Molina Washington Marketplace 1/1/16

Transcription

Molina Washington Marketplace
Drug Name
1/1/16
Drug Tier Requirements/Limits
ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS
Amphetamines
amphetamine cap 5mg er
amphetamine tab 5mg
amphetamine tab 7.5mg
amphetamine tab 10mg
amphetamine tab 12.5mg
dextroamphet cap 5mg er
dextroamphet tab 5mg
dextroamphet tab 10mg
methamphetam tab 5mg
VYVANSE CAP 20MG
VYVANSE CAP 30MG
VYVANSE CAP 40MG
VYVANSE CAP 50MG
VYVANSE CAP 60MG
VYVANSE CAP 70MG
zenzedi tab 5mg
zenzedi tab 10mg
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
3
3
3
3
3
3
1
1
AGE
AGE
AGE
AGE
AGE
AGE
AGE
AGE
AGE
AGE
AGE
AGE
AGE
PA; AGE
PA; AGE
PA; AGE
AGE
AGE
PA; AGE
PA; AGE
PA; AGE
PA; AGE
PA; AGE
PA; AGE
PA; AGE
AGE
AGE
Attention-Deficit/Hyperactivity Disorder (ADHD) Agents
guanfacine tab 1mg er
STRATTERA CAP 10MG
STRATTERA CAP 18MG
STRATTERA CAP 25MG
STRATTERA CAP 40MG
STRATTERA CAP 60MG
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
1
1
1
1
2
2
2
2
2
PA; MAIL
PA; MAIL
PA; MAIL
PA; MAIL
AGE, MAIL
AGE, MAIL
AGE, MAIL
AGE, MAIL
AGE, MAIL
PA - Prior Authorization
ST - Step Therapy
Age - Special Age Limit may apply
MAIL – Mail Order Available
Tier 1 = Most generics and low cost preferred brands
Tier 2 = Non-preferred generic drugs and Preferred brand name drugs
Tier 3 = Non-preferred brand name drugs; Tier 4 = Specialty Drugs
PREV = Preventative Services at $0 copay; DME = Coinsurance may apply
1
Drug Name
STRATTERA CAP 80MG
STRATTERA CAP 100MG
Tier 2
AGE, MAIL
Tier 2
AGE, MAIL
Stimulants - Misc.
dexmethylph tab 2.5mg
dexmethylph tab 5mg
dexmethylph tab 10mg
metadate tab 20mg er
methylphenid cap 10mg
methylphenid cap 20mg er
methylphenid sol 5mg/5ml
methylphenid sol 10mg/5ml
methylphenid tab 5mg
methylphenid tab 10mg er
methylphenid tab 18mg er TBCR
methylphenid tab 20mg er
modafinil tab 100mg
NUVIGIL TAB 200MG
NUVIGIL TAB 50MG
NUVIGIL TAB 150MG
NUVIGIL TAB 250MG
RITALIN LA CAP 10MG
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
AGE
AGE
AGE
AGE
AGE
AGE
PA; AGE
AGE
PA; AGE
AGE
PA; AGE
AGE
AGE
AGE
AGE
AGE
AGE
AGE
AGE
AGE
AGE
AGE
AGE
AGE
PA
PA
PA
PA
PA
PA; AGE
Tier
Tier
Tier
Tier
Tier
Tier
1
1
2
1
1
1
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
ALTERNATIVE MEDICINES
Alternative Medicine - M's
melatonin cap 3mg
melatonin cap 5mg
MELATONIN LIQ 1MG/4ML
melatonin tab 1mg
melatonin tab 3mg TABS
melatonin tab 5mg
ST - Step Therapy
2
Drug Name
melatonin tab 10mg cr
melatonin tab 300mcg
Tier 1
MAIL
Tier 1
MAIL
Alternative Medicine Combinations
melatin tab 3-1mg
melatonin tab 3-2mg
melatonin tr tab /vit-b6
Tier 1
Tier 1
Tier 1
MAIL
MAIL
MAIL
Tier 1
Tier 1
Tier 4
PA
AMINOGLYCOSIDES
Aminoglycosides
neomycin tab 500mg
paromomycin cap 250mg
tobramycin neb 300/5ml
ANALGESICS - ANTI-INFLAMMATORY
Anti-TNF-alpha - Monoclonoal Antibodies
HUMIRA KIT 20MG/0.4
HUMIRA KIT 40MG/0.8
HUMIRA PEN KIT 40MG/0.8
SIMPONI INJ 50MG
SIMPONI INJ 100MG/ML SOSY
Tier
Tier
Tier
Tier
Tier
4
4
4
4
4
PA
PA
PA
PA, ST
PA, ST
Gold Compounds
RIDAURA CAP 3MG
Tier 3
MAIL
Interleukin-1 Receptor Antagonist (IL-1Ra)
KINERET INJ
Tier 4
PA
Tier
Tier
Tier
Tier
PA,
PA,
PA,
PA,
Interleukin-6 Receptor Inhibitors
ACTEMRA
ACTEMRA
ACTEMRA
ACTEMRA
INJ
INJ
INJ
INJ
80MG/4ML
162/0.9
200/10ML
400/20ML
4
4
4
4
ST
ST
ST
ST
Nonsteroidal Anti-inflammatory Agents (NSAIDs)
celecoxib cap 50mg
Tier 1
PA; MAIL
celecoxib cap 100mg
Tier 1
PA; MAIL
celecoxib cap 200mg
Tier 1
PA; MAIL
celecoxib cap 400mg
Tier 1
PA; MAIL
diclofen pot tab 50mg
Tier 1
MAIL
diclofenac tab 25mg dr
Tier 1
MAIL
Tier 1
MAIL
Tier 1
MAIL
etodolac tab 400mg
Tier 1
MAIL
etodolac tab 500mg
Tier 1
MAIL
fenoprofen tab 600mg
Tier 1
MAIL
flurbiprofen tab 50mg
Tier 1
MAIL
flurbiprofen tab 100mg
Tier 1
MAIL
ST - Step Therapy
3
Drug Name
ibu-drops dro 40mg/ml
ibuprofen cap 200mg
ibuprofen jr chw 100mg
ibuprofen sus 100/5ml
ibuprofen tab 200mg
ibuprofen tab 400mg
ibuprofen tab 600mg
ibuprofen tab 800mg
indomethacin cap 25mg
indomethacin cap 50mg
ketoprofen cap 50mg
ketoprofen cap 75mg
ketorolac tab 10mg
meclofen sod cap 50mg
meclofen sod cap 100mg
mefenam acid cap 250mg
meloxicam tab 7.5mg
meloxicam tab 15mg
nabumetone tab 500mg
nabumetone tab 750mg
naproxen dr tab 375mg
naproxen dr tab 500mg
naproxen sod tab 220mg
naproxen sus 125/5ml
naproxen tab 250mg
naproxen tab 375mg
naproxen tab 500mg
oxaprozin tab 600mg
piroxicam cap 10mg
piroxicam cap 20mg
sm ibuprofen tab 100mg jr
sulindac tab 150mg
sulindac tab 200mg
tolmetin sod cap 400mg
tolmetin sod tab 200mg
tolmetin sod tab 600mg
Drug Tier
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Requirements/Limits
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
PA; MAIL
PA; MAIL
PA; MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
PA; MAIL
PA; MAIL
PA; MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
Tier 1
Tier 1
MAIL
MAIL
Pyrimidine Synthesis Inhibitors
leflunomide tab 10mg
leflunomide tab 20mg
Soluble Tumor Necrosis Factor Receptor Agents
ST - Step Therapy
4
Drug Name
ENBREL INJ 25/0.5ML
ENBREL INJ 25MG
ENBREL INJ 50MG/ML
ENBREL SRCLK INJ 50MG/ML
Drug Tier
Tier 4
Tier 4
Tier 4
Tier 4
Requirements/Limits
PA
PA
PA
PA
Tier
Tier
Tier
Tier
Tier
1
1
1
1
1
MAIL
MAIL
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
1
1
1
1
1
1
1
1
1
1
1
1
2
1
1
1
1
1
1
2
1
1
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
PREV
PREV
PREV
PREV
PREV
PREV
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
ANALGESICS - NonNarcotic
Analgesic Combinations
but/apap/caf cap 50-325-40 mg
but/apap/caf tab 50-325-40 mg
but/asa/caff cap 50-325-40 mg
but/asa/caff tab 50-325-40 mg
butal/apap tab 50-325mg
MAIL
Analgesics Other
acetam melts tab 80mg
acetamin cap 500mg
acetamin jr tab 160mg rt
acetamin liq 500/15ml
acetamin sol 160/5ml
acetamin sup 120mg
acetamin sup 325mg
acetamin sup 650mg
acetamin tab 325mg
acetamin tab 650mg
acetaminophn sus 160/5ml
acetaminophn tab 500mg
APAP 500 LIQ 500/5ML
apap chw 80mg
apap dro 80/0.8ml
apap infants dro 80/0.8ml
apra elx 160/5ml
asa free chw 160mg jr
chld asafree elx 80/2.5ml
FEVERALL INF SUP 80MG
medi-tabs elx 80/2.5ml
q-pap liq 160/5ml
Salicylates
aspirin 81 tab 81mg ec
aspirin adlt tab 81mg
aspirin chw 81mg
ASPIRIN TAB 81MG
aspirin tab 325mg
aspirin tab 325mg ec
ST - Step Therapy
5
Drug Name
diflunisal tab 500mg
salsalate tab 500mg
salsalate tab 750mg
Drug Tier
Tier 1
Tier 1
Tier 1
Requirements/Limits
MAIL
MAIL
MAIL
ANALGESICS - OPIOID
Opioid Agonists
codeine sulf tab 15mg
Tier 1
Tier 1
Tier 1
fentanyl dis 12mcg/hr
Tier 1
PA
Tier 1
PA
Tier 1
PA
Tier 1
PA
fentanyl dis 100mcg/h
Tier 1
PA
hydromorphon tab 2mg
Tier 1
hydromorphon tab 4mg
Tier 1
hydromorphon tab 8mg er
Tier 1
PA
Tier 1
PA
Tier 1
PA
Tier 1
PA
levorphanol tab 2mg
Tier 1
PA
meperidine sol 50mg/5ml
Tier 1
meperidine tab 50mg
Tier 1
meperidine tab 100mg
Tier 1
methadone sol 5mg/5ml
Tier 1
methadone sol 10mg/5ml
Tier 1
methadone tab 5mg
Tier 1
methadone tab 10mg
Tier 1
morphine sul sol 10mg/5ml
Tier 1
PA
morphine sul sol 20mg/5ml
Tier 1
PA
morphine sul sol 20mg/ml
Tier 1
PA
morphine sul tab 15mg
Tier 1
morphine sul tab 15mg er
Tier 1
morphine sul tab 30mg
Tier 1
Tier 1
Tier 1
Tier 1
NUCYNTA ER TAB 50MG
Tier 3
PA
NUCYNTA ER TAB 100MG
Tier 3
PA
Tier 3
PA
Tier 3
PA
Tier 3
PA
NUCYNTA TAB 50MG
Tier 3
PA
ST - Step Therapy
6
Drug Name
NUCYNTA TAB 75MG
NUCYNTA TAB 100MG
oxycodone sol 5mg/5ml
oxycodone tab 5mg
oxycodone tab 10mg
oxycodone tab 10mg er
oxycodone tab 15mg
oxycodone tab 20mg
oxycodone tab 30mg
OXYCONTIN TAB 10MG CR
oxymorphone tab 5mg er
oxymorphone tab 7.5mg er
oxymorphone tab hcl 5mg
oxymorphone tab hcl 10mg
tramadol hcl tab 50mg
tramadol hcl tab 100mg er
Drug Tier
Tier 3
Tier 3
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Requirements/Limits
PA
PA
QL (240 ml per 90 days)
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
Opioid Combinations
apap/codeine sol 120-12/5
Tier 1
apap/codeine tab 300-15mg
Tier 1
Tier 1
Tier 1
but/apap/caf cap 50-325-40 mg
Tier 1
hydroco/apap sol 7.5-325
Tier 1
hydroco/apap tab 2.5-500
Tier 1
hydroco/apap tab 5-325mg
Tier 1
Tier 1
ST - Step Therapy
7
Drug Name
hydrogesic cap 5-500mg
oxycod/apap tab 5-325mg
oxycod/apap tab 7.5-325
oxycod/apap tab 10-325mg
oxycod/ibu tab 5-400mg
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Opioid Partial Agonists
buprenorphin sub 2mg
buprenorphin sub 8mg
butorphanol sol 10mg/ml
BUTRANS DIS 5MCG/HR
BUTRANS DIS 10MCG/HR
BUTRANS DIS 20MCG/HR
Tier
Tier
Tier
Tier
Tier
Tier
1
1
1
3
3
3
PA
PA
PA
PA
PA
PA
Tier 3
Tier 1
Tier 1
PA
PA
PA
ANDROGENS-ANABOLIC
Anabolic Steroids
ANADROL 50 TAB 50MG
oxandrolone tab 2.5mg
oxandrolone tab 10mg
Androgens
ANDROXY TAB 10MG
danazol cap 50mg
danazol cap 100mg
danazol cap 200mg
METHITEST TAB 10MG
testost cyp inj 100mg/ml
testost cyp inj 200mg/ml
testost enan inj 200mg/ml
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
3
1
1
1
2
1
1
1
MAIL
MAIL
MAIL
ANORECTAL AGENTS
Rectal Combinations
hemorrhoidal cre
Tier 1
MAIL
Tier 1
MAIL
Tier 1
MAIL
Rectal Local Anesthetics
dibucaine oin 1%
Rectal Steroids
proctosol hc cre 2.5%
ANTACIDS
ST - Step Therapy
8
Drug Name
Antacid Combinations
acid gone chw 80-20mg
acid gone sus
alamag-plus chw
almacone chw
antacid chw dbl st
antacid extr chw 675-135
antacid sus ultra st
calcium rich sus antacid
foam antacid chw 80-20mg
foam antacid sus
heartbrn ant chw 160-105
heartburn chw ex st
maalox multi sus symp max
maalox sus advanced
maalox sus reg st
mag-al plus liq
mag-al plus liq xs
mi-acid chw
mintox plus chw
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
Tier 1
Tier 1
Tier 1
MAIL
MAIL
MAIL
Tier
Tier
Tier
Tier
Tier
1
1
1
2
1
MAIL
MAIL
MAIL
MAIL
MAIL
Tier
Tier
Tier
Tier
1
1
1
1
MAIL
MAIL
MAIL
MAIL
Tier
Tier
Tier
Tier
2
3
1
1
Antacids - Bicarbonate
sodium bicar tab 10gr
sodium bicar tab 325mg
sodium bicar tab 650mg
Antacids - Calcium Salts
calc antacid chw 750mg
calc antacid chw 1000mg
calcium carb chw 500mg
CALCIUM CARB TAB 648MG
stomach rlf chw 400mg
Antacids - Magnesium Salts
mag oxide tab 250mg
mag oxide tab 400mg
mag oxide tab 420mg
magnesium tab 250mg
250mg
ANTHELMINTICS
Anthelmintics
ALBENZA TAB 200MG
BILTRICIDE TAB 600MG
ivermectin tab 3mg
pamix sus 50mg/ml
ST - Step Therapy
9
Drug Name
PIN-X CHW 250MG
pin-x sus 50mg/ml
reeses med sus pinworm
Tier 2
Tier 1
Tier 1
ANTI-INFECTIVE AGENTS - MISC.
Anti-infective Agents - Misc.
CAYSTON INH 75MG
metronidazol tab 250mg
metronidazol tab 500mg
NEBUPENT INH 300MG
trimethoprim tab 100mg
vancomycin cap 125mg
vancomycin cap 250mg
XIFAXAN TAB 200MG
XIFAXAN TAB 550MG
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
4
1
1
3
1
1
1
4
4
Tier
Tier
Tier
Tier
Tier
Tier
1
1
1
1
1
1
PA
PA
PA
PA
PA
Anti-infective Misc. - Combinations
e.s.p. sus 200-600
ees/sulfisox sus 200-600
smz-tmp sus 200-40/5
smz-tmp tab 400-80mg
smz/tmp ds tab 800-160
sulfatrim pd sus 200-40/5
Antiprotozoal Agents
ALINIA SUS 100/5ML
ALINIA TAB 500MG
atovaquone sus 750/5ml
Tier 3
Tier 3
Tier 1
PA
PA
PA
Tier 3
Tier 3
Tier 3
PA
PA
PA
Ketolides
KETEK PAK TAB 400MG
KETEK TAB 300MG
KETEK TAB 400MG
Leprostatics
dapsone tab 25mg
dapsone tab 100mg
Tier 1
Tier 1
Lincosamides
clindamycin cap 150mg
clindamycin cap 300mg
clindamycin sol 75mg/5ml
Tier 1
Tier 1
Tier 1
Oxazolidinones
linezolid sus 100/5ml
linezolid tab 600mg
Tier 1
Tier 1
PA
PA
ANTIANGINAL AGENTS
ST - Step Therapy
10
Drug Name
Antianginals-Other
RANEXA TAB 500MG
RANEXA TAB 1000MG
Tier 2
Tier 2
PA; MAIL
PA; MAIL
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
2
2
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
1
1
1
1
1
1
1
1
1
1
1
1
1
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
Tier
Tier
Tier
Tier
1
1
1
1
Nitrates
isosorb din sub 2.5mg
isosorb din tab 5mg
isosorb din tab 10mg
isosorb mono tab 10mg
isosorb mono tab 20mg
isosorb mono tab 30mg er
nitroglycer cap 9mg er
nitroglycer dis 0.2mg/hr
NITROSTAT SUB 0.3MG
NITROSTAT SUB 0.4MG
NITROSTAT SUB 0.6MG
ANTIANXIETY AGENTS
Antianxiety Agents - Misc.
buspirone tab 5mg
buspirone tab 7.5mg
buspirone tab 10mg
buspirone tab 15mg
hydroxyz hcl syp 10mg/5ml
hydroxyz hcl tab 10mg
hydroxyz pam cap 25mg
meprobamate tab 200mg
meprobamate tab 400mg
Benzodiazepines
alprazolam
alprazolam
alprazolam
alprazolam
tab
tab
tab
tab
0.5mg
0.25mg
1mg
2mg
ST - Step Therapy
11
Drug Name
chlordiazep cap 5mg
chlordiazep cap 10mg
chlordiazep cap 25mg
cloraz dipot tab 3.75mg
cloraz dipot tab 7.5mg
cloraz dipot tab 15mg
DIAZEPAM CON 5MG/ML
diazepam sol 1mg/ml
diazepam tab 2mg
diazepam tab 5mg
diazepam tab 10mg
lorazepam con 2mg/ml
lorazepam tab 0.5mg
lorazepam tab 1mg
lorazepam tab 2mg
oxazepam cap 10mg
oxazepam cap 15mg
oxazepam cap 30mg
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
PA
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
ANTIARRHYTHMICS
Antiarrhythmics Type I-A
disopyramide cap 150mg
quinidine su tab 300mg
Tier 1
Tier 1
MAIL
MAIL
Tier 1
Tier 1
Tier 1
MAIL
MAIL
MAIL
Tier
Tier
Tier
Tier
Tier
Tier
1
1
1
1
1
1
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
Tier
Tier
Tier
Tier
Tier
1
3
3
3
3
MAIL
MAIL
MAIL
MAIL
MAIL
Antiarrhythmics Type I-B
mexiletine cap 150mg
Antiarrhythmics Type I-C
flecainide tab 50mg
flecainide tab 100mg
flecainide tab 150mg
propafenone tab 150mg
Antiarrhythmics Type III
amiodarone tab 200mg
MULTAQ TAB 400MG
TIKOSYN CAP 125MCG
TIKOSYN CAP 250MCG
TIKOSYN CAP 500MCG
ANTIASTHMATIC AND BRONCHODILATOR AGENTS
Anti-Inflammatory Agents
ST - Step Therapy
12
Drug Name
cromolyn sod neb 20mg/2ml
Tier 1
MAIL
Antiasthmatic - Monoclonal Antibodies
XOLAIR SOL 150MG
Tier 4
PA
Tier 2
Tier 1
Tier 2
MAIL
MAIL
MAIL
Tier
Tier
Tier
Tier
Tier
Tier
MAIL
MAIL
MAIL
MAIL
MAIL
PA; MAIL
Bronchodilators - Anticholinergics
ATROVENT HFA AER 17MCG
ipratropium sol 0.02%inh
TUDORZA PRES AER 400/ACT
Leukotriene Modulators
montelukast chw 4mg
montelukast chw 5mg
montelukast tab 10mg
zafirlukast tab 10mg
zafirlukast tab 20mg
ZYFLO CR TAB 600MG
1
1
1
1
1
3
Selective Phosphodiesterase 4 (PDE4) Inhibitors
DALIRESP TAB 500MCG
Tier 3
PA; MAIL
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
2
2
2
2
2
2
2
1
1
2
2
2
2
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
2
1
1
1
1
1
1
3
3
2
ST; AGE, MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
ST; MAIL
Steroid Inhalants
AEROSPAN AER 80MCG
ASMANEX 7 AER 110MCG
budesonide sus 0.5mg/2
budesonide sus 0.25mg/2
PULMICORT INH 90MCG
PULMICORT INH 180MCG
QVAR AER 40MCG
QVAR AER 80MCG
Sympathomimetics
ADVAIR DISKU AER 100/50
albuterol neb 0.5%
albuterol neb 0.63mg/3
albuterol neb 0.083%
albuterol neb 1.25mg/3
albuterol syp 2mg/5ml
albuterol tab 4mg
ARCAPTA CAP 75MCG
BROVANA NEB 15MCG
DULERA AER 100-5MCG
ST - Step Therapy
13
Drug Name
DULERA AER 200-5MCG
FORADIL CAP AEROLIZE
levalbuterol neb 0.31mg
metaproteren syp 10mg/5ml
metaproteren tab 10mg
metaproteren tab 20mg
PROAIR HFA AER
SEREVENT DIS AER 50MCG
SYMBICORT AER 80-4.5
SYMBICORT AER 160-4.5
terbutaline tab 2.5mg
terbutaline tab 5mg
VENTOLIN HFA AER
Drug Tier
Tier 2
Tier 2
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 2
Tier 2
Tier 2
Tier 2
Tier 1
Tier 1
Tier 3
Requirements/Limits
ST; MAIL
MAIL
PA; MAIL
PA; MAIL
PA; MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
ST; MAIL
ST; MAIL
MAIL
MAIL
ST; MAIL
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
1
1
1
2
1
1
1
1
1
1
1
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
2
2
2
2
2
2
2
2
2
1
1
1
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
Xanthines
aminophyllin inj 25mg/ml
aminophyllin tab 100mg
aminophyllin tab 200mg
LUFYLLIN TAB 200MG
theophylline sol 80/15ml
theophylline tab 100mg er
ANTICOAGULANTS
Coumarin Anticoagulants
COUMADIN TAB 1MG
COUMADIN TAB 2.5MG
COUMADIN TAB 2MG
COUMADIN TAB 3MG
COUMADIN TAB 4MG
COUMADIN TAB 5MG
COUMADIN TAB 6MG
COUMADIN TAB 7.5MG
COUMADIN TAB 10MG
jantoven tab 1mg
jantoven tab 2.5mg
jantoven tab 2mg
ST - Step Therapy
14
Drug Name
jantoven tab 3mg
jantoven tab 4mg
jantoven tab 5mg
jantoven tab 6mg
jantoven tab 7.5mg
jantoven tab 10mg
warfarin tab 1mg
warfarin tab 2.5mg
warfarin tab 2mg
warfarin tab 3mg
warfarin tab 4mg
warfarin tab 5mg
warfarin tab 6mg
warfarin tab 7.5mg
warfarin tab 10mg
Drug Tier
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Requirements/Limits
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
Tier 3
Tier 3
Tier 3
MAIL
MAIL
MAIL
enoxaparin inj 30/0.3ml
Tier 4
Tier 4
Tier 4
Tier 4
enoxaparin inj 100mg/ml
Tier 4
enoxaparin inj 120/0.8
Tier 4
enoxaparin inj 150mg/ml
Tier 4
enoxaparin inj 300/3ml
Tier 4
fondaparinux sol 2.5/0.5
fondaparinux sol 10/0.8
FRAGMIN INJ 2500/0.2
Tier
Tier
Tier
Tier
Tier
Tier
QL (Max 7 days
without PA)
QL (Max 7 days
without PA)
QL (Max 7 days
without PA)
QL (Max 7 days
without PA)
QL (Max 7 days
without PA)
QL (Max 7 days
without PA)
QL (Max 7 days
without PA)
QL (Max 7 days
without PA)
PA
PA
PA
PA
PA
PA
Direct Factor Xa Inhibitors
XARELTO TAB 10MG
XARELTO TAB 15MG
XARELTO TAB 20MG
Heparins And Heparinoid-Like Agents
4
4
4
4
4
4
ST - Step Therapy
supply
supply
supply
supply
supply
supply
supply
supply
15
Drug Name
FRAGMIN INJ 10000/ML
FRAGMIN INJ 12500UNT
heparin sod inj 1000/ml
heparin sod inj 5000/0.5
heparin sod inj 10000/ml
Drug Tier
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 1
Tier 1
Tier 1
Requirements/Limits
PA
PA
PA
PA
PA
PA; MAIL
PA; MAIL
PA; MAIL
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
1
1
1
1
1
1
2
2
2
QL (2 kits / month)
QL (2 kits / month)
QL (2 kits / month)
PA
PA
PA
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
2
2
2
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
PA; MAIL
PA; MAIL
PA; MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
ANTICONVULSANTS
Anticonvulsants - Benzodiazepines
clonazepam tab 0.5mg
clonazepam tab 1mg
clonazepam tab 2mg
diazepam gel 2.5mg
diazepam gel 10mg
diazepam gel 20mg
ONFI TAB 5MG
ONFI TAB 10MG
ONFI TAB 20MG
Anticonvulsants - Misc.
BANZEL SUS 40MG/ML
BANZEL TAB 200MG
BANZEL TAB 400MG
carbamazepin cap 100mg er
carbamazepin chw 100mg
carbamazepin sus 100/5ml
carbamazepin tab 200mg
carbamazepin tab 200mg er
carbamazepin tab 400mg er
gabapentin cap 100mg
gabapentin sol 250/5ml
gabapentin tab 100mg
lamotrigine chw 5mg
lamotrigine chw 25mg
lamotrigine tab 25mg
ST - Step Therapy
16
Drug Name
lamotrigine tab 100mg TABS
lamotrigine tab 150mg
lamotrigine tab 200mg TABS
levetiraceta sol 100mg/ml
levetiraceta tab 250mg
LYRICA CAP 25MG
LYRICA CAP 50MG
LYRICA CAP 75MG
LYRICA CAP 100MG
LYRICA CAP 150MG
LYRICA CAP 200MG
LYRICA CAP 225MG
LYRICA CAP 300MG
oxcarbazepin sus 300mg/5m
oxcarbazepin tab 150mg
POTIGA TAB 50MG
POTIGA TAB 200MG
POTIGA TAB 400MG
primidone tab 50mg
primidone tab 250mg
TEGRETOL-XR TAB 100MG
topiramate cap 15mg
topiramate cap 25mg
topiramate tab 25mg
topiramate tab 50mg
topiramate tab 100mg
topiramate tab 200mg
VIMPAT SOL 10MG/ML
VIMPAT TAB 50MG
VIMPAT TAB 100MG
VIMPAT TAB 150MG
VIMPAT TAB 200MG
zonisamide cap 25mg
zonisamide cap 50mg
zonisamide cap 100mg
Drug Tier
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 1
Tier 1
Tier 1
Tier 1
Tier 2
Tier 2
Tier 2
Tier 1
Tier 1
Tier 2
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 1
Tier 1
Tier 1
Requirements/Limits
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
PA
PA
PA
PA
PA
PA
PA
PA
MAIL
MAIL
MAIL
MAIL
PA
PA
PA
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
PA
PA
PA
PA
PA
MAIL
MAIL
MAIL
Carbamates
felbamate sus 600/5ml
Tier 1
MAIL
ST - Step Therapy
17
Drug Name
felbamate tab 400mg
felbamate tab 600mg
Tier 1
MAIL
Tier 1
MAIL
GABA Modulators
SABRIL POW 500MG
SABRIL TAB 500MG
tiagabine tab 2mg
tiagabine tab 4mg
Tier
Tier
Tier
Tier
4
4
1
1
PA
PA
PA; MAIL
PA; MAIL
Tier
Tier
Tier
Tier
Tier
Tier
Tier
2
3
1
1
1
1
1
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
Tier 3
Tier 1
Tier 1
MAIL
MAIL
MAIL
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
Hydantoins
DILANTIN CAP 30MG
PEGANONE TAB 250MG
phenytoin chw 50mg
phenytoin ex cap 100mg
phenytoin sus 125/5ml
Succinimides
CELONTIN CAP 300MG
ethosuximide cap 250mg
ethosuximide sol 250/5ml
Valproic Acid
divalproex cap 125mg
divalproex tab 125mg dr
divalproex tab 250mg er
divalproex tab 500mg er
valproic acd cap 250mg
valproic acd sol 250/5ml
1
1
1
1
1
1
1
1
ANTIDEPRESSANTS
Alpha-2 Receptor Antagonists (Tetracyclics)
mirtazapine tab 15mg
Tier 1
Tier 1
Tier 1
MAIL
MAIL
MAIL
Tier
Tier
Tier
Tier
Tier
Tier
Tier
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
Antidepressants - Misc.
bupropion tab 75mg
bupropion tab 100mg
bupropion tab 100mg er
bupropn hcl tab 150mg xl
bupropn hcl tab 300mg xl
1
1
1
1
1
1
1
ST - Step Therapy
18
Drug Name
maprotiline tab 50mg
maprotiline tab 75mg
Tier 1
MAIL
Tier 1
MAIL
Modified Cyclics
nefazodone tab 50mg
nefazodone tab 100mg
trazodone tab 50mg
trazodone tab 100mg
trazodone tab 150mg
trazodone tab 300mg
VIIBRYD KIT
VIIBRYD TAB 10MG
VIIBRYD TAB 20MG
VIIBRYD TAB 40MG
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
1
1
1
1
1
1
1
1
1
3
3
3
3
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
PA; MAIL
PA; MAIL
PA; MAIL
PA; MAIL
3
3
3
3
1
1
PA; MAIL
PA; MAIL
PA; MAIL
MAIL
MAIL
MAIL
Monoamine Oxidase Inhibitors (MAOIs)
EMSAM DIS 6MG/24HR
EMSAM DIS 9MG/24HR
EMSAM DIS 12MG/24H
MARPLAN TAB 10MG
phenelzine tab 15mg
tranylcyprom tab 10mg
Tier
Tier
Tier
Tier
Tier
Tier
Selective Serotonin Reuptake Inhibitors (SSRIs)
citalopram sol 10mg/5ml
citalopram tab 10mg
citalopram tab 20mg
citalopram tab 40mg
escitalopram sol 5mg/5ml
escitalopram tab 5mg
fluoxetine cap 10mg
fluoxetine cap 20mg
fluoxetine sol 20mg/5ml
fluoxetine tab 10mg
fluoxetine tab 20mg
fluvoxamine tab 25mg
paroxetine tab 10mg
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
MAIL
MAIL
MAIL
MAIL
PA; MAIL
PA; MAIL
PA; MAIL
PA; MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
ST - Step Therapy
19
Drug Name
paroxetine tab 20mg
paroxetine tab 30mg
paroxetine tab 40mg
sertraline con 20mg/ml
sertraline tab 25mg
sertraline tab 50mg
sertraline tab 100mg
Drug Tier
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Requirements/Limits
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)
duloxetine cap 20mg
duloxetine cap 30mg
duloxetine cap 60mg
PRISTIQ TAB 50MG
PRISTIQ TAB 100MG
venlafaxine cap 37.5 er
venlafaxine cap 75mg er
venlafaxine cap 150mg er
venlafaxine tab 25mg
venlafaxine tab 37.5mg
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
1
1
1
3
3
1
1
1
1
1
1
1
1
ST; MAIL
ST; MAIL
ST; MAIL
PA; MAIL
PA; MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
Tricyclic Agents
amitriptylin tab 10mg
amoxapine tab 25mg
amoxapine tab 50mg
amoxapine tab 100mg
amoxapine tab 150mg
clomipramine cap 25mg
desipramine tab 10mg
ST - Step Therapy
20
Drug Name
doxepin hcl cap 10mg
doxepin hcl con 10mg/ml
imipram hcl tab 10mg
nortriptylin cap 10mg
protriptylin tab 5mg
protriptylin tab 10mg
trimipramine cap 25mg
Drug Tier
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Requirements/Limits
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
Tier
Tier
Tier
Tier
Tier
Tier
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
ANTIDIABETICS
Alpha-Glucosidase Inhibitors
acarbose tab 25mg
acarbose tab 50mg
acarbose tab 100mg
GLYSET TAB 25MG
GLYSET TAB 50MG
GLYSET TAB 100MG
1
1
1
2
2
2
Antidiabetic - Amylin Analogs
SYMLINPEN 60 INJ 1000MCG
SYMLNPEN 120 INJ 1000MCG
Tier 3
Tier 3
PA; MAIL
PA; MAIL
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
MAIL
MAIL
MAIL
PA; MAIL
PA; MAIL
PA; MAIL
PA; MAIL
PA; MAIL
PA; MAIL
PA; MAIL
Antidiabetic Combinations
glyb/metform tab 1.25-250
glyb/metform tab 2.5-500
glyb/metform tab 5-500mg
JANUMET TAB 50-500MG
JANUMET TAB 50-1000
JANUMET XR TAB 50-1000
JANUMET XR TAB 100-1000
JENTADUETO TAB 2.5-500
1
1
1
2
2
2
2
2
2
2
ST - Step Therapy
21
Drug Name
KOMBIGLYZE TAB 2.5-1000
KOMBIGLYZE TAB 5-500MG
KOMBIGLYZE TAB 5-1000MG
Drug Tier
Tier 3
Tier 3
Tier 3
Requirements/Limits
PA; MAIL
PA; MAIL
PA; MAIL
Tier
Tier
Tier
Tier
Tier
1
1
1
1
1
MAIL
MAIL
MAIL
MAIL
MAIL
Tier 2
Tier 2
MAIL
MAIL
Tier 2
Tier 3
Tier 3
MAIL
MAIL
MAIL
Biguanides
metformin
metformin
metformin
metformin
metformin
tab
tab
tab
tab
tab
500mg
500mg er
750mg er
850mg
1000mg
Diabetic Other
GLUCAGON KIT 1MG
GLUCOSE-VITAMIN C CHEW TAB 4-0.006
GM
GNP GLUCOSE CHW RASPBERY
JARDIANCE TAB 10MG
JARDIANCE TAB 25MG
Dipeptidyl Peptidase-4 (DPP-4) Inhibitors
JANUVIA TAB 25MG
JANUVIA TAB 50MG
JANUVIA TAB 100MG
ONGLYZA TAB 2.5MG
ONGLYZA TAB 5MG
TRADJENTA TAB 5MG
Tier
Tier
Tier
Tier
Tier
Tier
2
2
2
3
3
2
PA;
PA;
PA;
PA;
PA;
PA;
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
Dopamine Receptor Agonists - Antidiabetic
CYCLOSET TAB 0.8MG
Tier 2
MAIL
Incretin Mimetic Agents (GLP-1 Receptor Agonists)
BYETTA INJ 5MCG
BYETTA INJ 10MCG
VICTOZA INJ 18MG/3ML
Tier 2
Tier 2
Tier 3
PA; MAIL
PA; MAIL
PA; MAIL
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
ST;
ST;
ST;
ST;
ST;
ST;
ST;
ST;
ST;
ST;
ST;
Insulin
APIDRA INJ SOLOSTAR
APIDRA INJ U-100
HUMALOG INJ 100/ML
HUMALOG KWIK INJ 100/ML
HUMALOG MIX INJ 50/50
HUMALOG MIX INJ 50/50KWP
HUMALOG MIX INJ 75/25KWP
HUMALOG MIX SUS 75/25
HUMULIN INJ 70/30
HUMULIN INJ 70/30KWP
HUMULIN N INJ U-100
3
3
3
3
3
3
3
3
3
3
3
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
ST - Step Therapy
22
Drug Name
HUMULIN N INJ U-100KWP
HUMULIN N PN INJ U-100
HUMULIN PEN INJ 70/30
HUMULIN R INJ U-100
HUMULIN R INJ U-500
LANTUS INJ 100/ML
LANTUS INJ SOLOSTAR
LEVEMIR INJ
LEVEMIR INJ FLEXPEN
NOVOLIN INJ 70/30
NOVOLIN N INJ U-100
NOVOLIN R INJ PENFILL
NOVOLIN R INJ U-100
NOVOLOG INJ 100/ML
NOVOLOG INJ FLEXPEN
NOVOLOG INJ PENFILL
NOVOLOG MIX INJ 70/30
NOVOLOG MIX INJ FLEXPEN
Drug Tier
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 2
Tier 2
Tier 2
Tier 2
Tier 1
Tier 1
Tier 2
Tier 1
Tier 1
Tier 2
Tier 2
Tier 1
Tier 2
Requirements/Limits
ST; MAIL
ST; MAIL
ST; MAIL
ST; MAIL
ST; MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
Tier
Tier
Tier
Tier
Tier
Tier
3
3
3
1
1
1
PA; MAIL
PA; MAIL
PA; MAIL
MAIL
MAIL
MAIL
Tier
Tier
Tier
Tier
Tier
1
1
1
1
1
MAIL
MAIL
MAIL
MAIL
MAIL
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
1
1
1
1
1
1
1
1
1
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
Insulin Sensitizing Agents
AVANDIA TAB 2MG
AVANDIA TAB 4MG
AVANDIA TAB 8MG
pioglitazone tab 15mg
Meglitinide Analogues
nateglinide
nateglinide
repaglinide
repaglinide
repaglinide
tab
tab
tab
tab
tab
60mg
120mg
0.5mg
1mg
2mg
Sulfonylureas
chlorpropam tab 100mg
chlorpropam tab 250mg
glimepiride tab 1mg
glimepiride tab 2mg
glimepiride tab 4mg
glipizide er tab 2.5mg
glipizide er tab 5mg
glipizide er tab 10mg
glipizide tab 5mg
ST - Step Therapy
23
Drug Name
glipizide tab 10mg
glipizide xl tab 2.5mg
glipizide xl tab 5mg
glipizide xl tab 10mg
glyburid mcr tab 1.5mg
glyburid mcr tab 3mg
glyburid mcr tab 6mg
glyburide tab 1.25mg
glyburide tab 2.5mg
glyburide tab 5mg
tolazamide tab 250mg
tolazamide tab 500mg
tolbutamide tab 500mg
Drug Tier
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Requirements/Limits
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
Tier
Tier
Tier
Tier
Tier
1
1
1
1
1
MAIL
MAIL
MAIL
MAIL
MAIL
Tier
Tier
Tier
Tier
Tier
Tier
Tier
1
1
1
1
1
1
3
Tier
Tier
Tier
Tier
Tier
3
4
4
4
4
MAIL
PA
PA
PA
PA
Tier 1
MAIL
Tier 3
Tier 3
PA; MAIL
PA; MAIL
ANTIDIARRHEALS
Antidiarrheal Agents - Misc.
