Standard Drug Formulary - Blue Cross and Blue Shield of Illinois

Transcription

October 2014
Standard Drug Formulary
Click to search for a drug name in this document
Contents
Introduction .................................................................... I Therapeutic Class Drug List ........................................ 1
How formulary drugs are selected ................................... I Anti-Infective Drugs ........................................................ 1
How member payment is determined .............................. I Cancer Drugs .................................................................. 6
How to use this list ........................................................... I Hormones, Diabetes and Related Drugs ........................ 8
Generic drugs ................................................................. II Heart and Circulatory Drugs ......................................... 14
Coverage considerations ............................................... III Respiratory Agents ....................................................... 21
Specialty drugs .............................................................. IV Gastrointestinal Drugs .................................................. 23
Abbreviation/acronym key .............................................. V Genitourinary Drugs ...................................................... 26
Central Nervous System Drugs .................................... 27
Pain Relief Drugs .......................................................... 33
Neuromuscular Drugs ................................................... 37
Supplements ................................................................. 40
Blood Modifying Drugs .................................................. 41
Topical Drugs ................................................................ 45
Miscellaneous Categories (includes Supplies
and Devices) ............................................................... 50
Index............................................................................. 52
Please consider talking to your doctor about prescribing formulary medications, which may help reduce your
out-of-pocket costs. This list may help guide you and your doctor in selecting an appropriate medication for you.
The drug formulary is regularly updated. Please visit bcbsil.com for the most up-to-date information.
To search for a drug name within this PDF document, use the Control and F keys on your keyboard, or go to
Edit in the drop-down menu and select Find/Search. Type in the word or phrase you are looking for and click
on Search.
2656-A IL © Prime Therapeutics LLC 10/14
Introduction
Blue Cross and Blue Shield of Illinois (BCBSIL) is pleased to present the 2014 Drug Formulary. This is a list of
formulary drugs which includes Formulary Brand drugs and a partial listing of generic drugs. Members are
encouraged to show this list to their physicians and pharmacists. Physicians are encouraged to prescribe
drugs on this list, when right for the member. However, decisions regarding therapy and treatment are
always between members and their physician.
Drug formulary updates – This list is regularly updated as generic drugs become available and changes take
place in the pharmaceuticals market. For the most up-to-date information, visit bcbsil.com and log in to
Blue Access for MembersSM or call the number on the back of your ID card. Physicians can access the list from
the provider portal at bcbsil.com.
How formulary drugs are selected
Drugs on this list are selected based on the recommendations of a committee made up of physicians and
pharmacists from throughout the country. The committee, which includes at least one representative from BCBSIL,
reviews drugs regulated by the U.S. Food and Drug Administration (FDA).
Both drugs that are newly approved by the FDA as well as those that have been on the market for some time are
considered. Drugs are selected based on safety, efficacy, cost and how they compare to other drugs currently on
the list.
How member payment is determined
This list shows prescription drug products in tiers. Generally, each drug is placed into one of three or four member
payment tiers: generic, Formulary Brand or Non-Formulary Brand (not listed in this document). Specialty drugs
can either be within the previous three tiers or can be a separate fourth tier depending on your benefit design. To
verify your payment amount for a drug, visit bcbsil.com and log in to Blue Access for Members or call the number
on the back of your ID card.
Your pharmacy benefit includes coverage for many prescription drugs, although some exclusions may apply. For
example, drugs indicated for cosmetic purposes, e.g., Propecia, for hair growth, may not be covered. Prescription
products that have over-the-counter (OTC) equivalents may not be covered. Drugs that are not FDA-approved for
self-administration may be available through your medical benefit.
How to use this list
Generic drugs are shown in lower-case boldface type. Most generic drugs are followed by a reference
brand drug in (parentheses). The reference brand drug is a non-formulary (NF) brand and is only included as
a reference to the brand. Some generic products have no reference brand.
Example: atorvastatin (Lipitor)
Formulary brand drugs are listed in all CAPITAL letters.
Example: PROAIR HFA
Drugs used to treat multiple conditions
Some drugs in the same dosage form may be used to treat more than one medical condition. In these instances,
each medication is classified according to its first FDA-approved use. Please check the index if you do not find
your particular medication in the class/condition section that corresponds to your use.
I
Blue Cross and Blue Shield of Illinois October 2014 Standard Drug Formulary
Generic drugs
Using generic drugs, when right for you, can help you save on your out-of-pocket medication costs. Generic drugs
must be approved by the FDA just as brand drugs are, and must meet the same standards.
There are two types of generic drugs:

A generic equivalent is made with the same active ingredient(s) at the same dosage as the reference drug.

A generic alternative is a drug typically used to treat the same condition, but the active ingredient(s)
differs from the brand drug.
According to the FDA, compared to its brand counterpart, an FDA-approved generic drug:

Is chemically the same

Works just as well in the body

Is as safe and effective

Meets the same standards set by the FDA
The main difference between the reference brand drug and the generic equivalent is that the generic often costs
much less.
Formulary brand drugs typically move to a non-formulary brand tier after a generic equivalent becomes available.
You may be responsible for the non-formulary brand member payment amount plus the difference in cost
between the brand and generic equivalent if you or your doctor requests the reference brand rather than the
generic. Generic drugs have the lowest member payment amount.
Consider talking to your doctor about generic drugs
If your doctor writes a prescription for a brand drug that does not have a generic equivalent, consider asking if an
appropriate generic alternative is available.
You can also let your pharmacist know that you would like a generic equivalent for a brand drug, whenever one is
available. Your pharmacist can usually substitute a generic equivalent for its brand counterpart without a new
prescription from your doctor.
Only your doctor can determine whether a generic alternative is right for you and must prescribe the medication.
II
Coverage considerations
Most prescription drug benefit plans provide coverage for up to a 30-day supply of medication, with some
exceptions. Your plan may also provide coverage for up to a 90-day supply of maintenance medications.
Maintenance medications are those drugs you may take on an ongoing basis for conditions such as high blood
pressure, diabetes or high cholesterol. Some plans may exclude coverage for certain agents or drug categories,
like those used for erectile dysfunction or weight loss.
Over-the-counter exclusions: Your benefit plan may not provide coverage for prescription medications that
have an over-the-counter version. You should refer to your benefit plan material for details about your particular
benefits.
Compounded medications: Your benefit plan may not provide coverage for compounded medications. Please
see your plan materials or call the number on the back of your ID card to determine whether compounded
medications are covered and/or verify your payment amount.
Repackaged medications: Repackaged versions of medications already available on the market are not covered.
Prior Authorization (PA): Your benefit plan may require prior authorization for certain drugs. This means that
your doctor will need to submit a prior authorization request for coverage of these medications, and the request
will need to be approved, before the medication will be covered under your plan. For the formulary medications
listed in this document, if a prior authorization is commonly required, it will generally be noted next to the
medication with a dot under the prior authorization column. Some plans may have prior authorization on additional
medications beyond those noted in this document. Refer to your benefit plan materials for details about your
particular benefits.
Step Therapy (ST): Your benefit plan may include a step therapy program. This means you may need to try
another proven, cost-effective medication before coverage may be available for the drug included in the program.
Many brand drugs have less-expensive generic or brand alternatives that might be an option for you. For the
formulary medications listed in this document, if a step therapy is commonly required, it will generally be noted
next to the medication with a dot under the step therapy column. Some plans may have step therapy programs on
additional medications beyond those noted in this document. Refer to your benefit plan materials for details about
your particular benefits.
Dispensing Limits (DL): Drug Dispensing limits help encourage medication use as intended by the FDA.
Dispensing limits are placed on medications in certain drug categories. For the formulary medications listed in this
document, if a dispensing limit applies, it will generally be noted next to the medication with a dot under the
dispensing limits column. Limits may include: quantity of covered medication per prescription, quantity of covered
medication in a given time period, coverage only for members within a certain age range, and coverage only for
members of a specific gender. If your doctor prescribes a greater quantity of medication than what the dispensing
limit allows, you can still get the medication. However, you will be responsible for the full cost of the prescription
beyond what your coverage allows. For a list of medications and their dispensing limits, visit bcbsil.com.
Remember, medication decisions are between you and your doctor. Only you and your doctor can determine
which medication is right for you. Discuss any questions or concerns you have about medications you are taking
or are prescribed with your doctor. BCBSIL does not provide health care services and, therefore, cannot
guarantee any results or outcomes.
III
Specialty drugs
Specialty drugs are used in the treatment of medical conditions such as hepatitis, hemophilia, multiple sclerosis
and rheumatoid arthritis. Specialty drugs may be oral, topical or injectable medications that can either be
self-administered or administered by a health care professional. For a current list of specialty medications,
visit myprime.com or bcbsil.com and log in to Blue Access for Members.
Note that some drug classes may be excluded by some plans and therefore may not be covered under your
pharmacy benefit. Your plan may have a different coverage level for self-administered specialty drugs. If you
have questions about your coverage for specialty medications or your prescription drug benefit, call the
number on the back of your ID card.
Prime Therapeutics Specialty Pharmacy Program
Through Prime Therapeutics Specialty Pharmacy, members can have covered specialty medications delivered
directly to them or their doctor’s office. When you receive specialty medications through Prime, you also receive at
no additional charge the following services:

Coordination of coverage between you, your doctor and your health plan

Educational materials about your particular condition and information about managing potential
medication side effects

Syringes, sharps containers and other supplies with every shipment for self-injectables

24/7/365 phone access to a pharmacist for urgent medication issues
To order through Prime Therapeutics Specialty Pharmacy:

Have your doctor call or fax your prescription to Prime Therapeutics Specialty Pharmacy. Your doctor can
call 877-627-6337 or fax to 877-828-3939.

If you have an existing prescription for a covered specialty medication, you can call 877-627-6337 to
transfer your prescription.

A Prime Therapeutics coordinator will contact you to arrange delivery of your medication.

