL TITRADOSE - isosorbide
dinitrate tab 5 mg
4
24hr 0.8 mg/hr
4
ISORDIL TITRADOSE - isosorbide
dinitrate tab 40 mg
4
nitroglycerin cap cr 2.5 mg
1
nitroglycerin cap cr 6.5 mg
1
ISOSORBIDE DINITRATE - isosorbide
dinitrate tab 30 mg
1
nitroglycerin cap cr 9 mg
1
1
NITROGLYCERIN LINGUAL nitroglycerin lingual aerosol 400 mcg/
spray
4
dinitrate sl tab 2.5 mg
dinitrate sl tab 5 mg
1
nitroglycerin td patch 24hr 0.1 mg/hr
(Nitro-dur)
1
isosorbide dinitrate tab cr 40 mg
1
isosorbide dinitrate tab 10 mg
(Nitro-dur)
1
1
1
1
1
(Nitro-dur)
Quantity Limits
Restricted Access
Prior Review
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Drug Tier
2014
• •
35
BYSTOLIC - nebivolol hcl tab 2.5 mg
(base equivalent)
4
• •
nitroglycerin tl soln 0.4 mg/spray
(400 mcg/spray) (Nitrolingual
pumpspr)
2
BYSTOLIC - nebivolol hcl tab 5 mg
(base equivalent)
4
• •
• •
NITROLINGUAL PUMPSPRAY nitroglycerin tl soln 0.4 mg/spray (400
mcg/spray)
(base equivalent)
4
4
(base equivalent)
4
• •
NITROMIST - nitroglycerin lingual
aerosol 400 mcg/spray
4
carvedilol tab 12.5 mg (Coreg)
1
carvedilol tab 25 mg (Coreg)
1
1
1
COREG - carvedilol tab 3.125 mg
4
4
4
COREG - carvedilol tab 25 mg
4
COREG CR - carvedilol phosphate cap
sr 24hr 10 mg
4
• •
sr 24hr 20 mg
4
• •
sr 24hr 40 mg
4
• •
• •
NITROSTAT - nitroglycerin sl tab 0.3 mg 3
4
RANEXA - ranolazine tab sr 12hr 500
mg
4
RANEXA - ranolazine tab sr 12hr 1000
mg
BETA BLOCKERS
• •
Drug Name
acebutolol hcl cap 200 mg (Sectral)
1
acebutolol hcl cap 400 mg (Sectral)
1
atenolol tab 100 mg (Tenormin)
1
1
1
4
sr 24hr 80 mg
4
BETAPACE - sotalol hcl tab 80 mg
4
CORGARD - nadolol tab 20 mg
4
4
4
BETAPACE AF - sotalol hcl (afib/afl) tab
80 mg
4
4
120 mg
4
160 mg
4
betaxolol hcl tab 10 mg (Kerlone)
1
betaxolol hcl tab 20 mg (Kerlone)
1
bisoprolol fumarate tab 10 mg
(Zebeta)
1
bisoprolol fumarate tab 5 mg
(Zebeta)
1
36
HEMANGEOL - propranolol hcl oral soln 4
4.28 mg/ml
4
INDERAL LA - propranolol hcl cap sr
24hr 60 mg
4
24hr 80 mg
4
24hr 120 mg
4
24hr 160 mg
Quantity Limits
Prior Review
Restricted Access
Drug Tier
Quantity Limits
Restricted Access
1
Drug Tier
(Nitro-dur)
Drug Name
Prior Review
2014
4
• •
INNOPRAN XL - propranolol hcl
sustained-release beads cap sr 24hr
80 mg
4
• •
INNOPRAN XL - propranolol hcl
120 mg
4
KERLONE - betaxolol hcl tab 10 mg
4
KERLONE - betaxolol hcl tab 20 mg
4
labetalol hcl tab 100 mg (Trandate)
1
1
1
LEVATOL - penbutolol sulfate tab 20 mg 4
4
LOPRESSOR - metoprolol tartrate tab
50 mg
4
LOPRESSOR - metoprolol tartrate tab
100 mg
1
metoprolol succinate tab sr 24hr
100 mg (Toprol xl)
1
200 mg (Toprol xl)
1
25 mg (Toprol xl)
1
50 mg (Toprol xl)
1
metoprolol tartrate tab 100 mg
(Lopressor)
1
(Lopressor)
1
nadolol tab 20 mg (Corgard)
1
1
1
pindolol tab 10 mg
2
• •
pindolol tab 5 mg
2
PROPRANOLOL HCL - propranolol hcl
oral soln 20 mg/5ml
4
• •
PROPRANOLOL HCL - propranolol hcl
oral soln 40 mg/5ml
4
• •
propranolol hcl cap sr 24hr 120 mg
(Inderal la)
1
(Inderal la)
1
(Inderal la)
1
(Inderal la)
1
propranolol hcl tab 10 mg
1
1
1
1
1
SECTRAL - acebutolol hcl cap 200 mg
4
SECTRAL - acebutolol hcl cap 400 mg
4
sotalol hcl (afib/afl) tab 120 mg
(Betapace af)
1
(Betapace af)
1
(Betapace af)
1
sotalol hcl tab 120 mg (Betapace)
1
1
sotalol hcl tab 240 mg
1
1
TENORMIN - atenolol tab 25 mg
4
4
4
TIMOLOL MALEATE - timolol maleate
tab 5 mg
4
tab 10 mg
4
Quantity Limits
INDERAL XL - propranolol hcl
120 mg
Restricted Access
• •
Prior Review
4
Drug Name
Drug Tier
Prior Review
INDERAL XL - propranolol hcl
80 mg
Drug Name
Quantity Limits
Drug Tier
Restricted Access
2014
37
CARDENE SR - nicardipine hcl cap sr
12hr 45 mg
4
• •
TOPROL XL - metoprolol succinate tab
sr 24hr 25 mg
4
12hr 60 mg
4
• •
sr 24hr 50 mg
4
CARDIZEM - diltiazem hcl tab 30 mg
4
4
sr 24hr 100 mg
4
4
4
4
sr 24hr 200 mg
4
TRANDATE - labetalol hcl tab 100 mg
4
CARDIZEM CD - diltiazem hcl coated
beads cap sr 24hr 120 mg
4
4
4
ZEBETA - bisoprolol fumarate tab 5 mg
4
4
ZEBETA - bisoprolol fumarate tab 10
mg
4
4
4
CALCIUM CHANNEL BLOCKERS
Drug Name
ADALAT CC - nifedipine tab sr 24hr 30
mg
4
4
mg
4
CARDIZEM LA - diltiazem hcl coated
beads tab sr 24hr 120 mg
4
mg
4
4
amlodipine besylate tab 10 mg
(Norvasc)
1
4
amlodipine besylate tab 2.5 mg
(Norvasc)
1
4
amlodipine besylate tab 5 mg
(Norvasc)
1
4
CALAN - verapamil hcl tab 80 mg
4
CALAN - verapamil hcl tab 120 mg
4
4
• •
CALAN SR - verapamil hcl tab cr 120
mg
4
COVERA-HS - verapamil hcl tab sr 24hr
(controlled onset) 180 mg
4
• •
mg
4
COVERA-HS - verapamil hcl tab sr 24hr
(controlled onset) 240 mg
4
mg
4
DILACOR XR - diltiazem hcl cap sr 24hr
240 mg
diltiazem hcl cap sr 12hr 120 mg
1
12hr 30 mg
4
1
1
38
• •
Quantity Limits
Prior Review
Restricted Access
Drug Tier
Quantity Limits
Restricted Access
4
Drug Tier
tab 20 mg
Drug Name
Prior Review
2014
1
diltiazem hcl tab 60 mg (Cardizem)
1
1
diltiazem hcl tab 90 mg
1
1
4
• •
diltiazem hcl coated beads cap sr
24hr 120 mg (Cardizem cd)
1
DYNACIRC CR - isradipine tab sr 24hr
5 mg
4
• •
1
DYNACIRC CR - isradipine tab sr 24hr
10 mg
felodipine tab sr 24hr 10 mg
2
1
felodipine tab sr 24hr 2.5 mg
2
felodipine tab sr 24hr 5 mg
2
1
ISOPTIN SR - verapamil hcl tab cr 120
mg
4
1
mg
4
2
mg
4
diltiazem hcl coated beads tab sr
24hr 180 mg (Cardizem la)
2
ISRADIPINE - isradipine cap 2.5 mg
4
2
ISRADIPINE - isradipine cap 5 mg
4
nicardipine hcl cap 20 mg
1
2
nicardipine hcl cap 30 mg
1
nifedipine cap 10 mg (Procardia)
2
2
nifedipine cap 20 mg
2
2
nifedipine tab sr 24hr osmotic 30 mg
(Procardia xl)
1
1
(Procardia xl)
1
diltiazem hcl extended release beads
cap sr 24hr 120 mg (Tiazac)
(Procardia xl)
1
1
nifedipine tab sr 24hr 30 mg (Adalat
cc)
1
1
cc)
1
1
1
cc)
1
2
1
nimodipine cap 30 mg
NIMOTOP - nimodipine cap 30 mg
4
1
1
NISOLDIPINE - nisoldipine tab sr 24hr
20 mg
4
Quantity Limits
Restricted Access
Prior Review
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Drug Tier
2014
39
30 mg
4
40 mg
2
NISOLDIPINE ER - nisoldipine tab sr
24hr 25.5 mg
4
nisoldipine tab sr 24hr 17 mg (Sular)
2
nisoldipine tab sr 24hr 25.5 mg
2
nisoldipine tab sr 24hr 34 mg (Sular)
2
nisoldipine tab sr 24hr 8.5 mg (Sular)
2
NORVASC - amlodipine besylate tab
2.5 mg
4
NORVASC - amlodipine besylate tab 5
mg
4
NORVASC - amlodipine besylate tab 10
mg
4
NYMALIZE - nimodipine oral soln 60
mg/20ml
5
PROCARDIA - nifedipine cap 10 mg
4
PROCARDIA XL - nifedipine tab sr 24hr
osmotic 30 mg
4
osmotic 60 mg
4
osmotic 90 mg
4
SULAR - nisoldipine tab sr 24hr 8.5 mg
4
SULAR - nisoldipine tab sr 24hr 17 mg
1
4
VERELAN - verapamil hcl cap sr 24hr
120 mg
4
SULAR - nisoldipine tab sr 24hr 25.5 mg 4
4
SULAR - nisoldipine tab sr 24hr 34 mg
180 mg
4
240 mg
4
360 mg
4
VERELAN PM - verapamil hcl cap sr
24hr 100 mg
4
24hr 200 mg
4
24hr 300 mg
4
40
Quantity Limits
Restricted Access
TIAZAC - diltiazem hcl extended release 4
VERAPAMIL HCL - verapamil hcl tab 40 1
mg
1
verapamil hcl cap sr 24hr 100 mg
(Verelan pm)
1
(Verelan)
1
(Verelan)
1
(Verelan pm)
1
(Verelan)
1
(Verelan pm)
1
(Verelan)
1
verapamil hcl tab cr 120 mg (Calan
sr)
1
sr)
1
sr)
1
verapamil hcl tab 120 mg (Calan)
verapamil hcl tab 80 mg (Calan)
Prior Review
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Drug Name
Prior Review
Drug Tier
2014
ANTIARRHYTHMICS
1
amiodarone hcl tab 100 mg
2
propafenone hcl tab 225 mg
(Rythmol)
(Cordarone)
1
1
quinidine gluconate tab cr 324 mg
2
1
2
2
QUINIDINE SULFATE - quinidine
sulfate tab 200 mg
QUINIDINE SULFATE ER - quinidine
sulfate tab cr 300 mg
4
quinidine sulfate tab 200 mg
2
quinidine sulfate tab 300 mg
2
RYTHMOL - propafenone hcl tab 150
mg
4
RYTHMOL - propafenone hcl tab 225
mg
4
RYTHMOL SR - propafenone hcl cap sr
12hr 225 mg
4
12hr 325 mg
4
CORDARONE - amiodarone hcl tab 200 4
mg
disopyramide phosphate cap 100 mg 1
(Norpace)
disopyramide phosphate cap 150 mg 1
(Norpace)
1
flecainide acetate tab 100 mg
1
1
mexiletine hcl cap 150 mg
2
2
2
MULTAQ - dronedarone hcl tab 400 mg
(base equivalent)
12hr 425 mg
4
4
NORPACE - disopyramide phosphate
cap 100 mg
TAMBOCOR - flecainide acetate tab 50
mg
4
4
4
NORPACE - disopyramide phosphate
cap 150 mg
4
TAMBOCOR - flecainide acetate tab
100 mg
4
• •
TAMBOCOR - flecainide acetate tab
150 mg
4
NORPACE CR - disopyramide
phosphate cap sr 12hr 100 mg
NORPACE CR - disopyramide
phosphate cap sr 12hr 150 mg
• •
TIKOSYN - dofetilide cap 125 mcg
(0.125 mg)
4
4
PACERONE - amiodarone hcl tab 400
mg
4
propafenone hcl cap sr 12hr 225 mg
(Rythmol sr)
2
(Rythmol sr)
2
(Rythmol sr)
2
(Rythmol)
1
Quantity Limits
Restricted Access
Prior Review
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Drug Tier
2014
• •
TIKOSYN - dofetilide cap 250 mcg (0.25 4
mg)
4
TIKOSYN - dofetilide cap 500 mcg (0.5
mg)
ANTIHYPERTENSIVES
ACCUPRIL - quinapril hcl tab 5 mg
4
4
4
4
ACCURETIC - quinaprilhydrochlorothiazide tab 10-12.5 mg
4
41
ACCURETIC - quinaprilhydrochlorothiazide tab 20-12.5 mg
4
ATACAND - candesartan cilexetil tab 8
mg
4
ACCURETIC - quinaprilhydrochlorothiazide tab 20-25 mg
4
mg
4
ACEON - perindopril erbumine tab 2 mg
4
4
4
mg
4
4
ALTACE - ramipril cap 1.25 mg
4
ATACAND HCT - candesartan cilexetilhydrochlorothiazide tab 16-12.5 mg
4
ATACAND HCT - candesartan cilexetilhydrochlorothiazide tab 32-12.5 mg
4
ALTACE - ramipril cap 2.5 mg
ALTACE - ramipril cap 5 mg
4
ALTACE - ramipril cap 10 mg
ATACAND HCT - candesartan cilexetilhydrochlorothiazide tab 32-25 mg
4
4
amlodipine besylate-benazepril hcl
cap 10-20 mg (Lotrel)
2
atenolol & chlorthalidone tab
100-25 mg (Tenoretic 100)
1
2
atenolol & chlorthalidone tab
50-25 mg (Tenoretic 50)
1
cap 2.5-10 mg (Lotrel)
2
AVALIDE - irbesartanhydrochlorothiazide tab 150-12.5 mg
4
2
AVALIDE - irbesartanhydrochlorothiazide tab 300-12.5 mg
4
2
AVAPRO - irbesartan tab 75 mg
4
4
2
4
4
AZOR - amlodipine besylate-olmesartan
medoxomil tab 5-20 mg
4
AMTURNIDE - aliskiren-amlodipinehydrochlorothiazide tab 150-5-12.5
mg
• •
4
• •
mg
4
4
• •
AMTURNIDE - aliskiren-amlodipinehydrochlorothiazide tab 300-5-25 mg
4
• •
4
• •
mg
4
• •
benazepril & hydrochlorothiazide tab
10-12.5 mg (Lotensin hct)
1
1
AMTURNIDE - aliskiren-amlodipinehydrochlorothiazide tab 300-10-25
mg
4
20-12.5 mg (Lotensin hct)
20-25 mg (Lotensin hct)
1
mg
4
5-6.25 mg
1
benazepril hcl tab 10 mg (Lotensin)
1
42
• •
• •
• •
Quantity Limits
Restricted Access
Prior Review
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Drug Name
Prior Review
Drug Tier
2014
1
1
captopril tab 12.5 mg
1
benazepril hcl tab 5 mg
1
captopril tab 25 mg
1
• •
captopril tab 50 mg
1
CAPTOPRIL/HYDROCHLOROTHIA captopril & hydrochlorothiazide tab
25-15 mg
1
• •
1
• •
25-25 mg
1
• •
50-15 mg
1
• •
50-25 mg
CARDURA - doxazosin mesylate tab 1
mg
4
mg
4
mg
4
mg
4
CATAPRES - clonidine hcl tab 0.1 mg
4
4
4
CATAPRES-TTS-1 - clonidine hcl td
patch weekly 0.1 mg/24hr
4
4
4
clonidine hcl tab 0.1 mg (Catapres)
1
1
1
clonidine hcl td patch weekly
0.1 mg/24hr (Catapres-tts-1)
2
BENICAR - olmesartan medoxomil tab 5 3
mg
3
BENICAR - olmesartan medoxomil tab
20 mg
3
BENICAR - olmesartan medoxomil tab
40 mg
3
BENICAR HCT - olmesartan
medoxomil-hydrochlorothiazide tab
20-12.5 mg
3
40-12.5 mg
3
40-25 mg
bisoprolol & hydrochlorothiazide tab 1
10-6.25 mg (Ziac)
2.5-6.25 mg (Ziac)
5-6.25 mg (Ziac)
2
candesartan cilexetil tab 16 mg
(Atacand)
2
(Atacand)
2
(Atacand)
2
(Atacand)
2
candesartan cilexetilhydrochlorothiazide tab 16-12.5 mg
(Atacand hct)
2
candesartan cilexetilhydrochlorothiazide tab 32-12.5 mg
(Atacand hct)
2
candesartan cilexetilhydrochlorothiazide tab 32-25 mg
(Atacand hct)
• •
Quantity Limits
captopril tab 100 mg
Restricted Access
1
Prior Review
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Drug Tier
2014
43
2
doxazosin mesylate tab 2 mg
(Cardura)
1
2
(Cardura)
1
CLORPRES - clonidine & chlorthalidone
tab 0.1-15 mg
4
• •
(Cardura)
1
tab 0.2-15 mg
4
• •
3
tab 0.3-15 mg
4
• •
DUTOPROL - metoprolol &
hydrochlorothiazide tab sr 24hr
25-12.5 mg
3
CORZIDE - nadolol &
bendroflumethiazide tab 40-5 mg
4
50-12.5 mg
CORZIDE - nadolol &
bendroflumethiazide tab 80-5 mg
4
3
COZAAR - losartan potassium tab 25
mg
4
100-12.5 mg
4
• •
mg
4
EDARBI - azilsartan medoxomil tab 40
mg
4
• •
mg
4
EDARBI - azilsartan medoxomil tab 80
mg
4
• •
DEMSER - metyrosine cap 250 mg
4
EDARBYCLOR - azilsartan medoxomilchlorthalidone tab 40-12.5 mg
4
EDARBYCLOR - azilsartan medoxomilchlorthalidone tab 40-25 mg
4
DIBENZYLINE - phenoxybenzamine hcl
cap 10 mg
• •
4
DIOVAN - valsartan tab 80 mg
4
enalapril maleate &
hydrochlorothiazide tab 10-25 mg
(Vaseretic)
1
4
1
4
enalapril maleate &
hydrochlorothiazide tab 5-12.5 mg
DIOVAN HCT - valsartanhydrochlorothiazide tab 80-12.5 mg
4
4
DIOVAN HCT - valsartanhydrochlorothiazide tab 160-25 mg
4
enalapril maleate tab 5 mg (Vasotec)
1
4
4
EPANED - enalapril maleate for oral
soln 1 mg/ml
eplerenone tab 25 mg (Inspra)
2
DIOVAN HCT - valsartanhydrochlorothiazide tab 320-25 mg
4
eplerenone tab 50 mg (Inspra)
2
1
eprosartan mesylate tab 600 mg
(Teveten)
2
(Cardura)
44
• •
• •
•
•
•
•
•
•
•
•
enalapril maleate tab 10 mg (Vasotec) 1
1
enalapril maleate tab 2.5 mg
(Vasotec)
enalapril maleate tab 20 mg (Vasotec) 1
Quantity Limits
Restricted Access
Prior Review
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Drug Name
Prior Review
Drug Tier
2014
HYZAAR - losartan potassium &
4
EXFORGE - amlodipine besylatevalsartan tab 5-320 mg
4
• •
INSPRA - eplerenone tab 25 mg
4
4
• •
INSPRA - eplerenone tab 50 mg
4
irbesartan tab 150 mg (Avapro)
2
4
• •
2
2
EXFORGE HCT - amlodipine-valsartanhydrochlorothiazide tab 5-160-12.5
mg
4
• •
irbesartan-hydrochlorothiazide tab
150-12.5 mg (Avalide)
2
2
EXFORGE HCT - amlodipine-valsartanhydrochlorothiazide tab 5-160-25 mg
4
• •
irbesartan-hydrochlorothiazide tab
300-12.5 mg (Avalide)
1
EXFORGE HCT - amlodipine-valsartanhydrochlorothiazide tab 10-160-12.5
mg
4
• •
lisinopril & hydrochlorothiazide tab
10-12.5 mg (Zestoretic)
20-12.5 mg (Zestoretic)
1
EXFORGE HCT - amlodipine-valsartanhydrochlorothiazide tab 10-160-25
mg
4
• •
20-25 mg (Zestoretic)
1
EXFORGE HCT - amlodipine-valsartanhydrochlorothiazide tab 10-320-25
mg
• •
lisinopril tab 10 mg (Prinivil)
1
4
lisinopril tab 2.5 mg (Zestril)
1
1
fosinopril sodium &
1
lisinopril tab 30 mg (Zestril)
1
lisinopril tab 40 mg (Zestril)
1
fosinopril sodium &
1
1
1
LOPRESSOR HCT - metoprolol &
4
fosinopril sodium tab 10 mg
1
4
1
LOPRESSOR HCT - metoprolol &
guanfacine hcl tab 1 mg (Tenex)
1
1
guanfacine hcl tab 2 mg (Tenex)
1
hydralazine hcl tab 10 mg
1
losartan potassium &
hydrochlorothiazide tab
100-12.5 mg (Hyzaar)
1
(Hyzaar)
1
1
1
1
4
(Hyzaar)
4
losartan potassium tab 100 mg
(Cozaar)
1
Quantity Limits
• •
Restricted Access
4
Drug Name
Prior Review
Drug Name
Drug Tier
Prior Review
Quantity Limits
Drug Tier
Restricted Access
2014
45
(Cozaar)
1
metoprolol & hydrochlorothiazide
tab 100-50 mg
1
(Cozaar)
1
tab 50-25 mg (Lopressor hct)
1
LOTENSIN - benazepril hcl tab 10 mg
4
MICARDIS - telmisartan tab 20 mg
4
4
4
4
4
LOTENSIN HCT - benazepril &
4
MICARDIS HCT - telmisartanhydrochlorothiazide tab 40-12.5 mg
4
4
MICARDIS HCT - telmisartanhydrochlorothiazide tab 80-12.5 mg
4
4
MICARDIS HCT - telmisartanhydrochlorothiazide tab 80-25 mg
4
LOTREL - amlodipine besylatebenazepril hcl cap 2.5-10 mg
4
MINIPRESS - prazosin hcl cap 1 mg
4
4
LOTREL - amlodipine besylatebenazepril hcl cap 5-10 mg
4
4
4
minoxidil tab 10 mg
1
minoxidil tab 2.5 mg
1
4
moexipril hcl tab 15 mg (Univasc)
1
moexipril hcl tab 7.5 mg (Univasc)
1
4
moexipril-hydrochlorothiazide tab
15-12.5 mg (Uniretic)
1
4
15-25 mg
1
MAVIK - trandolapril tab 1 mg
4
1
4
7.5-12.5 mg
4
2
methyldopa tab 250 mg
1
nadolol & bendroflumethiazide tab
40-5 mg (Corzide)
1
nadolol & bendroflumethiazide tab
80-5 mg (Corzide)
2
methyldopa tab 500 mg
METHYLDOPA/HYDROCHLOROTHI methyldopa & hydrochlorothiazide tab
250-15 mg
1
NEXICLON XR - clonidine hcl extended
release susp 0.09 mg/ml (base equiv)
4
• •
1
NEXICLON XR - clonidine hcl tab sr
24hr 0.17 mg (base equivalent)
4
METHYLDOPA/HYDROCHLOROTHI methyldopa & hydrochlorothiazide tab
250-25 mg
• •
perindopril erbumine tab 2 mg
1
tab 100-25 mg (Lopressor hct)
1
(Aceon)
1
(Aceon)
1
46
Quantity Limits
Restricted Access
Prior Review
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Drug Name
Prior Review
Drug Tier
2014
• •
TEKAMLO - aliskiren-amlodipine tab
150-5 mg
4
• •
150-10 mg
4
• •
300-5 mg
4
• •
4
• •
PRINZIDE - lisinopril &
300-10 mg
4
4
• •
PROPRANOLOL/HYDROCHLOROTH propranolol & hydrochlorothiazide tab
40-25 mg
TEKTURNA - aliskiren fumarate tab 150
4
1
TEKTURNA - aliskiren fumarate tab 300
4
• •
PROPRANOLOL/HYDROCHLOROTH propranolol & hydrochlorothiazide tab
80-25 mg
1
TEKTURNA HCT - aliskirenhydrochlorothiazide tab 150-12.5 mg
4
• •
1
TEKTURNA HCT - aliskirenhydrochlorothiazide tab 150-25 mg
4
quinapril hcl tab 10 mg (Accupril)
• •
1
• •
TEKTURNA HCT - aliskirenhydrochlorothiazide tab 300-12.5 mg
4
1
1
4
• •
quinapril-hydrochlorothiazide tab
10-12.5 mg (Accuretic)
1
TEKTURNA HCT - aliskirenhydrochlorothiazide tab 300-25 mg
telmisartan tab 20 mg (Micardis)
2
20-12.5 mg (Accuretic)
1
2
2
20-25 mg (Accuretic)
1
telmisartan-amlodipine tab 40-10 mg
(Twynsta)
2
ramipril cap 1.25 mg (Altace)
1
ramipril cap 10 mg (Altace)
(Twynsta)
2
1
ramipril cap 2.5 mg (Altace)
1
2
ramipril cap 5 mg (Altace)
1
(Twynsta)
RESERPINE - reserpine tab 0.1 mg
3
2
RESERPINE - reserpine tab 0.25 mg
3
(Twynsta)
4
• •
telmisartan-hydrochlorothiazide tab
40-12.5 mg (Micardis hct)
2
TARKA - trandolapril-verapamil hcl tab
cr 1-240 mg
4
• •
80-12.5 mg (Micardis hct)
2
cr 2-180 mg
4
• •
80-25 mg (Micardis hct)
2
cr 2-240 mg
TENEX - guanfacine hcl tab 1 mg
4
prazosin hcl cap 1 mg (Minipress)
1
1
1
PRINIVIL - lisinopril tab 5 mg
4
4
4
PRINZIDE - lisinopril &
Drug Name
Quantity Limits
Prior Review
Restricted Access
Drug Tier
Quantity Limits
Restricted Access
4
Drug Tier
cr 4-240 mg
Drug Name
Prior Review
2014
47
4
4
UNIRETIC - moexiprilhydrochlorothiazide tab 7.5-12.5 mg
4
TENORETIC 50 - atenolol &
chlorthalidone tab 50-25 mg
4
UNIRETIC - moexiprilhydrochlorothiazide tab 15-12.5 mg
4
terazosin hcl cap 1 mg
1
UNIRETIC - moexiprilhydrochlorothiazide tab 15-25 mg
1
UNIVASC - moexipril hcl tab 7.5 mg
4
1
UNIVASC - moexipril hcl tab 15 mg
4
1
2
TEVETEN - eprosartan mesylate tab
400 mg
4
valsartan-hydrochlorothiazide tab
160-12.5 mg (Diovan hct)
2
TEVETEN - eprosartan mesylate tab
600 mg
4
160-25 mg (Diovan hct)
2
TEVETEN HCT - eprosartan mesylatehydrochlorothiazide tab 600-12.5 mg
4
2
TEVETEN HCT - eprosartan mesylatehydrochlorothiazide tab 600-25 mg
4
320-25 mg (Diovan hct)
2
trandolapril tab 1 mg (Mavik)
1
1
VALTURNA - aliskiren-valsartan tab
150-160 mg
4
• •
1
• •
• •
TRIBENZOR - olmesartan-amlodipinehydrochlorothiazide tab 20-5-12.5 mg
VALTURNA - aliskiren-valsartan tab
300-320 mg
4
4
4
TRIBENZOR - olmesartan-amlodipinehydrochlorothiazide tab 40-5-12.5 mg
4
• •
VASERETIC - enalapril maleate &
4
• •
VASOTEC - enalapril maleate tab 2.5
mg
4
TRIBENZOR - olmesartan-amlodipinehydrochlorothiazide tab 40-5-25 mg
4
TRIBENZOR - olmesartan-amlodipinehydrochlorothiazide tab 40-10-12.5
mg
• •
VASOTEC - enalapril maleate tab 5 mg
4
VASOTEC - enalapril maleate tab 10
mg
4
4
• •
VASOTEC - enalapril maleate tab 20
mg
4
TRIBENZOR - olmesartan-amlodipinehydrochlorothiazide tab 40-10-25 mg
4
VECAMYL - mecamylamine hcl tab 2.5
mg
4
TWYNSTA - telmisartan-amlodipine tab
40-5 mg
4
ZESTORETIC - lisinopril &
4
40-10 mg
4
4
80-5 mg
4
4
80-10 mg
ZESTRIL - lisinopril tab 2.5 mg
4
48
• •
• •
• •
•
Quantity Limits
Restricted Access
Prior Review
Drug Name
Drug Tier
TENORETIC 100 - atenolol &
chlorthalidone tab 100-25 mg
Quantity Limits
4
Restricted Access
TENEX - guanfacine hcl tab 2 mg
Prior Review
Drug Name
Drug Tier
2014
ZESTRIL - lisinopril tab 30 mg
4
4
ZIAC - bisoprolol & hydrochlorothiazide
tab 2.5-6.25 mg
4
tab 5-6.25 mg
4
tab 10-6.25 mg
4
DIURETICS
CHLORTHALIDONE - chlorthalidone
tab 50 mg
1
tab 100 mg
4
chlorthalidone tab 25 mg
1
DEMADEX - torsemide tab 5 mg
4
4
4
4
4
ACETAZOLAMIDE - acetazolamide tab
125 mg
1
DIAMOX - acetazolamide cap sr 12hr
500 mg
4
acetazolamide cap sr 12hr 500 mg
(Diamox)
2
DIURIL - chlorothiazide susp 250
mg/5ml
4
acetazolamide tab 250 mg
1
DYAZIDE - triamterene &
hydrochlorothiazide cap 37.5-25 mg
ALDACTAZIDE - spironolactone &
4
DYRENIUM - triamterene cap 50 mg
4
DYRENIUM - triamterene cap 100 mg
4
ALDACTAZIDE - spironolactone &
4
EDECRIN - ethacrynic acid tab 25 mg
4
ALDACTONE - spironolactone tab 25
mg
4
FUROSEMIDE - furosemide oral soln 8
mg/ml
3
furosemide oral soln 10 mg/ml
1
mg
4
furosemide tab 20 mg (Lasix)
1
4
1
mg
1
amiloride & hydrochlorothiazide tab
5-50 mg
1
hydrochlorothiazide cap 12.5 mg
(Microzide)
1
amiloride hcl tab 5 mg
1
hydrochlorothiazide tab 12.5 mg
2
bumetanide tab 0.5 mg
1
hydrochlorothiazide tab 25 mg
1
bumetanide tab 1 mg
1
hydrochlorothiazide tab 50 mg
1
bumetanide tab 2 mg
1
indapamide tab 1.25 mg
1
CHLOROTHIAZIDE - chlorothiazide tab
250 mg
1
indapamide tab 2.5 mg
1
INTROL - glycerin soln 75%
4
chlorothiazide tab 250 mg
1
LASIX - furosemide tab 20 mg
4
chlorothiazide tab 500 mg
1
4
4
Quantity Limits
4
1
Restricted Access
tab 25 mg
Prior Review
4
Drug Name
Drug Tier
Quantity Limits
4
Restricted Access
Prior Review
Drug Name
Drug Tier
2014
• •
• •
• •
49
MAXZIDE - triamterene &
4
MAXZIDE-25 - triamterene &
hydrochlorothiazide tab 37.5-25 mg
4
methazolamide tab 25 mg
(Neptazane)
2
methazolamide tab 50 mg
(Neptazane)
2
METHYCLOTHIAZIDE methyclothiazide tab 5 mg
4
metolazone tab 10 mg
1
metolazone tab 2.5 mg (Zaroxolyn)
1
metolazone tab 5 mg (Zaroxolyn)
1
MICROZIDE - hydrochlorothiazide cap
12.5 mg
TRIAMTERENE/HYDROCHLOROTH triamterene & hydrochlorothiazide
cap 50-25 mg
4
ZAROXOLYN - metolazone tab 2.5 mg
4
ZAROXOLYN - metolazone tab 5 mg
4
4
ADRENACLICK - epinephrine solution
auto-injector 0.3 mg/0.3ml (1:1000)
4
AUVI-Q - epinephrine solution autoinjector 0.15 mg/0.15ml (1:1000)
4
4
4
AUVI-Q - epinephrine solution autoinjector 0.3 mg/0.3ml (1:1000)
4
MIDAMOR - amiloride hcl tab 5 mg
4
EPINEPHRINE - epinephrine solution
NEPTAZANE - methazolamide tab 25
mg
4
EPINEPHRINE - epinephrine solution
4
NEPTAZANE - methazolamide tab 50
mg
4
EPIPEN - epinephrine solution autoinjector 0.3 mg/0.3ml (1:1000)
3
spironolactone &
(Aldactazide)
1
EPIPEN 2-PAK - epinephrine solution
3
3
spironolactone tab 100 mg
(Aldactone)
1
EPIPEN-JR - epinephrine solution autoinjector 0.15 mg/0.3ml (1:2000)
3
spironolactone tab 25 mg (Aldactone)
1
spironolactone tab 50 mg (Aldactone)
1
EPIPEN-JR 2-PAK - epinephrine
solution auto-injector 0.15 mg/0.3ml
(1:2000)
4
midodrine hcl tab 10 mg
1
THALITONE - chlorthalidone tab 15 mg
1
midodrine hcl tab 2.5 mg
1
torsemide tab 10 mg (Demadex)
1
midodrine hcl tab 5 mg
1
1
1
triamterene & hydrochlorothiazide
cap 37.5-25 mg (Dyazide)
1
tab 37.5-25 mg (Maxzide-25)
1
tab 75-50 mg (Maxzide)
1
• •
• •
ANTIHYPERLIPIDEMICS
ADVICOR - niacin-lovastatin tab sr 24hr
500-20 mg
4
• •
750-20 mg
4
• •
1000-20 mg
4
• •
1000-40 mg
4
• •
Quantity Limits
Restricted Access
VASOPRESSORS
ADRENACLICK - epinephrine solution
50
Prior Review
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Drug Name
Prior Review
Drug Tier
2014
COLESTID FLAVORED - colestipol hcl
granules 5 gm
4
ALTOPREV - lovastatin tab sr 24hr 40
mg
4
• •
COLESTID FLAVORED - colestipol hcl
granule packets 5 gm
4
mg
4
• •
colestipol hcl granule packets 5 gm
(Colestid flavored)
2
ANTARA - fenofibrate micronized cap
30 mg
4
43 mg
4
colestipol hcl granules 5 gm (Colestid 2
flavored)
2
colestipol hcl tab 1 gm (Colestid)
90 mg
4
CRESTOR - rosuvastatin calcium tab 5
mg
130 mg
4
atorvastatin calcium tab 10 mg (base
equivalent) (Lipitor)
2
2
2
2
cholestyramine light powder packets
4 gm
2
cholestyramine light powder 4 gm/
dose (Questran light)
2
cholestyramine powder packets
4 gm (Questran)
2
cholestyramine powder 4 gm/dose
(Questran)
2
choline fenofibrate cap dr 135 mg
(fenofibric acid equiv) (Trilipix)
2
choline fenofibrate cap dr 45 mg
(fenofibric acid equiv) (Trilipix)
2
COLESTID - colestipol hcl tab 1 gm
3
• •
CRESTOR - rosuvastatin calcium tab 10 3
mg
mg
mg
FENOFIBRATE - fenofibrate cap 50 mg 4
• •
• •
• •
• •
FENOFIBRATE - fenofibrate cap 150
mg
4
fenofibrate micronized cap 130 mg
(Antara)
2
(Lofibra)
1
(Lofibra)
1
(Antara)
2
(Lofibra)
1
fenofibrate tab 145 mg (Tricor)
2
fenofibrate tab 160 mg (Lofibra)
1
fenofibrate tab 48 mg (Tricor)
2
4
fenofibrate tab 54 mg (Lofibra)
1
COLESTID - colestipol hcl granules 5
gm
4
FENOFIBRIC ACID - fenofibric acid tab
35 mg
4
• •
COLESTID - colestipol hcl granule
packets 5 gm
4
FENOFIBRIC ACID - fenofibric acid tab
105 mg
4
• •
FENOGLIDE - fenofibrate tab 40 mg
4
• •
Quantity Limits
• •
Restricted Access
4
Drug Name
Prior Review
mg
Drug Name
Drug Tier
Prior Review
Quantity Limits
Drug Tier
Restricted Access
2014
51
• •
LIVALO - pitavastatin calcium tab 4 mg
(base equiv)
4
• •
LOFIBRA - fenofibrate tab 54 mg
4
2
LOFIBRA - fenofibrate tab 160 mg
4
4
gemfibrozil tab 600 mg (Lopid)
1
LOFIBRA - fenofibrate micronized cap
67 mg
JUXTAPID - lomitapide mesylate cap 5
mg (base equiv)
5
• • •
134 mg
4
JUXTAPID - lomitapide mesylate cap 10 5
mg (base equiv)
JUXTAPID - lomitapide mesylate cap 20 5
mg (base equiv)
LESCOL - fluvastatin sodium cap 20 mg 4
• • •
200 mg
4
• • •
LOPID - gemfibrozil tab 600 mg
4
lovastatin tab 10 mg
1
lovastatin tab 20 mg (Mevacor)
1
lovastatin tab 40 mg (Mevacor)
1
LOVAZA - omega-3-acid ethyl esters
cap 1 gm
4
MEVACOR - lovastatin tab 20 mg
4
MEVACOR - lovastatin tab 40 mg
4
niacin tab cr 1000 mg
(antihyperlipidemic) (Niaspan)
2
2
2
NIACOR - niacin (antihyperlipidemic)
tab 500 mg
1
NIASPAN - niacin tab cr 500 mg
(antihyperlipidemic)
3
FENOGLIDE - fenofibrate tab 120 mg
4
FIBRICOR - fenofibric acid tab 35 mg
4
FIBRICOR - fenofibric acid tab 105 mg
4
fluvastatin sodium cap 20 mg
(Lescol)
2
fluvastatin sodium cap 40 mg
(Lescol)
• •
• •
• •
Drug Name
LESCOL - fluvastatin sodium cap 40 mg
4
LESCOL XL - fluvastatin sodium tab sr
24 hr 80 mg
4
LIPITOR - atorvastatin calcium tab 10
4
4
4
4
LIPOFEN - fenofibrate cap 50 mg
4
LIPOFEN - fenofibrate cap 150 mg
4
LIPTRUZET - ezetimibe-atorvastatin tab
10-10 mg
4
• •
• •
• •
10-20 mg
4
• •
3
10-40 mg
4
• •
3
10-80 mg
4
• •
omega-3-acid ethyl esters cap 1 gm
(Lovaza)
2
(base equiv)
4
• •
PRAVACHOL - pravastatin sodium tab
20 mg
4
52
• •
Quantity Limits
Prior Review
Restricted Access
Drug Tier
Quantity Limits
Restricted Access
4
Drug Tier
(base equiv)
Drug Name
Prior Review
2014
40 mg
4
TRILIPIX - choline fenofibrate cap dr 45
mg (fenofibric acid equiv)
4
80 mg
4
TRILIPIX - choline fenofibrate cap dr
135 mg (fenofibric acid equiv)
4
pravastatin sodium tab 10 mg
1
VASCEPA - icosapent ethyl cap 1 gm
4
(Pravachol)
1
VYTORIN - ezetimibe-simvastatin tab
10-10 mg
4
• •
• •
(Pravachol)
1
10-20 mg
4
• •
(Pravachol)
1
10-40 mg
4
• •
QUESTRAN - cholestyramine powder 4
gm/dose
4
10-80 mg
4
• •
QUESTRAN - cholestyramine powder
packets 4 gm
4
WELCHOL - colesevelam hcl tab 625
mg
4
QUESTRAN LIGHT - cholestyramine
light powder 4 gm/dose
4
WELCHOL - colesevelam hcl packet for
susp 3.75 gm
4
QUESTRAN LIGHT - cholestyramine
light powder packets 4 gm
4
ZETIA - ezetimibe tab 10 mg
4
ZOCOR - simvastatin tab 5 mg
4
4
• •
4
4
• •
4
SIMCOR - niacin-simvastatin tab sr 24hr 4
500-20 mg
500-40 mg
750-20 mg
1000-20 mg
1000-40 mg
1
simvastatin tab 10 mg (Zocor)
• •
Quantity Limits
Restricted Access
Prior Review
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Drug Tier
2014
CARDIOVASCULAR AGENTS - MISC.
• •
• •
ADCIRCA - tadalafil tab 20 mg (pah)
5
ADEMPAS - riociguat tab 0.5 mg
5
ADEMPAS - riociguat tab 1 mg
5
5
1
ADEMPAS - riociguat tab 2 mg
5
1
5
1
1
amlodipine besylate-atorvastatin
calcium tab 10-10 mg (Caduet)
2
4
2
TRICOR - fenofibrate tab 48 mg
TRICOR - fenofibrate tab 145 mg
4
2
TRIGLIDE - fenofibrate tab 50 mg
4
TRIGLIDE - fenofibrate tab 160 mg
4
2
• •
• •
•
•
•
•
•
•
53
ISOXSUPRINE HCL - isoxsuprine hcl
tab 20 mg
4
• •
calcium tab 2.5-20 mg (Caduet)
2
isoxsuprine hcl tab 10 mg
2
LETAIRIS - ambrisentan tab 5 mg
5
2
LETAIRIS - ambrisentan tab 10 mg
5
2
OPSUMIT - macitentan tab 10 mg
5
5
2
ORENITRAM - treprostinil diolamine tab
cr 0.125 mg (base equiv)
•
•
•
•
5
•
2
5
•
2
cr 1 mg (base equiv)
5
•
BIDIL - isosorbide dinitrate-hydralazine
hcl tab 20-37.5 mg
4
REVATIO - sildenafil citrate tab 20 mg
5
CADUET - amlodipine besylateatorvastatin calcium tab 2.5-10 mg
4
sildenafil citrate tab 20 mg (Revatio)
5
TRACLEER - bosentan tab 62.5 mg
5
4
TRACLEER - bosentan tab 125 mg
5
•
•
•
•
4
CADUET - amlodipine besylateatorvastatin calcium tab 5-10 mg
Drug Name
ERECTLIE DYSFUNCTION
CAVERJECT - alprostadil for inj 20 mcg
4
4
CAVERJECT - alprostadil for inj 40 mcg
4
4
4
CAVERJECT IMPULSE - alprostadil for
inj kit 10 mcg
• •
• •
• •
4
• •
4
CAVERJECT IMPULSE - alprostadil for
inj kit 20 mcg
CIALIS - tadalafil tab 2.5 mg
4
4
CIALIS - tadalafil tab 5 mg
4
4
4
4
4
4
EDEX - alprostadil for inj kit 10 mcg
4
4
4
LEVITRA - vardenafil hcl tab 2.5 mg
4
4
LEVITRA - vardenafil hcl tab 5 mg
4
4
ISOXSUPRINE HCL - isoxsuprine hcl
tab 10 mg
4
4
•
•
•
•
•
•
•
•
•
•
•
54
•
•
•
•
•
•
•
•
•
•
•
Quantity Limits
Prior Review
Restricted Access
Drug Tier
Quantity Limits
Restricted Access
2
Drug Tier
Drug Name
Prior Review
2014
4
• •
MUSE - alprostadil urethral pellet 500
mcg
4
• •
mcg
4
• •
STAXYN - vardenafil hcl orally
disintegrating tab 10 mg
4
• •
STENDRA - avanafil tab 50 mg
4
4
4
• •
• •
• •
VIAGRA - sildenafil citrate tab 25 mg
3
3
3
RESPIRATORY AGENTS
ANTIHISTAMINES
AEROHIST - chlorpheniraminemethscopolamine tab sr 12hr 8-2.5
mg
4
AHIST - chlorpheniramine tannate tab
12 mg
4
brompheniramine maleate tab sr
12hr 6 mg
1
BROMPHENIRAMINE TANNATE brompheniramine tannate chew tab
12 mg
4
carbinoxamine maleate soln
4 mg/5ml (Palgic)
1
carbinoxamine maleate tab 4 mg
(Palgic)
1
CLARINEX - desloratadine tab 5 mg
4
CLARINEX - desloratadine syrup 0.5
mg/ml
4
CLARINEX REDITABS - desloratadine
tab orally disintegrating 2.5 mg
4
CLARINEX REDITABS - desloratadine
tab orally disintegrating 5 mg
4
• •
• •
• •
• •
Quantity Limits
mcg
Restricted Access
• •
Prior Review
4
Drug Name
Drug Tier
Prior Review
mcg
Drug Name
Quantity Limits
Drug Tier
Restricted Access
2014
CLEMASTINE FUMARATE - clemastine 4
fumarate syrup 0.67 mg/5ml (0.5
mg/5ml base eq)
2
clemastine fumarate syrup
0.67 mg/5ml (0.5 mg/5ml base eq)
2
clemastine fumarate tab 2.68 mg
cyproheptadine hcl syrup 2 mg/5ml
1
cyproheptadine hcl tab 4 mg
1
desloratadine tab orally
disintegrating 2.5 mg (Clarinex
reditabs)
2
desloratadine tab orally
disintegrating 5 mg (Clarinex
reditabs)
2
desloratadine tab 5 mg (Clarinex)
2
DEXCHLORPHENIRAMINE MALEA dexchlorpheniramine maleate tab cr 4
mg
4
• •
DEXCHLORPHENIRAMINE MALEA dexchlorpheniramine maleate syrup 2
mg/5ml
4
• •
diphenhydramine hcl cap 50 mg
2
diphenhydramine hcl elixir
12.5 mg/5ml
2
diphenhydramine hcl syrup
12.5 mg/5ml
2
DOXYTEX - doxylamine succinate liquid 4
2.5 mg/2.5ml
4
ED CHLORPED - chlorpheniramine
tannate susp 2 mg/ml
4
ED-CHLOR-TAN - chlorpheniramine
tannate tab 8 mg
KARBINAL ER - carbinoxamine maleate 4
er susp 4 mg/5ml
2
levocetirizine dihydrochloride soln
2.5 mg/5ml (0.5 mg/ml) (Xyzal)
2
levocetirizine dihydrochloride tab
5 mg (Xyzal)
PALGIC - carbinoxamine maleate tab 4 4
mg
• •
• •
• •
• •
55
PALGIC - carbinoxamine maleate soln 4 4
mg/5ml
4
PBZ - tripelennamine hcl tab 50 mg
budesonide nasal susp 32 mcg/act
(Rhinocort aqua)
2
DYMISTA - azelastine hcl-fluticasone
prop nasal spray 137-50 mcg/act
4
FLONASE - fluticasone propionate
nasal susp 50 mcg/act
4
FLUNISOLIDE - flunisolide nasal soln
25 mcg/act (0.025%)
4
FLUNISOLIDE - flunisolide nasal soln
29 mcg/act (0.025%)
4
flunisolide nasal soln 0.025%
(Flunisolide)
2
promethazine hcl suppos 12.5 mg
1
promethazine hcl suppos 25 mg
1
promethazine hcl syrup 6.25 mg/5ml
1
promethazine hcl tab 12.5 mg
1
promethazine hcl tab 25 mg
1
promethazine hcl tab 50 mg
1
PROMETHEGAN - promethazine hcl
suppos 50 mg
1
RESPA-BR - brompheniramine maleate
tab sr 12hr 11 mg
4
• •
fluticasone propionate nasal susp
50 mcg/act (Flonase)
1
VAZOL - brompheniramine maleate
liquid 2 mg/5ml
4
• •
ipratropium bromide nasal soln
0.03% (21 mcg/spray) (Atrovent)
1
XYZAL - levocetirizine dihydrochloride
tab 5 mg
4
ipratropium bromide nasal soln
0.06% (42 mcg/spray) (Atrovent)
1
XYZAL - levocetirizine dihydrochloride
soln 2.5 mg/5ml (0.5 mg/ml)
4
LUSONAL - phenylephrine hcl liquid 7.5
mg/5ml
4
NASACORT AQ - triamcinolone
acetonide nasal inhal 55 mcg/act
4
NASONEX - mometasone furoate nasal
susp 50 mcg/act
3
OMNARIS - ciclesonide nasal susp 50
mcg/act
4
PATANASE - olopatadine hcl nasal soln
0.6%
4
QNASL - beclomethasone dipropionate
nasal aerosol 80 mcg/act
4
NASAL AGENTS - SYSTEMIC and TOPICAL
4
ADRENALIN - epinephrine hcl nasal
soln 0.1%
4
ASTELIN - azelastine hcl nasal spray
137 mcg/spray (1 mg/ml)
4 •
ASTEPRO - azelastine hcl nasal spray
0.15% (205.5 mcg/spray)
ATROVENT - ipratropium bromide nasal 4
soln 0.03% (21 mcg/spray)
ATROVENT - ipratropium bromide nasal 4
soln 0.06% (42 mcg/spray)
2
azelastine hcl nasal spray 0.15%
(205.5 mcg/spray) (Astepro)
2
azelastine hcl nasal spray 137 mcg/
spray (1 mg/ml)
4
BACTROBAN NASAL - mupirocin
calcium nasal oint 2%
4 •
BECONASE AQ - beclomethasone
dipropionate monohyd nasal susp 42
mcg/spray
56
•
•
RHINOCORT AQUA - budesonide nasal 4
susp 32 mcg/act
2
triamcinolone acetonide nasal inhal
55 mcg/act (Nasacort aq)
TYZINE - tetrahydrozoline hcl nasal soln 4
0.1%
4
TYZINE PEDIATRIC NASAL DR tetrahydrozoline hcl nasal soln 0.05%
4
VERAMYST - fluticasone furoate nasal
susp 27.5 mcg/spray
•
• •
• •
• •
• •
Quantity Limits
Restricted Access
Prior Review
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Drug Name
Prior Review
Drug Tier
2014
4
• •
acetylcysteine inhal soln 10%
2
4
acetylcysteine inhal soln 20%
2
CAPCOF - phenylephrine-chlorphen w/
codeine syrup 5-2-10 mg/5ml
4
CARBAPHEN 12 - phenylephchlorphen-carbetapentane liqd
10-4-27.5 mg/5ml
4
ALAHIST AC - phenylephrine w/
codeine liqd 7.5-10 mg/5ml
ALAHIST DHC - phenylephrinedihydrocodeine liqd 7.5-3 mg/5ml
4
4
ALBATUSSIN - phenylephrinecarbetapentane-gg cap 10-25-400 mg
4
• •
CARBAPHEN 12 PED - phenylephchlorphen-carbetapentane susp
2.5-1.25-7.5 mg/ml
ALBATUSSIN NN - phenyleph-dm-pyrilpot guai-sod cit-cit acid liquid
• •
CGU WC - guaifenesin-codeine soln
100-6.3 mg/5ml
4
4
ALLERSCRIPT - chlorphen tab 4 mg &
pseudoephed tab 60 mg therapy pack
• •
chlorpheniramine tan-phenylephrine
tan susp 4.5-5 mg/5ml
2
4
2
ALLFEN CD - guaifenesin-codeine tab
400-10 mg
4
• •
chlorpheniramine w/ codeine liquid
2-10 mg/5ml
4
• •
CLARINEX-D 12 HOUR - desloratadine
& pseudoephedrine tab sr 12hr
2.5-120 mg
4
ALLFEN CDX - guaifenesin-codeine tab
400-20 mg
ALLFEN CDX - guaifenesin-codeine
liquid 200-20 mg/5ml
4
• •
4
AMBIFED CD - pseudoephedrine w/
cod-gg tab 30-10-400 mg
4
• •
CLARINEX-D 24 HOUR - desloratadine
& pseudoephedrine tab sr 24hr 5-240
mg
4
AMBIFED CDX - pseudoephedrine w/
4
• •
CODAR AR - chlorpheniramine w/
codeine liquid 2-8 mg/5ml
4
AMBIFED-G CD - pseudoephedrine w/
4
• •
CODAR D - pseudoephedrine w/
4
• •
CODAR GF - guaifenesin-codeine liquid
200-8 mg/5ml
COTAB A - chlorpheniramine w/
codeine tab 4-10 mg
4
• •
COTAB AX - chlorpheniramine w/
codeine tab 4-20 mg
4
• •
COTABFLU - codeinechlorpheniramine-acetaminophen tab
20-4-500 mg
4
• •
COUGH/COLD/ALLERGY
AMBIFED-G CDX - pseudoephedrine w/ 4
4
ATUSS DS - pseudoephed hclchlorphen mal-dm hbr tan susp
30-4-30 mg/5ml
1
benzonatate cap 100 mg (Tessalon
perles)
1
benzonatate cap 200 mg
Drug Name
brompheniramine & phenylephrine
susp 6-10 mg/5ml
2
CPB WC - pseudoephedrine-bromphencodeine liq 10-1.3-6.3 mg/5ml
4
brompheniramine &
pseudoephedrine tab sr 12hr
6-45 mg
2
DECON-A - brompheniramine &
phenylephrine elixir 2-5 mg/5ml
4
Quantity Limits
Prior Review
Restricted Access
Drug Tier
Quantity Limits
Restricted Access
BRONCOPECTOL - phenylephchlorphen w/ dm-gg syrup 5-2-5-75
mg/5ml
ZETONNA - ciclesonide nasal aerosol
soln 37 mcg/act (50 mcg/valve)
Drug Tier
4
Drug Name
Prior Review
2014
•
57
DECON-G - phenylephrinebrompheniramine-guaifenesin liqd
2-1-40 mg/ml
4
guaifenesin-codeine soln
100-6.3 mg/5ml
2
DELTUSS DMX - pseudoephedbromphen-dm liquid 30-1-20 mg/5ml
HDC DM - pseudoephed-chlorphen-dm
syrup 15-2-15 mg/5ml
4
4
DESPEC-EXP - pseudoephedrinedihydrocodeine-gg syrup 15-7.5-100
mg/5ml
• •
hydrocod polst-chlorphen polst
cr susp 10-8 mg/5ml (Tussionex
pennkineti)
2
4
4
• •
hydrocodone w/ homatropine syrup
5-1.5 mg/5ml
1
DESPEC-PDC - phenylephrinechlorphen-dihydrocodeine liqd
7.5-2.5-3 mg/5ml
hydrocodone w/ homatropine tab
5-1.5 mg
1
DEX-TUSS - guaifenesin-codeine liquid
300-10 mg/5ml
4
HYPER-SAL - sodium chloride soln
nebu 7%
4
DEXTROMETHORPHAN HBR/CHLO phenylephrine-chlorphen-dm liquid
1.75-0.75-2.75 mg/ml
2
DONATUSS DC - phenylephrinedihydrocodeine-gg syrup 7.5-7.5-50
mg/5ml
4
DURAFLU - pseudoephedrine-dm-gg w/
apap tab 60-20-200-500 mg
4
EXACTUSS - phenylephrine w/ dm-gg
liqd 10-28-388 mg/5ml
4
GENEXA LA - phenylephrineguaifenesin cap sr 12hr 30-400 mg
4
GILPHEX TR - phenylephrineguaifenesin tab 10-388 mg
4
GILTUSS - phenylephrine w/ dm-gg liqd
10-28-388 mg/5ml
4
GILTUSS PED-C - phenylephrine w/
codeine-gg liquid 2.5-3-50 mg/ml
4
GILTUSS TR - phenylephrine w/ dm-gg
cap 7-14-288 mg
4
tab 10-28-388 mg
4
tab sr 12hr 20-30-600 mg
4
guaifenesin-codeine liquid
225-7.5 mg/5ml
2
guaifenesin-codeine soln
100-10 mg/5ml
2
58
• •
• •
HYPERSAL - sodium chloride soln nebu 4
3.5%
HYPERSAL - sodium chloride soln nebu 4
7%
J-COF DHC - pseudoephed-bromphen- 4
dihydrocodeine liqd 15-3-7.5 mg/5ml
4
J-MAX DHC - dihydrocodeineguaifenesin liquid 7.5-100 mg/5ml
LARTUS - phenyleph-chlorphen w/ dm- 4
gg liquid 5-2-15-150 mg/5ml
4
LEMOHIST PLUS - pseudoephedchlorphen-gg cap 32.4-2-100 mg
4
LORTUSS EX - pseudoephedrine w/
cod-gg liqd 22.5-10-100 mg/5ml
4
M-END MAX D - pseudoephedrinedexbromphen-codeine liqd
20-0.667-6 mg/5ml
4
M-END PE - phenylephrine-bromphen
w/ codeine liqd 3.33-1.33-6.33
mg/5ml
4
MAR-COF BP - pseudoephedrinebromphen-codeine liqd 30-2-7.5
mg/5ml
4
MAR-COF CG EXPECTORANT guaifenesin-codeine liquid 225-7.5
mg/5ml
4
MAXIFED CD - pseudoephedrine w/
• •
• •
• •
Quantity Limits
Restricted Access
Prior Review
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Drug Name
Prior Review
Drug Tier
2014
• •
phenylephrine w/ dm-gg liqd
10-30-200 mg/5ml
2
MAXIFED-G CD - pseudoephedrine w/
4
• •
2.5-5-50 mg/ml
2
MAXIFED-G CDX - pseudoephedrine w/ 4
4
MAXIFLU CD - pseudoephed-codeineguaifenesin-apap tab 40-10-400-500
mg
MAXIFLU CDX - pseudoephed-codeine- 4
guaifenesin-apap tab 60-20-400-500
mg
4
MAXIPHEN CD - phenylephrine w/
codeine-gg tab 10-10-400 mg
4
MAXIPHEN CDX - phenylephrine w/
codeine-gg tab 10-20-400 mg
4
NEBUSAL - sodium chloride soln nebu
6%
4
NEOTUSS PLUS - phenylephrinechlorphen-dm liquid 7.5-4-30 mg/5ml
NEOTUSS-D - pseudoephed-chlorphen 4
w/ dm-gg liqd 30-2-30-200 mg/5ml
4
NORTUSS-EX - dextromethorphanguaifenesin liquid 20-200 mg/5ml
4
PANATUSS DXP - phenylephrinedexbromphen-dm-gg liquid
5-1-15-100 mg/5ml
4
PEDIATEX TD - triprolidine &
pseudoephedrine liquid 0.938-10 mg/
ml
4
PEDIATEX TDM - pseudoephedtriprolidine-dm susp 10-0.938-4 mg/
ml
PHENFLU CD - phenylephrine-codeine- 4
guaifenesin-apap tab 10-10-400-500
mg
4
PHENFLU CDX - phenylephrinecodeine-guaifenesin-apap tab
10-20-400-500 mg
2
10-15-300 mg/5ml
• •
2.5-7.5-88 mg/ml
2
• •
phenylephrine-bromphen w/ codeine
liqd 7.5-4-10 mg/5ml
2
phenylephrine-bromphencarbetapentane liq 10-6-30 mg/5ml
2
phenylephrine-brompheniramine-dm
liquid 7.5-4-15 mg/5ml
2
phenylephrine-chlorphen-dm liquid
1.5-1-3 mg/ml
2
phenylephrine-guaifenesin liqd
7.5-100 mg/5ml (1.5-20 mg/ml)
2
phenylephrine-guaifenesin syrup
5-200 mg/5ml
2
phenylephrine-promethazine w/
codeine syrup 5-6.25-10 mg/5ml
2
PHENYLHISTINE DH pseudoephedrine-chlorphen w/
codeine liq 30-2-10 mg/5ml
4
POLY HIST DHC - phenylephrinepyrilamine-dihydrocod liqd 5-7.5-7.5
mg/5ml
4
• •
POLY HIST NC - pseudoephedrinetriprolidine w/ cod liquid 15-1.25-10
mg/5ml
4
• •
POLY-TUSSIN - codeine-chlorcyclizine
liquid 10-9.375 mg/5ml
4
4
• •
POLY-TUSSIN AC - phenylephrinebromphen w/ codeine liqd 7.5-4-10
mg/5ml
4
• •
POLY-TUSSIN D - codeinepseudoephedrine-chlorcyclizine liq
10-30-9.375mg/5ml
POLY-TUSSIN DHC - phenylephrinebromphen-dihydrocodeine liqd
7.5-4-3 mg/5ml
4
• •
• •
• •
• •
Quantity Limits
Restricted Access
4
Drug Name
Prior Review
MAXIFED CDX - pseudoephedrine w/
Drug Name
Drug Tier
Prior Review
Quantity Limits
Drug Tier
Restricted Access
2014
59
• •
RESCON - chlorphen-pemethscopolamine tab sr 12hr
12-40-1.25 mg
4
• •
PRO-CLEAR AC - codeine-pyrilamine
syrup 9-8.33 mg/5ml
4
RESCON-JR - chlorpheniramine &
phenylephrine tab sr 12hr 4-20 mg
4
PRO-RED AC - phenylephrinedexchlorphenir-codeine syrup 5-1-9
mg/5ml
4
RESCON-JR - dexchlorpheniraminephenylephrine tab sr 12hr 3-20 mg
4
4
• •
RESCON-MX - dexchlorpheniraminephenylephrine tab sr 12hr 6-40 mg
4
PROHIST CD - phenyleph-triprolidinechlophedianol liqd 10-2.5-25 mg/5ml
PROHIST CF - chlophedianoltriprolidine liqd 25-2.5 mg/5ml
• •
REZIRA - pseudoephedrine w/
hydrocodone soln 60-5 mg/5ml
4
4
PROHIST LQ - triprolidinephenylephrine liquid 2.5-10 mg/5ml
• •
RYDEX - pseudoephedrine-bromphencodeine liq 10-1.33-6.33 mg/5ml
4
4
promethazine & phenylephrine syrup
6.25-5 mg/5ml
SEMPREX-D - acrivastine &
pseudoephedrine cap 8-60 mg
4
2
sodium chloride soln nebu 0.9%
1
PROMETHAZINE VC PLAIN promethazine & phenylephrine syrup
6.25-5 mg/5ml
2
sodium chloride soln nebu 10%
2
1
PROMETHAZINE VC/CODEINE phenylephrine-promethazine w/
codeine syrup 5-6.25-10 mg/5ml
2
(Hyper-sal)
1
4
promethazine w/ codeine syrup
6.25-10 mg/5ml
2
STATUSS GREEN - codeinepseudoephedrine-chlorcyclizine liq
9-30-12.5 mg/5ml
promethazine-dm syrup
6.25-15 mg/5ml
2
SUTTAR-SF - pseudoephedrine w/ codgg syrup 30-10-100 mg/5ml
4
PROTID - chlorphen-phenylephrine w/
apap tab cr 8-40-500 mg
4
SUTTAR-2 - pseudoephedrine w/ codgg syrup 30-10-100 mg/5ml
4
pseudoeph-chlorphen w/
hydrocodone soln 60-4-5 mg/5ml
(Zutripro)
2
TEKRAL - diphenhydramine &
pseudoephedrine tab sr 12hr 100-120
mg
4
pseudoephed-bromphen-dm syrup
30-2-10 mg/5ml
2
TESSALON - benzonatate cap 200 mg
4
pseudoephedrine w/ cod-gg soln
30-10-100 mg/5ml
2
pseudoephedrine w/ cod-gg syrup
30-10-100 mg/5ml (Suttar-sf)
2
pseudoephedrine-bromphen-codeine
liq 10-1.33-6.33 mg/5ml
2
Drug Name
RELHIST - bromphen tan-phenyleph tan 4
chew tab 6-15 mg
60
• •
Drug Name
TESSALON PERLES - benzonatate cap 4
100 mg
4
TGQ 15DM/5PEH/2CPM phenylephrine-chlorphen-dm syrup
5-2-15 mg/5ml
4
TGQ 30PSE/150GFN/15DM pseudoephedrine w/ dm-gg syrup
30-15-150 mg/5ml
• •
• •
Quantity Limits
Prior Review
4
Restricted Access
Drug Tier
Prior Review
POLY-TUSSIN EX - phenylephrinedihydrocodeine-gg syrup 5-7.5-50
mg/5ml
Quantity Limits
Drug Tier
Restricted Access
2014
TRICODE AR - pseudoephedrinechlorphen w/ codeine liq 30-2-8
mg/5ml
4
TRICODE GF - pseudoephedrine w/
cod-gg liquid 30-8-200 mg/5ml
4
TRISPEC DMX - dextromethorphanguaifenesin liquid 15-25 mg/5ml
4
TRISPEC DMX PEDIATRIC dextromethorphan-guaifenesin liquid
15-25 mg/5ml
4
TRISPEC PSE - pseudoephedrine w/
dm-gg liquid 30-15-25 mg/5ml
4
TRISPEC PSE PEDIATRIC pseudoephedrine w/ dm-gg liquid
30-15-25 mg/5ml
4
ZODRYL AC 25 - chlorpheniramine w/
codeine susp 0.333-1 mg/ml
4
4
4
4
ZODRYL DAC 25 - pseudoephedrinechlorphen w/codeine susp 5-0.333-1
mg/ml
4
ZODRYL DAC 30 - pseudoephedrinechlorphen w/codeine susp
4.286-0.286-1 mg/ml
4
4
4
3.75-0.25-1 mg/ml
4
TUSNEL - brompheniramine w/ dm-gg
cap 2-15-200 mg
4
3.333-0.222-1 mg/ml
TUSNEL PED-C - pseudoephedrine w/
cod-gg syrup 15-5-50 mg/5ml
ZODRYL DEC 25 - pseudoephedrine w/
cod-gg susp 5-1-20 mg/ml
4
4
TUSSICAPS - hydrocod polst-chlorphen
polst cap sr 12hr 5-4 mg
cod-gg susp 4.286-1-20 mg/ml
4
4
4
4
TUSSICAPS - hydrocod polst-chlorphen
polst cap sr 12hr 10-8 mg
TUSSIONEX PENNKINETIC EXT hydrocod polst-chlorphen polst cr
susp 10-8 mg/5ml
4
4
ZONATUSS - benzonatate cap 150 mg
4
4
ZUTRIPRO - pseudoeph-chlorphen w/
hydrocodone soln 60-4-5 mg/5ml
4
VANACOF CD - phenylephrinedexchlorphenir-codeine liquid 5-1-10
mg/5ml
VITUZ - hydrocodone-chlorpheniramine
soln 5-4 mg/5ml
4
Z-COF I - pseudoephedrine w/ dm-gg
susp 30-15-211 mg/5ml
Z-TUSS AC - chlorpheniramine w/
• •
Quantity Limits
TGQ 50PSE/3BRM/30DM pseudoephed-bromphen-dm syrup
50-3-30 mg/5ml
4
Z-TUSS E - pseudoephedrine w/ cod-gg
liquid 30-9-200 mg/5ml
Restricted Access
• •
Prior Review
4
Drug Name
Drug Tier
Prior Review
TGQ 30PSE/3BRM/15DM pseudoephed-bromphen-dm syrup
30-3-15 mg/5ml
Drug Name
Quantity Limits
Drug Tier
Restricted Access
2014
ANTIASTHMATIC and BRONCHODILATOR AGENTS
4
ACCOLATE - zafirlukast tab 10 mg
ACCOLATE - zafirlukast tab 20 mg
4
4
ACCUNEB - albuterol sulfate soln nebu
0.63 mg/3ml (base equiv)
4
4
ACCUNEB - albuterol sulfate soln nebu
4
61
ADVAIR DISKUS - fluticasonesalmeterol aer powder ba 100-50
mcg/dose
3
ANORO ELLIPTA - umeclidiniumvilanterol aero powd ba 62.5-25 mcg/
inh
3
mcg/dose
3
ARCAPTA NEOHALER - indacaterol
maleate inhal powder cap 75 mcg
(base equiv)
4
mcg/dose
3
ASMANEX 120 METERED DOSES mometasone furoate inhal powd 220
mcg/inh (breath activated)
3
ADVAIR HFA - fluticasone-salmeterol
inhal aerosol 45-21 mcg/act
3
3
3
3
3
AEROSPAN - flunisolide hfa inhal
aerosol 80 mcg/act
4
3
albuterol sulfate soln nebu 0.083%
(2.5 mg/3ml)
1
3
albuterol sulfate soln nebu 0.5%
(5 mg/ml)
1
1
3
albuterol sulfate soln nebu
albuterol sulfate soln nebu
1
ATROVENT HFA - ipratropium bromide
hfa inhal aerosol 17 mcg/act
4
albuterol sulfate syrup 2 mg/5ml
1
3
albuterol sulfate tab sr 12hr 4 mg
(Vospire er)
1
BREO ELLIPTA - fluticasone furoatevilanterol aero powd ba 100-25 mcg/
inh
albuterol sulfate tab sr 12hr 8 mg
(Vospire er)
1
BRONCOMAR-1 - theophylline-pse-gg
elixir 150-30-150 mg/15ml
4
• •
albuterol sulfate tab 2 mg
1
4
• •
albuterol sulfate tab 4 mg
1
BRONDIL - dyphylline-guaifenesin liqd
100-100 mg/15ml
• •
BROVANA - arformoterol tartrate soln
nebu 15 mcg/2ml (base equiv)
4
• •
• •
budesonide inhalation susp
0.25 mg/2ml (Pulmicort)
2
budesonide inhalation susp
0.5 mg/2ml (Pulmicort)
2
COMBIVENT - ipratropium-albuterol
aerosol 18-103 mcg/act (20-120mcg/
act)
3
ALVESCO - ciclesonide inhal aerosol 80 4
mcg/act
4
ALVESCO - ciclesonide inhal aerosol
160 mcg/act
4
AMINOPHYLLINE - aminophylline tab
100 mg
4
AMINOPHYLLINE - aminophylline tab
200 mg
62
• •
• •
Quantity Limits
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COMBIVENT RESPIMAT - ipratropiumalbuterol inhal aerosol soln 20-100
mcg/act
3
ipratropium bromide inhal soln
0.02%
1
cromolyn sodium soln nebu
20 mg/2ml
ipratropium-albuterol nebu soln
0.5-2.5(3) mg/3ml (Duoneb)
2
2
DALIRESP - roflumilast tab 500 mcg
DULERA - mometasone furoateformoterol fumarate aerosol 100-5
mcg/act
4
levalbuterol hcl soln nebu conc
1.25 mg/0.5ml (base equiv)
(Xopenex concentrate)
1
4
DULERA - mometasone furoateformoterol fumarate aerosol 200-5
mcg/act
4
DUONEB - ipratropium-albuterol nebu
soln 0.5-2.5(3) mg/3ml
4
DYLIX - dyphylline elixir 100 mg/15ml
4
dyphylline-guaifenesin liqd
100-100 mg/5ml
2
dyphylline-guaifenesin tab
200-200 mg
• •
• •
• •
2
levalbuterol hcl soln nebu
0.31 mg/3ml (base equiv) (Xopenex)
2
2
4
LUFYLLIN - dyphylline tab 200 mg
LUFYLLIN - dyphylline tab 400 mg
4
4
2
MAXAIR AUTOHALER - pirbuterol
acetate breath activated inhal aerosol
200mcg/inh
dyphylline-guaifenesin tab
200-400 mg
METAPROTERENOL SULFATE metaproterenol sulfate tab 10 mg
1
2
ED-BRON G - theophylline sod
glycinate-gg syrup 300-100 mg/15ml
METAPROTERENOL SULFATE metaproterenol sulfate tab 20 mg
1
4
ELIXOPHYLLIN - theophylline elixir 80
mg/15ml
METAPROTERENOL SULFATE metaproterenol sulfate syrup 10
mg/5ml
1
1
FLOVENT DISKUS - fluticasone
propionate aer pow ba 50 mcg/blister
3
metaproterenol sulfate syrup
10 mg/5ml
2
propionate aer pow ba 100 mcg/
blister
3
montelukast sodium chew tab 4 mg
(base equiv) (Singulair)
2
propionate aer pow ba 250 mcg/
blister
montelukast sodium chew tab 5 mg
(base equiv) (Singulair)
2
3
FLOVENT HFA - fluticasone propionate
hfa inhal aero 44 mcg/act (50/valve)
3
hfa inhal aer 110 mcg/act (125/valve)
3
hfa inhal aer 220 mcg/act (250/valve)
3
FORADIL AEROLIZER - formoterol
fumarate inhal cap 12 mcg
3
• •
2
montelukast sodium oral granules
packet 4 mg (base equiv) (Singulair)
montelukast sodium tab 10 mg (base 2
equiv) (Singulair)
4
PERFOROMIST - formoterol fumarate
soln nebu 20 mcg/2ml
3
PROAIR HFA - albuterol sulfate inhal
aero 108 mcg/act (90mcg base equiv)
Quantity Limits
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Quantity Limits
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Drug Name
Drug Tier
2014
• •
• •
• •
•
• •
63
• •
THEO-24 - theophylline cap sr 24hr 100
mg
4
• •
• •
PULMICORT - budesonide inhalation
susp 0.25 mg/2ml
mg
4
4
• •
susp 0.5 mg/2ml
mg
4
4
• •
• •
4
mg
4
susp 1 mg/2ml
1
PULMICORT FLEXHALER budesonide inhal aero powd 90 mcg/
act (breath activated)
• •
theophylline soln 80 mg/15ml
4
theophylline tab sr 12hr 100 mg
1
1
PULMICORT FLEXHALER budesonide inhal aero powd 180
mcg/act (breath activated)
4
1
1
QVAR - beclomethasone dipropionate
inhal aero soln 40 mcg/act
• •
1
4
1
4
• •
• •
SEREVENT DISKUS - salmeterol
xinafoate aer pow ba 50 mcg/dose
(base equiv)
3
TUDORZA PRESSAIR - aclidinium
bromide aerosol powd breath
activated 400 mcg/act
4
QVAR - beclomethasone dipropionate
inhal aero soln 80 mcg/act
VENTOLIN HFA - albuterol sulfate inhal
aero 108 mcg/act (90mcg base equiv)
4
• •
4
VOSPIRE ER - albuterol sulfate tab sr
12hr 4 mg
4
SINGULAIR - montelukast sodium tab
10 mg (base equiv)
4
VOSPIRE ER - albuterol sulfate tab sr
12hr 8 mg
4
SINGULAIR - montelukast sodium chew
4
XOPENEX - levalbuterol hcl soln nebu
4
SINGULAIR - montelukast sodium chew
4
4
SINGULAIR - montelukast sodium oral
granules packet 4 mg (base equiv)
3
4
SPIRIVA HANDIHALER - tiotropium
bromide monohydrate inhal cap 18
mcg (base equiv)
4
SYMBICORT - budesonide-formoterol
fumarate dihyd aerosol 80-4.5 mcg/
act
4
XOPENEX CONCENTRATE levalbuterol hcl soln nebu conc 1.25
mg/0.5ml (base equiv)
4
SYMBICORT - budesonide-formoterol
fumarate dihyd aerosol 160-4.5 mcg/
act
4
XOPENEX HFA - levalbuterol tartrate
inhal aerosol 45 mcg/act (base equiv)
zafirlukast tab 10 mg (Accolate)
2
zafirlukast tab 20 mg (Accolate)
2
terbutaline sulfate tab 2.5 mg
1
ZYFLO - zileuton tab 600 mg
4
terbutaline sulfate tab 5 mg
1
ZYFLO CR - zileuton tab sr 12hr 600 mg 4
Drug Name
64
• •
• •
• •
Drug Name
• •
• •
• •
Quantity Limits
Prior Review
4
Restricted Access
Drug Tier
Prior Review
PROVENTIL HFA - albuterol sulfate
inhal aero 108 mcg/act (90mcg base
equiv)
Quantity Limits
Drug Tier
Restricted Access
2014
RESPIRATORY AGENTS - MISC.
INFASURF - calfactant in nacl 0.9%
intratracheal susp 35 mg/ml
4
KALYDECO - ivacaftor tab 150 mg
5
PULMOZYME - dornase alfa inhal soln
1 mg/ml
5
• •
•
GASTROINTESTINAL AGENTS
LAXATIVES
peg 3350-kcl-na bicarb-nacl-na
sulfate for soln 236 gm (Golytely)
1
peg 3350-kcl-na bicarb-nacl-na
sulfate for soln 240 gm (Colyteflavor packs)
1
peg 3350-kcl-sod bicarb-nacl for soln
420 gm (Nulytely/flavor pack)
1
polyethylene glycol 3350 oral packet
2
4
polyethylene glycol 3350 oral
powder
2
CASCARA SAGRADA - cascara
sagrada fl ext 1 gm/ml
4
PREPOPIK - sod picosulfate-mg oxidecitric acid pack 10 mg-3.5 gm-12 gm
4
CASCARA SAGRADA AROMATIC cascara sagrada fl ext 1 gm/ml
3
SENNA - senna powder
4
COLYTE-FLAVOR PACKS - peg 3350kcl-na bicarb-nacl-na sulfate for soln
227.1 gm
SENNA LEAVES - senna leaves
4
4
COLYTE-FLAVOR PACKS - peg 3350kcl-na bicarb-nacl-na sulfate for soln
240 gm
3
SUCLEAR - na sulf-k sulf-mg sulf & peg
3350-nacl-na bicarb-kcl kit
4
GOLYTELY - peg 3350-kcl-na bicarbnacl-na sulfate for soln 236 gm
3
SUPREP BOWEL PREP - sodium
sulfate-potassium sulfate-magnesium
sulfate oral soln
4
GOLYTELY - peg 3350-kcl-na bicarbnacl-na sulfate packet 227.1 gm
3
VISICOL - sod phos monobasic-sod
phos dibasic-mcc tabs 1.102-0.398
gm
HALFLYTELY BOWEL PREP/FLA bisacodyl tab & peg 3350-kcl-sod
bicarb-nacl for soln kit
4
KRISTALOSE - lactulose oral crystal
packet 10 gm
4
• •
KRISTALOSE - lactulose oral crystal
packet 20 gm
4
• •
lactulose solution 10 gm/15ml
1
MINERAL OIL HEAVY - mineral oil
4
MOVIPREP - peg 3350-kcl-nacl-na
sulfate-na acorbate-c for soln 100 gm
4
NULYTELY/FLAVOR PACKS - peg
3350-kcl-sod bicarb-nacl for soln 420
gm
4
OSMOPREP - sod phos mono-sod phos 4
di tabs 1.102-0.398 gm(1.5gm na
phos)
• •
• •
Quantity Limits
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2014
• •
• •
ANTIDIARRHEALS
diphenoxylate w/ atropine tab
2.5-0.025 mg (Lomotil)
1
DIPHENOXYLATE/ATROPINE diphenoxylate w/ atropine liq
2.5-0.025 mg/5ml
1
FULYZAQ - crofelemer tab delayed
release 125 mg
4
LOMOTIL - diphenoxylate w/ atropine
tab 2.5-0.025 mg
4
loperamide hcl cap 2 mg
1
MOTOFEN - difenoxin w/ atropine tab
1-0.025 mg
4
• •
OPIUM TINCTURE (PAREGORIC paregoric 2 mg/5ml
4
• •
opium tincture 1% (10 mg/ml)
(morphine equiv)
2
• •
65
ANTACIDS
SODIUM BICARBONATE - sodium
bicarbonate powder
4
•
ULCER DRUGS
CARAFATE - sucralfate susp 1 gm/10ml 4
1
cimetidine hcl soln 300 mg/5ml
cimetidine tab 200 mg
1
1
1
1
clidinium & chlordiazepoxide cap
2.5-5 mg (Librax)
2
CUVPOSA - glycopyrrolate oral soln 1
mg/5ml
4
CYTOTEC - misoprostol tab 100 mcg
4
CYTOTEC - misoprostol tab 200 mcg
4
DEXILANT - dexlansoprazole cap
4
• •
• •
ACIPHEX - rabeprazole sodium ec tab
20 mg
4
ACIPHEX SPRINKLE - rabeprazole
sodium capsule sprinkle dr 5 mg
4
ACIPHEX SPRINKLE - rabeprazole
sodium capsule sprinkle dr 10 mg
4
amoxicillin cap-clarithro tablansopraz cap dr therapy pack
(Prevpac)
2
ANASPAZ - hyoscyamine sulfate tab
disp 0.125 mg
4
DEXILANT - dexlansoprazole cap
4
AXID - nizatidine cap 150 mg
4
4
AXID - nizatidine cap 300 mg
4
DICYCLOMINE HCL - dicyclomine hcl
oral soln 10 mg/5ml
AXID - nizatidine oral soln 15 mg/ml
4
dicyclomine hcl cap 10 mg (Bentyl)
1
BELLADONNA & OPIUM - belladonna
alkaloids & opium suppos 16.2-30 mg
4
• •
dicyclomine hcl tab 20 mg (Bentyl)
1
4
BELLADONNA ALKALOIDS belladonna alkaloids tincture 30
mg/100ml
4
• •
DIGEX NF - hyoscyaminephenyltoloxamine cap 0.0625-15 mg
DONNATAL - belladonna alkaloidsphenobarbital tab 16.2 mg
4
BELLADONNA ALKALOIDS & OP belladonna alkaloids & opium suppos
16.2-60 mg
4
DONNATAL - belladonna alkaloidsphenobarbital elixir 16.2 mg/5ml
4
• •
belladonna alkaloids-phenobarbital
elixir 16.2 mg/5ml (Donnatal)
DONNATAL EXTENTABS - belladonna
alkaloids-phenobarbital tab cr 48 mg
4
1
• •
belladonna alkaloids-phenobarbital
tab 16.2 mg (Donnatal)
ESOMEPRAZOLE STRONTIUM esomeprazole strontium cap delayed
release 24.65 mg
4
1
BENTYL - dicyclomine hcl cap 10 mg
4
4
• •
BENTYL - dicyclomine hcl tab 20 mg
4
BENTYL - dicyclomine hcl oral soln 10
mg/5ml
4
ESOMEPRAZOLE STRONTIUM esomeprazole strontium cap delayed
release 49.3 mg
2
CANTIL - mepenzolate bromide tab 25
mg
4
famotidine for susp 40 mg/5ml
(Pepcid)
famotidine tab 20 mg (Pepcid)
1
CARAFATE - sucralfate tab 1 gm
4
famotidine tab 40 mg (Pepcid)
1
66
• •
• •
• •
• •
• •
Quantity Limits
Restricted Access
Prior Review
• •
Drug Name
Drug Tier
4
Quantity Limits
Prior Review
REZYST SB - saccharomyces boulardii
chew tab 250 mg
Drug Tier
Drug Name
Restricted Access
2014
FIRST-LANSOPRAZOLE - lansoprazole 4
susp 3 mg/ml (compound kit)
4
FIRST-OMEPRAZOLE - omeprazole
susp 2 mg/ml (compound kit)
2
GASTRINEX NF - hyoscyaminephenyltoloxamine cap 0.0625-15 mg
4
GLYCATE - glycopyrrolate tab 1.5 mg
glycopyrrolate tab 1 mg (Robinul)
2
glycopyrrolate tab 2 mg (Robinul
forte)
2
HELIDAC - metronidaz tab-tetracyc cap- 4
bis subsal chew tab therapy pack
1
hyoscyamine sulfate elixir
0.125 mg/5ml
1
hyoscyamine sulfate soln 0.125 mg/
ml
1
hyoscyamine sulfate tab disp
0.125 mg (Anaspaz)
1
hyoscyamine sulfate tab sl 0.125 mg
(Levsin/sl)
2
hyoscyamine sulfate tab sr 12hr
0.375 mg (Levbid)
1
hyoscyamine sulfate tab 0.125 mg
(Levsin)
2
lansoprazole cap delayed release
15 mg (Prevacid)
2
lansoprazole cap delayed release
30 mg (Prevacid)
2
lansoprazole tab delayed release
orally disintegrating 15 mg
2
lansoprazole tab delayed release
orally disintegrating 30 mg
4
LEVBID - hyoscyamine sulfate tab sr
12hr 0.375 mg
LEVSIN - hyoscyamine sulfate tab 0.125 4
mg
LEVSIN/SL - hyoscyamine sulfate tab sl 4
0.125 mg
4
LIBRAX - clidinium & chlordiazepoxide
cap 2.5-5 mg
• •
methscopolamine bromide tab
2.5 mg (Pamine)
2
• •
methscopolamine bromide tab 5 mg
(Pamine forte)
2
misoprostol tab 100 mcg (Cytotec)
1
misoprostol tab 200 mcg (Cytotec)
1
• •
• •
Quantity Limits
Restricted Access
Prior Review
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Drug Tier
2014
NEXIUM - esomeprazole magnesium for 3
delayed release susp pack 2.5 mg
delayed release susp packet 5 mg
3
NEXIUM - esomeprazole magnesium
cap delayed release 20 mg
3
NEXIUM - esomeprazole magnesium
cap delayed release 40 mg
1
nizatidine cap 150 mg
nizatidine cap 300 mg (Axid)
1
nizatidine oral soln 15 mg/ml (Axid)
2
OMECLAMOX-PAK - amoxicillin capclarithro tab w/ omepraz cap dr
therapy pack
4
• •
OMEPRAZOLE + SYRSPEND SF omeprazole susp 2 mg/ml (compound
kit)
4
• •
omeprazole cap delayed release
10 mg (Prilosec)
1
20 mg (Prilosec)
1
40 mg (Prilosec)
1
omeprazole-sodium bicarbonate cap
20-1100 mg (Zegerid)
2
•
omeprazole-sodium bicarbonate cap
40-1100 mg (Zegerid)
2
•
67
PAMINE - methscopolamine bromide
tab 2.5 mg
4
PROTONIX - pantoprazole sodium ec
4
PAMINE FORTE - methscopolamine
bromide tab 5 mg
4
PROTONIX - pantoprazole sodium ec
4
PAMINE FQ - methscopolamine tab 5
mg & misc intestinal flora reg cap
4
PROTONIX - pantoprazole sodium for
4
• •
pantoprazole sodium ec tab 20 mg
(base equiv) (Protonix)
1
4
• •
pantoprazole sodium ec tab 40 mg
(base equiv) (Protonix)
1
PYLERA - bismuth subcitmetronidazole-tetracycline cap
140-125-125 mg
2
PEPCID - famotidine tab 20 mg
4
rabeprazole sodium ec tab 20 mg
(Aciphex)
PEPCID - famotidine tab 40 mg
4
ranitidine hcl cap 150 mg
1
PEPCID - famotidine for susp 40
mg/5ml
4
ranitidine hcl cap 300 mg
1
1
PREVACID - lansoprazole cap delayed
release 15 mg
4
ranitidine hcl syrup 15 mg/ml
(75 mg/5ml)
ranitidine hcl tab 150 mg (Zantac)
1
PREVACID - lansoprazole cap delayed
release 30 mg
4
ranitidine hcl tab 300 mg (Zantac)
1
4
PREVACID SOLUTAB - lansoprazole
tab delayed release orally
disintegrating 15 mg
• •
ROBINUL - glycopyrrolate tab 1 mg
4
ROBINUL FORTE - glycopyrrolate tab 2
mg
4
4
• •
sucralfate tab 1 gm (Carafate)
1
PREVACID SOLUTAB - lansoprazole
tab delayed release orally
disintegrating 30 mg
PREVPAC - amoxicillin cap-clarithro
tab-lansopraz cap dr therapy pack
4
PRILOSEC - omeprazole cap delayed
release 10 mg
4
release 20 mg
• •
SYMAX DUOTAB - hyoscyamine sulfate 4
tab cr 0.375 mg (0.125 mg ir/0.25 mg
cr)
4
ZANTAC - ranitidine hcl tab 150 mg
ZANTAC - ranitidine hcl tab 300 mg
4
ZANTAC - ranitidine hcl effer tab 25 mg
4
4
ZANTAC - ranitidine hcl syrup 15 mg/ml
(75 mg/5ml)
4
release 40 mg
4
ZEGERID - omeprazole-sodium
bicarbonate cap 20-1100 mg
4
PRILOSEC - omeprazole magnesium
for delayed release susp packet 2.5
mg
4
• •
bicarbonate cap 40-1100 mg
4
• •
• •
4
bicarbonate powd pack for susp
20-1680 mg
4
PRILOSEC - omeprazole magnesium
for delayed release susp packet 10
mg
• •
PROPANTHELINE BROMIDE propantheline bromide tab 15 mg
• •
bicarbonate powd pack for susp
40-1680 mg
4
4
68
• •
Quantity Limits
Restricted Access
Prior Review
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Drug Name
Prior Review
Drug Tier
2014
ANTIEMETICS
ANTIVERT - meclizine hcl tab 12.5 mg
4
ANTIVERT - meclizine hcl tab 25 mg
4
ANTIVERT - meclizine hcl tab 50 mg
4
ANZEMET - dolasetron mesylate tab 50
mg
5
• •
• •
ANZEMET - dolasetron mesylate tab
100 mg
5
• •
CESAMET - nabilone cap 1 mg
4
COCA COLA SYURP - phosphorated
carbohydrate w/ caffeine syrup
4
• •
• •
DICLEGIS - doxylamine-pyridoxine tab
delayed release 10-10 mg
4
dronabinol cap 10 mg (Marinol)
2
dronabinol cap 2.5 mg (Marinol)
2
dronabinol cap 5 mg (Marinol)
2
EMEND - aprepitant capsule 40 mg
4
4
4
EMEND - aprepitant capsule therapy
pack 80 & 125 mg
ondansetron orally disintegrating tab
4 mg (Zofran odt)
1
ondansetron orally disintegrating tab
8 mg (Zofran odt)
1
SANCUSO - granisetron td patch 3.1
mg/24hr (contains 34.3 mg)
5
• •
TIGAN - trimethobenzamide hcl cap 300 4
mg
4
TRANSDERM-SCOP - scopolamine td
patch 72hr 1.5 mg
2
trimethobenzamide hcl cap 300 mg
(Tigan)
4
ZOFRAN - ondansetron hcl tab 4 mg
ZOFRAN - ondansetron hcl tab 8 mg
4
ZOFRAN - ondansetron hcl oral soln 4
mg/5ml
4
ZOFRAN ODT - ondansetron orally
4
ZOFRAN ODT - ondansetron orally
4
4
ZUPLENZ - ondansetron oral soluble
film 4 mg
4
• •
granisetron hcl tab 1 mg
2
4
• •
GRANISOL - granisetron hcl oral soln 2
mg/10ml (base equivalent)
5
ZUPLENZ - ondansetron oral soluble
film 8 mg
MARINOL - dronabinol cap 2.5 mg
4
4
• •
MARINOL - dronabinol cap 5 mg
4
CREON - pancrelipase (lip-prot-amyl) dr
cap 3000-9500-15000 unit
4
cap 6000-19000-30000 unit
4
MARINOL - dronabinol cap 10 mg
• •
meclizine hcl tab 12.5 mg
1
• •
meclizine hcl tab 25 mg
cap 12000-38000-60000 unit
4
1
meclizine hcl tab 32 mg
2
4
• •
ondansetron hcl oral soln 4 mg/5ml
(Zofran)
2
cap 24000-76000-120000 unit
4
• •
ondansetron hcl tab 24 mg
1
cap 36000-114000-180000 unit
ondansetron hcl tab 4 mg (Zofran)
1
4
• •
ondansetron hcl tab 8 mg
2
PANCREAZE - pancrelipase (lip-protamyl) dr cap 4200-10000-17500 unit
1
4
• •
ondansetron hcl tab 8 mg (Zofran)
• •
Quantity Limits
Restricted Access
Prior Review
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Drug Tier
2014
DIGESTIVE AIDS
69
Quantity Limits
Restricted Access
4
• •
AMITIZA - lubiprostone cap 24 mcg
4
• •
APRISO - mesalamine cap sr 24hr
0.375 gm
4
4
PANCRELIPASE - pancrelipase (lipprot-amyl) dr cap 5000-17000-27000
unit
ASACOL - mesalamine tab delayed
release 400 mg
3
3
4
PERTZYE - pancrelipase (lip-prot-amyl)
dr cap 8000-28750-30250 unit
4
• •
ASACOL HD - mesalamine tab delayed
release 800 mg
AZULFIDINE - sulfasalazine tab 500 mg
4
4
• •
AZULFIDINE EN-TABS - sulfasalazine
tab delayed release 500 mg
4
PERTZYE - pancrelipase (lip-prot-amyl)
dr cap 16000-57500-60500 unit
5
• •
balsalazide disodium cap 750 mg
(Colazal)
2
SUCRAID - sacrosidase soln 8500 unit/
ml
4
• •
calcium acetate (phosphate binder)
cap 667 mg (169 mg ca) (Phoslo)
2
ULTRESA - pancrelipase (lip-prot-amyl)
dr cap 13800-27600-27600 unit
4
• •
calcium acetate (phosphate binder)
tab 667 mg (Eliphos)
2
dr cap 20700-41400-41400 unit
4
• •
CANASA - mesalamine suppos 1000
mg
4
dr cap 23000-46000-46000 unit
4
• •
CHENODAL - chenodiol tab 250 mg
4
VIOKACE - pancrelipase (lip-prot-amyl)
tab 10440-39150-39150 unit
5
VIOKACE - pancrelipase (lip-prot-amyl)
tab 20880-78300-78300 unit
4
CIMZIA - certolizumab pegol for inj kit 2
x 200 mg
• •
• • •
5
• • •
ZENPEP - pancrelipase (lip-prot-amyl)
dr cap 3000-10000-16000 unit
3
CIMZIA - certolizumab pegol inj kit 2 x
200 mg/ml
5
• •
dr cap 5000-17000-27000 unit
3
CIMZIA STARTER KIT - certolizumab
pegol inj kit 6 x 200 mg/ml
4
dr cap 10000-34000-55000 unit
3
COLAZAL - balsalazide disodium cap
750 mg
5
dr cap 15000-51000-82000 unit
3
cromolyn sodium oral conc
100 mg/5ml (Gastrocrom)
dr cap 20000-68000-109000 unit
3
dr cap 25000-85000-136000 unit
3
• •
Drug Name
• •
• •
• •
DELZICOL - mesalamine cap dr 400 mg 3
DIPENTUM - olsalazine sodium cap 250 4
mg
ELIPHOS - calcium acetate (phosphate 4
binder) tab 667 mg
5
ENTEREG - alvimopan cap 12 mg
GASTROINTESTINAL AGENTS- MISC.
mesalamine rectal enema 4 gm &
cleanser wipe kit (Rowasa)
2
FOSRENOL - lanthanum carbonate
chew tab 500 mg
4
ACTIGALL - ursodiol cap 300 mg
4
4
AMITIZA - lubiprostone cap 8 mcg
4
chew tab 750 mg
70
Prior Review
Drug Name
Drug Tier
Prior Review
Quantity Limits
Drug Tier
Restricted Access
2014
• •
RELISTOR - methylnaltrexone bromide
inj 12 mg/0.6ml (20 mg/ml)
5
• •
GASTROCROM - cromolyn sodium oral
conc 100 mg/5ml
5
RELISTOR - methylnaltrexone bromide
inj kit 12 mg/0.6ml
5
• •
GIAZO - balsalazide disodium tab 1.1
gm
4
RENAGEL - sevelamer hcl tab 400 mg
4
RENAGEL - sevelamer hcl tab 800 mg
4
lactulose (encephalopathy) solution
10 gm/15ml
1
RENVELA - sevelamer carbonate tab
800 mg
4
LIALDA - mesalamine tab delayed
release 1.2 gm
4
RENVELA - sevelamer carbonate
packet 0.8 gm
4
LINZESS - linaclotide cap 145 mcg
4
LINZESS - linaclotide cap 290 mcg
RENVELA - sevelamer carbonate
packet 2.4 gm
4
4
LOTRONEX - alosetron hcl tab 0.5 mg
(base equiv)
4
ROWASA - mesalamine rectal enema 4
gm & cleanser wipe kit
4
LOTRONEX - alosetron hcl tab 1 mg
(base equiv)
4
SEVELAMER CARBONATE sevelamer carbonate tab 800 mg
4
mesalamine enema 4 gm
2
4
metoclopramide hcl soln 5 mg/5ml
(10 mg/10ml)
1
SFROWASA - mesalamine sulfite-free
(sf) enema 4 gm/60ml
1
metoclopramide hcl tab 10 mg
(Reglan)
1
sulfasalazine tab delayed release
500 mg (Azulfidine en-tabs)
sulfasalazine tab 500 mg (Azulfidine)
1
metoclopramide hcl tab 5 mg
(Reglan)
1
URSO FORTE - ursodiol tab 500 mg
4
4
METOZOLV ODT - metoclopramide hcl
orally disintegrating tab 5 mg
• •
URSO 250 - ursodiol tab 250 mg
4
ursodiol cap 300 mg (Actigall)
2
4
• •
ursodiol tab 250 mg (Urso 250)
2
METOZOLV ODT - metoclopramide hcl
ursodiol tab 500 mg (Urso forte)
2
PENTASA - mesalamine cap cr 250 mg
4
4
PENTASA - mesalamine cap cr 500 mg
4
VELPHORO - sucroferric oxyhydroxide
chew tab 500 mg
PHOSLO - calcium acetate (phosphate
binder) cap 667 mg (169 mg ca)
4
PHOSLYRA - calcium acetate
(phosphate binder) oral soln 667
mg/5ml
4
• •
• •
• •
Drug Name
Quantity Limits
Prior Review
Restricted Access
Drug Tier
Quantity Limits
Restricted Access
4
Drug Tier
chew tab 1000 mg
Drug Name
Prior Review
2014
• •
• •
GENITOURINARY AGENTS
URINARY ANTI-INFECTIVES
REGLAN - metoclopramide hcl tab 5 mg 4
4
REGLAN - metoclopramide hcl tab 10
mg
RELISTOR - methylnaltrexone bromide 5
inj 8 mg/0.4ml (20 mg/ml)
• •
• •
methenamine-hyos-meth blue-sod
phos-phen sal tab 81.6 mg
2
methenamine-hyosamine-meth bluesod phos tab 81.6 mg (Urogesicblue)
2
methenamine-hyosc-meth blue-sod
phos-phen sal cap 120 mg
2
FURADANTIN - nitrofurantoin susp 25
mg/5ml
4
71
URIBEL - methenamine-hyosc-meth
blue-sod phos-phen sal cap 118 mg
4
• •
MACROBID - nitrofurantoin
monohydrate macrocrystalline cap
100 mg
4
URIMAR-T - methenamine-hyosc-meth
blue-sod phos-phen sal tab 120 mg
4
• •
MACRODANTIN - nitrofurantoin
macrocrystalline cap 25 mg
UROGESIC-BLUE - methenaminehyosamine-meth blue-sod phos tab
81.6 mg
4
4
4
4
4
UROQID #2 - methenamine mandelatesod phosphate monobasic tab
500-500 mg
methenamine hippurate tab 1 gm
(Hiprex)
2
bethanechol chloride tab 10 mg
(Urecholine)
1
METHENAMINE MANDELATE methenamine mandelate tab 0.5 gm
3
(Urecholine)
1
methenamine mandelate tab 1 gm
2
(Urecholine)
1
(Urecholine)
1
DETROL - tolterodine tartrate tab 1 mg
4
DETROL - tolterodine tartrate tab 2 mg
4
DETROL LA - tolterodine tartrate cap sr
24hr 2 mg
4
DETROL LA - tolterodine tartrate cap sr
24hr 4 mg
4
DITROPAN XL - oxybutynin chloride tab
sr 24hr 5 mg
4
sr 24hr 10 mg
4
sr 24hr 15 mg
4
ENABLEX - darifenacin hydrobromide
tab sr 24hr 7.5 mg (base equiv)
4
• •
ENABLEX - darifenacin hydrobromide
tab sr 24hr 15 mg (base equiv)
4
• •
flavoxate hcl tab 100 mg
2
GELNIQUE - oxybutynin td gel 3% (28
mg/act metered-dose pump)
4
• •
GELNIQUE - oxybutynin chloride td gel
10%
4
• •
• •
URINARY ANTISPASMODICS
methenamine-hyosc-meth blue-benz 2
acid-phenyl sal tab 81.6mg (Prosed/
ds)
4
MONUROL - fosfomycin tromethamine
powd pack 3 gm (base equivalent)
1
nitrofurantoin macrocrystalline cap
100 mg (Macrodantin)
1
nitrofurantoin macrocrystalline cap
50 mg (Macrodantin)
1
nitrofurantoin monohydrate
(Macrobid)
2
nitrofurantoin susp 25 mg/5ml
(Furadantin)
4
PROSED/DS - methenamine-hyoscmeth blue-benz acid-phenyl sal tab
81.6mg
4
URELLE - methenamine-hyosc-meth
blue-sod phos-phen sal tab 81 mg
4
URETRON D/S - methenamine-hyoscmeth blue-sod phos-phen sal tab 120
mg
4
UREX - methenamine hippurate tab 1
gm
72
Drug Name
• •
• •
• •
Quantity Limits
Prior Review
Restricted Access
Drug Tier
Quantity Limits
Restricted Access
4
Drug Tier
HIPREX - methenamine hippurate tab 1
gm
Drug Name
Prior Review
2014
URECHOLINE - bethanechol chloride
tab 50 mg
4
MYRBETRIQ - mirabegron tab sr 24 hr
50 mg
4
• •
2
oxybutynin chloride syrup 5 mg/5ml
1
URELIEF PLUS - phenazopyridinebutabarbital-hyoscyamine tab
150-15-0.3 mg
oxybutynin chloride tab sr 24hr
10 mg (Ditropan xl)
2
VESICARE - solifenacin succinate tab 5
mg
4
oxybutynin chloride tab sr 24hr
15 mg (Ditropan xl)
2
VESICARE - solifenacin succinate tab
10 mg
4
oxybutynin chloride tab sr 24hr 5 mg
(Ditropan xl)
2
VAGINAL PRODUCTS
oxybutynin chloride tab 5 mg
1
OXYTROL - oxybutynin td patch
4
phenazopyridine-butabarbitalhyoscyamine tab 150-15-0.3 mg
• •
• •
ACID JELLY - acetic acid vaginal gel
4
AVC - sulfanilamide vaginal cream 15%
4
CLEOCIN - clindamycin phosphate
vaginal cream 2%
4
2
CLEOCIN - clindamycin phosphate
vaginal suppos 100 mg
4
SANCTURA - trospium chloride tab 20
mg
4
clindamycin phosphate vaginal
cream 2% (Cleocin)
1
SANCTURA XR - trospium chloride cap
sr 24hr 60 mg
4
CLINDESSE - clindamycin phosphate
(one dose) vaginal cream 2%
4
tolterodine tartrate cap sr 24hr 2 mg
(Detrol la)
2
CRINONE - progesterone vaginal gel
4%
4
tolterodine tartrate cap sr 24hr 4 mg
(Detrol la)
2
CRINONE - progesterone vaginal gel
8%
4
tolterodine tartrate tab 1 mg (Detrol)
2
5
tolterodine tartrate tab 2 mg (Detrol)
2
ENDOMETRIN - progesterone vaginal
insert 100 mg
TOVIAZ - fesoterodine fumarate tab sr
24hr 4 mg
4
• •
ESTRACE - estradiol vaginal cream 0.1
mg/gm
3
TOVIAZ - fesoterodine fumarate tab sr
24hr 8 mg
4
• •
ESTRING - estradiol vaginal ring 2 mg
(7.5 mcg/24hrs)
4
trospium chloride cap sr 24hr 60 mg
2
4
• •
trospium chloride tab 20 mg
(Sanctura)
2
FEM PH - acetic acid-oxyquinoline
vaginal gel 0.9-0.025%
4
• •
tab 5 mg
4
FEMRING - estradiol acetate vaginal
ring 0.05 mg/24hr
4
• •
tab 10 mg
4
FEMRING - estradiol acetate vaginal
ring 0.1 mg/24hr
4
• •
tab 25 mg
4
FIRST-PROGESTERONE VGS 10 progesterone vaginal suppository 100
mg
• •
Quantity Limits
• •
Restricted Access
4
Drug Name
Prior Review
MYRBETRIQ - mirabegron tab sr 24 hr
25 mg
Drug Name
Drug Tier
Prior Review
Quantity Limits
Drug Tier
Restricted Access
2014
• •
73
4
mg
4
mg
4
GYNAZOLE-1 - butoconazole nitrate
(one dose) vaginal cream 2%
4
METROGEL-VAGINAL - metronidazole
vaginal gel 0.75%
GENITOURINARY AGENTS - MISC.