bismatrol sus 262/15ml
bismuth chw 262mg
bismuth ms sus 525/15ml
kaopectate sus 262/15ml
pink bismuth tab 262mg
Antiperistaltic Agents
diphen/atrop liq 2.5/5
diphen/atrop tab 2.5mg
loperamide cap 2mg
loperamide liq 1mg/5ml
loperamide sus 1mg/7.5
loperamide tab 2mg
MOTOFEN TAB
MAIL
MAIL
MAIL
MAIL
ANTIDOTES
Antidotes - Chelating Agents
CHEMET CAP 100MG
EXJADE TAB 125MG
EXJADE TAB 250MG
EXJADE TAB 500MG
FERRIPROX TAB 500MG
Opioid Antagonists
naltrexone tab 50mg
ANTIEMETICS
5-HT3 Receptor Antagonists
ALOXI INJ 0.25MG/5
ANZEMET TAB 50MG
ST - Step Therapy
24
Drug Name
ANZEMET TAB 100MG
granisetron tab 1mg
ondansetron sol 4mg/5ml
ondansetron tab 4mg
ondansetron tab 4mg odt
ondansetron tab 8mg
ondansetron tab 8mg odt
Drug Tier
Tier 3
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Requirements/Limits
PA; MAIL
MAIL
PA; MAIL
MAIL
MAIL
MAIL
MAIL
Tier
Tier
Tier
Tier
Tier
1
1
1
1
2
MAIL
MAIL
MAIL
MAIL
PA; MAIL
Tier
Tier
Tier
Tier
1
1
1
1
MAIL
PA
PA
PA
Antiemetics - Anticholinergic
dimenhydrin tab 50mg
meclizine chw 25mg
meclizine tab 12.5mg
meclizine tab 25mg
TRANSDERM-SC DIS 1.5MG
Antiemetics - Miscellaneous
anti-nausea liq
dronabinol cap 2.5mg
dronabinol cap 5mg
dronabinol cap 10mg
Substance P/Neurokinin 1 (NK1) Receptor Antagonists
EMEND
EMEND
EMEND
EMEND
CAP
CAP
CAP
PAK
40MG
80MG
125MG
80 & 125
Tier
Tier
Tier
Tier
3
3
3
3
PA;
PA;
PA;
PA;
Tier
Tier
Tier
Tier
Tier
1
1
1
1
1
PA
PA
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
1
1
1
1
1
1
1
1
4
4
PA
PA
MAIL
MAIL
MAIL
MAIL
ANTIFUNGALS
Antifungals
flucytosine cap 250mg
flucytosine cap 500mg
griseofulvin sus 125/5ml
nystatin tab 500000
terbinafine tab 250mg
Imidazole-Related Antifungals
fluconazole sus 10mg/ml
fluconazole sus 40mg/ml
fluconazole tab 50mg
itraconazole cap 100mg
ketoconazole tab 200mg
voriconazole inj 200mg
voriconazole tab 50mg
PA
PA
ST - Step Therapy
25
Drug Name
voriconazole tab 200mg
Tier 4
PA
ANTIHISTAMINES
Antihistamines - Alkylamines
aller-chlor syp 2mg/5ml
chlorphenir tab 4mg
chlorphenir tab 12mg cr
dexchlorphen syp 2mg/5ml
Tier
Tier
Tier
Tier
1
1
1
1
MAIL
MAIL
MAIL
MAIL
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
2
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
2
1
1
1
1
1
1
1
1
1
1
1
1
1
PA; MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
PA; MAIL
PA; MAIL
Antihistamines - Ethanolamines
ALER-DRYL TAB 50MG
allrgy melts tab 12.5mg
allrgy relf tab 12.5mg
carbinoxamin sol 4mg/5ml
carbinoxamin tab 4mg
child comple chw allergy
clemastine syp 0.5/5ml
clemastine tab 1.34mg
clemastine tab 2.68mg
cvs allergy chw 12.5mg
diphedryl liq 12.5/5ml
diphenhydram cap 25mg
diphenhydram cap 50mg
diphenhydram elx 12.5/5ml
diphenhydram inj 50mg/ml
diphenhydram tab 25mg
dytuss syp 12.5/5ml
wal-dryl alr tab 12.5mg
Antihistamines - Non-Sedating
ALLEGRA ALRG TAB 30MG TABS
cetirizine chw 5mg
cetirizine chw 10mg
cetirizine sol 1mg/ml
cetirizine sol 5mg/5ml
cetirizine syp 1mg/ml SYRP
cetirizine syp 5mg/5ml
cetirizine tab 5mg
cetirizine tab 10mg
desloratadin tab 2.5 odt
desloratadin tab 5mg
desloratadin tab 5mg odt
fexofenadine tab 60mg
fexofenadine tab 180mg
ST - Step Therapy
26
Drug Name
levocetirizi sol 2.5/5ml
levocetirizi tab 5mg
loratadine sol 5mg/5ml
loratadine syp 5mg/5ml
loratadine tab 10mg
Drug Tier
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Requirements/Limits
MAIL
MAIL
MAIL
MAIL
MAIL
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
PA; MAIL
Antihistamines - Phenothiazines
promethazine inj 25mg/ml
promethazine sol 6.25/5ml
promethazine sup 12.5mg
promethazine sup 25mg
promethazine syp 6.25/5ml
promethazine tab 12.5mg
promethazine tab 25mg
promethazine tab 50mg
promethegan sup 50mg
1
1
1
1
1
1
1
1
1
Antihistamines - Piperidines
cyproheptad syp 2mg/5ml
cyproheptad tab 4mg
Tier 1
Tier 1
MAIL
MAIL
Tier 3
Tier 1
PA; MAIL
PA; MAIL
cholestyramine
Tier 1
cholestyramine light
Tier 1
colestipol tab 1gm
prevalite
Tier 1
Tier 1
WELCHOL PAK 3.75GM
WELCHOL TAB 625MG
Tier 3
Tier 3
USE BULK POWDER,
MAIL
USE BULK POWDER,
MAIL
MAIL
USE BULK POWDER,
MAIL
MAIL
MAIL
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
ANTIHYPERLIPIDEMICS
Antihyperlipidemics - Misc.
OMACOR CAP 1GM
omega-3-acid cap 1gm
Bile Acid Sequestrants
Fibric Acid Derivatives
fenofibrate cap 43mg
fenofibrate tab 48mg
fenofibric tab 35mg
1
1
1
1
1
1
1
1
ST - Step Therapy
27
Drug Name
gemfibrozil tab 600mg
Tier 1
MAIL
HMG CoA Reductase Inhibitors
atorvastatin tab 10mg
CRESTOR TAB 5MG
CRESTOR TAB 10MG
CRESTOR TAB 20MG
CRESTOR TAB 40MG
fluvastatin cap 20mg
fluvastatin cap 40mg
lescol xl tab 80mg
LIVALO TAB 1MG
LIVALO TAB 2MG
LIVALO TAB 4MG
lovastatin tab 10mg
lovastatin tab 20mg
lovastatin tab 40mg
pravastatin tab 10mg
simvastatin tab 5mg
simvastatin tab 10mg
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
1
1
1
1
3
3
3
3
1
1
1
3
3
3
1
1
1
1
1
1
1
1
1
1
1
MAIL
MAIL
MAIL
MAIL
ST; MAIL
ST; MAIL
ST; MAIL
ST; MAIL
ST; MAIL
ST; MAIL
ST; MAIL
ST; MAIL
ST; MAIL
ST; MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
Intestinal Cholesterol Absorption Inhibitors
ZETIA TAB 10MG
Tier 3
ST; MAIL
Tier 1
MAIL
Nicotinic Acid Derivatives
niacor tab 500mg
ANTIHYPERTENSIVE COMBINATIONS
ANGIOTENSIN II RECEPTOR ANTAG
valsart/hctz
valsart/hctz
valsart/hctz
valsart/hctz
valsart/hctz
tab
tab
tab
tab
tab
80-12.5mg
160-12.5mg
160-25mg
320-12.5mg
320-25mg
THIAZIDE/THIAZIDE-LIKE
Tier
Tier
Tier
Tier
Tier
1
1
1
1
1
ST;
ST;
ST;
ST;
ST;
MAIL
MAIL
MAIL
MAIL
MAIL
ANTIHYPERTENSIVES
ACE Inhibitors
benazepril tab 5mg
Tier 1
MAIL
ST - Step Therapy
28
Drug Name
benazepril tab 10mg
benazepril tab 20mg
benazepril tab 40mg
captopril tab 12.5mg
captopril tab 25mg
captopril tab 50mg
captopril tab 100mg
enalapril tab 2.5mg
enalapril tab 5mg
enalapril tab 10mg
enalapril tab 20mg
fosinopril tab 10mg
fosinopril tab 20mg
fosinopril tab 40mg
lisinopril tab 2.5mg
lisinopril tab 5mg
lisinopril tab 10mg
lisinopril tab 20mg
lisinopril tab 30mg
lisinopril tab 40mg
moexipril tab 7.5mg
moexipril tab 15mg
perindopril tab 2mg
perindopril tab 4mg
perindopril tab 8mg
quinapril tab 5mg
quinapril tab 10mg
quinapril tab 20mg
quinapril tab 40mg
ramipril cap 1.25mg
ramipril cap 2.5mg
ramipril cap 5mg
ramipril cap 10mg
trandolapril tab 1mg
Drug Tier
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Requirements/Limits
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
Tier 1
MAIL
Tier 3
Tier 3
ST; MAIL
ST; MAIL
Agents for Pheochromocytoma
phenoxybenza cap 10mg
Angiotensin II Receptor Antagonists
BENICAR TAB 5MG
BENICAR TAB 20MG
ST - Step Therapy
29
Drug Name
BENICAR TAB 40MG
candesartan tab 4mg
candesartan tab 8mg
candesartan tab 16mg
candesartan tab 32mg
EDARBI TAB 40MG
EDARBI TAB 80MG
eprosart mes tab 600mg
irbesartan tab 75mg
irbesartan tab 150mg
irbesartan tab 300mg
losartan pot tab 25mg
telmisartan tab 20mg
TEVETEN TAB 400MG
valsartan tab 40mg
valsartan tab 80mg
valsartan tab 160mg
valsartan tab 320mg
Drug Tier
Tier 3
Tier 1
Tier 1
Tier 1
Tier 1
Tier 3
Tier 3
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 3
Tier 1
Tier 1
Tier 1
Tier 1
Requirements/Limits
ST; MAIL
ST; MAIL
MAIL
ST; MAIL
ST; MAIL
ST; MAIL
ST; MAIL
ST; MAIL
ST; MAIL
ST; MAIL
ST; MAIL
MAIL
MAIL
MAIL
ST; MAIL
ST; MAIL
ST; MAIL
ST; MAIL
ST; MAIL
ST; MAIL
ST; MAIL
ST; MAIL
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
Antiadrenergic Antihypertensives
clonidine tab 0.1mg
clonidine tab 0.2mg
clonidine tab 0.3mg
doxazosin tab 1mg
doxazosin tab 2mg
doxazosin tab 4mg
doxazosin tab 8mg
guanfacine tab 1mg
guanfacine tab 2mg
methyldopa tab 250mg
methyldopa tab 500mg
prazosin hcl cap 1mg
terazosin cap 1mg
terazosin cap 2mg
terazosin cap 5mg
terazosin cap 10mg
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Antihypertensive Combinations
ST - Step Therapy
30
Drug Name
atenol/chlor tab 50-25mg
atenol/chlor tab 100-25mg
benazep/hctz tab 10-12.5
benazep/hctz tab 20-12.5
benazep/hctz tab 20-25mg
bisoprl/hctz tab 2.5/6.25
bisoprl/hctz tab 5-6.25mg
bisoprl/hctz tab 10/6.25
captopr/hctz tab 25-15mg
enalapr/hctz tab 5-12.5mg
enalapr/hctz tab 10-25mg
fosinop/hctz tab 10/12.5
irbesar/hctz tab 150-12.5
irbesar/hctz tab 300-12.5
lisinop/hctz tab 10-12.5
lisinop/hctz tab 20-12.5
lisinop/hctz tab 20-25mg
losartan/hct tab 50-12.5
losartan/hct tab 100-12.5
losartan/hct tab 100-25
Drug Tier
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Requirements/Limits
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
ST; MAIL
ST; MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
Tier 3
Tier 3
MAIL
MAIL
Direct Renin Inhibitors
TEKTURNA TAB 150MG
TEKTURNA TAB 300MG
Selective Aldosterone Receptor Antagonists (SARAs)
eplerenone tab 25mg
eplerenone tab 50mg
Tier 1
Tier 1
MAIL
MAIL
Tier
Tier
Tier
Tier
Tier
Tier
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
Vasodilators
hydralazine tab 10mg
minoxidil tab 2.5mg
minoxidil tab 10mg
1
1
1
1
1
1
ANTIMALARIALS
Antimalarial Combinations
atovaq/progu tab 62.5-25
atovaq/progu tab 250-100
COARTEM TAB 20-120MG
Tier 1
Tier 1
Tier 3
ST - Step Therapy
31
Drug Name
Antimalarials
chloroquine tab 250mg
chloroquine tab 500mg
DARAPRIM TAB 25MG
hydroxychlor tab 200mg
mefloquine tab 250mg
PRIMAQUINE TAB 26.3MG
quinine sulf cap 324mg
Tier
Tier
Tier
Tier
Tier
Tier
Tier
1
1
3
1
1
2
1
PA
ANTIMYASTHENIC AGENTS
Antimyasthenic Agents
GUANIDINE TAB 125MG
MYTELASE TAB 10MG
pyridostigm tab 60mg
Tier 3
Tier 3
Tier 1
MAIL
MAIL
MAIL
ANTIMYCOBACTERIAL AGENTS
Anti TB Combinations
isonarif cap
RIFATER TAB
Tier 1
Tier 3
Antimycobacterial Agents
cycloserine cap 250mg
ethambutol tab 100mg
ethambutol tab 400mg
isoniazid syp 50mg/5ml
isoniazid tab 100mg
isoniazid tab 300mg
PASER GRA 4GM
PRIFTIN TAB 150MG
pyrazinamide tab 500mg
rifabutin cap 150mg
rifampin cap 150mg
rifampin cap 300mg
TRECATOR TAB 250MG
TRECATOR-SC TAB 250MG
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
1
1
1
1
1
1
2
2
1
1
1
1
3
3
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES
Alkylating Agents
ALKERAN TAB 2MG
CYCLOPHOSPH CAP 25MG
CYCLOPHOSPH CAP 50MG
cyclophosph tab 25mg
cyclophosph tab 50mg
LEUKERAN TAB 2MG
lomustine cap 10mg
Tier
Tier
Tier
Tier
Tier
Tier
Tier
2
2
2
1
1
2
1
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
ST - Step Therapy
32
Drug Name
lomustine cap 40mg
lomustine cap 100mg
melphalan inj 50mg
temozolomide cap 5mg
Drug Tier
Tier 1
Tier 1
Tier 1
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Requirements/Limits
MAIL
MAIL
PA; MAIL
PA
PA
PA
PA
PA
PA
Tier
Tier
Tier
Tier
Tier
PA
PA
MAIL
MAIL
MAIL
Antimetabolites
capecitabine tab 150mg
capecitabine tab 500mg
mercaptopur tab 50mg
methotrexate tab 2.5mg
THIOGUANINE TAB 40MG
4
4
1
1
3
Antineoplastic - Antibodies
RITUXAN INJ 100MG
RITUXAN INJ 500MG
Tier 4
Tier 4
PA
PA
Antineoplastic - Hedgehog Pathway Inhibitors
ERIVEDGE CAP 150MG
Tier 4
PA
Antineoplastic - Hormonal and Related Agents
anastrozole tab 1mg
bicalutamide tab 50mg
EMCYT CAP 140MG
exemestane tab 25mg
FARESTON TAB 60MG
FIRMAGON INJ 80MG
FIRMAGON INJ 120MG
flutamide cap 125mg
letrozole tab 2.5mg
leuprolide inj 1mg/0.2
LYSODREN TAB 500MG
megestrol ac sus 40mg/ml
megestrol ac tab 20mg
megestrol ac tab 40mg
NILANDRON TAB 150MG
tamoxifen tab 10mg
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
1
1
3
1
3
4
4
1
1
4
2
1
1
1
3
1
tamoxifen tab 20mg
Tier 1
MAIL
MAIL
MAIL
MAIL
MAIL
PA
PA
MAIL
MAIL
PA
MAIL
MAIL
MAIL
MAIL
MAIL
$0 Copay for Breast
Cancer Prevention for
Women age 35+, MAIL
$0 Copay for Breast
Women age 35+, MAIL
ST - Step Therapy
33
Drug Name
TRELSTAR DEP INJ 3.75MG
TRELSTAR LA INJ 11.25MG
TRELSTAR MIX INJ 22.5MG
ZOLADEX IMP 3.6MG
ZOLADEX IMP 10.8MG
Drug Tier
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Requirements/Limits
PA
PA
PA
PA
PA
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
Tier 4
PA
Antineoplastic Enzyme Inhibitors
AFINITOR DIS TAB 2MG
AFINITOR TAB 2.5MG
AFINITOR TAB 5MG
AFINITOR TAB 7.5MG
AFINITOR TAB 10MG
CAPRELSA TAB 100MG
CAPRELSA TAB 300MG
GLEEVEC TAB 100MG
GLEEVEC TAB 400MG
JAKAFI TAB 5MG
JAKAFI TAB 10MG
JAKAFI TAB 15MG
JAKAFI TAB 20MG
JAKAFI TAB 25MG
NEXAVAR TAB 200MG
SPRYCEL TAB 20MG
SPRYCEL TAB 50MG
SPRYCEL TAB 70MG
SPRYCEL TAB 100MG
SPRYCEL TAB 140MG
STIVARGA TAB 40MG
SUTENT CAP 12.5MG
SUTENT CAP 25MG
SUTENT CAP 50MG
TARCEVA TAB 25MG
TARCEVA TAB 100MG
TARCEVA TAB 150MG
TASIGNA CAP 150MG
TASIGNA CAP 200MG
TYKERB TAB 250MG
VOTRIENT TAB 200MG
Antineoplastics Misc.
ACTIMMUNE INJ 2MU/0.5
ST - Step Therapy
34
Drug Name
bexarotene cap 75mg
hydroxyurea cap 500mg
INTRON-A INJ 10MU
INTRON-A INJ 25MU
MATULANE CAP 50MG
tretinoin cap 10mg
Drug Tier
Tier 4
Tier 1
Tier 4
Tier 4
Tier 2
Tier 1
Requirements/Limits
PA
MAIL
PA
PA
PA; MAIL
PA; MAIL
Tier 4
PA
Chemotherapy Adjuncts
KEPIVANCE INJ 6.25MG
Chemotherapy Rescue/Antidote Agents
leucovor
leucovor
leucovor
leucovor
ca
ca
ca
ca
tab
tab
tab
tab
5mg
10mg
15mg
25mg
Tier
Tier
Tier
Tier
1
1
1
1
MAIL
MAIL
MAIL
MAIL
Mitotic Inhibitors
etoposide cap 50mg
etoposide inj 20mg/ml
100mg/5ml
20mg/ml,
Tier 1
Tier 4
PA; MAIL
PA
Tier 1
MAIL
Tier
Tier
Tier
Tier
Tier
Tier
MAIL
MAIL
MAIL
PA; MAIL
MAIL
MAIL
ANTIPARKINSON AGENTS
Antiparkinson Adjuvants
carbidopa tab 25mg
Antiparkinson Anticholinergics
benztropine tab 0.5mg
benztropine tab 1mg
benztropine tab 2mg
trihexyphen elx 0.4mg/ml
trihexyphen tab 2mg
trihexyphen tab 5mg
1
1
1
1
1
1
Antiparkinson COMT Inhibitors
entacapone tab 200mg
tolcapone tab 100mg
Tier 1
Tier 1
MAIL
MAIL
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
MAIL
MAIL
PA
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
Antiparkinson Dopaminergics
amantadine cap 100mg
amantadine syp 50mg/5ml
APOKYN INJ 10MG/ML
bromocriptin cap 5mg
bromocriptin tab 2.5mg
carb/levo er tab 25-100mg
carb/levo er tab 50-200mg
carb/levo tab 10-100mg TABS
1
1
4
1
1
1
1
1
1
1
ST - Step Therapy
35
Drug Name
pramipexole tab 0.5mg
pramipexole tab 1mg
ropinirole tab 0.5mg
ropinirole tab 0.25mg
ropinirole tab 1mg
ropinirole tab 2mg
ropinirole tab 3mg
ropinirole tab 4mg
ropinirole tab 5mg
Drug Tier
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Requirements/Limits
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
Antiparkinson Monoamine Oxidase Inhibitors
AZILECT TAB 0.5MG
AZILECT TAB 1MG
selegiline cap 5mg
selegiline tab 5mg
Tier
Tier
Tier
Tier
2
2
1
1
MAIL
MAIL
MAIL
MAIL
Tier
Tier
Tier
Tier
Tier
Tier
Tier
1
1
1
1
1
1
2
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
2
2
2
2
1
1
1
1
PA;
PA;
PA;
PA;
ST;
ST;
ST;
ST;
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
Tier
Tier
Tier
Tier
2
2
2
2
PA;
PA;
PA;
PA;
MAIL
MAIL
MAIL
MAIL
ANTIPSYCHOTICS/ANTIMANIC AGENTS
Antimanic Agents
lithium carb cap 150mg
lithium carb tab 300mg
lithium carb tab 300mg er
lithium carb tab 450mg er
LITHIUM CITR SOL 8MEQ/5ML
Antipsychotics - Misc.
LATUDA TAB 20MG
LATUDA TAB 40MG
LATUDA TAB 80MG
LATUDA TAB 120MG
ziprasidone cap 20mg
Benzisoxazoles
FANAPT
FANAPT
FANAPT
FANAPT
PAK
TAB 1MG
TAB 2MG
TAB 4MG
ST - Step Therapy
36
Drug Name
FANAPT TAB 6MG
FANAPT TAB 8MG
FANAPT TAB 10MG
FANAPT TAB 12MG
INVEGA SUST INJ 39/0.25
INVEGA SUST INJ 78/0.5ML
INVEGA SUST INJ 156MG/ML
invega tab 1.5mg
invega tab 3mg
invega tab 6mg
invega tab 9mg
RISPERDAL INJ 12.5MG
RISPERDAL INJ 25MG
RISPERDAL INJ 37.5MG
RISPERDAL INJ 50MG
risperidone sol 1mg/ml
risperidone tab 0.5mg
risperidone tab 0.5mg od
risperidone tab 0.25 odt
risperidone tab 0.25mg
risperidone tab 1mg
risperidone tab 1mg odt
risperidone tab 2mg
risperidone tab 3mg
risperidone tab 4mg
Drug Tier
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 1
Tier 1
Tier 1
Tier 1
Tier 2
Tier 2
Tier 2
Tier 2
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Requirements/Limits
PA; MAIL
PA; MAIL
PA; MAIL
PA; MAIL
PA; MAIL
PA; MAIL
PA; MAIL
PA; MAIL
PA; MAIL
PA; MAIL
PA; MAIL
PA; MAIL
PA; MAIL
PA; MAIL
PA; MAIL
PA; MAIL
PA; MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
Butyrophenones
haloper dec inj 50mg/ml
haloper dec inj 100mg/ml
haloper lac inj 5mg/ml
haloperidol con 2mg/ml
haloperidol tab 0.5mg
haloperidol tab 1mg
haloperidol tab 2mg
haloperidol tab 5mg
haloperidol tab 10mg
haloperidol tab 20mg
1
1
1
1
1
1
1
1
1
1
Dibenzapines
ST - Step Therapy
37
Drug Name
clozapine tab 25mg
clozapine tab 50mg
clozapine tab 100mg
clozapine tab 200mg
loxapine cap 5mg
loxapine cap 10mg
loxapine cap 25mg
loxapine cap 50mg
olanzapine tab 2.5mg
olanzapine tab 5mg
olanzapine tab 7.5mg
olanzapine tab 10mg
olanzapine tab 15mg
olanzapine tab 20mg
quetiapine tab 25mg
quetiapine tab 50mg
quetiapine tab 100mg
SAPHRIS SUB 5MG
SAPHRIS SUB 10MG
SEROQUEL XR TAB 50MG
Drug Tier
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Requirements/Limits
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
ST; MAIL
ST; MAIL
ST; MAIL
ST; MAIL
ST; MAIL
ST; MAIL
PA; MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
PA; MAIL
PA; MAIL
PA; MAIL
PA; MAIL
PA; MAIL
PA; MAIL
PA; MAIL
Phenothiazines
chlorpromaz tab 10mg
Tier 1
MAIL
Tier 1
MAIL
Tier 1
MAIL
Tier 1
MAIL
Tier 1
MAIL
fluphenaz de inj 25mg/ml
Tier 1
MAIL
fluphenazine inj 2.5mg/ml
Tier 1
MAIL
fluphenazine tab 1mg
Tier 1
MAIL
fluphenazine tab 2.5mg
Tier 1
MAIL
Tier 1
MAIL
Tier 1
MAIL
perphenazine tab 2mg
Tier 1
MAIL
Tier 1
MAIL
Tier 1
MAIL
ST - Step Therapy
38
Drug Name
prochlorper sup 25mg
prochlorper tab 5mg
prochlorper tab 10mg
thioridazine tab 10mg
trifluoperaz tab 1mg
Drug Tier
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Requirements/Limits
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
2
2
2
2
1
1
1
1
1
1
1
PA;
PA;
PA;
PA;
PA;
PA;
PA;
PA;
PA;
PA;
PA;
Tier
Tier
Tier
Tier
1
1
1
1
MAIL
MAIL
MAIL
MAIL
Tier 1
Tier 2
MAIL
MAIL
Tier
Tier
Tier
Tier
Tier
Tier
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
Quinolinone Derivatives
ABILIFY DISC TAB 10MG
ABILIFY DISC TAB 15MG
ABILIFY MAIN INJ 300MG
ABILIFY MAIN INJ 400MG
abilify sol 1mg/ml
aripiprazole tab 2mg
aripiprazole tab 10mg TABS
aripiprazole tab 15mg TABS
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
Thioxanthenes
thiothixene
thiothixene
thiothixene
thiothixene
cap
cap
cap
cap
1mg
2mg
5mg
10mg
ANTISEPTICS DISINFECTANTS
Chlorine Antiseptics
betasept liq 4%
PHISOHEX LIQ 3%
ANTIVIRALS
Antiretrovirals
abacav/lamiv tab /zidovud
abacavir tab 300mg
APTIVUS CAP 250MG
APTIVUS SOL
ATRIPLA TAB
COMPLERA TAB
1
1
2
2
2
2
ST - Step Therapy
39
Drug Name
CRIXIVAN CAP 200MG
CRIXIVAN CAP 400MG
didanosine cap 125mg
EDURANT TAB 25MG
EMTRIVA CAP 200MG
EMTRIVA SOL 10MG/ML
EPZICOM TAB 600-300
EVOTAZ TAB 300-150
FUZEON INJ 90MG
INTELENCE TAB 25MG
INTELENCE TAB 100MG
INTELENCE TAB 200MG
INVIRASE TAB 500MG
ISENTRESS CHW 100MG
ISENTRESS TAB 400MG
KALETRA SOL
KALETRA TAB 100-25MG
KALETRA TAB 200-50MG
lamivud/zido tab 150-300
lamivudine oral soln 10 mg/ml
lamivudine tab 100mg
LEXIVA TAB 700MG
nevirapine sus 50mg/5ml
nevirapine tab 200mg
nevirapine tab 400mg er
NORVIR CAP 100MG
NORVIR SOL 80MG/ML
NORVIR TAB 100MG
PREZCOBIX TAB 800-150
PREZISTA SUS 100MG/ML
PREZISTA TAB 400MG
PREZISTA TAB 600MG
PREZISTA TAB 800MG
RESCRIPTOR TAB 100 MG
RESCRIPTOR TAB 100MG
RESCRIPTOR TAB 200MG
REYATAZ CAP 150MG
REYATAZ CAP 200MG
Drug Tier
Tier 2
Tier 2
Tier 1
Tier 1
Tier 1
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 4
Tier 4
Tier 4
Tier 4
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 2
Tier 1
Tier 1
Tier 1
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Requirements/Limits
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
PA
PA
PA
PA
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
ST - Step Therapy
40
Drug Name
REYATAZ CAP 300MG
SELZENTRY TAB 150MG
SELZENTRY TAB 300MG
stavudine cap 20mg
stavudine cap 30mg
stavudine cap 40mg
STRIBILD TAB
SUSTIVA CAP 50MG
SUSTIVA CAP 200MG
SUSTIVA TAB 600MG
TIVICAY TAB 50MG
TRIUMEQ
TRUVADA TAB 200-300
TYBOST TAB 150MG
VIRACEPT TAB 250MG
VIRACEPT TAB 625MG
VIREAD TAB 150MG
VIREAD TAB 300MG
VITEKTA TAB 150MG
ZIAGEN SOL 20MG/ML
zidovudine cap 100mg
zidovudine syp 50mg/5ml
zidovudine tab 300mg
Drug Tier
Tier 2
Tier 2
Tier 2
Tier 1
Tier 1
Tier 1
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 1
Tier 1
Tier 1
Requirements/Limits
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
PA; MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
Tier 2
Tier 1
PA
PA
CMV Agents
VALCYTE SOL 50MG/ML
valganciclovir hcl
Hepatitis Agents
adefov dipiv tab 10mg
BARACLUDE SOL .05MG/ML
entecavir tab 0.5mg
entecavir tab 1mg
HARVONI TAB 90-400MG
INCIVEK TAB 375MG
INFERGEN INJ 15MCG
PEG-INTRON KIT 150MCG
PEGASYS INJ
PEGASYS INJ 180MCG/M
ribavirin cap 200mg
ribavirin tab 200mg
SOVALDI TAB 400MG
TYZEKA TAB 600MG
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
1
2
1
1
4
4
4
4
4
4
4
4
4
3
PA
PA
PA
PA
PA
PA
PA
PA
PA
ST - Step Therapy
41
Drug Name
Herpes Agents
acyclovir cap 200mg
acyclovir sus 200/5ml
acyclovir tab 400mg
acyclovir tab 800mg
famciclovir tab 125mg
valacyclovir tab 1gm
valacyclovir tab 500mg
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
1
1
1
1
1
1
1
1
1
Influenza Agents
RELENZA MIS DISKHALE
rimantadine tab 100mg
TAMIFLU CAP 30MG
Tier 2
Tier 1
Tier 2
TAMIFLU CAP 45MG
Tier 2
TAMIFLU CAP 75MG
Tier 2
TAMIFLU SUS 6MG/ML
Tier 2
QL (60 per 30 Days)
QL (60 per 30 Days)
QL (1 Treatment per
year)
QL (1 Treatment per
year)
QL (1 Treatment per
year)
QL (1 Treatment per
year)
ASSORTED CLASSES
Chelating Agents
CUPRIMINE CAP 250MG
DEPEN TITRA TAB 250MG
SYPRINE CAP 250MG
Tier 2
Tier 2
Tier 3
MAIL
MAIL
MAIL
Tier
Tier
Tier
Tier
Tier
4
4
4
4
4
PA
PA
PA
PA
PA
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
1
1
1
1
1
1
1
1
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
Immunomodulators
REVLIMID CAP 5MG
REVLIMID CAP 10MG
REVLIMID CAP 15MG
REVLIMID CAP 25MG
THALOMID CAP 100MG
Immunosuppressive Agents
azathioprine tab 50mg
cyclosporine cap 25mg
cyclosporine cap 25mg mod
cyclosporine cap 50mg mod
cyclosporine cap 100mg
cyclosporine cap 100mg md
cyclosporine sol modified
gengraf cap 25mg
ST - Step Therapy
42
Drug Name
gengraf cap 100mg
gengraf sol 100mg/ml
hecoria cap 0.5mg
hecoria cap 1mg
mycophenolat cap 250mg
mycophenolat tab 500mg
mycophenolic tab 180mg dr
mycophenolic tab 360mg dr
NEORAL CAP 25MG
NEORAL CAP 100MG
NEORAL SOL 100MG/ML
NULOJIX INJ 250MG
RAPAMUNE SOL 1MG/ML
SANDIMMUNE CAP 25MG
SANDIMMUNE CAP 100MG
sirolimus
sirolimus tab 0.5mg
tacrolimus cap 0.5mg
tacrolimus cap 1mg
ZORTRESS TAB 0.5MG
ZORTRESS TAB 0.25MG
ZORTRESS TAB 0.75MG
Drug Tier
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 2
Tier 2
Tier 2
Tier 3
Tier 3
Tier 2
Tier 2
Tier 1
Tier 1
Tier 1
Tier 1
Tier 4
Tier 4
Tier 4
Requirements/Limits
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
PA; MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
PA
PA
PA
Tier 1
Tier 1
MAIL
MAIL
Tier 1
Tier 1
MAIL
MAIL
Tier
Tier
Tier
Tier
Tier
Tier
Tier
1
1
1
1
1
1
1
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
Tier 1
Tier 1
Tier 1
MAIL
MAIL
MAIL
Irrigation Solutions
physiosol sol irrigat
steril water sol irrig
Potassium Removing Resins
kionex sus 15gm/60
sod poly sul pow
BETA BLOCKERS
Alpha-Beta Blockers
carvedilol tab 3.125mg
carvedilol tab 25mg
labetalol tab 100mg
labetalol tab 200mg
labetalol tab 300mg
Beta Blockers Cardio-Selective
acebutolol cap 200mg
acebutolol cap 400mg
atenolol tab 25mg
ST - Step Therapy
43
Drug Name
atenolol tab 50mg
atenolol tab 100mg
betaxolol tab 10mg
betaxolol tab 20mg
bisoprol fum tab 5mg
bisoprol fum tab 10mg
BYSTOLIC TAB 2.5MG
BYSTOLIC TAB 5MG
BYSTOLIC TAB 10MG
BYSTOLIC TAB 20MG
metoprol tar tab 25mg
metoprolol tab 25mg er
Drug Tier
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 3
Tier 3
Tier 3
Tier 3
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Requirements/Limits
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
Beta Blockers Non-Selective
LEVATOL TAB 20MG
Tier 3
MAIL
nadolol tab 20mg
Tier 1
MAIL
nadolol tab 40mg
Tier 1
MAIL
nadolol tab 80mg
Tier 1
MAIL
pindolol tab 5mg
Tier 1
MAIL
pindolol tab 10mg
Tier 1
MAIL
propranolol cap 60mg er
Tier 1
MAIL
Tier 1
MAIL
Tier 1
MAIL
Tier 1
MAIL
propranolol sol 20mg/5ml
Tier 1
MAIL
propranolol sol 40mg/5ml
Tier 1
MAIL
propranolol tab 10mg
Tier 1
MAIL
Tier 1
MAIL
Tier 1
MAIL
Tier 1
MAIL
Tier 1
MAIL
sotalol af tab 80mg
Tier 1
MAIL
sotalol af tab 120mg
Tier 1
MAIL
sotalol hcl tab 80mg
Tier 1
MAIL
Tier 1
MAIL
Tier 1
MAIL
Tier 1
MAIL
timolol mal tab 5mg
Tier 1
MAIL
ST - Step Therapy
44
Drug Name
timolol mal tab 10mg
timolol mal tab 20mg
Tier 1
MAIL
Tier 1
MAIL
CALCIUM CHANNEL BLOCKERS
Calcium Channel Blockers
amlodipine tab 2.5mg
Tier 1
MAIL
amlodipine tab 5mg
Tier 1
MAIL
amlodipine tab 10mg
Tier 1
MAIL
diltiazem cap 120mg er CP24
Tier 1
MAIL
diltiazem cap 120mg/24
Tier 1
MAIL
diltiazem cap 180mg er
Tier 1
MAIL
Tier 1
MAIL
Tier 1
MAIL
Tier 1
MAIL
Tier 1
MAIL
Tier 1
MAIL
Tier 1
MAIL
Tier 1
MAIL
diltiazem tab 30mg
Tier 1
MAIL
diltiazem tab 60mg
Tier 1
MAIL
diltiazem tab 90mg
Tier 1
MAIL
diltiazem tab 120mg
Tier 1
MAIL
felodipine tab 5mg er
Tier 1
MAIL
felodipine tab 10mg er
Tier 1
MAIL
isradipine cap 2.5mg
Tier 1
MAIL
isradipine cap 5mg
Tier 1
MAIL
nicardipine cap 20mg
Tier 1
MAIL
nicardipine cap 30mg
Tier 1
MAIL
nifedipine cap 20mg
Tier 1
MAIL
nifedipine tab 30mg er
Tier 1
MAIL
Tier 1
MAIL
Tier 1
MAIL
nimodipine cap 30mg
Tier 1
PA; MAIL
nisoldipine tab 8.5mg er
Tier 1
PA; MAIL
nisoldipine tab 17mg er
Tier 1
PA; MAIL
nisoldipine tab 20mg
Tier 1
PA; MAIL
nisoldipine tab 25.5mg
Tier 1
PA; MAIL
Tier 1
PA; MAIL
nisoldipine tab 34mg er
Tier 1
PA; MAIL
Tier 1
PA; MAIL
verapamil cap 100mg er
Tier 1
MAIL
Tier 1
MAIL
Tier 1
MAIL
ST - Step Therapy
45
Drug Name
verapamil cap 360mg sr
verapamil tab 40mg
verapamil tab 80mg
verapamil tab 120mg
verapamil tab 120mg er
Drug Tier
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Requirements/Limits
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
Tier
Tier
Tier
Tier
Tier
MAIL
MAIL
MAIL
MAIL
MAIL
CARDIOTONICS
Cardiac Glycosides
digoxin sol 50mcg/ml
digoxin tab 0.25mg
digoxin tab 0.125mg
LANOXIN TAB 0.25MG
LANOXIN TAB 0.125MG
1
1
1
2
2
CARDIOVASCULAR AGENTS - MISC.
