CareSource MyCare Ohio (Medicare

Transcription

CareSource® MyCare Ohio (Medicare-Medicaid Plan)
Formulary
Version 14
Last updated 10/01/2016
CareSource MyCare Ohio Member Services Department: 1-855-475-3163
(TTY: 1-800-750-0750 or 711)
H8452_OHMMC660
CareSource MyCare Ohio | 2016 List of Covered Drugs
(Formulary)
This is a list of drugs that members can get in CareSource® MyCare Ohio (Medicare-Medicaid
Plan)
CareSource MyCare Ohio (Medicare-Medicaid Plan) is a health plan that contracts with both
Medicare and Ohio Medicaid to provide benefits of both programs to enrollees.
The List of Covered Drugs and/or pharmacy and provider networks may change throughout
the year. We will send you a notice before we make a change that affects you.
Benefits may change on January 1 of each year.
You can always check CareSource MyCare Ohioʼs up-to-date List of Covered Drugs online at
CareSource.com/MyCare.
Limitations, co-pays and restrictions may apply. For more information, call CareSource
MyCare Ohio Member Services or read the CareSource MyCare Ohio Member Handbook
(also known as the Evidence of Coverage).
You can get this information for free in other formats, such as large print, braille, or audio. Call
1-855-475-3163 (TTY: 1-800-750-0750 or 711). The call is free.
You can get this information for free in other languages. Call 1-855-475-3163 (TTY: 1-800
750-0750 or 711). The call is free.
Si usted prefiere esta información en Español, favor de llamar a CareSource al 1-855-475
3163. La llamada es gratuita.
If you have questions, please call CareSource MyCare Ohio at 1-855-475-3163, Monday –
Friday 8:00am – 8:00pm. The call is free. For more information, visit CareSource.com/MyCare.
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Frequently Asked Questions (FAQ)
Find answers here to questions you have about this List of Covered Drugs. You can read all of
the FAQ to learn more, or look for a question and answer.
1. What prescription drugs are on the List of Covered Drugs?
(We call the List of Covered Drugs the “Drug List” for short.)
The drugs on the List of Covered Drugs that starts on page 1 are the drugs covered by
CareSource MyCare Ohio. These drugs are available at pharmacies within our network. A
pharmacy is in our network if we have an agreement with them to work with us and provide you
services. We refer to these pharmacies as “network pharmacies.”
o CareSource MyCare Ohio will cover all medically necessary drugs on the Drug List if:
x your doctor or other prescriber says you need them to get better or stay healthy, and
x you fill the prescription at a CareSource MyCare Ohio network pharmacy.
o CareSource MyCare Ohio may have additional steps to access certain drugs (see question #5
below).
You can also see an up-to-date list of drugs that we cover on our website at
CareSource.com/MyCare or call Member Services at 1-855-475-3163 (TTY: 1-800-750-0750 or
711).
2. Does the Drug List ever change?
Yes. CareSource MyCare Ohio may add or remove drugs on the Drug List during the year.
Generally, the Drug List will only change if:
x a cheaper drug comes along that works as well as a drug on the Drug List now, or
x we learn that a drug is not safe.
We may also change our rules about drugs. For example, we could:
x Decide to require or not require prior approval for a drug. (Prior approval is permission from
CareSource MyCare Ohio before you can get a drug.)
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x Add or change the amount of a drug you can get (called “quantity limits”).
x Add or change step therapy restrictions on a drug. (Step therapy means you must try one
drug before we will cover another drug.)
(For more information on these drug rules, see pages iii and iv.)
We will tell you when a drug you are taking is removed from the Drug List. We will also tell you
when we change our rules for covering a drug. Questions 3, 4, and 7 below have more
information on what happens when the Drug List changes.
o You can always check CareSource MyCare Ohioʼs up to date Drug List online at
CareSource.com/MyCare. You can also call Member Services to check the current Drug List
at 1-855-475-3163 or TTY: 1-800-750-0750 or 711.
3. What happens when a cheaper drug comes along that works as
well as a drug on the Drug List now?
If you are taking a drug that is removed because a cheaper drug that works just as well comes
along, we will tell you. We will tell you at least 60 days before we remove it from the Drug List or
when you ask for a refill. Then you can get a 60-day supply of the drug before the change to the
Drug List is made. We will notify you by letter to tell you about changes to this drug list.
4. What happens when we find out a drug is not safe?
If the Food and Drug Administration (FDA) says a drug you are taking is not safe, we will take it
off the Drug List right away. We will also send you a letter telling you that. If you receive a letter
informing you that the FDA says the drug is no longer safe, you should talk to your prescribing
doctor about taking a different drug.
5. Are there any restrictions or limits on drug coverage? Or are there
any required actions to take in order to get certain drugs?
Yes, some drugs have coverage rules or have limits on the amount you can get. In some cases
you or your doctor or other prescriber must do something before you can get the drug. For
example:
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x Prior approval (or prior authorization): For some drugs, you or your doctor or other
prescriber must get approval from CareSource MyCare Ohio before you fill your
prescription. If you donʼt get approval, CareSource MyCare Ohio may not cover the drug.
x Quantity limits: Sometimes CareSource MyCare Ohio limits the amount of a drug you can
get.
x Step therapy: Sometimes CareSource MyCare Ohio requires you to do step therapy. This
means you will have to try drugs in a certain order for your medical condition. You might
have to try one drug before we will cover another drug. If your doctor thinks the first drug
doesnʼt work for you, then we will cover the second.
You can find out if your drug has any additional requirements or limits by looking in the tables on
pages 1-144. You can also get more information by visiting our web site at
CareSource.com/MyCare. We have posted online documents that explain our prior authorization
and step therapy restrictions. You may also ask us to send you a copy.
You can ask for an “exception” from these limits. Please see question 11 for more information on
exceptions.
o If you are in a nursing home or other long-term care facility and need a drug that is not on the
Drug List, or if you cannot easily get the drug you need, we can help. We will cover a 31-day
emergency supply of the drug you need (unless you have a prescription for fewer days),
whether or not you are a new CareSource MyCare Ohio member. This will give you time to
talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug
on the Drug List you can take instead or whether to request an exception. Please see
question 11 for more information about exceptions.
6.
How will you know if the drug you want has limitations or if there
are required actions to take to get the drug?
The List of Covered Drugs on page 1 has a column labeled “Necessary actions, restrictions, or
limits on use.”
7. What happens if we change our rules on how we cover some
drugs? For example, if we add prior authorization (approval),
quantity limits, and/or step therapy restrictions on a drug.
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We will tell you if we add prior approval, quantity limits, and/or step therapy restrictions on a drug.
We will tell you at least 60 days before the restriction is added or when you next ask for a refill.
Then, you can get a 60-day supply of the drug before the change to the Drug List is made. This
gives you time to talk to your doctor or other prescriber about what to do next.
8.
How can you find a drug on the Drug List?
There are two ways to find a drug:
x You can search alphabetically (if you know how to spell the drug), or
x You can search by medical condition.
To search alphabetically, go to the Alphabetical Listing section. You can find it in the index
section at the end of the formulary. The index provides an alphabetical list of all the drugs
included in this document. Both brand name drugs and generic drugs are listed in the index. Look
in the index and find your drug. You will see the page number where you can find coverage
information. Turn to the page listed in the index and find the name of your drug in the first column
of the list.
To search by medical condition, find the section labeled “List of drugs by medical condition” on
page 1. The drugs in this section are grouped into categories depending on the type of medical
conditions they are used to treat. For example, if you have a heart condition, you should look in
the category, Diuretics – Drugs To Treat Heart Conditions. That is where you will find drugs that
treat heart conditions.
9.
What if the drug you want to take is not on the Drug List?
If you donʼt see your drug on the Drug List, call Member Services at 1-855-475-3163 (TTY: 1-800

750-0750 or 711) and ask about it. If you learn that CareSource MyCare Ohio will not cover the
drug, you can do one of these things:
x Ask Member Services for a list of drugs like the one you want to take. Then show the list to
your doctor or other prescriber. He or she can prescribe a drug on the Drug List that is like
the one you want to take. Or
x You can ask the health plan to make an exception to cover your drug. Please see question
11 for more information about exceptions.
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10. What if you are a new CareSource MyCare Ohio member and canʼt
find your drug on the Drug List or have a problem getting your
drug?
We can help. We may cover a temporary 30-day supply of your drug during the first 90 days you
are a member of CareSource MyCare Ohio. This will give you time to talk to your doctor or other
prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take
instead or whether to request an exception.
We will cover a 30-day supply of your drug if:
x you are taking a drug that is not on our Drug List, or
x health plan rules do not let you get the amount ordered by your prescriber, or
x the drug requires prior approval by CareSource MyCare Ohio, or
x you are taking a drug that is part of a step therapy restriction.
If you live in a nursing home or other long-term care facility, you may refill your prescription
for as long as 91 days, but may be up to 98 days. You may refill the drug multiple times during
your first 98 days in the plan. This gives your prescriber time to change your drugs to ones on the
Drug List or ask for an exception.
Below is the CareSource MyCare Ohio Transition Policy for current enrollees with level of
care changes:
1. Level of Care Changes
a. In addition to circumstances impacting new enrollees who may enroll in CareSource
MyCare Ohio with a medication list that contains non-formulary Part D drugs, other
circumstances exist in which unplanned transitions for current members could arise and
in which prescribed drug regimens may not be on the CareSource MyCare Ohio
formulary.
b. These circumstances usually involve level of care changes in which a beneficiary is
changing from one treatment setting to another.
i. Beneficiaries who enter Long Term Care (LTC) facilities with a discharge list of
medications from the hospital formulary with very short term planning into account (often
under 8 hours).
ii. for beneficiaries who are admitted to or discharged from a hospital to a home;
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iii. for beneficiaries who end their skilled nursing facility Medicare Part A stay (where
payments include all pharmacy charges) and who need to revert to their Part D plan
formulary;
iv. for beneficiaries who give up hospice status to revert to standard Medicare Part A and
B benefits;
v. for beneficiaries who end a Long Term Care (LTC) facility stay and return to the
community; and
vi. for beneficiaries who are discharged from psychiatric hospitals with drug regimens that
are highly individualized.
c. For non-Long Term Care (LTC) residents, the pharmacy must call the Pharmacy
Benefit Manager (PBM) Pharmacy Help Desk in order to obtain an override to submit a
Level of Care transition fill request.
d. For Long Term Care (LTC) residents, a submission clarification code is submitted by
the pharmacy to allow transition fills and to override Refill Too Soon rejects for new
patient admissions.
e. When an enrollee is admitted to or discharged from a Long Term Care (LTC) facility,
the Pharmacy Benefit Manager (PBM), on behalf of CareSource MyCare Ohio, allows the
enrollee to access a refill upon admission or discharge.
11. Can you ask for an exception to cover your drug?
Yes. You can ask CareSource MyCare Ohio to make an exception to cover a drug that is not on
the Drug List.
You can also ask us to change the rules on your drug.
x For example, CareSource MyCare Ohio may limit the amount of a drug we will cover. If your
drug has
a limit, you can ask us to change the limit and cover more.
x Other examples: You can ask us to drop step therapy restrictions or prior approval
requirements.
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12. How long does it take to get an exception?
First, we must receive a statement from your prescriber supporting your request for an
exception. After we receive the statement, we will give you a decision on your exception request
within 72 hours.
If you or your prescriber think your health may be harmed if you have to wait 72 hours for a
decision, you can ask for an expedited exception. This is a faster decision. If your prescriber
supports your request, we will give you a decision within 24 hours of receiving your prescriberʼs
supporting statement.
13. How can you ask for an exception?
To ask for an exception, call Member Services at 1-855-475-3163 (TTY:1-800-750-0750 or 711).
A Member Services representative will work with you and your provider to help you ask for an
exception.
14. What are generic drugs?
Generic drugs are made up of the same active ingredients as brand name drugs. They usually
cost less than the brand name drug and usually donʼt have well-known names. Generic drugs are
approved by the Food and Drug Administration (FDA).
CareSource MyCare Ohio covers both brand name drugs and generic drugs.
15. What are OTC drugs?
OTC stands for “over-the-counter”. CareSource MyCare Ohio covers some OTC drugs when
they are written as prescriptions by your provider.
You can read the CareSource MyCare Ohio Drug List to see what OTC drugs are covered.
16. What is your copay?
You can read the CareSource MyCare Ohio Drug List to learn about the copay for each drug.
CareSource MyCare Ohio members living in nursing homes or other long-term care facilities will
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have no copays. Some members getting long-term care in the community will also have no
copays.
There are no copays for CareSource MyCare Ohio covered prescription drugs. For
members with CareSource MyCare Ohio coverage for both Medicare and Medicaid you
have no copays for your covered prescription drugs.
NOTE – If you only have CareSource MyCare Ohio for Medicaid benefits, your Medicare
plan covers your Part D drugs. You may have co-pays with your Medicare plan. Confirm
your copays with your Medicare plan. For the drugs that are not Part D Drugs, there are
no copays.
List of Covered Drugs by Medical Condition
The drugs in this section are grouped into categories depending on the type of medical conditions
they are used to treat. For example, if you have a heart condition, you should look in that
category, That is where you will find drugs that treat heart conditions.
The list of covered drugs that begins on the next page gives you information about the drugs
covered by CareSource MyCare Ohio. If you have trouble finding your drug in the list, turn to
the Index that begins on page number 153.
The first column of the chart lists the name of the drug. Brand name drugs are capitalized (e.g.,
COUMADIN) and generic drugs are listed in lower-case italics (e.g., warfarin sodium).
The information in the necessary actions, restrictions, or limits on use column tells you if
CareSource MyCare Ohio has any rules for covering your drug.
Note: The asterisk * next to a drug means the drug is not a “Part D drug.” The amount you pay
when you fill a prescription for this drug does not count towards your total drug costs (that is, the
amount you pay does not help you qualify for catastrophic coverage). In addition, if you are
receiving Extra Help to pay for your prescriptions, you will not get any Extra Help to pay for these
drugs. These drugs also have different rules for appeals. An appeal is a formal way of asking us
to review a coverage decision and to change it if you think we made a mistake. For example, we
might decide that a drug that you want is not covered or is no longer covered by Medicare or
Medicaid. If you or your doctor disagrees with our decision, you can appeal. To ask for
instructions on how to appeal, call Member Services at 1-855-475-3163. You can also read the
Member Handbook to learn how to appeal a decision.
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2016 Formulary Abbreviations
B/D indicates that the prescription can be covered through the Part B or D benefit depending on
the situation. Information may need to be submitted describing the use and setting of the drug to make the determination.
LA indicates a prescription may be available only at certain pharmacies.
NM indicates that the drug is not available by mail-order.
PA indicates that prior authorization may apply.
QL indicates that quantities dispensed may be limited.
ST indicates that step therapy may apply.
(*) indicates Non-Part D Drugs, or OTC items that are covered by Medicaid
Name of drug
What the drug will cost you
Necessary actions,
(tier level)
restrictions, or limits on use
Cardiovascular Agents – Drugs to treat high blood pressure
amlodipine-benazepril hcl
CAP 2.5-10mg
1
QL (30 caps / 30 days)
BENICAR TAB 5MG
2
QL (60 tabs / 30 days)
Central Nervous System – Drugs to treat seizures
Gabapentin TAB 600mg
1
LYRICA CAP 200MG
2
Endocrine and Metabolic (Antidiabetic) – Drugs to treat high blood sugar
JANUMENT XR TAB 50
500MG
2
Metformin hcl TAB 500mg
1
PA-Prior Authorization QL – Quantity Limits
ST – Step Therapy *-Non-Part D Drugs, or OTC
items that are covered by Medicaid NM- Not available mail-order B/D – Covered under
Medicare B or D
LA – Limited Access
x
Name of Drug
What the
Drug will
cost you
(Tier
Level)
Necessary actions,
restrictions, or limit
on use
ANALGESICS - DRUGS TO TREAT PAIN AND INFLAMMATION
GOUT - DRUGS TO TREAT GOUT
allopurinol tab 100 mg
allopurinol tab 300 mg
colchicine w/ probenecid tab 0.5-500 mg
COLCRYS TAB 0.6MG
probenecid tab 500 mg
ULORIC TAB 40MG
ULORIC TAB 80MG
1
1
1
2
1
2
2
ST
ST
NSAIDS - DRUGS TO TREAT PAIN AND INFLAMMATION
ACEPHEN SUP 120MG
acephen sup 325mg
acephen sup 650mg
acetaminophen suppos 120 mg
acetaminophen suppos 650 mg
ADVIL JR ST TAB 100MG
ADVIL JR STR CHW 100MG
all day pain tab 220mg
all day relf tab 220mg
aspir-81 tab 81mg ec
aspir-low tab 81mg ec
aspirin chew tab 81 mg
aspirin chw 81mg
aspirin low chw 81mg
aspirin low tab 81mg ec
aspirin tab 81mg ec
aspirin tab 325 mg
aspirin tab 325mg ec
aspirin tab delayed release 81 mg
aspirin tab delayed release 325 mg
celecoxib cap 50 mg
celecoxib cap 100 mg
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
1
1
1
1
NM; *
NM; *
NM; *
NM; *
NM; *
NM; *
NM; *
NM; *
NM; *
NM; *
NM; *
NM; *
NM; *
NM; *
NM; *
NM; *
NM; *
NM; *
NM; *
NM; *
QL (60
QL (60
QL (60
QL (60
caps
caps
caps
caps
/
/
/
/
30
30
30
30
PA - Prior Authorization
QL - Quantity Limits
ST - Step Therapy
NM - Not
available at mail-order
B/D - Covered under Medicare B or D
LA - Limited Access
* - Non-Part D Drugs, or OTC items that are covered by Medicaid
B/D This drug may be covered under Medicare Part B or D depending upon the
circumstances. Information may need to be submitted describing the use and setting of
the drug to make the determination.
days)
days)
days)
days)
1
Name of Drug
child asa chw 81mg
child asa ls chw 81mg
chld ibuprfn dro 40mg/ml
diclofenac potassium tab 50 mg
diclofenac sodium tab delayed release 25
mg
mg
mg
diclofenac sodium tab sr 24hr 100 mg
diflunisal tab 500 mg
ecpirin tab 325mg ec
etodolac cap 200 mg
etodolac cap 300 mg
etodolac tab 400 mg
etodolac tab 500 mg
etodolac tab sr 24hr 400 mg
fever reduce sup 120mg
FEVERALL INF SUP 80MG
FEVERALL SUP 120MG
FEVERALL SUP 325MG
FEVERALL SUP 650MG
flurbiprofen tab 50 mg
flurbiprofen tab 100 mg
gnp aspirin chw 81mg
gnp aspirin tab 81mg ec
gnp aspirin tab 325mg ec
hm aspirin chw 81mg
hm aspirin tab 325mg
hm ibuprofen tab 200mg
ibu-drops dro 40mg/ml
ibu-drops dro 50/1.25
ibuprofen cap 200 mg
ibuprofen cap 200mg
What the
Drug will
cost you
(Tier
Level)
4
4
4
1
1
Necessary actions,
on use
NM; *
NM; *
NM; *
1
1
1
1
4
1
1
1
1
1
1
1
4
4
4
4
4
1
1
4
4
4
4
4
4
4
4
4
4
NM; *
NM;
NM;
NM;
NM;
NM;
*
*
*
*
*
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
*
*
*
*
*
*
*
*
*
*
ST - Step Therapy
NM - Not
LA - Limited Access
2
Name of Drug
ibuprofen dro 50/1.25
ibuprofen jr chw 100mg
ibuprofen sus 100/5ml
ibuprofen susp 100 mg/5ml
ibuprofen tab 200 mg
ibuprofen tab 200mg
ketoprofen cap 50 mg
ketoprofen cap 75 mg
MELOXICAM SUSP 7.5 MG/5ML
meloxicam tab 7.5 mg
meloxicam tab 15 mg
nabumetone tab 500 mg
nabumetone tab 750 mg
naproxen dr tab 375mg
naproxen dr tab 500mg
NAPROXEN SOD CAP 220MG
naproxen sod tab 220mg
NAPROXEN SODIUM CAP 220 MG
naproxen sodium tab 220 mg
naproxen susp 125 mg/5ml
naproxen tab 250 mg
naproxen tab 375 mg
naproxen tab 500 mg
piroxicam cap 10 mg
piroxicam cap 20 mg
provil tab 200mg
qc aspirin tab 325mg
qc aspirin tab 325mg ec
qc child asa chw 81mg
qc ibuprofen tab 200mg
sb ibuprofen tab 200mg
sm aspirin chw 81mg
What the
Drug will
cost you
(Tier
Level)
4
4
4
1
4
4
1
1
1
1
1
1
1
1
1
1
1
1
4
4
4
4
1
1
1
1
1
1
1
1
4
4
4
4
4
4
4
Necessary actions,
on use
NM; *
NM; *
NM; *
NM; *
NM; *
NM;
NM;
NM;
NM;
*
*
*
*
NM;
NM;
NM;
NM;
NM;
NM;
NM;
*
*
*
*
*
*
*
ST - Step Therapy
NM - Not
LA - Limited Access
3
Name of Drug
sm aspirin tab 81mg ec
sm aspirin tab 325mg ec
sm child asa chw 81mg
sm ibuprofen tab 200mg
sulindac tab 150 mg
sulindac tab 200 mg
What the
Drug will
cost you
(Tier
Level)
4
4
4
4
1
1
Necessary actions,
on use
NM;
NM;
NM;
NM;
*
*
*
*
OPIOID ANALGESICS - DRUGS TO TREAT PAIN
acetaminophen w/ codeine soln 120-12
mg/5ml
acetaminophen w/ codeine tab 300-15 mg
butorphanol tartrate inj 1 mg/ml
butorphanol tartrate inj 2 mg/ml
nalbuphine hcl inj 10 mg/ml
nalbuphine hcl inj 20 mg/ml
tramadol hcl tab 50 mg
tramadol-acetaminophen tab 37.5-325 mg
1
QL (5000 mL / 30 days)
1
1
1
1
1
1
1
1
1
OPIOID ANALGESICS, CII - DRUGS TO TREAT PAIN
DURAMORPH INJ 0.5MG/ML
DURAMORPH INJ 1MG/ML
endocet tab 5-325mg
endocet tab 7.5-325
endocet tab 10-325mg
fentanyl citrate lozenge on a handle
mcg
mcg
mcg
mcg
mcg
mcg
fentanyl td patch 72hr 12 mcg/hr
1
1
1
1
1
2
B/D
B/D
200
QL (120 lozenges / 30
days), PA
400
2
days), PA
600
2
days), PA
2
800
days), PA
1200 2
days), PA
1600 2
days), PA
1
QL (10 patches / 30
days)
ST - Step Therapy
NM - Not
4
LA - Limited Access
Name of Drug
What the
Drug will
cost you
(Tier
Level)
1
1
1
1
FENTORA TAB 100MCG
2
FENTORA TAB 200MCG
2
FENTORA TAB 400MCG
2
FENTORA TAB 600MCG
2
FENTORA TAB 800MCG
2
hydrocodone-acetaminophen soln 7.5-325 1
mg/15ml
hydrocodone-acetaminophen tab 5-325 mg 1
hydrocodone-acetaminophen tab 7.5-325 1
mg
hydrocodone-acetaminophen tab 10-325 1
mg
hydrocodone-ibuprofen tab 7.5-200 mg
1
hydromorphone hcl liqd 1 mg/ml
1
hydromorphone hcl preservative free (pf) 1
inj 10 mg/ml
hydromorphone hcl tab 2 mg
1
1
1
methadone con 10mg/ml
1
methadone hcl soln 5 mg/5ml
1
methadone hcl soln 10 mg/5ml
1
methadone hcl tab 5 mg
1
methadone hcl tab 10 mg
1
MORPHINE SUL INJ 2MG/ML
1
Necessary actions,
on use
QL (10 patches / 30
days)
QL (10 patches / 30
days), PA
QL (10 patches / 30
days), PA
QL (10 patches / 30
days), PA
QL (120 tabs / 30 days),
PA
PA
PA
PA
PA
QL (5400 mL / 30 days)
B/D
QL (270
QL (270
QL (270
QL (120
QL (600
QL (600
QL (240
QL (240
B/D
tabs / 30 days)
tabs / 30 days)
tabs / 30 days)
mL / 30 days)
mL / 30 days)
mL / 30 days)
tabs / 30 days)
tabs / 30 days)
ST - Step Therapy
NM - Not
LA - Limited Access
5
Name of Drug
What the
Drug will
cost you
(Tier
Level)
1
1
1
1
1
1
1
1
morphine sulfate beads cap sr 24hr 30 mg
morphine sulfate beads cap sr 24hr 120
mg
morphine sulfate cap sr 24hr 10 mg
1
1
1
1
1
2
2
morphine sulfate inj pf 0.5 mg/ml
1
morphine sulfate inj pf 1 mg/ml
1
MORPHINE SULFATE IV SOLN 1 MG/ML
1
morphine sulfate iv soln pf 4 mg/ml
1
morphine sulfate iv soln pf 8 mg/ml
1
MORPHINE SULFATE IV SOLN PF 10 MG/ML 1
MORPHINE SULFATE IV SOLN PF 15 MG/ML 1
MORPHINE SULFATE ORAL SOLN 10
1
MG/5ML
1
MG/5ML
1
MG/5ML (20 MG/ML)
MORPHINE SULFATE TAB 15 MG
1
MORPHINE SULFATE TAB 30 MG
1
morphine sulfate tab cr 15 mg
1
1
1
1
1
oxycodone hcl cap 5 mg
1
Necessary actions,
on use
B/D
B/D
QL (60
QL (60
QL (60
QL (60
QL (60
QL (60
QL (60
QL (60
QL (60
QL (60
QL (60
QL (60
QL (60
B/D
B/D
B/D
B/D
B/D
B/D
B/D
QL
QL
QL
QL
QL
QL
QL
QL
caps
caps
caps
caps
caps
caps
/
/
/
/
/
/
30
30
30
30
30
30
days)
days)
days)
days)
days)
days)
caps
caps
caps
caps
caps
caps
caps
/
/
/
/
/
/
/
30
30
30
30
30
30
30
days)
days)
days)
days)
days)
days)
days)
(180 tabs / 30 days)
(90 tabs / 30 days)
(90 tabs / 30 days)
(90 tabs / 30 days)
(90 tabs / 30 days)
(60 tabs / 30 days)
(180 caps / 30 days)
ST - Step Therapy
NM - Not
LA - Limited Access
6
Name of Drug
oxycodone hcl conc 100 mg/5ml (20
mg/ml)
OXYCODONE HCL SOLN 5 MG/5ML
oxycodone hcl tab 5 mg
oxycodone w/ acetaminophen soln 5-325
mg/5ml
oxycodone w/ acetaminophen tab 2.5-325
mg
oxycodone w/ acetaminophen tab 5-325
mg
oxycodone w/ acetaminophen tab 7.5-325
mg
oxycodone w/ acetaminophen tab 10-325
mg
What the
Drug will
cost you
(Tier
Level)
1
Necessary actions,
on use
1
1
1
1
1
1
1
QL
QL
QL
QL
QL
QL
1
1
1
1
1
1
1
1
1
B/D
B/D
B/D
B/D
B/D
hcl local preservative free (pf) inj 1
B/D
(180 tabs
(180 tabs
(180 tabs
(180 tabs
(180 tabs
(1800 mL
/
/
/
/
/
/
30
30
30
30
30
30
days)
days)
days)
days)
days)
days)
ANESTHETICS - DRUGS FOR NUMBING
LOCAL ANESTHETICS
lidocaine
lidocaine
lidocaine
lidocaine
lidocaine
0.5%
lidocaine
1%
hcl
hcl
hcl
hcl
hcl
local
local
local
local
local
inj 0.5%
inj 1%
inj 1.5%
inj 2%
preservative free (pf) inj
ANTI-INFECTIVES - DRUGS TO TREAT INFECTIONS
ANTI-BACTERIALS - MISCELLANEOUS
amikacin sulfate inj 1 gm/4ml (250 mg/ml) 1
amikacin sulfate inj 500 mg/2ml (250
1
mg/ml)
gentam/nacl inj 0.9mg/ml
1
gentam/nacl inj 1.4mg/ml
1
gentamicin in saline inj 0.8 mg/ml
1
gentamicin in saline inj 1 mg/ml
1
1
ST - Step Therapy
NM - Not
LA - Limited Access
7
Name of Drug
gentamicin in saline inj 2 mg/ml
gentamicin sulfate inj 10 mg/ml
gentamicin sulfate inj 40 mg/ml
gentamicin sulfate iv soln 10 mg/ml
neomycin sulfate tab 500 mg
paromomycin sulfate cap 250 mg
streptomycin sulfate for inj 1 gm
sulfadiazine tab 500mg
tobramycin nebu soln 300 mg/5ml
tobramycin sulfate for inj 1.2 gm
tobramycin sulfate inj 1.2 gm/30ml (40
mg/ml) (base equiv)
tobramycin sulfate inj 2 gm/50ml (40
mg/ml) (base equiv)
tobramycin sulfate inj 10 mg/ml (base
equivalent)
tobramycin sulfate inj 80 mg/2ml (40
mg/ml) (base equiv)
What the
Drug will
cost you
(Tier
Level)
1
1
1
1
1
1
1
1
2
2
1
1
Necessary actions,
on use
B/D, NM
1
1
1
ANTI-INFECTIVES - MISCELLANEOUS
ALBENZA TAB 200MG
ALINIA SUS 100/5ML
ALINIA TAB 500MG
atovaquone susp 750 mg/5ml
AZACTAM/DEX INJ 1GM
AZACTAM/DEX INJ 2GM
aztreonam for inj 1 gm
aztreonam for inj 2 gm
BILTRICIDE TAB 600MG
CAYSTON INH 75MG
clindamycin hcl cap 75 mg
clindamycin palmitate hcl for soln 75
mg/5ml (base equiv)
clindamycin phosphate in d5w iv soln 300
mg/50ml
2
2
2
2
2
2
1
1
2
2
1
1
1
1
NM, LA, PA
1
ST - Step Therapy
NM - Not
LA - Limited Access
8
Name of Drug
What the
Drug will
cost you
(Tier
Level)
clindamycin phosphate in d5w iv soln 600 1
mg/50ml
clindamycin phosphate in d5w iv soln 900 1
mg/50ml
clindamycin phosphate inj 9 gm/60ml
1
clindamycin phosphate inj 300 mg/2ml
1
1
1
clindamycin phosphate iv soln 300 mg/2ml 1
colistimethate sodium for inj 150 mg
1
CUBICIN SOL 500MG
2
dapsone tab 25 mg
1
dapsone tab 100 mg
1
DARAPRIM TAB 25MG
2
emverm chw 100mg
2
imipenem-cilastatin intravenous for soln
1
250 mg
1
500 mg
INVANZ INJ 1GM
2
ivermectin tab 3 mg
1
LINEZOLID FOR SUSP 100 MG/5ML
2
LINEZOLID IN SODIUM CHLORIDE IV SOLN 2
600 MG/300ML-0.9%
linezolid iv soln 600 mg/300ml (2 mg/ml) 2
LINEZOLID TAB 600 MG
2
meropenem iv for soln 1 gm
1
meropenem iv for soln 500 mg
1
methenamine hippurate tab 1 gm
1
metronidazole in nacl 0.79% iv soln 500
1
mg/100ml
metronidazole tab 250 mg
1
metronidazole tab 500 mg
1
NEBUPENT INH 300MG
2
Necessary actions,
on use
B/D
ST - Step Therapy
NM - Not
LA - Limited Access
9
Name of Drug
What the
Drug will
cost you
(Tier
Level)
nitrofurantoin macrocrystalline cap 50 mg 2
nitrofurantoin macrocrystalline cap 100 mg 2
nitrofurantoin monohydrate
macrocrystalline cap 100 mg
2
PENTAM 300 INJ 300MG
2
reeses med sus pinworm
4
SIVEXTRO INJ 200MG
2
SIVEXTRO TAB 200MG
2
sulfamethoxazole-trimethoprim iv soln
1
400-80 mg/5ml
sulfamethoxazole-trimethoprim susp 200- 1
40 mg/5ml
sulfamethoxazole-trimethoprim tab 400-80 1
mg
sulfamethoxazole-trimethoprim tab 800- 1
160 mg
SYNERCID INJ 500MG
2
trimethoprim tab 100 mg
1
TYGACIL INJ 50MG
2
vancomycin hcl cap 125 mg
2
vancomycin hcl cap 250 mg
2
vancomycin hcl for inj 10 gm
1
vancomycin hcl for inj 500 mg
1
1
1
VANCOMYCIN INJ 1 GM
2
VANCOMYCIN INJ 500MG
2
vancomycin inj 750mg
1
VANCOMYCIN INJ 750MG
2
ZYVOX TAB 600MG
2
Necessary actions,
on use
PA; PA applies if 65
years and older after a
90 day supply in a
calendar year
90 day supply in a
calendar year
90 day supply in a
calendar year
NM; *
ST - Step Therapy
NM - Not
LA - Limited Access
10
Name of Drug
What the
Drug will
cost you
(Tier
Level)
Necessary actions,
on use
ANTIFUNGALS - DRUGS TO TREAT FUNGAL INFECTIONS
ABELCET INJ 5MG/ML
2
AMBISOME INJ 50MG
2
amphotericin b for inj 50 mg
1
CANCIDAS INJ 50MG
2
CANCIDAS INJ 70MG
2
fluconazole for susp 10 mg/ml
1
fluconazole for susp 40 mg/ml
1
fluconazole in dextrose inj 200 mg/100ml 1
fluconazole in dextrose inj 400 mg/200ml 1
fluconazole in nacl 0.9% inj 200 mg/100ml 1
fluconazole in nacl 0.9% inj 400 mg/200ml 1
fluconazole tab 50 mg
1
1
1
1
fluconazole/ inj nacl 100
1
flucytosine cap 250 mg
2
flucytosine cap 500 mg
2
griseofulvin microsize susp 125 mg/5ml
1
griseofulvin microsize tab 500 mg
1
griseofulvin ultramicrosize tab 125 mg
1
griseofulvin ultramicrosize tab 250 mg
1
itraconazole cap 100 mg
1
ketoconazole tab 200 mg
1
MYCAMINE INJ 50MG
2
MYCAMINE INJ 100MG
2
NOXAFIL SUS 40MG/ML
2
NOXAFIL TAB 100MG
2
nystatin tab 500000 unit
1
terbinafine hcl tab 250 mg
1
voriconazole for inj 200 mg
1
voriconazole for susp 40 mg/ml
2
voriconazole tab 50 mg
2
voriconazole tab 200 mg
2
B/D
B/D
B/D
PA
PA
ANTIMALARIALS - DRUGS TO TREAT MALARIA
atovaquone-proguanil hcl tab 62.5-25 mg 1
ST - Step Therapy
NM - Not
LA - Limited Access
11
Name of Drug
What the
Drug will
cost you
(Tier
Level)
atovaquone-proguanil hcl tab 250-100 mg 1
chloroquine phosphate tab 250 mg
1
chloroquine phosphate tab 500 mg
1
COARTEM TAB 20-120MG
2
mefloquine hcl tab 250 mg
1
PRIMAQUINE TAB 26.3MG
2
quinine sulfate cap 324 mg
1
Necessary actions,
on use
PA
ANTIRETROVIRAL AGENTS - DRUGS TO SUPPRESS HIV/AIDS
INFECTION
abacavir sulfate tab 300 mg (base equiv) 1
APTIVUS CAP 250MG
2
APTIVUS SOL
2
CRIXIVAN CAP 200MG
2
CRIXIVAN CAP 400MG
2
didanosine delayed release capsule 125 mg1
EDURANT TAB 25MG
2
EMTRIVA CAP 200MG
2
EMTRIVA SOL 10MG/ML
2
FUZEON INJ 90MG
2
INTELENCE TAB 25MG
2
INTELENCE TAB 100MG
2
INTELENCE TAB 200MG
2
INVIRASE CAP 200MG
2
INVIRASE TAB 500MG
2
ISENTRESS CHW 25MG
2
ISENTRESS CHW 100MG
2
ISENTRESS POW 100MG
2
ISENTRESS TAB 400MG
2
lamivudine oral soln 10 mg/ml
1
lamivudine tab 150 mg
1
lamivudine tab 300 mg
1
LEXIVA SUS 50MG/ML
2
LEXIVA TAB 700MG
2
NEVIRAPINE SUSP 50 MG/5ML
1
NM
ST - Step Therapy
NM - Not
LA - Limited Access
12
Name of Drug
nevirapine tab 200 mg
nevirapine tab sr 24hr 100 mg
nevirapine tab sr 24hr 400 mg
NORVIR CAP 100MG
NORVIR SOL 80MG/ML
NORVIR TAB 100MG
PREZISTA SUS 100MG/ML
PREZISTA TAB 75MG
PREZISTA TAB 150MG
PREZISTA TAB 600MG
PREZISTA TAB 800MG
RESCRIPTOR TAB 100 MG
RESCRIPTOR TAB 200MG
RETROVIR INJ 10MG/ML
REYATAZ CAP 150MG
REYATAZ CAP 200MG
REYATAZ CAP 300MG
REYATAZ POW 50MG
SELZENTRY TAB 150MG
SELZENTRY TAB 300MG
stavudine cap 15 mg
stavudine cap 20 mg
stavudine cap 30 mg
stavudine cap 40 mg
stavudine for oral soln 1 mg/ml
SUSTIVA CAP 50MG
SUSTIVA CAP 200MG
SUSTIVA TAB 600MG
TIVICAY TAB 10MG
TIVICAY TAB 25MG
TIVICAY TAB 50MG
TYBOST TAB 150MG
VIDEX SOL 2GM
VIDEX SOL 4GM
VIRACEPT TAB 250MG
VIRACEPT TAB 625MG
VIRAMUNE XR TAB 100MG
What the
Drug will
cost you
(Tier
Level)
1
1
1
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
1
1
1
1
1
2
2
2
2
2
2
2
2
2
2
2
2
Necessary actions,
on use
ST - Step Therapy
NM - Not
LA - Limited Access
13
Name of Drug
VIREAD POW 40MG/GM
VIREAD TAB 150MG
VIREAD TAB 200MG
VIREAD TAB 250MG
VIREAD TAB 300MG
VITEKTA TAB 85MG
VITEKTA TAB 150MG
ZIAGEN SOL 20MG/ML
zidovudine cap 100 mg
zidovudine syrup 10 mg/ml
zidovudine tab 300 mg
What the
Drug will
cost you
(Tier
Level)
2
2
2
2
2
2
2
2
1
1
1
Necessary actions,
on use
ANTIRETROVIRAL COMBINATION AGENTS - DRUGS TO SUPPRESS
HIV/AIDS INFECTION
abacavir sulfate-lamivudine-zidovudine tab 2
300-150-300 mg
ATRIPLA TAB
2
COMPLERA TAB
2
DESCOVY TAB 200/25
2
EPZICOM TAB 600-300
2
EVOTAZ TAB 300-150
2
GENVOYA TAB
2
KALETRA SOL
2
KALETRA TAB 100-25MG
2
KALETRA TAB 200-50MG
2
lamivudine-zidovudine tab 150-300 mg
2
ODEFSEY TAB
2
PREZCOBIX TAB 800-150
2
STRIBILD TAB
2
TRIUMEQ TAB
2
TRUVADA TAB 100-150
2
TRUVADA TAB 133-200
2
TRUVADA TAB 167-250
2
TRUVADA TAB 200-300
2
QL
QL
QL
QL
(60
(30
(30
(30
tabs
tabs
tabs
tabs
/
/
/
/
30
30
30
30
days)
days)
days)
days)
ANTITUBERCULAR AGENTS - DRUGS TO TREAT TUBERCULOSIS
CAPASTAT SUL INJ 1GM
cycloserine cap 250 mg
ethambutol hcl tab 100 mg
2
2
1
ST - Step Therapy
NM - Not
LA - Limited Access
14
Name of Drug
ethambutol hcl tab 400 mg
isoniazid inj 100 mg/ml
isoniazid syrup 50 mg/5ml
isoniazid tab 100 mg
isoniazid tab 300 mg
paser gra 4gm
PRIFTIN TAB 150MG
pyrazinamide tab 500 mg
rifabutin cap 150 mg
rifampin cap 150 mg
rifampin cap 300 mg
rifampin for inj 600 mg
RIFATER TAB
SIRTURO TAB 100MG
TRECATOR TAB 250MG
What the
Drug will
cost you
(Tier
Level)
1
1
1
1
1
2
2
1
1
1
1
1
2
2
2
Necessary actions,
on use
LA, PA
ANTIVIRALS - DRUGS TO TREAT VIRAL INFECTIONS
acyclovir cap 200 mg
acyclovir sodium for inj 500 mg
acyclovir sodium iv soln 50 mg/ml
acyclovir susp 200 mg/5ml
acyclovir tab 400 mg
acyclovir tab 800 mg
adefovir dipivoxil tab 10 mg
BARACLUDE SOL .05MG/ML
DAKLINZA TAB 30MG
DAKLINZA TAB 60MG
DAKLINZA TAB 90MG
entecavir tab 0.5 mg
entecavir tab 1 mg
EPIVIR HBV SOL 5MG/ML
famciclovir tab 125 mg
ganciclovir sodium for inj 500 mg
HARVONI TAB 90-400MG
lamivudine tab 100 mg (hbv)
moderiba pak 600/day
1
1
1
1
1
1
2
2
2
2
2
2
2
2
1
1
1
1
2
1
2
B/D
B/D
NM, PA
NM, PA
NM, PA
B/D
NM, PA
NM
ST - Step Therapy
NM - Not
LA - Limited Access
15
Name of Drug
MODERIBA PAK 1200/DAY
PEG-INTRON KIT 50MCG RP
PEG-INTRON KIT 80MCG RP
PEG-INTRON KIT 120 RP
PEG-INTRON KIT 150 RP
PEGASYS INJ
PEGASYS INJ 180MCG/M
PEGASYS INJ PROCLICK
PEGINTRON KIT 50MCG
PEGINTRON KIT 80MCG
PEGINTRON KIT 120MCG
PEGINTRON KIT 150MCG
REBETOL SOL 40MG/ML
RELENZA MIS DISKHALE
ribapak pak 600/day
ribapak pak 800/day
ribapak pak 1000/day
ribapak pak 1200/day
ribasphere cap 200mg
ribasphere tab 200mg
ribavirin cap 200 mg
ribavirin tab 200 mg
rimantadine hydrochloride tab 100 mg
SOVALDI TAB 400MG
TAMIFLU CAP 30MG
TAMIFLU CAP 45MG
TAMIFLU CAP 75MG
TAMIFLU SUS 6MG/ML
TYZEKA TAB 600MG
valacyclovir hcl tab 1 gm
valacyclovir hcl tab 500 mg
VALCYTE SOL 50MG/ML
What the
Drug will
cost you
(Tier
Level)
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
1
1
1
2
1
1
1
2
2
2
2
2
2
1
1
2
Necessary actions,
on use
NM
NM
NM
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
NM
NM
NM
NM
NM
NM
NM
NM
NM
NM
NM, PA
ST - Step Therapy
NM - Not
LA - Limited Access
16
Name of Drug
valganciclovir hcl tab 450 mg (base
equivalent)
What the
Drug will
cost you
(Tier
Level)
2
Necessary actions,
on use
CEPHALOSPORINS - DRUGS TO TREAT INFECTIONS
cefaclor cap 250 mg
cefaclor cap 500 mg
cefaclor er tab 500mg
cefaclor for susp 125 mg/5ml
cefadroxil cap 500 mg
cefadroxil for susp 250 mg/5ml
cefadroxil for susp 500 mg/5ml
cefadroxil tab 1 gm
cefazolin inj 1gm/50ml
cefazolin sodium for inj 1 gm
cefazolin sodium for inj 500 mg
cefazolin sodium for iv soln 1 gm
CEFAZOLIN SOL
cefdinir cap 300 mg
cefdinir for susp 125 mg/5ml
cefdinir for susp 250 mg/5ml
cefepime hcl for inj 1 gm
cefepime hcl for inj 2 gm
cefixime for susp 100 mg/5ml
cefixime for susp 200 mg/5ml
cefotaxime sodium for inj 1 gm
cefotaxime sodium for inj 2 gm
cefotaxime sodium for inj 500 mg
cefoxitin sodium for inj 10 gm
cefoxitin sodium for iv soln 1 gm
cefoxitin sodium for iv soln 2 gm
cefpodoxime proxetil for susp 50 mg/5ml
cefpodoxime proxetil tab 100 mg
cefpodoxime proxetil tab 200 mg
1
1
2
1
1
1
1
1
1
1
2
1
1
1
1
1
2
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
ST - Step Therapy
NM - Not
LA - Limited Access
17
Name of Drug
cefprozil for susp 125 mg/5ml
cefprozil for susp 250 mg/5ml
cefprozil tab 250 mg
cefprozil tab 500 mg
ceftazidime for inj 1 gm
CEFTAZIDIME/ SOL D5W 1GM
CEFTAZIDIME/ SOL D5W 2GM
ceftriaxone sodium for inj 1 gm
ceftriaxone sodium for inj 250 mg
ceftriaxone sodium for inj 500 mg
ceftriaxone sodium for iv soln 1 gm
ceftriaxone sodium for iv soln 2 gm
cefuroxime axetil tab 250 mg
cefuroxime axetil tab 500 mg
cefuroxime sodium for inj 1.5 gm
cefuroxime sodium for inj 7.5 gm
cefuroxime sodium for inj 750 mg
cefuroxime sodium for iv soln 1.5 gm
cephalexin cap 250 mg
cephalexin cap 500 mg
cephalexin for susp 125 mg/5ml
cephalexin for susp 250 mg/5ml
SUPRAX CAP 400MG
suprax chw 100mg
suprax chw 200mg
SUPRAX SUS 500/5ML
tazicef inj 1gm
tazicef inj 2gm
tazicef inj 6gm
TEFLARO INJ 400MG
TEFLARO INJ 600MG
What the
Drug will
cost you
(Tier
Level)
1
1
1
1
1
1
1
2
2
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
2
2
2
1
1
1
2
2
Necessary actions,
on use
ERYTHROMYCINS/MACROLIDES - DRUGS TO TREAT INFECTIONS
azithromycin for susp 100 mg/5ml
1
ST - Step Therapy
NM - Not
LA - Limited Access
18
Name of Drug
azithromycin for susp 200 mg/5ml
azithromycin iv for soln 500 mg
AZITHROMYCIN POWD PACK FOR SUSP 1
GM
azithromycin tab 250 mg
clarithromycin for susp 125 mg/5ml
clarithromycin for susp 250 mg/5ml
clarithromycin tab 250 mg
clarithromycin tab 500 mg
clarithromycin tab sr 24hr 500 mg
DIFICID TAB 200MG
e.e.s. 400 tab 400mg
ery-tab tab 250mg ec
erythrocin inj 500mg
erythrocin tab 250mg
erythromycin ethylsuccinate tab 400 mg
erythromycin tab 250 mg
erythromycin tab 500 mg
erythromycin w/ delayed release particles
cap 250 mg
What the
Drug will
cost you
(Tier
Level)
1
1
1
Necessary actions,
on use
1
1
1
1
1
1
1
1
2
1
1
1
1
2
1
1
1
1
1
FLUOROQUINOLONES - DRUGS TO TREAT INFECTIONS
ciprofloxacin 200 mg/100ml in d5w
ciprofloxacin 400 mg/200ml in d5w
ciprofloxacin for oral susp 250 mg/5ml
(5%) (5 gm/100ml)
(10%) (10 gm/100ml)
ciprofloxacin hcl tab 100 mg (base equiv)
ciprofloxacin iv soln 200 mg/20ml (1%)
1
1
1
1
1
1
1
1
1
1
ST - Step Therapy
NM - Not
LA - Limited Access
19
Name of Drug
ciprofloxacin-ciprofloxacin hcl tab sr 24hr
500 mg (base eq)
ciprofloxacin-ciprofloxacin hcl tab sr 24hr
1000 mg(base eq)
levofloxacin in d5w iv soln 250 mg/50ml
levofloxacin iv soln 25 mg/ml
levofloxacin oral soln 25 mg/ml
levofloxacin tab 250 mg
What the
Drug will
cost you
(Tier
Level)
1
Necessary actions,
on use
1
1
1
1
1
1
1
1
1
PENICILLINS - DRUGS TO TREAT INFECTIONS
amoxicillin & k clavulanate chew tab 200- 1
28.5 mg
amoxicillin & k clavulanate chew tab 400- 1
57 mg
amoxicillin & k clavulanate for susp 2001
28.5 mg/5ml
62.5 mg/5ml
amoxicillin & k clavulanate for susp 400-57 1
mg/5ml
42.9 mg/5ml
amoxicillin & k clavulanate tab 250-125 mg1
amoxicillin & k clavulanate tab sr 12hr
1
1000-62.5 mg
amoxicillin (trihydrate) cap 250 mg
1
amoxicillin (trihydrate) cap 500 mg
1
amoxicillin (trihydrate) chew tab 125 mg 1
amoxicillin (trihydrate) chew tab 250 mg 1
amoxicillin (trihydrate) for susp 125
1
mg/5ml
1
mg/5ml
ST - Step Therapy
NM - Not
LA - Limited Access
20
Name of Drug
What the
Drug will
cost you
(Tier
Level)
1
Necessary actions,
on use
mg/5ml
1
mg/5ml
amoxicillin (trihydrate) tab 500 mg
1
amoxicillin (trihydrate) tab 875 mg
1
ampicillin & sulbactam sodium for inj 1-0.5 1
gm
ampicillin & sulbactam sodium for inj 2-1 1
gm
ampicillin & sulbactam sodium for inj 10-5 1
gm
ampicillin & sulbactam sodium for iv soln 1
2-1 gm
ampicillin & sulbactam sodium for iv soln 1
10-5 gm
ampicillin cap 250 mg
1
ampicillin cap 500 mg
1
ampicillin for susp 125 mg/5ml
1
ampicillin for susp 250 mg/5ml
1
ampicillin sodium for inj 1 gm
1
ampicillin sodium for inj 2 gm
1
ampicillin sodium for inj 125 mg
1
1
1
ampicillin sodium for iv soln 1 gm
1
1
1
BICILLIN L-A INJ 600000
2
2
2
dicloxacillin sodium cap 250 mg
1
dicloxacillin sodium cap 500 mg
1
nafcillin sodium for inj 1 gm
1
2
2
nafcillin sodium for iv soln 1 gm
1
nafcillin sodium for iv soln 2 gm
2
ST - Step Therapy
NM - Not
LA - Limited Access
21
Name of Drug
What the
Drug will
cost you
(Tier
Level)
oxacillin sodium for inj 1 gm
1
1
2
pen g proc inj 600000
2
PENICILL GK/ INJ DEX 2MU
2
PENICILL GK/ INJ DEX 3MU
2
penicillin g potassium for inj 5000000 unit 1
penicillin g potassium for inj 20000000 unit1
penicillin g sodium for inj 5000000 unit
1
penicillin v potassium for soln 125 mg/5ml 1
penicillin v potassium for soln 250 mg/5ml 1
penicillin v potassium tab 250 mg
1
penicillin v potassium tab 500 mg
1
piperacillin sod-tazobactam na for inj 3.3751
gm (3-0.375 gm)
piperacillin sod-tazobactam sod for inj 2.25 1
gm (2-0.25 gm)
gm (4-0.5 gm)
gm (36-4.5 gm)
Necessary actions,
on use
TETRACYCLINES - DRUGS TO TREAT INFECTIONS
doxy 100 inj 100mg
doxycycline hyclate cap 50 mg
doxycycline hyclate cap 100 mg
doxycycline hyclate for inj 100 mg
doxycycline hyclate tab 20 mg
doxycycline hyclate tab 100 mg
doxycycline monohydrate cap 50 mg
doxycycline monohydrate cap 100 mg
doxycycline monohydrate tab 50 mg
minocycline hcl cap 50 mg
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
ST - Step Therapy
NM - Not
LA - Limited Access
22
Name of Drug
morgidox cap 1x50mg
What the
Drug will
cost you
(Tier
Level)
1
Necessary actions,
on use
ANTINEOPLASTIC AGENTS - DRUGS TO TREAT CANCER
ALKYLATING AGENTS
BENDEKA INJ 100/4ML
BICNU INJ 100MG
BUSULFEX INJ 6MG/ML
CYCLOPHOSPH CAP 25MG
CYCLOPHOSPH CAP 50MG
cyclophosphamide for inj 1 gm
cyclophosphamide for inj 2 gm
cyclophosphamide for inj 500 mg
dacarbazine for inj 100 mg
dacarbazine for inj 200 mg
EMCYT CAP 140MG
GLEOSTINE CAP 5MG
GLEOSTINE CAP 10MG
GLEOSTINE CAP 40MG
GLEOSTINE CAP 100MG
HEXALEN CAP 50MG
IFEX INJ 3GM
ifosfamide for inj 1 gm
IFOSFAMIDE INJ 3GM
ifosfamide iv inj 1 gm/20ml (50 mg/ml)
LEUKERAN TAB 2MG
melphalan hcl for inj 50 mg (base equiv)
MUSTARGEN INJ 10MG
TREANDA INJ 25MG
TREANDA INJ 45/0.5ML
TREANDA INJ 100MG
TREANDA INJ 180/2ML
2
2
2
2
2
2
1
2
1
1
2
2
2
2
2
2
2
1
2
1
1
2
2
2
2
2
2
2
B/D, NM
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
1
1
1
2
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D,
B/D,
B/D,
B/D,
NM
NM
NM
NM
ANTHRACYCLINES
daunorubicin hcl inj 5 mg/ml (base equiv)
doxorubicin hcl for inj 50 mg
doxorubicin hcl inj 2 mg/ml
doxorubicin hcl liposomal inj (for iv
infusion) 2 mg/ml
ST - Step Therapy
NM - Not
LA - Limited Access
23
Name of Drug
epirubicin
mg/ml)
epirubicin
mg/ml)
idarubicin
idarubicin
idarubicin
hcl iv soln 50 mg/25ml (2
What the
Drug will
cost you
(Tier
Level)
1
Necessary actions,
on use
B/D
hcl iv soln 200 mg/100ml (2
1
B/D
hcl iv inj 5 mg/5ml (1 mg/ml)
2
hcl iv inj 10 mg/10ml (1 mg/ml) 2
hcl iv inj 20 mg/20ml (1 mg/ml) 2
B/D
B/D
B/D
ANTIBIOTICS
bleomycin sulfate for
bleomycin sulfate for
mitomycin for iv soln
inj 15 unit
inj 30 unit
5 mg
20 mg
40 mg
1
1
1
1
1
B/D
B/D
B/D
B/D
B/D
ANTIMETABOLITES
adrucil inj 2.5g/50m
1
adrucil inj 5gm/100m
1
adrucil inj 500/10ml
1
ALIMTA INJ 100MG
2
ALIMTA INJ 500MG
2
azacitidine for inj 100 mg
2
cladribine iv soln 10 mg/10ml (1 mg/ml) 2
cytarabine inj 20 mg/ml
1
fludarabine phosphate for inj 50 mg
1
fludarabine phosphate inj 25 mg/ml
1
fluorouracil inj 1 gm/20ml (50 mg/ml)
1
fluorouracil inj 2.5 gm/50ml (50 mg/ml)
1
1
fluorouracil inj 500 mg/10ml (50 mg/ml) 1
gemcitabine hcl for inj 1 gm
2
gemcitabine hcl for inj 2 gm
2
gemcitabine hcl for inj 200 mg
2
GEMCITABINE HCL INJ 1 GM/26.3ML (38 2
MG/ML) (BASE EQUIV)
GEMCITABINE HCL INJ 2 GM/52.6ML (38 2
MG/ML) (BASE EQUIV)
GEMCITABINE HCL INJ 200 MG/5.26ML (38 2
MG/ML) (BASE EQUIV)
B/D
B/D
B/D
B/D
B/D
B/D, NM
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
ST - Step Therapy
NM - Not
LA - Limited Access
24
Name of Drug
What the
Drug will
cost you
(Tier
Level)
1
1
1
mercaptopurine tab 50 mg
methotrexate sodium for inj 1 gm
METHOTREXATE SODIUM INJ 50 MG/2ML
(25 MG/ML)
methotrexate sodium inj 250 mg/10ml (25 1
mg/ml)
methotrexate sodium inj pf 50 mg/2ml (25 1
mg/ml)
methotrexate sodium inj pf 100 mg/4ml
1
(25 mg/ml)
1
(25 mg/ml)
methotrexate sodium inj pf 250 mg/10ml 1
(25 mg/ml)
methotrexate sodium inj pf 1000 mg/40ml 1
(25 mg/ml)
NIPENT INJ 10MG
2
PURIXAN SUS 20MG/ML
2
TABLOID TAB 40MG
2
Necessary actions,
on use
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
NM
ANTIMITOTIC, TAXOIDS
ABRAXANE INJ 100MG
2
DOCETAXEL FOR INJ CONC 20 MG/ML
2
DOCETAXEL FOR INJ CONC 80 MG/4ML (20 2
MG/ML)
DOCETAXEL INJ 20MG/2ML
1
DOCETAXEL INJ 80MG/8ML
2
docetaxel inj 140/7ml
2
DOCETAXEL INJ 160/16ML
2
DOCETAXEL INJ 200MG/20
2
paclitaxel iv conc 30 mg/5ml (6 mg/ml)
1
paclitaxel iv conc 100 mg/16.7ml (6
1
mg/ml)
paclitaxel iv conc 150 mg/25ml (6 mg/ml) 1
paclitaxel iv conc 300 mg/50ml (6 mg/ml) 1
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
ANTIMITOTIC, VINCA ALKALOIDS
vinblastine sulfate inj 1 mg/ml
vincasar pfs inj 1mg/ml
vincristine sulfate iv soln 1 mg/ml
2
1
1
B/D
B/D
B/D
ST - Step Therapy
NM - Not
LA - Limited Access
25
Name of Drug
vinorelbine tartrate inj 10 mg/ml (base
equiv)
vinorelbine tartrate inj 50 mg/5ml (10
mg/ml) (base equiv)
What the
Drug will
cost you
(Tier
Level)
1
Necessary actions,
on use
B/D
1
B/D
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
B/D, NM, LA
B/D, NM, LA
NM, PA
NM, LA, PA
NM, LA, PA
NM, LA, PA
NM, LA, PA
B/D, NM
NM, LA, PA
NM, LA, PA
NM, LA, PA
B/D, NM
B/D, NM
B/D, NM
NM, PA
NM, PA
NM, LA, PA
NM, PA
NM, PA
NM, PA
B/D, NM
NM, LA, PA
NM, LA, PA
NM, LA, PA
B/D, NM
NM, LA, PA
NM, LA, PA
NM, LA, PA
NM, LA, PA
NM, PA
NM, PA
NM, PA
BIOLOGIC RESPONSE MODIFIERS
AVASTIN INJ
AVASTIN INJ 400/16ML
BELEODAQ INJ 500MG
ERIVEDGE CAP 150MG
FARYDAK CAP 10MG
FARYDAK CAP 15MG
FARYDAK CAP 20MG
HERCEPTIN INJ 440MG
IBRANCE CAP 75MG
IBRANCE CAP 100MG
IBRANCE CAP 125MG
ISTODAX INJ 10MG
KADCYLA INJ 100MG
KADCYLA INJ 160MG
KEYTRUDA INJ 100MG/4M
KEYTRUDA SOL 50MG
LYNPARZA CAP 50MG
NINLARO CAP 2.3MG
NINLARO CAP 3MG
NINLARO CAP 4MG
PROLEUKIN INJ 22MU
RITUXAN INJ 100MG
RITUXAN INJ 500MG
TECENTRIQ INJ 1200/20
VELCADE INJ 3.5MG
VENCLEXTA TAB 10MG
VENCLEXTA TAB 50MG
VENCLEXTA TAB 100MG
VENCLEXTA TAB START PK
YERVOY INJ 50MG
YERVOY INJ 200MG
ZOLINZA CAP 100MG
ST - Step Therapy
NM - Not
LA - Limited Access
26
Name of Drug
What the
Drug will
cost you
(Tier
Level)
Necessary actions,
on use
HORMONAL ANTINEOPLASTIC AGENTS
anastrozole tab 1 mg
bicalutamide tab 50 mg
DEPO-PROVERA INJ 400/ML
exemestane tab 25 mg
FARESTON TAB 60MG
FASLODEX INJ 250MG
flutamide cap 125 mg
hydroxyprogesterone caproate im in oil
1.25 gm/5ml
letrozole tab 2.5 mg
leuprolide acetate inj kit 5 mg/ml
LUPR DEP-PED INJ 7.5MG
LUPR DEP-PED INJ 11.25MG
LUPR DEP-PED INJ 15MG
LUPR DEP-PED INJ 30MG
LUPRON DEPOT INJ 3.75MG
LUPRON DEPOT INJ 11.25MG
LYSODREN TAB 500MG
megestrol acetate susp 40 mg/ml
1
1
2
1
2
2
1
2
MEGESTROL ACETATE SUSP 625 MG/5ML
megestrol acetate tab 20 mg
2
2
megestrol acetate tab 40 mg
2
NILANDRON TAB 150MG
nilutamide tab 150 mg
SOLTAMOX SOL 10MG/5ML
tamoxifen citrate tab 10 mg (base
equivalent)
tamoxifen citrate tab 20 mg (base
equivalent)
TRELSTAR MIX INJ 3.75MG
TRELSTAR MIX INJ 11.25MG
XTANDI CAP 40MG
ZYTIGA TAB 250MG
2
2
2
1
1
1
2
2
2
2
2
2
2
2
B/D
B/D
B/D
NM,
NM,
NM,
NM,
NM,
NM,
NM,
PA
PA
PA
PA
PA
PA
PA
PA; PA if 65 years and
older
PA
older
older
1
2
2
2
2
NM,
NM,
NM,
NM,
PA
PA
LA, PA
LA, PA
ST - Step Therapy
NM - Not
LA - Limited Access
27
Name of Drug
What the
Drug will
cost you
(Tier
Level)
Necessary actions,
on use
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
2
NM, PA
2
2
2
2
2
2
2
2
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
KINASE INHIBITORS
AFINITOR DIS TAB 2MG
AFINITOR TAB 2.5MG
AFINITOR TAB 5MG
AFINITOR TAB 7.5MG
AFINITOR TAB 10MG
ALECENSA CAP 150MG
BOSULIF TAB 100MG
BOSULIF TAB 500MG
CABOMETYX TAB 20MG
CABOMETYX TAB 40MG
CABOMETYX TAB 60MG
CAPRELSA TAB 100MG
CAPRELSA TAB 300MG
COMETRIQ KIT 60MG
COMETRIQ KIT 100MG
COMETRIQ KIT 140MG
COTELLIC TAB 20MG
GILOTRIF TAB 20MG
GILOTRIF TAB 30MG
GILOTRIF TAB 40MG
ICLUSIG TAB 15MG
ICLUSIG TAB 45MG
imatinib mesylate tab 100 mg (base
equivalent)
imatinib mesylate tab 400 mg (base
equivalent)
IMBRUVICA CAP 140MG
INLYTA TAB 1MG
INLYTA TAB 5MG
IRESSA TAB 250MG
JAKAFI TAB 5MG
JAKAFI TAB 10MG
JAKAFI TAB 15MG
JAKAFI TAB 20MG
PA
PA
PA
PA
PA
PA
PA
LA,
PA
PA
LA,
LA,
LA,
LA,
LA,
LA,
LA,
LA,
LA,
LA,
LA,
LA,
LA,
LA,
PA
LA,
LA,
LA,
LA,
LA,
LA,
LA,
LA,
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
ST - Step Therapy
NM - Not
LA - Limited Access
28
Name of Drug
JAKAFI TAB 25MG
LENVIMA CAP 8 MG
LENVIMA CAP 10 MG
LENVIMA CAP 14 MG
LENVIMA CAP 18 MG
LENVIMA CAP 20 MG
LENVIMA CAP 24 MG
MEKINIST TAB 0.5MG
MEKINIST TAB 2MG
NEXAVAR TAB 200MG
SPRYCEL TAB 20MG
SPRYCEL TAB 50MG