The prescription can be shipped directly to you or your prescribing doctor’s office. Each package is
individually marked for each member. Refrigerated drugs are shipped in temperature-controlled
packaging.
If you have questions, please contact Prime Therapeutics Specialty Pharmacy at 877-627-6337,
visit www.PrimeTherapeutics.com/specialty, or call the number on the back of your ID card.
* Blue Cross and Blue Shield of Illinois (BCBSIL) is a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent
Licensee of the Blue Cross and Blue Shield Association. BCBSIL contracts with Prime Therapeutics to provide pharmacy benefit management, home
delivery pharmacy and specialty pharmacy services. BCBSIL, as well as several other independent Blue Cross and Blue Shield Plans, has an
ownership interest in Prime Therapeutics LLC.
IV
Abbreviation/acronym key
caps .................................................................... capsules odt ......................................... orally disintegrating tablets
chew .................................................................. chewable oint ..................................................................... ointment
conc .............................................................. concentrate ophth ............................................................... ophthalmic
cr .......................................................... controlled release osm.......................................................... osmotic release
dr ............................................................. delayed release powd..................................................................... powder
ec ................................................................enteric coated sa ............................................................ sustained action
effe................................................................. effervescent sl ...................................................................... sublingual
equiv ................................................................ equivalent soln ....................................................................... solution
er ...........................................................extended release sr .......................................................... sustained release
inhal................................................................... inhalation suppos ........................................................ suppositories
inj ......................................................................... injection susp................................................................ suspension
liq .............................................................................. liquid tab...........................................................................tablets
lotn ........................................................................... lotion td ................................................................... transdermal
nebu ................................................................... nebulizer
V
ANTI-INFECTIVE AGENTS
PENICILLINS
amoxicillin (trihydrate) cap 250 mg
amoxicillin (trihydrate) cap 500 mg
amoxicillin (trihydrate) for susp
125 mg/5ml
penicillin v potassium tab 250 mg
penicillin v potassium tab 500 mg
250 mg/5ml
cefaclor cap 500 mg
400 mg/5ml
cefadroxil for susp 250 mg/5ml
amoxicillin & k clavulanate chew tab
200-28.5 mg
amoxicillin & k clavulanate chew tab
400-57 mg
amoxicillin & k clavulanate for susp
200-28.5 mg/5ml
250-62.5 mg/5ml (Augmentin)
Step Therapy
penicillin v potassium for soln
250 mg/5ml
CEPHALOSPORINS
amoxicillin (trihydrate) tab 875 mg
Dispensing Limits
penicillin v potassium for soln
125 mg/5ml
200 mg/5ml
amoxicillin (trihydrate) tab 500 mg
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
2014
cefaclor cap 250 mg
cefadroxil cap 500 mg
cefadroxil for susp 500 mg/5ml
cefadroxil tab 1 gm
cefdinir cap 300 mg
cefdinir for susp 125 mg/5ml
cefdinir for susp 250 mg/5ml
cefpodoxime proxetil for susp
100 mg/5ml
cefpodoxime proxetil for susp
50 mg/5ml
cefpodoxime proxetil tab 100 mg
400-57 mg/5ml
cefpodoxime proxetil tab 200 mg
600-42.9 mg/5ml (Augmentin es-600)
cefprozil for susp 250 mg/5ml
amoxicillin & k clavulanate tab sr
12hr 1000-62.5 mg (Augmentin xr)
cefprozil tab 500 mg
cefprozil for susp 125 mg/5ml
cefprozil tab 250 mg
amoxicillin & k clavulanate tab
250-125 mg
ceftriaxone sodium for inj 1 gm
(Rocephin)
500-125 mg (Augmentin)
ceftriaxone sodium for inj 2 gm
875-125 mg (Augmentin)
ceftriaxone sodium for inj 500 mg
(Rocephin)
ampicillin cap 250 mg
ampicillin cap 500 mg
cefuroxime axetil for susp
125 mg/5ml (Ceftin)
dicloxacillin sodium cap 250 mg
cefuroxime axetil tab 250 mg (Ceftin)
dicloxacillin sodium cap 500 mg
cefuroxime axetil tab 500 mg (Ceftin)
ceftriaxone sodium for inj 250 mg
cephalexin cap 250 mg (Keflex)
1
cephalexin cap 500 mg (Keflex)
doxycycline monohydrate cap 50 mg
cephalexin for susp 125 mg/5ml
doxycycline monohydrate cap 75 mg
(Monodox)
cephalexin for susp 250 mg/5ml
MACROLIDES
doxycycline monohydrate tab 50 mg
(Adoxa)
azithromycin for susp 100 mg/5ml
(Zithromax)
doxycycline monohydrate tab 75 mg
(Adoxa)
azithromycin for susp 200 mg/5ml
(Zithromax)
azithromycin tab 600 mg (Zithromax)
•
•
•
clarithromycin for susp 125 mg/5ml
clarithromycin tab 250 mg (Biaxin)
clarithromycin tab 500 mg (Biaxin)
minocycline hcl cap 100 mg (Minocin)
minocycline hcl tab 100 mg
clarithromycin for susp 250 mg/5ml
(Biaxin)
clarithromycin tab sr 24hr 500 mg
(Biaxin xl pac)
•
FLUOROQUINOLONES
ciprofloxacin for oral susp
250 mg/5ml (5%) (5 gm/100ml)
(Cipro)
erythromycin w/ delayed release
particles cap 250 mg
ciprofloxacin for oral susp
500 mg/5ml (10%) (10 gm/100ml)
(Cipro)
ZITHROMAX – Azithromycin powd
pack for susp 1 gm
ciprofloxacin hcl tab 100 mg (base
equiv)
TETRACYCLINES
equiv) (Cipro)
demeclocycline hcl tab 150 mg
demeclocycline hcl tab 300 mg
doxycycline hyclate cap 100 mg
(Vibramycin)
doxycycline hyclate cap 50 mg
doxycycline hyclate tab 100 mg
doxycycline hyclate tab 20 mg
doxycycline monohydrate cap
100 mg (Monodox)
doxycycline monohydrate cap
150 mg (Adoxa)
2
Step Therapy
doxycycline monohydrate tab
150 mg (Adoxa pak 1/150)
AZITHROMYCIN – Azithromycin powd
pack for susp 1 gm
Dispensing Limits
doxycycline monohydrate tab
100 mg (Adoxa pak 1/100)
SUPRAX – Cefixime tab 400 mg
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
2014
equiv) (Cipro)
equiv)
ciprofloxacin-ciprofloxacin hcl tab sr
24hr 1000 mg(base eq) (Cipro xr)
ciprofloxacin-ciprofloxacin hcl tab sr
24hr 500 mg (base eq) (Cipro xr)
levofloxacin oral soln 25 mg/ml
(Levaquin)
levofloxacin tab 250 mg (Levaquin)
griseofulvin microsize tab 500 mg
(Grifulvin v)
ofloxacin tab 200 mg
itraconazole cap 100 mg (Sporanox)
NOXAFIL – Posaconazole susp 40 mg/
ml
paromomycin sulfate cap 250 mg
ethambutol hcl tab 100 mg
(Myambutol)
•
•
voriconazole for susp 40 mg/ml
(Vfend)
•
voriconazole tab 200 mg (Vfend)
•
•
voriconazole tab 50 mg (Vfend)
Cytomegalovirus
VALCYTE – Valganciclovir hcl tab 450
mg
isoniazid & rifampin cap 150-300 mg
VALCYTE – Valganciclovir hcl for soln
50 mg/ml (base equiv)
isoniazid tab 300 mg
Hepatitis
PRIFTIN – Rifapentine tab 150 mg
adefovir dipivoxil tab 10 mg
(Hepsera)
pyrazinamide tab 500 mg
BARACLUDE – Entecavir tab 0.5 mg
rifabutin cap 150 mg (Mycobutin)
BARACLUDE – Entecavir tab 1 mg
rifampin cap 150 mg (Rifadin)
rifampin cap 300 mg (Rifadin)
BARACLUDE – Entecavir oral soln 0.05
mg/ml
FUNGAL INFECTIONS
lamivudine tab 100 mg (Epivir hbv)
fluconazole for susp 10 mg/ml
(Diflucan)
OLYSIO – Simeprevir sodium cap 150
mg (base equivalent)
• •
fluconazole for susp 40 mg/ml
(Diflucan)
PEGASYS – Peginterferon alfa-2a inj
180 mcg/ml
• •
fluconazole tab 100 mg (Diflucan)
180 mcg/0.5ml
• •
kit 180 mcg/0.5ml
• •
PEGASYS PROCLICK – Peginterferon
alfa-2a inj 135 mcg/0.5ml
• •
PEGASYS PROCLICK – Peginterferon
alfa-2a inj 180 mcg/0.5ml
• •
ribavirin cap 200 mg (Rebetol)
•
flucytosine cap 250 mg (Ancobon)
flucytosine cap 500 mg (Ancobon)
griseofulvin microsize susp
125 mg/5ml
Step Therapy
VIRAL INFECTIONS
ethambutol hcl tab 400 mg
(Myambutol)
isoniazid tab 100 mg
Dispensing Limits
terbinafine hcl tab 250 mg (Lamisil)
neomycin sulfate tab 500 mg
TUBERCULOSIS
•
nystatin tab 500000 unit
AMINOGLYCOSIDES
tobramycin nebu soln 300 mg/5ml
(Tobi)
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
2014
3
ribavirin tab 200 mg (Copegus)
SOVALDI – Sofosbuvir tab 400 mg
•
• •
Herpes
acyclovir cap 200 mg (Zovirax)
•
EPZICOM – Abacavir sulfatelamivudine tab 600-300 mg
•
INTELENCE – Etravirine tab 25 mg
acyclovir tab 400 mg (Zovirax)
acyclovir tab 800 mg (Zovirax)
famciclovir tab 125 mg (Famvir)
INVIRASE – Saquinavir mesylate cap
200 mg
valacyclovir hcl tab 1 gm (Valtrex)
valacyclovir hcl tab 500 mg (Valtrex)
HIV/AIDS
•
•
•
•
•
•
INVIRASE – Saquinavir mesylate tab
500 mg
•
ISENTRESS – Raltegravir potassium
tab 400 mg (base equiv)
•
abacavir sulfate tab 300 mg (base
equiv) (Ziagen)
•
chew tab 25 mg (base equiv)
•
abacavir sulfate-lamivudinezidovudine tab 300-150-300 mg
(Trizivir)
•
chew tab 100 mg (base equiv)
•
•
APTIVUS – Tipranavir cap 250 mg
•
•
KALETRA – Lopinavir-ritonavir tab
100-25 mg
KALETRA – Lopinavir-ritonavir tab
200-50 mg
•
APTIVUS – Tipranavir oral soln 100
mg/ml
ATRIPLA – Efavirenz-emtricitabinetenofovir df tab 600-200-300 mg
•
KALETRA – Lopinavir-ritonavir soln
400-100 mg/5ml (80-20 mg/ml)
•
CRIXIVAN – Indinavir sulfate cap 200
mg
•
lamivudine tab 150 mg (Epivir)
CRIXIVAN – Indinavir sulfate cap 400
mg
•
lamivudine-zidovudine tab
150-300 mg (Combivir)
•
•
•
didanosine delayed release capsule
125 mg (Videx ec)
•
LEXIVA – Fosamprenavir calcium tab
700 mg (base equiv)
•
200 mg (Videx ec)
•
LEXIVA – Fosamprenavir calcium susp
•
250 mg (Videx ec)
•
nevirapine tab sr 24hr 400 mg
(Viramune xr)
•
400 mg (Videx ec)
•
nevirapine tab 200 mg (Viramune)
EMTRIVA – Emtricitabine caps 200 mg
•
•
•
•
•
•
EMTRIVA – Emtricitabine soln 10 mg/
ml
4
lamivudine tab 300 mg (Epivir)
NORVIR – Ritonavir cap 100 mg
NORVIR – Ritonavir tab 100 mg
NORVIR – Ritonavir oral soln 80 mg/ml
Step Therapy
Dispensing Limits
EPIVIR – Lamivudine oral soln 10 mg/
ml
FUZEON – Enfuvirtide for inj 90 mg
acyclovir susp 200 mg/5ml (Zovirax)
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
2014
PREZISTA – Darunavir ethanolate tab
75 mg (base equiv)
•
TIVICAY – Dolutegravir sodium tab 50
mg (base equiv)
•
150 mg (base equiv)
•
TRUVADA – Emtricitabine-tenofovir
disoproxil fumarate tab 200-300 mg
•
400 mg (base equiv)
•
VIDEX – Didanosine for soln 2 gm
600 mg (base equiv)
•
•
•
•
800 mg (base equiv)
•
PREZISTA – Darunavir ethanolate susp
•
RESCRIPTOR – Delavirdine mesylate
tab 100 mg
•
RESCRIPTOR – Delavirdine mesylate
tab 200 mg
•
REYATAZ – Atazanavir sulfate cap 100
mg (base equiv)
•
mg (base equiv)
•
mg (base equiv)
•
mg (base equiv)
•
SELZENTRY – Maraviroc tab 150 mg
•
•
•
•
•
•
•
SELZENTRY – Maraviroc tab 300 mg
stavudine cap 15 mg (Zerit)
stavudine for oral soln 1 mg/ml
(Zerit)
STRIBILD – Elvitegrav-cobicisemtricitab-tenofov tab
150-150-200-300 mg
•
SUSTIVA – Efavirenz cap 50 mg
•
•
•
SUSTIVA – Efavirenz cap 200 mg
SUSTIVA – Efavirenz tab 600 mg
VIDEX – Didanosine for soln 4 gm
VIRACEPT – Nelfinavir mesylate tab
250 mg
VIRACEPT – Nelfinavir mesylate tab
625 mg
•
VIRAMUNE – Nevirapine susp 50
mg/5ml
•
VIRAMUNE XR – Nevirapine tab sr
24hr 100 mg
•
VIREAD – Tenofovir disoproxil
fumarate tab 150 mg
•
fumarate tab 200 mg
•
fumarate tab 250 mg
•
fumarate tab 300 mg
•
fumarate oral powder 40 mg/gm
•
ZIAGEN – Abacavir sulfate soln 20 mg/
ml (base equiv)
•
zidovudine cap 100 mg (Retrovir)
•
•
•
zidovudine syrup 10 mg/ml (Retrovir)
zidovudine tab 300 mg
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
2014
MALARIA
atovaquone-proguanil hcl tab
250-100 mg (Malarone)
atovaquone-proguanil hcl tab
62.5-25 mg (Malarone)
chloroquine phosphate tab 250 mg
chloroquine phosphate tab 500 mg
(Aralen)
DARAPRIM – Pyrimethamine tab 25
mg
5
hydroxychloroquine sulfate tab
200 mg (Plaquenil)
AFINITOR – Everolimus tab 2.5 mg
mefloquine hcl tab 250 mg
AFINITOR – Everolimus tab 7.5 mg
PRIMAQUINE PHOSPHATE –
Primaquine phosphate tab 26.3 mg
AFINITOR – Everolimus tab 10 mg
AFINITOR – Everolimus tab 5 mg
•
•
•
•
ALKERAN – Melphalan tab 2 mg
WORM INFECTIONS
anastrozole tab 1 mg (Arimidex)
ALBENZA – Albendazole tab 200 mg
bicalutamide tab 50 mg (Casodex)
BILTRICIDE – Praziquantel tab 600 mg
capecitabine tab 150 mg (Xeloda)
STROMECTOL – Ivermectin tab 3 mg
capecitabine tab 500 mg (Xeloda)
OTHER ANTI-INFECTIVES
• •
• •
CEENU – Lomustine cap 10 mg
clindamycin hcl cap 150 mg (Cleocin)
CYCLOPHOSPHAMIDE –
Cyclophosphamide tab 25 mg
clindamycin palmitate hcl for soln
75 mg/5ml (base equiv) (Cleocin
pediatric gr)
CYCLOPHOSPHAMIDE –
Cyclophosphamide tab 50 mg
DAPSONE – Dapsone tab 25 mg
DAPSONE – Dapsone tab 100 mg
EMCYT – Estramustine phosphate
sodium cap 140 mg
erythromycin-sulfisoxazole for susp
200-600 mg/5ml
exemestane tab 25 mg (Aromasin)
metronidazole tab 250 mg (Flagyl)
FARESTON – Toremifene citrate tab 60
metronidazole tab 500 mg (Flagyl)
flutamide cap 125 mg
sulfamethoxazole-trimethoprim susp
200-40 mg/5ml
GLEEVEC – Imatinib mesylate tab 100
• •
sulfamethoxazole-trimethoprim tab
400-80 mg (Bactrim)
GLEEVEC – Imatinib mesylate tab 400
• •
sulfamethoxazole-trimethoprim tab
800-160 mg (Bactrim ds)
hydroxyurea cap 500 mg (Hydrea)
letrozole tab 2.5 mg (Femara)
trimethoprim tab 100 mg
LEUCOVORIN CALCIUM – Leucovorin
calcium tab 10 mg
vancomycin hcl cap 125 mg
(Vancocin hcl)
LEUCOVORIN CALCIUM – Leucovorin
calcium tab 15 mg
vancomycin hcl cap 250 mg
(Vancocin hcl)
XIFAXAN – Rifaximin tab 550 mg
ZYVOX – Linezolid tab 600 mg
ZYVOX – Linezolid for susp 100
mg/5ml
CANCER DRUGS
6
Step Therapy
•
•
•
•
Dispensing Limits
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
2014
•
•
•
leucovorin calcium tab 25 mg
leucovorin calcium tab 5 mg
LEUKERAN – Chlorambucil tab 2 mg
megestrol acetate susp 40 mg/ml
(Megace oral)
megestrol acetate tab 20 mg
megestrol acetate tab 40 mg
MEKINIST – Trametinib dimethyl
sulfoxide tab 0.5 mg (base
equivalent)
• •
MEKINIST – Trametinib dimethyl
sulfoxide tab 2 mg (base equivalent)
• •
SYLATRON – Peginterferon alfa-2b for
inj kit 4 x 444 mcg
• •
inj kit 4 x 888 mcg
• •
• •
mercaptopurine tab 50 mg
(Purinethol)
TAFINLAR – Dabrafenib mesylate cap
75 mg (base equivalent)
• •
MESNEX – Mesna tab 400 mg
tamoxifen citrate tab 10 mg (base
equivalent)
methotrexate sodium tab 2.5 mg
(base equiv)
tamoxifen citrate tab 20 mg (base
equivalent)
MYLERAN – Busulfan tab 2 mg
• •
SPRYCEL – Dasatinib tab 50 mg
SUTENT – Sunitinib malate cap 12.5
TARCEVA – Erlotinib tab 25 mg
NILANDRON – Nilutamide tab 150 mg
Step Therapy
TABLOID – Thioguanine tab 40 mg
TAFINLAR – Dabrafenib mesylate cap
50 mg (base equivalent)
NEXAVAR – Sorafenib tosylate tab 200
Dispensing Limits
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
2014
•
•
•
•
•
•
•
•
•
•
•
•
•
•
TASIGNA – Nilotinib cap 150 mg
TASIGNA – Nilotinib cap 200 mg
temozolomide cap 100 mg (Temodar)
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
SUTENT – Sunitinib malate cap 25 mg
(base equivalent)
• •
SUTENT – Sunitinib malate cap 37.5
• •
TREXALL – Methotrexate sodium tab 5
mg (base equiv)
SUTENT – Sunitinib malate cap 50 mg
(base equivalent)
• •
TREXALL – Methotrexate sodium tab
7.5 mg (base equiv)
inj kit 296 mcg
• •
10 mg (base equiv)
inj kit 444 mcg
• •
15 mg (base equiv)
inj kit 888 mcg
• •
VOTRIENT – Pazopanib hcl tab 200
mg (base equiv)
• •
inj kit 4 x 296 mcg
• •
XALKORI – Crizotinib cap 200 mg
• •
• •
tretinoin cap 10 mg
XALKORI – Crizotinib cap 250 mg
7
ZELBORAF – Vemurafenib tab 240 mg
(base equivalent)
• •
prednisolone syrup 15 mg/5ml (usp
solution equivalent) (Prelone)
ZYTIGA – Abiraterone acetate tab 250
mg
• •
PREDNISONE – Prednisone tab 50 mg
HORMONES, DIABETES AND RELATED DRUGS
CORTICOSTEROIDS
budesonide cap sr 24hr 3 mg
(Entocort ec)
prednisone tab 1 mg
DEXAMETHASONE – Dexamethasone
soln 0.5 mg/5ml
prednisone tab 2.5 mg
dexamethasone tab 0.75 mg
dexamethasone tab 4 mg
dexamethasone tab 6 mg
fludrocortisone acetate tab 0.1 mg
hydrocortisone tab 10 mg (Cortef)
methylprednisolone tab 16 mg
(Medrol)
(Medrol)
(Medrol)
methylprednisolone tab 4 mg dose
pack (Medrol dosepak)
(Medrol)
prednisolone sod phosph oral
soln 6.7 mg/5ml (5 mg/5ml base)
(Pediapred)
prednisolone sod phosphate oral
soln 15 mg/5ml (base equiv)
8
Step Therapy
PREDNISONE INTENSOL –
Prednisone conc 5 mg/ml
prednisone tab 10 mg
Dispensing Limits
PREDNISONE – Prednisone oral soln 5
mg/5ml
CORTISONE ACETATE – Cortisone
acetate tab 25 mg
dexamethasone elixir 0.5 mg/5ml
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
2014
prednisone tab 10 mg dose pack
prednisone tab 20 mg
prednisone tab 5 mg
prednisone tab 5 mg dose pack
MALE HORMONES
ANDRODERM – Testosterone td patch
24hr 2 mg/24hr
• •
ANDRODERM – Testosterone td patch
24hr 4 mg/24hr
• •
ANDROGEL – Testosterone td gel 25
mg/2.5gm (1%)
• •
ANDROGEL – Testosterone td gel 50
mg/5gm (1%)
• •
ANDROGEL – Testosterone td gel
20.25 mg/1.25gm (1.62%)
• •
ANDROGEL – Testosterone td gel 40.5
mg/2.5gm (1.62%)
• •
ANDROGEL PUMP – Testosterone td
gel 12.5 mg/act (1%)
• •
ANDROGEL PUMP – Testosterone td
gel 20.25 mg/act (1.62%)
• •
ANDROXY – Fluoxymesterone tab 10
mg
•
danazol cap 100 mg
•
•
•
• •
danazol cap 200 mg
danazol cap 50 mg
testosterone cypionate im in oil
100 mg/ml (Depo-testosterone)
testosterone cypionate im in oil
200 mg/ml (Depo-testosterone)
• •
estradiol td patch weekly
0.05 mg/24hr (Climara)
•
testosterone enanthate im in oil
200 mg/ml
• •
•
•
•
ESTROGENS
COMBIPATCH – Estradiolnorethindrone ace td pttw 0.05-0.14
mg/day
COMBIPATCH – Estradiolnorethindrone ace td pttw 0.05-0.25
mg/day
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
2014
estropipate tab 0.75 mg
estropipate tab 1.5 mg
norethindrone acetate-ethinyl
estradiol tab 1 mg-5 mcg
DIVIGEL – Estradiol td gel 0.25
mg/0.25gm (0.1%)
DIVIGEL – Estradiol td gel 0.5
mg/0.5gm (0.1%)
DIVIGEL – Estradiol td gel 1 mg/gm
(0.1%)
ENJUVIA – Estrogens, conjugated
synthetic b tab 0.3 mg
VIVELLE-DOT – Estradiol td patch
biweekly 0.025 mg/24hr
•
•
•
•
•
PROGESTINS
medroxyprogesterone acetate tab
10 mg (Provera)
2.5 mg (Provera)
estradiol & norethindrone acetate
tab 0.5-0.1 mg (Activella)
5 mg (Provera)
estradiol & norethindrone acetate
tab 1-0.5 mg (Activella)
norethindrone acetate tab 5 mg
(Aygestin)
estradiol tab 0.5 mg (Estrace)
progesterone micronized cap 100 mg
(Prometrium)
estradiol tab 1 mg (Estrace)
estradiol tab 2 mg (Estrace)
•
0.0375 mg/24hr (37.5 mcg/24hr)
(Climara)
•
progesterone micronized cap 200 mg
(Prometrium)
BIRTH CONTROL
ELLA – Ulipristal acetate tab 30 mg
levonorgestrel tab 0.75 mg (Plan b)
•
•
9
•
levonorgestrel tab 1.5 mg (Plan b
one-step)
medroxyprogesterone acetate im
susp 150 mg/ml (Depo-provera
contrac)
glipizide tab sr 24hr 5 mg (Glucotrol
xl)
NUVARING – Etonogestrel-ethinyl
estradiol va ring 0.120-0.015 mg/24hr
•
oral contraceptives– all generics
•
glipizide-metformin hcl tab
2.5-250 mg
•
glipizide-metformin hcl tab
2.5-500 mg
INFERTILITY
•
•
clomiphene citrate tab 50 mg
(Clomid)
glipizide tab 10 mg (Glucotrol)
glipizide tab 5 mg (Glucotrol)
glipizide-metformin hcl tab 5-500 mg
GLUCAGON EMERGENCY KIT –
Glucagon (rdna) for inj kit 1 mg
FOLLISTIM AQ – Follitropin beta inj 75
unit/0.5ml
•
•
FOLLISTIM AQ – Follitropin beta inj
150 unit/0.5ml
•
•
300 unit/0.36ml
•
•
600 unit/0.72ml
•
•
900 unit/1.08ml
•
•
glyburide tab 2.5 mg
GANIRELIX ACETATE – Ganirelix
acetate inj 250 mcg/0.5ml
•
•
glyburide-metformin tab 1.25-250 mg
(Glucovance)
REPRONEX – Menotropins for inj 75
unit
•
•
(Glucovance)
glyburide micronized tab 1.5 mg
(Glynase)
glyburide micronized tab 3 mg
(Glynase)
glyburide micronized tab 6 mg
(Glynase)
glyburide tab 1.25 mg
glyburide tab 5 mg
SYNAREL – Nafarelin acetate nasal
soln 2 mg/ml
glyburide-metformin tab 5-500 mg
(Glucovance)
DIABETES
INVOKANA – Canagliflozin tab 100 mg
acarbose tab 100 mg (Precose)
INVOKANA – Canagliflozin tab 300 mg
JANUMET – Sitagliptin-metformin hcl
tab 50-500 mg
glimepiride tab 1 mg (Amaryl)
10
Step Therapy
glipizide tab sr 24hr 2.5 mg (Glucotrol
xl)
•
Dispensing Limits
glipizide tab sr 24hr 10 mg (Glucotrol
xl)
norelgestromin-ethinyl estradiol td
ptwk 150-35 mcg/24hr (Ortho evra)
chorionic gonadotropin for inj 10000
unit
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
2014
•
•
•
JANUMET – Sitagliptin-metformin hcl
tab 50-1000 mg
•
JANUMET XR – Sitagliptin-metformin
hcl tab sr 24hr 50-500 mg
•
•
nateglinide tab 60 mg (Starlix)
ONGLYZA – Saxagliptin hcl tab 2.5 mg
(base equiv)
•
•
•
ONGLYZA – Saxagliptin hcl tab 5 mg
(base equiv)
•
JANUVIA – Sitagliptin phosphate tab 25
mg (base equiv)
JANUVIA – Sitagliptin phosphate tab 50
mg (base equiv)
•
pioglitazone hcl tab 15 mg (base
equiv) (Actos)
JANUVIA – Sitagliptin phosphate tab
100 mg (base equiv)
•
equiv) (Actos)
JUVISYNC – Sitagliptin-simvastatin tab
50-10 mg
•
equiv) (Actos)
50-20 mg
•
pioglitazone hcl-metformin hcl tab
15-500 mg (Actoplus met)
50-40 mg
•
pioglitazone hcl-metformin hcl tab
15-850 mg (Actoplus met)
100-10 mg
•
100-20 mg
•
100-40 mg
•
KOMBIGLYZE XR – Saxagliptinmetformin hcl tab sr 24hr 2.5-1000
mg
•
KOMBIGLYZE XR – Saxagliptinmetformin hcl tab sr 24hr 5-500 mg
•
KOMBIGLYZE XR – Saxagliptinmetformin hcl tab sr 24hr 5-1000 mg
•
repaglinide tab 0.5 mg (Prandin)
repaglinide tab 1 mg (Prandin)
repaglinide tab 2 mg (Prandin)
VICTOZA – Liraglutide soln pen-injector
18 mg/3ml (6 mg/ml)
• •
DIABETES - INSULINS
Rapid-Acting Insulins
HUMALOG – Insulin lispro (human)
soln cartridge 100 unit/ml
•
HUMALOG – Insulin lispro (human) inj
100 unit/ml
•
HUMALOG KWIKPEN – Insulin lispro
(human) soln pen-injector 100 unit/ml
•
metformin hcl tab sr 24hr 500 mg
(Glucophage xr)
NOVOLOG – Insulin aspart inj 100 unit/
ml
•
metformin hcl tab sr 24hr 750 mg
(Glucophage xr)
NOVOLOG FLEXPEN – Insulin aspart
soln pen-injector 100 unit/ml
•
metformin hcl tab 1000 mg
(Glucophage)
NOVOLOG PENFILL – Insulin aspart
soln cartridge 100 unit/ml
•
(Glucophage)
NOVOLOG PENFILL – Insulin aspart
inj 100 unit/ml
•
(Glucophage)
Short-Acting Insulins
nateglinide tab 120 mg (Starlix)
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
2014
HUMULIN R – Insulin regular (human)
inj 100 unit/ml
•
11
HUMULIN R U-500 (CONCENTR –
Insulin regular (human) inj 500 unit/ml
•
NOVOLIN R – Insulin regular (human)
inj 100 unit/ml
•
NOVOLIN R RELION – Insulin regular
(human) inj 100 unit/ml
•
•
NOVOLIN 70/30 RELION – Insulin
isophane & regular (human) inj 100
unit/ml (70-30)
•
•
•
HUMALOG MIX 50/50 – Insulin lispro
prot & lispro (human) inj 100 unit/ml
(50-50)
•
HUMALOG MIX 50/50 KWIKPEN –
Insulin lispro prot & lispro sus pen-inj
100 unit/ml (50-50)
•
NOVOLOG MIX 70/30 PREFILL –
Insulin aspart prot & aspart sus peninj 100 unit/ml (70-30)
HUMALOG MIX 75/25 – Insulin lispro
prot & lispro (human) inj 100 unit/ml
(75-25)
•
HUMALOG MIX 75/25 KWIKPEN –
Insulin lispro prot & lispro sus pen-inj
100 unit/ml (75-25)
•
HUMULIN N – Insulin isophane
Basal Insulins
LANTUS – Insulin glargine inj 100 unit/
ml
•
LANTUS SOLOSTAR – Insulin glargine
•
LEVEMIR – Insulin detemir inj 100 unit/
ml
•
•
LEVEMIR FLEXPEN – Insulin detemir
•
HUMULIN N KWIKPEN – Insulin
isophane (human) susp pen-injector
100 unit/ml
•
LEVEMIR FLEXTOUCH – Insulin
detemir soln pen-injector 100 unit/ml
•
HUMULIN N U-100 PEN – Insulin
isophane (human) susp pen-injector
100 unit/ml
•
HUMULIN 70/30 – Insulin isophane
& regular (human) inj 100 unit/ml
(70-30)
•
HUMULIN 70/30 KWIKPEN – Insulin
isophane & regular susp pen-inj 100
unit/ml (70-30)
•
HUMULIN 70/30 PEN – Insulin
isophane & regular susp pen-inj 100
unit/ml (70-30)
•
NOVOLIN N – Insulin isophane
•
levothyroxine sodium tab 175 mcg
(Synthroid)
NOVOLIN N RELION – Insulin
isophane (human) inj 100 unit/ml
•
(Synthroid)
12
Step Therapy
Dispensing Limits
NOVOLIN 70/30 – Insulin isophane
& regular (human) inj 100 unit/ml
(70-30)
NOVOLOG MIX 70/30 – Insulin aspart
prot & aspart (human) inj 100 unit/ml
(70-30)
Intermediate-Acting Insulins
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
2014
THYROID REGULATION
(Synthroid)
(Synthroid)
(Synthroid)
(Synthroid)
(Synthroid)
(Synthroid)
(Synthroid)
alendronate sodium tab 70 mg
(Fosamax)
(Synthroid)
cabergoline tab 0.5 mg
Step Therapy
calcitriol cap 0.25 mcg (Rocaltrol)
(Synthroid)
calcitriol cap 0.5 mcg (Rocaltrol)
calcitriol oral soln 1 mcg/ml
(Rocaltrol)
liothyronine sodium tab 25 mcg
(Cytomel)
desmopressin acetate inj 4 mcg/ml
(Ddavp)
(Cytomel)
desmopressin acetate nasal soln
0.01% (refrigerated) (Ddavp)
(Cytomel)
desmopressin acetate nasal spray
soln 0.01% (Ddavp)
methimazole tab 10 mg (Tapazole)
methimazole tab 5 mg (Tapazole)
desmopressin acetate nasal spray
soln 0.01% (refrigerated)
propylthiouracil tab 50 mg
GROWTH HORMONE
INCRELEX – Mecasermin inj 40
mg/4ml (10 mg/ml)
•
desmopressin acetate tab 0.1 mg
(Ddavp)
OMNITROPE – Somatropin inj 5
mg/1.5ml
• •
desmopressin acetate tab 0.2 mg
(Ddavp)
OMNITROPE – Somatropin inj 10
mg/1.5ml
• •
FORTEO – Teriparatide (recombinant)
inj 600 mcg/2.4ml
OMNITROPE – Somatropin for inj 5.8
mg
• •
ibandronate sodium tab 150 mg
(base equivalent) (Boniva)
• • •
•
levocarnitine oral soln 1 gm/10ml
(10%) (Carnitor)
OTHER HORMONES AND RELATED DRUGS
ACTONEL – Risedronate sodium tab 5
mg
•
levocarnitine tab 330 mg (Carnitor)
ACTONEL – Risedronate sodium tab
30 mg
•
methylergonovine maleate tab
0.2 mg
•
35 mg
•
octreotide acetate inj 100 mcg/ml
(0.1 mg/ml) (Sandostatin)
•
150 mg
•
(1 mg/ml) (Sandostatin)
•
•
•
•
•
•
Dispensing Limits
•
calcitonin (salmon) nasal soln 200
unit/act (Miacalcin)
(Synthroid)
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
2014
13
ORFADIN – Nitisinone cap 2 mg
•
•
•
enalapril maleate &
hydrochlorothiazide tab 5-12.5 mg
paricalcitol cap 2 mcg (Zemplar)
enalapril maleate tab 10 mg (Vasotec)
enalapril maleate tab 2.5 mg
(Vasotec)
raloxifene hcl tab 60 mg (Evista)
•
fosinopril sodium &
SENSIPAR – Cinacalcet hcl tab 60 mg
(base equiv)
fosinopril sodium &
(base equiv)
fosinopril sodium tab 10 mg
STIMATE – Desmopressin acetate
nasal soln 1.5 mg/ml
HEART AND CIRCULATORY DRUGS
ANGIOTENSIN CONVERTING ENZYME (ACE)
INHIBITORS AND COMBINATI
benazepril & hydrochlorothiazide tab
20-12.5 mg (Lotensin hct)
lisinopril & hydrochlorothiazide tab
10-12.5 mg (Zestoretic)
20-12.5 mg (Zestoretic)
20-25 mg (Zestoretic)
lisinopril tab 10 mg (Prinivil)
20-25 mg (Lotensin hct)
lisinopril tab 2.5 mg (Zestril)
5-6.25 mg
lisinopril tab 30 mg (Zestril)
benazepril hcl tab 10 mg (Lotensin)
moexipril hcl tab 15 mg (Univasc)
moexipril hcl tab 7.5 mg (Univasc)
benazepril hcl tab 5 mg
moexipril-hydrochlorothiazide tab
15-12.5 mg (Uniretic)
captopril tab 100 mg
captopril tab 12.5 mg
captopril tab 25 mg
captopril tab 50 mg
Step Therapy
(base equiv)
10-12.5 mg (Lotensin hct)
Dispensing Limits
enalapril maleate &
hydrochlorothiazide tab 10-25 mg
(Vaseretic)
risedronate sodium tab 150 mg
(Actonel)
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
2014
lisinopril tab 40 mg (Zestril)
15-25 mg
7.5-12.5 mg
perindopril erbumine tab 2 mg
14
(Aceon)
irbesartan tab 300 mg (Avapro)
(Aceon)
irbesartan-hydrochlorothiazide tab
150-12.5 mg (Avalide)
quinapril hcl tab 10 mg (Accupril)
irbesartan-hydrochlorothiazide tab
300-12.5 mg (Avalide)
quinapril-hydrochlorothiazide tab
10-12.5 mg (Accuretic)
20-12.5 mg (Accuretic)
20-25 mg (Accuretic)
ramipril cap 1.25 mg (Altace)
ramipril cap 10 mg (Altace)
ramipril cap 2.5 mg (Altace)
ramipril cap 5 mg (Altace)
trandolapril tab 1 mg (Mavik)
ANGIOTENSIN II RECEPTOR ANTAGONISTS (ARBS)
AND COMBINATIONS
BENICAR – Olmesartan medoxomil tab
5 mg
20 mg
40 mg
BENICAR HCT – Olmesartan
medoxomil-hydrochlorothiazide tab
20-12.5 mg
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
2014
losartan potassium &
hydrochlorothiazide tab
100-12.5 mg (Hyzaar)
(Hyzaar)
(Hyzaar)
losartan potassium tab 100 mg
(Cozaar)
(Cozaar)
(Cozaar)
valsartan tab 160 mg (Diovan)
valsartan-hydrochlorothiazide tab
160-12.5 mg (Diovan hct)
160-25 mg (Diovan hct)
320-25 mg (Diovan hct)
40-12.5 mg
40-25 mg
acebutolol hcl cap 200 mg (Sectral)
BETA BLOCKERS AND COMBINATIONS
acebutolol hcl cap 400 mg (Sectral)
15
atenolol & chlorthalidone tab
100-25 mg (Tenoretic 100)
metoprolol tartrate tab 100 mg
(Lopressor)
atenolol & chlorthalidone tab
50-25 mg (Tenoretic 50)
atenolol tab 100 mg (Tenormin)
(Lopressor)
nadolol tab 20 mg (Corgard)
bisoprolol & hydrochlorothiazide tab
10-6.25 mg (Ziac)
2.5-6.25 mg (Ziac)
pindolol tab 5 mg
5-6.25 mg (Ziac)
bisoprolol fumarate tab 10 mg
(Zebeta)
bisoprolol fumarate tab 5 mg
(Zebeta)
carvedilol tab 12.5 mg (Coreg)
carvedilol tab 25 mg (Coreg)
INNOPRAN XL – Propranolol hcl
sustained-release beads cap sr 24hr
80 mg
PROPRANOLOL HCL – Propranolol hcl
oral soln 40 mg/5ml
propranolol hcl cap sr 24hr 120 mg
(Inderal la)
(Inderal la)
(Inderal la)
(Inderal la)
propranolol hcl tab 10 mg
labetalol hcl tab 100 mg (Trandate)
TIMOLOL MALEATE – Timolol maleate
tab 5 mg
metoprolol succinate tab sr 24hr
200 mg (Toprol xl)
25 mg (Toprol xl)
50 mg (Toprol xl)
16
Step Therapy
PROPRANOLOL HCL – Propranolol hcl
oral soln 20 mg/5ml
100 mg (Toprol xl)
Dispensing Limits
pindolol tab 10 mg
INNOPRAN XL – Propranolol hcl
sustained-release beads cap sr 24hr
120 mg
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
2014
tab 10 mg
tab 20 mg
CALCIUM CHANNEL BLOCKERS AND
COMBINATIONS
amlodipine besylate tab 10 mg
(Norvasc)
amlodipine besylate tab 2.5 mg
(Norvasc)
amlodipine besylate tab 5 mg
(Norvasc)
amlodipine besylate-atorvastatin
calcium tab 10-10 mg (Caduet)
calcium tab 2.5-10 mg (Caduet)
diltiazem hcl coated beads cap sr
24hr 180 mg (Cardizem cd)
diltiazem hcl extended release beads
cap sr 24hr 120 mg (Tiazac)
diltiazem hcl tab 120 mg (Cardizem)
amlodipine besylate-benazepril hcl
cap 10-20 mg (Lotrel)
diltiazem hcl tab 90 mg
felodipine tab sr 24hr 10 mg
cap 2.5-10 mg (Lotrel)
felodipine tab sr 24hr 5 mg
diltiazem hcl cap sr 24hr 120 mg
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
2014
felodipine tab sr 24hr 2.5 mg
nifedipine tab sr 24hr osmotic 30 mg
(Procardia xl)
(Procardia xl)
(Procardia xl)
nifedipine tab sr 24hr 30 mg (Adalat
cc)
17
cc)
nitroglycerin td patch 24hr 0.4 mg/hr
(Nitro-dur)
cc)
(Nitro-dur)
verapamil hcl cap sr 24hr 120 mg
(Verelan)
NITROSTAT – Nitroglycerin sl tab 0.3
mg
(Verelan)
mg
(Verelan)
mg
(Verelan)
CHOLESTEROL LOWERING
verapamil hcl tab cr 120 mg (Calan
sr)
sr)
sr)
verapamil hcl tab 120 mg (Calan)
verapamil hcl tab 80 mg (Calan)
CHEST PAIN
isosorbide dinitrate tab 10 mg
atorvastatin calcium tab 40 mg (base
equivalent) (Lipitor)
cholestyramine light powder packets
4 gm
cholestyramine light powder 4 gm/
dose (Questran light)
isosorbide dinitrate tab 5 mg (Isordil
titradose)
cholestyramine powder 4 gm/dose
(Questran)
isosorbide mononitrate tab sr 24hr
120 mg (Imdur)
choline fenofibrate cap dr 135 mg
(fenofibric acid equiv) (Trilipix)
30 mg (Imdur)
choline fenofibrate cap dr 45 mg
(fenofibric acid equiv) (Trilipix)
60 mg (Imdur)
colestipol hcl granule packets 5 gm
(Colestid flavored)
isosorbide mononitrate tab 10 mg
colestipol hcl granules 5 gm (Colestid
flavored)
(Nitro-dur)
18
Step Therapy
cholestyramine powder packets
4 gm (Questran)
(Nitro-dur)
Dispensing Limits
isosorbide mononitrate tab 20 mg
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
2014
colestipol hcl tab 1 gm (Colestid)
CRESTOR – Rosuvastatin calcium tab
5 mg
10 mg
20 mg
WELCHOL – Colesevelam hcl packet
for susp 3.75 gm
40 mg
FLUID RETENTION
fenofibrate micronized cap 134 mg
(Lofibra)
(Lofibra)
amiloride hcl tab 5 mg
fenofibrate tab 48 mg (Tricor)
fenofibrate tab 54 mg (Lofibra)
gemfibrozil tab 600 mg (Lopid)
lovastatin tab 10 mg
lovastatin tab 20 mg (Mevacor)
lovastatin tab 40 mg (Mevacor)
niacin tab cr 1000 mg
(antihyperlipidemic) (Niaspan)
bumetanide tab 0.5 mg
bumetanide tab 1 mg
bumetanide tab 2 mg
chlorothiazide tab 250 mg
chlorothiazide tab 500 mg
furosemide oral soln 10 mg/ml
furosemide tab 20 mg (Lasix)
hydrochlorothiazide cap 12.5 mg
(Microzide)
hydrochlorothiazide tab 25 mg
hydrochlorothiazide tab 50 mg
pravastatin sodium tab 10 mg
indapamide tab 2.5 mg
(Pravachol)
methazolamide tab 25 mg
(Neptazane)
(Pravachol)
methazolamide tab 50 mg
(Neptazane)
(Pravachol)
metolazone tab 10 mg
simvastatin tab 10 mg (Zocor)
metolazone tab 5 mg (Zaroxolyn)
spironolactone &
(Aldactazide)
WELCHOL – Colesevelam hcl tab 625
mg
Step Therapy
acetazolamide tab 250 mg
amiloride & hydrochlorothiazide tab
5-50 mg
fenofibrate tab 160 mg (Lofibra)
Dispensing Limits
acetazolamide cap sr 12hr 500 mg
(Diamox)
(Lofibra)
fenofibrate tab 145 mg (Tricor)
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
2014
indapamide tab 1.25 mg
metolazone tab 2.5 mg (Zaroxolyn)
spironolactone tab 100 mg
(Aldactone)
spironolactone tab 25 mg (Aldactone)
19
spironolactone tab 50 mg (Aldactone)
propafenone hcl tab 300 mg
torsemide tab 10 mg (Demadex)
quinidine gluconate tab cr 324 mg
quinidine sulfate tab 200 mg
quinidine sulfate tab 300 mg
sotalol hcl (afib/afl) tab 120 mg
(Betapace af)
triamterene & hydrochlorothiazide
cap 37.5-25 mg (Dyazide)
tab 37.5-25 mg (Maxzide-25)
tab 75-50 mg (Maxzide)
sotalol hcl tab 120 mg (Betapace)
amiodarone hcl tab 100 mg
sotalol hcl tab 240 mg
(Cordarone)
ADCIRCA – Tadalafil tab 20 mg (pah)
disopyramide phosphate cap 100 mg
(Norpace)
clonidine hcl tab 0.1 mg (Catapres)
disopyramide phosphate cap 150 mg
(Norpace)
flecainide acetate tab 50 mg
mexiletine hcl cap 150 mg
MULTAQ – Dronedarone hcl tab 400
propafenone hcl cap sr 12hr 225 mg
(Rythmol sr)
(Rythmol sr)
(Rythmol sr)
(Rythmol)
(Rythmol)
20
Step Therapy
(Betapace af)
Dispensing Limits
(Betapace af)
HEART RHYTHM
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
2014
OTHER HEART RELATED DRUGS
• • •
clonidine hcl td patch weekly
0.1 mg/24hr (Catapres-tts-1)
DIBENZYLINE – Phenoxybenzamine
hcl cap 10 mg
digoxin tab 125 mcg (0.125 mg)
(Lanoxin)
digoxin tab 250 mcg (0.25 mg)
(Lanoxin)
doxazosin mesylate tab 1 mg
(Cardura)
(Cardura)
(Cardura)
(Cardura)
guanfacine hcl tab 2 mg (Tenex)
RESPIRATORY AGENTS
hydralazine hcl tab 10 mg
ANTIHISTAMINES
AEROHIST – Chlorpheniraminemethscopolamine tab sr 12hr 8-2.5
mg
• • •
• • •
cetirizine hcl oral soln 1 mg/ml
(5 mg/5ml)
methyldopa tab 250 mg
cyproheptadine hcl syrup 2 mg/5ml
methyldopa tab 500 mg
cyproheptadine hcl tab 4 mg
midodrine hcl tab 10 mg
promethazine hcl suppos 12.5 mg
midodrine hcl tab 2.5 mg
promethazine hcl suppos 25 mg
midodrine hcl tab 5 mg
promethazine hcl suppos 50 mg
minoxidil tab 10 mg
promethazine hcl syrup 6.25 mg/5ml
minoxidil tab 2.5 mg
promethazine hcl tab 12.5 mg
• • •
promethazine hcl tab 25 mg
prazosin hcl cap 1 mg (Minipress)
promethazine hcl tab 50 mg
NASAL PRODUCTS
ASTEPRO – Azelastine hcl nasal spray
0.15% (205.5 mcg/spray)
•
azelastine hcl nasal spray 0.15%
(205.5 mcg/spray) (Astepro)
•
azelastine hcl nasal spray 137 mcg/
spray (1 mg/ml)
•
flunisolide nasal soln 0.025%
(Flunisolide)
•
fluticasone propionate nasal susp
50 mcg/act (Flonase)
•
ipratropium bromide nasal soln
0.03% (21 mcg/spray) (Atrovent)
•
ipratropium bromide nasal soln
0.06% (42 mcg/spray) (Atrovent)
•
sildenafil citrate tab 20 mg (Revatio)
• • •
terazosin hcl cap 1 mg
TRACLEER – Bosentan tab 62.5 mg
TRACLEER – Bosentan tab 125 mg
• • •
• • •
ERECTILE DYSFUNCTION
CIALIS – Tadalafil tab 2.5 mg
CIALIS – Tadalafil tab 5 mg
Step Therapy
Dispensing Limits
Prior Authorization
EPIPEN-JR 2-PAK – Epinephrine
solution auto-injector 0.15 mg/0.3ml
(1:2000)
guanfacine hcl tab 1 mg (Tenex)
OPSUMIT – Macitentan tab 10 mg
Specialty
EPIPEN 2-PAK – Epinephrine solution
auto-injector 0.3 mg/0.3ml (1:1000)
eplerenone tab 50 mg (Inspra)
LETAIRIS – Ambrisentan tab 10 mg
Drug Name
BEE STING KITS
eplerenone tab 25 mg (Inspra)
LETAIRIS – Ambrisentan tab 5 mg
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
2014
•
•
•
•
•
•
•
•
21
NASONEX – Mometasone furoate
nasal susp 50 mcg/act