Impotence Agents
CIALIS TAB 5MG
Tier 3
PA; MAIL
Tier 1
MAIL
Tier 4
Tier 4
Tier 4
PA
PA
PA
Peripheral Vasodilators
niacin cap 500mg
Prostaglandin Vasodilators
REMODULIN INJ 1MG/ML
REMODULIN INJ 2.5MG/ML
REMODULIN INJ 5MG/ML
Pulmonary Hypertension - Endothelin Receptor Antagonists
LETAIRIS TAB 5MG
LETAIRIS TAB 10MG
TRACLEER TAB 62.5MG
TRACLEER TAB 125MG
Tier
Tier
Tier
Tier
4
4
4
4
PA
PA
PA
PA
Pulmonary Hypertension - Phosphodiesterase Inhibitors
ADCIRCA TAB 20MG
sildenafil tab 20mg
Tier 4
Tier 4
PA
PA
Tier
Tier
Tier
Tier
Tier
PA
PA
PA
CEPHALOSPORINS
Cephalosporins - 1st Generation
cefadroxil sus 250/5ml
cefadroxil sus 500/5ml
cefazolin inj 1gm
cefazolin inj 20gm
cefazolin inj 500mg
1
1
1
1
1
ST - Step Therapy
46
Drug Name
cephalexin cap 250mg
cephalexin cap 500mg
cephalexin sus 125/5ml
cephalexin sus 250/5ml
Tier 1
Tier 1
Tier 1
Tier 1
Cephalosporins - 2nd Generation
cefaclor cap 250mg
cefaclor sus 125/5ml
cefaclor sus 250/5ml
cefprozil sus 125/5ml
cefprozil sus 250/5ml
cefuroxime tab 250mg
cefuroxime tab 500mg
Tier
Tier
Tier
Tier
Tier
Tier
Tier
1
1
1
1
1
1
1
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
1
1
1
1
1
1
1
1
1
1
1
3
Cephalosporins - 3rd Generation
cefdinir cap 300mg
cefdinir sus 125/5ml
cefdinir sus 250/5ml
cefditoren tab 200mg
cefditoren tab 400mg
cefixime sus 100/5ml
cefixime sus 200/5ml
cefpodo prox sus 50mg/5ml
cefpodo prox sus 100/5ml
cefpodoxime tab 100mg
cefpodoxime tab 200mg
SUPRAX TAB 400MG
PA
PA
CONTRACEPTIVES
Combination Contraceptives - Oral
altavera tab
alyacen tab 1/35
alyacen tab 7/7/7
amethyst tab 90-20mcg
apri tab
aranelle tab
aubra tab 0.1-0.02
aviane tab
azurette tab 28 day
balziva tab
briellyn tab
caziant pak
cesia pak
chateal tab 0.15/30
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
ST - Step Therapy
47
Drug Name
cryselle-28 tab 28 tabs
cyclafem tab 1/35
cyclafem tab 7/7/7
dasetta tab 1/35
dasetta tab 7/7/7
deso/ethinyl tab estradio
drospir/ethi tab 3-0.03mg
elinest tab
emoquette tab
enpresse-28 tab
enskyce tab
estarylla tab 0.25-35
falmina tab
gianvi tab 3-0.02mg
gildagia tab 0.4-35
gildess fe tab 1.5/30
gildess fe tab 1/20
gildess tab 1.5/30
gildess tab 1/20
junel 1.5/30 tab
junel 1/20 tab
junel fe tab 1.5/30
junel fe tab 1/20
kariva tab 28 day
kelnor tab 1/35
kurvelo tab 0.15/30
larin fe tab 1.5/30
larin fe tab 1/20
leena tab
lessina tab
levonest tab
levonor/ethi tab 0.1-0.02
levonor/ethi tab estradio
levora-28 tab 0.15/30
loryna tab 3-0.02mg
low-ogestrel tab
lutera tab
marlissa tab 0.15/30
microgestin tab 1.5/30
microgestin tab 1/20
microgestin tab fe1.5/30
microgestin tab fe 1/20
PREV
MAIL
PREV
MAIL
PREV
MAIL
PREV
MAIL
PREV
MAIL
PREV
MAIL
PREV
MAIL
PREV
MAIL
PREV
MAIL
PREV
MAIL
PREV
MAIL
PREV
MAIL
PREV
MAIL
PREV
MAIL
PREV
MAIL
PREV
MAIL
PREV
MAIL
PREV
MAIL
PREV
MAIL
PREV
MAIL
PREV
MAIL
PREV
MAIL
PREV
MAIL
PREV
MAIL
PREV
MAIL
PREV
MAIL
PREV
MAIL
PREV
MAIL
PREV
MAIL
PREV
MAIL
PREV
MAIL
PREV
MAIL
PREV
MAIL
PREV
MAIL
PREV
MAIL
PREV
MAIL
PREV
MAIL
PREV
MAIL
PREV
MAIL
PREV
MAIL
PREV
MAIL
PREV
MAIL
ST - Step Therapy
48
Drug Name
mono-linyah tab 0.25-35
mononessa tab
myzilra tab
necon tab 0.5/35
necon tab 1/35
necon tab 1/50-28
necon tab 7/7/7
norgest/eth tab estrad
norgest/ethi tab 0.25/35
norgest/ethi tab estradio
nortrel tab 0.5/35
nortrel tab 1/35
nortrel tab 7/7/7
ocella tab 3-0.03mg
ogestrel tab
orsythia tab
philith tab 0.4-35
pimtrea tab
pirmella tab 1/35
pirmella tab 7/7/7
portia-28 tab
previfem tab
reclipsen tab
solia tab
sprintec 28 tab 28 day
sronyx tab
syeda tab 3-0.03mg
tilia fe tab
tri-estaryll tab
tri-legest tab fe
tri-linyah tab
tri-previfem tab
tri-sprintec tab
trinessa tab
trivora-28 tab
velivet pak
vestura tab 3-0.02mg
viorele tab
vyfemla tab 0.4-35
wera tab 0.5/35
wymzya fe chw 0.4mg-35
zarah tab 3-0.03mg
PREV
MAIL
PREV
MAIL
PREV
MAIL
PREV
MAIL
PREV
MAIL
PREV
MAIL
PREV
MAIL
PREV
MAIL
PREV
MAIL
PREV
MAIL
PREV
MAIL
PREV
MAIL
PREV
MAIL
PREV
MAIL
PREV
MAIL
PREV
MAIL
PREV
MAIL
PREV
MAIL
PREV
MAIL
PREV
MAIL
PREV
MAIL
PREV
MAIL
PREV
MAIL
PREV
MAIL
PREV
MAIL
PREV
MAIL
PREV
MAIL
PREV
MAIL
PREV
MAIL
PREV
MAIL
PREV
MAIL
PREV
MAIL
PREV
MAIL
PREV
MAIL
PREV
MAIL
PREV
MAIL
PREV
MAIL
PREV
MAIL
PREV
MAIL
PREV
MAIL
PREV
MAIL
PREV
MAIL
ST - Step Therapy
49
Drug Name
zenchent fe chw 0.4mg-35
zenchent tab
zeosa chw
zovia 1/35e tab
zovia 1/50e tab
PREV
MAIL
PREV
MAIL
PREV
MAIL
PREV
MAIL
PREV
MAIL
Combination Contraceptives - Transdermal
xulane dis 150-35
PREV
MAIL
PREV
MAIL
PREV
PREV
PREV
PREV
QL
QL
QL
QL
PREV
PA; MAIL
PREV
MAIL
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
Combination Contraceptives - Vaginal
NUVARING MIS
Emergency Contraceptives
ELLA TAB 30MG
levonorgestr tab 1.5mg
my way tab 1.5mg
next choice tab 1.5mg
(4
(4
(4
(4
tabs / year)
/ year)
/ year)
/ year)
Progestin Contraceptives - IUD
MIRENA IUD SYSTEM
Progestin Contraceptives - Injectable
medroxypr ac inj 150mg/ml
Progestin Contraceptives - Oral
camila tab 0.35mg
errin tab 0.35mg
heather tab 0.35mg
jencycla tab 0.35mg
jolivette tab 0.35mg
lyza tab 0.35mg
nora-be tab 0.35mg
norethindron tab 0.35mg
CORTICOSTEROIDS
Glucocorticosteroids
budesonide cap 3mg/24hr
Tier 1
PA; MAIL
cortisone ac tab 25mg
Tier 1
MAIL
dexamethason elx 0.5/5ml
Tier 1
MAIL
dexamethason sol 0.5/5ml
Tier 1
MAIL
dexamethason tab 0.5mg
Tier 1
MAIL
Tier 1
MAIL
Tier 1
MAIL
dexamethason tab 1mg
Tier 1
MAIL
Tier 1
MAIL
Tier 1
MAIL
Tier 1
MAIL
hydrocort tab 5mg
Tier 1
MAIL
ST - Step Therapy
50
Drug Name
hydrocort tab 10mg
hydrocort tab 20mg
methylpred pak 4mg
methylpred tab 4mg
methylpred tab 8mg
methylpred tab 16mg
methylpred tab 32mg
pred sod pho sol 5mg/5ml
pred sod pho sol 6.7/5ml
prednisolone sol 15mg/5ml
prednisolone sol 25mg/5ml
prednisolone syp 15mg/5ml
prednisone pak 5mg
prednisone pak 10mg
prednisone sol 5mg/5ml
prednisone tab 1mg
prednisone tab 2.5mg
prednisone tab 5mg
prednisone tab 10mg
prednisone tab 20mg
prednisone tab 50mg
Drug Tier
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Requirements/Limits
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
Tier 1
MAIL
Tier
Tier
Tier
Tier
Tier
Tier
1
1
1
1
1
1
MAIL
MAIL
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
1
1
1
1
1
2
1
1
1
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
Mineralocorticoids
fludrocort tab 0.1mg
COUGH/COLD/ALLERGY
Antitussives
benzonatate cap 100mg
benzonatate cap 200mg
hydrocod/hom syp 5-1.5/5
robitussin syp 7.5/5ml
st joseph co syp 7.5/5ml
triaminic syp cough
MAIL
MAIL
MAIL
Cough/Cold/Allergy Combinations
allergy-d tab 25-10mg
brom/pse/dm syp
bromfed dm syp
brotapp dm liq 15-1-5/5
brotapp liq
CAPMIST DM TAB
cetiriz/pse tab 5-120mg
cgh dm max liq 10-200
cold & cough liq 6.25-2.5
ST - Step Therapy
51
Drug Name
cold/allergy elx children
cold/cough elx children
cold/cough elx dm
cold/cough liq 6.25-2.5
cough dm syp 100-10/5
delsym night liq cgh/cold
dimetane dx syp
dimetapp liq nighttim
dm/gg sol 10-100/5
eql triactin elx cld/cgh
guaiatussin syp ac
guaifenesin syp dm
loratadine d tab 5-120mg
loratadine-d tab 10-240mg
MUCINEX D TAB 60-600MG
mucus-dm tab 30-600mg
night time liq cgh/cold
PRO-CLEAR AC SYP
prometh vc syp 6.25-5/5
prometh vc/ syp codeine
prometh/cod syp 6.25-10
promethazine syp dm
q-tapp dm elx
q-tapp elx 1-15/5ml
q-tussin dm syp 100-10/5
ra allergy tab sinus
robitussin liq cgh/cong
robitussin liq nighttim
robitussin liq to go dm
rynex pse liq
triacting nt liq cold/cgh
tussin dm liq 10-200/5
tussin dm liq 100-10/5
tussin dm syp 100-10/5
wal-dryl-d tab alrg/sin
wal-tap dm elx cold/cgh
wal-tap elx cld/alle
Drug Tier
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 2
Tier 1
Tier 1
Tier 2
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Requirements/Limits
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
Expectorants
guaifenesin sol 100/5ml
Tier 1
MAIL
guaifenesin syp 100/5ml
Tier 1
MAIL
guaifenesin tab 200mg
Tier 1
MAIL
guaifenesin tab 400mg
Tier 1
MAIL
ST - Step Therapy
52
Drug Name
guaifenesin tab 600mg er
Tier 1
MAIL
Misc. Respiratory Inhalants
sod chloride neb 0.9%
sodium chlor neb 3%
sodium chlor neb 7%
Tier 1
Tier 1
Tier 1
MAIL
MAIL
MAIL
Tier 1
MAIL
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
AGE, MAIL
AGE, MAIL
MAIL
MAIL
MAIL
PA; MAIL
PA; MAIL
PA; MAIL
AGE, MAIL
AGE, MAIL
AGE, MAIL
AGE, MAIL
PA; MAIL
PA; MAIL
PA; MAIL
PA; MAIL
AGE, MAIL
PA; MAIL
AGE, MAIL
AGE, MAIL
MAIL
MAIL
PA; MAIL
AGE, MAIL
MAIL
AGE, MAIL
PA; MAIL
PA; MAIL
PA; MAIL
PA; AGE, MAIL
PA; AGE, MAIL
AGE, MAIL
Mucolytics
acetylcyst sol 20%
DERMATOLOGICALS
Acne Products
ACNE MEDICAT LOT 5%
ACNE MEDICAT LOT 10%
adapalene cre 0.1%
adapalene gel 0.1%
adapalene gel 0.3%
amnesteem cap 10mg
amnesteem cap 20mg
amnesteem cap 40mg
benzoyl per gel 5%
benzoyl per gel 10%
bpo-5 wash liq 5%
bpo-10 wash liq 10%
claravis cap 10mg
claravis cap 20mg
claravis cap 30mg
claravis cap 40mg
CLEAN&CLEAR LOT EXFOLIAT
clindamy/ben gel 1.2-5%
clindamycin gel 1%
clindamycin lot 1%
clindamycin sol 1%
differin lot 0.1%
EPIDUO GEL 0.1-2.5%
erythromycin gel 2%
erythromycin gel /benzoyl
erythromycin sol 2%
myorisan cap 10mg
myorisan cap 20mg
myorisan cap 40mg
tretinoin cre 0.1%
tretinoin cre 0.05%
tretinoin cre 0.025%
2
2
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
1
1
1
1
1
3
1
1
1
1
1
1
1
1
1
ST - Step Therapy
53
Drug Name
tretinoin gel 0.01%
tretinoin gel 0.025%
VELTIN GEL
zenatane cap 10mg
zenatane cap 20mg
zenatane cap 40mg
ZIANA GEL
Drug Tier
Tier 1
Tier 1
Tier 3
Tier 1
Tier 1
Tier 1
Tier 3
Requirements/Limits
PA; AGE, MAIL
PA; AGE, MAIL
PA; AGE, MAIL
PA; MAIL
PA; MAIL
PA; MAIL
PA; AGE, MAIL
Agents for External Genital and Perianal Warts
VEREGEN OIN 15%
Tier 3
PA; MAIL
Tier 2
PA; MAIL
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
3
1
3
1
1
1
1
1
1
PA; MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
1
1
1
1
1
1
1
3
2
2
1
1
2
1
1
1
1
3
3
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
PA; MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
Anti-inflammatory Agents - Topical
VOLTAREN GEL 1%
Antibiotics - Topical
ALTABAX OIN 1%
bacitracin oin 500/gm
CORTISPORIN OIN
gentamicin cre 0.1%
gentamicin oin 0.1%
mupirocin oin 2%
poly bacitra oin
triple antib oin
triple antib oin plus
Antifungals - Topical
ciclodan cre 0.77%
clotrim/beta cre diprop
clotrim/beta lot diprop
clotrimazole cre 1% 1%
clotrimazole sol 1%
dermafungal oin 2%
econazole cre 1%
ERTACZO CRE 2%
EXELDERM CRE 1%
EXELDERM SOL 1%
ketoconazole cre 2%
ketoconazole sha 2%
MENTAX CRE 1%
miconazole aer 2%
miconazole cre 2% 2%
miconazorb pow af 2%
naftifine cre hcl 1%
NAFTIN CRE 1%
NAFTIN CRE 2%
ST - Step Therapy
54
Drug Name
NAFTIN GEL 1%
nystat/triam cre
nystat/triam oin
nystatin cre 100000
nystatin oin 100000
nystatin pow 100000
OXISTAT CRE 1%
OXISTAT LOT 1%
terbinafine cre 1%
tolnaftate aer 1% AERP
tolnaftate cre 1% 1%
tolnaftate pow 1%
tolnaftate sol 1%
Drug Tier
Tier 3
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 3
Tier 3
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Requirements/Limits
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
Tier 1
MAIL
Antihistamines-Topical
allergy cre 2-0.1%
Antineoplastic or Premalignant Lesion Agents - Topical
fluorouracil cre 5%
PANRETIN GEL 0.1%
PICATO GEL 0.05%
PICATO GEL 0.015%
TARGRETIN GEL 1%
Tier
Tier
Tier
Tier
Tier
1
4
3
3
4
MAIL
PA
PA; MAIL
PA; MAIL
PA
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
1
1
1
1
1
1
2
4
4
3
3
3
3
PA; MAIL
PA; MAIL
PA; MAIL
PA; MAIL
PA; MAIL
MAIL
MAIL
PA
PA
PA; MAIL
PA; MAIL
PA; MAIL
PA; MAIL
Antipsoriatics
acitretin cap 10mg
acitretin cap 17.5mg
acitretin cap 25mg
calcipotrien oin 0.005%
calcipotrien sol 0.005%
calcitriol oin 3mcg/gm
DRITHO-CREME CRE HP 1%
STELARA INJ 45MG/0.5 SOLN
STELARA INJ 90MG/ML
TAZORAC CRE 0.1%
TAZORAC CRE 0.05%
TAZORAC GEL 0.1%
TAZORAC GEL 0.05%
Antiseborrheic Products
dandruff sha 1%
selenium sul lot 2.5%
selenium sul sha 2.5%
Tier 1
Tier 1
Tier 1
MAIL
MAIL
MAIL
Tier 2
MAIL
Antivirals - Topical
ABREVA CRE 10%
ST - Step Therapy
55
Drug Name
acyclovir oin 5%
DENAVIR CRE 1%
ZOVIRAX CRE 5%
Drug Tier
Tier 1
Tier 2
Tier 2
Requirements/Limits
PA; MAIL
MAIL
PA; MAIL
Tier 1
Tier 1
Tier 3
MAIL
MAIL
MAIL
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
PA; MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
Burn Products
mafenide ace pak 5%
silver sulfa cre 1%
SULFAMYLON CRE 85MG/GM
Corticosteroids - Topical
alclometason cre 0.05%
alclometason oin 0.05%
amcinonide cre 0.1%
amcinonide lot 0.1%
AMCINONIDE OIN 0.1%
APEXICON E CRE 0.05%
aug betamet cre 0.05%
aug betamet gel 0.05%
aug betamet lot 0.05%
aug betamet oin 0.05%
betameth dip cre 0.05%
betameth dip lot 0.05%
betameth dip oin 0.05%
betameth val cre 0.1%
betameth val oin 0.1%
calcipotrien oin betameth
clobetasol cre 0.05%
clobetasol gel 0.05%
clobetasol oin 0.05%
clobetasol sol 0.05%
clocortolone cre piv 0.1%
CORDRAN 24X3 TAP 4MCG/CM
CORDRAN 24X3 TAP SMALL
CORDRAN 24X3 TAP SML 24IN
CORDRAN 80X3 TAP 4MCG/CM
CORDRAN 80X3 TAP LARGE
CORDRAN LOT 0.05%
CORDRAN SP CRE 0.05%
CORDRAN TAPE TAP LRG 80IN
cortizone-10 gel 1%
desonide cre 0.05%
desonide oin 0.05%
desoximetas cre 0.05%
1
1
1
1
3
3
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
3
3
3
3
3
3
3
3
1
1
1
1
ST - Step Therapy
56
Drug Name
desoximetas cre 0.25%
desoximetas gel 0.05%
desoximetas oin 0.05%
desoximetas oin 0.25%
diflorasone cre 0.05%
diflorasone oin 0.05%
fluocin acet cre 0.025%
fluocin acet oil 0.01% sc
fluocin acet oin 0.025%
fluocinonide cre 0.05%
fluocinonide gel 0.05%
fluocinonide oin 0.05%
fluocinonide sol 0.05%
fluticasone cre 0.05%
fluticasone oin 0.005%
halobetasol cre 0.05%
halobetasol oin 0.05%
HALOG CRE 0.1%
HALOG OIN 0.1%
hc valerate cre 0.2%
hc-1% hemorr oin 1%
hc/aloe cre 0.5%
hydrocort ac cre 0.5%
hydrocort ac cre 1%
hydrocort cre 0.5%
hydrocort cre 1%
hydrocort cre 2.5%
hydrocort lot 1%
hydrocort lot 2.5%
hydrocort oin 0.5%
hydrocort oin 1%
hydrocort oin 2.5%
hydrocort/ cre aloe 1%
mometasone cre 0.1%
mometasone oin 0.1%
mometasone sol 0.1%
prednicarbat cre 0.1%
prednicarbat oin 0.1%
TACLONEX SUS
triamcinolon cre 0.1%
Drug Tier
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 3
Tier 3
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 3
Tier 1
Tier 1
Tier 1
Requirements/Limits
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
PA; MAIL
MAIL
MAIL
MAIL
ST - Step Therapy
57
Drug Name
triamcinolon
triamcinolon
triamcinolon
triamcinolon
triamcinolon
lot 0.1%
lot 0.025%
oin 0.1%
oin 0.5%
oin 0.025%
Drug Tier
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Requirements/Limits
MAIL
MAIL
MAIL
MAIL
MAIL
Tier 1
Tier 1
MAIL
MAIL
Tier 3
PA; MAIL
Tier 1
PA; MAIL
Tier 2
Tier 1
PA; MAIL
PA; MAIL
Tier 1
MAIL
Tier
Tier
Tier
Tier
Tier
Tier
MAIL
MAIL
MAIL
PA; MAIL
MAIL
MAIL
Emollients
ammonium lac cre 12%
ammonium lac lot 12%
Enzymes - Topical
SANTYL OIN 250/GM
Immunomodulating Agents - Topical
imiquimod cre 5%
Immunosuppressive Agents - Topical
ELIDEL CRE 1%
tacrolimus (topical)
Keratolytic/Antimitotic Agents
podofilox sol 0.5%
Local Anesthetics - Topical
lido/prilocn cre 2.5-2.5%
lidocaine gel 2%
lidocaine oin 5%
lidocaine pad 5%
lidocaine sol 4%
SYNERA DIS 70-70MG
1
1
1
1
1
3
Misc. Topical
DRYSOL SOL 20%
ZINC-OXYDE OIN 0.44-20%
Tier 2
Tier 1
MAIL
MAIL
Tier 3
PA; MAIL
Tier
Tier
Tier
Tier
3
1
1
1
MAIL
MAIL
MAIL
MAIL
Tier
Tier
Tier
Tier
Tier
1
2
1
1
1
MAIL
ST; MAIL
MAIL
MAIL
MAIL
Pigmenting-Depigmenting Agents
OXSORALEN LOT 1%
Rosacea Agents
FINACEA GEL 15%
metronidazol cre 0.75%
metronidazol gel 0.75%
metronidazol lot 0.75%
Scabicides Pediculicides
eql lice kit solution
EURAX CRE 10%
lice bedding aer 0.5%
lice control aer 0.5%
lice killing sha
ST - Step Therapy
58
Drug Name
lice soln kit
lice treatmt sha 0.33-4%
lice trtmnt liq 1%
licide aer 0.5%
lindane lot 1%
lindane sha 1%
malathion lot 0.5%
permethrin cre 5%
permethrin lot 1%
ra lice kit solution
spinosad sus 0.9%
tolnaftate cre 1% 1%
ULESFIA LOT 5%
Drug Tier
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 2
Requirements/Limits
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
ST; MAIL
MAIL
MAIL
MAIL
PA; MAIL
MAIL
ST; MAIL
Tier 3
PA; MAIL
Tier 4
PA
Tier 2
QL (50/30 for
non-insulin, 200/30 for
insulin/pregnant); MAIL
QL (50/30 for
non-insulin, 200/30 for
insulin/pregnant); MAIL
Wound Care Products
REGRANEX GEL 0.01%
DIAGNOSTIC PRODUCTS
Diagnostic Drugs
THYROGEN INJ 1.1MG
Diagnostic Tests
TRUE METRIX BLOOD GLUCOSE
TRUETEST TES
STRP
Tier 2
DIAGNOSTIC TESTS
DIAGNOSTIC TESTS
ACETONE (URINE) TEST STRIP
Tier 2
MAIL
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
DIGESTIVE AIDS
Digestive Enzymes
CREON CAP 3000UNIT
CREON CAP 6000UNIT
CREON CAP 12000UNT
CREON CAP 24000UNT
pancrelipase cap 5000unit
ZENPEP CAP 3000UNIT
ZENPEP CAP 10000UNT
ZENPEP CAP 15000UNT
ZENPEP CAP 20000UNT
ZENPEP CAP 25000UNT
ZENPEP CAP 40000UNT
2
2
2
2
1
2
2
2
2
2
2
ST - Step Therapy
59
Drug Name
DIURETICS
Carbonic Anhydrase Inhibitors
acetazolamid cap 500mg er
acetazolamid tab 125mg
acetazolamid tab 250mg
methazolamid tab 25mg
methazolamid tab 50mg
Tier
Tier
Tier
Tier
Tier
1
1
1
1
1
MAIL
MAIL
MAIL
MAIL
MAIL
Tier
Tier
Tier
Tier
Tier
Tier
2
1
1
1
1
1
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
1
1
1
1
2
1
1
1
1
1
1
1
1
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
Tier
Tier
Tier
Tier
Tier
Tier
1
2
2
1
1
1
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
Tier
Tier
Tier
Tier
Tier
1
1
1
1
1
MAIL
MAIL
MAIL
MAIL
MAIL
Diuretic Combinations
ALDACTAZIDE TAB 50/50
amilor/hctz tab 5-50
spirono/hctz tab 25/25
triamt/hctz cap 37.5-25
triamt/hctz tab 37.5-25
triamt/hctz tab 75-50mg
Loop Diuretics
bumetanide tab 0.5mg
bumetanide tab 1mg
bumetanide tab 2mg
EDECRIN TAB 25MG
FUROSEMIDE SOL 8MG/ML
furosemide sol 10mg/ml
furosemide tab 20mg
furosemide tab 40mg
furosemide tab 80mg
torsemide tab 5mg
torsemide tab 10mg
torsemide tab 20mg
torsemide tab 100mg
Potassium Sparing Diuretics
amiloride tab 5mg
DYRENIUM CAP 50MG
DYRENIUM CAP 100MG
spironolact tab 25mg
Thiazides and Thiazide-Like Diuretics
chlorothiaz tab 250mg
chlorothiaz tab 500mg
chlorthalid tab 25mg
chlorthalid tab 50mg
hydrochlorot cap 12.5mg
ST - Step Therapy
60
Drug Name
hydrochlorot tab 12.5mg
hydrochlorot tab 25mg
hydrochlorot tab 50mg
indapamide tab 1.25mg
indapamide tab 2.5mg
methyclothia tab 5mg
metolazone tab 2.5mg
metolazone tab 5mg
metolazone tab 10mg
Drug Tier
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Requirements/Limits
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
ENDOCRINE AND METABOLIC AGENTS - MISC.
Bone Density Regulators
alendronate tab 5mg
alendronate tab 10mg
calcitonin spr 200/act
etidron disd tab 200mg
etidron disd tab 400mg
FORTEO SOL 600/2.4
FOSAMAX + D TAB 70-2800
FOSAMAX + D TAB 70-5600
ibandronate tab 150mg
risedronate tab 5mg
risedronate tab 30mg
SKELID TAB 200MG
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
1
1
1
1
1
1
1
1
4
2
2
1
1
1
1
1
4
MAIL
MAIL
MAIL
MAIL
MAIL
PA; MAIL
MAIL
MAIL
PA
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
PA
Growth Hormones
OMNITROPE INJ 5.8MG
Tier 4
PA
Tier 1
PA; $0 Copay for Breast
Women age 35+, MAIL
Hormone Receptor Modulators
raloxifene tab 60mg
Insulin-Like Growth Factors (Somatomedins)
INCRELEX INJ 40MG/4ML
Tier 4
PA
LHRH/GnRH Agonist Analog Pituitary Suppressants
LUPR
LUPR
LUPR
LUPR
DEP-PED
DEP-PED
DEP-PED
DEP-PED
INJ
INJ
INJ
INJ
7.5MG
11.25MG
15MG
30MG
Tier
Tier
Tier
Tier
4
4
4
4
PA
PA
PA
PA
ST - Step Therapy
61
Drug Name
SYNAREL SOL 2MG/ML
Tier 4
PA
Metabolic Modifiers
BUPHENYL TAB 500MG
calcitriol cap 0.5mcg
calcitriol cap 0.25mcg
CYSTADANE POW
doxercalcif cap 0.5mcg
doxercalcif cap 1mcg
doxercalcif cap 2.5mcg
doxercalcif inj 4mcg/2ml
ELAPRASE INJ 6MG/3ML
FABRAZYME INJ 5MG
KUVAN TAB 100MG
levocarnitin sol 1gm/10ml
levocarnitin tab 330mg
ORFADIN CAP 2MG
ORFADIN CAP 5MG
ORFADIN CAP 10MG
paricalcitol cap 1 mcg
paricalcitol inj 5mcg/ml
phenylbutyra pow sodium
SENSIPAR TAB 30MG
SENSIPAR TAB 60MG
SENSIPAR TAB 90MG
zemplar inj 2mcg/ml
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
4
1
1
3
1
1
1
1
4
4
4
1
1
4
4
4
1
1
1
1
4
4
4
4
1
PA
MAIL
MAIL
PA; MAIL
MAIL
MAIL
MAIL
MAIL
PA
PA
PA
MAIL
MAIL
PA
PA
PA
PA; MAIL
PA; MAIL
PA; MAIL
PA; MAIL
PA
PA
PA
PA
PA; MAIL
Tier
Tier
Tier
Tier
1
1
1
4
PA; MAIL
MAIL
MAIL
PA
Posterior Pituitary Hormones
desmopressin spr 0.01%
desmopressin tab 0.1mg
desmopressin tab 0.2mg
STIMATE SOL 1.5MG/ML
.1mg/ml
Prolactin Inhibitors
cabergoline tab 0.5mg
Tier 1
MAIL
Tier 4
Tier 4
Tier 4
PA
PA
PA
Tier 4
Tier 4
PA
PA
Somatostatic Agents
octreotide inj 100mcg
SANDOSTATIN KIT LAR 20MG
SANDOSTATIN KIT LAR 30MG
Vasopressin Receptor Antagonists
SAMSCA TAB 15MG
SAMSCA TAB 30MG
ST - Step Therapy
62
Drug Name
ESTROGENS
Estrogen Combinations
noreth/ethin tab 0.5-2.5
PREMPHASE TAB
PREMPRO TAB 0.3-1.5
PREMPRO TAB 0.45-1.5
PREMPRO TAB 0.625-5
PREMPRO TAB .625-2.5
Tier
Tier
Tier
Tier
Tier
Tier
1
2
2
2
2
2
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
2
2
2
2
2
2
2
2
2
2
1
1
1
1
1
1
2
2
2
2
1
1
2
2
2
2
2
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
Estrogens
CENESTIN TAB 0.3MG
CENESTIN TAB 0.9MG
CENESTIN TAB 0.45MG
CENESTIN TAB 0.625MG
CENESTIN TAB 1.25MG
ENJUVIA TAB 0.3MG
ENJUVIA TAB 0.9MG
ENJUVIA TAB 0.45MG
ENJUVIA TAB 0.625MG
ENJUVIA TAB 1.25MG
estradiol tab 0.5mg
estradiol tab 1mg
estradiol tab 2mg
estropipate tab 0.75mg
estropipate tab 1.5mg
estropipate tab 3mg
MENEST TAB 0.3MG
MENEST TAB 0.625MG
MENEST TAB 1.25MG
MENEST TAB 2.5MG
ortho-est tab 0.625
ortho-est tab 1.25
PREMARIN TAB 0.3MG
PREMARIN TAB 0.9MG
PREMARIN TAB 0.45MG
PREMARIN TAB 0.625MG
PREMARIN TAB 1.25MG
FLUOROQUINOLONES
Fluoroquinolones
ciprofloxacn tab 250mg
Tier 1
QL (60 per 30 Days (max
#20 per fill))
ST - Step Therapy
63
Drug Name
FACTIVE TAB 320MG
levofloxacin sol 25mg/ml
levofloxacin tab 250mg
NOROXIN TAB 400MG
Tier 1
#20 per fill))
Tier 1
#20 per fill))
Tier 3
PA
Tier 1
PA
Tier 1
QL (60 per 30 Days)
Tier 1
QL (60 per 30 Days)
Tier 1
QL (30 per 30 Days)
Tier 3
GASTROINTESTINAL AGENTS - MISC.
Antiflatulents
gas relief cap 125mg
gas relief cap 180mg
gas relief dro infants
LITTLE TUMMY DRO 20/0.3ML
simethicone chw 80mg
simethicone chw 125mg
simethicone dro 40/0.6ml
Tier
Tier
Tier
Tier
Tier
Tier
Tier
1
1
1
1
1
1
1
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
Gallstone Solubilizing Agents
ursodiol cap 300mg
ursodiol tab 250mg
Tier 1
Tier 1
ursodiol tab 500mg
Tier 1
MAIL
QL (30 per 30 days);
MAIL
MAIL
Gastrointestinal Chloride Channel Activators
AMITIZA CAP 8MCG
AMITIZA CAP 24MCG
Tier 3
Tier 3
PA; MAIL
PA; MAIL
Tier 1
Tier 1
Tier 1
MAIL
MAIL
MAIL
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
MAIL
MAIL
MAIL
MAIL
PA, ST
PA, ST
PA, ST
MAIL
Gastrointestinal Stimulants
metoclopram sol 5mg/5ml
metoclopram tab 5mg
metoclopram tab 10mg
Inflammatory Bowel Agents
APRISO CAP 0.375GM
ASACOL HD TAB 800MG
ASACOL TAB 400MG DR
balsalazide cap 750mg
CIMZIA KIT
CIMZIA KIT STARTER
CIMZIA PREFL KIT 200MG/ML
DIPENTUM CAP 250MG
2
3
3
1
4
4
4
3
ST - Step Therapy
64
Drug Name
sulfasalazin tab 500mg
sulfasalazin tab 500mg dr
Tier 1
MAIL
Tier 1
MAIL
Intestinal Acidifiers
lactulose sol 10gm/15 10gm/15ml
Tier 1
MAIL
Irritable Bowel Syndrome (IBS) Agents
LINZESS CAP 145MCG
LINZESS CAP 290MCG
Tier 3
Tier 3
PA; MAIL
PA; MAIL
Peripheral Opioid Receptor Antagonists
RELISTOR KIT 12/0.6ML
Tier 4
PA
Tier
Tier
Tier
Tier
Tier
Tier
Tier
1
3
3
3
3
3
3
MAIL
ST; MAIL
ST; MAIL
ST; MAIL
ST; MAIL
ST; MAIL
ST; MAIL
Tier
Tier
Tier
Tier
1
1
1
1
MAIL
MAIL
MAIL
MAIL
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
3
3
1
1
1
1
1
1
1
3
3
1
1
3
3
ST; MAIL
ST; MAIL
MAIL
MAIL
ST; MAIL
ST; MAIL
ST; MAIL
ST; MAIL
ST; MAIL
ST; MAIL
ST; MAIL
ST; MAIL
ST; MAIL
ST; MAIL
ST; MAIL
Phosphate Binder Agents
calc acetate cap 667mg
FOSRENOL CHW 500MG
FOSRENOL CHW 750MG
FOSRENOL CHW 1000MG
RENVELA PAK 0.8GM
RENVELA PAK 2.4GM
RENVELA TAB 800MG
GENITOURINARY
Miscellaneous
bethanechol
bethanechol
bethanechol
bethanechol
tab
tab
tab
tab
5mg
10mg
25mg
50mg
Urinary Antispasmodics
ENABLEX TAB 7.5MG
ENABLEX TAB 15MG
oxybutynin syp 5mg/5ml
oxybutynin tab 5mg
oxybutynin tab 5mg er
tolterodine tab 1mg
tolterodine tab 2mg
TOVIAZ TAB 4MG
TOVIAZ TAB 8MG
trospium chl cap 60mg er
trospium cl tab 20mg
VESICARE TAB 5MG
VESICARE TAB 10MG
GENITOURINARY AGENTS - MISCELLANEOUS
Alkalinizers
ST - Step Therapy
65
Drug Name
citric acid/ sol sod citr
cytra-2 sol
cytra-k sol
k citrate sol citr acd
pot citrate tab 540mg
pot citrate tab 1080mg
Drug Tier
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Requirements/Limits
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
Tier 3
Tier 3
PA; MAIL
PA; MAIL
Tier 1
Tier 1
MAIL
MAIL
Tier 2
MAIL
Tier
Tier
Tier
Tier
Tier
Tier
1
1
1
3
3
1
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
Tier 1
Tier 1
MAIL
MAIL
Tier 1
MAIL
Tier
Tier
Tier
Tier
Tier
MAIL
MAIL
PA; MAIL
PA; MAIL
PA; MAIL
Cystinosis Agents
CYSTAGON CAP 50MG
CYSTAGON CAP 150MG
Genitourinary Irrigants
acetic acid sol 0.25%irr
sodium chlor sol 0.9% irr
Interstitial Cystitis Agents
ELMIRON CAP 100MG
Prostatic Hypertrophy Agents
alfuzosin tab 10mg
dutasteride cap 0.5mg
finasteride tab 5mg
RAPAFLO CAP 4MG
RAPAFLO CAP 8MG
tamsulosin cap 0.4mg
Urinary Analgesics
phenazopyrid tab 100mg
phenazopyrid tab 200mg
GOUT AGENTS
Gout Agent Combinations
proben/colch tab 500-0.5
Gout Agents
allopurinol tab 100mg
allopurinol tab 300mg
colchicine tab 0.6mg
ULORIC TAB 40MG
ULORIC TAB 80MG
1
1
1
3
3
Uricosurics
probenecid tab 500mg
Tier 1
MAIL
Tier 4
Tier 4
Tier 4
PA
PA
PA
HEMATOLOGICAL AGENTS - MISC.
