PDF - Cox HealthPlans

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INTRODUCTION
EnvisionRx utilizes a Pharmacy and Therapeutics Committee (P & T Committee), made up of practicing
physicians and pharmacists to help ensure that our formulary is medically sound and that it supports patient
health. This committee reviews and evaluates medications on the formulary based on safety and efficacy to
help maintain clinical integrity in all therapeutic categories.
FORMULARY DESIGN
There are numerous formulary designs that can be used by a pharmacy benefits administrator. EnvisionRx has
chosen a formulary structure which is open and incentive based.
•
Open Formulary: features co-payments for medications that are preferred and non-preferred brands,
plus lower co-payments for generic drugs.
• Incentive Based: features different co-payments for medications that are preferred or non preferred.
In this type of formulary, the patient cost structure may be two-tier, three-tier, or four-tier design.
USING THIS FORMULARY REFERENCE GUIDE TO HELP CONTAIN COSTS
Many benefit sponsors use the EnvisionRx formulary to help manage the overall cost of providing prescription
drug benefits. This formulary offers a wide range of medications from which to choose.We realize that this
formulary reference guide may not include every drug from every manufacturer. However, choosing a
preferred drug (Tier 2 or generic) when it is appropriate can provide access to the necessary medications to
stay healthy, at a cost that is more affordable.
Mandatory Generic
The Prescription Drug benefit is a “Mandatory Generic” program. Each Prescription will be filled as a Generic when available. If
the Physician or the Covered Person requests a Brand Name Medication when there is an FDA “AB” rated Generic available, the
Covered Person will be charged the applicable Deductible/ Co- insurance/ Co-payments plus the difference in the price of the
Brand Name Medication and the available Generic. This charge is referred to as a DAW (Dispense as Written). The fee is
applicable regardless of prescriber request or member request.
Brand Drugs with a Generic Equivalent
Brand drugs which have a generic equivalent will be classified as non-preferred brand products, with the generic versions of
those drugs available on the generic tier. Most covered individuals need not do anything as a result of this change as the
dispensing pharmacy will typically substitute the generic equivalent, unless prohibited by the prescribing physician. Beginning
January 1, 2016, brand drugs will immediately be reclassified as non-preferred once the generic equivalent becomes
commercially available. Exceptions may occur on the formulary should the cost of the brand drug be less expensive than the
generic equivalent.
June 2016
CONSIDERING PREFERRED ALTERNATIVES
EnvisionRx realizes that the medications on the formulary may not always be appropriate for all patients.
However, by referring to this formulary reference guide, one can help ensure the full advantage of the
coverage provided by the prescription drug plan.
Pharmacies cannot substitute a preferred brand-name drug without the prescriber’s approval. Therefore, a
pharmacist may contact the prescriber to obtain authorization to dispense an alternative preferred product
when a non-preferred product is prescribed.
SAVING ON OUT-OF-POCKET COSTS
The prescription drug plan determines the cost for generic, preferred brand-name, and on-preferred brandname medications. Benefit providers often design prescription drug plans to encourage the use of generic and
preferred brand-name drugs. Choosing non-preferred drugs may mean paying higher out-of-pocket expenses
(such as coinsurance, co-payments, and deductible amounts) or not receiving coverage at all. Patients may
also pay less for generic drugs, or they may be asked to pay the cost difference between brand-name drugs
and their generic alternatives, which are preferred by the plan.
CONSULTING THE PRESCRIBER’S OFFICE WHEN APPROPRIATE
When employers and other benefit sponsors design their prescription drug plans, they may choose to provide
coverage only for certain medications or for particular uses, time periods, doses, or quantities (e.g. they may
exclude coverage for medications for unapproved, unproven, or cosmetic indications, as well as over-thecounter medications). When coverage for medications is provided based on use or quantity, EnvisionRx may
contact your prescriber’s office for additional information to determine whether coverage is available under
your plan.
June 2016
LEGEND
TIER
NAME
1
Generics
2
Preferred Brands
3
Non-Preferred Brands
4
Specialty
5
Preventative
SYMBOL
NAME
DESCRIPTION
Quantity Limit
There is a limit on the amount of this drug that is covered per
prescription, or within a specific time frame.
PA
Prior Authorization
You (or your physician) are required to get prior
authorization before you fill your prescription for this drug.
Without prior approval, we may not cover this drug.
ST
Step Therapy
In some cases, you may be required to first try certain drugs
to treat your medical condition before we will cover another
drug for that condition.
QL
1
List of Covered Drugs
DRUG NAME
DRUG
TIER
REQUIREMENTS/LIMITS
*ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS*
*ADHD AGENT - SELECTIVE ALPHA ADRENERGIC AGONISTS***
clonidine
tab 0.1mg er
1
guanfacine tab 1mg er
1
1
1
1
INTUNIV
TAB 1MG
3
INTUNIV
TAB 2MG
3
INTUNIV
TAB 3MG
3
INTUNIV
TAB 4MG
3
KAPVAY
MIS 0.1&0.2
3
KAPVAY
TAB 0.1 MG
3
*ADHD AGENT - SELECTIVE NOREPINEPHRINE REUPTAKE INHIBITOR***
STRATTERA CAP 100MG
3
STRATTERA CAP 10MG
3
STRATTERA CAP 18MG
3
STRATTERA CAP 25MG
3
STRATTERA CAP 40MG
3
STRATTERA CAP 60MG
3
You can find information on what the symbols and abbreviations on this table mean
by going to page 1 of the introduction.
2
DRUG NAME
DRUG
TIER
STRATTERA CAP 80MG
REQUIREMENTS/LIMITS
3
*AMPHETAMINE MIXTURES***
ADDERALL
TAB 10MG
3
ADDERALL
TAB 12.5MG
3
ADDERALL
TAB 15MG
3
ADDERALL
TAB 20MG
3
ADDERALL
TAB 30MG
3
ADDERALL
TAB 5MG
3
ADDERALL
TAB 7.5MG
3
ADDERALL XR CAP 10MG
3
3
3
3
3
ADDERALL XR CAP 5MG
3
amphet/dextr tab 10mg
1
amphet/dextr tab 12.5mg
1
1
1
1
1
amphet/dextr tab 7.5mg
1
amphetamine cap 10mg er
1
3
DRUG NAME
DRUG
TIER
1
1
1
1
1
amphetamine tab 10mg
1
amphetamine tab 12.5mg
1
1
1
1
amphetamine tab 5mg
1
amphetamine tab 7.5mg
1
REQUIREMENTS/LIMITS
*AMPHETAMINES***
DESOXYN
TAB 5MG
3
DEXEDRINE
CAP 10MG CR
3
DEXEDRINE
CAP 15MG CR
3
DEXEDRINE
CAP 5MG CR
3
dexedrine
tab 10mg
1
dexedrine
tab 5mg
1
dextroamphet cap 10mg er
1
1
1
dextroamphet sol 5mg/5ml
1
4
DRUG NAME
DRUG
TIER
dextroamphet tab 10mg
1
dextroamphet tab 5mg
1
dextroamphet tab sulf 5mg
1
EVEKEO
TAB 10MG
3
EVEKEO
TAB 5MG
3
methamphetam tab 5mg
1
procentra
1
sol 5mg/5ml
REQUIREMENTS/LIMITS
VYVANSE
CAP 10MG
2
ST
VYVANSE
CAP 20MG
2
ST
VYVANSE
CAP 30MG
2
ST
VYVANSE
CAP 40MG
2
ST
VYVANSE
CAP 50MG
2
ST
VYVANSE
CAP 60MG
2
ST
VYVANSE
CAP 70MG
2
ST
zenzedi
tab 10mg
1
zenzedi
tab 15mg
1
ZENZEDI
TAB 2.5MG
3
zenzedi
tab 20mg
1
zenzedi
tab 30mg
1
zenzedi
tab 5mg
1
ZENZEDI
TAB 7.5MG
3
*STIMULANTS - MISC & NUTRITIONAL SUPPLEMENT COMBINATIONS***
SENTRAMODAFI PAK AM-100
3
5
DRUG NAME
DRUG
TIER
REQUIREMENTS/LIMITS
*STIMULANTS - MISC.***
APTENSIO XR CAP 10MG
3
ST
3
ST
3
ST
3
ST
3
ST
3
ST
3
ST
CONCERTA
TAB 18MG
3
CONCERTA
TAB 27MG
3
CONCERTA
TAB 36MG
3
CONCERTA
TAB 54MG
3
DAYTRANA
DIS 10MG/9HR
3
ST
DAYTRANA
DIS 15MG/9HR
3
ST
DAYTRANA
DIS 20MG/9HR
3
ST
DAYTRANA
DIS 30MG/9HR
3
ST
dexmethylph cap 15mg er
1
1
1
dexmethylph tab 10mg
1
dexmethylph tab 2.5mg
1
dexmethylph tab 5mg
1
dexmethylphe cap 10mg er
1
6
DRUG NAME
DRUG
TIER
1
1
FOCALIN
TAB 10MG
3
FOCALIN
TAB 2.5MG
3
FOCALIN
TAB 5MG
3
REQUIREMENTS/LIMITS
FOCALIN XR CAP 10MG
3
ST
FOCALIN XR CAP 15MG
3
ST
FOCALIN XR CAP 20MG
3
ST
FOCALIN XR CAP 25MG
3
ST
FOCALIN XR CAP 30MG
3
ST
FOCALIN XR CAP 35MG
3
ST
FOCALIN XR CAP 40MG
3
ST
FOCALIN XR CAP 5MG
3
ST
metadate
1
tab 20mg er
METADATE CD CAP 10MG
3
3
3
3
3
3
methlphenida chw 2.5mg
1
methylin
chw 10mg
1
methylin
chw 2.5mg
1
7
DRUG NAME
methylin
DRUG
TIER
chw 5mg
REQUIREMENTS/LIMITS
1
METHYLIN
SOL 10MG/5ML
3
METHYLIN
SOL 5MG/5ML
3
methylphenid cap 10mg
1
1
methylphenid cap 20mg er
1
1
1
1
1
1
1
methylphenid chw 10mg
1
methylphenid chw 5mg
1
methylphenid sol 10mg/5ml
1
methylphenid sol 5mg/5ml
1
methylphenid tab 10mg
1
methylphenid tab 10mg er
1
METHYLPHENID TAB 18MG ER
3
1
methylphenid tab 20mg er
1
methylphenid tab 20mg sr
1
3
ST
ST
8
DRUG NAME
DRUG
TIER
3
3
1
modafinil
tab 100mg
1
modafinil
tab 200mg
1
NUVIGIL
TAB 150MG
2
NUVIGIL
TAB 200MG
2
NUVIGIL
TAB 250MG
2
NUVIGIL
TAB 50MG
2
PROVIGIL
TAB 100MG
3
PROVIGIL
TAB 200MG
3
QUILLIVANT SUS 25MG/5ML
3
RITALIN
TAB 10MG
3
RITALIN
TAB 20MG
3
RITALIN
TAB 20MG SR
3
RITALIN
TAB 5MG
3
REQUIREMENTS/LIMITS
ST
RITALIN LA CAP 10MG
2
ST
RITALIN LA CAP 20MG
3
ST
RITALIN LA CAP 30MG
3
ST
RITALIN LA CAP 40MG
3
ST
RITALIN LA CAP 60MG
3
ST
*ALTERNATIVE MEDICINES*
*ALTERNATIVE MEDICINE - CO'S***
9
DRUG NAME
DRUG
TIER
QUINZYME
TAB 90MG
REQUIREMENTS/LIMITS
3
*ALTERNATIVE MEDICINE - EU***
ISCAR MALI INJ 5MG/ML
3
*ALTERNATIVE MEDICINE COMBINATIONS - FIVE INGREDIENTS***
PRYFLEX
TAB
RELAMINE
TAB
3
3
*ALTERNATIVE MEDICINE COMBINATIONS - FOUR INGREDIENTS***
CO-VERATROL CAP
3
*AMEBICIDES*
*AMEBICIDES***
YODOXIN
TAB 210MG
2
YODOXIN
TAB 650MG
2
*AMINOGLYCOSIDES*
*AMINOGLYCOSIDES***
amikacin
inj 1gm/4ml
1
amikacin
inj 500/2ml
1
BETHKIS
NEB 300/4ML
3
gentam/nacl inj 0.9mg/ml
1
gentam/nacl inj 1.4mg/ml
1
gentam/nacl inj 100mg
1
GENTAM/NACL INJ 100MG PB
3
1
1
PA
10
DRUG NAME
DRUG
TIER
gentam/nacl inj 60mg pb
1
1
gentam/nacl inj 80mg pb
1
gentamicin inj 10mg/ml
1
gentamicin inj 40mg/ml
1
kanamycin
1
inj 333mg/ml
KITABIS PAK NEB 300/5ML
4
NEO-FRADIN SOL 125/5ML
3
neomycin
1
tab 500mg
REQUIREMENTS/LIMITS
PA
paromomycin cap 250mg
1
streptomycin inj 1gm
1
TOBI
4
PA
TOBI PODHALR CAP 28MG
4
PA
tobra/nacl inj 60/0.9
1
tobra/nacl inj 80/0.9
1
tobramycin inj 1.2/30ml
1
tobramycin inj 1.2gm
1
tobramycin inj 10mg/ml
1
tobramycin inj 40mg/ml
1
tobramycin inj 80mg/2ml
1
tobramycin neb 300/5
4
PA
tobramycin neb 300/5ml
4
PA
NEB 300/5ML
*ANALGESICS - ANTI-INFLAMMATORY*
11
DRUG NAME
DRUG
TIER
REQUIREMENTS/LIMITS
*ANTI-TNF-ALPHA - MONOCLONAL ANTIBODIES***
HUMIRA
INJ 10MG/0.2
4
PA, ST
HUMIRA
KIT 20MG/0.4
4
PA, ST
HUMIRA
KIT 40MG/0.8
4
PA, ST
HUMIRA PEDIA INJ CROHNS
4
PA, ST
HUMIRA PEN INJ 40MG/0.8
4
PA, ST
HUMIRA PEN INJ CROHNS
4
PA, ST
HUMIRA PEN INJ PSORIASI
4
PA, ST
SIMPONI
INJ 100MG/ML
4
PA, ST
SIMPONI
INJ 50/0.5ML
4
PA, ST
4
PA, ST
SIMPONI ARIA SOL 50MG/4ML
*ANTIRHEUMATIC - JANUS KINASE (JAK) INHIBITORS***
XELJANZ
TAB 5MG
4
PA, ST
*ANTIRHEUMATIC ANTIMETABOLITES***
OTREXUP
INJ 10MG
3
OTREXUP
INJ 15MG
3
OTREXUP
INJ 20MG
3
OTREXUP
INJ 25MG
3
OTREXUP
INJ 7.5/0.4
3
RASUVO
INJ 10MG
3
RASUVO
INJ 12.5MG
3
RASUVO
INJ 15MG
3
RASUVO
INJ 17.5MG
3
12
DRUG NAME
DRUG
TIER
RASUVO
INJ 20MG
3
RASUVO
INJ 22.5MG
3
RASUVO
INJ 25MG
3
RASUVO
INJ 27.5MG
3
RASUVO
INJ 30MG
3
RASUVO
INJ 7.5MG
3
RHEUMATREX TAB 2.5MG
REQUIREMENTS/LIMITS
3
*CYCLOOXYGENASE 2 (COX-2) INHIBITORS***
CELEBREX
CAP 100MG
3
ST
CELEBREX
CAP 200MG
3
ST
CELEBREX
CAP 400MG
3
ST
CELEBREX
CAP 50MG
3
ST
celecoxib
cap 100mg
1
ST
celecoxib
cap 200mg
1
ST
celecoxib
cap 400mg
1
ST
celecoxib
cap 50mg
1
ST
*GOLD COMPOUNDS***
RIDAURA
CAP 3MG
2
*INTERLEUKIN-1 BLOCKERS***
ARCALYST
INJ 220MG
4
PA
*INTERLEUKIN-1 RECEPTOR ANTAGONIST (IL-1RA)***
KINERET
INJ
4
PA, ST
4
PA
*INTERLEUKIN-1BETA BLOCKERS***
ILARIS
INJ 180MG
13
DRUG NAME
DRUG
TIER
REQUIREMENTS/LIMITS
*INTERLEUKIN-6 RECEPTOR INHIBITORS***
ACTEMRA
INJ 162/0.9
4
PA, ST
ACTEMRA
INJ 200/10ML
4
PA, ST
ACTEMRA
INJ 400/20ML
4
PA, ST
ACTEMRA
INJ 80MG/4ML
4
PA, ST
*NONSTEROIDAL ANTI-INFLAMMATORY AGENT COMBINATIONS***
ARTHROTEC 50 TAB
3
ARTHROTEC 75 TAB
3
DERMA SILKRX PAK ANODYNEX
3
DERMA SILKRX PAK DICLOPAK
3
DERMACINRX KIT ANALGESI
3
DERMACINRX PAK INFLAMMA
3
diclo/misopr tab 50-0.2mg
1
diclo/misopr tab 75-0.2mg
1
FLEXIZOL
3
PAK COMBIPAK
IC 400
KIT 400MG
3
IC 800
KIT 800MG
3
INFLAMMATION PAK REDUCTIO
3
KETOROCAINE KIT -L
3
KETOROCAINE KIT -LM
3
NAPROPAK
PAK
3
NAPROPAK
PAK COOL
3
*NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)***
14
DRUG NAME
ANAPROX
DRUG
TIER
TAB 275MG
3
ANAPROX DS TAB 550MG
3
CALDOLOR
INJ 400/4ML
3
CALDOLOR
INJ 800/8ML
3
CATAFLAM
TAB 50MG
3
CLINORIL
TAB 200MG
3
DAYPRO
TAB 600MG
3
diclofen pot tab 50mg
1
diclofenac tab 100mg er
1
diclofenac tab 25mg dr
1
1
1
DYLOJECT
INJ 37.5MG/M
3
EC-NAPROSYN TAB 375MG
3
EC-NAPROSYN TAB 500MG
3
etodolac
cap 200mg
1
etodolac
cap 300mg
1
etodolac
tab 400mg
1
etodolac
tab 500mg
1
etodolac er tab 400mg
1
1
1
FELDENE
3
CAP 10MG
REQUIREMENTS/LIMITS
15
DRUG NAME
FELDENE
DRUG
TIER
CAP 20MG
3
FENOPROFEN CAP 400MG
3
fenoprofen tab 600mg
1
FLANAX PAIN KIT RELIEF
3
flurbiprofen tab 100mg
1
flurbiprofen tab 50mg
1
IBUPROFEN
3
KIT COMFORT
REQUIREMENTS/LIMITS
ibuprofen
tab 400mg
1
ibuprofen
tab 600mg
1
ibuprofen
tab 800mg
1
INDOCIN
SUP 50MG
3
INDOCIN
SUS 25MG/5ML
3
INDOCIN IV INJ 1MG
3
indomethacin cap 25mg
1
indomethacin cap 50mg
1
indomethacin cap 75mg er
1
INDOMETHACIN INJ 1MG
3
ketoprofen cap 200mg er
1
ketoprofen cap 50mg
1
ketoprofen cap 75mg
1
ketorolac
inj 15mg/ml
1
ketorolac
inj 30mg/ml
1
ketorolac
inj 60mg/2ml
1
16
DRUG NAME
ketorolac
DRUG
TIER
tab 10mg
1
meclofen sod cap 100mg
1
meclofen sod cap 50mg
1
mefenam acid cap 250mg
1
MELOXICAM
3
KIT COMFORT
meloxicam
sus 7.5/5ml
1
meloxicam
tab 15mg
1
meloxicam
tab 7.5mg
1
MOBIC
SUS 7.5/5ML
3
MOBIC
TAB 15MG
3
MOBIC
TAB 7.5MG
3
nabumetone tab 500mg
1
nabumetone tab 750mg
1
NALFON
CAP 200MG
3
NALFON
CAP 400MG
3
NAPRELAN
PAK
3
NAPRELAN
TAB 375MG CR
3
NAPRELAN
TAB 500MG CR
3
NAPRELAN
TAB 750MG CR
3
NAPROSYN
SUS 125/5ML
3
NAPROSYN
TAB 250MG
3
NAPROSYN
TAB 375MG
3
NAPROSYN
TAB 500MG
3
REQUIREMENTS/LIMITS
QL (X)
17
DRUG NAME
NAPROXEN
DRUG
TIER
KIT COMFORT
3
naproxen
sus 125/5ml
1
naproxen
tab 250mg
1
naproxen
tab 375mg
1
naproxen
tab 500mg
1
naproxen dr tab 375mg
1
naproxen dr tab 500mg
1
naproxen sod tab 275mg
1
1
naproxen sod tab 375mg cr
1
naproxen sod tab 500mg cr
1
1
NEOPROFEN
3
SOL 10MG/ML
oxaprozin
tab 600mg
1
piroxicam
cap 10mg
1
piroxicam
cap 20mg
1
PONSTEL
CAP 250MG
3
SPRIX
SPR 15.75MG
3
sulindac
tab 150mg
1
sulindac
tab 200mg
1
TIVORBEX
CAP 20MG
3
TIVORBEX
CAP 40MG
3
tolmetin sod cap 400mg
REQUIREMENTS/LIMITS
1
18
DRUG NAME
DRUG
TIER
tolmetin sod tab 200mg
1
tolmetin sod tab 600mg
1
VOLTAREN-XR TAB 100MG
3
ZIPSOR
3
CAP 25MG
ZORVOLEX
CAP 18MG
3
ZORVOLEX
CAP 35MG
3
REQUIREMENTS/LIMITS
*PHOSPHODIESTERASE 4 (PDE4) INHIBITORS***
OTEZLA
TAB 10/20/30
4
PA, ST
OTEZLA
TAB 30MG
4
PA, ST
*PYRIMIDINE SYNTHESIS INHIBITORS***
ARAVA
TAB 10MG
3
ARAVA
TAB 20MG
3
leflunomide tab 10mg
1
leflunomide tab 20mg
1
*SELECTIVE COSTIMULATION MODULATORS***
ORENCIA
INJ 125MG/ML
4
PA, ST
ORENCIA
INJ 250MG
4
PA, ST
*SOLUBLE TUMOR NECROSIS FACTOR RECEPTOR AGENTS***
ENBREL
INJ 25/0.5ML
4
PA
ENBREL
INJ 25MG
4
PA
ENBREL
INJ 50MG/ML
4
PA
4
PA
ENBREL SRCLK INJ 50MG/ML
*ANALGESICS - NONNARCOTIC*
19
DRUG NAME
DRUG
TIER
REQUIREMENTS/LIMITS
*ANALGESIC COMBINATIONS***
ANABAR
TAB
duraxin
ed-flex
cap
3
1
cap
1
FRENADOL
TAB
LEVACET
TAB
3
3
*ANALGESICS OTHER***
clonidine
inj
1
clonidine
inj 100/ml
1
clonidine
inj 500/ml
1
DURACLON
OFIRMEV
INJ
INJ 10MG/ML
3
3
*ANALGESICS-SEDATIVES***
ACUFLEX
alagesic
TAB
3
cap
1
alagesic lq sol
1
ali-flex
1
ALPAIN
biogesic
tab 50-500mg
TAB
tab 30-500mg
3
1
BIOREGESIC TAB 50-650MG
3
BUPAP
TAB 50-300MG
3
BUPAP
TAB 50-650MG
3
but/apap/caf cap
1
20
DRUG NAME
DRUG
TIER
but/apap/caf tab
1
but/asa/caff cap
1
but/asa/caff tab
1
butal/apap tab 50-325mg
1
butalbital tab cpd
1
capacet
1
cap
cephadyn
tab 50-650mg
1
DOLGIC PLUS TAB
3
DOLOGESIC
3
LIQ 30-500MG
dologesic tab 30-500mg
1
dolorex
1
tab 50-500mg
EQUAGESIC
esgic
TAB 200-325
cap
ESGIC
3
1
TAB
3
ESGIC-PLUS CAP
3
ESGIC-PLUS TAB
3
FIORICET
CAP
3
FIORICET
TAB
3
FIORINAL
CAP
3
margesic
cap
1
marten-tab tab 50-325mg
1
novagesic
1
tab 30-500mg
ORBIVAN
REQUIREMENTS/LIMITS
CAP
3
21
DRUG NAME
DRUG
TIER
ORBIVAN CF TAB 50-300MG
3
PHRENILIN
3
promacet
CAP FORTE
tab 50-650mg
RELAGESIC
TAB 50-650MG
1
3
repan
tab
1
rhinoflex
tab 50-650mg
1
SEDAPAP
TAB 50-650MG
3
STAFLEX
TAB 55-500MG
3
tencon
tab 50-325mg
TENCON
TAB 50-650MG
1
3
VANATOL LQ SOL
3
zebutal
1
zflex
ZGESIC
cap
tab
REQUIREMENTS/LIMITS
1
TAB 66-600MG
3
*SALICYLATE COMBINATIONS***
cho mag tris liq 500/5ml
1
cho mag tris tab 1000mg
1
1
1
*SALICYLATES***
aspirin
ASPIRIN
aspirin
tab 325mg
TAB 75MG
tab 81mg
5
PA
5
PA
5
PA
22
DRUG NAME
DRUG
TIER
diflunisal tab 500mg
1
DISALCID
TAB 500MG
3
DISALCID
TAB 750MG
3
EASPRIN
TAB 975MG EC
3
MST 600
TAB
REQUIREMENTS/LIMITS
3
salsalate tab 500mg
1
salsalate tab 750mg
1
SOD SALICYLA CRY
3
SOD SALICYLA CRY USP NF
3
*SELECTIVE N-TYPE NEURONAL CALCIUM CHANNEL BLOCKERS***
PRIALT
INJ 100MCG
4
PA
PRIALT
INJ 25MCG/ML
4
PA
PRIALT
INJ 500MCG
4
PA
apap/codeine sol 120-12/5
1
QL (X)
apap/codeine tab 300-15mg
1
QL (X)
1
QL (X)
1
QL (X)
ascomp/cod cap 30mg
1
but/apap/caf cap codeine
1
but/asa/caf/ cap cod 30mg
1
CAPITAL/COD SUS 120-12/5
3
*ANALGESICS - OPIOID*
*CODEINE COMBINATIONS***
QL (X)
QL (X)
23
DRUG NAME
COCET
TAB 650-30MG
DRUG
TIER
REQUIREMENTS/LIMITS
3
QL (X)
COCET PLUS TAB 650-60MG
3
QL (X)
FIORICET
3
CAP CODEINE
FIORICET/COD CAP
3
QL (X)
FIORINAL/COD CAP 30MG
3
TYLENOL/COD TAB #3
3
QL (X)
TYLENOL/COD TAB #4
3
QL (X)
*CODEINE-NUTRITIONAL SUPPLEMENT COMBINATIONS***
THERACODEINE PAK -300
3
*DIHYDROCODEINE COMBINATIONS***
apap-caffein cap dihydroc
1
apap/caff/di tab hydrocod
1
dihydrocod/ cap asa/caff
1
SYNALGOS-DC CAP
3
TREZIX
3
CAP
QL (X)
*FENTANYL COMBINATIONS***
FENTANYL/BUP INJ SOD CL
3
*HYDROCODONE COMBINATIONS***
co-gesic
1
QL (X)
3
QL (X)
hydroco/apap sol 10-325mg
1
QL (X)
hydroco/apap sol 5-217/10
1
QL (X)
hydroco/apap sol 7.5-325
1
QL (X)
HYCET
tab 5-500mg
SOL 7.5-325
24
DRUG NAME
DRUG
TIER
REQUIREMENTS/LIMITS
hydroco/apap sol 7.5-500
1
QL (X)
hydroco/apap tab 10-300mg
1
QL (X)
1
QL (X)
1
QL (X)
1
QL (X)
1
QL (X)
1
QL (X)
hydroco/apap tab 2.5-325
1
QL (X)
1
QL (X)
1
QL (X)
1
QL (X)
1
QL (X)
1
QL (X)
1
QL (X)
1
QL (X)
1
QL (X)
1
QL (X)
hydrocod/ibu tab 10-200mg
1
hydrocod/ibu tab 2.5-200
1
hydrocod/ibu tab 5-200mg
1
hydrocod/ibu tab 7.5-200
1
hydrogesic cap 5-500mg
1
IBUDONE
3
TAB 10-200MG
25
DRUG NAME
ibudone
DRUG
TIER
tab 5-200mg
REQUIREMENTS/LIMITS
1
LIQUICET
SOL 10-500MG
3
QL (X)
LORCET
TAB 10-650MG
3
QL (X)
1
QL (X)
1
QL (X)
lorcet plus tab 7.5-325
1
QL (X)
LORCET PLUS TAB 7.5-650
3
QL (X)
lortab
1
QL (X)
3
QL (X)
1
QL (X)
3
QL (X)
1
QL (X)
3
QL (X)
1
QL (X)
3
QL (X)
3
QL (X)
lorcet
lorcet hd
tab 5-325mg
tab 10-325mg
elx 10-300mg
LORTAB
lortab
ELX 7.5-500
tab 10-325mg
LORTAB
lortab
TAB 10-500MG
tab 5-325mg
LORTAB
lortab
TAB 5-500MG
tab 7.5-325
LORTAB
TAB 7.5-500
MAXIDONE
TAB 10-750MG
NORCO
TAB 10-325MG
3
QL (X)
NORCO
TAB 5-325MG
3
QL (X)
NORCO
TAB 7.5-325
3
QL (X)
polygesic
cap 5-500mg
1
reprexain
tab 10-200mg
1
REPREXAIN
TAB 2.5-200
3
REPREXAIN
TAB 5-200MG
3
26
DRUG NAME
DRUG
TIER
REQUIREMENTS/LIMITS
stagesic
cap 5-500mg
1
verdrocet
tab 2.5-325
1
QL (X)
tab 5-300mg
1
QL (X)
3
QL (X)
vicodin es tab 7.5-300
1
QL (X)
VICODIN ES TAB 7.5-750
3
QL (X)
vicodin hp tab 10-300mg
1
QL (X)
VICODIN HP TAB 10-660MG
3
QL (X)
VICOPROFEN TAB 7.5-200
3
XODOL
TAB 10-300MG
3
QL (X)
XODOL
TAB 5-300MG
3
QL (X)
XODOL
TAB 7.5-300
3
QL (X)
vicodin
VICODIN
xylon
zamicet
ZOLVIT
TAB 5-500MG
tab 10-200mg
1
sol 10-325mg
1
QL (X)
3
QL (X)
SOL 10-300MG
ZYDONE
TAB 10-400MG
2
QL (X)
ZYDONE
TAB 5-400MG
2
QL (X)
ZYDONE
TAB 7.5-400
2
QL (X)
*HYDROCODONE-NUTRITIONAL SUPPLEMENT COMBINATIONS***
THERACODOPHE PAK -750
3
THERACODOPHN PAK -325
3
THERACODOPHN PAK -650
3
THERACODOPHN PAK -LOW-90
3
27
DRUG NAME
DRUG
TIER
REQUIREMENTS/LIMITS
*MEPERIDINE COMBINATIONS***
MEPER/PROMET CAP 50-25MG
3
*OPIOID AGONISTS***
ABSTRAL
SUB 100MCG
3
PA, QL (X)
ABSTRAL
SUB 200MCG
3
PA, QL (X)
ABSTRAL
SUB 300MCG
3
PA, QL (X)
ABSTRAL
SUB 400MCG
3
PA, QL (X)
ABSTRAL
SUB 600MCG
3
PA, QL (X)
ABSTRAL
SUB 800MCG
3
PA, QL (X)
ACTIQ
LOZ 1200MCG
3
PA, QL (X)
ACTIQ
LOZ 1600MCG
3
PA, QL (X)
ACTIQ
LOZ 200MCG
3
PA, QL (X)
ACTIQ
LOZ 400MCG
3
PA, QL (X)
ACTIQ
LOZ 600MCG
3
PA, QL (X)
ACTIQ
LOZ 800MCG
3
PA, QL (X)
INJ 500/ML
3
ALFENTA
alfentanil inj 500/ml
1
astramorph inj 10/10ml
1
astramorph inj 1mg/2ml
1
astramorph inj 2mg/2ml
1
AVINZA
CAP 120MG
3
AVINZA
CAP 30MG
3
AVINZA
CAP 45MG
3
28
DRUG NAME
DRUG
TIER
AVINZA
CAP 60MG
3
AVINZA
CAP 75MG
3
AVINZA
CAP 90MG
3
CODEINE PHOS INJ 30MG/2ML
3
CODEINE PHOS INJ 60MG/2ML
3
CODEINE SULF SOL 30MG/5ML
3
codeine sulf tab 15mg
1
1
1
CONZIP
CAP 100MG
3
CONZIP
CAP 200MG
3
CONZIP
CAP 300MG
3
DEMEROL
INJ 100/2ML
3
DEMEROL
INJ 100MG/ML
3
DEMEROL
INJ 25MG/0.5
3
DEMEROL
INJ 25MG/ML
3
DEMEROL
INJ 50MG/ML
3
DEMEROL
INJ 75MG/1.5
3
DEMEROL
INJ 75MG/ML
3
DEMEROL
TAB 100MG
3
DEMEROL
TAB 50MG
3
DEPODUR
INJ 10MG/ML
3
DEPODUR
INJ 15/1.5ML
3
REQUIREMENTS/LIMITS
29
DRUG NAME
DRUG
TIER
DILAUDID
INJ 1MG/ML
3
DILAUDID
INJ 2MG/ML
3
DILAUDID
INJ 4MG/ML
3
DILAUDID
LIQ 1MG/ML
3
DILAUDID
TAB 2MG
3
DILAUDID
TAB 4MG
3
DILAUDID
TAB 8MG
3
REQUIREMENTS/LIMITS
DILAUDID-HP INJ 10MG/ML
3
DILAUDID-HP INJ 250MG
3
DOLOPHINE
TAB 10MG
3
DOLOPHINE
TAB 5MG
3
DURAGESIC
DIS 100MCG/H
3
PA, QL (X)
DURAGESIC
DIS 12MCG/HR
3
PA, QL (X)
DURAGESIC
DIS 25MCG/HR
3
PA, QL (X)
DURAGESIC
DIS 50MCG/HR
3
PA, QL (X)
DURAGESIC
DIS 75MCG/HR
3
PA, QL (X)
duramorph
inj 0.5mg/ml
1
duramorph
inj 1mg/ml
1
EMBEDA
CAP 100-4MG
3
EMBEDA
CAP 20-0.8MG
3
EMBEDA
CAP 30-1.2MG
3
EMBEDA
CAP 50-2MG
3
EMBEDA
CAP 60-2.4MG
3
30
DRUG NAME
DRUG
TIER
EMBEDA
CAP 80-3.2MG
3
EXALGO
TAB 12MG
3
EXALGO
TAB 16MG
3
EXALGO
TAB 32MG
3
EXALGO
TAB 8MG
3
REQUIREMENTS/LIMITS
fentanyl
dis 100mcg/h
1
PA, QL (X)
fentanyl
dis 12mcg/hr
1
PA, QL (X)
fentanyl
dis 25mcg/hr
1
PA, QL (X)
fentanyl
dis 37.5mcg
1
PA, QL (X)
fentanyl
dis 50mcg/hr
1
PA, QL (X)
fentanyl
dis 62.5mcg
1
PA, QL (X)
fentanyl
dis 75mcg/hr
1
PA, QL (X)
fentanyl
dis 87.5mcg
1
PA, QL (X)
fentanyl cit inj 0.05mg/1
1
PA, QL (X)
fentanyl cit inj 1000mcg
1
PA, QL (X)
1
PA, QL (X)
1
PA, QL (X)
1
PA, QL (X)
FENTANYL CIT INJ SOD CL
3
PA
fentanyl ot loz 1200mcg
1
PA, QL (X)
1
PA, QL (X)
1
PA, QL (X)
1
PA, QL (X)
31
DRUG NAME
DRUG
TIER
REQUIREMENTS/LIMITS
1
PA, QL (X)
1
PA, QL (X)
FENTORA
TAB 100MCG
3
PA, QL (X)
FENTORA
TAB 200MCG
3
PA, QL (X)
FENTORA
TAB 400MCG
3
PA, QL (X)
FENTORA
TAB 600MCG
3
PA, QL (X)
FENTORA
TAB 800MCG
3
PA, QL (X)
HYDROMORPH INJ SOD CL
3
hydromorphon inj 10mg/ml
1
1
1
1
hydromorphon inj 500/50ml
1
hydromorphon inj 50mg/5ml
1
HYDROMORPHON INJ HCL/NACL
3
hydromorphon liq 1mg/ml
1
HYDROMORPHON SUP 3MG
3
hydromorphon tab 12mg er
1
1
hydromorphon tab 2mg
1
1
1
1
32
DRUG NAME
DRUG
TIER
1
HYSINGLA ER TAB 100 MG
2
2
2
2
2
2
2
infumorph
1
inj 10mg/ml
INFUMORPH
INJ 25MG/ML
REQUIREMENTS/LIMITS
3
IONSYS
PAD 40MCG/AC
3
KADIAN
CAP 100MG ER
3
KADIAN
CAP 10MG ER
2
KADIAN
CAP 130MG ER
2
KADIAN
CAP 150MG ER
2
KADIAN
CAP 200MG ER
2
KADIAN
CAP 20MG ER
3
KADIAN
CAP 30MG ER
3
KADIAN
CAP 40MG ER
2
KADIAN
CAP 50MG ER
3
KADIAN
CAP 60MG ER
3
KADIAN
CAP 70MG ER
2
KADIAN
CAP 80MG ER
3
PA
33
DRUG NAME
DRUG
TIER
REQUIREMENTS/LIMITS
LAZANDA
SPR 100MCG
3
PA, QL (X)
LAZANDA
SPR 400MCG
3
PA, QL (X)
LEVORPHANOL TAB 2MG
3
meperidine inj 100mg/ml
1
1
1
1
meperidine sol 50mg/5ml
1
meperidine tab 100mg
1
meperidine tab 50mg
1
meperitab
tab 100mg
1
meperitab
tab 50mg
1
methadone
con 10mg/ml
METHADONE
INJ 10MG/ML
1
3
methadone
sol 10mg/5ml
1
methadone
sol 5mg/5ml
1
methadone
tab 10mg
1
methadone
tab 40mg
1
methadone
tab 5mg
1
methadose
con 10mg/ml
1
methadose
tab 10mg
1
methadose
tab 40mg
1
methadose
tab 5mg
1
34
DRUG NAME
DRUG
TIER
methadose sf con 10mg/ml
1
morphine sul cap 100mg er
1
1
MORPHINE SUL CAP 120MG ER
3
1
1
3
1
1
3
1
3
morphine sul inj 0.5mg/ml
1
MORPHINE SUL INJ 10/0.7ML
3
morphine sul inj 10mg/ml
1
MORPHINE SUL INJ 150/30ML
3
1
1
1
1
1
1
1
REQUIREMENTS/LIMITS
35
DRUG NAME
DRUG
TIER
1
MORPHINE SUL INJ SOD CL
3
morphine sul sol 100/5ml
1
morphine sul sol 10mg/5ml
1
morphine sul sol 20mg/5ml
1
morphine sul sol 20mg/ml
1
MORPHINE SUL SUP 10MG
3
3
morphine sul sup 30mg
1
3
morphine sul tab 100mg er
1
morphine sul tab 15mg
1
1
1
morphine sul tab 30mg
1
1
1
morphine/d5w inj 1mg/ml
1
MS CONTIN
TAB 100MG CR
3
MS CONTIN
TAB 15MG CR
3
MS CONTIN
TAB 200MG CR
3
MS CONTIN
TAB 30MG CR
3
MS CONTIN
TAB 60MG CR
3
REQUIREMENTS/LIMITS
36
DRUG NAME
DRUG
TIER
NUCYNTA
TAB 100MG
2
NUCYNTA
TAB 50MG
2
NUCYNTA
TAB 75MG
2
REQUIREMENTS/LIMITS
NUCYNTA ER TAB 100MG
2
2
2
2
NUCYNTA ER TAB 50MG
2
ONSOLIS
MIS 1200MCG
3
PA, QL (X)
ONSOLIS
MIS 200MCG
3
PA, QL (X)
ONSOLIS
MIS 400MCG
3
PA, QL (X)
ONSOLIS
MIS 600MCG
3
PA, QL (X)
ONSOLIS
MIS 800MCG
3
PA, QL (X)
OPANA
INJ 1MG/ML
3
OPANA
TAB 10MG
3
OPANA
TAB 5MG
3
OPANA ER
TAB 10MG
2
OPANA ER
TAB 15MG
2
OPANA ER
TAB 20MG
2
OPANA ER
TAB 30MG
2
OPANA ER
TAB 40MG
2
OPANA ER
TAB 5MG
2
OPANA ER
TAB 7.5MG
2
QL (X)
QL (X)
37
DRUG NAME
DRUG
TIER
ORAMORPH SR TAB 100MG
3
3
3
3
OXAYDO
TAB 5MG
3
OXAYDO
TAB 7.5MG
3
OXECTA
TAB 5MG
3
OXECTA
TAB 7.5MG
3
oxycodone
cap 5mg
1
oxycodone
con 100/5ml
1
oxycodone
con 20mg/ml
1
oxycodone
sol 5mg/5ml
1
oxycodone
tab 10mg
1
OXYCODONE
TAB 10MG ER
3
oxycodone
tab 15mg
1
oxycodone
tab 20mg
1
OXYCODONE
oxycodone
tab 30mg
OXYCODONE
oxycodone
TAB 20MG ER
TAB 40MG ER
tab 5mg
OXYCODONE
TAB 80MG ER
3
REQUIREMENTS/LIMITS
QL (X)
QL (X)
1
3
QL (X)
1
3
QL (X)
OXYCONTIN
TAB 10MG CR
2
QL (X)
OXYCONTIN
TAB 15MG CR
2
QL (X)
38
DRUG NAME
DRUG
TIER
REQUIREMENTS/LIMITS
OXYCONTIN
TAB 20MG CR
2
QL (X)
OXYCONTIN
TAB 30MG CR
2
QL (X)
OXYCONTIN
TAB 40MG CR
2
QL (X)
OXYCONTIN
TAB 60MG CR
2
QL (X)
OXYCONTIN
TAB 80MG CR
2
QL (X)
oxymorphone tab 10mg er
1
QL (X)
1
1
QL (X)
1
QL (X)
1
QL (X)
1
QL (X)
oxymorphone tab 7.5mg er
1
oxymorphone tab hcl 10mg
1
oxymorphone tab hcl 5mg
1
ROXICODONE TAB 15MG
3
ROXICODONE TAB 30MG
3
ROXICODONE TAB 5MG
3
RYBIX ODT
TAB 50MG
3
RYZOLT
TAB 100MG
3
RYZOLT
TAB 200MG
3
RYZOLT
TAB 300MG
3
SUBLIMAZE
SUBSYS
INJ 0.05MG/1
SPR 100MCG
3
PA, QL (X)
3
PA, QL (X)
39
DRUG NAME
DRUG
TIER
REQUIREMENTS/LIMITS
SUBSYS
SPR 1200MCG
3
PA, QL (X)
SUBSYS
SPR 1600MCG
3
PA, QL (X)
SUBSYS
SPR 200MCG
3
PA, QL (X)
SUBSYS
SPR 400MCG
3
PA, QL (X)
SUBSYS
SPR 600MCG
3
PA, QL (X)
SUBSYS
SPR 800MCG
3
PA, QL (X)
SUFENTA
INJ 50MCG/ML
3
sufentanil inj 100/2ml
1
sufentanil inj 250/5ml
1
sufentanil inj 50mcg/ml
1
SYNAPRYN
3
SUS 10MG/ML
TRAMADOL HCL CAP 150MG ER
3
tramadol hcl cap er 100mg
1
1
1
tramadol hcl tab 100mg er
1
1
1
tramadol hcl tab 50mg
1
ULTIVA
INJ 1MG
3
ULTIVA
INJ 2MG
3
ULTIVA
INJ 5MG
3
ULTRAM
TAB 50MG
3
40
DRUG NAME
DRUG
TIER
REQUIREMENTS/LIMITS
ULTRAM ER
TAB 100MG
3
ULTRAM ER
TAB 200MG
3
ULTRAM ER
TAB 300MG
3
ZOHYDRO ER CAP 10MG
3
PA
ZOHYDRO ER CAP 15MG
3
PA
ZOHYDRO ER CAP 20MG
3
PA
ZOHYDRO ER CAP 30MG
3
PA
ZOHYDRO ER CAP 40MG
3
PA
ZOHYDRO ER CAP 50MG
3
PA
*OPIOID COMBINATIONS***
endocet
tab 10-325mg
1
QL (X)
endocet
tab 10-650mg
1
QL (X)
endocet
tab 2.5-325
1
QL (X)
endocet
tab 5-325mg
1
QL (X)
endocet
tab 7.5-325
1
QL (X)
endocet
tab 7.5-500m
1
QL (X)
endodan
tab
1
MAGNACET
TAB 10-400MG
3
QL (X)
MAGNACET
TAB 5-400MG
3
QL (X)
MAGNACET
TAB 7.5-400
3
QL (X)
oxycod/apap cap 5-500mg
1
QL (X)
oxycod/apap tab 10-325mg
1
QL (X)
1
QL (X)
41
DRUG NAME
DRUG
TIER
REQUIREMENTS/LIMITS
oxycod/apap tab 2.5-325
1
QL (X)
1
QL (X)
1
QL (X)
1
QL (X)
oxycod/asa tab
1
oxycod/ibu tab 5-400mg
1
PERCOCET
TAB 10-325MG
3
QL (X)
PERCOCET
TAB 10-650MG
3
QL (X)
PERCOCET
TAB 2.5-325
3
QL (X)
PERCOCET
TAB 5-325MG
3
QL (X)
PERCOCET
TAB 7.5-325
3
QL (X)
PERCOCET
TAB 7.5-500
3
QL (X)
PERCODAN
TAB
3
PRIMLEV
TAB 10-300MG
3
QL (X)
PRIMLEV
TAB 5-300MG
3
QL (X)
PRIMLEV
TAB 7.5-300
3
QL (X)
roxicet
sol 5-325/5
1
QL (X)
roxicet
tab 5-325mg
1
QL (X)
3
QL (X)
TYLOX
CAP 5-500MG
XARTEMIS XR TAB 7.5-325
3
XOLOX
3
QL (X)
3
PA, ST
TAB 10-500MG
*OPIOID PARTIAL AGONISTS***
BUNAVAIL
MIS 2.1-0.3
42
DRUG NAME
DRUG
TIER
REQUIREMENTS/LIMITS
BUNAVAIL
MIS 4.2-0.7
3
PA, ST
BUNAVAIL
MIS 6.3-1MG
3
PA, ST
bupren/nalox sub 2-0.5mg
1
PA, ST, QL (X)
bupren/nalox sub 8-2mg
1
PA, ST, QL (X)
BUPRENEX
4
PA
buprenorphin inj 0.3mg/ml
4
PA
buprenorphin sub 2mg
1
PA
buprenorphin sub 8mg
1
PA
butorphanol inj 1mg/ml
1
butorphanol inj 2mg/ml
1
butorphanol sol 10mg/ml
1
BUTRANS
DIS 10MCG/HR
2
BUTRANS
DIS 15MCG/HR
2
BUTRANS
DIS 20MCG/HR
2
BUTRANS
DIS 5MCG/HR
2
BUTRANS
DIS 7.5/HR
2
INJ 0.3MG/ML
QL (X)
nalbuphine inj 10mg/ml
1
nalbuphine inj 20mg/ml
1
pentaz/nalox tab 50-0.5mg
1
SUBOXONE
MIS 12-3MG
2
PA, QL (X)
SUBOXONE
MIS 2-0.5MG
2
PA, QL (X)
SUBOXONE
MIS 4-1MG
2
PA, QL (X)
SUBOXONE
MIS 8-2MG
2
PA, QL (X)
43
DRUG NAME
DRUG
TIER
REQUIREMENTS/LIMITS
SUBOXONE
SUB 2-0.5MG
3
PA, QL (X)
SUBOXONE
SUB 8-2MG
3
PA, QL (X)
SUBUTEX
SUB 2MG
3
PA
SUBUTEX
SUB 8MG
3
PA
TALWIN
INJ 30MG/ML
3
ZUBSOLV
SUB 1.4-0.36
3
PA, ST, QL (X)
ZUBSOLV
SUB 11.4-2.9
3
PA, ST, QL (X)
ZUBSOLV
SUB 2.9-0.71
3
PA, ST, QL (X)
ZUBSOLV
SUB 5.7-1.4
3
PA, ST, QL (X)
ZUBSOLV
SUB 8.6-2.1
3
PA, ST, QL (X)
*PENTAZOCINE COMBINATIONS***
penta/apap tab 25-650mg
1
*TRAMADOL COMBINATIONS***
tramadl/apap tab 37.5-325
1
ULTRACET
3
TAB 37.5-325
*TRAMADOL-NUTRITIONAL SUPPLEMENT COMBINATIONS***
THERATRAMADO PAK -60
3
THERATRAMADO PAK -90
3
*ANDROGENS-ANABOLIC*
*ANABOLIC STEROIDS***
ANADROL-50 TAB 50MG
3
OXANDRIN
TAB 10MG
3
OXANDRIN
TAB 2.5MG
3
44
DRUG NAME
DRUG
TIER
oxandrolone tab 10mg
1
oxandrolone tab 2.5mg
1
REQUIREMENTS/LIMITS
*ANDROGEN COMBINATIONS***
TEST EO-PRO- INJ CYP 220
3
*ANDROGENS***
ANDROGEL
GEL 1%(25MG)
3
ANDROGEL
GEL 1%(50MG)
3
ANDROGEL
GEL 1.62%
2
ANDROGEL
GEL PUMP 1%
3
ANDROID
CAP 10MG
ANDROXY
AVEED
TAB 10MG
INJ 750/3ML
3
3
4
danazol
cap 100mg
1
danazol
cap 200mg
1
danazol
cap 50mg
1
DELATESTRYL INJ 200MG/ML
3
DEPO-TESTOST INJ 100MG/ML
3
DEPO-TESTOST INJ 200MG/ML
3
FIRST-TESTOS CRE MC 2%
3
FIRST-TESTOS OIN 2%
3
METHITEST
3
TAB 10MG
methyltestos cap 10mg
1
NATESTO
3
GEL 5.5MG
PA
45
DRUG NAME
STRIANT
DRUG
TIER
MIS 30MG
3
TESTONE CIK KIT 200MG/ML
3
TESTOPEL
3
MIS PELLETS
testost cyp inj 100mg/ml
1
testost cyp inj 200mg/ml
1
testost enan inj 200mg/ml
1
testosterone gel 1%(25mg)
1
testosterone gel 1%(50mg)
1
TESTOSTERONE GEL 10MG/ACT
3
testosterone gel pump 1%
1
TESTOSTERONE INJ 250MG/ML
3
TESTOSTERONE MIS 100MG
3
TESTOSTERONE MIS 12.5MG
3
3
3
3
3
3
TESTRED
3
CAP 10MG
REQUIREMENTS/LIMITS
VOGELXO
GEL 1%(50MG)
3
VOGELXO
GEL PUMP 1%
3
*ANORECTAL AGENTS*
*INTRARECTAL STEROIDS***
46
DRUG NAME
colocort
ene 100mg
CORTENEMA
CORTIFOAM
hydrocort
UCERIS
DRUG
TIER
ENE 100MG
AER 90MG
ene 100mg
AER 2MG/ACT
REQUIREMENTS/LIMITS
1
3
3
1
3
*NITRATE VASODILATING AGENTS***
RECTIV
OIN 0.4%
3
*RECTAL ANESTHETIC/STEROIDS***
ana-lex
kit
ANALPRAM
1
KIT ADVANCED
2
ANALPRAM E KIT
3
ANALPRAM HC CRE 2.5-1%
3
ANALPRAM-HC CRE 1-1%
3
ANALPRAM-HC CRE 1-2.5%
3
ANALPRAM-HC CRE SINGLES
3
ANALPRAM-HC LOT 2.5%
3
ANALPRM SNGL CRE HC 2.5-1
3
hc pramoxine cre 1-1%
1
hc pramoxine cre 2.5-1%
1
hc/lidocaine kit 2-2%
1
hydrocort/ kit pramoxin
1
lidazone
1
cre
LIDO-HYDRO GEL 2.8-0.55
3
47
DRUG NAME
DRUG
TIER
lidocaine/hc cre 3%-0.5%
1
lidocaine/hc kit 2-2%
1
lidocaine/hc kit 3%-0.5%
1
lidocaine/hc kit 3%-1%
1
lidocaine/hc kit 3-2.5%
1
pram-hca
kit 2.35-1%
1
pramcort
cre 1-1%
1
CRE
3
PROCORT
PROCTOFOAM AER HC 1%
2
Z-PRAM
3
KIT 2.35-1%
ZYPRAM
CRE 2.35-1%
REQUIREMENTS/LIMITS
3
*RECTAL STEROIDS***
anucort-hc sup 25mg
1
ANUSOL-HC
CRE 2.5%
3
ANUSOL-HC
SUP 25MG
3
grx hicort sup 25mg
1
hemmorex-hc sup 25mg
1
hemmorex-hc sup 30mg
1
hemril-30
1
sup 30mg
hydrocort ac sup 25mg
1
hydrocort ac sup 30mg
1
procto-pak cre 1%
1
PROCTOCORT CRE 1%
3
48
DRUG NAME
DRUG
TIER
PROCTOCORT SUP 30MG
3
proctocream cre hc 2.5%
1
proctosol hc cre 2.5%
1
proctozone cre -hc 2.5%
1
rectacort-hc sup 25mg
1
REQUIREMENTS/LIMITS
*ANTHELMINTICS*
*ANTHELMINTICS***
ALBENZA
TAB 200MG
2
BILTRICIDE TAB 600MG
2
ivermectin tab 3mg
1
STROMECTOL TAB 3MG
3
*ANTI-INFECTIVE AGENTS - MISC.*
*ANTI-INFECTIVE AGENTS - MISC.***
AZACTAM
INJ 1GM
3
AZACTAM
INJ 2GM
3
AZACTAM/DEX INJ 1GM
3
AZACTAM/DEX INJ 2GM
3
aztreonam
inj 1gm
1
aztreonam
inj 2gm
1
inj 50000unt
1
baciim
bacitracin inj 50000unt
1
CAYSTON
4
INH 75MG
PA
49
DRUG NAME
DRUG
TIER
REQUIREMENTS/LIMITS
colistimeth inj 150mg
4
PA
COLY-MYCIN M INJ 150MG
4
PA
DALVANCE
4
PA
SOL 500MG
FLAGYL
CAP 375MG
3
FLAGYL
TAB 250MG
3
FLAGYL
TAB 500MG
3
FLAGYL ER
METRO IV
TAB 750MG
3
INJ 5MG/ML
3
metron/nacl inj 500mg
1
metronidazol cap 375mg
1
metronidazol tab 250mg
1
metronidazol tab 500mg
1
NEBUPENT
INH 300MG
2
ORBACTIV
SOL 400MG
4
PA
PENTAM 300 INJ 300MG
4
PA
PRIMSOL
SOL 50MG/5ML
3
TINDAMAX
TAB 250MG
3
TINDAMAX
TAB 500MG
3
tinidazole tab 250mg
1
tinidazole tab 500mg
1
trimethoprim tab 100mg
1
VANCOCIN HCL CAP 125MG
3
VANCOCIN HCL CAP 250MG
3
50
DRUG NAME
DRUG
TIER
VANCOMYC/DEX INJ 1GM
3
VANCOMYC/DEX INJ 500MG
3
VANCOMYC/DEX INJ 750MG
3
vancomycin cap 125mg
1
vancomycin cap 250mg
1
vancomycin inj 1 gm
1
vancomycin inj 1000mg
1
vancomycin inj 10gm
1
vancomycin inj 500mg
1
vancomycin inj 5gm
1
VANCOMYCIN INJ 750MG
3
VANCOMYCIN SUS +SYRSPEN
3
VANCOMYCN 25 SOL 25MG/ML
3
VANCOMYCN 50 SOL 50MG/ML
3
VIBATIV
INJ 250MG
3
VIBATIV
INJ 750MG
3
XIFAXAN
TAB 200MG
2
XIFAXAN
TAB 550MG
2
REQUIREMENTS/LIMITS
*ANTI-INFECTIVE MISC. - COMBINATIONS***
BACTRIM
TAB 400-80MG
3
BACTRIM DS TAB 800-160
3
e.s.p.
1
sus 200-600
ees/sulfisox sus 200-600
1
51
DRUG NAME
DRUG
TIER
SEPTRA DS TAB 800-160
3
smz-tmp
inj 400-80/5
1
smz-tmp
sus
1
smz-tmp
sus 200-40/5
1
smz-tmp
tab 400-80mg
1
smz-tmp ds tab 800-160
1
smz/tmp ds tab 800-160
1
sulfatrim pd sus 200-40/5
1
REQUIREMENTS/LIMITS
*ANTIPROTOZOAL AGENTS***
ALINIA
SUS 100/5ML
2
ALINIA
TAB 500MG
2
atovaquone sus 750/5ml
1
MEPRON
3
SUS
*CARBAPENEM COMBINATIONS***
imipenem/cil inj 250mg
1
imipenem/cil inj 500mg
1
PRIMAXIN IV INJ 250MG
3
PRIMAXIN IV INJ 500MG
3
*CARBAPENEMS***
DORIBAX
INJ 250MG
3
DORIBAX
INJ 500MG
3
INVANZ
INJ 1GM
MEROP/NACL INJ 1GM/50ML
3
3
52
DRUG NAME
DRUG
TIER
MEROP/NACL INJ 500/50ML
3
meropenem
inj 1gm
1
meropenem
inj 500mg
1
MERREM
INJ 1GM
3
MERREM
INJ 500MG
3
REQUIREMENTS/LIMITS
*CHLORAMPHENICALS***
chloramphen inj 1gm
1
*CYCLIC LIPOPEPTIDES***
CUBICIN
SOL 500MG
3
*FOLATE ANTAGONISTS***
NEUTREXIN
INJ 25MG
3
*GLYCYLCYCLINES***
TYGACIL
INJ 50MG
3
*KETOLIDES***
KETEK
TAB 300MG
3
KETEK
TAB 400MG
3
*LEPROSTATICS***
dapsone
tab 100mg
1
dapsone
tab 25mg
1
*LINCOSAMIDES***
CLEOCIN
CAP 150MG
3
CLEOCIN
CAP 300MG
3
CLEOCIN
CAP 75MG
3
CLEOCIN PED SOL 75MG/5ML
3
53
DRUG NAME
DRUG
TIER
CLEOCIN PHOS INJ 300MG
3
3
3
CLEOCIN PHOS INJ 9GM/60ML
3
CLEOCIN/D5W INJ 300MG
3
3
3
CLIN SINGLE KIT USE
3
CLIN-LIDO
3
KIT
clindamycin cap 150mg
1
1
1
clindamycin inj 150mg/ml
1
clindamycin inj 300/2ml
1
clindamycin inj 300mg
1
1
1
1
clindamycin inj 9000/60
1
1
clindamycin sol 75mg/5ml
1
LINCOCIN
3
INJ 300MG/ML
LINCOMYCIN INJ LIDOCAIN
REQUIREMENTS/LIMITS
3
54
DRUG NAME
DRUG
TIER
REQUIREMENTS/LIMITS
*OXAZOLIDINONES***
linezolid
inj 2mg/ml
1
linezolid
sus 100/5ml
1
linezolid
tab 600mg
1
SIVEXTRO
INJ 200MG
4
PA
SIVEXTRO
TAB 200MG
4
PA
ZYVOX
SOL 2MG/ML
3
ZYVOX
SUS 100MG/5M
3
ZYVOX
TAB 600MG
3
*POLYMYXINS***
polymyxin b inj 500000
1
*STREPTOGRAMIN COMBINATIONS***
SYNERCID
INJ 500MG
3
*ANTIANGINAL AGENTS*
*ANTIANGINALS-OTHER***
RANEXA
TAB 1000MG
2
RANEXA
TAB 500MG
2
*NITRATES***
AMYL NITRITE INH 0.3ML
3
DILATRATE SR CAP 40MG
3
IMDUR
TAB 120MG ER
3
IMDUR
TAB 30MG ER
3
IMDUR
TAB 60MG ER
3
55
DRUG NAME
isochron
DRUG
TIER
tab 40mg cr
1
isoditrate tab 40mg er
1
ISORDIL
TAB 40MG
3
ISORDIL
TAB 5MG
3
isosorb din sub 2.5mg
1
isosorb din sub 5mg
1
isosorb din tab 10mg
1
1
1
isosorb din tab 40mg er
1
isosorb din tab 5mg
1
isosorb mono tab 10mg
1
isosorb mono tab 120mg er
1
isosorb mono tab 20mg
1
1
1
minitran
dis 0.1mg/hr
1
minitran
dis 0.2mg/hr
1
minitran
dis 0.4mg/hr
1
minitran
dis 0.6mg/hr
1
MONOKET
TAB 10MG
3
MONOKET
TAB 20MG
3
NITRO-BID
OIN 2%
REQUIREMENTS/LIMITS
3
56
DRUG NAME
DRUG
TIER
NITRO-DUR
DIS 0.1MG/HR
3
NITRO-DUR
DIS 0.2MG/HR
3
NITRO-DUR
DIS 0.3MG/HR
3
NITRO-DUR
DIS 0.4MG/HR
3
NITRO-DUR
DIS 0.6MG/HR
3
NITRO-DUR
DIS 0.8MG/HR
3
nitro-time cap 2.5mg cr
1
nitro-time cap 6.5mg cr
1
nitro-time cap 9mg cr
1
nitrogly/d5w inj
1
nitrogly/d5w inj 100mg
1
1
NITROGLY/D5W INJ 25MG
3
1
NITROGLYCER AER 400MCG
3
nitroglycer cap 2.5mg er
1
nitroglycer cap 2.5mg sr
1
nitroglycer cap 6.5mg cr
1
nitroglycer cap 6.5mg er
1
nitroglycer cap 9mg cr
1
nitroglycer cap 9mg er
1
nitroglycer dis 0.1mg/hr
1
1
REQUIREMENTS/LIMITS
57
DRUG NAME
DRUG
TIER
1
1
nitroglycer inj 5mg/ml
1
nitroglycrn spr 0.4mg
1
nitroglycrn spr lingual
1
NITROLINGUAL SPR PUMPSPRA
3
NITROMIST
AER 400MCG
3
NITRONAL
SOL 1MG/ML
3
NITROSTAT
SUB 0.3MG
3
NITROSTAT
SUB 0.4MG
3
NITROSTAT
SUB 0.6MG
3
REQUIREMENTS/LIMITS
*ANTIANXIETY AGENTS*
*ANTIANXIETY AGENTS - MISC.***
buspirone tab 10mg
1
buspirone tab 15mg
1
buspirone tab 30mg
1
buspirone tab 5mg
1
buspirone tab 7.5mg
1
droperidol inj 2.5mg/ml
4
hydroxyz hcl inj 25mg/ml
1
hydroxyz hcl inj 50mg/ml
1
hydroxyz hcl sol 10mg/5ml
1
hydroxyz hcl syp 10mg/5ml
1
PA
58
DRUG NAME
DRUG
TIER
hydroxyz hcl tab 10mg
1
1
1
hydroxyz pam cap 100mg
1
1
1
meprobamate tab 200mg
1
meprobamate tab 400mg
1
VISTARIL
CAP 25MG
3
VISTARIL
CAP 50MG
3
REQUIREMENTS/LIMITS
*BENZODIAZEPINE-NUTRITIONAL SUPPLEMENT COMBINATIONS***
GABAVALE-5 PAK
3
GABAZOLAMINE PAK
3
GABAZOLAMINE PAK 0.5MG
3
SENTRAZOLAM PAK AM 0.25
3
*BENZODIAZEPINES***
ALPRAZOLAM CON 1 MG/ML
3
alprazolam tab 0.25 odt
1
alprazolam tab 0.25mg
1
alprazolam tab 0.5mg
1
alprazolam tab 0.5mg er
1
alprazolam tab 0.5mg od
1
alprazolam tab 0.5mg xr
1
59
DRUG NAME
DRUG
TIER
alprazolam tab 1mg
1
alprazolam tab 1mg er
1
alprazolam tab 1mg odt
1
alprazolam tab 1mg xr
1
alprazolam tab 2mg
1
1
alprazolam tab 2mg odt
1
1
1
1
ATIVAN
INJ 2MG/ML
3
ATIVAN
INJ 4MG/ML
3
ATIVAN
TAB 0.5MG
3
ATIVAN
TAB 1MG
3
ATIVAN
TAB 2MG
3
chlordiazep cap 10mg
1
chlordiazep cap 25mg
1
chlordiazep cap 5mg
1
cloraz dipot tab 15mg
1
cloraz dipot tab 3.75mg
1
cloraz dipot tab 7.5mg
1
diazepam
1
con 5mg/ml
DIAZEPAM
INJ 10MG/2ML
REQUIREMENTS/LIMITS
3
60
DRUG NAME
diazepam
DRUG
TIER
inj 5mg/ml
DIAZEPAM
SOL 1MG/ML
REQUIREMENTS/LIMITS
1
3
diazepam
tab 10mg
1
diazepam
tab 2mg
1
diazepam
tab 5mg
1
lorazepam
con 2mg/ml
1
lorazepam
inj 2mg/ml
1
lorazepam
inj 4mg/ml
1
lorazepam
tab 0.5mg
1
lorazepam
tab 1mg
1
lorazepam
tab 2mg
1
NIRAVAM
TAB 0.25MG
3
NIRAVAM
TAB 0.5MG
3
NIRAVAM
TAB 1MG
3
NIRAVAM
TAB 2MG
3
oxazepam
cap 10mg
1
oxazepam
cap 15mg
1
oxazepam
cap 30mg
1
TRANXENE T TAB 15MG
3
TRANXENE T TAB 3.75MG
3
TRANXENE T TAB 7.5MG
3
VALIUM
TAB 10MG
3
VALIUM
TAB 2MG
3
61
DRUG NAME
DRUG
TIER
VALIUM
TAB 5MG
3
XANAX
TAB 0.25MG
3
XANAX
TAB 0.5MG
3
XANAX
TAB 1MG
3
XANAX
TAB 2MG
3
XANAX XR
TAB 0.5MG
3
XANAX XR
TAB 1MG
3
XANAX XR
TAB 2MG
3
XANAX XR
TAB 3MG
3
REQUIREMENTS/LIMITS
*ANTIARRHYTHMICS*
*ANTIARRHYTHMICS - MISC.***
ADENOCARD
INJ 12MG/4ML
3
ADENOCARD
INJ 3MG/ML
3
ADENOCARD
INJ 6MG/2ML
3
adenosine
inj 12mg/4ml
1
adenosine
inj 3mg/ml
1
adenosine
inj 6mg/2ml
1
*ANTIARRHYTHMICS TYPE I-A***
disopyramide cap 100mg
1
disopyramide cap 150mg
1
NORPACE
CAP 100MG
3
NORPACE
CAP 100MG CR
2
NORPACE
CAP 150MG
3
62
DRUG NAME
NORPACE
DRUG
TIER
CAP 150MG CR
REQUIREMENTS/LIMITS
3
procainamide inj 100mg/ml
1
procainamide inj 500mg/ml
1
QUINIDINE GL INJ 80MG/ML
3
quinidine gl tab 324mg cr
1
quinidine gl tab 324mg er
1
quinidine su tab 200mg
1
quinidine su tab 300mg
1
quinidine su tab 300mg er
1
*ANTIARRHYTHMICS TYPE I-B***
lidocain/d5w inj 4mg/ml
1
lidocain/d5w inj 8mg/ml
1
lidocaine
inj 10mg/ml
1
lidocaine
inj 20mg/ml
1
mexiletine cap 150mg
1
1
1
XYLOCAINE
3
INJ 2%
*ANTIARRHYTHMICS TYPE I-C***
flecainide tab 100mg
1
flecainide tab 150mg
1
flecainide tab 50mg
1
propafenone cap 225mg er
1
63
DRUG NAME
DRUG
TIER
propafenone cap 325mg er
1
propafenone cap 425mg sr
1
propafenone tab 150mg
1
1
1
RYTHMOL
TAB 150MG
3
RYTHMOL
TAB 225MG
3
RYTHMOL SR CAP 225MG
3
3
3
TAMBOCOR
TAB 100MG
3
TAMBOCOR
TAB 150MG
3
TAMBOCOR
TAB 50MG
3
REQUIREMENTS/LIMITS
*ANTIARRHYTHMICS TYPE III***
amiodarone inj 150mg/3m
1
amiodarone inj 50mg/ml
1
amiodarone tab 100mg
1
1
1
CORDARONE
TAB 200MG
3
INJ 1MG/10ML
3
CORVERT
ibutilide inj 1mg/10ml
1
MULTAQ
2
TAB 400MG
64
DRUG NAME
NEXTERONE
DRUG
TIER
INJ
REQUIREMENTS/LIMITS
3
pacerone
tab 100mg
1
pacerone
tab 200mg
1
pacerone
tab 400mg
1
TIKOSYN
CAP 125MCG
2
TIKOSYN
CAP 250MCG
2
TIKOSYN
CAP 500MCG
2
*ANTIASTHMATIC AND BRONCHODILATOR AGENTS*
*5-LIPOXYGENASE INHIBITORS***
ZYFLO
TAB 600MG
ZYFLO CR
TAB 600MG
3
3
*ADRENERGIC COMBINATIONS***
ADVAIR DISKU AER 100/50
2
QL (X)
2
QL (X)
2
QL (X)
ADVAIR HFA AER 115/21
2
QL (X)
2
QL (X)
2
QL (X)
ANORO ELLIPT AER 62.5-25
2
BREO ELLIPTA INH 100-25
2
BREO ELLIPTA INH 200-25
3
COMBIVENT
AER
3
QL (X)
COMBIVENT
AER RESPIMAT
2
QL (X)
65
DRUG NAME
DRUG
TIER
REQUIREMENTS/LIMITS
DULERA
AER 100-5MCG
3
QL (X)
DULERA
AER 200-5MCG
3
QL (X)
DUONEB
SOL
3
ipratropium/ sol albuter
1
ipratropium/ sol sulfate
1
STIOLTO
2
AER RESPIMAT
SYMBICORT
AER 160-4.5
2
QL (X)
SYMBICORT
AER 80-4.5
2
QL (X)
UTIBRON
CAP NEOHALER
3
*ANTI-IGE MONOCLONAL ANTIBODIES***
XOLAIR
SOL 150MG
4
PA
*ANTI-INFLAMMATORY AGENTS***
cromolyn sod neb 20mg/2ml
1
*BETA ADRENERGICS***
ACCUNEB
NEB 0.63MG/3
3
ACCUNEB
NEB 1.25MG/3
3
albuterol
neb 0.083%
1
albuterol
neb 0.5%
1
albuterol
neb 0.63mg/3
1
albuterol
neb 1.25mg/3
1
albuterol
syp 2mg/5ml
1
albuterol
tab 2mg
1
albuterol
tab 4mg
1
66
DRUG NAME
DRUG
TIER
albuterol
tab 4mg er
1
albuterol
tab 8mg er
1
ARCAPTA
CAP 75MCG
3
BROVANA
NEB 15MCG
3
FORADIL
CAP AEROLIZE
2
ISUPREL
INJ 0.2MG/ML
3
REQUIREMENTS/LIMITS
QL (X)
levalbuterol neb 0.31mg
1
1
levalbuterol neb 1.25/0.5
1
1
MAXAIR AUTOH AER 200MCG
3
metaproteren syp 10mg/5ml
1
metaproteren tab 10mg
1
metaproteren tab 20mg
1
PERFOROMIST NEB 20MCG
3
PROAIR HFA AER
2
PROAIR RESPI AER
2
PROVENTIL
3
ST, QL (X)
SEREVENT DIS AER 50MCG
2
QL (X)
STRIVERDI
3
AER HFA
AER RESPIMAT
terbutaline inj 1mg/ml
1
terbutaline tab 2.5mg
1
terbutaline tab 5mg
1
QL (X)
QL (X)
67
DRUG NAME
DRUG
TIER
VENTOLIN HFA AER
2
VOSPIRE ER TAB 4MG
3
VOSPIRE ER TAB 8MG
3
XOPENEX
NEB 0.31MG
3
XOPENEX
NEB 0.63MG
3
XOPENEX
NEB 1.25/3ML
3
XOPENEX CONC NEB 1.25/0.5
3
XOPENEX HFA AER
2
REQUIREMENTS/LIMITS
QL (X)
ST
*BRONCHODILATORS - ANTICHOLINERGICS***
ATROVENT HFA AER 17MCG
2
INCRUSE ELPT INH 62.5MCG
2
ipratropium sol 0.02%inh
1
SEEBRI NEOHA CAP 15.6MCG
3
SPIRIVA
AER RESPIMAT
2
SPIRIVA
CAP HANDIHLR
2
SPIRIVA
SPR RESPIMAT
2
TUDORZA PRES AER 400/ACT
QL (X)
QL (X)
3
*LEUKOTRIENE RECEPTOR ANTAGONISTS***
ACCOLATE
TAB 10MG
3
ACCOLATE
TAB 20MG
3
montelukast chw 4mg
1
montelukast chw 5mg
1
montelukast gra 4mg
1
68
DRUG NAME
DRUG
TIER
montelukast tab 10mg
1
SINGULAIR
CHW 4MG
3
SINGULAIR
CHW 5MG
3
SINGULAIR
GRA 4MG
3
SINGULAIR
TAB 10MG
3
zafirlukast tab 10mg
1
zafirlukast tab 20mg
1
REQUIREMENTS/LIMITS
*MIXED ADRENERGICS***
ADRENALIN
INJ 1MG/ML
4
epinephrine inj 0.1mg/ml
1
epinephrine inj 1mg/ml
4
PA
PA
*SELECTIVE PHOSPHODIESTERASE 4 (PDE4) INHIBITORS***
DALIRESP
TAB 500MCG
2
*STEROID INHALANTS***
AEROSPAN
AER 80MCG
3
ALVESCO
AER 160MCG
3
ALVESCO
AER 80MCG
3
ARNUITY ELPT INH 100MCG
2
ARNUITY ELPT INH 200MCG
2
ASMANEX 120 AER 220MCG
2
QL (X)
3
QL (X)
2
QL (X)
2
QL (X)
69
DRUG NAME
DRUG
TIER
REQUIREMENTS/LIMITS
2
QL (X)
ASMANEX 7
3
QL (X)
AER 110MCG
ASMANEX HFA AER 100 MCG
3
ASMANEX HFA AER 200 MCG
3
budesonide sus 0.25mg/2
1
QL (X)
budesonide sus 0.5mg/2
1
QL (X)
budesonide sus 1mg/2ml
1
QL (X)
FLOVENT DISK AER 100MCG
2
QL (X)
2
QL (X)
2
QL (X)
FLOVENT HFA AER 110MCG
2
QL (X)
2
QL (X)
2
QL (X)
PULMICORT
INH 180MCG
2
QL (X)
PULMICORT
INH 90MCG
2
QL (X)
PULMICORT
SUS 0.25MG/2
3
QL (X)
PULMICORT
SUS 0.5MG/2
3
QL (X)
PULMICORT
SUS 1MG/2ML
3
QL (X)
QVAR
AER 40MCG
2
QL (X)
QVAR
AER 80MCG
2
QL (X)
*XANTHINE-EXPECTORANTS***
BRONDIL
dg 200
LIQ
3
tab 200-200
1
70
DRUG NAME
DRUG
TIER
difil-g 400 tab
1
difil-g fort liq 100-100
1
dilex-g
1
tab 200-200
DILEX-G 200 SYP
REQUIREMENTS/LIMITS
3
*XANTHINE-NUTRITIONAL SUPPLEMENT COMBINATIONS***
PULMOPHYLLIN PAK
3
SENOPHYLLINE PAK
3
*XANTHINE-SYMPATHOMIMETICS-EXPECTORANT***
BRONCOMAR-1 ELX
2
*XANTHINES***
aminophyllin inj 25mg/ml
1
aminophyllin tab 100mg
1
aminophyllin tab 200mg
1
DYLIX
3
ELX 100/15ML
ELIXOPHYLLIN ELX 80/15ML
3
LUFYLLIN
TAB 200MG
3
LUFYLLIN
TAB 400MG
3
THEO-24
CAP 100MG CR
2
THEO-24
CAP 200MG CR
2
THEO-24
CAP 300MG CR
2
THEO-24
CAP 400MG ER
2
theochron
tab 100mg cr
1
theochron
tab 200mg cr
1
71
DRUG NAME
theochron
DRUG
TIER
tab 300mg cr
1
theophyl/d5w inj 0.8mg/ml
1
1
theophyl/d5w inj 2mg/ml
1
1
theophyl/d5w inj 4mg/ml
1
theophylline sol 80/15ml
1
theophylline tab 100mg cr
1
theophylline tab 100mg er
1
1
1
1
1
theophylline tab 400mg
1
1
1
1
REQUIREMENTS/LIMITS
*ANTICOAGULANTS*
*COUMARIN ANTICOAGULANTS***
COUMADIN
INJ 5 MG
3
COUMADIN
TAB 10MG
3
COUMADIN
TAB 1MG
3
COUMADIN
TAB 2.5MG
3
72
DRUG NAME
DRUG
TIER
COUMADIN
TAB 2MG
3
COUMADIN
TAB 3MG
3
COUMADIN
TAB 4MG
3
COUMADIN
TAB 5MG
3
COUMADIN
TAB 6MG
3
COUMADIN
TAB 7.5MG
3
jantoven
tab 10mg
1
jantoven
tab 1mg
1
jantoven
tab 2.5mg
1
jantoven
tab 2mg
1
jantoven
tab 3mg
1
jantoven
tab 4mg
1
jantoven
tab 5mg
1
jantoven
tab 6mg
1
jantoven
tab 7.5mg
1
warfarin
tab 10mg
1
warfarin
tab 1mg
1
warfarin
tab 2.5mg
1
warfarin
tab 2mg
1
warfarin
tab 3mg
1
warfarin
tab 4mg
1
warfarin
tab 5mg
1
warfarin
tab 6mg
1
REQUIREMENTS/LIMITS
73
DRUG NAME
warfarin
tab 7.5mg
warfarin sod tab 10mg
DRUG
TIER
REQUIREMENTS/LIMITS
1
1
*DIRECT FACTOR XA INHIBITORS***
ELIQUIS
TAB 2.5MG
2
ELIQUIS
TAB 5MG
2
SAVAYSA
TAB 15MG
3
SAVAYSA
TAB 30MG
3
SAVAYSA
TAB 60MG
3
XARELTO
TAB 10MG
2
XARELTO
TAB 15MG
2
XARELTO
TAB 20MG
2
XARELTO STAR TAB 15/20MG
2
*HEPARINS AND HEPARINOID-LIKE AGENTS***
hep flush-10 inj 10unt/ml
1
hep sod/d5w inj 100/ml
1
hep sod/d5w inj 20000unt
1
hep sod/d5w inj 25000unt
4
PA
hep sod/d5w inj 50unt/ml
4
PA
hep sod/nacl inj 1000unit
1
hep sod/nacl inj 12500unt
1
HEP SOD/NACL INJ 2000UNIT
3
hep sod/nacl inj 25000unt
1
hep sod/nacl inj 2unit/ml
1
74
DRUG NAME
DRUG
TIER
REQUIREMENTS/LIMITS
heparin lock inj 100/ml
1
heparin lock inj 10unt/ml
1
heparin lock inj 1unit/ml
1
HEPARIN LOCK INJ 2UNIT/ML
3
heparin lock kit 100/ml
1
heparin lock kit 10unt/ml
1
heparin sod inj 1000/ml
4
PA
4
PA
4
PA
4
PA
1
heparin sod inj 5000/0.5
4
PA
4
PA
sash
kit 100/ml
1
sash
kit 10unt/ml
1
*IN VITRO ANTICOAGULANTS***
ACD FORMULA SOL A
3
ACD FORMULA SOL B
3
ACD-A
3
SOL
ANTICOAG CIT SOL DEX SOL
3
ANTICOAG CPD SOL
3
ANTICOAGULNT SOL SOD CITR
3
NOCLOT-50
3
SOL ACD-A
75
DRUG NAME
DRUG
TIER
TRICITRASOL CON
REQUIREMENTS/LIMITS
3
*LOW MOLECULAR WEIGHT HEPARINS***
enoxaparin inj 100mg/ml
1
enoxaparin inj 120/0.8
1
enoxaparin inj 150mg/ml
1
enoxaparin inj 30/0.3ml
1
enoxaparin inj 300/3ml
1
1
1
1
FRAGMIN
INJ 10000/ML
3
FRAGMIN
INJ 12500UNT
3
FRAGMIN
INJ 15000UNT
3
FRAGMIN
INJ 18000UNT
3
FRAGMIN
INJ 2500/0.2
3
FRAGMIN
INJ 25000/ML
3
FRAGMIN
INJ 5000/0.2
3
FRAGMIN
INJ 7500/0.3
3
FRAGMIN
INJ 95000UNT
3
LOVENOX
INJ 100MG/ML
3
LOVENOX
INJ 120/0.8
3
LOVENOX
INJ 150MG/ML
3
LOVENOX
INJ 30/0.3ML
3
76
DRUG NAME
DRUG
TIER
LOVENOX
INJ 300/3ML
3
LOVENOX
INJ 40/0.4ML
3
LOVENOX
INJ 60/0.6ML
3
LOVENOX
INJ 80/0.8ML
3
REQUIREMENTS/LIMITS
*SYNTHETIC HEPARINOID-LIKE AGENTS***
ARIXTRA
INJ 10/0.8ML
3
ARIXTRA
INJ 2.5/0.5
3
ARIXTRA
INJ 5/0.4ML
3
ARIXTRA
INJ 7.5/0.6
3
fondaparinux inj 10/0.8ml
1
fondaparinux inj 2.5/0.5
1
fondaparinux inj 5/0.4ml
1
fondaparinux inj 7.5/0.6
1
*THROMBIN INHIBITORS - HIRUDIN TYPE***
ANGIOMAX
4
PA
bivalirudin inj 250mg
4
PA
IPRIVASK
3
REFLUDAN
INJ 250MG
INJ 15MG
INJ 50MG
4
PA
*THROMBIN INHIBITORS - SELECTIVE DIRECT & REVERSIBLE***
argatroban inj 100mg/ml
1
ARGATROBAN INJ 125/125
3
ARGATROBAN INJ 250/250
3
ARGATROBAN INJ 50MG/50M
3
77
DRUG NAME
DRUG
TIER
PRADAXA
CAP 150MG
2
PRADAXA
CAP 75MG
2
REQUIREMENTS/LIMITS
*ANTICONVULSANTS*
*AMPA GLUTAMATE RECEPTOR ANTAGONISTS***
FYCOMPA
TAB 10MG
3
PA
FYCOMPA
TAB 12MG
3
PA
FYCOMPA
TAB 2MG
3
PA
FYCOMPA
TAB 4MG
3
PA
FYCOMPA
TAB 6MG
3
PA
FYCOMPA
TAB 8MG
3
PA
*ANTICONVULSANT - MISC. & NUTRITIONAL SUPPLEMENT COMB***
THERAPENTIN PAK -60
3
THERAPENTIN PAK -90
3
*ANTICONVULSANTS - BENZODIAZEPINES***
clonazep odt tab 0.125mg
1
1
1
clonazep odt tab 1mg
1
clonazep odt tab 2mg
1
clonazepam tab 0.5mg
1
clonazepam tab 1mg
1
clonazepam tab 2mg
1
DIASTAT ACDL GEL 12.5-20
3
78
DRUG NAME
DRUG
TIER
DIASTAT ACDL GEL 5-10MG
3
DIASTAT PED GEL 2.5M GEL
3
diazepam
gel 10mg
1
diazepam
gel 2.5mg
1
diazepam
gel 20mg
1
KLONOPIN
TAB 0.5MG
3
KLONOPIN
TAB 1MG
3
KLONOPIN
TAB 2MG
3
ONFI
SUS 2.5MG/ML
3
ONFI
TAB 10MG
3
ONFI
TAB 20MG
3
ONFI
TAB 5MG
3
REQUIREMENTS/LIMITS
*ANTICONVULSANTS - MISC.***
APTIOM
TAB 200MG
3
APTIOM
TAB 400MG
3
APTIOM
TAB 600MG
3
APTIOM
TAB 800MG
3
BANZEL
SUS 40MG/ML
3
BANZEL
TAB 200MG
3
BANZEL
TAB 400MG
3
carbamazepin cap 100mg er
1
1
1
79
DRUG NAME
DRUG
TIER
carbamazepin chw 100mg
1
carbamazepin sus 100/5ml
1
carbamazepin tab 200mg
1
carbamazepin tab 200mg er
1
carbamazepin tab 400mg er
1
CARBATROL
CAP 100MG
3
CARBATROL
CAP 200MG
3
CARBATROL
CAP 300MG
3
epitol
tab 200mg
FANATREX
SUS 25MG/ML
1
3
gabapentin cap 100mg
1
1
1
gabapentin sol 250/5ml
1
gabapentin tab 600mg
1
gabapentin tab 800mg
1
KEPPRA
INJ 500/5ML
3
KEPPRA
SOL 100MG/ML
3
KEPPRA
TAB 1000MG
3
KEPPRA
TAB 250MG
3
KEPPRA
TAB 500MG
3
KEPPRA
TAB 750MG
3
KEPPRA XR
TAB 500MG
REQUIREMENTS/LIMITS
3
80
DRUG NAME
DRUG
TIER
KEPPRA XR
TAB 750MG
3
LAMICTAL
CHW 25MG
3
LAMICTAL
CHW 2MG
3
LAMICTAL
CHW 5MG
3
LAMICTAL
KIT START 35
3
LAMICTAL
KIT START 49
3
LAMICTAL
KIT START 98
3
LAMICTAL
TAB 100MG
3
LAMICTAL
TAB 150MG
3
LAMICTAL
TAB 200MG
3
LAMICTAL
TAB 25MG
3
LAMICTAL ODT KIT
3
LAMICTAL ODT TAB 100MG
3
3
3
3
LAMICTAL XR KIT
3
LAMICTAL XR TAB 100MG
3
3
3
3
3
3
REQUIREMENTS/LIMITS
81
DRUG NAME
DRUG
TIER
lamotrig odt kit 25/50mg
1
lamotrig odt kit 50/100mg
1
lamotrigine chw 25mg
1
lamotrigine chw 5mg
1
lamotrigine kit odt
1
lamotrigine tab 100mg
1
lamotrigine tab 100mg er
1
1
1
1
1
1
1
lamotrigine tab 25mg odt
1
1
1
lamotrigine tab 50mg odt
1
LEVETIRACETA INJ 10MG/ML
3
3
3
levetiraceta sol 100mg/ml
1
levetiraceta sol 500/5ml
1
levetiraceta tab 1000mg
1
REQUIREMENTS/LIMITS
82
DRUG NAME
DRUG
TIER
1
1
levetiraceta tab 500mg er
1
1
levetiraceta tab 750mg er
1
levetiracetm inj 500/5ml
1
LYRICA
CAP 100MG
2
LYRICA
CAP 150MG
2
LYRICA
CAP 200MG
2
LYRICA
CAP 225MG
2
LYRICA
CAP 25MG
2
LYRICA
CAP 300MG
2
LYRICA
CAP 50MG
2
LYRICA
CAP 75MG
2
LYRICA
SOL 20MG/ML
3
MYSOLINE
TAB 250MG
3
MYSOLINE
TAB 50MG
3
NEURONTIN
CAP 100MG
3
NEURONTIN
CAP 300MG
3
NEURONTIN
CAP 400MG
3
NEURONTIN
SOL 250/5ML
3
NEURONTIN
TAB 600MG
3
NEURONTIN
TAB 800MG
3
REQUIREMENTS/LIMITS
83
DRUG NAME
DRUG
TIER
oxcarbazepin sus 300mg/5m
1
oxcarbazepin tab 150mg
1
1
1
OXTELLAR XR TAB 150MG
3
3
3
POTIGA
TAB 200MG
3
POTIGA
TAB 300MG
3
POTIGA
TAB 400MG
3
POTIGA
TAB 50MG
3
primidone
tab 250mg
1
primidone
tab 50mg
1
QUDEXY XR
CAP 100/24HR
3
QUDEXY XR
CAP 150/24HR
3
QUDEXY XR
CAP 200/24HR
3
QUDEXY XR
CAP 25/24HR
3
QUDEXY XR
CAP 50/24HR
3
TEGRETOL
CHW 100MG
3
TEGRETOL
SUS 100/5ML
3
TEGRETOL
TAB 200MG
3
TEGRETOL-XR TAB 100MG
3
3
REQUIREMENTS/LIMITS
84
DRUG NAME
DRUG
TIER
3
TOPAMAX
TAB 100MG
3
TOPAMAX
TAB 200MG
3
TOPAMAX
TAB 25MG
3
TOPAMAX
TAB 50MG
3
TOPAMAX SPR CAP 15MG
3
TOPAMAX SPR CAP 25MG
3
topiragen
tab 100mg
1
topiragen
tab 200mg
1
topiragen
tab 25mg
1
topiragen
tab 50mg
1
topiramate cap 15mg
1
topiramate cap 25mg
1
TOPIRAMATE CAP ER 100MG
3
3
3
3
3
topiramate tab 100mg
1
topiramate tab 200mg
1
topiramate tab 25mg
1
topiramate tab 50mg
1
TRILEPTAL
3
SUS 300MG/5M
REQUIREMENTS/LIMITS
85
DRUG NAME
DRUG
TIER
TRILEPTAL
TAB 150MG
3
TRILEPTAL
TAB 300MG
3
TRILEPTAL
TAB 600MG
3
TROKENDI XR CAP 100MG
3
3
3
3
VIMPAT
INJ 200MG/20
3
VIMPAT
SOL 10MG/ML
3
VIMPAT
TAB 100MG
3
VIMPAT
TAB 150MG
3
VIMPAT
TAB 200MG
3
VIMPAT
TAB 50MG
3
ZONEGRAN
CAP 100MG
3
ZONEGRAN
CAP 25MG
3
zonisamide cap 100mg
1
zonisamide cap 25mg
1
zonisamide cap 50mg
1
REQUIREMENTS/LIMITS
*CARBAMATES***
felbamate sus 600/5ml
1
felbamate tab 400mg
1
felbamate tab 600mg
1
FELBATOL
3
SUS 600/5ML
86
DRUG NAME
DRUG
TIER
FELBATOL
TAB 400MG
3
FELBATOL
TAB 600MG
3
REQUIREMENTS/LIMITS
*GABA MODULATORS***
GABITRIL
TAB 12MG
3
GABITRIL
TAB 16MG
3
GABITRIL
TAB 2MG
3
GABITRIL
TAB 4MG
3
SABRIL
POW 500MG
4
PA
SABRIL
TAB 500MG
4
PA
tiagabine tab 2mg
1
tiagabine tab 4mg
1
*HYDANTOINS***
CEREBYX
INJ 100/2ML
3
CEREBYX
INJ 500/10ML
3
DILANTIN
CAP 100MG
3
DILANTIN
CAP 30MG
3
DILANTIN
CHW 50MG
3
DILANTIN-125 SUS 125/5ML
3
fosphenytoin inj 100/2ml
1
fosphenytoin inj 500/10ml
1
PEGANONE
TAB 250MG
2
PHENYTEK
CAP 200MG
3
PHENYTEK
CAP 300MG
3
87
DRUG NAME
DRUG
TIER
phenytoin
chw 50mg
1
phenytoin
inj 50mg/ml
1
phenytoin
sus 125/5ml
1
phenytoin ex cap 100mg
1
1
1
REQUIREMENTS/LIMITS
*SUCCINIMIDES***
CELONTIN
CAP 300MG
2
ethosuximide cap 250mg
1
ethosuximide sol 250/5ml
1
ZARONTIN
CAP 250MG
3
ZARONTIN
SOL 250/5ML
3
*VALPROIC ACID***
DEPACON
INJ 100MG/ML
3
DEPAKENE
CAP 250MG
3
DEPAKENE
SYP 250/5ML
3
DEPAKOTE
TAB 125MG DR
3
DEPAKOTE
TAB 250MG DR
3
DEPAKOTE
TAB 500MG DR
3
DEPAKOTE ER TAB 250MG
3
DEPAKOTE ER TAB 500MG
3
DEPAKOTE SPR CAP 125MG
3
divalproex cap 125mg
1
88
DRUG NAME
DRUG
TIER
divalproex tab 125mg dr
1
1
divalproex tab 250mg er
1
1
divalproex tab 500mg er
1
STAVZOR
CAP 125MG
3
STAVZOR
CAP 250MG
3
STAVZOR
CAP 500MG
3
valproate
inj 100mg/ml
1
valproate
inj 500/5ml
1
valproic acd cap 250mg
1
valproic acd sol 250/5ml
1
valproic acd syp 250/5ml
1
REQUIREMENTS/LIMITS
*ANTIDEPRESSANTS*
*ALPHA-2 RECEPTOR ANTAGONISTS (TETRACYCLICS)***
mirtazapine tab 15mg
1
mirtazapine tab 15mg odt
1
1
1
1
1
mirtazapine tab 7.5mg
1
REMERON
3
TAB 15MG
89
DRUG NAME
DRUG
TIER
REMERON
TAB 30MG
3
REMERON
TAB 45MG
3
REMERON SLTB TAB 15MG
3
3
3
REQUIREMENTS/LIMITS
*ANTIDEPRESSANT MISC-NUTRITIONAL SUPPLEMENT COMBINATIONS***
APPBUTAMONE PAK
3
APPBUTAMONE PAK -D
3
*ANTIDEPRESSANTS - MISC.***
APLENZIN
TAB 174MG
3
APLENZIN
TAB 348MG
3
APLENZIN
TAB 522MG
3
budeprion
tab 100mg sr
1
budeprion
tab 150mg sr
1
budeprion xl tab 150mg
1
budeprion xl tab 300mg
1
bupropion
tab 100mg
1
bupropion
tab 100mg er
1
bupropion
tab 100mg sr
1
bupropion
tab 150mg er
1
bupropion
tab 150mg sr
1
bupropion
tab 200mg er
1
bupropion
tab 200mg sr
1
90
DRUG NAME
bupropion
DRUG
TIER
tab 75mg
REQUIREMENTS/LIMITS
1
bupropn hcl tab 150mg xl
1
bupropn hcl tab 300mg xl
1
FORFIVO XL TAB 450MG
3
maprotiline tab 25mg
1
1
1
WELLBUTRIN TAB 100MG
3
WELLBUTRIN TAB 100MG SR
2
2
2
WELLBUTRIN TAB 75MG
3
WELLBUTRIN TAB XL 150MG
3
WELLBUTRIN TAB XL 300MG
3
*MONOAMINE OXIDASE INHIBITORS (MAOIS)***
EMSAM
DIS 12MG/24H
3
EMSAM
DIS 6MG/24HR
3
EMSAM
DIS 9MG/24HR
3
TAB 10MG
3
MARPLAN
NARDIL
TAB 15MG
PARNATE
TAB 10MG
3
3
phenelzine tab 15mg
1
tranylcyprom tab 10mg
1
91
DRUG NAME
DRUG
TIER
REQUIREMENTS/LIMITS
*SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIS)***
CELEXA
TAB 10MG
3
CELEXA
TAB 20MG
3
CELEXA
TAB 40MG
3
citalopram sol 10mg/5ml
1
citalopram tab 10mg
1
citalopram tab 20mg
1
citalopram tab 40mg
1
escitalopram sol 5mg/5ml
1
escitalopram tab 10mg
1
1
1
fluoxetine cap 10mg
1
fluoxetine cap 20mg
1
fluoxetine cap 40mg
1
fluoxetine cap 90mg dr
1
fluoxetine sol 20mg/5ml
1
fluoxetine tab 10mg
1
fluoxetine tab 20mg
1
FLUOXETINE TAB 60MG
3
fluvoxamine cap 100mg er
1
fluvoxamine cap 150mg er
1
fluvoxamine tab 100mg
1
92
DRUG NAME
DRUG
TIER
1
1
LEXAPRO
SOL 5MG/5ML
3
LEXAPRO
TAB 10MG
3
LEXAPRO
TAB 20MG
3
LEXAPRO
TAB 5MG
3
LUVOX CR
CAP 100MG
3
LUVOX CR
CAP 150MG
3
paroxetin er tab 12.5mg
1
paroxetin er tab 37.5mg
1
paroxetine tab 10mg
1
paroxetine tab 20mg
1
paroxetine tab 25mg er
1
paroxetine tab 30mg
1
paroxetine tab 40mg
1
PAXIL
SUS 10MG/5ML
3
PAXIL
TAB 10MG
3
PAXIL
TAB 20MG
3
PAXIL
TAB 30MG
3
PAXIL
TAB 40MG
3
PAXIL CR
TAB 12.5MG
3
PAXIL CR
TAB 25MG
3
PAXIL CR
TAB 37.5MG
3
REQUIREMENTS/LIMITS
93
DRUG NAME
DRUG
TIER
PEXEVA
TAB 10MG
3
PEXEVA
TAB 20MG
3
PEXEVA
TAB 30MG
3
PEXEVA
TAB 40MG
3
PROZAC
CAP 10MG
3
PROZAC
CAP 20MG
3
PROZAC
CAP 40MG
3
PROZAC WEEKL CAP 90MG
3
sertraline con 20mg/ml
1
sertraline tab 100mg
1
sertraline tab 25mg
1
sertraline tab 50mg
1
ZOLOFT
CON 20MG/ML
3
ZOLOFT
TAB 100MG
3
ZOLOFT
TAB 25MG
3
ZOLOFT
TAB 50MG
3
REQUIREMENTS/LIMITS
*SEROTONIN MODULATORS***
BRINTELLIX TAB 10MG
2
ST
BRINTELLIX TAB 20MG
2
ST
BRINTELLIX TAB 5MG
2
ST
nefazodone tab 100mg
1
1
1
94
DRUG NAME
DRUG
TIER
1
nefazodone tab 50mg
1
OLEPTRO
TAB 24HR150
3
OLEPTRO
TAB 24HR300
3
REQUIREMENTS/LIMITS
trazodone tab 100mg
1
trazodone tab 150mg
1
trazodone tab 300mg
1
trazodone tab 50mg
1
VIIBRYD
KIT
2
ST
VIIBRYD
KIT STARTER
2
ST
VIIBRYD
TAB 10MG
2
ST
VIIBRYD
TAB 20MG
2
ST
VIIBRYD
TAB 40MG
2
ST
*SEROTONIN MODULATORS-NUTRITIONAL SUPPLEMENT COMBINATIONS***
TRAZAMINE
PAK
3
TRAZAMINE
PAK 50MG
3
*SEROTONIN-NOREPINEPHRINE REUPTAKE INHIBITORS (SNRIS)***
CYMBALTA
CAP 20MG
3
ST
CYMBALTA
CAP 30MG
3
ST
CYMBALTA
CAP 60MG
3
ST
desvenlafax tab 100mg er
1
desvenlafax tab 50mg er
1
duloxetine cap 20mg
1
ST
95
DRUG NAME
DRUG
TIER
REQUIREMENTS/LIMITS
duloxetine cap 30mg
1
ST
DULOXETINE CAP 40MG
3
ST
duloxetine cap 60mg
1
ST
EFFEXOR XR CAP 150MG
3
EFFEXOR XR CAP 37.5MG
3
EFFEXOR XR CAP 75MG
3
FETZIMA
CAP 120MG
2
FETZIMA
CAP 20MG
2
FETZIMA
CAP 40MG
2
FETZIMA
CAP 80MG
2
FETZIMA
CAP TITRATIO
2
IRENKA
CAP 40MG
3
KHEDEZLA
TAB 100MG ER
2
KHEDEZLA
TAB 50MG ER
2
PRISTIQ
TAB 100MG
2
PRISTIQ
TAB 25MG
2
PRISTIQ
TAB 50MG
2
venlafaxine cap 150mg er
1
venlafaxine cap 37.5 er
1
venlafaxine cap 37.5mg
1
venlafaxine cap 75mg er
1
venlafaxine tab 100mg
1
venlafaxine tab 150mg er
1
ST
96
DRUG NAME
DRUG
TIER
1
1
venlafaxine tab 37.5 er
1
venlafaxine tab 37.5mg
1
1
1
1
REQUIREMENTS/LIMITS
*SSRIS-NUTRITIONAL SUPPLEMENT COMBINATIONS***
GABOXETINE PAK
3
SENTRAFLOX PAK AM-10
3
SENTRALOPRAM PAK AM-10
3
SENTROXATINE PAK
3
*TRICYCLIC AGENTS***
amitriptylin tab 100mg
1
1
1
1
1
1
amoxapine
tab 100mg
1
amoxapine
tab 150mg
1
amoxapine
tab 25mg
1
amoxapine
tab 50mg
1
97
DRUG NAME
DRUG
TIER
ANAFRANIL CAP 25MG
3
ANAFRANIL CAP 50MG
3
ANAFRANIL CAP 75MG
3
clomipramine cap 25mg
1
1
1
desipramine tab 100mg
1
1
1
1
1
1
doxepin hcl cap 100mg
1
1
1
1
1
1
doxepin hcl con 10mg/ml
1
imipram hcl tab 10mg
1
1
1
imipram pam cap 100mg
1
REQUIREMENTS/LIMITS
98
DRUG NAME
DRUG
TIER
1
1
1
NORPRAMIN
TAB 100MG
3
NORPRAMIN
TAB 10MG
3
NORPRAMIN
TAB 150MG
3
NORPRAMIN
TAB 25MG
3
NORPRAMIN
TAB 50MG
3
NORPRAMIN
TAB 75MG
3
nortriptylin cap 10mg
1
1
1
1
NORTRIPTYLIN SOL 10MG/5ML
3
PAMELOR
CAP 10MG
3
PAMELOR
CAP 25MG
3
PAMELOR
CAP 50MG
3
PAMELOR
CAP 75MG
3
protriptylin tab 10mg
1
protriptylin tab 5mg
1
SURMONTIL
CAP 100MG
3
SURMONTIL
CAP 25MG
3
SURMONTIL
CAP 50MG
3
REQUIREMENTS/LIMITS
99
DRUG NAME
DRUG
TIER
TOFRANIL
TAB 10MG
3
TOFRANIL
TAB 25MG
3
TOFRANIL
TAB 50MG
3
TOFRANIL-PM CAP 100MG
3
3
3
3
trimipramine cap 100mg
1
1
1
VIVACTIL
TAB 10MG
3
VIVACTIL
TAB 5MG
3
REQUIREMENTS/LIMITS
*TRICYCLIC AGENTS-NUTRITIONAL SUPPLEMENT COMBINATIONS***
SENTRAVIL PM PAK -25
3
*ANTIDIABETICS*
*ALPHA-GLUCOSIDASE INHIBITORS***
acarbose
tab 100mg
1
acarbose
tab 25mg
1
acarbose
tab 50mg
1
GLYSET
TAB 100MG
3
GLYSET
TAB 25MG
3
GLYSET
TAB 50MG
3
PRECOSE
TAB 100MG
3
100
DRUG NAME
DRUG
TIER
PRECOSE
TAB 25MG
3
PRECOSE
TAB 50MG
3
REQUIREMENTS/LIMITS
*ANTIDIABETIC - AMYLIN ANALOGS***
SYMLIN
INJ 600MCG
3
SYMLINPEN 60 INJ 1000MCG
3
SYMLNPEN 120 INJ 1000MCG
3
*BIGUANIDE-NUTRITIONAL SUPPLEMENT COMBINATIONS***
APPFORMIN
PAK
APPFORMIN-D PAK
3
3
*BIGUANIDES***
FORTAMET
TAB 1000MG
3
FORTAMET
TAB 500MG
3
GLUCOPHAGE TAB 1000MG
3
3
GLUCOPHAGE TAB 500MG XR
3
GLUCOPHAGE TAB 750MG XR
3
3
metformin
tab 1000mg
1
metformin
tab 500mg
1
metformin
tab 500mg er
1
metformin
tab 750mg er
1
101
DRUG NAME
metformin
DRUG
TIER
tab 850mg
REQUIREMENTS/LIMITS
1
RIOMET
SOL
3
RIOMET
SOL 500/5ML
3
*DIABETIC OTHER***
GLUCAGEN
INJ HYPOKIT
2
GLUCAGON
KIT 1MG
2
PROGLYCEM
SUS 50MG/ML
3
*DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS***
JANUVIA
TAB 100MG
2
JANUVIA
TAB 25MG
2
JANUVIA
TAB 50MG
2
NESINA
TAB 12.5MG
3
NESINA
TAB 25MG
3
NESINA
TAB 6.25MG
3
ONGLYZA
TAB 2.5MG
2
ONGLYZA
TAB 5MG
2
TRADJENTA
TAB 5MG
3
ST
*DIPEPTIDYL PEPTIDASE-4 INHIBITOR-BIGUANIDE COMBINATIONS***
JANUMET
TAB 50-1000
2
JANUMET
TAB 50-500MG
2
JANUMET XR TAB 100-1000
2
JANUMET XR TAB 50-1000
2
102
DRUG NAME
DRUG
TIER
REQUIREMENTS/LIMITS
JANUMET XR TAB 50-500MG
2
JENTADUETO TAB 2.5-1000
3
ST
3
ST
3
ST
KAZANO 12.5- TAB 1000MG
3
KAZANO 12.5- TAB 500MG
3
KOMBIGLYZE TAB 2.5-1000
2
KOMBIGLYZE TAB 5-1000MG
2
KOMBIGLYZE TAB 5-500MG
2
*DOPAMINE RECEPTOR AGONISTS - ERGOT DERIVATIVES***
CYCLOSET
TAB 0.8MG
3
*DPP-4 INHIBITOR-HMG COA REDUCCTASE INHIBITOR COMB***
JUVISYNC
TAB 100-10MG
3
JUVISYNC
TAB 100-20MG
3
JUVISYNC
TAB 100-40MG
3
JUVISYNC
TAB 50-10MG
3
JUVISYNC
TAB 50-20MG
3
JUVISYNC
TAB 50-40MG
3
*DPP-4 INHIBITOR-THIAZOLIDINEDIONE COMBINATIONS***
OSENI
TAB 12.5-15
3
OSENI
TAB 12.5-30
3
OSENI
TAB 12.5-45
3
OSENI
TAB 25-15MG
3
103
DRUG NAME
DRUG
TIER
OSENI
TAB 25-30MG
3
OSENI
TAB 25-45MG
3
REQUIREMENTS/LIMITS
*HUMAN INSULIN***
AFREZZA
POW 4& 8UNIT
3
AFREZZA
POW 4UNIT
3
AFREZZA
POW 8&12UNIT
3
LANTUS
INJ 100/ML
2
LANTUS
INJ SOLOSTAR
2
LEVEMIR
INJ
2
LEVEMIR
INJ FLEXPEN
2
LEVEMIR
INJ FLEXTOUC
2
NOVOLIN
INJ 70/30
2
NOVOLIN N
INJ RELION
2
NOVOLIN N
INJ U-100
2
NOVOLIN R
INJ RELION
2
NOVOLIN R
INJ U-100
2
NOVOLIN70/30 INJ RELION
2
NOVOLOG
INJ 100/ML
2
NOVOLOG
INJ FLEXPEN
2
NOVOLOG
INJ PENFILL
2
NOVOLOG MIX INJ 70/30
2
NOVOLOG MIX INJ FLEXPEN
2
TOUJEO SOLO INJ 300IU/ML
2
104
DRUG NAME
DRUG
TIER
TRESIBA FLEX INJ 100UNIT
3
TRESIBA FLEX INJ 200UNIT
3
REQUIREMENTS/LIMITS
*INCRETIN MIMETIC AGENTS (GLP-1 RECEPTOR AGONISTS)***
BYDUREON
INJ
2
BYETTA
INJ 10MCG
2
BYETTA
INJ 5MCG
2
VICTOZA
INJ 18MG/3ML
2
*MEGLITINIDE ANALOGUES***
nateglinide tab 120mg
1
nateglinide tab 60mg
1
PRANDIN
TAB 0.5MG
3
PRANDIN
TAB 1MG
3
PRANDIN
TAB 2MG
3
repaglinide tab 0.5mg
1
repaglinide tab 1mg
1
repaglinide tab 2mg
1
STARLIX
TAB 120MG
3
STARLIX
TAB 60MG
3
*MEGLITINIDE-BIGUANIDE COMBINATIONS***
PRANDIMET
TAB 1-500MG
2
PRANDIMET
TAB 2-500MG
2
repaglinide tab 1-500mg
1
repaglinide tab 2-500mg
1
105
DRUG NAME
DRUG
TIER
REQUIREMENTS/LIMITS
*PROGESTERONE RECEPTOR ANTAGONISTS***
KORLYM
TAB 300MG
3
PA
*SGLT2 INHIBITOR - DPP-4 INHIBITOR COMBINATIONS***
GLYXAMBI
TAB 10-5 MG
3
GLYXAMBI
TAB 25-5 MG
3
*SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITORS***
FARXIGA
TAB 10MG
2
FARXIGA
TAB 5MG
2
INVOKANA
TAB 100MG
2
INVOKANA
TAB 300MG
2
JARDIANCE
TAB 10MG
3
JARDIANCE
TAB 25MG
3
*SODIUM-GLUCOSE CO-TRANSPORTER 2 INHIBITOR-BIGUANIDE COMB***
INVOKAMET
TAB 150-1000
2
INVOKAMET
TAB 150-500
2
INVOKAMET
TAB 50-1000
2
INVOKAMET
TAB 50-500MG
2
SYNJARDY
TAB
3
SYNJARDY
TAB 12.5-500
3
SYNJARDY
TAB 5-1000MG
3
SYNJARDY
TAB 5-500MG
3
XIGDUO XR
TAB 10-1000
3
XIGDUO XR
TAB 10-500MG
3
106
DRUG NAME
DRUG
TIER
XIGDUO XR
TAB 5-1000MG
3
XIGDUO XR
TAB 5-500MG
3
REQUIREMENTS/LIMITS
*SULFONYLUREA-BIGUANIDE COMBINATIONS***
glip/metform tab 2.5-250m
1
glip/metform tab 2.5-500m
1
glip/metform tab 5-500mg
1
GLUCOVANCE TAB 1.25-250
3
GLUCOVANCE TAB 2.5-500
3
GLUCOVANCE TAB 5-500MG
3
glyb/metform tab 1.25-250
1
glyb/metform tab 2.5-500
1
glyb/metform tab 5-500mg
1
METAGLIP
3
TAB 2.5-250M
*SULFONYLUREA-THIAZOLIDINEDIONE COMBINATIONS***
AVANDARYL
TAB 4-1MG
3
AVANDARYL
TAB 4-2MG
3
AVANDARYL
TAB 4-4MG
3
AVANDARYL
TAB 8-2MG
3
AVANDARYL
TAB 8-4MG
3
DUETACT
TAB 30-2MG
3
DUETACT
TAB 30-4MG
3
pioglit/glim tab 30-2mg
1
pioglit/glim tab 30-4mg
1
107
DRUG NAME
DRUG
TIER
REQUIREMENTS/LIMITS
*SULFONYLUREAS***
AMARYL
TAB 1MG
3
AMARYL
TAB 2MG
3
AMARYL
TAB 4MG
3
chlorpropam tab 100mg
1
chlorpropam tab 250mg
1
DIABETA
TAB 1.25MG
3
DIABETA
TAB 2.5MG
3
DIABETA
TAB 5MG
3
glimepiride tab 1mg
1
glimepiride tab 2mg
1
glimepiride tab 4mg
1
glipizide tab 10mg
1
glipizide tab 5mg
1
glipizide er tab 10mg
1
glipizide er tab 2.5mg
1
glipizide er tab 5mg
1
glipizide xl tab 10mg
1
glipizide xl tab 2.5mg
1
glipizide xl tab 5mg
1
GLUCOTROL
TAB 10MG
3
GLUCOTROL
TAB 5MG
3
GLUCOTROL XL TAB 10MG
3
108
DRUG NAME
DRUG
TIER
GLUCOTROL XL TAB 2.5MG
3
GLUCOTROL XL TAB 5MG
3
glyburid mcr tab 1.5mg
1
glyburid mcr tab 3mg
1
glyburid mcr tab 6mg
1
glyburide tab 1.25mg
1
glyburide tab 2.5mg
1
glyburide tab 5mg
1
GLYNASE
TAB 1.5MG
3
GLYNASE
TAB 3MG
3
GLYNASE
TAB 6MG
3
tolazamide tab 250mg
1
tolazamide tab 500mg
1
tolbutamide tab 500mg
1
REQUIREMENTS/LIMITS
*THIAZOLIDINEDIONE-BIGUANIDE COMBINATIONS***
ACTOPLUS MET TAB 15-500MG
3
ACTOPLUS MET TAB 15-850MG
3
ACTOPLUS MET TAB XR
3
AVANDAMET
TAB 2-1000MG
3
AVANDAMET
TAB 2-500MG
3
AVANDAMET
TAB 4-1000MG
3
AVANDAMET
TAB 4-500MG
3
pioglita/met tab 15-500mg
1
109
DRUG NAME
pioglita/met tab 15-850mg
DRUG
TIER
REQUIREMENTS/LIMITS
1
*THIAZOLIDINEDIONES***
ACTOS
TAB 15MG
3
ACTOS
TAB 30MG
3
ACTOS
TAB 45MG
3
AVANDIA
TAB 2MG
3
AVANDIA
TAB 4MG
3
AVANDIA
TAB 8MG
3
pioglitazone tab 15mg
1
1
1
*ANTIDIARRHEALS*
*ANTIDIARRHEAL - CHLORIDE CHANNEL ANTAGONISTS***
FULYZAQ
TAB 125MG
3
PA
*ANTIDIARRHEAL AGENTS - MISC.***
REZYST IM
CHW
3
REZYST SB
CHW 250MG
3
VSL#3 DS
PAK
3
*ANTIDIARRHEAL COMBINATIONS***
RESTORA RX CAP 60-1.25
3
RESTORA SPRI PAK 15-0.25
3
*ANTIPERISTALTIC AGENTS***
diphen/atrop liq 2.5/5
1
110
DRUG NAME
DRUG
TIER
diphen/atrop tab 2.5mg
1
lofene
1
tab 2.5mg
LOMOTIL
lonox
TAB 2.5MG
tab 2.5mg
3
1
loperamide cap 2mg
1
MOTOFEN
3
opium
TAB 1-0.025
tin 1%
OPIUM TINCT TIN 2MG/5ML
REQUIREMENTS/LIMITS
1
3
*ANTIDOTES*
*ANTIDOTE COMBINATIONS AND KITS***
CYANIDE ANTI KIT PKG UNIT
3
DUODOTE
3
INJ
NITHIODOTE KIT
3
*ANTIDOTES - CHELATING AGENTS***
CA-DTPA
SOL 1000MG
3
CHEMET
CAP 100MG
3
EXJADE
TAB 125MG
4
PA
EXJADE
TAB 250MG
4
PA
EXJADE
TAB 500MG
4
PA
FERRIPROX
TAB 500MG
3
JADENU
TAB 180MG
4
PA
JADENU
TAB 360MG
4
PA
JADENU
TAB 90MG
4
PA
111
DRUG NAME
ZN-DTPA
DRUG
TIER
SOL 1000MG
REQUIREMENTS/LIMITS
3
*ANTIDOTES***
ACETADOTE
INJ 200MG/ML
3
acetylcyst inj 200mg/ml
1
ANTIZOL
3
INJ 1GM/ML
BAL IN OIL INJ 100MG/ML
3
CALCIUM DISO INJ 1GM/5ML
3
CALCIUM DISO INJ 500/2.5M
3
CYANOKIT
3
INJ 5GM
deferoxamine inj 2gm
4
PA
deferoxamine inj 500mg
4
PA
DESFERAL
INJ 2GM
4
PA
DESFERAL
INJ 500MG
4
PA
DIGIFAB
INJ 40MG
3
fomepizole inj 1.5gm
1
fomepizole inj 1gm/ml
1
methylene bl inj 1%
1
PHYSOS SALIC INJ 1MG/ML
3
PRALIDOXIME INJ 600/2ML
3
PRAXBIND
4
INJ 2.5/50
PROTOPAM CHL INJ 1GM
3
RADIOGARDASE CAP 0.5GM
3
SOD NITRITE INJ 30MG/ML
3
PA
112
DRUG NAME
DRUG
TIER
SOD THIOSULF INJ 10%
3
sod thiosulf inj 25%
1
REQUIREMENTS/LIMITS
*BENZODIAZEPINE ANTAGONISTS***
flumazenil inj 0.5mg/5
1
flumazenil inj 1mg/10ml
1
ROMAZICON
3
INJ 1MG/10ML
*OPIOID ANTAGONISTS***
EVZIO
INJ
3
naloxone
inj 0.4mg/ml
1
naloxone
inj 1mg/ml
1
naltrexone tab 50mg
1
NARCAN
3
SPR 0.4MG/ML
REVIA
TAB 50MG
VIVITROL
INJ 380MG
3
4
PA
4
PA
*ANTIEMETICS*
*5-HT3 RECEPTOR ANTAGONISTS***
ALOXI
INJ 0.25MG/5
ANZEMET
INJ 20MG/ML
4
PA, QL (X)
ANZEMET
TAB 100MG
2
QL (X)
ANZEMET
TAB 50MG
2
QL (X)
granisetron inj 0.1mg/ml
4
PA
granisetron inj 1mg/ml
4
PA
granisetron inj 4mg/4ml
4
PA
113
DRUG NAME
DRUG
TIER
REQUIREMENTS/LIMITS
granisetron tab 1mg
1
QL (X)
GRANISOL
3
QL (X)
ondansetron inj 32/50ml
4
PA
ondansetron inj 40/20ml
4
PA, QL (X)
ondansetron inj 4mg/2ml
4
PA, QL (X)
ONDANSETRON SOL 32MG/50M
3
ondansetron sol 4mg/5ml
1
QL (X)
ondansetron tab 24mg
1
QL (X)
ondansetron tab 4mg
1
QL (X)
ondansetron tab 4mg odt
1
QL (X)
ondansetron tab 8mg
1
QL (X)
ondansetron tab 8mg odt
1
QL (X)
SANCUSO
DIS 3.1MG
3
ZOFRAN
INJ 40/20ML
4
PA, QL (X)
ZOFRAN
SOL 4MG/5ML
3
QL (X)
ZOFRAN
TAB 4MG
3
QL (X)
ZOFRAN
TAB 4MG ODT
3
QL (X)
ZOFRAN
TAB 8MG
3
QL (X)
ZOFRAN
TAB 8MG ODT
3
QL (X)
ZUPLENZ
MIS 4MG
3
QL (X)
ZUPLENZ
MIS 8MG
3
QL (X)
SOL 2MG/10ML
*ANTIEMETIC COMBINATIONS***
AKYNZEO
CAP
3
114
DRUG NAME
COCA COLA
DICLEGIS
DRUG
TIER
SYP
TAB 10-10MG
REQUIREMENTS/LIMITS
3
3
*ANTIEMETICS - ANTICHOLINERGIC***
ANTIVERT
TAB 12.5MG
3
ANTIVERT
TAB 25MG
3
ANTIVERT
TAB 50MG
3
DIMENHYDRIN INJ 50MG/ML
3
meclizine
1
tab 25mg
TIGAN
CAP 300MG
3
TIGAN
INJ 100MG/ML
3
TRANSDERM-SC DIS 1MG
3
trimethobenz cap 300mg
1
trimethobenz inj 100mg/ml
1
univert
1
tab 32mg
*ANTIEMETICS - MISCELLANEOUS***
CESAMET
CAP 1MG
3
dronabinol cap 10mg
1
dronabinol cap 2.5mg
1
dronabinol cap 5mg
1
MARINOL
CAP 10MG
3
MARINOL
CAP 2.5MG
3
MARINOL
CAP 5MG
3
*SUBSTANCE P/NEUROKININ 1 (NK1) RECEPTOR ANTAGONISTS***
115
DRUG NAME
DRUG
TIER
REQUIREMENTS/LIMITS
EMEND
CAP 125MG
3
EMEND
CAP 40MG
3
EMEND
CAP 80MG
3
EMEND
PAK 80 & 125
3
EMEND
SOL 150MG
4
PA
VARUBI
TAB 90MG
4
PA
*ANTIFUNGALS*
*ANTIFUNGAL - GLUCAN SYNTHESIS INHIBITORS (ECHINOCANDINS)***
CANCIDAS
INJ 50MG
3
CANCIDAS
INJ 70MG
3
ERAXIS
INJ 100MG
3
ERAXIS
INJ 50MG
3
MYCAMINE
INJ 100MG
3
MYCAMINE
INJ 50MG
3
*ANTIFUNGALS***
ABELCET
INJ 5MG/ML
3
AMBISOME
INJ 50MG
3
AMPHOTEC
INJ 100MG
3
AMPHOTEC
INJ 50MG
3
amphotericin inj 50mg
1
ANCOBON
CAP 250MG
3
ANCOBON
CAP 500MG
3
BIO-STATIN CAP 1000000
3
116
DRUG NAME
DRUG
TIER
BIO-STATIN CAP 500000
3
flucytosine cap 250mg
1
flucytosine cap 500mg
1
GRIFULVIN V TAB 500MG
3
GRIS-PEG
TAB 125MG
3
GRIS-PEG
TAB 250MG
3
griseofulvin sus 125/5ml
1
griseofulvin tab micr 500
1
griseofulvin tab ultr 125
1
griseofulvin tab ultr 250
1
LAMISIL
GRA 125MG
3
LAMISIL
GRA 187.5MG
3
LAMISIL
TAB 250MG
3
nystatin
tab 500000
1
terbinafine tab 250mg
1
TERBINEX
3
KIT
REQUIREMENTS/LIMITS
QL (X)
QL (X)
*IMIDAZOLES***
ketoconazole tab 200mg
1
*TRIAZOLES***
CRESEMBA
CAP 186 MG
3
CRESEMBA
INJ 372MG
3
DIFLUCAN
SUS 10MG/ML
3
DIFLUCAN
SUS 40MG/ML
3
117
DRUG NAME
DRUG
TIER
DIFLUCAN
TAB 100MG
3
DIFLUCAN
TAB 150MG
3
DIFLUCAN
TAB 200MG
3
DIFLUCAN
TAB 50MG
3
fluconazole sus 10mg/ml
1
fluconazole sus 40mg/ml
1
fluconazole tab 100mg
1
1
1
1
fluconazole/ inj dex 200
1
fluconazole/ inj dex 400
1
FLUCONAZOLE/ INJ NACL 100
3
fluconazole/ inj nacl 200
1
fluconazole/ inj nacl 400
1
itraconazole cap 100mg
1
NOXAFIL
INJ 300/16.7
3
NOXAFIL
SUS 40MG/ML
3
NOXAFIL
TAB 100MG
3
ONMEL
TAB 200MG
REQUIREMENTS/LIMITS
QL (X)
3
SPORANOX
CAP 100MG
3
QL (X)
SPORANOX
CAP PULSEPAK
3
QL (X)
SPORANOX
SOL 10MG/ML
3
118
DRUG NAME
DRUG
TIER
VFEND
SUS 40MG/ML
3
VFEND
TAB 200MG
3
VFEND
TAB 50MG
3
VFEND IV
INJ 200MG
REQUIREMENTS/LIMITS
3
voriconazole inj 200mg
1
voriconazole sus 40mg/ml
1
voriconazole tab 200mg
1
voriconazole tab 50mg
1
*ANTIHISTAMINES*
*ANTIHISTAMINES - ALKYLAMINES***
AHIST
bpm
TAB 12MG
tab 6mg
3
1
brompheniram chw 12mg
1
BROMPHENIRAM INJ 10MG/ML
3
BROVEX
SUS 12MG/5ML
3
CHW 12MG
3
BROVEX CT
dexchlorphen syp 2mg/5ml
1
dexchlorphen tab 4mg cr
1
ED CHLORPED SUS 2MG/ML
3
ED-CHLOR-TAN TAB 8MG
3
RESPA-BR
TAB 11MG
3
LIQ 2MG/5ML
3
VAZOL
*ANTIHISTAMINES - ETHANOLAMINES***
119
DRUG NAME
DRUG
TIER
arbinoxa
sol 4mg/5ml
1
arbinoxa
tab 4mg
1
carbinoxamin sol 4mg/5ml
1
carbinoxamin tab 4mg
1
clemastine syp 0.5/5ml
1
clemastine tab 2.68mg
1
DICOPANOL
3
SUS 5MG/ML
diphenhydram elx 12.5/5ml
1
diphenhydram inj 50mg/ml
1
DOXYTEX
3
dytuss
LIQ
syp 12.5/5ml
1
KARBINAL ER SUS 4MG/5ML
3
palgic
1
sol 4mg/5ml
PALGIC
TAB 4MG
REQUIREMENTS/LIMITS
3
*ANTIHISTAMINES - ETHYLENEDIAMINES***
PYRILAMINE CRY USP NF
3
*ANTIHISTAMINES - NON-SEDATING***
cetirizine syp
1
cetirizine tab 10mg
1
cetirizine tab 5mg
1
CLARINEX
SYP 0.5MG/ML
3
CLARINEX
TAB 5MG
3
CLARINEX RDT TAB 2.5MG
3
120
DRUG NAME
DRUG
TIER
CLARINEX RDT TAB 5MG
3
desloratadin tab 2.5 odt
1
desloratadin tab 5mg
1
desloratadin tab 5mg odt
1
fexofenadine tab 60mg
1
levocetirizi sol 2.5/5ml
1
levocetirizi tab 5mg
1
loratadine tab 10mg
1
loratadine tab 5mg
1
loratadine syp
1
XYZAL
SOL
3
XYZAL
SOL 2.5/5ML
3
XYZAL
TAB 5MG
3
REQUIREMENTS/LIMITS
*ANTIHISTAMINES - PHENOTHIAZINES***
phenadoz
sup 12.5mg
1
phenadoz
sup 25mg
1
PHENERGAN
INJ 25MG/ML
3
PHENERGAN
INJ 50MG/ML
3
phenergan
sup 12.5mg
1
phenergan
sup 25mg
1
phenergan
sup 50mg
1
promethazine inj 25mg/ml
1
promethazine inj 50mg/ml
1
121
DRUG NAME
DRUG
TIER
promethazine sol 6.25/5ml
1
promethazine sup 12.5mg
1
promethazine sup 25mg
1