•
triamcinolone acetonide nasal inhal
55 mcg/act (Nasacort aq)
•
COUGH/COLD/ALLERGY
acetylcysteine inhal soln 10%
acetylcysteine inhal soln 20%
ASTHMA/COPD
ASMANEX 14 METERED DOSES –
Mometasone furoate inhal powd 220
mcg/inh (breath activated)
•
•
•
ADVAIR DISKUS – Fluticasonesalmeterol aer powder ba 100-50
mcg/dose
•
•
mcg/dose
•
•
mcg/dose
•
ATROVENT HFA – Ipratropium
bromide hfa inhal aerosol 17 mcg/act
•
•
BREO ELLIPTA – Fluticasone furoatevilanterol aero powd ba 100-25 mcg/
inh
•
ADVAIR HFA – Fluticasone-salmeterol
inhal aerosol 45-21 mcg/act
•
budesonide inhalation susp
0.25 mg/2ml (Pulmicort)
•
•
budesonide inhalation susp
0.5 mg/2ml (Pulmicort)
•
albuterol sulfate soln nebu 0.083%
(2.5 mg/3ml)
•
•
albuterol sulfate soln nebu 0.5%
(5 mg/ml)
•
COMBIVENT – Ipratropium-albuterol
aerosol 18-103 mcg/act (20-120mcg/
act)
•
albuterol sulfate soln nebu
0.63 mg/3ml (base equiv)
•
COMBIVENT RESPIMAT –
Ipratropium-albuterol inhal aerosol
soln 20-100 mcg/act
albuterol sulfate soln nebu
1.25 mg/3ml (base equiv)
•
cromolyn sodium soln nebu
20 mg/2ml
•
DULERA – Mometasone furoateformoterol fumarate aerosol 100-5
mcg/act
•
albuterol sulfate syrup 2 mg/5ml
albuterol sulfate tab 2 mg
•
DULERA – Mometasone furoateformoterol fumarate aerosol 200-5
mcg/act
•
ANORO ELLIPTA – Umeclidiniumvilanterol aero powd ba 62.5-25 mcg/
inh
FLOVENT DISKUS – Fluticasone
propionate aer pow ba 50 mcg/blister
•
•
albuterol sulfate tab 4 mg
22
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
2014
propionate aer pow ba 100 mcg/
blister
•
propionate aer pow ba 250 mcg/
blister
QVAR – Beclomethasone dipropionate
inhal aero soln 40 mcg/act
•
•
QVAR – Beclomethasone dipropionate
inhal aero soln 80 mcg/act
•
•
FLOVENT HFA – Fluticasone
propionate hfa inhal aero 44 mcg/act
(50/valve)
•
SPIRIVA HANDIHALER – Tiotropium
bromide monohydrate inhal cap 18
mcg (base equiv)
•
propionate hfa inhal aer 110 mcg/act
(125/valve)
•
SYMBICORT – Budesonide-formoterol
fumarate dihyd aerosol 80-4.5 mcg/
act
•
propionate hfa inhal aer 220 mcg/act
(250/valve)
•
SYMBICORT – Budesonide-formoterol
fumarate dihyd aerosol 160-4.5 mcg/
act
FORADIL AEROLIZER – Formoterol
fumarate inhal cap 12 mcg
•
terbutaline sulfate tab 5 mg
ipratropium bromide inhal soln
0.02%
•
theophylline tab sr 12hr 200 mg
ipratropium-albuterol nebu soln
0.5-2.5(3) mg/3ml (Duoneb)
•
levalbuterol hcl soln nebu conc
1.25 mg/0.5ml (base equiv)
(Xopenex concentrate)
•
levalbuterol hcl soln nebu
0.31 mg/3ml (base equiv) (Xopenex)
•
VENTOLIN HFA – Albuterol sulfate
inhal aero 108 mcg/act (90mcg base
equiv)
•
zafirlukast tab 10 mg (Accolate)
•
OTHER RESPIRATORY DRUGS
terbutaline sulfate tab 2.5 mg
•
zafirlukast tab 20 mg (Accolate)
KALYDECO – Ivacaftor tab 150 mg
montelukast sodium chew tab 4 mg
(base equiv) (Singulair)
PULMOZYME – Dornase alfa inhal soln
1 mg/ml
montelukast sodium chew tab 5 mg
(base equiv) (Singulair)
GASTROINTESTINAL DRUGS
• •
•
LAXATIVES
montelukast sodium oral granules
packet 4 mg (base equiv) (Singulair)
lactulose solution 10 gm/15ml
peg 3350-kcl-na bicarb-nacl-na
sulfate for soln 236 gm (Golytely)
montelukast sodium tab 10 mg (base
equiv) (Singulair)
PROAIR HFA – Albuterol sulfate inhal
aero 108 mcg/act (90mcg base equiv)
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
2014
•
peg 3350-kcl-na bicarb-nacl-na
sulfate for soln 240 gm (Colyteflavor packs)
23
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
2014
peg 3350-kcl-sod bicarb-nacl for soln
420 gm (Nulytely/flavor pack)
NEXIUM – Esomeprazole magnesium
for delayed release susp pack 2.5 mg
• •
ANTIDIARRHEALS
for delayed release susp packet 5 mg
• •
for delayed release susp packet 10
mg
• •
mg
• •
mg
• •
cap delayed release 20 mg
• •
cap delayed release 40 mg
• •
omeprazole cap delayed release
10 mg (Prilosec)
•
20 mg (Prilosec)
•
40 mg (Prilosec)
•
pantoprazole sodium ec tab 20 mg
(base equiv) (Protonix)
•
pantoprazole sodium ec tab 40 mg
(base equiv) (Protonix)
•
diphenoxylate w/ atropine tab
2.5-0.025 mg (Lomotil)
loperamide hcl cap 2 mg
ULCER/GERD
cimetidine hcl soln 300 mg/5ml
cimetidine tab 300 mg
dicyclomine hcl cap 10 mg (Bentyl)
dicyclomine hcl tab 20 mg (Bentyl)
famotidine tab 20 mg (Pepcid)
famotidine tab 40 mg (Pepcid)
glycopyrrolate tab 1 mg (Robinul)
glycopyrrolate tab 2 mg (Robinul
forte)
hyoscyamine sulfate elixir
0.125 mg/5ml
hyoscyamine sulfate soln 0.125 mg/
ml
hyoscyamine sulfate tab sl 0.125 mg
(Levsin/sl)
hyoscyamine sulfate tab sr 12hr
0.375 mg (Levbid)
ranitidine hcl cap 150 mg
ranitidine hcl cap 300 mg
hyoscyamine sulfate tab 0.125 mg
(Levsin)
lansoprazole cap delayed release
15 mg (Prevacid)
•
lansoprazole cap delayed release
30 mg (Prevacid)
•
methscopolamine bromide tab
2.5 mg (Pamine)
ranitidine hcl syrup 15 mg/ml
(75 mg/5ml)
ranitidine hcl tab 150 mg (Zantac)
ranitidine hcl tab 300 mg (Zantac)
sucralfate tab 1 gm (Carafate)
NAUSEA AND VOMITING
methscopolamine bromide tab 5 mg
(Pamine forte)
EMEND – Aprepitant capsule 40 mg
misoprostol tab 100 mcg (Cytotec)
•
•
•
misoprostol tab 200 mcg (Cytotec)
24
EMEND – Aprepitant capsule therapy
pack 80 & 125 mg
•
ZENPEP – Pancrelipase (lip-prot-amyl)
dr cap 20000-68000-109000 unit
granisetron hcl tab 1 mg
•
meclizine hcl tab 12.5 mg
dr cap 25000-85000-136000 unit
meclizine hcl tab 25 mg
OTHER GASTROINTESTINAL DRUGS
ondansetron hcl inj 4 mg/2ml (2 mg/
ml)
•
ASACOL – Mesalamine tab delayed
release 400 mg
ondansetron hcl inj 40 mg/20ml
(2 mg/ml) (Zofran)
•
ASACOL HD – Mesalamine tab
delayed release 800 mg
ondansetron hcl oral soln 4 mg/5ml
(Zofran)
•
balsalazide disodium cap 750 mg
(Colazal)
ondansetron hcl tab 24 mg
•
•
•
•
calcium acetate (phosphate binder)
cap 667 mg (169 mg ca) (Phoslo)
ondansetron hcl tab 4 mg (Zofran)
ondansetron hcl tab 8 mg (Zofran)
ondansetron orally disintegrating tab
4 mg (Zofran odt)
ondansetron orally disintegrating tab
8 mg (Zofran odt)
trimethobenzamide hcl cap 300 mg
(Tigan)
•
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
2014
calcium acetate (phosphate binder)
tab 667 mg (Eliphos)
CANASA – Mesalamine suppos 1000
mg
CHENODAL – Chenodiol tab 250 mg
•
DELZICOL – Mesalamine cap dr 400
mg
DIGESTIVE ENZYMES
lactulose (encephalopathy) solution
10 gm/15ml
CREON – Pancrelipase (lip-prot-amyl)
dr cap 3000-9500-15000 unit
LIALDA – Mesalamine tab delayed
release 1.2 gm
dr cap 6000-19000-30000 unit
LINZESS – Linaclotide cap 145 mcg
dr cap 12000-38000-60000 unit
mesalamine enema 4 gm
LINZESS – Linaclotide cap 290 mcg
dr cap 24000-76000-120000 unit
metoclopramide hcl soln 5 mg/5ml
(10 mg/10ml)
dr cap 36000-114000-180000 unit
metoclopramide hcl tab 10 mg
(Reglan)
dr cap 3000-10000-16000 unit
metoclopramide hcl tab 5 mg
(Reglan)
dr cap 5000-17000-27000 unit
PENTASA – Mesalamine cap cr 250
mg
dr cap 10000-34000-55000 unit
PENTASA – Mesalamine cap cr 500
mg
dr cap 15000-51000-82000 unit
RENVELA – Sevelamer carbonate tab
800 mg
25
RENVELA – Sevelamer carbonate
packet 0.8 gm
VESICARE – Solifenacin succinate tab
10 mg
RENVELA – Sevelamer carbonate
packet 2.4 gm
VAGINAL PRODUCTS
sulfasalazine tab delayed release
500 mg (Azulfidine en-tabs)
sulfasalazine tab 500 mg (Azulfidine)
ursodiol cap 300 mg (Actigall)
ursodiol tab 250 mg (Urso 250)
ursodiol tab 500 mg (Urso forte)
GENITOURINARY DRUGS
CRINONE – Progesterone vaginal gel
4%
•
CRINONE – Progesterone vaginal gel
8%
•
nitrofurantoin macrocrystalline cap
100 mg (Macrodantin)
metronidazole vaginal gel 0.75%
(Metrogel-vaginal)
nitrofurantoin macrocrystalline cap
50 mg (Macrodantin)
terconazole vaginal cream 0.4%
(Terazol 7)
nitrofurantoin monohydrate
macrocrystalline cap 100 mg
(Macrobid)
terconazole vaginal cream 0.8%
(Terazol 3)
oxybutynin chloride syrup 5 mg/5ml
oxybutynin chloride tab sr 24hr
10 mg (Ditropan xl)
oxybutynin chloride tab sr 24hr
15 mg (Ditropan xl)
oxybutynin chloride tab sr 24hr 5 mg
(Ditropan xl)
oxybutynin chloride tab 5 mg
tolterodine tartrate cap sr 24hr 2 mg
(Detrol la)
tolterodine tartrate cap sr 24hr 4 mg
(Detrol la)
tolterodine tartrate tab 1 mg (Detrol)
tolterodine tartrate tab 2 mg (Detrol)
VESICARE – Solifenacin succinate tab
5 mg
26
Step Therapy
clindamycin phosphate vaginal
cream 2% (Cleocin)
ESTRACE – Estradiol vaginal cream
0.1 mg/gm
URINARY TRACT SPASMS
Dispensing Limits
CLEOCIN – Clindamycin phosphate
vaginal suppos 100 mg
URINARY TRACT INFECTIONS
nitrofurantoin susp 25 mg/5ml
(Furadantin)
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
2014
terconazole vaginal suppos 80 mg
VAGIFEM – Estradiol vaginal tab 10
mcg
OTHER GENITOURINARY DRUGS
alfuzosin hcl tab sr 24hr 10 mg
(Uroxatral)
AVODART – Dutasteride cap 0.5 mg
CYSTAGON – Cysteamine bitartrate
cap 50 mg
•
CYSTAGON – Cysteamine bitartrate
cap 150 mg
•
finasteride tab 5 mg (Proscar)
POTASSIUM CITRATE – Potassium
citrate tab cr 5 meq (540 mg)
POTASSIUM CITRATE – Potassium
citrate tab cr 10 meq (1080 mg)
potassium citrate & citric acid
powder pack 3300-1002 mg
sodium citrate & citric acid soln
500-334 mg/5ml (Shohls solution
modi)
tamsulosin hcl cap 0.4 mg (Flomax)
amitriptyline hcl tab 10 mg
CENTRAL NERVOUS SYSTEM DRUGS
ANXIETY
alprazolam tab sr 24hr 0.5 mg (Xanax
xr)
alprazolam tab sr 24hr 1 mg (Xanax
xr)
xr)
xr)
alprazolam tab 0.25 mg (Xanax)
alprazolam tab 0.5 mg (Xanax)
alprazolam tab 1 mg (Xanax)
alprazolam tab 2 mg (Xanax)
bupropion hcl tab sr 12hr 150 mg
(Wellbutrin sr)
(Wellbutrin sr)
(Wellbutrin xl)
buspirone hcl tab 15 mg
bupropion hcl tab 100 mg (Wellbutrin)
bupropion hcl tab 75 mg (Wellbutrin)
citalopram hydrobromide oral soln
10 mg/5ml
diazepam tab 2 mg (Valium)
hydroxyzine hcl syrup 10 mg/5ml
hydroxyzine hcl tab 10 mg
hydroxyzine pamoate cap 25 mg
(Vistaril)
hydroxyzine pamoate cap 50 mg
(Vistaril)
lorazepam conc 2 mg/ml (Lorazepam
intensol)
lorazepam tab 0.5 mg (Ativan)
lorazepam tab 1 mg (Ativan)
lorazepam tab 2 mg (Ativan)
Step Therapy
(Wellbutrin sr)
Dispensing Limits
(Wellbutrin xl)
DIAZEPAM – Diazepam soln 1 mg/ml
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
2014
citalopram hydrobromide tab 10 mg
(base equiv) (Celexa)
clomipramine hcl cap 25 mg
(Anafranil)
(Anafranil)
(Anafranil)
desipramine hcl tab 10 mg
(Norpramin)
(Norpramin)
(Norpramin)
DEPRESSION
27
(Norpramin)
mirtazapine tab 15 mg (Remeron)
(Norpramin)
(Norpramin)
nortriptyline hcl cap 10 mg (Pamelor)
doxepin hcl cap 100 mg
paroxetine hcl tab sr 24hr 12.5 mg
(Paxil cr)
doxepin hcl conc 10 mg/ml
duloxetine hcl enteric coated pellets
cap 20 mg (Cymbalta)
•
paroxetine hcl tab sr 24hr 25 mg
(Paxil cr)
•
paroxetine hcl tab sr 24hr 37.5 mg
(Paxil cr)
•
paroxetine hcl tab 10 mg (Paxil)
escitalopram oxalate soln 5 mg/5ml
(base equiv) (Lexapro)
escitalopram oxalate tab 10 mg
phenelzine sulfate tab 15 mg (Nardil)
fluoxetine hcl cap 10 mg (Prozac)
sertraline hcl oral conc 20 mg/ml
(Zoloft)
sertraline hcl tab 100 mg (Zoloft)
tranylcypromine sulfate tab 10 mg
(Parnate)
trazodone hcl tab 100 mg
fluoxetine hcl solution 20 mg/5ml
fluoxetine hcl tab 10 mg
fluoxetine hcl tab 20 mg
fluvoxamine maleate tab 100 mg
venlafaxine hcl cap sr 24hr 150 mg
(base equivalent) (Effexor xr)
imipramine hcl tab 10 mg (Tofranil)
28
Step Therapy
mirtazapine tab 7.5 mg
escitalopram oxalate tab 5 mg (base
equiv) (Lexapro)
Dispensing Limits
escitalopram oxalate tab 20 mg
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
2014
venlafaxine hcl cap sr 24hr 37.5 mg
venlafaxine hcl cap sr 24hr 75 mg
venlafaxine hcl tab sr 24hr 150 mg
(base equivalent) (Venlafaxine hcl
er)
haloperidol tab 1 mg
venlafaxine hcl tab 100 mg
lithium carbonate cap 150 mg
(Lithium carbonate)
venlafaxine hcl tab 37.5 mg
(Lithium carbonate)
PSYCHOTIC AND BIPOLAR DISORDERS
lithium carbonate tab cr 300 mg
(Lithobid)
chlorpromazine hcl tab 10 mg
lithium carbonate tab cr 450 mg
lithium carbonate tab 300 mg
loxapine succinate cap 10 mg
(Loxitane)
•
•
•
•
olanzapine orally disintegrating tab
10 mg (Zyprexa zydis)
•
•
fluphenazine decanoate inj 25 mg/ml
FLUPHENAZINE HCL – Fluphenazine
hcl elixir 2.5 mg/5ml
•
FLUPHENAZINE HCL – Fluphenazine
hcl oral conc 5 mg/ml
•
fluphenazine hcl tab 1 mg
olanzapine tab 10 mg (Zyprexa)
fluphenazine hcl tab 2.5 mg
olanzapine tab 2.5 mg (Zyprexa)
haloperidol decanoate im soln
100 mg/ml (Haldol decanoate 100)
•
•
•
•
•
•
haloperidol decanoate im soln
50 mg/ml (Haldol decanoate 50)
perphenazine tab 16 mg
clozapine tab 25 mg (Clozaril)
clozapine tab 50 mg
Step Therapy
haloperidol tab 0.5 mg
venlafaxine hcl tab sr 24hr 75 mg
er)
clozapine tab 200 mg
Dispensing Limits
haloperidol lactate oral conc 2 mg/ml
venlafaxine hcl tab sr 24hr 37.5 mg
er)
clozapine tab 100 mg (Clozaril)
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
2014
olanzapine tab 7.5 mg (Zyprexa)
29
•
SEROQUEL XR – Quetiapine fumarate
tab sr 24hr 50 mg
prochlorperazine maleate tab 10 mg
(Compazine)
tab sr 24hr 150 mg
•
prochlorperazine maleate tab 5 mg
(Compazine)
tab sr 24hr 200 mg
•
prochlorperazine suppos 25 mg
tab sr 24hr 300 mg
•
tab sr 24hr 400 mg
•
quetiapine fumarate tab 100 mg
(Seroquel)
•
(Seroquel)
•
(Seroquel)
•
(Seroquel)
•
(Seroquel)
•
(Seroquel)
•
trifluoperazine hcl tab 2 mg
risperidone orally disintegrating tab
0.25 mg
•
ziprasidone hcl cap 20 mg (Geodon)
0.5 mg (Risperdal m-tab)
•
1 mg (Risperdal m-tab)
•
•
estazolam tab 1 mg
•
phenobarbital elixir 20 mg/5ml
•
risperidone soln 1 mg/ml (Risperdal)
•
•
•
•
•
•
•
risperidone tab 0.25 mg (Risperdal)
risperidone tab 0.5 mg (Risperdal)
risperidone tab 1 mg (Risperdal)
30
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
2014
thiothixene cap 1 mg
•
•
•
•
SLEEP AIDS
estazolam tab 2 mg
phenobarbital tab 16.2 mg
phenobarbital tab 32.4 mg
temazepam cap 15 mg (Restoril)
temazepam cap 22.5 mg (Restoril)
temazepam cap 30 mg (Restoril)
temazepam cap 7.5 mg (Restoril)
zaleplon cap 10 mg (Sonata)
zaleplon cap 5 mg (Sonata)
zolpidem tartrate tab cr 12.5 mg
(Ambien cr)
•
•
•
zolpidem tartrate tab cr 6.25 mg
(Ambien cr)
•
INTUNIV – Guanfacine hcl tab sr 24hr 1
mg (base equiv)
•
zolpidem tartrate tab 10 mg (Ambien)
•
•
mg (base equiv)
•
mg (base equiv)
•
mg (base equiv)
•
methylphenidate hcl tab cr 20 mg
(Ritalin sr)
•
methylphenidate hcl tab 10 mg
(Ritalin)
•
(Ritalin)
•
(Ritalin)
•
zolpidem tartrate tab 5 mg (Ambien)
HYPERACTIVITY/NARCOLEPSY
amphetamine-dextroamphetamine
cap sr 24hr 10 mg (Adderall xr)
•
•
•
•
•
•
tab 10 mg (Adderall)
•
modafinil tab 200 mg (Provigil)
•
tab 12.5 mg (Adderall)
•
VYVANSE – Lisdexamfetamine
dimesylate cap 20 mg
•
•
•
•
•
•
•
tab 5 mg (Adderall)
•
•
tab 7.5 mg (Adderall)
•
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
2014
•
•
modafinil tab 100 mg (Provigil)
MULTIPLE SCLEROSIS
caffeine citrate oral soln 60 mg/3ml
(10 mg/ml base equiv) (Cafcit)
BETASERON – Interferon beta-1b for
inj kit 0.3 mg
•
• •
dextroamphetamine sulfate cap sr
24hr 10 mg (Dexedrine)
•
COPAXONE – Glatiramer acetate soln
prefilled syringe 40 mg/ml
•
• •
•
COPAXONE – Glatiramer acetate inj kit
20 mg/ml
•
• •
•
REBIF – Interferon beta-1a inj 22
mcg/0.5ml (12mu/ml) (44 mcg/ml)
•
• •
dextroamphetamine sulfate tab 5 mg
•
31
REBIF – Interferon beta-1a inj 44
mcg/0.5ml (24mu/ml) (88 mcg/ml)
•
• •
donepezil hydrochloride orally
disintegrating tab 5 mg (Aricept odt)
REBIF REBIDOSE – Interferon beta-1a
inj 22 mcg/0.5ml (12mu/ml) (44 mcg/
ml)
•
• •
donepezil hydrochloride tab 10 mg
(Aricept)
REBIF REBIDOSE – Interferon beta-1a
inj 44 mcg/0.5ml (24mu/ml) (88 mcg/
ml)
•
• •
REBIF REBIDOSE TITRATION
– Interferon beta-1a inj 6 x 8.8
mcg/0.2ml & 6 x 22 mcg/0.5ml
•
• •
REBIF TITRATION PACK – Interferon
beta-1a inj 6 x 8.8 mcg/0.2ml & 6 x 22
mcg/0.5ml
•
• •
TECFIDERA – Dimethyl fumarate
capsule delayed release 120 mg
•
• •
TECFIDERA – Dimethyl fumarate
capsule delayed release 240 mg
•
• •
TECFIDERA STARTER PACK –
Dimethyl fumarate capsule dr starter
pack 120 mg & 240 mg
•
• •
OTHER CENTRAL NERVOUS SYSTEM DRUGS
acamprosate calcium tab delayed
release 333 mg (Campral)
bupropion hcl (smoking deterrent)
tab sr 12hr 150 mg (Zyban)
CHANTIX – Varenicline tartrate tab 0.5
mg (base equiv)
CHANTIX – Varenicline tartrate tab 1
mg (base equiv)
CHANTIX CONTINUING MONTH –
Varenicline tartrate tab 1 mg (base
equiv)
CHANTIX STARTING MONTH PA –
Varenicline tartrate tab 0.5 mg x 11 &
tab 1 mg x 42 pack
Step Therapy
Dispensing Limits
donepezil hydrochloride tab 5 mg
(Aricept)
EXELON – Rivastigmine td patch 24hr
4.6 mg/24hr
9.5 mg/24hr
13.3 mg/24hr
EXELON – Rivastigmine tartrate soln 2
mg/ml
galantamine hydrobromide cap sr
24hr 16 mg (Razadyne er)
galantamine hydrobromide oral soln
4 mg/ml (Razadyne)
galantamine hydrobromide tab
12 mg (Razadyne)
galantamine hydrobromide tab 4 mg
(Razadyne)
galantamine hydrobromide tab 8 mg
(Razadyne)
NICOTROL INHALER – Nicotine
inhaler system 10 mg (4 mg
delivered)
NICOTROL NS – Nicotine nasal spray
10 mg/ml (0.5 mg/spray)
NUEDEXTA – Dextromethorphan hbrquinidine sulfate cap 20-10 mg
disulfiram tab 250 mg (Antabuse)
ORAP – Pimozide tab 1 mg
disulfiram tab 500 mg (Antabuse)
ORAP – Pimozide tab 2 mg
donepezil hydrochloride orally
disintegrating tab 10 mg (Aricept
odt)
rivastigmine tartrate cap 1.5 mg
(Exelon)
32
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
2014
rivastigmine tartrate cap 3 mg
(Exelon)
buprenorphine hcl-naloxone hcl sl
tab 8-2 mg (base equiv)
rivastigmine tartrate cap 4.5 mg
(Exelon)
butalbital-aspirin-caff w/ codeine cap
50-325-40-30 mg (Fiorinal/codeine
#3)
rivastigmine tartrate cap 6 mg
(Exelon)
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
2014
• •
CODEINE SULFATE – Codeine sulfate
tab 15 mg
PAIN RELIEF DRUGS
NON-NARCOTIC DRUGS
butalbital-acetaminophen tab
50-325 mg
butalbital-acetaminophen tab
50-650 mg
butalbital-acetaminophen-caffeine
cap 50-325-40 mg
tab 50-325-40 mg
tab 50-500-40 mg
butalbital-aspirin-caffeine cap
50-325-40 mg (Fiorinal)
butalbital-aspirin-caffeine tab
50-325-40 mg
salsalate tab 500 mg
salsalate tab 750 mg
NARCOTIC DRUGS
acetaminophen w/ codeine soln
120-12 mg/5ml
acetaminophen w/ codeine tab
300-15 mg (Tylenol/codeine)
fentanyl citrate lollipop 1200 mcg
(Actiq)
• •
(Actiq)
• •
(Actiq)
• •
(Actiq)
• •
(Actiq)
• •
(Actiq)
• •
fentanyl td patch 72hr 100 mcg/hr
(Duragesic)
•
(Duragesic)
•
(Duragesic)
•
(Duragesic)
•
(Duragesic)
•
hydrocodone-acetaminophen cap
5-500 mg
300-30 mg (Tylenol/codeine #3)
hydrocodone-acetaminophen soln
7.5-325 mg/15ml (Hycet)
300-60 mg (Tylenol/codeine #4)
buprenorphine hcl sl tab 2 mg (base
equiv)
• •
hydrocodone-acetaminophen soln
7.5-500 mg/15ml
buprenorphine hcl sl tab 8 mg (base
equiv)
• •
hydrocodone-acetaminophen tab
10-325 mg (Norco)
buprenorphine hcl-naloxone hcl sl
tab 2-0.5 mg (base equiv)
• •
10-500 mg
33
10-650 mg
KADIAN – Morphine sulfate cap sr 24hr
40 mg
•
10-660 mg
50 mg
•
10-750 mg
60 mg
•
2.5-500 mg
70 mg
•
5-325 mg (Norco)
80 mg
•
5-500 mg
100 mg
•
7.5-325 mg (Norco)
130 mg
•
7.5-500 mg
150 mg
•
7.5-650 mg
200 mg
•
7.5-750 mg
methadone hcl conc 10 mg/ml
(Methadose)
hydrocodone-ibuprofen tab
10-200 mg (Ibudone)
methadone hcl soln 10 mg/5ml
(Methadone hcl)
hydrocodone-ibuprofen tab 5-200 mg
(Reprexain)
methadone hcl soln 5 mg/5ml
(Methadone hcl)
hydrocodone-ibuprofen tab
7.5-200 mg (Vicoprofen)
methadone hcl tab for oral susp
40 mg
hydromorphone hcl liqd 1 mg/ml
(Dilaudid)
methadone hcl tab 10 mg (Dolophine)
methadone hcl tab 5 mg (Dolophine
hcl)
hydromorphone hcl tab 2 mg
(Dilaudid)
MORPHINE SULFATE – Morphine
sulfate tab 15 mg
(Dilaudid)
sulfate tab 30 mg
(Dilaudid)
10 mg
•
sulfate suppos 5 mg
20 mg
•
sulfate suppos 10 mg
30 mg
•
34
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
2014
oxycodone hcl conc 100 mg/5ml
(20 mg/ml) (Oxycodone hcl)
morphine sulfate (concentrate) oral
soln 20 mg/ml
oxycodone hcl soln 5 mg/5ml
(Oxycodone hcl)
morphine sulfate beads cap sr 24hr
120 mg (Avinza)
•
oxycodone hcl tab 10 mg
30 mg (Avinza)
•
(Roxicodone)
45 mg (Avinza)
•
60 mg (Avinza)
•
75 mg (Avinza)
•
oxycodone w/ acetaminophen cap
5-500 mg
90 mg (Avinza)
•
oxycodone w/ acetaminophen tab
10-325 mg (Percocet)
(Roxicodone)
oxycodone hcl tab 5 mg (Roxicodone)
10-650 mg
morphine sulfate oral soln 10 mg/5ml
morphine sulfate oral soln 20 mg/5ml
morphine sulfate tab cr 100 mg (Ms
contin)
•
5-325 mg (Percocet)
contin)
•
7.5-325 mg (Percocet)
contin)
•
7.5-500 mg
contin)
•
oxycodone-aspirin tab
4.8355-325 mg (Percodan)
•
OXYCONTIN – Oxycodone hcl tab er
12hr deter 10 mg
•
contin)
12hr deter 15 mg
•
NUCYNTA ER – Tapentadol hcl tab sr
12hr 50 mg
•
•
•
12hr 100 mg
12hr deter 20 mg
•
12hr deter 30 mg
•
12hr 150 mg
•
12hr deter 40 mg
•
12hr 200 mg
•
12hr deter 60 mg
•
12hr 250 mg
12hr deter 80 mg
•
oxycodone hcl cap 5 mg
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
2014
35
SUBOXONE – Buprenorphine hclnaloxone hcl sl film 2-0.5 mg (base
equiv)
• •
SUBOXONE – Buprenorphine hclnaloxone hcl sl film 4-1 mg (base
equiv)
• •
equiv)
• •
equiv)
• •
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
2014
ENBREL – Etanercept for
subcutaneous inj kit 25 mg
•
• •
ENBREL SURECLICK – Etanercept
subcutaneous inj 50 mg/ml
•
• •
etodolac cap 200 mg
etodolac cap 300 mg
etodolac tab sr 24hr 400 mg
etodolac tab 400 mg
tramadol hcl tab sr 24hr 100 mg
(Ultram er)
•
etodolac tab 500 mg
(Ultram er)
•
flurbiprofen tab 50 mg
•
• •
(Ultram er)
•
HUMIRA – Adalimumab inj kit 20
mg/0.4ml
•
• •
tramadol hcl tab 50 mg (Ultram)
•
HUMIRA – Adalimumab inj kit 40
mg/0.8ml (50 mg/ml)
tramadol-acetaminophen tab
37.5-325 mg (Ultracet)
HUMIRA PEN – Adalimumab inj kit 40
mg/0.8ml (50 mg/ml)
•
• •
RHEUMATOID AND OSTEOARTHRITIS
HUMIRA PEN-CROHNS DISEASE –
Adalimumab inj kit 40 mg/0.8ml (50
mg/ml)
•
• •
HUMIRA PEN-PSORIASIS STAR –
Adalimumab inj kit 40 mg/0.8ml (50
mg/ml)
•
• •
•
•
•
•
CELEBREX – Celecoxib cap 50 mg
flurbiprofen tab 100 mg
•
•
•
•
diclofenac potassium tab 50 mg
(Cataflam)
ibuprofen susp 100 mg/5ml
diclofenac sodium tab delayed
release 25 mg
ibuprofen tab 600 mg
release 50 mg
indomethacin cap 25 mg
release 75 mg
ketoprofen cap 50 mg
indomethacin cap 50 mg
ketoprofen cap 75 mg
diclofenac sodium tab sr 24hr
100 mg (Voltaren-xr)
leflunomide tab 10 mg (Arava)
ENBREL – Etanercept subcutaneous
inj 50 mg/ml
•
• •
ENBREL – Etanercept subcutaneous
inj 25 mg/0.5ml
•
• •
36
leflunomide tab 20 mg (Arava)
meloxicam tab 15 mg (Mobic)
meloxicam tab 7.5 mg (Mobic)
•
nabumetone tab 750 mg
rizatriptan benzoate tab 10 mg
(Maxalt)
naproxen sodium tab 275 mg
(Anaprox)
rizatriptan benzoate tab 5 mg
(Maxalt)
•
naproxen sodium tab 550 mg
(Anaprox ds)
sumatriptan succinate inj 6 mg/0.5ml
(Imitrex)
•
naproxen susp 125 mg/5ml
(Naprosyn)
sumatriptan succinate solution autoinjector 4 mg/0.5ml (Imitrex statdose
sys)
•
sumatriptan succinate solution autoinjector 6 mg/0.5ml (Imitrex statdose
sys)
•
sumatriptan succinate solution
cartridge 4 mg/0.5ml (Imitrex
statdose ref)
•
sumatriptan succinate solution
cartridge 6 mg/0.5ml (Imitrex
statdose ref)
•
sumatriptan succinate tab 100 mg
(Imitrex)
•
(Imitrex)
•
(Imitrex)
•
nabumetone tab 500 mg
naproxen tab ec 375 mg (Ecnaprosyn)
naproxen tab ec 500 mg (Ecnaprosyn)
naproxen tab 250 mg (Naprosyn)
oxaprozin tab 600 mg (Daypro)
piroxicam cap 10 mg (Feldene)
piroxicam cap 20 mg (Feldene)
sulindac tab 150 mg
sulindac tab 200 mg
MIGRAINE HEADACHES
acetaminophen-isometheptenedichloral cap 325-65-100 mg
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
2014
GOUT
IMITREX – Sumatriptan nasal spray 5
mg/act
•
IMITREX – Sumatriptan nasal spray 20
mg/act
•
MIGRANAL – Dihydroergotamine
mesylate nasal spray 4 mg/ml
•
naratriptan hcl tab 1 mg (base equiv)
(Amerge)
•
probenecid tab 500 mg
naratriptan hcl tab 2.5 mg (base
equiv) (Amerge)
•
lidocaine hcl local inj 1% (Xylocaine)
rizatriptan benzoate orally
disintegrating tab 10 mg (Maxaltmlt)
•
lidocaine hcl local preservative free
(pf) inj 1% (Xylocaine-mpf)
rizatriptan benzoate orally
disintegrating tab 5 mg (Maxalt-mlt)
•
allopurinol tab 100 mg (Zyloprim)
allopurinol tab 300 mg (Zyloprim)
colchicine w/ probenecid tab
0.5-500 mg
COLCRYS – Colchicine tab 0.6 mg
LOCAL ANESTHETICS INJECTABLE
NEUROMUSCULAR DRUGS
SEIZURES
carbamazepine cap sr 12hr 100 mg
(Carbatrol)
37
(Carbatrol)
ethosuximide soln 250 mg/5ml
(Zarontin)
(Carbatrol)
gabapentin cap 100 mg (Neurontin)
carbamazepine chew tab 100 mg
carbamazepine susp 100 mg/5ml
(Tegretol)
gabapentin oral soln 250 mg/5ml
(Neurontin)
carbamazepine tab sr 12hr 200 mg
(Tegretol-xr)
gabapentin tab 600 mg (Neurontin)
carbamazepine tab sr 12hr 400 mg
(Tegretol-xr)
GABITRIL – Tiagabine hcl tab 12 mg
CELONTIN – Methsuximide cap 300
mg
lamotrigine tab chewable dispersible
25 mg (Lamictal chewable di)
clonazepam tab 0.5 mg (Klonopin)
lamotrigine tab chewable dispersible
5 mg (Lamictal chewable di)
DIASTAT ACUDIAL – Diazepam rectal
gel delivery system 10 mg
DIASTAT ACUDIAL – Diazepam rectal
gel delivery system 20 mg
DIASTAT PEDIATRIC – Diazepam
rectal gel delivery system 2.5 mg
lamotrigine tab 100 mg (Lamictal)
levetiracetam oral soln 100 mg/ml
(Keppra)
levetiracetam tab 1000 mg (Keppra)
DILANTIN – Phenytoin sodium
extended cap 30 mg
divalproex sodium cap sprinkle
125 mg (Depakote sprinkles)
divalproex sodium tab delayed
release 125 mg (Depakote)
LYRICA – Pregabalin cap 50 mg
divalproex sodium tab sr 24 hr
250 mg (Depakote er)
divalproex sodium tab sr 24 hr
500 mg (Depakote er)
ethosuximide cap 250 mg (Zarontin)
38
Step Therapy
gabapentin tab 800 mg (Neurontin)
GABITRIL – Tiagabine hcl tab 16 mg
clonazepam tab 2 mg (Klonopin)
Dispensing Limits
carbamazepine tab 200 mg (Tegretol)
clonazepam tab 1 mg (Klonopin)
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
2014
oxcarbazepine susp 300 mg/5ml
(60 mg/ml) (Trileptal)
oxcarbazepine tab 150 mg (Trileptal)
benztropine mesylate tab 0.5 mg
phenytoin sodium extended cap
100 mg (Dilantin)
benztropine mesylate tab 2 mg
300 mg (Phenytek)
phenytoin susp 125 mg/5ml (Dilantin)
primidone tab 250 mg (Mysoline)
primidone tab 50 mg (Mysoline)
SABRIL – Vigabatrin tab 500 mg
SABRIL – Vigabatrin powd pack 500
mg
TEGRETOL-XR – Carbamazepine tab
sr 12hr 100 mg
topiramate sprinkle cap 15 mg
(Topamax sprinkle)
topiramate sprinkle cap 25 mg
(Topamax sprinkle)
topiramate tab 100 mg (Topamax)
bromocriptine mesylate cap 5 mg
(Parlodel)
bromocriptine mesylate tab 2.5 mg
(Parlodel)
carbidopa & levodopa orally
disintegrating tab 10-100 mg
carbidopa & levodopa tab cr
25-100 mg (Sinemet cr)
carbidopa & levodopa tab cr
50-200 mg (Sinemet cr)
carbidopa & levodopa tab 10-100 mg
(Sinemet)
(Sinemet)
(Sinemet)
entacapone tab 200 mg (Comtan)
pramipexole dihydrochloride tab
0.125 mg (Mirapex)
valproic acid cap 250 mg (Depakene)
zonisamide cap 100 mg (Zonegran)
zonisamide cap 25 mg (Zonegran)
zonisamide cap 50 mg
PARKINSON'S DISEASE
amantadine hcl cap 100 mg
amantadine hcl syrup 50 mg/5ml
AZILECT – Rasagiline mesylate tab 0.5
mg (base equiv)
Step Therapy
benztropine mesylate tab 1 mg
valproate sodium syrup 250 mg/5ml
(base equiv) (Depakene)
Dispensing Limits
AZILECT – Rasagiline mesylate tab 1
mg (base equiv)
phenytoin chew tab 50 mg (Dilantin
infatabs)
200 mg (Phenytek)
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
2014
0.25 mg (Mirapex)
0.5 mg (Mirapex)
0.75 mg (Mirapex)
1 mg (Mirapex)
1.5 mg (Mirapex)
ropinirole hydrochloride tab 0.25 mg
(Requip)
39
ropinirole hydrochloride tab 0.5 mg
(Requip)
MESTINON TIMESPAN –
Pyridostigmine bromide tab cr 180
mg
ropinirole hydrochloride tab 3 mg
(Requip)
pyridostigmine bromide tab 60 mg
(Mestinon)
(Requip)
riluzole tab 50 mg (Rilutek)
(Requip)
VITAMINS
SUPPLEMENTS
selegiline hcl cap 5 mg (Eldepryl)
ergocalciferol cap 50000 unit
(Drisdol)
selegiline hcl tab 5 mg
MEPHYTON – Phytonadione tab 5 mg
trihexyphenidyl hcl elixir 0.4 mg/ml
MULTIVITAMINS
trihexyphenidyl hcl tab 2 mg
pediatric multiple vitamins w/ fl-fe
drops 0.25-10 mg/ml
trihexyphenidyl hcl tab 5 mg
MUSCLE RELAXANTS
pediatric multiple vitamins w/
fluoride chew tab 0.25 mg
baclofen tab 10 mg
fluoride chew tab 0.5 mg
baclofen tab 20 mg
chlorzoxazone tab 500 mg (Parafon
forte dsc)
fluoride chew tab 1 mg
cyclobenzaprine hcl tab 10 mg
cyclobenzaprine hcl tab 5 mg
fluoride soln 0.25 mg/ml
dantrolene sodium cap 25 mg
(Dantrium)
fluoride soln 0.5 mg/ml
dantrolene sodium cap 50 mg
(Dantrium)
pediatric vitamins acd w/ fluoride
soln 0.25 mg/ml
metaxalone tab 800 mg (Skelaxin)
methocarbamol tab 500 mg (Robaxin)
pediatric vitamins acd w/ fluoride
soln 0.5 mg/ml
methocarbamol tab 750 mg
(Robaxin-750)
PRENAPLUS – prenatal vit w/ fe
fumarate-fa tab 27-1 mg
orphenadrine citrate tab sr 12hr
100 mg
PRENATABS FA – prenatal vit w/ fe
orphenadrine w/ aspirin & caffeine
tab 25-385-30 mg
PRENATAL LOW IRON – prenatal vit
w/ fe fumarate-fa tab 27-1 mg
40
Step Therapy
MESTINON – Pyridostigmine bromide
syrup 60 mg/5ml
(Requip)
tizanidine hcl tab 4 mg (Zanaflex)
Dispensing Limits
OTHER NEUROMUSCULAR DRUGS
(Requip)
tizanidine hcl tab 2 mg
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
2014
•
•
PRENATAL PLUS – prenatal vit w/ fe
PRENATAL VITAMINS PLUS –
prenatal vit w/ fe fumarate-fa tab 27-1
mg
PRENATAL 19 – prenatal vit w/ fe
fumarate-fa chew tab 29-1 mg
PRENATAL 19 – prenatal vit w/ dss-fe
SE-NATAL 19 – prenatal vit w/ fe
fumarate-fa chew tab 29-1 mg
sodium fluoride soln 0.125 mg/drop f
(0.275 mg/drop naf)
sodium fluoride soln 0.5 mg/ml f
(from 1.1 mg/ml naf) (Luride)
BLOOD MODIFYING DRUGS
•
MINERALS AND ELECTROLYTES
ADVATE – Antihemophilic factor rahfpfm for inj 500 unit
•
•
•
•
potassium chloride cap cr 10 meq
(Micro-k)
•
potassium chloride cap cr 8 meq
(Micro-k)
•
potassium chloride
microencapsulated crys cr tab 10
meq
ALPHANATE/VON WILLEBRAND –
Antihemophilic factor/vwf (human) for
inj 250 unit
•
potassium chloride
microencapsulated crys cr tab 20
meq
inj 500 unit
•
potassium chloride oral liq 10% (20
meq/15ml)
inj 1000 unit
•
inj 1500 unit
•
potassium chloride powder packet
20 meq
potassium chloride tab cr 10 meq (Ktab)
ALPHANINE SD – Coagulation factor ix
for inj 500 unit
•
potassium chloride tab cr 8 meq
(600 mg)
for inj 1000 unit
•
sodium fluoride chew tab 0.25 mg f
(from 0.55 mg naf) (Luride)
for inj 1500 unit
•
pot phos monobasic w/sod phos di
& monobas tab 155-852-130mg (Kphos neutral)
potassium chloride oral liq 20% (40
meq/15ml)
Step Therapy
sodium fluoride chew tab 1 mg f
pot bicarbonate & chloride effer tab
25 meq
Dispensing Limits
sodium fluoride chew tab 0.5 mg f
SE-NATAL 19 – prenatal vit w/ dss-fe
K-PHOS – Potassium phosphate
monobasic tab 500 mg
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
2014
41
ALPROLIX – Coagulation factor ix
(recomb) (rfixfc) for inj 500 unit
•
•
•
•
anagrelide hcl cap 0.5 mg (Agrylin)
ARANESP ALBUMIN FREE –
Darbepoetin alfa-polysorbate 80 soln
inj 200 mcg/ml
• •
inj 200 mcg/0.4ml
• •
inj 300 mcg/ml
• •
• •
inj 25 mcg/ml
• •
inj 300 mcg/0.6ml
• •
inj 25 mcg/0.42ml
• •
inj 500 mcg/ml
•
inj 40 mcg/ml
• •
BEBULIN – Factor ix complex for inj
200-1200 unit
BEBULIN VH – Factor ix complex for inj
200-1200 unit
•
inj 40 mcg/0.4ml
• •
BENEFIX – Coagulation factor ix
(recombinant) for inj 250 unit
•
•
inj 60 mcg/ml
• •
•
inj 60 mcg/0.3ml
• •
•
•
inj 100 mcg/ml
• •
inj 100 mcg/0.5ml
• •
inj 150 mcg/0.75ml
• •
inj 150 mcg/0.3ml
• •
anagrelide hcl cap 1 mg
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
2014
cilostazol tab 100 mg (Pletal)
cilostazol tab 50 mg (Pletal)
clopidogrel bisulfate tab 75 mg (base
equiv) (Plavix)
CORIFACT – Factor xiii concentrate
(human) for inj kit 1000-1600 unit
•
cyanocobalamin inj 1000 mcg/ml
dipyridamole tab 25 mg (Persantine)
DROXIA – Hydroxyurea cap 200 mg
42
HELIXATE FS – Antihemophilic factor
(recombinant) for inj kit 3000 unit
•
enoxaparin sodium inj 100 mg/ml
(Lovenox)
•
HEMOFIL M – Antihemophilic factor
(human) for inj 220-400 unit
•
enoxaparin sodium inj 120 mg/0.8ml
(Lovenox)
•
(human) for inj 250 unit
•
enoxaparin sodium inj 150 mg/ml
(Lovenox)
•
•
(Lovenox)
•
•
enoxaparin sodium inj 300 mg/3ml
(Lovenox)
•
•
(Lovenox)
•
•
(Lovenox)
•
•
(Lovenox)
•
•
HUMATE-P – Antihemophilic factor/vwf
•
•
•
KOATE-DVI – Antihemophilic factor
•
•
•
•
EPOGEN – Epoetin alfa inj 2000 unit/ml
EPOGEN – Epoetin alfa inj 10000 unit/
ml
•
•
•
•
•
•
•
•
EPOGEN – Epoetin alfa inj 20000 unit/
ml
• •
FEIBA NF – antiinhibitor coagulant
complex for inj
•
FIRAZYR – Icatibant acetate inj 30
mg/3ml (base equivalent)
•
folic acid tab 1 mg
•
•
KOGENATE FS – Antihemophilic factor
•
•
•
•
•
•
•
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
2014
43
KOGENATE FS BIO-SET –
Antihemophilic factor (recombinant)
for inj kit 250 unit
•
•
•
•
•
MONOCLATE-P – Antihemophilic
factor (human) for inj kit 250 unit
NOVOSEVEN RT – Coagulation factor
viia (recomb) for inj 2 mg (2000 mcg)
•
•
•
Step Therapy
pentoxifylline tab cr 400 mg
PROCRIT – Epoetin alfa inj 2000 unit/
ml
• •
ml
• •
ml
• •
• •
•
ml
• •
•
ml
• •
•
ml
•
•
PROFILNINE SD – Factor ix complex
for inj 500 unit
•
MONONINE – Coagulation factor ix for
inj 250 unit
•
for inj 1000 unit
•
inj 500 unit
•
for inj 1500 unit
•
inj 1000 unit
•
RECOMBINATE – Antihemophilic
factor (recombinant) for inj 220-400
unit
NEULASTA – Pegfilgrastim inj 6
mg/0.6ml
•
•
NEUPOGEN – Filgrastim inj 300 mcg/
ml
•
unit
•
NEUPOGEN – Filgrastim inj 480
mcg/1.6ml (300 mcg/ml)
•
unit
•
•
•
unit
•
•
unit
44
Dispensing Limits
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
2014
RIXUBIS – Coagulation factor ix
•
•
•
•
•
TRETTEN – Coagulation factor xiii asubunit for inj 2000-3125 unit
•
warfarin sodium tab 1 mg (Coumadin)
warfarin sodium tab 10 mg
(Coumadin)
XYNTHA SOLOFUSE – Antihemophilic
factor recombinant paf for inj kit 250
unit
•
unit
•
unit
•
unit
•
unit
•
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
2014
TOPICAL PRODUCTS
EYE
warfarin sodium tab 2.5 mg
(Coumadin)
Anti-infectives
BACITRACIN – Bacitracin ophth oint
500 unit/gm
bacitracin-polymyxin b ophth oint
ciprofloxacin hcl ophth soln 0.3%
(Ciloxan)
erythromycin ophth oint 5 mg/gm
warfarin sodium tab 7.5 mg
(Coumadin)
WILATE – Antihemophilic factor/vwf
•
WILATE – Antihemophilic factor/vwf
•
gentamicin sulfate ophth oint 0.3%
gentamicin sulfate ophth soln 0.3%
(Garamycin)
NATACYN – Natamycin ophth susp 5%
•
•
•
XARELTO – Rivaroxaban tab 10 mg
neomycin-bacitrac zn-polymyx
5(3.5)mg-400unt-10000unt op oin
neomycin-polymy-gramicid op sol
1.75-10000-0.025mg-unt-mg/ml
(Neosporin)
XYNTHA – Antihemophilic factor
recombinant paf for inj kit 250 unit
•
•
polymyxin b-trimethoprim ophth
soln 10000 unit/ml-0.1% (Polytrim)
•
sulfacetamide sodium ophth soln
10% (Bleph-10)
•
tobramycin ophth soln 0.3% (Tobrex)
ofloxacin ophth soln 0.3% (Ocuflox)
trifluridine ophth soln 1% (Viroptic)
45
VIGAMOX – Moxifloxacin hcl ophth
soln 0.5% (base equiv)
brimonidine tartrate ophth soln 0.2%
Steroids and Combination Products
dorzolamide hcl ophth soln 2%
(Trusopt)
bacitracin-polymyxin-neomycin-hc
ophth oint 1%
dexamethasone sodium phosphate
ophth soln 0.1%
fluorometholone ophth susp 0.1%
(Fml liquifilm)
LOTEMAX – Loteprednol etabonate
ophth susp 0.5%
ophth gel 0.5%
ophth oint 0.5%
neomycin-polymyxindexamethasone ophth oint 0.1%
(Maxitrol)
neomycin-polymyxindexamethasone ophth susp 0.1%
(Maxitrol)
latanoprost ophth soln 0.005%
(Xalatan)
LUMIGAN – Bimatoprost ophth soln
0.01%
•
LUMIGAN – Bimatoprost ophth soln
0.03%
•
pilocarpine hcl ophth soln 1% (Isopto
carpine)
carpine)
carpine)
timolol maleate ophth gel forming
soln 0.25% (Timoptic-xe)
timolol maleate ophth gel forming
soln 0.5% (Timoptic-xe)
timolol maleate ophth soln 0.25%
(Timoptic)
timolol maleate ophth soln 0.5%
(Timoptic)
ZYLET – Loteprednol etabonatetobramycin ophth susp 0.5-0.3%
TRAVATAN Z – Travoprost ophth soln
0.004% (benzalkonium free) (bak
free)
Glaucoma
Other Eye Products
ALPHAGAN P – Brimonidine tartrate
ophth soln 0.1%
atropine sulfate ophth soln 1%
(Isopto atropine)
AZOPT – Brinzolamide ophth susp 1%
azelastine hcl ophth soln 0.05%
(Optivar)
brimonidine tartrate ophth soln
0.15% (Alphagan p)
46
•
levobunolol hcl ophth soln 0.5%
(Betagan)
PREDNISOLONE SODIUM PHOSP
– Prednisolone sodium phosphate
ophth soln 1%
tobramycin-dexamethasone ophth
susp 0.3-0.1% (Tobradex)
Step Therapy
dorzolamide hcl-timolol maleate
ophth soln 22.3-6.8 mg/ml (Cosopt)