acetic acid irrigation soln 0.25%
2
alfuzosin hcl tab sr 24hr 10 mg
(Uroxatral)
2
AVODART - dutasteride cap 0.5 mg
3
CARDURA XL - doxazosin mesylate tab
sr 24 hr 4 mg (base equiv)
4
• •
CARDURA XL - doxazosin mesylate tab
sr 24 hr 8 mg (base equiv)
4
• •
CITROLITH - potassium & sodium
citrates tab 50-950 mg
4
CYSTAGON - cysteamine bitartrate cap
50 mg
4
4
CYSTAGON - cysteamine bitartrate cap
150 mg
4
metronidazole vaginal gel 0.75%
(Metrogel-vaginal)
1
CYTRA-K - potassium citrate & citric
acid soln 1100-334 mg/5ml
4
miconazole nitrate vaginal supp
200 mg & 2% cream 9 gm kit
2
CYTRA-3 - pot & sod citrates w/ cit ac
syrup 550-500-334 mg/5ml
4
MICONAZOLE 3 - miconazole nitrate
vaginal suppos 200 mg
4
ELMIRON - pentosan polysulfate
sodium caps 100 mg
4
NYSTATIN VAGINAL - nystatin vaginal
tab 100000 unit
1
finasteride tab 5 mg (Proscar)
1
FLOMAX - tamsulosin hcl cap 0.4 mg
4
PREMARIN - estrogens, conjugated
vaginal cream 0.625 mg/gm
3
glycine irrigation soln 1.5%
2
4
JALYN - dutasteride-tamsulosin hcl cap
0.5-0.4 mg
4
RELAGARD - acetic acid-oxyquinoline
vaginal gel 0.9-0.025%
4
K-PHOS MF - potassium & sodium acid
phosphates tab 155-350 mg
4
TERAZOL 3 - terconazole vaginal
cream 0.8%
4
K-PHOS NO 2 - potassium & sodium
acid phosphates tab 305-700 mg
4
suppos 80 mg
4
LITHOSTAT - acetohydroxamic acid tab
250 mg
4
cream 0.4%
1
neomycin-polymyxin b gu irrigation
soln (Neosporin gu irrigan)
2
terconazole vaginal cream 0.4%
(Terazol 7)
1
terconazole vaginal suppos 80 mg
1
NEOSPORIN GU IRRIGANT neomycin-polymyxin b gu irrigation
soln
4
terconazole vaginal cream 0.8%
(Terazol 3)
ORACIT - sodium citrate & citric acid
soln 490-640 mg/5ml
4
VAGIFEM - estradiol vaginal tab 10 mcg 4
74
• •
• •
• •
• •
• •
• •
• •
• •
• •
Quantity Limits
mg
Restricted Access
• •
Prior Review
4
Drug Name
Drug Tier
Prior Review
mg
Drug Name
Quantity Limits
Drug Tier
Restricted Access
2014
SORBITOL - sorbitol irrigation soln 3.3% 4
4
SORBITOL-MANNITOL - sorbitolmannitol irrigation soln 2.7-0.54
gm/100ml
1
tamsulosin hcl cap 0.4 mg (Flomax)
• •
• •
THIOLA - tiopronin tab 100 mg
4
2
TRICITRATES - pot & sod citrates w/ cit
ac soln 550-500-334 mg/5ml
4
• •
• •
2
UROCIT-K 10 - potassium citrate tab cr
10 meq (1080 mg)
4
POTASSIUM CITRATE - potassium
citrate tab cr 10 meq (1080 mg)
1
UROCIT-K 15 - potassium citrate tab cr
15 meq (1620 mg)
4
potassium citrate & citric acid
powder pack 3300-1002 mg
1
UROCIT-K 5 - potassium citrate tab cr 5
meq (540 mg)
4
potassium citrate & citric acid soln
1100-334 mg/5ml
4
UROXATRAL - alfuzosin hcl tab sr 24hr
10 mg
4
POTASSIUM CITRATE ER - potassium
PROCYSBI - cysteamine bitartrate cap
delayed release 25 mg (base equiv)
5
PROCYSBI - cysteamine bitartrate cap
delayed release 75 mg (base equiv)
5
ALPRAZOLAM INTENSOL - alprazolam
conc 1 mg/ml
4
PROSCAR - finasteride tab 5 mg
4
2
PYRIDIUM - phenazopyridine hcl tab
100 mg
4
alprazolam orally disintegrating tab
0.25 mg (Niravam)
2
PYRIDIUM - phenazopyridine hcl tab
200 mg
4
0.5 mg
2
RAPAFLO - silodosin cap 4 mg
4
1 mg
4
2 mg
2
RAPAFLO - silodosin cap 8 mg
RENACIDIN - citric acid & d-gluconic
acid soln
4
alprazolam tab sr 24hr 0.5 mg (Xanax
xr)
1
SHOHLS SOLUTION MODIFIED sodium citrate & citric acid soln
500-334 mg/5ml
4
alprazolam tab sr 24hr 1 mg (Xanax
xr)
1
1
xr)
1
sodium chloride irrigation soln 0.9%
SODIUM CITRATE - sodium citrate
granules
4
xr)
1
sodium citrate & citric acid soln
500-334 mg/5ml (Shohls solution
modi)
1
alprazolam tab 0.25 mg (Xanax)
1
alprazolam tab 0.5 mg (Xanax)
1
SORBITOL - sorbitol irrigation soln 3%
4
alprazolam tab 1 mg (Xanax)
1
phenazopyridine hcl tab 100 mg
(Pyridium)
1
phenazopyridine hcl tab 200 mg
(Pyridium)
1
POLYCITRA-K CRYSTALS - potassium
citrate & citric acid powder pack
3300-1002 mg
4
POTASSIUM CITRATE - potassium
Quantity Limits
Restricted Access
Prior Review
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Drug Tier
2014
CENTRAL NERVOUS SYSTEM DRUGS
ANTIANXIETY AGENTS
• •
• •
• •
• •
• •
• •
75
4
4
LORAZEPAM INTENSOL - lorazepam
conc 2 mg/ml
ATIVAN - lorazepam tab 1 mg
4
lorazepam tab 0.5 mg (Ativan)
1
ATIVAN - lorazepam tab 2 mg
4
lorazepam tab 1 mg (Ativan)
1
buspirone hcl tab 10 mg
1
lorazepam tab 2 mg (Ativan)
1
1
meprobamate tab 200 mg
2
1
meprobamate tab 400 mg
2
1
4
buspirone hcl tab 7.5 mg
2
NIRAVAM - alprazolam orally
disintegrating tab 0.25 mg
1
4
chlordiazepoxide hcl cap 10 mg
1
4
1
clorazepate dipotassium tab 15 mg
(Tranxene t)
1
4
clorazepate dipotassium tab 3.75 mg
(Tranxene t)
1
oxazepam cap 10 mg
1
oxazepam cap 15 mg
1
clorazepate dipotassium tab 7.5 mg
(Tranxene t)
1
oxazepam cap 30 mg
1
4
TRANXENE T - clorazepate
dipotassium tab 3.75 mg
4
DIAZEPAM - diazepam soln 1 mg/ml
DIAZEPAM INTENSOL - diazepam
conc 5 mg/ml
4
dipotassium tab 7.5 mg
4
diazepam tab 10 mg (Valium)
1
1
dipotassium tab 15 mg
4
1
VALIUM - diazepam tab 2 mg
4
hydroxyzine hcl syrup 10 mg/5ml
1
4
hydroxyzine hcl tab 10 mg
1
4
1
4
1
VISTARIL - hydroxyzine pamoate cap
25 mg
HYDROXYZINE PAMOATE hydroxyzine pamoate cap 100 mg
1
VISTARIL - hydroxyzine pamoate cap
50 mg
4
hydroxyzine pamoate cap 25 mg
(Vistaril)
1
XANAX - alprazolam tab 0.25 mg
4
XANAX - alprazolam tab 0.5 mg
4
hydroxyzine pamoate cap 50 mg
(Vistaril)
1
XANAX - alprazolam tab 1 mg
4
XANAX - alprazolam tab 2 mg
4
lorazepam conc 2 mg/ml (Lorazepam
intensol)
2
XANAX XR - alprazolam tab sr 24hr 0.5
mg
4
76
• •
• •
Quantity Limits
Restricted Access
Prior Review
Drug Name
Drug Tier
ATIVAN - lorazepam tab 0.5 mg
Quantity Limits
1
Restricted Access
alprazolam tab 2 mg (Xanax)
Prior Review
Drug Name
Drug Tier
2014
XANAX XR - alprazolam tab sr 24hr 1
mg
4
bupropion hcl tab sr 12hr 200 mg
(Wellbutrin sr)
1
mg
4
(Wellbutrin xl)
1
mg
4
(Wellbutrin xl)
1
1
amitriptyline hcl tab 100 mg
1
1
1
1
1
AMOXAPINE - amoxapine tab 25 mg
4
4
4
4
ANAFRANIL - clomipramine hcl cap 25
mg
Quantity Limits
Restricted Access
bupropion hcl tab 100 mg (Wellbutrin) 1
1
bupropion hcl tab 75 mg (Wellbutrin)
ANTIDEPRESSANTS
Prior Review
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Drug Tier
2014
CELEXA - citalopram hydrobromide tab
10 mg (base equiv)
4
20 mg (base equiv)
4
40 mg (base equiv)
4
citalopram hydrobromide oral soln
10 mg/5ml
1
citalopram hydrobromide tab 10 mg
(base equiv) (Celexa)
1
4
1
mg
4
1
mg
4
clomipramine hcl cap 25 mg
(Anafranil)
1
APLENZIN - bupropion hbr tab sr 24hr
174 mg
4
• •
(Anafranil)
1
348 mg
4
• •
(Anafranil)
1
522 mg
4
• •
CYMBALTA - duloxetine hcl enteric
coated pellets cap 20 mg
4
BRINTELLIX - vortioxetine hbr tab 5 mg
(base equiv)
4
• •
4
BRINTELLIX - vortioxetine hbr tab 10
mg (base equiv)
4
• •
4
BRINTELLIX - vortioxetine hbr tab 20
mg (base equiv)
4
• •
desipramine hcl tab 10 mg
(Norpramin)
2
(Wellbutrin sr)
1
(Norpramin)
2
(Wellbutrin sr)
1
(Norpramin)
2
77
EMSAM - selegiline td patch 24hr 12
mg/24hr
4
• •
(Norpramin)
2
escitalopram oxalate soln 5 mg/5ml
(base equiv) (Lexapro)
2
(Norpramin)
2
escitalopram oxalate tab 10 mg
2
DESVENLAFAXINE ER desvenlafaxine tab sr 24hr 50 mg
4
• •
escitalopram oxalate tab 20 mg
2
DESVENLAFAXINE ER desvenlafaxine tab sr 24hr 100 mg
4
• •
escitalopram oxalate tab 5 mg (base
equiv) (Lexapro)
2
DESVENLAFAXINE ER desvenlafaxine fumarate tab sr 24hr
50 mg (base equiv)
4
• •
FETZIMA - levomilnacipran hcl cap sr
24hr 20 mg (base equivalent)
4
• •
• •
DESVENLAFAXINE ER desvenlafaxine fumarate tab sr 24hr
100 mg (base equiv)
4
4
4
• •
DOXEPIN HCL - doxepin hcl cap 75 mg
1
• •
1
4
doxepin hcl cap 10 mg
1
4
• •
2
1
FETZIMA TITRATION PACK levomilnacipran hcl cap sr 24hr 20 &
40 mg therapy pack
1
FLUOXETINE HCL - fluoxetine hcl tab
60 mg
4
doxepin hcl conc 10 mg/ml
1
2
duloxetine hcl enteric coated pellets
cap 20 mg (Cymbalta)
2
fluoxetine hcl cap delayed release
90 mg (Prozac weekly)
fluoxetine hcl cap 10 mg (Prozac)
1
2
1
2
1
fluoxetine hcl solution 20 mg/5ml
1
EFFEXOR XR - venlafaxine hcl cap sr
24hr 37.5 mg (base equivalent)
4
fluoxetine hcl tab 10 mg
1
fluoxetine hcl tab 20 mg
1
4
fluvoxamine maleate cap sr 24hr
100 mg (Luvox cr)
2
4
fluvoxamine maleate cap sr 24hr
150 mg (Luvox cr)
2
mg/24hr
4
• •
fluvoxamine maleate tab 100 mg
1
1
mg/24hr
• •
4
1
78
• •
Drug Name
Quantity Limits
Prior Review
Restricted Access
Drug Tier
Quantity Limits
Restricted Access
2
Drug Tier
(Norpramin)
Drug Name
Prior Review
2014
FORFIVO XL - bupropion hcl tab sr 24hr 4
450 mg
1
imipramine hcl tab 10 mg (Tofranil)
• •
mirtazapine orally disintegrating tab
45 mg (Remeron soltab)
1
mirtazapine tab 15 mg (Remeron)
1
1
1
1
1
imipramine pamoate cap 100 mg
(Tofranil-pm)
2
mirtazapine tab 7.5 mg
1
NARDIL - phenelzine sulfate tab 15 mg
4
(Tofranil-pm)
2
NEFAZODONE HCL - nefazodone hcl
tab 50 mg
4
• •
(Tofranil-pm)
2
tab 100 mg
4
• •
(Tofranil-pm)
2
tab 150 mg
4
• •
tab 200 mg
4
• •
nefazodone hcl tab 250 mg
2
NORPRAMIN - desipramine hcl tab 10
mg
4
mg
4
mg
4
mg
4
mg
4
mg
4
KHEDEZLA - desvenlafaxine tab sr 24hr 4
50 mg
KHEDEZLA - desvenlafaxine tab sr 24hr 4
100 mg
4
LEXAPRO - escitalopram oxalate tab 5
mg (base equiv)
LEXAPRO - escitalopram oxalate tab 10 4
mg (base equiv)
LEXAPRO - escitalopram oxalate tab 20 4
mg (base equiv)
LEXAPRO - escitalopram oxalate soln 5 4
mg/5ml (base equiv)
4
LUVOX CR - fluvoxamine maleate cap
sr 24hr 100 mg
4
LUVOX CR - fluvoxamine maleate cap
sr 24hr 150 mg
4
MAPROTILINE HCL - maprotiline hcl
tab 25 mg
4
tab 50 mg
4
tab 75 mg
4
MARPLAN - isocarboxazid tab 10 mg
• •
• •
NORTRIPTYLINE HCL - nortriptyline hcl 4
soln 10 mg/5ml
nortriptyline hcl cap 10 mg (Pamelor) 1
• •
nortriptyline hcl cap 25 mg (Pamelor)
1
1
1
nortriptyline hcl soln 10 mg/5ml
2
• •
1
OLEPTRO - trazodone hcl tab sr 24hr
150 mg
4
• •
1
OLEPTRO - trazodone hcl tab sr 24hr
300 mg
4
• •
Quantity Limits
Restricted Access
Prior Review
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Drug Tier
2014
79
• •
PRISTIQ - desvenlafaxine succinate tab
sr 24hr 100 mg (base equiv)
4
• •
protriptyline hcl tab 10 mg (Vivactil)
2
protriptyline hcl tab 5 mg (Vivactil)
2
PROZAC - fluoxetine hcl cap 10 mg
4
4
2
4
paroxetine hcl tab sr 24hr 37.5 mg
(Paxil cr)
PROZAC WEEKLY - fluoxetine hcl cap
4
2
REMERON - mirtazapine tab 15 mg
4
paroxetine hcl tab 10 mg (Paxil)
1
4
1
4
1
1
REMERON SOLTAB - mirtazapine
4
PAXIL - paroxetine hcl tab 10 mg
4
4
4
4
4
4
4
sertraline hcl oral conc 20 mg/ml
(Zoloft)
2
PAXIL - paroxetine hcl oral susp 10
mg/5ml (base equiv)
4
sertraline hcl tab 100 mg (Zoloft)
1
PAXIL CR - paroxetine hcl tab sr 24hr
12.5 mg
1
25 mg
4
1
4
37.5 mg
4
SURMONTIL - trimipramine maleate
cap 25 mg
4
PEXEVA - paroxetine mesylate tab 10
mg (base equiv)
4
• •
cap 50 mg
4
mg (base equiv)
4
• •
cap 100 mg
TOFRANIL - imipramine hcl tab 10 mg
4
mg (base equiv)
4
• •
4
4
mg (base equiv)
• •
4
TOFRANIL-PM - imipramine pamoate
cap 75 mg
4
phenelzine sulfate tab 15 mg (Nardil)
2
cap 100 mg
4
PAMELOR - nortriptyline hcl cap 10 mg
4
4
4
4
PARNATE - tranylcypromine sulfate tab
10 mg
4
paroxetine hcl tab sr 24hr 12.5 mg
(Paxil cr)
2
paroxetine hcl tab sr 24hr 25 mg
(Paxil cr)
80
• •
Drug Name
Quantity Limits
Prior Review
Restricted Access
Drug Tier
Quantity Limits
Restricted Access
4
Drug Tier
PRISTIQ - desvenlafaxine succinate tab
sr 24hr 50 mg (base equiv)
Drug Name
Prior Review
2014
venlafaxine hcl tab 25 mg
1
venlafaxine hcl tab 37.5 mg
1
1
1
cap 150 mg
4
tranylcypromine sulfate tab 10 mg
(Parnate)
2
trazodone hcl tab 100 mg
1
VIIBRYD - vilazodone hcl tab 10 mg
4
1
4
1
4
1
4
trimipramine maleate cap 100 mg
2
VIIBRYD - vilazodone hcl tab starter kit
10 (7) & 20 (7) & 40 (16) mg
2
VIVACTIL - protriptyline hcl tab 5 mg
4
2
VIVACTIL - protriptyline hcl tab 10 mg
4
1
WELLBUTRIN - bupropion hcl tab 75
mg
4
venlafaxine hcl cap sr 24hr 150 mg
(base equivalent) (Effexor xr)
1
WELLBUTRIN - bupropion hcl tab 100
mg
4
venlafaxine hcl cap sr 24hr 37.5 mg
1
WELLBUTRIN SR - bupropion hcl tab sr
12hr 100 mg
4
venlafaxine hcl cap sr 24hr 75 mg
4
12hr 150 mg
4
VENLAFAXINE HCL ER - venlafaxine
hcl tab sr 24hr 37.5 mg (base
equivalent)
4
hcl tab sr 24hr 75 mg (base
equivalent)
4
12hr 200 mg
WELLBUTRIN XL - bupropion hcl tab sr
24hr 150 mg
4
equivalent)
4
WELLBUTRIN XL - bupropion hcl tab sr
24hr 300 mg
4
ZOLOFT - sertraline hcl tab 25 mg
4
equivalent)
4
4
4
2
ZOLOFT - sertraline hcl oral conc 20
mg/ml
4
venlafaxine hcl tab sr 24hr 150 mg
(base equivalent) (Venlafaxine hcl
er)
venlafaxine hcl tab sr 24hr 37.5 mg
er)
2
venlafaxine hcl tab sr 24hr 75 mg
er)
2
•
•
•
•
•
•
•
•
Quantity Limits
1
4
Restricted Access
cap 125 mg
Prior Review
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Drug Tier
2014
ANTIPSYCHOTICS
ABILIFY - aripiprazole tab 2 mg
4
4
4
4
4
81
4
FANAPT - iloperidone tab 8 mg
4
ABILIFY - aripiprazole oral solution 1
mg/ml
4
4
4
ABILIFY DISCMELT - aripiprazole orally
• •
4
4
ABILIFY DISCMELT - aripiprazole orally
4
• •
FANAPT TITRATION PACK iloperidone tab 1 mg & 2 mg & 4 mg
& 6 mg titratration pak
1
FAZACLO - clozapine orally
4
chlorpromazine hcl tab 10 mg
1
4
1
1
4
1
4
4
CLOZAPINE ODT - clozapine orally
4
4
4
FLUPHENAZINE HCL - fluphenazine
hcl elixir 2.5 mg/5ml
4
• •
2
FLUPHENAZINE HCL - fluphenazine
hcl oral conc 5 mg/ml
4
clozapine tab 100 mg (Clozaril)
• •
clozapine tab 200 mg
2
fluphenazine hcl tab 1 mg
1
clozapine tab 25 mg (Clozaril)
2
1
clozapine tab 50 mg
2
fluphenazine hcl tab 2.5 mg
1
CLOZARIL - clozapine tab 25 mg
4
1
CLOZARIL - clozapine tab 100 mg
4
GEODON - ziprasidone hcl cap 20 mg
4
COMPAZINE - prochlorperazine
maleate tab 5 mg
4
4
4
4
COMPAZINE - prochlorperazine
maleate tab 10 mg
4
EQUETRO - carbamazepine
(antipsychotic) cap sr 12hr 100 mg
4
haloperidol lactate oral conc 2 mg/ml
2
haloperidol tab 0.5 mg
1
4
• •
haloperidol tab 1 mg
1
1
4
• •
1
4
1
4
1
4
INVEGA - paliperidone tab sr 24hr 1.5
mg
4
4
INVEGA - paliperidone tab sr 24hr 3 mg
4
82
• •
Quantity Limits
Restricted Access
Prior Review
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Drug Tier
2014
LATUDA - lurasidone hcl tab 40 mg
4
4
4
4
LITHIUM CARBONATE - lithium
carbonate cap 150 mg
4
LITHIUM CARBONATE - lithium
carbonate cap 600 mg
4
lithium carbonate cap 150 mg
(Lithium carbonate)
1
• •
• •
olanzapine orally disintegrating tab
15 mg (Zyprexa zydis)
2
2
• •
• •
2
olanzapine tab 10 mg (Zyprexa)
2
2
olanzapine tab 2.5 mg (Zyprexa)
2
2
2
1
olanzapine tab 7.5 mg (Zyprexa)
2
(Lithium carbonate)
1
perphenazine tab 16 mg
2
2
lithium carbonate tab cr 300 mg
(Lithobid)
1
2
2
lithium carbonate tab cr 450 mg
1
lithium carbonate tab 300 mg
prochlorperazine maleate tab 10 mg
(Compazine)
1
1
LITHIUM CITRATE - lithium citrate oral
soln 8 meq/5ml
3
prochlorperazine maleate tab 5 mg
(Compazine)
1
LITHOBID - lithium carbonate tab cr 300 4
mg
1
loxapine succinate cap 10 mg
prochlorperazine suppos 25 mg
1
quetiapine fumarate tab 100 mg
(Seroquel)
2
1
2
(Loxitane)
1
(Seroquel)
2
1
(Seroquel)
LOXITANE - loxapine succinate cap 5
mg
4
(Seroquel)
2
mg
4
(Seroquel)
2
mg
4
(Seroquel)
2
mg
4
RISPERDAL - risperidone tab 0.25 mg
4
RISPERDAL - risperidone tab 0.5 mg
4
NAVANE - thiothixene cap 20 mg
4
RISPERDAL - risperidone tab 1 mg
4
• •
Quantity Limits
4
2
Restricted Access
Prior Review
4
Drug Name
Drug Tier
Quantity Limits
4
Restricted Access
Prior Review
Drug Name
Drug Tier
2014
83
RISPERDAL - risperidone soln 1 mg/ml
4
RISPERDAL M-TAB - risperidone orally
SEROQUEL - quetiapine fumarate tab
50 mg
4
100 mg
4
4
200 mg
4
4
300 mg
4
4
400 mg
4
4
SEROQUEL XR - quetiapine fumarate
tab sr 24hr 50 mg
4
• •
4
tab sr 24hr 150 mg
4
• •
2
tab sr 24hr 200 mg
4
risperidone orally disintegrating tab
0.25 mg
• •
2
tab sr 24hr 300 mg
4
0.5 mg (Risperdal m-tab)
• •
2
tab sr 24hr 400 mg
4
1 mg (Risperdal m-tab)
• •
2
thioridazine hcl tab 10 mg
1
1
2
1
1
2
thiothixene cap 1 mg
1
1
risperidone soln 1 mg/ml (Risperdal)
2
1
risperidone tab 0.25 mg (Risperdal)
1
1
risperidone tab 0.5 mg (Risperdal)
1
trifluoperazine hcl tab 1 mg
1
risperidone tab 1 mg (Risperdal)
1
1
1
1
1
1
1
SAPHRIS - asenapine maleate sl tab 5
mg (base equiv)
4
• •
SAPHRIS - asenapine maleate sl tab 10
mg (base equiv)
4
• •
25 mg
4
84
VERSACLOZ - clozapine susp 50 mg/ml 4
2
ziprasidone hcl cap 20 mg (Geodon)
2
2
2
ZYPREXA - olanzapine tab 2.5 mg
4
• •
Quantity Limits
4
Restricted Access
Prior Review
4
Drug Name
Drug Tier
Quantity Limits
4
Restricted Access
Prior Review
Drug Name
Drug Tier
2014
4
flurazepam hcl cap 30 mg
1
ZYPREXA - olanzapine tab 7.5 mg
4
HALCION - triazolam tab 0.25 mg
4
ZYPREXA - olanzapine tab 10 mg
4
HETLIOZ - tasimelteon capsule 20 mg
4
4
4
• •
4
INTERMEZZO - zolpidem tartrate sl tab
1.75 mg
ZYPREXA ZYDIS - olanzapine orally
4
INTERMEZZO - zolpidem tartrate sl tab
3.5 mg
4
• •
4
LUNESTA - eszopiclone tab 1 mg
4
4
4
4
midazolam hcl syrup 2 mg/ml (base
equivalent)
1
4
PHENOBARBITAL - phenobarbital tab
15 mg
1
30 mg
1
HYPNOTICS
AMBIEN - zolpidem tartrate tab 5 mg
4
AMBIEN - zolpidem tartrate tab 10 mg
4
AMBIEN CR - zolpidem tartrate tab cr
6.25 mg
4
60 mg
1
AMBIEN CR - zolpidem tartrate tab cr
12.5 mg
4
64.8 mg
1
BUTISOL SODIUM - butabarbital
sodium tab 30 mg
4
• •
97.2 mg
1
sodium tab 50 mg
4
• •
100 mg
1
sodium elixir 30 mg/5ml
4
• •
phenobarbital elixir 20 mg/5ml
1
phenobarbital tab 100 mg
1
CHLORAL HYDRATE - chloral hydrate
syrup 500 mg/5ml
4
• •
1
1
DORAL - quazepam tab 15 mg
1
EDLUAR - zolpidem tartrate sl tab 5 mg
4
phenobarbital tab 32.4 mg
1
EDLUAR - zolpidem tartrate sl tab 10
mg
4
• •
• •
• •
phenobarbital tab 16.2 mg
4
1
1
QUAZEPAM - quazepam tab 15 mg
4
estazolam tab 1 mg
1
RESTORIL - temazepam cap 7.5 mg
4
estazolam tab 2 mg
2
RESTORIL - temazepam cap 15 mg
4
eszopiclone tab 1 mg (Lunesta)
2
RESTORIL - temazepam cap 22.5 mg
4
2
RESTORIL - temazepam cap 30 mg
4
1
ROZEREM - ramelteon tab 8 mg
4
flurazepam hcl cap 15 mg
Quantity Limits
Restricted Access
Prior Review
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Drug Tier
2014
• •
• •
85
Quantity Limits
Restricted Access
• •
ADDERALL - amphetaminedextroamphetamine tab 20 mg
4
•
SILENOR - doxepin hcl (sleep) tab 3 mg 4
(base equiv)
SILENOR - doxepin hcl (sleep) tab 6 mg 4
(base equiv)
4
SOMNOTE - chloral hydrate cap 500
mg
4
SONATA - zaleplon cap 5 mg
• •
4
•
• •
ADDERALL XR - amphetaminedextroamphetamine cap sr 24hr 5 mg
4
•
• •
ADDERALL XR - amphetaminedextroamphetamine cap sr 24hr 10
mg
4
•
mg
4
•
mg
4
•
mg
4
•
mg
4
•
ALLI - orlistat cap 60 mg
4
SECONAL - secobarbital sodium cap
100 mg
Drug Name
Prior Review
4
Drug Name
Drug Tier
Prior Review
Quantity Limits
Drug Tier
Restricted Access
2014
SONATA - zaleplon cap 10 mg
4
temazepam cap 15 mg (Restoril)
1
temazepam cap 22.5 mg (Restoril)
2
temazepam cap 30 mg (Restoril)
1
temazepam cap 7.5 mg (Restoril)
2
triazolam tab 0.125 mg
1
triazolam tab 0.25 mg (Halcion)
1
zaleplon cap 10 mg (Sonata)
1
zaleplon cap 5 mg (Sonata)
1
zolpidem tartrate tab cr 12.5 mg
(Ambien cr)
2
zolpidem tartrate tab cr 6.25 mg
(Ambien cr)
2
amphetamine-dextroamphetamine
cap sr 24hr 10 mg (Adderall xr)
2
•
zolpidem tartrate tab 10 mg (Ambien)
1
2
•
zolpidem tartrate tab 5 mg (Ambien)
1
ZOLPIMIST - zolpidem tartrate oral
spray 5 mg/act
4
2
•
2
•
•
2
•
•
2
•
•
tab 10 mg (Adderall)
2
•
•
tab 12.5 mg (Adderall)
2
•
•
2
•
ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/
ANOREXIANTS
4
4
ADDERALL - amphetaminedextroamphetamine tab 7.5 mg
4
4
ADDERALL - amphetaminedextroamphetamine tab 12.5 mg
4
86
• •
Quantity Limits
Restricted Access
Prior Review
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Drug Tier
2014
2
•
dexmethylphenidate hcl cap sr 24 hr
15 mg (Focalin xr)
2
•
2
•
30 mg (Focalin xr)
2
•
tab 5 mg (Adderall)
2
•
40 mg (Focalin xr)
2
•
tab 7.5 mg (Adderall)
2
•
dexmethylphenidate hcl tab 10 mg
(Focalin)
1
•
BELVIQ - lorcaserin hcl tab 10 mg
4
1
•
CAFCIT - caffeine citrate oral soln 60
mg/3ml (10 mg/ml base equiv)
4
dexmethylphenidate hcl tab 2.5 mg
(Focalin)
1
•
caffeine citrate oral soln 60 mg/3ml
(10 mg/ml base equiv) (Cafcit)
2
dexmethylphenidate hcl tab 5 mg
(Focalin)
2
•
clonidine hcl tab sr 12hr 0.1 mg
(Kapvay)
2
•
dextroamphetamine sulfate cap sr
24hr 10 mg (Dexedrine)
2
•
CONCERTA - methylphenidate hcl tab
sa osm 18 mg
4
•
2
•
sa osm 27 mg
4
•
2
•
sa osm 36 mg
4
•
dextroamphetamine sulfate oral
solution 5 mg/5ml (Procentra)
1
•
sa osm 54 mg
4
•
dextroamphetamine sulfate tab
10 mg
dextroamphetamine sulfate tab 5 mg
1
DAYTRANA - methylphenidate td patch
10 mg/9hr
4
• • •
FOCALIN - dexmethylphenidate hcl tab
2.5 mg
4
•
•
15 mg/9hr
4
• • •
5 mg
4
•
20 mg/9hr
4
• • •
10 mg
4
•
30 mg/9hr
4
• • •
FOCALIN XR - dexmethylphenidate hcl
cap sr 24 hr 5 mg
4
• • •
DESOXYN - methamphetamine hcl tab
5 mg
4
•
cap sr 24 hr 10 mg
4
• • •
DEXEDRINE - dextroamphetamine
sulfate cap sr 24hr 5 mg
4
•
cap sr 24 hr 15 mg
4
• • •
4
•
cap sr 24 hr 20 mg
4
• • •
4
•
cap sr 24 hr 25 mg
4
• • •
•
87
Quantity Limits
Restricted Access
4
• • •
METHYLIN - methylphenidate hcl soln
10 mg/5ml
4
•
cap sr 24 hr 35 mg
4
• • •
methylphenidate hcl cap cr 10 mg
(Metadate cd)
2
•
cap sr 24 hr 40 mg
4
• • •
(Metadate cd)
2
•
INTUNIV - guanfacine hcl tab sr 24hr 1
mg (base equiv)
4
• • •
(Metadate cd)
2
•
mg (base equiv)
4
• • •
(Metadate cd)
2
•
mg (base equiv)
4
• • •
(Metadate cd)
2
•
mg (base equiv)
4
• • •
(Metadate cd)
2
•
KAPVAY - clonidine hcl tab sr 12hr 0.1
mg
4
•
methylphenidate hcl cap sr 24hr
20 mg (Ritalin la)
2
•
KAPVAY DOSE PACK - clonidine hcl
tab sr 12hr therapy pack 0.1 & 0.2 mg
4
• • •
30 mg (Ritalin la)
2
•
METADATE CD - methylphenidate hcl
cap cr 10 mg
4
•
40 mg (Ritalin la)
2
•
cap cr 20 mg
4
•
METHYLPHENIDATE HCL ER methylphenidate hcl tab cr 10 mg
2
•
cap cr 30 mg
4
•
methylphenidate hcl soln 10 mg/5ml
(Methylin)
2
•
cap cr 40 mg
4
•
methylphenidate hcl soln 5 mg/5ml
(Methylin)
2
•
cap cr 50 mg
4
•
methylphenidate hcl tab cr 20 mg
(Ritalin sr)
2
•
cap cr 60 mg
4
•
methylphenidate hcl tab sa osm
18 mg (Concerta)
2
•
methamphetamine hcl tab 5 mg
(Desoxyn)
2
•
27 mg (Concerta)
2
•
METHYLIN - methylphenidate hcl chew
tab 2.5 mg
4
• • •
36 mg (Concerta)
2
•
tab 5 mg
4
• • •
54 mg (Concerta)
2
•
tab 10 mg
4
• • •
methylphenidate hcl tab 10 mg
(Ritalin)
1
•
METHYLIN - methylphenidate hcl soln 5
mg/5ml
4
•
(Ritalin)
1
•
88
Drug Name
Prior Review
cap sr 24 hr 30 mg
Drug Name
Drug Tier
Prior Review
Quantity Limits
Drug Tier
Restricted Access
2014
Quantity Limits
Prior Review
Restricted Access
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Drug Tier
2014
•
STRATTERA - atomoxetine hcl cap 18
mg (base equiv)
4
• • •
•
•
•
•
•
•
•
mg (base equiv)
4
• • •
mg (base equiv)
4
• • •
mg (base equiv)
4
• • •
mg (base equiv)
4
• • •
mg (base equiv)
4
• • •
VYVANSE - lisdexamfetamine
dimesylate cap 20 mg
4
• • •
4
• • •
•
4
• • •
•
4
• • •
•
4
• • •
• • •
4
• • •
XENICAL - orlistat cap 120 mg
4
4
• • •
•
ZENZEDI - dextroamphetamine sulfate
tab 2.5 mg
4
• • •
•
tab 7.5 mg
4
• • •
•
tab 15 mg
4
• • •
•
tab 20 mg
4
• • •
•
tab 30 mg
(Ritalin)
1
modafinil tab 100 mg (Provigil)
2
modafinil tab 200 mg (Provigil)
2
NUVIGIL - armodafinil tab 50 mg
4
4
4
4
PROCENTRA - dextroamphetamine
sulfate oral solution 5 mg/5ml
4
PROVIGIL - modafinil tab 100 mg
4
PROVIGIL - modafinil tab 200 mg
4
QSYMIA - phentermine hcl-topiramate
cap sr 24hr 3.75-23 mg
4
cap sr 24hr 7.5-46 mg
4
cap sr 24hr 11.25-69 mg
4
cap sr 24hr 15-92 mg
4
QUILLIVANT XR - methylphenidate hcl
for er susp 25 mg/5ml (5 mg/ml)
4
RITALIN - methylphenidate hcl tab 5 mg
4
RITALIN - methylphenidate hcl tab 10
mg
4
RITALIN - methylphenidate hcl tab 20
mg
4
RITALIN LA - methylphenidate hcl cap
sr 24hr 10 mg
4
sr 24hr 20 mg
4
sr 24hr 30 mg
4
sr 24hr 40 mg
4
RITALIN SR - methylphenidate hcl tab
cr 20 mg
4
•
mg (base equiv)
4
• • •
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Drug Name
PSYCHOTHERAPEUTIC and NEUROLOGICAL
AGENTS - MISC.
2
acamprosate calcium tab delayed
release 333 mg (Campral)
89
4
ANTABUSE - disulfiram tab 500 mg
4
ARICEPT - donepezil hydrochloride tab
5 mg
4
10 mg
4
23 mg
4
ARICEPT ODT - donepezil
hydrochloride orally disintegrating tab
5 mg
4
ARICEPT ODT - donepezil
hydrochloride orally disintegrating tab
10 mg
4
AUBAGIO - teriflunomide tab 7 mg
5
AUBAGIO - teriflunomide tab 14 mg
5
AVONEX - interferon beta-1a for im inj
kit 30mcg (33mcg(6.6 mu)/vial)
5
• •
• •
• •
AVONEX - interferon beta-1a im inj kit
30 mcg/0.5ml
5
• •
AVONEX PEN - interferon beta-1a im inj 5
kit 30 mcg/0.5ml
BETASERON - interferon beta-1b for inj 5
kit 0.3 mg
4
BRISDELLE - paroxetine mesylate cap
7.5 mg (base equiv)
1
bupropion hcl (smoking deterrent)
tab sr 12hr 150 mg (Zyban)
4
CAMPRAL - acamprosate calcium tab
3
CHANTIX - varenicline tartrate tab 0.5
mg (base equiv)
CHANTIX - varenicline tartrate tab 1 mg 3
(base equiv)
3
CHANTIX CONTINUING MONTH varenicline tartrate tab 1 mg (base
equiv)
• •
90
•
• •
CHANTIX STARTING MONTH PA varenicline tartrate tab 0.5 mg x 11 &
tab 1 mg x 42 pack
3
CHLORDIAZEPOXIDE/AMITRIPT chlordiazepoxide-amitriptyline tab
5-12.5 mg
4
• •
CHLORDIAZEPOXIDE/AMITRIPT chlordiazepoxide-amitriptyline tab
10-25 mg
4
• •
COPAXONE - glatiramer acetate soln
prefilled syringe 40 mg/ml
5
•
COPAXONE - glatiramer acetate inj kit
20 mg/ml
5
•
disulfiram tab 250 mg (Antabuse)
2
disulfiram tab 500 mg (Antabuse)
2
donepezil hydrochloride orally
disintegrating tab 10 mg (Aricept
odt)
2
2
donepezil hydrochloride orally
disintegrating tab 5 mg (Aricept odt)
2
donepezil hydrochloride tab 10 mg
(Aricept)
2
(Aricept)
2
(Aricept)
4
ERGOLOID MESYLATES - ergoloid
mesylates tab 1 mg
4
EXELON - rivastigmine td patch 24hr
4.6 mg/24hr
4
9.5 mg/24hr
4
13.3 mg/24hr
4
EXELON - rivastigmine tartrate cap 1.5
mg
4
EXELON - rivastigmine tartrate cap 3
mg
4
EXELON - rivastigmine tartrate cap 4.5
mg
• •
• •
• •
• •
Quantity Limits
ANTABUSE - disulfiram tab 250 mg
Restricted Access
•
Prior Review
5
Drug Name
Drug Tier
Prior Review
AMPYRA - dalfampridine tab sr 12hr 10
mg
Drug Name
Quantity Limits
Drug Tier
Restricted Access
2014
4
• •
• •
NAMENDA TITRATION PAK memantine hcl tab 5 mg (28) & 10 mg
(21) titration pak
4
• •
• •
NAMENDA XR - memantine hcl cap sr
24hr 7 mg
24hr 14 mg
4
• •
24hr 21 mg
4
• •
24hr 28 mg
4
• •
NAMENDA XR TITRATION PACK memantine hcl cap sr 24hr 7 mg & 14
mg & 21 mg & 28 mg pack
4
• •
NICOTROL INHALER - nicotine inhaler
system 10 mg (4 mg delivered)
4
EXELON - rivastigmine tartrate cap 6
mg
4
EXELON - rivastigmine tartrate soln 2
mg/ml
4
EXTAVIA - interferon beta-1b for inj kit
0.3 mg
5
fluoxetine hcl (pmdd) cap 10 mg
1
fluoxetine hcl (pmdd) cap 20 mg
1
galantamine hydrobromide cap sr
24hr 16 mg (Razadyne er)
2
2
2
galantamine hydrobromide oral soln
4 mg/ml (Razadyne)
2
galantamine hydrobromide tab
12 mg (Razadyne)
2
galantamine hydrobromide tab 4 mg
(Razadyne)
2
galantamine hydrobromide tab 8 mg
(Razadyne)
2
GILENYA - fingolimod hcl cap 0.5 mg
(base equiv)
5
• •
GRALISE - gabapentin (phn) tab 300
mg
4
• •
GRALISE - gabapentin (phn) tab 600
mg
4
• •
GRALISE STARTER - gabapentin (phn)
tab starter pack 300 mg (9) & 600 mg
(69)
4
• •
HORIZANT - gabapentin enacarbil tab
sr 24hr 300 mg
4
HORIZANT - gabapentin enacarbil tab
sr 24hr 600 mg
Drug Name
NICOTROL NS - nicotine nasal spray 10 4
mg/ml (0.5 mg/spray)
5
NUEDEXTA - dextromethorphan hbrquinidine sulfate cap 20-10 mg
2
olanzapine-fluoxetine hcl cap
12-25 mg (Symbyax)
2
12-50 mg (Symbyax)
2
3-25 mg (Symbyax)
2
6-25 mg (Symbyax)
2
6-50 mg (Symbyax)
4
ORAP - pimozide tab 1 mg
• •
• •
ORAP - pimozide tab 2 mg
4
4
4
• •
PERPHENAZINE/AMITRIPTYLIN perphenazine-amitriptyline tab 2-10
mg
• •
• •
• •
NAMENDA - memantine hcl tab 5 mg
4
• •
4
mg
4
NAMENDA - memantine hcl tab 10 mg
NAMENDA - memantine hcl oral
solution 2 mg/ml
4
• •
• •
• •
mg
4
• •
Quantity Limits
Prior Review
Restricted Access
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Drug Tier
2014
91
RAZADYNE - galantamine
hydrobromide tab 4 mg
4
4
4
hydrobromide oral soln 4 mg/ml
rivastigmine tartrate cap 4.5 mg
(Exelon)
2
rivastigmine tartrate cap 6 mg
(Exelon)
2
SARAFEM - fluoxetine hcl (pmdd) tab
10 mg
4
• •
SARAFEM - fluoxetine hcl (pmdd) tab
20 mg
4
• •
SAVELLA - milnacipran hcl tab 12.5 mg
4
SAVELLA - milnacipran hcl tab 25 mg
4
4
4
4
4
RAZADYNE ER - galantamine
hydrobromide cap sr 24hr 8 mg
4
SAVELLA TITRATION PACK milnacipran hcl tab 12.5 mg (5) & 25
mg (8) & 50 mg (42) pak
•
•
•
•
•
4
SYMBYAX - olanzapine-fluoxetine hcl
cap 3-25 mg
4
4
cap 6-25 mg
4
REBIF - interferon beta-1a inj 22
mcg/0.5ml (12mu/ml) (44 mcg/ml)
5
•
cap 6-50 mg
4
REBIF - interferon beta-1a inj 44
mcg/0.5ml (24mu/ml) (88 mcg/ml)
5
•
cap 12-25 mg
4
REBIF REBIDOSE - interferon beta-1a
inj 22 mcg/0.5ml (12mu/ml) (44 mcg/
ml)
5
•
cap 12-50 mg
4
5
•
REBIF REBIDOSE - interferon beta-1a
inj 44 mcg/0.5ml (24mu/ml) (88 mcg/
ml)
5
TECFIDERA - dimethyl fumarate
capsule delayed release 120 mg
TECFIDERA - dimethyl fumarate
capsule delayed release 240 mg
5
•
REBIF REBIDOSE TITRATION interferon beta-1a inj 6 x 8.8
mcg/0.2ml & 6 x 22 mcg/0.5ml
5
•
TECFIDERA STARTER PACK dimethyl fumarate capsule dr starter
pack 120 mg & 240 mg
5
•
REBIF TITRATION PACK - interferon
beta-1a inj 6 x 8.8 mcg/0.2ml & 6 x 22
mcg/0.5ml
5
•
XENAZINE - tetrabenazine tab 12.5 mg
5
XENAZINE - tetrabenazine tab 25 mg
5
2
XYREM - sodium oxybate oral solution
500 mg/ml
5
rivastigmine tartrate cap 1.5 mg
(Exelon)
• •
• •
•
2
ZYBAN - bupropion hcl (smoking
deterrent) tab sr 12hr 150 mg
4
rivastigmine tartrate cap 3 mg
(Exelon)
92
• •
•
•
•
•
•
•
ANALGESICS AND ANESTHETICS
Quantity Limits
mg
4
Restricted Access
• •
Prior Review
4
Drug Name
Drug Tier
Prior Review
mg
Drug Name
Quantity Limits
Drug Tier
Restricted Access
2014
ANALGESICS - NON-NARCOTIC
butalbital-acetaminophen-caffeine
tab 50-500-40 mg
2
butalbital-aspirin-caffeine cap
50-325-40 mg (Fiorinal)
2
butalbital-aspirin-caffeine tab
50-325-40 mg
2
BUTALBITAL/ASPIRIN/CAFFEI butalbital-aspirin-caffeine tab
50-325-40 mg
2
choline & magnesium salicylates liq
500 mg/5ml
2
acetaminophen-salicylamidephenyltoloxamine cap
300-200-20mg
2
ACUFLEX - phenyltoloxamineacetaminophen tab 55-635 mg
4
ADULT ASPIRIN LOW STRENGT aspirin dispersible tab 81 mg
4
ALAGESIC LQ - butalbitalacetaminophen-caffeine soln
50-325-40 mg/15ml
4
ALPAIN - phenyltoloxamineacetaminophen tab 60-500 mg
4
• •
choline & magnesium salicylates tab
1000 mg
2
ANABAR - acetaminophen-salicylamide- 4
phenyltoloxamine tab 300-200-20mg
1
aspirin chew tab 81 mg
• •
500 mg
2
750 mg
2
diflunisal tab 500 mg
1
DOLGIC PLUS - butalbitalacetaminophen-caffeine tab
50-750-40 mg
4
• •
4
• •
• •
DOLOGESIC - phenyltoloxamineacetaminophen liquid 30-500
mg/15ml
ECOTRIN REGULAR STRENGTH aspirin tab delayed release 325 mg
4
• •
• •
ASPIRIN LOW DOSE - aspirin tab 81
mg
4
aspirin tab delayed release 325 mg
1
aspirin tab delayed release 81 mg
1
aspirin tab 325 mg
1
aspirin tab 81 mg
1
BIOREGESIC - phenyltoloxamineacetaminophen tab 50-650 mg
4
BUPAP - butalbital-acetaminophen tab
50-300 mg
4
• •
BUPAP - butalbital-acetaminophen tab
50-650 mg
2
• •
butalbital-acetaminophen tab
50-325 mg
2
butalbital-acetaminophen tab
50-650 mg
2
cap 50-300-40 mg (Fioricet)
2
cap 50-325-40 mg
2
cap 50-500-40 mg
2
tab 50-325-40 mg
2
EQUAGESIC - meprobamate-aspirin tab 4
200-325 mg
4
ESGIC - butalbital-acetaminophencaffeine cap 50-325-40 mg
4
ESGIC - butalbital-acetaminophencaffeine tab 50-325-40 mg
4
ESGIC-PLUS - butalbitalacetaminophen-caffeine cap
50-500-40 mg
4
ESGIC-PLUS - butalbitalacetaminophen-caffeine tab
50-500-40 mg
4
FIORICET - butalbital-acetaminophencaffeine cap 50-300-40 mg
Quantity Limits
Restricted Access
Prior Review
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Drug Tier
2014
• •
93
Quantity Limits
Prior Review
Restricted Access
Drug Tier
Quantity Limits
Restricted Access
4
ABSTRAL - fentanyl citrate sl tab 100
mcg (base equiv)
5
• • •
FIORINAL - butalbital-aspirin-caffeine
cap 50-325-40 mg
4
mcg (base equiv)
5
• • •
FRENADOL - acetaminophensalicylamide tab 250-600 mg
4
mcg (base equiv)
5
• • •
HALFPRIN - aspirin tab delayed release
162 mg
4
mcg (base equiv)
5
• • •
LEVACET - aspirin-apap-salicylamidecaffeine tab 500-250-150-32.5 mg
4
mcg (base equiv)
5
• • •
MST 600 - magnesium salicylate tab
600 mg
4
mcg (base equiv)
5
• • •
ORBIVAN - butalbital-acetaminophencaffeine cap 50-300-40 mg
4
acetaminophen w/ codeine soln
120-12 mg/5ml
1
ORBIVAN CF - butalbitalacetaminophen tab 50-300 mg
4
acetaminophen w/ codeine tab
300-15 mg (Tylenol/codeine)
1
phenyltoloxamine-acetaminophen
tab 30-500 mg
2
300-30 mg (Tylenol/codeine #3)
1
tab 50-500 mg
2
300-60 mg (Tylenol/codeine #4)
1
tab 55-500 mg
2
4
PHRENILIN FORTE - butalbitalacetaminophen cap 50-650 mg
4
• •
ACETAMINOPHEN/CAFFEINE/
DI - acetaminophen-caffeinedihydrocodeine tab 712.8-60-32 mg
RELAGESIC - phenyltoloxamineacetaminophen tab 50-650 mg
4
• •
ACTIQ - fentanyl citrate lollipop 200 mcg 5
RHINOFLEX-650 - phenyltoloxamineacetaminophen tab 50-650 mg
4
• •
salsalate tab 500 mg
1
salsalate tab 750 mg
1
SEDAPAP - butalbital-acetaminophen
tab 50-650 mg
4
STAFLEX - phenyltoloxamineacetaminophen tab 55-500 mg
4
Drug Tier
FIORICET - butalbital-acetaminophencaffeine tab 50-325-40 mg
Drug Name
TENCON - butalbital-acetaminophen tab 4
50-650 mg
4
ZGESIC - phenyltoloxamineacetaminophen tab cr 66-600 mg
ANALGESICS - NARCOTIC
94
Prior Review
2014
• •
• •
• •
• •
• •
• •
Drug Name
• •
ACTIQ - fentanyl citrate lollipop 1200
mcg
5
•
•
•
•
•
ACTIQ - fentanyl citrate lollipop 1600
mcg
5
•
ASPIRIN-CAFFEINE-DIHYDROC dihydrocodeine compound cap
4
• •
AVINZA - morphine sulfate beads cap sr 4
24hr 30 mg
24hr 45 mg
24hr 60 mg
• •
• •
• •
•
•
•
•
•
•
24hr 75 mg
24hr 90 mg
24hr 120 mg
2
buprenorphine hcl sl tab 2 mg (base
equiv)
2
buprenorphine hcl sl tab 8 mg (base
equiv)
2
buprenorphine hcl-naloxone hcl sl
tab 2-0.5 mg (base equiv)
2
buprenorphine hcl-naloxone hcl sl
tab 8-2 mg (base equiv)
2
butalbital-acetaminophen-caff w/
cod cap 50-300-40-30 mg (Fioricet/
codeine)
butalbital-acetaminophen-caff w/ cod 2
cap 50-325-40-30 mg
butalbital-aspirin-caff w/ codeine cap 2
50-325-40-30 mg (Fiorinal/codeine
#3)
2
butorphanol tartrate inj 1 mg/ml
• •
CODEINE SULFATE - codeine sulfate
tab 15 mg
1
• •
tab 30 mg
1
• •
tab 60 mg
1
•
•
oral soln 30 mg/5ml
4
•
•
CONZIP - tramadol hcl cap sr 24hr
biphasic release 100 mg
4
• •
•
•
4
• •
•
•
4
• •
DEMEROL - meperidine hcl tab 50 mg
4
DEMEROL - meperidine hcl tab 100 mg
4
DILAUDID - hydromorphone hcl tab 2
mg
4
mg
4
mg
4
DILAUDID - hydromorphone hcl liqd 1
mg/ml
4
DOLOPHINE - methadone hcl tab 10
mg
4
DOLOPHINE HCL - methadone hcl tab
5 mg
4
butorphanol tartrate inj 2 mg/ml
2
butorphanol tartrate nasal soln
10 mg/ml
2
BUTRANS - buprenorphine td patch
weekly 5 mcg/hr
4
• •
weekly 10 mcg/hr
4
• •
weekly 15 mcg/hr
4
• •
weekly 20 mcg/hr
4
• •
CAPITAL/CODEINE - acetaminophen
w/ codeine susp 120-12 mg/5ml
4
• •
COCET - acetaminophen w/ codeine tab 4
650-30 mg
4
COCET PLUS - acetaminophen w/
codeine tab 650-60 mg
• •
• •
DURAGESIC - fentanyl td patch 72hr 12 4
mcg/hr
mcg/hr
mcg/hr
mcg/hr
4
DURAGESIC - fentanyl td patch 72hr
100 mcg/hr
4
EXALGO - hydromorphone hcl tab er
24hr deter 8 mg
Quantity Limits
Restricted Access
Prior Review
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Drug Tier
2014
• •
95
24hr deter 16 mg
4
• •
24hr deter 32 mg
4
• •
fentanyl citrate lollipop 1200 mcg
(Actiq)
5
•
•
(Actiq)
5
•
•
(Actiq)
5
•
•
(Actiq)
5
•
•
(Actiq)
5
•
•
(Actiq)
5
•
•
fentanyl td patch 72hr 100 mcg/hr
(Duragesic)
2
(Duragesic)
2
(Duragesic)
2
(Duragesic)
2
(Duragesic)
2
FENTORA - fentanyl citrate buccal tab
100 mcg (base equiv)
5
• • •
5
• • •
5
• • •
5
• • •
5
• • •
96
FIORICET/CODEINE - butalbitalacetaminophen-caff w/ cod cap
50-300-40-30 mg
4
FIORICET/CODEINE - butalbitalacetaminophen-caff w/ cod cap
50-325-40-30 mg
4
FIORINAL/CODEINE #3 - butalbitalaspirin-caff w/ codeine cap
50-325-40-30 mg
4
HYCET - hydrocodone-acetaminophen
soln 7.5-325 mg/15ml
4
HYDROCODONE BITARTRATE/AC hydrocodone-acetaminophen tab
2.5-325 mg
4
HYDROCODONE BITARTRATE/AC hydrocodone-acetaminophen tab
10-750 mg
1
hydrocodone-acetaminophen cap
5-500 mg
1
hydrocodone-acetaminophen soln
7.5-325 mg/15ml (Hycet)
2
hydrocodone-acetaminophen soln
7.5-500 mg/15ml
2
hydrocodone-acetaminophen tab
10-300 mg (Xodol)
2
10-325 mg (Norco)
1
10-500 mg
1
10-650 mg
1
10-660 mg
1
10-750 mg
1
2.5-500 mg
1
5-300 mg (Xodol)
2
5-325 mg (Norco)
1
• •
Quantity Limits
• •
Restricted Access
4
Drug Name
Prior Review
24hr deter 12 mg
Drug Name
Drug Tier
Prior Review
Quantity Limits
Drug Tier
Restricted Access
2014
Quantity Limits
Restricted Access
Prior Review
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Drug Tier
2014
5-500 mg
1
hydromorphone hcl tab 8 mg
(Dilaudid)
1
7.5-300 mg (Xodol)
2
IBUDONE - hydrocodone-ibuprofen tab
10-200 mg
4
7.5-325 mg (Norco)
1
KADIAN - morphine sulfate cap sr 24hr
10 mg
4
7.5-500 mg
1
20 mg
4
7.5-650 mg
1
30 mg
4
7.5-750 mg
1
40 mg
4
hydrocodone-ibuprofen tab
10-200 mg (Ibudone)
2
50 mg
4
2.5-200 mg (Reprexain)
2
60 mg
4
hydrocodone-ibuprofen tab 5-200 mg
(Reprexain)
1
70 mg
4
7.5-200 mg (Vicoprofen)
1
80 mg
4
HYDROCODONE/ACETAMINOPHEN hydrocodone-acetaminophen tab
7.5-500 mg
1
100 mg
4
• •
7.5-650 mg
130 mg
4
1
150 mg
4
• •
7.5-750 mg
1
200 mg
4
• •
4
LAZANDA - fentanyl citrate nasal spray
100 mcg/act (base equiv)
5
HYDROCODONE/ACETAMINOPHEN hydrocodone-acetaminophen soln
10-325 mg/15ml
• • •
5
• • •
HYDROMORPHONE HCL hydromorphone hcl suppos 3 mg
3
LAZANDA - fentanyl citrate nasal spray
400 mcg/act (base equiv)
4
• •
hydromorphone hcl liqd 1 mg/ml
(Dilaudid)
2
LEVORPHANOL TARTRATE levorphanol tartrate tab 2 mg
4
• •
(Dilaudid)
1
LIQUICET - hydrocodoneacetaminophen soln 10-500 mg/15ml
4
(Dilaudid)
1
LORCET PLUS - hydrocodoneacetaminophen tab 7.5-650 mg
LORCET 10/650 - hydrocodoneacetaminophen tab 10-650 mg
4
• •
• •
• •
97
LORTAB - hydrocodone-acetaminophen 4
tab 5-500 mg
tab 7.5-500 mg
tab 10-500 mg
soln 7.5-500 mg/15ml
soln 10-300 mg/15ml
4
MAGNACET - oxycodone w/
acetaminophen tab 5-400 mg
4
acetaminophen tab 7.5-400 mg
4
4
MAXIDONE - hydrocodoneacetaminophen tab 10-750 mg
MEPERIDINE HCL - meperidine hcl oral 4
soln 50 mg/5ml
meperidine hcl tab 100 mg (Demerol) 1
METHADOSE SUGAR-FREE methadone hcl conc 10 mg/ml
4
MORPHINE SULFATE - morphine
sulfate tab 15 mg
1
sulfate tab 30 mg
1
sulfate suppos 5 mg
4
• •
sulfate suppos 10 mg
4
• •
4
• •
4
• •
morphine sulfate (concentrate) oral
soln 20 mg/ml
1
morphine sulfate beads cap sr 24hr
120 mg (Avinza)
2
30 mg (Avinza)
2
45 mg (Avinza)
2
• •
meperidine hcl tab 50 mg (Demerol)
1
METHADONE HCL - methadone hcl
soln 5 mg/5ml
4
60 mg (Avinza)
2
METHADONE HCL - methadone hcl
soln 10 mg/5ml
4
75 mg (Avinza)
2
methadone hcl conc 10 mg/ml
(Methadose)
2
90 mg (Avinza)
2
methadone hcl soln 10 mg/5ml
(Methadone hcl)
2
morphine sulfate cap sr 24hr 10 mg
(Kadian)
2
methadone hcl soln 5 mg/5ml
(Methadone hcl)
2
(Kadian)
2
methadone hcl tab for oral susp
40 mg
2
(Kadian)
2
methadone hcl tab 10 mg (Dolophine)
1
2
methadone hcl tab 5 mg (Dolophine
hcl)
1
(Kadian)
2
METHADOSE - methadone hcl conc 10
mg/ml
4
(Kadian)
(Kadian)
2
98
Quantity Limits
Restricted Access
Prior Review
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Drug Name
Prior Review
Drug Tier
2014
Quantity Limits
Restricted Access
Prior Review
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Drug Tier
2014
(Kadian)
2
NUCYNTA ER - tapentadol hcl tab sr
12hr 200 mg
4
morphine sulfate oral soln 10 mg/5ml
1
4
morphine sulfate oral soln 20 mg/5ml
1
12hr 250 mg
morphine sulfate tab cr 100 mg (Ms
contin)
1
ONSOLIS - fentanyl citrate buccal
soluble film 200 mcg
5
• • •
contin)
1
5
• • •
contin)
1
5
• • •
contin)
1
5
• • •
contin)
1
5
• • •
MS CONTIN - morphine sulfate tab cr
15 mg
4
OPANA - oxymorphone hcl tab 5 mg
4
OPANA - oxymorphone hcl tab 10 mg
4
30 mg
4
OPANA ER - oxymorphone hcl tab sr
12hr 5 mg
4
60 mg
4
12hr 10 mg
4
100 mg
4
12hr 20 mg
4
200 mg
4
12hr 30 mg
1
NORCO - hydrocodone-acetaminophen
tab 10-325 mg
4
12hr 40 mg
4
tab 5-325 mg
4
4
• •
tab 7.5-325 mg
4
OPANA ER (CRUSH RESISTANT oxymorphone hcl tab er 12hr deter 5
mg
4
• •
NUCYNTA - tapentadol hcl tab 50 mg
4
4
OPANA ER (CRUSH RESISTANT oxymorphone hcl tab er 12hr deter
7.5 mg
4
• •
12hr 50 mg
4
mg
4
• •
4
mg
4
12hr 100 mg
12hr 150 mg
4
mg
4
• •
99
ORAMORPH SR - morphine sulfate tab
cr 15 mg
4
cr 30 mg
4
cr 60 mg
4
cr 100 mg
4
OXECTA - oxycodone hcl tab abuse
deter 5 mg
4
OXECTA - oxycodone hcl tab abuse
deter 7.5 mg
4
OXYCODONE HCL - oxycodone hcl
conc 100 mg/5ml (20 mg/ml)
Quantity Limits
mg
4
Restricted Access
• •
Prior Review
4
Drug Name
Drug Tier
Prior Review
mg
Drug Name
Quantity Limits
Drug Tier
Restricted Access
2014
oxycodone w/ acetaminophen tab
10-650 mg
1
2.5-325 mg (Percocet)
1
5-325 mg (Percocet)
1
7.5-325 mg (Percocet)
1
7.5-500 mg
1
oxycodone-aspirin tab
4.8355-325 mg (Percodan)
1
oxycodone-ibuprofen tab 5-400 mg
2
• •
OXYCONTIN - oxycodone hcl tab er
12hr deter 10 mg
4
•
• •
12hr deter 15 mg
4
•
2
12hr deter 20 mg
4
•
2
12hr deter 30 mg
4
soln 5 mg/5ml
•
4
12hr deter 40 mg
4
soln 5 mg/5ml
•
1
12hr deter 60 mg
4
oxycodone hcl cap 5 mg
•
oxycodone hcl conc 100 mg/5ml
(20 mg/ml) (Oxycodone hcl)
2
12hr deter 80 mg
4
•
oxycodone hcl soln 5 mg/5ml
(Oxycodone hcl)
2
oxymorphone hcl tab sr 12hr 10 mg
2
1
2
oxycodone hcl tab 10 mg
1
2
(Roxicodone)
2
1
2
(Roxicodone)
1
2
oxymorphone hcl tab sr 12hr 7.5 mg
2
oxymorphone hcl tab 10 mg (Opana)
2
oxymorphone hcl tab 5 mg (Opana)
2
pentazocine w/ naloxone tab
50-0.5 mg
2
oxycodone hcl tab 5 mg (Roxicodone) 1
1
oxycodone w/ acetaminophen cap
5-500 mg
1
10-325 mg (Percocet)
100
• •
Quantity Limits
Restricted Access
Prior Review
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Drug Tier
2014
pentazocine-acetaminophen tab
25-650 mg
2
RYZOLT - tramadol hcl tab sr 24hr
4
PERCOCET - oxycodone w/
4
4
•
•
4
SUBOXONE - buprenorphine hclnaloxone hcl sl tab 2-0.5 mg (base
equiv)
4
•
•
4
SUBOXONE - buprenorphine hclnaloxone hcl sl tab 8-2 mg (base
equiv)
4
3
•
•
4
SUBOXONE - buprenorphine hclnaloxone hcl sl film 2-0.5 mg (base
equiv)
3
•
•
4
SUBOXONE - buprenorphine hclnaloxone hcl sl film 4-1 mg (base
equiv)
4
•
•
PRIMLEV - oxycodone w/
4
• •
equiv)
3
PERCODAN - oxycodone-aspirin tab
4.8355-325 mg
3
•
•
4
• •
equiv)
4
• •
REPREXAIN - hydrocodone-ibuprofen
tab 2.5-200 mg
4
REPREXAIN - hydrocodone-ibuprofen
tab 5-200 mg
4
ROXICET - oxycodone w/
acetaminophen soln 5-325 mg/5ml
4
ROXICODONE - oxycodone hcl tab 5
mg
4
mg
4
mg
4
RYBIX ODT - tramadol hcl orally
4
4
4
• •
• •
• •
SUBSYS - fentanyl sublingual spray 100 5
mcg
mcg
mcg
mcg
mcg
5
SUBSYS - fentanyl sublingual spray
1200 mcg (600 mcg x 2)
5
SUBSYS - fentanyl sublingual spray
1600 mcg (800 mcg x 2)
4
SUBUTEX - buprenorphine hcl sl tab 2
mg (base equiv)
4
SUBUTEX - buprenorphine hcl sl tab 8
mg (base equiv)
4
SYNALGOS-DC - dihydrocodeine
compound cap
• • •
• • •
• • •
• • •
• • •
• • •
• • •
•
•
•
•
• •
101
Quantity Limits
tramadol hcl tab sr 24hr biphasic
release 100 mg
Restricted Access
• •
Prior Review
4
Drug Name
Drug Tier
Prior Review
TRAMADOL HCL ER - tramadol hcl cap
sr 24hr biphasic release 150 mg
Drug Name
Quantity Limits
Drug Tier
Restricted Access
2014
VICODIN ES - hydrocodoneacetaminophen tab 7.5-750 mg
4
2
VICOPROFEN - hydrocodone-ibuprofen
tab 7.5-200 mg
4
release 200 mg
2
XARTEMIS XR - oxycodone w/
acetaminophen tab cr 7.5-325 mg
4
release 300 mg
2
XODOL - hydrocodone-acetaminophen
tab 5-300 mg
4
tramadol hcl tab sr 24hr 100 mg
(Ultram er)
2
tab 7.5-300 mg
4
(Ultram er)
2
tab 10-300 mg
4
(Ultram er)
2
XOLOX - oxycodone w/ acetaminophen
tab 10-500 mg
4
• •
tramadol hcl tab 50 mg (Ultram)
1
4
• •
tramadol-acetaminophen tab
37.5-325 mg (Ultracet)
1
ZAMICET - hydrocodoneacetaminophen soln 10-325 mg/15ml
4
• • •
TREZIX - acetaminophen-caffeinedihydrocodeine cap 356.4-30-16 mg
4
ZOHYDRO ER - hydrocodone bitartrate
cap sr 12hr 10 mg
4
• • •
TYLENOL/CODEINE - acetaminophen
w/ codeine tab 300-15 mg
4
cap sr 12hr 15 mg
4
• • •
TYLENOL/CODEINE #3 acetaminophen w/ codeine tab
300-30 mg
4
cap sr 12hr 20 mg
cap sr 12hr 30 mg
4
• • •
TYLENOL/CODEINE #4 acetaminophen w/ codeine tab
300-60 mg
4
cap sr 12hr 40 mg
4
• • •
• • •
4
cap sr 12hr 50 mg
4
TYLOX - oxycodone w/ acetaminophen
cap 5-500 mg
• •
ULTRACET - tramadol-acetaminophen
tab 37.5-325 mg
ZOLVIT - hydrocodone-acetaminophen
soln 10-300 mg/15ml
4
4
ULTRAM - tramadol hcl tab 50 mg
4
ULTRAM ER - tramadol hcl tab sr 24hr
100 mg
4
200 mg
4
300 mg
4
VICODIN - hydrocodoneacetaminophen tab 5-500 mg
4
102
• •
ZUBSOLV - buprenorphine hcl-naloxone 4
hcl sl tab 1.4-0.36 mg (base eq)
ZUBSOLV - buprenorphine hcl-naloxone 4
hcl sl tab 5.7-1.4 mg (base eq)
4
ZYDONE - hydrocodoneacetaminophen tab 5-400 mg
4
ZYDONE - hydrocodoneacetaminophen tab 7.5-400 mg
4
ZYDONE - hydrocodoneacetaminophen tab 10-400 mg
• •
• • •
• • •
• •
• •
• •
4
• •
Quantity Limits
Restricted Access
Prior Review
Drug Name
Drug Tier
ANALGESICS - ANTI-INFLAMMATORY
Quantity Limits
Restricted Access
Prior Review
Drug Name
Drug Tier
2014
ANAPROX - naproxen sodium tab 275
mg
4
DUEXIS - ibuprofen-famotidine tab
800-26.6 mg
4
ANAPROX DS - naproxen sodium tab
550 mg
4
EC-NAPROSYN - naproxen tab ec 375
mg
4
ARAVA - leflunomide tab 10 mg
5
EC-NAPROSYN - naproxen tab ec 500
mg
ARAVA - leflunomide tab 20 mg
5
5
•
•
ARCALYST - rilonacept for inj 220 mg
5
ENBREL - etanercept subcutaneous inj
50 mg/ml
4
ENBREL - etanercept subcutaneous inj
25 mg/0.5ml
5
ARTHROTEC 50 - diclofenac w/
misoprostol tab delayed release
50-0.2 mg
•
•
5
•
•
ARTHROTEC 75 - diclofenac w/
misoprostol tab delayed release
75-0.2 mg
4
ENBREL - etanercept for subcutaneous
inj kit 25 mg
ENBREL SURECLICK - etanercept
subcutaneous inj 50 mg/ml
5
•
•
CATAFLAM - diclofenac potassium tab
50 mg
4
etodolac cap 200 mg
1
etodolac cap 300 mg
1
CELEBREX - celecoxib cap 50 mg
4
etodolac tab sr 24hr 400 mg
1
4
1
4
1
4
etodolac tab 400 mg
1
CLINORIL - sulindac tab 200 mg
4
etodolac tab 500 mg
1
DAYPRO - oxaprozin tab 600 mg
4
FELDENE - piroxicam cap 10 mg
4
diclofenac potassium tab 50 mg
(Cataflam)
1
FELDENE - piroxicam cap 20 mg
4
1
FENOPROFEN CALCIUM - fenoprofen
calcium tab 600 mg
4
diclofenac sodium tab delayed
release 25 mg
flurbiprofen tab 100 mg
1
release 50 mg
1
flurbiprofen tab 50 mg
1
1
HUMIRA - adalimumab inj kit 20
mg/0.4ml
5
release 75 mg
•
•
2
HUMIRA - adalimumab inj kit 40
mg/0.8ml (50 mg/ml)
5
diclofenac sodium tab sr 24hr
100 mg (Voltaren-xr)
•
•
2
HUMIRA PEN - adalimumab inj kit 40
mg/0.8ml (50 mg/ml)
5
diclofenac w/ misoprostol tab
delayed release 50-0.2 mg
(Arthrotec 50)
•
•
5
•
•
diclofenac w/ misoprostol tab
delayed release 75-0.2 mg
(Arthrotec 75)
2
HUMIRA PEN-CROHNS DISEASE adalimumab inj kit 40 mg/0.8ml (50
mg/ml)
HUMIRA PEN-PSORIASIS STAR adalimumab inj kit 40 mg/0.8ml (50
mg/ml)
5
•
•
• •
•
•
•
•
• •
103
ibuprofen susp 100 mg/5ml
2
ibuprofen tab 400 mg
1
1
1
IC 400 - ibuprofen tab 400 mg &
caffeine-vitamins cap kit
4
IC 800 - ibuprofen tab 800 mg &
caffeine-vitamins cap kit
4
INDOCIN - indomethacin susp 25
mg/5ml
4
INDOCIN - indomethacin suppos 50 mg
4
indomethacin cap cr 75 mg
2
indomethacin cap 25 mg
1
indomethacin cap 50 mg
1
ketoprofen cap 50 mg
1
ketoprofen cap 75 mg
1
KETOPROFEN ER - ketoprofen cap sr
24hr 200 mg
4
KETOROLAC TROMETHAMINE ketorolac tromethamine inj 300
mg/10ml (30 mg/ml)
4
ketorolac tromethamine tab 10 mg
1
KINERET - anakinra subcutaneous inj
100 mg/0.67ml
5
leflunomide tab 10 mg (Arava)
1
leflunomide tab 20 mg (Arava)
1
MECLOFENAMATE SODIUM meclofenamate sodium cap 50 mg
4
•
naproxen sodium tab 550 mg
(Anaprox ds)
1
MECLOFENAMATE SODIUM meclofenamate sodium cap 100 mg
4
•
naproxen susp 125 mg/5ml
(Naprosyn)
1
mefenamic acid cap 250 mg (Ponstel)
2
1
MELOXICAM - meloxicam susp 7.5
mg/5ml
4
naproxen tab ec 375 mg (Ecnaprosyn)
1
MELOXICAM COMFORT PAC meloxicam tab 15 mg & liniment
topical gel kit
4
naproxen tab ec 500 mg (Ecnaprosyn)
naproxen tab 250 mg (Naprosyn)
1
1
104
• •
• •
• •
• •
• •
•
• •
Drug Name
meloxicam tab 15 mg (Mobic)
1
meloxicam tab 7.5 mg (Mobic)
1
MOBIC - meloxicam tab 7.5 mg
4
MOBIC - meloxicam tab 15 mg
4
MOBIC - meloxicam susp 7.5 mg/5ml
4
nabumetone tab 500 mg
1
nabumetone tab 750 mg
1
NALFON - fenoprofen calcium cap 200
mg
4
• •
NALFON - fenoprofen calcium cap 400
mg
4
• •
NAPRELAN - naproxen sodium tab sr
24hr 375 mg (base equiv)
4
• •
4
• •
4
• •
24hr 500 mg (14) & 750 mg (6) pack
4
• •
NAPROSYN - naproxen tab 250 mg
4
4
4
NAPROSYN - naproxen susp 125
mg/5ml
4
NAPROXEN COMFORT PAC naproxen tab 500 mg & liniment
topical gel kit
4
naproxen sodium tab 275 mg
(Anaprox)
1
• •
Quantity Limits
• •
Restricted Access
4
Prior Review
IBUPROFEN COMFORT PAC ibuprofen tab 800 mg & liniment
topical gel kit
Drug Name
Drug Tier
Prior Review
Quantity Limits
Drug Tier
Restricted Access
2014
Quantity Limits
Restricted Access
OTEZLA - apremilast tab starter therapy
pack 10 mg & 20 mg & 30 mg
Prior Review
5
Drug Name
Drug Tier
ORENCIA - abatacept subcutaneous inj
125 mg/ml
Quantity Limits
1
Restricted Access
Prior Review
Drug Name
Drug Tier
2014
VOLTAREN-XR - diclofenac sodium tab
sr 24hr 100 mg
4
5
• • •
5
XELJANZ - tofacitinib citrate tab 5 mg
(base equivalent)
4
• •
OTEZLA - apremilast tab 30 mg
5
ZIPSOR - diclofenac potassium cap 25
mg
OTREXUP - methotrexate soln pf autoinjector 10mg/0.4ml
5
ZORVOLEX - diclofenac cap 18 mg
4
ZORVOLEX - diclofenac cap 35 mg
4
5
• •
MIGRAINE PRODUCTS
• •
acetaminophen-isometheptenecaffeine tab 325-65-20 mg (Prodrin)
2
5
• •
acetaminophen-isometheptenedichloral cap 325-65-100 mg
2
5
4
• • •
oxaprozin tab 600 mg (Daypro)
1
ALSUMA - sumatriptan succinate
solution auto-injector 6 mg/0.5ml
piroxicam cap 10 mg (Feldene)
2
4
•
piroxicam cap 20 mg (Feldene)
2
AMERGE - naratriptan hcl tab 1 mg
(base equiv)
PONSTEL - mefenamic acid cap 250
mg
4
AMERGE - naratriptan hcl tab 2.5 mg
(base equiv)
4
•
RHEUMATREX - methotrexate sodium
tab 2.5 mg (antirheumatic)
4
• •
AXERT - almotriptan malate tab 6.25
mg
4
• • •
RIDAURA - auranofin cap 3 mg
4
• • •
5
AXERT - almotriptan malate tab 12.5
mg
4
SIMPONI - golimumab subcutaneous inj
50 mg/0.5ml
• •
•
•
4
• •
SIMPONI - golimumab subcutaneous inj
100 mg/ml
5
CAFERGOT - ergotamine w/ caffeine
tab 1-100 mg
4
• • •
SPRIX - ketorolac tromethamine nasal
spray 15.75 mg/spray
4
CAMBIA - diclofenac potassium packet
50 mg
5
sulindac tab 150 mg
1
D.H.E. 45 - dihydroergotamine mesylate
inj 1 mg/ml
1
TOLMETIN SODIUM - tolmetin sodium
tab 200 mg
4
DIHYDROERGOTAMINE MESYLAT dihydroergotamine mesylate nasal
spray 4 mg/ml
4
sulindac tab 200 mg
2
TOLMETIN SODIUM - tolmetin sodium
tab 600 mg
4
dihydroergotamine mesylate inj
1 mg/ml (D.h.e. 45)
• •
2
ERGOMAR - ergotamine tartrate sl tab
2 mg
4
tolmetin sodium cap 400 mg
VIMOVO - naproxen-esomeprazole
magnesium tab dr 375-20 mg
4
• •
FROVA - frovatriptan succinate tab 2.5
4
• • •
VIMOVO - naproxen-esomeprazole
magnesium tab dr 500-20 mg
4
• •
IMITREX - sumatriptan nasal spray 5
mg/act
4
•
• • •
• •
•
• •
•
• •
105
Quantity Limits
Restricted Access
Prior Review
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Drug Name
Prior Review
Drug Tier
2014
IMITREX - sumatriptan nasal spray 20
mg/act
4
•
naratriptan hcl tab 1 mg (base equiv)
(Amerge)
2
•
IMITREX - sumatriptan succinate tab 25
mg
4
•
naratriptan hcl tab 2.5 mg (base
equiv) (Amerge)
2
•
IMITREX - sumatriptan succinate tab 50
mg
4
•
4
IMITREX - sumatriptan succinate tab
100 mg
4
•
PRODRIN - acetaminophenisometheptene-caffeine tab
325-65-20 mg
4
IMITREX - sumatriptan succinate inj 6
mg/0.5ml
4
• • •
PRODRIN - acetaminophenisometheptene-caffeine tab
500-130-20 mg
IMITREX STATDOSE REFILL sumatriptan succinate solution
cartridge 4 mg/0.5ml
4
•
RELPAX - eletriptan hydrobromide tab
4
• • •
4
• • •
IMITREX STATDOSE REFILL sumatriptan succinate solution
cartridge 6 mg/0.5ml
4
•
RELPAX - eletriptan hydrobromide tab
2
•
IMITREX STATDOSE SYSTEM sumatriptan succinate solution autoinjector 4 mg/0.5ml
4
•
rizatriptan benzoate orally
disintegrating tab 10 mg (Maxaltmlt)
rizatriptan benzoate orally
disintegrating tab 5 mg (Maxalt-mlt)
2
•
IMITREX STATDOSE SYSTEM sumatriptan succinate solution autoinjector 6 mg/0.5ml
4
rizatriptan benzoate tab 10 mg
(Maxalt)
2
•
•
ISOMETHEPTENE/CAFFEINE/AC acetaminophen-isometheptenecaffeine tab 500-130-20 mg
rizatriptan benzoate tab 5 mg
(Maxalt)
2
2
SUMATRIPTAN - sumatriptan nasal
spray 5 mg/act
4
•
SUMATRIPTAN - sumatriptan nasal
spray 20 mg/act
4
•
SUMATRIPTAN SUCCINATE sumatriptan succinate solution
prefilled syringe 6 mg/0.5ml
2
•
SUMATRIPTAN SUCCINATE sumatriptan succinate inj 4 mg/0.5ml
2
•
sumatriptan succinate inj 4 mg/0.5ml
2
sumatriptan succinate inj 6 mg/0.5ml
(Imitrex)
2
•
•
MAXALT - rizatriptan benzoate tab 5 mg 4
4
MAXALT - rizatriptan benzoate tab 10
mg
4
MAXALT-MLT - rizatriptan benzoate
4
MAXALT-MLT - rizatriptan benzoate
4
MIGERGOT - ergotamine w/ caffeine
suppos 2-100 mg
4
MIGRAL - isometheptene mucate tab
130 mg
4
MIGRALAM - acetaminophenisometheptene-caffeine cap
325-65-100 mg
4
MIGRANAL - dihydroergotamine
mesylate nasal spray 4 mg/ml
106
• • •
•
•
•
•
• •
• •
• •
• •
sumatriptan succinate solution auto- 2
injector 4 mg/0.5ml (Imitrex statdose
sys)
sumatriptan succinate solution auto- 2
injector 6 mg/0.5ml (Imitrex statdose
sys)
•
•
•
sumatriptan succinate solution
cartridge 4 mg/0.5ml (Imitrex
statdose ref)
2
cartridge 6 mg/0.5ml (Imitrex
statdose ref)
2
prefilled syringe 6 mg/0.5ml
2
sumatriptan succinate tab 100 mg
(Imitrex)
1
•
(Imitrex)
1
•
(Imitrex)
1
•
SUMAVEL DOSEPRO - sumatriptan
succinate solution jet-injector 6
mg/0.5ml
4
TREXIMET - sumatriptan-naproxen
sodium tab 85-500 mg
4
• • •
zolmitriptan orally disintegrating tab
2.5 mg (Zomig zmt)
2
•
zolmitriptan orally disintegrating tab
5 mg (Zomig zmt)
2
•
zolmitriptan tab 2.5 mg (Zomig)
2
zolmitriptan tab 5 mg (Zomig)
2
ZOMIG - zolmitriptan tab 2.5 mg
4
ZOMIG - zolmitriptan tab 5 mg
4
ZOMIG - zolmitriptan nasal spray 2.5
mg/spray unit
4
•
•
•
•
• • •
ZOMIG - zolmitriptan nasal spray 5 mg/
spray unit
4
• • •
ZOMIG NASAL SPRAY - zolmitriptan
nasal spray 5 mg/spray unit
4
• • •
ZOMIG ZMT - zolmitriptan orally
4
•
ZOMIG ZMT - zolmitriptan orally
4
•
•
• •
colchicine w/ probenecid tab
0.5-500 mg
1
COLCRYS - colchicine tab 0.6 mg
3
probenecid tab 500 mg
1
ULORIC - febuxostat tab 40 mg
4
ULORIC - febuxostat tab 80 mg
4
ZYLOPRIM - allopurinol tab 100 mg
4
ZYLOPRIM - allopurinol tab 300 mg
4
Quantity Limits
Restricted Access
Prior Review
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Drug Tier
2014
• •
• •
LOCAL ANESTHETICS - PARENTERAL
4
• •
enflurane inhal soln
2
•
ETHRANE - enflurane inhal soln
4
FORANE - isoflurane inhal soln
4
isoflurane inhal soln (Forane)
2
sevoflurane inhal soln (Ultane)
2
SUPRANE - desflurane inhal soln
4
ULTANE - sevoflurane inhal soln
4
LETS KIT - lidocaine & tetracaine w/
epineph kit (compounding kit)
GENERAL ANESTHETICS
NEUROMUSCULAR DRUGS
GOUT AGENTS
allopurinol tab 100 mg (Zyloprim)
1
allopurinol tab 300 mg (Zyloprim)
1
•
ANTICONVULSANTS
APTIOM - eslicarbazepine acetate tab
200 mg
4
• •
400 mg
4
• •
600 mg
4
• •
800 mg
4
• •
BANZEL - rufinamide tab 200 mg
4
BANZEL - rufinamide tab 400 mg
4
BANZEL - rufinamide susp 40 mg/ml
4
• •
• •
• •
carbamazepine cap sr 12hr 100 mg
(Carbatrol)
2
(Carbatrol)
2
107
(Carbatrol)
2
DEPAKOTE ER - divalproex sodium tab
sr 24 hr 250 mg
4
carbamazepine chew tab 100 mg
1
4
carbamazepine susp 100 mg/5ml
(Tegretol)
1
DEPAKOTE ER - divalproex sodium tab
sr 24 hr 500 mg
4
carbamazepine tab sr 12hr 200 mg
(Tegretol-xr)
2
DEPAKOTE SPRINKLES - divalproex
sodium cap sprinkle 125 mg
4
carbamazepine tab sr 12hr 400 mg
(Tegretol-xr)
2
DIASTAT ACUDIAL - diazepam rectal
gel delivery system 10 mg
4
carbamazepine tab 200 mg (Tegretol)
1
DIASTAT ACUDIAL - diazepam rectal
gel delivery system 20 mg
CARBATROL - carbamazepine cap sr
12hr 100 mg
4
DIASTAT PEDIATRIC - diazepam rectal
gel delivery system 2.5 mg
4
12hr 200 mg
4
DIAZEPAM - diazepam rectal gel
delivery system 2.5 mg
4
12hr 300 mg
4
delivery system 10 mg
4
CELONTIN - methsuximide cap 300 mg
4
4
clonazepam orally disintegrating tab
0.125 mg
2
delivery system 20 mg
DILANTIN - phenytoin susp 125 mg/5ml
4
0.25 mg
2
DILANTIN - phenytoin sodium extended
cap 30 mg
4
0.5 mg
2
DILANTIN - phenytoin sodium extended
cap 100 mg
4
1 mg
2
DILANTIN INFATABS - phenytoin chew
tab 50 mg
4
2 mg
2
divalproex sodium cap sprinkle
125 mg (Depakote sprinkles)
2
clonazepam tab 0.5 mg (Klonopin)
1
1
clonazepam tab 1 mg (Klonopin)
1
divalproex sodium tab delayed
release 125 mg (Depakote)
1
1
clonazepam tab 2 mg (Klonopin)
DEPAKENE - valproate sodium syrup
250 mg/5ml (base equiv)
4
1
DEPAKENE - valproic acid cap 250 mg
4
1
DEPAKOTE - divalproex sodium tab
4
divalproex sodium tab sr 24 hr
250 mg (Depakote er)
divalproex sodium tab sr 24 hr
500 mg (Depakote er)
1
4
ethosuximide cap 250 mg (Zarontin)
1
4
ethosuximide soln 250 mg/5ml
(Zarontin)
1
108
• •
Quantity Limits
Restricted Access
Prior Review
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Drug Name
Prior Review
Drug Tier
2014
2
KLONOPIN - clonazepam tab 2 mg
4
felbamate tab 400 mg (Felbatol)
2
LAMICTAL - lamotrigine tab 25 mg
4
felbamate tab 600 mg (Felbatol)
2
4
FELBATOL - felbamate tab 400 mg
4
4
FELBATOL - felbamate tab 600 mg
4
4
FELBATOL - felbamate susp 600
mg/5ml
4
LAMICTAL - lamotrigine tab chewable
dispersible 2 mg
4
FYCOMPA - perampanel tab 2 mg
4
4
4
4
LAMICTAL CHEWABLE DISPERS lamotrigine tab chewable dispersible
5 mg
4
4
LAMICTAL CHEWABLE DISPERS lamotrigine tab chewable dispersible
25 mg
4
4
4
• •
gabapentin cap 100 mg (Neurontin)
1
LAMICTAL ODT - lamotrigine tab disp
25 mg (21) & 50 mg (7) titration kit
1
4
• •
1
2
25 (14) & 50 mg (14) & 100 mg (7) kit
4
gabapentin oral soln 250 mg/5ml
(Neurontin)
• •
1
LAMICTAL ODT - lamotrigine orally
4
gabapentin tab 600 mg (Neurontin)
• •
gabapentin tab 800 mg (Neurontin)
1
4
• •
GABITRIL - tiagabine hcl tab 2 mg
4
4
4
• •
4
4
4
• •
KEPPRA - levetiracetam tab 250 mg
4
4
4
LAMICTAL STARTER/NOT TAKI lamotrigine tab 25 mg (42) & 100 mg
(7) starter kit
4
4
4
KEPPRA - levetiracetam oral soln 100
mg/ml
4
LAMICTAL STARTER/TAKING C lamotrigine tab 25 mg (84) & 100 mg
(14) starter kit
KEPPRA XR - levetiracetam tab sr 24hr
500 mg
4
LAMICTAL STARTER/TAKING V lamotrigine tab 25 mg (35) starter kit
4
KEPPRA XR - levetiracetam tab sr 24hr
750 mg
4
LAMICTAL XR - lamotrigine tab sr 24hr
4
KLONOPIN - clonazepam tab 0.5 mg
4
4
KLONOPIN - clonazepam tab 1 mg
4
25 (14) & 50 mg (14) & 100 mg(7) kit
•
•
•
•
•
•
•
•
•
•
•
•
• •
• •
Quantity Limits
Restricted Access
Prior Review
Drug Name
Drug Tier
Quantity Limits
Restricted Access
felbamate susp 600 mg/5ml (Felbatol)
Prior Review
Drug Name
Drug Tier
2014
109
levetiracetam tab 250 mg (Keppra)
1
1
1
LYRICA - pregabalin cap 25 mg
4
4
4
4
4
4
4
4
LYRICA - pregabalin soln 20 mg/ml
4
MYSOLINE - primidone tab 50 mg
4
MYSOLINE - primidone tab 250 mg
4
NEURONTIN - gabapentin cap 100 mg
4
4
4
NEURONTIN - gabapentin tab 600 mg
4
50 (14) & 100 mg(14) & 200 mg(7) kit
4
25 mg
4
50 mg
4
100 mg
4
200 mg
4
250 mg
4
300 mg
4
lamotrigine tab chewable dispersible
25 mg (Lamictal chewable di)
2
lamotrigine tab chewable dispersible
5 mg (Lamictal chewable di)
2
lamotrigine tab sr 24hr 100 mg
(Lamictal xr)
2
(Lamictal xr)
2
(Lamictal xr)
2
NEURONTIN - gabapentin tab 800 mg
4
4
(Lamictal xr)
2
NEURONTIN - gabapentin oral soln 250
mg/5ml
ONFI - clobazam tab 5 mg
4
(Lamictal xr)
2
4
4
(Lamictal xr)
2
ONFI - clobazam suspension 2.5 mg/ml
4
lamotrigine tab 100 mg (Lamictal)
1
2
1
oxcarbazepine susp 300 mg/5ml
(60 mg/ml) (Trileptal)
1
1
oxcarbazepine tab 150 mg (Trileptal)
1
1
1
1
levetiracetam oral soln 100 mg/ml
(Keppra)
4
• •
levetiracetam tab sr 24hr 500 mg
(Keppra xr)
2
OXTELLAR XR - oxcarbazepine tab sr
24hr 150 mg
4
• •
levetiracetam tab sr 24hr 750 mg
(Keppra xr)
2
24hr 300 mg
110
Quantity Limits
1
Restricted Access
Prior Review
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Drug Name
Prior Review
Drug Tier
2014
• •
TEGRETOL-XR - carbamazepine tab sr
12hr 200 mg
4
PEGANONE - ethotoin tab 250 mg
4
• •
4
PHENYTEK - phenytoin sodium
extended cap 200 mg
4
12hr 400 mg
tiagabine hcl tab 2 mg (Gabitril)
2
PHENYTEK - phenytoin sodium
extended cap 300 mg
4
tiagabine hcl tab 4 mg (Gabitril)
2
TOPAMAX - topiramate tab 25 mg
4
phenytoin chew tab 50 mg (Dilantin
infatabs)
2
4
1
4
phenytoin sodium extended cap
100 mg (Dilantin)
4
200 mg (Phenytek)
1
TOPAMAX SPRINKLE - topiramate
sprinkle cap 15 mg
4
300 mg (Phenytek)
1
TOPAMAX SPRINKLE - topiramate
sprinkle cap 25 mg
4
phenytoin susp 125 mg/5ml (Dilantin)
2
2
POTIGA - ezogabine tab 50 mg
4
topiramate sprinkle cap 15 mg
(Topamax sprinkle)
4
topiramate sprinkle cap 25 mg
(Topamax sprinkle)
2
4
topiramate tab 100 mg (Topamax)
1
4
1
primidone tab 250 mg (Mysoline)
1
1
primidone tab 50 mg (Mysoline)
1
1
SABRIL - vigabatrin tab 500 mg
5
5
TRILEPTAL - oxcarbazepine tab 150
mg
4
SABRIL - vigabatrin powd pack 500 mg
STAVZOR - valproic acid cap delayed
release 125 mg
4
mg
4
release 250 mg
4
mg
4
release 500 mg
4
TRILEPTAL - oxcarbazepine susp 300
mg/5ml (60 mg/ml)
4
TEGRETOL - carbamazepine tab 200
mg
4
TROKENDI XR - topiramate cap sr 24hr
25 mg
4
• •
TEGRETOL - carbamazepine chew tab
100 mg
4
50 mg
4
• •
TEGRETOL - carbamazepine susp 100
mg/5ml
4
100 mg
4
• •
12hr 100 mg
4
200 mg
4
• •
• •
• •
Quantity Limits
Restricted Access
4
Drug Name
Prior Review
24hr 600 mg
Drug Name
Drug Tier
Prior Review
Quantity Limits
Drug Tier
Restricted Access
2014
111
valproate sodium syrup 250 mg/5ml
(base equiv) (Depakene)
1
carbidopa & levodopa orally
disintegrating tab 25-100 mg
2
valproic acid cap 250 mg (Depakene)
1
2
VIMPAT - lacosamide tab 50 mg
4
4
1
4
carbidopa & levodopa tab cr
25-100 mg (Sinemet cr)
4
carbidopa & levodopa tab cr
50-200 mg (Sinemet cr)
1
VIMPAT - lacosamide oral solution 10
mg/ml
4
carbidopa & levodopa tab 10-100 mg
(Sinemet)
1
ZARONTIN - ethosuximide cap 250 mg
4
ZARONTIN - ethosuximide soln 250
mg/5ml
(Sinemet)
1
4
ZONEGRAN - zonisamide cap 25 mg
(Sinemet)
1
4
ZONEGRAN - zonisamide cap 100 mg
4
carbidopa tab 25 mg (Lodosyn)
2
zonisamide cap 100 mg (Zonegran)
1
3
zonisamide cap 25 mg (Zonegran)
1
zonisamide cap 50 mg
1
CARBIDOPA/LEVODOPA/ENTACA carbidopa-levodopa-entacapone tabs
12.5-50-200 mg
18.75-75-200 mg
3
25-100-200 mg
3
31.25-125-200 mg
3
37.5-150-200 mg
3
3
ANTIPARKINSON AGENTS
AMANTADINE HCL - amantadine hcl
tab 100 mg
1
amantadine hcl cap 100 mg
1
amantadine hcl syrup 50 mg/5ml
1
APOKYN - apomorphine hydrochloride
inj 10 mg/ml
5
AZILECT - rasagiline mesylate tab 0.5
mg (base equiv)
4
AZILECT - rasagiline mesylate tab 1 mg
(base equiv)
4
benztropine mesylate tab 0.5 mg
1
benztropine mesylate tab 1 mg
1
50-200-200 mg
benztropine mesylate tab 2 mg
1
COMTAN - entacapone tab 200 mg
4
bromocriptine mesylate cap 5 mg
(Parlodel)
2
ELDEPRYL - selegiline hcl cap 5 mg
4
entacapone tab 200 mg (Comtan)
2
bromocriptine mesylate tab 2.5 mg
(Parlodel)
2
LODOSYN - carbidopa tab 25 mg
4
2
112
MIRAPEX - pramipexole dihydrochloride 4
tab 0.125 mg
Quantity Limits
Restricted Access
Prior Review
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Drug Name
Prior Review
Drug Tier
2014
tab 0.25 mg
tab 0.5 mg
tab 0.75 mg
tab 1 mg
tab 1.5 mg
4
MIRAPEX ER - pramipexole
dihydrochloride tab sr 24hr 0.375 mg
4
4
4
4
dihydrochloride tab sr 24hr 3 mg
4
4
4
NEUPRO - rotigotine td patch 24hr 1
mg/24hr
4
mg/24hr
4
mg/24hr
4
mg/24hr
4
mg/24hr
4
mg/24hr
4
PARCOPA - carbidopa & levodopa
orally disintegrating tab 10-100 mg
4
4
PARLODEL - bromocriptine mesylate
cap 5 mg
4
PARLODEL - bromocriptine mesylate
tab 2.5 mg
4
pramipexole dihydrochloride tab
0.125 mg (Mirapex)
1
0.25 mg (Mirapex)
1
• •
0.5 mg (Mirapex)
1
• •
0.75 mg (Mirapex)
1
• •
1 mg (Mirapex)
1
• •
1.5 mg (Mirapex)
1
• •
REQUIP - ropinirole hydrochloride tab
0.25 mg
4
• •
REQUIP - ropinirole hydrochloride tab
0.5 mg
4
• •
REQUIP - ropinirole hydrochloride tab 1
mg
4
• •
mg
4
• •
mg
4
• •
mg
4
• •
mg
4
• •
REQUIP XL - ropinirole hydrochloride
tab sr 24hr 2 mg (base equivalent)
4
• •
4
4
4
Quantity Limits
Restricted Access
Prior Review
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Drug Tier
2014
113
4
STALEVO 125 - carbidopa-levodopaentacapone tabs 31.25-125-200 mg
4
ropinirole hydrochloride tab sr 24hr
12 mg (base equivalent) (Requip xl)
2
4
2
STALEVO 200 - carbidopa-levodopaentacapone tabs 50-200-200 mg
4
2
4
2
4
2
TASMAR - tolcapone tab 100 mg
4
trihexyphenidyl hcl elixir 0.4 mg/ml
2
ropinirole hydrochloride tab 0.25 mg
(Requip)
1
trihexyphenidyl hcl tab 2 mg
1
1
trihexyphenidyl hcl tab 5 mg
1
ropinirole hydrochloride tab 0.5 mg
(Requip)
4
ropinirole hydrochloride tab 1 mg
(Requip)
1
ZELAPAR - selegiline hcl orally
(Requip)
1
(Requip)
1
(Requip)
1
(Requip)
1
selegiline hcl cap 5 mg (Eldepryl)
2
selegiline hcl tab 5 mg
2
SINEMET - carbidopa & levodopa tab
10-100 mg
4
25-100 mg
• •
RILUTEK - riluzole tab 50 mg
5
riluzole tab 50 mg (Rilutek)
5
MUSCULOSKELETAL THERAPY AGENTS
4
ACTIVE-CYCLOBENZAPRINE KI cyclobenzaprine hcl td cream 5%
(compound kit)
4
AMRIX - cyclobenzaprine hcl cap sr
24hr 15 mg
4
AMRIX - cyclobenzaprine hcl cap sr
24hr 30 mg
1
baclofen tab 10 mg
1
4
CARISOPRODOL - carisoprodol tab
250 mg
4
25-250 mg
4
carisoprodol tab 350 mg (Soma)
2
4
carisoprodol w/ aspirin & codeine
tab 200-325-16 mg
2
SINEMET CR - carbidopa & levodopa
tab cr 25-100 mg
4
carisoprodol w/ aspirin tab
200-325 mg
2
SINEMET CR - carbidopa & levodopa
tab cr 50-200 mg
STALEVO 100 - carbidopa-levodopaentacapone tabs 25-100-200 mg
chlorzoxazone tab 500 mg (Parafon
forte dsc)
1
4
•
• •
• •
• •
Quantity Limits
Restricted Access
• •
NEUROMUSCULAR AGENTS
baclofen tab 20 mg
114
Prior Review
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Drug Name
Prior Review
Drug Tier
2014
• •
ORPHENADRINE COMPOUND DS orphenadrine w/ aspirin & caffeine tab
50-770-60 mg
4
• •
cyclobenzaprine hcl cap sr 24hr
15 mg
2
orphenadrine w/ aspirin & caffeine
tab 25-385-30 mg
2
cyclobenzaprine hcl cap sr 24hr
30 mg
2
PARAFON FORTE DSC chlorzoxazone tab 500 mg
4
cyclobenzaprine hcl tab 10 mg
1
ROBAXIN - methocarbamol tab 500 mg
4
cyclobenzaprine hcl tab 5 mg
1
cyclobenzaprine hcl tab 7.5 mg
(Fexmid)
1
ROBAXIN-750 - methocarbamol tab 750 4
mg
4
SKELAXIN - metaxalone tab 800 mg
DANTRIUM - dantrolene sodium cap 25
mg
4
SOMA - carisoprodol tab 250 mg
4
SOMA - carisoprodol tab 350 mg
4
DANTRIUM - dantrolene sodium cap 50
mg
4
4
DANTRIUM - dantrolene sodium cap
100 mg
4
TIZANIDINE COMFORT PAC tizanidine tab 4 mg & liniment topical
gel pack
tizanidine hcl cap 2 mg (Zanaflex)
2
dantrolene sodium cap 100 mg
(Dantrium)
2
2
2
2
(Dantrium)
tizanidine hcl tab 2 mg
1
(Dantrium)
2
tizanidine hcl tab 4 mg (Zanaflex)
1
ZANAFLEX - tizanidine hcl cap 2 mg
4
ENOVARX-CYCLOBENZAPRINE H cyclobenzaprine hcl td cream 20 mg/
gm (compound kit)
4
4
4
4
ZANAFLEX - tizanidine hcl tab 4 mg
4
FEXMID - cyclobenzaprine hcl tab 7.5
mg
FLEXERIL - cyclobenzaprine hcl tab 5
mg
4
GUANIDINE HCL - guanidine hcl tab
125 mg
4
FLEXERIL - cyclobenzaprine hcl tab 10
mg
4
MESTINON - pyridostigmine bromide
tab 60 mg
4
LORZONE - chlorzoxazone tab 375 mg
4
4
• •
LORZONE - chlorzoxazone tab 750 mg
4
MESTINON - pyridostigmine bromide
syrup 60 mg/5ml
2
MESTINON TIMESPAN pyridostigmine bromide tab cr 180 mg
4
metaxalone tab 800 mg (Skelaxin)
• •
MYTELASE - ambenonium chloride tab
10 mg
4
• •
PROSTIGMIN - neostigmine bromide
tab 15 mg
4
• •
Drug Name
•
Drug Name
Quantity Limits
Prior Review
4
Restricted Access
Drug Tier
Prior Review
CYCLOBENZAPRINE COMFORT P cyclobenzaprine hcl tab 10 mg &
liniment topical gel kit
Quantity Limits
Drug Tier
Restricted Access
2014
• •
• •
ANTIMYASTHENIC AGENTS
methocarbamol tab 500 mg (Robaxin) 1
1
methocarbamol tab 750 mg
(Robaxin-750)
1
orphenadrine citrate tab sr 12hr
100 mg
• •
• •
• •
115
pyridostigmine bromide tab 60 mg
(Mestinon)
1
NUTRITIONAL PRODUCTS
VITAMINS
SUPER DAILY D3 - cholecalciferol
drops 1000 unit/0.03ml (per drop)
4
VITAMIN D - cholecalciferol cap 400
unit
4
VITAMIN D2 - ergocalciferol tab 400 unit 4
4
VITAMIN D3 - cholecalciferol cap 400
unit
4
VITAMIN D3 - cholecalciferol spray
1000 unit/spray
4
VITAMIN D3 400 - cholecalciferol cap
400 unit
4
WELLESSE VITAMIN D3 cholecalciferol oral liquid 1000
unit/10ml
4
WHEAT GERM - wheat germ - oil
AMINOBENZOATE POTASSIUM potassium aminobenzoate packet 2
gm
4
• •
ASCORBIC ACID - ascorbic acid
granules
4
•
BABY DDROPS - cholecalciferol drops
400 unit/0.03ml (per drop)
4
cholecalciferol cap 1000 unit
1
cholecalciferol chew tab 1000 unit
1
cholecalciferol chew tab 400 unit
1
cholecalciferol drops 400 unit/0.03ml
(per drop)
1
cholecalciferol drops 5000 unit/ml
(1000 unit/0.2ml)
1
b-complex w/ c & folic acid cap 1 mg
(Nephrocaps)
1
cholecalciferol oral liquid 400 unit/ml
1
1
cholecalciferol tab 1000 unit
1
b-complex w/ c & folic acid tab 1 mg
(Nephro-vite rx)
1
b-complex w/ c & folic acid tab 5 mg
2
cholecalciferol tab 400 unit
4
b-complex w/ c & folic acid tab
1
CVS VITAMIN D3 - cholecalciferol cap
400 unit
multiple vitamins w/ minerals cap
2
D-VI-SOL - cholecalciferol oral liquid
400 unit/ml
4
pediatric multiple vitamin w/
minerals & c drops 45 mg/ml
2
DDROPS - cholecalciferol drops 1000
unit/0.03ml (per drop)
4
pediatric multiple vitamins w/ fl-fe
drops 0.25-10 mg/ml
1
DECARA - cholecalciferol cap 25000
unit
4
pediatric multiple vitamins w/
fluoride chew tab 0.25 mg
1
DRISDOL - ergocalciferol cap 50000
unit
4
fluoride chew tab 1 mg
1
D3 - cholecalciferol cap 400 unit
4
1
ergocalciferol cap 50000 unit
(Drisdol)
1
fluoride soln 0.25 mg/ml
1
MEPHYTON - phytonadione tab 5 mg
4
fluoride soln 0.5 mg/ml
4
• •
pediatric vitamins acd w/ fluoride
soln 0.25 mg/ml
1
POTABA - potassium aminobenzoate
cap 500 mg
4
• •
pediatric vitamins acd w/ fluoride
soln 0.5 mg/ml
1
POTABA - potassium aminobenzoate
tab 500 mg
116
• •
MULTIVITAMINS
• •
Quantity Limits
Restricted Access
Prior Review
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Drug Name
Prior Review
Drug Tier
2014
4
• •
AP-ZEL - multiple vitamins w/ minerals
tab
4
ATABEX EC - prenatal vit w/ dss-iron
carbonyl-fa tab dr 29-1 mg
4
ATABEX PRENATAL - prenatal vit w/
iron carbonyl-fa tab 65-1 mg
4
B-NEXA - prenatal w/ calcium-vit b6-faginger tab 1.22 mg
4
BACMIN - multiple vitamins w/ minerals
tab
4
BAL-CARE DHA - prenat w/fe poly-na
fered-fa tab 27-1 & omega cap dr
430mg
4
BAL-CARE DHA ESSENTIAL - prenat
w/fe poly-na fered-fa tab 27-1 &
omega cap dr 374mg
4
BP FOLINATAL PLUS B - prenatal w/
calcium carbonate-b6-b12-fa tab 1
mg
4
BP MULTINATAL PLUS - prenatal w/o a 4
vit w/ fe fumarate-fa tab 30-1 mg
BP MULTINATAL PLUS - prenatal w/o a 4
vit w/ fe fum-fa tab chew 40-1 mg
C-NATE DHA - prenatal vit w/ fe fum-fa- 4
omega 3 cap 28-1-200 mg
4
CAVAN ONE OMEGA - prenatal vit w/
fe cbn-fe asp glyc-fa-omega 3 cap
27-1mg
4
CAVAN PRENATAL/EC CALCIUM prenatal w/o a vit w/ fe fumarate-fa
tab dr 30-1 mg
4
CAVAN-ALPHA KIT - prenat w/fe polyna fered-fa tab 27-1 & omega cap dr
300mg
CAVAN-EC SOD DHA - prenatal w/ sod 4
feredetate-fa tab 30-1 & omega 3 cap
dr
4
CITRANATAL B-CALM - prenat w/o a
w/fecbn-feglu-fa tab 20-1 mg & vit b6
tab pak
4
CITRANATAL DHA - prenat w/o a w/
fecbn-fegl-dss-fa tab & dha cap 250
mg pack
4
CITRANATAL HARMONY - prenatal w/
o a w/fe cbn-dss-fa-dha cap 29-1-265
mg
4
CITRANATAL HARMONY - prenat w/
o a w/fe fum-fe cbn-dss-fa-dha cap
27-1-260 mg
4
CITRANATAL RX - prenatal w/o a w/ fe
carbonyl-fe gluc-dss-fa tab 27-1mg
4
CITRANATAL 90 DHA - prenat w/o a
w/fecbn-fegl-dss-fa tab 90 &dha cap
300mg pak
4
CO-NATAL FA - prenatal vit w/ fe
fumarate-fa tab 29-1 mg
4
COD LIVER OIL - cod liver oil
4
COMPLETE NATAL DHA - prenat-fe
bis-fe prot succ-fa-ca tab & omega 3
cap 250 pk
4
COMPLETE-RF PRENATAL - prenatal
without a w/ fe carbonyl-docusate-fa
tab 90-1mg
4
COMPLETENATE - prenatal vit w/ fe
fumarate-fa chew tab 29-1 mg
4
CONCEPT DHA - prenatal w/fe fum-fe
poly -fa-omega 3 cap 53.5-38-1 mg
4
CONCEPT OB - prenatal w/o a w/fe
fum-fe poly-fa cap 130-92.4-1 mg
4
CORVITE - multiple vitamins w/
minerals & fa tab 1.25 mg
4
CRNATAL - prenatal mv w/fecbn-fegldss-fa tab & dha cap 275 mg pack
4
DIALYVITE SUPREME D - multiple
vitamins w/ minerals & fa tab 3 mg
4
Quantity Limits
ADVANCED AM/PM - multiple vitamins
w/ calcium therapy pack
CITRANATAL ASSURE - prenat w/o
a w/fecbn-fegl-dss-fa tab & dha cap
300 mg pack
Restricted Access
• •
Prior Review
4
Drug Name
Drug Tier
Prior Review
ADRENAL C FORMULA - bioflavonoid
products tab
Drug Name
Quantity Limits
Drug Tier
Restricted Access
2014
• •
• •
117
4
DIALYVITE/ZINC - b-complex w/ c-zn &
folic acid tab 1 mg
4
DUET DHA - prenat w/fe poly-na feredfa tab 25-1 & omega cap 400 mg
4
• •
4
• •
FOLGARD OS - multiple vit w/ min &
calcium-folic acid tab 500-1.1 mg
4
4
FOLIVANE-EC CALCIUM DHA N prenatal w/fe fum-fa tab dr 27-1 mg &
dha cap 250 mg pack
DUET DHA - prenat w/fe poly-na feredfa tab 25-1 & omega cap 430 mg
4
FOLIVANE-OB - prenatal w/o a w/fe
fum-fe poly-fa cap 130-92.4-1 mg
4
DUET DHA BALANCED - prenat w/fe
poly-na fered-fa tab 26-1 & omega
cap 278 mg
4
FOLIVANE-PRX DHA NF - prenatal
w/o vit a w/fe fum-dss-fa-dha cap
30-1.24-265 mg
4
DUET DHA BALANCED - prenat w/fe
cap dr 380mg
4
FORTAVIT - multiple vitamins w/
minerals cap
4
4
DUET DHA EC - prenat w/fe poly-na
400mg
4
GENTEX ADE - prenatal vit w/ fe
bisglycinate chelate-fa tab 28-1 mg
4
DUET DHA EC - prenat w/fe poly-na
430mg
4
GESTICARE DHA - prenatal w/fe fumfa tab dr 27-1 mg & dha cap 250 mg
pack
HEMENATAL OB - prenat vit-fe poly
cmplx-fe heme poly-fa tab 28-6-1 mg
4
HEMENATAL OB + DHA - prenat-fe
poly cmplx-fe heme poly-fa tab &
omega 3 cap pck
4
ELITE OB WITH DHA - prenatal vit w/ fe 4
fum-fa-omega 3 cap 28-1.25-200 mg
ELITE-OB - prenatal vit w/ iron carbonyl- 4
fa tab 50-1.25 mg
4
ELITE-OB 400 - prenat w/ fe cbn-fe
bisglyc-fa-fish oil cap 35-5-1.2 mg
4
ESCAVITE - pediatric multiple vitamins
w/ fl-fe chew tab 0.25-7.5 mg
4
EXTRA-VIRT PLUS DHA - prenatal
w/o vit a w/ fe fum-doc-fa-dha cap
29-1.25-350 mg
4
FOCALGIN-B - prenatal w/ calcium-vit
b6-fa-ginger tab 1.22 mg
4
FOLBECAL - prenatal w/ calcium
carbonate-b6-b12-fa tab 1 mg
4
FOLCAL DHA - prenatal w/o vit a w/ fe
fum-dss-fa-dha cap 27-1.25-300 mg
118
• •
• •
• •
INATAL ADVANCE - prenatal vit w/ dss- 4
iron carbonyl-fa tab 90-1 mg
4
INATAL GT - prenatal vit w/ dss-iron
carbonyl-fa tab 90-1 mg
INATAL ULTRA - prenatal vit w/ dss-iron 4
4
LACTOCAL-F - prenatal vit w/ fe
4
MACNATAL CN DHA - prenatal w/o a
w/fe cbn-dss-fa-dha cap 28-1-250 mg
4
MARNATAL-F - prenatal w/o vit a w/ fe
polysac cmplx-fa cap 60-1 mg
4
MARNATAL-F PLUS DUO PACK prenatal w/fe polys cmplx-fa-ca tab &
omega 3 cap pack
Quantity Limits
DIALYVITE 5000 - b-complex w/ cbiotin-e-minerals & folic acid tab 5 mg
FOLCAPS OMEGA 3 - prenatal vit w/
27-1mg
Restricted Access
• •
Prior Review
4
Drug Name
Drug Tier
Prior Review
DIALYVITE 3000 - b-complex w/ cbiotin-e-minerals & folic acid tab 3 mg
Drug Name
Quantity Limits
Drug Tier
Restricted Access
2014
MYNATAL ADVANCE - prenatal vit w/
dss-iron carbonyl-fa tab 90-1 mg
MYNATAL PLUS - prenatal vit w/ fe
4
NESTABS DHA - prenat w/o a w/ fe
bisglyc-fa tab 32-1 mg & omega cap
pack
4
4
NEXA PLUS - prenatal w/o vit a w/ fe
fum-doc-fa-dha cap 29-1.25-350 mg
4
4
NEXA SELECT - prenat w/o vit a w/ fe
fum-dss-fa-dha cap 29-1.25-337.5 mg
4
niacinamide w/ zinc-copper &folic
acid tab 750-25-1.5-0.5 mg
1
NICADAN - multiple vitamins w/
minerals tab
4
MYNATAL ULTRACAPLET - prenatal vit 4
w/ dss-iron carbonyl-fa tab 90-1 mg
4
MYNATAL-Z - prenatal vit w/ fe
MYNATE 90 PLUS - prenatal vit w/ dss- 4
fe fumarate-fa tab cr 90-1 mg
4
NATA KOMPLETE - prenatal vit w/ fe
fum-fe bisglycinate-fa tab 25-1 mg
4
NATACHEW - prenatal vit w/ fe fum-fe
bisglycin-fa chew tab 28-1 mg
4
NATAFORT - prenatal w/o a vit w/ fe
cbn-fe fum-fa tab 60-1 mg
NATALVIRT CA - prenat w/o a w/fecbn- 4
fegl-dss-fa tab & dha cap 300 mg
pack
4
NATALVIRT 90 DHA - prenat w/o a w/
fecbn-fegl-dss-fa tab 90 &dha cap
300mg pak
NATALVIT - prenatal vit w/ fe fumarate- 4
fa tab 75-1 mg
NATELLE ONE - prenatal w/o vit a w/ fe 4
fum-fa-omega 3 cap 28-1-250 mg
4
NATELLE-EZ - prenatal vit w/ fe
fumarate-fa tab 25-0.8 mg
4
NEPHPLEX RX - b-complex w/ c-zn &
folic acid tab 1 mg
4
NEPHRO-VITE RX - b-complex w/ c &
folic acid tab 1 mg
NEPHROCAPS - b-complex w/ c & folic 4
acid cap 1 mg
4
NEPHROCAPS QT - b-complex w/ cbiotin-d & folic acid tab disp 1 mg
• •
• •
NICAZEL - multiple vitamins w/ minerals 4
tab
4
NICOMIDE - niacinamide w/ zn-cumethylfolate tab 750-25-1.5-0.5 mg
4
NUTRICAP - multiple vitamins w/
minerals tab
NUTRIVIT - b-complex w/ lysine-min-fe 4
& fa liqd 800-15-1 mg/15ml
4
O-CAL PRENATAL - prenatal vit w/ fe
4
OB COMPLETE - prenatal vit w/ iron
carbonyl-fa tab 50-1.25 mg
4
OB COMPLETE ONE - prenatal w/
o a w/fecbn-fe asp glyc-fa-fish cap
50-1-476 mg
4
OB COMPLETE PETITE - prenat w/o
a w/fecbn-feaspglyc-fa-omega cap
35-5-1-200 mg
OB COMPLETE PREMIER - prenatal vit 4
w/ fe cbn-fe asp glyc-fa tab 30-20-1
mg
OB COMPLETE 400 - prenatal w/o a w/ 4
fecbn-fe asp glyc-fa-fish cap 40-10-1
mg
4
OB COMPLETE/DHA - prenat w/
iron cbn-fe asp glyc-fa-omega cap
30-10-1-200 mg
Quantity Limits
MYNATAL - prenatal multivitamins &
minerals w/ iron & fa cap 1 mg
4
NESTABS - prenatal vit w/o vit a w/ fe
bisglycinate-fa tab 32-1 mg
Restricted Access
• •
Prior Review
4
Drug Name
Drug Tier
Prior Review
MYKIDZ IRON FL - pediatric vitamins
acd fluoride & fe susp 0.25-10
mg/2ml
Drug Name
Quantity Limits
Drug Tier
Restricted Access
2014
• •
• •
119
120
POLY-VI-FLOR/IRON - ped multiple
vitamin w/ fl-fe biphasic susp 0.25-7
mg/ml
4
• •
POLY-VITAMIN/IRON/FLUORID pediatric multiple vitamins w/ fl-fe
drops 0.5-10 mg/ml
4
• •
PR NATAL 400 - prenat-fe bis-fe prot
succ-fa-ca tab & omega 3 cap 400 pk
4
PR NATAL 400 EC - prenat-fe bis-fe
prot succ-fa-ca tab & omega cap dr
400 pk
4
PR NATAL 430 - prenat-fe bis-fe prot
succ-fa-ca tab & omega 3 cap 430 pk
4
PR NATAL 430 EC - prenat-fe bis-fe
prot succ-fa-ca tab & omega cap dr
430 pk
4
Drug Name
PREFERA OB - prenat vit-fe poly cmplx- 4
fe heme poly-fa tab 28-6-1 mg
4
PREFERA OB + DHA - prenat-fe poly
cmplx-fe heme poly-fa tab & omega 3
cap pck
4
PREFERAOB ONE - prenat-fe poly
cmplx-fe heme poly-fa-dha cap
22-6-1-200 mg
4
PRENAFIRST - prenatal vit w/ fe
PRENAISSANCE - prenatal w/o vit a w/ 4
fe fum-dss-fa-dha cap 29-1.25-325
mg
4
PRENAISSANCE BALANCE - prenatal
w/o vit a w/ fe cbn-dss-fa-dha cap
30-1-260 mg
4
PRENAISSANCE HARMONY DHA prenat w/fe poly-na fered-fa tab 27-1
& omega cap dr 380mg
4
PRENAISSANCE NEXT - prenatal w/
calcium-vit b6-fa-ginger tab 1.2 mg
PRENAISSANCE NEXT-B - prenatal w/ 4
PRENAISSANCE PLUS - prenatal w/o a 4
w/fe cbn-dss-fa-dha cap 28-1-250 mg
Quantity Limits
Restricted Access
Prior Review
Quantity Limits
Restricted Access
• •
Drug Tier
OB-NATAL ONE - prenatal vit w/ fe cbn- 4
fe asp glyc-fa-omega 3 cap 27-1mg
4
OB-NATAL ONE - prenatal w/fe cbnylfe asp glyc-fa-dss-omega cap 20-7-1
mg
4
OBSTETRIX DHA - prenat w/fecbn-fadss tab 29-1 mg & omega 3 cap 387
mg pak
4
OBSTETRIX EC - prenatal vit w/ dssiron carbonyl-fa tab 29-1 mg
4
PAIRE OB - prenat w/ fe poly cmplx-fe
asp-fe gly-fa tab & dha cap pak
4
PNV FERROUS FUMARATE/DOCU prenatal vit w/ dss-fe fumarate-fa tab
29-1 mg
4
PNV OB+DHA - prenat w/o a w/fecbnfegl-dss-fa tab & dha cap 250 mg
pack
4
PNV-DHA - prenat w/o a w/ fe fummethylfol-fa-dha cap 27-0.6-0.4 mg
4
PNV-DHA+DOCUSATE - prenatal
w/o vit a w/ fe fum-dss-fa-dha cap
27-1.25-300 mg
4
PNV-OMEGA - prenat w/o a w/ fe
fumerate-methylfolate-fa-omega 3
cap
4
PNV-SELECT - prenatal vit w/ fe fummethylfolate-fa tab 27-0.6-0.4 mg
4
PNV-TOTAL - prenat w/ fe cbn-fe
bisglyc-fa-fish oil cap 35-5-1.2 mg
4
POLY-VI-FLOR - ped multiple vit w/
fluoride biphasic chew tab 0.25 mg
4
fluoride biphasic chew tab 0.5 mg
4
fluoride biphasic chew tab 1 mg
4
fluoride biphasic susp 0.25 mg/ml
4
POLY-VI-FLOR/IRON - ped multiple vit
w/ fl-fe biphasic chew tab 0.5-10 mg
Prior Review
Drug Name
Drug Tier
2014
PRENATABS FA - prenatal vit w/ fe
4
PRENATABS OBN - prenatal w/o a vit
w/ fe carbonyl-fa tab 29-1 mg
4
PRENATABS RX - prenatal vit w/ iron
PREQUE 10 - prenatal mv w/fe
carbonyl-dss-fa-dha tab 15-25-0.5-50
mg
4
PROMAR - iron & b12 w/ vitamin cap
4
4
PROTECT PLUS - multiple vitamins w/
minerals cap
4
• •
• •
PRENATAL AD - prenatal vit w/ dss-iron 4
4
PRENATAL PLUS IRON - prenatal vit
w/ iron carbonyl-fa tab 29-1 mg
4
PRENATAL 19 - prenatal vit w/ fe
4
PRENATAL 19 - prenatal vit w/ dss-fe
4
PRENATAL-U - prenatal w/o a vit w/ fe
fumarate-fa cap 106.5-1 mg
4
PRENATE - prenat mv & min w/ lmethylfolate-fa chew tab 0.6-0.4 mg
4
PRENATE DHA - prenat w/o a w/ fe
fum-methylfol-fa-dha cap 28-0.6-0.4
mg
4
PRENATE ELITE - prenatal vit w/ fe
fum-methylfolate-fa tab 26-0.6-0.4 mg
4
PRENATE ESSENTIAL - prenat w/
o a w/feasp-methylf-fa-omeg cap
29-0.6-0.4-340 mg
PRENATE MINI - prenat w/o a w/fecbn- 4
methylf-fa-dha cap 29-0.6-0.4-350 mg
4
PRENA1 CHEW/QUATREFOLIC prenat w/ b2-b6-b12-d3-methylfol-fa
chew tab 0.6-0.4 mg
PRENA1 PEARL - prenat w/oa w/fefum- 4
na fered-fa-dha cap cr 30-1.4-200 mg
4
PRENA1 PLUS/QUATREFOLIC prenat w/o a w/ fe chelate-l methylfolfa tab & dha cap pk
4
PRENA1/QUATREFOLIC - prenat w/
o a w/ fe fum-methylfol-fa-dha cap
30-0.6-0.4 mg
PRENEXA - prenatal w/o vit a w/ fe fum- 4
dss-fa-dha cap 27-1.25-300 mg
PROTECT PLUS - multiple vitamins w/
minerals liquid
4
• •
PROTECT PLUS NR - multiple vitamins
w/ minerals cap
4
• •
PROTECTBONE - multiple vit w/ min &
calcium-folic acid wafer 500-1 mg
4
• •
PROTECTNATAL - prenatal vit w/poly
fe-fa-fish oil tab dr 13.5-0.5-700 mg
4
PUREFE OB PLUS - prenatal w/o a w/fe 4
fum-fe poly-fa cap 162.115.2-1 mg
REAPHIRM - prenatal mv w/ fe polysac 4
cmplx-fa-dha cap 29-1-200 mg
RELNATE DHA - prenatal vit w/ fe fum- 4
fa-omega 3 cap 28-1-200 mg