Antihemophilic Products
ADVATE INJ 250UNIT
ADVATE INJ 500UNIT
ADVATE INJ 1000UNIT
ST - Step Therapy
66
Drug Name
ADVATE INJ 1500UNIT
ADVATE INJ 2000UNIT
ADVATE INJ 3000UNIT
ADVATE INJ 4000UNIT
BENEFIX INJ 250UNIT
BENEFIX INJ 500UNIT
BENEFIX INJ 1000UNIT
HELIXATE FS INJ 250UNIT
HELIXATE FS SOL 250UNIT
HUMATE-P SOL 1200UNIT
HUMATE-P SOL 2400UNIT
KOGENATE FS INJ 250/BS
KOGENATE FS INJ 250UNIT
RIXUBIS INJ 250 UNIT
RIXUBIS INJ 500UNIT
RIXUBIS INJ 1000UNIT
Drug Tier
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Requirements/Limits
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
Tier 1
MAIL
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
PA; MAIL
PA; MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
PA; MAIL
PA; MAIL
Hematorheologic Agents
pentoxifylli tab 400mg er
Platelet Aggregation Inhibitors
asa/dipyrida cap 25-200mg
BRILINTA TAB 90MG
cilostazol tab 50mg
cilostazol tab 100mg
clopidogrel tab 75mg
dipyridamole tab 25mg
EFFIENT TAB 5MG
EFFIENT TAB 10MG
1
3
1
1
1
1
1
1
3
3
ST - Step Therapy
67
Drug Name
ticlopidine tab 250mg
Tier 1
MAIL
HEMATOPOIETIC AGENTS
Cobalamins
vitamin
vitamin
vitamin
vitamin
vitamin
vitamin
vitamin
vitamin
b12 tab 1000 cr
b-12 sub 500mcg
b-12 sub 1000mcg
b-12 sub 2500mcg
b-12 tab 100mcg
b-12 tab 250mcg
b-12 tab 500mcg
b-12 tab 1000mcg
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
1
1
1
1
1
1
1
1
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
Tier 1
PREV
PREV
MAIL
MAIL
MAIL
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
Folic Acid/Folates
folic acid tab 1mg
folic acid tab 400mcg
folic acid tab 800mcg
Hematopoietic Growth Factors
ARANESP INJ 25MCG
ARANESP INJ 40MCG SOSY
ARANESP INJ 60MCG
ARANESP INJ 100MCG
ARANESP INJ 150MCG SOLN
ARANESP INJ 500MCG
EPOGEN INJ 2000/ML
EPOGEN INJ 4000/ML
EPOGEN INJ 10000/ML
EPOGEN INJ 20000/ML
LEUKINE INJ 250MCG
NEULASTA INJ 6MG/0.6M
NEUPOGEN INJ 300/0.5
NEUPOGEN INJ 300MCG
NEUPOGEN INJ 480/0.8
NEUPOGEN INJ 480MCG
PROCRIT INJ 2000/ML
PROCRIT INJ 4000/ML
PROCRIT INJ 10000/ML
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
Hematopoietic Mixtures
ferocon cap
Tier 1
MAIL
ST - Step Therapy
68
Drug Name
ferotrin cap
ferotrinsic cap
foltrin cap
iron complex cap
martinic cap
polysacchari cap iron
tl icon cap
tricon cap
Drug Tier
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Requirements/Limits
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
Tier 1
Tier 1
Tier 1
Tier 2
Tier 1
Tier 2
PREV
PREV
Tier 2
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
PREV
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
Tier 1
PA; MAIL
Iron
ferrous fum tab 324mg
ferrous gluc tab 240mg
ferrous gluc tab 324mg 324mg
FERROUS GLUC TAB 324MG 324mg
ferrous gluc tab 325mg
FERROUS SUL LIQ 220/5ML
ferrous sulf dro 15mg/ml
ferrous sulf elx 220/5ml
FERROUS SULF TAB 324MG EC
ferrous sulf tab 325mg
ferrous sulf tab 325mg ec
ferus cap 150mg
gnp iron tab 45mg
hm iron tab 45mg
iron chews chw pediatri
iron slow tab 45mg
iron tab 160mg cr
iron therapy tab 200mg
slow iron tab 50mg
slow release tab 47.5mg
sm iron tab 45mg
wee care sus 15/1.25
HEMOSTATICS
Hemostatics - Systemic
tranex acid inj 100mg/ml
HEPATITIS AGENTS
HEPATITIS C AGENT - COMBINATIONS
VIEKIRA PAK TAB
Tier 4
PA
Tier 1
Tier 1
MAIL
MAIL
HYPNOTICS
Antihistamine Hypnotics
calcium rich sus antacid
sleep aid tab 25mg
ST - Step Therapy
69
Drug Name
sleep aid tab 50mg
sleep tab 25mg
Tier 1
MAIL
Tier 1
MAIL
Barbiturate Hypnotics
phenobarb
phenobarb
phenobarb
phenobarb
phenobarb
phenobarb
phenobarb
phenobarb
phenobarb
sol 20mg/5ml
tab 15mg
tab 16.2mg
tab 30mg
tab 32.4mg
tab 60mg
tab 64.8mg
tab 97.2mg
tab 100mg
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
1
1
1
1
1
1
1
1
1
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Non-Barbiturate Hypnotics
chloral hydr syp 500/5ml
estazolam tab 1mg
estazolam tab 2mg
eszopiclone tab 2mg
eszopiclone tab 3mg
flurazepam cap 15mg
flurazepam cap 30mg
temazepam cap 15mg
temazepam cap 30mg
triazolam tab 0.25mg
triazolam tab 0.125mg
zaleplon cap 5mg
zaleplon cap 10mg
zolpidem tab 5mg
zolpidem tab 10mg
Selective Melatonin Receptor Agonists
ROZEREM TAB 8MG
Tier 3
PA; MAIL
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
LAXATIVES
Bulk Laxatives
best fiber pow
clr soluble pow fiber
eq fiber pow
fiber cap 0.52gm
fiber laxatv tab 625mg
fiber laxtiv cap 0.52gm
fiber powder pow
fiber tab 625mg
fiber therap cap 0.52gm
1
1
1
1
1
1
1
1
1
ST - Step Therapy
70
Drug Name
fiber therap pow 28.3%
fiber therap tab 500mg
fiber therap tab 625mg
fiber-caps tab 625mg
fiber-lax tab 625mg
fibergen tab 625mg
fibertab tab 625mg
gnp best pow fiber
hm fiber tab 500mg
KONSYL POW 28.3%
KONSYL POW 100% PACK
KONSYL-D POW 52.3%
metafiber pow 30.9%
metafiber pow 48.57%
metafiber pow 58.6%
METAMUCIL POW 28%
metamucil pow 30.9%
METAMUCIL POW 55.46%
metamucil pow 58.6%
METAMUCIL POW 58.12%
METAMUCIL POW CLEAR
METAMUCIL WAF
NAT FIBER POW 58.6%
psyllium pow 100%
qc natural pow vegetabl
ra fiber tab 500mg
sb fib lax pow 33%
sm fiber lax tab 500mg
soluble fib tab therapy
total fiber pow
UNIFIBER POW
veg fiber pow 63%
Drug Tier
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 2
Tier 2
Tier 2
Tier 1
Tier 1
Tier 1
Tier 2
Tier 1
Tier 2
Tier 1
Tier 2
Tier 2
Tier 2
Tier 2
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 2
Tier 1
Requirements/Limits
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
Tier
Tier
Tier
Tier
MAIL
MAIL
MAIL
MAIL, $0 Copay for
Bowel Preparation for
age +50
Laxative Combinations
gavilyte-c sol
gavilyte-g sol
GOLYTELY SOL
HALFLYTELY KIT FLAV PKS
1
1
2
2
ST - Step Therapy
71
Drug Name
MOVIPREP SOL
peg 3350 sol electrol
peg-3350 sol electrol
peg-3350/kcl sol /sodium
PREPOPIK PAK
senna-s tab 8.6-50mg
Tier 2
MAIL, $0 Copay for
age +50
Tier 1
MAIL
Tier 1
MAIL
Tier 1
MAIL
Tier 2
MAIL, $0 Copay for
age +50
Tier 1
MAIL
Laxatives - Miscellaneous
glycerin sup 1.2gm
glycerin sup 2.1gm
glycerin sup 2gm
glycerin sup 80.7%
lactulose sol 10gm/15 10gm/15ml
lactulose sol 20gm/30
polyeth glyc pow 3350 nf
Tier
Tier
Tier
Tier
Tier
Tier
Tier
1
1
1
1
1
1
1
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
Tier 2
Tier 1
MAIL
MAIL
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
Lubricant Laxatives
MINERAL OIL
mineral oil ene
Saline Laxatives
disposable ene
disposable ene single
disposable ene twin pk
enema ene double
enema ene single
enema ready- ene -to-use
eq enema ene double
mag citrate sol cherry
mag citrate sol grape
mag citrate sol lemon
milk of magn sus
MILK OF MAGN SUS 2400MG
oral saline sol laxative
OSMOPREP TAB 1.5GM
phosphate sol laxative
saline ene laxative
VISICOL TAB 1.5GM
1
1
1
1
1
1
1
1
1
1
1
2
1
3
1
1
3
Stimulant Laxatives
bisacodyl sup 10mg
Tier 1
MAIL
bisacodyl tab 5mg ec
Tier 1
MAIL
ST - Step Therapy
72
Drug Name
laxative chw 15mg
senna syp 8.8mg/5
senna tab 8.6mg
senna tab 25mg
SENNA TAB 187MG
VERACOLATE TAB
Drug Tier
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Requirements/Limits
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
1
1
1
1
1
1
1
1
2
1
1
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
Tier
Tier
Tier
Tier
Tier
Tier
1
1
1
1
1
1
Tier
Tier
Tier
Tier
Tier
1
1
1
1
1
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
1
2
1
1
1
2
1
1
Surfactant Laxatives
docu soft cap 100mg
docusate cal cap 240mg
docusate sod cap 250mg
docusate sod liq 50mg/5ml
docusate sod syp 20mg/5ml
docusate sod tab 100mg
docusol plus ene 20-283
enemeez plus ene 20-283
PEDIA-LAX LIQ 50MG
stool softnr cap 50mg
vacuant plus ene 20-283
MACROLIDES
Azithromycin
azithromycin
azithromycin
azithromycin
azithromycin
azithromycin
azithromycin
pow 1gm pak
sus 100/5ml
sus 200/5ml
tab 250mg
tab 500mg
tab 600mg
Clarithromycin
clarithromyc
clarithromyc
clarithromyc
clarithromyc
clarithromyc
sus 125/5ml
sus 250/5ml
tab 250mg
tab 500mg
tab 500mg er
Erythromycins
e.e.s. 400 tab 400mg
E.E.S. GRAN SUS 200/5ML
ERY-TAB TAB 250MG EC
ERYPED SUS 200/5ML
erythrocin tab 250mg
erythrom eth tab 400mg
ST - Step Therapy
73
Drug Name
erythromycin tab 250mg bs
erythromycin tab 500mg bs
Tier 1
Tier 1
Fidaxomicin
DIFICID TAB 200MG
Tier 4
PA
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MEDICAL DEVICES
Contraceptives
FEMALE CONDOMS
FEMCAP MIS 22MM
FEMCAP MIS 26MM
FEMCAP MIS 30MM
OMNIFLEX DPR
ORTHO COIL DPR KIT 50
ORTHO FLAT DPR KIT 55
ORTHO FLEX DPR 65MM
ORTHO FLEX DPR 70MM
ORTHO FLEX DPR 75MM
ORTHO FLEX DPR 80MM
PRENTIF MIS 22MM
PRENTIF MIS 25MM
PRENTIF MIS 28MM
PRENTIF MIS 31MM
PRENTIF MIS FITTING
TODAY SPONGE MIS
WIDE-SEAL DPR KIT 60
ST - Step Therapy
74
Drug Name
Diabetic Supplies
LANCETS
TRUE METRIX BLOOD GLUCOSE KIT
DME
DME
TRUERESULT KIT
DME
MAIL
QL (1 per 365 Days);
MAIL
MAIL
Misc. Devices
ALCOHOL SWABS
Tier 2
MAIL
DME
DME
MAIL
MAIL
Tier 2
Tier 2
Tier 2
MAIL
MAIL
MAIL
Tier 1
Tier 3
MAIL
MAIL
almotrip mal tab 6.25mg
Tier 1
almotrip mal tab 12.5mg
Tier 1
FROVA TAB 2.5MG
Tier 3
naratriptan tab 1mg
naratriptan tab 2.5mg
RELPAX TAB 20MG
Tier 1
Tier 1
Tier 3
RELPAX TAB 40MG
Tier 3
rizatriptan tab 5mg
Tier 1
rizatriptan tab 10mg
Tier 1
sumatriptan tab 25mg
zolmitriptan tab 2.5 mg
Tier
Tier
Tier
Tier
QL (6 per 30 days), ST;
MAIL
QL (12 per 50 days), ST;
MAIL
QL (9 per 45 Days), ST;
MAIL
QL (9 per 30 Days); MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
Parenteral Therapy Supplies
INSULIN PEN NEEDLES
INSULIN SYRINGES
Respiratory Therapy Supplies
NEBULIZERS
RESPIRATORY MASKS
SPACERS
MIGRAINE PRODUCTS
Migraine Products
dihydroergot inj 1mg/ml
ERGOMAR SUB 2MG
Serotonin Agonists
1
1
1
1
ST - Step Therapy
75
Drug Name
zolmitriptan tab 2.5mg
zolmitriptan tab 5mg
ZOMIG NASAL SPR 5MG
Tier 1
MAIL
Tier 1
MAIL
Tier 3
MAIL
MINERALS ELECTROLYTES
Calcium
ca cit/vit d tab 315/200
ca cit/vit d tab 315/250
ca/mg/zn tab
calc 600+d tab 600-800
calc cit+d3 tab 250-200
calc citr/d3 tab 200-250
calcitrate tab 950mg
calcium 500 tab +d
CALCIUM 600 CHW +D/MINER
calcium 600 chw +d/mnrls
calcium 600 chw w/vit d
calcium + d3 tab 600mg
calcium carb sus 1250/5ml
calcium carb tab 600mg
calcium carb tab 1250mg
calcium chw 500mg
calcium tab 600mg 1500mg
calcium+d tab 600-400
calcium/d3 tab 500-400
calcium/d cap 600mg
calcium/d chw 500-400
calcium/d tab 250mg
calcium/d tab 500-200
calcium/d tab 500/200
calcium/d tab 500mg
calcium/d tab 600mg
calcium/vitd tab 500-400
calcium/vt d tab 600-125
calvite p&d tab
os-cal 500 chw
oys shell+d tab 250-125
oysco 500+d chw
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
ST - Step Therapy
76
Drug Name
oyst shell/d tab 500mg
oyster shell tab 500mg
ra calcium+d tab 600mg
Drug Tier
Tier 1
Tier 1
Tier 1
Requirements/Limits
MAIL
MAIL
MAIL
Tier 1
MAIL
PREV
PREV
PREV
PREV
PREV
PREV
PREV
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
1
1
1
1
1
1
1
1
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
Tier 1
MAIL
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
1
1
1
1
1
1
1
1
1
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
Tier 1
MAIL
Tier 1
MAIL
Electrolyte Mixtures
ped elctrlyt sol
Fluoride
fluoride chw 0.5mg f
fluoride chw 0.25mg f
fluoride chw 1mg f
fluoritab dro 0.125mg
flura-drops dro 0.25mg f
sod fluoride dro 0.5mg/ml
sod fluoride tab 0.5mg f
Magnesium
mag-sr tab 535mg
magnesium cap 500mg
magnesium gl tab 500mg
magnesium su inj 50%
magnesium tab 200mg
magnesium tab 250mg 250mg
magnesium tab 500mg
magnesium-ox tab 400mg
Phosphate
phospha 250 tab neutral
Potassium
pot chloride cap 8meq er
pot chloride cap 10meq er
pot chloride liq 10%
pot chloride liq 20%
pot chloride tab 8meq er
pot chloride tab 10meq er
pot cl micro tab 10meq er
pot cl micro tab 20meq er
potassium tab 25meq ef
Sodium
sod chloride tab 1000mg
Zinc
zinc sulfate cap 220mg
MISC. NUTRITIONAL SUBSTANCES
MISC. NUTRITIONAL SUBSTANCES
ST - Step Therapy
77
Drug Name
prenatal dha cap 200mg
Tier 1
MAIL
MOUTH/THROAT/DENTAL AGENTS
Anesthetics Topical Oral
lidocaine sol 2% visc
Tier 1
MAIL
Tier 1
Tier 1
Tier 3
MAIL
MAIL
MAIL
Tier 1
Tier 1
MAIL
MAIL
Tier 1
Tier 1
MAIL
MAIL
Tier 1
MAIL
Tier 1
Tier 1
Tier 1
PA; MAIL
MAIL
MAIL
Tier
Tier
Tier
Tier
Tier
Tier
1
1
1
1
1
1
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
Tier 1
MAIL
Tier 1
Tier 1
Tier 1
MAIL
MAIL
MAIL
Tier 1
Tier 1
MAIL
MAIL
Tier 1
Tier 1
MAIL
MAIL
Anti-infectives - Throat
clotrimazole tro 10mg
nystatin sus 100000
ORAVIG TAB 50MG
Antiseptics - Mouth/Throat
paroex sol 0.12%
periogard sol 0.12%
Dental Products
denta 5000 cre plus
fluoridex gel 1.1%
Steroids - Mouth/Throat
triamcinolon pst 0.1%
Throat Products - Misc.
cevimeline cap 30mg
pilocarpine tab 5mg
pilocarpine tab 7.5mg
MULTIVITAMINS
B-Complex w/ Folic Acid
b complex tab vit c
folbee plus tab
rena-vite rx tab
renal tab multivit
reno cap
virt-vite tab plus
Multiple Vitamins w/ Iron
multi-day tab /iron
Multiple Vitamins w/ Minerals
multi cap complete
multi vitamn tab minerals
multivitamin liq mineral
Multivitamins
mult vitamin tab daily
multivitamin cap
Ped MV w/ Fluoride
mult-vit/fl chw 0.5mg
multi-vit/fl chw 0.25mg
ST - Step Therapy
78
Drug Name
multi-vit/fl chw 1mg
multi-vit/fl dro 0.5mg/ml
multi-vit/fl dro 0.25mg
QUFLORA PED CHW 0.5MG
QUFLORA PED CHW 0.25MG
QUFLORA PED CHW 1MG
tri-vit/fluo dro 0.5mg
tri-vit/fluo dro 0.25mg
Drug Tier
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Requirements/Limits
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
Tier 1
Tier 1
MAIL
MAIL
Tier 1
Tier 1
MAIL
MAIL
Tier 1
Tier 1
Tier 1
MAIL
MAIL
MAIL
Tier 1
Tier 1
Tier 1
MAIL
MAIL
MAIL
Tier 1
MAIL
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
Ped MV w/ Iron
childrens chw /iron
polyvitamin dro /iron
Ped Multi Vitamins w/Fl FE
multi-vit/fl dro /fe 0.25
tri-vit/fe dro /fl 0.25
Ped Multiple Vitamins w/ Minerals
childrens chw gummies
multivitamin dro pediatrc
polyvitamin chw /iron
Pediatric Multiple Vitamins
kids vitamin chw extra c
poly vitamin chw
polyvitamin dro
Pediatric Vitamins
tri-vitamin dro
Prenatal Vitamins
CL PRENATAL TAB 28-0.8MG
CO-NATAL FA TAB 29-1MG
COMPLETENATE CHW
CVS PRENATAL TAB
CVS PRENATAL TAB 28-0.8MG
EQL PRENATAL TAB FORMULA
GNP PRENATAL TAB 28-0.8MG
HM PRENATAL TAB
inatal adv tab
inatal gt tab
inatal ultra tab
KP PRENATAL TAB MULTIVIT
M-VIT TAB 27-1MG
MISSION PREN TAB /FA
MISSION PREN TAB HP
MULTI PRENAT TAB
2
2
2
2
2
2
2
2
1
1
1
2
2
2
2
2
ST - Step Therapy
79
Drug Name
NATAL-V RX TAB 29-1MG
PNV FOLIC AC TAB + IRON
PRE-NATAL TAB FORMULA
prenaplus tab
prenatabs fa tab
prenatabs rx tab
prenatal 19 chw tab
prenatal 19 tab
prenatal ad tab
PRENATAL ONE TAB DAILY
PRENATAL TAB
PRENATAL TAB 27-0.8MG
PRENATAL TAB 27-1MG
PRENATAL TAB 28-0.8MG
PRENATAL TAB COMPLETE
PRENATAL TAB FORMULA
PRENATAL TAB FORTE
PRENATAL TAB LOW IRON
prenatal tab plus
PRENATAL TAB PLUS
prenatal tab plus fe
PRENATAL TAB VITAMINS
PRENATAL VIT TAB PLUS
PRENATAL/FE TAB
PX PRENATAL TAB MULTIVIT
QC PRENATAL TAB 28-0.8MG
RA PRENATAL TAB 28-0.8MG
RA PRENATAL TAB FORMULA
RIGHT STEP TAB PRENATAL
SE-NATAL 19 CHW
SE-NATAL ONE TAB
SM PRENATAL TAB VITAMINS
STUART PREN TAB
TH PRENATAL TAB VITAMINS
THERANATAL TAB 27-1
triadvance tab
trinate tab
ultra tabs tab
VINATE ONE TAB
VOL-PLUS TAB
VOL-TAB RX TAB
Drug Tier
Tier 2
Tier 2
Tier 2
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 1
Tier 2
Tier 1
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 1
Tier 1
Tier 1
Tier 2
Tier 2
Tier 2
Requirements/Limits
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MUSCULOSKELETAL THERAPY AGENTS
ST - Step Therapy
80
Drug Name
Central Muscle Relaxants
baclofen tab 10mg
baclofen tab 20mg
carisoprodol tab 350mg
chlorzoxazon tab 500mg
cyclobenzapr tab 5mg
cyclobenzapr tab 10mg
metaxalone tab 800mg
methocarbam tab 500mg
methocarbam tab 750mg
orphenadrine tab 100mg er
tizanidine tab 2mg
tizanidine tab 4mg
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
1
1
1
1
1
1
1
1
1
1
1
1
MAIL
MAIL
Tier 1
Tier 1
Tier 1
MAIL
MAIL
MAIL
Tier 4
PA
MAIL
MAIL
MAIL
PA; MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
Direct Muscle Relaxants
dantrolene cap 25mg
dantrolene cap 50mg
dantrolene cap 100mg
Viscosupplements
EUFLEXXA INJ 10MG/ML
NASAL AGENTS - SYSTEMIC AND TOPICAL
Nasal Agents - Misc.
saline nasal spr 0.65%
Tier 1
MAIL
Tier 2
PA; MAIL
Tier 1
Tier 1
Tier 1
MAIL
MAIL
MAIL
Tier 1
Tier 1
MAIL
MAIL
Tier
Tier
Tier
Tier
1
1
1
3
MAIL
MAIL
MAIL
MAIL
Tier 1
Tier 1
Tier 1
MAIL
MAIL
MAIL
Nasal Anti-infectives
BACTROBAN OIN NASAL 2%
Nasal Antiallergy
azelastine spr 0.1%
cromolyn sod spr 5.2/act
olopatadine spr 0.6%
Nasal Anticholinergics
ipratropium spr 0.03%
ipratropium spr 0.06%
Nasal Steroids
flunisolide spr 0.025%
flunisolide spr 29mcg
fluticasone spr 50mcg
NASACORT ALR SPR 55MCG/AC
Sympathomimetic Decongestants
child silfed liq 15mg/5ml
chld decongs liq 15mg/5ml
nasal decon liq 15mg/5ml
ST - Step Therapy
81
Drug Name
nasal decong liq 30mg/5ml
nasal decong tab 10mg
non-pseudo tab 10mg
pseudoephedr syp 30mg/5ml
pseudoephedr tab 30mg
pseudoephedr tab 60mg
pseudoephedr tab 120mg er
sinus/conges tab 10mg
SUDAFED PE SOL CHILDREN
sudogest pe tab 10mg
suphedrine tab 10mg
suphedrine tab pe 10mg
TYZINE PED DRO 0.05%
TYZINE SOL 0.1%
unifed liq 30mg/5ml
Drug Tier
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 2
Tier 1
Tier 1
Tier 1
Tier 3
Tier 3
Tier 1
Requirements/Limits
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
Tier 1
PA; MAIL
NEUROMUSCULAR AGENTS
ALS Agents
riluzole tab 50mg
NON-BARBITURATE HYPNOTICS
NON-BENZODIAZEPINE - GABA-RECEPTOR MODULATORS
eszopiclone tab 1mg
Tier 1
NUTRIENTS
Misc. Nutritional Substances
fish oil cap 1000mg
fish oil cap 1200mg
CPDR
CPDR
Tier 1
Tier 1
MAIL
MAIL
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
PA; MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
OPHTHALMIC AGENTS
Artificial Tears and Lubricants
artifi tears dro 1-0.3%
artifi tears oin op
artifi tears sol op
artificial dro tears
artificial sol tears
artificial sol tears op
LACRISERT MIS 5MG OP
lubricant dro 1.4%
lubricating sol 0.5%
lubricnt eye dro 0.4-0.3%
lubricnt eye dro 0.5% op
pure & gentl dro 0.3%
1
1
1
1
1
1
3
1
1
1
1
1
Beta-blockers - Ophthalmic
betaxolol sol 0.5% op
Tier 1
MAIL
ST - Step Therapy
82
Drug Name
carteolol sol 1% op
COMBIGAN SOL 0.2/0.5%
dorzol/timol sol 2-0.5%op
levobunolol sol 0.5% op
levobunolol sol 0.25% op
metipranolol sol 0.3% oph
timolol gel sol 0.5% op
timolol gel sol 0.25% op
timolol mal sol 0.5% op
timolol mal sol 0.25% op
Drug Tier
Tier 1
Tier 2
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Requirements/Limits
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
Tier 1
Tier 1
Tier 1
MAIL
MAIL
MAIL
Tier
Tier
Tier
Tier
2
1
1
1
MAIL
MAIL
MAIL
MAIL
Tier 1
Tier 1
Tier 1
MAIL
MAIL
MAIL
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
Cycloplegic Mydriatics
atropine sul sol 1% op
tropicamide sol 0.5% op
tropicamide sol 1% op
Miotics
PHOSPHOLINE SOL 0.125%OP
pilocarpine sol 1% op
Ophthalmic Adrenergic Agents
apraclonidin sol 0.5% op
brimonidine sol 0.2% op
brimonidine sol 0.15%
Ophthalmic Anti-infectives
bacit/polymy oin op
bacitracin oin op
BESIVANCE SUS 0.6%
ciprofloxacn sol 0.3% op
erythromycin oin 5mg/gm
gatifloxacin sol 0.5%
gentamicin oin 0.3% op
gentamicin sol 0.3% op
levofloxacin sol 0.5%
NATACYN SUS 5% OP
neo/bac/poly oin op
neo/poly/gra sol op
ofloxacin dro 0.3% op
sulfacet sod sol 10% op
tobramycin sol 0.3% op
trifluridine sol 1% op
trimethoprim sol polymyxn
1
1
3
1
1
1
1
1
1
3
1
1
1
1
1
1
1
ST - Step Therapy
83
Drug Name
VIGAMOX DRO 0.5%
ZIRGAN GEL 0.15%
Tier 3
PA; MAIL
Tier 3
PA; MAIL
Ophthalmic Decongestants
naphazoline sol 0.1% op
Tier 1
MAIL
Tier 1
MAIL
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
3
1
3
1
3
3
3
1
1
1
1
1
1
2
2
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
3
3
1
2
3
1
1
1
1
3
1
1
4
1
1
1
3
3
MAIL
MAIL
PA; MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
PA
MAIL
MAIL
MAIL
MAIL
MAIL
Ophthalmic Local Anesthetics
proparacaine sol 0.5% op
Ophthalmic Steroids
ALREX SUS 0.2%
dexameth pho sol 0.1% op
DUREZOL EMU 0.05%
fluoromethol sus 0.1% op
LOTEMAX GEL 0.5%
LOTEMAX OIN 0.5%
LOTEMAX SUS 0.5%
neo/poly/bac oin /hc 1%op
neo/poly/dex oin 0.1% op
neo/poly/dex sus 0.1% op
prednisolone sus 1% op
sulf/pred na sol op
tobra/dexame sus 0.3-0.1%
TOBRADEX OIN 0.3-0.1%
VEXOL SUS 1% OP
Ophthalmics - Misc.
ALOCRIL SOL 2%
ALOMIDE SOL 0.1% OP
azelastine dro 0.05%
AZOPT SUS 1% OP
BEPREVE DRO 1.5%
bromfenac sol 0.09%
cromolyn sod sol 4% op
diclofenac sol 0.1% op
dorzolamide sol 2% op
EMADINE SOL 0.05% OP
epinastine dro 0.05%
flurbiprofen sol 0.03% op
JETREA INJ 2.5MG/ML
ketorolac sol 0.4%
ketorolac sol 0.5%
ketotif fum dro 0.025%op
LASTACAFT SOL 0.25%
NEVANAC SUS 0.1%
ST - Step Therapy
84
Drug Name
PATADAY SOL 0.2%
PATANOL SOL 0.1% OP
sod chloride oin 5% op
sod chloride sol 5% op
Drug Tier
Tier 3
Tier 3
Tier 1
Tier 1
Requirements/Limits
MAIL
MAIL
MAIL
MAIL
Tier
Tier
Tier
Tier
Tier
Tier
MAIL
ST; MAIL
ST; MAIL
ST; MAIL
ST; MAIL
ST; MAIL
Prostaglandins - Ophthalmic
latanoprost sol 0.005%
LUMIGAN SOL 0.01%
LUMIGAN SOL 0.03%
TRAVATAN Z DRO 0.004%
travoprost dro 0.004%
ZIOPTAN DRO 0.0015%
1
3
3
2
1
2
OTIC AGENTS
Otic Agents - Miscellaneous
acetic acid sol 2% otic
ear drying dro 95-5%
ear wax remv sol 6.5% ot
Tier 1
Tier 1
Tier 1
MAIL
MAIL
MAIL
Tier 1
MAIL
Tier
Tier
Tier
Tier
Tier
Tier
1
3
3
3
1
1
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
Tier 1
Tier 1
MAIL
MAIL
Tier 1
MAIL
Otic Anti-infectives
ofloxacin dro 0.3%otic
Otic Combinations
antipy/benzo sol otic
CIPRO HC SUS OTIC
CIPRODEX SUS 0.3-0.1%
CORTISPORIN SUS -TC OTIC
neo/poly/hc sol 1% otic
neo/poly/hc sus 1% otic
Otic Steroids
fluocin acet oil 0.01%
hc/acet acid sol otic
OXYTOCICS
Oxytocics
methylergon tab 0.2mg
PASSIVE IMMUNIZING AGENTS
Immune Serums
CARIMUNE INJ 12GM
Tier 4
PA
CARIMUNE NF INJ 12GM
Tier 4
PA
FLEBOGAMMA INJ 5%
Tier 4
PA
FLEBOGAMMA INJ 10%
Tier 4
PA
FLEBOGAMMA INJ DIF 5% .5gm/10ml,
Tier 4
PA
5gm/100ml
GAMASTAN S/D INJ
Tier 4
PA
GAMMAGARD INJ 1GM/10ML
Tier 4
PA
ST - Step Therapy
85
Drug Name
GAMMAGARD SD INJ 10GM HU
GAMMAKED INJ 1GM/10ML
GAMMAPLEX INJ 5GM
GAMUNEX INJ 10%
GAMUNEX-C INJ 1GM/10ML
HIZENTRA INJ 2GM/10ML
IMMUNE GLOBU INJ HUMAN
OCTAGAM INJ 5GM
PANGLOBULIN INJ 12GM
PANGLOBULIN SOL 12GM
POLYGAM S/D SOL 10GM
PRIVIGEN INJ 20GRAMS
RHOGAM PLUS INJ 300MCG
SANDOGLOBULI INJ IV 12GM
VENOGLOBUL-S INJ 10%
Drug Tier
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Requirements/Limits
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
Tier 4
Tier 4
PA
PA
Monoclonal Antibodies
SYNAGIS INJ 50MG
SYNAGIS INJ 100MG/ML
PENICILLINS
Aminopenicillins
amoxicillin cap 250mg
amoxicillin cap 500mg
amoxicillin chw 125mg
amoxicillin chw 250mg
amoxicillin sus 125/5ml
amoxicillin tab 500mg
amoxicillin tab 875mg
ampicillin cap 250mg
ampicillin cap 500mg
ampicillin sus 125/5ml
ampicillin sus 250/5ml
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Tier
Tier
Tier
Tier
1
1
1
1
Natural Penicillins
penicilln
penicilln
penicilln
penicilln
vk
vk
vk
vk
sol 125/5ml
sol 250/5ml
tab 250mg
tab 500mg
Penicillin Combinations
amox/k clav chw 200mg
Tier 1
AGE
ST - Step Therapy
86
Drug Name
amox/k clav
amox/k clav
amox/k clav
amox/k clav
amox/k clav
amox/k clav
amox/k clav
amox/k clav
AUGMENTIN
chw 400mg
sus 200/5ml
sus 250/5ml
sus 400/5ml
sus 600/5ml
tab 250mg
tab 500mg
tab 875mg
SUS 125/5ML
Drug Tier
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 2
Requirements/Limits
AGE
AGE
AGE
AGE
AGE
AGE
Penicillinase-Resistant Penicillins
dicloxacill cap 250mg
dicloxacill cap 500mg
Tier 1
Tier 1
PRENATAL VITAMINS
PRENATAL MV MIN W/FE-FA
PRENATAL MUL CAP +DHA
PRENATAL MV
Tier 2
MAIL
Tier 2
MAIL
Tier
Tier
Tier
Tier
Tier
Tier
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MIN W/FE-FA-DHA
PRENATAL MV MIS + DHA
PROGESTINS
Progestins
medroxypr ac tab 2.5mg
medroxypr ac tab 5mg
medroxypr ac tab 10mg
norethin ace tab 5mg
progesterone cap 100mg
progesterone cap 200mg
1
1
1
1
1
1
PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.
Agents for Chemical Dependency
acamprosate calcium tab 333 mg
disulfiram tab 250mg
disulfiram tab 500mg
Tier 1
Tier 1
Tier 1
PA; MAIL
MAIL
MAIL
Tier 2
PA
Tier
Tier
Tier
Tier
Tier
Tier
Tier
MAIL
MAIL
MAIL
MAIL
PA; MAIL
PA; MAIL
MAIL
Anti-Cataplectic Agents
XYREM SOL 500MG/ML
Antidementia Agents
donepezil tab 5mg
donepezil tab 5mg odt
donepezil tab 10mg
donepezil tab 10mg odt
exelon dis 4.6mg/24
exelon dis 9.5mg/24
galantamine cap 8mg er
1
1
1
1
1
1
1
ST - Step Therapy
87
Drug Name
galantamine cap 24mg er
galantamine tab 4mg
galantamine tab 8mg
galantamine tab 12mg
memant titra pak 5-10mg
memantine hcl tab 5 mg
memantine hcl tab 10 mg
namenda sol 10mg/5ml 2mg/ml
NAMENDA XR CAP 7MG
NAMENDA XR CAP 14MG
NAMENDA XR CAP 21MG
NAMENDA XR CAP 28MG
NAMENDA XR TITRATION PACK
Drug Tier
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Requirements/Limits
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
Tier
Tier
Tier
Tier
Tier
PA;
PA;
PA;
PA;
PA;
Fibromyalgia Agents
SAVELLA
SAVELLA
SAVELLA
SAVELLA
SAVELLA
MIS
TAB
TAB
TAB
TAB
TITR PAK
12.5MG
25MG
50MG
100MG
3
3
3
3
3
MAIL
MAIL
MAIL
MAIL
MAIL
Movement Disorder Drug Therapy
xenazine tab 12.5mg
xenazine tab 25mg
Tier 4
Tier 4
PA
PA
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
PA
PA
PA
PA
PA
PA
PA
PA, ST
Multiple Sclerosis Agents
AMPYRA TAB 10MG
AVONEX KIT 30MCG
AVONEX PEN KIT 30MCG
AVONEX PREFL KIT 30MCG KIT
EXTAVIA INJ 0.3MG
GILENYA CAP 0.5MG
glatiramer acetate 20mg/ml
TYSABRI INJ 300/15ML
4
4
4
4
4
4
4
4
Pseudobulbar Affect (PBA) Agents
NUEDEXTA CAP 20-10MG
Tier 3
PA; MAIL
Psychotherapeutic and Neurological Agents - Misc.
ergoloid mes tab 1mg oral
orap tab 1mg
orap tab 2mg
Tier 1
Tier 1
Tier 1
MAIL
MAIL
MAIL
Tier 3
PA; MAIL
Restless Leg Syndrome (RLS) Agents
HORIZANT TAB 600MG
Smoking Deterrents
ST - Step Therapy
88
Drug Name
bupropion tab 150mg
CHANTIX PAK 0.5& 1MG
CHANTIX PAK 1MG
CHANTIX TAB 0.5MG
CHANTIX TAB 1MG
nicotine dis 7mg/24hr
nicotine dis 14mg/24h
nicotine dis 21mg/24h
nicotine lozenge 2 mg
nicotine lozenge 4 mg
nicotine pol gum 2mg
nicotine pol gum 4mg
NICOTROL INH
NICOTROL NS SPR 10MG/ML
PREV
MAIL
PREV
QL (1 Treatment per
year); MAIL
PREV
QL (1 Treatment per
year); MAIL
PREV
QL (1 Treatment per
year); MAIL
PREV
QL (1 Treatment per
year); MAIL
PREV
MAIL
PREV
MAIL
PREV
MAIL
PREV
QL (1726 per Year);
MAIL
PREV
QL (1726 per Year);
MAIL
PREV
MAIL
PREV
MAIL
PREV
MAIL
PREV
MAIL
RESPIRATORY AGENTS - MISC.