SPRYCEL TAB 70MG
SPRYCEL TAB 80MG
SPRYCEL TAB 100MG
SPRYCEL TAB 140MG
STIVARGA TAB 40MG
SUTENT CAP 12.5MG
SUTENT CAP 25MG
SUTENT CAP 37.5MG
SUTENT CAP 50MG
TAFINLAR CAP 50MG
TAFINLAR CAP 75MG
TAGRISSO TAB 40MG
TAGRISSO TAB 80MG
TARCEVA TAB 25MG
TARCEVA TAB 100MG
TARCEVA TAB 150MG
TASIGNA CAP 150MG
TASIGNA CAP 200MG
TYKERB TAB 250MG
VOTRIENT TAB 200MG
XALKORI CAP 200MG
XALKORI CAP 250MG
ZELBORAF TAB 240MG
ZYDELIG TAB 100MG
ZYDELIG TAB 150MG
What the
Drug will
cost you
(Tier
Level)
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
Necessary actions,
on use
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
LA,
LA,
LA,
LA,
LA,
LA,
LA,
LA,
LA,
LA,
PA
PA
PA
PA
PA
PA
LA,
PA
PA
PA
PA
LA,
LA,
LA,
LA,
LA,
LA,
LA,
PA
PA
LA,
LA,
LA,
LA,
LA,
LA,
LA,
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
ST - Step Therapy
NM - Not
LA - Limited Access
29
Name of Drug
ZYKADIA CAP 150MG
What the
Drug will
cost you
(Tier
Level)
2
Necessary actions,
on use
NM, LA, PA
MISCELLANEOUS
bexarotene cap 75 mg
2
DROXIA CAP 200MG
2
DROXIA CAP 300MG
2
DROXIA CAP 400MG
2
hydroxyurea cap 500 mg
1
LONSURF TAB 15-6.14
2
LONSURF TAB 20-8.19
2
MATULANE CAP 50MG
2
mitoxantrone hcl inj conc 20 mg/10ml (2 1
mg/ml)
mitoxantrone hcl inj conc 25 mg/12.5ml (2 1
mg/ml)
mitoxantrone hcl inj conc 30 mg/15ml (2 1
mg/ml)
ODOMZO CAP 200MG
2
POMALYST CAP 1MG
2
POMALYST CAP 2MG
2
POMALYST CAP 3MG
2
POMALYST CAP 4MG
2
SYLATRON KIT 200MCG
2
SYLATRON KIT 300MCG
2
SYLATRON KIT 600MCG
2
SYNRIBO INJ 3.5MG
2
tretinoin cap 10 mg
2
TRISENOX SOL 10MG/10M
2
NM, PA
NM, PA
NM, PA
LA
B/D, NM
B/D, NM
B/D, NM
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
LA,
LA,
LA,
LA,
LA,
PA
PA
PA
PA
PA
PA
PA
PA
PA
B/D
PLATINUM-BASED AGENTS
carboplatin iv soln 50 mg/5ml
cisplatin inj 50 mg/50ml (1 mg/ml)
oxaliplatin for iv inj 50 mg
oxaliplatin for iv inj 100 mg
1
1
1
1
1
1
1
2
2
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
ST - Step Therapy
NM - Not
LA - Limited Access
30
Name of Drug
oxaliplatin iv soln 50 mg/10ml
oxaliplatin iv soln 100 mg/20ml
What the
Drug will
cost you
(Tier
Level)
2
2
Necessary actions,
on use
B/D
B/D
PROTECTIVE AGENTS
amifostine crystalline for inj 500 mg
dexrazoxane for inj 250 mg
ELITEK INJ 1.5MG
ELITEK INJ 7.5MG
FUSILEV INJ 50MG
leucovorin calcium for inj 50 mg
leucovorin calcium tab 5 mg
levoleucovor sol 250mg/25
levoleucovorin calcium for iv inj 50 mg
(base equiv)
levoleucovorin calcium inj 175 mg/17.5ml
(base equiv)
mesna inj 100 mg/ml
MESNEX TAB 400MG
2
2
2
2
2
1
1
1
1
1
1
1
1
1
2
2
B/D
B/D
B/D
B/D
B/D, NM
B/D
B/D
B/D
B/D
B/D
2
B/D, NM
1
2
B/D
etoposide inj 500 mg/25ml (20 mg/ml)
1
irinotecan hcl inj 40 mg/2ml (20 mg/ml)
1
irinotecan hcl inj 100 mg/5ml (20 mg/ml) 1
irinotecan hcl inj 500 mg/25ml (20 mg/ml) 1
toposar inj 1gm/50ml
1
topotecan hcl for inj 4 mg
2
B/D
B/D
B/D
B/D
B/D
B/D
B/D, NM
B/D, NM
TOPOISOMERASE INHIBITORS
CARDIOVASCULAR - DRUGS TO TREAT HEART AND CIRCULATION
CONDITIONS
ACE INHIBITOR COMBINATIONS - DRUGS TO TREAT HIGH BLOOD
PRESSURE
amlodipine besylate-benazepril hcl cap 2.5-1
10 mg
ST - Step Therapy
NM - Not
31
LA - Limited Access
Name of Drug
What the
Drug will
cost you
(Tier
Level)
1
amlodipine besylate-benazepril hcl cap 510 mg
amlodipine besylate-benazepril hcl cap 5- 1
20 mg
40 mg
20 mg
40 mg
benazepril & hydrochlorothiazide tab 51
6.25 mg
benazepril & hydrochlorothiazide tab 10- 1
12.5 mg
benazepril & hydrochlorothiazide tab 20- 1
12.5 mg
benazepril & hydrochlorothiazide tab 20-25 1
mg
captopril & hydrochlorothiazide tab 25-15 1
mg
mg
mg
mg
enalapril maleate & hydrochlorothiazide tab1
5-12.5 mg
enalapril maleate & hydrochlorothiazide tab1
10-25 mg
fosinopril sodium & hydrochlorothiazide tab 1
10-12.5 mg
fosinopril sodium & hydrochlorothiazide tab 1
20-12.5 mg
lisinopril & hydrochlorothiazide tab 10-12.5 1
mg
lisinopril & hydrochlorothiazide tab 20-12.5 1
mg
Necessary actions,
on use
ST - Step Therapy
NM - Not
LA - Limited Access
32
Name of Drug
What the
Drug will
cost you
(Tier
Level)
1
Necessary actions,
on use
lisinopril & hydrochlorothiazide tab 20-25
mg
moexipril-hydrochlorothiazide tab 7.5-12.5 1
mg
moexipril-hydrochlorothiazide tab 15-12.5 1
mg
moexipril-hydrochlorothiazide tab 15-25
1
mg
quinapril-hydrochlorothiazide tab 10-12.5 1
mg
quinapril-hydrochlorothiazide tab 20-12.5 1
mg
quinapril-hydrochlorothiazide tab 20-25 mg1
ACE INHIBITORS - DRUGS TO TREAT HIGH BLOOD PRESSURE
benazepril hcl tab 5 mg
1
1
1
1
captopril tab 12.5 mg
1
captopril tab 25 mg
1
captopril tab 50 mg
1
captopril tab 100 mg
1
enalapril maleate tab 2.5 mg
1
enalapril maleate tab 5 mg
1
1
1
fosinopril sodium tab 10 mg
1
1
1
lisinopril tab 2.5 mg
1
lisinopril tab 5 mg
1
lisinopril tab 10 mg
1
1
1
1
moexipril hcl tab 7.5 mg
1
moexipril hcl tab 15 mg
1
perindopril erbumine tab 2 mg
1
ST - Step Therapy
NM - Not
LA - Limited Access
33
Name of Drug
quinapril hcl tab 5 mg
ramipril cap 1.25 mg
ramipril cap 2.5 mg
ramipril cap 5 mg
ramipril cap 10 mg
trandolapril tab 1 mg
What the
Drug will
cost you
(Tier
Level)
1
1
1
1
1
1
1
1
1
1
1
1
1
Necessary actions,
on use
ALDOSTERONE RECEPTOR ANTAGONISTS - DRUGS TO TREAT HIGH
BLOOD PRESSURE
eplerenone tab 25 mg
eplerenone tab 50 mg
spironolactone tab 25 mg
1
1
1
1
1
ALPHA BLOCKERS - DRUGS TO TREAT HIGH BLOOD PRESSURE
doxazosin mesylate tab 1
prazosin hcl cap 1 mg
terazosin hcl cap 1 mg
mg
mg
mg
mg
1
1
1
1
1
1
1
1
1
1
1
ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS - DRUGS
TO TREAT HIGH BLOOD PRESSURE
amlodipine besylate-valsartan tab 5-160
mg
1
ST - Step Therapy
NM - Not
LA - Limited Access
34
Name of Drug
mg
mg
mg
amlodipine-valsartan-hydrochlorothiazide
tab 5-160-12.5 mg
tab 5-160-25 mg
tab 10-160-12.5 mg
tab 10-160-25 mg
tab 10-320-25 mg
AZOR TAB 5-20MG
AZOR TAB 5-40MG
AZOR TAB 10-20MG
AZOR TAB 10-40MG
BENICAR HCT TAB 20-12.5
BENICAR HCT TAB 40-12.5
BENICAR HCT TAB 40-25MG
ENTRESTO TAB 24-26MG
irbesartan-hydrochlorothiazide tab 15012.5 mg
irbesartan-hydrochlorothiazide tab 30012.5 mg
losartan potassium & hydrochlorothiazide
tab 50-12.5 mg
tab 100-12.5 mg
tab 100-25 mg
TRIBENZOR20- TAB 5-12.5MG
TRIBENZOR40- TAB 5-12.5MG
What the
Drug will
cost you
(Tier
Level)
1
Necessary actions,
on use
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
2
1
PA
PA
PA
1
1
1
1
2
2
ST - Step Therapy
NM - Not
LA - Limited Access
35
Name of Drug
TRIBENZOR40- TAB 5-25MG
TRIBENZOR40- TAB 10-12.5
TRIBENZOR40- TAB 10-25MG
valsartan-hydrochlorothiazide
mg
mg
mg
mg
mg
What the
Drug will
cost you
(Tier
Level)
2
2
2
tab 80-12.5 1
Necessary actions,
on use
tab 160-12.5 1
tab 160-25
1
tab 320-12.5 1
tab 320-25
1
ANGIOTENSIN II RECEPTOR ANTAGONISTS - DRUGS TO TREAT
HIGH BLOOD PRESSURE
BENICAR TAB 5MG
BENICAR TAB 20MG
BENICAR TAB 40MG
irbesartan tab 75 mg
losartan potassium tab 25 mg
valsartan tab 40 mg
valsartan tab 80 mg
valsartan tab 160 mg
valsartan tab 320 mg
2
2
2
1
1
1
1
1
1
1
1
1
1
ANTIARRHYTHMICS - DRUGS TO CONTROL HEART RHYTHM
amiodarone hcl inj 150 mg/3ml (50
1
mg/ml)
1
mg/ml)
1
mg/ml)
amiodarone hcl tab 100 mg
1
1
1
ST - Step Therapy
NM - Not
LA - Limited Access
36
Name of Drug
disopyramide phosphate cap 100 mg
What the
Drug will
cost you
(Tier
Level)
2
disopyramide phosphate cap 150 mg
2
dofetilide cap 125 mcg (0.125 mg)
flecainide acetate tab 50 mg
mexiletine hcl cap 150 mg
MULTAQ TAB 400MG
NORPACE CAP 100MG CR
1
1
1
1
1
1
1
1
1
2
2
NORPACE CAP 150MG CR
2
pacerone tab 100mg
pacerone tab 200mg
pacerone tab 400mg
propafenone hcl cap sr 12hr 225 mg
propafenone hcl tab 150 mg
quinidine gluconate tab cr 324 mg
quinidine sulfate tab 200 mg
quinidine sulfate tab 300 mg
sorine tab 80mg
sorine tab 120mg
sorine tab 160mg
sorine tab 240mg
sotalol hcl (afib/afl) tab 80 mg
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Necessary actions,
on use
older
older
NM
NM
NM
older
older
ST - Step Therapy
NM - Not
LA - Limited Access
37
Name of Drug
sotalol hcl tab 80 mg
TIKOSYN CAP 125MCG
TIKOSYN CAP 250MCG
TIKOSYN CAP 500MCG
What the
Drug will
cost you
(Tier
Level)
1
1
1
1
2
2
2
Necessary actions,
on use
NM
NM
NM
ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS - DRUGS TO
TREAT HIGH CHOLESTEROL
atorvastatin calcium tab 10 mg (base
equivalent)
equivalent)
equivalent)
equivalent)
CRESTOR TAB 5MG
CRESTOR TAB 10MG
CRESTOR TAB 20MG
CRESTOR TAB 40MG
lovastatin tab 10 mg
pravastatin sodium tab 10 mg
rosuvastatin calcium tab 5 mg
simvastatin tab 5 mg
1
1
1
1
2
2
2
2
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
(30 tabs / 30 days)
(30 tabs / 30 days)
(30 tabs / 30 days)
(30 tabs / 30 days)
(30 tabs / 30 days)
(60 tabs / 30 days)
(30 tabs / 30 days)
(30 tabs / 30 days)
(30 tabs / 30 days)
(30 tabs / 30 days)
(30 tabs / 30 days)
(30 tabs / 30 days)
(30 tabs / 30 days)
(30 tabs / 30 days)
(30 tabs / 30 days)
(30 tabs / 30 days)
(30 tabs / 30 days)
(30 tabs / 30 days)
(30 tabs / 30 days)
ST - Step Therapy
NM - Not
LA - Limited Access
38
Name of Drug
What the
Drug will
cost you
(Tier
Level)
Necessary actions,
on use
ANTILIPEMICS, MISCELLANEOUS - DRUGS TO TREAT HIGH
CHOLESTEROL
cholestyramine light powder 4 gm/dose
1
cholestyramine light powder packets 4 gm 1
cholestyramine powder 4 gm/dose
1
cholestyramine powder packets 4 gm
1
choline fenofibrate cap dr 45 mg (fenofibric 1
acid equiv)
choline fenofibrate cap dr 135 mg
1
(fenofibric acid equiv)
colestipol hcl granule packets 5 gm
1
colestipol hcl granules 5 gm
1
colestipol hcl tab 1 gm
1
fenofibrate micronized cap 67 mg
1
1
1
fenofibrate tab 48 mg
1
1
1
1
gemfibrozil tab 600 mg
1
JUXTAPID CAP 5MG
2
JUXTAPID CAP 10MG
2
JUXTAPID CAP 20MG
2
JUXTAPID CAP 30MG
2
JUXTAPID CAP 40MG
2
JUXTAPID CAP 60MG
2
KYNAMRO INJ 200MG/ML
2
niacin tab cr 500 mg (antihyperlipidemic) 1
niacor tab 500mg
1
omega-3-acid ethyl esters cap 1 gm
1
PRALUENT INJ 75MG/ML
2
PRALUENT INJ 150MG/ML
2
prevalite pow 4gm
1
prevalite pow 4gm pk
1
NM, LA, PA
NM, LA, PA
NM, LA, PA
NM, LA, PA
NM, LA, PA
NM, LA, PA
NM, PA
NM, PA
NM, PA
ST - Step Therapy
NM - Not
LA - Limited Access
39
Name of Drug
VASCEPA CAP 1GM
WELCHOL PAK 3.75GM
WELCHOL TAB 625MG
ZETIA TAB 10MG
What the
Drug will
cost you
(Tier
Level)
2
2
2
2
Necessary actions,
on use
BETA-BLOCKER/DIURETIC COMBINATIONS - DRUGS TO TREAT
HIGH BLOOD PRESSURE AND HEART CONDITIONS
atenolol & chlorthalidone tab 50-25 mg
1
1
bisoprolol & hydrochlorothiazide tab 2.5- 1
6.25 mg
bisoprolol & hydrochlorothiazide tab 5-6.25 1
mg
bisoprolol & hydrochlorothiazide tab 101
6.25 mg
metoprolol & hydrochlorothiazide tab 50- 1
25 mg
25 mg
50 mg
propranolol & hydrochlorothiazide tab 40- 1
25 mg
propranolol & hydrochlorothiazide tab 80- 1
25 mg
BETA-BLOCKERS - DRUGS TO TREAT HIGH BLOOD PRESSURE AND
HEART CONDITIONS
acebutolol hcl cap 200 mg
acebutolol hcl cap 400 mg
atenolol tab 25 mg
atenolol tab 50 mg
atenolol tab 100 mg
bisoprolol fumarate tab 5 mg
bisoprolol fumarate tab 10 mg
BYSTOLIC TAB 2.5MG
BYSTOLIC TAB 5MG
BYSTOLIC TAB 10MG
BYSTOLIC TAB 20MG
1
1
1
1
1
1
1
2
2
2
2
ST - Step Therapy
NM - Not
LA - Limited Access
40
Name of Drug
carvedilol tab 3.125 mg
carvedilol tab 25 mg
labetalol hcl tab 100 mg
metoprolol succinate tab sr 24hr 25 mg
(tartrate equiv)
(tartrate equiv)
(tartrate equiv)
(tartrate equiv)
metoprolol tartrate inj 1 mg/ml
metoprolol tartrate tab 25 mg
nadolol tab 20 mg
nadolol tab 40 mg
nadolol tab 80 mg
pindolol tab 5 mg
pindolol tab 10 mg
propranolol hcl cap sr 24hr 60 mg
propranolol hcl inj 1 mg/ml
propranolol hcl oral soln 20 mg/5ml
propranolol hcl oral soln 40 mg/5ml
propranolol hcl tab 10 mg
timolol maleate tab 5 mg
What the
Drug will
cost you
(Tier
Level)
1
1
1
1
1
1
1
1
Necessary actions,
on use
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
ST - Step Therapy
NM - Not
LA - Limited Access
41
Name of Drug
What the
Drug will
cost you
(Tier
Level)
1
1
Necessary actions,
on use
CALCIUM CHANNEL BLOCKERS - DRUGS TO TREAT HIGH BLOOD
PRESSURE AND HEART CONDITIONS
afeditab tab 30mg cr
afeditab tab 60mg cr
amlodipine besylate tab 2.5 mg
amlodipine besylate tab 5 mg
amlodipine besylate tab 10 mg
diltiazem hcl cap sr 12hr 60 mg
diltiazem hcl coated beads cap sr 24hr 120
mg
mg
mg
mg
mg
diltiazem hcl extended release beads cap
sr 24hr 120 mg
sr 24hr 180 mg
sr 24hr 240 mg
sr 24hr 300 mg
sr 24hr 360 mg
sr 24hr 420 mg
diltiazem hcl iv soln 25 mg/5ml (5 mg/ml)
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
ST - Step Therapy
NM - Not
LA - Limited Access
42
Name of Drug
What the
Drug will
cost you
(Tier
Level)
1
Necessary actions,
on use
diltiazem hcl iv soln 50 mg/10ml (5
mg/ml)
1
mg/ml)
diltiazem hcl tab 30 mg
1
1
1
1
felodipine tab sr 24hr 2.5 mg
1
QL (30 tabs / 30
felodipine tab sr 24hr 5 mg
1
QL (60 tabs / 30
felodipine tab sr 24hr 10 mg
1
isradipine cap 2.5 mg
1
isradipine cap 5 mg
1
nicardipine hcl cap 20 mg
1
nicardipine hcl cap 30 mg
1
nifedical xl tab 30mg
1
QL (30 tabs / 30
nifedical xl tab 60mg
1
nifedipine tab sr 24hr 30 mg
1
QL (60 tabs / 30
1
1
nifedipine tab sr 24hr osmotic release 30 1
QL (30 tabs / 30
mg
mg
mg
nimodipine cap 30 mg
2
NYMALIZE SOL 60/20ML
2
taztia xt cap 120mg/24
1
1
1
1
1
verapamil hcl cap sr 24hr 100 mg
1
1
1
1
1
ST - Step Therapy
NM - Not
LA - Limited Access
days)
days)
days)
days)
days)
43
Name of Drug
VERAPAMIL HCL CAP SR 24HR 360 MG
verapamil hcl iv soln 2.5 mg/ml
verapamil hcl tab 40 mg
verapamil hcl tab cr 120 mg
What the
Drug will
cost you
(Tier
Level)
1
1
1
1
1
1
1
1
1
Necessary actions,
on use
DIGITALIS GLYCOSIDES - DRUGS TO TREAT HEART CONDITIONS
digitek tab 0.25mg
1
digitek tab 0.125mg
digoxin inj 0.25 mg/ml
DIGOXIN ORAL SOLN 0.05 MG/ML
1
1
1
digoxin tab 125 mcg (0.125 mg)
digoxin tab 250 mcg (0.25 mg)
1
1
older
older
older
DIRECT RENIN INHIBITORS/COMBINATIONS - DRUGS TO TREAT
HEART CONDITIONS
TEKTURNA
TEKTURNA
TEKTURNA
TEKTURNA
TEKTURNA
TEKTURNA
HCT TAB 150-12.5
HCT TAB 150-25MG
HCT TAB 300-12.5
HCT TAB 300-25MG
TAB 150MG
TAB 300MG
2
2
2
2
2
2
DIURETICS - DRUGS TO TREAT HEART CONDITIONS
acetazolamide cap sr 12hr 500 mg
acetazolamide tab 125 mg
acetazolamide tab 250 mg
amiloride & hydrochlorothiazide tab 5-50
mg
amiloride hcl tab 5 mg
bumetanide inj 0.25 mg/ml
bumetanide tab 0.5 mg
bumetanide tab 1 mg
1
1
1
1
1
1
1
1
ST - Step Therapy
NM - Not
LA - Limited Access
44
Name of Drug
bumetanide tab 2 mg
chlorothiazide tab 250 mg
chlorothiazide tab 500 mg
chlorthalidone tab 25 mg
chlorthalidone tab 50 mg
furosemide inj 10 mg/ml
FUROSEMIDE INJ 10 MG/ML
furosemide oral soln 8 mg/ml
furosemide oral soln 10 mg/ml
furosemide tab 20 mg
hydrochlorothiazide cap 12.5 mg
hydrochlorothiazide tab 12.5 mg
hydrochlorothiazide tab 25 mg
hydrochlorothiazide tab 50 mg
indapamide tab 1.25 mg
indapamide tab 2.5 mg
methazolamide tab 25 mg
methazolamide tab 50 mg
methyclothiazide tab 5 mg
metolazone tab 2.5 mg
metolazone tab 5 mg
metolazone tab 10 mg
spironolactone & hydrochlorothiazide tab
25-25 mg
torsemide inj 50mg/5ml
torsemide tab 5 mg
torsemide tab 10 mg
torsemide tab 20 mg
torsemide tab 100 mg
triamterene & hydrochlorothiazide cap
37.5-25 mg
triamterene & hydrochlorothiazide tab
37.5-25 mg
triamterene & hydrochlorothiazide tab 7550 mg
What the
Drug will
cost you
(Tier
Level)
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Necessary actions,
on use
1
1
1
1
1
1
1
1
ST - Step Therapy
NM - Not
LA - Limited Access
45
Name of Drug
What the
Drug will
cost you
(Tier
Level)
Necessary actions,
on use
MISCELLANEOUS
clonidine hcl tab 0.1 mg
1
1
1
clonidine hcl td patch weekly 0.1 mg/24hr 1
DEMSER CAP 250MG
2
hydralazine hcl inj 20 mg/ml
1
hydralazine hcl tab 10 mg
1
1
1
1
midodrine hcl tab 2.5 mg
1
midodrine hcl tab 5 mg
1
midodrine hcl tab 10 mg
1
minoxidil tab 2.5 mg
1
minoxidil tab 10 mg
1
RANEXA TAB 500MG
2
RANEXA TAB 1000MG
2
NITRATES - DRUGS TO TREAT HEART CONDITIONS
isosorbide dinitrate tab 5 mg
1
1
1
1
isosorbide dinitrate tab cr 40 mg
1
isosorbide mononitrate tab 10 mg
1
isosorbide mononitrate tab 20 mg
1
isosorbide mononitrate tab sr 24hr 30 mg 1
minitran dis 0.1mg/hr
1
1
1
1
nitro-bid oin 2%
2
NITRO-DUR DIS 0.3MG/HR
2
ST - Step Therapy
NM - Not
LA - Limited Access
46
Name of Drug
NITRO-DUR DIS 0.8MG/HR
nitroglycerin td patch 24hr 0.1
NITROSTAT SUB 0.3MG
NITROSTAT SUB 0.4MG
NITROSTAT SUB 0.6MG
mg/hr
mg/hr
mg/hr
mg/hr
What the
Drug will
cost you
(Tier
Level)
2
1
1
1
1
2
2
2
Necessary actions,
on use
PULMONARY ARTERIAL HYPERTENSION - DRUGS TO TREAT
PULMONARY HYPERTENSION
ADEMPAS TAB 0.5MG
2
ADEMPAS TAB 1.5MG
2
ADEMPAS TAB 1MG
2
ADEMPAS TAB 2.5MG
2
ADEMPAS TAB 2MG
2
LETAIRIS TAB 5MG
2
LETAIRIS TAB 10MG
2
OPSUMIT TAB 10MG
2
REMODULIN INJ 1MG/ML
REMODULIN INJ 2.5MG/ML
REVATIO SUS 10MG/ML
2
2
2
2
2
sildenafil citrate tab 20 mg
1
TRACLEER TAB 62.5MG
2
TRACLEER TAB 125MG
2
NM, LA, PA
NM, LA, PA
NM, LA, PA
NM, LA, PA
NM, LA, PA
NM, LA, PA
NM, LA, PA
NM, LA, PA
B/D, NM, LA
B/D, NM, LA
B/D, NM, LA
B/D, NM, LA
QL (224 mL / 30 days),
NM, PA
NM, PA
NM, LA, PA
NM, LA, PA
ST - Step Therapy
NM - Not
LA - Limited Access
47
Name of Drug
UPTRAVI TAB 200/800
UPTRAVI TAB 200MCG
What the
Drug will
cost you
(Tier
Level)
2
2
UPTRAVI TAB 400MCG
2
UPTRAVI TAB 600MCG
2
UPTRAVI TAB 800MCG
2
UPTRAVI TAB 1000MCG
2
UPTRAVI TAB 1200MCG
2
UPTRAVI TAB 1400MCG
2
UPTRAVI TAB 1600MCG
2
Necessary actions,
on use
NM, LA, PA
NM, LA, PA
NM, LA, PA
NM, LA, PA
NM, LA, PA
NM, LA, PA
NM, LA, PA
NM, LA, PA
NM, LA, PA
CENTRAL NERVOUS SYSTEM - DRUGS TO TREAT NERVOUS SYSTEM
DISORDERS
ANTIANXIETY - DRUGS TO TREAT ANXIETY
alprazolam tab 0.5 mg
1
alprazolam tab 0.25 mg
1
alprazolam tab 1 mg
1
alprazolam tab 2 mg
1
buspirone hcl tab 5 mg
1
buspirone hcl tab 7.5 mg
1
1
1
1
fluvoxamine maleate tab 25 mg
1
1
1
lorazepam con 2mg/ml
1
QL (150 mL / 30 days)
lorazepam inj 2 mg/ml
1
lorazepam inj 4 mg/ml
1
lorazepam tab 0.5 mg
1
lorazepam tab 1 mg
1
lorazepam tab 2 mg
1
ST - Step Therapy
NM - Not
48
LA - Limited Access
Name of Drug
What the
Drug will
cost you
(Tier
Level)
Necessary actions,
on use
ANTICONVULSANTS - DRUGS TO TREAT SEIZURES
APTIOM TAB 200MG
APTIOM TAB 400MG
APTIOM TAB 600MG
APTIOM TAB 800MG
BANZEL SUS 40MG/ML
BANZEL TAB 200MG
BANZEL TAB 400MG
BRIVIACT INJ 50MG/5ML
BRIVIACT SOL 10MG/ML
BRIVIACT TAB 10MG
BRIVIACT TAB 25MG
BRIVIACT TAB 50MG
BRIVIACT TAB 75MG
BRIVIACT TAB 100MG
carbamazepine cap sr 12hr 100 mg
carbamazepine chew tab 100 mg
carbamazepine susp 100 mg/5ml
carbamazepine tab 200 mg
carbamazepine tab sr 12hr 100 mg
CELONTIN CAP 300MG
clonazepam orally disintegrating tab
mg
mg
mg
clonazepam tab 0.5 mg
clonazepam tab 1 mg
clonazepam tab 2 mg
QL
QL
QL
QL
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
0.5
2
2
2
2
2
2
2
2
2
2
2
2
2
2
1
1
1
1
1
1
1
1
1
2
1
(90 tabs / 30 days)
(60 tabs / 30 days)
(30 tabs / 30 days)
0.25
1
0.125 1
1 mg 1
2 mg 1
1
1
1
QL
QL
QL
QL
QL
(120
(300
(240
(120
(300
tabs
tabs
tabs
tabs
tabs
/
/
/
/
/
30
30
30
30
30
ST - Step Therapy
NM - Not
LA - Limited Access
days)
days)
days)
days)
days)
49
Name of Drug
clorazepate dipotassium tab 3.75 mg
What the
Drug will
cost you
(Tier
Level)
1
clorazepate dipotassium tab 7.5 mg
1
clorazepate dipotassium tab 15 mg
1
diazepam con 5mg/ml
1
diazepam inj 5 mg/ml
diazepam oral soln 1 mg/ml
1
1
DIAZEPAM RECTAL GEL DELIVERY SYSTEM 1
2.5 MG
10 MG
20 MG
diazepam tab 2 mg
1
diazepam tab 5 mg
1
diazepam tab 10 mg
1
dilantin cap 30mg
dilantin cap 100mg
dilantin chw 50mg
DILANTIN-125 SUS 125/5ML
divalproex sodium cap delayed release
sprinkle 125 mg
divalproex sodium tab delayed release 125
mg
mg
mg
divalproex sodium tab sr 24 hr 250 mg
divalproex sodium tab sr 24 hr 500 mg
epitol tab 200mg
ethosuximide cap 250 mg
2
2
2
2
1
Necessary actions,
on use
QL
PA
QL
PA
QL
PA
QL
PA
(120 tabs / 30 days),
(120 tabs / 30 days),
(180 tabs / 30 days),
(240 mL / 30 days),
QL (1200 mL / 30 days),
PA
PA
PA
PA
1
1
1
1
1
1
1
ST - Step Therapy
NM - Not
LA - Limited Access
50
Name of Drug
ethosuximide soln 250 mg/5ml
felbamate susp 600 mg/5ml
felbamate tab 400 mg
felbamate tab 600 mg
FYCOMPA SUS 0.5MG/ML
What the
Drug will
cost you
(Tier
Level)
1
2
1
1
2
FYCOMPA TAB 2MG
2
FYCOMPA TAB 4MG
2
FYCOMPA TAB 6MG
2
FYCOMPA TAB 8MG
2
FYCOMPA TAB 10MG
2
FYCOMPA TAB 12MG
2
gabapentin cap 100 mg
1
1
1
gabapentin oral soln 250 mg/5ml
1
gabapentin tab 600 mg
1
gabapentin tab 800 mg
1
GABITRIL TAB 12MG
2
GABITRIL TAB 16MG
2
lamotrigine tab 25 mg
1
1
1
1
lamotrigine tab chewable dispersible 5 mg 1
lamotrigine tab chewable dispersible 25 mg1
lamotrigine tab sr 24hr 25 mg
1
1
1
1
1
Necessary actions,
on use
QL (720 mL / 30 days),
PA
PA
PA
PA
PA
PA
PA
QL (1080 caps / 30
days)
QL (2160 mL / 30 days)
ST - Step Therapy
NM - Not
LA - Limited Access
51
Name of Drug
What the
Drug will
cost you
(Tier
Level)
1
LEVETIRACETA INJ 5MG/ML
2
2
2
levetiracetam inj 500 mg/5ml (100 mg/ml) 1
levetiracetam oral soln 100 mg/ml
1
levetiracetam tab 250 mg
1
1
1
1
levetiracetam tab sr 24hr 500 mg
1
levetiracetam tab sr 24hr 750 mg
1
LYRICA CAP 25MG
2
LYRICA CAP 50MG
2
LYRICA CAP 75MG
2
LYRICA CAP 100MG
2
LYRICA CAP 150MG
2
LYRICA CAP 200MG
2
LYRICA CAP 225MG
2
LYRICA CAP 300MG
2
LYRICA SOL 20MG/ML
2
ONFI SUS 2.5MG/ML
2
ONFI TAB 10MG
2
ONFI TAB 20MG
2
oxcarbazepine susp 300 mg/5ml (60
1
mg/ml)
oxcarbazepine tab 150 mg
1
1
1
PEGANONE TAB 250MG
2
PHENOBARB INJ 65MG/ML
2
Necessary actions,
on use
QL (946 mL / 30 days)
PA
PA
PA
PA; PA if 65 years
older
phenobarbital elixir 20 mg/5ml
2
PA; PA if 65 years
older
phenobarbital sodium inj 130 mg/ml
2
PA; PA if 65 years
older
phenobarbital tab 15 mg
2
PA; PA if 65 years
older
ST - Step Therapy
NM - Not
LA - Limited Access
and
and
and
and
52
Name of Drug
phenobarbital tab 16.2 mg
What the
Drug will
cost you
(Tier
Level)
2
2
2
2
2
2
2
phenytek cap 200mg
phenytek cap 300mg
phenytoin chew tab 50 mg
phenytoin sodium extended cap 100 mg
phenytoin sodium inj 50 mg/ml
phenytoin susp 125 mg/5ml
POTIGA TAB 50MG
POTIGA TAB 200MG
POTIGA TAB 300MG
POTIGA TAB 400MG
primidone tab 50 mg
primidone tab 250 mg
roweepra tab 500mg
SABRIL POW 500MG
2
2
1
1
1
1
1
1
2
2
2
2
1
1
1
2
SABRIL TAB 500MG
2
SPRITAM TAB 250MG
SPRITAM TAB 500MG
SPRITAM TAB 750MG
SPRITAM TAB 1000MG
TEGRETOL SUS 100/5ML
2
2
2
2
2
Necessary actions,
on use
PA; PA
older
PA; PA
older
PA; PA
older
PA; PA
older
PA; PA
older
PA; PA
older
PA; PA
older
if 65 years and
if 65 years and
if 65 years and
if 65 years and
if 65 years and
if 65 years and
if 65 years and
QL (180 packets / 30
days), NM, LA, PA
NM, LA, PA
ST - Step Therapy
NM - Not
LA - Limited Access
53
Name of Drug
What the
Drug will
cost you
(Tier
Level)
TEGRETOL TAB 200MG
2
TEGRETOL-XR TAB 100MG
2
2
2
tiagabine hcl tab 2 mg
1
tiagabine hcl tab 4 mg
1
topiramate sprinkle cap 15 mg
1
topiramate sprinkle cap 25 mg
1
topiramate tab 25 mg
1
1
1
1
valproate sodium inj 100 mg/ml
1
valproate sodium syrup 250 mg/5ml (base 1
equiv)
valproic acid cap 250 mg
1
VIMPAT INJ 200MG/20
2
VIMPAT SOL 10MG/ML
2
VIMPAT TAB 50MG
2
VIMPAT TAB 100MG
2
VIMPAT TAB 150MG
2
VIMPAT TAB 200MG
2
zonisamide cap 25 mg
1
1
1
Necessary actions,
on use
QL
QL
QL
QL
QL
(1200 mL / 30 days)
(60 tabs / 30 days)
(60 tabs / 30 days)
(60 tabs / 30 days)
ANTIDEMENTIA - DRUGS TO TREAT DEMENTIA AND MEMORY LOSS
donepezil hydrochloride orally
disintegrating tab 5 mg
donepezil hydrochloride orally
disintegrating tab 10 mg
donepezil hydrochloride tab 5 mg
EXELON DIS 4.6MG/24
1
EXELON DIS 9.5MG/24
2
1
1
1
1
2
QL (30 patches / 30
days)
QL (30 patches / 30
days)
ST - Step Therapy
NM - Not
LA - Limited Access
54
Name of Drug
EXELON DIS 13.3/24
What the
Drug will
cost you
(Tier
Level)
2
Necessary actions,
on use
1
QL (30 patches / 30
days)
1
galantamine hydrobromide cap sr 24hr 8
mg
mg
mg
galantamine hydrobromide oral soln 4
mg/ml
galantamine hydrobromide tab 4 mg
memantine hcl oral solution 2 mg/ml
memantine hcl tab 5 mg
memantine hcl tab 10 mg
NAMENDA XR CAP 7MG
NAMENDA XR CAP 14MG
NAMENDA XR CAP 21MG
NAMENDA XR CAP 28MG
NAMENDA XR CAP TITRATIO
NAMZARIC CAP 14-10MG
NAMZARIC CAP 28-10MG
rivastigmine tartrate cap 1.5 mg
rivastigmine tartrate cap 3 mg
rivastigmine tartrate cap 4.5 mg
rivastigmine tartrate cap 6 mg
rivastigmine td patch 24hr 4.6 mg/24hr
1
1
1
1
1
1
2
2
2
2
2
2
2
1
1
1
1
1
1
1
1
1
PA;
PA;
PA;
PA;
PA;
PA;
PA;
PA;
PA
PA
PA
PA
PA
PA
PA
PA
if
if
if
if
if
if
if
if
<
<
<
<
<
<
<
<
30
30
30
30
30
30
30
30
yrs
yrs
yrs
yrs
yrs
yrs
yrs
yrs
QL (30 patches / 30
days)
QL (30 patches / 30
days)
QL (30 patches / 30
days)
ANTIDEPRESSANTS - DRUGS TO TREAT DEPRESSION
amitriptyline hcl tab 10 mg
2
2
older
older
ST - Step Therapy
NM - Not
LA - Limited Access
55
What the
Drug will
cost you
(Tier
Level)
2
2
2
2
amoxapine tab 25 mg
amoxapine tab 50 mg
amoxapine tab 100 mg
amoxapine tab 150 mg
BRINTELLIX TAB 5MG
BRINTELLIX TAB 10MG
BRINTELLIX TAB 20MG
bupropion hcl tab 75 mg
bupropion hcl tab 100 mg
bupropion hcl tab sr 12hr 100 mg
citalopram hydrobromide oral soln 10
mg/5ml
citalopram hydrobromide tab 10 mg (base
equiv)
equiv)
equiv)
clomipramine hcl cap 25 mg
1
1
1
1
2
2
2
1
1
1
1
1
1
1
1
2
2
desipramine hcl tab 10 mg
1
1
Name of Drug
Necessary actions,
on use
PA; PA
older
PA; PA
older
PA; PA
older
PA; PA
older
if 65 years and
if 65 years and
if 65 years and
if 65 years and
1
1
1
2
older
older
older
ST - Step Therapy
NM - Not
LA - Limited Access
56
Name of Drug
doxepin hcl cap 10 mg
What the
Drug will
cost you
(Tier
Level)
1
1
1
1
2
2
2
2
2
2
doxepin hcl conc 10 mg/ml
2
duloxetine hcl enteric coated pellets cap 20 1
mg
mg
mg
EMSAM DIS 6MG/24HR
2
PA; PA
older
PA; PA
older
PA; PA
older
PA; PA
older
PA; PA
older
PA; PA
older
PA; PA
older
QL (60
if 65 years and
if 65 years and
if 65 years and
if 65 years and
if 65 years and
if 65 years and
if 65 years and
caps / 30 days)
soln 5 mg/5ml (base 1
QL (30 patches / 30
days), PA
QL (30 patches / 30
days), PA
QL (30 patches / 30
days), PA
QL (600 mL / 30 days)
tab 5 mg (base
1
tab 10 mg (base
1
tab 20 mg (base
1
2
EMSAM DIS 9MG/24HR
2
EMSAM DIS 12MG/24H
2
escitalopram oxalate
equiv)
equiv)
equiv)
equiv)
FETZIMA CAP 20MG
Necessary actions,
on use
ST - Step Therapy
NM - Not
LA - Limited Access
57
Name of Drug
FETZIMA CAP 40MG
FETZIMA CAP 80MG
FETZIMA CAP 120MG
FETZIMA CAP TITRATIO
fluoxetine hcl cap 10 mg
fluoxetine hcl solution 20 mg/5ml
fluoxetine hcl tab 10 mg
fluoxetine hcl tab 20 mg
imipramine hcl tab 10 mg
What the
Drug will
cost you
(Tier
Level)
2
2
2
2
1
1
1
1
1
1
2
2
2
maprotiline hcl tab 25 mg
1
1
1
MARPLAN TAB 10MG
2
mirtazapine orally disintegrating tab 15 mg 1
mirtazapine tab 7.5 mg
1
mirtazapine tab 15 mg
1
1
1
nefazodone hcl tab 50 mg
1
1
1
1
1
nortriptyline hcl cap 10 mg
1
1
1
1
nortriptyline hcl soln 10 mg/5ml
1
Necessary actions,
on use
older
older
older
ST - Step Therapy
NM - Not
LA - Limited Access
58
Name of Drug
paroxetine hcl tab 10 mg
PAXIL SUS 10MG/5ML
phenelzine sulfate tab 15 mg
PRISTIQ TAB 25MG
PRISTIQ TAB 50MG
PRISTIQ TAB 100MG
protriptyline hcl tab 5 mg
protriptyline hcl tab 10 mg
sertraline hcl oral conc 20 mg/ml
sertraline hcl tab 25 mg
SURMONTIL CAP 25MG
What the
Drug will
cost you
(Tier
Level)
1
1
1
1
2
1
2
2
2
1
1
1
1
1
1
2
SURMONTIL CAP 50MG
2
SURMONTIL CAP 100MG
2
tranylcypromine sulfate tab 10 mg
trazodone hcl tab 50 mg
trimipramine maleate cap 25 mg
1
1
1
1
2
2
2
TRINTELLIX TAB 5MG
2
Necessary actions,
on use
QL
QL
QL
QL
QL
(45 tabs
(45 tabs
(60 tabs
(45 tabs
(900 mL
/
/
/
/
/
30
30
30
30
30
days)
days)
days)
days)
days)
QL (240 caps / 30
days), PA; PA if 65 years and older
QL (120 caps / 30
QL (60 caps / 30 days),
older
QL (240 caps / 30
QL (120 caps / 30
older
ST - Step Therapy
NM - Not
LA - Limited Access
59
Name of Drug
What the
Drug will
cost you
(Tier
Level)
TRINTELLIX TAB 10MG
2
TRINTELLIX TAB 20MG
2
venlafaxine hcl cap sr 24hr 37.5 mg (base 1
equivalent)
venlafaxine hcl cap sr 24hr 75 mg (base
1
equivalent)
venlafaxine hcl cap sr 24hr 150 mg (base 1
equivalent)
venlafaxine hcl tab 25 mg
1
venlafaxine hcl tab 37.5 mg
1
1
1
1
VIIBRYD KIT
2
VIIBRYD KIT STARTER
2
VIIBRYD TAB 10MG
2
VIIBRYD TAB 20MG
2
VIIBRYD TAB 40MG
2
Necessary actions,
on use
ANTIPARKINSONIAN AGENTS - DRUGS TO TREAT PARKINSONS
DISEASE
amantadine hcl cap 100 mg
amantadine hcl syrup 50 mg/5ml
amantadine hcl tab 100 mg
APOKYN INJ 10MG/ML
AZILECT TAB 0.5MG
AZILECT TAB 1MG
BENZTROPINE MESYLATE INJ 1 MG/ML
benztropine mesylate tab 0.5 mg
1
1
1
2
2
2
1
2
benztropine mesylate tab 1 mg
2
benztropine mesylate tab 2 mg
2
NM, LA, PA
older
older
older
bromocriptine mesylate cap 5 mg
1
bromocriptine mesylate tab 2.5 mg
1
carbidopa & levodopa orally disintegrating 1
tab 10-100 mg
ST - Step Therapy
NM - Not
LA - Limited Access
60
Name of Drug
What the
Drug will
cost you
(Tier
Level)
tab 25-100 mg
tab 25-250 mg
carbidopa & levodopa tab 10-100 mg
1
1
1
carbidopa & levodopa tab cr 25-100 mg
1
1
CARBIDOPA-LEVODOPA-ENTACAPONE
1
TABS 12.5-50-200 MG
1
TABS 18.75-75-200 MG
1
TABS 25-100-200 MG
1
TABS 31.25-125-200 MG
1
TABS 37.5-150-200 MG
1
TABS 50-200-200 MG
ENTACAPONE TAB 200 MG
1
NEUPRO DIS 1MG/24HR
2
NEUPRO DIS 2MG/24HR
2
NEUPRO DIS 3MG/24HR
2
NEUPRO DIS 4MG/24HR
2
NEUPRO DIS 6MG/24HR
2
NEUPRO DIS 8MG/24HR
2
pramipexole dihydrochloride tab 0.5 mg
1
pramipexole dihydrochloride tab 0.25 mg 1
pramipexole dihydrochloride tab 1 mg
1
1
ropinirole hydrochloride tab 0.5 mg
1
ropinirole hydrochloride tab 0.25 mg
1
ropinirole hydrochloride tab 1 mg
1
1
Necessary actions,
on use
ST - Step Therapy
NM - Not
LA - Limited Access
61
Name of Drug
selegiline hcl cap 5 mg
selegiline hcl tab 5 mg
trihexyphenidyl hcl elixir 0.4 mg/ml
What the
Drug will
cost you
(Tier
Level)
1
1
1
1
1
2
trihexyphenidyl hcl tab 2 mg
2
trihexyphenidyl hcl tab 5 mg
2
Necessary actions,
on use
older
older
older
ANTIPSYCHOTICS - DRUGS TO TREAT PSYCHOSES
ABILIFY DISC TAB 10MG
ABILIFY MAIN INJ 300MG
2
2
ABILIFY MAIN INJ 400MG
2
aripiprazole oral solution 1 mg/ml
2
aripiprazole orally disintegrating tab 10 mg 2
aripiprazole orally disintegrating tab 15 mg 2
aripiprazole tab 2 mg
2
2
2
2
2
2
chlorpromaz inj 25mg/ml
2
chlorpromaz inj 50mg/2ml
2
chlorpromazine hcl tab 10 mg
1
1
1
1
1
CLOZAPINE ORALLY DISINTEGRATING TAB 1
12.5 MG
25 MG
QL (1 injection / 28
days)
days)
QL (900ml / 30 days)
PA
PA
ST - Step Therapy
NM - Not
LA - Limited Access
62
Name of Drug
What the
Drug will
cost you
(Tier
Level)
100 MG
150 MG
200 MG
clozapine tab 25 mg
1
clozapine tab 50 mg
1
clozapine tab 100 mg
1
clozapine tab 200 mg
1
FANAPT PAK
2
FANAPT TAB 1MG
2
FANAPT TAB 2MG
2
FANAPT TAB 4MG
2
FANAPT TAB 6MG
2
FANAPT TAB 8MG
2
FANAPT TAB 10MG
2
FANAPT TAB 12MG
2
FAZACLO TAB 150 ODT
2
FAZACLO TAB 200 ODT
2
fluphenazine decanoate inj 25 mg/ml
fluphenazine hcl elixir 2.5 mg/5ml
fluphenazine hcl inj 2.5 mg/ml
fluphenazine hcl oral conc 5 mg/ml
fluphenazine hcl tab 1 mg
fluphenazine hcl tab 2.5 mg
GEODON INJ 20MG
1
1
1
1
1
1
1
1
2
Necessary actions,
on use
PA
PA
PA
ST
ST
ST
ST
ST
ST
ST
ST
PA
PA
QL (6 mL / 3 days)
ST - Step Therapy
NM - Not
LA - Limited Access
63
Name of Drug
haloperidol decanoate im soln 50 mg/ml
haloperidol lactate inj 5 mg/ml
haloperidol lactate oral conc 2 mg/ml
haloperidol tab 0.5 mg
haloperidol tab 1 mg
INVEGA SUST INJ 39/0.25
What the
Drug will
cost you
(Tier
Level)
1
1
1
1
1
1
1
1
1
1
2
INVEGA SUST INJ 78/0.5ML
2
2
INVEGA SUST INJ 156MG/ML
2
2
Necessary actions,
on use
days)
days)
days)
days)
days)
QL (1 syringe / 90 days)
INVEGA TAB 1.5MG
2
INVEGA TAB 3MG
2
INVEGA TAB 6MG
2
INVEGA TAB 9MG
2
INVEGA TRINZ INJ 273MG
2
2
2
2
LATUDA TAB 20MG
2
LATUDA TAB 40MG
2
LATUDA TAB 60MG
2
LATUDA TAB 80MG
2
LATUDA TAB 120MG
2
loxapine succinate cap 5 mg
1
1
1
1
molindone hcl tab 5 mg
1
ST - Step Therapy
NM - Not
LA - Limited Access
64
Name of Drug
NUPLAZID TAB 17MG
olanzapine for im inj 10 mg
olanzapine orally disintegrating tab
olanzapine tab 2.5 mg
olanzapine tab 5 mg
olanzapine tab 7.5 mg
olanzapine tab 10 mg
paliperidone tab sr 24hr 1.5 mg
paliperidone tab sr 24hr 3 mg
perphenazine tab 2 mg
pimozide tab 1 mg
pimozide tab 2 mg
quetiapine fumarate tab 25 mg
REXULTI TAB 0.5MG
What the
Drug will
cost you
(Tier
Level)
1
1
2
1
5 mg 1
10 mg 1
15 mg 1
20 mg 1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
REXULTI TAB 0.25MG
2
REXULTI TAB 1MG
2
Necessary actions,
on use
NM, LA, PA
QL (3 vials / 1 day)
QL
QL
QL
QL
QL
QL
QL
ST
QL
ST
QL
ST
(90 tabs / 30 days)
(90 tabs / 30 days)
(90 tabs / 30 days)
(90 tabs / 30 days)
(90 tabs / 30 days)
(90 tabs / 30 days)
(180 tabs / 30 days),
(360 tabs / 30 days),
(90 tabs / 30 days),
ST - Step Therapy
NM - Not
LA - Limited Access
65
Name of Drug
REXULTI TAB 2MG
What the
Drug will
cost you
(Tier
Level)
2
REXULTI TAB 3MG
2
REXULTI TAB 4MG
2
RISPERDAL INJ 12.5MG
2
RISPERDAL INJ 25MG
2
RISPERDAL INJ 37.5MG
2
RISPERDAL INJ 50MG
2
risperidone orally disintegrating
mg
risperidone soln 1 mg/ml
risperidone tab 0.5 mg
risperidone tab 0.25 mg
risperidone tab 1 mg
SAPHRIS SUB 2.5MG
SAPHRIS SUB 5MG
SAPHRIS SUB 10MG
SEROQUEL XR TAB 50MG
thioridazine hcl tab 10 mg
tab 0.5 mg 1
tab 0.25 1
tab
tab
tab
tab
1
2
3
4
mg
mg
mg
mg
1
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
Necessary actions,
on use
ST
ST
ST
QL (2 injections / 28
days)
days)
days)
days)
QL (240 mL / 30 days)
older
ST - Step Therapy
NM - Not
LA - Limited Access
66
Name of Drug
What the
Drug will
cost you
(Tier
Level)
2
2
2
thiothixene cap 1 mg
trifluoperazine hcl tab 1 mg
VERSACLOZ SUS 50MG/ML
1
1
1
1
1
1
1
1
2
VRAYLAR CAP 1.5-3MG
VRAYLAR CAP 1.5MG
2
2
VRAYLAR CAP 3MG
2
VRAYLAR CAP 4.5MG
2
VRAYLAR CAP 6MG
2
ziprasidone hcl
ziprasidone hcl
ziprasidone hcl
ziprasidone hcl
ZYPREXA RELP
cap 20 mg
cap 40 mg
cap 60 mg
cap 80 mg
INJ 210MG
1
1
1
1
2
ZYPREXA RELP INJ 300MG
2
ZYPREXA RELP INJ 405MG
2
Necessary actions,
on use
older
older
older
QL (600 mL / 30 days),
PA
ST
QL (120 caps / 30
days), ST
ST
ST
ST
QL (2 vials / 28 days),
PA
QL (2 vials / 28 days),
PA
QL (1 vial / 28 days), PA
ATTENTION DEFICIT HYPERACTIVITY DISORDER - DRUGS TO TREAT
ADHD
amphetamine-dextroamphetamine cap sr
24hr 5 mg
1
ST - Step Therapy
NM - Not
LA - Limited Access
67
Name of Drug
24hr 10 mg
24hr 15 mg
24hr 20 mg
24hr 25 mg
24hr 30 mg
amphetamine-dextroamphetamine tab 5
mg
amphetamine-dextroamphetamine tab 7.5
mg
mg
amphetamine-dextroamphetamine tab
12.5 mg
mg
mg
mg
guanfacine hcl tab sr 24hr 1 mg (base
equiv)
equiv)
equiv)
equiv)
methylphenidate hcl soln 5 mg/5ml
methylphenidate hcl soln 10 mg/5ml
methylphenidate hcl tab 5 mg
methylphenidate hcl tab cr 10 mg
methylphenidate hcl tab cr 20 mg
What the
Drug will
cost you
(Tier
Level)
1
Necessary actions,
on use
1
1
1
1
1
1
1
1
1
1
1
2
older
older
older
older
QL (1800 mL / 30 days)
QL (900 mL / 30 days)
2
2
2
1
1
1
1
1
1
1
ST - Step Therapy
NM - Not
LA - Limited Access
68
Name of Drug
STRATTERA
STRATTERA
STRATTERA
STRATTERA
STRATTERA
STRATTERA
STRATTERA
CAP
CAP
CAP
CAP
CAP
CAP
CAP
10MG
18MG
25MG
40MG
60MG
80MG
100MG
What the
Drug will
cost you
(Tier
Level)
2
2
2
2
2
2
2
Necessary actions,
on use
QL
QL
QL
QL
QL
QL
QL
(60 caps / 30 days)
(30 caps / 30 days)
(30 caps / 30 days)
(30 caps / 30 days)
HYPNOTICS - DRUGS TO TREAT INSOMNIA
HETLIOZ CAP 20MG
ROZEREM TAB 8MG
SILENOR TAB 3MG
SILENOR TAB 6MG
temazepam cap 7.5 mg
2
2
2
2
1
temazepam cap 15 mg
1
zolpidem tartrate tab 5 mg
2
zolpidem tartrate tab 10 mg
2
NM, LA, PA
90 day supply in a
calendar year
90 day supply in a
calendar year
90 day supply in a
calendar year
90 day supply in a
calendar year
MIGRAINE - DRUGS TO TREAT SEVERE HEADACHES
dihydroergotamine mesylate inj 1 mg/ml
naratriptan hcl tab 1 mg (base equiv)
naratriptan hcl tab 2.5 mg (base equiv)
RELPAX TAB 20MG
RELPAX TAB 40MG
1
1
1
2
2
QL
QL
QL
QL
(9 tabs / 30 days)
(9 tabs / 30 days)
(12 tabs / 30 days)
(12 tabs / 30 days)
ST - Step Therapy
NM - Not
LA - Limited Access
69
Name of Drug
What the
Drug will
cost you
(Tier
Level)
rizatriptan benzoate oral disintegrating tab 1
5 mg (base eq)
rizatriptan benzoate oral disintegrating tab 1
10 mg (base eq)
rizatriptan benzoate tab 5 mg (base
1
equivalent)
rizatriptan benzoate tab 10 mg (base
1
equivalent)
SUMATRIPTAN NASAL SPRAY 5 MG/ACT
1
Necessary actions,
on use
1
1
1
1
QL (24 inhalers / 30
days)
QL (12 inhalers / 30
days)
days)
days)
days)
days)
days)
days)
1
1
1
1
sumatriptan succinate inj 6 mg/0.5ml
1
sumatriptan succinate solution autoinjector 4 mg/0.5ml
sumatriptan succinate solution autoinjector 6 mg/0.5ml
SUMATRIPTAN SUCCINATE SOLUTION
CARTRIDGE 4 MG/0.5ML
SUMATRIPTAN SUCCINATE SOLUTION
CARTRIDGE 6 MG/0.5ML
sumatriptan succinate solution prefilled
syringe 6 mg/0.5ml
sumatriptan succinate tab 25 mg
zolmitriptan orally disintegrating tab 2.5
mg
zolmitriptan orally disintegrating tab 5 mg
zolmitriptan tab 2.5 mg
zolmitriptan tab 5 mg
1
1
1
1
1
MISCELLANEOUS
lithium
lithium
lithium
lithium
lithium
carbonate
carbonate
carbonate
carbonate
carbonate
cap 150 mg
cap 300 mg
cap 600 mg
tab 300 mg
tab cr 300 mg
1
1
1
1
1
ST - Step Therapy
NM - Not
LA - Limited Access
70
Name of Drug
lithium carbonate tab cr 450 mg
LITHIUM SOL 8MEQ/5ML
NUEDEXTA CAP 20-10MG
pyridostigmine bromide tab 60 mg
riluzole tab 50 mg
tetrabenazine tab 12.5 mg
What the
Drug will
cost you
(Tier
Level)
1
2
2
1
1
2
tetrabenazine tab 25 mg
2
Necessary actions,
on use
PA
NM, PA
NM, PA
MULTIPLE SCLEROSIS AGENTS - DRUGS TO TREAT MULTIPLE
SCLEROSIS
AMPYRA TAB 10MG
BETASERON INJ 0.3MG
2
2
COPAXONE INJ 40MG/ML
2
GILENYA CAP 0.5MG
2
glatopa inj 20mg/ml
2
TYSABRI INJ 300/15ML
2
NM, LA, PA
QL (14 syringes / 28
days), NM, PA
days), NM, PA
NM, PA
days), NM, PA
NM, LA, PA
MUSCULOSKELETAL THERAPY AGENTS - DRUGS TO TREAT MUSCLE
SPASMS
baclofen tab 10 mg
baclofen tab 20 mg
dantrolene sodium cap
tizanidine hcl tab 2 mg
tizanidine hcl tab 4 mg
25 mg
50 mg
100 mg
(base equivalent)
(base equivalent)
1
1
1
1
1
1
1
NARCOLEPSY/CATAPLEXY - DRUGS FOR SLEEP DISORDERS
armodafinil tab 50 mg
1
1
ARMODAFINIL TAB 200 MG
1
PA
PA
PA
ST - Step Therapy
NM - Not
LA - Limited Access
71
Name of Drug
What the
Drug will
cost you
(Tier
Level)
1
NUVIGIL TAB 50MG
2
NUVIGIL TAB 150MG
2
NUVIGIL TAB 200MG
2
NUVIGIL TAB 250MG
2
XYREM SOL 500MG/ML
2
Necessary actions,
on use
PA
PA
PA
PA
PA
QL (540 mL / 30 days),
LA, PA
PSYCHOTHERAPEUTIC-MISC
acamprosate calcium tab delayed release 1
333 mg
buprenorphine hcl sl tab 2 mg (base equiv) 1
buprenorphine hcl sl tab 8 mg (base equiv) 1
buprenorphine hcl-naloxone hcl sl tab 21
0.5 mg (base equiv)
buprenorphine hcl-naloxone hcl sl tab 8-2 1
mg (base equiv)
bupropion hcl (smoking deterrent) tab sr 1
12hr 150 mg
CHANTIX PAK 0.5& 1MG
2
CHANTIX PAK 1MG
2
CHANTIX TAB 0.5MG
2
CHANTIX TAB 1MG
2
disulfiram tab 250 mg
1
disulfiram tab 500 mg
1
gnp nicotine gum 2mg mint
4
gnp nicotine gum 2mg orig
4
gnp nicotine gum 4mg mint
4
gnp nicotine loz 2mg mint
4
gnp nicotine loz 4mg mint
4
gnp nicotine loz mini 2mg
4
HM NICOTINE DIS 14MG/24H
4
HM NICOTINE DIS 21MG/24H
4
hm nicotine gum 2mg mint
4
PA
PA
PA
PA
PA
PA
PA
PA
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
*
*
*
*
*
*
*
*
*
ST - Step Therapy
NM - Not
LA - Limited Access
72
Name of Drug
hm nicotine gum 4mg mint
hm nicotine loz 2mg mint
hm nicotine loz 4mg mint
naloxone hcl inj 0.4 mg/ml
naloxone hcl inj 1 mg/ml
naltrexone hcl tab 50 mg
nicorelief gum 2mg mint
nicorelief gum 2mg orig
nicorelief gum 4mg mint
nicorelief gum 4mg orig
nicotine polacrilex gum 2 mg
nicotine polacrilex gum 4 mg
nicotine polacrilex lozenge 2 mg
nicotine polacrilex lozenge 4 mg
NICOTINE TD DIS 7MG/24HR
nicotine td patch 24hr 7 mg/24hr
NICOTINE TD PATCH 24HR 7 MG/24HR
NICOTROL INH
NICOTROL NS SPR 10MG/ML
nighttime tab 25mg
sleep aid tab 25mg
SM NICOTINE DIS 7MG/24HR
SM NICOTINE DIS 14MG/24H
SM NICOTINE DIS 21MG
sm nicotine gum 2mg
sm nicotine gum 2mg mint
sm nicotine gum 4mg
sm nicotine gum 4mg mint
sm nicotine loz 2mg mint
sm nicotine loz 4mg mint
SUBOXONE MIS 2-0.5MG
What the
Drug will
cost you
(Tier
Level)
4
4
4
1
1
1
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
2
2
4
4
4
4
4
4
4
4
4
4
4
2
Necessary actions,
on use
NM; *
NM; *
NM; *
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
NM; *
NM; *
NM; *
NM; *
NM; *
NM; *
NM; *
NM; *
NM; *
NM; *
NM; *
QL (120 SL films / 30
days), PA
ST - Step Therapy
NM - Not
LA - Limited Access
73
Name of Drug
SUBOXONE MIS 4-1MG
What the
Drug will
cost you
(Tier
Level)
2
SUBOXONE MIS 8-2MG
2
SUBOXONE MIS 12-3MG
2
Necessary actions,
on use
days), PA
days), PA
days), PA
ENDOCRINE AND METABOLIC - DRUGS TO TREAT DIABETES AND
REGULATE HORMONES
ANDROGENS - DRUGS TO REGULATE MALE HORMONES
ANDRODERM DIS 2MG/24HR
2
ANDRODERM DIS 4MG/24HR
2
AXIRON SOL 30MG/ACT
2
oxandrolone tab 2.5 mg
oxandrolone tab 10 mg
testosterone cypionate im inj in oil 100
mg/ml
mg/ml
testosterone enanthate im inj in oil 200
mg/ml
1
2
1
QL (30 patches / 30
days), PA
QL (30 patches / 30
days), PA
QL (440 mL / 30 days),
PA
PA
PA
PA
1
PA
1
PA
ANTIDIABETICS, INJECTABLE - DRUGS TO TREAT DIABETES
ALCOHOL SWABS
2
BYDUREON INJ 2MG
2
QL (4 vials / 28 days)
BYDUREON PEN INJ 2MG
2
QL (4 pens / 28 days)
BYETTA INJ 5MCG
2
QL (1 pen / 30 days)
BYETTA INJ 10MCG
2
QL (1 pen / 30 days)
GAUZE PADS 2" X 2"
2
HUMULIN R INJ U-500
2
HUMULIN R INJ U-500
2
B/D
INSULIN PEN NEEDLE
2
INSULIN SAFETY NEEDLES
2
INSULIN SYRINGE
2
LANTUS INJ 100/ML
2
LANTUS INJ SOLOSTAR
2
LEVEMIR INJ
2
ST - Step Therapy
NM - Not
74
LA - Limited Access
Name of Drug
LEVEMIR INJ FLEXTOUC
NOVOLIN INJ 70/30
What the
Drug will
cost you
(Tier
Level)
2
2
NOVOLIN N INJ U-100
2
NOVOLIN R INJ U-100
2
NOVOLOG INJ 100/ML
NOVOLOG INJ FLEXPEN
NOVOLOG INJ PENFILL
NOVOLOG MIX INJ 70/30
NOVOLOG MIX INJ FLEXPEN
SYMLINPEN 60 INJ 1000MCG
2
2
2
2
2
2
SYMLNPEN 120 INJ 1000MCG
2
TOUJEO SOLO INJ 300IU/ML
TRESIBA FLEX INJ 100UNIT
TRESIBA FLEX INJ 200UNIT
TRULICITY INJ 0.75/0.5
TRULICITY INJ 1.5/0.5
VICTOZA INJ 18MG/3ML
2
2
2
2
2
2
Necessary actions,
on use
(brand RELION not
covered)
(brand RELION not
covered)
(brand RELION not
covered)
QL (8 pens / 30 days),
PA
QL (4 pens / 30 days),
PA
ANTIDIABETICS, ORAL - DRUGS TO TREAT DIABETES
acarbose tab 25 mg
acarbose tab 50 mg
acarbose tab 100 mg
FARXIGA TAB 5MG
FARXIGA TAB 10MG
glimepiride tab 1 mg
glipizide tab 5 mg
glipizide tab 10 mg
glipizide tab sr 24hr 2.5 mg
GLIPIZIDE TAB SR 24HR 2.5 MG
glipizide tab sr 24hr 5 mg
glipizide tab sr 24hr 10 mg
1
1
1
2
2
1
1
1
1
1
1
1
1
1
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
(60 tabs / 30 days)
(30 tabs / 30 days)
(60 tabs / 30 days)
(60 tabs / 30 days)
ST - Step Therapy
NM - Not
LA - Limited Access
75
Name of Drug
GLIPIZIDE XL TAB 5MG
glipizide-metformin hcl tab 2.5-250 mg
glipizide-metformin hcl tab 5-500 mg
INVOKAMET TAB 50-500MG
INVOKAMET TAB 50-1000
INVOKANA TAB 100MG
INVOKANA TAB 300MG
JANUMET TAB 50-500MG
JANUMET TAB 50-1000
JANUMET XR TAB 50-500MG
JANUMET XR TAB 50-1000
JANUMET XR TAB 100-1000
JANUVIA TAB 25MG
JANUVIA TAB 50MG
JANUVIA TAB 100MG
JENTADUETO TAB 2.5-500
JENTADUETO TAB XR
JENTADUETO TAB XR
metformin hcl tab 500 mg
metformin hcl tab sr 24hr 500 mg
metformin hcl tab sr 24hr 750 mg
nateglinide tab 60 mg
nateglinide tab 120 mg
pioglitazone hcl tab 15 mg (base equiv)
repaglinide tab 0.5 mg
repaglinide tab 1 mg
repaglinide tab 2 mg
TRADJENTA TAB 5MG
What the
Drug will
cost you
(Tier
Level)
1
1
1
1
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
1
1
1
1
1
1
1
1
1
1
1
1
1
2
Necessary actions,
on use
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
(60 tabs / 30 days)
(60 tabs / 30 days)
(60 tabs / 30 days)
(90 tabs / 30 days)
(30 tabs / 30 days)
(60 tabs / 30 days)
(60 tabs / 30 days)
(60 tabs / 30 days)
(60 tabs / 30 days)
(30 tabs / 30 days)
(30 tabs / 30 days)
(30 tabs / 30 days)
(30 tabs / 30 days)
(60 tabs / 30 days)
(60 tabs / 30 days)
(60 tabs / 30 days)
(30 tabs / 30 days)
(60 tabs / 30 days)
(90 tabs / 30 days)
(75 tabs / 30 days)
(60 tabs / 30 days)
(90 tabs / 30 days)
(90 tabs / 30 days)
(30 tabs / 30 days)
(30 tabs / 30 days)
(30 tabs / 30 days)
(30 tabs / 30 days)
ST - Step Therapy
NM - Not
LA - Limited Access
76
Name of Drug
XIGDUO
XIGDUO
XIGDUO
XIGDUO
XR
XR
XR
XR
TAB
TAB
TAB
TAB
5-500MG
5-1000MG
10-500MG
10-1000
What the
Drug will
cost you
(Tier
Level)
2
2
2
2
BISPHOSPHONATES - DRUGS TO TREAT
alendronate sodium tab 5 mg
ibandronate sodium tab 150 mg (base
equivalent)
pamidronate disodium iv soln 3 mg/ml
pamidronate disodium iv soln 9 mg/ml
pamidronate inj 6mg/ml
zoledronic acid inj conc for iv infusion 4
mg/5ml
zoledronic acid iv soln 5 mg/100ml
1
1
1
1
1
1
Necessary actions,
on use
QL
QL
QL
QL
(60
(60
(30
(30
tabs
tabs
tabs
tabs
/
/
/
/
30
30
30
30
days)
days)
days)
days)
BONE LOSS
1
1
1
1
B/D, QL (1 tab / 30
days)
B/D
B/D
B/D
B/D, NM
1
B/D, NM
SENSIPAR TAB 30MG
2
SENSIPAR TAB 60MG
2
SENSIPAR TAB 90MG
2
NM
NM
NM
CALCIUM RECEPTOR AGONISTS
CHELATING AGENTS
CHEMET CAP 100MG
DEPEN TITRA TAB 250MG
EXJADE TAB 125MG
EXJADE TAB 250MG
EXJADE TAB 500MG
FERRIPROX SOL 100MG/ML
FERRIPROX TAB 500MG
kionex pow
kionex sus 15gm/60
sodium polystyrene sulfonate oral susp 15
gm/60ml
2
2
2
2
2
2
2
1
1
1
NM,
NM,
NM,
NM,
NM,
LA,
LA,
LA,
LA,
LA,
PA
PA
PA
PA
PA
ST - Step Therapy
NM - Not
LA - Limited Access
77
Name of Drug
sodium polystyrene sulfonate powder
sps sus 15gm/60
SYPRINE CAP 250MG
What the
Drug will
cost you
(Tier
Level)
1
1
2
Necessary actions,
on use
CONTRACEPTIVES - DRUGS FOR BIRTH CONTROL
altavera tab
1
apri tab
1
aranelle tab
1
aubra tab 0.1-0.02
1
aviane tab
1
balziva tab
1
bekyree tab
1
blisovi fe tab 1.5/30
1
blisovi fe tab 1/20
1
briellyn tab
1
camila tab 0.35mg
1
cryselle-28 tab 28 tabs
1
cyclafem tab 1/35
1
cyclafem tab 7/7/7
1
deblitane tab 0.35mg
1
delyla tab 0.1-0.02
1
desogest-eth estrad & eth estrad tab 0.15- 1
0.02/0.01 mg(21/5)
desogestrel & ethinyl estradiol tab 0.15
1
mg-30 mcg
drospirenone-ethinyl estradiol tab 3-0.02 1
mg
DROSPIRENONE-ETHINYL ESTRADIOL TAB 1
3-0.02 MG
drospirenone-ethinyl estradiol tab 3-0.03 1
mg
DROSPIRENONE-ETHINYL ESTRADIOL TAB 1
3-0.03 MG
ELLA TAB 30MG
2
emoquette tab
1
enpresse-28 tab
1
errin tab 0.35mg
1
fallback tab 1.5mg
4
NM; *
falmina tab
1
ST - Step Therapy
NM - Not
LA - Limited Access
78
Name of Drug
What the
Drug will
cost you
(Tier
Level)
gildagia tab 0.4-35
1
gildess tab 1.5/30
1
heather tab 0.35mg
1
introvale tab
1
JOLIVETTE TAB 0.35MG
1
juleber tab
1
junel 1.5/30 tab
1
junel 1/20 tab
1
junel fe tab 1.5/30
1
junel fe tab 1/20
1
kariva tab 28 day
1
kelnor tab 1/35
1
kimidess tab
1
larin fe tab 1.5/30
1
larin fe tab 1/20
1
larin tab 1.5/30
1
larin tab 1/20
1
lessina tab
1
levonest tab
1
levonorgestrel & ethinyl estradiol (91-day) 1
tab 0.15-0.03 mg
LEVONORGESTREL & ETHINYL ESTRADIOL 1
(91-DAY) TAB 0.15-0.03 MG
levonorgestrel & ethinyl estradiol tab 0.1 1
mg-20 mcg
levonorgestrel tab 0.75 mg
1
1
4
levonorgestrel-eth estra tab 0.051
30/0.075-40/0.125-30mg-mcg
levora-28 tab 0.15/30
1
loryna tab 3-0.02mg
1
lutera tab
1
lyza tab 0.35mg
1
marlissa tab 0.15/30
1
medroxyprogesterone acetate im susp 150 1
mg/ml
Necessary actions,
on use
NM; *
ST - Step Therapy
NM - Not
LA - Limited Access
79
Name of Drug
MEDROXYPROGESTERONE ACETATE IM
SUSP 150 MG/ML
MONONESSA TAB
my way tab 1.5mg
myzilra tab
necon tab 0.5/35
necon tab 1/35
NECON TAB 1/50-28
NECON TAB 7/7/7
necon tab 10/11-28
next choice tab 1.5mg
nikki tab 3-0.02mg
norelgestromin-ethinyl estradiol td ptwk
150-35 mcg/24hr
NORETHINDRONE ACE & ETHINYL
ESTRADIOL TAB 1 MG-20 MCG
ESTRADIOL TAB 1.5 MG-30 MCG
ESTRADIOL-FE TAB 1 MG-20 MCG
ESTRADIOL-FE TAB 1.5 MG-30 MCG
norethindrone tab 0.35 mg
NORETHINDRONE TAB 0.35 MG
NORETHINDRONE-ETH ESTRADIOL TAB
0.5-35/1-35/0.5-35 MG-MCG
norgestimate & ethinyl estradiol tab 0.25
mg-35 mcg
norgestimate-eth estrad tab 0.1835/0.215-35/0.25-35 mg-mcg
norgestrel & ethinyl estradiol tab 0.3 mg30 mcg
norlyroc tab 0.35mg
nortrel tab 0.5/35
nortrel tab 1/35
nortrel tab 7/7/7
NUVARING MIS
opcicon tab 1.5mg
What the
Drug will
cost you
(Tier
Level)
1
1
4
1
1
1
1
1
2
4
1
1
Necessary actions,
on use
NM; *
NM; *
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
4
NM; *
ST - Step Therapy
NM - Not
LA - Limited Access
80
Name of Drug
orsythia tab
philith tab 0.4-35
pimtrea tab
pirmella tab 1/35
portia-28 tab
previfem tab
quasense tab
reclipsen tab
sharobel tab 0.35mg
sprintec 28 tab 28 day
TAKE ACTION TAB 1.5MG
tarina fe tab 1/20
tri-legest tab fe
tri-previfem tab
tri-sprintec tab
TRINESSA TAB
trivora-28 tab
velivet pak
vienva tab 0.1-20
viorele tab
vyfemla tab 0.4-35
zarah tab 3-0.03mg
zenchent tab
zovia 1/35e tab
zovia 1/50e tab
What the
Drug will
cost you
(Tier
Level)
1
1
1
1
1
1
1
1
1
1
4
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Necessary actions,
on use
NM; *
ENDOMETRIOSIS
danazol cap 50 mg
danazol cap 100 mg
danazol cap 200 mg
SYNAREL SOL 2MG/ML
1
1
1
2
ENZYME REPLACEMENTS - DRUGS TO TREAT ENZYME DEFICIENCIES
ADAGEN INJ 250/ML
ALDURAZYME INJ 2.9MG/5M
BUPHENYL TAB 500MG
CARBAGLU TAB 200MG
CERDELGA CAP 84MG
CEREZYME INJ 200UNIT
2
2
2
2
2
2
NM,
NM,
NM,
NM,
NM,
NM,
LA,
LA,
LA,
LA,
PA
LA,
PA
PA
PA
PA
PA
ST - Step Therapy
NM - Not
LA - Limited Access
81
Name of Drug
CEREZYME INJ 400UNIT
CYSTADANE POW
CYSTAGON CAP 50MG
CYSTAGON CAP 150MG
FABRAZYME INJ 5MG
FABRAZYME INJ 35MG
KUVAN POW 100MG
KUVAN POW 500MG
KUVAN TAB 100MG
levocarnitine inj 200 mg/ml
levocarnitine oral soln 1 gm/10ml (10%)
levocarnitine tab 330 mg
LUMIZYME INJ 50MG
MYOZYME INJ 50MG
NAGLAZYME INJ 1MG/ML
ORFADIN CAP 2MG
ORFADIN CAP 5MG
ORFADIN CAP 10MG
ORFADIN CAP 20MG
ORFADIN SUS 4MG/ML
RAVICTI LIQ 1.1GM/ML
sodium phenylbutyrate oral powder 3
gm/teaspoonful
ZAVESCA CAP 100MG
What the
Drug will
cost you
(Tier
Level)
2
2
2
2
2
2
2
2
2
1
1
1
2
2
2
2
2
2
2
2
2
2
Necessary actions,
on use
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
B/D
B/D
B/D
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM
2
NM, LA, PA
LA,
LA
LA,
LA,
LA,
LA,
LA,
LA,
LA,
PA
LA,
LA,
LA,
LA,
LA,
LA,
LA,
LA,
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
ESTROGENS - DRUGS TO REGULATE FEMALE HORMONES
DELESTROGEN INJ 10MG/ML
estrace vag cre 0.1mg/gm
estradiol tab 0.5 mg
2
2
2
estradiol tab 1 mg
2
estradiol tab 2 mg
2
estradiol td patch weekly 0.1 mg/24hr
2
2
PA; PA
older
PA; PA
older
PA; PA
older
PA; PA
older
PA; PA
older
if 65 years and
if 65 years and
if 65 years and
if 65 years and
if 65 years and
ST - Step Therapy
NM - Not
LA - Limited Access
82
Name of Drug
What the
Drug will
cost you
(Tier
Level)
2
2
2
(37.5 mcg/24hr)
estradiol valerate im in oil 20 mg/ml
estradiol valerate im in oil 40 mg/ml
jinteli tab 1mg-5mcg
2
1
1
2
norethindrone acetate-ethinyl estradiol tab 2
1 mg-5 mcg
VAGIFEM TAB 10MCG
2
Necessary actions,
on use
PA; PA
older
PA; PA
older
PA; PA
older
PA; PA
older
if 65 years and
if 65 years and
if 65 years and
if 65 years and
older
older
GLUCOCORTICOIDS - DRUGS TO TREAT INFLAMMATORY RESPONSE
a-hydrocort inj 100mg
cortisone acetate tab 25 mg
dexamethason con 1mg/ml
dexamethasone elixir 0.5 mg/5ml