RENATABS - b-complex w/ c-biotin-vit e 4
& folic acid tab 1 mg
RENATABS WITH IRON - b complex-c- 4
biotin-e-fa tab 1mg & fe cbn tab 100
mg pack
4
RENAX - multiple vitamins w/ minerals
& fa tab 2.5 mg
REQ 49+ - multiple vitamins w/ minerals 4
tab
SE-CARE - prenatal w/o a vit w/ fe fum- 4
fa tab chew 40-1 mg
4
SE-CARE CONCEIVE - prenatal w/o a
vit w/ fe fumarate-fa tab 30-1 mg
4
SE-NATAL ONE - prenatal vit w/ fe
4
SE-NATAL 19 - prenatal vit w/ fe
4
SE-NATAL 19 - prenatal vit w/ dss-fe
Quantity Limits
Restricted Access
Prior Review
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Drug Tier
2014
• •
• •
• •
121
SE-NATAL 90 - prenatal vit w/ dss-fe
fumarate-fa tab cr 90-1 mg
4
TANDEM DHA - prenatal w/fe fum-fe
poly -fa-omega 3 cap 15-15-1 mg
4
SE-PLETE DHA - prenatal vit w/ fe fumfa-omega 3 cap 28-1.25-200 mg
4
TANDEM OB - prenatal w/o a w/fe fumfe poly-fa cap 162.115.2-1 mg
4
SE-TAN DHA - prenatal w/fe fum-fe poly 4
-fa-omega 3 cap 15-15-1 mg
SELECT-OB - prenatal vit w/ fe polysac 4
cmplx-fa chew tab 29-1 mg
4
SELECT-OB+DHA - prenatal mv w/fe
poly-fa chw 29-1 mg & dha cap 250
mg pak
4
SETON ET-EC - prenat-fe bis-fe prot
succ-fa-ca tab & omega cap dr 430
pk
4
SETONET - prenat-fe bis-fe prot succfa-ca tab & omega 3 cap 430 pk
4
SIDEROL - multiple vitamins w/
minerals tab
4
SM B-COMPLEX/VITAMIN C - bcomplex w/ c & folic acid tab
STROVITE - b-complex w/ c & folic acid 4
tab
4
STROVITE FORTE - multiple vitamins
w/ minerals tab
4
STROVITE FORTE - multiple vitamins
w/ minerals & fa syrup 1 mg/15ml
4
STROVITE ONE - multiple vitamins w/
minerals tab
SUPERVITE - b-complex w/ lysine-zn & 4
folic acid liquid
4
SUPERVITE EC - multiple vitamins w/
minerals & fa tab dr 1 mg
4
SUPPORT - multiple vitamins w/
minerals liquid
4
SUPPORT-500 - speciality vitamin
product cap
4
SYNAGEX - multiple vitamins w/
minerals & fa cap 1.25 mg
4
SYNATEK - multiple vitamins w/
minerals & fa cap 1.25 mg
TARON EC CALCIUM - prenatal mv w/
fe fum-fa tab 28-1 mg & dha cap 250
mg pack
4
TARON-BC - prenat w/o a w/ fe cbnyl-fa
tab 20-1 mg & vit b6 tab pak
4
TARON-C DHA - prenatal w/fe fum-fe
poly -fa-omega 3 cap 53.5-38-1 mg
4
TARON-DUO EC - prenat-fe bis-fe prot
succ-fa-ca tab & omega cap dr 400
pk
4
TARON-EC CAL - prenatal w/o a vit w/
fe fumarate-fa tab dr 30-1 mg
4
TARON-PREX - prenatal w/o vit a w/ fe
4
TL G-FOL OS - multiple vit w/ min &
calcium-folic acid tab 500-1.1 mg
4
TL-ASSURE ONE - prenatal mv w/ fe
polysac cmplx-fa-dha cap 29-1-200
mg
4
TL-FLUORIVITE - pediatric multiple
vitamins w/ fl-fe chew tab 0.25-7.5 mg
4
TL-SELECT - prenatal w/o vit a w/ fe
4
4
• •
TL-SELECT DHA - prenatal w/o vit a w/
fe fum-doc-fa-dha cap 29-1.25-350
mg
• •
TRI RX - prenatal w/o a w/ fe carbonylfe gluc-dss-fa tab 27-1mg
4
• •
TRI-TABS DHA - prenat w/o a w/ fe
bisglyc-fa tab 32-1 mg & omega cap
pack
4
TRI-VI-FLOR - ped vit acd & l-methylfol
w/ fl biphasic susp 0.25 mg/ml
4
• •
TRI-VI-FLOR - ped vit acd & l-methylfol
w/ fl biphasic susp 0.5 mg/ml
4
• •
122
• •
• •
• •
• •
• •
Quantity Limits
Restricted Access
Prior Review
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Drug Name
Prior Review
Drug Tier
2014
• •
TRUST NATAL DHA - prenat-fe bis-fe
prot succ-fa-ca tab & omega 3 cap
250 pk
4
TRI-VI-FLORO - ped vit acd & lmethylfol w/ fl biphasic susp 0.5 mg/
ml
4
• •
UDAMIN - multiple vitamins w/ minerals
& fa tab 2 mg
4
• •
4
• •
TRI-VIT/FLUORIDE/IRON - pediatric
vitamins acd fluoride & fe drops
0.25-10 mg/ml
4
UDAMIN SP - multiple vitamins w/
minerals & fa tab 1 mg
4
TRI-ZEL - multiple vitamins w/ minerals
tab
4
ULTIMATE OB DHA - prenat w/ fe poly
cmplx-fe asp-fe gly-fa tab & dha cap
pak
TRIADVANCE - prenatal vit w/ dss-iron
4
TRICARE DHA 301 - prenatal w/fe
fumarate-fa-dss-fish oil cap 27-1-710
mg
4
TRICARE PRENATAL DHA ONE prenatal w/fe fumarate-fa-dss-fish oil
cap 27-1-500 mg
4
TRIMESIS RX - prenatal w/ calcium
carbonate-b6-b12-fa tab 1 mg
4
TRINATAL GT - prenatal vit w/ dss-iron
4
TRINATAL RX 1 - prenatal vit w/ fe
4
TRINATAL ULTRA - prenatal vit w/ dssiron carbonyl-fa tab 90-1 mg
4
TRINATE - prenatal vit w/ fe fumarate-fa 4
tab 28-1 mg
4
TRIVEEN-DUO DHA - prenat-fe bis-fe
prot succ-fa-ca tab & omega 3 cap
400 pk
TRIVEEN-ONE - prenatal w/o vit a w/ fe 4
fum-fa-omega 3 cap 27-1-250 mg
TRIVEEN-PRX RNF - prenatal w/o vit a 4
w/ fe fum-dss-fa-dha cap 26-1.2-300
mg
TRIVEEN-TEN - prenatal mv & min w/fe 4
carbonyl-fa-dha tab 15-0.5-50 mg
4
TRIVEEN-U - prenatal w/o a vit w/ fe
fumarate-fa cap 106.5-1 mg
• •
Quantity Limits
Restricted Access
4
Drug Name
Prior Review
TRI-VI-FLORO - ped vit acd & lmethylfol w/ fl biphasic susp 0.25 mg/
ml
Drug Name
Drug Tier
Prior Review
Quantity Limits
Drug Tier
Restricted Access
2014
ULTIMATECARE ADVANTAGE - prenat 4
w/o a w/ fe asp gly-fa-dss-omega ther
pak 30-1 mg
ULTIMATECARE COMBO - prenat w/o 4
a w/ fe asp gly-fa-dss-omega ther pak
30-1 mg
4
ULTIMATECARE ONE - prenatal vit w/
27-1mg
4
ULTIMATECARE ONE NF - prenatal
w/fe cbnyl-fe asp glyc-fa-dss-omega
cap 20-7-1 mg
4
ULTRA TABS - prenatal vit w/ dss-iron
4
VEMAVITE-PRX 2 - prenatal w/o vit a
w/ fe fum-dss-fa-dha cap 27-1.25-300
mg
4
VENA-BAL DHA - prenat w/fe poly-na
430mg
VENATAL COMPLETE DHA - prenat w/ 4
fe poly-na fered-fa tab 27-1 & omega
cap dr 430mg
4
VENATAL-FA - prenatal vit w/ fe
4
VINACAL - prenatal w/o a w/ fe
carbonyl-fe gluc-dss-fa tab 27-1mg
4
VINATE AZ - prenatal vit w/ fe
4
VINATE AZ EXTRA - prenatal vit w/ fe
123
VINATE C - prenatal w/o a vit w/ fe
4
VINATE CALCIUM - prenatal vit w/ iron
carbonyl-fe gluc-fa tab 27-1 mg
4
VINATE CARE - prenatal w/o a vit w/ fe
fum-fa tab chew 40-1 mg
VITAFOL-ONE - prenatal mv w/ fe
mg
4
4
4
VITAFOL-PLUS - prenatal mv w/ fe
mg
VINATE GT - prenatal vit w/ dss-iron
4
VITAFOL-PN - prenatal vit w/ fe
4
VINATE IC - prenatal w/o a w/fe fum-fe
poly-fa cap 162.115.2-1 mg
4
VITAL-D RX - b-complex w/ c-biotin-dzinc & folic acid tab 1 mg
4
VINATE II - prenatal vit w/ fe
4
4
VINATE M - prenatal vit w/ sel-fe
4
VITAMEDMD ONE RX/QUATREFO prenat w/o a w/ fe fum-methylfol-fadha cap 30-0.6-0.4 mg
4
VINATE ONE - prenatal vit w/ fe
4
VITAMEDMD PLUS RX/QUATRE prenat w/o a w/ fe chelate-l methylfolfa tab & dha cap pk
4
VITAMEDMD REDICHEW RX/QUA prenat w/ b2-b6-b12-d3-methylfol-fa
chew tab 0.6-0.4 mg
4
VINATE PN CARE - prenatal without a
w/ fe asparto gly-doc-fa tab 30-1mg
VINATE ULTRA - prenatal vit w/ dssiron carbonyl-fa tab 90-1 mg
4
VITAPEARL - prenat w/oa w/fefum-na
fered-fa-dha cap cr 30-1.4-200 mg
4
VIRT-BAL DHA PLUS - prenat w/fe
cap dr 380mg
4
VITAROCA PLUS - multiple vitamins w/
minerals tab
4
4
VITASPIRE - prenatal w/o a vit w/ fe
4
VIRT-PN - prenatal vit w/ fe fummethylfolate-fa tab 27-0.6-0.4 mg
VIRT-PN DHA - prenat w/o a w/ fe fummethylfol-fa-dha cap 27-0.6-0.4 mg
4
VIRT-SELECT - prenatal w/o vit a w/ fe
4
VITA-PREN - prenatal vit w/ docusateiron-fa tab 65-1 mg
4
VITAFOL - iron w/ vitamin tab
4
VITAFOL - iron w/ vitamin syrup
4
VITAFOL-NANO - prenatal w/o a w/
fefum-l methylfol-fa tab 18-0.6-0.4 mg
4
VITAFOL-OB - prenatal vit w/ fe
4
VITAFOL-OB+DHA - prenatal mv w/fe
fum-fa tab 65-1 mg & dha cap 250
mg pack
4
124
• •
VIVA CT PRENATAL - prenatal w/o a vit 4
w/ fe fum-fa tab chew 28-1 mg
4
VIVA DHA - prenatal vit w/ fe fum-faomega 3 cap 28-1-200 mg
VOL-NATE - prenatal vit w/ fe fumarate- 4
fa tab 28-1 mg
VOL-PLUS - prenatal vit w/ fe fumarate- 4
fa tab 27-1 mg
4
VOL-TAB RX - prenatal vit w/ iron
VP CH ULTRA - prenat w/o a w/fe fum- 4
fe cbn-dss-fa-dha cap 27-1-260 mg
4
VP-CH-PNV - prenatal w/o vit a w/ fe
cbn-dss-fa-dha cap 30-1-260 mg
4
VP-GGR-B6 PRENATAL - prenatal w/
Quantity Limits
Restricted Access
Prior Review
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Drug Name
Prior Review
Drug Tier
2014
VP-HEME OB - prenat vit-fe poly cmplxfe heme poly-fa tab 28-6-1 mg
4
VP-HEME OB + DHA - prenat-fe poly
cmplx-fe heme poly-fa tab & omega 3
cap pck
4
4
FLUORABON - sodium fluoride soln
0.25 mg/0.6ml (from 0.55 mg/0.6ml
naf)
4
VP-PNV-DHA - prenatal vit w/ fe fum-faomega 3 cap 28-1-215.8 mg
4
FLURA-DROPS - sodium fluoride soln
0.25 mg/drop f (from 0.55 mg/drop
naf)
GALZIN - zinc acetate cap 25 mg
4
ZATEAN-CH - prenatal w/o a w/fe cbndss-fa-dha cap 27-1-250 mg
4
GALZIN - zinc acetate cap 50 mg
4
ZATEAN-PN - prenatal vit w/ fe fummethylfolate-fa tab 27-0.6-0.4 mg
IODINE STRONG - iodine solution
strong 5% (lugol's)
4
4
ZATEAN-PN DHA - prenat w/o a w/ fe
fum-methylfol-fa-dha cap 27-0.6-0.4
mg
K-LOR HOSPITAL PACK - potassium
chloride powder packet 20 meq
4
4
K-PHOS - potassium phosphate
monobasic tab 500 mg
4
ZATEAN-PN PLUS - prenat w/o a w/
fe fumerate-methylfolate-fa-omega 3
cap
4
K-PHOS NEUTRAL - pot phos
monobasic w/sod phos di & monobas
tab 155-852-130mg
4
ZINGIBER - prenatal w/ calcium-vit b6fa-ginger tab 1.2 mg
4
K-TAB - potassium chloride tab cr 10
meq
4
K-TAB - potassium chloride tab cr 20
meq (1500 mg)
4
• •
4
• •
KLOR-CON M15 - potassium chloride
microencapsulated crys cr tab 15
meq
4
4
MINERALS and ELECTROLYTES
CALCIFOL - ca carb-folic acid-vit d-b6b12-boron-mag wafer 1342-1.6 mg
4
CALCIUM-FOLIC ACID PLUS D - ca
carb-folic acid-vit d-b6-b12-boronmag wafer 1342-1 mg
4
EFFER-K - potassium bicarbonate-citric
acid effer tab 10 meq
4
KLOR-CON 25 - potassium chloride
powder packet 25 meq
EFFER-K - potassium bicarbonate-citric
acid effer tab 20 meq
4
LOZI-FLUR - sodium fluoride lozenge 1
mg f (from 2.2 mg naf)
FLORICAL - sodium fluoride w/ calcium
carb cap 8.3-364 mg
4
FLORICAL - sodium fluoride w/ calcium
carb tab 8.3-364 mg
4
FLUOR-A-DAY - sodium fluoride-xylitol
chew tab 0.55 (0.25 mg f)-236.79 mg
4
chew tab 1.1 (0.5 mg f)-236.79 mg
4
chew tab 2.2 (1 mg f)-236.79 mg
4
LURIDE - sodium fluoride chew tab 0.25 4
4
LURIDE - sodium fluoride chew tab 0.5
4
LURIDE - sodium fluoride chew tab 1
4
LURIDE - sodium fluoride soln 0.5 mg/
ml f (from 1.1 mg/ml naf)
4
MAGNEBIND 400 - magnesiumcalcium-folic acid tab 400-200-1 mg
MICRO-K - potassium chloride cap cr 8 4
meq
Quantity Limits
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2014
• •
• •
• •
• •
• •
• •
125
MICRO-K - potassium chloride cap cr 10 4
meq
4
MONOCAL - sodium
monofluorophosphate-calcium carb
tab 22.75-625 mg
2
pot bicarbonate & chloride effer tab
25 meq
1
pot phos monobasic w/sod phos di
& monobas tab 155-852-130mg (Kphos neutral)
1
potassium bicarbonate effer tab 25
meq
1
potassium chloride cap cr 10 meq
(Micro-k)
1
potassium chloride cap cr 8 meq
(Micro-k)
4
POTASSIUM CHLORIDE ER potassium chloride tab cr 20 meq
(1500 mg)
1
potassium chloride
meq
1
potassium chloride
meq
1
potassium chloride oral liq 10% (20
meq/15ml)
1
potassium chloride oral liq 20% (40
meq/15ml)
1
potassium chloride powder packet
20 meq
2
potassium chloride powder packet
25 meq
potassium chloride tab cr 10 meq (K- 1
tab)
1
potassium chloride tab cr 8 meq
(600 mg)
4
SODIUM FLUORIDE - sodium fluoride
tab 0.5 mg f (from 1.1 mg naf)
1
SODIUM FLUORIDE - sodium fluoride
tab 1 mg f (from 2.2 mg naf)
126
sodium fluoride chew tab 0.25 mg f
(from 0.55 mg naf) (Luride)
1
sodium fluoride chew tab 0.5 mg f
1
sodium fluoride chew tab 1 mg f
1
sodium fluoride soln 0.125 mg/drop f
(0.275 mg/drop naf)
2
sodium fluoride soln 0.5 mg/ml f
(from 1.1 mg/ml naf) (Luride)
1
SSKI - potassium iodide soln 1 gm/ml
4
zinc sulfate cap 220 mg (50 mg
elemental zn)
1
• •
NUTRIENTS
acetylcysteine cap 600 mg
2
CARDIOVID PLUS - dha-epa-vit b6b12-folic acid cap 240-360-20-0.5-0.8
mg
4
• •
LECITHIN - lecithin granules
4
NUTRESTORE - glutamine powd pack
5 gm
4
•
• •
TRYPTOPHAN - tryptophan cap 500 mg 4
• •
DIETARY PRODUCTS
CALAFOL RX - fa-hydroxocobalaminpolicosanol-vit b6-vit d-ca tab
4
• •
CARDIOTEK-RX - folic acid-b12-b6arginine-black pepper tab
4
• •
ENTERAGAM - serum-derived bovine
immunoglob/protein isolate 5 gm
packet
4
Q-TABS - levomefolate glucosamine tab 4
1 mg (folate equivalent)
4
SACCHARIN SODIUM - sodium
saccharin granules
4
SACCHARIN SODIUM - sodium
saccharin powder
4
SODIUM SACCHARIN - sodium
saccharin granules
4
SODIUM SACCHARIN DIHYDRAT sodium saccharin powder
•
•
•
•
Quantity Limits
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2014
HEMATOLOGICAL AGENTS
HEMATOPOIETIC AGENTS
ARANESP ALBUMIN FREE darbepoetin alfa-polysorbate 80 soln
inj 100 mcg/0.5ml
5
inj 150 mcg/0.75ml
5
inj 150 mcg/0.3ml
5
inj 200 mcg/ml
5
inj 200 mcg/0.4ml
5
inj 300 mcg/ml
5
5
fe fum-iron polysacch complex-fab cmplx-c-zn-mn-cu cap (Tandem
plus)
1
ferrous fumarate-fa-b complex-c-znmg-mn-cu tab 106-1 mg
1
folic acid-vit b6-vit b12-omega 3phytosterols cap 1 mg
2
iron combination cap
2
iron-docusate-b12-folic acid-c-e-cubiotin tab 150-1 mg (Hematron-af)
1
ACTIVE FE - fe carbonyl-fa-b complexa-c-d-e-min tab 75-1.25 mg
4
ANIMI-3 - folic acid-b6-b12-d-omega 3phytosterols cap 1 mg
4
• •
ANIMI-3/VITAMIN D - folic acid-b6-b12d-omega 3-phytosterols cap 1 mg
4
• •
inj 25 mcg/ml
5
inj 300 mcg/0.6ml
5
inj 25 mcg/0.42ml
5
inj 500 mcg/ml
4
inj 40 mcg/ml
5
B-6 FOLIC ACID - cobalamine
combination cap
4
inj 40 mcg/0.4ml
5
BIFERARX - polysacch fe cmplx-fe
heme poly-fa-b12 tab 22-6-1-0.025
mg
BP VIT 3 - folic acid-vit b6-vit b12omega 3-phytosterols cap 1 mg
4
inj 60 mcg/ml
5
carbonyl iron chew tab 15 mg
(elemental iron)
1
inj 60 mcg/0.3ml
carbonyl iron susp 15 mg/1.25ml
(elemental iron)
1
5
4
• •
inj 100 mcg/ml
5
CENTRATEX - ferrous fumarate-fa-b
complex-c-zn-mg-mn-cu cap 106-1
mg
CORVITE FE - iron combination tab
4
CORVITE 150 - iron combination tab
4
• •
• •
Quantity Limits
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2014
• •
127
DIVISTA - folic acid-vit b6-vit b12omega 3-biotin-cr cap 1 mg
4
DROXIA - hydroxyurea cap 200 mg
5
5
5
ED CYTE F - ferrous fumarate-folic
acid-docusate sodium tab 324-1-50
mg
4
EPOGEN - epoetin alfa inj 2000 unit/ml
5
5
5
• •
• •
EPOGEN - epoetin alfa inj 10000 unit/ml 5
EPOGEN - epoetin alfa inj 20000 unit/ml 5
FERREX 28 - fe asparto gly-fe fum-b12fa-c-succinic ac tab ther pack
4
• •
FERRO-PLEX HEMATINIC - fe fumdss-vit c-vit e-vit b12-if-fa tab 115-1
mg
4
• •
FERROTRIN - iron w/ b12-vit c-fa-ifc
cap 36-0.015-75-0.5-240 mg
4
• •
ferrous fumarate-folic acid tab
324-1 mg
1
FERROUS SULFATE - ferrous sulfate
liquid 220 mg/5ml (44 mg/5ml
elemental fe)
4
FERROUS SULFATE - ferrous sulfate
syrup 300 mg/5ml (60 mg/5ml
elemental fe)
4
ferrous sulfate elixir 220 mg/5ml
(44 mg/5ml elemental fe)
1
Drug Name
FA-8 - folic acid cap 0.8 mg
4
1
ferrous sulfate soln 75 mg/ml (15 mg/
ml elemental fe)
1
fe fumarate w/ b12-vit c-fa-ifc cap
110-0.015-75-0.5-240 mg
1
ferrous sulfate-vit c-folic acid tab cr
105-500-0.8 mg
1
fe fumarate-vit c-vit b12-fa cap 460
(151 fe)-60-0.01-1 mg
4
FETRIN - iron combination cap cr
4
FE 90 PLUS - fe carbonyl-fe gluconatefa-vit b12-vit c-dss tab 90-1 mg
4
FER-IN-SOL - ferrous sulfate soln 75
mg/ml (15 mg/ml elemental fe)
4
FOLGARD RX - folic acid-vitamin b6vitamin b12 tab 2.2-25-1 mg
folic acid tab 1 mg
1
FERIVA - fe bisglycin-fe carbonyl-c-fab12-biotin-dss cap 75-1 mg
4
folic acid tab 400 mcg
1
folic acid tab 800 mcg
1
• •
folic acid-vitamin b6-vitamin b12 tab
2.2-25-0.5 mg
1
• •
folic acid-vitamin b6-vitamin b12 tab
2.2-25-1 mg (Folgard rx)
1
FOLIVANE-F - fe fum-fe poly-fa-c-b3
cap 62.5-62.5-1-40-3mg(125 mg fe)
4
• •
FOLIVANE-PLUS - fe fum-iron
polysacch complex-fa-b complex-cbiotin cap
4
• •
FOLTRATE - cobalamine combination
tab
4
FUMATINIC - iron combination cap cr
4
FERIVAFA - iron-c-fa-b12-biotin-copper- 4
docusate cap 110-1 mg
4
FERRALET 90 - fe carbonyl-fe
gluconate-fa-vit b12-vit c-dss tab 90-1
mg
FERRAPLUS 90 - iron-folic acid-vit b12- 4
vit c-docusate sod tab 90-1 mg
4
FERRETTS CHEWABLE IRON carbonyl iron chew tab 18 mg
(elemental iron)
4
FERREX 150 FORTE PLUS - fe asp
gly-fe polysacch-succ ac-c-threon acb12-fa cap
128
• •
• •
• •
• •
• •
• •
Quantity Limits
Restricted Access
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4
Drug Tier
CORVITE 150 - iron-folic acid-vit c-vit
b6-vit b12-zinc tab 150-1.25 mg
Restricted Access
Drug Name
Prior Review
Drug Tier
2014
• •
MAXARON FORTE - fe bisglycinate-fe
polysacch-vit c-vit b12-fa cap
4
• •
GRANIX - tbo-filgrastim soln prefilled
syringe 300 mcg/0.5ml
5
MAXARON FORTE - fe gly-fe fum-vit cvit b12-methylfolate tab
4
• •
GRANIX - tbo-filgrastim soln prefilled
syringe 480 mcg/0.8ml
5
MOZOBIL - plerixafor subcutaneous inj
24 mg/1.2ml (20 mg/ml)
5
• •
HEMATOGEN FA - fe fumarate-vit c-vit
b12-fa cap 200-250-0.01-1 mg
4
MULTIGEN - fe asparto gly-succ acd-cthreonic acd-b12-des stom tab
4
• •
HEMATRON-AF - iron-docusate-b12folic acid-c-e-cu-biotin tab 150-1 mg
4
4
• •
HEMETAB - polysacch fe cmplx-fe
heme poly-fa-b12 tab 22-6-1-0.025
mg
4
MULTIGEN FOLIC - fe asparto glysuccinic acd-vit c-threonic acd-b12-fa
tab
• •
HEMOCYTE PLUS - ferrous fumaratefa-b complex-c-zn-mg-mn-cu cap
106-1 mg
4
• •
HEMOCYTE-F - iron combination elixir
4
• •
ICAR - carbonyl iron chew tab 15 mg
(elemental iron)
4
ICAR PEDIATRIC - carbonyl iron susp
15 mg/1.25ml (elemental iron)
4
ICAR-C PLUS - iron-vit c-vit b12-folic
acid tab 100-250-0.025-1 mg
4
INTEGRA F - fe fum-fe poly-fa-c-b3 cap
62.5-62.5-1-40-3mg(125 mg fe)
4
• •
MULTIGEN PLUS - fe aspart gly-fe fum- 4
succ acd-c-threonic acd-b12-fa tab
4
MYKIDZ IRON 10 - iron susp 15
mg/1.5ml
4
NASCOBAL - cyanocobalamin nasal
spray 500 mcg/0.1ml
4
NATALVIRT FLT - fe carbonyl-fe
gluconate-fa-vit b12-vit c-dss tab 90-1
mg
NEPHRON FA - ferrous fumarate w/ fa- 4
dss-b complex-vit c tab
5
NEULASTA - pegfilgrastim inj 6
mg/0.6ml
5
NEUMEGA - oprelvekin for inj 5 mg
INTEGRA PLUS - fe fum-iron polysacch
complex-fa-b complex-c-biotin cap
4
• •
NEUPOGEN - filgrastim inj 300 mcg/ml
5
4
• •
NEUPOGEN - filgrastim inj 480
mcg/1.6ml (300 mcg/ml)
5
IRON - iron combination tab
iron polysacch complex-vit b12-fa
cap 150-0.025-1 mg
1
5
iron-folic acid-vit c-vit b6-vit b12-zinc
tab 150-1.25 mg (Corvite 150)
1
5
iron-vit c-vit b12-folic acid tab
100-250-0.025-1 mg (Icar-c plus)
1
NEURIN-SL - cyanocobalaminmethylcobalamin tab sl 600-600 mcg
4
• •
IROSPAN 24/6 - fe asp gly-fe polyssucc acd-b cmplx-c-ca-fa tab ther pk
4
NIRON KOMPLETE - fe bisglycinate-fe
fum-vit c-vit b12-vit e-fa tab 30-1 mg
4
• •
NOVAFERRUM - polysacch iron
complex-vit c-fa for soln 100-60-1
mg/5ml
4
• •
Drug Name
LEUKINE - sargramostim inj 500 mcg/ml 5
LEUKINE - sargramostim lyophilized for 5
inj 250 mcg
• •
• •
• •
Drug Name
Quantity Limits
Prior Review
4
Restricted Access
Drug Tier
Prior Review
FUSION PLUS - fe fum-iron poly cmplxfa-b cmplx-c-biotin-probiotic cap
Quantity Limits
Drug Tier
Restricted Access
2014
• •
• •
• •
129
PROCRIT - epoetin alfa inj 3000 unit/ml
5
5
PROCRIT - epoetin alfa inj 10000 unit/
ml
ANTICOAGULANTS
ARIXTRA - fondaparinux sodium inj 2.5
mg/0.5ml
5
ARIXTRA - fondaparinux sodium inj 5
mg/0.4ml
5
5
ARIXTRA - fondaparinux sodium inj 7.5
mg/0.6ml
5
ml
5
ARIXTRA - fondaparinux sodium inj 10
mg/0.8ml
5
ml
5
COUMADIN - warfarin sodium tab 1 mg
4
4
PROFERRIN-FORTE - iron heme
polypeptide-folic acid tab 12-1 mg (fe
equiv)
4
COUMADIN - warfarin sodium tab 2.5
mg
4
4
PROMACTA - eltrombopag olamine tab
12.5 mg (base equiv)
5
4
5
4
25 mg (base equiv)
4
50 mg (base equiv)
5
COUMADIN - warfarin sodium tab 7.5
mg
4
75 mg (base equiv)
5
COUMADIN - warfarin sodium tab 10
mg
4
PROTECTIRON - iron polysacch-fa-b
complex-vit c-e & minerals tab 60-1
mg
4
ELIQUIS - apixaban tab 2.5 mg
4
ELIQUIS - apixaban tab 5 mg
4
4
enoxaparin sodium inj 100 mg/ml
(Lovenox)
2
PUREFE PLUS - ferrous fumarate-fab complex-c-zn-mg-mn-cu cap 106-1
mg
2
SENILEZOL - iron combination elixir
4
enoxaparin sodium inj 120 mg/0.8ml
(Lovenox)
SPATONE PUR-ABSORB IRON ferrous sulfate liquid 5 mg/20ml
(elemental iron)
enoxaparin sodium inj 150 mg/ml
(Lovenox)
2
4
2
TANDEM F - ferrous fum-iron
polysacch-fa cap 162-115.2-1 mg
(106 mg fe)
4
(Lovenox)
enoxaparin sodium inj 300 mg/3ml
(Lovenox)
2
4
(Lovenox)
2
TANDEM PLUS - fe fum-iron polysacch
complex-fa-b cmplx-c-zn-mn-cu cap
4
• •
(Lovenox)
2
TARON FORTE - fe bisglycinate-fe
polysacch-vit c-vit b12-fa cap
5
• •
(Lovenox)
2
ZAVESCA - miglustat cap 100 mg
130
• •
• •
• •
• •
• •
Quantity Limits
5
Restricted Access
• •
Prior Review
4
Drug Name
Drug Tier
Prior Review
PRE-FOLIC - folic acid-vitamin c tab
1-100 mg
Drug Name
Quantity Limits
Drug Tier
Restricted Access
2014
fondaparinux sodium inj 10 mg/0.8ml
(Arixtra)
2
LOVENOX - enoxaparin sodium inj 30
mg/0.3ml
4
fondaparinux sodium inj
2.5 mg/0.5ml (Arixtra)
2
mg/0.4ml
4
fondaparinux sodium inj 5 mg/0.4ml
(Arixtra)
2
mg/0.6ml
4
fondaparinux sodium inj
7.5 mg/0.6ml (Arixtra)
2
mg/0.8ml
4
FRAGMIN - dalteparin sodium inj 10000
unit/ml
5
mg/ml
4
unit/0.2ml
5
mg/0.8ml
4
unit/0.2ml
5
mg/ml
4
unit/0.3ml
5
mg/3ml
4
unit/0.5ml
5
4
unit/0.6ml
5
PRADAXA - dabigatran etexilate
mesylate cap 75 mg (etexilate base
eq)
4
unit/0.72ml
5
PRADAXA - dabigatran etexilate
mesylate cap 150 mg (etexilate base
eq)
unit/ml
5
heparin sodium (porcine) 100 unit/ml
in d5w (Heparin sodium/d5w)
1
in sodium chloride 0.9% (Heparin
sodium/sodiu)
1
in d5w (Heparin sodium/d5w)
1
warfarin sodium tab 3 mg (Coumadin) 1
HEPARIN SODIUM/D5W - heparin
sodium (porcine) 50 unit/ml in d5w
4
HEPARIN SODIUM/D5W - heparin
sodium (porcine) 100 unit/ml in d5w
4
warfarin sodium tab 7.5 mg
(Coumadin)
1
HEPARIN SODIUM/SODIUM CHL heparin sodium (porcine) 2 unit/ml in
sodium chloride 0.9%
4
XARELTO - rivaroxaban tab 10 mg
3
3
3
IPRIVASK - desirudin for inj 15 mg
5
Quantity Limits
Restricted Access
Prior Review
Drug Name
Drug Tier
Quantity Limits
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Prior Review
Drug Name
Drug Tier
2014
1
warfarin sodium tab 10 mg
(Coumadin)
warfarin sodium tab 2.5 mg
(Coumadin)
• •
1
HEMOSTATICS
131
AMICAR - aminocaproic acid tab 500
mg
4
THROMBIN-JMI W/DIL SPRAY thrombin for soln kit 20000 unit
4
AMICAR - aminocaproic acid tab 1000
mg
4
THROMBOGEN - thrombin for soln
1000 unit
4
AMICAR - aminocaproic acid syrup 25% 4
AMINOCAPROIC ACID - aminocaproic 4
acid tab 1000 mg
2
aminocaproic acid syrup 25%
(Amicar)
2
aminocaproic acid tab 500 mg
(Amicar)
4
ARTISS - fibrin sealant component
solution
ASTRINGYN - ferric subsulfate soln 259 4
mg/gm
EVICEL - fibrin sealant component kit 2 4
ml
EVICEL - fibrin sealant component kit 5 4
ml
4
EVITHROM - thrombin (human) topical
soln 800-1200 unit/ml
LYSTEDA - tranexamic acid tab 650 mg 4
THROMBOGEN - thrombin for soln
10000 unit
4
THROMBOGEN - thrombin for soln kit
10000 unit
4
TISSEEL - fibrin sealant component
solution
4
TISSEEL - fibrin sealant component kit
2 ml
4
4 ml
4
10 ml
4
tranexamic acid tab 650 mg (Lysteda)
2
• •
• •
AGGRENOX - aspirin-dipyridamole cap
sr 12hr 25-200 mg
4
AGRYLIN - anagrelide hcl cap 0.5 mg
4
anagrelide hcl cap 0.5 mg (Agrylin)
1
anagrelide hcl cap 1 mg
1
BRILINTA - ticagrelor tab 90 mg
4
cilostazol tab 100 mg (Pletal)
1
MONSELS FERRIC SUBSULFATE ferric subsulfate soln
RECOTHROM - thrombin (recombinant)
for soln 5000 unit
4
RECOTHROM - thrombin (recombinant)
for soln 20000 unit
4
cilostazol tab 50 mg (Pletal)
1
1
RECOTHROM SPRAY KIT - thrombin
(recombinant) for soln 20000 unit
4
clopidogrel bisulfate tab 300 mg
(base equiv) (Plavix)
1
THROMBIN-JMI DILUENT - thrombin
for soln 5000 unit
4
clopidogrel bisulfate tab 75 mg (base
equiv) (Plavix)
dipyridamole tab 25 mg (Persantine)
1
THROMBIN-JMI DILUENT - thrombin
for soln 20000 unit
4
1
1
4
THROMBIN-JMI EPISTAXIS - thrombin
for soln kit 5000 unit
4
THROMBIN-JMI SYRINGE SPRA thrombin for soln kit 5000 unit
4
EFFIENT - prasugrel hcl tab 5 mg (base
equiv)
4
THROMBIN-JMI SYRINGE SPRA thrombin for soln kit 20000 unit
4
EFFIENT - prasugrel hcl tab 10 mg
(base equiv)
FIRAZYR - icatibant acetate inj 30
mg/3ml (base equivalent)
5
•
Quantity Limits
Restricted Access
HEMATOLOGICAL AGENTS - MISC.
4
132
Prior Review
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Drug Name
Prior Review
Drug Tier
2014
PERSANTINE - dipyridamole tab 75 mg
4
PLAVIX - clopidogrel bisulfate tab 75 mg 4
(base equiv)
4
PLAVIX - clopidogrel bisulfate tab 300
mg (base equiv)
4
PLETAL - cilostazol tab 50 mg
PLETAL - cilostazol tab 100 mg
4
ticlopidine hcl tab 250 mg
1
TRENTAL - pentoxifylline tab cr 400 mg
4
ZONTIVITY - vorapaxar sulfate tab 2.08
4
ATROPINE SULFATE - atropine sulfate
ophth oint 1%
4
atropine sulfate ophth soln 1%
(Isopto atropine)
1
AZASITE - azithromycin ophth soln 1%
4
azelastine hcl ophth soln 0.05%
(Optivar)
2
AZOPT - brinzolamide ophth susp 1%
4
Quantity Limits
4
2
Restricted Access
apraclonidine hcl ophth soln 0.5%
(base equivalent) (Iopidine)
Prior Review
4
Drug Name
Drug Tier
Quantity Limits
1
Restricted Access
pentoxifylline tab cr 400 mg
Prior Review
Drug Name
Drug Tier
2014
• •
• •
• •
BACITRACIN - bacitracin ophth oint 500 1
unit/gm
1
bacitracin-polymyxin b ophth oint
TOPICAL PRODUCTS
OPHTHALMIC AGENTS
bacitracin-polymyxin-neomycin-hc
ophth oint 1%
1
BEPREVE - bepotastine besilate ophth
soln 1.5%
4
• •
4
• •
• •
ophthalmic irrigation solution
2
ACULAR - ketorolac tromethamine
ophth soln 0.5%
4
BESIVANCE - besifloxacin hcl ophth
susp 0.6% (base equiv)
4
ACULAR LS - ketorolac tromethamine
ophth soln 0.4%
4
BETADINE OPHTHALMIC PREP povidone-iodine ophth soln 5%
4
ACUVAIL - ketorolac tromethamine
ophth soln 0.45%
4
BETAGAN - levobunolol hcl ophth soln
0.5%
betaxolol hcl ophth soln 0.5%
1
AKTEN - lidocaine hcl ophth gel 3.5%
4
BETIMOL - timolol ophth soln 0.25%
4
ALAMAST - pemirolast potassium ophth
soln 0.1%
4
BETIMOL - timolol ophth soln 0.5%
4
ALCAINE - proparacaine hcl ophth soln
0.5%
BETOPTIC-S - betaxolol hcl ophth susp
0.25%
4
4
ALOCRIL - nedocromil sodium ophth
soln 2%
• •
BLEPH-10 - sulfacetamide sodium
ophth soln 10%
4
4
4
4
• •
• •
ALOMIDE - lodoxamide tromethamine
ophth soln 0.1%
BLEPHAMIDE - sulfacetamide sodiumprednisolone ophth susp 10-0.2%
• •
4
BLEPHAMIDE S.O.P. - sulfacetamide
sodium-prednisolone ophth oint
10-0.2%
4
ALPHAGAN P - brimonidine tartrate
ophth soln 0.1%
ALPHAGAN P - brimonidine tartrate
ophth soln 0.15%
4
brimonidine tartrate ophth soln
0.15% (Alphagan p)
2
ALREX - loteprednol etabonate ophth
susp 0.2%
4
brimonidine tartrate ophth soln 0.2%
1
• •
• •
• •
• •
• •
• •
• •
133
BROMDAY - bromfenac sodium ophth
soln 0.09% (base equiv) (once-daily)
4
•
BROMFENAC - bromfenac sodium
ophth soln 0.09% (base equivalent)
4
• •
bromfenac sodium ophth soln 0.09%
(base equiv) (once-daily)
dorzolamide hcl-timolol maleate
ophth soln 22.3-6.8 mg/ml (Cosopt)
1
DUREZOL - difluprednate ophth
emulsion 0.05%
4
2
ELESTAT - epinastine hcl ophth soln
0.05%
4
carteolol hcl ophth soln 1%
1
4
CILOXAN - ciprofloxacin hcl ophth soln
0.3%
4
EMADINE - emedastine difumarate
ophth soln 0.05% (base equiv)
2
CILOXAN - ciprofloxacin hcl ophth oint
0.3%
4
epinastine hcl ophth soln 0.05%
(Elestat)
erythromycin ophth oint 5 mg/gm
1
ciprofloxacin hcl ophth soln 0.3%
(Ciloxan)
1
FLAREX - fluorometholone acetate
ophth susp 0.1%
4
COMBIGAN - brimonidine tartratetimolol maleate ophth soln 0.2-0.5%
4
fluorometholone ophth susp 0.1%
(Fml liquifilm)
1
COSOPT - dorzolamide hcl-timolol
maleate ophth soln 22.3-6.8 mg/ml
4
flurbiprofen sodium ophth soln
0.03% (Ocufen)
1
COSOPT PF - dorzolamide hcl-timolol
maleate ophth sol 22.3-6.8 mg/ml pf
4
FML - fluorometholone ophth oint 0.1%
4
cromolyn sodium ophth soln 4%
FML FORTE - fluorometholone ophth
susp 0.25%
4
1
CYCLOGYL - cyclopentolate hcl ophth
soln 0.5%
4
FML LIQUIFILM - fluorometholone
ophth susp 0.1%
4
soln 1%
4
GARAMYCIN - gentamicin sulfate ophth
soln 0.3%
4
soln 2%
4
gatifloxacin ophth soln 0.5%
(Zymaxid)
2
CYCLOMYDRIL - cyclopentolate w/
phenylephrine ophth soln 0.2-1%
4
cyclopentolate hcl ophth soln 1%
(Cyclogyl)
1
GELFILM OP - gelatin adsorbable ophth 4
film
1
gentamicin sulfate ophth oint 0.3%
cyclopentolate hcl ophth soln 2%
(Cyclogyl)
gentamicin sulfate ophth soln 0.3%
(Garamycin)
1
2
homatropine hbr ophth soln 5%
(Isopto homatropine)
1
ILEVRO - nepafenac ophth susp 0.3%
4
IOPIDINE - apraclonidine hcl ophth soln
0.5% (base equivalent)
4
IOPIDINE - apraclonidine hcl ophth soln
1% (base equivalent)
4
• •
IQUIX - levofloxacin ophth soln 1.5%
4
• •
CYSTARAN - cysteamine hcl ophth soln 4
1
dexamethasone sodium phosphate
ophth soln 0.1%
1
diclofenac sodium ophth soln 0.1%
dorzolamide hcl ophth soln 2%
(Trusopt)
134
1
• •
• •
• •
• •
• •
• •
• •
• •
• •
• •
• •
Quantity Limits
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2014
• •
• •
LUMIGAN - bimatoprost ophth soln
0.03%
4
• •
• •
MAXIDEX - dexamethasone ophth susp
0.1%
4
• •
4
MAXITROL - neomycin-polymyxindexamethasone ophth susp 0.1%
4
ISOPTO CARPINE - pilocarpine hcl
ophth soln 2%
4
MAXITROL - neomycin-polymyxindexamethasone ophth oint 0.1%
4
ophth soln 4%
4
METIPRANOLOL - metipranolol ophth
soln 0.3%
2
MITOSOL - mitomycin for ophth soln kit
0.2 mg
4
• •
MOXEZA - moxifloxacin hcl ophth soln
0.5% (base eq) (2 times daily)
4
• •
MYDFRIN - phenylephrine hcl ophth
soln 2.5%
4
MYDRIACYL - tropicamide ophth soln
1%
4
NAPHAZOLINE HCL - naphazoline hcl
ophth soln 0.1%
1
NATACYN - natamycin ophth susp 5%
4
neomycin-bacitrac zn-polymyx
5(3.5)mg-400unt-10000unt op oin
1
neomycin-polymyxin b-gramicidin
ophth soln (Neosporin)
1
neomycin-polymyxindexamethasone ophth oint 0.1%
(Maxitrol)
1
1
ISOPTO ATROPINE - atropine sulfate
ophth soln 1%
4
ISOPTO CARBACHOL - carbachol
ophth soln 1.5%
4
ISOPTO CARBACHOL - carbachol
ophth soln 3%
4
ophth soln 1%
ISOPTO HOMATROPINE - homatropine 4
hbr ophth soln 2%
ISOPTO HOMATROPINE - homatropine 4
hbr ophth soln 5%
ISOPTO HYOSCINE - scopolamine hbr 3
ophth soln 0.25%
4
ISTALOL - timolol maleate ophth soln
0.5% (once-daily)
1
ketorolac tromethamine ophth soln
0.4% (Acular ls)
1
ketorolac tromethamine ophth soln
0.5% (Acular)
LACRISERT - artificial tear ophth insert 4
• •
• •
• •
• •
Drug Name
LASTACAFT - alcaftadine ophth soln
0.25%
4
latanoprost ophth soln 0.005%
(Xalatan)
1
LEVOBUNOLOL HCL - levobunolol hcl
ophth soln 0.25%
1
levobunolol hcl ophth soln 0.5%
(Betagan)
1
neomycin-polymyxindexamethasone ophth susp 0.1%
(Maxitrol)
levofloxacin ophth soln 0.5%
2
1
LOTEMAX - loteprednol etabonate
ophth susp 0.5%
4
NEOMYCIN/POLYMYXIN/HYDROC neomycin-polymyxin-hc ophth susp
4
ophth gel 0.5%
3
NEOSPORIN - neomycin-polymyxin bgramicidin ophth soln
4
ophth oint 0.5%
4
NEVANAC - nepafenac ophth susp
0.1%
• •
• •
• •
Quantity Limits
Prior Review
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4
Drug Tier
LUMIGAN - bimatoprost ophth soln
0.01%
Drug Name
Prior Review
2014
• •
• •
135
OCUFEN - flurbiprofen sodium ophth
soln 0.03%
4
prednisolone acetate ophth susp 1%
(Pred forte)
1
OCUFLOX - ofloxacin ophth soln 0.3%
4
1
ofloxacin ophth soln 0.3% (Ocuflox)
1
OMNIPRED - prednisolone acetate
ophth susp 1%
4
PREDNISOLONE SODIUM PHOSP prednisolone sodium phosphate
ophth soln 1%
4
OPTIPRANOLOL - metipranolol ophth
soln 0.3%
4
PROLENSA - bromfenac sodium ophth
soln 0.07% (base equivalent)
1
OPTIVAR - azelastine hcl ophth soln
0.05%
4
proparacaine hcl ophth soln 0.5%
(Alcaine)
QUIXIN - levofloxacin ophth soln 0.5%
4
PATADAY - olopatadine hcl ophth soln
0.2%
4
• •
RESCULA - unoprostone isopropyl
ophth soln 0.15%
4
• •
PATANOL - olopatadine hcl ophth soln
0.1%
4
• •
RESTASIS - cyclosporine (ophth)
emulsion 0.05%
4
•
phenylephrine hcl ophth soln 10%
2
3
phenylephrine hcl ophth soln 2.5%
(Mydfrin)
2
SIMBRINZA - brinzolamide-brimonidine
tartrate ophth susp 1-0.2%
2
PHOSPHOLINE IODIDE echothiophate iodide ophth for soln
0.125%
4
SULFACETAMIDE SODIUM sulfacetamide sodium ophth oint 10%
sulfacetamide sodium ophth soln
10% (Bleph-10)
2
pilocarpine hcl ophth soln 1% (Isopto
carpine)
1
sulfacetamide sodium-prednisolone
ophth soln 10-0.23(0.25)%
1
carpine)
1
tetracaine hcl ophth soln 0.5%
1
1
carpine)
1
timolol maleate ophth gel forming
soln 0.25% (Timoptic-xe)
timolol maleate ophth gel forming
soln 0.5% (Timoptic-xe)
1
timolol maleate ophth soln 0.25%
(Timoptic)
1
timolol maleate ophth soln 0.5%
(Timoptic)
1
TIMOPTIC - timolol maleate ophth soln
0.25%
4
TIMOPTIC - timolol maleate ophth soln
0.5%
4
TIMOPTIC OCUDOSE - timolol maleate
preservative free ophth soln 0.25%
4
• •
TIMOPTIC OCUDOSE - timolol maleate
preservative free ophth soln 0.5%
4
• •
PILOPINE HS - pilocarpine hcl ophth gel 4
4%
1
polymyxin b-trimethoprim ophth
soln 10000 unit/ml-0.1% (Polytrim)
4
POLYTRIM - polymyxin b-trimethoprim
ophth soln 10000 unit/ml-0.1%
4
PRED FORTE - prednisolone acetate
ophth susp 1%
3
PRED MILD - prednisolone acetate
ophth susp 0.12%
PRED-G - gentamicin-prednisolone ace 2
ophth susp 0.3-1%
4
PRED-G S.O.P. - gentamicinprednisolone ace ophth oint 0.3-0.6%
136
• •
• •
• •
• •
Quantity Limits
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ZYLET - loteprednol etabonatetobramycin ophth susp 0.5-0.3%
4
• •
TIMOPTIC-XE - timolol maleate ophth
gel forming soln 0.5%
4
ZYMAXID - gatifloxacin ophth soln 0.5%
4
TOBRADEX - tobramycindexamethasone ophth susp 0.3-0.1%
4
TOBRADEX - tobramycindexamethasone ophth oint 0.3-0.1%
4
• •
TOBRADEX ST - tobramycindexamethasone ophth susp
0.3-0.05%
4
• •
tobramycin ophth soln 0.3% (Tobrex)
1
Drug Name
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4
Drug Tier
TIMOPTIC-XE - timolol maleate ophth
gel forming soln 0.25%
Drug Name
Prior Review
2014
OTIC AGENTS
antipyrine-benzocaine-polycosanol
otic sol 5.4-1.4-0.0097% (Treagan
otic)
2
acetic acid otic soln 2%
1
ACETIC ACID/ALUMINUM ACET acetic acid 2% in aluminum acetate
otic soln
2
tobramycin-dexamethasone ophth
susp 0.3-0.1% (Tobradex)
antipyrine-benzocaine otic soln
54-14 mg/ml (5.4-1.4%)
1
2
TOBREX - tobramycin sulfate ophth
soln 0.3%
antipyrine-benzocaine otic soln
55-14 mg/ml (5.5-1.4%) (Auralgan)
2
4
4
• •
AURALGAN - antipyrine-benzocaine
otic soln 55-14 mg/ml (5.5-1.4%)
4
TOBREX - tobramycin sulfate ophth oint
0.3%
4
• •
CETRAXAL - ciprofloxacin hcl otic soln
4
TRAVATAN Z - travoprost ophth soln
0.004% (benzalkonium free) (bak
free)
CIPRO HC - ciprofloxacinhydrocortisone otic susp 0.2-1%
4
• •
TRAVOPROST - travoprost ophth soln
0.004%
4
CIPRODEX - ciprofloxacindexamethasone otic susp 0.3-0.1%
4
• •
trifluridine ophth soln 1% (Viroptic)
2
4
tropicamide ophth soln 0.5%
2
CIPROFLOXACIN - ciprofloxacin hcl
otic soln 0.2% (base equivalent)
tropicamide ophth soln 1%
(Mydriacyl)
2
4
TRUSOPT - dorzolamide hcl ophth soln
2%
4
COLY-MYCIN S - neomycin-colistin-hcthonzonium otic susp 3.3-3-10-0.5
mg/ml
4
VEXOL - rimexolone ophth susp 1%
4
VIGAMOX - moxifloxacin hcl ophth soln
0.5% (base equiv)
4
CORTANE-B AQUEOUS - pramoxinehc-chloroxylenol aqueous otic soln
10-10-1 mg/ml
4
VIROPTIC - trifluridine ophth soln 1%
4
CORTANE-B-OTIC - pramoxine-hcchloroxylenol otic soln 10-10-1 mg/ml
4
CORTISPORIN - neomycin-polymyxinhc otic soln 1%
4
VOLTAREN - diclofenac sodium ophth
soln 0.1%
4
• •
ZIOPTAN - tafluprost ophth soln
0.0015%
4
• •
CORTISPORIN-TC - neomycin-colistinhc-thonzonium otic susp 3.3-3-10-0.5
mg/ml
4
XALATAN - latanoprost ophth soln
0.005%
4
• •
ZIRGAN - ganciclovir ophth gel 0.15%
4
• •
CRESYLATE - cresyl acetate otic soln
25%
• •
• •
137
fluocinolone acetonide (otic) oil
0.01% (Dermotic)
1
hydrocortisone w/ acetic acid otic
soln 1-2% (Vosol hc)
2
MYOXIN - benzocaine-chloroxylenol-hc
otic soln 15-1-10 mg/ml
4
neomycin-polymyxin-hc otic soln 1%
(Cortisporin)
1
neomycin-polymyxin-hc otic susp
3.5 mg/ml-10000 unit/ml-1%
1
NEOTIC - antipyrine-benzocaineglycerin-zinc ace otic liqd 5.4-1-2-1%
4
ofloxacin otic soln 0.3%
1
OTICIN HC NR - pramoxine-hcchloroxylenol otic soln 10-10-1 mg/ml
4
OTOZIN - antipyrine-benzocaineglycerin-zinc ace otic liqd 5.4-1-2-1%
4
PINNACAINE OTIC - benzocaine otic
soln 20%
4
PRAMOTIC - pramoxine-chloroxylenol
otic liquid 1-0.1%
4
pramoxine-chloroxylenol otic liquid
1-0.1% (Pramotic)
2
pramoxine-hc-chloroxylenol
aqueous otic soln 10-10-1 mg/ml
(Cortane-b aqueous)
1
pramoxine-hc-chloroxylenol otic
soln 10-10-1 mg/ml (Cortane-b-otic)
1
TREAGAN OTIC - antipyrinebenzocaine-polycosanol otic sol
5.4-1.4-0.0097%
4
TRIOXIN - benzocaine-chloroxylenol-hc
otic soln 15-1-10 mg/ml
4
VOSOL HC - hydrocortisone w/ acetic
acid otic soln 1-2%
4
ZINOTIC - chloroxylenol-glycpramoxine-zn ace otic liqd
0.1-1-0.5-0.1%
4
138
4
• •
MOUTH/THROAT/DENTAL AGENTS
• •
• •
• •
• •
• •
• •
mouthwashes - liquid
2
ACT TOTAL CARE DRY MOUTH sodium fluoride rinse 0.02%
4
APHTHASOL - amlexanox oral paste
5%
4
• •
AQUORAL - artificial saliva - aero soln
4
ARESTIN - minocycline hcl subgingival
powder cartridge 1 mg
4
• •
• •
benzocaine dental soln 20%
2
CAPHOSOL - artificial saliva - solution
4
cevimeline hcl cap 30 mg (Evoxac)
2
chlorhexidine gluconate soln 0.12%
(Peridex)
1
clotrimazole troche 10 mg
1
COLGATE DRY MOUTH RELIEF sodium fluoride mouthwash 2.1
mg/10ml
4
• •
DEBACTEROL - sulfuric acid-sulfonated 4
phenolics soln 30-50%
4
EVOXAC - cevimeline hcl cap 30 mg
• •
FIRST-BXN MOUTHWASH diphenhydramine-lidocaine-nystatin
susp
4
• •
FIRST-DUKES MOUTHWASH diphenhydramine-hydrocortisonenystatin susp
4
• •
FIRST-MARYS MOUTHWASH diphenhydramine-hydrocortisonenystatin-tetracycline susp
4
• •
FIRST-MOUTHWASH BLM diphenhyd-lidocaine-al hydroxide-mg
hydroxide-simeth susp
4
• •
FLUORIDEX DAILY DEFENSE S sodium fluoride-potassium nitrate gel
1.1-5%
4
GEL-KAM - stannous fluoride gel 0.4%
4
Quantity Limits
Restricted Access
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ZINOTIC ES - chloroxylenol-glycerinpramoxine-zn ace otic liqd
0.1-1-1-1%
Prior Review
4
Drug Name
Drug Tier
DERMOTIC - fluocinolone acetonide
(otic) oil 0.01%
Restricted Access
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Drug Tier
2014
GEL-KAM ORAL CARE RINSE stannous fluoride conc 0.63%
4
GELCLAIR - povidone-sodium
hyaluronate-glycyrrhetinic acid gel
4
GELX - oral wound care products - gel
4
lidocaine hcl laryngotracheal soln
4% (Lta 360 kit)
4
• •
NAFRINSE DAILY/ACIDULATED sodium fluoride-phosphoric acid for
soln 1 mg/5ml (f equiv)
4
• •
NAFRINSE DAILY/NEUTRAL - sodium
fluoride for soln rinse 0.05%
1
NAFRINSE WEEKLY - sodium fluoride
for soln rinse 0.2%
4
lidocaine hcl viscous soln 2%
1
NEUTRASAL - artificial saliva - packet
4
LISTERINE ESSENTIAL CARE - sod
monofluorophosph-eucal-men-methyl
sal-thymol gel 0.76%
4
NUMOISYN - artificial saliva - solution
4
NUMOISYN - artificial saliva - lozenge
4
nystatin susp 100000 unit/ml
1
LISTERINE ESSENTIAL CARE - sod
monofluorophos-eucal-men-methyl
sal-thymol paste 0.76%
4
OMNI GEL - stannous fluoride gel 0.4%
4
4
LISTERINE RESTORING - sodium
fluoride rinse 0.0221% (0.01% f)
4
ORAFATE - sucralfate-malate paste
10%
4
• •
LISTERINE SMART RINSE - sodium
4
ORAMAGICRX - oral wound care
products - for susp rinse
4
• •
LISTERINE SMART RINSE ANT sodium fluoride rinse 0.02%
4
ORAVIG - miconazole buccal tab 50 mg
(mouth-throat)
LISTERINE TOOTH DEFENSE sodium fluoride rinse 0.0221%
(0.01% f)
4
LISTERINE TOTAL CARE - sodium
4
LISTERINE TOTAL CARE PLUS sodium fluoride rinse 0.0221%
(0.01% f)
4
LISTERINE TOTAL CARE ZERO sodium fluoride rinse 0.02%
• •
• •
PERIDEX - chlorhexidine gluconate soln 4
0.12%
4
PHOS FLUR - sodium fluoride rinse
0.044%
4
PHOS-FLUR ORTHO DEFENSE sodium fluoride rinse 0.044%
2
pilocarpine hcl tab 5 mg (Salagen)
pilocarpine hcl tab 7.5 mg (Salagen)
2
PREVIDENT - sodium fluoride rinse
0.2%
4
4
LISTERINE WHITENING/RESTO sodium fluoride rinse 0.0221%
(0.01% f)
PREVIDENT FLUORIDE - sodium
fluoride gel 1.1% (0.5% f)
4
4
4
LISTERMINT - sodium fluoride rinse
0.02%
4
PREVIDENT 5000 BOOSTER - sodium
fluoride paste 1.1%
4
LTA 360 KIT - lidocaine hcl
laryngotracheal soln 4%
4
PREVIDENT 5000 BOOSTER PL sodium fluoride paste 1.1%
PREVIDENT 5000 DRY MOUTH sodium fluoride gel 1.1% (0.5% f)
4
PREVIDENT 5000 ENAMEL PRO sodium fluoride-potassium nitrate
paste 1.1-5%
4
MUCOTROL - oral wound care products 4
- wafer
Quantity Limits
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• •
139
PREVIDENT 5000 PLUS - sodium
fluoride cream 1.1%
4
4
SALICEPT - oral wound care products for susp rinse
4
sodium fluoride cream 1.1%
(Prevident 5000 plus)
1
sodium fluoride gel 1.1% (0.5% f)
(Prevident fluoride)
1
sodium fluoride paste 1.1%
(Prevident 5000 boost)
1
sodium fluoride rinse 0.0221%
(0.01% f)
1
1
(Prevident)
1
sodium fluoride-potassium nitrate
paste 1.1-5% (Prevident 5000 sensi)
1
stannous fluoride conc 0.63% (Gelkam oral care ri)
1
stannous fluoride gel 0.4%
1
THERA-FLUR-N - sodium fluoride gel
1.1% (0.5% f)
4
140
1
ANORECTAL AGENTS
• •
2
hc-pramoxine emol cream 2.5-1% &
pramoxine wipe 1% kit (Analpram e)
4
ANALPRAM E - hc-pramoxine emol
cream 2.5-1% & pramoxine wipe 1%
kit
4
ANALPRAM-HC - hydrocortisone
acetate w/ pramoxine rectal cream
1-1%
4
acetate w/ pramoxine rectal cream
2.5-1%
4
acetate w/ pramoxine rectal lotn
2.5-1%
4
ANALPRAM-HC SINGLES hydrocortisone acetate w/ pramoxine
rectal cream 1-1%
4
ANALPRAM-HC SINGLES hydrocortisone acetate w/ pramoxine
rectal cream 2.5-1%
4
ANUSOL-HC - hydrocortisone rectal
cream 2.5%
4
ANUSOL-HC - hydrocortisone acetate
suppos 25 mg
4
CORTENEMA - hydrocortisone enema
100 mg/60ml
3
CORTIFOAM - hydrocortisone acetate
rectal foam 90 mg/dose
1
hydrocortisone acetate suppos
25 mg (Anusol-hc)
1
hydrocortisone acetate suppos
30 mg (Proctocort)
hydrocortisone acetate w/ pramoxine 2
rectal cream kit 2.35-1%
rectal cream 1-1% (Analpram-hc)
rectal cream 2.5-1% (Analpram-hc)
• •
Quantity Limits
Restricted Access
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Drug Name
triamcinolone acetonide dental paste
0.1%
PREVIDENT 5000 SENSITIVE - sodium 4
fluoride-potassium nitrate paste
1.1-5%
PROTHELIAL - sucralfate-malate paste 4
10%
4
REACH KIDS - sodium fluoride paste
0.15%
4
REMBRANDT CANKER SORE sodium fluoride paste 0.243%
4
REMBRANDT DEEPLY WHITE+PE sodium monofluorophosphate paste
0.884%
4
REMBRANDT INTENSE STAIN sodium fluoride paste 0.243%
4
REMBRANDT WHITENING - sodium
fluoride rinse 0.02%
4
SALAGEN - pilocarpine hcl tab 5 mg
SALAGEN - pilocarpine hcl tab 7.5 mg
Quantity Limits
Restricted Access
Drug Name
Prior Review
Drug Tier
2014
•
•
•
•
•
•
•
•
•
•
salicylic acid cream 6% & cleanser
liqd kit (Salex cream)
2
hydrocortisone enema 100 mg/60ml
(Cortenema)
salicylic acid lotion 6% & cleanser
liqd kit (Salex lotion)
2
2
hydrocortisone rectal cream 1%
(Proctocort)
sulfacetamide sod-sulfur wash
9-4.5% & skin cleanser kit
(Sumadan kit)
2
1
hydrocortisone rectal cream 2.5%
(Anusol-hc)
1
sulfacetamide sodium-sulfur w/
sunscreens cream 10-5%
2
LIDOCAINE HCL-HYDROCORTIS lidocaine-hydrocortisone acetate
rectal gel 2.8-0.55%
4
wound dressings - cream
2
ABSORICA - isotretinoin cap 10 mg
5
4
5
LIDOCAINE HCL/HYDROCORTIS lidocaine-hydrocortisone acetate
rectal cream kit 2-2%
5
5
lidocaine-hydrocortisone acetate
rectal cream kit 3-0.5%
2
ACANYA - clindamycin phosphatebenzoyl peroxide gel 1.2-2.5%
4
2
acitretin cap 10 mg (Soriatane)
2
acitretin cap 17.5 mg (Soriatane)
2
rectal cream 3-0.5%
2
acitretin cap 25 mg (Soriatane)
2
2
ACLOVATE - alclometasone
dipropionate cream 0.05%
4
rectal gel kit 3-2.5%
4
ACTIVE-KETOPROFEN KIT ketoprofen cream 5% (compound kit)
4
PROCORT - hydrocortisone acetate w/
pramoxine rectal cream 1.85-1.15%
• •
4
ACTIVE-TRAMADOL KIT - tramadol hcl
cream 8% (compound kit)
4
PROCTOCORT - hydrocortisone rectal
cream 1%
•
4
acyclovir oint 5% (Zovirax)
2
PROCTOCORT - hydrocortisone
acetate suppos 30 mg
ACZONE - dapsone gel 5%
4
PROCTOFOAM HC - hydrocortisone
acetate w/ pramoxine rectal foam
1-1%
3
adapalene cream 0.1% (Differin)
2
adapalene gel 0.1% (Differin)
2
adapalene gel 0.3% (Differin)
2
RECTIV - nitroglycerin oint 0.4%
4
AIF #2 DRUG PREPARATION flurbiprofen-gabapent-cycloben-lidodexameth cr (cmp kit)
4
Z-PRAM - hydrocortisone acetate w/
pramoxine rectal cream kit 2.35-1%
4
ZYPRAM - hydrocortisone acetate w/
pramoxine rectal cream 2.35-1%
4
AKNE-MYCIN - erythromycin oint 2%
4
ALA QUIN - clioquinol-hc cream 3-0.5%
4
ALA SCALP - hydrocortisone lotion 2%
4
alclometasone dipropionate cream
0.05% (Aclovate)
1
DERMATOLOGICALS
nystatin topical powder
1
• •
• •
• •
• •
• •
Quantity Limits
Restricted Access
• •
Prior Review
4
Drug Name
Drug Tier
Prior Review
HYDROCORTISONE ACETATE/LI lidocaine-hydrocortisone acetate
Drug Name
Quantity Limits
Drug Tier
Restricted Access
2014
•
•
•
•
• •
• •
141
1
ALCORTIN A - iodoquinolhydrocortisone-aloe polysaccharide
gel 1-2-1%
4
ALDARA - imiquimod cream 5%
4
ALEVEER - capsaicin-menthol topical
patch 0.0375-5%
4
ALLEVYN AG ADHESIVE - wound
dressings - pads
4
• •
ALLEVYN AG GENTLE BORDER wound dressings - pads
4
• •
ALLEVYN AG NON-ADHESIVE - wound 4
dressings - pads
4
ALLEVYN AG SACRUM - wound
dressings - pads
ALLEVYN GENTLE - wound dressings - 4
pads
4
ALOQUIN - iodoquinol-aloe
polysaccharides gel 1.25-1%
4
ALTABAX - retapamulin oint 1%
• •
ALUMINUM ACETATE - aluminum
acetate soln
4
aluminum chloride soln 20% (Drysol)
1
ALUVEA - urea cream 39%
4
AMCINONIDE - amcinonide lotion 0.1%
2
AMCINONIDE - amcinonide oint 0.1%
2
amcinonide cream 0.1%
2
ANACAINE - benzocaine oint 10%
4
APEXICON E - diflorasone diacetate
emollient base cream 0.05%
4
AQUA GLYCOLIC HC SCALP & hydrocortisone lot 2% & cleanser liq
kit
4
ARNICA FLOWER - arnica - tincture
4
ARZOL SILVER NITRATE APP - silver
nitrate-potassium nitrate applicator
75-25%
4
ATOPICLAIR - emollient - cream
4
142
• •
• •
• •
• •
• •
• •
• •
• •
• •
•
• •
ATRALIN - tretinoin gel 0.05%
4
ATRAPRO ANTIPRURITIC HYDR wound dressings - gel
4
ATRAPRO CP - wound dressings - kit
4
ATRAPRO DERMAL SPRAY - wound
cleansers - liquid
4
• •
• •
AURSTAT - emollient cream & wound
dressing gel kit
4
• •
AURSTAT ANTI-ITCH HYDROGE dermatological products misc - gel
4
• •
AURSTAT ANTI-ITCH HYDROGE dermatological products misc - kit
4
• •
AVAR - sulfacetamide sodium w/ sulfur
cleansing pad 9.5-5%
4
AVAR LS - sulfacetamide sodium w/
sulfur cleansing pad 10-2%
4
AVAR LS CLEANSER - sulfacetamide
sodium w/ sulfur cleanser 10-2%
4
AVAR-E LS - sulfacetamide sodium w/
sulfur cream 10-2%
4
AVO CREAM - wound dressings emulsion
4
• •
AZELEX - azelaic acid cream 20%
4
• •
BACTROBAN - mupirocin oint 2%
4
BACTROBAN - mupirocin calcium
cream 2%
4
BENSAL HP - salicylic acid & benzoic
acid oint 3-6%
4
BENZAC AC WASH - benzoyl peroxide
liq 5%
4
BENZAC W WASH - benzoyl peroxide
liq 5%
4
BENZACLIN - clindamycin phosphatebenzoyl peroxide gel 1-5%
4
BENZACLIN WITH PUMP - clindamycin
phosphate-benzoyl peroxide gel 1-5%
4
BENZAMYCIN - benzoyl peroxideerythromycin gel 5-3%
4
BENZAMYCINPAK - benzoyl peroxideerythromycin gel pack 5-3%
4
• •
• •
• •
• •
Quantity Limits
Restricted Access
Prior Review
Drug Name
Drug Tier
alclometasone dipropionate oint
0.05%
Quantity Limits
Restricted Access
Drug Name
Prior Review
Drug Tier
2014
2
2
• •
• •
betamethasone dipropionate
augmented cream 0.05% (Diprolene
af)
BENZIQ LS - benzoyl peroxide gel
2.75%
4
2
• •
augmented gel 0.05%
BENZOIN COMPOUND TINCTURE benzoin compound tincture
4
BENZOIN TINCTURE - benzoin tincture
4
benzoyl peroxide cleanser 4.25%
2
benzoyl peroxide cloth 3%
2
2
2
benzoyl peroxide creamy wash 4% &
cleanser lotion kit
2
benzoyl peroxide creamy wash 4%
&benzoyl peroxide bar 5% kit
2
benzoyl peroxide creamy wash 8% &
cleanser lotion kit
2
benzoyl peroxide creamy wash 8%
&benzoyl peroxide bar 5% kit (Bpo
creamy wash comp)
2
benzoyl peroxide foam 5.3%
(Benzefoam)
• •
Quantity Limits
benzoyl peroxide-erythromycin gel
5-3% (Benzamycin)
Restricted Access
2
Prior Review
benzoyl peroxide pad 9%
4
BENZEFOAMULTRA - benzoyl peroxide 4
foam 9.8%
4
BENZIQ - benzoyl peroxide gel 5.25 %
Quantity Limits
Restricted Access
Drug Name
Drug Tier
BENZEFOAM - benzoyl peroxide foam
5.3%
Prior Review
Drug Name
Drug Tier
2014
2
augmented lotion 0.05% (Diprolene)
2
augmented oint 0.05% (Diprolene)
2
betamethasone dipropionate cream
0.05%
2
betamethasone dipropionate lotion
0.05%
2
betamethasone dipropionate oint
0.05%
2
betamethasone valerate aerosol
foam 0.12% (Luxiq)
1
betamethasone valerate cream 0.1%
betamethasone valerate lotion 0.1%
1
betamethasone valerate oint 0.1%
1
2
BIAFINE - wound dressings - emulsion
4
4
benzoyl peroxide foam 9.8%
(Benzefoamultra)
2
BIONECT - hyaluronate sodium gel
0.2%
BORIC ACID - boric acid granules
4
benzoyl peroxide gel 10%
2
BPO - benzoyl peroxide gel 4%
4
benzoyl peroxide gel 5%
2
BPO - benzoyl peroxide gel 8%
4
benzoyl peroxide liq 2.5%
2
4
benzoyl peroxide liq 5.25%
2
benzoyl peroxide liq 7%
2
BPO CREAMY WASH COMPLETE benzoyl peroxide creamy wash 8%
&benzoyl peroxide bar 5% kit
2
BPO 3% FOAMING CLOTHS - benzoyl
peroxide cloth 3%
2
benzoyl peroxide lotion 3%
• •
2
• •
peroxide cloth 6%
2
2
2
2
• •
2
peroxide cloth 9%
2
• •
• •
•
• •
• •
143
calcipotriene cream 0.005%
(Dovonex)
2
calcipotriene oint 0.005%
2
calcipotriene soln 0.005% (50 mcg/
ml)
2
calcipotriene-betamethasone
dipropionate oint 0.005-0.064%
(Taclonex)
2
CALCITRIOL - calcitriol oint 3 mcg/gm
4
CAPEX - fluocinolone acetonide
shampoo 0.01%
4
• •
CARAC - fluorouracil cream 0.5%
4
• •
CARMOL-HC - urea-hc acetate cream
1%
4
CARRASYN HYDROGEL WOUND D wound dressings - gel
4
• •
CEM-UREA - urea soln 45%
4
•
CENTANY - mupirocin oint 2%
1
CENTANY AT - mupirocin oint kit 2%
4
CETACAINE - butamben-tetracainebenzocaine aerosol spray 2-2-14%
4
CICLODAN CREAM KIT - ciclopirox
olamine cream 0.77% (base equiv) &
cleanser kit
4
CICLODAN SOLUTION KIT - ciclopirox
solution kit 8%
4
ciclopirox gel 0.77% (Loprox)
2
ciclopirox olamine cream 0.77%
(base equiv)
2
ciclopirox olamine susp 0.77% (base
equiv)
2
ciclopirox shampoo 1% (Loprox
shampoo)
2
ciclopirox solution kit 8% (Ciclodan
solution ki)
2
ciclopirox solution 8% (Penlac nail
lacquer)
2
144
• •
• •
CICLOPIROX TOPICAL SOLUTI ciclopirox solution 8% & vitamin e 5%
topical kit
4
• •
CLARAVIS - isotretinoin cap 30 mg
2
Drug Name
CLARIFOAM EF - sulfacetamide sodium 4
w/ sulfur foam 10-5%
4
CLEOCIN-T - clindamycin phosphate
soln 1%
4
gel 1%
4
lotion 1%
4
swab 1%
4
CLINDACIN ETZ - clindamycin
phosphate swab 1% & cleanser kit
4
CLINDACIN PAC - clindamycin
phosphate swab 1% & cleanser kit
4
CLINDAGEL - clindamycin phosphate
gel 1%
2
clindamycin phosph-benzoyl
peroxide (refrig) gel 1.2 (1)-5%
(Duac)
2
clindamycin phosphate foam 1%
(Evoclin)
1
clindamycin phosphate gel 1%
(Cleocin-t)
1
clindamycin phosphate lotion 1%
(Cleocin-t)
1
clindamycin phosphate soln 1%
(Cleocin-t)
1
clindamycin phosphate swab 1%
(Cleocin-t)
2
clindamycin phosphate-benzoyl
peroxide gel 1-5% (Benzaclin)
4
CLINDAREACH - clindamycin
phosphate swab kit 1%
4
CLOBETA CREAM - clobetasol
propionate cream 0.05% & coal tar
soln 2.3% kit
• •
• •
• •
• •
• •
• •
Quantity Limits
Restricted Access
Prior Review
2
Drug Tier
butamben-tetracaine-benzocaine
aerosol spray 2-2-14%
Quantity Limits
Restricted Access
Drug Name
Prior Review
Drug Tier
2014
• •
CNL8 NAIL KIT - ciclopirox soln 8% &
lacquer removal pads kit
4
• •
clobetasol propionate cream 0.05%
(Temovate)
1
COAL TAR - coal tar soln 20%
4
COAL TAR BASE - coal tar oint 1%
4
COCAINE HCL - cocaine hcl soln 4%
4
COCAINE HCL - cocaine hcl soln 10%
4
•
•
•
•
clobetasol propionate emollient base
cream 0.05% (Temovate e)
1
clobetasol propionate emulsion
foam 0.05% (Olux-e)
2
CONDYLOX - podofilox soln 0.5%
4
CONDYLOX - podofilox gel 0.5%
4
2
CORDRAN - flurandrenolide lotion
0.05%
4
• •
• •
clobetasol propionate foam 0.05%
(Olux)
clobetasol propionate gel 0.05%
(Temovate)
1
CORDRAN SP - flurandrenolide cream
0.05%
4
• •
clobetasol propionate lotion 0.05%
(Clobex)
2
CORDRAN TAPE - flurandrenolide tape
4 mcg/sqcm
4
• •
clobetasol propionate oint 0.05%
(Temovate)
1
4
• •
clobetasol propionate shampoo
0.05% (Clobex)
2
CORTANE-B - hydrocortisonepramoxine-chloroxylenol lot
10-10-1mg/ml
4
• •
clobetasol propionate soln 0.05%
(Temovate)
1
CORTISPORIN - neomycin-polymyxinhc cream 0.5%
4
• •
CLOBEX - clobetasol propionate spray
0.05%
4
CORTISPORIN - bacitracin-polymyxinneomycin hc oint 1%
4
• •
CLOBEX - clobetasol propionate lotion
0.05%
4
CURAGEL HYDROGEL ISLAND W hydroactive (sterile) dressing
4
• •
CLOBEX - clobetasol propionate
shampoo 0.05%
4
CURAGEL HYDROGEL WOUND DR hydroactive (sterile) dressing
4
• •
CLOCORTOLONE PIVALATE clocortolone pivalate cream 0.1%
4
• •
CURITY HYPERTONIC SODIUM wound dressings - misc
4
• •
CLOCORTOLONE PIVALATE PUM clocortolone pivalate cream 0.1%
4
• •
CURITY SODIUM CHLORIDE DR wound dressings - pads
4
CLODERM - clocortolone pivalate
cream 0.1%
4
• •
CUTIVATE - fluticasone propionate
cream 0.05%
4
CLODERM PUMP - clocortolone
pivalate cream 0.1%
4
• •
CUTIVATE - fluticasone propionate
lotion 0.05%
4
clotrimazole w/ betamethasone
cream 1-0.05% (Lotrisone)
2
CUTIVATE - fluticasone propionate oint
0.005%
4
• •
clotrimazole w/ betamethasone
lotion 1-0.05%
2
DELOS - benzoyl peroxide cleanser
3.5%
DELOS - benzoyl peroxide lotion 3.5%
4
• •
DENAVIR - penciclovir cream 1%
4
Drug Name
• •
Drug Name
Quantity Limits
Prior Review
4
Restricted Access
Drug Tier
Prior Review
CLOBETA OINTMENT - clobetasol
propionate oint 0.05% & coal tar soln
2.3% kit
Quantity Limits
Drug Tier
Restricted Access
2014
•
•
•
•
145
DERMA-SMOOTHE/FS BODY fluocinolone acetonide oil 0.01%
4
DESOXIMETASONE - desoximetasone
cream 0.05%
2
DERMA-SMOOTHE/FS BODY OIL fluocinolone acetonide oil 0.01%
4
DESOXIMETASONE - desoximetasone
oint 0.05%
4
DERMA-SMOOTHE/FS SCALP fluocinolone acetonide oil 0.01%
4
desoximetasone cream 0.25%
(Topicort)
2
DERMA-SMOOTHE/FS SCALP OI fluocinolone acetonide oil 0.01%
4
desoximetasone gel 0.05% (Topicort)
2
DERMASORB AF - clioquinol-hc cream
3-0.5% & emollient liqd kit
4
• •
desoximetasone oint 0.25% (Topicort) 2
4
DIAB - wound dressings - gel
4
• •
DIAB F.D.G. FREEZE-DRIED - wound
dressings - gel
4
DERMASORB HC - hydrocortisone lot
2% & cleanser liq kit
DERMASORB TA - triamcinolone cream 4
0.1% & emollient cream kit
DERMASORB XM - urea cream 39% & 4
emollient cream kit
4
DERMATOP - prednicarbate cream
0.1%
4
DERMATOP - prednicarbate oint 0.1%
• •
diclofenac sodium (actinic
keratoses) gel 3% (Solaraze)
2
• •
DIFFERIN - adapalene cream 0.1%
4
DIFFERIN - adapalene gel 0.1%
4
DIFFERIN - adapalene gel 0.3%
4
DIFFERIN - adapalene lotion 0.1%
4
2
DESONATE - desonide gel 0.05%
4
• •
DIFLORASONE DIACETATE diflorasone diacetate cream 0.05%
desonide cream 0.05% (Desowen)
1
diflorasone diacetate oint 0.05%
2
desonide lotion 0.05% (Desowen)
2
4
desonide oint 0.05% (Desowen)
1
DIPROLENE - betamethasone
dipropionate augmented lotion 0.05%
4
• •
DIPROLENE - betamethasone
dipropionate augmented oint 0.05%
4
DESONIL - desonide cream 0.05% w/
wound dressing cream kit
4
• •
DIPROLENE AF - betamethasone
dipropionate augmented cream
0.05%
4
DESONIL - desonide oint 0.05% w/
wound dressing cream kit
DESOWEN - desonide cream 0.05%
4
DESOWEN - desonide lotion 0.05%
DOVONEX - calcipotriene cream
0.005%
4
4
DESOWEN - desonide oint 0.05%
4
4
DESOWEN CREAM/CETAPHIL
LO - desonide cream 0.05% w/
moisturizing lotion kit
4
DOVONEX SCALP - calcipotriene soln
0.005% (50 mcg/ml)
DRITHO-CREME HP - anthralin cream
1%
3
DESOWEN LOTION/CETAPHIL C desonide lotion 0.05% w/ moisturizing
cream kit
4
DRITHO-SCALP - anthralin cream 0.5%
3
DRYSOL - aluminum chloride soln 20%
4
4
DUAC - clindamycin phosph-benzoyl
peroxide (refrig) gel 1.2 (1)-5%
4
DESOWEN OINTMENT/CETAPHIL desonide ointment 0.05% w/
moisturizing lotion kit
DURASAL - salicylic acid soln 26%
4
econazole nitrate cream 1%
1
146
•
• •
• •
•
•
•
•
•
•
•
•
• •
Quantity Limits
Restricted Access
Prior Review
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Drug Name
Prior Review
Drug Tier
2014
erythromycin pads 2%
2
4
erythromycin soln 2%
1
ELENZAPATCH - lidocaine-menthol
patch 4-1%
4
ETHYL CHLORIDE - ethyl chloride
aerosol spray
4
• •
ELETONE - emollient - cream
4
4
• •
ELIDEL - pimecrolimus cream 1%
4
ETHYL CHLORIDE/FINE PINPO - ethyl
chloride aerosol spray
ELIMITE - permethrin cream 5%
4
• •
ELOCON - mometasone furoate
solution 0.1% (lotion)
4
ELOCON - mometasone furoate cream
0.1%
4
ELOCON - mometasone furoate oint
0.1%
4
EMLA - lidocaine-prilocaine cream
2.5-2.5%
4
EMULSION SB - dermatological
products misc - emulsion
4
• •
ETHYL CHLORIDE/FINE STREA - ethyl 4
4
ETHYL CHLORIDE/MEDIUM JET ethyl chloride aerosol spray
4
ETHYL CHLORIDE/MEDIUM STR ethyl chloride aerosol spray
4
ETHYL CHLORIDE/MIST - ethyl
4
EUCALYPTUS OIL - eucalyptus
(topical) oil
4
EURAX - crotamiton cream 10%
ENOVARX-BACLOFEN - baclofen
4
•
ENOVARX-IBUPROFEN - ibuprofen
cream 10% (compounding kit)
4
ENOVARX-LIDOCAINE HCL - lidocaine
hcl cream 5% (compound kit)
4
ENOVARX-LIDOCAINE HCL - lidocaine
hcl cream 10% (compound kit)
4
•
ENOVARX-NAPROXEN - naproxen
4
•
ENOVARX-TRAMADOL - tramadol hcl
4
•
EPICERAM - dermatological products
misc - emulsion
4
• •
EPIDUO - adapalene-benzoyl peroxide
gel 0.1-2.5%
4
• •
EPIFOAM - pramoxine-hc aerosol foam
1-1%
4
• •
ERTACZO - sertaconazole nitrate
cream 2%
4
• •
ERYGEL - erythromycin gel 2%
4
erythromycin gel 2% (Erygel)
2
• •
• •
•
•
EURAX - crotamiton lotion 10%
• •
• •
• •
• •
4
EVOCLIN - clindamycin phosphate foam 4
1%
4
EXELDERM - sulconazole nitrate
solution 1%
EXELDERM - sulconazole nitrate cream 4
1%
4
EXTINA - ketoconazole foam 2%
• •
• •
FABIOR - tazarotene (acne) foam 0.1%
4
FINACEA - azelaic acid gel 15%
4
FINACEA PLUS - azelaic acid gel 15%
w/cleanser & moisturizing lotion kit
4
•
• •
• •
FIRST-HYDROCORTISONE hydrocortisone gel 10%
4
• •
FLECTOR - diclofenac epolamine patch
1.3%
4
•
fluocinolone acetonide cream 0.01%
1
fluocinolone acetonide cream
0.025% (Synalar)
1
fluocinolone acetonide oil 0.01%
(Derma-smoothe/fs bod)
1
Quantity Limits
EFUDEX - fluorouracil cream 5%
Restricted Access
• •
Prior Review
4
Drug Name
Drug Tier
Prior Review
ECOZA - econazole nitrate foam 1%
Quantity Limits
Drug Name
Drug Tier
Restricted Access
2014
147
GLYCOLIC ACID 70% HIGH PU glycolic acid soln 70%
4
• •
fluocinolone acetonide soln 0.01%
(Synalar)
1
GORDOFILM - salicylic & lactic acids
soln 16.7-16.7%
4
• •
fluocinonide cream 0.05%
1
GORDONS UREA - urea ointment 40%
4
• •
fluocinonide cream 0.1% (Vanos)
2
4
fluocinonide emulsified base cream
0.05%
1
GRANULEX - trypsin w/ castor oil &
peruvian balsam spray
GREEN SOAP - green soap tincture
4
fluocinonide gel 0.05%
1
2
fluocinonide oint 0.05%
1
fluocinonide soln 0.05%
1
halobetasol prop oint 0.05% &
ammonium lactate lot 12% kit
(Ultravate pac)
4
halobetasol propionate cream 0.05%
(Ultravate)
2
FLUOROPLEX - fluorouracil cream 1%
fluorouracil cream 5% (Efudex)
2
2
fluorouracil soln 2%
2
halobetasol propionate oint 0.05%
(Ultravate)
fluorouracil soln 5%
2
HALOG - halcinonide cream 0.1%
4
fluticasone propionate cream 0.05%
(Cutivate)
1
HALOG - halcinonide oint 0.1%
4
fluticasone propionate lotion 0.05%
(Cutivate)
HALONATE - halobetasol prop oint
0.05% & ammonium lactate foam
12% kit
4
1
fluticasone propionate oint 0.005%
(Cutivate)
1
HALOTIN - haloprogin cream 1%
4
HPR - emollient - aerosol foam
4
GEBAUERS PAIN EASE pentafluoropropane-tetrafluoroethane
aero spray
4
HPR PLUS - emollient - cream
4
HPR PLUS - emollient - aerosol foam
4
GEBAUERS SPRAY AND STRETC pentafluoropropane-tetrafluoroethane
aero spray
4
HPR PLUS/MB HYDROGEL - emollient
foam & wound dressing gel kit
4
2
GENADUR - dermatological products
misc - liquid
4
• •
hyaluronate sodium (emollient) gel
0.2% (Hylira)
4
GENADUR KIT - dermatological
products misc topical/oral - kit
4
•
HYDRO 35 - urea in lactic acid vehicle
foam 35%
HYDRO 40 FOAM - urea foam 40%
4
GENTAMICIN SULFATE - gentamicin
sulfate cream 0.1%
1
GENTAMICIN SULFATE - gentamicin
sulfate oint 0.1%
1
gentamicin sulfate cream 0.1%
1
gentamicin sulfate oint 0.1%
1
GLYCOLIC ACID - glycolic acid soln
70%
4
148
• •
• •
• •
• •
Drug Name
HYDRO-IODOQUINOL 2-1 - iodoquinol- 4
hydrocortisone-aloe polysaccharide
gel 1-2-1%
hydrocortisone acetate-aloe vera gel 2
2% (Nuzon)
2
hydrocortisone butyrate cream 0.1%
(Locoid)
• •
• •
• •
• •
•
•
•
•
•
•
•
•
•
•
• •
Quantity Limits
Prior Review
Restricted Access
Drug Tier
Quantity Limits
Restricted Access
1
Drug Tier
fluocinolone acetonide oint 0.025%
(Synalar)
Drug Name
Prior Review
2014
INOVA 4/1 ACNE CONTROL TH benzoyl perox pad 4% & salicylic ac
pad 1% & vit e 5% kit
4
• •
hydrocortisone butyrate oint 0.1%
(Locoid)
2
4
• •
hydrocortisone butyrate soln 0.1%
(Locoid)
2
INOVA 8/2 ACNE CONTROL TH benzoyl perox pad 8% & salicylic ac
pad 2% & vit e 5% kit
iodoquinol-hc cream 1%
1
hydrocortisone cream 1%
1
isotretinoin cap 10 mg
2
hydrocortisone cream 2.5%
1
2
hydrocortisone lotion 2.5%
2
2
hydrocortisone lotion 2% (Ala scalp)
2
4
• •
hydrocortisone oint 1%
2
KENALOG - triamcinolone acetonide
aerosol soln
hydrocortisone oint 2.5%
2
4
• •
hydrocortisone valerate cream 0.2%
2
KENDALL AMORPHOUS HYDROGE wound dressings - gel
2
KENDALL HYDROGEL IMPREGNA hydroactive (sterile) dressing
4
hydrocortisone valerate oint 0.2%
(Westcort)
• •
4
• •
KENDALL HYDROGEL WOUND DR hydroactive (sterile) dressing
4
HYDROFERA BLUE FOAM DRESS wound dressings - pads
• •
4
• •
KENDALL ZINC CALCIUM ALGI wound dressings - pads
4
HYDROFERA BLUE 4"X4" - wound
dressings - pads
• •
4
• •
KENDALL ZINC CALCIUM ALGI wound dressings - misc
4
HYLASE WOUND - hyaluronate sodium
gel
• •
4
KERAFOAM - urea foam 30%
4
KERAFOAM 42 - urea foam 42%
4
HYLATOPIC PLUS - emollient - cream
4
KERALAC - urea cream 47%
4
HYLATOPIC PLUS - emollient - aerosol
foam
• •
• •
• •
4
HYLATOPIC - emollient - aerosol foam
• •
• •
• •
KERALYT - salicylic acid gel 6%
4
HYLATOPIC PLUS/AURSTAT emollient foam & wound dressing gel
kit
4
• •
KERALYT SCALP - salicylic acid
shampoo 6% & salicylic acid gel 6%
kit
4
• •
HYLIRA - hyaluronate sodium
(emollient) gel 0.2%
4
KETOCON - ketoconazole cream 2% &
hydrocortisone gel 1% kit
4
• •
HYLIRA - hyaluronate sodium
(emollient) lotion 0.1%
4
ketoconazole cream 2%
1
ketoconazole foam 2% (Extina)
2
imiquimod cream 5% (Aldara)
2
ketoconazole shampoo 2% (Nizoral)
1
INOVA - benzoyl peroxide pad 4% &
vitamin e topical 5% kit
4
• •
KETODAN KIT - ketoconazole foam 2%
& cleanser kit
4
INOVA - benzoyl peroxide pad 8% &
vitamin e topical 5% kit
4
• •
KLARON - sulfacetamide sodium lotion
10% (acne)
4
• •
Drug Name
Quantity Limits
Prior Review
Restricted Access
Drug Tier
Quantity Limits
Restricted Access
2
Drug Tier
hydrocortisone butyrate hydrophilic
lipo base cream 0.1% (Locoid
lipocream)
Drug Name
Prior Review
2014
• •
149
LAC-HYDRIN - lactic acid (ammonium
lactate) cream 12%
4
LIDORX - lidocaine hcl gel 3%
4
LAC-HYDRIN - lactic acid (ammonium
lactate) lotion 12%
LIDOVIR - acyclovir-lidocaine hcl oint
4-4% (compounding kit)
4
4
lindane lotion 1%
2
lactic acid (ammonium lactate)
cream 12% (Lac-hydrin)
2
lindane shampoo 1%
2
2
LOCOID - hydrocortisone butyrate soln
0.1%
4
lactic acid (ammonium lactate) lotion
10%
2
LOCOID - hydrocortisone butyrate
cream 0.1%
4
lactic acid (ammonium lactate) lotion
12% (Lac-hydrin)
lactic acid w/ vitamin e cream
10%-3500 unit/30gm
2
LAMISIL SPRAY - terbinafine hcl soln
1%
4
• •
LATRIX XM - urea in zinc undecylenate- 4
lactic acid vehicle emulsion 45%
4
LAVARE WOUND WASH - wound
cleansers - gel
4
LAVOCLEN-4 CREAMY WASH benzoyl peroxide liq 4%
4
LAVOCLEN-8 CREAMY WASH benzoyl peroxide liq 8%
LEVULAN KERASTICK - aminolevulinic 4
acid hcl for soln 20% (stick applicator)
4
LIDOCAINE HCL - lidocaine hcl lotion
3%
2
lidocaine hcl cream 3%
• •
LOCOID - hydrocortisone butyrate lotion 4
0.1%
4
LOCOID - hydrocortisone butyrate oint
0.1%
LOCOID LIPOCREAM - hydrocortisone 4
butyrate hydrophilic lipo base cream
0.1%
4
LOPROX - ciclopirox gel 0.77%
• •
LOPROX SHAMPOO - ciclopirox
shampoo 1%
4
• •
LOTRISONE - clotrimazole w/
betamethasone cream 1-0.05%
4
• •
LOUTREX - antiseborrheic products
misc - cream
4
• •
LUXIQ - betamethasone valerate
aerosol foam 0.12%
4
LUZU - luliconazole cream 1%
4
LYCELLE - nit remover - gel
4
mafenide acetate packet for topical
soln 5% (50 gm) (Sulfamylon)
2
malathion lotion 0.5% (Ovide)
2
• •
• •
• •
• •
• •
• •
lidocaine hcl gel 2%
1
lidocaine hcl soln 4% (Xylocaine)
1
lidocaine oint 5%
1
lidocaine patch 5% (Lidoderm)
2
• •
lidocaine-prilocaine cream 2.5-2.5%
(Emla)
MB HYDROGEL - emollient cream &
wound dressing gel kit
4
1
• •
4
MEDIHONEY CALCIUM ALGINAT wound dressings - pads
4
LIDOCAINE/PRILOCAINE - lidocaineprilocaine kit 2.5-2.5%
• •
4
MEDROX-RX - capsaicin-mentholmethyl salicylate oint 0.05-7-20%
4
LIDODERM - lidocaine patch 5%
LIDOPROFEN - ketoprofenketamine-lidocaine cream 5-5-2%
(compounding kit)
4
MENTAX - butenafine hcl cream 1%
4
METHYL SALICYLATE - methyl
salicylate liquid
4
• •
• •
150
•
•
•
•
•
Quantity Limits
Restricted Access
Prior Review
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Drug Name
Prior Review
Drug Tier
2014
NEOBENZ MICRO - benzoyl peroxide
cream 5.5%
4
• •
METROGEL - metronidazole gel 1%
4
4
• •
METROLOTION - metronidazole lotion
0.75%
4
cream 8.5%
4
• •
metronidazole cream 0.75%
(Metrocream)
2
NEOBENZ MICRO PLUS PACK benzoyl peroxide cream 5.5%
4
• •
metronidazole gel 0.75%
2
NEOBENZ MICRO SD - benzoyl
peroxide cream 3.5%
metronidazole gel 1% (Metrogel)
2
4
• •
metronidazole lotion 0.75%
(Metrolotion)
2
peroxide cream 5.5%
4
• •
METVIXIA - methyl aminolevulinate hcl
cream 16.8% (base equiv)
4
peroxide cream 8.5%
4
MIMYX - emollient - cream
4
NEOBENZ MICRO WASH - benzoyl
peroxide liq 7%
4
NEOBENZ MICRO WASH PLUS P benzoyl peroxide wash 7% & benzoyl
peroxide cream 5.5% kit
4
MIRVASO - brimonidine tartrate gel
• •
mometasone furoate cream 0.1%
(Elocon)
1
NEOSALUS - emollient - cream
4
1
NEOSALUS - emollient - aerosol foam
4
mometasone furoate oint 0.1%
(Elocon)
NEOSALUS - emollient - lotion
4
mometasone furoate solution 0.1%
(lotion) (Elocon)
1
NEOSALUS CP - emollient - cream
4
NEOSALUS 180 PACK - emollient cream
4
•
•
•
•
•
NIVATOPIC PLUS - dermatological
products misc - cream
4
• •
NIZORAL - ketoconazole shampoo 2%
4
NORITATE - metronidazole cream 1%
4
NOVACORT - hydrocortisone acepramoxine-aloe polysacch gel 2-1-1%
4
MOMEXIN - mometasone furoate cream 4
0.1% & ammon lactate foam 12% kit
2
mupirocin calcium cream 2%
(Bactroban)
1
mupirocin oint 2% (Bactroban)
• •
• •
• •
NAFTIN - naftifine hcl cream 1%
4
NAFTIN - naftifine hcl cream 2%
4
NAFTIN - naftifine hcl gel 1%
4
NAFTIN - naftifine hcl gel 2%
4
NAPRO 15% COMPOUNDING KIT naproxen cream 15%
4
•
•
•
•
•
•
•
•
•
•
NAPRODERM COMPOUNDING KIT naproxen cream 15%
4
• •
NATROBA - spinosad susp 0.9%
4
cream 3.5%
4
• •
• •
Drug Name
NUCORT - hydrocortisone acetate lotion 4
2%
4
NUOX - benzoyl peroxide-sulfur gel
6-3%
NUVAIL - dermatological products misc 4
- solution
4
NUZON - hydrocortisone acetate-aloe
vera gel 2%
1
nystatin cream 100000 unit/gm
nystatin oint 100000 unit/gm
Quantity Limits
Prior Review
Restricted Access
Drug Tier
Quantity Limits
Restricted Access
4
Drug Tier
METROCREAM - metronidazole cream
0.75%
Drug Name
Prior Review
2014
•
•
•
•
•
• •
• •
• •
• •
• •
1
151
4
OLUX - clobetasol propionate foam
0.05%
4
PENLAC NAIL LACQUER - ciclopirox
solution 8%
4
•
OLUX-E - clobetasol propionate
emulsion foam 0.05%
4
PENNSAID - diclofenac sodium soln
1.5%
•
OPTASE - trypsin w/ castor oil &
peruvian balsam gel
4
• •
PENNSAID - diclofenac sodium soln 2% 4
2
permethrin cream 5% (Elimite)
ORACEA - doxycycline (rosacea) cap
4
• •
OVACE PLUS - sulfacetamide sodium
cream 10%
4
• •
OVACE PLUS - sulfacetamide sodium
shampoo 10%
4
OVACE PLUS WASH - sulfacetamide
sodium liquid 10%
4
OVACE PLUS WASH - sulfacetamide
sodium cleansing gel 10%
4
OVACE WASH - sulfacetamide sodium
liquid 10%
4
OVIDE - malathion lotion 0.5%
4
OXISTAT - oxiconazole nitrate cream
1%
4
• •
OXISTAT - oxiconazole nitrate lotion 1% 4
4
OXSORALEN - methoxsalen lotion 1%
nystatin-triamcinolone cream
100000-0.1 unit/gm-%
1
nystatin-triamcinolone oint
100000-0.1 unit/gm-%
OXSORALEN ULTRA - methoxsalen
rapid cap 10 mg
4
• •
• •
• •
PANDEL - hydrocortisone probutate
cream 0.1%
4
• •
PANRETIN - alitretinoin gel 0.1%
5
PEDIADERM AF COMPLETE KIT nystatin cream 100000 unit/gm &
diaper rash cream kit
4
• •
• •
PEDIADERM HC - hydrocortisone lot
2% & emollient cream kit
4
PEDIADERM TA - triamcinolone cream
0.1% & emollient cream kit
4
152
Drug Name
PICATO - ingenol mebutate gel 0.015%
4
PICATO - ingenol mebutate gel 0.05%
4
PICO SINGLE USE NEGATIVE - wound 4
dressings - kit
4
PLEXION - sulfacetamide sodium w/
sulfur cream 9.8-4.8%
4
PLEXION - sulfacetamide sodium w/
sulfur lotion 9.8-4.8%
4
PLEXION CLEANSER - sulfacetamide
sodium w/ sulfur cleanser 9.8-4.8%
4
PLEXION CLEANSER - sulfacetamide
sodium w/ sulfur emulsion 10-5%
4
PLEXION CLEANSING CLOTH sulfacetamide sodium w/ sulfur
cleansing cloth 10-5%
4
PLEXION CLEANSING CLOTHS sulfacetamide sodium w/ sulfur
cleansing cloth 9.8-4.8%
4
PLEXION SCT - sulfacetamide sodium
w/ sulfur cream 10-5%
4
PLIAGLIS - lidocaine-tetracaine cream
7-7%
4
PODOCON 25 IN BENZOIN TIN podophyllum resin soln 25%
2
podofilox soln 0.5% (Condylox)
PONTOCAINE - tetracaine hcl soln 2%
4
• •
PR CREAM - dermatological products
misc - kit
4
• •
PRAMOSONE - pramoxine-hc cream
1-1%
4
• •
• •
• •
• •
• •
• •
• •
• •
• •
• •
• •
Quantity Limits
Prior Review
Restricted Access
Drug Tier
Quantity Limits
Restricted Access
• •
Drug Tier
4
1
PEDIPIROX-4 NAIL - ciclopirox soln 8%
& lacquer removal pads & foot powd
kit
Drug Name
Prior Review
2014
• •
• •
RESTORE SILVER DRESSING 4 wound dressings - pads
4
• •
4
• •
4
• •
PRAMOSONE - pramoxine-hc oint 1-1% 4
4
PRAMOSONE - pramoxine-hc oint
1-2.5%
4
PRAMOSONE E - pramoxine-hc
emollient base cream 1-2.5%
2
pramoxine hcl gel 1%
• •
• •
RETIN-A - tretinoin cream 0.025%
4
4
4
RETIN-A - tretinoin gel 0.01%
4
RETIN-A - tretinoin gel 0.025%
4
•
•
•
•
•
•
PRAMOSONE - pramoxine-hc cream
1-2.5%
4
PRAMOSONE - pramoxine-hc lotion
1-1%
4
PRAMOSONE - pramoxine-hc lotion
1-2.5%
• •
pramoxine-hc cream 1-2.5%
(Pramosone)
2
prednicarbate cream 0.1%
(Dermatop)
1
prednicarbate oint 0.1% (Dermatop)
1
PRESERA - emollient - aerosol foam
4
PROMISEB - antiseborrheic products
misc - cream
4
PROMISEB COMPLETE antiseborrheic products misc - kit
4
PROTOPIC - tacrolimus oint 0.03%
4
PROTOPIC - tacrolimus oint 0.1%
4
PRUCLAIR - emollient - cream
4
PRUDOXIN - doxepin hcl cream 5%
4
PRUMYX - emollient - cream
4
PRUTECT - wound dressings emulsion
4
PYROGALLIC ACID - pyrogallolchlorobutanol oint 25-2%
4
RADIAGEL - wound dressings - gel
4
RADIAPLEXRX - wound dressings - gel
4
RADIGEL - dermatological products
misc - gel
4
• •
• •
• •
REGENECARE - lidocaine hcl-collagenaloe vera gel 2%
4
REGRANEX - becaplermin gel 0.01%
5
• •
• •
Drug Name
RETIN-A MICRO - tretinoin microsphere 4
gel 0.04%
RETIN-A MICRO - tretinoin microsphere 4
gel 0.1%
4
RETIN-A MICRO PUMP - tretinoin
microsphere gel 0.04%
4
RETIN-A MICRO PUMP - tretinoin
microsphere gel 0.1%
4
RIAX - benzoyl peroxide foam 5.5%
•
•
•
•
•
•
• •
• •
• •
RIAX - benzoyl peroxide foam 9.5%
4
RINNOVI NAIL SYSTEM - urea soln
50% w/ cleanser spray & protectant
spray kit
4
•
•
• •
ROSADAN KIT - metronidazole gel
0.75% w/ cleanser kit
4
• •
ROSADAN KIT - metronidazole cream
0.75% w/ cleanser kit
4
• •
ROSANIL - sulfacetamide sod-sulfur
emul 10-5% & skin cleanser kit
4
RTD WOUND CARE DRESSING wound dressings - pads
4
SALEX - salicylic acid shampoo 6%
4
SALEX CREAM - salicylic acid cream
6% & cleanser liqd kit
4
• •
SALEX LOTION - salicylic acid lotion
6% & cleanser liqd kit
4
• •
SALICYLIC ACID - salicylic acid soln
26%
2
• •
•
•
•
•
•
•
•
•
• •
Quantity Limits
Prior Review
Restricted Access
Drug Tier
Quantity Limits
Restricted Access
4
Drug Tier
Drug Name
Prior Review
2014
• •
• •
153
4
• •
salicylic acid foam 6% (Salvax)
2
SILVER NITRATE - silver nitrate soln
10%
salicylic acid gel 6% (Keralyt)
2
4
• •
SALICYLIC ACID IN AMMONIU salicylic acid in ammonium lactate
vehicle foam 6%
4
25%
50%
4
• •
salicylic acid lotion 6%
2
4
• •
salicylic acid shampoo 6% (Salex)
2
SILVER NITRATE - silver nitrate oint
10%
4
silver nitrate-potassium nitrate
applicator 75-25% (Arzol silver
nitrate)
2
SALKERA - salicylic acid in ammonium
lactate vehicle foam 6%
SALVAX - salicylic acid foam 6%
4
SALVAX DUO PLUS - salicylic acid
foam 6% & urea in lactic acid foam
35% kit
silver sulfadiazine cream 1%
(Silvadene)
1
4
SILVERSEAL HYDROGEL DRESS silver - pad 2"x3"
4
•
SANARE SCAR THERAPY - scar
treatment products - cream
4
SILVERSEAL HYDROGEL DRESS silver - pad 4"x5"
4
•
SANTYL - collagenase oint 250 unit/gm
4
• •
SCALACORT DK - hc lot 2% & sal acidsulfur shampoo 2-2% & shampoo kit
SILVRSTAT WOUND DRESSING silver - gel
4
4
4
SE BPO 7-5.5 WASH KIT - benzoyl
peroxide wash 7% & benzoyl
peroxide cream 5.5% kit
• •
SKLICE - ivermectin lotion 0.5%
4
4
SEB-PREV - sulfacetamide sodium
lotion 10%
4
• •
SODIUM SULFACETAMIDE WASH sulfacetamide sodium in bakuchiol
vehicle wash 10%
• •
• •
4
• •
SELENIUM SULFIDE - selenium
sulfide-pyrithione zinc in urea
shampoo 2.25%
1
SODIUM SULFACETAMIDE/SULF sulfacetamide sodium w/ sulfur susp
10-5%
4
• •
selenium sulfide lotion 2.5%
1
SODIUM SULFACETAMIDE/SULF sulfacetamide sodium-sulfur in urea
emulsion 10-5%
selenium sulfide-pyrithione zinc in
urea shampoo 2.25%
1
4
• •
SELRX - selenium sulfide-pyrithione
zinc in urea shampoo 2.3%
4
SODIUM SULFACETAMIDE/SULF sulfacetamide sodium-sulfur in urea
gel 10-5%
4
• •
SELSUN SHAMPOO - selenium sulfide
lotion 2.5%
4
SODIUM SULFACETAMIDE/UREA sulfacetamide sodium-urea pad 10%
2
SILVADENE - silver sulfadiazine cream
1%
4
sodium thiosulfate-salicylic acid
lotion 25-1%
4
SILVASORB - wound dressings - gel
4
SOLARAZE - diclofenac sodium (actinic
keratoses) gel 3%
salicylic acid cream 6%
2
salicylic acid film forming liquid
27.5% (Virasal)
154
• •
• •
• •
• •
• •
• •
Drug Name
Quantity Limits
Prior Review
Restricted Access
Drug Tier
Quantity Limits
Restricted Access
• •
Drug Tier
4
2
0.5%
Drug Name
Prior Review
2014
4
SORIATANE - acitretin cap 17.5 mg
4
SORIATANE - acitretin cap 25 mg
4
SORILUX - calcipotriene foam 0.005%
4
SPECTRAGEL - wound dressings - gel
4
SPINOSAD - spinosad susp 0.9%
4
SSS 10-4 - sulfacetamide sodium w/
sulfur foam 10-4%
4
STELARA - ustekinumab inj 45
mg/0.5ml
5
STELARA - ustekinumab inj 90 mg/ml
5
sulfacetamide sodium cleansing gel
10% (Ovace plus wash)
sulfacetamide sodium w/ sulfur susp
8-4% (Sumaxin ts)
2
sulfacetamide sodium w/ sulfur wash
9-4.5% (Sumadan wash)
2
sulfacetamide sodium w/ sulfur wash
9-4% (Sumaxin wash)
2
sulfacetamide sodium-sulfur in urea
emulsion 10-4%
2
SULFAMYLON - mafenide acetate
packet for topical soln 5% (50 gm)
4
SULFAMYLON - mafenide acetate
cream 85 mg/gm
4
• •
SULFOAM - sulfur shampoo 2%
4
• •
• •
2
SULFURATED LIME - sulfurated lime
solution
4
2
SUMADAN KIT - sulfacetamide sodsulfur wash 9-4.5% & skin cleanser
kit
4
sulfacetamide sodium liquid 10%
(Ovace wash)
sulfacetamide sodium lotion 10%
(acne) (Klaron)
2
SUMADAN WASH - sulfacetamide
sodium w/ sulfur wash 9-4.5%
4
sulfacetamide sodium shampoo 10%
(Ovace plus)
2
SUMADAN XLT - sulfacetamide sodsulfur wash 9-4.5% & sunscreen kit
4
sulfacetamide sodium w/ sulfur
cleanser 10-2% (Avar ls cleanser)
2
SUMAXIN - sulfacetamide sodium w/
sulfur cleansing pad 10-4%
4
cleansing cloth 10-5%
2
SUMAXIN CP KIT - sulfacetamide sodsulfur pad 10-4% & skin cleanser kit
4
cleansing pad 10-4% (Sumaxin)
2
cream 10-2% (Avar-e ls)
2
cream 10-5%
2
emulsion 10-1%
2
emulsion 10-5%
2
sulfacetamide sodium w/ sulfur foam
10-5% (Clarifoam ef)
2
SUMAXIN TS - sulfacetamide sodium w/ 4
sulfur susp 8-4%
4
SUMAXIN WASH - sulfacetamide
sodium w/ sulfur wash 9-4%
SYNALAR - fluocinolone acetonide soln 4
0.01%
1
SYNALAR - fluocinolone acetonide
cream 0.025%
SYNALAR - fluocinolone acetonide oint 1
0.025%
4
SYNALAR CREAM KIT - fluocinolone
cream 0.025%-emollient cream kit
lotion 10-5%
2
•
•
•
•
•
•
•
•
•
•
•
•
Quantity Limits
SORIATANE - acitretin cap 10 mg
Restricted Access
• •
Prior Review
4
Drug Name
Drug Tier
Prior Review
SONAFINE - wound dressings emulsion
Drug Name
Quantity Limits
Drug Tier
Restricted Access
2014
• •
• •
155
• •
TOPICORT - desoximetasone spray
0.25%
4
•
SYNALAR TS - fluocinolone acetonide
soln 0.01% & cleanser kit
4
2
• •
TOPICORT - desoximetasone cream
0.05%
SYNERA - lidocaine-tetracaine topical
patch 70-70 mg
4
4
• •
TOPICORT - desoximetasone cream
0.25%
TACLONEX - calcipotrienebetamethasone dipropionate susp
0.005-0.064%
4
TOPICORT - desoximetasone gel
0.05%
4
TOPICORT - desoximetasone oint
0.05%
4
TACLONEX - calcipotrienebetamethasone dipropionate oint
0.005-0.064%
4
TOPICORT - desoximetasone oint
0.25%
4
TARGRETIN - bexarotene gel 1%
5
TRETIN-X - tretinoin cream 0.0375%
4
TRETIN-X - tretinoin cream 0.075%
4
TRETIN-X - tretinoin gel 0.01% w/
cleanser & moisturizer kit
4
• •
• •
• •
TAZORAC - tazarotene cream 0.05%
4
TAZORAC - tazarotene cream 0.1%
4
TAZORAC - tazarotene gel 0.05%
4
TAZORAC - tazarotene gel 0.1%
4
TRETIN-X - tretinoin gel 0.025% w/
4
• •
TEGADERM AG MESH DRESSING wound dressings - pads
4
TRETIN-X - tretinoin cream 0.025% w/
4
• •
TEMOVATE - clobetasol propionate
soln 0.05%
4
4
• •
TEMOVATE - clobetasol propionate
cream 0.05%
4
4
• •
TEMOVATE - clobetasol propionate gel
0.05%
4
tretinoin cream 0.025% (Retin-a)
2
2
TEMOVATE - clobetasol propionate oint
0.05%
4
2
4
tretinoin gel 0.01% (Retin-a)
2
TEMOVATE E - clobetasol propionate
emollient base cream 0.05%
tretinoin gel 0.025% (Retin-a)
2
TERSI FOAM - selenium sulfide foam
2.25%
4
• •
tretinoin microsphere gel 0.04%
(Retin-a micro)
2
•
•
•
•
•
•
TETRIX - dermatological products misc
- kit
4
• •
tretinoin microsphere gel 0.1%
(Retin-a micro)
2
•
TEXACORT - hydrocortisone soln 2.5%
4
• •
4
TRI-CHLOR - trichloroacetic acid liqd
80%
4
THERAHONEY - wound dressings - gel
4
TRIAMCINOLONE ACETONIDE triamcinolone acetonide oint 0.5%
1
TL TRISEB - antiseborrheic products
misc - cream
• •
• •
• •
4
• •
triamcinolone acetonide cream
0.025%
1
TL-CERMIDE - dermatological products
misc - emulsion
Drug Name
156
•
•
•
•
•
•
•
•
•
•
Drug Name
•
Quantity Limits
Prior Review
4
Restricted Access
Drug Tier
Prior Review
SYNALAR OINTMENT KIT fluocinolone oint 0.025%-emollient
cream kit
Quantity Limits
Drug Tier
Restricted Access
2014
triamcinolone acetonide lotion
0.025%
1
triamcinolone acetonide lotion 0.1%
1
triamcinolone acetonide oint 0.025%
1
triamcinolone acetonide oint 0.1%
1
TRIANEX - triamcinolone acetonide oint
0.05%
ULTRAVATE - halobetasol propionate
oint 0.05%
4
ULTRAVATE PAC - halobetasol prop
cream 0.05% & ammonium lactate lot
12% kit
4
ULTRAVATE PAC - halobetasol prop
oint 0.05% & ammonium lactate lot
12% kit
4
4
• •
4
ULTRAVATE X - halobetasol prop
cream 0.05% & lactic acid cream
10% kit
4
• •
TRIAZ - benzoyl peroxide pad 3%
4
ULTRAVATE X - halobetasol prop oint
0.05% & lactic acid cream 10% kit
4
UMECTA - urea emulsion 40%
4
4
UMECTA - urea suspension 40%
4
TRIAZ CLEANSER - benzoyl peroxide
lotion 3%
4
UMECTA NAIL FILM - urea suspension
40%
4
lotion 6%
4
lotion 9%
4
TRIAZ FOAMING CLOTHS - benzoyl
peroxide cloth 3%
4
UMECTA PD - urea-hyaluronate sodium 4
emulsion 40-0.3%
UMECTA PD - urea-hyaluronate sodium 4
susp 40-0.3%
4
URAMAXIN - urea cream 45%
peroxide cloth 6%
4
peroxide cloth 9%
• •
URAMAXIN - urea gel 45%
4
• •
URAMAXIN - urea lotion 45%
4
• •
URAMAXIN - urea in ammonium lactate
vehicle foam 20%
4
4
4
TROPAZONE - emollient - lotion
• •
URAMAXIN GT - urea gel 45%
4
trypsin w/ castor oil & peruvian
balsam oint (Xenaderm)
URAMAXIN GT KIT - urea soln 45% &
emollient cream kit
4
1
urea cream 39% (Aluvea)
2
trypsin w/ castor oil & peruvian
balsam spray (Granulex)
1
urea cream 40%
2
4
• •
urea cream 45% (Uramaxin)
2
TURPENTINE SPIRITS - turpentine
spirit
urea cream 50%
2
ULESFIA - benzyl alcohol lotion 5%
4
urea foam 40% (Hydro 40 foam)
2
ULTRASAL-ER - salicylic acid filmforming soln 28.5%
4
• •
• •
urea gel 40%
2
urea gel 45% (Uramaxin)
2
ULTRAVATE - halobetasol propionate
cream 0.05%
4
urea in lactic acid vehicle foam 35%
(Hydro 35)
2
Quantity Limits
1
Restricted Access
TRIAMCINOLONE ACETONIDE I triamcinolone acetonide oint 0.05%
Prior Review
1
Drug Name
Drug Tier
triamcinolone acetonide cream 0.5%
Quantity Limits
1
Restricted Access
triamcinolone acetonide cream 0.1%
Prior Review
Drug Name
Drug Tier
2014
• •
• •
• •
• •
• •
157
VYTONE - iodoquinol-hydrocortisone in
aloe vehicle cream 1-1.9%
4
•
urea in zinc undecylenate-lactic acid
vehicle emulsion 50%
2
WESTCORT - hydrocortisone valerate
oint 0.2%
4
urea lotion 40%
2
4
• •
urea lotion 45% (Uramaxin)
2
WITCH HAZEL - witch hazel
(hamamelis virginiana) liqd
(hamamelis water)
XCLAIR - dermatological products misc
- cream
4
• •
XENADERM - trypsin w/ castor oil &
peruvian balsam oint
4
XERAC AC - aluminum chloride in
alcohol solution 6.25%
3
UREA NAIL - urea in zinc undecylenate- 4
lactic acid vehicle stick 50%
4
UREA NAIL KIT - urea susp 40% &
hyaluronate sodium gel 0.2% kit
2
urea suspension 40% (Umecta)
• •
• •
Drug Name
urea-hc acetate cream 1%
2
UTOPIC - urea cream 41%
4
• •
VALCHLOR - mechlorethamine hcl gel
XERESE - acyclovir-hydrocortisone
cream 5-1%
4
5
• •
4
VANOXIDE HC - benzoyl peroxide-hc
lot 5-0.5% & cleanser lot kit
4
XEROFORM NON-OCCLUSIVE OI bismuth tribromophenate-petrolatum
dressing pads
4
VANOS - fluocinonide cream 0.1%
4
• •
VANOXIDE-HC - benzoyl peroxide-hc
lotion 5-0.5%
4
XEROFORM NON-OCCLUSIVE OI bismuth tribromophenate-petrolatum
dressing - misc
VECTICAL - calcitriol oint 3 mcg/gm
4
4
• •
VELTIN - clindamycin phosphatetretinoin gel 1.2-0.025%
4
• •
XEROFORM OCCLUSIVE PETROL bismuth tribromophenate-petrolatum
dressing pads
4
4
XEROFORM OCCLUSIVE PETROL bismuth tribromophenate-petrolatum
dressing - misc
• •
VERDESO - desonide foam 0.05%
VEREGEN - sinecatechins oint 15%
4
• •
• •
• •
4
VENELEX - balsam peru-castor oil oint
4
• •
VIRASAL - salicylic acid film forming
liquid 27.5%
4
XEROFORM PETROLATUM DRESS bismuth tribromophenate-petrolatum
dressing pads
VOLTAREN - diclofenac sodium gel 1%
3
• •
4
XEROFORM PETROLATUM DRESS bismuth tribromophenate-petrolatum