SIMBRINZA – Brinzolamidebrimonidine tartrate ophth susp
1-0.2%
TOBRADEX – Tobramycindexamethasone ophth oint 0.3-0.1%
Dispensing Limits
carteolol hcl ophth soln 1%
prednisolone acetate ophth susp 1%
(Pred forte)
sulfacetamide sodium-prednisolone
ophth soln 10-0.23(0.25)%
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
2014
•
cromolyn sodium ophth soln 4%
cyclopentolate hcl ophth soln 1%
(Cyclogyl)
pilocarpine hcl tab 5 mg (Salagen)
diclofenac sodium ophth soln 0.1%
sodium fluoride cream 1.1%
(Prevident 5000 plus)
flurbiprofen sodium ophth soln
0.03% (Ocufen)
homatropine hbr ophth soln 5%
(Isopto homatropine)
ketorolac tromethamine ophth soln
0.4% (Acular ls)
triamcinolone acetonide dental paste
0.1%
ANORECTAL AGENTS
PATADAY – Olopatadine hcl ophth soln
0.2%
hydrocortisone acetate suppos
25 mg (Anusol-hc)
tropicamide ophth soln 0.5%
hydrocortisone enema 100 mg/60ml
(Cortenema)
EAR
hydrocortisone rectal cream 2.5%
(Anusol-hc)
acetic acid otic soln 2%
SKIN CONDITIONS/PRODUCTS
antipyrine-benzocaine otic soln
54-14 mg/ml (5.4-1.4%)
Acne
CIPRODEX – Ciprofloxacindexamethasone otic susp 0.3-0.1%
adapalene gel 0.1% (Differin)
neomycin-polymyxin-hc otic soln 1%
(Cortisporin)
neomycin-polymyxin-hc otic susp
3.5 mg/ml-10000 unit/ml-1%
ofloxacin otic soln 0.3%
MOUTH AND THROAT (LOCAL)
adapalene cream 0.1% (Differin)
adapalene gel 0.3% (Differin)
benzoyl peroxide-erythromycin gel
5-3% (Benzamycin)
clindamycin phosph-benzoyl
peroxide (refrig) gel 1.2 (1)-5%
(Duac)
clindamycin phosphate gel 1%
(Cleocin-t)
cevimeline hcl cap 30 mg (Evoxac)
clindamycin phosphate lotion 1%
(Cleocin-t)
chlorhexidine gluconate soln 0.12%
(Peridex)
clindamycin phosphate soln 1%
(Cleocin-t)
clotrimazole troche 10 mg
clindamycin phosphate swab 1%
(Cleocin-t)
lidocaine hcl laryngotracheal soln
4% (Lta 360 kit)
Step Therapy
sodium fluoride gel 1.1% (0.5% f)
(Prevident fluoride)
CORTIFOAM – Hydrocortisone acetate
rectal foam 90 mg/dose
hydrocortisone w/ acetic acid otic
soln 1-2% (Vosol hc)
Dispensing Limits
pilocarpine hcl tab 7.5 mg (Salagen)
ketorolac tromethamine ophth soln
0.5% (Acular)
tropicamide ophth soln 1%
(Mydriacyl)
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
2014
lidocaine hcl viscous soln 2%
clindamycin phosphate-benzoyl
peroxide gel 1-5% (Benzaclin)
nystatin susp 100000 unit/ml
DIFFERIN – Adapalene gel 0.3%
erythromycin gel 2% (Erygel)
47
erythromycin pads 2%
erythromycin soln 2%
FINACEA – Azelaic acid gel 15%
isotretinoin cap 10 mg
econazole nitrate cream 1%
metronidazole cream 0.75%
(Metrocream)
ketoconazole cream 2%
ketoconazole shampoo 2% (Nizoral)
metronidazole gel 1% (Metrogel)
mupirocin calcium cream 2%
(Bactroban)
metronidazole lotion 0.75%
(Metrolotion)
mupirocin oint 2% (Bactroban)
sulfacetamide sodium lotion 10%
(acne) (Klaron)
nystatin oint 100000 unit/gm
sulfacetamide sodium w/ sulfur
emulsion 10-5%
lotion 10-5%
TAZORAC – Tazarotene cream 0.05%
TAZORAC – Tazarotene cream 0.1%
TAZORAC – Tazarotene gel 0.05%
TAZORAC – Tazarotene gel 0.1%
tretinoin cream 0.025% (Retin-a)
nystatin cream 100000 unit/gm
nystatin topical powder
silver sulfadiazine cream 1%
(Silvadene)
VOLTAREN – Diclofenac sodium gel
1%
Corticosteroids
alclometasone dipropionate cream
0.05% (Aclovate)
alclometasone dipropionate oint
0.05%
amcinonide cream 0.1%
betamethasone dipropionate
augmented cream 0.05% (Diprolene
af)
tretinoin gel 0.025% (Retin-a)
augmented gel 0.05%
tretinoin microsphere gel 0.04%
(Retin-a micro)
augmented lotion 0.05% (Diprolene)
tretinoin microsphere gel 0.1%
(Retin-a micro)
augmented oint 0.05% (Diprolene)
Anti-infectives
betamethasone dipropionate cream
0.05%
tretinoin gel 0.01% (Retin-a)
ciclopirox gel 0.77% (Loprox)
ciclopirox olamine cream 0.77%
(base equiv)
48
Step Therapy
ciclopirox shampoo 1% (Loprox
shampoo)
ciclopirox solution 8% (Penlac nail
lacquer)
cream 10-5%
Dispensing Limits
ciclopirox olamine susp 0.77% (base
equiv)
metronidazole gel 0.75%
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
2014
betamethasone dipropionate lotion
0.05%
betamethasone dipropionate oint
0.05%
fluocinonide oint 0.05%
betamethasone valerate cream 0.1%
fluticasone propionate cream 0.05%
(Cutivate)
betamethasone valerate lotion 0.1%
betamethasone valerate oint 0.1%
clobetasol propionate cream 0.05%
(Temovate)
clobetasol propionate emollient base
cream 0.05% (Temovate e)
clobetasol propionate foam 0.05%
(Olux)
halobetasol propionate cream 0.05%
(Ultravate)
halobetasol propionate oint 0.05%
(Ultravate)
hydrocortisone cream 2.5%
clobetasol propionate oint 0.05%
(Temovate)
hydrocortisone valerate cream 0.2%
desonide lotion 0.05% (Desowen)
hydrocortisone oint 2.5%
hydrocortisone valerate oint 0.2%
(Westcort)
mometasone furoate cream 0.1%
(Elocon)
desonide oint 0.05% (Desowen)
mometasone furoate oint 0.1%
(Elocon)
desoximetasone cream 0.25%
(Topicort)
mometasone furoate solution 0.1%
(lotion) (Elocon)
desoximetasone gel 0.05% (Topicort)
nystatin-triamcinolone cream
100000-0.1 unit/gm-%
desoximetasone oint 0.25% (Topicort)
diflorasone diacetate oint 0.05%
fluocinolone acetonide cream 0.01%
fluocinolone acetonide cream
0.025% (Synalar)
fluocinolone acetonide oil 0.01%
(Derma-smoothe/fs bod)
Step Therapy
fluticasone propionate oint 0.005%
(Cutivate)
hydrocortisone lotion 2.5%
desonide cream 0.05% (Desowen)
Dispensing Limits
fluocinonide soln 0.05%
clobetasol propionate gel 0.05%
(Temovate)
clobetasol propionate soln 0.05%
(Temovate)
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
2014
nystatin-triamcinolone oint
100000-0.1 unit/gm-%
triamcinolone acetonide cream
0.025%
triamcinolone acetonide cream 0.1%
triamcinolone acetonide cream 0.5%
fluocinolone acetonide oint 0.025%
(Synalar)
triamcinolone acetonide lotion
0.025%
fluocinolone acetonide soln 0.01%
(Synalar)
triamcinolone acetonide lotion 0.1%
fluocinonide cream 0.05%
triamcinolone acetonide oint 0.1%
fluocinonide emulsified base cream
0.05%
Other Skin Products
fluocinonide gel 0.05%
acitretin cap 17.5 mg (Soriatane)
triamcinolone acetonide oint 0.025%
acitretin cap 10 mg (Soriatane)
49
acitretin cap 25 mg (Soriatane)
calcipotriene cream 0.005%
(Dovonex)
MISCELLANEOUS CATEGORIES
calcipotriene soln 0.005% (50 mcg/
ml)
INSULIN PEN NEEDLES –BD
ULTRAFINE, NOVOFINE,
NOVOTWIST
•
INSULIN SYRINGES –BD
•
•
DIABETIC SUPPLIES
CARAC – Fluorouracil cream 0.5%
diclofenac sodium (actinic
keratoses) gel 3% (Solaraze)
TEST STRIPS – BAYERASCENSIA
AUTODISC, BREEZE 2, CONTOUR,
CONTOUR NEXT
ELIDEL – Pimecrolimus cream 1%
FLUOROPLEX – Fluorouracil cream
1%
fluorouracil cream 5% (Efudex)
fluorouracil soln 2%
fluorouracil soln 5%
•
imiquimod cream 5% (Aldara)
TEST STRIPS – ROCHE ACCUCHEKACTIVE, AVIVA, AVIVA PLUS,
COMFORT CURVE, COMPACT,
SMARTVIEW
•
TEST STRIPS – ROCHE
ACCUTREND
•
LANCETS – BAYER FINGERSTIX,
MICROLET, SINGLE-LET
lidocaine hcl gel 2%
lidocaine hcl soln 4% (Xylocaine)
LANCETS – BDMICROTAINER,
ULTRAFINE
lidocaine oint 5%
lidocaine patch 5% (Lidoderm)
lidocaine-prilocaine cream 2.5-2.5%
(Emla)
LANCETS – ROCHE ACCUCHEKFASTCLIX, MULTICLIX, SOFT
TOUCH, SOFTCLIX
lindane lotion 1%
RESPIRATORY INHALER-ASSIST DEVICES
malathion lotion 0.5% (Ovide)
BREATHERITE – spacer/aerosolholding chambers - device
permethrin cream 5% (Elimite)
MISCELLANEOUS DRUGS
podofilox soln 0.5% (Condylox)
azathioprine tab 50 mg (Imuran)
PROTOPIC – Tacrolimus oint 0.03%
CELLCEPT – Mycophenolate mofetil
cap 250 mg
PROTOPIC – Tacrolimus oint 0.1%
selenium sulfide lotion 2.5%
VALCHLOR – Mechlorethamine hcl gel
0.016% (base equivalent)
tab 500 mg
•
for oral susp 200 mg/ml
XERAC AC – Aluminum chloride in
alcohol solution 6.25%
ZYCLARA – Imiquimod cream 3.75%
ZYCLARA PUMP – Imiquimod cream
2.5%
50
Step Therapy
Dispensing Limits
•
ZYCLARA PUMP – Imiquimod cream
3.75%
aluminum chloride soln 20% (Drysol)
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
2014
•
•
CHEMET – Succimer cap 100 mg
CUPRIMINE – Penicillamine cap 250
mg
•
cyclosporine cap 100 mg
(Sandimmune)
cyclosporine cap 25 mg
(Sandimmune)
sodium polystyrene sulfonate
powder (Kayexalate)
CYCLOSPORINE MODIFIED –
Cyclosporine modified cap 50 mg
tacrolimus cap 0.5 mg (Prograf)
cyclosporine modified cap 100 mg
(Neoral)
tacrolimus cap 5 mg (Prograf)
cyclosporine modified cap 25 mg
(Neoral)
THALOMID – Thalidomide cap 100 mg
•
•
•
•
Step Therapy
•
•
•
•
Dispensing Limits
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
2014
tacrolimus cap 1 mg (Prograf)
cyclosporine modified oral soln
100 mg/ml (Neoral)
mycophenolate mofetil cap 250 mg
(Cellcept)
ZORTRESS – Everolimus tab 0.25 mg
mycophenolate mofetil tab 500 mg
(Cellcept)
mycophenolate sodium tab dr
180 mg (mycophenolic acid equiv)
(Myfortic)
mycophenolate sodium tab dr
360 mg (mycophenolic acid equiv)
(Myfortic)
naltrexone hcl tab 50 mg (Revia)
PROGRAF – Tacrolimus cap 0.5 mg
PROGRAF – Tacrolimus cap 1 mg
PROGRAF – Tacrolimus cap 5 mg
RAPAMUNE – Sirolimus tab 1 mg
RAPAMUNE – Sirolimus tab 2 mg
RAPAMUNE – Sirolimus oral soln 1
mg/ml
REVLIMID – Lenalidomide caps 2.5 mg
REVLIMID – Lenalidomide cap 5 mg
•
•
•
•
•
•
•
•
•
•
•
•
sirolimus tab 0.5 mg (Rapamune)
sodium polystyrene sulfonate oral
susp 15 gm/60ml (Sps)
51
2014
INDEX
A
abacavir sulfate-lamivudine-zidovudine tab
300-150-300 mg (Trizivir).................................................4
abacavir sulfate tab 300 mg (base equiv) (Ziagen).........4
acamprosate calcium tab delayed release 333 mg
(Campral)........................................................................ 32
acarbose tab 100 mg (Precose)..................................... 10
acarbose tab 25 mg (Precose)....................................... 10
acarbose tab 50 mg (Precose)....................................... 10
acebutolol hcl cap 200 mg (Sectral).............................. 15
acebutolol hcl cap 400 mg (Sectral)..............................15
acetaminophen-isometheptene-dichloral cap
325-65-100 mg................................................................ 37
acetaminophen w/ codeine soln 120-12 mg/5ml...........33
acetaminophen w/ codeine tab 300-15 mg (Tylenol/
codeine).......................................................................... 33
codeine #3).....................................................................33
codeine #4).....................................................................33
acetazolamide cap sr 12hr 500 mg (Diamox)................19
acetazolamide tab 250 mg..............................................19
acetic acid otic soln 2%................................................. 47
acetylcysteine inhal soln 10%........................................22
acetylcysteine inhal soln 20%........................................22
acitretin cap 10 mg (Soriatane)......................................49
acitretin cap 17.5 mg (Soriatane)...................................49
acitretin cap 25 mg (Soriatane)......................................50
ACTONEL – Risedronate sodium tab 150 mg.................. 13
ACTONEL – Risedronate sodium tab 30 mg.................... 13
ACTONEL – Risedronate sodium tab 35 mg.................... 13
ACTONEL – Risedronate sodium tab 5 mg...................... 13
acyclovir cap 200 mg (Zovirax)........................................4
acyclovir susp 200 mg/5ml (Zovirax).............................. 4
acyclovir tab 400 mg (Zovirax)........................................ 4
acyclovir tab 800 mg (Zovirax)........................................ 4
adapalene cream 0.1% (Differin)....................................47
adapalene gel 0.1% (Differin)......................................... 47
adapalene gel 0.3% (Differin)......................................... 47
ADCIRCA – Tadalafil tab 20 mg (pah)..............................20
adefovir dipivoxil tab 10 mg (Hepsera)........................... 3
ADVAIR DISKUS – Fluticasone-salmeterol aer powder ba
100-50 mcg/dose............................................................. 22
250-50 mcg/dose............................................................. 22
500-50 mcg/dose............................................................. 22
ADVAIR HFA – Fluticasone-salmeterol inhal aerosol
115-21 mcg/act................................................................ 22
ADVAIR HFA – Fluticasone-salmeterol inhal aerosol
230-21 mcg/act................................................................ 22
52
ADVAIR HFA – Fluticasone-salmeterol inhal aerosol 45-21
mcg/act............................................................................ 22
ADVATE – Antihemophilic factor rahf-pfm for inj 1000
unit................................................................................... 41
unit................................................................................... 41
unit................................................................................... 41
unit................................................................................... 41
unit................................................................................... 41
unit................................................................................... 41
unit................................................................................... 41
AEROHIST – Chlorpheniramine-methscopolamine tab sr
12hr 8-2.5 mg.................................................................. 21
AFINITOR – Everolimus tab 10 mg.................................... 6
AFINITOR – Everolimus tab 2.5 mg................................... 6
AFINITOR – Everolimus tab 5 mg...................................... 6
AFINITOR – Everolimus tab 7.5 mg................................... 6
ALBENZA – Albendazole tab 200 mg.................................6
albuterol sulfate soln nebu 0.083% (2.5 mg/3ml)..........22
albuterol sulfate soln nebu 0.5% (5 mg/ml).................. 22
albuterol sulfate soln nebu 0.63 mg/3ml (base
equiv).............................................................................. 22
albuterol sulfate soln nebu 1.25 mg/3ml (base
equiv).............................................................................. 22
albuterol sulfate syrup 2 mg/5ml................................... 22
albuterol sulfate tab 2 mg.............................................. 22
albuterol sulfate tab 4 mg.............................................. 22
alclometasone dipropionate cream 0.05%
(Aclovate)........................................................................48
alclometasone dipropionate oint 0.05%........................ 48
alendronate sodium tab 10 mg...................................... 13
alendronate sodium tab 35 mg...................................... 13
alendronate sodium tab 5 mg........................................ 13
alendronate sodium tab 70 mg (Fosamax)................... 13
alfuzosin hcl tab sr 24hr 10 mg (Uroxatral).................. 26
ALKERAN – Melphalan tab 2 mg....................................... 6
allopurinol tab 100 mg (Zyloprim)................................. 37
allopurinol tab 300 mg (Zyloprim)................................. 37
ALPHAGAN P – Brimonidine tartrate ophth soln 0.1%......46
ALPHANATE/VON WILLEBRAND – Antihemophilic factor/
vwf (human) for inj 1000 unit...........................................41
vwf (human) for inj 1500 unit...........................................41
vwf (human) for inj 250 unit............................................ 41
vwf (human) for inj 500 unit............................................ 41
ALPHANINE SD – Coagulation factor ix for inj 1000
unit................................................................................... 41
unit................................................................................... 41
2014
unit................................................................................... 41
alprazolam tab 0.25 mg (Xanax).................................... 27
alprazolam tab 0.5 mg (Xanax)...................................... 27
alprazolam tab 1 mg (Xanax)......................................... 27
alprazolam tab 2 mg (Xanax)......................................... 27
alprazolam tab sr 24hr 0.5 mg (Xanax xr)..................... 27
alprazolam tab sr 24hr 1 mg (Xanax xr)........................ 27
ALPROLIX – Coagulation factor ix (recomb) (rfixfc) for inj
1000 unit..........................................................................42
2000 unit..........................................................................42
3000 unit..........................................................................42
500 unit............................................................................42
aluminum chloride soln 20% (Drysol)........................... 50
amantadine hcl cap 100 mg........................................... 39
amantadine hcl syrup 50 mg/5ml...................................39
amcinonide cream 0.1%................................................. 48
amiloride & hydrochlorothiazide tab 5-50 mg...............19
amiloride hcl tab 5 mg....................................................19
amiodarone hcl tab 100 mg........................................... 20
amiodarone hcl tab 200 mg (Cordarone)...................... 20
amiodarone hcl tab 400 mg........................................... 20
amitriptyline hcl tab 100 mg...........................................27
amitriptyline hcl tab 10 mg............................................ 27
amitriptyline hcl tab 150 mg...........................................27
amlodipine besylate-atorvastatin calcium tab 10-10 mg
(Caduet).......................................................................... 17
(Caduet).......................................................................... 17
(Caduet).......................................................................... 17
(Caduet).......................................................................... 17
amlodipine besylate-atorvastatin calcium tab 2.5-10
mg (Caduet)....................................................................17
mg (Caduet)....................................................................17
mg (Caduet)....................................................................17
(Caduet).......................................................................... 17
(Caduet).......................................................................... 17
(Caduet).......................................................................... 17
(Caduet).......................................................................... 17
amlodipine besylate-benazepril hcl cap 10-20 mg
(Lotrel).............................................................................17
(Lotrel).............................................................................17
amlodipine besylate-benazepril hcl cap 2.5-10 mg
(Lotrel).............................................................................17
(Lotrel).............................................................................17
(Lotrel).............................................................................17
(Lotrel).............................................................................17
amlodipine besylate tab 10 mg (Norvasc).....................16
amlodipine besylate tab 2.5 mg (Norvasc)....................17
amlodipine besylate tab 5 mg (Norvasc)...................... 17
amoxicillin (trihydrate) cap 250 mg................................. 1
amoxicillin (trihydrate) cap 500 mg................................. 1
amoxicillin (trihydrate) for susp 125 mg/5ml.................. 1
amoxicillin (trihydrate) tab 500 mg..................................1
amoxicillin (trihydrate) tab 875 mg..................................1
amoxicillin & k clavulanate chew tab 200-28.5 mg.........1
amoxicillin & k clavulanate chew tab 400-57 mg............1
amoxicillin & k clavulanate for susp 200-28.5
mg/5ml.............................................................................. 1
amoxicillin & k clavulanate for susp 250-62.5 mg/5ml
(Augmentin)......................................................................1
amoxicillin & k clavulanate for susp 400-57 mg/5ml...... 1
amoxicillin & k clavulanate for susp 600-42.9 mg/5ml
(Augmentin es-600)......................................................... 1
amoxicillin & k clavulanate tab 250-125 mg................... 1
amoxicillin & k clavulanate tab 500-125 mg
(Augmentin)......................................................................1
amoxicillin & k clavulanate tab 875-125 mg
(Augmentin)......................................................................1
amoxicillin & k clavulanate tab sr 12hr 1000-62.5 mg
(Augmentin xr)................................................................. 1
amphetamine-dextroamphetamine cap sr 24hr 10 mg
(Adderall xr)................................................................... 31
(Adderall xr)................................................................... 31
(Adderall xr)................................................................... 31
(Adderall xr)................................................................... 31
(Adderall xr)................................................................... 31
(Adderall xr)................................................................... 31
amphetamine-dextroamphetamine tab 10 mg
(Adderall)........................................................................ 31
amphetamine-dextroamphetamine tab 12.5 mg
(Adderall)........................................................................ 31
53
2014
(Adderall)........................................................................ 31
(Adderall)........................................................................ 31
(Adderall)........................................................................ 31
(Adderall)........................................................................ 31
amphetamine-dextroamphetamine tab 7.5 mg
(Adderall)........................................................................ 31
ampicillin cap 250 mg.......................................................1
ampicillin cap 500 mg.......................................................1
anagrelide hcl cap 0.5 mg (Agrylin).............................. 42
anagrelide hcl cap 1 mg................................................. 42
anastrozole tab 1 mg (Arimidex)..................................... 6
ANDRODERM – Testosterone td patch 24hr 2 mg/24hr..... 8
ANDRODERM – Testosterone td patch 24hr 4 mg/24hr..... 8
ANDROGEL PUMP – Testosterone td gel 12.5 mg/act
(1%)................................................................................... 8
ANDROGEL PUMP – Testosterone td gel 20.25 mg/act
(1.62%).............................................................................. 8
ANDROGEL – Testosterone td gel 20.25 mg/1.25gm
(1.62%).............................................................................. 8
ANDROGEL – Testosterone td gel 25 mg/2.5gm (1%)....... 8
ANDROGEL – Testosterone td gel 40.5 mg/2.5gm
(1.62%).............................................................................. 8
ANDROGEL – Testosterone td gel 50 mg/5gm (1%).......... 8
ANDROXY – Fluoxymesterone tab 10 mg..........................8
ANORO ELLIPTA – Umeclidinium-vilanterol aero powd ba
62.5-25 mcg/inh............................................................... 22
antipyrine-benzocaine otic soln 54-14 mg/ml
(5.4-1.4%)........................................................................ 47
APTIVUS – Tipranavir cap 250 mg.....................................4
APTIVUS – Tipranavir oral soln 100 mg/ml........................ 4
ARANESP ALBUMIN FREE – Darbepoetin alfapolysorbate 80 soln inj 100 mcg/0.5ml............................ 42
ARANESP ALBUMIN FREE – Darbepoetin alfapolysorbate 80 soln inj 100 mcg/ml.................................42
ARANESP ALBUMIN FREE – Darbepoetin alfapolysorbate 80 soln inj 150 mcg/0.75ml.......................... 42
ARANESP ALBUMIN FREE – Darbepoetin alfapolysorbate 80 soln inj 25 mcg/ml...................................42
ARANESP ALBUMIN FREE – Darbepoetin alfapolysorbate 80 soln inj 40 mcg/0.4ml.............................. 42
54
ARANESP ALBUMIN FREE – Darbepoetin alfapolysorbate 80 soln inj 60 mcg/0.3ml.............................. 42
ASACOL HD – Mesalamine tab delayed release 800
mg.................................................................................... 25
ASACOL – Mesalamine tab delayed release 400 mg....... 25
ASMANEX 120 METERED DOSES – Mometasone
furoate inhal powd 220 mcg/inh (breath activated)..........22
ASMANEX 14 METERED DOSES – Mometasone furoate
inhal powd 220 mcg/inh (breath activated)......................22
ASTEPRO – Azelastine hcl nasal spray 0.15% (205.5
mcg/spray)....................................................................... 21
atenolol & chlorthalidone tab 100-25 mg (Tenoretic
100)..................................................................................16
atenolol & chlorthalidone tab 50-25 mg (Tenoretic
50)....................................................................................16
atenolol tab 100 mg (Tenormin).....................................16
atenolol tab 25 mg (Tenormin).......................................16
atenolol tab 50 mg (Tenormin).......................................16
atorvastatin calcium tab 10 mg (base equivalent)
(Lipitor)........................................................................... 18
(Lipitor)........................................................................... 18
(Lipitor)........................................................................... 18
(Lipitor)........................................................................... 18
atovaquone-proguanil hcl tab 250-100 mg
(Malarone).........................................................................5
atovaquone-proguanil hcl tab 62.5-25 mg
(Malarone).........................................................................5
ATRIPLA – Efavirenz-emtricitabine-tenofovir df tab
600-200-300 mg................................................................ 4
atropine sulfate ophth soln 1% (Isopto atropine)......... 46
ATROVENT HFA – Ipratropium bromide hfa inhal aerosol
17 mcg/act....................................................................... 22
AVODART – Dutasteride cap 0.5 mg............................... 26
azathioprine tab 50 mg (Imuran)....................................50
azelastine hcl nasal spray 0.15% (205.5 mcg/spray)
(Astepro)......................................................................... 21
azelastine hcl nasal spray 137 mcg/spray (1 mg/
ml)....................................................................................21
azelastine hcl ophth soln 0.05% (Optivar).................... 46
2014
AZILECT – Rasagiline mesylate tab 0.5 mg (base
equiv)............................................................................... 39
AZILECT – Rasagiline mesylate tab 1 mg (base
equiv)............................................................................... 39
AZITHROMYCIN – Azithromycin powd pack for susp 1
gm...................................................................................... 2
azithromycin for susp 100 mg/5ml (Zithromax)..............2
azithromycin for susp 200 mg/5ml (Zithromax)..............2
azithromycin tab 250 mg (Zithromax)............................. 2
AZOPT – Brinzolamide ophth susp 1%.............................46
B
BACITRACIN – Bacitracin ophth oint 500 unit/gm............ 45
bacitracin-polymyxin b ophth oint.................................45
bacitracin-polymyxin-neomycin-hc ophth oint 1%.......46
baclofen tab 10 mg......................................................... 40
baclofen tab 20 mg......................................................... 40
balsalazide disodium cap 750 mg (Colazal)..................25
BARACLUDE – Entecavir oral soln 0.05 mg/ml.................. 3
BARACLUDE – Entecavir tab 0.5 mg................................. 3
BARACLUDE – Entecavir tab 1 mg.................................... 3
BEBULIN – Factor ix complex for inj 200-1200 unit.......... 42
BEBULIN VH – Factor ix complex for inj 200-1200
unit................................................................................... 42
benazepril & hydrochlorothiazide tab 10-12.5 mg
(Lotensin hct)................................................................. 14
benazepril & hydrochlorothiazide tab 20-12.5 mg
(Lotensin hct)................................................................. 14
benazepril & hydrochlorothiazide tab 20-25 mg
(Lotensin hct)................................................................. 14
benazepril & hydrochlorothiazide tab 5-6.25 mg..........14
benazepril hcl tab 10 mg (Lotensin).............................. 14
benazepril hcl tab 5 mg.................................................. 14
BENEFIX – Coagulation factor ix (recombinant) for inj
1000 unit..........................................................................42
2000 unit..........................................................................42
BENEFIX – Coagulation factor ix (recombinant) for inj 250
unit................................................................................... 42
3000 unit..........................................................................42
BENEFIX – Coagulation factor ix (recombinant) for inj 500
unit................................................................................... 42
BENICAR HCT – Olmesartan medoxomilhydrochlorothiazide tab 20-12.5 mg................................ 15
BENICAR HCT – Olmesartan medoxomilhydrochlorothiazide tab 40-12.5 mg................................ 15
BENICAR HCT – Olmesartan medoxomilhydrochlorothiazide tab 40-25 mg................................... 15
BENICAR – Olmesartan medoxomil tab 20 mg................ 15
BENICAR – Olmesartan medoxomil tab 40 mg................ 15
BENICAR – Olmesartan medoxomil tab 5 mg.................. 15
benzoyl peroxide-erythromycin gel 5-3%
(Benzamycin)..................................................................47
benztropine mesylate tab 0.5 mg...................................39
benztropine mesylate tab 1 mg..................................... 39
benztropine mesylate tab 2 mg..................................... 39
betamethasone dipropionate augmented cream 0.05%
(Diprolene af)................................................................. 48
betamethasone dipropionate augmented gel
0.05%...............................................................................48
betamethasone dipropionate augmented lotion 0.05%
(Diprolene)...................................................................... 48
betamethasone dipropionate augmented oint 0.05%
(Diprolene)...................................................................... 48
betamethasone dipropionate cream 0.05%...................48
betamethasone dipropionate lotion 0.05%................... 48
betamethasone dipropionate oint 0.05%...................... 49
betamethasone valerate cream 0.1%.............................49
betamethasone valerate lotion 0.1%............................. 49
betamethasone valerate oint 0.1%.................................49
BETASERON – Interferon beta-1b for inj kit 0.3 mg......... 31
bicalutamide tab 50 mg (Casodex).................................. 6
BILTRICIDE – Praziquantel tab 600 mg............................. 6
bisoprolol & hydrochlorothiazide tab 10-6.25 mg
(Ziac)............................................................................... 16
bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg
(Ziac)............................................................................... 16
bisoprolol & hydrochlorothiazide tab 5-6.25 mg
(Ziac)............................................................................... 16
bisoprolol fumarate tab 10 mg (Zebeta)........................16
bisoprolol fumarate tab 5 mg (Zebeta)..........................16
BREATHERITE – spacer/aerosol-holding chambers device...............................................................................50
BREO ELLIPTA – Fluticasone furoate-vilanterol aero
powd ba 100-25 mcg/inh.................................................22
brimonidine tartrate ophth soln 0.15% (Alphagan
p)......................................................................................46
brimonidine tartrate ophth soln 0.2%............................46
bromocriptine mesylate cap 5 mg (Parlodel)................39
bromocriptine mesylate tab 2.5 mg (Parlodel)..............39
budesonide cap sr 24hr 3 mg (Entocort ec)................... 8
budesonide inhalation susp 0.25 mg/2ml
(Pulmicort)...................................................................... 22
budesonide inhalation susp 0.5 mg/2ml
(Pulmicort)...................................................................... 22
bumetanide tab 0.5 mg................................................... 19
bumetanide tab 1 mg...................................................... 19
bumetanide tab 2 mg...................................................... 19
buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg (base
equiv).............................................................................. 33
buprenorphine hcl-naloxone hcl sl tab 8-2 mg (base
equiv).............................................................................. 33
buprenorphine hcl sl tab 2 mg (base equiv)................. 33
buprenorphine hcl sl tab 8 mg (base equiv)................. 33
bupropion hcl (smoking deterrent) tab sr 12hr 150 mg
(Zyban)............................................................................ 32
bupropion hcl tab 100 mg (Wellbutrin)......................... 27
55
2014
bupropion hcl tab 75 mg (Wellbutrin)........................... 27
bupropion hcl tab sr 12hr 100 mg (Wellbutrin sr)........ 27
bupropion hcl tab sr 24hr 150 mg (Wellbutrin xl).........27
bupropion hcl tab sr 24hr 300 mg (Wellbutrin xl).........27
buspirone hcl tab 10 mg................................................ 27
buspirone hcl tab 5 mg.................................................. 27
butalbital-acetaminophen-caffeine cap 50-325-40
mg....................................................................................33
butalbital-acetaminophen-caffeine tab 50-325-40
mg....................................................................................33
butalbital-acetaminophen-caffeine tab 50-500-40
mg....................................................................................33
butalbital-acetaminophen tab 50-325 mg...................... 33
butalbital-acetaminophen tab 50-650 mg...................... 33
butalbital-aspirin-caffeine cap 50-325-40 mg
(Fiorinal)..........................................................................33
butalbital-aspirin-caffeine tab 50-325-40 mg.................33
butalbital-aspirin-caff w/ codeine cap 50-325-40-30 mg
(Fiorinal/codeine #3)......................................................33
C
cabergoline tab 0.5 mg................................................... 13
caffeine citrate oral soln 60 mg/3ml (10 mg/ml base
equiv) (Cafcit).................................................................31
calcipotriene cream 0.005% (Dovonex).........................50
calcipotriene soln 0.005% (50 mcg/ml)..........................50
calcitonin (salmon) nasal soln 200 unit/act
(Miacalcin)...................................................................... 13
calcitriol cap 0.25 mcg (Rocaltrol).................................13
calcitriol cap 0.5 mcg (Rocaltrol)...................................13
calcitriol oral soln 1 mcg/ml (Rocaltrol)........................13
calcium acetate (phosphate binder) cap 667 mg (169
mg ca) (Phoslo)............................................................. 25
calcium acetate (phosphate binder) tab 667 mg
(Eliphos)..........................................................................25