promethazine sup 50mg
1
promethazine syp 6.25/5ml
1
promethazine tab 12.5mg
1
promethazine tab 25mg
1
promethazine tab 50mg
1
promethegan sup 12.5mg
1
promethegan sup 25mg
1
promethegan sup 50mg
1
REQUIREMENTS/LIMITS
*ANTIHISTAMINES - PIPERIDINES***
cyproheptad syp 2mg/5ml
1
cyproheptad tab 4mg
1
*ANTIHISTAMINES W/ ANTICHOLINERGICS***
AEROHIST
TAB 8-2.5MG
3
ALLERX DF
MIS
3
ALLERX DF 30 MIS
3
relcof cpm tab 8-2.5mg
1
*ANTIHYPERLIPIDEMICS*
*ANTIHYPERLIPIDEMICS - MISC.***
KYNAMRO
LOVAZA
INJ 200MG/ML
CAP 1GM
3
3
122
DRUG NAME
DRUG
TIER
omega-3-acid cap 1gm
1
VASCEPA
2
CAP 1GM
REQUIREMENTS/LIMITS
*ANTIHYPERLIPIDEMICS, OTHER*
OMEGA-3/D-3 KIT WELLNESS
3
PRALUENT
INJ 150MG/ML
4
PA
PRALUENT
INJ 75MG/ML
4
PA
REPATHA
INJ 140MG/ML
4
PA
4
PA
REPATHA SURE INJ 140MG/ML
*BILE ACID SEQUESTRANTS***
COLESTID
GRA 5GM
3
COLESTID
TAB 1GM
3
COLESTID FLA GRA 5/7.5GM
3
COLESTID FLA GRA 5GM
3
colestipol gra 5gm
1
colestipol tab 1gm
1
WELCHOL
PAK 3.75GM
2
WELCHOL
TAB 625MG
2
*FIBRIC ACID DERIVATIVES***
ANTARA
CAP 130MG
3
ANTARA
CAP 30MG
3
ANTARA
CAP 43MG
3
ANTARA
CAP 90MG
3
fenofibrate cap 130mg
ST
ST
1
123
DRUG NAME
DRUG
TIER
1
1
1
1
1
1
FENOFIBRATE TAB 120MG
3
fenofibrate tab 145mg
1
1
FENOFIBRATE TAB 40MG
3
1
1
fenofibric cap 135mg dr
1
fenofibric cap 45mg dr
1
FENOFIBRIC TAB 105MG
3
FENOFIBRIC TAB 35MG
3
FENOGLIDE
TAB 120MG
3
FENOGLIDE
TAB 40MG
3
FIBRICOR
TAB 105MG
3
FIBRICOR
TAB 35MG
3
REQUIREMENTS/LIMITS
gemfibrozil tab 600mg
1
LIPOFEN
CAP 150MG
2
ST
LIPOFEN
CAP 50MG
2
ST
124
DRUG NAME
DRUG
TIER
LOFIBRA
CAP 134MG
3
LOFIBRA
CAP 200MG
3
LOFIBRA
CAP 67MG
3
LOFIBRA
TAB 160MG
3
LOFIBRA
TAB 54MG
3
LOPID
TAB 600MG
REQUIREMENTS/LIMITS
ST
3
TRICOR
TAB 145MG
3
ST
TRICOR
TAB 48MG
3
ST
TRIGLIDE
TAB 160MG
3
ST
TRIGLIDE
TAB 50MG
3
ST
TRILIPIX
CAP 135MG
3
TRILIPIX
CAP 45MG
3
*HMG COA REDUCTASE INHIBITOR COMBINATIONS***
ADVICOR
TAB 1000-20
3
ADVICOR
TAB 1000-40
3
ADVICOR
TAB 500-20MG
3
ADVICOR
TAB 750-20MG
3
ATORVA/COQ10 PAK 20-100MG
3
SIMCOR
TAB 1000-20
3
SIMCOR
TAB 1000-40
3
SIMCOR
TAB 500-20MG
3
SIMCOR
TAB 500-40MG
3
SIMCOR
TAB 750-20MG
3
125
DRUG NAME
DRUG
TIER
REQUIREMENTS/LIMITS
*HMG COA REDUCTASE INHIBITORS***
ALTOPREV
TAB 20MG ER
3
ST
ALTOPREV
TAB 40MG ER
3
ST
ALTOPREV
TAB 60MG ER
3
ST
atorvastatin tab 10mg
1
1
1
1
CRESTOR
TAB 10MG
3
CRESTOR
TAB 20MG
3
CRESTOR
TAB 40MG
3
CRESTOR
TAB 5MG
3
ST
rosuvastatin 10mg
1
rosuvastatin 20mg
1
rosuvastatin 40mg
1
rosuvastatin 5mg
1
ST
fluvastatin cap 20mg
1
ST
fluvastatin cap 40mg
1
ST
fluvastatin tab 80mg er
1
ST
LESCOL
CAP 20MG
3
ST
LESCOL
CAP 40MG
3
ST
3
ST
LESCOL XL
TAB 80MG
LIPITOR
TAB 10MG
3
ST
LIPITOR
TAB 20MG
3
ST
LIPITOR
TAB 40MG
3
LIPITOR
TAB 80MG
3
LIVALO
TAB 1MG
2
126
ST
DRUG NAME
DRUG
TIER
REQUIREMENTS/LIMITS
LIVALO
TAB 2MG
2
ST
LIVALO
TAB 4MG
2
ST
lovastatin tab 10mg
1
lovastatin tab 20mg
1
lovastatin tab 40mg
1
MEVACOR
TAB 20MG
3
ST
MEVACOR
TAB 40MG
3
ST
PRAVACHOL TAB 20MG
3
ST
PRAVACHOL TAB 40MG
3
ST
PRAVACHOL TAB 80MG
3
ST
pravastatin tab 10mg
1
1
1
1
simvastatin tab 10mg
1
1
1
simvastatin tab 5mg
1
1
ZOCOR
TAB 10MG
3
ST
ZOCOR
TAB 20MG
3
ST
ZOCOR
TAB 40MG
3
ST
ZOCOR
TAB 5MG
3
ST
127
DRUG NAME
ZOCOR
DRUG
TIER
TAB 80MG
3
REQUIREMENTS/LIMITS
ST
*INTEST CHOLEST ABSORP INHIB-HMG COA REDUCTASE INHIB COMB***
LIPTRUZET
TAB 10-10MG
3
LIPTRUZET
TAB 10-20MG
3
LIPTRUZET
TAB 10-40MG
3
LIPTRUZET
TAB 10-80MG
3
VYTORIN
TAB 10-10MG
2
ST
VYTORIN
TAB 10-20MG
2
ST
VYTORIN
TAB 10-40MG
2
ST
VYTORIN
TAB 10-80MG
2
ST
*INTESTINAL CHOLESTEROL ABSORPTION INHIBITORS***
ZETIA
TAB 10MG
2
*MICROSOMAL TRIGLYCERIDE TRANSFER PROTEIN INHIBITORS***
JUXTAPID
CAP 10MG
3
JUXTAPID
CAP 20MG
3
JUXTAPID
CAP 30MG
3
JUXTAPID
CAP 40MG
3
JUXTAPID
CAP 5MG
3
JUXTAPID
CAP 60MG
3
*NICOTINIC ACID DERIVATIVES***
niacin
tab 500mg er
1
niacin er
tab 1000mg
1
niacin er
tab 500mg
1
128
DRUG NAME
niacin er
DRUG
TIER
tab 750mg
REQUIREMENTS/LIMITS
1
NIACOR
TAB 500MG
3
NIASPAN
TAB 1000 ER
3
NIASPAN
TAB 500MG ER
3
NIASPAN
TAB 750MG ER
3
*ANTIHYPERTENSIVES*
*ACE INHIBITOR & CALCIUM CHANNEL BLOCKER COMBINATIONS***
amlod/benazp cap 10-20mg
1
1
amlod/benazp cap 2.5-10mg
1
1
1
1
LOTREL
CAP 10-20MG
3
LOTREL
CAP 10-40MG
3
LOTREL
CAP 2.5-10MG
3
LOTREL
CAP 5-10MG
3
LOTREL
CAP 5-20MG
3
LOTREL
CAP 5-40MG
3
PRESTALIA
TAB 14-10MG
3
PRESTALIA
TAB 3.5-2.5
3
PRESTALIA
TAB 7-5MG
3
TAB 1-240 CR
3
TARKA
129
DRUG NAME
DRUG
TIER
TARKA
TAB 2-180 CR
3
TARKA
TAB 2-240 CR
3
TARKA
TAB 4-240 CR
3
trando/verap tab 1-240 cr
1
trando/verap tab 1-240 er
1
1
1
1
1
1
1
REQUIREMENTS/LIMITS
*ACE INHIBITOR-NUTRITIONAL SUPPLEMENT COMBINATIONS***
LYTENSOPRIL MIS -90 KIT
3
LYTENSOPRIL PAK -90
3
LYTENSOPRIL PAK KIT
3
*ACE INHIBITORS & THIAZIDE/THIAZIDE-LIKE***
ACCURETIC
TAB 10-12.5
3
ACCURETIC
TAB 20-12.5
3
ACCURETIC
TAB 20-25MG
3
benazep/hctz tab 10-12.5
1
1
benazep/hctz tab 20-25mg
1
1
130
DRUG NAME
DRUG
TIER
captopr/hctz tab 25-15mg
1
1
1
1
enalapr/hctz tab 10-25mg
1
enalapr/hctz tab 5-12.5mg
1
fosinop/hctz tab 10/12.5
1
fosinop/hctz tab 20/12.5
1
lisinop/hctz tab 10-12.5
1
lisinop/hctz tab 20-12.5
1
lisinop/hctz tab 20-25mg
1
LOTENSIN HCT TAB 10-12.5
3
LOTENSIN HCT TAB 20-12.5
3
LOTENSIN HCT TAB 20-25MG
3
moexipr/hctz tab 15-12.5
1
moexipr/hctz tab 15-25mg
1
moexipr/hctz tab 7.5-12.5
1
PRINZIDE
TAB 10-12.5
3
PRINZIDE
TAB 20-12.5
3
qnapril/hctz tab 10-12.5
1
qnapril/hctz tab 20-12.5
1
qnapril/hctz tab 20-25mg
1
UNIRETIC
3
TAB 15-12.5
REQUIREMENTS/LIMITS
131
DRUG NAME
DRUG
TIER
UNIRETIC
TAB 15-25MG
3
UNIRETIC
TAB 7.5-12.5
3
VASERETIC
TAB 10-25MG
REQUIREMENTS/LIMITS
3
ZESTORETIC TAB 10-12.5
3
ZESTORETIC TAB 20-12.5
3
ZESTORETIC TAB 20-25MG
3
*ACE INHIBITORS***
ACCUPRIL
TAB 10MG
3
ACCUPRIL
TAB 20MG
3
ACCUPRIL
TAB 40MG
3
ACCUPRIL
TAB 5MG
3
ACEON
TAB 2MG
3
ACEON
TAB 4MG
3
ACEON
TAB 8MG
3
ALTACE
CAP 1.25MG
3
ALTACE
CAP 10MG
3
ALTACE
CAP 2.5MG
3
ALTACE
CAP 5MG
3
benazepril tab 10mg
1
benazepril tab 20mg
1
benazepril tab 40mg
1
benazepril tab 5mg
1
captopril
1
tab 100mg
132
DRUG NAME
DRUG
TIER
captopril
tab 12.5mg
1
captopril
tab 25mg
1
captopril
tab 50mg
1
enalapril
tab 10mg
1
enalapril
tab 2.5mg
1
enalapril
tab 20mg
1
enalapril
tab 5mg
1
enalaprilat inj 1.25/ml
1
EPANED
3
SOL 1MG/ML
fosinopril tab 10mg
1
fosinopril tab 20mg
1
fosinopril tab 40mg
1
lisinopril tab 10mg
1
lisinopril tab 2.5mg
1
lisinopril tab 20mg
1
lisinopril tab 30mg
1
lisinopril tab 40mg
1
lisinopril tab 5mg
1
LOTENSIN
TAB 10MG
3
LOTENSIN
TAB 20MG
3
LOTENSIN
TAB 40MG
3
MAVIK
TAB 1MG
3
MAVIK
TAB 2MG
3
REQUIREMENTS/LIMITS
133
DRUG NAME
MAVIK
TAB 4MG
DRUG
TIER
REQUIREMENTS/LIMITS
3
moexipril
tab 15mg
1
moexipril
tab 7.5mg
1
perindopril tab 2mg
1
perindopril tab 4mg
1
perindopril tab 8mg
1
PRINIVIL
TAB 10MG
3
PRINIVIL
TAB 20MG
3
PRINIVIL
TAB 5MG
3
quinapril tab 10mg
1
quinapril tab 20mg
1
quinapril tab 40mg
1
quinapril tab 5mg
1
ramipril
cap 1.25mg
1
ramipril
cap 10mg
1
ramipril
cap 2.5mg
1
ramipril
cap 5mg
1
trandolapril tab 1mg
1
1
1
UNIVASC
TAB 15MG
3
UNIVASC
TAB 7.5MG
3
VASOTEC
TAB 10MG
3
134
DRUG NAME
DRUG
TIER
VASOTEC
TAB 2.5MG
3
VASOTEC
TAB 20MG
3
VASOTEC
TAB 5MG
3
ZESTRIL
TAB 10MG
3
ZESTRIL
TAB 2.5MG
3
ZESTRIL
TAB 20MG
3
ZESTRIL
TAB 30MG
3
ZESTRIL
TAB 40MG
3
ZESTRIL
TAB 5MG
3
REQUIREMENTS/LIMITS
*ADRENOLYTICS-CENTRAL & THIAZIDE/THIAZIDE-LIKE COMB***
CLORPRES
TAB 0.1-15MG
3
CLORPRES
TAB 0.2-15MG
3
CLORPRES
TAB 0.3-15MG
3
methyld/hctz tab 250/15
1
methyld/hctz tab 250/25
1
*AGENTS FOR PHEOCHROMOCYTOMA***
DEMSER
CAP 250MG
3
DIBENZYLINE CAP 10MG
3
phenoxybenza cap 10mg
1
PHENTOL MESY INJ 5MG
3
PHENTOLAMINE INJ 5MG
3
PHENTOLAMINE INJ MESYLATE
3
*ANGIOTENSIN II RECEPTOR ANT-CA CHANNEL BLOCKER-THIAZIDES***
135
DRUG NAME
DRUG
TIER
amlod/valsar tab /hctz
1
EXFORGEH/10- TAB 160-12.5
3
EXFORGEH/10- TAB 160-25
3
3
EXFORGEH/5- TAB 160-12.5
3
3
TRIBENZOR20- TAB 5-12.5MG
2
TRIBENZOR40- TAB 10-12.5
2
TRIBENZOR40- TAB 10-25MG
2
TRIBENZOR40- TAB 5-12.5MG
2
TRIBENZOR40- TAB 5-25MG
2
REQUIREMENTS/LIMITS
*ANGIOTENSIN II RECEPTOR ANTAG & CA CHANNEL BLOCKER COMB***
amlod/valsar tab 10-160mg
1
1
1
1
AZOR
TAB 10-20MG
2
AZOR
TAB 10-40MG
2
AZOR
TAB 5-20MG
2
AZOR
TAB 5-40MG
2
EXFORGE
TAB 10-160MG
2
EXFORGE
TAB 10-320MG
2
EXFORGE
TAB 5-160MG
2
136
DRUG NAME
EXFORGE
DRUG
TIER
TAB 5-320MG
REQUIREMENTS/LIMITS
2
telmis/amlod tab 40-10mg
1
1
1
1
TWYNSTA
TAB 40-10MG
3
TWYNSTA
TAB 40-5MG
3
TWYNSTA
TAB 80-10MG
3
TWYNSTA
TAB 80-5MG
3
*ANGIOTENSIN II RECEPTOR ANTAG & THIAZIDE/THIAZIDE-LIKE***
ATACAND HCT TAB 16-12.5
3
ST
ATACAND HCT TAB 32-12.5
3
ST
ATACAND HCT TAB 32-25MG
3
ST
AVALIDE
TAB 150-12.5
3
ST
AVALIDE
TAB 300-12.5
3
ST
BENICAR HCT TAB 20-12.5
2
ST
BENICAR HCT TAB 40-12.5
2
ST
BENICAR HCT TAB 40-25MG
2
ST
candesa/hctz tab 16-12.5
1
candesa/hctz tab 32-12.5
1
candesa/hctz tab 32-25mg
1
DIOVAN HCT TAB 160-12.5
3
DIOVAN HCT TAB 160-25MG
3
137
DRUG NAME
DRUG
TIER
REQUIREMENTS/LIMITS
DIOVAN HCT TAB 320-12.5
3
DIOVAN HCT TAB 320-25MG
3
DIOVAN HCT TAB 80/12.5
3
EDARBYCLOR TAB 40-12.5
3
EDARBYCLOR TAB 40-25MG
3
HYZAAR
TAB 100-12.5
3
ST
HYZAAR
TAB 100-25
3
ST
HYZAAR
TAB 50-12.5
3
ST
irbesar/hctz tab 150-12.5
1
irbesar/hctz tab 300-12.5
1
losartan/hct tab 100-12.5
1
losartan/hct tab 100-25
1
losartan/hct tab 50-12.5
1
MICARDIS HCT TAB 40/12.5
3
ST
MICARDIS HCT TAB 80-25MG
3
ST
MICARDIS HCT TAB 80/12.5
3
ST
telmisa/hctz tab 40-12.5
1
telmisa/hctz tab 80-12.5
1
telmisa/hctz tab 80-25mg
1
TEVETEN HCT TAB 600-12.5
3
ST
TEVETEN HCT TAB 600-25MG
3
ST
valsart/hctz tab 160-12.5
1
valsart/hctz tab 160-25mg
1
138
DRUG NAME
DRUG
TIER
1
valsart/hctz tab 320-25mg
1
1
REQUIREMENTS/LIMITS
*ANGIOTENSIN II RECEPTOR ANTAGONISTS***
ATACAND
TAB 16MG
3
ST
ATACAND
TAB 32MG
3
ST
ATACAND
TAB 4MG
3
ST
ATACAND
TAB 8MG
3
ST
AVAPRO
TAB 150MG
3
ST
AVAPRO
TAB 300MG
3
ST
AVAPRO
TAB 75MG
3
ST
BENICAR
TAB 20MG
2
ST
BENICAR
TAB 40MG
2
ST
BENICAR
TAB 5MG
2
ST
candesartan tab 16mg
1
candesartan tab 32mg
1
candesartan tab 4mg
1
candesartan tab 8mg
1
COZAAR
TAB 100MG
3
ST
COZAAR
TAB 25MG
3
ST
COZAAR
TAB 50MG
3
ST
DIOVAN
TAB 160MG
2
DIOVAN
TAB 320MG
2
139
DRUG NAME
DRUG
TIER
REQUIREMENTS/LIMITS
DIOVAN
TAB 40MG
2
DIOVAN
TAB 80MG
2
EDARBI
TAB 40MG
3
ST
EDARBI
TAB 80MG
3
ST
EPROSART MES TAB 600MG
3
ST
irbesartan tab 150mg
1
irbesartan tab 300mg
1
irbesartan tab 75mg
1
losartan pot tab 100mg
1
1
1
MICARDIS
TAB 20MG
3
ST
MICARDIS
TAB 40MG
3
ST
MICARDIS
TAB 80MG
3
ST
telmisartan tab 20mg
1
1
1
TEVETEN
TAB 400MG
3
ST
TEVETEN
TAB 600MG
3
ST
valsartan
tab 160mg
1
valsartan
tab 320mg
1
valsartan
tab 40mg
1
valsartan
tab 80mg
1
140
DRUG NAME
DRUG
TIER
REQUIREMENTS/LIMITS
*ANTIADRENERGICS - CENTRALLY ACTING***
CATAPRES
TAB 0.1MG
3
CATAPRES
TAB 0.2MG
3
CATAPRES
TAB 0.3MG
3
CATAPRES-TTS DIS 0.1/24HR
3
3
3
clonidine
dis 0.1/24hr
1
clonidine
dis 0.2/24hr
1
clonidine
dis 0.3/24hr
1
clonidine
tab 0.1mg
1
clonidine
tab 0.2mg
1
clonidine
tab 0.3mg
1
guanfacine tab 1mg
1
guanfacine tab 2mg
1
methyldopa tab 250mg
1
methyldopa tab 500mg
1
methyldopate inj 250/5ml
1
NEXICLON XR SUS 0.09/ML
3
NEXICLON XR TAB 0.17MG
3
TENEX
TAB 1MG
3
TENEX
TAB 2MG
3
*ANTIADRENERGICS - PERIPHERALLY ACTING***
141
DRUG NAME
DRUG
TIER
CARDURA
TAB 1MG
3
CARDURA
TAB 2MG
3
CARDURA
TAB 4MG
3
CARDURA
TAB 8MG
3
doxazosin
tab 1mg
1
doxazosin
tab 2mg
1
doxazosin
tab 4mg
1
doxazosin
tab 8mg
1
MINIPRESS
CAP 1MG
3
MINIPRESS
CAP 2MG
3
MINIPRESS
CAP 5MG
3
prazosin hcl cap 1mg
1
1
1
terazosin
cap 10mg
1
terazosin
cap 1mg
1
terazosin
cap 2mg
1
terazosin
cap 5mg
1
REQUIREMENTS/LIMITS
*ANTIHYPERTENSIVES - MISC.***
VECAMYL
TAB 2.5MG
3
*BETA BLOCKER & DIURETIC COMBINATIONS***
atenol/chlor tab 100-25mg
1
atenol/chlor tab 50-25mg
1
142
DRUG NAME
DRUG
TIER
bisoprl/hctz tab 10/6.25
1
bisoprl/hctz tab 2.5/6.25
1
bisoprl/hctz tab 5-6.25mg
1
CORZIDE
TAB 40-5MG
3
CORZIDE
TAB 80-5MG
3
DUTOPROL
TAB 100-12.5
3
DUTOPROL
TAB 25-12.5
3
DUTOPROL
TAB 50-12.5
3
LOPRESS HCT TAB 100-25MG
3
LOPRESS HCT TAB 50-25MG
3
metoprl/hctz tab 100-25mg
1
1
1
nadolol/bend tab 40-5mg
1
nadolol/bend tab 80-5mg
1
propran/hctz tab 40/25
1
propran/hctz tab 80/25
1
TENORETIC
TAB 100
3
TENORETIC
TAB 50
3
ZIAC
TAB 10/6.25
3
ZIAC
TAB 2.5/6.25
3
ZIAC
TAB 5-6.25MG
3
REQUIREMENTS/LIMITS
*BETA BLOCKER-NUTRITIONAL SUPPLEMENT COMBINATIONS***
143
DRUG NAME
DRUG
TIER
HYPERTENSOLO PAK
REQUIREMENTS/LIMITS
3
*DIRECT RENIN INHIBITORS & ANGIOTENSIN II RECEPTOR ANTAG***
VALTURNA
TAB 150-160
3
VALTURNA
TAB 300-320
3
*DIRECT RENIN INHIBITORS & CALCIUM CHANNEL BLOCKER COMB***
TEKAMLO
TAB 150-10MG
2
TEKAMLO
TAB 150-5MG
2
TEKAMLO
TAB 300-10MG
2
TEKAMLO
TAB 300-5MG
2
*DIRECT RENIN INHIBITORS & THIAZIDE/THIAZIDE-LIKE COMB***
TEKTURNA HCT TAB 150-12.5
2
TEKTURNA HCT TAB 150-25MG
2
TEKTURNA HCT TAB 300-12.5
2
TEKTURNA HCT TAB 300-25MG
2
*DIRECT RENIN INHIBITORS***
TEKTURNA
TAB 150MG
2
TEKTURNA
TAB 300MG
2
*DIRECT RENIN INHIBITORS-CA CHANNEL BLOCKER-THIAZIDE COMB***
AMTURNIDE150 TAB -5-12.5
2
2
AMTURNIDE300 TAB -10-25MG
2
2
AMTURNIDE300 TAB -5-25MG
2
*DOPAMINE D1 RECEPTOR AGONISTS***
144
DRUG NAME
CORLOPAM
DRUG
TIER
INJ 10MG/ML
REQUIREMENTS/LIMITS
3
fenoldopam inj 10mg/ml
1
fenoldopam inj 20mg/2ml
1
*RESERPINE***
reserpine
tab 0.1mg
1
reserpine
tab 0.25mg
1
*SELECTIVE ALDOSTERONE RECEPTOR ANTAGONISTS (SARAS)***
eplerenone tab 25mg
1
eplerenone tab 50mg
1
INSPRA
TAB 25MG
3
INSPRA
TAB 50MG
3
*VASODILATORS***
hydralazine inj 20mg/ml
1
hydralazine tab 100mg
1
1
1
1
minoxidil
tab 10mg
1
minoxidil
tab 2.5mg
1
nitropress inj 25mg/ml
1
*ANTIMALARIALS*
*ANTIMALARIAL COMBINATIONS***
atovaq/progu tab 250-100
1
145
DRUG NAME
DRUG
TIER
atovaq/progu tab 62.5-25
1
COARTEM
TAB 20-120MG
3
MALARONE
TAB 250-100
3
MALARONE
TAB 62.5-25
3
REQUIREMENTS/LIMITS
*ANTIMALARIALS***
ARALEN
TAB 500MG
3
chloroquine tab 250mg
1
chloroquine tab 500mg
1
DARAPRIM
4
TAB 25MG
hydroxychlor tab 200mg
1
mefloquine tab 250mg
1
PLAQUENIL
3
TAB 200MG
PRIMAQUINE TAB 26.3MG
3
QUALAQUIN
3
CAP 324MG
quinine sulf cap 324mg
PA
1
*ANTIMYASTHENIC/CHOLINERGIC AGENTS*
*ANTIMYASTHENIC COMBINATIONS***
ENLON-PLUS INJ 10-0.14
3
*ANTIMYASTHENIC/CHOLINERGIC AGENTS***
BLOXIVERZ
INJ 1MG/ML
3
BLOXIVERZ
INJ 5MG/10ML
3
ENLON
INJ 150/15ML
GUANIDINE
TAB 125MG
3
3
146
DRUG NAME
DRUG
TIER
MESTINON
SYP 60MG/5ML
2
MESTINON
TAB 60MG
3
MESTINON
TAB TIMESPAN
3
MYTELASE
TAB 10MG
3
neostig meth inj 0.5mg/ml
1
neostig meth inj 1mg/ml
1
NEOSTIGMINE INJ 1MG/1ML
3
3
3
PROSTIGMIN INJ 0.5MG/ML
3
PROSTIGMIN INJ 1MG/ML
3
PROSTIGMIN TAB 15MG
3
pyridostigm tab 60mg
1
pyridostigmi tab 180mg
1
REGONOL
3
INJ 5MG/ML
REQUIREMENTS/LIMITS
*ANTIMYCOBACTERIAL AGENTS*
*ANTI TB COMBINATIONS***
isonarif
cap
RIFAMATE
RIFATER
1
CAP
TAB
3
2
*ANTIMYCOBACTERIAL AGENTS***
CAPASTAT SUL INJ 1GM
3
cycloserine cap 250mg
1
147
DRUG NAME
DRUG
TIER
ethambutol tab 100mg
1
ethambutol tab 400mg
1
isoniazid
inj 100mg/ml
1
isoniazid
syp 50mg/5ml
1
isoniazid
tab 100mg
1
isoniazid
tab 300mg
1
MYAMBUTOL
TAB 100MG
3
MYAMBUTOL
TAB 400MG
3
MYCOBUTIN
CAP 150MG
3
PASER
GRA 4GM
2
PRIFTIN
TAB 150MG
2
pyrazinamide tab 500mg
1
rifabutin
1
cap 150mg
RIFADIN
CAP 150MG
3
RIFADIN
CAP 300MG
3
RIFADIN
INJ 600 MG
3
rifampin
cap 150mg
1
rifampin
cap 300mg
1
rifampin
inj 600 mg
1
SEROMYCIN
SIRTURO
CAP 250MG
TAB 100MG
TRECATOR
TAB 250MG
REQUIREMENTS/LIMITS
3
3
3
*ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES*
148
DRUG NAME
DRUG
TIER
REQUIREMENTS/LIMITS
*ALKYLATING AGENTS***
BUSULFEX
4
PA
carboplatin inj 150/15ml
4
PA
CARBOPLATIN INJ 150MG
4
PA
4
PA
carboplatin inj 50mg/5ml
4
PA
4
PA
cisplatin
4
PA
4
PA
4
PA
inj 100mg
CISPLATIN
cisplatin
INJ 6MG/ML
INJ 200MG
inj 50/50ml
ELOXATIN
INJ 100MG
4
PA
ELOXATIN
INJ 200MG
4
PA
ELOXATIN
INJ 50MG
4
PA
MYLERAN
TAB 2MG
2
PA
oxaliplatin inj 100mg
4
PA
oxaliplatin inj 50/10ml
4
PA
oxaliplatin inj 50mg
4
PA
thiotepa
1
inj 15mg
TREANDA
INJ 100MG
4
TREANDA
INJ 180/2ML
3
TREANDA
INJ 25MG
4
TREANDA
INJ 45/0.5ML
3
PA
PA
*ANDROGEN BIOSYNTHESIS INHIBITORS***
149
DRUG NAME
ZYTIGA
DRUG
TIER
TAB 250MG
REQUIREMENTS/LIMITS
4
PA
2
PA
*ANTIADRENALS***
LYSODREN
TAB 500MG
*ANTIANDROGENS***
bicalutamide tab 50mg
1
CASODEX
3
TAB 50MG
flutamide cap 125mg
1
NILANDRON
4
PA
4
PA
4
PA
5
PA
XTANDI
TAB 150MG
CAP 40MG
*ANTIESTROGENS***
FARESTON
SOLTAMOX
TAB 60MG
SOL 10MG/5ML
tamoxifen
tab 10mg
5
PA
tamoxifen
tab 20mg
5
PA
*ANTIMETABOLITES***
adrucil
inj 2.5g/50m
4
PA
adrucil
inj 500/10ml
4
PA
adrucil
inj 5gm/100m
4
PA
PA
ALIMTA
INJ 100MG
4
ALIMTA
INJ 500MG
3
ARRANON
INJ 5MG/ML
3
azacitidine inj 100mg
4
PA
capecitabine tab 150mg
4
PA
150
DRUG NAME
DRUG
TIER
REQUIREMENTS/LIMITS
capecitabine tab 500mg
4
PA
cladribine inj 1mg/ml
4
PA
CLOLAR
3
INJ 1MG/ML
cytarabine inj 100mg
4
PA
cytarabine inj 100mg/ml
4
PA
cytarabine inj 1gm
4
PA
cytarabine inj 20mg/ml
4
PA
CYTARABINE INJ 500MG
4
PA
DACOGEN
4
PA
decitabine inj 50mg
4
PA
DEPOCYT
4
PA
FLOXURIDINE INJ 0.5GM
4
PA
FLUDARA
4
PA
fludarabine inj 50mg
4
PA
FLUDARABINE INJ 50MG/2ML
4
PA
fluorouracil inj 1gm/20ml
4
PA
fluorouracil inj 2.5g/50m
4
PA
fluorouracil inj 500/10ml
4
PA
fluorouracil inj 5gm/100m
4
PA
FOLOTYN
INJ 20MG/ML
4
PA
FOLOTYN
INJ 40MG/2ML
4
PA
4
PA
4
PA
FUDR
INJ 50MG
INJ 50MG/5ML
INJ 50MG
INJ 0.5GM
GEMCITABINE INJ 1GM
151
DRUG NAME
DRUG
TIER
REQUIREMENTS/LIMITS
GEMCITABINE INJ 200MG
4
PA
GEMCITABINE INJ 2GM
4
PA
GEMZAR
INJ 1GM
4
PA
GEMZAR
INJ 200MG
4
PA
4
PA
LEUSTATIN
INJ 1MG/ML
mercaptopur tab 50mg
1
methotrexate inj 100/4ml
1
methotrexate inj 1gm
1
methotrexate inj 1gm/40ml
1
1
1
methotrexate inj 25mg/ml
1
methotrexate inj 50mg/2ml
1
methotrexate tab 2.5mg
1
PURINETHOL TAB 50MG
3
PURIXAN
SUS 20MG/ML
3
TABLOID
TAB 40MG
2
TREXALL
TAB 10MG
2
TREXALL
TAB 15MG
2
TREXALL
TAB 5MG
2
TREXALL
TAB 7.5MG
2
PA
VIDAZA
INJ 100MG
4
PA
XELODA
TAB 150MG
4
PA
152
DRUG NAME
XELODA
DRUG
TIER
TAB 500MG
4
REQUIREMENTS/LIMITS
PA
*ANTINEOPLASTIC - AUTOLOGOUS CELLULAR IMMUNOTHERAPY***
PROVENGE
INJ
3
*ANTINEOPLASTIC - BRAF KINASE INHIBITORS***
TAFINLAR
CAP 50MG
4
PA
TAFINLAR
CAP 75MG
4
PA
ZELBORAF
TAB 240MG
4
PA
*ANTINEOPLASTIC - HEDGEHOG PATHWAY INHIBITORS***
ERIVEDGE
CAP 150MG
4
PA
ODOMZO
CAP 200MG
4
PA
*ANTINEOPLASTIC - HISTONE DEACETYLASE INHIBITORS***
BELEODAQ
INJ 500MG
4
PA
FARYDAK
CAP 10MG
4
PA
FARYDAK
CAP 15MG
4
PA
FARYDAK
CAP 20MG
4
PA
ISTODAX
INJ 10MG
4
PA
ZOLINZA
CAP 100MG
4
PA
*ANTINEOPLASTIC - IMMUNOMODULATORS***
POMALYST
CAP 1MG
4
PA
POMALYST
CAP 2MG
4
PA
POMALYST
CAP 3MG
4
PA
POMALYST
CAP 4MG
4
PA
4
PA
*ANTINEOPLASTIC - MEK INHIBITORS***
COTELLIC
TAB 20MG
153
DRUG NAME
DRUG
TIER
REQUIREMENTS/LIMITS
MEKINIST
TAB 0.5MG
4
PA
MEKINIST
TAB 2MG
4
PA
*ANTINEOPLASTIC - MONOCLONAL ANTIBODIES***
ARZERRA
CON 100/5ML
4
PA
ARZERRA
CON 1000/50
3
BLINCYTO
INJ 35MCG
4
PA
CAMPATH
INJ 30MG/ML
4
PA
DARZALEX
SOL 100MG/5M
4
PA
DARZALEX
SOL 400MG/20
4
PA
ERBITUX
INJ 100MG
4
PA
ERBITUX
INJ 200MG
4
PA
GAZYVA
INJ 25MG/ML
4
PA
HERCEPTIN
INJ 440MG
4
PA
KEYTRUDA
INJ 100MG/4M
4
PA
KEYTRUDA
SOL 50MG
4
PA
OPDIVO
INJ 100MG/10
4
PA
OPDIVO
INJ 40MG/4ML
4
PA
PERJETA
INJ 420/14ML
4
PA
RITUXAN
INJ 100MG
4
PA
RITUXAN
INJ 500MG
4
PA
UNITUXIN
INJ
4
PA
VECTIBIX
INJ 100MG
4
PA
VECTIBIX
INJ 400MG
4
PA
154
DRUG NAME
DRUG
TIER
REQUIREMENTS/LIMITS
YERVOY
INJ 200MG
4
PA
YERVOY
INJ 50MG
4
PA
*ANTINEOPLASTIC - MTOR KINASE INHIBITORS***
AFINITOR
TAB 10MG
4
PA
AFINITOR
TAB 2.5MG
4
PA
AFINITOR
TAB 5MG
4
PA
AFINITOR
TAB 7.5MG
4
PA
AFINITOR DIS TAB 2MG
2
2
2
TORISEL
4
SOL 25MG/ML
PA
*ANTINEOPLASTIC - MULTIKINASE INHIBITORS***
NEXAVAR
TAB 200MG
4
PA
STIVARGA
TAB 40MG
4
PA
SUTENT
CAP 12.5MG
4
PA
SUTENT
CAP 25MG
4
PA
SUTENT
CAP 37.5MG
2
SUTENT
CAP 50MG
4
PA
*ANTINEOPLASTIC - PROTEASOME INHIBITORS***
KYPROLIS
SOL 60MG
4
PA
NINLARO
CAP 2.3MG
4
PA
NINLARO
CAP 3MG
4
PA
NINLARO
CAP 4MG
4
PA
155
DRUG NAME
VELCADE
DRUG
TIER
INJ 3.5MG
4
REQUIREMENTS/LIMITS
PA
*ANTINEOPLASTIC - TYROSINE KINASE INHIBITORS***
BOSULIF
TAB 100MG
4
PA
BOSULIF
TAB 500MG
4
PA
CAPRELSA
TAB 100MG
4
PA
CAPRELSA
TAB 300MG
4
PA
COMETRIQ
KIT 100MG
4
PA
COMETRIQ
KIT 140MG
4
PA
COMETRIQ
KIT 60MG
4
PA
GILOTRIF
TAB 20MG
4
PA
GILOTRIF
TAB 30MG
4
PA
GILOTRIF
TAB 40MG
4
PA
GLEEVEC
TAB 100MG
4
PA
GLEEVEC
TAB 400MG
4
PA
ICLUSIG
TAB 15MG
4
PA
ICLUSIG
TAB 45MG
4
PA
4
PA
IMBRUVICA
CAP 140MG
INLYTA
TAB 1MG
4
PA
INLYTA
TAB 5MG
4
PA
IRESSA
TAB 250MG
4
PA
LENVIMA
CAP 10MG
3
PA
LENVIMA
CAP 14MG
4
PA
LENVIMA
CAP 20MG
4
PA
156
DRUG NAME
DRUG
TIER
REQUIREMENTS/LIMITS
LENVIMA
CAP 24MG
4
PA
SPRYCEL
TAB 100MG
4
PA
SPRYCEL
TAB 140MG
4
PA
SPRYCEL
TAB 20MG
4
PA
SPRYCEL
TAB 50MG
4
PA
SPRYCEL
TAB 70MG
4
PA
SPRYCEL
TAB 80MG
4
PA
TAGRISSO
TAB 40MG
4
PA
TAGRISSO
TAB 80MG
4
PA
TARCEVA
TAB 100MG
4
PA
TARCEVA
TAB 150MG
4
PA
TARCEVA
TAB 25MG
4
PA
TASIGNA
CAP 150MG
4
PA
TASIGNA
CAP 200MG
4
PA
TYKERB
TAB 250MG
4
PA
VANDETANIB TAB 100MG
4
PA
VANDETANIB TAB 300MG
4
PA
VOTRIENT
TAB 200MG
4
PA
XALKORI
CAP 200MG
4
PA
XALKORI
CAP 250MG
4
PA
ZYKADIA
CAP 150MG
4
PA
*ANTINEOPLASTIC -ANTIBODY FOR RADIOPHARMACEUTICAL THERAPY***
BEXXAR
CON 14MG/ML
3
157
DRUG NAME
DRUG
TIER
ZEVALIN
KIT IN-111
3
ZEVALIN
KIT Y-90
3
REQUIREMENTS/LIMITS
*ANTINEOPLASTIC ANTIBIOTICS***
adriamyc
inj 50mg
4
PA
adriamycin inj 10mg
4
PA
adriamycin inj 20mg
4
PA
adriamycin inj 2mg/ml
4
PA
bleomycin
inj 15unit
4
PA
bleomycin
inj 30unit
4
PA
CERUBIDINE INJ 20MG
4
PA
COSMEGEN
4
PA
dactinomycin inj 0.5mg
4
PA
daunorubicin inj 20mg
4
PA
daunorubicin inj 5mg/ml
4
PA
DAUNOXOME
4
PA
4
PA
doxorubicin inj 10/5ml
4
PA
doxorubicin inj 10mg
4
PA
doxorubicin inj 10mg/5ml
4
PA
4
PA
4
PA
doxorubicin inj 200/100
4
PA
4
PA
DOXIL
INJ 0.5MG
INJ 2MG/ML
INJ 2MG/ML
158
DRUG NAME
DRUG
TIER
REQUIREMENTS/LIMITS
doxorubicin inj 2mg/ml
4
PA
4
PA
4
PA
ELLENCE
4
PA
epirubicin inj 10mg/5ml
4
PA
epirubicin inj 150/75ml
4
PA
epirubicin inj 200mg
4
PA
epirubicin inj 50/25ml
4
PA
EPIRUBICIN INJ 50MG
4
PA
IDAMYCIN PFS INJ 10/10ML
4
PA
IDAMYCIN PFS INJ 20/20ML
4
PA
IDAMYCIN PFS INJ 5MG/5ML
4
PA
idarubicin inj 10/10ml
4
PA
idarubicin inj 20/20ml
4
PA
idarubicin inj 5mg/5ml
4
PA
lipodox
4
PA
lipodox 50 inj 2mg/ml
4
PA
mitomycin
inj 20mg
4
PA
mitomycin
inj 40mg
4
PA
mitomycin
inj 5mg
4
PA
mitoxantron inj 2mg/ml
4
PA
VALSTAR
4
PA
INJ 2MG/ML
inj 2mg/ml
SOL 40MG/ML
*ANTINEOPLASTIC ANTIBODY-DRUG COMPLEXES***
159
DRUG NAME
DRUG
TIER
REQUIREMENTS/LIMITS
ADCETRIS
INJ 50MG
4
PA
KADCYLA
INJ 100MG
4
PA
KADCYLA
INJ 160MG
4
PA
IFOSFAMIDE KIT MESNA
4
PA
LONSURF
TAB 15-6.14
4
PA
LONSURF
TAB 20-8.19
4
PA
*ANTINEOPLASTIC COMBINATIONS***
*ANTINEOPLASTIC ENZYME INHIBITORS**
IBRANCE
CAP 100MG
4
PA
IBRANCE
CAP 125MG
4
PA
IBRANCE
CAP 75MG
4
PA
CAP 50MG
4
PA
ZYDELIG
TAB 100MG
4
PA
ZYDELIG
TAB 150MG
4
PA
4
PA
LYNPARZA
*ANTINEOPLASTIC ENZYMES***
ELSPAR
INJ 10000UNT
ERWINAZE
INJ 10000UNT
4
PA
ONCASPAR
INJ 750/ML
4
PA
*ANTINEOPLASTIC RADIOPHARMACEUTICALS***
BEXXAR 131 I INJ 0.61/ML
3
BEXXAR 131 I INJ 5.6MCI/M
3
METASTRON
INJ
3
QUADRAMET
INJ
3
160
DRUG NAME
XOFIGO
DRUG
TIER
INJ 1000KBQ
REQUIREMENTS/LIMITS
3
*ANTINEOPLASTICS - INTERLEUKINS***
PROLEUKIN
INJ 22MU
4
PA
*ANTINEOPLASTICS - PHOTOACTIVATED AGENTS***
PHOTOFRIN
INJ 75MG
UVADEX
INJ 20MCG/ML
4
PA
3
*ANTINEOPLASTICS MISC.***
ACTIMMUNE
4
PA
INJ 5MU/ML
4
PA
DACARBAZINE INJ 100MG
4
PA
dacarbazine inj 200mg
4
PA
HYDREA
3
PA
hydroxyurea cap 500mg
1
PA
IMLYGIC
INJ
3
INTRON A
INJ 10MU
4
PA
INTRON A
INJ 18MU
4
PA
INTRON A
INJ 25MU
4
PA
INTRON A
INJ 50MU
4
PA
INTRON-A
INJ 10MU PEN
4
PA
INTRON-A
INJ 3MU PEN
4
PA
INTRON-A
INJ 5MU PEN
4
PA
CAP 50MG
4
PA
4
PA
ALFERON N
CAP 500MG
MATULANE
NIPENT
INJ 2MU/0.5
INJ 10MG
161
DRUG NAME
DRUG
TIER
REQUIREMENTS/LIMITS
pentostatin inj 10mg
4
PA
SYLATRON
KIT 200MCG
4
PA
SYLATRON
KIT 300MCG
4
PA
SYLATRON
KIT 600MCG
4
PA
3
PA
4
PA
4
PA
4
PA
SYNRIBO
THERACYS
TICE BCG
TRISENOX
INJ 3.5MG
INJ
INJ
SOL 10MG/10M
*AROMATASE INHIBITORS***
anastrozole tab 1mg
1
ARIMIDEX
3
AROMASIN
TAB 1MG
TAB 25MG
3
exemestane tab 25mg
1
FEMARA
3
TAB 2.5MG
letrozole tab 2.5mg
1
*CARBOXYPEPTIDASE ENZYME AGENTS***
VORAXAZE
INJ 1000UNIT
3
*CARDIAC PROTECTIVE AGENTS***
dexrazoxane inj 250mg
4
PA
dexrazoxane inj 500mg
4
PA
TOTECT
4
PA
INJ 500MG
ZINECARD
INJ 250MG
4
PA
ZINECARD
INJ 500MG
4
PA
162
DRUG NAME
DRUG
TIER
REQUIREMENTS/LIMITS
*CHEMOTHERAPY ADJUNCTS - HYPERURICEMIA AGENTS***
ELITEK
INJ 1.5MG
3
ELITEK
INJ 7.5MG
4
PA
*CHEMOTHERAPY ADJUNCTS - KERATINOCYTE GROWTH FACTORS***
KEPIVANCE
INJ 6.25MG
4
PA
4
PA
4
PA
*ESTROGEN RECEPTOR ANTAGONIST***
FASLODEX
INJ 250MG
*ESTROGENS-ANTINEOPLASTIC***
EMCYT
CAP 140MG
*FOLIC ACID ANTAGONISTS RESCUE AGENTS***
CALC FOLINAT INJ 100/10ML
4
PA
CALC FOLINAT INJ 300/30ML
4
PA
FUSILEV
3
INJ 50MG
leucovor ca inj 100mg
4
PA
LEUCOVOR CA INJ 10MG/ML
4
PA
4
PA
4
PA
4
PA
leucovor ca tab 10mg
1
1
1
leucovor ca tab 5mg
1
leucovorin inj calcium
4
PA
levoleucovor inj 175/17.5
4
PA
163
DRUG NAME
DRUG
TIER
REQUIREMENTS/LIMITS
levoleucovor inj 50mg
4
PA
LEVOLEUCOVOR SOL 250MG/25
4
PA
*GONADOTROPIN RELEASING HORMONE (GNRH) ANTAGONISTS***
FIRMAGON
INJ 120MG
4
PA
FIRMAGON
INJ 80MG
4
PA
*IMIDAZOTETRAZINES***
TEMODAR
CAP 100MG
4
PA
TEMODAR
CAP 140MG
4
PA
TEMODAR
CAP 180MG
4
PA
TEMODAR
CAP 20MG
4
PA
TEMODAR
CAP 250MG
4
PA
TEMODAR
CAP 5MG
4
PA
TEMODAR
INJ 100MG
4
PA
temozolomide cap 100mg
4
PA
4
PA
4
PA
4
PA
4
PA
4
PA
*JANUS ASSOCIATED KINASE (JAK) INHIBITORS***
JAKAFI
TAB 10MG
4
PA
JAKAFI
TAB 15MG
4
PA
JAKAFI
TAB 20MG
4
PA
164
DRUG NAME
DRUG
TIER
REQUIREMENTS/LIMITS
JAKAFI
TAB 25MG
4
PA
JAKAFI
TAB 5MG
4
PA
*LHRH ANALOGS***
ELIGARD
INJ 22.5MG
4
PA
ELIGARD
INJ 30MG
4
PA
ELIGARD
INJ 45MG
3
ELIGARD
INJ 7.5MG
4
PA
leuprolide inj 1mg/0.2
4
PA
LUPRON DEPOT INJ 11.25MG
4
PA
4
PA
4
PA
LUPRON DEPOT INJ 30MG
4
PA
LUPRON DEPOT INJ 45MG
2
4
PA
TRELSTAR
INJ 11.25MG
4
PA
TRELSTAR
INJ 3.75MG
4
PA
TRELSTAR MIX INJ 11.25MG
4
PA
4
PA
4
PA
VANTAS
4
PA
KIT 50MG
ZOLADEX
IMP 10.8MG
4
PA
ZOLADEX
IMP 3.6MG
4
PA
*MITOTIC INHIBITORS***
165
DRUG NAME
ABRAXANE
DRUG
TIER
INJ 100MG
REQUIREMENTS/LIMITS
4
PA
DOCEFREZ
INJ 20MG
4
PA
DOCEFREZ
INJ 80MG
4
PA
DOCETAXEL
INJ 140/7ML
3
DOCETAXEL
INJ 160/16ML
4
PA
DOCETAXEL
INJ 160/8ML
4
PA
DOCETAXEL
INJ 20/0.5ML
4
PA
DOCETAXEL
INJ 200MG/20
3
DOCETAXEL
INJ 20MG/2ML
4
PA
DOCETAXEL
INJ 20MG/ML
4
PA
DOCETAXEL
INJ 80MG/2ML
4
PA
DOCETAXEL
INJ 80MG/4ML
4
PA
DOCETAXEL
INJ 80MG/8ML
4
PA
ETOPOPHOS
INJ 100MG
4
PA
etoposide
cap 50mg
4
PA
etoposide
inj 100/5ml
4
PA
etoposide
inj 1gm/50ml
1
etoposide
inj 20mg/ml
4
etoposide
inj 500/25ml
1
HALAVEN
INJ 1MG/2ML
PA
4
PA
IXEMPRA KIT INJ 15MG
4
PA
IXEMPRA KIT INJ 45MG
4
PA
JEVTANA
3
INJ 60/1.5ML
166
DRUG NAME
MARQIBO
DRUG
TIER
REQUIREMENTS/LIMITS
INJ 5MG/31ML
3
NAVELBINE
INJ 10MG/ML
4
PA
NAVELBINE
INJ 50MG/5ML
4
PA
paclitaxel inj 100mg
4
PA
paclitaxel inj 150/25ml
4
PA
paclitaxel inj 300/50ml
4
PA
paclitaxel inj 30mg/5ml
4
PA
TAXOTERE
INJ 20/0.5ML
4
PA
TAXOTERE
INJ 20MG/ML
4
PA
TAXOTERE
INJ 80MG/4ML
4
PA
TENIPOSIDE INJ 50MG/5ML
4
PA
toposar
inj 100/5ml
4
PA
toposar
inj 1gm/50ml
1
toposar
inj 20mg/ml
1
toposar
inj 500/25ml
1
vinblastine inj 10mg
4
PA
vinblastine inj 1mg/ml
4
PA
vincasar pfs inj 1mg/ml
4
PA
vincristine inj 1mg/ml
4
PA
vinorelbine inj 10mg/ml
4
PA
vinorelbine inj 50mg/5ml
4
PA
vinorelbine inj soln
4
PA
VUMON
4
PA
INJ 50MG/5ML
167
DRUG NAME
DRUG
TIER
REQUIREMENTS/LIMITS
*NITROGEN MUSTARDS***
ALKERAN
INJ 50MG
4
PA
ALKERAN
TAB 2MG
4
PA
CYCLOPHOSPH CAP 25MG
3
CYCLOPHOSPH CAP 50MG
3
cyclophosph inj 1gm
4
PA
cyclophosph inj 2gm
4
PA
cyclophosph inj 500mg
4
PA
cyclophosph tab 25mg
1
cyclophosph tab 50mg
1
IFEX
INJ 1GM
4
PA
IFEX
INJ 3GM
4
PA
ifosfamide inj 1gm
4
PA
ifosfamide inj 1gm/20ml
4
PA
ifosfamide inj 3gm
4
PA
ifosfamide inj 3gm/60ml
4
PA
LEUKERAN
2
PA
4
PA
4
PA
melphalan
TAB 2MG
inj 50mg
MUSTARGEN
INJ 10MG
*NITROSOUREAS***
BICNU
INJ 100MG
4
PA
CEENU
CAP 100MG
4
PA
CEENU
CAP 10MG
4
PA
168
DRUG NAME
CEENU
DRUG
TIER
CAP 40MG
REQUIREMENTS/LIMITS
4
PA
GLEOSTINE
CAP 100MG
4
PA
GLEOSTINE
CAP 10MG
4
PA
GLEOSTINE
CAP 40MG
4
PA
GLEOSTINE
CAP 5MG
3
WAF 7.7MG
3
GLIADEL
lomustine cap 100mg
4
PA
lomustine cap 10mg
4
PA
lomustine cap 40mg
4
PA
ZANOSAR
4
PA
INJ 1GM
*PROGESTINS-ANTINEOPLASTIC***
DEPO-PROVERA INJ 400/ML
2
MEGACE ORAL SUS 40MG/ML
3
megestrol ac sus 400mg/10
1
megestrol ac sus 40mg/ml
1
megestrol ac tab 20mg
1
megestrol ac tab 40mg
1
*RETINOIDS***
tretinoin
cap 10mg
4
PA
*SELECTIVE RETINOID X RECEPTOR AGONISTS***
bexarotene cap 75mg
4
PA
TARGRETIN
4
PA
CAP 75MG
*TETRAHYDROISOQUINOLINES***
169
DRUG NAME
YONDELIS
DRUG
TIER
INJ 1MG
REQUIREMENTS/LIMITS
4
PA
PA
*TOPOISOMERASE I INHIBITORS***
CAMPTOSAR
INJ 100/5ML
4
CAMPTOSAR
INJ 300/15ML
3
CAMPTOSAR
INJ 40MG/2ML
4
PA
HYCAMTIN
CAP 0.25MG
4
PA
HYCAMTIN
CAP 1MG
4
PA
HYCAMTIN
INJ 4MG
4
PA
irinotecan inj 100/5ml
4
PA
irinotecan inj 40mg/2ml
4
PA
irinotecan inj 500mg/25
4
PA
ONIVYDE
4
PA
4
PA
4
PA
topotecan
INJ 4.3MG/ML
inj 4mg
TOPOTECAN
INJ 4MG/4ML
*URINARY TRACT PROTECTIVE AGENTS***
amifostine inj 500mg
4
PA
ETHYOL
4
PA
4
PA
mesna
INJ 500MG
inj 1gm
MESNEX
INJ 1GM
4
PA
MESNEX
TAB 400MG
4
PA
*VASCULAR ENDOTHELIAL GROWTH FACTOR (VEGF) INHIBITORS***
AVASTIN
INJ
4
PA
AVASTIN
INJ 400/16ML
4
PA
170
DRUG NAME
DRUG
TIER
REQUIREMENTS/LIMITS
CYRAMZA
INJ 100/10ML
4
PA
CYRAMZA
INJ 500/50ML
4
PA
ZALTRAP
INJ 100/4ML
3
ZALTRAP
INJ 200/8ML
3
*ANTIPARKINSON AGENTS*
*ANTIPARKINSON ANTICHOLINERGICS***
benztropine inj 1mg/ml
1
benztropine tab 0.5mg
1
benztropine tab 1mg
1
benztropine tab 2mg
1
COGENTIN
3
INJ 1MG/ML
trihexyphen elx 0.4mg/ml
1
trihexyphen tab 2mg
1
trihexyphen tab 5mg
1
*ANTIPARKINSON DOPAMINERGICS***
amantadine cap 100mg
1
amantadine syp 50mg/5ml
1
amantadine tab 100mg
1
bromocriptin cap 5mg
1
bromocriptin tab 2.5mg
1
PARLODEL
CAP 5MG
3
PARLODEL
TAB 2.5MG
3
*ANTIPARKINSON MONOAMINE OXIDASE INHIBITORS***
171
DRUG NAME
DRUG
TIER
AZILECT
TAB 0.5MG
2
AZILECT
TAB 1MG
2
ELDEPRYL
CAP 5MG
3
selegiline cap 5mg
1
selegiline tab 5mg
1
ZELAPAR
3
TAB 1.25MG
REQUIREMENTS/LIMITS
*CENTRAL/PERIPHERAL COMT INHIBITORS***
TASMAR
TAB 100MG
tolcapone
tab 100mg
3
1
*DECARBOXYLASE INHIBITORS***
carbidopa
tab 25mg
LODOSYN
TAB 25MG
1
3
*LEVODOPA COMBINATIONS***
carb/levo
tab 10-100mg
1
carb/levo
tab 25-100mg
1
carb/levo
tab 25-250mg
1
carb/levo 50 tab /entacap
1
carb/levo 75 tab /entacap
1
carb/levo er tab 25-100mg
1
carb/levo er tab 50-200mg
1
carb/levo100 tab /entacap
1
1
1
172
DRUG NAME
DRUG
TIER
1
DUOPA
4
SUS 4.63-20
PARCOPA
TAB 10-100MG
3
PARCOPA
TAB 25-100MG
3
PARCOPA
TAB 25-250MG
3
RYTARY
CAP
3
RYTARY
CAP 23.75-95
3
SINEMET
TAB 10-100MG
3
SINEMET
TAB 25-100MG
3
SINEMET
TAB 25-250MG
3
SINEMET CR TAB 25-100MG
3
SINEMET CR TAB 50-200MG
3
STALEVO 100 TAB
3
STALEVO 125 TAB
3
STALEVO 150 TAB
3
STALEVO 200 TAB
3
STALEVO 50 TAB
3
STALEVO 75 TAB
3
REQUIREMENTS/LIMITS
PA
*NONERGOLINE DOPAMINE RECEPTOR AGONISTS***
APOKYN
INJ
4
PA
APOKYN
INJ 10MG/ML
4
PA
MIRAPEX
TAB 0.125MG
3
MIRAPEX
TAB 0.25MG
3
173
DRUG NAME
DRUG
TIER
MIRAPEX
TAB 0.5MG
3
MIRAPEX
TAB 0.75MG
3
MIRAPEX
TAB 1.5MG
3
MIRAPEX
TAB 1MG
3
MIRAPEX ER TAB 0.375MG
3
3
3
3
3
MIRAPEX ER TAB 3MG
3
3
NEUPRO
DIS 1MG/24HR
3
NEUPRO
DIS 2MG/24HR
3
NEUPRO
DIS 3MG/24HR
3
NEUPRO
DIS 4MG/24HR
3
NEUPRO
DIS 6MG/24HR
3
NEUPRO
DIS 8MG/24HR
3
pramipexole tab 0.125mg
1
1
1
1
pramipexole tab 0.75 er
1
1
REQUIREMENTS/LIMITS
174
DRUG NAME
DRUG
TIER
1
pramipexole tab 1.5mg er
1
pramipexole tab 1mg
1
1
pramipexole tab 3mg
1
1
REQUIP
TAB 0.25MG
3
REQUIP
TAB 0.5MG
3
REQUIP
TAB 1MG
3
REQUIP
TAB 2MG
3
REQUIP
TAB 3MG
3
REQUIP
TAB 4MG
3
REQUIP
TAB 5MG
3
REQUIP XL TAB 12MG
3
REQUIP XL TAB 2MG
3
REQUIP XL TAB 4MG
3
REQUIP XL TAB 6MG
3
REQUIP XL TAB 8MG
3
ropinirole tab 0.25mg
1
ropinirole tab 0.5mg
1
ropinirole tab 12mg er
1
ropinirole tab 1mg
1
ropinirole tab 2mg
1
REQUIREMENTS/LIMITS
175
DRUG NAME
DRUG
TIER
1
ropinirole tab 3mg
1
ropinirole tab 4mg
1
1
ropinirole tab 5mg
1
1
1
REQUIREMENTS/LIMITS
*PERIPHERAL COMT INHIBITORS***
COMTAN
TAB 200MG
entacapone tab 200mg
3
1
*ANTIPSYCHOTICS/ANTIMANIC AGENTS*
*ANTIMANIC AGENTS***
lithium
sol 8meq/5ml
1
lithium carb cap 150mg
1
1
1
lithium carb tab 300mg
1
lithium carb tab 300mg er
1
lithium carb tab 450mg er
1
LITHOBID
3
TAB 300MG CR
*ANTIPSYCHOTICS - MISC.***
EQUETRO
CAP 100MG
3
EQUETRO
CAP 200MG
3
176
DRUG NAME
DRUG
TIER
EQUETRO
CAP 300MG
3
GEODON
CAP 20MG
3
GEODON
CAP 40MG
3
GEODON
CAP 60MG
3
GEODON
CAP 80MG
3
GEODON
INJ 20MG
3
LATUDA
TAB 120MG
3
LATUDA
TAB 20MG
3
LATUDA
TAB 40MG
3
LATUDA
TAB 60MG
3
LATUDA
TAB 80MG
3
ziprasidone cap 20mg
1
1
1
1
REQUIREMENTS/LIMITS
*BENZISOXAZOLES***
FANAPT
PAK
3
FANAPT
TAB 10MG
3
FANAPT
TAB 12MG
3
FANAPT
TAB 1MG
3
FANAPT
TAB 2MG
3
FANAPT
TAB 4MG
3
FANAPT
TAB 6MG
3
177
DRUG NAME
DRUG
TIER
FANAPT
TAB 8MG
3
INVEGA
TAB 1.5MG
3
INVEGA
TAB 3MG
3
INVEGA
TAB 6MG
3
INVEGA
TAB 9MG
3
INVEGA SUST INJ 117/0.75
3
INVEGA SUST INJ 156MG/ML
3
3
3
INVEGA SUST INJ 78/0.5ML
3
INVEGA TRINZ INJ 273MG
3
3
3
3
paliperidone tab er 1.5mg
1
paliperidone tab er 3mg
1
1
1
RISPERDAL
INJ 12.5MG
3
RISPERDAL
INJ 25MG
3
RISPERDAL
INJ 37.5MG
3
RISPERDAL
INJ 50MG
3
RISPERDAL
SOL 1MG/ML
3
REQUIREMENTS/LIMITS
178
DRUG NAME
DRUG
TIER
RISPERDAL
TAB 0.25MG
3
RISPERDAL
TAB 0.5MG
3
RISPERDAL
TAB 1MG
3
RISPERDAL
TAB 2MG
3
RISPERDAL
TAB 3MG
3
RISPERDAL
TAB 4MG
3
RISPERDAL M TAB 0.5MG
3
RISPERDAL M TAB 1MG
3
RISPERDAL M TAB 2MG
3
RISPERDAL M TAB 3MG
3
RISPERDAL M TAB 4MG
3
risperidone sol 1mg/ml
1
risperidone tab 0.25 odt
1
risperidone tab 0.25mg
1
risperidone tab 0.5mg
1
risperidone tab 0.5mg od
1
risperidone tab 1mg
1
risperidone tab 1mg odt
1
risperidone tab 2mg
1
1
risperidone tab 3mg
1
1
risperidone tab 4mg
1
REQUIREMENTS/LIMITS
179
DRUG NAME
DRUG
TIER
REQUIREMENTS/LIMITS
1
*BUTYROPHENONES***
HALDOL
INJ 5MG/ML
3
HALDOL DECAN INJ 100MG/ML
3
HALDOL DECAN INJ 50MG/ML
3
haloper dec inj 100mg/ml
1
haloper dec inj 50mg/ml
1
haloper lac inj 5mg/ml
1
haloperidol con 2mg/ml
1
haloperidol tab 0.5mg
1
haloperidol tab 10mg
1
haloperidol tab 1mg
1
haloperidol tab 20mg
1
haloperidol tab 2mg
1
haloperidol tab 5mg
1
*DIBENZO-OXEPINO PYRROLES***
SAPHRIS
SUB 10MG
3
SAPHRIS
SUB 2.5MG
3
SAPHRIS
SUB 5MG
3
*DIBENZODIAZEPINES***
clozapine
tab 100/odt
1
clozapine
tab 100mg
1
CLOZAPINE
TAB 12.5/ODT
3
180
DRUG NAME
DRUG
TIER
clozapine
tab 150/odt
1
clozapine
tab 200/odt
1
clozapine
tab 200mg
1
clozapine
tab 25mg
1
clozapine
tab 25mg odt
1
clozapine
tab 50mg
1
CLOZARIL
TAB 100MG
3
CLOZARIL
TAB 25MG
3
FAZACLO
TAB 100/ODT
3
FAZACLO
TAB 12.5/ODT
3
FAZACLO
TAB 150MG
3
FAZACLO
TAB 200MG
3
FAZACLO
TAB 25MG ODT
3
SUS 50MG/ML
3
VERSACLOZ
REQUIREMENTS/LIMITS
*DIBENZOTHIAZEPINES***
quetiapine tab 100mg
1
1
quetiapine tab 25mg
1
1
1
quetiapine tab 50mg
1
SEROQUEL
TAB 100MG
3
SEROQUEL
TAB 200MG
3
181
DRUG NAME
DRUG
TIER
SEROQUEL
TAB 25MG
3
SEROQUEL
TAB 300MG
3
SEROQUEL
TAB 400MG
3
SEROQUEL
TAB 50MG
3
SEROQUEL XR TAB 150MG
2
2
2
2
2
REQUIREMENTS/LIMITS
*DIBENZOXAZEPINES***
ADASUVE
INH 10MG
3
loxapine
cap 10mg
1
loxapine
cap 25mg
1
loxapine
cap 50mg
1
loxapine
cap 5mg
1
LOXITANE
CAP 10MG
3
LOXITANE
CAP 25MG
3
LOXITANE
CAP 50MG
3
LOXITANE
CAP 5MG
3
*DIHYDROINDOLONES***
MOLINDONE
TAB HCL 10MG
3
MOLINDONE
TAB HCL 25MG
3
MOLINDONE
TAB HCL 5MG
3
182
DRUG NAME
DRUG
TIER
REQUIREMENTS/LIMITS
*PHENOTHIAZINES***
chlorpromaz inj 25mg/ml
1
chlorpromaz inj 50mg/2ml
1
chlorpromaz tab 100mg
1
1
1
1
1
COMPAZINE
3
compazine
sup 25mg
COMPAZINE
compro
PAK 5MG
TAB 10MG
sup 25mg
1
3
1
fluphenaz de inj 25mg/ml
1
fluphenazine con 5mg/ml
1
fluphenazine elx 2.5/5ml
1
fluphenazine inj 2.5mg/ml
1
fluphenazine tab 10mg
1
1
fluphenazine tab 2.5mg
1
1
perphenazine tab 16mg
1
1
1
183
DRUG NAME
DRUG
TIER
1
prochlorper inj 10mg/2ml
1
prochlorper inj 5mg/ml
1
prochlorper sup 25mg
1
prochlorper tab 10mg
1
prochlorper tab 5mg
1
thioridazine tab 100mg
1
1
1
1
trifluoperaz tab 10mg
1
1
1
1
REQUIREMENTS/LIMITS
*QUINOLINONE DERIVATIVES***
ABILIFY
INJ 9.75MG
3
ABILIFY
SOL 1MG/ML
2
ABILIFY
TAB 10MG
3
ABILIFY
TAB 15MG
3
ABILIFY
TAB 20MG
3
ABILIFY
TAB 2MG
3
ABILIFY
TAB 30MG
3
ABILIFY
TAB 5MG
3
184
DRUG NAME
DRUG
TIER
ABILIFY DISC TAB 10MG
2
ABILIFY DISC TAB 15MG
2
ABILIFY MAIN INJ 300MG
2
ABILIFY MAIN INJ 400MG
2
aripiprazole sol 1mg/ml
1
aripiprazole tab 10mg
1
1
1
1
1
1
ARISTADA
INJ 441MG/1.
3
ARISTADA
INJ 662MG/2
3
ARISTADA
INJ 882MG/3
3
REXULTI
TAB 0.25MG
3
REXULTI
TAB 0.5MG
3
REXULTI
TAB 1MG
3
REXULTI
TAB 2MG
3
REXULTI
TAB 3MG
3
REXULTI
TAB 4MG
3
REQUIREMENTS/LIMITS
*THIENBENZODIAZEPINES***
olanzapine inj 10mg
1
olanzapine tab 10mg
1
185
DRUG NAME
DRUG
TIER
olanzapine tab 10mg odt
1
olanzapine tab 15mg
1
1
olanzapine tab 2.5mg
1
olanzapine tab 20mg
1
1
olanzapine tab 5mg
1
1
olanzapine tab 7.5mg
1
ZYPREXA
INJ 10MG
3
ZYPREXA
TAB 10MG
3
ZYPREXA
TAB 15MG
3
ZYPREXA
TAB 2.5MG
3
ZYPREXA
TAB 20MG
3
ZYPREXA
TAB 5MG
3
ZYPREXA
TAB 7.5MG
3
ZYPREXA RELP INJ 210MG
3
3
3
ZYPREXA ZYDI TAB 10MG
3
3
3
3
REQUIREMENTS/LIMITS
186
DRUG NAME
DRUG
TIER
REQUIREMENTS/LIMITS
*THIOXANTHENES***
NAVANE
CAP 2MG
3
thiothixene cap 10mg
1
thiothixene cap 1mg
1
thiothixene cap 2mg
1
thiothixene cap 5mg
1
*ANTISEPTICS & DISINFECTANTS*
*ANTISEPTIC COMBINATIONS***
BUCALSEP
SOL
3
BUCALSEP
SPR
3
SKIN SCRUB KIT PREP TRY
3
*ANTISEPTICS & DISINFECTANTS***
CETYLCIDE-G CON
3
FORMA-RAY
3
formadon
SOL 20%
sol
1
formaldehyde sol 10%
1
FORMALDEHYDE SOL 37%
3
HYDROGEN PER SOL 30%
3
HYDROGEN PER SOL 35% FCC
3
KERR TRIPLE MIS DYE SWAB
3
PHENOL
CRY
3
PHENOL
LIQ 89%
3
TRIPLE DYE LIQ
3
187
DRUG NAME
DRUG
TIER
REQUIREMENTS/LIMITS
*CHLORINE ANTISEPTICS***
ANASEPT
SPR
3
BENZALKONIUM SOL 17%
3
benzalkonium sol 50%
1
BENZALKONIUM SOL NF
3
CHLORHEX DIG SOL 20%
3
CHLORHEX GLU SOL 20%
3
HYPOCHLORITE SOL SODIUM
3
PHISOHEX
2
LIQ 3%
SOD HYPOCHLR SOL 5%
3
*IODINE ANTISEPTICS***
IODINE
TIN 2%
3
IODINE
TIN STRONG
2
PAD PAD
3
IODOFLEX
LUGOLS
SOL STRONG
3
*ANTIVIRALS*
*ANTIRETROVIRAL COMBINATIONS***
abacav/lamiv tab /zidovud
1
ATRIPLA
2
TAB
COMBIVIR
COMPLERA
TAB 150-300
TAB
3
3
EPZICOM
TAB 600-300
2
EVOTAZ
TAB 300-150
4
PA
188
DRUG NAME
DRUG
TIER
GENVOYA
TAB
4
KALETRA
SOL
2
KALETRA
TAB 100-25MG
2
KALETRA
TAB 200-50MG
2
lamivud/zido tab 150-300
1
PREZCOBIX
3
TAB 800-150
STRIBILD
TAB
TRIUMEQ
TRIZIVIR
TAB
TAB
TRUVADA
TYBOST
TAB 200-300
TAB 150MG
REQUIREMENTS/LIMITS
PA
3
PA
4
PA
3
2
3
*ANTIRETROVIRALS - CCR5 ANTAGONISTS (ENTRY INHIBITOR)***
SELZENTRY
TAB 150MG
3
SELZENTRY
TAB 300MG
3
*ANTIRETROVIRALS - FUSION INHIBITORS***
FUZEON
INJ 90MG
4
PA
FUZEON
KIT
4
PA
*ANTIRETROVIRALS - INTEGRASE INHIBITORS***
ISENTRESS
CHW 100MG
3
ISENTRESS
CHW 25MG
3
ISENTRESS
TAB 400MG
3
TIVICAY
TAB 50MG
4
PA
VITEKTA
TAB 150MG
4
PA
189
DRUG NAME
VITEKTA
TAB 85MG
DRUG
TIER
4
REQUIREMENTS/LIMITS
PA
*ANTIRETROVIRALS - PROTEASE INHIBITORS***
APTIVUS
CAP 250MG
2
APTIVUS
SOL
3
CRIXIVAN
CAP 200MG
2
CRIXIVAN
CAP 400MG
2
INVIRASE
CAP 200MG
2
INVIRASE
TAB 500MG
2
LEXIVA
SUS 50MG/ML
2
LEXIVA
TAB 700MG
2
NORVIR
CAP 100MG
2
NORVIR
SOL 80MG/ML
2
NORVIR
TAB 100MG
2
PREZISTA
SUS 100MG/ML
3
PREZISTA
TAB 150MG
3
PREZISTA
TAB 400MG
3
PREZISTA
TAB 600MG
2
PREZISTA
TAB 75MG
3
PREZISTA
TAB 800MG
3
REYATAZ
CAP 100MG
2
REYATAZ
CAP 150MG
2
REYATAZ
CAP 200MG
2
REYATAZ
CAP 300MG
2
190
DRUG NAME
DRUG
TIER
VIRACEPT
TAB 250MG
2
VIRACEPT
TAB 625MG
2
REQUIREMENTS/LIMITS
*ANTIRETROVIRALS - RTI-NON-NUCLEOSIDE ANALOGUES***
EDURANT
TAB 25MG
3
INTELENCE
TAB 100MG
3
INTELENCE
TAB 200MG
3
INTELENCE
TAB 25MG
3
NEVIRAPINE SUS 50MG/5ML
3
nevirapine tab 100mg
1
1
nevirapine tab 400mg er
1
RESCRIPTOR TAB 100 MG
2
RESCRIPTOR TAB 200MG
2
SUSTIVA
CAP 200MG
2
SUSTIVA
CAP 50MG
2
SUSTIVA
TAB 600MG
2
VIRAMUNE
SUS 50MG/5ML
3
VIRAMUNE
TAB 200MG
3
VIRAMUNE XR TAB 100MG
3
VIRAMUNE XR TAB 400MG
3
*ANTIRETROVIRALS - RTI-NUCLEOSIDE ANALOGUES-PURINES***
abacavir
tab 300mg
didanosine cap 125mg
1
1
191
DRUG NAME
DRUG
TIER
1
1
1
VIDEX
SOL 2GM
2
VIDEX
SOL 4GM
2
VIDEX EC
CAP 125MG
3
VIDEX EC
CAP 200MG
3
VIDEX EC
CAP 250MG
3
VIDEX EC
CAP 400MG
3
ZIAGEN
SOL 20MG/ML
2
ZIAGEN
TAB 300MG
3
REQUIREMENTS/LIMITS
*ANTIRETROVIRALS - RTI-NUCLEOSIDE ANALOGUES-PYRIMIDINES***
EMTRIVA
CAP 200MG
2
EMTRIVA
SOL 10MG/ML
2
EPIVIR
SOL 10MG/ML
3
EPIVIR
TAB 150MG
3
EPIVIR
TAB 300MG
3
lamivudine sol 10mg/ml
1
lamivudine tab 150mg
1
1
*ANTIRETROVIRALS - RTI-NUCLEOSIDE ANALOGUES-THYMIDINES***
RETROVIR
CAP 100MG
3
RETROVIR
INJ 10MG/ML
3
192
DRUG NAME
DRUG
TIER
RETROVIR
SYP 50MG/5ML
3
RETROVIR
TAB 300MG
3
stavudine cap 15mg
1
stavudine cap 20mg
1
stavudine cap 30mg
1
stavudine cap 40mg
1
stavudine sol 1mg/ml
1
ZERIT
CAP 15MG
3
ZERIT
CAP 20MG
3
ZERIT
CAP 30MG
3
ZERIT
CAP 40MG
3
ZERIT
SOL 1MG/ML
3
zidovudine cap 100mg
1
zidovudine syp 50mg/5ml
1
zidovudine tab 300mg
1
REQUIREMENTS/LIMITS
*ANTIRETROVIRALS - RTI-NUCLEOTIDE ANALOGUES***
VIREAD
POW 40MG/GM
2
VIREAD
TAB 150MG
2
VIREAD
TAB 200MG
2
VIREAD
TAB 250MG
2
VIREAD
TAB 300MG
2
*CMV AGENTS***
cidofovir
inj 75mg/ml
4
PA
193
DRUG NAME
CYTOVENE
foscarnet
DRUG
TIER
INJ 500MG
inj 24mg/ml
FOSCAVIR
INJ 24MG/ML
4
REQUIREMENTS/LIMITS
PA
1
3
ganciclovir cap 250mg
1
ganciclovir cap 500mg
1
ganciclovir inj 500mg
4
VALCYTE
SOL 50MG/ML
3
VALCYTE
TAB 450MG
3
PA
valganciclov tab 450mg
1
VISTIDE
4
PA
adefov dipiv tab 10mg
4
PA
BARACLUDE
SOL .05MG/ML
4
PA
BARACLUDE
TAB 0.5MG
4
PA
BARACLUDE
TAB 1MG
4
PA
INJ 75MG/ML
*HEPATITIS B AGENTS***
entecavir
tab 0.5mg
4
PA
entecavir
tab 1mg
4
PA
EPIVIR HBV SOL 5MG/ML
4
PA
EPIVIR HBV TAB 100MG
4
PA
HEPSERA
4
PA
4
PA
TYZEKA
4
PA
TAB 10MG
TAB 600MG
*HEPATITIS C AGENTS - COMBINATIONS
194
DRUG NAME
HARVONI
DRUG
TIER
TAB 90-400MG
REQUIREMENTS/LIMITS
4
PA
*HEPATITIS C AGENTS***
COPEGUS
TAB 200MG
4
PA
DAKLINZA
TAB 30MG
4
PA
DAKLINZA
TAB 60MG
4
PA
TAB 375MG
4
PA
INFERGEN
INJ 15MCG
4
PA
INFERGEN
INJ 9MCG
4
PA
moderiba
pak 1000/day
4
PA
moderiba
pak 1200/day
4
PA
moderiba
pak 600/day
4
PA
moderiba
pak 800/day
4
PA
moderiba
tab 200mg
4
PA
PEG-INTRON KIT 120 RP
4
PA
PEG-INTRON KIT 120MCG
4
PA
PEG-INTRON KIT 150 RP
4
PA
4
PA
4
PA
PEG-INTRON KIT 50MCG RP
4
PA
4
PA
PEG-INTRON KIT 80MCG RP
4
PA
PEGASYS
INJ
4
PA
PEGASYS
INJ 180MCG/M
4
PA
INCIVEK
195
DRUG NAME
DRUG
TIER
REQUIREMENTS/LIMITS
PEGASYS
INJ PROCLICK
4
PA
PEGASYS
KIT
4
PA
PEGINTRON
KIT 120MCG
4
PA
PEGINTRON
KIT 150MCG
4
PA
PEGINTRON
KIT 50MCG
4
PA
PEGINTRON
KIT 80MCG
4
PA
REBETOL
CAP 200MG
4
PA
REBETOL
SOL 40MG/ML
4
PA
ribapak
pak 1000/day
4
PA
ribapak
pak 1200/day
4
PA
ribapak
pak 600/day
4
PA
ribapak
pak 800/day
4
PA
ribasphere cap 200mg
4
PA
ribasphere tab 200mg
4
PA
RIBASPHERE TAB 400MG
4
PA
RIBASPHERE TAB 600MG
4
PA
RIBATAB
PAK 1000/DAY
4
PA
RIBATAB
TAB 1200/DAY
4
PA
RIBATAB
TAB 800/DAY
4
PA
ribavirin
cap 200mg
4
PA
ribavirin
tab 200mg
4
PA
SOVALDI
TAB 400MG
4
PA
VICTRELIS
CAP 200MG
4
PA
196
DRUG NAME
DRUG
TIER
REQUIREMENTS/LIMITS
*HERPES AGENTS - PURINE ANALOGUES***
acyclovir
cap 200mg
1
acyclovir
sus 200/5ml
1
acyclovir
tab 400mg
1
acyclovir
tab 800mg
1
acyclovir na inj 1000mg
1
acyclovir na inj 500mg
1
acyclovir na inj 50mg/ml
1
SITAVIG
3
TAB 50MG
valacyclovir tab 1gm
1
valacyclovir tab 500mg
1
VALTREX
TAB 1GM
2
VALTREX
TAB 500MG
2
ZOVIRAX
CAP 200MG
3
ZOVIRAX
SUS 200/5ML
3
ZOVIRAX
TAB 400MG
3
ZOVIRAX
TAB 800MG
3
*HERPES AGENTS - THYMIDINE ANALOGUES***
famciclovir tab 125mg
1
1
1
FAMVIR
TAB 125MG
3
FAMVIR
TAB 250MG
3
197
DRUG NAME
FAMVIR
DRUG
TIER
TAB 500MG
REQUIREMENTS/LIMITS
3
*INFLUENZA AGENTS***
FLUMADINE
TAB 100MG
rimantadine tab 100mg
3
1
*INFLUENZA AGENTS-NUTRITIONAL SUPPLEMENT COMBINATIONS***
RIMANTALIST PAK
3
*NEURAMINIDASE INHIBITORS***
RAPIVAB
INJ 200MG/20
3
RELENZA
MIS DISKHALE
3
TAMIFLU
CAP 30MG
2
TAMIFLU
CAP 45MG
2
TAMIFLU
CAP 75MG
2
TAMIFLU
SUS 12MG/ML
3
TAMIFLU
SUS 6MG/ML
2
QL (X)
QL (X)
*RSV AGENTS - NUCLEOSIDE ANALOGUES***
VIRAZOLE
INH 6GM
4
PA
*ASSORTED CLASSES*
*ANTILEPROTICS***
THALOMID
CAP 100MG
4
PA
THALOMID
CAP 150MG
4
PA
THALOMID
CAP 200MG
4
PA
THALOMID
CAP 50MG
4
PA
*ASSORTED CLASSES***
198
DRUG NAME
NEXAVIR
DRUG
TIER
INJ
REQUIREMENTS/LIMITS
3
*B-LYMPHOCYTE STIMULATOR (BLYS)-SPECIFIC INHIBITORS***
BENLYSTA
INJ 120MG
4
PA
BENLYSTA
INJ 400MG
4
PA
*CHELATING AGENTS***
CUPRIMINE
CAP 250MG
2
DEPEN TITRA TAB 250MG
2
ENDRATE
3
SYPRINE
INJ 150MG/ML
CAP 250MG
3
*CYCLOSPORINE ANALOGS***
cyclosporine cap 100mg
1
cyclosporine cap 100mg md
1
cyclosporine cap 25mg
1
cyclosporine cap 25mg mod
1
cyclosporine cap 50mg mod
1
cyclosporine inj 50mg/ml
1
cyclosporine sol modified
1
gengraf
cap 100mg
1
gengraf
cap 25mg
1
gengraf
sol 100mg/ml
1
NEORAL
CAP 100MG
3
NEORAL
CAP 25MG
3
NEORAL
SOL 100MG/ML
3
199
DRUG NAME
DRUG
TIER
SANDIMMUNE CAP 100MG
3
SANDIMMUNE CAP 25MG
3
SANDIMMUNE INJ 50MG/ML
3
SANDIMMUNE SOL 100MG/ML
3
REQUIREMENTS/LIMITS
*ENZYMES***
AMPHADASE
INJ 150/ML
4
HYALURONIDAS INJ 150/ML
3
HYLENEX
4
INJ 150 UNIT
VITRASE
INJ 200/ML
3
XIAFLEX
INJ 0.9MG
4
PA
PA
PA
*FECAL INCONTINENCE BULKING AGENT - COMBINATIONS***
SOLESTA
INJ 50-15ML
3
*IMMUNE GLOBULIN IMMUNOSUPPRESSANTS***
ATGAM
INJ 250MG
THYMOGLOBULN INJ 25MG
4
PA
4
PA
*IMMUNOMODULATORS FOR MYELODYSPLASTIC SYNDROMES***
REVLIMID
CAP 10MG
4
PA
REVLIMID
CAP 15MG
4
PA
REVLIMID
CAP 2.5MG
4
PA
REVLIMID
CAP 20MG
4
PA
REVLIMID
CAP 25MG
4
PA
REVLIMID
CAP 5MG
4
PA
*INOSINE MONOPHOSPHATE DEHYDROGENASE INHIBITORS***
CELLCEPT
CAP 250MG
3
200
DRUG NAME
DRUG
TIER
CELLCEPT
SUS 200MG/ML
3
CELLCEPT
TAB 500MG
3
CELLCEPT IV INJ 500MG
4
mycophenolat cap 250mg
1
mycophenolat sus 200mg/ml
1
mycophenolat tab 500mg
1
mycophenolic tab 180mg dr
1
mycophenolic tab 360mg dr
1
MYFORTIC
TAB 180MG
3
MYFORTIC
TAB 360MG
3
REQUIREMENTS/LIMITS
PA
*LYMPHATIC AGENTS***
SYLVANT
SOL 100MG
4
PA
SYLVANT
SOL 400MG
4
PA
*MACROLIDE IMMUNOSUPPRESSANTS***
ASTAGRAF XL CAP 0.5MG
3
ASTAGRAF XL CAP 1MG
3
ASTAGRAF XL CAP 5MG
3
ENVARSUS XR TAB 0.75MG
3
ENVARSUS XR TAB 1MG
3
ENVARSUS XR TAB 4MG
3
hecoria
cap 0.5mg
1
hecoria
cap 1mg
1
hecoria
cap 5mg
1
201
DRUG NAME
DRUG
TIER
PROGRAF
CAP 0.5MG
3
PROGRAF
CAP 1MG
3
PROGRAF
CAP 5MG
3
PROGRAF
INJ 5MG/ML
4
RAPAMUNE
SOL 1MG/ML
2
RAPAMUNE
TAB 0.5MG
3
RAPAMUNE
TAB 1MG
2
RAPAMUNE
TAB 2MG
2
sirolimus
tab 0.5mg
1
sirolimus
tab 1mg
1
sirolimus
tab 2mg
1
REQUIREMENTS/LIMITS
PA
tacrolimus cap 0.5mg
1
tacrolimus cap 1mg
1
tacrolimus cap 5mg
1
ZORTRESS
TAB 0.25MG
4
PA
ZORTRESS
TAB 0.5MG
4
PA
ZORTRESS
TAB 0.75MG
4
PA
*MONOCLONAL ANTIBODIES***
SIMULECT
INJ 10MG
3
SIMULECT
INJ 20MG
3
*POTASSIUM REMOVING RESINS***
kionex
sus 15gm/60
sod poly sul sus 15gm/60
1
1
202
DRUG NAME
DRUG
TIER
sod poly sul sus 30/120ml
1
sod poly sul sus 50/200ml
1
sps
1
sus 15gm/60
REQUIREMENTS/LIMITS
*PROSTAGLANDINS***
alprostadil inj 500mcg
1
PROSTIN VR INJ 500MCG
3
*PURINE ANALOGS***
AZASAN
TAB 100MG
3
AZASAN
TAB 75 MG
3
azathioprine inj 100mg
1
azathioprine tab 50mg
1
IMURAN
3
TAB 50MG
*SELECTIVE T-CELL COSTIMULATION BLOCKERS***
NULOJIX
INJ 250MG
3
*BETA BLOCKERS*
*ALPHA-BETA BLOCKER-NUTRITIONAL SUPPLEMENT COMBINATIONS***
HYPERTENEVID PAK 12.5MG
3
*ALPHA-BETA BLOCKERS***
carvedilol tab 12.5mg
1
carvedilol tab 25mg
1
1
1
COREG
3
TAB 12.5MG
203
DRUG NAME
DRUG
TIER
COREG
TAB 25MG
3
COREG
TAB 3.125MG
3
COREG
TAB 6.25MG
3
COREG CR
CAP 10MG
2
COREG CR
CAP 20MG
2
COREG CR
CAP 40MG
2
COREG CR
CAP 80MG
2
labetalol
inj 5mg/ml
1
labetalol
tab 100mg
1
labetalol
tab 200mg
1
labetalol
tab 300mg
1
TRANDATE
TAB 100MG
3
TRANDATE
TAB 200MG
3
TRANDATE
TAB 300MG
3
REQUIREMENTS/LIMITS
*BETA BLOCKERS CARDIO-SELECTIVE***
acebutolol cap 200mg
1
acebutolol cap 400mg
1
atenolol
tab 100mg
1
atenolol
tab 25mg
1
atenolol
tab 50mg
1
betaxolol
tab 10mg
1
betaxolol
tab 20mg
1
bisoprol fum tab 10mg
1
204
DRUG NAME
DRUG
TIER
bisoprol fum tab 5mg
1
BREVIBLOC
INJ 10MG/ML
3
BREVIBLOC
SOL
3
BREVIBLOC
SOL 10MG/ML
3
BYSTOLIC
TAB 10MG
2
BYSTOLIC
TAB 2.5MG
2
BYSTOLIC
TAB 20MG
2
BYSTOLIC
TAB 5MG
2
esmolol hcl inj 100mg/10
1
esmolol hcl inj 10mg/ml
1
KERLONE
TAB 10MG
3
KERLONE
TAB 20MG
3
LOPRESSOR
INJ 5MG/5ML
3
LOPRESSOR
TAB 100MG
3
LOPRESSOR
TAB 50MG
3
metoprol tar tab 100mg
1
1
1
metoprolol inj 1mg/ml
1
metoprolol inj 5mg/5ml
1
metoprolol tab 100mg er
1
1
1
REQUIREMENTS/LIMITS
205
DRUG NAME
DRUG
TIER
1
SECTRAL
CAP 200MG
3
SECTRAL
CAP 400MG
3
TENORMIN
TAB 100MG
3
TENORMIN
TAB 25MG
3
TENORMIN
TAB 50MG
3
TOPROL XL TAB 100MG
3
TOPROL XL TAB 200MG
3
TOPROL XL TAB 25MG
3
TOPROL XL TAB 50MG
3
ZEBETA
TAB 10MG
3
ZEBETA
TAB 5MG
3
REQUIREMENTS/LIMITS
*BETA BLOCKERS NON-SELECTIVE***
BETAPACE
TAB 120MG
3
BETAPACE
TAB 160MG
3
BETAPACE
TAB 80MG
3
BETAPACE AF TAB 120MG
3
3
3
CORGARD
TAB 20MG
3
CORGARD
TAB 40MG
3
CORGARD
TAB 80MG
3
HEMANGEOL
SOL 4.28/ML
3
206
DRUG NAME
DRUG
TIER
INDERAL LA CAP 120MG
3
INDERAL LA CAP 160MG
3
INDERAL LA CAP 60MG
3
INDERAL LA CAP 80MG
3
INDERAL XL CAP 120MG
3
INDERAL XL CAP 80MG
3
INNOPRAN XL CAP 120MG
3
INNOPRAN XL CAP 80MG
3
LEVATOL
3
TAB 20MG
nadolol
tab 20mg
1
nadolol
tab 40mg
1
nadolol
tab 80mg
1
pindolol
tab 10mg
1
pindolol
tab 5mg
1
propranolol cap 120mg er
1
1
1
1
propranolol inj 1mg/ml
1
propranolol sol 20mg/5ml
1
propranolol sol 40mg/5ml
1
propranolol tab 10mg
1
1
REQUIREMENTS/LIMITS
207
DRUG NAME
DRUG
TIER
1
1
1
sorine
tab 120mg
1
sorine
tab 160mg
1
sorine
tab 240mg
1
sorine
tab 80mg
1
sotalol af tab 120mg
1
sotalol af tab 160mg
1
sotalol af tab 80mg
1
SOTALOL HCL INJ 150/10ML
3
sotalol hcl tab 120mg
1
1
1
1
SOTYLIZE
3
SOL 5MG/ML
timolol mal tab 10mg
1
timolol mal tab 20mg
1
timolol mal tab 5mg
1
REQUIREMENTS/LIMITS
*BIOLOGICALS MISC*
*BIOLOGICALS MISC***
ADAGEN
INJ 250/ML
STAPHAGE LYS INJ
4
PA
3
208
DRUG NAME
DRUG
TIER
REQUIREMENTS/LIMITS
*CALCIUM CHANNEL BLOCKERS*
*CALCIUM CHANNEL BLOCKER-NUTRITIONAL SUPPLEMENT COMB***
HYPERTENIPIN PAK 2.5MG
3
*CALCIUM CHANNEL BLOCKERS***
ADALAT CC
TAB 30MG ER
3
ADALAT CC
TAB 60MG ER
3
ADALAT CC
TAB 90MG ER
3
afeditab
tab 30mg cr
1
afeditab
tab 60mg cr
1
amlodipine tab 10mg
1
amlodipine tab 2.5mg
1
amlodipine tab 5mg
1
CALAN
TAB 120MG
3
CALAN
TAB 80MG
3
CALAN SR
TAB 120MG
3
CALAN SR
TAB 180MG
3
CALAN SR
TAB 240MG
3
CARDENE I.V. INJ 2.5MG/ML
3
CARDENE IV INJ 40/200ML
3
CARDENE IV SOL 20/200ML
3
CARDENE SR CAP 30MG
3
CARDENE SR CAP 45MG
3
CARDENE SR CAP 60MG
3
209
DRUG NAME
DRUG
TIER
CARDIZEM
TAB 120MG
3
CARDIZEM
TAB 30MG
3
CARDIZEM
TAB 60MG
3
CARDIZEM
TAB 90MG
3
CARDIZEM CD CAP 120MG/24
3
3
3
3
3
CARDIZEM LA TAB 120MG
3
3
3
CARDIZEM LA TAB 300MG/24
3
3
CARDIZEM LA TAB 420MG/24
3
cartia xt
cap 120/24hr
1
cartia xt
cap 180/24hr
1
cartia xt
cap 240/24hr
1
cartia xt
cap 300/24hr
1
CLEVIPREX
EMU 0.5MG/ML
3
COVERA-HS
TAB 180MG
3
COVERA-HS
TAB 240MG
3
DILACOR XR CAP 240MG/24
REQUIREMENTS/LIMITS
3
210
DRUG NAME
DRUG
TIER
dilt-cd
cap 120mg
1
dilt-cd
cap 180mg
1
dilt-cd
cap 240mg
1
dilt-cd
cap 300mg
1
dilt-xr
cap 120mg
1
dilt-xr
cap 180mg
1
dilt-xr
cap 240mg
1
diltiazem
cap 120mg cd
1
diltiazem
cap 120mg er
1
diltiazem
cap 120mg/24
1
diltiazem
cap 180mg cd
1
diltiazem
cap 180mg er
1
diltiazem
cap 180mg/24
1
diltiazem
cap 240mg cd
1
diltiazem
cap 240mg er
1
diltiazem
cap 240mg/24
1
diltiazem
cap 300mg cd
1
diltiazem
cap 300mg er
1
diltiazem
cap 300mg/24
1
diltiazem
cap 360mg cd
1
diltiazem
cap 360mg er
1
diltiazem
cap 360mg/24
1
diltiazem
cap 420mg/24
1
REQUIREMENTS/LIMITS
211
DRUG NAME
DRUG
TIER
diltiazem
cap 60mg er
1
diltiazem
cap 90mg er
1
diltiazem
inj 100mg
1
diltiazem
inj 125/25ml
1
diltiazem
inj 25mg/5ml
1
diltiazem
inj 50/10ml
1
diltiazem
tab 120mg
1
diltiazem
tab 30mg
1
diltiazem
tab 60mg
1
diltiazem
tab 90mg
1
diltiazem er tab 180mg
1
1
1
1
1
diltzac
cap 120mg/24
1
diltzac
cap 180mg/24
1
diltzac
cap 240mg/24
1
diltzac
cap 300mg/24
1
diltzac
cap 360mg/24
1
DYNACIRC CR TAB 10MG
3
DYNACIRC CR TAB 5MG
3
felodipine tab 10mg er
1
REQUIREMENTS/LIMITS
212
DRUG NAME
DRUG
TIER
felodipine tab 2.5mg er
1
felodipine tab 5mg er
1
ISOPTIN SR TAB 120MG
3
3
3
isradipine cap 2.5mg
1
isradipine cap 5mg
1
matzim la
tab 180mg/24
1
matzim la
tab 240mg/24
1
matzim la
tab 300mg/24
1
matzim la
tab 360mg/24
1
matzim la
tab 420mg/24
1
nicardipine cap 20mg
1
nicardipine cap 30mg
1
nicardipine inj 2.5mg/ml
1
nicardipine inj 25/10ml
1
nifediac cc tab 30mg er
1
1
1
nifedical xl tab 30mg
1
nifedical xl tab 60mg
1
nifedipine cap 10mg
1
nifedipine cap 20mg
1
REQUIREMENTS/LIMITS
213
DRUG NAME
DRUG
TIER
nifedipine tab 30mg er
1
1
1
nimodipine cap 30mg
1
nisoldipine tab 17mg er
1
nisoldipine tab 20mg
1
nisoldipine tab 25.5mg
1
1
nisoldipine tab 34mg er
1
1
nisoldipine tab 8.5mg er
1
NORVASC
TAB 10MG
3
NORVASC
TAB 2.5MG
3
NORVASC
TAB 5MG
3
NYMALIZE
SOL 60/20ML
3
CAP 10MG
3
PROCARDIA
PROCARDIA XL TAB 30MG CR
3
3
3
SULAR
TAB 17MG
3
SULAR
TAB 34MG
3
SULAR
TAB 8.5MG
3
taztia xt
cap 120mg/24
REQUIREMENTS/LIMITS
1
214
DRUG NAME
DRUG
TIER
taztia xt
cap 180mg/24
1
taztia xt
cap 240mg/24
1
taztia xt
cap 300mg/24
1
taztia xt
cap 360mg/24
1
TIAZAC
CAP 120MG/24
3
TIAZAC
CAP 180MG/24
3
TIAZAC
CAP 240MG/24
3
TIAZAC
CAP 300MG/24
3
TIAZAC
CAP 360MG/24
3
TIAZAC
CAP 420MG/24
3
verapamil
cap 100mg er
1
verapamil
cap 120mg er
1
verapamil
cap 120mg sr
1
verapamil
cap 180mg er
1
verapamil
cap 180mg sr
1
verapamil
cap 200mg er
1
verapamil
cap 240mg er
1
verapamil
cap 240mg sr
1
verapamil
cap 300mg er
1
verapamil
cap 360mg sr
1
verapamil
inj 2.5mg/ml
1
verapamil
tab 120mg
1
verapamil
tab 120mg er
1
REQUIREMENTS/LIMITS
215
DRUG NAME
DRUG
TIER
verapamil
tab 120mg sr
1
verapamil
tab 180mg er
1
verapamil
tab 180mg sr
1
verapamil
tab 240mg er
1
verapamil
tab 240mg sr
1
verapamil
tab 40mg
1
verapamil
tab 80mg
1
VERELAN
CAP 120MG SR
3
VERELAN
CAP 180MG
3
VERELAN
CAP 180MG SR
3
VERELAN
CAP 240MG SR
3
VERELAN
CAP 360MG SR
3
VERELAN PM CAP 100MG
3
VERELAN PM CAP 100MG ER
3
3
3
3
3
REQUIREMENTS/LIMITS
*CARDIOTONICS*
*CARDIAC GLYCOSIDES***
digitek
tab 0.125mg
1
digitek
tab 0.25mg
1
digox
tab 0.125mg
1
216
DRUG NAME
DRUG
TIER
digox
tab 0.25mg
1
digoxin
inj 0.25mg/1
1
digoxin
sol 50mcg/ml
1
digoxin
tab 0.125mg
1
digoxin
tab 0.25mg
1
LANOXIN
INJ 0.25MG/1
3
LANOXIN
TAB 0.0625MG
3
LANOXIN
TAB 0.125MG
3
LANOXIN
TAB 0.1875MG
3
lanoxin
tab 0.25mg
1
LANOXIN PED INJ 0.1MG/ML
3
REQUIREMENTS/LIMITS
*PHOSPHODIESTERASE INHIBITORS***
milrinone inj 10/10ml
1
milrinone inj 1mg/ml
1
1
1
milrinone/d5 inj 20/100ml
1
milrinone/d5 inj 40/200ml
1
*CARDIOVASCULAR AGENTS - MISC.*
*CALCIUM CHANNEL BLOCKER & HMG COA REDUCTASE INHIBIT COMB***
amlod/atorva tab 10-10mg
1
1
1
217
DRUG NAME
DRUG
TIER
1
amlod/atorva tab 2.5-10mg
1
1
1
1
1
1
1
CADUET
TAB 10-10MG
3
CADUET
TAB 10-20MG
3
CADUET
TAB 10-40MG
3
CADUET
TAB 10-80MG
3
CADUET
TAB 2.5-10MG
3
CADUET
TAB 2.5-20MG
3
CADUET
TAB 2.5-40MG
3
CADUET
TAB 5-10MG
3
CADUET
TAB 5-20MG
3
CADUET
TAB 5-40MG
3
CADUET
TAB 5-80MG
3
REQUIREMENTS/LIMITS
*CARDIOPLEGIC SOLUTIONS***
cardioplegic sol
1
PLEGISOL
3
SOL
*CARDIOVASCULAR AGENTS - MISC.*
218
DRUG NAME
DRUG
TIER
ENTRESTO
TAB 24-26MG
3
ENTRESTO
TAB 49-51MG
3
ENTRESTO
TAB 97-103MG
3
REQUIREMENTS/LIMITS
*MISCELLANEOUS ANTIANGINAL AGENTS**
CORLANOR
TAB 5MG
3
CORLANOR
TAB 7.5MG
3
*NITRATE & VASODILATOR COMBINATIONS***
BIDIL
TAB
3
*PERIPHERAL VASODILATORS***
isoxsuprine tab 10mg
1
ISOXSUPRINE TAB HCL 20MG
3
papaverine inj 30mg/ml
1
papaverine sol 30mg/ml
1
PARA-TIME
3
CAP 150MG ER
*PROSTAGLANDIN - IMPOTENCE AGENTS***
CAVERJECT INJ 20MCG
3
QL (X)
CAVERJECT INJ 40MCG
3
QL (X)
CAVERJECT KIT 10MCG
3
QL (X)
CAVERJECT KIT 20MCG
3
QL (X)
EDEX
KIT 10MCG
3
QL (X)
EDEX
KIT 20MCG
3
QL (X)
EDEX
KIT 40MCG
3
QL (X)
MUSE
SUP 1000MCG
3
QL (X)
219
DRUG NAME
DRUG
TIER
REQUIREMENTS/LIMITS
MUSE
SUP 125MCG
3
QL (X)
MUSE
SUP 250MCG
3
QL (X)
MUSE
SUP 500MCG
3
QL (X)
epoprostenol inj 0.5mg
4
PA
epoprostenol inj 1.5mg
4
PA
FLOLAN
INJ 0.5MG
4
PA
FLOLAN
INJ 1.5MG
4
PA
*PROSTAGLANDIN VASODILATORS***
ORENITRAM
TAB 0.125MG
3
ORENITRAM
TAB 0.25MG
3
ORENITRAM
TAB 1MG
3
ORENITRAM
TAB 2.5MG
3
REMODULIN
INJ 10MG/ML
4
PA
REMODULIN
INJ 1MG/ML
4
PA
REMODULIN
INJ 2.5MG/ML
4
PA
REMODULIN
INJ 5MG/ML
4
PA
SOL 0.6MG/ML
4
PA
TYVASO REFIL SOL 0.6MG/ML
4
PA
TYVASO START SOL 0.6MG/ML
4
PA
VELETRI
INJ 0.5MG
4
PA
VELETRI
INJ 1.5MG
4
PA
TYVASO
VENTAVIS
SOL 10MCG/ML
4
PA
VENTAVIS
SOL 20MCG/ML
4
PA
220
DRUG NAME
DRUG
TIER
REQUIREMENTS/LIMITS
*PULM HYPERTEN-SOLUBLE GUANYLATE CYCLASE STIMULATOR (SGC)***
ADEMPAS
TAB 0.5MG
4
PA
ADEMPAS
TAB 1.5MG
4
PA
ADEMPAS
TAB 1MG
4
PA
ADEMPAS
TAB 2.5MG
4
PA
ADEMPAS
TAB 2MG
4
PA
*PULMONARY HYPERTENSION - ENDOTHELIN RECEPTOR ANTAGONISTS***
LETAIRIS
TAB 10MG
4
PA
LETAIRIS
TAB 5MG
4
PA
OPSUMIT
TAB 10MG
4
PA
TRACLEER
TAB 125MG
4
PA
TRACLEER
TAB 62.5MG
4
PA
*PULMONARY HYPERTENSION - PHOSPHODIESTERASE INHIBITORS***
ADCIRCA
TAB 20MG
4
PA
REVATIO
INJ
4
PA
REVATIO
SUS 10MG/ML
3
REVATIO
TAB 20MG
4
PA, QL (X)
sildenafil inj
4
PA
sildenafil tab 20mg
4
PA, QL (X)
*SELECTIVE CGMP PHOSPHODIESTERASE TYPE 5 INHIBITORS***
CIALIS
TAB 10MG
3
PA, QL (X)
CIALIS
TAB 2.5MG
3
PA, QL (X)
CIALIS
TAB 20MG
3
PA, QL (X)
221
DRUG NAME
CIALIS
DRUG
TIER
TAB 5MG
REQUIREMENTS/LIMITS
3
PA, QL (X)
LEVITRA
TAB 10MG
2
QL (X)
LEVITRA
TAB 2.5MG
2
QL (X)
LEVITRA
TAB 20MG
2
QL (X)
LEVITRA
TAB 5MG
2
QL (X)
STAXYN
TAB 10MG
3
ST, QL (X)
STENDRA
TAB 100MG
3
ST, QL (X)
STENDRA
TAB 200MG
3
ST, QL (X)
STENDRA
TAB 50MG
3
ST, QL (X)
VIAGRA
TAB 100MG
2
QL (X)
VIAGRA
TAB 25MG
2
QL (X)
VIAGRA
TAB 50MG
2
QL (X)
*VASOACTIVE NATRIURETIC PEPTIDES***
NATRECOR
INJ 1.5MG
3
*YOHIMBINE***
yohimbine
tab 5.4mg
1
*CEPHALOSPORINS*
*CEPHALOSPORIN COMBINATIONS***
AVYCAZ
INJ 2-0.5GM
3
ZERBAXA
INJ 1-0.5 GM
3
*CEPHALOSPORINS - 1ST GENERATION***
cefadroxil cap 500mg
1
cefadroxil sus 250/5ml
1
222
DRUG NAME
DRUG
TIER
cefadroxil sus 500/5ml
1
cefadroxil tab 1gm
1
cefazol/dex sol 1gm
1
CEFAZOL/DEX SOL 2GM
3
CEFAZOLIN
3
INJ 100GM
cefazolin
inj 10gm
1
cefazolin
inj 1gm
1
cefazolin
inj 1gm/50ml
1
cefazolin
inj 20gm
1
CEFAZOLIN
cefazolin
INJ 300GM
inj 500mg
CEFAZOLIN
SOL
REQUIREMENTS/LIMITS
3
1
3
cephalexin cap 250mg
1
1
1
cephalexin sus 125/5ml
1
cephalexin sus 250/5ml
1
cephalexin tab 250mg
1
cephalexin tab 500mg
1
KEFLEX
CAP 250MG
3
KEFLEX
CAP 500MG
3
KEFLEX
CAP 750MG
3
*CEPHALOSPORINS - 2ND GENERATION***
223
DRUG NAME
DRUG
TIER
cefaclor
cap 250mg
1
cefaclor
cap 500mg
1
CEFACLOR
SUS 125/5ML
3
CEFACLOR
SUS 250/5ML
3
CEFACLOR
SUS 375/5ML
3
cefaclor er tab 500mg
1
CEFOTET/DEX INJ 1-3.58%
3
CEFOTET/DEX INJ 2-2.08%
3
CEFOTETAN
INJ 10G
3
cefotetan
inj 1gm/10ml
1
cefotetan
inj 2gm/20ml
1
cefoxitin
inj 10gm
1
cefoxitin
inj 1gm
1
cefoxitin
inj 2gm
1
cefprozil
sus 125/5ml
1
cefprozil
sus 250/5ml
1
cefprozil
tab 250mg
1
cefprozil
tab 500mg
1
CEFTIN
SUS 125/5ML
3
CEFTIN
SUS 250/5ML
3
CEFTIN
TAB 250MG
3
CEFTIN
TAB 500MG
3
cefurox/dext inj 1.5gm
REQUIREMENTS/LIMITS
1
224
DRUG NAME
DRUG
TIER
cefurox/dext inj 750mg
1
cefuroxime inj 1.5gm
1
CEFUROXIME INJ 225GM
3
cefuroxime inj 7.5gm
1
cefuroxime inj 750mg
1
CEFUROXIME INJ 75GM
3
cefuroxime sus 125/5ml
1
cefuroxime tab 250mg
1
cefuroxime tab 500mg
1
MEFOXIN
INJ 1GM/50ML
3
MEFOXIN
INJ 2GM/50ML
3
ZINACEF
INJ 1.5GM
3
ZINACEF
INJ 7.5GM
3
ZINACEF
INJ 750MG
3
ZINACEF/D5W INJ 750MG PB
3
ZINACEF/H20 INJ 1.5GM PB
3
REQUIREMENTS/LIMITS
*CEPHALOSPORINS - 3RD GENERATION***
CEDAX
CAP 400MG
3
CEDAX
SUS 180/5ML
3
CEDAX
SUS 90MG/5ML
3
cefdinir
cap 300mg
1
cefdinir
sus 125/5ml
1
cefdinir
sus 250/5ml
1
225
DRUG NAME
DRUG
TIER
CEFDITOREN TAB 200MG
3
CEFDITOREN TAB 400MG
3
cefixime
sus 100/5ml
1
cefixime
sus 200/5ml
1
cefotaxime inj 10gm
1
cefotaxime inj 1gm
1
cefotaxime inj 2gm
1
cefotaxime inj 500mg
1
cefpodo prox sus 100/5ml
1
cefpodo prox sus 50mg/5ml
1
cefpodoxime tab 100mg
1
cefpodoxime tab 200mg
1
CEFTAZIDIME INJ 100GM
3
ceftazidime inj 1gm
1
ceftazidime inj 2gm
1
ceftazidime inj 500mg
1
ceftazidime inj 6gm
1
CEFTAZIDIME/ SOL D5W 1GM
3
CEFTAZIDIME/ SOL D5W 2GM
3
ceftibuten cap 400mg
1
ceftibuten sus 180/5ml
1
ceftriax/dex inj 1gm
1
ceftriax/dex inj 2gm
1
REQUIREMENTS/LIMITS
226
DRUG NAME
DRUG
TIER
CEFTRIAXONE INJ 100GM
3
ceftriaxone inj 10gm
1
ceftriaxone inj 1gm
1
ceftriaxone inj 250mg
1
ceftriaxone inj 2gm
1
ceftriaxone inj 500mg
1
CEFTRIAXONE/ INJ DEX 1GM
3
CEFTRIAXONE/ INJ DEX 2GM
3
CLAFORAN
INJ 10GM
3
CLAFORAN
INJ 1GM
3
CLAFORAN
INJ 2GM
3
CLAFORAN
INJ 500MG
3
CLAFORAN/D5W INJ 1GM
3
CLAFORAN/D5W INJ 2GM
3
FORTAZ
INJ 1GM
3
FORTAZ
INJ 2GM
3
FORTAZ
INJ 500MG
3
FORTAZ
INJ 6GM
3
ROCEPHIN
INJ 1GM
3
ROCEPHIN
INJ 500MG
3
SPECTRACEF TAB 200MG
3
SPECTRACEF TAB 400MG
3
SUPRAX
3
CAP 400MG
REQUIREMENTS/LIMITS
227
DRUG NAME
DRUG
TIER
SUPRAX
CHW 100MG
3
SUPRAX
CHW 200MG
3
SUPRAX
SUS 100/5ML
3
SUPRAX
SUS 200/5ML
3
SUPRAX
SUS 500/5ML
3
SUPRAX
TAB 400MG
3
tazicef
inj 1gm
TAZICEF
REQUIREMENTS/LIMITS
1
INJ 1GM/50ML
3
tazicef
inj 2gm
1
tazicef
inj 6gm
1
*CEPHALOSPORINS - 4TH GENERATION***
cefepime
inj 1gm
1
cefepime
inj 2gm
1
MAXIPIME
INJ 1GM
3
MAXIPIME
INJ 2GM
3
*CEPHALOSPORINS - 5TH GENERATION***
TEFLARO
INJ 400MG
3
TEFLARO
INJ 600MG
3
*CONTRACEPTIVES*
*BIPHASIC CONTRACEPTIVES - ORAL***
azurette
tab 28 day
1
kariva
tab 28 day
1
kimidess
tab
1
228
DRUG NAME
DRUG
TIER
LO LOESTRIN TAB
3
LO MINASTRIN PAK FE
3
MIRCETTE
3
TAB 28 DAY
necon
tab 10/11-28
1
pimtrea
tab
1
viorele
tab
REQUIREMENTS/LIMITS
1
*COMBINATION CONTRACEPTIVES - ORAL***
altavera
tab
1
alyacen
tab 1/35
1
apri
tab
1
aubra
tab 0.1-0.02
1
aviane
tab
1
balziva
tab
1
BEYAZ
TAB
BREVICON
TAB 0.5/35
2
3
briellyn
tab
1
chateal
tab 0.15/30
1
cryselle-28 tab 28 tabs
1
cyclafem
1
tab 1/35
cyred
tab
1
dasetta
tab 1/35
1
delyla
tab 0.1-0.02
1
deso/ethinyl tab estradio
1
229
DRUG NAME
DRUG
TIER
DESOGEN-28 TAB
3
elinest
1
tab
emoquette
tab
1
enskyce
tab
1
estarylla
tab 0.25-35
1
KIT
3
FALESSA
falmina
tab
FEMCON FE
REQUIREMENTS/LIMITS
1
CHW
3
GENERESS FE CHW
3
gildagia
1
tab 0.4-35
gildess
tab 1.5/30
1
gildess
tab 1/20
1
gildess 24 tab fe 1/20
1
gildess fe tab 1.5/30
1
gildess fe tab 1/20
1
juleber
1
tab
junel 1.5/30 tab
1
junel 1/20 tab
1
junel fe
tab 1.5/30
1
junel fe
tab 1/20
1
junel fe 24 tab 1/20
1
kelnor
tab 1/35
1
kurvelo
tab 0.15/30
1
230
DRUG NAME
DRUG
TIER
larin
tab 1.5/30
1
larin
tab 1/20
1
larin 24
tab fe 1/20
1
larin fe
tab 1.5/30
1
larin fe
tab 1/20
1
layolis fe chw
1
lessina
tab
1
levonor/ethi tab 0.1-0.02
1
levonor/ethi tab estradio
1
levora-28
1
tab 0.15/30
LO/OVRAL-28 TAB
3
LOESTRIN
TAB 1/20-21
3
LOESTRIN 21 TAB 1.5/30
3
LOESTRIN 24 TAB FE
3
LOESTRIN FE TAB 1.5/30
3
LOESTRIN FE TAB 1/20
3
lomedia 24 tab fe
1
low-ogestrel tab
5
lutera
5
marlissa
tab
tab 0.15/30
1
micrgstin 24 tab fe 1/20
1
microgestin tab 1.5/30
5
microgestin tab 1/20
5
REQUIREMENTS/LIMITS
231
DRUG NAME
DRUG
TIER
microgestin tab fe 1/20
5
microgestin tab fe1.5/30
5
MINASTRIN 24 CHW FE
3
MODICON
3
TAB 0.5/35
mono-linyah tab 0.25-35
1
mononessa
5
tab
necon
tab 0.5/35
1
necon
tab 1/35
1
NECON
TAB 1/50-28
REQUIREMENTS/LIMITS
3
NORDETTE-28 TAB
3
noreth/ethin chw fe
1
noreth/ethin tab 1/20
1
noreth/ethin tab fe 1/20
1
norgest/eth tab estrad
1
norgest/ethi tab 0.25/35
1
NORINYL
TAB 1+50-28
3
NORINYL
TAB 1/35
3
nortrel
tab 0.5/35
1
nortrel
tab 1/35
1
ogestrel
tab
1
orsythia
tab
1
ORTHO-CEPT TAB 28
3
ORTHO-CYCLEN TAB 0.25/35
3
232
DRUG NAME
DRUG
TIER
ORTHO-NOVUM TAB 1/35
3
OVCON 50
TAB 28
3
OVCON-35
TAB
3
tab 0.4-35
1
pirmella
tab 1/35
1
portia-28
tab
1
previfem
tab
1
reclipsen
tab
1
philith
SAFYRAL
solia
TAB
2
tab
1
sprintec 28 tab 28 day
5
sronyx
5
tab
tarina fe tab 1/20
1
vyfemla
1
wera
wymzya fe
zenchent
tab 0.4-35
tab 0.5/35
chw 0.4mg-35
1
1
tab
1
zenchent fe chw 0.4mg-35
1
zeosa
1
chw
REQUIREMENTS/LIMITS
zovia 1/35e tab
1
ZOVIA 1/50E TAB
3
*COMBINATION CONTRACEPTIVES - TRANSDERMAL***
ORTHO EVRA DIS WEEK
3
233
DRUG NAME
DRUG
TIER
XULANE DIS 150-35
REQUIREMENTS/LIMITS
5
*COMBINATION CONTRACEPTIVES - VAGINAL***
NUVARING
MIS
5
*CONTINUOUS CONTRACEPTIVES - ORAL***
amethyst
tab 90-20mcg
1
levo-eth est tab 90-20mcg
1
LYBREL
3
TAB 90-20MCG
*COPPER CONTRACEPTIVES - IUD***
PARAGARD
IUD T380A
5
*EMERGENCY CONTRACEPTIVES***
aftera
tab 1.5mg
5
econtra ez tab 1.5mg
5
ELLA
3
fallback
TAB 30MG
tab 1.5mg
5
LEVONORGESTR TAB 0.75MG
3
levonorgestr tab 1.5mg
5
my way
5
tab 1.5mg
next choice tab 0.75mg
1
next choice tab 1.5mg
5
opcicon
5
tab 1.5mg
PLAN B
TAB 0.75MG
3
PLAN B
TAB 1.5MG
3
take action tab 1.5mg
5
*EXTENDED-CYCLE CONTRACEPTIVES - ORAL***
234
DRUG NAME
amethia
DRUG
TIER
tab
1
amethia lo tab
1
ashlyna
tab
1
camrese
tab
1
camrese lo tab
1
daysee
tab
1
introvale
tab
1
jolessa
tab
1
LOSEASONIQUE TAB
3
QUARTETTE
3
quasense
TAB
tab
SEASONALE
REQUIREMENTS/LIMITS
1
TAB
3
SEASONIQUE TAB
3
setlakin
1
tab
*FOUR PHASE CONTRACEPTIVES - ORAL***
NATAZIA
TAB
5
*PROGESTIN CONTRACEPTIVES - INJECTABLE***
DEPO-PROVERA INJ 150MG/ML
3
DEPO-SQ PROV INJ 104
3
medroxypr ac inj 150mg/ml
5
*PROGESTIN CONTRACEPTIVES - ORAL***
camila
tab 0.35mg
5
deblitane
tab 0.35mg
5
235
DRUG NAME
errin
DRUG
TIER
tab 0.35mg
5
heather
tab 0.35mg
5
jencycla
tab 0.35mg
5
jolivette
lyza
tab 0.35mg
tab 0.35mg
NOR-QD
nora-be
TAB 0.35MG
tab 0.35mg
5
5
5
5
norethindron tab 0.35mg
5
norlyroc
tab 0.35mg
5
ORTHO MICRON TAB 0.35MG
5
sharobel
5
tab 0.35mg
REQUIREMENTS/LIMITS
*TRIPHASIC CONTRACEPTIVES - ORAL***
alyacen
tab 7/7/7
1
aranelle
tab
1
caziant
pak
5
cesia
cyclafem
pak
tab 7/7/7
CYCLESSA
dasetta
1
PAK
tab 7/7/7
1
3
1
enpresse-28 tab
1
ESTROSTEP FE TAB
3
leena
1
levonest
tab
tab
1
236
DRUG NAME
DRUG
TIER
myzilra
tab
1
necon
tab 7/7/7
1
norgest/ethi tab estradio
1
nortrel
tab 7/7/7
1
ORTHO TRI- TAB CYCLEN
3
ORTHO TRI- TAB CYCLN LO
3
ORTHO-NOVUM TAB 7/7/7
3
pirmella
1
tilia fe
tab 7/7/7
tab
1
tri-estaryll tab
1
tri-legest tab fe
1
tri-linyah tab
1
TRI-NORINYL TAB 28
3
tri-previfem tab
1
tri-sprintec tab
5
trinessa
5
tab
trivora-28 tab
1
velivet
1
pak
REQUIREMENTS/LIMITS
*CORTICOSTEROIDS*
*GLUCOCORTICOSTEROIDS***
A-HYDROCORT INJ 100MG
4
a-methapred inj 125mg
1
a-methapred inj 40mg
1
PA
237
DRUG NAME
DRUG
TIER
ARISTOSPAN INJ 20MG/ML
3
ARISTOSPAN INJ 5MG/ML
3
asmalpred
sol 15mg/5ml
1
asmalpred
sol plus
1
baycadron
elx 0.5/5ml
1
BETAMETH SP INJ 24MG/2ML
3
budesonide cap 3mg/24hr
1
CELESTONE
3
SOL 0.6MG/5
CORTEF
TAB 10MG
3
CORTEF
TAB 20MG
3
CORTEF
TAB 5MG
3
cortisone ac tab 25mg
1
deltasone
tab 20mg
1
DEPO-MEDROL INJ 20MG/ML
3
3
3
DEX LA 16
INJ 16MG/ML
3
DEX LA 8
INJ 8MG/ML
3
dexameth pho inj 10mg/ml
1
dexameth pho inj 120mg/30
1
dexameth pho inj 20mg/5ml
1
dexameth pho inj 4mg/ml
1
dexamethason con 1mg/ml
1
REQUIREMENTS/LIMITS
238
DRUG NAME
DRUG
TIER
dexamethason elx 0.5/5ml
1
dexamethason sol 0.5/5ml
1
dexamethason tab 0.5mg
1
1
1
dexamethason tab 1mg
1
1
1
1
DEXPAK
PAK 10 DAY
3
DEXPAK
PAK 13 DAY
3
DEXPAK
PAK 6 DAY
3
DOUBLEDEX
KIT
REQUIREMENTS/LIMITS
3
ENTOCORT EC CAP 3MG/24HR
3
FLO-PRED
SUS
3
hydrocort
tab 10mg
1
hydrocort
tab 20mg
1
hydrocort
tab 5mg
1
KENALOG-10 INJ 10MG/ML
3
KENALOG-40 INJ 40MG/ML
3
MEDROL
PAK 4MG
3
MEDROL
TAB 16MG
3
MEDROL
TAB 2MG
2
239
DRUG NAME
DRUG
TIER
MEDROL
TAB 32MG
3
MEDROL
TAB 4MG
3
MEDROL
TAB 8MG
3
methylpr ace inj 40mg/ml
1
methylpr ace inj 80mg/ml
1
methylpr ss inj 1000mg
1
1
methylpr ss inj 1gm
1
1
1
METHYLPRD PF INJ 160/2ML
3
METHYLPRD PF INJ 40MG/ML
3
METHYLPRD PF INJ 80MG/ML
3
methylpred pak 4mg
1
methylpred tab 16mg
1
methylpred tab 32mg
1
methylpred tab 4mg
1
methylpred tab 8mg
1
METHYLPREDNI INJ 100MG/ML
3
MILLIPRED
SOL 10MG/5ML
3
MILLIPRED
TAB 5MG
3
MILLIPRED DP PAK 5MG
3
ORAPRED
3
SOL 15MG/5ML
REQUIREMENTS/LIMITS
240
DRUG NAME
DRUG
TIER
ORAPRED ODT TAB 10MG
3
3
3
PEDIAPRED
3
SOL 6.7/5ML
pred sod pho sol 5mg/5ml
1
pred sod pho sol 6.7/5ml
1
prednisolone sol 15mg/5ml
1
prednisolone sol 25mg/5ml
1
prednisolone syp 15mg/5ml
1
prednisolone tab 10mg odt
1
1
1
prednisone con 5mg/ml
1
prednisone pak 10mg
1
prednisone pak 5mg
1
prednisone sol 5mg/5ml
1
prednisone tab 10mg
1
prednisone tab 1mg
1
prednisone tab 2.5mg
1
prednisone tab 20mg
1
prednisone tab 50mg
1
prednisone tab 5mg
1
PRELONE
3
SYP 15MG/5ML
REQUIREMENTS/LIMITS
241
DRUG NAME
DRUG
TIER
PRO-C-DURE 5 KIT 40MG/ML
3
PRO-C-DURE 6 KIT 40MG/ML
3
RAYOS
TAB 1MG
3
RAYOS
TAB 2MG
3
RAYOS
TAB 5MG
3
SOLU-CORTEF INJ 1000MG
3
4
3
4
SOLU-MEDROL INJ 125MG
3
SOLU-MEDROL INJ 1GM
3
SOLU-MEDROL INJ 2GM
3
3
3
triamcin ace inj 10mg/ml
1
TRIAMCINOLON INJ 40MG/ML
3
3
TRIAMCINOLON INJ 80MG/2ML
3
3
UCERIS
3
TAB 9MG
VERIPRED 20 SOL 20MG/5ML
REQUIREMENTS/LIMITS
PA
PA
PA
3
*MINERALOCORTICOIDS***
fludrocort tab 0.1mg
1
242
DRUG NAME
DRUG
TIER
REQUIREMENTS/LIMITS
*STEROID COMBINATIONS***
BETA 1 KIT KIT 30MG/5ML
3
BETA INJECT KIT
3
beta-phos/ac inj 3-3mg/ml
1
BETALIDO
KIT
3
BETAMETH COM INJ 7MG/ML
3
BETAMETH PF INJ 12MG/2ML
3
BT INJECTION KIT 40-0.5%
3
BUPIVILOG
3
KIT
CELESTONE
INJ SOLUSPAN
3
DEX COMBO
INJ 8-4MG/ML
3
DEXLIDO
KIT
3
DEXLIDO-M
KIT
3
DYURAL-40
KIT
3
DYURAL-80
KIT
3
DYURAL-L
KIT
3
DYURAL-LM
KIT
3
INTERARTICUL KIT JOINT
3
JNT/TUNNEL/ KIT TRIGGER
3
K10-LIDO
KIT
3
K40-LIDO
KIT
3
LIDOLOG
KIT
3
LT INJECTION KIT
3
243
DRUG NAME
DRUG
TIER
MARBETA-25 KIT
3
MARBETA-L
KIT
3
MARDEX-25
KIT
3
METHYLP/LIDO INJ 40-10/ML
3
METHYLP/LIDO INJ 80-10/ML
3
MLK F1
KIT
3
MLK F2
KIT
3
MLK F3
KIT
3
MLK F4
KIT
3
MULTI-
KIT SPECIALT
3
PHYS EZ USE KIT M-PRED
3
PRO-C-DURE 1 KIT
3
PRO-C-DURE 2 KIT
3
PRO-C-DURE 3 KIT
3
PRO-C-DURE 4 KIT
3
TRIAMCN/LIDO INJ 40MG-1%
3
REQUIREMENTS/LIMITS
*COUGH/COLD/ALLERGY*
*ANTITUSSIVE - NONNARCOTIC***
benzonatate cap 100mg
1
1
1
TESSALON
3
CAP 200MG
TESSALON PER CAP 100MG
3
244
DRUG NAME
ZONATUSS
DRUG
TIER
CAP 150MG
REQUIREMENTS/LIMITS
3
*ANTITUSSIVE - OPIOID***
hydroc/homat tab 5-1.5mg
1
hydrocod/hom syp 5-1.5/5
1
hydromet
syp 5-1.5/5
1
tussigon
tab 5-1.5mg
1
*ANTITUSSIVE-ANTIHISTAMINE-ANALGESIC***
COTABFLU
TAB 20-4-500
3
*ANTITUSSIVE-EXPECTORANT - DECONGEST-ANALGESIC***
MAXIFLU CD TAB
3
MAXIFLU CDX TAB
3
PHENFLU CD TAB
3
PHENFLU CDX TAB
3
*ANTITUSSIVE-EXPECTORANT - DECONGEST-ANTIHIST***
ALBATUSSIN LIQ NN
3
BRONCOPECTOL SYP
3
LARTUS
3
LIQ
pediahist dm syp
1
*ANTITUSSIVE-EXPECTORANT***
ALLFEN CD
TAB 400-10MG
3
ALLFEN CDX LIQ
3
ALLFEN CDX TAB 400-20MG
3
CGU WC
LIQ 100-6.3
3
codeine/guai liq 10-300mg
1
245
DRUG NAME
DRUG
TIER
FLOWTUSS
SOL 2.5-200
3
J-MAX DHC
LIQ 7.5-100
3
nortuss-ex liq 200-20/5
1
OBREDON
3
SOL 2.5-200
PROLEX DMX LIQ
REQUIREMENTS/LIMITS
3
*ANTITUSSIVE-EXPECTORANTS-ANTIHISTAMINE***
TUSNEL
CAP
3
*ANTITUSSIVE-EXPECTORANTS-DECONGESTANT***
ALBATUSSIN CAP
3
AMBIFED CD TAB
3
AMBIFED CDX TAB
3
AMBIFED-G
3
TAB CDX
AMBIFED-G CD TAB
3
biotuss
liq
1
biotuss
liq pediatrc
1
DESPEC-EXP SYP
3
DONATUSS DC SYP
3
EXACTUSS
3
LIQ
GILTUSS
LIQ
3
GILTUSS
LIQ PED-C
3
giltuss ped liq
1
GILTUSS TR CAP 7-14-288
3
GILTUSS TR TAB
3
246
DRUG NAME
DRUG
TIER
HYCOFENIX
SOL
3
MAXIFED CD TAB
3
MAXIFED CDX TAB
3
MAXIFED-G
3
TAB CDX
MAXIFED-G CD TAB
3
MAXIPHEN CD TAB
3
MAXIPHEN CDX TAB
3
nortuss-de dro
1
POLY-TUSSIN SYP EX
3
SUTTAR-2
3
SYP
SUTTAR-SF
tgq 30/
SYP
syp 150/15
REQUIREMENTS/LIMITS
3
1
TUSNEL PED-C SYP
3
tussafed ex liq
1
*DECONGESTANT & ANTIHISTAMINE***
BROVEX PD
SUS
3
BROVEX SR
CAP 9-90MG
3
CLARINEX-D TAB 2.5-120
3
CLARINEX-D TAB 5-240MG
3
DECON-A
3
entre-b
ELX 2-5MG/5M
sus 6-10mg/5
1
PEDIATEX TD LIQ
3
PROHIST LQ LIQ
3
247
DRUG NAME
DRUG
TIER
prometh vc syp 6.25-5/5
1
prometh vc syp plain
1
prometh/pe syp 6.25-5/5
1
RELHIST
3
CHW
RESCON-JR
TAB
REQUIREMENTS/LIMITS
3
RESCON-MX
TAB
3
SEMPREX-D
CAP 8-60MG
3
*DECONGESTANT W/ EXPECTORANT***
gg/pe
syp 200-5mg
1
GILPHEX TR TAB 10-388MG
3
pe/guaifenes dro 1.5-20mg
1
*DECONGESTANT-ANTIHISTAMINE W/ EXPECTORANT***
DECON-G
DRO 2-1-40MG
3
LEMOHIST
CAP PLUS
3
*DECONGESTANT-ANTIHISTAMINE-ANALGESIC***
PROTID
TAB CR
3
*DECONGESTANT-ANTIHISTAMINE-ANTICHOLINERGIC***
norel sd
syp
1
qv-allergy syp
RELCOF DN
1
MIS PSE
3
RELCOF DN PE MIS
3
RELCOF PE
3
RESCON
TAB
TAB
3
*MISC. RESPIRATORY INHALANTS***
248
DRUG NAME
DRUG
TIER
HYPER-SAL NEB 7%
3
HYPERSAL
NEB 3.5%
3
HYPERSAL
NEB 7%
3
nebusal
neb 3%
NEBUSAL
NEB 6%
pulmosal
neb 7%
REQUIREMENTS/LIMITS
1
3
1
sodium chlor neb 10%
1
sodium chlor neb 3%
1
sodium chlor neb 7%
1
*MUCOLYTICS***
acetylcyst sol 10%
1
acetylcyst sol 20%
1
*NON-NARC ANTITUSSIVE-ANTIHISTAMINE***
PROHIST CF LIQ
3
promethazine syp dm
1
*NON-NARC ANTITUSSIVE-DECONGESTANT-ANTIHISTAMINE***
ATUSS DS
SUS
3
bromfed dm syp
1
CARBAPHEN 12 LIQ
3
CARBAPHEN 12 SUS PED
3
dm/cpm/pe
1
hdc dm
dro
syp
NEOTUSS PLUS LIQ
1
3
249
DRUG NAME
DRUG
TIER
PEDIATEX TDM SUS
3
PEDIATEX-JR SUS DM
3
POLY HIST DM LIQ
3
PROHIST CD LIQ
3
TGQ 15DM/5PE SYP H/2CPM
3
tgq 30/pse/3 syp brm/15dm
1
TGQ 50PSE/3 SYP BRM/30DM
3
trexbrom
1
liq
REQUIREMENTS/LIMITS
*OPIOID ANTITUSSIVE-ANTIHISTAMINE***
BROVEX CB
TAB 10-4MG
3
BROVEX CBX TAB 20-4MG
3
CODAR AR
3
COTAB A
LIQ 2-8/5ML
TAB 4-10MG
COTAB AX
TAB 4-20MG