dressing - misc
4
VOPAC - ketoprofen-lidocaine hcl
cream 10-2% (compound kit)
•
•
4
•
XOLEGEL - ketoconazole gel 2%
4
VOPAC GB - ketoprofen-lidocainegabapentin cream 5-2-5% (cmpd kit)
• •
• •
VOPAC KT - ketoprofen-ketaminelidocaine cream 5-5-2% (compound
kit)
4
XOLEGEL COREPAK - ketoconazole
gel 2% & hydrocortisone gel 1% kit
4
4
• •
VUSION - miconazole-zinc oxide-white
petrolatum oint 0.25-15-81.35%
4
XOLEGEL DUO/HEAD & SHOULD ketoconazole gel 2% & pyrithione
zinc shampoo 1% kit
158
• •
• •
•
• •
Quantity Limits
Prior Review
Restricted Access
Drug Tier
Quantity Limits
Restricted Access
2
Drug Tier
urea in lactic acid-salicylic acid
vehicle susp 50%
Drug Name
Prior Review
2014
BUCALSEP - antiseptic products misc solution
4
• •
XYLOCAINE - lidocaine hcl soln 4%
4
CHLORHEXIDINE DIGLUCONATE chlorhexidine gluconate soln 20%
4
XYLOCAINE JELLY - lidocaine hcl gel
2%
4
CHLORHEXIDINE GLUCONATE chlorhexidine gluconate soln 20%
4
ZACARE 4% KIT - benzoyl peroxide
lotion 4% & hyaluronate sodium gel
0.2% kit
4
• •
FORMA-RAY - formaldehyde solution
20%
4
• •
ZACARE 8% KIT - benzoyl peroxide
lotion 8% & hyaluronate sodium gel
0.2% kit
4
• •
FORMALDEHYDE - formaldehyde
solution 37%
4
• •
formaldehyde solution 10%
1
ZACLIR CLEANSING - benzoyl
peroxide lotion 8%
4
• •
GLUTARALDEHYDE - glutaral soln
25%
4
• •
ZENIEVA - emollient - cream
4
• •
• •
HYDROGEN PEROXIDE - hydrogen
peroxide soln 30%
4
•
HYDROGEN PEROXIDE - hydrogen
peroxide soln 35%
4
•
IODINE TINCTURE - iodine tincture
4
IODINE TINCTURE MILD - iodine
tincture
4
• •
• •
IODINE TINCTURE STRONG - iodine
tincture strong
4
• •
• •
• •
IODINE TINCTURE STRONG DE iodine tincture strong
4
• •
KERR TRIPLE DYE - triple dye swabs
4
• •
• •
•
•
•
•
•
•
•
•
Drug Name
ZITHRANOL-RR - anthralin cream 1.2%
4
ZONALON - doxepin hcl cream 5%
4
ZOVIRAX - acyclovir cream 5%
4
ZOVIRAX - acyclovir oint 5%
4
ZYCLARA - imiquimod cream 3.75%
4
ZYCLARA PUMP - imiquimod cream
2.5%
4
ZYCLARA PUMP - imiquimod cream
3.75%
4
• •
LUGOLS STRONG IODINE - iodine
solution
4
8-MOP - methoxsalen cap 10 mg
5
• •
PHISOHEX - hexachlorophene liq 3%
4
SODIUM HYPOCHLORITE - sodium
hypochlorite soln 5%
4
• •
• •
• •
TRIPLE DYE - triple dye solution
4
• •
• •
CHEMET - succimer cap 100 mg
4
4
• •
CYANIDE ANTIDOTE PKG - cyanide
antidote kit
5
• •
EXJADE - deferasirox tab for oral susp
125 mg
250 mg
5
MISCELLANEOUS PRODUCTS
ANTISEPTICS & DISINFECTANTS
BENZALKONIUM CHLORIDE benzalkonium chloride soln
4
BENZALKONIUM CHLORIDE benzalkonium chloride soln 17%
4
BENZALKONIUM CHLORIDE benzalkonium chloride soln 50%
4
BUCALSEP - antiseptic products misc liquid
4
Quantity Limits
• •
Restricted Access
Prior Review
4
ZIANA - clindamycin phosphate-tretinoin 4
gel 1.2-0.025%
4
ZITHRANOL - anthralin shampoo 1%
Drug Tier
Prior Review
XOLEGEL DUO/XOLEX - ketoconazole
gel 2% & pyrithione zinc shampoo 1%
kit
Drug Name
Quantity Limits
Drug Tier
Restricted Access
2014
ANTIDOTES
159
500 mg
5
THYROGEN - thyrotropin alfa for inj 1.1
mg
FERRIPROX - deferiprone tab 500 mg
5
ALTERNATIVE MEDICINES
naltrexone hcl tab 50 mg (Revia)
1
4
• •
PENTETATE CALCIUM TRISODI pentetate calcium trisodium iv or
inhalation soln 200 mg/ml
4
PRYFLEX - glucosamine-chondroitinpaba-vit e-alpha lipoic acid tab
RELAMINE - glucosamine-chondroitinpaba-vit e-alpha lipoic acid tab
4
• •
PENTETATE ZINC TRISODIUM pentetate zinc trisodium iv or
inhalation soln 200 mg/ml
4
• •
VALERIAN ROOT - valerian (valeriana
officinalis) fl extract
4
•
RADIOGARDASE - prussian blue
insoluble cap 0.5 gm
4
•
C INDICUM EXTRACT/C SINES - c
indicum & c sinesis leaf extract liquid
4
•
REVIA - naltrexone hcl tab 50 mg
5
DENATURED ALCOHOL - alcohol,
rubbing 95%
4
• •
ENOVARX-AMITRIPTYLINE amitriptyline hcl cream 2% kit
(compounding kit)
4
•
•
•
• •
5
CHEMICALS
DIAGNOSTIC PRODUCTS
ASCENSIA AUTODISC TEST ST glucose blood test disk
1
BAYER BREEZE 2 TEST DISC glucose blood test disk
1
BAYER CONTOUR BLOOD GLUCO glucose blood test strip
1
BAYER CONTOUR NEXT BLOOD glucose blood test strip
1
ISOPROPANOL - isopropyl alcohol 70% 4
4
ISOPROPYL ALCOHOL - isopropyl
alcohol 70%
2
isopropyl alcohol, rubbing 70%
• •
FASTTAKE TEST STRIPS - glucose
blood test strip
POTASSIUM HYDROXIDE - potassium
hydroxide solution 5%
4
1
4
• •
GLUCOSE BLOOD TEST STRIPS –
VARIOUS
4
SODIUM HYDROXIDE - sodium
hydroxide solution 10%
ONETOUCH BASIC/PROFILE TE glucose blood test strip
1
4
•
ONETOUCH BASIC/PROFILE/ON glucose blood test strip
1
ONETOUCH ULTRA BLUE - glucose
blood test strip
1
ONETOUCH ULTRA TEST STRIP glucose blood test strip
1
ONETOUCH VERIO TEST STRIP glucose blood test strip
1
SURESTEP PRO TEST STRIPS glucose blood test strip
1
SURESTEP TEST STRIPS - glucose
blood test strip
1
160
•
MEDICAL DEVICES
ALCOH-GLOVE CONTOURED WIP alcohol swabs
ALCOH-WIPE 12" X 12" - alcohol swabs 4
4
ERECAID CLASSIC - impotence aid
device - kit
4
ERECAID ESTEEM - impotence aid
device - kit
4
EROS-CTD - clitoral vacuum device
FC FEMALE CONDOM - condoms female
4
FC2 FEMALE CONDOM - condoms female
4
FEMCAP - cervical cap 22 mm
4
•
• •
• •
• •
Quantity Limits
Restricted Access
Prior Review
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Drug Name
Prior Review
Drug Tier
2014
MI PASTE PLUS - dentifrices - paste
4
OMNIFLEX DIAPHRAGM - diaphragms
4
ORTHO DIAPHRAGM ALL-FLEX/ diaphragm arc-spring 65 mm
3
PRENTIF CAVITY-RIM CERVIC cervical cap 25 mm
4
4
4
PRENTIF FITTING SET - cervical caps
4
3
Q-CARE Q2 ORAL CLEANSING/ - oral
hygiene products - kit
4
• •
3
Q-CARE Q4 ORAL CLEANSING/ - oral
hygiene products - kit
4
• •
3
RAPPORT RING LOADING SYST impotence aid device - kit
4
• •
3
RAPPORT VACUUM THERAPY DE impotence aid device - kit
4
ORTHO DIAPHRAGM COIL SPRI diaphragm coil spring kit 50 mm
• •
3
REMESENSE - dental desensitizing
product - misc
4
• •
3
TODAY SPONGE - contraceptive
sponge
4
3
WIDE-SEAL SILICONE DIAPHR diaphragm wide seal 60 mm
3
ORTHO DIAPHRAGM FLAT SPRI diaphragm flat spring kit 55 mm
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
4
• •
• •
Quantity Limits
4
Restricted Access
MI PASTE - dentifrices - paste
Prior Review
4
Drug Name
Drug Tier
Quantity Limits
4
Restricted Access
Prior Review
Drug Name
Drug Tier
2014
PHARMACEUTICAL ADJUVANTS
ALBA-DERM - cream base
4
ANHYDROUS BASE - anhydrous
ointment base
4
• •
• •
161
BASE CREAM WITH LIPOSOME cream base liposomic
4
• •
• •
BASE W301 - cream base
4
CARBOGEL 940 - carbomer gel base
4
CARBOHOL 940 - carbomer gel base
4
CARBOMER GEL AQUEOUS carbomer gel base
4
CARBOMER GEL HYDROALCOHOL carbomer gel base
4
CHERRY SYRUP - cherry syrup
4
CHRYSADERM DAY - cream base
4
CHRYSADERM NIGHT - cream base
4
COLD CREAM - cold cream
4
COLLODION FLEXIBLE - collodion
flexible
4
CREAM BASE - cream base
4
CREAM CONCENTRATE - cream base
4
•
•
•
•
•
•
•
•
• •
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
FLAVOR SWEET-SF - oral vehicles
4
FOOD COLOR BLUE - dye fdc blue 1
(brilliant blue fcf) - liquid
4
• •
• •
FREEDOM ALCOHOL GEL - alcohol
gel base
4
• •
FREEDOM DERMA-D - cream base
4
FREEDOM DERMA-N - cream base
4
FREEDOM EMOLLIENT CREAM cream base
4
• •
• •
• •
HUMCO BASE PAIN MGMT - cream
base
4
• •
HYDROGEL - carbomer gel base
4
KRISGEL 100 - krisgel 100 gel
4
• •
• •
lanolin
2
LANOLIN - lanolin anhydrous oil
4
LANOLIN ANHYDROUS - lanolin
anhydrous
4
• •
• •
LECITHIN ORGANOGEL - premium
lecithin organogel base gel
4
• •
LIPO CREAM BASE - cream base
4
LIPOBASE HEAVY - cream base
4
LIPOBASE REGULAR - cream base
4
•
•
•
LIPOFOAM RX - foam base - foam
4
LIPOPEN - cream base
4
LIPOPEN PLUS - cream base
4
LIPOPEN ULTRA - cream base
4
MEDIDERM - cream base
4
MEDIHOL BASE - alcohol gel base
4
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
DPI ALCOHOL GEL - alcohol gel base
4
DPI CLASSIC AEB - cream base
4
DPI ELEDERM-D - cream base
4
DPI ELEDERM-N - cream base
4
DPI LS PLUS - cream base
4
DPI LS ULTRA - cream base
4
DPI NATURAL CREAM BASE - cream
base
4
DPI NATURAL LOTION BASE - cream
base
4
• •
MULTIUSE BASE - cream base
4
4
• •
NOURIVAN ANTIOX CREAM BAS cream base
4
DPI SUPREME CREAM BASE - cream
base
4
4
ORA-BLEND SF - oral vehicles
4
ESPUMIL - foam base - foam
4
ORA-PLUS - oral vehicles
4
FLAVOR BLEND - oral vehicles
4
ORA-SWEET - oral vehicles
4
FLAVOR PLUS - oral vehicles
4
ORA-SWEET SF - oral vehicles
4
FLAVOR SWEET - oral vehicles
4
•
•
•
•
•
ORA-BLEND - oral vehicles
EMOLLIENT CREAM - cream base
162
•
•
•
•
•
•
•
•
•
•
•
Quantity Limits
AZ CREAM - cream base
4
Restricted Access
• •
Prior Review
4
Drug Name
Drug Tier
Prior Review
AUXIPRO PLASTICIZED - plastibase
ointment
Drug Name
Quantity Limits
Drug Tier
Restricted Access
2014
Prior Review
ORAL MIX FLAVORED SUSPEND oral vehicles
4
• •
PCCA POLYPEG BASE - polyethylene
glycol ointment
4
• •
ORAL MIX SF - oral vehicles
4
• •
4
PCCA PRACASIL TM-PLUS BAS cream base
4
ORAL SUSPEND - oral vehicles
ORAL SYRUP FLAVORED VEHIC oral vehicles
4
• •
• •
• •
PCCA SOLID TRANSDERMAL PE transdermal base misc
4
• •
ORAL SYRUP SF - oral vehicles
4
PCCA SWEET-SF - oral vehicles
4
P-SILOXAN DS - cream base
4
PCCA SYRUP VEHICLE - oral vehicles
4
PCCA ACACIA SYRUP BASE - acacia
syrup
4
• •
• •
• •
PCCA VANISHING CREAM LIGH cream base
4
• •
• •
• •
PCCA ALADERM BASE - cream base
4
• •
• •
PCCA VANISHING CREAM/LOTI cream base
4
• •
PCCA VANPEN BASE - cream base
4
• •
PCCA-PLUS - oral vehicles
4
4
• •
PEG-8 DISTEARATE BASE L polyethylene glycol ointment
• •
• •
• •
PENCREAM - cream base
4
• •
PENDERM - cream base
4
PETROLATUM WHITE - white
petrolatum ointment
4
• •
• •
• •
• •
4
• •
PETROLATUM YELLOW - petrolatum
ointment
• •
PHARMABASE COSMETIC - cream
base
4
• •
PHARMABASE COSMETIC NATUR cream base
4
• •
PHARMABASE HEAVY - cream base
4
PLACEBO #00 - placebo - cap
4
PLO GEL - MEDIFLO KIT - premium
lecithin organogel base kit
4
• •
• •
• •
PLO GEL - MEDIFLO PRE-MIX premium lecithin organogel base gel
4
• •
PLO TRANSDERMAL CREAM transdermal base cream
4
• •
PLO20 BASE - premium lecithin
organogel base gel
4
• •
POLYETHYLENE GLYCOL 8000 polyethylene glycol 8000 oint
4
• •
Drug Name
PCCA ANHYDROUS BASE - anhydrous 4
ointment base
4
PCCA ANHYDROUS LIPODERM B cream base
4
PCCA BIOPEPTIDE BASE - cream
base
4
PCCA COBASE #1 - cobase #1
ointment base
4
PCCA COSMETIC HRT BASE - cream
base
4
PCCA CUSTOM LIPO-MAX - cream
base liposomic
PCCA LIPODERM BASE - cream base 4
PCCA LIPODERM CUSTOM BASE cream base
4
• •
• •
PCCA LIPOSOMIC BASE FOR D cream base liposomic
4
• •
PCCA LIPOSOMIC BASE FOR N cream base liposomic
4
• •
PCCA LIPOSOMIC BASE FOR O cream base liposomic
4
• •
PCCA LIPOSOMIC BASE FOR P cream base liposomic
4
• •
PCCA LIPOSOMIC BASE FOR S cream base liposomic
4
• •
PCCA MVC BASE - cream base
4
PCCA NATACREAM - cream base
4
• •
• •
Drug Name
Quantity Limits
Drug Tier
Restricted Access
Prior Review
Quantity Limits
Drug Tier
Restricted Access
2014
163
RASPBERRY SYRUP - raspberry syrup
4
SALT STABLE LO - cream base
4
SALT STABLE LS ADVANCED - cream
base
4
•
•
•
•
•
•
•
•
SILPROTEX PLUS - cream base
4
SIMPLE SYRUP - simple - syrup
4
STERA BASE - cream base
4
SYRPALTA - oral vehicles
4
SYRPALTA - simple - syrup
4
TERODERM - cream base
4
TRANS-PEN - transdermal base cream
4
TRANSDERMAL PAIN BASE transdermal base cream
4
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
TRANSDERMAL PATCH 2" X 3" transdermal patch 2" x 3"
4
• •
ULTRADERM - cream base
4
UNIVERSAL WATER GEL - alcohol gel
base
4
• •
• •
VANISH-PEN - cream base
4
VANISHING BASE II - cream base
4
VANISHING CREAM - cream base
4
VANISHING CREAM BOTANICAL cream base
4
VERSAFREE - oral vehicles
4
VERSAPLUS - oral vehicles
4
VERSAPRO - cream base
4
VERSATILE CREAM BASE - cream
base
4
•
•
•
•
VERSATILE RICH CREAM BASE cream base
4
WHITE PETROLATUM - white
petrolatum ointment
YELLOW PETROLATUM - petrolatum
ointment
•
•
•
•
•
•
•
•
2
sodium polystyrene sulfonate
powder (Kayexalate)
2
AMMONIA AROMATIC INHALANT ammonia aromatic spirit
4
ASTAGRAF XL - tacrolimus cap sr 24hr
0.5 mg
5
1 mg
5
5 mg
5
AURUM - misc natural products liqd
4
AZASAN - azathioprine tab 75 mg
4
AZASAN - azathioprine tab 100 mg
4
azathioprine tab 50 mg (Imuran)
1
CELLCEPT - mycophenolate mofetil cap 5
250 mg
CELLCEPT - mycophenolate mofetil tab 5
500 mg
CELLCEPT - mycophenolate mofetil for 5
oral susp 200 mg/ml
4
CHELIDONIUM COMPOUND - misc
natural products liqd
CUPRIMINE - penicillamine cap 250 mg 4
cyclosporine cap 100 mg
(Sandimmune)
5
cyclosporine cap 25 mg
(Sandimmune)
5
CYCLOSPORINE MODIFIED cyclosporine modified cap 50 mg
2
cyclosporine modified cap 100 mg
(Neoral)
2
• •
cyclosporine modified cap 25 mg
(Neoral)
2
4
• •
cyclosporine modified oral soln
100 mg/ml (Neoral)
2
4
• •
DEPEN TITRATABS - penicillamine tab
250 mg
4
•
•
•
•
• •
• •
• •
ASSORTED CLASSES
164
Quantity Limits
PURIFIED WATER - distilled water
4
irrigation solution, physiological
Restricted Access
• •
Prior Review
4
Drug Name
Drug Tier
Prior Review
PROPYLENE GLYCOL - propylene
glycol
Drug Name
Quantity Limits
Drug Tier
Restricted Access
2014
KAYEXALATE - sodium polystyrene
sulfonate powder
4
lactated ringer's for irrigation
2
mycophenolate mofetil cap 250 mg
(Cellcept)
5
mycophenolate mofetil tab 500 mg
(Cellcept)
5
mycophenolate sodium tab dr
180 mg (mycophenolic acid equiv)
(Myfortic)
5
mycophenolate sodium tab dr
360 mg (mycophenolic acid equiv)
(Myfortic)
5
MYFORTIC - mycophenolate sodium
tab dr 180 mg (mycophenolic acid
equiv)
5
MYFORTIC - mycophenolate sodium
tab dr 360 mg (mycophenolic acid
equiv)
5
NEORAL - cyclosporine modified cap 25 5
mg
5
NEORAL - cyclosporine modified cap
100 mg
5
NEORAL - cyclosporine modified oral
soln 100 mg/ml
4
PHYSIOSOL IRRIGATION PH 7 irrigation solution, physiological
5
PROGRAF - tacrolimus cap 0.5 mg
• •
5
REVLIMID - lenalidomide cap 10 mg
5
5
5
5
ringer's solution for irrigation
2
SANDIMMUNE - cyclosporine cap 25
mg
5
SANDIMMUNE - cyclosporine cap 100
mg
5
SANDIMMUNE - cyclosporine oral soln
100 mg/ml
5
sirolimus tab 0.5 mg (Rapamune)
5
sodium polystyrene sulfonate oral
susp 15 gm/60ml (Sps)
2
sodium polystyrene sulfonate rectal
susp 30 gm/120ml
2
SPS - sodium polystyrene sulfonate oral
susp 15 gm/60ml
4
SYPRINE - trientine hcl cap 250 mg
4
tacrolimus cap 0.5 mg (Prograf)
2
tacrolimus cap 0.5 mg (Prograf)
5
tacrolimus cap 1 mg (Prograf)
2
5
2
5
THALOMID - thalidomide cap 50 mg
5
5
5
5
PROGRAF - tacrolimus cap 1 mg
5
5
PROGRAF - tacrolimus cap 5 mg
5
VIASPAN - organ preservation solution
4
RAPAMUNE - sirolimus tab 0.5 mg
5
RAPAMUNE - sirolimus tab 2 mg
5
water for irrigation, sterile irrigation
soln
2
RAPAMUNE - sirolimus tab 1 mg
ZORTRESS - everolimus tab 0.25 mg
4
RAPAMUNE - sirolimus oral soln 1 mg/
ml
5
4
5
4
REVLIMID - lenalidomide caps 2.5 mg
•
Quantity Limits
IMURAN - azathioprine tab 50 mg
4
Restricted Access
• •
Prior Review
4
Drug Name
Drug Tier
Prior Review
ERYSIDORON #2 - misc natural
products tab
Drug Name
Quantity Limits
Drug Tier
Restricted Access
2014
•
•
•
•
•
• •
•
•
•
•
• •
165
2014
INDEX
8-MOP -methoxsalen cap 10 mg.....................................159
A
abacavir sulfate-lamivudine-zidovudine tab
300-150-300 mg (Trizivir)................................................. 7
abacavir sulfate tab 300 mg (base equiv) (Ziagen)......... 7
ABILIFY -aripiprazole oral solution 1 mg/ml...................... 82
ABILIFY -aripiprazole tab 10 mg....................................... 81
ABILIFY -aripiprazole tab 2 mg......................................... 81
ABILIFY -aripiprazole tab 5 mg......................................... 81
ABILIFY DISCMELT -aripiprazole orally disintegrating tab
10 mg............................................................................... 82
ABILIFY DISCMELT -aripiprazole orally disintegrating tab
15 mg............................................................................... 82
ABSORICA -isotretinoin cap 10 mg.................................141
ABSTRAL -fentanyl citrate sl tab 100 mcg (base
equiv)................................................................................94
equiv)................................................................................94
equiv)................................................................................94
equiv)................................................................................94
equiv)................................................................................94
equiv)................................................................................94
acamprosate calcium tab delayed release 333 mg
(Campral).........................................................................89
ACANYA -clindamycin phosphate-benzoyl peroxide gel
1.2-2.5%......................................................................... 141
acarbose tab 100 mg (Precose)..................................... 23
acarbose tab 25 mg (Precose)....................................... 23
acarbose tab 50 mg (Precose)....................................... 23
ACCOLATE -zafirlukast tab 10 mg....................................61
ACCOLATE -zafirlukast tab 20 mg....................................61
ACCUNEB -albuterol sulfate soln nebu 0.63 mg/3ml (base
equiv)................................................................................61
ACCUNEB -albuterol sulfate soln nebu 1.25 mg/3ml (base
equiv)................................................................................61
ACCUPRIL -quinapril hcl tab 10 mg..................................41
ACCUPRIL -quinapril hcl tab 5 mg....................................41
ACCURETIC -quinapril-hydrochlorothiazide tab 10-12.5
mg.................................................................................... 41
166
ACCURETIC -quinapril-hydrochlorothiazide tab 20-12.5
mg.................................................................................... 42
ACCURETIC -quinapril-hydrochlorothiazide tab 20-25
mg.................................................................................... 42
acebutolol hcl cap 200 mg (Sectral).............................. 36
acebutolol hcl cap 400 mg (Sectral).............................. 36
ACEON -perindopril erbumine tab 2 mg............................42
ACETAMINOPHEN/CAFFEINE/DI -acetaminophencaffeine-dihydrocodeine tab 712.8-60-32 mg...................94
acetaminophen-isometheptene-caffeine tab 325-65-20
mg (Prodrin)................................................................. 105
acetaminophen-isometheptene-dichloral cap
325-65-100 mg.............................................................. 105
acetaminophen-salicylamide-phenyltoloxamine cap
300-200-20mg..................................................................93
acetaminophen w/ codeine soln 120-12 mg/5ml........... 94
acetaminophen w/ codeine tab 300-15 mg (Tylenol/
codeine)...........................................................................94
codeine #3)..................................................................... 94
codeine #4)..................................................................... 94
ACETAZOLAMIDE -acetazolamide tab 125 mg................ 49
acetazolamide cap sr 12hr 500 mg (Diamox)................ 49
acetazolamide tab 250 mg.............................................. 49
ACETIC ACID/ALUMINUM ACET -acetic acid 2% in
aluminum acetate otic soln............................................ 137
acetic acid irrigation soln 0.25%....................................74
acetic acid otic soln 2%................................................137
acetylcysteine cap 600 mg........................................... 126
acetylcysteine inhal soln 10%........................................ 57
acetylcysteine inhal soln 20%........................................ 57
ACID JELLY -acetic acid vaginal gel.................................73
ACIPHEX -rabeprazole sodium ec tab 20 mg................... 66
ACIPHEX SPRINKLE -rabeprazole sodium capsule
sprinkle dr 10 mg.............................................................66
ACIPHEX SPRINKLE -rabeprazole sodium capsule
sprinkle dr 5 mg...............................................................66
acitretin cap 10 mg (Soriatane).................................... 141
acitretin cap 17.5 mg (Soriatane)................................. 141
acitretin cap 25 mg (Soriatane).................................... 141
ACLOVATE -alclometasone dipropionate cream
0.05%............................................................................. 141
ACTHAR HP -corticotropin inj gel 80 unit/ml..................... 30
ACTIGALL -ursodiol cap 300 mg...................................... 70
ACTIMMUNE -interferon gamma-1b inj 100 mcg/0.5ml
(2000000 unit/0.5ml)........................................................ 13
ACTIQ -fentanyl citrate lollipop 1200 mcg......................... 94
ACTIQ -fentanyl citrate lollipop 1600 mcg......................... 94
ACTIQ -fentanyl citrate lollipop 200 mcg........................... 94
2014
ACTIVE-CYCLOBENZAPRINE KI - cyclobenzaprine hcl td
cream 5% (compound kit) ............................................ 114
ACTIVE FE - fe carbonyl-fa-b complex-a-c-d-e-min tab
75-1.25 mg ................................................................... 127
ACTIVE-KETOPROFEN KIT - ketoprofen cream 5%
(compound kit) .............................................................. 141
ACTIVELLA -estradiol & norethindrone acetate tab 0.5-0.1
mg.................................................................................... 18
ACTIVELLA -estradiol & norethindrone acetate tab 1-0.5
mg.................................................................................... 18
ACTIVE-TRAMADOL KIT - tramadol hcl cream 8%
(compound kit) .............................................................. 141
ACTONEL -risedronate sodium tab 150 mg......................30
ACTONEL -risedronate sodium tab 30 mg........................30
ACTONEL -risedronate sodium tab 35 mg........................30
ACTONEL -risedronate sodium tab 5 mg..........................30
ACTOPLUS MET -pioglitazone hcl-metformin hcl tab
15-500 mg........................................................................23
ACTOPLUS MET -pioglitazone hcl-metformin hcl tab
15-850 mg........................................................................23
ACTOPLUS MET XR -pioglitazone hcl-metformin hcl tab sr
24hr 15-1000 mg............................................................. 23
ACTOPLUS MET XR -pioglitazone hcl-metformin hcl tab sr
24hr 30-1000 mg............................................................. 23
ACTOS -pioglitazone hcl tab 15 mg (base equiv)..............23
ACT TOTAL CARE DRY MOUTH -sodium fluoride rinse
0.02%............................................................................. 138
ACUFLEX -phenyltoloxamine-acetaminophen tab 55-635
mg.................................................................................... 93
ACULAR -ketorolac tromethamine ophth soln 0.5%........133
ACULAR LS -ketorolac tromethamine ophth soln
0.4%............................................................................... 133
ACUVAIL -ketorolac tromethamine ophth soln 0.45%..... 133
acyclovir cap 200 mg (Zovirax)........................................ 7
acyclovir oint 5% (Zovirax)........................................... 141
acyclovir susp 200 mg/5ml (Zovirax)...............................7
acyclovir tab 400 mg (Zovirax).........................................7
acyclovir tab 800 mg (Zovirax).........................................7
ACZONE -dapsone gel 5%............................................. 141
ADAGEN -pegademase bovine inj 250 unit/ml..................12
ADALAT CC -nifedipine tab sr 24hr 30 mg....................... 38
adapalene cream 0.1% (Differin).................................. 141
adapalene gel 0.1% (Differin)........................................141
adapalene gel 0.3% (Differin)........................................141
ADCIRCA -tadalafil tab 20 mg (pah)................................. 53
ADDERALL -amphetamine-dextroamphetamine tab 10
mg.................................................................................... 86
ADDERALL -amphetamine-dextroamphetamine tab 12.5
mg.................................................................................... 86
mg.................................................................................... 86
mg.................................................................................... 86
mg.................................................................................... 86
mg.................................................................................... 86
ADDERALL -amphetamine-dextroamphetamine tab 7.5
mg.................................................................................... 86
ADDERALL XR -amphetamine-dextroamphetamine cap sr
24hr 10 mg...................................................................... 86
24hr 15 mg...................................................................... 86
24hr 20 mg...................................................................... 86
24hr 25 mg...................................................................... 86
24hr 30 mg...................................................................... 86
24hr 5 mg........................................................................ 86
adefovir dipivoxil tab 10 mg (Hepsera)........................... 7
ADEMPAS -riociguat tab 0.5 mg....................................... 53
ADEMPAS -riociguat tab 1 mg.......................................... 53
ADEMPAS -riociguat tab 2 mg.......................................... 53
ADOXA -doxycycline monohydrate cap 150 mg..................3
ADOXA -doxycycline monohydrate tab 100 mg.................. 3
ADOXA -doxycycline monohydrate tab 50 mg.................... 3
ADOXA -doxycycline monohydrate tab 75 mg.................... 3
ADOXA PAK 1/100 -doxycycline monohydrate tab 100
mg...................................................................................... 3
mg...................................................................................... 3
mg...................................................................................... 3
ADRENACLICK -epinephrine solution auto-injector 0.15
mg/0.15ml (1:1000).......................................................... 50
ADRENACLICK -epinephrine solution auto-injector 0.3
mg/0.3ml (1:1000)............................................................50
ADRENAL C FORMULA - bioflavonoid products tab ......117
ADRENALIN -epinephrine hcl nasal soln 0.1%................. 56
ADULT ASPIRIN LOW STRENGT -aspirin dispersible tab
81 mg............................................................................... 93
ADVAIR DISKUS -fluticasone-salmeterol aer powder ba
100-50 mcg/dose............................................................. 62
250-50 mcg/dose............................................................. 62
500-50 mcg/dose............................................................. 62
ADVAIR HFA -fluticasone-salmeterol inhal aerosol 115-21
mcg/act.............................................................................62
mcg/act.............................................................................62
167
2014
mcg/act.............................................................................62
ADVANCED AM/PM - multiple vitamins w/ calcium therapy
pack .............................................................................. 117
ADVICOR -niacin-lovastatin tab sr 24hr 1000-20 mg........ 50
ADVICOR -niacin-lovastatin tab sr 24hr 1000-40 mg........ 50
ADVICOR -niacin-lovastatin tab sr 24hr 500-20 mg.......... 50
ADVICOR -niacin-lovastatin tab sr 24hr 750-20 mg.......... 50
AEROHIST -chlorpheniramine-methscopolamine tab sr
12hr 8-2.5 mg.................................................................. 55
AEROSPAN -flunisolide hfa inhal aerosol 80 mcg/act....... 62
AFINITOR DISPERZ -everolimus tab for oral susp 2
mg.................................................................................... 13
mg.................................................................................... 13
mg.................................................................................... 13
AFINITOR -everolimus tab 10 mg..................................... 13
AFINITOR -everolimus tab 2.5 mg.................................... 13
AFINITOR -everolimus tab 5 mg....................................... 13
AFINITOR -everolimus tab 7.5 mg.................................... 13
AGGRENOX -aspirin-dipyridamole cap sr 12hr 25-200
mg.................................................................................. 132
AGRYLIN -anagrelide hcl cap 0.5 mg............................. 132
AHIST -chlorpheniramine tannate tab 12 mg.................... 55
AIF #2 DRUG PREPARATION - flurbiprofen-gabapentcycloben-lido-dexameth cr (cmp kit) ............................. 141
AKNE-MYCIN -erythromycin oint 2%.............................. 141
AKTEN -lidocaine hcl ophth gel 3.5%............................. 133
ALAGESIC LQ -butalbital-acetaminophen-caffeine soln
50-325-40 mg/15ml.......................................................... 93
ALAHIST AC -phenylephrine w/ codeine liqd 7.5-10
mg/5ml..............................................................................57
ALAHIST DHC -phenylephrine-dihydrocodeine liqd 7.5-3
mg/5ml..............................................................................57
ALAMAST -pemirolast potassium ophth soln 0.1%......... 133
ALA QUIN -clioquinol-hc cream 3-0.5%.......................... 141
ALA SCALP -hydrocortisone lotion 2%........................... 141
ALBA-DERM - cream base ............................................ 161
ALBATUSSIN NN - phenyleph-dm-pyril-pot guai-sod cit-cit
acid liquid ........................................................................57
ALBATUSSIN -phenylephrine-carbetapentane-gg cap
10-25-400 mg...................................................................57
ALBENZA -albendazole tab 200 mg................................. 11
albuterol sulfate soln nebu 0.083% (2.5 mg/3ml).......... 62
albuterol sulfate soln nebu 0.5% (5 mg/ml)...................62
albuterol sulfate soln nebu 0.63 mg/3ml (base
equiv)...............................................................................62
albuterol sulfate soln nebu 1.25 mg/3ml (base
equiv)...............................................................................62
albuterol sulfate syrup 2 mg/5ml................................... 62
albuterol sulfate tab 2 mg...............................................62
albuterol sulfate tab 4 mg...............................................62
albuterol sulfate tab sr 12hr 4 mg (Vospire er)............. 62
albuterol sulfate tab sr 12hr 8 mg (Vospire er)............. 62
168
ALCAINE -proparacaine hcl ophth soln 0.5%..................133
alclometasone dipropionate cream 0.05%
(Aclovate)...................................................................... 141
alclometasone dipropionate oint 0.05%...................... 142
ALCOH-GLOVE CONTOURED WIP - alcohol swabs
....................................................................................... 160
ALCOH-WIPE 12" X 12" - alcohol swabs .......................160
ALCORTIN A - iodoquinol-hydrocortisone-aloe
polysaccharide gel 1-2-1% ........................................... 142
ALDACTAZIDE -spironolactone & hydrochlorothiazide tab
25-25 mg..........................................................................49
ALDACTAZIDE -spironolactone & hydrochlorothiazide tab
50-50 mg..........................................................................49
ALDACTONE -spironolactone tab 100 mg........................ 49
ALDACTONE -spironolactone tab 25 mg.......................... 49
ALDACTONE -spironolactone tab 50 mg.......................... 49
ALDARA -imiquimod cream 5%...................................... 142
ALENDRONATE SODIUM -alendronate sodium oral soln
70 mg/75ml...................................................................... 30
ALENDRONATE SODIUM -alendronate sodium tab 40
mg.................................................................................... 30
alendronate sodium tab 10 mg...................................... 30
alendronate sodium tab 35 mg...................................... 30
alendronate sodium tab 5 mg........................................ 30
alendronate sodium tab 70 mg (Fosamax)....................30
ALEVEER -capsaicin-menthol topical patch
0.0375-5%...................................................................... 142
alfuzosin hcl tab sr 24hr 10 mg (Uroxatral)...................74
ALINIA -nitazoxanide for susp 100 mg/5ml....................... 11
ALINIA -nitazoxanide tab 500 mg......................................11
ALKERAN -melphalan tab 2 mg........................................13
ALLERSCRIPT -chlorphen tab 4 mg & pseudoephed tab
60 mg therapy pack......................................................... 57
ALLEVYN AG ADHESIVE - wound dressings - pads ..... 142
ALLEVYN AG GENTLE BORDER - wound dressings pads .............................................................................. 142
ALLEVYN AG NON-ADHESIVE - wound dressings - pads
....................................................................................... 142
ALLEVYN AG SACRUM - wound dressings - pads ........142
ALLEVYN GENTLE - wound dressings - pads ............... 142
ALLFEN CD -guaifenesin-codeine tab 400-10 mg.............57
ALLFEN CDX -guaifenesin-codeine liquid 200-20
mg/5ml..............................................................................57
ALLFEN CDX -guaifenesin-codeine tab 400-20 mg.......... 57
ALLI -orlistat cap 60 mg.................................................... 86
allopurinol tab 100 mg (Zyloprim)................................107
allopurinol tab 300 mg (Zyloprim)................................107
ALOCRIL -nedocromil sodium ophth soln 2%................. 133
ALODOX CONVENIENCE KIT - doxycycline hyclate tab
20 mg w/ eyelid cleansers kit ........................................... 4
ALOMIDE -lodoxamide tromethamine ophth soln
0.1%............................................................................... 133
ALOQUIN - iodoquinol-aloe polysaccharides gel 1.25-1%
....................................................................................... 142
ALORA -estradiol td patch biweekly 0.025 mg/24hr.......... 18
2014
ALORA -estradiol td patch biweekly 0.05 mg/24hr............ 18
ALORA -estradiol td patch biweekly 0.075 mg/24hr.......... 18
ALORA -estradiol td patch biweekly 0.1 mg/24hr.............. 18
ALPAIN -phenyltoloxamine-acetaminophen tab 60-500
mg.................................................................................... 93
ALPHAGAN P -brimonidine tartrate ophth soln 0.1%...... 133
ALPHAGAN P -brimonidine tartrate ophth soln
0.15%............................................................................. 133
ALPRAZOLAM INTENSOL -alprazolam conc 1 mg/ml......75
alprazolam orally disintegrating tab 0.25 mg
(Niravam).........................................................................75
alprazolam orally disintegrating tab 0.5 mg..................75
alprazolam orally disintegrating tab 1 mg.....................75
alprazolam orally disintegrating tab 2 mg.....................75
alprazolam tab 0.25 mg (Xanax).....................................75
alprazolam tab 0.5 mg (Xanax).......................................75
alprazolam tab 1 mg (Xanax)..........................................75
alprazolam tab 2 mg (Xanax)..........................................76
alprazolam tab sr 24hr 0.5 mg (Xanax xr)..................... 75
alprazolam tab sr 24hr 1 mg (Xanax xr)........................ 75
ALREX -loteprednol etabonate ophth susp 0.2%............ 133
ALSUMA -sumatriptan succinate solution auto-injector 6
mg/0.5ml.........................................................................105
ALTABAX -retapamulin oint 1%...................................... 142
ALTACE -ramipril cap 1.25 mg......................................... 42
ALTACE -ramipril cap 10 mg............................................ 42
ALTACE -ramipril cap 2.5 mg........................................... 42
ALTACE -ramipril cap 5 mg.............................................. 42
ALTOPREV -lovastatin tab sr 24hr 20 mg.........................51
ALUMINUM ACETATE -aluminum acetate soln.............. 142
aluminum chloride soln 20% (Drysol)......................... 142
ALUVEA -urea cream 39%..............................................142
ALVESCO -ciclesonide inhal aerosol 160 mcg/act............ 62
ALVESCO -ciclesonide inhal aerosol 80 mcg/act.............. 62
AMANTADINE HCL -amantadine hcl tab 100 mg............112
amantadine hcl cap 100 mg......................................... 112
amantadine hcl syrup 50 mg/5ml................................. 112
AMARYL -glimepiride tab 1 mg......................................... 23
AMBIEN CR -zolpidem tartrate tab cr 12.5 mg..................85
AMBIEN CR -zolpidem tartrate tab cr 6.25 mg..................85
AMBIEN -zolpidem tartrate tab 10 mg...............................85
AMBIEN -zolpidem tartrate tab 5 mg.................................85
AMBIFED CD -pseudoephedrine w/ cod-gg tab 30-10-400
mg.................................................................................... 57
AMBIFED CDX -pseudoephedrine w/ cod-gg tab
30-20-400 mg...................................................................57
AMBIFED-G CD -pseudoephedrine w/ cod-gg tab
20-10-400 mg...................................................................57
AMBIFED-G CDX -pseudoephedrine w/ cod-gg tab
20-20-400 mg...................................................................57
AMCINONIDE -amcinonide lotion 0.1%.......................... 142
AMCINONIDE -amcinonide oint 0.1%............................. 142
amcinonide cream 0.1%................................................142
AMERGE -naratriptan hcl tab 1 mg (base equiv)............ 105
AMERGE -naratriptan hcl tab 2.5 mg (base equiv)..........105
AMETHYST -levonorgestrel-ethinyl estradiol (continuous)
tab 90-20 mcg..................................................................20
AMICAR -aminocaproic acid syrup 25%......................... 132
AMICAR -aminocaproic acid tab 1000 mg...................... 132
AMICAR -aminocaproic acid tab 500 mg........................ 132
amiloride & hydrochlorothiazide tab 5-50 mg............... 49
amiloride hcl tab 5 mg.................................................... 49
AMINOBENZOATE POTASSIUM -potassium
aminobenzoate packet 2 gm..........................................116
AMINOCAPROIC ACID -aminocaproic acid tab 1000
mg.................................................................................. 132
aminocaproic acid syrup 25% (Amicar).......................132
aminocaproic acid tab 500 mg (Amicar)......................132
AMINOPHYLLINE -aminophylline tab 100 mg.................. 62
AMINOPHYLLINE -aminophylline tab 200 mg.................. 62
amiodarone hcl tab 100 mg............................................41
amiodarone hcl tab 200 mg (Cordarone).......................41
AMITIZA -lubiprostone cap 24 mcg...................................70
AMITIZA -lubiprostone cap 8 mcg.....................................70
amitriptyline hcl tab 100 mg...........................................77
amitriptyline hcl tab 10 mg.............................................77
amitriptyline hcl tab 150 mg...........................................77
amlodipine besylate-atorvastatin calcium tab 10-10 mg
(Caduet)...........................................................................53
(Caduet)...........................................................................53
(Caduet)...........................................................................53
(Caduet)...........................................................................53
amlodipine besylate-atorvastatin calcium tab 2.5-10
mg (Caduet).................................................................... 54
mg (Caduet).................................................................... 54
mg (Caduet).................................................................... 54
(Caduet)...........................................................................54
(Caduet)...........................................................................54
(Caduet)...........................................................................54
169
2014
(Caduet)...........................................................................54
amlodipine besylate-benazepril hcl cap 10-20 mg
(Lotrel)............................................................................. 42
(Lotrel)............................................................................. 42
amlodipine besylate-benazepril hcl cap 2.5-10 mg
(Lotrel)............................................................................. 42
(Lotrel)............................................................................. 42
(Lotrel)............................................................................. 42
(Lotrel)............................................................................. 42
amlodipine besylate tab 10 mg (Norvasc)..................... 38
amlodipine besylate tab 2.5 mg (Norvasc).................... 38
amlodipine besylate tab 5 mg (Norvasc).......................38
AMMONIA AROMATIC INHALANT -ammonia aromatic
spirit................................................................................164
AMOXAPINE -amoxapine tab 100 mg.............................. 77
AMOXAPINE -amoxapine tab 150 mg.............................. 77
AMOXAPINE -amoxapine tab 25 mg................................ 77
AMOXAPINE -amoxapine tab 50 mg................................ 77
amoxicillin (trihydrate) cap 250 mg................................. 1
amoxicillin (trihydrate) cap 500 mg................................. 1
amoxicillin (trihydrate) for susp 125 mg/5ml.................. 1
amoxicillin (trihydrate) tab 500 mg.................................. 1
amoxicillin (trihydrate) tab 875 mg.................................. 1
amoxicillin & k clavulanate chew tab 200-28.5 mg......... 1
amoxicillin & k clavulanate chew tab 400-57 mg............ 1
amoxicillin & k clavulanate for susp 200-28.5
mg/5ml...............................................................................1
amoxicillin & k clavulanate for susp 250-62.5 mg/5ml
(Augmentin)...................................................................... 1
amoxicillin & k clavulanate for susp 400-57 mg/5ml...... 1
amoxicillin & k clavulanate for susp 600-42.9 mg/5ml
(Augmentin es-600)..........................................................1
amoxicillin & k clavulanate tab 250-125 mg....................1
amoxicillin & k clavulanate tab 500-125 mg
(Augmentin)...................................................................... 1
amoxicillin & k clavulanate tab 875-125 mg
(Augmentin)...................................................................... 1
amoxicillin & k clavulanate tab sr 12hr 1000-62.5 mg
(Augmentin xr)................................................................. 1
AMOXICILLIN -amoxicillin (trihydrate) chew tab 125 mg.....1
AMOXICILLIN -amoxicillin (trihydrate) chew tab 250 mg.....1
amoxicillin cap-clarithro tab-lansopraz cap dr therapy
pack (Prevpac)............................................................... 66
amphetamine-dextroamphetamine cap sr 24hr 10 mg
(Adderall xr)....................................................................86
(Adderall xr)....................................................................86
170
(Adderall xr)....................................................................86
(Adderall xr)....................................................................86
(Adderall xr)....................................................................86
(Adderall xr)....................................................................86
amphetamine-dextroamphetamine tab 10 mg
(Adderall).........................................................................86
amphetamine-dextroamphetamine tab 12.5 mg
(Adderall).........................................................................86
(Adderall).........................................................................86
(Adderall).........................................................................87
(Adderall).........................................................................87
(Adderall).........................................................................87
amphetamine-dextroamphetamine tab 7.5 mg
(Adderall).........................................................................87
AMPICILLIN -ampicillin for susp 125 mg/5ml...................... 1
AMPICILLIN -ampicillin for susp 250 mg/5ml...................... 1
ampicillin cap 250 mg....................................................... 1
ampicillin cap 500 mg....................................................... 1
AMPYRA -dalfampridine tab sr 12hr 10 mg...................... 90
AMRIX -cyclobenzaprine hcl cap sr 24hr 15 mg..............114
AMRIX -cyclobenzaprine hcl cap sr 24hr 30 mg..............114
AMTURNIDE -aliskiren-amlodipine-hydrochlorothiazide tab
150-5-12.5 mg..................................................................42
300-10-12.5 mg................................................................42
300-10-25 mg...................................................................42
300-5-12.5 mg..................................................................42
300-5-25 mg.....................................................................42
AMYL NITRITE -amyl nitrite inhal soln 0.3 ml................... 35
ANABAR -acetaminophen-salicylamide-phenyltoloxamine
tab 300-200-20mg............................................................93
ANACAINE -benzocaine oint 10%...................................142
ANADROL-50 -oxymetholone tab 50 mg.......................... 17
ANAFRANIL -clomipramine hcl cap 25 mg....................... 77
anagrelide hcl cap 0.5 mg (Agrylin).............................132
anagrelide hcl cap 1 mg............................................... 132
ANALPRAM E -hc-pramoxine emol cream 2.5-1% &
pramoxine wipe 1% kit...................................................140
ANALPRAM-HC -hydrocortisone acetate w/ pramoxine
rectal cream 1-1%..........................................................140
rectal cream 2.5-1%.......................................................140
2014
rectal lotn 2.5-1%...........................................................140
ANALPRAM-HC SINGLES -hydrocortisone acetate w/
pramoxine rectal cream 1-1%........................................140
ANALPRAM-HC SINGLES -hydrocortisone acetate w/
pramoxine rectal cream 2.5-1%.....................................140
ANAPROX DS -naproxen sodium tab 550 mg................ 103
ANAPROX -naproxen sodium tab 275 mg...................... 103
ANASPAZ -hyoscyamine sulfate tab disp 0.125 mg..........66
anastrozole tab 1 mg (Arimidex)....................................13
ANCOBON -flucytosine cap 250 mg................................... 6
ANCOBON -flucytosine cap 500 mg................................... 6
ANDRODERM -testosterone td patch 24hr 2 mg/24hr...... 17
ANDRODERM -testosterone td patch 24hr 4 mg/24hr...... 17
ANDROGEL PUMP -testosterone td gel 12.5 mg/act
(1%)..................................................................................17
ANDROGEL PUMP -testosterone td gel 20.25 mg/act
(1.62%).............................................................................17
ANDROGEL -testosterone td gel 20.25 mg/1.25gm
(1.62%).............................................................................17
ANDROGEL -testosterone td gel 25 mg/2.5gm (1%)........ 17
ANDROGEL -testosterone td gel 40.5 mg/2.5gm
(1.62%).............................................................................17
ANDROGEL -testosterone td gel 50 mg/5gm (1%)........... 17
ANDROID -methyltestosterone cap 10 mg........................18
ANDROXY -fluoxymesterone tab 10 mg........................... 18
ANGELIQ -drospirenone-estradiol tab 0.25-0.5 mg...........18
ANGELIQ -drospirenone-estradiol tab 0.5-1 mg................18
ANHYDROUS BASE -anhydrous ointment base.............161
ANIMI-3/VITAMIN D - folic acid-b6-b12-d-omega 3phytosterols cap 1 mg .................................................. 127
ANIMI-3 - folic acid-b6-b12-d-omega 3-phytosterols cap 1
mg ................................................................................. 127
ANORO ELLIPTA -umeclidinium-vilanterol aero powd ba
62.5-25 mcg/inh............................................................... 62
ANTABUSE -disulfiram tab 250 mg.................................. 90
ANTABUSE -disulfiram tab 500 mg.................................. 90
ANTARA -fenofibrate micronized cap 130 mg...................51
ANTARA -fenofibrate micronized cap 30 mg.....................51
antipyrine-benzocaine otic soln 54-14 mg/ml
(5.4-1.4%).......................................................................137
antipyrine-benzocaine otic soln 55-14 mg/ml (5.5-1.4%)
(Auralgan)..................................................................... 137
antipyrine-benzocaine-polycosanol otic sol
5.4-1.4-0.0097% (Treagan otic)....................................137
ANTIVERT -meclizine hcl tab 12.5 mg..............................69
ANTIVERT -meclizine hcl tab 25 mg.................................69
ANTIVERT -meclizine hcl tab 50 mg.................................69
ANUSOL-HC -hydrocortisone acetate suppos 25 mg......140
ANUSOL-HC -hydrocortisone rectal cream 2.5%............ 140
ANZEMET -dolasetron mesylate tab 100 mg.................... 69
ANZEMET -dolasetron mesylate tab 50 mg...................... 69
APEXICON E -diflorasone diacetate emollient base cream
0.05%............................................................................. 142
APHTHASOL -amlexanox oral paste 5%........................ 138
APIDRA -insulin glulisine inj 100 unit/ml........................... 27
APIDRA SOLOSTAR -insulin glulisine soln pen-injector inj
100 unit/ml....................................................................... 27
APLENZIN -bupropion hbr tab sr 24hr 174 mg................. 77
APOKYN -apomorphine hydrochloride inj 10 mg/ml........112
apraclonidine hcl ophth soln 0.5% (base equivalent)
(Iopidine)....................................................................... 133
APRISO -mesalamine cap sr 24hr 0.375 gm.................... 70
APTIOM -eslicarbazepine acetate tab 200 mg................ 107
APTIVUS -tipranavir cap 250 mg........................................ 7
APTIVUS -tipranavir oral soln 100 mg/ml............................7
AP-ZEL - multiple vitamins w/ minerals tab .................... 117
AQUA GLYCOLIC HC SCALP & -hydrocortisone lot 2% &
cleanser liq kit................................................................ 142
AQUORAL - artificial saliva - aero soln .......................... 138
ARALEN -chloroquine phosphate tab 500 mg...................11
ARANESP ALBUMIN FREE -darbepoetin alfa-polysorbate
80 soln inj 100 mcg/0.5ml..............................................127
80 soln inj 100 mcg/ml...................................................127
80 soln inj 150 mcg/0.3ml..............................................127
80 soln inj 150 mcg/0.75ml............................................127
80 soln inj 200 mcg/0.4ml..............................................127
80 soln inj 200 mcg/ml...................................................127
80 soln inj 25 mcg/0.42ml..............................................127
80 soln inj 25 mcg/ml.................................................... 127
80 soln inj 300 mcg/0.6ml..............................................127
80 soln inj 300 mcg/ml...................................................127
80 soln inj 40 mcg/0.4ml................................................127
80 soln inj 40 mcg/ml.................................................... 127
80 soln inj 500 mcg/ml...................................................127
80 soln inj 60 mcg/0.3ml................................................127
80 soln inj 60 mcg/ml.................................................... 127
ARAVA -leflunomide tab 10 mg.......................................103
171
2014
ARAVA -leflunomide tab 20 mg.......................................103
ARCALYST -rilonacept for inj 220 mg.............................103
ARCAPTA NEOHALER -indacaterol maleate inhal powder
cap 75 mcg (base equiv)................................................. 62
ARESTIN -minocycline hcl subgingival powder cartridge 1
mg.................................................................................. 138
ARICEPT -donepezil hydrochloride tab 10 mg.................. 90
ARICEPT -donepezil hydrochloride tab 23 mg.................. 90
ARICEPT -donepezil hydrochloride tab 5 mg.................... 90
ARICEPT ODT -donepezil hydrochloride orally
disintegrating tab 10 mg.................................................. 90
ARICEPT ODT -donepezil hydrochloride orally
disintegrating tab 5 mg.................................................... 90
ARIMIDEX -anastrozole tab 1 mg..................................... 13
ARIXTRA -fondaparinux sodium inj 10 mg/0.8ml............ 130
ARIXTRA -fondaparinux sodium inj 2.5 mg/0.5ml........... 130
ARIXTRA -fondaparinux sodium inj 5 mg/0.4ml.............. 130
ARIXTRA -fondaparinux sodium inj 7.5 mg/0.6ml........... 130
ARMOUR THYROID -thyroid tab 120 mg (2 grain)........... 28
ARMOUR THYROID -thyroid tab 15 mg (1/4 grain).......... 28
ARMOUR THYROID -thyroid tab 30 mg (1/2 grain).......... 28
ARMOUR THYROID -thyroid tab 60 mg (1 grain)............. 28
ARMOUR THYROID -thyroid tab 90 mg (1 1/2 grain)....... 28
ARNICA FLOWER - arnica - tincture ............................. 142
AROMASIN -exemestane tab 25 mg.................................13
ARTHROTEC 50 -diclofenac w/ misoprostol tab delayed
release 50-0.2 mg..........................................................103
ARTHROTEC 75 -diclofenac w/ misoprostol tab delayed
release 75-0.2 mg..........................................................103
ARTISS - fibrin sealant component solution ...................132
ARZOL SILVER NITRATE APP -silver nitrate-potassium
nitrate applicator 75-25%............................................... 142
ASACOL HD -mesalamine tab delayed release 800
mg.................................................................................... 70
ASACOL -mesalamine tab delayed release 400 mg......... 70
ASCENSIA AUTODISC TEST ST -glucose blood test
disk................................................................................. 160
ASCORBIC ACID -ascorbic acid granules...................... 116
ASMANEX 120 METERED DOSES -mometasone furoate
inhal powd 220 mcg/inh (breath activated)...................... 62
ASPIRIN-CAFFEINE-DIHYDROC -dihydrocodeine
compound cap................................................................. 94
172
aspirin chew tab 81 mg.................................................. 93
ASPIRIN LOW DOSE -aspirin tab 81 mg..........................93
aspirin tab 325 mg...........................................................93
aspirin tab 81 mg.............................................................93
aspirin tab delayed release 325 mg............................... 93
aspirin tab delayed release 81 mg................................. 93
ASTAGRAF XL -tacrolimus cap sr 24hr 0.5 mg.............. 164
ASTAGRAF XL -tacrolimus cap sr 24hr 1 mg................. 164
ASTAGRAF XL -tacrolimus cap sr 24hr 5 mg................. 164
ASTELIN -azelastine hcl nasal spray 137 mcg/spray (1
mg/ml).............................................................................. 56
ASTEPRO -azelastine hcl nasal spray 0.15% (205.5 mcg/
spray)............................................................................... 56
ASTRINGYN -ferric subsulfate soln 259 mg/gm..............132
ATABEX EC - prenatal vit w/ dss-iron carbonyl-fa tab dr
29-1 mg ........................................................................ 117
ATABEX PRENATAL - prenatal vit w/ iron carbonyl-fa tab
65-1 mg ........................................................................ 117
ATACAND -candesartan cilexetil tab 16 mg......................42
ATACAND -candesartan cilexetil tab 32 mg......................42
ATACAND -candesartan cilexetil tab 4 mg........................42
ATACAND -candesartan cilexetil tab 8 mg........................42
ATACAND HCT -candesartan cilexetil-hydrochlorothiazide
tab 16-12.5 mg................................................................ 42
tab 32-12.5 mg................................................................ 42
tab 32-25 mg................................................................... 42
ATELVIA -risedronate sodium tab delayed release 35
mg.................................................................................... 30
atenolol & chlorthalidone tab 100-25 mg (Tenoretic
100).................................................................................. 42
atenolol & chlorthalidone tab 50-25 mg (Tenoretic
50).................................................................................... 42
atenolol tab 100 mg (Tenormin)..................................... 36
atenolol tab 25 mg (Tenormin)....................................... 36
atenolol tab 50 mg (Tenormin)....................................... 36
ATIVAN -lorazepam tab 0.5 mg........................................ 76
ATIVAN -lorazepam tab 1 mg........................................... 76
ATIVAN -lorazepam tab 2 mg........................................... 76
ATOPICLAIR - emollient - cream ................................... 142
atorvastatin calcium tab 10 mg (base equivalent)
(Lipitor)............................................................................51
(Lipitor)............................................................................51
(Lipitor)............................................................................51
(Lipitor)............................................................................51
ATOVAQUONE/PROGUANIL HCL -atovaquone-proguanil
hcl tab 62.5-25 mg...........................................................11
atovaquone-proguanil hcl tab 250-100 mg
(Malarone)....................................................................... 11
atovaquone susp 750 mg/5ml (Mepron)........................ 11
ATRALIN -tretinoin gel 0.05%......................................... 142
2014
ATRAPRO ANTIPRURITIC HYDR - wound dressings - gel
....................................................................................... 142
ATRAPRO CP - wound dressings - kit ...........................142
ATRAPRO DERMAL SPRAY - wound cleansers - liquid
....................................................................................... 142
ATRIPLA -efavirenz-emtricitabine-tenofovir df tab
600-200-300 mg.................................................................7
ATROPINE SULFATE -atropine sulfate ophth oint
1%.................................................................................. 133
atropine sulfate ophth soln 1% (Isopto atropine)....... 133
ATROVENT HFA -ipratropium bromide hfa inhal aerosol
17 mcg/act....................................................................... 62
ATROVENT -ipratropium bromide nasal soln 0.03% (21
mcg/spray)........................................................................56
ATROVENT -ipratropium bromide nasal soln 0.06% (42
mcg/spray)........................................................................56
ATUSS DS -pseudoephed hcl-chlorphen mal-dm hbr tan
susp 30-4-30 mg/5ml....................................................... 57
AUBAGIO -teriflunomide tab 14 mg.................................. 90
AUBAGIO -teriflunomide tab 7 mg.................................... 90
AUGMENTIN -amoxicillin & k clavulanate for susp
125-31.25 mg/5ml.............................................................. 1
AUGMENTIN -amoxicillin & k clavulanate for susp
250-62.5 mg/5ml................................................................ 1
AUGMENTIN -amoxicillin & k clavulanate tab 500-125
mg...................................................................................... 1
AUGMENTIN -amoxicillin & k clavulanate tab 875-125
mg...................................................................................... 1
AUGMENTIN ES-600 -amoxicillin & k clavulanate for susp
600-42.9 mg/5ml................................................................ 1
AUGMENTIN XR -amoxicillin & k clavulanate tab sr 12hr
1000-62.5 mg.....................................................................1
AURALGAN -antipyrine-benzocaine otic soln 55-14 mg/ml
(5.5-1.4%).......................................................................137
AURSTAT ANTI-ITCH HYDROGE - dermatological
products misc - gel ....................................................... 142
AURSTAT ANTI-ITCH HYDROGE - dermatological
products misc - kit ........................................................ 142
AURSTAT -emollient cream & wound dressing gel kit.....142
AURUM - misc natural products liqd .............................. 164
AUVI-Q -epinephrine solution auto-injector 0.15 mg/0.15ml
(1:1000)............................................................................ 50
AUVI-Q -epinephrine solution auto-injector 0.3 mg/0.3ml
(1:1000)............................................................................ 50
AUXIPRO PLASTICIZED -plastibase ointment............... 162
AVALIDE -irbesartan-hydrochlorothiazide tab 150-12.5
mg.................................................................................... 42
AVALIDE -irbesartan-hydrochlorothiazide tab 300-12.5
mg.................................................................................... 42
AVANDAMET -rosiglitazone maleate-metformin hcl tab
2-1000 mg........................................................................23
2-500 mg..........................................................................23
4-1000 mg........................................................................24
4-500 mg..........................................................................23
AVANDARYL -rosiglitazone maleate-glimepiride tab 4-1
mg.................................................................................... 24
mg.................................................................................... 24
mg.................................................................................... 24
mg.................................................................................... 24
mg.................................................................................... 24
AVANDIA -rosiglitazone maleate tab 2 mg (base
equiv)................................................................................24
equiv)................................................................................24
equiv)................................................................................24
AVAPRO -irbesartan tab 150 mg...................................... 42
AVAPRO -irbesartan tab 300 mg...................................... 42
AVAPRO -irbesartan tab 75 mg........................................ 42
AVAR-E LS -sulfacetamide sodium w/ sulfur cream
10-2%............................................................................. 142
AVAR LS CLEANSER -sulfacetamide sodium w/ sulfur
cleanser 10-2%.............................................................. 142
AVAR LS -sulfacetamide sodium w/ sulfur cleansing pad
10-2%............................................................................. 142
AVAR -sulfacetamide sodium w/ sulfur cleansing pad
9.5-5%............................................................................ 142
AVC -sulfanilamide vaginal cream 15%............................ 73
AVEED -testosterone undecanoate im inj in oil 750 mg/3ml
(250mg/ml)....................................................................... 18
AVELOX ABC PACK -moxifloxacin hcl tab 400 mg (base
equiv)..................................................................................5
AVELOX -moxifloxacin hcl tab 400 mg (base equiv)........... 5
AVIDOXY DK -doxycycline tab 100 mg & suncreen & sal
acid wash 2% kit................................................................4
AVINZA -morphine sulfate beads cap sr 24hr 120 mg...... 95
AVINZA -morphine sulfate beads cap sr 24hr 30 mg........ 94
AVO CREAM - wound dressings - emulsion .................. 142
AVODART -dutasteride cap 0.5 mg.................................. 74
AVONEX -interferon beta-1a for im inj kit 30mcg
(33mcg(6.6 mu)/vial)........................................................ 90
AVONEX -interferon beta-1a im inj kit 30 mcg/0.5ml.........90
AVONEX PEN -interferon beta-1a im inj kit 30
mcg/0.5ml.........................................................................90
AXERT -almotriptan malate tab 12.5 mg.........................105
AXERT -almotriptan malate tab 6.25 mg.........................105
AXID -nizatidine cap 150 mg.............................................66
AXID -nizatidine cap 300 mg.............................................66
AXID -nizatidine oral soln 15 mg/ml.................................. 66
173
2014
AXIRON -testosterone td soln 30 mg/act.......................... 18
AYGESTIN -norethindrone acetate tab 5 mg.................... 23
azacitidine for inj 100 mg (Vidaza).................................13
AZASAN -azathioprine tab 100 mg................................. 164
AZASAN -azathioprine tab 75 mg................................... 164
AZASITE -azithromycin ophth soln 1%........................... 133
azathioprine tab 50 mg (Imuran).................................. 164
AZ CREAM - cream base .............................................. 162
azelastine hcl nasal spray 0.15% (205.5 mcg/spray)
(Astepro)......................................................................... 56
azelastine hcl nasal spray 137 mcg/spray (1 mg/
ml).................................................................................... 56
azelastine hcl ophth soln 0.05% (Optivar)...................133
AZELEX -azelaic acid cream 20%.................................. 142
AZILECT -rasagiline mesylate tab 0.5 mg (base
equiv)..............................................................................112
AZILECT -rasagiline mesylate tab 1 mg (base equiv)......112
AZITHROMYCIN -azithromycin powd pack for susp 1
gm...................................................................................... 2
azithromycin for susp 100 mg/5ml (Zithromax).............. 2
azithromycin for susp 200 mg/5ml (Zithromax).............. 2
azithromycin tab 250 mg (Zithromax)..............................2
AZOPT -brinzolamide ophth susp 1%............................. 133
AZOR -amlodipine besylate-olmesartan medoxomil tab
10-20 mg..........................................................................42
10-40 mg..........................................................................42
5-20 mg............................................................................42
5-40 mg............................................................................42
AZULFIDINE EN-TABS -sulfasalazine tab delayed release
500 mg............................................................................. 70
AZULFIDINE -sulfasalazine tab 500 mg............................70
B
B-6 FOLIC ACID - cobalamine combination cap ............ 127
BABY DDROPS -cholecalciferol drops 400 unit/0.03ml
(per drop)....................................................................... 116
BACITRACIN -bacitracin ophth oint 500 unit/gm............. 133
bacitracin-polymyxin b ophth oint............................... 133
bacitracin-polymyxin-neomycin-hc ophth oint 1%..... 133
baclofen tab 10 mg........................................................114
baclofen tab 20 mg........................................................114
BACMIN - multiple vitamins w/ minerals tab ...................117
BACTRIM DS -sulfamethoxazole-trimethoprim tab 800-160
mg.................................................................................... 12
BACTRIM -sulfamethoxazole-trimethoprim tab 400-80
mg.................................................................................... 12
BACTROBAN -mupirocin calcium cream 2%.................. 142
BACTROBAN -mupirocin oint 2%................................... 142
BACTROBAN NASAL -mupirocin calcium nasal oint
2%.................................................................................... 56
174
BAL-CARE DHA ESSENTIAL -prenat w/fe poly-na fered-fa
tab 27-1 & omega cap dr 374mg...................................117
BAL-CARE DHA -prenat w/fe poly-na fered-fa tab 27-1 &
omega cap dr 430mg.....................................................117
balsalazide disodium cap 750 mg (Colazal).................. 70
BANZEL -rufinamide susp 40 mg/ml............................... 107
BANZEL -rufinamide tab 200 mg.................................... 107
BANZEL -rufinamide tab 400 mg.................................... 107
BARACLUDE -entecavir oral soln 0.05 mg/ml.................... 7
BARACLUDE -entecavir tab 0.5 mg....................................7
BARACLUDE -entecavir tab 1 mg.......................................7
BASE CREAM WITH LIPOSOME - cream base liposomic
....................................................................................... 162
BASE W301 - cream base ............................................. 162
BAYER BREEZE 2 TEST DISC -glucose blood test
disk................................................................................. 160
BAYER CONTOUR BLOOD GLUCO -glucose blood test
strip.................................................................................160
BAYER CONTOUR NEXT BLOOD -glucose blood test
strip.................................................................................160
b-complex w/ c & folic acid cap 1 mg
(Nephrocaps)................................................................ 116
b-complex w/ c & folic acid tab....................................116
b-complex w/ c & folic acid tab 1 mg (Nephro-vite
rx)...................................................................................116
b-complex w/ c & folic acid tab 5 mg.......................... 116
BECONASE AQ -beclomethasone dipropionate monohyd
nasal susp 42 mcg/spray.................................................56
BELLADONNA & OPIUM -belladonna alkaloids & opium
suppos 16.2-30 mg.......................................................... 66
BELLADONNA ALKALOIDS & OP -belladonna alkaloids &
opium suppos 16.2-60 mg............................................... 66
BELLADONNA ALKALOIDS -belladonna alkaloids tincture
30 mg/100ml.................................................................... 66
belladonna alkaloids-phenobarbital elixir 16.2 mg/5ml
(Donnatal)........................................................................66
belladonna alkaloids-phenobarbital tab 16.2 mg
(Donnatal)........................................................................66
BELVIQ -lorcaserin hcl tab 10 mg.....................................87
benazepril & hydrochlorothiazide tab 10-12.5 mg
(Lotensin hct)................................................................. 42
benazepril & hydrochlorothiazide tab 20-12.5 mg
(Lotensin hct)................................................................. 42
benazepril & hydrochlorothiazide tab 20-25 mg
(Lotensin hct)................................................................. 42
benazepril & hydrochlorothiazide tab 5-6.25 mg.......... 42
benazepril hcl tab 10 mg (Lotensin).............................. 42
benazepril hcl tab 5 mg.................................................. 43
BENICAR HCT -olmesartan medoxomilhydrochlorothiazide tab 20-12.5 mg................................ 43
BENICAR HCT -olmesartan medoxomilhydrochlorothiazide tab 40-12.5 mg................................ 43
2014
BENICAR HCT -olmesartan medoxomilhydrochlorothiazide tab 40-25 mg................................... 43
BENICAR -olmesartan medoxomil tab 20 mg................... 43
BENICAR -olmesartan medoxomil tab 40 mg................... 43
BENICAR -olmesartan medoxomil tab 5 mg..................... 43
BENSAL HP -salicylic acid & benzoic acid oint 3-6%...... 142
BENTYL -dicyclomine hcl cap 10 mg................................ 66
BENTYL -dicyclomine hcl oral soln 10 mg/5ml..................66
BENTYL -dicyclomine hcl tab 20 mg.................................66
BENZAC AC WASH -benzoyl peroxide liq 5%................ 142
BENZACLIN -clindamycin phosphate-benzoyl peroxide gel
1-5%............................................................................... 142
BENZACLIN WITH PUMP -clindamycin phosphatebenzoyl peroxide gel 1-5%............................................ 142
BENZAC W WASH -benzoyl peroxide liq 5%..................142
BENZALKONIUM CHLORIDE -benzalkonium chloride
soln.................................................................................159
BENZALKONIUM CHLORIDE -benzalkonium chloride soln
17%................................................................................ 159
BENZALKONIUM CHLORIDE -benzalkonium chloride soln
50%................................................................................ 159
BENZAMYCIN -benzoyl peroxide-erythromycin gel
5-3%............................................................................... 142
BENZAMYCINPAK -benzoyl peroxide-erythromycin gel
pack 5-3%...................................................................... 142
BENZEFOAM -benzoyl peroxide foam 5.3%...................143
BENZEFOAMULTRA -benzoyl peroxide foam 9.8%....... 143
BENZIQ -benzoyl peroxide gel 5.25 %............................143
BENZIQ LS -benzoyl peroxide gel 2.75%....................... 143
benzocaine dental soln 20%.........................................138
BENZOIN COMPOUND TINCTURE -benzoin compound
tincture............................................................................143
BENZOIN TINCTURE -benzoin tincture.......................... 143
benzonatate cap 100 mg (Tessalon perles)...................57
benzonatate cap 200 mg.................................................57
benzoyl peroxide cleanser 4.25%................................ 143
benzoyl peroxide cloth 3%........................................... 143
benzoyl peroxide creamy wash 4% &benzoyl peroxide
bar 5% kit......................................................................143
benzoyl peroxide creamy wash 4% & cleanser lotion
kit................................................................................... 143
benzoyl peroxide creamy wash 8% &benzoyl peroxide
bar 5% kit (Bpo creamy wash comp)......................... 143
benzoyl peroxide creamy wash 8% & cleanser lotion
kit................................................................................... 143
benzoyl peroxide-erythromycin gel 5-3%
(Benzamycin)................................................................ 143
benzoyl peroxide foam 5.3% (Benzefoam).................. 143
benzoyl peroxide foam 9.8% (Benzefoamultra).......... 143
benzoyl peroxide gel 10%.............................................143
benzoyl peroxide gel 5%...............................................143
benzoyl peroxide liq 2.5%.............................................143
benzoyl peroxide liq 5.25%...........................................143
benzoyl peroxide liq 7%................................................143
benzoyl peroxide lotion 3%.......................................... 143
benzoyl peroxide pad 3%............................................. 143
benztropine mesylate tab 0.5 mg................................. 112
benztropine mesylate tab 1 mg....................................112
benztropine mesylate tab 2 mg....................................112
BEPREVE -bepotastine besilate ophth soln 1.5%........... 133
BESIVANCE -besifloxacin hcl ophth susp 0.6% (base
equiv)..............................................................................133
BETADINE OPHTHALMIC PREP -povidone-iodine ophth
soln 5%.......................................................................... 133
BETAGAN -levobunolol hcl ophth soln 0.5%...................133
betamethasone dipropionate augmented cream 0.05%
(Diprolene af)................................................................143
betamethasone dipropionate augmented gel
0.05%............................................................................. 143
betamethasone dipropionate augmented lotion 0.05%
(Diprolene).................................................................... 143
betamethasone dipropionate augmented oint 0.05%
(Diprolene).................................................................... 143
betamethasone dipropionate cream 0.05%................. 143
betamethasone dipropionate lotion 0.05%..................143
betamethasone dipropionate oint 0.05%..................... 143
betamethasone valerate aerosol foam 0.12%
(Luxiq)........................................................................... 143
betamethasone valerate cream 0.1%........................... 143
betamethasone valerate lotion 0.1%............................143
betamethasone valerate oint 0.1%............................... 143
BETAPACE AF -sotalol hcl (afib/afl) tab 120 mg...............36
BETAPACE AF -sotalol hcl (afib/afl) tab 160 mg...............36
BETAPACE AF -sotalol hcl (afib/afl) tab 80 mg.................36
BETAPACE -sotalol hcl tab 120 mg.................................. 36
BETAPACE -sotalol hcl tab 160 mg.................................. 36
BETAPACE -sotalol hcl tab 80 mg....................................36
BETASERON -interferon beta-1b for inj kit 0.3 mg............90
betaxolol hcl ophth soln 0.5%......................................133
betaxolol hcl tab 10 mg (Kerlone)..................................36
betaxolol hcl tab 20 mg (Kerlone)..................................36
bethanechol chloride tab 10 mg (Urecholine)............... 72
bethanechol chloride tab 5 mg (Urecholine).................72
BETHKIS -tobramycin nebu soln 300 mg/4ml..................... 6
BETIMOL -timolol ophth soln 0.25%............................... 133
BETIMOL -timolol ophth soln 0.5%................................. 133
BETOPTIC-S -betaxolol hcl ophth susp 0.25%............... 133
BEYAZ -drospirenone-ethinyl estrad-levomefolate tab
3-0.02-0.451 mg...............................................................20
BIAFINE - wound dressings - emulsion ..........................143
BIAXIN -clarithromycin for susp 250 mg/5ml.......................3
175
2014
BIAXIN -clarithromycin tab 250 mg..................................... 2
BIAXIN -clarithromycin tab 500 mg..................................... 3
BIAXIN XL -clarithromycin tab sr 24hr 500 mg....................3
BIAXIN XL PAC -clarithromycin tab sr 24hr 500 mg............3
bicalutamide tab 50 mg (Casodex)................................ 13
BIDIL -isosorbide dinitrate-hydralazine hcl tab 20-37.5
mg.................................................................................... 54
BIFERARX -polysacch fe cmplx-fe heme poly-fa-b12 tab
22-6-1-0.025 mg............................................................ 127
BILTRICIDE -praziquantel tab 600 mg.............................. 11
BINOSTO -alendronate sodium effervescent tab 70
mg.................................................................................... 30
BIONECT -hyaluronate sodium gel 0.2%........................ 143
BIOREGESIC -phenyltoloxamine-acetaminophen tab
50-650 mg........................................................................93
BIO-STATIN -nystatin cap 1000000 unit............................. 6
BIO-STATIN -nystatin cap 500000 unit............................... 6
bisoprolol & hydrochlorothiazide tab 10-6.25 mg
(Ziac)................................................................................43
bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg
(Ziac)................................................................................43
bisoprolol & hydrochlorothiazide tab 5-6.25 mg
(Ziac)................................................................................43
bisoprolol fumarate tab 10 mg (Zebeta)........................ 36
bisoprolol fumarate tab 5 mg (Zebeta).......................... 36
BLEPH-10 -sulfacetamide sodium ophth soln 10%......... 133
BLEPHAMIDE S.O.P. -sulfacetamide sodium-prednisolone
ophth oint 10-0.2%.........................................................133
BLEPHAMIDE -sulfacetamide sodium-prednisolone ophth
susp 10-0.2%................................................................. 133
B-NEXA - prenatal w/ calcium-vit b6-fa-ginger tab 1.22 mg
....................................................................................... 117
