BCBSND Formulary - Blue Cross Blue Shield of North Dakota

Transcription

October 2015
Blue Cross Blue Shield of North Dakota Drug Formulary
Click to search for a drug name in this document
Contents
Therapeutic Class Drug List
Introduction .................................................................... I Anti-Infective Drugs ........................................................ 1
Formulary ......................................................................... I Immunizing Agents ......................................................... 7
Members .......................................................................... I Cancer Drugs .................................................................. 7
Specialty Products ........................................................... I Hormones, Diabetes and Related Drugs ........................ 9
Providers ......................................................................... II Heart and Circulatory Drugs ......................................... 16
Generic Utilization........................................................... II Respiratory Agents ....................................................... 25
Prior Approval ................................................................. II Gastrointestinal Drugs .................................................. 27
Dispensing Limits............................................................ II Genitourinary Drugs ...................................................... 29
How to Use This List ...................................................... III Central Nervous System Drugs .................................... 30
Abbreviation/acronym key ............................................. IV Pain Relief Drugs .......................................................... 38
Neuromuscular Drugs ................................................... 42
Blood Modifying Drugs .................................................. 46
Topical Products ........................................................... 47
Miscellaneous Categories............................................. 52
Index............................................................................. 55
Please consider talking to your doctor about prescribing formulary medications, which may help reduce your
out-of-pocket costs. This list may help guide you and your doctor in selecting an appropriate medication for you.
The drug formulary is regularly updated. Please visit bcbsnd.com for the most up-to-date information.
To search for a drug name within this PDF document, use the Control and F keys on your keyboard, or go to
Edit in the drop-down menu and select Find/Search. Type in the word or phrase you are looking for and click
on Search.
2626 ND © Prime Therapeutics LLC 10/15
Introduction
Formulary
The goal of the Blue Cross Blue Shield of North Dakota (BCBSND) formulary is to provide our members broad
access to drugs and supplies at a reasonable overall cost. The BCBSND Drug Formulary is the list of products
(drugs and supplies) that reflect the current recommendations of the BCBSND Pharmacy & Therapeutics (P&T)
Committee. The formulary is intended for use in the ambulatory setting. Drugs are selected for addition to the
formulary after considering safety, efficacy, uniqueness, and market considerations. Providers are encouraged
to prescribe formulary drugs.
Benefits are not limited to the drugs on this formulary list. Products not listed in this formulary are non-formulary
(NF). The P&T committee may choose to not add a drug or remove a drug from formulary for reasons including
safety or efficacy concerns, or because a clinically similar, more cost-effective drug is already on formulary. Newly
marketed drugs are non-formulary until reviewed by the P&T Committee. The entire formulary is reviewed annually
by the P&T Committee. This formulary list is subject to change. Drug coverage is dependent on individual plan
benefits.
Members
To save the most money on prescription drugs, take this Formulary with you each time you visit your physician.
Consider asking your physician to prescribe drugs listed in this Formulary, if appropriate. Any and all decisions
that require or pertain to independent professional medical judgment or training, or the need for, and dosage of,
a prescription drug, must be made solely by you and your physician in accordance with the patient/physician
relationship.
The current version and recent changes to this Formulary is available at the BCBSND website at www.bcbsnd.com
or by calling the customer service number listed on your identification card. Online pharmacy tools are available
through the Prime Therapeutics® website at www.MyPrime.com. BCBSND members can find drug cost estimates
or check if a particular drug is on the BCBSND formulary.
Under some circumstances, formulary drugs may be excluded from coverage under the drug benefit (e.g., oral
contraceptives, nicotine replacement therapy, Retin-A, various injectables, etc.). In all cases, plan
inclusions/exclusions determine specific coverage regardless of formulary status. Drugs not listed are non-formulary.
Specialty Products
Specialty drugs are used in the treatment of medical conditions such as hepatitis, multiple sclerosis and
rheumatoid arthritis. Specialty drugs may be oral or injectable medications that can either be self-administered or
administered by a health care professional. These high cost medications also have one or more of the following
characteristics:
I

Unique storage or shipment requirements

Additional education and support required from a health care professional

Usually not stocked at retail pharmacies
Blue Cross Blue Shield of North Dakota Drug Formulary, October 2015
Providers
Generic Utilization
The BCBSND Committee encourages generic utilization as a way to provide high-quality drugs at a reduced cost.