dexamethasone sod phosphate
preservative free inj 10 mg/ml
dexamethasone sodium phosphate
mg/ml
mg/ml
mg/5ml
mg/10ml
mg/30ml
dexamethasone soln 0.5 mg/5ml
dexamethasone tab 0.5 mg
dexamethasone tab 1 mg
1
1
1
1
1
inj 4
1
inj 10
1
inj 20
1
inj 100 1
inj 120 1
1
1
1
1
1
1
ST - Step Therapy
NM - Not
LA - Limited Access
83
Name of Drug
fludrocortisone acetate tab 0.1 mg
hydrocortisone tab 5 mg
methylprednisolone acetate inj susp 40
mg/ml
mg/ml
methylprednisolone sodium succinate for
inj 40 mg
inj 125 mg
inj 1000 mg
methylprednisolone tab 4 mg
methylprednisolone tab therapy pack 4 mg
(21)
prednisolone sod phosph oral soln 6.7
mg/5ml (5 mg/5ml base)
prednisolone sod phosphate oral soln 15
mg/5ml (base equiv)
prednisolone sodium phosphate oral soln
25 mg/5ml (base eq)
prednisolone syrup 15 mg/5ml (usp
solution equivalent)
prednisone con 5mg/ml
prednisone oral soln 5 mg/5ml
prednisone tab 1 mg
prednisone tab 2.5 mg
prednisone tab 5 mg
prednisone tab 10 mg
What the
Drug will
cost you
(Tier
Level)
1
1
1
1
1
1
1
Necessary actions,
on use
B/D
1
B/D
1
B/D
1
B/D
1
B/D
1
1
1
1
1
B/D
B/D
B/D
B/D
1
B/D
1
B/D
1
B/D
1
B/D
2
1
1
1
1
1
1
1
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
ST - Step Therapy
NM - Not
LA - Limited Access
84
Name of Drug
prednisone tab therapy pack
SOLU-CORTEF INJ 250MG
5 mg (21)
5 mg (48)
10 mg (21)
10 mg (48)
What the
Drug will
cost you
(Tier
Level)
1
1
1
1
2
Necessary actions,
on use
GLUCOSE ELEVATING AGENTS - DRUGS TO TREAT LOW BLOOD
SUGAR
GLUCAGEN INJ HYPOKIT
GLUCAGON KIT 1MG
GLUCOSE CHW 4GM
glutose 15 gel 40%
HM GLUCOSE CHW ORANGE
HM GLUCOSE CHW RASPBERY
KORLYM TAB 300MG
niacin cap 500mg
PROGLYCEM SUS 50MG/ML
SM GLUCOSE CHW ORANGE
SM GLUCOSE CHW RASPBERY
SM GLUCOSE CHW SOUR APP
TGT GLUCOSE CHW GRAPE
2
2
4
4
4
4
2
4
2
4
4
4
4
NM; *
NM; *
NM; *
NM; *
NM, LA, PA
NM; *
NM;
NM;
NM;
NM;
*
*
*
*
HUMAN GROWTH HORMONES - DRUGS TO REGULATE PITUITARY
HORMONES
NORDITROPIN
NORDITROPIN
NORDITROPIN
NORDITROPIN
INJ
INJ
INJ
INJ
5/1.5ML
10/1.5ML
15/1.5ML
30/3ML
2
2
2
2
NM,
NM,
NM,
NM,
PA
PA
PA
PA
MISCELLANEOUS
cabergoline tab 0.5 mg
1
calcitonin (salmon) nasal soln 200 unit/act 1
FORTICAL SPR 200/ACT
2
INCRELEX INJ 40MG/4ML
2
NM, LA, PA
methylergonovine maleate tab 0.2 mg
1
MIACALCIN INJ 200/ML
2
B/D
octreotide acetate inj 50 mcg/ml (0.05
1
NM, PA
mg/ml)
1
NM, PA
mg/ml)
ST - Step Therapy
NM - Not
LA - Limited Access
85
Name of Drug
mg/ml)
mg/ml)
octreotide acetate inj 1000 mcg/ml (1
mg/ml)
PROLIA SOL 60MG/ML
raloxifene hcl tab 60 mg
SANDOSTATIN KIT LAR 10MG
SIGNIFOR INJ 0.3MG/ML
SOMATULINE INJ 60/0.2ML
SOMATULINE INJ 90/0.3ML
SOMATULINE INJ 120/.5ML
SOMAVERT INJ 10MG
SOMAVERT INJ 15MG
SOMAVERT INJ 20MG
SOMAVERT INJ 25MG
SOMAVERT INJ 30MG
XGEVA INJ
What the
Drug will
cost you
(Tier
Level)
2
Necessary actions,
on use
2
NM, PA
2
NM, PA
2
QL (1 syringe / 180
days), NM
1
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
NM, PA
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
PA
PA
PA
LA,
LA,
LA,
PA
PA
PA
LA,
LA,
LA,
LA,
LA,
PA
PA
PA
PA
PA
PA
PA
PA
PA
PARATHYROID HORMONES - DRUGS TO REGULATE PARATHYROID
LEVELS
FORTEO SOL 600/2.4
2
NATPARA
NATPARA
NATPARA
NATPARA
2
2
2
2
INJ
INJ
INJ
INJ
25MCG
50MCG
75MCG
100MCG
QL (1 pen / 28 days),
NM, PA
NM, PA
NM, PA
NM, PA
NM, PA
PHOSPHATE BINDER AGENTS - DRUGS TO REGULATE CALCIUM AND
PHOSPHORUS LEVELS
calcium acetate (phosphate binder) cap
667 mg (169 mg ca)
1
ST - Step Therapy
NM - Not
LA - Limited Access
86
Name of Drug
calcium acetate (phosphate binder) tab
667 mg
RENVELA PAK 0.8GM
RENVELA PAK 2.4GM
RENVELA TAB 800MG
What the
Drug will
cost you
(Tier
Level)
1
Necessary actions,
on use
2
2
2
PROGESTINS - DRUGS TO REGULATE FEMALE HORMONES
medroxyprogesterone acetate tab 2.5 mg
medroxyprogesterone acetate tab 5 mg
norethindrone acetate tab 5 mg
1
1
1
1
THYROID AGENTS - DRUGS TO REGULATE
levothyroxine sodium tab 25 mcg
LEVOXYL TAB 25MCG
LEVOXYL TAB 50MCG
LEVOXYL TAB 75MCG
LEVOXYL TAB 88MCG
LEVOXYL TAB 100MCG
LEVOXYL TAB 112MCG
LEVOXYL TAB 125MCG
LEVOXYL TAB 137MCG
LEVOXYL TAB 150MCG
LEVOXYL TAB 175MCG
LEVOXYL TAB 200MCG
liothyronine sodium tab 5 mcg
THYROID LEVELS
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
ST - Step Therapy
NM - Not
LA - Limited Access
87
Name of Drug
methimazole tab 5 mg
methimazole tab 10 mg
propylthiouracil tab 50 mg
SYNTHROID TAB 25MCG
SYNTHROID TAB 50MCG
SYNTHROID TAB 75MCG
SYNTHROID TAB 88MCG
SYNTHROID TAB 100MCG
UNITHROID TAB 25MCG
UNITHROID TAB 50MCG
UNITHROID TAB 75MCG
UNITHROID TAB 88MCG
UNITHROID TAB 100MCG
What the
Drug will
cost you
(Tier
Level)
1
1
1
2
2
2
2
2
2
2
2
2
2
2
2
1
1
1
1
1
1
1
1
1
1
1
Necessary actions,
on use
VASOPRESSINS - DRUGS TO REGULATE PITUITARY HORMONES
desmopressin acetate inj 4 mcg/ml
DESMOPRESSIN ACETATE NASAL SOLN
0.01% (REFRIGERATED)
desmopressin acetate nasal spray soln
0.01%
0.01% (refrigerated)
desmopressin acetate tab 0.1 mg
desmopressin acetate tab 0.2 mg
1
1
1
1
1
1
ST - Step Therapy
NM - Not
LA - Limited Access
88
Name of Drug
What the
Drug will
cost you
(Tier
Level)
Necessary actions,
on use
GASTROINTESTINAL - DRUGS TO TREAT STOMACH AND INTESTINAL
DISORDERS
ANTACIDS
acid gone sus
4
acid reducer tab 150mg
4
advanced sus antacid
4
almacone dbl sus strength
4
ALUM HYDROX SUS 320/5ML
4
antacid fast sus relief
4
antacid plus sus anti-gas
4
antacid plus sus gas rel
4
antacid sus
4
antacid sus anti-gas
4
antacid sus max st
4
CALCIUM CARBONATE (ANTACID) TAB 648 4
MG
foam antacid chw 80-20mg
4
foam antacid sus
4
gnp antacid sus anti-gas
4
gnp antacid sus cherry
4
gnp masanti sus max st
4
gnp masanti sus reg st
4
hm antacid sus anti-gas
4
maalox advan sus max st
4
maalox sus advanced
4
magnesium oxide tab 400 mg
4
mi-acid sus
4
mi-acid sus max st
4
mintox sus
4
mintox sus max st
4
qc antacid sus
4
qc antacid sus anti-gas
4
rulox sus
4
sb antacid sus anti-gas
4
sm antacid sus advanced
4
sm antacid sus anti-gas
4
sm antacid/ sus antigas
4
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
*
*
*
*
*
*
*
*
*
*
*
*
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
ST - Step Therapy
NM - Not
LA - Limited Access
89
Name of Drug
sodium bicarbonate tab 325 mg
sodium bicarbonate tab 650 mg
What the
Drug will
cost you
(Tier
Level)
4
4
Necessary actions,
on use
NM; *
NM; *
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
ANTI-DIARRHEAL
ACIDOPHILUS/ TAB CIT PECT
anti-diarrhe liq 1mg/5ml
anti-diarrhe tab 2mg
bismatrol sus 262/15ml
bismatrol sus 525/15ml
gnp k-pec sus 262/15ml
kao-tin sus 262/15ml
lactobacillus tab
LOPERAMIDE CAP 2MG
loperamide hcl liq 1 mg/5ml (0.2 mg/ml)
loperamide hcl liq 1 mg/7.5ml
loperamide sus 1mg/7.5
peptic relf sus 262/15ml
sb bismuth sus 262/15ml
sm anti-diar tab 2mg
sm stomach sus 262/15ml
stomach relf sus 262/15ml
stomach relf sus 525/15ml
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
ANTIEMETICS - DRUGS FOR NAUSEA AND VOMITING
anti-nausea liq
anti-nausea sol
compro sup 25mg
dimenhydrinate tab 50 mg
driminate tab 50mg
dronabinol cap 2.5 mg
4
4
1
4
4
1
dronabinol cap 5 mg
1
dronabinol cap 10 mg
2
EMEND
EMEND
EMEND
EMEND
2
2
2
2
CAP
CAP
CAP
PAK
40MG
80MG
125MG
80 & 125
NM; *
NM; *
NM; *
NM; *
B/D, QL (60 caps / 30
days)
B/D, QL (60 caps / 30
days)
B/D, QL (60 caps / 30
days)
B/D
B/D
B/D
B/D
ST - Step Therapy
NM - Not
LA - Limited Access
90
Name of Drug
What the
Drug will
cost you
(Tier
Level)
2
4
1
1
1
1
4
4
1
1
1
1
EMEND SUS 125MG
formula em sol
granisetron hcl inj 0.1 mg/ml
granisetron hcl inj 1 mg/ml
granisetron hcl inj 4 mg/4ml (1 mg/ml)
granisetron hcl tab 1 mg
LACTRASE CAP 250MG
meclizine hcl chew tab 25 mg
meclizine hcl tab 12.5 mg
meclizine hcl tab 25 mg
metoclopramide hcl inj 5 mg/ml
metoclopramide hcl soln 5 mg/5ml (10
mg/10ml)
metoclopramide hcl tab 5 mg
1
metoclopramide hcl tab 10 mg
1
motion relf tab 25mg
4
motion sick tab 50mg
4
motion-time chw 25mg
4
ondansetron hcl inj 4 mg/2ml (2 mg/ml) 1
ondansetron hcl inj 40 mg/20ml (2 mg/ml) 1
ondansetron hcl oral soln 4 mg/5ml
1
ondansetron hcl tab 4 mg
1
1
1
ondansetron orally disintegrating tab 4 mg 1
ondansetron orally disintegrating tab 8 mg 1
phenadoz sup 12.5mg
2
phenergan sup 12.5mg
2
phenergan sup 25mg
2
phenergan sup 50mg
2
prochlorperazine edisylate inj 5 mg/ml
prochlorperazine maleate tab 5 mg (base
equivalent)
1
1
Necessary actions,
on use
B/D
NM; *
B/D
NM; *
NM; *
NM; *
NM; *
NM; *
B/D
B/D
B/D
B/D
B/D
B/D
PA; PA
older
PA; PA
older
PA; PA
older
PA; PA
older
if 65 years and
if 65 years and
if 65 years and
if 65 years and
ST - Step Therapy
NM - Not
LA - Limited Access
91
Name of Drug
What the
Drug will
cost you
(Tier
Level)
prochlorperazine maleate tab 10 mg (base 1
equivalent)
prochlorperazine suppos 25 mg
1
promethazine hcl inj 25 mg/ml
2
promethazine hcl inj 50 mg/ml
2
promethazine hcl suppos 12.5 mg
2
promethazine hcl suppos 25 mg
2
promethazine hcl suppos 50 mg
2
promethazine hcl syrup 6.25 mg/5ml
2
promethazine hcl tab 12.5 mg
2
promethazine hcl tab 25 mg
2
promethazine hcl tab 50 mg
2
promethegan sup 25mg
2
promethegan sup 50mg
2
TRANSDERM-SC DIS 1MG
2
travel sick chw 25mg
travel sick tab 50mg
4
4
Necessary actions,
on use
older
older
older
older
older
older
older
older
older
older
older
QL (10 patches / 30
days), PA; PA if 65 years
and older
NM; *
NM; *
ANTISPASMODICS - DRUGS FOR STOMACH SPASMS
CUVPOSA SOL 1MG/5ML
dicyclomine hcl cap 10 mg
dicyclomine hcl oral soln 10 mg/5ml
dicyclomine hcl tab 20 mg
glycopyrrolate inj 4 mg/20ml (0.2 mg/ml)
glycopyrrolate tab 1 mg
glycopyrrolate tab 2 mg
2
1
1
1
1
1
1
ST - Step Therapy
NM - Not
LA - Limited Access
92
Name of Drug
What the
Drug will
cost you
(Tier
Level)
Necessary actions,
on use
H2-RECEPTOR ANTAGONISTS - DRUGS FOR ULCERS AND STOMACH
ACID
acid control tab 10mg
4
acid reducer tab 10mg
4
famotidine for susp 40 mg/5ml
1
famotidine in nacl 0.9% iv soln 20
1
mg/50ml
famotidine inj 20 mg/2ml
1
1
1
famotidine tab 10 mg
4
famotidine tab 10mg
4
1
1
heartburn tab relief
4
ranitidine hcl inj 50 mg/2ml (25 mg/ml)
1
ranitidine hcl inj 150 mg/6ml (25 mg/ml) 1
ranitidine hcl syrup 15 mg/ml (75 mg/5ml) 1
ranitidine hcl tab 150 mg
1
ranitidine hcl tab 300 mg
1
NM; *
NM; *
NM; *
NM; *
NM; *
INFLAMMATORY BOWEL DISEASE
APRISO CAP 0.375GM
ASACOL HD TAB 800MG
balsalazide disodium cap 750 mg
budesonide delayed release particles cap 3
mg
CANASA SUP 1000MG
DELZICOL CAP 400MG
DIPENTUM CAP 250MG
hydrocortisone enema 100 mg/60ml
HYDROCORTISONE ENEMA 100 MG/60ML
mesalamine enema 4 gm
mesalamine rectal enema 4 gm & cleanser
wipe kit
sulfasalazin tab 500mg dr
sulfasalazine tab 500 mg
UCERIS TAB 9MG
2
2
1
2
2
2
2
1
1
1
1
1
1
2
ST - Step Therapy
NM - Not
LA - Limited Access
93
Name of Drug
What the
Drug will
cost you
(Tier
Level)
Necessary actions,
on use
4
4
4
1
NM; *
NM; *
NM; *
4
4
4
1
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
1
4
4
4
4
4
4
NM; *
NM; *
NM; *
LAXATIVES
bisac-evac sup 10mg
bisacodyl suppos 10 mg
bisacodyl tab 5mg ec
bisacodyl tab & peg 3350-kcl-sod bicarbnacl for soln kit
biscolax sup 10mg
calcium polycarbophil tab 625 mg
clearlax pow
constulose sol 10gm/15
diocto liq 50mg/5ml
diocto syp 60/15ml
doc-q-lax tab 8.6-50mg
docqlace cap 100mg
docu liq 50mg/5ml
docusate cal cap 240mg
docusate calcium cap 240 mg
docusate sod liq 50mg/5ml
docusate sodium cap 100 mg
docusate sodium cap 250 mg
docusate sodium tab 100 mg
docusil cap 100mg
docusol mini ene
dok cap 100mg
dok cap 250mg
dok plus tab 8.6-50mg
dok tab 100mg
ducodyl tab 5mg ec
enemeez mini ene
enemeez plus ene 20-283
enulose sol 10gm/15
fiber laxatv tab 625mg
fiber laxtiv cap 0.52gm
fiber therap pow 58.6%
fiber therap tab 500mg
fiber-caps tab 625mg
fiber-lax tab 625mg
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
NM;
NM;
NM;
NM;
NM;
NM;
*
*
*
*
*
*
ST - Step Therapy
NM - Not
LA - Limited Access
94
Name of Drug
FLEET BISACO ENE 10/30ML
fleet laxati tab 5mg ec
gavilax pow
gavilyte-c sol
gavilyte-g sol
gavilyte-n sol flav pk
generlac sol 10gm/15
glycolax pow 3350 nf
gnp bisa-lax tab 5mg ec
gnp castor oil 100%
gnp clearlax pow
gnp enema ene
gnp laxative tab 5mg ec
gnp milk mag sus
GOLYTELY SOL
healthylax pow
hm clearlax pow
hm enema ene
hm fiber cap 0.52gm
hm fiber pow 28.3%
hm fiber pow 30.9%
hm fiber pow 48.57%
hm fiber pow 58.6%
hm fiber tab 500mg
hm laxative tab 5mg ec
hm senna tab 8.6mg
kao-tin cap 240mg
konsyl cap 520mg
konsyl fiber tab 625mg
konsyl pow 28.3%
konsyl pow 30.9%
KONSYL POW 60.3%
KONSYL POW 71.67%
KONSYL-D POW 52.3%
lactulose (encephalopathy) solution 10
gm/15ml
lactulose solution 10 gm/15ml
What the
Drug will
cost you
(Tier
Level)
4
4
4
1
1
1
1
4
4
4
4
4
4
4
2
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
1
Necessary actions,
on use
NM; *
NM; *
NM; *
NM;
NM;
NM;
NM;
NM;
NM;
NM;
*
*
*
*
*
*
*
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
1
ST - Step Therapy
NM - Not
LA - Limited Access
95
Name of Drug
What the
Drug will
cost you
(Tier
Level)
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
2
4
4
4
4
4
2
4
4
1
lax/stl soft tab 8.6-50mg
laxative sup 10mg
laxative tab 5mg ec
mag citrate sol cherry
mag citrate sol lemon
magnesium citrate soln
metamucil pow 28.3%org
metamucil pow 58.6%
metamucil pow 58.6% sf
metamucil pow 58.6%org
milk of magn sus
milk of magn sus 400/5ml
milk of magn sus 1200/15
MILK OF MAGN SUS 2400MG
milk of magn sus cherry
milk of magn sus mint
mineral oil ene
MOVIPREP SOL
nat fiber pow 48.57%
nat fiber pow therapy
naturl fiber pow 28.3%
naturl fiber pow 30.9%
naturl fiber pow therapy
NULYTELY SOL FLAV PKS
oral saline sol laxative
PEDIA-LAX LIQ 50MG
PEG 3350-KCL-NA BICARB-NACL-NA
SULFATE FOR SOLN 236 GM
PEG 3350-KCL-NA BICARB-NACL-NA
1
SULFATE FOR SOLN 240 GM
peg 3350-kcl-sod bicarb-nacl for soln 420 1
gm
polyethylene glycol 3350 oral packet
1
polyethylene glycol 3350 oral powder
1
qc enema ene
4
qc laxative sup 10mg
4
qc natural pow vegetabl
4
Necessary actions,
on use
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
NM;
NM;
NM;
NM;
NM;
*
*
*
*
*
NM; *
NM; *
NM; *
NM; *
NM; *
ST - Step Therapy
NM - Not
LA - Limited Access
96
Name of Drug
qc senna tab 8.6mg
reguloid cap 0.52gm
reguloid pow 28.3%
reguloid pow 48.57%
reguloid pow 58.6%
RELISTOR INJ 8/0.4ML
RELISTOR INJ 12/0.6ML
senexon liq 8.8mg/5
senexon tab 8.6mg
senexon-s tab 8.6-50mg
senna lax tab 8.6mg
senna plus tab 8.6-50mg
SENNA PROMPT CAP 9-500MG
senna-s tab 8.6-50mg
senna-tabs tab 8.6mg
senna-time tab 8.6mg
sennalax-s tab 8.6-50mg
senno tab 8.6mg
sennosides syrup 8.8 mg/5ml
sennosides tab 8.6 mg
sennosides-docusate sodium tab 8.6-50
mg
silace liq 10mg/ml
silace syp 60/15ml
sm castor oil 100%
sm clearlax pow
sm enema ene
sm fiber lax cap 0.52gm
sm fiber lax tab 500mg
sm fiber pow 28.3%
sm fiber pow 48.57%
sm fiber pow 58.6%
sm laxative sup 10mg
sm laxative tab 5mg ec
sm milk magn sus cherry
sodium phosphates - enema
stim laxat tab 5mg ec
What the
Drug will
cost you
(Tier
Level)
4
4
4
4
4
2
2
4
4
4
4
4
4
4
4
4
4
4
4
4
4
Necessary actions,
on use
NM;
NM;
NM;
NM;
NM;
PA
PA
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
*
*
*
*
*
*
*
*
*
*
*
*
*
*
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
ST - Step Therapy
NM - Not
LA - Limited Access
97
Name of Drug
stool softnr cap 100mg
stool softnr syp 60/15ml
stool softnr tab 8.6-50mg
SUPREP BOWEL SOL PREP
trilyte sol
womans laxat tab 5mg ec
womens laxat tab 5mg ec
What the
Drug will
cost you
(Tier
Level)
4
4
4
4
4
2
1
4
4
Necessary actions,
on use
NM;
NM;
NM;
NM;
NM;
*
*
*
*
*
NM; *
NM; *
MISCELLANEOUS
alosetron hcl tab 0.5 mg (base equiv)
alosetron hcl tab 1 mg (base equiv)
AMITIZA CAP 8MCG
AMITIZA CAP 24MCG
cromolyn sodium oral conc 100 mg/5ml
diphenoxylate w/ atropine liq 2.5-0.025
mg/5ml
diphenoxylate w/ atropine tab 2.5-0.025
mg
gas relief chw 80mg
gas relief chw 125mg
gas relief dro 20/0.3ml
gas relief dro 40/0.6ml
GATTEX KIT 5MG
gnp gas relf chw 80mg
gnp gas relf chw 125mg
hm gas relf chw 80mg
LINZESS CAP 145MCG
LINZESS CAP 290MCG
loperamide hcl cap 2 mg
mi-acid gas chw 80mg
misoprostol tab 100 mcg
misoprostol tab 200 mcg
MOVANTIK TAB 12.5MG
MOVANTIK TAB 25MG
mytab gas chw 80mg
mytab gas chw 125mg
2
2
2
2
2
1
PA
PA
1
4
4
4
4
2
4
4
4
2
2
1
4
1
1
2
2
4
4
NM; *
NM; *
NM; *
NM; *
NM, LA, PA
NM; *
NM; *
NM; *
NM; *
NM; *
NM; *
ST - Step Therapy
NM - Not
LA - Limited Access
98
Name of Drug
ORA-BLEND SF SUS
ORA-BLEND SUS
ORA-PLUS LIQ
ORA-SWEET SF SYP
simethicone chew tab 80 mg
simethicone chew tab 125 mg
simethicone dro 20/0.3ml
simethicone susp 40 mg/0.6ml
sm gas relf chw 80mg
SUCRAID SOL 8500/ML
sucralfate tab 1 gm
ursodiol cap 300 mg
ursodiol tab 250 mg
ursodiol tab 500 mg
XIFAXAN TAB 550MG
What the
Drug will
cost you
(Tier
Level)
4
4
4
4
4
4
4
4
4
2
1
1
1
1
2
Necessary actions,
on use
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
LA
*
*
*
*
*
*
*
*
*
PA
PANCREATIC ENZYMES
CREON CAP 3000UNIT
CREON CAP 6000UNIT
CREON CAP 12000UNT
CREON CAP 24000UNT
CREON CAP 36000UNT
ZENPEP CAP 3000UNIT
ZENPEP CAP 5000UNIT
ZENPEP CAP 10000UNT
ZENPEP CAP 15000UNT
ZENPEP CAP 20000UNT
ZENPEP CAP 25000UNT
ZENPEP CAP 40000UNT
2
2
2
2
2
2
2
2
2
2
2
2
PROTON PUMP INHIBITORS - DRUGS FOR ULCERS AND STOMACH
ACID
DEXILANT CAP 30MG DR
DEXILANT CAP 60MG DR
esomeprazole magnesium cap delayed
release 20 mg (base eq)
esomeprazole magnesium cap delayed
release 40 mg (base eq)
2
2
1
1
ST - Step Therapy
NM - Not
LA - Limited Access
99
Name of Drug
What the
Drug will
cost you
(Tier
Level)
esomeprazole sodium for intravenous soln 1
20 mg (base equiv)
esomeprazole sodium for intravenous soln 1
40 mg (base equiv)
NEXIUM CAP 20MG
2
NEXIUM CAP 40MG
2
NEXIUM GRA 2.5MG DR
2
NEXIUM GRA 5MG DR
2
NEXIUM GRA 10MG DR
2
Necessary actions,
on use
NEXIUM GRA 20MG DR
2
NEXIUM GRA 40MG DR
2
omeprazole cap delayed release 10 mg
OMEPRAZOLE TAB 20MG
pantoprazole sodium ec tab 20 mg (base
equiv)
pantoprazole sodium ec tab 40 mg (base
equiv)
PRILOSEC OTC TAB 20MG
1
1
1
4
1
QL (30
days)
QL (30
days)
QL (30
days)
QL (30
QL (60
QL (30
NM; *
QL (30
packets / 30
1
4
NM; *
packets / 30
packets / 30
caps / 30 days)
caps / 30 days)
caps / 30 days)
tabs / 30 days)
GENITOURINARY - DRUGS TO TREAT GENITAL AND URINARY TRACT
CONDITIONS
BENIGN PROSTATIC HYPERPLASIA - DRUGS TO TREAT ENLARGED
PROSTATE
alfuzosin hcl tab sr 24hr 10 mg
1
dutasteride cap 0.5 mg
1
dutasteride-tamsulosin hcl cap 0.5-0.4 mg 1
finasteride tab 5 mg
1
tamsulosin hcl cap 0.4 mg
1
MISCELLANEOUS
bethanechol
bethanechol
bethanechol
bethanechol
chloride
chloride
chloride
chloride
tab
tab
tab
tab
5 mg
10 mg
25 mg
50 mg
1
1
1
1
ST - Step Therapy
NM - Not
LA - Limited Access
100
Name of Drug
What the
Drug will
cost you
(Tier
Level)
ELMIRON CAP 100MG
2
POTASSIUM CITRATE TAB CR 5 MEQ (540 1
MG)
POTASSIUM CITRATE TAB CR 10 MEQ
1
(1080 MG)
Necessary actions,
on use
URINARY ANTISPASMODICS - DRUGS TO TREAT URINARY
INCONTINENCE
MYRBETRIQ TAB 25MG
MYRBETRIQ TAB 50MG
oxybutynin chloride syrup 5 mg/5ml
oxybutynin chloride tab 5 mg
oxybutynin chloride tab sr 24hr 5 mg
tolterodine tartrate cap sr 24hr 2 mg
tolterodine tartrate cap sr 24hr 4 mg
tolterodine tartrate tab 1 mg
tolterodine tartrate tab 2 mg
TOVIAZ TAB 4MG
TOVIAZ TAB 8MG
trospium chloride tab 20 mg
VESICARE TAB 5MG
VESICARE TAB 10MG
2
2
1
1
1
1
1
1
1
1
1
2
2
1
2
2
QL
QL
QL
QL
QL
(30
(60
(60
(30
(30
tabs / 30 days)
tabs / 30 days)
tabs / 30 days)
caps / 30 days)
caps / 30 days)
QL
QL
QL
QL
QL
(30
(30
(60
(30
(30
tabs
tabs
tabs
tabs
tabs
/
/
/
/
/
30
30
30
30
30
days)
days)
days)
days)
days)
VAGINAL ANTI-INFECTIVES
clindamycin phosphate vaginal cream 2% 1
clotrimazole cre 1% vag
4
CLOTRIMAZOLE CRE 3 DAY
4
clotrimazole vaginal cream 1%
4
3 DAY VAGINL CRE 2%
4
3 day vagnal cre 4%
4
metronidazole vaginal gel 0.75%
1
miconazole 3 kit combo pk
4
miconazole 7 cre 2%
4
miconazole 7 cre tube/kit
4
miconazole 7 sup 100mg
4
miconazole nitrate vaginal cream 2%
4
NM;
NM;
NM;
NM;
NM;
*
*
*
*
*
NM;
NM;
NM;
NM;
NM;
*
*
*
*
*
ST - Step Therapy
NM - Not
LA - Limited Access
101
Name of Drug
What the
Drug will
cost you
(Tier
Level)
miconazole nitrate vaginal supp 1200 mg & 4
2% cream kit
miconazole nitrate vaginal suppos 100 mg 4
qc azo tab 95mg
4
sm micon 7 sup 100mg
4
terconazole vaginal cream 0.4%
1
terconazole vaginal cream 0.8%
1
TERCONAZOLE VAGINAL CREAM 0.8%
1
terconazole vaginal suppos 80 mg
1
tioconazole oin 6.5% vag
4
vagistat-3 kit combo pk
4
VANDAZOLE GEL 0.75%
1
Necessary actions,
on use
NM; *
NM; *
NM; *
NM; *
NM; *
NM; *
HEMATOLOGIC - DRUGS TO TREAT BLOOD DISORDERS
ANTICOAGULANTS - BLOOD THINNERS
COUMADIN TAB 1MG
2
COUMADIN TAB 2.5MG
2
COUMADIN TAB 2MG
2
COUMADIN TAB 3MG
2
COUMADIN TAB 4MG
2
COUMADIN TAB 5MG
2
COUMADIN TAB 6MG
2
COUMADIN TAB 7.5MG
2
COUMADIN TAB 10MG
2
ELIQUIS TAB 2.5MG
2
ELIQUIS TAB 5MG
2
enoxaparin sodium inj 30 mg/0.3ml
1
1
1
1
enoxaparin sodium inj 100 mg/ml
2
2
enoxaparin sodium inj 150 mg/ml
2
enoxaparin sodium inj 300 mg/3ml
1
fondaparinux sodium subcutaneous inj 2.5 1
mg/0.5ml
fondaparinux sodium subcutaneous inj 5
2
mg/0.4ml
ST - Step Therapy
NM - Not
LA - Limited Access
102
Name of Drug
What the Necessary actions,
Drug will restrictions, or limit
cost you on use
(Tier
Level)
fondaparinux sodium subcutaneous inj 7.5 2
mg/0.6ml
fondaparinux sodium subcutaneous inj 10 2
mg/0.8ml
HEP SOD/NACL INJ 25000UNT
2
HEPARIN SOD INJ 2000/ML
2
B/D
HEPARIN SOD INJ 2500/ML
2
B/D
HEPARIN SODIUM (PORCINE) 40 UNIT/ML 2
IN D5W
IN D5W
IN D5W
heparin sodium (porcine) inj 1000 unit/ml 1
B/D
B/D
B/D
B/D
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
jantoven tab 10mg
1
PRADAXA CAP 75MG
2
PRADAXA CAP 110MG
2
PRADAXA CAP 150MG
2
warfarin sodium tab 1 mg
1
1
warfarin sodium tab 2.5 mg
1
1
1
1
1
warfarin sodium tab 7.5 mg
1
1
ST - Step Therapy
NM - Not
103
LA - Limited Access
Name of Drug
XARELTO
XARELTO
XARELTO
XARELTO
STAR TAB 15/20MG
TAB 10MG
TAB 15MG
TAB 20MG
What the
Drug will
cost you
(Tier
Level)
2
2
2
2
Necessary actions,
on use
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
NM,
NM,
NM,
NM,
NM
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
PA
PA
PA
PA
3
4
4
3
4
4
4
3
4
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
*
*
*
*
*
*
*
*
*
4
NM; *
4
4
4
NM; *
NM; *
NM; *
HEMATOPOIETIC GROWTH FACTORS
GRANIX INJ 300/0.5
GRANIX INJ 480/0.8
LEUKINE INJ 250MCG
MOZOBIL INJ
NEUMEGA INJ 5MG
NEUPOGEN INJ 300/0.5
NEUPOGEN INJ 300MCG
NEUPOGEN INJ 480/0.8
NEUPOGEN INJ 480MCG
PROCRIT INJ 2000/ML
PROCRIT INJ 3000/ML
PROCRIT INJ 4000/ML
PROCRIT INJ 10000/ML
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
IRON
DEXFERRUM INJ 50MG/ML
DUOFER TAB 28MG
fer-iron dro 15mg/ml
FERAHEME INJ 510/17ML
ferate tab 27mg
ferosul elx 220/5ml
ferrex 150 cap 150mg
FERRLECIT INJ 12.5MG/M
ferrous gluconate tab 240 mg (27 mg
elemental fe)
ferrous gluconate tab 324 mg (37.5 mg
elemental iron)
FERROUS SUL LIQ 220/5ML
FERROUS SULF TAB 140MG
ferrous sulfate elixir 220 mg/5ml (44
mg/5ml elemental fe)
ST - Step Therapy
NM - Not
LA - Limited Access
104
Name of Drug
ferrous sulfate soln 75 mg/ml (15 mg/ml
elemental fe)
ferrous sulfate tab 325 mg (65 mg
elemental fe)
FOLITAB 500 TAB
gnp iron tab 45mg
gnp iron tab 65mg
iferex 150 cap
INFED INJ 50MG/ML
IRON CHEWS CHW PEDIATRI
MYKIDZ IRON SUS 15/1.5ML
NOVAFERRUM CAP 50MG
NOVAFERRUM DRO 15MG/ML
NOVAFERRUM LIQ 125
poly-iron cap 150mg
PROFE CAP 180MG
SLOW REL FE TAB 140MG CR
slow release tab 47.5mg
sm iron tab 325mg
VENOFER INJ 20MG/ML
What the
Drug will
cost you
(Tier
Level)
4
Necessary actions,
on use
4
NM; *
4
4
4
4
3
4
4
4
4
4
4
4
4
4
4
3
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM; *
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
MISCELLANEOUS
anagrelide hcl cap 0.5 mg
anagrelide hcl cap 1 mg
cilostazol tab 50 mg
cilostazol tab 100 mg
CINRYZE SOL 500 UNIT
FIRAZYR INJ 30MG/3ML
pentoxifylline tab cr 400 mg
PROMACTA TAB 12.5MG
1
1
1
1
2
2
1
2
PROMACTA TAB 25MG
2
PROMACTA TAB 50MG
2
PROMACTA TAB 75MG
2
NM, LA, PA
NM, PA
NM, LA, PA
NM, LA, PA
NM, LA, PA
NM, LA, PA
tranexamic acid iv soln 1000 mg/10ml
1
(100 mg/ml)
ST - Step Therapy
NM - Not
LA - Limited Access
105
Name of Drug
tranexamic acid tab 650 mg
What the
Drug will
cost you
(Tier
Level)
1
Necessary actions,
on use
PLATELET AGGREGATION INHIBITORS
AGGRENOX CAP 25-200MG
2
ASPIRIN-DIPYRIDAMOLE CAP SR 12HR 25- 1
200 MG
BRILINTA TAB 60MG
2
BRILINTA TAB 90MG
2
clopidogrel bisulfate tab 75 mg (base
1
equiv)
EFFIENT TAB 5MG
2
EFFIENT TAB 10MG
2
ZONTIVITY TAB 2.08MG
2
IMMUNOLOGIC AGENTS - DRUGS TO TREAT DISORDERS OF THE
IMMUNE SYSTEM
DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS (DMARDS) - DRUGS
TO TREAT RHEUMATOID ARTHRITIS
CIMZIA KIT
CIMZIA KIT STARTER
CIMZIA PREFL KIT 200MG/ML
HUMIRA INJ 10MG/0.2
HUMIRA KIT 20MG/0.4
HUMIRA KIT 40MG/0.8
HUMIRA PEDIA INJ CROHNS
HUMIRA PEN INJ 40MG/0.8
HUMIRA PEN INJ CROHNS
HUMIRA PEN INJ PSORIASI
hydroxychloroquine sulfate tab 200 mg
leflunomide tab 10 mg
leflunomide tab 20 mg
methotrexate sodium tab 2.5 mg (base
equiv)
REMICADE INJ 100MG
2
2
2
2
2
2
2
2
2
2
1
1
1
1
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
2
NM, PA
IMMUNOGLOBULINS
BIVIGAM INJ 10%
2
NM, PA
CARIMUNE NF INJ 6GM
2
NM, PA
CARIMUNE NF INJ 12GM
2
NM, PA
FLEBOGAMMA INJ 5%
2
NM, PA
ST - Step Therapy
NM - Not
LA - Limited Access
106
Name of Drug
FLEBOGAMMA INJ 10/200ML
FLEBOGAMMA INJ 20/400ML
FLEBOGAMMA INJ DIF 5%
FLEBOGAMMA INJ DIF 10%
GAMASTAN S/D INJ
GAMMAGARD INJ 1GM/10ML
GAMMAGARD INJ 2.5GM/25
GAMMAGARD INJ 5GM/50ML
GAMMAGARD INJ 10GM/100
GAMMAGARD SD INJ 2.5GM HU
GAMMAGARD SD INJ 5GM HU
GAMMAGARD SD INJ 10GM HU
GAMMAKED INJ 1GM/10ML
GAMMAKED INJ 2.5GM/25
GAMMAKED INJ 5GM/50ML
GAMMAKED INJ 10GM/100
GAMMAKED INJ 20GM/200
GAMMAPLEX INJ 2.5GM
GAMMAPLEX INJ 5GM
GAMMAPLEX INJ 10GM
GAMUNEX-C INJ 1GM/10ML
GAMUNEX-C INJ 2.5GM/25
GAMUNEX-C INJ 5GM/50ML
GAMUNEX-C INJ 10GM/100
GAMUNEX-C INJ 20GM/200
GAMUNEX-C INJ 40/400ML
OCTAGAM INJ 1GM
OCTAGAM INJ 2.5GM
OCTAGAM INJ 2GM/20ML
OCTAGAM INJ 5GM
OCTAGAM INJ 10GM
OCTAGAM INJ 25GM
PRIVIGEN INJ 5 GRAMS
PRIVIGEN INJ 10GRAMS
What the
Drug will
cost you
(Tier
Level)
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
Necessary actions,
on use
NM, PA
NM, PA
NM, PA
NM, PA
B/D, NM
NM, PA
NM, PA
NM, PA
NM, PA
NM, PA
NM, PA
NM, PA
NM, PA
NM, PA
NM, PA
NM, PA
NM, PA
NM, PA
NM, PA
NM, PA
NM, PA
NM, PA
NM, PA
NM, PA
NM, PA
NM, PA
NM, PA
NM, PA
NM, PA
NM, PA
NM, PA
NM, PA
NM, PA
NM, PA
NM, PA
NM, PA
NM, PA
ST - Step Therapy
NM - Not
LA - Limited Access
107
Name of Drug
What the
Drug will
cost you
(Tier
Level)
2
Necessary actions,
on use
NM, PA
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
NM, LA, PA
NM, PA
B/D, NM
B/D, NM
B/D, NM
B/D, NM
NM, LA, PA
NM, LA, PA
NM, LA, PA
NM, LA, PA
NM, LA, PA
NM, LA, PA
NM, PA
NM, PA
NM, PA
NM, PA
1
1
2
2
1
1
1
1
1
1
1
1
1
1
1
1
2
B/D
B/D
NM, PA
NM, PA
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
IMMUNOMODULATORS
ACTIMMUNE INJ 2MU/0.5
ARCALYST INJ 220MG
INTRON A INJ 10MU
INTRON A INJ 18MU
INTRON A INJ 25MU
INTRON A INJ 50MU
REVLIMID CAP 2.5MG
REVLIMID CAP 5MG
REVLIMID CAP 10MG
REVLIMID CAP 15MG
REVLIMID CAP 20MG
REVLIMID CAP 25MG
THALOMID CAP 50MG
THALOMID CAP 100MG
THALOMID CAP 150MG
THALOMID CAP 200MG
IMMUNOSUPPRESSANTS
azathioprine inj 100mg
azathioprine tab 50 mg
BENLYSTA INJ 120MG
BENLYSTA INJ 400MG
cyclosporine cap 25 mg
cyclosporine cap 100 mg
cyclosporine iv soln 50 mg/ml
cyclosporine modified cap 25 mg
cyclosporine modified oral soln 100 mg/ml
gengraf cap 25mg
gengraf cap 50mg
gengraf cap 100mg
gengraf sol 100mg/ml
mycophenolate mofetil cap 250 mg
mycophenolate mofetil for oral susp 200
mg/ml
ST - Step Therapy
NM - Not
LA - Limited Access
108
Name of Drug
mycophenolate mofetil tab 500 mg
mycophenolate sodium tab dr 180 mg
(mycophenolic acid equiv)
mycophenolate sodium tab dr 360 mg
(mycophenolic acid equiv)
NEORAL CAP 25MG
NEORAL CAP 100MG
NEORAL SOL 100MG/ML
NULOJIX INJ 250MG
PROGRAF CAP 0.5MG
PROGRAF CAP 1MG
PROGRAF CAP 5MG
RAPAMUNE SOL 1MG/ML
SANDIMMUNE SOL 100MG/ML
sirolimus tab 0.5 mg
sirolimus tab 1 mg
SIROLIMUS TAB 2 MG
tacrolimus cap 0.5 mg
tacrolimus cap 1 mg
tacrolimus cap 5 mg
ZORTRESS TAB 0.5MG
ZORTRESS TAB 0.25MG
ZORTRESS TAB 0.75MG
What the
Drug will
cost you
(Tier
Level)
1
1
Necessary actions,
on use
B/D
B/D
2
B/D
2
2
2
2
2
2
2
2
2
1
1
2
1
1
2
2
2
2
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
VACCINES
ACTHIB INJ
ADACEL INJ
BCG VACCINE INJ
BEXSERO INJ
BOOSTRIX INJ
CERVARIX INJ
COMVAX INJ
DAPTACEL INJ
DIP/TET PED INJ 25-5LFU
ENGERIX-B INJ 10/0.5ML
ENGERIX-B INJ 20MCG/ML
GARDASIL 9 INJ
GARDASIL INJ
2
2
2
2
2
2
2
2
2
2
2
2
2
B/D
B/D
B/D
ST - Step Therapy
NM - Not
LA - Limited Access
109
Name of Drug
HAVRIX INJ 720UNIT
HAVRIX INJ 1440UNIT
HIBERIX SOL 10MCG
IMOVAX RABIE INJ 2.5/ML
INFANRIX INJ
IPOL INJ INACTIVE
IXIARO INJ
KINRIX INJ
M-M-R II INJ
MENACTRA INJ
MENHIBRIX INJ
MENOMUNE INJ A/C/Y/W
MENVEO INJ
PEDIARIX INJ 0.5ML
PEDVAX HIB INJ
PENTACEL INJ
PROQUAD INJ
QUADRACEL INJ
RABAVERT INJ
RECOMBIVA HB INJ 5MCG/0.5
RECOMBIVA HB INJ 10MCG/ML
RECOMBIVA-HB INJ 40MCG/ML
ROTARIX SUS
ROTATEQ SOL
SYNAGIS INJ 50MG
SYNAGIS INJ 100MG/ML
TENIVAC INJ 5-2LF
TET/DIP TOX INJ 2-2 LF
TRUMENBA INJ
TWINRIX INJ
TYPHIM VI INJ
VAQTA INJ 25/0.5ML
VAQTA INJ 50UNT/ML
VARIVAX INJ
YF-VAX INJ
ZOSTAVAX INJ
What the
Drug will
cost you
(Tier
Level)
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
Necessary actions,
on use
B/D
B/D
B/D
NM
NM
B/D
B/D
QL (1 vial per lifetime)
NUTRITIONAL/SUPPLEMENTS - VITAMINS AND SUPPLEMENTS
ST - Step Therapy
NM - Not
LA - Limited Access
110
Name of Drug
What the
Drug will
cost you
(Tier
Level)
Necessary actions,
on use
ELECTROLYTES
KLOR-CON 8 TAB 8MEQ ER
KLOR-CON 10 TAB 10MEQ ER
klor-con m15 tab 15meq er
klor-con pow 20meq
MAGNESIUM SU INJ 2GM/50ML
MAGNESIUM SU INJ 4G/100ML
MAGNESIUM SU INJ 20/500ML
MAGNESIUM SU INJ 40G/1000
MAGNESIUM SU INJ 80MG/ML
magnesium sulfate inj 50%
MAGNESIUM SULFATE INJ 50%
magnesium sulfate iv soln 2 gm/50ml (40
mg/ml)
MG SO4/D5W INJ 10MG/ML
MG SO4/D5W INJ 20MG/ML
potassium chloride cap cr 8 meq
potassium chloride cap cr 10 meq
potassium chloride microencapsulated crys
cr tab 10 meq
potassium chloride microencapsulated crys
cr tab 20 meq
POTASSIUM CHLORIDE ORAL SOLN 10%
(20 MEQ/15ML)
(40 MEQ/15ML)
potassium chloride tab cr 8 meq (600 mg)
POTASSIUM CHLORIDE TAB CR 10 MEQ
(1500 MG)
SODIUM CHLORIDE INJ 2.5 MEQ/ML
(14.6%)
SODIUM FLUORIDE CHEW; TAB; 1.1 (0.5
F) MG/ML SOLN
TPN ELECTROL INJ
1
1
1
1
2
2
2
2
2
1
1
1
2
2
1
1
1
1
1
1
1
1
1
1
1
2
B/D
1
2
B/D
B/D
IV NUTRITION
amino acid infusion 6%
AMINOSYN 7% INJ /LYTES
ST - Step Therapy
NM - Not
LA - Limited Access
111
Name of Drug
What the
Drug will
cost you
(Tier
Level)
AMINOSYN II INJ 7%
2
AMINOSYN II INJ 8.5%
2
AMINOSYN II INJ 8.5/LYTE
2
AMINOSYN II INJ 10%
2
AMINOSYN INJ 8.5%
2
AMINOSYN INJ 8.5/LYTE
2
AMINOSYN INJ 10%
2
AMINOSYN M INJ 3.5%
2
AMINOSYN-HBC INJ 7%
2
AMINOSYN-PF INJ 7%
2
AMINOSYN-PF INJ 10%
2
AMINOSYN-RF INJ 5.2%
2
CHROMIC CHLORIDE INJ 40 MCG/10ML (4 3
MCG/ML) (ELEMENTAL CR)
CLINIMIX INJ 2.75/D5W
2
CLINIMIX INJ 4.25/D5W
2
CLINIMIX INJ 4.25/D10
2
2
2
CLINIMIX INJ 5%/D15W
2
2
2
CUPRIC CHLORIDE INJ 0.4 MG/ML
3
FAT EMULSION IV SOLN 20%
2
FREAMINE HBC INJ 6.9%
2
FREAMINE III INJ 10%
2
HEPATAMINE SOL 8%
2
INTRALIPID INJ 20%
2
INTRALIPID INJ 30%
2
NEPHRAMINE INJ 5.4%
2
premasol sol 10%
2
PROCALAMINE INJ 3%
2
PROSOL INJ 20%
2
TRAVASOL INJ 10%
2
TROPHAMINE INJ 10%
2
ZINC CHLORIDE INJ 1 MG/ML
3
Necessary actions,
on use
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
NM; *
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
NM; *
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
NM; *
IV REPLACEMENT SOLUTIONS
ST - Step Therapy
NM - Not
LA - Limited Access
112
Name of Drug
What the
Drug will
cost you
(Tier
Level)
2
1
2
1
Necessary actions,
on use
D5W/LYTES INJ #48
D5W/NACL INJ 0.3%
D10W/NACL INJ 0.2%
DEXTROSE 2.5% W/ SODIUM CHLORIDE
0.45%
DEXTROSE 5% IN LACTATED RINGERS
1
DEXTROSE 5% W/ SODIUM CHLORIDE
1
0.2%
1
0.9%
1
0.33%
1
0.45%
1
0.225%
1
0.45%
DEXTROSE INJ 5%
1
DEXTROSE INJ 10%
1
DEXTROSE INJ 50%
1
DEXTROSE INJ 70%
1
IONOSOL-B/ INJ D5W
2
IONOSOL-MB INJ /D5W
2
ISOLYTE-P INJ /D5W
2
ISOLYTE-S INJ
2
KCL 10 MEQ/L (0.075%) IN DEXTROSE 5% 1
& NACL 0.45% INJ
& NACL 0.2% INJ
& NACL 0.9% INJ
& NACL 0.33% INJ
& NACL 0.45% INJ
KCL 20 MEQ/L (0.15%) IN NACL 0.9% INJ 1
kcl 20 meq/l (0.15%) in nacl 0.45% inj
1
ST - Step Therapy
NM - Not
LA - Limited Access
113
Name of Drug
What the
Drug will
cost you
(Tier
Level)
1
KCL 20 MEQ/L (0.15%) IN NACL 0.45%
INJ
& NACL 0.45% INJ
KCL 40 MEQ/L (0.3%) IN DEXTROSE 5% & 1
NACL 0.45% INJ
KCL 40 MEQ/L (0.3%) IN NACL 0.9% INJ 1
KCL/D5W/NACL INJ 0.3/0.9%
1
KCL/D5W/NACL INJ 0.15/0.2
2
LACTATED RINGER'S SOLUTION
1
NORMOSOL -M INJ /D5W
1
NORMOSOL -R INJ /D5W
2
NORMOSOL-R INJ PH 7.4
2
PLASMA-LYTE INJ 56/D5W
2
PLASMA-LYTE INJ -148
2
PLASMA-LYTE INJ -A
2
POTASSIUM CHLORIDE 20 MEQ/L (0.15%) 1
IN DEXTROSE 5% INJ
POTASSIUM CHLORIDE 40 MEQ/L (0.3%) 1
IN DEXTROSE 5% INJ
potassium chloride inj 2 meq/ml
1
POTASSIUM CHLORIDE INJ 10 MEQ/50ML 1
RINGER'S SOLUTION
1
SODIUM CHLORIDE INJ 0.45%
1
SODIUM CHLORIDE INJ 3%
1
SODIUM CHLORIDE INJ 5%
1
SODIUM CHLORIDE IV SOLN 0.9%
1
WATER FOR INJECT, BACTERIOSTATIC
3
BENZYL ALCOHOL
WATER FOR INJECTION
3
WATER FOR IV INJECTION
3
Necessary actions,
on use
NM; *
NM; *
NM; *
MINERALS
CALCET PETIT TAB 200-250
4
NM; *
CALCI-CHEW CHW 1250MG
4
NM; *
ST - Step Therapy
NM - Not
LA - Limited Access
114
Name of Drug
What the
Drug will
cost you
(Tier
Level)
4
4
4
4
4
4
4
CALCI-MIX CAP 1250MG
CALCIONATE SYP 1.8GM/5
calcitrate tab
calcitrate tab 950mg
calcium 600 chw +d/miner
calcium 600 tab + d
calcium carb-vit d w/ minerals chew tab
600 mg-400 unit
calcium carbonate susp 1250 mg/5ml (500 4
mg/5ml elemental ca)
calcium carbonate tab 1250 mg (500 mg 4
elemental ca)
calcium carbonate tab 1500 mg (600 mg 4
elemental ca)
calcium carbonate-cholecalciferol tab 250 4
mg-125 unit
mg-200 unit
mg-200 unit
mg-400 unit
calcium carbonate-vitamin d tab 500 mg- 4
200 unit
400 unit
200 unit
calcium citr tab +d
4
calcium citr tab w/vit d3
4
calcium citrate-vitamin d tab 200 mg-250 4
unit (elemental ca)
CALCIUM LACT TAB 648MG
4
calcium plus cap d3
4
calcium plus tab 600 +d
4
calcium tab vit d
4
calcium w/ vitamin d tab 600 mg-200 unit 4
calcium+d tab 600-400
4
Necessary actions,
on use
NM;
NM;
NM;
NM;
NM;
NM;
NM;
*
*
*
*
*
*
*
NM; *
NM; *
NM; *
NM; *
NM; *
NM; *
NM; *
NM; *
NM; *
NM; *
NM; *
NM; *
NM; *
NM;
NM;
NM;
NM;
NM;
NM;
*
*
*
*
*
*
ST - Step Therapy
NM - Not
LA - Limited Access
115
Name of Drug
What the
Drug will
cost you
(Tier
Level)
4
4
4
4
4
4
4
4
4
4
4
4
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
4
NM; *
4
4
3
4
4
4
4
4
4
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
*
*
*
*
*
*
*
*
*
ALPHA LIPOIC CAP 300MG
4
alpha-lipoic acid (thioctic acid) cap 100 mg 4
arginine tab 500 mg
4
CASTOR OIL
4
CO Q-10 PLUS CAP 100-20MG
4
coenzyme q10 cap 30 mg
4
4
4
CYTO-Q MAX LIQ 100MG/ML
4
ENFAMIL SOL ENFALYTE
4
GLYCERIN LIQ
4
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
*
*
*
*
*
*
*
*
*
*
*
calcium/d3 tab
calcium/d tab 500-200
calcium/d tab 600-200
CALPHRON TAB 667MG
calvite p&d tab
cit calc/d tab 315-250
gnp calcium tab cit +d3
mag-delay tab
mag-g tab 500mg
MAG-TAB SR TAB 84MG
MAGNEBIND TAB 300
magnesium oxide tab 400 mg (240 mg
elemental mg)
magnesium oxide tab 400 mg (241.3 mg
elemental mg)
MAGONATE LIQ 1000/5ML
magonate tab 500mg
MANGANESE CHLORIDE INJ 0.1 MG/ML
oysco 500+d chw
oyster shell calcium tab 500 mg
PHOS-NAK POW CONCENTR
risacal-d tab
SLOW-MAG TAB
zinc sulfate cap 220 mg (50 mg elemental
zn)
Necessary actions,
on use
*
*
*
*
*
*
*
*
*
*
*
*
MISCELLANEOUS
ST - Step Therapy
NM - Not
LA - Limited Access
116
Name of Drug
gnp fish oil cap
gnp fish oil cap 1200mg
gnp pediatri sol electrol
HM CASTOR OIL
hm fish oil cap 1000mg
L-ARGININE POW
L-CITRULLINE POW
L-GLUTAMINE POW
LIQ-10 SYP
omega-3 cap 1200mg
omega-3 fatty acids cap 1000 mg
omega-3 fatty acids cap 1200 mg
omega-3 fatty acids cap delayed release
1000 mg
oral electrolyte solution
oralyte sol
oralyte sol freeze
ped elctrlyt sol /zinc
ped elctrlyt sol freezer
ped elctrlyt sol fruit
ped elctrlyt sol grape
ped elctrlyt sol unflavrd
q-gel mega cap 100mg
QC CASTOR OIL
sea-omega 30 cap 1200mg
sea-omega 50 cap 1000mg
SESAME OIL
What the
Drug will
cost you
(Tier
Level)
4
4
4
4
4
4
4
4
4
4
4
4
4
Necessary actions,
on use
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
*
*
*
*
*
*
*
*
*
*
*
*
*
4
4
4
4
4
4
4
4
4
4
4
4
4
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
*
*
*
*
*
*
*
*
*
*
*
*
*
4
4
4
4
4
4
4
3
4
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
*
*
*
*
*
*
*
*
*
VITAMINS
ADULT 50+ CAP OCUVITE
animal shape chw
animal shape chw + iron
AQUA-E LIQ
AQUADEKS CAP
AQUADEKS CHW
aquadeks dro
AQUASOL A INJ 50000/ML
aqueous e dro 15/0.3ml
ST - Step Therapy
NM - Not
LA - Limited Access
117
Name of Drug
ascorbic acid tab 500 mg
b-complex w/ c & calcium tab
biotin cap 5 mg
calciferol dro 8000/ml
calcitriol cap 0.5 mcg
calcitriol cap 0.25 mcg
calcitriol inj 1 mcg/ml
calcitriol oral soln 1 mcg/ml
centamin liq
centavite az tab minerals
CENTRUM TAB ULTRA
cerovite adv liq formula
cerovite jr chw
cerovite tab advanced
certa plus tab
certavite liq antioxid
certavite/ tab antioxid
chewabl vite chw childrns
child chew chw iron
child chew chw vitamins
child chew/ chw extra c
childrens chw /iron
childrens chw vitamins
cholecalciferol cap 1000 unit
cholecalciferol drops 5000 unit/ml (1000
unit/0.2ml)
cholecalciferol oral liquid 400 unit/ml
cholecalciferol tab 1000 unit
cholecalciferol tab 5000 unit
complete tab
cyanocobalamin inj 1000 mcg/ml
d3 cap 1000unit
d3 super str cap 2000unit
What the
Drug will
cost you
(Tier
Level)
4
4
4
4
1
1
1
1
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
Necessary actions,
on use
NM;
NM;
NM;
NM;
B/D
B/D
B/D
B/D
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
*
*
*
*
4
4
4
4
3
4
4
NM;
NM;
NM;
NM;
NM;
NM;
NM;
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
ST - Step Therapy
NM - Not
LA - Limited Access
118
Name of Drug
d-vita liq 400unit
daily multi tab vit/min
daily multi tab vitamins
daily tab vitamin
daily vit tab +iron
daily vit tab +mineral
daily vite tab
daily-vite/ tab iron
dialyvite tab 800
ENFAMIL MIS EXPECTA
ergocalciferol cap 50000 unit
ergocalciferol soln 8000 unit/ml
essentl one tab daily
EZFE FORTE CAP
folic acid inj 5 mg/ml
folic acid tab 1 mg
folic acid tab 800 mcg
geravim liq
geriaton liq
gnp century tab
gnp century tab senior
gnp century tab ultimate
GNP DAILY MIS PRENATAL
gnp little chw ones
GNP PRENATAL TAB 28-0.8MG
healthy eyes tab
hm b complex tab with c
hm complete tab
HM COMPLETE TAB
hm complete tab 50+
hm niacin tab 250mg
hm one daily tab /iron
hydroxocobalamin inj 1000 mcg/ml
i-vite tab
icaps cap
INFUVITE INJ
INFUVITE INJ ADULT
What the
Drug will
cost you
(Tier
Level)
4
4
4
4
4
4
4
4
4
4
3
4
4
4
3
3
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
3
4
4
3
3
Necessary actions,
on use
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
ST - Step Therapy
NM - Not
LA - Limited Access
119
Name of Drug
INFUVITE INJ PEDIATRI
M.V.I PEDIAT INJ
M.V.I-12 W/O INJ VIT K
M.V.I. ADULT INJ
MEPHYTON TAB 5MG
meribin cap 5mg
multi-delyn liq
MULTI-DELYN LIQ /IRON
multi-vitamn tab
multi-vite tab
multilex tab
multilex-t&m tab
multivitamin chw children
multivitamin tab womens
MYKIDZ IRON SUS 10MG/2ML
niacin cap cr 250 mg
niacin cap cr 500 mg
niacin tab 500 mg
niacin tab cr 500 mg
niacin tab cr 750 mg
once daily tab
once daily tab iron
one daily tab
one daily tab maximum
one daily tab mens
one daily tab pls iron
paricalcitol cap 1 mcg
phytonadione inj 1 mg/0.5ml (2 mg/ml)
phytonadione inj 10 mg/ml
poly vitamin chw
polyvitamin chw /iron
polyvitamin dro
polyvitamin dro /iron
PRENATAL TAB
PRENATAL TAB 27-0.8MG
What the
Drug will
cost you
(Tier
Level)
3
3
3
3
3
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
1
1
1
3
3
4
4
4
4
4
4
Necessary actions,
on use
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
B/D
B/D
B/D
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
ST - Step Therapy
NM - Not
LA - Limited Access
120
Name of Drug
What the
Drug will
cost you
(Tier
Level)
PRENATAL VITAMIN/FOLIC ACID > 0.8 MG 1
(GENERIC)
PROFE FORTE CAP 155-1MG
4
qc childrens chw extra c
4
QC PRENATAL TAB 28-0.8MG
4
rena-vite tab
4
sentry tab
4
sentry tab senior
4
slo-niacin tab 250mg cr
4
sm complete tab adv form
4
sm complete tab senior
4
stress form/ tab zinc
4
stress formu tab
4
stress formu tab w/iron
4
STUART ONE CAP
4
superplex-t tab
4
tab-a-vite tab
4
tab-a-vite tab /iron
4
tab-a-vite tab beta car
4
TAB-A-VITE TAB WOMENS
4
THERA BETA- TAB CAROTENE
4
THERA M PLUS TAB
4
thera tab
4
thera-m tab
4
THERA-M TAB
4
therems tab
4
THEREMS-H TAB
4
THEREMS-M TAB
4
thiamine hcl inj 100 mg/ml
3
tri-vita sol
4
tri-vitamin dro
4
UNICOMPLEX-M TAB
4
vita-bee/c tab
4
vitamin d3 cap 10000unt
4
vitamin d3 cap 50000unt
4
vitamin d3 tab 2000unit
4
VITAMIN D3 TAB 50000UNT
4
Necessary actions,
on use
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
ST - Step Therapy
NM - Not
LA - Limited Access
121
Name of Drug
vitamin d dro 400unit
vitamin d-3 tab 5000unit
vite/iron chw children
vt b complex cap
zoo friends chw
ZOO FRIENDS CHW COMPLETE
zoo friends chw extra c
zoo friends chw gummies
zoo friends chw pls iron
What the
Drug will
cost you
(Tier
Level)
4
4
4
4
4
4
4
4
4
Necessary actions,
on use
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
*
*
*
*
*
*
*
*
*
OPHTHALMIC - DRUGS TO TREAT EYE CONDITIONS
ANTI-INFECTIVE/ANTI-INFLAMMATORY - DRUGS TO TREAT
INFECTIONS AND INFLAMMATION
bacitracin-polymyxin-neomycin-hc ophth
oint 1%
blephamide oin s.o.p.
neomycin-polymyxin-dexamethasone
ophth oint 0.1%
ophth susp 0.1%
neomycin-polymyxin-hc ophth susp
sulfacetamide sodium-prednisolone ophth
soln 10-0.23(0.25)%
TOBRADEX OIN 0.3-0.1%
TOBRADEX ST SUS 0.3-0.05
tobramycin-dexamethasone ophth susp
0.3-0.1%
ZYLET SUS 0.5-0.3%
1
2
1
1
1
1
2
2
1
2
ANTI-INFECTIVES - DRUGS TO TREAT INFECTIONS
bacitracin ophth oint 500 unit/gm
bacitracin-polymyxin b ophth oint
BESIVANCE SUS 0.6%
CILOXAN OIN 0.3% OP
ciprofloxacin hcl ophth soln 0.3%
erythromycin ophth oint 5 mg/gm
gatifloxacin ophth soln 0.5%
gentak oin 0.3% op
gentamicin sulfate ophth oint 0.3%
1
1
2
2
1
1
1
1
1
ST - Step Therapy
NM - Not
LA - Limited Access
122
Name of Drug
What the
Drug will
cost you
(Tier
Level)
gentamicin sulfate ophth soln 0.3%
1
ilotycin oin op
1
MOXEZA SOL 0.5%
2
NATACYN SUS 5% OP
2
neomycin-bacitrac zn-polymyx 5(3.5)mg- 1
400unt-10000unt op oin
neomycin-polymy-gramicid op sol 1.751
10000-0.025mg-unt-mg/ml
ofloxacin ophth soln 0.3%
1
polymyxin b-trimethoprim ophth soln
1
10000 unit/ml-0.1%
sulfacetamide sodium ophth oint 10%
1
sulfacetamide sodium ophth soln 10%
1
tobramycin ophth soln 0.3%
1
TOBREX OIN 0.3% OP
2
trifluridine ophth soln 1%
1
VIGAMOX DRO 0.5%
2
ZIRGAN GEL 0.15%
2
Necessary actions,
on use
ANTI-INFLAMMATORIES - DRUGS TO TREAT INFLAMMATION
ALREX SUS 0.2%
2
BROMFENAC SODIUM OPHTH SOLN 0.09% 1
(BASE EQUIV) (ONCE-DAILY)
bromfenac sodium ophth soln 0.09% (base 1
equivalent)
dexamethasone sodium phosphate ophth 1
soln 0.1%
diclofenac sodium ophth soln 0.1%
1
DUREZOL EMU 0.05%
2
FLUOROMETHOLONE OPHTH SUSP 0.1%
1
flurbiprofen sodium ophth soln 0.03%
1
ILEVRO DRO 0.3% OP
2
ketorolac tromethamine ophth soln 0.4% 1
ketorolac tromethamine ophth soln 0.5% 1
LOTEMAX GEL 0.5%
2
LOTEMAX OIN 0.5%
2
LOTEMAX SUS 0.5%
2
MAXIDEX SUS 0.1% OP
2
pred sod pho sol 1% op
2
ST - Step Therapy
NM - Not
LA - Limited Access
123
Name of Drug
What the
Drug will
cost you
(Tier
Level)
PREDNISOLONE ACETATE OPHTH SUSP 1%1
Necessary actions,
on use
ANTIALLERGICS - DRUGS TO TREAT ALLERGIES
ALAWAY CHILD DRO 0.025%OP
ALAWAY DRO 0.025%OP
allergy eye dro 0.025%op
azelastine hcl ophth soln 0.05%
BEPREVE DRO 1.5%
cromolyn sodium ophth soln 4%
eye drops sol a/r
eye itch rel dro 0.025%op
ketotifen fumarate ophth soln 0.025%
(base equiv)
LASTACAFT SOL 0.25%
PATADAY SOL 0.2%
PAZEO DRO 0.7%
4
4
4
1
2
1
4
4
4
NM; *
NM; *
NM; *
NM; *
NM; *
NM; *
2
2
2
ANTIGLAUCOMA - DRUGS TO TREAT GLAUCOMA
ALPHAGAN P SOL 0.1%
2
AZOPT SUS 1% OP
2
betaxolol hcl ophth soln 0.5%
1
BETOPTIC-S SUS 0.25% OP
2
brimonidine tartrate ophth soln 0.2%
1
BRIMONIDINE TARTRATE OPHTH SOLN
1
0.15%
carteolol hcl ophth soln 1%
1
COMBIGAN SOL 0.2/0.5%
2
dorzolamide hcl ophth soln 2%
1
dorzolamide hcl-timolol maleate ophth soln 1
22.3-6.8 mg/ml
ISTALOL SOL 0.5% OP
2
latanoprost ophth soln 0.005%
1
levobunolol hcl ophth soln 0.5%
1
LUMIGAN SOL 0.01%
2
metipranolol ophth soln 0.3%
1
PHOSPHOLINE SOL 0.125%OP
2
PILOCARPINE HCL OPHTH SOLN 1%
1
1
1
ST - Step Therapy
NM - Not
LA - Limited Access
124
Name of Drug
SIMBRINZA SUS 1-0.2%
TIMOLOL MALEATE OPHTH GEL FORMING
SOLN 0.5%
SOLN 0.25%
timolol maleate ophth soln 0.5%
timolol maleate ophth soln 0.25%
TRAVATAN Z DRO 0.004%
What the
Drug will
cost you
(Tier
Level)
2
1
Necessary actions,
on use
1
1
1
2
MISCELLANEOUS
akwa tears oin op
artifi tears oin op
artifi tears sol 1.4% op
artifi tears sol op
artificial sol tears
bion tears sol op
FRESHKOTE SOL 2.7-2%
GENTEAL GEL 0.3%
GENTEAL MILD DRO 0.2%
genteal pm oin
ISOPTO TEARS SOL 0.5% OP
lubricant dro 0.4-0.3%
lubricant dro eye
lubricating sol 0.5%
lubricnt eye dro 0.5% op
naphazoline hcl ophth soln 0.1%
opti-clear sol 0.05%
PROLENSA SOL 0.07%
proparacaine hcl ophth soln 0.5%
puralube oin
pure & gentl dro 0.3%
REFRESH CELL DRO 1% OP
refresh p.m. oin op
RESTASIS EMU 0.05%
sm artificia sol tears
sm lubricant dro 0.4-0.3%
sodium chloride hypertonic ophth oint 5%
sodium chloride hypertonic ophth soln 5%
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
1
4
2
1
4
4
4
4
2
4
4
4
4
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
NM; *
NM; *
NM; *
NM; *
NM; *
QL (64 vials / 30 days)
NM; *
NM; *
NM; *
NM; *
ST - Step Therapy
NM - Not
LA - Limited Access
125
Name of Drug
SYSTANE BAL SOL RESTOR
SYSTANE GEL 0.3%
SYSTANE GEL DRO 0.4-0.3%
systane oin
tears natura sol forte
tears natura sol free op
tears natura sol ii op
tears pure sol
What the
Drug will
cost you
(Tier
Level)
4
4
4
4
4
4
4
4
Necessary actions,
on use
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
*
*
*
*
*
*
*
*
RESPIRATORY - DRUGS TO TREAT BREATHING DISORDERS
ANTICHOLINERGIC/BETA AGONIST COMBINATIONS - DRUGS TO
TREAT COPD
ANORO ELLIPT AER 62.5-25
2
COMBIVENT AER 20-100
2
ipratropium-albuterol nebu soln 0.5-2.5(3) 1
mg/3ml
QL (60 inhalations / 30
days)
QL (2 inhalers / 30
days)
B/D
ANTICHOLINERGICS - DRUGS TO TREAT COPD
ATROVENT HFA AER 17MCG
2
INCRUSE ELPT INH 62.5MCG
2
ipratropium bromide inhal soln 0.02%
1
ipratropium bromide nasal soln 0.03% (21 1
mcg/spray)
ipratropium bromide nasal soln 0.06% (42 1
mcg/spray)
QL (2 inhalers / 30
days)
QL (1 inhaler / 30 days)
B/D
ANTIHISTAMINES - DRUGS TO TREAT ALLERGIES
ALAVERT TAB 10MG
all day allg chw 10mg
all day allg tab 10mg
aller-chlor syp 2mg/5ml
aller-chlor tab 4mg
aller-ease tab 60mg
aller-ease tab 180mg
allergy cap 25mg
allergy relf cap 25mg
allergy relf syp 5mg/5ml
4
4
4
4
4
4
4
4
4
4
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
*
*
*
*
*
*
*
*
*
*
ST - Step Therapy
NM - Not
LA - Limited Access
126
Name of Drug
What the
Drug will
cost you
(Tier
Level)
4
4
4
4
4
4
4
4
2
1
allergy relf tab 1.34mg
allergy relf tab 10mg
allergy relf tab 25mg
allergy tab 4mg
allergy tab 10mg
allergy tab 25mg
allergy-time tab 4mg
allerhist-1 tab 1.34mg
ASTEPRO SPR 0.15%
azelastine hcl nasal spray 0.1% (137
mcg/spray)
azelastine hcl nasal spray 0.15% (205.5
1
mcg/spray)
banophen cap 25mg
4
banophen cap 50mg
4
banophen liq 12.5/5ml
4
banophen tab 25mg
4
cetirizine hcl chew tab 5 mg
4
cetirizine hcl chew tab 10 mg
4
cetirizine hcl oral soln 1 mg/ml (5 mg/5ml) 1
cetirizine hcl tab 5 mg
4
cetirizine hcl tab 10 mg
4
chlor-phenir tab 4mg
4
chlorpheniramine maleate tab cr 12 mg
4
CLARITIN CAP 10MG
4
CLARITIN CHW 5MG
4
CLARITIN RDT TAB 5MG
4
clemastine fumarate tab 1.34 mg (1 mg
4
base equiv)
comp allergy cap 25mg
4
comp allergy tab 25mg
4
dayhist alrg tab 12 hour
4
diphenhist cap 25mg
4
diphenhist liq 12.5/5ml
4
diphenhist tab 25mg
4
diphenhydramine hcl cap 25 mg
4
diphenhydramine hcl cap 50 mg
4
Necessary actions,
on use
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
*
*
*
*
*
*
*
*
NM;
NM;
NM;
NM;
NM;
NM;
*
*
*
*
*
*
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
*
*
*
*
*
*
*
*
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
*
*
*
*
*
*
*
*
ST - Step Therapy
NM - Not
LA - Limited Access
127
Name of Drug
diphenhydramine hcl inj 50 mg/ml
diphenhydramine hcl tab 25 mg
ED CHLORPED LIQ 2MG/ML
ed chlorped syp jr
ed-chlortan tab 4mg
fexofenadine hcl tab 60 mg
fexofenadine hcl tab 180 mg
fexofenadine tab 60mg
fexofenadine tab 180mg
gnp all day tab allergy
gnp allergy cap 25mg
gnp allergy tab 4mg
gnp allergy tab 25mg
gnp allergy tab 180mg
gnp dayhist tab 1.34mg
hm allergy tab 4mg
hm allergy tab 25mg
hydroxyzine hcl im soln 25 mg/ml
What the
Drug will
cost you
(Tier
Level)
1
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
2
hydroxyzine hcl im soln 50 mg/ml
2
hydroxyzine hcl syrup 10 mg/5ml
2
hydroxyzine hcl tab 10 mg
2
2
2
hydroxyzine pamoate cap 25 mg
2
2
2
levocetirizine dihydrochloride soln 2.5
mg/5ml (0.5 mg/ml)
levocetirizine dihydrochloride tab 5 mg
1
Necessary actions,
on use
NM; *
NM; *
NM; *
NM; *
NM; *
NM; *
NM; *
NM; *
NM; *
NM; *
NM; *
NM; *
NM; *
NM; *
NM; *
NM; *
PA; PA
older
PA; PA
older
PA; PA
older
PA; PA
older
PA; PA
older
PA; PA
older
PA; PA
older
PA; PA
older
PA; PA
older
if 65 years and
if 65 years and
if 65 years and
if 65 years and
if 65 years and
if 65 years and
if 65 years and
if 65 years and
if 65 years and
1
ST - Step Therapy
NM - Not
LA - Limited Access
128
Name of Drug
loratadine sol 5mg/5ml
loratadine syp 5mg/5ml
loratadine tab 10 mg
loratadine tab 10mg
mucinex allr tab 180mg
olopatadine hcl nasal soln 0.6%
pharbechlor tab 4mg
pharbedryl cap 25mg
pharbedryl cap 50mg
q-dryl cap 25mg
qc allergy tab 10mg
qlearquil 24 tab 10mg
qlearquil tab 25mg
sb allergy tab 10mg
siladryl alr liq 12.5/5ml
sm all day tab allergy
sm allergy tab 4mg
sm allergy tab 25mg rlf
VANAHIST PD LIQ 0.625MG
What the
Drug will
cost you
(Tier
Level)
4
4
4
4
4
1
4
4
4
4
4
4
4
4
4
4
4
4
4
Necessary actions,
on use
NM;
NM;
NM;
NM;
NM;
*
*
*
*
*
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
*
*
*
*
*
*
*
*
*
*
*
*
*
BETA AGONISTS - DRUGS TO TREAT ASTHMA AND COPD
albuterol sulfate soln nebu 0.5% (5 mg/ml)1
albuterol sulfate soln nebu 0.63 mg/3ml
1
(base equiv)
albuterol sulfate soln nebu 0.083% (2.5
1
mg/3ml)
1
(base equiv)
albuterol sulfate syrup 2 mg/5ml
1