3
3
hyd pol/cpm liq 10-8/5ml
1
LEXUSS 210 LIQ 2-10/5ML
3
prometh/cod syp 6.25-10
1
TUSSICAPS
CAP 10-8MG
3
TUSSICAPS
CAP 5-4MG
3
TUSSIONEX
SUS 10-8/5ML
3
TUZISTRA XR SUS
3
VITUZ
3
SOL 5-4MG
*OPIOID ANTITUSSIVE-DECONGESTANT***
250
DRUG NAME
DRUG
TIER
ALAHIST AC LIQ 7.5-10
3
ALAHIST DHC LIQ 7.5-3
3
REZIRA
3
SOL 60-5/5ML
REQUIREMENTS/LIMITS
*OPIOID ANTITUSSIVE-DECONGESTANT-ANTIHISTAMINE***
BROVEX PB C TAB 10-4-10
3
BROVEX PB CX TAB 10-4-20
3
CPB WC
3
LIQ
DESPEC-PDC LIQ
3
hydro/chlor/ liq 5-4-60mg
1
J-COF DHC
LIQ 15-3-7.5
3
POLY HIST
LIQ DHC
3
POLY HIST NC LIQ
3
POLY-TUSSIN LIQ DHC
3
prometh vc/ syp codeine
1
prometh/pe/ syp codeine
1
ZUTRIPRO
3
LIQ 60-4-5MG
*DERMATOLOGICALS*
*ACNE ANTIBIOTICS***
ACZONE
GEL 5%
3
AKNE-MYCIN OIN 2%
3
CLEOCIN-T
GEL 1%
3
CLEOCIN-T
LOT 1%
3
CLEOCIN-T
PAD 1%
3
251
DRUG NAME
CLEOCIN-T
clindacin
DRUG
TIER
SOL 1%
mis etz 1%
3
1
clindacin-p pad 1%
1
CLINDAGEL
3
GEL 1%
clindamax
gel 1%
1
clindamax
lot 10mg/ml
1
clindamycin aer 1%
1
clindamycin gel 1%
1
clindamycin lot 1%
1
clindamycin lot 10mg/ml
1
clindamycin pad 1%
1
clindamycin sol 1%
1
CLINDAREACH KIT 1%
3
ery
1
pad 2%
ERYGEL
GEL 2%
REQUIREMENTS/LIMITS
3
erythromycin gel 2%
1
erythromycin pad 2%
1
erythromycin sol 2%
1
EVOCLIN
AER 1%
3
KLARON
LOT 10%
3
sulfacetamid lot 10%
1
sulfacetamid sus 10%
1
*ACNE COMBINATIONS***
252
DRUG NAME
ACANYA
DRUG
TIER
GEL 1.2-2.5%
2
AVAR
AER 9.5-5%
3
AVAR
PAD 9.5-5%
3
avar cleanse emu 10-5%
1
AVAR LS
AER 10-2%
3
AVAR LS
LIQ 10-2%
3
AVAR LS
PAD 10-2%
3
avar-e emoll cre 10-5%
1
avar-e green cre 10-5%
1
AVAR-E LS
CRE 10-2%
3
BENZACLIN
GEL 1-5%
3
BENZACLIN
GEL 1-5%PUMP
3
BENZAMYCIN GEL
3
BENZAMYCIN GEL 5-3%
3
BENZAMYCIN GEL PAK
2
bp 10-1
1
emu
BP CLEANSING EMU 10-4%
3
cerisa wash emu 10-1%
1
CLARIFOAM EF AER 10-5%
3
claris wash emu 10-4%
1
clenia
cre 10-5%
1
clenia
emu foaming
1
kit etz 1%
1
clindacin
REQUIREMENTS/LIMITS
253
DRUG NAME
CLINDACIN
DRUG
TIER
KIT PAC 1%
3
clindamy/ben gel 1-5%
1
clindamy/ben gel 1.2-5%
1
CLINDAP-T
3
CLINOIN
CRE
CRE
DERMAPAK
DUAC
PAK PLUS
GEL 1.2-5%
EPIDUO
GEL 0.1-2.5%
3
3
3
3
EPIDUO FORTE GEL 0.3-2.5%
3
erythromycin gel /benzoyl
1
INOVA
KIT 4%
3
INOVA
KIT 8%
3
INOVA 4/1
KIT ACNE CON
3
INOVA 8/2
KIT ACNE CON
3
neuac
gel 1.2-5%
1
neuac
kit 1.2-5%
1
ONEXTON
REQUIREMENTS/LIMITS
GEL 1.2-3.75
2
PLEXION
CRE 9.8-4.8%
3
PLEXION
LIQ 9.8-4.8%
3
PLEXION
LOT 9.8-4.8%
3
PLEXION CLNS EMU 10-5%
3
PLEXION CLTH MIS 10-5%
3
PLEXION CLTH PAD 9.8-4.8%
3
254
DRUG NAME
DRUG
TIER
PLEXION SCT CRE 10-5%
3
prascion
1
emu
prascion fc pad 10-5%
1
PRASCION RA CRE 10-5%
3
rosanil
1
emu cleanser
ROSANIL
KIT
3
ROSULA
LIQ 10-4.5%
3
rosula
pad 10-5%
1
se 10-5 ss cre 10-5%
1
sod sul/sulf aer 10-5%
1
sod sul/sulf cre 10-2%
1
sod sul/sulf cre 10-5%
1
sod sul/sulf cre 9.8-4.8%
1
sod sul/sulf emu 10-5%
1
SOD SUL/SULF GEL 10-5%
3
sod sul/sulf kit
1
sod sul/sulf liq 10-2%
1
sod sul/sulf liq 9-4.5%
1
sod sul/sulf liq 9.8-4.8%
1
sod sul/sulf liq wash
1
sod sul/sulf lot 10-5%
1
sod sul/sulf lot 9.8-4.8%
1
sod sul/sulf pad 10-4%
1
REQUIREMENTS/LIMITS
255
DRUG NAME
DRUG
TIER
sod sul/sulf pad 10-5%
1
SOD SUL/SULF SUS 10-5%
3
sod sul/sulf sus 8-4%
1
ss 10-2
sol 10-2%
1
cre 10%-5%
1
sss
SSS 10-4
sss 10-5
AER 10-4%
aer 10-5%
3
1
sulf/sunscrn kit 9-4.5%
1
sulfacleanse sus 8-4%
1
SUMADAN
3
KIT
SUMADAN WASH LIQ 9-4.5%
3
SUMADAN XLT KIT 9-4.5%
3
SUMAXIN
3
PAD 10-4%
SUMAXIN CP KIT
3
SUMAXIN TS SUS 8-4%
3
SUMAXIN WASH LIQ 9-4%
3
suphera
cre 10-5%
1
CRE
3
TRISEON
VANOXIDE HC KIT
3
VANOXIDE-HC LOT 5-0.5%
3
VELTIN
3
GEL
REQUIREMENTS/LIMITS
virti-sulf cre 10-5%
1
ZACARE KIT KIT 4%
3
256
DRUG NAME
DRUG
TIER
ZACARE KIT KIT 8%
3
zencia
liq 9-4%
1
ZIANA
GEL
2
REQUIREMENTS/LIMITS
*ACNE PRODUCTS***
adapalene cre 0.1%
1
adapalene gel 0.1%
1
adapalene gel 0.3%
1
ADAPALENE
3
ATRALIN
LOT 0.1%
GEL 0.05%
3
avita
cre 0.025%
1
avita
gel 0.025%
1
AZELEX
CRE 20%
2
BENZAC AC
GEL 10%
3
BENZAC AC
GEL 5%
3
BENZAC AC
LIQ 10% WASH
3
BENZAC AC
LIQ 5% WASH
3
BENZAC W
LIQ 10% WASH
3
BENZAC W
LIQ 5% WASH
3
BENZEFOAM
AER 5.3%
3
BENZEFOAM
AER 9.8%
3
benzepro
aer 5.3%
1
benzepro
liq creamy
1
benzepro
mis 6%
1
257
DRUG NAME
DRUG
TIER
benzepro sc aer 9.8%
1
BENZIQ
3
GEL 5.25%
BENZIQ LS
GEL 2.75%
3
benziq wash liq 5.25%
1
benzoyl per aer 5.3%
1
benzoyl per aer 9.8%
1
benzoyl per liq 7% wash
1
benzoyl per lot 3%
1
benzoyl per lot 4%
1
benzoyl per lot 6%
1
benzoyl per lot 9%
1
benzoyl per pad 3%
1
benzoyl per pad 6%
1
benzoyl per pad 9%
1
benzoyl pero aer 9.8%
1
bp cleanser liq 4.25%
1
bp foam
aer 5.3%
1
bp foam
aer 9.8%
1
bp foaming liq wash 10%
1
bp wash
liq 2.5%
1
bp wash
liq 5.25%
1
bp wash
liq 7%
1
bpo
gel 4%
REQUIREMENTS/LIMITS
1
258
DRUG NAME
BPO
GEL 8%
DRUG
TIER
3
BPO CLOTHS MIS 3%
3
bpo cloths mis 6%
1
BPO CLOTHS MIS 9%
3
clearplex x gel 10%
1
CLINAC BPO GEL 7%
3
DELOS
3
LOT 3.5%
DIFFERIN
CRE 0.1%
3
DIFFERIN
GEL 0.1%
3
DIFFERIN
GEL 0.3%
3
DIFFERIN
LOT 0.1%
2
AER 0.1%
3
lavoclen-4 kit acne wsh
1
LAVOCLEN-4 LIQ CREM WSH
3
lavoclen-8 kit acne wsh
1
LAVOCLEN-8 LIQ CREM WSH
3
NUOX
3
FABIOR
GEL 6-3%
REQUIREMENTS/LIMITS
oscion
pad 3%
1
oscion
pad 6%
1
oscion
pad 9%
1
oscion clnsr lot 3%
1
oscion clnsr lot 6%
1
oscion clnsr lot 9%
1
259
DRUG NAME
DRUG
TIER
pr benzoyl liq 7% wash
1
RETIN-A
CRE 0.025%
3
RETIN-A
CRE 0.05%
3
RETIN-A
CRE 0.1%
3
RETIN-A
GEL 0.01%
3
RETIN-A
GEL 0.025%
3
RETIN-A MICR GEL 0.04%
3
RETIN-A MICR GEL 0.04%PMP
3
2
3
RETIN-A MICR GEL 0.1%PUMP
3
RIAX
AER 5.5%
3
RIAX
AER 9.5%
3
se bpo 7-5.5 kit wash kit
1
se bpo cloth mis 3%
1
se bpo cloth mis 6%
1
se bpo cloth mis 9%
1
se bpo wash liq 7%
1
SULFOAM
3
SHA 2%
tl bpo mx liq 4.25%
1
TRETIN-X
CRE 0.0375%
3
TRETIN-X
CRE 0.075%
3
TRETIN-X CRE KIT 0.025%
REQUIREMENTS/LIMITS
3
260
DRUG NAME
DRUG
TIER
3
3
TRETIN-X GEL KIT 0.01%
3
TRETIN-X GEL KIT 0.025%
3
tretinoin
cre 0.025%
1
tretinoin
cre 0.05%
1
tretinoin
cre 0.1%
1
tretinoin
gel 0.01%
1
tretinoin
gel 0.025%
1
tretinoin
gel 0.04%
1
tretinoin
gel 0.04%pmp
1
tretinoin
gel 0.05%
1
tretinoin
gel 0.1%
1
tretinoin
gel 0.1%pump
1
zaclir
lot 8%
REQUIREMENTS/LIMITS
1
*AGENTS FOR EXTERNAL GENITAL AND PERIANAL WARTS***
VEREGEN
OIN 15%
3
*AGENTS FOR FACIAL LIPOATROPHY***
SCULPTRA
INJ 367.5MG
3
*ANALGESIC COMBINATIONS - TOPICAL***
A.A.G.C KIT CRE TERODERM
3
ACTIVE-PREP CRE KIT IV
3
*ANALGESICS - TOPICAL***
261
DRUG NAME
DRUG
TIER
BACLOFEN
CRE
3
BACLOFEN
CRE 1%
3
BACLOFEN
CRE 2%
3
TRAMADOL
CRE 5%
3
TRAMADOL
CRE 8% KIT
3
REQUIREMENTS/LIMITS
*ANTI-INFLAMMATORY AGENTS - TOPICAL***
diclofenac sol 1.5%
1
FLECTOR
2
DIS 1.3%
IBUPROFEN
CRE 10%
3
KETOPROFEN CRE 5% KIT
3
KETOROLAC
3
NAPRO
GEL 2%
CRE 15%
NAPRODERM
CRE 15%
3
3
NAPROXEN
CRE
3
NAPROXEN
CRE 10%
3
PENNSAID
SOL 1.5%
3
PENNSAID
SOL 2%
2
REXAPHENAC CRE 1%
3
VOLTAREN
3
GEL 1%
*ANTI-INFLAMMATORY COMBINATIONS - TOPICAL***
ACTIVE-PREP CRE KIT I
3
ACTIVE-PREP CRE KIT II
3
ACTIVE-PREP CRE KIT III
3
262
DRUG NAME
DRUG
TIER
AIF #2 DRUG CRE PREP KIT
3
AIF #3 DRUG CRE PREP KIT
3
DERMACINRX PAK LEXITRAL
3
DIPENTOCAINE CRE 5-5-2%
3
DSG PAK
3
PAK
EMVOREN
CRE
3
EXTARDOL
CRE
3
FBL KIT
CRE 15-4-5%
3
INNOPRAX-5 CRE
3
K.B.G.L IN CRE TERODERM
3
LIDOPROFEN CRE 5-5-2%
3
NAPROPAX
3
MIS
NAPROXENPAX MIS
3
NOVOCLAIR
3
CRE
REQUIREMENTS/LIMITS
NP #2 DRUG CRE PREP KIT
3
NUVYA
CRE
3
VOPAC
CRE 10-2%
3
VOPAC GB
CRE 5-2-5%
3
VOPAC KT
CRE 5-5-2%
3
ZYVODOL
CRE
3
*ANTIBIOTIC STEROID COMBINATIONS - TOPICAL***
CORTISPORIN CRE 0.5%
3
CORTISPORIN OIN 1%
3
263
DRUG NAME
DRUG
TIER
NEO-SYNALAR CRE
3
NEO-SYNALAR KIT
3
REQUIREMENTS/LIMITS
*ANTIBIOTICS - TOPICAL***
ALTABAX
OIN 1%
3
BACITRACIN POW ZINC USP
3
BACTROBAN
CRE 2%
3
BACTROBAN
OIN 2%
3
CENTANY
OIN 2%
3
CENTANY AT KIT 2%
3
gentamicin cre 0.1%
1
gentamicin oin 0.1%
1
mupirocin
cre 2%
1
mupirocin
oin 2%
1
mupirocin ca cre 2%
1
*ANTIFUNGALS - TOPICAL COMBINATIONS***
ACTIVE-PREP CRE KIT V
3
ALA-QUIN
3
CRE 3-0.5%
ALCORTIN A GEL
3
ALOQUIN
3
GEL 1.25-1%
clotrim/beta cre 1-0.05%
1
clotrim/beta cre diprop
1
clotrim/beta lot diprop
1
DERMASORB AF KIT 3-0.5%
3
264
DRUG NAME
dermazene
DRUG
TIER
cre 1%
EXODERM
1
LOT 25-1%
3
HYDRO-IODOQU GEL 2-1
3
hydrocort
cre iodoquin
1
hydrocort/ cre iodoquin
1
KETOCON
KIT
3
LOTRISONE
CRE
3
LOTRISONE
LOT
3
nystat/triam cre
1
nystat/triam oin
1
PEDIPAK
3
PAK
versiclear lot
1
VUSION
3
OIN
REQUIREMENTS/LIMITS
VYTONE
CRE 1-1.9%
3
XOLEGEL
KIT COREPAK
3
XOLEGEL DUO/ KIT HEAD&SHD
3
XOLEGEL DUO/ KIT XOLEX
3
*ANTIFUNGALS - TOPICAL***
ciclodan
cre 0.77%
1
ciclodan
sol 8%
1
CICLODAN CRE KIT 0.77%
3
CICLODAN SOL KIT 8%
3
ciclopirox cre 0.77%
1
265
DRUG NAME
DRUG
TIER
ciclopirox gel 0.77%
1
ciclopirox kit 8%
1
ciclopirox sha 1%
1
ciclopirox sol 8%
1
ciclopirox sus 0.77%
1
CNL8 NAIL
KIT
3
HALOTIN
CRE 1%
3
LAMISIL
SPR 1%
3
LOPROX
GEL 0.77%
3
LOPROX
SHA 1%
3
MENTAX
CRE 1%
2
NAFTIFINE
CRE HCL 1%
3
NAFTIN
CRE 1%
3
NAFTIN
CRE 2%
3
NAFTIN
GEL 1%
3
NAFTIN
GEL 2%
3
nystatin
cre 100000
1
nystatin
oin 100000
1
nystatin
pow 100000
1
NYSTATIN
POW 10BU
3
NYSTATIN
POW 150MU
3
NYSTATIN
POW 1BU
3
NYSTATIN
POW 2BU
3
REQUIREMENTS/LIMITS
266
DRUG NAME
DRUG
TIER
NYSTATIN
POW 500MU
3
NYSTATIN
POW 50MU
3
NYSTATIN
POW 5BU
3
NYSTATIN
POW DOMESTIC
3
nystop
pow 100000
1
PEDIADERM AF KIT COMPLETE
3
PEDIPIROX-4 KIT NAIL
3
PENLAC
3
SOL 8%
REQUIREMENTS/LIMITS
*ANTIHISTAMINE-TOPICAL COMBINATIONS***
ALLO-PAX
NAZIREX
CRE 5-5%
CRE
3
3
*ANTINEOPLASTIC ALKYLATING AGENTS - TOPICAL***
VALCHLOR
GEL 0.016%
3
*ANTINEOPLASTIC ANTIMETABOLITES - TOPICAL***
CARAC
CRE 0.5%
3
EFUDEX
CRE 5%
3
FLUOROPLEX CRE 1%
2
FLUOROURACIL CRE 0.5%
3
fluorouracil cre 5%
1
fluorouracil dro 2%
1
fluorouracil dro 5%
1
fluorouracil sol 2%
1
fluorouracil sol 5%
1
267
DRUG NAME
TOLAK
DRUG
TIER
CRE 4%
REQUIREMENTS/LIMITS
3
*ANTINEOPLASTIC OR PREMALIGNANT LESIONS - TOPICAL MISC.***
FLUORAC
CRE 5-1%
3
HYALUCIL-0.5 CRE
3
HYALUCIL-4 CRE
3
PICATO
GEL 0.015%
3
PICATO
GEL 0.05%
3
*ANTINEOPLASTIC OR PREMALIGNANT LESIONS - TOPICAL NSAID'S***
diclofenac gel 3%
1
SOLARAZE
3
GEL 3% W/W
*ANTINEOPLASTIC RETINOIDS - TOPICAL***
PANRETIN
GEL 0.1%
3
*ANTIPRURITICS - TOPICAL***
CAMPHOR
CRY
3
CAMPHOR
GRA
3
PRUDOXIN
CRE 5%
3
ZONALON
CRE 5%
3
*ANTIPSORIATICS - SYSTEMIC***
8-MOP
CAP 10MG
2
acitretin
cap 10mg
4
PA
acitretin
cap 17.5mg
4
PA
acitretin
cap 25mg
4
PA
4
PA
4
PA, ST
AMEVIVE
COSENTYX
INJ 15MG
INJ 150MG/ML
268
DRUG NAME
DRUG
TIER
REQUIREMENTS/LIMITS
COSENTYX PEN INJ 150MG/ML
4
PA, ST
methoxsalen cap 10mg
4
PA
OXSORALEN-UL CAP 10MG
4
PA
SORIATANE
CAP 10MG
4
PA
SORIATANE
CAP 17.5MG
4
PA
SORIATANE
CAP 25MG
4
PA
STELARA
INJ 45MG/0.5
4
PA, ST
STELARA
INJ 90MG/ML
4
PA, ST
*ANTIPSORIATICS***
calcipotrien cre 0.005%
1
calcipotrien oin 0.005%
1
calcipotrien sol 0.005%
1
calcitrene oin 0.005%
1
CALCITRIOL OIN 3MCG/GM
3
DOVONEX
3
CRE 0.005%
DOVONX SCALP SOL 0.005%
3
DRITHO-CREME CRE HP 1%
3
DRITHO-SCALP CRE 0.5%
2
SORILUX
AER 0.005%
3
TAZORAC
CRE 0.05%
2
TAZORAC
CRE 0.1%
2
TAZORAC
GEL 0.05%
2
TAZORAC
GEL 0.1%
2
269
DRUG NAME
VECTICAL
DRUG
TIER
OIN 3MCG/GM
ZITHRANOL
SHA 1%
ZITHRANOL-RR CRE 1.2%
REQUIREMENTS/LIMITS
3
3
3
*ANTISEBORRHEIC COMBINATIONS***
APOP
GEL 10%
3
LOUTREX
CRE
3
PROMISEB
CRE
3
PROMISEB
KIT COMPLETE
3
selenium sul sha 2.25%
1
SELRX
3
SHA 2.3%
SOD SULFACET PAD 10%
3
TL TRISEB
3
CRE
*ANTISEBORRHEIC PRODUCTS***
mexar wash liq 10%
1
OVACE PLUS AER 9.8%
3
OVACE PLUS CRE 10%
3
OVACE PLUS GEL 10% WASH
3
OVACE PLUS LIQ 10% WASH
3
OVACE PLUS LOT 9.8%
3
OVACE PLUS SHA 10%
3
OVACE WASH LIQ 10%
3
seb-prev
1
liq wash
SEB-PREV
LOT 10%
3
270
DRUG NAME
DRUG
TIER
selenium sul lot 2.5%
1
SELSUN
3
SHA 2.5%
sod sulfacet gel 10%
1
sod sulfacet sha 10%
1
sodium sulfa liq 10% wash
1
TERSI FOAM AER 2.25%
3
REQUIREMENTS/LIMITS
*ANTIVIRAL TOPICAL COMBINATIONS***
LIDOVIR
OIN 4-4%
3
XERESE
CRE 5-1%
3
*ANTIVIRALS - TOPICAL***
acyclovir
oin 5%
1
DENAVIR
CRE 1%
2
ZOVIRAX
CRE 5%
3
ZOVIRAX
OIN 5%
3
*ASTRINGENTS***
XERAC-AC
SOL 6.25%
3
*BURN PRODUCTS***
mafenide ace pak 5%
1
SILVADENE
3
CRE 1%
silver sulfa cre 1%
1
ssd
1
cre 1%
SULFAMYLON CRE 85MG/GM
3
SULFAMYLON PAK 5%
3
271
DRUG NAME
DRUG
TIER
thermazene cre 1%
REQUIREMENTS/LIMITS
1
*CAUTERIZING AGENT COMBINATIONS***
ARZOL SILVER MIS NITR APP
3
grafco silvr mis nit appl
1
*CAUTERIZING AGENTS***
MONOCHLOROAC CRY ACID
3
SILVER
3
CRY NITRATE
SILVER NITRA OIN 10%
3
SILVER NITRA SOL 0.5%
3
SILVER NITRA SOL 10%
3
3
3
TRI-CHLOR
3
LIQ 80%
TRICHLOROACE CRY ACID
3
*CORTICOSTEROIDS - TOPICAL***
ACLOVATE
CRE 0.05%
3
ADV ALLERGY KIT COLLECTI
3
ala cort
1
cre 1%
ALA SCALP
ala-cort
LOT 2%
lot 1%
3
1
alclometason cre 0.05%
1
alclometason oin 0.05%
1
alphatrex
1
gel 0.05%
272
DRUG NAME
DRUG
TIER
amcinonide cre 0.1%
1
amcinonide lot 0.1%
1
amcinonide oin 0.1%
1
apexicon
1
oin 0.05%
APEXICON E CRE 0.05%
3
AQUA GLYC HC KIT SCLP/BDY
3
aug betamet cre 0.05%
1
aug betamet gel 0.05%
1
aug betamet lot 0.05%
1
aug betamet oin 0.05%
1
betameth dip cre 0.05%
1
betameth dip lot 0.05%
1
betameth dip oin 0.05%
1
betameth val aer 0.12%
1
betameth val cre 0.1%
1
betameth val lot 0.1%
1
betameth val oin 0.1%
1
CAPEX
3
SHA 0.01%
clobetasol aer 0.05%
1
clobetasol cre 0.05%
1
clobetasol gel 0.05%
1
clobetasol lot 0.05%
1
clobetasol oin 0.05%
1
REQUIREMENTS/LIMITS
273
DRUG NAME
DRUG
TIER
clobetasol sha 0.05%
1
clobetasol sol 0.05%
1
clobetasol spr 0.05%
1
clobetasol e cre 0.05%
1
CLOBEX
LOT 0.05%
3
CLOBEX
SHA 0.05%
3
CLOBEX
SPR 0.05%
3
clocortolone cre piv 0.1%
1
clodan
1
sha 0.05%
CLODERM
CRE 0.1%
3
CLODERM
CRE 0.1% PMP
3
CORDRAN
CRE 0.05%
3
CORDRAN
LOT 0.05%
3
CORDRAN
OIN 0.05%
3
CORDRAN 24X3 TAP 4MCG/CM
3
CORDRAN 80X3 TAP 4MCG/CM
3
cormax
oin 0.05%
1
cormax
sol 0.05%
1
cormax scalp sol 0.05%
1
CUTIVATE
CRE 0.05%
3
CUTIVATE
LOT 0.05%
3
CUTIVATE
OIN 0.005%
3
DERMA-SMOOTH OIL /FS BODY
REQUIREMENTS/LIMITS
3
274
DRUG NAME
DRUG
TIER
DERMA-SMOOTH OIL /FS SCLP
3
DERMASORB HC KIT 2%
3
DERMASORB TA KIT 0.1%
3
DERMATOP
CRE 0.1%
3
DERMATOP
OIN 0.1%
3
DESONATE
GEL 0.05%
3
desonide
cre 0.05%
1
desonide
lot 0.05%
1
desonide
oin 0.05%
1
DESONIL
KIT 0.05%
REQUIREMENTS/LIMITS
3
DESOWEN
CRE 0.05%
3
DESOWEN
LOT 0.05%
3
DESOWEN
OIN 0.05%
3
DESOWEN CRM KIT 0.05%
3
DESOWEN LOT KIT 0.05%
3
DESOWEN OINT KIT 0.05%
3
desoximetas cre 0.05%
1
desoximetas cre 0.25%
1
desoximetas gel 0.05%
1
DESOXIMETAS OIN 0.05%
3
desoximetas oin 0.25%
1
diflorasone cre 0.05%
1
diflorasone oin 0.05%
1
275
DRUG NAME
DRUG
TIER
DIPROLENE
LOT 0.05%
3
DIPROLENE
OIN 0.05%
3
DIPROLENE AF CRE 0.05%
3
ELOCON
CRE 0.1%
3
ELOCON
LOT 0.1%
3
ELOCON
OIN 0.1%
3
fluocin acet cre 0.01%
1
fluocin acet cre 0.025%
1
fluocin acet oil 0.01% sc
1
fluocin acet oil body
1
fluocin acet oil scalp
1
fluocin acet oin 0.025%
1
fluocin acet sol 0.01%
1
fluocinonide cre -e 0.05%
1
fluocinonide cre 0.05%
1
fluocinonide cre 0.1%
1
fluocinonide gel 0.05%
1
fluocinonide oin 0.05%
1
fluocinonide sol 0.05%
1
fluticasone cre 0.05%
1
fluticasone lot 0.05%
1
fluticasone oin 0.005%
1
FRST-HYDRCRT GEL 10%
3
REQUIREMENTS/LIMITS
276
DRUG NAME
DRUG
TIER
halobetasol cre 0.05%
1
halobetasol oin 0.05%
1
HALOG
CRE 0.1%
3
HALOG
OIN 0.1%
3
hc butyrate cre 0.1%
1
hc butyrate oin 0.1%
1
hc butyrate sol 0.1%
1
hc valerate cre 0.2%
1
hc valerate oin 0.2%
1
hydrocort
cre 2.5%
1
hydrocort
lot 2.5%
1
hydrocort
oin 2.5%
1
hydrocort/ab oin 1%
1
KENALOG
3
AER SPRAY
LOCOID
CRE 0.1%
3
LOCOID
LOT 0.1%
2
LOCOID
OIN 0.1%
3
LOCOID
SOL 0.1%
3
LOCOID LIPO CRE 0.1%
3
lokara
1
LUXIQ
lot 0.05%
AER 0.12%
REQUIREMENTS/LIMITS
3
mometasone cre 0.1%
1
mometasone oin 0.1%
1
277
DRUG NAME
DRUG
TIER
mometasone sol 0.1%
1
NUCORT
LOT 2%
3
AER 0.05%
3
OLUX
OLUX-E
AER 0.05%
3
PANDEL
CRE 0.1%
3
PEDIADERM HC KIT
3
PEDIADERM TA KIT
3
prednicarbat cre 0.1%
1
prednicarbat oin 0.1%
1
PSORCON
3
scalacort
CRE 0.05%
lot 2%
REQUIREMENTS/LIMITS
1
SYNALAR
CRE 0.025%
3
SYNALAR
OIN 0.025%
3
SYNALAR
SOL 0.01%
3
TEMOVATE
CRE 0.05%
3
TEMOVATE
GEL 0.05%
3
TEMOVATE
OIN 0.05%
3
TEMOVATE
SOL 0.05%
3
TEMOVATE E CRE 0.05%EML
3
TEXACORT
SOL 2.5%
3
TOPICORT
CRE 0.05%
3
TOPICORT
CRE 0.25%
3
TOPICORT
GEL 0.05%
3
278
DRUG NAME
DRUG
TIER
TOPICORT
OIN 0.05%
3
TOPICORT
OIN 0.25%
3
TOPICORT
SPR 0.25%
3
triamcinolon aer spray
1
triamcinolon cre 0.025%
1
1
1
triamcinolon lot 0.025%
1
triamcinolon lot 0.1%
1
triamcinolon oin 0.025%
1
1
1
1
TRIANEX
3
OIN 0.05%
triderm
cre 0.1%
1
ULTRAVATE
CRE 0.05%
3
ULTRAVATE
OIN 0.05%
3
VANOS
CRE 0.1%
VERDESO
WESTCORT
REQUIREMENTS/LIMITS
3
AER 0.05%
3
OIN 0.2%
3
*EMOLLIENT COMBINATIONS***
lactic acid cre /vit e
1
lactic acid cre e
1
279
DRUG NAME
DRUG
TIER
REQUIREMENTS/LIMITS
*EMOLLIENT/KERATOLYTIC AGENTS***
ALUVEA
CRE 39%
3
carb-o-philc cre /40
1
carb-o-philc gel 40%
1
CEM-UREA
3
SOL 45%
cerovel
gel 40%
1
cerovel
lot 40%
1
DERMASORB XM KIT 39%
3
GORDONS UREA OIN 40%
3
HYDRO 40
AER FOAM
3
AER 30%
3
KERAFOAM
KERAFOAM 42 AER 42%
3
KERALAC
3
CRE 47%
rea lo 39
cre 39%
1
rea lo 40
cre 40%
1
rea lo 40
lot 40%
1
remeven
cre 50%
1
RINNOVI NAIL KIT SYSTEM
3
tl urea
1
lot 45%
u-kera e
cre 40%
1
UMECTA
EMU
3
UMECTA
SUS 40%
3
umecta mouss aer 40%
1
280
DRUG NAME
DRUG
TIER
UMECTA NAIL SUS FILM
3
URAMAXIN
CRE 45%
3
URAMAXIN
GEL 45%
3
URAMAXIN
LOT 45%
3
URAMAXIN GT GEL 45%
3
URAMAXIN GT KIT 45%
3
urea
cre 39%
1
urea
cre 40%
1
urea
cre 45%
1
urea
cre 47%
1
urea
cre 50%
1
urea
gel 40%
1
urea
lot 40%
1
urea
lot 45%
1
urea 40%
urea nail
sus nail
gel 45%
1
1
urea topical sus 40%
1
urea-c40
1
UREVAZ
UTOPIC
lot 40%
CRE 44%
CRE 41%
REQUIREMENTS/LIMITS
3
3
x-viate
cre 40%
1
x-viate
gel 40%
1
x-viate
lot 40%
1
281
DRUG NAME
DRUG
TIER
REQUIREMENTS/LIMITS
*EMOLLIENT/KERATOLYTIC COMBINATIONS***
HYDRO 35
latrix
AER
sus 50%
3
1
latrix xm emu 45%
1
UMECTA PD EMU 40-0.3%
3
UMECTA PD SUS 40-0.3%
3
URAMAXIN
3
AER 20%
urea
emu 50%
1
urea
sus 50%
1
urea hydrati aer 35%
1
UREA NAIL KIT
3
UREA NAIL MIS 50%
3
*EMOLLIENTS***
COPASIL
GEL
3
HPR PLUS MB KIT HYDROGEL
3
hyaluronate gel 0.2%
1
hygel
1
gel 0.2%
HYLATOPC PLS KIT /AURSTAT
3
HYLIRA
GEL 0.2%
3
HYLIRA
LOT 0.1%
3
LAC-HYDRIN CRE 12%
3
LAC-HYDRIN LOT 12%
3
laclotion
1
lot 12%
282
DRUG NAME
DRUG
TIER
lactic acid lot 10%
1
NEOSALUS
3
LOT
TROPAZONE
LOT
REQUIREMENTS/LIMITS
3
*ENZYMES - TOPICAL***
GRANULEX
AER
OPTASE
revina
GEL
oin
SANTYL
tbc
3
1
OIN 250/GM
aer
vasolex
3
3
1
oin
XENADERM
1
OIN
3
*EYELID CLEANSERS & LUBRICANTS***
ACUICYN
LIQ
AVENOVA
SOL 0.01%
3
3
*IMIDAZOLE-RELATED ANTIFUNGALS - TOPICAL***
CLOTRIMAZOLE CRY
3
clotrimazole sol 1%
1
econazole
1
cre 1%
ECOZA
AER 1%
ERTACZO
CRE 2%
3
3
EXELDERM
CRE 1%
3
EXELDERM
SOL 1%
3
EXTINA
AER 2%
3
283
DRUG NAME
JUBLIA
DRUG
TIER
SOL 10%
3
ketoconazole aer 2%
1
ketoconazole cre 2%
1
ketoconazole sha 2%
1
ketodan
1
aer 2%
KETODAN
LUZU
KIT 2%
CRE 1%
NIZORAL
nuzole
SHA 2%
cre 2%
3
3
3
1
OXISTAT
CRE 1%
3
OXISTAT
LOT 1%
3
XOLEGEL
GEL 2%
REQUIREMENTS/LIMITS
3
*IMMUNOMODULATORS IMIDAZOQUINOLINAMINES - TOPICAL***
ALDARA
CRE 5%
imiquimod
cre 5%
ZYCLARA
CRE 3.75%
3
1
3
ZYCLARA PUMP CRE 2.5%
3
ZYCLARA PUMP CRE 3.75%
3
*KERATOLYTIC AND/OR ANTIMITOTIC COMBINATIONS***
BENSAL HP
GORDOFILM
OIN
SOL
3
3
PYROGALL ACD OIN
3
SALICYLIC AC AER 6%
3
284
DRUG NAME
SALKERA
DRUG
TIER
AER 6%
3
SALVAX DUO KIT PLUS
3
SUPRACIL
3
CRE
VERRUNEX
CRE
REQUIREMENTS/LIMITS
3
*KERATOLYTIC/ANTIMITOTIC AGENTS***
aliclen
sha 6%
1
CONDYLOX
GEL 0.5%
2
CONDYLOX
SOL 0.5%
3
KERALYT
GEL 6%
3
KERALYT
KIT SCALP 6%
3
PODOCON
SOL 25%
3
podofilox sol 0.5%
1
salacyn
cre 6%
1
salacyn
lot 6%
1
SALEX
SHA 6%
3
SALEX CREAM KIT 6%
3
SALEX LOTION KIT 6%
3
salicylic
1
aer 6%
SALICYLIC
CRY ACID
3
salicylic ac cre 6%
1
salicylic ac gel 6%
1
salicylic ac kit 6%
1
salicylic ac kit 6% cream
1
285
DRUG NAME
DRUG
TIER
salicylic ac kit 6% lotn
1
salicylic ac liq 26%
1
salicylic ac liq 27.5%
1
salicylic ac lot 6%
1
salicylic ac sha 6%
1
salicylic ac sol 28.5%
1
SALVAX
3
AER 6%
ULTRASAL-ER SOL 28.5%
3
VIRASAL
3
LIQ 27.5%
REQUIREMENTS/LIMITS
*LINIMENT COMBINATIONS***
CAMPHOMEX
SPR
3
MEDI-DERM
CRE -RX
3
MEDROX-RX
OIN
3
REMATEX
CRE
3
SILMANIX
CRE
3
*LINIMENTS***
METHYL SALIC LIQ
3
METHYL SALIC OIL NATURAL
3
TURPENTINE SOL SPIRITS
3
*LOCAL ANESTHETICS - TOPICAL***
ANACAINE
cidaleaze
OIN
cre 3%
cocaine hcl sol 10%
3
1
1
286
DRUG NAME
DRUG
TIER
cocaine hcl sol 4%
1
glydo
1
gel 2%
LDO PLUS
GEL 4%
LIDOCAINE
lidocaine
CRE 10%
cre 3%
LIDOCAINE
CRE 5%
3
3
1
3
lidocaine
gel 2%
1
lidocaine
gel 2% jelly
1
LIDOCAINE
LOT 3%
3
lidocaine
oin 5%
1
lidocaine
pad 5%
1
LIDOCIN
GEL 3%
LIDODERM
lidopin
DIS 5%
cre 3%
3
3
1
LIDOPIN
CRE 3.25%
3
LIDORX
GEL 3%
3
LIDOTRAL
CRE 3.88%
3
LIDOVEX
CRE 3.75%
3
LIDOVIN
CRE 3.95%
3
LIDOZOL
CRE 3.75%
3
PONTOCAINE SOL 2%
3
pramox
1
gel 1%
QUTENZA
KIT 8% 1-PCH
REQUIREMENTS/LIMITS
3
287
DRUG NAME
QUTENZA
DRUG
TIER
KIT 8% 2-PCH
REQUIREMENTS/LIMITS
3
XYLOCAINE
GEL 2%
3
XYLOCAINE
SOL 4%
3
*MACROLIDE IMMUNOSUPPRESSANTS - TOPICAL***
ELIDEL
CRE 1%
2
PROTOPIC
OIN 0.03%
3
PROTOPIC
OIN 0.1%
3
tacrolimus oin 0.03%
1
tacrolimus oin 0.1%
1
*MISC. DERMATOLOGICAL PRODUCTS***
ALEVICYN SG LIQ ANTIPRUR
3
ATOPICLAIR CRE
3
AURSTAT
KIT
3
AURSTAT
KIT HYDROGEL
3
AURSTAT ANTI GEL -ITCH
3
ELETONE
CRE
3
ELETONE
CRE TWINPACK
3
EMULSION SB EMU
3
EPICERAM
EMU
3
GENADUR
KIT
3
GENADUR
LIQ
3
HPR
AER
HPR PLUS
AER
3
3
288
DRUG NAME
DRUG
TIER
HPR PLUS
CRE
3
HPR PLUS
KIT
3
HYLATOPIC
AER
3
HYLATOPIC
AER PLUS
3
HYLATOPIC
CRE PLUS
3
MB HYDROGEL KIT
3
MIMYX
3
CRE
NEOSALUS
AER
3
NEOSALUS
CRE
3
NEOSALUS
CRE 180 PACK
3
NEOSALUS CP CRE
3
NIVATOPIC
3
NUVAIL
CRE PLUS
SOL 16%
PEDIAPALM
PR CREAM
EMU SPRAY
3
3
KIT
3
PRESERA
AER
3
PRUCLAIR
CRE
3
PRUMYX
CRE
3
RADIGEL
GEL
3
tetrix
TETRIX
cre
REQUIREMENTS/LIMITS
1
KIT
3
TL-CERMIDE EMU
3
XCLAIR
3
CRE
289
DRUG NAME
ZENIEVA
CRE
DRUG
TIER
REQUIREMENTS/LIMITS
3
*MISC. TOPICAL COMBINATIONS***
DERMACINRX KIT COMBOPAK
3
DERMACINRX KIT PHARMAPA
3
*MISC. TOPICAL***
ALUMINUM CL CRY HEXAHYDR
3
ARNICA
TIN FLOWER
3
DRYSOL
SOL 20%
3
hypercare
sol 20%
WITCH HAZEL LIQ
1
3
*NIT REMOVERS***
LYCELLE
GEL
3
*OXABOROLE-RELATED ANTIFUNGALS - TOPICAL***
KERYDIN
SOL 5%
3
*PHOTODYNAMIC THERAPY AGENTS - TOPICAL***
LEVULAN KERA SOL 20%
3
METVIXIA
3
CRE 16.8%
*PIGMENTING AGENTS***
METHOXSALEN CRY USP/NF
3
*ROSACEA AGENTS***
DOXYCYCLINE CAP 40MG
3
FINACEA
AER 15%
3
FINACEA
GEL 15%
2
FINACEA PLUS KIT
2
290
DRUG NAME
DRUG
TIER
METROCREAM CRE 0.75%
3
METROGEL
3
GEL 1%
METROLOTION LOT 0.75%
3
metronidazol cre 0.75%
1
metronidazol gel 0.75%
1
metronidazol gel 1%
1
metronidazol lot 0.75%
1
MIRVASO
GEL 0.33%
3
NORITATE
CRE 1%
2
CAP 40MG
3
ORACEA
rosadan
cre 0.75%
1
rosadan
gel 0.75%
1
ROSADAN
SOOLANTRA
vitazol
KIT 0.75%
3
CRE 1%
3
cre 0.75%
REQUIREMENTS/LIMITS
1
*SCABICIDES & PEDICULICIDES***
acticin
cre 5%
1
ELIMITE
CRE 5%
3
EURAX
CRE 10%
2
EURAX
LOT 10%
2
lindane
lot 1%
1
lindane
sha 1%
1
malathion
lot 0.5%
1
291
DRUG NAME
NATROBA
ovide
DRUG
TIER
SUS 0.9%
lot 0.5%
3
1
permethrin cre 5%
1
SKLICE
3
LOT 0.5%
SPINOSAD
SUS 0.9%
3
SULF LIME
SOL
3
LOT 5%
2
ULESFIA
REQUIREMENTS/LIMITS
*SCAR TREATMENT PRODUCTS***
BEAU RX
celacyn
GEL
gel
RECEDO
1
GEL
RENUU NL
3
PAD 2-30%
3
3
*SKIN CLEANSERS***
ESSENTRA
MIS 9X9"
3
*SKIN PROTECTANTS***
BENZOIN
TIN NF
3
*STEROID-LOCAL ANESTHETIC COMBINATIONS***
CORTANE-B
EPIFOAM
NOVACORT
LOT
3
AER 1%
2
GEL
3
PRAMOSONE
CRE 1%
3
PRAMOSONE
CRE 1-1%
3
PRAMOSONE
CRE 1-2.5%
3
292
DRUG NAME
DRUG
TIER
PRAMOSONE
LOT 1%
2
PRAMOSONE
LOT 2.5%
2
PRAMOSONE
OIN 1%
2
PRAMOSONE
OIN 2.5%
2
PRAMOSONE E CRE 1-2.5%
REQUIREMENTS/LIMITS
2
*TAR PRODUCTS***
COAL TAR
OIN 1%
3
COAL TAR
SOL 20%
3
*TISSUE REPLACEMENTS***
APLIGRAF
MIS
4
BIOVANCE
MIS 1CMX2CM
3
BIOVANCE
MIS 2CMX3CM
3
BIOVANCE
MIS 4CMX4CM
3
BIOVANCE
MIS 6CMX6CM
3
DERMAGRAFT MIS
3
EPIFIX
MIS 14MM
3
EPIFIX
MIS 18MM
3
EPIFIX
MIS 24MM
3
EPIFIX
MIS 2CMX2CM
3
EPIFIX
MIS 2CMX3CM
3
EPIFIX
MIS 2CMX4CM
3
EPIFIX
MIS 3CMX3CM
3
EPIFIX
MIS 3CMX5CM
3
PA
293
DRUG NAME
DRUG
TIER
EPIFIX
MIS 4CMX3CM
3
EPIFIX
MIS 4CMX4CM
3
EPIFIX
MIS 5CMX6CM
3
EPIFIX
MIS 7CMX7CM
3
GRAFIX CORE MIS 2CMX2CM
3
GRAFIX CORE MIS 5CMX5CM
3
GRAFIX PRIME MIS 2CMX2CM
3
GRAFIX PRIME MIS 5CMX5CM
3
GRAFIX PRIME MIS 7.5X15CM
3
NEOX 100
MIS 2CMX2CM
3
NEOX 100
MIS 4CMX4CM
3
NEOX 100
MIS 7CMX7CM
3
NEOX CORD 1K MIS 1.5X1.5
3
NEOX CORD 1K MIS 2.5X2.5
3
NEOX CORD 1K MIS 4CMX3CM
3
3
3
REQUIREMENTS/LIMITS
*TOPICAL ANESTHETIC COMBINATIONS***
ADAZIN
alegenix
CRE
mis .0375-5%
ANODYNERX
anodynz
ATENDIA
PAD
mis 0.0375-5
PAD 4-3%
3
1
3
1
3
294
DRUG NAME
avalin-rx
DRUG
TIER
pad 4-1%
1
CAPSIDERM
PAD .0375-5%
3
CAPTRACIN
PAD .0375-5%
3
CETACAINE
AER
3
COMFORT EZ PAD 2-4-1%
3
COMFORT EZ PAD 20-4-1%
3
DERMACINRX PAK
3
DERMACINRX PAK DUOPATCH
3
elenzapatch dis 4-1%
1
EMLA
CRE
3
EMLA
CRE 2.5-2.5%
3
exactacain aer
1
FLEXIN
3
PAD .0375-5%
k2k pain rel pad 4-4%
1
LEVATIO
3
lidenza
PAD 0.3-5%
pad 4-1%
1
lido/prilocn cre 2.5-2.5%
1
lido/prilocn kit 2.5-2.5%
1
lidocaine
1
cre tetracai
lidodextrapi pad 4-1%
1
LIDOTHOL
3
PAD 4.5-5%
livixil pak kit 2.5-2.5%
1
lorenza
1
pad 4-1%
REQUIREMENTS/LIMITS
295
DRUG NAME
DRUG
TIER
lp lite pak kit 2.5-2.5%
1
MAC PATCH PAD .0375-5%
3
MEDI-DERM/L- CRE RX
3
MEDI-PATCH PAD RX
3
MEGRIX
3
MIS
MENTHOCIN
PAD LIDOCAIN
3
MENTHOLIX
SPR 4-1%
3
migryl
mis 0.0375-5
NEUVAXIN
PAD 0.0375-5
1
3
PAIN RELIEF PAD PATCH
3
PERMAVAN
3
PAD
PHARM CH TSX PAD 2-4-1%
3
PLIAGLIS
3
prolida
CRE 7-7%
pad 4-1%
1
provenza
pad 4-1%
1
QROXIN
PAD
3
reciphexamin dis 4-1%
1
relador pak kit 2.5-2.5%
1
relador pak kit plus
1
RELEEVIA
3
PAD .0375-5%
RELEEVIA MC PAD .0375-5%
3
releevia ml pad 4-1%
1
RELYYKS
3
PAD
REQUIREMENTS/LIMITS
296
DRUG NAME
RELYYT
DRUG
TIER
DIS 0.025-5%
REMAXAZON
RENOVO
PAD
PAD 0.0375-5
3
3
3
RENOVO LIDO5 CRE 5-0.05%
3
RENUU
3
PAD 2-5-30%
SCAR PATCH PAD
3
SCAR PATCH PAD PREMIUM
3
SILVERA PAIN PAD RELIEF
3
SINELEE
PAD 0.0375-5
3
SINELEE
PAD 0.05-5%
3
SOLAICE
PAD
3
SOLMARA
PAD 4-5%
3
SOOTHEE
PAD
3
SYNERA
DIS 70-70MG
3
synvexia
pad 4-1%
1
SYNVEXIA TC CRE 4-1%
3
TETRAMEX
3
SPR 2-1-3%
VELMA
PAD 16-4-2%
3
VELTRIX
CRE 4-1%
3
PAD 2-4-30%
3
VEXA
REQUIREMENTS/LIMITS
xyphex
mis
1
zeruvia
pad 4-1%
1
*TOPICAL ANESTHETIC GASSES***
297
DRUG NAME
DRUG
TIER
ETHYL CHLOR AER FINE PIN
3
ETHYL CHLOR AER FN STRM
3
ETHYL CHLOR AER MED JET
3
ETHYL CHLOR AER MED STRM
3
ETHYL CHLOR AER MIST
3
ETHYL CHLOR AER SPRAY
3
GEBAUERS SPR AER /STRETCH
3
PAIN EASE
AER MD STRM
3
PAIN EASE
AER MIST
3
REQUIREMENTS/LIMITS
*TOPICAL SELECTIVE RETINOID X RECEPTOR AGONISTS***
TARGRETIN
GEL 1%
4
PA
*TOPICAL STEROID COMBINATIONS***
calcipotrien oin betameth
1
CARMOL-HC
CRE 1%
3
CLOBETA
KIT CREAM
3
CLOBETA
KIT OINTMENT
3
CLODAN
KIT 0.05%
3
CORTALO
GEL 2%
3
DERMA SILKRX KIT SDS PAK
3
DERMACINRX KIT SILAPAK
3
HALAC
3
KIT
HALONATE
halonate pac kit
KIT
3
1
298
DRUG NAME
DRUG
TIER
hc ac/aloe gel 2%
1
NUZON
GEL 2%
3
SANADERMRX KIT SKIN REP
3
SCALACORT DK KIT
3
SILAZONE
PAK PHARMAPA
3
SYNALAR
KIT 0.025%
3
SYNALAR TS KIT 0.01%
3
TACLONEX
OIN
3
TACLONEX
SUS
3
TRIAMSIL
PAK COMBIPAK
3
TRIAMSIL
PAK MULTIPAK
3
TRIDERMA
u-cort
CRE FORTE
cre 1%
3
1
ULTRAVATE
KIT
3
ULTRAVATE
KIT PAC
3
ULTRAVATE X KIT 0.05-10%
3
VALIDERM
3
WHYTEDERM
REQUIREMENTS/LIMITS
CRE
KIT TRILASIL
WHYTEDERM TD KIT PAK
3
3
*WOUND CARE - GROWTH FACTOR AGENTS***
REGRANEX
GEL 0.01%
2
*WOUND CARE COMBINATIONS***
COLLIGINIX MIS
3
299
DRUG NAME
DRUG
TIER
REGENECARE GEL
3
VENELEX
3
OIN
XEROFORM OIL MIS 1"X8"
3
XEROFORM OIL PAD 2"X2"
3
XEROFORM PET MIS OVERWRAP
3
XEROFORM PET MIS ROLL
3
XEROFORM PET PAD 1"X8"
3
3
3
3
XEROFRM GAUZ MIS 1"X8"
3
XEROFRM GAUZ MIS 5"X9"
3
XEROFRM GAUZ PAD 5"X9"
3
XEROFRM PETR PAD 2"X2"
3
XEROFRM PETR PAD 4"X4"
3
XEROFRM ROLL MIS 4"X9"
3
XEROFRM ROLL MIS 4"X9'
3
XROFORM PET MIS OVERWRAP
3
REQUIREMENTS/LIMITS
*WOUND CLEANSERS/DECUBITUS ULCER THERAPY***
ATRAPRO DERM SPR
3
LAVARE WOUND GEL WASH
3
MICROCYN
GEL
3
MICROCYN
GEL SKIN/WOU
3
300
DRUG NAME
MICROCYN
DRUG
TIER
LIQ
REQUIREMENTS/LIMITS
3
*WOUND DRESSINGS***
ACTCT FLEX 3 PAD 4"X4"
3
ACTI ANTIMIC PAD 2"X2"
3
ACTI ANTIMIC PAD 4"X4"
3
ACTICOAT
MIS 16"X16"
3
ACTICOAT
MIS 4"X4"
3
ACTICOAT
MIS 4"X48"
3
ACTICOAT
MIS 4"X8"
3
ACTICOAT
MIS 5"X5"
3
ACTICOAT
MIS 8"X16"
3
ACTICOAT
MIS SITE
3
ACTICOAT 3 MIS 16"X16"
3
3
3
3
3
3
3
3
3
3
3
301
DRUG NAME
DRUG
TIER
ACTICOAT 7 PAD 2"X2"
3
ACTICOAT 7 PAD 4"X5"
3
ACTICOAT ABS MIS 3/4"X12"
3
ACTICOAT ABS PAD 4"X5"
3
ACTICOAT MOI PAD 2"X2"
3
3
3
ACTICOAT SUR PAD 4"X10"
3
ACTICOAT SUR PAD 4"X8"
3
ACTICOAT SUR PAD 4X13.75"
3
ACTICOAT SUR PAD 4X4-3/4"
3
ALEVICYN
GEL
3
ALEVICYN
SOL DERMAL
3
ALLEVYN AG PAD 2"X2"
3
3
3
3
3
ALLEVYN AG PAD 6-3/4"
3
3
ALLEVYN AG PAD 8"X8
3
3
ALLEVYN AG PAD 9"X9"SAC
3
REQUIREMENTS/LIMITS
302
DRUG NAME
DRUG
TIER
ALLEVYN GENT PAD 4"X4
3
ALLEVYN GENT PAD 8"X8"
3
AMORPH WOUND GEL DRESSING
3
ARIDA
3
GEL
ATRAPRO
GEL HYDROGEL
3
ATRAPRO CP KIT
3
AVO CREAM
3
BIAFINE
EMU
EMU
3
BIONECT
AER 0.2%
3
BIONECT
CRE 0.2%
3
BIONECT
GEL 0.2%
3
BIONECT
SPR 0.2%
3
BIOSTEP
MIS 2"X2"
3
BIOSTEP
MIS 4"X4"
3
BIOSTEP AG MIS 2"X2"
3
BIOSTEP AG MIS 4"X4"
3
CA ALGINATE MIS 12" ROPE
3
CA ALGINATE PAD 2"X2"
3
3
3
CARRASYN
3
CELACYN
GEL DRESSING
KIT
CURAGEL HYDR PAD 2"X3"
REQUIREMENTS/LIMITS
3
3
303
DRUG NAME
DRUG
TIER
3
3
3
3
CURAGEL HYDR PAD 8.5"X9.5
3
CURITY HYPER MIS 1/2"X15'
3
CURITY NACL PAD 6"X6-3/4
3
DIAB
3
GEL
DIAB F.D.G. GEL
3
DURAFIBER
PAD 4X4-3/4"
3
DURAFIBER AG PAD 2"X2"
3
DURAFIBER AG PAD 3/4X18"
3
3
DURAFIBER AG PAD 4X4-3/4"
3
3
DURAFIBER AG PAD 8X11.75"
3
ENDO DERMAL MIS 10X12.7
3
ENDO DERMAL MIS 5X5 CM
3
FORTADERM
MIS
3
FORTADERM
MIS ANTIMICR
3
HYDRFRA BLUE PAD RDY 2.5"
3
HYDRFRA BLUE PAD RDY 4X5"
3
HYDRFRA BLUE PAD RDY 8X8"
3
REQUIREMENTS/LIMITS
304
DRUG NAME
DRUG
TIER
HYDRFRA MRF PAD 2"X2.75"
3
HYDROFERA
PAD 4"X4"
3
HYDROFERA
PAD BLUE 2X2
3
HYDROFERA
PAD BLUE 4X4
3
HYDROFERA
PAD BLUE 6X6
3
HYDROFERA
PAD BLUE 9MM
3
HYDROFERA
PAD MRF 2.5"
3
HYDROFERA
PAD MRF4"X4"
3
HYDROFRA MRF PAD 2-1/4X8"
3
HYDROG WOUND MIS 3" DISK
3
HYDROG WOUND MIS 4-3/4"
3
HYDROGEL DRE PAD 2"X3"
3
HYDROGEL DRE PAD 4"X5"
3
HYDROGEL GAU PAD 1"X36"
3
3
3
3
HYGEL
3
GEL 2.5%
HYLASE WOUND GEL
3
luxamend
1
cre
MEDIHONEY
PAD 2"X2"
3
MEDIHONEY
PAD 3/4"X12"
3
MEDIHONEY
PAD 4"X5"
3
REQUIREMENTS/LIMITS
305
DRUG NAME
DRUG
TIER
OASIS MATRIX MIS 3X7CM
3
OASIS ULTRA MIS 3X3.5CM
3
OASIS ULTRA MIS 5 X 7CM
3
OASIS ULTRA MIS TRI MESH
3
OASIS WOUND MIS 3X3.5CM
3
OASIS WOUND MIS 3X7CM
3
PICO WOUND KIT THER SYS
3
PRUTECT
3
EMU
RADIAPLEXRX GEL
3
RESTORE SILV PAD 2"X2"
3
3
RESTORE SILV PAD 4"X4.75"
3
3
3
SILVASORB
GEL
3
SILVRSTAT
GEL DRESSING
3
SONAFINE
EMU
3
SPECTRAGEL GEL
3
TEGADERM AG PAD 2"X2"
3
3
3
3
THERAHONEY GEL
3
REQUIREMENTS/LIMITS
306
DRUG NAME
DRUG
TIER
tropazone cre
REQUIREMENTS/LIMITS
1
VASCUDERM
GEL HYDROGEL
3
VASCUDERM
KIT STASIS
3
WOUND CARE PAD 2" X 2"
3
3
3
ZANABIN
3
GEL HYDROGEL
*DIAGNOSTIC PRODUCTS*
*DIAGNOSTIC DRUGS***
ACTHREL
INJ 100MCG
4
GLUCAGON
INJ 1MG
2
THYROGEN
INJ 1.1MG
4
PA
PA
*DIAGNOSTIC TESTS***
FREESTYLE
TEST STRIPS
2
ONETOUCH
TEST STRIPS
2
*DIGESTIVE AIDS*
*DIGESTIVE ENZYMES W/ ANTICHOLINERGICS***
DIGEX
CAP
3
*DIGESTIVE ENZYMES***
CREON
CAP 12000UNT
2
CREON
CAP 24000UNT
2
CREON
CAP 3000UNIT
2
CREON
CAP 36000UNT
2
307
DRUG NAME
CREON
DRUG
TIER
CAP 6000UNIT
REQUIREMENTS/LIMITS
2
PANCREAZE
CAP 10500UNT
3
PANCREAZE
CAP 16800UNT
3
PANCREAZE
CAP 21000UNT
3
PANCREAZE
CAP 4200UNIT
3
PANCRELIPASE CAP 5000UNIT
3
PERTZYE
CAP
3
SUCRAID
SOL 8500/ML
2
ULTRESA
CAP 13800UNT
3
ULTRESA
CAP 20700UNT
3
ULTRESA
CAP 23000UNT
3
VIOKACE
TAB
3
VIOKACE
TAB 20880
3
ZENPEP
CAP 10000UNT
2
ZENPEP
CAP 15000UNT
2
ZENPEP
CAP 20000UNT
2
ZENPEP
CAP 25000UNT
2
ZENPEP
CAP 3000UNIT
2
ZENPEP
CAP 40000UNT
2
ZENPEP
CAP 5000UNIT
2
*DIURETICS*
*CARBONIC ANHYDRASE INHIBITORS***
acetazolamid cap 500mg er
1
308
DRUG NAME
DRUG
TIER
acetazolamid inj 500mg
1
acetazolamid tab 125mg
1
acetazolamid tab 250mg
1
DIAMOX SEQUE CAP 500MG CR
3
KEVEYIS
3
TAB 50MG
methazolamid tab 25mg
1
methazolamid tab 50mg
1
NEPTAZANE
TAB 25MG
3
NEPTAZANE
TAB 50MG
3
REQUIREMENTS/LIMITS
*DIURETIC COMBINATIONS***
ALDACTAZIDE TAB 25/25
3
ALDACTAZIDE TAB 50/50
3
amilor/hctz tab 5-50
1
DYAZIDE
CAP 37.5-25
3
MAXZIDE
TAB 75-50
3
MAXZIDE-25 TAB
3
spirono/hctz tab 25/25
1
triamt/hctz cap 37.5-25
1
triamt/hctz cap 50-25mg
1
triamt/hctz tab 37.5-25
1
triamt/hctz tab 75-50mg
1
*LOOP DIURETICS***
bumetanide inj 0.25/ml
1
309
DRUG NAME
DRUG
TIER
bumetanide tab 0.5mg
1
bumetanide tab 1mg
1
bumetanide tab 2mg
1
BUMEX
TAB 0.5MG
3
BUMEX
TAB 1MG
3
BUMEX
TAB 2MG
3
DEMADEX
TAB 100MG
3
DEMADEX
TAB 10MG
3
DEMADEX
TAB 20MG
3
DEMADEX
TAB 5MG
3
TAB 25MG
3
EDECRIN
ETHACRYNATE INJ 50MG
3
furosemide inj 100/10ml
1
furosemide inj 10mg/ml
1
furosemide inj 20mg/2ml
1
furosemide inj 40mg/4ml
1
furosemide sol 10mg/ml
1
furosemide sol 8mg/ml
1
furosemide tab 20mg
1
furosemide tab 40mg
1
furosemide tab 80mg
1
LASIX
TAB 20MG
3
LASIX
TAB 40MG
3
REQUIREMENTS/LIMITS
310
DRUG NAME
LASIX
DRUG
TIER
TAB 80MG
REQUIREMENTS/LIMITS
3
SOD EDECRIN INJ 50MG
3
TORSEMIDE
INJ 20MG/2ML
3
TORSEMIDE
INJ 50MG/5ML
3
torsemide
tab 100mg
1
torsemide
tab 10mg
1
torsemide
tab 20mg
1
torsemide
tab 5mg
1
*OSMOTIC DIURETICS***
INTROL
SOL 75%
3
mannitol
inj 10%
1
mannitol
inj 15%
1
mannitol
inj 20%
1
mannitol
inj 25%
1
mannitol
inj 5%
1
osmitrol
inj 10%
1
osmitrol
inj 15%
1
osmitrol
inj 5%
1
osmitrol vfx inj 20%
1
*POTASSIUM SPARING DIURETICS***
ALDACTONE
TAB 100MG
3
ALDACTONE
TAB 25MG
3
ALDACTONE
TAB 50MG
3
311
DRUG NAME
DRUG
TIER
amiloride tab 5mg
1
DYRENIUM
CAP 100MG
3
DYRENIUM
CAP 50MG
3
MIDAMOR
TAB 5MG
3
spironolact tab 100mg
1
1
1
REQUIREMENTS/LIMITS
*THIAZIDES AND THIAZIDE-LIKE DIURETICS***
chlorothiaz inj 500mg
1
chlorothiaz tab 250mg
1
chlorothiaz tab 500mg
1
chlorthalid tab 100mg
1
1
1
DIURIL
3
SUS 250/5ML
hydrochlorot cap 12.5mg
1
hydrochlorot tab 12.5mg
1
hydrochlorot tab 25mg
1
hydrochlorot tab 50mg
1
indapamide tab 1.25mg
1
indapamide tab 2.5mg
1
methyclothia tab 5mg
1
metolazone tab 10mg
1
312
DRUG NAME
DRUG
TIER
metolazone tab 2.5mg
1
metolazone tab 5mg
1
MICROZIDE
3
CAP 12.5MG
SOD DIURIL INJ 500MG
3
THALITONE
3
TAB 15MG
ZAROXOLYN
TAB 2.5MG
3
ZAROXOLYN
TAB 5MG
3
REQUIREMENTS/LIMITS
*ENDOCRINE AND METABOLIC AGENTS - MISC.*
*BISPHOSPHONATES***
ACTONEL
TAB 150MG
3
ST, QL (X)
ACTONEL
TAB 30MG
3
ST, QL (X)
ACTONEL
TAB 35MG
3
ST, QL (X)
ACTONEL
TAB 5MG
3
ST, QL (X)
ALENDRONATE SOL 70/75ML
3
ST
alendronate tab 10mg
1
QL (X)
1
QL (X)
1
QL (X)
alendronate tab 5mg
1
QL (X)
1
QL (X)
ATELVIA
TAB
3
ST
BINOSTO
TAB 70MG
3
ST
BONIVA
INJ 3MG/3ML
4
PA, ST
BONIVA
TAB 150MG
3
ST
313
DRUG NAME
DIDRONEL
DRUG
TIER
TAB 400MG
REQUIREMENTS/LIMITS
3
ETIDRON DISD TAB 200MG
3
ETIDRON DISD TAB 400MG
3
FOSAMAX
SOL
3
ST
FOSAMAX
TAB 10MG
3
ST, QL (X)
FOSAMAX
TAB 35MG
3
ST, QL (X)
FOSAMAX
TAB 40MG
3
ST, QL (X)
FOSAMAX
TAB 5MG
3
ST, QL (X)
FOSAMAX
TAB 70MG
3
ST, QL (X)
FOSAMAX + D TAB 70-2800
3
FOSAMAX + D TAB 70-5600
3
ibandronate inj 3mg/3ml
4
PA, ST
ibandronate tab 150mg
1
ST
pamidronate inj 30/10ml
4
PA
pamidronate inj 30mg
4
PA
pamidronate inj 6mg/ml
4
PA
pamidronate inj 90/10ml
4
PA
pamidronate inj 90mg
4
PA
RECLAST
4
PA
risedron sod tab 35mg dr
1
ST
risedronate tab 150mg
1
ST, QL (X)
1
ST, QL (X)
1
ST, QL (X)
INJ 5/100ML
314
DRUG NAME
DRUG
TIER
REQUIREMENTS/LIMITS
risedronate tab 5mg
1
ST, QL (X)
SKELID
TAB 200MG
3
ZOLEDRONIC INJ 4MG
3
zoledronic inj 4mg/100
4
PA
zoledronic inj 4mg/5ml
4
PA
zoledronic inj 5/100ml
4
PA
ZOMETA
INJ 4MG/100
4
PA
ZOMETA
INJ 4MG/5ML
4
PA
*CALCIMIMETIC AGENTS***
SENSIPAR
TAB 30MG
4
PA
SENSIPAR
TAB 60MG
4
PA
SENSIPAR
TAB 90MG
4
PA
STRENSIQ
INJ 18/0.45
4
PA
STRENSIQ
INJ 28/0.7ML
4
PA
STRENSIQ
INJ 40MG/ML
4
PA
STRENSIQ
INJ 80/0.8ML
4
PA
*CALCITONINS***
calcitonin spr 200/act
1
FORTICAL
SPR 200/ACT
3
MIACALCIN
INJ 200/ML
3
MIACALCIN
SPR 200/ACT
3
*CALCIUM REGULATORS - MISC.***
GANITE
INJ 25MG/ML
3
315
DRUG NAME
DRUG
TIER
REQUIREMENTS/LIMITS
*CARNITINE REPLENISHER - AGENTS***
CARNITOR
INJ 1GM/5ML
3
CARNITOR
SOL 1GM/10ML
3
CARNITOR SF SOL 1GM/10ML
3
levocarnitin inj 200mg/ml
1
levocarnitin sol 1gm/10ml
1
levocarnitin tab 330mg
1
*CORTICOTROPIN***
ACTHAR HP
INJ 80UNIT
4
PA
H.P. ACTHAR INJ 80UNIT
4
PA
*DOPAMINE RECEPTOR AGONISTS***
cabergoline tab 0.5mg
1
*FABRY DISEASE - AGENTS***
FABRAZYME
INJ 35MG
4
PA
FABRAZYME
INJ 5MG
4
PA
*GAA DEFICIENCY TREATMENT - AGENTS***
LUMIZYME
INJ 50MG
4
PA
MYOZYME
INJ 50MG
4
PA
*GROWTH HORMONE RECEPTOR ANTAGONISTS***
SOMAVERT
INJ 10MG
4
PA
SOMAVERT
INJ 15MG
4
PA
SOMAVERT
INJ 20MG
4
PA
SOMAVERT
INJ 25MG
3
SOMAVERT
INJ 30MG
3
316
DRUG NAME
DRUG
TIER
REQUIREMENTS/LIMITS
*GROWTH HORMONE RELEASING HORMONES (GHRH)***
EGRIFTA
INJ 1MG
4
PA
EGRIFTA
SOL 1MG
4
PA
EGRIFTA
SOL 2MG
3
PA
GENOTROPIN INJ 0.2MG
4
PA
4
PA
4
PA
4
PA
4
PA
4
PA
4
PA
4
PA
GENOTROPIN INJ 12MG
4
PA
GENOTROPIN INJ 1MG
4
PA
GENOTROPIN INJ 2MG
4
PA
GENOTROPIN INJ 5MG
4
PA
HUMATROPE
INJ 12MG
4
PA, ST
HUMATROPE
INJ 24MG
4
PA, ST
HUMATROPE
INJ 5MG
4
PA, ST
HUMATROPE
INJ 6MG
4
PA, ST
NORDITROPIN INJ 10/1.5ML
4
PA
4
PA
*GROWTH HORMONES***
317
DRUG NAME
DRUG
TIER
REQUIREMENTS/LIMITS
NORDITROPIN INJ 30/3ML
4
PA
4
PA
NUTROPIN
INJ 10MG
4
PA, ST
NUTROPIN
INJ 5MG
4
PA, ST
NUTROPIN AQ INJ 10MG/2ML
4
PA, ST
NUTROPIN AQ INJ 20MG/2ML
4
PA, ST
NUTROPIN AQ INJ NUSPIN 5
4
PA, ST
OMNITROPE
INJ 10/1.5ML
4
PA, ST
OMNITROPE
INJ 5.8MG
4
PA, ST
OMNITROPE
INJ 5/1.5ML
4
PA, ST
SAIZEN
INJ 5MG
4
PA, ST
SAIZEN
INJ 8.8MG
4
PA, ST
SEROSTIM
INJ 4MG
4
PA
SEROSTIM
INJ 5MG
4
PA
SEROSTIM
INJ 6MG
4
PA
TEV-TROPIN INJ 5MG
4
PA, ST
ZOMACTON
INJ 10MG
4
PA, ST
ZOMACTON
INJ 5MG
4
PA, ST
INJ 8.8MG
4
PA
ZORBTIVE
*HEREDITARY TYROSINEMIA TYPE 1 (HT-1) TREATMENT - AGENTS***
ORFADIN
CAP 10MG
4
PA
ORFADIN
CAP 2MG
4
PA
ORFADIN
CAP 5MG
4
PA
318
DRUG NAME
DRUG
TIER
REQUIREMENTS/LIMITS
*HOMOCYSTINURIA TREATMENT - AGENTS***
CYSTADANE
POW
2
PA
*HYPERAMMONEMIA TREATMENT - AGENTS***
CARBAGLU
TAB 200MG
4
PA
*HYPERPARATHYROID TREATMENT - VITAMIN D ANALOGS***
CALCIJEX
INJ 1MCG/ML
3
calcitriol cap 0.25mcg
1
calcitriol cap 0.5mcg
1
calcitriol inj 1mcg/ml
1
calcitriol sol 1mcg/ml
1
doxercalcif cap 0.5mcg
1
doxercalcif cap 1mcg
1
doxercalcif cap 2.5mcg
1
doxercalcif inj
4
PA
doxercalcif inj 4mcg/2ml
4
PA
HECTOROL
CAP 0.5MCG
3
HECTOROL
CAP 1MCG
3
HECTOROL
CAP 2.5MCG
3
HECTOROL
INJ 2MCG/ML
4
PA
HECTOROL
INJ 4MCG/2ML
4
PA
paricalcitol cap 1 mcg
1
1
1
319
DRUG NAME
DRUG
TIER
paricalcitol inj 2mcg/ml
1
paricalcitol inj 5mcg/ml
1
ROCALTROL
CAP 0.25MCG
3
ROCALTROL
CAP 0.5MCG
3
ROCALTROL
SOL 1MCG/ML
3
ZEMPLAR
CAP 1MCG
3
ZEMPLAR
CAP 2MCG
3
ZEMPLAR
CAP 4MCG
3
ZEMPLAR
INJ 2MCG/ML
3
ZEMPLAR
INJ 5MCG/ML
3
REQUIREMENTS/LIMITS
*INSULIN-LIKE GROWTH FACTORS (SOMATOMEDINS)***
INCRELEX
INJ 40MG/4ML
4
PA
4
PA
*LEPTIN ANALOGUES***
MYALEPT
INJ 11.3MG
*LHRH/GNRH AGONIST ANALOG COMBINATIONS***
LUPANETA
KIT 11.25-5
3
LUPANETA
KIT 3.75-5
3
*LHRH/GNRH AGONIST ANALOG PITUITARY SUPPRESSANTS***
LUPR DEP-PED INJ 11.25MG
2
LUPR DEP-PED INJ 15MG
4
LUPR DEP-PED INJ 30MG
2
LUPR DEP-PED INJ 7.5MG
4
SYNAREL
2
SOL 2MG/ML
PA
PA
*MUCOPOLYSACCHARIDOSIS I (MPS I) - AGENTS***
320
DRUG NAME
DRUG
TIER
ALDURAZYME INJ 2.9MG/5M
4
REQUIREMENTS/LIMITS
PA
*MUCOPOLYSACCHARIDOSIS II (MPS II) - AGENTS***
ELAPRASE
INJ 6MG/3ML
4
PA
*MUCOPOLYSACCHARIDOSIS IV (MPS IV) - AGENTS***
VIMIZIM
INJ 5MG/5ML
4
PA
*MUCOPOLYSACCHARIDOSIS VI (MPS VI) - AGENTS***
NAGLAZYME
INJ 1MG/ML
4
PA
*PARATHYROID HORMONE AND DERIVATIVES***
FORTEO
SOL 600/2.4
4
PA
NATPARA
INJ 100MCG
4
PA
NATPARA
INJ 25MCG
4
PA
NATPARA
INJ 50MCG
4
PA
NATPARA
INJ 75MCG
4
PA
*PHENYLKETONURIA TREATMENT - AGENTS***
KUVAN
TAB 100MG
4
PA
*RANK LIGAND (RANKL) INHIBITORS***
PROLIA
SOL 60MG/ML
4
PA
XGEVA
INJ
4
PA
*SELECTIVE ESTROGEN RECEPTOR MODULATORS (SERMS)***
EVISTA
TAB 60MG
OSPHENA
TAB 60MG
raloxifene tab 60mg
3
3
1
*SELECTIVE VASOPRESSIN V2-RECEPTOR ANTAGONISTS***
SAMSCA
TAB 15MG
4
PA
321
DRUG NAME
SAMSCA
TAB 30MG
DRUG
TIER
REQUIREMENTS/LIMITS
4
PA
octreotide inj 1000mcg
4
PA
4
PA
4
PA
4
PA
octreotide inj 50mcg/ml
4
PA
SANDOSTATIN INJ 1000MCG
4
PA
4
PA
4
PA
4
PA
SANDOSTATIN INJ 50MCG/ML
4
PA
SANDOSTATIN KIT LAR 10MG
4
PA
4
PA
4
PA
SIGNIFOR
INJ 0.3MG/ML
3
SIGNIFOR
INJ 0.6MG/ML
3
SIGNIFOR
INJ 0.9MG/ML
3
*SOMATOSTATIC AGENTS***
SIGNIFOR LAR INJ 20MG
4
PA
4
PA
4
PA
SOMATULINE INJ 120/.5ML
4
PA
SOMATULINE INJ 60/0.2ML
4
PA
322
DRUG NAME
DRUG
TIER
SOMATULINE INJ 90/0.3ML
4
REQUIREMENTS/LIMITS
PA
*UREA CYCLE DISORDER - AGENTS***
AMMONUL
INJ 10%
3
BUPHENYL
TAB 500MG
3
LIQ 1.1GM/ML
4
RAVICTI
PA
*V1A/V2-ARGININE VASOPRESSIN (AVP) RECEPTOR ANTAGONISTS***
VAPRISOL
INJ
3
VAPRISOL
INJ 20/100ML
3
*VASOPRESSIN***
DDAVP
INJ 4MCG/ML
4
DDAVP
SOL 0.01%
3
DDAVP
SPR 0.01%
3
DDAVP
TAB 0.1MG
3
DDAVP
TAB 0.2MG
3
desmopressin inj 4mcg/ml
4
desmopressin sol 0.01%
1
desmopressin spr 0.01%
1
desmopressin tab 0.1mg
1
desmopressin tab 0.2mg
1
PITRESSIN
INJ 20UNT/ML
3
STIMATE
SOL 1.5MG/ML
4
vasopressin inj 10/0.5ml
1
vasopressin inj 20unt/ml
1
PA
PA
PA
323
DRUG NAME
DRUG
TIER
VASOSTRICT INJ 20UNT/ML
REQUIREMENTS/LIMITS
3
*ESTROGENS*
*ESTROGEN & ANDROGEN***
covaryx
tab 1.25-2.5
1
covaryx hs tab
1
eemt
1
tab 1.25-2.5
eemt hs
tab
1
essian
tab
1
essian h.s. tab
1
est estrogen tab mtest
1
est estrogen tab mtest hs
1
estrog/mtest tab 1.25-2.5
1
mtest hs/est tab estrogen
1
mtest/est
1
tab estrogen
*ESTROGEN & PROGESTIN***
ACTIVELLA
TAB 0.5-0.1
3
ACTIVELLA
TAB 1-0.5MG
3
ANGELIQ
TAB 0.25-0.5
3
ANGELIQ
TAB 0.5-1MG
3
BIEST/PROGES CRE
3
CLIMARA PRO DIS WEEKLY
2
COMBIPATCH DIS .05/.14
2
COMBIPATCH DIS .05/.25
2
324
DRUG NAME
DRUG
TIER
estra/noreth tab 0.5-0.1
1
estra/noreth tab 1-0.5mg
1
FEMHRT
3
TAB 0.5-2.5
FEMHRT 1/5 TAB
3
jevantique tab 1mg-5mcg
1
JEVANTIQUE L TAB 0.5-2.5
3
jinteli
tab 1mg-5mcg
1
lopreeza
tab 0.5-0.1
1
lopreeza
tab 1-0.5mg
1
mimvey
tab 1-0.5mg
1
mimvey lo
tab 0.5-0.1
1
noreth/ethin tab 0.5-2.5
1
noreth/ethin tab 1mg-5mcg
1
PREFEST
3
TAB
PREMPHASE
TAB
REQUIREMENTS/LIMITS
2
PREMPRO
TAB .625-2.5
2
PREMPRO
TAB 0.3-1.5
2
PREMPRO
TAB 0.45-1.5
2
PREMPRO
TAB 0.625-5
2
*ESTROGEN-SELECTIVE ESTROGEN RECEPTOR MODULATOR COMB***
DUAVEE
TAB 0.45-20
3
*ESTROGENS***
ALORA
DIS 0.025MG
3
325
DRUG NAME
DRUG
TIER
ALORA
DIS 0.05MG
3
ALORA
DIS 0.075MG
3
ALORA
DIS 0.1MG
3
CENESTIN
TAB 0.3MG
3
CENESTIN
TAB 0.45MG
3
CENESTIN
TAB 0.625MG
3
CENESTIN
TAB 0.9MG
3
CENESTIN
TAB 1.25MG
3
CLIMARA
DIS 0.025MG
3
CLIMARA
DIS 0.0375MG
3
CLIMARA
DIS 0.05MG
3
CLIMARA
DIS 0.06MG
3
CLIMARA
DIS 0.075MG
3
CLIMARA
DIS 0.1MG
3
DELESTROGEN INJ 10MG/ML
3
3
3
DEPO-ESTRADI INJ 5MG/ML
3
DIVIGEL
GEL 0.25MG
3
DIVIGEL
GEL 0.5MG
3
DIVIGEL
GEL 1MG/GM
3
ELESTRIN
GEL 0.06%
3
ENJUVIA
TAB 0.3MG
3
REQUIREMENTS/LIMITS
326
DRUG NAME
DRUG
TIER
ENJUVIA
TAB 0.45MG
3
ENJUVIA
TAB 0.625MG
3
ENJUVIA
TAB 0.9MG
3
ENJUVIA
TAB 1.25MG
3
ESTRACE
TAB 0.5MG
3
ESTRACE
TAB 1MG
3
ESTRACE
TAB 2MG
3
estrad val inj 10mg/ml
1
estrad val inj 200mg/5
1
1
1
estradiol
dis 0.025mg
1
estradiol
dis 0.0375mg
1
estradiol
dis 0.05mg
1
estradiol
dis 0.06mg
1
estradiol
dis 0.075mg
1
estradiol
dis 0.1mg
1
ESTRADIOL
MIS 10MG
3
ESTRADIOL
MIS 12.5MG
3
ESTRADIOL
MIS 25MG
3
ESTRADIOL
MIS 6MG
3
estradiol
tab 0.5mg
1
estradiol
tab 1mg
1
REQUIREMENTS/LIMITS
327
DRUG NAME
estradiol
DRUG
TIER
tab 2mg
1
ESTRASORB EMU
3
ESTROGEL
GEL
3
CRY
3
ESTRONE
estropipate tab 0.75mg
1
estropipate tab 1.5mg
1
estropipate tab 3mg
1
EVAMIST
3
SPR 1.53MG
FEMTRACE
TAB 0.45MG
3
FEMTRACE
TAB 0.9MG
3
MENEST
TAB 0.3MG
2
MENEST
TAB 0.625MG
2
MENEST
TAB 1.25MG
2
MENEST
TAB 2.5MG
2
MENOSTAR
DIS 14MCG
2
MINIVELLE
DIS 0.025 MG
3
MINIVELLE
DIS 0.0375MG
3
MINIVELLE
DIS 0.05MG
3
MINIVELLE
DIS 0.075MG
3
MINIVELLE
DIS 0.1MG
3
ortho-est
tab 0.625
1
ortho-est
tab 1.25
1
PREMARIN
INJ 25MG
REQUIREMENTS/LIMITS
3
328
DRUG NAME
DRUG
TIER
PREMARIN
TAB 0.3MG
2
PREMARIN
TAB 0.45MG
2
PREMARIN
TAB 0.625MG
2
PREMARIN
TAB 0.9MG
2
PREMARIN
TAB 1.25MG
2
VIVELLE-DOT DIS 0.025MG
3
3
3
3
3
REQUIREMENTS/LIMITS
*FLUOROQUINOLONES*
*FLUOROQUINOLONES***
AVELOX
INJ
3
AVELOX
TAB 400MG
3
AVELOX ABC TAB 400MG
3
CIPRO
TAB 250MG
3
CIPRO
TAB 500MG
3
CIPRO
TAB 750MG
3
CIPRO (10%) SUS 500MG/5
3
CIPRO (5%) SUS 250MG/5
3
CIPRO I.V. INJ 200MG
3
CIPRO I.V. INJ 400MG
3
CIPRO XR
3
TAB 1000MG
329
DRUG NAME
CIPRO XR
DRUG
TIER
TAB 500MG
3
ciprofloxacn inj 200mg
1
ciprofloxacn inj 400mg
1
ciprofloxacn sus 250mg/5
1
ciprofloxacn sus 500mg/5
1
ciprofloxacn tab 1000mg
1
1
1
1
ciprofloxacn tab 500mg er
1
1
FACTIVE
3
TAB 320MG
REQUIREMENTS/LIMITS
LEVAQUIN
SOL 25MG/ML
3
LEVAQUIN
TAB 250MG
3
LEVAQUIN
TAB 500MG
3
LEVAQUIN
TAB 750MG
3
LEVAQUIN/D5W INJ 250/50ML
3
LEVAQUIN/D5W INJ 500/100M
3
LEVAQUIN/D5W INJ 750/150
3
levoflox/d5w inj 250/50ml
1
levoflox/d5w inj 500/100m
1
levoflox/d5w inj 750/150
1
levofloxacin inj 25mg/ml
1
330
DRUG NAME
DRUG
TIER
levofloxacin sol 25mg/ml
1
levofloxacin tab 250mg
1
1
1
MOXIFLOXACIN INJ
3
moxifloxacin tab 400mg
1
NOROXIN
3
TAB 400MG
ofloxacin
tab 200mg
1
ofloxacin
tab 300mg
1
ofloxacin
tab 400mg
1
REQUIREMENTS/LIMITS
*GASTROINTESTINAL AGENTS - MISC.*
*GALLSTONE SOLUBILIZING AGENTS***
ACTIGALL
CHENODAL
URSO 250
CAP 300MG
TAB 250MG
TAB 250MG
3
4
PA
3
URSO FORTE TAB 500MG
3
ursodiol
cap 300mg
1
ursodiol
tab 250mg
1
ursodiol
tab 500mg
1
*GASTROINTESTINAL AGENTS - MISC.*
CHOLBAM
CAP 250MG
4
PA
CHOLBAM
CAP 50MG
4
PA
*GASTROINTESTINAL ANTIALLERGY AGENTS***
331
DRUG NAME
DRUG
TIER
cromolyn sod con 100/5ml
1
GASTROCROM CON 100/5ML
3
REQUIREMENTS/LIMITS
*GASTROINTESTINAL CHLORIDE CHANNEL ACTIVATORS***
AMITIZA
CAP 24MCG
2
AMITIZA
CAP 8MCG
2
*GASTROINTESTINAL STIMULANTS***
dexpanthenol inj 250mg/ml
1
metoclopram inj 10mg/2ml
1
metoclopram inj 5mg/ml
1
metoclopram sol 10/10ml
1
metoclopram sol 5mg/5ml
1
metoclopram tab 10mg
1
metoclopram tab 5mg
1
metoclopram tab 5mg odt
1
METOCLOPRAMI TAB 10MG
3
METOZOLV ODT TAB 10MG
3
METOZOLV ODT TAB 5MG
3
REGLAN
3
TAB 10MG
*GLUCAGON-LIKE PEPTIDE-2 (GLP-2) ANALOGS***
GATTEX
KIT 5MG
4
PA
*IBS AGENT - GUANYLATE CYCLASE-C (GC-C) AGONISTS***
LINZESS
CAP 145MCG
2
LINZESS
CAP 290MCG
2
332
DRUG NAME
DRUG
TIER
VIBERZI
TAB 100MG
3
VIBERZI
TAB 75MG
3
REQUIREMENTS/LIMITS
*IBS AGENT - SELECTIVE 5-HT3 RECEPTOR ANTAGONISTS***
alosetron tab 0.5mg
1
alosetron tab 1mg
1
LOTRONEX
TAB 0.5MG
3
LOTRONEX
TAB 1MG
3
*INFLAMMATORY BOWEL AGENTS***
APRISO
CAP 0.375GM
ASACOL
2
TAB 400MG DR
3
TAB 800MG
3
AZULFIDINE TAB 500MG
3
AZULFIDINE TAB 500MG EN
3
balsalazide cap 750mg
1
CANASA
SUP 1000MG
3
COLAZAL
CAP 750MG
3
DELZICOL
CAP 400MG
3
DIPENTUM
CAP 250MG
3
ASACOL HD
GIAZO
LIALDA
TAB 1.1GM
TAB 1.2GM
ST
3
2
mesalamine ene 4gm
1
mesalamine kit 4gm
1
PENTASA
3
CAP 250MG CR
ST
ST
333
DRUG NAME
DRUG
TIER
PENTASA
CAP 500MG CR
3
ROWASA
KIT 4GM
3
SFROWASA
ENE 4GM
REQUIREMENTS/LIMITS
ST
3
sulfasalazin tab 500mg
1
sulfasalazin tab 500mg dr
1
sulfazine tab 500mg
1
sulfazine ec tab 500mg
1
*INTEGRIN RECEPTOR ANTAGONISTS***
ENTYVIO
INJ 300MG
4
PA
*INTESTINAL ACIDIFIERS***
enulose
sol 10gm/15
1
generlac
sol 10gm/15
1
*PERIPHERAL OPIOID RECEPTOR ANTAGONISTS***
ENTEREG
CAP 12MG
3
MOVANTIK
TAB 12.5MG
2
MOVANTIK
TAB 25MG
2
RELISTOR
INJ 12/0.6ML
3
RELISTOR
INJ 8/0.4ML
3
RELISTOR
KIT 12/0.6ML
3
*PHOSPHATE BINDER AGENTS***
AURYXIA
TAB 210MG
3
calc acetate cap 667mg
1
calc acetate tab 667mg
1
334
DRUG NAME
eliphos
DRUG
TIER
tab 667mg
1
FOSRENOL
CHW 1000MG
2
FOSRENOL
CHW 500MG
2
FOSRENOL
CHW 750MG
2
PHOSLO
CAP 667MG
PHOSLYRA
SOL
3
3
RENAGEL
TAB 400MG
2
RENAGEL
TAB 800MG
2
RENVELA
PAK 0.8GM
2
RENVELA
PAK 2.4GM
2
RENVELA
TAB 800MG
2
sevelamer
tab 800mg
VELPHORO
CHW 500MG
REQUIREMENTS/LIMITS
1
3
*PROTON PUMP INHIBITORS***
lansoprazole cap 15mg dr
1
lansoprazole cap 30mg dr
1
LANSOPRAZOLE SUS 3MG/ML
1
lansoprazole tab 15mg odt
1
lansoprazole tab 30mg odt
1
omeprazole cap 10mg
1
omeprazole cap 20mg
1
omeprazole cap 40mg
1
*TUMOR NECROSIS FACTOR ALPHA BLOCKERS***
335
DRUG NAME
DRUG
TIER
REQUIREMENTS/LIMITS
CIMZIA
KIT
4
PA, ST
CIMZIA
KIT STARTER
4
PA, ST
CIMZIA PREFL KIT 200MG/ML
4
PA, ST
REMICADE
4
PA
INJ 100MG
*GENERAL ANESTHETICS*
*ANESTHETICS - MISC.***
AMIDATE
INJ 2MG/ML
3
DIPRIVAN
INJ 10MG/ML
3
etomidate
inj 20/10ml
1
etomidate
inj 2mg/ml
1
etomidate
inj 40/20ml
1
KETALAR
INJ 100MG/ML
3
KETALAR
INJ 10MG/ML
3
KETALAR
INJ 50MG/ML
3
ketamine
inj 100mg/ml
1
ketamine
inj 10mg/ml
1
ketamine
inj 50mg/ml
1
KETAMINE HCL INJ SOD CL
3
LUSEDRA
INJ
3
inj 10mg/ml
1
propofol
propoven
inj 10mg/ml
1
*BARBITURATE ANESTHETICS***
BREVITAL SOD INJ 2.5GM
3
336
DRUG NAME
DRUG
TIER
BREVITAL SOD INJ 200MG
3
BREVITAL SOD INJ 500MG
3
METHOHEXITAL INJ 100/10ML
3
PENTOTHAL
3
INJ 400MG
REQUIREMENTS/LIMITS
*VOLATILE ANESTHETICS***
compound 347 liq
1
ETHRANE
INH
3
SOL
3
FORANE
isoflurane sol
1
sevoflurane sol
1
sojourn
1
sol
SUPRANE
INH
3
SUPRANE
SOL
3
terrell
sol
ULTANE
1
SOL
3
*GENITOURINARY AGENTS - MISCELLANEOUS*
*5-ALPHA REDUCTASE INHIBITORS***
AVODART
CAP 0.5MG
3
dutasteride cap 0.5mg
1
finasteride tab 5mg
1
PROSCAR
3
TAB 5MG
*ALPHA 1-ADRENOCEPTOR ANTAGONISTS***
alfuzosin
tab 10mg
1
337
DRUG NAME
DRUG
TIER
CARDURA XL TAB 4MG
3
CARDURA XL TAB 8MG
3
FLOMAX
CAP 0.4MG
3
RAPAFLO
CAP 4MG
2
RAPAFLO
CAP 8MG
2
tamsulosin cap 0.4mg
1
UROXATRAL
3
TAB 10MG
REQUIREMENTS/LIMITS
*ANTI-INFECTIVE GENITOURINARY IRRIGANTS***
neo/poly gu sol 40/ml ir
1
NEOSPORIN GU SOL 40/ML IR
3
*CITRATES***
citric acid/ sol sod citr
1
CITROLITH
3
TAB
cytra k
gra crystals
1
cytra-2
sol
1
cytra-3
syp
1
cytra-k
sol
1
k citrate
sol citr acd
1
k/na citrate sol citr acd
1
ORACIT
3
SOL
POT CITRATE GRA
3
POT CITRATE GRA MONOHYDR
3
pot citrate tab 1080mg
1
338
DRUG NAME
DRUG
TIER
pot citrate tab 1620mg
1
pot citrate tab 540mg er
1
pot citrate- pak cit acid
1
SHOHLS
3
SOL MODIFIED
SOD CITRATE CRY
3
sod citrate sol citr acd
1
SODIUM CITRA GRA
3
taron
1
gra crystals
tricitrates sol
1
UROCIT-K 10 TAB
3
UROCIT-K 15 TAB
3
UROCIT-K 5 TAB
3
virtrate-2 sol
1
virtrate-2 sol 500-334
1
virtrate-3 sol
1
virtrate-k sol
1
virtrate-k sol 1100-334
1
REQUIREMENTS/LIMITS
*CYSTINOSIS AGENTS***
CYSTAGON
CAP 150MG
3
CYSTAGON
CAP 50MG
3
PROCYSBI
CAP 25MG
3
PROCYSBI
CAP 75MG
3
*GENITOURINARY IRRIGANTS***
339
DRUG NAME
DRUG
TIER
acetic acid sol 0.25%irr
1
aminoac acid sol 1.5% irr
1
argyl saline sol 0.9%
1
curity salin sol 0.9% irr
1
glycine
1
sol 1.5% irr
RENACIDIN
SOL IRR
2
RESECTISOL SOL 5%
3
sodium chlor sol 0.9% irr
1
SORBITOL
SOL 3% IRR
3
SORBITOL
SOL 3.3% IRR
3
SORBITOL-MAN SOL
REQUIREMENTS/LIMITS
3
*INTERSTITIAL CYSTITIS AGENTS***
ELMIRON
CAP 100MG
2
RIMSO-50
SOL 50%
3
*PHOSPHATES***
K-PHOS
TAB MF
2
K-PHOS
TAB NO 2
2
*PROSTATIC HYPERTROPHY AGENT COMBINATIONS***
dutast/tamsu cap 0.5-0.4
1
JALYN
3
CAP
*SYSTEMIC ACIDIFIERS***
hydrochloric inj 1:500
1
*URINARY ANALGESICS***
phenazo
tab 200mg
1
340
DRUG NAME
DRUG
TIER
phenazopyrid tab 100mg
1
phenazopyrid tab 200mg
1
PYRIDIUM
TAB 100MG
3
PYRIDIUM
TAB 200MG
3
REQUIREMENTS/LIMITS
*URINARY STONE AGENTS***
LITHOSTAT
THIOLA
TAB 250MG
TAB 100MG
3
2
*GOUT AGENTS*
*GOUT AGENT COMBINATIONS***
proben/colch tab 500-0.5
1
*GOUT AGENTS***
allopurinol inj 500mg
1
allopurinol tab 100mg
1
allopurinol tab 300mg
1
ALOPRIM
3
INJ 500MG
COLCHICINE CAP 0.6MG
3
COLCHICINE TAB 0.6MG
3
COLCRYS
2
TAB 0.6MG
KRYSTEXXA
MITIGARE
INJ 8MG/ML
CAP 0.6MG
4
PA
3
ULORIC
TAB 40MG
2
ST
ULORIC
TAB 80MG
2
ST
3
ST
ZYLOPRIM
TAB 100MG
341
DRUG NAME
ZYLOPRIM
DRUG
TIER
TAB 300MG
3
REQUIREMENTS/LIMITS
ST
*URICOSURICS***
probenecid tab 500mg
1
*HEMATOLOGICAL AGENTS - MISC.*
*BRADYKININ B2 RECEPTOR ANTAGONISTS***
FIRAZYR
INJ 30MG/3ML
4
PA
4
PA
*COMPLEMENT INHIBITORS***
SOLIRIS
INJ 10MG/ML
*CYCLOPENTYLTRIAZOLOPYRIMIDINE (CPTP) DERIVATIVES***
BRILINTA
TAB 60MG
2
BRILINTA
TAB 90MG
2
KENGREAL
SOL 50MG
3
*GLYCOPROTEIN IIB/IIIA RECEPTOR INHIBITORS***
AGGRASTAT
INJ 25MG/500
3
INTEGRILIN INJ 0.75MG/1
3
INTEGRILIN INJ 2MG/ML
3
REOPRO
3
INJ 2MG/ML
*HEMATORHEOLOGIC AGENTS***
pentoxifylli tab 400mg er
1
TRENTAL
3
TAB 400MG CR
*PHOSPHODIESTERASE III INHIBITORS***
cilostazol tab 100mg
1
cilostazol tab 50mg
1
342
DRUG NAME
DRUG
TIER
PLETAL
TAB 100MG
3
PLETAL
TAB 50MG
3
ZONTIVITY
TAB 2.08MG
REQUIREMENTS/LIMITS
3
*PLASMA EXPANDERS***
DEXTRAN 70 INJ NACL 0.9
3
DEXTRAN HM INJ 32%
3
HESPAN
3
INJ 6%/NACL
hetastarch inj 6%/nacl
1
HEXTEND
3
SOL 6%
LMD 10%/D5W INJ
3
LMD 10%/NACL INJ 0.9%
3
VOLUVEN
3
INJ 6%/NACL
*PLASMA KALLIKREIN INHIBITORS***
KALBITOR
INJ 10MG/ML
4
PA
*PLATELET AGGREGATION INHIBITOR COMBINATIONS***
AGGRENOX
CAP 25-200MG
asa/dipyrida cap 25-200mg
3
1
*PLATELET AGGREGATION INHIBITORS***
dipyridamole tab 25mg
1
1
1
DURLAZA
3
CAP 162.5MG
PERSANTINE TAB 25MG
3
343
DRUG NAME
DRUG
TIER
PERSANTINE TAB 50MG
3
PERSANTINE TAB 75MG
3
REQUIREMENTS/LIMITS
*PROTAMINE***
PROTAMINE SU SOL 10MG/ML
3
*QUINAZOLINE AGENTS***
AGRYLIN
CAP 0.5MG
3
anagrelide cap 0.5mg
1
anagrelide cap 1mg
1
*THIENOPYRIDINE DERIVATIVES***
clopidogrel tab 300mg
1
clopidogrel tab 75mg
1
EFFIENT
TAB 10MG
3
EFFIENT
TAB 5MG
3
PLAVIX
TAB 300MG
3
PLAVIX
TAB 75MG
3
ticlopidine tab 250mg
1
*THROMBOLYTIC ENZYMES***
KINLYTIC
INJ 250000
3
*TISSUE PLASMINOGEN ACTIVATORS***
ACTIVASE
INJ 100MG
4
PA
ACTIVASE
INJ 50MG
4
PA
CATHFLO ACTI INJ VASE
3
RETAVASE
INJ
3
RETAVASE
INJ HALF-KIT
3
344
DRUG NAME
TNKASE
DRUG
TIER
KIT 50MG
REQUIREMENTS/LIMITS
3
*HEMATOPOIETIC AGENTS*
*AGENTS FOR GAUCHER DISEASE***
CERDELGA
CAP 84MG
4
PA
CEREZYME
INJ 200UNIT
4
PA
CEREZYME
INJ 400UNIT
4
PA
4
PA
4
PA
4
PA
ELELYSO
INJ 200UNIT
VPRIV
INJ 400UNIT
ZAVESCA
CAP 100MG
*COBALAMINS***
B-12 COMP KIT 1000MCG
3
HYDROXOCOBAL INJ 1000MCG
3
NASCOBAL
2
SPR 500MCG
*CXCR4 RECEPTOR ANTAGONIST***
MOZOBIL
INJ
4
PA
*CYTOTOXIC AGENTS***
DROXIA
CAP 200MG
2
DROXIA
CAP 300MG
2
DROXIA
CAP 400MG
2
*ERYTHROPOIESIS-STIMULATING AGENTS (ESAS)***
ARANESP
EPOGEN
INJ
INJ
MIRCERA
INJ
4
PA
4
PA
3
345
DRUG NAME
DRUG
TIER
REQUIREMENTS/LIMITS
OMONTYS
INJ 10MG/ML
4
PA
OMONTYS
INJ 20MG/2ML
4
PA
4
PA
PROCRIT
INJ
*FOLIC ACID/FOLATE COMBINATIONS***
FOLIC ACID
5
*FOLIC ACID/FOLATES***
FA-8
fa-8
CAP 800MCG
tab 0.8mg
5
5
FOLIC ACID CAP 20MG
5
FOLIC ACID CAP 5MG
5
FOLIC ACID POW
5
folic acid tab 1000mcg
5
FOLIC ACID TAB 200MCG
5
5
5
sm folic acd tab 400mcg
5
yl folic aci tab 400mcg
5
*GRANULOCYTE COLONY-STIMULATING FACTORS (G-CSF)***
GRANIX
INJ 300/0.5
3
PA
GRANIX
INJ 480/0.8
3
PA
NEULASTA
INJ 6MG/0.6M
4
PA
NEULASTA
KIT 6MG/0.6M
4
PA
NEUPOGEN
INJ 300/0.5
4
PA
346
DRUG NAME
DRUG
TIER
REQUIREMENTS/LIMITS
NEUPOGEN
INJ 300MCG
4
PA
NEUPOGEN
INJ 480/0.8
4
PA
NEUPOGEN
INJ 480MCG
4
PA
ZARXIO
INJ 300/0.5
4
PA
ZARXIO
INJ 480/0.8
4
PA
*GRANULOCYTE/MACROPHAGE COLONY-STIMULATING FACTOR(GM-CSF)***
LEUKINE
INJ 250MCG
4
PA
LEUKINE
INJ 500 MCG
4
PA
4
PA
*INTERLEUKINS***
NEUMEGA
INJ 5MG
*IRON W/ FOLIC ACID***
iron with folic acid
5
*IRON***
FER-IN-SOL DRO 15MG/ML
5
fer-iron
dro 15mg/ml
5
ferosul
elx 220/5ml
5
ferrous
dro 15mg/ml
5
FERROUS SUL LIQ 220/5ML
5
ferrous sulf dro 15mg/ml
5
ferrous sulf elx 220/5ml
5
FERROUS SULF GRA
5
FERROUS SULF SYP 300/5ML
5
iron supplmt dro 15mg/ml
5
347
DRUG NAME
DRUG
TIER
pedia iron dro 15mg/ml
5
PUR-ABSORB LIQ 5MG/20ML
5
REQUIREMENTS/LIMITS
*IRON-B12-FOLATE***
IRON-B12-FOLATE
5
*THROMBOPOIETIN (TPO) RECEPTOR AGONISTS***
NPLATE
INJ 250MCG
4
PA
NPLATE
INJ 500MCG
4
PA
PROMACTA
TAB 12.5MG
4
PA
PROMACTA
TAB 25MG
4
PA
PROMACTA
TAB 50MG
4
PA
PROMACTA
TAB 75MG
4
PA
*HEMOSTATICS*
*HEMOSTATICS - SYSTEMIC***
AMICAR
SOL 0.25/ML
3
AMICAR
SYP 25%
3
AMICAR
TAB 1000MG
3
AMICAR
TAB 500MG
3
aminocapr ac inj 250mg/ml
1
aminocapr ac syp 25%
1
AMINOCAPR AC TAB 1000MG
3
aminocapr ac tab 500mg
1
CYKLOKAPRON INJ 100MG/ML
3
LYSTEDA
3
TAB 650MG
348
DRUG NAME
DRUG
TIER
tranex acid inj 1000m/10
1
tranex acid inj 100mg/ml
1
tranex acid tab 650mg
1
TRASYLOL
3
INJ 10000/ML
REQUIREMENTS/LIMITS
*HYPNOTICS*
*BARBITURATE HYPNOTICS***
AMYTAL SOD INJ 500MG
3
BUTISOL SOD ELX 30MG/5ML
3
BUTISOL SOD TAB 30MG
3
BUTISOL SOD TAB 50MG
3
LUMINAL
INJ 130MG/ML
3
MEBARAL
TAB 100MG
3
MEBARAL
TAB 32MG
3
MEBARAL
TAB 50MG
3
NEMBUTAL
INJ 50MG/ML
3
NEMBUTAL SOD INJ 50MG/ML
3
phenobarb
elx 20mg/5ml
1
phenobarb
inj 130mg/ml
1
PHENOBARB
INJ 65MG/ML
3
phenobarb
sol 20mg/5ml
1
phenobarb
tab 100mg
1
phenobarb
tab 15mg
1
phenobarb
tab 16.2mg
1
349
DRUG NAME
DRUG
TIER
phenobarb
tab 30mg
1
phenobarb
tab 32.4mg
1
phenobarb
tab 60mg
1
phenobarb
tab 64.8mg
1
phenobarb
tab 97.2mg
1
SECONAL
CAP 100MG
REQUIREMENTS/LIMITS
3
*BENZODIAZEPINE HYPNOTIC-NUTRITIONAL SUPPLEMENT COMB***
STRAZEPAM
PAK
3
*BENZODIAZEPINE HYPNOTICS***
DORAL
TAB 15MG
3
estazolam
tab 1mg
1
estazolam
tab 2mg
1
flurazepam cap 15mg
1
flurazepam cap 30mg
1
HALCION
3
TAB 0.25MG
midazolam inj 10/10ml
1
midazolam inj 10mg/2ml
1
1
1
midazolam inj 50mg/10
1
1
midazolam inj 5mg/ml
1
midazolam syp 2mg/ml
1
350
DRUG NAME
quazepam
DRUG
TIER
tab 15mg
REQUIREMENTS/LIMITS
1
RESTORIL
CAP 15MG
3
RESTORIL
CAP 22.5MG
3
RESTORIL
CAP 30MG
3
RESTORIL
CAP 7.5MG
3
temazepam
cap 15mg
1
temazepam
cap 22.5mg
1
temazepam
cap 30mg
1
temazepam
cap 7.5mg
1
triazolam tab 0.125mg
1
triazolam tab 0.25mg
1
*GABA RECEPTOR MODULATOR-NUTRITIONAL SUPPLEMENT COMB***
GABAZOLPIDEM PAK 5MG
3
SENTRAZOLPID PAK PM-5
3
*HYPNOTICS - TRICYCLIC AGENTS***
SILENOR
TAB 3MG
3
SILENOR
TAB 6MG
3
*NON-BARBITURATE HYPNOTICS***
CHLORAL
CRY HYDRATE
3
CHLORAL HYDR SYP 500/5ML
3
PARALDEHYDE LIQ
3
SOMNOTE
3
CAP 500MG
*NON-BENZODIAZEPINE - GABA-RECEPTOR MODULATORS***
351
DRUG NAME
DRUG
TIER
REQUIREMENTS/LIMITS
AMBIEN
TAB 10MG
3
ST, QL (X)
AMBIEN
TAB 5MG
3
ST, QL (X)
AMBIEN CR
TAB 12.5MG
3
ST, QL (X)
AMBIEN CR
TAB 6.25MG
3
ST, QL (X)
EDLUAR
SUB 10MG
3
ST
EDLUAR
SUB 5MG
3
ST
eszopiclone tab 1mg
1
eszopiclone tab 2mg
1
eszopiclone tab 3mg
1
INTERMEZZO SUB 1.75MG
3
ST
INTERMEZZO SUB 3.5MG
3
ST
LUNESTA
TAB 1MG
3
ST
LUNESTA
TAB 2MG
3
ST
LUNESTA
TAB 3MG
3
ST
SONATA
CAP 10MG
3
ST
SONATA
CAP 5MG
3
ST
zaleplon
cap 10mg
1
zaleplon
cap 5mg
1
zolpidem
tab 10mg
1
QL (X)
zolpidem
tab 5mg
1
QL (X)
zolpidem er tab 12.5mg
1
ST, QL (X)
zolpidem er tab 6.25mg
1
ST, QL (X)
ZOLPIMIST
3
ST
SPR 5MG
352
DRUG NAME
DRUG
TIER
REQUIREMENTS/LIMITS
*OREXIN RECEPTOR ANTAGONISTS*
BELSOMRA
TAB 10MG
3
BELSOMRA
TAB 15MG
3
BELSOMRA
TAB 20MG
3
BELSOMRA
TAB 5MG
3
*SELECTIVE ALPHA2-ADRENORECEPTOR AGONIST SEDATIVES***
dexmedetomid inj 200/2ml
1
PRECEDEX
INJ 100MCG
3
PRECEDEX
INJ 200/50ML
3
PRECEDEX
INJ 400/100
3
PRECEDEX
INJ 80/20ML
3
*SELECTIVE MELATONIN RECEPTOR AGONISTS***
HETLIOZ
CAP 20MG
4
TAB 8MG
3
ROZEREM
PA
*LAXATIVES*
*BOWEL EVACUANT COMBINATIONS***
COLYTE/FLAVR SOL PACKS
3
gavilyte-c sol
1
gavilyte-g sol
1
gavilyte-h kit
1
gavilyte-n sol flav pk
1
GOLYTELY
SOL
3
GOLYTELY
SOL PINEAPPL
3
353
DRUG NAME
DRUG
TIER
HALFLYTELY KIT FLAV PKS
3
MOVIPREP
SOL
3
NULYTELY
SOL FLAV PKS
3
PCP 100
KIT
3
peg 3350
sol electrol
1
peg-3350
sol electrol
1
peg-3350/kcl sol /sodium
1
peg-prep
1
kit
PREPOPIK
PAK
3
SUCLEAR
KIT
3
SUPREP BOWEL SOL PREP
2
trilyte
1
sol
REQUIREMENTS/LIMITS
*LAXATIVES - MISCELLANEOUS***
constulose sol 10gm/15
1
KRISTALOSE PAK 10GM
2
KRISTALOSE PAK 20GM
3
lactulose sol 10gm/15
1
lactulose sol 20gm/30
1
*LUBRICANT LAXATIVES***
MINERAL
MURI-LUBE
OIL HEAVY
OIL
3
3
*SALINE LAXATIVE MIXTURES***
OSMOPREP
TAB 1.5GM
3
354
DRUG NAME
VISICOL
TAB 1.5GM
DRUG
TIER
REQUIREMENTS/LIMITS
2
*SALINE LAXATIVES***
MAGN SULFATE GRA
3
*STIMULANT LAXATIVES***
CASCARA
EXT SAGRADA
3
CASCARA SAGR EXT
3
CASCARA SAGR EXT AROMATIC
3
*LOCAL ANESTHETICS-PARENTERAL*
*LOCAL ANESTHETIC & SYMPATHOMIMETIC***
ARTICADENT INJ DENTAL
3
BL INJECTION KIT
3
bupivacaine/ inj epi 0.25
1
bupivacaine/ inj epi 0.5%
1
CITANEST FOR INJ DENT 4%
3
LETS
3
KIT
lido/epi
inj 0.5%
1
lido/epi
inj 1.5%
1
lido/epi
inj 2%
1
lido/epi 1%- inj 1:100000
1
MARCAINE/EPI INJ 0.25%
3
MARCAINE/EPI INJ 0.5%
3
sensorcaine inj -mpf/epi
1
sensorcaine/ inj epi 0.25
1
355
DRUG NAME
DRUG
TIER
sensorcaine/ inj epi 0.5%
1
XYLO-MPF/EPI INJ 1%
3
XYLO-MPF/EPI INJ 1.5%
3
XYLO-MPF/EPI INJ 2%
3
XYLO/EPI
INJ 0.5%
3
XYLO/EPI
INJ 2%
3
XYLO/EPI 1%- INJ 1:100000
3
xylocaine
1
inj dent 2%
REQUIREMENTS/LIMITS
*LOCAL ANESTHETIC COMBINATIONS***
DUOCAINE
INJ
3
MARLIDO
KIT
3
MARLIDO-25 KIT
3
*LOCAL ANESTHETICS - AMIDES***
BIOPSY TRAY KIT MARROW
3
BONE MARROW KIT 16GX2"
3
BONE MARROW KIT BIOPSY
3
bupivacaine inj 0.25%
1
1
1
bupivacaine inj spinal
1
CARBOCAINE INJ 1%
3
CARBOCAINE INJ 1% PF
3
CARBOCAINE INJ 1.5% PF
3
356
DRUG NAME
DRUG
TIER
CARBOCAINE INJ 2%
3
CARBOCAINE INJ 2% PF
3
CITANEST
INJ PLAIN 4%
3
EXPAREL
INJ 1.3%
3
LIDO/DEXTROS INJ 5-7.5%
3
lidocaine
inj 0.5%
1
lidocaine
inj 1%
1
lidocaine
inj 1.5%
1
lidocaine
inj 2%
1
lidocaine
inj 4%
1
MARCAINE
INJ 0.25%
3
MARCAINE
INJ 0.5%
3
MARCAINE
INJ 0.75%
3
MARCAINE
INJ SPINAL
3
MEPIVACAINE INJ 3%
3
NAROPIN
INJ 10MG/ML
3
NAROPIN
INJ 2MG/ML
3
NAROPIN
INJ 5MG/ML
3
NAROPIN
INJ 7.5MG/ML
3
PARACENTESIS KIT TRAY 8FR
3
polocaine inj -mpf 1%
1
polocaine inj -mpf 2%
1
polocaine inj 1%
1
REQUIREMENTS/LIMITS
357
DRUG NAME
DRUG
TIER
polocaine inj 2%
1
polocaine inj mpf 1.5%
1
PUDEND/LOCAL KIT 1% LIDO
3
ropivacaine inj 10mg/ml
1
1
1
ropivacaine inj 7.5mg/ml
1
sensorcaine inj 0.25%
1
sensorcaine inj 0.5%
1
sensorcaine inj mpf 0.5%
1
sensorcaine inj mpf spin
1
sensorcaine inj mpf0.25%
1
sensorcaine inj mpf0.75%
1
SPINAL/EPIDU KIT CL CATH
3
SPINAL/EPIDU KIT OPN CATH
3
XYLOCAINE
INJ -MPF 1%
3
XYLOCAINE
INJ -MPF 2%
3
XYLOCAINE
INJ -MPF 4%
3
XYLOCAINE
INJ 0.5%
3
XYLOCAINE
INJ 1%
3
XYLOCAINE
INJ MPF 0.5%
3
XYLOCAINE
INJ MPF 1.5%
3
ZINGO
INJ 0.5MG
REQUIREMENTS/LIMITS
3
358
DRUG NAME
DRUG
TIER
REQUIREMENTS/LIMITS
*LOCAL ANESTHETICS - ESTERS***
chloroproc inj 2%
1
chloroproc inj 3%
1
NESACAINE
INJ -MPF 2%
3
NESACAINE
INJ -MPF 3%
3
NESACAINE
INJ 1%
3
NESACAINE
INJ 2%
3
NOVOCAIN
INJ 1%
3
PONTOCAINE INJ 1%
3
PONTOCAINE INJ 20MG
3
PROCAINE HCL CRY
3
tetracaine inj 1%
1
*MACROLIDES*
*AZITHROMYCIN***
AZITHROMYCIN INJ 2.5GM
3
azithromycin inj 500mg
1
azithromycin sus 100/5ml
1
azithromycin sus 200/5ml
1
azithromycin tab 250mg
1
1
1
ZITHROMAX
INJ 500MG
3
ZITHROMAX
SUS 100/5ML
3
359
DRUG NAME
DRUG
TIER
ZITHROMAX
SUS 200/5ML
3
ZITHROMAX
TAB 250MG
3
ZITHROMAX
TAB 500MG
3
ZITHROMAX
TAB 600MG
3
ZITHROMAX
TAB TRI-PAK
3
ZITHROMAX
TAB Z-PAK
3
ZMAX
SUS 2GM
REQUIREMENTS/LIMITS
3
*CLARITHROMYCIN***
BIAXIN
SUS 250/5ML
3
BIAXIN
TAB 250MG
3
BIAXIN
TAB 500MG
3
BIAXIN XL
TAB 500MG
3
BIAXIN XL
TAB PAC 500
3
clarithromyc sus 125/5ml
1
clarithromyc sus 250/5ml
1
clarithromyc tab 250mg
1
clarithromyc tab 500mg
1
clarithromyc tab 500mg er
1
*ERYTHROMYCINS***
e.e.s. 400 tab 400mg
1
E.E.S. GRAN SUS 200/5ML
3
ERY-TAB
TAB 250MG EC
3
ERY-TAB
TAB 333MG EC
3
360
DRUG NAME
ery-tab
DRUG
TIER
tab 500mg ec
REQUIREMENTS/LIMITS
1
ERYPED
SUS 200/5ML
3
ERYPED
SUS 400/5ML
3
erythrocin inj 1000mg
1
erythrocin inj 500mg
1
erythrocin tab 250mg
1
erythrom eth tab 400mg
1
erythromycin cap 250mg ec
1
erythromycin tab 250mg bs
1
erythromycin tab 500mg bs
1
PCE
TAB 333MG EC
3
PCE
TAB 500MG EC
3
*FIDAXOMICIN***
DIFICID
TAB 200MG
3
*MEDICAL DEVICES*
*GLUCOSE MONITORING TEST SUPPLIES***
FREESTYLE
GLUCOSE MONITOR
LANCETS
ONETOUCH
PRECISION
2
2
GLUCOSE MONITOR
GLUCOSE MONITOR
2
2
*INSULIN ADMINISTRATION SUPPLIES***
V-GO
KIT
3
*NEEDLES & SYRINGES***
361
DRUG NAME
DRUG
TIER
INSULIN SYRINGES AND NEEDLES
REQUIREMENTS/LIMITS
2
*MIGRAINE PRODUCTS*
*ERGOT COMBINATIONS***
CAFERGOT
TAB 1-100MG
3
ergotam/caff tab 1/100
1
migergot
1
sup 2/100
*MIGRAINE COMBINATIONS***
isometh/apap cap dichlor
1
isometh/caff tab /apap
1
migragesic cap ida
1
MIGRALAM
3
nodolor
CAP
cap
PRODRIN
1
TAB
3
*MIGRAINE PRODUCTS***
D.H.E. 45
INJ 1MG/ML
3
DIHYDROERGOT CRY MESYLATE
3
dihydroergot inj 1mg/ml
1
dihydroergot spr 4mg/ml
1
ERGOMAR
SUB 2MG
3
TAB 130MG
3
MIGRAL
MIGRANAL
SPR 4MG/ML
3
*SELECTIVE SEROTONIN AGONIST-NSAID COMBINATIONS***
TREXIMET
TAB 85-500MG
3
QL (X)
362
DRUG NAME
DRUG
TIER
REQUIREMENTS/LIMITS
*SELECTIVE SEROTONIN AGONISTS 5-HT(1)***
almotrip mal tab 12.5mg
1
QL (X)
almotrip mal tab 6.25mg
1
QL (X)
almotriptan tab 12.5mg
1
QL (X)
almotriptan tab 6.25mg
1
QL (X)
ALSUMA
INJ 6MG/0.5
3
QL (X)
AMERGE
TAB 1MG
3
QL (X)
AMERGE
TAB 2.5MG
3
QL (X)
AXERT
TAB 12.5MG
3
QL (X)
AXERT
TAB 6.25MG
3
QL (X)
FROVA
TAB 2.5MG
3
QL (X)
IMITREX
INJ 4MG/0.5
3
QL (X)
IMITREX
INJ 6MG/0.5
3
QL (X)
IMITREX
SPR 20MG/ACT
2
QL (X)
IMITREX
SPR 5MG/ACT
2
QL (X)
IMITREX
TAB 100MG
3
QL (X)
IMITREX
TAB 25MG
3
QL (X)
IMITREX
TAB 50MG
3
QL (X)
MAXALT
TAB 10MG
3
QL (X)
MAXALT
TAB 5MG
3
QL (X)
MAXALT-MLT TAB 10MG
3
QL (X)
MAXALT-MLT TAB 5MG
3
QL (X)
naratriptan tab 1mg
1
QL (X)
363
DRUG NAME
DRUG
TIER
REQUIREMENTS/LIMITS
naratriptan tab 2.5mg
1
QL (X)
RELPAX
TAB 20MG
2
QL (X)
RELPAX
TAB 40MG
2
QL (X)
rizatriptan tab 10mg
1
QL (X)
rizatriptan tab 10mg odt
1
QL (X)
rizatriptan tab 5mg
1
QL (X)
rizatriptan tab 5mg odt
1
QL (X)
sumatriptan inj 4mg/0.5
1
QL (X)
sumatriptan inj 6mg/0.5
1
QL (X)
sumatriptan spr 20mg/act
1
QL (X)
sumatriptan spr 5mg/act
1
QL (X)
sumatriptan tab 100mg
1
QL (X)
1
QL (X)
1
QL (X)
SUMAVEL DOSE INJ 4MG/0.5
3
QL (X)
SUMAVEL DOSE INJ 6MG/0.5
3
QL (X)
ZECUITY
3
PAD 6.5MG/4H
zolmitriptan tab 2.5 mg
1
QL (X)
zolmitriptan tab 2.5mg
1
QL (X)
zolmitriptan tab 5mg
1
QL (X)
ZOMIG
SPR 2.5MG
3
ZOMIG
SPR 5MG
3
QL (X)
ZOMIG
TAB 2.5MG
3
QL (X)
364
DRUG NAME
ZOMIG
DRUG
TIER
TAB 5MG
REQUIREMENTS/LIMITS
3
QL (X)
ZOMIG NASAL SPR 5MG
3
QL (X)
ZOMIG ZMT
TAB 2.5 MG
3
QL (X)
ZOMIG ZMT
TAB 5MG
3
QL (X)
*MINERALS & ELECTROLYTES*
*FLUORIDE***
FLUORIDE PREPARATIONS
5
*IODINE PRODUCTS***
IODINE
SOL STRONG
2
*PHOSPHATE***
K-PHOS
TAB
2
*MOUTH/THROAT/DENTAL AGENTS*
*ANESTHETICS TOPICAL ORAL - COMBINATIONS***
FIRST-MOUTHW SUS BLM
3
*ANESTHETICS TOPICAL ORAL***
lidocaine
sol 2% visc
1
lidocaine
sol 4%
1
LTA 360 KIT SOL 4%
3
topex topcal spr anesthet
1
*ANTI-INFECTIVE COMBINATIONS - THROAT***
BXN MOUTHWSH SUS
3
FIRST DUKES SUS MOUTHWSH
3
FIRST-MARYS SUS MOUTHWSH
3
365
DRUG NAME
DRUG
TIER
REQUIREMENTS/LIMITS
*ANTI-INFECTIVES - THROAT***
clotrimazole loz 10mg
1
clotrimazole tro 10mg
1
nystatin
1
ORAVIG
sus 100000
TAB 50MG
3
*ANTIALLERGY AGENTS - MOUTH/THROAT***
APHTHASOL PST 5%
3
*ANTISEPTIC COMBINATIONS - MOUTH/THROAT***
DEBACTEROL SOL 30-50%
3
*ANTISEPTICS - MOUTH/THROAT***
chlorhex glu sol 0.12%
1
paroex
1
PERIDEX
periogard
sol 0.12%
SOL 0.12%
sol 0.12%
3
1
*DENTAL AIDS***
ZINC ACETATE CRY
3
366
DRUG NAME
DRUG
TIER
367
REQUIREMENTS/LIMITS
DRUG NAME
DRUG
TIER
368
REQUIREMENTS/LIMITS
DRUG NAME
SALICEPT
DRUG
TIER
SUS
REQUIREMENTS/LIMITS
3
*SALIVA STIMULANTS***
cevimeline cap 30mg
1
EVOXAC
3
CAP 30MG
pilocarpine tab 5mg
1
pilocarpine tab 7.5mg
1
SALAGEN
TAB 5MG
3
SALAGEN
TAB 7.5MG
3
*STEROIDS - MOUTH/THROAT***
oralone
pst 0.1%
1
triamcin/ora pst 0.1%
1
triamcinolon pst 0.1%
1
*MULTIVITAMINS*
*B-COMPLEX W/ C & FOLIC ACID***
renal caps
5
*B-COMPLEX W/ FOLIC ACID***
b complex
with folic acid
5
*PRENATAL MV & MIN W/FE-FA***
PRENATAL VITAMINS
5
*MUSCULOSKELETAL THERAPY AGENTS*
*ARTICULAR CARTILAGE REPAIR THERAPY***
CARTICEL
IMP
3
*CENTRAL MUSCLE RELAXANTS***
369
DRUG NAME
DRUG
TIER
AMRIX
CAP 15MG
3
AMRIX
CAP 30MG
3
baclofen
tab 10mg
1
baclofen
tab 20mg
1
carisoprodol tab 250mg
1
carisoprodol tab 350mg
1
chlorzoxazon tab 500mg
1
cyclobenzapr cap 15mg er
1
cyclobenzapr cap 30mg er
1
CYCLOBENZAPR CRE 20MG/GM
3
CYCLOBENZAPR CRE 5% KIT
3
CYCLOBENZAPR KIT COMFORT
3
cyclobenzapr tab 10mg
1
cyclobenzapr tab 5mg
1
cyclobenzapr tab 7.5mg
1
ed baclofen tab 10mg
1
FEXMID
TAB 7.5MG
3
FLEXERIL
TAB 10MG
3
FLEXERIL
TAB 5MG
3
REQUIREMENTS/LIMITS
GABLOFEN
INJ 10000/20
4
PA
GABLOFEN
INJ 20000/20
4
PA
GABLOFEN
INJ 40000/20
4
PA
GABLOFEN
INJ 50MCG/ML
4
PA
370
DRUG NAME
DRUG
TIER
REQUIREMENTS/LIMITS
LIORESAL INT INJ 0.05MG/1
4
PA
LIORESAL INT INJ 10MG/20
4
PA
LIORESAL INT INJ 10MG/5ML
4
PA
LIORESAL INT INJ 40MG/20
4
PA
LORZONE
TAB 375MG
3
LORZONE
TAB 750MG
3
METAXALONE TAB 400MG
3
metaxalone tab 800mg
1
methocarbam inj 100mg/ml
1
methocarbam tab 500mg
1
methocarbam tab 750mg
1
NORFLEX
3
INJ 30MG/ML
orphenadrine inj 30mg/ml
1
orphenadrine tab 100mg er
1
PARAFON FORT TAB 500MG
3
ROBAXIN
INJ 100MG/ML
3
ROBAXIN
TAB 500MG
3
ROBAXIN-750 TAB 750MG
3
SKELAXIN
3
TAB 800MG
SOMA
TAB 250MG
3
SOMA
TAB 350MG
3
TABRADOL
SUS 1MG/ML
tizanidine cap 2mg
3
1
371
DRUG NAME
DRUG
TIER
tizanidine cap 4mg
1
tizanidine cap 6mg
1
tizanidine tab 2mg
1
tizanidine tab 4mg
1
ZANAFLEX
CAP 2MG
3
ZANAFLEX
CAP 4MG
3
ZANAFLEX
CAP 6MG
3
ZANAFLEX
TAB 4MG
3
REQUIREMENTS/LIMITS
*DIRECT MUSCLE RELAXANTS***
DANTRIUM
CAP 100MG
3
DANTRIUM
CAP 25MG
3
DANTRIUM
CAP 50MG
3
DANTRIUM IV INJ 20MG
3
dantrolene cap 100mg
1
dantrolene cap 25mg
1
dantrolene cap 50mg
1
revonto
1
inj 20mg
RYANODEX
INJ 250MG
3
*MUSCLE RELAXANT COMBINATIONS***
carisopr/asa tab 200-325
1
carisoprodol tab asa/cod
1
orph/asa/caf tab
1
orphen cpd tab ds
1
372
DRUG NAME
DRUG
TIER
REQUIREMENTS/LIMITS
*MUSCLE RELAXANT-LINIMENTS COMBINATIONS***
CYCLOBENZAPR PAK PAX
3
FLEXEPAX
3
MIS
TIZANIDINE KIT COMFORT
3
*MUSCLE RELAXANT-NUTRITIONAL SUPPLEMENT COMBINATIONS***
PRAZOLAMINE PAK
3
THERABENZAPR PAK -60
3
THERABENZAPR PAK -90
3
THERABENZAPR PAK -90-5
3
*VISCOSUPPLEMENTS***
EUFLEXXA
GEL-ONE
HYALGAN
INJ 10MG/ML
4
INJ 30MG/3ML
3
INJ 20MG/2ML
4
PA
PA
HYALURONIC/ INJ LIDOCAIN
3
MONOVISC
INJ 88MG/4ML
4
PA
ORTHOVISC
INJ 15MG/ML
4
PA
4
PA
SUPARTZ FX INJ 25/2.5ML
4
PA
SYNVISC
4
PA
4
PA
SUPARTZ
INJ 25/2.5ML
INJ 8MG/ML
SYNVISC ONE INJ 8MG/ML
*NASAL AGENTS - SYSTEMIC AND TOPICAL*
*ANTIHISTAMINE-STEROID***
AZENASE PAK MIS 137-50
3
373
DRUG NAME
DYMISTA
DRUG
TIER
SPR 137-50
REQUIREMENTS/LIMITS
3
*NASAL ANTIBIOTICS***
BACTROBAN
OIN NASAL 2%
3
*NASAL ANTICHOLINERGICS***
ATROVENT NAS SOL 0.03%
3
ATROVENT NAS SOL 0.06%
3
ipratropium spr 0.03%
1
ipratropium spr 0.06%
1
*NASAL ANTIHISTAMINES***
ASTELIN NASA SPR 137MCG
3
ASTEPRO
3
SPR 0.15%
azelastine spr 0.1%
1
azelastine spr 0.15%
1
olopatadine spr 0.6%
1
PATANASE
3
SPR 0.6%
*NASAL STEROIDS***
BECONASE AQ SUS 0.042%
3
budesonide sus 32mcg
1
FLONASE
3
SPR 0.05%
flunisolide spr 0.025%
1
flunisolide spr 29mcg
1
NASACORT AQ AER 55MCG/AC
3
NASONEX
3
SPR 50MCG/AC
374
DRUG NAME
OMNARIS
QNASL
DRUG
TIER
SPR
AER 80MCG
3
2
QNASL CHILD SPR 40MCG
2
RHINOCORT
3
SUS AQUA
triamcinolon aer 55mcg/ac
1
VERAMYST
2
SPR 27.5MCG
ZETONNA
AER 37MCG
REQUIREMENTS/LIMITS
3
*SYSTEMIC DECONGESTANTS***
PSEUDOEPHEDR CRY HCL
3
*TOPICAL DECONGESTANTS***
ADRENALIN
SOL 1:1000
3
PHENYLEPHRIN CRY
3
TYZINE
3
SOL 0.1%
TYZINE PED DRO 0.05%
3
*NEUROMUSCULAR AGENTS*
*BENZATHIAZOLES***
RILUTEK
riluzole
TAB 50MG
tab 50mg
3
1
*DEPOLARIZING MUSCLE RELAXANTS***
ANECTINE
INJ 20MG/ML
3
QUELICIN
INJ -1000
3
QUELICIN
INJ 20MG/ML
3
*NEUROMUSCULAR BLOCKING AGENT - NEUROTOXINS***
375
DRUG NAME
DRUG
TIER
REQUIREMENTS/LIMITS
BOTOX
INJ 100UNIT
4
PA
BOTOX
INJ 200UNIT
4
PA
DYSPORT
INJ 300UNIT
4
PA
DYSPORT
INJ 500UNIT
4
PA
MYOBLOC
INJ 10000/2
4
PA
MYOBLOC
INJ 2500/0.5
4
PA
MYOBLOC
INJ 5000/ML
4
PA
XEOMIN
INJ 100UNIT
3
XEOMIN
INJ 50 UNIT
3
*NONDEPOLARIZING MUSCLE RELAXANTS***
atracurium inj 10mg/ml
1
atracurium inj 50mg/5ml
1
cisatracuriu inj 10mg/ml
1
cisatracuriu inj 2mg/ml
1
NIMBEX
INJ 10MG/ML
3
NIMBEX
INJ 2MG/ML
3
pancuronium inj 1mg/ml
1
pancuronium inj 2mg/ml
1
rocuronium inj 100mg/10
1
rocuronium inj 10mg/ml
1
rocuronium inj 50mg/5ml
1
vecuronium inj 10mg
1
vecuronium inj 20mg
1
376
DRUG NAME
ZEMURON
DRUG
TIER
INJ 10MG/ML
REQUIREMENTS/LIMITS
3
*NUTRIENTS*
*AMINO ACID MIXTURES***
AMINOSYN
INJ 10%
3
AMINOSYN
INJ 3.5%
3
AMINOSYN
INJ 5%
3
AMINOSYN
INJ 7%
3
AMINOSYN
INJ 8.5%
3
aminosyn
inj 8.5/lyte
1
AMINOSYN 2-M INJ 4.25/D10
3
AMINOSYN 7% INJ /LYTES
3
AMINOSYN II INJ 10%
3
AMINOSYN II INJ 15%
3
AMINOSYN II INJ 3.5/D25
3
3
3
3
AMINOSYN II INJ 7%
3
AMINOSYN II INJ 8.5%
3
aminosyn ii inj 8.5/lyte
1
AMINOSYN IIM INJ 3.5%/D5W
3
AMINOSYN M INJ 3.5%
3
AMINOSYN-HBC INJ 7%
3
377
DRUG NAME
DRUG
TIER
aminosyn-hf inj 8%
1
AMINOSYN-PF INJ 10%
3
AMINOSYN-PF INJ 7%
3
AMINOSYN-RF INJ 5.2%
3
AMINOSYN/D20 INJ II 4.25%
3
3
3
CLINIMIX
INJ 2.75/D5W
3
CLINIMIX
INJ 4.25/D10
3
CLINIMIX
INJ 4.25/D20
3
CLINIMIX
INJ 4.25/D25
3
CLINIMIX
INJ 4.25/D5W
3
CLINIMIX
INJ 5%/D15W
3
CLINIMIX
INJ 5%/D20W
3
CLINIMIX
INJ 5%/D25W
3
CLINIMIX E INJ 2.75/D10
3
CLINIMIX E INJ 2.75/D5W
3
3
3
CLINIMIX E INJ 4.25/D5W
3
CLINIMIX E INJ 5%/D15W
3
3
3
REQUIREMENTS/LIMITS
378
DRUG NAME
DRUG
TIER
clinisol sf inj 15%
1
FREAMINE HBC INJ 6.9%
3
FREAMINE III INJ 10%
3
FREAMINE III INJ 3%
3
freamine iii inj 8.5%
1
hepatamine sol 8%
1
hepatasol
1
inj 8%
NEPHRAMINE INJ 5.4%
3
novamine
inj 15%
1
plenamine
inj 15%
1
PREMASOL
premasol
SOL 10%