BONIVA -ibandronate sodium tab 150 mg (base
equivalent)........................................................................31
BORIC ACID -boric acid granules................................... 143
BOSULIF -bosutinib tab 100 mg....................................... 13
BOSULIF -bosutinib tab 500 mg....................................... 13
BP FOLINATAL PLUS B - prenatal w/ calcium carbonateb6-b12-fa tab 1 mg .......................................................117
BP MULTINATAL PLUS - prenatal w/o a vit w/ fe
fumarate-fa tab 30-1 mg ...............................................117
BP MULTINATAL PLUS - prenatal w/o a vit w/ fe fum-fa
tab chew 40-1 mg .........................................................117
BPO 3% FOAMING CLOTHS -benzoyl peroxide cloth
3%.................................................................................. 143
6%.................................................................................. 143
9%.................................................................................. 143
BPO -benzoyl peroxide gel 4%....................................... 143
BPO -benzoyl peroxide gel 8%....................................... 143
BPO CREAMY WASH COMPLETE -benzoyl peroxide
creamy wash 8% &benzoyl peroxide bar 5% kit............ 143
BP VIT 3 - folic acid-vit b6-vit b12-omega 3-phytosterols
cap 1 mg ...................................................................... 127
176
BRAVELLE -urofollitropin purified for inj 75 unit................ 31
BREO ELLIPTA -fluticasone furoate-vilanterol aero powd
ba 100-25 mcg/inh........................................................... 62
BREVICON-28 -norethindrone & ethinyl estradiol tab 0.5
mg-35 mcg....................................................................... 20
BRILINTA -ticagrelor tab 90 mg...................................... 132
brimonidine tartrate ophth soln 0.15% (Alphagan
p).................................................................................... 133
brimonidine tartrate ophth soln 0.2%.......................... 133
BRINTELLIX -vortioxetine hbr tab 10 mg (base equiv)...... 77
BRINTELLIX -vortioxetine hbr tab 20 mg (base equiv)...... 77
BRINTELLIX -vortioxetine hbr tab 5 mg (base equiv)........77
BRISDELLE -paroxetine mesylate cap 7.5 mg (base
equiv)................................................................................90
BROMDAY -bromfenac sodium ophth soln 0.09% (base
equiv) (once-daily)......................................................... 134
BROMFENAC -bromfenac sodium ophth soln 0.09% (base
equivalent)......................................................................134
bromfenac sodium ophth soln 0.09% (base equiv)
(once-daily)................................................................... 134
bromocriptine mesylate cap 5 mg (Parlodel).............. 112
bromocriptine mesylate tab 2.5 mg (Parlodel)............ 112
brompheniramine & phenylephrine susp 6-10
mg/5ml.............................................................................57
brompheniramine & pseudoephedrine tab sr 12hr 6-45
mg.................................................................................... 57
brompheniramine maleate tab sr 12hr 6 mg................. 55
BROMPHENIRAMINE TANNATE -brompheniramine
tannate chew tab 12 mg.................................................. 55
BRONCOMAR-1 -theophylline-pse-gg elixir 150-30-150
mg/15ml............................................................................62
BRONCOPECTOL -phenyleph-chlorphen w/ dm-gg syrup
5-2-5-75 mg/5ml...............................................................57
BRONDIL -dyphylline-guaifenesin liqd 100-100
mg/15ml............................................................................62
BROVANA -arformoterol tartrate soln nebu 15 mcg/2ml
(base equiv)..................................................................... 62
BUCALSEP - antiseptic products misc - liquid ............... 159
BUCALSEP - antiseptic products misc - solution ........... 159
budesonide cap sr 24hr 3 mg (Entocort ec)..................16
budesonide inhalation susp 0.25 mg/2ml
(Pulmicort)...................................................................... 62
budesonide inhalation susp 0.5 mg/2ml
(Pulmicort)...................................................................... 62
budesonide nasal susp 32 mcg/act (Rhinocort
aqua)................................................................................56
bumetanide tab 0.5 mg................................................... 49
bumetanide tab 1 mg...................................................... 49
bumetanide tab 2 mg...................................................... 49
BUPAP -butalbital-acetaminophen tab 50-300 mg............ 93
BUPAP -butalbital-acetaminophen tab 50-650 mg............ 93
BUPHENYL -sodium phenylbutyrate oral powder 3 gm/
teaspoonful.......................................................................31
BUPHENYL -sodium phenylbutyrate tab 500 mg.............. 31
2014
buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg (base
equiv)...............................................................................95
buprenorphine hcl-naloxone hcl sl tab 8-2 mg (base
equiv)...............................................................................95
buprenorphine hcl sl tab 2 mg (base equiv)................. 95
buprenorphine hcl sl tab 8 mg (base equiv)................. 95
bupropion hcl (smoking deterrent) tab sr 12hr 150 mg
(Zyban)............................................................................ 90
bupropion hcl tab 100 mg (Wellbutrin)..........................77
bupropion hcl tab 75 mg (Wellbutrin)............................77
bupropion hcl tab sr 12hr 100 mg (Wellbutrin sr).........77
bupropion hcl tab sr 24hr 150 mg (Wellbutrin xl)......... 77
bupropion hcl tab sr 24hr 300 mg (Wellbutrin xl)......... 77
buspirone hcl tab 10 mg.................................................76
buspirone hcl tab 5 mg...................................................76
buspirone hcl tab 7.5 mg................................................76
BUTALBITAL/ASPIRIN/CAFFEI -butalbital-aspirin-caffeine
tab 50-325-40 mg............................................................ 93
butalbital-acetaminophen-caffeine cap 50-300-40 mg
(Fioricet).......................................................................... 93
butalbital-acetaminophen-caffeine cap 50-325-40
mg.................................................................................... 93
butalbital-acetaminophen-caffeine cap 50-500-40
mg.................................................................................... 93
butalbital-acetaminophen-caffeine tab 50-325-40
mg.................................................................................... 93
butalbital-acetaminophen-caffeine tab 50-500-40
mg.................................................................................... 93
butalbital-acetaminophen-caff w/ cod cap 50-300-40-30
mg (Fioricet/codeine).....................................................95
butalbital-acetaminophen-caff w/ cod cap 50-325-40-30
mg.................................................................................... 95
butalbital-acetaminophen tab 50-325 mg...................... 93
butalbital-acetaminophen tab 50-650 mg...................... 93
butalbital-aspirin-caffeine cap 50-325-40 mg
(Fiorinal).......................................................................... 93
butalbital-aspirin-caffeine tab 50-325-40 mg................. 93
butalbital-aspirin-caff w/ codeine cap 50-325-40-30 mg
(Fiorinal/codeine #3)...................................................... 95
butamben-tetracaine-benzocaine aerosol spray
2-2-14%..........................................................................144
BUTISOL SODIUM -butabarbital sodium elixir 30
mg/5ml..............................................................................85
BUTISOL SODIUM -butabarbital sodium tab 30 mg..........85
BUTISOL SODIUM -butabarbital sodium tab 50 mg..........85
butorphanol tartrate inj 1 mg/ml.................................... 95
butorphanol tartrate inj 2 mg/ml.................................... 95
butorphanol tartrate nasal soln 10 mg/ml..................... 95
BUTRANS -buprenorphine td patch weekly 10 mcg/hr......95
BUTRANS -buprenorphine td patch weekly 5 mcg/hr........95
BYDUREON -exenatide extended release for inj susp 2
mg.................................................................................... 24
BYETTA -exenatide soln pen-injector 10 mcg/0.04ml....... 24
BYETTA -exenatide soln pen-injector 5 mcg/0.02ml......... 24
BYSTOLIC -nebivolol hcl tab 10 mg (base equivalent)......36
BYSTOLIC -nebivolol hcl tab 2.5 mg (base equivalent).....36
BYSTOLIC -nebivolol hcl tab 20 mg (base equivalent)......36
BYSTOLIC -nebivolol hcl tab 5 mg (base equivalent)........36
C
cabergoline tab 0.5 mg................................................... 31
CADUET -amlodipine besylate-atorvastatin calcium tab
10-10 mg..........................................................................54
10-20 mg..........................................................................54
10-40 mg..........................................................................54
10-80 mg..........................................................................54
2.5-10 mg.........................................................................54
2.5-20 mg.........................................................................54
2.5-40 mg.........................................................................54
5-10 mg............................................................................54
5-20 mg............................................................................54
5-40 mg............................................................................54
5-80 mg............................................................................54
CAFCIT -caffeine citrate oral soln 60 mg/3ml (10 mg/ml
base equiv)...................................................................... 87
CAFERGOT -ergotamine w/ caffeine tab 1-100 mg........ 105
caffeine citrate oral soln 60 mg/3ml (10 mg/ml base
equiv) (Cafcit)................................................................. 87
CALAFOL RX - fa-hydroxocobalamin-policosanol-vit b6-vit
d-ca tab .........................................................................126
CALAN SR -verapamil hcl tab cr 120 mg.......................... 38
CALAN -verapamil hcl tab 120 mg....................................38
CALAN -verapamil hcl tab 80 mg......................................38
CALCIFOL -ca carb-folic acid-vit d-b6-b12-boron-mag
wafer 1342-1.6 mg.........................................................125
calcipotriene-betamethasone dipropionate oint
0.005-0.064% (Taclonex)..............................................144
calcipotriene cream 0.005% (Dovonex)....................... 144
calcipotriene oint 0.005%..............................................144
calcipotriene soln 0.005% (50 mcg/ml)........................ 144
calcitonin (salmon) nasal soln 200 unit/act
(Miacalcin).......................................................................31
CALCITRIOL -calcitriol oint 3 mcg/gm.............................144
177
2014
calcitriol cap 0.25 mcg (Rocaltrol)................................. 31
calcitriol cap 0.5 mcg (Rocaltrol)................................... 31
calcitriol oral soln 1 mcg/ml (Rocaltrol)........................ 31
calcium acetate (phosphate binder) cap 667 mg (169
mg ca) (Phoslo)..............................................................70
calcium acetate (phosphate binder) tab 667 mg
(Eliphos).......................................................................... 70
CALCIUM-FOLIC ACID PLUS D -ca carb-folic acid-vit db6-b12-boron-mag wafer 1342-1 mg............................. 125
CAMBIA -diclofenac potassium packet 50 mg.................105
CAMPRAL -acamprosate calcium tab delayed release 333
mg.................................................................................... 90
CANASA -mesalamine suppos 1000 mg...........................70
candesartan cilexetil-hydrochlorothiazide tab 16-12.5
mg (Atacand hct)........................................................... 43
candesartan cilexetil-hydrochlorothiazide tab 32-12.5
mg (Atacand hct)........................................................... 43
candesartan cilexetil-hydrochlorothiazide tab 32-25
mg (Atacand hct)........................................................... 43
candesartan cilexetil tab 16 mg (Atacand).................... 43
candesartan cilexetil tab 32 mg (Atacand).................... 43
candesartan cilexetil tab 4 mg (Atacand)......................43
candesartan cilexetil tab 8 mg (Atacand)......................43
CANTIL -mepenzolate bromide tab 25 mg........................ 66
CAPCOF -phenylephrine-chlorphen w/ codeine syrup
5-2-10 mg/5ml..................................................................57
capecitabine tab 150 mg (Xeloda)..................................13
capecitabine tab 500 mg (Xeloda)..................................13
CAPEX -fluocinolone acetonide shampoo 0.01%............144
CAPHOSOL - artificial saliva - solution .......................... 138
CAPITAL/CODEINE -acetaminophen w/ codeine susp
120-12 mg/5ml................................................................. 95
CAPRELSA -vandetanib tab 100 mg................................ 13
CAPRELSA -vandetanib tab 300 mg................................ 13
CAPTOPRIL/HYDROCHLOROTHIA -captopril &
hydrochlorothiazide tab 25-15 mg................................... 43
captopril tab 100 mg....................................................... 43
captopril tab 12.5 mg...................................................... 43
captopril tab 25 mg......................................................... 43
captopril tab 50 mg......................................................... 43
CARAC -fluorouracil cream 0.5%.................................... 144
CARAFATE -sucralfate susp 1 gm/10ml........................... 66
CARAFATE -sucralfate tab 1 gm...................................... 66
CARBAGLU -carglumic acid tab 200 mg...........................31
carbamazepine cap sr 12hr 100 mg (Carbatrol).......... 107
carbamazepine chew tab 100 mg.................................108
carbamazepine susp 100 mg/5ml (Tegretol)............... 108
178
carbamazepine tab 200 mg (Tegretol)......................... 108
carbamazepine tab sr 12hr 200 mg (Tegretol-xr)........ 108
carbamazepine tab sr 12hr 400 mg (Tegretol-xr)........ 108
CARBAPHEN 12 PED -phenyleph-chlorphencarbetapentane susp 2.5-1.25-7.5 mg/ml........................ 57
CARBAPHEN 12 -phenyleph-chlorphen-carbetapentane
liqd 10-4-27.5 mg/5ml...................................................... 57
CARBATROL -carbamazepine cap sr 12hr 100 mg........ 108
CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopaentacapone tabs 12.5-50-200 mg.................................. 112
CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopaentacapone tabs 18.75-75-200 mg................................ 112
CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopaentacapone tabs 25-100-200 mg...................................112
CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopaentacapone tabs 31.25-125-200 mg.............................. 112
CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopaentacapone tabs 37.5-150-200 mg................................ 112
CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopaentacapone tabs 50-200-200 mg...................................112
carbidopa & levodopa orally disintegrating tab 10-100
mg.................................................................................. 112
mg.................................................................................. 112
mg.................................................................................. 112
carbidopa & levodopa tab 10-100 mg (Sinemet)......... 112
carbidopa & levodopa tab cr 25-100 mg (Sinemet
cr)...................................................................................112
carbidopa & levodopa tab cr 50-200 mg (Sinemet
cr)...................................................................................112
carbidopa tab 25 mg (Lodosyn)................................... 112
carbinoxamine maleate soln 4 mg/5ml (Palgic)............ 55
carbinoxamine maleate tab 4 mg (Palgic)..................... 55
CARBOGEL 940 - carbomer gel base ........................... 162
CARBOHOL 940 - carbomer gel base ........................... 162
CARBOMER GEL AQUEOUS - carbomer gel base ....... 162
CARBOMER GEL HYDROALCOHOL - carbomer gel base
....................................................................................... 162
carbonyl iron chew tab 15 mg (elemental iron)...........127
carbonyl iron susp 15 mg/1.25ml (elemental iron)......127
CARDENE SR -nicardipine hcl cap sr 12hr 30 mg............ 38
CARDIOTEK-RX - folic acid-b12-b6-arginine-black pepper
tab ................................................................................. 126
CARDIOVID PLUS -dha-epa-vit b6-b12-folic acid cap
240-360-20-0.5-0.8 mg.................................................. 126
CARDIZEM CD -diltiazem hcl coated beads cap sr 24hr
120 mg............................................................................. 38
2014
180 mg............................................................................. 38
240 mg............................................................................. 38
300 mg............................................................................. 38
360 mg............................................................................. 38
CARDIZEM -diltiazem hcl tab 120 mg...............................38
CARDIZEM -diltiazem hcl tab 30 mg.................................38
CARDIZEM LA -diltiazem hcl coated beads tab sr 24hr
120 mg............................................................................. 38
180 mg............................................................................. 38
240 mg............................................................................. 38
300 mg............................................................................. 38
360 mg............................................................................. 38
420 mg............................................................................. 38
CARDURA -doxazosin mesylate tab 1 mg........................ 43
CARDURA XL -doxazosin mesylate tab sr 24 hr 4 mg
(base equiv)..................................................................... 74
CARDURA XL -doxazosin mesylate tab sr 24 hr 8 mg
(base equiv)..................................................................... 74
CARISOPRODOL -carisoprodol tab 250 mg................... 114
carisoprodol tab 350 mg (Soma)..................................114
carisoprodol w/ aspirin & codeine tab 200-325-16
mg.................................................................................. 114
carisoprodol w/ aspirin tab 200-325 mg...................... 114
CARMOL-HC -urea-hc acetate cream 1%.......................144
CARNITOR -levocarnitine oral soln 1 gm/10ml (10%)....... 31
CARNITOR -levocarnitine tab 330 mg.............................. 31
CARNITOR SF -levocarnitine oral soln 1 gm/10ml
(10%)................................................................................31
CARRASYN HYDROGEL WOUND D - wound dressings gel ................................................................................. 144
carteolol hcl ophth soln 1%......................................... 134
carvedilol tab 12.5 mg (Coreg)....................................... 36
carvedilol tab 25 mg (Coreg).......................................... 36
carvedilol tab 3.125 mg (Coreg)..................................... 36
carvedilol tab 6.25 mg (Coreg)....................................... 36
CASCARA SAGRADA AROMATIC -cascara sagrada fl ext
1 gm/ml............................................................................ 65
CASCARA SAGRADA -cascara sagrada fl ext 1 gm/
ml......................................................................................65
CASODEX -bicalutamide tab 50 mg................................. 13
CATAFLAM -diclofenac potassium tab 50 mg.................103
CATAPRES -clonidine hcl tab 0.1 mg............................... 43
CATAPRES-TTS-1 -clonidine hcl td patch weekly 0.1
mg/24hr............................................................................ 43
mg/24hr............................................................................ 43
mg/24hr............................................................................ 43
CAVAN-ALPHA KIT -prenat w/fe poly-na fered-fa tab 27-1
& omega cap dr 300mg................................................. 117
CAVAN-EC SOD DHA -prenatal w/ sod feredetate-fa tab
30-1 & omega 3 cap dr................................................. 117
CAVAN ONE OMEGA - prenatal vit w/ fe cbn-fe asp glycfa-omega 3 cap 27-1mg ............................................... 117
CAVAN PRENATAL/EC CALCIUM - prenatal w/o a vit w/
fe fumarate-fa tab dr 30-1 mg ...................................... 117
CAVERJECT -alprostadil for inj 20 mcg............................ 54
CAVERJECT -alprostadil for inj 40 mcg............................ 54
CAVERJECT IMPULSE -alprostadil for inj kit 10 mcg....... 54
CAVERJECT IMPULSE -alprostadil for inj kit 20 mcg....... 54
CAYSTON -aztreonam lysine for inhal soln 75 mg (base
equivalent)........................................................................12
CEDAX -ceftibuten cap 400 mg.......................................... 1
CEDAX -ceftibuten for susp 180 mg/5ml.............................1
CEDAX -ceftibuten for susp 90 mg/5ml...............................1
CEENU -lomustine cap 100 mg........................................ 13
CEENU -lomustine cap 10 mg.......................................... 13
CEENU -lomustine cap 40 mg.......................................... 13
cefaclor cap 250 mg..........................................................2
cefaclor cap 500 mg..........................................................2
CEFACLOR -cefaclor for susp 125 mg/5ml.........................1
CEFACLOR ER -cefaclor monohydrate tab sr 12hr 500
mg...................................................................................... 2
cefadroxil cap 500 mg.......................................................2
cefadroxil for susp 250 mg/5ml........................................2
cefadroxil for susp 500 mg/5ml........................................2
cefadroxil tab 1 gm........................................................... 2
cefdinir cap 300 mg...........................................................2
cefdinir for susp 125 mg/5ml........................................... 2
cefdinir for susp 250 mg/5ml........................................... 2
CEFDITOREN PIVOXIL -cefditoren pivoxil tab 200 mg
(base equivalent)............................................................... 2
CEFDITOREN PIVOXIL -cefditoren pivoxil tab 400 mg
(base equivalent)............................................................... 2
cefpodoxime proxetil for susp 100 mg/5ml.....................2
cefpodoxime proxetil for susp 50 mg/5ml.......................2
cefpodoxime proxetil tab 100 mg.................................... 2
cefpodoxime proxetil tab 200 mg.................................... 2
cefprozil for susp 125 mg/5ml..........................................2
cefprozil for susp 250 mg/5ml..........................................2
cefprozil tab 250 mg..........................................................2
cefprozil tab 500 mg..........................................................2
179
2014
CEFTIBUTEN -ceftibuten cap 400 mg................................ 2
CEFTIBUTEN -ceftibuten for susp 180 mg/5ml...................2
CEFTIN -cefuroxime axetil for susp 125 mg/5ml................. 2
CEFTIN -cefuroxime axetil for susp 250 mg/5ml................. 2
CEFTIN -cefuroxime axetil tab 250 mg............................... 2
CEFTIN -cefuroxime axetil tab 500 mg............................... 2
cefuroxime axetil for susp 125 mg/5ml (Ceftin).............. 2
cefuroxime axetil tab 250 mg (Ceftin)..............................2
cefuroxime axetil tab 500 mg (Ceftin)..............................2
CELEBREX -celecoxib cap 100 mg................................ 103
CELEBREX -celecoxib cap 50 mg.................................. 103
CELESTONE -betamethasone soln 0.6 mg/5ml................16
CELEXA -citalopram hydrobromide tab 10 mg (base
equiv)................................................................................77
equiv)................................................................................77
equiv)................................................................................77
CELLCEPT -mycophenolate mofetil cap 250 mg............ 164
CELLCEPT -mycophenolate mofetil for oral susp 200 mg/
ml....................................................................................164
CELLCEPT -mycophenolate mofetil tab 500 mg............. 164
CELONTIN -methsuximide cap 300 mg.......................... 108
CEM-UREA -urea soln 45%............................................ 144
CENESTIN -estrogens, conjugated synthetic a tab 0.3
mg.................................................................................... 18
mg.................................................................................... 18
mg.................................................................................... 18
mg.................................................................................... 18
mg.................................................................................... 18
CENTANY AT -mupirocin oint kit 2%.............................. 144
CENTANY -mupirocin oint 2%.........................................144
CENTRATEX - ferrous fumarate-fa-b complex-c-zn-mgmn-cu cap 106-1 mg .................................................... 127
cephalexin cap 250 mg (Keflex)....................................... 2
CEPHALEXIN -cephalexin tab 250 mg............................... 2
CEPHALEXIN -cephalexin tab 500 mg............................... 2
cephalexin for susp 125 mg/5ml...................................... 2
cephalexin for susp 250 mg/5ml...................................... 2
CERVIDIL -dinoprostone vaginal inserts 10 mg................ 30
CESAMET -nabilone cap 1 mg......................................... 69
CETACAINE -butamben-tetracaine-benzocaine aerosol
spray 2-2-14%................................................................144
CETRAXAL -ciprofloxacin hcl otic soln 0.2% (base
equivalent)......................................................................137
CETROTIDE -cetrorelix acetate for inj kit 0.25 mg............ 31
CETROTIDE -cetrorelix acetate for inj kit 3 mg.................31
180
cevimeline hcl cap 30 mg (Evoxac)............................. 138
CGU WC -guaifenesin-codeine soln 100-6.3 mg/5ml........ 57
CHANTIX CONTINUING MONTH -varenicline tartrate tab
1 mg (base equiv)............................................................90
CHANTIX STARTING MONTH PA -varenicline tartrate tab
0.5 mg x 11 & tab 1 mg x 42 pack.................................. 90
CHANTIX -varenicline tartrate tab 0.5 mg (base equiv).....90
CHANTIX -varenicline tartrate tab 1 mg (base equiv)........90
CHELIDONIUM COMPOUND - misc natural products liqd
....................................................................................... 164
CHEMET -succimer cap 100 mg.....................................159
CHENODAL -chenodiol tab 250 mg.................................. 70
CHERRY SYRUP -cherry syrup...................................... 162
CHLORAL HYDRATE -chloral hydrate syrup 500
mg/5ml..............................................................................85
CHLORDIAZEPOXIDE/AMITRIPT -chlordiazepoxideamitriptyline tab 10-25 mg............................................... 90
CHLORDIAZEPOXIDE/AMITRIPT -chlordiazepoxideamitriptyline tab 5-12.5 mg.............................................. 90
chlordiazepoxide hcl cap 10 mg.................................... 76
chlordiazepoxide hcl cap 25 mg.................................... 76
chlordiazepoxide hcl cap 5 mg...................................... 76
CHLORHEXIDINE DIGLUCONATE -chlorhexidine
gluconate soln 20%....................................................... 159
CHLORHEXIDINE GLUCONATE -chlorhexidine gluconate
soln 20%........................................................................ 159
chlorhexidine gluconate soln 0.12% (Peridex)............138
chloroquine phosphate tab 250 mg............................... 11
chloroquine phosphate tab 500 mg (Aralen).................11
CHLOROTHIAZIDE -chlorothiazide tab 250 mg................49
chlorothiazide tab 250 mg.............................................. 49
chlorothiazide tab 500 mg.............................................. 49
chlorpheniramine tan-phenylephrine tan susp 4.5-5
mg/5ml.............................................................................57
chlorpheniramine w/ codeine liquid 2-10 mg/5ml......... 57
chlorpromazine hcl tab 100 mg......................................82
chlorpromazine hcl tab 10 mg........................................82
chlorpromazine hcl tab 200 mg......................................82
CHLORPROPAMIDE -chlorpropamide tab 100 mg...........24
CHLORPROPAMIDE -chlorpropamide tab 250 mg...........24
CHLORTHALIDONE -chlorthalidone tab 100 mg.............. 49
CHLORTHALIDONE -chlorthalidone tab 25 mg................ 49
CHLORTHALIDONE -chlorthalidone tab 50 mg................ 49
chlorthalidone tab 25 mg................................................49
chlorzoxazone tab 500 mg (Parafon forte dsc)........... 114
cholecalciferol cap 1000 unit........................................116
cholecalciferol chew tab 1000 unit.............................. 116
cholecalciferol chew tab 400 unit................................ 116
cholecalciferol drops 400 unit/0.03ml (per drop)........ 116
cholecalciferol drops 5000 unit/ml (1000
unit/0.2ml)..................................................................... 116
cholecalciferol oral liquid 400 unit/ml......................... 116
cholecalciferol tab 1000 unit........................................ 116
2014
cholecalciferol tab 400 unit.......................................... 116
cholestyramine light powder 4 gm/dose (Questran
light).................................................................................51
cholestyramine light powder packets 4 gm.................. 51
cholestyramine powder 4 gm/dose (Questran).............51
cholestyramine powder packets 4 gm (Questran)........51
choline & magnesium salicylates liq 500 mg/5ml.........93
choline & magnesium salicylates tab 1000 mg.............93
choline & magnesium salicylates tab 500 mg...............93
choline & magnesium salicylates tab 750 mg...............93
choline fenofibrate cap dr 135 mg (fenofibric acid
equiv) (Trilipix)............................................................... 51
choline fenofibrate cap dr 45 mg (fenofibric acid equiv)
(Trilipix)........................................................................... 51
chorionic gonadotropin for inj 10000 unit.....................31
CHRYSADERM DAY - cream base ............................... 162
CHRYSADERM NIGHT - cream base ............................162
CIALIS -tadalafil tab 10 mg............................................... 54
CIALIS -tadalafil tab 2.5 mg.............................................. 54
CIALIS -tadalafil tab 20 mg............................................... 54
CIALIS -tadalafil tab 5 mg................................................. 54
CICLODAN CREAM KIT -ciclopirox olamine cream 0.77%
(base equiv) & cleanser kit............................................ 144
CICLODAN SOLUTION KIT -ciclopirox solution kit
8%.................................................................................. 144
ciclopirox gel 0.77% (Loprox).......................................144
ciclopirox olamine cream 0.77% (base equiv).............144
ciclopirox olamine susp 0.77% (base equiv)...............144
ciclopirox shampoo 1% (Loprox shampoo)................ 144
ciclopirox solution 8% (Penlac nail lacquer)...............144
ciclopirox solution kit 8% (Ciclodan solution ki)........ 144
CICLOPIROX TOPICAL SOLUTI -ciclopirox solution 8% &
vitamin e 5% topical kit..................................................144
cilostazol tab 100 mg (Pletal)....................................... 132
cilostazol tab 50 mg (Pletal)......................................... 132
CILOXAN -ciprofloxacin hcl ophth oint 0.3%................... 134
CILOXAN -ciprofloxacin hcl ophth soln 0.3%.................. 134
cimetidine hcl soln 300 mg/5ml..................................... 66
cimetidine tab 200 mg.....................................................66
CIMZIA -certolizumab pegol for inj kit 2 x 200 mg............. 70
CIMZIA -certolizumab pegol inj kit 2 x 200 mg/ml............. 70
CIMZIA STARTER KIT -certolizumab pegol inj kit 6 x 200
mg/ml................................................................................70
C INDICUM EXTRACT/C SINES -c indicum & c sinesis
leaf extract liquid............................................................160
CIPRO -ciprofloxacin for oral susp 250 mg/5ml (5%) (5
gm/100ml).......................................................................... 5
CIPRO -ciprofloxacin for oral susp 500 mg/5ml (10%) (10
gm/100ml).......................................................................... 5
CIPRO -ciprofloxacin hcl tab 250 mg (base equiv)..............5
CIPRO -ciprofloxacin hcl tab 500 mg (base equiv)..............5
CIPRODEX -ciprofloxacin-dexamethasone otic susp
0.3-0.1%......................................................................... 137
CIPROFLOXACIN -ciprofloxacin hcl otic soln 0.2% (base
equivalent)......................................................................137
ciprofloxacin-ciprofloxacin hcl tab sr 24hr 1000
mg(base eq) (Cipro xr).................................................... 5
ciprofloxacin-ciprofloxacin hcl tab sr 24hr 500 mg
(base eq) (Cipro xr)......................................................... 5
ciprofloxacin hcl ophth soln 0.3% (Ciloxan)............... 134
ciprofloxacin hcl tab 100 mg (base equiv)...................... 5
ciprofloxacin hcl tab 250 mg (base equiv) (Cipro)..........5
ciprofloxacin hcl tab 500 mg (base equiv) (Cipro)..........5
ciprofloxacin hcl tab 750 mg (base equiv)...................... 5
CIPRO HC -ciprofloxacin-hydrocortisone otic susp
0.2-1%............................................................................ 137
CIPRO XR -ciprofloxacin-ciprofloxacin hcl tab sr 24hr 1000
mg(base eq).......................................................................5
CIPRO XR -ciprofloxacin-ciprofloxacin hcl tab sr 24hr 500
mg (base eq)..................................................................... 5
citalopram hydrobromide oral soln 10 mg/5ml............. 77
citalopram hydrobromide tab 10 mg (base equiv)
(Celexa)........................................................................... 77
(Celexa)........................................................................... 77
(Celexa)........................................................................... 77
CITRANATAL 90 DHA -prenat w/o a w/fecbn-fegl-dss-fa
tab 90 &dha cap 300mg pak......................................... 117
CITRANATAL ASSURE -prenat w/o a w/fecbn-fegl-dss-fa
tab & dha cap 300 mg pack.......................................... 117
CITRANATAL B-CALM -prenat w/o a w/fecbn-feglu-fa tab
20-1 mg & vit b6 tab pak............................................... 117
CITRANATAL DHA -prenat w/o a w/fecbn-fegl-dss-fa tab &
dha cap 250 mg pack.................................................... 117
CITRANATAL HARMONY - prenatal w/o a w/fe cbn-dssfa-dha cap 29-1-265 mg ............................................... 117
CITRANATAL HARMONY - prenat w/o a w/fe fum-fe cbndss-fa-dha cap 27-1-260 mg ........................................ 117
CITRANATAL RX - prenatal w/o a w/ fe carbonyl-fe glucdss-fa tab 27-1mg ........................................................ 117
CITROLITH -potassium & sodium citrates tab 50-950
mg.................................................................................... 74
CLARAVIS -isotretinoin cap 30 mg................................. 144
CLARIFOAM EF -sulfacetamide sodium w/ sulfur foam
10-5%............................................................................. 144
CLARINEX-D 12 HOUR -desloratadine &
pseudoephedrine tab sr 12hr 2.5-120 mg........................57
CLARINEX-D 24 HOUR -desloratadine &
pseudoephedrine tab sr 24hr 5-240 mg...........................57
CLARINEX -desloratadine syrup 0.5 mg/ml...................... 55
CLARINEX -desloratadine tab 5 mg..................................55
CLARINEX REDITABS -desloratadine tab orally
disintegrating 2.5 mg....................................................... 55
CLARINEX REDITABS -desloratadine tab orally
disintegrating 5 mg.......................................................... 55
181
2014
clarithromycin for susp 125 mg/5ml................................ 3
clarithromycin for susp 250 mg/5ml (Biaxin).................. 3
clarithromycin tab 250 mg (Biaxin)..................................3
clarithromycin tab 500 mg (Biaxin)..................................3
clarithromycin tab sr 24hr 500 mg (Biaxin xl pac).......... 3
CLEMASTINE FUMARATE -clemastine fumarate syrup
0.67 mg/5ml (0.5 mg/5ml base eq)..................................55
clemastine fumarate syrup 0.67 mg/5ml (0.5 mg/5ml
base eq).......................................................................... 55
clemastine fumarate tab 2.68 mg...................................55
CLEOCIN -clindamycin hcl cap 150 mg............................ 12
CLEOCIN -clindamycin hcl cap 300 mg............................ 12
CLEOCIN -clindamycin hcl cap 75 mg.............................. 12
CLEOCIN -clindamycin phosphate vaginal cream 2%.......73
CLEOCIN -clindamycin phosphate vaginal suppos 100
mg.................................................................................... 73
CLEOCIN PEDIATRIC GRANULE -clindamycin palmitate
hcl for soln 75 mg/5ml (base equiv)................................ 12
CLEOCIN-T -clindamycin phosphate gel 1%...................144
CLEOCIN-T -clindamycin phosphate lotion 1%............... 144
CLEOCIN-T -clindamycin phosphate soln 1%................. 144
CLEOCIN-T -clindamycin phosphate swab 1%............... 144
clidinium & chlordiazepoxide cap 2.5-5 mg
(Librax)............................................................................ 66
CLIMARA -estradiol td patch weekly 0.025 mg/24hr......... 18
CLIMARA -estradiol td patch weekly 0.0375 mg/24hr (37.5
mcg/24hr)......................................................................... 18
CLIMARA -estradiol td patch weekly 0.05 mg/24hr........... 18
CLIMARA -estradiol td patch weekly 0.06 mg/24hr........... 18
CLIMARA -estradiol td patch weekly 0.075 mg/24hr......... 18
CLIMARA -estradiol td patch weekly 0.1 mg/24hr............. 19
CLIMARA PRO -estradiol-levonorgestrel td patch weekly
0.045-0.015 mg/day......................................................... 19
CLINDACIN ETZ -clindamycin phosphate swab 1% &
cleanser kit.....................................................................144
CLINDACIN PAC -clindamycin phosphate swab 1% &
cleanser kit.....................................................................144
CLINDAGEL -clindamycin phosphate gel 1%..................144
clindamycin hcl cap 150 mg (Cleocin)...........................12
clindamycin hcl cap 300 mg (Cleocin)...........................12
clindamycin hcl cap 75 mg (Cleocin)............................ 12
clindamycin palmitate hcl for soln 75 mg/5ml (base
equiv) (Cleocin pediatric gr)......................................... 12
clindamycin phosphate-benzoyl peroxide gel 1-5%
(Benzaclin).................................................................... 144
clindamycin phosphate foam 1% (Evoclin)................. 144
clindamycin phosphate gel 1% (Cleocin-t)..................144
clindamycin phosphate lotion 1% (Cleocin-t)............. 144
clindamycin phosphate soln 1% (Cleocin-t)................144
clindamycin phosphate swab 1% (Cleocin-t).............. 144
clindamycin phosphate vaginal cream 2%
(Cleocin).......................................................................... 73
clindamycin phosph-benzoyl peroxide (refrig) gel 1.2
(1)-5% (Duac)................................................................ 144
182
CLINDAREACH -clindamycin phosphate swab kit
1%.................................................................................. 144
CLINDESSE -clindamycin phosphate (one dose) vaginal
cream 2%.........................................................................73
CLINORIL -sulindac tab 200 mg..................................... 103
CLOBETA CREAM -clobetasol propionate cream 0.05% &
coal tar soln 2.3% kit..................................................... 144
CLOBETA OINTMENT -clobetasol propionate oint 0.05%
& coal tar soln 2.3% kit................................................. 145
clobetasol propionate cream 0.05% (Temovate).........145
clobetasol propionate emollient base cream 0.05%
(Temovate e).................................................................145
clobetasol propionate emulsion foam 0.05% (Oluxe).................................................................................... 145
clobetasol propionate foam 0.05% (Olux)................... 145
clobetasol propionate gel 0.05% (Temovate).............. 145
clobetasol propionate lotion 0.05% (Clobex).............. 145
clobetasol propionate oint 0.05% (Temovate).............145
clobetasol propionate shampoo 0.05% (Clobex)........ 145
clobetasol propionate soln 0.05% (Temovate)............145
CLOBEX -clobetasol propionate lotion 0.05%................. 145
CLOBEX -clobetasol propionate shampoo 0.05%........... 145
CLOBEX -clobetasol propionate spray 0.05%.................145
CLOCORTOLONE PIVALATE -clocortolone pivalate
cream 0.1%....................................................................145
CLOCORTOLONE PIVALATE PUM -clocortolone pivalate
cream 0.1%....................................................................145
CLODERM -clocortolone pivalate cream 0.1%................145
CLODERM PUMP -clocortolone pivalate cream 0.1%.....145
CLOMID -clomiphene citrate tab 50 mg............................ 31
clomiphene citrate tab 50 mg (Clomid)......................... 31
clomipramine hcl cap 25 mg (Anafranil)....................... 77
clonazepam orally disintegrating tab 0.125 mg.......... 108
clonazepam orally disintegrating tab 0.25 mg............ 108
clonazepam orally disintegrating tab 0.5 mg.............. 108
clonazepam orally disintegrating tab 1 mg................. 108
clonazepam orally disintegrating tab 2 mg................. 108
clonazepam tab 0.5 mg (Klonopin).............................. 108
clonazepam tab 1 mg (Klonopin)................................. 108
clonazepam tab 2 mg (Klonopin)................................. 108
clonidine hcl tab 0.1 mg (Catapres)...............................43
clonidine hcl tab sr 12hr 0.1 mg (Kapvay).....................87
clonidine hcl td patch weekly 0.1 mg/24hr (Cataprestts-1).................................................................................43
clopidogrel bisulfate tab 300 mg (base equiv)
(Plavix)...........................................................................132
2014
clopidogrel bisulfate tab 75 mg (base equiv)
(Plavix)...........................................................................132
clorazepate dipotassium tab 15 mg (Tranxene t)..........76
clorazepate dipotassium tab 3.75 mg (Tranxene t).......76
clorazepate dipotassium tab 7.5 mg (Tranxene t).........76
CLORPRES -clonidine & chlorthalidone tab 0.1-15 mg..... 44
clotrimazole troche 10 mg............................................ 138
clotrimazole w/ betamethasone cream 1-0.05%
(Lotrisone).....................................................................145
clotrimazole w/ betamethasone lotion 1-0.05%...........145
CLOZAPINE ODT -clozapine orally disintegrating tab 100
mg.................................................................................... 82
CLOZAPINE ODT -clozapine orally disintegrating tab 12.5
mg.................................................................................... 82
CLOZAPINE ODT -clozapine orally disintegrating tab 25
mg.................................................................................... 82
clozapine tab 100 mg (Clozaril)......................................82
clozapine tab 200 mg...................................................... 82
clozapine tab 25 mg (Clozaril)........................................82
clozapine tab 50 mg........................................................ 82
CLOZARIL -clozapine tab 100 mg.................................... 82
CLOZARIL -clozapine tab 25 mg...................................... 82
C-NATE DHA - prenatal vit w/ fe fum-fa-omega 3 cap
28-1-200 mg ................................................................. 117
CNL8 NAIL KIT -ciclopirox soln 8% & lacquer removal
pads kit...........................................................................145
COAL TAR BASE -coal tar oint 1%.................................145
COAL TAR -coal tar soln 20%........................................ 145
COARTEM -artemether-lumefantrine tab 20-120 mg........ 11
COCA COLA SYURP -phosphorated carbohydrate w/
caffeine syrup...................................................................69
COCAINE HCL -cocaine hcl soln 10%............................ 145
COCAINE HCL -cocaine hcl soln 4%..............................145
COCET -acetaminophen w/ codeine tab 650-30 mg......... 95
COCET PLUS -acetaminophen w/ codeine tab 650-60
mg.................................................................................... 95
CODAR AR -chlorpheniramine w/ codeine liquid 2-8
mg/5ml..............................................................................57
CODAR D -pseudoephedrine w/ codeine liquid 30-8
mg/5ml..............................................................................57
CODAR GF -guaifenesin-codeine liquid 200-8 mg/5ml..... 57
CODEINE SULFATE -codeine sulfate oral soln 30
mg/5ml..............................................................................95
CODEINE SULFATE -codeine sulfate tab 15 mg..............95
COD LIVER OIL - cod liver oil ....................................... 117
COLAZAL -balsalazide disodium cap 750 mg................... 70
colchicine w/ probenecid tab 0.5-500 mg.................... 107
COLCRYS -colchicine tab 0.6 mg................................... 107
COLD CREAM -cold cream.............................................162
COLESTID -colestipol hcl granule packets 5 gm...............51
COLESTID -colestipol hcl granules 5 gm.......................... 51
COLESTID -colestipol hcl tab 1 gm.................................. 51
COLESTID FLAVORED -colestipol hcl granule packets 5
gm.................................................................................... 51
COLESTID FLAVORED -colestipol hcl granules 5 gm...... 51
colestipol hcl granule packets 5 gm (Colestid
flavored).......................................................................... 51
colestipol hcl granules 5 gm (Colestid flavored).......... 51
colestipol hcl tab 1 gm (Colestid).................................. 51
COLGATE DRY MOUTH RELIEF -sodium fluoride
mouthwash 2.1 mg/10ml................................................138
COLLODION FLEXIBLE -collodion flexible..................... 162
COLY-MYCIN S -neomycin-colistin-hc-thonzonium otic
susp 3.3-3-10-0.5 mg/ml................................................ 137
COLYTE-FLAVOR PACKS -peg 3350-kcl-na bicarb-naclna sulfate for soln 227.1 gm............................................65
COLYTE-FLAVOR PACKS -peg 3350-kcl-na bicarb-naclna sulfate for soln 240 gm...............................................65
COMBIGAN -brimonidine tartrate-timolol maleate ophth
soln 0.2-0.5%................................................................. 134
COMBIPATCH -estradiol-norethindrone ace td pttw
0.05-0.14 mg/day............................................................. 19
COMBIPATCH -estradiol-norethindrone ace td pttw
0.05-0.25 mg/day............................................................. 19
COMBIVENT -ipratropium-albuterol aerosol 18-103 mcg/
act (20-120mcg/act)......................................................... 62
COMBIVENT RESPIMAT -ipratropium-albuterol inhal
aerosol soln 20-100 mcg/act............................................63
COMBIVIR -lamivudine-zidovudine tab 150-300 mg........... 7
COMETRIQ -cabozantinib s-malate cap 3 x 20 mg (60 mg
dose) kit........................................................................... 13
COMETRIQ -cabozantinib s-mal cap 1 x 80 mg & 1 x 20
mg (100 dose) kit.............................................................13
COMETRIQ -cabozantinib s-mal cap 1 x 80 mg & 3 x 20
mg (140 dose) kit.............................................................13
COMPAZINE -prochlorperazine maleate tab 10 mg..........82
COMPAZINE -prochlorperazine maleate tab 5 mg............82
COMPLERA -emtricitabine-rilpivirine-tenofovir df tab
200-25-300 mg...................................................................7
COMPLETE NATAL DHA -prenat-fe bis-fe prot succ-fa-ca
tab & omega 3 cap 250 pk............................................ 117
COMPLETENATE - prenatal vit w/ fe fumarate-fa chew tab
29-1 mg ........................................................................ 117
COMPLETE-RF PRENATAL - prenatal without a w/ fe
carbonyl-docusate-fa tab 90-1mg ................................. 117
COMTAN -entacapone tab 200 mg................................. 112
CO-NATAL FA - prenatal vit w/ fe fumarate-fa tab 29-1 mg
....................................................................................... 117
CONCEPT DHA - prenatal w/fe fum-fe poly -fa-omega 3
cap 53.5-38-1 mg ......................................................... 117
CONCEPT OB - prenatal w/o a w/fe fum-fe poly-fa cap
130-92.4-1 mg .............................................................. 117
CONCERTA -methylphenidate hcl tab sa osm 18 mg....... 87
183
2014
CONDYLOX -podofilox gel 0.5%.....................................145
CONDYLOX -podofilox soln 0.5%................................... 145
CONZIP -tramadol hcl cap sr 24hr biphasic release 100
mg.................................................................................... 95
mg.................................................................................... 95
mg.................................................................................... 95
COPAXONE -glatiramer acetate inj kit 20 mg/ml.............. 90
COPAXONE -glatiramer acetate soln prefilled syringe 40
mg/ml................................................................................90
COPEGUS -ribavirin tab 200 mg.........................................7
CORDARONE -amiodarone hcl tab 200 mg..................... 41
CORDRAN -flurandrenolide lotion 0.05%........................145
CORDRAN SP -flurandrenolide cream 0.05%.................145
CORDRAN TAPE -flurandrenolide tape 4 mcg/sqcm...... 145
COREG -carvedilol tab 12.5 mg........................................36
COREG -carvedilol tab 25 mg...........................................36
COREG -carvedilol tab 3.125 mg......................................36
COREG -carvedilol tab 6.25 mg........................................36
COREG CR -carvedilol phosphate cap sr 24hr 10 mg...... 36
CORGARD -nadolol tab 20 mg......................................... 36
CORTANE-B AQUEOUS -pramoxine-hc-chloroxylenol
aqueous otic soln 10-10-1 mg/ml.................................. 137
CORTANE-B -hydrocortisone-pramoxine-chloroxylenol lot
10-10-1mg/ml................................................................. 145
CORTANE-B-OTIC -pramoxine-hc-chloroxylenol otic soln
10-10-1 mg/ml................................................................137
CORTEF -hydrocortisone tab 10 mg................................. 16
CORTEF -hydrocortisone tab 20 mg................................. 16
CORTEF -hydrocortisone tab 5 mg...................................16
CORTENEMA -hydrocortisone enema 100 mg/60ml.......140
CORTIFOAM -hydrocortisone acetate rectal foam 90 mg/
dose................................................................................140
CORTISONE ACETATE -cortisone acetate tab 25 mg......16
CORTISPORIN -bacitracin-polymyxin-neomycin hc oint
1%.................................................................................. 145
CORTISPORIN -neomycin-polymyxin-hc cream
0.5%............................................................................... 145
CORTISPORIN -neomycin-polymyxin-hc otic soln
1%.................................................................................. 137
CORTISPORIN-TC -neomycin-colistin-hc-thonzonium otic
susp 3.3-3-10-0.5 mg/ml................................................ 137
CORVITE 150 - iron combination tab .............................127
CORVITE 150 -iron-folic acid-vit c-vit b6-vit b12-zinc tab
150-1.25 mg...................................................................128
CORVITE FE - iron combination tab .............................. 127
CORVITE -multiple vitamins w/ minerals & fa tab 1.25
mg.................................................................................. 117
184
CORZIDE -nadolol & bendroflumethiazide tab 40-5
mg.................................................................................... 44
CORZIDE -nadolol & bendroflumethiazide tab 80-5
mg.................................................................................... 44
COSOPT -dorzolamide hcl-timolol maleate ophth soln
22.3-6.8 mg/ml............................................................... 134
COSOPT PF -dorzolamide hcl-timolol maleate ophth sol
22.3-6.8 mg/ml pf...........................................................134
COTAB A -chlorpheniramine w/ codeine tab 4-10 mg....... 57
COTAB AX -chlorpheniramine w/ codeine tab 4-20 mg.....57
COTABFLU -codeine-chlorpheniramine-acetaminophen
tab 20-4-500 mg.............................................................. 57
COUMADIN -warfarin sodium tab 10 mg........................ 130
COUMADIN -warfarin sodium tab 1 mg.......................... 130
COUMADIN -warfarin sodium tab 2.5 mg....................... 130
COUMADIN -warfarin sodium tab 7.5 mg....................... 130
COVERA-HS -verapamil hcl tab sr 24hr (controlled onset)
180 mg............................................................................. 38
COVERA-HS -verapamil hcl tab sr 24hr (controlled onset)
240 mg............................................................................. 38
COZAAR -losartan potassium tab 100 mg........................ 44
COZAAR -losartan potassium tab 25 mg.......................... 44
COZAAR -losartan potassium tab 50 mg.......................... 44
CPB WC -pseudoephedrine-bromphen-codeine liq
10-1.3-6.3 mg/5ml............................................................57
CREAM BASE - cream base ......................................... 162
CREAM CONCENTRATE - cream base ........................ 162
CREON -pancrelipase (lip-prot-amyl) dr cap
12000-38000-60000 unit.................................................. 69
24000-76000-120000 unit................................................ 69
3000-9500-15000 unit...................................................... 69
36000-114000-180000 unit.............................................. 69
6000-19000-30000 unit.................................................... 69
CRESTOR -rosuvastatin calcium tab 10 mg..................... 51
CRESTOR -rosuvastatin calcium tab 5 mg....................... 51
CRESYLATE -cresyl acetate otic soln 25%.................... 137
CRINONE -progesterone vaginal gel 4%.......................... 73
CRINONE -progesterone vaginal gel 8%.......................... 73
CRIXIVAN -indinavir sulfate cap 200 mg............................ 7
CRIXIVAN -indinavir sulfate cap 400 mg............................ 7
CRNATAL -prenatal mv w/fecbn-fegl-dss-fa tab & dha cap
275 mg pack.................................................................. 117
cromolyn sodium ophth soln 4%................................. 134
2014
cromolyn sodium oral conc 100 mg/5ml
(Gastrocrom)...................................................................70
cromolyn sodium soln nebu 20 mg/2ml........................ 63
CUPRIMINE -penicillamine cap 250 mg..........................164
CURAGEL HYDROGEL ISLAND W - hydroactive (sterile)
dressing ........................................................................ 145
CURAGEL HYDROGEL WOUND DR - hydroactive
(sterile) dressing ........................................................... 145
CURITY HYPERTONIC SODIUM - wound dressings misc ...............................................................................145
CURITY SODIUM CHLORIDE DR - wound dressings pads .............................................................................. 145
CUTIVATE -fluticasone propionate cream 0.05%............145
CUTIVATE -fluticasone propionate lotion 0.05%............. 145
CUTIVATE -fluticasone propionate oint 0.005%..............145
CUVPOSA -glycopyrrolate oral soln 1 mg/5ml.................. 66
CVS VITAMIN D3 -cholecalciferol cap 400 unit...............116
CYANIDE ANTIDOTE PKG -cyanide antidote kit............ 159
CYCLESSA -desogest-ethin est tab
0.1-0.025/0.125-0.025/0.15-0.025mg-mg.........................20
CYCLOBENZAPRINE COMFORT P -cyclobenzaprine hcl
tab 10 mg & liniment topical gel kit................................115
cyclobenzaprine hcl cap sr 24hr 15 mg.......................115
cyclobenzaprine hcl cap sr 24hr 30 mg.......................115
cyclobenzaprine hcl tab 10 mg.................................... 115
cyclobenzaprine hcl tab 5 mg...................................... 115
cyclobenzaprine hcl tab 7.5 mg (Fexmid)....................115
CYCLOGYL -cyclopentolate hcl ophth soln 0.5%............134
CYCLOGYL -cyclopentolate hcl ophth soln 1%...............134
CYCLOGYL -cyclopentolate hcl ophth soln 2%...............134
CYCLOMYDRIL -cyclopentolate w/ phenylephrine ophth
soln 0.2-1%.................................................................... 134
cyclopentolate hcl ophth soln 1% (Cyclogyl)..............134
cyclopentolate hcl ophth soln 2% (Cyclogyl)..............134
CYCLOPHOSPHAMIDE -cyclophosphamide tab 25
mg.................................................................................... 13
CYCLOPHOSPHAMIDE -cyclophosphamide tab 50
mg.................................................................................... 13
CYCLOSERINE -cycloserine cap 250 mg...........................6
CYCLOSET -bromocriptine mesylate tab 0.8 mg (base
equivalent)........................................................................24
cyclosporine cap 100 mg (Sandimmune).................... 164
cyclosporine cap 25 mg (Sandimmune)...................... 164
cyclosporine modified cap 100 mg (Neoral)............... 164
cyclosporine modified cap 25 mg (Neoral)................. 164
CYCLOSPORINE MODIFIED -cyclosporine modified cap
50 mg............................................................................. 164
cyclosporine modified oral soln 100 mg/ml
(Neoral)..........................................................................164
CYMBALTA -duloxetine hcl enteric coated pellets cap 20
mg.................................................................................... 77
mg.................................................................................... 77
mg.................................................................................... 77
cyproheptadine hcl syrup 2 mg/5ml.............................. 55
cyproheptadine hcl tab 4 mg......................................... 55
CYSTADANE - betaine powder for oral solution .............. 31
CYSTAGON -cysteamine bitartrate cap 150 mg............... 74
CYSTAGON -cysteamine bitartrate cap 50 mg................. 74
CYSTARAN -cysteamine hcl ophth soln 0.44% (base
equivalent)......................................................................134
CYTOMEL -liothyronine sodium tab 25 mcg..................... 28
CYTOMEL -liothyronine sodium tab 50 mcg..................... 28
CYTOMEL -liothyronine sodium tab 5 mcg....................... 28
CYTOTEC -misoprostol tab 100 mcg................................ 66
CYTOTEC -misoprostol tab 200 mcg................................ 66
CYTOVENE -ganciclovir sodium for inj 500 mg.................. 8
CYTRA-3 -pot & sod citrates w/ cit ac syrup 550-500-334
mg/5ml..............................................................................74
CYTRA-K -potassium citrate & citric acid soln 1100-334
mg/5ml..............................................................................74
D
D.H.E. 45 -dihydroergotamine mesylate inj 1 mg/ml........105
D3 -cholecalciferol cap 400 unit...................................... 116
DALIRESP -roflumilast tab 500 mcg................................. 63
danazol cap 100 mg........................................................ 18
danazol cap 200 mg........................................................ 18
danazol cap 50 mg.......................................................... 18
DANTRIUM -dantrolene sodium cap 100 mg.................. 115
DANTRIUM -dantrolene sodium cap 25 mg.................... 115
DANTRIUM -dantrolene sodium cap 50 mg.................... 115
dantrolene sodium cap 100 mg (Dantrium).................115
dantrolene sodium cap 25 mg (Dantrium)...................115
dantrolene sodium cap 50 mg (Dantrium)...................115
DAPSONE -dapsone tab 100 mg......................................12
DAPSONE -dapsone tab 25 mg........................................12
DARAPRIM -pyrimethamine tab 25 mg.............................11
DAYPRO -oxaprozin tab 600 mg.................................... 103
DAYTRANA -methylphenidate td patch 10 mg/9hr............87
DDAVP -desmopressin acetate inj 4 mcg/ml.....................31
DDAVP -desmopressin acetate nasal soln 0.01%
(refrigerated).....................................................................31
DDAVP -desmopressin acetate nasal spray soln
0.01%............................................................................... 31
DDAVP -desmopressin acetate tab 0.1 mg.......................31
DDAVP -desmopressin acetate tab 0.2 mg.......................31
DDROPS -cholecalciferol drops 1000 unit/0.03ml (per
drop)............................................................................... 116
DEBACTEROL -sulfuric acid-sulfonated phenolics soln
30-50%........................................................................... 138
DECARA -cholecalciferol cap 25000 unit........................ 116
DECON-A -brompheniramine & phenylephrine elixir 2-5
mg/5ml..............................................................................57
DECON-G -phenylephrine-brompheniramine-guaifenesin
liqd 2-1-40 mg/ml............................................................. 58
185
2014
DELATESTRYL -testosterone enanthate im in oil 200 mg/
ml......................................................................................18
DELESTROGEN -estradiol valerate im in oil 10 mg/ml..... 19
DELOS -benzoyl peroxide cleanser 3.5%....................... 145
DELOS -benzoyl peroxide lotion 3.5%............................ 145
DELTUSS DMX -pseudoephed-bromphen-dm liquid
30-1-20 mg/5ml................................................................58
DELZICOL -mesalamine cap dr 400 mg........................... 70
DEMADEX -torsemide tab 100 mg....................................49
DEMADEX -torsemide tab 10 mg......................................49
DEMADEX -torsemide tab 20 mg......................................49
DEMADEX -torsemide tab 5 mg........................................49
demeclocycline hcl tab 150 mg........................................4
demeclocycline hcl tab 300 mg........................................4
DEMEROL -meperidine hcl tab 100 mg............................ 95
DEMEROL -meperidine hcl tab 50 mg.............................. 95
DEMSER -metyrosine cap 250 mg................................... 44
DENATURED ALCOHOL -alcohol, rubbing 95%.............160
DENAVIR -penciclovir cream 1%.................................... 145
DEPAKENE -valproate sodium syrup 250 mg/5ml (base
equiv)..............................................................................108
DEPAKENE -valproic acid cap 250 mg........................... 108
DEPAKOTE -divalproex sodium tab delayed release 125
mg.................................................................................. 108
mg.................................................................................. 108
mg.................................................................................. 108
DEPAKOTE ER -divalproex sodium tab sr 24 hr 250
mg.................................................................................. 108
DEPAKOTE ER -divalproex sodium tab sr 24 hr 500
mg.................................................................................. 108
DEPAKOTE SPRINKLES -divalproex sodium cap sprinkle
125 mg........................................................................... 108
DEPEN TITRATABS -penicillamine tab 250 mg..............164
DEPO-ESTRADIOL -estradiol cypionate im in oil 5 mg/
ml......................................................................................19
DEPO-PROVERA CONTRACEPTIV medroxyprogesterone acetate im susp 150 mg/ml.......... 20
DEPO-SUBQ PROVERA 104 -medroxyprogesterone
acetate subcutaneous susp 104 mg/0.65ml.................... 20
DEPO-TESTOSTERONE -testosterone cypionate im in oil
100 mg/ml........................................................................ 18
DEPO-TESTOSTERONE -testosterone cypionate im in oil
200 mg/ml........................................................................ 18
DERMA-SMOOTHE/FS BODY -fluocinolone acetonide oil
0.01%............................................................................. 146
DERMA-SMOOTHE/FS BODY OIL -fluocinolone
acetonide oil 0.01%....................................................... 146
DERMA-SMOOTHE/FS SCALP -fluocinolone acetonide oil
0.01%............................................................................. 146
DERMA-SMOOTHE/FS SCALP OI -fluocinolone acetonide
oil 0.01%........................................................................ 146
186
DERMASORB AF -clioquinol-hc cream 3-0.5% & emollient
liqd kit.............................................................................146
DERMASORB HC -hydrocortisone lot 2% & cleanser liq
kit....................................................................................146
DERMASORB TA -triamcinolone cream 0.1% & emollient
cream kit........................................................................ 146
DERMASORB XM -urea cream 39% & emollient cream
kit....................................................................................146
DERMATOP -prednicarbate cream 0.1%........................ 146
DERMATOP -prednicarbate oint 0.1%............................ 146
DERMOTIC -fluocinolone acetonide (otic) oil 0.01%....... 138
desipramine hcl tab 100 mg (Norpramin)......................77
desipramine hcl tab 10 mg (Norpramin)........................77
desipramine hcl tab 150 mg (Norpramin)......................77
desloratadine tab 5 mg (Clarinex)..................................55
desloratadine tab orally disintegrating 2.5 mg
(Clarinex reditabs)......................................................... 55
desloratadine tab orally disintegrating 5 mg (Clarinex
reditabs).......................................................................... 55
desmopressin acetate inj 4 mcg/ml (Ddavp).................31
desmopressin acetate nasal soln 0.01% (refrigerated)
(Ddavp)............................................................................ 31
desmopressin acetate nasal spray soln 0.01%
(Ddavp)............................................................................ 31
desmopressin acetate nasal spray soln 0.01%
(refrigerated)................................................................... 31
desmopressin acetate tab 0.1 mg (Ddavp)....................31
desmopressin acetate tab 0.2 mg (Ddavp)....................31
DESOGEN -desogestrel & ethinyl estradiol tab 0.15 mg-30
mcg...................................................................................20
desogest-eth estrad & eth estrad tab 0.15-0.02/0.01
mg(21/5) (Mircette)......................................................... 21
desogest-ethin est tab
0.1-0.025/0.125-0.025/0.15-0.025mg-mg (Cyclessa).....21
desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg
(Desogen)........................................................................21
DESONATE -desonide gel 0.05%................................... 146
desonide cream 0.05% (Desowen)............................... 146
desonide lotion 0.05% (Desowen)................................146
desonide oint 0.05% (Desowen)...................................146
DESONIL - desonide cream 0.05% w/ wound dressing
cream kit ....................................................................... 146
DESONIL - desonide oint 0.05% w/ wound dressing cream
kit .................................................................................. 146
DESOWEN CREAM/CETAPHIL LO -desonide cream
0.05% w/ moisturizing lotion kit..................................... 146
DESOWEN -desonide cream 0.05%............................... 146
DESOWEN -desonide lotion 0.05%................................ 146
DESOWEN -desonide oint 0.05%................................... 146
DESOWEN LOTION/CETAPHIL C -desonide lotion 0.05%
w/ moisturizing cream kit............................................... 146
2014
DESOWEN OINTMENT/CETAPHIL -desonide ointment
0.05% w/ moisturizing lotion kit..................................... 146
desoximetasone cream 0.25% (Topicort).................... 146
DESOXIMETASONE -desoximetasone cream 0.05%.....146
DESOXIMETASONE -desoximetasone oint 0.05%......... 146
desoximetasone gel 0.05% (Topicort)......................... 146
desoximetasone oint 0.25% (Topicort)........................ 146
DESOXYN -methamphetamine hcl tab 5 mg.................... 87
DESPEC-EXP -pseudoephedrine-dihydrocodeine-gg syrup
15-7.5-100 mg/5ml...........................................................58
DESPEC-PDC -phenylephrine-chlorphen-dihydrocodeine
liqd 7.5-2.5-3 mg/5ml....................................................... 58
DESVENLAFAXINE ER -desvenlafaxine fumarate tab sr
24hr 100 mg (base equiv)............................................... 78
DESVENLAFAXINE ER -desvenlafaxine fumarate tab sr
24hr 50 mg (base equiv)................................................. 78
DESVENLAFAXINE ER -desvenlafaxine tab sr 24hr 100
mg.................................................................................... 78
DESVENLAFAXINE ER -desvenlafaxine tab sr 24hr 50
mg.................................................................................... 78
DETROL LA -tolterodine tartrate cap sr 24hr 2 mg........... 72
DETROL LA -tolterodine tartrate cap sr 24hr 4 mg........... 72
DETROL -tolterodine tartrate tab 1 mg............................. 72
DETROL -tolterodine tartrate tab 2 mg............................. 72
DEX4 GLUCOSE -glucose oral liquid 15 gm/59ml............ 24
DEXAMETHASONE -dexamethasone soln 0.5
mg/5ml..............................................................................16
DEXAMETHASONE -dexamethasone tab 1 mg............... 16
DEXAMETHASONE -dexamethasone tab 2 mg............... 16
dexamethasone elixir 0.5 mg/5ml.................................. 16
DEXAMETHASONE INTENSOL -dexamethasone conc 1
mg/ml................................................................................16
dexamethasone sodium phosphate ophth soln
0.1%............................................................................... 134
dexamethasone tab 0.5 mg............................................ 16
dexamethasone tab 0.75 mg.......................................... 16
dexamethasone tab 1.5 mg............................................ 16
dexamethasone tab 4 mg............................................... 16
dexamethasone tab 6 mg............................................... 16
DEXCHLORPHENIRAMINE MALEA -dexchlorpheniramine
maleate syrup 2 mg/5ml.................................................. 55
DEXCHLORPHENIRAMINE MALEA -dexchlorpheniramine
maleate tab cr 4 mg........................................................ 55
DEXEDRINE -dextroamphetamine sulfate cap sr 24hr 10
mg.................................................................................... 87
mg.................................................................................... 87
mg.................................................................................... 87
DEXILANT -dexlansoprazole cap delayed release 30
mg.................................................................................... 66
DEXILANT -dexlansoprazole cap delayed release 60
mg.................................................................................... 66
dexmethylphenidate hcl cap sr 24 hr 15 mg (Focalin
xr).....................................................................................87
xr).....................................................................................87
xr).....................................................................................87
dexmethylphenidate hcl tab 10 mg (Focalin)................ 87
dexmethylphenidate hcl tab 2.5 mg (Focalin)............... 87
dexmethylphenidate hcl tab 5 mg (Focalin).................. 87
DEXPAK 10 DAY -dexamethasone tab 1.5 mg taper
pack..................................................................................16
pack..................................................................................16
pack..................................................................................16
dextroamphetamine sulfate cap sr 24hr 10 mg
(Dexedrine)......................................................................87
(Dexedrine)......................................................................87
(Dexedrine)......................................................................87
dextroamphetamine sulfate oral solution 5 mg/5ml
(Procentra)...................................................................... 87
dextroamphetamine sulfate tab 10 mg.......................... 87
dextroamphetamine sulfate tab 5 mg............................ 87
DEXTROMETHORPHAN HBR/CHLO -phenylephrinechlorphen-dm liquid 1.75-0.75-2.75 mg/ml...................... 58
DEX-TUSS -guaifenesin-codeine liquid 300-10
mg/5ml..............................................................................58
DIABETA -glyburide tab 1.25 mg...................................... 24
DIABETA -glyburide tab 2.5 mg........................................ 24
DIABETA -glyburide tab 5 mg........................................... 24
DIAB F.D.G. FREEZE-DRIED - wound dressings - gel
....................................................................................... 146
DIAB - wound dressings - gel ........................................ 146
DIALYVITE/ZINC -b-complex w/ c-zn & folic acid tab 1
mg.................................................................................. 118
DIALYVITE 3000 -b-complex w/ c-biotin-e-minerals & folic
acid tab 3 mg.................................................................118
DIALYVITE 5000 -b-complex w/ c-biotin-e-minerals & folic
acid tab 5 mg.................................................................118
DIALYVITE SUPREME D -multiple vitamins w/ minerals &
fa tab 3 mg.................................................................... 117
DIAMOX -acetazolamide cap sr 12hr 500 mg................... 49
DIASTAT ACUDIAL -diazepam rectal gel delivery system
10 mg............................................................................. 108
DIASTAT ACUDIAL -diazepam rectal gel delivery system
20 mg............................................................................. 108
DIASTAT PEDIATRIC -diazepam rectal gel delivery
system 2.5 mg............................................................... 108
DIAZEPAM -diazepam rectal gel delivery system 10
mg.................................................................................. 108
DIAZEPAM -diazepam rectal gel delivery system 2.5
mg.................................................................................. 108
DIAZEPAM -diazepam rectal gel delivery system 20
mg.................................................................................. 108
DIAZEPAM -diazepam soln 1 mg/ml................................. 76
187
2014
DIAZEPAM INTENSOL -diazepam conc 5 mg/ml............. 76
diazepam tab 10 mg (Valium)......................................... 76
diazepam tab 2 mg (Valium)...........................................76
diazepam tab 5 mg (Valium)........................................... 76
DIBENZYLINE -phenoxybenzamine hcl cap 10 mg...........44
DICLEGIS -doxylamine-pyridoxine tab delayed release
10-10 mg..........................................................................69
diclofenac potassium tab 50 mg (Cataflam)................103
diclofenac sodium (actinic keratoses) gel 3%
(Solaraze)...................................................................... 146
diclofenac sodium ophth soln 0.1%............................ 134
diclofenac sodium tab delayed release 25 mg............103
diclofenac sodium tab sr 24hr 100 mg (Voltarenxr)...................................................................................103
diclofenac w/ misoprostol tab delayed release 50-0.2
mg (Arthrotec 50).........................................................103
diclofenac w/ misoprostol tab delayed release 75-0.2
mg (Arthrotec 75).........................................................103
dicloxacillin sodium cap 250 mg..................................... 1
dicloxacillin sodium cap 500 mg..................................... 1
dicyclomine hcl cap 10 mg (Bentyl).............................. 66
DICYCLOMINE HCL -dicyclomine hcl oral soln 10
mg/5ml..............................................................................66
dicyclomine hcl tab 20 mg (Bentyl)............................... 66
didanosine delayed release capsule 125 mg (Videx
ec)...................................................................................... 8
ec)...................................................................................... 8
ec)...................................................................................... 8
ec)...................................................................................... 8
DIDRONEL -etidronate disodium tab 400 mg....................31
DIFFERIN -adapalene cream 0.1%.................................146
DIFFERIN -adapalene gel 0.1%...................................... 146
DIFFERIN -adapalene gel 0.3%...................................... 146
DIFFERIN -adapalene lotion 0.1%.................................. 146
DIFICID -fidaxomicin tab 200 mg........................................ 3
DIFLORASONE DIACETATE -diflorasone diacetate cream
0.05%............................................................................. 146
diflorasone diacetate oint 0.05%..................................146
DIFLUCAN -fluconazole for susp 10 mg/ml.........................6
DIFLUCAN -fluconazole for susp 40 mg/ml.........................6
DIFLUCAN -fluconazole tab 100 mg................................... 6
DIFLUCAN -fluconazole tab 50 mg..................................... 6
diflunisal tab 500 mg.......................................................93
DIGEX NF -hyoscyamine-phenyltoloxamine cap 0.0625-15
mg.................................................................................... 66
DIGOXIN -digoxin oral soln 0.05 mg/ml............................ 35
digoxin tab 125 mcg (0.125 mg) (Lanoxin).................... 35
digoxin tab 250 mcg (0.25 mg) (Lanoxin)...................... 35
188
DIHYDROERGOTAMINE MESYLAT -dihydroergotamine
mesylate nasal spray 4 mg/ml....................................... 105
dihydroergotamine mesylate inj 1 mg/ml (D.h.e.