albuterol sulfate tab 2 mg
1
albuterol sulfate tab 4 mg
1
albuterol sulfate tab sr 12hr 4 mg
1
albuterol sulfate tab sr 12hr 8 mg
1
1
levalbuterol hcl soln nebu conc 1.25
mg/0.5ml (base equiv)
PERFOROMIST NEB 20MCG
2
SEREVENT DIS AER 50MCG
2
B/D
B/D
B/D
B/D
B/D
B/D
days)
ST - Step Therapy
NM - Not
LA - Limited Access
129
Name of Drug
terbutaline sulfate inj 1 mg/ml
terbutaline sulfate tab 2.5 mg
terbutaline sulfate tab 5 mg
VENTOLIN HFA AER
What the
Drug will
cost you
(Tier
Level)
2
1
1
2
XOPENEX HFA AER
2
Necessary actions,
on use
QL (2 inhalers / 30
days)
QL (2 inhalers / 30
days)
COUGH AND COLD
AIRZONE PEAK MIS FLOW MTR
alavert alrg tab /sinus
all day alrg tab 5-120mg
all-nite liq cold/flu
aller/conges tab 10-240mg
allergy d tab 5-120mg
allergy plus tab sev/sinu
allergy rel/ tab deconges
allergy relf tab d-24
allergy relf tab deconges
allergy tab multi-sy
allergy-d tab 5-120mg
allergy/cong tab 5-120mg
allgy comp-d tab 5-120mg
aprodine tab 2.5-60mg
ASSESS METER MIS FULL RNG
ASTHMA CHECK MIS SYSTEM
ASTHMAMENTOR MIS
benzonatate cap 100 mg
benzonatate cap 200 mg
bromfed dm syp
brotapp dm liq 15-1-5/5
brotapp liq
BROVEX PSB LIQ
CAPCOF SYP 5-2-10MG
CAPMIST DM TAB
CAPRON DM LIQ
cetirizine-pseudoephedrine tab sr 12hr 5120 mg
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
3
3
3
4
4
4
4
4
4
4
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
ST - Step Therapy
NM - Not
LA - Limited Access
130
Name of Drug
cgh/cold day liq delsym
cheratussin sol dac
cheratussin syp 100-10/5
chest conges tab 400mg
chest conges tab relf dm
cld head cng tab nighttim
CODITUSS DM SYP
cold & sinus tab relief
cold head tab cong dt
cold head tab congesti
cold mult-sy tab daytime
cold mult-sy tab sevr day
cold multi-s tab nighttim
cold relief tab multi-s
cold relief tab multi-sy
cold/allergy elx children
cold/allergy tab 4-10mg
cold/cough elx child
cold/cough elx dm child
CONEX SOL CLD/ALRG
CONEX TAB 2-60MG
coricidin liq hbp
cough & sore liq thrt day
cough cont liq dm max
cough dm sus 30mg/5ml
cough syp 100/5ml
coughtab tab 200mg
dallergy dro 1-2.5mg
day cold/flu cap 10-5-325
day time liq cold/flu
day time liq cough
dayquil sev liq cold/flu
dayquil sev tab cold/flu
decongestant sol 1%
decongestant tab 120mg er
delsym cough liq congs dm
delsym night liq cgh+cld
What the
Drug will
cost you
(Tier
Level)
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
Necessary actions,
on use
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
ST - Step Therapy
NM - Not
LA - Limited Access
131
Name of Drug
dextromethorphan polistirex extended
release susp 30 mg/5ml
dextromethorphan-guaifenesin liquid 10100 mg/5ml
dextromethorphan-guaifenesin syrup 10100 mg/5ml
diabetic tus liq 100/5ml
diabetic tus liq dm
diabetic tus liq max st
dimaphen dm elx cold/cgh
dimaphen elx children
dimetapp liq nighttim
DIMETAPP SYP CGH/COLD
dristan cold tab
ed a-hist dm liq
ed a-hist tab 2.5-60mg
ed bron gp liq
ED CHLORPED DRO D
endacof-dm liq 2.5-1-5
exefen-ir tab 60-400mg
extra action syp 100-10/5
gnp allergy tab multi-sy
gnp cgh relf liq 15mg/5ml
gnp children liq plus cgh
gnp cld/alle elx children
gnp cold rlf tab daytime
gnp cold/cgh elx child
gnp cough dm sus 30mg/5ml
gnp day time cap cold/flu
gnp day time cap sinus
gnp day time liq cold/flu
gnp flu relf liq daytime
gnp flu relf liq nightime
gnp mucus-er tab 600mg
gnp nasal spr 0.05%
gnp nose dro 1%
gnp sinus tab cng/pain
What the
Drug will
cost you
(Tier
Level)
4
Necessary actions,
on use
NM; *
4
NM; *
4
NM; *
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
ST - Step Therapy
NM - Not
LA - Limited Access
132
Name of Drug
What the
Drug will
cost you
(Tier
Level)
gnp suphedrn liq 15mg/5ml
4
gnp tussin liq dm
4
gnp tussin liq dm cough
4
gnp tussin liq dm max
4
gnp tussin liq nighttim
4
gnp tussin syp 100/5ml
4
gnp tussin syp cf
4
guaiatussin syp 100-10/5
4
guaifenesin liquid 100 mg/5ml
4
guaifenesin sol dac
4
guaifenesin syp 100-10/5
4
guaifenesin tab 200 mg
4
guaifenesin tab sr 12hr 600 mg
4
guaifenesin-codeine soln 100-10 mg/5ml 4
hm cgh relf liq 15mg/5ml
4
hm cold/cgh elx children
4
hm cough dm sus 30mg/5ml
4
hm day time cap
4
hm mucus er tab 600mg
4
hm nasal spr 0.05%
4
hm nose dro 1%
4
hm tussin liq adlt dm
4
12 hr nasal spr 0.05%
4
hydrocod polst-chlorphen polst er susp 10- 3
8 mg/5ml
HYDROCOD POLST-CHLORPHEN POLST ER 3
SUSP 10-8 MG/5ML
hydrocodone w/ homatropine syrup 5-1.5 3
mg/5ml
hydromet syp 5-1.5/5
3
intense coug liq reliever
4
iophen c-nr liq 100-10/5
4
iophen dm-nr liq 100-10/5
4
iophen-nr liq 100/5ml
4
J-TAN D PD DRO 1-7.5MG
4
kidkare liq cgh/cold
4
liquituss gg liq 200/5ml
4
Necessary actions,
on use
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
NM; *
NM; *
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
*
*
*
*
*
*
*
*
ST - Step Therapy
NM - Not
LA - Limited Access
133
Name of Drug
LOHIST-D LIQ
lohist-dm syp 5-2-10mg
lohist-peb liq 4-10/5ml
lorata-dine tab d 24hr
loratadine d tab 5-120mg
loratadine-d tab 5-120mg
loratadine-d tab 10-240mg
LORTUSS EX LIQ
m-clear wc liq 100-6.3
M-END PE LIQ
m-end wc liq
mapap sinus tab max st
MICROLIFE MIS PEAK FLO
mucinex cgh liq 5-100mg
mucinex chld liq 100/5ml
mucinex cold tab flu&sore
mucinex cold tab sinus
MUCINEX D TAB 60-600MG
MUCINEX D TAB 120-1200
mucinex fast liq cold flu
mucinex fast tab 25-5-325
mucinex fast tab sev cold
mucinex ff spr 0.05%
mucinex ms liq cold ngh
MUCINEX TAB 600MG ER
MUCINEX TAB 1200MG
mucinex tab sinus
MUCINEX/KIDS GRA 100MG
mucosa dm tab 20-400mg
mucosa tab 400mg
mucus relief liq 5-100mg
mucus relief liq 100/5ml
mucus relief liq cold/sin
mucus relief liq cong/cgh
mucus relief tab 400mg
mucus relief tab cld/sinu
mucus relief tab cold/flu
What the
Drug will
cost you
(Tier
Level)
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
Necessary actions,
on use
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
ST - Step Therapy
NM - Not
LA - Limited Access
134
Name of Drug
mucus relief tab cong/cld
mucus relief tab dm
mucus+chst liq 100/5ml
mucus-dm max tab 60-1200
mucus-dm tab 30-600mg
mucus-er tab 600mg
multi-sympt liq cld nght
multi-sympt sus pls cold
nasal 12 hr spr 0.05%
nasal decon syp 30mg/5ml
NASAL DECONG LIQ 30MG/5ML
nasal decong spr 0.05%
nasal decong tab 10mg
nasal decong tab 30mg
nasal decong tab 120mg er
nasal spr 0.05%
night time cap cold/flu
night time cap sinus
night time liq cld/flu
night time liq cold/flu
night time liq cough
night time tab sinus
nite time liq cold/flu
nite time liq cough
nite-time cap cold/flu
nite-time liq cold/flu
nohist-dm liq
nohist-lq liq 4-10/5ml
nrs nasal spr 0.05%
nyquil sev liq cold/flu
organ-i nr tab 200mg
pain relief sus pls cold
pain relief tab cold
pain rlf sin tab pe day
PEAK AIR FLO MIS ADLT/PED
pedia relief liq cgh/cold
pediatric liq cgh/cold
What the
Drug will
cost you
(Tier
Level)
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
Necessary actions,
on use
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
ST - Step Therapy
NM - Not
LA - Limited Access
135
Name of Drug
What the
Drug will
cost you
(Tier
Level)
4
4
4
4
4
4
4
4
4
3
3
PEDIATRIC MD MIS MASK
PEDIATRIC SM MIS MASK
PERSONAL BES MIS FULL RNG
PERSONAL BES MIS LOW RANG
PHENHIST DH LIQ 30-2-10
PIKO 1 MIS ELECTRON
POCKET PEAK MIS METER
PRO-CLEAR AC SYP 9-8.33MG
PRO-RED AC SYP 5-1-9/5
prometh vc/ syp codeine
promethazine w/ codeine syrup 6.25-10
mg/5ml
promethazine-dm syrup 6.25-15 mg/5ml 3
pseudoephed-bromphen-dm syrup 30-2-10 3
mg/5ml
pseudoephedr tab 120mg er
4
pseudoephedrine hcl tab 30 mg
4
pseudoephedrine hcl tab 60 mg
4
pseudoephedrine hcl tab sr 12hr 120 mg 4
q-tapp dm elx
4
q-tapp elx 1-15/5ml
4
q-tussin dm syp 100-10/5
4
q-tussin sol 100/5ml
4
qc allergy tab relief
4
qc cgh relf liq 15mg/5ml
4
qc cold relf sus plus ms
4
qc cough liq sore thr
4
qc sinus pai tab relief
4
qc suphedrin tab 120mg sr
4
qlearquil spr 0.05%
4
relcof c sol 100-6.3
4
RESCON-DM SYP
4
RESPAIRE-30 CAP
4
robafen cf syp cgh/cld
4
robafen dm syp 100-10/5
4
robafen syp 100/5ml
4
robitussin cap cold+flu
4
Necessary actions,
on use
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
*
*
*
*
*
*
*
*
*
*
*
NM; *
NM; *
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
ST - Step Therapy
NM - Not
LA - Limited Access
136
Name of Drug
robitussin liq 15mg/5ml
ROBITUSSIN LIQ CF
ROBITUSSIN LIQ CGH/COLD
robitussin liq cgh/cong
robitussin liq ms max
ROBITUSSIN LIQ NIGHT TM
robitussin syp 7.5/5ml
rynex dm liq
rynex pe elx
rynex pse liq
sb cgh contr liq cf
sb cgh contr liq dm
sb cgh relf liq 15mg/5ml
sb cold head tab congest
sb cold mult tab symp sev
sb cold/cgh tab hbp
sb coughtab tab 200mg
sb daytime liq
sb flu hbp tab max st
sb sinus cng pak /pain
sb sinus cng tab /pain
sb sinus cng tab /pain dt
SIDESTREAM MIS PED MASK
siltuss das liq 100/5ml
siltussin sa syp 100/5ml
siltussin-dm liq diabetic
siltussin-dm liq max st
siltussin-dm syp alc free
sinus congst tab /pain dt
sinus nasal spr 0.05%
sinus relief pak cng/pain
sinus/alergy tab max st
sm 12-hour spr 0.05%
sm allergy tab multi-sy
sm childrens sus ms cold
sm cld/alrgy elx children
sm cold head tab congest
What the
Drug will
cost you
(Tier
Level)
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
Necessary actions,
on use
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
ST - Step Therapy
NM - Not
LA - Limited Access
137
Name of Drug
sm cold/cgh elx dm child
sm cough rel syp 15mg/5ml
sm day time cap pe
sm day time liq cold/flu
sm flu relf liq nightime
sm mucus er tab 600mg
sm nasal dec tab 30mg
sm nasal spr 0.05%
sm nite time cap cold/flu
sm nite time liq cld/flu
sm nite time liq cold/flu
sm nose dro 1%
sm tussin cf liq
sm tussin dm liq max
sm tussin dm syp 100-10/5
sm tussin syp 100/5ml
sm tussin syp dm
sodium chloride soln nebu 0.9%
sudogest pe tab 10mg
sudogest tab 4-60mg
sudogest tab 30mg
sudogest tab 60mg
sudogest tab 120mg er
suphedrine tab 10mg
suphedrine tab 30mg
tab tussin tab 400mg
tab tussin tab dm
triacting nt liq cold/cgh
TRIAMINIC SOL COLD/CGH
TRIAMINIC SUS CGH/ST
TRIAMINIC SYP CGH/CNG
TRIAMINIC SYP CLD/ALRG
TRIAMINIC SYP COLD/CGH
TRIAMINIC SYP FEVER
tusnel diabt liq 10-100/5
TUSNEL LIQ
TUSNEL PEDI LIQ 15-5-50
What the
Drug will
cost you
(Tier
Level)
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
3
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
Necessary actions,
on use
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
ST - Step Therapy
NM - Not
LA - Limited Access
138
Name of Drug
tussi-pres liq pe ped
tussin adult liq 100/5ml
tussin adult liq cgh/cong
tussin adult liq cold
tussin cf liq
tussin cf liq max/m-s
tussin chest syp 100/5ml
tussin cough syp 15mg/5ml
tussin dm liq
tussin dm liq 10-200/5
tussin dm liq 100-10/5
tussin dm liq max
tussin dm syp 100-10/5
tussin syp 100/5ml
vcks dayquil liq mucus dm
vick dayquil cap cold/flu
vick dayquil liq cold/flu
vicks nyquil cap cold/flu
virtussin ac sol 100-10/5
virtussin sol dac
zonatuss cap 150mg
What the
Drug will
cost you
(Tier
Level)
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
3
Necessary actions,
on use
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
LEUKOTRIENE RECEPTOR ANTAGONISTS - DRUGS TO TREAT
ASTHMA AND ALLERGIES
montelukast sodium chew tab 4 mg (base 1
equiv)
montelukast sodium chew tab 5 mg (base 1
equiv)
montelukast sodium oral granules packet 4 1
mg (base equiv)
montelukast sodium tab 10 mg (base
1
equiv)
zafirlukast tab 10 mg
1
zafirlukast tab 20 mg
1
MAST CELL STABILIZERS - DRUGS TO TREAT ALLERGIES
cromolyn sodium nasal aerosol soln 5.2
mg/act (4%)
cromolyn sodium soln nebu 20 mg/2ml
4
NM; *
1
B/D
ST - Step Therapy
NM - Not
LA - Limited Access
139
Name of Drug
What the
Drug will
cost you
(Tier
Level)
Necessary actions,
on use
MISCELLANEOUS
acetylcysteine inhal soln 10%
1
acetylcysteine inhal soln 20%
1
ARALAST NP INJ 500MG
2
ARALAST NP INJ 1000MG
2
DALIRESP TAB 500MCG
2
deep sea spr 0.65%
4
EPIPEN 2-PAK INJ 0.3MG
2
EPIPEN-JR INJ 2-PAK
2
ESBRIET CAP 267MG
2
hm saline spr 0.65%
4
hydrocodone w/ homatropine tab 5-1.5 mg 3
KALYDECO PAK 50MG
2
KALYDECO PAK 75MG
2
KALYDECO TAB 150MG
2
nasal moist spr 0.65%
4
nasal saline spr 0.65%
4
ocean kids spr 0.65%
4
OFEV CAP 100MG
2
OFEV CAP 150MG
2
ORKAMBI TAB 200-125
2
PROLASTIN-C INJ 1000MG
2
PULMOZYME SOL 1MG/ML
2
RHINARIS GEL 0.2%
4
saline mist spr 0.65%
4
saline nasal spray 0.65%
4
sea soft spr 0.65%
4
tussigon tab 5-1.5mg
3
XOLAIR SOL 150MG
2
ZEMAIRA INJ 1000MG
2
B/D
B/D
NM, LA, PA
NM, LA, PA
NM; *
NM, PA
NM; *
NM; *
NM, PA
NM, PA
NM, PA
NM; *
NM; *
NM; *
NM, PA
NM, PA
NM, PA
NM, LA, PA
B/D, NM
NM; *
NM; *
NM; *
NM; *
NM; *
NM, LA, PA
NM, LA, PA
NASAL STEROIDS - DRUGS TO TREAT ALLERGIES
flunisolide nasal soln 25 mcg/act (0.025%) 1
fluticasone propionate nasal susp 50
1
mcg/act
mometasone furoate nasal susp 50
1
mcg/act
QL (2 bottles / 30 days)
QL (1 bottle / 30 days)
QL (2 bottles / 30 days)
ST - Step Therapy
NM - Not
LA - Limited Access
140
Name of Drug
NASONEX SPR 50MCG/AC
What the
Drug will
cost you
(Tier
Level)
2
Necessary actions,
on use
QL (2 inhalers / 30
days)
STEROID INHALANTS - DRUGS TO TREAT ASTHMA
ARNUITY ELPT INH 100MCG
2
ARNUITY ELPT INH 200MCG
2
budesonide inhalation susp 0.5 mg/2ml
FLOVENT DISK AER 50MCG
1
1
2
2
2
FLOVENT HFA AER 44MCG
2
2
2
PULMICORT INH 90MCG
2
PULMICORT INH 180MCG
2
days)
days)
B/D
B/D
days)
days)
days)
QL (2 inhalers / 30
days)
QL (2 inhalers / 30
days)
QL (2 inhalers / 30
days)
QL (2 inhalers / 30
days)
QL (2 inhalers / 30
days)
STEROID/BETA-AGONIST COMBINATIONS - DRUGS TO TREAT
ASTHMA AND COPD
ADVAIR DISKU AER 100/50
2
2
2
ADVAIR HFA AER 45/21
BREO ELLIPTA INH 100-25
2
2
2
2
days)
days)
days)
QL (60 blisters / 30
days)
ST - Step Therapy
NM - Not
LA - Limited Access
141
Name of Drug
BREO ELLIPTA INH 200-25
What the
Drug will
cost you
(Tier
Level)
2
SYMBICORT AER 80-4.5
SYMBICORT AER 160-4.5
2
2
Necessary actions,
on use
QL (60 blisters / 30
days)
XANTHINES - DRUGS TO TREAT COPD
aminophylline inj 25 mg/ml
elixophyllin elx 80/15ml
theo-24 cap 100mg cr
theo-24 cap 400mg er
theophylline soln 80 mg/15ml
theophylline tab sr 12hr 100 mg
TOPICAL - DRUGS TO TREAT EAR
DERMATOLOGY, ACNE
1
2
2
2
2
2
1
1
1
1
1
1
1
AND SKIN CONDITIONS
adapalene cream 0.1%
adapalene gel 0.1%
AVITA CRE 0.025%
AVITA GEL 0.025%
benzoyl peroxide-erythromycin gel 5-3%
claravis cap 10mg
claravis cap 20mg
claravis cap 30mg
claravis cap 40mg
clindamax gel 1%
clindamycin phosphate gel 1%
clindamycin phosphate lotion 1%
clindamycin phosphate soln 1%
clindamycin phosphate swab 1%
erythromycin gel 2%
erythromycin pads 2%
erythromycin soln 2%
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
ST - Step Therapy
NM - Not
LA - Limited Access
142
Name of Drug
isotretinoin cap 10 mg
myorisan cap 10mg
myorisan cap 20mg
myorisan cap 30mg
myorisan cap 40mg
sulfacetamide sodium lotion 10% (acne)
tretinoin cream 0.1%
TRETINOIN GEL 0.01%
tretinoin gel 0.025%
zenatane cap 10mg
zenatane cap 20mg
zenatane cap 30mg
zenatane cap 40mg
What the
Drug will
cost you
(Tier
Level)
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Necessary actions,
on use
4
4
4
4
4
4
4
4
4
4
4
4
1
1
4
4
1
4
4
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
DERMATOLOGY, ANTIBIOTICS
ACNE MEDICAT LOT 5%
ACNE MEDICAT LOT 10%
bacitr zinc oin 500/gm
bacitracin oin 500/gm
bacitracin oint 500 unit/gm
bacitracin zinc oint 500 unit/gm
BENZOYL PER GEL 2.5%
benzoyl per liq 5% wash
benzoyl per liq 10% wash
benzoyl per lot 6%
benzoyl pero kit acne pck
double antib oin
gentamicin sulfate cream 0.1%
gentamicin sulfate oint 0.1%
gnp triple oin antibiot
hm triple oin antibiot
mupirocin oint 2%
neomycin-bacitracin-polymyxin oint
panoxyl wash liq 10%
*
*
*
*
*
*
*
*
*
*
*
*
NM; *
NM; *
NM; *
NM; *
ST - Step Therapy
NM - Not
LA - Limited Access
143
Name of Drug
PANOXYL-4 LIQ CREM WSH
SILVER SULFADIAZINE CREAM 1%
sm triple oin antibiot
SSD CRE 1%
SULFAMYLON CRE 85MG/GM
SULFAMYLON PAK 5%
triple antib oin
triple antib oin plus
What the
Drug will
cost you
(Tier
Level)
4
1
4
1
2
2
4
4
Necessary actions,
on use
NM; *
NM; *
NM; *
NM; *
DERMATOLOGY, ANTIFUNGALS
ALEVAZOL OIN 1%
anti-fungal pow 1%
antifungal cre 1%
antifungal cre 2%
ath foot spr aer 1%
athlete foot cre 1%
athlete foot cre af
baza antifun cre 2%
ciclopirox gel 0.77%
ciclopirox olamine cream 0.77% (base
equiv)
ciclopirox olamine susp 0.77% (base
equiv)
ciclopirox shampoo 1%
clotrimazole cream 1%
clotrimazole soln 1%
desenex cre 1%
desenex shak pow 2%
econazole nitrate cream 1%
FUNGOID TINC SOL 2%
fungoid-d cre 1%
jock itch aer 1%
ketoconazole cream 2%
LAMISIL ADV GEL 1%
lamisil af aer 1%
LAMISIL AT SPR 1%
lotrimin af pow 2%
LOTRIMIN ULT CRE 1%
4
4
4
4
4
4
4
4
1
1
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
*
*
*
*
*
*
*
*
1
1
1
1
4
4
1
4
4
4
1
4
4
4
4
4
NM; *
NM; *
NM; *
NM; *
NM; *
NM;
NM;
NM;
NM;
NM;
*
*
*
*
*
ST - Step Therapy
NM - Not
LA - Limited Access
144
Name of Drug
miconazole nitrate cream 2%
miconazorb pow af 2%
micro guard pow 2%
nyamyc pow 100000
nystatin cream 100000 unit/gm
nystatin oint 100000 unit/gm
nystatin topical powder
nystop pow 100000
remedy cre antifung
remedy pow antifung
sm antifungl cre 1%
sm antifungl cre 2%
soothe&cool cre inzo 2%
terbinafine cre 1%
terbinafine hcl cream 1%
tolnaftate cre 1%
tolnaftate cream 1%
tolnaftate powder 1%
tolnaftate soln 1%
triple paste oin af 2%
zeasorb-af pow 2%
What the
Drug will
cost you
(Tier
Level)
4
4
4
1
1
1
1
1
4
4
4
4
4
4
4
4
4
4
4
4
4
Necessary actions,
on use
NM; *
NM; *
NM; *
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
*
*
*
*
*
*
*
*
*
*
*
*
*
DERMATOLOGY, ANTIPRURITIC
DOXEPIN HCL CREAM 5%
hydrocortisone rectal cream 2.5%
procto-med cre hc 2.5%
procto-pak cre 1%
proctozone cre -hc 2.5%
PRUDOXIN CRE 5%
1
1
1
1
1
1
DERMATOLOGY, ANTIPSORIATICS
acitretin cap 10 mg
acitretin cap 17.5 mg
acitretin cap 25 mg
calcipotriene cream 0.005%
calcipotriene oint 0.005%
calcipotriene soln 0.005% (50 mcg/ml)
calcitrene oin 0.005%
8-MOP CAP 10MG
2
2
2
1
1
1
1
2
PA
PA
PA
ST - Step Therapy
NM - Not
LA - Limited Access
145
Name of Drug
TAZORAC CRE 0.1%
TAZORAC CRE 0.05%
What the
Drug will
cost you
(Tier
Level)
2
2
Necessary actions,
on use
PA
PA
DERMATOLOGY, ANTISEBORRHEICS
ketoconazole shampoo 2%
selenium sulfide lotion 2.5%
1
1
DERMATOLOGY, CORTICOSTEROIDS
ala cort cre 1%
1
alclometasone dipropionate cream 0.05% 1
alclometasone dipropionate oint 0.05%
1
AMLACTIN CRE ULTRA
4
beta hc lot 1%
4
betamethasone dipropionate augmented
1
cream 0.05%
1
gel 0.05%
1
lotion 0.05%
1
oint 0.05%
betamethasone dipropionate cream 0.05% 1
betamethasone dipropionate lotion 0.05% 1
betamethasone dipropionate oint 0.05%
1
betamethasone valerate cream 0.1%
1
betamethasone valerate lotion 0.1%
1
betamethasone valerate oint 0.1%
1
clobetasol propionate cream 0.05%
1
clobetasol propionate emollient base cream 1
0.05%
clobetasol propionate gel 0.05%
1
clobetasol propionate oint 0.05%
1
clobetasol propionate soln 0.05%
1
cormax scalp sol 0.05%
1
DESONIDE CREAM 0.05%
1
desonide lotion 0.05%
1
desonide oint 0.05%
1
desoximetasone cream 0.05%
1
desoximetasone cream 0.25%
1
NM; *
NM; *
ST - Step Therapy
NM - Not
LA - Limited Access
146
Name of Drug
What the
Drug will
cost you
(Tier
Level)
desoximetasone gel 0.05%
1
DESOXIMETASONE OINT 0.05%
1
desoximetasone oint 0.25%
1
diflorasone diacetate cream 0.05%
1
diflorasone diacetate oint 0.05%
1
fluocin acet oil body
1
fluocin acet oil scalp
1
fluocinolone acetonide cream 0.01%
1
fluocinolone acetonide cream 0.025%
1
fluocinolone acetonide oint 0.025%
1
fluocinolone acetonide soln 0.01%
1
fluocinonide cream 0.05%
1
fluocinonide emulsified base cream 0.05% 1
fluocinonide gel 0.05%
1
fluocinonide oint 0.05%
1
fluocinonide soln 0.05%
1
fluticasone propionate cream 0.05%
1
fluticasone propionate oint 0.005%
1
halobetasol propionate cream 0.05%
1
halobetasol propionate oint 0.05%
1
hydro skin lot 1%
4
hydrocort cre 0.5%
4
hydrocortisone butyrate cream 0.1%
1
hydrocortisone butyrate oint 0.1%
1
hydrocortisone butyrate soln 0.1%
1
hydrocortisone cream 0.5%
4
hydrocortisone cream 1%
1
hydrocortisone cream 1%
4
hydrocortisone cream 2.5%
1
hydrocortisone lotion 2.5%
1
hydrocortisone oint 0.5%
4
hydrocortisone oint 1%
1
hydrocortisone oint 2.5%
1
hydrocortisone valerate cream 0.2%
1
hydrocortisone valerate oint 0.2%
1
hydrocortisone-aloe vera cream 0.5%
4
lokara lot 0.05%
1
Necessary actions,
on use
NM; *
NM; *
NM; *
NM; *
NM; *
NM; *
ST - Step Therapy
NM - Not
LA - Limited Access
147
Name of Drug
What the
Drug will
cost you
(Tier
Level)
medi-cort cre 1%
4
MOISTURIZING CRE
4
mometasone furoate cream 0.1%
1
mometasone furoate oint 0.1%
1
mometasone furoate solution 0.1% (lotion) 1
RISABAL-PH CRE
4
texacort sol 2.5%
2
triamcinolone acetonide cream 0.1%
1
1
1
triamcinolone acetonide lotion 0.1%
1
1
triamcinolone acetonide oint 0.1%
1
1
1
triderm cre 0.1%
1
Necessary actions,
on use
NM; *
NM; *
NM; *
DERMATOLOGY, LOCAL ANESTHETICS
lidocaine
lidocaine
lidocaine
lidocaine
hcl gel 2%
hcl soln 4%
oint 5%
patch 5%
lidocaine-prilocaine cream 2.5-2.5%
1
1
1
1
1
QL (3 patches / 1 day),
PA
B/D
DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE
acyclovir oint 5%
AIMSCO MIS LUBRICAT
ALOE VESTA LOT SKN COND
ALOE VESTA OIN PROTECT
ameriphor oin
amlactin lot 12%
anti-itch cre 2-0.1%
banophen cre 2-0.1%
baza protect cre
BENZOIN CMPD TIN
benzoyl peroxide gel 5%
benzoyl peroxide gel 10%
betatar gel sha 2.5%
1
4
4
4
4
4
4
4
4
4
4
4
4
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
NM;
*
*
*
*
*
*
*
*
*
*
*
*
ST - Step Therapy
NM - Not
LA - Limited Access
148
Name of Drug
What the
Drug will
cost you
(Tier
Level)
4
4
4
4
4
4
4
1
4
capsaicin cre 0.1%
CONDOMS MIS LUBRICAT
dermacerin cre
dermamed oin
dermaphor oin
dermazinc sha 2%
DHS SAL SHA 3%
diclofenac sodium gel 1%
diphenhydramine-zinc acetate cream 20.1%
ELIDEL CRE 1%
2
FANTASY LUBR MIS COLORS
4
FANTASY LUBR MIS SPERMICI
4
FANTASY MIS LUBRICAT
4
fluorouracil cream 5%
1
fluorouracil soln 2%
1
fluorouracil soln 5%
1
hem-prep sup
4
hemorrhoidal oin
4
hemorrhoidal sup
4
hm povid-iod sol 10%
4
imiquimod cream 5%
1
ionil-t sha 1%
4
itch relief cre ex st
4
KIMONO MICRO MIS THIN
4
KIMONO MICRO MIS THIN +
4
KIMONO MIS LUBRICAT
4
KIMONO MIS SENSATIO
4
KIMONO SENSA MIS PLUS
4
lactic acid (ammonium lactate) cream 12% 1
lactic acid (ammonium lactate) lotion 12% 1
lidocaine cream 4%
4
lidocream cre 4%
4
major-prep oin hemorrho
4
MAXX MIS LUBRICAT
4
metronidazole cream 0.75%
1
metronidazole gel 0.75%
1
Necessary actions,
on use
NM;
NM;
NM;
NM;
NM;
NM;
NM;
*
*
*
*
*
*
*
NM; *
PA
NM; *
NM; *
NM; *
NM;
NM;
NM;
NM;
*
*
*
*
NM;
NM;
NM;
NM;
NM;
NM;
NM;
*
*
*
*
*
*
*
NM;
NM;
NM;
NM;
*
*
*
*
ST - Step Therapy
NM - Not
LA - Limited Access
149
Name of Drug
metronidazole lotion 0.75%
minerin cre
NAIL SCRUB LIQ W/BRUSH
nutraplus lot 10%
operand scrb sol 7.5%
PANRETIN GEL 0.1%
pedi-boro pow soak pak
PELEVERUS SPR
periguard oin
PETROLATUM OIN
podofilox soln 0.5%
povidone-iodine oint 10%
povidone-iodine soln 10%
REMEDY NUTRA CRE 1%
REMEDY SKIN CRE REPAIR
rosadan cre 0.75%
sal-plant gel 17%
salactic fil sol 17%
sb anti-itch cre 2-0.1%
SENSI-CARE CRE MOISTURI
SENSI-CARE OIN 49-15%
sm anti-itch cre 2-0.1%
sm hemorrhoi oin
SOOTHE&COOL OIN MOISTURE
tacrolimus oint 0.1%
tacrolimus oint 0.03%
TARGRETIN GEL 1%
therapeutic sha
TRIXAICIN CRE 0.025%
trixaicin hp cre 0.075%
TRUSTEX LUBR MIS ASSORTED
TRUSTEX LUBR MIS BANANA
TRUSTEX LUBR MIS CHOC
TRUSTEX LUBR MIS COLA
TRUSTEX LUBR MIS COLORS
TRUSTEX LUBR MIS EX LARGE
TRUSTEX LUBR MIS EX STR
What the
Drug will
cost you
(Tier
Level)
1
4
4
4
4
2
4
4
4
4
1
4
4
4
4
1
4
4
4
4
4
4
4
4
1
1
2
4
4
4
4
4
4
4
4
4
4
Necessary actions,
on use
NM;
NM;
NM;
NM;
*
*
*
*
NM;
NM;
NM;
NM;
*
*
*
*
NM;
NM;
NM;
NM;
*
*
*
*
NM; *
NM; *
NM; *
NM; *
NM; *
NM; *
NM; *
NM; *
PA
PA
NM, PA
NM; *
NM; *
NM; *
NM; *
NM; *
NM; *
NM; *
NM; *
NM; *
NM; *
ST - Step Therapy
NM - Not
LA - Limited Access
150
Name of Drug
TRUSTEX LUBR MIS GRAPE
TRUSTEX LUBR MIS RIB/STUD
TRUSTEX LUBR MIS SPERMICI
TRUSTEX LUBR MIS STRWBRY
TRUSTEX LUBR MIS VANILLA
TRUSTEX MIS BANANA
TRUSTEX MIS CHOCOLAT
TRUSTEX MIS FLAVORS
TRUSTEX MIS MINT
TRUSTEX MIS STRWBRY
TRUSTEX MIS VANILLA
TRUSTEX/RIA MIS LUBRICAT
TRUSTEX/RIA MIS NON-LUB
TRUSTEX/RIA MIS SPERMICI
TRUSTX NON-9 MIS RIB/STUD
urea cream 10%
urea lotion 10%
ureacin-10 lot 10%
VALCHLOR GEL 0.016%
VOLTAREN GEL 1%
ZIKS ARTHRIT CRE RELIEF
What the
Drug will
cost you
(Tier
Level)
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
2
2
4
Necessary actions,
on use
NM; *
NM; *
NM; *
NM; *
NM; *
NM; *
NM; *
NM; *
NM; *
NM; *
NM; *
NM; *
NM; *
NM; *
NM; *
NM; *
NM; *
NM; *
NM, LA, PA
NM; *
DERMATOLOGY, SCABICIDES AND PEDICULIDES
complete kit lice
EURAX CRE 10%
EURAX LOT 10%
gnp lice kit
lice killing sha 0.33-4%
lice soln kit
lice treatme lot 1%
lice trtmnt liq 1%
lice trtmnt liq crm rnse
malathion lotion 0.5%
permethrin cream 5%
permethrin lotion 1%
sm lice lot treatmnt
4
2
2
4
4
4
4
4
4
1
1
4
4
NM; *
NM;
NM;
NM;
NM;
NM;
NM;
*
*
*
*
*
*
NM; *
NM; *
DERMATOLOGY, WOUND CARE AGENTS
acetic acid irrigation soln 0.25%
1
ST - Step Therapy
NM - Not
LA - Limited Access
151
Name of Drug
REGRANEX GEL 0.01%
SANTYL OIN 250/GM
SODIUM CHLORIDE IRRIGATION SOLN
0.9%
WATER FOR IRRIGATION, STERILE
IRRIGATION SOLN
What the
Drug will
cost you
(Tier
Level)
2
2
1
Necessary actions,
on use
PA
1
MOUTH/THROAT/DENTAL AGENTS
cevimeline hcl cap 30 mg
chlorhexidine gluconate soln 0.12%
clotrimazole troche 10 mg
lidocaine hcl viscous soln 2%
nystatin susp 100000 unit/ml
periogard sol 0.12%
PILOCARPINE HCL TAB 5 MG
pilocarpine hcl tab 7.5 mg
triamcinolone acetonide dental paste 0.1%
1
1
1
1
1
1
1
1
1
OTIC - DRUGS TO TREAT CONDITIONS OF THE EAR
acetic acid 2% in aluminum acetate otic
soln
acetic acid otic soln 2%
CIPRODEX SUS 0.3-0.1%
ear drops sol 6.5% ot
ear wax remv dro 6.5% ot
ear wax remv sol 6.5% ot
earwax remv sol 6.5% ot
fluocinolone acetonide (otic) oil 0.01%
gnp ear drop sol 6.5% ot
gnp ear sys sol 6.5% ot
neomycin-polymyxin-hc otic soln 1%
neomycin-polymyxin-hc otic susp 3.5
mg/ml-10000 unit/ml-1%
ofloxacin otic soln 0.3%
1
1
2
4
4
4
4
1
4
4
1
1
NM;
NM;
NM;
NM;
*
*
*
*
NM; *
NM; *
1
ST - Step Therapy
NM - Not
LA - Limited Access
152
Index
1
12 hr nasal spr 0.05% ..................... 133
3
3 DAY VAGINL CRE 2% .................... 101
3 day vagnal cre 4% ....................... 101
8
8-MOP CAP 10MG ........................... 145
A
abacavir sulfate tab 300 mg (base equiv)
......................................................12
abacavir sulfate-lamivudine-zidovudine
tab 300-150-300 mg .........................14
ABELCET INJ 5MG/ML ........................11
ABILIFY DISC TAB 10MG....................62
ABILIFY MAIN INJ 300MG ..................62
ABILIFY MAIN INJ 400MG ..................62
ABRAXANE INJ 100MG .......................25
acamprosate calcium tab delayed release 333 mg ...........................................72
acarbose tab 100 mg.........................75
acarbose tab 25 mg ..........................75
acarbose tab 50 mg ..........................75
acebutolol hcl cap 200 mg .................40
acebutolol hcl cap 400 mg .................40
ACEPHEN SUP 120MG ......................... 1
acephen sup 325mg ........................... 1
acephen sup 650mg ........................... 1
acetaminophen suppos 120 mg ........... 1
acetaminophen suppos 650 mg ........... 1
acetaminophen w/ codeine soln 120-12 mg/5ml ............................................ 4
acetaminophen w/ codeine tab 300-15 mg ................................................... 4
acetazolamide cap sr 12hr 500 mg ......44
acetazolamide tab 125 mg .................44
acetazolamide tab 250 mg .................44
acetic acid 2% in aluminum acetate otic soln............................................... 152
acetic acid irrigation soln 0.25% ....... 151
acetic acid otic soln 2% ................... 152
acetylcysteine inhal soln 10% ........... 140
acetylcysteine inhal soln 20% ........... 140
acid control tab 10mg ....................... 93
acid gone sus .................................. 89
acid reducer tab 10mg ...................... 93
acid reducer tab 150mg .................... 89
ACIDOPHILUS/ TAB CIT PECT ............ 90
acitretin cap 10 mg ........................ 145
acitretin cap 17.5 mg...................... 145
acitretin cap 25 mg ........................ 145
ACNE MEDICAT LOT 10% ................ 143
ACNE MEDICAT LOT 5% .................. 143
ACTHIB INJ ................................... 109
ACTIMMUNE INJ 2MU/0.5 ................ 108
acyclovir cap 200 mg ........................ 15
acyclovir oint 5% ........................... 148
acyclovir sodium for inj 500 mg ......... 15
acyclovir sodium iv soln 50 mg/ml...... 15
acyclovir susp 200 mg/5ml ................ 15
acyclovir tab 400 mg ........................ 15
acyclovir tab 800 mg ........................ 15
ADACEL INJ ................................... 109
ADAGEN INJ 250/ML ......................... 81
adapalene cream 0.1% ................... 142
adapalene gel 0.1% ........................ 142
adefovir dipivoxil tab 10 mg .............. 15
ADEMPAS TAB 0.5MG ....................... 47
ADEMPAS TAB 1.5MG ....................... 47
ADEMPAS TAB 1MG .......................... 47
ADEMPAS TAB 2.5MG ....................... 47
ADEMPAS TAB 2MG .......................... 47
adrucil inj 2.5g/50m ......................... 24
adrucil inj 500/10ml ......................... 24
adrucil inj 5gm/100m ....................... 24
ADULT 50+ CAP OCUVITE ............... 117
ADVAIR DISKU AER 100/50 ............. 141
ADVAIR DISKU AER 250/50 ............. 141
ADVAIR DISKU AER 500/50 ............. 141
ADVAIR HFA AER 115/21 ................ 141
ADVAIR HFA AER 230/21 ................ 141
ADVAIR HFA AER 45/21 .................. 141
advanced sus antacid ....................... 89
ADVIL JR ST TAB 100MG ..................... 1
ADVIL JR STR CHW 100MG .................. 1
afeditab tab 30mg cr ........................ 42
afeditab tab 60mg cr ........................ 42
AFINITOR DIS TAB 2MG .................... 28
AFINITOR DIS TAB 3MG .................... 28
153
AFINITOR DIS TAB 5MG.....................28
AFINITOR TAB 10MG .........................28
AFINITOR TAB 2.5MG ........................28
AFINITOR TAB 5MG ...........................28
AFINITOR TAB 7.5MG ........................28
AGGRENOX CAP 25-200MG .............. 106
a-hydrocort inj 100mg .......................83
AIMSCO MIS LUBRICAT ................... 148
AIRZONE PEAK MIS FLOW MTR ......... 130
akwa tears oin op ........................... 125
ala cort cre 1% ............................... 146
alavert alrg tab /sinus ..................... 130
ALAVERT TAB 10MG ........................ 126
ALAWAY CHILD DRO 0.025%OP ....... 124
ALAWAY DRO 0.025%OP ................. 124
ALBENZA TAB 200MG ......................... 8
albuterol sulfate soln nebu 0.083% (2.5
mg/3ml) ........................................ 129
albuterol sulfate soln nebu 0.5% (5
mg/ml) .......................................... 129
(base equiv) ................................... 129
(base equiv) ................................... 129
albuterol sulfate syrup 2 mg/5ml ...... 129
albuterol sulfate tab 2 mg ................ 129
albuterol sulfate tab 4 mg ................ 129
albuterol sulfate tab sr 12hr 4 mg ..... 129
albuterol sulfate tab sr 12hr 8 mg ..... 129
alclometasone dipropionate cream 0.05%
.................................................... 146
alclometasone dipropionate oint 0.05%
.................................................... 146
ALCOHOL SWABS .............................74
ALDURAZYME INJ 2.9MG/5M ..............81
ALECENSA CAP 150MG ......................28
alendronate sodium tab 10 mg ...........77
alendronate sodium tab 5 mg .............77
ALEVAZOL OIN 1% ......................... 144
alfuzosin hcl tab sr 24hr 10 mg......... 100
ALIMTA INJ 100MG ...........................24
ALIMTA INJ 500MG ...........................24
ALINIA SUS 100/5ML ......................... 8
ALINIA TAB 500MG ............................ 8
all day allg chw 10mg ...................... 126
all day allg tab 10mg ...................... 126
all day alrg tab 5-120mg ................. 130
all day pain tab 220mg ....................... 1
all day relf tab 220mg......................... 1
aller/conges tab 10-240mg.............. 130
aller-chlor syp 2mg/5ml .................. 126
aller-chlor tab 4mg ......................... 126
aller-ease tab 180mg ...................... 126
aller-ease tab 60mg ....................... 126
allergy cap 25mg ........................... 126
allergy d tab 5-120mg .................... 130
allergy eye dro 0.025%op ............... 124
allergy plus tab sev/sinu ................. 130
allergy rel/ tab deconges ................. 130
allergy relf cap 25mg ...................... 126
allergy relf syp 5mg/5ml ................. 126
allergy relf tab 1.34mg ................... 127
allergy relf tab 10mg ...................... 127
allergy relf tab 25mg ...................... 127
allergy relf tab d-24 ........................ 130
allergy relf tab deconges ................. 130
allergy tab 10mg ............................ 127
allergy tab 25mg ............................ 127
allergy tab 4mg ............................. 127
allergy tab multi-sy ........................ 130
allergy/cong tab 5-120mg ............... 130
allergy-d tab 5-120mg .................... 130
allergy-time tab 4mg ...................... 127
allerhist-1 tab 1.34mg .................... 127
allgy comp-d tab 5-120mg .............. 130
all-nite liq cold/flu .......................... 130
allopurinol tab 100 mg ........................ 1
allopurinol tab 300 mg ........................ 1
almacone dbl sus strength ................. 89
ALOE VESTA LOT SKN COND ........... 148
ALOE VESTA OIN PROTECT .............. 148
alosetron hcl tab 0.5 mg (base equiv) . 98
alosetron hcl tab 1 mg (base equiv) ... 98
ALPHA LIPOIC CAP 300MG .............. 116
ALPHAGAN P SOL 0.1%................... 124
alpha-lipoic acid (thioctic acid) cap 100
mg ............................................... 116
alprazolam tab 0.25 mg .................... 48
alprazolam tab 0.5 mg ...................... 48
alprazolam tab 1 mg ......................... 48
alprazolam tab 2 mg ......................... 48
ALREX SUS 0.2% ........................... 123
altavera tab ..................................... 78
154
ALUM HYDROX SUS 320/5ML .............89
amantadine hcl cap 100 mg ...............60
amantadine hcl syrup 50 mg/5ml ........60
amantadine hcl tab 100 mg ................60
AMBISOME INJ 50MG ........................11
ameriphor oin ................................. 148
amifostine crystalline for inj 500 mg....31
amikacin sulfate inj 1 gm/4ml (250
mg/ml) ............................................. 7
amikacin sulfate inj 500 mg/2ml (250
mg/ml) ............................................. 7
amiloride & hydrochlorothiazide tab 5-50 mg ..................................................44
amiloride hcl tab 5 mg .......................44
amino acid infusion 6% ................... 111
aminophylline inj 25 mg/ml .............. 142
AMINOSYN 7% INJ /LYTES ............... 111
AMINOSYN II INJ 10%..................... 112
AMINOSYN II INJ 7% ...................... 112
AMINOSYN II INJ 8.5%.................... 112
AMINOSYN II INJ 8.5/LYTE............... 112
AMINOSYN INJ 10% ........................ 112
AMINOSYN INJ 8.5% ....................... 112
AMINOSYN INJ 8.5/LYTE .................. 112
AMINOSYN M INJ 3.5%.................... 112
AMINOSYN-HBC INJ 7% .................. 112
AMINOSYN-PF INJ 10% ................... 112
AMINOSYN-PF INJ 7% ..................... 112
AMINOSYN-RF INJ 5.2% .................. 112
mg/ml) ............................................36
mg/ml) ............................................36
mg/ml) ............................................36
amiodarone hcl tab 100 mg ................36
AMITIZA CAP 24MCG .........................98
AMITIZA CAP 8MCG ..........................98
amitriptyline hcl tab 10 mg ................55
amitriptyline hcl tab 100 mg ..............56
amitriptyline hcl tab 150 mg ..............56
AMLACTIN CRE ULTRA ..................... 146
amlactin lot 12% ............................ 148
amlodipine besylate tab 10 mg .......... 42
amlodipine besylate tab 2.5 mg ......... 42
amlodipine besylate tab 5 mg ............ 42
amlodipine besylate-benazepril hcl cap
10-20 mg ........................................ 32
10-40 mg ........................................ 32
2.5-10 mg ....................................... 31
amlodipine besylate-benazepril hcl cap 510 mg............................................. 32
amlodipine besylate-valsartan tab 10160 mg ........................................... 35
amlodipine besylate-valsartan tab 10320 mg ........................................... 35
amlodipine besylate-valsartan tab 5-160 mg ................................................. 34
amlodipine besylate-valsartan tab 5-320 mg ................................................. 35
tab 10-160-12.5 mg ......................... 35
tab 10-160-25 mg ............................ 35
tab 10-320-25 mg ............................ 35
tab 5-160-12.5 mg ........................... 35
tab 5-160-25 mg.............................. 35
amoxapine tab 100 mg ..................... 56
amoxapine tab 150 mg ..................... 56
amoxapine tab 25 mg ....................... 56
amoxapine tab 50 mg ....................... 56
amoxicillin & k clavulanate chew tab 20028.5 mg .......................................... 20
amoxicillin & k clavulanate chew tab 40057 mg............................................. 20
amoxicillin & k clavulanate for susp 20028.5 mg/5ml ................................... 20
amoxicillin & k clavulanate for susp 25062.5 mg/5ml ................................... 20
amoxicillin & k clavulanate for susp 40057 mg/5ml ...................................... 20
155
42.9 mg/5ml ....................................20
amoxicillin & k clavulanate tab 250-125 mg ..................................................20
amoxicillin & k clavulanate tab sr 12hr 1000-62.5 mg ..................................20
amoxicillin (trihydrate) cap 250 mg .....20
amoxicillin (trihydrate) cap 500 mg .....20
amoxicillin (trihydrate) chew tab 125 mg
......................................................20
amoxicillin (trihydrate) chew tab 250 mg
......................................................20
mg/5ml ...........................................20
mg/5ml ...........................................20
mg/5ml ...........................................21
mg/5ml ...........................................21
amoxicillin (trihydrate) tab 500 mg .....21
amoxicillin (trihydrate) tab 875 mg .....21
amphetamine-dextroamphetamine cap sr 24hr 10 mg ......................................68
amphetamine-dextroamphetamine cap sr 24hr 5 mg........................................67
10 mg .............................................68
12.5 mg ..........................................68
15 mg .............................................68
20 mg .............................................68
30 mg .............................................68
mg ................................................. 68
7.5 mg............................................ 68
amphotericin b for inj 50 mg ............. 11
ampicillin & sulbactam sodium for inj 10.5 gm............................................ 21
ampicillin & sulbactam sodium for inj 105 gm .............................................. 21
ampicillin & sulbactam sodium for inj 2-1 gm ................................................. 21
ampicillin & sulbactam sodium for iv soln
10-5 gm.......................................... 21
ampicillin & sulbactam sodium for iv soln
2-1 gm ........................................... 21
ampicillin cap 250 mg ....................... 21
ampicillin cap 500 mg ....................... 21
ampicillin for susp 125 mg/5ml .......... 21
ampicillin for susp 250 mg/5ml .......... 21
ampicillin sodium for inj 1 gm ............ 21
ampicillin sodium for inj 125 mg ........ 21
ampicillin sodium for inj 2 gm ............ 21
ampicillin sodium for iv soln 1 gm ...... 21
ampicillin sodium for iv soln 10 gm ..... 21
ampicillin sodium for iv soln 2 gm ...... 21
AMPYRA TAB 10MG........................... 71
anagrelide hcl cap 0.5 mg ............... 105
anagrelide hcl cap 1 mg .................. 105
anastrozole tab 1 mg ........................ 27
ANDRODERM DIS 2MG/24HR ............. 74
ANDRODERM DIS 4MG/24HR ............. 74
animal shape chw .......................... 117
animal shape chw + iron ................. 117
ANORO ELLIPT AER 62.5-25 ............ 126
antacid fast sus relief ........................ 89
antacid plus sus anti-gas ................... 89
antacid plus sus gas rel ..................... 89
antacid sus ...................................... 89
antacid sus anti-gas ......................... 89
antacid sus max st ........................... 89
anti-diarrhe liq 1mg/5ml ................... 90
anti-diarrhe tab 2mg ........................ 90
antifungal cre 1% ........................... 144
antifungal cre 2% ........................... 144
anti-fungal pow 1% ........................ 144
anti-itch cre 2-0.1% ....................... 148
anti-nausea liq ................................. 90
156
anti-nausea sol .................................90
APOKYN INJ 10MG/ML .......................60
apri tab ...........................................78
APRISO CAP 0.375GM .......................93
aprodine tab 2.5-60mg .................... 130
APTIOM TAB 200MG ..........................49
APTIOM TAB 400MG ..........................49
APTIOM TAB 600MG ..........................49
APTIOM TAB 800MG ..........................49
APTIVUS CAP 250MG .........................12
APTIVUS SOL ...................................12
AQUADEKS CAP .............................. 117
AQUADEKS CHW ............................. 117
aquadeks dro ................................. 117
AQUA-E LIQ ................................... 117
AQUASOL A INJ 50000/ML ............... 117
aqueous e dro 15/0.3ml .................. 117
ARALAST NP INJ 1000MG ................. 140
ARALAST NP INJ 500MG .................. 140
aranelle tab ......................................78
ARCALYST INJ 220MG ..................... 108
arginine tab 500 mg ........................ 116
aripiprazole oral solution 1 mg/ml .......62
aripiprazole orally disintegrating tab 10
mg ..................................................62
aripiprazole orally disintegrating tab 15
mg ..................................................62
aripiprazole tab 10 mg.......................62
aripiprazole tab 2 mg ........................62
aripiprazole tab 5 mg ........................62
armodafinil tab 150 mg .....................71
ARMODAFINIL TAB 200 MG ................71
armodafinil tab 250 mg .....................72
armodafinil tab 50 mg .......................71
ARNUITY ELPT INH 100MCG ............. 141
ARNUITY ELPT INH 200MCG ............. 141
artifi tears oin op ............................ 125
artifi tears sol 1.4% op .................... 125
artifi tears sol op ............................ 125
artificial sol tears ............................ 125
ASACOL HD TAB 800MG ....................93
ascorbic acid tab 500 mg ................. 118
aspir-81 tab 81mg ec ......................... 1
aspirin chew tab 81 mg ...................... 1
aspirin chw 81mg .............................. 1
aspirin low chw 81mg ......................... 1
aspirin low tab 81mg ec ...................... 1
aspirin tab 325 mg ............................. 1
aspirin tab 325mg ec .......................... 1
aspirin tab 81mg ec ............................ 1
aspirin tab delayed release 325 mg ...... 1
aspirin tab delayed release 81 mg ........ 1
ASPIRIN-DIPYRIDAMOLE CAP SR 12HR
25-200 MG .................................... 106
aspir-low tab 81mg ec ........................ 1
ASSESS METER MIS FULL RNG......... 130
ASTEPRO SPR 0.15% ...................... 127
ASTHMA CHECK MIS SYSTEM .......... 130
ASTHMAMENTOR MIS ..................... 130
...................................................... 40
...................................................... 40
atenolol tab 100 mg ......................... 40
atenolol tab 25 mg ........................... 40
atenolol tab 50 mg ........................... 40
ath foot spr aer 1% ........................ 144
athlete foot cre 1% ........................ 144
athlete foot cre af........................... 144
atorvastatin calcium tab 10 mg (base equivalent) ...................................... 38
atovaquone susp 750 mg/5ml .............. 8
atovaquone-proguanil hcl tab 250-100 mg ................................................. 12
atovaquone-proguanil hcl tab 62.5-25 mg ................................................. 11
ATRIPLA TAB ................................... 14
ATROVENT HFA AER 17MCG ............ 126
aubra tab 0.1-0.02 ........................... 78
AVASTIN INJ ................................... 26
AVASTIN INJ 400/16ML..................... 26
aviane tab ....................................... 78
AVITA CRE 0.025% ........................ 142
AVITA GEL 0.025% ........................ 142
AXIRON SOL 30MG/ACT .................... 74
azacitidine for inj 100 mg .................. 24
AZACTAM/DEX INJ 1GM ...................... 8
157
AZACTAM/DEX INJ 2GM ...................... 8
azathioprine inj 100mg .................... 108
azathioprine tab 50 mg .................... 108
azelastine hcl nasal spray 0.1% (137
mcg/spray) .................................... 127
azelastine hcl nasal spray 0.15% (205.5
mcg/spray) .................................... 127
azelastine hcl ophth soln 0.05% ....... 124
AZILECT TAB 0.5MG ..........................60
AZILECT TAB 1MG.............................60
azithromycin for susp 100 mg/5ml ......18
azithromycin for susp 200 mg/5ml ......19
azithromycin iv for soln 500 mg ..........19
AZITHROMYCIN POWD PACK FOR SUSP 1
GM ..................................................19
azithromycin tab 250 mg ...................19
AZOPT SUS 1% OP ......................... 124
AZOR TAB 10-20MG ..........................35
AZOR TAB 10-40MG ..........................35
AZOR TAB 5-20MG ............................35
AZOR TAB 5-40MG ............................35
aztreonam for inj 1 gm ....................... 8
aztreonam for inj 2 gm ....................... 8
B
bacitr zinc oin 500/gm ..................... 143
bacitracin oin 500/gm...................... 143
bacitracin oint 500 unit/gm .............. 143
bacitracin ophth oint 500 unit/gm ..... 122
bacitracin zinc oint 500 unit/gm ........ 143
bacitracin-polymyxin b ophth oint ..... 122
bacitracin-polymyxin-neomycin-hc ophth
oint 1% ......................................... 122
baclofen tab 10 mg ...........................71
baclofen tab 20 mg ...........................71
balsalazide disodium cap 750 mg ........93
balziva tab .......................................78
banophen cap 25mg ........................ 127
banophen cap 50mg ........................ 127
banophen cre 2-0.1% ...................... 148
banophen liq 12.5/5ml .................... 127
banophen tab 25mg ........................ 127
BANZEL SUS 40MG/ML ......................49
BANZEL TAB 200MG ..........................49
BANZEL TAB 400MG ..........................49
BARACLUDE SOL .05MG/ML ...............15
baza antifun cre 2% ........................ 144
baza protect cre ............................. 148
BCG VACCINE INJ .......................... 109
b-complex w/ c & calcium tab .......... 118
bekyree tab ..................................... 78
BELEODAQ INJ 500MG ...................... 26
benazepril & hydrochlorothiazide tab 1012.5 mg .......................................... 32
benazepril & hydrochlorothiazide tab 2025 mg............................................. 32
benazepril hcl tab 10 mg ................... 33
benazepril hcl tab 5 mg ..................... 33
BENDEKA INJ 100/4ML ..................... 23
BENICAR HCT TAB 20-12.5................ 35
BENICAR HCT TAB 40-12.5................ 35
BENICAR HCT TAB 40-25MG .............. 35
BENICAR TAB 20MG ......................... 36
BENICAR TAB 40MG ......................... 36
BENICAR TAB 5MG ........................... 36
BENLYSTA INJ 120MG ..................... 108
BENLYSTA INJ 400MG ..................... 108
BENZOIN CMPD TIN ....................... 148
benzonatate cap 100 mg ................. 130
benzonatate cap 200 mg ................. 130
BENZOYL PER GEL 2.5% ................. 143
benzoyl per liq 10% wash ............... 143
benzoyl per liq 5% wash ................. 143
benzoyl per lot 6% ......................... 143
benzoyl pero kit acne pck ................ 143
benzoyl peroxide gel 10% ............... 148
benzoyl peroxide gel 5% ................. 148
benzoyl peroxide-erythromycin gel 5-3%
.................................................... 142
BENZTROPINE MESYLATE INJ 1 MG/ML 60
benztropine mesylate tab 0.5 mg ....... 60
benztropine mesylate tab 1 mg .......... 60
benztropine mesylate tab 2 mg .......... 60
BEPREVE DRO 1.5% ....................... 124
BESIVANCE SUS 0.6% .................... 122
beta hc lot 1% ............................... 146
cream 0.05%................................. 146
158
gel 0.05% ...................................... 146
lotion 0.05% .................................. 146
oint 0.05% ..................................... 146
betamethasone dipropionate cream
0.05% ........................................... 146
betamethasone dipropionate lotion
0.05% ........................................... 146
betamethasone dipropionate oint 0.05%
.................................................... 146
betamethasone valerate cream 0.1% 146
betamethasone valerate lotion 0.1% . 146
betamethasone valerate oint 0.1%.... 146
BETASERON INJ 0.3MG......................71
betatar gel sha 2.5% ....................... 148
betaxolol hcl ophth soln 0.5% .......... 124
bethanechol chloride tab 10 mg ........ 100
bethanechol chloride tab 5 mg .......... 100
BETOPTIC-S SUS 0.25% OP ............. 124
bexarotene cap 75 mg .......................30
BEXSERO INJ ................................. 109
bicalutamide tab 50 mg .....................27
BICILLIN L-A INJ 1200000 .................21