sol 6%
3
1
PROCALAMINE INJ 3%
3
PROSOL
3
INJ 20%
TRAVASOL
INJ 10%
REQUIREMENTS/LIMITS
3
TROPHAMINE INJ 10%
3
TROPHAMINE INJ 6%
3
*LIPIDS***
intralipid inj 20%
1
INTRALIPID INJ 30%
3
LIPOSYN II INJ 10%
3
LIPOSYN II INJ 20%
3
LIPOSYN III INJ 10%
3
379
DRUG NAME
DRUG
TIER
LIPOSYN III INJ 20%
3
liposyn iii inj 30%
1
nutrilipid emu 20%
1
REQUIREMENTS/LIMITS
*OPHTHALMIC AGENTS*
*ALPHA ADRENERGIC AGONIST & CARBONIC ANHYDRASE INHIB COMB***
SIMBRINZA
SUS 1-0.2%
3
*ARTIFICIAL TEAR INSERTS***
LACRISERT
MIS 5MG OP
3
*BETA-BLOCKERS - OPHTHALMIC COMBINATIONS***
COMBIGAN
COSOPT
SOL 0.2/0.5%
SOL 22.3-6.8
2
3
COSOPT PF SOL
3
dorzol/timol sol 22.3-6.8
1
*BETA-BLOCKERS - OPHTHALMIC***
BETAGAN
betaxolol
SOL 0.5% OP
sol 0.5% op
3
1
BETIMOL
SOL 0.25%
2
BETIMOL
SOL 0.5%
2
BETOPTIC-S SUS 0.25% OP
2
carteolol
1
ISTALOL
sol 1% op
SOL 0.5% OP
3
LEVOBUNOLOL SOL 0.25% OP
3
levobunolol sol 0.5% op
1
380
DRUG NAME
DRUG
TIER
metipranolol sol 0.3% oph
1
OPTIPRANOLOL SOL 0.3% OP
3
timolol gel sol 0.25% op
1
timolol gel sol 0.5% op
1
timolol mal sol 0.25% op
1
timolol mal sol 0.5% op
1
TIMOPTIC
SOL 0.25% OP
3
TIMOPTIC
SOL 0.5% OP
3
TIMOPTIC OCU SOL 0.25% OP
3
TIMOPTIC OCU SOL 0.5% OP
3
TIMOPTIC-XE SOL 0.25% OP
3
TIMOPTIC-XE SOL 0.5% OP
3
REQUIREMENTS/LIMITS
*CYCLOPLEGIC MYDRIATIC COMBINATIONS***
CYCLOMYDRIL SOL OP
3
*CYCLOPLEGIC MYDRIATICS***
atropin-care sol 1% op
1
atropine sul oin 1% op
1
atropine sul sol 1% op
1
CYCLOGYL
SOL 0.5% OP
3
CYCLOGYL
SOL 1% OP
3
CYCLOGYL
SOL 2% OP
3
cyclopentol sol 1% op
1
cyclopentol sol 2% op
1
381
DRUG NAME
DRUG
TIER
homatropaire sol 5% op
1
homatropine sol 5% op
1
ISO ATROPINE SOL 1% OP
3
ISO HOMATROP SOL 2% OP
3
ISO HOMATROP SOL 5% OP
3
ISO HYOSCINE SOL 0.25% OP
3
mydral
sol 0.5% op
1
mydral
sol 1% op
1
MYDRIACYL
SOL 1% OP
REQUIREMENTS/LIMITS
3
tropicamide sol 0.5% op
1
tropicamide sol 1% op
1
*MIOTICS - CHOLINESTERASE INHIBITORS***
PHOSPHOLINE SOL 0.125%OP
3
*MIOTICS - DIRECT ACTING***
ISO CARBACHO SOL 1.5% OP
3
ISO CARBACHO SOL 3% OP
3
ISOPTO CARP SOL 1% OP
3
3
3
MIOCHOL-E
SOL 1:100
3
INJ 0.01% OP
3
MIOSTAT
pilocarpine sol 1% op
1
1
382
DRUG NAME
DRUG
TIER
1
PILOPINE HS GEL 4% OP
3
REQUIREMENTS/LIMITS
*OPHTHALMIC ANTI-INFECTIVE COMBINATIONS***
ak-poly-bac oin op
1
bacit/polymy oin op
1
neo-polycin oin op
1
neo/bac/poly oin op
1
neo/poly/gra sol op
1
NEOSPORIN
3
SOL OP
polycin
oin op
1
polycin b
oin op
1
polymyxin b/ sol trimethp
1
POLYTRIM
3
SOL OP
trimethoprim sol polymyxn
1
*OPHTHALMIC ANTIALLERGIC***
ALOCRIL
SOL 2%
3
ALOMIDE
SOL 0.1% OP
2
azelastine dro 0.05%
1
BEPREVE
3
DRO 1.5%
cromolyn sod sol 4% op
1
ELESTAT
DRO 0.05%
3
EMADINE
SOL 0.05% OP
3
epinastine dro 0.05%
1
383
DRUG NAME
LASTACAFT
DRUG
TIER
SOL 0.25%
3
OPTIVAR
DRO 0.05%
3
PATADAY
SOL 0.2%
2
PATANOL
SOL 0.1% OP
3
PAZEO
DRO 0.7%
REQUIREMENTS/LIMITS
2
*OPHTHALMIC ANTIBIOTICS***
AZASITE
SOL 1%
3
bacitracin oin op
1
BESIVANCE
SUS 0.6%
2
CILOXAN
OIN 0.3% OP
2
CILOXAN
SOL 0.3% OP
3
ciprofloxacn sol 0.3% op
1
erythromycin oin 5mg/gm
1
erythromycin oin op
1
garamycin
1
oin 0.3% op
GARAMYCIN
SOL 0.3% OP
3
gatifloxacin sol 0.5%
1
gentak
1
oin 0.3% op
gentamicin oin 0.3% op
1
gentamicin sol 0.3% op
1
ilotycin
1
oin op
levofloxacin sol 0.5%
1
MITOSOL
3
KIT 0.2MG
384
DRUG NAME
DRUG
TIER
MOXEZA
SOL 0.5%
2
OCUFLOX
DRO 0.3% OP
3
ofloxacin
dro 0.3% op
1
romycin
oin op
1
tobramycin sol 0.3% op
1
TOBREX
OIN 0.3% OP
3
TOBREX
SOL 0.3% OP
3
VIGAMOX
DRO 0.5%
2
ZYMAXID
SOL 0.5%
3
REQUIREMENTS/LIMITS
*OPHTHALMIC ANTIFUNGAL***
NATACYN
SUS 5% OP
3
*OPHTHALMIC ANTISEPTICS***
BETADINE
SOL 5% OP
3
*OPHTHALMIC ANTIVIRALS***
trifluridine sol 1% op
1
VIROPTIC
3
SOL 1% OP
VITRASERT
IMP 4.5MG
3
VITRAVENE
INJ 6.6MG/ML
3
ZIRGAN
GEL 0.15%
2
*OPHTHALMIC CARBONIC ANHYDRASE INHIBITORS***
AZOPT
SUS 1% OP
2
dorzolamide sol 2% op
1
TRUSOPT
3
SOL 2% OP
*OPHTHALMIC DECONGESTANTS***
385
DRUG NAME
DRUG
TIER
altafrin
sol 10% op
1
altafrin
sol 2.5% op
1
MYDFRIN
SOL 2.5% OP
REQUIREMENTS/LIMITS
3
naphazoline sol 0.1% op
1
neofrin
sol 10% op
1
neofrin
sol 2.5% op
1
phenylephrin sol 10% op
1
phenylephrin sol 2.5% op
1
*OPHTHALMIC DIAGNOSTIC PRODUCTS***
ak-fluor
inj 10% op
AK-FLUOR
INJ 25% OP
1
3
altafluor sol 0.25-0.4
1
bio glo
tes 1mg op
1
flucaine
sol 0.25-0.5
1
fluor-i-stri tes 1mg op
1
FLUORACAINE SOL OP
3
fluore-benox sol 0.25-0.4
1
fluorescein inj 10% op
1
fluorescein inj 25% op
1
fluorescein/ sol proparac
1
FLUORESCITE INJ 10% OP
3
fluorets
tes 1mg op
1
FLURA-SAFE SOL
3
386
DRUG NAME
FLURESS
flurox
DRUG
TIER
SOL OP
sol op
FUL-GLO
ful-glo
TES 0.6MG OP
tes 1mg op
green glo
3
1
3
1
mis 1.5mg
1
lissamine gr tes 1.5mg
1
PAREMYD
3
SOL 1-0.25%
prop-fluore sol 0.5-0.25
1
ROSE GLO
3
TES 1.5MG
REQUIREMENTS/LIMITS
*OPHTHALMIC ENZYMES***
JETREA
INJ 2.5MG/ML
3
*OPHTHALMIC IMMUNOMODULATORS***
RESTASIS
EMU 0.05%
2
*OPHTHALMIC IRRIGATION SOLUTIONS***
akorn balanc sol salt op
1
balanced sal sol op
1
bss
1
sol op
BSS PLUS
SOL OP
3
*OPHTHALMIC LOCAL ANESTHETICS***
AKTEN
GEL 3.5%
ALCAINE
SOL 0.5% OP
3
3
altacaine
sol 0.5% op
1
parcaine
sol 0.5% op
1
387
DRUG NAME
DRUG
TIER
proparacaine sol 0.5% op
1
tetcaine
1
sol 0.5% op
tetracaine sol 0.5% op
1
tetravisc
sol 0.5% op
1
tetravisc
sol forte
1
REQUIREMENTS/LIMITS
*OPHTHALMIC NONSTEROIDAL ANTI-INFLAMMATORY AGENTS***
ACULAR
ACULAR LS
ACUVAIL
BROMDAY
SOL 0.5% OP
3
SOL 0.4%
3
SOL 0.45%
2
SOL 0.09%
3
bromfenac
sol 0.09%
1
bromfenac
sol 0.09% op
1
diclofenac sol 0.1% op
1
flurbiprofen sol 0.03% op
1
ILEVRO
3
DRO 0.3% OP
ketorolac
sol 0.4%
1
ketorolac
sol 0.5%
1
NEVANAC
OCUFEN
SUS 0.1%
2
SOL 0.03% OP
3
PROLENSA
SOL 0.07%
2
VOLTAREN
SOL 0.1% OP
3
*OPHTHALMIC PHOTODYNAMIC THERAPY AGENTS***
VISUDYNE
INJ 15MG
4
PA
388
DRUG NAME
DRUG
TIER
REQUIREMENTS/LIMITS
*OPHTHALMIC SELECTIVE ALPHA ADRENERGIC AGONISTS***
ALPHAGAN P SOL 0.1%
2
ALPHAGAN P SOL 0.15%
3
apraclonidin sol 0.5% op
1
brimonidine sol 0.15%
1
brimonidine sol 0.2% op
1
IOPIDINE
SOL 0.5% OP
3
IOPIDINE
SOL 1% OP
3
*OPHTHALMIC STEROID COMBINATIONS***
BLEPHAMIDE OIN S.O.P.
3
BLEPHAMIDE SUS OP
3
MAXITROL
OIN 0.1% OP
3
MAXITROL
SUS 0.1% OP
3
neo-polycin oin hc 1%op
1
neo/poly/bac oin /hc 1%op
1
neo/poly/dex oin 0.1% op
1
neo/poly/dex sus 0.1% op
1
neo/poly/hc sus op
1
poly-dex
oin 0.1% op
1
PRED-G
SUS OP
2
PRED-G S.O.P OIN OP
2
sulf/pred na sol op
1
tobra/dexame sus 0.3-0.1%
1
389
DRUG NAME
DRUG
TIER
TOBRADEX
OIN 0.3-0.1%
2
TOBRADEX
SUS 0.3-0.1%
3
TOBRADEX ST SUS 0.3-0.05
2
ZYLET
3
SUS 0.5-0.3%
REQUIREMENTS/LIMITS
*OPHTHALMIC STEROIDS***
ALREX
SUS 0.2%
2
dexameth pho sol 0.1% op
1
DUREZOL
EMU 0.05%
2
SUS 0.1% OP
3
FLAREX
fluoromethol sus 0.1% op
1
FML
2
OIN 0.1% OP
FML FORTE
SUS 0.25% OP
2
FML LIQUIFLM SUS 0.1% OP
3
ILUVIEN
IMP 0.19MG
3
LOTEMAX
GEL 0.5%
2
LOTEMAX
OIN 0.5%
2
LOTEMAX
SUS 0.5%
2
MAXIDEX
SUS 0.1% OP
2
OMNIPRED
SUS 1% OP
3
OZURDEX
IMP 0.7MG
3
PRED FORTE SUS 1% OP
3
PRED MILD
2
SUS 0.12% OP
pred sod pho sol 1% op
1
390
DRUG NAME
DRUG
TIER
prednisolone sus 1% op
1
RETISERT
3
IMP 0.59MG
TRIESENCE
VEXOL
INJ 40MG/ML
SUS 1% OP
REQUIREMENTS/LIMITS
3
2
*OPHTHALMIC SULFONAMIDES***
BLEPH-10
SOL 10% OP
3
sod sulfacet sol 10% op
1
SULFACET SOD OIN 10% OP
3
sulfacet sod sol 10% op
1
*OPHTHALMIC SURGICAL AIDS - COMBINATIONS***
DISCOVISC
SOL
3
DUOVISC
KIT 0.35/0.4
3
DUOVISC
KIT 0.5/0.55
3
OMIDRIA
INJ 1-0.3%
3
VISCOAT
SOL
3
*OPHTHALMIC SURGICAL AIDS***
AMVISC
INJ 12MG/ML
3
AMVISC PLUS INJ 16MG/ML
3
CELLUGEL
3
SOL 2%
GELFILM
MIS OP
3
HEALON
INJ 10MG/ML
4
PA
4
PA
4
PA
HEALON GV
HEALON5
INJ 14MG/ML
INJ 23MG/ML
391
DRUG NAME
DRUG
TIER
MEMBRANEBLUE SOL 0.15%
3
ocucoat
sol 2% op
1
PROVISC
INJ 1%
4
SHELLGEL
SOL
3
VISIONBLUE SOL 0.06%
REQUIREMENTS/LIMITS
PA
3
*OPHTHALMICS - CYSTINOSIS AGENTS**
CYSTARAN
SOL 0.44%
3
*PROSTAGLANDINS - OPHTHALMIC***
BIMATOPROST SOL 0.03%
3
latanoprost sol 0.005%
1
LUMIGAN
SOL 0.01%
2
LUMIGAN
SOL 0.03%
2
RESCULA
SOL 0.15%
3
TRAVATAN Z DRO 0.004%
2
travoprost dro 0.004%
1
XALATAN
SOL 0.005%
3
ZIOPTAN
DRO 0.0015%
3
*VASCULAR ENDOTHELIAL GROWTH FACTOR (VEGF) ANTAGONISTS***
EYLEA
INJ 2/0.05ML
4
LUCENTIS
SOL 0.3MG
3
LUCENTIS
SOL 0.5MG
4
PA
4
PA
MACUGEN
INJ
PA
*OTIC AGENTS*
392
DRUG NAME
DRUG
TIER
REQUIREMENTS/LIMITS
*OTIC AGENTS - MISCELLANEOUS***
ace acd/alum sol 2% otic
1
acetic acid sol 2% otic
1
CRESYLATE
3
SOL 25% OTIC
*OTIC ANALGESIC COMBINATIONS***
aero otic hc sol
1
antipy/benzo sol otic
1
AURALGAN
3
aurax
SOL 5.5-1.4%
sol 5.5-1.4%
aurodex
sol otic
1
1
CORTANE-B
DRO AQ OTIC
3
CORTANE-B
DRO OTIC
3
cortic-nd
dro
cyotic
dro
exotic-hc
1
dro otic
MYOXIN
SUS OTIC
NEOTIC
1
DRO
1
3
3
otic care dro
1
oticin
1
dro 1-0.1%
OTICIN HC
DRO
3
oto-end 10 sol
1
otomar
sol otic
1
dro
1
otomax-hc
393
DRUG NAME
OTOZIN
DRUG
TIER
DRO
PRAMOTIC
DRO 1-0.1%
3
3
pramoxine-hc dro aq otic
1
TREAGAN OTIC DRO
3
TRIOXIN
3
SUS OTIC
REQUIREMENTS/LIMITS
*OTIC ANALGESICS***
PINNACAINE DRO 20% OTIC
3
*OTIC ANTI-INFECTIVES***
CETRAXAL
SOL 0.2%
3
CIPROFLOXACN SOL 0.2%
3
ofloxacin
1
dro 0.3%otic
*OTIC STEROID-ANTI-INFECTIVE COMBINATIONS***
CIPRO HC
CIPRODEX
SUS OTIC
2
SUS 0.3-0.1%
2
COLY-MYCIN S SUS OTIC
3
CORTISPORIN SOL 1% OTIC
3
CORTISPORIN SUS -TC OTIC
3
neo/poly/hc sol 1% otic
1
neo/poly/hc sus 1% otic
1
*OTIC STEROIDS***
acetasol hc sol otic
1
DERMOTIC
3
OIL 0.01%
fluocin acet oil 0.01%
1
394
DRUG NAME
DRUG
TIER
fluocin acet oil ear0.01%
1
hc/acet acid sol otic
1
VOSOL HC
3
SOL OTIC
REQUIREMENTS/LIMITS
*OXYTOCICS*
*ABORTIFACIENTS/CERVICAL RIPENING - PROSTAGLANDINS***
CERVIDIL VAG MIS 10MG INS
3
PREPIDIL
3
GEL 0.5MG/3G
PROSTIN E2 SUP 20MG
3
*OXYTOCICS***
METHERGINE INJ 0.2MG/ML
3
METHERGINE TAB 0.2MG
3
methylergon inj 0.2mg/ml
1
methylergon tab 0.2mg
1
oxytocin
inj 10unt/ml
1
OXYTOCIN/LAC INJ 30/500ML
3
PITOCIN
3
INJ 10UNT/ML
*PASSIVE IMMUNIZING AGENTS*
*ANTITOXINS-ANTIVENINS***
ANASCORP
INJ
3
ANTIVENIN
KIT LAT MACT
3
ANTIVENIN MI INJ
3
CROFAB
3
INJ
*ANTIVIRAL MONOCLONAL ANTIBODIES***
395
DRUG NAME
DRUG
TIER
REQUIREMENTS/LIMITS
SYNAGIS
INJ 100MG/ML
4
PA
SYNAGIS
INJ 50MG
4
PA
4
PA
CARIMUNE NF INJ 12GM
4
PA
CARIMUNE NF INJ 3GM
4
PA
CARIMUNE NF INJ 6GM
4
PA
CYTOGAM
4
PA
FLEBOGAMMA INJ 10/200ML
4
PA
FLEBOGAMMA INJ 20/400ML
4
PA
FLEBOGAMMA INJ 5%
4
PA
FLEBOGAMMA INJ DIF 10%
4
PA
FLEBOGAMMA INJ DIF 5%
4
PA
GAMASTAN S/D INJ
3
GAMMAGARD
INJ 10GM/100
4
PA
GAMMAGARD
INJ 1GM/10ML
4
PA
GAMMAGARD
INJ 2.5GM/25
4
PA
GAMMAGARD
INJ 20GM/200
4
PA
GAMMAGARD
INJ 30GM/300
4
PA
GAMMAGARD
INJ 5GM/50ML
4
PA
GAMMAGARD SD INJ 10GM HU
4
PA
GAMMAGARD SD INJ 2.5GM HU
4
PA
GAMMAGARD SD INJ 5GM HU
4
PA
*IMMUNE SERUMS***
BIVIGAM
INJ 10%
INJ
396
DRUG NAME
DRUG
TIER
REQUIREMENTS/LIMITS
GAMMAKED
INJ 10GM/100
4
PA
GAMMAKED
INJ 1GM/10ML
4
PA
GAMMAKED
INJ 2.5GM/25
4
PA
GAMMAKED
INJ 20GM/200
4
PA
GAMMAKED
INJ 5GM/50ML
4
PA
GAMMAPLEX
INJ 10GM
4
PA
GAMMAPLEX
INJ 2.5GM
4
PA
GAMMAPLEX
INJ 20GM
4
PA
GAMMAPLEX
INJ 5GM
4
PA
4
PA
GAMUNEX
INJ 10%
GAMUNEX-C
INJ 10GM/100
4
PA
GAMUNEX-C
INJ 1GM/10ML
4
PA
GAMUNEX-C
INJ 2.5GM/25
4
PA
GAMUNEX-C
INJ 20GM/200
4
PA
GAMUNEX-C
INJ 40/400ML
3
GAMUNEX-C
INJ 5GM/50ML
4
PA
HEPAGAM B
INJ
4
PA
HIZENTRA
INJ 10/50ML
4
PA
HIZENTRA
INJ 1GM/5ML
4
PA
HIZENTRA
INJ 2GM/10ML
4
PA
HIZENTRA
INJ 4GM/20ML
4
PA
HYPERHEP B INJ S/D
3
HYPERRAB S/D INJ 150/ML
3
397
DRUG NAME
DRUG
TIER
REQUIREMENTS/LIMITS
HYPERRHO S/D INJ 300MCG
4
PA
HYPERRHO S/D INJ 50MCG
4
PA
HYPERTET S/D INJ 250/ML
3
IMOGAM RABIE INJ 150/ML
3
MICRHOGAM PL INJ 50MCG
4
NABI-HB
3
INJ
PA
OCTAGAM
INJ 10/100ML
4
PA
OCTAGAM
INJ 10GM
4
PA
OCTAGAM
INJ 1GM
4
PA
OCTAGAM
INJ 2.5GM
4
PA
OCTAGAM
INJ 20/200ML
4
PA
OCTAGAM
INJ 25GM
4
PA
OCTAGAM
INJ 2GM/20ML
3
OCTAGAM
INJ 5GM
4
PA
OCTAGAM
INJ 5GM/50ML
4
PA
PRIVIGEN
INJ 10GRAMS
4
PA
PRIVIGEN
INJ 20GRAMS
4
PA
PRIVIGEN
INJ 40GRAMS
4
PA
PRIVIGEN
INJ 5 GRAMS
4
PA
RHOGAM PLUS INJ 300MCG
4
PA
RHOPHYLAC
4
PA
VARIZIG
INJ 1500/2ML
INJ 125UNIT
WINRHO SDF INJ 15000UNT
3
4
PA
398
DRUG NAME
DRUG
TIER
REQUIREMENTS/LIMITS
WINRHO SDF INJ 1500UNIT
4
PA
4
PA
4
PA
*PASSIVE IMMUNIZING AGENTS - COMBINATIONS***
HYQVIA
INJ 10-800
3
HYQVIA
INJ 2.5-200
3
HYQVIA
INJ 20-1600
3
HYQVIA
INJ 30-2400
3
HYQVIA
INJ 5-400
3
*PENICILLINS*
*AMINOPENICILLINS***
amoxicillin cap 250mg
1
amoxicillin cap 500mg
1
amoxicillin chw 125mg
1
amoxicillin chw 250mg
1
amoxicillin sus 125/5ml
1
1
1
amoxicillin sus 250mg/5m
1
1
amoxicillin tab 500mg
1
AMOXICILLIN TAB 775MG
3
amoxicillin tab 875mg
1
400
DRUG NAME
DRUG
TIER
ampicillin cap 250mg
1
ampicillin cap 500mg
1
ampicillin inj 10gm
1
ampicillin inj 125mg
1
ampicillin inj 1gm
1
1
ampicillin inj 2gm
1
1
ampicillin sus 125/5ml
1
ampicillin sus 250/5ml
1
MOXATAG
3
TAB 775MG
REQUIREMENTS/LIMITS
*NATURAL PENICILLINS***
BICILLIN L-A INJ 1200000
4
PA
4
PA
4
PA
PEN G PROC INJ 600000
3
pen g sod
1
inj 5000000
penicill gk/ inj dex 1mu
1
1
1
penicilln gk inj 20mu
1
penicilln gk inj 5mu
1
penicilln vk sol 125/5ml
1
401
DRUG NAME
DRUG
TIER
penicilln vk sol 250/5ml
1
penicilln vk tab 250mg
1
penicilln vk tab 500mg
1
PFIZERPEN-G INJ 20MU
3
pfizerpen-g inj 5mu
1
REQUIREMENTS/LIMITS
*PENICILLIN COMBINATIONS***
amox-pot cla tab er
1
amox/k clav chw 200mg
1
amox/k clav chw 400mg
1
amox/k clav sus 200/5ml
1
1
1
1
amox/k clav tab 250-125
1
amox/k clav tab 250mg
1
amox/k clav tab 500-125
1
1
1
amp-sulbacta inj 1-0.5gm
1
amp-sulbacta inj 1.5gm
1
amp-sulbacta inj 10-5gm
1
amp-sulbacta inj 15gm
1
amp-sulbacta inj 2-1gm
1
402
DRUG NAME
DRUG
TIER
amp-sulbacta inj 3gm
1
AUGMENTIN
SUS 125/5ML
2
AUGMENTIN
SUS 250/5ML
3
AUGMENTIN
SUS ES-600
3
AUGMENTIN
TAB 500MG
3
AUGMENTIN
TAB 875MG
3
AUGMENTIN XR TAB 12HR
3
BICILLIN C-R INJ 1200000
3
BICILLIN C-R INJ 900/300
4
piper/tazoba inj 2-0.25gm
1
piper/tazoba inj 3-0.375g
1
1
1
TIMENTIN
INJ 3.1GM
3
TIMENTIN
INJ 31GM
3
UNASYN
INJ 1.5GM
3
UNASYN
INJ 1.5GM PB
3
UNASYN
INJ 15GM
3
UNASYN
INJ 3GM
3
ZOSYN
INJ 2-0.25GM
3
ZOSYN
INJ 3-0.375G
3
ZOSYN
INJ 36-4.5GM
3
ZOSYN
INJ 4-0.5GM
3
REQUIREMENTS/LIMITS
PA
403
DRUG NAME
DRUG
TIER
ZOSYN
SOL 2-0.25GM
3
ZOSYN
SOL 3-0.375G
3
ZOSYN
SOL 4-0.50GM
3
REQUIREMENTS/LIMITS
*PENICILLINASE-RESISTANT PENICILLINS***
BACTOCILL
INJ DEX 1GM
3
BACTOCILL
INJ DEX 2GM
3
dicloxacill cap 250mg
1
dicloxacill cap 500mg
1
nafcillin
inj 10gm
1
nafcillin
inj 1gm
1
nafcillin
inj 2gm
1
NALLPEN/DEX INJ 1GM/50ML
3
NALLPEN/DEX INJ 2GM
3
NALLPEN/DEX INJ 2GM/100
3
oxacillin
inj 10gm
1
oxacillin
inj 1gm
1
oxacillin
inj 2gm
1
*PHARMACEUTICAL ADJUVANTS*
*ALKALIZING AGENTS***
TROLAMINE
LIQ
3
TROLAMINE
LIQ 99%
3
*ANTIMICROBIAL AGENTS***
BENZYL ALC LIQ
3
404
DRUG NAME
DRUG
TIER
REQUIREMENTS/LIMITS
*PROGESTINS*
*PROGESTINS***
AYGESTIN
TAB 5MG
3
MAKENA
INJ 250MG/ML
3
medroxypr ac tab 10mg
1
medroxypr ac tab 2.5mg
1
medroxypr ac tab 5mg
1
MEDROXYPROG INJ LIDOCAIN
3
MEGACE ES
3
megestrol
SUS 625/5ML
sus 625mg/5m
1
norethin ace tab 5mg
1
progesterone cap 100mg
1
progesterone cap 200mg
1
PROGESTERONE CRE 10% KIT
3
progesterone inj 50mg/ml
1
PROMETRIUM CAP 100MG
3
PROMETRIUM CAP 200MG
3
PROVERA
TAB 10MG
3
PROVERA
TAB 2.5MG
3
PROVERA
TAB 5MG
3
*PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.*
*ALCOHOL DETERRENTS***
acampro cal tab 333mg
1
405
DRUG NAME
DRUG
TIER
ANTABUSE
TAB 250MG
3
ANTABUSE
TAB 500MG
3
CAMPRAL
TAB 333MG
3
disulfiram tab 250mg
1
disulfiram tab 500mg
1
REQUIREMENTS/LIMITS
*ANTI-CATAPLECTIC AGENTS***
XYREM
SOL 500MG/ML
4
PA
*BENZODIAZEPINES & TRICYCLIC AGENTS***
cdp/amitrip tab 10-25mg
1
cdp/amitrip tab 5-12.5mg
1
*CHOLINOMIMETICS - ACHE INHIBITORS***
ARICEPT
TAB 10MG
3
ARICEPT
TAB 23MG
3
ARICEPT
TAB 5MG
3
ARICEPT ODT TAB 10MG
3
ARICEPT ODT TAB 5MG
3
donepezil
tab 10mg
1
donepezil
tab 10mg odt
1
donepezil
tab 5mg
1
donepezil
tab 5mg odt
1
donepezil
tab hcl 23mg
1
EXELON
CAP 1.5MG
3
EXELON
CAP 3MG
3
406
DRUG NAME
DRUG
TIER
EXELON
CAP 4.5MG
3
EXELON
CAP 6MG
3
EXELON
DIS 13.3/24
3
EXELON
DIS 4.6MG/24
3
EXELON
DIS 9.5MG/24
3
EXELON
SOL 2MG/ML
3
galantamine cap 16mg er
1
1
1
GALANTAMINE SOL 4MG/ML
3
galantamine tab 12mg
1
galantamine tab 4mg
1
galantamine tab 8mg
1
RAZADYNE
SOL 4MG/ML
3
RAZADYNE
TAB 12MG
3
RAZADYNE
TAB 4MG
3
RAZADYNE
TAB 8MG
3
RAZADYNE ER CAP 16MG
3
RAZADYNE ER CAP 24MG
3
RAZADYNE ER CAP 8MG
3
rivastigmine cap 1.5mg
1
rivastigmine cap 3mg
1
rivastigmine cap 4.5mg
1
REQUIREMENTS/LIMITS
407
DRUG NAME
DRUG
TIER
rivastigmine cap 6mg
1
rivastigmine dis 13.3/24
1
rivastigmine dis 4.6mg/24
1
rivastigmine dis 9.5mg/24
1
REQUIREMENTS/LIMITS
*FIBROMYALGIA AGENT - SNRIS***
SAVELLA
MIS TITR PAK
2
SAVELLA
TAB 100MG
2
SAVELLA
TAB 12.5MG
2
SAVELLA
TAB 25MG
2
SAVELLA
TAB 50MG
2
*MOVEMENT DISORDER DRUG THERAPY***
tetrabenazin tab 12.5mg
4
PA
tetrabenazin tab 25mg
4
PA
XENAZINE
TAB 12.5MG
4
PA
XENAZINE
TAB 25MG
4
PA
*MS AGENTS - PYRIMIDINE SYNTHESIS INHIBITORS***
AUBAGIO
TAB 14MG
4
PA, ST
AUBAGIO
TAB 7MG
4
PA, ST
*MULTIPLE SCLEROSIS AGENTS - INTERFERONS***
AVONEX
KIT 30MCG
4
PA
AVONEX PEN KIT 30MCG
4
PA
AVONEX PREFL KIT 30MCG
4
PA
BETASERON
4
PA, ST
INJ 0.3MG
408
DRUG NAME
DRUG
TIER
REQUIREMENTS/LIMITS
EXTAVIA
INJ 0.3MG
4
PA, ST
PLEGRIDY
INJ
4
PA
PLEGRIDY
INJ PEN
4
PA
PLEGRIDY
INJ STARTER
4
PA
PLEGRIDY PEN INJ STARTER
4
PA
REBIF
INJ 22/0.5
4
PA, ST
REBIF
INJ 44/0.5
4
PA, ST
REBIF REBIDO INJ 22/0.5
4
PA, ST
REBIF REBIDO INJ 44/0.5
4
PA, ST
REBIF REBIDO INJ TITRATN
4
PA, ST
REBIF TITRTN INJ PACK
4
PA, ST
*MULTIPLE SCLEROSIS AGENTS - MONOCLONAL ANTIBODIES***
LEMTRADA
TYSABRI
INJ 12/1.2ML
INJ 300/15ML
4
PA
4
PA
*MULTIPLE SCLEROSIS AGENTS - NRF2 PATHWAY ACTIVATORS***
TECFIDERA
CAP 120MG
4
PA
TECFIDERA
CAP 240MG
4
PA
TECFIDERA
MIS STARTER
4
PA
*MULTIPLE SCLEROSIS AGENTS - POTASSIUM CHANNEL BLOCKERS***
AMPYRA
TAB 10MG
4
PA
*MULTIPLE SCLEROSIS AGENTS***
COPAXONE
INJ 20MG/ML
4
PA
COPAXONE
INJ 40MG/ML
4
PA
409
DRUG NAME
glatopa
DRUG
TIER
inj 20mg/ml
4
REQUIREMENTS/LIMITS
PA
*N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONISTS***
memant titra pak 5-10mg
1
memantine
tab hcl 10mg
1
memantine
tab hcl 5mg
1
memantine hc sol 2mg/ml
1
NAMENDA
SOL 10MG/5ML
3
NAMENDA
TAB 10MG
3
NAMENDA
TAB 5-10MG
3
NAMENDA
TAB 5MG
3
NAMENDA XR CAP 14MG
2
NAMENDA XR CAP 21MG
2
NAMENDA XR CAP 28MG
2
NAMENDA XR CAP 7MG
2
NAMENDA XR CAP TITRATIO
2
*PHENOTHIAZINES & TRICYCLIC AGENTS***
perphen/amit tab 2-10mg
1
1
1
1
1
*POSTHERPETIC NEURALGIA (PHN) AGENTS***
GRALISE
TAB 300MG
3
410
DRUG NAME
GRALISE
DRUG
TIER
TAB 600MG
GRALISE STAR MIS 300/600
REQUIREMENTS/LIMITS
3
3
*PREMENSTRUAL DYSPHORIC DISORDER (PMDD) AGENTS - SSRIS***
SARAFEM
TAB 10MG
3
SARAFEM
TAB 20MG
3
*PSEUDOBULBAR AFFECT AGENT COMBINATIONS***
NUEDEXTA
CAP 20-10MG
3
PA
*PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.*
ACTIVE-PAC/ MIS GABA 300
3
NAMZARIC CAP 14-10MG
3
NAMZARIC
3
CAP 28-10MG
*PSYCHOTHERAPEUTIC AND
NEUROLOGICAL AGENTS ergoloid mes tab 1mg oral
ORAP
TAB 1MG
1
3
ORAP
TAB 2MG
3
pimozide
tab 1mg
1
pimozide
tab 2mg
1
*RESTLESS LEG SYNDROME
(RLS) AGENTS***
HORIZANT TAB 300MG
HORIZANT
TAB 600MG
3
3
*SMOKING DETERRENTS***
buproban
bupropion
5
tab 150mg
tab 150mg
5
411
DRUG NAME
DRUG
TIER
CHANTIX
PAK 0.5& 1MG
2
CHANTIX
PAK 1MG
2
CHANTIX
TAB 0.5MG
2
CHANTIX
TAB 1MG
2
NICOTINE
LOZ
5
nicotine gum
5
NICOTINE PATCHES
5
NICOTROL
5
INH
NICOTROL NS SPR 10MG/ML
5
ZYBAN
5
TAB 150MG SR
REQUIREMENTS/LIMITS
*SPHINGOSINE 1-PHOSPHATE (S1P) RECEPTOR MODULATORS***
GILENYA
CAP 0.5MG
4
PA
*THIENBENZODIAZEPINES & SSRIS***
olanza/fluox cap 12-25mg
1
1
1
1
1
SYMBYAX
CAP 12-25MG
3
SYMBYAX
CAP 12-50MG
3
SYMBYAX
CAP 3-25MG
3
SYMBYAX
CAP 6-25MG
3
SYMBYAX
CAP 6-50MG
3
412
DRUG NAME
DRUG
TIER
REQUIREMENTS/LIMITS
*VASOMOTOR SYMPTOM AGENTS - SSRIS***
BRISDELLE
CAP 7.5MG
3
*RESPIRATORY AGENTS - MISC.*
*ALPHA-PROTEINASE INHIBITOR (HUMAN)***
ARALAST NP INJ 1000MG
4
PA
4
PA
4
PA
4
PA
GLASSIA
4
PA
INJ
PROLASTIN
INJ 1000MG
4
PA
PROLASTIN
INJ 500MG
4
PA
PROLASTIN-C INJ 1000MG
4
PA
ZEMAIRA
4
PA
INJ 1000MG
*CFTR POTENTIATORS***
KALYDECO
PAK 50MG
4
PA
KALYDECO
PAK 75MG
4
PA
KALYDECO
TAB 150MG
4
PA
4
PA
4
PA, QL (X)
*CYSTIC FIBROSIS AGENTS**
ORKAMBI
TAB 200-125
*HYDROLYTIC ENZYMES***
PULMOZYME
SOL 1MG/ML
*PLEURAL SCLEROSING AGENTS***
SCLEROSOL
AER INTRAPLE
3
413
DRUG NAME
DRUG
TIER
STERIL TALC SUS 5GM
REQUIREMENTS/LIMITS
3
*PULMONARY FIBROSIS AGENTS***
ESBRIET
CAP 267MG
4
PA
*RESPIRATORY AGENTS - MISC.***
CUROSURF
SUS 80MG/ML
3
INFASURF
SUS 35MG/ML
3
NUCALA
INJ 100MG
4
OFEV
CAP 100MG
3
OFEV
CAP 150MG
3
SURFAXIN
SURVANTA
SUS 30MG/ML
INH
PA
3
3
*SULFONAMIDES*
*SULFONAMIDES***
sulfadiazine tab 500mg
1
SULFISOXIZOL CRY
3
SULFISOXIZOL CRY USP NF
3
*TETRACYCLINES*
*TETRACYCLINE COMBINATIONS***
AVIDOXY DK KIT
3
BENZODOX 30 MIS
3
BENZODOX 60 MIS
3
NICAZELDOXY KIT 30
3
NICAZELDOXY KIT 60
3
414
DRUG NAME
DRUG
TIER
REQUIREMENTS/LIMITS
*TETRACYCLINES***
ACTICLATE
TAB 150MG
3
ACTICLATE
TAB 75MG
3
ADOXA
CAP 150MG
3
ADOXA
TAB 100MG
3
ADOXA
TAB 50MG
3
ADOXA
TAB 75MG
3
ADOXA PAK 1/ TAB 100MG
3
3
3
ALODOX
3
avidoxy
KIT 20MG
tab 100mg
1
CHLORTETRACY CRY HCL
3
demeclocycl tab 150mg
1
demeclocycl tab 300mg
1
DORYX
TAB 150MG
3
DORYX
TAB 200MG
3
DORYX
TAB 50MG
3
doxy 100
inj 100mg
1
doxycyc mono cap 100mg
1
doxycyc mono cap 50mg
1
doxycyc mono tab 100mg
1
1
415
DRUG NAME
DRUG
TIER
1
1
doxycycl hyc cap 100mg
1
doxycycl hyc cap 50mg
1
doxycycl hyc inj 100mg
1
doxycycl hyc tab 100mg
1
doxycycl hyc tab 100mg dr
1
1
1
doxycycline cap 150mg
1
doxycycline cap 75mg
1
doxycycline sus 25mg/5ml
1
doxycycline tab 20mg
1
DYNACIN
TAB 100MG
3
DYNACIN
TAB 50MG
3
DYNACIN
TAB 75MG
3
MINOCIN
CAP 100MG
3
MINOCIN
CAP 50MG
3
MINOCIN
CAP 75MG
3
MINOCIN
INJ 100MG
3
MINOCIN
KIT 100MG
3
MINOCIN
KIT 50MG
3
minocycline cap 100mg
REQUIREMENTS/LIMITS
1
416
DRUG NAME
DRUG
TIER
1
1
minocycline tab 100mg
1
minocycline tab 135mg er
1
1
1
1
1
mondoxyne nl cap 100mg
1
1
1
MONODOX
CAP 100MG
3
MONODOX
CAP 50MG
3
MONODOX
CAP 75MG
3
morgidox
cap 1x100mg
1
morgidox
cap 2x100mg
1
MORGIDOX
KIT 1X100MG
3
MORGIDOX
KIT 2X100MG
3
NUTRIDOX
KIT
3
OCUDOX
KIT
3
ORAXYL
CAP 20MG
3
PERIOSTAT
TAB
3
SOLODYN
TAB 105MG
3
REQUIREMENTS/LIMITS
417
DRUG NAME
DRUG
TIER
SOLODYN
TAB 115MG
3
SOLODYN
TAB 55MG
3
SOLODYN
TAB 65MG
3
SOLODYN
TAB 80MG
3
TARGADOX
TAB 50MG
REQUIREMENTS/LIMITS
3
tetracycline cap 250mg
1
tetracycline cap 500mg
1
VIBRAMYCIN CAP 100MG
3
VIBRAMYCIN SUS 25MG/5ML
3
VIBRAMYCIN SYP 50MG/5ML
3
*THYROID AGENTS*
*ANTITHYROID AGENTS***
methimazole tab 10mg
1
methimazole tab 5mg
1
propylthiour tab 50mg
1
TAPAZOLE
TAB 10MG
3
TAPAZOLE
TAB 5MG
3
*THYROID HORMONES***
ARMOUR THYRO TAB 120MG
2
2
2
2
2
418
DRUG NAME
DRUG
TIER
3
3
3
CYTOMEL
TAB 25MCG
3
CYTOMEL
TAB 50MCG
3
CYTOMEL
TAB 5MCG
3
levo-t
tab 100mcg
1
levo-t
tab 112mcg
1
levo-t
tab 125mcg
1
levo-t
tab 137mcg
1
levo-t
tab 150mcg
1
levo-t
tab 175mcg
1
levo-t
tab 200 mcg
1
levo-t
tab 25mcg
1
levo-t
tab 300 mcg
1
levo-t
tab 50mcg
1
levo-t
tab 75mcg
1
levo-t
tab 88mcg
1
levothroid tab 100mcg
1
1
1
1
1
REQUIREMENTS/LIMITS
419
DRUG NAME
DRUG
TIER
1
1
1
1
1
1
1
levothyroxin inj 100mcg
1
LEVOTHYROXIN INJ 200MCG
3
LEVOTHYROXIN INJ 500MCG
3
levothyroxin tab 100mcg
1
1
1
1
1
1
1
1
1
1
1
1
levoxyl
1
tab 100mcg
REQUIREMENTS/LIMITS
420
DRUG NAME
DRUG
TIER
levoxyl
tab 112mcg
1
levoxyl
tab 125mcg
1
levoxyl
tab 137mcg
1
levoxyl
tab 150mcg
1
levoxyl
tab 175mcg
1
levoxyl
tab 200mcg
1
levoxyl
tab 25mcg
1
levoxyl
tab 50mcg
1
levoxyl
tab 75mcg
1
levoxyl
tab 88mcg
1
liothyronine inj 10mcg/ml
1
liothyronine tab 25mcg
1
1
1
NATURE THROI TAB 162.5MG
3
NATURE-THROI TAB 113.75MG
3
NATURE-THROI TAB 130MG
3
3
nature-throi tab 16.25mg
1
3
3
3
3
REQUIREMENTS/LIMITS
421
DRUG NAME
DRUG
TIER
3
3
3
3
np thyroid tab 30mg
1
np thyroid tab 60mg
1
np thyroid tab 90mg
1
SYNTHROID
TAB 100MCG
2
SYNTHROID
TAB 112MCG
2
SYNTHROID
TAB 125MCG
2
SYNTHROID
TAB 137MCG
2
SYNTHROID
TAB 150MCG
2
SYNTHROID
TAB 175MCG
2
SYNTHROID
TAB 200MCG
2
SYNTHROID
TAB 25MCG
2
SYNTHROID
TAB 300MCG
2
SYNTHROID
TAB 50MCG
2
SYNTHROID
TAB 75MCG
2
SYNTHROID
TAB 88MCG
2
THYROLAR-1 TAB 60MG
3
THYROLAR-1/2 TAB 30MG
3
THYROLAR-1/4 TAB 15MG
3
THYROLAR-2 TAB 120MG
3
REQUIREMENTS/LIMITS
422
DRUG NAME
DRUG
TIER
THYROLAR-3 TAB 180MG
3
TIROSINT
CAP 100MCG
3
TIROSINT
CAP 112MCG
3
TIROSINT
CAP 125MCG
3
TIROSINT
CAP 137MCG
3
TIROSINT
CAP 13MCG
3
TIROSINT
CAP 150MCG
3
TIROSINT
CAP 25MCG
3
TIROSINT
CAP 50MCG
3
TIROSINT
CAP 75MCG
3
TIROSINT
CAP 88MCG
3
TRIOSTAT
INJ 10MCG/ML
3
unith direct tab 100mcg
1
1
1
1
1
1
1
1
1
1
1
REQUIREMENTS/LIMITS
423
DRUG NAME
DRUG
TIER
unithroid tab 100mcg
1
1
1
1
1
1
1
unithroid tab 25mcg
1
1
unithroid tab 50mcg
1
unithroid tab 75mcg
1
unithroid tab 88mcg
1
WESTHROID
TAB 113.75MG
3
WESTHROID
TAB 130MG
3
WESTHROID
TAB 146.25MG
3
WESTHROID
TAB 16.25MG
3
WESTHROID
TAB 162.50MG
3
WESTHROID
TAB 195MG
3
WESTHROID
TAB 260MG
3
WESTHROID
TAB 32.5MG
3
WESTHROID
TAB 325MG
3
WESTHROID
TAB 48.75MG
3
WESTHROID
TAB 65MG
3
REQUIREMENTS/LIMITS
424
DRUG NAME
DRUG
TIER
WESTHROID
TAB 81.25MG
3
WESTHROID
TAB 97.5MG
3
WESTHROID-P TAB 130MG
3
WESTHROID-P TAB 16.25MG
3
3
3
WESTHROID-P TAB 65MG
3
3
WP THYROID TAB 113.75MG
3
WP THYROID TAB 130MG
3
3
3
3
WP THYROID TAB 65MG
3
3
3
REQUIREMENTS/LIMITS
*ULCER DRUGS*
*ANTICHOLINERGIC COMBINATIONS***
bella alk/pb tab 16.2mg
1
BELLA/OPIUM SUP 16.2-30
3
bella/opium sup 16.2-60
1
chlord/clidi cap 5-2.5mg
1
DIGEX NF
3
CAP
425
DRUG NAME
DRUG
TIER
DONNATAL
ELX
3
DONNATAL
ELX GRAPE
3
DONNATAL
ELX MINT
3
DONNATAL
TAB
3
DONNATAL
TAB 16.2MG
3
DONNATAL
TAB EXTENTAB
3
GASTRINEX NF CAP
3
LIBRAX
3
CAP 5-2.5MG
PAMINE FQ
KIT
3
quadrapax elx
1
se-donna
1
elx pb hyos
REQUIREMENTS/LIMITS
*ANTISPASMODICS***
BENTYL
CAP 10MG
3
BENTYL
INJ 10MG/ML
3
BENTYL
SYP 10MG/5ML
3
BENTYL
TAB 20MG
3
dicyclomine cap 10mg
1
dicyclomine sol 10mg/5ml
1
dicyclomine tab 20mg
1
*BELLADONNA ALKALOIDS***
ANASPAZ
TAB 0.125MG
3
ATROPEN
INJ 0.25MG
3
ATROPEN
INJ 0.5MG
3
426
DRUG NAME
DRUG
TIER
ATROPEN
INJ 1MG
3
ATROPEN
INJ 2MG
3
atropine sul inj 0.05mg/1
1
atropine sul inj 0.1mg/ml
1
atropine sul inj 0.4/0.5
1
atropine sul inj 0.4mg/ml
1
atropine sul inj 1mg/ml
1
BELLADONNA TIN 30/100ML
3
colidrops
dro 0.125/ml
1
ed-spaz
tab 0.125mg
1
hyomax
tab 0.125mg
1
hyomax-dt
tab
1
hyomax-ft
tab 0.125mg
1
hyomax-sl
sub 0.125mg
1
hyomax-sr
tab 0.375mg
1
hyoscyamine dro 0.125/ml
1
hyoscyamine elx 0.125/5
1
hyoscyamine sub 0.125mg
1
hyoscyamine tab 0.125mg
1
hyoscyamine tab 0.375 er
1
hyoscyamine tab 0.375 sr
1
hyosyne
dro 0.125/ml
1
hyosyne
elx 0.125/5
1
REQUIREMENTS/LIMITS
427
DRUG NAME
DRUG
TIER
LEVBID
TAB 0.375 ER
3
LEVSIN
INJ 0.5MG/ML
3
LEVSIN
TAB 0.125MG
3
LEVSIN/SL
nulev
SUB 0.125MG
tab 0.125mg
REQUIREMENTS/LIMITS
3
1
oscimin
sub 0.125mg
1
oscimin
tab 0.125mg
1
oscimin sr tab 0.375mg
1
SCOPOLAMINE INJ 0.4MG/ML
3
SYMAX DUOTAB TAB
3
symax fastab tab 0.125mg
1
symax-sl
sub 0.125mg
1
symax-sr
tab 0.375mg
1
*H-2 ANTAGONIST-NUTRITIONAL SUPPLEMENT COMBINATIONS***
GABITIDINE PAK
3
GABITIDINE PAK 150MG
3
SENTRADINE PAK
3
*H-2 ANTAGONISTS***
AXID
CAP 150MG
3
AXID
CAP 300MG
3
AXID
SOL 15MG/ML
3
CIMETID/NACL INJ 300/50ML
3
cimetidine sol 300/5ml
1
428
DRUG NAME
DRUG
TIER
cimetidine tab 300mg
1
1
1
DEPRIZINE
3
SUS 22.4/ML
famotidine inj 10mg/ml
1
famotidine inj 200/20ml
1
famotidine inj 20mg/2ml
1
FAMOTIDINE INJ 20MG/50M
3
famotidine inj 40mg/4ml
1
famotidine sus 40mg/5ml
1
famotidine tab 20mg
1
famotidine tab 40mg
1
nizatidine cap 150mg
1
nizatidine cap 300mg
1
nizatidine sol 15mg/ml
1
PEPCID
SUS 40MG/5ML
3
PEPCID
TAB 20MG
3
PEPCID
TAB 40MG
3
ranitidine cap 150mg
1
ranitidine cap 300mg
1
ranitidine inj 150/6ml
1
ranitidine inj 25mg/ml
1
ranitidine inj 50mg/2ml
1
REQUIREMENTS/LIMITS
429
DRUG NAME
DRUG
TIER
ranitidine syp 150/10ml
1
ranitidine syp 15mg/ml
1
ranitidine syp 75mg/5ml
1
ranitidine tab 150mg
1
ranitidine tab 300mg
1
ZANTAC
INJ 25MG/ML
3
ZANTAC
INJ 50/50ML
4
ZANTAC
INJ 50MG/2ML
3
ZANTAC
SYP 15MG/ML
3
ZANTAC
TAB 25MG EF
3
ZANTAC
TAB 300MG
3
REQUIREMENTS/LIMITS
PA
*MISC. ANTI-ULCER***
CARAFATE
SUS 1GM/10ML
2
CARAFATE
TAB 1GM
3
sucralfate tab 1gm
1
*PROTON PUMP INHIBITOR-ANTACID COMBINATIONS***
omepra/bicar cap 40-1100
1
ZEGERID
CAP 20-1100
3
ZEGERID
CAP 40-1100
3
*QUATERNARY ANTICHOLINERGICS***
CANTIL
TAB 25MG
2
CUVPOSA
SOL 1MG/5ML
2
GLYCATE
TAB 1.5MG
3
430
DRUG NAME
DRUG
TIER
glycopyrrol inj 0.2mg/ml
1
glycopyrrol inj 0.4/2ml
1
glycopyrrol inj 1mg/5ml
1
glycopyrrol inj 4mg/20ml
1
glycopyrrol tab 1mg
1
glycopyrrol tab 2mg
1
methscopolam tab 2.5mg
1
methscopolam tab 5mg
1
PAMINE
3
TAB 2.5MG
PAMINE FORTE TAB 5MG
3
propanthelin tab 15mg
1
ROBINUL
INJ 0.2MG/ML
3
ROBINUL
INJ 0.4/2ML
3
ROBINUL
INJ 1MG/5ML
3
ROBINUL
INJ 4MG/20ML
3
ROBINUL
TAB 1MG
3
ROBINUL FORT TAB 2MG
REQUIREMENTS/LIMITS
3
*ULCER ANTI-INFECTIVE W/ BISMUTH COMBINATIONS***
HELIDAC
MIS
3
PYLERA
CAP
3
*ULCER ANTI-INFECTIVE W/ PROTON PUMP INHIBITORS***
lansopr/amox mis /clarith
1
OMECLAMOX- MIS PAK
3
431
DRUG NAME
PREVPAC
DRUG
TIER
MIS
REQUIREMENTS/LIMITS
3
*ULCER DRUGS - PROSTAGLANDINS***
CYTOTEC
TAB 100MCG
3
CYTOTEC
TAB 200MCG
3
misoprostol tab 100mcg
1
misoprostol tab 200mcg
1
*URINARY ANTI-INFECTIVES*
*METHENAMINE COMBOS***
UROQID #2
TAB
3
*URINARY ANTI-INFECTIVES***
FURADANTIN SUS 25MG/5ML
3
HIPREX
3
TAB 1GM
MACROBID
CAP 100MG
3
MACRODANTIN CAP 100MG
3
3
3
methenam hip tab 1gm
1
methenam man tab 1000mg
1
methenam man tab 1gm
1
METHENAM MAN TAB 500MG
3
MONUROL
3
PAK GRANULES
nitrofur mac cap 100mg
1
1
432
DRUG NAME
DRUG
TIER
1
nitrofurantn cap 100mg
1
nitrofurantn sus 25mg/5ml
1
UREX
3
TAB 1GM
REQUIREMENTS/LIMITS
*URINARY ANTISEPTIC-ANTISPASMODIC &/OR ANALGESICS***
azuphen mb cap 120mg
1
hyolev mb
tab 81mg
1
hyophen
tab
1
indiomin mb cap 120mg
1
phosphasal tab
1
PROSED/DS TAB
3
ur n-c
1
tab
uramit mb
urelle
cap 118mg
tab
1
1
uretron d/s tab
1
uribel
1
cap 118mg
URIMAR-T
urin d/s
uro-blue
uro-l
uro-mp
TAB
tab
urolet mb
1
tab 81.6mg
tab 81mg
cap 118mg
UROGESICtab
3
TAB BLUE
1
1
1
3
1
433
DRUG NAME
DRUG
TIER
urophen mb tab 81.6mg
1
uryl
tab
1
ustell
cap
1
uta
cap 120mg
1
uticap
cap
1
utira-c
tab
1
utrona-c
tab
REQUIREMENTS/LIMITS
1
*URINARY ANTISPASMODICS*
*URINARY ANTISPASMODIC - ANTIMUSCARINIC (ANTICHOLINERGIC)***
DETROL
TAB 1MG
3
DETROL
TAB 2MG
3
DETROL LA
CAP 2MG
3
DETROL LA
CAP 4MG
3
DITROPAN XL TAB 10MG
3
DITROPAN XL TAB 15MG
3
DITROPAN XL TAB 5MG
3
ENABLEX
TAB 15MG
3
ENABLEX
TAB 7.5MG
3
GELNIQUE
GEL 10%
3
GELNIQUE
GEL 3%
3
oxybutynin syp 5mg/5ml
1
oxybutynin tab 10mg er
1
1
434
DRUG NAME
DRUG
TIER
oxybutynin tab 5mg
1
1
OXYTROL
DIS 3.9MG/24
3
TAB 20MG
3
SANCTURA
SANCTURA XR CAP 60MG
3
tolterodine cap 2mg er
1
tolterodine cap 4mg er
1
tolterodine tab 1mg
1
tolterodine tab 2mg
1
TOVIAZ
TAB 4MG
3
TOVIAZ
TAB 8MG
3
trospium chl cap 60mg er
1
trospium cl tab 20mg
1
VESICARE
TAB 10MG
2
VESICARE
TAB 5MG
2
REQUIREMENTS/LIMITS
*URINARY ANTISPASMODICS - BETA-3 ADRENERGIC AGONISTS***
MYRBETRIQ
TAB 25MG
2
MYRBETRIQ
TAB 50MG
2
*URINARY ANTISPASMODICS - CHOLINERGIC AGONISTS***
bethanechol tab 10mg
1
1
1
bethanechol tab 5mg
1
435
DRUG NAME
DRUG
TIER
URECHOLINE TAB 10MG
3
URECHOLINE TAB 25MG
3
URECHOLINE TAB 50MG
3
URECHOLINE TAB 5MG
3
REQUIREMENTS/LIMITS
*URINARY ANTISPASMODICS - DIRECT MUSCLE RELAXANTS***
flavoxate
tab 100mg
1
*VACCINES*
*VACCINES*
GARDASIL 9 INJ
5
PNEUMOVAX 23 INJ 25/0.5
5
ZOSTAVAX
5
INJ
*VAGINAL PRODUCTS*
*IMIDAZOLE-RELATED ANTIFUNGALS***
GYNAZOLE-1 CRE 2%
3
miconazole 3 sup 200mg
1
TERAZOL 3
CRE 0.8%
3
TERAZOL 3
SUP 80MG
3
TERAZOL 7
CRE 0.4%
3
terconazole cre 0.4%
1
terconazole cre 0.8%
1
terconazole sup 80mg
1
zazole
cre 0.4%
1
zazole
cre 0.8%
1
436
DRUG NAME
zazole
DRUG
TIER
sup 80mg
REQUIREMENTS/LIMITS
1
*MISCELLANEOUS VAGINAL COMBINATIONS***
FEM PH
GEL
RELAGARD
GEL
3
3
*VAGINAL ANTI-INFECTIVES***
AVC
CRE 15%
2
CLEOCIN
CRE 2% VAG
3
CLEOCIN
SUP 100MG
2
clindamycin cre 2% vag
1
CLINDESSE
3
CRE 2%
METROGEL-VAG GEL 0.75%
3
metronidazol gel 0.75%vag
1
NUVESSA
3
GEL 1.3%
nystatin vag tab 100000
1
vandazole
1
gel 0.75%
*VAGINAL ESTROGENS***
ESTRACE VAG CRE 0.1MG/GM
3
ESTRING
MIS 2MG
2
FEMRING
MIS 0.05/24H
2
FEMRING
MIS 0.1MG/24
2
PREMARIN VAG CRE 0.625MG
2
VAGIFEM
2
TAB 10MCG
*VAGINAL PROGESTINS***
437
DRUG NAME
DRUG
TIER
CRINONE
GEL 4% VAG
4
CRINONE
GEL 8% VAG
2
PROGESTERONE SUP VGS 100
3
3
3
3
3
REQUIREMENTS/LIMITS
PA
*VASOPRESSORS*
*ANAPHYLAXIS THERAPY AGENTS***
ADRENACLICK INJ 0.15MG
3
ADRENACLICK INJ 0.3MG
3
ADRENALIN
3
INJ 30/30ML
AUVI-Q
INJ 0.15MG
2
AUVI-Q
INJ 0.3MG
2
QL (X)
QL (X)
epinephrine inj 0.15mg
1
epinephrine inj 0.3mg
1
QL (X)
EPIPEN 2-PAK INJ 0.3MG
2
QL (X)
EPIPEN-JR
INJ 2-PAK
2
QL (X)
EPISNAP
KIT
3
TWINJECT
INJ 0.15MG
3
TWINJECT
INJ 0.3MG
3
QL (X)
*NEUROGENIC ORTHOSTATIC HYPOTENSION (NOH) - AGENTS***
NORTHERA
CAP 100MG
4
PA
438
DRUG NAME
DRUG
TIER
REQUIREMENTS/LIMITS
NORTHERA
CAP 200MG
4
PA
NORTHERA
CAP 300MG
4
PA
*VASOPRESSORS***
dobutam/d5w inj 1mg/ml
1
1
1
dobutamine inj 250mg
1
dobutamine inj 500mg
1
DOPAMINE
3
INJ 160MG/ML
dopamine
inj 40mg/ml
1
dopamine
inj 80mg/ml
1
dopamine/d5w inj 0.8mg/ml
1
1
1
EPHEDRINE
3
INJ SOD CL
ephedrine su inj 50mg/ml
1
LEVOPHED
3
INJ 1MG/ML
midodrine tab 10mg
1
midodrine tab 2.5mg
1
midodrine tab 5mg
1
NEO-SYNEPHRI INJ 10MG/ML
3
norepinephr inj 1mg/ml
1
phenylephrin inj 10mg/ml
1
439
DRUG NAME
DRUG
TIER
PHENYLEPHRIN INJ SOD CL
3
VAZCULEP
3
INJ 10MG/ML
REQUIREMENTS/LIMITS
440
Alphabetical Listing
8
8-MOP
A
ACD-A
SOL ................................................... 75
ace acd/alum sol 2% otic ..................................... 394
acebutolol cap 200mg ........................................ 204
acebutolol cap 400mg ........................................ 204
ACEON
TAB 2MG ...................................... 132
ACEON
TAB 4MG ...................................... 132
ACEON
TAB 8MG ...................................... 132
ACETADOTE INJ 200MG/ML ....................... 112
acetasol hc sol otic.............................................. 395
acetazolamid cap 500mg er ................................. 308
acetazolamid inj 500mg ....................................... 309
acetazolamid tab 125mg ...................................... 309
acetazolamid tab 250mg ...................................... 309
acetic acid sol 0.25%irr ...................................... 340
acetic acid sol 2% otic ........................................ 394
acetylcyst inj 200mg/ml...................................... 112
acetylcyst sol 10%.............................................. 249
acetylcyst sol 20%.............................................. 249
acitretin cap 10mg ............................................ 268
acitretin cap 17.5mg ......................................... 268
acitretin cap 25mg ............................................ 268
ACLOVATE
CRE 0.05%................................ 272
act fluoride sol 0.05% .......................................... 366
act total sol 0.05% ............................................ 366
ACTCT FLEX 3 PAD 4....................................... 301
ACTEMRA
INJ 162/0.9 ................................... 14
ACTEMRA
INJ 200/10ML .............................. 14
ACTEMRA
INJ 400/20ML .............................. 14
ACTEMRA
INJ 80MG/4ML............................ 14
ACTHAR HP INJ 80UNIT............................... 316
ACTHREL INJ 100MCG ............................... 307
ACTI ANTIMIC PAD 2 ...................................... 301
ACTI ANTIMIC PAD 4 ...................................... 301
acticin
cre 5% ................................................. 291
ACTICLATE TAB 150MG .............................. 415
ACTICLATE TAB 75MG ................................ 415
ACTICOAT MIS 16 ........................................ 301
ACTICOAT MIS 4 .......................................... 301
ACTICOAT MIS 5 .......................................... 301
ACTICOAT MIS 8 .......................................... 301
ACTICOAT MIS SITE.................................... 301
ACTICOAT 3 MIS 16 ....................................... 301
ACTICOAT 3 MIS 2 ......................................... 301
ACTICOAT 3 MIS 4 ......................................... 301
ACTICOAT 3 MIS 8 ......................................... 301
CAP 10MG ...................................... 268
A.A.G.C KIT CRE TERODERM....................... 261
abacav/lamiv tab /zidovud ................................... 188
abacavir tab 300mg ......................................... 191
ABELCET
INJ 5MG/ML ............................... 116
ABILIFY
INJ 9.75MG ................................... 184
ABILIFY
SOL 1MG/ML ............................... 184
ABILIFY
TAB 10MG .................................... 184
ABILIFY
TAB 15MG .................................... 184
ABILIFY
TAB 20MG .................................... 184
ABILIFY
TAB 2MG ...................................... 184
ABILIFY
TAB 30MG .................................... 184
ABILIFY
TAB 5MG ...................................... 184
ABILIFY DISC TAB 10MG ............................... 185
ABILIFY DISC TAB 15MG ............................... 185
ABILIFY MAIN INJ 300MG.............................. 185
ABILIFY MAIN INJ 400MG.............................. 185
ABRAXANE INJ 100MG............................... 166
ABSTRAL
SUB 100MCG ............................... 28
ABSTRAL
SUB 200MCG ............................... 28
ABSTRAL
SUB 300MCG ............................... 28
ABSTRAL
SUB 400MCG ............................... 28
ABSTRAL
SUB 600MCG ............................... 28
ABSTRAL
SUB 800MCG ............................... 28
acampro cal tab 333mg ...................................... 405
ACANYA
GEL 1.2-2.5%.............................. 253
acarbose tab 100mg......................................... 100
acarbose tab 25mg........................................... 100
acarbose tab 50mg........................................... 100
ACCOLATE
TAB 10MG.................................. 68
ACCOLATE
TAB 20MG.................................. 68
ACCUNEB
NEB 0.63MG/3............................. 66
ACCUNEB
NEB 1.25MG/3............................. 66
ACCUPRIL TAB 10MG ................................. 132
ACCUPRIL TAB 20MG ................................. 132
ACCUPRIL TAB 40MG ................................. 132
ACCUPRIL TAB 5MG ................................... 132
ACCURETIC TAB 10-12.5 ............................. 130
ACCURETIC TAB 20-12.5 ............................. 130
ACCURETIC TAB 20-25MG.......................... 130
ACD FORMULA SOL A ..................................... 75
ACD FORMULA SOL B ..................................... 75
441
ACTICOAT 7 MIS 1 ......................................... 301
ACTICOAT 7 MIS 16 ....................................... 301
ACTICOAT 7 MIS 2 ......................................... 301
ACTICOAT 7 MIS 4 ......................................... 301
ACTICOAT 7 MIS 6 ......................................... 301
ACTICOAT 7 MIS 8 ......................................... 301
ACTICOAT 7 PAD 2 ........................................ 302
ACTICOAT 7 PAD 4 ........................................ 302
ACTICOAT ABS MIS 3/4 .................................. 302
ACTICOAT ABS PAD 4 .................................... 302
ACTICOAT MOI PAD 2 .................................... 302
ACTICOAT MOI PAD 4 .................................... 302
ACTICOAT SUR PAD 4 .................................... 302
ACTICOAT SUR PAD 4X13.75......................... 302
ACTICOAT SUR PAD 4X4-3/4 ......................... 302
ACTIGALL CAP 300MG ............................... 331
ACTIMMUNE INJ 2MU/0.5 ........................... 161
ACTIQ
LOZ 1200MCG ................................. 28
ACTIQ
LOZ 1600MCG ................................. 28
ACTIQ
LOZ 200MCG ................................... 28
ACTIQ
LOZ 400MCG ................................... 28
ACTIQ
LOZ 600MCG ................................... 28
ACTIQ
LOZ 800MCG ................................... 28
ACTIVASE INJ 100MG ................................. 344
ACTIVASE INJ 50MG ................................... 344
ACTIVELLA TAB 0.5-0.1............................... 324
ACTIVELLA TAB 1-0.5MG ........................... 324
ACTIVE-PAC/ MIS GABA 300 ........................ 411
ACTIVE-PREP CRE KIT I ................................ 262
ACTIVE-PREP CRE KIT II............................... 262
ACTIVE-PREP CRE KIT III ............................. 262
ACTIVE-PREP CRE KIT IV............................... 261
ACTIVE-PREP CRE KIT V............................... 264
ACTONEL TAB 150MG ............................... 313
ACTONEL TAB 30MG ................................. 313
ACTONEL TAB 35MG ................................. 313
ACTONEL TAB 5MG ................................... 313
ACTOPLUS MET TAB 15-500MG ................... 109
ACTOPLUS MET TAB 15-850MG ................... 109
ACTOPLUS MET TAB XR................................ 109
ACTOS
TAB 15MG..................................... 110
ACTOS
TAB 30MG..................................... 110
ACTOS
TAB 45MG..................................... 110
ACUFLEX
TAB............................................... 20
ACUICYN
LIQ................................................. 283
ACULAR
SOL 0.5% OP............................... 389
ACULAR LS SOL 0.4% .................................. 389
ACUVAIL SOL 0.45% .................................. 389
acyclovir cap 200mg......................................... 197
acyclovir oin 5% ............................................... 271
acyclovir sus 200/5ml ....................................... 197
acyclovir tab 400mg.......................................... 197
acyclovir tab 800mg.......................................... 197
acyclovir na inj 1000mg....................................... 197
acyclovir na inj 500mg......................................... 197
acyclovir na inj 50mg/ml...................................... 197
ACZONE
GEL 5% ........................................ 251
ADAGEN
INJ 250/ML.................................. 208
ADALAT CC TAB 30MG ER ......................... 209
adapalene cre 0.1%........................................... 257
adapalene gel 0.1%........................................... 257
adapalene gel 0.3%........................................... 257
ADAPALENE LOT 0.1% ................................ 257
ADASUVE
INH 10MG.................................. 182
ADAZIN
CRE ............................................... 294
ADCETRIS
INJ 50MG.................................... 160
ADCIRCA
TAB 20MG .................................. 221
ADDERALL
TAB 10MG.................................... 3
ADDERALL
TAB 12.5MG................................. 3
ADDERALL
TAB 15MG.................................... 3
ADDERALL
TAB 20MG.................................... 3
ADDERALL
TAB 30MG.................................... 3
ADDERALL
TAB 5MG...................................... 3
ADDERALL
TAB 7.5MG................................... 3
ADDERALL XR CAP 10MG ................................ 3
ADDERALL XR CAP 5MG .................................. 3
ADDYI
TAB 100MG ................................... 411
adefov dipiv tab 10mg.......................................... 194
ADEMPAS
TAB 0.5MG ................................ 221
ADEMPAS
TAB 1.5MG ................................ 221
ADEMPAS
TAB 1MG ................................... 221
ADEMPAS
TAB 2.5MG ................................ 221
ADEMPAS
TAB 2MG ................................... 221
ADENOCARD INJ 12MG/4ML ........................ 62
ADENOCARD INJ 3MG/ML ............................ 62
ADENOCARD INJ 6MG/2ML .......................... 62
adenosine inj 12mg/4ml ...................................... 62
adenosine inj 3mg/ml .......................................... 62
adenosine inj 6mg/2ml ........................................ 62
ADOXA
CAP 150MG.................................. 415
ADOXA
TAB 100MG.................................. 415
ADOXA
TAB 50MG.................................... 415
442
ADOXA
TAB 75MG ................................... 415
ADOXA PAK 1/ TAB 100MG ........................... 415
ADOXA PAK 1/ TAB 150MG ........................... 415
ADOXA PAK 2/ TAB 100MG ........................... 415
ADRENACLICK INJ 0.15MG........................... 438
ADRENACLICK INJ 0.3MG............................. 438
ADRENALIN INJ 1MG/ML.............................. 69
ADRENALIN INJ 30/30ML ............................ 438
ADRENALIN SOL 1
1000 ................................................................. 376
adriamyc inj 50mg ........................................... 158
adriamycin inj 10mg .......................................... 158
adriamycin inj 20mg .......................................... 158
adriamycin inj 2mg/ml ....................................... 158
adrucil
inj 2.5g/50m ....................................... 150
adrucil
inj 500/10ml ....................................... 150
adrucil
inj 5gm/100m...................................... 150
ADV ALLERGY KIT COLLECTI .................... 272
ADVAIR DISKU AER 100/50.............................. 65
ADVAIR DISKU AER 250/50.............................. 65
ADVAIR DISKU AER 500/50.............................. 65
ADVAIR HFA AER 115/21................................ 65
ADVAIR HFA AER 230/21................................ 65
ADVAIR HFA AER 45/21.................................. 65
ADVICOR
TAB 1000-20............................... 125
ADVICOR
TAB 1000-40............................... 125
ADVICOR
TAB 500-20MG .......................... 125
ADVICOR
TAB 750-20MG .......................... 125
aero otic hc sol..................................................... 394
AEROHIST TAB 8-2.5MG............................. 122
AEROSPAN AER 80MCG ............................... 69
afeditab tab 30mg cr........................................ 209
afeditab tab 60mg cr........................................ 209
AFINITOR TAB 10MG .................................. 155
AFINITOR TAB 2.5MG ................................. 155
AFINITOR TAB 5MG .................................... 155
AFINITOR TAB 7.5MG ................................. 155
AFINITOR DIS TAB 2MG................................. 155
AFREZZA
POW 4& 8UNIT.......................... 104
AFREZZA
POW 4UNIT................................ 104
AFREZZA
POW 8&12UNIT......................... 104
aftera
tab 1.5mg............................................. 234
AGGRASTAT INJ 25MG/500......................... 342
AGGRENOX CAP 25-200MG ....................... 343
AGRYLIN
CAP 0.5MG ................................. 344
AHIST
TAB 12MG ...................................... 119
A-HYDROCORT INJ 100MG ........................... 237
AIF #2 DRUG CRE PREP KIT ...........................263
AIF #3 DRUG CRE PREP KIT ...........................263
ak-fluor inj 10% op .......................................... 387
AK-FLUOR INJ 25% OP ................................ 387
AKNE-MYCIN OIN 2%.................................... 251
akorn balanc sol salt op....................................... 388
ak-poly-bac oin op............................................... 384
AKTEN
GEL 3.5% ....................................... 388
AKYNZEO
CAP ............................................ 114
ala cort cre 1%................................................. 272
ALA SCALP LOT 2%...................................... 272
ala-cort lot 1% ................................................. 272
alagesic cap ....................................................... 20
alagesic lq sol ....................................................... 20
ALAHIST AC LIQ 7.5-10 ................................. 251
ALAHIST DHC LIQ 7.5-3 ................................. 251
ALA-QUIN CRE 3-0.5%................................. 264
ALBATUSSIN CAP .......................................... 246
ALBATUSSIN LIQ NN .................................... 245
ALBENZA
TAB 200MG ................................. 49
albuterol neb 0.083%.......................................... 66
albuterol neb 0.5%.............................................. 66
albuterol neb 0.63mg/3 ....................................... 66
albuterol neb 1.25mg/3 ....................................... 66
albuterol syp 2mg/5ml......................................... 66
albuterol tab 2mg................................................ 66
albuterol tab 4mg................................................ 66
albuterol tab 4mg er............................................ 67
albuterol tab 8mg er............................................ 67
ALCAINE
SOL 0.5% OP ............................... 388
alclometason cre 0.05% ....................................... 272
alclometason oin 0.05%....................................... 272
ALCORTIN A GEL........................................... 264
ALDACTAZIDE TAB 25/25 ............................. 309
ALDACTAZIDE TAB 50/50 ............................. 309
ALDACTONE TAB 100MG............................ 311
ALDACTONE TAB 25MG.............................. 311
ALDACTONE TAB 50MG.............................. 311
ALDARA
CRE 5%........................................ 284
ALDURAZYME INJ 2.9MG/5M...................... 321
alegenix mis .0375-5%..................................... 294
ALENDRONATE SOL 70/75ML ...................... 313
alendronate tab 10mg ......................................... 313
alendronate tab 5mg ........................................... 313
ALEVICYN
GEL ............................................ 302
ALEVICYN
SOL DERMAL........................... 302
443
ALEVICYN SG LIQ ANTIPRUR ..................... 288
ALFENTA
INJ 500/ML ................................... 28
alfentanil inj 500/ml............................................. 28
ALFERON N INJ 5MU/ML............................. 161
alfuzosin tab 10mg ........................................... 337
aliclen
sha 6% ................................................ 285
ali-flex tab 50-500mg......................................... 20
ALIMTA
INJ 100MG.................................... 150
ALIMTA
INJ 500MG.................................... 150
ALINIA
SUS 100/5ML ................................... 52
ALINIA
TAB 500MG ..................................... 52
ALKERAN
INJ 50MG ................................... 168
ALKERAN
TAB 2MG................................... 168
ALLERX DF MIS ............................................ 122
ALLERX DF 30 MIS .......................................... 122
ALLEVYN AG PAD 2...................................... 302
ALLEVYN AG PAD 3...................................... 302
ALLEVYN AG PAD 4...................................... 302
ALLEVYN AG PAD 5...................................... 302
ALLEVYN AG PAD 6...................................... 302
ALLEVYN AG PAD 6-3/4 ............................... 302
ALLEVYN AG PAD 7...................................... 302
ALLEVYN AG PAD 8...................................... 302
ALLEVYN AG PAD 9...................................... 302
ALLEVYN GENT PAD 4................................... 303
ALLEVYN GENT PAD 8................................... 303
ALLFEN CD TAB 400-10MG......................... 245
ALLFEN CDX LIQ ............................................. 245
ALLFEN CDX TAB 400-20MG....................... 245
ALLO-PAX
CRE 5-5%................................... 267
allopurinol inj 500mg ......................................... 341
allopurinol tab 100mg ........................................ 341
allopurinol tab 300mg ........................................ 341
almotrip mal tab 12.5mg ..................................... 363
almotrip mal tab 6.25mg ..................................... 363
almotriptan tab 12.5mg ...................................... 363
almotriptan tab 6.25mg ...................................... 363
ALOCRIL
SOL 2% ........................................ 384
ALODOX
KIT 20MG ................................... 415
ALOMIDE
SOL 0.1% OP .............................. 384
ALOPRIM
INJ 500MG .................................. 341
ALOQUIN
GEL 1.25-1%............................... 264
ALORA
DIS 0.025MG................................. 325
ALORA
DIS 0.05MG................................... 326
ALORA
DIS 0.075MG................................. 326
ALORA
DIS 0.1MG..................................... 326
alosetron tab 0.5mg .......................................... 333
alosetron tab 1mg ............................................. 333
ALOXI
INJ 0.25MG/5.................................. 113
ALPAIN
TAB.................................................. 20
ALPHAGAN P SOL 0.1%................................. 390
ALPHAGAN P SOL 0.15%............................... 390
alphatrex gel 0.05% .......................................... 272
ALPRAZOLAM CON 1 MG/ML ....................... 59
alprazolam tab 0.25 odt ....................................... 59
alprazolam tab 0.25mg ........................................ 59
alprazolam tab 0.5mg .......................................... 59
alprazolam tab 0.5mg er ...................................... 59
alprazolam tab 0.5mg od ..................................... 59
alprazolam tab 0.5mg xr ...................................... 59
alprazolam tab 1mg ............................................. 60
alprazolam tab 1mg er ......................................... 60
alprazolam tab 1mg odt ....................................... 60
alprazolam tab 1mg xr ......................................... 60
alprazolam tab 2mg ............................................. 60
alprazolam tab 2mg odt ....................................... 60
alprostadil inj 500mcg ........................................ 203
ALREX
SUS 0.2%........................................ 391
ALSUMA
INJ 6MG/0.5 ................................ 363
ALTABAX
OIN 1% ....................................... 264
altacaine sol 0.5% op........................................ 388
ALTACE
CAP 1.25MG................................. 132
ALTACE
CAP 10MG.................................... 132
ALTACE
CAP 2.5MG................................... 132
ALTACE
CAP 5MG...................................... 132
altafluor sol 0.25-0.4 ........................................ 387
altafrin sol 10% op .......................................... 387
altafrin sol 2.5% op ......................................... 387
altavera tab ...................................................... 229
ALTOPREV
TAB 20MG ER .......................... 126
ALTOPREV
TAB 40MG ER .......................... 126
ALTOPREV
TAB 60MG ER .......................... 126
ALUMINUM CL CRY HEXAHYDR................ 290
ALUVEA
CRE 39% ...................................... 280
ALVESCO
AER 160MCG ............................... 69
ALVESCO
AER 80MCG ................................. 69
alyacen
tab 1/35.............................................. 229
alyacen
tab 7/7/7............................................. 236
amantadine cap 100mg ...................................... 171
amantadine syp 50mg/5ml ................................. 171
amantadine tab 100mg....................................... 171
AMARYL
TAB 1MG.................................... 108
AMARYL
TAB 2MG.................................... 108
AMARYL
TAB 4MG.................................... 108
444
AMBIEN
TAB 10MG ................................... 352
AMBIEN
TAB 5MG ..................................... 352
AMBIEN CR TAB 12.5MG............................. 352
AMBIEN CR TAB 6.25MG............................. 352
AMBIFED CD TAB.......................................... 246
AMBIFED CDX TAB ........................................ 246
AMBIFED-G TAB CDX.................................. 246
AMBIFED-G CD TAB........................................ 246
AMBISOME INJ 50MG.................................. 116
amcinonide cre 0.1% ......................................... 273
amcinonide lot 0.1% .......................................... 273
amcinonide oin 0.1% ......................................... 273
AMERGE
TAB 1MG .................................... 363
AMERGE
TAB 2.5MG ................................. 363
a-methapred inj 125mg....................................... 237
a-methapred inj 40mg......................................... 237
amethia
tab ..................................................... 235
amethia lo tab .................................................... 235
amethyst tab 90-20mcg .................................... 234
AMEVIVE
INJ 15MG.................................... 268
AMICAR
SOL 0.25/ML................................ 348
AMICAR
SYP 25%....................................... 348
AMICAR
TAB 1000MG............................... 348
AMICAR
TAB 500MG ................................. 348
AMIDATE
INJ 2MG/ML............................... 336
amifostine inj 500mg ......................................... 170
amikacin inj 1gm/4ml ........................................ 10
amikacin inj 500/2ml ......................................... 10
amilor/hctz tab 5-50............................................ 309
amiloride tab 5mg............................................. 312
aminoac acid sol 1.5% irr ................................... 340
aminocapr ac inj 250mg/ml ................................. 348
aminocapr ac syp 25%......................................... 348
AMINOCAPR AC TAB 1000MG ...................... 348
aminocapr ac tab 500mg ..................................... 348
aminophyllin inj 25mg/ml ...................................... 71
aminophyllin tab 100mg ........................................ 71
aminophyllin tab 200mg ........................................ 71
AMINOSYN INJ 10%..................................... 378
AMINOSYN INJ 3.5%.................................... 378
AMINOSYN INJ 5%....................................... 378
AMINOSYN INJ 7%....................................... 378
AMINOSYN INJ 8.5%.................................... 378
aminosyn inj 8.5/lyte........................................ 378
AMINOSYN 2-M INJ 4.25/D10 ......................... 378
AMINOSYN 7% INJ /LYTES ........................... 378
AMINOSYN II INJ 10% .................................... 378
AMINOSYN II INJ 15% .................................... 378
AMINOSYN II INJ 3.5/D25 .............................. 378
AMINOSYN II INJ 3.5/D5................................. 378
AMINOSYN II INJ 4.25/D10............................. 378
AMINOSYN II INJ 4.25/D20............................. 378
AMINOSYN II INJ 7% ...................................... 378
AMINOSYN II INJ 8.5% ................................... 378
aminosyn ii inj 8.5/lyte ........................................ 378
AMINOSYN IIM INJ 3.5%/D5W ....................... 378
AMINOSYN M INJ 3.5%.................................. 378
AMINOSYN/D20 INJ II 4.25% .......................... 379
AMINOSYN/D25 INJ II 3.5% ............................ 379
AMINOSYN/D25 INJ II 4.25% .......................... 379
AMINOSYN-HBC INJ 7%.................................. 378
aminosyn-hf inj 8% ............................................. 379
AMINOSYN-PF INJ 10% .................................. 379
AMINOSYN-PF INJ 7% .................................... 379
AMINOSYN-RF INJ 5.2%................................. 379
amiodarone inj 150mg/3m ................................... 64
amiodarone inj 50mg/ml ...................................... 64
amiodarone tab 100mg ........................................ 64
AMITIZA
CAP 24MCG................................. 332
AMITIZA
CAP 8MCG................................... 332
amitriptylin tab 100mg........................................... 97
amitriptylin tab 10mg............................................. 97
amitriptylin tab 150mg........................................... 97
amlod/atorva tab 10-10mg................................... 217
amlod/atorva tab 2.5-10mg.................................. 218
amlod/atorva tab 5-10mg..................................... 218
amlod/benazp cap 10-20mg ................................. 129
amlod/benazp cap 10-40mg ................................. 129
amlod/benazp cap 2.5-10mg ................................ 129
amlod/benazp cap 5-10mg ................................... 129
amlod/valsar tab /hctz.......................................... 136
amlod/valsar tab 10-160mg ................................. 136
amlod/valsar tab 10-320mg ................................. 136
445
amlod/valsar tab 5-160mg................................... 136
amlod/valsar tab 5-320mg................................... 136
amlodipine tab 10mg ......................................... 209
amlodipine tab 2.5mg ........................................ 209
amlodipine tab 5mg ........................................... 209
AMMONUL INJ 10% .................................... 323
AMORPH WOUND GEL DRESSING............... 303
amox/k clav chw 200mg...................................... 402
amox/k clav chw 400mg...................................... 402
amox/k clav sus 200/5ml ..................................... 402
amox/k clav sus 250/5ml ..................................... 402
amox/k clav sus 400/5ml ..................................... 402
amox/k clav sus 600/5ml ..................................... 402
amox/k clav tab 250-125..................................... 402
amox/k clav tab 250mg ....................................... 402
amox/k clav tab 500-125..................................... 402
amox/k clav tab 500mg ....................................... 402
amox/k clav tab 875mg ....................................... 402
amoxapine tab 100mg......................................... 97
amoxapine tab 150mg......................................... 97
amoxapine tab 25mg........................................... 97
amoxapine tab 50mg........................................... 97
amoxicillin cap 250mg........................................ 400
amoxicillin cap 500mg........................................ 400
amoxicillin chw 125mg ....................................... 400
amoxicillin chw 250mg ....................................... 400
amoxicillin sus 125/5ml ...................................... 400
amoxicillin sus 250mg/5m .................................. 400
amoxicillin tab 500mg ........................................ 400
amphetamine tab 10mg ........................................... 4
amphetamine tab 12.5mg ........................................ 4
amphetamine tab 5mg ............................................. 4
amphetamine tab 7.5mg .......................................... 4
AMPHOTEC
INJ 100MG ............................... 116
AMPHOTEC
INJ 50MG ................................. 116
amphotericin inj 50mg ......................................... 116
ampicillin cap 250mg......................................... 401
ampicillin cap 500mg......................................... 401
ampicillin inj 10gm ............................................ 401
ampicillin inj 125mg .......................................... 401
ampicillin inj 1gm .............................................. 401
ampicillin inj 2gm .............................................. 401
ampicillin sus 125/5ml ....................................... 401
ampicillin sus 250/5ml ....................................... 401
amp-sulbacta inj 1.5gm........................................ 402
amp-sulbacta inj 1-0.5gm..................................... 402
amp-sulbacta inj 10-5gm...................................... 402
amp-sulbacta inj 15gm......................................... 402
amp-sulbacta inj 2-1gm........................................ 402
amp-sulbacta inj 3gm........................................... 403
AMPYRA
TAB 10MG .................................. 409
AMRIX
CAP 15MG ..................................... 371
AMRIX
CAP 30MG ..................................... 371
AMTURNIDE150 TAB -5-12.5 .......................... 144
AMTURNIDE300 TAB -10-12.5 ........................ 144
AMTURNIDE300 TAB -10-25MG..................... 144
AMOXICILLIN TAB 775MG ........................... 400
amoxicillin tab 875mg ........................................ 400
amox-pot cla tab er .............................................. 402
AMPHADASE INJ 150/ML............................. 200
amphet/dextr tab 10mg ............................................ 3
amphet/dextr tab 12.5mg ......................................... 3
amphet/dextr tab 5mg .............................................. 3
amphet/dextr tab 7.5mg ........................................... 3
amphetamine cap 10mg er ...................................... 3
amphetamine cap 5mg er ........................................ 4
AMTURNIDE300 TAB -5-12.5 .......................... 144
AMTURNIDE300 TAB -5-25MG....................... 144
AMVISC
INJ 12MG/ML............................... 392
AMVISC PLUS INJ 16MG/ML ......................... 392
AMYL NITRITE INH 0.3ML ............................... 55
AMYTAL SOD INJ 500MG ............................. 349
ANABAR
TAB................................................ 20
ANACAINE OIN............................................. 286
ANADROL-50 TAB 50MG ................................ 44
ANAFRANIL CAP 25MG ................................. 98
ANAFRANIL CAP 50MG ................................. 98
ANAFRANIL CAP 75MG ................................. 98
anagrelide cap 0.5mg......................................... 344
anagrelide cap 1mg............................................ 344
ana-lex
kit.......................................................... 47
ANALPRAM
KIT ADVANCED ...................... 47
ANALPRAM E KIT ............................................ 47
446
ANALPRAM HC CRE 2.5-1% ............................ 47
ANALPRAM-HC CRE 1-1%............................... 47
ANALPRAM-HC CRE 1-2.5%............................ 47
ANALPRAM-HC CRE SINGLES ....................... 47
ANALPRAM-HC LOT 2.5% ............................... 47
ANALPRM SNGL CRE HC 2.5-1........................ 47
ANAPROX
TAB 275MG................................. 15
ANAPROX DS TAB 550MG.............................. 15
ANASCORP
INJ ............................................... 396
ANASEPT
SPR .............................................. 188
ANASPAZ TAB 0.125MG ............................ 426
anastrozole tab 1mg............................................ 162
ANCOBON
CAP 250MG .............................. 116
ANCOBON
CAP 500MG .............................. 116
ANDROGEL GEL 1%(25MG) ........................ 45
ANDROGEL GEL 1%(50MG) ........................ 45
ANDROGEL GEL 1.62% ................................ 45
ANDROGEL GEL PUMP 1% ......................... 45
ANDROID
CAP 10MG.................................... 45
ANDROXY
TAB 10MG ................................. 45
ANECTINE
INJ 20MG/ML ............................ 376
ANGELIQ
TAB 0.25-0.5 ............................... 324
ANGELIQ
TAB 0.5-1MG.............................. 324
ANGIOMAX INJ 250MG................................. 77
ANODYNERX PAD ........................................ 294
anodynz
mis 0.0375-5 ..................................... 294
ANORO ELLIPT AER 62.5-25............................. 65
ANTABUSE
TAB 250MG.............................. 406
ANTABUSE
TAB 500MG.............................. 406
ANTARA
CAP 130MG ................................ 123
ANTARA
CAP 30MG .................................. 123
ANTARA
CAP 43MG .................................. 123
ANTARA
CAP 90MG .................................. 123
ANTICOAG CIT SOL DEX SOL......................... 75
ANTICOAG CPD SOL ......................................... 75
ANTICOAGULNT SOL SOD CITR .................... 75
antipy/benzo sol otic ............................................ 394
ANTIVENIN KIT LAT MACT ....................... 396
ANTIVENIN MI INJ ............................................. 396
ANTIVERT TAB 12.5MG.............................. 115
ANTIVERT TAB 25MG................................. 115
ANTIVERT TAB 50MG................................. 115
ANTIZOL
INJ 1GM/ML................................ 112
anucort-hc sup 25mg ........................................... 48
ANUSOL-HC CRE 2.5% ................................... 48
ANUSOL-HC SUP 25MG ................................. 48
ANZEMET
INJ 20MG/ML............................ 113
ANZEMET
TAB 100MG............................... 113
ANZEMET
TAB 50MG................................. 113
apap/caff/di tab hydrocod ...................................... 24
apap/codeine sol 120-12/5 ..................................... 23
apap/codeine tab 300-15mg................................... 23
apap-caffein cap dihydroc...................................... 24
apexicon oin 0.05%.......................................... 273
APEXICON E CRE 0.05%................................ 273
APHTHASOL PST 5%..................................... 366
APLENZIN
TAB 174MG.................................. 90
APLENZIN
TAB 348MG.................................. 90
APLENZIN
TAB 522MG.................................. 90
APLIGRAF MIS .............................................. 293
APOKYN
INJ ..................................................173
APOKYN
INJ 10MG/ML.............................. 173
APOP
GEL 10% .......................................... 270
APPBUTAMONE PAK........................................ 90
APPBUTAMONE PAK -D .................................. 90
APPFORMIN PAK........................................... 101
APPFORMIN-D PAK......................................... 101
apraclonidin sol 0.5% op ..................................... 390
apri
tab......................................................... 229
APRISO
CAP 0.375GM ................................ 333
APTENSIO XR CAP 10MG................................... 6
APTIOM
TAB 200MG.................................... 79
APTIOM
TAB 400MG.................................... 79
APTIOM
TAB 600MG.................................... 79
APTIOM
TAB 800MG.................................... 79
APTIVUS
CAP 250MG ................................. 190
APTIVUS
SOL ............................................... 190
AQUA GLYC HC KIT SCLP/BDY .................... 273
AQUORAL
AER ............................................ 366
ARALAST NP INJ 1000MG............................. 413
ARALAST NP INJ 400MG............................... 413
ARALAST NP INJ 500MG............................... 413
ARALAST NP INJ 800MG............................... 413
ARALEN
TAB 500MG ................................. 146
aranelle tab ...................................................... 236
ARANESP
INJ ............................................... 345
ARAVA
TAB 10MG ..................................... 19
ARAVA
TAB 20MG...................................... 19
arbinoxa sol 4mg/5ml ...................................... 120
arbinoxa tab 4mg ............................................. 120
447
ARCALYST INJ 220MG .................................. 13
ARCAPTA CAP 75MCG................................. 67
argatroban inj 100mg/ml...................................... 77
ARGATROBAN INJ 125/125............................. 77
ARGATROBAN INJ 250/250............................. 77
ARGATROBAN INJ 50MG/50M....................... 77
argyl saline sol 0.9% ........................................... 340
ARICEPT .................................................. TAB 10MG
.............................................................................