By prescribing drugs listed in this formulary that are available generically, you are providing a product that can be
expected to have the same effectiveness and safety profile as the brand product while lowering overall medical
insurance costs for your patients. In addition, your patient will likely have a lower cost share for generic drugs
because most benefit plans are based on a tiered or brand/generic copayment and coinsurance structure.
Prior Approval
Use of some products may be approved only after certain criteria are met. If prior approval is not obtained, benefits
may be denied. A physician (or clinic personnel) should submit a written request to the address shown below for
prior approval consideration. The Prior Approval Request form is available at
https://www.bcbsnd.com/web/providers/forms. A list of the products requiring prior approval may be found at
https://www.bcbsnd.com/web/providers/pharmacy under Restricted-Use Drugs.
Fax to: (701) 277-2253
Mail to:
BCBSND
Attn: Medical Management
4510 13th Ave S
Fargo, ND 58121
Dispensing Limits
Products in certain drug categories may have dispensing limits to encourage appropriate prescribing quantities as
recommended by the FDA approved product labeling, or as otherwise clinically appropriate. Requests for a
quantity that exceeds the dispensing limit should be submitted for consideration on the Dispensing Limits
Authorization form available at https://www.myprime.com/v/BCBSND/COMMERCIAL/en/forms.html. A list of
products with dispensing limits may also be found at at this site and at
https://www.bcbsnd.com/web/providers/pharmacy under Restricted-Use Drugs.
Fax to: (877) 480-8130
Mail to:
Prime Therapeutics LLC, Clinical Review Department
1305 Corporate Center Drive
Eagan, Minnesota 55121
II
How to use this list
The Formulary is organized into broad categories (e.g. Anti-Infective drugs). Within most categories, drugs are
sub-grouped by drug class (e.g. Penicillins) or by use for a specific medical condition (e.g. Diabetes). These
categories can help determine which specific product is on formulary. The graphic below shows the information
that is provided in each column of the medication list and is an example only. Please use the drug search function
to find current information for drugs on the medication list.
The first column of the chart lists the drug name. Generic drugs are shown in lower-case boldface type.
Most generic drugs are followed by a reference brand drug in (parentheses). The reference brand is a
non-formulary drug. Some generic products have no reference brand.
Brand prescription drugs are shown in capital letters followed by the generic name.
The second column indicates if the drug is a specialty drug. Note: Additional information about specialty
drugs can be found in this document under the header for Specialty Products.
The columns indicates the Utilization Management (UM) program(s) that apply to the prescription drug
(e.g., Prior Approval and Dispensing Limits). If an indicator is present in the column(s), then the UM program
noted is possibly applied to your benefit. Some plans may have UM on additional medications beyond those
noted in this document.
III
Abbreviation/acronym key
cap ...................................................................... capsules
chew .................................................................. chewable
odt ......................................... orally disintegrating tablets
oint ..................................................................... ointment
conc .............................................................. concentrate