CANASA – Mesalamine suppos 1000 mg........................ 25
capecitabine tab 150 mg (Xeloda)................................... 6
capecitabine tab 500 mg (Xeloda)................................... 6
captopril tab 100 mg....................................................... 14
captopril tab 12.5 mg...................................................... 14
captopril tab 25 mg......................................................... 14
captopril tab 50 mg......................................................... 14
CARAC – Fluorouracil cream 0.5%...................................50
carbamazepine cap sr 12hr 100 mg (Carbatrol)............37
carbamazepine chew tab 100 mg.................................. 38
carbamazepine susp 100 mg/5ml (Tegretol)................. 38
carbamazepine tab 200 mg (Tegretol)........................... 38
carbamazepine tab sr 12hr 200 mg (Tegretol-xr)..........38
carbamazepine tab sr 12hr 400 mg (Tegretol-xr)..........38
56
carbidopa & levodopa orally disintegrating tab 10-100
mg....................................................................................39
mg....................................................................................39
mg....................................................................................39
carbidopa & levodopa tab 10-100 mg (Sinemet)...........39
carbidopa & levodopa tab cr 25-100 mg (Sinemet
cr).................................................................................... 39
carbidopa & levodopa tab cr 50-200 mg (Sinemet
cr).................................................................................... 39
carteolol hcl ophth soln 1%........................................... 46
carvedilol tab 12.5 mg (Coreg).......................................16
carvedilol tab 25 mg (Coreg)..........................................16
carvedilol tab 3.125 mg (Coreg).....................................16
carvedilol tab 6.25 mg (Coreg).......................................16
CEENU – Lomustine cap 100 mg.......................................6
CEENU – Lomustine cap 10 mg.........................................6
CEENU – Lomustine cap 40 mg.........................................6
cefaclor cap 250 mg......................................................... 1
cefaclor cap 500 mg......................................................... 1
cefadroxil cap 500 mg...................................................... 1
cefadroxil for susp 250 mg/5ml....................................... 1
cefadroxil for susp 500 mg/5ml....................................... 1
cefadroxil tab 1 gm........................................................... 1
cefdinir cap 300 mg.......................................................... 1
cefdinir for susp 125 mg/5ml........................................... 1
cefdinir for susp 250 mg/5ml........................................... 1
cefpodoxime proxetil for susp 100 mg/5ml.................... 1
cefpodoxime proxetil for susp 50 mg/5ml...................... 1
cefpodoxime proxetil tab 100 mg.................................... 1
cefpodoxime proxetil tab 200 mg.................................... 1
cefprozil for susp 125 mg/5ml......................................... 1
cefprozil for susp 250 mg/5ml......................................... 1
cefprozil tab 250 mg......................................................... 1
cefprozil tab 500 mg......................................................... 1
ceftriaxone sodium for inj 1 gm (Rocephin)................... 1
ceftriaxone sodium for inj 250 mg...................................1
ceftriaxone sodium for inj 2 gm...................................... 1
ceftriaxone sodium for inj 500 mg (Rocephin)............... 1
cefuroxime axetil for susp 125 mg/5ml (Ceftin)..............1
cefuroxime axetil tab 250 mg (Ceftin)............................. 1
cefuroxime axetil tab 500 mg (Ceftin)............................. 1
CELEBREX – Celecoxib cap 100 mg............................... 36
CELEBREX – Celecoxib cap 50 mg................................. 36
CELLCEPT – Mycophenolate mofetil cap 250 mg............ 50
CELLCEPT – Mycophenolate mofetil for oral susp 200 mg/
ml..................................................................................... 50
CELLCEPT – Mycophenolate mofetil tab 500 mg............. 50
CELONTIN – Methsuximide cap 300 mg.......................... 38
cephalexin cap 250 mg (Keflex).......................................1
cephalexin cap 500 mg (Keflex).......................................2
2014
cephalexin for susp 125 mg/5ml......................................2
cephalexin for susp 250 mg/5ml......................................2
cetirizine hcl oral soln 1 mg/ml (5 mg/5ml)...................21
cevimeline hcl cap 30 mg (Evoxac)...............................47
CHANTIX CONTINUING MONTH – Varenicline tartrate
tab 1 mg (base equiv)..................................................... 32
CHANTIX STARTING MONTH PA – Varenicline tartrate
tab 0.5 mg x 11 & tab 1 mg x 42 pack............................ 32
CHANTIX – Varenicline tartrate tab 0.5 mg (base
equiv)............................................................................... 32
CHANTIX – Varenicline tartrate tab 1 mg (base equiv)..... 32
CHEMET – Succimer cap 100 mg.................................... 50
CHENODAL – Chenodiol tab 250 mg...............................25
chlorhexidine gluconate soln 0.12% (Peridex)............. 47
chloroquine phosphate tab 250 mg.................................5
chloroquine phosphate tab 500 mg (Aralen).................. 5
chlorothiazide tab 250 mg.............................................. 19
chlorothiazide tab 500 mg.............................................. 19
chlorpromazine hcl tab 100 mg..................................... 29
chlorpromazine hcl tab 10 mg....................................... 29
chlorpromazine hcl tab 200 mg..................................... 29
chlorzoxazone tab 500 mg (Parafon forte dsc).............40
cholestyramine light powder 4 gm/dose (Questran
light)................................................................................ 18
cholestyramine light powder packets 4 gm..................18
cholestyramine powder 4 gm/dose (Questran)............ 18
cholestyramine powder packets 4 gm (Questran)........18
choline fenofibrate cap dr 135 mg (fenofibric acid
equiv) (Trilipix)............................................................... 18
choline fenofibrate cap dr 45 mg (fenofibric acid
equiv) (Trilipix)............................................................... 18
chorionic gonadotropin for inj 10000 unit.................... 10
CIALIS – Tadalafil tab 10 mg............................................21
CIALIS – Tadalafil tab 2.5 mg...........................................21
CIALIS – Tadalafil tab 20 mg............................................21
CIALIS – Tadalafil tab 5 mg..............................................21
ciclopirox gel 0.77% (Loprox)........................................ 48
ciclopirox olamine cream 0.77% (base equiv).............. 48
ciclopirox olamine susp 0.77% (base equiv)................ 48
ciclopirox shampoo 1% (Loprox shampoo)..................48
ciclopirox solution 8% (Penlac nail lacquer)................ 48
cilostazol tab 100 mg (Pletal).........................................42
cilostazol tab 50 mg (Pletal)...........................................42
cimetidine hcl soln 300 mg/5ml..................................... 24
cimetidine tab 300 mg.................................................... 24
CIPRODEX – Ciprofloxacin-dexamethasone otic susp
0.3-0.1%...........................................................................47
ciprofloxacin-ciprofloxacin hcl tab sr 24hr 1000
mg(base eq) (Cipro xr)....................................................2
ciprofloxacin-ciprofloxacin hcl tab sr 24hr 500 mg
(base eq) (Cipro xr)......................................................... 2
ciprofloxacin for oral susp 250 mg/5ml (5%) (5
gm/100ml) (Cipro)............................................................ 2
ciprofloxacin for oral susp 500 mg/5ml (10%) (10
gm/100ml) (Cipro)............................................................ 2
ciprofloxacin hcl ophth soln 0.3% (Ciloxan).................45
ciprofloxacin hcl tab 100 mg (base equiv)......................2
ciprofloxacin hcl tab 250 mg (base equiv) (Cipro)......... 2
ciprofloxacin hcl tab 500 mg (base equiv) (Cipro)......... 2
ciprofloxacin hcl tab 750 mg (base equiv)......................2
citalopram hydrobromide oral soln 10 mg/5ml.............27
citalopram hydrobromide tab 10 mg (base equiv)
(Celexa)........................................................................... 27
(Celexa)........................................................................... 27
(Celexa)........................................................................... 27
clarithromycin for susp 125 mg/5ml................................2
clarithromycin for susp 250 mg/5ml (Biaxin)..................2
clarithromycin tab 250 mg (Biaxin)................................. 2
clarithromycin tab 500 mg (Biaxin)................................. 2
clarithromycin tab sr 24hr 500 mg (Biaxin xl pac)..........2
CLEOCIN – Clindamycin phosphate vaginal suppos 100
mg.................................................................................... 26
clindamycin hcl cap 150 mg (Cleocin)............................ 6
clindamycin hcl cap 300 mg (Cleocin)............................ 6
clindamycin hcl cap 75 mg (Cleocin).............................. 6
clindamycin palmitate hcl for soln 75 mg/5ml (base
equiv) (Cleocin pediatric gr)...........................................6
clindamycin phosphate-benzoyl peroxide gel 1-5%
(Benzaclin)......................................................................47
clindamycin phosphate gel 1% (Cleocin-t)................... 47
clindamycin phosphate lotion 1% (Cleocin-t)...............47
clindamycin phosphate soln 1% (Cleocin-t)................. 47
clindamycin phosphate swab 1% (Cleocin-t)................47
clindamycin phosphate vaginal cream 2%
(Cleocin)..........................................................................26
clindamycin phosph-benzoyl peroxide (refrig) gel 1.2
(1)-5% (Duac)..................................................................47
clobetasol propionate cream 0.05% (Temovate).......... 49
clobetasol propionate emollient base cream 0.05%
(Temovate e).................................................................. 49
clobetasol propionate foam 0.05% (Olux).....................49
clobetasol propionate gel 0.05% (Temovate)................49
clobetasol propionate oint 0.05% (Temovate).............. 49
clobetasol propionate soln 0.05% (Temovate)............. 49
clomiphene citrate tab 50 mg (Clomid)......................... 10
clomipramine hcl cap 25 mg (Anafranil)....................... 27
clonazepam tab 0.5 mg (Klonopin)................................38
clonazepam tab 1 mg (Klonopin)...................................38
clonazepam tab 2 mg (Klonopin)...................................38
clonidine hcl tab 0.1 mg (Catapres).............................. 20
57
2014
clonidine hcl td patch weekly 0.1 mg/24hr (Cataprestts-1)................................................................................ 20
clopidogrel bisulfate tab 75 mg (base equiv)
(Plavix)............................................................................ 42
clotrimazole troche 10 mg..............................................47
clozapine tab 100 mg (Clozaril)..................................... 29
clozapine tab 200 mg......................................................29
clozapine tab 25 mg (Clozaril)....................................... 29
clozapine tab 50 mg........................................................29
CODEINE SULFATE – Codeine sulfate tab 15 mg........... 33
colchicine w/ probenecid tab 0.5-500 mg......................37
COLCRYS – Colchicine tab 0.6 mg.................................. 37
colestipol hcl granule packets 5 gm (Colestid
flavored)..........................................................................18
colestipol hcl granules 5 gm (Colestid flavored)..........18
colestipol hcl tab 1 gm (Colestid)..................................18
COMBIPATCH – Estradiol-norethindrone ace td pttw
0.05-0.14 mg/day...............................................................9
COMBIPATCH – Estradiol-norethindrone ace td pttw
0.05-0.25 mg/day...............................................................9
COMBIVENT – Ipratropium-albuterol aerosol 18-103 mcg/
act (20-120mcg/act).........................................................22
COMBIVENT RESPIMAT – Ipratropium-albuterol inhal
aerosol soln 20-100 mcg/act........................................... 22
COPAXONE – Glatiramer acetate inj kit 20 mg/ml............31
COPAXONE – Glatiramer acetate soln prefilled syringe 40
mg/ml............................................................................... 31
CORIFACT – Factor xiii concentrate (human) for inj kit
1000-1600 unit.................................................................42
CORTIFOAM – Hydrocortisone acetate rectal foam 90 mg/
dose................................................................................. 47
CORTISONE ACETATE – Cortisone acetate tab 25 mg.....8
CREON – Pancrelipase (lip-prot-amyl) dr cap
12000-38000-60000 unit..................................................25
24000-76000-120000 unit................................................25
3000-9500-15000 unit......................................................25
36000-114000-180000 unit..............................................25
6000-19000-30000 unit....................................................25
CRESTOR – Rosuvastatin calcium tab 10 mg..................18
CRESTOR – Rosuvastatin calcium tab 5 mg....................18
CRINONE – Progesterone vaginal gel 4%........................26
CRINONE – Progesterone vaginal gel 8%........................26
CRIXIVAN – Indinavir sulfate cap 200 mg.......................... 4
CRIXIVAN – Indinavir sulfate cap 400 mg.......................... 4
cromolyn sodium ophth soln 4%...................................46
cromolyn sodium soln nebu 20 mg/2ml........................22
58
CUPRIMINE – Penicillamine cap 250 mg......................... 50
cyanocobalamin inj 1000 mcg/ml.................................. 42
cyclobenzaprine hcl tab 10 mg......................................40
cyclobenzaprine hcl tab 5 mg........................................40
cyclopentolate hcl ophth soln 1% (Cyclogyl)............... 47
CYCLOPHOSPHAMIDE – Cyclophosphamide tab 25
mg...................................................................................... 6
CYCLOPHOSPHAMIDE – Cyclophosphamide tab 50
mg...................................................................................... 6
cyclosporine cap 100 mg (Sandimmune)......................50
cyclosporine cap 25 mg (Sandimmune)........................51
cyclosporine modified cap 100 mg (Neoral)................. 51
cyclosporine modified cap 25 mg (Neoral)................... 51
CYCLOSPORINE MODIFIED – Cyclosporine modified cap
50 mg...............................................................................51
cyclosporine modified oral soln 100 mg/ml
(Neoral)........................................................................... 51
cyproheptadine hcl syrup 2 mg/5ml..............................21
cyproheptadine hcl tab 4 mg......................................... 21
CYSTAGON – Cysteamine bitartrate cap 150 mg............ 26
CYSTAGON – Cysteamine bitartrate cap 50 mg.............. 26
D
danazol cap 100 mg..........................................................8
danazol cap 200 mg..........................................................8
danazol cap 50 mg............................................................8
dantrolene sodium cap 25 mg (Dantrium).................... 40
dantrolene sodium cap 50 mg (Dantrium).................... 40
DAPSONE – Dapsone tab 100 mg.....................................6
DAPSONE – Dapsone tab 25 mg.......................................6
DARAPRIM – Pyrimethamine tab 25 mg............................ 5
DELZICOL – Mesalamine cap dr 400 mg......................... 25
demeclocycline hcl tab 150 mg....................................... 2
demeclocycline hcl tab 300 mg....................................... 2
desipramine hcl tab 100 mg (Norpramin)......................27
desipramine hcl tab 10 mg (Norpramin)....................... 27
desipramine hcl tab 150 mg (Norpramin)......................27
desmopressin acetate inj 4 mcg/ml (Ddavp)................ 13
desmopressin acetate nasal soln 0.01% (refrigerated)
(Ddavp)............................................................................13
desmopressin acetate nasal spray soln 0.01%
(Ddavp)............................................................................13
desmopressin acetate nasal spray soln 0.01%
(refrigerated)...................................................................13
desmopressin acetate tab 0.1 mg (Ddavp)................... 13
desmopressin acetate tab 0.2 mg (Ddavp)................... 13
desonide cream 0.05% (Desowen).................................49
desonide lotion 0.05% (Desowen)................................. 49
desonide oint 0.05% (Desowen).................................... 49
desoximetasone cream 0.25% (Topicort)......................49
desoximetasone gel 0.05% (Topicort)........................... 49
desoximetasone oint 0.25% (Topicort)..........................49
2014
DEXAMETHASONE – Dexamethasone soln 0.5
mg/5ml............................................................................... 8
dexamethasone elixir 0.5 mg/5ml.................................... 8
dexamethasone sodium phosphate ophth soln
0.1%.................................................................................46
dexamethasone tab 0.5 mg.............................................. 8
dexamethasone tab 0.75 mg............................................ 8
dexamethasone tab 1.5 mg.............................................. 8
dexamethasone tab 4 mg................................................. 8
dexamethasone tab 6 mg................................................. 8
dextroamphetamine sulfate cap sr 24hr 10 mg
(Dexedrine)..................................................................... 31
(Dexedrine)..................................................................... 31
(Dexedrine)..................................................................... 31
dextroamphetamine sulfate tab 5 mg............................31
DIASTAT ACUDIAL – Diazepam rectal gel delivery system
10 mg...............................................................................38
DIASTAT ACUDIAL – Diazepam rectal gel delivery system
20 mg...............................................................................38
DIASTAT PEDIATRIC – Diazepam rectal gel delivery
system 2.5 mg................................................................. 38
DIAZEPAM – Diazepam soln 1 mg/ml.............................. 27
diazepam tab 10 mg (Valium).........................................27
diazepam tab 2 mg (Valium)...........................................27
diazepam tab 5 mg (Valium)...........................................27
DIBENZYLINE – Phenoxybenzamine hcl cap 10 mg........ 20
diclofenac potassium tab 50 mg (Cataflam)................. 36
diclofenac sodium (actinic keratoses) gel 3%
(Solaraze)........................................................................50
diclofenac sodium ophth soln 0.1%.............................. 47
diclofenac sodium tab delayed release 25 mg............. 36
diclofenac sodium tab sr 24hr 100 mg (Voltarenxr).................................................................................... 36
dicloxacillin sodium cap 250 mg..................................... 1
dicloxacillin sodium cap 500 mg..................................... 1
dicyclomine hcl cap 10 mg (Bentyl).............................. 24
dicyclomine hcl tab 20 mg (Bentyl)...............................24
didanosine delayed release capsule 125 mg (Videx
ec)......................................................................................4
ec)......................................................................................4
ec)......................................................................................4
ec)......................................................................................4
DIFFERIN – Adapalene gel 0.3%..................................... 47
diflorasone diacetate oint 0.05%................................... 49
digoxin tab 125 mcg (0.125 mg) (Lanoxin)....................20
digoxin tab 250 mcg (0.25 mg) (Lanoxin)......................20
DILANTIN – Phenytoin sodium extended cap 30 mg........ 38
diltiazem hcl cap sr 24hr 120 mg...................................17
diltiazem hcl coated beads cap sr 24hr 120 mg
(Cardizem cd)................................................................. 17
(Cardizem cd)................................................................. 17
(Cardizem cd)................................................................. 17
(Cardizem cd)................................................................. 17
(Cardizem cd)................................................................. 17
diltiazem hcl extended release beads cap sr 24hr 120
mg (Tiazac).....................................................................17
mg (Tiazac).....................................................................17
mg (Tiazac).....................................................................17
mg (Tiazac).....................................................................17
mg (Tiazac).....................................................................17
mg (Tiazac).....................................................................17
diltiazem hcl tab 120 mg (Cardizem)............................. 17
diltiazem hcl tab 30 mg (Cardizem)............................... 17
diltiazem hcl tab 60 mg (Cardizem)............................... 17
diltiazem hcl tab 90 mg.................................................. 17
diphenoxylate w/ atropine tab 2.5-0.025 mg
(Lomotil)..........................................................................24
dipyridamole tab 25 mg (Persantine)............................ 42
disopyramide phosphate cap 100 mg (Norpace)..........20
disopyramide phosphate cap 150 mg (Norpace)..........20
disulfiram tab 250 mg (Antabuse)................................. 32
disulfiram tab 500 mg (Antabuse)................................. 32
divalproex sodium cap sprinkle 125 mg (Depakote
sprinkles)........................................................................ 38
divalproex sodium tab delayed release 125 mg
(Depakote)...................................................................... 38
(Depakote)...................................................................... 38
(Depakote)...................................................................... 38
divalproex sodium tab sr 24 hr 250 mg (Depakote
er).................................................................................... 38
divalproex sodium tab sr 24 hr 500 mg (Depakote
er).................................................................................... 38
DIVIGEL – Estradiol td gel 0.25 mg/0.25gm (0.1%)............ 9
DIVIGEL – Estradiol td gel 0.5 mg/0.5gm (0.1%)................9
DIVIGEL – Estradiol td gel 1 mg/gm (0.1%)....................... 9
donepezil hydrochloride orally disintegrating tab 10
mg (Aricept odt).............................................................32
donepezil hydrochloride orally disintegrating tab 5 mg
(Aricept odt)................................................................... 32
donepezil hydrochloride tab 10 mg (Aricept)............... 32
59
2014
donepezil hydrochloride tab 5 mg (Aricept)................. 32
dorzolamide hcl ophth soln 2% (Trusopt).....................46
dorzolamide hcl-timolol maleate ophth soln 22.3-6.8
mg/ml (Cosopt).............................................................. 46
doxazosin mesylate tab 1 mg (Cardura)....................... 20
doxepin hcl cap 100 mg................................................. 28
doxepin hcl cap 10 mg................................................... 28
doxepin hcl conc 10 mg/ml............................................ 28
doxycycline hyclate cap 100 mg (Vibramycin)............... 2
doxycycline hyclate cap 50 mg....................................... 2
doxycycline hyclate tab 100 mg...................................... 2
doxycycline hyclate tab 20 mg........................................ 2
doxycycline monohydrate cap 100 mg (Monodox)........ 2
doxycycline monohydrate cap 150 mg (Adoxa)............. 2
doxycycline monohydrate cap 50 mg............................. 2
doxycycline monohydrate cap 75 mg (Monodox).......... 2
doxycycline monohydrate tab 100 mg (Adoxa pak
1/100).................................................................................2
doxycycline monohydrate tab 150 mg (Adoxa pak
1/150).................................................................................2
doxycycline monohydrate tab 50 mg (Adoxa)................ 2
doxycycline monohydrate tab 75 mg (Adoxa)................ 2
DROXIA – Hydroxyurea cap 200 mg................................ 42
DULERA – Mometasone furoate-formoterol fumarate
aerosol 100-5 mcg/act..................................................... 22
DULERA – Mometasone furoate-formoterol fumarate
aerosol 200-5 mcg/act..................................................... 22
duloxetine hcl enteric coated pellets cap 20 mg
(Cymbalta)...................................................................... 28
(Cymbalta)...................................................................... 28
(Cymbalta)...................................................................... 28
E
econazole nitrate cream 1%........................................... 48
ELIDEL – Pimecrolimus cream 1%................................... 50
ELLA – Ulipristal acetate tab 30 mg................................... 9
EMCYT – Estramustine phosphate sodium cap 140 mg..... 6
EMEND – Aprepitant capsule 125 mg.............................. 24
EMEND – Aprepitant capsule 40 mg................................ 24
EMEND – Aprepitant capsule 80 mg................................ 24
EMEND – Aprepitant capsule therapy pack 80 & 125
mg.................................................................................... 25
EMTRIVA – Emtricitabine caps 200 mg..............................4
EMTRIVA – Emtricitabine soln 10 mg/ml............................ 4
enalapril maleate & hydrochlorothiazide tab 10-25 mg
(Vaseretic).......................................................................14
60
enalapril maleate & hydrochlorothiazide tab 5-12.5
mg....................................................................................14
enalapril maleate tab 10 mg (Vasotec).......................... 14
enalapril maleate tab 2.5 mg (Vasotec)......................... 14
enalapril maleate tab 20 mg (Vasotec).......................... 14
enalapril maleate tab 5 mg (Vasotec)............................ 14
ENBREL – Etanercept for subcutaneous inj kit 25 mg...... 36
ENBREL – Etanercept subcutaneous inj 25 mg/0.5ml...... 36
ENBREL – Etanercept subcutaneous inj 50 mg/ml........... 36
ENBREL SURECLICK – Etanercept subcutaneous inj 50
mg/ml............................................................................... 36
ENJUVIA – Estrogens, conjugated synthetic b tab 0.3
mg...................................................................................... 9
mg...................................................................................... 9
mg...................................................................................... 9
mg...................................................................................... 9
mg...................................................................................... 9
enoxaparin sodium inj 100 mg/ml (Lovenox)............... 43
enoxaparin sodium inj 120 mg/0.8ml (Lovenox)...........43
enoxaparin sodium inj 150 mg/ml (Lovenox)............... 43
enoxaparin sodium inj 300 mg/3ml (Lovenox)..............43
enoxaparin sodium inj 30 mg/0.3ml (Lovenox).............43
entacapone tab 200 mg (Comtan)..................................39
EPIPEN 2-PAK – Epinephrine solution auto-injector 0.3
mg/0.3ml (1:1000)............................................................21
EPIPEN-JR 2-PAK – Epinephrine solution auto-injector
0.15 mg/0.3ml (1:2000)................................................... 21
EPIVIR – Lamivudine oral soln 10 mg/ml........................... 4
eplerenone tab 25 mg (Inspra).......................................21
eplerenone tab 50 mg (Inspra).......................................21
EPOGEN – Epoetin alfa inj 10000 unit/ml........................ 43
EPOGEN – Epoetin alfa inj 20000 unit/ml........................ 43
EPOGEN – Epoetin alfa inj 2000 unit/ml.......................... 43
EPZICOM – Abacavir sulfate-lamivudine tab 600-300
mg...................................................................................... 4
ergocalciferol cap 50000 unit (Drisdol)......................... 40
erythromycin gel 2% (Erygel).........................................47
erythromycin ophth oint 5 mg/gm................................. 45
erythromycin pads 2%....................................................48
erythromycin soln 2%.....................................................48
erythromycin-sulfisoxazole for susp 200-600
mg/5ml.............................................................................. 6
erythromycin w/ delayed release particles cap 250
mg......................................................................................2
escitalopram oxalate soln 5 mg/5ml (base equiv)
(Lexapro).........................................................................28
2014
escitalopram oxalate tab 10 mg (base equiv)
(Lexapro).........................................................................28
(Lexapro).........................................................................28
(Lexapro).........................................................................28
estazolam tab 1 mg.........................................................30
estazolam tab 2 mg.........................................................30
ESTRACE – Estradiol vaginal cream 0.1 mg/gm.............. 26
estradiol & norethindrone acetate tab 0.5-0.1 mg
(Activella)..........................................................................9
estradiol & norethindrone acetate tab 1-0.5 mg
(Activella)..........................................................................9
estradiol tab 0.5 mg (Estrace)..........................................9
estradiol tab 1 mg (Estrace).............................................9
estradiol tab 2 mg (Estrace).............................................9
estradiol td patch weekly 0.025 mg/24hr (Climara)........ 9
estradiol td patch weekly 0.0375 mg/24hr (37.5
mcg/24hr) (Climara)......................................................... 9
estradiol td patch weekly 0.05 mg/24hr (Climara).......... 9
estradiol td patch weekly 0.06 mg/24hr (Climara).......... 9
estradiol td patch weekly 0.075 mg/24hr (Climara)........ 9
estradiol td patch weekly 0.1 mg/24hr (Climara)............ 9
estropipate tab 0.75 mg....................................................9
estropipate tab 1.5 mg......................................................9
ethambutol hcl tab 100 mg (Myambutol)........................ 3
ethambutol hcl tab 400 mg (Myambutol)........................ 3
ethosuximide cap 250 mg (Zarontin).............................38
ethosuximide soln 250 mg/5ml (Zarontin).................... 38
etodolac cap 200 mg.......................................................36
etodolac cap 300 mg.......................................................36
etodolac tab 400 mg....................................................... 36
etodolac tab 500 mg....................................................... 36
etodolac tab sr 24hr 400 mg.......................................... 36
EXELON – Rivastigmine tartrate soln 2 mg/ml................. 32
EXELON – Rivastigmine td patch 24hr 13.3 mg/24hr....... 32
EXELON – Rivastigmine td patch 24hr 4.6 mg/24hr......... 32
EXELON – Rivastigmine td patch 24hr 9.5 mg/24hr......... 32
exemestane tab 25 mg (Aromasin)..................................6
F
famciclovir tab 125 mg (Famvir)...................................... 4
famotidine tab 20 mg (Pepcid).......................................24
famotidine tab 40 mg (Pepcid).......................................24
FARESTON – Toremifene citrate tab 60 mg (base
equivalent)......................................................................... 6
FEIBA NF – antiinhibitor coagulant complex for inj........... 43
felodipine tab sr 24hr 10 mg.......................................... 17
felodipine tab sr 24hr 2.5 mg......................................... 17
felodipine tab sr 24hr 5 mg............................................17
fenofibrate micronized cap 134 mg (Lofibra)................19
fenofibrate micronized cap 200 mg (Lofibra)................19
fenofibrate micronized cap 67 mg (Lofibra)..................19
fenofibrate tab 145 mg (Tricor)...................................... 19
fenofibrate tab 160 mg (Lofibra).................................... 19
fenofibrate tab 48 mg (Tricor)........................................ 19
fenofibrate tab 54 mg (Lofibra)...................................... 19
fentanyl citrate lollipop 1200 mcg (Actiq)..................... 33
fentanyl citrate lollipop 1600 mcg (Actiq)..................... 33
fentanyl citrate lollipop 200 mcg (Actiq)....................... 33
fentanyl td patch 72hr 100 mcg/hr (Duragesic)............ 33
fentanyl td patch 72hr 12 mcg/hr (Duragesic).............. 33
FINACEA – Azelaic acid gel 15%..................................... 48
finasteride tab 5 mg (Proscar)....................................... 26
FIRAZYR – Icatibant acetate inj 30 mg/3ml (base
equivalent)....................................................................... 43
flecainide acetate tab 100 mg........................................ 20
flecainide acetate tab 150 mg........................................ 20
flecainide acetate tab 50 mg.......................................... 20
FLOVENT DISKUS – Fluticasone propionate aer pow ba
100 mcg/blister................................................................ 23
250 mcg/blister................................................................ 23
50 mcg/blister.................................................................. 22
FLOVENT HFA – Fluticasone propionate hfa inhal aer 110
mcg/act (125/valve)......................................................... 23
FLOVENT HFA – Fluticasone propionate hfa inhal aer 220
mcg/act (250/valve)......................................................... 23
FLOVENT HFA – Fluticasone propionate hfa inhal aero 44
mcg/act (50/valve)........................................................... 23
fluconazole for susp 10 mg/ml (Diflucan)....................... 3
fluconazole for susp 40 mg/ml (Diflucan)....................... 3
fluconazole tab 100 mg (Diflucan)................................... 3
fluconazole tab 50 mg (Diflucan).....................................3
flucytosine cap 250 mg (Ancobon)..................................3
flucytosine cap 500 mg (Ancobon)..................................3
fludrocortisone acetate tab 0.1 mg..................................8
flunisolide nasal soln 0.025% (Flunisolide).................. 21