BICILLIN L-A INJ 2400000 .................21
BICILLIN L-A INJ 600000 ...................21
BICNU INJ 100MG .............................23
BILTRICIDE TAB 600MG ..................... 8
bion tears sol op ............................. 125
biotin cap 5 mg .............................. 118
bisac-evac sup 10mg .........................94
bisacodyl suppos 10 mg .....................94
bisacodyl tab & peg 3350-kcl-sod bicarbnacl for soln kit .................................94
bisacodyl tab 5mg ec .........................94
biscolax sup 10mg ............................94
bismatrol sus 262/15ml .....................90
bismatrol sus 525/15ml .....................90
bisoprolol & hydrochlorothiazide tab 106.25 mg ..........................................40
bisoprolol & hydrochlorothiazide tab 2.56.25 mg ..........................................40
bisoprolol & hydrochlorothiazide tab 56.25 mg ..........................................40
bisoprolol fumarate tab 10 mg ............40
bisoprolol fumarate tab 5 mg .............40
BIVIGAM INJ 10% .......................... 106
bleomycin sulfate for inj 15 unit ......... 24
bleomycin sulfate for inj 30 unit ......... 24
blephamide oin s.o.p. ..................... 122
blisovi fe tab 1.5/30 ......................... 78
blisovi fe tab 1/20 ............................ 78
BOOSTRIX INJ ............................... 109
BOSULIF TAB 100MG ........................ 28
BOSULIF TAB 500MG ........................ 28
BREO ELLIPTA INH 100-25 .............. 141
BREO ELLIPTA INH 200-25 .............. 142
briellyn tab ...................................... 78
BRILINTA TAB 60MG ....................... 106
BRILINTA TAB 90MG ....................... 106
BRIMONIDINE TARTRATE OPHTH SOLN 0.15% .......................................... 124
brimonidine tartrate ophth soln 0.2% 124
BRINTELLIX TAB 10MG ..................... 56
BRINTELLIX TAB 20MG ..................... 56
BRINTELLIX TAB 5MG ....................... 56
BRIVIACT INJ 50MG/5ML .................. 49
BRIVIACT SOL 10MG/ML ................... 49
BRIVIACT TAB 100MG ....................... 49
BRIVIACT TAB 10MG ........................ 49
BRIVIACT TAB 25MG ........................ 49
BRIVIACT TAB 50MG ........................ 49
BRIVIACT TAB 75MG ........................ 49
bromfed dm syp ............................. 130
BROMFENAC SODIUM OPHTH SOLN 0.09% (BASE EQUIV) (ONCE-DAILY) 123
bromfenac sodium ophth soln 0.09%
(base equivalent) ........................... 123
bromocriptine mesylate cap 5 mg....... 60
bromocriptine mesylate tab 2.5 mg .... 60
brotapp dm liq 15-1-5/5 ................. 130
brotapp liq .................................... 130
BROVEX PSB LIQ............................ 130
budesonide delayed release particles cap
3 mg .............................................. 93
.................................................... 141
.................................................... 141
bumetanide inj 0.25 mg/ml ............... 44
bumetanide tab 0.5 mg ..................... 44
bumetanide tab 1 mg ....................... 44
bumetanide tab 2 mg ....................... 45
BUPHENYL TAB 500MG ..................... 81
159
buprenorphine hcl sl tab 2 mg (base
equiv) .............................................72
buprenorphine hcl sl tab 8 mg (base equiv) .............................................72
buprenorphine hcl-naloxone hcl sl tab 20.5 mg (base equiv) ..........................72
buprenorphine hcl-naloxone hcl sl tab 82 mg (base equiv) ............................72
bupropion hcl (smoking deterrent) tab sr 12hr 150 mg ....................................72
bupropion hcl tab 100 mg ..................56
bupropion hcl tab 75 mg ....................56
bupropion hcl tab sr 12hr 100 mg .......56
buspirone hcl tab 10 mg ....................48
buspirone hcl tab 5 mg ......................48
buspirone hcl tab 7.5 mg ...................48
BUSULFEX INJ 6MG/ML ......................23
butorphanol tartrate inj 1 mg/ml ......... 4
butorphanol tartrate inj 2 mg/ml ......... 4
BYDUREON INJ 2MG ..........................74
BYDUREON PEN INJ 2MG ...................74
BYETTA INJ 10MCG ...........................74
BYETTA INJ 5MCG .............................74
BYSTOLIC TAB 10MG .........................40
BYSTOLIC TAB 2.5MG ........................40
BYSTOLIC TAB 20MG .........................40
BYSTOLIC TAB 5MG ..........................40
C
cabergoline tab 0.5 mg ......................85
CABOMETYX TAB 20MG .....................28
CABOMETYX TAB 40MG .....................28
CABOMETYX TAB 60MG .....................28
CALCET PETIT TAB 200-250 ............. 114
CALCI-CHEW CHW 1250MG .............. 114
calciferol dro 8000/ml ..................... 118
CALCI-MIX CAP 1250MG .................. 115
CALCIONATE SYP 1.8GM/5 ............... 115
calcipotriene cream 0.005% ............. 145
calcipotriene oint 0.005% ................ 145
calcipotriene soln 0.005% (50 mcg/ml)
.................................................... 145
calcitonin (salmon) nasal soln 200
unit/act ........................................... 85
calcitrate tab ................................. 115
calcitrate tab 950mg....................... 115
calcitrene oin 0.005% ..................... 145
calcitriol cap 0.25 mcg .................... 118
calcitriol cap 0.5 mcg ...................... 118
calcitriol inj 1 mcg/ml ..................... 118
calcitriol oral soln 1 mcg/ml ............. 118
calcium 600 chw +d/miner .............. 115
calcium 600 tab + d ....................... 115
calcium acetate (phosphate binder) cap
667 mg (169 mg ca)......................... 86
calcium acetate (phosphate binder) tab
667 mg ........................................... 87
CALCIUM CARBONATE (ANTACID) TAB 648 MG ........................................... 89
calcium carbonate susp 1250 mg/5ml
(500 mg/5ml elemental ca) ............. 115
calcium carbonate tab 1250 mg (500 mg elemental ca) ................................ 115
calcium carbonate tab 1500 mg (600 mg elemental ca) ................................ 115
calcium carbonate-cholecalciferol tab 250
mg-125 unit .................................. 115
mg-200 unit .................................. 115
mg-200 unit .................................. 115
mg-400 unit .................................. 115
calcium carbonate-vitamin d tab 500 mg200 unit ........................................ 115
calcium carb-vit d w/ minerals chew tab
600 mg-400 unit ............................ 115
calcium citr tab +d ......................... 115
calcium citr tab w/vit d3 .................. 115
calcium citrate-vitamin d tab 200 mg250 unit (elemental ca)................... 115
CALCIUM LACT TAB 648MG ............. 115
calcium plus cap d3 ........................ 115
calcium plus tab 600 +d.................. 115
calcium polycarbophil tab 625 mg ...... 94
calcium tab vit d ............................ 115
160
unit ............................................... 115
calcium/d tab 500-200 .................... 116
calcium/d tab 600-200 .................... 116
calcium/d3 tab ............................... 116
calcium+d tab 600-400 ................... 115
CALPHRON TAB 667MG .................... 116
calvite p&d tab ............................... 116
camila tab 0.35mg ............................78
CANASA SUP 1000MG .......................93
CANCIDAS INJ 50MG .........................11
CANCIDAS INJ 70MG .........................11
CAPASTAT SUL INJ 1GM ....................14
CAPCOF SYP 5-2-10MG .................... 130
CAPMIST DM TAB ............................ 130
CAPRELSA TAB 100MG ......................28
CAPRELSA TAB 300MG ......................28
CAPRON DM LIQ ............................. 130
capsaicin cre 0.1% .......................... 149
captopril & hydrochlorothiazide tab 25-15 mg ..................................................32
captopril tab 100 mg .........................33
captopril tab 12.5 mg ........................33
captopril tab 25 mg ...........................33
captopril tab 50 mg ...........................33
CARBAGLU TAB 200MG ......................81
carbamazepine cap sr 12hr 100 mg.....49
carbamazepine chew tab 100 mg ........49
carbamazepine susp 100 mg/5ml........49
carbamazepine tab 200 mg ................49
carbamazepine tab sr 12hr 100 mg .....49
carbidopa & levodopa orally disintegrating tab 10-100 mg .............60
carbidopa & levodopa tab 10-100 mg ..61
carbidopa & levodopa tab 25-100 mg ..61
carbidopa & levodopa tab 25-250 mg . 61
...................................................... 61
...................................................... 61
CARBIDOPA-LEVODOPA-ENTACAPONE TABS 12.5-50-200 MG ...................... 61
CARBIDOPA-LEVODOPA-ENTACAPONE TABS 18.75-75-200 MG .................... 61
CARBIDOPA-LEVODOPA-ENTACAPONE TABS 25-100-200 MG ....................... 61
CARBIDOPA-LEVODOPA-ENTACAPONE TABS 31.25-125-200 MG .................. 61
CARBIDOPA-LEVODOPA-ENTACAPONE TABS 37.5-150-200 MG .................... 61
CARBIDOPA-LEVODOPA-ENTACAPONE TABS 50-200-200 MG ....................... 61
carboplatin iv soln 150 mg/15ml ........ 30
carboplatin iv soln 50 mg/5ml ............ 30
CARIMUNE NF INJ 12GM ................. 106
CARIMUNE NF INJ 6GM ................... 106
carteolol hcl ophth soln 1% ............. 124
carvedilol tab 12.5 mg ...................... 41
carvedilol tab 25 mg ......................... 41
carvedilol tab 3.125 mg .................... 41
carvedilol tab 6.25 mg ...................... 41
CASTOR OIL .................................. 116
CAYSTON INH 75MG ........................... 8
cefaclor cap 250 mg ......................... 17
cefaclor cap 500 mg ......................... 17
cefaclor er tab 500mg ....................... 17
cefaclor for susp 125 mg/5ml ............ 17
cefadroxil cap 500 mg....................... 17
cefadroxil for susp 250 mg/5ml .......... 17
cefadroxil for susp 500 mg/5ml .......... 17
cefadroxil tab 1 gm .......................... 17
cefazolin inj 1gm/50ml ..................... 17
cefazolin sodium for inj 1 gm ............. 17
cefazolin sodium for inj 10 gm ........... 17
cefazolin sodium for inj 20 gm ........... 17
cefazolin sodium for inj 500 mg ......... 17
cefazolin sodium for iv soln 1 gm ....... 17
CEFAZOLIN SOL ............................... 17
cefdinir cap 300 mg .......................... 17
161
cefdinir for susp 125 mg/5ml..............17
cefdinir for susp 250 mg/5ml..............17
cefepime hcl for inj 1 gm ...................17
cefepime hcl for inj 2 gm ...................17
cefixime for susp 100 mg/5ml ............17
cefixime for susp 200 mg/5ml ............17
cefotaxime sodium for inj 1 gm ..........17
cefotaxime sodium for inj 2 gm ..........17
cefotaxime sodium for inj 500 mg .......17
cefoxitin sodium for inj 10 gm ............17
cefoxitin sodium for iv soln 1 gm ........17
cefoxitin sodium for iv soln 2 gm ........17
cefpodoxime proxetil for susp 100
mg/5ml ...........................................17
......................................................17
cefpodoxime proxetil tab 100 mg ........17
cefpodoxime proxetil tab 200 mg ........17
cefprozil for susp 125 mg/5ml ............18
cefprozil for susp 250 mg/5ml ............18
cefprozil tab 250 mg .........................18
cefprozil tab 500 mg .........................18
ceftazidime for inj 1 gm .....................18
CEFTAZIDIME/ SOL D5W 1GM ............18
CEFTAZIDIME/ SOL D5W 2GM ............18
ceftriaxone sodium for inj 1 gm ..........18
ceftriaxone sodium for inj 10 gm ........18
ceftriaxone sodium for inj 2 gm ..........18
ceftriaxone sodium for inj 250 mg .......18
ceftriaxone sodium for inj 500 mg .......18
ceftriaxone sodium for iv soln 1 gm .....18
ceftriaxone sodium for iv soln 2 gm .....18
cefuroxime axetil tab 250 mg .............18
cefuroxime axetil tab 500 mg .............18
cefuroxime sodium for inj 1.5 gm .......18
cefuroxime sodium for inj 7.5 gm .......18
cefuroxime sodium for inj 750 mg .......18
cefuroxime sodium for iv soln 1.5 gm ..18
celecoxib cap 100 mg ......................... 1
celecoxib cap 200 mg ......................... 1
celecoxib cap 400 mg ......................... 1
celecoxib cap 50 mg ........................... 1
CELONTIN CAP 300MG ......................49
centamin liq ................................... 118
centavite az tab minerals ................. 118
CENTRUM TAB ULTRA ...................... 118
cephalexin cap 250 mg ..................... 18
cephalexin cap 500 mg ..................... 18
cephalexin for susp 125 mg/5ml ........ 18
cephalexin for susp 250 mg/5ml ........ 18
CERDELGA CAP 84MG ....................... 81
CEREZYME INJ 200UNIT .................... 81
CEREZYME INJ 400UNIT .................... 82
cerovite adv liq formula .................. 118
cerovite jr chw ............................... 118
cerovite tab advanced ..................... 118
certa plus tab ................................ 118
certavite liq antioxid ....................... 118
certavite/ tab antioxid .................... 118
CERVARIX INJ ................................ 109
cetirizine hcl chew tab 10 mg........... 127
cetirizine hcl chew tab 5 mg ............ 127
cetirizine hcl oral soln 1 mg/ml (5
mg/5ml) ....................................... 127
cetirizine hcl tab 10 mg ................... 127
cetirizine hcl tab 5 mg .................... 127
cetirizine-pseudoephedrine tab sr 12hr 5120 mg ......................................... 130
cevimeline hcl cap 30 mg ................ 152
cgh/cold day liq delsym................... 131
CHANTIX PAK 0.5& 1MG ................... 72
CHANTIX PAK 1MG ........................... 72
CHANTIX TAB 0.5MG ........................ 72
CHANTIX TAB 1MG ........................... 72
CHEMET CAP 100MG ......................... 77
cheratussin sol dac ......................... 131
cheratussin syp 100-10/5 ................ 131
chest conges tab 400mg ................. 131
chest conges tab relf dm ................. 131
chewabl vite chw childrns ................ 118
child asa chw 81mg ............................ 2
child asa ls chw 81mg ......................... 2
child chew chw iron ........................ 118
child chew chw vitamins .................. 118
child chew/ chw extra c................... 118
childrens chw /iron ......................... 118
childrens chw vitamins .................... 118
chld ibuprfn dro 40mg/ml .................... 2
chlorhexidine gluconate soln 0.12%.. 152
chloroquine phosphate tab 250 mg ..... 12
chloroquine phosphate tab 500 mg ..... 12
chlorothiazide tab 250 mg ................. 45
chlorothiazide tab 500 mg ................. 45
chlor-phenir tab 4mg ...................... 127
162
chlorpheniramine maleate tab cr 12 mg
.................................................... 127
chlorpromaz inj 25mg/ml ...................62
chlorpromaz inj 50mg/2ml .................62
chlorpromazine hcl tab 10 mg ............62
chlorpromazine hcl tab 100 mg ...........62
chlorpromazine hcl tab 200 mg ...........62
chlorthalidone tab 25 mg ...................45
chlorthalidone tab 50 mg ...................45
cholecalciferol cap 1000 unit ............ 118
cholecalciferol cap 10000 unit........... 118
cholecalciferol cap 50000 unit........... 118
cholecalciferol drops 5000 unit/ml (1000
unit/0.2ml) .................................... 118
cholecalciferol oral liquid 400 unit/ml 118
cholecalciferol tab 1000 unit ............. 118
cholecalciferol tab 5000 unit ............. 118
cholestyramine light powder 4 gm/dose
......................................................39
cholestyramine light powder packets 4
gm ..................................................39
cholestyramine powder 4 gm/dose ......39
cholestyramine powder packets 4 gm ..39
choline fenofibrate cap dr 135 mg (fenofibric acid equiv) ........................39
choline fenofibrate cap dr 45 mg (fenofibric acid equiv) ........................39
CHROMIC CHLORIDE INJ 40 MCG/10ML
(4 MCG/ML) (ELEMENTAL CR)........... 112
ciclopirox gel 0.77% ........................ 144
ciclopirox olamine cream 0.77% (base equiv) ........................................... 144
ciclopirox olamine susp 0.77% (base equiv) ........................................... 144
ciclopirox shampoo 1% .................... 144
cilostazol tab 100 mg ...................... 105
cilostazol tab 50 mg ........................ 105
CILOXAN OIN 0.3% OP .................... 122
CIMZIA KIT .................................... 106
CIMZIA KIT STARTER ...................... 106
CIMZIA PREFL KIT 200MG/ML ........... 106
CINRYZE SOL 500 UNIT ................... 105
CIPRODEX SUS 0.3-0.1% ................ 152
ciprofloxacin 200 mg/100ml in d5w .....19
ciprofloxacin 400 mg/200ml in d5w .... 19
(5%) (5 gm/100ml).......................... 19
(10%) (10 gm/100ml) ...................... 19
ciprofloxacin hcl ophth soln 0.3% ..... 122
...................................................... 19
...................................................... 19
...................................................... 19
...................................................... 19
...................................................... 19
...................................................... 19
ciprofloxacin-ciprofloxacin hcl tab sr 24hr 1000 mg(base eq) ............................ 20
ciprofloxacin-ciprofloxacin hcl tab sr 24hr 500 mg (base eq) ............................ 20
cisplatin inj 100 mg/100ml (1 mg/ml) . 30
cisplatin inj 200 mg/200ml (1 mg/ml) . 30
cisplatin inj 50 mg/50ml (1 mg/ml) .... 30
cit calc/d tab 315-250 ..................... 116
citalopram hydrobromide oral soln 10
mg/5ml ........................................... 56
citalopram hydrobromide tab 10 mg (base equiv) .................................... 56
cladribine iv soln 10 mg/10ml (1 mg/ml)
...................................................... 24
claravis cap 10mg .......................... 142
claravis cap 20mg .......................... 142
claravis cap 30mg .......................... 142
claravis cap 40mg .......................... 142
clarithromycin for susp 125 mg/5ml ... 19
clarithromycin for susp 250 mg/5ml ... 19
clarithromycin tab 250 mg ................ 19
clarithromycin tab 500 mg ................ 19
clarithromycin tab sr 24hr 500 mg ..... 19
CLARITIN CAP 10MG ....................... 127
CLARITIN CHW 5MG ....................... 127
CLARITIN RDT TAB 5MG .................. 127
163
cld head cng tab nighttim ................ 131
clearlax pow .....................................94
clemastine fumarate tab 1.34 mg (1 mg base equiv) .................................... 127
clindamax gel 1% ........................... 142
clindamycin hcl cap 150 mg ................ 8
clindamycin hcl cap 300 mg ................ 8
clindamycin hcl cap 75 mg .................. 8
clindamycin palmitate hcl for soln 75
mg/5ml (base equiv) .......................... 8
clindamycin phosphate gel 1% ......... 142
clindamycin phosphate in d5w iv soln
300 mg/50ml .................................... 8
600 mg/50ml .................................... 9
900 mg/50ml .................................... 9
clindamycin phosphate inj 300 mg/2ml . 9
clindamycin phosphate inj 9 gm/60ml .. 9
clindamycin phosphate iv soln 300
mg/2ml ............................................ 9
mg/4ml ............................................ 9
mg/6ml ............................................ 9
clindamycin phosphate lotion 1% ...... 142
clindamycin phosphate soln 1% ........ 142
clindamycin phosphate swab 1% ...... 142
clindamycin phosphate vaginal cream 2%
.................................................... 101
CLINIMIX INJ 2.75/D5W .................. 112
CLINIMIX INJ 4.25/D10 ................... 112
CLINIMIX INJ 4.25/D20 ................... 112
CLINIMIX INJ 4.25/D25 ................... 112
CLINIMIX INJ 4.25/D5W .................. 112
CLINIMIX INJ 5%/D15W .................. 112
CLINIMIX INJ 5%/D20W .................. 112
CLINIMIX INJ 5%/D25W .................. 112
clobetasol propionate cream 0.05% .. 146
clobetasol propionate emollient base cream 0.05% ................................. 146
clobetasol propionate gel 0.05% ....... 146
clobetasol propionate oint 0.05% ...... 146
clobetasol propionate soln 0.05% ..... 146
clomipramine hcl cap 25 mg ...............56
clomipramine hcl cap 50 mg ...............56
clomipramine hcl cap 75 mg .............. 56
0.125 mg ........................................ 49
clonazepam orally disintegrating tab 0.25
mg ................................................. 49
clonazepam orally disintegrating tab 0.5 mg ................................................. 49
clonazepam orally disintegrating tab 1 mg ................................................. 49
clonazepam orally disintegrating tab 2 mg ................................................. 49
clonazepam tab 0.5 mg ..................... 49
clonazepam tab 1 mg ....................... 49
clonazepam tab 2 mg ....................... 49
clonidine hcl tab 0.1 mg .................... 46
clonidine hcl td patch weekly 0.1 mg/24hr ......................................... 46
clopidogrel bisulfate tab 75 mg (base equiv) ........................................... 106
clorazepate dipotassium tab 15 mg .... 50
clorazepate dipotassium tab 3.75 mg .. 50
clorazepate dipotassium tab 7.5 mg ... 50
clotrimazole cre 1% vag .................. 101
CLOTRIMAZOLE CRE 3 DAY ............. 101
clotrimazole cream 1% ................... 144
clotrimazole soln 1% ...................... 144
clotrimazole troche 10 mg ............... 152
clotrimazole vaginal cream 1% ........ 101
CLOZAPINE ORALLY DISINTEGRATING
TAB 100 MG .................................... 63
TAB 12.5 MG ................................... 62
TAB 150 MG .................................... 63
TAB 200 MG .................................... 63
TAB 25 MG ...................................... 62
clozapine tab 100 mg ....................... 63
clozapine tab 200 mg ....................... 63
clozapine tab 25 mg ......................... 63
clozapine tab 50 mg ......................... 63
164
CO Q-10 PLUS CAP 100-20MG .......... 116
COARTEM TAB 20-120MG ..................12
CODITUSS DM SYP ......................... 131
coenzyme q10 cap 100 mg .............. 116
coenzyme q10 cap 200 mg .............. 116
coenzyme q10 cap 30 mg ................ 116
colchicine w/ probenecid tab 0.5-500 mg
....................................................... 1
COLCRYS TAB 0.6MG.......................... 1
cold & sinus tab relief ...................... 131
cold head tab cong dt ...................... 131
cold head tab congesti ..................... 131
cold multi-s tab nighttim .................. 131
cold mult-sy tab daytime ................. 131
cold mult-sy tab sevr day................. 131
cold relief tab multi-s ...................... 131
cold relief tab multi-sy ..................... 131
cold/allergy elx children ................... 131
cold/allergy tab 4-10mg .................. 131
cold/cough elx child ........................ 131
cold/cough elx dm child ................... 131
colestipol hcl granule packets 5 gm .....39
colestipol hcl granules 5 gm ...............39
colestipol hcl tab 1 gm .......................39
colistimethate sodium for inj 150 mg .... 9
COMBIGAN SOL 0.2/0.5% ................ 124
COMBIVENT AER 20-100.................. 126
COMETRIQ KIT 100MG ......................28
COMETRIQ KIT 140MG ......................28
COMETRIQ KIT 60MG ........................28
comp allergy cap 25mg ................... 127
comp allergy tab 25mg .................... 127
COMPLERA TAB ................................14
complete kit lice ............................. 151
complete tab .................................. 118
compro sup 25mg .............................90
COMVAX INJ................................... 109
CONDOMS MIS LUBRICAT ................ 149
CONEX SOL CLD/ALRG .................... 131
CONEX TAB 2-60MG ........................ 131
constulose sol 10gm/15 .....................94
COPAXONE INJ 40MG/ML ...................71
coricidin liq hbp .............................. 131
cormax scalp sol 0.05% ................... 146
cortisone acetate tab 25 mg ...............83
COTELLIC TAB 20MG .........................28
cough & sore liq thrt day.................. 131
cough cont liq dm max .................... 131
cough dm sus 30mg/5ml ................. 131
cough syp 100/5ml ......................... 131
coughtab tab 200mg ...................... 131
COUMADIN TAB 10MG .................... 102
COUMADIN TAB 1MG ...................... 102
COUMADIN TAB 2.5MG ................... 102
COUMADIN TAB 2MG ...................... 102
COUMADIN TAB 3MG ...................... 102
COUMADIN TAB 4MG ...................... 102
COUMADIN TAB 5MG ...................... 102
COUMADIN TAB 6MG ...................... 102
COUMADIN TAB 7.5MG ................... 102
CREON CAP 12000UNT...................... 99
CREON CAP 24000UNT...................... 99
CREON CAP 3000UNIT ...................... 99
CREON CAP 36000UNT...................... 99
CREON CAP 6000UNIT ...................... 99
CRESTOR TAB 10MG ......................... 38
CRESTOR TAB 20MG ......................... 38
CRESTOR TAB 40MG ......................... 38
CRESTOR TAB 5MG .......................... 38
CRIXIVAN CAP 200MG ...................... 12
CRIXIVAN CAP 400MG ...................... 12
cromolyn sodium nasal aerosol soln 5.2 mg/act (4%) ................................. 139
cromolyn sodium ophth soln 4% ...... 124
cromolyn sodium oral conc 100 mg/5ml
...................................................... 98
cromolyn sodium soln nebu 20 mg/2ml
.................................................... 139
cryselle-28 tab 28 tabs ..................... 78
CUBICIN SOL 500MG .......................... 9
CUPRIC CHLORIDE INJ 0.4 MG/ML ... 112
CUVPOSA SOL 1MG/5ML ................... 92
cyanocobalamin inj 1000 mcg/ml ..... 118
cyclafem tab 1/35 ............................ 78
cyclafem tab 7/7/7 ........................... 78
CYCLOPHOSPH CAP 25MG ................. 23
CYCLOPHOSPH CAP 50MG ................. 23
cyclophosphamide for inj 1 gm .......... 23
cyclophosphamide for inj 2 gm .......... 23
cyclophosphamide for inj 500 mg ....... 23
cycloserine cap 250 mg..................... 14
cyclosporine cap 100 mg ................. 108
cyclosporine cap 25 mg ................... 108
cyclosporine iv soln 50 mg/ml .......... 108
cyclosporine modified cap 100 mg .... 108
cyclosporine modified cap 25 mg ...... 108
165
cyclosporine modified cap 50 mg ...... 108
cyclosporine modified oral soln 100
mg/ml ........................................... 108
CYSTADANE POW..............................82
CYSTAGON CAP 150MG .....................82
CYSTAGON CAP 50MG .......................82
cytarabine inj 20 mg/ml ....................24
CYTO-Q MAX LIQ 100MG/ML ............ 116
D
D10W/NACL INJ 0.2% ..................... 113
d3 cap 1000unit ............................. 118
d3 super str cap 2000unit ................ 118
D5W/LYTES INJ #48 ....................... 113
D5W/NACL INJ 0.3% ....................... 113
dacarbazine for inj 100 mg ................23
dacarbazine for inj 200 mg ................23
daily multi tab vit/min ..................... 119
daily multi tab vitamins ................... 119
daily tab vitamin ............................. 119
daily vit tab +iron ........................... 119
daily vit tab +mineral ...................... 119
daily vite tab .................................. 119
daily-vite/ tab iron .......................... 119
DAKLINZA TAB 30MG ........................15
DAKLINZA TAB 60MG ........................15
DAKLINZA TAB 90MG ........................15
DALIRESP TAB 500MCG ................... 140
dallergy dro 1-2.5mg ...................... 131
danazol cap 100 mg ..........................81
danazol cap 200 mg ..........................81
danazol cap 50 mg ............................81
dantrolene sodium cap 100 mg ...........71
dantrolene sodium cap 25 mg ............71
dantrolene sodium cap 50 mg ............71
dapsone tab 100 mg .......................... 9
dapsone tab 25 mg ............................ 9
DAPTACEL INJ ................................ 109
DARAPRIM TAB 25MG ......................... 9
daunorubicin hcl inj 5 mg/ml (base equiv) .............................................23
day cold/flu cap 10-5-325 ................ 131
day time liq cold/flu ........................ 131
day time liq cough .......................... 131
dayhist alrg tab 12 hour .................. 127
dayquil sev liq cold/flu ..................... 131
dayquil sev tab cold/flu .................... 131
deblitane tab 0.35mg ........................78
decongestant sol 1% ....................... 131
decongestant tab 120mg er ............. 131
deep sea spr 0.65% ....................... 140
DELESTROGEN INJ 10MG/ML ............. 82
delsym cough liq congs dm.............. 131
delsym night liq cgh+cld ................. 131
delyla tab 0.1-0.02 ........................... 78
DELZICOL CAP 400MG ...................... 93
DEMSER CAP 250MG ........................ 46
DEPEN TITRA TAB 250MG ................. 77
DEPO-PROVERA INJ 400/ML .............. 27
dermacerin cre .............................. 149
dermamed oin ............................... 149
dermaphor oin ............................... 149
dermazinc sha 2% .......................... 149
DESCOVY TAB 200/25 ...................... 14
desenex cre 1% ............................. 144
desenex shak pow 2% .................... 144
desipramine hcl tab 10 mg ................ 56
desipramine hcl tab 100 mg .............. 57
desipramine hcl tab 150 mg .............. 57
desmopressin acetate inj 4 mcg/ml .... 88
DESMOPRESSIN ACETATE NASAL SOLN
0.01% (REFRIGERATED) ................... 88
0.01% ............................................ 88
0.01% (refrigerated) ........................ 88
desmopressin acetate tab 0.1 mg ....... 88
desmopressin acetate tab 0.2 mg ....... 88
desogest-eth estrad & eth estrad tab
0.15-0.02/0.01 mg(21/5).................. 78
desogestrel & ethinyl estradiol tab 0.15
mg-30 mcg ..................................... 78
DESONIDE CREAM 0.05% ............... 146
desonide lotion 0.05% .................... 146
desonide oint 0.05%....................... 146
desoximetasone cream 0.05% ......... 146
desoximetasone cream 0.25% ......... 146
desoximetasone gel 0.05%.............. 147
DESOXIMETASONE OINT 0.05% ...... 147
desoximetasone oint 0.25% ............ 147
dexamethason con 1mg/ml ............... 83
dexamethasone elixir 0.5 mg/5ml ...... 83
dexamethasone sod phosphate
preservative free inj 10 mg/ml ........... 83
166
dexamethasone sodium phosphate inj 10
mg/ml .............................................83
dexamethasone sodium phosphate inj
100 mg/10ml ...................................83
dexamethasone sodium phosphate inj
120 mg/30ml ...................................83
dexamethasone sodium phosphate inj 20
mg/5ml ...........................................83
dexamethasone sodium phosphate inj 4 mg/ml .............................................83
dexamethasone sodium phosphate ophth
soln 0.1% ...................................... 123
dexamethasone soln 0.5 mg/5ml ........83
dexamethasone tab 0.5 mg ................83
dexamethasone tab 0.75 mg ..............83
dexamethasone tab 1 mg ..................83
dexamethasone tab 1.5 mg ................83
DEXFERRUM INJ 50MG/ML ............... 104
DEXILANT CAP 30MG DR ...................99
DEXILANT CAP 60MG DR ...................99
dexrazoxane for inj 250 mg ...............31
dextromethorphan polistirex extended
release susp 30 mg/5ml .................. 132
dextromethorphan-guaifenesin liquid 10100 mg/5ml ................................... 132
dextromethorphan-guaifenesin syrup 10100 mg/5ml ................................... 132
0.45% ........................................... 113
DEXTROSE 2.5% W/ SODIUM CHLORIDE 0.45% ........................................... 113
DEXTROSE 5% IN LACTATED RINGERS
.................................................... 113
0.2% ............................................. 113
0.225% ......................................... 113
0.33% ........................................... 113
0.45% ........................................... 113
0.9% ............................................. 113
DEXTROSE INJ 10% ........................ 113
DEXTROSE INJ 5% .......................... 113
DEXTROSE INJ 50% ....................... 113
DEXTROSE INJ 70% ....................... 113
DHS SAL SHA 3% .......................... 149
diabetic tus liq 100/5ml .................. 132
diabetic tus liq dm .......................... 132
diabetic tus liq max st ..................... 132
dialyvite tab 800 ............................ 119
diazepam con 5mg/ml ...................... 50
diazepam inj 5 mg/ml ....................... 50
diazepam oral soln 1 mg/ml .............. 50
DIAZEPAM RECTAL GEL DELIVERY
SYSTEM 10 MG ................................ 50
SYSTEM 2.5 MG ............................... 50
SYSTEM 20 MG ................................ 50
diazepam tab 10 mg ......................... 50
diazepam tab 2 mg........................... 50
diazepam tab 5 mg........................... 50
diclofenac potassium tab 50 mg ........... 2
diclofenac sodium gel 1% ................ 149
diclofenac sodium ophth soln 0.1% .. 123
mg ................................................... 2
mg ................................................... 2
mg ................................................... 2
diclofenac sodium tab sr 24hr 100 mg .. 2
dicloxacillin sodium cap 250 mg ......... 21
dicloxacillin sodium cap 500 mg ......... 21
dicyclomine hcl cap 10 mg ................ 92
dicyclomine hcl oral soln 10 mg/5ml ... 92
dicyclomine hcl tab 20 mg ................. 92
didanosine delayed release capsule 125
mg ................................................. 12
mg ................................................. 12
mg ................................................. 12
mg ................................................. 12
DIFICID TAB 200MG ......................... 19
diflorasone diacetate cream 0.05%... 147
diflorasone diacetate oint 0.05% ...... 147
diflunisal tab 500 mg .......................... 2
digitek tab 0.125mg ......................... 44
digitek tab 0.25mg ........................... 44
167
digoxin inj 0.25 mg/ml ......................44
DIGOXIN ORAL SOLN 0.05 MG/ML ......44
digoxin tab 125 mcg (0.125 mg).........44
digoxin tab 250 mcg (0.25 mg) ..........44
dihydroergotamine mesylate inj 1 mg/ml
......................................................69
dilantin cap 100mg ...........................50
dilantin cap 30mg .............................50
dilantin chw 50mg ............................50
DILANTIN-125 SUS 125/5ML ..............50
diltiazem hcl cap sr 12hr 120 mg ........42
diltiazem hcl cap sr 12hr 60 mg ..........42
diltiazem hcl cap sr 12hr 90 mg ..........42
diltiazem hcl coated beads cap sr 24hr 120 mg ...........................................42
sr 24hr 120 mg ................................42
sr 24hr 180 mg ................................42
sr 24hr 240 mg ................................42
sr 24hr 300 mg ................................42
sr 24hr 360 mg ................................42
sr 24hr 420 mg ................................42
mg/ml) ............................................43
mg/ml) ............................................42
mg/ml) ............................................43
diltiazem hcl tab 120 mg ...................43
diltiazem hcl tab 30 mg .....................43
dimaphen dm elx cold/cgh .............. 132
dimaphen elx children ..................... 132
dimenhydrinate tab 50 mg ................ 90
dimetapp liq nighttim...................... 132
DIMETAPP SYP CGH/COLD ............... 132
diocto liq 50mg/5ml ......................... 94
diocto syp 60/15ml........................... 94
DIP/TET PED INJ 25-5LFU ............... 109
DIPENTUM CAP 250MG ..................... 93
diphenhist cap 25mg ...................... 127
diphenhist liq 12.5/5ml ................... 127
diphenhist tab 25mg ....................... 127
diphenhydramine hcl cap 25 mg ....... 127
diphenhydramine hcl cap 50 mg ....... 127
diphenhydramine hcl inj 50 mg/ml ... 128
diphenhydramine hcl tab 25 mg ....... 128
diphenhydramine-zinc acetate cream 20.1% ............................................ 149
diphenoxylate w/ atropine liq 2.5-0.025
mg/5ml ........................................... 98
diphenoxylate w/ atropine tab 2.5-0.025
mg ................................................. 98
disopyramide phosphate cap 100 mg .. 37
disopyramide phosphate cap 150 mg .. 37
disulfiram tab 250 mg ....................... 72
disulfiram tab 500 mg ....................... 72
divalproex sodium cap delayed release sprinkle 125 mg ............................... 50
divalproex sodium tab delayed release 125 mg ........................................... 50
divalproex sodium tab sr 24 hr 250 mg50
divalproex sodium tab sr 24 hr 500 mg50
DOCETAXEL FOR INJ CONC 20 MG/ML 25
DOCETAXEL FOR INJ CONC 80 MG/4ML
(20 MG/ML) ..................................... 25
docetaxel inj 140/7ml ....................... 25
DOCETAXEL INJ 160/16ML ................ 25
DOCETAXEL INJ 200MG/20 ................ 25
DOCETAXEL INJ 20MG/2ML ............... 25
DOCETAXEL INJ 80MG/8ML ............... 25
docqlace cap 100mg ......................... 94
doc-q-lax tab 8.6-50mg .................... 94
docu liq 50mg/5ml ........................... 94
docusate cal cap 240mg .................... 94
168
docusate calcium cap 240 mg .............94
docusate sod liq 50mg/5ml ................94
docusate sodium cap 100 mg .............94
docusate sodium cap 250 mg .............94
docusate sodium tab 100 mg .............94
docusil cap 100mg ............................94
docusol mini ene ...............................94
dofetilide cap 125 mcg (0.125 mg) .....37
dofetilide cap 250 mcg (0.25 mg) .......37
dofetilide cap 500 mcg (0.5 mg) .........37
dok cap 100mg .................................94
dok cap 250mg .................................94
dok plus tab 8.6-50mg ......................94
dok tab 100mg .................................94
donepezil hydrochloride orally disintegrating tab 10 mg ....................54
donepezil hydrochloride orally disintegrating tab 5 mg .....................54
donepezil hydrochloride tab 10 mg ......54
donepezil hydrochloride tab 23 mg ......54
donepezil hydrochloride tab 5 mg .......54
dorzolamide hcl ophth soln 2% ......... 124
dorzolamide hcl-timolol maleate ophth
soln 22.3-6.8 mg/ml ....................... 124
double antib oin .............................. 143
doxazosin mesylate tab 1 mg .............34
doxepin hcl cap 10 mg.......................57
doxepin hcl cap 100 mg .....................57
doxepin hcl cap 150 mg .....................57
doxepin hcl conc 10 mg/ml ................57
DOXEPIN HCL CREAM 5% ................ 145
doxorubicin hcl for inj 50 mg ..............23
doxorubicin hcl inj 2 mg/ml ................23
doxorubicin hcl liposomal inj (for iv infusion) 2 mg/ml .............................23
doxy 100 inj 100mg ..........................22
doxycycline hyclate cap 100 mg .........22
doxycycline hyclate cap 50 mg ...........22
doxycycline hyclate for inj 100 mg ......22
doxycycline hyclate tab 100 mg ..........22
doxycycline hyclate tab 20 mg ............22
doxycycline monohydrate cap 100 mg .22
doxycycline monohydrate cap 50 mg .. 22
doxycycline monohydrate tab 100 mg . 22
doxycycline monohydrate tab 150 mg . 22
doxycycline monohydrate tab 50 mg .. 22
doxycycline monohydrate tab 75 mg .. 22
driminate tab 50mg .......................... 90
dristan cold tab .............................. 132
dronabinol cap 10 mg ....................... 90
dronabinol cap 2.5 mg ...................... 90
dronabinol cap 5 mg ......................... 90
drospirenone-ethinyl estradiol tab 3-0.02
mg ................................................. 78
DROSPIRENONE-ETHINYL ESTRADIOL
TAB 3-0.02 MG ................................ 78
drospirenone-ethinyl estradiol tab 3-0.03
mg ................................................. 78
DROSPIRENONE-ETHINYL ESTRADIOL
TAB 3-0.03 MG ................................ 78
DROXIA CAP 200MG ......................... 30
DROXIA CAP 300MG ......................... 30
DROXIA CAP 400MG ......................... 30
ducodyl tab 5mg ec .......................... 94
duloxetine hcl enteric coated pellets cap
20 mg............................................. 57
30 mg............................................. 57
60 mg............................................. 57
DUOFER TAB 28MG ........................ 104
DURAMORPH INJ 0.5MG/ML ................. 4
DURAMORPH INJ 1MG/ML ................... 4
DUREZOL EMU 0.05% ..................... 123
dutasteride cap 0.5 mg ................... 100
dutasteride-tamsulosin hcl cap 0.5-0.4
mg ............................................... 100
d-vita liq 400unit ........................... 119
E
e.e.s. 400 tab 400mg ....................... 19
ear drops sol 6.5% ot ..................... 152
ear wax remv dro 6.5% ot .............. 152
ear wax remv sol 6.5% ot ............... 152
earwax remv sol 6.5% ot ................ 152
econazole nitrate cream 1% ............ 144
ecpirin tab 325mg ec .......................... 2
ed a-hist dm liq.............................. 132
ed a-hist tab 2.5-60mg ................... 132
ed bron gp liq ................................ 132
ED CHLORPED DRO D ..................... 132
169
ED CHLORPED LIQ 2MG/ML .............. 128
ed chlorped syp jr ........................... 128
ed-chlortan tab 4mg........................ 128
EDURANT TAB 25MG .........................12
EFFIENT TAB 10MG ......................... 106
EFFIENT TAB 5MG ........................... 106
ELIDEL CRE 1% .............................. 149
ELIQUIS TAB 2.5MG ........................ 102
ELIQUIS TAB 5MG ........................... 102
ELITEK INJ 1.5MG .............................31
ELITEK INJ 7.5MG .............................31
elixophyllin elx 80/15ml ................... 142
ELLA TAB 30MG ................................78
ELMIRON CAP 100MG ...................... 101
EMCYT CAP 140MG ...........................23
EMEND CAP 125MG ...........................90
EMEND CAP 40MG .............................90
EMEND CAP 80MG .............................90
EMEND PAK 80 & 125 ........................90
EMEND SUS 125MG...........................91
emoquette tab ..................................78
EMSAM DIS 12MG/24H ......................57
EMSAM DIS 6MG/24HR ......................57
EMSAM DIS 9MG/24HR ......................57
EMTRIVA CAP 200MG ........................12
EMTRIVA SOL 10MG/ML .....................12
emverm chw 100mg .......................... 9
enalapril maleate & hydrochlorothiazide
tab 10-25 mg ...................................32
enalapril maleate & hydrochlorothiazide
tab 5-12.5 mg ..................................32
enalapril maleate tab 10 mg ...............33
enalapril maleate tab 2.5 mg ..............33
enalapril maleate tab 20 mg ...............33
enalapril maleate tab 5 mg ................33
endacof-dm liq 2.5-1-5 .................... 132
endocet tab 10-325mg ....................... 4
endocet tab 5-325mg ......................... 4
endocet tab 7.5-325 ........................... 4
enemeez mini ene .............................94
enemeez plus ene 20-283 ..................94
ENFAMIL MIS EXPECTA .................... 119
ENFAMIL SOL ENFALYTE .................. 116
ENGERIX-B INJ 10/0.5ML................. 109
ENGERIX-B INJ 20MCG/ML ............... 109
enoxaparin sodium inj 100 mg/ml ..... 102
enoxaparin sodium inj 120 mg/0.8ml 102
enoxaparin sodium inj 150 mg/ml ..... 102
enoxaparin sodium inj 30 mg/0.3ml . 102
enoxaparin sodium inj 300 mg/3ml .. 102
enpresse-28 tab ............................... 78
ENTACAPONE TAB 200 MG ................ 61
entecavir tab 0.5 mg ........................ 15
entecavir tab 1 mg ........................... 15
ENTRESTO TAB 24-26MG .................. 35
ENTRESTO TAB 49-51MG .................. 35
ENTRESTO TAB 97-103MG ................ 35
enulose sol 10gm/15 ........................ 94
EPIPEN 2-PAK INJ 0.3MG ................ 140
EPIPEN-JR INJ 2-PAK ...................... 140
epirubicin hcl iv soln 200 mg/100ml (2
mg/ml) ........................................... 24
epirubicin hcl iv soln 50 mg/25ml (2
mg/ml) ........................................... 24
epitol tab 200mg .............................. 50
EPIVIR HBV SOL 5MG/ML .................. 15
eplerenone tab 25 mg ....................... 34
eplerenone tab 50 mg ....................... 34
EPZICOM TAB 600-300 ..................... 14
ergocalciferol cap 50000 unit ........... 119
ergocalciferol soln 8000 unit/ml ....... 119
ERIVEDGE CAP 150MG ...................... 26
errin tab 0.35mg .............................. 78
ery-tab tab 250mg ec ....................... 19
ery-tab tab 333mg ec ....................... 19
ery-tab tab 500mg ec ....................... 19
erythrocin inj 500mg ........................ 19
erythrocin tab 250mg ....................... 19
erythromycin ethylsuccinate tab 400 mg
...................................................... 19
erythromycin gel 2% ...................... 142
erythromycin ophth oint 5 mg/gm .... 122
erythromycin pads 2% .................... 142
erythromycin soln 2% ..................... 142
erythromycin tab 250 mg .................. 19
erythromycin tab 500 mg .................. 19
erythromycin w/ delayed release particles cap 250 mg ........................ 19
ESBRIET CAP 267MG ...................... 140
escitalopram oxalate soln 5 mg/5ml
(base equiv) .................................... 57
escitalopram oxalate tab 10 mg (base equiv) ............................................. 57
170
escitalopram oxalate tab 20 mg (base equiv) .............................................57
escitalopram oxalate tab 5 mg (base equiv) .............................................57
esomeprazole magnesium cap delayed release 20 mg (base eq) ....................99
esomeprazole magnesium cap delayed release 40 mg (base eq) ....................99
esomeprazole sodium for intravenous soln 20 mg (base equiv) .................. 100
esomeprazole sodium for intravenous soln 40 mg (base equiv) .................. 100
essentl one tab daily ....................... 119
estrace vag cre 0.1mg/gm .................82
estradiol tab 0.5 mg ..........................82
estradiol tab 1 mg .............................82
estradiol tab 2 mg .............................82
......................................................83
estradiol td patch weekly 0.0375
mg/24hr (37.5 mcg/24hr) ..................83
......................................................82
......................................................83
......................................................83
estradiol td patch weekly 0.1 mg/24hr 82
estradiol valerate im in oil 20 mg/ml ...83
estradiol valerate im in oil 40 mg/ml ...83
ethambutol hcl tab 100 mg ................14
ethambutol hcl tab 400 mg ................15
ethosuximide cap 250 mg ..................50
ethosuximide soln 250 mg/5ml ...........51
etodolac cap 200 mg .......................... 2
etodolac cap 300 mg .......................... 2
etodolac tab 400 mg .......................... 2
etodolac tab 500 mg .......................... 2
etodolac tab sr 24hr 400 mg ............... 2
etoposide inj 500 mg/25ml (20 mg/ml)
......................................................31
EURAX CRE 10%............................. 151
EURAX LOT 10% ............................. 151
EVOTAZ TAB 300-150........................14
exefen-ir tab 60-400mg ................... 132
EXELON DIS 13.3/24 .........................55
EXELON DIS 4.6MG/24 ..................... 54
EXELON DIS 9.5MG/24 ..................... 54
exemestane tab 25 mg ..................... 27
EXJADE TAB 125MG.......................... 77
EXJADE TAB 250MG.......................... 77
EXJADE TAB 500MG.......................... 77
extra action syp 100-10/5 ............... 132
eye drops sol a/r ............................ 124
eye itch rel dro 0.025%op ............... 124
EZFE FORTE CAP ............................ 119
F
FABRAZYME INJ 35MG ...................... 82
FABRAZYME INJ 5MG ........................ 82
fallback tab 1.5mg ........................... 78
falmina tab ...................................... 78
famciclovir tab 125 mg ..................... 15
famotidine for susp 40 mg/5ml .......... 93
famotidine in nacl 0.9% iv soln 20
mg/50ml ......................................... 93
famotidine inj 20 mg/2ml .................. 93
famotidine inj 200 mg/20ml .............. 93
famotidine inj 40 mg/4ml .................. 93
famotidine tab 10 mg ....................... 93
famotidine tab 10mg ........................ 93
FANAPT PAK .................................... 63
FANAPT TAB 10MG ........................... 63
FANAPT TAB 12MG ........................... 63
FANAPT TAB 1MG ............................. 63
FANAPT TAB 2MG ............................. 63
FANAPT TAB 4MG ............................. 63
FANAPT TAB 6MG ............................. 63
FANAPT TAB 8MG ............................. 63
FANTASY LUBR MIS COLORS ........... 149
FANTASY LUBR MIS SPERMICI ......... 149
FANTASY MIS LUBRICAT ................. 149
FARESTON TAB 60MG ....................... 27
FARXIGA TAB 10MG ......................... 75
FARXIGA TAB 5MG ........................... 75
FARYDAK CAP 10MG ......................... 26
FARYDAK CAP 15MG ......................... 26
FARYDAK CAP 20MG ......................... 26
FASLODEX INJ 250MG ...................... 27
FAT EMULSION IV SOLN 20% .......... 112
FAZACLO TAB 150 ODT ..................... 63
171
FAZACLO TAB 200 ODT .....................63
felbamate susp 600 mg/5ml ...............51
felbamate tab 400 mg .......................51
felbamate tab 600 mg .......................51
felodipine tab sr 24hr 10 mg ..............43
felodipine tab sr 24hr 2.5 mg .............43
felodipine tab sr 24hr 5 mg ................43
fenofibrate micronized cap 134 mg .....39
fenofibrate micronized cap 200 mg .....39