Cystic Fibrosis Agents
PULMOZYME SOL 1MG/ML
Tier 4
PA
DME
QL (1 per year); MAIL
RESPIRATORY THERAPY SUPPLIES
PEAK FLOW METERS
PEAK FLOW METER
SULFONAMIDES
Sulfonamides
SULFADIAZINE TAB 500MG
Tier 1
SYMPATHOMIMETICS
ADRENERGIC COMBINATIONS
COMBIVENT RESPIMAT
Tier 2
ipratropium-albuterol nebu soln 0.5-2.5(3) Tier 1
mg/3ml
MAIL
QL (240 ml / 30 days);
MAIL
ST - Step Therapy
89
Drug Name
TETRACYCLINES
Tetracyclines
demeclocycl tab 150mg
demeclocycl tab 300mg
doxycyc mono cap 50mg
doxycyc mono cap 100mg
doxycyc mono tab 100mg
minocycline cap 50mg
minocycline cap 100mg
tetracycline cap 250mg
tetracycline cap 500mg
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
1
1
1
1
1
1
1
1
1
THYROID AGENTS
Antithyroid Agents
methimazole tab 5mg
methimazole tab 10mg
propylthiour tab 50mg
Tier 1
Tier 1
Tier 1
MAIL
MAIL
MAIL
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
Thyroid Hormones
ARMOUR THYRO TAB 15MG
EUTHROID TAB 120MG
EUTHROID-1 TAB 60MG
EUTHROID-2 TAB 120MG
EUTHROID-3 TAB 180MG
levothroid tab 25mcg
levothyroxin tab 25mcg
2
2
2
2
2
2
2
2
2
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
ST - Step Therapy
90
Drug Name
levoxyl tab 25mcg
levoxyl tab 50mcg
levoxyl tab 75mcg
levoxyl tab 88mcg
levoxyl tab 100mcg
levoxyl tab 112mcg
levoxyl tab 125mcg
levoxyl tab 137mcg
levoxyl tab 150mcg
levoxyl tab 175mcg
levoxyl tab 200mcg
liothyronine inj 10mcg/ml
liothyronine tab 5mcg
NATURE-THROI TAB 16.25MG
NATURE-THROI TAB 65MG
np thyroid tab 30mg
np thyroid tab 60mg
np thyroid tab 90mg
SYNTHROID TAB 25MCG
SYNTHROID TAB 50MCG
SYNTHROID TAB 75MCG
SYNTHROID TAB 88MCG
SYNTHROID TAB 100MCG
Drug Tier
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 1
Tier 1
Tier 1
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Requirements/Limits
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
ST - Step Therapy
91
Drug Name
THYROLAR-1 TAB 60MG
THYROLAR-1/2 TAB 30MG
THYROLAR-1/4 TAB 15MG
THYROLAR-2 TAB 120MG
THYROLAR-3 TAB 180MG
unith direct tab 25mcg
unithroid tab 25mcg
unithroid tab 50mcg
unithroid tab 75mcg
unithroid tab 88mcg
unithroid tab 100mcg
WESTHROID TAB 16.25MG
WESTHROID TAB 65MG
WESTHROID TAB 130MG
WESTHROID TAB 195MG
WESTHROID-P TAB 16.25MG
Drug Tier
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Requirements/Limits
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
ST - Step Therapy
92
Drug Name
WESTHROID-P TAB 65MG
WESTHROID-P TAB 130MG
WP THYROID TAB 16.25MG
WP THYROID TAB 65MG
WP THYROID TAB 130MG
Drug Tier
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Requirements/Limits
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
1
1
2
1
1
1
1
1
1
1
1
1
1
1
1
MAIL
MAIL
PA; MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
1
1
1
1
1
1
1
1
1
1
1
1
1
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
PA; MAIL
PA; MAIL
MAIL
MAIL
MAIL
ULCER DRUGS
Antispasmodics
atropine sul inj 0.1mg/ml
atropine sul inj 0.05mg/1
CUVPOSA SOL 1MG/5ML
dicyclomine cap 10mg
dicyclomine sol 10mg/5ml
dicyclomine tab 20mg
glycopyrrol tab 1mg
glycopyrrol tab 2mg
hyoscyamine dro 0.125/ml
hyoscyamine sub 0.125mg
hyoscyamine tab 0.125mg
hyoscyamine tab 0.375 er
hyosyne elx 0.125/5
methscopolam tab 2.5mg
methscopolam tab 5mg
H-2 Antagonists
cimetidine sol 300/5ml
cimetidine tab 200mg
famotidine tab 10mg
famotidine tab 20mg
famotidine tab 40mg
nizatidine cap 150mg
nizatidine sol 15mg/ml
ranitidine syp 15mg/ml
ranitidine tab 75mg
ranitidine tab 150mg
ST - Step Therapy
93
Drug Name
ranitidine tab 300mg
Tier 1
MAIL
Misc. Anti-Ulcer
CARAFATE SUS 1GM/10ML
sucralfate tab 1gm
Tier 2
Tier 1
PA; MAIL
MAIL
DEXILANT CAP 30MG DR
DEXILANT CAP 60MG DR
FIRST-OMEPRA SUS 2MG/ML
KAPIDEX CAP 30MG DR
KAPIDEX CAP 60MG DR
lansoprazole cap 15mg dr
lansoprazole cap 15mg dr otc
Tier
Tier
Tier
Tier
Tier
Tier
Tier
3
3
2
3
3
1
1
lansoprazole cap 30mg dr
NEXIUM 24HR CAP 20MG OTC
OMEPRAZOLE + SUS SYRSPEND
omeprazole cap 10mg
omeprazole cap 20.6mgdr
omeprazole cap 20mg
omeprazole cap delayed release 40 mg
omeprazole tab 20mg
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
1
1
2
1
1
1
1
1
pantoprazole tab 20mg
pantoprazole tab 40mg
PRILOSEC OTC TAB 20MG
rabeprazole tab 20mg
Tier
Tier
Tier
Tier
1
1
1
1
ST; MAIL
ST; MAIL
PA; MAIL
ST; MAIL
ST; MAIL
PA; MAIL
MAIL
PA; MAIL
MAIL
PA; MAIL
MAIL
MAIL
MAIL
MAIL
MAIL, Specific NDCs may
not be reimbursable
MAIL
MAIL
MAIL
ST; MAIL
Proton Pump Inhibitors
Ulcer Drugs - Prostaglandins
misoprostol tab 100mcg
misoprostol tab 200mcg
Tier 1
Tier 1
MAIL
MAIL
Tier
Tier
Tier
Tier
Tier
1
3
1
1
1
MAIL
MAIL
MAIL
MAIL
MAIL
Tier 1
MAIL
URINARY ANTI-INFECTIVES
Urinary Anti-infectives
methenam hip tab 1gm
MONUROL PAK GRANULES
nitrofur mac cap 50mg
nitrofur mac cap 100mg
nitrofurantn cap 100mg
URINARY ANTISPASMODICS
Urinary Antispasmodics
flavoxate tab 100mg
VACCINES
Viral Vaccines
ST - Step Therapy
94
Drug Name
AFLURIA INJ
AFLURIA INJ PF
EZ USE FLU KIT
FLUARIX INJ PF
FLUARIX QUAD INJ
FLULAVAL INJ
FLULAVAL QUA INJ
FLUMIST QUADRIVALENT
FLUVIRIN INJ
FLUVIRIN INJ PF
FLUZONE INJ INTRADRM
FLUZONE INJ PF
FLUZONE PED/ INJ PF
FLUZONE QUAD INJ
FLUZONE SPLT INJ
PREV
MAIL
PREV
MAIL
PREV
MAIL
PREV
MAIL
PREV
MAIL
PREV
MAIL
PREV
MAIL
PREV
MAIL
PREV
MAIL
PREV
MAIL
PREV
MAIL
PREV
MAIL
PREV
MAIL
PREV
MAIL
PREV
MAIL
VAGINAL PRODUCTS
Spermicides
nonoxynol-9 gel 4%
PREV
MAIL
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
1
1
1
2
1
1
1
1
1
1
1
1
1
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
Tier 2
Tier 2
Tier 2
MAIL
MAIL
MAIL
Tier 1
Tier 2
Tier 2
MAIL
MAIL
MAIL
Vaginal Anti-infectives
clindamycin cre 2% vag
clotrimazole cre 1% 1%
clotrimazole cre 2%
GYNAZOLE-1 CRE 2%
metronidazol gel 0.75%vag
miconazole 3 cre 4%
miconazole 3 kit combo pk
miconazole cre 2% 2%
miconazole sup 100mg
terconazole cre 0.4%
terconazole cre 0.8%
terconazole sup 80mg
tioconazole oin 6.5% vag
Vaginal Estrogens
ESTRACE VAG CRE 0.1MG/GM
PREMARIN VAG CRE 0.625MG
VAGIFEM TAB 10MCG
VASOPRESSORS
Anaphylaxis Therapy Agents
epinephrine inj 0.15mg
EPIPEN 2-PAK INJ 0.3MG
EPIPEN-JR INJ 2-PAK
ST - Step Therapy
95
Drug Name
Vasopressors
midodrine tab 2.5mg
midodrine tab 5mg
midodrine tab 10mg
Tier 1
Tier 1
Tier 1
MAIL
MAIL
MAIL
PREV
PREV
MAIL
MAIL
PREV
Tier 1
Tier 2
Tier 1
Tier 1
Tier 1
Tier 1
PREV
Tier 1
Tier 1
PREV
Tier 1
Tier 1
PREV
Tier 1
Tier 1
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
Tier
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
MAIL
VIRAL VACCINES
VIRAL VACCINES
FLUBLOK
FLUCELVAX INJ
VITAMINS
Oil Soluble Vitamins
bio-d-mulsio liq 400unit
ergocalcifer cap 50000unt
MEPHYTON TAB 5MG
vitamin d3 cap 2000unit
vitamin d3 cap 5000unit
vitamin d3 cap 10000unt
vitamin d3 cap 50000unt
vitamin d3 chw 400unit
vitamin d3 chw 1000unit
vitamin d3 dro 5000unit
vitamin d3 tab 400unit
vitamin d3 tab 1000unit
vitamin d cap 1000unit
vitamin d dro 400unit
vitamin d-3 tab 2000unit
vitamin d-3 tab 5000unit
Water Soluble Vitamins
niacin cap 250mg er
niacin cap 500mg sr
niacin tab 50mg
niacin tab 100mg
niacin tab 250mg
niacin tab 250mg sr
niacin tab 500mg
niacin tab 500mg er
niacin tab 750mg tr
niacinamide tab 500mg
pyridoxine tab 25mg
pyridoxine tab 50mg
pyridoxine tab 100mg
vitamin b-6 tab 200mg cr
1
1
1
1
1
1
1
1
1
1
1
1
1
1
ST - Step Therapy
96
Index
A
abacav/lamiv tab /zidovud .................39
abacavir tab 300mg ..........................39
ABILIFY DISC TAB 10MG....................38
ABILIFY DISC TAB 15MG....................38
ABILIFY MAIN INJ 300MG ..................38
ABILIFY MAIN INJ 400MG ..................38
abilify sol 1mg/ml .............................38
ABREVA CRE 10% .............................55
acamprosate calcium tab 333 mg........86
acarbose tab 100mg..........................21
acarbose tab 25mg ...........................21
acarbose tab 50mg ...........................21
acebutolol cap 200mg .......................43
acebutolol cap 400mg .......................43
acetam melts tab 80mg ...................... 5
acetamin cap 500mg .......................... 5
acetamin jr tab 160mg rt .................... 5
acetamin liq 500/15ml ........................ 5
acetamin sol 160/5ml ......................... 5
acetamin sup 120mg .......................... 5
acetamin sup 325mg .......................... 5
acetamin sup 650mg .......................... 5
acetamin tab 325mg .......................... 5
acetamin tab 650mg .......................... 5
acetaminophn sus 160/5ml ................. 5
acetaminophn tab 500mg ................... 5
acetazolamid cap 500mg er................59
acetazolamid tab 125mg ....................59
acetazolamid tab 250mg ....................59
acetic acid sol 0.25%irr .....................65
acetic acid sol 2% otic .......................83
ACETONE (URINE) TEST STRIP ...........58
acetylcyst sol 20% ............................52
acid gone chw 80-20mg...................... 8
acid gone sus .................................... 8
acitretin cap 10mg ............................54
acitretin cap 17.5mg .........................54
acitretin cap 25mg ............................54
ACNE MEDICAT LOT 10% ...................52
ACNE MEDICAT LOT 5% ....................52
ACTEMRA INJ 162/0.9 ........................ 3
ACTEMRA INJ 200/10ML ..................... 3
ACTEMRA INJ 400/20ML ..................... 3
ACTEMRA INJ 80MG/4ML .................... 3
ACTIMMUNE INJ 2MU/0.5...................34
acyclovir cap 200mg ......................... 41
acyclovir oin 5% .............................. 55
acyclovir sus 200/5ml ....................... 41
acyclovir tab 400mg ......................... 41
acyclovir tab 800mg ......................... 41
adapalene cre 0.1% ......................... 52
adapalene gel 0.1% .......................... 52
adapalene gel 0.3% .......................... 52
ADCIRCA TAB 20MG ......................... 46
adefov dipiv tab 10mg ...................... 41
ADVAIR DISKU AER 100/50 ............... 13
ADVATE INJ 1000UNIT ...................... 65
ADVATE INJ 1500UNIT ...................... 65
ADVATE INJ 2000UNIT ...................... 65
ADVATE INJ 250UNIT ....................... 65
ADVATE INJ 3000UNIT ...................... 66
ADVATE INJ 4000UNIT ...................... 66
ADVATE INJ 500UNIT ....................... 65
AEROSPAN AER 80MCG ..................... 13
AFINITOR DIS TAB 2MG .................... 33
AFINITOR TAB 10MG ........................ 33
AFINITOR TAB 2.5MG ....................... 33
AFINITOR TAB 5MG .......................... 33
AFINITOR TAB 7.5MG ....................... 33
AFLURIA INJ .................................... 93
AFLURIA INJ PF ................................ 93
alamag-plus chw ................................ 9
ALBENZA TAB 200MG ......................... 9
albuterol neb 0.083% ....................... 13
albuterol neb 0.5% ........................... 13
albuterol neb 0.63mg/3 .................... 13
albuterol neb 1.25mg/3 .................... 13
albuterol syp 2mg/5ml ...................... 13
albuterol tab 4mg ............................. 13
alclometason cre 0.05% .................... 55
alclometason oin 0.05% .................... 55
ALCOHOL SWABS ............................. 74
ALDACTAZIDE TAB 50/50 .................. 59
alendronate tab 10mg ...................... 60
alendronate tab 5mg ........................ 60
ALER-DRYL TAB 50MG ...................... 25
97
alfuzosin tab 10mg ...........................65
ALINIA SUS 100/5ML ........................10
ALINIA TAB 500MG ...........................10
ALKERAN TAB 2MG ...........................32
ALLEGRA ALRG TAB 30MG .................26
aller-chlor syp 2mg/5ml .....................25
allergy cre 2-0.1% ............................54
allergy-d tab 25-10mg .......................51
allopurinol tab 100mg .......................65
allopurinol tab 300mg .......................65
allrgy melts tab 12.5mg .....................25
allrgy relf tab 12.5mg ........................25
almacone chw ................................... 9
almotrip mal tab 12.5mg ...................74
almotrip mal tab 6.25mg ...................74
ALOCRIL SOL 2% ..............................83
ALOMIDE SOL 0.1% OP .....................83
ALOXI INJ 0.25MG/5 .........................24
alprazolam tab 0.25mg ......................11
alprazolam tab 0.5mg .......................11
alprazolam tab 1mg ..........................11
alprazolam tab 2mg ..........................11
ALREX SUS 0.2% ..............................82
ALTABAX OIN 1% .............................53
altavera tab .....................................46
alyacen tab 1/35...............................46
alyacen tab 7/7/7 .............................47
amantadine cap 100mg .....................35
amantadine syp 50mg/5ml ................35
amcinonide cre 0.1% ........................55
amcinonide lot 0.1% .........................55
AMCINONIDE OIN 0.1% ....................55
amethyst tab 90-20mcg ....................47
amilor/hctz tab 5-50 .........................59
amiloride tab 5mg .............................59
aminophyllin inj 25mg/ml ..................14
aminophyllin tab 100mg ....................14
aminophyllin tab 200mg ....................14
amiodarone tab 200mg......................12
AMITIZA CAP 24MCG .........................63
AMITIZA CAP 8MCG ..........................63
amitriptylin tab 100mg ......................20
amitriptylin tab 10mg ........................20
amitriptylin tab 150mg ......................20
amlodipine tab 10mg ........................ 44
amlodipine tab 2.5mg ....................... 44
amlodipine tab 5mg .......................... 44
ammonium lac cre 12% .................... 57
ammonium lac lot 12% ..................... 57
amnesteem cap 10mg ...................... 52
amnesteem cap 20mg ...................... 52
amnesteem cap 40mg ...................... 52
amox/k clav chw 200mg ................... 85
amox/k clav chw 400mg ................... 85
amox/k clav sus 200/5ml .................. 85
amox/k clav sus 250/5ml .................. 85
amox/k clav sus 400/5ml .................. 85
amox/k clav sus 600/5ml .................. 85
amox/k clav tab 250mg .................... 85
amox/k clav tab 500mg .................... 85
amox/k clav tab 875mg .................... 85
amoxapine tab 100mg ...................... 20
amoxapine tab 150mg ...................... 20
amoxapine tab 25mg ........................ 20
amoxapine tab 50mg ........................ 20
amoxicillin cap 250mg ...................... 85
amoxicillin cap 500mg ...................... 85
amoxicillin chw 125mg ...................... 85
amoxicillin chw 250mg ...................... 85
amoxicillin sus 125/5ml .................... 85
amoxicillin tab 500mg ....................... 85
amoxicillin tab 875mg ....................... 85
amphetamine cap 10mg er .................. 1
amphetamine cap 5mg er.................... 1
amphetamine tab 10mg ...................... 1
amphetamine tab 12.5mg ................... 1
amphetamine tab 5mg ........................ 1
amphetamine tab 7.5mg ..................... 1
ampicillin cap 250mg ........................ 85
ampicillin cap 500mg ........................ 85
ampicillin sus 125/5ml ...................... 85
98
ampicillin sus 250/5ml .......................85
AMPYRA TAB 10MG ...........................87
ANADROL 50 TAB 50MG...................... 8
anastrozole tab 1mg .........................33
ANDROXY TAB 10MG .......................... 8
antacid chw dbl st .............................. 9
antacid extr chw 675-135 ................... 9
antacid sus ultra st ............................ 9
anti-nausea liq .................................24
antipy/benzo sol otic .........................84
ANZEMET TAB 100MG .......................24
ANZEMET TAB 50MG .........................24
APAP 500 LIQ 500/5ML ....................... 5
apap chw 80mg ................................. 5
apap dro 80/0.8ml ............................. 5
apap infants dro 80/0.8ml ................... 5
apap/codeine sol 120-12/5 ................. 7
apap/codeine tab 300-15mg ............... 7
APEXICON E CRE 0.05% ....................55
APIDRA INJ SOLOSTAR ......................22
APIDRA INJ U-100 ............................22
APOKYN INJ 10MG/ML .......................35
apra elx 160/5ml ............................... 5
apraclonidin sol 0.5% op ...................82
apri tab ...........................................47
APRISO CAP 0.375GM .......................63
APTIVUS CAP 250MG .........................39
APTIVUS SOL ...................................39
aranelle tab ......................................47
ARANESP INJ 100MCG .......................67
ARANESP INJ 150MCG .......................67
ARANESP INJ 200MCG .......................67
ARANESP INJ 25MCG .........................67
ARANESP INJ 300MCG .......................67
ARANESP INJ 40MCG .........................67
ARANESP INJ 500MCG .......................67
ARANESP INJ 60MCG .........................67
ARCAPTA CAP 75MCG ........................13
aripiprazole tab 10mg........................38
aripiprazole tab 2mg .........................38
aripiprazole tab 5mg .........................38
ARMOUR THYRO TAB 120MG ..............89
ARMOUR THYRO TAB 15MG ............... 89
ARMOUR THYRO TAB 180MG ............. 89
artifi tears dro 1-0.3% ...................... 81
artifi tears oin op ............................. 81
artifi tears sol op .............................. 81
artificial dro tears ............................. 81
artificial sol tears.............................. 81
artificial sol tears op ......................... 81
asa free chw 160mg jr ........................ 5
asa/dipyrida cap 25-200mg ............... 66
ASACOL HD TAB 800MG .................... 63
ASACOL TAB 400MG DR .................... 63
ASMANEX 120 AER 220MCG .............. 13
ASMANEX 14 AER 220MCG ................ 13
ASMANEX 30 AER 110MCG ................ 13
ASMANEX 30 AER 220MCG ................ 13
ASMANEX 60 AER 220MCG ................ 13
ASMANEX 7 AER 110MCG .................. 13
aspirin 81 tab 81mg ec ....................... 5
aspirin adlt tab 81mg.......................... 5
aspirin chw 81mg ............................... 5
aspirin tab 325mg .............................. 5
aspirin tab 325mg ec .......................... 5
ASPIRIN TAB 81MG ............................ 5
atenol/chlor tab 100-25mg ................ 30
atenol/chlor tab 50-25mg.................. 30
atenolol tab 100mg .......................... 43
atenolol tab 25mg ............................ 43
atenolol tab 50mg ............................ 43
atorvastatin tab 10mg ...................... 27
atovaq/progu tab 250-100 ................ 31
atovaq/progu tab 62.5-25 ................. 31
atovaquone sus 750/5ml ................... 10
ATRIPLA TAB ................................... 39
atropine sul inj 0.05mg/1 .................. 91
atropine sul inj 0.1mg/ml .................. 91
atropine sul sol 1% op ...................... 81
ATROVENT HFA AER 17MCG .............. 12
aubra tab 0.1-0.02 ........................... 47
aug betamet cre 0.05% .................... 55
aug betamet gel 0.05% .................... 55
aug betamet lot 0.05% ..................... 55
99
aug betamet oin 0.05% .....................55
AUGMENTIN SUS 125/5ML .................85
AVANDIA TAB 2MG ...........................23
AVANDIA TAB 4MG ...........................23
AVANDIA TAB 8MG ...........................23
aviane tab........................................47
AVONEX KIT 30MCG ..........................87
AVONEX PEN KIT 30MCG ...................87
AVONEX PREFL KIT 30MCG ................87
azathioprine tab 50mg .......................42
azelastine dro 0.05% ........................83
azelastine spr 0.1% ..........................80
AZILECT TAB 0.5MG ..........................35
AZILECT TAB 1MG.............................35
azithromycin pow 1gm pak ................72
azithromycin sus 100/5ml ..................72
azithromycin sus 200/5ml ..................72
azithromycin tab 250mg ....................72
AZOPT SUS 1% OP ...........................83
azurette tab 28 day ...........................47
B
b complex tab vit c ...........................77
bacit/polymy oin op ..........................82
bacitracin oin 500/gm........................53
bacitracin oin op ...............................82
baclofen tab 10mg ............................79
baclofen tab 20mg ............................79
BACTROBAN OIN NASAL 2% ..............80
balsalazide cap 750mg ......................63
balziva tab .......................................47
BANZEL SUS 40MG/ML ......................16
BANZEL TAB 200MG ..........................16
BANZEL TAB 400MG ..........................16
BARACLUDE SOL .05MG/ML ...............41
benazep/hctz tab 10-12.5 ..................30
benazep/hctz tab 20-12.5 ..................30
benazep/hctz tab 20-25mg ................30
benazepril tab 10mg .........................28
benazepril tab 5mg ...........................28
BENEFIX INJ 1000UNIT .....................66
BENEFIX INJ 2000UNIT .....................66
BENEFIX INJ 250UNIT .......................66
BENEFIX INJ 3000UNIT .....................66
BENEFIX INJ 500UNIT ....................... 66
BENICAR TAB 20MG ......................... 29
BENICAR TAB 40MG ......................... 29
BENICAR TAB 5MG ........................... 29
benzonatate cap 100mg .................... 50
benzonatate cap 200mg .................... 50
benzoyl per gel 10% ......................... 52
benzoyl per gel 5% .......................... 52
benztropine tab 0.5mg ...................... 34
benztropine tab 1mg ........................ 34
benztropine tab 2mg ........................ 35
BEPREVE DRO 1.5% ......................... 83
BESIVANCE SUS 0.6% ...................... 82
best fiber pow .................................. 69
betameth dip cre 0.05% ................... 55
betameth dip lot 0.05% .................... 55
betameth dip oin 0.05% ................... 55
betameth val cre 0.1% ..................... 55
betameth val oin 0.1% ..................... 55
betasept liq 4% ............................... 39
betaxolol sol 0.5% op ....................... 81
betaxolol tab 10mg .......................... 43
betaxolol tab 20mg .......................... 43
bethanechol tab 10mg ...................... 64
bethanechol tab 5mg ........................ 64
bexarotene cap 75mg ....................... 34
bicalutamide tab 50mg ..................... 33
BILTRICIDE TAB 600MG ...................... 9
bio-d-mulsio liq 400unit .................... 94
bisacodyl sup 10mg .......................... 71
bisacodyl tab 5mg ec ........................ 71
bismatrol sus 262/15ml .................... 23
bismuth chw 262mg ......................... 24
bismuth ms sus 525/15ml ................. 24
bisoprl/hctz tab 10/6.25 .................... 30
bisoprl/hctz tab 2.5/6.25 ................... 30
bisoprl/hctz tab 5-6.25mg ................. 30
bisoprol fum tab 10mg ...................... 43
bisoprol fum tab 5mg ....................... 43
bpo-10 wash liq 10% ........................ 52
bpo-5 wash liq 5% ........................... 52
briellyn tab ...................................... 47
BRILINTA TAB 90MG ......................... 66
brimonidine sol 0.15% ...................... 82
brimonidine sol 0.2% op ................... 82
100
brom/pse/dm syp .............................51
bromfed dm syp ...............................51
bromfenac sol 0.09% ........................83
bromocriptin cap 5mg .......................35
bromocriptin tab 2.5mg .....................35
brotapp dm liq 15-1-5/5 ....................51
brotapp liq .......................................51
BROVANA NEB 15MCG .......................13
budesonide cap 3mg/24hr..................50
budesonide sus 0.25mg/2 ..................13
budesonide sus 0.5mg/2 ....................13
bumetanide tab 0.5mg ......................59
bumetanide tab 1mg .........................59
bumetanide tab 2mg .........................59
BUPHENYL TAB 500MG ......................61
buprenorphin sub 2mg ....................... 8
buprenorphin sub 8mg ....................... 8
bupropion tab 100mg ........................18
bupropion tab 100mg er ....................18
bupropion tab 150mg ........................87
bupropion tab 75mg ..........................18
bupropn hcl tab 150mg xl ..................18
bupropn hcl tab 300mg xl ..................18
buspirone tab 10mg ..........................11
buspirone tab 15mg ..........................11
buspirone tab 5mg ............................11
buspirone tab 7.5mg .........................11
but/apap/caf cap 50-325-40 mg .......5, 7
but/apap/caf tab 50-325-40 mg .......... 5
but/asa/caff cap 50-325-40 mg ........... 5
but/asa/caff tab 50-325-40 mg ........... 5
butal/apap tab 50-325mg ................... 5
butorphanol sol 10mg/ml .................... 8
BUTRANS DIS 10MCG/HR ................... 8
BUTRANS DIS 20MCG/HR ................... 8
BUTRANS DIS 5MCG/HR ..................... 8
BYETTA INJ 10MCG ...........................22
BYETTA INJ 5MCG .............................22
BYSTOLIC TAB 10MG .........................43
BYSTOLIC TAB 2.5MG ........................43
BYSTOLIC TAB 20MG .........................43
BYSTOLIC TAB 5MG ..........................43
C
ca cit/vit d tab 315/200 .....................75
ca cit/vit d tab 315/250 .....................75
ca/mg/zn tab ................................... 75
cabergoline tab 0.5mg ...................... 61
calc 600+d tab 600-800.................... 75
calc acetate cap 667mg .................... 64
calc antacid chw 1000mg .................... 9
calc antacid chw 750mg ...................... 9
calc cit+d3 tab 250-200 .................... 75
calc citr/d3 tab 200-250 .................... 75
calcipotrien oin 0.005% .................... 54
calcipotrien oin betameth .................. 55
calcipotrien sol 0.005% ..................... 54
calcitonin spr 200/act ....................... 60
calcitrate tab 950mg......................... 75
calcitriol cap 0.25mcg ....................... 61
calcitriol cap 0.5mcg ......................... 61
calcitriol oin 3mcg/gm ...................... 54
calcium + d3 tab 600mg ................... 75
calcium 500 tab +d .......................... 75
CALCIUM 600 CHW +D/MINER ........... 75
calcium 600 chw +d/mnrls ................ 75
calcium 600 chw w/vit d.................... 75
calcium carb chw 500mg ..................... 9
calcium carb sus 1250/5ml ................ 75
calcium carb tab 1250mg .................. 75
calcium carb tab 600mg .................... 75
CALCIUM CARB TAB 648MG ................. 9
calcium chw 500mg .......................... 75
calcium rich sus antacid ................ 9, 68
calcium tab 600mg ........................... 75
calcium/d cap 600mg ....................... 75
calcium/d chw 500-400 ..................... 75
calcium/d tab 250mg ........................ 75
calcium/d tab 500/200 ...................... 75
calcium/d tab 500-200 ...................... 75
calcium/d tab 500mg ........................ 75
calcium/d tab 600-200 ...................... 75
calcium/d tab 600-400 ...................... 75
calcium/d tab 600mg ........................ 75
calcium/d3 tab 500-400 .................... 75
calcium/vitd tab 500-400 .................. 75
calcium/vt d tab 600-125 .................. 75
calcium+d tab 600-400 ..................... 75
calvite p&d tab................................. 75
camila tab 0.35mg ........................... 49
candesartan tab 16mg ...................... 29
candesartan tab 32mg ...................... 29
candesartan tab 4mg ........................ 29
101
candesartan tab 8mg ........................29
capecitabine tab 150mg .....................32
capecitabine tab 500mg .....................32
CAPMIST DM TAB ..............................51
CAPRELSA TAB 100MG ......................33
CAPRELSA TAB 300MG ......................33
captopr/hctz tab 25-15mg .................30
captopril tab 100mg ..........................28
captopril tab 12.5mg .........................28
captopril tab 25mg ............................28
captopril tab 50mg ............................28
CARAFATE SUS 1GM/10ML .................92
carb/levo er tab 25-100mg ................35
carb/levo er tab 50-200mg ................35
carb/levo tab 10-100mg ....................35
carb/levo tab 25-100mg ....................35
carb/levo tab 25-250mg ....................35
carbamazepin cap 100mg er ..............16
carbamazepin chw 100mg..................16
carbamazepin sus 100/5ml ................16
carbamazepin tab 200mg...................16
carbamazepin tab 200mg er ...............16
carbamazepin tab 400mg er ...............16
carbidopa tab 25mg ..........................34
carbinoxamin sol 4mg/5ml .................25
carbinoxamin tab 4mg .......................25
CARIMUNE INJ 12GM.........................84
CARIMUNE NF INJ 12GM ....................84
carisoprodol tab 350mg .....................79
carteolol sol 1% op ...........................81
carvedilol tab 12.5mg ........................43
carvedilol tab 25mg ..........................43
carvedilol tab 3.125mg ......................43
carvedilol tab 6.25mg ........................43
CAYSTON INH 75MG .........................10
caziant pak ......................................47
cefaclor cap 250mg ...........................46
cefaclor sus 125/5ml .........................46
cefaclor sus 250/5ml .........................46
cefadroxil sus 250/5ml ......................46
cefadroxil sus 500/5ml ......................46
cefazolin inj 1gm ..............................46
cefazolin inj 20gm ............................ 46
cefazolin inj 500mg .......................... 46
cefdinir cap 300mg ........................... 46
cefdinir sus 125/5ml ......................... 46
cefdinir sus 250/5ml ......................... 46
cefditoren tab 200mg ....................... 46
cefditoren tab 400mg ....................... 46
cefixime sus 100/5ml........................ 46
cefixime sus 200/5ml........................ 46
cefpodo prox sus 100/5ml ................. 46
cefpodo prox sus 50mg/5ml .............. 46
cefpodoxime tab 100mg .................... 46
cefpodoxime tab 200mg .................... 46
cefprozil sus 125/5ml ....................... 46
cefprozil sus 250/5ml ....................... 46
cefuroxime tab 250mg ...................... 46
cefuroxime tab 500mg ...................... 46
celecoxib cap 100mg .......................... 3
celecoxib cap 200mg .......................... 3
celecoxib cap 400mg .......................... 3
celecoxib cap 50mg ............................ 3
CELONTIN CAP 300MG ...................... 18
CENESTIN TAB 0.3MG ....................... 62
CENESTIN TAB 0.45MG ..................... 62
CENESTIN TAB 0.625MG ................... 62
CENESTIN TAB 0.9MG ....................... 62
CENESTIN TAB 1.25MG ..................... 62
cephalexin cap 250mg ...................... 46
cephalexin cap 500mg ...................... 46
cephalexin sus 125/5ml .................... 46
cephalexin sus 250/5ml .................... 46
cesia pak......................................... 47
cetiriz/pse tab 5-120mg .................... 51
cetirizine chw 10mg .......................... 26
cetirizine chw 5mg ........................... 26
cetirizine sol 1mg/ml ........................ 26
cetirizine sol 5mg/5ml ...................... 26
cetirizine syp 1mg/ml ....................... 26
cetirizine syp 5mg/5ml...................... 26
cetirizine tab 10mg........................... 26
cetirizine tab 5mg ............................ 26
cevimeline cap 30mg ........................ 77
cgh dm max liq 10-200 ..................... 51
CHANTIX PAK 0.5& 1MG ................... 87
CHANTIX PAK 1MG ........................... 87
CHANTIX TAB 0.5MG ........................ 87
CHANTIX TAB 1MG ........................... 87
102
chateal tab 0.15/30...........................47
CHEMET CAP 100MG .........................24
child comple chw allergy ....................25
child silfed liq 15mg/5ml ....................80
childrens chw /iron ............................77
childrens chw gummies .....................78
chld asafree elx 80/2.5ml ................... 5
chld decongs liq 15mg/5ml ................80
chloral hydr syp 500/5ml ...................69
chlordiazep cap 10mg ........................11
chlordiazep cap 25mg ........................11
chlordiazep cap 5mg .........................11
chloroquine tab 250mg ......................31
chloroquine tab 500mg ......................31
chlorothiaz tab 250mg .......................59
chlorothiaz tab 500mg .......................60
chlorphenir tab 12mg cr ....................25
chlorphenir tab 4mg ..........................25
chlorpromaz tab 100mg .....................38
chlorpromaz tab 10mg.......................38
chlorpromaz tab 200mg .....................38
chlorpropam tab 100mg ....................23
chlorpropam tab 250mg ....................23
chlorthalid tab 25mg .........................60
chlorthalid tab 50mg .........................60
chlorzoxazon tab 500mg ....................79
cholestyramine .................................27
cholestyramine light ..........................27
CIALIS TAB 5MG ...............................45
ciclodan cre 0.77% ...........................53
cilostazol tab 100mg .........................66
cilostazol tab 50mg ...........................66
cimetidine sol 300/5ml ......................92
cimetidine tab 200mg ........................92
CIMZIA KIT ......................................63
CIMZIA KIT STARTER ........................63
CIMZIA PREFL KIT 200MG/ML .............63
CIPRO HC SUS OTIC .........................84
CIPRODEX SUS 0.3-0.1% ..................84
ciprofloxacn sol 0.3% op ....................82
ciprofloxacn tab 250mg .....................62
ciprofloxacn tab 500mg .....................63
ciprofloxacn tab 750mg ..................... 63
citalopram sol 10mg/5ml .................. 19
citalopram tab 10mg ........................ 19
citric acid/ sol sod citr ....................... 64
CL PRENATAL TAB 28-0.8MG ............. 78
claravis cap 10mg ............................ 52
claravis cap 20mg ............................ 52
claravis cap 30mg ............................ 52
claravis cap 40mg ............................ 52
clarithromyc sus 125/5ml .................. 72
clarithromyc sus 250/5ml .................. 72
clarithromyc tab 250mg .................... 72
clarithromyc tab 500mg .................... 72
clarithromyc tab 500mg er ................ 72
CLEAN&CLEAR LOT EXFOLIAT ............ 52
clemastine syp 0.5/5ml ..................... 25
clemastine tab 1.34mg ..................... 25
clemastine tab 2.68mg ..................... 26
clindamy/ben gel 1.2-5% .................. 52
clindamycin cap 150mg..................... 10
clindamycin cap 300mg..................... 10
clindamycin cre 2% vag .................... 94
clindamycin gel 1% .......................... 52
clindamycin lot 1% ........................... 52
clindamycin sol 1% .......................... 52
clindamycin sol 75mg/5ml ................. 10
clobetasol cre 0.05% ........................ 55
clobetasol gel 0.05% ........................ 55
clobetasol oin 0.05% ........................ 55
clobetasol sol 0.05% ........................ 55
clocortolone cre piv 0.1% .................. 55
clomipramine cap 25mg .................... 20
clonazepam tab 0.5mg...................... 16
clonazepam tab 1mg ........................ 16
clonazepam tab 2mg ........................ 16
clonidine tab 0.1mg .......................... 30
clonidine tab 0.2mg .......................... 30
clonidine tab 0.3mg .......................... 30
clopidogrel tab 75mg ........................ 66
cloraz dipot tab 15mg ....................... 11
cloraz dipot tab 3.75mg .................... 11
cloraz dipot tab 7.5mg ...................... 11
clotrim/beta cre diprop ..................... 53
103
clotrim/beta lot diprop .......................53
clotrimazole cre 1% .................... 53, 94
clotrimazole cre 2% ..........................94
clotrimazole sol 1% ...........................53
clotrimazole tro 10mg .......................76
clozapine tab 100mg .........................37
clozapine tab 200mg .........................37
clozapine tab 25mg ...........................37
clozapine tab 50mg ...........................37
clr soluble pow fiber ..........................69
COARTEM TAB 20-120MG ..................31
codeine sulf tab 15mg ........................ 6
colchicine tab 0.6mg .........................65
cold & cough liq 6.25-2.5 ...................51
cold/allergy elx children .....................51
cold/cough elx children ......................51
cold/cough elx dm ............................51
cold/cough liq 6.25-2.5......................51
colestipol tab 1gm.............................27
COMBIGAN SOL 0.2/0.5% ..................81
COMBIVENT RESPIMAT ......................88
COMPLERA TAB ................................39
COMPLETENATE CHW ........................78
CO-NATAL FA TAB 29-1MG .................78
CORDRAN 24X3 TAP 4MCG/CM ...........55
CORDRAN 24X3 TAP SMALL ...............55
CORDRAN 24X3 TAP SML 24IN ...........55
CORDRAN 80X3 TAP 4MCG/CM ...........55
CORDRAN 80X3 TAP LARGE ...............55
CORDRAN LOT 0.05% .......................56
CORDRAN SP CRE 0.05% ...................56
CORDRAN TAPE TAP LRG 80IN ...........56
cortisone ac tab 25mg .......................50
CORTISPORIN OIN ............................53
CORTISPORIN SUS -TC OTIC ..............84
cortizone-10 gel 1% ..........................56
cough dm syp 100-10/5.....................51
COUMADIN TAB 10MG .......................14
COUMADIN TAB 1MG .........................14
COUMADIN TAB 2.5MG ......................14
COUMADIN TAB 2MG .........................14
COUMADIN TAB 3MG .........................14
COUMADIN TAB 4MG .........................14
COUMADIN TAB 5MG .........................14
COUMADIN TAB 6MG .........................14
COUMADIN TAB 7.5MG ..................... 14
CREON CAP 12000UNT...................... 58
CREON CAP 24000UNT...................... 58
CREON CAP 3000UNIT ...................... 58
CREON CAP 6000UNIT ...................... 58
CRESTOR TAB 10MG ......................... 27
CRESTOR TAB 20MG ......................... 27
CRESTOR TAB 40MG ......................... 27
CRESTOR TAB 5MG .......................... 27
CRIXIVAN CAP 200MG ...................... 39
CRIXIVAN CAP 400MG ...................... 39
cromolyn sod neb 20mg/2ml ............. 12
cromolyn sod sol 4% op .................... 83
cromolyn sod spr 5.2/act .................. 80