45).................................................................................. 105
DILACOR XR -diltiazem hcl cap sr 24hr 240 mg...............38
DILANTIN INFATABS -phenytoin chew tab 50 mg..........108
DILANTIN -phenytoin sodium extended cap 100 mg.......108
DILANTIN -phenytoin sodium extended cap 30 mg.........108
DILANTIN -phenytoin susp 125 mg/5ml.......................... 108
DILATRATE SR -isosorbide dinitrate cap cr 40 mg........... 35
DILAUDID -hydromorphone hcl liqd 1 mg/ml.................... 95
DILAUDID -hydromorphone hcl tab 2 mg..........................95
diltiazem hcl cap sr 12hr 120 mg................................... 38
diltiazem hcl cap sr 12hr 60 mg.....................................38
diltiazem hcl cap sr 12hr 90 mg.....................................38
diltiazem hcl coated beads cap sr 24hr 120 mg
(Cardizem cd)................................................................. 39
(Cardizem cd)................................................................. 39
(Cardizem cd)................................................................. 39
(Cardizem cd)................................................................. 39
(Cardizem cd)................................................................. 39
(Cardizem cd)................................................................. 39
diltiazem hcl coated beads tab sr 24hr 180 mg
(Cardizem la).................................................................. 39
(Cardizem la).................................................................. 39
(Cardizem la).................................................................. 39
(Cardizem la).................................................................. 39
(Cardizem la).................................................................. 39
diltiazem hcl extended release beads cap sr 24hr 120
mg (Tiazac)..................................................................... 39
mg (Tiazac)..................................................................... 39
mg (Tiazac)..................................................................... 39
mg (Tiazac)..................................................................... 39
mg (Tiazac)..................................................................... 39
mg (Tiazac)..................................................................... 39
diltiazem hcl tab 120 mg (Cardizem)............................. 39
2014
diltiazem hcl tab 30 mg (Cardizem)............................... 39
diltiazem hcl tab 60 mg (Cardizem)............................... 39
diltiazem hcl tab 90 mg...................................................39
DIOVAN HCT -valsartan-hydrochlorothiazide tab 160-12.5
mg.................................................................................... 44
DIOVAN HCT -valsartan-hydrochlorothiazide tab 160-25
mg.................................................................................... 44
mg.................................................................................... 44
DIOVAN HCT -valsartan-hydrochlorothiazide tab 320-25
mg.................................................................................... 44
mg.................................................................................... 44
DIOVAN -valsartan tab 160 mg.........................................44
DIOVAN -valsartan tab 320 mg.........................................44
DIOVAN -valsartan tab 40 mg...........................................44
DIOVAN -valsartan tab 80 mg...........................................44
DIPENTUM -olsalazine sodium cap 250 mg..................... 70
diphenhydramine hcl cap 50 mg....................................55
diphenhydramine hcl elixir 12.5 mg/5ml........................55
diphenhydramine hcl syrup 12.5 mg/5ml...................... 55
DIPHENOXYLATE/ATROPINE -diphenoxylate w/ atropine
liq 2.5-0.025 mg/5ml........................................................ 65
diphenoxylate w/ atropine tab 2.5-0.025 mg
(Lomotil).......................................................................... 65
DIPROLENE AF -betamethasone dipropionate augmented
cream 0.05%..................................................................146
DIPROLENE -betamethasone dipropionate augmented
lotion 0.05%................................................................... 146
DIPROLENE -betamethasone dipropionate augmented
oint 0.05%...................................................................... 146
dipyridamole tab 25 mg (Persantine)...........................132
disopyramide phosphate cap 100 mg (Norpace).......... 41
disopyramide phosphate cap 150 mg (Norpace).......... 41
disulfiram tab 250 mg (Antabuse)..................................90
disulfiram tab 500 mg (Antabuse)..................................90
DITROPAN XL -oxybutynin chloride tab sr 24hr 10 mg..... 72
DITROPAN XL -oxybutynin chloride tab sr 24hr 15 mg..... 72
DITROPAN XL -oxybutynin chloride tab sr 24hr 5 mg.......72
DIURIL -chlorothiazide susp 250 mg/5ml.......................... 49
divalproex sodium cap sprinkle 125 mg (Depakote
sprinkles)...................................................................... 108
divalproex sodium tab delayed release 125 mg
(Depakote).....................................................................108
(Depakote).....................................................................108
(Depakote).....................................................................108
divalproex sodium tab sr 24 hr 250 mg (Depakote
er)...................................................................................108
divalproex sodium tab sr 24 hr 500 mg (Depakote
er)...................................................................................108
DIVIGEL -estradiol td gel 0.25 mg/0.25gm (0.1%)............ 19
DIVIGEL -estradiol td gel 0.5 mg/0.5gm (0.1%)................ 19
DIVIGEL -estradiol td gel 1 mg/gm (0.1%)........................ 19
DIVISTA - folic acid-vit b6-vit b12-omega 3-biotin-cr cap 1
mg ................................................................................. 128
DOLGIC PLUS -butalbital-acetaminophen-caffeine tab
50-750-40 mg...................................................................93
DOLOGESIC -phenyltoloxamine-acetaminophen liquid
30-500 mg/15ml............................................................... 93
DOLOPHINE HCL -methadone hcl tab 5 mg.................... 95
DOLOPHINE -methadone hcl tab 10 mg...........................95
DONATUSS DC -phenylephrine-dihydrocodeine-gg syrup
7.5-7.5-50 mg/5ml............................................................58
donepezil hydrochloride orally disintegrating tab 10
mg (Aricept odt)............................................................. 90
donepezil hydrochloride orally disintegrating tab 5 mg
(Aricept odt)....................................................................90
donepezil hydrochloride tab 10 mg (Aricept)................90
donepezil hydrochloride tab 23 mg (Aricept)................90
donepezil hydrochloride tab 5 mg (Aricept)..................90
DONNATAL -belladonna alkaloids-phenobarbital elixir 16.2
mg/5ml..............................................................................66
DONNATAL -belladonna alkaloids-phenobarbital tab 16.2
mg.................................................................................... 66
DONNATAL EXTENTABS -belladonna alkaloidsphenobarbital tab cr 48 mg..............................................66
DORAL -quazepam tab 15 mg.......................................... 85
DORYX -doxycycline hyclate tab delayed release 150
mg...................................................................................... 4
DORYX -doxycycline hyclate tab delayed release 200
mg...................................................................................... 4
dorzolamide hcl ophth soln 2% (Trusopt)................... 134
dorzolamide hcl-timolol maleate ophth soln 22.3-6.8
mg/ml (Cosopt).............................................................134
DOVONEX -calcipotriene cream 0.005%........................ 146
DOVONEX SCALP -calcipotriene soln 0.005% (50 mcg/
ml).................................................................................. 146
doxazosin mesylate tab 1 mg (Cardura)........................44
doxepin hcl cap 100 mg..................................................78
doxepin hcl cap 10 mg................................................... 78
doxepin hcl cap 150 mg..................................................78
doxepin hcl conc 10 mg/ml............................................ 78
DOXEPIN HCL -doxepin hcl cap 75 mg............................78
doxercalciferol cap 0.5 mcg (Hectorol)......................... 31
doxercalciferol cap 1 mcg (Hectorol)............................ 31
doxercalciferol cap 2.5 mcg (Hectorol)......................... 31
doxycycline hyclate cap 100 mg (Vibramycin)............... 4
doxycycline hyclate cap 100 mg (Vibramycin)............... 4
doxycycline hyclate cap 50 mg........................................4
DOXYCYCLINE HYCLATE -doxycycline hyclate cap dr
particles 100 mg................................................................ 4
189
2014
doxycycline hyclate tab 100 mg.......................................4
doxycycline hyclate tab 20 mg.........................................4
doxycycline hyclate tab delayed release 100 mg........... 4
doxycycline hyclate tab delayed release 150 mg
(Doryx)...............................................................................4
doxycycline hyclate tab delayed release 75 mg............. 4
doxycycline monohydrate cap 100 mg (Monodox).........4
doxycycline monohydrate cap 150 mg (Adoxa)............. 4
doxycycline monohydrate cap 50 mg..............................4
doxycycline monohydrate cap 75 mg (Monodox)...........4
doxycycline monohydrate for susp 25 mg/5ml
(Vibramycin)......................................................................4
doxycycline monohydrate tab 100 mg (Adoxa pak
1/100)................................................................................. 4
doxycycline monohydrate tab 150 mg (Adoxa pak
1/150)................................................................................. 4
doxycycline monohydrate tab 50 mg (Adoxa)................ 4
doxycycline monohydrate tab 75 mg (Adoxa)................ 4
DOXYTEX -doxylamine succinate liquid 2.5 mg/2.5ml...... 55
DPI ALCOHOL GEL - alcohol gel base ..........................162
DPI CLASSIC AEB - cream base ...................................162
DPI ELEDERM-D - cream base ..................................... 162
DPI ELEDERM-N - cream base ..................................... 162
DPI LS PLUS - cream base ........................................... 162
DPI LS ULTRA - cream base .........................................162
DPI NATURAL CREAM BASE - cream base ................. 162
DPI NATURAL LOTION BASE - cream base .................162
DPI SUPREME CREAM BASE - cream base ................ 162
DRISDOL -ergocalciferol cap 50000 unit........................ 116
DRITHO-CREME HP -anthralin cream 1%......................146
DRITHO-SCALP -anthralin cream 0.5%..........................146
dronabinol cap 10 mg (Marinol)..................................... 69
dronabinol cap 2.5 mg (Marinol).................................... 69
dronabinol cap 5 mg (Marinol)....................................... 69
drospirenone-ethinyl estradiol tab 3-0.02 mg (Yaz)......21
drospirenone-ethinyl estradiol tab 3-0.03 mg (Yasmin
28).................................................................................... 21
DROXIA -hydroxyurea cap 200 mg................................. 128
DRYSOL -aluminum chloride soln 20%...........................146
DUAC -clindamycin phosph-benzoyl peroxide (refrig) gel
1.2 (1)-5%...................................................................... 146
DUAVEE -conjugated estrogens-bazedoxifene tab 0.45-20
mg.................................................................................... 19
DUETACT -pioglitazone hcl-glimepiride tab 30-2 mg........ 24
DUETACT -pioglitazone hcl-glimepiride tab 30-4 mg........ 24
DUET DHA BALANCED -prenat w/fe poly-na fered-fa tab
26-1 & omega cap 278 mg............................................118
DUET DHA BALANCED -prenat w/fe poly-na fered-fa tab
27-1 & omega cap dr 380mg.........................................118
DUET DHA EC -prenat w/fe poly-na fered-fa tab 25-1 &
omega cap dr 400mg.....................................................118
DUET DHA EC -prenat w/fe poly-na fered-fa tab 25-1 &
omega cap dr 430mg.....................................................118
190
DUET DHA -prenat w/fe poly-na fered-fa tab 25-1 &
omega cap 400 mg........................................................118
DUET DHA -prenat w/fe poly-na fered-fa tab 25-1 &
omega cap 430 mg........................................................118
DUEXIS -ibuprofen-famotidine tab 800-26.6 mg............. 103
DULERA -mometasone furoate-formoterol fumarate
aerosol 100-5 mcg/act..................................................... 63
DULERA -mometasone furoate-formoterol fumarate
aerosol 200-5 mcg/act..................................................... 63
duloxetine hcl enteric coated pellets cap 20 mg
(Cymbalta).......................................................................78
(Cymbalta).......................................................................78
(Cymbalta).......................................................................78
DUONEB -ipratropium-albuterol nebu soln 0.5-2.5(3)
mg/3ml..............................................................................63
DURAFLU -pseudoephedrine-dm-gg w/ apap tab
60-20-200-500 mg........................................................... 58
DURAGESIC -fentanyl td patch 72hr 100 mcg/hr..............95
DURAGESIC -fentanyl td patch 72hr 12 mcg/hr................95
DURASAL -salicylic acid soln 26%................................. 146
DUREZOL -difluprednate ophth emulsion 0.05%............ 134
DUTOPROL -metoprolol & hydrochlorothiazide tab sr 24hr
100-12.5 mg.....................................................................44
25-12.5 mg.......................................................................44
50-12.5 mg.......................................................................44
D-VI-SOL -cholecalciferol oral liquid 400 unit/ml............. 116
DYAZIDE -triamterene & hydrochlorothiazide cap 37.5-25
mg.................................................................................... 49
DYLIX -dyphylline elixir 100 mg/15ml................................63
DYMISTA -azelastine hcl-fluticasone prop nasal spray
137-50 mcg/act................................................................ 56
DYNACIN -minocycline hcl tab 100 mg...............................4
DYNACIN -minocycline hcl tab 50 mg.................................4
DYNACIN -minocycline hcl tab 75 mg.................................4
DYNACIRC CR -isradipine tab sr 24hr 10 mg...................39
DYNACIRC CR -isradipine tab sr 24hr 5 mg.....................39
dyphylline-guaifenesin liqd 100-100 mg/5ml.................63
dyphylline-guaifenesin tab 200-200 mg.........................63
dyphylline-guaifenesin tab 200-400 mg.........................63
DYRENIUM -triamterene cap 100 mg............................... 49
DYRENIUM -triamterene cap 50 mg................................. 49
E
E.E.S. 400 -erythromycin ethylsuccinate tab 400 mg.......... 3
E.E.S. GRANULES -erythromycin ethylsuccinate for susp
200 mg/5ml........................................................................ 3
EC-NAPROSYN -naproxen tab ec 375 mg..................... 103
EC-NAPROSYN -naproxen tab ec 500 mg..................... 103
econazole nitrate cream 1%......................................... 146
2014
ECOTRIN REGULAR STRENGTH -aspirin tab delayed
release 325 mg................................................................ 93
ECOZA -econazole nitrate foam 1%............................... 147
EDARBI -azilsartan medoxomil tab 40 mg........................ 44
EDARBI -azilsartan medoxomil tab 80 mg........................ 44
EDARBYCLOR -azilsartan medoxomil-chlorthalidone tab
40-12.5 mg.......................................................................44
EDARBYCLOR -azilsartan medoxomil-chlorthalidone tab
40-25 mg..........................................................................44
ED-BRON G -theophylline sod glycinate-gg syrup 300-100
mg/15ml............................................................................63
ED CHLORPED -chlorpheniramine tannate susp 2 mg/
ml......................................................................................55
ED-CHLOR-TAN -chlorpheniramine tannate tab 8 mg...... 55
ED CYTE F -ferrous fumarate-folic acid-docusate sodium
tab 324-1-50 mg............................................................ 128
EDECRIN -ethacrynic acid tab 25 mg............................... 49
EDEX -alprostadil for inj kit 10 mcg...................................54
EDLUAR -zolpidem tartrate sl tab 10 mg.......................... 85
EDLUAR -zolpidem tartrate sl tab 5 mg............................ 85
EDURANT -rilpivirine hcl tab 25 mg (base equivalent)........ 8
EFFER-K -potassium bicarbonate-citric acid effer tab 10
meq................................................................................ 125
EFFER-K -potassium bicarbonate-citric acid effer tab 20
meq................................................................................ 125
EFFEXOR XR -venlafaxine hcl cap sr 24hr 150 mg (base
equivalent)........................................................................78
EFFEXOR XR -venlafaxine hcl cap sr 24hr 37.5 mg (base
equivalent)........................................................................78
EFFEXOR XR -venlafaxine hcl cap sr 24hr 75 mg (base
equivalent)........................................................................78
EFFIENT -prasugrel hcl tab 10 mg (base equiv)............. 132
EFFIENT -prasugrel hcl tab 5 mg (base equiv)............... 132
EFUDEX -fluorouracil cream 5%..................................... 147
EGRIFTA -tesamorelin acetate for inj 1 mg (base
equiv)................................................................................31
EGRIFTA -tesamorelin acetate for inj 2 mg (base
equiv)................................................................................31
ELDEPRYL -selegiline hcl cap 5 mg............................... 112
ELENZAPATCH -lidocaine-menthol patch 4-1%............. 147
ELESTAT -epinastine hcl ophth soln 0.05%....................134
ELESTRIN -estradiol gel 0.06% (0.52 mg/0.87 gm
metered-dose pump)........................................................19
ELETONE - emollient - cream ........................................147
ELIDEL -pimecrolimus cream 1%....................................147
ELIGARD -leuprolide acetate (3 month) for subcutaneous
inj kit 22.5mg................................................................... 13
inj kit 30 mg..................................................................... 13
inj kit 45 mg..................................................................... 13
ELIGARD -leuprolide acetate for subcutaneous inj kit 7.5
mg.................................................................................... 13
ELIMITE -permethrin cream 5%...................................... 147
ELIPHOS -calcium acetate (phosphate binder) tab 667
mg.................................................................................... 70
ELIQUIS -apixaban tab 2.5 mg....................................... 130
ELIQUIS -apixaban tab 5 mg.......................................... 130
ELITE-OB 400 - prenat w/ fe cbn-fe bisglyc-fa-fish oil cap
35-5-1.2 mg .................................................................. 118
ELITE-OB - prenatal vit w/ iron carbonyl-fa tab 50-1.25 mg
....................................................................................... 118
ELITE OB WITH DHA - prenatal vit w/ fe fum-fa-omega 3
cap 28-1.25-200 mg ..................................................... 118
ELIXOPHYLLIN -theophylline elixir 80 mg/15ml................63
ELLA -ulipristal acetate tab 30 mg.................................... 21
ELMIRON -pentosan polysulfate sodium caps 100 mg..... 74
ELOCON -mometasone furoate cream 0.1%.................. 147
ELOCON -mometasone furoate oint 0.1%...................... 147
ELOCON -mometasone furoate solution 0.1%
(lotion)............................................................................ 147
EMADINE -emedastine difumarate ophth soln 0.05%
(base equiv)................................................................... 134
EMCYT -estramustine phosphate sodium cap 140 mg......13
EMEND -aprepitant capsule 125 mg................................. 69
EMEND -aprepitant capsule 40 mg...................................69
EMEND -aprepitant capsule 80 mg...................................69
EMEND -aprepitant capsule therapy pack 80 & 125
mg.................................................................................... 69
EMLA -lidocaine-prilocaine cream 2.5-2.5%....................147
EMOLLIENT CREAM - cream base ............................... 162
EMSAM -selegiline td patch 24hr 12 mg/24hr................... 78
EMSAM -selegiline td patch 24hr 6 mg/24hr..................... 78
EMSAM -selegiline td patch 24hr 9 mg/24hr..................... 78
EMTRIVA -emtricitabine caps 200 mg................................ 8
EMTRIVA -emtricitabine soln 10 mg/ml...............................8
EMULSION SB - dermatological products misc - emulsion
....................................................................................... 147
ENABLEX -darifenacin hydrobromide tab sr 24hr 15 mg
(base equiv)..................................................................... 72
ENABLEX -darifenacin hydrobromide tab sr 24hr 7.5 mg
(base equiv)..................................................................... 72
enalapril maleate & hydrochlorothiazide tab 10-25 mg
(Vaseretic)....................................................................... 44
enalapril maleate & hydrochlorothiazide tab 5-12.5
mg.................................................................................... 44
enalapril maleate tab 10 mg (Vasotec).......................... 44
enalapril maleate tab 2.5 mg (Vasotec)......................... 44
enalapril maleate tab 20 mg (Vasotec).......................... 44
enalapril maleate tab 5 mg (Vasotec)............................ 44
ENBREL -etanercept for subcutaneous inj kit 25 mg.......103
ENBREL -etanercept subcutaneous inj 25 mg/0.5ml.......103
ENBREL -etanercept subcutaneous inj 50 mg/ml............103
ENBREL SURECLICK -etanercept subcutaneous inj 50
mg/ml..............................................................................103
ENDOMETRIN -progesterone vaginal insert 100 mg........ 73
enflurane inhal soln.......................................................107
191
2014
ENJUVIA -estrogens, conjugated synthetic b tab 0.3
mg.................................................................................... 19
mg.................................................................................... 19
mg.................................................................................... 19
mg.................................................................................... 19
mg.................................................................................... 19
ENOVARX-AMITRIPTYLINE -amitriptyline hcl cream 2%
kit (compounding kit)......................................................160
ENOVARX-BACLOFEN - baclofen cream 1% (compound
kit) ................................................................................. 147
ENOVARX-CYCLOBENZAPRINE H -cyclobenzaprine hcl
td cream 20 mg/gm (compound kit)...............................115
ENOVARX-IBUPROFEN -ibuprofen cream 10%
(compounding kit).......................................................... 147
ENOVARX-LIDOCAINE HCL - lidocaine hcl cream 10%
(compound kit) .............................................................. 147
ENOVARX-LIDOCAINE HCL - lidocaine hcl cream 5%
(compound kit) .............................................................. 147
ENOVARX-NAPROXEN - naproxen cream 10%
(compound kit) .............................................................. 147
ENOVARX-TRAMADOL - tramadol hcl cream 5%
(compound kit) .............................................................. 147
enoxaparin sodium inj 100 mg/ml (Lovenox).............. 130
enoxaparin sodium inj 120 mg/0.8ml (Lovenox)......... 130
enoxaparin sodium inj 150 mg/ml (Lovenox).............. 130
enoxaparin sodium inj 300 mg/3ml (Lovenox)............ 130
enoxaparin sodium inj 30 mg/0.3ml (Lovenox)........... 130
entacapone tab 200 mg (Comtan)................................ 112
ENTERAGAM -serum-derived bovine immunoglob/protein
isolate 5 gm packet....................................................... 126
ENTEREG -alvimopan cap 12 mg.....................................70
ENTOCORT EC -budesonide cap sr 24hr 3 mg................16
EPANED -enalapril maleate for oral soln 1 mg/ml.............44
EPICERAM - dermatological products misc - emulsion
....................................................................................... 147
EPIDUO -adapalene-benzoyl peroxide gel 0.1-2.5%.......147
EPIFOAM -pramoxine-hc aerosol foam 1-1%................. 147
epinastine hcl ophth soln 0.05% (Elestat)................... 134
EPINEPHRINE -epinephrine solution auto-injector 0.15
mg/0.15ml (1:1000).......................................................... 50
EPINEPHRINE -epinephrine solution auto-injector 0.3
mg/0.3ml (1:1000)............................................................50
EPIPEN 2-PAK -epinephrine solution auto-injector 0.3
mg/0.3ml (1:1000)............................................................50
EPIPEN -epinephrine solution auto-injector 0.3 mg/0.3ml
(1:1000)............................................................................ 50
EPIPEN-JR 2-PAK -epinephrine solution auto-injector 0.15
mg/0.3ml (1:2000)............................................................50
192
EPIPEN-JR -epinephrine solution auto-injector 0.15
mg/0.3ml (1:2000)............................................................50
EPIVIR HBV -lamivudine oral soln 5 mg/ml........................ 8
EPIVIR HBV -lamivudine tab 100 mg..................................8
EPIVIR -lamivudine oral soln 10 mg/ml...............................8
EPIVIR -lamivudine tab 150 mg.......................................... 8
EPIVIR -lamivudine tab 300 mg.......................................... 8
eplerenone tab 25 mg (Inspra)....................................... 44
eplerenone tab 50 mg (Inspra)....................................... 44
EPOGEN -epoetin alfa inj 10000 unit/ml......................... 128
EPOGEN -epoetin alfa inj 20000 unit/ml......................... 128
EPOGEN -epoetin alfa inj 2000 unit/ml........................... 128
eprosartan mesylate tab 600 mg (Teveten)................... 44
EPZICOM -abacavir sulfate-lamivudine tab 600-300 mg.....8
EQUAGESIC -meprobamate-aspirin tab 200-325 mg....... 93
EQUETRO -carbamazepine (antipsychotic) cap sr 12hr
100 mg............................................................................. 82
200 mg............................................................................. 82
300 mg............................................................................. 82
ERECAID CLASSIC - impotence aid device - kit ............160
ERECAID ESTEEM - impotence aid device - kit ............ 160
ergocalciferol cap 50000 unit (Drisdol)........................116
ERGOLOID MESYLATES -ergoloid mesylates tab 1
mg.................................................................................... 90
ERGOMAR -ergotamine tartrate sl tab 2 mg...................105
ERIVEDGE -vismodegib cap 150 mg................................13
EROS-CTD - clitoral vacuum device .............................. 160
ERTACZO -sertaconazole nitrate cream 2%...................147
ERYGEL -erythromycin gel 2%....................................... 147
ERYPED 200 -erythromycin ethylsuccinate for susp 200
mg/5ml................................................................................3
ERYPED 400 -erythromycin ethylsuccinate for susp 400
mg/5ml................................................................................3
ERYSIDORON #2 - misc natural products tab ............... 165
ERY-TAB -erythromycin tab delayed release 250 mg......... 3
ERYTHROCIN STEARATE -erythromycin stearate tab 250
mg...................................................................................... 3
ERYTHROMYCIN BASE -erythromycin tab 250 mg........... 3
ERYTHROMYCIN BASE -erythromycin tab 500 mg........... 3
ERYTHROMYCIN -erythromycin w/ delayed release
particles cap 250 mg......................................................... 3
ERYTHROMYCIN ETHYLSUCCINA -erythromycin
ethylsuccinate tab 400 mg.................................................3
erythromycin ethylsuccinate tab 400 mg........................ 3
erythromycin gel 2% (Erygel)....................................... 147
erythromycin ophth oint 5 mg/gm............................... 134
erythromycin pads 2%.................................................. 147
erythromycin soln 2%................................................... 147
2014
erythromycin-sulfisoxazole for susp 200-600
mg/5ml.............................................................................12
erythromycin w/ delayed release particles cap 250
mg...................................................................................... 3
ESCAVITE - pediatric multiple vitamins w/ fl-fe chew tab
0.25-7.5 mg .................................................................. 118
escitalopram oxalate soln 5 mg/5ml (base equiv)
(Lexapro)......................................................................... 78
escitalopram oxalate tab 10 mg (base equiv)
(Lexapro)......................................................................... 78
(Lexapro)......................................................................... 78
(Lexapro)......................................................................... 78
ESGIC -butalbital-acetaminophen-caffeine cap 50-325-40
mg.................................................................................... 93
ESGIC -butalbital-acetaminophen-caffeine tab 50-325-40
mg.................................................................................... 93
ESGIC-PLUS -butalbital-acetaminophen-caffeine cap
50-500-40 mg...................................................................93
ESGIC-PLUS -butalbital-acetaminophen-caffeine tab
50-500-40 mg...................................................................93
ESOMEPRAZOLE STRONTIUM -esomeprazole strontium
cap delayed release 24.65 mg........................................ 66
ESOMEPRAZOLE STRONTIUM -esomeprazole strontium
cap delayed release 49.3 mg.......................................... 66
ESPUMIL - foam base - foam ........................................ 162
estazolam tab 1 mg......................................................... 85
estazolam tab 2 mg......................................................... 85
esterified estrogens & methyltestosterone tab
0.625-1.25 mg................................................................. 19
esterified estrogens & methyltestosterone tab 1.25-2.5
mg.................................................................................... 19
ESTRACE -estradiol tab 0.5 mg........................................19
ESTRACE -estradiol tab 1 mg.......................................... 19
ESTRACE -estradiol tab 2 mg.......................................... 19
ESTRACE -estradiol vaginal cream 0.1 mg/gm.................73
estradiol & norethindrone acetate tab 0.5-0.1 mg
(Activella)........................................................................ 19
estradiol & norethindrone acetate tab 1-0.5 mg
(Activella)........................................................................ 19
estradiol tab 0.5 mg (Estrace)........................................ 19
estradiol tab 1 mg (Estrace)........................................... 19
estradiol tab 2 mg (Estrace)........................................... 19
estradiol td patch weekly 0.025 mg/24hr (Climara).......19
estradiol td patch weekly 0.0375 mg/24hr (37.5
mcg/24hr) (Climara)....................................................... 19
estradiol td patch weekly 0.05 mg/24hr (Climara).........19
estradiol td patch weekly 0.06 mg/24hr (Climara).........19
estradiol td patch weekly 0.075 mg/24hr (Climara).......19
estradiol td patch weekly 0.1 mg/24hr (Climara)...........19
estradiol valerate im in oil 10 mg/ml (Delestrogen)...... 19
ESTRASORB -estradiol transdermal emulsion 4.35
mg/1.74gm....................................................................... 19
ESTRING -estradiol vaginal ring 2 mg (7.5 mcg/24hrs).....73
ESTROGEL -estradiol gel 0.06% (0.75 mg/1.25 gm
metered-dose pump)........................................................19
ESTROPIPATE -estropipate tab 3 mg.............................. 19
estropipate tab 0.75 mg.................................................. 19
estropipate tab 1.5 mg.................................................... 19
ESTROSTEP FE -norethindrone ac-ethinyl estrad-fe tab
1-20/1-30/1-35 mg-mcg....................................................21
eszopiclone tab 1 mg (Lunesta).....................................85
ethambutol hcl tab 100 mg (Myambutol).........................6
ethambutol hcl tab 400 mg (Myambutol).........................6
ethosuximide cap 250 mg (Zarontin)........................... 108
ethosuximide soln 250 mg/5ml (Zarontin)...................108
ETHRANE -enflurane inhal soln...................................... 107
ETHYL CHLORIDE/FINE PINPO -ethyl chloride aerosol
spray...............................................................................147
ETHYL CHLORIDE/FINE STREA -ethyl chloride aerosol
spray...............................................................................147
ETHYL CHLORIDE/MEDIUM JET -ethyl chloride aerosol
spray...............................................................................147
ETHYL CHLORIDE/MEDIUM STR -ethyl chloride aerosol
spray...............................................................................147
ETHYL CHLORIDE/MIST -ethyl chloride aerosol
spray...............................................................................147
ETHYL CHLORIDE -ethyl chloride aerosol spray............147
ethynodiol diacetate & ethinyl estradiol tab 1 mg-35
mcg.................................................................................. 21
ETIDRONATE DISODIUM -etidronate disodium tab 200
mg.................................................................................... 31
ETIDRONATE DISODIUM -etidronate disodium tab 400
mg.................................................................................... 31
etodolac cap 200 mg..................................................... 103
etodolac cap 300 mg..................................................... 103
etodolac tab 400 mg......................................................103
etodolac tab 500 mg......................................................103
etodolac tab sr 24hr 400 mg.........................................103
ETOPOSIDE -etoposide cap 50 mg.................................. 13
EUCALYPTUS OIL -eucalyptus (topical) oil.................... 147
EURAX -crotamiton cream 10%...................................... 147
EURAX -crotamiton lotion 10%....................................... 147
EVAMIST -estradiol transdermal spray 1.53 mg/spray...... 20
EVICEL - fibrin sealant component kit 2 ml ....................132
EVICEL - fibrin sealant component kit 5 ml ....................132
EVISTA -raloxifene hcl tab 60 mg..................................... 31
EVITHROM -thrombin (human) topical soln 800-1200 unit/
ml....................................................................................132
EVOCLIN -clindamycin phosphate foam 1%................... 147
EVOXAC -cevimeline hcl cap 30 mg...............................138
193
2014
EXACTUSS -phenylephrine w/ dm-gg liqd 10-28-388
mg/5ml..............................................................................58
EXALGO -hydromorphone hcl tab er 24hr deter 12 mg.....96
EXALGO -hydromorphone hcl tab er 24hr deter 8 mg.......95
EXELDERM -sulconazole nitrate cream 1%....................147
EXELDERM -sulconazole nitrate solution 1%................. 147
EXELON -rivastigmine tartrate cap 1.5 mg....................... 90
EXELON -rivastigmine tartrate cap 3 mg.......................... 90
EXELON -rivastigmine tartrate cap 4.5 mg....................... 90
EXELON -rivastigmine tartrate cap 6 mg.......................... 91
EXELON -rivastigmine tartrate soln 2 mg/ml..................... 91
EXELON -rivastigmine td patch 24hr 13.3 mg/24hr...........90
EXELON -rivastigmine td patch 24hr 4.6 mg/24hr.............90
EXELON -rivastigmine td patch 24hr 9.5 mg/24hr.............90
exemestane tab 25 mg (Aromasin)................................ 13
EXFORGE -amlodipine besylate-valsartan tab 10-160
mg.................................................................................... 45
mg.................................................................................... 45
mg.................................................................................... 45
mg.................................................................................... 45
EXFORGE HCT -amlodipine-valsartan-hydrochlorothiazide
tab 10-160-12.5 mg......................................................... 45
tab 10-160-25 mg............................................................ 45
tab 10-320-25 mg............................................................ 45
tab 5-160-12.5 mg........................................................... 45
tab 5-160-25 mg.............................................................. 45
EXJADE -deferasirox tab for oral susp 125 mg............... 159
EXTAVIA -interferon beta-1b for inj kit 0.3 mg.................. 91
EXTINA -ketoconazole foam 2%..................................... 147
EXTRA-VIRT PLUS DHA - prenatal w/o vit a w/ fe fumdoc-fa-dha cap 29-1.25-350 mg ................................... 118
F
FA-8 -folic acid cap 0.8 mg............................................. 128
FABIOR -tazarotene (acne) foam 0.1%...........................147
FACTIVE -gemifloxacin mesylate tab 320 mg (base
equiv)..................................................................................5
FALESSA -levonorgest-eth estrad tab 0.1 mg-20 mcg & fa
tab 1 mg kit......................................................................21
famciclovir tab 125 mg (Famvir)...................................... 8
famotidine for susp 40 mg/5ml (Pepcid)....................... 66
famotidine tab 20 mg (Pepcid)....................................... 66
famotidine tab 40 mg (Pepcid)....................................... 66
194
FAMVIR -famciclovir tab 125 mg.........................................8
FANAPT -iloperidone tab 10 mg....................................... 82
FANAPT -iloperidone tab 12 mg....................................... 82
FANAPT -iloperidone tab 1 mg......................................... 82
FANAPT TITRATION PACK -iloperidone tab 1 mg & 2 mg
& 4 mg & 6 mg titratration pak........................................ 82
FARESTON -toremifene citrate tab 60 mg (base
equivalent)........................................................................13
FARXIGA -dapagliflozin propanediol tab 10 mg (base
equivalent)........................................................................24
FARXIGA -dapagliflozin propanediol tab 5 mg (base
equivalent)........................................................................24
FASLODEX -fulvestrant inj 250 mg/5ml............................ 13
FASTTAKE TEST STRIPS -glucose blood test strip....... 160
FAZACLO -clozapine orally disintegrating tab 100 mg...... 82
FAZACLO -clozapine orally disintegrating tab 12.5 mg..... 82
FAZACLO -clozapine orally disintegrating tab 25 mg........ 82
FC2 FEMALE CONDOM - condoms - female ................ 160
FC FEMALE CONDOM - condoms - female .................. 160
FE 90 PLUS - fe carbonyl-fe gluconate-fa-vit b12-vit c-dss
tab 90-1 mg .................................................................. 128
fe fumarate-vit c-vit b12-fa cap 460 (151 fe)-60-0.01-1
mg.................................................................................. 128
fe fumarate w/ b12-vit c-fa-ifc cap 110-0.015-75-0.5-240
mg.................................................................................. 128
fe fum-iron polysacch complex-fa-b cmplx-c-zn-mn-cu
cap (Tandem plus)....................................................... 127
felbamate susp 600 mg/5ml (Felbatol).........................109
felbamate tab 400 mg (Felbatol)...................................109
felbamate tab 600 mg (Felbatol)...................................109
FELBATOL -felbamate susp 600 mg/5ml........................ 109
FELBATOL -felbamate tab 400 mg................................. 109
FELBATOL -felbamate tab 600 mg................................. 109
FELDENE -piroxicam cap 10 mg.................................... 103
FELDENE -piroxicam cap 20 mg.................................... 103
felodipine tab sr 24hr 10 mg.......................................... 39
felodipine tab sr 24hr 2.5 mg......................................... 39
felodipine tab sr 24hr 5 mg............................................ 39
FEMARA -letrozole tab 2.5 mg......................................... 13
FEMCAP -cervical cap 22 mm........................................ 160
FEMCON FE -norethindrone & ethinyl estradiol-fe chew
tab 0.4 mg-35 mcg.......................................................... 21
FEMHRT 1/5 -norethindrone acetate-ethinyl estradiol tab 1
mg-5 mcg......................................................................... 21
2014
FEMHRT LOW DOSE -norethindrone acetate-ethinyl
estradiol tab 0.5 mg-2.5 mcg........................................... 21
FEM PH -acetic acid-oxyquinoline vaginal gel
0.9-0.025%....................................................................... 73
FEMRING -estradiol acetate vaginal ring 0.05
mg/24hr............................................................................ 73
FEMRING -estradiol acetate vaginal ring 0.1 mg/24hr...... 73
FEMTRACE -estradiol acetate tab 0.45 mg...................... 20
FEMTRACE -estradiol acetate tab 0.9 mg........................ 20
FENOFIBRATE -fenofibrate cap 150 mg.......................... 51
FENOFIBRATE -fenofibrate cap 50 mg............................ 51
fenofibrate micronized cap 130 mg (Antara).................51
fenofibrate micronized cap 134 mg (Lofibra)................ 51
fenofibrate micronized cap 200 mg (Lofibra)................ 51
fenofibrate micronized cap 43 mg (Antara)...................51
fenofibrate micronized cap 67 mg (Lofibra).................. 51
fenofibrate tab 145 mg (Tricor)...................................... 51
fenofibrate tab 160 mg (Lofibra).................................... 51
fenofibrate tab 48 mg (Tricor)........................................ 51
fenofibrate tab 54 mg (Lofibra)...................................... 51
FENOFIBRIC ACID -fenofibric acid tab 105 mg................ 51
FENOFIBRIC ACID -fenofibric acid tab 35 mg.................. 51
FENOGLIDE -fenofibrate tab 120 mg................................52
FENOGLIDE -fenofibrate tab 40 mg................................. 51
FENOPROFEN CALCIUM -fenoprofen calcium tab 600
mg.................................................................................. 103
fentanyl citrate lollipop 1200 mcg (Actiq)..................... 96
fentanyl citrate lollipop 1600 mcg (Actiq)..................... 96
fentanyl citrate lollipop 200 mcg (Actiq)....................... 96
fentanyl td patch 72hr 100 mcg/hr (Duragesic).............96
fentanyl td patch 72hr 12 mcg/hr (Duragesic)...............96
FENTORA -fentanyl citrate buccal tab 100 mcg (base
equiv)................................................................................96
equiv)................................................................................96
equiv)................................................................................96
equiv)................................................................................96
equiv)................................................................................96
FER-IN-SOL -ferrous sulfate soln 75 mg/ml (15 mg/ml
elemental fe).................................................................. 128
FERIVAFA - iron-c-fa-b12-biotin-copper-docusate cap
110-1 mg ...................................................................... 128
FERIVA - fe bisglycin-fe carbonyl-c-fa-b12-biotin-dss cap
75-1 mg ........................................................................ 128
FERRALET 90 - fe carbonyl-fe gluconate-fa-vit b12-vit cdss tab 90-1 mg ........................................................... 128
FERRAPLUS 90 - iron-folic acid-vit b12-vit c-docusate sod
tab 90-1 mg .................................................................. 128
FERRETTS CHEWABLE IRON -carbonyl iron chew tab 18
mg (elemental iron)........................................................128
FERREX 150 FORTE PLUS - fe asp gly-fe polysacch-succ
ac-c-threon ac-b12-fa cap ............................................ 128
FERREX 28 - fe asparto gly-fe fum-b12-fa-c-succinic ac
tab ther pack .................................................................128
FERRIPROX -deferiprone tab 500 mg............................ 160
FERRO-PLEX HEMATINIC - fe fum-dss-vit c-vit e-vit b12if-fa tab 115-1 mg ......................................................... 128
FERROTRIN -iron w/ b12-vit c-fa-ifc cap
36-0.015-75-0.5-240 mg................................................ 128
ferrous fumarate-fa-b complex-c-zn-mg-mn-cu tab
106-1 mg ...................................................................... 127
ferrous fumarate-folic acid tab 324-1 mg.................... 128
ferrous sulfate elixir 220 mg/5ml (44 mg/5ml elemental
fe)................................................................................... 128
FERROUS SULFATE -ferrous sulfate liquid 220 mg/5ml
(44 mg/5ml elemental fe)...............................................128
FERROUS SULFATE -ferrous sulfate syrup 300 mg/5ml
(60 mg/5ml elemental fe)...............................................128
ferrous sulfate soln 75 mg/ml (15 mg/ml elemental
fe)................................................................................... 128
ferrous sulfate-vit c-folic acid tab cr 105-500-0.8
mg.................................................................................. 128
FETRIN - iron combination cap cr ..................................128
FETZIMA -levomilnacipran hcl cap sr 24hr 120 mg (base
equivalent)........................................................................78
equivalent)........................................................................78
equivalent)........................................................................78
equivalent)........................................................................78
FETZIMA TITRATION PACK -levomilnacipran hcl cap sr
24hr 20 & 40 mg therapy pack........................................ 78
FEXMID -cyclobenzaprine hcl tab 7.5 mg....................... 115
FIBRICOR -fenofibric acid tab 105 mg..............................52
FIBRICOR -fenofibric acid tab 35 mg................................52
FINACEA -azelaic acid gel 15%......................................147
FINACEA PLUS -azelaic acid gel 15% w/cleanser &
moisturizing lotion kit..................................................... 147
finasteride tab 5 mg (Proscar)........................................74
FIORICET/CODEINE -butalbital-acetaminophen-caff w/
cod cap 50-300-40-30 mg............................................... 96
FIORICET/CODEINE -butalbital-acetaminophen-caff w/
cod cap 50-325-40-30 mg............................................... 96
FIORICET -butalbital-acetaminophen-caffeine cap
50-300-40 mg...................................................................93
FIORICET -butalbital-acetaminophen-caffeine tab
50-325-40 mg...................................................................94
FIORINAL/CODEINE #3 -butalbital-aspirin-caff w/ codeine
cap 50-325-40-30 mg...................................................... 96
195
2014
FIORINAL -butalbital-aspirin-caffeine cap 50-325-40
mg.................................................................................... 94
FIRAZYR -icatibant acetate inj 30 mg/3ml (base
equivalent)......................................................................132
FIRST-BXN MOUTHWASH - diphenhydramine-lidocainenystatin susp .................................................................138
FIRST-DUKES MOUTHWASH - diphenhydraminehydrocortisone-nystatin susp ........................................ 138
FIRST-HYDROCORTISONE -hydrocortisone gel
10%................................................................................ 147
FIRST-LANSOPRAZOLE -lansoprazole susp 3 mg/ml
(compound kit)................................................................. 67
FIRST-MARYS MOUTHWASH - diphenhydraminehydrocortisone-nystatin-tetracycline susp ..................... 138
FIRST-MOUTHWASH BLM - diphenhyd-lidocaine-al
hydroxide-mg hydroxide-simeth susp ........................... 138
FIRST-OMEPRAZOLE -omeprazole susp 2 mg/ml
(compound kit)................................................................. 67
FIRST-PROGESTERONE VGS 10 -progesterone vaginal
suppository 100 mg......................................................... 73
suppository 200 mg......................................................... 74
suppository 25 mg........................................................... 74
suppository 400 mg......................................................... 74
suppository 50 mg........................................................... 74
FIRST-TESTOSTERONE MC COM -testosterone
propionate td cream 2%.................................................. 18
FIRST-TESTOSTERONE -testosterone propionate td
ointment 2%..................................................................... 18
FIRST-VANCOMYCIN 25 - vancomycin hcl oral soln 25
mg/ml (compound kit) ..................................................... 12
FIRST-VANCOMYCIN 50 - vancomycin hcl oral soln 50
mg/ml (compound kit) ..................................................... 12
FLAGYL ER -metronidazole tab sr 24hr 750 mg............... 12
FLAGYL -metronidazole cap 375 mg................................ 12
FLAGYL -metronidazole tab 250 mg................................. 12
FLAGYL -metronidazole tab 500 mg................................. 12
FLAREX -fluorometholone acetate ophth susp 0.1%...... 134
FLAVOR BLEND - oral vehicles .....................................162
FLAVOR PLUS - oral vehicles ....................................... 162
FLAVOR SWEET - oral vehicles ....................................162
FLAVOR SWEET-SF - oral vehicles .............................. 162
flavoxate hcl tab 100 mg.................................................72
flecainide acetate tab 100 mg.........................................41
flecainide acetate tab 150 mg.........................................41
flecainide acetate tab 50 mg.......................................... 41
FLECTOR -diclofenac epolamine patch 1.3%................. 147
FLEXERIL -cyclobenzaprine hcl tab 10 mg..................... 115
FLEXERIL -cyclobenzaprine hcl tab 5 mg.......................115
FLOMAX -tamsulosin hcl cap 0.4 mg................................74
FLONASE -fluticasone propionate nasal susp 50 mcg/
act.....................................................................................56
196
FLO-PRED -prednisolone acetate oral susp 16.7 mg/5ml
(15 mg/5ml base).............................................................16
FLORICAL -sodium fluoride w/ calcium carb cap 8.3-364
mg.................................................................................. 125
FLORICAL -sodium fluoride w/ calcium carb tab 8.3-364
mg.................................................................................. 125
FLOVENT DISKUS -fluticasone propionate aer pow ba
100 mcg/blister.................................................................63
FLOVENT DISKUS -fluticasone propionate aer pow ba
250 mcg/blister.................................................................63
FLOVENT DISKUS -fluticasone propionate aer pow ba 50
mcg/blister........................................................................ 63
FLOVENT HFA -fluticasone propionate hfa inhal aer 110
mcg/act (125/valve)..........................................................63
FLOVENT HFA -fluticasone propionate hfa inhal aer 220
mcg/act (250/valve)..........................................................63
FLOVENT HFA -fluticasone propionate hfa inhal aero 44
mcg/act (50/valve)............................................................63
fluconazole for susp 10 mg/ml (Diflucan)....................... 6
fluconazole for susp 40 mg/ml (Diflucan)....................... 6
fluconazole tab 100 mg (Diflucan)................................... 6
fluconazole tab 50 mg (Diflucan)..................................... 7
flucytosine cap 250 mg (Ancobon).................................. 7
flucytosine cap 500 mg (Ancobon).................................. 7
fludrocortisone acetate tab 0.1 mg................................ 16
FLUMADINE -rimantadine hydrochloride tab 100 mg..........8
FLUNISOLIDE -flunisolide nasal soln 25 mcg/act
(0.025%)...........................................................................56
FLUNISOLIDE -flunisolide nasal soln 29 mcg/act
(0.025%)...........................................................................56
flunisolide nasal soln 0.025% (Flunisolide)...................56
fluocinolone acetonide (otic) oil 0.01% (Dermotic).....138
fluocinolone acetonide cream 0.01%...........................147
fluocinolone acetonide cream 0.025% (Synalar).........147
fluocinolone acetonide oil 0.01% (Derma-smoothe/fs
bod)................................................................................147
fluocinolone acetonide oint 0.025% (Synalar).............148
fluocinolone acetonide soln 0.01% (Synalar)..............148
fluocinonide cream 0.05%............................................ 148
fluocinonide cream 0.1% (Vanos)................................ 148
fluocinonide emulsified base cream 0.05%.................148
fluocinonide gel 0.05%..................................................148
fluocinonide oint 0.05%................................................ 148
fluocinonide soln 0.05%................................................148
FLUORABON -sodium fluoride soln 0.25 mg/0.6ml (from
0.55 mg/0.6ml naf).........................................................125
FLUOR-A-DAY -sodium fluoride-xylitol chew tab 0.55 (0.25
mg f)-236.79 mg............................................................ 125
FLUOR-A-DAY -sodium fluoride-xylitol chew tab 1.1 (0.5
mg f)-236.79 mg............................................................ 125
FLUOR-A-DAY -sodium fluoride-xylitol chew tab 2.2 (1 mg
f)-236.79 mg...................................................................125
2014
FLUORIDEX DAILY DEFENSE S -sodium fluoridepotassium nitrate gel 1.1-5%......................................... 138
fluorometholone ophth susp 0.1% (Fml liquifilm).......134
FLUOROPLEX -fluorouracil cream 1%............................148
fluorouracil cream 5% (Efudex)....................................148
fluorouracil soln 2%...................................................... 148
fluorouracil soln 5%...................................................... 148
fluoxetine hcl (pmdd) cap 10 mg................................... 91
fluoxetine hcl (pmdd) cap 20 mg................................... 91
fluoxetine hcl cap 10 mg (Prozac)................................. 78
fluoxetine hcl cap delayed release 90 mg (Prozac
weekly)............................................................................ 78
FLUOXETINE HCL -fluoxetine hcl tab 60 mg....................78
fluoxetine hcl solution 20 mg/5ml..................................78
fluoxetine hcl tab 10 mg................................................. 78
fluoxetine hcl tab 20 mg................................................. 78
FLUPHENAZINE HCL -fluphenazine hcl elixir 2.5
mg/5ml..............................................................................82
FLUPHENAZINE HCL -fluphenazine hcl oral conc 5 mg/
ml......................................................................................82
fluphenazine hcl tab 10 mg............................................ 82
fluphenazine hcl tab 1 mg.............................................. 82
fluphenazine hcl tab 2.5 mg........................................... 82
fluphenazine hcl tab 5 mg.............................................. 82
FLURA-DROPS -sodium fluoride soln 0.25 mg/drop f (from
0.55 mg/drop naf).......................................................... 125
flurazepam hcl cap 15 mg.............................................. 85
flurazepam hcl cap 30 mg.............................................. 85
flurbiprofen sodium ophth soln 0.03% (Ocufen).........134
flurbiprofen tab 100 mg................................................ 103
flurbiprofen tab 50 mg.................................................. 103
flutamide cap 125 mg......................................................13
fluticasone propionate cream 0.05% (Cutivate).......... 148
fluticasone propionate lotion 0.05% (Cutivate)...........148
fluticasone propionate nasal susp 50 mcg/act
(Flonase)......................................................................... 56
fluticasone propionate oint 0.005% (Cutivate)............ 148
fluvastatin sodium cap 20 mg (Lescol)......................... 52
fluvastatin sodium cap 40 mg (Lescol)......................... 52
fluvoxamine maleate cap sr 24hr 100 mg (Luvox
cr).....................................................................................78
fluvoxamine maleate cap sr 24hr 150 mg (Luvox
cr).....................................................................................78
fluvoxamine maleate tab 100 mg................................... 78
fluvoxamine maleate tab 25 mg..................................... 78
fluvoxamine maleate tab 50 mg..................................... 78
FML -fluorometholone ophth oint 0.1%........................... 134
FML FORTE -fluorometholone ophth susp 0.25%...........134
FML LIQUIFILM -fluorometholone ophth susp 0.1%....... 134
FOCALGIN-B - prenatal w/ calcium-vit b6-fa-ginger tab
1.22 mg .........................................................................118
FOCALIN -dexmethylphenidate hcl tab 10 mg.................. 87
FOCALIN -dexmethylphenidate hcl tab 2.5 mg................. 87
FOCALIN -dexmethylphenidate hcl tab 5 mg.................... 87
FOCALIN XR -dexmethylphenidate hcl cap sr 24 hr 10
mg.................................................................................... 87
mg.................................................................................... 87
mg.................................................................................... 87
mg.................................................................................... 87
mg.................................................................................... 88
mg.................................................................................... 88
mg.................................................................................... 88
mg.................................................................................... 87
FOLBECAL - prenatal w/ calcium carbonate-b6-b12-fa tab
1 mg ..............................................................................118
FOLCAL DHA - prenatal w/o vit a w/ fe fum-dss-fa-dha cap
27-1.25-300 mg ............................................................ 118
FOLCAPS OMEGA 3 - prenatal vit w/ fe cbn-fe asp glycfa-omega 3 cap 27-1mg ............................................... 118
FOLGARD OS -multiple vit w/ min & calcium-folic acid tab
500-1.1 mg.....................................................................118
FOLGARD RX -folic acid-vitamin b6-vitamin b12 tab
2.2-25-1 mg....................................................................128
folic acid tab 1 mg.........................................................128
folic acid tab 400 mcg...................................................128
folic acid tab 800 mcg...................................................128
folic acid-vitamin b6-vitamin b12 tab 2.2-25-0.5
mg.................................................................................. 128
folic acid-vitamin b6-vitamin b12 tab 2.2-25-1 mg
(Folgard rx)................................................................... 128
folic acid-vit b6-vit b12-omega 3-phytosterols cap 1
mg .................................................................................127
FOLIVANE-EC CALCIUM DHA N -prenatal w/fe fum-fa tab
dr 27-1 mg & dha cap 250 mg pack ............................. 118
FOLIVANE-F - fe fum-fe poly-fa-c-b3 cap
62.5-62.5-1-40-3mg(125 mg fe) ....................................128
FOLIVANE-OB - prenatal w/o a w/fe fum-fe poly-fa cap
130-92.4-1 mg .............................................................. 118
FOLIVANE-PLUS - fe fum-iron polysacch complex-fa-b
complex-c-biotin cap .....................................................128
FOLIVANE-PRX DHA NF - prenatal w/o vit a w/fe fum-dssfa-dha cap 30-1.24-265 mg .......................................... 118
FOLLISTIM AQ -follitropin beta inj 150 unit/0.5ml............. 31
FOLLISTIM AQ -follitropin beta inj 300 unit/0.36ml........... 31
FOLLISTIM AQ -follitropin beta inj 75 unit/0.5ml............... 31
FOLTRATE - cobalamine combination tab ..................... 128
fondaparinux sodium inj 10 mg/0.8ml (Arixtra)...........131
fondaparinux sodium inj 2.5 mg/0.5ml (Arixtra)..........131
fondaparinux sodium inj 5 mg/0.4ml (Arixtra).............131
197
2014
fondaparinux sodium inj 7.5 mg/0.6ml (Arixtra)..........131
FOOD COLOR BLUE -dye fdc blue 1 (brilliant blue fcf) liquid............................................................................... 162
FORADIL AEROLIZER -formoterol fumarate inhal cap 12
mcg...................................................................................63
FORANE -isoflurane inhal soln........................................107
FORFIVO XL -bupropion hcl tab sr 24hr 450 mg.............. 79
FORMALDEHYDE -formaldehyde solution 37%............. 159
formaldehyde solution 10%.......................................... 159
FORMA-RAY -formaldehyde solution 20%......................159
FORTAMET -metformin hcl tab sr 24hr osmotic 1000
mg.................................................................................... 24
FORTAMET -metformin hcl tab sr 24hr osmotic 500
mg.................................................................................... 24
FORTAVIT - multiple vitamins w/ minerals cap .............. 118
FORTEO -teriparatide (recombinant) inj 600
mcg/2.4ml.........................................................................32
FORTESTA -testosterone td gel 10mg/act (2%)............... 18
FORTICAL -calcitonin (salmon) nasal soln 200 unit/
act.....................................................................................32
FOSAMAX -alendronate sodium tab 10 mg...................... 32
FOSAMAX -alendronate sodium tab 70 mg...................... 32
FOSAMAX PLUS D -alendronate sodium-cholecalciferol
tab 70-2800 mg-unit.........................................................32
FOSAMAX PLUS D -alendronate sodium-cholecalciferol
tab 70-5600 mg-unit.........................................................32
fosinopril sodium & hydrochlorothiazide tab 10-12.5
mg.................................................................................... 45
fosinopril sodium & hydrochlorothiazide tab 20-12.5
mg.................................................................................... 45
fosinopril sodium tab 10 mg.......................................... 45
FOSRENOL -lanthanum carbonate chew tab 1000 mg..... 71
FOSRENOL -lanthanum carbonate chew tab 500 mg....... 70
FOSRENOL -lanthanum carbonate chew tab 750 mg....... 70
FRAGMIN -dalteparin sodium inj 10000 unit/ml.............. 131
FRAGMIN -dalteparin sodium inj 12500 unit/0.5ml..........131
FRAGMIN -dalteparin sodium inj 15000 unit/0.6ml..........131
FRAGMIN -dalteparin sodium inj 18000 unit/0.72ml........131
FRAGMIN -dalteparin sodium inj 25000 unit/ml.............. 131
FRAGMIN -dalteparin sodium inj 2500 unit/0.2ml............131
FREEDOM ALCOHOL GEL - alcohol gel base .............. 162
FREEDOM DERMA-D - cream base ..............................162
FREEDOM DERMA-N - cream base ..............................162
FREEDOM EMOLLIENT CREAM - cream base ............ 162
FRENADOL -acetaminophen-salicylamide tab 250-600
mg.................................................................................... 94
FROVA -frovatriptan succinate tab 2.5 mg (base
equivalent)......................................................................105
FULYZAQ -crofelemer tab delayed release 125 mg..........65
FUMATINIC - iron combination cap cr ........................... 128
FURADANTIN -nitrofurantoin susp 25 mg/5ml.................. 71
198
FUROSEMIDE -furosemide oral soln 8 mg/ml.................. 49
furosemide oral soln 10 mg/ml...................................... 49
furosemide tab 20 mg (Lasix).........................................49
FUSION PLUS - fe fum-iron poly cmplx-fa-b cmplx-cbiotin-probiotic cap ........................................................129
FUZEON -enfuvirtide for inj 90 mg......................................8
FYCOMPA -perampanel tab 10 mg.................................109
FYCOMPA -perampanel tab 12 mg.................................109
FYCOMPA -perampanel tab 2 mg.................................. 109
G
gabapentin cap 100 mg (Neurontin)............................ 109
gabapentin oral soln 250 mg/5ml (Neurontin).............109
gabapentin tab 600 mg (Neurontin)............................. 109
gabapentin tab 800 mg (Neurontin)............................. 109
GABITRIL -tiagabine hcl tab 12 mg.................................109
GABITRIL -tiagabine hcl tab 16 mg.................................109
GABITRIL -tiagabine hcl tab 2 mg.................................. 109
GABITRIL -tiagabine hcl tab 4 mg.................................. 109
galantamine hydrobromide cap sr 24hr 16 mg
(Razadyne er)................................................................. 91
(Razadyne er)................................................................. 91
(Razadyne er)................................................................. 91
galantamine hydrobromide oral soln 4 mg/ml
(Razadyne)...................................................................... 91
galantamine hydrobromide tab 12 mg (Razadyne)....... 91
galantamine hydrobromide tab 4 mg (Razadyne).........91
galantamine hydrobromide tab 8 mg (Razadyne).........91
GALZIN -zinc acetate cap 25 mg.................................... 125
GALZIN -zinc acetate cap 50 mg.................................... 125
ganciclovir sodium for inj 500 mg (Cytovene)................ 8
GANIRELIX ACETATE -ganirelix acetate inj 250
mcg/0.5ml.........................................................................32
GARAMYCIN -gentamicin sulfate ophth soln 0.3%......... 134
GASTRINEX NF -hyoscyamine-phenyltoloxamine cap
0.0625-15 mg...................................................................67
GASTROCROM -cromolyn sodium oral conc 100
mg/5ml..............................................................................71
gatifloxacin ophth soln 0.5% (Zymaxid)...................... 134
GEBAUERS PAIN EASE -pentafluoropropanetetrafluoroethane aero spray..........................................148
GEBAUERS SPRAY AND STRETC -pentafluoropropanetetrafluoroethane aero spray..........................................148
GELCLAIR - povidone-sodium hyaluronate-glycyrrhetinic
acid gel ......................................................................... 139
GELFILM OP -gelatin adsorbable ophth film................... 134
2014
GEL-KAM ORAL CARE RINSE -stannous fluoride conc
0.63%............................................................................. 139
GEL-KAM -stannous fluoride gel 0.4%............................138
GELNIQUE -oxybutynin chloride td gel 10%..................... 72
GELNIQUE -oxybutynin td gel 3% (28 mg/act metereddose pump)...................................................................... 72
GELX - oral wound care products - gel .......................... 139
gemfibrozil tab 600 mg (Lopid)...................................... 52
GENADUR - dermatological products misc - liquid .........148
GENADUR KIT - dermatological products misc topical/oral
- kit ................................................................................148
GENERESS FE -norethindrone & ethinyl estradiol-fe chew
tab 0.8 mg-25 mcg.......................................................... 21
GENEXA LA -phenylephrine-guaifenesin cap sr 12hr
30-400 mg........................................................................58
GENOTROPIN MINIQUICK -somatropin for inj 0.2 mg..... 32
GENOTROPIN MINIQUICK -somatropin for inj 1 mg........ 32
GENOTROPIN MINIQUICK -somatropin for inj 2 mg........ 32
GENOTROPIN -somatropin for inj 12 mg (13.8 mg
overfill)..............................................................................32
GENOTROPIN -somatropin for subcutaneous inj 5 mg.....32
gentamicin sulfate cream 0.1%.................................... 148
GENTAMICIN SULFATE -gentamicin sulfate cream
0.1%............................................................................... 148
GENTAMICIN SULFATE -gentamicin sulfate oint
0.1%............................................................................... 148
gentamicin sulfate oint 0.1%........................................ 148
gentamicin sulfate ophth oint 0.3%............................. 134
gentamicin sulfate ophth soln 0.3% (Garamycin)....... 134
GENTEX ADE - prenatal vit w/ fe bisglycinate chelate-fa
tab 28-1 mg .................................................................. 118
GEODON -ziprasidone hcl cap 20 mg.............................. 82
GESTICARE DHA -prenatal w/fe fum-fa tab dr 27-1 mg &
dha cap 250 mg pack ...................................................118
GIAZO -balsalazide disodium tab 1.1 gm..........................71
GILENYA -fingolimod hcl cap 0.5 mg (base equiv)........... 91
GILOTRIF -afatinib dimaleate tab 20 mg (base
equivalent)........................................................................13
equivalent)........................................................................13
equivalent)........................................................................13
GILPHEX TR -phenylephrine-guaifenesin tab 10-388
mg.................................................................................... 58
GILTUSS PED-C -phenylephrine w/ codeine-gg liquid
2.5-3-50 mg/ml.................................................................58
GILTUSS -phenylephrine w/ dm-gg liqd 10-28-388
mg/5ml..............................................................................58
GILTUSS TR -phenylephrine w/ dm-gg cap 7-14-288
mg.................................................................................... 58
GILTUSS TR -phenylephrine w/ dm-gg tab 10-28-388
mg.................................................................................... 58
GILTUSS TR -phenylephrine w/ dm-gg tab sr 12hr
20-30-600 mg...................................................................58
GLEEVEC -imatinib mesylate tab 100 mg (base
equivalent)........................................................................13
GLEEVEC -imatinib mesylate tab 400 mg (base
equivalent)........................................................................13
glimepiride tab 1 mg (Amaryl)........................................24
glipizide-metformin hcl tab 2.5-250 mg......................... 24
glipizide-metformin hcl tab 2.5-500 mg......................... 24
glipizide-metformin hcl tab 5-500 mg............................ 24
glipizide tab 10 mg (Glucotrol).......................................24
glipizide tab 5 mg (Glucotrol).........................................24
glipizide tab sr 24hr 10 mg (Glucotrol xl)......................24
glipizide tab sr 24hr 2.5 mg (Glucotrol xl)..................... 24
glipizide tab sr 24hr 5 mg (Glucotrol xl)........................24
GLUCAGEN -glucagon hcl (rdna) for inj 1 mg (base
equiv)................................................................................24
GLUCAGEN HYPOKIT -glucagon hcl (rdna) for inj 1 mg
(base equiv)..................................................................... 24
GLUCAGON EMERGENCY KIT -glucagon (rdna) for inj kit
1 mg................................................................................. 24
GLUCOPHAGE -metformin hcl tab 1000 mg.................... 24
GLUCOPHAGE -metformin hcl tab 500 mg...................... 24
GLUCOPHAGE -metformin hcl tab 850 mg...................... 24
GLUCOPHAGE XR -metformin hcl tab sr 24hr 500 mg.....24
GLUCOPHAGE XR -metformin hcl tab sr 24hr 750 mg.....25
GLUCOSE BLOOD TEST STRIPS – VARIOUS............. 160
glucose gel 40%.............................................................. 25
glucose oral liquid 15 gm/59ml...................................... 25
GLUCOTROL -glipizide tab 10 mg....................................25
GLUCOTROL -glipizide tab 5 mg......................................25
GLUCOTROL XL -glipizide tab sr 24hr 10 mg.................. 25
GLUCOTROL XL -glipizide tab sr 24hr 2.5 mg................. 25
GLUCOTROL XL -glipizide tab sr 24hr 5 mg.................... 25
GLUCOVANCE -glyburide-metformin tab 1.25-250 mg.....25
GLUCOVANCE -glyburide-metformin tab 2.5-500 mg.......25
GLUCOVANCE -glyburide-metformin tab 5-500 mg..........25
GLUMETZA -metformin hcl tab sr 24hr modified release
1000 mg........................................................................... 25
GLUMETZA -metformin hcl tab sr 24hr modified release
500 mg............................................................................. 25
GLUTARALDEHYDE -glutaral soln 25%......................... 159
GLYBURIDE -glyburide tab 1.25 mg................................. 25
GLYBURIDE -glyburide tab 2.5 mg...................................25
GLYBURIDE -glyburide tab 5 mg......................................25
199
2014
(Glucovance)...................................................................25
glyburide-metformin tab 2.5-500 mg (Glucovance)...... 25
glyburide-metformin tab 5-500 mg (Glucovance)......... 25
glyburide micronized tab 1.5 mg (Glynase).................. 25
glyburide micronized tab 3 mg (Glynase)..................... 25
glyburide micronized tab 6 mg (Glynase)..................... 25
glyburide tab 1.25 mg..................................................... 25
glyburide tab 2.5 mg....................................................... 25
glyburide tab 5 mg.......................................................... 25
GLYCATE -glycopyrrolate tab 1.5 mg............................... 67
glycine irrigation soln 1.5%............................................ 74
GLYCOLIC ACID 70% HIGH PU -glycolic acid soln
70%................................................................................ 148
GLYCOLIC ACID -glycolic acid soln 70%....................... 148
glycopyrrolate tab 1 mg (Robinul)................................. 67
glycopyrrolate tab 2 mg (Robinul forte)........................ 67
GLYNASE -glyburide micronized tab 1.5 mg.................... 25
GLYNASE -glyburide micronized tab 3 mg....................... 25
GLYNASE -glyburide micronized tab 6 mg....................... 25
GLYSET -miglitol tab 100 mg............................................25
GLYSET -miglitol tab 25 mg..............................................25
GLYSET -miglitol tab 50 mg..............................................25
GOLYTELY -peg 3350-kcl-na bicarb-nacl-na sulfate for
soln 236 gm..................................................................... 65
GOLYTELY -peg 3350-kcl-na bicarb-nacl-na sulfate
packet 227.1 gm.............................................................. 65
GONAL-F -follitropin alfa for inj 1050 unit......................... 32
GONAL-F -follitropin alfa for inj 450 unit........................... 32
GONAL-F RFF -follitropin alfa for inj 75 unit..................... 32
GONAL-F RFF PEN -follitropin alfa inj 300 unit/0.5ml....... 32
GONAL-F RFF PEN -follitropin alfa inj 450 unit/0.75ml..... 32
GONAL-F RFF PEN -follitropin alfa inj 900 unit/1.5ml....... 32
GONAL-F RFF REDIJECT -follitropin alfa inj 300
unit/0.5ml..........................................................................32
unit/0.75ml........................................................................32
unit/1.5ml..........................................................................32
GORDOFILM -salicylic & lactic acids soln
16.7-16.7%..................................................................... 148
GORDONS UREA -urea ointment 40%...........................148
GRALISE -gabapentin (phn) tab 300 mg...........................91
GRALISE -gabapentin (phn) tab 600 mg...........................91
GRALISE STARTER -gabapentin (phn) tab starter pack
300 mg (9) & 600 mg (69)...............................................91
granisetron hcl tab 1 mg................................................ 69
GRANISOL -granisetron hcl oral soln 2 mg/10ml (base
equivalent)........................................................................69
GRANIX -tbo-filgrastim soln prefilled syringe 300
mcg/0.5ml.......................................................................129
GRANIX -tbo-filgrastim soln prefilled syringe 480
mcg/0.8ml.......................................................................129
GRANULEX -trypsin w/ castor oil & peruvian balsam
spray...............................................................................148
200
GRASTEK -timothy grass pollen allergen ext tab sl 2800
bau................................................................................... 12
GREEN SOAP -green soap tincture................................148
GRIFULVIN V -griseofulvin microsize tab 500 mg...............7
griseofulvin microsize susp 125 mg/5ml.........................7
griseofulvin microsize tab 500 mg (Grifulvin v)..............7
griseofulvin ultramicrosize tab 125 mg (Gris-peg)......... 7
griseofulvin ultramicrosize tab 250 mg (Gris-peg)......... 7
GRIS-PEG -griseofulvin ultramicrosize tab 125 mg.............7
GRIS-PEG -griseofulvin ultramicrosize tab 250 mg.............7
guaifenesin-codeine liquid 225-7.5 mg/5ml...................58
guaifenesin-codeine soln 100-10 mg/5ml......................58
guaifenesin-codeine soln 100-6.3 mg/5ml..................... 58
guanfacine hcl tab 1 mg (Tenex)................................... 45
guanfacine hcl tab 2 mg (Tenex)................................... 45
GUANIDINE HCL -guanidine hcl tab 125 mg.................. 115
GYNAZOLE-1 -butoconazole nitrate (one dose) vaginal
cream 2%.........................................................................74
H
HALCION -triazolam tab 0.25 mg......................................85
HALFLYTELY BOWEL PREP/FLA -bisacodyl tab & peg
3350-kcl-sod bicarb-nacl for soln kit................................ 65
HALFPRIN -aspirin tab delayed release 162 mg...............94
halobetasol propionate cream 0.05% (Ultravate)........ 148
halobetasol propionate oint 0.05% (Ultravate)............148
halobetasol prop oint 0.05% & ammonium lactate lot
12% kit (Ultravate pac)................................................ 148
HALOG -halcinonide cream 0.1%................................... 148
HALOG -halcinonide oint 0.1%........................................148
HALONATE -halobetasol prop oint 0.05% & ammonium
lactate foam 12% kit...................................................... 148
haloperidol lactate oral conc 2 mg/ml........................... 82
haloperidol tab 0.5 mg.................................................... 82
haloperidol tab 10 mg..................................................... 82
haloperidol tab 1 mg....................................................... 82
haloperidol tab 20 mg..................................................... 82
HALOTIN -haloprogin cream 1%.....................................148
hc-pramoxine emol cream 2.5-1% & pramoxine wipe
1% kit (Analpram e)..................................................... 140
HDC DM -pseudoephed-chlorphen-dm syrup 15-2-15
mg/5ml..............................................................................58
HECTOROL -doxercalciferol cap 0.5 mcg.........................32
HECTOROL -doxercalciferol cap 1 mcg............................32
HECTOROL -doxercalciferol cap 2.5 mcg.........................32
HELIDAC -metronidaz tab-tetracyc cap-bis subsal chew
tab therapy pack.............................................................. 67
HEMANGEOL -propranolol hcl oral soln 4.28 mg/ml.........36
HEMATOGEN FA -fe fumarate-vit c-vit b12-fa cap
200-250-0.01-1 mg........................................................ 129
HEMATRON-AF - iron-docusate-b12-folic acid-c-e-cubiotin tab 150-1 mg ...................................................... 129
HEMENATAL OB + DHA -prenat-fe poly cmplx-fe heme
poly-fa tab & omega 3 cap pck......................................118
2014
HEMENATAL OB - prenat vit-fe poly cmplx-fe heme polyfa tab 28-6-1 mg ...........................................................118
HEMETAB -polysacch fe cmplx-fe heme poly-fa-b12 tab
22-6-1-0.025 mg............................................................ 129
HEMOCYTE-F - iron combination elixir ..........................129
HEMOCYTE PLUS - ferrous fumarate-fa-b complex-c-znmg-mn-cu cap 106-1 mg .............................................. 129
HEPARIN SODIUM/D5W -heparin sodium (porcine) 100
unit/ml in d5w.................................................................131
HEPARIN SODIUM/D5W -heparin sodium (porcine) 50
unit/ml in d5w.................................................................131
HEPARIN SODIUM/SODIUM CHL -heparin sodium
(porcine) 2 unit/ml in sodium chloride 0.9%................... 131
heparin sodium (porcine) 100 unit/ml in d5w (Heparin
sodium/d5w)................................................................. 131
heparin sodium (porcine) 2 unit/ml in sodium chloride
0.9% (Heparin sodium/sodiu)......................................131
heparin sodium (porcine) 50 unit/ml in d5w (Heparin
sodium/d5w)................................................................. 131
HEPSERA -adefovir dipivoxil tab 10 mg............................. 8
HETLIOZ -tasimelteon capsule 20 mg.............................. 85
HEXALEN -altretamine cap 50 mg....................................13
HIPREX -methenamine hippurate tab 1 gm...................... 72
homatropine hbr ophth soln 5% (Isopto
homatropine)................................................................ 134
HORIZANT -gabapentin enacarbil tab sr 24hr 300 mg...... 91
HORIZANT -gabapentin enacarbil tab sr 24hr 600 mg...... 91
HPR - emollient - aerosol foam ......................................148
HPR PLUS/MB HYDROGEL -emollient foam & wound
dressing gel kit...............................................................148
HPR PLUS - emollient - aerosol foam ............................148
HPR PLUS - emollient - cream ...................................... 148
HUMALOG -insulin lispro (human) inj 100 unit/ml............. 27
HUMALOG -insulin lispro (human) soln cartridge 100 unit/
ml......................................................................................27
HUMALOG KWIKPEN -insulin lispro (human) soln peninjector 100 unit/ml...........................................................27
HUMALOG MIX 50/50 -insulin lispro prot & lispro (human)
inj 100 unit/ml (50-50)......................................................27
HUMALOG MIX 50/50 KWIKPEN -insulin lispro prot &
lispro sus pen-inj 100 unit/ml (50-50).............................. 27
HUMALOG MIX 75/25 -insulin lispro prot & lispro (human)
inj 100 unit/ml (75-25)......................................................27
HUMALOG MIX 75/25 KWIKPEN -insulin lispro prot &
lispro sus pen-inj 100 unit/ml (75-25).............................. 27
HUMATROPE COMBO PACK -somatropin for inj 5
mg.................................................................................... 32
HUMATROPE -somatropin for inj 12 mg (36 unit).............32
HUMATROPE -somatropin for inj 24 mg...........................32
HUMATROPE -somatropin for inj 5 mg.............................32
HUMATROPE -somatropin for inj 6 mg (18 unit)...............32
HUMCO BASE PAIN MGMT - cream base .................... 162
HUMIRA -adalimumab inj kit 20 mg/0.4ml.......................103
HUMIRA -adalimumab inj kit 40 mg/0.8ml (50 mg/ml)..... 103
HUMIRA PEN -adalimumab inj kit 40 mg/0.8ml (50 mg/
ml).................................................................................. 103
HUMIRA PEN-CROHNS DISEASE -adalimumab inj kit 40
mg/0.8ml (50 mg/ml)......................................................103
HUMIRA PEN-PSORIASIS STAR -adalimumab inj kit 40
mg/0.8ml (50 mg/ml)......................................................103
HUMULIN 70/30 -insulin isophane & regular (human) inj
100 unit/ml (70-30)...........................................................27
HUMULIN 70/30 KWIKPEN -insulin isophane & regular
susp pen-inj 100 unit/ml (70-30)...................................... 28
HUMULIN 70/30 PEN -insulin isophane & regular susp
pen-inj 100 unit/ml (70-30)...............................................28
HUMULIN N -insulin isophane (human) inj 100 unit/ml......27
HUMULIN N KWIKPEN -insulin isophane (human) susp
pen-injector 100 unit/ml................................................... 27
HUMULIN N U-100 PEN -insulin isophane (human) susp
pen-injector 100 unit/ml................................................... 27
HUMULIN R -insulin regular (human) inj 100 unit/ml.........27
HUMULIN R U-500 (CONCENTR -insulin regular (human)
inj 500 unit/ml.................................................................. 27
hyaluronate sodium (emollient) gel 0.2% (Hylira)....... 148
HYCAMTIN -topotecan hcl cap 0.25 mg (base equiv)....... 13
HYCAMTIN -topotecan hcl cap 1 mg (base equiv)............13
HYCET -hydrocodone-acetaminophen soln 7.5-325
mg/15ml............................................................................96
hydralazine hcl tab 100 mg............................................ 45
hydralazine hcl tab 10 mg.............................................. 45
HYDREA -hydroxyurea cap 500 mg..................................13
HYDRO 35 -urea in lactic acid vehicle foam 35%........... 148
HYDRO 40 FOAM -urea foam 40%................................ 148
hydrochlorothiazide cap 12.5 mg (Microzide)............... 49
hydrochlorothiazide tab 12.5 mg................................... 49
hydrochlorothiazide tab 25 mg...................................... 49
hydrochlorothiazide tab 50 mg...................................... 49
HYDROCODONE/ACETAMINOPHEN -hydrocodoneacetaminophen soln 10-325 mg/15ml..............................97
HYDROCODONE/ACETAMINOPHEN -hydrocodoneacetaminophen tab 7.5-500 mg....................................... 97
hydrocodone-acetaminophen cap 5-500 mg.................96
hydrocodone-acetaminophen soln 7.5-325 mg/15ml
(Hycet)............................................................................. 96
hydrocodone-acetaminophen soln 7.5-500
mg/15ml...........................................................................96
hydrocodone-acetaminophen tab 10-300 mg
(Xodol)............................................................................. 96
(Norco).............................................................................96
hydrocodone-acetaminophen tab 10-500 mg................96
201
2014
hydrocodone-acetaminophen tab 2.5-500 mg...............96
(Xodol)............................................................................. 96
(Norco).............................................................................96
hydrocodone-acetaminophen tab 5-500 mg..................97
hydrocodone-acetaminophen tab 7.5-300 mg
(Xodol)............................................................................. 97
hydrocodone-acetaminophen tab 7.5-325 mg
(Norco).............................................................................97
HYDROCODONE BITARTRATE/AC -hydrocodoneacetaminophen tab 10-750 mg........................................ 96
HYDROCODONE BITARTRATE/AC -hydrocodoneacetaminophen tab 2.5-325 mg....................................... 96
hydrocodone-ibuprofen tab 10-200 mg (Ibudone)........ 97
hydrocodone-ibuprofen tab 2.5-200 mg
(Reprexain)......................................................................97
hydrocodone-ibuprofen tab 5-200 mg (Reprexain).......97
hydrocodone-ibuprofen tab 7.5-200 mg
(Vicoprofen).................................................................... 97
hydrocodone w/ homatropine syrup 5-1.5 mg/5ml....... 58
hydrocodone w/ homatropine tab 5-1.5 mg.................. 58
hydrocod polst-chlorphen polst cr susp 10-8 mg/5ml
(Tussionex pennkineti).................................................. 58
HYDROCORTISONE ACETATE/LI -lidocainehydrocortisone acetate rectal cream kit 2-2%................ 141
hydrocortisone acetate-aloe vera gel 2% (Nuzon)...... 148
hydrocortisone acetate suppos 25 mg (Anusolhc).................................................................................. 140
hydrocortisone acetate suppos 30 mg
(Proctocort)...................................................................140
hydrocortisone acetate w/ pramoxine rectal cream
1-1% (Analpram-hc)..................................................... 140
hydrocortisone acetate w/ pramoxine rectal cream
2.5-1% (Analpram-hc).................................................. 140
hydrocortisone acetate w/ pramoxine rectal cream kit
2.35-1%.......................................................................... 140
hydrocortisone butyrate cream 0.1% (Locoid)............148
hydrocortisone butyrate hydrophilic lipo base cream
0.1% (Locoid lipocream)..............................................149
hydrocortisone butyrate oint 0.1% (Locoid)................149
hydrocortisone butyrate soln 0.1% (Locoid)...............149
hydrocortisone cream 1%.............................................149
hydrocortisone cream 2.5%..........................................149
hydrocortisone enema 100 mg/60ml (Cortenema)......141
hydrocortisone lotion 2.5%...........................................149
hydrocortisone lotion 2% (Ala scalp).......................... 149
hydrocortisone oint 1%.................................................149
hydrocortisone oint 2.5%..............................................149
hydrocortisone rectal cream 1% (Proctocort).............141
202
hydrocortisone rectal cream 2.5% (Anusol-hc).......... 141
hydrocortisone tab 10 mg (Cortef).................................16
hydrocortisone tab 20 mg (Cortef).................................16
hydrocortisone tab 5 mg (Cortef).................................. 16
hydrocortisone valerate cream 0.2%........................... 149
hydrocortisone valerate oint 0.2% (Westcort).............149
hydrocortisone w/ acetic acid otic soln 1-2% (Vosol
hc).................................................................................. 138
HYDROFERA BLUE 4"X4" - wound dressings - pads
....................................................................................... 149
HYDROFERA BLUE FOAM DRESS - wound dressings pads .............................................................................. 149
HYDROGEL - carbomer gel base .................................. 162
HYDROGEN PEROXIDE -hydrogen peroxide soln
30%................................................................................ 159
HYDROGEN PEROXIDE -hydrogen peroxide soln
35%................................................................................ 159
HYDRO-IODOQUINOL 2-1 - iodoquinol-hydrocortisonealoe polysaccharide gel 1-2-1% ................................... 148
HYDROMORPHONE HCL -hydromorphone hcl suppos 3
mg.................................................................................... 97
hydromorphone hcl liqd 1 mg/ml (Dilaudid)................. 97
hydromorphone hcl tab 2 mg (Dilaudid)....................... 97
hydroxychloroquine sulfate tab 200 mg (Plaquenil).....11
hydroxyurea cap 500 mg (Hydrea).................................13
hydroxyzine hcl syrup 10 mg/5ml.................................. 76
hydroxyzine hcl tab 10 mg............................................. 76
hydroxyzine pamoate cap 25 mg (Vistaril).................... 76
hydroxyzine pamoate cap 50 mg (Vistaril).................... 76
HYDROXYZINE PAMOATE -hydroxyzine pamoate cap
100 mg............................................................................. 76
HYLASE WOUND - hyaluronate sodium gel .................. 149
HYLATOPIC - emollient - aerosol foam ......................... 149
HYLATOPIC PLUS/AURSTAT -emollient foam & wound
dressing gel kit...............................................................149
HYLATOPIC PLUS - emollient - aerosol foam ............... 149
HYLATOPIC PLUS - emollient - cream ..........................149
HYLIRA -hyaluronate sodium (emollient) gel 0.2%..........149
HYLIRA -hyaluronate sodium (emollient) lotion 0.1%...... 149
hyoscyamine sulfate elixir 0.125 mg/5ml...................... 67
hyoscyamine sulfate soln 0.125 mg/ml......................... 67
hyoscyamine sulfate tab 0.125 mg (Levsin)..................67
hyoscyamine sulfate tab disp 0.125 mg (Anaspaz)...... 67
hyoscyamine sulfate tab sl 0.125 mg (Levsin/sl).......... 67
hyoscyamine sulfate tab sr 12hr 0.375 mg (Levbid)..... 67
HYPERSAL -sodium chloride soln nebu 3.5%.................. 58
HYPERSAL -sodium chloride soln nebu 7%..................... 58
HYPER-SAL -sodium chloride soln nebu 7%.................... 58
HYZAAR -losartan potassium & hydrochlorothiazide tab
100-12.5 mg.....................................................................45
2014
100-25 mg........................................................................45
50-12.5 mg.......................................................................45
I
ibandronate sodium tab 150 mg (base equivalent)
(Boniva)........................................................................... 32
IBUDONE -hydrocodone-ibuprofen tab 10-200 mg........... 97
IBUPROFEN COMFORT PAC -ibuprofen tab 800 mg &
liniment topical gel kit.................................................... 104
ibuprofen susp 100 mg/5ml.......................................... 104
ibuprofen tab 400 mg.................................................... 104
ibuprofen tab 600 mg.................................................... 104
ibuprofen tab 800 mg.................................................... 104
IC 400 -ibuprofen tab 400 mg & caffeine-vitamins cap
kit....................................................................................104
IC 800 -ibuprofen tab 800 mg & caffeine-vitamins cap
kit....................................................................................104
ICAR -carbonyl iron chew tab 15 mg (elemental iron)..... 129
ICAR-C PLUS -iron-vit c-vit b12-folic acid tab
100-250-0.025-1 mg...................................................... 129
ICAR PEDIATRIC -carbonyl iron susp 15 mg/1.25ml
(elemental iron).............................................................. 129
ICLUSIG -ponatinib hcl tab 15 mg (base equiv)................ 14
ICLUSIG -ponatinib hcl tab 45 mg (base equiv)................ 14
ILEVRO -nepafenac ophth susp 0.3%.............................134
IMBRUVICA -ibrutinib cap 140 mg....................................14
IMDUR -isosorbide mononitrate tab sr 24hr 120 mg......... 35
IMDUR -isosorbide mononitrate tab sr 24hr 30 mg........... 35
IMDUR -isosorbide mononitrate tab sr 24hr 60 mg........... 35
imipramine hcl tab 10 mg (Tofranil)...............................79
imipramine pamoate cap 100 mg (Tofranil-pm)............ 79
imipramine pamoate cap 75 mg (Tofranil-pm).............. 79
imiquimod cream 5% (Aldara)...................................... 149
IMITREX STATDOSE REFILL -sumatriptan succinate
solution cartridge 4 mg/0.5ml.........................................106
IMITREX STATDOSE REFILL -sumatriptan succinate
solution cartridge 6 mg/0.5ml.........................................106
IMITREX STATDOSE SYSTEM -sumatriptan succinate
solution auto-injector 4 mg/0.5ml...................................106
IMITREX STATDOSE SYSTEM -sumatriptan succinate
solution auto-injector 6 mg/0.5ml...................................106
IMITREX -sumatriptan nasal spray 20 mg/act................. 106
IMITREX -sumatriptan nasal spray 5 mg/act................... 105
IMITREX -sumatriptan succinate inj 6 mg/0.5ml..............106
IMITREX -sumatriptan succinate tab 100 mg.................. 106
IMITREX -sumatriptan succinate tab 25 mg.................... 106
IMITREX -sumatriptan succinate tab 50 mg.................... 106
IMURAN -azathioprine tab 50 mg................................... 165
INATAL ADVANCE - prenatal vit w/ dss-iron carbonyl-fa
tab 90-1 mg .................................................................. 118
INATAL GT - prenatal vit w/ dss-iron carbonyl-fa tab 90-1
mg ................................................................................. 118
INATAL ULTRA - prenatal vit w/ dss-iron carbonyl-fa tab
90-1 mg ........................................................................ 118
INCIVEK -telaprevir tab 375 mg.......................................... 8
INCRELEX -mecasermin inj 40 mg/4ml (10 mg/ml)...........32
indapamide tab 1.25 mg..................................................49
indapamide tab 2.5 mg....................................................49
INDERAL LA -propranolol hcl cap sr 24hr 120 mg............ 36
INDERAL LA -propranolol hcl cap sr 24hr 160 mg............ 36
INDERAL LA -propranolol hcl cap sr 24hr 60 mg.............. 36
INDERAL LA -propranolol hcl cap sr 24hr 80 mg.............. 36
INDERAL XL -propranolol hcl sustained-release beads cap
sr 24hr 120 mg................................................................ 37
INDERAL XL -propranolol hcl sustained-release beads cap
sr 24hr 80 mg.................................................................. 37
INDOCIN -indomethacin suppos 50 mg.......................... 104
INDOCIN -indomethacin susp 25 mg/5ml........................104
indomethacin cap 25 mg.............................................. 104
indomethacin cap 50 mg.............................................. 104
indomethacin cap cr 75 mg.......................................... 104
INFASURF -calfactant in nacl 0.9% intratracheal susp 35
mg/ml................................................................................65
INFERGEN -interferon alfacon-1 inj 15 mcg/0.5ml.............. 8
INFERGEN -interferon alfacon-1 inj 9 mcg/0.3ml................8
INLYTA -axitinib tab 1 mg................................................. 14
INLYTA -axitinib tab 5 mg................................................. 14
INNOPRAN XL -propranolol hcl sustained-release beads
cap sr 24hr 120 mg......................................................... 37
INNOPRAN XL -propranolol hcl sustained-release beads
cap sr 24hr 80 mg........................................................... 37
INOVA 4/1 ACNE CONTROL TH -benzoyl perox pad 4% &
salicylic ac pad 1% & vit e 5% kit..................................149
INOVA 8/2 ACNE CONTROL TH -benzoyl perox pad 8% &
salicylic ac pad 2% & vit e 5% kit..................................149
INOVA -benzoyl peroxide pad 4% & vitamin e topical 5%
kit....................................................................................149
INOVA -benzoyl peroxide pad 8% & vitamin e topical 5%
kit....................................................................................149
INSPRA -eplerenone tab 25 mg........................................45
INSPRA -eplerenone tab 50 mg........................................45
INTEGRA F - fe fum-fe poly-fa-c-b3 cap
62.5-62.5-1-40-3mg(125 mg fe) ....................................129
INTEGRA PLUS - fe fum-iron polysacch complex-fa-b
complex-c-biotin cap .....................................................129
INTELENCE -etravirine tab 100 mg.................................... 8
INTELENCE -etravirine tab 200 mg.................................... 8
INTELENCE -etravirine tab 25 mg...................................... 8
INTERARTICULAR JOINT KIT -triamcinolone inj 40 mg/ml
& lidocaine 1% & ammonia inh kit................................... 16
INTERMEZZO -zolpidem tartrate sl tab 1.75 mg...............85
INTERMEZZO -zolpidem tartrate sl tab 3.5 mg.................85
INTROL -glycerin soln 75%...............................................49
INTRON-A -interferon alfa-2b inj 10000000 unit/ml........... 14
INTRON-A -interferon alfa-2b inj 6000000 unit/ml............. 14
203
2014
INTRON-A W/DILUENT -interferon alfa-2b for inj
10000000 unit.................................................................. 14
18000000 unit.................................................................. 14
50000000 unit.................................................................. 14
INTUNIV -guanfacine hcl tab sr 24hr 1 mg (base
equiv)................................................................................88
equiv)................................................................................88
equiv)................................................................................88
equiv)................................................................................88
INVEGA -paliperidone tab sr 24hr 1.5 mg.........................82
INVEGA -paliperidone tab sr 24hr 3 mg............................82
INVIRASE -saquinavir mesylate cap 200 mg...................... 8
INVIRASE -saquinavir mesylate tab 500 mg.......................8
INVOKANA -canagliflozin tab 100 mg............................... 25
INVOKANA -canagliflozin tab 300 mg............................... 25
IODINE STRONG -iodine solution strong 5%
(lugol's)........................................................................... 125
IODINE TINCTURE - iodine tincture .............................. 159
IODINE TINCTURE MILD - iodine tincture .....................159
IODINE TINCTURE STRONG DE - iodine tincture strong
....................................................................................... 159
IODINE TINCTURE STRONG - iodine tincture strong
....................................................................................... 159
iodoquinol-hc cream 1%............................................... 149
IOPIDINE -apraclonidine hcl ophth soln 0.5% (base
equivalent)......................................................................134
IOPIDINE -apraclonidine hcl ophth soln 1% (base
equivalent)......................................................................134
ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml
(Duoneb)..........................................................................63
ipratropium bromide inhal soln 0.02%.......................... 63
ipratropium bromide nasal soln 0.03% (21 mcg/spray)
(Atrovent)........................................................................ 56
ipratropium bromide nasal soln 0.06% (42 mcg/spray)
(Atrovent)........................................................................ 56
IPRIVASK -desirudin for inj 15 mg.................................. 131
IQUIX -levofloxacin ophth soln 1.5%............................... 134
irbesartan-hydrochlorothiazide tab 150-12.5 mg
(Avalide).......................................................................... 45
irbesartan-hydrochlorothiazide tab 300-12.5 mg
(Avalide).......................................................................... 45
irbesartan tab 150 mg (Avapro)..................................... 45
irbesartan tab 300 mg (Avapro)..................................... 45
irbesartan tab 75 mg (Avapro)....................................... 45
IRESSA -gefitinib tab 250 mg........................................... 14
iron combination cap ................................................... 127
iron-docusate-b12-folic acid-c-e-cu-biotin tab 150-1 mg
(Hematron-af)................................................................127
204
iron-folic acid-vit c-vit b6-vit b12-zinc tab 150-1.25 mg
(Corvite 150)................................................................. 129
IRON - iron combination tab .......................................... 129
iron polysacch complex-vit b12-fa cap 150-0.025-1
mg.................................................................................. 129
iron-vit c-vit b12-folic acid tab 100-250-0.025-1 mg
(Icar-c plus)...................................................................129
IROSPAN 24/6 - fe asp gly-fe polys-succ acd-b cmplx-cca-fa tab ther pk ........................................................... 129
irrigation solution, physiological ................................ 164
ISENTRESS -raltegravir potassium chew tab 100 mg
(base equiv)....................................................................... 8
ISENTRESS -raltegravir potassium chew tab 25 mg (base
equiv)..................................................................................8
ISENTRESS -raltegravir potassium tab 400 mg (base
equiv)..................................................................................8
isoflurane inhal soln (Forane)...................................... 107
ISOMETHEPTENE/CAFFEINE/AC -acetaminophenisometheptene-caffeine tab 500-130-20 mg.................. 106
isoniazid & rifampin cap 150-300 mg.............................. 6
ISONIAZID -isoniazid syrup 50 mg/5ml...............................6
isoniazid tab 100 mg......................................................... 6
isoniazid tab 300 mg......................................................... 6
ISOPROPANOL -isopropyl alcohol 70%......................... 160
isopropyl alcohol, rubbing 70%................................... 160
ISOPROPYL ALCOHOL -isopropyl alcohol 70%.............160
ISOPTIN SR -verapamil hcl tab cr 120 mg........................39
ISOPTO ATROPINE -atropine sulfate ophth soln 1%......135
ISOPTO CARBACHOL -carbachol ophth soln 1.5%....... 135
ISOPTO CARBACHOL -carbachol ophth soln 3%.......... 135
ISOPTO CARPINE -pilocarpine hcl ophth soln 1%......... 135
ISOPTO HOMATROPINE -homatropine hbr ophth soln
2%.................................................................................. 135
ISOPTO HOMATROPINE -homatropine hbr ophth soln
5%.................................................................................. 135
ISOPTO HYOSCINE -scopolamine hbr ophth soln
0.25%............................................................................. 135
ISORDIL TITRADOSE -isosorbide dinitrate tab 40 mg......35
ISORDIL TITRADOSE -isosorbide dinitrate tab 5 mg........35
ISOSORBIDE DINITRATE -isosorbide dinitrate sl tab 2.5
mg.................................................................................... 35
ISOSORBIDE DINITRATE -isosorbide dinitrate sl tab 5
mg.................................................................................... 35
ISOSORBIDE DINITRATE -isosorbide dinitrate tab 30
mg.................................................................................... 35
isosorbide dinitrate tab 10 mg....................................... 35
isosorbide dinitrate tab 5 mg (Isordil titradose)........... 35
isosorbide dinitrate tab cr 40 mg...................................35
isosorbide mononitrate tab 10 mg.................................35
2014
isosorbide mononitrate tab 20 mg.................................35
isosorbide mononitrate tab sr 24hr 120 mg (Imdur)..... 35
isosorbide mononitrate tab sr 24hr 30 mg (Imdur)....... 35
isosorbide mononitrate tab sr 24hr 60 mg (Imdur)....... 35
isotretinoin cap 10 mg.................................................. 149
ISOXSUPRINE HCL -isoxsuprine hcl tab 10 mg............... 54
ISOXSUPRINE HCL -isoxsuprine hcl tab 20 mg............... 54
isoxsuprine hcl tab 10 mg.............................................. 54
ISRADIPINE -isradipine cap 2.5 mg..................................39
ISRADIPINE -isradipine cap 5 mg.....................................39
ISTALOL -timolol maleate ophth soln 0.5% (oncedaily)...............................................................................135
itraconazole cap 100 mg (Sporanox)............................... 7
J
JAKAFI -ruxolitinib phosphate tab 10 mg (base
equivalent)........................................................................14
equivalent)........................................................................14
equivalent)........................................................................14
equivalent)........................................................................14
equivalent)........................................................................14
JALYN -dutasteride-tamsulosin hcl cap 0.5-0.4 mg...........74
JANUMET -sitagliptin-metformin hcl tab 50-1000 mg........ 25
JANUMET -sitagliptin-metformin hcl tab 50-500 mg..........25
JANUMET XR -sitagliptin-metformin hcl tab sr 24hr
100-1000 mg....................................................................25
JANUMET XR -sitagliptin-metformin hcl tab sr 24hr
50-1000 mg......................................................................25
JANUMET XR -sitagliptin-metformin hcl tab sr 24hr 50-500
mg.................................................................................... 25
JANUVIA -sitagliptin phosphate tab 100 mg (base
equiv)................................................................................25
equiv)................................................................................25
equiv)................................................................................25
J-COF DHC -pseudoephed-bromphen-dihydrocodeine liqd
15-3-7.5 mg/5ml...............................................................58
JENTADUETO -linagliptin-metformin hcl tab 2.5-1000
mg.................................................................................... 25
mg.................................................................................... 25
mg.................................................................................... 25
JINTELI -norethindrone acetate-ethinyl estradiol tab 1
mg-5 mcg......................................................................... 21
J-MAX DHC -dihydrocodeine-guaifenesin liquid 7.5-100
mg/5ml..............................................................................58
JUVISYNC -sitagliptin-simvastatin tab 100-10 mg.............26
JUVISYNC -sitagliptin-simvastatin tab 50-10 mg...............25
JUXTAPID -lomitapide mesylate cap 10 mg (base
equiv)................................................................................52
equiv)................................................................................52
equiv)................................................................................52
K
KADIAN -morphine sulfate cap sr 24hr 100 mg................ 97
KADIAN -morphine sulfate cap sr 24hr 10 mg.................. 97
KALETRA -lopinavir-ritonavir soln 400-100 mg/5ml (80-20
mg/ml)................................................................................ 8
KALETRA -lopinavir-ritonavir tab 100-25 mg.......................8
KALETRA -lopinavir-ritonavir tab 200-50 mg.......................8
KALYDECO -ivacaftor tab 150 mg.................................... 65
KAPVAY -clonidine hcl tab sr 12hr 0.1 mg........................88
KAPVAY DOSE PACK -clonidine hcl tab sr 12hr therapy
pack 0.1 & 0.2 mg........................................................... 88
KARBINAL ER -carbinoxamine maleate er susp 4
mg/5ml..............................................................................55
KAYEXALATE - sodium polystyrene sulfonate powder
....................................................................................... 165
KAZANO -alogliptin-metformin hcl tab 12.5-1000 mg........26
KAZANO -alogliptin-metformin hcl tab 12.5-500 mg..........26
KEFLEX -cephalexin cap 250 mg....................................... 2
KENALOG -triamcinolone acetonide aerosol soln........... 149
KENDALL AMORPHOUS HYDROGE - wound dressings gel ................................................................................. 149
KENDALL HYDROGEL IMPREGNA - hydroactive (sterile)
dressing ........................................................................ 149
KENDALL HYDROGEL WOUND DR - hydroactive (sterile)
dressing ........................................................................ 149
KENDALL ZINC CALCIUM ALGI - wound dressings - misc
....................................................................................... 149
KENDALL ZINC CALCIUM ALGI - wound dressings - pads
....................................................................................... 149
KEPPRA -levetiracetam oral soln 100 mg/ml.................. 109
KEPPRA -levetiracetam tab 1000 mg............................. 109
KEPPRA -levetiracetam tab 250 mg............................... 109
205
2014
KEPPRA XR -levetiracetam tab sr 24hr 500 mg............. 109
KEPPRA XR -levetiracetam tab sr 24hr 750 mg............. 109
KERAFOAM 42 -urea foam 42%.....................................149
KERAFOAM -urea foam 30%..........................................149
KERALAC -urea cream 47%........................................... 149
KERALYT -salicylic acid gel 6%......................................149
KERALYT SCALP -salicylic acid shampoo 6% & salicylic
acid gel 6% kit............................................................... 149
KERLONE -betaxolol hcl tab 10 mg.................................. 37
KERLONE -betaxolol hcl tab 20 mg.................................. 37
KERR TRIPLE DYE -triple dye swabs............................ 159
KETEK -telithromycin tab 300 mg..................................... 12
KETEK -telithromycin tab 400 mg..................................... 12
ketoconazole cream 2%................................................ 149
ketoconazole foam 2% (Extina)....................................149
ketoconazole shampoo 2% (Nizoral)........................... 149
ketoconazole tab 200 mg..................................................7
KETOCON -ketoconazole cream 2% & hydrocortisone gel
1% kit............................................................................. 149
KETODAN KIT -ketoconazole foam 2% & cleanser
kit....................................................................................149
ketoprofen cap 50 mg................................................... 104
ketoprofen cap 75 mg................................................... 104
KETOPROFEN ER -ketoprofen cap sr 24hr 200 mg....... 104
KETOROLAC TROMETHAMINE -ketorolac tromethamine
inj 300 mg/10ml (30 mg/ml)........................................... 104
ketorolac tromethamine ophth soln 0.4% (Acular
ls)................................................................................... 135
ketorolac tromethamine ophth soln 0.5% (Acular)..... 135
ketorolac tromethamine tab 10 mg.............................. 104
KHEDEZLA -desvenlafaxine tab sr 24hr 100 mg.............. 79
KHEDEZLA -desvenlafaxine tab sr 24hr 50 mg................ 79
KINERET -anakinra subcutaneous inj 100 mg/0.67ml.....104
KLARON -sulfacetamide sodium lotion 10% (acne)........ 149
KLONOPIN -clonazepam tab 0.5 mg.............................. 109
KLONOPIN -clonazepam tab 1 mg................................. 109
KLONOPIN -clonazepam tab 2 mg................................. 109
KLOR-CON 25 -potassium chloride powder packet 25
meq................................................................................ 125
KLOR-CON M15 -potassium chloride microencapsulated
crys cr tab 15 meq.........................................................125
K-LOR HOSPITAL PACK -potassium chloride powder
packet 20 meq............................................................... 125
KOMBIGLYZE XR -saxagliptin-metformin hcl tab sr 24hr
2.5-1000 mg.....................................................................26
5-1000 mg........................................................................26
5-500 mg..........................................................................26
KORLYM -mifepristone tab 300 mg.................................. 26
K-PHOS MF -potassium & sodium acid phosphates tab
155-350 mg......................................................................74
K-PHOS NEUTRAL -pot phos monobasic w/sod phos di &
monobas tab 155-852-130mg........................................125
206
K-PHOS NO 2 -potassium & sodium acid phosphates tab
305-700 mg......................................................................74
K-PHOS -potassium phosphate monobasic tab 500
mg.................................................................................. 125
KRISGEL 100 -krisgel 100 gel........................................ 162
KRISTALOSE -lactulose oral crystal packet 10 gm........... 65
KRISTALOSE -lactulose oral crystal packet 20 gm........... 65
K-TAB -potassium chloride tab cr 10 meq.......................125
K-TAB -potassium chloride tab cr 20 meq (1500 mg)...... 125
KUVAN -sapropterin dihydrochloride powder packet 100
mg.................................................................................... 32
KUVAN -sapropterin dihydrochloride soluble tab 100
mg.................................................................................... 33
L
labetalol hcl tab 100 mg (Trandate)............................... 37
LAC-HYDRIN -lactic acid (ammonium lactate) cream
12%................................................................................ 150
LAC-HYDRIN -lactic acid (ammonium lactate) lotion
12%................................................................................ 150
LACRISERT - artificial tear ophth insert .........................135
lactated ringer's for irrigation.......................................165
lactic acid (ammonium lactate) cream 12% (Lachydrin)........................................................................... 150
lactic acid (ammonium lactate) lotion 10%................. 150
lactic acid (ammonium lactate) lotion 12% (Lachydrin)........................................................................... 150
lactic acid w/ vitamin e cream 10%-3500
unit/30gm...................................................................... 150
LACTOCAL-F - prenatal vit w/ fe fumarate-fa tab 65-1 mg
....................................................................................... 118
lactulose (encephalopathy) solution 10 gm/15ml......... 71
lactulose solution 10 gm/15ml....................................... 65
LAMICTAL CHEWABLE DISPERS -lamotrigine tab
chewable dispersible 25 mg.......................................... 109
LAMICTAL CHEWABLE DISPERS -lamotrigine tab
chewable dispersible 5 mg............................................ 109
LAMICTAL -lamotrigine tab 100 mg................................ 109
LAMICTAL -lamotrigine tab 25 mg.................................. 109
LAMICTAL -lamotrigine tab chewable dispersible 2
mg.................................................................................. 109
LAMICTAL ODT -lamotrigine orally disintegrating tab 100
mg.................................................................................. 109
mg.................................................................................. 109
mg.................................................................................. 109
mg.................................................................................. 109
LAMICTAL ODT -lamotrigine tab disp 25 (14) & 50 mg (14)
& 100 mg (7) kit.............................................................109
2014
LAMICTAL ODT -lamotrigine tab disp 25 mg (21) & 50 mg
(7) titration kit................................................................. 109
LAMICTAL ODT -lamotrigine tab disp 50 mg (42) & 100
mg (14) titration kit.........................................................109
LAMICTAL STARTER/NOT TAKI -lamotrigine tab 25 mg
(42) & 100 mg (7) starter kit.......................................... 109
LAMICTAL STARTER/TAKING C -lamotrigine tab 25 mg
(84) & 100 mg (14) starter kit........................................ 109
LAMICTAL STARTER/TAKING V -lamotrigine tab 25 mg
(35) starter kit................................................................ 109
LAMICTAL XR -lamotrigine tab sr 24hr 100 mg.............. 110
LAMICTAL XR -lamotrigine tab sr 24hr 25 (14) & 50 mg
(14) & 100 mg(7) kit...................................................... 109
LAMICTAL XR -lamotrigine tab sr 24hr 25 mg................ 110
LAMICTAL XR -lamotrigine tab sr 24hr 25 mg (21) & 50
mg (7) titration kit...........................................................109
LAMICTAL XR -lamotrigine tab sr 24hr 50 (14) & 100
mg(14) & 200 mg(7) kit..................................................110
LAMICTAL XR -lamotrigine tab sr 24hr 50 mg................ 110
LAMISIL SPRAY -terbinafine hcl soln 1%....................... 150
LAMISIL -terbinafine hcl oral granules packet 125 mg........ 7
LAMISIL -terbinafine hcl oral granules packet 187.5 mg..... 7
LAMISIL -terbinafine hcl tab 250 mg................................... 7
lamivudine tab 100 mg (Epivir hbv)................................. 8
lamivudine tab 150 mg (Epivir)........................................ 8
lamivudine tab 300 mg (Epivir)........................................ 8
lamivudine-zidovudine tab 150-300 mg (Combivir)........ 8
lamotrigine tab 100 mg (Lamictal)............................... 110
lamotrigine tab 25 mg (Lamictal)................................. 110
lamotrigine tab chewable dispersible 25 mg (Lamictal
chewable di)................................................................. 110
lamotrigine tab chewable dispersible 5 mg (Lamictal
chewable di)................................................................. 110
lamotrigine tab sr 24hr 100 mg (Lamictal xr).............. 110
lamotrigine tab sr 24hr 25 mg (Lamictal xr)................ 110
lamotrigine tab sr 24hr 50 mg (Lamictal xr)................ 110
lanolin..............................................................................162
LANOLIN ANHYDROUS -lanolin anhydrous................... 162
LANOLIN -lanolin anhydrous oil...................................... 162
LANOXIN -digoxin tab 125 mcg (0.125 mg)...................... 35
LANOXIN -digoxin tab 187.5 mcg (0.1875 mg)................. 35
LANOXIN -digoxin tab 250 mcg (0.25 mg)........................ 35
LANOXIN -digoxin tab 62.5 mcg (0.0625 mg)................... 35
lansoprazole cap delayed release 15 mg
(Prevacid)........................................................................ 67
lansoprazole cap delayed release 30 mg
(Prevacid)........................................................................ 67
lansoprazole tab delayed release orally disintegrating
15 mg...............................................................................67
lansoprazole tab delayed release orally disintegrating
30 mg...............................................................................67
LANTUS -insulin glargine inj 100 unit/ml........................... 28
LANTUS SOLOSTAR -insulin glargine soln pen-injector
100 unit/ml....................................................................... 28
LARTUS -phenyleph-chlorphen w/ dm-gg liquid 5-2-15-150
mg/5ml..............................................................................58
LASIX -furosemide tab 20 mg........................................... 49
LASTACAFT -alcaftadine ophth soln 0.25%....................135
latanoprost ophth soln 0.005% (Xalatan).................... 135
LATRIX XM -urea in zinc undecylenate-lactic acid vehicle
emulsion 45%................................................................ 150
LATUDA -lurasidone hcl tab 120 mg.................................83
LATUDA -lurasidone hcl tab 20 mg...................................83
LAVARE WOUND WASH - wound cleansers - gel .........150
LAVOCLEN-4 CREAMY WASH -benzoyl peroxide liq
4%.................................................................................. 150
LAVOCLEN-8 CREAMY WASH -benzoyl peroxide liq
8%.................................................................................. 150
LAZANDA -fentanyl citrate nasal spray 100 mcg/act (base
equiv)................................................................................97
LAZANDA -fentanyl citrate nasal spray 400 mcg/act (base
equiv)................................................................................97
LECITHIN -lecithin granules............................................ 126
LECITHIN ORGANOGEL -premium lecithin organogel
base gel......................................................................... 162
leflunomide tab 10 mg (Arava)..................................... 104
leflunomide tab 20 mg (Arava)..................................... 104
LEMOHIST PLUS -pseudoephed-chlorphen-gg cap
32.4-2-100 mg..................................................................58
LESCOL -fluvastatin sodium cap 20 mg........................... 52
LESCOL -fluvastatin sodium cap 40 mg........................... 52
LESCOL XL -fluvastatin sodium tab sr 24 hr 80 mg.......... 52
LETAIRIS -ambrisentan tab 10 mg................................... 54
LETAIRIS -ambrisentan tab 5 mg..................................... 54
letrozole tab 2.5 mg (Femara).........................................14
LETS KIT -lidocaine & tetracaine w/ epineph kit
(compounding kit).......................................................... 107
LEUCOVORIN CALCIUM -leucovorin calcium tab 10
mg.................................................................................... 14
LEUCOVORIN CALCIUM -leucovorin calcium tab 15
mg.................................................................................... 14
leucovorin calcium tab 25 mg........................................ 14
leucovorin calcium tab 5 mg.......................................... 14
LEUKERAN -chlorambucil tab 2 mg..................................14
LEUKINE -sargramostim inj 500 mcg/ml......................... 129
LEUKINE -sargramostim lyophilized for inj 250 mcg....... 129
207
2014
LEVACET -aspirin-apap-salicylamide-caffeine tab
500-250-150-32.5 mg...................................................... 94
levalbuterol hcl soln nebu 0.31 mg/3ml (base equiv)
(Xopenex)........................................................................ 63
(Xopenex)........................................................................ 63
(Xopenex)........................................................................ 63
levalbuterol hcl soln nebu conc 1.25 mg/0.5ml (base
equiv) (Xopenex concentrate).......................................63
LEVAQUIN -levofloxacin oral soln 25 mg/ml....................... 5
LEVAQUIN -levofloxacin tab 250 mg.................................. 5
LEVATOL -penbutolol sulfate tab 20 mg........................... 37
LEVBID -hyoscyamine sulfate tab sr 12hr 0.375 mg......... 67
LEVEMIR FLEXPEN -insulin detemir soln pen-injector 100
unit/ml...............................................................................28
LEVEMIR -insulin detemir inj 100 unit/ml.......................... 28
levetiracetam oral soln 100 mg/ml (Keppra)............... 110
levetiracetam tab 1000 mg (Keppra)............................ 110
levetiracetam tab 250 mg (Keppra).............................. 110
levetiracetam tab sr 24hr 500 mg (Keppra xr).............110
levetiracetam tab sr 24hr 750 mg (Keppra xr).............110
LEVITRA -vardenafil hcl tab 10 mg................................... 54
LEVITRA -vardenafil hcl tab 2.5 mg.................................. 54
LEVITRA -vardenafil hcl tab 20 mg................................... 54
LEVITRA -vardenafil hcl tab 5 mg.....................................54
LEVOBUNOLOL HCL -levobunolol hcl ophth soln
0.25%............................................................................. 135
levobunolol hcl ophth soln 0.5% (Betagan)................ 135
levocarnitine oral soln 1 gm/10ml (10%) (Carnitor)...... 33
levocarnitine tab 330 mg (Carnitor)............................... 33
levocetirizine dihydrochloride soln 2.5 mg/5ml (0.5 mg/
ml) (Xyzal)....................................................................... 55
levocetirizine dihydrochloride tab 5 mg (Xyzal)............55
levofloxacin ophth soln 0.5%....................................... 135
levofloxacin oral soln 25 mg/ml (Levaquin).................... 5
levofloxacin tab 250 mg (Levaquin).................................5
levonorgestrel & ethinyl estradiol (91-day) tab
0.15-0.03 mg................................................................... 21
levonorgestrel & ethinyl estradiol tab 0.15 mg-30
mcg.................................................................................. 21
levonorgestrel & ethinyl estradiol tab 0.1 mg-20
mcg.................................................................................. 21
levonorgestrel-eth estra tab
0.05-30/0.075-40/0.125-30mg-mcg.................................21
levonorgestrel tab 0.75 mg (Plan b)...............................21
levonorgestrel tab 1.5 mg (Plan b one-step)................. 21
levonorg-eth est tab 0.1-0.02mg(84) & eth est tab
0.01mg(7) (Loseasonique).............................................21
208
levonorg-eth est tab 0.15-0.03mg(84) & eth est tab
0.01mg(7) (Seasonique).................................................21
LEVORPHANOL TARTRATE -levorphanol tartrate tab 2
mg.................................................................................... 97
levothyroxine sodium tab 100 mcg (Synthroid)............28
levothyroxine sodium tab 25 mcg (Synthroid)..............28
LEVSIN/SL -hyoscyamine sulfate tab sl 0.125 mg............ 67
LEVSIN -hyoscyamine sulfate tab 0.125 mg..................... 67
LEVULAN KERASTICK -aminolevulinic acid hcl for soln
20% (stick applicator).................................................... 150
LEXAPRO -escitalopram oxalate soln 5 mg/5ml (base
equiv)................................................................................79
LEXAPRO -escitalopram oxalate tab 10 mg (base
equiv)................................................................................79
equiv)................................................................................79
equiv)................................................................................79
LEXIVA -fosamprenavir calcium susp 50 mg/ml (base
equiv)..................................................................................8
LEXIVA -fosamprenavir calcium tab 700 mg (base
equiv)..................................................................................8
LIALDA -mesalamine tab delayed release 1.2 gm............ 71
LIBRAX -clidinium & chlordiazepoxide cap 2.5-5 mg.........67
LIDOCAINE/PRILOCAINE -lidocaine-prilocaine kit
2.5-2.5%......................................................................... 150
LIDOCAINE HCL/HYDROCORTIS -lidocainehydrocortisone acetate rectal cream kit 2-2%................ 141
lidocaine hcl cream 3%.................................................150
lidocaine hcl gel 2%...................................................... 150
LIDOCAINE HCL-HYDROCORTIS -lidocainehydrocortisone acetate rectal gel 2.8-0.55%..................141
lidocaine hcl laryngotracheal soln 4% (Lta 360
kit).................................................................................. 139
LIDOCAINE HCL -lidocaine hcl lotion 3%....................... 150
lidocaine hcl soln 4% (Xylocaine)................................ 150
lidocaine hcl viscous soln 2%......................................139
lidocaine-hydrocortisone acetate rectal cream
3-0.5%............................................................................ 141
lidocaine-hydrocortisone acetate rectal cream kit
3-0.5%............................................................................ 141
lidocaine-hydrocortisone acetate rectal cream kit
3-1%............................................................................... 141
lidocaine-hydrocortisone acetate rectal gel kit
3-2.5%............................................................................ 141
2014
lidocaine oint 5%........................................................... 150