fenofibrate micronized cap 67 mg .......39
fenofibrate tab 145 mg ......................39
fenofibrate tab 160 mg ......................39
fenofibrate tab 48 mg ........................39
fenofibrate tab 54 mg ........................39
fentanyl citrate lozenge on a handle 1200
mcg ................................................. 4
mcg ................................................. 4
mcg ................................................. 4
mcg ................................................. 4
mcg ................................................. 4
mcg ................................................. 4
fentanyl td patch 72hr 100 mcg/hr ....... 5
fentanyl td patch 72hr 12 mcg/hr ........ 4
FENTORA TAB 100MCG ....................... 5
FENTORA TAB 200MCG ....................... 5
FENTORA TAB 400MCG ....................... 5
FENTORA TAB 600MCG ....................... 5
FENTORA TAB 800MCG ....................... 5
FERAHEME INJ 510/17ML ................. 104
ferate tab 27mg.............................. 104
fer-iron dro 15mg/ml ...................... 104
ferosul elx 220/5ml ......................... 104
ferrex 150 cap 150mg ..................... 104
FERRIPROX SOL 100MG/ML ................77
FERRIPROX TAB 500MG .....................77
FERRLECIT INJ 12.5MG/M ................ 104
ferrous gluconate tab 240 mg (27 mg elemental fe) .................................. 104
ferrous gluconate tab 324 mg (37.5 mg elemental iron) ............................... 104
FERROUS SUL LIQ 220/5ML ............. 104
FERROUS SULF TAB 140MG ............. 104
ferrous sulfate elixir 220 mg/5ml (44
mg/5ml elemental fe) ..................... 104
ferrous sulfate soln 75 mg/ml (15 mg/ml
elemental fe) ................................. 105
ferrous sulfate tab 325 mg (65 mg elemental fe) ................................. 105
FETZIMA CAP 120MG ........................ 58
FETZIMA CAP 20MG .......................... 57
FETZIMA CAP 40MG .......................... 58
FETZIMA CAP 80MG .......................... 58
FETZIMA CAP TITRATIO .................... 58
fever reduce sup 120mg ..................... 2
FEVERALL INF SUP 80MG .................... 2
FEVERALL SUP 120MG ........................ 2
FEVERALL SUP 325MG ........................ 2
FEVERALL SUP 650MG ........................ 2
fexofenadine hcl tab 180 mg ........... 128
fexofenadine hcl tab 60 mg ............. 128
fexofenadine tab 180mg ................. 128
fexofenadine tab 60mg ................... 128
fiber laxatv tab 625mg ...................... 94
fiber laxtiv cap 0.52gm ..................... 94
fiber therap pow 58.6% .................... 94
fiber therap tab 500mg ..................... 94
fiber-caps tab 625mg ....................... 94
fiber-lax tab 625mg .......................... 94
finasteride tab 5 mg ....................... 100
FIRAZYR INJ 30MG/3ML .................. 105
FLEBOGAMMA INJ 10/200ML ........... 107
FLEBOGAMMA INJ 20/400ML ........... 107
FLEBOGAMMA INJ 5% ..................... 106
FLEBOGAMMA INJ DIF 10% ............. 107
FLEBOGAMMA INJ DIF 5% ............... 107
flecainide acetate tab 100 mg ............ 37
flecainide acetate tab 150 mg ............ 37
flecainide acetate tab 50 mg .............. 37
FLEET BISACO ENE 10/30ML ............. 95
fleet laxati tab 5mg ec ...................... 95
FLOVENT DISK AER 100MCG ........... 141
FLOVENT DISK AER 250MCG ........... 141
FLOVENT DISK AER 50MCG ............. 141
FLOVENT HFA AER 110MCG ............. 141
FLOVENT HFA AER 220MCG ............. 141
FLOVENT HFA AER 44MCG ............... 141
fluconazole for susp 10 mg/ml ........... 11
fluconazole for susp 40 mg/ml ........... 11
172
fluconazole in dextrose inj 200
mg/100ml ........................................11
fluconazole in dextrose inj 400
mg/200ml ........................................11
fluconazole in nacl 0.9% inj 200
mg/100ml ........................................11
fluconazole in nacl 0.9% inj 400
mg/200ml ........................................11
fluconazole tab 100 mg .....................11
fluconazole tab 50 mg .......................11
fluconazole/ inj nacl 100 ....................11
flucytosine cap 250 mg ......................11
flucytosine cap 500 mg ......................11
fludarabine phosphate for inj 50 mg ....24
fludarabine phosphate inj 25 mg/ml ....24
fludrocortisone acetate tab 0.1 mg ......84
flunisolide nasal soln 25 mcg/act
(0.025%)....................................... 140
fluocin acet oil body ........................ 147
fluocin acet oil scalp ........................ 147
fluocinolone acetonide (otic) oil 0.01%
.................................................... 152
fluocinolone acetonide cream 0.01% . 147
fluocinolone acetonide cream 0.025% 147
fluocinolone acetonide oint 0.025% ... 147
fluocinolone acetonide soln 0.01% .... 147
fluocinonide cream 0.05%................ 147
fluocinonide emulsified base cream
0.05% ........................................... 147
fluocinonide gel 0.05% .................... 147
fluocinonide oint 0.05% ................... 147
fluocinonide soln 0.05%................... 147
FLUOROMETHOLONE OPHTH SUSP 0.1%
.................................................... 123
fluorouracil cream 5% ..................... 149
fluorouracil inj 1 gm/20ml (50 mg/ml).24
fluorouracil inj 2.5 gm/50ml (50 mg/ml)
......................................................24
......................................................24
fluorouracil inj 500 mg/10ml (50 mg/ml)
......................................................24
fluorouracil soln 2% ........................ 149
fluorouracil soln 5% ........................ 149
fluoxetine hcl cap 10 mg ....................58
fluoxetine hcl cap 20 mg ....................58
fluoxetine hcl cap 40 mg ................... 58
fluoxetine hcl solution 20 mg/5ml ...... 58
fluoxetine hcl tab 10 mg ................... 58
fluoxetine hcl tab 20 mg ................... 58
fluphenazine decanoate inj 25 mg/ml . 63
fluphenazine hcl elixir 2.5 mg/5ml ...... 63
fluphenazine hcl inj 2.5 mg/ml ........... 63
fluphenazine hcl oral conc 5 mg/ml .... 63
fluphenazine hcl tab 1 mg ................. 63
fluphenazine hcl tab 10 mg ............... 63
fluphenazine hcl tab 2.5 mg .............. 63
fluphenazine hcl tab 5 mg ................. 63
flurbiprofen sodium ophth soln 0.03%
.................................................... 123
flurbiprofen tab 100 mg ...................... 2
flurbiprofen tab 50 mg ........................ 2
flutamide cap 125 mg ....................... 27
fluticasone propionate cream 0.05% . 147
fluticasone propionate nasal susp 50
mcg/act ........................................ 140
fluticasone propionate oint 0.005% .. 147
fluvoxamine maleate tab 100 mg ....... 48
fluvoxamine maleate tab 25 mg ......... 48
fluvoxamine maleate tab 50 mg ......... 48
foam antacid chw 80-20mg ............... 89
foam antacid sus .............................. 89
folic acid inj 5 mg/ml ...................... 119
folic acid tab 1 mg .......................... 119
folic acid tab 800 mcg ..................... 119
FOLITAB 500 TAB ........................... 105
fondaparinux sodium subcutaneous inj
10 mg/0.8ml ................................. 103
2.5 mg/0.5ml ................................ 102
fondaparinux sodium subcutaneous inj 5
mg/0.4ml ...................................... 102
7.5 mg/0.6ml ................................ 103
formula em sol................................. 91
FORTEO SOL 600/2.4 ....................... 86
FORTICAL SPR 200/ACT .................... 85
fosinopril sodium & hydrochlorothiazide
tab 10-12.5 mg................................ 32
fosinopril sodium & hydrochlorothiazide
tab 20-12.5 mg................................ 32
fosinopril sodium tab 10 mg .............. 33
173
FREAMINE HBC INJ 6.9% ................. 112
FREAMINE III INJ 10% .................... 112
FRESHKOTE SOL 2.7-2% ................. 125
FUNGOID TINC SOL 2% ................... 144
fungoid-d cre 1% ............................ 144
furosemide inj 10 mg/ml....................45
FUROSEMIDE INJ 10 MG/ML ...............45
furosemide oral soln 10 mg/ml ...........45
furosemide oral soln 8 mg/ml .............45
furosemide tab 20 mg .......................45
FUSILEV INJ 50MG ............................31
FUZEON INJ 90MG ............................12
FYCOMPA SUS 0.5MG/ML ...................51
FYCOMPA TAB 10MG .........................51
FYCOMPA TAB 12MG .........................51
FYCOMPA TAB 2MG ...........................51
FYCOMPA TAB 4MG ...........................51
FYCOMPA TAB 6MG ...........................51
FYCOMPA TAB 8MG ...........................51
G
gabapentin cap 100 mg .....................51
gabapentin oral soln 250 mg/5ml........51
gabapentin tab 600 mg .....................51
gabapentin tab 800 mg .....................51
GABITRIL TAB 12MG .........................51
GABITRIL TAB 16MG .........................51
galantamine hydrobromide cap sr 24hr 16 mg .............................................55
galantamine hydrobromide cap sr 24hr 24 mg .............................................55
mg ..................................................55
galantamine hydrobromide oral soln 4 mg/ml .............................................55
galantamine hydrobromide tab 12 mg .55
galantamine hydrobromide tab 4 mg ...55
galantamine hydrobromide tab 8 mg ...55
GAMASTAN S/D INJ......................... 107
GAMMAGARD INJ 10GM/100 ............ 107
GAMMAGARD INJ 1GM/10ML ............ 107
GAMMAGARD INJ 2.5GM/25 ............. 107
GAMMAGARD INJ 20GM/200 ............ 107
GAMMAGARD INJ 30GM/300 ............ 107
GAMMAGARD INJ 5GM/50ML ............ 107
GAMMAGARD SD INJ 10GM HU ........ 107
GAMMAGARD SD INJ 2.5GM HU ....... 107
GAMMAGARD SD INJ 5GM HU .......... 107
GAMMAKED INJ 10GM/100 .............. 107
GAMMAKED INJ 1GM/10ML .............. 107
GAMMAKED INJ 2.5GM/25 ............... 107
GAMMAKED INJ 20GM/200 .............. 107
GAMMAKED INJ 5GM/50ML .............. 107
GAMMAPLEX INJ 10GM.................... 107
GAMMAPLEX INJ 2.5GM................... 107
GAMMAPLEX INJ 5GM ..................... 107
GAMUNEX-C INJ 10GM/100 ............. 107
GAMUNEX-C INJ 1GM/10ML ............. 107
GAMUNEX-C INJ 2.5GM/25 .............. 107
GAMUNEX-C INJ 20GM/200 ............. 107
GAMUNEX-C INJ 40/400ML .............. 107
GAMUNEX-C INJ 5GM/50ML ............. 107
ganciclovir sodium for inj 500 mg ....... 15
GARDASIL 9 INJ ............................. 109
GARDASIL INJ ............................... 109
gas relief chw 125mg........................ 98
gas relief chw 80mg ......................... 98
gas relief dro 20/0.3ml ..................... 98
gas relief dro 40/0.6ml ..................... 98
gatifloxacin ophth soln 0.5% ........... 122
GATTEX KIT 5MG ............................. 98
GAUZE PADS 2" X 2" ........................ 74
gavilax pow ..................................... 95
gavilyte-c sol ................................... 95
gavilyte-g sol ................................... 95
gavilyte-n sol flav pk ........................ 95
gemcitabine hcl for inj 1 gm .............. 24
gemcitabine hcl for inj 2 gm .............. 24
gemcitabine hcl for inj 200 mg ........... 24
GEMCITABINE HCL INJ 1 GM/26.3ML (38
MG/ML) (BASE EQUIV) ...................... 24
GEMCITABINE HCL INJ 2 GM/52.6ML (38
MG/ML) (BASE EQUIV) ...................... 24
GEMCITABINE HCL INJ 200 MG/5.26ML
(38 MG/ML) (BASE EQUIV) ................ 24
gemfibrozil tab 600 mg ..................... 39
generlac sol 10gm/15 ....................... 95
gengraf cap 100mg ........................ 108
gengraf cap 25mg .......................... 108
gengraf cap 50mg .......................... 108
gengraf sol 100mg/ml..................... 108
gentak oin 0.3% op ........................ 122
gentam/nacl inj 0.9mg/ml ................... 7
174
gentam/nacl inj 1.4mg/ml................... 7
gentamicin in saline inj 0.8 mg/ml ....... 7
gentamicin in saline inj 1 mg/ml .......... 7
gentamicin in saline inj 2 mg/ml .......... 8
gentamicin sulfate cream 0.1% ........ 143
gentamicin sulfate inj 10 mg/ml .......... 8
gentamicin sulfate inj 40 mg/ml .......... 8
gentamicin sulfate iv soln 10 mg/ml ..... 8
gentamicin sulfate oint 0.1% ............ 143
gentamicin sulfate ophth oint 0.3% ... 122
gentamicin sulfate ophth soln 0.3% .. 123
GENTEAL GEL 0.3% ........................ 125
GENTEAL MILD DRO 0.2% ............... 125
genteal pm oin ............................... 125
GENVOYA TAB ..................................14
GEODON INJ 20MG ...........................63
geravim liq ..................................... 119
geriaton liq .................................... 119
gildagia tab 0.4-35 ............................79
gildess tab 1.5/30 .............................79
GILENYA CAP 0.5MG .........................71
GILOTRIF TAB 20MG .........................28
GILOTRIF TAB 30MG .........................28
GILOTRIF TAB 40MG .........................28
glatopa inj 20mg/ml ..........................71
GLEOSTINE CAP 100MG .....................23
GLEOSTINE CAP 10MG ......................23
GLEOSTINE CAP 40MG ......................23
GLEOSTINE CAP 5MG ........................23
glimepiride tab 1 mg .........................75
glipizide tab 10 mg ...........................75
glipizide tab 5 mg .............................75
glipizide tab sr 24hr 10 mg ................75
glipizide tab sr 24hr 2.5 mg ...............75
GLIPIZIDE TAB SR 24HR 2.5 MG .........75
glipizide tab sr 24hr 5 mg ..................75
GLIPIZIDE XL TAB 5MG .....................76
......................................................76
......................................................76
glipizide-metformin hcl tab 5-500 mg ..76
GLUCAGEN INJ HYPOKIT ....................85
GLUCAGON KIT 1MG .........................85
GLUCOSE CHW 4GM ......................... 85
glutose 15 gel 40% .......................... 85
GLYCERIN LIQ ............................... 116
glycolax pow 3350 nf ........................ 95
glycopyrrolate inj 4 mg/20ml (0.2
mg/ml) ........................................... 92
glycopyrrolate tab 1 mg .................... 92
glycopyrrolate tab 2 mg .................... 92
gnp all day tab allergy .................... 128
gnp allergy cap 25mg ..................... 128
gnp allergy tab 180mg .................... 128
gnp allergy tab 25mg...................... 128
gnp allergy tab 4mg ....................... 128
gnp allergy tab multi-sy .................. 132
gnp antacid sus anti-gas ................... 89
gnp antacid sus cherry ...................... 89
gnp aspirin chw 81mg ......................... 2
gnp aspirin tab 325mg ec .................... 2
gnp aspirin tab 81mg ec...................... 2
gnp bisa-lax tab 5mg ec .................... 95
gnp calcium tab cit +d3 .................. 116
gnp castor oil 100% ......................... 95
gnp century tab ............................. 119
gnp century tab senior .................... 119
gnp century tab ultimate ................. 119
gnp cgh relf liq 15mg/5ml ............... 132
gnp children liq plus cgh ................. 132
gnp cld/alle elx children .................. 132
gnp clearlax pow .............................. 95
gnp cold rlf tab daytime .................. 132
gnp cold/cgh elx child ..................... 132
gnp cough dm sus 30mg/5ml .......... 132
GNP DAILY MIS PRENATAL .............. 119
gnp day time cap cold/flu ................ 132
gnp day time cap sinus ................... 132
gnp day time liq cold/flu ................. 132
gnp dayhist tab 1.34mg .................. 128
gnp ear drop sol 6.5% ot ................ 152
gnp ear sys sol 6.5% ot .................. 152
gnp enema ene ................................ 95
gnp fish oil cap .............................. 117
gnp fish oil cap 1200mg .................. 117
gnp flu relf liq daytime .................... 132
gnp flu relf liq nightime ................... 132
gnp gas relf chw 125mg .................... 98
gnp gas relf chw 80mg...................... 98
gnp iron tab 45mg.......................... 105
gnp iron tab 65mg.......................... 105
175
gnp k-pec sus 262/15ml ....................90
gnp laxative tab 5mg ec ....................95
gnp lice kit ..................................... 151
gnp little chw ones .......................... 119
gnp masanti sus max st .....................89
gnp masanti sus reg st ......................89
gnp milk mag sus .............................95
gnp mucus-er tab 600mg ................. 132
gnp nasal spr 0.05% ....................... 132
gnp nicotine gum 2mg mint ...............72
gnp nicotine gum 2mg orig ................72
gnp nicotine gum 4mg mint ...............72
gnp nicotine loz 2mg mint ..................72
gnp nicotine loz 4mg mint ..................72
gnp nicotine loz mini 2mg ..................72
gnp nose dro 1% ............................ 132
gnp pediatri sol electrol ................... 117
GNP PRENATAL TAB 28-0.8MG.......... 119
gnp sinus tab cng/pain .................... 132
gnp suphedrn liq 15mg/5ml ............. 133
gnp triple oin antibiot ...................... 143
gnp tussin liq dm ............................ 133
gnp tussin liq dm cough ................... 133
gnp tussin liq dm max ..................... 133
gnp tussin liq nighttim ..................... 133
gnp tussin syp 100/5ml ................... 133
gnp tussin syp cf............................. 133
GOLYTELY SOL .................................95
granisetron hcl inj 0.1 mg/ml .............91
granisetron hcl inj 1 mg/ml ................91
granisetron hcl inj 4 mg/4ml (1 mg/ml)
......................................................91
granisetron hcl tab 1 mg ....................91
GRANIX INJ 300/0.5 ....................... 104
GRANIX INJ 480/0.8 ....................... 104
griseofulvin microsize susp 125 mg/5ml
......................................................11
griseofulvin microsize tab 500 mg .......11
griseofulvin ultramicrosize tab 125 mg 11
griseofulvin ultramicrosize tab 250 mg 11
guaiatussin syp 100-10/5 ................ 133
guaifenesin liquid 100 mg/5ml .......... 133
guaifenesin sol dac .......................... 133
guaifenesin syp 100-10/5 ................ 133
guaifenesin tab 200 mg ................... 133
guaifenesin tab sr 12hr 600 mg ........ 133
guaifenesin-codeine soln 100-10 mg/5ml
.................................................... 133
guanfacine hcl tab sr 24hr 1 mg (base equiv) ............................................. 68
H
halobetasol propionate cream 0.05% 147
halobetasol propionate oint 0.05% ... 147
...................................................... 64
...................................................... 64
haloperidol lactate inj 5 mg/ml .......... 64
haloperidol lactate oral conc 2 mg/ml . 64
haloperidol tab 0.5 mg ...................... 64
haloperidol tab 1 mg......................... 64
haloperidol tab 10 mg ....................... 64
haloperidol tab 20 mg ....................... 64
HARVONI TAB 90-400MG .................. 15
HAVRIX INJ 1440UNIT .................... 110
HAVRIX INJ 720UNIT ...................... 110
healthy eyes tab ............................ 119
healthylax pow ................................ 95
heartburn tab relief .......................... 93
heather tab 0.35mg.......................... 79
hemorrhoidal oin ............................ 149
hemorrhoidal sup ........................... 149
hem-prep sup ................................ 149
HEP SOD/NACL INJ 25000UNT ......... 103
HEPARIN SOD INJ 2000/ML ............. 103
HEPARIN SOD INJ 2500/ML ............. 103
HEPARIN SODIUM (PORCINE) 100
UNIT/ML IN D5W............................ 103
UNIT/ML IN D5W............................ 103
UNIT/ML IN D5W............................ 103
heparin sodium (porcine) inj 1000
unit/ml ......................................... 103
unit/ml ......................................... 103
unit/ml ......................................... 103
176
unit/ml .......................................... 103
HEPATAMINE SOL 8% ..................... 112
HERCEPTIN INJ 440MG ......................26
HETLIOZ CAP 20MG ..........................69
HEXALEN CAP 50MG ..........................23
HIBERIX SOL 10MCG ....................... 110
hm allergy tab 25mg ....................... 128
hm allergy tab 4mg ......................... 128
hm antacid sus anti-gas .....................89
hm aspirin chw 81mg ......................... 2
hm aspirin tab 325mg ........................ 2
hm b complex tab with c .................. 119
HM CASTOR OIL ............................. 117
hm cgh relf liq 15mg/5ml ................. 133
hm clearlax pow ...............................95
hm cold/cgh elx children .................. 133
hm complete tab............................. 119
HM COMPLETE TAB ......................... 119
hm complete tab 50+ ...................... 119
hm cough dm sus 30mg/5ml ............ 133
hm day time cap ............................. 133
hm enema ene .................................95
hm fiber cap 0.52gm .........................95
hm fiber pow 28.3% .........................95
hm fiber pow 30.9% .........................95
hm fiber pow 48.57% ........................95
hm fiber pow 58.6% .........................95
hm fiber tab 500mg ..........................95
hm fish oil cap 1000mg ................... 117
hm gas relf chw 80mg .......................98
HM GLUCOSE CHW ORANGE...............85
HM GLUCOSE CHW RASPBERY ............85
hm ibuprofen tab 200mg .................... 2
hm laxative tab 5mg ec .....................95
hm mucus er tab 600mg .................. 133
hm nasal spr 0.05% ........................ 133
hm niacin tab 250mg ...................... 119
HM NICOTINE DIS 14MG/24H .............72
HM NICOTINE DIS 21MG/24H .............72
hm nicotine gum 2mg mint ................72
hm nicotine gum 4mg mint ................73
hm nicotine loz 2mg mint ..................73
hm nicotine loz 4mg mint ..................73
hm nose dro 1% ............................. 133
hm one daily tab /iron ..................... 119
hm povid-iod sol 10% ..................... 149
hm saline spr 0.65% ....................... 140
hm senna tab 8.6mg ........................ 95
hm triple oin antibiot ...................... 143
hm tussin liq adlt dm ...................... 133
HUMIRA INJ 10MG/0.2 .................... 106
HUMIRA KIT 20MG/0.4 ................... 106
HUMIRA KIT 40MG/0.8 ................... 106
HUMIRA PEDIA INJ CROHNS ............ 106
HUMIRA PEN INJ 40MG/0.8 ............. 106
HUMIRA PEN INJ CROHNS ............... 106
HUMIRA PEN INJ PSORIASI ............. 106
HUMULIN R INJ U-500 ...................... 74
hydralazine hcl inj 20 mg/ml ............. 46
hydralazine hcl tab 10 mg ................. 46
hydralazine hcl tab 100 mg ............... 46
hydro skin lot 1% ........................... 147
hydrochlorothiazide cap 12.5 mg ........ 45
hydrochlorothiazide tab 12.5 mg ........ 45
hydrochlorothiazide tab 25 mg ........... 45
hydrochlorothiazide tab 50 mg ........... 45
hydrocod polst-chlorphen polst er susp
10-8 mg/5ml ................................. 133
HYDROCOD POLST-CHLORPHEN POLST
ER SUSP 10-8 MG/5ML ................... 133
hydrocodone w/ homatropine syrup 51.5 mg/5ml ................................... 133
hydrocodone w/ homatropine tab 5-1.5
mg ............................................... 140
hydrocodone-acetaminophen soln 7.5325 mg/15ml..................................... 5
hydrocodone-acetaminophen tab 10-325 mg ................................................... 5
hydrocodone-acetaminophen tab 5-325 mg ................................................... 5
hydrocodone-acetaminophen tab 7.5-325
mg ................................................... 5
hydrocodone-ibuprofen tab 7.5-200 mg 5
hydrocort cre 0.5% ........................ 147
hydrocortisone butyrate cream 0.1% 147
hydrocortisone butyrate oint 0.1% ... 147
hydrocortisone butyrate soln 0.1% ... 147
hydrocortisone cream 0.5% ............. 147
hydrocortisone cream 1% ............... 147
hydrocortisone cream 2.5% ............. 147
hydrocortisone enema 100 mg/60ml .. 93
HYDROCORTISONE ENEMA 100 MG/60ML
...................................................... 93
177
hydrocortisone lotion 2.5% .............. 147
hydrocortisone oint 0.5% ................. 147
hydrocortisone oint 1% ................... 147
hydrocortisone oint 2.5% ................. 147
hydrocortisone rectal cream 2.5%..... 145
hydrocortisone tab 10 mg ..................84
hydrocortisone tab 20 mg ..................84
hydrocortisone tab 5 mg ....................84
hydrocortisone valerate cream 0.2% . 147
hydrocortisone valerate oint 0.2% .... 147
hydrocortisone-aloe vera cream 0.5%147
hydromet syp 5-1.5/5 ..................... 133
hydromorphone hcl liqd 1 mg/ml ......... 5
hydromorphone hcl preservative free (pf)
inj 10 mg/ml ..................................... 5
hydromorphone hcl tab 2 mg .............. 5
hydroxocobalamin inj 1000 mcg/ml ... 119
hydroxychloroquine sulfate tab 200 mg
.................................................... 106
hydroxyprogesterone caproate im in oil
1.25 gm/5ml ....................................27
hydroxyurea cap 500 mg ...................30
hydroxyzine hcl im soln 25 mg/ml ..... 128
hydroxyzine hcl im soln 50 mg/ml ..... 128
hydroxyzine hcl syrup 10 mg/5ml ..... 128
hydroxyzine hcl tab 10 mg ............... 128
hydroxyzine pamoate cap 100 mg..... 128
hydroxyzine pamoate cap 25 mg ...... 128
hydroxyzine pamoate cap 50 mg ...... 128
I
ibandronate sodium tab 150 mg (base equivalent) ......................................77
IBRANCE CAP 100MG ........................26
IBRANCE CAP 125MG ........................26
IBRANCE CAP 75MG ..........................26
ibu-drops dro 40mg/ml ....................... 2
ibu-drops dro 50/1.25 ........................ 2
ibuprofen cap 200 mg ........................ 2
ibuprofen cap 200mg ......................... 2
ibuprofen dro 50/1.25 ........................ 3
ibuprofen jr chw 100mg ...................... 3
ibuprofen sus 100/5ml........................ 3
ibuprofen susp 100 mg/5ml ................ 3
ibuprofen tab 200 mg ......................... 3
ibuprofen tab 200mg .......................... 3
ibuprofen tab 400 mg ......................... 3
ibuprofen tab 600 mg ......................... 3
ibuprofen tab 800 mg ......................... 3
icaps cap ....................................... 119
ICLUSIG TAB 15MG .......................... 28
ICLUSIG TAB 45MG .......................... 28
idarubicin hcl iv inj 10 mg/10ml (1
mg/ml) ........................................... 24
idarubicin hcl iv inj 20 mg/20ml (1
mg/ml) ........................................... 24
idarubicin hcl iv inj 5 mg/5ml (1 mg/ml)
...................................................... 24
iferex 150 cap................................ 105
IFEX INJ 3GM .................................. 23
ifosfamide for inj 1 gm ...................... 23
IFOSFAMIDE INJ 3GM ....................... 23
...................................................... 23
...................................................... 23
ILEVRO DRO 0.3% OP .................... 123
ilotycin oin op ................................ 123
imatinib mesylate tab 100 mg (base equivalent) ...................................... 28
imatinib mesylate tab 400 mg (base equivalent) ...................................... 28
IMBRUVICA CAP 140MG .................... 28
250 mg ............................................. 9
500 mg ............................................. 9
imipramine hcl tab 10 mg ................. 58
imiquimod cream 5%...................... 149
IMOVAX RABIE INJ 2.5/ML .............. 110
INCRELEX INJ 40MG/4ML .................. 85
INCRUSE ELPT INH 62.5MCG ........... 126
indapamide tab 1.25 mg ................... 45
indapamide tab 2.5 mg ..................... 45
INFANRIX INJ ................................ 110
INFED INJ 50MG/ML ....................... 105
INFUVITE INJ ................................. 119
INFUVITE INJ ADULT ...................... 119
INFUVITE INJ PEDIATRI .................. 120
INLYTA TAB 1MG .............................. 28
INLYTA TAB 5MG .............................. 28
178
INSULIN PEN NEEDLE ........................74
INSULIN SAFETY NEEDLES .................74
INSULIN SYRINGE.............................74
INTELENCE TAB 100MG .....................12
INTELENCE TAB 200MG .....................12
INTELENCE TAB 25MG .......................12
intense coug liq reliever ................... 133
INTRALIPID INJ 20% ....................... 112
INTRALIPID INJ 30% ....................... 112
INTRON A INJ 10MU ........................ 108
INTRON A INJ 18MU ........................ 108
INTRON A INJ 25MU ........................ 108
INTRON A INJ 50MU ........................ 108
introvale tab ....................................79
INVANZ INJ 1GM ............................... 9
INVEGA SUST INJ 117/0.75 ...............64
INVEGA SUST INJ 156MG/ML .............64
INVEGA SUST INJ 234/1.5 .................64
INVEGA SUST INJ 39/0.25 .................64
INVEGA SUST INJ 78/0.5ML ...............64
INVEGA TAB 1.5MG ...........................64
INVEGA TAB 3MG .............................64
INVEGA TAB 6MG .............................64
INVEGA TAB 9MG .............................64
INVEGA TRINZ INJ 273MG .................64
INVIRASE CAP 200MG .......................12
INVIRASE TAB 500MG .......................12
INVOKAMET TAB 150-1000 ................76
INVOKAMET TAB 150-500 ..................76
INVOKAMET TAB 50-1000 ..................76
INVOKAMET TAB 50-500MG ...............76
INVOKANA TAB 100MG ......................76
INVOKANA TAB 300MG ......................76
ionil-t sha 1%................................. 149
IONOSOL-B/ INJ D5W ..................... 113
IONOSOL-MB INJ /D5W ................... 113
iophen c-nr liq 100-10/5 .................. 133
iophen dm-nr liq 100-10/5 ............... 133
iophen-nr liq 100/5ml ...................... 133
IPOL INJ INACTIVE.......................... 110
ipratropium bromide inhal soln 0.02%
.................................................... 126
ipratropium bromide nasal soln 0.03%
(21 mcg/spray) .............................. 126
ipratropium bromide nasal soln 0.06%
(42 mcg/spray) .............................. 126
ipratropium-albuterol nebu soln 0.52.5(3) mg/3ml ............................... 126
irbesartan tab 150 mg ...................... 36
irbesartan tab 300 mg ...................... 36
irbesartan tab 75 mg ........................ 36
irbesartan-hydrochlorothiazide tab 15012.5 mg .......................................... 35
irbesartan-hydrochlorothiazide tab 30012.5 mg .......................................... 35
IRESSA TAB 250MG .......................... 28
irinotecan hcl inj 100 mg/5ml (20
mg/ml) ........................................... 31
irinotecan hcl inj 40 mg/2ml (20 mg/ml)
...................................................... 31
irinotecan hcl inj 500 mg/25ml (20
mg/ml) ........................................... 31
IRON CHEWS CHW PEDIATRI........... 105
ISENTRESS CHW 100MG ................... 12
ISENTRESS CHW 25MG ..................... 12
ISENTRESS POW 100MG ................... 12
ISENTRESS TAB 400MG .................... 12
ISOLYTE-P INJ /D5W ...................... 113
ISOLYTE-S INJ ............................... 113
isoniazid inj 100 mg/ml ..................... 15
isoniazid syrup 50 mg/5ml ................ 15
isoniazid tab 100 mg ........................ 15
isoniazid tab 300 mg ........................ 15
ISOPTO TEARS SOL 0.5% OP........... 125
isosorbide dinitrate tab 10 mg ........... 46
isosorbide dinitrate tab 5 mg ............. 46
isosorbide dinitrate tab cr 40 mg ........ 46
isosorbide mononitrate tab 10 mg ...... 46
isosorbide mononitrate tab 20 mg ...... 46
isosorbide mononitrate tab sr 24hr 120
mg ................................................. 46
mg ................................................. 46
mg ................................................. 46
isotretinoin cap 10 mg .................... 143
isradipine cap 2.5 mg ....................... 43
isradipine cap 5 mg .......................... 43
ISTALOL SOL 0.5% OP .................... 124
179
ISTODAX INJ 10MG ...........................26
itch relief cre ex st .......................... 149
itraconazole cap 100 mg ....................11
ivermectin tab 3 mg ........................... 9
i-vite tab........................................ 119
IXIARO INJ .................................... 110
J
JAKAFI TAB 10MG .............................28
JAKAFI TAB 15MG .............................28
JAKAFI TAB 20MG .............................28
JAKAFI TAB 25MG .............................29
JAKAFI TAB 5MG ...............................28
jantoven tab 10mg.......................... 103
jantoven tab 1mg ........................... 103
jantoven tab 2.5mg......................... 103
jantoven tab 2mg ........................... 103
jantoven tab 3mg ........................... 103
jantoven tab 4mg ........................... 103
jantoven tab 5mg ........................... 103
jantoven tab 6mg ........................... 103
jantoven tab 7.5mg......................... 103
JANUMET TAB 50-1000 ......................76
JANUMET TAB 50-500MG ...................76
JANUMET XR TAB 100-1000 ...............76
JANUMET XR TAB 50-1000 .................76
JANUMET XR TAB 50-500MG ..............76
JANUVIA TAB 100MG .........................76
JANUVIA TAB 25MG ..........................76
JANUVIA TAB 50MG ..........................76
JENTADUETO TAB 2.5-1000 ...............76
JENTADUETO TAB 2.5-500 .................76
JENTADUETO TAB 2.5-850 .................76
JENTADUETO TAB XR ........................76
jinteli tab 1mg-5mcg .........................83
jock itch aer 1% ............................. 144
JOLIVETTE TAB 0.35MG .....................79
J-TAN D PD DRO 1-7.5MG ................ 133
juleber tab .......................................79
junel 1.5/30 tab................................79
junel 1/20 tab ..................................79
junel fe tab 1.5/30 ............................79
junel fe tab 1/20 ...............................79
JUXTAPID CAP 10MG .........................39
JUXTAPID CAP 20MG .........................39
JUXTAPID CAP 30MG .........................39
JUXTAPID CAP 40MG .........................39
JUXTAPID CAP 5MG ...........................39
JUXTAPID CAP 60MG .........................39
K
KADCYLA INJ 100MG ........................ 26
KADCYLA INJ 160MG ........................ 26
KALETRA SOL .................................. 14
KALETRA TAB 100-25MG ................... 14
KALETRA TAB 200-50MG ................... 14
KALYDECO PAK 50MG ..................... 140
KALYDECO PAK 75MG ..................... 140
KALYDECO TAB 150MG ................... 140
kao-tin cap 240mg ........................... 95
kao-tin sus 262/15ml ....................... 90
kariva tab 28 day ............................. 79
KCL 10 MEQ/L (0.075%) IN DEXTROSE
5% & NACL 0.45% INJ.................... 113
5% & NACL 0.2% INJ ..................... 113
5% & NACL 0.33% INJ.................... 113
5% & NACL 0.45% INJ.................... 113
5% & NACL 0.9% INJ ..................... 113
kcl 20 meq/l (0.15%) in nacl 0.45% inj
.................................................... 113
KCL 20 MEQ/L (0.15%) IN NACL 0.45%
INJ ............................................... 114
KCL 20 MEQ/L (0.15%) IN NACL 0.9%
INJ ............................................... 113
5% & NACL 0.45% INJ.................... 114
KCL 40 MEQ/L (0.3%) IN DEXTROSE 5%
& NACL 0.45% INJ ......................... 114
KCL 40 MEQ/L (0.3%) IN NACL 0.9% INJ
.................................................... 114
KCL/D5W/NACL INJ 0.15/0.2 ........... 114
KCL/D5W/NACL INJ 0.3/0.9% .......... 114
kelnor tab 1/35 ................................ 79
ketoconazole cream 2% .................. 144
ketoconazole shampoo 2% .............. 146
ketoconazole tab 200 mg .................. 11
ketoprofen cap 50 mg ......................... 3
ketoprofen cap 75 mg ......................... 3
ketorolac tromethamine ophth soln 0.4%
.................................................... 123
ketorolac tromethamine ophth soln 0.5%
.................................................... 123
ketotifen fumarate ophth soln 0.025%
(base equiv) .................................. 124
180
KEYTRUDA INJ 100MG/4M .................26
KEYTRUDA SOL 50MG .......................26
kidkare liq cgh/cold ......................... 133
kimidess tab .....................................79
KIMONO MICRO MIS THIN ............... 149
KIMONO MICRO MIS THIN + ............ 149
KIMONO MIS LUBRICAT ................... 149
KIMONO MIS SENSATIO .................. 149
KIMONO SENSA MIS PLUS ............... 149
KINRIX INJ..................................... 110
kionex pow ......................................77
kionex sus 15gm/60 ..........................77
KLOR-CON 10 TAB 10MEQ ER ........... 111
KLOR-CON 8 TAB 8MEQ ER .............. 111
klor-con m15 tab 15meq er .............. 111
klor-con pow 20meq........................ 111
konsyl cap 520mg .............................95
konsyl fiber tab 625mg ......................95
konsyl pow 28.3% ............................95
konsyl pow 30.9% ............................95
KONSYL POW 60.3% .........................95
KONSYL POW 71.67% .......................95
KONSYL-D POW 52.3%......................95
KORLYM TAB 300MG .........................85
KUVAN POW 100MG ..........................82
KUVAN POW 500MG ..........................82
KUVAN TAB 100MG ...........................82
KYNAMRO INJ 200MG/ML ...................39
L
labetalol hcl tab 100 mg ....................41
LACTATED RINGER'S SOLUTION ....... 114
lactic acid (ammonium lactate) cream
12% .............................................. 149
lactic acid (ammonium lactate) lotion
12% .............................................. 149
lactobacillus tab ................................90
LACTRASE CAP 250MG ......................91
lactulose (encephalopathy) solution 10
gm/15ml .........................................95
lactulose solution 10 gm/15ml ............95
LAMISIL ADV GEL 1%...................... 144
lamisil af aer 1% ............................ 144
LAMISIL AT SPR 1% ........................ 144
lamivudine oral soln 10 mg/ml ...........12
lamivudine tab 100 mg (hbv) .............15
lamivudine tab 150 mg ......................12
lamivudine tab 300 mg ..................... 12
lamivudine-zidovudine tab 150-300 mg
...................................................... 14
lamotrigine tab 100 mg ..................... 51
lamotrigine tab 25 mg ...................... 51
lamotrigine tab chewable dispersible 25
mg ................................................. 51
lamotrigine tab chewable dispersible 5 mg ................................................. 51
lamotrigine tab sr 24hr 100 mg.......... 51
lamotrigine tab sr 24hr 25 mg ........... 51
lamotrigine tab sr 24hr 50 mg ........... 51
LANTUS INJ 100/ML ......................... 74
LANTUS INJ SOLOSTAR ..................... 74
L-ARGININE POW ........................... 117
larin fe tab 1.5/30 ............................ 79
larin fe tab 1/20 ............................... 79
larin tab 1.5/30 ................................ 79
larin tab 1/20 .................................. 79
LASTACAFT SOL 0.25%................... 124
latanoprost ophth soln 0.005% ........ 124
LATUDA TAB 120MG ......................... 64
LATUDA TAB 20MG ........................... 64
LATUDA TAB 40MG ........................... 64
LATUDA TAB 60MG ........................... 64
LATUDA TAB 80MG ........................... 64
lax/stl soft tab 8.6-50mg .................. 96
laxative sup 10mg ............................ 96
laxative tab 5mg ec .......................... 96
L-CITRULLINE POW ........................ 117
leflunomide tab 10 mg .................... 106
leflunomide tab 20 mg .................... 106
LENVIMA CAP 10 MG ........................ 29
LENVIMA CAP 14 MG ........................ 29
LENVIMA CAP 18 MG ........................ 29
LENVIMA CAP 20 MG ........................ 29
LENVIMA CAP 24 MG ........................ 29
LENVIMA CAP 8 MG .......................... 29
lessina tab....................................... 79
LETAIRIS TAB 10MG ......................... 47
LETAIRIS TAB 5MG ........................... 47
letrozole tab 2.5 mg ......................... 27
leucovorin calcium for inj 100 mg ....... 31
181
leucovorin calcium for inj 200 mg .......31
leucovorin calcium for inj 50 mg .........31
leucovorin calcium tab 10 mg .............31
leucovorin calcium tab 5 mg ...............31
LEUKERAN TAB 2MG..........................23
LEUKINE INJ 250MCG ...................... 104
leuprolide acetate inj kit 5 mg/ml .......27
levalbuterol hcl soln nebu conc 1.25
mg/0.5ml (base equiv) .................... 129
LEVEMIR INJ ....................................74
LEVEMIR INJ FLEXTOUC .....................75
LEVETIRACETA INJ 10MG/ML..............52
LEVETIRACETA INJ 15MG/ML..............52
LEVETIRACETA INJ 5MG/ML ...............52
levetiracetam inj 500 mg/5ml (100
mg/ml) ............................................52
levetiracetam oral soln 100 mg/ml ......52
levetiracetam tab 1000 mg ................52
levetiracetam tab 250 mg ..................52
levetiracetam tab sr 24hr 500 mg .......52
levetiracetam tab sr 24hr 750 mg .......52
levobunolol hcl ophth soln 0.5% ....... 124
levocarnitine inj 200 mg/ml ...............82
levocarnitine oral soln 1 gm/10ml (10%)
......................................................82
levocarnitine tab 330 mg ...................82
levocetirizine dihydrochloride soln 2.5 mg/5ml (0.5 mg/ml) ....................... 128
levocetirizine dihydrochloride tab 5 mg
.................................................... 128
......................................................20
levofloxacin in d5w iv soln 500
mg/100ml ........................................20
levofloxacin in d5w iv soln 750
mg/150ml ........................................20
levofloxacin iv soln 25 mg/ml .............20
levofloxacin oral soln 25 mg/ml ..........20
levofloxacin tab 250 mg .....................20
levoleucovor sol 250mg/25 ................31
levoleucovorin calcium for iv inj 50 mg (base equiv) .................................... 31
levoleucovorin calcium inj 175
mg/17.5ml (base equiv).................... 31
levonest tab .................................... 79
levonorgestrel & ethinyl estradiol (91day) tab 0.15-0.03 mg ..................... 79
LEVONORGESTREL & ETHINYL
ESTRADIOL (91-DAY) TAB 0.15-0.03 MG
...................................................... 79
levonorgestrel & ethinyl estradiol tab 0.1
mg-20 mcg ..................................... 79
levonorgestrel tab 0.75 mg ............... 79
levonorgestrel tab 1.5 mg ................. 79
levonorgestrel-eth estra tab 0.0530/0.075-40/0.125-30mg-mcg .......... 79
levora-28 tab 0.15/30....................... 79
levothyroxine sodium tab 100 mcg ..... 87
levothyroxine sodium tab 25 mcg ....... 87
LEVOXYL TAB 100MCG ...................... 87
LEVOXYL TAB 112MCG ...................... 87
LEVOXYL TAB 125MCG ...................... 87
LEVOXYL TAB 137MCG ...................... 87
LEVOXYL TAB 150MCG ...................... 87
LEVOXYL TAB 175MCG ...................... 87
LEVOXYL TAB 200MCG ...................... 87
LEVOXYL TAB 25MCG........................ 87
LEVOXYL TAB 50MCG........................ 87
LEVOXYL TAB 75MCG........................ 87
LEVOXYL TAB 88MCG........................ 87
LEXIVA SUS 50MG/ML ...................... 12
LEXIVA TAB 700MG .......................... 12
L-GLUTAMINE POW ........................ 117
lice killing sha 0.33-4%................... 151
lice soln kit .................................... 151
lice treatme lot 1% ......................... 151
lice trtmnt liq 1% ........................... 151
lice trtmnt liq crm rnse ................... 151
182
lidocaine cream 4% ......................... 149
lidocaine hcl gel 2% ........................ 148
lidocaine hcl local inj 0.5% .................. 7
lidocaine hcl local inj 1%..................... 7
lidocaine hcl local inj 1.5% .................. 7
lidocaine hcl local inj 2%..................... 7
lidocaine hcl local preservative free (pf)
inj 0.5% ........................................... 7
lidocaine hcl local preservative free (pf)
inj 1% .............................................. 7
lidocaine hcl soln 4% ....................... 148
lidocaine hcl viscous soln 2% ........... 152
lidocaine oint 5% ............................ 148
lidocaine patch 5%.......................... 148
lidocaine-prilocaine cream 2.5-2.5% . 148
lidocream cre 4% ............................ 149
LINEZOLID FOR SUSP 100 MG/5ML ...... 9
LINEZOLID IN SODIUM CHLORIDE IV
SOLN 600 MG/300ML-0.9% ................ 9
linezolid iv soln 600 mg/300ml (2
mg/ml) ............................................. 9
LINEZOLID TAB 600 MG ..................... 9
LINZESS CAP 145MCG .......................98
LINZESS CAP 290MCG .......................98
liothyronine sodium tab 25 mcg ..........87
liothyronine sodium tab 5 mcg............87
liothyronine sodium tab 50 mcg ..........87
LIQ-10 SYP .................................... 117
liquituss gg liq 200/5ml ................... 133
lisinopril & hydrochlorothiazide tab 1012.5 mg ..........................................32
lisinopril & hydrochlorothiazide tab 2012.5 mg ..........................................32
lisinopril & hydrochlorothiazide tab 20-25 mg ..................................................33
lisinopril tab 10 mg ...........................33
lisinopril tab 2.5 mg ..........................33
lisinopril tab 5 mg .............................33
lithium carbonate cap 150 mg ............70
lithium carbonate tab 300 mg.............70
lithium carbonate tab cr 300 mg .........70
lithium carbonate tab cr 450 mg .........71
LITHIUM SOL 8MEQ/5ML ....................71
LOHIST-D LIQ ................................ 134
lohist-dm syp 5-2-10mg.................. 134
lohist-peb liq 4-10/5ml ................... 134
lokara lot 0.05% ............................ 147
LONSURF TAB 15-6.14 ...................... 30
LONSURF TAB 20-8.19 ...................... 30
LOPERAMIDE CAP 2MG ..................... 90
loperamide hcl cap 2 mg ................... 98
loperamide hcl liq 1 mg/5ml (0.2 mg/ml)
...................................................... 90
loperamide hcl liq 1 mg/7.5ml ........... 90
loperamide sus 1mg/7.5 ................... 90
loratadine d tab 5-120mg ................ 134
loratadine sol 5mg/5ml ................... 129
loratadine syp 5mg/5ml .................. 129
loratadine tab 10 mg ...................... 129
loratadine tab 10mg ....................... 129
lorata-dine tab d 24hr ..................... 134
loratadine-d tab 10-240mg.............. 134
loratadine-d tab 5-120mg ............... 134
lorazepam con 2mg/ml ..................... 48
lorazepam inj 2 mg/ml ...................... 48
lorazepam inj 4 mg/ml ...................... 48
lorazepam tab 0.5 mg ....................... 48
lorazepam tab 1 mg ......................... 48
lorazepam tab 2 mg ......................... 48
LORTUSS EX LIQ ............................ 134
loryna tab 3-0.02mg ......................... 79
tab 100-12.5 mg .............................. 35
tab 100-25 mg................................. 35
tab 50-12.5 mg................................ 35
losartan potassium tab 100 mg .......... 36
losartan potassium tab 25 mg ............ 36
losartan potassium tab 50 mg ............ 36
LOTEMAX GEL 0.5% ....................... 123
LOTEMAX OIN 0.5% ....................... 123
LOTEMAX SUS 0.5% ....................... 123
lotrimin af pow 2% ......................... 144
LOTRIMIN ULT CRE 1% ................... 144
lovastatin tab 10 mg......................... 38
loxapine succinate cap 10 mg ............ 64
loxapine succinate cap 25 mg ............ 64
loxapine succinate cap 5 mg .............. 64
183
loxapine succinate cap 50 mg .............64
lubricant dro 0.4-0.3% .................... 125
lubricant dro eye............................. 125
lubricating sol 0.5% ........................ 125
lubricnt eye dro 0.5% op ................. 125
LUMIGAN SOL 0.01% ...................... 124
LUMIZYME INJ 50MG .........................82
LUPR DEP-PED INJ 11.25MG...............27
LUPR DEP-PED INJ 15MG ...................27
LUPR DEP-PED INJ 30MG ...................27
LUPR DEP-PED INJ 7.5MG ..................27
LUPRON DEPOT INJ 11.25MG .............27
LUPRON DEPOT INJ 3.75MG ...............27
lutera tab .........................................79
LYNPARZA CAP 50MG ........................26
LYRICA CAP 100MG ...........................52
LYRICA CAP 150MG ...........................52
LYRICA CAP 200MG ...........................52
LYRICA CAP 225MG ...........................52
LYRICA CAP 25MG ............................52
LYRICA CAP 300MG ...........................52
LYRICA CAP 50MG ............................52
LYRICA CAP 75MG ............................52
LYRICA SOL 20MG/ML .......................52
LYSODREN TAB 500MG ......................27
lyza tab 0.35mg ...............................79
M
M.V.I PEDIAT INJ ............................ 120
M.V.I. ADULT INJ ............................ 120
M.V.I-12 W/O INJ VIT K ................... 120
maalox advan sus max st ..................89
maalox sus advanced ........................89
mag citrate sol cherry .......................96
mag citrate sol lemon ........................96
mag-delay tab ................................ 116
mag-g tab 500mg ........................... 116
MAGNEBIND TAB 300 ...................... 116
magnesium citrate soln .....................96
magnesium oxide tab 400 mg ............89
magnesium oxide tab 400 mg (240 mg elemental mg) ................................ 116
magnesium oxide tab 400 mg (241.3 mg elemental mg) ................................ 116
MAGNESIUM SU INJ 20/500ML ......... 111
MAGNESIUM SU INJ 2GM/50ML ........ 111
MAGNESIUM SU INJ 40G/1000 ......... 111
MAGNESIUM SU INJ 4G/100ML ......... 111
MAGNESIUM SU INJ 80MG/ML .......... 111
magnesium sulfate inj 50% ............. 111