cryselle-28 tab 28 tabs ..................... 47
CUPRIMINE CAP 250MG .................... 41
CUVPOSA SOL 1MG/5ML ................... 91
cvs allergy chw 12.5mg .................... 26
CVS PRENATAL TAB .......................... 78
CVS PRENATAL TAB 28-0.8MG ........... 78
cyclafem tab 1/35 ............................ 47
cyclafem tab 7/7/7 ........................... 47
cyclobenzapr tab 10mg ..................... 79
cyclobenzapr tab 5mg ....................... 79
CYCLOPHOSPH CAP 25MG ................. 32
CYCLOPHOSPH CAP 50MG ................. 32
cyclophosph tab 25mg ...................... 32
cyclophosph tab 50mg ...................... 32
cycloserine cap 250mg...................... 31
CYCLOSET TAB 0.8MG ...................... 22
cyclosporine cap 100mg .................... 42
cyclosporine cap 100mg md .............. 42
cyclosporine cap 25mg...................... 42
cyclosporine cap 25mg mod .............. 42
cyclosporine cap 50mg mod .............. 42
cyclosporine sol modified .................. 42
cyproheptad syp 2mg/5ml ................. 26
cyproheptad tab 4mg........................ 27
CYSTADANE POW ............................. 61
CYSTAGON CAP 150MG ..................... 65
CYSTAGON CAP 50MG ...................... 65
cytra-2 sol ....................................... 65
cytra-k sol ....................................... 65
D
DALIRESP TAB 500MCG .................... 13
danazol cap 100mg ............................ 8
danazol cap 200mg ............................ 8
104
danazol cap 50mg .............................. 8
dandruff sha 1% ...............................55
dantrolene cap 100mg .......................80
dantrolene cap 25mg ........................80
dantrolene cap 50mg ........................80
dapsone tab 100mg ..........................10
dapsone tab 25mg ............................10
DARAPRIM TAB 25MG ........................31
dasetta tab 1/35 ...............................47
dasetta tab 7/7/7..............................47
delsym night liq cgh/cold ...................51
demeclocycl tab 150mg .....................88
demeclocycl tab 300mg .....................88
DENAVIR CRE 1% .............................55
denta 5000 cre plus ..........................77
DEPEN TITRA TAB 250MG ..................41
dermafungal oin 2% ..........................53
desipramine tab 100mg .....................20
desipramine tab 10mg .......................20
desipramine tab 150mg .....................20
desloratadin tab 2.5 odt.....................26
desloratadin tab 5mg ........................26
desloratadin tab 5mg odt ...................26
desmopressin spr 0.01% ...................61
desmopressin tab 0.1mg....................61
desmopressin tab 0.2mg....................61
deso/ethinyl tab estradio ...................47
desonide cre 0.05% ..........................56
desonide oin 0.05% ..........................56
desoximetas cre 0.05% .....................56
desoximetas cre 0.25% .....................56
desoximetas gel 0.05% .....................56
desoximetas oin 0.05% .....................56
desoximetas oin 0.25% .....................56
dexameth pho sol 0.1% op ................82
dexamethason elx 0.5/5ml .................50
dexamethason sol 0.5/5ml .................50
dexamethason tab 0.5mg ..................50
dexamethason tab 0.75mg.................50
dexamethason tab 1.5mg ..................50
dexamethason tab 1mg .....................50
dexchlorphen syp 2mg/5ml ............... 25
DEXILANT CAP 30MG DR ................... 92
DEXILANT CAP 60MG DR ................... 92
dexmethylph tab 10mg ....................... 2
dexmethylph tab 2.5mg ...................... 2
dexmethylph tab 5mg ......................... 2
dextroamphet cap 10mg er ................. 1
dextroamphet cap 15mg er ................. 1
dextroamphet cap 5mg er ................... 1
dextroamphet tab 10mg...................... 1
dextroamphet tab 5mg ....................... 1
DIAZEPAM CON 5MG/ML ................... 12
diazepam gel 10mg .......................... 16
diazepam gel 2.5mg ......................... 16
diazepam gel 20mg .......................... 16
diazepam sol 1mg/ml ....................... 12
diazepam tab 10mg .......................... 12
diazepam tab 2mg ........................... 12
diazepam tab 5mg ........................... 12
dibucaine oin 1% ............................... 8
diclofen pot tab 50mg ......................... 3
diclofenac sol 0.1% op ...................... 83
diclofenac tab 25mg dr ....................... 3
dicloxacill cap 250mg........................ 85
dicloxacill cap 500mg........................ 85
dicyclomine cap 10mg ...................... 91
dicyclomine sol 10mg/5ml ................. 91
dicyclomine tab 20mg ....................... 91
didanosine cap 125mg ...................... 39
differin lot 0.1% ............................... 52
DIFICID TAB 200MG ......................... 72
diflorasone cre 0.05% ....................... 56
diflorasone oin 0.05% ....................... 56
diflunisal tab 500mg ........................... 5
digoxin sol 50mcg/ml ....................... 45
digoxin tab 0.125mg ........................ 45
digoxin tab 0.25mg .......................... 45
dihydroergot inj 1mg/ml ................... 74
DILANTIN CAP 30MG ........................ 17
diltiazem cap 120mg er ..................... 44
diltiazem cap 120mg/24 .................... 44
diltiazem cap 180mg er ..................... 44
diltiazem cap 180mg/24 .................... 44
105
diltiazem cap 240mg er .....................44
diltiazem cap 240mg/24 ....................44
diltiazem cap 300mg er .....................44
diltiazem cap 300mg/24 ....................44
diltiazem cap 360mg/24 ....................44
diltiazem cap 420mg/24 ....................44
diltiazem tab 120mg .........................44
diltiazem tab 30mg ...........................44
diltiazem tab 60mg ...........................44
diltiazem tab 90mg ...........................44
dimenhydrin tab 50mg ......................24
dimetane dx syp ...............................51
dimetapp liq nighttim ........................51
DIPENTUM CAP 250MG ......................63
diphedryl liq 12.5/5ml .......................26
diphen/atrop liq 2.5/5 .......................24
diphen/atrop tab 2.5mg .....................24
diphenhydram cap 25mg ...................26
diphenhydram cap 50mg ...................26
diphenhydram elx 12.5/5ml ...............26
diphenhydram inj 50mg/ml ................26
diphenhydram tab 25mg ....................26
dipyridamole tab 25mg ......................66
disopyramide cap 150mg ...................12
disposable ene..................................71
disposable ene single ........................71
disposable ene twin pk ......................71
disulfiram tab 250mg ........................86
disulfiram tab 500mg ........................86
divalproex cap 125mg .......................18
divalproex tab 125mg dr ....................18
divalproex tab 250mg er ....................18
divalproex tab 500mg er ....................18
dm/gg sol 10-100/5 ..........................51
docu soft cap 100mg .........................72
docusate cal cap 240mg ....................72
docusate sod cap 250mg ...................72
docusate sod liq 50mg/5ml ................72
docusate sod syp 20mg/5ml ...............72
docusate sod tab 100mg ....................72
docusol plus ene 20-283 ....................72
donepezil tab 10mg ...........................86
donepezil tab 10mg odt .....................86
donepezil tab 5mg ............................ 86
donepezil tab 5mg odt ...................... 86
dorzol/timol sol 2-0.5%op ................. 81
dorzolamide sol 2% op ..................... 83
doxazosin tab 1mg ........................... 30
doxazosin tab 2mg ........................... 30
doxazosin tab 4mg ........................... 30
doxazosin tab 8mg ........................... 30
doxepin hcl cap 100mg ..................... 20
doxepin hcl cap 10mg ....................... 20
doxepin hcl cap 150mg ..................... 20
doxepin hcl con 10mg/ml .................. 20
doxercalcif cap 0.5mcg ..................... 61
doxercalcif cap 1mcg ........................ 61
doxercalcif cap 2.5mcg ..................... 61
doxercalcif inj 4mcg/2ml ................... 61
doxycyc mono cap 100mg ................. 88
doxycyc mono cap 50mg ................... 88
doxycyc mono tab 100mg ................. 88
DRITHO-CREME CRE HP 1% .............. 54
dronabinol cap 10mg ........................ 25
dronabinol cap 2.5mg ....................... 24
dronabinol cap 5mg .......................... 25
drospir/ethi tab 3-0.03mg ................. 47
DRYSOL SOL 20% ............................ 57
DULERA AER 100-5MCG .................... 13
DULERA AER 200-5MCG .................... 13
duloxetine cap 20mg ........................ 19
DUREZOL EMU 0.05% ....................... 82
dutasteride cap 0.5mg ...................... 65
DYRENIUM CAP 100MG ..................... 59
DYRENIUM CAP 50MG ....................... 59
dytuss syp 12.5/5ml ......................... 26
E
e.e.s. 400 tab 400mg ....................... 72
E.E.S. GRAN SUS 200/5ML ................ 72
e.s.p. sus 200-600 ........................... 10
ear drying dro 95-5% ....................... 84
ear wax remv sol 6.5% ot ................. 84
econazole cre 1% ............................. 53
EDARBI TAB 40MG ........................... 29
EDARBI TAB 80MG ........................... 29
106
EDECRIN TAB 25MG ..........................59
EDURANT TAB 25MG .........................39
ees/sulfisox sus 200-600 ...................10
EFFIENT TAB 10MG ...........................66
EFFIENT TAB 5MG .............................66
ELAPRASE INJ 6MG/3ML ....................61
ELIDEL CRE 1% ................................57
elinest tab ........................................47
ELLA TAB 30MG ................................49
ELMIRON CAP 100MG ........................65
EMADINE SOL 0.05% OP ...................83
EMCYT CAP 140MG ...........................33
EMEND CAP 125MG ...........................25
EMEND CAP 40MG .............................25
EMEND CAP 80MG .............................25
EMEND PAK 80 & 125 ........................25
emoquette tab ..................................47
EMSAM DIS 12MG/24H ......................19
EMSAM DIS 6MG/24HR ......................19
EMSAM DIS 9MG/24HR ......................19
EMTRIVA CAP 200MG ........................39
EMTRIVA SOL 10MG/ML .....................39
ENABLEX TAB 15MG ..........................64
ENABLEX TAB 7.5MG .........................64
enalapr/hctz tab 10-25mg..................30
enalapr/hctz tab 5-12.5mg.................30
enalapril tab 10mg ............................28
enalapril tab 2.5mg ...........................28
enalapril tab 20mg ............................28
enalapril tab 5mg ..............................28
ENBREL INJ 25/0.5ML......................... 4
ENBREL INJ 25MG .............................. 4
ENBREL INJ 50MG/ML ......................... 5
ENBREL SRCLK INJ 50MG/ML .............. 5
enema ene double ............................71
enema ene single ..............................71
enema ready- ene -to-use .................71
enemeez plus ene 20-283 ..................72
ENJUVIA TAB 0.3MG..........................62
ENJUVIA TAB 0.45MG ........................62
ENJUVIA TAB 0.625MG ......................62
ENJUVIA TAB 0.9MG..........................62
ENJUVIA TAB 1.25MG ........................62
enoxaparin inj 100mg/ml ...................15
enoxaparin inj 120/0.8 ......................15
enoxaparin inj 150mg/ml ...................15
enoxaparin inj 30/0.3ml ....................15
enoxaparin inj 300/3ml ..................... 15
enoxaparin inj 40/0.4ml .................... 15
enpresse-28 tab ............................... 47
enskyce tab ..................................... 47
entacapone tab 200mg ..................... 35
entecavir tab 0.5mg ......................... 41
entecavir tab 1mg ............................ 41
EPIDUO GEL 0.1-2.5% ...................... 53
epinastine dro 0.05% ....................... 83
epinephrine inj 0.15mg ..................... 94
EPIPEN 2-PAK INJ 0.3MG .................. 94
EPIPEN-JR INJ 2-PAK ........................ 94
eplerenone tab 25mg ........................ 31
eplerenone tab 50mg ........................ 31
EPOGEN INJ 10000/ML ..................... 67
EPOGEN INJ 2000/ML ....................... 67
EPOGEN INJ 20000/ML ..................... 67
EPOGEN INJ 4000/ML ....................... 67
eprosart mes tab 600mg ................... 29
EPZICOM TAB 600-300 ..................... 39
eq enema ene double ....................... 71
eq fiber pow .................................... 69
eql lice kit solution ........................... 58
EQL PRENATAL TAB FORMULA............ 78
eql triactin elx cld/cgh ...................... 51
ergocalcifer cap 50000unt ................. 94
ergoloid mes tab 1mg oral ................. 87
ERGOMAR SUB 2MG ......................... 74
ERIVEDGE CAP 150MG ...................... 32
errin tab 0.35mg .............................. 49
ERTACZO CRE 2% ............................ 53
ERYPED SUS 200/5ML....................... 72
ERY-TAB TAB 250MG EC ................... 72
ERY-TAB TAB 333MG EC ................... 72
ERY-TAB TAB 500MG EC ................... 72
erythrocin tab 250mg ....................... 72
erythrom eth tab 400mg ................... 72
erythromycin gel /benzoyl ................. 53
erythromycin gel 2% ........................ 53
erythromycin oin 5mg/gm ................. 82
erythromycin sol 2% ........................ 53
erythromycin tab 250mg bs ............... 72
erythromycin tab 500mg bs ............... 72
escitalopram sol 5mg/5ml ................. 19
escitalopram tab 10mg ..................... 19
107
escitalopram tab 20mg ......................19
escitalopram tab 5mg ........................19
estarylla tab 0.25-35 .........................47
estazolam tab 1mg ...........................69
estazolam tab 2mg ...........................69
ESTRACE VAG CRE 0.1MG/GM ............94
estradiol tab 0.5mg ...........................62
estradiol tab 1mg..............................62
estradiol tab 2mg..............................62
estropipate tab 0.75mg .....................62
estropipate tab 1.5mg .......................62
estropipate tab 3mg ..........................62
eszopiclone tab 1mg .........................81
ethambutol tab 100mg ......................31
ethambutol tab 400mg ......................32
ethosuximide cap 250mg ...................18
ethosuximide sol 250/5ml ..................18
etidron disd tab 200mg .....................60
etidron disd tab 400mg .....................60
etodolac tab 400mg ........................... 3
etodolac tab 500mg ........................... 3
etoposide cap 50mg ..........................34
etoposide inj 20mg/ml .......................34
EUFLEXXA INJ 10MG/ML ....................80
EURAX CRE 10%...............................58
EUTHROID TAB 120MG ......................89
EUTHROID-1 TAB 60MG .....................89
EUTHROID-2 TAB 120MG ...................89
EUTHROID-3 TAB 180MG ...................89
EVOTAZ TAB 300-150........................39
EXELDERM CRE 1% ...........................53
EXELDERM SOL 1% ...........................53
exelon dis 4.6mg/24 .........................86
exelon dis 9.5mg/24 .........................86
exemestane tab 25mg .......................33
EXJADE TAB 125MG ..........................24
EXJADE TAB 250MG ..........................24
EXJADE TAB 500MG ..........................24
EXTAVIA INJ 0.3MG ..........................87
EZ USE FLU KIT ................................93
F
FABRAZYME INJ 5MG.........................61
FACTIVE TAB 320MG .........................63
falmina tab ......................................47
famciclovir tab 125mg .......................41
famciclovir tab 250mg ...................... 41
famciclovir tab 500mg ...................... 41
famotidine tab 10mg ........................ 92
FANAPT PAK .................................... 36
FANAPT TAB 10MG ........................... 36
FANAPT TAB 12MG ........................... 36
FANAPT TAB 1MG ............................. 36
FANAPT TAB 2MG ............................. 36
FANAPT TAB 4MG ............................. 36
FANAPT TAB 6MG ............................. 36
FANAPT TAB 8MG ............................. 36
FARESTON TAB 60MG ....................... 33
felbamate sus 600/5ml ..................... 17
felbamate tab 400mg ....................... 17
felbamate tab 600mg ....................... 17
felodipine tab 10mg er ...................... 44
felodipine tab 5mg er........................ 44
FEMALE CONDOMS ........................... 73
FEMCAP MIS 22MM ........................... 73
FEMCAP MIS 26MM ........................... 73
FEMCAP MIS 30MM ........................... 73
fenofibrate cap 134mg ...................... 27
fenofibrate cap 200mg ...................... 27
fenofibrate cap 43mg ........................ 27
fenofibrate cap 67mg ........................ 27
fenofibrate tab 160mg ...................... 27
fenofibrate tab 48mg ........................ 27
fenofibrate tab 54mg ........................ 27
fenofibric tab 35mg .......................... 27
fenoprofen tab 600mg ........................ 3
fentanyl dis 100mcg/h ........................ 6
fentanyl dis 12mcg/hr ......................... 6
ferocon cap ..................................... 67
ferotrin cap ..................................... 67
ferotrinsic cap .................................. 67
FERRIPROX TAB 500MG .................... 24
ferrous fum tab 324mg ..................... 68
ferrous gluc tab 240mg ..................... 68
FERROUS GLUC TAB 324MG .............. 68
FERROUS SUL LIQ 220/5ML ............... 68
108
ferrous sulf dro 15mg/ml ...................68
ferrous sulf elx 220/5ml.....................68
FERROUS SULF TAB 324MG EC ...........68
ferrous sulf tab 325mg ......................68
ferrous sulf tab 325mg ec ..................68
ferus cap 150mg ...............................68
FEVERALL INF SUP 80MG .................... 5
fexofenadine tab 180mg ....................26
fexofenadine tab 60mg ......................26
fiber cap 0.52gm ..............................69
fiber laxatv tab 625mg ......................69
fiber laxtiv cap 0.52gm ......................69
fiber powder pow ..............................69
fiber tab 625mg ................................69
fiber therap cap 0.52gm ....................69
fiber therap pow 28.3% .....................69
fiber therap pow 48.57% ...................69
fiber therap pow 58.6% .....................69
fiber therap tab 500mg ......................69
fiber therap tab 625mg ......................69
fiber-caps tab 625mg ........................70
fibergen tab 625mg...........................70
fiber-lax tab 625mg ..........................70
fibertab tab 625mg ...........................70
FINACEA GEL 15% ............................57
finasteride tab 5mg ...........................65
FIRMAGON INJ 120MG .......................33
FIRMAGON INJ 80MG ........................33
FIRST-OMEPRA SUS 2MG/ML ..............92
fish oil cap 1000mg ...........................81
fish oil cap 1200mg ...........................81
flavoxate tab 100mg .........................93
FLEBOGAMMA INJ 10%......................84
FLEBOGAMMA INJ 5% .......................84
FLEBOGAMMA INJ DIF 5% .................84
flecainide tab 100mg .........................12
flecainide tab 150mg .........................12
flecainide tab 50mg ...........................12
FLUARIX INJ PF ................................93
FLUARIX QUAD INJ ...........................93
FLUBLOK .........................................94
FLUCELVAX INJ .................................94
fluconazole sus 10mg/ml ...................25
fluconazole sus 40mg/ml ...................25
fluconazole tab 100mg ......................25
fluconazole tab 50mg ....................... 25
flucytosine cap 250mg ...................... 25
flucytosine cap 500mg ...................... 25
fludrocort tab 0.1mg ......................... 50
FLULAVAL INJ .................................. 93
FLULAVAL QUA INJ ........................... 93
FLUMIST QUADRIVALENT .................. 93
flunisolide spr 0.025% ...................... 80
flunisolide spr 29mcg ........................ 80
fluocin acet cre 0.025% .................... 56
fluocin acet oil 0.01% ....................... 84
fluocin acet oil 0.01% sc ................... 56
fluocin acet oin 0.025% .................... 56
fluocinonide cre 0.05% ..................... 56
fluocinonide gel 0.05% ..................... 56
fluocinonide oin 0.05% ..................... 56
fluocinonide sol 0.05% ...................... 56
fluoride chw 0.25mg f ....................... 75
fluoride chw 0.5mg f ......................... 75
fluoride chw 1mg f ........................... 76
fluoridex gel 1.1% ............................ 77
fluoritab dro 0.125mg ....................... 76
fluoromethol sus 0.1% op ................. 82
fluorouracil cre 5% ........................... 54
fluoxetine cap 10mg ......................... 19
fluoxetine cap 20mg ......................... 19
fluoxetine sol 20mg/5ml ................... 19
fluoxetine tab 10mg ......................... 19
fluoxetine tab 20mg ......................... 19
fluphenaz de inj 25mg/ml ................. 38
fluphenazine inj 2.5mg/ml ................. 38
fluphenazine tab 10mg ..................... 38
fluphenazine tab 1mg ....................... 38
fluphenazine tab 2.5mg .................... 38
fluphenazine tab 5mg ....................... 38
flura-drops dro 0.25mg f ................... 76
flurazepam cap 15mg ....................... 69
flurazepam cap 30mg ....................... 69
flurbiprofen sol 0.03% op .................. 83
flurbiprofen tab 100mg ....................... 3
flurbiprofen tab 50mg ......................... 3
flutamide cap 125mg ........................ 33
fluticasone cre 0.05% ....................... 56
fluticasone oin 0.005% ..................... 56
fluticasone spr 50mcg ....................... 80
fluvastatin cap 20mg ........................ 27
fluvastatin cap 40mg ........................ 27
109
FLUVIRIN INJ ...................................93
FLUVIRIN INJ PF ...............................93
fluvoxamine tab 100mg .....................19
fluvoxamine tab 25mg .......................19
fluvoxamine tab 50mg .......................19
FLUZONE INJ INTRADRM ...................93
FLUZONE INJ PF ...............................93
FLUZONE PED/ INJ PF........................93
FLUZONE QUAD INJ ..........................93
FLUZONE SPLT INJ ............................93
foam antacid chw 80-20mg ................. 9
foam antacid sus ............................... 9
folbee plus tab ..................................77
folic acid tab 1mg .............................67
folic acid tab 400mcg ........................67
folic acid tab 800mcg ........................67
foltrin cap ........................................67
fondaparinux sol 10/0.8 .....................15
fondaparinux sol 2.5/0.5 ....................15
FORADIL CAP AEROLIZE ....................13
FORTEO SOL 600/2.4 ........................60
FOSAMAX + D TAB 70-2800 ...............60
FOSAMAX + D TAB 70-5600 ...............60
fosinop/hctz tab 10/12.5....................30
fosinopril tab 10mg ...........................28
FOSRENOL CHW 1000MG ...................64
FOSRENOL CHW 500MG ....................64
FOSRENOL CHW 750MG ....................64
FRAGMIN INJ 10000/ML .....................15
FRAGMIN INJ 12500UNT ....................15
FRAGMIN INJ 15000UNT ....................15
FRAGMIN INJ 18000UNT ....................15
FRAGMIN INJ 2500/0.2 ......................15
FRAGMIN INJ 5000/0.2 ......................15
FRAGMIN INJ 7500/0.3 ......................15
FROVA TAB 2.5MG ............................74
furosemide sol 10mg/ml ....................59
FUROSEMIDE SOL 8MG/ML ................59
furosemide tab 20mg ........................59
FUZEON INJ 90MG ............................39
G
gabapentin cap 100mg ..................... 16
gabapentin sol 250/5ml .................... 16
gabapentin tab 100mg ...................... 16
galantamine cap 24mg er .................. 86
galantamine cap 8mg er ................... 86
galantamine tab 12mg ...................... 86
galantamine tab 4mg ........................ 86
galantamine tab 8mg ........................ 86
GAMASTAN S/D INJ .......................... 84
GAMMAGARD INJ 1GM/10ML ............. 84
GAMMAGARD SD INJ 10GM HU .......... 84
GAMMAKED INJ 1GM/10ML ................ 84
GAMMAPLEX INJ 5GM ....................... 84
GAMUNEX INJ 10% .......................... 84
GAMUNEX-C INJ 1GM/10ML ............... 84
gas relief cap 125mg ........................ 63
gas relief cap 180mg ........................ 63
gas relief dro infants ......................... 63
gatifloxacin sol 0.5% ........................ 82
gavilyte-c sol ................................... 70
gavilyte-g sol ................................... 70
gemfibrozil tab 600mg ...................... 27
gengraf cap 100mg .......................... 42
gengraf cap 25mg ............................ 42
gengraf sol 100mg/ml....................... 42
gentamicin cre 0.1% ........................ 53
gentamicin oin 0.1% ........................ 53
gentamicin oin 0.3% op .................... 82
gentamicin sol 0.3% op .................... 82
gianvi tab 3-0.02mg ......................... 47
gildagia tab 0.4-35 ........................... 47
gildess fe tab 1.5/30......................... 47
gildess fe tab 1/20 ........................... 47
gildess tab 1.5/30 ............................ 47
gildess tab 1/20 ............................... 47
GILENYA CAP 0.5MG ......................... 87
glatiramer acetate 20mg/ml .............. 87
GLEEVEC TAB 100MG ....................... 33
GLEEVEC TAB 400MG ....................... 33
glimepiride tab 1mg ......................... 23
110
glipizide er tab 10mg .........................23
glipizide er tab 2.5mg ........................23
glipizide er tab 5mg ..........................23
glipizide tab 10mg ............................23
glipizide tab 5mg ..............................23
glipizide xl tab 10mg .........................23
glipizide xl tab 2.5mg ........................23
glipizide xl tab 5mg ...........................23
GLUCAGON KIT 1MG .........................21
GLUCOSE-VITAMIN C CHEW TAB 4-0.006
GM ..................................................21
glyb/metform tab 1.25-250 ................21
glyb/metform tab 2.5-500 .................21
glyb/metform tab 5-500mg ................21
glyburid mcr tab 1.5mg .....................23
glyburid mcr tab 3mg ........................23
glyburid mcr tab 6mg ........................23
glyburide tab 1.25mg ........................23
glyburide tab 2.5mg ..........................23
glyburide tab 5mg .............................23
glycerin sup 1.2gm ...........................71
glycerin sup 2.1gm ...........................71
glycerin sup 2gm ..............................71
glycerin sup 80.7% ...........................71
glycopyrrol tab 1mg ..........................92
glycopyrrol tab 2mg ..........................92
GLYSET TAB 100MG ..........................21
GLYSET TAB 25MG ............................21
GLYSET TAB 50MG ............................21
gnp best pow fiber ............................70
GNP GLUCOSE CHW RASPBERY ..........21
gnp iron tab 45mg ............................68
GNP PRENATAL TAB 28-0.8MG............78
GOLYTELY SOL .................................70
granisetron tab 1mg ..........................24
griseofulvin sus 125/5ml ....................25
guaiatussin syp ac ............................51
guaifenesin sol 100/5ml .....................52
guaifenesin syp 100/5ml ....................52
guaifenesin syp dm ...........................51
guaifenesin tab 200mg ......................52
guaifenesin tab 400mg ......................52
guaifenesin tab 600mg er ..................52
guanfacine tab 1mg ..........................30
guanfacine tab 1mg er........................ 1
guanfacine tab 2mg ..........................30
guanfacine tab 2mg er........................ 1
guanfacine tab 3mg er ........................ 1
guanfacine tab 4mg er ........................ 1
GUANIDINE TAB 125MG .................... 31
GYNAZOLE-1 CRE 2% ....................... 94
H
HALFLYTELY KIT FLAV PKS ................ 70
halobetasol cre 0.05% ...................... 56
halobetasol oin 0.05% ...................... 56
HALOG CRE 0.1%............................. 56
HALOG OIN 0.1% ............................. 56
haloper dec inj 100mg/ml ................. 37
haloper dec inj 50mg/ml ................... 37
haloper lac inj 5mg/ml ...................... 37
haloperidol con 2mg/ml .................... 37
haloperidol tab 0.5mg ....................... 37
haloperidol tab 10mg ........................ 37
haloperidol tab 1mg ......................... 37
haloperidol tab 20mg ........................ 37
HARVONI TAB 90-400MG .................. 41
hc valerate cre 0.2% ........................ 56
hc/acet acid sol otic .......................... 84
hc/aloe cre 0.5%.............................. 56
hc-1% hemorr oin 1% ...................... 56
heartbrn ant chw 160-105 ................... 9
heartburn chw ex st ........................... 9
heather tab 0.35mg.......................... 49
hecoria cap 0.5mg............................ 42
hecoria cap 1mg .............................. 42
HELIXATE FS INJ 1000UNIT ............... 66
HELIXATE FS INJ 250UNIT ................ 66
HELIXATE FS INJ 500UNIT ................ 66
HELIXATE FS SOL 1000UNIT.............. 66
HELIXATE FS SOL 250UNIT ............... 66
HELIXATE FS SOL 500UNIT ............... 66
hemorrhoidal cre ................................ 8
heparin sod inj 1000/ml .................... 15
heparin sod inj 10000/ml .................. 15
heparin sod inj 5000/0.5 ................... 15
HIZENTRA INJ 2GM/10ML .................. 84
hm fiber tab 500mg .......................... 70
hm iron tab 45mg ............................ 68
HM PRENATAL TAB ........................... 78
HORIZANT TAB 600MG ..................... 87
HUMALOG INJ 100/ML ...................... 22
HUMALOG KWIK INJ 100/ML .............. 22
111
HUMALOG MIX INJ 50/50 ...................22
HUMALOG MIX INJ 50/50KWP ............22
HUMALOG MIX INJ 75/25KWP ............22
HUMALOG MIX SUS 75/25 .................22
HUMATE-P SOL 1200UNIT ..................66
HUMATE-P SOL 2400UNIT ..................66
HUMIRA KIT 20MG/0.4 ....................... 3
HUMIRA KIT 40MG/0.8 ....................... 3
HUMIRA PEN KIT 40MG/0.8 ................. 3
HUMULIN INJ 70/30 ..........................22
HUMULIN INJ 70/30KWP ....................22
HUMULIN N INJ U-100 .......................22
HUMULIN N INJ U-100KWP ................22
HUMULIN N PN INJ U-100 ..................22
HUMULIN PEN INJ 70/30 ....................22
HUMULIN R INJ U-100 .......................22
HUMULIN R INJ U-500 .......................22
hydralazine tab 100mg ......................31
hydralazine tab 10mg ........................31
hydrochlorot cap 12.5mg ...................60
hydrochlorot tab 12.5mg ...................60
hydrochlorot tab 25mg ......................60
hydrochlorot tab 50mg ......................60
hydroco/apap sol 7.5-325 ................... 7
hydroco/apap tab 10-325mg ............... 8
hydroco/apap tab 2.5-500 .................. 7
hydroco/apap tab 5-325mg ................. 7
hydroco/apap tab 5-500mg ................. 7
hydroco/apap tab 7.5-325 .................. 7
hydroco/apap tab 7.5-500 .................. 7
hydroco/apap tab 7.5-650 .................. 7
hydroco/apap tab 7.5-750 .................. 8
hydrocod/hom syp 5-1.5/5.................50
hydrocort ac cre 0.5% .......................56
hydrocort ac cre 1% ..........................56
hydrocort cre 0.5% ...........................56
hydrocort cre 1% ..............................56
hydrocort cre 2.5% ...........................56
hydrocort lot 1%...............................56
hydrocort lot 2.5% ............................56
hydrocort oin 0.5% ...........................56
hydrocort oin 1% ..............................56
hydrocort oin 2.5% ...........................56
hydrocort tab 10mg .......................... 50
hydrocort tab 20mg .......................... 50
hydrocort tab 5mg ........................... 50
hydrocort/ cre aloe 1% ..................... 56
hydrogesic cap 5-500mg ..................... 8
hydromorphon tab 12mg er ................. 6
hydromorphon tab 2mg ...................... 6
hydromorphon tab 4mg ...................... 6
hydromorphon tab 8mg er................... 6
hydroxychlor tab 200mg ................... 31
hydroxyurea cap 500mg ................... 34
hydroxyz hcl syp 10mg/5ml ............... 11
hydroxyz hcl tab 10mg ..................... 11
hydroxyz pam cap 100mg ................. 11
hydroxyz pam cap 25mg ................... 11
hydroxyz pam cap 50mg ................... 11
hyoscyamine dro 0.125/ml ................ 92
hyoscyamine sub 0.125mg ................ 92
hyoscyamine tab 0.125mg ................ 92
hyoscyamine tab 0.375 er ................. 92
hyosyne elx 0.125/5 ......................... 92
I
ibandronate tab 150mg ..................... 60
ibu-drops dro 40mg/ml ....................... 3
ibuprofen cap 200mg .......................... 3
ibuprofen jr chw 100mg ...................... 4
ibuprofen sus 100/5ml ........................ 4
ibuprofen tab 200mg .......................... 4
ibuprofen tab 400mg .......................... 4
ibuprofen tab 600mg .......................... 4
ibuprofen tab 800mg .......................... 4
imipram hcl tab 10mg ....................... 20
imiquimod cre 5% ............................ 57
IMMUNE GLOBU INJ HUMAN .............. 84
inatal adv tab .................................. 78
inatal gt tab..................................... 78
inatal ultra tab ................................. 78
INCIVEK TAB 375MG ........................ 41
INCRELEX INJ 40MG/4ML .................. 60
indapamide tab 1.25mg .................... 60
indapamide tab 2.5mg ...................... 60
112
indomethacin cap 25mg ...................... 4
indomethacin cap 50mg ...................... 4
INFERGEN INJ 15MCG .......................41
INSULIN PEN NEEDLES ......................74
INSULIN SYRINGES ...........................74
INTELENCE TAB 100MG .....................39
INTELENCE TAB 200MG .....................39
INTELENCE TAB 25MG .......................39
INTRON-A INJ 10MU..........................34
INTRON-A INJ 25MU..........................34
INVEGA SUST INJ 117/0.75 ...............36
INVEGA SUST INJ 156MG/ML .............36
INVEGA SUST INJ 234/1.5 .................36
INVEGA SUST INJ 39/0.25 .................36
INVEGA SUST INJ 78/0.5ML ...............36
invega tab 1.5mg..............................36
invega tab 3mg ................................36
invega tab 6mg ................................36
invega tab 9mg ................................36
INVIRASE TAB 500MG .......................39
ipratropium sol 0.02%inh ..................12
ipratropium spr 0.03% ......................80
ipratropium spr 0.06% ......................80
ipratropium-albuterol nebu soln
0.5-2.5(3) mg/3ml ............................88
irbesar/hctz tab 150-12.5 ..................30
irbesar/hctz tab 300-12.5 ..................30
irbesartan tab 150mg ........................29
irbesartan tab 300mg ........................29
irbesartan tab 75mg ..........................29
iron chews chw pediatri .....................68
iron complex cap ..............................67
iron slow tab 45mg ...........................68
iron tab 160mg cr .............................68
iron therapy tab 200mg .....................68
ISENTRESS CHW 100MG....................39
ISENTRESS TAB 400MG .....................39
isonarif cap ......................................31
isoniazid syp 50mg/5ml .....................32
isoniazid tab 100mg ..........................32
isoniazid tab 300mg ..........................32
isosorb din sub 2.5mg .......................10
isosorb din tab 10mg .........................11
isosorb din tab 5mg ..........................11
isosorb mono tab 10mg .....................11
isosorb mono tab 120mg er ............... 11
isosorb mono tab 20mg .................... 11
isosorb mono tab 30mg er................. 11
isosorb mono tab 60mg er................. 11
isradipine cap 2.5mg ........................ 44
isradipine cap 5mg ........................... 44
itraconazole cap 100mg .................... 25
ivermectin tab 3mg ............................ 9
J
JAKAFI TAB 10MG ............................ 33
JAKAFI TAB 15MG ............................ 33
JAKAFI TAB 20MG ............................ 33
JAKAFI TAB 25MG ............................ 33
JAKAFI TAB 5MG .............................. 33
jantoven tab 10mg ........................... 14
jantoven tab 1mg ............................. 14
jantoven tab 2.5mg .......................... 14
jantoven tab 2mg ............................. 14
jantoven tab 3mg ............................. 14
jantoven tab 4mg ............................. 14
jantoven tab 5mg ............................. 14
jantoven tab 6mg ............................. 14
jantoven tab 7.5mg .......................... 14
JANUMET TAB 50-1000 ..................... 21
JANUMET TAB 50-500MG .................. 21
JANUMET XR TAB 100-1000............... 21
JANUMET XR TAB 50-1000 ................ 21
JANUVIA TAB 100MG ........................ 22
JANUVIA TAB 25MG .......................... 22
JANUVIA TAB 50MG .......................... 22
JARDIANCE TAB 10MG ...................... 22
JARDIANCE TAB 25MG ...................... 22
jencycla tab 0.35mg ......................... 49
JENTADUETO TAB 2.5-1000 ............... 21
JENTADUETO TAB 2.5-500 ................ 21
JENTADUETO TAB 2.5-850 ................ 21
JETREA INJ 2.5MG/ML....................... 83
jolivette tab 0.35mg ......................... 49
junel 1.5/30 tab ............................... 47
junel 1/20 tab .................................. 47
junel fe tab 1.5/30 ........................... 47
junel fe tab 1/20 .............................. 47
K
k citrate sol citr acd .......................... 65
KALETRA SOL .................................. 39
KALETRA TAB 100-25MG ................... 39
KALETRA TAB 200-50MG ................... 39
113
kaopectate sus 262/15ml ...................24