cr .......................................................... controlled release
ophth ............................................................... ophthalmic
osm .......................................................... osmotic release
dr ............................................................. delayed release
powd ..................................................................... powder
sa ............................................................ sustained action
ec ................................................................enteric coated
effe................................................................. effervescent
equiv ................................................................ equivalent
er ...........................................................extended release
inhal................................................................... inhalation
inj ......................................................................... injection
liq .............................................................................. liquid
lotn ........................................................................... lotion
sl ...................................................................... sublingual
soln ....................................................................... solution
sr .......................................................... sustained release
suppos ........................................................ suppositories
susp ................................................................ suspension
tab ...........................................................................tablets
td ................................................................... transdermal
nebu ................................................................... nebulizer
IV
ANTI-INFECTIVE AGENTS
PENICILLINS
AMPICILLIN – ampicillin for susp 125
mg/5ml
AMOXICILLIN – amoxicillin (trihydrate)
chew tab 125 mg
AMPICILLIN – ampicillin for susp 250
mg/5ml
AMOXICILLIN – amoxicillin (trihydrate)
chew tab 250 mg
ampicillin cap 250 mg
amoxicillin (trihydrate) cap 250 mg
AUGMENTIN – amoxicillin & k clavulanate
for susp 125-31.25 mg/5ml
amoxicillin (trihydrate) cap 500 mg
dicloxacillin sodium cap 250 mg
amoxicillin (trihydrate) for susp
200 mg/5ml
penicillin v potassium for soln
125 mg/5ml
250 mg/5ml
penicillin v potassium for soln
250 mg/5ml
400 mg/5ml
penicillin v potassium tab 250 mg
amoxicillin (trihydrate) tab 500 mg
CEPHALOSPORINS
amoxicillin (trihydrate) tab 875 mg
cefaclor cap 250 mg
amoxicillin & k clavulanate chew tab
200-28.5 mg
cefaclor cap 500 mg
amoxicillin & k clavulanate chew tab
400-57 mg
cefadroxil for susp 250 mg/5ml
dicloxacillin sodium cap 500 mg
penicillin v potassium tab 500 mg
cefadroxil cap 500 mg
amoxicillin & k clavulanate for susp
200-28.5 mg/5ml
cefadroxil for susp 500 mg/5ml
250-62.5 mg/5ml (Augmentin)
cefdinir cap 300 mg
400-57 mg/5ml
cefdinir for susp 250 mg/5ml
600-42.9 mg/5ml (Augmentin es-600)
cefixime for susp 200 mg/5ml (Suprax)
amoxicillin & k clavulanate tab
250-125 mg
500-125 mg (Augmentin)
875-125 mg (Augmentin)
Dispensing Limits
ampicillin cap 500 mg
125 mg/5ml
amoxicillin & k clavulanate tab sr 12hr
1000-62.5 mg (Augmentin xr)
Prior Approval
Drug Name
Specialty
Dispensing Limits
Prior Approval
Drug Name
Specialty
2015
cefadroxil tab 1 gm
cefdinir for susp 125 mg/5ml
cefixime for susp 100 mg/5ml (Suprax)
cefpodoxime proxetil for susp 50 mg/5ml
cefpodoxime proxetil for susp
100 mg/5ml
cefpodoxime proxetil tab 100 mg
cefpodoxime proxetil tab 200 mg
cefprozil for susp 125 mg/5ml
cefprozil for susp 250 mg/5ml
cefprozil tab 250 mg
1
cefprozil tab 500 mg
CEFTIN – cefuroxime axetil for susp 125