ARICEPT
TAB 23MG ................................... 406
ARICEPT
TAB 5MG ..................................... 406
ARICEPT ODT TAB 10MG .............................. 406
ARICEPT ODT TAB 5MG ................................ 406
ARIDA................................................................GEL
.............................................................................
303
ARIMIDEX
TAB 1MG ....................................... 162
aripiprazole sol 1mg/ml....................................... 185
aripiprazole tab 10mg ......................................... 185
aripiprazole tab 2mg ........................................... 185
aripiprazole tab 5mg ........................................... 185
ARISTADA ........................................ INJ 441MG/1.
.............................................................................
ARISTADA
INJ 662MG/2.............................. 185
ARISTADA INJ 882MG/3.............................. 185
ARISTOSPAN INJ 20MG/ML ......................... 238
ARISTOSPAN INJ 5MG/ML ........................... 238
ARIXTRA ..............................................INJ 10/0.8ML
...............................................................................
ARIXTRA
INJ 2.5/0.5...................................... 77
ARIXTRA
INJ 5/0.4ML................................... 77
ARIXTRA
INJ 7.5/0.6...................................... 77
ARMOUR THYRO TAB 120MG....................... 418
ARMOUR THYRO TAB 15MG......................... 418
ARNICA ............................................ TIN FLOWER
.............................................................................
ARNUITY
ELPT INH 100MCG...........................290
69
ARNUITY ELPT INH 200MCG........................... 69
AROMASIN TAB 25MG................................ 162
ARRANON..........................................
INJ 5MG/ML
ARTHROTEC 50 TAB .........................................
14
ARZOL SILVER MIS NITR APP....................... 272
asa/dipyrida cap 25-200mg ................................. 343
ASACOL
TAB 400MG DR........................... 333
ASACOL HD TAB 800MG ............................. 333
ascomp/cod cap 30mg.......................................... 23
ashlyna
tab ...................................................... 235
asmalpred sol 15mg/5ml ................................... 238
asmalpred sol plus ............................................ 238
ASMANEX 120 AER 220MCG........................... 69
ASMANEX 14 AER 220MCG............................ 69
ASMANEX 30 AER 110MCG............................ 69
ASMANEX 30 AER 220MCG............................ 69
ASMANEX 60 AER 220MCG............................ 70
ASMANEX 7 AER 110MCG............................. 70
ASMANEX HFA AER 100 MCG........................ 70
ASMANEX HFA AER 200 MCG........................ 70
aspirin tab 325mg ............................................. 22
ASPIRIN
TAB 75MG....................................... 22
aspirin tab 81mg ............................................... 22
ASTAGRAF XL CAP 0.5MG ............................ 201
ASTAGRAF XL CAP 1MG ............................... 201
ASTAGRAF XL CAP 5MG ............................... 201
ASTELIN NASA SPR 137MCG......................... 375
ASTEPRO SPR 0.15% ................................... 375
astramorph inj 10/10ml........................................ 28
astramorph inj 1mg/2ml....................................... 28
astramorph inj 2mg/2ml....................................... 28
ATACAND
TAB 16MG................................. 139
ATACAND
TAB 32MG................................. 139
ATACAND
TAB 4MG................................... 139
ATACAND
TAB 8MG................................... 139
ATACAND HCT TAB 16-12.5.......................... 137
ATACAND HCT TAB 32-12.5.......................... 137
ATACAND HCT TAB 32-25MG ...................... 137
ATELVIA
TAB .............................................. 313
ATENDIA
PAD 4-3% .................................... 294
atenol/chlor tab 100-25mg................................... 142
atenol/chlor tab 50-25mg..................................... 142
atenolol tab 100mg .......................................... 204
atenolol tab 25mg ............................................ 204
atenolol tab 50mg ............................................ 204
ATGAM
INJ 250MG.................................... 200
ATIVAN
INJ 2MG/ML................................... 60
ATIVAN
INJ 4MG/ML................................... 60
ATIVAN
TAB 0.5MG..................................... 60
ATIVAN
TAB 1MG........................................ 60
ATIVAN
TAB 2MG........................................ 60
ATOPICLAIR CRE ........................................... 288
ATORVA/COQ10 PAK 20-100MG.................... 125
ARTHROTEC 75 TAB ......................................... 14
ARTICADENT INJ DENTAL .......................... 355
ARZERRA.........................................CON 100/5ML
.............................................................................
ARZERRA
CON 1000/50 .............................. 154
448
atorvastatin tab 10mg.......................................... 126
atovaq/progu tab 250-100 ................................... 145
atovaq/progu tab 62.5-25 .................................... 146
atovaquone sus 750/5ml ...................................... 52
atracurium inj 10mg/ml ..................................... 377
atracurium inj 50mg/5ml ................................... 377
ATRALIN
GEL 0.05%................................... 257
ATRAPRO
GEL HYDROGEL...................... 303
ATRAPRO CP KIT ............................................. 303
ATRAPRO DERM SPR ...................................... 300
ATRIPLA
TAB .............................................. 188
ATROPEN
INJ 0.25MG................................. 426
ATROPEN
INJ 0.5MG................................... 426
ATROPEN
INJ 1MG...................................... 427
ATROPEN
INJ 2MG...................................... 427
atropin-care sol 1% op ........................................ 382
atropine sul inj 0.05mg/1..................................... 427
atropine sul inj 0.1mg/ml..................................... 427
atropine sul inj 0.4/0.5......................................... 427
atropine sul inj 0.4mg/ml..................................... 427
atropine sul inj 1mg/ml........................................ 427
atropine sul oin 1% op......................................... 382
atropine sul sol 1% op ......................................... 382
ATROVENT HFA AER 17MCG.......................... 68
ATROVENT NAS SOL 0.03% ........................... 375
ATROVENT NAS SOL 0.06% ........................... 375
ATUSS DS SUS .............................................. 249
AUBAGIO
TAB 14MG ................................. 408
AUBAGIO
TAB 7MG ................................... 408
aubra
tab 0.1-0.02 ........................................ 229
aug betamet cre 0.05% ....................................... 273
aug betamet gel 0.05% ....................................... 273
aug betamet lot 0.05% ........................................ 273
aug betamet oin 0.05% ....................................... 273
AUGMENTIN SUS 125/5ML.......................... 403
AUGMENTIN SUS 250/5ML.......................... 403
AUGMENTIN SUS ES-600............................. 403
AUGMENTIN TAB 500MG............................ 403
AUGMENTIN TAB 875MG............................ 403
AUGMENTIN XR TAB 12HR ........................... 403
AURALGAN SOL 5.5-1.4%........................... 394
aurax
sol 5.5-1.4%........................................ 394
aurodex
sol otic .............................................. 394
AURSTAT
KIT .............................................. 288
AURSTAT
KIT HYDROGEL ....................... 288
AURSTAT ANTI GEL -ITCH ............................ 288
AURYXIA
TAB 210MG................................ 334
AUVI-Q
INJ 0.15MG .................................... 438
AUVI-Q
INJ 0.3MG ...................................... 438
AVALIDE
TAB 150-12.5............................... 137
AVALIDE
TAB 300-12.5............................... 137
avalin-rx pad 4-1% ........................................... 295
AVANDAMET TAB 2-1000MG .................... 109
AVANDAMET TAB 2-500MG ...................... 109
AVANDAMET TAB 4-1000MG .................... 109
AVANDAMET TAB 4-500MG ...................... 109
AVANDARYL TAB 4-1MG............................ 107
AVANDARYL TAB 4-2MG............................ 107
AVANDARYL TAB 4-4MG............................ 107
AVANDARYL TAB 8-2MG............................ 107
AVANDARYL TAB 8-4MG............................ 107
AVANDIA
TAB 2MG ................................... 110
AVANDIA
TAB 4MG ................................... 110
AVANDIA
TAB 8MG ................................... 110
AVAPRO
TAB 150MG................................. 139
AVAPRO
TAB 300MG................................. 139
AVAPRO
TAB 75MG................................... 139
AVAR
AER 9.5-5%..................................... 253
AVAR
PAD 9.5-5%..................................... 253
avar cleanse emu 10-5% ...................................... 253
AVAR LS
AER 10-2%................................... 253
AVAR LS
LIQ 10-2% .................................... 253
AVAR LS
PAD 10-2%................................... 253
avar-e emoll cre 10-5%........................................ 253
avar-e green cre 10-5% ....................................... 253
AVAR-E LS CRE 10-2% ................................. 253
AVASTIN
INJ...................................................170
AVASTIN
INJ 400/16ML .............................. 170
AVC
CRE 15% ........................................... 437
AVEED
INJ 750/3ML .................................... 45
AVELOX
INJ...................................................329
AVELOX
TAB 400MG................................. 329
AVELOX ABC TAB 400MG............................ 329
AVENOVA SOL 0.01% ................................. 283
aviane
tab....................................................... 229
avidoxy
tab 100mg .......................................... 415
AVIDOXY DK KIT........................................... 414
AVINZA
CAP 120MG .................................... 28
AVINZA
CAP 30MG ...................................... 28
AVINZA
CAP 45MG ...................................... 28
AVINZA
CAP 60MG ...................................... 29
AVINZA
CAP 75MG ...................................... 29
AVINZA
CAP 90MG ...................................... 29
avita
cre 0.025% ........................................... 257
avita
gel 0.025% ........................................... 257
449
B-12 COMP KIT 1000MCG ............................ 345
baciim
inj 50000unt ......................................... 49
bacit/polymy oin op .............................................. 384
bacitracin inj 50000unt........................................ 49
bacitracin oin op ................................................ 385
BACITRACIN POW ZINC USP....................... 264
BACLOFEN CRE............................................ 262
BACLOFEN CRE 1% ..................................... 262
BACLOFEN CRE 2% ..................................... 262
baclofen tab 10mg............................................ 371
baclofen tab 20mg............................................ 371
BACTOCILL INJ DEX 1GM........................... 404
BACTOCILL INJ DEX 2GM........................... 404
BACTRIM
TAB 400-80MG............................. 51
BACTRIM DS TAB 800-160 .............................. 51
BACTROBAN CRE 2%................................... 264
BACTROBAN OIN 2% ................................... 264
BACTROBAN OIN NASAL 2% ..................... 375
BAL IN OIL INJ 100MG/ML............................ 112
balanced sal sol op............................................... 388
balsalazide cap 750mg........................................ 333
balziva
tab....................................................... 229
BANZEL
SUS 40MG/ML............................... 79
BANZEL
TAB 200MG ................................... 79
BANZEL
TAB 400MG ................................... 79
BARACLUDE SOL .05MG/ML ...................... 194
BARACLUDE TAB 0.5MG............................. 194
BARACLUDE TAB 1MG................................ 194
baycadron elx 0.5/5ml....................................... 238
BEAU RX GEL .............................................. 292
BECONASE AQ SUS 0.042% ........................... 375
BELEODAQ INJ 500MG................................ 153
bella alk/pb tab 16.2mg........................................ 425
BELLA/OPIUM SUP 16.2-30 ............................ 425
bella/opium sup 16.2-60...................................... 425
BELLADONNA TIN 30/100ML....................... 427
BELSOMRA TAB 10MG ............................... 353
BELSOMRA TAB 15MG ............................... 353
BELSOMRA TAB 20MG ............................... 353
BELSOMRA TAB 5MG ................................. 353
benazep/hctz tab 10-12.5...................................... 130
benazep/hctz tab 20-12.5...................................... 130
benazep/hctz tab 20-25mg.................................... 130
benazep/hctz tab 5-6.25........................................ 130
benazepril tab 10mg........................................... 132
benazepril tab 5mg............................................. 132
BENICAR
TAB 20MG .................................. 139
AVO CREAM EMU......................................... 303
AVODART
CAP 0.5MG................................ 337
AVONEX
KIT 30MCG................................. 408
AVONEX PEN KIT 30MCG ............................ 408
AVONEX PREFL KIT 30MCG.......................... 408
AVYCAZ
INJ 2-0.5GM ................................ 222
AXERT
TAB 12.5MG.................................. 363
AXERT
TAB 6.25MG.................................. 363
AXID
CAP 150MG ..................................... 428
AXID
CAP 300MG ..................................... 428
AXID
SOL 15MG/ML ................................ 428
AYGESTIN
TAB 5MG ................................... 405
azacitidine inj 100mg.......................................... 150
AZACTAM
INJ 1GM ...................................... 49
AZACTAM
INJ 2GM ...................................... 49
AZACTAM/DEX INJ 1GM ................................. 49
AZACTAM/DEX INJ 2GM ................................. 49
AZASAN
TAB 100MG................................. 203
AZASAN
TAB 75 MG................................. 203
AZASITE
SOL 1%......................................... 385
azathioprine inj 100mg........................................ 203
azathioprine tab 50mg ......................................... 203
azelastine dro 0.05%.......................................... 384
azelastine spr 0.1% ............................................ 375
azelastine spr 0.15% .......................................... 375
AZELEX
CRE 20%....................................... 257
AZENASE PAK MIS 137-50............................. 374
AZILECT
TAB 0.5MG .................................. 172
AZILECT
TAB 1MG ..................................... 172
AZITHROMYCIN INJ 2.5GM ........................... 359
azithromycin inj 500mg ....................................... 359
azithromycin sus 100/5ml .................................... 359
azithromycin sus 200/5ml .................................... 359
azithromycin tab 250mg....................................... 359
AZOPT
SUS 1% OP..................................... 386
AZOR
TAB 10-20MG................................. 136
AZOR
TAB 10-40MG................................. 136
AZOR
TAB 5-20MG................................... 136
AZOR
TAB 5-40MG................................... 136
aztreonam inj 1gm .............................................. 49
aztreonam inj 2gm .............................................. 49
AZULFIDINE TAB 500MG ............................. 333
AZULFIDINE TAB 500MG EN ....................... 333
azuphen mb cap 120mg...................................... 433
azurette tab 28 day .......................................... 228
B
b complex
with folic acid .................................. 370
450
BENICAR
TAB 40MG ................................. 139
BENICAR
TAB 5MG ................................... 139
BENICAR HCT TAB 20-12.5............................ 137
BENICAR HCT TAB 40-12.5............................ 137
BENICAR HCT TAB 40-25MG ........................ 137
BENLYSTA
INJ 120MG ................................ 199
BENLYSTA
INJ 400MG ................................ 199
BENSAL HP OIN............................................. 284
BENTYL
CAP 10MG ................................... 426
BENTYL
INJ 10MG/ML .............................. 426
BENTYL
SYP 10MG/5ML........................... 426
BENTYL
TAB 20MG ................................... 426
BENZAC AC GEL 10%................................... 257
BENZAC AC GEL 5%..................................... 257
BENZAC AC LIQ 10% WASH ....................... 257
BENZAC AC LIQ 5% WASH ......................... 257
BENZAC W LIQ 10% WASH........................ 257
BENZAC W LIQ 5% WASH.......................... 257
BENZACLIN GEL 1-5% ................................. 253
BENZACLIN GEL 1-5%PUMP ...................... 253
BENZALKONIUM SOL 17% ............................ 188
benzalkonium sol 50% ......................................... 188
BENZALKONIUM SOL NF............................... 188
BENZAMYCIN GEL ........................................ 253
BENZAMYCIN GEL 5-3% .............................. 253
BENZAMYCIN GEL PAK ............................... 253
BENZEFOAM AER 5.3%................................ 257
BENZEFOAM AER 9.8%................................ 257
benzepro aer 5.3% ........................................... 257
benzepro liq creamy......................................... 257
benzepro mis 6%.............................................. 257
benzepro sc aer 9.8%.......................................... 258
BENZIQ
GEL 5.25%..................................... 258
BENZIQ LS GEL 2.75%.................................. 258
benziq wash liq 5.25% ........................................ 258
BENZODOX 30 MIS ......................................... 414
BENZODOX 60 MIS ......................................... 414
BENZOIN
TIN NF ......................................... 292
benzonatate cap 100mg ...................................... 244
benzoyl per aer 5.3% .......................................... 258
benzoyl per aer 9.8% .......................................... 258
benzoyl per liq 7% wash ..................................... 258
benzoyl per lot 3% .............................................. 258
benzoyl per lot 4% .............................................. 258
benzoyl per lot 6% .............................................. 258
benzoyl per lot 9% .............................................. 258
benzoyl per pad 3% ............................................ 258
benzoyl per pad 6%............................................. 258
benzoyl per pad 9%............................................. 258
benzoyl pero aer 9.8% ......................................... 258
benztropine inj 1mg/ml........................................ 171
benztropine tab 0.5mg......................................... 171
benztropine tab 1mg............................................ 171
benztropine tab 2mg............................................ 171
BENZYL ALC LIQ .............................................404
BEPREVE
DRO 1.5% .................................... 384
BESIVANCE SUS 0.6% .................................. 385
BETA 1 KIT KIT 30MG/5ML .......................... 243
BETA INJECT KIT ............................................ 243
BETADINE
SOL 5% OP................................. 386
BETAGAN
SOL 0.5% OP.............................. 381
BETALIDO
KIT .............................................. 243
BETAMETH COM INJ 7MG/ML ...................... 243
betameth dip cre 0.05%........................................ 273
betameth dip lot 0.05% ........................................ 273
betameth dip oin 0.05% ....................................... 273
BETAMETH PF INJ 12MG/2ML ...................... 243
BETAMETH SP INJ 24MG/2ML ...................... 238
betameth val aer 0.12% ....................................... 273
betameth val cre 0.1%.......................................... 273
betameth val lot 0.1%........................................... 273
betameth val oin 0.1%.......................................... 273
BETAPACE
TAB 120MG .............................. 206
BETAPACE
TAB 160MG .............................. 206
BETAPACE
TAB 80MG ................................ 206
BETAPACE AF TAB 120MG ........................... 206
BETAPACE AF TAB 160MG ........................... 206
BETAPACE AF TAB 80MG ............................. 206
beta-phos/ac inj 3-3mg/ml.................................... 243
BETASERON INJ 0.3MG................................ 408
betaxolol sol 0.5% op........................................ 381
betaxolol tab 10mg............................................ 204
betaxolol tab 20mg............................................ 204
bethanechol tab 10mg ......................................... 435
bethanechol tab 5mg ........................................... 435
BETHKIS
NEB 300/4ML................................. 10
BETIMOL
SOL 0.25%................................... 381
BETIMOL
SOL 0.5% ..................................... 381
BETOPTIC-S SUS 0.25% OP ........................... 381
bexarotene cap 75mg ......................................... 169
BEXXAR
CON 14MG/ML ........................... 157
BEXXAR 131 I INJ 0.61/ML.............................. 160
BEXXAR 131 I INJ 5.6MCI/M ........................... 160
BEYAZ
TAB ................................................ 229
451
BIAFINE
EMU............................................... 303
BIAXIN
SUS 250/5ML................................. 360
BIAXIN
TAB 250MG................................... 360
BIAXIN
TAB 500MG................................... 360
BIAXIN XL TAB 500MG................................ 360
BIAXIN XL TAB PAC 500 ............................. 360
bicalutamide tab 50mg ........................................ 150
BICILLIN C-R INJ 1200000............................... 403
BICILLIN C-R INJ 900/300................................ 403
BICILLIN L-A INJ 1200000............................... 401
BICILLIN L-A INJ 2400000............................... 401
BICILLIN L-A INJ 600000................................. 401
BICNU
INJ 100MG...................................... 168
BIDIL
TAB................................................... 219
BIEST/PROGES CRE ......................................... 324
BILTRICIDE TAB 600MG................................. 49
BIMATOPROST SOL 0.03% ............................ 393
BINOSTO
TAB 70MG................................... 313
bio glo tes 1mg op........................................... 387
biogesic tab 30-500mg....................................... 20
BIONECT
AER 0.2%..................................... 303
BIONECT
CRE 0.2%..................................... 303
BIONECT
GEL 0.2% ..................................... 303
BIONECT
SPR 0.2%...................................... 303
BIOPSY TRAY KIT MARROW ....................... 356
BIOREGESIC TAB 50-650MG .......................... 20
BIO-STATIN CAP 1000000 ............................. 116
BIO-STATIN CAP 500000 ............................... 117
BIOSTEP
MIS 2 ............................................. 303
BIOSTEP
MIS 4 ............................................. 303
BIOSTEP AG MIS 2 ......................................... 303
BIOSTEP AG MIS 4 ......................................... 303
biotuss liq........................................................ 246
biotuss liq pediatrc ......................................... 246
BIOVANCE MIS 1CMX2CM ........................ 293
bisoprl/hctz tab 10/6.25 ....................................... 143
bisoprl/hctz tab 2.5/6.25 ...................................... 143
bisoprl/hctz tab 5-6.25mg .................................... 143
bisoprol fum tab 10mg......................................... 204
bisoprol fum tab 5mg........................................... 205
bivalirudin inj 250mg ........................................... 77
BIVIGAM
INJ 10%........................................ 397
BL INJECTION KIT ........................................... 355
bleomycin inj 15unit ......................................... 158
bleomycin inj 30unit ......................................... 158
BLEPH-10 SOL 10% OP ................................ 392
BLEPHAMIDE OIN S.O.P ............................... 390
BLEPHAMIDE SUS OP ................................... 390
BLINCYTO
INJ 35MCG ................................ 154
BLOXIVERZ INJ 1MG/ML............................. 146
BLOXIVERZ INJ 5MG/10ML......................... 146
BONE MARROW KIT 16GX2.......................... 356
BONE MARROW KIT BIOPSY ....................... 356
BONIVA
INJ 3MG/3ML............................... 313
BONIVA
TAB 150MG.................................. 313
BOSULIF
TAB 100MG ................................. 156
BOSULIF
TAB 500MG ................................. 156
BOTOX
INJ 100UNIT.................................. 377
BOTOX
INJ 200UNIT.................................. 377
bp 10-1
emu..................................................... 253
bp cleanser liq 4.25%.......................................... 258
BP CLEANSING EMU 10-4%............................ 253
bp foam aer 5.3%............................................ 258
bp foam aer 9.8%............................................ 258
bp foaming liq wash 10%................................... 258
bp wash
liq 2.5%............................................. 258
bp wash
liq 5.25%........................................... 258
bp wash
liq 7%................................................ 258
bpm
tab 6mg................................................ 119
bpo
gel 4% .................................................. 258
BPO
GEL 8%.............................................. 259
BPO CLOTHS MIS 3% ..................................... 259
bpo cloths mis 6% .............................................. 259
BPO CLOTHS MIS 9% ..................................... 259
BREO ELLIPTA INH 100-25 ............................... 65
BREO ELLIPTA INH 200-25 ............................... 65
BREVIBLOC INJ 10MG/ML........................... 205
BREVIBLOC SOL ........................................... 205
BREVIBLOC SOL 10MG/ML......................... 205
BREVICON
TAB 0.5/35 ................................. 229
BREVITAL SOD INJ 2.5GM.............................. 336
BREVITAL SOD INJ 200MG............................. 337
BREVITAL SOD INJ 500MG............................. 337
briellyn tab ....................................................... 229
BRILINTA TAB 60MG .................................. 342
BRILINTA TAB 90MG .................................. 342
brimonidine sol 0.15% ........................................ 390
brimonidine sol 0.2% op ..................................... 390
BRINTELLIX TAB 10MG.................................. 94
BRINTELLIX TAB 20MG.................................. 94
BRINTELLIX TAB 5MG.................................... 94
BRISDELLE CAP 7.5MG................................ 413
BROMDAY
SOL 0.09% ................................ 389
bromfed dm syp .................................................. 249
bromfenac sol 0.09% ........................................ 389
452
bromfenac sol 0.09% op ................................... 389
bromocriptin cap 5mg.......................................... 171
bromocriptin tab 2.5mg ....................................... 171
brompheniram chw 12mg .................................... 119
BROMPHENIRAM INJ 10MG/ML ................... 119
BRONCOMAR-1 ELX......................................... 71
BRONCOPECTOL SYP ..................................... 245
BRONDIL
LIQ ................................................... 70
BROVANA
NEB 15MCG ............................... 67
BROVEX
SUS 12MG/5ML .......................... 119
BROVEX CB TAB 10-4MG............................ 250
BROVEX CBX TAB 20-4MG .......................... 250
BROVEX CT CHW 12MG .............................. 119
BROVEX PB C TAB 10-4-10............................ 251
BROVEX PB CX TAB 10-4-20.......................... 251
BROVEX PD SUS ........................................... 247
BROVEX SR CAP 9-90MG ............................ 247
bss
sol op .................................................... 388
BSS PLUS SOL OP......................................... 388
BT INJECTION KIT 40-0.5%............................. 243
BUCALSEP SOL ............................................ 187
BUCALSEP SPR............................................. 187
budeprion tab 100mg sr...................................... 90
budeprion tab 150mg sr...................................... 90
budeprion xl tab 150mg ......................................... 90
budeprion xl tab 300mg ......................................... 90
budesonide cap 3mg/24hr .................................. 238
budesonide sus 0.25mg/2 ..................................... 70
budesonide sus 0.5mg/2 ....................................... 70
budesonide sus 1mg/2ml ...................................... 70
budesonide sus 32mcg........................................ 375
bumetanide inj 0.25/ml ...................................... 309
bumetanide tab 0.5mg........................................ 310
bumetanide tab 1mg........................................... 310
bumetanide tab 2mg........................................... 310
BUMEX
TAB 0.5MG .................................. 310
BUMEX
TAB 1MG ..................................... 310
BUMEX
TAB 2MG ..................................... 310
BUNAVAIL MIS 2.1-0.3 .................................. 42
BUNAVAIL MIS 4.2-0.7 .................................. 43
BUNAVAIL MIS 6.3-1MG............................... 43
BUPAP
TAB 50-300MG................................ 20
BUPAP
TAB 50-650MG................................ 20
BUPHENYL
TAB 500MG.............................. 323
bupivacaine inj 0.25% ........................................ 356
bupivacaine inj 0.5% .......................................... 356
bupivacaine inj 0.75% ........................................ 356
bupivacaine inj spinal......................................... 356
bupivacaine/ inj epi 0.25...................................... 355
bupivacaine/ inj epi 0.5%..................................... 355
BUPIVILOG KIT ............................................. 243
bupren/nalox sub 2-0.5mg...................................... 43
bupren/nalox sub 8-2mg......................................... 43
BUPRENEX
INJ 0.3MG/ML ............................ 43
buprenorphin inj 0.3mg/ml .................................... 43
buprenorphin sub 2mg ........................................... 43
buprenorphin sub 8mg ........................................... 43
buproban tab 150mg ........................................ 411
bupropion tab 100mg.......................................... 90
bupropion tab 100mg er...................................... 90
bupropion tab 100mg sr...................................... 90
bupropion tab 150mg........................................ 411
bupropion tab 150mg er...................................... 90
bupropion tab 200mg er ..................................... 90
bupropion tab 75mg............................................ 91
bupropn hcl tab 150mg xl ..................................... 91
bupropn hcl tab 300mg xl ..................................... 91
buspirone tab 10mg............................................. 58
buspirone tab 15mg............................................. 58
buspirone tab 30mg............................................. 58
buspirone tab 5mg............................................... 58
buspirone tab 7.5mg............................................ 58
BUSULFEX
INJ 6MG/ML.............................. 149
but/apap/caf cap..................................................... 20
but/apap/caf cap codeine ....................................... 23
but/apap/caf tab ..................................................... 21
but/asa/caf/ cap cod 30mg ..................................... 23
but/asa/caff cap ...................................................... 21
but/asa/caff tab....................................................... 21
butal/apap tab 50-325mg ..................................... 21
butalbital tab cpd ................................................. 21
BUTISOL SOD ELX 30MG/5ML...................... 349
BUTISOL SOD TAB 30MG .............................. 349
BUTISOL SOD TAB 50MG .............................. 349
butorphanol inj 1mg/ml......................................... 43
butorphanol inj 2mg/ml......................................... 43
butorphanol sol 10mg/ml ...................................... 43
BUTRANS
DIS 10MCG/HR............................ 43
BUTRANS
DIS 15MCG/HR............................ 43
BUTRANS
DIS 20MCG/HR............................ 43
BUTRANS
DIS 5MCG/HR.............................. 43
BUTRANS
DIS 7.5/HR.................................... 43
BXN MOUTHWSH SUS .................................... 365
BYDUREON
INJ...............................................105
BYETTA
INJ 10MCG ................................... 105
BYETTA
INJ 5MCG ..................................... 105
453
BYSTOLIC
BYSTOLIC
BYSTOLIC
BYSTOLIC
C
CAMPHOMEX SPR ........................................ 286
CAMPHOR
CRY ........................................... 268
CAMPHOR
GRA ........................................... 268
CAMPRAL TAB 333MG............................... 406
CAMPTOSAR INJ 100/5ML ........................... 170
CAMPTOSAR INJ 300/15ML ......................... 170
CAMPTOSAR INJ 40MG/2ML....................... 170
camrese
tab ..................................................... 235
camrese lo tab .................................................... 235
CANASA
SUP 1000MG ............................... 333
CANCIDAS INJ 50MG................................... 116
CANCIDAS INJ 70MG................................... 116
candesa/hctz tab 16-12.5...................................... 137
candesa/hctz tab 32-12.5...................................... 137
candesa/hctz tab 32-25mg.................................... 137
candesartan tab 16mg......................................... 139
candesartan tab 32mg......................................... 139
candesartan tab 4mg........................................... 139
candesartan tab 8mg........................................... 139
CANTIL
TAB 25MG .................................... 430
capacet
cap ....................................................... 21
CAPASTAT SUL INJ 1GM ................................ 147
capecitabine tab 150mg ....................................... 150
capecitabine tab 500mg ....................................... 151
CAPEX
SHA 0.01% ..................................... 273
CAPHOSOL SOL............................................ 366
CAPITAL/COD SUS 120-12/5 ............................ 23
CAPRELSA
TAB 100MG............................... 156
CAPRELSA
TAB 300MG............................... 156
CAPSIDERM PAD .0375-5% .......................... 295
captopr/hctz tab 25-15mg .................................... 131
captopril tab 100mg.......................................... 132
captopril tab 12.5mg......................................... 133
captopril tab 25mg............................................ 133
captopril tab 50mg............................................ 133
CAPTRACIN PAD .0375-5% .......................... 295
CARAC
CRE 0.5%....................................... 267
CARAFATE SUS 1GM/10ML........................ 430
CARAFATE TAB 1GM .................................. 430
carb/levo tab 10-100mg .................................... 172
carb/levo tab 25-100mg .................................... 172
carb/levo tab 25-250mg .................................... 172
carb/levo 50 tab /entacap..................................... 172
carb/levo 75 tab /entacap..................................... 172
carb/levo er tab 25-100mg ................................... 172
carb/levo er tab 50-200mg ................................... 172
TAB 10MG ................................. 205
TAB 2.5MG ................................ 205
TAB 20MG ................................. 205
TAB 5MG ................................... 205
CA ALGINATE MIS 12..................................... 303
CA ALGINATE PAD 2...................................... 303
CA ALGINATE PAD 4...................................... 303
cabergoline tab 0.5mg ........................................ 316
CA-DTPA
SOL 1000MG ............................... 111
CADUET
TAB 10-10MG ............................. 218
CADUET
TAB 10-20MG ............................. 218
CADUET
TAB 10-40MG ............................. 218
CADUET
TAB 10-80MG ............................. 218
CADUET
TAB 2.5-10MG ............................ 218
CADUET
TAB 2.5-20MG ............................ 218
CADUET
TAB 2.5-40MG ............................ 218
CADUET
TAB 5-10MG ............................... 218
CADUET
TAB 5-20MG ............................... 218
CADUET
TAB 5-40MG ............................... 218
CADUET
TAB 5-80MG ............................... 218
CAFERGOT
TAB 1-100MG .......................... 362
CALAN
TAB 120MG .................................. 209
CALAN
TAB 80MG .................................... 209
CALAN SR TAB 120MG ............................... 209
CALAN SR TAB 180MG ............................... 209
CALAN SR TAB 240MG ............................... 209
calc acetate cap 667mg........................................ 334
calc acetate tab 667mg ........................................ 334
CALC FOLINAT INJ 100/10ML........................ 163
CALC FOLINAT INJ 300/30ML........................ 163
CALCIJEX INJ 1MCG/ML ............................ 319
calcipotrien cre 0.005%....................................... 269
calcipotrien oin 0.005%....................................... 269
calcipotrien oin betameth .................................... 298
calcipotrien sol 0.005% ....................................... 269
calcitonin spr 200/act ........................................ 315
calcitrene oin 0.005% ........................................ 269
calcitriol cap 0.25mcg ....................................... 319
calcitriol cap 0.5mcg ......................................... 319
calcitriol inj 1mcg/ml......................................... 319
CALCITRIOL OIN 3MCG/GM ........................ 269
calcitriol sol 1mcg/ml ........................................ 319
CALCIUM DISO INJ 1GM/5ML ....................... 112
CALCIUM DISO INJ 500/2.5M ......................... 112
CALDOLOR INJ 400/4ML............................... 15
CALDOLOR INJ 800/8ML............................... 15
camila
tab 0.35mg ......................................... 235
CAMPATH
INJ 30MG/ML ........................... 154
454
carb/levo100 tab /entacap ................................... 172
CARBAGLU TAB 200MG............................. 319
carbamazepin cap 100mg er.................................. 79
carbamazepin chw 100mg ..................................... 80
carbamazepin sus 100/5ml..................................... 80
carbamazepin tab 200mg....................................... 80
carbamazepin tab 200mg er .................................. 80
carbamazepin tab 400mg er .................................. 80
CARBAPHEN 12 LIQ........................................... 249
CARBAPHEN 12 SUS PED ............................... 249
CARBATROL CAP 100MG.............................. 80
CARBATROL CAP 200MG.............................. 80
CARBATROL CAP 300MG.............................. 80
carbidopa tab 25mg.......................................... 172
carbinoxamin sol 4mg/5ml................................... 120
carbinoxamin tab 4mg ......................................... 120
CARBOCAINE INJ 1% .................................... 356
CARBOCAINE INJ 1% PF............................... 356
CARBOCAINE INJ 1.5% PF............................ 356
CARBOCAINE INJ 2% .................................... 357
CARBOCAINE INJ 2% PF............................... 357
carb-o-philc cre /40 ............................................. 280
carb-o-philc gel 40% ........................................... 280
carboplatin inj 150/15ml..................................... 149
CARBOPLATIN INJ 150MG ............................ 149
carboplatin inj 50mg/5ml.................................... 149
CARDENE I.V. INJ 2.5MG/ML ......................... 209
CARDENE IV INJ 40/200ML .......................... 209
CARDENE IV SOL 20/200ML......................... 209
CARDENE SR CAP 30MG .............................. 209
CARDENE SR CAP 45MG .............................. 209
CARDENE SR CAP 60MG .............................. 209
cardioplegic sol.................................................... 218
CARDIZEM
TAB 120MG .............................. 210
CARDIZEM
TAB 30MG ................................ 210
CARDIZEM
TAB 60MG ................................ 210
CARDIZEM
TAB 90MG ................................ 210
CARDIZEM CD CAP 120MG/24...................... 210
CARDIZEM LA TAB 120MG ........................... 210
CARDIZEM LA TAB 300MG/24 ...................... 210
CARDIZEM LA TAB 420MG/24 ...................... 210
CARDURA
TAB 1MG................................... 142
CARDURA
TAB 2MG................................... 142
CARDURA
TAB 4MG................................... 142
CARDURA
TAB 8MG................................... 142
CARDURA XL TAB 4MG ............................... 338
CARDURA XL TAB 8MG ............................... 338
CARIMUNE NF INJ 12GM ............................... 397
CARIMUNE NF INJ 3GM ................................. 397
CARIMUNE NF INJ 6GM ................................. 397
carisopr/asa tab 200-325 ..................................... 373
carisoprodol tab 250mg ....................................... 371
carisoprodol tab 350mg ....................................... 371
carisoprodol tab asa/cod ..................................... 373
CARMOL-HC CRE 1% ................................... 298
CARNITOR INJ 1GM/5ML............................ 316
CARNITOR SOL 1GM/10ML ........................ 316
CARNITOR SF SOL 1GM/10ML...................... 316
CARRASYN GEL DRESSING....................... 303
carteolol sol 1% op ........................................... 381
cartia xt cap 120/24hr....................................... 210
cartia xt cap 180/24hr....................................... 210
cartia xt cap 240/24hr....................................... 210
cartia xt cap 300/24hr....................................... 210
CARTICEL
IMP ................................................370
carvedilol tab 12.5mg ........................................ 203
carvedilol tab 25mg ........................................... 203
carvedilol tab 3.125mg ...................................... 203
carvedilol tab 6.25mg ........................................ 203
CASCARA EXT SAGRADA......................... 355
CASCARA SAGR EXT ...................................... 355
CASCARA SAGR EXT AROMATIC ................ 355
CASODEX
TAB 50MG ................................. 150
CATAFLAM TAB 50MG ................................. 15
CATAPRES TAB 0.1MG................................ 141
CATAPRES TAB 0.2MG................................ 141
CATAPRES TAB 0.3MG................................ 141
CATAPRES-TTS DIS 0.1/24HR......................... 141
CATHFLO ACTI INJ VASE............................... 344
CAVERJECT INJ 20MCG ............................... 219
CAVERJECT INJ 40MCG ............................... 219
455
CAVERJECT KIT 10MCG.............................. 219
CAVERJECT KIT 20MCG.............................. 219
cefotetan inj 1gm/10ml...................................... 224
cefotetan inj 2gm/20ml...................................... 224
cefoxitin inj 10gm.............................................. 224
cefoxitin inj 1gm................................................ 224
cefoxitin inj 2gm................................................ 224
cefpodo prox sus 100/5ml .................................... 226
cefpodo prox sus 50mg/5ml.................................. 226
cefpodoxime tab 100mg....................................... 226
cefpodoxime tab 200mg....................................... 226
cefprozil sus 125/5ml ........................................ 224
cefprozil sus 250/5ml ........................................ 224
cefprozil tab 250mg........................................... 224
cefprozil tab 500mg........................................... 224
CEFTAZIDIME INJ 100GM .............................. 226
ceftazidime inj 1gm ............................................. 226
ceftazidime inj 500mg ......................................... 226
CEFTAZIDIME/ SOL D5W 1GM ...................... 226
CEFTAZIDIME/ SOL D5W 2GM ...................... 226
ceftibuten cap 400mg ......................................... 226
ceftibuten sus 180/5ml........................................ 226
CEFTIN
SUS 125/5ML ................................. 224
CEFTIN
SUS 250/5ML ................................. 224
CEFTIN
TAB 250MG ................................... 224
CEFTIN
TAB 500MG ................................... 224
ceftriax/dex inj 1gm.............................................. 226
ceftriax/dex inj 2gm.............................................. 226
CEFTRIAXONE INJ 100GM............................. 227
ceftriaxone inj 10gm............................................ 227
ceftriaxone inj 1gm.............................................. 227
ceftriaxone inj 250mg.......................................... 227
ceftriaxone inj 2gm.............................................. 227
ceftriaxone inj 500mg.......................................... 227
CEFTRIAXONE/ INJ DEX 1GM ....................... 227
CEFTRIAXONE/ INJ DEX 2GM ....................... 227
cefurox/dext inj 1.5gm.......................................... 224
cefurox/dext inj 750mg......................................... 225
cefuroxime inj 1.5gm.......................................... 225
CEFUROXIME INJ 225GM.............................. 225
cefuroxime inj 7.5gm.......................................... 225
cefuroxime inj 750mg......................................... 225
CEFUROXIME INJ 75GM................................ 225
cefuroxime sus 125/5ml...................................... 225
cefuroxime tab 250mg........................................ 225
cefuroxime tab 500mg........................................ 225
celacyn
gel ...................................................... 292
CELACYN
KIT .............................................. 303
CELEBREX CAP 100MG................................. 13
CAYSTON
INH 75MG .................................... 49
caziant
pak ...................................................... 236
cdp/amitrip tab 10-25mg..................................... 406
cdp/amitrip tab 5-12.5mg.................................... 406
CEDAX
CAP 400MG .................................. 225
CEDAX
SUS 180/5ML ................................ 225
CEDAX
SUS 90MG/5ML............................ 225
CEENU
CAP 100MG................................... 168
CEENU
CAP 10MG..................................... 168
CEENU
CAP 40MG..................................... 169
cefaclor cap 250mg.......................................... 224
cefaclor cap 500mg.......................................... 224
CEFACLOR
SUS 125/5ML............................ 224
CEFACLOR
SUS 250/5ML............................ 224
CEFACLOR
SUS 375/5ML............................ 224
cefaclor er tab 500mg ......................................... 224
cefadroxil cap 500mg......................................... 222
cefadroxil sus 250/5ml ....................................... 222
cefadroxil sus 500/5ml ....................................... 223
cefadroxil tab 1gm ............................................. 223
cefazol/dex sol 1gm............................................. 223
CEFAZOL/DEX SOL 2GM ............................... 223
CEFAZOLIN INJ 100GM ................................ 223
cefazolin inj 10gm............................................. 223
cefazolin inj 1gm............................................... 223
cefazolin inj 1gm/50ml...................................... 223
cefazolin inj 20gm............................................. 223
CEFAZOLIN INJ 300GM ................................ 223
cefazolin inj 500mg........................................... 223
CEFAZOLIN SOL............................................ 223
cefdinir cap 300mg .......................................... 225
cefdinir sus 125/5ml......................................... 225
cefdinir sus 250/5ml......................................... 225
CEFDITOREN TAB 200MG ............................ 226
CEFDITOREN TAB 400MG ............................ 226
cefepime inj 1gm .............................................. 228
cefepime inj 2gm .............................................. 228
cefixime sus 100/5ml........................................ 226
cefixime sus 200/5ml........................................ 226
cefotaxime inj 10gm ........................................... 226
cefotaxime inj 1gm ............................................. 226
cefotaxime inj 2gm ............................................. 226
cefotaxime inj 500mg ......................................... 226
CEFOTET/DEX INJ 1-3.58% ............................ 224
CEFOTET/DEX INJ 2-2.08% ............................ 224
CEFOTETAN INJ 10G .................................... 224
456
CELEBREX CAP 200MG ................................ 13
CELEBREX CAP 400MG ................................ 13
CELEBREX CAP 50MG .................................. 13
celecoxib cap 100mg........................................... 13
celecoxib cap 200mg........................................... 13
celecoxib cap 400mg........................................... 13
celecoxib cap 50mg............................................. 13
CELESTONE INJ SOLUSPAN ....................... 243
CELESTONE SOL 0.6MG/5 ........................... 238
CELEXA
TAB 10MG ..................................... 92
CELEXA
TAB 20MG ..................................... 92
CELEXA
TAB 40MG ..................................... 92
CELLCEPT
CAP 250MG ............................... 200
CELLCEPT
SUS 200MG/ML......................... 201
CELLCEPT
TAB 500MG ............................... 201
CELLCEPT IV INJ 500MG ............................... 201
CELLUGEL
SOL 2%...................................... 392
CELONTIN
CAP 300MG ................................. 88
CEM-UREA SOL 45%.................................... 280
CENESTIN
TAB 0.3MG................................. 326
CENESTIN
TAB 0.45MG............................... 326
CENESTIN
TAB 0.625MG............................. 326
CENESTIN
TAB 0.9MG................................. 326
CENESTIN
TAB 1.25MG............................... 326
CENTANY
OIN 2%....................................... 264
CENTANY AT KIT 2% .................................... 264
cephadyn tab 50-650mg..................................... 21
cephalexin cap 250mg ....................................... 223
cephalexin sus 125/5ml...................................... 223
cephalexin sus 250/5ml...................................... 223
cephalexin tab 250mg ........................................ 223
cephalexin tab 500mg ........................................ 223
CERDELGA
CAP 84MG................................ 345
CEREBYX
INJ 100/2ML................................. 87
CEREBYX
INJ 500/10ML............................... 87
CEREZYME INJ 200UNIT............................. 345
CEREZYME INJ 400UNIT............................. 345
cerisa wash emu 10-1% ...................................... 253
cerovel
gel 40% .............................................. 280
cerovel
lot 40% ............................................... 280
CERUBIDINE INJ 20MG ................................. 158
CERVIDIL VAG MIS 10MG INS ....................... 396
CESAMET
CAP 1MG ................................... 115
cesia
pak ....................................................... 236
CETACAINE AER........................................... 295
cetirizine syp ...................................................... 120
cetirizine tab 10mg............................................. 120
cetirizine tab 5mg............................................... 120
CETRAXAL SOL 0.2% .................................. 395
CETYLCIDE-G CON......................................... 187
cevimeline cap 30mg .......................................... 370
CGU WC
LIQ 100-6.3................................... 245
CHANTIX
PAK 0.5& 1MG ........................... 412
CHANTIX
PAK 1MG .................................... 412
CHANTIX
TAB 0.5MG ................................. 412
CHANTIX
TAB 1MG .................................... 412
chateal
tab 0.15/30.......................................... 229
CHEMET
CAP 100MG ................................ 111
CHENODAL TAB 250MG ............................. 331
CHLORAL
CRY HYDRATE ........................ 351
CHLORAL HYDR SYP 500/5ML ...................... 351
chloramphen inj 1gm ............................................ 53
chlord/clidi cap 5-2.5mg ...................................... 425
chlordiazep cap 10mg ........................................... 60
chlordiazep cap 25mg ........................................... 60
chlordiazep cap 5mg ............................................. 60
CHLORHEX DIG SOL 20%............................... 188
chlorhex glu sol 0.12%......................................... 366
CHLORHEX GLU SOL 20%.............................. 188
chloroproc inj 2% .............................................. 359
chloroproc inj 3% .............................................. 359
chloroquine tab 250mg ....................................... 146
chloroquine tab 500mg ....................................... 146
chlorothiaz inj 500mg ......................................... 312
chlorothiaz tab 250mg ........................................ 312
chlorothiaz tab 500mg ........................................ 312
chlorpromaz inj 25mg/ml .................................... 183
chlorpromaz inj 50mg/2ml .................................. 183
chlorpromaz tab 100mg ...................................... 183
chlorpromaz tab 10mg ........................................ 183
chlorpromaz tab 200mg ...................................... 183
chlorpropam tab 100mg...................................... 108
chlorpropam tab 250mg...................................... 108
CHLORTETRACY CRY HCL............................ 415
chlorthalid tab 100mg......................................... 312
chlorthalid tab 25mg........................................... 312
chlorthalid tab 50mg........................................... 312
chlorzoxazon tab 500mg ...................................... 371
cho mag tris liq 500/5ml ........................................ 22
cho mag tris tab 1000mg........................................ 22
cho mag tris tab 500mg.......................................... 22
cho mag tris tab 750mg.......................................... 22
CHOLBAM
CAP 250MG .............................. 331
CHOLBAM
CAP 50MG ................................ 331
457
CIALIS
TAB 10MG ...................................... 221
CIALIS
TAB 2.5MG ..................................... 221
CIALIS
TAB 20MG ...................................... 221
CIALIS
TAB 5MG ........................................ 222
ciclodan cre 0.77% .......................................... 265
ciclodan sol 8% ............................................... 265
CICLODAN CRE KIT 0.77% ............................. 265
CICLODAN SOL KIT 8% .................................. 265
ciclopirox cre 0.77%.......................................... 265
ciclopirox gel 0.77% .......................................... 266
ciclopirox kit 8%................................................ 266
ciclopirox sha 1% .............................................. 266
ciclopirox sol 8% ............................................... 266
ciclopirox sus 0.77%.......................................... 266
cidaleaze cre 3%............................................... 286
cidofovir inj 75mg/ml........................................ 193
cilostazol tab 100mg .......................................... 342
cilostazol tab 50mg ............................................ 342
CILOXAN
OIN 0.3% OP............................... 385
CILOXAN
SOL 0.3% OP .............................. 385
CIMETID/NACL INJ 300/50ML........................ 428
cimetidine sol 300/5ml ....................................... 428
cimetidine tab 300mg......................................... 429
CIMZIA
KIT ................................................. 336
CIMZIA
KIT STARTER............................... 336
CIMZIA PREFL KIT 200MG/ML...................... 336
CIPRO
TAB 250MG .................................... 329
CIPRO
TAB 500MG .................................... 329
CIPRO
TAB 750MG .................................... 329
CIPRO (10%) SUS 500MG/5............................. 329
CIPRO (5%) SUS 250MG/5.............................. 329
CIPRO HC SUS OTIC .................................... 395
CIPRO I.V. INJ 200MG .................................... 329
CIPRO I.V. INJ 400MG .................................... 329
CIPRO XR TAB 1000MG............................... 329
CIPRO XR TAB 500MG................................. 330
CIPRODEX SUS 0.3-0.1% ............................. 395
ciprofloxacn inj 200mg ........................................ 330
ciprofloxacn inj 400mg ........................................ 330
CIPROFLOXACN SOL 0.2%............................. 395
ciprofloxacn sol 0.3% op ..................................... 385
ciprofloxacn sus 250mg/5 .................................... 330
ciprofloxacn sus 500mg/5 .................................... 330
ciprofloxacn tab 1000mg ..................................... 330
ciprofloxacn tab 100mg ....................................... 330
ciprofloxacn tab 500mg er ................................... 330
ciprofloxacn tab 750mg........................................ 330
cisatracuriu inj 10mg/ml ...................................... 377
cisatracuriu inj 2mg/ml ........................................ 377
cisplatin inj 100mg............................................ 149
CISPLATIN INJ 200MG.................................. 149
cisplatin inj 50/50ml ......................................... 149
citalopram sol 10mg/5ml ..................................... 92
citalopram tab 10mg ............................................ 92
CITANEST
INJ PLAIN 4% ............................ 357
CITANEST FOR INJ DENT 4%......................... 355
citric acid/ sol sod citr.......................................... 338
CITROLITH TAB ............................................ 338
cladribine inj 1mg/ml ......................................... 151
CLAFORAN INJ 10GM.................................. 227
CLAFORAN INJ 1GM.................................... 227
CLAFORAN INJ 2GM.................................... 227
CLAFORAN INJ 500MG................................ 227
CLAFORAN/D5W INJ 1GM .............................. 227
CLAFORAN/D5W INJ 2GM .............................. 227
CLARIFOAM EF AER 10-5%............................ 253
CLARINEX SYP 0.5MG/ML ......................... 120
CLARINEX TAB 5MG ................................... 120
CLARINEX RDT TAB 2.5MG ........................... 120
CLARINEX RDT TAB 5MG .............................. 121
CLARINEX-D TAB 2.5-120 ............................. 247
CLARINEX-D TAB 5-240MG.......................... 247
claris wash emu 10-4% ....................................... 253
clarithromyc sus 125/5ml..................................... 360
clarithromyc sus 250/5ml..................................... 360
clarithromyc tab 250mg ....................................... 360
clarithromyc tab 500mg ....................................... 360
clarithromyc tab 500mg er................................... 360
clearplex x gel 10%............................................. 259
clemastine syp 0.5/5ml ....................................... 120
clemastine tab 2.68mg........................................ 120
clenia
cre 10-5% ............................................ 253
clenia
emu foaming ........................................ 253
CLEOCIN
CAP 150MG ................................... 53
CLEOCIN
CAP 300MG ................................... 53
CLEOCIN
CAP 75MG ..................................... 53
CLEOCIN
CRE 2% VAG .............................. 437
CLEOCIN
SUP 100MG ................................. 437
CLEOCIN PED SOL 75MG/5ML........................ 53
CLEOCIN PHOS INJ 300MG............................... 54
458
CLINIMIX INJ 2.75/D5W............................... 379
CLINIMIX INJ 4.25/D10 ................................ 379
CLINIMIX INJ 4.25/D20 ................................ 379
CLINIMIX INJ 4.25/D25 ................................ 379
CLINIMIX INJ 4.25/D5W............................... 379
CLINIMIX INJ 5%/D15W .............................. 379
CLINIMIX INJ 5%/D20W .............................. 379
CLINIMIX INJ 5%/D25W .............................. 379
CLINIMIX E INJ 2.75/D10 ............................... 379
CLINIMIX E INJ 2.75/D5W ............................. 379
CLINIMIX E INJ 4.25/D10 ............................... 379
CLINIMIX E INJ 4.25/D25 ............................... 379
CLINIMIX E INJ 4.25/D5W ............................. 379
CLINIMIX E INJ 5%/D15W ............................. 379
CLINIMIX E INJ 5%/D20W ............................. 379
CLINIMIX E INJ 5%/D25W ............................. 379
clinisol sf inj 15%................................................ 380
CLIN-LIDO KIT................................................. 54
CLINOIN
CRE ............................................... 254
CLINORIL TAB 200MG .................................. 15
CLOBETA
KIT CREAM ............................... 298
CLOBETA
KIT OINTMENT......................... 298
clobetasol aer 0.05%.......................................... 273
clobetasol cre 0.05%.......................................... 273
clobetasol gel 0.05% .......................................... 273
clobetasol lot 0.05%........................................... 273
clobetasol oin 0.05%.......................................... 273
clobetasol sha 0.05% ......................................... 274
clobetasol sol 0.05% .......................................... 274
clobetasol spr 0.05%.......................................... 274
clobetasol e cre 0.05% ......................................... 274
CLOBEX
LOT 0.05% ................................... 274
CLOBEX
SHA 0.05% ................................... 274
CLOBEX
SPR 0.05% .................................... 274
clocortolone cre piv 0.1% .................................... 274
CLODAN
KIT 0.05%.................................... 298
clodan
sha 0.05%........................................... 274
CLODERM
CRE 0.1%................................... 274
CLODERM
CRE 0.1% PMP.......................... 274
CLOLAR
INJ 1MG/ML ................................ 151
clomipramine cap 25mg......................................... 98
clonazep odt tab 0.125mg ...................................... 78
clonazep odt tab 0.25mg ........................................ 78
clonazep odt tab 0.5mg .......................................... 78
clonazep odt tab 1mg ............................................. 78
clonazep odt tab 2mg ............................................. 78
CLEOCIN PHOS INJ 9GM/60ML........................ 54
CLEOCIN/D5W INJ 300MG ............................... 54
CLEOCIN/D5W INJ 600MG ............................... 54
CLEOCIN/D5W INJ 900MG ............................... 54
CLEOCIN-T GEL 1% ...................................... 251
CLEOCIN-T LOT 1% ...................................... 251
CLEOCIN-T PAD 1%...................................... 251
CLEOCIN-T SOL 1% ...................................... 252
CLEVIPREX EMU 0.5MG/ML....................... 210
CLIMARA
DIS 0.025MG .............................. 326
CLIMARA
DIS 0.0375MG ............................ 326
CLIMARA
DIS 0.05MG ................................ 326
CLIMARA
DIS 0.06MG ................................ 326
CLIMARA
DIS 0.075MG .............................. 326
CLIMARA
DIS 0.1MG .................................. 326
CLIMARA PRO DIS WEEKLY ........................ 324
CLIN SINGLE KIT USE...................................... 54
CLINAC BPO GEL 7%..................................... 259
clindacin kit etz 1%........................................... 253
CLINDACIN KIT PAC 1%.............................. 254
clindacin mis etz 1% ......................................... 252
clindacin-p pad 1%............................................. 252
CLINDAGEL GEL 1% .................................... 252
clindamax gel 1% ............................................. 252
clindamax lot 10mg/ml ..................................... 252
clindamy/ben gel 1.2-5% ..................................... 254
clindamy/ben gel 1-5% ........................................ 254
clindamycin aer 1% ............................................ 252
clindamycin cap 150mg ........................................ 54
clindamycin cap 300mg ........................................ 54
clindamycin cap 75mg .......................................... 54
clindamycin cre 2% vag...................................... 437
clindamycin gel 1%............................................. 252
clindamycin inj 150mg/ml..................................... 54
clindamycin inj 300/2ml........................................ 54
clindamycin inj 300mg.......................................... 54
clindamycin inj 9000/60........................................ 54
clindamycin lot 1% ............................................. 252
clindamycin lot 10mg/ml..................................... 252
clindamycin pad 1%............................................ 252
clindamycin sol 1%............................................. 252
clindamycin sol 75mg/5ml .................................... 54
CLINDAP-T CRE ............................................ 254
CLINDAREACH KIT 1%.................................. 252
CLINDESSE CRE 2%...................................... 437
459
clonazepam tab 0.5mg ......................................... 78
clonazepam tab 1mg ............................................ 78
clonazepam tab 2mg ............................................ 78
clonidine dis 0.1/24hr ....................................... 141
clonidine dis 0.2/24hr ....................................... 141
clonidine dis 0.3/24hr ....................................... 141
clonidine inj ........................................................ 20
clonidine inj 100/ml ............................................ 20
clonidine inj 500/ml ............................................ 20
clonidine tab 0.1mg .......................................... 141
clonidine tab 0.1mg er .......................................... 2
clonidine tab 0.2mg .......................................... 141
clonidine tab 0.3mg .......................................... 141
clopidogrel tab 300mg ........................................ 344
clopidogrel tab 75mg .......................................... 344
cloraz dipot tab 15mg ............................................ 60
cloraz dipot tab 3.75mg ......................................... 60
cloraz dipot tab 7.5mg ........................................... 60
CLORPRES TAB 0.1-15MG .......................... 135
CLORPRES TAB 0.2-15MG .......................... 135
CLORPRES TAB 0.3-15MG .......................... 135
clotrim/beta cre 1-0.05% ..................................... 264
clotrim/beta cre diprop ........................................ 264
clotrim/beta lot diprop ......................................... 264
CLOTRIMAZOLE CRY ..................................... 283
clotrimazole loz 10mg.......................................... 366
clotrimazole sol 1% ............................................. 283
clotrimazole tro 10mg.......................................... 366
clozapine tab 100/odt........................................ 180
clozapine tab 100mg ......................................... 180
CLOZAPINE TAB 12.5/ODT.......................... 180
clozapine tab 200mg ......................................... 181
clozapine tab 25mg ........................................... 181
clozapine tab 25mg odt..................................... 181
clozapine tab 50mg ........................................... 181
CLOZARIL
TAB 100MG ............................... 181
CLOZARIL
TAB 25MG ................................. 181
CNL8 NAIL KIT .............................................. 266
COAL TAR OIN 1% ....................................... 293
COAL TAR SOL 20%..................................... 293
COARTEM
TAB 20-120MG ......................... 146
COCA COLA SYP ........................................... 115
cocaine hcl sol 10% ............................................ 286
cocaine hcl sol 4% .............................................. 287
COCET
TAB 650-30MG ............................... 24
COCET PLUS TAB 650-60MG.......................... 24
CODAR AR LIQ 2-8/5ML.............................. 250
CODEINE PHOS INJ 30MG/2ML........................ 29
CODEINE PHOS INJ 60MG/2ML........................ 29
CODEINE SULF SOL 30MG/5ML ...................... 29
codeine sulf tab 15mg ............................................ 29
codeine/guai liq 10-300mg................................... 245
COGENTIN INJ 1MG/ML.............................. 171
co-gesic tab 5-500mg......................................... 24
COLAZAL
CAP 750MG................................ 333
COLCHICINE CAP 0.6MG .............................. 341
COLCHICINE TAB 0.6MG .............................. 341
COLCRYS
TAB 0.6MG................................. 341
COLESTID
GRA 5GM ................................... 123
COLESTID
TAB 1GM.................................... 123
COLESTID FLA GRA 5/7.5GM......................... 123
COLESTID FLA GRA 5GM ............................... 123
colestipol gra 5gm.............................................. 123
colestipol tab 1gm .............................................. 123
colidrops dro 0.125/ml...................................... 427
colistimeth inj 150mg ............................................ 50
COLLIGINIX MIS ............................................ 299
colocort ene 100mg............................................ 47
COLY-MYCIN M INJ 150MG ............................. 50
COLY-MYCIN S SUS OTIC................................395
COLYTE/FLAVR SOL PACKS ......................... 353
COMBIGAN SOL 0.2/0.5%............................ 381
COMBIPATCH DIS .05/.14 .............................. 324
COMBIPATCH DIS .05/.25 .............................. 324
COMBIVENT AER............................................ 65
COMBIVENT AER RESPIMAT ....................... 65
COMBIVIR TAB 150-300 .............................. 188
COMETRIQ KIT 100MG................................ 156
COMETRIQ KIT 140MG................................ 156
COMETRIQ KIT 60MG.................................. 156
COMFORT EZ PAD 20-4-1% .......................... 295
COMFORT EZ PAD 2-4-1% ............................ 295
COMPAZINE PAK 5MG................................. 183
compazine sup 25mg ......................................... 183
COMPAZINE TAB 10MG............................... 183
COMPLERA TAB........................................... 188
compound 347 liq................................................. 337
compro
sup 25mg........................................... 183
COMTAN
TAB 200MG................................ 176
CONCERTA TAB 18MG.................................... 6
CONCERTA TAB 27MG.................................... 6
CONCERTA TAB 36MG.................................... 6
CONCERTA TAB 54MG.................................... 6
CONDYLOX GEL 0.5% ................................. 285
460
CONDYLOX SOL 0.5% ................................. 285
constulose sol 10gm/15...................................... 354
CONZIP CAP 100MG ......................................29
CONZIP CAP 200MG ......................................29
CONZIP
CAP 300MG....................................29
COPASIL GEL ................................................ 282
COPAXONE...................................... INJ 20MG/ML
COPAXONE409
INJ 40MG/ML .............................. 409
COPEGUS
TAB 200MG ............................. 195
CORDARONE TAB 200MG ............................... 64
CORDRAN CRE 0.05%.................................. 274
CORDRAN
LOT 0.05% ............................. 274
CORDRAN OIN 0.05% ................................. 274
CORDRAN 24X3 TAP 4MCG/CM.................... 274
CORDRAN 80X3 TAP 4MCG/CM.................... 274
COREG................................................ TAB 12.5MG
.............................................................................
203
COREG...................................................
TAB 25MG
.............................................................................
COREG
TAB 3.125MG ............................... 204
COREG
TAB 6.25MG ................................. 204
COREG CR CAP 10MG..................................... 204
COREG CR CAP 20MG..................................... 204
COREG CR CAP 40MG ................................. 204
COREG CR CAP 80MG ................................. 204
CORGARD TAB 20MG ................................. 206
CORGARD TAB 40MG ................................. 206
CORGARD
TAB 80MG ................................ 206
CORLANOR TAB 5MG .................................. 219
CORLANOR TAB 7.5MG ............................... 219
CORLOPAM INJ 10MG/ML .......................... 145
cormax
oin 0.05%.................................. 274
cormax
sol 0.05% .................................. 274
cormax scalp sol 0.05% ....................................... 274
CORTALOGEL 2% ............................................ 298
CORTANE-B ...................................DRO AQ OTIC
.............................................................................
CORTANE-B
DRO OTIC.................................. 394
CORTANE-B LOT........................................... 292
CORTEF
TAB 10MG ............................... 238
CORTEF
TAB 20MG ............................... 238
CORTEF
TAB 5MG...................................... 238
CORTENEMA ..................................... ENE 100MG
cortic-nd dro47..................................................... 394
CORTIFOAM.........................................AER
90MG
cortisone
ac tab 25mg..........................................
238
CORTISPORIN CRE 0.5% ................................ 263
CORVERT
INJ 1MG/10ML............................. 64
CORZIDE
TAB 40-5MG................................ 143
CORZIDE
TAB 80-5MG................................ 143
COSENTYX
INJ 150MG/ML......................... 268
COSENTYX PEN INJ 150MG/ML .................... 269
COSMEGEN INJ 0.5MG ................................ 158
COSOPT
SOL 22.3-6.8 ................................. 381
COSOPT PF SOL ............................................. 381
COTAB A
TAB 4-10MG ............................... 250
COTAB AX TAB 4-20MG ............................. 250
COTABFLU TAB 20-4-500............................ 245
COTELLIC
TAB 20MG.................................. 153
COUMADIN INJ 5 MG .................................... 72
COUMADIN TAB 10MG ................................. 72
COUMADIN TAB 1MG ................................... 72
COUMADIN TAB 2.5MG ................................ 72
COUMADIN TAB 2MG ................................... 73
COUMADIN TAB 3MG ................................... 73
COUMADIN TAB 4MG ................................... 73
COUMADIN TAB 5MG ................................... 73
COUMADIN TAB 6MG ................................... 73
COUMADIN TAB 7.5MG ................................ 73
covaryx tab 1.25-2.5 ....................................... 324
covaryx hs tab .................................................... 324
COVERA-HS TAB 180MG ............................. 210
COVERA-HS TAB 240MG ............................. 210
CO-VERATROL CAP.......................................... 10
COZAAR
TAB 100MG................................. 139
COZAAR
TAB 25MG................................... 139
COZAAR
TAB 50MG................................... 139
CPB WC
LIQ ...................................................251
CREON
CAP 12000UNT ............................. 307
CREON
CAP 24000UNT ............................. 307
CREON
CAP 3000UNIT.............................. 307
CREON
CAP 36000UNT ............................. 307
CREON
CAP 6000UNIT.............................. 308
CRESEMBA
CAP 186 MG............................. 117
CRESEMBA
INJ 372MG................................ 117
CRESTOR ................................................TAB 10MG
...............................................................................
CRESTOR
TAB 20MG .................................. 126
CRESTOR
TAB 40MG .................................. 126
CRESTOR
TAB 5MG .................................... 126
CRESYLATE
SOL
25%
........................... 394
CRINONE
GEL
4%OTIC
VAG...........................
438
CORTISPORIN OIN 1%.................................... 263
CORTISPORIN SOL 1% OTIC ......................... 395
CORTISPORIN SUS -TC OTIC ......................... 395
CRINONE
CRIXIVAN
CRIXIVAN
CROFAB
461
GEL 8% VAG .............................. 438
CAP 200MG................................. 190
CAP 400MG................................ 190
INJ..................................................396
cyclosporine cap 100mg....................................... 199
cyclosporine cap 100mg md................................. 199
cyclosporine cap 25mg......................................... 199
cyclosporine cap 25mg mod................................. 199
cyclosporine cap 50mg mod................................. 199
cyclosporine inj 50mg/ml ..................................... 199
cyclosporine sol modified..................................... 199
CYKLOKAPRON INJ 100MG/ML ................... 348
CYMBALTA CAP 20MG................................. 95
CYMBALTA CAP 30MG................................. 95
CYMBALTA CAP 60MG................................. 95
cyotic
dro ....................................................... 394
cyproheptad syp 2mg/5ml ................................... 122
cyproheptad tab 4mg........................................... 122
CYRAMZA
INJ 100/10ML............................ 171
CYRAMZA
INJ 500/50ML............................ 171
cyred
tab........................................................ 229
CYSTADANE POW ........................................ 319
CYSTAGON CAP 150MG ............................. 339
CYSTAGON CAP 50MG ............................... 339
CYSTARAN SOL 0.44% ................................ 393
cytarabine inj 100mg ......................................... 151
cytarabine inj 100mg/ml .................................... 151
cytarabine inj 1gm ............................................. 151
cytarabine inj 20mg/ml ...................................... 151
CYTARABINE INJ 500MG.............................. 151
CYTOGAM
INJ................................................397
CYTOMEL TAB 25MCG .............................. 419
CYTOMEL TAB 50MCG .............................. 419
CYTOMEL TAB 5MCG ................................ 419
CYTOTEC
TAB 100MCG ............................. 432
CYTOTEC
TAB 200MCG ............................. 432
CYTOVENE INJ 500MG................................ 194
cytra k
gra crystals.......................................... 338
cytra-2
sol ....................................................... 338
cytra-3
syp....................................................... 338
cytra-k
sol........................................................ 338
D
cromolyn sod con 100/5ml ................................... 332
cromolyn sod neb 20mg/2ml .................................. 66
cromolyn sod sol 4% op....................................... 384
cryselle-28 tab 28 tabs........................................ 229
CUBICIN
SOL 500MG ................................... 53
CUPRIMINE CAP 250MG .............................. 199
CURAGEL HYDR PAD 2 .................................. 303
CURAGEL HYDR PAD 3 .................................. 304
CURAGEL HYDR PAD 4 .................................. 304
CURAGEL HYDR PAD 5 .................................. 304
CURAGEL HYDR PAD 8 .................................. 304
CURAGEL HYDR PAD 8.5 ............................... 304
CURITY HYPER MIS 1/2 .................................. 304
CURITY NACL PAD 6...................................... 304
curity salin sol 0.9% irr ....................................... 340
CUROSURF SUS 80MG/ML ......................... 414
CUTIVATE CRE 0.05% ................................. 274
CUTIVATE LOT 0.05% ................................. 274
CUTIVATE OIN 0.005% ................................ 274
CUVPOSA
SOL 1MG/5ML........................... 430
CYANIDE ANTI KIT PKG UNIT...................... 111
CYANOKIT INJ 5GM .................................... 112
cyclafem tab 1/35............................................. 229
cyclafem tab 7/7/7............................................ 236
CYCLESSA PAK............................................ 236
cyclobenzapr cap 15mg er ................................... 371
cyclobenzapr cap 30mg er ................................... 371
CYCLOBENZAPR CRE 20MG/GM.................. 371
CYCLOBENZAPR CRE 5% KIT ....................... 371
CYCLOBENZAPR KIT COMFORT.................. 371
CYCLOBENZAPR PAK PAX............................ 374
cyclobenzapr tab 10mg ........................................ 371
cyclobenzapr tab 5mg .......................................... 371
cyclobenzapr tab 7.5mg ....................................... 371
CYCLOGYL SOL 0.5% OP............................ 382
CYCLOGYL SOL 1% OP............................... 382
CYCLOGYL SOL 2% OP............................... 382
CYCLOMYDRIL SOL OP................................. 382
cyclopentol sol 1% op ......................................... 382
cyclopentol sol 2% op ......................................... 382
CYCLOPHOSPH CAP 25MG ........................... 168
CYCLOPHOSPH CAP 50MG ........................... 168
cyclophosph inj 1gm ........................................... 168
cyclophosph inj 2gm ........................................... 168
cyclophosph inj 500mg ....................................... 168
cyclophosph tab 25mg ........................................ 168
cyclophosph tab 50mg ........................................ 168
cycloserine cap 250mg........................................ 147
CYCLOSET TAB 0.8MG ............................... 103
D.H.E. 45 INJ 1MG/ML ................................... 362
DACARBAZINE INJ 100MG............................ 161
dacarbazine inj 200mg........................................ 161
DACOGEN
INJ 50MG................................... 151
dactinomycin inj 0.5mg ........................................ 158
DAKLINZA
TAB 30MG ................................ 195
DAKLINZA
TAB 60MG ................................ 195
DALIRESP TAB 500MCG ............................... 69
DALVANCE SOL 500MG................................ 50
danazol
cap 100mg ........................................... 45
danazol
cap 200mg ........................................... 45
462
danazol
cap 50mg ............................................. 45
DANTRIUM
CAP 100MG ............................. 373
DANTRIUM
CAP 25MG ............................... 373
DANTRIUM
CAP 50MG ............................... 373
DANTRIUM IV INJ 20MG ............................... 373
dantrolene cap 100mg ....................................... 373
dantrolene cap 25mg ......................................... 373
dantrolene cap 50mg ......................................... 373
dapsone
tab 100mg ........................................... 53
dapsone
tab 25mg ............................................. 53
DARAPRIM TAB 25MG................................ 146
DARZALEX SOL 100MG/5M ....................... 154
daunorubicin inj 20mg......................................... 158
daunorubicin inj 5mg/ml...................................... 158
DAUNOXOME INJ 2MG/ML......................... 158
DAYPRO
TAB 600MG .................................. 15
daysee
tab ...................................................... 235
DAYTRANA
DIS 10MG/9HR ........................... 6
DAYTRANA
DIS 15MG/9HR ........................... 6
DAYTRANA
DIS 20MG/9HR ........................... 6
DAYTRANA
DIS 30MG/9HR ........................... 6
DDAVP
INJ 4MCG/ML............................... 323
DDAVP
SOL 0.01%..................................... 323
DDAVP
SPR 0.01% ..................................... 323
DDAVP
TAB 0.1MG ................................... 323
DDAVP
TAB 0.2MG ................................... 323
DEBACTEROL SOL 30-50%........................... 366
deblitane tab 0.35mg ........................................ 235
decitabine inj 50mg............................................ 151
DECON-A
ELX 2-5MG/5M .......................... 247
DECON-G
DRO 2-1-40MG........................... 248
deferoxamine inj 2gm........................................... 112
deferoxamine inj 500mg....................................... 112
DELATESTRYL INJ 200MG/ML....................... 45
DELESTROGEN INJ 10MG/ML ...................... 326
DELOS
LOT 3.5% ....................................... 259
deltasone tab 20mg ........................................... 238
delyla
tab 0.1-0.02 ......................................... 229
DELZICOL CAP 400MG................................ 333
DEMADEX
TAB 100MG.............................. 310
DEMADEX
TAB 10MG................................ 310
DEMADEX
TAB 20MG................................ 310
DEMADEX
TAB 5MG.................................. 310
demeclocycl tab 150mg....................................... 415
demeclocycl tab 300mg ....................................... 415
DEMEROL INJ 100/2ML ................................ 29
DEMEROL INJ 100MG/ML............................ 29
DEMEROL INJ 25MG/0.5............................... 29
DEMEROL INJ 25MG/ML.............................. 29
DEMEROL INJ 50MG/ML.............................. 29
DEMEROL INJ 75MG/1.5............................... 29
DEMEROL INJ 75MG/ML.............................. 29
DEMEROL TAB 100MG................................. 29
DEMEROL TAB 50MG................................... 29
DEMSER
CAP 250MG ................................. 135
DENAVIR
CRE 1% ....................................... 271
DEPACON
INJ 100MG/ML ............................ 88
DEPAKENE
CAP 250MG ................................ 88
DEPAKENE
SYP 250/5ML .............................. 88
DEPAKOTE
TAB 125MG DR.......................... 88
DEPAKOTE
TAB 250MG DR.......................... 88
DEPAKOTE
TAB 500MG DR.......................... 88
DEPAKOTE ER TAB 250MG ............................. 88
DEPAKOTE ER TAB 500MG ............................. 88
DEPAKOTE SPR CAP 125MG ............................ 88
DEPEN TITRA TAB 250MG............................. 199
DEPOCYT
INJ 50MG/5ML........................... 151
DEPODUR
INJ 10MG/ML .............................. 29
DEPODUR
INJ 15/1.5ML................................ 29
DEPO-ESTRADI INJ 5MG/ML.......................... 326
DEPO-MEDROL INJ 20MG/ML....................... 238
DEPO-PROVERA INJ 150MG/ML .................... 235
DEPO-PROVERA INJ 400/ML .......................... 169
DEPO-SQ PROV INJ 104 ................................... 235
DEPO-TESTOST INJ 100MG/ML........................ 45
DEPO-TESTOST INJ 200MG/ML........................ 45
DEPRIZINE SUS 22.4/ML .............................. 429
DERMA SILKRX KIT SDS PAK....................... 298
DERMA SILKRX PAK ANODYNEX ................. 14
DERMA SILKRX PAK DICLOPAK.................... 14
DERMACINRX KIT ANALGESI ...................... 14
DERMACINRX KIT COMBOPAK ................. 290
DERMACINRX KIT PHARMAPA.................. 290
DERMACINRX KIT SILAPAK ....................... 298
DERMACINRX PAK........................................ 295
DERMACINRX PAK DUOPATCH ................. 295
DERMACINRX PAK INFLAMMA ................... 14
DERMACINRX PAK LEXITRAL ................... 263
463
DERMAGRAFT MIS........................................ 293
DERMAPAK PAK PLUS ............................... 254
DERMA-SMOOTH OIL /FS BODY .................. 274
DERMA-SMOOTH OIL /FS SCLP ..................... 275
DERMASORB AF KIT 3-0.5% .......................... 264
DERMASORB HC KIT 2% ................................ 275
DERMASORB TA KIT 0.1% ............................. 275
DERMASORB XM KIT 39% ............................. 280
DERMATOP CRE 0.1% ................................. 275
DERMATOP OIN 0.1%.................................. 275
dermazene cre 1%............................................. 265
DERMOTIC OIL 0.01% ................................. 395
DESFERAL
INJ 2GM ..................................... 112
DESFERAL
INJ 500MG................................. 112
desipramine tab 100mg......................................... 98
desipramine tab 10mg........................................... 98
desipramine tab 150mg......................................... 98
desloratadin tab 2.5 odt ....................................... 121
desloratadin tab 5mg ........................................... 121
desloratadin tab 5mg odt ..................................... 121
desmopressin inj 4mcg/ml.................................... 323
desmopressin sol 0.01%....................................... 323
desmopressin spr 0.01% ...................................... 323
desmopressin tab 0.1mg....................................... 323
desmopressin tab 0.2mg....................................... 323
deso/ethinyl tab estradio ...................................... 229
DESOGEN-28 TAB .......................................... 230
DESONATE
GEL 0.05% ................................ 275
desonide cre 0.05%.......................................... 275
desonide lot 0.05% .......................................... 275
desonide oin 0.05%.......................................... 275
DESONIL KIT 0.05% .................................... 275
DESOWEN
CRE 0.05%................................. 275
DESOWEN
LOT 0.05%................................. 275
DESOWEN
OIN 0.05% ................................. 275
DESOWEN CRM KIT 0.05% ............................ 275
DESOWEN LOT KIT 0.05% ............................. 275
DESOWEN OINT KIT 0.05% ............................ 275
desoximetas cre 0.05% ....................................... 275
desoximetas cre 0.25% ....................................... 275
desoximetas gel 0.05%........................................ 275
DESOXIMETAS OIN 0.05%............................. 275
desoximetas oin 0.25% ....................................... 275
DESOXYN
TAB 5MG....................................... 4
DESPEC-EXP SYP ........................................... 246
DESPEC-PDC LIQ .............................................. 251
desvenlafax tab 100mg er...................................... 95
desvenlafax tab 50mg er........................................ 95
DETROL
TAB 1MG ..................................... 434
DETROL
TAB 2MG ..................................... 434
DETROL LA CAP 2MG .................................. 434
DETROL LA CAP 4MG .................................. 434
DEX COMBO INJ 8-4MG/ML ........................ 243
DEX LA 16 INJ 16MG/ML.............................. 238
DEX LA 8 INJ 8MG/ML................................. 238
dexameth pho inj 10mg/ml ................................... 238
dexameth pho inj 120mg/30 ................................. 238
dexameth pho inj 20mg/5ml ................................. 238
dexameth pho inj 4mg/ml ..................................... 238
dexameth pho sol 0.1% op ................................... 391
dexamethason con 1mg/ml ................................... 238
dexamethason elx 0.5/5ml .................................... 239
dexamethason sol 0.5/5ml .................................... 239
dexamethason tab 0.5mg...................................... 239
dexamethason tab 0.75mg.................................... 239
dexamethason tab 1.5mg...................................... 239
dexamethason tab 1mg......................................... 239
dexchlorphen syp 2mg/5ml................................... 119
dexchlorphen tab 4mg cr...................................... 119
DEXEDRINE CAP 10MG CR ............................. 4
DEXEDRINE CAP 15MG CR ............................. 4
DEXEDRINE CAP 5MG CR ............................... 4
dexedrine tab 10mg............................................... 4
dexedrine tab 5mg................................................. 4
DEXLIDO
KIT ............................................... 243
DEXLIDO-M KIT ............................................ 243
dexmedetomid inj 200/2ml ................................... 353
dexmethylph cap 15mg er........................................ 6
dexmethylph tab 10mg ............................................ 6
dexmethylph tab 2.5mg ........................................... 6
dexmethylph tab 5mg .............................................. 6
dexmethylphe cap 10mg er....................................... 6
dexmethylphe cap 20mg er....................................... 7
dexmethylphe cap 5mg er......................................... 7
DEXPAK
PAK 10 DAY................................ 239
DEXPAK
PAK 13 DAY................................ 239
DEXPAK
PAK 6 DAY.................................. 239
dexpanthenol inj 250mg/ml .................................. 332
dexrazoxane inj 250mg ....................................... 162
dexrazoxane inj 500mg ....................................... 162
464
DEXTRAN 70 INJ NACL 0.9........................... 343
DEXTRAN HM INJ 32%.................................. 343
dextroamphet cap 10mg er ...................................... 4
dextroamphet cap 15mg er ...................................... 4
dextroamphet cap 5mg er ........................................ 4
dextroamphet sol 5mg/5ml....................................... 4
dextroamphet tab 10mg ........................................... 5
dextroamphet tab 5mg ............................................. 5
dextroamphet tab sulf 5mg....................................... 5
dg 200
tab 200-200.......................................... 70
DIAB
GEL................................................... 304
DIAB F.D.G. GEL.............................................. 304
DIABETA
TAB 1.25MG ............................... 108
DIABETA
TAB 2.5MG ................................. 108
DIABETA
TAB 5MG .................................... 108
DIAMOX SEQUE CAP 500MG CR .................. 309
DIASTAT ACDL GEL 12.5-20 ............................ 78
DIASTAT ACDL GEL 5-10MG........................... 79
DIASTAT PED GEL 2.5M GEL.......................... 79
diazepam con 5mg/ml ........................................ 60
diazepam gel 10mg ............................................ 79
diazepam gel 2.5mg ........................................... 79
diazepam gel 20mg ............................................ 79
DIAZEPAM INJ 10MG/2ML ........................... 60
diazepam inj 5mg/ml.......................................... 61
DIAZEPAM SOL 1MG/ML.............................. 61
diazepam tab 10mg ............................................ 61
diazepam tab 2mg.............................................. 61
diazepam tab 5mg.............................................. 61
DIBENZYLINE CAP 10MG.............................. 135
DICLEGIS TAB 10-10MG ............................. 115
diclo/misopr tab 50-0.2mg..................................... 14
diclo/misopr tab 75-0.2mg..................................... 14
diclofen pot tab 50mg ............................................ 15
diclofenac gel 3% .............................................. 268
diclofenac sol 0.1% op....................................... 389
diclofenac sol 1.5%............................................ 262
diclofenac tab 100mg er ...................................... 15
diclofenac tab 25mg dr ........................................ 15
dicloxacill cap 250mg ......................................... 404
dicloxacill cap 500mg ......................................... 404
DICOPANOL SUS 5MG/ML .......................... 120
dicyclomine cap 10mg ........................................ 426
dicyclomine sol 10mg/5ml .................................. 426
dicyclomine tab 20mg ......................................... 426
didanosine cap 125mg ....................................... 191
DIDRONEL
TAB 400MG............................... 314
DIFFERIN CRE 0.1% ..................................... 259
DIFFERIN GEL 0.1%...................................... 259
DIFFERIN GEL 0.3%...................................... 259
DIFFERIN LOT 0.1% ..................................... 259
DIFICID
TAB 200MG ................................... 361
difil-g 400 tab........................................................ 71
difil-g fort liq 100-100............................................ 71
diflorasone cre 0.05%......................................... 275
diflorasone oin 0.05%......................................... 275
DIFLUCAN SUS 10MG/ML .......................... 117
DIFLUCAN SUS 40MG/ML .......................... 117
DIFLUCAN TAB 100MG ............................... 118
DIFLUCAN TAB 150MG ............................... 118
DIFLUCAN TAB 200MG ............................... 118
DIFLUCAN TAB 50MG ................................. 118
diflunisal tab 500mg ............................................ 23
DIGEX
CAP ................................................. 307
DIGEX NF CAP .............................................. 425
DIGIFAB
INJ 40MG ...................................... 112
digitek tab 0.125mg......................................... 216
digitek tab 0.25mg........................................... 216
digox
tab 0.125mg......................................... 216
digox
tab 0.25mg........................................... 217
digoxin
inj 0.25mg/1 ....................................... 217
digoxin
sol 50mcg/ml ...................................... 217
digoxin
tab 0.125mg ....................................... 217
digoxin
tab 0.25mg.......................................... 217
dihydrocod/ cap asa/caff....................................... 24
DIHYDROERGOT CRY MESYLATE .............. 362
dihydroergot inj 1mg/ml....................................... 362
dihydroergot spr 4mg/ml...................................... 362
DILACOR XR CAP 240MG/24 ........................ 210
DILANTIN
CAP 100MG .................................. 87
DILANTIN
CAP 30MG .................................... 87
DILANTIN
CHW 50MG................................... 87
DILANTIN-125 SUS 125/5ML............................. 87
DILATRATE SR CAP 40MG ............................... 55
DILAUDID INJ 1MG/ML................................. 30
DILAUDID LIQ 1MG/ML................................ 30
DILAUDID TAB 2MG...................................... 30
DILAUDID TAB 4MG...................................... 30
DILAUDID TAB 8MG...................................... 30
DILAUDID-HP INJ 10MG/ML ........................... 30
DILAUDID-HP INJ 250MG................................. 30
465
DIOVAN
TAB 80MG ................................... 140
DIOVAN HCT TAB 160-12.5........................... 137
DIOVAN HCT TAB 160-25MG ....................... 137
DIOVAN HCT TAB 320-12.5........................... 138
DIOVAN HCT TAB 320-25MG ....................... 138
DIOVAN HCT TAB 80/12.5............................. 138
DIPENTOCAINE CRE 5-5-2%........................... 263
DIPENTUM CAP 250MG............................... 333
diphen/atrop liq 2.5/5........................................... 110
diphen/atrop tab 2.5mg........................................ 111
diphenhydram elx 12.5/5ml.................................. 120
diphenhydram inj 50mg/ml .................................. 120
DIPRIVAN INJ 10MG/ML ............................. 336
DIPROLENE LOT 0.05% ................................ 276
DIPROLENE OIN 0.05% ................................. 276
DIPROLENE AF CRE 0.05% ............................. 276
dipyridamole tab 25mg ........................................ 343
DISALCID TAB 500MG .................................. 23
DISALCID TAB 750MG .................................. 23
DISCOVISC SOL............................................. 392
disopyramide cap 100mg ....................................... 62
disopyramide cap 150mg ....................................... 62
disulfiram tab 250mg ......................................... 406
disulfiram tab 500mg ......................................... 406
DITROPAN XL TAB 10MG.............................. 434
DITROPAN XL TAB 15MG.............................. 434
DITROPAN XL TAB 5MG................................ 434
DIURIL
SUS 250/5ML.................................. 312
divalproex cap 125mg .......................................... 88
divalproex tab 125mg dr ...................................... 89
divalproex tab 250mg er ...................................... 89
divalproex tab 500mg er ...................................... 89
DIVIGEL
GEL 0.25MG ................................. 326
DIVIGEL
GEL 0.5MG ................................... 326
DIVIGEL
GEL 1MG/GM............................... 326
dm/cpm/pe dro .....................................................249
dobutam/d5w inj 1mg/ml..................................... 439
dobutamine inj 250mg........................................ 439
dobutamine inj 500mg........................................ 439
DOCEFREZ
INJ 20MG................................... 166
DOCEFREZ
INJ 80MG................................... 166
DOCETAXEL INJ 140/7ML............................ 166
DOCETAXEL INJ 160/16ML.......................... 166
dilex-g
tab 200-200........................................... 71
DILEX-G 200 SYP............................................... 71
dilt-cd
cap 120mg ........................................... 211
dilt-cd
cap 180mg ........................................... 211
dilt-cd
cap 240mg ........................................... 211
dilt-cd
cap 300mg ........................................... 211
diltiazem cap 120mg cd .................................... 211
diltiazem cap 120mg er..................................... 211
diltiazem cap 120mg/24.................................... 211
diltiazem cap 180mg/24.................................... 211
diltiazem cap 240mg/24.................................... 211
diltiazem cap 300mg/24.................................... 211
diltiazem cap 360mg/24.................................... 211
diltiazem cap 420mg/24.................................... 211
diltiazem cap 60mg er....................................... 212
diltiazem cap 90mg er....................................... 212
diltiazem inj 100mg .......................................... 212
diltiazem inj 125/25ml ...................................... 212
diltiazem inj 25mg/5ml ..................................... 212
diltiazem inj 50/10ml ........................................ 212
diltiazem tab 120mg.......................................... 212
diltiazem tab 30mg............................................ 212
diltiazem tab 60mg............................................ 212
diltiazem tab 90mg............................................ 212
diltiazem er tab 180mg ........................................ 212
dilt-xr
cap 120mg............................................ 211
dilt-xr
cap 180mg............................................ 211
dilt-xr
cap 240mg............................................ 211
diltzac cap 120mg/24...................................... 212
diltzac cap 180mg/24...................................... 212
diltzac cap 240mg/24...................................... 212
diltzac cap 300mg/24...................................... 212
diltzac cap 360mg/24...................................... 212
DIMENHYDRIN INJ 50MG/ML ...................... 115
DIOVAN
TAB 160MG ................................. 139
DIOVAN
TAB 320MG ................................. 139
DIOVAN
TAB 40MG ................................... 140
466
DOCETAXEL INJ 160/8ML ........................... 166
DOCETAXEL INJ 20/0.5ML .......................... 166
DOCETAXEL INJ 200MG/20 ......................... 166
DOCETAXEL INJ 20MG/2ML ....................... 166
DOCETAXEL INJ 20MG/ML ......................... 166
DOLGIC PLUS TAB ........................................... 21
DOLOGESIC LIQ 30-500MG ........................... 21
dologesic tab 30-500mg...................................... 21
DOLOPHINE TAB 10MG ................................. 30
DOLOPHINE TAB 5MG ................................... 30
dolorex
tab 50-500mg....................................... 21
DONATUSS DC SYP ........................................ 246
donepezil tab 10mg ........................................... 406
donepezil tab 10mg odt..................................... 406
donepezil tab 5mg ............................................. 406
donepezil tab 5mg odt....................................... 406
donepezil tab hcl 23mg ..................................... 406
DONNATAL ELX .......................................... 426
DONNATAL ELX GRAPE ............................ 426
DONNATAL ELX MINT ............................... 426
DONNATAL TAB .......................................... 426
DONNATAL TAB 16.2MG............................ 426
DONNATAL TAB EXTENTAB .................... 426
DOPAMINE INJ 160MG/ML......................... 439
dopamine inj 40mg/ml ..................................... 439
dopamine inj 80mg/ml ..................................... 439
dopamine/d5w inj 0.8mg/ml................................. 439
DORAL
TAB 15MG .................................... 350
DORIBAX
INJ 250MG.................................... 52
DORIBAX
INJ 500MG.................................... 52
DORYX
TAB 150MG ................................. 415
DORYX
TAB 200MG ................................. 415
DORYX
TAB 50MG ................................... 415
dorzol/timol sol 22.3-6.8...................................... 381
dorzolamide sol 2% op ....................................... 386
DOUBLEDEX KIT .......................................... 239
DOVONEX
CRE 0.005% .............................. 269
DOVONX SCALP SOL 0.005%......................... 269
doxazosin tab 1mg ............................................ 142
doxazosin tab 2mg ............................................ 142
doxazosin tab 4mg ............................................ 142
doxazosin tab 8mg ............................................ 142
doxepin hcl cap 100mg ......................................... 98
doxepin hcl cap 10mg ........................................... 98
doxepin hcl cap 150mg ......................................... 98
doxepin hcl con 10mg/ml ...................................... 98
doxercalcif cap 0.5mcg ....................................... 319
doxercalcif cap 1mcg .......................................... 319
doxercalcif cap 2.5mcg ....................................... 319
doxercalcif inj ..................................................... 319
doxercalcif inj 4mcg/2ml..................................... 319
DOXIL
INJ 2MG/ML................................... 158
doxorubicin inj 10/5ml ........................................ 158
doxorubicin inj 10mg .......................................... 158
doxorubicin inj 10mg/5ml ................................... 158
doxorubicin inj 150/75ml .................................... 158
doxorubicin inj 20/10ml ...................................... 158
doxorubicin inj 200/100 ...................................... 158
doxorubicin inj 200mg ........................................ 158
doxorubicin inj 2mg/ml ....................................... 159
doxorubicin inj 50/25ml ...................................... 159
doxorubicin inj 50mg .......................................... 159
doxy 100 inj 100mg.......................................... 415
doxycyc mono cap 100mg .................................... 415
doxycyc mono cap 50mg ...................................... 415
doxycyc mono tab 100mg..................................... 415
doxycyc mono tab 150mg..................................... 415
doxycyc mono tab 50mg....................................... 416
doxycyc mono tab 75mg....................................... 416
doxycycl hyc cap 100mg....................................... 416
doxycycl hyc cap 50mg......................................... 416
doxycycl hyc inj 100mg ........................................ 416
doxycycl hyc tab 100mg ....................................... 416
doxycycl hyc tab 100mg dr................................... 416
doxycycl hyc tab 150mg dr................................... 416
doxycycl hyc tab 75mg dr..................................... 416
doxycycline cap 150mg ....................................... 416
DOXYCYCLINE CAP 40MG............................ 290
doxycycline cap 75mg ......................................... 416
doxycycline sus 25mg/5ml................................... 416
doxycycline tab 20mg.......................................... 416
DOXYTEX
LIQ................................................120
DRITHO-CREME CRE HP 1% .......................... 269
DRITHO-SCALP CRE 0.5%............................... 269
dronabinol cap 10mg ......................................... 115
dronabinol cap 2.5mg ........................................ 115
dronabinol cap 5mg ........................................... 115
droperidol inj 2.5mg/ml ....................................... 58
DROXIA
CAP 200MG ................................. 345
DROXIA
CAP 300MG ................................. 345
467
DYNACIN
TAB 75MG.................................. 416
DYNACIRC CR TAB 10MG ............................. 212
DYNACIRC CR TAB 5MG ............................... 212
DYRENIUM
CAP 100MG.............................. 312
DYRENIUM
CAP 50MG................................ 312
DYSPORT
INJ 300UNIT ............................... 377
DYSPORT
INJ 500UNIT ............................... 377
dytuss
syp 12.5/5ml ........................................ 120
DYURAL-40 KIT............................................. 243
DYURAL-80 KIT............................................. 243
DYURAL-L
KIT ............................................. 243
DYURAL-LM KIT........................................... 243
E
DROXIA
CAP 400MG ................................ 345
DRYSOL
SOL 20% ...................................... 290
DSG PAK PAK .............................................. 263
DUAC
GEL 1.2-5%..................................... 254
DUAVEE
TAB 0.45-20................................. 325
DUETACT
TAB 30-2MG.............................. 107
DUETACT
TAB 30-4MG.............................. 107
DULERA
AER 100-5MCG............................. 66
DULERA
AER 200-5MCG............................. 66
duloxetine cap 20mg ............................................ 95
DULOXETINE CAP 40MG................................ 96
DUOCAINE INJ................................................ 356
DUODOTE
INJ ................................................ 111
DUONEB
SOL ................................................ 66
DUOPA
SUS 4.63-20................................... 173
DUOVISC
KIT 0.35/0.4................................. 392
DUOVISC
KIT 0.5/0.55................................. 392
DURACLON INJ ................................................ 20
DURAFIBER PAD 4X4-3/4 ............................ 304
DURAFIBER AG PAD 2.................................... 304
DURAFIBER AG PAD 3/4X18.......................... 304
DURAFIBER AG PAD 4.................................... 304
DURAFIBER AG PAD 4X4-3/4......................... 304
DURAFIBER AG PAD 6.................................... 304
DURAFIBER AG PAD 8X11.75 ........................ 304
DURAGESIC DIS 100MCG/H.......................... 30
DURAGESIC DIS 12MCG/HR ......................... 30
duramorph inj 0.5mg/ml ..................................... 30
duramorph inj 1mg/ml ........................................ 30
duraxin
cap ....................................................... 20
DUREZOL EMU 0.05% ................................ 391
DURLAZA
CAP 162.5MG............................ 343
dutast/tamsu cap 0.5-0.4...................................... 340
dutasteride cap 0.5mg......................................... 337
DUTOPROL
TAB 100-12.5............................ 143
DUTOPROL
TAB 25-12.5.............................. 143
DUTOPROL
TAB 50-12.5.............................. 143
DYAZIDE
CAP 37.5-25 ................................ 309
e.e.s. 400 tab 400mg........................................... 360
E.E.S. GRAN SUS 200/5ML.............................. 360
e.s.p.