fluocinolone acetonide cream 0.01%............................ 49
fluocinolone acetonide cream 0.025% (Synalar).......... 49
fluocinolone acetonide oil 0.01% (Derma-smoothe/fs
bod)................................................................................. 49
fluocinolone acetonide oint 0.025% (Synalar).............. 49
fluocinolone acetonide soln 0.01% (Synalar)............... 49
fluocinonide cream 0.05%.............................................. 49
fluocinonide emulsified base cream 0.05%.................. 49
fluocinonide gel 0.05%................................................... 49
fluocinonide oint 0.05%.................................................. 49
fluocinonide soln 0.05%................................................. 49
61
2014
fluorometholone ophth susp 0.1% (Fml liquifilm)........ 46
FLUOROPLEX – Fluorouracil cream 1%.......................... 50
fluorouracil cream 5% (Efudex)..................................... 50
fluorouracil soln 2%........................................................50
fluorouracil soln 5%........................................................50
fluoxetine hcl cap 10 mg (Prozac)................................. 28
fluoxetine hcl solution 20 mg/5ml................................. 28
fluoxetine hcl tab 10 mg.................................................28
fluoxetine hcl tab 20 mg.................................................28
fluphenazine decanoate inj 25 mg/ml............................29
FLUPHENAZINE HCL – Fluphenazine hcl elixir 2.5
mg/5ml............................................................................. 29
FLUPHENAZINE HCL – Fluphenazine hcl oral conc 5 mg/
ml..................................................................................... 29
fluphenazine hcl tab 10 mg............................................ 29
fluphenazine hcl tab 1 mg..............................................29
fluphenazine hcl tab 2.5 mg........................................... 29
fluphenazine hcl tab 5 mg..............................................29
flurbiprofen sodium ophth soln 0.03% (Ocufen).......... 47
flurbiprofen tab 100 mg.................................................. 36
flurbiprofen tab 50 mg.................................................... 36
flutamide cap 125 mg....................................................... 6
fluticasone propionate cream 0.05% (Cutivate)............49
fluticasone propionate nasal susp 50 mcg/act
(Flonase)......................................................................... 21
fluticasone propionate oint 0.005% (Cutivate)..............49
fluvoxamine maleate tab 100 mg................................... 28
fluvoxamine maleate tab 25 mg.....................................28
fluvoxamine maleate tab 50 mg.....................................28
folic acid tab 1 mg.......................................................... 43
FOLLISTIM AQ – Follitropin beta inj 150 unit/0.5ml.......... 10
FOLLISTIM AQ – Follitropin beta inj 300 unit/0.36ml........ 10
FOLLISTIM AQ – Follitropin beta inj 75 unit/0.5ml............ 10
FORADIL AEROLIZER – Formoterol fumarate inhal cap
12 mcg.............................................................................23
FORTEO – Teriparatide (recombinant) inj 600
mcg/2.4ml........................................................................ 13
fosinopril sodium & hydrochlorothiazide tab 10-12.5
mg....................................................................................14
fosinopril sodium & hydrochlorothiazide tab 20-12.5
mg....................................................................................14
fosinopril sodium tab 10 mg.......................................... 14
furosemide oral soln 10 mg/ml...................................... 19
furosemide tab 20 mg (Lasix)........................................ 19
FUZEON – Enfuvirtide for inj 90 mg................................... 4
G
gabapentin cap 100 mg (Neurontin).............................. 38
62
gabapentin oral soln 250 mg/5ml (Neurontin).............. 38
gabapentin tab 600 mg (Neurontin)...............................38
gabapentin tab 800 mg (Neurontin)...............................38
GABITRIL – Tiagabine hcl tab 12 mg............................... 38
GABITRIL – Tiagabine hcl tab 16 mg............................... 38
galantamine hydrobromide cap sr 24hr 16 mg
(Razadyne er)................................................................. 32
(Razadyne er)................................................................. 32
(Razadyne er)................................................................. 32
galantamine hydrobromide oral soln 4 mg/ml
(Razadyne)......................................................................32
galantamine hydrobromide tab 12 mg (Razadyne).......32
galantamine hydrobromide tab 4 mg (Razadyne)........ 32
galantamine hydrobromide tab 8 mg (Razadyne)........ 32
GANIRELIX ACETATE – Ganirelix acetate inj 250
mcg/0.5ml........................................................................ 10
gemfibrozil tab 600 mg (Lopid)......................................19
gentamicin sulfate ophth oint 0.3%...............................45
gentamicin sulfate ophth soln 0.3% (Garamycin)........ 45
GLEEVEC – Imatinib mesylate tab 100 mg (base
equivalent)......................................................................... 6
GLEEVEC – Imatinib mesylate tab 400 mg (base
equivalent)......................................................................... 6
glimepiride tab 1 mg (Amaryl)....................................... 10
glipizide-metformin hcl tab 2.5-250 mg......................... 10
glipizide-metformin hcl tab 2.5-500 mg......................... 10
glipizide-metformin hcl tab 5-500 mg............................ 10
glipizide tab 10 mg (Glucotrol)...................................... 10
glipizide tab 5 mg (Glucotrol)........................................ 10
glipizide tab sr 24hr 10 mg (Glucotrol xl)......................10
glipizide tab sr 24hr 2.5 mg (Glucotrol xl).....................10
glipizide tab sr 24hr 5 mg (Glucotrol xl)....................... 10
GLUCAGON EMERGENCY KIT – Glucagon (rdna) for inj
kit 1 mg............................................................................10
(Glucovance).................................................................. 10
glyburide-metformin tab 2.5-500 mg (Glucovance)...... 10
glyburide-metformin tab 5-500 mg (Glucovance)......... 10
glyburide micronized tab 1.5 mg (Glynase).................. 10
glyburide micronized tab 3 mg (Glynase)..................... 10
glyburide micronized tab 6 mg (Glynase)..................... 10
glyburide tab 1.25 mg..................................................... 10
glyburide tab 2.5 mg....................................................... 10
glyburide tab 5 mg.......................................................... 10
glycopyrrolate tab 1 mg (Robinul).................................24
glycopyrrolate tab 2 mg (Robinul forte)........................24
granisetron hcl tab 1 mg................................................ 25
griseofulvin microsize susp 125 mg/5ml........................ 3
griseofulvin microsize tab 500 mg (Grifulvin v)............. 3
guanfacine hcl tab 1 mg (Tenex)................................... 21
2014
guanfacine hcl tab 2 mg (Tenex)................................... 21
H
halobetasol propionate cream 0.05% (Ultravate)......... 49
halobetasol propionate oint 0.05% (Ultravate)............. 49
haloperidol decanoate im soln 100 mg/ml (Haldol
decanoate 100)...............................................................29
haloperidol decanoate im soln 50 mg/ml (Haldol
decanoate 50).................................................................29
haloperidol lactate oral conc 2 mg/ml...........................29
haloperidol tab 0.5 mg....................................................29
haloperidol tab 10 mg.....................................................29
haloperidol tab 1 mg.......................................................29
haloperidol tab 20 mg.....................................................29
HELIXATE FS – Antihemophilic factor (recombinant) for inj
kit 1000 unit..................................................................... 43
kit 2000 unit..................................................................... 43
kit 250 unit.......................................................................43
kit 3000 unit..................................................................... 43
kit 500 unit.......................................................................43
HEMOFIL M – Antihemophilic factor (human) for inj 1000
unit................................................................................... 43
HEMOFIL M – Antihemophilic factor (human) for inj
1501-2000 unit.................................................................43
unit................................................................................... 43
220-400 unit.....................................................................43
unit................................................................................... 43
401-800 unit.....................................................................43
unit................................................................................... 43
801-1500 unit...................................................................43
homatropine hbr ophth soln 5% (Isopto
homatropine).................................................................. 47
HUMALOG – Insulin lispro (human) inj 100 unit/ml...........11
HUMALOG – Insulin lispro (human) soln cartridge 100
unit/ml.............................................................................. 11
HUMALOG KWIKPEN – Insulin lispro (human) soln peninjector 100 unit/ml.......................................................... 11
HUMALOG MIX 50/50 – Insulin lispro prot & lispro
(human) inj 100 unit/ml (50-50)....................................... 12
HUMALOG MIX 50/50 KWIKPEN – Insulin lispro prot &
lispro sus pen-inj 100 unit/ml (50-50).............................. 12
HUMALOG MIX 75/25 – Insulin lispro prot & lispro
(human) inj 100 unit/ml (75-25)....................................... 12
HUMALOG MIX 75/25 KWIKPEN – Insulin lispro prot &
lispro sus pen-inj 100 unit/ml (75-25).............................. 12
HUMATE-P – Antihemophilic factor/vwf (human) for inj
1000-2400 unit.................................................................43
250-600 unit.....................................................................43
500-1200 unit...................................................................43
HUMIRA – Adalimumab inj kit 20 mg/0.4ml...................... 36
HUMIRA – Adalimumab inj kit 40 mg/0.8ml (50 mg/
ml).................................................................................... 36
HUMIRA PEN – Adalimumab inj kit 40 mg/0.8ml (50 mg/
ml).................................................................................... 36
HUMIRA PEN-CROHNS DISEASE – Adalimumab inj kit
40 mg/0.8ml (50 mg/ml).................................................. 36
HUMIRA PEN-PSORIASIS STAR – Adalimumab inj kit 40
mg/0.8ml (50 mg/ml)....................................................... 36
HUMULIN 70/30 – Insulin isophane & regular (human) inj
100 unit/ml (70-30).......................................................... 12
HUMULIN 70/30 KWIKPEN – Insulin isophane & regular
susp pen-inj 100 unit/ml (70-30)......................................12
HUMULIN 70/30 PEN – Insulin isophane & regular susp
pen-inj 100 unit/ml (70-30).............................................. 12
HUMULIN N – Insulin isophane (human) inj 100 unit/
ml..................................................................................... 12
HUMULIN N KWIKPEN – Insulin isophane (human) susp
pen-injector 100 unit/ml................................................... 12
HUMULIN N U-100 PEN – Insulin isophane (human) susp
pen-injector 100 unit/ml................................................... 12
HUMULIN R – Insulin regular (human) inj 100 unit/ml.......11
HUMULIN R U-500 (CONCENTR – Insulin regular
(human) inj 500 unit/ml....................................................12
hydralazine hcl tab 100 mg............................................ 21
hydralazine hcl tab 10 mg.............................................. 21
hydrochlorothiazide cap 12.5 mg (Microzide)...............19
hydrochlorothiazide tab 25 mg...................................... 19
hydrochlorothiazide tab 50 mg...................................... 19
hydrocodone-acetaminophen cap 5-500 mg................ 33
hydrocodone-acetaminophen soln 7.5-325 mg/15ml
(Hycet).............................................................................33
hydrocodone-acetaminophen soln 7.5-500
mg/15ml.......................................................................... 33
hydrocodone-acetaminophen tab 10-325 mg
(Norco)............................................................................ 33
hydrocodone-acetaminophen tab 10-500 mg............... 33
hydrocodone-acetaminophen tab 2.5-500 mg.............. 34
hydrocodone-acetaminophen tab 5-325 mg
(Norco)............................................................................ 34
hydrocodone-acetaminophen tab 5-500 mg................. 34
hydrocodone-acetaminophen tab 7.5-325 mg
(Norco)............................................................................ 34
63
2014
hydrocodone-ibuprofen tab 10-200 mg (Ibudone)........34
hydrocodone-ibuprofen tab 5-200 mg (Reprexain)...... 34
hydrocodone-ibuprofen tab 7.5-200 mg
(Vicoprofen)....................................................................34
hydrocortisone acetate suppos 25 mg (Anusol-hc)..... 47
hydrocortisone cream 2.5%........................................... 49
hydrocortisone enema 100 mg/60ml (Cortenema)....... 47
hydrocortisone lotion 2.5%............................................ 49
hydrocortisone oint 2.5%............................................... 49
hydrocortisone rectal cream 2.5% (Anusol-hc)............ 47
hydrocortisone tab 10 mg (Cortef).................................. 8
hydrocortisone tab 20 mg (Cortef).................................. 8
hydrocortisone tab 5 mg (Cortef).................................... 8
hydrocortisone valerate cream 0.2%.............................49
hydrocortisone valerate oint 0.2% (Westcort).............. 49
hydrocortisone w/ acetic acid otic soln 1-2% (Vosol
hc)....................................................................................47
hydromorphone hcl liqd 1 mg/ml (Dilaudid)................. 34
hydromorphone hcl tab 2 mg (Dilaudid)....................... 34
hydroxychloroquine sulfate tab 200 mg (Plaquenil)...... 6
hydroxyurea cap 500 mg (Hydrea).................................. 6
hydroxyzine hcl syrup 10 mg/5ml..................................27
hydroxyzine hcl tab 10 mg.............................................27
hydroxyzine pamoate cap 25 mg (Vistaril)....................27
hydroxyzine pamoate cap 50 mg (Vistaril)....................27
hyoscyamine sulfate elixir 0.125 mg/5ml...................... 24
hyoscyamine sulfate soln 0.125 mg/ml......................... 24
hyoscyamine sulfate tab 0.125 mg (Levsin)................. 24
hyoscyamine sulfate tab sl 0.125 mg (Levsin/sl)..........24
hyoscyamine sulfate tab sr 12hr 0.375 mg (Levbid).....24
I
ibandronate sodium tab 150 mg (base equivalent)
(Boniva)...........................................................................13
ibuprofen susp 100 mg/5ml............................................36
ibuprofen tab 400 mg......................................................36
ibuprofen tab 600 mg......................................................36
ibuprofen tab 800 mg......................................................36
imipramine hcl tab 10 mg (Tofranil).............................. 28
imiquimod cream 5% (Aldara)........................................50
IMITREX – Sumatriptan nasal spray 20 mg/act................ 37
IMITREX – Sumatriptan nasal spray 5 mg/act.................. 37
INCRELEX – Mecasermin inj 40 mg/4ml (10 mg/ml)........ 13
indapamide tab 1.25 mg................................................. 19
indapamide tab 2.5 mg................................................... 19
indomethacin cap 25 mg................................................ 36
indomethacin cap 50 mg................................................ 36
64
INNOPRAN XL – Propranolol hcl sustained-release beads
cap sr 24hr 120 mg.........................................................16
INNOPRAN XL – Propranolol hcl sustained-release beads
cap sr 24hr 80 mg...........................................................16
INSULIN PEN NEEDLES –BD ULTRAFINE, NOVOFINE,
NOVOTWIST................................................................... 50
INSULIN SYRINGES –BD................................................ 50
INTELENCE – Etravirine tab 100 mg..................................4
INTELENCE – Etravirine tab 200 mg..................................4
INTELENCE – Etravirine tab 25 mg....................................4
INTUNIV – Guanfacine hcl tab sr 24hr 1 mg (base
equiv)............................................................................... 31
equiv)............................................................................... 31
equiv)............................................................................... 31
equiv)............................................................................... 31
INVIRASE – Saquinavir mesylate cap 200 mg................... 4
INVIRASE – Saquinavir mesylate tab 500 mg.................... 4
INVOKANA – Canagliflozin tab 100 mg............................ 10
INVOKANA – Canagliflozin tab 300 mg............................ 10
ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml
(Duoneb)......................................................................... 23
ipratropium bromide inhal soln 0.02%.......................... 23
ipratropium bromide nasal soln 0.03% (21 mcg/spray)
(Atrovent)........................................................................21
ipratropium bromide nasal soln 0.06% (42 mcg/spray)
(Atrovent)........................................................................21
irbesartan-hydrochlorothiazide tab 150-12.5 mg
(Avalide)..........................................................................15
irbesartan-hydrochlorothiazide tab 300-12.5 mg
(Avalide)..........................................................................15
irbesartan tab 150 mg (Avapro)..................................... 15
irbesartan tab 300 mg (Avapro)..................................... 15
irbesartan tab 75 mg (Avapro)....................................... 15
ISENTRESS – Raltegravir potassium chew tab 100 mg
(base equiv).......................................................................4
ISENTRESS – Raltegravir potassium chew tab 25 mg
(base equiv).......................................................................4
ISENTRESS – Raltegravir potassium tab 400 mg (base
equiv)................................................................................. 4
isoniazid & rifampin cap 150-300 mg.............................. 3
isoniazid tab 100 mg.........................................................3
isoniazid tab 300 mg.........................................................3
isosorbide dinitrate tab 10 mg.......................................18
isosorbide dinitrate tab 5 mg (Isordil titradose)........... 18
isosorbide mononitrate tab 10 mg................................ 18
isosorbide mononitrate tab 20 mg................................ 18
isosorbide mononitrate tab sr 24hr 120 mg (Imdur).....18
isosorbide mononitrate tab sr 24hr 30 mg (Imdur).......18
isosorbide mononitrate tab sr 24hr 60 mg (Imdur).......18
isotretinoin cap 10 mg....................................................48
2014
itraconazole cap 100 mg (Sporanox)...............................3
J
JANUMET – Sitagliptin-metformin hcl tab 50-1000 mg..... 10
JANUMET – Sitagliptin-metformin hcl tab 50-500 mg....... 10
JANUMET XR – Sitagliptin-metformin hcl tab sr 24hr
100-1000 mg................................................................... 11
50-1000 mg..................................................................... 11
50-500 mg....................................................................... 10
JANUVIA – Sitagliptin phosphate tab 100 mg (base
equiv)............................................................................... 11
equiv)............................................................................... 11
equiv)............................................................................... 11
JUVISYNC – Sitagliptin-simvastatin tab 100-10 mg..........11
JUVISYNC – Sitagliptin-simvastatin tab 50-10 mg............11
K
KADIAN – Morphine sulfate cap sr 24hr 100 mg.............. 34
KADIAN – Morphine sulfate cap sr 24hr 10 mg................ 34
KALETRA – Lopinavir-ritonavir soln 400-100 mg/5ml
(80-20 mg/ml).................................................................... 4
KALETRA – Lopinavir-ritonavir tab 100-25 mg................... 4
KALETRA – Lopinavir-ritonavir tab 200-50 mg................... 4
KALYDECO – Ivacaftor tab 150 mg..................................23
ketoconazole cream 2%..................................................48
ketoconazole shampoo 2% (Nizoral)............................. 48
ketoprofen cap 50 mg.....................................................36
ketoprofen cap 75 mg.....................................................36
ketorolac tromethamine ophth soln 0.4% (Acular
ls).....................................................................................47
ketorolac tromethamine ophth soln 0.5% (Acular).......47
KOATE-DVI – Antihemophilic factor (human) for inj 1000
unit................................................................................... 43
unit................................................................................... 43
unit................................................................................... 43
KOGENATE FS – Antihemophilic factor (recombinant) for
inj kit 1000 unit................................................................ 43
inj kit 2000 unit................................................................ 43
inj kit 250 unit.................................................................. 43
inj kit 3000 unit................................................................ 43
inj kit 500 unit.................................................................. 43
KOGENATE FS BIO-SET – Antihemophilic factor
(recombinant) for inj kit 1000 unit....................................44
(recombinant) for inj kit 250 unit......................................44
(recombinant) for inj kit 500 unit......................................44
KOMBIGLYZE XR – Saxagliptin-metformin hcl tab sr 24hr
2.5-1000 mg.................................................................... 11
5-1000 mg....................................................................... 11
5-500 mg......................................................................... 11
K-PHOS – Potassium phosphate monobasic tab 500
mg.................................................................................... 41
L
labetalol hcl tab 100 mg (Trandate)...............................16
lactulose (encephalopathy) solution 10 gm/15ml.........25
lactulose solution 10 gm/15ml....................................... 23
lamivudine tab 100 mg (Epivir hbv).................................3
lamivudine tab 150 mg (Epivir)........................................ 4
lamivudine tab 300 mg (Epivir)........................................ 4
lamivudine-zidovudine tab 150-300 mg (Combivir)........ 4
lamotrigine tab 100 mg (Lamictal)................................. 38
lamotrigine tab 25 mg (Lamictal)................................... 38
lamotrigine tab chewable dispersible 25 mg (Lamictal
chewable di)................................................................... 38
lamotrigine tab chewable dispersible 5 mg (Lamictal
chewable di)................................................................... 38
LANCETS – BAYER FINGERSTIX, MICROLET, SINGLELET.................................................................................. 50
LANCETS – BDMICROTAINER, ULTRAFINE..................50
LANCETS – ROCHE ACCU-CHEKFASTCLIX,
MULTICLIX, SOFT TOUCH, SOFTCLIX......................... 50
lansoprazole cap delayed release 15 mg
(Prevacid)........................................................................24
lansoprazole cap delayed release 30 mg
(Prevacid)........................................................................24
65
2014
LANTUS – Insulin glargine inj 100 unit/ml.........................12
LANTUS SOLOSTAR – Insulin glargine soln pen-injector
100 unit/ml....................................................................... 12
latanoprost ophth soln 0.005% (Xalatan)...................... 46
leflunomide tab 10 mg (Arava).......................................36
leflunomide tab 20 mg (Arava).......................................36
LETAIRIS – Ambrisentan tab 10 mg.................................21
LETAIRIS – Ambrisentan tab 5 mg...................................21
letrozole tab 2.5 mg (Femara).......................................... 6
LEUCOVORIN CALCIUM – Leucovorin calcium tab 10
mg...................................................................................... 6
LEUCOVORIN CALCIUM – Leucovorin calcium tab 15
mg...................................................................................... 6
leucovorin calcium tab 25 mg..........................................6
leucovorin calcium tab 5 mg........................................... 6
LEUKERAN – Chlorambucil tab 2 mg.................................6
levalbuterol hcl soln nebu 0.31 mg/3ml (base equiv)
(Xopenex)........................................................................23
(Xopenex)........................................................................23
(Xopenex)........................................................................23
levalbuterol hcl soln nebu conc 1.25 mg/0.5ml (base
equiv) (Xopenex concentrate)...................................... 23
LEVEMIR FLEXPEN – Insulin detemir soln pen-injector
100 unit/ml....................................................................... 12
LEVEMIR FLEXTOUCH – Insulin detemir soln pen-injector
100 unit/ml....................................................................... 12
LEVEMIR – Insulin detemir inj 100 unit/ml........................12
levetiracetam oral soln 100 mg/ml (Keppra)................. 38
levetiracetam tab 1000 mg (Keppra)..............................38
levetiracetam tab 250 mg (Keppra)................................38
levobunolol hcl ophth soln 0.5% (Betagan)..................46
levocarnitine oral soln 1 gm/10ml (10%) (Carnitor)...... 13
levocarnitine tab 330 mg (Carnitor)...............................13
levofloxacin oral soln 25 mg/ml (Levaquin)....................2
levofloxacin tab 250 mg (Levaquin)................................ 2
levonorgestrel tab 0.75 mg (Plan b)................................ 9
levonorgestrel tab 1.5 mg (Plan b one-step).................10
levothyroxine sodium tab 100 mcg (Synthroid)........... 12
levothyroxine sodium tab 25 mcg (Synthroid)............. 12
66
LEXIVA – Fosamprenavir calcium susp 50 mg/ml (base
equiv)................................................................................. 4
LEXIVA – Fosamprenavir calcium tab 700 mg (base
equiv)................................................................................. 4
LIALDA – Mesalamine tab delayed release 1.2 gm.......... 25
lidocaine hcl gel 2%........................................................50
lidocaine hcl laryngotracheal soln 4% (Lta 360 kit)......47
lidocaine hcl local inj 1% (Xylocaine)............................37
lidocaine hcl local preservative free (pf) inj 1%
(Xylocaine-mpf).............................................................. 37
lidocaine hcl soln 4% (Xylocaine)..................................50
lidocaine hcl viscous soln 2%....................................... 47
lidocaine oint 5%.............................................................50
lidocaine patch 5% (Lidoderm)...................................... 50
lidocaine-prilocaine cream 2.5-2.5% (Emla)..................50
lindane lotion 1%.............................................................50
LINZESS – Linaclotide cap 145 mcg................................ 25
LINZESS – Linaclotide cap 290 mcg................................ 25
liothyronine sodium tab 25 mcg (Cytomel)...................13
liothyronine sodium tab 50 mcg (Cytomel)...................13
liothyronine sodium tab 5 mcg (Cytomel).....................13
lisinopril & hydrochlorothiazide tab 10-12.5 mg
(Zestoretic)..................................................................... 14
lisinopril & hydrochlorothiazide tab 20-12.5 mg
(Zestoretic)..................................................................... 14
lisinopril & hydrochlorothiazide tab 20-25 mg
(Zestoretic)..................................................................... 14
lisinopril tab 10 mg (Prinivil)..........................................14
lisinopril tab 2.5 mg (Zestril).......................................... 14
lisinopril tab 20 mg (Prinivil)..........................................14
lisinopril tab 30 mg (Zestril)........................................... 14
lisinopril tab 40 mg (Zestril)........................................... 14
lisinopril tab 5 mg (Prinivil)............................................14
lithium carbonate cap 150 mg (Lithium carbonate)......29
lithium carbonate cap 300 mg....................................... 29
lithium carbonate cap 600 mg (Lithium carbonate)......29
lithium carbonate tab 300 mg........................................ 29
lithium carbonate tab cr 300 mg (Lithobid)...................29
lithium carbonate tab cr 450 mg....................................29
loperamide hcl cap 2 mg................................................24
lorazepam conc 2 mg/ml (Lorazepam intensol)............27
lorazepam tab 0.5 mg (Ativan)....................................... 27
lorazepam tab 1 mg (Ativan).......................................... 27
lorazepam tab 2 mg (Ativan).......................................... 27
losartan potassium & hydrochlorothiazide tab
100-12.5 mg (Hyzaar).....................................................15
losartan potassium & hydrochlorothiazide tab 100-25
mg (Hyzaar).................................................................... 15
losartan potassium & hydrochlorothiazide tab 50-12.5
mg (Hyzaar).................................................................... 15
losartan potassium tab 100 mg (Cozaar)...................... 15
losartan potassium tab 25 mg (Cozaar)........................ 15
losartan potassium tab 50 mg (Cozaar)........................ 15
LOTEMAX – Loteprednol etabonate ophth gel 0.5%........ 46
LOTEMAX – Loteprednol etabonate ophth oint 0.5%....... 46
LOTEMAX – Loteprednol etabonate ophth susp 0.5%......46
2014
lovastatin tab 10 mg....................................................... 19
lovastatin tab 20 mg (Mevacor)..................................... 19
lovastatin tab 40 mg (Mevacor)..................................... 19
loxapine succinate cap 10 mg....................................... 29
loxapine succinate cap 5 mg (Loxitane)....................... 29
LUMIGAN – Bimatoprost ophth soln 0.01%...................... 46
LUMIGAN – Bimatoprost ophth soln 0.03%...................... 46
LYRICA – Pregabalin cap 100 mg.................................... 38
LYRICA – Pregabalin cap 25 mg......................................38
M
malathion lotion 0.5% (Ovide)........................................50
meclizine hcl tab 12.5 mg...............................................25
meclizine hcl tab 25 mg..................................................25
medroxyprogesterone acetate im susp 150 mg/ml
(Depo-provera contrac)................................................. 10
medroxyprogesterone acetate tab 10 mg (Provera).......9
medroxyprogesterone acetate tab 2.5 mg (Provera)......9
medroxyprogesterone acetate tab 5 mg (Provera).........9
mefloquine hcl tab 250 mg...............................................6
megestrol acetate susp 40 mg/ml (Megace oral)............6
megestrol acetate tab 20 mg........................................... 7
megestrol acetate tab 40 mg........................................... 7
MEKINIST – Trametinib dimethyl sulfoxide tab 0.5 mg
(base equivalent)............................................................... 7
MEKINIST – Trametinib dimethyl sulfoxide tab 2 mg (base
equivalent)......................................................................... 7
meloxicam tab 15 mg (Mobic)........................................36
meloxicam tab 7.5 mg (Mobic).......................................36
MEPHYTON – Phytonadione tab 5 mg.............................40
mercaptopurine tab 50 mg (Purinethol).......................... 7
mesalamine enema 4 gm................................................25
MESNEX – Mesna tab 400 mg...........................................7
MESTINON – Pyridostigmine bromide syrup 60
mg/5ml............................................................................. 40
MESTINON TIMESPAN – Pyridostigmine bromide tab cr
180 mg.............................................................................40
metaxalone tab 800 mg (Skelaxin).................................40
metformin hcl tab 1000 mg (Glucophage).....................11
metformin hcl tab 500 mg (Glucophage)...................... 11
metformin hcl tab 850 mg (Glucophage)...................... 11
metformin hcl tab sr 24hr 500 mg (Glucophage xr)......11
metformin hcl tab sr 24hr 750 mg (Glucophage xr)......11
methadone hcl conc 10 mg/ml (Methadose).................34
methadone hcl soln 10 mg/5ml (Methadone hcl)..........34
methadone hcl soln 5 mg/5ml (Methadone hcl)............34
methadone hcl tab 10 mg (Dolophine).......................... 34
methadone hcl tab 5 mg (Dolophine hcl)......................34
methadone hcl tab for oral susp 40 mg........................ 34
methazolamide tab 25 mg (Neptazane)......................... 19
methazolamide tab 50 mg (Neptazane)......................... 19
methimazole tab 10 mg (Tapazole)................................13
methimazole tab 5 mg (Tapazole)..................................13
methocarbamol tab 500 mg (Robaxin).......................... 40
methocarbamol tab 750 mg (Robaxin-750)................... 40
methotrexate sodium tab 2.5 mg (base equiv)............... 7
methscopolamine bromide tab 2.5 mg (Pamine)..........24
methscopolamine bromide tab 5 mg (Pamine
forte)................................................................................24
methyldopa tab 250 mg.................................................. 21
methyldopa tab 500 mg.................................................. 21
methylergonovine maleate tab 0.2 mg.......................... 13
methylphenidate hcl tab 10 mg (Ritalin)....................... 31
methylphenidate hcl tab 20 mg (Ritalin)....................... 31
methylphenidate hcl tab 5 mg (Ritalin)......................... 31
methylphenidate hcl tab cr 20 mg (Ritalin sr)...............31
methylprednisolone tab 16 mg (Medrol)......................... 8
methylprednisolone tab 32 mg (Medrol)......................... 8
methylprednisolone tab 4 mg (Medrol)........................... 8
methylprednisolone tab 4 mg dose pack (Medrol
dosepak)........................................................................... 8