mg/5ml
cefuroxime axetil tab 250 mg (Ceftin)
cefuroxime axetil tab 500 mg (Ceftin)
cephalexin cap 250 mg (Keflex)
cephalexin cap 500 mg (Keflex)
cephalexin for susp 125 mg/5ml
cephalexin for susp 250 mg/5ml
SUPRAX – cefixime cap 400 mg
SUPRAX – cefixime chew tab 100 mg
SUPRAX – cefixime chew tab 200 mg
SUPRAX – cefixime for susp 100 mg/5ml
MACROLIDES
AZITHROMYCIN – azithromycin powd pack
for susp 1 gm
azithromycin for susp 100 mg/5ml
(Zithromax)
ERY-TAB – erythromycin tab delayed
release 333 mg
release 500 mg
ERYTHROCIN STEARATE – erythromycin
stearate tab 250 mg
ERYTHROMYCIN BASE – erythromycin tab
250 mg
ERYTHROMYCIN BASE – erythromycin tab
500 mg
ERYTHROMYCIN ETHYLSUCCINA –
erythromycin ethylsuccinate tab 400 mg
erythromycin w/ delayed release
particles cap 250 mg
TETRACYCLINES
demeclocycline hcl tab 150 mg
demeclocycline hcl tab 300 mg
doxycycline hyclate cap 50 mg
doxycycline hyclate cap 100 mg
(Vibramycin)
doxycycline hyclate tab 20 mg
azithromycin for susp 200 mg/5ml
(Zithromax)
doxycycline hyclate tab 100 mg
azithromycin tab 250 mg (Zithromax)
doxycycline monohydrate cap 75 mg
(Monodox)
clarithromycin for susp 125 mg/5ml
clarithromycin for susp 250 mg/5ml
(Biaxin)
clarithromycin tab sr 24hr 500 mg (Biaxin
xl pac)
clarithromycin tab 250 mg (Biaxin)
clarithromycin tab 500 mg (Biaxin)
E.E.S. 400 – erythromycin ethylsuccinate
tab 400 mg
release 250 mg
(Monodox)
(Adoxa)
doxycycline monohydrate tab 50 mg
(Adoxa)
(Adoxa)
(Adoxa pak 1/100)
(Adoxa pak 1/150)
minocycline hcl cap 50 mg (Minocin)
2
Dispensing Limits
Prior Approval
Drug Name
Specialty
Dispensing Limits
Prior Approval
Drug Name
Specialty
2015
ethambutol hcl tab 400 mg (Myambutol)
minocycline hcl tab 50 mg
ISONIAZID – isoniazid syrup 50 mg/5ml
isoniazid tab 100 mg
isoniazid tab 300 mg
TETRACYCLINE HCL – tetracycline hcl cap
250 mg
PRIFTIN – rifapentine tab 150 mg
TETRACYCLINE HCL – tetracycline hcl cap
500 mg
rifabutin cap 150 mg (Mycobutin)
RIFAMATE – isoniazid & rifampin cap
150-300 mg
ciprofloxacin for oral susp 250 mg/5ml
(5%) (5 gm/100ml) (Cipro)
rifampin cap 150 mg (Rifadin)
ciprofloxacin for oral susp 500 mg/5ml
(10%) (10 gm/100ml) (Cipro)
FUNGAL INFECTIONS
rifampin cap 300 mg (Rifadin)
CIPROFLOXACIN HCL – ciprofloxacin hcl
tab 100 mg (base equiv)
fluconazole for susp 10 mg/ml (Diflucan)
ciprofloxacin hcl tab 250 mg (base equiv)
(Cipro)
fluconazole tab 50 mg (Diflucan)
(Cipro)
fluconazole for susp 40 mg/ml (Diflucan)
flucytosine cap 250 mg (Ancobon)
ciprofloxacin-ciprofloxacin hcl tab sr
24hr 500 mg (base eq) (Cipro xr)
flucytosine cap 500 mg (Ancobon)
griseofulvin microsize susp 125 mg/5ml
ciprofloxacin-ciprofloxacin hcl tab sr
24hr 1000 mg(base eq) (Cipro xr)
griseofulvin microsize tab 500 mg
(Grifulvin v)
levofloxacin oral soln 25 mg/ml
(Levaquin)
itraconazole cap 100 mg (Sporanox)
levofloxacin tab 250 mg (Levaquin)
LAMISIL – terbinafine hcl oral granules
packet 125 mg
LAMISIL – terbinafine hcl oral granules
packet 187.5 mg
moxifloxacin hcl tab 400 mg (base equiv)
(Avelox)
NOXAFIL – posaconazole susp 40 mg/ml
OFLOXACIN – ofloxacin tab 400 mg
nystatin tab 500000 unit
AMINOGLYCOSIDES
SPORANOX – itraconazole oral soln 10 mg/
ml
neomycin sulfate tab 500 mg
ethambutol hcl tab 100 mg (Myambutol)
•
terbinafine hcl tab 250 mg (Lamisil)
paromomycin sulfate cap 250 mg
TUBERCULOSIS
Dispensing Limits
pyrazinamide tab 500 mg
FLUOROQUINOLONES
tobramycin nebu soln 300 mg/5ml (Tobi)
Prior Approval
Drug Name
Specialty
Dispensing Limits
Prior Approval
Drug Name
Specialty
2015
•
voriconazole for susp 40 mg/ml (Vfend)
voriconazole tab 50 mg (Vfend)
voriconazole tab 200 mg (Vfend)
•
•
•
3
VIRAL INFECTIONS
famciclovir tab 500 mg (Famvir)