lidocaine patch 5% (Lidoderm).................................... 150
lidocaine-prilocaine cream 2.5-2.5% (Emla)................ 150
LIDODERM -lidocaine patch 5%..................................... 150
LIDOPROFEN -ketoprofen-ketamine-lidocaine cream
5-5-2% (compounding kit)..............................................150
LIDORX -lidocaine hcl gel 3%......................................... 150
LIDOVIR -acyclovir-lidocaine hcl oint 4-4% (compounding
kit)...................................................................................150
lindane lotion 1%........................................................... 150
lindane shampoo 1%.....................................................150
LINZESS -linaclotide cap 145 mcg....................................71
LINZESS -linaclotide cap 290 mcg....................................71
liothyronine sodium tab 25 mcg (Cytomel)................... 28
liothyronine sodium tab 50 mcg (Cytomel)................... 29
liothyronine sodium tab 5 mcg (Cytomel)..................... 28
LIPITOR -atorvastatin calcium tab 10 mg (base
equivalent)........................................................................52
equivalent)........................................................................52
equivalent)........................................................................52
equivalent)........................................................................52
LIPOBASE HEAVY - cream base .................................. 162
LIPOBASE REGULAR - cream base ............................. 162
LIPO CREAM BASE - cream base ................................ 162
LIPOFEN -fenofibrate cap 150 mg.................................... 52
LIPOFEN -fenofibrate cap 50 mg...................................... 52
LIPOFOAM RX - foam base - foam ............................... 162
LIPOPEN - cream base ..................................................162
LIPOPEN PLUS - cream base ....................................... 162
LIPOPEN ULTRA - cream base .....................................162
LIPTRUZET -ezetimibe-atorvastatin tab 10-10 mg............52
LIQUICET -hydrocodone-acetaminophen soln 10-500
mg/15ml............................................................................97
lisinopril & hydrochlorothiazide tab 10-12.5 mg
(Zestoretic)......................................................................45
lisinopril & hydrochlorothiazide tab 20-12.5 mg
(Zestoretic)......................................................................45
lisinopril & hydrochlorothiazide tab 20-25 mg
(Zestoretic)......................................................................45
lisinopril tab 10 mg (Prinivil).......................................... 45
lisinopril tab 2.5 mg (Zestril).......................................... 45
lisinopril tab 20 mg (Prinivil).......................................... 45
lisinopril tab 30 mg (Zestril)........................................... 45
lisinopril tab 40 mg (Zestril)........................................... 45
lisinopril tab 5 mg (Prinivil)............................................ 45
LISTERINE ESSENTIAL CARE - sod monofluorophoseucal-men-methyl sal-thymol paste 0.76% ................... 139
LISTERINE ESSENTIAL CARE - sod monofluorophospheucal-men-methyl sal-thymol gel 0.76% ....................... 139
LISTERINE RESTORING -sodium fluoride rinse 0.0221%
(0.01% f)........................................................................ 139
LISTERINE SMART RINSE ANT -sodium fluoride rinse
0.02%............................................................................. 139
LISTERINE SMART RINSE -sodium fluoride rinse
0.0221% (0.01% f)......................................................... 139
LISTERINE TOOTH DEFENSE -sodium fluoride rinse
0.0221% (0.01% f)......................................................... 139
LISTERINE TOTAL CARE PLUS -sodium fluoride rinse
0.0221% (0.01% f)......................................................... 139
LISTERINE TOTAL CARE -sodium fluoride rinse 0.0221%
(0.01% f)........................................................................ 139
LISTERINE TOTAL CARE ZERO -sodium fluoride rinse
0.02%............................................................................. 139
LISTERINE WHITENING/RESTO -sodium fluoride rinse
0.0221% (0.01% f)......................................................... 139
LISTERMINT -sodium fluoride rinse 0.02%.....................139
lithium carbonate cap 150 mg (Lithium carbonate)...... 83
lithium carbonate cap 300 mg........................................83
lithium carbonate cap 600 mg (Lithium carbonate)...... 83
LITHIUM CARBONATE -lithium carbonate cap 150
mg.................................................................................... 83
LITHIUM CARBONATE -lithium carbonate cap 600
mg.................................................................................... 83
lithium carbonate tab 300 mg.........................................83
lithium carbonate tab cr 300 mg (Lithobid)................... 83
lithium carbonate tab cr 450 mg.................................... 83
LITHIUM CITRATE -lithium citrate oral soln 8 meq/5ml.....83
LITHOBID -lithium carbonate tab cr 300 mg..................... 83
LITHOSTAT -acetohydroxamic acid tab 250 mg............... 74
LIVALO -pitavastatin calcium tab 1 mg (base equiv)......... 52
LOCOID -hydrocortisone butyrate cream 0.1%............... 150
LOCOID -hydrocortisone butyrate lotion 0.1%................ 150
LOCOID -hydrocortisone butyrate oint 0.1%................... 150
LOCOID -hydrocortisone butyrate soln 0.1%.................. 150
LOCOID LIPOCREAM -hydrocortisone butyrate
hydrophilic lipo base cream 0.1%.................................. 150
LODOSYN -carbidopa tab 25 mg....................................112
LOESTRIN 1/20-21 -norethindrone ace & ethinyl estradiol
tab 1 mg-20 mcg............................................................. 21
LOESTRIN 1.5/30-21 -norethindrone ace & ethinyl
estradiol tab 1.5 mg-30 mcg............................................ 21
LOESTRIN 24 FE -norethindrone ace-ethinyl estradiol-fe
tab 1 mg-20 mcg (24)......................................................21
LOESTRIN FE 1/20 -norethindrone ace & ethinyl estradiolfe tab 1 mg-20 mcg......................................................... 21
LOESTRIN FE 1.5/30 -norethindrone ace & ethinyl
estradiol-fe tab 1.5 mg-30 mcg........................................21
LOFIBRA -fenofibrate micronized cap 134 mg.................. 52
LOFIBRA -fenofibrate micronized cap 200 mg.................. 52
LOFIBRA -fenofibrate micronized cap 67 mg.................... 52
LOFIBRA -fenofibrate tab 160 mg.....................................52
LOFIBRA -fenofibrate tab 54 mg.......................................52
209
2014
LO LOESTRIN FE -norethin-eth estradiol-fe tab 1 mg-10
mcg (24)/10 mcg (2)........................................................ 21
LOMEDIA 24 FE -norethindrone ace-ethinyl estradiol-fe
tab 1 mg-20 mcg (24)......................................................21
LO MINASTRIN FE -norethin-eth estrad-fe chew/tab 1
mg-10 mcg/10 mcg ther pack.......................................... 21
LOMOTIL -diphenoxylate w/ atropine tab 2.5-0.025
mg.................................................................................... 65
LOMUSTINE -lomustine cap 100 mg................................ 14
LOMUSTINE -lomustine cap 10 mg.................................. 14
LOMUSTINE -lomustine cap 40 mg.................................. 14
loperamide hcl cap 2 mg................................................ 65
LOPID -gemfibrozil tab 600 mg......................................... 52
LOPRESSOR HCT -metoprolol & hydrochlorothiazide tab
100-25 mg........................................................................45
LOPRESSOR HCT -metoprolol & hydrochlorothiazide tab
50-25 mg..........................................................................45
LOPRESSOR -metoprolol tartrate tab 100 mg.................. 37
LOPRESSOR -metoprolol tartrate tab 50 mg.................... 37
LOPROX -ciclopirox gel 0.77%....................................... 150
LOPROX SHAMPOO -ciclopirox shampoo 1%............... 150
lorazepam conc 2 mg/ml (Lorazepam intensol)............ 76
LORAZEPAM INTENSOL -lorazepam conc 2 mg/ml........ 76
lorazepam tab 0.5 mg (Ativan)....................................... 76
lorazepam tab 1 mg (Ativan).......................................... 76
lorazepam tab 2 mg (Ativan).......................................... 76
LORCET 10/650 -hydrocodone-acetaminophen tab 10-650
mg.................................................................................... 97
LORCET PLUS -hydrocodone-acetaminophen tab 7.5-650
mg.................................................................................... 97
LORTAB -hydrocodone-acetaminophen soln 10-300
mg/15ml............................................................................98
LORTAB -hydrocodone-acetaminophen soln 7.5-500
mg/15ml............................................................................98
LORTAB -hydrocodone-acetaminophen tab 10-500
mg.................................................................................... 98
LORTAB -hydrocodone-acetaminophen tab 5-500 mg......98
LORTAB -hydrocodone-acetaminophen tab 7.5-500
mg.................................................................................... 98
LORTUSS EX -pseudoephedrine w/ cod-gg liqd
22.5-10-100 mg/5ml......................................................... 58
LORZONE -chlorzoxazone tab 375 mg...........................115
LORZONE -chlorzoxazone tab 750 mg...........................115
losartan potassium & hydrochlorothiazide tab 100-12.5
mg (Hyzaar).................................................................... 45
losartan potassium & hydrochlorothiazide tab 100-25
mg (Hyzaar).................................................................... 45
losartan potassium & hydrochlorothiazide tab 50-12.5
mg (Hyzaar).................................................................... 45
losartan potassium tab 100 mg (Cozaar)...................... 45
losartan potassium tab 25 mg (Cozaar)........................ 46
losartan potassium tab 50 mg (Cozaar)........................ 46
LOSEASONIQUE -levonorg-eth est tab 0.1-0.02mg(84) &
eth est tab 0.01mg(7)...................................................... 21
LOTEMAX -loteprednol etabonate ophth gel 0.5%..........135
210
LOTEMAX -loteprednol etabonate ophth oint 0.5%.........135
LOTEMAX -loteprednol etabonate ophth susp 0.5%....... 135
LOTENSIN -benazepril hcl tab 10 mg............................... 46
LOTENSIN HCT -benazepril & hydrochlorothiazide tab
10-12.5 mg.......................................................................46
20-12.5 mg.......................................................................46
20-25 mg..........................................................................46
LOTREL -amlodipine besylate-benazepril hcl cap 10-20
mg.................................................................................... 46
mg.................................................................................... 46
LOTREL -amlodipine besylate-benazepril hcl cap 2.5-10
mg.................................................................................... 46
mg.................................................................................... 46
mg.................................................................................... 46
mg.................................................................................... 46
LOTRISONE -clotrimazole w/ betamethasone cream
1-0.05%.......................................................................... 150
LOTRONEX -alosetron hcl tab 0.5 mg (base equiv)..........71
LOTRONEX -alosetron hcl tab 1 mg (base equiv).............71
LOUTREX - antiseborrheic products misc - cream .........150
lovastatin tab 10 mg........................................................52
lovastatin tab 20 mg (Mevacor)......................................52
lovastatin tab 40 mg (Mevacor)......................................52
LOVAZA -omega-3-acid ethyl esters cap 1 gm................. 52
LOVENOX -enoxaparin sodium inj 100 mg/ml................ 131
LOVENOX -enoxaparin sodium inj 120 mg/0.8ml............131
LOVENOX -enoxaparin sodium inj 150 mg/ml................ 131
LOVENOX -enoxaparin sodium inj 300 mg/3ml.............. 131
LOVENOX -enoxaparin sodium inj 30 mg/0.3ml............. 131
loxapine succinate cap 10 mg........................................83
loxapine succinate cap 5 mg (Loxitane)........................83
LOXITANE -loxapine succinate cap 10 mg....................... 83
LOXITANE -loxapine succinate cap 5 mg......................... 83
LOZI-FLUR -sodium fluoride lozenge 1 mg f (from 2.2 mg
naf)................................................................................. 125
LTA 360 KIT -lidocaine hcl laryngotracheal soln 4%....... 139
LUFYLLIN -dyphylline tab 200 mg.................................... 63
LUFYLLIN -dyphylline tab 400 mg.................................... 63
LUGOLS STRONG IODINE - iodine solution ................. 159
LUMIGAN -bimatoprost ophth soln 0.01%.......................135
2014
LUMIGAN -bimatoprost ophth soln 0.03%.......................135
LUNESTA -eszopiclone tab 1 mg......................................85
LUPANETA PACK -leuprolide (1 mon) inj 3.75 mg &
norethindrone tab 5 mg kit...............................................33
LUPANETA PACK -leuprolide (3 mon) inj 11.25 mg &
norethindrone tab 5 mg kit...............................................33
LUPRON DEPOT -leuprolide acetate (3 month) for inj kit
11.25 mg.......................................................................... 14
22.5 mg............................................................................ 14
30 mg............................................................................... 14
45 mg............................................................................... 14
LUPRON DEPOT -leuprolide acetate for inj kit 3.75
mg.................................................................................... 14
LUPRON DEPOT -leuprolide acetate for inj kit 7.5 mg......14
LUPRON DEPOT-PED -leuprolide acetate (3 month) for inj
pediatric kit 11.25 mg...................................................... 33
LUPRON DEPOT-PED -leuprolide acetate (3 month) for inj
pediatric kit 30 mg........................................................... 33
LUPRON DEPOT-PED -leuprolide acetate for inj pediatric
kit 11.25 mg..................................................................... 33
kit 15 mg.......................................................................... 33
kit 7.5 mg......................................................................... 33
LURIDE -sodium fluoride chew tab 0.25 mg f (from 0.55
mg naf)...........................................................................125
LURIDE -sodium fluoride chew tab 0.5 mg f (from 1.1 mg
naf)................................................................................. 125
LURIDE -sodium fluoride chew tab 1 mg f (from 2.2 mg
naf)................................................................................. 125
LURIDE -sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml
naf)................................................................................. 125
LUSONAL -phenylephrine hcl liquid 7.5 mg/5ml............... 56
LUVERIS -lutropin alfa for subcutaneous inj 75 unit..........33
LUVOX CR -fluvoxamine maleate cap sr 24hr 100 mg......79
LUVOX CR -fluvoxamine maleate cap sr 24hr 150 mg......79
LUXIQ -betamethasone valerate aerosol foam 0.12%.....150
LUZU -luliconazole cream 1%......................................... 150
LYCELLE - nit remover - gel ..........................................150
LYRICA -pregabalin cap 100 mg.....................................110
LYRICA -pregabalin cap 25 mg.......................................110
LYRICA -pregabalin soln 20 mg/ml................................. 110
LYSODREN -mitotane tab 500 mg....................................14
LYSTEDA -tranexamic acid tab 650 mg..........................132
M
MACNATAL CN DHA - prenatal w/o a w/fe cbn-dss-fa-dha
cap 28-1-250 mg .......................................................... 118
MACROBID -nitrofurantoin monohydrate macrocrystalline
cap 100 mg......................................................................72
MACRODANTIN -nitrofurantoin macrocrystalline cap 100
mg.................................................................................... 72
mg.................................................................................... 72
mg.................................................................................... 72
mafenide acetate packet for topical soln 5% (50 gm)
(Sulfamylon)..................................................................150
MAGNACET -oxycodone w/ acetaminophen tab 10-400
mg.................................................................................... 98
MAGNACET -oxycodone w/ acetaminophen tab 5-400
mg.................................................................................... 98
MAGNACET -oxycodone w/ acetaminophen tab 7.5-400
mg.................................................................................... 98
MAGNEBIND 400 -magnesium-calcium-folic acid tab
400-200-1 mg.................................................................125
MALARONE -atovaquone-proguanil hcl tab 250-100
mg.................................................................................... 11
MALARONE -atovaquone-proguanil hcl tab 62.5-25
mg.................................................................................... 11
malathion lotion 0.5% (Ovide)...................................... 150
MAPROTILINE HCL -maprotiline hcl tab 25 mg................79
MAR-COF BP -pseudoephedrine-bromphen-codeine liqd
30-2-7.5 mg/5ml...............................................................58
MAR-COF CG EXPECTORANT -guaifenesin-codeine
liquid 225-7.5 mg/5ml...................................................... 58
MARINOL -dronabinol cap 10 mg..................................... 69
MARINOL -dronabinol cap 2.5 mg.................................... 69
MARINOL -dronabinol cap 5 mg....................................... 69
MARNATAL-F PLUS DUO PACK -prenatal w/fe polys
cmplx-fa-ca tab & omega 3 cap pack............................ 118
MARNATAL-F - prenatal w/o vit a w/ fe polysac cmplx-fa
cap 60-1 mg ................................................................. 118
MARPLAN -isocarboxazid tab 10 mg................................ 79
MATULANE -procarbazine hcl cap 50 mg.........................14
MAVIK -trandolapril tab 1 mg............................................ 46
MAXAIR AUTOHALER -pirbuterol acetate breath activated
inhal aerosol 200mcg/inh................................................. 63
MAXALT-MLT -rizatriptan benzoate orally disintegrating
tab 10 mg.......................................................................106
MAXALT-MLT -rizatriptan benzoate orally disintegrating
tab 5 mg.........................................................................106
MAXALT -rizatriptan benzoate tab 10 mg....................... 106
MAXALT -rizatriptan benzoate tab 5 mg......................... 106
MAXARON FORTE - fe bisglycinate-fe polysacch-vit c-vit
b12-fa cap .....................................................................129
211
2014
MAXARON FORTE - fe gly-fe fum-vit c-vit b12methylfolate tab ............................................................ 129
MAXIDEX -dexamethasone ophth susp 0.1%................. 135
MAXIDONE -hydrocodone-acetaminophen tab 10-750
mg.................................................................................... 98
MAXIFED CD -pseudoephedrine w/ cod-gg tab 60-10-400
mg.................................................................................... 58
MAXIFED CDX -pseudoephedrine w/ cod-gg tab
60-20-400 mg...................................................................59
MAXIFED-G CD -pseudoephedrine w/ cod-gg tab
40-10-400 mg...................................................................59
MAXIFED-G CDX -pseudoephedrine w/ cod-gg tab
40-20-400 mg...................................................................59
MAXIFLU CD -pseudoephed-codeine-guaifenesin-apap
tab 40-10-400-500 mg..................................................... 59
MAXIFLU CDX -pseudoephed-codeine-guaifenesin-apap
tab 60-20-400-500 mg..................................................... 59
MAXIPHEN CD -phenylephrine w/ codeine-gg tab
10-10-400 mg...................................................................59
MAXIPHEN CDX -phenylephrine w/ codeine-gg tab
10-20-400 mg...................................................................59
MAXITROL -neomycin-polymyxin-dexamethasone ophth
oint 0.1%........................................................................ 135
MAXITROL -neomycin-polymyxin-dexamethasone ophth
susp 0.1%...................................................................... 135
MAXZIDE-25 -triamterene & hydrochlorothiazide tab
37.5-25 mg.......................................................................50
MAXZIDE -triamterene & hydrochlorothiazide tab 75-50
mg.................................................................................... 50
MB HYDROGEL -emollient cream & wound dressing gel
kit....................................................................................150
MEBENDAZOLE -mebendazole chew tab 100 mg............11
meclizine hcl tab 12.5 mg............................................... 69
meclizine hcl tab 25 mg.................................................. 69
meclizine hcl tab 32 mg.................................................. 69
MECLOFENAMATE SODIUM -meclofenamate sodium
cap 100 mg....................................................................104
MECLOFENAMATE SODIUM -meclofenamate sodium
cap 50 mg......................................................................104
MEDIDERM - cream base ..............................................162
MEDIHOL BASE - alcohol gel base ............................... 162
MEDIHONEY CALCIUM ALGINAT - wound dressings pads .............................................................................. 150
MEDROL DOSEPAK -methylprednisolone tab 4 mg dose
pack..................................................................................16
MEDROL -methylprednisolone tab 16 mg......................... 16
MEDROL -methylprednisolone tab 2 mg...........................16
MEDROL -methylprednisolone tab 32 mg......................... 16
MEDROX-RX -capsaicin-menthol-methyl salicylate oint
0.05-7-20%.....................................................................150
medroxyprogesterone acetate im susp 150 mg/ml
(Depo-provera contrac)................................................. 21
medroxyprogesterone acetate tab 10 mg (Provera)..... 23
212
medroxyprogesterone acetate tab 2.5 mg
(Provera)..........................................................................23
medroxyprogesterone acetate tab 5 mg (Provera)....... 23
mefenamic acid cap 250 mg (Ponstel).........................104
mefloquine hcl tab 250 mg............................................. 11
MEGACE ES -megestrol acetate susp 625 mg/5ml.......... 23
MEGACE ORAL -megestrol acetate susp 40 mg/ml......... 14
megestrol acetate susp 40 mg/ml (Megace oral).......... 14
megestrol acetate tab 20 mg.......................................... 14
megestrol acetate tab 40 mg.......................................... 14
MEKINIST -trametinib dimethyl sulfoxide tab 0.5 mg (base
equivalent)........................................................................14
MEKINIST -trametinib dimethyl sulfoxide tab 2 mg (base
equivalent)........................................................................14
MELOXICAM COMFORT PAC -meloxicam tab 15 mg &
MELOXICAM -meloxicam susp 7.5 mg/5ml.................... 104
meloxicam tab 15 mg (Mobic)...................................... 104
meloxicam tab 7.5 mg (Mobic)..................................... 104
M-END MAX D -pseudoephedrine-dexbromphen-codeine
liqd 20-0.667-6 mg/5ml.................................................... 58
M-END PE -phenylephrine-bromphen w/ codeine liqd
3.33-1.33-6.33 mg/5ml..................................................... 58
MENEST -esterified estrogens tab 0.3 mg........................ 20
MENEST -esterified estrogens tab 0.625 mg.................... 20
MENEST -esterified estrogens tab 1.25 mg...................... 20
MENEST -esterified estrogens tab 2.5 mg........................ 20
MENOPUR -menotropins for subcutaneous inj 75 unit......33
MENOSTAR -estradiol td patch weekly 14 mcg/24hr........ 20
MENTAX -butenafine hcl cream 1%................................150
MEPERIDINE HCL -meperidine hcl oral soln 50
mg/5ml..............................................................................98
meperidine hcl tab 100 mg (Demerol)........................... 98
meperidine hcl tab 50 mg (Demerol)............................. 98
MEPHYTON -phytonadione tab 5 mg............................. 116
meprobamate tab 200 mg............................................... 76
meprobamate tab 400 mg............................................... 76
MEPRON -atovaquone susp 750 mg/5ml......................... 12
mercaptopurine tab 50 mg (Purinethol).........................14
mesalamine enema 4 gm................................................ 71
mesalamine rectal enema 4 gm & cleanser wipe kit
(Rowasa)......................................................................... 70
MESNEX -mesna tab 400 mg........................................... 14
MESTINON -pyridostigmine bromide syrup 60
mg/5ml............................................................................115
MESTINON -pyridostigmine bromide tab 60 mg............. 115
MESTINON TIMESPAN -pyridostigmine bromide tab cr
180 mg........................................................................... 115
METADATE CD -methylphenidate hcl cap cr 10 mg......... 88
METAGLIP -glipizide-metformin hcl tab 2.5-250 mg..........26
2014
METAPROTERENOL SULFATE -metaproterenol sulfate
syrup 10 mg/5ml.............................................................. 63
tab 10 mg.........................................................................63
tab 20 mg.........................................................................63
metaproterenol sulfate syrup 10 mg/5ml.......................63
metaxalone tab 800 mg (Skelaxin)............................... 115
metformin hcl tab 1000 mg (Glucophage)..................... 26
metformin hcl tab 500 mg (Glucophage).......................26
metformin hcl tab 850 mg (Glucophage).......................26
metformin hcl tab sr 24hr 500 mg (Glucophage xr)...... 26
metformin hcl tab sr 24hr 750 mg (Glucophage xr)...... 26
metformin hcl tab sr 24hr osmotic 1000 mg
(Fortamet)........................................................................26
metformin hcl tab sr 24hr osmotic 500 mg
(Fortamet)........................................................................26
methadone hcl conc 10 mg/ml (Methadose)................. 98
METHADONE HCL -methadone hcl soln 10 mg/5ml.........98
METHADONE HCL -methadone hcl soln 5 mg/5ml...........98
methadone hcl soln 10 mg/5ml (Methadone hcl).......... 98
methadone hcl soln 5 mg/5ml (Methadone hcl)............ 98
methadone hcl tab 10 mg (Dolophine).......................... 98
methadone hcl tab 5 mg (Dolophine hcl)...................... 98
methadone hcl tab for oral susp 40 mg........................ 98
METHADOSE -methadone hcl conc 10 mg/ml..................98
METHADOSE SUGAR-FREE -methadone hcl conc 10 mg/
ml......................................................................................98
methamphetamine hcl tab 5 mg (Desoxyn)...................88
methazolamide tab 25 mg (Neptazane)......................... 50
methazolamide tab 50 mg (Neptazane)......................... 50
methenamine hippurate tab 1 gm (Hiprex)....................72
methenamine-hyosamine-meth blue-sod phos tab 81.6
mg (Urogesic-blue)........................................................ 71
methenamine-hyosc-meth blue-benz acid-phenyl sal
tab 81.6mg (Prosed/ds)................................................. 72
methenamine-hyosc-meth blue-sod phos-phen sal cap
120 mg ........................................................................... 71
methenamine-hyos-meth blue-sod phos-phen sal tab
81.6 mg .......................................................................... 71
METHENAMINE MANDELATE -methenamine mandelate
tab 0.5 gm........................................................................72
methenamine mandelate tab 1 gm.................................72
METHERGINE -methylergonovine maleate tab 0.2 mg.....30
methimazole tab 10 mg (Tapazole)................................ 29
methimazole tab 5 mg (Tapazole).................................. 29
METHITEST -methyltestosterone oral tab 10 mg.............. 18
methocarbamol tab 500 mg (Robaxin)........................ 115
methocarbamol tab 750 mg (Robaxin-750)................. 115
methotrexate sodium for inj 1 gm..................................14
methotrexate sodium inj 25 mg/ml................................ 14
methotrexate sodium inj pf 25 mg/ml............................ 14
methotrexate sodium tab 2.5 mg (base equiv)..............14
methscopolamine bromide tab 2.5 mg (Pamine).......... 67
methscopolamine bromide tab 5 mg (Pamine
forte)................................................................................ 67
METHYCLOTHIAZIDE -methyclothiazide tab 5 mg...........50
METHYLDOPA/HYDROCHLOROTHI -methyldopa &
hydrochlorothiazide tab 250-15 mg................................. 46
METHYLDOPA/HYDROCHLOROTHI -methyldopa &
hydrochlorothiazide tab 250-25 mg................................. 46
methyldopa tab 250 mg.................................................. 46
methyldopa tab 500 mg.................................................. 46
methylergonovine maleate tab 0.2 mg.......................... 30
METHYLIN -methylphenidate hcl chew tab 10 mg............ 88
METHYLIN -methylphenidate hcl chew tab 2.5 mg........... 88
METHYLIN -methylphenidate hcl chew tab 5 mg.............. 88
METHYLIN -methylphenidate hcl soln 10 mg/5ml............. 88
METHYLIN -methylphenidate hcl soln 5 mg/5ml............... 88
methylphenidate hcl cap cr 10 mg (Metadate cd)......... 88
methylphenidate hcl cap sr 24hr 20 mg (Ritalin la)...... 88
METHYLPHENIDATE HCL ER -methylphenidate hcl tab cr
10 mg............................................................................... 88
methylphenidate hcl soln 10 mg/5ml (Methylin)........... 88
methylphenidate hcl soln 5 mg/5ml (Methylin)............. 88
methylphenidate hcl tab 10 mg (Ritalin)........................88
methylphenidate hcl tab 20 mg (Ritalin)........................88
methylphenidate hcl tab 5 mg (Ritalin)..........................89
methylphenidate hcl tab cr 20 mg (Ritalin sr)............... 88
methylphenidate hcl tab sa osm 18 mg (Concerta)...... 88
methylprednisolone tab 16 mg (Medrol)........................16
methylprednisolone tab 32 mg (Medrol)........................16
methylprednisolone tab 4 mg (Medrol)......................... 16
methylprednisolone tab 4 mg dose pack (Medrol
dosepak)..........................................................................16
methylprednisolone tab 8 mg (Medrol)......................... 16
METHYL SALICYLATE - methyl salicylate liquid ............150
METIPRANOLOL -metipranolol ophth soln 0.3%............ 135
metoclopramide hcl soln 5 mg/5ml (10 mg/10ml)......... 71
metoclopramide hcl tab 10 mg (Reglan)....................... 71
metoclopramide hcl tab 5 mg (Reglan)......................... 71
metolazone tab 10 mg.....................................................50
metolazone tab 2.5 mg (Zaroxolyn)............................... 50
metolazone tab 5 mg (Zaroxolyn).................................. 50
metoprolol & hydrochlorothiazide tab 100-25 mg
(Lopressor hct)...............................................................46
metoprolol & hydrochlorothiazide tab 100-50 mg........ 46
metoprolol & hydrochlorothiazide tab 50-25 mg
(Lopressor hct)...............................................................46
213
2014
metoprolol succinate tab sr 24hr 100 mg (Toprol
xl)..................................................................................... 37
metoprolol succinate tab sr 24hr 200 mg (Toprol
xl)..................................................................................... 37
metoprolol succinate tab sr 24hr 25 mg (Toprol xl)......37
metoprolol succinate tab sr 24hr 50 mg (Toprol xl)......37
metoprolol tartrate tab 100 mg (Lopressor).................. 37
metoprolol tartrate tab 25 mg.........................................37
metoprolol tartrate tab 50 mg (Lopressor).................... 37
METOZOLV ODT -metoclopramide hcl orally disintegrating
tab 10 mg.........................................................................71
METOZOLV ODT -metoclopramide hcl orally disintegrating
tab 5 mg...........................................................................71
METROCREAM -metronidazole cream 0.75%................ 151
METROGEL -metronidazole gel 1%................................151
METROGEL-VAGINAL -metronidazole vaginal gel
0.75%............................................................................... 74
METROLOTION -metronidazole lotion 0.75%................. 151
metronidazole cap 375 mg (Flagyl)................................12
metronidazole cream 0.75% (Metrocream).................. 151
metronidazole gel 0.75%...............................................151
metronidazole gel 1% (Metrogel)................................. 151
metronidazole lotion 0.75% (Metrolotion)....................151
metronidazole tab 250 mg (Flagyl).................................12
metronidazole tab 500 mg (Flagyl).................................12
metronidazole vaginal gel 0.75% (Metrogelvaginal)............................................................................74
METVIXIA -methyl aminolevulinate hcl cream 16.8% (base
equiv)..............................................................................151
MEVACOR -lovastatin tab 20 mg......................................52
MEVACOR -lovastatin tab 40 mg......................................52
mexiletine hcl cap 150 mg..............................................41
MIACALCIN -calcitonin (salmon) nasal soln 200 unit/
act.....................................................................................33
MICARDIS HCT -telmisartan-hydrochlorothiazide tab
40-12.5 mg.......................................................................46
80-12.5 mg.......................................................................46
80-25 mg..........................................................................46
MICARDIS -telmisartan tab 20 mg.................................... 46
MICONAZOLE 3 -miconazole nitrate vaginal suppos 200
mg.................................................................................... 74
miconazole nitrate vaginal supp 200 mg & 2% cream 9
gm kit.............................................................................. 74
MICRO-K -potassium chloride cap cr 10 meq................. 126
MICRO-K -potassium chloride cap cr 8 meq................... 125
MICROZIDE -hydrochlorothiazide cap 12.5 mg................ 50
MIDAMOR -amiloride hcl tab 5 mg................................... 50
midazolam hcl syrup 2 mg/ml (base equivalent).......... 85
midodrine hcl tab 10 mg.................................................50
214
midodrine hcl tab 2.5 mg................................................50
midodrine hcl tab 5 mg...................................................50
MIGERGOT -ergotamine w/ caffeine suppos 2-100
mg.................................................................................. 106
MIGRALAM -acetaminophen-isometheptene-caffeine cap
325-65-100 mg...............................................................106
MIGRAL -isometheptene mucate tab 130 mg................. 106
MIGRANAL -dihydroergotamine mesylate nasal spray 4
mg/ml..............................................................................106
MILLIPRED DP -prednisolone tab 5 mg dose pack...........17
MILLIPRED -prednisolone sod phosphate oral soln 10
mg/5ml (base equiv)........................................................ 17
MILLIPRED -prednisolone tab 5 mg..................................16
MIMYX - emollient - cream ............................................ 151
MINASTRIN 24 FE -norethindrone ace-eth estradiol-fe
chew tab 1 mg-20 mcg (24)............................................ 21
MINERAL OIL HEAVY -mineral oil....................................65
MINIPRESS -prazosin hcl cap 1 mg................................. 46
MINIVELLE -estradiol td patch biweekly 0.0375
mg/24hr............................................................................ 20
MINIVELLE -estradiol td patch biweekly 0.05 mg/24hr......20
MINIVELLE -estradiol td patch biweekly 0.075
mg/24hr............................................................................ 20
MINIVELLE -estradiol td patch biweekly 0.1 mg/24hr........20
MINOCIN KIT - minocycline hcl cap 100 mg w/ acne care
products kit ....................................................................... 4
MINOCIN KIT - minocycline hcl cap 50 mg w/ acne care
products kit ....................................................................... 4
MINOCIN -minocycline hcl cap 100 mg.............................. 4
MINOCIN -minocycline hcl cap 50 mg................................ 4
MINOCIN -minocycline hcl cap 75 mg................................ 4
minocycline hcl cap 100 mg (Minocin)............................ 4
minocycline hcl cap 50 mg (Minocin)..............................4
minocycline hcl cap 75 mg (Minocin)..............................4
minocycline hcl tab 100 mg............................................. 4
minocycline hcl tab 50 mg............................................... 4
minocycline hcl tab 75 mg............................................... 4
minocycline hcl tab sr 24hr 135 mg................................ 4
minocycline hcl tab sr 24hr 45 mg.................................. 4
minocycline hcl tab sr 24hr 90 mg.................................. 4
minoxidil tab 10 mg.........................................................46
minoxidil tab 2.5 mg........................................................46
MI PASTE - dentifrices - paste .......................................161
MI PASTE PLUS - dentifrices - paste ............................ 161
MIRAPEX ER -pramipexole dihydrochloride tab sr 24hr
0.375 mg........................................................................ 113
0.75 mg.......................................................................... 113
MIRAPEX ER -pramipexole dihydrochloride tab sr 24hr 1.5
mg.................................................................................. 113
2.25 mg.......................................................................... 113
2014
3.75 mg.......................................................................... 113
MIRAPEX ER -pramipexole dihydrochloride tab sr 24hr 3
mg.................................................................................. 113
MIRAPEX ER -pramipexole dihydrochloride tab sr 24hr 4.5
mg.................................................................................. 113
MIRAPEX -pramipexole dihydrochloride tab 0.125
mg.................................................................................. 112
MIRAPEX -pramipexole dihydrochloride tab 0.25 mg......113
MIRAPEX -pramipexole dihydrochloride tab 0.5 mg........113
MIRAPEX -pramipexole dihydrochloride tab 0.75 mg......113
MIRAPEX -pramipexole dihydrochloride tab 1.5 mg........113
MIRAPEX -pramipexole dihydrochloride tab 1 mg...........113
MIRCETTE -desogest-eth estrad & eth estrad tab
0.15-0.02/0.01 mg(21/5)...................................................21
mirtazapine orally disintegrating tab 15 mg (Remeron
soltab)..............................................................................79
soltab)..............................................................................79
soltab)..............................................................................79
mirtazapine tab 15 mg (Remeron)..................................79
mirtazapine tab 7.5 mg....................................................79
MIRVASO -brimonidine tartrate gel 0.33% (base
equivalent)......................................................................151
misoprostol tab 100 mcg (Cytotec)................................67
misoprostol tab 200 mcg (Cytotec)................................67
MITOSOL -mitomycin for ophth soln kit 0.2 mg...............135
MOBIC -meloxicam susp 7.5 mg/5ml.............................. 104
MOBIC -meloxicam tab 15 mg........................................ 104
MOBIC -meloxicam tab 7.5 mg....................................... 104
modafinil tab 100 mg (Provigil)...................................... 89
modafinil tab 200 mg (Provigil)...................................... 89
MODERIBA -ribavirin tab 200 mg & ribavirin tab 400 mg
dose pack...........................................................................8
MODERIBA -ribavirin tab 400 mg....................................... 8
MODERIBA -ribavirin tab 400 mg & ribavirin tab 600 mg
dose pack...........................................................................8
MODERIBA -ribavirin tab 600 mg....................................... 8
MODICON -norethindrone & ethinyl estradiol tab 0.5
mg-35 mcg....................................................................... 22
moexipril hcl tab 15 mg (Univasc)................................. 46
moexipril hcl tab 7.5 mg (Univasc)................................ 46
moexipril-hydrochlorothiazide tab 15-12.5 mg
(Uniretic)..........................................................................46
moexipril-hydrochlorothiazide tab 15-25 mg................ 46
moexipril-hydrochlorothiazide tab 7.5-12.5 mg............ 46
mometasone furoate cream 0.1% (Elocon)................. 151
mometasone furoate oint 0.1% (Elocon)..................... 151
mometasone furoate solution 0.1% (lotion)
(Elocon)......................................................................... 151
MOMEXIN -mometasone furoate cream 0.1% & ammon
lactate foam 12% kit...................................................... 151
MONOCAL -sodium monofluorophosphate-calcium carb
tab 22.75-625 mg...........................................................126
MONODOX -doxycycline monohydrate cap 100 mg........... 4
MONODOX -doxycycline monohydrate cap 50 mg............. 4
MONODOX -doxycycline monohydrate cap 75 mg............. 4
MONOKET -isosorbide mononitrate tab 10 mg................. 35
MONOKET -isosorbide mononitrate tab 20 mg................. 35
MONSELS FERRIC SUBSULFATE - ferric subsulfate soln
....................................................................................... 132
montelukast sodium chew tab 4 mg (base equiv)
(Singulair)........................................................................63
montelukast sodium chew tab 5 mg (base equiv)
(Singulair)........................................................................63
montelukast sodium oral granules packet 4 mg (base
equiv) (Singulair)............................................................63
montelukast sodium tab 10 mg (base equiv)
(Singulair)........................................................................63
MONUROL -fosfomycin tromethamine powd pack 3 gm
(base equivalent)............................................................. 72
MORGIDOX 1X100MG - doxycycline hyclate cap 1 x 100
mg w/ cleanser kit ............................................................ 4
MORGIDOX 2X100MG - doxycycline hyclate cap 2 x 100
mg w/ cleanser kit ............................................................ 4
morphine sulfate (concentrate) oral soln 20 mg/ml......98
morphine sulfate beads cap sr 24hr 120 mg
(Avinza)........................................................................... 98
(Avinza)........................................................................... 98
(Avinza)........................................................................... 98
(Avinza)........................................................................... 98
(Avinza)........................................................................... 98
(Avinza)........................................................................... 98
morphine sulfate cap sr 24hr 100 mg (Kadian).............98
morphine sulfate cap sr 24hr 10 mg (Kadian)...............98
MORPHINE SULFATE -morphine sulfate suppos 10
mg.................................................................................... 98
mg.................................................................................... 98
mg.................................................................................... 98
mg.................................................................................... 98
MORPHINE SULFATE -morphine sulfate tab 15 mg.........98
MORPHINE SULFATE -morphine sulfate tab 30 mg.........98
morphine sulfate oral soln 10 mg/5ml........................... 99
morphine sulfate oral soln 20 mg/5ml........................... 99
215
2014
morphine sulfate tab cr 100 mg (Ms contin)................. 99
morphine sulfate tab cr 15 mg (Ms contin)................... 99
morphine sulfate tab cr 200 mg (Ms contin)................. 99
MOTOFEN -difenoxin w/ atropine tab 1-0.025 mg............ 65
mouthwashes - liquid ...................................................138
MOVIPREP -peg 3350-kcl-nacl-na sulfate-na acorbate-c
for soln 100 gm................................................................65
MOXATAG -amoxicillin (trihydrate) tab sr 24hr 775 mg.......1
MOXEZA -moxifloxacin hcl ophth soln 0.5% (base eq) (2
times daily).....................................................................135
moxifloxacin hcl tab 400 mg (base equiv) (Avelox)........6
MOZOBIL -plerixafor subcutaneous inj 24 mg/1.2ml (20
mg/ml)............................................................................ 129
MS CONTIN -morphine sulfate tab cr 100 mg...................99
MS CONTIN -morphine sulfate tab cr 15 mg.....................99
MS CONTIN -morphine sulfate tab cr 200 mg...................99
MST 600 -magnesium salicylate tab 600 mg.................... 94
MUCOTROL - oral wound care products - wafer ............139
MULTAQ -dronedarone hcl tab 400 mg (base
equivalent)........................................................................41
MULTIGEN - fe asparto gly-succ acd-c-threonic acd-b12des stom tab .................................................................129
MULTIGEN FOLIC - fe asparto gly-succinic acd-vit cthreonic acd-b12-fa tab .................................................129
MULTIGEN PLUS - fe aspart gly-fe fum-succ acd-cthreonic acd-b12-fa tab .................................................129
multiple vitamins w/ minerals cap .............................. 116
MULTIUSE BASE - cream base .................................... 162
mupirocin calcium cream 2% (Bactroban).................. 151
mupirocin oint 2% (Bactroban).................................... 151
MUSE -alprostadil urethral pellet 1000 mcg...................... 55
MUSE -alprostadil urethral pellet 125 mcg........................ 55
MYALEPT -metreleptin for subcutaneous inj 11.3 mg....... 33
MYAMBUTOL -ethambutol hcl tab 100 mg......................... 6
MYAMBUTOL -ethambutol hcl tab 400 mg......................... 6
MYCOBUTIN -rifabutin cap 150 mg.................................... 6
mycophenolate mofetil cap 250 mg (Cellcept)............165
mycophenolate mofetil tab 500 mg (Cellcept).............165
mycophenolate sodium tab dr 180 mg (mycophenolic
acid equiv) (Myfortic)...................................................165
mycophenolate sodium tab dr 360 mg (mycophenolic
acid equiv) (Myfortic)...................................................165
MYDFRIN -phenylephrine hcl ophth soln 2.5%............... 135
MYDRIACYL -tropicamide ophth soln 1%....................... 135
MYFORTIC -mycophenolate sodium tab dr 180 mg
(mycophenolic acid equiv)............................................. 165
MYFORTIC -mycophenolate sodium tab dr 360 mg
(mycophenolic acid equiv)............................................. 165
MYKIDZ IRON 10 -iron susp 15 mg/1.5ml...................... 129
216
MYKIDZ IRON FL -pediatric vitamins acd fluoride & fe
susp 0.25-10 mg/2ml..................................................... 119
MYLERAN -busulfan tab 2 mg.......................................... 14
MYNATAL ADVANCE - prenatal vit w/ dss-iron carbonyl-fa
tab 90-1 mg .................................................................. 119
MYNATAL PLUS - prenatal vit w/ fe fumarate-fa tab 65-1
mg ................................................................................. 119
MYNATAL -prenatal multivitamins & minerals w/ iron & fa
cap 1 mg........................................................................119
MYNATAL ULTRACAPLET - prenatal vit w/ dss-iron
carbonyl-fa tab 90-1 mg ............................................... 119
MYNATAL-Z - prenatal vit w/ fe fumarate-fa tab 65-1 mg
....................................................................................... 119
MYNATE 90 PLUS - prenatal vit w/ dss-fe fumarate-fa tab
cr 90-1 mg .................................................................... 119
MYOXIN -benzocaine-chloroxylenol-hc otic soln 15-1-10
mg/ml..............................................................................138
MYRBETRIQ -mirabegron tab sr 24 hr 25 mg...................73
MYRBETRIQ -mirabegron tab sr 24 hr 50 mg...................73
MYSOLINE -primidone tab 250 mg................................. 110
MYSOLINE -primidone tab 50 mg...................................110
MYTELASE -ambenonium chloride tab 10 mg................ 115
N
nabumetone tab 500 mg............................................... 104
nabumetone tab 750 mg............................................... 104
nadolol & bendroflumethiazide tab 40-5 mg
(Corzide)..........................................................................46
nadolol & bendroflumethiazide tab 80-5 mg
(Corzide)..........................................................................46
nadolol tab 20 mg (Corgard).......................................... 37
NAFRINSE DAILY/ACIDULATED -sodium fluoridephosphoric acid for soln 1 mg/5ml (f equiv)................... 139
NAFRINSE DAILY/NEUTRAL -sodium fluoride for soln
rinse 0.05%.................................................................... 139
NAFRINSE WEEKLY -sodium fluoride for soln rinse
0.2%............................................................................... 139
NAFTIN -naftifine hcl cream 1%......................................151
NAFTIN -naftifine hcl cream 2%......................................151
NAFTIN -naftifine hcl gel 1%...........................................151
NAFTIN -naftifine hcl gel 2%...........................................151
NALFON -fenoprofen calcium cap 200 mg......................104
NALFON -fenoprofen calcium cap 400 mg......................104
naltrexone hcl tab 50 mg (Revia)................................. 160
NAMENDA -memantine hcl oral solution 2 mg/ml............. 91
NAMENDA -memantine hcl tab 10 mg..............................91
NAMENDA -memantine hcl tab 5 mg................................91
NAMENDA TITRATION PAK -memantine hcl tab 5 mg
(28) & 10 mg (21) titration pak........................................ 91
NAMENDA XR -memantine hcl cap sr 24hr 14 mg........... 91
NAMENDA XR -memantine hcl cap sr 24hr 7 mg............. 91
2014
NAMENDA XR TITRATION PACK -memantine hcl cap sr
24hr 7 mg & 14 mg & 21 mg & 28 mg pack.................... 91
NAPHAZOLINE HCL -naphazoline hcl ophth soln
0.1%............................................................................... 135
NAPRELAN -naproxen sodium tab sr 24hr 375 mg (base
equiv)..............................................................................104
NAPRELAN -naproxen sodium tab sr 24hr 500 mg (14) &
750 mg (6) pack............................................................ 104
equiv)..............................................................................104
equiv)..............................................................................104
NAPRO 15% COMPOUNDING KIT -naproxen cream
15%................................................................................ 151
NAPRODERM COMPOUNDING KIT -naproxen cream
15%................................................................................ 151
NAPROSYN -naproxen susp 125 mg/5ml....................... 104
NAPROSYN -naproxen tab 250 mg................................ 104
NAPROXEN COMFORT PAC -naproxen tab 500 mg &
naproxen sodium tab 275 mg (Anaprox)..................... 104
naproxen sodium tab 550 mg (Anaprox ds)................104
naproxen susp 125 mg/5ml (Naprosyn).......................104
naproxen tab 250 mg (Naprosyn).................................104
naproxen tab ec 375 mg (Ec-naprosyn)...................... 104
naproxen tab ec 500 mg (Ec-naprosyn)...................... 104
naratriptan hcl tab 1 mg (base equiv) (Amerge)......... 106
naratriptan hcl tab 2.5 mg (base equiv) (Amerge)...... 106
NARDIL -phenelzine sulfate tab 15 mg............................. 79
NASACORT AQ -triamcinolone acetonide nasal inhal 55
mcg/act.............................................................................56
NASCOBAL -cyanocobalamin nasal spray 500
mcg/0.1ml.......................................................................129
NASONEX -mometasone furoate nasal susp 50 mcg/
act.....................................................................................56
NATACHEW - prenatal vit w/ fe fum-fe bisglycin-fa chew
tab 28-1 mg .................................................................. 119
NATACYN -natamycin ophth susp 5%............................ 135
NATAFORT - prenatal w/o a vit w/ fe cbn-fe fum-fa tab
60-1 mg ........................................................................ 119
NATA KOMPLETE - prenatal vit w/ fe fum-fe bisglycinatefa tab 25-1 mg ..............................................................119
NATALVIRT 90 DHA -prenat w/o a w/fecbn-fegl-dss-fa tab
90 &dha cap 300mg pak............................................... 119
NATALVIRT CA -prenat w/o a w/fecbn-fegl-dss-fa tab &
dha cap 300 mg pack.................................................... 119
NATALVIRT FLT - fe carbonyl-fe gluconate-fa-vit b12-vit cdss tab 90-1 mg ........................................................... 129
NATALVIT - prenatal vit w/ fe fumarate-fa tab 75-1 mg
....................................................................................... 119
NATAZIA -estradiol valerate-dienogest tab 3 mg /2-2
mg/2-3 mg/1 mg...............................................................22
nateglinide tab 120 mg (Starlix)..................................... 26
nateglinide tab 60 mg (Starlix)....................................... 26
NATELLE-EZ - prenatal vit w/ fe fumarate-fa tab 25-0.8 mg
....................................................................................... 119
NATELLE ONE - prenatal w/o vit a w/ fe fum-fa-omega 3
cap 28-1-250 mg .......................................................... 119
NATROBA -spinosad susp 0.9%.....................................151
NATURE-THROID NT-2.5 -thyroid tab 162.5 mg (2 1/2
grain)................................................................................ 29
NATURE-THROID -thyroid tab 113.75 mg........................ 29
NATURE-THROID -thyroid tab 130 mg.............................29
NATURE-THROID -thyroid tab 146.25 mg........................ 29
NATURE-THROID -thyroid tab 16.25 mg.......................... 29
NATURE-THROID -thyroid tab 32.5 mg............................29
NATURE-THROID -thyroid tab 325 mg (5 grain)...............29
NATURE-THROID -thyroid tab 48.75 mg (3/4 grain).........29
NATURE-THROID -thyroid tab 65 mg...............................29
NATURE-THROID -thyroid tab 81.25 mg.......................... 29
NATURE-THROID -thyroid tab 97.5 mg............................29
NAVANE -thiothixene cap 20 mg...................................... 83
NEBUPENT -pentamidine isethionate for nebulization soln
300 mg............................................................................. 12
NEBUSAL -sodium chloride soln nebu 6%........................59
NECON 1/50-28 -norethindrone & mestranol tab 1 mg-50
mcg...................................................................................22
NECON 10/11-28 -norethindrone-eth estradiol tab
0.5-35/1-35 mg-mcg (10/11)............................................ 22
NEFAZODONE HCL -nefazodone hcl tab 100 mg............ 79
NEFAZODONE HCL -nefazodone hcl tab 50 mg.............. 79
nefazodone hcl tab 250 mg............................................ 79
NEOBENZ MICRO -benzoyl peroxide cream 3.5%......... 151
NEOBENZ MICRO PLUS PACK -benzoyl peroxide cream
5.5%............................................................................... 151
NEOBENZ MICRO SD -benzoyl peroxide cream
3.5%............................................................................... 151
5.5%............................................................................... 151
8.5%............................................................................... 151
NEOBENZ MICRO WASH -benzoyl peroxide liq 7%.......151
NEOBENZ MICRO WASH PLUS P -benzoyl peroxide
wash 7% & benzoyl peroxide cream 5.5% kit................ 151
NEO-FRADIN -neomycin sulfate soln 25 mg/ml..................6
NEOMYCIN/POLYMYXIN/HYDROC -neomycinpolymyxin-hc ophth susp............................................... 135
neomycin-bacitrac zn-polymyx
5(3.5)mg-400unt-10000unt op oin............................... 135
217
2014
neomycin-polymyxin b-gramicidin ophth soln
(Neosporin)................................................................... 135
neomycin-polymyxin b gu irrigation soln (Neosporin
gu irrigan)....................................................................... 74
neomycin-polymyxin-dexamethasone ophth oint 0.1%
(Maxitrol)....................................................................... 135
neomycin-polymyxin-dexamethasone ophth susp 0.1%
(Maxitrol)....................................................................... 135
neomycin-polymyxin-hc otic soln 1%
(Cortisporin)..................................................................138
neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000
unit/ml-1%..................................................................... 138
neomycin sulfate tab 500 mg........................................... 6
NEORAL -cyclosporine modified cap 100 mg................. 165
NEORAL -cyclosporine modified cap 25 mg................... 165
NEORAL -cyclosporine modified oral soln 100 mg/ml..... 165
NEOSALUS 180 PACK - emollient - cream ................... 151
NEOSALUS CP - emollient - cream ...............................151
NEOSALUS - emollient - aerosol foam .......................... 151
NEOSALUS - emollient - cream .....................................151
NEOSALUS - emollient - lotion ...................................... 151
NEOSPORIN GU IRRIGANT -neomycin-polymyxin b gu
irrigation soln....................................................................74
NEOSPORIN -neomycin-polymyxin b-gramicidin ophth
soln.................................................................................135
NEOTIC -antipyrine-benzocaine-glycerin-zinc ace otic liqd
5.4-1-2-1%......................................................................138
NEOTUSS-D -pseudoephed-chlorphen w/ dm-gg liqd
30-2-30-200 mg/5ml.........................................................59
NEOTUSS PLUS -phenylephrine-chlorphen-dm liquid
7.5-4-30 mg/5ml...............................................................59
NEPHPLEX RX -b-complex w/ c-zn & folic acid tab 1
mg.................................................................................. 119
NEPHROCAPS -b-complex w/ c & folic acid cap 1
mg.................................................................................. 119
NEPHROCAPS QT -b-complex w/ c-biotin-d & folic acid
tab disp 1 mg.................................................................119
NEPHRON FA - ferrous fumarate w/ fa-dss-b complex-vit c
tab ................................................................................. 129
NEPHRO-VITE RX -b-complex w/ c & folic acid tab 1
mg.................................................................................. 119
NEPTAZANE -methazolamide tab 25 mg......................... 50
NEPTAZANE -methazolamide tab 50 mg......................... 50
NESINA -alogliptin benzoate tab 12.5 mg (base equiv).....26
NESINA -alogliptin benzoate tab 25 mg (base equiv)........26
NESINA -alogliptin benzoate tab 6.25 mg (base equiv).....26
NESTABS DHA -prenat w/o a w/ fe bisglyc-fa tab 32-1 mg
& omega cap pack.........................................................119
NESTABS - prenatal vit w/o vit a w/ fe bisglycinate-fa tab
32-1 mg ........................................................................ 119
NEULASTA -pegfilgrastim inj 6 mg/0.6ml........................129
NEUMEGA -oprelvekin for inj 5 mg.................................129
NEUPOGEN -filgrastim inj 300 mcg/0.5ml (600 mcg/
ml).................................................................................. 129
NEUPOGEN -filgrastim inj 300 mcg/ml........................... 129
218
ml).................................................................................. 129
ml).................................................................................. 129
NEUPRO -rotigotine td patch 24hr 1 mg/24hr................. 113
NEURIN-SL -cyanocobalamin-methylcobalamin tab sl
600-600 mcg.................................................................. 129
NEURONTIN -gabapentin cap 100 mg........................... 110
NEURONTIN -gabapentin oral soln 250 mg/5ml............. 110
NEURONTIN -gabapentin tab 600 mg............................ 110
NEURONTIN -gabapentin tab 800 mg............................ 110
NEUTRASAL - artificial saliva - packet .......................... 139
NEVANAC -nepafenac ophth susp 0.1%........................ 135
NEVIRAPINE -nevirapine susp 50 mg/5ml..........................8
nevirapine tab 200 mg (Viramune)...................................9
nevirapine tab sr 24hr 400 mg (Viramune xr)..................9
NEXA PLUS - prenatal w/o vit a w/ fe fum-doc-fa-dha cap
29-1.25-350 mg ............................................................ 119
NEXA SELECT - prenat w/o vit a w/ fe fum-dss-fa-dha cap
29-1.25-337.5 mg ......................................................... 119
NEXAVAR -sorafenib tosylate tab 200 mg (base
equivalent)........................................................................14
NEXICLON XR -clonidine hcl extended release susp 0.09
mg/ml (base equiv).......................................................... 46
NEXICLON XR -clonidine hcl tab sr 24hr 0.17 mg (base
equivalent)........................................................................46
NEXIUM -esomeprazole magnesium cap delayed release
20 mg............................................................................... 67
NEXIUM -esomeprazole magnesium cap delayed release
40 mg............................................................................... 67
NEXIUM -esomeprazole magnesium for delayed release
susp pack 2.5 mg............................................................ 67
susp packet 10 mg.......................................................... 67
susp packet 20 mg.......................................................... 67
susp packet 40 mg.......................................................... 67
susp packet 5 mg............................................................ 67
niacinamide w/ zinc-copper &folic acid tab
750-25-1.5-0.5 mg......................................................... 119
niacin tab cr 1000 mg (antihyperlipidemic)
(Niaspan)......................................................................... 52
(Niaspan)......................................................................... 52
(Niaspan)......................................................................... 52
2014
NIACOR -niacin (antihyperlipidemic) tab 500 mg.............. 52
NIASPAN -niacin tab cr 1000 mg (antihyperlipidemic)...... 52
NIASPAN -niacin tab cr 500 mg (antihyperlipidemic)........ 52
NIASPAN -niacin tab cr 750 mg (antihyperlipidemic)........ 52
NICADAN - multiple vitamins w/ minerals tab ................ 119
nicardipine hcl cap 20 mg.............................................. 39
nicardipine hcl cap 30 mg.............................................. 39
NICAZELDOXY 30 KIT -doxycycline monohyd tab 100 mg
&multivit/minerals tab kit.................................................... 4
NICAZELDOXY 60 KIT -doxycycline monohyd tab 100 mg
&multivit/minerals tab kit.................................................... 5
NICAZEL - multiple vitamins w/ minerals tab ................. 119
NICOMIDE - niacinamide w/ zn-cu-methylfolate tab
750-25-1.5-0.5 mg ........................................................ 119
NICOTROL INHALER -nicotine inhaler system 10 mg (4
mg delivered)................................................................... 91
NICOTROL NS -nicotine nasal spray 10 mg/ml (0.5 mg/
spray)............................................................................... 91
nifedipine cap 10 mg (Procardia)...................................39
nifedipine cap 20 mg.......................................................39
nifedipine tab sr 24hr 30 mg (Adalat cc)....................... 39
nifedipine tab sr 24hr osmotic 30 mg (Procardia xl).....39
NILANDRON -nilutamide tab 150 mg................................14
nimodipine cap 30 mg.....................................................39
NIMOTOP -nimodipine cap 30 mg.................................... 39
NIRAVAM -alprazolam orally disintegrating tab 0.25
mg.................................................................................... 76
NIRAVAM -alprazolam orally disintegrating tab 0.5 mg..... 76
NIRAVAM -alprazolam orally disintegrating tab 1 mg........76
NIRAVAM -alprazolam orally disintegrating tab 2 mg........76
NIRON KOMPLETE - fe bisglycinate-fe fum-vit c-vit b12-vit
e-fa tab 30-1 mg ...........................................................129
NISOLDIPINE ER -nisoldipine tab sr 24hr 25.5 mg...........40
NISOLDIPINE -nisoldipine tab sr 24hr 20 mg................... 39
nisoldipine tab sr 24hr 17 mg (Sular)............................ 40
nisoldipine tab sr 24hr 25.5 mg..................................... 40
nisoldipine tab sr 24hr 34 mg (Sular)............................ 40
nisoldipine tab sr 24hr 8.5 mg (Sular)........................... 40
NITRO-BID -nitroglycerin oint 2%......................................35
NITRO-DUR -nitroglycerin td patch 24hr 0.1 mg/hr........... 35
nitrofurantoin macrocrystalline cap 100 mg
(Macrodantin)..................................................................72
nitrofurantoin macrocrystalline cap 50 mg
(Macrodantin)..................................................................72
nitrofurantoin monohydrate macrocrystalline cap 100
mg (Macrobid)................................................................ 72
nitrofurantoin susp 25 mg/5ml (Furadantin)................. 72
nitroglycerin cap cr 2.5 mg............................................ 35
nitroglycerin cap cr 6.5 mg............................................ 35
nitroglycerin cap cr 9 mg............................................... 35
NITROGLYCERIN LINGUAL -nitroglycerin lingual aerosol
400 mcg/spray................................................................. 35
nitroglycerin td patch 24hr 0.1 mg/hr (Nitro-dur)..........35
nitroglycerin tl soln 0.4 mg/spray (400 mcg/spray)
(Nitrolingual pumpspr).................................................. 36
NITROLINGUAL PUMPSPRAY -nitroglycerin tl soln 0.4
mg/spray (400 mcg/spray)............................................... 36
NITROMIST -nitroglycerin lingual aerosol 400 mcg/
spray.................................................................................36
NITROSTAT -nitroglycerin sl tab 0.3 mg........................... 36
NIVATOPIC PLUS - dermatological products misc - cream
....................................................................................... 151
nizatidine cap 150 mg..................................................... 67
nizatidine cap 300 mg (Axid).......................................... 67
nizatidine oral soln 15 mg/ml (Axid).............................. 67
NIZORAL -ketoconazole shampoo 2%............................151
NORCO -hydrocodone-acetaminophen tab 10-325 mg.....99
NORCO -hydrocodone-acetaminophen tab 5-325 mg.......99
NORCO -hydrocodone-acetaminophen tab 7.5-325
mg.................................................................................... 99
NORDETTE-28 -levonorgestrel & ethinyl estradiol tab 0.15
mg-30 mcg....................................................................... 22
NORDITROPIN CARTRIDGE -somatropin inj 5
mg/1.5ml...........................................................................33
NORDITROPIN FLEXPRO -somatropin inj 10
mg/1.5ml...........................................................................33
NORDITROPIN FLEXPRO -somatropin inj 15
mg/1.5ml...........................................................................33
NORDITROPIN FLEXPRO -somatropin inj 5 mg/1.5ml.....33
NORDITROPIN NORDIFLEX PEN -somatropin inj 10
mg/1.5ml...........................................................................33
mg/1.5ml...........................................................................33
mg/3ml..............................................................................33
mg/1.5ml...........................................................................33
norelgestromin-ethinyl estradiol td ptwk 150-35
mcg/24hr (Ortho evra)................................................... 22
norethindrone & ethinyl estradiol-fe chew tab 0.4
mg-35 mcg (Femcon fe)................................................ 22
norethindrone & ethinyl estradiol tab 0.4 mg-35 mcg
(Ovcon-35).......................................................................22
219
2014
norethindrone & ethinyl estradiol tab 0.5 mg-35 mcg
(Brevicon-28).................................................................. 22
norethindrone & ethinyl estradiol tab 1 mg-35 mcg
(Norinyl 1+35)................................................................. 22
norethindrone ace & ethinyl estradiol-fe tab 1.5 mg-30
mcg (Loestrin fe 1.5/30)................................................ 22
norethindrone ace & ethinyl estradiol-fe tab 1 mg-20
mcg (Loestrin fe 1/20)................................................... 22
norethindrone ace & ethinyl estradiol tab 1.5 mg-30
mcg (Loestrin 1.5/30-21)................................................22
norethindrone ace & ethinyl estradiol tab 1 mg-20 mcg
(Loestrin 1/20-21)........................................................... 22
norethindrone acetate-ethinyl estradiol tab 1 mg-5
mcg.................................................................................. 22
norethindrone acetate tab 5 mg (Aygestin)...................23
norethindrone ac-ethinyl estrad-fe tab 1-20/1-30/1-35
mg-mcg (Estrostep fe)...................................................22
norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35 mgmcg (Ortho-novum 7/7/7).............................................. 22
norethindrone-eth estradiol tab 0.5-35/1-35/0.5-35 mgmcg (Tri-norinyl 28)....................................................... 22
norethindrone tab 0.35 mg (Nor-qd).............................. 22
norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg
(Ortho-cyclen).................................................................22
norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35
mg-mcg (Ortho tri-cyclen).............................................22
norgestrel & ethinyl estradiol tab 0.3 mg-30 mcg.........22
NORINYL 1+35 -norethindrone & ethinyl estradiol tab 1
mg-35 mcg....................................................................... 22
NORINYL 1+50 -norethindrone & mestranol tab 1 mg-50
mcg...................................................................................22
NORITATE -metronidazole cream 1%.............................151
NOROXIN -norfloxacin tab 400 mg..................................... 6
NORPACE CR -disopyramide phosphate cap sr 12hr 100
mg.................................................................................... 41
NORPACE CR -disopyramide phosphate cap sr 12hr 150
mg.................................................................................... 41
NORPACE -disopyramide phosphate cap 100 mg............ 41
NORPACE -disopyramide phosphate cap 150 mg............ 41
NORPRAMIN -desipramine hcl tab 100 mg...................... 79
NORPRAMIN -desipramine hcl tab 10 mg........................ 79
NORPRAMIN -desipramine hcl tab 150 mg...................... 79
NOR-QD -norethindrone tab 0.35 mg................................22
nortriptyline hcl cap 10 mg (Pamelor)........................... 79
NORTRIPTYLINE HCL -nortriptyline hcl soln 10
mg/5ml..............................................................................79
nortriptyline hcl soln 10 mg/5ml.................................... 79
NORTUSS-EX -dextromethorphan-guaifenesin liquid
20-200 mg/5ml................................................................. 59
220
NORVASC -amlodipine besylate tab 10 mg......................40
NORVASC -amlodipine besylate tab 2.5 mg..................... 40
NORVASC -amlodipine besylate tab 5 mg........................40
NORVIR -ritonavir cap 100 mg........................................... 9
NORVIR -ritonavir oral soln 80 mg/ml................................. 9
NORVIR -ritonavir tab 100 mg............................................ 9
NOURIVAN ANTIOX CREAM BAS - cream base .......... 162
NOVACORT - hydrocortisone ace-pramoxine-aloe
polysacch gel 2-1-1% ................................................... 151
NOVAFERRUM -polysacch iron complex-vit c-fa for soln
100-60-1 mg/5ml............................................................129
NOVOLIN 70/30 -insulin isophane & regular (human) inj
100 unit/ml (70-30)...........................................................28
NOVOLIN 70/30 RELION -insulin isophane & regular
(human) inj 100 unit/ml (70-30)....................................... 28
NOVOLIN N -insulin isophane (human) inj 100 unit/ml......28
NOVOLIN N RELION -insulin isophane (human) inj 100
unit/ml...............................................................................28
NOVOLIN R -insulin regular (human) inj 100 unit/ml......... 27
NOVOLIN R RELION -insulin regular (human) inj 100 unit/
ml......................................................................................27
NOVOLOG FLEXPEN -insulin aspart soln pen-injector 100
unit/ml...............................................................................27
NOVOLOG -insulin aspart inj 100 unit/ml..........................27
NOVOLOG MIX 70/30 -insulin aspart prot & aspart
(human) inj 100 unit/ml (70-30)....................................... 28
NOVOLOG MIX 70/30 PREFILL -insulin aspart prot &
aspart sus pen-inj 100 unit/ml (70-30)............................. 28
NOVOLOG PENFILL -insulin aspart inj 100 unit/ml...........27
NOVOLOG PENFILL -insulin aspart soln cartridge 100
unit/ml...............................................................................27
NOXAFIL -posaconazole susp 40 mg/ml............................ 7
NOXAFIL -posaconazole tab delayed release 100 mg........7
NUCORT -hydrocortisone acetate lotion 2%................... 151
NUCYNTA ER -tapentadol hcl tab sr 12hr 100 mg............99
NUCYNTA ER -tapentadol hcl tab sr 12hr 50 mg..............99
NUCYNTA -tapentadol hcl tab 100 mg............................. 99
NUCYNTA -tapentadol hcl tab 50 mg............................... 99
NUCYNTA -tapentadol hcl tab 75 mg............................... 99
NUEDEXTA -dextromethorphan hbr-quinidine sulfate cap
20-10 mg..........................................................................91
NULYTELY/FLAVOR PACKS -peg 3350-kcl-sod bicarbnacl for soln 420 gm........................................................65
NUMOISYN - artificial saliva - lozenge ...........................139
NUMOISYN - artificial saliva - solution ...........................139
NUOX -benzoyl peroxide-sulfur gel 6-3%........................151
NUTRESTORE -glutamine powd pack 5 gm................... 126
NUTRICAP - multiple vitamins w/ minerals tab .............. 119
NUTRIDOX - doxycycline monohyd cap 75 mg w/ omega
3-vit e cap kit ....................................................................5
NUTRIVIT -b-complex w/ lysine-min-fe & fa liqd 800-15-1
mg/15ml..........................................................................119
2014
NUTROPIN AQ NUSPIN 10 -somatropin inj 10
mg/2ml..............................................................................33
NUTROPIN AQ NUSPIN 20 -somatropin inj 20
mg/2ml..............................................................................33
NUTROPIN AQ NUSPIN 5 -somatropin inj 5 mg/2ml........ 33
NUTROPIN AQ PEN -somatropin inj 10 mg/2ml............... 33
NUTROPIN AQ PEN -somatropin inj 20 mg/2ml............... 33
NUTROPIN AQ -somatropin inj 10 mg/2ml....................... 33
NUTROPIN -somatropin for inj 10 mg...............................33
NUVAIL - dermatological products misc - solution ..........151
NUVARING -etonogestrel-ethinyl estradiol va ring
0.120-0.015 mg/24hr........................................................22
NUVIGIL -armodafinil tab 150 mg..................................... 89
NUVIGIL -armodafinil tab 50 mg....................................... 89
NUZON -hydrocortisone acetate-aloe vera gel 2%..........151
NYMALIZE -nimodipine oral soln 60 mg/20ml...................40
nystatin cream 100000 unit/gm.................................... 151
nystatin oint 100000 unit/gm........................................ 151
nystatin oral powder ........................................................ 6
nystatin susp 100000 unit/ml........................................139
nystatin tab 500000 unit....................................................7
nystatin topical powder ............................................... 141
nystatin-triamcinolone cream 100000-0.1 unit/gm%.................................................................................... 152
nystatin-triamcinolone oint 100000-0.1 unit/gm-%..... 152
NYSTATIN VAGINAL -nystatin vaginal tab 100000
unit....................................................................................74
O
OB COMPLETE/DHA - prenat w/ iron cbn-fe asp glyc-faomega cap 30-10-1-200 mg ......................................... 119
OB COMPLETE 400 - prenatal w/o a w/fecbn-fe asp glycfa-fish cap 40-10-1 mg ................................................. 119
OB COMPLETE ONE - prenatal w/o a w/fecbn-fe asp glycfa-fish cap 50-1-476 mg ............................................... 119
OB COMPLETE PETITE - prenat w/o a w/fecbn-feaspglycfa-omega cap 35-5-1-200 mg ....................................... 119
OB COMPLETE PREMIER - prenatal vit w/ fe cbn-fe asp
glyc-fa tab 30-20-1 mg ................................................. 119
OB COMPLETE - prenatal vit w/ iron carbonyl-fa tab
50-1.25 mg ................................................................... 119
OB-NATAL ONE - prenatal vit w/ fe cbn-fe asp glyc-faomega 3 cap 27-1mg ................................................... 120
OB-NATAL ONE - prenatal w/fe cbnyl-fe asp glyc-fa-dssomega cap 20-7-1 mg .................................................. 120
OBSTETRIX DHA -prenat w/fecbn-fa-dss tab 29-1 mg &
omega 3 cap 387 mg pak..............................................120
OBSTETRIX EC - prenatal vit w/ dss-iron carbonyl-fa tab
29-1 mg ........................................................................ 120
O-CAL PRENATAL - prenatal vit w/ fe fumarate-fa tab
15-1 mg ........................................................................ 119
octreotide acetate inj 1000 mcg/ml (1 mg/ml)
(Sandostatin).................................................................. 33
octreotide acetate inj 100 mcg/ml (0.1 mg/ml)
(Sandostatin).................................................................. 33
(Sandostatin).................................................................. 33
(Sandostatin).................................................................. 33
(Sandostatin).................................................................. 33
OCUDOX -doxycycline hyclate cap 50 mg & eyelid cleans
& spray kit..........................................................................5
OCUFEN -flurbiprofen sodium ophth soln 0.03%............ 136
OCUFLOX -ofloxacin ophth soln 0.3%............................ 136
ofloxacin ophth soln 0.3% (Ocuflox)........................... 136
ofloxacin otic soln 0.3%................................................138
ofloxacin tab 200 mg.........................................................6
ofloxacin tab 300 mg.........................................................6
ofloxacin tab 400 mg.........................................................6
OGESTREL -norgestrel & ethinyl estradiol tab 0.5 mg-50
mcg...................................................................................22
olanzapine-fluoxetine hcl cap 12-25 mg (Symbyax)..... 91
olanzapine-fluoxetine hcl cap 12-50 mg (Symbyax)..... 91
olanzapine-fluoxetine hcl cap 3-25 mg (Symbyax)....... 91
olanzapine orally disintegrating tab 10 mg (Zyprexa
zydis)............................................................................... 83
zydis)............................................................................... 83
zydis)............................................................................... 83
zydis)............................................................................... 83
olanzapine tab 10 mg (Zyprexa).....................................83
olanzapine tab 2.5 mg (Zyprexa)....................................83
olanzapine tab 5 mg (Zyprexa).......................................83
olanzapine tab 7.5 mg (Zyprexa)....................................83
OLEPTRO -trazodone hcl tab sr 24hr 150 mg.................. 79
OLEPTRO -trazodone hcl tab sr 24hr 300 mg.................. 79
OLUX -clobetasol propionate foam 0.05%...................... 152
OLUX-E -clobetasol propionate emulsion foam
0.05%............................................................................. 152
OLYSIO -simeprevir sodium cap 150 mg (base
equivalent)..........................................................................9
OMECLAMOX-PAK -amoxicillin cap-clarithro tab w/
omepraz cap dr therapy pack.......................................... 67
omega-3-acid ethyl esters cap 1 gm (Lovaza).............. 52
OMEPRAZOLE + SYRSPEND SF -omeprazole susp 2
mg/ml (compound kit)...................................................... 67
omeprazole cap delayed release 10 mg (Prilosec)....... 67
omeprazole-sodium bicarbonate cap 20-1100 mg
(Zegerid).......................................................................... 67
221
2014
omeprazole-sodium bicarbonate cap 40-1100 mg
(Zegerid).......................................................................... 67
OMNARIS -ciclesonide nasal susp 50 mcg/act................. 56
OMNIFLEX DIAPHRAGM - diaphragms ........................ 161
OMNI GEL -stannous fluoride gel 0.4%.......................... 139
OMNIPRED -prednisolone acetate ophth susp 1%......... 136
OMNITROPE -somatropin for inj 5.8 mg........................... 33
OMNITROPE -somatropin inj 10 mg/1.5ml........................33
OMNITROPE -somatropin inj 5 mg/1.5ml......................... 33
ondansetron hcl oral soln 4 mg/5ml (Zofran)................69
ondansetron hcl tab 24 mg............................................ 69
ondansetron hcl tab 4 mg (Zofran)................................ 69
ondansetron hcl tab 8 mg.............................................. 69
ondansetron hcl tab 8 mg (Zofran)................................ 69
ondansetron orally disintegrating tab 4 mg (Zofran
odt)...................................................................................69
ondansetron orally disintegrating tab 8 mg (Zofran
odt)...................................................................................69
ONETOUCH BASIC/PROFILE/ON -glucose blood test
strip.................................................................................160
ONETOUCH BASIC/PROFILE TE -glucose blood test
strip.................................................................................160
ONETOUCH ULTRA BLUE -glucose blood test strip...... 160
ONETOUCH ULTRA TEST STRIP -glucose blood test
strip.................................................................................160
ONETOUCH VERIO TEST STRIP -glucose blood test
strip.................................................................................160
ONFI -clobazam suspension 2.5 mg/ml.......................... 110
ONFI -clobazam tab 10 mg............................................. 110
ONFI -clobazam tab 20 mg............................................. 110
ONFI -clobazam tab 5 mg............................................... 110
ONGLYZA -saxagliptin hcl tab 2.5 mg (base equiv).......... 26
ONGLYZA -saxagliptin hcl tab 5 mg (base equiv)............. 26
ONMEL -itraconazole tab 200 mg....................................... 7
ONSOLIS -fentanyl citrate buccal soluble film 1200
mcg...................................................................................99
mcg...................................................................................99
mcg...................................................................................99
mcg...................................................................................99
mcg...................................................................................99
OPANA ER (CRUSH RESISTANT -oxymorphone hcl tab
er 12hr deter 10 mg.........................................................99
er 12hr deter 15 mg.........................................................99
er 12hr deter 20 mg.........................................................99
er 12hr deter 30 mg.......................................................100
er 12hr deter 40 mg.......................................................100
222
er 12hr deter 5 mg...........................................................99
er 12hr deter 7.5 mg........................................................99
OPANA ER -oxymorphone hcl tab sr 12hr 10 mg............. 99
OPANA ER -oxymorphone hcl tab sr 12hr 5 mg............... 99
OPANA -oxymorphone hcl tab 10 mg............................... 99
OPANA -oxymorphone hcl tab 5 mg................................. 99
ophthalmic irrigation solution .....................................133
OPIUM TINCTURE (PAREGORIC -paregoric 2
mg/5ml..............................................................................65
opium tincture 1% (10 mg/ml) (morphine equiv)...........65
OPSUMIT -macitentan tab 10 mg..................................... 54
OPTASE -trypsin w/ castor oil & peruvian balsam gel..... 152
OPTIPRANOLOL -metipranolol ophth soln 0.3%............ 136
OPTIVAR -azelastine hcl ophth soln 0.05%.................... 136
ORA-BLEND - oral vehicles ........................................... 162
ORA-BLEND SF - oral vehicles ..................................... 162
ORACEA -doxycycline (rosacea) cap delayed release 40
mg.................................................................................. 152
ORACIT -sodium citrate & citric acid soln 490-640
mg/5ml..............................................................................74
ORAFATE - sucralfate-malate paste 10% ......................139
ORALAIR - grass mixed pollen ext tab sl 300 ir (index of
reactivity) .........................................................................12
ORAL MIX FLAVORED SUSPEND - oral vehicles .........163
ORAL MIX SF - oral vehicles ......................................... 163
ORAL SUSPEND - oral vehicles ....................................163
ORAL SYRUP FLAVORED VEHIC - oral vehicles ......... 163
ORAL SYRUP SF - oral vehicles ................................... 163
ORAMAGICRX - oral wound care products - for susp rinse
....................................................................................... 139
ORAMORPH SR -morphine sulfate tab cr 100 mg.......... 100
ORAMORPH SR -morphine sulfate tab cr 15 mg............100
ORA-PLUS - oral vehicles ..............................................162
ORAP -pimozide tab 1 mg................................................ 91
ORAP -pimozide tab 2 mg................................................ 91
ORAPRED ODT -prednisolone sod phos orally disintegr
tab 10 mg (base eq)........................................................ 17
tab 15 mg (base eq)........................................................ 17
tab 30 mg (base eq)........................................................ 17
ORAPRED -prednisolone sod phosphate oral soln 15
mg/5ml (base equiv)........................................................ 17
ORA-SWEET - oral vehicles .......................................... 162
ORA-SWEET SF - oral vehicles .....................................162
ORAVIG -miconazole buccal tab 50 mg (mouththroat)............................................................................. 139
ORAXYL -doxycycline hyclate cap 20 mg........................... 5
2014
ORBIVAN -butalbital-acetaminophen-caffeine cap
50-300-40 mg...................................................................94
ORBIVAN CF -butalbital-acetaminophen tab 50-300
mg.................................................................................... 94
ORENCIA -abatacept subcutaneous inj 125 mg/ml.........105
ORENITRAM -treprostinil diolamine tab cr 0.125 mg (base
equiv)................................................................................54
equiv)................................................................................54
ORENITRAM -treprostinil diolamine tab cr 1 mg (base
equiv)................................................................................54
equiv)................................................................................54
ORFADIN -nitisinone cap 10 mg....................................... 33
ORFADIN -nitisinone cap 2 mg......................................... 33
ORFADIN -nitisinone cap 5 mg......................................... 33
orphenadrine citrate tab sr 12hr 100 mg..................... 115
ORPHENADRINE COMPOUND DS -orphenadrine w/
aspirin & caffeine tab 50-770-60 mg..............................115
orphenadrine w/ aspirin & caffeine tab 25-385-30
mg.................................................................................. 115
ORTHO-CEPT -desogestrel & ethinyl estradiol tab 0.15
mg-30 mcg....................................................................... 22
ORTHO-CYCLEN -norgestimate & ethinyl estradiol tab
0.25 mg-35 mcg...............................................................22
ORTHO DIAPHRAGM ALL-FLEX/ -diaphragm arc-spring
65 mm............................................................................ 161
70 mm............................................................................ 161
75 mm............................................................................ 161
80 mm............................................................................ 161
ORTHO DIAPHRAGM COIL SPRI -diaphragm coil spring
kit 100 mm..................................................................... 161
kit 105 mm..................................................................... 161
kit 50 mm....................................................................... 161
ORTHO DIAPHRAGM FLAT SPRI -diaphragm flat spring
kit 55 mm....................................................................... 161
kit 60 mm....................................................................... 161
kit 65 mm....................................................................... 161
kit 70 mm....................................................................... 161
kit 75 mm....................................................................... 161
kit 80 mm....................................................................... 161
kit 85 mm....................................................................... 161
kit 90 mm....................................................................... 161
kit 95 mm....................................................................... 161
ORTHO EVRA -norelgestromin-ethinyl estradiol td ptwk
150-35 mcg/24hr..............................................................22
ORTHO MICRONOR -norethindrone tab 0.35 mg.............22
ORTHO-NOVUM 1/35 -norethindrone & ethinyl estradiol
tab 1 mg-35 mcg............................................................. 22
ORTHO-NOVUM 7/7/7 -norethindrone-eth estradiol tab
0.5-35/0.75-35/1-35 mg-mcg............................................22
ORTHO TRI-CYCLEN LO -norgestimate-eth estrad tab
0.18-25/0.215-25/0.25-25 mg-mcg...................................22
ORTHO TRI-CYCLEN -norgestimate-eth estrad tab
0.18-35/0.215-35/0.25-35 mg-mcg...................................22
OSENI -alogliptin-pioglitazone tab 12.5-15 mg..................26
OSENI -alogliptin-pioglitazone tab 25-15 mg.....................26
OSMOPREP -sod phos mono-sod phos di tabs
1.102-0.398 gm(1.5gm na phos)..................................... 65
OSPHENA -ospemifene tab 60 mg................................... 33
OTEZLA -apremilast tab 30 mg.......................................105
OTEZLA -apremilast tab starter therapy pack 10 mg & 20
mg & 30 mg................................................................... 105
OTICIN HC NR -pramoxine-hc-chloroxylenol otic soln
10-10-1 mg/ml................................................................138
OTOZIN -antipyrine-benzocaine-glycerin-zinc ace otic liqd
5.4-1-2-1%......................................................................138
OTREXUP -methotrexate soln pf auto-injector
10mg/0.4ml.....................................................................105
15mg/0.4ml.....................................................................105
20mg/0.4ml.....................................................................105
25mg/0.4ml.....................................................................105
OVACE PLUS -sulfacetamide sodium cream 10%..........152
OVACE PLUS -sulfacetamide sodium shampoo 10%..... 152
OVACE PLUS WASH -sulfacetamide sodium cleansing gel
10%................................................................................ 152
OVACE PLUS WASH -sulfacetamide sodium liquid
10%................................................................................ 152
OVACE WASH -sulfacetamide sodium liquid 10%.......... 152
OVCON-35 -norethindrone & ethinyl estradiol tab 0.4
mg-35 mcg....................................................................... 23
OVIDE -malathion lotion 0.5%.........................................152
OVIDREL -choriogonadotropin alfa inj 250 mcg/0.5ml...... 34
OXANDRIN -oxandrolone tab 10 mg.................................18
OXANDRIN -oxandrolone tab 2.5 mg................................18
oxandrolone tab 10 mg (Oxandrin)................................ 18
oxandrolone tab 2.5 mg (Oxandrin)............................... 18
oxaprozin tab 600 mg (Daypro)....................................105
oxazepam cap 10 mg...................................................... 76
oxazepam cap 15 mg...................................................... 76
223
2014
oxazepam cap 30 mg...................................................... 76
oxcarbazepine susp 300 mg/5ml (60 mg/ml)
(Trileptal)....................................................................... 110
oxcarbazepine tab 150 mg (Trileptal).......................... 110
OXECTA -oxycodone hcl tab abuse deter 5 mg..............100
OXECTA -oxycodone hcl tab abuse deter 7.5 mg........... 100
OXISTAT -oxiconazole nitrate cream 1%........................ 152
OXISTAT -oxiconazole nitrate lotion 1%......................... 152
OXSORALEN -methoxsalen lotion 1%............................ 152
OXSORALEN ULTRA -methoxsalen rapid cap 10 mg.....152
OXTELLAR XR -oxcarbazepine tab sr 24hr 150 mg....... 110
oxybutynin chloride syrup 5 mg/5ml............................. 73
oxybutynin chloride tab 5 mg........................................ 73
oxybutynin chloride tab sr 24hr 10 mg (Ditropan
xl)..................................................................................... 73
oxybutynin chloride tab sr 24hr 15 mg (Ditropan
xl)..................................................................................... 73
oxybutynin chloride tab sr 24hr 5 mg (Ditropan xl)...... 73
oxycodone-aspirin tab 4.8355-325 mg (Percodan)..... 100
oxycodone hcl cap 5 mg.............................................. 100
oxycodone hcl conc 100 mg/5ml (20 mg/ml)
(Oxycodone hcl)........................................................... 100
OXYCODONE HCL -oxycodone hcl conc 100 mg/5ml (20
mg/ml)............................................................................ 100
OXYCODONE HCL -oxycodone hcl soln 5 mg/5ml.........100
OXYCODONE HCL -oxycodone hcl soln 5 mg/5ml.........100
oxycodone hcl soln 5 mg/5ml (Oxycodone hcl)..........100
oxycodone hcl tab 10 mg............................................. 100
oxycodone hcl tab 15 mg (Roxicodone)......................100
oxycodone hcl tab 20 mg............................................. 100
oxycodone hcl tab 30 mg (Roxicodone)......................100
oxycodone hcl tab 5 mg (Roxicodone)........................100
oxycodone-ibuprofen tab 5-400 mg............................. 100
oxycodone w/ acetaminophen cap 5-500 mg.............. 100
oxycodone w/ acetaminophen tab 10-325 mg
(Percocet)......................................................................100
oxycodone w/ acetaminophen tab 10-650 mg.............100
oxycodone w/ acetaminophen tab 2.5-325 mg
(Percocet)......................................................................100
oxycodone w/ acetaminophen tab 5-325 mg
(Percocet)......................................................................100
oxycodone w/ acetaminophen tab 7.5-325 mg
(Percocet)......................................................................100
oxycodone w/ acetaminophen tab 7.5-500 mg............100
OXYCONTIN -oxycodone hcl tab er 12hr deter 10
mg.................................................................................. 100
mg.................................................................................. 100
mg.................................................................................. 100
224
mg.................................................................................. 100
mg.................................................................................. 100
mg.................................................................................. 100
mg.................................................................................. 100
oxymorphone hcl tab 10 mg (Opana).......................... 100
oxymorphone hcl tab 5 mg (Opana)............................ 100
oxymorphone hcl tab sr 12hr 10 mg............................100
oxymorphone hcl tab sr 12hr 5 mg............................. 100
oxymorphone hcl tab sr 12hr 7.5 mg...........................100
OXYTROL -oxybutynin td patch biweekly 3.9 mg/24hr......73
P
PACERONE -amiodarone hcl tab 400 mg.........................41
PAIRE OB -prenat w/ fe poly cmplx-fe asp-fe gly-fa tab &
dha cap pak................................................................... 120
PALGIC -carbinoxamine maleate soln 4 mg/5ml...............56
PALGIC -carbinoxamine maleate tab 4 mg....................... 55
PAMELOR -nortriptyline hcl cap 10 mg.............................80
PAMINE FORTE -methscopolamine bromide tab 5 mg.....68
PAMINE FQ -methscopolamine tab 5 mg & misc intestinal
flora reg cap.....................................................................68
PAMINE -methscopolamine bromide tab 2.5 mg...............68
PANATUSS DXP -phenylephrine-dexbromphen-dm-gg
liquid 5-1-15-100 mg/5ml................................................. 59
PANCREAZE -pancrelipase (lip-prot-amyl) dr cap
10500-25000-43750 unit.................................................. 69
16800-40000-70000 unit.................................................. 70
21000-37000-61000 unit.................................................. 70
4200-10000-17500 unit.................................................... 69
PANCRELIPASE -pancrelipase (lip-prot-amyl) dr cap
5000-17000-27000 unit.................................................... 70
PANDEL -hydrocortisone probutate cream 0.1%............ 152
PANRETIN -alitretinoin gel 0.1%.....................................152
pantoprazole sodium ec tab 20 mg (base equiv)
(Protonix)........................................................................ 68
pantoprazole sodium ec tab 40 mg (base equiv)
(Protonix)........................................................................ 68
PARAFON FORTE DSC -chlorzoxazone tab 500 mg......115
PARCOPA -carbidopa & levodopa orally disintegrating tab
10-100 mg......................................................................113
25-100 mg......................................................................113
2014
25-250 mg......................................................................113
paricalcitol cap 1 mcg (Zemplar)................................... 34
PARLODEL -bromocriptine mesylate cap 5 mg.............. 113
PARLODEL -bromocriptine mesylate tab 2.5 mg............ 113
PARNATE -tranylcypromine sulfate tab 10 mg..................80
paromomycin sulfate cap 250 mg....................................6
paroxetine hcl tab 10 mg (Paxil).................................... 80
paroxetine hcl tab sr 24hr 12.5 mg (Paxil cr)................ 80
paroxetine hcl tab sr 24hr 25 mg (Paxil cr)................... 80
paroxetine hcl tab sr 24hr 37.5 mg (Paxil cr)................ 80
PASER -aminosalicylic acid cr granules packet 4 gm......... 6
PATADAY -olopatadine hcl ophth soln 0.2%...................136
PATANASE -olopatadine hcl nasal soln 0.6%...................56
PATANOL -olopatadine hcl ophth soln 0.1%...................136
PAXIL CR -paroxetine hcl tab sr 24hr 12.5 mg................. 80
PAXIL CR -paroxetine hcl tab sr 24hr 25 mg.................... 80
PAXIL CR -paroxetine hcl tab sr 24hr 37.5 mg................. 80
PAXIL -paroxetine hcl oral susp 10 mg/5ml (base
equiv)................................................................................80
PAXIL -paroxetine hcl tab 10 mg...................................... 80
PBZ -tripelennamine hcl tab 50 mg................................... 56
PCCA ACACIA SYRUP BASE -acacia syrup.................. 163
PCCA ALADERM BASE - cream base .......................... 163
PCCA ANHYDROUS BASE -anhydrous ointment
base................................................................................163
PCCA ANHYDROUS LIPODERM B - cream base .........163
PCCA BIOPEPTIDE BASE - cream base ...................... 163
PCCA COBASE #1 -cobase #1 ointment base............... 163
PCCA COSMETIC HRT BASE - cream base .................163
PCCA CUSTOM LIPO-MAX - cream base liposomic ..... 163
PCCA LIPODERM BASE - cream base ......................... 163
PCCA LIPODERM CUSTOM BASE - cream base ......... 163
PCCA LIPOSOMIC BASE FOR D - cream base liposomic
....................................................................................... 163
PCCA LIPOSOMIC BASE FOR N - cream base liposomic
....................................................................................... 163
PCCA LIPOSOMIC BASE FOR O - cream base liposomic
....................................................................................... 163
PCCA LIPOSOMIC BASE FOR P - cream base liposomic
....................................................................................... 163
PCCA LIPOSOMIC BASE FOR S - cream base liposomic
....................................................................................... 163
PCCA MVC BASE - cream base ................................... 163
PCCA NATACREAM - cream base ................................163
PCCA-PLUS - oral vehicles ........................................... 163
PCCA POLYPEG BASE -polyethylene glycol
ointment..........................................................................163
PCCA PRACASIL TM-PLUS BAS - cream base ............ 163
PCCA SOLID TRANSDERMAL PE -transdermal base
misc................................................................................ 163
PCCA SWEET-SF - oral vehicles .................................. 163
PCCA SYRUP VEHICLE - oral vehicles ........................ 163
PCCA VANISHING CREAM/LOTI - cream base ............ 163
PCCA VANISHING CREAM LIGH - cream base ............163
PCCA VANPEN BASE - cream base ............................. 163
PCE -erythromycin w/ enteric coated particles tab 333
mg...................................................................................... 3
PCE -erythromycin w/ enteric coated particles tab 500
mg...................................................................................... 3
PEDIADERM AF COMPLETE KIT -nystatin cream 100000
unit/gm & diaper rash cream kit.....................................152
PEDIADERM HC -hydrocortisone lot 2% & emollient
cream kit........................................................................ 152
PEDIADERM TA -triamcinolone cream 0.1% & emollient
cream kit........................................................................ 152
PEDIAPRED -prednisolone sod phosph oral soln 6.7
mg/5ml (5 mg/5ml base)..................................................17
PEDIATEX TDM -pseudoephed-triprolidine-dm susp
10-0.938-4 mg/ml.............................................................59
PEDIATEX TD -triprolidine & pseudoephedrine liquid
0.938-10 mg/ml................................................................ 59
pediatric multiple vitamins w/ fl-fe drops 0.25-10 mg/ml
....................................................................................... 116
pediatric multiple vitamins w/ fluoride chew tab 0.25
mg .................................................................................116
pediatric multiple vitamins w/ fluoride chew tab 1 mg
....................................................................................... 116
pediatric multiple vitamins w/ fluoride soln 0.25 mg/ml
....................................................................................... 116
pediatric multiple vitamins w/ fluoride soln 0.5 mg/ml
....................................................................................... 116
pediatric multiple vitamin w/ minerals & c drops 45
mg/ml.............................................................................116
pediatric vitamins acd w/ fluoride soln 0.25 mg/ml
....................................................................................... 116
pediatric vitamins acd w/ fluoride soln 0.5 mg/ml ..... 116
PEDIPIROX-4 NAIL -ciclopirox soln 8% & lacquer removal
pads & foot powd kit......................................................152
peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm
(Golytely).........................................................................65
peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240 gm
(Colyte-flavor packs)......................................................65
peg 3350-kcl-sod bicarb-nacl for soln 420 gm
(Nulytely/flavor pack).....................................................65
PEG-8 DISTEARATE BASE L -polyethylene glycol
ointment..........................................................................163
PEGANONE -ethotoin tab 250 mg.................................. 111
PEGASYS -peginterferon alfa-2a inj 180 mcg/0.5ml........... 9
PEGASYS -peginterferon alfa-2a inj 180 mcg/ml................ 9
PEGASYS -peginterferon alfa-2a inj kit 180 mcg/0.5ml.......9
225
2014
PEGASYS PROCLICK -peginterferon alfa-2a inj 135
mcg/0.5ml...........................................................................9
PEGASYS PROCLICK -peginterferon alfa-2a inj 180
mcg/0.5ml...........................................................................9
PEG-INTRON -peginterferon alfa-2b for inj kit 120
mcg/0.5ml...........................................................................9
mcg/0.5ml...........................................................................9
mcg/0.5ml...........................................................................9
mcg/0.5ml...........................................................................9
PEG-INTRON REDIPEN PAK 4 -peginterferon alfa-2b for
inj kit 120 mcg/0.5ml..........................................................9
inj kit 150 mcg/0.5ml..........................................................9
inj kit 50 mcg/0.5ml............................................................9
inj kit 80 mcg/0.5ml............................................................9
PEG-INTRON REDIPEN -peginterferon alfa-2b for inj kit
120 mcg/0.5ml................................................................... 9
150 mcg/0.5ml................................................................... 9
50 mcg/0.5ml..................................................................... 9
80 mcg/0.5ml..................................................................... 9
PENCREAM - cream base .............................................163
PENDERM - cream base ............................................... 163
penicillin v potassium for soln 125 mg/5ml.................... 1
penicillin v potassium for soln 250 mg/5ml.................... 1
penicillin v potassium tab 250 mg................................... 1
penicillin v potassium tab 500 mg................................... 1
PENLAC NAIL LACQUER -ciclopirox solution 8%.......... 152
PENNSAID -diclofenac sodium soln 1.5%.......................152
PENNSAID -diclofenac sodium soln 2%......................... 152
PENTASA -mesalamine cap cr 250 mg............................ 71
PENTASA -mesalamine cap cr 500 mg............................ 71
pentazocine-acetaminophen tab 25-650 mg................101
pentazocine w/ naloxone tab 50-0.5 mg...................... 100
PENTETATE CALCIUM TRISODI -pentetate calcium
trisodium iv or inhalation soln 200 mg/ml.......................160
PENTETATE ZINC TRISODIUM -pentetate zinc trisodium
iv or inhalation soln 200 mg/ml......................................160
pentoxifylline tab cr 400 mg......................................... 133
PEPCID -famotidine for susp 40 mg/5ml...........................68
PEPCID -famotidine tab 20 mg......................................... 68
PEPCID -famotidine tab 40 mg......................................... 68
PERCOCET -oxycodone w/ acetaminophen tab 10-325
mg.................................................................................. 101
mg.................................................................................. 101
PERCOCET -oxycodone w/ acetaminophen tab 2.5-325
mg.................................................................................. 101
226
mg.................................................................................. 101
mg.................................................................................. 101
mg.................................................................................. 101
PERCODAN -oxycodone-aspirin tab 4.8355-325 mg...... 101
PERFOROMIST -formoterol fumarate soln nebu 20
mcg/2ml............................................................................63
PERIDEX -chlorhexidine gluconate soln 0.12%.............. 139
perindopril erbumine tab 2 mg.......................................46
perindopril erbumine tab 4 mg (Aceon)........................ 46
perindopril erbumine tab 8 mg (Aceon)........................ 46
permethrin cream 5% (Elimite).....................................152
PERPHENAZINE/AMITRIPTYLIN -perphenazineamitriptyline tab 2-10 mg................................................. 91
perphenazine tab 16 mg................................................. 83
perphenazine tab 2 mg................................................... 83
PERSANTINE -dipyridamole tab 25 mg.......................... 133
PERTZYE -pancrelipase (lip-prot-amyl) dr cap
16000-57500-60500 unit.................................................. 70
PERTZYE -pancrelipase (lip-prot-amyl) dr cap
8000-28750-30250 unit.................................................... 70
PETROLATUM WHITE -white petrolatum ointment........ 163
PETROLATUM YELLOW -petrolatum ointment.............. 163
PEXEVA -paroxetine mesylate tab 10 mg (base equiv).....80
PHARMABASE COSMETIC - cream base .....................163
PHARMABASE COSMETIC NATUR - cream base ........163
PHARMABASE HEAVY - cream base ........................... 163
phenazopyridine-butabarbital-hyoscyamine tab
150-15-0.3 mg................................................................. 73
phenazopyridine hcl tab 100 mg (Pyridium)................. 75
phenazopyridine hcl tab 200 mg (Pyridium)................. 75
phenelzine sulfate tab 15 mg (Nardil)............................ 80
PHENFLU CD -phenylephrine-codeine-guaifenesin-apap
tab 10-10-400-500 mg..................................................... 59
PHENFLU CDX -phenylephrine-codeine-guaifenesin-apap
tab 10-20-400-500 mg..................................................... 59
phenobarbital elixir 20 mg/5ml.......................................85
PHENOBARBITAL -phenobarbital tab 100 mg..................85
2014
PHENOBARBITAL -phenobarbital tab 15 mg....................85
PHENOBARBITAL -phenobarbital tab 64.8 mg.................85
PHENOBARBITAL -phenobarbital tab 97.2 mg.................85
phenobarbital tab 100 mg...............................................85
phenobarbital tab 15 mg.................................................85
phenobarbital tab 16.2 mg..............................................85
phenobarbital tab 32.4 mg..............................................85
phenylephrine-bromphen-carbetapentane liq 10-6-30
mg/5ml.............................................................................59
phenylephrine-brompheniramine-dm liquid 7.5-4-15
mg/5ml.............................................................................59
phenylephrine-bromphen w/ codeine liqd 7.5-4-10
mg/5ml.............................................................................59
phenylephrine-chlorphen-dm liquid 1.5-1-3 mg/ml.......59
phenylephrine-guaifenesin liqd 7.5-100 mg/5ml (1.5-20
mg/ml)..............................................................................59
phenylephrine-guaifenesin syrup 5-200 mg/5ml...........59
phenylephrine hcl ophth soln 10%.............................. 136
phenylephrine hcl ophth soln 2.5% (Mydfrin)............. 136
phenylephrine-promethazine w/ codeine syrup
5-6.25-10 mg/5ml............................................................ 59
phenylephrine w/ dm-gg liqd 10-15-300 mg/5ml........... 59
phenylephrine w/ dm-gg liqd 10-30-200 mg/5ml........... 59
phenylephrine w/ dm-gg liqd 2.5-5-50 mg/ml................ 59
phenylephrine w/ dm-gg liqd 2.5-7.5-88 mg/ml............. 59
PHENYLHISTINE DH -pseudoephedrine-chlorphen w/
codeine liq 30-2-10 mg/5ml............................................. 59
phenyltoloxamine-acetaminophen tab 30-500 mg........ 94
PHENYTEK -phenytoin sodium extended cap 200
mg.................................................................................. 111
PHENYTEK -phenytoin sodium extended cap 300
mg.................................................................................. 111
phenytoin chew tab 50 mg (Dilantin infatabs)............ 111
phenytoin sodium extended cap 100 mg
(Dilantin)........................................................................111
(Phenytek)..................................................................... 111
(Phenytek)..................................................................... 111
phenytoin susp 125 mg/5ml (Dilantin)......................... 111
PHISOHEX -hexachlorophene liq 3%..............................159
PHOS-FLUR ORTHO DEFENSE -sodium fluoride rinse
0.044%........................................................................... 139
PHOS FLUR -sodium fluoride rinse 0.044%....................139
PHOSLO -calcium acetate (phosphate binder) cap 667 mg
(169 mg ca)..................................................................... 71
PHOSLYRA -calcium acetate (phosphate binder) oral soln
667 mg/5ml...................................................................... 71
PHOSPHOLINE IODIDE -echothiophate iodide ophth for
soln 0.125%................................................................... 136
PHRENILIN FORTE -butalbital-acetaminophen cap 50-650
mg.................................................................................... 94
PHYSICIANS EZ USE JOINT T -triamcinolone inj 40 mg/
ml & lidocaine 1% & ammonia inh kit.............................. 17
PHYSIOSOL IRRIGATION PH 7 - irrigation solution,
physiological ................................................................. 165
PICATO -ingenol mebutate gel 0.015%.......................... 152
PICATO -ingenol mebutate gel 0.05%............................ 152
PICO SINGLE USE NEGATIVE - wound dressings - kit
....................................................................................... 152
pilocarpine hcl ophth soln 1% (Isopto carpine).......... 136
pilocarpine hcl tab 5 mg (Salagen).............................. 139
pilocarpine hcl tab 7.5 mg (Salagen)........................... 139
PILOPINE HS -pilocarpine hcl ophth gel 4%...................136
pindolol tab 10 mg.......................................................... 37
pindolol tab 5 mg............................................................ 37
PINNACAINE OTIC -benzocaine otic soln 20%.............. 138
pioglitazone hcl-glimepiride tab 30-2 mg (Duetact)...... 26
pioglitazone hcl-glimepiride tab 30-4 mg (Duetact)...... 26
pioglitazone hcl-metformin hcl tab 15-500 mg
(Actoplus met)................................................................26
pioglitazone hcl-metformin hcl tab 15-850 mg
(Actoplus met)................................................................26
pioglitazone hcl tab 15 mg (base equiv) (Actos)...........26
piroxicam cap 10 mg (Feldene)....................................105
piroxicam cap 20 mg (Feldene)....................................105
PLACEBO #00 - placebo - cap ...................................... 163
PLAN B -levonorgestrel tab 0.75 mg.................................23
PLAN B ONE-STEP -levonorgestrel tab 1.5 mg................23
PLAQUENIL -hydroxychloroquine sulfate tab 200 mg....... 11
PLAVIX -clopidogrel bisulfate tab 300 mg (base
equiv)..............................................................................133
PLAVIX -clopidogrel bisulfate tab 75 mg (base equiv).....133
PLETAL -cilostazol tab 100 mg....................................... 133
PLETAL -cilostazol tab 50 mg......................................... 133
PLEXION CLEANSER -sulfacetamide sodium w/ sulfur
cleanser 9.8-4.8%.......................................................... 152
PLEXION CLEANSER -sulfacetamide sodium w/ sulfur
emulsion 10-5%............................................................. 152
PLEXION CLEANSING CLOTHS -sulfacetamide sodium
w/ sulfur cleansing cloth 9.8-4.8%................................. 152
PLEXION CLEANSING CLOTH -sulfacetamide sodium w/
sulfur cleansing cloth 10-5%..........................................152
PLEXION SCT -sulfacetamide sodium w/ sulfur cream
10-5%............................................................................. 152
PLEXION -sulfacetamide sodium w/ sulfur cream
9.8-4.8%......................................................................... 152
PLEXION -sulfacetamide sodium w/ sulfur lotion
9.8-4.8%......................................................................... 152
227
2014
PLIAGLIS -lidocaine-tetracaine cream 7-7%................... 152
PLO20 BASE -premium lecithin organogel base gel....... 163
PLO GEL - MEDIFLO KIT -premium lecithin organogel
base kit...........................................................................163
PLO GEL - MEDIFLO PRE-MIX -premium lecithin
organogel base gel........................................................ 163
PLO TRANSDERMAL CREAM - transdermal base cream
....................................................................................... 163
PNV-DHA+DOCUSATE - prenatal w/o vit a w/ fe fum-dssfa-dha cap 27-1.25-300 mg .......................................... 120
PNV-DHA - prenat w/o a w/ fe fum-methylfol-fa-dha cap
27-0.6-0.4 mg ............................................................... 120
PNV FERROUS FUMARATE/DOCU - prenatal vit w/ dssfe fumarate-fa tab 29-1 mg ...........................................120
PNV OB+DHA -prenat w/o a w/fecbn-fegl-dss-fa tab & dha
cap 250 mg pack........................................................... 120
PNV-OMEGA - prenat w/o a w/ fe fumerate-methylfolatefa-omega 3 cap ............................................................ 120
PNV-SELECT - prenatal vit w/ fe fum-methylfolate-fa tab
27-0.6-0.4 mg ............................................................... 120
PNV-TOTAL - prenat w/ fe cbn-fe bisglyc-fa-fish oil cap
35-5-1.2 mg .................................................................. 120
PODOCON 25 IN BENZOIN TIN -podophyllum resin soln
25%................................................................................ 152
podofilox soln 0.5% (Condylox)................................... 152
POLYCITRA-K CRYSTALS -potassium citrate & citric acid
powder pack 3300-1002 mg............................................ 75
polyethylene glycol 3350 oral packet............................ 65
polyethylene glycol 3350 oral powder...........................65
POLYETHYLENE GLYCOL 8000 -polyethylene glycol
8000 oint........................................................................ 163
POLY HIST DHC -phenylephrine-pyrilamine-dihydrocod
liqd 5-7.5-7.5 mg/5ml....................................................... 59
POLY HIST NC -pseudoephedrine-triprolidine w/ cod liquid
15-1.25-10 mg/5ml........................................................... 59
polymyxin b-trimethoprim ophth soln 10000 unit/
ml-0.1% (Polytrim)........................................................136
POLYTRIM -polymyxin b-trimethoprim ophth soln 10000
unit/ml-0.1%................................................................... 136
POLY-TUSSIN AC -phenylephrine-bromphen w/ codeine
liqd 7.5-4-10 mg/5ml........................................................ 59
POLY-TUSSIN -codeine-chlorcyclizine liquid 10-9.375
mg/5ml..............................................................................59
POLY-TUSSIN D -codeine-pseudoephedrinechlorcyclizine liq 10-30-9.375mg/5ml............................... 59
POLY-TUSSIN DHC -phenylephrine-bromphendihydrocodeine liqd 7.5-4-3 mg/5ml.................................59
POLY-TUSSIN EX -phenylephrine-dihydrocodeine-gg
syrup 5-7.5-50 mg/5ml.....................................................60
POLY-VI-FLOR/IRON - ped multiple vitamin w/ fl-fe
biphasic susp 0.25-7 mg/ml ..........................................120
POLY-VI-FLOR/IRON - ped multiple vit w/ fl-fe biphasic
chew tab 0.5-10 mg ......................................................120
POLY-VI-FLOR - ped multiple vit w/ fluoride biphasic chew
tab 0.25 mg .................................................................. 120
228
tab 0.5 mg .................................................................... 120
tab 1 mg ....................................................................... 120
POLY-VI-FLOR - ped multiple vit w/ fluoride biphasic susp
0.25 mg/ml ....................................................................120
POLY-VITAMIN/IRON/FLUORID - pediatric multiple
vitamins w/ fl-fe drops 0.5-10 mg/ml .............................120
POMALYST -pomalidomide cap 1 mg...............................14
PONSTEL -mefenamic acid cap 250 mg.........................105
PONTOCAINE -tetracaine hcl soln 2%........................... 152
POTABA -potassium aminobenzoate cap 500 mg.......... 116
POTABA -potassium aminobenzoate tab 500 mg........... 116
potassium bicarbonate effer tab 25 meq.....................126
potassium chloride cap cr 10 meq (Micro-k)...............126
potassium chloride cap cr 8 meq (Micro-k).................126
POTASSIUM CHLORIDE ER -potassium chloride tab cr
20 meq (1500 mg)......................................................... 126
potassium chloride microencapsulated crys cr tab 10
meq................................................................................ 126
potassium chloride microencapsulated crys cr tab 20
meq................................................................................ 126
potassium chloride oral liq 10% (20 meq/15ml).......... 126
potassium chloride oral liq 20% (40 meq/15ml).......... 126
potassium chloride powder packet 20 meq................ 126
potassium chloride powder packet 25 meq................ 126
potassium chloride tab cr 10 meq (K-tab)................... 126
potassium chloride tab cr 8 meq (600 mg)..................126
potassium citrate & citric acid powder pack 3300-1002
mg.................................................................................... 75
potassium citrate & citric acid soln 1100-334
mg/5ml.............................................................................75
POTASSIUM CITRATE ER -potassium citrate tab cr 15
meq (1620 mg)................................................................ 75
POTASSIUM CITRATE -potassium citrate tab cr 10 meq
(1080 mg).........................................................................75
POTASSIUM CITRATE -potassium citrate tab cr 5 meq
(540 mg)...........................................................................75
POTASSIUM HYDROXIDE -potassium hydroxide solution
5%.................................................................................. 160
pot bicarbonate & chloride effer tab 25 meq...............126
POTIGA -ezogabine tab 200 mg..................................... 111
POTIGA -ezogabine tab 50 mg....................................... 111
pot phos monobasic w/sod phos di & monobas tab
155-852-130mg (K-phos neutral)................................ 126
PRADAXA -dabigatran etexilate mesylate cap 150 mg
(etexilate base eq)......................................................... 131
PRADAXA -dabigatran etexilate mesylate cap 75 mg
(etexilate base eq)......................................................... 131
2014
pramipexole dihydrochloride tab 0.125 mg
(Mirapex)....................................................................... 113
(Mirapex)....................................................................... 113
(Mirapex)....................................................................... 113
(Mirapex)....................................................................... 113
(Mirapex)....................................................................... 113
pramipexole dihydrochloride tab 1 mg (Mirapex)....... 113
PRAMOSONE E -pramoxine-hc emollient base cream
1-2.5%............................................................................ 153
PRAMOSONE -pramoxine-hc cream 1-1%..................... 152
PRAMOSONE -pramoxine-hc cream 1-2.5%.................. 153
PRAMOSONE -pramoxine-hc lotion 1-1%...................... 153
PRAMOSONE -pramoxine-hc lotion 1-2.5%................... 153
PRAMOSONE -pramoxine-hc oint 1-1%......................... 153
PRAMOSONE -pramoxine-hc oint 1-2.5%...................... 153
PRAMOTIC -pramoxine-chloroxylenol otic liquid
1-0.1%............................................................................ 138
pramoxine-chloroxylenol otic liquid 1-0.1%
(Pramotic)......................................................................138
pramoxine-hc-chloroxylenol aqueous otic soln 10-10-1
mg/ml (Cortane-b aqueous)........................................ 138
pramoxine-hc-chloroxylenol otic soln 10-10-1 mg/ml
(Cortane-b-otic)............................................................ 138
pramoxine-hc cream 1-2.5% (Pramosone).................. 153
pramoxine hcl gel 1%....................................................153
PRANDIMET -repaglinide-metformin hcl tab 1-500 mg..... 26
PRANDIMET -repaglinide-metformin hcl tab 2-500 mg..... 26
PRANDIN -repaglinide tab 0.5 mg.................................... 26
PRANDIN -repaglinide tab 1 mg....................................... 26
PRANDIN -repaglinide tab 2 mg....................................... 27
PRAVACHOL -pravastatin sodium tab 20 mg................... 52
pravastatin sodium tab 10 mg........................................53
pravastatin sodium tab 20 mg (Pravachol)................... 53
prazosin hcl cap 1 mg (Minipress).................................47
PR CREAM - dermatological products misc - kit ............ 152
PRECOSE -acarbose tab 100 mg.....................................27
PRECOSE -acarbose tab 25 mg.......................................27
PRECOSE -acarbose tab 50 mg.......................................27
PRED FORTE -prednisolone acetate ophth susp 1%......136
PRED-G -gentamicin-prednisolone ace ophth susp
0.3-1%............................................................................ 136
PRED-G S.O.P. -gentamicin-prednisolone ace ophth oint
0.3-0.6%......................................................................... 136
PRED MILD -prednisolone acetate ophth susp
0.12%............................................................................. 136
prednicarbate cream 0.1% (Dermatop)........................ 153
prednicarbate oint 0.1% (Dermatop)............................ 153
prednisolone acetate ophth susp 1% (Pred forte)...... 136
PREDNISOLONE SODIUM PHOSP -prednisolone sodium
phosphate ophth soln 1%.............................................. 136
PREDNISOLONE SODIUM PHOSP -prednisolone sodium
phosphate oral soln 25 mg/5ml (base eq)....................... 17
prednisolone sod phosphate oral soln 15 mg/5ml
(base equiv).................................................................... 17
prednisolone sod phosph oral soln 6.7 mg/5ml (5
mg/5ml base) (Pediapred)............................................. 17
prednisolone syrup 15 mg/5ml (usp solution
equivalent) (Prelone)......................................................17
PREDNISONE INTENSOL -prednisone conc 5 mg/ml...... 17
PREDNISONE -prednisone oral soln 5 mg/5ml.................17
PREDNISONE -prednisone tab 10 mg dose pack.............17
PREDNISONE -prednisone tab 50 mg..............................17
PREDNISONE -prednisone tab 5 mg dose pack...............17
prednisone tab 10 mg..................................................... 17
prednisone tab 10 mg dose pack.................................. 17
prednisone tab 1 mg....................................................... 17
prednisone tab 2.5 mg.................................................... 17
prednisone tab 20 mg..................................................... 17
prednisone tab 5 mg....................................................... 17
prednisone tab 5 mg dose pack.................................... 17
PREFERA OB + DHA -prenat-fe poly cmplx-fe heme polyfa tab & omega 3 cap pck............................................. 120
PREFERAOB ONE - prenat-fe poly cmplx-fe heme poly-fadha cap 22-6-1-200 mg ................................................ 120
PREFERA OB - prenat vit-fe poly cmplx-fe heme poly-fa
tab 28-6-1 mg ............................................................... 120
PREFEST -estradiol tab 1 mg(15)/estrad-norgestimate tab
1-0.09mg(15)....................................................................20
PRE-FOLIC -folic acid-vitamin c tab 1-100 mg................130
PRELONE -prednisolone syrup 15 mg/5ml (usp solution
equivalent)........................................................................17
PREMARIN -estrogens, conjugated tab 0.3 mg................ 20
PREMARIN -estrogens, conjugated tab 0.45 mg.............. 20
PREMARIN -estrogens, conjugated tab 0.625 mg............ 20
PREMARIN -estrogens, conjugated tab 0.9 mg................ 20
PREMARIN -estrogens, conjugated tab 1.25 mg.............. 20
PREMARIN -estrogens, conjugated vaginal cream 0.625
mg/gm.............................................................................. 74