methylprednisolone tab 8 mg (Medrol)........................... 8
metoclopramide hcl soln 5 mg/5ml (10 mg/10ml).........25
metoclopramide hcl tab 10 mg (Reglan)....................... 25
metoclopramide hcl tab 5 mg (Reglan)......................... 25
metolazone tab 10 mg.................................................... 19
metolazone tab 2.5 mg (Zaroxolyn)............................... 19
metolazone tab 5 mg (Zaroxolyn).................................. 19
metoprolol succinate tab sr 24hr 100 mg (Toprol
xl).....................................................................................16
metoprolol succinate tab sr 24hr 200 mg (Toprol
xl).....................................................................................16
metoprolol succinate tab sr 24hr 25 mg (Toprol xl)..... 16
metoprolol succinate tab sr 24hr 50 mg (Toprol xl)..... 16
metoprolol tartrate tab 100 mg (Lopressor)..................16
metoprolol tartrate tab 25 mg........................................ 16
metoprolol tartrate tab 50 mg (Lopressor)....................16
metronidazole cream 0.75% (Metrocream)....................48
metronidazole gel 0.75%................................................ 48
metronidazole gel 1% (Metrogel)................................... 48
metronidazole lotion 0.75% (Metrolotion)..................... 48
metronidazole tab 250 mg (Flagyl).................................. 6
metronidazole tab 500 mg (Flagyl).................................. 6
metronidazole vaginal gel 0.75% (Metrogelvaginal)........................................................................... 26
mexiletine hcl cap 150 mg............................................. 20
midodrine hcl tab 10 mg................................................ 21
midodrine hcl tab 2.5 mg............................................... 21
midodrine hcl tab 5 mg.................................................. 21
MIGRANAL – Dihydroergotamine mesylate nasal spray 4
mg/ml............................................................................... 37
minocycline hcl cap 100 mg (Minocin)............................2
67
2014
minocycline hcl cap 50 mg (Minocin)............................. 2
minocycline hcl cap 75 mg (Minocin)............................. 2
minocycline hcl tab 100 mg............................................. 2
minocycline hcl tab 50 mg............................................... 2
minocycline hcl tab 75 mg............................................... 2
minoxidil tab 10 mg........................................................ 21
minoxidil tab 2.5 mg....................................................... 21
mirtazapine tab 15 mg (Remeron)................................. 28
mirtazapine tab 7.5 mg................................................... 28
misoprostol tab 100 mcg (Cytotec)............................... 24
misoprostol tab 200 mcg (Cytotec)............................... 24
modafinil tab 100 mg (Provigil)......................................31
modafinil tab 200 mg (Provigil)......................................31
moexipril hcl tab 15 mg (Univasc).................................14
moexipril hcl tab 7.5 mg (Univasc)................................14
moexipril-hydrochlorothiazide tab 15-12.5 mg
(Uniretic)......................................................................... 14
moexipril-hydrochlorothiazide tab 15-25 mg................ 14
moexipril-hydrochlorothiazide tab 7.5-12.5 mg............ 14
mometasone furoate cream 0.1% (Elocon)................... 49
mometasone furoate oint 0.1% (Elocon).......................49
mometasone furoate solution 0.1% (lotion)
(Elocon)...........................................................................49
MONOCLATE-P – Antihemophilic factor (human) for inj kit
1000 unit..........................................................................44
1500 unit..........................................................................44
250 unit............................................................................44
500 unit............................................................................44
MONONINE – Coagulation factor ix for inj 1000 unit........ 44
MONONINE – Coagulation factor ix for inj 250 unit.......... 44
MONONINE – Coagulation factor ix for inj 500 unit.......... 44
montelukast sodium chew tab 4 mg (base equiv)
(Singulair)....................................................................... 23
montelukast sodium chew tab 5 mg (base equiv)
(Singulair)....................................................................... 23
montelukast sodium oral granules packet 4 mg (base
equiv) (Singulair)........................................................... 23
montelukast sodium tab 10 mg (base equiv)
(Singulair)....................................................................... 23
morphine sulfate (concentrate) oral soln 20 mg/ml..... 35
morphine sulfate beads cap sr 24hr 120 mg
(Avinza)........................................................................... 35
(Avinza)........................................................................... 35
(Avinza)........................................................................... 35
(Avinza)........................................................................... 35
(Avinza)........................................................................... 35
68
(Avinza)........................................................................... 35
MORPHINE SULFATE – Morphine sulfate suppos 10
mg.................................................................................... 34
mg.................................................................................... 34
mg.................................................................................... 35
mg.................................................................................... 34
MORPHINE SULFATE – Morphine sulfate tab 15 mg.......34
MORPHINE SULFATE – Morphine sulfate tab 30 mg.......34
morphine sulfate oral soln 10 mg/5ml...........................35
morphine sulfate oral soln 20 mg/5ml...........................35
morphine sulfate tab cr 100 mg (Ms contin)................. 35
morphine sulfate tab cr 15 mg (Ms contin)...................35
morphine sulfate tab cr 200 mg (Ms contin)................. 35
MULTAQ – Dronedarone hcl tab 400 mg (base
equivalent)....................................................................... 20
mupirocin calcium cream 2% (Bactroban)....................48
mupirocin oint 2% (Bactroban)......................................48
mycophenolate mofetil cap 250 mg (Cellcept)............. 51
mycophenolate mofetil tab 500 mg (Cellcept).............. 51
mycophenolate sodium tab dr 180 mg (mycophenolic
acid equiv) (Myfortic).................................................... 51
mycophenolate sodium tab dr 360 mg (mycophenolic
acid equiv) (Myfortic).................................................... 51
MYLERAN – Busulfan tab 2 mg......................................... 7
N
nabumetone tab 500 mg.................................................37
nabumetone tab 750 mg.................................................37
nadolol tab 20 mg (Corgard).......................................... 16
naltrexone hcl tab 50 mg (Revia)...................................51
naproxen sodium tab 275 mg (Anaprox)...................... 37
naproxen sodium tab 550 mg (Anaprox ds)................. 37
naproxen susp 125 mg/5ml (Naprosyn)........................ 37
naproxen tab 250 mg (Naprosyn).................................. 37
naproxen tab ec 375 mg (Ec-naprosyn)........................ 37
naproxen tab ec 500 mg (Ec-naprosyn)........................ 37
naratriptan hcl tab 1 mg (base equiv) (Amerge)........... 37
naratriptan hcl tab 2.5 mg (base equiv) (Amerge)........ 37
NASONEX – Mometasone furoate nasal susp 50 mcg/
act.................................................................................... 22
NATACYN – Natamycin ophth susp 5%........................... 45
nateglinide tab 120 mg (Starlix).....................................11
nateglinide tab 60 mg (Starlix).......................................11
neomycin-bacitrac zn-polymyx
5(3.5)mg-400unt-10000unt op oin.................................45
2014
neomycin-polymy-gramicid op sol
1.75-10000-0.025mg-unt-mg/ml (Neosporin)............... 45
neomycin-polymyxin-dexamethasone ophth oint 0.1%
(Maxitrol).........................................................................46
neomycin-polymyxin-dexamethasone ophth susp
0.1% (Maxitrol)............................................................... 46
neomycin-polymyxin-hc otic soln 1% (Cortisporin).....47
neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000
unit/ml-1%.......................................................................47
neomycin sulfate tab 500 mg...........................................3
NEULASTA – Pegfilgrastim inj 6 mg/0.6ml....................... 44
NEUPOGEN – Filgrastim inj 300 mcg/0.5ml (600 mcg/
ml).................................................................................... 44
NEUPOGEN – Filgrastim inj 300 mcg/ml..........................44
ml).................................................................................... 44
ml).................................................................................... 44
nevirapine tab 200 mg (Viramune)...................................4
nevirapine tab sr 24hr 400 mg (Viramune xr)................. 4
NEXAVAR – Sorafenib tosylate tab 200 mg (base
equivalent)......................................................................... 7
NEXIUM – Esomeprazole magnesium cap delayed
release 20 mg..................................................................24
NEXIUM – Esomeprazole magnesium cap delayed
release 40 mg..................................................................24
NEXIUM – Esomeprazole magnesium for delayed release
susp pack 2.5 mg............................................................24
susp packet 10 mg.......................................................... 24
susp packet 20 mg.......................................................... 24
susp packet 40 mg.......................................................... 24
susp packet 5 mg............................................................24
niacin tab cr 1000 mg (antihyperlipidemic)
(Niaspan).........................................................................19
(Niaspan).........................................................................19
(Niaspan).........................................................................19
NICOTROL INHALER – Nicotine inhaler system 10 mg (4
mg delivered)................................................................... 32
NICOTROL NS – Nicotine nasal spray 10 mg/ml (0.5 mg/
spray)............................................................................... 32
nifedipine tab sr 24hr 30 mg (Adalat cc).......................17
nifedipine tab sr 24hr 60 mg (Adalat cc)....................... 18
nifedipine tab sr 24hr 90 mg (Adalat cc).......................18
nifedipine tab sr 24hr osmotic 30 mg (Procardia
xl).....................................................................................17
xl).....................................................................................17
xl).....................................................................................17
NILANDRON – Nilutamide tab 150 mg...............................7
nitrofurantoin macrocrystalline cap 100 mg
(Macrodantin)................................................................. 26
nitrofurantoin macrocrystalline cap 50 mg
(Macrodantin)................................................................. 26
nitrofurantoin monohydrate macrocrystalline cap 100
mg (Macrobid)................................................................ 26
nitrofurantoin susp 25 mg/5ml (Furadantin)................. 26
nitroglycerin td patch 24hr 0.1 mg/hr (Nitro-dur)......... 18
NITROSTAT – Nitroglycerin sl tab 0.3 mg........................ 18
norelgestromin-ethinyl estradiol td ptwk 150-35
mcg/24hr (Ortho evra)................................................... 10
norethindrone acetate-ethinyl estradiol tab 1 mg-5
mcg....................................................................................9
norethindrone acetate tab 5 mg (Aygestin).................... 9
nortriptyline hcl cap 10 mg (Pamelor)...........................28
NORVIR – Ritonavir cap 100 mg........................................4
NORVIR – Ritonavir oral soln 80 mg/ml............................. 4
NORVIR – Ritonavir tab 100 mg.........................................4
NOVOLIN 70/30 – Insulin isophane & regular (human) inj
100 unit/ml (70-30).......................................................... 12
NOVOLIN 70/30 RELION – Insulin isophane & regular
(human) inj 100 unit/ml (70-30)....................................... 12
NOVOLIN N – Insulin isophane (human) inj 100 unit/
ml..................................................................................... 12
NOVOLIN N RELION – Insulin isophane (human) inj 100
unit/ml.............................................................................. 12
NOVOLIN R – Insulin regular (human) inj 100 unit/ml.......12
NOVOLIN R RELION – Insulin regular (human) inj 100
unit/ml.............................................................................. 12
NOVOLOG FLEXPEN – Insulin aspart soln pen-injector
100 unit/ml....................................................................... 11
NOVOLOG – Insulin aspart inj 100 unit/ml....................... 11
NOVOLOG MIX 70/30 – Insulin aspart prot & aspart
(human) inj 100 unit/ml (70-30)....................................... 12
NOVOLOG MIX 70/30 PREFILL – Insulin aspart prot &
aspart sus pen-inj 100 unit/ml (70-30).............................12
NOVOLOG PENFILL – Insulin aspart inj 100 unit/ml........ 11
NOVOLOG PENFILL – Insulin aspart soln cartridge 100
unit/ml.............................................................................. 11
NOVOSEVEN RT – Coagulation factor viia (recomb) for inj
1 mg (1000 mcg).............................................................44
2 mg (2000 mcg).............................................................44
5 mg (5000 mcg).............................................................44
8 mg (8000 mcg).............................................................44
NOXAFIL – Posaconazole susp 40 mg/ml..........................3
69
2014
NUCYNTA ER – Tapentadol hcl tab sr 12hr 100 mg........ 35
NUCYNTA ER – Tapentadol hcl tab sr 12hr 50 mg.......... 35
NUEDEXTA – Dextromethorphan hbr-quinidine sulfate
cap 20-10 mg.................................................................. 32
NUVARING – Etonogestrel-ethinyl estradiol va ring
0.120-0.015 mg/24hr....................................................... 10
nystatin cream 100000 unit/gm......................................48
nystatin oint 100000 unit/gm..........................................48
nystatin susp 100000 unit/ml......................................... 47
nystatin tab 500000 unit................................................... 3
nystatin topical powder.................................................. 48
nystatin-triamcinolone cream 100000-0.1 unit/gm%......................................................................................49
nystatin-triamcinolone oint 100000-0.1 unit/gm-%....... 49
O
octreotide acetate inj 1000 mcg/ml (1 mg/ml)
(Sandostatin).................................................................. 13
octreotide acetate inj 100 mcg/ml (0.1 mg/ml)
(Sandostatin).................................................................. 13
(Sandostatin).................................................................. 13
(Sandostatin).................................................................. 13
(Sandostatin).................................................................. 13
ofloxacin ophth soln 0.3% (Ocuflox)............................. 45
ofloxacin otic soln 0.3%................................................. 47
ofloxacin tab 200 mg........................................................ 3
ofloxacin tab 300 mg........................................................ 3
ofloxacin tab 400 mg........................................................ 3
olanzapine orally disintegrating tab 10 mg (Zyprexa
zydis)...............................................................................29
zydis)...............................................................................29
zydis)...............................................................................29
zydis)...............................................................................29
olanzapine tab 10 mg (Zyprexa).................................... 29
olanzapine tab 2.5 mg (Zyprexa)................................... 29
olanzapine tab 5 mg (Zyprexa)...................................... 29
olanzapine tab 7.5 mg (Zyprexa)................................... 29
OLYSIO – Simeprevir sodium cap 150 mg (base
equivalent)......................................................................... 3
omeprazole cap delayed release 10 mg (Prilosec)....... 24
OMNITROPE – Somatropin for inj 5.8 mg........................ 13
OMNITROPE – Somatropin inj 10 mg/1.5ml.....................13
OMNITROPE – Somatropin inj 5 mg/1.5ml.......................13
70
ondansetron hcl inj 40 mg/20ml (2 mg/ml) (Zofran)..... 25
ondansetron hcl inj 4 mg/2ml (2 mg/ml)....................... 25
ondansetron hcl oral soln 4 mg/5ml (Zofran)............... 25
ondansetron hcl tab 24 mg............................................ 25
ondansetron hcl tab 4 mg (Zofran)................................25
ondansetron hcl tab 8 mg (Zofran)................................25
ondansetron orally disintegrating tab 4 mg (Zofran
odt).................................................................................. 25
ondansetron orally disintegrating tab 8 mg (Zofran
odt).................................................................................. 25
ONGLYZA – Saxagliptin hcl tab 2.5 mg (base equiv)....... 11
ONGLYZA – Saxagliptin hcl tab 5 mg (base equiv).......... 11
OPSUMIT – Macitentan tab 10 mg................................... 21
oral contraceptives– all generics.......................................10
ORAP – Pimozide tab 1 mg..............................................32
ORAP – Pimozide tab 2 mg..............................................32
ORFADIN – Nitisinone cap 10 mg.................................... 14
ORFADIN – Nitisinone cap 2 mg...................................... 14
ORFADIN – Nitisinone cap 5 mg...................................... 14
orphenadrine citrate tab sr 12hr 100 mg.......................40
orphenadrine w/ aspirin & caffeine tab 25-385-30
mg....................................................................................40
oxaprozin tab 600 mg (Daypro)..................................... 37
oxcarbazepine susp 300 mg/5ml (60 mg/ml)
(Trileptal).........................................................................38
oxcarbazepine tab 150 mg (Trileptal)............................ 38
oxybutynin chloride syrup 5 mg/5ml.............................26
oxybutynin chloride tab 5 mg........................................ 26
oxybutynin chloride tab sr 24hr 10 mg (Ditropan
xl).....................................................................................26
oxybutynin chloride tab sr 24hr 15 mg (Ditropan
xl).....................................................................................26
oxybutynin chloride tab sr 24hr 5 mg (Ditropan xl)......26
oxycodone-aspirin tab 4.8355-325 mg (Percodan)....... 35
oxycodone hcl cap 5 mg................................................ 35
oxycodone hcl conc 100 mg/5ml (20 mg/ml)
(Oxycodone hcl).............................................................35
oxycodone hcl soln 5 mg/5ml (Oxycodone hcl)........... 35
oxycodone hcl tab 10 mg...............................................35
oxycodone hcl tab 15 mg (Roxicodone)....................... 35
oxycodone hcl tab 20 mg...............................................35
oxycodone hcl tab 30 mg (Roxicodone)....................... 35
oxycodone hcl tab 5 mg (Roxicodone)......................... 35
oxycodone w/ acetaminophen cap 5-500 mg............... 35
oxycodone w/ acetaminophen tab 10-325 mg
(Percocet)....................................................................... 35
oxycodone w/ acetaminophen tab 10-650 mg.............. 35
oxycodone w/ acetaminophen tab 5-325 mg
(Percocet)....................................................................... 35
oxycodone w/ acetaminophen tab 7.5-325 mg
(Percocet)....................................................................... 35
oxycodone w/ acetaminophen tab 7.5-500 mg............. 35
OXYCONTIN – Oxycodone hcl tab er 12hr deter 10
mg.................................................................................... 35
2014
mg.................................................................................... 35
mg.................................................................................... 35
mg.................................................................................... 35
mg.................................................................................... 35
mg.................................................................................... 35
mg.................................................................................... 35
P
pantoprazole sodium ec tab 20 mg (base equiv)
(Protonix)........................................................................ 24
pantoprazole sodium ec tab 40 mg (base equiv)
(Protonix)........................................................................ 24
paricalcitol cap 1 mcg (Zemplar)................................... 14
paromomycin sulfate cap 250 mg................................... 3
paroxetine hcl tab 10 mg (Paxil).................................... 28
paroxetine hcl tab sr 24hr 12.5 mg (Paxil cr)................ 28
paroxetine hcl tab sr 24hr 25 mg (Paxil cr)...................28
paroxetine hcl tab sr 24hr 37.5 mg (Paxil cr)................ 28
PATADAY – Olopatadine hcl ophth soln 0.2%..................47
pediatric multiple vitamins w/ fl-fe drops 0.25-10 mg/
ml ................................................................................... 40
pediatric multiple vitamins w/ fluoride chew tab 0.25
mg .................................................................................. 40
pediatric multiple vitamins w/ fluoride chew tab 0.5 mg
......................................................................................... 40
pediatric multiple vitamins w/ fluoride chew tab 1 mg
......................................................................................... 40
pediatric multiple vitamins w/ fluoride soln 0.25 mg/ml
......................................................................................... 40
pediatric multiple vitamins w/ fluoride soln 0.5 mg/ml
......................................................................................... 40
pediatric vitamins acd w/ fluoride soln 0.25 mg/ml ..... 40
pediatric vitamins acd w/ fluoride soln 0.5 mg/ml ....... 40
peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm
(Golytely)........................................................................ 23
peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240 gm
(Colyte-flavor packs)..................................................... 23
peg 3350-kcl-sod bicarb-nacl for soln 420 gm
(Nulytely/flavor pack).................................................... 24
PEGASYS – Peginterferon alfa-2a inj 180 mcg/0.5ml.........3
PEGASYS – Peginterferon alfa-2a inj 180 mcg/ml............. 3
PEGASYS – Peginterferon alfa-2a inj kit 180
mcg/0.5ml.......................................................................... 3
PEGASYS PROCLICK – Peginterferon alfa-2a inj 135
mcg/0.5ml.......................................................................... 3
PEGASYS PROCLICK – Peginterferon alfa-2a inj 180
mcg/0.5ml.......................................................................... 3
penicillin v potassium for soln 125 mg/5ml.................... 1
penicillin v potassium for soln 250 mg/5ml.................... 1
penicillin v potassium tab 250 mg...................................1
penicillin v potassium tab 500 mg...................................1
PENTASA – Mesalamine cap cr 250 mg.......................... 25
PENTASA – Mesalamine cap cr 500 mg.......................... 25
pentoxifylline tab cr 400 mg...........................................44
perindopril erbumine tab 2 mg...................................... 14
perindopril erbumine tab 4 mg (Aceon)........................ 15
perindopril erbumine tab 8 mg (Aceon)........................ 15
permethrin cream 5% (Elimite)...................................... 50
perphenazine tab 16 mg................................................. 29
perphenazine tab 2 mg................................................... 29
phenelzine sulfate tab 15 mg (Nardil)............................28
phenobarbital elixir 20 mg/5ml...................................... 30
phenobarbital tab 16.2 mg............................................. 30
phenobarbital tab 32.4 mg............................................. 30
phenytoin chew tab 50 mg (Dilantin infatabs).............. 39
phenytoin sodium extended cap 100 mg (Dilantin)......39
phenytoin sodium extended cap 200 mg
(Phenytek).......................................................................39
phenytoin sodium extended cap 300 mg
(Phenytek).......................................................................39
phenytoin susp 125 mg/5ml (Dilantin).......................... 39
pilocarpine hcl ophth soln 1% (Isopto carpine)............46
pilocarpine hcl tab 5 mg (Salagen)................................47
pilocarpine hcl tab 7.5 mg (Salagen).............................47
pindolol tab 10 mg.......................................................... 16
pindolol tab 5 mg............................................................ 16
pioglitazone hcl-metformin hcl tab 15-500 mg
(Actoplus met)............................................................... 11
pioglitazone hcl-metformin hcl tab 15-850 mg
(Actoplus met)............................................................... 11
pioglitazone hcl tab 15 mg (base equiv) (Actos).......... 11
piroxicam cap 10 mg (Feldene)..................................... 37
piroxicam cap 20 mg (Feldene)..................................... 37
podofilox soln 0.5% (Condylox).....................................50
polymyxin b-trimethoprim ophth soln 10000 unit/
ml-0.1% (Polytrim)......................................................... 45
potassium chloride cap cr 10 meq (Micro-k)................ 41
potassium chloride cap cr 8 meq (Micro-k).................. 41
potassium chloride microencapsulated crys cr tab 10
meq..................................................................................41
potassium chloride microencapsulated crys cr tab 20
meq..................................................................................41
potassium chloride oral liq 10% (20 meq/15ml)............41
potassium chloride oral liq 20% (40 meq/15ml)............41
potassium chloride powder packet 20 meq..................41
71
2014
potassium chloride tab cr 10 meq (K-tab).................... 41
potassium chloride tab cr 8 meq (600 mg)................... 41
potassium citrate & citric acid powder pack 3300-1002
mg....................................................................................26
POTASSIUM CITRATE – Potassium citrate tab cr 10 meq
(1080 mg)........................................................................ 26
POTASSIUM CITRATE – Potassium citrate tab cr 5 meq
(540 mg).......................................................................... 26
pot bicarbonate & chloride effer tab 25 meq................ 41
pot phos monobasic w/sod phos di & monobas tab
155-852-130mg (K-phos neutral).................................. 41
pramipexole dihydrochloride tab 0.125 mg
(Mirapex)......................................................................... 39
(Mirapex)......................................................................... 39
pramipexole dihydrochloride tab 0.5 mg (Mirapex)......39
(Mirapex)......................................................................... 39
pramipexole dihydrochloride tab 1.5 mg (Mirapex)......39
pramipexole dihydrochloride tab 1 mg (Mirapex)........ 39
pravastatin sodium tab 10 mg....................................... 19
pravastatin sodium tab 20 mg (Pravachol)................... 19
prazosin hcl cap 1 mg (Minipress)................................ 21
prednisolone acetate ophth susp 1% (Pred forte)........46
PREDNISOLONE SODIUM PHOSP – Prednisolone
sodium phosphate ophth soln 1%................................... 46
prednisolone sod phosphate oral soln 15 mg/5ml
(base equiv)......................................................................8
prednisolone sod phosph oral soln 6.7 mg/5ml (5
mg/5ml base) (Pediapred)...............................................8
prednisolone syrup 15 mg/5ml (usp solution
equivalent) (Prelone)....................................................... 8
PREDNISONE INTENSOL – Prednisone conc 5 mg/ml..... 8
PREDNISONE – Prednisone oral soln 5 mg/5ml................ 8
PREDNISONE – Prednisone tab 50 mg............................. 8
prednisone tab 10 mg.......................................................8
prednisone tab 10 mg dose pack.................................... 8
prednisone tab 1 mg.........................................................8
prednisone tab 2.5 mg......................................................8
prednisone tab 20 mg.......................................................8
prednisone tab 5 mg.........................................................8
prednisone tab 5 mg dose pack...................................... 8
PRENAPLUS – prenatal vit w/ fe fumarate-fa tab 27-1
mg.................................................................................... 40
PRENATABS FA – prenatal vit w/ fe fumarate-fa tab 29-1
mg.................................................................................... 40
PRENATAL 19 – prenatal vit w/ dss-fe fumarate-fa tab
29-1 mg........................................................................... 41
PRENATAL 19 – prenatal vit w/ fe fumarate-fa chew tab
29-1 mg........................................................................... 41
PRENATAL LOW IRON – prenatal vit w/ fe fumarate-fa
tab 27-1 mg..................................................................... 40
72
PRENATAL PLUS – prenatal vit w/ fe fumarate-fa tab 27-1
mg.................................................................................... 40
PRENATAL VITAMINS PLUS – prenatal vit w/ fe
fumarate-fa tab 27-1 mg..................................................41
PREZISTA – Darunavir ethanolate susp 100 mg/ml (base
equiv)................................................................................. 5
PREZISTA – Darunavir ethanolate tab 150 mg (base
equiv)................................................................................. 5
equiv)................................................................................. 5
equiv)................................................................................. 5
equiv)................................................................................. 5
equiv)................................................................................. 5
PRIFTIN – Rifapentine tab 150 mg.....................................3
PRIMAQUINE PHOSPHATE – Primaquine phosphate tab
26.3 mg..............................................................................6
primidone tab 250 mg (Mysoline).................................. 39
primidone tab 50 mg (Mysoline).................................... 39
PROAIR HFA – Albuterol sulfate inhal aero 108 mcg/act
(90mcg base equiv).........................................................23
probenecid tab 500 mg...................................................37
prochlorperazine maleate tab 10 mg (Compazine).......30
prochlorperazine maleate tab 5 mg (Compazine).........30
prochlorperazine suppos 25 mg....................................30
PROCRIT – Epoetin alfa inj 10000 unit/ml........................44
PROCRIT – Epoetin alfa inj 2000 unit/ml..........................44
PROFILNINE SD – Factor ix complex for inj 1000 unit..... 44
PROFILNINE SD – Factor ix complex for inj 1500 unit..... 44
PROFILNINE SD – Factor ix complex for inj 500 unit....... 44
progesterone micronized cap 100 mg (Prometrium)......9
progesterone micronized cap 200 mg (Prometrium)......9
PROGRAF – Tacrolimus cap 0.5 mg................................51
PROGRAF – Tacrolimus cap 1 mg...................................51
PROGRAF – Tacrolimus cap 5 mg...................................51
promethazine hcl suppos 12.5 mg................................ 21
promethazine hcl suppos 25 mg................................... 21
promethazine hcl suppos 50 mg................................... 21
promethazine hcl syrup 6.25 mg/5ml............................ 21
promethazine hcl tab 12.5 mg........................................21
promethazine hcl tab 25 mg...........................................21
promethazine hcl tab 50 mg...........................................21
propafenone hcl cap sr 12hr 225 mg (Rythmol sr)....... 20
propafenone hcl tab 150 mg (Rythmol).........................20
propafenone hcl tab 225 mg (Rythmol).........................20
propafenone hcl tab 300 mg.......................................... 20
propranolol hcl cap sr 24hr 120 mg (Inderal la)........... 16
propranolol hcl cap sr 24hr 160 mg (Inderal la)........... 16
2014
propranolol hcl cap sr 24hr 60 mg (Inderal la)............. 16
propranolol hcl cap sr 24hr 80 mg (Inderal la)............. 16
PROPRANOLOL HCL – Propranolol hcl oral soln 20
mg/5ml............................................................................. 16
PROPRANOLOL HCL – Propranolol hcl oral soln 40
mg/5ml............................................................................. 16
propranolol hcl tab 10 mg..............................................16
propylthiouracil tab 50 mg............................................. 13
PROTOPIC – Tacrolimus oint 0.03%................................50
PROTOPIC – Tacrolimus oint 0.1%..................................50
PULMOZYME – Dornase alfa inhal soln 1 mg/ml............. 23
pyrazinamide tab 500 mg................................................. 3
pyridostigmine bromide tab 60 mg (Mestinon).............40
Q
quetiapine fumarate tab 100 mg (Seroquel)..................30
quetiapine fumarate tab 25 mg (Seroquel)....................30
quetiapine fumarate tab 50 mg (Seroquel)....................30
quinapril hcl tab 10 mg (Accupril)................................. 15
quinapril hcl tab 5 mg (Accupril)................................... 15
quinapril-hydrochlorothiazide tab 10-12.5 mg
(Accuretic)...................................................................... 15
quinapril-hydrochlorothiazide tab 20-12.5 mg
(Accuretic)...................................................................... 15
quinapril-hydrochlorothiazide tab 20-25 mg
(Accuretic)...................................................................... 15
quinidine gluconate tab cr 324 mg................................20
quinidine sulfate tab 200 mg..........................................20
quinidine sulfate tab 300 mg..........................................20
QVAR – Beclomethasone dipropionate inhal aero soln 40