sus 200-600............................................. 51
EASPRIN
TAB 975MG EC ............................. 23
EC-NAPROSYN TAB 375MG ............................ 15
EC-NAPROSYN TAB 500MG ............................ 15
econazole cre 1% .............................................. 283
econtra ez tab 1.5mg .......................................... 234
ECOZA
AER 1%.......................................... 283
ed baclofen tab 10mg .......................................... 371
ED CHLORPED SUS 2MG/ML ........................ 119
EDARBI
TAB 40MG .................................... 140
EDARBI
TAB 80MG .................................... 140
EDARBYCLOR TAB 40-12.5 .......................... 138
EDARBYCLOR TAB 40-25MG....................... 138
ED-CHLOR-TAN TAB 8MG.............................. 119
EDECRIN
TAB 25MG................................... 310
EDEX
KIT 10MCG ..................................... 219
EDEX
KIT 20MCG ..................................... 219
EDEX
KIT 40MCG ..................................... 219
ed-flex
cap ......................................................... 20
EDLUAR
SUB 10MG ................................... 352
EDLUAR
SUB 5MG ..................................... 352
ed-spaz
tab 0.125mg ....................................... 427
EDURANT
TAB 25MG ................................. 191
eemt
tab 1.25-2.5.......................................... 324
eemt hs
tab .........................................................324
ees/sulfisox sus 200-600......................................... 51
EFFEXOR XR CAP 150MG ............................... 96
EFFEXOR XR CAP 37.5MG .............................. 96
EFFEXOR XR CAP 75MG ................................. 96
EFFIENT
TAB 10MG .................................... 344
EFFIENT
TAB 5MG ...................................... 344
EFUDEX
CRE 5%......................................... 267
EGRIFTA
INJ 1MG ....................................... 317
EGRIFTA
SOL 1MG...................................... 317
DYLIX
ELX 100/15ML ................................. 71
DYLOJECT INJ 37.5MG/M ............................. 15
DYMISTA
SPR 137-50.................................. 375
DYNACIN
TAB 100MG ............................... 416
DYNACIN
TAB 50MG ................................. 416
468
EGRIFTA
SOL 2MG ..................................... 317
ELAPRASE
INJ 6MG/3ML............................ 321
ELDEPRYL CAP 5MG................................... 172
ELELYSO
INJ 200UNIT ............................... 345
elenzapatch dis 4-1% .......................................... 295
ELESTAT
DRO 0.05% .................................. 384
ELESTRIN GEL 0.06% .................................. 326
ELETONE
CRE.............................................. 288
ELETONE
CRE TWINPACK ....................... 288
ELIDEL
CRE 1% .......................................... 288
ELIGARD
INJ 22.5MG.................................. 165
ELIGARD
INJ 30MG..................................... 165
ELIGARD
INJ 45MG..................................... 165
ELIGARD
INJ 7.5MG.................................... 165
ELIMITE
CRE 5% ......................................... 291
elinest
tab........................................................ 230
eliphos
tab 667mg........................................... 335
ELIQUIS
TAB 2.5MG ..................................... 74
ELIQUIS
TAB 5MG ........................................ 74
ELITEK
INJ 1.5MG ...................................... 163
ELITEK
INJ 7.5MG ...................................... 163
ELIXOPHYLLIN ELX 80/15ML ......................... 71
ELLA
TAB 30MG....................................... 234
ELLENCE
INJ 2MG/ML ............................... 159
ELMIRON
CAP 100MG................................ 340
ELOCON
CRE 0.1%..................................... 276
ELOCON
LOT 0.1% ..................................... 276
ELOCON
OIN 0.1%...................................... 276
ELOXATIN
INJ 100MG................................. 149
ELOXATIN
INJ 200MG................................. 149
ELOXATIN
INJ 50MG................................... 149
ELSPAR
INJ 10000UNT .............................. 160
EMADINE
SOL 0.05% OP ............................ 384
EMBEDA
CAP 100-4MG............................... 30
EMBEDA
CAP 20-0.8MG.............................. 30
EMBEDA
CAP 30-1.2MG.............................. 30
EMBEDA
CAP 50-2MG................................. 30
EMBEDA
CAP 60-2.4MG.............................. 30
EMBEDA
CAP 80-3.2MG.............................. 31
EMCYT
CAP 140MG .................................. 163
EMEND
CAP 125MG ................................. 116
EMEND
CAP 40MG ................................... 116
EMEND
CAP 80MG ................................... 116
EMEND
PAK 80 & 125 .............................. 116
EMEND
SOL 150MG ................................. 116
EMLA
CRE ................................................. 295
EMLA
CRE 2.5-2.5%.................................. 295
emoquette tab.................................................... 230
EMSAM
DIS 12MG/24H............................... 91
EMSAM
DIS 6MG/24HR .............................. 91
EMSAM
DIS 9MG/24HR .............................. 91
EMTRIVA
CAP 200MG ............................... 192
EMTRIVA
SOL 10MG/ML .......................... 192
EMULSION SB EMU ........................................ 288
EMVOREN
CRE ............................................ 263
ENABLEX
TAB 15MG ................................. 434
ENABLEX
TAB 7.5MG ................................ 434
enalapr/hctz tab 10-25mg .................................... 131
enalapr/hctz tab 5-12.5mg.................................... 131
enalapril tab 10mg............................................ 133
enalapril tab 2.5mg........................................... 133
enalapril tab 20mg............................................ 133
enalapril tab 5mg.............................................. 133
enalaprilat inj 1.25/ml......................................... 133
ENBREL
INJ 25/0.5ML .................................. 19
ENBREL
INJ 25MG........................................ 19
ENBREL
INJ 50MG/ML................................. 19
ENBREL SRCLK INJ 50MG/ML ......................... 19
ENDO DERMAL MIS 10X12.7......................... 304
ENDO DERMAL MIS 5X5 CM ........................ 304
endocet
tab 10-325mg....................................... 41
endocet
tab 10-650mg....................................... 41
endocet
tab 2.5-325........................................... 41
endocet
tab 5-325mg......................................... 41
endocet
tab 7.5-325........................................... 41
endocet
tab 7.5-500m........................................ 41
endodan
tab....................................................... 41
ENDRATE
INJ 150MG/ML........................... 199
ENJUVIA
TAB 0.3MG .................................. 326
ENJUVIA
TAB 0.45MG ................................ 327
ENJUVIA
TAB 0.625MG .............................. 327
ENJUVIA
TAB 0.9MG .................................. 327
ENJUVIA
TAB 1.25MG ................................ 327
ENLON
INJ 150/15ML ................................ 146
ENLON-PLUS INJ 10-0.14 ............................... 146
enoxaparin inj 100mg/ml ..................................... 76
enoxaparin inj 120/0.8 ......................................... 76
enoxaparin inj 150mg/ml ..................................... 76
enoxaparin inj 30/0.3ml ....................................... 76
enoxaparin inj 300/3ml ........................................ 76
enpresse-28 tab ................................................... 236
enskyce
tab ...................................................... 230
entacapone tab 200mg ....................................... 176
entecavir tab 0.5mg........................................... 194
entecavir tab 1mg.............................................. 194
469
ENTEREG
CAP 12MG.................................. 334
ENTOCORT EC CAP 3MG/24HR .................... 239
entre-b
sus 6-10mg/5 ...................................... 247
ENTRESTO
TAB 24-26MG ........................... 219
ENTRESTO
TAB 49-51MG ........................... 219
ENTRESTO
TAB 97-103MG ......................... 219
ENTYVIO
INJ 300MG .................................. 334
enulose
sol 10gm/15 ....................................... 334
ENVARSUS XR TAB 0.75MG ......................... 201
ENVARSUS XR TAB 1MG .............................. 201
ENVARSUS XR TAB 4MG .............................. 201
EPANED
SOL 1MG/ML .............................. 133
EPHEDRINE INJ SOD CL ............................. 439
ephedrine su inj 50mg/ml..................................... 439
EPICERAM
EMU ........................................... 288
EPIDUO
GEL 0.1-2.5% ................................ 254
EPIDUO FORTE GEL 0.3-2.5%......................... 254
EPIFIX
MIS 14MM....................................... 293
EPIFIX
MIS 18MM....................................... 293
EPIFIX
MIS 24MM....................................... 293
EPIFIX
MIS 2CMX2CM .............................. 293
EPIFIX
MIS 2CMX3CM .............................. 293
EPIFIX
MIS 2CMX4CM .............................. 293
EPIFIX
MIS 3CMX3CM .............................. 293
EPIFIX
MIS 3CMX5CM .............................. 293
EPIFIX
MIS 4CMX3CM .............................. 294
EPIFIX
MIS 4CMX4CM .............................. 294
EPIFIX
MIS 5CMX6CM .............................. 294
EPIFIX
MIS 7CMX7CM .............................. 294
EPIFOAM
AER 1% ....................................... 292
epinastine dro 0.05% ......................................... 384
epinephrine inj 0.15mg ....................................... 438
epinephrine inj 0.1mg/ml ...................................... 69
epinephrine inj 0.3mg ......................................... 438
epinephrine inj 1mg/ml ......................................... 69
EPIPEN 2-PAK INJ 0.3MG ................................ 438
EPIPEN-JR INJ 2-PAK .................................... 438
epirubicin inj 10mg/5ml..................................... 159
epirubicin inj 150/75ml...................................... 159
epirubicin inj 200mg.......................................... 159
epirubicin inj 50/25ml........................................ 159
EPIRUBICIN INJ 50MG................................... 159
EPISNAP
KIT ................................................ 438
EPIVIR HBV TAB 100MG ............................... 194
eplerenone tab 25mg.......................................... 145
eplerenone tab 50mg.......................................... 145
EPOGEN
INJ ...................................................345
epoprostenol inj 0.5mg......................................... 220
epoprostenol inj 1.5mg......................................... 220
EPROSART MES TAB 600MG ......................... 140
EPZICOM
TAB 600-300................................ 188
EQUAGESIC TAB 200-325............................... 21
EQUETRO
CAP 100MG................................ 176
EQUETRO
CAP 200MG................................ 176
EQUETRO
CAP 300MG................................ 177
ERAXIS
INJ 100MG ..................................... 116
ERAXIS
INJ 50MG ....................................... 116
ERBITUX
INJ 100MG ................................... 154
ERBITUX
INJ 200MG ................................... 154
ergoloid mes tab 1mg oral ................................... 411
ERGOMAR
SUB 2MG .................................. 362
ergotam/caff tab 1/100 ......................................... 362
ERIVEDGE
CAP 150MG ............................... 153
errin
tab 0.35mg............................................ 236
ERTACZO
CRE 2% ....................................... 283
ERWINAZE
INJ 10000UNT........................... 160
ery
pad 2% .................................................. 252
ERYGEL
GEL 2%......................................... 252
ERYPED
SUS 200/5ML................................ 361
ERYPED
SUS 400/5ML................................ 361
ERY-TAB
TAB 250MG EC........................... 360
ERY-TAB
TAB 333MG EC........................... 360
ery-tab
tab 500mg ec ...................................... 361
erythrocin inj 1000mg........................................ 361
erythrocin inj 500mg.......................................... 361
erythrocin tab 250mg ......................................... 361
erythrom eth tab 400mg ....................................... 361
erythromycin cap 250mg ec ................................. 361
erythromycin gel /benzoyl .................................... 254
erythromycin gel 2% ............................................ 252
erythromycin oin 5mg/gm .................................... 385
erythromycin oin op ............................................. 385
erythromycin pad 2% ........................................... 252
erythromycin sol 2% ............................................ 252
erythromycin tab 250mg bs.................................. 361
erythromycin tab 500mg bs.................................. 361
ESBRIET
CAP 267MG .................................. 414
escitalopram sol 5mg/5ml ...................................... 92
escitalopram tab 10mg........................................... 92
escitalopram tab 20mg........................................... 92
escitalopram tab 5mg............................................. 92
esgic
cap.......................................................... 21
epitol
tab 200mg .............................................. 80
EPIVIR
SOL 10MG/ML ............................... 192
EPIVIR
TAB 150MG .................................... 192
EPIVIR
TAB 300MG .................................... 192
EPIVIR HBV SOL 5MG/ML ............................ 194
470
ESGIC
TAB.................................................... 21
ESGIC-PLUS CAP .............................................. 21
ESGIC-PLUS TAB.............................................. 21
esmolol hcl inj 100mg/10.................................... 205
esmolol hcl inj 10mg/ml...................................... 205
ESSENTRA
MIS 9X9 ..................................... 292
essian
tab ...................................................... 324
essian h.s. tab...................................................... 324
est estrogen tab mtest........................................... 324
est estrogen tab mtest hs ...................................... 324
estarylla tab 0.25-35......................................... 230
estazolam tab 1mg ............................................ 350
estazolam tab 2mg ............................................ 350
estra/noreth tab 0.5-0.1 ....................................... 325
estra/noreth tab 1-0.5mg...................................... 325
ESTRACE TAB 0.5MG ................................. 327
ESTRACE TAB 1MG .................................... 327
ESTRACE TAB 2MG .................................... 327
ESTRACE VAG CRE 0.1MG/GM .................... 437
estrad val inj 10mg/ml ....................................... 327
estrad val inj 200mg/5 ....................................... 327
estradiol dis 0.025mg ....................................... 327
estradiol dis 0.0375mg ..................................... 327
estradiol dis 0.05mg ......................................... 327
estradiol dis 0.06mg ......................................... 327
estradiol dis 0.075mg ....................................... 327
estradiol dis 0.1mg ........................................... 327
ESTRADIOL MIS 10MG................................. 327
ESTRADIOL MIS 12.5MG.............................. 327
ESTRADIOL MIS 25MG................................. 327
ESTRADIOL MIS 6MG................................... 327
estradiol tab 0.5mg ........................................... 327
estradiol tab 1mg .............................................. 327
estradiol tab 2mg .............................................. 328
ESTRASORB EMU ......................................... 328
ESTRING
MIS 2MG ...................................... 437
estrog/mtest tab 1.25-2.5...................................... 324
ESTROGEL GEL ............................................ 328
ESTRONE CRY ............................................. 328
estropipate tab 0.75mg ....................................... 328
estropipate tab 1.5mg ......................................... 328
estropipate tab 3mg ............................................ 328
ESTROSTEP FE TAB......................................... 236
eszopiclone tab 1mg............................................ 352
ETHACRYNATE INJ 50MG............................. 310
ethambutol tab 100mg........................................ 148
ethambutol tab 400mg........................................ 148
ethosuximide cap 250mg ........................................ 88
ethosuximide sol 250/5ml....................................... 88
ETHRANE
INH ................................................337
ETHYL CHLOR AER FINE PIN....................... 298
ETHYL CHLOR AER FN STRM ...................... 298
ETHYL CHLOR AER MED JET....................... 298
ETHYL CHLOR AER MED STRM .................. 298
ETHYL CHLOR AER MIST ............................. 298
ETHYL CHLOR AER SPRAY .......................... 298
ETHYOL
INJ 500MG ................................... 170
ETIDRON DISD TAB 200MG ........................... 314
ETIDRON DISD TAB 400MG ........................... 314
etodolac cap 200mg ........................................... 15
etodolac cap 300mg ........................................... 15
etodolac tab 400mg............................................ 15
etodolac tab 500mg............................................ 15
etodolac er tab 400mg........................................... 15
etomidate inj 20/10ml ....................................... 336
etomidate inj 2mg/ml......................................... 336
etomidate inj 40/20ml ....................................... 336
ETOPOPHOS INJ 100MG ............................... 166
etoposide cap 50mg........................................... 166
etoposide inj 100/5ml........................................ 166
etoposide inj 1gm/50ml ..................................... 166
etoposide inj 20mg/ml ....................................... 166
etoposide inj 500/25ml...................................... 166
EUFLEXXA INJ 10MG/ML ........................... 374
EURAX
CRE 10%........................................ 291
EURAX
LOT 10%........................................ 291
EVAMIST
SPR 1.53MG ................................ 328
EVEKEO
TAB 10MG ....................................... 5
EVEKEO
TAB 5MG ......................................... 5
EVISTA
TAB 60MG ..................................... 321
EVOCLIN
AER 1%........................................ 252
EVOTAZ
TAB 300-150 ................................ 188
EVOXAC
CAP 30MG................................... 370
EVZIO
INJ ......................................................113
exactacain aer .................................................... 295
EXACTUSS
LIQ ...............................................246
EXALGO
TAB 12MG..................................... 31
EXALGO
TAB 16MG..................................... 31
EXALGO
TAB 32MG..................................... 31
EXALGO
TAB 8MG....................................... 31
EXELDERM CRE 1%..................................... 283
EXELDERM SOL 1% ..................................... 283
471
FAMVIR
TAB 125MG.................................. 197
FAMVIR
TAB 250MG.................................. 197
FAMVIR
TAB 500MG.................................. 198
FANAPT
PAK ............................................... 177
FANAPT
TAB 10MG.................................... 177
FANAPT
TAB 12MG.................................... 177
FANAPT
TAB 1MG...................................... 177
FANAPT
TAB 2MG...................................... 177
FANAPT
TAB 4MG...................................... 177
FANAPT
TAB 6MG...................................... 177
FANAPT
TAB 8MG...................................... 178
FANATREX
SUS 25MG/ML ........................... 80
FARESTON TAB 60MG ................................ 150
FARXIGA
TAB 10MG .................................. 106
FARXIGA
TAB 5MG .................................... 106
FARYDAK
CAP 10MG ................................. 153
FARYDAK
CAP 15MG ................................. 153
FARYDAK
CAP 20MG ................................. 153
FASLODEX
INJ 250MG ................................ 163
FAZACLO
TAB 100/ODT............................. 181
FAZACLO
TAB 12.5/ODT............................ 181
FAZACLO
TAB 150MG................................ 181
FAZACLO
TAB 200MG................................ 181
FAZACLO
TAB 25MG ODT......................... 181
FBL KIT
CRE 15-4-5%.................................. 263
felbamate sus 600/5ml ........................................ 86
felbamate tab 400mg........................................... 86
felbamate tab 600mg........................................... 86
FELBATOL
SUS 600/5ML............................... 86
FELBATOL
TAB 400MG................................. 87
FELBATOL
TAB 600MG................................. 87
FELDENE
CAP 10MG..................................... 15
FELDENE
CAP 20MG..................................... 16
felodipine tab 10mg er ....................................... 212
felodipine tab 2.5mg er ...................................... 213
felodipine tab 5mg er ......................................... 213
FEM PH
GEL ................................................ 437
FEMARA
TAB 2.5MG ................................. 162
FEMCON FE CHW.......................................... 230
FEMHRT
TAB 0.5-2.5 .................................. 325
FEMHRT 1/5 TAB ............................................ 325
FEMRING
MIS 0.05/24H .............................. 437
FEMRING
MIS 0.1MG/24 ............................. 437
FEMTRACE TAB 0.45MG............................. 328
FEMTRACE TAB 0.9MG............................... 328
fenofibrate cap 130mg ........................................ 123
EXELON
CAP 1.5MG .................................. 406
EXELON
CAP 3MG ..................................... 406
EXELON
CAP 4.5MG .................................. 407
EXELON
CAP 6MG ..................................... 407
EXELON
DIS 13.3/24................................... 407
EXELON
DIS 4.6MG/24 .............................. 407
EXELON
DIS 9.5MG/24 .............................. 407
EXELON
SOL 2MG/ML .............................. 407
exemestane tab 25mg ......................................... 162
EXFORGE
TAB 10-160MG .......................... 136
EXFORGE
TAB 10-320MG .......................... 136
EXFORGE
TAB 5-160MG ............................ 136
EXFORGE
TAB 5-320MG ............................ 137
EXFORGEH/10- TAB 160-12.5 ......................... 136
EXFORGEH/10- TAB 160-25 ............................ 136
EXFORGEH/10- TAB 320-25 ............................ 136
EXFORGEH/5- TAB 160-12.5 .......................... 136
EXFORGEH/5- TAB 160-25 ............................. 136
EXJADE
TAB 125MG.................................. 111
EXJADE
TAB 250MG.................................. 111
EXJADE
TAB 500MG.................................. 111
EXODERM
LOT 25-1% ................................ 265
exotic-hc dro otic .............................................. 394
EXPAREL
INJ 1.3% ...................................... 357
EXTARDOL
CRE ........................................... 263
EXTAVIA
INJ 0.3MG ................................... 409
EXTINA
AER 2% ......................................... 283
EYLEA
INJ 2/0.05ML ................................. 393
F
FA-8
CAP 800MCG .................................... 346
fa-8
tab 0.8mg.............................................. 346
FABIOR
AER 0.1% ...................................... 259
FABRAZYME INJ 35MG ............................... 316
FABRAZYME INJ 5MG ................................. 316
FACTIVE
TAB 320MG ................................. 330
FALESSA
KIT ............................................... 230
fallback tab 1.5mg ........................................... 234
falmina
tab ...................................................... 230
famciclovir tab 125mg ........................................ 197
famotidine inj 10mg/ml ...................................... 429
famotidine inj 200/20ml..................................... 429
famotidine inj 20mg/2ml .................................... 429
FAMOTIDINE INJ 20MG/50M........................ 429
famotidine inj 40mg/4ml .................................... 429
famotidine sus 40mg/5ml ................................... 429
famotidine tab 20mg .......................................... 429
famotidine tab 40mg .......................................... 429
472
fenofibrate cap 43mg .......................................... 124
FENOFIBRATE TAB 120MG........................... 124
fenofibrate tab 145mg......................................... 124
fenofibrate tab 160mg......................................... 124
FENOFIBRATE TAB 40MG............................. 124
fenofibrate tab 48mg........................................... 124
fenofibrate tab 54mg........................................... 124
fenofibric cap 135mg dr..................................... 124
fenofibric cap 45mg dr....................................... 124
FENOFIBRIC TAB 105MG.............................. 124
FENOFIBRIC TAB 35MG................................ 124
FENOGLIDE TAB 120MG ............................. 124
FENOGLIDE TAB 40MG ............................... 124
fenoldopam inj 10mg/ml .................................... 145
fenoldopam inj 20mg/2ml .................................. 145
FENOPROFEN CAP 400MG ............................. 16
fenoprofen tab 600mg .......................................... 16
fentanyl dis 100mcg/h ........................................ 31
fentanyl dis 12mcg/hr ........................................ 31
fentanyl dis 37.5mcg .......................................... 31
fentanyl dis 62.5mcg .......................................... 31
fentanyl dis 87.5mcg .......................................... 31
fentanyl cit inj 0.05mg/1 ........................................ 31
fentanyl cit inj 1000mcg......................................... 31
fentanyl cit inj 100mcg........................................... 31
fentanyl cit inj 2500mcg......................................... 31
fentanyl cit inj 250mcg........................................... 31
FENTANYL CIT INJ SOD CL ............................. 31
fentanyl ot loz 1200mcg ........................................ 31
fentanyl ot loz 1600mcg ........................................ 31
fentanyl ot loz 200mcg .......................................... 31
FENTANYL/BUP INJ SOD CL ...........................24
FENTORA
TAB 100MCG............................... 32
FENTORA
TAB 200MCG............................... 32
FENTORA
TAB 400MCG............................... 32
FENTORA
TAB 600MCG............................... 32
FENTORA
TAB 800MCG............................... 32
FER-IN-SOL DRO 15MG/ML.......................... 347
fer-iron dro 15mg/ml ....................................... 347
ferosul elx 220/5ml ......................................... 347
FERRIPROX TAB 500MG .............................. 111
ferrous
dro 15mg/ml ....................................... 347
FERROUS SUL LIQ 220/5ML .......................... 347
ferrous sulf dro 15mg/ml...................................... 347
ferrous sulf elx 220/5ml ....................................... 347
FERROUS SULF GRA........................................ 347
FERROUS SULF SYP 300/5ML ........................ 347
FETZIMA
CAP 120MG ................................... 96
FETZIMA
CAP 20MG ..................................... 96
FETZIMA
CAP 40MG ..................................... 96
FETZIMA
CAP 80MG ..................................... 96
FETZIMA
CAP TITRATIO ............................. 96
FEXMID
TAB 7.5MG................................... 371
fexofenadine tab 60mg ......................................... 121
FIBRICOR TAB 105MG................................. 124
FIBRICOR TAB 35MG................................... 124
FINACEA
AER 15%...................................... 290
FINACEA
GEL 15% ...................................... 290
FINACEA PLUS KIT .......................................... 290
finasteride tab 5mg.............................................. 337
FIORICET CAP................................................. 21
FIORICET CAP CODEINE .............................. 24
FIORICET TAB................................................. 21
FIORICET/COD CAP ........................................... 24
FIORINAL
CAP ................................................ 21
FIORINAL/COD CAP 30MG ............................... 24
FIRAZYR
INJ 30MG/3ML ............................ 342
FIRMAGON
INJ 120MG ................................ 164
FIRMAGON
INJ 80MG .................................. 164
FIRST DUKES SUS MOUTHWSH................... 365
FIRST-MARYS SUS MOUTHWSH ................. 365
FIRST-MOUTHW SUS BLM ............................. 365
FIRST-TESTOS CRE MC 2% .............................. 45
FIRST-TESTOS OIN 2% ...................................... 45
FLAGYL
CAP 375MG.................................... 50
FLAGYL
TAB 250MG ................................... 50
FLAGYL
TAB 500MG ................................... 50
FLAGYL ER TAB 750MG ................................ 50
FLANAX PAIN KIT RELIEF .............................. 16
FLAREX
SUS 0.1% OP ................................ 391
flavoxate tab 100mg.......................................... 436
FLEBOGAMMA INJ 10/200ML ...................... 397
FLEBOGAMMA INJ 20/400ML ...................... 397
FLEBOGAMMA INJ 5% .................................. 397
FLEBOGAMMA INJ DIF 10%......................... 397
FLEBOGAMMA INJ DIF 5%........................... 397
flecainide tab 100mg............................................ 63
flecainide tab 150mg............................................ 63
flecainide tab 50mg.............................................. 63
FLECTOR
DIS 1.3% ...................................... 262
473
FLEXEPAX
MIS............................................. 374
FLEXERIL TAB 10MG .................................. 371
FLEXERIL
TAB 5MG .................................... 371
FLEXIN
PAD .0375-5% ............................... 295
FLEXIZOL
PAK COMBIPAK ......................... 14
FLOLAN
INJ 0.5MG .................................... 220
FLOLAN
INJ 1.5MG .................................... 220
FLOMAX
CAP 0.4MG ................................. 338
FLONASE
SPR 0.05%................................... 375
FLO-PRED
SUS.............................................. 239
FLOVENT DISK AER 100MCG.......................... 70
FLOVENT DISK AER 250MCG.......................... 70
FLOVENT DISK AER 50MCG............................ 70
FLOVENT HFA AER 110MCG .......................... 70
FLOVENT HFA AER 220MCG .......................... 70
FLOVENT HFA AER 44MCG ............................ 70
FLOWTUSS SOL 2.5-200 .............................. 246
FLOXURIDINE INJ 0.5GM .............................. 151
flucaine sol 0.25-0.5 ........................................ 387
fluconazole sus 10mg/ml..................................... 118
fluconazole sus 40mg/ml..................................... 118
fluconazole tab 100mg ........................................ 118
fluconazole tab 50mg .......................................... 118
fluconazole/ inj dex 200 ....................................... 118
fluconazole/ inj dex 400 ....................................... 118
FLUCONAZOLE/ INJ NACL 100...................... 118
fluconazole/ inj nacl 200...................................... 118
fluconazole/ inj nacl 400...................................... 118
flucytosine cap 250mg ........................................ 117
flucytosine cap 500mg ........................................ 117
FLUDARA
INJ 50MG ................................... 151
fludarabine inj 50mg .......................................... 151
FLUDARABINE INJ 50MG/2ML..................... 151
fludrocort tab 0.1mg .......................................... 242
FLUMADINE TAB 100MG ............................ 198
flumazenil inj 0.5mg/5........................................ 113
flumazenil inj 1mg/10ml..................................... 113
flunisolide spr 0.025%........................................ 375
flunisolide spr 29mcg.......................................... 375
fluocin acet cre 0.01% ......................................... 276
fluocin acet cre 0.025% ....................................... 276
fluocin acet oil 0.01% .......................................... 395
fluocin acet oil 0.01% sc...................................... 276
fluocin acet oil body............................................. 276
fluocin acet oil ear0.01%..................................... 396
fluocin acet oil scalp ............................................ 276
fluocin acet oin 0.025% ....................................... 276
fluocin acet sol 0.01%.......................................... 276
fluocinonide cre 0.05% ........................................ 276
fluocinonide cre 0.1% .......................................... 276
fluocinonide cre -e 0.05% .................................... 276
fluocinonide gel 0.05%......................................... 276
fluocinonide oin 0.05% ........................................ 276
fluocinonide sol 0.05%......................................... 276
FLUORAC
CRE 5-1% .................................. 268
FLUORACAINE SOL OP.................................. 387
fluore-benox sol 0.25-0.4 ..................................... 387
fluorescein inj 10% op ........................................ 387
fluorescein inj 25% op ........................................ 387
fluorescein/ sol proparac ..................................... 387
FLUORESCITE INJ 10% OP............................. 387
fluorets tes 1mg op ........................................... 387
FLUORIDE PREPARATIONS ........................... 365
fluor-i-stri tes 1mg op........................................... 387
fluoromethol sus 0.1% op..................................... 391
FLUOROPLEX CRE 1%................................... 267
FLUOROURACIL CRE 0.5%............................. 267
fluorouracil cre 5%.............................................. 267
fluorouracil dro 2% ............................................. 267
fluorouracil dro 5% ............................................. 267
fluorouracil inj 1gm/20ml .................................... 151
fluorouracil inj 2.5g/50m..................................... 151
fluorouracil inj 500/10ml..................................... 151
fluorouracil inj 5gm/100m ................................... 151
fluorouracil sol 2% .............................................. 267
fluorouracil sol 5% .............................................. 267
fluoxetine cap 10mg ............................................. 92
fluoxetine cap 90mg dr......................................... 92
fluoxetine sol 20mg/5ml ....................................... 92
fluoxetine tab 10mg.............................................. 92
fluoxetine tab 20mg.............................................. 92
FLUOXETINE TAB 60MG ................................ 92
fluphenaz de inj 25mg/ml ..................................... 183
fluphenazine con 5mg/ml...................................... 183
fluphenazine elx 2.5/5ml....................................... 183
fluphenazine inj
.................................... 183
tab 2.5mg/ml
10mg .........................................
fluphenazine tab 1mg ........................................... 183
fluphenazine tab 2.5mg ........................................ 183
fluphenazine tab 5mg ........................................... 183
FLURA-SAFE SOL........................................... 387
474
flurazepam cap 15mg......................................... 350
flurazepam cap 30mg......................................... 350
flurbiprofen sol 0.03% op ...................................... 389
flurbiprofen tab 100mg .......................................... 16
flurbiprofen tab 50mg ............................................ 16
FLURESS
SOL OP......................................... 388
flurox
sol op ................................................... 388
flutamide cap 125mg......................................... 150
fluticasone cre 0.05%.......................................... 276
fluticasone lot 0.05% .......................................... 276
fluticasone oin 0.005% ....................................... 276
fluvastatin cap 20mg........................................... 126
fluvastatin cap 40mg........................................... 126
fluvastatin tab 80mg er ....................................... 126
fluvoxamine cap 100mg er .................................... 92
fluvoxamine cap 150mg er .................................... 92
fluvoxamine tab 100mg......................................... 92
fluvoxamine tab 25mg........................................... 93
fluvoxamine tab 50mg........................................... 93
FML
OIN 0.1% OP..................................... 391
FML FORTE SUS 0.25% OP........................... 391
FML LIQUIFLM SUS 0.1% OP ......................... 391
FOCALIN
TAB 10MG....................................... 7
FOCALIN
TAB 2.5MG...................................... 7
FOCALIN
TAB 5MG......................................... 7
FOCALIN XR CAP 10MG ................................... 7
FOCALIN XR CAP 15MG ................................... 7
FOCALIN XR CAP 20MG ................................... 7
FOCALIN XR CAP 25MG ................................... 7
FOCALIN XR CAP 30MG ................................... 7
FOCALIN XR CAP 35MG ................................... 7
FOCALIN XR CAP 40MG ................................... 7
FOCALIN XR CAP 5MG ..................................... 7
FOLIC ACID ....................................................... 346
FOLIC ACID CAP 20MG................................. 346
FOLIC ACID CAP 5MG................................... 346
FOLIC ACID POW ........................................... 346
folic acid tab 1000mcg....................................... 346
FOLIC ACID TAB 200MCG ............................ 346
folic acid tab 400mcg......................................... 346
folic acid tab 800mcg......................................... 346
FOLOTYN
INJ 20MG/ML ............................ 151
FOLOTYN
INJ 40MG/2ML .......................... 151
fomepizole inj 1.5gm .......................................... 112
fomepizole inj 1gm/ml........................................ 112
fondaparinux inj 10/0.8ml ..................................... 77
fondaparinux inj 2.5/0.5 ........................................ 77
fondaparinux inj 5/0.4ml ....................................... 77
fondaparinux inj 7.5/0.6 ........................................ 77
FORADIL
CAP AEROLIZE ........................... 67
FORANE
SOL .............................................. 337
FORFIVO XL TAB 450MG................................ 91
formadon sol .................................................... 187
formaldehyde sol 10%.......................................... 187
FORMALDEHYDE SOL 37%............................ 187
FORMA-RAY SOL 20%.................................. 187
FORTADERM MIS.......................................... 304
FORTADERM MIS ANTIMICR ..................... 304
FORTAMET TAB 1000MG............................ 101
FORTAMET TAB 500MG.............................. 101
FORTAZ
INJ 1GM........................................ 227
FORTAZ
INJ 2GM........................................ 227
FORTAZ
INJ 500MG.................................... 227
FORTAZ
INJ 6GM........................................ 227
FORTEO
SOL 600/2.4 .................................. 321
FORTICAL SPR 200/ACT.............................. 315
FOSAMAX
SOL ............................................ 314
FOSAMAX
TAB 10MG................................. 314
FOSAMAX
TAB 35MG................................. 314
FOSAMAX
TAB 40MG................................. 314
FOSAMAX
TAB 5MG................................... 314
FOSAMAX
TAB 70MG................................. 314
FOSAMAX + D TAB 70-2800........................... 314
FOSAMAX + D TAB 70-5600........................... 314
foscarnet inj 24mg/ml ....................................... 194
FOSCAVIR
INJ 24MG/ML ............................ 194
fosinop/hctz tab 10/12.5....................................... 131
fosinop/hctz tab 20/12.5....................................... 131
fosinopril tab 10mg............................................ 133
fosphenytoin inj 100/2ml ........................................ 87
fosphenytoin inj 500/10ml ...................................... 87
FOSRENOL
CHW 1000MG ........................... 335
FOSRENOL
CHW 500MG ............................. 335
FOSRENOL
CHW 750MG ............................. 335
FRAGMIN
INJ 10000/ML ............................... 76
FRAGMIN
INJ 12500UNT .............................. 76
FRAGMIN
INJ 15000UNT .............................. 76
FRAGMIN
INJ 18000UNT .............................. 76
FRAGMIN
INJ 2500/0.2 .................................. 76
FRAGMIN
INJ 25000/ML ............................... 76
FRAGMIN
INJ 5000/0.2 .................................. 76
FRAGMIN
INJ 7500/0.3 .................................. 76
FRAGMIN
INJ 95000UNT .............................. 76
FREAMINE HBC INJ 6.9% ................................ 380
FREAMINE III INJ 10% ..................................... 380
FREAMINE III INJ 3% ....................................... 380
475
GABLOFEN INJ 50MCG/ML ........................ 371
GABOXETINE PAK........................................... 97
galantamine cap 16mg er.................................... 407
galantamine cap 24mg er.................................... 407
galantamine cap 8mg er...................................... 407
GALANTAMINE SOL 4MG/ML ...................... 407
galantamine tab 12mg......................................... 407
galantamine tab 4mg........................................... 407
galantamine tab 8mg........................................... 407
GAMASTAN S/D INJ ...........................................397
GAMMAGARD INJ 10GM/100 ...................... 397
GAMMAGARD INJ 1GM/10ML .................... 397
GAMMAGARD INJ 2.5GM/25 ....................... 397
GAMMAGARD INJ 20GM/200 ...................... 397
GAMMAGARD INJ 30GM/300 ...................... 397
GAMMAGARD INJ 5GM/50ML .................... 397
GAMMAGARD SD INJ 10GM HU ................... 397
GAMMAGARD SD INJ 2.5GM HU................... 397
GAMMAGARD SD INJ 5GM HU...................... 397
GAMMAKED INJ 10GM/100 ........................ 398
GAMMAKED INJ 1GM/10ML ...................... 398
GAMMAKED INJ 2.5GM/25 ......................... 398
GAMMAKED INJ 20GM/200 ........................ 398
GAMMAKED INJ 5GM/50ML ...................... 398
GAMMAPLEX INJ 10GM............................... 398
GAMMAPLEX INJ 2.5GM.............................. 398
GAMMAPLEX INJ 20GM............................... 398
GAMMAPLEX INJ 5GM................................. 398
GAMUNEX
INJ 10% ..................................... 398
GAMUNEX-C INJ 10GM/100......................... 398
GAMUNEX-C INJ 1GM/10ML....................... 398
GAMUNEX-C INJ 2.5GM/25.......................... 398
GAMUNEX-C INJ 20GM/200......................... 398
GAMUNEX-C INJ 40/400ML ......................... 398
GAMUNEX-C INJ 5GM/50ML....................... 398
ganciclovir cap 250mg........................................ 194
ganciclovir cap 500mg........................................ 194
ganciclovir inj 500mg ......................................... 194
GANITE
INJ 25MG/ML ............................... 315
garamycin oin 0.3% op ..................................... 385
GARAMYCIN SOL 0.3% OP .......................... 385
GARDASIL 9 INJ................................................436
GASTRINEX NF CAP ........................................ 426
GASTROCROM CON 100/5ML ...................... 332
gatifloxacin sol 0.5%............................................ 385
GATTEX
KIT 5MG ...................................... 332
gavilyte-c sol ...................................................... 353
gavilyte-g sol ...................................................... 353
gavilyte-h kit....................................................... 353
freamine iii inj 8.5% ............................................ 380
FREESTYLE GLUCOSE MONITOR ............. 361
FREESTYLE TEST STRIPS............................ 307
FRENADOL
TAB ............................................. 20
FROVA
TAB 2.5MG ................................... 363
FRST-HYDRCRT GEL 10% .............................. 276
FUDR
INJ 0.5GM........................................ 151
FUL-GLO
TES 0.6MG OP............................. 388
ful-glo
tes 1mg op ........................................... 388
FULYZAQ
TAB 125MG ............................... 110
FURADANTIN SUS 25MG/5ML..................... 432
furosemide inj 100/10ml .................................... 310
furosemide inj 10mg/ml ..................................... 310
furosemide inj 20mg/2ml ................................... 310
furosemide inj 40mg/4ml ................................... 310
furosemide sol 10mg/ml ..................................... 310
furosemide sol 8mg/ml ....................................... 310
furosemide tab 20mg.......................................... 310
FUSILEV
INJ 50MG...................................... 163
FUZEON
INJ 90MG ..................................... 189
FUZEON
KIT................................................ 189
FYCOMPA
TAB 10MG................................... 78
FYCOMPA
TAB 12MG................................... 78
FYCOMPA
TAB 2MG..................................... 78
FYCOMPA
TAB 4MG..................................... 78
FYCOMPA
TAB 6MG..................................... 78
FYCOMPA
TAB 8MG..................................... 78
G
gabapentin cap 100mg......................................... 80
gabapentin sol 250/5ml........................................ 80
gabapentin tab 600mg ......................................... 80
gabapentin tab 800mg ......................................... 80
GABAVALE-5 PAK ........................................... 59
GABAZOLAMINE PAK ...................................... 59
GABAZOLAMINE PAK 0.5MG.......................... 59
GABAZOLPIDEM PAK 5MG ........................... 351
GABITIDINE PAK ........................................... 428
GABITIDINE PAK 150MG.............................. 428
GABITRIL TAB 12MG .................................... 87
GABITRIL TAB 16MG .................................... 87
GABITRIL TAB 2MG ...................................... 87
GABITRIL TAB 4MG ...................................... 87
GABLOFEN INJ 10000/20 ............................. 371
GABLOFEN INJ 20000/20 ............................. 371
GABLOFEN INJ 40000/20 ............................. 371
476
gavilyte-n sol flav pk .......................................... 353
GAZYVA
INJ 25MG/ML ............................. 154
GEBAUERS SPR AER /STRETCH ................... 298
GELFILM
MIS OP ....................................... 392
GELNIQUE GEL 10% ...................................... 434
GELNIQUE
GEL 3% ...................................... 434
GEL-ONE
INJ 30MG/3ML.......................... 374
GEMCITABINE INJ 1GM................................. 151
GEMCITABINE INJ 200MG............................. 152
GEMCITABINE INJ 2GM................................. 152
gemfibrozil tab 600mg ........................................ 124
GEMZAR .......................................................INJ 1GM
.............................................................................
152
GEMZAR
.................................................. INJ 200MG
.............................................................................
152
GENADUR
KIT............................................... 288
GENADUR LIQ ................................................. 288
GENERESS FE CHW ........................................ 230
generlac
sol 10gm/15 ................................ 334
gengraf......................................................cap 100mg
.............................................................................
gengraf
cap 25mg........................................... 199
gengraf
sol 100mg/ml ..................................... 199
GENOTROPIN INJ 0.2MG............................... 317
GENOTROPIN INJ 12MG................................ 317
GENOTROPIN INJ 1MG.................................. 317
gentak......................................................oin 0.3% op
.............................................................................
gentam/nacl
inj 0.9mg/ml .....................................385
10
gentam/nacl inj 1.4mg/ml ..................................... 10
gentam/nacl inj 100mg.......................................... 10
GENTAM/NACL INJ 100MG PB ....................... 10
gentam/nacl inj 120mg.......................................... 10
gentam/nacl inj 60mg............................................ 10
gentam/nacl inj 60mg pb....................................... 11
gentam/nacl inj 80mg............................................ 11
gentam/nacl cre
inj 0.1%
80mg..........................................
pb.......................................264
11
gentamicin
gentamicin inj 10mg/ml ....................................... 11
gentamicin sol 0.3% op...................................... 385
GENVOYA
TAB............................................ 189
GEODON
CAP 20MG .................................. 177
GEODON
CAP 40MG .................................. 177
GEODON
CAP 60MG .................................. 177
GEODON
CAP 80MG .................................. 177
GEODON
INJ 20MG .................................... 177
gg/pe
syp 200-5mg ........................................ 248
GIAZO
TAB 1.1GM..................................... 333
gildagia tab 0.4-35........................................... 230
gildess
tab 1.5/30 ............................................ 230
gildess
tab 1/20 ............................................... 230
gildess 24 tab fe 1/20 ......................................... 230
gildess fe tab 1.5/30 ........................................... 230
gildess fe tab 1/20 .............................................. 230
GILENYA
CAP 0.5MG.................................. 412
GILOTRIF TAB 20MG................................... 156
GILOTRIF TAB 30MG................................... 156
GILOTRIF TAB 40MG................................... 156
GILPHEX TR TAB 10-388MG......................... 248
GILTUSS
LIQ...................................................246
GILTUSS
LIQ PED-C .................................... 246
giltuss ped liq ...................................................... 246
GILTUSS TR CAP 7-14-288............................. 246
GILTUSS TR TAB ............................................ 246
GLASSIA
INJ ...................................................413
glatopa inj 20mg/ml ........................................ 410
GLEEVEC
TAB 100MG ................................ 156
GLEEVEC
TAB 400MG ................................ 156
GLEOSTINE CAP 100MG .............................. 169
GLEOSTINE CAP 10MG ................................ 169
GLEOSTINE CAP 40MG ................................ 169
GLEOSTINE CAP 5MG .................................. 169
GLIADEL
WAF 7.7MG ................................. 169
glimepiride tab 1mg ............................................ 108
glip/metform tab 2.5-250m................................... 107
glip/metform tab 2.5-500m................................... 107
glip/metform tab 5-500mg.................................... 107
glipizide tab 10mg............................................. 108
glipizide tab 5mg............................................... 108
glipizide er tab 10mg ........................................... 108
glipizide er tab 2.5mg .......................................... 108
glipizide er tab 5mg ............................................. 108
glipizide xl tab 10mg............................................ 108
glipizide xl tab 2.5mg........................................... 108
glipizide xl tab 5mg.............................................. 108
GLUCAGEN
INJ HYPOKIT .......................... 102
gentamicin inj 40mg/ml ....................................... 11
gentamicin oin 0.1% .......................................... 264
gentamicin oin 0.3% op ..................................... 385
477
GRAFIX CORE MIS 5CMX5CM...................... 294
GRAFIX PRIME MIS 2CMX2CM ..................... 294
GRAFIX PRIME MIS 5CMX5CM ..................... 294
GRAFIX PRIME MIS 7.5X15CM ...................... 294
GRALISE
TAB 300MG ................................. 410
GRALISE
TAB 600MG ................................. 411
GRALISE STAR MIS 300/600 ........................... 411
granisetron inj 0.1mg/ml..................................... 113
granisetron inj 1mg/ml........................................ 113
granisetron inj 4mg/4ml...................................... 113
granisetron tab 1mg ............................................ 114
GRANISOL
SOL 2MG/10ML ........................ 114
GRANIX
INJ 300/0.5 ................................... 346
GRANIX
INJ 480/0.8 ................................... 346
GRANULEX
AER........................................... 283
green glo mis 1.5mg.......................................... 388
GRIFULVIN V TAB 500MG............................. 117
griseofulvin sus 125/5ml ...................................... 117
griseofulvin tab micr 500 ..................................... 117
griseofulvin tab ultr 125....................................... 117
griseofulvin tab ultr 250....................................... 117
GRIS-PEG TAB 125MG ................................. 117
GRIS-PEG TAB 250MG ................................. 117
grx hicort sup 25mg ............................................. 48
guanfacine tab 1mg............................................ 141
guanfacine tab 1mg er ........................................... 2
guanfacine tab 2mg............................................ 141
GUANIDINE TAB 125MG.............................. 146
GYNAZOLE-1 CRE 2% ................................... 436
H
GLUCAGON
INJ 1MG................................... 307
GLUCAGON
KIT 1MG.................................. 102
GLUCOPHAGE TAB 1000MG........................ 101
GLUCOPHAGE TAB 500MG.......................... 101
GLUCOPHAGE TAB 500MG XR ................... 101
GLUCOPHAGE TAB 750MG XR ................... 101
GLUCOPHAGE TAB 850MG.......................... 101
GLUCOTROL TAB 10MG.............................. 108
GLUCOTROL TAB 5MG................................ 108
GLUCOTROL XL TAB 10MG........................... 108
GLUCOTROL XL TAB 2.5MG.......................... 109
GLUCOTROL XL TAB 5MG............................. 109
GLUCOVANCE TAB 1.25-250........................ 107
GLUCOVANCE TAB 2.5-500.......................... 107
GLUCOVANCE TAB 5-500MG ...................... 107
glyb/metform tab 1.25-250................................... 107
glyb/metform tab 2.5-500..................................... 107
glyb/metform tab 5-500mg................................... 107
glyburid mcr tab 1.5mg........................................ 109
glyburid mcr tab 3mg........................................... 109
glyburid mcr tab 6mg........................................... 109
glyburide tab 1.25mg ........................................ 109
glyburide tab 2.5mg .......................................... 109
glyburide tab 5mg ............................................. 109
GLYCATE
TAB 1.5MG ................................ 430
glycine
sol 1.5% irr ........................................ 340
glycopyrrol inj 0.2mg/ml..................................... 431
glycopyrrol inj 0.4/2ml ....................................... 431
glycopyrrol inj 1mg/5ml...................................... 431
glycopyrrol inj 4mg/20ml.................................... 431
glycopyrrol tab 1mg............................................ 431
glycopyrrol tab 2mg............................................ 431
glydo
gel 2% ................................................. 287
GLYNASE
TAB 1.5MG ................................ 109
GLYNASE
TAB 3MG ................................... 109
GLYNASE
TAB 6MG ................................... 109
GLYSET
TAB 100MG.................................. 100
GLYSET
TAB 25MG.................................... 100
GLYSET
TAB 50MG.................................... 100
GLYXAMBI TAB 10-5 MG ........................... 106
GLYXAMBI TAB 25-5 MG ........................... 106
GOLYTELY
SOL ........................................... 353
GOLYTELY
SOL PINEAPPL........................ 353
GORDOFILM SOL.......................................... 284
GORDONS UREA OIN 40%.............................. 280
grafco silvr mis nit appl ....................................... 272
GRAFIX CORE MIS 2CMX2CM ..................... 294
H.P. ACTHAR INJ 80UNIT............................... 316
HALAC
KIT ................................................. 298
HALAVEN
INJ 1MG/2ML............................ 166
HALCION
TAB 0.25MG ............................... 350
HALDOL
INJ 5MG/ML................................ 180
HALDOL DECAN INJ 100MG/ML ................... 180
HALDOL DECAN INJ 50MG/ML ..................... 180
HALFLYTELY KIT FLAV PKS ...................... 354
halobetasol cre 0.05% ........................................ 277
halobetasol oin 0.05% ........................................ 277
HALOG
CRE 0.1% ...................................... 277
HALOG
OIN 0.1% ....................................... 277
HALONATE
KIT ............................................ 298
halonate pac kit.................................................... 298
haloper dec inj 100mg/ml ................................... 180
haloper dec inj 50mg/ml ..................................... 180
478
haloper lac inj 5mg/ml........................................ 180
haloperidol con 2mg/ml...................................... 180
haloperidol tab 0.5mg......................................... 180
haloperidol tab 10mg.......................................... 180
haloperidol tab 1mg............................................ 180
haloperidol tab 20mg.......................................... 180
HALOTIN
CRE 1% ....................................... 266
HARVONI TAB 90-400MG .......................... 195
hc ac/aloe gel 2%............................................... 299
hc butyrate cre 0.1%........................................... 277
hc butyrate oin 0.1%........................................... 277
hc butyrate sol 0.1% ........................................... 277
hc pramoxine cre 1-1%.......................................... 47
hc pramoxine cre 2.5-1%....................................... 47
hc valerate cre 0.2% ........................................... 277
hc valerate oin 0.2% ........................................... 277
hc/acet acid sol otic ............................................. 396
hc/lidocaine kit 2-2% ............................................. 47
hdc dm
syp ..................................................... 249
HEALON
INJ 10MG/ML.............................. 392
HEALON GV INJ 14MG/ML.......................... 392
HEALON5
INJ 23MG/ML............................. 392
heather
tab 0.35mg ......................................... 236
hecoria
cap 0.5mg .......................................... 201
hecoria
cap 1mg ............................................. 201
hecoria
cap 5mg ............................................. 201
HECTOROL CAP 0.5MCG ............................ 319
HECTOROL CAP 1MCG ............................... 319
HECTOROL CAP 2.5MCG ............................ 319
HECTOROL INJ 2MCG/ML .......................... 319
HECTOROL INJ 4MCG/2ML ........................ 319
HELIDAC
MIS............................................... 431
HEMANGEOL SOL 4.28/ML ......................... 206
hemmorex-hc sup 25mg ........................................ 48
hemmorex-hc sup 30mg ........................................ 48
hemril-30 sup 30mg ............................................ 48
hep flush-10 inj 10unt/ml ....................................... 74
hep sod/d5w inj 100/ml......................................... 74
hep sod/d5w inj 20000unt ..................................... 74
hep sod/d5w inj 25000unt ..................................... 74
hep sod/d5w inj 50unt/ml...................................... 74
hep sod/nacl inj 1000unit....................................... 74
hep sod/nacl inj 12500unt...................................... 74
HEP SOD/NACL INJ 2000UNIT.......................... 74
hep sod/nacl inj 25000unt...................................... 74
hep sod/nacl inj 2unit/ml........................................ 74
HEPAGAM B INJ .............................................. 398
heparin lock inj 100/ml .......................................... 75
heparin lock inj 10unt/ml ....................................... 75
heparin lock inj 1unit/ml ........................................ 75
HEPARIN LOCK INJ 2UNIT/ML ........................ 75
heparin lock kit 100/ml........................................... 75
heparin lock kit 10unt/ml ....................................... 75
heparin sod inj 1000/ml ........................................ 75
heparin sod inj 10000/ml ...................................... 75
heparin sod inj 20000/ml ...................................... 75
heparin sod inj 5000/0.5 ....................................... 75
hepatamine sol 8% ............................................. 380
hepatasol inj 8% ............................................... 380
HEPSERA
TAB 10MG .................................. 194
HERCEPTIN INJ 440MG ................................ 154
HESPAN
INJ 6%/NACL............................... 343
hetastarch inj 6%/nacl ....................................... 343
HETLIOZ
CAP 20MG ................................... 353
HEXTEND
SOL 6%....................................... 343
HIPREX
TAB 1GM....................................... 432
HIZENTRA
INJ 10/50ML............................... 398
HIZENTRA
INJ 1GM/5ML ............................ 398
HIZENTRA
INJ 2GM/10ML .......................... 398
HIZENTRA
INJ 4GM/20ML .......................... 398
homatropaire sol 5% op....................................... 383
homatropine sol 5% op ....................................... 383
HORIZANT
TAB 300MG............................... 411
HORIZANT
TAB 600MG............................... 411
HPR
AER.................................................... 288
HPR PLUS AER .............................................. 288
HPR PLUS CRE .............................................. 289
HPR PLUS KIT ............................................... 289
HPR PLUS MB KIT HYDROGEL .................... 282
HUMATROPE INJ 12MG ............................... 317
HUMATROPE INJ 24MG ............................... 317
HUMATROPE INJ 5MG ................................. 317
HUMATROPE INJ 6MG ................................. 317
HUMIRA
INJ 10MG/0.2 ................................. 12
HUMIRA
KIT 20MG/0.4 ................................ 12
HUMIRA
KIT 40MG/0.8 ................................ 12
HUMIRA PEDIA INJ CROHNS........................... 12
HUMIRA PEN INJ 40MG/0.8............................. 12
HUMIRA PEN INJ CROHNS ............................. 12
HUMIRA PEN INJ PSORIASI ........................... 12
HYALGAN
INJ 20MG/2ML ......................... 374
HYALUCIL-0.5 CRE .......................................... 268
HYALUCIL-4 CRE ........................................... 268
479
hyaluronate gel 0.2%.......................................... 282
HYALURONIC/ INJ LIDOCAIN...................... 374
HYALURONIDAS INJ 150/ML......................... 200
HYCAMTIN CAP 0.25MG ............................ 170
HYCAMTIN CAP 1MG ................................. 170
HYCAMTIN INJ 4MG.................................... 170
HYCET
SOL 7.5-325 ..................................... 24
HYCOFENIX SOL........................................... 247
hyd pol/cpm liq 10-8/5ml .................................... 250
hydralazine inj 20mg/ml ..................................... 145
hydralazine tab 100mg........................................ 145
hydralazine tab 10mg.......................................... 145
HYDREA
CAP 500MG ................................ 161
HYDRFRA BLUE PAD RDY 2.5 ...................... 304
HYDRFRA BLUE PAD RDY 4X5..................... 304
HYDRFRA BLUE PAD RDY 8X8..................... 304
HYDRFRA MRF PAD 2.................................... 305
HYDRO 35 AER ............................................. 282
HYDRO 40 AER FOAM................................. 280
hydro/chlor/ liq 5-4-60mg.................................... 251
hydroc/homat tab 5-1.5mg................................... 245
hydrochloric inj 1
500 ................................................................... 340
hydrochlorot cap 12.5mg ..................................... 312
hydrochlorot tab 12.5mg...................................... 312
hydrochlorot tab 25mg......................................... 312
hydrochlorot tab 50mg......................................... 312
hydroco/apap sol 10-325mg .................................. 24
hydroco/apap sol 5-217/10 .................................... 24
hydroco/apap sol 7.5-325 ...................................... 24
hydroco/apap sol 7.5-500 ...................................... 25
hydroco/apap tab 10-300mg.................................. 25
hydroco/apap tab 2.5-325...................................... 25
hydroco/apap tab 2.5-500...................................... 25
hydroco/apap tab 5-300mg.................................... 25
hydroco/apap tab 7.5-300...................................... 25
hydroco/apap tab 7.5-325...................................... 25
hydroco/apap tab 7.5-500...................................... 25
hydroco/apap tab 7.5-650...................................... 25
hydroco/apap tab 7.5-750...................................... 25
hydrocod/hom syp 5-1.5/5.................................... 245
hydrocod/ibu tab 10-200mg ................................... 25
hydrocod/ibu tab 2.5-200....................................... 25
hydrocod/ibu tab 5-200mg ..................................... 25
hydrocod/ibu tab 7.5-200....................................... 25
hydrocort cre 2.5% ........................................... 277
hydrocort cre iodoquin ..................................... 265
hydrocort ene 100mg .......................................... 47
hydrocort lot 2.5% ............................................ 277
hydrocort oin 2.5% ........................................... 277
hydrocort tab 10mg........................................... 239
hydrocort tab 20mg........................................... 239
hydrocort tab 5mg............................................. 239
hydrocort ac sup 25mg........................................... 48
hydrocort ac sup 30mg........................................... 48
hydrocort/ cre iodoquin...................................... 265
hydrocort/ kit pramoxin........................................ 47
hydrocort/ab oin 1% ............................................ 277
HYDROFERA PAD 4 ...................................... 305
HYDROFERA PAD BLUE 2X2...................... 305
HYDROFERA PAD BLUE 9MM.................... 305
HYDROFERA PAD MRF 2.5.......................... 305
HYDROFERA PAD MRF4.............................. 305
HYDROFRA MRF PAD 2-1/4X8....................... 305
HYDROG WOUND MIS 3 ................................. 305
HYDROG WOUND MIS 4-3/4........................... 305
HYDROGEL DRE PAD 2................................... 305
HYDROGEL DRE PAD 4................................... 305
HYDROGEL GAU PAD 1 .................................. 305
HYDROGEL GAU PAD 2 .................................. 305
HYDROGEL GAU PAD 4 .................................. 305
HYDROGEN PER SOL 30% .............................. 187
HYDROGEN PER SOL 35% FCC...................... 187
hydrogesic cap 5-500mg ...................................... 25
HYDRO-IODOQU GEL 2-1 ............................... 265
hydromet syp 5-1.5/5 ....................................... 245
HYDROMORPH INJ SOD CL...........................32
hydromorphon inj 10mg/ml.................................... 32
hydromorphon inj 1mg/ml...................................... 32
hydromorphon inj 500/50ml................................... 32
hydromorphon inj 50mg/5ml.................................. 32
HYDROMORPHON INJ HCL/NACL.................. 32
hydromorphon liq 1mg/ml...................................... 32
HYDROMORPHON SUP 3MG............................ 32
hydromorphon tab 12mg er.................................... 32
480
HYPERSAL NEB 3.5%................................... 249
HYPERSAL NEB 7%...................................... 249
HYPER-SAL NEB 7% ..................................... 249
HYPERTENEVID PAK 12.5MG........................ 203
HYPERTENIPIN PAK 2.5MG............................ 209
HYPERTENSOLO PAK ..................................... 144
HYPERTET S/D INJ 250/ML ............................. 399
HYPOCHLORITE SOL SODIUM...................... 188
HYQVIA
INJ 10-800..................................... 400
HYQVIA
INJ 2.5-200.................................... 400
HYQVIA
INJ 20-1600................................... 400
HYQVIA
INJ 30-2400................................... 400
HYQVIA
INJ 5-400....................................... 400
HYSINGLA ER TAB 100 MG............................. 33
HYSINGLA ER TAB 120 MG............................. 33
HYSINGLA ER TAB 20 MG............................... 33
HYZAAR
TAB 100-12.5............................... 138
HYZAAR
TAB 100-25.................................. 138
HYZAAR
TAB 50-12.5................................. 138
I
hydromorphon tab 16mg er ................................... 32
hydromorphon tab 2mg.......................................... 32
hydromorphon tab 32mg er ................................... 32
hydromorphon tab 8mg er ..................................... 33
HYDROXOCOBAL INJ 1000MCG ................... 345
hydroxychlor tab 200mg ...................................... 146
hydroxyurea cap 500mg...................................... 161
hydroxyz hcl inj 25mg/ml....................................... 58
hydroxyz hcl inj 50mg/ml....................................... 58
hydroxyz hcl sol 10mg/5ml .................................... 58
hydroxyz hcl syp 10mg/5ml.................................... 58
hydroxyz hcl tab 10mg ........................................... 59
hydroxyz pam cap 100mg ...................................... 59
hydroxyz pam cap 25mg ........................................ 59
hydroxyz pam cap 50mg ........................................ 59
hygel
gel 0.2% .............................................. 282
HYGEL
GEL 2.5%....................................... 305
HYLASE WOUND GEL..................................... 305
HYLATOPC PLS KIT /AURSTAT .................... 282
HYLATOPIC AER........................................... 289
HYLATOPIC AER PLUS ................................ 289
HYLATOPIC CRE PLUS ................................ 289
HYLENEX
INJ 150 UNIT ............................. 200
HYLIRA
GEL 0.2% ...................................... 282
HYLIRA
LOT 0.1% ...................................... 282
hyolev mb tab 81mg .......................................... 433
hyomax
tab 0.125mg...................................... 427
hyomax-dt tab ................................................... 427
hyomax-ft tab 0.125mg ..................................... 427
hyomax-sl sub 0.125mg .................................... 427
hyomax-sr tab 0.375mg .................................... 427
hyophen
tab..................................................... 433
hyoscyamine dro 0.125/ml .................................. 427
hyoscyamine elx 0.125/5 ..................................... 427
hyoscyamine sub 0.125mg .................................. 427
hyoscyamine tab 0.125mg................................... 427
hyoscyamine tab 0.375 er ................................... 427
hyoscyamine tab 0.375 sr.................................... 427
hyosyne
dro 0.125/ml...................................... 427
hyosyne
elx 0.125/5......................................... 427
hypercare sol 20% ............................................ 290
HYPERHEP B INJ S/D ..................................... 398
HYPERRAB S/D INJ 150/ML ............................ 398
HYPERRHO S/D INJ 300MCG.......................... 399
HYPERRHO S/D INJ 50MCG............................ 399
ibandronate inj 3mg/3ml..................................... 314
ibandronate tab 150mg ....................................... 314
IBRANCE
CAP 100MG................................. 160
IBRANCE
CAP 125MG................................. 160
IBRANCE
CAP 75MG................................... 160
IBUDONE
TAB 10-200MG............................. 25
ibudone
tab 5-200mg ........................................ 26
IBUPROFEN CRE 10% ................................... 262
IBUPROFEN KIT COMFORT .......................... 16
ibuprofen tab 400mg........................................... 16
ibuprofen tab 600mg........................................... 16
ibuprofen tab 800mg........................................... 16
ibutilide inj 1mg/10ml ......................................... 64
IC 400
KIT 400MG ......................................... 14
IC 800
KIT 800MG ......................................... 14
ICLUSIG
TAB 15MG .................................... 156
ICLUSIG
TAB 45MG .................................... 156
IDAMYCIN PFS INJ 10/10ML........................... 159
IDAMYCIN PFS INJ 20/20ML........................... 159
IDAMYCIN PFS INJ 5MG/5ML ........................ 159
idarubicin inj 10/10ml........................................ 159
idarubicin inj 20/20ml........................................ 159
idarubicin inj 5mg/5ml....................................... 159
IFEX
INJ 1GM ............................................ 168
IFEX
INJ 3GM ............................................ 168
481
ifosfamide inj 1gm ............................................. 168
ifosfamide inj 1gm/20ml .................................... 168
ifosfamide inj 3gm ............................................. 168
ifosfamide inj 3gm/60ml .................................... 168
IFOSFAMIDE KIT MESNA............................. 160
ILARIS
INJ 180MG ........................................ 13
ILEVRO
DRO 0.3% OP................................ 389
ilotycin oin op .................................................. 385
ILUVIEN
IMP 0.19MG.................................. 391
IMBRUVICA CAP 140MG ............................. 156
IMDUR
TAB 120MG ER .............................. 55
IMDUR
TAB 30MG ER ................................ 55
IMDUR
TAB 60MG ER ................................ 55
imipenem/cil inj 250mg.......................................... 52
imipenem/cil inj 500mg.......................................... 52
imipram hcl tab 10mg........................................... 98
imipram pam cap 100mg ...................................... 98
imipram pam cap 75mg ........................................ 99
imiquimod cre 5%............................................. 284
IMITREX
INJ 4MG/0.5 ................................. 363
IMITREX
INJ 6MG/0.5 ................................. 363
IMITREX
SPR 20MG/ACT........................... 363
IMITREX
SPR 5MG/ACT............................. 363
IMITREX
TAB 100MG ................................. 363
IMITREX
TAB 25MG ................................... 363
IMITREX
TAB 50MG ................................... 363
IMLYGIC
INJ................................................... 161
IMOGAM RABIE INJ 150/ML .......................... 399
IMURAN
TAB 50MG................................... 203
INCIVEK
TAB 375MG ................................. 195
INCRELEX
INJ 40MG/4ML .......................... 320
INCRUSE ELPT INH 62.5MCG........................... 68
indapamide tab 1.25mg ..................................... 312
indapamide tab 2.5mg ....................................... 312
INDERAL LA CAP 120MG ............................. 207
INDERAL LA CAP 160MG ............................. 207
INDERAL LA CAP 60MG ............................... 207
INDERAL LA CAP 80MG ............................... 207
INDERAL XL CAP 120MG ............................. 207
INDERAL XL CAP 80MG ............................... 207
indiomin mb cap 120mg...................................... 433
INDOCIN
SUP 50MG...................................... 16
INDOCIN
SUS 25MG/5ML............................. 16
INDOCIN IV INJ 1MG ....................................... 16
indomethacin cap 25mg ......................................... 16
indomethacin cap 50mg ......................................... 16
indomethacin cap 75mg er ..................................... 16
INDOMETHACIN INJ 1MG ................................ 16
INFASURF SUS 35MG/ML ........................... 414
INFERGEN
INJ 15MCG ................................. 195
INFERGEN
INJ 9MCG ................................... 195
INFLAMMATION PAK REDUCTIO .................. 14
infumorph inj 10mg/ml........................................ 33
INFUMORPH INJ 25MG/ML............................ 33
INLYTA
TAB 1MG ...................................... 156
INLYTA
TAB 5MG ...................................... 156
INNOPRAN XL CAP 120MG ........................... 207
INNOPRAN XL CAP 80MG ............................. 207
INNOPRAX-5 CRE........................................... 263
INOVA
KIT 4%............................................ 254
INOVA
KIT 8%............................................ 254
INOVA 4/1 KIT ACNE CON........................... 254
INOVA 8/2 KIT ACNE CON........................... 254
INSPRA
TAB 25MG ..................................... 145
INSPRA
TAB 50MG ..................................... 145
INSULIN SYRINGES AND NEEDLES............. 362
INTEGRILIN INJ 0.75MG/1............................. 342
INTEGRILIN INJ 2MG/ML.............................. 342
INTELENCE TAB 100MG .............................. 191
INTELENCE TAB 200MG .............................. 191
INTELENCE TAB 25MG ................................ 191
INTERARTICUL KIT JOINT ............................. 243
INTERMEZZO SUB 1.75MG ........................... 352
INTERMEZZO SUB 3.5MG ............................. 352
intralipid inj 20%............................................... 380
INTRALIPID INJ 30% ...................................... 380
INTROL
SOL 75% ........................................ 311
INTRON A INJ 10MU .................................... 161
INTRON A INJ 18MU .................................... 161
INTRON A INJ 25MU .................................... 161
INTRON A INJ 50MU .................................... 161
INTRON-A
INJ 10MU PEN ........................... 161
INTRON-A
INJ 3MU PEN ............................. 161
INTRON-A
INJ 5MU PEN ............................. 161
introvale tab ...................................................... 235
INTUNIV
TAB 1MG ......................................... 2
INTUNIV
TAB 2MG ......................................... 2
INTUNIV
TAB 3MG ......................................... 2
INTUNIV
TAB 4MG ......................................... 2
INVANZ
INJ 1GM .......................................... 52
INVEGA
TAB 1.5MG................................... 178
INVEGA
TAB 3MG...................................... 178
INVEGA
TAB 6MG...................................... 178
INVEGA
TAB 9MG...................................... 178
482
ISO CARBACHO SOL 3% OP ........................... 383
ISO HOMATROP SOL 2% OP........................... 383
ISO HOMATROP SOL 5% OP........................... 383
ISO HYOSCINE SOL 0.25% OP ........................ 383
isochron tab 40mg cr ......................................... 56
isoditrate tab 40mg er.......................................... 56
isoflurane sol...................................................... 337
isometh/apap cap dichlor..................................... 362
isometh/caff tab /apap.......................................... 362
isonarif cap ...................................................... 147
isoniazid inj 100mg/ml ..................................... 148
isoniazid syp 50mg/5ml .................................... 148
isoniazid tab 100mg ......................................... 148
isoniazid tab 300mg ......................................... 148
ISOPTIN SR TAB 120MG ................................ 213
ISOPTIN SR TAB 180MG ................................ 213
ISOPTIN SR TAB 240MG ................................ 213
ISOPTO CARP SOL 1% OP .............................. 383
ISORDIL
TAB 40MG ...................................... 56
ISORDIL
TAB 5MG ........................................ 56
isosorb din sub 2.5mg ........................................... 56
isosorb din sub 5mg .............................................. 56
isosorb din tab 10mg............................................. 56
isosorb din tab 40mg er ........................................ 56
isosorb din tab 5mg............................................... 56
isosorb mono tab 10mg.......................................... 56
isosorb mono tab 120mg er.................................... 56
isosorb mono tab 20mg.......................................... 56
isosorb mono tab 30mg er...................................... 56
isosorb mono tab 60mg er...................................... 56
isoxsuprine tab 10mg .......................................... 219
ISOXSUPRINE TAB HCL 20MG ..................... 219
isradipine cap 2.5mg.......................................... 213
isradipine cap 5mg............................................. 213
ISTALOL
SOL 0.5% OP ................................ 381
ISTODAX
INJ 10MG..................................... 153
ISUPREL
INJ 0.2MG/ML ................................ 67
itraconazole cap 100mg ....................................... 118
ivermectin tab 3mg............................................... 49
IXEMPRA KIT INJ 15MG................................. 166
IXEMPRA KIT INJ 45MG................................. 166
J
INVEGA SUST INJ 117/0.75 ............................ 178
INVEGA SUST INJ 156MG/ML ....................... 178
INVEGA SUST INJ 234/1.5 .............................. 178
INVEGA SUST INJ 39/0.25 .............................. 178
INVEGA SUST INJ 78/0.5ML .......................... 178
INVEGA TRINZ INJ 273MG ............................. 178
INVIRASE
CAP 200MG ................................ 190
INVIRASE
TAB 500MG ................................ 190
INVOKAMET TAB 150-1000......................... 106
INVOKAMET TAB 150-500........................... 106
INVOKAMET TAB 50-1000........................... 106
INVOKAMET TAB 50-500MG ...................... 106
INVOKANA TAB 100MG ............................. 106
INVOKANA TAB 300MG ............................. 106
IODINE
SOL STRONG ................................ 365
IODINE
TIN 2%............................................ 188
IODINE
TIN STRONG................................. 188
IODOFLEX
PAD PAD ................................... 188
IONSYS
PAD 40MCG/AC ............................. 33
IOPIDINE SOL 0.5% OP ................................ 390
IOPIDINE SOL 1% OP ................................... 390
ipratropium sol 0.02%inh ..................................... 68
ipratropium spr 0.03% ....................................... 375
ipratropium spr 0.06% ....................................... 375
ipratropium/ sol albuter......................................... 66
ipratropium/ sol sulfate.......................................... 66
IPRIVASK
INJ 15MG....................................... 77
irbesar/hctz tab 150-12.5 ..................................... 138
irbesar/hctz tab 300-12.5 ..................................... 138
irbesartan tab 150mg......................................... 140
irbesartan tab 300mg......................................... 140
irbesartan tab 75mg........................................... 140
IRENKA
CAP 40MG ...................................... 96
IRESSA
TAB 250MG ................................... 156
irinotecan inj 100/5ml........................................ 170
irinotecan inj 40mg/2ml..................................... 170
irinotecan inj 500mg/25..................................... 170
iron supplmt dro 15mg/ml ................................... 347
iron with folic acid............................................... 347
IRON-B12-FOLATE ........................................... 348
ISCAR MALI INJ 5MG/ML ............................... 10
ISENTRESS CHW 100MG.............................. 189
ISENTRESS CHW 25MG................................ 189
ISENTRESS TAB 400MG ............................... 189
ISO ATROPINE SOL 1% OP ............................. 383
ISO CARBACHO SOL 1.5% OP........................ 383
JADENU
JADENU
JADENU
483
TAB 180MG.................................. 111
TAB 360MG.................................. 111
TAB 90MG.................................... 111
JUVISYNC
JUVISYNC
JUVISYNC
JUXTAPID
JUXTAPID
JUXTAPID
JUXTAPID
JUXTAPID
JUXTAPID
K
JAKAFI
TAB 10MG ..................................... 164
JAKAFI
TAB 15MG ..................................... 164
JAKAFI
TAB 20MG ..................................... 164
JAKAFI
TAB 25MG ..................................... 165
JAKAFI
TAB 5MG ....................................... 165
JALYN
CAP................................................. 340
jantoven tab 10mg ............................................. 73
jantoven tab 1mg ............................................... 73
jantoven tab 2.5mg ............................................ 73
jantoven tab 2mg ............................................... 73
jantoven tab 3mg ............................................... 73
jantoven tab 4mg ............................................... 73
jantoven tab 5mg ............................................... 73
jantoven tab 6mg ............................................... 73
jantoven tab 7.5mg ............................................ 73
JANUMET TAB 50-1000 .............................. 102
JANUMET TAB 50-500MG.......................... 102
JANUMET XR TAB 100-1000......................... 102
JANUMET XR TAB 50-1000........................... 102
JANUMET XR TAB 50-500MG ...................... 103
JANUVIA
TAB 100MG................................. 102
JANUVIA
TAB 25MG................................... 102
JANUVIA
TAB 50MG................................... 102
JARDIANCE TAB 10MG................................ 106
JARDIANCE TAB 25MG................................ 106
J-COF DHC LIQ 15-3-7.5 ................................ 251
jencycla tab 0.35mg ......................................... 236
JENTADUETO TAB 2.5-1000 ......................... 103
JENTADUETO TAB 2.5-500 ........................... 103
JENTADUETO TAB 2.5-850 ........................... 103
JETREA
INJ 2.5MG/ML............................... 388
jevantique tab 1mg-5mcg................................... 325
JEVANTIQUE L TAB 0.5-2.5 ............................ 325
JEVTANA
INJ 60/1.5ML .............................. 166
jinteli
tab 1mg-5mcg ....................................... 325
J-MAX DHC LIQ 7.5-100................................ 246
JNT/TUNNEL/ KIT TRIGGER ......................... 243
jolessa
tab ....................................................... 235
jolivette tab 0.35mg .......................................... 236
JUBLIA
SOL 10%......................................... 284
juleber
tab.......................................................... 230
junel 1.5/30 tab .................................................... 230
junel 1/20 tab ..................................................... 230
junel fe tab 1.5/30 ............................................ 230
junel fe tab 1/20 ............................................... 230
junel fe 24 tab 1/20 ............................................. 230
JUVISYNC TAB 100-10MG .......................... 103
JUVISYNC TAB 100-20MG .......................... 103
JUVISYNC TAB 100-40MG .......................... 103
TAB 50-10MG............................. 103
TAB 50-20MG............................. 103
TAB 50-40MG............................. 103
CAP 10MG .................................. 128
CAP 20MG .................................. 128
CAP 30MG .................................. 128
CAP 40MG .................................. 128
CAP 5MG .................................... 128
CAP 60MG .................................. 128
k citrate sol citr acd .......................................... 338
K.B.G.L IN CRE TERODERM......................... 263
k/na citrate sol citr acd ........................................ 338
K10-LIDO KIT ................................................ 243
k2k pain rel pad 4-4%.......................................... 295
K40-LIDO KIT ................................................ 243
KADCYLA
INJ 100MG................................. 160
KADCYLA
INJ 160MG................................. 160
KADIAN
CAP 100MG ER ............................. 33
KADIAN
CAP 10MG ER ............................... 33
KADIAN
CAP 130MG ER ............................. 33
KADIAN
CAP 150MG ER ............................. 33
KADIAN
CAP 200MG ER ............................. 33
KADIAN
CAP 20MG ER ............................... 33
KADIAN
CAP 30MG ER ............................... 33
KADIAN
CAP 40MG ER ............................... 33
KADIAN
CAP 50MG ER ............................... 33
KADIAN
CAP 60MG ER ............................... 33
KADIAN
CAP 70MG ER ............................... 33
KADIAN
CAP 80MG ER ............................... 33
KALBITOR
INJ 10MG/ML ............................ 343
KALETRA
SOL ............................................. 189
KALETRA
TAB 100-25MG .......................... 189
KALETRA
TAB 200-50MG .......................... 189
KALYDECO PAK 50MG ............................... 413
KALYDECO PAK 75MG ............................... 413
KALYDECO TAB 150MG ............................. 413
kanamycin inj 333mg/ml ..................................... 11
KAPVAY
MIS 0.1&0.2..................................... 2
KAPVAY
TAB 0.1 MG .................................... 2
KARBINAL ER SUS 4MG/5ML ....................... 120
kariva
tab 28 day ........................................... 228
KAZANO 12.5- TAB 1000MG ........................... 103
KAZANO 12.5- TAB 500MG ............................. 103
KEFLEX
CAP 250MG .................................. 223
KEFLEX
CAP 500MG .................................. 223
KEFLEX
CAP 750MG .................................. 223
484
ketorolac sol 0.4% ............................................ 389
ketorolac sol 0.5% ............................................ 389
ketorolac tab 10mg ............................................. 17
KEVEYIS
TAB 50MG ................................... 309
KEYTRUDA INJ 100MG/4M......................... 154
KEYTRUDA SOL 50MG................................ 154
KHEDEZLA
TAB 100MG ER.......................... 96
KHEDEZLA
TAB 50MG ER............................ 96
kimidess tab...................................................... 228
KINERET
INJ ..................................................... 13
KINLYTIC INJ 250000 ................................... 344
kionex
sus 15gm/60 ........................................ 202
KITABIS PAK NEB 300/5ML............................. 11
KLARON
LOT 10%...................................... 252
KLONOPIN TAB 0.5MG.................................. 79
KLONOPIN TAB 1MG..................................... 79
KLONOPIN TAB 2MG..................................... 79
KOMBIGLYZE TAB 2.5-1000 ......................... 103
KOMBIGLYZE TAB 5-1000MG...................... 103
KOMBIGLYZE TAB 5-500MG........................ 103
KORLYM
TAB 300MG................................ 106
K-PHOS
TAB ................................................ 365
K-PHOS
TAB MF ......................................... 340
K-PHOS
TAB NO 2 ...................................... 340
KRISTALOSE PAK 10GM............................... 354
KRISTALOSE PAK 20GM............................... 354
KRYSTEXXA INJ 8MG/ML ........................... 341
kurvelo
tab 0.15/30 ......................................... 230
KUVAN
TAB 100MG.................................. 321
KYNAMRO
INJ 200MG/ML......................... 122
KYPROLIS SOL 60MG .................................. 155
L
kelnor
tab 1/35............................................... 230
KENALOG
AER SPRAY .............................. 277
KENALOG-10 INJ 10MG/ML ......................... 239
KENALOG-40 INJ 40MG/ML ......................... 239
KENGREAL SOL 50MG................................ 342
KEPIVANCE INJ 6.25MG .............................. 163
KEPPRA
INJ 500/5ML ................................... 80
KEPPRA
SOL 100MG/ML............................. 80
KEPPRA
TAB 1000MG.................................. 80
KEPPRA
TAB 250MG.................................... 80
KEPPRA
TAB 500MG.................................... 80
KEPPRA
TAB 750MG.................................... 80
KEPPRA XR TAB 500MG ................................ 80
KEPPRA XR TAB 750MG ................................ 81
KERAFOAM AER 30%.................................. 280
KERAFOAM 42 AER 42%................................ 280
KERALAC
CRE 47% .................................... 280
KERALYT
GEL 6%....................................... 285
KERALYT
KIT SCALP 6% .......................... 285
KERLONE
TAB 10MG ................................. 205
KERLONE
TAB 20MG ................................. 205
KERR TRIPLE MIS DYE SWAB ..................... 187
KERYDIN
SOL 5% ....................................... 290
KETALAR
INJ 100MG/ML .......................... 336
KETALAR
INJ 10MG/ML ............................ 336
KETALAR
INJ 50MG/ML ............................ 336
ketamine inj 100mg/ml..................................... 336
ketamine inj 10mg/ml....................................... 336
ketamine inj 50mg/ml....................................... 336
KETAMINE HCL INJ SOD CL.......................... 336
KETEK
TAB 300MG..................................... 53
KETEK
TAB 400MG..................................... 53
KETOCON
KIT.............................................. 265
ketoconazole aer 2% ............................................ 284
ketoconazole cre 2% ............................................ 284
ketoconazole sha 2%............................................ 284
ketoconazole tab 200mg....................................... 117
ketodan
aer 2% ............................................... 284
KETODAN
KIT 2% ....................................... 284
ketoprofen cap 200mg er ..................................... 16
ketoprofen cap 50mg............................................ 16
ketoprofen cap 75mg............................................ 16
KETOPROFEN CRE 5% KIT........................... 262
KETOROCAINE KIT -L...................................... 14
KETOROCAINE KIT -LM.................................... 14
KETOROLAC GEL 2% ................................... 262
ketorolac inj 15mg/ml ......................................... 16
ketorolac inj 30mg/ml ......................................... 16
ketorolac inj 60mg/2ml ....................................... 16
labetalol inj 5mg/ml .......................................... 204
labetalol tab 100mg .......................................... 204
labetalol tab 200mg .......................................... 204
labetalol tab 300mg .......................................... 204
LAC-HYDRIN CRE 12%.................................. 282
LAC-HYDRIN LOT 12%.................................. 282
laclotion lot 12%............................................... 282
LACRISERT MIS 5MG OP ............................. 381
lactic acid cre /vit e............................................. 279
lactic acid cre e ................................................... 279
lactic acid lot 10% .............................................. 283
lactulose sol 10gm/15 ....................................... 354
lactulose sol 20gm/30 ....................................... 354
LAMICTAL
CHW 25MG ................................. 81
LAMICTAL
CHW 2MG ................................... 81
LAMICTAL
CHW 5MG ................................... 81
LAMICTAL
KIT START 35............................. 81
485
LAMICTAL
KIT START 49 ............................ 81
LAMICTAL
KIT START 98 ............................ 81
LAMICTAL
TAB 100MG ................................ 81
LAMICTAL
TAB 150MG ................................ 81
LAMICTAL
TAB 200MG ................................ 81
LAMICTAL
TAB 25MG .................................. 81
LAMICTAL ODT KIT .......................................... 81
LAMICTAL ODT TAB 100MG ........................... 81
LAMICTAL ODT TAB 200MG ........................... 81
LAMICTAL ODT TAB 25MG ............................. 81
LAMICTAL ODT TAB 50MG ............................. 81
LAMICTAL XR KIT............................................ 81
LAMICTAL XR TAB 100MG............................. 81
LAMICTAL XR TAB 25MG............................... 81
LAMICTAL XR TAB 50MG............................... 81
LAMISIL
GRA 125MG ................................. 117
LAMISIL
GRA 187.5MG .............................. 117
LAMISIL
SPR 1%.......................................... 266
LAMISIL
TAB 250MG.................................. 117
lamivud/zido tab 150-300 .................................... 189
lamivudine sol 10mg/ml..................................... 192
lamivudine tab 100mg ....................................... 194
lamotrig odt kit 25/50mg ....................................... 82
lamotrig odt kit 50/100mg...................................... 82
lamotrigine chw 25mg .......................................... 82
lamotrigine chw 5mg ............................................ 82
lamotrigine kit odt................................................. 82
lamotrigine tab 100mg.......................................... 82
lamotrigine tab 100mg er ..................................... 82
lamotrigine tab 25mg............................................ 82
lamotrigine tab 25mg er ....................................... 82
lamotrigine tab 25mg odt ..................................... 82
lamotrigine tab 50mg er ....................................... 82
lamotrigine tab 50mg odt ..................................... 82
LANCETS ........................................................... 361
LANOXIN
INJ 0.25MG/1.............................. 217
LANOXIN
TAB 0.0625MG........................... 217
LANOXIN
TAB 0.125MG............................. 217
LANOXIN
TAB 0.1875MG........................... 217
lanoxin
tab 0.25mg.......................................... 217
LANOXIN PED INJ 0.1MG/ML........................ 217
lansopr/amox mis /clarith .................................... 431
lansoprazole cap 15mg dr.................................... 335
lansoprazole cap 30mg dr.................................... 335
LANSOPRAZOLE SUS 3MG/ML ..................... 335
lansoprazole tab 15mg odt................................... 335
lansoprazole tab 30mg odt................................... 335
LANTUS
INJ 100/ML................................... 104
LANTUS
INJ SOLOSTAR ........................... 104
larin
tab 1.5/30 ............................................. 231
larin
tab 1/20 ................................................ 231
larin 24 tab fe 1/20........................................... 231
larin fe tab 1.5/30............................................. 231
larin fe tab 1/20................................................ 231
LARTUS
LIQ...................................................245
LASIX
TAB 20MG ...................................... 310
LASIX
TAB 40MG ...................................... 310
LASIX
TAB 80MG ...................................... 311
LASTACAFT SOL 0.25%................................ 385
latanoprost sol 0.005% ....................................... 393
latrix
sus 50% ................................................ 282
latrix xm emu 45% ............................................ 282
LATUDA
TAB 120MG................................. 177
LATUDA
TAB 20MG................................... 177
LATUDA
TAB 40MG................................... 177
LATUDA
TAB 60MG................................... 177
LATUDA
TAB 80MG................................... 177
LAVARE WOUND GEL WASH........................ 300
lavoclen-4 kit acne wsh ...................................... 259
LAVOCLEN-4 LIQ CREM WSH..................... 259
lavoclen-8 kit acne wsh ...................................... 259
LAVOCLEN-8 LIQ CREM WSH..................... 259
layolis fe chw...................................................... 231
LAZANDA
SPR 100MCG ............................... 34
LAZANDA
SPR 400MCG ............................... 34
LDO PLUS GEL 4% ....................................... 287
leena
tab........................................................ 236
leflunomide tab 10mg............................................ 19
leflunomide tab 20mg............................................ 19
LEMOHIST
CAP PLUS.................................. 248
LEMTRADA
INJ 12/1.2ML ........................... 409
LENVIMA
CAP 10MG.................................. 156
LENVIMA
CAP 14MG.................................. 156
LENVIMA
CAP 20MG.................................. 156
LENVIMA
CAP 24MG.................................. 157
LESCOL
CAP 20MG .................................... 126
LESCOL
CAP 40MG .................................... 126
LESCOL XL TAB 80MG................................. 126
486
lessina tab ....................................................... 231
LETAIRIS TAB 10MG ................................... 221
LETAIRIS TAB 5MG ..................................... 221
letrozole tab 2.5mg ........................................... 162
LETS
KIT .................................................... 355
leucovor ca inj 100mg......................................... 163
LEUCOVOR CA INJ 10MG/ML....................... 163
leucovor ca inj 50mg........................................... 163
leucovor ca tab 10mg.......................................... 163
leucovor ca tab 5mg............................................ 163
leucovorin inj calcium........................................ 163
LEUKERAN TAB 2MG ................................ 168
LEUKINE
INJ 250MCG ................................ 347
LEUKINE
INJ 500 MCG ............................... 347
leuprolide inj 1mg/0.2........................................ 165
LEUSTATIN INJ 1MG/ML ............................. 152
LEVACET
TAB ............................................... 20
levalbuterol neb 0.31mg......................................... 67
levalbuterol neb 1.25/0.5 ....................................... 67
LEVAQUIN
SOL 25MG/ML.......................... 330
LEVAQUIN
TAB 250MG .............................. 330
LEVAQUIN
TAB 500MG .............................. 330
LEVAQUIN
TAB 750MG .............................. 330
LEVAQUIN/D5W INJ 250/50ML ...................... 330
LEVAQUIN/D5W INJ 500/100M....................... 330
LEVAQUIN/D5W INJ 750/150 .......................... 330
LEVATIO
PAD 0.3-5% ................................. 295
LEVATOL
TAB 20MG ................................. 207
LEVBID
TAB 0.375 ER................................ 428
LEVEMIR
INJ .................................................. 104
LEVEMIR
INJ FLEXPEN ............................. 104
LEVEMIR
INJ FLEXTOUC .......................... 104
LEVETIRACETA INJ 10MG/ML ........................ 82
LEVETIRACETA INJ 15MG/ML ........................ 82
LEVETIRACETA INJ 5MG/ML .......................... 82
levetiraceta sol 100mg/ml...................................... 82
levetiraceta sol 500/5ml......................................... 82
levetiraceta tab 1000mg......................................... 82
levetiraceta tab 250mg........................................... 83
levetiraceta tab 500mg er ...................................... 83
levetiraceta tab 750mg er ...................................... 83
levetiracetm inj 500/5ml......................................... 83
LEVITRA
TAB 10MG ................................... 222
LEVITRA
TAB 2.5MG .................................. 222
LEVITRA
TAB 20MG ................................... 222
LEVITRA
TAB 5MG ..................................... 222
LEVOBUNOLOL SOL 0.25% OP ..................... 381
levobunolol sol 0.5% op...................................... 381
levocarnitin inj 200mg/ml .................................... 316
levocarnitin sol 1gm/10ml.................................... 316
levocarnitin tab 330mg ........................................ 316
levocetirizi sol 2.5/5ml ......................................... 121
levocetirizi tab 5mg.............................................. 121
levo-eth est tab 90-20mcg .................................... 234
levoflox/d5w inj 250/50ml .................................... 330
levoflox/d5w inj 500/100m ................................... 330
levoflox/d5w inj 750/150...................................... 330
levofloxacin inj 25mg/ml ...................................... 330
levofloxacin sol 0.5% ........................................... 385
levofloxacin sol 25mg/ml...................................... 331
levofloxacin tab 250mg ........................................ 331
levoleucovor inj 175/17.5..................................... 163
levoleucovor inj 50mg.......................................... 164
LEVOLEUCOVOR SOL 250MG/25 .................. 164
levonest tab ...................................................... 236
levonor/ethi tab 0.1-0.02...................................... 231
levonor/ethi tab estradio ...................................... 231
LEVONORGESTR TAB 0.75MG ...................... 234
levonorgestr tab 1.5mg ........................................ 234
LEVOPHED
INJ 1MG/ML ............................. 439
levora-28 tab 0.15/30........................................ 231
LEVORPHANOL TAB 2MG............................... 34
levo-t
tab 100mcg........................................... 419
levo-t
tab 112mcg........................................... 419
levo-t
tab 125mcg........................................... 419
levo-t
tab 137mcg........................................... 419
levo-t
tab 150mcg........................................... 419
levo-t
tab 175mcg........................................... 419
levo-t
tab 200 mcg.......................................... 419
levo-t
tab 25mcg............................................. 419
levo-t
tab 300 mcg.......................................... 419
levo-t
tab 50mcg............................................. 419
levo-t
tab 75mcg............................................. 419
levo-t
tab 88mcg............................................. 419
levothroid tab 100mcg........................................ 419
487
levothroid tab 150mcg ....................................... 419
levothroid tab 25mcg ......................................... 420
levothyroxin inj 100mcg....................................... 420
LEVOTHYROXIN INJ 200MCG ....................... 420
LEVOTHYROXIN INJ 500MCG ....................... 420
levothyroxin tab 100mcg...................................... 420
levothyroxin tab 25mcg........................................ 420
levoxyl
tab 100mcg ......................................... 420
levoxyl
tab 112mcg ......................................... 421
levoxyl
tab 125mcg ......................................... 421
levoxyl
tab 137mcg ......................................... 421
levoxyl
tab 150mcg ......................................... 421
levoxyl
tab 175mcg ......................................... 421
levoxyl
tab 200mcg ......................................... 421
levoxyl
tab 25mcg ........................................... 421
levoxyl
tab 50mcg ........................................... 421
levoxyl
tab 75mcg ........................................... 421
levoxyl
tab 88mcg ........................................... 421
LEVSIN
INJ 0.5MG/ML............................... 428
LEVSIN
TAB 0.125MG................................ 428
LEVSIN/SL SUB 0.125MG ............................. 428
LEVULAN KERA SOL 20%.............................. 290
LEXAPRO
SOL 5MG/5ML............................. 93
LEXAPRO
TAB 10MG ................................... 93
LEXAPRO
TAB 20MG ................................... 93
LEXAPRO
TAB 5MG ..................................... 93
LEXIVA
SUS 50MG/ML.............................. 190
LEXIVA
TAB 700MG .................................. 190
LEXUSS 210 LIQ 2-10/5ML ............................ 250
LIALDA
TAB 1.2GM ................................... 333
LIBRAX
CAP 5-2.5MG................................ 426
lidazone cre........................................................ 47
lidenza
pad 4-1% ............................................ 295
LIDO/DEXTROS INJ 5-7.5% ............................. 357
lido/epi inj 0.5%............................................... 355
lido/epi inj 1.5%............................................... 355
lido/epi inj 2%.................................................. 355
lido/epi 1%- inj 1
100000.............................................................. 355
lido/prilocn cre 2.5-2.5% ..................................... 295
lido/prilocn kit 2.5-2.5% ...................................... 295
lidocain/d5w inj 4mg/ml......................................... 63
lidocain/d5w inj 8mg/ml......................................... 63
LIDOCAINE CRE 10%.................................... 287
lidocaine cre 3% ............................................... 287
LIDOCAINE CRE 5%...................................... 287
lidocaine cre tetracai ........................................ 295
lidocaine gel 2% ............................................... 287
lidocaine gel 2% jelly........................................ 287
lidocaine inj 0.5% ............................................. 357
lidocaine inj 1% ................................................ 357
lidocaine inj 1.5% ............................................. 357
lidocaine inj 10mg/ml ......................................... 63
lidocaine inj 2% ................................................ 357
lidocaine inj 20mg/ml ......................................... 63
lidocaine inj 4% ................................................ 357
LIDOCAINE LOT 3%...................................... 287
lidocaine oin 5% ............................................... 287
lidocaine pad 5% .............................................. 287
lidocaine sol 2% visc ........................................ 365
lidocaine sol 4%................................................ 365
lidocaine/hc cre 3%-0.5%...................................... 48
lidocaine/hc kit 2-2% ............................................. 48
lidocaine/hc kit 3%-0.5% ....................................... 48
lidocaine/hc kit 3%-1% .......................................... 48
lidocaine/hc kit 3-2.5% .......................................... 48
LIDOCIN
GEL 3% ......................................... 287
LIDODERM DIS 5%....................................... 287
lidodextrapi pad 4-1%.......................................... 295
LIDO-HYDRO GEL 2.8-0.55.............................. 47
LIDOLOG
KIT ............................................... 243
lidopin cre 3%................................................. 287
LIDOPIN
CRE 3.25% .................................... 287
LIDOPROFEN CRE 5-5-2% ............................. 263
LIDORX
GEL 3% ......................................... 287
LIDOTHOL
PAD 4.5-5%................................ 295
LIDOTRAL
CRE 3.88% ................................. 287
LIDOVEX
CRE 3.75%................................... 287
LIDOVIN
CRE 3.95%.................................... 287
LIDOVIR
OIN 4-4% ...................................... 271
LIDOZOL
CRE 3.75% ................................... 287
LINCOCIN INJ 300MG/ML ............................. 54
488
lindane sha 1% ............................................... 291
linezolid inj 2mg/ml ............................................ 55
linezolid sus 100/5ml .......................................... 55
linezolid tab 600mg ............................................ 55
LINZESS
CAP 145MCG ............................... 332
LINZESS
CAP 290MCG ............................... 332
LIORESAL INT INJ 0.05MG/1 .......................... 372
LIORESAL INT INJ 10MG/20 ........................... 372
LIORESAL INT INJ 10MG/5ML ....................... 372
LIORESAL INT INJ 40MG/20 ........................... 372
liothyronine inj 10mcg/ml.................................... 421
liothyronine tab 25mcg ........................................ 421
liothyronine tab 50mcg ........................................ 421
liothyronine tab 5mcg .......................................... 421
LIPITOR
TAB 10MG..................................... 126
LIPITOR
TAB 20MG..................................... 126
LIPITOR
TAB 40MG..................................... 126
LIPITOR
TAB 80MG..................................... 126
lipodox inj 2mg/ml .......................................... 159
lipodox 50 inj 2mg/ml ........................................ 159
LIPOFEN
CAP 150MG.................................. 124
LIPOFEN
CAP 50MG.................................... 124
LIPOSYN II INJ 10%........................................ 380
LIPOSYN II INJ 20%........................................ 380
LIPOSYN III INJ 10% ....................................... 380
LIPOSYN III INJ 20% ....................................... 381
liposyn iii inj 30%............................................... 381
LIPTRUZET TAB 10-10MG ........................... 128
LIPTRUZET TAB 10-20MG ........................... 128
LIPTRUZET TAB 10-40MG ........................... 128
LIPTRUZET TAB 10-80MG ........................... 128
LIQUICET SOL 10-500MG.............................. 26
lisinop/hctz tab 10-12.5 ....................................... 131
lisinop/hctz tab 20-12.5 ....................................... 131
lisinop/hctz tab 20-25mg ..................................... 131
lisinopril tab 10mg............................................. 133
lisinopril tab 2.5mg............................................ 133
lisinopril tab 5mg............................................... 133
lissamine gr tes 1.5mg ......................................... 388
lithium sol 8meq/5ml....................................... 176
lithium carb cap 150mg ....................................... 176
lithium carb tab 300mg........................................ 176
lithium carb tab 300mg er.................................... 176
lithium carb tab 450mg er.................................... 176
LITHOBID TAB 300MG CR .......................... 176
LITHOSTAT TAB 250MG .............................. 341
LIVALO
TAB 1MG ...................................... 126
LIVALO
TAB 2MG ...................................... 127
LIVALO
TAB 4MG ...................................... 127
livixil pak kit 2.5-2.5% ........................................ 295
LMD 10%/D5W INJ .............................................343
LMD 10%/NACL INJ 0.9% ................................ 343
LO LOESTRIN TAB .......................................... 229
LO MINASTRIN PAK FE .................................. 229
LO/OVRAL-28 TAB .......................................... 231
LOCOID
CRE 0.1% ...................................... 277
LOCOID
LOT 0.1% ...................................... 277
LOCOID
OIN 0.1% ....................................... 277
LOCOID
SOL 0.1%....................................... 277
LOCOID LIPO CRE 0.1%.................................. 277
LODOSYN
TAB 25MG ................................. 172
LOESTRIN
TAB 1/20-21................................ 231
LOESTRIN 21 TAB 1.5/30 ................................ 231
LOESTRIN 24 TAB FE...................................... 231
LOESTRIN FE TAB 1.5/30................................ 231
LOESTRIN FE TAB 1/20................................... 231
lofene
tab 2.5mg............................................. 111
LOFIBRA
CAP 134MG ................................. 125
LOFIBRA
CAP 200MG ................................. 125
LOFIBRA
CAP 67MG ................................... 125
LOFIBRA
TAB 160MG ................................. 125
LOFIBRA
TAB 54MG ................................... 125
lokara
lot 0.05%............................................. 277
lomedia 24 tab fe................................................ 231
LOMOTIL
TAB 2.5MG ................................. 111
lomustine cap 100mg ........................................ 169
lomustine cap 10mg .......................................... 169
lomustine cap 40mg .......................................... 169
lonox
tab 2.5mg............................................. 111
489
lopreeza tab 1-0.5mg ....................................... 325
LOPRESS HCT TAB 100-25MG....................... 143
LOPRESS HCT TAB 50-25MG......................... 143
LOPRESSOR INJ 5MG/5ML .......................... 205
LOPRESSOR TAB 100MG ............................. 205
LOPRESSOR TAB 50MG ............................... 205
LOPROX
GEL 0.77% ................................... 266
LOPROX
SHA 1% ........................................ 266
loratadine tab 10mg.......................................... 121
loratadine tab 5mg............................................ 121
loratadine syp .................................................... 121
lorazepam con 2mg/ml........................................ 61
lorazepam inj 2mg/ml ......................................... 61
lorazepam inj 4mg/ml ......................................... 61
lorazepam tab 0.5mg .......................................... 61
lorazepam tab 1mg ............................................. 61
lorazepam tab 2mg ............................................. 61
LORCET
TAB 10-650MG .............................. 26
lorcet
tab 5-325mg........................................... 26
lorcet hd tab 10-325mg....................................... 26
lorcet plus tab 7.5-325 .......................................... 26
LORCET PLUS TAB 7.5-650.............................. 26
lorenza pad 4-1%............................................ 295
lortab
elx 10-300mg......................................... 26
LORTAB
ELX 7.5-500 ................................... 26
lortab
tab 10-325mg ........................................ 26
LORTAB
TAB 10-500MG.............................. 26
lortab
tab 5-325mg .......................................... 26
LORTAB
TAB 5-500MG................................ 26
lortab
tab 7.5-325 ............................................ 26
LORTAB
TAB 7.5-500 ................................... 26
LORZONE
TAB 375MG ............................... 372
LORZONE
TAB 750MG ............................... 372
losartan pot tab 100mg........................................ 140
losartan pot tab 25mg.......................................... 140
losartan pot tab 50mg.......................................... 140
losartan/hct tab 100-12.5..................................... 138
losartan/hct tab 100-25........................................ 138
losartan/hct tab 50-12.5....................................... 138
LOSEASONIQUE TAB ...................................... 235
LOTEMAX
GEL 0.5%................................... 391
LOTEMAX
OIN 0.5% ................................... 391
LOTEMAX
SUS 0.5% ................................... 391
LOTENSIN TAB 10MG ................................. 133
LOTENSIN TAB 20MG ................................. 133
LOTENSIN TAB 40MG ................................. 133
LOTENSIN HCT TAB 10-12.5........................... 131
LOTENSIN HCT TAB 20-12.5........................... 131
LOTENSIN HCT TAB 20-25MG ....................... 131
LOTREL
CAP 10-20MG............................... 129
LOTREL
CAP 10-40MG............................... 129
LOTREL
CAP 2.5-10MG.............................. 129
LOTREL
CAP 5-10MG................................. 129
LOTREL
CAP 5-20MG................................. 129
LOTREL
CAP 5-40MG................................. 129
LOTRISONE CRE............................................ 265
LOTRISONE LOT............................................ 265
LOTRONEX TAB 0.5MG............................... 333
LOTRONEX TAB 1MG.................................. 333
LOUTREX
CRE ............................................. 270
lovastatin tab 10mg............................................ 127
LOVAZA
CAP 1GM..................................... 122
LOVENOX
INJ 100MG/ML............................ 76
LOVENOX
INJ 120/0.8 ................................... 76
LOVENOX
INJ 150MG/ML............................ 76
LOVENOX
INJ 30/0.3ML ............................... 76
LOVENOX
INJ 300/3ML ................................ 77
LOVENOX
INJ 40/0.4ML ............................... 77
LOVENOX
INJ 60/0.6ML ............................... 77
LOVENOX
INJ 80/0.8ML ............................... 77
low-ogestrel tab.................................................... 231
loxapine cap 10mg ........................................... 182
loxapine cap 25mg ........................................... 182
loxapine cap 50mg ........................................... 182
loxapine cap 5mg ............................................. 182
LOXITANE
CAP 10MG ................................. 182
LOXITANE
CAP 25MG ................................. 182
LOXITANE
CAP 50MG ................................. 182
LOXITANE
CAP 5MG ................................... 182
lp lite pak kit 2.5-2.5%........................................ 296
LT INJECTION KIT............................................ 243
LTA 360 KIT SOL 4% ....................................... 365
LUCENTIS SOL 0.3MG ................................. 393
LUCENTIS SOL 0.5MG ................................. 393
LUFYLLIN TAB 200MG.................................. 71
LUFYLLIN TAB 400MG.................................. 71
LUGOLS
SOL STRONG .............................. 188
LUMIGAN
SOL 0.01%.................................. 393
LUMIGAN
SOL 0.03%.................................. 393
LUMINAL
INJ 130MG/ML........................... 349
LUMIZYME
INJ 50MG.................................. 316
LUNESTA
TAB 1MG.................................... 352
LUNESTA
TAB 2MG .................................... 352
LUNESTA
TAB 3MG .................................... 352
LUPANETA
KIT 11.25-5 ............................... 320
LUPANETA
KIT 3.75-5 ................................. 320
490
MALARONE TAB 62.5-25............................. 146
malathion lot 0.5%............................................ 291
mannitol inj 10%.............................................. 311
mannitol inj 15%.............................................. 311
mannitol inj 20%.............................................. 311
mannitol inj 25%.............................................. 311
mannitol inj 5%................................................ 311
maprotiline tab 25mg............................................ 91
MARBETA-25 KIT ........................................... 244
MARBETA-L KIT............................................ 244
MARCAINE
INJ 0.25% .................................. 357
MARCAINE
INJ 0.5% .................................... 357
MARCAINE
INJ 0.75% .................................. 357
MARCAINE
INJ SPINAL............................... 357
MARCAINE/EPI INJ 0.25% ............................... 355
MARCAINE/EPI INJ 0.5% ................................. 355
MARDEX-25 KIT ............................................ 244
margesic cap.........................................................21
MARINOL
CAP 10MG.................................. 115
MARINOL
CAP 2.5MG................................. 115
MARINOL
CAP 5MG.................................... 115
MARLIDO
KIT .............................................. 356
MARLIDO-25 KIT ............................................ 356
marlissa tab 0.15/30 ........................................ 231
MARPLAN
TAB 10MG................................... 91
MARQIBO
INJ 5MG/31ML .......................... 167
marten-tab tab 50-325mg..................................... 21
MATULANE
CAP 50MG............................... 161
matzim la tab 180mg/24.................................... 213
matzim la tab 240mg/24.................................... 213
matzim la tab 300mg/24.................................... 213
matzim la tab 360mg/24.................................... 213
matzim la tab 420mg/24.................................... 213
MAVIK
TAB 1MG....................................... 133
MAVIK
TAB 2MG....................................... 133
MAVIK
TAB 4MG....................................... 134
MAXAIR AUTOH AER 200MCG ....................... 67
MAXALT
TAB 10MG .................................. 363
MAXALT
TAB 5MG .................................... 363
MAXALT-MLT TAB 10MG ............................ 363
MAXALT-MLT TAB 5MG .............................. 363
MAXIDEX
SUS 0.1% OP.............................. 391
MAXIDONE TAB 10-750MG .......................... 26
MAXIFED CD TAB.......................................... 247
MAXIFED CDX TAB ........................................ 247
MAXIFED-G TAB CDX.................................. 247
MAXIFED-G CD TAB........................................ 247
LUPR DEP-PED INJ 11.25MG........................... 320
LUPR DEP-PED INJ 15MG................................ 320
LUPR DEP-PED INJ 30MG................................ 320
LUPR DEP-PED INJ 7.5MG............................... 320
LUPRON DEPOT INJ 11.25MG ........................ 165
LUPRON DEPOT INJ 22.5MG .......................... 165
LUPRON DEPOT INJ 3.75MG .......................... 165
LUPRON DEPOT INJ 30MG ............................. 165
LUPRON DEPOT INJ 45MG ............................. 165
LUPRON DEPOT INJ 7.5MG ............................ 165
LUSEDRA
INJ ................................................. 336
lutera
tab........................................................ 231
LUVOX CR CAP 100MG................................. 93
LUVOX CR CAP 150MG................................. 93
luxamend cre.................................................... 305
LUXIQ
AER 0.12%...................................... 277
LUZU
CRE 1% ........................................... 284
LYBREL
TAB 90-20MCG ........................... 234
LYCELLE
GEL.............................................. 290
LYNPARZA
CAP 50MG................................ 160
LYRICA
CAP 100MG .................................... 83
LYRICA
CAP 150MG .................................... 83
LYRICA
CAP 200MG .................................... 83
LYRICA
CAP 225MG .................................... 83
LYRICA
CAP 25MG ...................................... 83
LYRICA
CAP 300MG .................................... 83
LYRICA
CAP 50MG ...................................... 83
LYRICA
CAP 75MG ...................................... 83
LYRICA
SOL 20MG/ML ............................... 83
LYSODREN
TAB 500MG.............................. 150
LYSTEDA
TAB 650MG................................ 348
LYTENSOPRIL MIS -90 KIT............................ 130
LYTENSOPRIL PAK -90 .................................. 130
LYTENSOPRIL PAK KIT ................................. 130
lyza
tab 0.35mg............................................ 236
M
MAC PATCH PAD .0375-5% ......................... 296
MACROBID
CAP 100MG ............................. 432
MACRODANTIN CAP 100MG ........................ 432
MACRODANTIN CAP 25MG .......................... 432
MACRODANTIN CAP 50MG .......................... 432
MACUGEN
INJ................................................ 393
mafenide ace pak 5% ........................................... 271
MAGN SULFATE GRA ..................................... 355
MAGNACET TAB 10-400MG......................... 41
MAGNACET TAB 5-400MG........................... 41
MAGNACET TAB 7.5-400 .............................. 41
MAKENA
INJ 250MG/ML .......................... 405
MALARONE TAB 250-100 ........................... 146
491
MAXIFLU CD TAB.......................................... 245
MAXIFLU CDX TAB........................................ 245
MAXIPHEN CD TAB........................................ 247
MAXIPHEN CDX TAB...................................... 247
MAXIPIME
INJ 1GM ..................................... 228
MAXIPIME
INJ 2GM ..................................... 228
MAXITROL
OIN 0.1% OP............................. 390
MAXITROL
SUS 0.1% OP ............................ 390
MAXZIDE
TAB 75-50................................... 309
MAXZIDE-25 TAB........................................... 309
MB HYDROGEL KIT ....................................... 289
MEBARAL TAB 100MG .............................. 349
MEBARAL TAB 32MG ................................ 349
MEBARAL TAB 50MG ................................ 349
meclizine tab 25mg ........................................... 115
meclofen sod cap 100mg........................................ 17
meclofen sod cap 50mg.......................................... 17
MEDI-DERM CRE -RX................................... 286
MEDI-DERM/L- CRE RX .................................. 296
MEDIHONEY PAD 2 ...................................... 305
MEDIHONEY PAD 3/4................................... 305
MEDIHONEY PAD 4 ...................................... 305
MEDI-PATCH PAD RX ................................... 296
MEDROL
PAK 4MG .................................... 239
MEDROL
TAB 16MG .................................. 239
MEDROL
TAB 2MG .................................... 239
MEDROL
TAB 32MG .................................. 240
MEDROL
TAB 4MG .................................... 240
MEDROL
TAB 8MG .................................... 240
MEDROX-RX OIN .......................................... 286
medroxypr ac inj 150mg/ml ................................. 235
medroxypr ac tab 10mg ....................................... 405
medroxypr ac tab 2.5mg ...................................... 405
medroxypr ac tab 5mg ......................................... 405
MEDROXYPROG INJ LIDOCAIN................... 405
mefenam acid cap 250mg ...................................... 17
mefloquine tab 250mg........................................ 146
MEFOXIN
INJ 1GM/50ML........................... 225
MEFOXIN
INJ 2GM/50ML........................... 225
MEGACE ES SUS 625/5ML ........................... 405
MEGACE ORAL SUS 40MG/ML..................... 169
megestrol sus 625mg/5m................................... 405
megestrol ac sus 400mg/10.................................. 169
megestrol ac sus 40mg/ml.................................... 169
megestrol ac tab 20mg......................................... 169
megestrol ac tab 40mg......................................... 169
MEGRIX
MIS ............................................... 296
MEKINIST
TAB 0.5MG................................. 154
MEKINIST
TAB 2MG.................................... 154
MELOXICAM KIT COMFORT ........................ 17
meloxicam sus 7.5/5ml ........................................ 17
meloxicam tab 15mg ........................................... 17
meloxicam tab 7.5mg .......................................... 17
melphalan inj 50mg........................................... 168
memant titra pak 5-10mg ..................................... 410
memantine tab hcl 10mg ................................... 410
memantine tab hcl 5mg ..................................... 410
memantine hc sol 2mg/ml..................................... 410
MEMBRANEBLUE SOL 0.15% ........................ 393
MENEST
TAB 0.3MG .................................. 328
MENEST
TAB 0.625MG .............................. 328
MENEST
TAB 1.25MG ................................ 328
MENEST
TAB 2.5MG .................................. 328
MENOSTAR
DIS 14MCG .............................. 328
MENTAX
CRE 1% ....................................... 266
MENTHOCIN PAD LIDOCAIN ..................... 296
MENTHOLIX SPR 4-1% ................................. 296
MEPER/PROMET CAP 50-25MG ....................... 28
meperidine inj 100mg/ml ..................................... 34
meperidine inj 10mg/ml ....................................... 34
meperidine sol 50mg/5ml ..................................... 34
meperidine tab 100mg.......................................... 34
meperidine tab 50mg............................................ 34
meperitab tab 100mg .......................................... 34
meperitab tab 50mg ............................................ 34
MEPIVACAINE INJ 3% .................................... 357
meprobamate tab 200mg....................................... 59
meprobamate tab 400mg....................................... 59
MEPRON
SUS................................................. 52
mercaptopur tab 50mg ........................................ 152
MEROP/NACL INJ 1GM/50ML......................... 52
MEROP/NACL INJ 500/50ML........................... 53
meropenem inj 1gm............................................. 53
meropenem inj 500mg......................................... 53
MERREM
INJ 1GM ........................................ 53
MERREM
INJ 500MG .................................... 53
mesalamine ene 4gm .......................................... 333
mesalamine kit 4gm............................................ 333
mesna
inj 1gm ............................................... 170
MESNEX
INJ 1GM ....................................... 170
MESNEX
TAB 400MG................................. 170
MESTINON SYP 60MG/5ML ....................... 147
MESTINON TAB 60MG ............................... 147
MESTINON TAB TIMESPAN ...................... 147
metadate tab 20mg er........................................... 7
METADATE CD CAP 10MG................................ 7
492
METAGLIP
TAB 2.5-250M ........................... 107
metaproteren syp 10mg/5ml................................... 67
metaproteren tab 10mg.......................................... 67
metaproteren tab 20mg.......................................... 67
METASTRON INJ ............................................. 160
METAXALONE TAB 400MG ......................... 372
metaxalone tab 800mg ....................................... 372
metformin tab 1000mg...................................... 101
metformin tab 500mg........................................ 101
metformin tab 500mg er.................................... 101
metformin tab 750mg er ................................... 101
metformin tab 850mg........................................ 102
methadone..............................................con 10mg/ml
...............................................................................