MAGNESIUM SULFATE INJ 50% ....... 111
magnesium sulfate iv soln 2 gm/50ml
(40 mg/ml) ................................... 111
MAGONATE LIQ 1000/5ML ............... 116
magonate tab 500mg ..................... 116
MAG-TAB SR TAB 84MG .................. 116
major-prep oin hemorrho ................ 149
malathion lotion 0.5% .................... 151
MANGANESE CHLORIDE INJ 0.1 MG/ML
.................................................... 116
mapap sinus tab max st .................. 134
maprotiline hcl tab 25 mg ................. 58
marlissa tab 0.15/30 ........................ 79
MARPLAN TAB 10MG ......................... 58
MATULANE CAP 50MG ....................... 30
MAXIDEX SUS 0.1% OP .................. 123
MAXX MIS LUBRICAT ...................... 149
m-clear wc liq 100-6.3 .................... 134
meclizine hcl chew tab 25 mg ............ 91
meclizine hcl tab 12.5 mg ................. 91
meclizine hcl tab 25 mg .................... 91
medi-cort cre 1% ........................... 148
medroxyprogesterone acetate im susp
150 mg/ml ...................................... 79
MEDROXYPROGESTERONE ACETATE IM
SUSP 150 MG/ML ............................. 80
...................................................... 87
medroxyprogesterone acetate tab 2.5 mg ................................................. 87
...................................................... 87
mefloquine hcl tab 250 mg ................ 12
megestrol acetate susp 40 mg/ml ...... 27
MEGESTROL ACETATE SUSP 625 MG/5ML
...................................................... 27
megestrol acetate tab 20 mg ............. 27
megestrol acetate tab 40 mg ............. 27
MEKINIST TAB 0.5MG ....................... 29
MEKINIST TAB 2MG .......................... 29
MELOXICAM SUSP 7.5 MG/5ML ............ 3
meloxicam tab 15 mg ......................... 3
meloxicam tab 7.5 mg ........................ 3
melphalan hcl for inj 50 mg (base equiv)
...................................................... 23
184
memantine hcl oral solution 2 mg/ml ..55
memantine hcl tab 10 mg ..................55
memantine hcl tab 5 mg ....................55
MENACTRA INJ ............................... 110
M-END PE LIQ ................................ 134
m-end wc liq .................................. 134
MENHIBRIX INJ .............................. 110
MENOMUNE INJ A/C/Y/W ................. 110
MENVEO INJ ................................... 110
MEPHYTON TAB 5MG ....................... 120
mercaptopurine tab 50 mg .................25
meribin cap 5mg ............................. 120
meropenem iv for soln 1 gm ............... 9
meropenem iv for soln 500 mg ............ 9
mesalamine enema 4 gm ...................93
mesalamine rectal enema 4 gm & cleanser wipe kit ...............................93
mesna inj 100 mg/ml ........................31
MESNEX TAB 400MG .........................31
metamucil pow 28.3%org ..................96
metamucil pow 58.6% .......................96
metamucil pow 58.6% sf ...................96
metamucil pow 58.6%org ..................96
metformin hcl tab 1000 mg ................76
metformin hcl tab 500 mg..................76
metformin hcl tab 850 mg..................76
metformin hcl tab sr 24hr 500 mg ......76
metformin hcl tab sr 24hr 750 mg ......76
methadone con 10mg/ml .................... 5
methadone hcl soln 10 mg/5ml ........... 5
methadone hcl soln 5 mg/5ml ............. 5
methadone hcl tab 10 mg ................... 5
methadone hcl tab 5 mg ..................... 5
methazolamide tab 25 mg .................45
methazolamide tab 50 mg .................45
methenamine hippurate tab 1 gm ........ 9
methimazole tab 10 mg .....................88
methimazole tab 5 mg .......................88
methotrexate sodium for inj 1 gm .......25
methotrexate sodium inj 250 mg/10ml
(25 mg/ml) ......................................25
METHOTREXATE SODIUM INJ 50 MG/2ML
(25 MG/ML)......................................25
(25 mg/ml) ......................................25
methotrexate sodium inj pf 1000
mg/40ml (25 mg/ml) ........................25
(25 mg/ml) ..................................... 25
(25 mg/ml) ..................................... 25
(25 mg/ml) ..................................... 25
methotrexate sodium tab 2.5 mg (base equiv) ........................................... 106
methyclothiazide tab 5 mg ................ 45
methylergonovine maleate tab 0.2 mg 85
methylphenidate hcl soln 10 mg/5ml .. 68
methylphenidate hcl soln 5 mg/5ml .... 68
methylphenidate hcl tab 10 mg .......... 68
methylphenidate hcl tab 20 mg .......... 68
methylphenidate hcl tab 5 mg............ 68
methylphenidate hcl tab cr 10 mg ...... 68
methylphenidate hcl tab cr 20 mg ...... 68
mg/ml ............................................ 84
mg/ml ............................................ 84
methylprednisolone sodium succinate for inj 1000 mg ..................................... 84
methylprednisolone sodium succinate for inj 125 mg ...................................... 84
methylprednisolone sodium succinate for inj 40 mg ........................................ 84
methylprednisolone tab 16 mg ........... 84
methylprednisolone tab 32 mg ........... 84
methylprednisolone tab 4 mg ............ 84
methylprednisolone tab 8 mg ............ 84
methylprednisolone tab therapy pack 4
mg (21) .......................................... 84
metipranolol ophth soln 0.3% .......... 124
metoclopramide hcl inj 5 mg/ml ......... 91
metoclopramide hcl soln 5 mg/5ml (10
mg/10ml)........................................ 91
metoclopramide hcl tab 10 mg ........... 91
metoclopramide hcl tab 5 mg ............ 91
metolazone tab 10 mg ...................... 45
metolazone tab 2.5 mg ..................... 45
metolazone tab 5 mg ........................ 45
metoprolol & hydrochlorothiazide tab
100-25 mg ...................................... 40
metoprolol & hydrochlorothiazide tab
100-50 mg ...................................... 40
metoprolol & hydrochlorothiazide tab 5025 mg............................................. 40
185
(tartrate equiv) ................................41
metoprolol succinate tab sr 24hr 200 mg (tartrate equiv) ................................41
metoprolol tartrate inj 1 mg/ml ..........41
metoprolol tartrate tab 100 mg ..........41
metoprolol tartrate tab 25 mg ............41
metoprolol tartrate tab 50 mg ............41
metronidazole cream 0.75% ............ 149
metronidazole gel 0.75% ................. 149
metronidazole in nacl 0.79% iv soln 500
mg/100ml ......................................... 9
metronidazole lotion 0.75% ............. 150
metronidazole tab 250 mg .................. 9
metronidazole tab 500 mg .................. 9
metronidazole vaginal gel 0.75% ...... 101
mexiletine hcl cap 150 mg .................37
MG SO4/D5W INJ 10MG/ML ............. 111
MG SO4/D5W INJ 20MG/ML ............. 111
MIACALCIN INJ 200/ML .....................85
mi-acid gas chw 80mg .......................98
mi-acid sus ......................................89
mi-acid sus max st ............................89
miconazole 3 kit combo pk ............... 101
miconazole 7 cre 2% ....................... 101
miconazole 7 cre tube/kit ................. 101
miconazole 7 sup 100mg ................. 101
miconazole nitrate cream 2% ........... 145
miconazole nitrate vaginal cream 2% 101
miconazole nitrate vaginal supp 1200 mg & 2% cream kit .............................. 102
miconazole nitrate vaginal suppos 100
mg ................................................ 102
miconazorb pow af 2% .................... 145
micro guard pow 2% ....................... 145
MICROLIFE MIS PEAK FLO ................ 134
midodrine hcl tab 10 mg ....................46
midodrine hcl tab 2.5 mg ...................46
midodrine hcl tab 5 mg ......................46
milk of magn sus ..............................96
milk of magn sus 1200/15 .................96
MILK OF MAGN SUS 2400MG ..............96
milk of magn sus 400/5ml .................96
milk of magn sus cherry .................... 96
milk of magn sus mint ...................... 96
mineral oil ene ................................. 96
minerin cre .................................... 150
minitran dis 0.1mg/hr ....................... 46
minocycline hcl cap 100 mg ............... 22
minocycline hcl cap 50 mg ................ 22
minocycline hcl cap 75 mg ................ 22
minoxidil tab 10 mg.......................... 46
minoxidil tab 2.5 mg......................... 46
mintox sus ...................................... 89
mintox sus max st ............................ 89
mirtazapine orally disintegrating tab 15
mg ................................................. 58
mg ................................................. 58
mg ................................................. 58
mirtazapine tab 15 mg ...................... 58
mirtazapine tab 7.5 mg ..................... 58
misoprostol tab 100 mcg ................... 98
misoprostol tab 200 mcg ................... 98
mitomycin for iv soln 20 mg .............. 24
mitomycin for iv soln 40 mg .............. 24
mitomycin for iv soln 5 mg ................ 24
mitoxantrone hcl inj conc 20 mg/10ml (2
mg/ml) ........................................... 30
mitoxantrone hcl inj conc 25 mg/12.5ml
(2 mg/ml) ....................................... 30
mitoxantrone hcl inj conc 30 mg/15ml (2
mg/ml) ........................................... 30
M-M-R II INJ.................................. 110
moderiba pak 1000/day .................... 16
MODERIBA PAK 1200/DAY ................. 16
moderiba pak 600/day ...................... 15
moderiba pak 800/day ...................... 16
moexipril hcl tab 15 mg .................... 33
moexipril hcl tab 7.5 mg ................... 33
moexipril-hydrochlorothiazide tab 1512.5 mg .......................................... 33
moexipril-hydrochlorothiazide tab 15-25 mg ................................................. 33
186
12.5 mg ..........................................33
MOISTURIZING CRE ........................ 148
molindone hcl tab 10 mg ...................65
molindone hcl tab 25 mg ...................65
molindone hcl tab 5 mg .....................64
mometasone furoate cream 0.1% ..... 148
mometasone furoate nasal susp 50
mcg/act ......................................... 140
mometasone furoate oint 0.1% ........ 148
mometasone furoate solution 0.1%
(lotion) .......................................... 148
MONONESSA TAB .............................80
montelukast sodium chew tab 4 mg (base equiv) ................................... 139
montelukast sodium chew tab 5 mg (base equiv) ................................... 139
montelukast sodium oral granules packet
4 mg (base equiv) .......................... 139
montelukast sodium tab 10 mg (base equiv) ........................................... 139
morgidox cap 1x50mg .......................23
MORPHINE SUL INJ 2MG/ML ................ 5
mg ................................................... 6
mg ................................................... 6
mg ................................................... 6
mg ................................................... 6
mg ................................................... 6
mg ................................................... 6
morphine sulfate cap sr 24hr 10 mg ..... 6
morphine sulfate cap sr 24hr 100 mg ... 6
morphine sulfate inj pf 0.5 mg/ml ........ 6
morphine sulfate inj pf 1 mg/ml ........... 6
MORPHINE SULFATE IV SOLN 1 MG/ML 6
MORPHINE SULFATE IV SOLN PF 10
MG/ML.............................................. 6
MORPHINE SULFATE IV SOLN PF 15
MG/ML .............................................. 6
morphine sulfate iv soln pf 4 mg/ml ..... 6
morphine sulfate iv soln pf 8 mg/ml ..... 6
MG/5ML ............................................ 6
MG/5ML (20 MG/ML) .......................... 6
MG/5ML ............................................ 6
MORPHINE SULFATE TAB 15 MG .......... 6
MORPHINE SULFATE TAB 30 MG .......... 6
morphine sulfate tab cr 100 mg ........... 6
morphine sulfate tab cr 15 mg ............. 6
morphine sulfate tab cr 200 mg ........... 6
motion relf tab 25mg ........................ 91
motion sick tab 50mg ....................... 91
motion-time chw 25mg ..................... 91
MOVANTIK TAB 12.5MG .................... 98
MOVANTIK TAB 25MG ....................... 98
MOVIPREP SOL ................................ 96
MOXEZA SOL 0.5% ........................ 123
MOZOBIL INJ ................................. 104
mucinex allr tab 180mg .................. 129
mucinex cgh liq 5-100mg ................ 134
mucinex chld liq 100/5ml ................ 134
mucinex cold tab flu&sore ............... 134
mucinex cold tab sinus.................... 134
MUCINEX D TAB 120-1200 .............. 134
MUCINEX D TAB 60-600MG ............. 134
mucinex fast liq cold flu .................. 134
mucinex fast tab 25-5-325 .............. 134
mucinex fast tab sev cold ................ 134
mucinex ff spr 0.05% ..................... 134
mucinex ms liq cold ngh .................. 134
MUCINEX TAB 1200MG ................... 134
MUCINEX TAB 600MG ER ................ 134
mucinex tab sinus .......................... 134
MUCINEX/KIDS GRA 100MG ............ 134
mucosa dm tab 20-400mg .............. 134
mucosa tab 400mg ......................... 134
mucus relief liq 100/5ml ................. 134
mucus relief liq 5-100mg ................ 134
mucus relief liq cold/sin .................. 134
mucus relief liq cong/cgh ................ 134
mucus relief tab 400mg .................. 134
187
mucus relief tab cld/sinu .................. 134
mucus relief tab cold/flu .................. 134
mucus relief tab cong/cld ................. 135
mucus relief tab dm ........................ 135
mucus+chst liq 100/5ml .................. 135
mucus-dm max tab 60-1200 ............ 135
mucus-dm tab 30-600mg ................ 135
mucus-er tab 600mg ....................... 135
MULTAQ TAB 400MG .........................37
multi-delyn liq ................................ 120
MULTI-DELYN LIQ /IRON ................. 120
multilex tab .................................... 120
multilex-t&m tab ............................ 120
multi-sympt liq cld nght ................... 135
multi-sympt sus pls cold .................. 135
multivitamin chw children ................ 120
multivitamin tab womens ................. 120
multi-vitamn tab ............................. 120
multi-vite tab ................................. 120
mupirocin oint 2% .......................... 143
MUSTARGEN INJ 10MG ......................23
my way tab 1.5mg ............................80
MYCAMINE INJ 100MG .......................11
MYCAMINE INJ 50MG ........................11
mycophenolate mofetil cap 250 mg ... 108
mycophenolate mofetil for oral susp 200
mg/ml ........................................... 108
mycophenolate mofetil tab 500 mg ... 109
mycophenolate sodium tab dr 180 mg (mycophenolic acid equiv)................ 109
mycophenolate sodium tab dr 360 mg (mycophenolic acid equiv)................ 109
MYKIDZ IRON SUS 10MG/2ML .......... 120
MYKIDZ IRON SUS 15/1.5ML ............ 105
myorisan cap 10mg ......................... 143
myorisan cap 20mg ......................... 143
myorisan cap 30mg ......................... 143
myorisan cap 40mg ......................... 143
MYOZYME INJ 50MG ..........................82
MYRBETRIQ TAB 25MG .................... 101
MYRBETRIQ TAB 50MG .................... 101
mytab gas chw 125mg ......................98
mytab gas chw 80mg ........................98
myzilra tab.......................................80
N
nabumetone tab 500 mg..................... 3
nabumetone tab 750 mg..................... 3
nadolol tab 20 mg .............................41
nadolol tab 40 mg ............................ 41
nadolol tab 80 mg ............................ 41
nafcillin sodium for inj 1 gm .............. 21
nafcillin sodium for inj 10 gm ............. 21
nafcillin sodium for inj 2 gm .............. 21
nafcillin sodium for iv soln 1 gm ......... 21
nafcillin sodium for iv soln 2 gm ......... 21
NAGLAZYME INJ 1MG/ML .................. 82
NAIL SCRUB LIQ W/BRUSH ............. 150
nalbuphine hcl inj 10 mg/ml ................ 4
nalbuphine hcl inj 20 mg/ml ................ 4
naloxone hcl inj 0.4 mg/ml ................ 73
naloxone hcl inj 1 mg/ml ................... 73
naltrexone hcl tab 50 mg .................. 73
NAMENDA XR CAP 14MG ................... 55
NAMENDA XR CAP 21MG ................... 55
NAMENDA XR CAP 28MG ................... 55
NAMENDA XR CAP 7MG ..................... 55
NAMENDA XR CAP TITRATIO.............. 55
NAMZARIC CAP 14-10MG .................. 55
NAMZARIC CAP 28-10MG .................. 55
naphazoline hcl ophth soln 0.1% ...... 125
naproxen dr tab 375mg ...................... 3
naproxen dr tab 500mg ...................... 3
NAPROXEN SOD CAP 220MG................ 3
naproxen sod tab 220mg .................... 3
NAPROXEN SODIUM CAP 220 MG ......... 3
naproxen sodium tab 220 mg .............. 3
naproxen susp 125 mg/5ml ................. 3
naproxen tab 250 mg ......................... 3
naproxen tab 375 mg ......................... 3
naproxen tab 500 mg ......................... 3
naratriptan hcl tab 1 mg (base equiv) . 69
naratriptan hcl tab 2.5 mg (base equiv)
...................................................... 69
nasal 12 hr spr 0.05% .................... 135
nasal decon syp 30mg/5ml .............. 135
NASAL DECONG LIQ 30MG/5ML ....... 135
nasal decong spr 0.05% .................. 135
nasal decong tab 10mg ................... 135
nasal decong tab 120mg er ............. 135
nasal decong tab 30mg ................... 135
nasal moist spr 0.65% .................... 140
nasal saline spr 0.65%.................... 140
nasal spr 0.05% ............................. 135
NASONEX SPR 50MCG/AC ............... 141
188
nat fiber pow 48.57% ........................96
nat fiber pow therapy ........................96
NATACYN SUS 5% OP ..................... 123
nateglinide tab 120 mg ......................76
nateglinide tab 60 mg .......................76
NATPARA INJ 100MCG .......................86
NATPARA INJ 25MCG .........................86
NATPARA INJ 50MCG .........................86
NATPARA INJ 75MCG .........................86
naturl fiber pow 28.3% ......................96
naturl fiber pow 30.9% ......................96
naturl fiber pow therapy ....................96
NEBUPENT INH 300MG ....................... 9
necon tab 0.5/35 ..............................80
necon tab 1/35 .................................80
NECON TAB 1/50-28 .........................80
necon tab 10/11-28 ..........................80
NECON TAB 7/7/7 .............................80
nefazodone hcl tab 100 mg ................58
nefazodone hcl tab 50 mg ..................58
neomycin sulfate tab 500 mg .............. 8
neomycin-bacitrac zn-polymyx
5(3.5)mg-400unt-10000unt op oin ... 123
neomycin-bacitracin-polymyxin oint .. 143
neomycin-polymy-gramicid op sol 1.7510000-0.025mg-unt-mg/ml ............. 123
ophth oint 0.1% ............................. 122
ophth susp 0.1% ............................ 122
neomycin-polymyxin-hc ophth susp .. 122
neomycin-polymyxin-hc otic soln 1% 152
neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000 unit/ml-1% ................ 152
NEORAL CAP 100MG........................ 109
NEORAL CAP 25MG ......................... 109
NEORAL SOL 100MG/ML .................. 109
NEPHRAMINE INJ 5.4% ................... 112
NEUMEGA INJ 5MG ......................... 104
NEUPOGEN INJ 300/0.5 ................... 104
NEUPOGEN INJ 300MCG .................. 104
NEUPOGEN INJ 480/0.8 ................... 104
NEUPOGEN INJ 480MCG .................. 104
NEUPRO DIS 1MG/24HR ....................61
NEUPRO DIS 2MG/24HR ....................61
NEUPRO DIS 3MG/24HR .................... 61
NEUPRO DIS 4MG/24HR.................... 61
NEUPRO DIS 6MG/24HR .................... 61
NEUPRO DIS 8MG/24HR .................... 61
NEVIRAPINE SUSP 50 MG/5ML ........... 12
nevirapine tab 200 mg ...................... 13
nevirapine tab sr 24hr 100 mg ........... 13
nevirapine tab sr 24hr 400 mg ........... 13
NEXAVAR TAB 200MG ....................... 29
NEXIUM CAP 20MG ......................... 100
NEXIUM CAP 40MG ......................... 100
NEXIUM GRA 10MG DR ................... 100
NEXIUM GRA 2.5MG DR .................. 100
NEXIUM GRA 20MG DR ................... 100
NEXIUM GRA 40MG DR ................... 100
NEXIUM GRA 5MG DR ..................... 100
next choice tab 1.5mg ...................... 80
niacin cap 500mg ............................. 85
niacin cap cr 250 mg ...................... 120
niacin cap cr 500 mg ...................... 120
niacin tab 500 mg .......................... 120
niacin tab cr 1000 mg (antihyperlipidemic) ......................... 39
niacin tab cr 500 mg ....................... 120
niacin tab cr 500 mg (antihyperlipidemic)
...................................................... 39
niacin tab cr 750 mg ....................... 120
niacin tab cr 750 mg (antihyperlipidemic)
...................................................... 39
niacor tab 500mg ............................. 39
nicardipine hcl cap 20 mg .................. 43
nicardipine hcl cap 30 mg .................. 43
nicorelief gum 2mg mint ................... 73
nicorelief gum 2mg orig .................... 73
nicorelief gum 4mg mint ................... 73
nicorelief gum 4mg orig .................... 73
nicotine polacrilex gum 2 mg ............. 73
nicotine polacrilex gum 4 mg ............. 73
nicotine polacrilex lozenge 2 mg ........ 73
nicotine polacrilex lozenge 4 mg ........ 73
NICOTINE TD DIS 7MG/24HR ............ 73
nicotine td patch 24hr 14 mg/24hr ..... 73
...................................................... 73
nicotine td patch 24hr 21 mg/24hr ..... 73
...................................................... 73
nicotine td patch 24hr 7 mg/24hr ....... 73
189
NICOTINE TD PATCH 24HR 7 MG/24HR73
NICOTROL INH .................................73
NICOTROL NS SPR 10MG/ML ..............73
nifedical xl tab 30mg .........................43
nifedical xl tab 60mg .........................43
nifedipine tab sr 24hr 30 mg ..............43
nifedipine tab sr 24hr osmotic release 30
mg ..................................................43
mg ..................................................43
mg ..................................................43
night time cap cold/flu ..................... 135
night time cap sinus ........................ 135
night time liq cld/flu ........................ 135
night time liq cold/flu ...................... 135
night time liq cough ........................ 135
night time tab sinus ........................ 135
nighttime tab 25mg ..........................73
nikki tab 3-0.02mg ...........................80
NILANDRON TAB 150MG ....................27
nilutamide tab 150 mg ......................27
nimodipine cap 30 mg .......................43
NINLARO CAP 2.3MG .........................26
NINLARO CAP 3MG............................26
NINLARO CAP 4MG............................26
NIPENT INJ 10MG .............................25
nite time liq cold/flu ........................ 135
nite time liq cough .......................... 135
nite-time cap cold/flu ...................... 135
nite-time liq cold/flu ........................ 135
nitro-bid oin 2% ...............................46
NITRO-DUR DIS 0.3MG/HR ................46
NITRO-DUR DIS 0.8MG/HR ................47
nitrofurantoin macrocrystalline cap 100
mg ..................................................10
nitrofurantoin macrocrystalline cap 50
mg ..................................................10
nitrofurantoin monohydrate macrocrystalline cap 100 mg ..............10
nitroglycerin td patch 24hr 0.1 mg/hr ..47
NITROSTAT SUB 0.3MG .....................47
NITROSTAT SUB 0.4MG .....................47
NITROSTAT SUB 0.6MG .................... 47
nohist-dm liq ................................. 135
nohist-lq liq 4-10/5ml ..................... 135
NORDITROPIN INJ 10/1.5ML.............. 85
NORDITROPIN INJ 15/1.5ML.............. 85
NORDITROPIN INJ 30/3ML ................ 85
NORDITROPIN INJ 5/1.5ML ............... 85
norelgestromin-ethinyl estradiol td ptwk
150-35 mcg/24hr ............................. 80
ESTRADIOL TAB 1 MG-20 MCG .......... 80
ESTRADIOL TAB 1.5 MG-30 MCG........ 80
ESTRADIOL-FE TAB 1 MG-20 MCG ...... 80
ESTRADIOL-FE TAB 1.5 MG-30 MCG ... 80
norethindrone acetate tab 5 mg ......... 87
norethindrone acetate-ethinyl estradiol
tab 1 mg-5 mcg ............................... 83
norethindrone tab 0.35 mg ................ 80
NORETHINDRONE TAB 0.35 MG ......... 80
NORETHINDRONE-ETH ESTRADIOL TAB
0.5-35/1-35/0.5-35 MG-MCG ............. 80
norgestimate & ethinyl estradiol tab 0.25
mg-35 mcg ..................................... 80
norgestimate-eth estrad tab 0.1835/0.215-35/0.25-35 mg-mcg ........... 80
norgestrel & ethinyl estradiol tab 0.3 mg30 mcg ........................................... 80
norlyroc tab 0.35mg ......................... 80
NORMOSOL -M INJ /D5W ................ 114
NORMOSOL -R INJ /D5W ................. 114
NORMOSOL-R INJ PH 7.4 ................ 114
NORPACE CAP 100MG CR .................. 37
NORPACE CAP 150MG CR .................. 37
nortrel tab 0.5/35 ............................ 80
nortrel tab 1/35 ............................... 80
nortrel tab 7/7/7 .............................. 80
nortriptyline hcl cap 10 mg ................ 58
nortriptyline hcl soln 10 mg/5ml ........ 58
NORVIR CAP 100MG ......................... 13
NORVIR SOL 80MG/ML...................... 13
NORVIR TAB 100MG ......................... 13
NOVAFERRUM CAP 50MG ................ 105
190
NOVAFERRUM DRO 15MG/ML ........... 105
NOVAFERRUM LIQ 125 .................... 105
NOVOLIN INJ 70/30 ..........................75
NOVOLIN N INJ U-100 .......................75
NOVOLIN R INJ U-100 .......................75
NOVOLOG INJ 100/ML .......................75
NOVOLOG INJ FLEXPEN .....................75
NOVOLOG INJ PENFILL ......................75
NOVOLOG MIX INJ 70/30 ...................75
NOVOLOG MIX INJ FLEXPEN ...............75
NOXAFIL SUS 40MG/ML .....................11
NOXAFIL TAB 100MG.........................11
nrs nasal spr 0.05% ........................ 135
NUEDEXTA CAP 20-10MG ...................71
NULOJIX INJ 250MG ........................ 109
NULYTELY SOL FLAV PKS ...................96
NUPLAZID TAB 17MG ........................65
nutraplus lot 10% ........................... 150
NUVARING MIS.................................80
NUVIGIL TAB 150MG .........................72
NUVIGIL TAB 200MG .........................72
NUVIGIL TAB 250MG .........................72
NUVIGIL TAB 50MG ...........................72
nyamyc pow 100000 ....................... 145
NYMALIZE SOL 60/20ML ....................43
nyquil sev liq cold/flu ...................... 135
nystatin cream 100000 unit/gm ........ 145
nystatin oint 100000 unit/gm ........... 145
nystatin susp 100000 unit/ml ........... 152
nystatin tab 500000 unit....................11
nystatin topical powder .................... 145
nystop pow 100000......................... 145
O
ocean kids spr 0.65% ...................... 140
OCTAGAM INJ 10GM........................ 107
OCTAGAM INJ 1GM ......................... 107
OCTAGAM INJ 2.5GM....................... 107
OCTAGAM INJ 25GM........................ 107
OCTAGAM INJ 2GM/20ML ................. 107
OCTAGAM INJ 5GM ......................... 107
mg/ml) ............................................85
octreotide acetate inj 1000 mcg/ml (1
mg/ml) ............................................86
mg/ml) ............................................86
mg/ml) ............................................85
mg/ml) ........................................... 86
ODEFSEY TAB .................................. 14
ODOMZO CAP 200MG ....................... 30
OFEV CAP 100MG ........................... 140
OFEV CAP 150MG ........................... 140
ofloxacin ophth soln 0.3% ............... 123
ofloxacin otic soln 0.3% .................. 152
olanzapine for im inj 10 mg ............... 65
olanzapine orally disintegrating tab 10
mg ................................................. 65
mg ................................................. 65
mg ................................................. 65
olanzapine orally disintegrating tab 5 mg
...................................................... 65
olanzapine tab 10 mg ....................... 65
olanzapine tab 2.5 mg ...................... 65
olanzapine tab 5 mg ......................... 65
olanzapine tab 7.5 mg ...................... 65
olopatadine hcl nasal soln 0.6% ....... 129
omega-3 cap 1200mg ..................... 117
omega-3 fatty acids cap 1000 mg .... 117
omega-3 fatty acids cap 1200 mg .... 117
omega-3 fatty acids cap delayed release
1000 mg ....................................... 117
omega-3-acid ethyl esters cap 1 gm ... 39
.................................................... 100
.................................................... 100
.................................................... 100
OMEPRAZOLE TAB 20MG ................. 100
once daily tab ................................ 120
once daily tab iron .......................... 120
ondansetron hcl inj 4 mg/2ml (2 mg/ml)
...................................................... 91
ondansetron hcl inj 40 mg/20ml (2
mg/ml) ........................................... 91
ondansetron hcl oral soln 4 mg/5ml .... 91
ondansetron hcl tab 24 mg ................ 91
ondansetron hcl tab 4 mg.................. 91
ondansetron hcl tab 8 mg.................. 91
191
mg ..................................................91
ondansetron orally disintegrating tab 8 mg ..................................................91
one daily tab .................................. 120
one daily tab maximum ................... 120
one daily tab mens.......................... 120
one daily tab pls iron ....................... 120
ONFI SUS 2.5MG/ML .........................52
ONFI TAB 10MG ................................52
ONFI TAB 20MG ................................52
opcicon tab 1.5mg ............................80
operand scrb sol 7.5% ..................... 150
OPSUMIT TAB 10MG ..........................47
opti-clear sol 0.05% ........................ 125
ORA-BLEND SF SUS ..........................99
ORA-BLEND SUS ...............................99
oral electrolyte solution ................... 117
oral saline sol laxative .......................96
oralyte sol ...................................... 117
oralyte sol freeze ............................ 117
ORA-PLUS LIQ ..................................99
ORA-SWEET SF SYP ..........................99
ORFADIN CAP 10MG ..........................82
ORFADIN CAP 20MG ..........................82
ORFADIN CAP 2MG ...........................82
ORFADIN CAP 5MG ...........................82
ORFADIN SUS 4MG/ML ......................82
organ-i nr tab 200mg ...................... 135
ORKAMBI TAB 200-125 ................... 140
orsythia tab .....................................81
oxacillin sodium for inj 1 gm ..............22
oxacillin sodium for inj 10 gm .............22
oxacillin sodium for inj 2 gm ..............22
oxaliplatin for iv inj 100 mg................30
oxaliplatin for iv inj 50 mg .................30
oxaliplatin iv soln 100 mg/20ml ..........31
oxaliplatin iv soln 50 mg/10ml ............31
oxandrolone tab 10 mg ......................74
oxandrolone tab 2.5 mg.....................74
oxcarbazepine susp 300 mg/5ml (60
mg/ml) ............................................52
oxcarbazepine tab 150 mg .................52
oxybutynin chloride syrup 5 mg/5ml . 101
oxybutynin chloride tab 5 mg ........... 101
.................................................... 101
.................................................... 101
oxybutynin chloride tab sr 24hr 5 mg 101
oxycodone hcl cap 5 mg ...................... 6
oxycodone hcl conc 100 mg/5ml (20
mg/ml) ............................................. 7
OXYCODONE HCL SOLN 5 MG/5ML ....... 7
oxycodone hcl tab 10 mg .................... 7
oxycodone hcl tab 5 mg ...................... 7
oxycodone w/ acetaminophen soln 5-325 mg/5ml ............................................. 7
oxycodone w/ acetaminophen tab 10-325 mg ................................................... 7
oxycodone w/ acetaminophen tab 2.5325 mg ............................................. 7
oxycodone w/ acetaminophen tab 5-325 mg ................................................... 7
oxycodone w/ acetaminophen tab 7.5325 mg ............................................. 7
oysco 500+d chw ........................... 116
oyster shell calcium tab 500 mg ....... 116
P
pacerone tab 100mg......................... 37
pacerone tab 200mg......................... 37
pacerone tab 400mg......................... 37
paclitaxel iv conc 100 mg/16.7ml (6
mg/ml) ........................................... 25
paclitaxel iv conc 150 mg/25ml (6
mg/ml) ........................................... 25
paclitaxel iv conc 30 mg/5ml (6 mg/ml)
...................................................... 25
paclitaxel iv conc 300 mg/50ml (6
mg/ml) ........................................... 25
pain relief sus pls cold .................... 135
pain relief tab cold.......................... 135
pain rlf sin tab pe day ..................... 135
paliperidone tab sr 24hr 1.5 mg ......... 65
paliperidone tab sr 24hr 3 mg ............ 65
pamidronate disodium iv soln 3 mg/ml 77
pamidronate disodium iv soln 9 mg/ml 77
pamidronate inj 6mg/ml.................... 77
panoxyl wash liq 10% ..................... 143
PANOXYL-4 LIQ CREM WSH ............. 144
192
PANRETIN GEL 0.1% ....................... 150
pantoprazole sodium ec tab 20 mg (base equiv) ........................................... 100
pantoprazole sodium ec tab 40 mg (base equiv) ........................................... 100
paricalcitol cap 1 mcg ...................... 120
paromomycin sulfate cap 250 mg ........ 8
paroxetine hcl tab 10 mg ...................59
paser gra 4gm ..................................15
PATADAY SOL 0.2% ........................ 124
PAXIL SUS 10MG/5ML .......................59
PAZEO DRO 0.7% ........................... 124
PEAK AIR FLO MIS ADLT/PED ........... 135
ped elctrlyt sol /zinc ........................ 117
ped elctrlyt sol freezer ..................... 117
ped elctrlyt sol fruit ......................... 117
ped elctrlyt sol grape ....................... 117
ped elctrlyt sol unflavrd ................... 117
pedia relief liq cgh/cold .................... 135
PEDIA-LAX LIQ 50MG ........................96
PEDIARIX INJ 0.5ML ........................ 110
pediatric liq cgh/cold ....................... 135
PEDIATRIC MD MIS MASK ................ 136
PEDIATRIC SM MIS MASK ................ 136
pedi-boro pow soak pak ................... 150
PEDVAX HIB INJ ............................. 110
PEG 3350-KCL-NA BICARB-NACL-NA SULFATE FOR SOLN 236 GM...............96
PEG 3350-KCL-NA BICARB-NACL-NA SULFATE FOR SOLN 240 GM...............96
peg 3350-kcl-sod bicarb-nacl for soln
420 gm ...........................................96
PEGANONE TAB 250MG .....................52
PEGASYS INJ ....................................16
PEGASYS INJ 180MCG/M ...................16
PEGASYS INJ PROCLICK ....................16
PEG-INTRON KIT 120 RP....................16
PEGINTRON KIT 120MCG ...................16
PEG-INTRON KIT 150 RP....................16
PEGINTRON KIT 150MCG ...................16
PEGINTRON KIT 50MCG .....................16
PEG-INTRON KIT 50MCG RP ...............16
PEGINTRON KIT 80MCG .....................16
PEG-INTRON KIT 80MCG RP .............. 16
PELEVERUS SPR ............................. 150
pen g proc inj 600000 ....................... 22
PENICILL GK/ INJ DEX 2MU ............... 22
PENICILL GK/ INJ DEX 3MU ............... 22
penicillin g potassium for inj 20000000
unit ................................................ 22
penicillin g potassium for inj 5000000
unit ................................................ 22
penicillin g sodium for inj 5000000 unit
...................................................... 22
penicillin v potassium for soln 125
mg/5ml ........................................... 22
penicillin v potassium for soln 250
mg/5ml ........................................... 22
penicillin v potassium tab 250 mg ...... 22
penicillin v potassium tab 500 mg ...... 22
PENTACEL INJ ................................ 110
PENTAM 300 INJ 300MG.................... 10
pentoxifylline tab cr 400 mg ............ 105
peptic relf sus 262/15ml ................... 90
PERFOROMIST NEB 20MCG ............. 129
periguard oin ................................. 150
perindopril erbumine tab 2 mg ........... 33
periogard sol 0.12% ....................... 152
permethrin cream 5% ..................... 151
permethrin lotion 1% ...................... 151
perphenazine tab 16 mg ................... 65
perphenazine tab 2 mg ..................... 65
PERSONAL BES MIS FULL RNG ......... 136
PERSONAL BES MIS LOW RANG ....... 136
PETROLATUM OIN .......................... 150
pharbechlor tab 4mg ...................... 129
pharbedryl cap 25mg ...................... 129
pharbedryl cap 50mg ...................... 129
phenadoz sup 12.5mg ...................... 91
phenelzine sulfate tab 15 mg ............. 59
phenergan sup 12.5mg ..................... 91
phenergan sup 25mg ........................ 91
phenergan sup 50mg ........................ 91
PHENHIST DH LIQ 30-2-10 .............. 136
PHENOBARB INJ 65MG/ML ................ 52
phenobarbital elixir 20 mg/5ml .......... 52
phenobarbital sodium inj 130 mg/ml .. 52
193
phenobarbital tab 100 mg ..................53
phenobarbital tab 15 mg ....................52
phenobarbital tab 16.2 mg .................53
phenytek cap 200mg .........................53
phenytek cap 300mg .........................53
phenytoin chew tab 50 mg .................53
......................................................53
......................................................53
......................................................53
phenytoin sodium inj 50 mg/ml ..........53
phenytoin susp 125 mg/5ml ...............53
philith tab 0.4-35 ..............................81
PHOS-NAK POW CONCENTR ............. 116
PHOSPHOLINE SOL 0.125%OP ......... 124
phytonadione inj 1 mg/0.5ml (2 mg/ml)
.................................................... 120
phytonadione inj 10 mg/ml .............. 120
PIKO 1 MIS ELECTRON .................... 136
PILOCARPINE HCL OPHTH SOLN 1% . 124
PILOCARPINE HCL TAB 5 MG ............ 152
pilocarpine hcl tab 7.5 mg ................ 152
pimozide tab 1 mg ............................65
pimozide tab 2 mg ............................65
pimtrea tab ......................................81
pindolol tab 10 mg ............................41
pindolol tab 5 mg ..............................41
......................................................76
......................................................76
......................................................76
piperacillin sod-tazobactam na for inj
3.375 gm (3-0.375 gm) .....................22
piperacillin sod-tazobactam sod for inj
2.25 gm (2-0.25 gm) ........................22
4.5 gm (4-0.5 gm) ............................22
40.5 gm (36-4.5 gm)........................ 22
pirmella tab 1/35 ............................. 81
piroxicam cap 10 mg .......................... 3
piroxicam cap 20 mg .......................... 3
PLASMA-LYTE INJ -148 ................... 114
PLASMA-LYTE INJ 56/D5W .............. 114
PLASMA-LYTE INJ -A ....................... 114
POCKET PEAK MIS METER ............... 136
podofilox soln 0.5% ........................ 150
poly vitamin chw ............................ 120
polyethylene glycol 3350 oral packet .. 96
polyethylene glycol 3350 oral powder . 96
poly-iron cap 150mg....................... 105
polymyxin b-trimethoprim ophth soln
10000 unit/ml-0.1% ....................... 123
polyvitamin chw /iron ..................... 120
polyvitamin dro .............................. 120
polyvitamin dro /iron ...................... 120
POMALYST CAP 1MG ......................... 30
POMALYST CAP 2MG ......................... 30
POMALYST CAP 3MG ......................... 30
POMALYST CAP 4MG ......................... 30
portia-28 tab ................................... 81
POTASSIUM CHLORIDE 20 MEQ/L
(0.15%) IN DEXTROSE 5% INJ ........ 114
POTASSIUM CHLORIDE 40 MEQ/L (0.3%)
IN DEXTROSE 5% INJ ..................... 114
potassium chloride cap cr 10 meq .... 111
potassium chloride cap cr 8 meq ...... 111
POTASSIUM CHLORIDE INJ 10
MEQ/100ML ................................... 114
MEQ/50ML..................................... 114
potassium chloride inj 2 meq/ml ...... 114
MEQ/100ML ................................... 114
MEQ/50ML..................................... 114
MEQ/100ML ................................... 114
potassium chloride microencapsulated
crys cr tab 10 meq ......................... 111
potassium chloride microencapsulated
crys cr tab 20 meq ......................... 111
(20 MEQ/15ML).............................. 111
194
(40 MEQ/15ML) .............................. 111
.................................................... 111
(1500 MG) ..................................... 111
potassium chloride tab cr 8 meq (600
mg) .............................................. 111
POTASSIUM CITRATE TAB CR 10 MEQ (1080 MG) ..................................... 101
POTASSIUM CITRATE TAB CR 5 MEQ (540 MG) ....................................... 101
POTIGA TAB 200MG ..........................53
POTIGA TAB 300MG ..........................53
POTIGA TAB 400MG ..........................53
POTIGA TAB 50MG ............................53
povidone-iodine oint 10% ................ 150
povidone-iodine soln 10% ................ 150
PRADAXA CAP 110MG ...................... 103
PRADAXA CAP 150MG ...................... 103
PRADAXA CAP 75MG ....................... 103
PRALUENT INJ 150MG/ML ..................39
PRALUENT INJ 75MG/ML ....................39
pramipexole dihydrochloride tab 0.125
mg ..................................................61
......................................................61
......................................................61
......................................................61
pramipexole dihydrochloride tab 1 mg .61
......................................................61
pravastatin sodium tab 10 mg ............38
prazosin hcl cap 1 mg........................34
pred sod pho sol 1% op ................... 123
PREDNISOLONE ACETATE OPHTH SUSP
1% ............................................... 124
prednisolone sod phosph oral soln 6.7 mg/5ml (5 mg/5ml base) ...................84
prednisolone sod phosphate oral soln 15
mg/5ml (base equiv) .........................84
prednisolone sodium phosphate oral soln
25 mg/5ml (base eq) ........................ 84
prednisolone syrup 15 mg/5ml (usp
solution equivalent) .......................... 84
prednisone con 5mg/ml .................... 84
prednisone oral soln 5 mg/5ml ........... 84
prednisone tab 1 mg......................... 84
prednisone tab 10 mg ....................... 84
prednisone tab 2.5 mg ...................... 84
prednisone tab 5 mg......................... 84
prednisone tab therapy pack 10 mg (21)
...................................................... 85
...................................................... 85
...................................................... 85
...................................................... 85
premasol sol 10% .......................... 112
PRENATAL TAB............................... 120
PRENATAL TAB 27-0.8MG ................ 120
PRENATAL VITAMIN/FOLIC ACID > 0.8 MG (GENERIC) ............................... 121
prevalite pow 4gm............................ 39
prevalite pow 4gm pk ....................... 39
previfem tab .................................... 81
PREZCOBIX TAB 800-150 .................. 14
PREZISTA SUS 100MG/ML ................. 13
PREZISTA TAB 150MG ...................... 13
PREZISTA TAB 600MG ...................... 13
PREZISTA TAB 75MG ........................ 13
PREZISTA TAB 800MG ...................... 13
PRIFTIN TAB 150MG ......................... 15
PRILOSEC OTC TAB 20MG ............... 100
PRIMAQUINE TAB 26.3MG ................. 12
primidone tab 250 mg ...................... 53
primidone tab 50 mg ........................ 53
PRISTIQ TAB 100MG ........................ 59
PRISTIQ TAB 25MG .......................... 59
PRISTIQ TAB 50MG .......................... 59
PRIVIGEN INJ 10GRAMS ................. 107
PRIVIGEN INJ 5 GRAMS .................. 107
probenecid tab 500 mg ....................... 1
PROCALAMINE INJ 3% .................... 112
195
prochlorperazine maleate tab 10 mg (base equivalent) ..............................92
prochlorperazine maleate tab 5 mg (base equivalent) ......................................91
prochlorperazine suppos 25 mg ..........92
PRO-CLEAR AC SYP 9-8.33MG .......... 136
PROCRIT INJ 10000/ML ................... 104
PROCRIT INJ 2000/ML ..................... 104
PROCRIT INJ 20000/ML ................... 104
PROCRIT INJ 3000/ML ..................... 104
PROCRIT INJ 4000/ML ..................... 104
PROCRIT INJ 40000/ML ................... 104
procto-med cre hc 2.5% .................. 145
procto-pak cre 1% .......................... 145
proctozone cre -hc 2.5%.................. 145
PROFE CAP 180MG .......................... 105
PROFE FORTE CAP 155-1MG............. 121
PROGLYCEM SUS 50MG/ML ................85
PROGRAF CAP 0.5MG ...................... 109
PROGRAF CAP 1MG ......................... 109
PROGRAF CAP 5MG ......................... 109
PROLASTIN-C INJ 1000MG ............... 140
PROLENSA SOL 0.07% .................... 125
PROLEUKIN INJ 22MU........................26
PROLIA SOL 60MG/ML .......................86
PROMACTA TAB 12.5MG .................. 105
PROMACTA TAB 25MG ..................... 105
PROMACTA TAB 50MG ..................... 105
PROMACTA TAB 75MG ..................... 105
prometh vc/ syp codeine .................. 136
promethazine hcl inj 25 mg/ml ...........92
promethazine hcl inj 50 mg/ml ...........92
promethazine hcl suppos 12.5 mg .......92
promethazine hcl suppos 25 mg .........92
promethazine hcl suppos 50 mg .........92
promethazine hcl syrup 6.25 mg/5ml ..92
promethazine hcl tab 12.5 mg ............92
promethazine hcl tab 25 mg ...............92
promethazine hcl tab 50 mg ...............92
promethazine w/ codeine syrup 6.25-10 mg/5ml ......................................... 136
promethazine-dm syrup 6.25-15 mg/5ml
.................................................... 136
promethegan sup 25mg .....................92
promethegan sup 50mg .....................92
propafenone hcl cap sr 12hr 225 mg ...37
propafenone hcl tab 150 mg .............. 37
proparacaine hcl ophth soln 0.5% .... 125
propranolol & hydrochlorothiazide tab
40-25 mg ........................................ 40
propranolol & hydrochlorothiazide tab
80-25 mg ........................................ 40
propranolol hcl cap sr 24hr 120 mg .... 41
propranolol hcl cap sr 24hr 160 mg .... 41
propranolol hcl cap sr 24hr 60 mg ...... 41
propranolol hcl cap sr 24hr 80 mg ...... 41
propranolol hcl inj 1 mg/ml ............... 41
propranolol hcl oral soln 20 mg/5ml ... 41
propranolol hcl oral soln 40 mg/5ml ... 41
propranolol hcl tab 10 mg ................. 41
propylthiouracil tab 50 mg................. 88
PROQUAD INJ ................................ 110
PRO-RED AC SYP 5-1-9/5 ................ 136
PROSOL INJ 20% ........................... 112
protriptyline hcl tab 10 mg ................ 59
protriptyline hcl tab 5 mg .................. 59
provil tab 200mg................................ 3
PRUDOXIN CRE 5% ........................ 145
pseudoephed-bromphen-dm syrup 30-210 mg/5ml .................................... 136
pseudoephedr tab 120mg er ............ 136
pseudoephedrine hcl tab 30 mg ....... 136
pseudoephedrine hcl tab 60 mg ....... 136
pseudoephedrine hcl tab sr 12hr 120 mg
.................................................... 136
PULMICORT INH 180MCG ................ 141
PULMICORT INH 90MCG .................. 141
PULMOZYME SOL 1MG/ML ............... 140
puralube oin .................................. 125
pure & gentl dro 0.3% .................... 125
PURIXAN SUS 20MG/ML .................... 25
pyrazinamide tab 500 mg .................. 15
pyridostigmine bromide tab 60 mg ..... 71
Q
qc allergy tab 10mg........................ 129
qc allergy tab relief......................... 136
qc antacid sus .................................. 89
qc antacid sus anti-gas ..................... 89
196
qc aspirin tab 325mg.......................... 3
qc aspirin tab 325mg ec ..................... 3
qc azo tab 95mg ............................. 102
QC CASTOR OIL .............................. 117
qc cgh relf liq 15mg/5ml .................. 136
qc child asa chw 81mg ....................... 3
qc childrens chw extra c .................. 121
qc cold relf sus plus ms ................... 136
qc cough liq sore thr ....................... 136
qc enema ene...................................96
qc ibuprofen tab 200mg ...................... 3
qc laxative sup 10mg ........................96
qc natural pow vegetabl .....................96
QC PRENATAL TAB 28-0.8MG ........... 121
qc senna tab 8.6mg ..........................97
qc sinus pai tab relief ...................... 136
qc suphedrin tab 120mg sr .............. 136
q-dryl cap 25mg ............................. 129
q-gel mega cap 100mg .................... 117
qlearquil 24 tab 10mg ..................... 129
qlearquil spr 0.05%......................... 136
qlearquil tab 25mg .......................... 129
q-tapp dm elx................................. 136
q-tapp elx 1-15/5ml ........................ 136
q-tussin dm syp 100-10/5 ................ 136
q-tussin sol 100/5ml ....................... 136
QUADRACEL INJ ............................. 110
quasense tab ....................................81
quetiapine fumarate tab 100 mg .........65
quetiapine fumarate tab 25 mg...........65
quetiapine fumarate tab 50 mg...........65