mcg/act............................................................................ 23
QVAR – Beclomethasone dipropionate inhal aero soln 80
mcg/act............................................................................ 23
R
raloxifene hcl tab 60 mg (Evista)................................... 14
ramipril cap 1.25 mg (Altace)......................................... 15
ramipril cap 10 mg (Altace)............................................ 15
ramipril cap 2.5 mg (Altace)........................................... 15
ramipril cap 5 mg (Altace)..............................................15
ranitidine hcl cap 150 mg...............................................24
ranitidine hcl cap 300 mg...............................................24
ranitidine hcl syrup 15 mg/ml (75 mg/5ml)................... 24
ranitidine hcl tab 150 mg (Zantac).................................24
ranitidine hcl tab 300 mg (Zantac).................................24
RAPAMUNE – Sirolimus oral soln 1 mg/ml.......................51
RAPAMUNE – Sirolimus tab 1 mg....................................51
RAPAMUNE – Sirolimus tab 2 mg....................................51
REBIF – Interferon beta-1a inj 22 mcg/0.5ml (12mu/ml)
(44 mcg/ml)......................................................................31
REBIF – Interferon beta-1a inj 44 mcg/0.5ml (24mu/ml)
(88 mcg/ml)......................................................................32
REBIF REBIDOSE – Interferon beta-1a inj 22 mcg/0.5ml
(12mu/ml) (44 mcg/ml).................................................... 32
REBIF REBIDOSE – Interferon beta-1a inj 44 mcg/0.5ml
(24mu/ml) (88 mcg/ml).................................................... 32
REBIF REBIDOSE TITRATION – Interferon beta-1a inj 6 x
8.8 mcg/0.2ml & 6 x 22 mcg/0.5ml..................................32
REBIF TITRATION PACK – Interferon beta-1a inj 6 x 8.8
mcg/0.2ml & 6 x 22 mcg/0.5ml........................................32
RECOMBINATE – Antihemophilic factor (recombinant) for
inj 1241-1800 unit............................................................44
inj 1801-2400 unit............................................................44
inj 220-400 unit................................................................44
inj 401-800 unit................................................................44
inj 801-1240 unit..............................................................44
RENVELA – Sevelamer carbonate packet 0.8 gm............ 26
RENVELA – Sevelamer carbonate packet 2.4 gm............ 26
RENVELA – Sevelamer carbonate tab 800 mg................ 25
repaglinide tab 0.5 mg (Prandin)................................... 11
repaglinide tab 1 mg (Prandin)...................................... 11
repaglinide tab 2 mg (Prandin)...................................... 11
REPRONEX – Menotropins for inj 75 unit.........................10
RESCRIPTOR – Delavirdine mesylate tab 100 mg.............5
RESCRIPTOR – Delavirdine mesylate tab 200 mg.............5
REVLIMID – Lenalidomide cap 10 mg..............................51
REVLIMID – Lenalidomide cap 5 mg................................51
REVLIMID – Lenalidomide caps 2.5 mg........................... 51
REYATAZ – Atazanavir sulfate cap 100 mg (base
equiv)................................................................................. 5
equiv)................................................................................. 5
equiv)................................................................................. 5
equiv)................................................................................. 5
ribavirin cap 200 mg (Rebetol).........................................3
ribavirin tab 200 mg (Copegus)....................................... 4
rifabutin cap 150 mg (Mycobutin)....................................3
rifampin cap 150 mg (Rifadin)..........................................3
rifampin cap 300 mg (Rifadin)..........................................3
riluzole tab 50 mg (Rilutek)............................................ 40
risedronate sodium tab 150 mg (Actonel).....................14
risperidone orally disintegrating tab 0.25 mg...............30
risperidone orally disintegrating tab 0.5 mg (Risperdal
m-tab).............................................................................. 30
73
2014
risperidone orally disintegrating tab 1 mg (Risperdal
m-tab).............................................................................. 30
m-tab).............................................................................. 30
m-tab).............................................................................. 30
m-tab).............................................................................. 30
risperidone soln 1 mg/ml (Risperdal)............................30
risperidone tab 0.25 mg (Risperdal).............................. 30
risperidone tab 0.5 mg (Risperdal)................................ 30
risperidone tab 1 mg (Risperdal)................................... 30
rivastigmine tartrate cap 1.5 mg (Exelon)..................... 32
rivastigmine tartrate cap 3 mg (Exelon)........................33
rivastigmine tartrate cap 4.5 mg (Exelon)..................... 33
rivastigmine tartrate cap 6 mg (Exelon)........................33
RIXUBIS – Coagulation factor ix (recombinant) for inj 1000
unit................................................................................... 45
unit................................................................................... 45
unit................................................................................... 45
unit................................................................................... 45
unit................................................................................... 45
rizatriptan benzoate orally disintegrating tab 10 mg
(Maxalt-mlt).....................................................................37
rizatriptan benzoate orally disintegrating tab 5 mg
(Maxalt-mlt).....................................................................37
rizatriptan benzoate tab 10 mg (Maxalt)........................37
rizatriptan benzoate tab 5 mg (Maxalt)..........................37
ropinirole hydrochloride tab 0.25 mg (Requip).............39
ropinirole hydrochloride tab 0.5 mg (Requip)...............40
ropinirole hydrochloride tab 1 mg (Requip)................. 40
S
SABRIL – Vigabatrin powd pack 500 mg..........................39
SABRIL – Vigabatrin tab 500 mg......................................39
salsalate tab 500 mg....................................................... 33
salsalate tab 750 mg....................................................... 33
selegiline hcl cap 5 mg (Eldepryl)................................. 40
selegiline hcl tab 5 mg................................................... 40
selenium sulfide lotion 2.5%.......................................... 50
SELZENTRY – Maraviroc tab 150 mg................................ 5
SELZENTRY – Maraviroc tab 300 mg................................ 5
SE-NATAL 19 – prenatal vit w/ dss-fe fumarate-fa tab 29-1
mg.................................................................................... 41
74
SE-NATAL 19 – prenatal vit w/ fe fumarate-fa chew tab
29-1 mg........................................................................... 41
SENSIPAR – Cinacalcet hcl tab 30 mg (base equiv)........ 14
SEROQUEL XR – Quetiapine fumarate tab sr 24hr 150
mg.................................................................................... 30
mg.................................................................................... 30
mg.................................................................................... 30
mg.................................................................................... 30
mg.................................................................................... 30
sertraline hcl oral conc 20 mg/ml (Zoloft).....................28
sertraline hcl tab 100 mg (Zoloft).................................. 28
sertraline hcl tab 25 mg (Zoloft).................................... 28
sertraline hcl tab 50 mg (Zoloft).................................... 28
sildenafil citrate tab 20 mg (Revatio).............................21
silver sulfadiazine cream 1% (Silvadene)..................... 48
SIMBRINZA – Brinzolamide-brimonidine tartrate ophth
susp 1-0.2%.....................................................................46
simvastatin tab 10 mg (Zocor)....................................... 19
simvastatin tab 5 mg (Zocor)......................................... 19
sirolimus tab 0.5 mg (Rapamune)..................................51
sodium citrate & citric acid soln 500-334 mg/5ml
(Shohls solution modi)..................................................26
sodium fluoride chew tab 0.25 mg f (from 0.55 mg naf)
(Luride)............................................................................41
sodium fluoride chew tab 0.5 mg f (from 1.1 mg naf)
(Luride)............................................................................41
sodium fluoride chew tab 1 mg f (from 2.2 mg naf)
(Luride)............................................................................41
sodium fluoride cream 1.1% (Prevident 5000 plus)......47
sodium fluoride gel 1.1% (0.5% f) (Prevident
fluoride)...........................................................................47
sodium fluoride soln 0.125 mg/drop f (0.275 mg/drop
naf).................................................................................. 41
sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml naf)
(Luride)............................................................................41
sodium polystyrene sulfonate oral susp 15 gm/60ml
(Sps)................................................................................ 51
sodium polystyrene sulfonate powder
(Kayexalate)....................................................................51
sotalol hcl (afib/afl) tab 120 mg (Betapace af).............. 20
sotalol hcl (afib/afl) tab 160 mg (Betapace af).............. 20
sotalol hcl (afib/afl) tab 80 mg (Betapace af)................ 20
sotalol hcl tab 120 mg (Betapace)................................. 20
sotalol hcl tab 160 mg (Betapace)................................. 20
sotalol hcl tab 240 mg.................................................... 20
sotalol hcl tab 80 mg (Betapace)................................... 20
SOVALDI – Sofosbuvir tab 400 mg.................................... 4
2014
SPIRIVA HANDIHALER – Tiotropium bromide
monohydrate inhal cap 18 mcg (base equiv)...................23
spironolactone & hydrochlorothiazide tab 25-25 mg
(Aldactazide)...................................................................19
spironolactone tab 100 mg (Aldactone)........................ 19
spironolactone tab 25 mg (Aldactone).......................... 19
spironolactone tab 50 mg (Aldactone).......................... 20
SPRYCEL – Dasatinib tab 100 mg..................................... 7
SPRYCEL – Dasatinib tab 140 mg..................................... 7
SPRYCEL – Dasatinib tab 20 mg....................................... 7
stavudine cap 15 mg (Zerit)............................................. 5
stavudine for oral soln 1 mg/ml (Zerit)............................5
STIMATE – Desmopressin acetate nasal soln 1.5 mg/
ml..................................................................................... 14
STRIBILD – Elvitegrav-cobicis-emtricitab-tenofov tab
150-150-200-300 mg......................................................... 5
STROMECTOL – Ivermectin tab 3 mg............................... 6
SUBOXONE – Buprenorphine hcl-naloxone hcl sl film 12-3
mg (base equiv)...............................................................36
SUBOXONE – Buprenorphine hcl-naloxone hcl sl film
2-0.5 mg (base equiv)..................................................... 36
mg (base equiv)...............................................................36
mg (base equiv)...............................................................36
sucralfate tab 1 gm (Carafate)....................................... 24
sulfacetamide sodium lotion 10% (acne) (Klaron)........48
sulfacetamide sodium ophth soln 10% (Bleph-10).......45
sulfacetamide sodium-prednisolone ophth soln
10-0.23(0.25)%................................................................ 46
sulfacetamide sodium w/ sulfur cream 10-5%.............. 48
sulfacetamide sodium w/ sulfur emulsion 10-5%......... 48
sulfacetamide sodium w/ sulfur lotion 10-5%...............48
sulfamethoxazole-trimethoprim susp 200-40
mg/5ml.............................................................................. 6
sulfamethoxazole-trimethoprim tab 400-80 mg
(Bactrim)........................................................................... 6
sulfamethoxazole-trimethoprim tab 800-160 mg
(Bactrim ds)......................................................................6
sulfasalazine tab 500 mg (Azulfidine)........................... 26
sulfasalazine tab delayed release 500 mg (Azulfidine
en-tabs)........................................................................... 26
sulindac tab 150 mg........................................................37
sulindac tab 200 mg........................................................37
sumatriptan succinate inj 6 mg/0.5ml (Imitrex)............ 37
sumatriptan succinate solution auto-injector 4
mg/0.5ml (Imitrex statdose sys)................................... 37
sumatriptan succinate solution auto-injector 6
mg/0.5ml (Imitrex statdose sys)................................... 37
sumatriptan succinate solution cartridge 4 mg/0.5ml
(Imitrex statdose ref)..................................................... 37
sumatriptan succinate solution cartridge 6 mg/0.5ml
(Imitrex statdose ref)..................................................... 37
sumatriptan succinate tab 100 mg (Imitrex)................. 37
sumatriptan succinate tab 25 mg (Imitrex)................... 37
sumatriptan succinate tab 50 mg (Imitrex)................... 37
SUPRAX – Cefixime tab 400 mg........................................ 2
SUSTIVA – Efavirenz cap 200 mg......................................5
SUSTIVA – Efavirenz cap 50 mg........................................5
SUSTIVA – Efavirenz tab 600 mg...................................... 5
SUTENT – Sunitinib malate cap 12.5 mg (base
equivalent)......................................................................... 7
SUTENT – Sunitinib malate cap 25 mg (base
equivalent)......................................................................... 7
SUTENT – Sunitinib malate cap 37.5 mg (base
equivalent)......................................................................... 7
SUTENT – Sunitinib malate cap 50 mg (base
equivalent)......................................................................... 7
SYLATRON – Peginterferon alfa-2b for inj kit 296 mcg.......7
SYLATRON – Peginterferon alfa-2b for inj kit 4 x 296
mcg.................................................................................... 7
mcg.................................................................................... 7
mcg.................................................................................... 7
SYMBICORT – Budesonide-formoterol fumarate dihyd
aerosol 160-4.5 mcg/act.................................................. 23
SYMBICORT – Budesonide-formoterol fumarate dihyd
aerosol 80-4.5 mcg/act.................................................... 23
SYNAREL – Nafarelin acetate nasal soln 2 mg/ml............10
T
TABLOID – Thioguanine tab 40 mg....................................7
tacrolimus cap 0.5 mg (Prograf).................................... 51
tacrolimus cap 1 mg (Prograf)....................................... 51
tacrolimus cap 5 mg (Prograf)....................................... 51
TAFINLAR – Dabrafenib mesylate cap 50 mg (base
equivalent)......................................................................... 7
TAFINLAR – Dabrafenib mesylate cap 75 mg (base
equivalent)......................................................................... 7
tamoxifen citrate tab 10 mg (base equivalent)............... 7
tamoxifen citrate tab 20 mg (base equivalent)............... 7
tamsulosin hcl cap 0.4 mg (Flomax)............................. 27
TARCEVA – Erlotinib tab 100 mg.......................................7
TARCEVA – Erlotinib tab 150 mg.......................................7
TARCEVA – Erlotinib tab 25 mg.........................................7
TASIGNA – Nilotinib cap 150 mg....................................... 7
TASIGNA – Nilotinib cap 200 mg....................................... 7
TAZORAC – Tazarotene cream 0.05%.............................48
TAZORAC – Tazarotene cream 0.1%...............................48
TAZORAC – Tazarotene gel 0.05%..................................48
TAZORAC – Tazarotene gel 0.1%....................................48
75
2014
TECFIDERA – Dimethyl fumarate capsule delayed release
120 mg.............................................................................32
TECFIDERA – Dimethyl fumarate capsule delayed release
240 mg.............................................................................32
TECFIDERA STARTER PACK – Dimethyl fumarate
capsule dr starter pack 120 mg & 240 mg...................... 32
TEGRETOL-XR – Carbamazepine tab sr 12hr 100 mg.....39
temazepam cap 15 mg (Restoril)................................... 30
temazepam cap 22.5 mg (Restoril)................................ 30
temazepam cap 30 mg (Restoril)................................... 30
temazepam cap 7.5 mg (Restoril).................................. 30
temozolomide cap 100 mg (Temodar).............................7
temozolomide cap 20 mg (Temodar)...............................7
temozolomide cap 5 mg (Temodar).................................7
terazosin hcl cap 10 mg................................................. 21
terazosin hcl cap 1 mg................................................... 21
terbinafine hcl tab 250 mg (Lamisil)................................3
terbutaline sulfate tab 2.5 mg........................................ 23
terbutaline sulfate tab 5 mg........................................... 23
terconazole vaginal cream 0.4% (Terazol 7)................. 26
terconazole vaginal cream 0.8% (Terazol 3)................. 26
terconazole vaginal suppos 80 mg................................26
testosterone cypionate im in oil 100 mg/ml (Depotestosterone).................................................................... 8
testosterone cypionate im in oil 200 mg/ml (Depotestosterone).................................................................... 9
testosterone enanthate im in oil 200 mg/ml................... 9
TEST STRIPS – BAYERASCENSIA AUTODISC,
BREEZE 2, CONTOUR, CONTOUR NEXT.................... 50
TEST STRIPS – ROCHE ACCU-CHEKACTIVE, AVIVA,
AVIVA PLUS, COMFORT CURVE, COMPACT,
SMARTVIEW................................................................... 50
TEST STRIPS – ROCHE ACCUTREND...........................50
THALOMID – Thalidomide cap 100 mg............................ 51
THALOMID – Thalidomide cap 50 mg.............................. 51
theophylline tab sr 12hr 100 mg.................................... 23
thiothixene cap 10 mg.................................................... 30
thiothixene cap 1 mg...................................................... 30
timolol maleate ophth gel forming soln 0.25%
(Timoptic-xe).................................................................. 46
timolol maleate ophth gel forming soln 0.5%
(Timoptic-xe).................................................................. 46
76
timolol maleate ophth soln 0.25% (Timoptic)............... 46
timolol maleate ophth soln 0.5% (Timoptic)................. 46
TIMOLOL MALEATE – Timolol maleate tab 10 mg...........16
TIMOLOL MALEATE – Timolol maleate tab 20 mg...........16
TIMOLOL MALEATE – Timolol maleate tab 5 mg............ 16
TIVICAY – Dolutegravir sodium tab 50 mg (base equiv)..... 5
tizanidine hcl tab 2 mg................................................... 40
tizanidine hcl tab 4 mg (Zanaflex)................................. 40
TOBRADEX – Tobramycin-dexamethasone ophth oint
0.3-0.1%...........................................................................46
tobramycin-dexamethasone ophth susp 0.3-0.1%
(Tobradex)...................................................................... 46
tobramycin nebu soln 300 mg/5ml (Tobi)....................... 3
tobramycin ophth soln 0.3% (Tobrex)........................... 45
tolterodine tartrate cap sr 24hr 2 mg (Detrol la)........... 26
tolterodine tartrate cap sr 24hr 4 mg (Detrol la)........... 26
tolterodine tartrate tab 1 mg (Detrol).............................26
tolterodine tartrate tab 2 mg (Detrol).............................26
topiramate sprinkle cap 15 mg (Topamax sprinkle)..... 39
topiramate sprinkle cap 25 mg (Topamax sprinkle)..... 39
topiramate tab 100 mg (Topamax).................................39
topiramate tab 200 mg (Topamax).................................39
topiramate tab 25 mg (Topamax)...................................39
topiramate tab 50 mg (Topamax)...................................39
torsemide tab 100 mg (Demadex)..................................20
torsemide tab 10 mg (Demadex)....................................20
torsemide tab 20 mg (Demadex)....................................20
torsemide tab 5 mg (Demadex)......................................20
TRACLEER – Bosentan tab 125 mg.................................21
TRACLEER – Bosentan tab 62.5 mg................................21
tramadol-acetaminophen tab 37.5-325 mg
(Ultracet)......................................................................... 36
tramadol hcl tab 50 mg (Ultram).................................... 36
tramadol hcl tab sr 24hr 100 mg (Ultram er).................36
trandolapril tab 1 mg (Mavik)......................................... 15
tranylcypromine sulfate tab 10 mg (Parnate)............... 28
TRAVATAN Z – Travoprost ophth soln 0.004%
(benzalkonium free) (bak free)........................................ 46
trazodone hcl tab 100 mg...............................................28
trazodone hcl tab 50 mg.................................................28
tretinoin cap 10 mg...........................................................7
tretinoin cream 0.025% (Retin-a)................................... 48
tretinoin cream 0.05% (Retin-a)..................................... 48
tretinoin cream 0.1% (Retin-a)....................................... 48
tretinoin gel 0.01% (Retin-a)...........................................48
tretinoin gel 0.025% (Retin-a).........................................48
tretinoin microsphere gel 0.04% (Retin-a micro)..........48
tretinoin microsphere gel 0.1% (Retin-a micro)............48
TRETTEN – Coagulation factor xiii a-subunit for inj
2000-3125 unit.................................................................45
2014
TREXALL – Methotrexate sodium tab 10 mg (base
equiv)................................................................................. 7
equiv)................................................................................. 7
equiv)................................................................................. 7
TREXALL – Methotrexate sodium tab 7.5 mg (base
equiv)................................................................................. 7
triamcinolone acetonide cream 0.025%........................ 49
triamcinolone acetonide cream 0.1%............................ 49
triamcinolone acetonide cream 0.5%............................ 49
triamcinolone acetonide dental paste 0.1%.................. 47
triamcinolone acetonide lotion 0.025%......................... 49
triamcinolone acetonide lotion 0.1%............................. 49
triamcinolone acetonide nasal inhal 55 mcg/act
(Nasacort aq)..................................................................22
triamcinolone acetonide oint 0.025%............................ 49
triamcinolone acetonide oint 0.1%................................ 49
triamterene & hydrochlorothiazide cap 37.5-25 mg
(Dyazide)......................................................................... 20
triamterene & hydrochlorothiazide tab 37.5-25 mg
(Maxzide-25)................................................................... 20
triamterene & hydrochlorothiazide tab 75-50 mg
(Maxzide).........................................................................20
trifluoperazine hcl tab 10 mg......................................... 30
trifluoperazine hcl tab 1 mg........................................... 30
trifluridine ophth soln 1% (Viroptic).............................. 45
trihexyphenidyl hcl elixir 0.4 mg/ml.............................. 40
trihexyphenidyl hcl tab 2 mg......................................... 40
trihexyphenidyl hcl tab 5 mg......................................... 40
trimethobenzamide hcl cap 300 mg (Tigan)..................25
trimethoprim tab 100 mg.................................................. 6
tropicamide ophth soln 0.5%......................................... 47
tropicamide ophth soln 1% (Mydriacyl)........................ 47
TRUVADA – Emtricitabine-tenofovir disoproxil fumarate
tab 200-300 mg................................................................. 5
U
ursodiol cap 300 mg (Actigall).......................................26
ursodiol tab 250 mg (Urso 250)..................................... 26
ursodiol tab 500 mg (Urso forte)................................... 26
V
VAGIFEM – Estradiol vaginal tab 10 mcg.........................26
valacyclovir hcl tab 1 gm (Valtrex).................................. 4
valacyclovir hcl tab 500 mg (Valtrex).............................. 4
VALCHLOR – Mechlorethamine hcl gel 0.016% (base
equivalent)....................................................................... 50
VALCYTE – Valganciclovir hcl for soln 50 mg/ml (base
equiv)................................................................................. 3
VALCYTE – Valganciclovir hcl tab 450 mg......................... 3
valproate sodium syrup 250 mg/5ml (base equiv)
(Depakene)......................................................................39
valproic acid cap 250 mg (Depakene)........................... 39
valsartan-hydrochlorothiazide tab 160-12.5 mg
(Diovan hct)....................................................................15
valsartan-hydrochlorothiazide tab 160-25 mg (Diovan
hct).................................................................................. 15
valsartan-hydrochlorothiazide tab 320-12.5 mg
(Diovan hct)....................................................................15
valsartan-hydrochlorothiazide tab 320-25 mg (Diovan
hct).................................................................................. 15
valsartan-hydrochlorothiazide tab 80-12.5 mg (Diovan
hct).................................................................................. 15
valsartan tab 160 mg (Diovan)....................................... 15
valsartan tab 320 mg (Diovan)....................................... 15
valsartan tab 40 mg (Diovan)......................................... 15
valsartan tab 80 mg (Diovan)......................................... 15
vancomycin hcl cap 125 mg (Vancocin hcl)................... 6
vancomycin hcl cap 250 mg (Vancocin hcl)................... 6
venlafaxine hcl cap sr 24hr 150 mg (base equivalent)
(Effexor xr)..................................................................... 28
venlafaxine hcl cap sr 24hr 37.5 mg (base equivalent)
(Effexor xr)..................................................................... 28
venlafaxine hcl cap sr 24hr 75 mg (base equivalent)
(Effexor xr)..................................................................... 28
venlafaxine hcl tab 100 mg............................................ 29
venlafaxine hcl tab 25 mg.............................................. 29
venlafaxine hcl tab 37.5 mg........................................... 29
venlafaxine hcl tab sr 24hr 150 mg (base equivalent)
(Venlafaxine hcl er)....................................................... 29
venlafaxine hcl tab sr 24hr 37.5 mg (base equivalent)
venlafaxine hcl tab sr 24hr 75 mg (base equivalent)
VENTOLIN HFA – Albuterol sulfate inhal aero 108 mcg/act
(90mcg base equiv).........................................................23
verapamil hcl cap sr 24hr 120 mg (Verelan)................. 18
verapamil hcl tab 120 mg (Calan).................................. 18
verapamil hcl tab 80 mg (Calan).................................... 18
verapamil hcl tab cr 120 mg (Calan sr)......................... 18
VESICARE – Solifenacin succinate tab 10 mg................. 26
VESICARE – Solifenacin succinate tab 5 mg................... 26
VICTOZA – Liraglutide soln pen-injector 18 mg/3ml (6 mg/
ml).................................................................................... 11
VIDEX – Didanosine for soln 2 gm..................................... 5
VIDEX – Didanosine for soln 4 gm..................................... 5
VIGAMOX – Moxifloxacin hcl ophth soln 0.5% (base
equiv)............................................................................... 46
VIRACEPT – Nelfinavir mesylate tab 250 mg.....................5
VIRACEPT – Nelfinavir mesylate tab 625 mg.....................5
VIRAMUNE – Nevirapine susp 50 mg/5ml..........................5
VIRAMUNE XR – Nevirapine tab sr 24hr 100 mg............... 5
77
2014
VIREAD – Tenofovir disoproxil fumarate oral powder 40
mg/gm................................................................................ 5
VIREAD – Tenofovir disoproxil fumarate tab 150 mg..........5
VIVELLE-DOT – Estradiol td patch biweekly 0.025
mg/24hr..............................................................................9
mg/24hr..............................................................................9
mg/24hr..............................................................................9
mg/24hr..............................................................................9
mg/24hr..............................................................................9
VOLTAREN – Diclofenac sodium gel 1%......................... 48
voriconazole for susp 40 mg/ml (Vfend)......................... 3
voriconazole tab 200 mg (Vfend).....................................3
voriconazole tab 50 mg (Vfend).......................................3
VOTRIENT – Pazopanib hcl tab 200 mg (base equiv)........ 7
VYVANSE – Lisdexamfetamine dimesylate cap 20 mg.....31
W
warfarin sodium tab 10 mg (Coumadin)........................45
warfarin sodium tab 1 mg (Coumadin)..........................45
warfarin sodium tab 2.5 mg (Coumadin).......................45
warfarin sodium tab 7.5 mg (Coumadin).......................45
WELCHOL – Colesevelam hcl packet for susp 3.75
gm.................................................................................... 19
WELCHOL – Colesevelam hcl tab 625 mg....................... 19
WILATE – Antihemophilic factor/vwf (human) for inj
1000-1000 unit.................................................................45
WILATE – Antihemophilic factor/vwf (human) for inj
500-500 unit.....................................................................45
X
XALKORI – Crizotinib cap 200 mg..................................... 7
XALKORI – Crizotinib cap 250 mg..................................... 7
XARELTO – Rivaroxaban tab 10 mg................................ 45
XERAC AC – Aluminum chloride in alcohol solution
6.25%...............................................................................50
XIFAXAN – Rifaximin tab 550 mg.......................................6
78
XYNTHA – Antihemophilic factor recombinant paf for inj kit
1000 unit..........................................................................45
2000 unit..........................................................................45
250 unit............................................................................45
500 unit............................................................................45
XYNTHA SOLOFUSE – Antihemophilic factor recombinant
paf for inj kit 1000 unit.................................................... 45
paf for inj kit 250 unit...................................................... 45
paf for inj kit 500 unit...................................................... 45
Y
Z
zafirlukast tab 10 mg (Accolate).................................... 23
zafirlukast tab 20 mg (Accolate).................................... 23
zaleplon cap 10 mg (Sonata)..........................................30
zaleplon cap 5 mg (Sonata)........................................... 30
ZELBORAF – Vemurafenib tab 240 mg (base
equivalent)......................................................................... 8
ZENPEP – Pancrelipase (lip-prot-amyl) dr cap
10000-34000-55000 unit..................................................25
15000-51000-82000 unit..................................................25
20000-68000-109000 unit................................................25
25000-85000-136000 unit................................................25
3000-10000-16000 unit....................................................25
5000-17000-27000 unit....................................................25
ZIAGEN – Abacavir sulfate soln 20 mg/ml (base equiv)......5
zidovudine cap 100 mg (Retrovir)................................... 5
zidovudine syrup 10 mg/ml (Retrovir).............................5
zidovudine tab 300 mg..................................................... 5
ziprasidone hcl cap 20 mg (Geodon)............................ 30
ZITHROMAX – Azithromycin powd pack for susp 1 gm...... 2
zolpidem tartrate tab 10 mg (Ambien)...........................31
zolpidem tartrate tab 5 mg (Ambien).............................31
zolpidem tartrate tab cr 12.5 mg (Ambien cr)............... 30
zolpidem tartrate tab cr 6.25 mg (Ambien cr)............... 31
zonisamide cap 100 mg (Zonegran).............................. 39
zonisamide cap 25 mg (Zonegran)................................ 39
zonisamide cap 50 mg....................................................39
2014
ZORTRESS – Everolimus tab 0.25 mg.............................51
ZORTRESS – Everolimus tab 0.5 mg...............................51
ZORTRESS – Everolimus tab 0.75 mg.............................51
ZYCLARA – Imiquimod cream 3.75%...............................50
ZYCLARA PUMP – Imiquimod cream 2.5%......................50
ZYCLARA PUMP – Imiquimod cream 3.75%....................50
ZYLET – Loteprednol etabonate-tobramycin ophth susp
0.5-0.3%...........................................................................46
ZYTIGA – Abiraterone acetate tab 250 mg.........................8
ZYVOX – Linezolid for susp 100 mg/5ml............................ 6
ZYVOX – Linezolid tab 600 mg.......................................... 6
79

Standard Drug Formulary - Blue Cross and Blue Shield of Illinois

Transcription

Similar documents

2015 Standard Drug List - Blue Cross and Blue Shield of Texas

Generics Plus April 2016 Drug Formulary

Blue Cross Blue Shield of Wyoming Standard Drug List, January 2016

BCBSND Formulary - Blue Cross Blue Shield of North Dakota

Blue Medicare Rx Standard

HealthPartners EnhancedRx

Lista de Medicamentos - Blue Cross and Blue Shield of Illinois

Florida Blue July 2016 Medication Guide

generic drug list - Blue Cross and Blue Shield of Texas

Horizon BCBSNJ Health Insurance Marketplace

Medi-Pak Rx Premier (PDP) 2015 Comprehensive

2015 Prescription Drug Formular and Network Pharmacies

Blue Cross and Blue Shield of North Carolina (BCBSNC)

Medi-Pak Rx Basic (PDP) 2015 Comprehensive

Rx Formulary - Millenium Medical Solutions Corp

Drug Formulary