34
METHADONE
.................................. INJ 10MG/ML
methadone 34 sol 10mg/5ml ............................ 34
methadone sol 5mg/5ml ...................................... 34
methadone tab 10mg........................................... 34
methadone tab 40mg........................................... 34
methadone tab 5mg............................................. 34
methadose con 10mg/ml ..................................... 34
methadose tab 10mg ........................................... 34
methadose tab 40mg ........................................... 34
methadose tab 5mg ............................................. 34
methadose sf con 10mg/ml..................................... 35
methamphetam tab 5mg ........................................... 5
methazolamid tab 25mg ....................................... 309
methazolamid tab 50mg ....................................... 309
methenam hip tab 1gm......................................... 432
methenam man tab 1000mg ................................. 432
methenam man tab 1gm ....................................... 432
METHENAM MAN TAB 500MG...................... 432
METHERGINE INJ 0.2MG/ML ....................... 396
METHERGINE TAB 0.2MG ............................ 396
methimazole tab 10mg ........................................ 418
methimazole tab 5mg .......................................... 418
METHITEST............................................. TAB 10MG
...............................................................................
methlphenida
chw 2.5mg .........................................457
methocarbam inj
................................ 372
tab100mg/ml
500mg ....................................
methocarbam tab 750mg .................................... 372
METHOHEXITAL INJ 100/10ML ..................... 337
methotrexate inj 100/4ml ..................................... 152
methotrexate inj 1gm ........................................... 152
493
methotrexate inj 1gm/40ml................................... 152
methotrexate inj 200/8ml...................................... 152
methotrexate inj 250/10ml ................................... 152
methotrexate inj 25mg/ml..................................... 152
methotrexate inj 50mg/2ml................................... 152
methotrexate tab 2.5mg........................................ 152
methoxsalen cap 10mg ........................................ 269
METHOXSALEN CRY USP/NF....................... 290
methscopolam tab 2.5mg...................................... 431
methscopolam tab 5mg......................................... 431
methyclothia tab 5mg ........................................... 312
METHYL SALIC LIQ...........................................286
METHYL SALIC OIL NATURAL..................... 286
methyld/hctz tab 250/15 ....................................... 135
methyld/hctz tab 250/25 ....................................... 135
methyldopa tab 250mg ....................................... 141
methyldopa tab 500mg ....................................... 141
methyldopate inj 250/5ml..................................... 141
methylene bl inj 1%.............................................. 112
methylergon inj 0.2mg/ml ................................... 396
methylergon tab 0.2mg........................................ 396
methylin chw 10mg .............................................. 7
methylin chw 2.5mg ............................................. 7
methylin chw 5mg ................................................ 8
METHYLIN
SOL 10MG/5ML............................ 8
METHYLIN
SOL 5MG/5ML.............................. 8
METHYLP/LIDO INJ 40-10/ML ........................ 244
METHYLP/LIDO INJ 80-10/ML ........................ 244
methylphenid cap 10mg............................................ 8
methylphenid cap 20mg er ....................................... 8
methylphenid chw 10mg........................................... 8
methylphenid chw 5mg............................................. 8
methylphenid sol 10mg/5ml...................................... 8
methylphenid sol 5mg/5ml ....................................... 8
methylphenid tab 10mg ............................................ 8
methylphenid tab 10mg er........................................ 8
METHYLPHENID TAB 18MG ER........................ 8
methylphenid tab 20mg ............................................ 8
methylphenid tab 20mg er........................................ 8
methylphenid tab 20mg sr ........................................ 8
methylphenid tab 5mg.............................................. 9
methylpr ace inj 40mg/ml .................................... 240
methylpr ace inj 80mg/ml .................................... 240
methylpr ss inj 1000mg....................................... 240
methylpr ss inj 125mg......................................... 240
methylpr ss inj 1gm............................................. 240
methylpr ss inj 40mg........................................... 240
methylpr ss inj 500mg......................................... 240
METHYLPRD PF INJ 160/2ML......................... 240
METHYLPRD PF INJ 40MG/ML ...................... 240
METHYLPRD PF INJ 80MG/ML ...................... 240
methylpred pak 4mg........................................... 240
methylpred tab 16mg ......................................... 240
methylpred tab 32mg ......................................... 240
methylpred tab 4mg ........................................... 240
methylpred tab 8mg ........................................... 240
METHYLPREDNI INJ 100MG/ML ................... 240
methyltestos cap 10mg ........................................... 45
metipranolol sol 0.3% oph................................... 382
metoclopram inj 10mg/2ml ................................. 332
metoclopram inj 5mg/ml ..................................... 332
metoclopram sol 10/10ml.................................... 332
metoclopram sol 5mg/5ml................................... 332
metoclopram tab 10mg ....................................... 332
metoclopram tab 5mg ......................................... 332
metoclopram tab 5mg odt ................................... 332
METOCLOPRAMI TAB 10MG ......................... 332
metolazone tab 10mg ......................................... 312
metolazone tab 2.5mg ........................................ 313
metolazone tab 5mg ........................................... 313
metoprl/hctz tab 100-25mg .................................. 143
metoprl/hctz tab 100-50mg .................................. 143
metoprl/hctz tab 50-25mg .................................... 143
metoprol tar tab 100mg ....................................... 205
metoprol tar tab 25mg ......................................... 205
metoprol tar tab 50mg ......................................... 205
metoprolol inj 1mg/ml........................................ 205
metoprolol inj 5mg/5ml...................................... 205
metoprolol tab 100mg er.................................... 205
metoprolol tab 200mg er.................................... 205
metoprolol tab 25mg er...................................... 205
metoprolol tab 50mg er...................................... 206
METOZOLV ODT TAB 10MG.......................... 332
METOZOLV ODT TAB 5MG............................ 332
METRO IV INJ 5MG/ML................................. 50
METROCREAM CRE 0.75% ........................... 291
METROGEL GEL 1% .................................... 291
METROGEL-VAG GEL 0.75%.......................... 437
METROLOTION LOT 0.75%............................ 291
metron/nacl inj 500mg .......................................... 50
metronidazol cap 375mg ........................................ 50
metronidazol cre 0.75% ....................................... 291
metronidazol gel 0.75% ....................................... 291
metronidazol gel 0.75%vag.................................. 437
metronidazol gel 1% ............................................ 291
metronidazol lot 0.75% ........................................ 291
metronidazol tab 250mg......................................... 50
metronidazol tab 500mg......................................... 50
METVIXIA CRE 16.8% ................................. 290
MEVACOR
TAB 20MG ................................ 127
MEVACOR
TAB 40MG ................................ 127
mexar wash liq 10%........................................... 270
mexiletine cap 150mg........................................... 63
MIACALCIN INJ 200/ML ............................... 315
MIACALCIN SPR 200/ACT............................ 315
MICARDIS TAB 20MG ................................. 140
MICARDIS TAB 40MG ................................. 140
MICARDIS TAB 80MG ................................. 140
MICARDIS HCT TAB 40/12.5 ........................... 138
MICARDIS HCT TAB 80/12.5 ........................... 138
MICARDIS HCT TAB 80-25MG ....................... 138
miconazole 3 sup 200mg ...................................... 436
micrgstin 24 tab fe 1/20 ....................................... 231
MICRHOGAM PL INJ 50MCG.......................... 399
MICROCYN
GEL ........................................... 300
MICROCYN
GEL SKIN/WOU ...................... 300
MICROCYN
LIQ...............................................301
microgestin tab 1.5/30......................................... 231
microgestin tab 1/20............................................ 231
microgestin tab fe 1/20........................................ 232
microgestin tab fe1.5/30...................................... 232
MICROZIDE CAP 12.5MG ............................. 313
MIDAMOR
TAB 5MG .................................. 312
midazolam inj 10/10ml...................................... 350
midazolam inj 10mg/2ml................................... 350
midazolam inj 25mg/5ml................................... 350
midazolam inj 2mg/2ml..................................... 350
midazolam inj 50mg/10..................................... 350
midazolam inj 5mg/5ml..................................... 350
midazolam inj 5mg/ml....................................... 350
midazolam syp 2mg/ml...................................... 350
midodrine tab 10mg .......................................... 439
midodrine tab 2.5mg ......................................... 439
midodrine tab 5mg ............................................ 439
migergot sup 2/100 .......................................... 362
494
migragesic cap ida............................................. 362
MIGRAL
TAB 130MG ................................. 362
MIGRALAM CAP .......................................... 362
MIGRANAL SPR 4MG/ML ........................... 362
migryl
mis 0.0375-5 ....................................... 296
MILLIPRED SOL 10MG/5ML........................ 240
MILLIPRED TAB 5MG................................... 240
MILLIPRED DP PAK 5MG ............................... 240
milrinone inj 10/10ml ...................................... 217
milrinone inj 1mg/ml ....................................... 217
milrinone inj 20/20ml ...................................... 217
milrinone inj 50/50ml ...................................... 217
milrinone/d5 inj 20/100ml.................................... 217
milrinone/d5 inj 40/200ml.................................... 217
mimvey
tab 1-0.5mg....................................... 325
mimvey lo tab 0.5-0.1........................................ 325
MIMYX
CRE ............................................... 289
MINASTRIN 24 CHW FE .................................. 232
MINERAL
OIL HEAVY ............................... 354
MINIPRESS CAP 1MG ................................... 142
MINIPRESS CAP 2MG ................................... 142
MINIPRESS CAP 5MG ................................... 142
minitran dis 0.1mg/hr ....................................... 56
MINIVELLE DIS 0.025 MG............................ 328
MINIVELLE DIS 0.0375MG........................... 328
MINIVELLE DIS 0.05MG............................... 328
MINIVELLE DIS 0.075MG............................. 328
MINIVELLE DIS 0.1MG................................. 328
MINOCIN
CAP 100MG................................. 416
MINOCIN
CAP 50MG................................... 416
MINOCIN
CAP 75MG................................... 416
MINOCIN
INJ 100MG................................... 416
MINOCIN
KIT 100MG.................................. 416
MINOCIN
KIT 50MG.................................... 416
minocycline cap 100mg ...................................... 416
minocycline cap 50mg ........................................ 417
minocycline cap 75mg ........................................ 417
minocycline tab 100mg ....................................... 417
minocycline tab 135mg er................................... 417
minocycline tab 45mg er..................................... 417
minocycline tab 50mg ......................................... 417
minocycline tab 75mg ......................................... 417
minocycline tab 90mg er..................................... 417
minoxidil tab 10mg ........................................... 145
minoxidil tab 2.5mg .......................................... 145
MIOCHOL-E SOL 1
100.................................................................... 383
MIOSTAT
INJ 0.01% OP............................... 383
MIRAPEX
TAB 0.125MG ............................. 173
MIRAPEX
TAB 0.25MG ............................... 173
MIRAPEX
TAB 0.5MG ................................. 174
MIRAPEX
TAB 0.75MG ............................... 174
MIRAPEX
TAB 1.5MG ................................. 174
MIRAPEX
TAB 1MG .................................... 174
MIRAPEX ER TAB 0.375MG .......................... 174
MIRAPEX ER TAB 0.75MG ............................ 174
MIRAPEX ER TAB 1.5MG .............................. 174
MIRAPEX ER TAB 2.25MG ............................ 174
MIRAPEX ER TAB 3.75MG ............................ 174
MIRAPEX ER TAB 3MG ................................. 174
MIRAPEX ER TAB 4.5MG .............................. 174
MIRCERA
INJ..................................................345
MIRCETTE
TAB 28 DAY .............................. 229
mirtazapine tab 15mg ........................................... 89
mirtazapine tab 15mg odt ..................................... 89
mirtazapine tab 7.5mg .......................................... 89
MIRVASO
GEL 0.33% .................................. 291
misoprostol tab 100mcg ...................................... 432
misoprostol tab 200mcg ...................................... 432
MITIGARE CAP 0.6MG................................. 341
mitomycin inj 20mg........................................... 159
mitomycin inj 40mg........................................... 159
mitomycin inj 5mg............................................. 159
MITOSOL
KIT 0.2MG................................... 385
mitoxantron inj 2mg/ml....................................... 159
MLK F1
KIT.................................................. 244
MLK F2
KIT.................................................. 244
MLK F3
KIT.................................................. 244
MLK F4
KIT.................................................. 244
MOBIC
SUS 7.5/5ML .................................... 17
MOBIC
TAB 15MG ....................................... 17
MOBIC
TAB 7.5MG ...................................... 17
modafinil tab 100mg ............................................. 9
modafinil tab 200mg ............................................. 9
moderiba pak 1000/day.................................... 195
moderiba pak 1200/day.................................... 195
moderiba pak 600/day...................................... 195
moderiba pak 800/day...................................... 195
moderiba tab 200mg ........................................ 195
MODICON
TAB 0.5/35 ................................. 232
moexipr/hctz tab 15-12.5...................................... 131
495
moexipr/hctz tab 15-25mg ................................... 131
moexipr/hctz tab 7.5-12.5 .................................... 131
moexipril tab 15mg ........................................... 134
moexipril tab 7.5mg .......................................... 134
MOLINDONE TAB HCL 10MG..................... 182
MOLINDONE TAB HCL 25MG..................... 182
MOLINDONE TAB HCL 5MG....................... 182
mometasone cre 0.1% ........................................ 277
mometasone oin 0.1% ........................................ 277
mometasone sol 0.1% ........................................ 278
mondoxyne nl cap 100mg .................................... 417
mondoxyne nl cap 50mg ...................................... 417
mondoxyne nl cap 75mg ...................................... 417
MONOCHLOROAC CRY ACID ....................... 272
MONODOX
CAP 100MG ............................. 417
MONODOX
CAP 50MG ............................... 417
MONODOX
CAP 75MG ............................... 417
MONOKET
TAB 10MG.................................. 56
MONOKET
TAB 20MG.................................. 56
mono-linyah tab 0.25-35..................................... 232
mononessa tab .................................................. 232
MONOVISC INJ 88MG/4ML......................... 374
montelukast chw 4mg............................................ 68
montelukast gra 4mg............................................. 68
montelukast tab 10mg ........................................... 69
MONUROL PAK GRANULES..................... 432
morgidox cap 1x100mg.................................... 417
morgidox cap 2x100mg.................................... 417
MORGIDOX KIT 1X100MG ......................... 417
MORGIDOX KIT 2X100MG ......................... 417
morphine sul cap 100mg er ................................... 35
morphine sul cap 10mg er ..................................... 35
MORPHINE SUL CAP 120MG ER...................... 35
MORPHINE SUL CAP 45MG ER........................ 35
morphine sul inj 0.5mg/ml ..................................... 35
MORPHINE SUL INJ 10/0.7ML .......................... 35
morphine sul inj 10mg/ml ...................................... 35
MORPHINE SUL INJ 150/30ML ......................... 35
morphine sul inj 1mg/ml ........................................ 35
MORPHINE SUL INJ SOD CL ...........................36
morphine sul sol 100/5ml....................................... 36
morphine sul sol 10mg/5ml.................................... 36
morphine sul sol 20mg/5ml.................................... 36
morphine sul sol 20mg/ml...................................... 36
MORPHINE SUL SUP 10MG .............................. 36
MORPHINE SUL SUP 20MG .............................. 36
morphine sul sup 30mg .......................................... 36
MORPHINE SUL SUP 5MG ................................ 36
morphine sul tab 100mg er .................................... 36
morphine sul tab 15mg........................................... 36
morphine sul tab 15mg er ...................................... 36
morphine sul tab 200mg er .................................... 36
morphine sul tab 30mg........................................... 36
morphine/d5w inj 1mg/ml ...................................... 36
MOTOFEN
TAB 1-0.025 ............................... 111
MOVANTIK TAB 12.5MG ............................ 334
MOVANTIK TAB 25MG ............................... 334
MOVIPREP SOL............................................. 354
MOXATAG
TAB 775MG.............................. 401
MOXEZA
SOL 0.5%..................................... 386
MOXIFLOXACIN INJ ..........................................331
moxifloxacin tab 400mg ....................................... 331
MOZOBIL
INJ..................................................345
MS CONTIN TAB 100MG CR .......................... 36
MS CONTIN TAB 15MG CR ............................ 36
MS CONTIN TAB 200MG CR .......................... 36
MST 600 TAB .................................................. 23
mtest hs/est tab estrogen ...................................... 324
mtest/est tab estrogen........................................ 324
MULTAQ
TAB 400MG .................................. 64
MULTIKIT
........................ 244
mupirocin
cre
2%SPECIALT
.........................................
264
mupirocin oin 2% ............................................. 264
mupirocin ca cre 2% ............................................ 264
MURI-LUBE .......................................................... OIL
354
MUSE ...............................................SUP
1000MCG
.............................................................................. 219
496
NAFTIN
CRE 1%.......................................... 266
NAFTIN
CRE 2%.......................................... 266
NAFTIN
GEL 1%.......................................... 266
NAFTIN
GEL 2%.......................................... 266
NAGLAZYME INJ 1MG/ML.......................... 321
nalbuphine inj 10mg/ml ....................................... 43
nalbuphine inj 20mg/ml ....................................... 43
NALFON
CAP 200MG ................................... 17
NALFON
CAP 400MG ................................... 17
NALLPEN/DEX INJ 1GM/50ML...................... 404
NALLPEN/DEX INJ 2GM ................................. 404
NALLPEN/DEX INJ 2GM/100.......................... 404
naloxone inj 0.4mg/ml...................................... 113
naloxone inj 1mg/ml......................................... 113
naltrexone tab 50mg........................................... 113
NAMENDA
SOL 10MG/5ML ....................... 410
NAMENDA
TAB 10MG................................ 410
NAMENDA
TAB 5-10MG ............................ 410
NAMENDA
TAB 5MG.................................. 410
NAMENDA XR CAP 14MG ............................ 410
NAMENDA XR CAP 21MG ............................ 410
NAMENDA XR CAP 28MG ............................ 410
NAMENDA XR CAP 7MG .............................. 410
NAMENDA XR CAP TITRATIO..................... 410
NAMZARIC
CAP 14-10MG........................... 411
NAMZARIC
CAP 28-10MG........................... 411
naphazoline sol 0.1% op ..................................... 387
NAPRELAN
PAK ............................................. 17
NAPRELAN
TAB 375MG CR.......................... 17
NAPRELAN
TAB 500MG CR.......................... 17
NAPRELAN
TAB 750MG CR.......................... 17
NAPRO
CRE 15%........................................ 262
NAPRODERM CRE 15% ................................ 262
NAPROPAK PAK............................................. 14
NAPROPAK PAK COOL ................................. 14
NAPROPAX MIS ..............................................263
NAPROSYN SUS 125/5ML ............................. 17
NAPROSYN TAB 250MG................................ 17
NAPROSYN TAB 375MG................................ 17
NAPROSYN TAB 500MG................................ 17
NAPROXEN
CRE ........................................... 262
NAPROXEN
CRE 10%................................... 262
NAPROXEN
KIT COMFORT.......................... 18
naproxen sus 125/5ml ........................................ 18
naproxen tab 250mg .......................................... 18
naproxen tab 375mg .......................................... 18
naproxen tab 500mg .......................................... 18
naproxen dr tab 375mg ......................................... 18
naproxen dr tab 500mg ......................................... 18
MUSE
SUP 125MCG.................................. 220
MUSE
SUP 250MCG.................................. 220
MUSE
SUP 500MCG.................................. 220
MUSTARGEN INJ 10MG ............................... 168
my way
tab 1.5mg .......................................... 234
MYALEPT
INJ 11.3MG ................................ 320
MYAMBUTOL TAB 100MG.......................... 148
MYAMBUTOL TAB 400MG.......................... 148
MYCAMINE INJ 100MG............................... 116
MYCAMINE INJ 50MG................................. 116
MYCOBUTIN CAP 150MG............................ 148
mycophenolat cap 250mg .................................... 201
mycophenolat sus 200mg/ml ................................ 201
mycophenolat tab 500mg ..................................... 201
mycophenolic tab 180mg dr................................. 201
mycophenolic tab 360mg dr................................. 201
MYDFRIN
SOL 2.5% OP .............................. 387
mydral
sol 0.5% op ........................................ 383
mydral
sol 1% op ........................................... 383
MYDRIACYL SOL 1% OP ............................. 383
MYFORTIC
TAB 180MG .............................. 201
MYFORTIC
TAB 360MG .............................. 201
MYLERAN
TAB 2MG .................................. 149
MYOBLOC
INJ 10000/2 ............................... 377
MYOBLOC
INJ 2500/0.5 .............................. 377
MYOBLOC
INJ 5000/ML ............................. 377
MYOXIN
SUS OTIC .................................... 394
MYOZYME
INJ 50MG ................................. 316
MYRBETRIQ TAB 25MG .............................. 435
MYRBETRIQ TAB 50MG .............................. 435
MYSOLINE
TAB 250MG ................................ 83
MYSOLINE
TAB 50MG .................................. 83
MYTELASE
TAB 10MG................................ 147
myzilra
tab ...................................................... 237
N
NABI-HB
INJ ................................................... 399
nabumetone tab 500mg........................................ 17
nabumetone tab 750mg........................................ 17
nadolol
tab 20mg ............................................ 207
nadolol
tab 40mg ............................................ 207
nadolol
tab 80mg ............................................ 207
nadolol/bend tab 40-5mg..................................... 143
nadolol/bend tab 80-5mg..................................... 143
nafcillin inj 10gm.............................................. 404
nafcillin inj 1gm................................................ 404
nafcillin inj 2gm................................................ 404
NAFTIFINE CRE HCL 1%.............................. 266
497
naproxen sod tab 275mg........................................ 18
naproxen sod tab 375mg cr ................................... 18
naproxen sod tab 500mg cr ................................... 18
NAPROXENPAX MIS......................................... 263
naratriptan tab 1mg............................................ 363
naratriptan tab 2.5mg......................................... 364
NARCAN
SPR 0.4MG/ML........................... 113
NARDIL
TAB 15MG...................................... 91
NAROPIN
INJ 10MG/ML ............................. 357
NAROPIN
INJ 2MG/ML ............................... 357
NAROPIN
INJ 5MG/ML ............................... 357
NAROPIN
INJ 7.5MG/ML ............................ 357
NASACORT AQ AER 55MCG/AC .................. 375
NASCOBAL SPR 500MCG............................ 345
NASONEX
SPR 50MCG/AC ........................ 375
NATACYN
SUS 5% OP ................................ 386
NATAZIA
TAB.............................................. 235
nateglinide tab 120mg ........................................ 105
nateglinide tab 60mg .......................................... 105
NATESTO
GEL 5.5MG................................... 45
NATPARA
INJ 100MCG............................... 321
NATPARA
INJ 25MCG................................. 321
NATPARA
INJ 50MCG................................. 321
NATPARA
INJ 75MCG................................. 321
NATRECOR INJ 1.5MG ................................ 222
NATROBA
SUS 0.9% ................................... 292
NATURE THROI TAB 162.5MG....................... 421
NATURE-THROI TAB 113.75MG .................... 421
NATURE-THROI TAB 130MG ......................... 421
NATURE-THROI TAB 146.25MG .................... 421
nature-throi tab 16.25mg..................................... 421
NATURE-THROI TAB 32.5MG ........................ 421
NATURE-THROI TAB 48.75MG ...................... 422
NATURE-THROI TAB 65MG ........................... 422
NATURE-THROI TAB 81.25MG ...................... 422
NATURE-THROI TAB 97.5MG ........................ 422
NAVANE
CAP 2MG .................................... 187
NAVELBINE INJ 10MG/ML .......................... 167
NAVELBINE INJ 50MG/5ML ........................ 167
NAZIREX
CRE .............................................. 267
NEBUPENT
INH 300MG ................................. 50
nebusal
neb 3%............................................... 249
NEBUSAL
NEB 6%....................................... 249
necon
tab 0.5/35 ........................................... 232
necon
tab 1/35............................................... 232
NECON
TAB 1/50-28 .................................. 232
necon
tab 10/11-28........................................ 229
necon
tab 7/7/7.............................................. 237
nefazodone tab 100mg ......................................... 94
nefazodone tab 50mg ........................................... 95
NEMBUTAL
INJ 50MG/ML .......................... 349
NEMBUTAL SOD INJ 50MG/ML ..................... 349
neo/bac/poly oin op.............................................. 384
neo/poly gu sol 40/ml ir ...................................... 338
neo/poly/bac oin /hc 1%op................................... 390
neo/poly/dex oin 0.1% op..................................... 390
neo/poly/dex sus 0.1% op..................................... 390
neo/poly/gra sol op............................................... 384
neo/poly/hc sol 1% otic ....................................... 395
neo/poly/hc sus 1% otic....................................... 395
neo/poly/hc sus op............................................... 390
NEO-FRADIN SOL 125/5ML............................. 11
neofrin
sol 10% op .......................................... 387
neofrin
sol 2.5% op ......................................... 387
neomycin tab 500mg .......................................... 11
neo-polycin oin hc 1%op..................................... 390
neo-polycin oin op............................................... 384
NEOPROFEN SOL 10MG/ML.......................... 18
NEORAL
CAP 100MG ................................. 199
NEORAL
CAP 25MG ................................... 199
NEORAL
SOL 100MG/ML .......................... 199
NEOSALUS
AER............................................ 289
NEOSALUS
CRE............................................ 289
NEOSALUS
CRE 180 PACK ......................... 289
NEOSALUS
LOT............................................ 283
NEOSALUS CP CRE ......................................... 289
NEOSPORIN SOL OP ..................................... 384
NEOSPORIN GU SOL 40/ML IR ........................338
neostig meth inj 0.5mg/ml .................................... 147
neostig meth inj 1mg/ml ....................................... 147
NEOSTIGMINE INJ 1MG/1ML ........................ 147
NEOSTIGMINE INJ 5MG/10ML ...................... 147
NEOSTIGMINE INJ 5MG/5ML ........................ 147
NEO-SYNALAR CRE ....................................... 264
NEO-SYNALAR KIT......................................... 264
NEO-SYNEPHRI INJ 10MG/ML ....................... 439
NEOTIC
DRO ............................................... 394
NEOTUSS PLUS LIQ ...........................................249
NEOX 100 MIS 2CMX2CM ........................... 294
NEOX 100 MIS 4CMX4CM ........................... 294
498
NEOX 100 MIS 7CMX7CM........................... 294
NEOX CORD 1K MIS 1.5X1.5 .......................... 294
NEOX CORD 1K MIS 2.5X2.5 .......................... 294
NEOX CORD 1K MIS 4CMX3CM.................... 294
NEPHRAMINE INJ 5.4% ................................. 380
NEPTAZANE TAB 25MG .............................. 309
NEPTAZANE TAB 50MG .............................. 309
NESACAINE INJ 1%....................................... 359
NESACAINE INJ 2%....................................... 359
NESACAINE INJ -MPF 2% ............................ 359
NESACAINE INJ -MPF 3% ............................ 359
NESINA
TAB 12.5MG ................................. 102
NESINA
TAB 25MG .................................... 102
NESINA
TAB 6.25MG ................................. 102
neuac
gel 1.2-5% .......................................... 254
neuac
kit 1.2-5% ........................................... 254
NEULASTA
INJ 6MG/0.6M .......................... 346
NEULASTA
KIT 6MG/0.6M ......................... 346
NEUMEGA
INJ 5MG .................................... 347
NEUPOGEN INJ 300/0.5................................ 346
NEUPOGEN INJ 300MCG............................. 347
NEUPOGEN INJ 480/0.8................................ 347
NEUPOGEN INJ 480MCG............................. 347
NEUPRO
DIS 1MG/24HR............................ 174
NEUPRO
DIS 2MG/24HR............................ 174
NEUPRO
DIS 3MG/24HR............................ 174
NEUPRO
DIS 4MG/24HR............................ 174
NEUPRO
DIS 6MG/24HR............................ 174
NEUPRO
DIS 8MG/24HR............................ 174
NEURONTIN CAP 100MG............................... 83
NEURONTIN CAP 300MG............................... 83
NEURONTIN CAP 400MG............................... 83
NEURONTIN SOL 250/5ML ............................ 83
NEURONTIN TAB 600MG............................... 83
NEURONTIN TAB 800MG............................... 83
NEUTREXIN ............................................ INJ 25MG
................................................................................
53
NEUVAXIN PAD 0.0375-5 ........................... 296
NEVANAC
SUS 0.1% .................................. 389
NEVIRAPINE SUS 50MG/5ML....................... 191
nevirapine tab 100mg ........................................ 191
200mg ........................................
er .................................... 191
next choice tab 0.75mg........................................ 234
next choice tab 1.5mg.......................................... 234
NEXTERONE INJ ................................................ 65
niacin
tab 500mg er ....................................... 128
niacin er tab 1000mg ........................................ 128
niacin er tab 500mg .......................................... 128
niacin er tab 750mg .......................................... 129
NIACOR
TAB 500MG.................................. 129
NIASPAN
TAB 1000 ER ............................... 129
NIASPAN
TAB 500MG ER........................... 129
NIASPAN
TAB 750MG ER........................... 129
nicardipine cap 20mg ......................................... 213
nicardipine cap 30mg ......................................... 213
nicardipine inj 2.5mg/ml..................................... 213
nicardipine inj 25/10ml....................................... 213
NICAZELDOXY KIT 30 ................................... 414
NICAZELDOXY KIT 60 ................................... 414
NICOTINE
LOZ............................................ 412
nicotine gum......................................................... 412
NICOTINE PATCHES ........................................ 412
NICOTROL
INH ...............................................412
NICOTROL NS SPR 10MG/ML........................ 412
nifediac cc tab 30mg er ....................................... 213
nifedical xl tab 30mg............................................ 213
nifedical xl tab 60mg............................................ 213
nifedipine cap 10mg ........................................... 213
nifedipine cap 20mg ........................................... 213
nifedipine tab 30mg er ....................................... 214
NILANDRON TAB 150MG ............................ 150
NIMBEX
INJ 10MG/ML .............................. 377
NIMBEX
INJ 2MG/ML ................................ 377
nimodipine cap 30mg......................................... 214
NINLARO
CAP 2.3MG ................................. 155
NINLARO
CAP 3MG .................................... 155
NINLARO
CAP 4MG .................................... 155
NIPENT
INJ 10MG ....................................... 161
NIRAVAM
TAB 0.25MG ................................ 61
NIRAVAM
TAB 0.5MG .................................. 61
NIRAVAM
TAB 1MG ..................................... 61
NIRAVAM
TAB 2MG ..................................... 61
nisoldipine tab 17mg er ...................................... 214
nisoldipine tab 20mg........................................... 214
nisoldipine tab 25.5mg........................................ 214
nisoldipine tab 30mg........................................... 214
nisoldipine tab 34mg er ...................................... 214
NEXAVAR........................................... TAB 200MG
.............................................................................
155
NEXAVIR
INJ ................................................ 199
NEXICLON XR SUS 0.09/ML.......................... 141
NEXICLON XR TAB 0.17MG .......................... 141
499
nisoldipine tab 40mg .......................................... 214
nisoldipine tab 8.5mg er ..................................... 214
NITHIODOTE KIT ........................................... 111
NITRO-BID OIN 2% ......................................... 56
NITRO-DUR DIS 0.1MG/HR............................ 57
nitrofur mac cap 100mg....................................... 432
nitrofur mac cap 25mg......................................... 432
nitrofur mac cap 50mg......................................... 433
nitrofurantn cap 100mg ....................................... 433
nitrofurantn sus 25mg/5ml................................... 433
nitrogly/d5w inj...................................................... 57
nitrogly/d5w inj 100mg.......................................... 57
nitrogly/d5w inj 200mg.......................................... 57
NITROGLY/D5W INJ 25MG ............................... 57
nitrogly/d5w inj 50mg............................................ 57
NITROGLYCER AER 400MCG ......................... 57
nitroglycer cap 2.5mg er....................................... 57
nitroglycer cap 2.5mg sr....................................... 57
nitroglycer cap 6.5mg cr....................................... 57
nitroglycer cap 6.5mg er....................................... 57
nitroglycer cap 9mg cr.......................................... 57
nitroglycer cap 9mg er.......................................... 57
nitroglycer dis 0.1mg/hr ....................................... 57
nitroglycer inj 5mg/ml .......................................... 58
nitroglycrn spr 0.4mg ........................................... 58
nitroglycrn spr lingual .......................................... 58
NITROLINGUAL SPR PUMPSPRA ................... 58
NITROMIST AER 400MCG ............................. 58
NITRONAL
SOL 1MG/ML.............................. 58
nitropress inj 25mg/ml....................................... 145
NITROSTAT SUB 0.3MG................................. 58
NITROSTAT SUB 0.4MG................................. 58
NITROSTAT SUB 0.6MG................................. 58
nitro-time cap 2.5mg cr........................................ 57
nitro-time cap 6.5mg cr........................................ 57
nitro-time cap 9mg cr........................................... 57
NIVATOPIC CRE PLUS ................................. 289
nizatidine cap 150mg......................................... 429
nizatidine cap 300mg......................................... 429
nizatidine sol 15mg/ml....................................... 429
NIZORAL SHA 2% ....................................... 284
NOCLOT-50 SOL ACD-A................................. 75
nodolor
cap ..................................................... 362
nora-be
tab 0.35mg......................................... 236
NORCO
TAB 10-325MG............................... 26
NORCO
TAB 5-325MG................................. 26
NORCO
TAB 7.5-325 .................................... 26
NORDETTE-28 TAB ......................................... 232
NORDITROPIN INJ 10/1.5ML.......................... 317
NORDITROPIN INJ 15/1.5ML.......................... 317
NORDITROPIN INJ 30/3ML............................. 318
NORDITROPIN INJ 5/1.5ML............................ 318
norel sd syp ...................................................... 248
norepinephr inj 1mg/ml....................................... 439
noreth/ethin chw fe............................................... 232
noreth/ethin tab 0.5-2.5........................................ 325
noreth/ethin tab 1/20............................................ 232
noreth/ethin tab 1mg-5mcg .................................. 325
noreth/ethin tab fe 1/20 ........................................ 232
norethin ace tab 5mg............................................ 405
norethindron tab 0.35mg...................................... 236
NORFLEX
INJ 30MG/ML............................. 372
norgest/eth tab estrad.......................................... 232
norgest/ethi tab 0.25/35 ....................................... 232
norgest/ethi tab estradio ...................................... 237
NORINYL
TAB 1/35 ..................................... 232
NORINYL
TAB 1+50-28 ............................... 232
NORITATE
CRE 1% ...................................... 291
norlyroc tab 0.35mg......................................... 236
NOROXIN
TAB 400MG................................ 331
NORPACE
CAP 100MG.................................. 62
NORPACE
CAP 100MG CR ........................... 62
NORPACE
CAP 150MG.................................. 62
NORPACE
CAP 150MG CR ........................... 63
NORPRAMIN TAB 100MG .............................. 99
NORPRAMIN TAB 10MG ................................ 99
NORPRAMIN TAB 150MG .............................. 99
NORPRAMIN TAB 25MG ................................ 99
NORPRAMIN TAB 50MG ................................ 99
NORPRAMIN TAB 75MG ................................ 99
NOR-QD
TAB 0.35MG................................. 236
NORTHERA CAP 100MG.............................. 438
NORTHERA CAP 200MG.............................. 439
NORTHERA CAP 300MG.............................. 439
nortrel
tab 0.5/35 ............................................ 232
nortrel
tab 1/35 ............................................... 232
nortrel
tab 7/7/7 .............................................. 237
nortriptylin cap 10mg............................................. 99
500
NUMOISYN
LIQ...............................................366
NUMOISYN
LOZ ........................................... 366
NUOX
GEL 6-3%........................................ 259
NUTRIDOX KIT ............................................. 417
nutrilipid emu 20% ............................................ 381
NUTROPIN
INJ 10MG ................................... 318
NUTROPIN
INJ 5MG ..................................... 318
NUTROPIN AQ INJ 10MG/2ML ...................... 318
NUTROPIN AQ INJ 20MG/2ML ...................... 318
NUTROPIN AQ INJ NUSPIN 5......................... 318
NUVAIL
SOL 16% ....................................... 289
NUVARING MIS ............................................ 234
NUVESSA
GEL 1.3% .................................... 437
NUVIGIL
TAB 150MG ..................................... 9
NUVIGIL
TAB 200MG ..................................... 9
NUVIGIL
TAB 250MG ..................................... 9
NUVIGIL
TAB 50MG ....................................... 9
NUVYA
CRE ............................................... 263
nuzole
cre 2%................................................. 284
NUZON
GEL 2% ......................................... 299
NYMALIZE
SOL 60/20ML ............................ 214
nystat/triam cre .................................................... 265
nystat/triam oin .................................................... 265
nystatin cre 100000.......................................... 266
nystatin oin 100000.......................................... 266
nystatin pow 100000 ........................................ 266
NYSTATIN
POW 10BU ................................. 266
NYSTATIN
POW 150MU .............................. 266
NYSTATIN
POW 1BU ................................... 266
NYSTATIN
POW 2BU ................................... 266
NYSTATIN
POW 500MU .............................. 267
NYSTATIN
POW 50MU ................................ 267
NYSTATIN
POW 5BU ................................... 267
NYSTATIN
POW DOMESTIC ...................... 267
nystatin sus 100000.......................................... 366
nystatin tab 500000.......................................... 117
nystatin vag tab 100000 ....................................... 437
nystop
pow 100000 ........................................ 267
O
nortriptylin cap 75mg ............................................ 99
NORTRIPTYLIN SOL 10MG/5ML ..................... 99
nortuss-de dro.................................................... 247
nortuss-ex liq 200-20/5 ...................................... 246
NORVASC
TAB 10MG................................. 214
NORVASC
TAB 2.5MG................................ 214
NORVASC
TAB 5MG................................... 214
NORVIR
CAP 100MG................................. 190
NORVIR
SOL 80MG/ML............................. 190
NORVIR
TAB 100MG.................................. 190
NOVACORT GEL .......................................... 292
novagesic tab 30-500mg ..................................... 21
novamine inj 15% ............................................ 380
NOVOCAIN INJ 1%....................................... 359
NOVOCLAIR CRE .......................................... 263
NOVOLIN
INJ 70/30 ..................................... 104
NOVOLIN N INJ RELION.............................. 104
NOVOLIN N INJ U-100 .................................. 104
NOVOLIN R INJ RELION .............................. 104
NOVOLIN R INJ U-100 .................................. 104
NOVOLIN70/30 INJ RELION............................ 104
NOVOLOG
INJ 100/ML................................ 104
NOVOLOG
INJ FLEXPEN ........................... 104
NOVOLOG
INJ PENFILL............................. 104
NOVOLOG MIX INJ 70/30 ............................... 104
NOVOLOG MIX INJ FLEXPEN....................... 104
NOXAFIL INJ 300/16.7 ................................. 118
NOXAFIL SUS 40MG/ML............................ 118
NOXAFIL TAB 100MG ................................ 118
NP #2 DRUG CRE PREP KIT ........................... 263
np thyroid tab 30mg........................................... 422
np thyroid tab 60mg........................................... 422
np thyroid tab 90mg........................................... 422
NPLATE
INJ 250MCG ................................. 348
NPLATE
INJ 500MCG ................................. 348
NUCALA
INJ 100MG .................................. 414
NUCORT
LOT 2%........................................ 278
NUCYNTA
TAB 100MG ................................ 37
NUCYNTA
TAB 50MG .................................. 37
NUCYNTA
TAB 75MG .................................. 37
NUCYNTA ER TAB 100MG ............................. 37
NUCYNTA ER TAB 150MG ............................. 37
NUCYNTA ER TAB 200MG ............................. 37
NUCYNTA ER TAB 250MG ............................. 37
NUCYNTA ER TAB 50MG ............................... 37
NUEDEXTA CAP 20-10MG .......................... 411
nulev
tab 0.125mg......................................... 428
NULOJIX
INJ 250MG ................................... 203
NULYTELY
SOL FLAV PKS........................ 354
OASIS MATRIX MIS 3X7CM ........................... 306
OASIS ULTRA MIS 3X3.5CM.......................... 306
OASIS ULTRA MIS 5 X 7CM........................... 306
OASIS ULTRA MIS TRI MESH ....................... 306
OASIS WOUND MIS 3X3.5CM........................ 306
OASIS WOUND MIS 3X7CM........................... 306
OBREDON
SOL 2.5-200 ............................... 246
OCTAGAM
INJ 10/100ML ........................... 399
OCTAGAM
INJ 10GM .................................. 399
OCTAGAM
INJ 1GM .................................... 399
501
OCTAGAM
INJ 2.5GM ................................. 399
OCTAGAM
INJ 20/200ML ........................... 399
OCTAGAM
INJ 25GM.................................. 399
OCTAGAM
INJ 2GM/20ML......................... 399
OCTAGAM
INJ 5GM.................................... 399
OCTAGAM
INJ 5GM/50ML......................... 399
octreotide inj 1000mcg ...................................... 322
octreotide inj 100mcg ........................................ 322
octreotide inj 50mcg/ml ..................................... 322
ocucoat
sol 2% op........................................... 393
OCUDOX
KIT............................................... 417
OCUFEN
SOL 0.03% OP ............................. 389
OCUFLOX
DRO 0.3% OP ............................ 386
ODOMZO
CAP 200MG ............................... 153
OFEV
CAP 100MG..................................... 414
OFEV
CAP 150MG..................................... 414
OFIRMEV
INJ 10MG/ML ............................... 20
ofloxacin dro 0.3% op ...................................... 386
ofloxacin dro 0.3%otic...................................... 395
ofloxacin tab 200mg ......................................... 331
ofloxacin tab 300mg ......................................... 331
ofloxacin tab 400mg ......................................... 331
ogestrel tab ...................................................... 232
olanza/fluox cap 12-25mg.................................... 412
olanza/fluox cap 12-50mg.................................... 412
olanza/fluox cap 3-25mg...................................... 412
olanzapine inj 10mg........................................... 185
olanzapine tab 10mg.......................................... 185
olanzapine tab 10mg odt.................................... 186
olanzapine tab 2.5mg......................................... 186
olanzapine tab 5mg............................................ 186
olanzapine tab 5mg odt...................................... 186
olanzapine tab 7.5mg......................................... 186
OLEPTRO
TAB 24HR150............................... 95
OLEPTRO
TAB 24HR300............................... 95
olopatadine spr 0.6%.......................................... 375
OLUX
AER 0.05%...................................... 278
OLUX-E
AER 0.05% .................................... 278
OMECLAMOX- MIS PAK............................... 431
OMEGA-3/D-3 KIT WELLNESS...................... 123
omega-3-acid cap 1gm......................................... 123
omepra/bicar cap 40-1100................................... 430
omeprazole cap 10mg ........................................ 335
OMIDRIA
INJ 1-0.3%.................................... 392
OMNARIS
SPR .............................................. 376
OMNIPRED SUS 1% OP................................ 391
OMNITROPE INJ 10/1.5ML ........................... 318
OMNITROPE INJ 5.8MG ................................ 318
OMNITROPE INJ 5/1.5ML ............................. 318
OMONTYS
INJ 10MG/ML ........................... 346
OMONTYS
INJ 20MG/2ML ......................... 346
ONCASPAR INJ 750/ML ............................... 160
ondansetron inj 32/50ml ..................................... 114
ondansetron inj 40/20ml ..................................... 114
ondansetron inj 4mg/2ml .................................... 114
ONDANSETRON SOL 32MG/50M .................. 114
ondansetron sol 4mg/5ml .................................... 114
ondansetron tab 24mg......................................... 114
ondansetron tab 4mg........................................... 114
ondansetron tab 4mg odt..................................... 114
ondansetron tab 8mg........................................... 114
ondansetron tab 8mg odt..................................... 114
ONETOUCH GLUCOSE MONITOR ............ 361
ONETOUCH TEST STRIPS .......................... 307
ONEXTON
GEL 1.2-3.75 .............................. 254
ONFI
SUS 2.5MG/ML .................................. 79
ONFI
TAB 10MG.......................................... 79
ONFI
TAB 20MG.......................................... 79
ONFI
TAB 5MG............................................ 79
ONGLYZA
TAB 2.5MG................................ 102
ONGLYZA
TAB 5MG................................... 102
ONIVYDE
INJ 4.3MG/ML ............................ 170
ONMEL
TAB 200MG.................................. 118
ONSOLIS
MIS 1200MCG................................ 37
ONSOLIS
MIS 200MCG.................................. 37
ONSOLIS
MIS 400MCG.................................. 37
ONSOLIS
MIS 600MCG.................................. 37
ONSOLIS
MIS 800MCG.................................. 37
OPANA
INJ 1MG/ML ................................... 37
OPANA
TAB 10MG ...................................... 37
OPANA
TAB 5MG ........................................ 37
OPANA ER TAB 10MG ................................... 37
OPANA ER TAB 15MG ................................... 37
OPANA ER TAB 20MG ................................... 37
OPANA ER TAB 30MG ................................... 37
OPANA ER TAB 40MG ................................... 37
OPANA ER TAB 5MG ..................................... 37
OPANA ER TAB 7.5MG .................................. 37
502
opcicon
tab 1.5mg........................................... 234
OPDIVO
INJ 100MG/10............................... 154
OPDIVO
INJ 40MG/4ML............................. 154
opium
tin 1%................................................. 111
OPIUM TINCT TIN 2MG/5ML ........................ 111
OPSUMIT
TAB 10MG .................................. 221
OPTASE
GEL ............................................... 283
OPTIPRANOLOL SOL 0.3% OP ....................... 382
OPTIVAR
DRO 0.05% .................................. 385
ORACEA
CAP 40MG................................... 291
ORACIT
SOL ............................................... 338
oralone
pst 0.1%....................................... 370
ORAMORPH SR TAB 100MG ........................... 38
ORAMORPH SR TAB 15MG ............................. 38
ORAP........................................................ TAB 1MG
.............................................................................
411
ORAP........................................................
TAB 2MG
.............................................................................
411
ORAPRED
SOL 15MG/5ML.............................. 240
ORAPRED ODT TAB 10MG ............................ 241
ORAVIG................................................. TAB 50MG
.............................................................................
366
ORAXYL................................................
CAP 20MG
.............................................................................
ORBACTIV
SOL 400MG....................................417
50
ORBIVAN CAP ............................................... 21
ORBIVAN CF TAB 50-300MG.......................... 22
ORENCIA
INJ 125MG/ML............................. 19
ORENCIA............................................... INJ 250MG
...............................................................................
19
ORENITRAMTAB
0.125MG ............................. 220
ORENITRAMTAB 0.25MG ............................... 220
ORENITRAM TAB 1MG ................................ 220
ORENITRAM TAB 2.5MG ............................. 220
ORFADIN
CAP 10MG .............................. 318
ORFADIN
CAP 2MG ................................ 318
ORFADIN
CAP 5MG .................................... 318
ORKAMBI TAB 200-125 .............................. 413
orph/asa/caf tab ................................................... 373
orphen cpd tab ds............................................... 373
orphenadrine inj 30mg/ml ................................... 372
orphenadrine tab 100mg er ................................. 372
orsythia .................................................................
tab
ORTHO
EVRA DIS WEEK.............................. 233
ORTHO MICRON TAB 0.35MG ....................... 236
ORTHO-CYCLEN TAB 0.25/35......................... 232
ortho-est tab 0.625 ............................................ 328
ortho-est tab 1.25 .............................................. 328
ORTHO-NOVUM TAB 1/35 ............................. 233
ORTHO-NOVUM TAB 7/7/7 ............................ 237
ORTHOVISC INJ 15MG/ML .......................... 374
oscimin
sub 0.125mg....................................... 428
oscimin
tab 0.125mg ....................................... 428
oscimin sr tab 0.375mg ...................................... 428
oscion
pad 3%................................................ 259
oscion
pad 6%................................................ 259
oscion
pad 9%................................................ 259
oscion clnsr lot 3%............................................... 259
oscion clnsr lot 6%............................................... 259
oscion clnsr lot 9%............................................... 259
OSENI
TAB 12.5-15..................................... 103
OSENI
TAB 12.5-30..................................... 103
OSENI
TAB 12.5-45..................................... 103
OSENI
TAB 25-15MG ................................. 103
OSENI
TAB 25-30MG ................................. 104
OSENI
TAB 25-45MG ................................. 104
osmitrol inj 10%............................................... 311
osmitrol inj 15%............................................... 311
osmitrol inj 5%................................................. 311
osmitrol vfx inj 20% ............................................. 311
OSMOPREP TAB 1.5GM ............................... 354
OSPHENA TAB 60MG.................................. 321
OTEZLA
TAB 10/20/30.................................. 19
OTEZLA
TAB 30MG...................................... 19
otic care dro...................................................... 394
oticin
dro 1-0.1% ........................................... 394
OTICIN HC DRO ............................................. 394
oto-end 10 sol..................................................... 394
otomar
sol otic ............................................... 394
otomax-hc dro ................................................... 394
OTOZIN
DRO ............................................... 395
OTREXUP
INJ 10MG...................................... 12
OTREXUP
INJ 15MG...................................... 12
OTREXUP
INJ 20MG...................................... 12
OTREXUP
INJ 25MG...................................... 12
OTREXUP
INJ 7.5/0.4 ..................................... 12
OVACE PLUS AER 9.8%................................. 270
OVACE PLUS CRE 10% .................................. 270
OVACE PLUS GEL 10% WASH ..................... 270
OVACE PLUS LIQ 10% WASH ...................... 270
OVACE PLUS LOT 9.8% ................................. 270
OVACE PLUS SHA 10%.................................. 270
OVACE WASH LIQ 10% ................................. 270
OVCON 50 TAB 28 ........................................ 233
ORTHO TRI- TAB CYCLEN........................... 237
ORTHO TRI- TAB CYCLN LO ........................ 237
ORTHO-CEPT TAB 28..................................... 232
503
OXYCODONE TAB 10MG ER......................... 38
oxycodone tab 15mg ........................................... 38
oxycodone tab 20mg ........................................... 38
oxycodone tab 30mg ........................................... 38
oxycodone tab 5mg ............................................. 38
OXYCONTIN TAB 10MG CR .......................... 38
oxymorphone tab 10mg er..................................... 39
oxymorphone tab 5mg er....................................... 39
oxymorphone tab 7.5mg er.................................... 39
oxymorphone tab hcl 10mg ................................... 39
oxymorphone tab hcl 5mg ..................................... 39
oxytocin inj 10unt/ml........................................ 396
OXYTOCIN/LAC INJ 30/500ML....................... 396
OXYTROL
DIS 3.9MG/24 ............................ 435
OZURDEX
IMP 0.7MG ................................. 391
P
OVCON-35 TAB............................................. 233
ovide
lot 0.5% ............................................... 292
oxacillin inj 10gm ............................................. 404
oxacillin inj 1gm ............................................... 404
oxacillin inj 2gm ............................................... 404
oxaliplatin inj 100mg .......................................... 149
oxaliplatin inj 50/10ml........................................ 149
oxaliplatin inj 50mg ............................................ 149
OXANDRIN TAB 10MG.................................. 44
OXANDRIN TAB 2.5MG................................. 44
oxandrolone tab 10mg .......................................... 45
oxandrolone tab 2.5mg ......................................... 45
oxaprozin tab 600mg .......................................... 18
OXAYDO
TAB 5MG...................................... 38
OXAYDO
TAB 7.5MG................................... 38
oxazepam cap 10mg........................................... 61
oxazepam cap 15mg........................................... 61
oxazepam cap 30mg........................................... 61
oxcarbazepin sus 300mg/5m.................................. 84
oxcarbazepin tab 150mg........................................ 84
OXECTA
TAB 5MG....................................... 38
OXECTA
TAB 7.5MG.................................... 38
OXISTAT
CRE 1% ........................................ 284
OXISTAT
LOT 1% ........................................ 284
OXSORALEN-UL CAP 10MG .......................... 269
OXTELLAR XR TAB 150MG ............................ 84
oxybutynin syp 5mg/5ml..................................... 434
oxybutynin tab 10mg er...................................... 434
oxybutynin tab 15mg er...................................... 434
oxybutynin tab 5mg............................................ 435
oxybutynin tab 5mg er........................................ 435
oxycod/apap cap 5-500mg .................................... 41
oxycod/apap tab 10-325mg................................... 41
oxycod/apap tab 10-650mg................................... 41
oxycod/apap tab 2.5-325....................................... 42
oxycod/apap tab 5-325mg..................................... 42
oxycod/apap tab 7.5-325....................................... 42
oxycod/apap tab 7.5-500....................................... 42
oxycod/asa tab ..................................................... 42
oxycod/ibu tab 5-400mg....................................... 42
oxycodone cap 5mg............................................. 38
oxycodone con 100/5ml ...................................... 38
oxycodone con 20mg/ml ..................................... 38
oxycodone sol 5mg/5ml....................................... 38
oxycodone tab 10mg ........................................... 38
pacerone tab 100mg........................................... 65
pacerone tab 200mg........................................... 65
pacerone tab 400mg........................................... 65
paclitaxel inj 100mg........................................... 167
paclitaxel inj 150/25ml....................................... 167
paclitaxel inj 300/50ml....................................... 167
paclitaxel inj 30mg/5ml...................................... 167
PAIN EASE AER MD STRM.......................... 298
PAIN EASE AER MIST................................... 298
PAIN RELIEF PAD PATCH.............................. 296
palgic
sol 4mg/5ml......................................... 120
PALGIC
TAB 4MG....................................... 120
paliperidone tab er 1.5mg .................................... 178
paliperidone tab er 3mg ....................................... 178
PAMELOR
CAP 10MG ................................... 99
PAMELOR
CAP 25MG ................................... 99
PAMELOR
CAP 50MG ................................... 99
PAMELOR
CAP 75MG ................................... 99
504
pamidronate inj 30/10ml .................................... 314
pamidronate inj 30mg......................................... 314
pamidronate inj 6mg/ml...................................... 314
pamidronate inj 90/10ml .................................... 314
pamidronate inj 90mg......................................... 314
PAMINE
TAB 2.5MG .................................. 431
PAMINE FORTE TAB 5MG .............................. 431
PAMINE FQ KIT ............................................. 426
PANCREAZE CAP 10500UNT....................... 308
PANCREAZE CAP 4200UNIT........................ 308
PANCRELIPASE CAP 5000UNIT..................... 308
pancuronium inj 1mg/ml..................................... 377
pancuronium inj 2mg/ml..................................... 377
PANDEL
CRE 0.1% ..................................... 278
PANRETIN
GEL 0.1% ................................... 268
papaverine inj 30mg/ml ..................................... 219
papaverine sol 30mg/ml..................................... 219
PARACENTESIS KIT TRAY 8FR..................... 357
PARAFON FORT TAB 500MG ......................... 372
PARAGARD
IUD T380A ............................... 234
PARALDEHYDE LIQ ......................................... 351
PARA-TIME CAP 150MG ER ........................ 219
parcaine sol 0.5% op ....................................... 388
PARCOPA TAB 10-100MG .......................... 173
PARCOPA TAB 25-100MG .......................... 173
PARCOPA TAB 25-250MG .......................... 173
PAREMYD
SOL 1-0.25%.............................. 388
paricalcitol cap 1 mcg ......................................... 319
paricalcitol inj 2mcg/ml....................................... 320
paricalcitol inj 5mcg/ml....................................... 320
PARLODEL
CAP 5MG .................................. 171
PARLODEL
TAB 2.5MG ............................... 171
PARNATE
TAB 10MG ................................... 91
paroex
sol 0.12% ........................................... 366
paromomycin cap 250mg...................................... 11
paroxetin er tab 12.5mg......................................... 93
paroxetin er tab 37.5mg......................................... 93
paroxetine tab 10mg ............................................ 93
paroxetine tab 25mg er ........................................ 93
PASER
GRA 4GM....................................... 148
PATADAY
SOL 0.2% ................................... 385
PATANASE
SPR 0.6%................................... 375
PATANOL
SOL 0.1% OP .............................. 385
PAXIL
SUS 10MG/5ML................................ 93
PAXIL
TAB 10MG ........................................ 93
PAXIL
TAB 20MG ........................................ 93
PAXIL
TAB 30MG ........................................ 93
PAXIL
TAB 40MG ........................................ 93
PAXIL CR TAB 12.5MG .................................. 93
PAXIL CR TAB 25MG ..................................... 93
PAXIL CR TAB 37.5MG .................................. 93
PAZEO
DRO 0.7%....................................... 385
PCE
TAB 333MG EC................................. 361
PCE
TAB 500MG EC................................. 361
PCP 100 KIT .....................................................354
pe/guaifenes dro 1.5-20mg................................... 248
pedia iron dro 15mg/ml ..................................... 348
PEDIADERM AF KIT COMPLETE .................. 267
PEDIADERM HC KIT ........................................ 278
PEDIADERM TA KIT ........................................ 278
pediahist dm syp................................................... 245
PEDIAPALM EMU SPRAY............................ 289
PEDIAPRED SOL 6.7/5ML............................. 241
PEDIATEX TD LIQ .............................................247
PEDIATEX TDM SUS........................................ 250
PEDIATEX-JR SUS DM......................................250
PEDIPAK
PAK............................................... 265
PEDIPIROX-4 KIT NAIL .................................. 267
peg 3350 sol electrol ........................................ 354
peg-3350 sol electrol........................................ 354
peg-3350/kcl sol /sodium...................................... 354
PEGANONE TAB 250MG................................ 87
PEGASYS
INJ ..................................................195
PEGASYS
INJ 180MCG/M ........................... 195
PEGASYS
INJ PROCLICK ........................... 196
PEGASYS
KIT .................................................196
PEGINTRON KIT 120MCG ............................ 196
PEGINTRON KIT 150MCG ............................ 196
PEGINTRON KIT 50MCG .............................. 196
PEGINTRON KIT 80MCG .............................. 196
PEG-INTRON KIT 120 RP ............................... 195
PEG-INTRON KIT 120MCG............................ 195
PEG-INTRON KIT 150 RP ............................... 195
PEG-INTRON KIT 150MCG............................ 195
PEG-INTRON KIT 50MCG.............................. 195
PEG-INTRON KIT 50MCG RP ........................ 195
PEG-INTRON KIT 80MCG.............................. 195
PEG-INTRON KIT 80MCG RP ........................ 195
peg-prep kit ...................................................... 354
PEN G PROC INJ 600000................................. 401
pen g sod inj 5000000 ....................................... 401
505
penicill gk/ inj dex 1mu ........................................ 401
penicilln gk inj 20mu............................................ 401
penicilln gk inj 5mu.............................................. 401
penicilln vk sol 125/5ml ....................................... 401
penicilln vk sol 250/5ml ....................................... 402
penicilln vk tab 250mg......................................... 402
penicilln vk tab 500mg......................................... 402
PENLAC
SOL 8% ......................................... 267
PENNSAID
SOL 1.5%.................................... 262
PENNSAID
SOL 2%....................................... 262
penta/apap tab 25-650mg .................................... 44
PENTAM 300 INJ 300MG.................................. 50
PENTASA
CAP 250MG CR.......................... 333
PENTASA
CAP 500MG CR.......................... 334
pentaz/nalox tab 50-0.5mg..................................... 43
pentostatin inj 10mg............................................ 162
PENTOTHAL INJ 400MG............................... 337
pentoxifylli tab 400mg er ..................................... 342
PEPCID
SUS 40MG/5ML............................. 429
PEPCID
TAB 20MG ..................................... 429
PEPCID
TAB 40MG ..................................... 429
PERCOCET TAB 10-325MG ........................... 42
PERCOCET TAB 10-650MG ........................... 42
PERCOCET TAB 2.5-325................................. 42
PERCOCET TAB 5-325MG ............................. 42
PERCOCET TAB 7.5-325................................. 42
PERCOCET TAB 7.5-500................................. 42
PERCODAN TAB............................................. 42
PERFOROMIST NEB 20MCG............................ 67
PERIDEX
SOL 0.12% ................................... 366
perindopril tab 2mg ............................................ 134
periogard sol 0.12% ......................................... 366
PERIOSTAT TAB............................................ 417
PERJETA INJ 420/14ML............................... 154
PERMAVAN
PAD.......................................... 296
permethrin cre 5% ............................................. 292
perphen/amit tab 2-10mg..................................... 410
perphenazine tab 16mg........................................ 183
perphenazine tab 2mg.......................................... 183
PERSANTINE TAB 25MG............................... 343
PERTZYE
CAP .............................................. 308
PEXEVA
TAB 10MG ..................................... 94
PEXEVA
TAB 20MG ..................................... 94
PEXEVA
TAB 30MG ..................................... 94
PEXEVA
TAB 40MG ..................................... 94
PFIZERPEN-G INJ 20MU ................................. 402
pfizerpen-g inj 5mu ............................................. 402
PHARM CH TSX PAD 2-4-1% .......................... 296
phenadoz sup 12.5mg....................................... 121
phenadoz sup 25mg.......................................... 121
phenazo
tab 200mg ......................................... 340
phenazopyrid tab 100mg...................................... 341
phenazopyrid tab 200mg...................................... 341
phenelzine tab 15mg............................................. 91
PHENERGAN INJ 25MG/ML ......................... 121
PHENERGAN INJ 50MG/ML ......................... 121
phenergan sup 12.5mg ...................................... 121
phenergan sup 25mg ......................................... 121
phenergan sup 50mg ......................................... 121
PHENFLU CD TAB .......................................... 245
PHENFLU CDX TAB ........................................ 245
phenobarb elx 20mg/5ml................................... 349
phenobarb inj 130mg/ml ................................... 349
PHENOBARB INJ 65MG/ML ......................... 349
phenobarb sol 20mg/5ml................................... 349
phenobarb tab 100mg ....................................... 349
phenobarb tab 15mg ......................................... 349
phenobarb tab 16.2mg ...................................... 349
phenobarb tab 30mg ......................................... 350
phenobarb tab 32.4mg ...................................... 350
phenobarb tab 60mg ......................................... 350
phenobarb tab 64.8mg ...................................... 350
phenobarb tab 97.2mg ...................................... 350
PHENOL
CRY............................................... 187
PHENOL
LIQ 89%........................................ 187
phenoxybenza cap 10mg ...................................... 135
PHENTOL MESY INJ 5MG ............................... 135
PHENTOLAMINE INJ 5MG .............................. 135
PHENTOLAMINE INJ MESYLATE ................. 135
PHENYLEPHRIN CRY ...................................... 376
phenylephrin inj 10mg/ml .................................... 439
PHENYLEPHRIN INJ SOD CL......................... 440
phenylephrin sol 10% op...................................... 387
phenylephrin sol 2.5% op..................................... 387
PHENYTEK
CAP 200MG ................................ 87
PHENYTEK
CAP 300MG ................................ 87
506
phenytoin chw 50mg ........................................... 88
phenytoin inj 50mg/ml ........................................ 88
phenytoin sus 125/5ml ........................................ 88
phenytoin ex cap 100mg ........................................ 88
philith
tab 0.4-35 ............................................ 233
PHISOHEX
LIQ 3%........................................ 188
PHOSLO
CAP 667MG............................... 335
PHOSLYRA .......................................................... SOL
phosphasal 335
tab................................................... 433
PHOSPHOLINE SOL 0.125%OP ...................... 383
PHOTOFRIN INJ 75MG .................................. 161
PHRENILIN ............................................ CAP FORTE
...............................................................................
22
PHYS
EZ USE KIT M-PRED ............................ 244
PHYSOS SALIC INJ 1MG/ML .......................... 112
PICATO
GEL 0.015% ............................... 268
PICATO.................................................. GEL 0.05%
.............................................................................
268
PICO
WOUND KIT THER SYS....................... 306
pilocarpine sol 1% op ......................................... 383
pilocarpine tab 5mg ............................................ 370
pilocarpine tab 7.5mg ......................................... 370
PILOPINE HS GEL 4% OP ............................... 384
pimozide........................................................ tab 1mg
.............................................................................
411
pimozide........................................................
tab 2mg
............................................................................. 411
pimtrea..................................................................
tab
.............................................................................
229
pindolol
tab 10mg........................................... 207
pindolol
tab 5mg............................................. 207
PINNACAINE DRO 20% OTIC ....................... 395
pioglit/glim tab 30-2mg ....................................... 107
pioglit/glim tab 30-4mg ....................................... 107
pioglita/met tab 15-500mg................................... 109
pioglita/met tab 15-850mg................................... 110
pioglitazone tab 15mg ......................................... 110
piper/tazoba inj 2-0.25gm.................................... 403
piper/tazoba inj 3-0.375g .................................... 403
piper/tazoba inj 36-4.5gm....................................
4-0.5gm...................................... 403
pirmella......................................................... tab 1/35
.............................................................................
233
pirmella........................................................
tab 7/7/7
............................................................................. 237
piroxicam ....................................................cap 10mg
...............................................................................
piroxicam
cap 20mg ............................................. 18
PITOCIN
INJ 10UNT/ML.............................. 396
PITRESSIN INJ 20UNT/ML............................ 323
PLAN B
TAB 0.75MG .................................. 234
PLAN B
TAB 1.5MG .................................... 234
PLAQUENIL TAB 200MG.............................. 146
PLAVIX
TAB 300MG .................................. 344
PLAVIX
TAB 75MG .................................... 344
PLEGISOL
SOL .............................................. 218
PLEGRIDY
INJ .................................................409
PLEGRIDY
INJ PEN ...................................... 409
PLEGRIDY
INJ STARTER ............................ 409
PLEGRIDY PEN INJ STARTER........................ 409
plenamine inj 15% ............................................ 380
PLETAL
TAB 100MG .................................. 343
PLETAL
TAB 50MG .................................... 343
PLEXION
CRE 9.8-4.8% ............................... 254
PLEXION
LIQ 9.8-4.8% ................................ 254
PLEXION
LOT 9.8-4.8% ............................... 254
PLEXION CLNS EMU 10-5%............................ 254
PLEXION CLTH MIS 10-5% ............................. 254
PLEXION CLTH PAD 9.8-4.8% ........................ 254
PLEXION SCT CRE 10-5%............................... 255
PLIAGLIS CRE 7-7% ..................................... 296
PNEUMOVAX 23 INJ 25/0.5 ............................. 436
PODOCON
SOL 25% .................................... 285
podofilox sol 0.5% ............................................ 285
polocaine inj 1% ............................................... 357
polocaine inj 2% ............................................... 358
polocaine inj -mpf 1%....................................... 357
polocaine inj mpf 1.5% ..................................... 358
polocaine inj -mpf 2%....................................... 357
POLY HIST LIQ DHC ..................................... 251
POLY HIST DM LIQ ............................................250
POLY HIST NC LIQ .............................................251
polycin
oin op.................................................. 384
polycin b oin op................................................. 384
poly-dex oin 0.1% op ....................................... 390
polygesic cap 5-500mg ....................................... 26
polymyxin b inj 500000 ......................................... 55
polymyxin b/ sol trimethp ..................................... 384
POLYTRIM SOL OP ...................................... 384
POLY-TUSSIN LIQ DHC.................................. 251
POLY-TUSSIN SYP EX .................................... 247
POMALYST CAP 1MG.................................. 153
POMALYST CAP 2MG.................................. 153
POMALYST CAP 3MG.................................. 153
POMALYST CAP 4MG.................................. 153
PONSTEL
CAP 250MG................................... 18
PONTOCAINE INJ 1% ..................................... 359
507
PONTOCAINE INJ 20MG................................ 359
PONTOCAINE SOL 2% ................................... 287
portia-28 tab ..................................................... 233
POT CITRATE GRA.......................................... 338
POT CITRATE GRA MONOHYDR ................. 338
pot citrate tab 1080mg........................................ 338
pot citrate tab 1620mg........................................ 339
pot citrate tab 540mg er ..................................... 339
pot citrate- pak cit acid........................................ 339
POTIGA
TAB 200MG .................................... 84
POTIGA
TAB 300MG .................................... 84
POTIGA
TAB 400MG .................................... 84
POTIGA
TAB 50MG ...................................... 84
pr benzoyl liq 7% wash...................................... 260
PR CREAM KIT................................................ 289
PRADAXA
CAP 150MG................................. 78
PRADAXA
CAP 75MG................................... 78
PRALIDOXIME INJ 600/2ML .......................... 112
PRALUENT
INJ 150MG/ML ......................... 123
PRALUENT
INJ 75MG/ML ........................... 123
pramcort cre 1-1%............................................. 48
pram-hca kit 2.35-1% ........................................ 48
pramipexole tab 0.125mg ................................... 174
pramipexole tab 0.25mg ..................................... 174
pramipexole tab 0.375mg ................................... 174
pramipexole tab 0.5mg ....................................... 174
pramipexole tab 0.75 er ...................................... 174
pramipexole tab 1.5mg er ................................... 175
pramipexole tab 1mg .......................................... 175
pramipexole tab 3mg .......................................... 175
PRAMOSONE CRE 1% .................................... 292
PRAMOSONE CRE 1-1% ............................... 292
PRAMOSONE CRE 1-2.5% ............................ 292
PRAMOSONE LOT 1%................................... 293
PRAMOSONE LOT 2.5%................................ 293
PRAMOSONE OIN 1% ................................... 293
PRAMOSONE OIN 2.5% ................................ 293
PRAMOSONE E CRE 1-2.5%........................... 293
PRAMOTIC
DRO 1-0.1%............................... 395
pramox
gel 1%............................................... 287
pramoxine-hc dro aq otic..................................... 395
PRANDIMET TAB 1-500MG ........................ 105
PRANDIMET TAB 2-500MG ........................ 105
PRANDIN
TAB 0.5MG ................................. 105
PRANDIN
TAB 1MG .................................... 105
PRANDIN
TAB 2MG .................................... 105
prascion emu.................................................... 255
prascion fc pad 10-5% ........................................ 255
PRASCION RA CRE 10-5%.............................. 255
PRAVACHOL TAB 20MG ............................. 127
PRAVACHOL TAB 40MG ............................. 127
PRAVACHOL TAB 80MG ............................. 127
pravastatin tab 10mg .......................................... 127
PRAXBIND
INJ 2.5/50 ................................... 112
PRAZOLAMINE PAK ....................................... 374
prazosin hcl cap 1mg ........................................... 142
PRECEDEX
INJ 100MCG .............................. 353
PRECEDEX
INJ 200/50ML ............................ 353
PRECEDEX
INJ 400/100 ................................ 353
PRECEDEX
INJ 80/20ML .............................. 353
PRECISION GLUCOSE MONITOR............... 361
PRECOSE TAB 100MG................................. 100
PRECOSE TAB 25MG................................... 101
PRECOSE TAB 50MG................................... 101
PRED FORTE SUS 1% OP ............................... 391
PRED MILD SUS 0.12% OP ........................... 391
pred sod pho sol 1% op........................................ 391
pred sod pho sol 5mg/5ml .................................... 241
pred sod pho sol 6.7/5ml...................................... 241
PRED-G
SUS OP........................................... 390
PRED-G S.O.P OIN OP....................................... 390
prednicarbat cre 0.1% ......................................... 278
prednicarbat oin 0.1% ......................................... 278
prednisolone sol 15mg/5ml .................................. 241
prednisolone sol 25mg/5ml .................................. 241
prednisolone sus 1% op ....................................... 392
prednisolone syp 15mg/5ml.................................. 241
prednisolone tab 10mg odt................................... 241
prednisone con 5mg/ml ...................................... 241
prednisone pak 10mg ......................................... 241
prednisone pak 5mg ........................................... 241
prednisone sol 5mg/5ml ..................................... 241
prednisone tab 10mg.......................................... 241
prednisone tab 1mg............................................ 241
prednisone tab 2.5mg......................................... 241
508
prednisone tab 5mg............................................ 241
PREFEST
TAB............................................... 325
PRELONE
SYP 15MG/5ML ......................... 241
PREMARIN
INJ 25MG .................................. 328
PREMARIN
TAB 0.3MG ............................... 329
PREMARIN
TAB 0.45MG ............................. 329
PREMARIN
TAB 0.625MG ........................... 329
PREMARIN
TAB 0.9MG ............................... 329
PREMARIN
TAB 1.25MG ............................. 329
PREMARIN VAG CRE 0.625MG...................... 437
PREMASOL
SOL 10% ................................... 380
premasol sol 6% .............................................. 380
PREMPHASE TAB.......................................... 325
PREMPRO TAB .625-2.5 .............................. 325
PREMPRO TAB 0.3-1.5 ................................ 325
PREMPRO TAB 0.45-1.5 .............................. 325
PREMPRO TAB 0.625-5 ............................... 325
PRENATAL VITAMINS .................................... 370
PREPIDIL GEL 0.5MG/3G............................. 396
PREPOPIK PAK ............................................. 354
PRESERA AER.............................................. 289
PRESTALIA TAB 14-10MG ........................... 129
PRESTALIA TAB 3.5-2.5 ............................... 129
PRESTALIA TAB 7-5MG ............................... 129
previfem ................................................................ tab
.............................................................................
233
PREVPAC
MIS .............................................. 432
PREZCOBIX TAB 800-150............................. 189
PREZISTA
SUS 100MG/ML ....................... 190
PREZISTA
TAB 150MG.............................. 190
PREZISTA
TAB 400MG.............................. 190
PREZISTA
TAB 600MG.............................. 190
PREZISTA
TAB 75MG................................ 190
PREZISTATAB 800MG..................................... 190
PRIALT
INJ 100MCG ................................. 23
PRIALT
INJ 25MCG/ML ............................... 23
PRIALT
INJ 150MG
500MCG
...............................148
23
PRIFTIN
TAB
................................
PRIMAQUINE TAB 26.3MG........................... 146
PRIMAXIN IV INJ 250MG ................................. 52
PRIMAXIN IV INJ 500MG ................................. 52
primidone
tab 250mg....................................... 84
primidone tab 50mg ............................................ 84
PRIMLEV
TAB 10-300MG ............................. 42
PRIMLEV
TAB 5-300MG ............................... 42
PRIMLEV
TAB 7.5-300................................... 42
PRIMSOL SOL 50MG/5ML ............................ 50
PRINIVIL TAB 10MG .................................... 134
PRINIVIL TAB 20MG .................................... 134
PRINIVIL TAB 5MG ...................................... 134
PRINZIDE TAB 10-12.5 ................................. 131
PRINZIDE TAB 20-12.5 ................................. 131
PRISTIQ
TAB 100MG....................................96
PRISTIQ
TAB 25MG ....................................... 96
PRISTIQ
TAB 50MG ....................................... 96
PRIVIGEN INJ 10GRAMS ............................. 399
PRIVIGEN INJ 5 GRAMS .............................. 399
PROAIR HFA AER ............................................. 67
PROAIR RESPI AER ............................................ 67
proben/colch tab 500-0.5 ..................................... 341
probenecid tab 500mg........................................ 342
procainamide inj 100mg/ml ................................... 63
procainamide inj 500mg/ml ................................... 63
PROCAINE HCL CRY ....................................... 359
PROCALAMINE INJ 3%................................... 380
PROCARDIA CAP 10MG ............................... 214
PROCARDIA XL TAB 30MG CR ..................... 214
PRO-C-DURE 1 KIT ........................................... 244
PRO-C-DURE 2 KIT ........................................... 244
PRO-C-DURE 3 KIT ........................................... 244
PRO-C-DURE 4 KIT ........................................... 244
PRO-C-DURE 5 KIT 40MG/ML......................... 242
PRO-C-DURE 6 KIT 40MG/ML......................... 242
procentra sol 5mg/5ml .......................................... 5
prochlorper inj 10mg/2ml ................................... 184
prochlorper inj 5mg/ml ....................................... 184
prochlorper sup 25mg......................................... 184
prochlorper tab 10mg ......................................... 184
prochlorper tab 5mg ........................................... 184
PROCORT CRE ............................................... 48
PROCRIT
INJ ...................................................346
PROCTOCORT CRE 1%...................................... 48
PROCTOCORT SUP 30MG ............................... 49
proctocream cre hc 2.5% ...................................... 49
PROCTOFOAM AER HC 1% ............................ 48
procto-pak cre 1%................................................ 48
proctosol hc cre 2.5% ............................................ 49
509
proctozone cre -hc 2.5% ...................................... 49
PROCYSBI CAP 25MG ................................. 339
PROCYSBI CAP 75MG ................................. 339
PRODRIN
TAB.............................................. 362
progesterone cap 100mg...................................... 405
progesterone cap 200mg...................................... 405
PROGESTERONE CRE 10% KIT...................... 405
progesterone inj 50mg/ml .................................... 405
PROGESTERONE SUP VGS 100 ...................... 438
PROGESTERONE SUP VGS 25 ........................ 438
PROGESTERONE SUP VGS 50 ........................ 438
PROGLYCEM SUS 50MG/ML....................... 102
PROGRAF
CAP 0.5MG................................. 202
PROGRAF
CAP 1MG.................................... 202
PROGRAF
CAP 5MG.................................... 202
PROGRAF
INJ 5MG/ML............................... 202
PROHIST CD LIQ................................................ 250
PROHIST CF LIQ ............................................... 249
PROHIST LQ LIQ ............................................... 247
PROLASTIN ........................................... INJ 1000MG
.............................................................................
PROLASTIN
INJ 500MG ................................ 413
PROLASTIN-C INJ 1000MG ............................ 413
PROLENSA ...............................................SOL 0.07%
.............................................................................
389
PROLEUKIN
INJ 22MU .................................. 161
PROLEX DMX LIQ ............................................ 246
PROLIA........................................... SOL 60MG/ML
.............................................................................
321
prolida
pad 4-1% ........................................ 296
promacet tab 50-650mg ....................................... 22
PROMACTA ....................................... TAB 12.5MG
348 TAB 25MG............................... 348
PROMACTA
PROMACTA TAB 50MG............................... 348
PROMACTA TAB 75MG............................... 348
prometh vc syp 6.25-5/5..................................... 248
prometh vc syp plain .......................................... 248
prometh vc/ syp codeine...................................... 251
prometh/cod syp 6.25-10..................................... 250
prometh/pe syp 6.25-5/5 .................................... 248
prometh/pe/ syp codeine ..................................... 251
promethazine inj 25mg/ml ................................... 121
promethazine inj 50mg/ml ................................... 121
promethazine sup
sol 6.25/5ml...................................
12.5mg .................................... 122
promethazine tab 12.5mg ..................................... 122
promethazine tab 25mg........................................ 122
promethazine tab 50mg........................................ 122
promethegan sup 12.5mg .................................... 122
promethegan sup 25mg ....................................... 122
promethegan sup 50mg ....................................... 122
PROMETRIUM CAP 100MG........................... 405
PROMETRIUM CAP 200MG........................... 405
PROMISEB
CRE............................................. 270
PROMISEB
KIT COMPLETE........................ 270
propafenone cap 225mg er.................................... 63
propafenone cap 325mg er.................................... 64
propafenone cap 425mg sr.................................... 64
propafenone tab 150mg ........................................ 64
propanthelin tab 15mg ......................................... 431
proparacaine sol 0.5% op .................................... 389
prop-fluore sol 0.5-0.25 ...................................... 388
propofol inj 10mg/ml ....................................... 336
propoven inj 10mg/ml ...................................... 336
propran/hctz tab 40/25......................................... 143
propran/hctz tab 80/25......................................... 143
propranolol cap 120mg er .................................. 207
propranolol cap 160mg er .................................. 207
propranolol cap 60mg er .................................... 207
propranolol cap 80mg er .................................... 207
propranolol inj 1mg/ml ....................................... 207
propranolol sol 20mg/5ml................................... 207
propranolol sol 40mg/5ml................................... 207
propranolol tab 10mg ......................................... 207
propylthiour tab 50mg ......................................... 418
PROSCAR
TAB 5MG.................................... 337
PROSED/DS TAB ............................................ 433
PROSOL
INJ 20% ......................................... 380
PROSTIGMIN INJ 0.5MG/ML......................... 147
PROSTIGMIN INJ 1MG/ML............................ 147
PROSTIGMIN TAB 15MG............................... 147
PROSTIN E2 SUP 20MG.................................. 396
PROSTIN VR INJ 500MCG.............................. 203
PROTAMINE SU SOL 10MG/ML ..................... 344
PROTID.......................................................... TAB CR
..............................................................................
248
PROTOPAM
CHL INJ 1GM............................... 112
PROTOPIC .................................................OIN 0.03%
.............................................................................. 288
promethazine sup 25mg ....................................... 122
promethazine sup 50mg ....................................... 122
promethazine syp 6.25/5ml .................................. 122
promethazine syp dm............................................ 249
510
QROXIN
PAD .............................................. 296
QUADRAMET INJ ............................................160
quadrapax elx.................................................... 426
QUALAQUIN CAP 324MG ............................ 146
QUARTETTE TAB .......................................... 235
quasense tab........................................................235
quazepam tab 15mg ......................................... 351
QUDEXY XR CAP 100/24HR........................... 84
QUDEXY XR CAP 150/24HR........................... 84
QUDEXY XR CAP 200/24HR........................... 84
QUDEXY XR CAP 25/24HR............................. 84
QUDEXY XR CAP 50/24HR............................. 84
QUELICIN INJ -1000...................................... 376
QUELICIN INJ 20MG/ML ............................. 376
quetiapine tab 100mg......................................... 181
quetiapine tab 25mg........................................... 181
quetiapine tab 50mg........................................... 181
QUILLIVANT SUS 25MG/5ML .......................... 9
quinapril tab 10mg............................................ 134
quinapril tab 20mg............................................ 134
quinapril tab 40mg............................................ 134
quinapril tab 5mg.............................................. 134
QUINIDINE GL INJ 80MG/ML ........................... 63
quinidine gl tab 324mg cr ...................................... 63
quinidine gl tab 324mg er ...................................... 63
quinidine su tab 200mg.......................................... 63
quinidine su tab 300mg.......................................... 63
quinidine su tab 300mg er...................................... 63
quinine sulf cap 324mg ........................................ 146
QUINZYME
TAB 90MG.................................. 10
QUTENZA
KIT 8% 1-PCH............................ 287
QUTENZA
KIT 8% 2-PCH............................ 288
qv-allergy syp ..................................................... 248
QVAR
AER 40MCG ..................................... 70
QVAR
AER 80MCG ..................................... 70
R
PROTOPIC
OIN 0.1%..................................... 288
protriptylin tab 10mg ............................................. 99
protriptylin tab 5mg ............................................... 99
PROVENGE
INJ ............................................... 153
PROVENTIL AER HFA .................................... 67
provenza pad 4-1% .......................................... 296
PROVERA
TAB 10MG ................................. 405
PROVERA
TAB 2.5MG ................................ 405
PROVERA
TAB 5MG ................................... 405
PROVIGIL TAB 100MG .................................... 9
PROVIGIL TAB 200MG .................................... 9
PROVISC
INJ 1% .......................................... 393
PROZAC
CAP 10MG ..................................... 94
PROZAC
CAP 20MG ..................................... 94
PROZAC
CAP 40MG ..................................... 94
PROZAC WEEKL CAP 90MG ............................ 94
PRUCLAIR
CRE............................................. 289
PRUDOXIN CRE 5% ..................................... 268
PRUMYX
CRE ............................................. 289
PRUTECT
EMU............................................. 306
PRYFLEX
TAB ............................................... 10
PSEUDOEPHEDR CRY HCL ............................ 376
PSORCON CRE 0.05%.................................. 278
PUDEND/LOCAL KIT 1% LIDO ...................... 358
PULMICORT INH 180MCG ............................. 70
PULMICORT INH 90MCG ............................... 70
PULMICORT SUS 0.25MG/2 ........................... 70
PULMICORT SUS 0.5MG/2 ............................. 70
PULMICORT SUS 1MG/2ML .......................... 70
PULMOPHYLLIN PAK ....................................... 71
pulmosal neb 7%.............................................. 249
PULMOZYME SOL 1MG/ML........................ 413
PUR-ABSORB LIQ 5MG/20ML ...................... 348
PURINETHOL TAB 50MG.............................. 152
PURIXAN
SUS 20MG/ML............................ 152
PYLERA
CAP ............................................... 431
pyrazinamide tab 500mg...................................... 148
PYRIDIUM TAB 100MG ............................... 341
PYRIDIUM TAB 200MG ............................... 341
pyridostigm tab 60mg ......................................... 147
pyridostigmi tab 180mg ....................................... 147
PYRILAMINE CRY USP NF ........................... 120
PYROGALL ACD OIN....................................... 284
Q
RADIAPLEXRX GEL........................................ 306
RADIGEL
GEL .............................................. 289
RADIOGARDASE CAP 0.5GM ......................... 112
raloxifene tab 60mg ........................................... 321
ramipril cap 1.25mg......................................... 134
ramipril cap 10mg............................................ 134
qnapril/hctz tab 10-12.5....................................... 131
qnapril/hctz tab 20-12.5....................................... 131
qnapril/hctz tab 20-25mg..................................... 131
QNASL
AER 80MCG.................................. 376
QNASL CHILD SPR 40MCG............................ 376
511
ramipril cap 2.5mg .......................................... 134
ramipril cap 5mg ............................................. 134
RANEXA
TAB 1000MG ................................ 55
RANEXA
TAB 500MG .................................. 55
ranitidine cap 150mg......................................... 429
ranitidine cap 300mg......................................... 429
ranitidine inj 150/6ml ........................................ 429
ranitidine inj 25mg/ml ....................................... 429
ranitidine inj 50mg/2ml ..................................... 429
ranitidine syp 150/10ml ..................................... 430
ranitidine syp 15mg/ml ...................................... 430
ranitidine syp 75mg/5ml .................................... 430
ranitidine tab 150mg ......................................... 430
ranitidine tab 300mg ......................................... 430
RAPAFLO
CAP 4MG.................................... 338
RAPAFLO
CAP 8MG.................................... 338
RAPAMUNE
SOL 1MG/ML.......................... 202
RAPAMUNE
TAB 0.5MG ............................. 202
RAPAMUNE
TAB 1MG ................................ 202
RAPAMUNE
TAB 2MG ................................ 202
RAPIVAB
INJ 200MG/20 ............................. 198
RASUVO
INJ 10MG....................................... 12
RASUVO
INJ 12.5MG.................................... 12
RASUVO
INJ 15MG....................................... 12
RASUVO
INJ 17.5MG.................................... 12
RASUVO
INJ 20MG....................................... 13
RASUVO
INJ 22.5MG.................................... 13
RASUVO
INJ 25MG....................................... 13
RASUVO
INJ 27.5MG.................................... 13
RASUVO
INJ 30MG....................................... 13
RASUVO
INJ 7.5MG...................................... 13
RAVICTI
LIQ 1.1GM/ML............................. 323
RAYOS
TAB 1MG ...................................... 242
RAYOS
TAB 2MG ...................................... 242
RAYOS
TAB 5MG ...................................... 242
RAZADYNE SOL 4MG/ML .......................... 407
RAZADYNE TAB 12MG............................... 407
RAZADYNE TAB 4MG................................. 407
RAZADYNE TAB 8MG................................. 407
RAZADYNE ER CAP 16MG ............................ 407
RAZADYNE ER CAP 24MG ............................ 407
RAZADYNE ER CAP 8MG .............................. 407
rea lo 39 cre 39% ............................................. 280
rea lo 40 cre 40% ............................................. 280
rea lo 40 lot 40% .............................................. 280
REBETOL ............................................. CAP 200MG
..............................................................................
REBETOL
SOL 40MG/ML ........................... 196
REBIF
INJ 22/0.5 .................................... 409
REBIF
INJ 44/0.5 ......................................... 409
REBIF REBIDO INJ 22/0.5................................. 409
REBIF REBIDO INJ 44/0.5................................. 409
REBIF REBIDO INJ TITRATN.......................... 409
REBIF TITRTN INJ PACK................................. 409
RECEDO
GEL............................................... 292
reciphexamin dis 4-1%......................................... 296
RECLAST
INJ 5/100ML................................ 314
reclipsen tab...................................................... 233
rectacort-hc sup 25mg............................................ 49
RECTIV
OIN 0.4%.......................................... 47
REFLUDAN
INJ 50MG .................................... 77
REGENECARE GEL ........................................ 300
REGLAN
TAB 10MG................................... 332
REGONOL
INJ 5MG/ML .............................. 147
REGRANEX GEL 0.01%................................ 299
relador pak kit 2.5-2.5% ..................................... 296
relador pak kit plus ............................................. 296
RELAGARD GEL .......................................... 437
RELAGESIC TAB 50-650MG........................... 22
RELAMINE TAB.............................................. 10
relcof cpm tab 8-2.5mg ...................................... 122
RELCOF DN MIS PSE .................................... 248
RELCOF DN PE MIS............................................248
RELCOF PE TAB............................................. 248
RELEEVIA
PAD .0375-5% ............................ 296
RELEEVIA MC PAD .0375-5% ........................ 296
releevia ml pad 4-1% .......................................... 296
RELENZA
MIS DISKHALE ......................... 198
RELHIST
CHW.............................................. 248
RELISTOR INJ 12/0.6ML............................... 334
RELISTOR INJ 8/0.4ML................................. 334
RELISTOR KIT 12/0.6ML.............................. 334
RELPAX
TAB 20MG.................................... 364
RELPAX
TAB 40MG.................................... 364
RELYYKS
PAD ............................................. 296
RELYYT
DIS 0.025-5%................................ 297
REMATEX
CRE ............................................ 286
REMAXAZON PAD ........................................ 297
REMERON
TAB 15MG................................... 89
REMERON
TAB 30MG
45MG ............................... 90
REMERON SLTB TAB 15MG............................. 90
remeven .........................................................cre 50%
.............................................................................. 280
512
REMICADE INJ 100MG ................................ 336
REMODULIN INJ 10MG/ML ......................... 220
REMODULIN INJ 1MG/ML ........................... 220
REMODULIN INJ 2.5MG/ML ........................ 220
REMODULIN INJ 5MG/ML ........................... 220
RENACIDIN SOL IRR .................................... 340
RENAGEL
TAB 400MG ............................... 335
RENAGEL
TAB 800MG ............................... 335
renal caps............................................................. 370
RENOVO
PAD 0.0375-5 .............................. 297
RENOVO LIDO5 CRE 5-0.05%......................... 297
RENUU
PAD 2-5-30% ................................ 297
RENUU NL PAD 2-30%................................. 292
RENVELA
PAK 0.8GM ................................ 335
RENVELA
PAK 2.4GM ................................ 335
RENVELA
TAB 800MG ............................... 335
REOPRO
INJ 2MG/ML ................................ 342
repaglinide tab 0.5mg ......................................... 105
repaglinide tab 1-500mg..................................... 105
repaglinide tab 1mg ............................................ 105
repaglinide tab 2-500mg..................................... 105
repaglinide tab 2mg ............................................ 105
repan
tab......................................................... 22
REPATHA
INJ 140MG/ML........................... 123
REPATHA SURE INJ 140MG/ML .................... 123
reprexain tab 10-200mg ..................................... 26
REPREXAIN TAB 2.5-200................................ 26
REPREXAIN TAB 5-200MG ............................ 26
REQUIP
TAB 0.25MG ................................. 175
REQUIP
TAB 0.5MG ................................... 175
REQUIP
TAB 1MG ...................................... 175
REQUIP
TAB 2MG ...................................... 175
REQUIP
TAB 3MG ...................................... 175
REQUIP
TAB 4MG ...................................... 175
REQUIP
TAB 5MG ...................................... 175
REQUIP XL TAB 12MG ................................. 175
REQUIP XL TAB 2MG ................................... 175
REQUIP XL TAB 4MG ................................... 175
REQUIP XL TAB 6MG ................................... 175
REQUIP XL TAB 8MG ................................... 175
RESCON
TAB .............................................. 248
RESCON-JR TAB............................................ 248
RESCON-MX TAB.......................................... 248
RESCRIPTOR TAB 100 MG............................ 191
RESCRIPTOR TAB 200MG............................. 191
RESCULA
SOL 0.15% .................................. 393
RESECTISOL SOL 5%..................................... 340
reserpine tab 0.1mg .......................................... 145
reserpine tab 0.25mg ........................................ 145
RESPA-BR TAB 11MG .................................. 119
RESTASIS
EMU 0.05%.................................. 388
RESTORA RX CAP 60-1.25............................. 110
RESTORA SPRI PAK 15-0.25............................ 110
RESTORE SILV PAD 2 ...................................... 306
RESTORE SILV PAD 4 ...................................... 306
RESTORE SILV PAD 6 ...................................... 306
RESTORIL
CAP 15MG .................................. 351
RESTORIL
CAP 22.5MG ............................... 351
RESTORIL
CAP 30MG .................................. 351
RESTORIL
CAP 7.5MG ................................. 351
RETAVASE
INJ ................................................344
RETAVASE
INJ HALF-KIT........................... 344
RETIN-A
CRE 0.025% .................................. 260
RETIN-A
CRE 0.05% .................................... 260
RETIN-A
CRE 0.1% ...................................... 260
RETIN-A
GEL 0.01% .................................... 260
RETIN-A
GEL 0.025% .................................. 260
RETIN-A MICR GEL 0.04% .............................. 260
RETIN-A MICR GEL 0.04%PMP ...................... 260
RETIN-A MICR GEL 0.08% .............................. 260
RETIN-A MICR GEL 0.1% ................................ 260
RETIN-A MICR GEL 0.1%PUMP...................... 260
RETISERT IMP 0.59MG ................................ 392
RETROVIR
CAP 100MG ............................... 192
RETROVIR
INJ 10MG/ML ............................ 192
RETROVIR
SYP 50MG/5ML......................... 193
RETROVIR
TAB 300MG ............................... 193
REVATIO
INJ...................................................221
REVATIO
SUS 10MG/ML ............................ 221
REVATIO
TAB 20MG................................... 221
REVIA
TAB 50MG ...................................... 113
revina
oin ....................................................... 283
REVLIMID CAP 10MG.................................. 200
REVLIMID CAP 15MG.................................. 200
REVLIMID CAP 2.5MG................................. 200
REVLIMID CAP 20MG.................................. 200
REVLIMID CAP 25MG.................................. 200
REVLIMID CAP 5MG.................................... 200
revonto
inj 20mg ............................................. 373
REXAPHENAC CRE 1%.................................. 262
REXULTI
TAB 0.25MG ................................ 185
REXULTI
TAB 0.5MG .................................. 185
REXULTI
TAB 1MG ..................................... 185
REXULTI
TAB 2MG ..................................... 185
REXULTI
TAB 3MG ..................................... 185
REXULTI
TAB 4MG ..................................... 185
REYATAZ
CAP 100MG................................ 190
REYATAZ
CAP 150MG................................ 190
513
REYATAZ
CAP 200MG ............................... 190
REYATAZ
CAP 300MG ............................... 190
REZIRA
SOL 60-5/5ML............................... 251
REZYST IM CHW ........................................... 110
REZYST SB CHW 250MG.............................. 110
RHEUMATREX TAB 2.5MG ............................ 13
RHINOCORT SUS AQUA .............................. 376
rhinoflex tab 50-650mg....................................... 22
RHOGAM PLUS INJ 300MCG ......................... 399
RHOPHYLAC INJ 1500/2ML ......................... 399
RIAX
AER 5.5% ......................................... 260
RIAX
AER 9.5% ......................................... 260
ribapak pak 1000/day ..................................... 196
ribapak pak 1200/day ..................................... 196
ribapak pak 600/day ....................................... 196
ribapak pak 800/day ....................................... 196
ribasphere cap 200mg ....................................... 196
ribasphere tab 200mg ........................................ 196
RIBASPHERE TAB 400MG............................. 196
RIBASPHERE TAB 600MG............................. 196
RIBATAB
PAK 1000/DAY ........................... 196
RIBATAB
TAB 1200/DAY ........................... 196
RIBATAB
TAB 800/DAY ............................. 196
ribavirin cap 200mg ......................................... 196
ribavirin tab 200mg .......................................... 196
RIDAURA
CAP 3MG...................................... 13
rifabutin cap 150mg.......................................... 148
RIFADIN
CAP 150MG.................................. 148
RIFADIN
CAP 300MG.................................. 148
RIFADIN
INJ 600 MG................................... 148
RIFAMATE CAP ............................................ 147
rifampin cap 150mg......................................... 148
rifampin cap 300mg......................................... 148
rifampin inj 600 mg ......................................... 148
RIFATER
TAB............................................... 147
RILUTEK
TAB 50MG................................... 376
riluzole tab 50mg ............................................. 376
rimantadine tab 100mg....................................... 198
RIMANTALIST PAK ........................................ 198
RIMSO-50 SOL 50% ...................................... 340
RINNOVI NAIL KIT SYSTEM.......................... 280
RIOMET
SOL ............................................... 102
RIOMET
SOL 500/5ML ............................... 102
risedron sod tab 35mg dr..................................... 314
risedronate tab 150mg ........................................ 314
risedronate tab 30mg .......................................... 314
risedronate tab 35mg .......................................... 314
risedronate tab 5mg ............................................ 315
RISPERDAL INJ 12.5MG ............................... 178
RISPERDAL INJ 25MG................................... 178
RISPERDAL INJ 37.5MG................................ 178
RISPERDAL INJ 50MG................................... 178
RISPERDAL SOL 1MG/ML............................ 178
RISPERDAL TAB 0.25MG ............................. 179
RISPERDAL TAB 0.5MG ............................... 179
RISPERDAL TAB 1MG .................................. 179
RISPERDAL TAB 2MG .................................. 179
RISPERDAL TAB 3MG .................................. 179
RISPERDAL TAB 4MG .................................. 179
RISPERDAL M TAB 0.5MG ............................. 179
RISPERDAL M TAB 1MG ................................ 179
risperidone sol 1mg/ml........................................ 179
risperidone tab 0.25 odt ...................................... 179
risperidone tab 0.25mg ....................................... 179
risperidone tab 0.5mg ......................................... 179
risperidone tab 0.5mg od .................................... 179
risperidone tab 1mg ............................................ 179
risperidone tab 1mg odt ...................................... 179
RITALIN
TAB 10MG ........................................ 9
RITALIN
TAB 20MG ........................................ 9
RITALIN
TAB 20MG SR .................................. 9
RITALIN
TAB 5MG .......................................... 9
RITALIN LA CAP 10MG ..................................... 9
RITALIN LA CAP 20MG ..................................... 9
RITALIN LA CAP 30MG ..................................... 9
RITALIN LA CAP 40MG ..................................... 9
RITALIN LA CAP 60MG ..................................... 9
RITUXAN
INJ 100MG .................................. 154
RITUXAN
INJ 500MG .................................. 154
rivastigmine cap 1.5mg........................................ 407
rivastigmine cap 3mg........................................... 407
rivastigmine cap 4.5mg........................................ 407
rivastigmine cap 6mg........................................... 408
rivastigmine dis 13.3/24....................................... 408
rivastigmine dis 4.6mg/24.................................... 408
rivastigmine dis 9.5mg/24.................................... 408
rizatriptan tab 10mg ........................................... 364
rizatriptan tab 10mg odt ..................................... 364
rizatriptan tab 5mg ............................................. 364
514
ROXICODONE TAB 5MG................................. 39
ROZEREM
TAB 8MG ................................... 353
RYANODEX INJ 250MG ............................... 373
RYBIX ODT TAB 50MG .................................. 39
RYTARY
CAP ............................................. 173
RYTARY
CAP 23.75-95 .............................. 173
RYTHMOL TAB 150MG ................................ 64
RYTHMOL TAB 225MG ................................ 64
RYTHMOL SR CAP 225MG.............................. 64
RYTHMOL SR CAP 325MG.............................. 64
RYTHMOL SR CAP 425MG.............................. 64
RYZOLT
TAB 100MG ................................... 39
RYZOLT
TAB 200MG ................................... 39
RYZOLT
TAB 300MG ................................... 39
S
rizatriptan tab 5mg odt ....................................... 364
ROBAXIN
INJ 100MG/ML........................... 372
ROBAXIN
TAB 500MG................................ 372
ROBAXIN-750 TAB 750MG ............................ 372
ROBINUL
INJ 0.2MG/ML ............................ 431
ROBINUL
INJ 0.4/2ML................................. 431
ROBINUL
INJ 1MG/5ML ............................. 431
ROBINUL
INJ 4MG/20ML ........................... 431
ROBINUL
TAB 1MG .................................... 431
ROBINUL FORT TAB 2MG .............................. 431
ROCALTROL CAP 0.25MCG ........................ 320
ROCALTROL CAP 0.5MCG .......................... 320
ROCALTROL SOL 1MCG/ML....................... 320
ROCEPHIN INJ 1GM ..................................... 227
ROCEPHIN INJ 500MG ................................. 227
rocuronium inj 100mg/10 .................................. 377
rocuronium inj 10mg/ml .................................... 377
rocuronium inj 50mg/5ml .................................. 377
ROMAZICON INJ 1MG/10ML....................... 113
romycin
oin op ................................................ 386
ropinirole tab 0.25mg ........................................ 175
ropinirole tab 0.5mg .......................................... 175
ropinirole tab 12mg er....................................... 175
ropinirole tab 1mg ............................................. 175
ropinirole tab 2mg er......................................... 176
ropivacaine inj 10mg/ml ..................................... 358
ropivacaine inj 2mg/ml ....................................... 358
ropivacaine inj 5mg/ml ....................................... 358
ropivacaine inj 7.5mg/ml .................................... 358
rosadan
cre 0.75%.......................................... 291
rosadan
gel 0.75% .......................................... 291
ROSADAN
KIT 0.75% .................................. 291
rosanil
emu cleanser....................................... 255
ROSANIL
KIT ............................................... 255
ROSE GLO TES 1.5MG ................................. 388
ROSULA
LIQ 10-4.5% ................................. 255
rosula
pad 10-5% .......................................... 255
ROWASA
KIT 4GM ..................................... 334
roxicet
sol 5-325/5 ............................................ 42
roxicet
tab 5-325mg .......................................... 42
ROXICODONE TAB 15MG............................... 39
ROXICODONE TAB 30MG............................... 39
SABRIL
POW 500MG .................................... 87
SABRIL
TAB 500MG..................................... 87
SAFYRAL
TAB ............................................. 233
SAIZEN
INJ 5MG ......................................... 318
SAIZEN
INJ 8.8MG ...................................... 318
salacyn
cre 6%................................................ 285
salacyn
lot 6%................................................. 285
SALAGEN
TAB 5MG ................................... 370
SALAGEN
TAB 7.5MG ................................ 370
SALEX
SHA 6% .......................................... 285
SALEX CREAM KIT 6%................................... 285
SALEX LOTION KIT 6% ................................... 285
SALICEPT
SUS............................................... 370
salicylic aer 6%................................................. 285
SALICYLIC CRY ACID.................................. 285
SALICYLIC AC AER 6%................................... 284
salicylic ac cre 6% ............................................... 285
salicylic ac gel 6% ............................................... 285
salicylic ac kit 6% ................................................ 285
salicylic ac kit 6% cream ..................................... 285
salicylic ac kit 6% lotn ......................................... 286
salicylic ac liq 26% .............................................. 286
salicylic ac liq 27.5% ........................................... 286
salicylic ac lot 6% ................................................ 286
salicylic ac sha 6%............................................... 286
salicylic ac sol 28.5%........................................... 286
SALKERA
AER 6%....................................... 285
salsalate tab 500mg ............................................ 23
salsalate tab 750mg ............................................ 23
SALVAX
AER 6% ........................................ 286
SALVAX DUO KIT PLUS ............................... 285
SAMSCA
TAB 15MG................................... 321
SAMSCA
TAB 30MG................................... 322
SANADERMRX KIT SKIN REP ..................... 299
515
SANCTURA TAB 20MG ............................... 435
SANCTURA XR CAP 60MG ............................ 435
SANCUSO
DIS 3.1MG.................................. 114
SANDIMMUNE CAP 100MG.......................... 200
SANDIMMUNE CAP 25MG............................ 200
SANDIMMUNE INJ 50MG/ML....................... 200
SANDIMMUNE SOL 100MG/ML................... 200
SANDOSTATIN INJ 1000MCG........................ 322
SANDOSTATIN INJ 100MCG.......................... 322
SANDOSTATIN INJ 50MCG/ML .................... 322
SANDOSTATIN KIT LAR 10MG .................... 322
SANTYL
OIN 250/GM ................................. 283
SAPHRIS
SUB 10MG.................................... 180
SAPHRIS
SUB 2.5MG................................... 180
SAPHRIS
SUB 5MG...................................... 180
SARAFEM
TAB 10MG ................................. 411
SARAFEM
TAB 20MG ................................. 411
sash
kit 100/ml ............................................... 75
sash
kit 10unt/ml ............................................ 75
SAVAYSA
TAB 15MG ................................... 74
SAVAYSA
TAB 30MG ................................... 74
SAVAYSA
TAB 60MG ................................... 74
SAVELLA
MIS TITR PAK ........................... 408
SAVELLA
TAB 100MG................................ 408
SAVELLA
TAB 12.5MG............................... 408
SAVELLA
TAB 25MG.................................. 408
SAVELLA
TAB 50MG.................................. 408
scalacort lot 2%................................................ 278
SCALACORT DK KIT ....................................... 299
SCAR PATCH PAD.......................................... 297
SCAR PATCH PAD PREMIUM ...................... 297
SCLEROSOL AER INTRAPLE ...................... 413
SCOPOLAMINE INJ 0.4MG/ML...................... 428
SCULPTRA INJ 367.5MG.............................. 261
se 10-5 ss cre 10-5%.......................................... 255
se bpo 7-5.5 kit wash kit....................................... 260
se bpo cloth mis 3% ............................................. 260
se bpo cloth mis 6% ............................................. 260
se bpo cloth mis 9% ............................................. 260
se bpo wash liq 7% ............................................. 260
SEASONALE TAB .......................................... 235
SEASONIQUE TAB ......................................... 235
seb-prev liq wash ............................................. 270
SEB-PREV
LOT 10% ..................................... 270
SECONAL CAP 100MG................................ 350
SECTRAL CAP 200MG................................. 206
SECTRAL CAP 400MG................................. 206
SEDAPAP
TAB 50-650MG ............................. 22
se-donna elx pb hyos ........................................ 426
SEEBRI NEOHA CAP 15.6MCG ......................... 68
selegiline cap 5mg.............................................. 172
selegiline tab 5mg .............................................. 172
selenium sul lot 2.5% ........................................... 271
selenium sul sha 2.25%........................................ 270
SELRX
SHA 2.3%........................................ 270
SELSUN
SHA 2.5% ...................................... 271
SELZENTRY TAB 150MG ............................. 189
SELZENTRY TAB 300MG ............................. 189
SEMPREX-D CAP 8-60MG ............................ 248
SENOPHYLLINE PAK......................................... 71
SENSIPAR
TAB 30MG .................................. 315
SENSIPAR
TAB 60MG .................................. 315
SENSIPAR
TAB 90MG .................................. 315
sensorcaine inj 0.25% ......................................... 358
sensorcaine inj 0.5% ........................................... 358
sensorcaine inj mpf 0.5% .................................... 358
sensorcaine inj mpf spin...................................... 358
sensorcaine inj -mpf/epi ...................................... 355
sensorcaine inj mpf0.25% ................................... 358
sensorcaine inj mpf0.75% ................................... 358
sensorcaine/ inj epi 0.25 ...................................... 355
sensorcaine/ inj epi 0.5% ..................................... 356
SENTRADINE PAK.......................................... 428
SENTRAFLOX PAK AM-10 .............................. 97
SENTRALOPRAM PAK AM-10.......................... 97
SENTRAMODAFI PAK AM-100........................... 5
SENTRAVIL PM PAK -25 ................................. 100
SENTRAZOLAM PAK AM 0.25 ........................ 59
SENTRAZOLPID PAK PM-5............................. 351
SENTROXATINE PAK ........................................ 97
SEPTRA DS TAB 800-160 ................................ 52
SEREVENT DIS AER 50MCG............................. 67
SEROMYCIN CAP 250MG............................. 148
SEROQUEL TAB 100MG .............................. 181
SEROQUEL TAB 200MG .............................. 181
SEROQUEL TAB 25MG ................................ 182
SEROQUEL TAB 300MG .............................. 182
SEROQUEL TAB 400MG .............................. 182
SEROQUEL TAB 50MG ................................ 182
SEROQUEL XR TAB 150MG........................... 182
SEROQUEL XR TAB 50MG............................. 182
516
SEROSTIM
INJ 4MG ..................................... 318
SEROSTIM
INJ 5MG ..................................... 318
SEROSTIM
INJ 6MG ..................................... 318
sertraline con 20mg/ml ........................................ 94
sertraline tab 100mg............................................ 94
sertraline tab 25mg.............................................. 94
sertraline tab 50mg.............................................. 94
setlakin tab....................................................... 235
sevelamer tab 800mg ........................................ 335
sevoflurane sol .................................................... 337
SFROWASA ................................................ENE 4GM
sharobel334
................................................... tab 0.35mg
.............................................................................