quinapril hcl tab 10 mg ......................34
quinapril hcl tab 5 mg........................34
quinapril-hydrochlorothiazide tab 10-12.5
mg ..................................................33
quinapril-hydrochlorothiazide tab 20-12.5
mg ..................................................33
quinapril-hydrochlorothiazide tab 20-25 mg ..................................................33
quinidine gluconate tab cr 324 mg ......37
quinidine sulfate tab 200 mg ..............37
quinidine sulfate tab 300 mg ..............37
quinine sulfate cap 324 mg ................12
R
RABAVERT INJ ............................... 110
raloxifene hcl tab 60 mg ................... 86
ramipril cap 1.25 mg ........................ 34
ramipril cap 10 mg ........................... 34
ramipril cap 2.5 mg .......................... 34
ramipril cap 5 mg ............................. 34
RANEXA TAB 1000MG ....................... 46
RANEXA TAB 500MG ......................... 46
...................................................... 93
...................................................... 93
ranitidine hcl syrup 15 mg/ml (75
mg/5ml) ......................................... 93
ranitidine hcl tab 150 mg .................. 93
ranitidine hcl tab 300 mg .................. 93
RAPAMUNE SOL 1MG/ML ................. 109
RAVICTI LIQ 1.1GM/ML ..................... 82
REBETOL SOL 40MG/ML .................... 16
reclipsen tab .................................... 81
RECOMBIVA HB INJ 10MCG/ML ........ 110
RECOMBIVA HB INJ 5MCG/0.5 ......... 110
RECOMBIVA-HB INJ 40MCG/ML ........ 110
reeses med sus pinworm ................... 10
REFRESH CELL DRO 1% OP ............. 125
refresh p.m. oin op ......................... 125
REGRANEX GEL 0.01% ................... 152
reguloid cap 0.52gm ......................... 97
reguloid pow 28.3% ......................... 97
reguloid pow 48.57%........................ 97
reguloid pow 58.6% ......................... 97
relcof c sol 100-6.3 ........................ 136
RELENZA MIS DISKHALE ................... 16
RELISTOR INJ 12/0.6ML .................... 97
RELISTOR INJ 8/0.4ML ..................... 97
RELPAX TAB 20MG ........................... 69
RELPAX TAB 40MG ........................... 69
remedy cre antifung ....................... 145
REMEDY NUTRA CRE 1% ................. 150
remedy pow antifung ...................... 145
REMEDY SKIN CRE REPAIR .............. 150
REMICADE INJ 100MG .................... 106
REMODULIN INJ 10MG/ML ................. 47
REMODULIN INJ 1MG/ML .................. 47
REMODULIN INJ 2.5MG/ML ................ 47
REMODULIN INJ 5MG/ML .................. 47
rena-vite tab ................................. 121
197
RENVELA PAK 0.8GM .........................87
RENVELA PAK 2.4GM .........................87
RENVELA TAB 800MG ........................87
repaglinide tab 0.5 mg ......................76
repaglinide tab 1 mg .........................76
repaglinide tab 2 mg .........................76
RESCON-DM SYP ............................ 136
RESCRIPTOR TAB 100 MG ..................13
RESCRIPTOR TAB 200MG ...................13
RESPAIRE-30 CAP ........................... 136
RESTASIS EMU 0.05% ..................... 125
RETROVIR INJ 10MG/ML ....................13
REVATIO SUS 10MG/ML .....................47
REVLIMID CAP 10MG ....................... 108
REVLIMID CAP 15MG ....................... 108
REVLIMID CAP 2.5MG ...................... 108
REVLIMID CAP 20MG ....................... 108
REVLIMID CAP 25MG ....................... 108
REVLIMID CAP 5MG ........................ 108
REXULTI TAB 0.25MG ........................65
REXULTI TAB 0.5MG ..........................65
REXULTI TAB 1MG ............................65
REXULTI TAB 2MG ............................66
REXULTI TAB 3MG ............................66
REXULTI TAB 4MG ............................66
REYATAZ CAP 150MG ........................13
REYATAZ CAP 200MG ........................13
REYATAZ CAP 300MG ........................13
REYATAZ POW 50MG .........................13
RHINARIS GEL 0.2% ....................... 140
ribapak pak 1000/day .......................16
ribapak pak 1200/day .......................16
ribapak pak 600/day .........................16
ribapak pak 800/day .........................16
ribasphere cap 200mg .......................16
ribasphere tab 200mg .......................16
ribavirin cap 200 mg .........................16
ribavirin tab 200 mg..........................16
rifabutin cap 150 mg .........................15
rifampin cap 150 mg .........................15
rifampin cap 300 mg .........................15
rifampin for inj 600 mg ......................15
RIFATER TAB ....................................15
riluzole tab 50 mg .............................71
rimantadine hydrochloride tab 100 mg 16
RINGER'S SOLUTION ....................... 114
RISABAL-PH CRE ............................ 148
risacal-d tab .................................. 116
RISPERDAL INJ 12.5MG .................... 66
RISPERDAL INJ 25MG ....................... 66
RISPERDAL INJ 37.5MG .................... 66
RISPERDAL INJ 50MG ....................... 66
risperidone orally disintegrating tab 0.25
mg ................................................. 66
risperidone orally disintegrating tab 0.5
mg ................................................. 66
risperidone orally disintegrating tab 1 mg
...................................................... 66
...................................................... 66
...................................................... 66
...................................................... 66
risperidone soln 1 mg/ml .................. 66
risperidone tab 0.25 mg .................... 66
risperidone tab 0.5 mg...................... 66
risperidone tab 1 mg ........................ 66
RITUXAN INJ 100MG......................... 26
RITUXAN INJ 500MG......................... 26
rivastigmine tartrate cap 1.5 mg ........ 55
rivastigmine tartrate cap 3 mg ........... 55
rivastigmine tartrate cap 4.5 mg ........ 55
rivastigmine tartrate cap 6 mg ........... 55
...................................................... 55
...................................................... 55
...................................................... 55
rizatriptan benzoate oral disintegrating tab 10 mg (base eq) ......................... 70
rizatriptan benzoate oral disintegrating tab 5 mg (base eq)........................... 70
rizatriptan benzoate tab 10 mg (base equivalent) ...................................... 70
rizatriptan benzoate tab 5 mg (base equivalent) ...................................... 70
robafen cf syp cgh/cld..................... 136
robafen dm syp 100-10/5................ 136
robafen syp 100/5ml ...................... 136
198
robitussin cap cold+flu .................... 136
robitussin liq 15mg/5ml ................... 137
ROBITUSSIN LIQ CF ........................ 137
ROBITUSSIN LIQ CGH/COLD ............ 137
robitussin liq cgh/cong..................... 137
robitussin liq ms max ...................... 137
ROBITUSSIN LIQ NIGHT TM ............. 137
robitussin syp 7.5/5ml ..................... 137
ropinirole hydrochloride tab 0.25 mg ...61
ropinirole hydrochloride tab 0.5 mg .....61
ropinirole hydrochloride tab 1 mg .......61
rosadan cre 0.75% ......................... 150
rosuvastatin calcium tab 10 mg ..........38
rosuvastatin calcium tab 5 mg ............38
ROTARIX SUS ................................. 110
ROTATEQ SOL ................................ 110
roweepra tab 500mg .........................53
ROZEREM TAB 8MG ...........................69
rulox sus..........................................89
rynex dm liq ................................... 137
rynex pe elx ................................... 137
rynex pse liq .................................. 137
S
SABRIL POW 500MG .........................53
SABRIL TAB 500MG...........................53
salactic fil sol 17% .......................... 150
saline mist spr 0.65%...................... 140
saline nasal spray 0.65% ................. 140
sal-plant gel 17% ........................... 150
SANDIMMUNE SOL 100MG/ML .......... 109
SANDOSTATIN KIT LAR 10MG ............86
SANTYL OIN 250/GM ....................... 152
SAPHRIS SUB 10MG ..........................66
SAPHRIS SUB 2.5MG .........................66
SAPHRIS SUB 5MG............................66
sb allergy tab 10mg ........................ 129
sb antacid sus anti-gas ......................89
sb anti-itch cre 2-0.1%.................... 150
sb bismuth sus 262/15ml ...................90
sb cgh contr liq cf ........................... 137
sb cgh contr liq dm ......................... 137
sb cgh relf liq 15mg/5ml ................. 137
sb cold head tab congest ................. 137
sb cold mult tab symp sev ............... 137
sb cold/cgh tab hbp ........................ 137
sb coughtab tab 200mg .................. 137
sb daytime liq ................................ 137
sb flu hbp tab max st ...................... 137
sb ibuprofen tab 200mg ...................... 3
sb sinus cng pak /pain .................... 137
sb sinus cng tab /pain ..................... 137
sb sinus cng tab /pain dt ................. 137
sea soft spr 0.65% ......................... 140
sea-omega 30 cap 1200mg ............. 117
sea-omega 50 cap 1000mg ............. 117
selegiline hcl cap 5 mg ...................... 62
selegiline hcl tab 5 mg ...................... 62
selenium sulfide lotion 2.5% ............ 146
SELZENTRY TAB 150MG .................... 13
SELZENTRY TAB 300MG .................... 13
senexon liq 8.8mg/5 ......................... 97
senexon tab 8.6mg .......................... 97
senexon-s tab 8.6-50mg ................... 97
senna lax tab 8.6mg ......................... 97
senna plus tab 8.6-50mg .................. 97
SENNA PROMPT CAP 9-500MG ........... 97
sennalax-s tab 8.6-50mg .................. 97
senna-s tab 8.6-50mg ...................... 97
senna-tabs tab 8.6mg ....................... 97
senna-time tab 8.6mg ...................... 97
senno tab 8.6mg .............................. 97
sennosides syrup 8.8 mg/5ml ............ 97
sennosides tab 8.6 mg ...................... 97
sennosides-docusate sodium tab 8.6-50
mg ................................................. 97
SENSI-CARE CRE MOISTURI ............ 150
SENSI-CARE OIN 49-15% ............... 150
SENSIPAR TAB 30MG ........................ 77
SENSIPAR TAB 60MG ........................ 77
SENSIPAR TAB 90MG ........................ 77
sentry tab ..................................... 121
sentry tab senior ............................ 121
SEREVENT DIS AER 50MCG ............. 129
SEROQUEL XR TAB 150MG ................ 66
SEROQUEL XR TAB 50MG .................. 66
199
sertraline hcl oral conc 20 mg/ml ........59
sertraline hcl tab 100 mg ...................59
sertraline hcl tab 25 mg .....................59
sertraline hcl tab 50 mg .....................59
SESAME OIL ................................... 117
sharobel tab 0.35mg .........................81
SIDESTREAM MIS PED MASK ............ 137
SIGNIFOR INJ 0.3MG/ML ...................86
silace liq 10mg/ml.............................97
silace syp 60/15ml ............................97
siladryl alr liq 12.5/5ml .................... 129
sildenafil citrate tab 20 mg .................47
SILENOR TAB 3MG ............................69
SILENOR TAB 6MG ............................69
siltuss das liq 100/5ml ..................... 137
siltussin sa syp 100/5ml .................. 137
siltussin-dm liq diabetic ................... 137
siltussin-dm liq max st .................... 137
siltussin-dm syp alc free .................. 137
SILVER SULFADIAZINE CREAM 1% ... 144
SIMBRINZA SUS 1-0.2%.................. 125
simethicone chew tab 125 mg ............99
simethicone chew tab 80 mg ..............99
simethicone dro 20/0.3ml ..................99
simethicone susp 40 mg/0.6ml ...........99
simvastatin tab 10 mg .......................38
simvastatin tab 5 mg.........................38
sinus congst tab /pain dt ................. 137
sinus nasal spr 0.05% ..................... 137
sinus relief pak cng/pain .................. 137
sinus/alergy tab max st ................... 137
sirolimus tab 0.5 mg ....................... 109
sirolimus tab 1 mg .......................... 109
SIROLIMUS TAB 2 MG ..................... 109
SIRTURO TAB 100MG ........................15
SIVEXTRO INJ 200MG .......................10
SIVEXTRO TAB 200MG ......................10
sleep aid tab 25mg ...........................73
slo-niacin tab 250mg cr ................... 121
SLOW REL FE TAB 140MG CR ........... 105
slow release tab 47.5mg .................. 105
SLOW-MAG TAB .............................. 116
sm 12-hour spr 0.05% .................... 137
sm all day tab allergy ..................... 129
sm allergy tab 25mg rlf ................... 129
sm allergy tab 4mg ........................ 129
sm allergy tab multi-sy ................... 137
sm antacid sus advanced .................. 89
sm antacid sus anti-gas .................... 89
sm antacid/ sus antigas .................... 89
sm anti-diar tab 2mg ........................ 90
sm antifungl cre 1% ....................... 145
sm antifungl cre 2% ....................... 145
sm anti-itch cre 2-0.1% .................. 150
sm artificia sol tears ....................... 125
sm aspirin chw 81mg .......................... 3
sm aspirin tab 325mg ec ..................... 4
sm aspirin tab 81mg ec ....................... 4
sm castor oil 100% .......................... 97
sm child asa chw 81mg ....................... 4
sm childrens sus ms cold................. 137
sm cld/alrgy elx children ................. 137
sm clearlax pow ............................... 97
sm cold head tab congest ................ 137
sm cold/cgh elx dm child ................. 138
sm complete tab adv form ............... 121
sm complete tab senior ................... 121
sm cough rel syp 15mg/5ml ............ 138
sm day time cap pe ........................ 138
sm day time liq cold/flu ................... 138
sm enema ene ................................. 97
sm fiber lax cap 0.52gm ................... 97
sm fiber lax tab 500mg ..................... 97
sm fiber pow 28.3% ......................... 97
sm fiber pow 48.57% ....................... 97
sm fiber pow 58.6% ......................... 97
sm flu relf liq nightime .................... 138
sm gas relf chw 80mg ....................... 99
SM GLUCOSE CHW ORANGE .............. 85
SM GLUCOSE CHW RASPBERY ........... 85
SM GLUCOSE CHW SOUR APP ............ 85
sm hemorrhoi oin ........................... 150
sm ibuprofen tab 200mg ..................... 4
sm iron tab 325mg ......................... 105
sm laxative sup 10mg....................... 97
sm laxative tab 5mg ec ..................... 97
sm lice lot treatmnt ........................ 151
sm lubricant dro 0.4-0.3% .............. 125
sm micon 7 sup 100mg ................... 102
sm milk magn sus cherry .................. 97
sm mucus er tab 600mg ................. 138
200
sm nasal dec tab 30mg.................... 138
sm nasal spr 0.05% ........................ 138
SM NICOTINE DIS 14MG/24H .............73
SM NICOTINE DIS 21MG ....................73
SM NICOTINE DIS 7MG/24HR .............73
sm nicotine gum 2mg ........................73
sm nicotine gum 2mg mint.................73
sm nicotine gum 4mg ........................73
sm nicotine gum 4mg mint.................73
sm nicotine loz 2mg mint ...................73
sm nicotine loz 4mg mint ...................73
sm nite time cap cold/flu ................. 138
sm nite time liq cld/flu ..................... 138
sm nite time liq cold/flu ................... 138
sm nose dro 1% ............................. 138
sm stomach sus 262/15ml .................90
sm triple oin antibiot ....................... 144
sm tussin cf liq ............................... 138
sm tussin dm liq max ...................... 138
sm tussin dm syp 100-10/5 ............. 138
sm tussin syp 100/5ml .................... 138
sm tussin syp dm ............................ 138
sodium bicarbonate tab 325 mg ..........90
sodium bicarbonate tab 650 mg ..........90
sodium chloride hypertonic ophth oint
5% ............................................... 125
sodium chloride hypertonic ophth soln
5% ............................................... 125
SODIUM CHLORIDE INJ 0.45% ......... 114
SODIUM CHLORIDE INJ 2.5 MEQ/ML
(14.6%) ........................................ 111
SODIUM CHLORIDE INJ 3% ............. 114
SODIUM CHLORIDE INJ 5% ............. 114
SODIUM CHLORIDE IRRIGATION SOLN 0.9% ............................................. 152
SODIUM CHLORIDE IV SOLN 0.9% ... 114
sodium chloride soln nebu 0.9% ....... 138
SODIUM FLUORIDE CHEW; TAB; 1.1 (0.5
F) MG/ML SOLN .............................. 111
sodium phenylbutyrate oral powder 3
gm/teaspoonful ................................82
sodium phosphates - enema ..............97
sodium polystyrene sulfonate oral susp
15 gm/60ml .....................................77
sodium polystyrene sulfonate powder ..78
SOLTAMOX SOL 10MG/5ML ................27
SOLU-CORTEF INJ 250MG ..................85
SOMATULINE INJ 120/.5ML ................86
SOMATULINE INJ 60/0.2ML ............... 86
SOMATULINE INJ 90/0.3ML ............... 86
SOMAVERT INJ 10MG ....................... 86
SOMAVERT INJ 15MG ....................... 86
SOMAVERT INJ 20MG ....................... 86
SOMAVERT INJ 25MG ....................... 86
SOMAVERT INJ 30MG ....................... 86
soothe&cool cre inzo 2% ................. 145
SOOTHE&COOL OIN MOISTURE ....... 150
sorine tab 120mg ............................. 37
sorine tab 160mg ............................. 37
sorine tab 240mg ............................. 37
sorine tab 80mg ............................... 37
sotalol hcl (afib/afl) tab 120 mg ......... 37
sotalol hcl (afib/afl) tab 160 mg ......... 37
sotalol hcl (afib/afl) tab 80 mg ........... 37
sotalol hcl tab 120 mg ...................... 38
sotalol hcl tab 80 mg ........................ 38
SOVALDI TAB 400MG ....................... 16
spironolactone & hydrochlorothiazide tab
25-25 mg ........................................ 45
spironolactone tab 100 mg ................ 34
spironolactone tab 25 mg .................. 34
spironolactone tab 50 mg .................. 34
sprintec 28 tab 28 day ...................... 81
SPRITAM TAB 1000MG ...................... 53
SPRITAM TAB 250MG ........................ 53
SPRITAM TAB 500MG ........................ 53
SPRITAM TAB 750MG ........................ 53
SPRYCEL TAB 100MG ........................ 29
SPRYCEL TAB 140MG ........................ 29
SPRYCEL TAB 20MG.......................... 29
SPRYCEL TAB 50MG.......................... 29
SPRYCEL TAB 70MG.......................... 29
SPRYCEL TAB 80MG.......................... 29
sps sus 15gm/60.............................. 78
SSD CRE 1% ................................. 144
stavudine cap 15 mg ........................ 13
stavudine cap 20 mg ........................ 13
stavudine cap 30 mg ........................ 13
stavudine cap 40 mg ........................ 13
stavudine for oral soln 1 mg/ml ......... 13
stim laxat tab 5mg ec ....................... 97
STIVARGA TAB 40MG ....................... 29
stomach relf sus 262/15ml ................ 90
stomach relf sus 525/15ml ................ 90
201
stool softnr cap 100mg ......................98
stool softnr syp 60/15ml ....................98
stool softnr tab 8.6-50mg ..................98
STRATTERA CAP 100MG ....................69
STRATTERA CAP 10MG ......................69
STRATTERA CAP 18MG ......................69
STRATTERA CAP 25MG ......................69
STRATTERA CAP 40MG ......................69
STRATTERA CAP 60MG ......................69
STRATTERA CAP 80MG ......................69
streptomycin sulfate for inj 1 gm ......... 8
stress form/ tab zinc ....................... 121
stress formu tab ............................. 121
stress formu tab w/iron ................... 121
STRIBILD TAB ..................................14
STUART ONE CAP............................ 121
SUBOXONE MIS 12-3MG ....................74
SUBOXONE MIS 2-0.5MG ...................73
SUBOXONE MIS 4-1MG......................74
SUBOXONE MIS 8-2MG......................74
SUCRAID SOL 8500/ML .....................99
sucralfate tab 1 gm ...........................99
sudogest pe tab 10mg ..................... 138
sudogest tab 120mg er .................... 138
sudogest tab 30mg ......................... 138
sudogest tab 4-60mg ...................... 138
sudogest tab 60mg ......................... 138
sulfacetamide sodium lotion 10% (acne)
.................................................... 143
sulfacetamide sodium ophth oint 10%
.................................................... 123
sulfacetamide sodium ophth soln 10%
.................................................... 123
sulfacetamide sodium-prednisolone
ophth soln 10-0.23(0.25)% .............. 122
sulfadiazine tab 500mg ....................... 8
sulfamethoxazole-trimethoprim iv soln
400-80 mg/5ml ................................10
sulfamethoxazole-trimethoprim susp
200-40 mg/5ml ................................10
sulfamethoxazole-trimethoprim tab 40080 mg .............................................10
sulfamethoxazole-trimethoprim tab 800160 mg ...........................................10
SULFAMYLON CRE 85MG/GM ............ 144
SULFAMYLON PAK 5% ..................... 144
sulfasalazin tab 500mg dr ................. 93
sulfasalazine tab 500 mg................... 93
sulindac tab 150 mg ........................... 4
sulindac tab 200 mg ........................... 4
...................................................... 70
...................................................... 70
sumatriptan succinate inj 6 mg/0.5ml . 70
sumatriptan succinate solution auto-
injector 4 mg/0.5ml.......................... 70
sumatriptan succinate solution auto-
injector 6 mg/0.5ml.......................... 70
SUMATRIPTAN SUCCINATE SOLUTION CARTRIDGE 4 MG/0.5ML ................... 70
SUMATRIPTAN SUCCINATE SOLUTION CARTRIDGE 6 MG/0.5ML ................... 70
sumatriptan succinate solution prefilled
syringe 6 mg/0.5ml .......................... 70
sumatriptan succinate tab 100 mg ..... 70
sumatriptan succinate tab 25 mg ....... 70
sumatriptan succinate tab 50 mg ....... 70
superplex-t tab .............................. 121
suphedrine tab 10mg ...................... 138
suphedrine tab 30mg ...................... 138
SUPRAX CAP 400MG ......................... 18
suprax chw 100mg ........................... 18
suprax chw 200mg ........................... 18
SUPRAX SUS 500/5ML ...................... 18
SUPREP BOWEL SOL PREP ................. 98
SURMONTIL CAP 100MG ................... 59
SURMONTIL CAP 25MG ..................... 59
SURMONTIL CAP 50MG ..................... 59
SUSTIVA CAP 200MG ........................ 13
SUSTIVA CAP 50MG.......................... 13
SUSTIVA TAB 600MG ........................ 13
SUTENT CAP 12.5MG ........................ 29
SUTENT CAP 25MG ........................... 29
SUTENT CAP 37.5MG ........................ 29
SUTENT CAP 50MG ........................... 29
SYLATRON KIT 200MCG .................... 30
SYLATRON KIT 300MCG .................... 30
SYLATRON KIT 600MCG .................... 30
SYMBICORT AER 160-4.5 ................ 142
SYMBICORT AER 80-4.5 .................. 142
SYMLINPEN 60 INJ 1000MCG ............. 75
SYMLNPEN 120 INJ 1000MCG ............ 75
SYNAGIS INJ 100MG/ML ................. 110
202
SYNAGIS INJ 50MG ......................... 110
SYNAREL SOL 2MG/ML ......................81
SYNERCID INJ 500MG .......................10
SYNRIBO INJ 3.5MG ..........................30
SYNTHROID TAB 100MCG ..................88
SYNTHROID TAB 25MCG ....................88
SYPRINE CAP 250MG .........................78
SYSTANE BAL SOL RESTOR .............. 126
SYSTANE GEL 0.3% ........................ 126
SYSTANE GEL DRO 0.4-0.3% ........... 126
systane oin .................................... 126
T
tab tussin tab 400mg ...................... 138
tab tussin tab dm ............................ 138
tab-a-vite tab ................................. 121
tab-a-vite tab /iron ......................... 121
tab-a-vite tab beta car .................... 121
TAB-A-VITE TAB WOMENS ............... 121
TABLOID TAB 40MG ..........................25
tacrolimus cap 0.5 mg ..................... 109
tacrolimus cap 1 mg ........................ 109
tacrolimus cap 5 mg ........................ 109
tacrolimus oint 0.03% ..................... 150
tacrolimus oint 0.1% ....................... 150
TAFINLAR CAP 50MG .........................29
TAFINLAR CAP 75MG .........................29
TAGRISSO TAB 40MG ........................29
TAGRISSO TAB 80MG ........................29
TAKE ACTION TAB 1.5MG ..................81
TAMIFLU CAP 30MG ..........................16
TAMIFLU CAP 45MG ..........................16
TAMIFLU CAP 75MG ..........................16
TAMIFLU SUS 6MG/ML .......................16
tamoxifen citrate tab 10 mg (base equivalent) ......................................27
tamoxifen citrate tab 20 mg (base equivalent) ......................................27
tamsulosin hcl cap 0.4 mg ............... 100
TARCEVA TAB 100MG ....................... 29
TARCEVA TAB 150MG ....................... 29
TARCEVA TAB 25MG ......................... 29
TARGRETIN GEL 1% ....................... 150
tarina fe tab 1/20 ............................. 81
TASIGNA CAP 150MG ....................... 29
TASIGNA CAP 200MG ....................... 29
tazicef inj 1gm ................................. 18
tazicef inj 2gm ................................. 18
tazicef inj 6gm ................................. 18
TAZORAC CRE 0.05% ..................... 146
TAZORAC CRE 0.1% ....................... 146
taztia xt cap 120mg/24 ..................... 43
taztia xt cap 180mg/24 ..................... 43
taztia xt cap 240mg/24 ..................... 43
taztia xt cap 300mg/24 ..................... 43
taztia xt cap 360mg/24 ..................... 43
tears natura sol forte ...................... 126
tears natura sol free op ................... 126
tears natura sol ii op ....................... 126
tears pure sol ................................ 126
TECENTRIQ INJ 1200/20 ................... 26
TEFLARO INJ 400MG ......................... 18
TEFLARO INJ 600MG ......................... 18
TEGRETOL SUS 100/5ML ................... 53
TEGRETOL TAB 200MG ..................... 54
TEGRETOL-XR TAB 100MG ................ 54
TEKTURNA HCT TAB 150-12.5 ........... 44
TEKTURNA HCT TAB 150-25MG .......... 44
TEKTURNA HCT TAB 300-12.5 ........... 44
TEKTURNA HCT TAB 300-25MG .......... 44
TEKTURNA TAB 150MG ..................... 44
TEKTURNA TAB 300MG ..................... 44
temazepam cap 15 mg ..................... 69
temazepam cap 7.5 mg .................... 69
TENIVAC INJ 5-2LF ......................... 110
terazosin hcl cap 1 mg ...................... 34
terazosin hcl cap 10 mg .................... 34
terbinafine cre 1%.......................... 145
terbinafine hcl cream 1% ................ 145
terbinafine hcl tab 250 mg ................ 11
terbutaline sulfate inj 1 mg/ml ......... 130
terbutaline sulfate tab 2.5 mg .......... 130
terbutaline sulfate tab 5 mg ............ 130
203
terconazole vaginal cream 0.4% ....... 102
terconazole vaginal cream 0.8% ....... 102
TERCONAZOLE VAGINAL CREAM 0.8%
.................................................... 102
terconazole vaginal suppos 80 mg .... 102
mg/ml .............................................74
mg/ml .............................................74
testosterone enanthate im inj in oil 200
mg/ml .............................................74
TET/DIP TOX INJ 2-2 LF................... 110
tetrabenazine tab 12.5 mg .................71
tetrabenazine tab 25 mg ....................71
texacort sol 2.5% ........................... 148
TGT GLUCOSE CHW GRAPE ................85
THALOMID CAP 100MG .................... 108
THALOMID CAP 150MG .................... 108
THALOMID CAP 200MG .................... 108
THALOMID CAP 50MG ...................... 108
theo-24 cap 100mg cr ..................... 142
theo-24 cap 200mg cr ..................... 142
theo-24 cap 300mg cr ..................... 142
theo-24 cap 400mg er ..................... 142
theophylline soln 80 mg/15ml .......... 142
theophylline tab sr 12hr 100 mg ....... 142
THERA BETA- TAB CAROTENE........... 121
THERA M PLUS TAB ......................... 121
thera tab ....................................... 121
thera-m tab ................................... 121
THERA-M TAB ................................. 121
therapeutic sha............................... 150
therems tab ................................... 121
THEREMS-H TAB ............................. 121
THEREMS-M TAB ............................. 121
thiamine hcl inj 100 mg/ml .............. 121
thioridazine hcl tab 10 mg..................66
thioridazine hcl tab 100 mg ................67
thiothixene cap 1 mg .........................67
thiothixene cap 10 mg .......................67
thiothixene cap 2 mg .........................67
thiothixene cap 5 mg ........................ 67
tiagabine hcl tab 2 mg ...................... 54
tiagabine hcl tab 4 mg ...................... 54
TIKOSYN CAP 125MCG ...................... 38
TIKOSYN CAP 250MCG ...................... 38
TIKOSYN CAP 500MCG ...................... 38
SOLN 0.25%.................................. 125
SOLN 0.5% ................................... 125
timolol maleate ophth soln 0.25% .... 125
timolol maleate ophth soln 0.5% ...... 125
timolol maleate tab 10 mg ................ 42
timolol maleate tab 20 mg ................ 42
timolol maleate tab 5 mg .................. 41
tioconazole oin 6.5% vag ................ 102
TIVICAY TAB 10MG........................... 13
TIVICAY TAB 25MG........................... 13
TIVICAY TAB 50MG........................... 13
tizanidine hcl tab 2 mg (base equivalent)
...................................................... 71
tizanidine hcl tab 4 mg (base equivalent)
...................................................... 71
TOBRADEX OIN 0.3-0.1% ............... 122
TOBRADEX ST SUS 0.3-0.05............ 122
tobramycin nebu soln 300 mg/5ml ....... 8
tobramycin ophth soln 0.3% ............ 123
tobramycin sulfate for inj 1.2 gm ......... 8
tobramycin sulfate inj 1.2 gm/30ml (40
mg/ml) (base equiv)........................... 8
tobramycin sulfate inj 10 mg/ml (base equivalent) ........................................ 8
tobramycin sulfate inj 2 gm/50ml (40
mg/ml) (base equiv)........................... 8
tobramycin sulfate inj 80 mg/2ml (40
mg/ml) (base equiv)........................... 8
tobramycin-dexamethasone ophth susp
0.3-0.1% ...................................... 122
TOBREX OIN 0.3% OP .................... 123
tolnaftate cre 1% ........................... 145
tolnaftate cream 1% ....................... 145
tolnaftate powder 1% ..................... 145
tolnaftate soln 1% .......................... 145
tolterodine tartrate cap sr 24hr 2 mg 101
tolterodine tartrate cap sr 24hr 4 mg 101
tolterodine tartrate tab 1 mg ........... 101
tolterodine tartrate tab 2 mg ........... 101
topiramate sprinkle cap 15 mg ........... 54
204
topiramate sprinkle cap 25 mg ...........54
topiramate tab 100 mg ......................54
topiramate tab 200 mg ......................54
topiramate tab 25 mg........................54
topiramate tab 50 mg........................54
toposar inj 1gm/50ml ........................31
topotecan hcl for inj 4 mg ..................31
torsemide inj 50mg/5ml ....................45
torsemide tab 10 mg .........................45
torsemide tab 100 mg .......................45
torsemide tab 20 mg .........................45
torsemide tab 5 mg ...........................45
TOUJEO SOLO INJ 300IU/ML ..............75
TOVIAZ TAB 4MG ............................ 101
TOVIAZ TAB 8MG ............................ 101
TPN ELECTROL INJ .......................... 111
TRACLEER TAB 125MG ......................47
TRACLEER TAB 62.5MG .....................47
TRADJENTA TAB 5MG ........................76
tramadol hcl tab 50 mg ...................... 4
tramadol-acetaminophen tab 37.5-325 mg ................................................... 4
trandolapril tab 1 mg.........................34
tranexamic acid iv soln 1000 mg/10ml
(100 mg/ml) .................................. 105
tranexamic acid tab 650 mg ............. 106
TRANSDERM-SC DIS 1MG ..................92
tranylcypromine sulfate tab 10 mg ......59
TRAVASOL INJ 10% ........................ 112
TRAVATAN Z DRO 0.004% ............... 125
travel sick chw 25mg.........................92
travel sick tab 50mg..........................92
trazodone hcl tab 100 mg ..................59
trazodone hcl tab 150 mg ..................59
trazodone hcl tab 50 mg ....................59
TREANDA INJ 100MG ........................23
TREANDA INJ 180/2ML ......................23
TREANDA INJ 25MG ..........................23
TREANDA INJ 45/0.5ML .....................23
TRECATOR TAB 250MG ......................15
TRELSTAR MIX INJ 11.25MG ..............27
TRELSTAR MIX INJ 3.75MG ................27
TRESIBA FLEX INJ 100UNIT ...............75
TRESIBA FLEX INJ 200UNIT ...............75
tretinoin cap 10 mg ...........................30
tretinoin cream 0.025% ................... 143
tretinoin cream 0.05% .................... 143
tretinoin cream 0.1% ...................... 143
TRETINOIN GEL 0.01% ................... 143
tretinoin gel 0.025% ....................... 143
triacting nt liq cold/cgh ................... 138
.................................................... 148
triamcinolone acetonide cream 0.1% 148
triamcinolone acetonide cream 0.5% 148
triamcinolone acetonide dental paste
0.1% ............................................ 152
.................................................... 148
triamcinolone acetonide lotion 0.1% . 148
triamcinolone acetonide oint 0.025% 148
triamcinolone acetonide oint 0.1% ... 148
triamcinolone acetonide oint 0.5% ... 148
TRIAMINIC SOL COLD/CGH ............. 138
TRIAMINIC SUS CGH/ST ................. 138
TRIAMINIC SYP CGH/CNG ............... 138
TRIAMINIC SYP CLD/ALRG .............. 138
TRIAMINIC SYP COLD/CGH .............. 138
TRIAMINIC SYP FEVER .................... 138
triamterene & hydrochlorothiazide cap
37.5-25 mg ..................................... 45
37.5-25 mg ..................................... 45
75-50 mg ........................................ 45
TRIBENZOR20- TAB 5-12.5MG ........... 35
TRIBENZOR40- TAB 10-12.5.............. 36
TRIBENZOR40- TAB 10-25MG ............ 36
TRIBENZOR40- TAB 5-12.5MG ........... 35
TRIBENZOR40- TAB 5-25MG .............. 36
triderm cre 0.1% ........................... 148
trifluoperazine hcl tab 1 mg ............... 67
trifluoperazine hcl tab 10 mg ............. 67
trifluridine ophth soln 1% ................ 123
trihexyphenidyl hcl elixir 0.4 mg/ml .... 62
trihexyphenidyl hcl tab 2 mg ............. 62
trihexyphenidyl hcl tab 5 mg ............. 62
tri-legest tab fe ................................ 81
trilyte sol ........................................ 98
trimethoprim tab 100 mg .................. 10
trimipramine maleate cap 100 mg ...... 59
trimipramine maleate cap 25 mg ........ 59
205
trimipramine maleate cap 50 mg ........59
TRINESSA TAB .................................81
TRINTELLIX TAB 10MG ......................60
TRINTELLIX TAB 20MG ......................60
TRINTELLIX TAB 5MG ........................59
triple antib oin ................................ 144
triple antib oin plus ......................... 144
triple paste oin af 2% ...................... 145
tri-previfem tab ................................81
TRISENOX SOL 10MG/10M .................30
tri-sprintec tab .................................81
TRIUMEQ TAB...................................14
tri-vita sol ...................................... 121
tri-vitamin dro ................................ 121
trivora-28 tab ...................................81
TRIXAICIN CRE 0.025%................... 150
trixaicin hp cre 0.075% ................... 150
TROPHAMINE INJ 10% .................... 112
trospium chloride tab 20 mg ............ 101
TRULICITY INJ 0.75/0.5 .....................75
TRULICITY INJ 1.5/0.5 ......................75
TRUMENBA INJ ............................... 110
TRUSTEX LUBR MIS ASSORTED ........ 150
TRUSTEX LUBR MIS BANANA ............ 150
TRUSTEX LUBR MIS CHOC ............... 150
TRUSTEX LUBR MIS COLA ................ 150
TRUSTEX LUBR MIS COLORS ............ 150
TRUSTEX LUBR MIS EX LARGE.......... 150
TRUSTEX LUBR MIS EX STR ............. 150
TRUSTEX LUBR MIS GRAPE .............. 151
TRUSTEX LUBR MIS RIB/STUD ......... 151
TRUSTEX LUBR MIS SPERMICI .......... 151
TRUSTEX LUBR MIS STRWBRY .......... 151
TRUSTEX LUBR MIS VANILLA ........... 151
TRUSTEX MIS BANANA .................... 151
TRUSTEX MIS CHOCOLAT ................ 151
TRUSTEX MIS FLAVORS ................... 151
TRUSTEX MIS MINT ......................... 151
TRUSTEX MIS STRWBRY .................. 151
TRUSTEX MIS VANILLA .................... 151
TRUSTEX/RIA MIS LUBRICAT ........... 151
TRUSTEX/RIA MIS NON-LUB............. 151
TRUSTEX/RIA MIS SPERMICI ............ 151
TRUSTX NON-9 MIS RIB/STUD ......... 151
TRUVADA TAB 100-150 .....................14
TRUVADA TAB 133-200 .....................14
TRUVADA TAB 167-250 .....................14
TRUVADA TAB 200-300 .....................14
tusnel diabt liq 10-100/5 ................. 138
TUSNEL LIQ ................................... 138
TUSNEL PEDI LIQ 15-5-50............... 138
tussigon tab 5-1.5mg ..................... 140
tussin adult liq 100/5ml .................. 139
tussin adult liq cgh/cong ................. 139
tussin adult liq cold ........................ 139
tussin cf liq .................................... 139
tussin cf liq max/m-s ...................... 139
tussin chest syp 100/5ml ................ 139
tussin cough syp 15mg/5ml ............. 139
tussin dm liq .................................. 139
tussin dm liq 100-10/5 ................... 139
tussin dm liq 10-200/5 ................... 139
tussin dm liq max ........................... 139
tussin dm syp 100-10/5 .................. 139
tussin syp 100/5ml ......................... 139
tussi-pres liq pe ped ....................... 139
TWINRIX INJ ................................. 110
TYBOST TAB 150MG ......................... 13
TYGACIL INJ 50MG ........................... 10
TYKERB TAB 250MG ......................... 29
TYPHIM VI INJ ............................... 110
TYSABRI INJ 300/15ML ..................... 71
TYZEKA TAB 600MG ......................... 16
U
UCERIS TAB 9MG ............................. 93
ULORIC TAB 40MG ............................. 1
ULORIC TAB 80MG ............................. 1
UNICOMPLEX-M TAB ....................... 121
UNITHROID TAB 100MCG .................. 88
UNITHROID TAB 25MCG .................... 88
UPTRAVI TAB 1000MCG .................... 48
UPTRAVI TAB 1200MCG .................... 48
UPTRAVI TAB 1400MCG .................... 48
UPTRAVI TAB 1600MCG .................... 48
UPTRAVI TAB 200/800 ...................... 48
UPTRAVI TAB 200MCG ...................... 48
UPTRAVI TAB 400MCG ...................... 48
206
UPTRAVI TAB 600MCG .......................48
UPTRAVI TAB 800MCG .......................48
urea cream 10% ............................. 151
urea lotion 10% .............................. 151
ureacin-10 lot 10% ......................... 151
ursodiol cap 300 mg ..........................99
ursodiol tab 250 mg ..........................99
ursodiol tab 500 mg ..........................99
V
VAGIFEM TAB 10MCG ........................83
vagistat-3 kit combo pk ................... 102
valacyclovir hcl tab 1 gm ...................16
valacyclovir hcl tab 500 mg ................16
VALCHLOR GEL 0.016% ................... 151
VALCYTE SOL 50MG/ML .....................16
valganciclovir hcl tab 450 mg (base equivalent) ......................................17
valproate sodium inj 100 mg/ml .........54
valproate sodium syrup 250 mg/5ml
(base equiv) .....................................54
valproic acid cap 250 mg ...................54
valsartan tab 160 mg ........................36
valsartan tab 320 mg ........................36
valsartan tab 40 mg ..........................36
valsartan tab 80 mg ..........................36
valsartan-hydrochlorothiazide tab 16012.5 mg ..........................................36
valsartan-hydrochlorothiazide tab 160-25 mg ..................................................36
valsartan-hydrochlorothiazide tab 320-25 mg ..................................................36
VANAHIST PD LIQ 0.625MG ............. 129
vancomycin hcl cap 125 mg ...............10
vancomycin hcl cap 250 mg ...............10
vancomycin hcl for inj 10 gm..............10
vancomycin hcl for inj 1000 mg ..........10
vancomycin hcl for inj 500 mg ............10
vancomycin hcl for inj 5000 mg ..........10
VANCOMYCIN INJ 1 GM .....................10
VANCOMYCIN INJ 500MG ...................10
vancomycin inj 750mg.......................10
VANCOMYCIN INJ 750MG ...................10
VANDAZOLE GEL 0.75% .................. 102
VAQTA INJ 25/0.5ML ....................... 110
VAQTA INJ 50UNT/ML ..................... 110
VARIVAX INJ ................................. 110
VASCEPA CAP 1GM ........................... 40
vcks dayquil liq mucus dm ............... 139
VELCADE INJ 3.5MG ......................... 26
velivet pak ...................................... 81
VENCLEXTA TAB 100MG .................... 26
VENCLEXTA TAB 10MG...................... 26
VENCLEXTA TAB 50MG...................... 26
VENCLEXTA TAB START PK ................ 26
venlafaxine hcl cap sr 24hr 150 mg (base equivalent) ...................................... 60
venlafaxine hcl cap sr 24hr 37.5 mg (base equivalent) ............................. 60
venlafaxine hcl cap sr 24hr 75 mg (base
equivalent) ...................................... 60
venlafaxine hcl tab 100 mg ............... 60
venlafaxine hcl tab 25 mg ................. 60
venlafaxine hcl tab 37.5 mg .............. 60
VENOFER INJ 20MG/ML ................... 105
VENTOLIN HFA AER ........................ 130
verapamil hcl cap sr 24hr 100 mg ...... 43
VERAPAMIL HCL CAP SR 24HR 360 MG 44
verapamil hcl iv soln 2.5 mg/ml ......... 44
verapamil hcl tab 120 mg .................. 44
verapamil hcl tab 40 mg ................... 44
verapamil hcl tab 80 mg ................... 44
verapamil hcl tab cr 120 mg .............. 44
VERSACLOZ SUS 50MG/ML ................ 67
VESICARE TAB 10MG ...................... 101
VESICARE TAB 5MG........................ 101
vick dayquil cap cold/flu .................. 139
vick dayquil liq cold/flu ................... 139
vicks nyquil cap cold/flu .................. 139
VICTOZA INJ 18MG/3ML ................... 75
VIDEX SOL 2GM ............................... 13
VIDEX SOL 4GM ............................... 13
vienva tab 0.1-20 ............................. 81
VIGAMOX DRO 0.5% ...................... 123
207
VIIBRYD KIT ....................................60
VIIBRYD KIT STARTER .......................60
VIIBRYD TAB 10MG ...........................60
VIIBRYD TAB 20MG ...........................60
VIIBRYD TAB 40MG ...........................60
VIMPAT INJ 200MG/20 ......................54
VIMPAT SOL 10MG/ML .......................54
VIMPAT TAB 100MG ..........................54
VIMPAT TAB 150MG ..........................54
VIMPAT TAB 200MG ..........................54
VIMPAT TAB 50MG ............................54
vinblastine sulfate inj 1 mg/ml ...........25
vincasar pfs inj 1mg/ml .....................25
vincristine sulfate iv soln 1 mg/ml .......25
vinorelbine tartrate inj 10 mg/ml (base equiv) .............................................26
vinorelbine tartrate inj 50 mg/5ml (10
mg/ml) (base equiv) .........................26
viorele tab .......................................81
VIRACEPT TAB 250MG .......................13
VIRACEPT TAB 625MG .......................13
VIRAMUNE XR TAB 100MG .................13
VIREAD POW 40MG/GM .....................14
VIREAD TAB 150MG ..........................14
VIREAD TAB 200MG ..........................14
VIREAD TAB 250MG ..........................14
VIREAD TAB 300MG ..........................14
virtussin ac sol 100-10/5 ................. 139
virtussin sol dac .............................. 139
vita-bee/c tab................................. 121
vitamin d dro 400unit ...................... 122
vitamin d3 cap 10000unt ................. 121
vitamin d3 cap 50000unt ................. 121
vitamin d3 tab 2000unit .................. 121
VITAMIN D3 TAB 50000UNT ............. 121
vitamin d-3 tab 5000unit ................. 122
vite/iron chw children ...................... 122
VITEKTA TAB 150MG .........................14
VITEKTA TAB 85MG ...........................14
VOLTAREN GEL 1% ......................... 151
voriconazole for inj 200 mg ................11
voriconazole for susp 40 mg/ml ..........11
voriconazole tab 200 mg ....................11
voriconazole tab 50 mg .....................11
VOTRIENT TAB 200MG ......................29
VRAYLAR CAP 1.5-3MG ......................67
VRAYLAR CAP 1.5MG .........................67
VRAYLAR CAP 3MG ............................67
VRAYLAR CAP 4.5MG ........................ 67
VRAYLAR CAP 6MG ........................... 67
vt b complex cap ............................ 122
vyfemla tab 0.4-35 ........................... 81
W
warfarin sodium tab 1 mg ............... 103
warfarin sodium tab 10 mg .............. 103
warfarin sodium tab 2.5 mg ............. 103
warfarin sodium tab 7.5 mg ............. 103
WATER FOR INJECT, BACTERIOSTATIC BENZYL ALCOHOL .......................... 114
WATER FOR INJECTION .................. 114
WATER FOR IRRIGATION, STERILE IRRIGATION SOLN ......................... 152
WATER FOR IV INJECTION .............. 114
WELCHOL PAK 3.75GM ..................... 40
WELCHOL TAB 625MG ...................... 40
womans laxat tab 5mg ec ................. 98
womens laxat tab 5mg ec ................. 98
X
XALKORI CAP 200MG ........................ 29
XALKORI CAP 250MG ........................ 29
XARELTO STAR TAB 15/20MG .......... 104
XARELTO TAB 10MG ....................... 104
XARELTO TAB 15MG ....................... 104
XARELTO TAB 20MG ....................... 104
XGEVA INJ ...................................... 86
XIFAXAN TAB 550MG ........................ 99
XIGDUO XR TAB 10-1000 .................. 77
XIGDUO XR TAB 10-500MG ............... 77
XIGDUO XR TAB 5-1000MG ............... 77
XIGDUO XR TAB 5-500MG ................. 77
XOLAIR SOL 150MG ....................... 140
XOPENEX HFA AER ......................... 130
XTANDI CAP 40MG ........................... 27
XYREM SOL 500MG/ML ..................... 72
Y
YERVOY INJ 200MG .......................... 26
YERVOY INJ 50MG ............................ 26
YF-VAX INJ .................................... 110
Z
zafirlukast tab 10 mg ...................... 139
zafirlukast tab 20 mg ...................... 139
208
zarah tab 3-0.03mg ..........................81
ZAVESCA CAP 100MG ........................82
zeasorb-af pow 2% ......................... 145
ZELBORAF TAB 240MG ......................29
ZEMAIRA INJ 1000MG ..................... 140
zenatane cap 10mg ......................... 143
zenatane cap 20mg ......................... 143
zenatane cap 30mg ......................... 143
zenatane cap 40mg ......................... 143
zenchent tab ....................................81
ZENPEP CAP 10000UNT .....................99
ZENPEP CAP 15000UNT .....................99
ZENPEP CAP 20000UNT .....................99
ZENPEP CAP 25000UNT .....................99
ZENPEP CAP 3000UNIT ......................99
ZENPEP CAP 40000UNT .....................99
ZENPEP CAP 5000UNIT ......................99
ZETIA TAB 10MG ..............................40
ZIAGEN SOL 20MG/ML ......................14
zidovudine cap 100 mg ......................14
zidovudine syrup 10 mg/ml ................14
zidovudine tab 300 mg ......................14
ZIKS ARTHRIT CRE RELIEF............... 151
ZINC CHLORIDE INJ 1 MG/ML........... 112
zinc sulfate cap 220 mg (50 mg elemental zn) ................................. 116
ziprasidone hcl cap 20 mg ..................67
ZIRGAN GEL 0.15% ........................ 123
zoledronic acid inj conc for iv infusion 4
mg/5ml ...........................................77
zoledronic acid iv soln 5 mg/100ml .....77
ZOLINZA CAP 100MG........................ 26
zolmitriptan orally disintegrating tab 2.5 mg ................................................. 70
zolmitriptan orally disintegrating tab 5 mg ................................................. 70
zolmitriptan tab 2.5 mg .................... 70
zolmitriptan tab 5 mg ....................... 70
zolpidem tartrate tab 10 mg .............. 69
zolpidem tartrate tab 5 mg ................ 69
zonatuss cap 150mg ....................... 139
zonisamide cap 100 mg .................... 54
zonisamide cap 25 mg ...................... 54
zonisamide cap 50 mg ...................... 54
ZONTIVITY TAB 2.08MG .................. 106
zoo friends chw .............................. 122
ZOO FRIENDS CHW COMPLETE ........ 122
zoo friends chw extra c ................... 122
zoo friends chw gummies ................ 122
zoo friends chw pls iron .................. 122
ZORTRESS TAB 0.25MG .................. 109
ZORTRESS TAB 0.5MG .................... 109
ZORTRESS TAB 0.75MG .................. 109
ZOSTAVAX INJ ............................... 110
zovia 1/35e tab ................................ 81
zovia 1/50e tab ................................ 81
ZYDELIG TAB 100MG ........................ 29
ZYDELIG TAB 150MG ........................ 29
ZYKADIA CAP 150MG ........................ 30
ZYLET SUS 0.5-0.3% ...................... 122
ZYPREXA RELP INJ 210MG................. 67
ZYTIGA TAB 250MG .......................... 27
ZYVOX TAB 600MG ........................... 10
209
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CareSource.com/MyCare
H8452_OHMMC-0660
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10/01/2016
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