KAPIDEX CAP 30MG DR .....................92
KAPIDEX CAP 60MG DR .....................92
kariva tab 28 day ..............................47
kelnor tab 1/35 ................................47
KEPIVANCE INJ 6.25MG .....................34
KETEK PAK TAB 400MG .....................10
KETEK TAB 300MG ............................10
KETEK TAB 400MG ............................10
ketoconazole cre 2% .........................54
ketoconazole sha 2% ........................54
ketoconazole tab 200mg ....................25
ketoprofen cap 50mg ......................... 4
ketoprofen cap 75mg ......................... 4
ketorolac sol 0.4% ............................83
ketorolac sol 0.5% ............................83
ketorolac tab 10mg ............................ 4
ketotif fum dro 0.025%op ..................83
kids vitamin chw extra c ....................78
KINERET INJ ..................................... 3
kionex sus 15gm/60 ..........................42
KOGENATE FS INJ 1000/BS ................66
KOGENATE FS INJ 1000UNIT ..............66
KOGENATE FS INJ 250/BS .................66
KOGENATE FS INJ 250UNIT ...............66
KOGENATE FS INJ 500/BS .................66
KOGENATE FS INJ 500UNIT ...............66
KOMBIGLYZE TAB 2.5-1000 ...............21
KOMBIGLYZE TAB 5-1000MG..............21
KOMBIGLYZE TAB 5-500MG ...............21
KONSYL POW 100% ..........................70
KONSYL POW 28.3% .........................70
KONSYL-D POW 52.3%......................70
KP PRENATAL TAB MULTIVIT ..............78
kurvelo tab 0.15/30 ..........................47
KUVAN TAB 100MG ...........................61
L
labetalol tab 100mg ..........................43
labetalol tab 200mg ..........................43
labetalol tab 300mg ..........................43
LACRISERT MIS 5MG OP ....................81
lactulose sol 10gm/15 ................. 64, 71
lactulose sol 20gm/30 .......................71
lamivud/zido tab 150-300 ..................39
lamivudine oral soln 10 mg/ml ...........39
lamivudine tab 100mg .......................39
lamivudine tab 150mg .......................39
lamivudine tab 300mg ...................... 39
lamotrigine chw 25mg ...................... 16
lamotrigine chw 5mg ........................ 16
lamotrigine tab 100mg ...................... 16
lamotrigine tab 25mg ....................... 16
LANCETS ......................................... 73
LANOXIN TAB 0.125MG ..................... 45
LANOXIN TAB 0.25MG ...................... 45
lansoprazole cap 15mg dr ................. 92
lansoprazole cap 15mg dr otc ............ 92
lansoprazole cap 30mg dr ................. 92
LANTUS INJ 100/ML ......................... 22
LANTUS INJ SOLOSTAR ..................... 22
larin fe tab 1.5/30 ............................ 47
larin fe tab 1/20 ............................... 47
LASTACAFT SOL 0.25%..................... 83
latanoprost sol 0.005% ..................... 83
LATUDA TAB 120MG ......................... 36
LATUDA TAB 20MG ........................... 36
LATUDA TAB 40MG ........................... 36
LATUDA TAB 80MG ........................... 36
laxative chw 15mg ........................... 71
leena tab......................................... 47
leflunomide tab 10mg ......................... 4
leflunomide tab 20mg ......................... 4
lescol xl tab 80mg ............................ 27
lessina tab....................................... 47
LETAIRIS TAB 10MG ......................... 45
LETAIRIS TAB 5MG ........................... 45
letrozole tab 2.5mg .......................... 33
leucovor ca tab 10mg ....................... 34
leucovor ca tab 5mg ......................... 34
LEUKERAN TAB 2MG ......................... 32
LEUKINE INJ 250MCG ....................... 67
leuprolide inj 1mg/0.2 ...................... 33
levalbuterol neb 0.31mg ................... 13
LEVATOL TAB 20MG ......................... 43
LEVEMIR INJ .................................... 22
LEVEMIR INJ FLEXPEN ...................... 22
levetiraceta sol 100mg/ml ................. 16
levetiraceta tab 1000mg ................... 16
114
levetiraceta tab 250mg ......................16
levobunolol sol 0.25% op ...................81
levobunolol sol 0.5% op.....................81
levocarnitin sol 1gm/10ml ..................61
levocarnitin tab 330mg ......................61
levocetirizi sol 2.5/5ml ......................26
levocetirizi tab 5mg ...........................26
levofloxacin sol 0.5% ........................82
levofloxacin sol 25mg/ml ...................63
levofloxacin tab 250mg......................63
levonest tab .....................................48
levonor/ethi tab 0.1-0.02 ...................48
levonor/ethi tab estradio ....................48
levonorgestr tab 1.5mg .....................49
levora-28 tab 0.15/30 .......................48
levorphanol tab 2mg .......................... 6
levothroid tab 100mcg .......................89
levothroid tab 25mcg ........................89
levothyroxin tab 100mcg ...................89
levothyroxin tab 25mcg .....................89
levoxyl tab 100mcg ...........................89
levoxyl tab 112mcg ...........................89
levoxyl tab 125mcg ...........................89
levoxyl tab 137mcg .......................... 89
levoxyl tab 150mcg .......................... 89
levoxyl tab 175mcg .......................... 90
levoxyl tab 200mcg .......................... 90
levoxyl tab 25mcg ............................ 89
levoxyl tab 50mcg ............................ 89
levoxyl tab 75mcg ............................ 89
levoxyl tab 88mcg ............................ 89
LEXIVA TAB 700MG .......................... 39
lice bedding aer 0.5% ....................... 58
lice control aer 0.5% ........................ 58
lice killing sha .................................. 58
lice soln kit ...................................... 58
lice treatmt sha 0.33-4% .................. 58
lice trtmnt liq 1% ............................. 58
licide aer 0.5% ................................ 58
lido/prilocn cre 2.5-2.5% .................. 57
lidocaine gel 2% .............................. 57
lidocaine oin 5% .............................. 57
lidocaine pad 5% ............................. 57
lidocaine sol 2% visc ........................ 76
lidocaine sol 4% ............................... 57
lindane lot 1% ................................. 58
lindane sha 1% ................................ 58
linezolid sus 100/5ml ........................ 10
linezolid tab 600mg .......................... 10
LINZESS CAP 145MCG ...................... 64
LINZESS CAP 290MCG ...................... 64
liothyronine inj 10mcg/ml ................. 90
liothyronine tab 25mcg ..................... 90
liothyronine tab 50mcg ..................... 90
liothyronine tab 5mcg ....................... 90
lisinop/hctz tab 10-12.5 .................... 30
lisinop/hctz tab 20-12.5 .................... 30
lisinop/hctz tab 20-25mg .................. 30
lisinopril tab 10mg ........................... 28
lisinopril tab 2.5mg .......................... 28
lisinopril tab 5mg ............................. 28
lithium carb cap 150mg .................... 35
lithium carb tab 300mg ..................... 35
lithium carb tab 300mg er ................. 36
lithium carb tab 450mg er ................. 36
115
LITHIUM CITR SOL 8MEQ/5ML ............36
LITTLE TUMMY DRO 20/0.3ML ............63
LIVALO TAB 1MG ..............................27
LIVALO TAB 2MG ..............................27
LIVALO TAB 4MG ..............................27
lomustine cap 100mg ........................32
lomustine cap 10mg ..........................32
lomustine cap 40mg ..........................32
loperamide cap 2mg ..........................24
loperamide liq 1mg/5ml .....................24
loperamide sus 1mg/7.5 ....................24
loperamide tab 2mg ..........................24
loratadine d tab 5-120mg ..................51
loratadine sol 5mg/5ml ......................26
loratadine syp 5mg/5ml .....................26
loratadine tab 10mg ..........................26
loratadine-d tab 10-240mg ................51
lorazepam con 2mg/ml ......................12
lorazepam tab 0.5mg ........................12
lorazepam tab 1mg ...........................12
lorazepam tab 2mg ...........................12
loryna tab 3-0.02mg .........................48
losartan pot tab 100mg .....................29
losartan pot tab 25mg .......................29
losartan pot tab 50mg .......................29
losartan/hct tab 100-12.5 ..................31
losartan/hct tab 100-25 .....................31
losartan/hct tab 50-12.5 ....................31
LOTEMAX GEL 0.5% ..........................82
LOTEMAX OIN 0.5% ..........................82
LOTEMAX SUS 0.5%..........................83
lovastatin tab 10mg ..........................27
low-ogestrel tab................................48
loxapine cap 10mg ............................37
loxapine cap 25mg ............................37
loxapine cap 50mg ............................37
loxapine cap 5mg..............................37
lubricant dro 1.4% ............................81
lubricating sol 0.5% ..........................81
lubricnt eye dro 0.4-0.3% ..................81
lubricnt eye dro 0.5% op ...................81
LUFYLLIN TAB 200MG ........................14
LUMIGAN SOL 0.01% ........................83
LUMIGAN SOL 0.03% ........................83
LUPR DEP-PED INJ 11.25MG...............61
LUPR DEP-PED INJ 15MG .................. 61
LUPR DEP-PED INJ 30MG .................. 61
LUPR DEP-PED INJ 7.5MG ................. 60
lutera tab ........................................ 48
LYRICA CAP 100MG .......................... 17
LYRICA CAP 150MG .......................... 17
LYRICA CAP 200MG .......................... 17
LYRICA CAP 225MG .......................... 17
LYRICA CAP 25MG ............................ 16
LYRICA CAP 300MG .......................... 17
LYRICA CAP 50MG ............................ 16
LYRICA CAP 75MG ............................ 17
LYSODREN TAB 500MG ..................... 33
lyza tab 0.35mg ............................... 49
M
maalox multi sus symp max ................ 9
maalox sus advanced ......................... 9
maalox sus reg st ............................... 9
mafenide ace pak 5% ....................... 55
mag citrate sol cherry ....................... 71
mag citrate sol grape ........................ 71
mag citrate sol lemon ....................... 71
mag oxide tab 250mg ......................... 9
mag oxide tab 400mg ......................... 9
mag oxide tab 420mg ......................... 9
mag-al plus liq ................................... 9
mag-al plus liq xs ............................... 9
magnesium cap 500mg ..................... 76
magnesium gl tab 500mg .................. 76
magnesium su inj 50% ..................... 76
magnesium tab 200mg ..................... 76
magnesium tab 250mg ................. 9, 76
magnesium tab 500mg ..................... 76
magnesium-ox tab 400mg................. 76
mag-sr tab 535mg ........................... 76
malathion lot 0.5% ........................... 58
maprotiline tab 50mg ....................... 18
maprotiline tab 75mg ....................... 18
marlissa tab 0.15/30 ........................ 48
MARPLAN TAB 10MG ......................... 19
martinic cap .................................... 68
MATULANE CAP 50MG ....................... 34
meclizine chw 25mg ......................... 24
meclizine tab 12.5mg ....................... 24
meclizine tab 25mg .......................... 24
meclofen sod cap 100mg .................... 4
meclofen sod cap 50mg ...................... 4
116
medi-tabs elx 80/2.5ml ...................... 5
medroxypr ac inj 150mg/ml ...............49
medroxypr ac tab 10mg.....................86
medroxypr ac tab 2.5mg....................86
medroxypr ac tab 5mg ......................86
mefenam acid cap 250mg ................... 4
mefloquine tab 250mg.......................31
megestrol ac sus 40mg/ml .................33
megestrol ac tab 20mg ......................33
megestrol ac tab 40mg ......................33
melatin tab 3-1mg ............................. 3
melatonin cap 3mg ............................ 2
melatonin cap 5mg ............................ 2
MELATONIN LIQ 1MG/4ML .................. 2
melatonin tab 10mg cr ....................... 2
melatonin tab 1mg ............................. 2
melatonin tab 300mcg ........................ 2
melatonin tab 3-2mg .......................... 3
melatonin tab 3mg ............................. 2
melatonin tab 5mg ............................. 2
melatonin tr tab /vit-b6 ...................... 3
meloxicam tab 15mg .......................... 4
meloxicam tab 7.5mg ......................... 4
melphalan inj 50mg ..........................32
memant titra pak 5-10mg ..................86
memantine hcl tab 10 mg ..................86
memantine hcl tab 5 mg ....................86
MENEST TAB 0.3MG ..........................62
MENEST TAB 0.625MG .......................62
MENEST TAB 1.25MG ........................62
MENEST TAB 2.5MG ..........................62
MENTAX CRE 1% ..............................54
meperidine sol 50mg/5ml ................... 6
meperidine tab 100mg ....................... 6
meperidine tab 50mg ......................... 6
MEPHYTON TAB 5MG .........................94
meprobamate tab 200mg...................11
meprobamate tab 400mg...................11
mercaptopur tab 50mg ......................32
metadate tab 20mg er ........................ 2
metafiber pow 30.9% ........................70
metafiber pow 48.57% ......................70
metafiber pow 58.6% ........................70
METAMUCIL POW 28% ......................70
metamucil pow 30.9% .......................70
METAMUCIL POW 55.46% ..................70
METAMUCIL POW 58.12% ..................70
metamucil pow 58.6% ...................... 70
METAMUCIL POW CLEAR ................... 70
METAMUCIL WAF.............................. 70
metaproteren syp 10mg/5ml ............. 13
metaproteren tab 10mg .................... 13
metaproteren tab 20mg .................... 14
metaxalone tab 800mg ..................... 79
metformin tab 1000mg ..................... 21
metformin tab 500mg ....................... 21
metformin tab 500mg er ................... 21
metformin tab 750mg er ................... 21
metformin tab 850mg ....................... 21
methadone sol 10mg/5ml ................... 6
methadone sol 5mg/5ml ..................... 6
methadone tab 10mg ......................... 6
methadone tab 5mg ........................... 6
methamphetam tab 5mg ..................... 1
methazolamid tab 25mg ................... 59
methazolamid tab 50mg ................... 59
methenam hip tab 1gm ..................... 93
methimazole tab 10mg ..................... 88
methimazole tab 5mg ....................... 88
METHITEST TAB 10MG ........................ 8
methocarbam tab 500mg .................. 79
methocarbam tab 750mg .................. 79
methotrexate tab 2.5mg ................... 32
methscopolam tab 2.5mg .................. 92
methscopolam tab 5mg..................... 92
methyclothia tab 5mg ....................... 60
methyldopa tab 250mg ..................... 30
methyldopa tab 500mg ..................... 30
methylergon tab 0.2mg .................... 84
methylphenid cap 10mg ...................... 2
methylphenid cap 20mg er .................. 2
methylphenid sol 10mg/5ml ................ 2
methylphenid sol 5mg/5ml .................. 2
methylphenid tab 10mg ...................... 2
methylphenid tab 10mg er .................. 2
methylphenid tab 20mg ...................... 2
117
methylphenid tab 5mg........................ 2
methylpred pak 4mg .........................50
methylpred tab 16mg ........................50
methylpred tab 32mg ........................50
methylpred tab 4mg ..........................50
methylpred tab 8mg ..........................50
metipranolol sol 0.3% oph .................81
metoclopram sol 5mg/5ml .................63
metoclopram tab 10mg .....................63
metoclopram tab 5mg .......................63
metolazone tab 10mg ........................60
metolazone tab 2.5mg .......................60
metolazone tab 5mg .........................60
metoprol tar tab 100mg.....................43
metoprol tar tab 25mg ......................43
metoprol tar tab 50mg ......................43
metoprolol tab 100mg er ...................43
metoprolol tab 200mg er ...................43
metoprolol tab 25mg er .....................43
metoprolol tab 50mg er .....................43
metronidazol cre 0.75% ....................57
metronidazol gel 0.75% .....................57
metronidazol gel 0.75%vag................94
metronidazol lot 0.75% .....................57
metronidazol tab 250mg ....................10
metronidazol tab 500mg ....................10
mexiletine cap 150mg .......................12
mi-acid chw ...................................... 9
miconazole 3 cre 4% .........................94
miconazole 3 kit combo pk .................94
miconazole aer 2% ...........................54
miconazole cre 2% ...................... 54, 94
miconazole sup 100mg ......................94
miconazorb pow af 2% ......................54
microgestin tab 1.5/30 ......................48
microgestin tab 1/20 .........................48
microgestin tab fe 1/20 .....................48
microgestin tab fe1.5/30....................48
midodrine tab 10mg ..........................94
midodrine tab 2.5mg .........................94
midodrine tab 5mg ............................94
milk of magn sus.............................. 71
MILK OF MAGN SUS 2400MG ............. 71
MINERAL OIL ................................... 71
mineral oil ene ................................. 71
minocycline cap 100mg ..................... 88
minocycline cap 50mg ...................... 88
minoxidil tab 10mg........................... 31
minoxidil tab 2.5mg.......................... 31
mintox plus chw ................................. 9
MIRENA IUD SYSTEM ........................ 49
mirtazapine tab 15mg ....................... 18
misoprostol tab 100mcg .................... 93
misoprostol tab 200mcg .................... 93
MISSION PREN TAB /FA .................... 78
MISSION PREN TAB HP ..................... 78
modafinil tab 100mg........................... 2
moexipril tab 15mg .......................... 29
moexipril tab 7.5mg ......................... 29
mometasone cre 0.1% ...................... 56
mometasone oin 0.1% ...................... 56
mometasone sol 0.1% ...................... 57
mono-linyah tab 0.25-35................... 48
mononessa tab ................................ 48
montelukast chw 4mg ....................... 13
montelukast chw 5mg ....................... 13
montelukast tab 10mg ...................... 13
MONUROL PAK GRANULES ................ 93
morphine sul sol 10mg/5ml ................. 6
morphine sul sol 20mg/5ml ................. 6
morphine sul sol 20mg/ml ................... 6
morphine sul tab 100mg er ................. 6
morphine sul tab 15mg ....................... 6
morphine sul tab 15mg er ................... 6
morphine sul tab 30mg ....................... 6
MOTOFEN TAB ................................. 24
MOVIPREP SOL ................................ 70
MUCINEX D TAB 60-600MG ............... 51
mucus-dm tab 30-600mg .................. 51
mult vitamin tab daily ....................... 77
MULTAQ TAB 400MG......................... 12
multi cap complete ........................... 77
MULTI PRENAT TAB .......................... 78
multi vitamn tab minerals ................. 77
118
multi-day tab /iron ............................77
multi-vit/fl chw 0.25mg .....................77
multi-vit/fl chw 1mg ..........................77
multi-vit/fl dro /fe 0.25 ......................78
multi-vit/fl dro 0.25mg ......................77
multi-vit/fl dro 0.5mg/ml ...................77
multivitamin cap ...............................77
multivitamin dro pediatrc ...................78
multivitamin liq mineral .....................77
mult-vit/fl chw 0.5mg ........................77
mupirocin oin 2% .............................53
M-VIT TAB 27-1MG ...........................78
my way tab 1.5mg ............................49
mycophenolat cap 250mg ..................42
mycophenolat tab 500mg ..................42
mycophenolic tab 180mg dr ...............42
mycophenolic tab 360mg dr ...............42
myorisan cap 10mg ...........................53
myorisan cap 20mg ...........................53
myorisan cap 40mg ...........................53
MYTELASE TAB 10MG ........................31
myzilra tab.......................................48
N
nabumetone tab 500mg...................... 4
nabumetone tab 750mg...................... 4
nadolol tab 20mg ..............................43
nadolol tab 40mg ..............................43
nadolol tab 80mg ..............................43
naftifine cre hcl 1% ...........................54
NAFTIN CRE 1% ...............................54
NAFTIN CRE 2% ...............................54
NAFTIN GEL 1% ...............................54
naltrexone tab 50mg .........................24
namenda sol 10mg/5ml .....................86
NAMENDA XR CAP 14MG ....................86
NAMENDA XR CAP 21MG ....................86
NAMENDA XR CAP 28MG ....................86
NAMENDA XR CAP 7MG .....................86
NAMENDA XR TITRATION PACK ..........86
naphazoline sol 0.1% op ....................82
naproxen dr tab 375mg ...................... 4
naproxen dr tab 500mg ...................... 4
naproxen sod tab 220mg .................... 4
naproxen sus 125/5ml ........................ 4
naproxen tab 250mg .......................... 4
naproxen tab 375mg .......................... 4
naproxen tab 500mg .......................... 4
naratriptan tab 1mg ......................... 74
naratriptan tab 2.5mg....................... 74
NASACORT ALR SPR 55MCG/AC ......... 80
nasal decon liq 15mg/5ml ................. 80
nasal decong liq 30mg/5ml ................ 80
nasal decong tab 10mg ..................... 80
NAT FIBER POW 58.6% ..................... 70
NATACYN SUS 5% OP ....................... 82
NATAL-V RX TAB 29-1MG .................. 78
nateglinide tab 120mg ...................... 23
nateglinide tab 60mg ........................ 23
NATURE-THROI TAB 130MG .............. 90
NATURE-THROI TAB 16.25MG ............ 90
NATURE-THROI TAB 195MG .............. 90
NATURE-THROI TAB 32.5MG ............. 90
NATURE-THROI TAB 48.75MG ............ 90
NATURE-THROI TAB 65MG ................ 90
NATURE-THROI TAB 97.5MG ............. 90
NEBULIZERS.................................... 74
NEBUPENT INH 300MG ..................... 10
necon tab 0.5/35 ............................. 48
necon tab 1/35 ................................ 48
necon tab 1/50-28 ........................... 48
necon tab 7/7/7 ............................... 48
nefazodone tab 100mg ..................... 18
nefazodone tab 50mg ....................... 18
neo/bac/poly oin op .......................... 82
neo/poly/bac oin /hc 1%op ............... 83
neo/poly/dex oin 0.1% op ................. 83
neo/poly/dex sus 0.1% op................. 83
neo/poly/gra sol op .......................... 82
neo/poly/hc sol 1% otic .................... 84
neo/poly/hc sus 1% otic.................... 84
neomycin tab 500mg .......................... 3
NEORAL CAP 100MG ......................... 42
NEORAL CAP 25MG ........................... 42
NEORAL SOL 100MG/ML .................... 42
NEULASTA INJ 6MG/0.6M .................. 67
NEUPOGEN INJ 300/0.5 .................... 67
NEUPOGEN INJ 300MCG .................... 67
NEUPOGEN INJ 480/0.8 .................... 67
NEUPOGEN INJ 480MCG .................... 67
119
NEVANAC SUS 0.1% .........................83
nevirapine sus 50mg/5ml...................40
nevirapine tab 200mg .......................40
nevirapine tab 400mg er ....................40
NEXAVAR TAB 200MG........................34
NEXIUM 24HR CAP 20MG OTC ............92
next choice tab 1.5mg .......................49
niacin cap 250mg er ..........................95
niacin cap 500mg .............................45
niacin cap 500mg sr ..........................95
niacin tab 100mg ..............................95
niacin tab 250mg ..............................95
niacin tab 250mg sr ..........................95
niacin tab 500mg ..............................95
niacin tab 500mg er ..........................95
niacin tab 50mg ................................95
niacin tab 750mg tr ...........................95
niacinamide tab 500mg .....................95
niacor tab 500mg .............................28
nicardipine cap 20mg ........................44
nicardipine cap 30mg ........................44
nicotine dis 14mg/24h .......................87
nicotine dis 21mg/24h .......................87
nicotine dis 7mg/24hr .......................87
nicotine lozenge 2 mg .......................87
nicotine lozenge 4 mg .......................88
nicotine pol gum 2mg ........................88
nicotine pol gum 4mg ........................88
NICOTROL INH .................................88
NICOTROL NS SPR 10MG/ML ..............88
nifedipine cap 20mg ..........................44
nifedipine tab 30mg er ......................44
night time liq cgh/cold .......................51
NILANDRON TAB 150MG ....................33
nimodipine cap 30mg ........................45
nisoldipine tab 17mg er .....................45
nisoldipine tab 20mg .........................45
nisoldipine tab 25.5mg ......................45
nisoldipine tab 34mg er .....................45
nisoldipine tab 8.5mg er ....................45
nitrofur mac cap 100mg ....................93
nitrofur mac cap 50mg ......................93
nitrofurantn cap 100mg .....................93
nitroglycer cap 9mg er ...................... 11
nitroglycer dis 0.2mg/hr.................... 11
NITROSTAT SUB 0.3MG .................... 11
NITROSTAT SUB 0.4MG .................... 11
NITROSTAT SUB 0.6MG .................... 11
nizatidine cap 150mg........................ 92
nizatidine sol 15mg/ml ...................... 92
nonoxynol-9 gel 4% ......................... 93
non-pseudo tab 10mg ....................... 80
nora-be tab 0.35mg ......................... 49
noreth/ethin tab 0.5-2.5 ................... 62
norethin ace tab 5mg ....................... 86
norethindron tab 0.35mg .................. 49
norgest/eth tab estrad ...................... 48
norgest/ethi tab 0.25/35 ................... 48
norgest/ethi tab estradio ................... 48
NOROXIN TAB 400MG ....................... 63
nortrel tab 0.5/35 ............................ 48
nortrel tab 1/35 ............................... 48
nortrel tab 7/7/7 .............................. 48
nortriptylin cap 10mg ....................... 20
NORVIR CAP 100MG ......................... 40
NORVIR SOL 80MG/ML...................... 40
NORVIR TAB 100MG ......................... 40
NOVOLIN INJ 70/30.......................... 22
NOVOLIN N INJ U-100 ...................... 22
NOVOLIN R INJ PENFILL .................... 22
NOVOLIN R INJ U-100 ...................... 22
NOVOLOG INJ 100/ML ...................... 22
NOVOLOG INJ FLEXPEN..................... 22
NOVOLOG INJ PENFILL ..................... 23
NOVOLOG MIX INJ 70/30 .................. 23
NOVOLOG MIX INJ FLEXPEN .............. 23
np thyroid tab 30mg ......................... 90
np thyroid tab 60mg ......................... 90
np thyroid tab 90mg ......................... 90
NUCYNTA ER TAB 100MG .................... 6
NUCYNTA ER TAB 150MG .................... 6
NUCYNTA ER TAB 200MG .................... 6
NUCYNTA ER TAB 250MG .................... 6
NUCYNTA ER TAB 50MG ...................... 6
NUCYNTA TAB 100MG ......................... 6
120
NUCYNTA TAB 50MG .......................... 6
NUCYNTA TAB 75MG .......................... 6
NUEDEXTA CAP 20-10MG ...................87
NULOJIX INJ 250MG ..........................42
NUVARING MIS.................................49
NUVIGIL ........................................... 2
NUVIGIL TAB 150MG .......................... 2
NUVIGIL TAB 250MG .......................... 2
NUVIGIL TAB 50MG ............................ 2
nystat/triam cre................................54
nystat/triam oin ................................54
nystatin cre 100000 ..........................54
nystatin oin 100000 ..........................54
nystatin pow 100000 .........................54
nystatin sus 100000 ..........................76
nystatin tab 500000 ..........................25
O
ocella tab 3-0.03mg ..........................48
OCTAGAM INJ 5GM ...........................84
octreotide inj 100mcg ........................61
ofloxacin dro 0.3% op .......................82
ofloxacin dro 0.3%otic .......................84
ogestrel tab .....................................48
olanzapine tab 10mg .........................37
olanzapine tab 2.5mg ........................37
olanzapine tab 5mg ...........................37
olanzapine tab 7.5mg ........................37
olopatadine spr 0.6% ........................80
OMACOR CAP 1GM ............................27
omega-3-acid cap 1gm ......................27
OMEPRAZOLE + SUS SYRSPEND .........92
omeprazole cap 10mg .......................92
omeprazole cap 20.6mgdr..................92
omeprazole cap 20mg .......................92
omeprazole cap delayed release 40 mg93
omeprazole tab 20mg ........................93
OMNIFLEX DPR .................................73
OMNITROPE INJ 5.8MG ......................60
ondansetron sol 4mg/5ml ..................24
ondansetron tab 4mg ........................24
ondansetron tab 4mg odt ...................24
ondansetron tab 8mg ........................24
ondansetron tab 8mg odt ...................24
ONFI TAB 10MG ................................16
ONFI TAB 20MG ................................16
ONFI TAB 5MG ................................. 16
ONGLYZA TAB 2.5MG........................ 22
ONGLYZA TAB 5MG .......................... 22
oral saline sol laxative ...................... 71
orap tab 1mg ................................... 87
orap tab 2mg ................................... 87
ORAVIG TAB 50MG ........................... 76
ORFADIN CAP 10MG ......................... 61
ORFADIN CAP 2MG ........................... 61
ORFADIN CAP 5MG ........................... 61
orphenadrine tab 100mg er ............... 79
orsythia tab ..................................... 48
ORTHO COIL DPR KIT 100 ................. 73
ORTHO COIL DPR KIT 105 ................. 73
ORTHO COIL DPR KIT 50................... 73
ORTHO FLAT DPR KIT 55 ................... 73
ORTHO FLEX DPR 65MM .................... 73
ORTHO FLEX DPR 70MM .................... 73
ORTHO FLEX DPR 75MM .................... 73
ORTHO FLEX DPR 80MM .................... 73
ortho-est tab 0.625 .......................... 62
ortho-est tab 1.25 ............................ 62
os-cal 500 chw................................. 75
OSMOPREP TAB 1.5GM ..................... 71
oxandrolone tab 10mg ........................ 8
oxandrolone tab 2.5mg ....................... 8
oxaprozin tab 600mg .......................... 4
oxazepam cap 10mg......................... 12
oxazepam cap 15mg......................... 12
oxazepam cap 30mg......................... 12
oxcarbazepin sus 300mg/5m ............. 17
oxcarbazepin tab 150mg ................... 17
OXISTAT CRE 1% ............................. 54
OXISTAT LOT 1% ............................. 54
OXSORALEN LOT 1% ........................ 57
oxybutynin syp 5mg/5ml ................... 64
oxybutynin tab 10mg er .................... 64
121
oxybutynin tab 15mg er ....................64
oxybutynin tab 5mg ..........................64
oxybutynin tab 5mg er ......................64
oxycod/apap tab 10-325mg ................ 8
oxycod/apap tab 5-325mg .................. 8
oxycod/apap tab 7.5-325 .................... 8
oxycod/ibu tab 5-400mg ..................... 8
oxycodone sol 5mg/5ml ...................... 6
oxycodone tab 10mg .......................... 7
oxycodone tab 10mg er ...................... 7
oxycodone tab 15mg .......................... 7
oxycodone tab 20mg .......................... 7
oxycodone tab 30mg .......................... 7
oxycodone tab 5mg ............................ 7
OXYCONTIN TAB 10MG CR .................. 7
oxymorphone tab 10mg er .................. 7
oxymorphone tab 5mg er .................... 7
oxymorphone tab 7.5mg er ................. 7
oxymorphone tab hcl 10mg ................. 7
oxymorphone tab hcl 5mg .................. 7
oys shell+d tab 250-125 ....................75
oysco 500+d chw..............................75
oyst shell/d tab 500mg ......................75
oyster shell tab 500mg ......................75
P
pamix sus 50mg/ml ........................... 9
pancrelipase cap 5000unit .................58
PANGLOBULIN INJ 12GM ...................84
PANGLOBULIN SOL 12GM ..................84
PANRETIN GEL 0.1% .........................54
pantoprazole tab 20mg ......................93
pantoprazole tab 40mg ......................93
paricalcitol cap 1 mcg ........................61
paricalcitol cap 2 mcg ........................61
paricalcitol cap 4 mcg ....................... 61
paricalcitol inj 5mcg/ml ..................... 61
paroex sol 0.12% ............................. 77
paromomycin cap 250mg .................... 3
paroxetine tab 10mg ........................ 19
PASER GRA 4GM .............................. 32
PATADAY SOL 0.2% ......................... 83
PATANOL SOL 0.1% OP..................... 83
PEAK FLOW METER ........................... 88
ped elctrlyt sol ................................. 75
PEDIA-LAX LIQ 50MG ....................... 72
peg 3350 sol electrol ........................ 70
peg-3350 sol electrol ........................ 70
peg-3350/kcl sol /sodium .................. 70
PEGANONE TAB 250MG ..................... 17
PEGASYS INJ ................................... 41
PEGASYS INJ 180MCG/M ................... 41
PEG-INTRON KIT 150MCG ................. 41
penicilln vk sol 125/5ml .................... 85
penicilln vk sol 250/5ml .................... 85
penicilln vk tab 250mg ...................... 85
penicilln vk tab 500mg ...................... 85
pentoxifylli tab 400mg er .................. 66
perindopril tab 2mg .......................... 29
periogard sol 0.12% ......................... 77
permethrin cre 5% ........................... 58
permethrin lot 1% ............................ 58
perphenazine tab 16mg .................... 38
perphenazine tab 2mg ...................... 38
phenazopyrid tab 100mg................... 65
phenazopyrid tab 200mg................... 65
phenelzine tab 15mg ........................ 19
phenobarb sol 20mg/5ml .................. 68
phenobarb tab 100mg ...................... 69
phenobarb tab 15mg ........................ 69
phenobarb tab 16.2mg ..................... 69
phenobarb tab 30mg ........................ 69
phenobarb tab 32.4mg ..................... 69
phenobarb tab 60mg ........................ 69
phenobarb tab 64.8mg ..................... 69
122
phenobarb tab 97.2mg ......................69
phenoxybenza cap 10mg ...................29
phenylbutyra pow sodium ..................61
phenytoin chw 50mg .........................18
phenytoin ex cap 100mg....................18
phenytoin sus 125/5ml ......................18
philith tab 0.4-35 ..............................48
PHISOHEX LIQ 3% ............................39
phospha 250 tab neutral ....................76
phosphate sol laxative .......................71
PHOSPHOLINE SOL 0.125%OP ...........82
physiosol sol irrigat ...........................42
PICATO GEL 0.015% .........................54
PICATO GEL 0.05% ...........................54
pilocarpine sol 1% op ........................82
pilocarpine tab 5mg ..........................77
pilocarpine tab 7.5mg ........................77
pimtrea tab ......................................48
pindolol tab 10mg .............................43
pindolol tab 5mg ...............................43
pink bismuth tab 262mg ....................24
PIN-X CHW 250MG............................. 9
pin-x sus 50mg/ml ............................. 9
pioglitazone tab 15mg .......................23
pirmella tab 1/35 ..............................48
pirmella tab 7/7/7 .............................48
piroxicam cap 10mg ........................... 4
piroxicam cap 20mg ........................... 4
PNV FOLIC AC TAB + IRON ................78
podofilox sol 0.5% ............................57
poly bacitra oin .................................53
poly vitamin chw...............................78
polyeth glyc pow 3350 nf ...................71
POLYGAM S/D SOL 10GM ...................84
polysacchari cap iron .........................68
polyvitamin chw /iron ........................78
polyvitamin dro ................................78
polyvitamin dro /iron .........................78
portia-28 tab ....................................48
pot chloride cap 10meq er .................76
pot chloride cap 8meq er ...................76
pot chloride liq 10% ......................... 76
pot chloride liq 20% ......................... 76
pot chloride tab 10meq er ................. 76
pot chloride tab 8meq er ................... 76
pot citrate tab 1080mg ..................... 65
pot citrate tab 540mg ....................... 65
pot cl micro tab 10meq er ................. 76
pot cl micro tab 20meq er ................. 76
potassium tab 25meq ef.................... 76
POTIGA TAB 200MG ......................... 17
POTIGA TAB 400MG ......................... 17
POTIGA TAB 50MG ........................... 17
pramipexole tab 0.125mg ................. 35
pramipexole tab 0.25mg ................... 35
pramipexole tab 0.5mg ..................... 35
pramipexole tab 0.75mg ................... 35
pramipexole tab 1.5mg ..................... 35
pramipexole tab 1mg ........................ 35
pravastatin tab 10mg ....................... 28
prazosin hcl cap 1mg ........................ 30
pred sod pho sol 5mg/5ml ................. 50
pred sod pho sol 6.7/5ml .................. 50
prednicarbat cre 0.1% ...................... 57
prednicarbat oin 0.1% ...................... 57
prednisolone sol 15mg/5ml ............... 50
prednisolone sol 25mg/5ml ............... 50
prednisolone sus 1% op .................... 83
prednisolone syp 15mg/5ml .............. 50
prednisone pak 10mg ....................... 50
prednisone pak 5mg ......................... 50
prednisone sol 5mg/5ml .................... 50
prednisone tab 10mg ........................ 50