236
SHELLGEL
SOL........................................... 393
SHOHLS SOL MODIFIED .............................. 339
SIGNIFOR
INJ 0.3MG/ML........................... 322
SIGNIFOR INJ 0.6MG/ML.............................. 322
SIGNIFOR INJ 0.9MG/ML............................. 322
SIGNIFOR LAR INJ 20MG................................ 322
SILAZONE....................................PAK PHARMAPA
.............................................................................
299
sildenafil
inj ....................................................... 221
sildenafil tab 20mg............................................. 221
SILENOR ................................................. TAB 3MG
.............................................................................
351
SILENOR
................................................. TAB 6MG
.............................................................................
351
SILMANIX
CRE............................................... 286
SILVADENE CRE 1% ........................................ 271
SILVASORB GEL............................................. 306
SILVER
CRY NITRATE......................... 272
SILVER NITRA OIN 10%.................................. 272
SILVER NITRA SOL 0.5% ................................ 272
SILVER NITRA SOL 10% ................................. 272
SILVER NITRA SOL 25% ................................. 272
SILVER NITRA SOL 50% ................................. 272
silver sulfa cre 1% ............................................... 271
SILVERA PAIN PAD RELIEF........................... 297
SILVRSTAT.................................. GEL DRESSING
.............................................................................
306
SIMBRINZA
......................................... SUS 1-0.2%
.............................................................................
381
SIMCOR
TAB 1000-20 ............................. 125
SIMCOR
TAB 1000-40 ............................. 125
SIMCOR
TAB 500-20MG ............................ 125
500-40MG ............................ 125
SIMCOR
TAB 750-20MG
SIMPONI INJ 100MG/ML............................... 12
SIMULECT
INJ 20MG ................................... 202
simvastatin tab 10mg .......................................... 127
simvastatin tab 5mg ............................................ 127
SINELEE
PAD 0.0375-5 ................................ 297
SINELEE
PAD 0.05-5%................................. 297
SINEMET
TAB 10-100MG ........................... 173
SINEMET
TAB 25-100MG .......................... 173
SINEMET
TAB 25-250MG ........................... 173
SINEMET CR TAB 25-100MG ........................ 173
SINEMET CR TAB 50-200MG ........................ 173
SINGULAIR CHW 4MG ................................... 69
SINGULAIR CHW 5MG ................................... 69
SINGULAIR GRA 4MG .................................... 69
SINGULAIR TAB 10MG................................... 69
sirolimus tab 0.5mg........................................... 202
sirolimus tab 1mg.............................................. 202
sirolimus tab 2mg.............................................. 202
SIRTURO
TAB 100MG ................................. 148
SITAVIG
TAB 50MG .................................... 197
SIVEXTRO
INJ 200MG.................................... 55
SIVEXTRO
TAB 200MG ................................. 55
SKELAXIN TAB 800MG ............................... 372
SKELID
TAB 200MG................................... 315
SKIN SCRUB KIT PREP TRY ......................... 187
SKLICE
LOT 0.5% ....................................... 292
sm folic acd tab 400mcg....................................... 346
smz/tmp ds tab 800-160........................................ 52
smz-tmp ...................................................inj 400-80/5
................................................................................
52
smz-tmp ................................................................. sus
................................................................................
52
smz-tmp
..................................................sus 200-40/5
................................................................................
52
smz-tmp
................................................tab 400-80mg
................................................................................
smz-tmp
ds tab 800-160 ....................................... 52
SOD CITRATE CRY.......................................... 339
sod citrate sol citr acd......................................... 339
DIURIL INJ
313
SOD EDECRIN
INJ500MG
50MG.................................
................................ 311
SOD HYPOCHLR SOL 5% ................................ 188
SOD NITRITE INJ 30MG/ML........................... 112
SIMPONI INJ 50/0.5ML .................................. 12
SIMPONI ARIA SOL 50MG/4ML ....................... 12
SIMULECT INJ 10MG...................................... 202
517
sod poly sul sus 15gm/60 ..................................... 202
sod poly sul sus 30/120ml .................................... 203
sod poly sul sus 50/200ml .................................... 203
SOD SALICYLA CRY ......................................... 23
SOD SALICYLA CRY USP NF........................... 23
sod sul/sulf aer 10-5% ......................................... 255
sod sul/sulf cre 10-2% ......................................... 255
sod sul/sulf cre 10-5% ......................................... 255
sod sul/sulf cre 9.8-4.8%...................................... 255
sod sul/sulf emu 10-5%........................................ 255
SOD SUL/SULF GEL 10-5%.............................. 255
sod sul/sulf kit ...................................................... 255
sod sul/sulf liq 10-2% .......................................... 255
sod sul/sulf liq 9.8-4.8% ...................................... 255
sod sul/sulf liq 9-4.5% ......................................... 255
sod sul/sulf liq wash............................................. 255
sod sul/sulf lot 10-5% .......................................... 255
sod sul/sulf lot 9.8-4.8% ...................................... 255
sod sul/sulf pad 10-4% ........................................ 255
sod sul/sulf pad 10-5% ........................................ 256
SOD SUL/SULF SUS 10-5% .............................. 256
sod sul/sulf sus 8-4% ........................................... 256
sod sulfacet gel 10% ............................................ 271
SOD SULFACET PAD 10%............................... 270
sod sulfacet sha 10% ........................................... 271
sod sulfacet sol 10% op ....................................... 392
SOD THIOSULF INJ 10% .................................. 113
sod thiosulf inj 25% ............................................. 113
sodium chlor neb 10% ......................................... 249
sodium chlor neb 3% ........................................... 249
sodium chlor neb 7% ........................................... 249
sodium chlor sol 0.9% irr .................................... 340
SODIUM CITRA GRA ....................................... 339
sodium sulfa liq 10% wash .................................. 271
sojourn sol ...................................................... 337
SOLAICE
PAD .............................................. 297
SOLARAZE
GEL 3% W/W............................ 268
SOLESTA
INJ 50-15ML................................ 200
solia
tab ........................................................ 233
SOLIRIS
INJ 10MG/ML................................ 342
SOLMARA
PAD 4-5% .................................. 297
SOLODYN
TAB 105MG............................... 417
SOLODYN
TAB 115MG............................... 418
SOLODYN
TAB 55MG................................. 418
SOLODYN
TAB 65MG................................. 418
SOLODYN
TAB 80MG................................. 418
SOLTAMOX SOL 10MG/5ML ...................... 150
SOLU-CORTEF INJ 1000MG ........................... 242
SOLU-CORTEF INJ 100MG ............................. 242
SOLU-MEDROL INJ 125MG............................ 242
SOLU-MEDROL INJ 1GM ................................ 242
SOLU-MEDROL INJ 2GM ................................ 242
SOLU-MEDROL INJ 40MG.............................. 242
SOLU-MEDROL INJ 500MG............................ 242
SOMA
TAB 250MG.................................... 372
SOMA
TAB 350MG.................................... 372
SOMATULINE INJ 120/.5ML.......................... 322
SOMATULINE INJ 60/0.2ML.......................... 322
SOMATULINE INJ 90/0.3ML.......................... 323
SOMAVERT INJ 10MG ................................. 316
SOMAVERT INJ 15MG ................................. 316
SOMAVERT INJ 20MG ................................. 316
SOMAVERT INJ 25MG ................................. 316
SOMAVERT INJ 30MG ................................. 316
SOMNOTE
CAP 500MG ............................... 351
SONAFINE
EMU............................................ 306
SONATA
CAP 10MG ................................... 352
SONATA
CAP 5MG ..................................... 352
SOOLANTRA CRE 1% ................................... 291
SOOTHEE
PAD ............................................. 297
SORBITOL
SOL 3% IRR ............................... 340
SORBITOL
SOL 3.3% IRR ..............................340
SORBITOL-MAN SOL....................................... 340
SORIATANE CAP 10MG................................ 269
SORIATANE CAP 17.5MG............................. 269
SORIATANE CAP 25MG................................ 269
SORILUX
AER 0.005%................................. 269
sorine
tab 120mg............................................ 208
sorine
tab 160mg............................................ 208
sorine
tab 240mg............................................ 208
sorine
tab 80mg.............................................. 208
sotalol af tab 120mg........................................... 208
sotalol af tab 160mg........................................... 208
sotalol af tab 80mg ............................................ 208
SOTALOL HCL INJ 150/10ML......................... 208
sotalol hcl tab 120mg.......................................... 208
sotalol hcl tab 80mg............................................ 208
SOTYLIZE
SOL 5MG/ML ............................. 208
SOVALDI
TAB 400MG................................. 196
SPECTRACEF TAB 200MG ............................ 227
SPECTRACEF TAB 400MG ............................ 227
SPECTRAGEL GEL.......................................... 306
SPINAL/EPIDU KIT CL CATH ......................... 358
SPINAL/EPIDU KIT OPN CATH ...................... 358
518
SPINOSAD
SUS 0.9% .................................... 292
SPIRIVA
AER RESPIMAT ............................. 68
SPIRIVA
CAP HANDIHLR ............................ 68
SPIRIVA
SPR RESPIMAT .............................. 68
spirono/hctz tab 25/25 ......................................... 309
spironolact tab 100mg ........................................ 312
spironolact tab 25mg .......................................... 312
spironolact tab 50mg .......................................... 312
SPORANOX CAP 100MG ............................. 118
SPORANOX CAP PULSEPAK...................... 118
SPORANOX SOL 10MG/ML......................... 118
sprintec 28 tab 28 day ........................................ 233
SPRIX
SPR 15.75MG .................................... 18
SPRYCEL
TAB 100MG ................................ 157
SPRYCEL
TAB 140MG ................................ 157
SPRYCEL
TAB 20MG .................................. 157
SPRYCEL
TAB 50MG .................................. 157
SPRYCEL
TAB 70MG .................................. 157
SPRYCEL
TAB 80MG .................................. 157
sps
sus 15gm/60 .......................................... 203
sronyx
tab ...................................................... 233
ss 10-2
sol 10-2%............................................ 256
ssd
cre 1%................................................... 271
sss
cre 10%-5%........................................... 256
SSS 10-4 AER 10-4%...................................... 256
sss 10-5 aer 10-5% .......................................... 256
STAFLEX
TAB 55-500MG ............................. 22
stagesic cap 5-500mg......................................... 27
STALEVO 100 TAB .......................................... 173
STALEVO 125 TAB .......................................... 173
STALEVO 150 TAB .......................................... 173
STALEVO 200 TAB .......................................... 173
STALEVO 50 TAB ........................................... 173
STALEVO 75 TAB ........................................... 173
STAPHAGE LYS INJ ........................................... 208
STARLIX
TAB 120MG ................................. 105
STARLIX
TAB 60MG ................................... 105
stavudine cap 15mg .......................................... 193
stavudine cap 20mg .......................................... 193
stavudine cap 30mg .......................................... 193
stavudine cap 40mg .......................................... 193
stavudine sol 1mg/ml ........................................ 193
STAVZOR
CAP 125MG.................................. 89
STAVZOR
CAP 250MG.................................. 89
STAVZOR
CAP 500MG.................................. 89
STAXYN
TAB 10MG................................... 222
STELARA
INJ 45MG/0.5 .............................. 269
STELARA
INJ 90MG/ML ............................. 269
STENDRA
TAB 100MG ............................... 222
STENDRA
TAB 200MG................................ 222
STENDRA
TAB 50MG.................................. 222
STERIL TALC SUS 5GM .................................. 414
STIMATE
SOL 1.5MG/ML ........................... 323
STIOLTO
AER RESPIMAT ............................ 66
STIVARGA TAB 40MG................................. 155
STRATTERA CAP 100MG ................................. 2
STRATTERA CAP 10MG ................................... 2
STRATTERA CAP 18MG ................................... 2
STRATTERA CAP 25MG ................................... 2
STRATTERA CAP 40MG ................................... 2
STRATTERA CAP 60MG ................................... 2
STRATTERA CAP 80MG ................................... 3
STRAZEPAM PAK.......................................... 350
STRENSIQ
INJ 18/0.45................................... 315
STRENSIQ
INJ 28/0.7ML............................... 315
STRENSIQ
INJ 40MG/ML ............................. 315
STRENSIQ
INJ 80/0.8ML............................... 315
streptomycin inj 1gm.............................................. 11
STRIANT
MIS 30MG ...................................... 46
STRIBILD TAB............................................... 189
STRIVERDI AER RESPIMAT .......................... 67
STROMECTOL TAB 3MG................................. 49
SUBLIMAZE INJ 0.05MG/1 ............................. 39
SUBOXONE MIS 12-3MG ............................... 43
SUBOXONE MIS 2-0.5MG .............................. 43
SUBOXONE MIS 4-1MG ................................. 43
SUBOXONE MIS 8-2MG ................................. 43
SUBOXONE SUB 2-0.5MG ............................. 44
SUBOXONE SUB 8-2MG ................................ 44
SUBSYS
SPR 100MCG .................................. 39
SUBSYS
SPR 1200MCG ................................ 40
SUBSYS
SPR 1600MCG ................................ 40
SUBSYS
SPR 200MCG .................................. 40
SUBSYS
SPR 400MCG .................................. 40
SUBSYS
SPR 600MCG .................................. 40
SUBSYS
SPR 800MCG .................................. 40
SUBUTEX
SUB 2MG ...................................... 44
SUBUTEX
SUB 8MG ...................................... 44
SUCLEAR
KIT............................................... 354
SUCRAID
SOL 8500/ML .............................. 308
sucralfate tab 1gm.............................................. 430
SUFENTA
INJ 50MCG/ML............................. 40
sufentanil inj 100/2ml .......................................... 40
sufentanil inj 250/5ml .......................................... 40
sufentanil inj 50mcg/ml........................................ 40
SULAR
TAB 17MG ..................................... 214
SULAR
TAB 34MG ..................................... 214
SULAR
TAB 8.5MG .................................... 214
519
SULF LIME SOL ............................................. 292
sulf/pred na sol op ............................................... 390
sulf/sunscrn kit 9-4.5% ........................................ 256
SULFACET SOD OIN 10% OP.......................... 392
sulfacet sod sol 10% op ....................................... 392
sulfacetamid lot 10% ........................................... 252
sulfacetamid sus 10%........................................... 252
sulfacleanse sus 8-4%.......................................... 256
sulfadiazine tab 500mg........................................ 414
SULFAMYLON CRE 85MG/GM .................... 271
SULFAMYLON PAK 5%................................. 271
sulfasalazin tab 500mg ........................................ 334
sulfasalazin tab 500mg dr ..................................... 334
sulfatrim pd sus 200-40/5 ...................................... 52
sulfazine tab 500mg .......................................... 334
sulfazine ec tab 500mg......................................... 334
SULFISOXIZOL CRY ........................................ 414
SULFISOXIZOL CRY USP NF.......................... 414
SULFOAM
SHA 2%...................................... 260
sulindac tab 150mg............................................ 18
sulindac tab 200mg............................................ 18
SUMADAN
KIT ............................................ 256
SUMADAN WASH LIQ 9-4.5% ........................ 256
SUMADAN XLT KIT 9-4.5% ........................... 256
sumatriptan inj 4mg/0.5...................................... 364
sumatriptan inj 6mg/0.5...................................... 364
sumatriptan spr 20mg/act ................................... 364
sumatriptan spr 5mg/act ..................................... 364
sumatriptan tab 100mg....................................... 364
sumatriptan tab 25mg......................................... 364
sumatriptan tab 50mg......................................... 364
SUMAVEL DOSE INJ 4MG/0.5 ........................ 364
SUMAVEL DOSE INJ 6MG/0.5 ........................ 364
SUMAXIN
PAD 10-4% ................................. 256
SUMAXIN CP KIT ........................................... 256
SUMAXIN TS SUS 8-4% ................................. 256
SUMAXIN WASH LIQ 9-4%............................. 256
SUPARTZ INJ 25/2.5ML............................... 374
SUPRAX
TAB 400MG ................................. 228
SUPREP BOWEL SOL PREP............................. 354
SURFAXIN SUS 30MG/ML........................... 414
SURMONTIL CAP 100MG ............................... 99
SURMONTIL CAP 25MG ................................. 99
SURMONTIL CAP 50MG ................................. 99
SURVANTA
INH..............................................414
SUSTIVA
CAP 200MG ................................. 191
SUSTIVA
CAP 50MG ................................... 191
SUSTIVA
TAB 600MG ................................. 191
SUTENT
CAP 12.5MG ................................. 155
SUTENT
CAP 25MG .................................... 155
SUTENT
CAP 37.5MG ................................. 155
SUTENT
CAP 50MG .................................... 155
SUTTAR-2 SYP .............................................. 247
SUTTAR-SF SYP............................................. 247
SYLATRON
KIT 200MCG............................. 162
SYLATRON
KIT 300MCG............................. 162
SYLATRON
KIT 600MCG............................. 162
SYLVANT
SOL 100MG ................................ 201
SYLVANT
SOL 400MG ................................ 201
SYMAX DUOTAB TAB..................................... 428
symax fastab tab 0.125mg.................................... 428
symax-sl sub 0.125mg ...................................... 428
symax-sr tab 0.375mg ...................................... 428
SYMBICORT AER 160-4.5............................... 66
SYMBICORT AER 80-4.5................................. 66
SYMBYAX
CAP 12-25MG ........................... 412
SYMBYAX
CAP 12-50MG ........................... 412
SYMBYAX
CAP 3-25MG ............................. 412
SYMBYAX
CAP 6-25MG ............................. 412
SYMBYAX
CAP 6-50MG ............................. 412
SYMLIN
INJ 600MCG ................................. 101
SYMLINPEN 60 INJ 1000MCG......................... 101
SYMLNPEN 120 INJ 1000MCG ........................ 101
SYNAGIS
INJ 100MG/ML............................ 397
SYNAGIS
INJ 50MG ..................................... 397
SYNALAR
CRE 0.025%................................ 278
SUPARTZ FX INJ 25/2.5ML............................ 374
suphera
cre 10-5%.......................................... 256
SUPRACIL
CRE ............................................. 285
SUPRANE
INH ................................................ 337
SUPRANE
SOL ................................................ 337
SUPRAX
CAP 400MG ................................. 227
SUPRAX
CHW 100MG................................ 228
SUPRAX
CHW 200MG................................ 228
SUPRAX
SUS 100/5ML ............................... 228
SUPRAX
SUS 200/5ML ............................... 228
SUPRAX
SUS 500/5ML ............................... 228
SYNALAR
KIT 0.025%................................. 299
SYNALAR
OIN 0.025% ................................ 278
SYNALAR
SOL 0.01%.................................. 278
SYNALAR TS KIT 0.01% ................................ 299
SYNALGOS-DC CAP.......................................... 24
SYNAPRYN SUS 10MG/ML ........................... 40
SYNAREL SOL 2MG/ML ............................. 320
SYNERA
DIS 70-70MG ............................... 297
SYNERCID INJ 500MG ................................... 55
SYNJARDY TAB............................................ 106
SYNJARDY TAB 12.5-500 ............................ 106
520
TARCEVA
TAB 100MG ............................... 157
TARCEVA
TAB 150MG ............................... 157
TARCEVA
TAB 25MG ................................. 157
TARGADOX TAB 50MG............................... 418
TARGRETIN CAP 75MG................................ 169
TARGRETIN GEL 1%..................................... 298
tarina fe tab 1/20............................................... 233
TARKA
TAB 1-240 CR ............................... 129
TARKA
TAB 2-180 CR ............................... 130
TARKA
TAB 2-240 CR ............................... 130
TARKA
TAB 4-240 CR ............................... 130
taron
gra crystals .......................................... 339
TASIGNA
CAP 150MG................................. 157
TASIGNA
CAP 200MG................................. 157
TASMAR
TAB 100MG ................................ 172
TAXOTERE
INJ 20/0.5ML............................. 167
TAXOTERE
INJ 20MG/ML ........................... 167
TAXOTERE
INJ 80MG/4ML ......................... 167
tazicef
inj 1gm ................................................. 228
TAZICEF
INJ 1GM/50ML............................. 228
tazicef
inj 2gm ................................................. 228
tazicef
inj 6gm................................................. 228
TAZORAC
CRE 0.05%.................................. 269
TAZORAC
CRE 0.1%.................................... 269
TAZORAC
GEL 0.05%.................................. 269
TAZORAC
GEL 0.1%.................................... 269
taztia xt cap 120mg/24 ...................................... 214
taztia xt cap 180mg/24 ...................................... 215
taztia xt cap 240mg/24 ...................................... 215
taztia xt cap 300mg/24 ...................................... 215
taztia xt cap 360mg/24...................................... 215
tbc
aer ......................................................... 283
TECFIDERA CAP 120MG .............................. 409
TECFIDERA CAP 240MG .............................. 409
TECFIDERA MIS STARTER.......................... 409
TEFLARO
INJ 400MG .................................. 228
TEFLARO
INJ 600MG .................................. 228
TEGADERM AG PAD 2.................................... 306
TEGADERM AG PAD 4.................................... 306
TEGADERM AG PAD 8.................................... 306
TEGRETOL
CHW 100MG ............................... 84
TEGRETOL
SUS 100/5ML .............................. 84
TEGRETOL
TAB 200MG ................................ 84
TEGRETOL-XR TAB 100MG............................. 84
TEKAMLO
TAB 150-10MG ......................... 144
TEKAMLO
TAB 150-5MG ........................... 144
TEKAMLO
TAB 300-10MG ......................... 144
SYNJARDY TAB 5-1000MG......................... 106
SYNJARDY TAB 5-500MG........................... 106
SYNRIBO
INJ 3.5MG.................................... 162
SYNTHROID TAB 100MCG .......................... 422
SYNTHROID TAB 25MCG ............................ 422
synvexia pad 4-1%........................................... 297
SYNVEXIA TC CRE 4-1% ............................... 297
SYNVISC
INJ 8MG/ML................................ 374
SYNVISC ONE INJ 8MG/ML........................... 374
SYPRINE
CAP 250MG ................................. 199
T
TABLOID
TAB 40MG .................................. 152
TABRADOL SUS 1MG/ML........................... 372
TACLONEX OIN............................................ 299
TACLONEX SUS ........................................... 299
tacrolimus cap 0.5mg......................................... 202
tacrolimus cap 1mg............................................ 202
tacrolimus cap 5mg............................................ 202
tacrolimus oin 0.03%......................................... 288
tacrolimus oin 0.1%........................................... 288
TAFINLAR
CAP 50MG ................................. 153
TAFINLAR
CAP 75MG ................................. 153
TAGRISSO
TAB 40MG ................................. 157
TAGRISSO
TAB 80MG ................................. 157
take action tab 1.5mg.......................................... 234
TALWIN
INJ 30MG/ML ................................ 44
TAMBOCOR TAB 100MG .............................. 64
TAMBOCOR TAB 150MG .............................. 64
TAMBOCOR TAB 50MG ................................ 64
TAMIFLU
CAP 30MG .................................. 198
TAMIFLU
CAP 45MG .................................. 198
TAMIFLU
CAP 75MG .................................. 198
TAMIFLU
SUS 12MG/ML............................ 198
TAMIFLU
SUS 6MG/ML.............................. 198
tamoxifen tab 10mg .......................................... 150
tamoxifen tab 20mg .......................................... 150
tamsulosin cap 0.4mg ........................................ 338
TAPAZOLE
TAB 10MG ................................ 418
TAPAZOLE
TAB 5MG .................................. 418
521
TEKAMLO
TAB 300-5MG ........................... 144
TEKTURNA TAB 150MG ............................. 144
TEKTURNA TAB 300MG ............................. 144
TEKTURNA HCT TAB 150-12.5....................... 144
TEKTURNA HCT TAB 150-25MG ................... 144
TEKTURNA HCT TAB 300-12.5....................... 144
TEKTURNA HCT TAB 300-25MG ................... 144
telmis/amlod tab 40-10mg ................................... 137
telmis/amlod tab 40-5mg ..................................... 137
telmis/amlod tab 80-10mg ................................... 137
telmis/amlod tab 80-5mg ..................................... 137
telmisa/hctz tab 40-12.5 ....................................... 138
telmisa/hctz tab 80-12.5 ....................................... 138
telmisa/hctz tab 80-25mg ..................................... 138
telmisartan tab 20mg .......................................... 140
temazepam cap 15mg........................................ 351
temazepam cap 22.5mg..................................... 351
temazepam cap 30mg........................................ 351
temazepam cap 7.5mg....................................... 351
TEMODAR
CAP 100MG ............................. 164
TEMODAR
CAP 140MG ............................. 164
TEMODAR
CAP 180MG ............................. 164
TEMODAR
CAP 20MG ............................... 164
TEMODAR
CAP 250MG ............................. 164
TEMODAR
CAP 5MG ................................. 164
TEMODAR
INJ 100MG ............................... 164
TEMOVATE CRE 0.05% .............................. 278
TEMOVATE GEL 0.05% .............................. 278
TEMOVATE OIN 0.05% ............................... 278
TEMOVATE SOL 0.05% .............................. 278
TEMOVATE E CRE 0.05%EML ..................... 278
temozolomide cap 100mg..................................... 164
temozolomide cap 20mg....................................... 164
temozolomide cap 5mg......................................... 164
tencon
tab 50-325mg ....................................... 22
TENCON
TAB 50-650MG ............................. 22
TENEX
TAB 1MG....................................... 141
TENEX
TAB 2MG....................................... 141
TENIPOSIDE INJ 50MG/5ML ......................... 167
TENORETIC TAB 100 .................................... 143
TENORETIC TAB 50 ...................................... 143
TENORMIN TAB 100MG.............................. 206
TENORMIN TAB 25MG................................ 206
TENORMIN TAB 50MG................................ 206
TERAZOL 3 CRE 0.8% ................................... 436
TERAZOL 3 SUP 80MG.................................. 436
TERAZOL 7 CRE 0.4% ................................... 436
terazosin cap 10mg ........................................... 142
terazosin cap 1mg ............................................. 142
terazosin cap 2mg ............................................. 142
terazosin cap 5mg ............................................. 142
terbinafine tab 250mg ......................................... 117
TERBINEX
KIT .............................................. 117
terbutaline inj 1mg/ml........................................... 67
terbutaline tab 2.5mg ............................................ 67
terbutaline tab 5mg ............................................... 67
terconazole cre 0.4%........................................... 436
terconazole cre 0.8%........................................... 436
terconazole sup 80mg.......................................... 436
terrell
sol......................................................... 337
TERSI FOAM AER 2.25%................................ 271
TESSALON
CAP 200MG............................... 244
TESSALON PER CAP 100MG........................... 244
TEST EO-PRO- INJ CYP 220............................... 45
TESTONE CIK KIT 200MG/ML......................... 46
TESTOPEL MIS PELLETS .............................. 46
testost cyp inj 100mg/ml........................................ 46
testost cyp inj 200mg/ml........................................ 46
testost enan inj 200mg/ml ...................................... 46
testosterone gel 1%(25mg)..................................... 46
testosterone gel 1%(50mg)..................................... 46
TESTOSTERONE GEL 10MG/ACT .................... 46
testosterone gel pump 1% ...................................... 46
TESTOSTERONE INJ 250MG/ML ...................... 46
TESTOSTERONE MIS 100MG............................ 46
TESTOSTERONE MIS 12.5MG........................... 46
TESTOSTERONE MIS 200MG............................ 46
TESTOSTERONE MIS 25MG.............................. 46
TESTOSTERONE MIS 50MG.............................. 46
TESTRED
CAP 10MG..................................... 46
tetcaine sol 0.5% op......................................... 389
tetrabenazin tab 12.5mg....................................... 408
tetrabenazin tab 25mg.......................................... 408
tetracaine inj 1%................................................ 359
tetracaine sol 0.5% op ....................................... 389
tetracycline cap 250mg ........................................ 418
tetracycline cap 500mg ........................................ 418
TETRAMEX SPR 2-1-3%............................... 297
tetravisc sol 0.5% op......................................... 389
tetravisc sol forte............................................... 389
tetrix
cre ......................................................... 289
522
TETRIX
KIT ................................................. 289
TEVETEN
TAB 400MG................................ 140
TEVETEN
TAB 600MG................................ 140
TEVETEN HCT TAB 600-12.5 ......................... 138
TEVETEN HCT TAB 600-25MG...................... 138
TEV-TROPIN INJ 5MG.................................... 318
TEXACORT
SOL 2.5% .................................. 278
TGQ 15DM/5PE SYP H/2CPM .......................... 250
tgq 30/
syp 150/15........................................... 247
tgq 30/pse/3 syp brm/15dm.................................. 250
TGQ 50PSE/3 SYP BRM/30DM ....................... 250
THALITONE TAB 15MG ............................... 313
THALOMID CAP 100MG.............................. 198
THALOMID CAP 150MG.............................. 198
THALOMID CAP 200MG.............................. 198
THALOMID CAP 50MG................................ 198
THEO-24
CAP 100MG CR.............................. 71
THEO-24
CAP 200MG CR.............................. 71
THEO-24
CAP 300MG CR.............................. 71
THEO-24
CAP 400MG ER .............................. 71
theochron tab 100mg cr...................................... 71
theophyl/d5w inj 0.8mg/ml..................................... 72
theophyl/d5w inj 2mg/ml........................................ 72
theophyl/d5w inj 4mg/ml........................................ 72
theophylline sol 80/15ml........................................ 72
theophylline tab 100mg cr ..................................... 72
theophylline tab 100mg er ..................................... 72
theophylline tab 400mg.......................................... 72
THERABENZAPR PAK -60............................... 374
THERABENZAPR PAK -90............................... 374
THERABENZAPR PAK -90-5 ........................... 374
THERACODEINE PAK -300 ............................... 24
THERACODOPHE PAK -750 .............................. 27
THERACODOPHN PAK -325 ............................. 27
THERACODOPHN PAK -650 ............................. 27
THERACODOPHN PAK -LOW-90 ..................... 27
THERACYS
INJ................................................ 162
THERAHONEY GEL........................................ 306
THERAPENTIN PAK -60.................................... 78
THERAPENTIN PAK -90.................................... 78
THERATRAMADO PAK -60............................... 44
THERATRAMADO PAK -90............................... 44
thermazene cre 1%............................................. 272
THIOLA
TAB 100MG .................................. 341
thioridazine tab 100mg ........................................ 184
thioridazine tab 10mg .......................................... 184
thiotepa inj 15mg ............................................. 149
thiothixene cap 10mg .......................................... 187
thiothixene cap 1mg ............................................ 187
THYMOGLOBULN INJ 25MG.......................... 200
THYROGEN
INJ 1.1MG ................................ 307
THYROLAR-1 TAB 60MG .............................. 422
THYROLAR-1/2 TAB 30MG ............................. 422
THYROLAR-1/4 TAB 15MG ............................. 422
THYROLAR-2 TAB 120MG ............................ 422
THYROLAR-3 TAB 180MG ............................ 423
tiagabine tab 2mg ............................................... 87
tiagabine tab 4mg ............................................... 87
TIAZAC
CAP 120MG/24.............................. 215
TIAZAC
CAP 180MG/24.............................. 215
TIAZAC
CAP 240MG/24.............................. 215
TIAZAC
CAP 300MG/24.............................. 215
TIAZAC
CAP 360MG/24.............................. 215
TIAZAC
CAP 420MG/24.............................. 215
TICE BCG INJ ...................................................162
ticlopidine tab 250mg.......................................... 344
TIGAN
CAP 300MG.................................... 115
TIGAN
INJ 100MG/ML............................... 115
TIKOSYN
CAP 125MCG ................................ 65
TIKOSYN
CAP 250MCG ................................ 65
TIKOSYN
CAP 500MCG ................................ 65
tilia fe tab ......................................................... 237
TIMENTIN INJ 3.1GM ................................... 403
TIMENTIN INJ 31GM .................................... 403
timolol gel sol 0.25% op ..................................... 382
timolol gel sol 0.5% op ....................................... 382
timolol mal sol 0.25% op ......................................382
timolol mal sol 0.5% op ...................................... 382
timolol mal tab 10mg .......................................... 208
timolol mal tab 20mg .......................................... 208
timolol mal tab 5mg ............................................ 208
TIMOPTIC SOL 0.25% OP............................. 382
523
TIMOPTIC SOL 0.5% OP .............................. 382
TIMOPTIC OCU SOL 0.25% OP ....................... 382
TIMOPTIC OCU SOL 0.5% OP ......................... 382
TIMOPTIC-XE SOL 0.25% OP ......................... 382
TIMOPTIC-XE SOL 0.5% OP ........................... 382
TINDAMAX
TAB 250MG ............................... 50
TINDAMAX
TAB 500MG ............................... 50
tinidazole tab 250mg ........................................... 50
tinidazole tab 500mg ........................................... 50
TIROSINT
CAP 100MCG .............................. 423
TIROSINT
CAP 112MCG .............................. 423
TIROSINT
CAP 125MCG .............................. 423
TIROSINT
CAP 137MCG .............................. 423
TIROSINT
CAP 13MCG ................................ 423
TIROSINT
CAP 150MCG .............................. 423
TIROSINT
CAP 25MCG ................................ 423
TIROSINT
CAP 50MCG ................................ 423
TIROSINT
CAP 75MCG ................................ 423
TIROSINT
CAP 88MCG ................................ 423
TIVICAY
TAB 50MG .................................. 189
TIVORBEX CAP 20MG................................... 18
TIVORBEX CAP 40MG................................... 18
tizanidine cap 2mg............................................. 372
TIZANIDINE KIT COMFORT......................... 374
tizanidine tab 2mg ............................................. 373
tizanidine tab 4mg ............................................. 373
tl bpo mx liq 4.25%........................................... 260
TL TRISEB CRE.............................................. 270
tl urea
lot 45% ................................................ 280
TL-CERMIDE EMU ......................................... 289
TNKASE
KIT 50MG .................................... 345
TOBI
NEB 300/5ML..................................... 11
TOBI PODHALR CAP 28MG .............................. 11
tobra/dexame sus 0.3-0.1%.................................. 390
tobra/nacl inj 60/0.9 ............................................ 11
tobra/nacl inj 80/0.9 ............................................ 11
TOBRADEX OIN 0.3-0.1%............................ 391
TOBRADEX SUS 0.3-0.1%............................ 391
TOBRADEX ST SUS 0.3-0.05 .......................... 391
tobramycin inj 1.2/30ml....................................... 11
tobramycin inj 1.2gm ........................................... 11
tobramycin inj 10mg/ml ....................................... 11
tobramycin inj 40mg/ml ....................................... 11
tobramycin inj 80mg/2ml ..................................... 11
tobramycin neb 300/5 .......................................... 11
tobramycin neb 300/5ml ...................................... 11
tobramycin sol 0.3% op ..................................... 386
TOBREX
OIN 0.3% OP ................................ 386
TOBREX
SOL 0.3% OP................................ 386
TOFRANIL TAB 10MG ................................. 100
TOFRANIL TAB 25MG ................................. 100
TOFRANIL TAB 50MG ................................. 100
TOFRANIL-PM CAP 100MG............................ 100
TOFRANIL-PM CAP 75MG.............................. 100
TOLAK
CRE 4%.......................................... 268
tolazamide tab 250mg ........................................ 109
tolazamide tab 500mg ........................................ 109
tolbutamide tab 500mg ....................................... 109
tolcapone tab 100mg......................................... 172
tolmetin sod cap 400mg ......................................... 18
tolmetin sod tab 200mg .......................................... 19
tolmetin sod tab 600mg .......................................... 19
tolterodine cap 2mg er ........................................ 435
tolterodine cap 4mg er ........................................ 435
tolterodine tab 1mg ............................................. 435
tolterodine tab 2mg ............................................. 435
TOPAMAX
TAB 100MG ................................ 85
TOPAMAX
TAB 200MG ................................ 85
TOPAMAX
TAB 25MG .................................. 85
TOPAMAX
TAB 50MG .................................. 85
TOPAMAX SPR CAP 15MG............................... 85
TOPAMAX SPR CAP 25MG............................... 85
topex topcal spr anesthet...................................... 365
TOPICORT CRE 0.05%.................................. 278
TOPICORT CRE 0.25%.................................. 278
TOPICORT GEL 0.05%.................................. 278
TOPICORT OIN 0.05%................................... 279
TOPICORT OIN 0.25%................................... 279
TOPICORT SPR 0.25%................................... 279
topiragen tab 100mg ........................................... 85
topiragen tab 200mg ........................................... 85
topiragen tab 25mg ............................................. 85
topiragen tab 50mg ............................................. 85
topiramate cap 15mg ........................................... 85
topiramate cap 25mg ........................................... 85
TOPIRAMATE CAP ER 100MG........................ 85
TOPIRAMATE CAP ER 25MG.......................... 85
TOPIRAMATE CAP ER 50MG.......................... 85
topiramate tab 100mg .......................................... 85
topiramate tab 200mg .......................................... 85
topiramate tab 25mg ............................................ 85
topiramate tab 50mg ............................................ 85
524
toposar inj 100/5ml......................................... 167
toposar inj 1gm/50ml...................................... 167
toposar inj 20mg/ml........................................ 167
toposar inj 500/25ml....................................... 167
topotecan inj 4mg ............................................. 170
TOPOTECAN INJ 4MG/4ML ......................... 170
TOPROL XL TAB 100MG .............................. 206
TOPROL XL TAB 200MG .............................. 206
TOPROL XL TAB 25MG ................................ 206
TOPROL XL TAB 50MG ................................ 206
TORISEL
SOL 25MG/ML............................. 155
TORSEMIDE INJ 20MG/2ML ........................ 311
TORSEMIDE INJ 50MG/5ML ........................ 311
torsemide tab 100mg ........................................ 311
torsemide tab 10mg .......................................... 311
torsemide tab 20mg .......................................... 311
torsemide tab 5mg ............................................ 311
TOTECT
INJ 500MG.................................... 162
TOUJEO SOLO INJ 300IU/ML......................... 104
TOVIAZ
TAB 4MG ...................................... 435
TOVIAZ
TAB 8MG ...................................... 435
TRACLEER
TAB 125MG .............................. 221
TRACLEER
TAB 62.5MG ............................. 221
TRADJENTA TAB 5MG................................. 102
tramadl/apap tab 37.5-325 .................................... 44
TRAMADOL CRE 5% ................................... 262
TRAMADOL CRE 8% KIT............................ 262
TRAMADOL HCL CAP 150MG ER ................... 40
tramadol hcl cap er 100mg.................................... 40
tramadol hcl tab 100mg er .................................... 40
tramadol hcl tab 50mg........................................... 40
TRANDATE
TAB 100MG ............................. 204
TRANDATE
TAB 200MG ............................. 204
TRANDATE
TAB 300MG ............................. 204
trando/verap tab 1-240 cr.................................... 130
trando/verap tab 1-240 er.................................... 130
trandolapril tab 1mg............................................ 134
tranex acid inj 1000m/10 .................................... 349
tranex acid inj 100mg/ml .................................... 349
tranex acid tab 650mg......................................... 349
TRANSDERM-SC DIS 1MG.............................. 115
TRANXENE T TAB 15MG ................................ 61
TRANXENE T TAB 3.75MG ............................. 61
TRANXENE T TAB 7.5MG ............................... 61
tranylcyprom tab 10mg .......................................... 91
TRASYLOL
INJ 10000/ML............................ 349
TRAVASOL INJ 10% ..................................... 380
TRAVATAN Z DRO 0.004% ........................... 393
travoprost dro 0.004% ....................................... 393
TRAZAMINE PAK ............................................ 95
TRAZAMINE PAK 50MG................................. 95
trazodone tab 100mg........................................... 95
trazodone tab 150mg........................................... 95
trazodone tab 300mg........................................... 95
trazodone tab 50mg............................................. 95
TREAGAN OTIC DRO....................................... 395
TREANDA
INJ 100MG ................................. 149
TREANDA
INJ 180/2ML............................... 149
TREANDA
INJ 25MG ................................... 149
TREANDA
INJ 45/0.5ML.............................. 149
TRECATOR
TAB 250MG .............................. 148
TRELSTAR INJ 11.25MG .............................. 165
TRELSTAR INJ 3.75MG ................................ 165
TRELSTAR MIX INJ 11.25MG.......................... 165
TRELSTAR MIX INJ 22.5MG............................ 165
TRELSTAR MIX INJ 3.75MG............................ 165
TRENTAL TAB 400MG CR.......................... 342
TRESIBA FLEX INJ 100UNIT........................... 105
TRESIBA FLEX INJ 200UNIT........................... 105
tretinoin cap 10mg ........................................... 169
tretinoin cre 0.025% ........................................ 261
tretinoin cre 0.05% .......................................... 261
tretinoin cre 0.1% ............................................ 261
tretinoin gel 0.01% ........................................... 261
tretinoin gel 0.025% ......................................... 261
tretinoin gel 0.04% ........................................... 261
tretinoin gel 0.04%pmp .................................... 261
tretinoin gel 0.05% ........................................... 261
tretinoin gel 0.1% ............................................. 261
tretinoin gel 0.1%pump .................................... 261
TRETIN-X CRE 0.0375% ............................... 260
TRETIN-X CRE 0.075% ................................. 260
TRETIN-X CRE KIT 0.025% ............................. 260
TRETIN-X CRE KIT 0.05% ............................... 261
TRETIN-X CRE KIT 0.1% ................................. 261
TRETIN-X GEL KIT 0.01%................................ 261
525
TRETIN-X GEL KIT 0.025% ............................. 261
TREXALL TAB 10MG.................................. 152
TREXALL TAB 15MG.................................. 152
TREXALL TAB 5MG.................................... 152
TREXALL TAB 7.5MG................................. 152
trexbrom liq .................................................... 250
TREXIMET
TAB 85-500MG ......................... 362
TREZIX
CAP .................................................. 24
triamcin ace inj 10mg/ml ..................................... 242
triamcin/ora pst 0.1% .......................................... 370
triamcinolon aer 55mcg/ac .................................. 376
triamcinolon aer spray......................................... 279
triamcinolon cre 0.025% ..................................... 279
triamcinolon cre 0.1% ......................................... 279
triamcinolon cre 0.5% ......................................... 279
TRIAMCINOLON INJ 40MG/ML ..................... 242
TRIAMCINOLON INJ 80MG/2ML ................... 242
triamcinolon lot 0.025% ...................................... 279
triamcinolon lot 0.1% .......................................... 279
triamcinolon oin 0.025% ..................................... 279
triamcinolon oin 0.05% ....................................... 279
triamcinolon oin 0.1% ......................................... 279
triamcinolon oin 0.5% ......................................... 279
triamcinolon pst 0.1%.......................................... 370
TRIAMCN/LIDO INJ 40MG-1%........................ 244
TRIAMSIL PAK COMBIPAK ....................... 299
TRIAMSIL PAK MULTIPAK........................ 299
triamt/hctz cap 37.5-25....................................... 309
triamt/hctz cap 50-25mg ..................................... 309
triamt/hctz tab 37.5-25........................................ 309
triamt/hctz tab 75-50mg...................................... 309
TRIANEX
OIN 0.05% ................................... 279
triazolam tab 0.125mg...................................... 351
triazolam tab 0.25mg........................................ 351
TRIBENZOR20- TAB 5-12.5MG ....................... 136
TRIBENZOR40- TAB 10-12.5 ........................... 136
TRIBENZOR40- TAB 10-25MG ........................ 136
TRIBENZOR40- TAB 5-12.5MG ....................... 136
TRIBENZOR40- TAB 5-25MG .......................... 136
TRI-CHLOR LIQ 80% ..................................... 272
TRICHLOROACE CRY ACID........................... 272
TRICITRASOL CON ........................................... 76
tricitrates sol ....................................................... 339
TRICOR
TAB 145MG .................................. 125
TRICOR
TAB 48MG .................................... 125
triderm
cre 0.1%............................................. 279
TRIDERMA CRE FORTE .............................. 299
TRIESENCE INJ 40MG/ML............................ 392
tri-estaryll tab ...................................................... 237
trifluoperaz tab 10mg........................................... 184
trifluoperaz tab 1mg............................................. 184
trifluridine sol 1% op ........................................... 386
TRIGLIDE TAB 160MG................................. 125
TRIGLIDE TAB 50MG................................... 125
trihexyphen elx 0.4mg/ml .................................... 171
trihexyphen tab 2mg............................................ 171
trihexyphen tab 5mg............................................ 171
tri-legest tab fe ................................................... 237
TRILEPTAL SUS 300MG/5M........................... 85
TRILEPTAL TAB 150MG................................. 86
TRILEPTAL TAB 300MG................................. 86
TRILEPTAL TAB 600MG................................. 86
tri-linyah tab ...................................................... 237
TRILIPIX CAP 135MG................................... 125
TRILIPIX CAP 45MG..................................... 125
trilyte sol ......................................................... 354
trimethobenz cap 300mg ...................................... 115
trimethobenz inj 100mg/ml................................... 115
trimethoprim sol polymyxn................................... 384
trimethoprim tab 100mg......................................... 50
trimipramine cap 100mg...................................... 100
trimipramine cap 25mg........................................ 100
trimipramine cap 50mg........................................ 100
trinessa tab....................................................... 237
TRI-NORINYL TAB 28 ..................................... 237
TRIOSTAT INJ 10MCG/ML .......................... 423
TRIOXIN
SUS OTIC...................................... 395
TRIPLE DYE LIQ ...............................................187
tri-previfem tab..................................................... 237
TRISENOX
SOL 10MG/10M ......................... 162
TRISEON
CRE............................................... 256
tri-sprintec tab ..................................................... 237
TRIUMEQ
TAB ............................................. 189
trivora-28 tab ..................................................... 237
TRIZIVIR TAB ............................................... 189
TROKENDI XR CAP 100MG ............................. 86
TROKENDI XR CAP 200MG ............................. 86
TROKENDI XR CAP 25MG ............................... 86
TROKENDI XR CAP 50MG ............................... 86
TROLAMINE LIQ .............................................404
TROLAMINE LIQ 99% ................................... 404
tropazone cre .................................................... 307
TROPAZONE LOT .......................................... 283
TROPHAMINE INJ 10% .................................. 380
526
ULTRAM
TAB 50MG .................................... 40
ULTRAM ER TAB 100MG ............................... 41
ULTRAM ER TAB 200MG ............................... 41
ULTRAM ER TAB 300MG ............................... 41
ULTRASAL-ER SOL 28.5%.............................. 286
ULTRAVATE CRE 0.05% .............................. 279
ULTRAVATE KIT ........................................... 299
ULTRAVATE KIT PAC .................................. 299
ULTRAVATE OIN 0.05% ............................... 279
ULTRAVATE X KIT 0.05-10% ........................ 299
ULTRESA
CAP 13800UNT........................... 308
ULTRESA
CAP 20700UNT........................... 308
ULTRESA
CAP 23000UNT........................... 308
UMECTA
EMU ...............................................280
UMECTA
SUS 40%...................................... 280
umecta mouss aer 40% ........................................ 280
UMECTA NAIL SUS FILM .............................. 281
UMECTA PD EMU 40-0.3% ........................... 282
UMECTA PD SUS 40-0.3%............................. 282
UNASYN
INJ 1.5GM.................................... 403
UNASYN
INJ 1.5GM PB.............................. 403
UNASYN
INJ 15GM..................................... 403
UNASYN
INJ 3GM....................................... 403
UNIRETIC
TAB 15-12.5................................. 131
UNIRETIC
TAB 15-25MG ............................. 132
UNIRETIC
TAB 7.5-12.5................................ 132
unith direct tab 100mcg ....................................... 423
unith direct tab 25mcg ......................................... 423
unithroid tab 100mcg........................................ 424
unithroid tab 25mcg.......................................... 424
TROPHAMINE INJ 6% .................................... 380
tropicamide sol 0.5% op ..................................... 383
tropicamide sol 1% op ........................................ 383
trospium chl cap 60mg er .................................... 435
trospium cl tab 20mg .......................................... 435
TRUSOPT
SOL 2% OP.................................. 386
TRUVADA
TAB 200-300 ............................. 189
TUDORZA PRES AER 400/ACT......................... 68
TURPENTINE SOL SPIRITS ........................... 286
TUSNEL
CAP ............................................... 246
TUSNEL PED-C SYP ......................................... 247
tussafed ex liq ..................................................... 247
TUSSICAPS CAP 10-8MG.............................. 250
TUSSICAPS CAP 5-4MG................................ 250
tussigon tab 5-1.5mg........................................ 245
TUSSIONEX SUS 10-8/5ML .......................... 250
TUZISTRA XR SUS .......................................... 250
TWINJECT INJ 0.15MG................................. 438
TWINJECT INJ 0.3MG................................... 438
TWYNSTA
TAB 40-10MG ........................... 137
TWYNSTA
TAB 40-5MG ............................. 137
TWYNSTA
TAB 80-10MG ........................... 137
TWYNSTA
TAB 80-5MG ............................. 137
TYBOST
TAB 150MG ................................. 189
TYGACIL INJ 50MG....................................... 53
TYKERB
TAB 250MG ................................. 157
TYLENOL/COD TAB #3 .................................... 24
TYLENOL/COD TAB #4 .................................... 24
TYLOX
CAP 5-500MG ................................. 42
TYSABRI
INJ 300/15ML .............................. 409
TYVASO
SOL 0.6MG/ML ........................... 220
TYVASO REFIL SOL 0.6MG/ML ..................... 220
TYVASO START SOL 0.6MG/ML ................... 220
TYZEKA
TAB 600MG ................................. 194
TYZINE
SOL 0.1% ....................................... 376
TYZINE PED DRO 0.05%................................ 376
U
UCERIS
AER 2MG/ACT................................ 47
UCERIS
TAB 9MG....................................... 242
u-cort
cre 1% ................................................. 299
u-kera e cre 40%.............................................. 280
ULESFIA
LOT 5%......................................... 292
ULORIC
TAB 40MG .................................... 341
ULORIC
TAB 80MG .................................... 341
ULTANE
SOL............................................... 337
ULTIVA
INJ 1MG .......................................... 40
ULTIVA
INJ 2MG .......................................... 40
ULTIVA
INJ 5MG .......................................... 40
ULTRACET
TAB 37.5-325 .............................. 44
527
UROQID #2 TAB ............................................. 432
UROXATRAL TAB 10MG ............................. 338
URSO 250 TAB 250MG ................................. 331
URSO FORTE TAB 500MG............................. 331
ursodiol cap 300mg.......................................... 331
ursodiol tab 250mg .......................................... 331
ursodiol tab 500mg .......................................... 331
uryl
tab............................................................434
ustell
cap ........................................................ 434
uta
cap 120mg............................................. 434
UTIBRON
CAP NEOHALER ......................... 66
uticap
cap..........................................................434
utira-c
tab ..........................................................434
UTOPIC
CRE 41% ........................................ 281
utrona-c tab...................................................... 434
UVADEX
INJ 20MCG/ML........................... 161
V
UNITUXIN INJ ................................................. 154
UNIVASC
TAB 15MG .................................. 134
UNIVASC
TAB 7.5MG ................................. 134
univert
tab 32mg ............................................. 115
ur n-c
tab ....................................................... 433
URAMAXIN AER 20% .................................. 282
URAMAXIN CRE 45% .................................. 281
URAMAXIN GEL 45% .................................. 281
URAMAXIN LOT 45% .................................. 281
URAMAXIN GT GEL 45% ............................... 281
URAMAXIN GT KIT 45% ................................ 281
uramit mb cap 118mg ....................................... 433
urea
cre 39%................................................ 281
urea
cre 40%................................................ 281
urea
cre 45%................................................ 281
urea
cre 47%................................................ 281
urea
cre 50%................................................ 281
urea
emu 50% .............................................. 282
urea
gel 40%................................................ 281
urea
lot 40% ................................................ 281
urea
lot 45% ................................................ 281
urea
sus 50%................................................ 282
urea 40% sus nail ............................................ 281
urea hydrati aer 35%........................................... 282
urea nail gel 45%.............................................. 281
UREA NAIL KIT ............................................. 282
UREA NAIL MIS 50% .................................... 282
urea topical sus 40%............................................ 281
urea-c40 lot 40% ............................................. 281
URECHOLINE TAB 10MG.............................. 436
URECHOLINE TAB 5MG ............................... 436
urelle
tab........................................................ 433
uretron d/s tab..................................................... 433
UREVAZ
CRE 44% ...................................... 281
UREX
TAB 1GM ........................................ 433
uribel
cap 118mg ........................................... 433
URIMAR-T
TAB............................................. 433
urin d/s tab....................................................... 433
uro-blue tab 81.6mg ........................................ 433
UROCIT-K 10 TAB ........................................... 339
UROCIT-K 15 TAB ........................................... 339
UROCIT-K 5 TAB ............................................ 339
UROGESIC- TAB BLUE ................................ 433
uro-l
tab 81mg .............................................. 433
urolet mb tab..................................................... 433
uro-mp
cap 118mg......................................... 433
urophen mb tab 81.6mg ..................................... 434
VAGIFEM
TAB 10MCG ............................... 437
valacyclovir tab 1gm............................................ 197
valacyclovir tab 500mg ........................................ 197
VALCHLOR GEL 0.016%.............................. 267
VALCYTE
SOL 50MG/ML........................... 194
VALCYTE
TAB 450MG ............................... 194
valganciclov tab 450mg ....................................... 194
VALIDERM CRE............................................ 299
VALIUM
TAB 10MG ..................................... 61
VALIUM
TAB 2MG ....................................... 61
VALIUM
TAB 5MG ....................................... 62
valproate inj 100mg/ml ....................................... 89
valproate inj 500/5ml.......................................... 89
valproic acd cap 250mg ......................................... 89
valproic acd sol 250/5ml........................................ 89
valproic acd syp 250/5ml ....................................... 89
valsart/hctz tab 160-12.5...................................... 138
valsart/hctz tab 160-25mg.................................... 138
valsart/hctz tab 320-12.5...................................... 139
valsart/hctz tab 320-25mg.................................... 139
valsart/hctz tab 80-12.5........................................ 139
valsartan tab 160mg ......................................... 140
valsartan tab 320mg ......................................... 140
valsartan tab 40mg ........................................... 140
valsartan tab 80mg ........................................... 140
VALSTAR
SOL 40MG/ML ........................... 159
VALTREX
TAB 1GM ................................... 197
VALTREX
TAB 500MG ............................... 197
VALTURNA TAB 150-160 ........................... 144
VALTURNA TAB 300-320 ........................... 144
VANATOL LQ SOL ........................................... 22
VANCOCIN HCL CAP 125MG ........................... 50
528
VANCOCIN HCL CAP 250MG ........................... 50
VANCOMYC/DEX INJ 1GM............................... 51
VANCOMYC/DEX INJ 500MG........................... 51
VANCOMYC/DEX INJ 750MG........................... 51
vancomycin cap 125mg........................................ 51
vancomycin cap 250mg........................................ 51
vancomycin inj 1 gm ............................................ 51
vancomycin inj 1000mg ....................................... 51
vancomycin inj 10gm ........................................... 51
vancomycin inj 500mg ......................................... 51
vancomycin inj 5gm ............................................. 51
VANCOMYCIN INJ 750MG.............................. 51
VANCOMYCIN SUS +SYRSPEN..................... 51
VANCOMYCN 25 SOL 25MG/ML ..................... 51
VANCOMYCN 50 SOL 50MG/ML ..................... 51
vandazole gel 0.75%......................................... 437
VANDETANIB TAB 100MG........................... 157
VANDETANIB TAB 300MG........................... 157
VANOS
CRE 0.1% ...................................... 279
VANOXIDE HC KIT ......................................... 256
VANOXIDE-HC LOT 5-0.5% ........................... 256
VANTAS
KIT 50MG .................................... 165
VAPRISOL INJ ................................................. 323
VAPRISOL INJ 20/100ML............................. 323
VARIZIG
INJ 125UNIT................................. 399
VARUBI
TAB 90MG.................................... 116
VASCEPA
CAP 1GM.................................... 123
VASCUDERM GEL HYDROGEL ................. 307
VASCUDERM KIT STASIS ........................... 307
VASERETIC TAB 10-25MG........................... 132
vasolex
oin ...................................................... 283
vasopressin inj 10/0.5ml ..................................... 323
vasopressin inj 20unt/ml ..................................... 323
VASOSTRICT INJ 20UNT/ML........................ 324
VASOTEC
TAB 10MG ................................. 134
VASOTEC
TAB 2.5MG ................................ 135
VASOTEC
TAB 20MG ................................. 135
VASOTEC
TAB 5MG ................................... 135
VAZCULEP
INJ 10MG/ML ........................... 440
VAZOL
LIQ 2MG/5ML............................... 119
VECAMYL TAB 2.5MG ............................... 142
VECTIBIX INJ 100MG .................................. 154
VECTIBIX INJ 400MG .................................. 154
VECTICAL
OIN 3MCG/GM.......................... 270
vecuronium inj 10mg ......................................... 377
vecuronium inj 20mg ......................................... 377
VELCADE
INJ 3.5MG .................................. 156
VELETRI
INJ 0.5MG .................................... 220
VELETRI
INJ 1.5MG .................................... 220
velivet
pak ....................................................... 237
VELMA
PAD 16-4-2% ................................ 297
VELPHORO
CHW 500MG ............................ 335
VELTIN
GEL ................................................ 256
VELTRIX
CRE 4-1% ..................................... 297
VENELEX
OIN .............................................. 300
venlafaxine cap 150mg er ..................................... 96
venlafaxine cap 37.5 er ......................................... 96
venlafaxine cap 37.5mg......................................... 96
venlafaxine cap 75mg er ....................................... 96
venlafaxine tab 100mg .......................................... 96
venlafaxine tab 150mg er ...................................... 96
venlafaxine tab 225mg er ...................................... 97
venlafaxine tab 25mg ............................................ 97
venlafaxine tab 37.5 er.......................................... 97
venlafaxine tab 37.5mg ......................................... 97
venlafaxine tab 75mg er ........................................ 97
VENTAVIS SOL 10MCG/ML........................ 220
VENTAVIS SOL 20MCG/ML........................ 220
VENTOLIN HFA AER ......................................... 68
VERAMYST SPR 27.5MCG .......................... 376
verapamil cap 100mg er ................................... 215
verapamil cap 120mg sr.................................... 215
verapamil inj 2.5mg/ml ..................................... 215
verapamil tab 120mg ........................................ 215
verapamil tab 120mg er .................................... 215
verapamil tab 120mg sr .................................... 216
verapamil tab 40mg .......................................... 216
verapamil tab 80mg .......................................... 216
VERDESO
AER 0.05%.................................. 279
verdrocet tab 2.5-325.......................................... 27
VEREGEN
OIN 15% ..................................... 261
VERELAN
CAP 120MG SR.......................... 216
VERELAN
CAP 180MG................................ 216
VERELAN
CAP 180MG SR.......................... 216
529
VERELAN
CAP 240MG SR ......................... 216
VERELAN
CAP 360MG SR ......................... 216
VERELAN PM CAP 100MG............................ 216
VERELAN PM CAP 100MG ER...................... 216
VERELAN PM CAP 200MG............................ 216
VERELAN PM CAP 300MG............................ 216
VERIPRED 20 SOL 20MG/5ML....................... 242
VERRUNEX
CRE........................................... 285
VERSACLOZ SUS 50MG/ML........................ 181
versiclear lot ...................................................... 265
VESICARE TAB 10MG ................................. 435
VESICARE TAB 5MG ................................... 435
VEXA
PAD 2-4-30% .................................. 297
VEXOL
SUS 1% OP .................................... 392
VFEND
SUS 40MG/ML .............................. 119
VFEND
TAB 200MG................................... 119
VFEND
TAB 50MG..................................... 119
VFEND IV INJ 200MG................................... 119
V-GO KIT....................................................... 361
VIAGRA
TAB 100MG ................................. 222
VIAGRA
TAB 25MG ................................... 222
VIAGRA
TAB 50MG ................................... 222
VIBATIV
INJ 250MG...................................... 51
VIBATIV
INJ 750MG...................................... 51
VIBERZI
TAB 100MG .................................. 333
VIBERZI
TAB 75MG .................................... 333
VIBRAMYCIN CAP 100MG ........................... 418
VIBRAMYCIN SUS 25MG/5ML..................... 418
VIBRAMYCIN SYP 50MG/5ML..................... 418
vicodin
tab 5-300mg ......................................... 27
VICODIN
TAB 5-500MG................................ 27
vicodin es tab 7.5-300.......................................... 27
VICODIN ES TAB 7.5-750................................. 27
vicodin hp tab 10-300mg ..................................... 27
VICODIN HP TAB 10-660MG........................... 27
VICOPROFEN TAB 7.5-200 .............................. 27
VICTOZA
INJ 18MG/3ML ........................... 105
VICTRELIS CAP 200MG................................ 196
VIDAZA
INJ 100MG.................................... 152
VIDEX
SOL 2GM ........................................ 192
VIDEX
SOL 4GM ........................................ 192
VIDEX EC CAP 125MG................................. 192
VIDEX EC CAP 200MG................................. 192
VIDEX EC CAP 250MG................................. 192
VIDEX EC CAP 400MG................................. 192
VIGAMOX
DRO 0.5% .................................. 386
VIIBRYD
KIT .................................................. 95
VIIBRYD
KIT STARTER ............................... 95
VIIBRYD
TAB 10MG ..................................... 95
VIIBRYD
TAB 20MG ..................................... 95
VIIBRYD
TAB 40MG ..................................... 95
VIMIZIM
INJ 5MG/5ML............................... 321
VIMPAT
INJ 200MG/20................................. 86
VIMPAT
SOL 10MG/ML ............................... 86
VIMPAT
TAB 100MG.................................... 86
VIMPAT
TAB 150MG.................................... 86
VIMPAT
TAB 200MG.................................... 86
VIMPAT
TAB 50MG...................................... 86
vinblastine inj 10mg ............................................ 167
vinblastine inj 1mg/ml ......................................... 167
vincasar pfs inj 1mg/ml ........................................ 167
vincristine inj 1mg/ml.......................................... 167
vinorelbine inj 10mg/ml ...................................... 167
vinorelbine inj 50mg/5ml .................................... 167
vinorelbine inj soln.............................................. 167
VIOKACE
TAB.............................................. 308
VIOKACE
TAB 20880................................... 308
viorele
tab ....................................................... 229
VIRACEPT TAB 250MG................................ 191
VIRACEPT TAB 625MG................................ 191
VIRAMUNE SUS 50MG/5ML ....................... 191
VIRAMUNE TAB 200MG.............................. 191
VIRAMUNE XR TAB 100MG .......................... 191
VIRAMUNE XR TAB 400MG .......................... 191
VIRASAL
LIQ 27.5% .................................... 286
VIRAZOLE
INH 6GM .................................... 198
VIREAD
POW 40MG/GM............................ 193
VIREAD
TAB 150MG .................................. 193
VIREAD
TAB 200MG .................................. 193
VIREAD
TAB 250MG .................................. 193
VIREAD
TAB 300MG .................................. 193
VIROPTIC
SOL 1% OP .................................. 386
virti-sulf cre 10-5% ............................................ 256
virtrate-2 sol....................................................... 339
virtrate-2 sol 500-334 ........................................ 339
virtrate-3 sol....................................................... 339
virtrate-k sol....................................................... 339
virtrate-k sol 1100-334....................................... 339
VISCOAT
SOL............................................... 392
VISICOL
TAB 1.5GM ................................... 355
VISIONBLUE SOL 0.06%................................ 393
VISTARIL
CAP 25MG ..................................... 59
VISTARIL
CAP 50MG ..................................... 59
VISTIDE
INJ 75MG/ML................................ 194
VISUDYNE
INJ 15MG................................... 389
vitazol
cre 0.75% ............................................ 291
530
W
VITEKTA
TAB 150MG................................. 189
VITEKTA
TAB 85MG................................... 190
VITRASE
INJ 200/ML................................... 200
VITRASERT IMP 4.5MG................................ 386
VITRAVENE INJ 6.6MG/ML ......................... 386
VITUZ
SOL 5-4MG ..................................... 250
VIVACTIL
TAB 10MG .................................. 100
VIVACTIL
TAB 5MG .................................... 100
VIVELLE-DOT DIS 0.025MG .......................... 329
VIVELLE-DOT DIS 0.0375MG ........................ 329
VIVELLE-DOT DIS 0.05MG ............................ 329
VIVELLE-DOT DIS 0.075MG .......................... 329
VIVELLE-DOT DIS 0.1MG .............................. 329
VIVITROL
INJ 380MG .................................. 113
VOGELXO
GEL 1%(50MG)........................... 46
VOGELXO
GEL PUMP 1% ............................ 46
VOLTAREN GEL 1%..................................... 262
VOLTAREN SOL 0.1% OP............................ 389
VOLTAREN-XR TAB 100MG............................ 19
VOLUVEN
INJ 6%/NACL............................ 343
VOPAC
CRE 10-2% .................................... 263
VOPAC GB CRE 5-2-5% ............................... 263
VOPAC KT CRE 5-5-2%................................ 263
VORAXAZE INJ 1000UNIT .......................... 162
voriconazole inj 200mg........................................ 119
voriconazole sus 40mg/ml.................................... 119
voriconazole tab 200mg....................................... 119
voriconazole tab 50mg......................................... 119
VOSOL HC SOL OTIC................................... 396
VOSPIRE ER TAB 4MG .................................... 68
VOSPIRE ER TAB 8MG .................................... 68
VOTRIENT
TAB 200MG ............................... 157
VPRIV
INJ 400UNIT ................................... 345
VSL#3 DS PAK............................................... 110
VUMON
INJ 50MG/5ML............................ 167
VUSION
OIN ................................................ 265
vyfemla
tab 0.4-35........................................... 233
VYTONE
CRE 1-1.9% ................................. 265
VYTORIN
TAB 10-10MG............................. 128
VYTORIN
TAB 10-20MG............................. 128
VYTORIN
TAB 10-40MG............................. 128
VYTORIN
TAB 10-80MG............................. 128
VYVANSE
CAP 10MG ..................................... 5
VYVANSE
CAP 20MG ..................................... 5
VYVANSE
CAP 30MG ..................................... 5
VYVANSE
CAP 40MG ..................................... 5
VYVANSE
CAP 50MG ..................................... 5
VYVANSE
CAP 60MG ..................................... 5
VYVANSE
CAP 70MG ..................................... 5
warfarin tab 10mg ............................................. 73
warfarin tab 1mg ............................................... 73
warfarin tab 2.5mg ............................................ 73
warfarin tab 2mg ............................................... 73
warfarin tab 3mg ............................................... 73
warfarin tab 4mg ............................................... 73
warfarin tab 5mg ............................................... 73
warfarin tab 6mg ............................................... 73
warfarin tab 7.5mg ............................................ 74
warfarin sod tab 10mg........................................... 74
WELCHOL
PAK 3.75GM.............................. 123
WELCHOL
TAB 625MG............................... 123
WELLBUTRIN TAB 100MG ............................. 91
WELLBUTRIN TAB 100MG SR ....................... 91
WELLBUTRIN TAB 75MG ............................... 91
WELLBUTRIN TAB XL 150MG ....................... 91
WELLBUTRIN TAB XL 300MG ....................... 91
wera
tab 0.5/35 ............................................ 233
WESTCORT OIN 0.2%................................... 279
WESTHROID TAB 113.75MG........................ 424
WESTHROID TAB 130MG............................. 424
WESTHROID TAB 146.25MG........................ 424
WESTHROID TAB 16.25MG.......................... 424
WESTHROID TAB 162.50MG........................ 424
WESTHROID TAB 195MG............................. 424
WESTHROID TAB 260MG............................. 424
WESTHROID TAB 32.5MG............................ 424
WESTHROID TAB 325MG............................. 424
WESTHROID TAB 48.75MG.......................... 424
WESTHROID TAB 65MG............................... 424
WESTHROID TAB 81.25MG.......................... 425
WESTHROID TAB 97.5MG............................ 425
WESTHROID-P TAB 130MG ........................... 425
WESTHROID-P TAB 16.25MG ........................ 425
WESTHROID-P TAB 32.5MG .......................... 425
WESTHROID-P TAB 48.75MG ........................ 425
WESTHROID-P TAB 65MG ............................. 425
WESTHROID-P TAB 97.5MG .......................... 425
WHYTEDERM KIT TRILASIL ...................... 299
WHYTEDERM TD KIT PAK............................. 299
WINRHO SDF INJ 15000UNT ......................... 399
WINRHO SDF INJ 1500UNIT.......................... 400
WITCH HAZEL LIQ............................................290
WOUND CARE PAD 2..................................... 307
531
XEROFRM PETR PAD 2.................................... 300
XEROFRM PETR PAD 4.................................... 300
XEROFRM ROLL MIS 4.................................... 300
XGEVA
INJ ....................................................321
XIAFLEX
INJ 0.9MG .................................... 200
XIFAXAN
TAB 200MG .................................. 51
XIFAXAN
TAB 550MG .................................. 51
XIGDUO XR TAB 10-1000 ............................. 106
XIGDUO XR TAB 10-500MG ........................ 106
XIGDUO XR TAB 5-1000MG ........................ 107
XIGDUO XR TAB 5-500MG .......................... 107
XODOL
TAB 10-300MG............................... 27
XODOL
TAB 5-300MG................................. 27
XODOL
TAB 7.5-300 .................................... 27
XOFIGO
INJ 1000KBQ ................................ 161
XOLAIR
SOL 150MG .................................... 66
XOLEGEL
GEL 2% ....................................... 284
XOLEGEL
KIT COREPAK........................... 265
XOLEGEL DUO/ KIT HEAD&SHD.................. 265
XOLEGEL DUO/ KIT XOLEX .......................... 265
XOLOX
TAB 10-500MG............................... 42
XOPENEX
NEB 0.31MG ................................ 68
XOPENEX
NEB 0.63MG ................................ 68
XOPENEX
NEB 1.25/3ML.............................. 68
XOPENEX CONC NEB 1.25/0.5.......................... 68
XOPENEX HFA AER .......................................... 68
XROFORM PET MIS OVERWRAP ................. 300
XTANDI
CAP 40MG .................................... 150
xulane
dis 150-35........................................... 234
x-viate
cre 40% ............................................... 281
x-viate
gel 40%................................................ 281
x-viate
lot 40% ................................................ 281
XYLO/EPI INJ 0.5% ....................................... 356
XYLO/EPI INJ 2% .......................................... 356
XYLO/EPI 1%- INJ 1
100000.............................................................. 356
XYLOCAINE GEL 2% .................................... 288
XYLOCAINE INJ 0.5% ................................... 358
XYLOCAINE INJ 1% ...................................... 358
XYLOCAINE INJ 2% ........................................ 63
xylocaine inj dent 2%........................................ 356
XYLOCAINE INJ MPF 0.5% .......................... 358
XYLOCAINE INJ -MPF 1%............................ 358
XYLOCAINE INJ MPF 1.5% .......................... 358
XYLOCAINE SOL 4% .................................... 288
XYLO-MPF/EPI INJ 1% ..................................... 356
XYLO-MPF/EPI INJ 1.5% .................................. 356
WOUND CARE PAD 4 .................................... 307
WP THYROID TAB 113.75MG ....................... 425
WP THYROID TAB 130MG ............................ 425
WP THYROID TAB 16.25MG ......................... 425
WP THYROID TAB 32.5MG ........................... 425
WP THYROID TAB 48.75MG ......................... 425
WP THYROID TAB 65MG .............................. 425
WP THYROID TAB 81.25MG ......................... 425
WP THYROID TAB 97.5MG ........................... 425
wymzya fe chw 0.4mg-35 .................................. 233
X
XALATAN
SOL 0.005% ............................... 393
XALKORI
CAP 200MG ................................ 157
XALKORI
CAP 250MG ................................ 157
XANAX
TAB 0.25MG .................................. 62
XANAX
TAB 0.5MG .................................... 62
XANAX
TAB 1MG ....................................... 62
XANAX
TAB 2MG ....................................... 62
XANAX XR TAB 0.5MG ................................. 62
XANAX XR TAB 1MG .................................... 62
XANAX XR TAB 2MG .................................... 62
XANAX XR TAB 3MG .................................... 62
XARELTO
TAB 10MG ................................... 74
XARELTO
TAB 15MG ................................... 74
XARELTO
TAB 20MG ................................... 74
XARELTO STAR TAB 15/20MG ........................ 74
XARTEMIS XR TAB 7.5-325 ............................. 42
XCLAIR
CRE................................................ 289
XELJANZ
TAB 5MG ...................................... 12
XELODA
TAB 150MG ................................ 152
XELODA
TAB 500MG ................................ 153
XENADERM OIN........................................... 283
XENAZINE
TAB 12.5MG.............................. 408
XENAZINE
TAB 25MG................................. 408
XEOMIN
INJ 100UNIT ................................ 377
XEOMIN
INJ 50 UNIT ................................. 377
XERAC-AC
SOL 6.25% ................................. 271
XERESE
CRE 5-1%...................................... 271
XEROFORM OIL MIS 1 .................................... 300
XEROFORM OIL PAD 2.................................... 300
XEROFORM PET MIS OVERWRAP................ 300
XEROFORM PET MIS ROLL............................ 300
XEROFORM PET PAD 1 ................................... 300
XEROFORM PET PAD 2 ................................... 300
XEROFORM PET PAD 4 ................................... 300
XEROFORM PET PAD 5 ................................... 300
XEROFRM GAUZ MIS 1................................... 300
XEROFRM GAUZ MIS 5................................... 300
XEROFRM GAUZ PAD 5 .................................. 300
532
ZEBETA
TAB 10MG.................................... 206
ZEBETA
TAB 5MG...................................... 206
zebutal
cap ...........................................................22
ZECUITY
PAD 6.5MG/4H ............................ 364
ZEGERID
CAP 20-1100 ................................ 430
ZEGERID
CAP 40-1100 ................................ 430
ZELAPAR
TAB 1.25MG ............................... 172
ZELBORAF
TAB 240MG .............................. 153
ZEMAIRA
INJ 1000MG ................................ 413
ZEMPLAR
CAP 1MCG ................................. 320
ZEMPLAR
CAP 2MCG ................................. 320
ZEMPLAR
CAP 4MCG ................................. 320
ZEMPLAR
INJ 2MCG/ML............................ 320
ZEMPLAR
INJ 5MCG/ML............................ 320
ZEMURON
INJ 10MG/ML ........................... 378
zenchent tab ..................................................... 233
zenchent fe chw 0.4mg-35 ................................... 233
zencia
liq 9-4% .............................................. 257
ZENIEVA
CRE .............................................. 290
ZENPEP
CAP 10000UNT............................. 308
ZENPEP
CAP 15000UNT............................. 308
ZENPEP
CAP 20000UNT............................. 308
ZENPEP
CAP 25000UNT............................. 308
ZENPEP
CAP 3000UNIT.............................. 308
ZENPEP
CAP 40000UNT............................. 308
ZENPEP
CAP 5000UNIT.............................. 308
zenzedi
tab 10mg................................................. 5
zenzedi
tab 15mg................................................. 5
ZENZEDI
TAB 2.5MG ...................................... 5
zenzedi
tab 20mg................................................. 5
zenzedi
tab 30mg................................................. 5
zenzedi
tab 5mg................................................... 5
ZENZEDI
TAB 7.5MG ...................................... 5
zeosa
chw ...................................................... 233
ZERBAXA
INJ 1-0.5 GM .............................. 222
ZERIT
CAP 15MG ....................................... 193
ZERIT
CAP 20MG ....................................... 193
ZERIT
CAP 30MG ....................................... 193
ZERIT
CAP 40MG ....................................... 193
ZERIT
SOL 1MG/ML .................................. 193
zeruvia
pad 4-1% ............................................ 297
ZESTORETIC TAB 10-12.5 ............................. 132
ZESTORETIC TAB 20-12.5 ............................. 132
ZESTORETIC TAB 20-25MG .......................... 132
ZESTRIL
TAB 10MG .................................... 135
ZESTRIL
TAB 2.5MG ................................... 135
ZESTRIL
TAB 20MG .................................... 135
ZESTRIL
TAB 30MG .................................... 135
ZESTRIL
TAB 40MG .................................... 135
XYLO-MPF/EPI INJ 2% ..................................... 356
xylon
tab 10-200mg ........................................ 27
xyphex
mis...................................................... 297
XYREM
SOL 500MG/ML........................... 406
XYZAL
SOL ................................................... 121
XYZAL
SOL 2.5/5ML ................................. 121
XYZAL
TAB 5MG ...................................... 121
Y
YERVOY
INJ 200MG .................................. 155
YERVOY
INJ 50MG .................................... 155
yl folic aci tab 400mcg......................................... 346
YODOXIN
TAB 210MG ................................. 10
YODOXIN
TAB 650MG ................................. 10
yohimbine tab 5.4mg......................................... 222
YONDELIS
INJ 1MG ..................................... 170
Z
ZACARE KIT KIT 4%...................................... 256
ZACARE KIT KIT 8%...................................... 257
zaclir
lot 8%................................................... 261
zafirlukast tab 10mg ............................................. 69
zafirlukast tab 20mg ............................................. 69
zaleplon cap 10mg ........................................... 352
zaleplon cap 5mg ............................................. 352
ZALTRAP
INJ 100/4ML ............................... 171
ZALTRAP
INJ 200/8ML ............................... 171
zamicet
sol 10-325mg ....................................... 27
ZANABIN
GEL HYDROGEL....................... 307
ZANAFLEX
CAP 2MG .................................. 373
ZANAFLEX
CAP 4MG .................................. 373
ZANAFLEX
CAP 6MG .................................. 373
ZANAFLEX
TAB 4MG.................................. 373
ZANOSAR
INJ 1GM ..................................... 169
ZANTAC
INJ 25MG/ML.............................. 430
ZANTAC
INJ 50/50ML ................................ 430
ZANTAC
INJ 50MG/2ML............................ 430
ZANTAC
SYP 15MG/ML ............................ 430
ZANTAC
TAB 25MG EF ............................. 430
ZANTAC
TAB 300MG................................. 430
ZARONTIN
CAP 250MG................................. 88
ZARONTIN
SOL 250/5ML .............................. 88
ZAROXOLYN TAB 2.5MG ............................ 313
ZAROXOLYN TAB 5MG ............................... 313
ZARXIO
INJ 300/0.5 .................................... 347
ZARXIO
INJ 480/0.8 .................................... 347
ZAVESCA
CAP 100MG................................ 345
zazole
cre 0.4%.............................................. 436
zazole
cre 0.8%.............................................. 436
zazole
sup 80mg............................................. 437
533
ZOFRAN
INJ 40/20ML................................. 114
ZOFRAN
SOL 4MG/5ML ............................ 114
ZOFRAN
TAB 4MG ..................................... 114
ZOFRAN
TAB 4MG ODT............................ 114
ZOFRAN
TAB 8MG ..................................... 114
ZOFRAN
TAB 8MG ODT............................ 114
ZOHYDRO ER CAP 10MG................................ 41
ZOHYDRO ER CAP 15MG................................ 41
ZOHYDRO ER CAP 20MG................................ 41
ZOHYDRO ER CAP 30MG................................ 41
ZOHYDRO ER CAP 40MG................................ 41
ZOHYDRO ER CAP 50MG................................ 41
ZOLADEX
IMP 10.8MG ............................... 165
ZOLADEX
IMP 3.6MG ................................. 165
ZOLEDRONIC INJ 4MG.................................. 315
zoledronic inj 4mg/100 ...................................... 315
zoledronic inj 4mg/5ml ...................................... 315
zoledronic inj 5/100ml ....................................... 315
ZOLINZA
CAP 100MG ................................. 153
zolmitriptan tab 2.5 mg........................................ 364
zolmitriptan tab 2.5mg......................................... 364
zolmitriptan tab 5mg............................................ 364
ZOLOFT
CON 20MG/ML .............................. 94
ZOLOFT
TAB 100MG.................................... 94
ZOLOFT
TAB 25MG...................................... 94
ZOLOFT
TAB 50MG...................................... 94
zolpidem tab 10mg ........................................... 352
zolpidem tab 5mg ............................................. 352
zolpidem er tab 12.5mg....................................... 352
zolpidem er tab 6.25mg....................................... 352
ZOLPIMIST SPR 5MG .................................... 352
ZOLVIT
SOL 10-300MG................................ 27
ZOMACTON
INJ 10MG................................. 318
ZOMACTON
INJ 5MG................................... 318
ZOMETA
INJ 4MG/100................................ 315
ZOMETA
INJ 4MG/5ML.............................. 315
ZOMIG
SPR 2.5MG..................................... 364
ZOMIG
SPR 5MG........................................ 364
ZOMIG
TAB 2.5MG .................................... 364
ZOMIG
TAB 5MG ....................................... 365
ZOMIG NASAL SPR 5MG................................ 365
ZOMIG ZMT TAB 2.5 MG.............................. 365
ZOMIG ZMT TAB 5MG.................................. 365
ZONALON
CRE 5% ...................................... 268
ZONATUSS
CAP 150MG .............................. 245
ZONEGRAN CAP 100MG ............................... 86
ZONEGRAN CAP 25MG ................................. 86
zonisamide cap 100mg......................................... 86
zonisamide cap 25mg........................................... 86
ZESTRIL
TAB 5MG ...................................... 135
ZETIA
TAB 10MG ...................................... 128
ZETONNA
AER 37MCG .............................. 376
ZEVALIN
KIT IN-111................................... 158
ZEVALIN
KIT Y-90 ...................................... 158
zflex
tab........................................................... 22
ZGESIC
TAB 66-600MG................................ 22
ZIAC
TAB 10/6.25 ...................................... 143
ZIAC
TAB 2.5/6.25 ..................................... 143
ZIAC
TAB 5-6.25MG ................................. 143
ZIAGEN
SOL 20MG/ML ............................. 192
ZIAGEN
TAB 300MG .................................. 192
ZIANA
GEL ................................................. 257
zidovudine cap 100mg ....................................... 193
zidovudine syp 50mg/5ml................................... 193
zidovudine tab 300mg ........................................ 193
ZINACEF
INJ 1.5GM .................................... 225
ZINACEF
INJ 7.5GM .................................... 225
ZINACEF
INJ 750MG ................................... 225
ZINACEF/D5W INJ 750MG PB........................ 225
ZINACEF/H20 INJ 1.5GM PB .......................... 225
ZINC ACETATE CRY........................................ 366
ZINECARD
INJ 250MG................................. 162
ZINECARD
INJ 500MG................................. 162
ZINGO
INJ 0.5MG....................................... 358
ZIOPTAN
DRO 0.0015% .............................. 393
ziprasidone cap 20mg ......................................... 177
ZIPSOR
CAP 25MG ....................................... 19
ZIRGAN
GEL 0.15% .................................... 386
ZITHRANOL SHA 1% .................................... 270
ZITHRANOL-RR CRE 1.2%.............................. 270
ZITHROMAX INJ 500MG .............................. 359
ZITHROMAX SUS 100/5ML.......................... 359
ZITHROMAX SUS 200/5ML.......................... 360
ZITHROMAX TAB 250MG ............................ 360
ZITHROMAX TAB 500MG ............................ 360
ZITHROMAX TAB 600MG ............................ 360
ZITHROMAX TAB TRI-PAK......................... 360
ZITHROMAX TAB Z-PAK............................. 360
ZMAX
SUS 2GM........................................ 360
ZN-DTPA
SOL 1000MG ............................... 112
ZOCOR
TAB 10MG .................................... 127
ZOCOR
TAB 20MG .................................... 127
ZOCOR
TAB 40MG .................................... 127
ZOCOR
TAB 5MG ...................................... 127
ZOCOR
TAB 80MG .................................... 128
534
zonisamide cap 50mg........................................... 86
ZONTIVITY TAB 2.08MG ............................. 343
ZORBTIVE
INJ 8.8MG .................................. 318
ZORTRESS TAB 0.25MG.............................. 202
ZORTRESS TAB 0.5MG................................ 202
ZORTRESS TAB 0.75MG.............................. 202
ZORVOLEX
CAP 18MG.................................. 19
ZORVOLEX
CAP 35MG.................................. 19
ZOSTAVAX INJ ............................................... 436
ZOSYN
INJ 2-0.25GM................................. 403
ZOSYN
INJ 3-0.375G .................................. 403
ZOSYN
INJ 36-4.5GM................................. 403
ZOSYN
INJ 4-0.5GM................................... 403
ZOSYN
SOL 2-0.25GM............................... 404
ZOSYN
SOL 3-0.375G ................................ 404
ZOSYN
SOL 4-0.50GM............................... 404
zovia 1/35e tab.................................................... 233
ZOVIA 1/50E TAB ............................................ 233
ZOVIRAX
CAP 200MG ................................ 197
ZOVIRAX
CRE 5% ....................................... 271
ZOVIRAX
OIN 5%........................................ 271
ZOVIRAX
SUS 200/5ML.............................. 197
ZOVIRAX
TAB 400MG ................................ 197
ZOVIRAX
TAB 800MG ................................ 197
Z-PRAM
KIT 2.35-1% .................................... 48
ZUBSOLV
SUB 1.4-0.36................................. 44
ZUBSOLV
SUB 11.4-2.9................................. 44
ZUBSOLV
SUB 2.9-0.71................................. 44
ZUBSOLV
SUB 5.7-1.4................................... 44
ZUBSOLV
SUB 8.6-2.1................................... 44
ZUPLENZ
MIS 4MG ..................................... 114
ZUPLENZ
MIS 8MG ..................................... 114
ZUTRIPRO
LIQ 60-4-5MG ............................ 251
ZYBAN
TAB 150MG SR ............................ 412
ZYCLARA
CRE 3.75% ................................. 284
ZYCLARA PUMP CRE 2.5% ............................ 284
ZYCLARA PUMP CRE 3.75% .......................... 284
ZYDELIG
TAB 100MG................................. 160
ZYDELIG
TAB 150MG................................. 160
ZYDONE
TAB 10-400MG ............................. 27
ZYDONE
TAB 5-400MG ............................... 27
ZYDONE
TAB 7.5-400................................... 27
ZYFLO
TAB 600MG ..................................... 65
535
ZYFLO CR TAB 600MG.................................. 65
ZYKADIA
CAP 150MG................................ 157
ZYLET
SUS 0.5-0.3%.................................. 391
ZYLOPRIM
TAB 100MG .............................. 341
ZYLOPRIM
TAB 300MG .............................. 342
ZYMAXID
SOL 0.5%.................................... 386
ZYPRAM
CRE 2.35-1% ................................. 48
ZYPREXA
INJ 10MG.................................... 186
ZYPREXA
TAB 10MG ................................. 186
ZYPREXA
TAB 15MG ................................. 186
ZYPREXA
TAB 2.5MG ................................ 186
ZYPREXA
TAB 20MG ................................. 186
ZYPREXA
TAB 5MG ................................... 186
ZYPREXA
TAB 7.5MG ................................ 186
ZYPREXA RELP INJ 210MG ............................ 186
ZYPREXA ZYDI TAB 10MG ............................ 186
ZYPREXA ZYDI TAB 5MG .............................. 186
ZYTIGA
TAB 250MG .................................. 150
ZYVODOL
CRE ............................................ 263
ZYVOX
SOL 2MG/ML ................................. 55
ZYVOX
SUS 100MG/5M.............................. 55
ZYVOX
TAB 600MG .................................... 55
536
STEP THERAPIES
Drug Category
Primary Treatment
Secondary Treatment
(Step One)
(Step Two)
ADD/ADHD
Vyvanse, generic ADHD medications
Daytrana, Focalin XR, Quillivant, Ritalin
LA
Angiotensin Receptor Blocker
Losartan/HCT, Valsartan HCT, or
Irbesartan/HCT
Edarbi, Micardis/HCT, Hyzaar, Cozaar,
Avapro, Avalide, Atacand/HCT,
Teveten/HCT, Benicar/HCT
Antidepressant
any generic antidepressant
Brintellix
Asthma
Proair, Ventolin
Proventil, Xopenex
Cholesterol/ Fibric Acid
Derivative
generic Fenofibrate
Tricor, Antara, Triglide, Lipofen
Cholesterol/Statin
Simvastatin, Pravastatin, Lovastatin, or
Atorvastatin
Crestor 5 mg, Lipitor 10mg /20mg,
Lescol/XL, Fluvastatin, Vytorin,
Altoprev, Mevacor, Pravachol, Zocor,
Livalo
Cox II Inhibitor
one (1) generic NSAID, or currently be on
GI, Steroid, or Anticoagulant therapy, or be
greater than age 50
Celebrex
Diabetes
Janumet, Januvia, Kombiglyze, Onglyza
Jentadueto, Tradjenta
Erectile Dysfunction
Levitra, Viagra
Cialis1, Staxyn, Stendra
Gout
Allopurinol
Uloric, Zyloprim
Growth Hormone
Genotropin, Norditropin
Humatrope, Nutropin AQ, Omnitrope,
Saizen, Zomacton
Inflammatory Bowel Disease
Apriso, Lialda
Asacol HD, Delzicol, Pentasa
Inflammatory Conditions
Enbrel, Humira
Actemra, Cimzia, Cosentyx, Kineret,
Orencia, Otezla, Simponi, Stelara,
Xeljanz, Cosentyx, Taltz
537
Step Therapies, Con’t…
Drug Category
Primary Treatment
Secondary Treatment
(Step One)
(Step Two)
Insomnia Agents
Zolpidem IR or Zaleplon
Ambien, Ambien Cr, Zolpidem CR,
Edluar, Zolpimist, Sonata, Lunesta
Multiple Sclerosis
Avonex, Copaxone, Gilenya, Plegridy,
Tecfideria
Aubagio2, Betaseron, Extavia, Rebif
Opioid Abuse
Suboxone film
Bunavail, buprenorphine/naloxone,
Zubsolv
Osteoporosis
Alendronate
Actonel, Boniva, Fosamax
Selective Serotonin Reuptake
Inhibitor (SSRI)
generic SSRI (citalopram, sertraline,
escitalopram, paroxetine, fluoxetine,
fluvoxamine)
Viibryd
Serotonin (SSRI) and
Norepinephrine Reuptake
Inhibitor (SNRI)
If diagnosis is depression, generic SSRI or
SNRI (venlafaxine). If diagnosis is chronic
pain, then the member is exempt from step
therapy
Cymbalta
¹Managed by Prior Authorization to assess indication
²Requires trial and failure of only one Primary Product
STANDARD PRIOR AUTHORIZATIONS
PA Category/Drug Name
Criteria
Acromegaly, Profuse Diarrhea
Documentation of medically accepted indication
Sandostatin, Sandostatin LAR
Anti-Seizure
Fycompa
Antineoplastics
Odomzo, Blincyto, Unituxin, Opdivo, Keytruda,
Ibrance, Farydak, Imbruvica, Lenvima, Lynparza,
Synribo, Erwinaze, Afinitor, Bosulif, Caprelsa,
Ceenu, Emcyt, Erivedge, Etoposide, Fareston,
Gilotrif, Gleevec, Hexalen, Hycamtin, Hydrea,
Iclusig, Inlyta, Iressa, Jakafi, Leukeran, Lysodren,
Matulane, Mekinist, Myleran, Nexavar, Nilandron,
Oforta, Sprycel, Stivarga, Sutent, Tabloid, Tafinlar,
Tarceva, Targretin, Tasigna, Temodar, Tretinoin,
Tykerb, Vandetanib, Votrient, Xalkori, Xeloda,
Xtandi, Zelboraf , Zolinza, Zytiga
538
Criteria
Asthma
Xolair
Benign Prostatic Hyperplasia (BPH)
If patient has a diagnosis of BPH:
Cialis 2.5mg & 5mg (Daily)
- must have tried and failed BOTH a generic alpha reductase inhibitor AND a
generic alpha 1 adrenergic blocker (for at least 6 months) prior to approval of
Cialis
Documentation of medically accepted indication and prior failure of injectable
steroids
Corticotropin
Acthar HP
Cushing’s Disease- Korlym
Documentation of medically accepted indication and have failed or are ineligible
for surgery
Cystic Fibrosis
Cayston, Kalydeco, Pulmozyme, Tobi, Orkambi
Fabry Disease- Fabrazyme
GAA Deficiency Treatment
Lumizyme, Myozyme
Gastrointestinal Agents
Fulyzaq
GastrointestinalCorticosteroids
Uceris
Gout
Krystexxa
Growth Hormone
Genotropin, Humatrope, Norditropin, Nutropin,
Saizen, Serostim, Tevtropin
Growth Hormone Releasing Hormone
Documentation of medically accepted indication and prior failure of conventional
gout treatment (such as allopurinol or Uloric)
Documentation of medically accepted indication, non-fused epiphyses, or
documentation of 2 growth stimulation tests showing growth hormone deficiency
as necessary depending upon diagnosis
Egrifta
Hepatitis C
Pegasys, Peg-Intron, Intron A, Infergen, Ribavirin,
Victrelis, Incivek, Harvoni, Sovaldi, Zepetier,
Viekira, Technivie
Hereditary Tyrosinemia- Orfadin
Documentation of medically accepted indication, pre-treatment viral titers,
demonstration of EVR, or liver function tests showing compensated liver disease,
trial of preferred agents.
Criteria
Hereditary Angioedema Agents
Cinryze, Firazyr, Kalbitor, Berinert
HIV Agents
Stribild
Homocytinuria
Cystadane
Hyperammonemia Treatment
Carbaglu
Hyperlipidemia Agents
Praluent
Hypoparathyroidism Agents
Natpara
Injectable Anti-Neoplastics
Approved for all FDA approved indications
Synribo, Erwinaze
Mucopolysaccharidosis
Aldurazyme, Elaprase, Naglazyme
Multiple Sclerosis
Avonex, Betaseron, Copaxone, Rebif, Extavia,
Gilenya, Ampyra, Lemtrada
Neutrophil Formation
(chemo drugs): Leukine, Neulasta, Neupogen
Opioid Addiction
Suboxone, Subutex
Documentation of medically accepted indication and ANC < 1000 cells/mm3 as
documented on labs drawn within the last 3 months
Documentation of medically accepted indication, patients 16 years of age or older,
is certified with SAMHSA/DATA2000, Patient has been referred to or is
participating in a substance abuse or behavioral health treatment program. For
renewals, Two (2) negative drug screens must be submitted, at least one dated
within the previous 3 months (if one or both are positive, the prescriber must
provide the steps being taken to address the patient’s non-compliance with
program);
Orthostatic Hypotension Agents
Northera
Osteoporosis
Documentation of medically accepted indication, T-score less than -2.5 SD from
the mean, and prior failure of bisphosphonates
Forteo
Criteria
Pain Management – Fentanyl
Documentation of medically accepted indication and cancer related pain
Abstral, Actiq, Duragesic, Fentanyl, Fentanyl Citrate,
Fentora, Lazanda, Onsolis, Sublimaze, and Subsys
Phenylketonuria Treatment
Kuvan
Pseudobulbar Affect
Nuedexta
Pulmonary Fibrosis Agents
Esbriet
Red Blood Cell Formation
Documentation of medically accepted indication and Hct < 33% and Hgb <
12 g/dl shown on labs drawn within the last 3 months
(chemo drugs): Aranesp, Procrit, Epogen
Rheumatoid Arthritis/Psoriatic Arthritis
Remicade, Humira, Enbrel, Kineret, Amevive, Orencia,
Raptiva, Simponi, Cimzia, Xeljanz, Stelara
Stimulants
Xyrem Oral Solution
Systemic Lupus Erythematosis
Benlysta
Procysbi
Documentation of medically accepted indication, prescribed by a specialist,
trial of Cystagon
Wilson’s Disease
Documentation of medically accepted indication, prescribed by a specialist,
trial of all DMARDS/biologics for RA, trial of zinc & Depen for Wilson’s disease
Cuprimine, Depen, Syprine
All Other Specialty tier medications not listed
*Cialis daily strength (2.5 & 5 mg) has a FDA approved indication for the treatment of benign prostatic hyperplasia (BPH), as well as erectile
dysfunction (ED).
FORMULARY EXCLUSIONS
Preferred products for each drug category are listed in the table below. Agents listed as Excluded Products are considered to be a
formulary exclusion.
Drug Category
Preferred Products
Excluded Products
Acne
Amnesteem, Claravis, Myorisan, Zenatane
Absorica
Androgens
Androgrel 1.62%, generic testosterone
Androderm, Axiron, Fortesta, Testim
Diabetes/Glucose Testing Supplies
Freestyle, Precision, OneTouch
Accu-Check, Breeze/Contour, Nipro
Gastrointestinal
Famotidone plus ibuprofen or omeprazole
plus naproxen
Duexis, Vimovo
Hepatitis C
Harvoni, Sovaldi
Olysio, Technivie, Viekira
Insulins
Novolog, Novolin
Apidra, Humalog, Humulin
Injectable Anti-diabetics
Bydureon, Byetta, Victoza
Tanzeum, Trulicity
Weight-loss
N/A
Regimex, Diethylpropion, Phentermine,
Qsymia, Xenical, Belviq, Contrave, Alli,
Saxenda
Proton Pump Inhibitors
Omeprazole, lansoprazole
Pantoprazole, Protonix, Dexilant,
Nexium, esomeprazole, Aciphex,
rabeprazole, Prevacid, Zegerid, Prilosec
Fertility
N/A
Chorionic Gonadotropin, Pregnyl,
Novarel, Ovidrel, Gonal-F, Follistim Aq,
Repronex, Menopur, Bravelle,
Clomiphene
*This list is not all inclusive and does not guarantee coverage of any medication.
QUANTITY LIMITS
Disease State
Anti-addiction
Drug Name
30 Day Retail Quantity Limits†
Suboxone 12mg/3mg Oral Strip
90 Strips
240 Strips
120 Strips
Suboxone 2mg/0.5mg Oral Strip
480 Strips
Disease State
Anti-fungal
Anti-infective
Asthma/COPD
Drug Name
30 Day Retail Quantity Limits†
Terbinafine 250 mg
90 tabs per year
Itraconazole 100 mg
240 caps per year
Tobi Podhaler Kit
224 capsules
Tamiflu
10 caps per 5 days
Advair Diskus
60 blisters (1 inh)
Advair HFA
12 gm (1 inh)
Asmanex
2 units (2 inh)
Atrovent HFA
13 gm (1 inh)
Azmacort 100mcg/20ml
40 ml (2 inh)
Budesonide respules
120 ml (60 units)
Combivent Inh 15ml
30 ml (2 inh)
Combivent Respimat 20/100 Metered Dose
Inhaler
1 inh
Dulera
13 gm (1 inh)
Flovent HFA 110 mcg inh 12gm
24 gm (2 inh)
Flovent HFA 220 mcg inh 12gm
24 gm (2 inh)
Flovent HFA 44 mcg inh 10.6gm
22 gm (2 inh)
Flovent Rotadisk
4 pak (60 discs)
Foradil Inhalant Caps/Aerolizer, 60s
60 caps
Intal Inhaler 14.2 gm
14.2 gm (1inh)
Intal Inhaler 8.1 gm
16.2 gm (2 inh)
Maxair Autoinhaler 14gm
28 gm (2 inh)
ProAir HFA
17 gm (2 inh)
Proventil HFA
20.1 gm (3 inh)
Pulmicort Flexhaler
2 inh
Pulmicort Turbihaler Pwd 200mcg
2 inh
QVAR
14.6 gm (2 inh)
Serevent diskus 50mcg
60 blisters
Spiriva
30 caps
Cystic Fibrosis
Impotency Medications
Migraine
Nausea
Osteoporosis
Symbicort
11 gms (1 inh)
Tilade
49 gm (3 inh)
Ventolin HFA 18 gm inhaler
36 gm (2 inh)
Pulmozyme
2 boxes (150 units)
Tobi
280 ml (56 ampules)
Cialis 2.5 mg, 5 mg
30 tabs
Cialis 10 mg, 20 mg
6 tabs
Edex & Caverject
6 inj
Levitra/Staxyn/Viagra/Stendra
6 tabs
Amerge/Axert/Frova/Maxalt/Relpax/
Sumatriptan/Zomig tabs
9 tabs per medication
Sumatriptan Ini. (cartridges)
2 kits (4 doses)
Sumatriptan NS 20 mg
1 box (6 doses/6 ml)
Sumatriptan NS 5 mg
3 boxes (18 doses/18 ml)
Sumatriptan Inj. Vial
5 vials (5 doses/2.5 ml)
Treximet
9 tabs
Zomig NS
6 units (1 pack)
Anzemet/Granisetron/Ondansetron tabs
21 tabs per medication
Anzemet vial
10 ml
Granisol
30 ml
Ondansetron soln
50 ml
Actonel 5 mg
30 tabs
Actonel 30 mg
30 tabs
Actonel 35 mg
4 tabs
Actonel 75 mg
2 tabs
Actonel 150 mg
1 tab
Actonel plus Calcium
4 tabs
Alendronate 5 mg
30 tabs
Alendronate 10 mg
30 tabs
Alendronate 35 mg tabs
8 tabs
Pain Management
Proton Pump Inhibitors
Pulmonary Arterial
Hypertension
Sleep Aids
30 tabs
4 tabs
Acetaminophen/Codeine,
Acetaminophen/Hydrocodone,
Acetaminophen/Oxycodone
Quantity varies per product up to 4000 mg/day of
acetaminophen
Actiq
120 unit
Actiq Buccal Lollipop
120 lollipops
Butorphanol NS 2.5ml
6 ml (2 units)
Fentanyl patches
10 patches
Fentora buccal tab
120 tabs
Ketorolac (Toradol)
20 tabs per 5 days
Lazanda Nasal Soln
30 units
Onsolis Buccal Film
120 Films
Opana 7.5, 15 mg ER
60 tabs
Oxycontin
60 tabs
Oxymorphone Hydrochloride 5 - 30 mg ER
60 tabs
Oxymorphone Hydrochloride 40mg
120 tabs
Subsys 0.1–0.8 mg/Actuat Mucosal Spray
360 tabs
Lansoprazole
60 caps
Omeprazole
60 caps
Revatio
90 caps
Zolpidem
30 tabs
Zolpidem CR
30 tabs
†Quan es as shown are per a 30 day supply and mail order quantities are triple the amount shown unless otherwise indicated and assuming
a mail order benefit
535
Cox HealthPlans ACA Preventative List (Tier 5)
Drug Category & Description
ASPIRIN
Aspirin to prevent cardiovascular
disease (CVD): Men
The USPSTF recommends the use
of aspirin for men age 45 to 79
years when the potential benefit
due to a reduction in myocardial
infarctions outweighs the
potential harm due to an increase
in gastrointestinal hemorrhage.
Aspirin to prevent cardiovascular
disease (CVD): Women
The USPSTF recommends the use
of aspirin for women age 55 to 79
when the potential benefit of a
reduction in ischemic strokes
outweighs the potential harm or
an increase in gastrointestinal
hemorrhage.
Criteria for Coverage
Criteria:
Age limit: 45 - 79
Quantity limit: 1/day
Generic Only
OTC (requires a prescription)
1. Cover generics:
Drug Description:
Aspirin Tab 81mg - 325mg
Aspirin Chew 81mg - 325 mg
Aspirin Delayed Release 81mg - 325mg
Aspirin Dispersible Tab 81mg
Criteria:
Age limit: 55 - 79
Generic Only
Drug Description:
Aspirin 81mg - 325mg
Aspirin Chew 81mg - 325mg
Aspirin Delayed Release 81mg - 325mg
PREECLAMPSIA PREVENTION: ASPIRIN
The USPSTF recommends the use of Criteria:
low-dose aspirin (81 mg/d) as
Women
preventive medication after 12
weeks of gestation in women who
Generic Only
are at high risk for preeclampsia.
☒
Yes☒ No☐
☐
1. Cover generics:
☒
Yes☒ No☐
☐
Covered
Y N
Additional
Criteria/Notes
1. Prior Authorization required:
2. Cover generics:
Drug Description:
Aspirin Tab 81mg
Aspirin Chew 81mg
Aspirin Delayed Release 81mg
FOLIC ACID
The USPSTF recommends that all
women planning or capable of
pregnancy take a daily supplement
containing 0.4 to 0.8 mg (400 to 800
µg) of folic acid.
Additional
Criteria/Notes
Covered
Y N
Criteria:
Women
Prescription or OTC (requires a
prescription)
Drug Description:
Multivitamin with folic acid
536
☒
☐
☒
1. Restrict to prenatal vitamins
only:
2. Cover generics:
3. Cover multisource
☐
brands/brands with generics
available:
4. Cover brands with no generics
available:
Yes☒ No☐
Yes☒ No☐
Yes☐ No☒
Yes☒ No☐
Yes☒ No☐
Yes☒ No☐
IRON SUPPLEMENTS
The USPSTF recommends routine
iron supplementation for
asymptomatic children aged 6 to
12 months who are at increased
risk for iron deficiency anemia.
CONTRACEPTIVE METHODS
The HRSA recommends that all
Food and Drug Administration
approved contraceptive methods,
sterilization procedures, and
patient education and counseling
for all women with reproductive
capacity.
FLUORIDE
The USPSTF recommends that
primary care clinicians prescribe
oral fluoride supplementation at
currently recommended doses to
preschool children older than 6
months of age whose primary water
source is deficient in fluoride.
IMMUNIZATIONS
The ACIP recommends
immunizations for routine use in
children and adults.
Criteria:
Age limit 0-1 year
☒
Drug Description:
Iron suspension 15 mg – 1.5ml
Ferrous sulfate elixir
Ferrous sulfate syrup
Ferrous sulfate solution
Criteria:
Women
Rx Only and OTC products
Generics unless medically inappropriate
Drug Description:
See contraceptive list
Additional Criteria/Notes
Cover
Y N
☒
☐
☐
Cover
Y
N
1. Cover generics:
Yes☒ No☐
available:
Yes☐ No☒
3. Cover brands with no
generics available:
Yes☒ No☐
1. See Custom list (preventative
contraceptives)
2. IUDs and Implants covered
under Medical only
Criteria:
Age limit 0 months – 5 years
Prescription products only
1. Restrict to generic products only
(Y only)
2. Cover generics:
Drug Description:
Sodium fluoride products only, not in
combination
Sodium fluoride tab 0.5mg
Sodium fluoride chew tab 0.25mg –
0.5mg
Sodium fluoride solution
available:
Yes☒ No☐
available:
Yes☒ No☐
☒
☐
Criteria:
Children: 0-18 years
Adults: 19+ years
Prescription only
1. Cover generics:
Plans who only cover under medical
benefit can continue to do so. Plans
must cover under their medical or
pharmacy benefit
Drug Description:
Afluria, Ez Flu Shot, Fluarix Pf, Fluarix
Quad, Flublok, Flucelvax, Flulaval Qua,
Flumist Quad, Fluvirin, Fluvirin Pf,
Fluzone Hd, Fluzone Quad, Fluzone Splt,
Pneumovax 23, Prevnar 13, Zostavax,
Gardasil, Gardasil 9
537
Yes☐ No☒
Yes☒ No☐
Yes☒ No☐
Yes☒ No☐
available:
☒
☐
Cover brands with no generics
available:
Yes☒ No☐
Criteria for coverage
SMOKING CESSATION MEDICATION
Criteria:
clinicians ask all adults about
Prescription or OTC (requires a
tobacco use and provide tobacco
prescription)
cessation interventions for those
who use tobacco products.
Prescription products require coverage
of branded products
Drug Description:
Zyban®/Bupropion SR 12 HR 150 mg
Nicotine TD patch 24 HR kit
Nicotine polacrilex gum 2/ 4 mg
Nicotine polacrilex lozenge 2/ 4 mg
Nicotrol® Nasal Spray
Nicotrol® Inhaler
VITAMIN D
The USPSTF recommends vitamin
D supplementation to prevent
falls in community-dwelling
adults age 65 years and older
who are at increased risk for falls.
Cover
Y N
Criteria:
Age limit: 65+
Generic Only
Patient Residence Code: “Home”
☒
1. Allow OTC coverage:
Yes☒ No☐
2. Restrict to generic products only
Yes☐ No☒
3. Cover generics:
Yes☒ No☐
available:
Yes☐ No☒
☐
available:
1. Cover generics:
☒
Drug Description:
Vitamin D only (400IU)
BREAST CANCER PREVENTION MEDICATIONS
Criteria:
clinicians engage in shared,
Asymptomatic women aged ≥35 years
informed decision-making with
without a prior diagnosis of breast
women who are at increased risk cancer who are at increased risk for the
for breast cancer about
disease.
medications to reduce their risk.
For women who are at increased Prior Authorization: Yes
risk for breast cancer and at low
risk for adverse medication
effects, clinicians should offer to
Drug Description:
prescribe risk-reducing
Tamoxifen
medications, such as tamoxifen.
538
☐
available:
available:
Yes☒ No☐
Yes☒ No☐
Yes☐ No☒
Yes☐ No☒
1.
Prior Authorization required:
2.
Cover generics:
3.
Cover multisource
available:
Yes☒ No☐
Cover brands with no
generics available:
Yes☒ No☐
Yes☒ No☐
Yes☒ No☐
☒
☐
4.

PDF - Cox HealthPlans

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