PREMPHASE -conj est 0.625(14)/conj est-medroxypro ac
tab 0.625-5mg(14)........................................................... 20
PREMPRO -conjugated estrogen-medroxyprogest acetate
tab 0.3-1.5 mg................................................................. 20
tab 0.45-1.5 mg............................................................... 20
tab 0.625-2.5 mg..............................................................20
tab 0.625-5 mg................................................................ 20
PRENA1/QUATREFOLIC - prenat w/o a w/ fe fummethylfol-fa-dha cap 30-0.6-0.4 mg ..............................121
229
2014
PRENA1 CHEW/QUATREFOLIC - prenat w/ b2-b6-b12d3-methylfol-fa chew tab 0.6-0.4 mg ............................ 121
PRENA1 PEARL - prenat w/oa w/fefum-na fered-fa-dha
cap cr 30-1.4-200 mg ................................................... 121
PRENA1 PLUS/QUATREFOLIC -prenat w/o a w/ fe
chelate-l methylfol-fa tab & dha cap pk......................... 121
PRENAFIRST - prenatal vit w/ fe fumarate-fa tab 17-1 mg
....................................................................................... 120
PRENAISSANCE BALANCE - prenatal w/o vit a w/ fe cbndss-fa-dha cap 30-1-260 mg ........................................ 120
PRENAISSANCE HARMONY DHA -prenat w/fe poly-na
fered-fa tab 27-1 & omega cap dr 380mg......................120
PRENAISSANCE NEXT-B - prenatal w/ calcium-vit b6-faginger tab 1.22 mg ....................................................... 120
PRENAISSANCE NEXT - prenatal w/ calcium-vit b6-faginger tab 1.2 mg ......................................................... 120
PRENAISSANCE PLUS - prenatal w/o a w/fe cbn-dss-fadha cap 28-1-250 mg ................................................... 120
PRENAISSANCE - prenatal w/o vit a w/ fe fum-dss-fa-dha
cap 29-1.25-325 mg ..................................................... 120
PRENATABS FA - prenatal vit w/ fe fumarate-fa tab 29-1
mg ................................................................................. 121
PRENATABS OBN - prenatal w/o a vit w/ fe carbonyl-fa
tab 29-1 mg .................................................................. 121
PRENATABS RX - prenatal vit w/ iron carbonyl-fa tab 29-1
mg ................................................................................. 121
PRENATAL 19 - prenatal vit w/ dss-fe fumarate-fa tab 29-1
mg ................................................................................. 121
PRENATAL 19 - prenatal vit w/ fe fumarate-fa chew tab
29-1 mg ........................................................................ 121
PRENATAL AD - prenatal vit w/ dss-iron carbonyl-fa tab
90-1 mg ........................................................................ 121
PRENATAL PLUS IRON - prenatal vit w/ iron carbonyl-fa
tab 29-1 mg .................................................................. 121
PRENATAL-U - prenatal w/o a vit w/ fe fumarate-fa cap
106.5-1 mg ................................................................... 121
PRENATE DHA - prenat w/o a w/ fe fum-methylfol-fa-dha
cap 28-0.6-0.4 mg ........................................................ 121
PRENATE ELITE - prenatal vit w/ fe fum-methylfolate-fa
tab 26-0.6-0.4 mg ......................................................... 121
PRENATE ESSENTIAL - prenat w/o a w/feasp-methylf-faomeg cap 29-0.6-0.4-340 mg ....................................... 121
PRENATE MINI - prenat w/o a w/fecbn-methylf-fa-dha cap
29-0.6-0.4-350 mg ........................................................ 121
PRENATE -prenat mv & min w/ l-methylfolate-fa chew tab
0.6-0.4 mg......................................................................121
PRENEXA - prenatal w/o vit a w/ fe fum-dss-fa-dha cap
27-1.25-300 mg ............................................................ 121
PRENTIF CAVITY-RIM CERVIC -cervical cap 22
mm................................................................................. 161
mm................................................................................. 161
mm................................................................................. 161
230
mm................................................................................. 161
PRENTIF FITTING SET - cervical caps ......................... 161
PREPIDIL -dinoprostone cervical gel 0.5 mg/3gm.............30
PREPOPIK -sod picosulfate-mg oxide-citric acid pack 10
mg-3.5 gm-12 gm............................................................ 65
PREQUE 10 - prenatal mv w/fe carbonyl-dss-fa-dha tab
15-25-0.5-50 mg ........................................................... 121
PRESERA - emollient - aerosol foam .............................153
PREVACID -lansoprazole cap delayed release 15 mg...... 68
PREVACID -lansoprazole cap delayed release 30 mg...... 68
PREVACID SOLUTAB -lansoprazole tab delayed release
orally disintegrating 15 mg...............................................68
PREVACID SOLUTAB -lansoprazole tab delayed release
orally disintegrating 30 mg...............................................68
PREVIDENT 5000 BOOSTER PL -sodium fluoride paste
1.1%............................................................................... 139
PREVIDENT 5000 BOOSTER -sodium fluoride paste
1.1%............................................................................... 139
PREVIDENT 5000 DRY MOUTH -sodium fluoride gel
1.1% (0.5% f)................................................................. 139
PREVIDENT 5000 ENAMEL PRO -sodium fluoridepotassium nitrate paste 1.1-5%..................................... 139
PREVIDENT 5000 PLUS -sodium fluoride cream
1.1%............................................................................... 140
PREVIDENT 5000 SENSITIVE -sodium fluoride-potassium
nitrate paste 1.1-5%.......................................................140
PREVIDENT FLUORIDE -sodium fluoride gel 1.1% (0.5%
f)..................................................................................... 139
PREVIDENT -sodium fluoride rinse 0.2%........................139
PREVPAC -amoxicillin cap-clarithro tab-lansopraz cap dr
therapy pack.................................................................... 68
PREZISTA -darunavir ethanolate susp 100 mg/ml (base
equiv)..................................................................................9
PREZISTA -darunavir ethanolate tab 150 mg (base
equiv)..................................................................................9
equiv)..................................................................................9
equiv)..................................................................................9
equiv)..................................................................................9
equiv)..................................................................................9
PRIFTIN -rifapentine tab 150 mg........................................ 6
PRILOSEC -omeprazole cap delayed release 10 mg........68
PRILOSEC -omeprazole magnesium for delayed release
susp packet 10 mg.......................................................... 68
PRILOSEC -omeprazole magnesium for delayed release
susp packet 2.5 mg......................................................... 68
PRIMAQUINE PHOSPHATE -primaquine phosphate tab
26.3 mg............................................................................ 11
primidone tab 250 mg (Mysoline).................................111
2014
primidone tab 50 mg (Mysoline).................................. 111
PRIMLEV -oxycodone w/ acetaminophen tab 10-300
mg.................................................................................. 101
PRIMLEV -oxycodone w/ acetaminophen tab 5-300
mg.................................................................................. 101
PRIMLEV -oxycodone w/ acetaminophen tab 7.5-300
mg.................................................................................. 101
PRIMSOL -trimethoprim hcl oral soln 50 mg/5ml (base
equiv)................................................................................12
PRINIVIL -lisinopril tab 10 mg........................................... 47
PRINIVIL -lisinopril tab 20 mg........................................... 47
PRINIVIL -lisinopril tab 5 mg............................................. 47
PRINZIDE -lisinopril & hydrochlorothiazide tab 10-12.5
mg.................................................................................... 47
PRINZIDE -lisinopril & hydrochlorothiazide tab 20-12.5
mg.................................................................................... 47
PRISTIQ -desvenlafaxine succinate tab sr 24hr 100 mg
(base equiv)..................................................................... 80
PRISTIQ -desvenlafaxine succinate tab sr 24hr 50 mg
(base equiv)..................................................................... 80
PR NATAL 400 EC -prenat-fe bis-fe prot succ-fa-ca tab &
omega cap dr 400 pk.................................................... 120
PR NATAL 400 -prenat-fe bis-fe prot succ-fa-ca tab &
omega 3 cap 400 pk......................................................120
PR NATAL 430 EC -prenat-fe bis-fe prot succ-fa-ca tab &
omega cap dr 430 pk.................................................... 120
PR NATAL 430 -prenat-fe bis-fe prot succ-fa-ca tab &
omega 3 cap 430 pk......................................................120
PROAIR HFA -albuterol sulfate inhal aero 108 mcg/act
(90mcg base equiv)......................................................... 63
probenecid tab 500 mg................................................. 107
PROCARDIA -nifedipine cap 10 mg..................................40
PROCARDIA XL -nifedipine tab sr 24hr osmotic 30
mg.................................................................................... 40
mg.................................................................................... 40
mg.................................................................................... 40
PROCENTRA -dextroamphetamine sulfate oral solution 5
mg/5ml..............................................................................89
prochlorperazine maleate tab 10 mg (Compazine)....... 83
prochlorperazine maleate tab 5 mg (Compazine)......... 83
prochlorperazine suppos 25 mg.................................... 83
PRO-CLEAR AC -codeine-pyrilamine syrup 9-8.33
mg/5ml..............................................................................60
PROCORT -hydrocortisone acetate w/ pramoxine rectal
cream 1.85-1.15%..........................................................141
PROCRIT -epoetin alfa inj 10000 unit/ml........................ 130
PROCRIT -epoetin alfa inj 2000 unit/ml.......................... 130
PROCTOCORT -hydrocortisone acetate suppos 30
mg.................................................................................. 141
PROCTOCORT -hydrocortisone rectal cream 1%...........141
PROCTOFOAM HC -hydrocortisone acetate w/ pramoxine
rectal foam 1-1%............................................................141
PROCYSBI -cysteamine bitartrate cap delayed release 25
mg (base equiv)............................................................... 75
PROCYSBI -cysteamine bitartrate cap delayed release 75
mg (base equiv)............................................................... 75
PRODRIN -acetaminophen-isometheptene-caffeine tab
325-65-20 mg.................................................................106
PRODRIN -acetaminophen-isometheptene-caffeine tab
500-130-20 mg...............................................................106
PROFERRIN-FORTE -iron heme polypeptide-folic acid tab
12-1 mg (fe equiv)......................................................... 130
progesterone im in oil 50 mg/ml.................................... 23
(Prometrium)...................................................................23
(Prometrium)...................................................................23
PROGLYCEM -diazoxide susp 50 mg/ml..........................27
PROGRAF -tacrolimus cap 0.5 mg................................. 165
PROGRAF -tacrolimus cap 1 mg.................................... 165
PROGRAF -tacrolimus cap 5 mg.................................... 165
PROHIST CD -phenyleph-triprolidine-chlophedianol liqd
10-2.5-25 mg/5ml.............................................................60
PROHIST CF -chlophedianol-triprolidine liqd 25-2.5
mg/5ml..............................................................................60
PROHIST LQ -triprolidine-phenylephrine liquid 2.5-10
mg/5ml..............................................................................60
PROLENSA -bromfenac sodium ophth soln 0.07% (base
equivalent)......................................................................136
PROMACTA -eltrombopag olamine tab 12.5 mg (base
equiv)..............................................................................130
PROMACTA -eltrombopag olamine tab 25 mg (base
equiv)..............................................................................130
equiv)..............................................................................130
equiv)..............................................................................130
PROMAR -iron & b12 w/ vitamin cap.............................. 121
promethazine & phenylephrine syrup 6.25-5
mg/5ml.............................................................................60
promethazine-dm syrup 6.25-15 mg/5ml....................... 60
promethazine hcl suppos 12.5 mg.................................56
promethazine hcl suppos 25 mg....................................56
promethazine hcl syrup 6.25 mg/5ml.............................56
promethazine hcl tab 12.5 mg........................................ 56
promethazine hcl tab 25 mg...........................................56
promethazine hcl tab 50 mg...........................................56
PROMETHAZINE VC/CODEINE -phenylephrinepromethazine w/ codeine syrup 5-6.25-10 mg/5ml.......... 60
PROMETHAZINE VC PLAIN -promethazine &
phenylephrine syrup 6.25-5 mg/5ml.................................60
promethazine w/ codeine syrup 6.25-10 mg/5ml...........60
PROMETHEGAN -promethazine hcl suppos 50 mg..........56
PROMETRIUM -progesterone micronized cap 100 mg..... 23
231
2014
PROMETRIUM -progesterone micronized cap 200 mg..... 23
PROMISEB - antiseborrheic products misc - cream ....... 153
PROMISEB COMPLETE - antiseborrheic products misc kit .................................................................................. 153
propafenone hcl cap sr 12hr 225 mg (Rythmol sr)....... 41
propafenone hcl tab 150 mg (Rythmol)......................... 41
propafenone hcl tab 225 mg (Rythmol)......................... 41
propafenone hcl tab 300 mg.......................................... 41
PROPANTHELINE BROMIDE -propantheline bromide tab
15 mg............................................................................... 68
proparacaine hcl ophth soln 0.5% (Alcaine)............... 136
PROPRANOLOL/HYDROCHLOROTH -propranolol &
PROPRANOLOL/HYDROCHLOROTH -propranolol &
propranolol hcl cap sr 24hr 120 mg (Inderal la)............37
propranolol hcl cap sr 24hr 160 mg (Inderal la)............37
propranolol hcl cap sr 24hr 60 mg (Inderal la)..............37
propranolol hcl cap sr 24hr 80 mg (Inderal la)..............37
PROPRANOLOL HCL -propranolol hcl oral soln 20
mg/5ml..............................................................................37
PROPRANOLOL HCL -propranolol hcl oral soln 40
mg/5ml..............................................................................37
propranolol hcl tab 10 mg.............................................. 37
PROPYLENE GLYCOL -propylene glycol....................... 164
propylthiouracil tab 50 mg............................................. 29
PRO-RED AC -phenylephrine-dexchlorphenir-codeine
syrup 5-1-9 mg/5ml..........................................................60
PROSCAR -finasteride tab 5 mg.......................................75
PROSED/DS -methenamine-hyosc-meth blue-benz acidphenyl sal tab 81.6mg..................................................... 72
PROSTIGMIN -neostigmine bromide tab 15 mg............. 115
PROSTIN E2 -dinoprostone vaginal suppos 20 mg...........30
PROTECTBONE -multiple vit w/ min & calcium-folic acid
wafer 500-1 mg..............................................................121
PROTECTIRON -iron polysacch-fa-b complex-vit c-e &
minerals tab 60-1 mg.....................................................130
PROTECTNATAL - prenatal vit w/poly fe-fa-fish oil tab dr
13.5-0.5-700 mg ........................................................... 121
PROTECT PLUS - multiple vitamins w/ minerals cap .....121
PROTECT PLUS - multiple vitamins w/ minerals liquid
....................................................................................... 121
PROTECT PLUS NR - multiple vitamins w/ minerals cap
....................................................................................... 121
PROTHELIAL - sucralfate-malate paste 10% .................140
PROTID -chlorphen-phenylephrine w/ apap tab cr
8-40-500 mg.....................................................................60
PROTONIX -pantoprazole sodium ec tab 20 mg (base
equiv)................................................................................68
232
PROTONIX -pantoprazole sodium ec tab 40 mg (base
equiv)................................................................................68
PROTONIX -pantoprazole sodium for delayed release
susp packet 40 mg.......................................................... 68
PROTOPIC -tacrolimus oint 0.03%................................. 153
PROTOPIC -tacrolimus oint 0.1%................................... 153
protriptyline hcl tab 10 mg (Vivactil)............................. 80
protriptyline hcl tab 5 mg (Vivactil)............................... 80
PROVENTIL HFA -albuterol sulfate inhal aero 108 mcg/act
(90mcg base equiv)......................................................... 64
PROVERA -medroxyprogesterone acetate tab 10 mg...... 23
PROVERA -medroxyprogesterone acetate tab 2.5 mg......23
PROVERA -medroxyprogesterone acetate tab 5 mg........ 23
PROVIGIL -modafinil tab 100 mg......................................89
PROVIGIL -modafinil tab 200 mg......................................89
PROZAC -fluoxetine hcl cap 10 mg.................................. 80
PROZAC WEEKLY -fluoxetine hcl cap delayed release 90
mg.................................................................................... 80
PRUCLAIR - emollient - cream ...................................... 153
PRUDOXIN -doxepin hcl cream 5%................................ 153
PRUMYX - emollient - cream ......................................... 153
PRUTECT - wound dressings - emulsion .......................153
PRYFLEX - glucosamine-chondroitin-paba-vit e-alpha
lipoic acid tab ................................................................160
pseudoeph-chlorphen w/ hydrocodone soln 60-4-5
mg/5ml (Zutripro)........................................................... 60
pseudoephed-bromphen-dm syrup 30-2-10 mg/5ml.....60
pseudoephedrine-bromphen-codeine liq 10-1.33-6.33
mg/5ml.............................................................................60
pseudoephedrine w/ cod-gg soln 30-10-100
mg/5ml.............................................................................60
pseudoephedrine w/ cod-gg syrup 30-10-100 mg/5ml
(Suttar-sf)........................................................................ 60
P-SILOXAN DS - cream base ........................................ 163
PULMICORT -budesonide inhalation susp 0.25
mg/2ml..............................................................................64
PULMICORT -budesonide inhalation susp 0.5 mg/2ml..... 64
PULMICORT -budesonide inhalation susp 1 mg/2ml........ 64
PULMICORT FLEXHALER -budesonide inhal aero powd
180 mcg/act (breath activated)........................................ 64
PULMICORT FLEXHALER -budesonide inhal aero powd
90 mcg/act (breath activated).......................................... 64
PULMOZYME -dornase alfa inhal soln 1 mg/ml................ 65
PUREFE OB PLUS - prenatal w/o a w/fe fum-fe poly-fa
cap 162.115.2-1 mg ......................................................121
PUREFE PLUS - ferrous fumarate-fa-b complex-c-zn-mgmn-cu cap 106-1 mg .................................................... 130
PURIFIED WATER - distilled water ................................164
PURINETHOL -mercaptopurine tab 50 mg....................... 15
PYLERA -bismuth subcit-metronidazole-tetracycline cap
140-125-125 mg...............................................................68
pyrazinamide tab 500 mg..................................................6
PYRIDIUM -phenazopyridine hcl tab 100 mg.................... 75
2014
PYRIDIUM -phenazopyridine hcl tab 200 mg.................... 75
pyridostigmine bromide tab 60 mg (Mestinon)........... 116
PYROGALLIC ACID -pyrogallol-chlorobutanol oint
25-2%............................................................................. 153
Q
Q-CARE Q2 ORAL CLEANSING/ - oral hygiene products kit .................................................................................. 161
Q-CARE Q4 ORAL CLEANSING/ - oral hygiene products kit .................................................................................. 161
QNASL -beclomethasone dipropionate nasal aerosol 80
mcg/act.............................................................................56
QSYMIA -phentermine hcl-topiramate cap sr 24hr
11.25-69 mg.....................................................................89
QSYMIA -phentermine hcl-topiramate cap sr 24hr 15-92
mg.................................................................................... 89
QSYMIA -phentermine hcl-topiramate cap sr 24hr 3.75-23
mg.................................................................................... 89
QSYMIA -phentermine hcl-topiramate cap sr 24hr 7.5-46
mg.................................................................................... 89
Q-TABS -levomefolate glucosamine tab 1 mg (folate
equivalent)......................................................................126
QUALAQUIN -quinine sulfate cap 324 mg........................ 11
QUARTETTE -levonor-eth est tab 0.15-0.02/0.025/0.03
mg &eth est 0.01 mg....................................................... 23
QUAZEPAM -quazepam tab 15 mg.................................. 85
QUESTRAN -cholestyramine powder 4 gm/dose.............. 53
QUESTRAN -cholestyramine powder packets 4 gm......... 53
QUESTRAN LIGHT -cholestyramine light powder 4 gm/
dose..................................................................................53
QUESTRAN LIGHT -cholestyramine light powder packets
4 gm................................................................................. 53
quetiapine fumarate tab 100 mg (Seroquel).................. 83
quetiapine fumarate tab 25 mg (Seroquel).................... 83
quetiapine fumarate tab 50 mg (Seroquel).................... 83
QUILLIVANT XR -methylphenidate hcl for er susp 25
mg/5ml (5 mg/ml).............................................................89
quinapril hcl tab 10 mg (Accupril)................................. 47
quinapril hcl tab 5 mg (Accupril)................................... 47
quinapril-hydrochlorothiazide tab 10-12.5 mg
(Accuretic).......................................................................47
quinapril-hydrochlorothiazide tab 20-12.5 mg
(Accuretic).......................................................................47
quinapril-hydrochlorothiazide tab 20-25 mg
(Accuretic).......................................................................47
quinidine gluconate tab cr 324 mg................................ 41
QUINIDINE SULFATE ER -quinidine sulfate tab cr 300
mg.................................................................................... 41
QUINIDINE SULFATE -quinidine sulfate tab 200 mg........ 41
quinidine sulfate tab 200 mg.......................................... 41
quinidine sulfate tab 300 mg.......................................... 41
quinine sulfate cap 324 mg (Qualaquin)........................11
QUIXIN -levofloxacin ophth soln 0.5%............................ 136
QVAR -beclomethasone dipropionate inhal aero soln 40
mcg/act.............................................................................64
QVAR -beclomethasone dipropionate inhal aero soln 80
mcg/act.............................................................................64
R
rabeprazole sodium ec tab 20 mg (Aciphex).................68
RADIAGEL - wound dressings - gel ...............................153
RADIAPLEXRX - wound dressings - gel ........................ 153
RADIGEL - dermatological products misc - gel .............. 153
RADIOGARDASE -prussian blue insoluble cap 0.5
gm.................................................................................. 160
RAGWITEK -short ragweed pollen allergen extract tab sl
12 amb a 1-u................................................................... 12
raloxifene hcl tab 60 mg (Evista)................................... 34
ramipril cap 1.25 mg (Altace)......................................... 47
ramipril cap 10 mg (Altace)............................................ 47
ramipril cap 2.5 mg (Altace)........................................... 47
ramipril cap 5 mg (Altace).............................................. 47
RANEXA -ranolazine tab sr 12hr 1000 mg........................36
RANEXA -ranolazine tab sr 12hr 500 mg..........................36
ranitidine hcl cap 150 mg............................................... 68
ranitidine hcl cap 300 mg............................................... 68
ranitidine hcl syrup 15 mg/ml (75 mg/5ml)....................68
ranitidine hcl tab 150 mg (Zantac)................................. 68
ranitidine hcl tab 300 mg (Zantac)................................. 68
RAPAFLO -silodosin cap 4 mg......................................... 75
RAPAFLO -silodosin cap 8 mg......................................... 75
RAPAMUNE -sirolimus oral soln 1 mg/ml....................... 165
RAPAMUNE -sirolimus tab 0.5 mg..................................165
RAPAMUNE -sirolimus tab 1 mg.....................................165
RAPAMUNE -sirolimus tab 2 mg.....................................165
RAPPORT RING LOADING SYST - impotence aid device
- kit ................................................................................161
RAPPORT VACUUM THERAPY DE - impotence aid
device - kit .................................................................... 161
RASPBERRY SYRUP -raspberry syrup.......................... 164
RAVICTI -glycerol phenylbutyrate liquid 1.1 gm/ml........... 34
RAYOS -prednisone tab delayed release 1 mg.................17
RAZADYNE ER -galantamine hydrobromide cap sr 24hr
16 mg............................................................................... 92
RAZADYNE ER -galantamine hydrobromide cap sr 24hr
24 mg............................................................................... 92
RAZADYNE ER -galantamine hydrobromide cap sr 24hr 8
mg.................................................................................... 92
RAZADYNE -galantamine hydrobromide oral soln 4 mg/
ml......................................................................................92
RAZADYNE -galantamine hydrobromide tab 12 mg..........92
RAZADYNE -galantamine hydrobromide tab 4 mg............92
RAZADYNE -galantamine hydrobromide tab 8 mg............92
REACH KIDS -sodium fluoride paste 0.15%................... 140
233
2014
REAPHIRM - prenatal mv w/ fe polysac cmplx-fa-dha cap
29-1-200 mg ................................................................. 121
REBETOL -ribavirin cap 200 mg......................................... 9
REBETOL -ribavirin soln 40 mg/ml..................................... 9
REBIF -interferon beta-1a inj 22 mcg/0.5ml (12mu/ml) (44
mcg/ml).............................................................................92
REBIF -interferon beta-1a inj 44 mcg/0.5ml (24mu/ml) (88
mcg/ml).............................................................................92
REBIF REBIDOSE -interferon beta-1a inj 22 mcg/0.5ml
(12mu/ml) (44 mcg/ml).....................................................92
REBIF REBIDOSE -interferon beta-1a inj 44 mcg/0.5ml
(24mu/ml) (88 mcg/ml).....................................................92
REBIF REBIDOSE TITRATION -interferon beta-1a inj 6 x
8.8 mcg/0.2ml & 6 x 22 mcg/0.5ml.................................. 92
REBIF TITRATION PACK -interferon beta-1a inj 6 x 8.8
mcg/0.2ml & 6 x 22 mcg/0.5ml........................................ 92
RECOTHROM SPRAY KIT -thrombin (recombinant) for
soln 20000 unit.............................................................. 132
RECOTHROM -thrombin (recombinant) for soln 20000
unit..................................................................................132
RECOTHROM -thrombin (recombinant) for soln 5000
unit..................................................................................132
RECTIV -nitroglycerin oint 0.4%......................................141
REGENECARE -lidocaine hcl-collagen-aloe vera gel
2%.................................................................................. 153
REGLAN -metoclopramide hcl tab 10 mg......................... 71
REGLAN -metoclopramide hcl tab 5 mg........................... 71
REGRANEX -becaplermin gel 0.01%..............................153
RELAGARD -acetic acid-oxyquinoline vaginal gel
0.9-0.025%....................................................................... 74
RELAGESIC -phenyltoloxamine-acetaminophen tab
50-650 mg........................................................................94
RELAMINE - glucosamine-chondroitin-paba-vit e-alpha
lipoic acid tab ................................................................160
RELENZA DISKHALER -zanamivir aero powder breath
activated 5 mg/blister.........................................................9
RELHIST -bromphen tan-phenyleph tan chew tab 6-15
mg.................................................................................... 60
RELION R -insulin regular (human) inj 100 unit/ml............27
RELISTOR -methylnaltrexone bromide inj 12 mg/0.6ml (20
mg/ml).............................................................................. 71
RELISTOR -methylnaltrexone bromide inj 8 mg/0.4ml (20
mg/ml).............................................................................. 71
RELISTOR -methylnaltrexone bromide inj kit 12
mg/0.6ml...........................................................................71
RELNATE DHA - prenatal vit w/ fe fum-fa-omega 3 cap
28-1-200 mg ................................................................. 121
RELPAX -eletriptan hydrobromide tab 20 mg (base
equivalent)......................................................................106
RELPAX -eletriptan hydrobromide tab 40 mg (base
equivalent)......................................................................106
REMBRANDT CANKER SORE -sodium fluoride paste
0.243%........................................................................... 140
REMBRANDT DEEPLY WHITE+PE -sodium
monofluorophosphate paste 0.884%............................. 140
234
REMBRANDT INTENSE STAIN -sodium fluoride paste
0.243%........................................................................... 140
REMBRANDT WHITENING -sodium fluoride rinse
0.02%............................................................................. 140
REMERON -mirtazapine tab 15 mg.................................. 80
REMERON SOLTAB -mirtazapine orally disintegrating tab
15 mg............................................................................... 80
30 mg............................................................................... 80
45 mg............................................................................... 80
REMESENSE - dental desensitizing product - misc ....... 161
RENACIDIN -citric acid & d-gluconic acid soln..................75
RENAGEL -sevelamer hcl tab 400 mg..............................71
RENAGEL -sevelamer hcl tab 800 mg..............................71
RENATABS -b-complex w/ c-biotin-vit e & folic acid tab 1
mg.................................................................................. 121
RENATABS WITH IRON -b complex-c-biotin-e-fa tab 1mg
& fe cbn tab 100 mg pack............................................. 121
RENAX -multiple vitamins w/ minerals & fa tab 2.5
mg.................................................................................. 121
RENVELA -sevelamer carbonate packet 0.8 gm...............71
RENVELA -sevelamer carbonate packet 2.4 gm...............71
RENVELA -sevelamer carbonate tab 800 mg................... 71
repaglinide tab 0.5 mg (Prandin)....................................27
repaglinide tab 1 mg (Prandin).......................................27
repaglinide tab 2 mg (Prandin).......................................27
REPREXAIN -hydrocodone-ibuprofen tab 2.5-200
mg.................................................................................. 101
REPREXAIN -hydrocodone-ibuprofen tab 5-200 mg....... 101
REPRONEX -menotropins for inj 75 unit...........................34
REQ 49+ - multiple vitamins w/ minerals tab ..................121
REQUIP -ropinirole hydrochloride tab 0.25 mg............... 113
REQUIP -ropinirole hydrochloride tab 0.5 mg................. 113
REQUIP -ropinirole hydrochloride tab 1 mg.................... 113
REQUIP XL -ropinirole hydrochloride tab sr 24hr 12 mg
(base equivalent)........................................................... 114
(base equivalent)........................................................... 113
(base equivalent)........................................................... 113
(base equivalent)........................................................... 113
(base equivalent)........................................................... 113
RESCON -chlorphen-pe-methscopolamine tab sr 12hr
12-40-1.25 mg..................................................................60
RESCON-JR -chlorpheniramine & phenylephrine tab sr
12hr 4-20 mg................................................................... 60
2014
RESCON-JR -dexchlorpheniramine-phenylephrine tab sr
12hr 3-20 mg................................................................... 60
RESCON-MX -dexchlorpheniramine-phenylephrine tab sr
12hr 6-40 mg................................................................... 60
RESCRIPTOR -delavirdine mesylate tab 100 mg............... 9
RESCRIPTOR -delavirdine mesylate tab 200 mg............... 9
RESCULA -unoprostone isopropyl ophth soln 0.15%......136
RESERPINE -reserpine tab 0.1 mg.................................. 47
RESERPINE -reserpine tab 0.25 mg.................................47
RESPA-BR -brompheniramine maleate tab sr 12hr 11
mg.................................................................................... 56
RESTASIS -cyclosporine (ophth) emulsion 0.05%.......... 136
RESTORE SILVER DRESSING 2 - wound dressings pads .............................................................................. 153
RESTORIL -temazepam cap 15 mg..................................85
RESTORIL -temazepam cap 22.5 mg...............................85
RESTORIL -temazepam cap 30 mg..................................85
RESTORIL -temazepam cap 7.5 mg.................................85
RETIN-A MICRO PUMP -tretinoin microsphere gel
0.04%............................................................................. 153
RETIN-A MICRO PUMP -tretinoin microsphere gel
0.1%............................................................................... 153
RETIN-A MICRO -tretinoin microsphere gel 0.04%.........153
RETIN-A MICRO -tretinoin microsphere gel 0.1%...........153
RETIN-A -tretinoin cream 0.025%................................... 153
RETIN-A -tretinoin cream 0.05%..................................... 153
RETIN-A -tretinoin cream 0.1%....................................... 153
RETIN-A -tretinoin gel 0.01%.......................................... 153
RETIN-A -tretinoin gel 0.025%........................................ 153
RETROVIR -zidovudine cap 100 mg...................................9
RETROVIR -zidovudine syrup 10 mg/ml............................. 9
RETROVIR -zidovudine tab 300 mg................................... 9
REVATIO -sildenafil citrate tab 20 mg...............................54
REVIA -naltrexone hcl tab 50 mg....................................160
REVLIMID -lenalidomide cap 10 mg............................... 165
REVLIMID -lenalidomide cap 5 mg................................. 165
REVLIMID -lenalidomide caps 2.5 mg.............................165
REYATAZ -atazanavir sulfate cap 100 mg (base equiv)......9
REZIRA -pseudoephedrine w/ hydrocodone soln 60-5
mg/5ml..............................................................................60
REZYST SB -saccharomyces boulardii chew tab 250
mg.................................................................................... 66
RHEUMATREX -methotrexate sodium tab 2.5 mg
(antirheumatic)............................................................... 105
RHINOCORT AQUA -budesonide nasal susp 32 mcg/
act.....................................................................................56
RHINOFLEX-650 -phenyltoloxamine-acetaminophen tab
50-650 mg........................................................................94
RIAX -benzoyl peroxide foam 5.5%................................ 153
RIAX -benzoyl peroxide foam 9.5%................................ 153
RIBASPHERE RIBAPAK -ribavirin tab 200 mg & ribavirin
tab 400 mg dose pack.....................................................10
RIBASPHERE RIBAPAK -ribavirin tab 400 mg................. 10
RIBASPHERE RIBAPAK -ribavirin tab 400 mg & ribavirin
tab 600 mg dose pack.....................................................10
RIBASPHERE RIBAPAK -ribavirin tab 600 mg................. 10
RIBASPHERE -ribavirin tab 400 mg................................... 9
RIBASPHERE -ribavirin tab 600 mg................................. 10
RIBATAB -ribavirin tab 400 mg......................................... 10
RIBATAB -ribavirin tab 400 mg & ribavirin tab 600 mg
dose pack.........................................................................10
RIBATAB -ribavirin tab 600 mg......................................... 10
ribavirin cap 200 mg (Rebetol)....................................... 10
ribavirin tab 200 mg (Copegus)......................................10
RIDAURA -auranofin cap 3 mg....................................... 105
rifabutin cap 150 mg (Mycobutin).................................... 6
RIFADIN -rifampin cap 150 mg........................................... 6
RIFADIN -rifampin cap 300 mg........................................... 6
RIFAMATE -isoniazid & rifampin cap 150-300 mg.............. 6
rifampin cap 150 mg (Rifadin).......................................... 6
rifampin cap 300 mg (Rifadin).......................................... 6
RIFATER -isoniazid-rifampin w/ pyrazinamide tab
50-120-300 mg...................................................................6
RILUTEK -riluzole tab 50 mg.......................................... 114
riluzole tab 50 mg (Rilutek).......................................... 114
rimantadine hydrochloride tab 100 mg (Flumadine).....10
ringer's solution for irrigation...................................... 165
RINNOVI NAIL SYSTEM -urea soln 50% w/ cleanser
spray & protectant spray kit........................................... 153
RIOMET -metformin hcl oral soln 500 mg/5ml.................. 27
RISPERDAL M-TAB -risperidone orally disintegrating tab
0.5 mg.............................................................................. 84
RISPERDAL M-TAB -risperidone orally disintegrating tab 1
mg.................................................................................... 84
mg.................................................................................... 84
mg.................................................................................... 84
mg.................................................................................... 84
RISPERDAL -risperidone soln 1 mg/ml.............................84
RISPERDAL -risperidone tab 0.25 mg.............................. 83
RISPERDAL -risperidone tab 0.5 mg................................ 83
RISPERDAL -risperidone tab 1 mg................................... 83
risperidone orally disintegrating tab 0.25 mg............... 84
235
2014
risperidone orally disintegrating tab 0.5 mg (Risperdal
m-tab).............................................................................. 84
risperidone orally disintegrating tab 1 mg (Risperdal
m-tab).............................................................................. 84
m-tab).............................................................................. 84
m-tab).............................................................................. 84
m-tab).............................................................................. 84
risperidone soln 1 mg/ml (Risperdal)............................ 84
risperidone tab 0.25 mg (Risperdal).............................. 84
risperidone tab 0.5 mg (Risperdal)................................ 84
risperidone tab 1 mg (Risperdal)................................... 84
RITALIN LA -methylphenidate hcl cap sr 24hr 10 mg........89
RITALIN -methylphenidate hcl tab 10 mg..........................89
RITALIN -methylphenidate hcl tab 20 mg..........................89
RITALIN -methylphenidate hcl tab 5 mg........................... 89
RITALIN SR -methylphenidate hcl tab cr 20 mg................89
rivastigmine tartrate cap 1.5 mg (Exelon)..................... 92
rivastigmine tartrate cap 3 mg (Exelon)........................ 92
rivastigmine tartrate cap 4.5 mg (Exelon)..................... 92
rivastigmine tartrate cap 6 mg (Exelon)........................ 92
rizatriptan benzoate orally disintegrating tab 10 mg
(Maxalt-mlt)................................................................... 106
rizatriptan benzoate orally disintegrating tab 5 mg
(Maxalt-mlt)................................................................... 106
rizatriptan benzoate tab 10 mg (Maxalt)...................... 106
rizatriptan benzoate tab 5 mg (Maxalt)........................ 106
ROBAXIN-750 -methocarbamol tab 750 mg................... 115
ROBAXIN -methocarbamol tab 500 mg.......................... 115
ROBINUL FORTE -glycopyrrolate tab 2 mg......................68
ROBINUL -glycopyrrolate tab 1 mg...................................68
ROCALTROL -calcitriol cap 0.25 mcg...............................34
ROCALTROL -calcitriol cap 0.5 mcg.................................34
ROCALTROL -calcitriol oral soln 1 mcg/ml....................... 34
ropinirole hydrochloride tab 0.25 mg (Requip)........... 114
ropinirole hydrochloride tab 0.5 mg (Requip)............. 114
ropinirole hydrochloride tab 1 mg (Requip)................114
ropinirole hydrochloride tab sr 24hr 12 mg (base
equivalent) (Requip xl)................................................ 114
236
ROSADAN KIT -metronidazole cream 0.75% w/ cleanser
kit....................................................................................153
ROSADAN KIT -metronidazole gel 0.75% w/ cleanser
kit....................................................................................153
ROSANIL -sulfacetamide sod-sulfur emul 10-5% & skin
cleanser kit.....................................................................153
ROWASA -mesalamine rectal enema 4 gm & cleanser
wipe kit............................................................................. 71
ROXICET -oxycodone w/ acetaminophen soln 5-325
mg/5ml............................................................................101
ROXICODONE -oxycodone hcl tab 15 mg......................101
ROXICODONE -oxycodone hcl tab 30 mg......................101
ROXICODONE -oxycodone hcl tab 5 mg........................101
ROZEREM -ramelteon tab 8 mg....................................... 85
RTD WOUND CARE DRESSING - wound dressings pads .............................................................................. 153
RYBIX ODT -tramadol hcl orally disintegrating tab 50
mg.................................................................................. 101
RYDEX -pseudoephedrine-bromphen-codeine liq
10-1.33-6.33 mg/5ml........................................................ 60
RYTHMOL -propafenone hcl tab 150 mg.......................... 41
RYTHMOL -propafenone hcl tab 225 mg.......................... 41
RYTHMOL SR -propafenone hcl cap sr 12hr 225 mg....... 41
RYZOLT -tramadol hcl tab sr 24hr biphasic release 100
mg.................................................................................. 101
mg.................................................................................. 101
mg.................................................................................. 101
S
SABRIL -vigabatrin powd pack 500 mg...........................111
SABRIL -vigabatrin tab 500 mg.......................................111
SACCHARIN SODIUM -sodium saccharin granules....... 126
SACCHARIN SODIUM -sodium saccharin powder......... 126
SAFYRAL -drospirenone-ethinyl estrad-levomefolate tab
3-0.03-0.451 mg...............................................................23
SAIZEN CLICK.EASY -somatropin (non-refrigerated) for
inj 8.8 mg......................................................................... 34
SAIZEN -somatropin (non-refrigerated) for inj 5 mg.......... 34
SAIZEN -somatropin (non-refrigerated) for inj 8.8 mg....... 34
SALAGEN -pilocarpine hcl tab 5 mg............................... 140
SALAGEN -pilocarpine hcl tab 7.5 mg............................ 140
SALEX CREAM -salicylic acid cream 6% & cleanser liqd
kit....................................................................................153
SALEX LOTION -salicylic acid lotion 6% & cleanser liqd
kit....................................................................................153
SALEX -salicylic acid shampoo 6%.................................153
SALICEPT - oral wound care products - for susp rinse
....................................................................................... 140
2014
salicylic acid cream 6%................................................ 154
salicylic acid cream 6% & cleanser liqd kit (Salex
cream)............................................................................141
salicylic acid film forming liquid 27.5% (Virasal)........ 154
salicylic acid foam 6% (Salvax)....................................154
salicylic acid gel 6% (Keralyt)...................................... 154
SALICYLIC ACID IN AMMONIU -salicylic acid in
ammonium lactate vehicle foam 6%.............................. 154
salicylic acid lotion 6%................................................. 154
salicylic acid lotion 6% & cleanser liqd kit (Salex
lotion)............................................................................ 141
SALICYLIC ACID -salicylic acid soln 26%.......................153
salicylic acid shampoo 6% (Salex).............................. 154
SALKERA -salicylic acid in ammonium lactate vehicle
foam 6%.........................................................................154
salsalate tab 500 mg....................................................... 94
salsalate tab 750 mg....................................................... 94
SALT STABLE LO - cream base ................................... 164
SALT STABLE LS ADVANCED - cream base ................164
SALVAX DUO PLUS -salicylic acid foam 6% & urea in
lactic acid foam 35% kit.................................................154
SALVAX -salicylic acid foam 6%..................................... 154
SAMSCA -tolvaptan tab 15 mg......................................... 34
SAMSCA -tolvaptan tab 30 mg......................................... 34
SANARE SCAR THERAPY - scar treatment products cream ............................................................................ 154
SANCTURA -trospium chloride tab 20 mg........................ 73
SANCTURA XR -trospium chloride cap sr 24hr 60 mg......73
SANCUSO -granisetron td patch 3.1 mg/24hr (contains
34.3 mg)...........................................................................69
SANDIMMUNE -cyclosporine cap 100 mg...................... 165
SANDIMMUNE -cyclosporine cap 25 mg........................ 165
SANDIMMUNE -cyclosporine oral soln 100 mg/ml..........165
SANDOSTATIN -octreotide acetate inj 1000 mcg/ml (1 mg/
ml).................................................................................... 34
SANDOSTATIN -octreotide acetate inj 100 mcg/ml (0.1
mg/ml).............................................................................. 34
mg/ml).............................................................................. 34
mg/ml).............................................................................. 34
mg/ml).............................................................................. 34
SANTYL -collagenase oint 250 unit/gm...........................154
SAPHRIS -asenapine maleate sl tab 10 mg (base
equiv)................................................................................84
SAPHRIS -asenapine maleate sl tab 5 mg (base
equiv)................................................................................84
SARAFEM -fluoxetine hcl (pmdd) tab 10 mg.....................92
SARAFEM -fluoxetine hcl (pmdd) tab 20 mg.....................92
SAVELLA -milnacipran hcl tab 100 mg............................. 92
SAVELLA -milnacipran hcl tab 12.5 mg............................ 92
SAVELLA -milnacipran hcl tab 25 mg............................... 92
SAVELLA -milnacipran hcl tab 50 mg............................... 92
SAVELLA TITRATION PACK -milnacipran hcl tab 12.5 mg
(5) & 25 mg (8) & 50 mg (42) pak................................... 92
SCALACORT DK -hc lot 2% & sal acid-sulfur shampoo
2-2% & shampoo kit...................................................... 154
SEASONIQUE -levonorg-eth est tab 0.15-0.03mg(84) &
eth est tab 0.01mg(7)...................................................... 23
SE BPO 7-5.5 WASH KIT -benzoyl peroxide wash 7% &
benzoyl peroxide cream 5.5% kit...................................154
SEB-PREV -sulfacetamide sodium lotion 10%................ 154
SE-CARE CONCEIVE - prenatal w/o a vit w/ fe fumaratefa tab 30-1 mg ..............................................................121
SE-CARE - prenatal w/o a vit w/ fe fum-fa tab chew 40-1
mg ................................................................................. 121
SECONAL -secobarbital sodium cap 100 mg....................86
SECTRAL -acebutolol hcl cap 200 mg..............................37
SECTRAL -acebutolol hcl cap 400 mg..............................37
SEDAPAP -butalbital-acetaminophen tab 50-650 mg....... 94
SELECT-OB+DHA -prenatal mv w/fe poly-fa chw 29-1 mg
& dha cap 250 mg pak .................................................122
SELECT-OB - prenatal vit w/ fe polysac cmplx-fa chew tab
29-1 mg ........................................................................ 122
selegiline hcl cap 5 mg (Eldepryl)................................114
selegiline hcl tab 5 mg..................................................114
selenium sulfide lotion 2.5%........................................ 154
selenium sulfide-pyrithione zinc in urea shampoo
2.25%............................................................................. 154
SELENIUM SULFIDE -selenium sulfide-pyrithione zinc in
urea shampoo 2.25%.....................................................154
SELRX -selenium sulfide-pyrithione zinc in urea shampoo
2.3%............................................................................... 154
SELSUN SHAMPOO -selenium sulfide lotion 2.5%........ 154
SELZENTRY -maraviroc tab 150 mg................................ 10
SELZENTRY -maraviroc tab 300 mg................................ 10
SEMPREX-D -acrivastine & pseudoephedrine cap 8-60
mg.................................................................................... 60
SE-NATAL 19 - prenatal vit w/ dss-fe fumarate-fa tab 29-1
mg ................................................................................. 121
SE-NATAL 19 - prenatal vit w/ fe fumarate-fa chew tab
29-1 mg ........................................................................ 121
SE-NATAL 90 - prenatal vit w/ dss-fe fumarate-fa tab cr
90-1 mg ........................................................................ 122
SE-NATAL ONE - prenatal vit w/ fe fumarate-fa tab 60-1
mg ................................................................................. 121
SENILEZOL - iron combination elixir ..............................130
SENNA LEAVES - senna leaves ..................................... 65
SENNA -senna powder..................................................... 65
SENSIPAR -cinacalcet hcl tab 30 mg (base equiv)........... 34
SE-PLETE DHA - prenatal vit w/ fe fum-fa-omega 3 cap
28-1.25-200 mg ............................................................ 122
SEPTRA DS -sulfamethoxazole-trimethoprim tab 800-160
mg.................................................................................... 12
SEREVENT DISKUS -salmeterol xinafoate aer pow ba 50
mcg/dose (base equiv).................................................... 64
237
2014
SEROMYCIN -cycloserine cap 250 mg...............................6
SEROQUEL -quetiapine fumarate tab 100 mg..................84
SEROQUEL -quetiapine fumarate tab 25 mg....................84
SEROQUEL -quetiapine fumarate tab 50 mg....................84
SEROQUEL XR -quetiapine fumarate tab sr 24hr 150
mg.................................................................................... 84
mg.................................................................................... 84
mg.................................................................................... 84
mg.................................................................................... 84
mg.................................................................................... 84
SEROSTIM -somatropin (non-refrigerated) for
subcutaneous inj 4 mg.....................................................34
sertraline hcl oral conc 20 mg/ml (Zoloft)..................... 80
sertraline hcl tab 100 mg (Zoloft)...................................80
sertraline hcl tab 25 mg (Zoloft).....................................80
sertraline hcl tab 50 mg (Zoloft).....................................80
SE-TAN DHA - prenatal w/fe fum-fe poly -fa-omega 3 cap
15-15-1 mg ................................................................... 122
SETON ET-EC -prenat-fe bis-fe prot succ-fa-ca tab &
omega cap dr 430 pk.................................................... 122
SETONET -prenat-fe bis-fe prot succ-fa-ca tab & omega 3
cap 430 pk..................................................................... 122
SEVELAMER CARBONATE -sevelamer carbonate tab
800 mg............................................................................. 71
sevoflurane inhal soln (Ultane).................................... 107
SFROWASA -mesalamine sulfite-free (sf) enema 4
gm/60ml............................................................................71
SHOHLS SOLUTION MODIFIED -sodium citrate & citric
acid soln 500-334 mg/5ml............................................... 75
SIDEROL - multiple vitamins w/ minerals tab .................122
sildenafil citrate tab 20 mg (Revatio).............................54
SILENOR -doxepin hcl (sleep) tab 3 mg (base equiv)....... 86
SILENOR -doxepin hcl (sleep) tab 6 mg (base equiv)....... 86
SILPROTEX PLUS - cream base ...................................164
SILVADENE -silver sulfadiazine cream 1%.....................154
SILVASORB - wound dressings - gel .............................154
silver nitrate-potassium nitrate applicator 75-25%
(Arzol silver nitrate)..................................................... 154
SILVER NITRATE -silver nitrate oint 10%.......................154
SILVER NITRATE -silver nitrate soln 0.5%..................... 154
SILVER NITRATE -silver nitrate soln 10%...................... 154
238
SILVERSEAL HYDROGEL DRESS - silver - pad 2"x3"
....................................................................................... 154
SILVERSEAL HYDROGEL DRESS - silver - pad 4"x5"
....................................................................................... 154
silver sulfadiazine cream 1% (Silvadene)....................154
SILVRSTAT WOUND DRESSING - silver - gel ..............154
SIMBRINZA -brinzolamide-brimonidine tartrate ophth susp
1-0.2%............................................................................ 136
SIMCOR -niacin-simvastatin tab sr 24hr 1000-20 mg....... 53
SIMCOR -niacin-simvastatin tab sr 24hr 1000-40 mg....... 53
SIMCOR -niacin-simvastatin tab sr 24hr 500-20 mg......... 53
SIMPLE SYRUP -simple - syrup..................................... 164
SIMPONI -golimumab subcutaneous inj 100 mg/ml........ 105
SIMPONI -golimumab subcutaneous inj 50 mg/0.5ml..... 105
simvastatin tab 10 mg (Zocor)....................................... 53
simvastatin tab 5 mg (Zocor)......................................... 53
SINEMET -carbidopa & levodopa tab 10-100 mg............114
SINEMET CR -carbidopa & levodopa tab cr 25-100
mg.................................................................................. 114
SINEMET CR -carbidopa & levodopa tab cr 50-200
mg.................................................................................. 114
SINGULAIR -montelukast sodium chew tab 4 mg (base
equiv)................................................................................64
SINGULAIR -montelukast sodium chew tab 5 mg (base
equiv)................................................................................64
SINGULAIR -montelukast sodium oral granules packet 4
mg (base equiv)............................................................... 64
SINGULAIR -montelukast sodium tab 10 mg (base
equiv)................................................................................64
sirolimus tab 0.5 mg (Rapamune)................................ 165
SIRTURO -bedaquiline fumarate tab 100 mg (base
equiv)..................................................................................6
SITAVIG -acyclovir buccal tab 50 mg................................10
SKELAXIN -metaxalone tab 800 mg............................... 115
SKELID -tiludronate disodium tab 200 mg (tiludronic acid
equivalent)........................................................................34
SKLICE -ivermectin lotion 0.5%...................................... 154
SM B-COMPLEX/VITAMIN C -b-complex w/ c & folic acid
tab.................................................................................. 122
SODIUM BICARBONATE - sodium bicarbonate powder
......................................................................................... 66
sodium chloride irrigation soln 0.9%.............................75
sodium chloride soln nebu 0.9%................................... 60
sodium chloride soln nebu 10%.................................... 60
sodium chloride soln nebu 3%...................................... 60
sodium chloride soln nebu 7% (Hyper-sal)................... 60
sodium citrate & citric acid soln 500-334 mg/5ml
(Shohls solution modi).................................................. 75
2014
SODIUM CITRATE -sodium citrate granules.....................75
sodium fluoride chew tab 0.25 mg f (from 0.55 mg naf)
(Luride).......................................................................... 126
sodium fluoride chew tab 0.5 mg f (from 1.1 mg naf)
(Luride).......................................................................... 126
sodium fluoride chew tab 1 mg f (from 2.2 mg naf)
(Luride).......................................................................... 126
sodium fluoride cream 1.1% (Prevident 5000
plus)...............................................................................140
sodium fluoride gel 1.1% (0.5% f) (Prevident
fluoride)......................................................................... 140
sodium fluoride paste 1.1% (Prevident 5000
boost)............................................................................ 140
sodium fluoride-potassium nitrate paste 1.1-5%
(Prevident 5000 sensi)................................................. 140
sodium fluoride rinse 0.0221% (0.01% f)..................... 140
sodium fluoride rinse 0.05%.........................................140
sodium fluoride rinse 0.2% (Prevident)....................... 140
SODIUM FLUORIDE -sodium fluoride tab 0.5 mg f (from
1.1 mg naf).................................................................... 126
SODIUM FLUORIDE -sodium fluoride tab 1 mg f (from 2.2
mg naf)...........................................................................126
sodium fluoride soln 0.125 mg/drop f (0.275 mg/drop
naf).................................................................................126
sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml naf)
(Luride).......................................................................... 126
SODIUM HYDROXIDE -sodium hydroxide solution
10%................................................................................ 160
SODIUM HYPOCHLORITE -sodium hypochlorite soln
5%.................................................................................. 159
sodium phenylbutyrate oral powder 3 gm/teaspoonful
(Buphenyl).......................................................................34
sodium polystyrene sulfonate oral susp 15 gm/60ml
(Sps).............................................................................. 165
sodium polystyrene sulfonate powder
(Kayexalate).................................................................. 164
sodium polystyrene sulfonate rectal susp 30
gm/120ml.......................................................................165
SODIUM SACCHARIN DIHYDRAT -sodium saccharin
powder............................................................................126
SODIUM SACCHARIN -sodium saccharin granules....... 126
SODIUM SULFACETAMIDE/SULF -sulfacetamide
sodium-sulfur in urea emulsion 10-5%.......................... 154
SODIUM SULFACETAMIDE/SULF -sulfacetamide
sodium-sulfur in urea gel 10-5%....................................154
SODIUM SULFACETAMIDE/SULF -sulfacetamide sodium
w/ sulfur susp 10-5%..................................................... 154
SODIUM SULFACETAMIDE/UREA -sulfacetamide
sodium-urea pad 10%....................................................154
SODIUM SULFACETAMIDE WASH -sulfacetamide
sodium in bakuchiol vehicle wash 10%......................... 154
sodium thiosulfate-salicylic acid lotion 25-1%........... 154
SOLARAZE -diclofenac sodium (actinic keratoses) gel
3%.................................................................................. 154
SOLODYN -minocycline hcl tab sr 24hr 105 mg................. 5
SOLODYN -minocycline hcl tab sr 24hr 45 mg................... 5
SOLTAMOX -tamoxifen citrate oral soln 10 mg/5ml (base
equivalent)........................................................................15
SOMA -carisoprodol tab 250 mg..................................... 115
SOMA -carisoprodol tab 350 mg..................................... 115
SOMATULINE DEPOT -lanreotide acetate extended
release inj 120 mg/0.5ml................................................. 34
release inj 60 mg/0.2ml................................................... 34
release inj 90 mg/0.3ml................................................... 34
SOMAVERT -pegvisomant for inj 10 mg (as protein)........ 34
SOMNOTE -chloral hydrate cap 500 mg...........................86
SONAFINE - wound dressings - emulsion ..................... 155
SONATA -zaleplon cap 10 mg.......................................... 86
SONATA -zaleplon cap 5 mg............................................ 86
SORBITOL-MANNITOL -sorbitol-mannitol irrigation soln
2.7-0.54 gm/100ml........................................................... 75
SORBITOL -sorbitol irrigation soln 3.3%........................... 75
SORBITOL -sorbitol irrigation soln 3%.............................. 75
SORIATANE -acitretin cap 10 mg................................... 155
SORIATANE -acitretin cap 17.5 mg................................ 155
SORIATANE -acitretin cap 25 mg................................... 155
SORILUX -calcipotriene foam 0.005%............................ 155
sotalol hcl (afib/afl) tab 120 mg (Betapace af)...............37
sotalol hcl (afib/afl) tab 160 mg (Betapace af)...............37
sotalol hcl (afib/afl) tab 80 mg (Betapace af)................ 37
sotalol hcl tab 120 mg (Betapace)................................. 37
sotalol hcl tab 160 mg (Betapace)................................. 37
sotalol hcl tab 240 mg.................................................... 37
sotalol hcl tab 80 mg (Betapace)................................... 37
SOVALDI -sofosbuvir tab 400 mg..................................... 10
SPATONE PUR-ABSORB IRON -ferrous sulfate liquid 5
mg/20ml (elemental iron)............................................... 130
SPECTRACEF -cefditoren pivoxil tab 200 mg (base
equivalent)..........................................................................2
SPECTRACEF -cefditoren pivoxil tab 400 mg (base
equivalent)..........................................................................2
SPECTRAGEL - wound dressings - gel ......................... 155
SPINOSAD -spinosad susp 0.9%....................................155
SPIRIVA HANDIHALER -tiotropium bromide monohydrate
inhal cap 18 mcg (base equiv)........................................ 64
spironolactone & hydrochlorothiazide tab 25-25 mg
(Aldactazide)................................................................... 50
spironolactone tab 100 mg (Aldactone)........................ 50
spironolactone tab 25 mg (Aldactone).......................... 50
spironolactone tab 50 mg (Aldactone).......................... 50
239
2014
SPORANOX -itraconazole cap 100 mg...............................7
SPORANOX -itraconazole oral soln 10 mg/ml.................... 7
SPORANOX PULSEPAK -itraconazole cap 100 mg........... 7
SPRIX -ketorolac tromethamine nasal spray 15.75 mg/
spray...............................................................................105
SPRYCEL -dasatinib tab 100 mg...................................... 15
SPRYCEL -dasatinib tab 140 mg...................................... 15
SPRYCEL -dasatinib tab 20 mg........................................ 15
SPS -sodium polystyrene sulfonate oral susp 15
gm/60ml..........................................................................165
SSKI -potassium iodide soln 1 gm/ml..............................126
SSS 10-4 -sulfacetamide sodium w/ sulfur foam
10-4%............................................................................. 155
STAFLEX -phenyltoloxamine-acetaminophen tab 55-500
mg.................................................................................... 94
STALEVO 100 -carbidopa-levodopa-entacapone tabs
25-100-200 mg...............................................................114
31.25-125-200 mg..........................................................114
37.5-150-200 mg............................................................114
50-200-200 mg...............................................................114
12.5-50-200 mg..............................................................114
18.75-75-200 mg............................................................114
stannous fluoride conc 0.63% (Gel-kam oral care
ri)....................................................................................140
stannous fluoride gel 0.4%........................................... 140
STARLIX -nateglinide tab 120 mg.....................................27
STARLIX -nateglinide tab 60 mg.......................................27
STATUSS GREEN -codeine-pseudoephedrinechlorcyclizine liq 9-30-12.5 mg/5ml..................................60
stavudine cap 15 mg (Zerit)............................................10
stavudine for oral soln 1 mg/ml (Zerit).......................... 10
STAVZOR -valproic acid cap delayed release 125
mg.................................................................................. 111
mg.................................................................................. 111
mg.................................................................................. 111
STAXYN -vardenafil hcl orally disintegrating tab 10
mg.................................................................................... 55
STELARA -ustekinumab inj 45 mg/0.5ml........................ 155
STELARA -ustekinumab inj 90 mg/ml............................. 155
STENDRA -avanafil tab 100 mg........................................55
STENDRA -avanafil tab 200 mg........................................55
STENDRA -avanafil tab 50 mg......................................... 55
240
STERA BASE - cream base .......................................... 164
STIMATE -desmopressin acetate nasal soln 1.5 mg/
ml......................................................................................34
STIVARGA -regorafenib tab 40 mg...................................15
STRATTERA -atomoxetine hcl cap 100 mg (base
equiv)................................................................................89
equiv)................................................................................89
equiv)................................................................................89
equiv)................................................................................89
equiv)................................................................................89
equiv)................................................................................89
equiv)................................................................................89
STRIANT -testosterone buccal mucoadhesive system 30
mg.................................................................................... 18
STRIBILD -elvitegrav-cobicis-emtricitab-tenofov tab
150-150-200-300 mg....................................................... 10
STROMECTOL -ivermectin tab 3 mg................................ 11
STROVITE -b-complex w/ c & folic acid tab.................... 122
STROVITE FORTE -multiple vitamins w/ minerals & fa
syrup 1 mg/15ml............................................................ 122
STROVITE FORTE - multiple vitamins w/ minerals tab
....................................................................................... 122
STROVITE ONE - multiple vitamins w/ minerals tab ...... 122
SUBOXONE -buprenorphine hcl-naloxone hcl sl film 12-3
mg (base equiv)............................................................. 101
SUBOXONE -buprenorphine hcl-naloxone hcl sl film 2-0.5
mg (base equiv)............................................................. 101
mg (base equiv)............................................................. 101
mg (base equiv)............................................................. 101
SUBOXONE -buprenorphine hcl-naloxone hcl sl tab 2-0.5
mg (base equiv)............................................................. 101
SUBOXONE -buprenorphine hcl-naloxone hcl sl tab 8-2
mg (base equiv)............................................................. 101
SUBSYS -fentanyl sublingual spray 100 mcg..................101
SUBSYS -fentanyl sublingual spray 1200 mcg (600 mcg x
2).................................................................................... 101
SUBSYS -fentanyl sublingual spray 1600 mcg (800 mcg x
2).................................................................................... 101
SUBUTEX -buprenorphine hcl sl tab 2 mg (base
equiv)..............................................................................101
SUBUTEX -buprenorphine hcl sl tab 8 mg (base
equiv)..............................................................................101
2014
SUCLEAR -na sulf-k sulf-mg sulf & peg 3350-nacl-na
bicarb-kcl kit..................................................................... 65
SUCRAID -sacrosidase soln 8500 unit/ml......................... 70
sucralfate tab 1 gm (Carafate)........................................68
SULAR -nisoldipine tab sr 24hr 17 mg.............................. 40
SULAR -nisoldipine tab sr 24hr 25.5 mg........................... 40
SULAR -nisoldipine tab sr 24hr 34 mg.............................. 40
SULAR -nisoldipine tab sr 24hr 8.5 mg............................. 40
sulfacetamide sodium cleansing gel 10% (Ovace plus
wash)............................................................................. 155
sulfacetamide sodium liquid 10% (Ovace wash)........ 155
sulfacetamide sodium lotion 10% (acne) (Klaron)...... 155
sulfacetamide sodium ophth soln 10% (Bleph-10)..... 136
sulfacetamide sodium-prednisolone ophth soln
10-0.23(0.25)%...............................................................136
sulfacetamide sodium shampoo 10% (Ovace
plus)...............................................................................155
SULFACETAMIDE SODIUM -sulfacetamide sodium ophth
oint 10%......................................................................... 136
sulfacetamide sodium-sulfur in urea emulsion
10-4%............................................................................. 155
sulfacetamide sodium-sulfur w/ sunscreens cream
10-5% ............................................................................141
sulfacetamide sodium w/ sulfur cleanser 10-2% (Avar
ls cleanser)................................................................... 155
sulfacetamide sodium w/ sulfur cleansing cloth
10-5%............................................................................. 155
sulfacetamide sodium w/ sulfur cleansing pad 10-4%
(Sumaxin)...................................................................... 155
sulfacetamide sodium w/ sulfur cream 10-2% (Avar-e
ls)................................................................................... 155
sulfacetamide sodium w/ sulfur cream 10-5%............ 155
sulfacetamide sodium w/ sulfur emulsion 10-1%....... 155
sulfacetamide sodium w/ sulfur emulsion 10-5%....... 155
sulfacetamide sodium w/ sulfur foam 10-5% (Clarifoam
ef)................................................................................... 155
sulfacetamide sodium w/ sulfur lotion 10-5%............. 155
sulfacetamide sodium w/ sulfur susp 8-4% (Sumaxin
ts)................................................................................... 155
sulfacetamide sodium w/ sulfur wash 9-4.5%
(Sumadan wash).......................................................... 155
sulfacetamide sodium w/ sulfur wash 9-4% (Sumaxin
wash)............................................................................. 155
sulfacetamide sod-sulfur wash 9-4.5% & skin cleanser
kit (Sumadan kit)..........................................................141
SULFADIAZINE -sulfadiazine tab 500 mg...........................6
sulfamethoxazole-trimethoprim susp 200-40
mg/5ml.............................................................................12
sulfamethoxazole-trimethoprim tab 400-80 mg
(Bactrim)..........................................................................12
sulfamethoxazole-trimethoprim tab 800-160 mg
(Bactrim ds).................................................................... 12
SULFAMYLON -mafenide acetate cream 85 mg/gm....... 155
SULFAMYLON -mafenide acetate packet for topical soln
5% (50 gm).................................................................... 155
sulfasalazine tab 500 mg (Azulfidine)............................71
sulfasalazine tab delayed release 500 mg (Azulfidine
en-tabs)........................................................................... 71
SULFOAM -sulfur shampoo 2%...................................... 155
SULFURATED LIME -sulfurated lime solution................ 155
sulindac tab 150 mg...................................................... 105
sulindac tab 200 mg...................................................... 105
SUMADAN KIT -sulfacetamide sod-sulfur wash 9-4.5% &
skin cleanser kit............................................................. 155
SUMADAN WASH -sulfacetamide sodium w/ sulfur wash
9-4.5%............................................................................ 155
SUMADAN XLT -sulfacetamide sod-sulfur wash 9-4.5% &
sunscreen kit..................................................................155
sumatriptan succinate inj 4 mg/0.5ml..........................106
sumatriptan succinate inj 6 mg/0.5ml (Imitrex)...........106
sumatriptan succinate solution auto-injector 4
mg/0.5ml (Imitrex statdose sys)................................. 106
sumatriptan succinate solution auto-injector 6
mg/0.5ml (Imitrex statdose sys)................................. 106
sumatriptan succinate solution cartridge 4 mg/0.5ml
(Imitrex statdose ref)................................................... 107
sumatriptan succinate solution cartridge 6 mg/0.5ml
(Imitrex statdose ref)................................................... 107
sumatriptan succinate solution prefilled syringe 6
mg/0.5ml........................................................................107
SUMATRIPTAN SUCCINATE -sumatriptan succinate inj 4
mg/0.5ml.........................................................................106
SUMATRIPTAN SUCCINATE -sumatriptan succinate
solution prefilled syringe 6 mg/0.5ml............................. 106
sumatriptan succinate tab 100 mg (Imitrex)................107
sumatriptan succinate tab 25 mg (Imitrex)..................107
sumatriptan succinate tab 50 mg (Imitrex)..................107
SUMATRIPTAN -sumatriptan nasal spray 20 mg/act...... 106
SUMATRIPTAN -sumatriptan nasal spray 5 mg/act........ 106
SUMAVEL DOSEPRO -sumatriptan succinate solution jetinjector 6 mg/0.5ml........................................................ 107
SUMAXIN CP KIT -sulfacetamide sod-sulfur pad 10-4% &
skin cleanser kit............................................................. 155
SUMAXIN -sulfacetamide sodium w/ sulfur cleansing pad
10-4%............................................................................. 155
SUMAXIN TS -sulfacetamide sodium w/ sulfur susp
8-4%............................................................................... 155
SUMAXIN WASH -sulfacetamide sodium w/ sulfur wash
9-4%............................................................................... 155
SUPER DAILY D3 -cholecalciferol drops 1000 unit/0.03ml
(per drop)....................................................................... 116
SUPERVITE -b-complex w/ lysine-zn & folic acid
liquid............................................................................... 122
SUPERVITE EC -multiple vitamins w/ minerals & fa tab dr
1 mg............................................................................... 122
SUPPORT-500 - speciality vitamin product cap ............. 122
SUPPORT - multiple vitamins w/ minerals liquid ............ 122
SUPRANE -desflurane inhal soln.................................... 107
SUPRAX -cefixime cap 400 mg.......................................... 2
SUPRAX -cefixime chew tab 100 mg..................................2
241
2014
SUPRAX -cefixime chew tab 200 mg..................................2
SUPRAX -cefixime for susp 100 mg/5ml.............................2
SUPRAX -cefixime tab 400 mg........................................... 2
SUPREP BOWEL PREP -sodium sulfate-potassium
sulfate-magnesium sulfate oral soln................................ 65
SURESTEP PRO TEST STRIPS -glucose blood test
strip.................................................................................160
SURESTEP TEST STRIPS -glucose blood test strip...... 160
SURMONTIL -trimipramine maleate cap 100 mg.............. 80
SURMONTIL -trimipramine maleate cap 25 mg................ 80
SURMONTIL -trimipramine maleate cap 50 mg................ 80
SUSTIVA -efavirenz cap 200 mg...................................... 10
SUSTIVA -efavirenz cap 50 mg........................................ 10
SUSTIVA -efavirenz tab 600 mg....................................... 10
SUTENT -sunitinib malate cap 12.5 mg (base
equivalent)........................................................................15
SUTENT -sunitinib malate cap 25 mg (base
equivalent)........................................................................15
SUTENT -sunitinib malate cap 50 mg (base
equivalent)........................................................................15
SUTTAR-2 -pseudoephedrine w/ cod-gg syrup 30-10-100
mg/5ml..............................................................................60
SUTTAR-SF -pseudoephedrine w/ cod-gg syrup
30-10-100 mg/5ml............................................................60
SYLATRON -peginterferon alfa-2b for inj kit 296 mcg....... 15
SYLATRON -peginterferon alfa-2b for inj kit 4 x 296
mcg...................................................................................15
mcg...................................................................................15
mcg...................................................................................15
SYMAX DUOTAB -hyoscyamine sulfate tab cr 0.375 mg
(0.125 mg ir/0.25 mg cr).................................................. 68
SYMBICORT -budesonide-formoterol fumarate dihyd
aerosol 160-4.5 mcg/act.................................................. 64
SYMBICORT -budesonide-formoterol fumarate dihyd
aerosol 80-4.5 mcg/act.................................................... 64
SYMBYAX -olanzapine-fluoxetine hcl cap 12-25 mg.........92
SYMBYAX -olanzapine-fluoxetine hcl cap 12-50 mg.........92
SYMBYAX -olanzapine-fluoxetine hcl cap 3-25 mg...........92
SYMLINPEN 120 -pramlintide acetate pen-inj 2700
mcg/2.7ml (1000 mcg/ml)................................................ 27
SYMLINPEN 60 -pramlintide acetate pen-inj 1500
mcg/1.5ml (1000 mcg/ml)................................................ 27
SYNAGEX -multiple vitamins w/ minerals & fa cap 1.25
mg.................................................................................. 122
SYNALAR CREAM KIT - fluocinolone cream 0.025%emollient cream kit ........................................................155
SYNALAR -fluocinolone acetonide cream 0.025%.......... 155
242
SYNALAR -fluocinolone acetonide oint 0.025%.............. 155
SYNALAR -fluocinolone acetonide soln 0.01%............... 155
SYNALAR OINTMENT KIT - fluocinolone oint 0.025%emollient cream kit ........................................................156
SYNALAR TS -fluocinolone acetonide soln 0.01% &
cleanser kit.....................................................................156
SYNALGOS-DC -dihydrocodeine compound cap............101
SYNAREL -nafarelin acetate nasal soln 2 mg/ml.............. 34
SYNATEK -multiple vitamins w/ minerals & fa cap 1.25
mg.................................................................................. 122
SYNERA -lidocaine-tetracaine topical patch 70-70
mg.................................................................................. 156
SYNTHROID -levothyroxine sodium tab 100 mcg............. 29
SYNTHROID -levothyroxine sodium tab 25 mcg...............29
SYPRINE -trientine hcl cap 250 mg................................ 165
SYRPALTA - oral vehicles ............................................. 164
SYRPALTA -simple - syrup............................................. 164
T
TABLOID -thioguanine tab 40 mg..................................... 15
TACLONEX -calcipotriene-betamethasone dipropionate
oint 0.005-0.064%..........................................................156
TACLONEX -calcipotriene-betamethasone dipropionate
susp 0.005-0.064%........................................................ 156
tacrolimus cap 0.5 mg (Prograf).................................. 165
tacrolimus cap 0.5 mg (Prograf).................................. 165
tacrolimus cap 1 mg (Prograf)..................................... 165
TAFINLAR -dabrafenib mesylate cap 50 mg (base
equivalent)........................................................................15
TAFINLAR -dabrafenib mesylate cap 75 mg (base
equivalent)........................................................................15
TAMBOCOR -flecainide acetate tab 100 mg.....................41
TAMBOCOR -flecainide acetate tab 150 mg.....................41
TAMBOCOR -flecainide acetate tab 50 mg.......................41
TAMIFLU -oseltamivir phosphate cap 30 mg (base
equiv)................................................................................10
equiv)................................................................................10
equiv)................................................................................10
TAMIFLU -oseltamivir phosphate for susp 12 mg/ml (base
equiv)................................................................................10
2014
TAMIFLU -oseltamivir phosphate for susp 6 mg/ml (base
equiv)................................................................................10
tamoxifen citrate tab 10 mg (base equivalent)..............15
tamoxifen citrate tab 20 mg (base equivalent)..............15
tamsulosin hcl cap 0.4 mg (Flomax)..............................75
TANDEM DHA - prenatal w/fe fum-fe poly -fa-omega 3 cap
15-15-1 mg ................................................................... 122
TANDEM F -ferrous fum-iron polysacch-fa cap
162-115.2-1 mg (106 mg fe)..........................................130
TANDEM OB - prenatal w/o a w/fe fum-fe poly-fa cap
162.115.2-1 mg .............................................................122
TANDEM PLUS - fe fum-iron polysacch complex-fa-b
cmplx-c-zn-mn-cu cap .................................................. 130
TAPAZOLE -methimazole tab 10 mg................................ 29
TAPAZOLE -methimazole tab 5 mg.................................. 29
TARCEVA -erlotinib tab 100 mg........................................15
TARCEVA -erlotinib tab 150 mg........................................15
TARCEVA -erlotinib tab 25 mg......................................... 15
TARGRETIN -bexarotene cap 75 mg................................15
TARGRETIN -bexarotene gel 1%....................................156
TARKA -trandolapril-verapamil hcl tab cr 1-240 mg.......... 47
TARON-BC -prenat w/o a w/ fe cbnyl-fa tab 20-1 mg & vit
b6 tab pak......................................................................122
TARON-C DHA - prenatal w/fe fum-fe poly -fa-omega 3
cap 53.5-38-1 mg ......................................................... 122
TARON-DUO EC -prenat-fe bis-fe prot succ-fa-ca tab &
omega cap dr 400 pk.................................................... 122
TARON EC CALCIUM -prenatal mv w/fe fum-fa tab 28-1
mg & dha cap 250 mg pack ......................................... 122
TARON-EC CAL - prenatal w/o a vit w/ fe fumarate-fa tab
dr 30-1 mg .................................................................... 122
TARON FORTE - fe bisglycinate-fe polysacch-vit c-vit b12fa cap ............................................................................130
TARON-PREX - prenatal w/o vit a w/ fe fum-dss-fa-dha
cap 30-1.2-265 mg ....................................................... 122
TASIGNA -nilotinib cap 150 mg........................................ 15
TASIGNA -nilotinib cap 200 mg........................................ 15
TASMAR -tolcapone tab 100 mg.....................................114
TAZORAC -tazarotene cream 0.05%.............................. 156
TAZORAC -tazarotene cream 0.1%................................ 156
TAZORAC -tazarotene gel 0.05%................................... 156
TAZORAC -tazarotene gel 0.1%..................................... 156
TECFIDERA -dimethyl fumarate capsule delayed release
120 mg............................................................................. 92
TECFIDERA -dimethyl fumarate capsule delayed release
240 mg............................................................................. 92
TECFIDERA STARTER PACK -dimethyl fumarate capsule
dr starter pack 120 mg & 240 mg....................................92
TEGADERM AG MESH DRESSING - wound dressings pads .............................................................................. 156
TEGRETOL -carbamazepine chew tab 100 mg.............. 111
TEGRETOL -carbamazepine susp 100 mg/5ml.............. 111
TEGRETOL -carbamazepine tab 200 mg........................111
TEGRETOL-XR -carbamazepine tab sr 12hr 100 mg......111
TEKAMLO -aliskiren-amlodipine tab 150-10 mg................47
TEKAMLO -aliskiren-amlodipine tab 150-5 mg................. 47
TEKAMLO -aliskiren-amlodipine tab 300-10 mg................47
TEKAMLO -aliskiren-amlodipine tab 300-5 mg................. 47
TEKRAL -diphenhydramine & pseudoephedrine tab sr
12hr 100-120 mg............................................................. 60
TEKTURNA -aliskiren fumarate tab 150 mg (base
equivalent)........................................................................47
TEKTURNA -aliskiren fumarate tab 300 mg (base
equivalent)........................................................................47
TEKTURNA HCT -aliskiren-hydrochlorothiazide tab
150-12.5 mg.....................................................................47
TEKTURNA HCT -aliskiren-hydrochlorothiazide tab 150-25
mg.................................................................................... 47
TEKTURNA HCT -aliskiren-hydrochlorothiazide tab
300-12.5 mg.....................................................................47
TEKTURNA HCT -aliskiren-hydrochlorothiazide tab 300-25
mg.................................................................................... 47
telmisartan-amlodipine tab 40-10 mg (Twynsta)...........47
telmisartan-amlodipine tab 40-5 mg (Twynsta).............47
telmisartan-amlodipine tab 80-10 mg (Twynsta)...........47
telmisartan-amlodipine tab 80-5 mg (Twynsta).............47
telmisartan-hydrochlorothiazide tab 40-12.5 mg
(Micardis hct)..................................................................47
telmisartan-hydrochlorothiazide tab 80-12.5 mg
(Micardis hct)..................................................................47
telmisartan-hydrochlorothiazide tab 80-25 mg
(Micardis hct)..................................................................47
telmisartan tab 20 mg (Micardis)................................... 47
temazepam cap 15 mg (Restoril)................................... 86
temazepam cap 22.5 mg (Restoril).................................86
temazepam cap 30 mg (Restoril)................................... 86
temazepam cap 7.5 mg (Restoril).................................. 86
TEMODAR -temozolomide cap 100 mg............................ 15
TEMODAR -temozolomide cap 20 mg.............................. 15
TEMODAR -temozolomide cap 5 mg................................ 15
TEMOVATE -clobetasol propionate cream 0.05%...........156
TEMOVATE -clobetasol propionate gel 0.05%................156
TEMOVATE -clobetasol propionate oint 0.05%...............156
TEMOVATE -clobetasol propionate soln 0.05%.............. 156
TEMOVATE E -clobetasol propionate emollient base
cream 0.05%..................................................................156
temozolomide cap 100 mg (Temodar)........................... 15
temozolomide cap 20 mg (Temodar)............................. 15
243
2014
temozolomide cap 5 mg (Temodar)............................... 15
TENCON -butalbital-acetaminophen tab 50-650 mg......... 94
TENEX -guanfacine hcl tab 1 mg......................................47
TENEX -guanfacine hcl tab 2 mg......................................48
TENORETIC 100 -atenolol & chlorthalidone tab 100-25
mg.................................................................................... 48
TENORETIC 50 -atenolol & chlorthalidone tab 50-25
mg.................................................................................... 48
TENORMIN -atenolol tab 100 mg..................................... 37
TENORMIN -atenolol tab 25 mg....................................... 37
TENORMIN -atenolol tab 50 mg....................................... 37
TERAZOL 3 -terconazole vaginal cream 0.8%..................74
TERAZOL 3 -terconazole vaginal suppos 80 mg.............. 74
TERAZOL 7 -terconazole vaginal cream 0.4%..................74
terazosin hcl cap 10 mg..................................................48
terazosin hcl cap 1 mg................................................... 48
terbinafine hcl tab 250 mg (Lamisil)................................ 7
TERBINEX -terbinafine oral tab 250 mg & hydrxyprop
chitosan liq 1% kit..............................................................7
terbutaline sulfate tab 2.5 mg.........................................64
terbutaline sulfate tab 5 mg........................................... 64
terconazole vaginal cream 0.4% (Terazol 7)..................74
terconazole vaginal cream 0.8% (Terazol 3)..................74
terconazole vaginal suppos 80 mg................................ 74
TERODERM - cream base .............................................164
TERSI FOAM -selenium sulfide foam 2.25%...................156
TESSALON -benzonatate cap 200 mg..............................60
TESSALON PERLES -benzonatate cap 100 mg...............60
TESTIM -testosterone td gel 50 mg/5gm (1%).................. 18
testosterone cypionate im in oil 100 mg/ml (Depotestosterone)...................................................................18
testosterone cypionate im in oil 200 mg/ml (Depotestosterone)...................................................................18
testosterone enanthate im in oil 200 mg/ml.................. 18
TESTRED -methyltestosterone cap 10 mg........................18
tetracaine hcl ophth soln 0.5%.....................................136
tetracycline hcl cap 250 mg............................................. 5
tetracycline hcl cap 500 mg............................................. 5
TETRACYCLINE HCL -tetracycline hcl cap 250 mg............5
TETRACYCLINE HCL -tetracycline hcl cap 500 mg............5
TETRIX - dermatological products misc - kit .................. 156
TEVETEN -eprosartan mesylate tab 400 mg.................... 48
TEVETEN -eprosartan mesylate tab 600 mg.................... 48
TEVETEN HCT -eprosartan mesylate-hydrochlorothiazide
tab 600-12.5 mg...............................................................48
TEVETEN HCT -eprosartan mesylate-hydrochlorothiazide
tab 600-25 mg................................................................. 48
TEV-TROPIN -somatropin for subcutaneous inj 5 mg....... 34
TEXACORT -hydrocortisone soln 2.5%...........................156
TGQ 15DM/5PEH/2CPM -phenylephrine-chlorphen-dm
syrup 5-2-15 mg/5ml........................................................60
244
TGQ 30PSE/150GFN/15DM -pseudoephedrine w/ dm-gg
syrup 30-15-150 mg/5ml..................................................60
TGQ 30PSE/3BRM/15DM -pseudoephed-bromphen-dm
syrup 30-3-15 mg/5ml......................................................61
TGQ 50PSE/3BRM/30DM -pseudoephed-bromphen-dm
syrup 50-3-30 mg/5ml......................................................61
THALITONE -chlorthalidone tab 15 mg.............................50
THALOMID -thalidomide cap 100 mg..............................165
THALOMID -thalidomide cap 50 mg................................165
THEO-24 -theophylline cap sr 24hr 100 mg...................... 64
theophylline soln 80 mg/15ml........................................ 64
theophylline tab sr 12hr 100 mg.................................... 64
THERA-FLUR-N -sodium fluoride gel 1.1% (0.5% f)....... 140
THERAHONEY - wound dressings - gel ........................ 156
THIOLA -tiopronin tab 100 mg.......................................... 75
thioridazine hcl tab 100 mg............................................ 84
thioridazine hcl tab 10 mg.............................................. 84
thiothixene cap 10 mg.....................................................84
thiothixene cap 1 mg...................................................... 84
THROMBIN-JMI DILUENT -thrombin for soln 20000
unit..................................................................................132
THROMBIN-JMI DILUENT -thrombin for soln 5000
unit..................................................................................132
THROMBIN-JMI EPISTAXIS -thrombin for soln kit 5000
unit..................................................................................132
THROMBIN-JMI SYRINGE SPRA -thrombin for soln kit
20000 unit...................................................................... 132
THROMBIN-JMI SYRINGE SPRA -thrombin for soln kit
5000 unit........................................................................ 132
THROMBIN-JMI W/DIL SPRAY -thrombin for soln kit
20000 unit...................................................................... 132
THROMBOGEN -thrombin for soln 10000 unit................132
THROMBOGEN -thrombin for soln 1000 unit..................132
THROMBOGEN -thrombin for soln kit 10000 unit........... 132
THYROGEN -thyrotropin alfa for inj 1.1 mg.................... 160
thyroid tab 30 mg (1/2 grain) (Armour thyroid)............. 29
thyroid tab 60 mg (1 grain) (Armour thyroid)................ 29
thyroid tab 90 mg (1 1/2 grain) (Armour thyroid).......... 29
THYROLAR-1/2 -liotrix (t3-t4) tab 30 mg (6.25-25
mcg)................................................................................. 29
2014
THYROLAR-1/4 -liotrix (t3-t4) tab 15 mg (3.1-12.5
mcg)................................................................................. 29
THYROLAR-1 -liotrix (t3-t4) tab 60 mg (12.5-50 mcg).......29
THYROLAR-2 -liotrix (t3-t4) tab 120 mg (25-100 mcg)......29
THYROLAR-3 -liotrix (t3-t4) tab 180 mg (37.5-150
mcg)................................................................................. 29
tiagabine hcl tab 2 mg (Gabitril).................................. 111
tiagabine hcl tab 4 mg (Gabitril).................................. 111
TIAZAC -diltiazem hcl extended release beads cap sr 24hr
120 mg............................................................................. 40
180 mg............................................................................. 40
240 mg............................................................................. 40
300 mg............................................................................. 40
360 mg............................................................................. 40
420 mg............................................................................. 40
ticlopidine hcl tab 250 mg............................................ 133
TIGAN -trimethobenzamide hcl cap 300 mg..................... 69
TIKOSYN -dofetilide cap 125 mcg (0.125 mg).................. 41
TIKOSYN -dofetilide cap 250 mcg (0.25 mg).................... 41
TIKOSYN -dofetilide cap 500 mcg (0.5 mg)...................... 41
timolol maleate ophth gel forming soln 0.25%
(Timoptic-xe).................................................................136
timolol maleate ophth gel forming soln 0.5% (Timopticxe).................................................................................. 136
timolol maleate ophth soln 0.25% (Timoptic)..............136
timolol maleate ophth soln 0.5% (Timoptic)................136
TIMOLOL MALEATE -timolol maleate tab 10 mg..............37
TIMOLOL MALEATE -timolol maleate tab 20 mg..............38
TIMOLOL MALEATE -timolol maleate tab 5 mg................37
TIMOPTIC OCUDOSE -timolol maleate preservative free
ophth soln 0.25%........................................................... 136
TIMOPTIC OCUDOSE -timolol maleate preservative free
ophth soln 0.5%............................................................. 136
TIMOPTIC -timolol maleate ophth soln 0.25%................ 136
TIMOPTIC -timolol maleate ophth soln 0.5%.................. 136
TIMOPTIC-XE -timolol maleate ophth gel forming soln
0.25%............................................................................. 137
TIMOPTIC-XE -timolol maleate ophth gel forming soln
0.5%............................................................................... 137
TINDAMAX -tinidazole tab 250 mg................................... 12
TINDAMAX -tinidazole tab 500 mg................................... 12
tinidazole tab 250 mg (Tindamax).................................. 12
tinidazole tab 500 mg (Tindamax).................................. 12
TIROSINT -levothyroxine sodium cap 100 mcg................ 29
TIROSINT -levothyroxine sodium cap 13 mcg.................. 29
TISSEEL - fibrin sealant component kit 10 ml ................ 132
TISSEEL - fibrin sealant component kit 2 ml .................. 132
TISSEEL - fibrin sealant component kit 4 ml .................. 132
TISSEEL - fibrin sealant component solution ................. 132
TIVICAY -dolutegravir sodium tab 50 mg (base equiv)......10
TIZANIDINE COMFORT PAC -tizanidine tab 4 mg &
liniment topical gel pack................................................ 115
tizanidine hcl cap 2 mg (Zanaflex)............................... 115
tizanidine hcl tab 2 mg..................................................115
tizanidine hcl tab 4 mg (Zanaflex)................................115
TL-ASSURE ONE - prenatal mv w/ fe polysac cmplx-fadha cap 29-1-200 mg ................................................... 122
TL-CERMIDE - dermatological products misc - emulsion
....................................................................................... 156
TL-FLUORIVITE - pediatric multiple vitamins w/ fl-fe chew
tab 0.25-7.5 mg ............................................................ 122
TL G-FOL OS -multiple vit w/ min & calcium-folic acid tab
500-1.1 mg.....................................................................122
TL-SELECT DHA - prenatal w/o vit a w/ fe fum-doc-fa-dha
cap 29-1.25-350 mg ..................................................... 122
TL-SELECT - prenatal w/o vit a w/ fe fum-dss-fa-dha cap
29-1.25-325 mg ............................................................ 122
TL TRISEB - antiseborrheic products misc - cream ........156
TOBI PODHALER -tobramycin inhal cap 28 mg................. 6
TOBI -tobramycin nebu soln 300 mg/5ml............................ 6
TOBRADEX ST -tobramycin-dexamethasone ophth susp
0.3-0.05%....................................................................... 137
TOBRADEX -tobramycin-dexamethasone ophth oint
0.3-0.1%......................................................................... 137
TOBRADEX -tobramycin-dexamethasone ophth susp
0.3-0.1%......................................................................... 137
tobramycin-dexamethasone ophth susp 0.3-0.1%
(Tobradex).....................................................................137
tobramycin nebu soln 300 mg/5ml (Tobi)........................6
tobramycin ophth soln 0.3% (Tobrex)......................... 137
TOBREX -tobramycin sulfate ophth oint 0.3%.................137
TOBREX -tobramycin sulfate ophth soln 0.3%................137
TODAY SPONGE - contraceptive sponge ..................... 161
TOFRANIL -imipramine hcl tab 10 mg.............................. 80
TOFRANIL-PM -imipramine pamoate cap 100 mg............ 80
TOFRANIL-PM -imipramine pamoate cap 75 mg.............. 80
tolazamide tab 250 mg.................................................... 27
TOLAZAMIDE -tolazamide tab 500 mg............................. 27
TOLBUTAMIDE -tolbutamide tab 500 mg......................... 27
tolmetin sodium cap 400 mg........................................ 105
TOLMETIN SODIUM -tolmetin sodium tab 200 mg......... 105
245
2014
TOLMETIN SODIUM -tolmetin sodium tab 600 mg......... 105
tolterodine tartrate cap sr 24hr 2 mg (Detrol la)........... 73
tolterodine tartrate cap sr 24hr 4 mg (Detrol la)........... 73
tolterodine tartrate tab 1 mg (Detrol).............................73
tolterodine tartrate tab 2 mg (Detrol).............................73
TOPAMAX SPRINKLE -topiramate sprinkle cap 15
mg.................................................................................. 111
TOPAMAX SPRINKLE -topiramate sprinkle cap 25
mg.................................................................................. 111
TOPAMAX -topiramate tab 100 mg.................................111
TOPAMAX -topiramate tab 200 mg.................................111
TOPAMAX -topiramate tab 25 mg...................................111
TOPAMAX -topiramate tab 50 mg...................................111
TOPICORT -desoximetasone cream 0.05%....................156
TOPICORT -desoximetasone cream 0.25%....................156
TOPICORT -desoximetasone gel 0.05%.........................156
TOPICORT -desoximetasone oint 0.05%........................156
TOPICORT -desoximetasone oint 0.25%........................156
TOPICORT -desoximetasone spray 0.25%..................... 156
topiramate sprinkle cap 15 mg (Topamax
sprinkle)........................................................................ 111
topiramate sprinkle cap 25 mg (Topamax
sprinkle)........................................................................ 111
topiramate tab 100 mg (Topamax)............................... 111
topiramate tab 200 mg (Topamax)............................... 111
topiramate tab 25 mg (Topamax)................................. 111
topiramate tab 50 mg (Topamax)................................. 111
TOPROL XL -metoprolol succinate tab sr 24hr 100 mg.....38
TOPROL XL -metoprolol succinate tab sr 24hr 200 mg.....38
TOPROL XL -metoprolol succinate tab sr 24hr 25 mg...... 38
TOPROL XL -metoprolol succinate tab sr 24hr 50 mg...... 38
torsemide tab 100 mg (Demadex).................................. 50
torsemide tab 10 mg (Demadex).................................... 50
torsemide tab 20 mg (Demadex).................................... 50
torsemide tab 5 mg (Demadex)...................................... 50
TOVIAZ -fesoterodine fumarate tab sr 24hr 4 mg............. 73
TOVIAZ -fesoterodine fumarate tab sr 24hr 8 mg............. 73
TRACLEER -bosentan tab 125 mg................................... 54
TRACLEER -bosentan tab 62.5 mg.................................. 54
TRADJENTA -linagliptin tab 5 mg..................................... 27
tramadol-acetaminophen tab 37.5-325 mg
(Ultracet)........................................................................102
TRAMADOL HCL ER -tramadol hcl cap sr 24hr biphasic
release 150 mg.............................................................. 102
tramadol hcl tab 50 mg (Ultram).................................. 102
tramadol hcl tab sr 24hr 100 mg (Ultram er)............... 102
tramadol hcl tab sr 24hr biphasic release 100 mg...... 102
TRANDATE -labetalol hcl tab 100 mg...............................38
trandolapril tab 1 mg (Mavik)......................................... 48
246
tranexamic acid tab 650 mg (Lysteda).........................132
TRANSDERMAL PAIN BASE - transdermal base cream
....................................................................................... 164
TRANSDERMAL PATCH 2" X 3" -transdermal patch 2" x
3".................................................................................... 164
TRANSDERM-SCOP -scopolamine td patch 72hr 1.5
mg.................................................................................... 69
TRANS-PEN - transdermal base cream .........................164
TRANXENE T -clorazepate dipotassium tab 15 mg.......... 76
TRANXENE T -clorazepate dipotassium tab 3.75 mg....... 76
TRANXENE T -clorazepate dipotassium tab 7.5 mg......... 76
tranylcypromine sulfate tab 10 mg (Parnate)................81
TRAVATAN Z -travoprost ophth soln 0.004%
(benzalkonium free) (bak free).......................................137
TRAVOPROST -travoprost ophth soln 0.004%............... 137
trazodone hcl tab 100 mg............................................... 81
trazodone hcl tab 50 mg................................................. 81
TREAGAN OTIC - antipyrine-benzocaine-polycosanol otic
sol 5.4-1.4-0.0097% ......................................................138
TRECATOR -ethionamide tab 250 mg................................ 6
TRENTAL -pentoxifylline tab cr 400 mg.......................... 133
tretinoin cap 10 mg......................................................... 15
tretinoin cream 0.025% (Retin-a)..................................156
tretinoin cream 0.05% (Retin-a)....................................156
tretinoin cream 0.1% (Retin-a)......................................156
tretinoin gel 0.01% (Retin-a)......................................... 156
tretinoin gel 0.025% (Retin-a)....................................... 156
tretinoin microsphere gel 0.04% (Retin-a micro)........ 156
tretinoin microsphere gel 0.1% (Retin-a micro).......... 156
TRETIN-X -tretinoin cream 0.025% w/ cleanser &
moisturizer kit.................................................................156
TRETIN-X -tretinoin cream 0.0375%............................... 156
TRETIN-X -tretinoin cream 0.05% w/ cleanser &
moisturizer kit.................................................................156
TRETIN-X -tretinoin cream 0.075%.................................156
TRETIN-X -tretinoin cream 0.1% w/ cleanser & moisturizer
kit....................................................................................156
TRETIN-X -tretinoin gel 0.01% w/ cleanser & moisturizer
kit....................................................................................156
TRETIN-X -tretinoin gel 0.025% w/ cleanser & moisturizer
kit....................................................................................156
TREXALL -methotrexate sodium tab 10 mg (base
equiv)................................................................................15
equiv)................................................................................15
equiv)................................................................................15
TREXALL -methotrexate sodium tab 7.5 mg (base
equiv)................................................................................15
TREXIMET -sumatriptan-naproxen sodium tab 85-500
mg.................................................................................. 107
2014
TREZIX -acetaminophen-caffeine-dihydrocodeine cap
356.4-30-16 mg..............................................................102
TRIADVANCE - prenatal vit w/ dss-iron carbonyl-fa tab
90-1 mg ........................................................................ 123
triamcinolone acetonide cream 0.025%.......................156
triamcinolone acetonide cream 0.1%...........................157
triamcinolone acetonide cream 0.5%...........................157
triamcinolone acetonide dental paste 0.1%................ 140
TRIAMCINOLONE ACETONIDE I -triamcinolone
acetonide oint 0.05%..................................................... 157
triamcinolone acetonide lotion 0.025%....................... 157
triamcinolone acetonide lotion 0.1%........................... 157
triamcinolone acetonide nasal inhal 55 mcg/act
(Nasacort aq).................................................................. 56
triamcinolone acetonide oint 0.025%...........................157
triamcinolone acetonide oint 0.1%...............................157
TRIAMCINOLONE ACETONIDE -triamcinolone acetonide
oint 0.5%........................................................................ 156
TRIAMTERENE/HYDROCHLOROTH -triamterene &
hydrochlorothiazide cap 50-25 mg...................................50
triamterene & hydrochlorothiazide cap 37.5-25 mg
(Dyazide)......................................................................... 50
triamterene & hydrochlorothiazide tab 37.5-25 mg
(Maxzide-25)....................................................................50
triamterene & hydrochlorothiazide tab 75-50 mg
(Maxzide)......................................................................... 50
TRIANEX -triamcinolone acetonide oint 0.05%............... 157
TRIAZ -benzoyl peroxide pad 3%................................... 157
TRIAZ CLEANSER -benzoyl peroxide lotion 3%............. 157
TRIAZ FOAMING CLOTHS -benzoyl peroxide cloth
3%.................................................................................. 157
6%.................................................................................. 157
9%.................................................................................. 157
triazolam tab 0.125 mg....................................................86
triazolam tab 0.25 mg (Halcion)..................................... 86
TRIBENZOR -olmesartan-amlodipine-hydrochlorothiazide
tab 20-5-12.5 mg............................................................. 48
tab 40-10-12.5 mg........................................................... 48
tab 40-10-25 mg.............................................................. 48
tab 40-5-12.5 mg............................................................. 48
tab 40-5-25 mg................................................................ 48
TRICARE DHA 301 - prenatal w/fe fumarate-fa-dss-fish oil
cap 27-1-710 mg .......................................................... 123
TRICARE PRENATAL DHA ONE - prenatal w/fe fumaratefa-dss-fish oil cap 27-1-500 mg .................................... 123
TRI-CHLOR -trichloroacetic acid liqd 80%...................... 156
TRICITRATES -pot & sod citrates w/ cit ac soln
550-500-334 mg/5ml........................................................ 75
TRICODE AR -pseudoephedrine-chlorphen w/ codeine liq
30-2-8 mg/5ml..................................................................61
TRICODE GF -pseudoephedrine w/ cod-gg liquid 30-8-200
mg/5ml..............................................................................61
TRICOR -fenofibrate tab 145 mg...................................... 53
TRICOR -fenofibrate tab 48 mg........................................ 53
trifluoperazine hcl tab 10 mg......................................... 84
trifluoperazine hcl tab 1 mg........................................... 84
trifluridine ophth soln 1% (Viroptic)............................ 137
TRIGLIDE -fenofibrate tab 160 mg....................................53
TRIGLIDE -fenofibrate tab 50 mg......................................53
trihexyphenidyl hcl elixir 0.4 mg/ml.............................114
trihexyphenidyl hcl tab 2 mg........................................114
trihexyphenidyl hcl tab 5 mg........................................114
TRILEPTAL -oxcarbazepine susp 300 mg/5ml (60 mg/
ml).................................................................................. 111
TRILEPTAL -oxcarbazepine tab 150 mg......................... 111
TRILIPIX -choline fenofibrate cap dr 135 mg (fenofibric
acid equiv)........................................................................53
TRILIPIX -choline fenofibrate cap dr 45 mg (fenofibric acid
equiv)................................................................................53
TRIMESIS RX - prenatal w/ calcium carbonate-b6-b12-fa
tab 1 mg ....................................................................... 123
trimethobenzamide hcl cap 300 mg (Tigan).................. 69
trimethoprim tab 100 mg................................................ 12
trimipramine maleate cap 100 mg..................................81
trimipramine maleate cap 25 mg....................................81
trimipramine maleate cap 50 mg....................................81
TRINATAL GT - prenatal vit w/ dss-iron carbonyl-fa tab
90-1 mg ........................................................................ 123
TRINATAL RX 1 - prenatal vit w/ fe fumarate-fa tab 60-1
mg ................................................................................. 123
TRINATAL ULTRA - prenatal vit w/ dss-iron carbonyl-fa
tab 90-1 mg .................................................................. 123
TRINATE - prenatal vit w/ fe fumarate-fa tab 28-1 mg
....................................................................................... 123
TRI-NORINYL 28 -norethindrone-eth estradiol tab
0.5-35/1-35/0.5-35 mg-mcg..............................................23
TRIOXIN -benzocaine-chloroxylenol-hc otic soln 15-1-10
mg/ml..............................................................................138
TRIPLE DYE -triple dye solution..................................... 159
TRI RX - prenatal w/o a w/ fe carbonyl-fe gluc-dss-fa tab
27-1mg ..........................................................................122
TRISPEC DMX -dextromethorphan-guaifenesin liquid
15-25 mg/5ml................................................................... 61
TRISPEC DMX PEDIATRIC -dextromethorphanguaifenesin liquid 15-25 mg/5ml...................................... 61
247
2014
TRISPEC PSE PEDIATRIC -pseudoephedrine w/ dm-gg
liquid 30-15-25 mg/5ml.................................................... 61
TRISPEC PSE -pseudoephedrine w/ dm-gg liquid
30-15-25 mg/5ml..............................................................61
TRI-TABS DHA -prenat w/o a w/ fe bisglyc-fa tab 32-1 mg
& omega cap pack.........................................................122
TRIVEEN-DUO DHA -prenat-fe bis-fe prot succ-fa-ca tab
& omega 3 cap 400 pk.................................................. 123
TRIVEEN-ONE - prenatal w/o vit a w/ fe fum-fa-omega 3
cap 27-1-250 mg .......................................................... 123
TRIVEEN-PRX RNF - prenatal w/o vit a w/ fe fum-dss-fadha cap 26-1.2-300 mg ................................................ 123
TRIVEEN-TEN -prenatal mv & min w/fe carbonyl-fa-dha
tab 15-0.5-50 mg........................................................... 123
TRIVEEN-U - prenatal w/o a vit w/ fe fumarate-fa cap
106.5-1 mg ................................................................... 123
TRI-VI-FLORO -ped vit acd & l-methylfol w/ fl biphasic
susp 0.25 mg/ml............................................................ 123
TRI-VI-FLORO -ped vit acd & l-methylfol w/ fl biphasic
susp 0.5 mg/ml.............................................................. 123
TRI-VI-FLOR -ped vit acd & l-methylfol w/ fl biphasic susp
0.25 mg/ml..................................................................... 122
TRI-VI-FLOR -ped vit acd & l-methylfol w/ fl biphasic susp
0.5 mg/ml....................................................................... 122
TRI-VIT/FLUORIDE/IRON -pediatric vitamins acd fluoride
& fe drops 0.25-10 mg/ml.............................................. 123
TRI-ZEL - multiple vitamins w/ minerals tab ................... 123
TRIZIVIR -abacavir sulfate-lamivudine-zidovudine tab
300-150-300 mg...............................................................10
TROKENDI XR -topiramate cap sr 24hr 100 mg............. 111
TROKENDI XR -topiramate cap sr 24hr 200 mg............. 111
TROKENDI XR -topiramate cap sr 24hr 25 mg............... 111
TROKENDI XR -topiramate cap sr 24hr 50 mg............... 111
TROPAZONE - emollient - lotion ................................... 157
tropicamide ophth soln 0.5%........................................137
tropicamide ophth soln 1% (Mydriacyl).......................137
trospium chloride cap sr 24hr 60 mg............................ 73
trospium chloride tab 20 mg (Sanctura)........................73
TRUSOPT -dorzolamide hcl ophth soln 2%.................... 137
TRUST NATAL DHA -prenat-fe bis-fe prot succ-fa-ca tab &
omega 3 cap 250 pk......................................................123
TRUVADA -emtricitabine-tenofovir disoproxil fumarate tab
200-300 mg......................................................................10
trypsin w/ castor oil & peruvian balsam oint
(Xenaderm)....................................................................157
trypsin w/ castor oil & peruvian balsam spray
(Granulex)..................................................................... 157
TRYPTOPHAN -tryptophan cap 500 mg......................... 126
TUDORZA PRESSAIR -aclidinium bromide aerosol powd
breath activated 400 mcg/act...........................................64
TURPENTINE SPIRITS -turpentine spirit........................ 157
TUSNEL -brompheniramine w/ dm-gg cap 2-15-200
mg.................................................................................... 61
TUSNEL PED-C -pseudoephedrine w/ cod-gg syrup
15-5-50 mg/5ml................................................................61
248
TUSSICAPS -hydrocod polst-chlorphen polst cap sr 12hr
10-8 mg............................................................................61
TUSSICAPS -hydrocod polst-chlorphen polst cap sr 12hr
5-4 mg..............................................................................61
TUSSIONEX PENNKINETIC EXT -hydrocod polstchlorphen polst cr susp 10-8 mg/5ml...............................61
TWYNSTA -telmisartan-amlodipine tab 40-10 mg.............48
TWYNSTA -telmisartan-amlodipine tab 40-5 mg...............48
TWYNSTA -telmisartan-amlodipine tab 80-10 mg.............48
TWYNSTA -telmisartan-amlodipine tab 80-5 mg...............48
TYKERB -lapatinib ditosylate tab 250 mg (base equiv)..... 15
TYLENOL/CODEINE #3 -acetaminophen w/ codeine tab
300-30 mg......................................................................102
TYLENOL/CODEINE #4 -acetaminophen w/ codeine tab
300-60 mg......................................................................102
TYLENOL/CODEINE -acetaminophen w/ codeine tab
300-15 mg......................................................................102
TYLOX -oxycodone w/ acetaminophen cap 5-500 mg.....102
TYZEKA -telbivudine tab 600 mg...................................... 10
TYZINE PEDIATRIC NASAL DR -tetrahydrozoline hcl
nasal soln 0.05%............................................................. 56
TYZINE -tetrahydrozoline hcl nasal soln 0.1%.................. 56
U
UCERIS -budesonide tab sr 24hr 9 mg.............................17
UDAMIN -multiple vitamins w/ minerals & fa tab 2 mg.....123
UDAMIN SP -multiple vitamins w/ minerals & fa tab 1
mg.................................................................................. 123
ULESFIA -benzyl alcohol lotion 5%.................................157
ULORIC -febuxostat tab 40 mg....................................... 107
ULORIC -febuxostat tab 80 mg....................................... 107
ULTANE -sevoflurane inhal soln..................................... 107
ULTIMATECARE ADVANTAGE - prenat w/o a w/ fe asp
gly-fa-dss-omega ther pak 30-1 mg ..............................123
ULTIMATECARE COMBO - prenat w/o a w/ fe asp gly-fadss-omega ther pak 30-1 mg ....................................... 123
ULTIMATECARE ONE NF - prenatal w/fe cbnyl-fe asp
glyc-fa-dss-omega cap 20-7-1 mg ................................ 123
ULTIMATECARE ONE - prenatal vit w/ fe cbn-fe asp glycfa-omega 3 cap 27-1mg ............................................... 123
ULTIMATE OB DHA -prenat w/ fe poly cmplx-fe asp-fe glyfa tab & dha cap pak..................................................... 123
ULTRACET -tramadol-acetaminophen tab 37.5-325
mg.................................................................................. 102
ULTRADERM - cream base ........................................... 164
ULTRAM ER -tramadol hcl tab sr 24hr 100 mg............... 102
ULTRAM -tramadol hcl tab 50 mg...................................102
ULTRASAL-ER -salicylic acid film-forming soln
28.5%............................................................................. 157
ULTRA TABS - prenatal vit w/ dss-iron carbonyl-fa tab
90-1 mg ........................................................................ 123
ULTRAVATE -halobetasol propionate cream 0.05%....... 157
ULTRAVATE -halobetasol propionate oint 0.05%........... 157
2014
ULTRAVATE PAC -halobetasol prop cream 0.05% &
ammonium lactate lot 12% kit........................................157
ULTRAVATE PAC -halobetasol prop oint 0.05% &
ammonium lactate lot 12% kit........................................157
ULTRAVATE X -halobetasol prop cream 0.05% & lactic
acid cream 10% kit........................................................ 157
ULTRAVATE X -halobetasol prop oint 0.05% & lactic acid
cream 10% kit................................................................ 157
ULTRESA -pancrelipase (lip-prot-amyl) dr cap
13800-27600-27600 unit.................................................. 70
20700-41400-41400 unit.................................................. 70
23000-46000-46000 unit.................................................. 70
UMECTA NAIL FILM -urea suspension 40%...................157
UMECTA PD -urea-hyaluronate sodium emulsion
40-0.3%.......................................................................... 157
UMECTA PD -urea-hyaluronate sodium susp
40-0.3%.......................................................................... 157
UMECTA -urea emulsion 40%........................................ 157
UMECTA -urea suspension 40%.....................................157
UNIRETIC -moexipril-hydrochlorothiazide tab 15-12.5
mg.................................................................................... 48
UNIRETIC -moexipril-hydrochlorothiazide tab 15-25
mg.................................................................................... 48
UNIRETIC -moexipril-hydrochlorothiazide tab 7.5-12.5
mg.................................................................................... 48
UNIVASC -moexipril hcl tab 15 mg................................... 48
UNIVASC -moexipril hcl tab 7.5 mg.................................. 48
UNIVERSAL WATER GEL - alcohol gel base ................ 164
URAMAXIN GT KIT -urea soln 45% & emollient cream
kit....................................................................................157
URAMAXIN GT -urea gel 45%........................................ 157
URAMAXIN -urea cream 45%......................................... 157
URAMAXIN -urea gel 45%.............................................. 157
URAMAXIN - urea in ammonium lactate vehicle foam 20%
....................................................................................... 157
URAMAXIN -urea lotion 45%.......................................... 157
urea cream 39% (Aluvea)..............................................157
urea cream 40%............................................................. 157
urea cream 45% (Uramaxin)......................................... 157
urea cream 50%............................................................. 157
urea foam 40% (Hydro 40 foam).................................. 157
urea gel 40%.................................................................. 157
urea gel 45% (Uramaxin)...............................................157
urea-hc acetate cream 1%............................................ 158
urea in lactic acid-salicylic acid vehicle susp 50%.....158
urea in lactic acid vehicle foam 35% (Hydro 35)......... 157
urea in zinc undecylenate-lactic acid vehicle emulsion
50%................................................................................ 158
urea lotion 40%.............................................................. 158
urea lotion 45% (Uramaxin).......................................... 158
UREA NAIL KIT -urea susp 40% & hyaluronate sodium gel
0.2% kit.......................................................................... 158
UREA NAIL -urea in zinc undecylenate-lactic acid vehicle
stick 50%........................................................................158
urea suspension 40% (Umecta)................................... 158
URECHOLINE -bethanechol chloride tab 10 mg...............73
URECHOLINE -bethanechol chloride tab 5 mg.................73
URELIEF PLUS -phenazopyridine-butabarbitalhyoscyamine tab 150-15-0.3 mg..................................... 73
URELLE - methenamine-hyosc-meth blue-sod phos-phen
sal tab 81 mg ................................................................. 72
URETRON D/S - methenamine-hyosc-meth blue-sod
phos-phen sal tab 120 mg ..............................................72
UREX -methenamine hippurate tab 1 gm..........................72
URIBEL - methenamine-hyosc-meth blue-sod phos-phen
sal cap 118 mg ...............................................................72
URIMAR-T - methenamine-hyosc-meth blue-sod phosphen sal tab 120 mg ...................................................... 72
UROCIT-K 10 -potassium citrate tab cr 10 meq (1080
mg)................................................................................... 75
UROCIT-K 15 -potassium citrate tab cr 15 meq (1620
mg)................................................................................... 75
UROCIT-K 5 -potassium citrate tab cr 5 meq (540 mg)..... 75
UROGESIC-BLUE - methenamine-hyosamine-meth bluesod phos tab 81.6 mg .................................................... 72
UROQID #2 -methenamine mandelate-sod phosphate
monobasic tab 500-500 mg............................................. 72
UROXATRAL -alfuzosin hcl tab sr 24hr 10 mg................. 75
URSO 250 -ursodiol tab 250 mg....................................... 71
ursodiol cap 300 mg (Actigall)....................................... 71
ursodiol tab 250 mg (Urso 250)......................................71
ursodiol tab 500 mg (Urso forte)....................................71
URSO FORTE -ursodiol tab 500 mg................................. 71
UTOPIC -urea cream 41%.............................................. 158
V
VAGIFEM -estradiol vaginal tab 10 mcg........................... 74
valacyclovir hcl tab 1 gm (Valtrex)................................ 10
valacyclovir hcl tab 500 mg (Valtrex)............................ 10
VALCHLOR -mechlorethamine hcl gel 0.016% (base
equivalent)......................................................................158
VALCYTE -valganciclovir hcl for soln 50 mg/ml (base
equiv)................................................................................10
VALCYTE -valganciclovir hcl tab 450 mg..........................10
VALERIAN ROOT -valerian (valeriana officinalis) fl
extract.............................................................................160
VALIUM -diazepam tab 10 mg.......................................... 76
VALIUM -diazepam tab 2 mg............................................ 76
VALIUM -diazepam tab 5 mg............................................ 76
valproate sodium syrup 250 mg/5ml (base equiv)
(Depakene).................................................................... 112
valproic acid cap 250 mg (Depakene)..........................112
valsartan-hydrochlorothiazide tab 160-12.5 mg (Diovan
hct)...................................................................................48
valsartan-hydrochlorothiazide tab 160-25 mg (Diovan
hct)...................................................................................48
249
2014
hct)...................................................................................48
valsartan-hydrochlorothiazide tab 320-25 mg (Diovan
hct)...................................................................................48
hct)...................................................................................48
VALTREX -valacyclovir hcl tab 1 gm.................................10
VALTREX -valacyclovir hcl tab 500 mg.............................10
VALTURNA -aliskiren-valsartan tab 150-160 mg.............. 48
VALTURNA -aliskiren-valsartan tab 300-320 mg.............. 48
VANACOF CD -phenylephrine-dexchlorphenir-codeine
liquid 5-1-10 mg/5ml........................................................ 61
VANCOCIN HCL -vancomycin hcl cap 125 mg................. 12
VANCOCIN HCL -vancomycin hcl cap 250 mg................. 12
vancomycin hcl cap 125 mg (Vancocin hcl)..................12
vancomycin hcl cap 250 mg (Vancocin hcl)..................12
VANDETANIB -vandetanib tab 100 mg.............................15
VANDETANIB -vandetanib tab 300 mg.............................15
VANISHING BASE II - cream base ................................164
VANISHING CREAM BOTANICAL - cream base ...........164
VANISHING CREAM - cream base ................................164
VANISH-PEN - cream base ........................................... 164
VANOS -fluocinonide cream 0.1%.................................. 158
VANOXIDE HC -benzoyl peroxide-hc lot 5-0.5% &
cleanser lot kit................................................................158
VANOXIDE-HC -benzoyl peroxide-hc lotion 5-0.5%........158
VASCEPA -icosapent ethyl cap 1 gm............................... 53
VASERETIC -enalapril maleate & hydrochlorothiazide tab
10-25 mg..........................................................................48
VASOTEC -enalapril maleate tab 10 mg...........................48
VASOTEC -enalapril maleate tab 2.5 mg..........................48
VASOTEC -enalapril maleate tab 20 mg...........................48
VASOTEC -enalapril maleate tab 5 mg.............................48
VAZOL -brompheniramine maleate liquid 2 mg/5ml.......... 56
VECAMYL -mecamylamine hcl tab 2.5 mg....................... 48
VECTICAL -calcitriol oint 3 mcg/gm................................

Blue Cross Blue Shield of North Carolina Open Basic 5 Tier

Transcription

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