prednisone tab 1mg.......................... 50
prednisone tab 2.5mg ....................... 50
prednisone tab 5mg.......................... 50
PREMARIN TAB 0.3MG ...................... 62
PREMARIN TAB 0.45MG .................... 62
PREMARIN TAB 0.625MG ................... 62
PREMARIN TAB 0.9MG ...................... 62
PREMARIN TAB 1.25MG .................... 62
123
PREMARIN VAG CRE 0.625MG ............94
PREMPHASE TAB ...............................62
PREMPRO TAB .625-2.5 .....................62
PREMPRO TAB 0.3-1.5 .......................62
PREMPRO TAB 0.45-1.5 .....................62
PREMPRO TAB 0.625-5 ......................62
prenaplus tab ...................................78
prenatabs fa tab ...............................78
prenatabs rx tab ...............................78
prenatal 19 chw tab ..........................78
prenatal 19 tab .................................78
prenatal ad tab .................................78
prenatal dha cap 200mg ....................76
PRENATAL MUL CAP +DHA .................85
PRENATAL MV MIS + DHA ..................86
PRENATAL ONE TAB DAILY .................78
PRENATAL TAB .................................78
PRENATAL TAB 27-0.8MG ..................79
PRENATAL TAB 27-1MG .....................79
PRENATAL TAB 28-0.8MG ..................79
PRENATAL TAB COMPLETE .................79
PRENATAL TAB FORMULA ...................79
PRE-NATAL TAB FORMULA .................78
PRENATAL TAB FORTE .......................79
PRENATAL TAB LOW IRON .................79
prenatal tab plus...............................79
PRENATAL TAB PLUS .........................79
prenatal tab plus fe ...........................79
PRENATAL TAB VITAMINS ..................79
PRENATAL VIT TAB PLUS ...................79
PRENATAL/FE TAB .............................79
PRENTIF MIS 22MM ...........................73
PRENTIF MIS 25MM ...........................73
PRENTIF MIS 28MM ...........................73
PRENTIF MIS 31MM ...........................73
PRENTIF MIS FITTING .......................73
PREPOPIK PAK ..................................71
prevalite ..........................................27
previfem tab ....................................48
PREZCOBIX TAB 800-150 ..................40
PREZISTA SUS 100MG/ML..................40
PREZISTA TAB 400MG .......................40
PREZISTA TAB 600MG .......................40
PREZISTA TAB 800MG .......................40
PRIFTIN TAB 150MG ..........................32
PRILOSEC OTC TAB 20MG ..................93
PRIMAQUINE TAB 26.3MG ..................31
primidone tab 250mg ....................... 17
primidone tab 50mg ......................... 17
PRISTIQ TAB 100MG ........................ 20
PRISTIQ TAB 50MG .......................... 19
PRIVIGEN INJ 20GRAMS ................... 84
PROAIR HFA AER .............................. 14
proben/colch tab 500-0.5 .................. 65
probenecid tab 500mg ...................... 65
prochlorper sup 25mg ....................... 38
prochlorper tab 10mg ....................... 38
prochlorper tab 5mg ......................... 38
PRO-CLEAR AC SYP .......................... 51
PROCRIT INJ 10000/ML..................... 67
PROCRIT INJ 2000/ML ...................... 67
PROCRIT INJ 20000/ML..................... 67
PROCRIT INJ 4000/ML ...................... 67
PROCRIT INJ 40000/ML..................... 67
proctosol hc cre 2.5% ......................... 8
progesterone cap 100mg................... 86
progesterone cap 200mg................... 86
prometh vc syp 6.25-5/5 .................. 51
prometh vc/ syp codeine ................... 51
prometh/cod syp 6.25-10 .................. 51
promethazine inj 25mg/ml ................ 26
promethazine sol 6.25/5ml ................ 26
promethazine sup 12.5mg ................. 26
promethazine sup 25mg.................... 26
promethazine syp 6.25/5ml ............... 26
promethazine syp dm ....................... 51
promethazine tab 12.5mg ................. 26
promethazine tab 25mg .................... 26
promethazine tab 50mg .................... 26
promethegan sup 50mg .................... 26
propafenone tab 150mg .................... 12
proparacaine sol 0.5% op.................. 82
propranolol cap 120mg er ................. 43
propranolol cap 160mg er ................. 43
propranolol cap 60mg er ................... 43
propranolol cap 80mg er ................... 43
propranolol sol 20mg/5ml ................. 43
propranolol sol 40mg/5ml ................. 44
propranolol tab 10mg ....................... 44
124
propranolol tab 80mg ........................44
propylthiour tab 50mg .......................88
protriptylin tab 10mg ........................21
protriptylin tab 5mg ..........................21
pseudoephedr syp 30mg/5ml .............80
pseudoephedr tab 120mg er ..............80
pseudoephedr tab 30mg ....................80
pseudoephedr tab 60mg ....................80
psyllium pow 100% ...........................70
PULMICORT INH 180MCG ...................13
PULMICORT INH 90MCG ....................13
PULMOZYME SOL 1MG/ML ..................88
pure & gentl dro 0.3% .......................81
PX PRENATAL TAB MULTIVIT ..............79
pyrazinamide tab 500mg ...................32
pyridostigm tab 60mg .......................31
pyridoxine tab 100mg .......................95
pyridoxine tab 25mg .........................95
pyridoxine tab 50mg .........................95
Q
qc natural pow vegetabl .....................70
QC PRENATAL TAB 28-0.8MG .............79
q-pap liq 160/5ml .............................. 5
q-tapp dm elx...................................51
q-tapp elx 1-15/5ml ..........................51
q-tussin dm syp 100-10/5 ..................51
quetiapine tab 100mg .......................37
quetiapine tab 25mg .........................37
quetiapine tab 50mg .........................37
QUFLORA PED CHW 0.25MG ...............77
QUFLORA PED CHW 0.5MG ................77
QUFLORA PED CHW 1MG ...................77
quinapril tab 10mg ............................29
quinapril tab 20mg ............................29
quinapril tab 40mg ............................29
quinapril tab 5mg .............................29
quinidine su tab 300mg .....................12
quinine sulf cap 324mg......................31
QVAR AER 40MCG .............................13
QVAR AER 80MCG .............................13
R
ra allergy tab sinus ...........................51
ra calcium+d tab 600mg ....................75
ra fiber tab 500mg ............................70
ra lice kit solution ............................. 58
RA PRENATAL TAB 28-0.8MG ............. 79
RA PRENATAL TAB FORMULA ............. 79
rabeprazole tab 20mg ....................... 93
raloxifene tab 60mg ......................... 60
ramipril cap 1.25mg ......................... 29
ramipril cap 10mg ............................ 29
ramipril cap 2.5mg ........................... 29
ramipril cap 5mg .............................. 29
RANEXA TAB 1000MG ....................... 10
RANEXA TAB 500MG ......................... 10
ranitidine syp 15mg/ml ..................... 92
ranitidine tab 150mg ........................ 92
ranitidine tab 300mg ........................ 92
ranitidine tab 75mg .......................... 92
RAPAFLO CAP 4MG ........................... 65
RAPAFLO CAP 8MG ........................... 65
RAPAMUNE SOL 1MG/ML ................... 42
reclipsen tab .................................... 48
reeses med sus pinworm ..................... 9
REGRANEX GEL 0.01% ..................... 58
RELENZA MIS DISKHALE ................... 41
RELISTOR KIT 12/0.6ML ................... 64
RELPAX TAB 20MG ........................... 74
RELPAX TAB 40MG ........................... 74
REMODULIN INJ 1MG/ML .................. 45
REMODULIN INJ 2.5MG/ML ................ 45
REMODULIN INJ 5MG/ML .................. 45
renal tab multivit ............................. 77
rena-vite rx tab................................ 77
reno cap ......................................... 77
RENVELA PAK 0.8GM ........................ 64
RENVELA PAK 2.4GM ........................ 64
RENVELA TAB 800MG ....................... 64
repaglinide tab 0.5mg ....................... 23
repaglinide tab 1mg ......................... 23
repaglinide tab 2mg ......................... 23
RESCRIPTOR TAB 100 MG ................. 40
RESCRIPTOR TAB 100MG .................. 40
RESCRIPTOR TAB 200MG .................. 40
RESPIRATORY MASKS ....................... 74
REVLIMID CAP 10MG ........................ 42
REVLIMID CAP 15MG ........................ 42
REVLIMID CAP 25MG ........................ 42
REVLIMID CAP 5MG .......................... 42
REYATAZ CAP 150MG ....................... 40
REYATAZ CAP 200MG ....................... 40
125
REYATAZ CAP 300MG ........................40
RHOGAM PLUS INJ 300MCG ...............84
ribavirin cap 200mg ..........................41
ribavirin tab 200mg...........................41
RIDAURA CAP 3MG ............................ 3
rifabutin cap 150mg ..........................32
rifampin cap 150mg ..........................32
rifampin cap 300mg ..........................32
RIFATER TAB ....................................31
RIGHT STEP TAB PRENATAL ...............79
riluzole tab 50mg ..............................81
rimantadine tab 100mg .....................41
risedronate tab 150mg ......................60
risedronate tab 30mg ........................60
risedronate tab 35mg ........................60
risedronate tab 5mg ..........................60
RISPERDAL INJ 12.5MG .....................36
RISPERDAL INJ 25MG ........................36
RISPERDAL INJ 37.5MG .....................36
RISPERDAL INJ 50MG ........................36
risperidone sol 1mg/ml ......................36
risperidone tab 0.25 odt ....................36
risperidone tab 0.25mg .....................36
risperidone tab 0.5mg .......................36
risperidone tab 0.5mg od ...................36
risperidone tab 1mg ..........................36
risperidone tab 1mg odt ....................36
RITALIN LA CAP 10MG ........................ 2
RITUXAN INJ 100MG .........................32
RITUXAN INJ 500MG .........................32
RIXUBIS INJ 1000UNIT ......................66
RIXUBIS INJ 2000UNIT ......................66
RIXUBIS INJ 250 UNIT ......................66
RIXUBIS INJ 3000UNIT ......................66
RIXUBIS INJ 500UNIT .......................66
rizatriptan tab 10mg .........................74
rizatriptan tab 5mg ...........................74
robitussin liq cgh/cong.......................51
robitussin liq nighttim ........................51
robitussin liq to go dm .......................51
robitussin syp 7.5/5ml .......................50
ropinirole tab 0.25mg ....................... 35
ropinirole tab 0.5mg ......................... 35
ropinirole tab 1mg ............................ 35
ROZEREM TAB 8MG .......................... 69
rynex pse liq .................................... 51
S
SABRIL POW 500MG ......................... 17
SABRIL TAB 500MG .......................... 17
saline ene laxative............................ 71
saline nasal spr 0.65%...................... 80
salsalate tab 500mg ........................... 5
salsalate tab 750mg ........................... 5
SAMSCA TAB 15MG .......................... 62
SAMSCA TAB 30MG .......................... 62
SANDIMMUNE CAP 100MG................. 42
SANDIMMUNE CAP 25MG .................. 42
SANDOGLOBULI INJ IV 12GM ............ 84
SANDOSTATIN KIT LAR 20MG ............ 61
SANDOSTATIN KIT LAR 30MG ............ 61
SANTYL OIN 250/GM ........................ 57
SAPHRIS SUB 10MG ......................... 37
SAPHRIS SUB 5MG ........................... 37
SAVELLA MIS TITR PAK ..................... 86
SAVELLA TAB 100MG ........................ 87
SAVELLA TAB 12.5MG ....................... 86
SAVELLA TAB 25MG .......................... 87
SAVELLA TAB 50MG .......................... 87
sb fib lax pow 33% ........................... 70
selegiline cap 5mg ............................ 35
selegiline tab 5mg ............................ 35
selenium sul lot 2.5% ....................... 55
selenium sul sha 2.5% ...................... 55
SELZENTRY TAB 150MG .................... 40
SELZENTRY TAB 300MG .................... 40
SE-NATAL 19 CHW ........................... 79
SE-NATAL ONE TAB .......................... 79
senna syp 8.8mg/5 .......................... 71
SENNA TAB 187MG........................... 71
senna tab 25mg ............................... 71
senna tab 8.6mg .............................. 71
senna-s tab 8.6-50mg ...................... 71
SENSIPAR TAB 30MG ........................ 61
SENSIPAR TAB 60MG ........................ 61
126
SENSIPAR TAB 90MG ........................61
SEREVENT DIS AER 50MCG ................14
SEROQUEL XR TAB 150MG .................37
SEROQUEL XR TAB 50MG...................37
sertraline con 20mg/ml .....................19
sertraline tab 100mg .........................19
sertraline tab 25mg ...........................19
sertraline tab 50mg ...........................19
sildenafil tab 20mg ...........................46
silver sulfa cre 1% ............................55
simethicone chw 125mg ....................63
simethicone chw 80mg ......................63
simethicone dro 40/0.6ml ..................63
SIMPONI INJ 100MG/ML ..................... 3
SIMPONI INJ 50MG ............................ 3
simvastatin tab 10mg ........................28
simvastatin tab 5mg .........................28
sinus/conges tab 10mg ......................80
sirolimus ..........................................42
sirolimus tab 0.5mg ..........................42
SKELID TAB 200MG ..........................60
sleep aid tab 25mg ...........................68
sleep aid tab 50mg ...........................68
sleep tab 25mg.................................68
slow iron tab 50mg ...........................68
slow release tab 47.5mg ....................68
sm fiber lax tab 500mg......................70
sm ibuprofen tab 100mg jr.................. 4
sm iron tab 45mg .............................68
SM PRENATAL TAB VITAMINS .............79
smz/tmp ds tab 800-160 ...................10
smz-tmp sus 200-40/5 ......................10
smz-tmp tab 400-80mg .....................10
sod chloride neb 0.9% .......................52
sod chloride oin 5% op ......................83
sod chloride sol 5% op ......................83
sod chloride tab 1000mg ...................76
sod fluoride dro 0.5mg/ml ..................76
sod fluoride tab 0.5mg f ....................76
sod poly sul pow ...............................42
sodium bicar tab 10gr ........................ 9
sodium bicar tab 325mg ..................... 9
sodium bicar tab 650mg ..................... 9
sodium chlor neb 3% ........................ 52
sodium chlor neb 7% ........................ 52
sodium chlor sol 0.9% irr .................. 65
solia tab .......................................... 48
soluble fib tab therapy ...................... 70
sotalol af tab 120mg ......................... 44
sotalol af tab 80mg .......................... 44
sotalol hcl tab 120mg ....................... 44
sotalol hcl tab 80mg ......................... 44
SOVALDI TAB 400MG ....................... 41
SPACERS......................................... 74
spinosad sus 0.9% ........................... 58
spirono/hctz tab 25/25 ..................... 59
spironolact tab 100mg ...................... 59
spironolact tab 25mg ........................ 59
spironolact tab 50mg ........................ 59
sprintec 28 tab 28 day ...................... 48
SPRYCEL TAB 100MG ........................ 34
SPRYCEL TAB 140MG ........................ 34
SPRYCEL TAB 20MG.......................... 34
SPRYCEL TAB 50MG.......................... 34
SPRYCEL TAB 70MG.......................... 34
sronyx tab ....................................... 48
st joseph co syp 7.5/5ml ................... 50
stavudine cap 20mg ......................... 40
stavudine cap 30mg ......................... 40
stavudine cap 40mg ......................... 40
STELARA INJ 45MG/0.5 ..................... 54
STELARA INJ 90MG/ML ..................... 54
steril water sol irrig .......................... 42
STIMATE SOL 1.5MG/ML ................... 61
STIVARGA TAB 40MG ....................... 34
stomach rlf chw 400mg ....................... 9
stool softnr cap 50mg ....................... 72
STRATTERA CAP 100MG ...................... 2
STRATTERA CAP 10MG ........................ 1
STRATTERA CAP 18MG........................ 1
STRATTERA CAP 25MG ........................ 1
STRATTERA CAP 40MG ........................ 1
STRATTERA CAP 60MG ........................ 1
STRATTERA CAP 80MG ........................ 1
STRIBILD TAB.................................. 40
STUART PREN TAB ........................... 79
sucralfate tab 1gm ........................... 92
127
SUDAFED PE SOL CHILDREN ..............80
sudogest pe tab 10mg .......................80
sulf/pred na sol op ............................83
sulfacet sod sol 10% op .....................82
SULFADIAZINE TAB 500MG ................88
SULFAMYLON CRE 85MG/GM ..............55
sulfasalazin tab 500mg ......................63
sulfasalazin tab 500mg dr ..................64
sulfatrim pd sus 200-40/5 ..................10
sulindac tab 150mg ............................ 4
sulindac tab 200mg ............................ 4
sumatriptan tab 100mg .....................74
sumatriptan tab 25mg .......................74
sumatriptan tab 50mg .......................74
suphedrine tab 10mg ........................80
suphedrine tab pe 10mg ....................80
SUPRAX TAB 400MG ..........................46
SUSTIVA CAP 200MG ........................40
SUSTIVA CAP 50MG ..........................40
SUSTIVA TAB 600MG ........................40
SUTENT CAP 12.5MG .........................34
SUTENT CAP 25MG ...........................34
SUTENT CAP 50MG ...........................34
syeda tab 3-0.03mg ..........................48
SYMBICORT AER 160-4.5 ...................14
SYMBICORT AER 80-4.5.....................14
SYMLINPEN 60 INJ 1000MCG .............21
SYMLNPEN 120 INJ 1000MCG .............21
SYNAGIS INJ 100MG/ML ....................85
SYNAGIS INJ 50MG ...........................85
SYNAREL SOL 2MG/ML ......................61
SYNERA DIS 70-70MG .......................57
SYNTHROID TAB 100MCG ..................90
SYNTHROID TAB 25MCG ....................90
SYPRINE CAP 250MG .........................41
T
TACLONEX SUS ................................57
tacrolimus (topical) .......................... 57
tacrolimus cap 0.5mg ....................... 42
tacrolimus cap 1mg .......................... 42
TAMIFLU CAP 30MG .......................... 41
TAMIFLU CAP 45MG .......................... 41
TAMIFLU CAP 75MG .......................... 41
TAMIFLU SUS 6MG/ML ...................... 41
tamoxifen tab 10mg ......................... 33
tamoxifen tab 20mg ......................... 33
tamsulosin cap 0.4mg ....................... 65
TARCEVA TAB 100MG ....................... 34
TARCEVA TAB 150MG ....................... 34
TARCEVA TAB 25MG ......................... 34
TARGRETIN GEL 1% ......................... 54
TASIGNA CAP 150MG ....................... 34
TASIGNA CAP 200MG ....................... 34
TAZORAC CRE 0.05% ....................... 54
TAZORAC CRE 0.1% ......................... 54
TAZORAC GEL 0.05% ....................... 55
TAZORAC GEL 0.1% ......................... 55
TEGRETOL-XR TAB 100MG ................ 17
TEKTURNA TAB 150MG ..................... 31
TEKTURNA TAB 300MG ..................... 31
telmisartan tab 20mg ....................... 29
temazepam cap 15mg ...................... 69
temazepam cap 30mg ...................... 69
temozolomide cap 100mg ................. 32
temozolomide cap 20mg ................... 32
temozolomide cap 5mg ..................... 32
terazosin cap 10mg .......................... 30
terazosin cap 1mg ............................ 30
terazosin cap 2mg ............................ 30
terazosin cap 5mg ............................ 30
terbinafine cre 1%............................ 54
terbinafine tab 250mg ...................... 25
terbutaline tab 2.5mg ....................... 14
terbutaline tab 5mg .......................... 14
terconazole cre 0.4% ........................ 94
terconazole cre 0.8% ........................ 94
terconazole sup 80mg ....................... 94
testost cyp inj 100mg/ml .................... 8
testost cyp inj 200mg/ml .................... 8
128
testost enan inj 200mg/ml .................. 8
tetracycline cap 250mg .....................88
tetracycline cap 500mg .....................88
TEVETEN TAB 400MG ........................29
TH PRENATAL TAB VITAMINS .............79
THALOMID CAP 100MG ......................42
theophylline sol 80/15ml....................14
theophylline tab 100mg er .................14
THERANATAL TAB 27-1 ......................79
THIOGUANINE TAB 40MG ..................32
thioridazine tab 100mg ......................38
thioridazine tab 10mg........................38
thiothixene cap 10mg ........................39
thiothixene cap 1mg..........................39
THYROGEN INJ 1.1MG .......................58
THYROLAR-1 TAB 60MG .....................90
THYROLAR-1/2 TAB 30MG ..................90
THYROLAR-1/4 TAB 15MG ..................90
THYROLAR-2 TAB 120MG ...................90
THYROLAR-3 TAB 180MG ...................90
tiagabine tab 2mg .............................17
tiagabine tab 4mg .............................17
ticlopidine tab 250mg ........................66
TIKOSYN CAP 125MCG ......................12
TIKOSYN CAP 250MCG ......................12
TIKOSYN CAP 500MCG ......................12
tilia fe tab ........................................48
timolol gel sol 0.25% op ....................81
timolol gel sol 0.5% op ......................81
timolol mal sol 0.25% op ...................81
timolol mal sol 0.5% op .....................81
timolol mal tab 10mg ........................44
timolol mal tab 20mg ........................44
timolol mal tab 5mg ..........................44
tioconazole oin 6.5% vag ...................94
TIVICAY TAB 50MG ...........................40
tizanidine tab 2mg ............................80
tizanidine tab 4mg ............................80
tl icon cap ....................................... 68
tobra/dexame sus 0.3-0.1% .............. 83
TOBRADEX OIN 0.3-0.1% ................. 83
tobramycin neb 300/5ml ..................... 3
tobramycin sol 0.3% op .................... 82
TODAY SPONGE MIS ......................... 73
tolazamide tab 250mg ...................... 23
tolazamide tab 500mg ...................... 23
tolbutamide tab 500mg ..................... 23
tolcapone tab 100mg ........................ 35
tolmetin sod cap 400mg ...................... 4
tolmetin sod tab 200mg ...................... 4
tolmetin sod tab 600mg ...................... 4
tolnaftate aer 1% ............................. 54
tolnaftate cre 1% ........................ 54, 58
tolnaftate pow 1% ............................ 54
tolnaftate sol 1% ............................. 54
tolterodine tab 1mg .......................... 64
tolterodine tab 2mg .......................... 64
topiramate cap 15mg........................ 17
topiramate cap 25mg........................ 17
topiramate tab 100mg ...................... 17
topiramate tab 200mg ...................... 17
topiramate tab 25mg ........................ 17
topiramate tab 50mg ........................ 17
torsemide tab 100mg ....................... 59
torsemide tab 10mg ......................... 59
torsemide tab 20mg ......................... 59
torsemide tab 5mg ........................... 59
total fiber pow ................................. 70
TOVIAZ TAB 4MG ............................. 64
TOVIAZ TAB 8MG ............................. 64
TRACLEER TAB 125MG ...................... 46
TRACLEER TAB 62.5MG ..................... 46
TRADJENTA TAB 5MG ....................... 22
tramadol hcl tab 100mg er .................. 7
tramadol hcl tab 50mg ........................ 7
trandolapril tab 1mg ......................... 29
tranex acid inj 100mg/ml .................. 68
TRANSDERM-SC DIS 1.5MG............... 24
tranylcyprom tab 10mg ..................... 19
TRAVATAN Z DRO 0.004% ................ 83
travoprost dro 0.004% ..................... 83
129
trazodone tab 100mg ........................18
trazodone tab 150mg ........................18
trazodone tab 300mg ........................19
trazodone tab 50mg ..........................18
TRECATOR TAB 250MG ......................32
TRECATOR-SC TAB 250MG .................32
TRELSTAR DEP INJ 3.75MG ................33
TRELSTAR LA INJ 11.25MG ................33
TRELSTAR MIX INJ 22.5MG ................33
tretinoin cap 10mg ............................34
tretinoin cre 0.025% .........................53
tretinoin cre 0.05% ...........................53
tretinoin cre 0.1% .............................53
tretinoin gel 0.01% ...........................53
tretinoin gel 0.025% .........................53
triacting nt liq cold/cgh ......................51
triadvance tab ..................................79
triamcinolon cre 0.025% ....................57
triamcinolon cre 0.1% .......................57
triamcinolon cre 0.5% .......................57
triamcinolon lot 0.025% ....................57
triamcinolon lot 0.1% ........................57
triamcinolon oin 0.025% ....................57
triamcinolon oin 0.1% .......................57
triamcinolon oin 0.5% .......................57
triamcinolon pst 0.1% .......................77
triaminic syp cough ...........................51
triamt/hctz cap 37.5-25 .....................59
triamt/hctz tab 37.5-25 .....................59
triamt/hctz tab 75-50mg ...................59
triazolam tab 0.125mg ......................69
triazolam tab 0.25mg ........................69
tricon cap ........................................68
tri-estaryll tab ..................................48
trifluoperaz tab 10mg ........................38
trifluoperaz tab 1mg ..........................38
trifluridine sol 1% op .........................82
trihexyphen elx 0.4mg/ml ..................35
trihexyphen tab 2mg .........................35
trihexyphen tab 5mg .........................35
tri-legest tab fe ................................48
tri-linyah tab ....................................49
trimethoprim sol polymyxn ................82
trimethoprim tab 100mg ....................10
trimipramine cap 100mg ....................21
trimipramine cap 25mg ..................... 21
trimipramine cap 50mg ..................... 21
trinate tab ....................................... 79
trinessa tab ..................................... 49
triple antib oin ................................. 53
triple antib oin plus .......................... 53
tri-previfem tab ............................... 49
tri-sprintec tab ................................. 49
TRIUMEQ ........................................ 40
tri-vit/fe dro /fl 0.25 ......................... 78
tri-vit/fluo dro 0.25mg ...................... 77
tri-vit/fluo dro 0.5mg ........................ 77
tri-vitamin dro ................................. 78
trivora-28 tab .................................. 49
tropicamide sol 0.5% op ................... 82
tropicamide sol 1% op ...................... 82
trospium chl cap 60mg er .................. 64
trospium cl tab 20mg........................ 64
TRUE METRIX BLOOD GLUCOSE .... 58, 73
TRUERESULT KIT ............................. 73
TRUETEST TES ................................. 58
TRUVADA TAB 200-300 ..................... 40
TUDORZA PRES AER 400/ACT ............ 13
tussin dm liq 100-10/5 ..................... 52
tussin dm liq 10-200/5 ..................... 52
tussin dm syp 100-10/5 .................... 52
TYBOST TAB 150MG ......................... 40
TYKERB TAB 250MG ......................... 34
TYSABRI INJ 300/15ML ..................... 87
TYZEKA TAB 600MG ......................... 41
TYZINE PED DRO 0.05% ................... 81
TYZINE SOL 0.1% ............................ 81
U
ULESFIA LOT 5% ............................. 58
ULORIC TAB 40MG ........................... 65
ULORIC TAB 80MG ........................... 65
ultra tabs tab ................................... 79
unifed liq 30mg/5ml ......................... 81
UNIFIBER POW ................................ 70
unith direct tab 100mcg .................... 90
unith direct tab 25mcg ...................... 90
130
unith direct tab 50mcg ......................90
unithroid tab 100mcg ........................91
unithroid tab 25mcg ..........................91
ursodiol cap 300mg ...........................63
ursodiol tab 250mg ...........................63
ursodiol tab 500mg ...........................63
V
vacuant plus ene 20-283 ...................72
VAGIFEM TAB 10MCG ........................94
valacyclovir tab 1gm .........................41
valacyclovir tab 500mg ......................41
VALCYTE SOL 50MG/ML .....................40
valganciclovir hcl ..............................40
valproic acd cap 250mg .....................18
valproic acd sol 250/5ml ....................18
valsart/hctz tab 160-12.5mg ..............28
valsart/hctz tab 160-25mg .................28
valsart/hctz tab 320-12.5mg ..............28
valsart/hctz tab 320-25mg .................28
valsart/hctz tab 80-12.5mg ................28
valsartan tab 160mg .........................30
valsartan tab 320mg .........................30
valsartan tab 40mg ...........................29
valsartan tab 80mg ...........................29
vancomycin cap 125mg .....................10
vancomycin cap 250mg .....................10
veg fiber pow 63% ............................70
velivet pak .......................................49
VELTIN GEL......................................53
venlafaxine cap 150mg er ..................20
venlafaxine cap 37.5 er .....................20
venlafaxine cap 75mg er ....................20
venlafaxine tab 100mg ......................20
venlafaxine tab 25mg ........................20
venlafaxine tab 37.5mg .....................20
venlafaxine tab 50mg ....................... 20
venlafaxine tab 75mg ....................... 20
VENOGLOBUL-S INJ 10% .................. 84
VENTOLIN HFA AER .......................... 14
VERACOLATE TAB ............................ 71
verapamil cap 100mg er ................... 45
verapamil cap 360mg sr .................... 45
verapamil tab 120mg........................ 45
verapamil tab 120mg er .................... 45
verapamil tab 40mg ......................... 45
verapamil tab 80mg ......................... 45
VEREGEN OIN 15% .......................... 53
VESICARE TAB 10MG ........................ 64
VESICARE TAB 5MG.......................... 64
vestura tab 3-0.02mg ....................... 49
VEXOL SUS 1% OP ........................... 83
VICTOZA INJ 18MG/3ML ................... 22
VIEKIRA PAK TAB ............................. 68
VIGAMOX DRO 0.5% ........................ 82
VIIBRYD KIT .................................... 19
VIIBRYD TAB 10MG .......................... 19
VIIBRYD TAB 20MG .......................... 19
VIIBRYD TAB 40MG .......................... 19
VIMPAT SOL 10MG/ML ...................... 17
VIMPAT TAB 100MG.......................... 17
VIMPAT TAB 150MG.......................... 17
VIMPAT TAB 200MG.......................... 17
VIMPAT TAB 50MG ........................... 17
VINATE ONE TAB.............................. 79
viorele tab ....................................... 49
VIRACEPT TAB 250MG ...................... 40
VIRACEPT TAB 625MG ...................... 40
VIREAD TAB 150MG ......................... 40
VIREAD TAB 300MG ......................... 40
virt-vite tab plus .............................. 77
VISICOL TAB 1.5GM ......................... 71
vitamin b-12 sub 1000mcg ................ 67
vitamin b-12 sub 2500mcg ................ 67
vitamin b-12 sub 500mcg.................. 67
vitamin b12 tab 1000 cr .................... 67
vitamin b-12 tab 1000mcg ................ 67
131
vitamin b-12 tab 100mcg ...................67
vitamin b-12 tab 250mcg ...................67
vitamin b-12 tab 500mcg ...................67
vitamin b-6 tab 200mg cr ..................95
vitamin d cap 1000unit ......................95
vitamin d dro 400unit ........................95
vitamin d3 cap 10000unt ...................94
vitamin d3 cap 2000unit ....................94
vitamin d3 cap 50000unt ...................94
vitamin d3 cap 5000unit ....................94
vitamin d3 chw 1000unit ...................94
vitamin d3 chw 400unit .....................94
vitamin d3 dro 5000unit ....................95
vitamin d3 tab 1000unit ....................95
vitamin d-3 tab 2000unit ...................95
vitamin d3 tab 400unit ......................95
vitamin d-3 tab 5000unit ...................95
VITEKTA TAB 150MG .........................40
VOL-PLUS TAB ..................................79
VOL-TAB RX TAB ..............................79
VOLTAREN GEL 1% ...........................53
voriconazole inj 200mg ......................25
voriconazole tab 200mg .....................25
voriconazole tab 50mg ......................25
VOTRIENT TAB 200MG ......................34
vyfemla tab 0.4-35 ...........................49
VYVANSE CAP 20MG........................... 1
VYVANSE CAP 30MG........................... 1
VYVANSE CAP 40MG........................... 1
VYVANSE CAP 50MG........................... 1
VYVANSE CAP 60MG........................... 1
VYVANSE CAP 70MG........................... 1
W
wal-dryl alr tab 12.5mg .....................26
wal-dryl-d tab alrg/sin .......................52
wal-tap dm elx cold/cgh ....................52
wal-tap elx cld/alle ............................52
warfarin tab 10mg ............................15
warfarin tab 1mg ..............................14
warfarin tab 2.5mg ...........................14
warfarin tab 2mg ..............................15
warfarin tab 3mg ..............................15
warfarin tab 4mg ..............................15
warfarin tab 5mg ..............................15
warfarin tab 6mg ..............................15
warfarin tab 7.5mg ...........................15
wee care sus 15/1.25 ........................68
WELCHOL PAK 3.75GM ..................... 27
WELCHOL TAB 625MG ...................... 27
wera tab 0.5/35 ............................... 49
WESTHROID TAB 130MG ................... 91
WESTHROID TAB 16.25MG ................ 91
WESTHROID TAB 195MG ................... 91
WESTHROID TAB 32.5MG .................. 91
WESTHROID TAB 48.75MG ................ 91
WESTHROID TAB 65MG .................... 91
WESTHROID TAB 97.5MG .................. 91
WESTHROID-P TAB 130MG ................ 91
WESTHROID-P TAB 16.25MG ............. 91
WESTHROID-P TAB 32.5MG ............... 91
WESTHROID-P TAB 48.75MG ............. 91
WESTHROID-P TAB 65MG ................. 91
WESTHROID-P TAB 97.5MG ............... 91
WIDE-SEAL DPR KIT 60 .................... 73
WIDE-SEAL DPR KIT 65 .................... 73
WIDE-SEAL DPR KIT 70 .................... 73
WIDE-SEAL DPR KIT 75 .................... 73
WIDE-SEAL DPR KIT 80 .................... 73
WIDE-SEAL DPR KIT 85 .................... 73
WIDE-SEAL DPR KIT 90 .................... 73
WIDE-SEAL DPR KIT 95 .................... 73
WP THYROID TAB 130MG .................. 91
WP THYROID TAB 16.25MG ............... 91
WP THYROID TAB 32.5MG ................. 91
WP THYROID TAB 48.75MG ............... 91
WP THYROID TAB 65MG .................... 91
WP THYROID TAB 81.25MG ............... 91
WP THYROID TAB 97.5MG ................. 91
wymzya fe chw 0.4mg-35 ................. 49
X
XARELTO TAB 10MG ......................... 15
XARELTO TAB 15MG ......................... 15
XARELTO TAB 20MG ......................... 15
xenazine tab 12.5mg ........................ 87
xenazine tab 25mg ........................... 87
XIFAXAN TAB 200MG ........................ 10
XIFAXAN TAB 550MG ........................ 10
XOLAIR SOL 150MG ......................... 12
xulane dis 150-35 ............................ 49
XYREM SOL 500MG/ML ..................... 86
Z
zafirlukast tab 10mg ......................... 13
zafirlukast tab 20mg ......................... 13
zaleplon cap 10mg ........................... 69
132
zaleplon cap 5mg ..............................69
zarah tab 3-0.03mg ..........................49
zemplar inj 2mcg/ml .........................61
zenatane cap 10mg ...........................53
zenatane cap 20mg ...........................53
zenatane cap 40mg ...........................53
zenchent fe chw 0.4mg-35 .................49
zenchent tab ....................................49
ZENPEP CAP 10000UNT .....................59
ZENPEP CAP 15000UNT .....................59
ZENPEP CAP 20000UNT .....................59
ZENPEP CAP 25000UNT .....................59
ZENPEP CAP 3000UNIT ......................58
ZENPEP CAP 40000UNT .....................59
zenzedi tab 10mg .............................. 1
zenzedi tab 5mg ................................ 1
zeosa chw ........................................49
ZETIA TAB 10MG ..............................28
ZIAGEN SOL 20MG/ML ......................40
ZIANA GEL .......................................53
zidovudine cap 100mg .......................40
zidovudine syp 50mg/5ml ..................40
zidovudine tab 300mg .......................40
zinc sulfate cap 220mg ......................76
ZINC-OXYDE OIN 0.44-20% ...............57
ZIOPTAN DRO 0.0015% .................... 83
ziprasidone cap 20mg ....................... 36
ZIRGAN GEL 0.15% .......................... 82
ZOLADEX IMP 10.8MG ...................... 33
ZOLADEX IMP 3.6MG ........................ 33
zolmitriptan tab 2.5 mg .................... 74
zolmitriptan tab 2.5mg ..................... 74
zolmitriptan tab 5mg ........................ 74
zolpidem tab 10mg ........................... 69
zolpidem tab 5mg ............................ 69
ZOMIG NASAL SPR 5MG .................... 74
zonisamide cap 100mg ..................... 17
zonisamide cap 25mg ....................... 17
zonisamide cap 50mg ....................... 17
ZORTRESS TAB 0.25MG .................... 42
ZORTRESS TAB 0.5MG ...................... 42
ZORTRESS TAB 0.75MG .................... 42
zovia 1/35e tab ................................ 49
zovia 1/50e tab ................................ 49
ZOVIRAX CRE 5% ............................ 55
ZYFLO CR TAB 600MG ...................... 13
133

Molina Washington Marketplace 1/1/16

Transcription

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