Cytomegalovirus
valacyclovir hcl tab 500 mg (Valtrex)
VALCYTE – valganciclovir hcl for soln 50
mg/ml (base equiv)
valacyclovir hcl tab 1 gm (Valtrex)
valganciclovir hcl tab 450 mg (base
equivalent) (Valcyte)
abacavir sulfate tab 300 mg (base equiv)
(Ziagen)
Hepatitis
abacavir sulfate-lamivudine-zidovudine
tab 300-150-300 mg (Trizivir)
HIV/AIDS
adefovir dipivoxil tab 10 mg (Hepsera)
BARACLUDE – entecavir oral soln 0.05 mg/
ml
APTIVUS – tipranavir cap 250 mg
entecavir tab 0.5 mg (Baraclude)
entecavir tab 1 mg (Baraclude)
ATRIPLA – efavirenz-emtricitabine-tenofovir
df tab 600-200-300 mg
EPIVIR HBV – lamivudine oral soln 5 mg/ml
(hbv)
COMPLERA – emtricitabine-rilpivirinetenofovir df tab 200-25-300 mg
HARVONI – ledipasvir-sofosbuvir tab
90-400 mg
APTIVUS – tipranavir oral soln 100 mg/ml
• •
CRIXIVAN – indinavir sulfate cap 200 mg
CRIXIVAN – indinavir sulfate cap 400 mg
lamivudine tab 100 mg (hbv) (Epivir hbv)
PEGASYS – peginterferon alfa-2a inj 180
mcg/ml
•
didanosine delayed release capsule
125 mg (Videx ec)
PEGASYS – peginterferon alfa-2a inj 180
mcg/0.5ml
•
200 mg (Videx ec)
PEGASYS PROCLICK – peginterferon
alfa-2a inj 135 mcg/0.5ml
•
250 mg (Videx ec)
PEGASYS PROCLICK – peginterferon
alfa-2a inj 180 mcg/0.5ml
•
400 mg (Videx ec)
ribavirin cap 200 mg (Rebetol)
•
•
• •
• •
ribavirin tab 200 mg (Copegus)
SOVALDI – sofosbuvir tab 400 mg
VIEKIRA PAK – ombitas-paritapre-riton &
dasab tab pak 12.5-75-50 & 250 mg
Herpes
EDURANT – rilpivirine hcl tab 25 mg (base
equivalent)
EMTRIVA – emtricitabine caps 200 mg
EMTRIVA – emtricitabine soln 10 mg/ml
EPZICOM – abacavir sulfate-lamivudine tab
600-300 mg
acyclovir cap 200 mg (Zovirax)
EVOTAZ – atazanavir sulfate-cobicistat tab
300-150 mg (base equiv)
acyclovir susp 200 mg/5ml (Zovirax)
FUZEON – enfuvirtide for inj 90 mg
acyclovir tab 400 mg (Zovirax)
INTELENCE – etravirine tab 25 mg
acyclovir tab 800 mg (Zovirax)
INVIRASE – saquinavir mesylate cap 200
mg
4
•
Dispensing Limits
Prior Approval
Drug Name
Specialty
Dispensing Limits
Prior Approval
Drug Name
Specialty
2015
INVIRASE – saquinavir mesylate tab 500
mg
PREZISTA – darunavir ethanolate tab 600
mg (base equiv)
ISENTRESS – raltegravir potassium tab
400 mg (base equiv)
mg (base equiv)
ISENTRESS – raltegravir potassium packet
for susp 100 mg (base equiv)
RESCRIPTOR – delavirdine mesylate tab
100 mg
ISENTRESS – raltegravir potassium chew
RESCRIPTOR – delavirdine mesylate tab
200 mg
ISENTRESS – raltegravir potassium chew
REYATAZ – atazanavir sulfate oral powder
packet 50 mg (base equiv)
KALETRA – lopinavir-ritonavir soln 400-100
mg/5ml (80-20 mg/ml)
REYATAZ – atazanavir sulfate cap 150 mg
(base equiv)
KALETRA – lopinavir-ritonavir tab 100-25
mg
(base equiv)
KALETRA – lopinavir-ritonavir tab 200-50
mg
(base equiv)
lamivudine oral soln 10 mg/ml (Epivir)
SELZENTRY – maraviroc tab 150 mg
lamivudine tab 150 mg (Epivir)
SELZENTRY – maraviroc tab 300 mg
lamivudine tab 300 mg (Epivir)
stavudine cap 15 mg (Zerit)
lamivudine-zidovudine tab 150-300 mg
(Combivir)
LEXIVA – fosamprenavir calcium tab 700
mg (base equiv)
LEXIVA – fosamprenavir calcium susp 50
mg/ml (base equiv)
nevirapine tab sr 24hr 400 mg (Viramune
xr)
stavudine for oral soln 1 mg/ml (Zerit)
STRIBILD – elvitegrav-cobicis-emtricitabtenofov tab 150-150-200-300 mg
SUSTIVA – efavirenz tab 600 mg
SUSTIVA – efavirenz cap 50 mg
NORVIR – ritonavir cap 100 mg
SUSTIVA – efavirenz cap 200 mg
NORVIR – ritonavir tab 100 mg
TIVICAY – dolutegravir sodium tab 50 mg
(base equiv)
PREZCOBIX – darunavir-cobicistat tab
800-150 mg
PREZISTA – darunavir ethanolate susp 100
mg/ml (base equiv)
mg (base equiv)
mg (base equiv)
Dispensing Limits
nevirapine tab 200 mg (Viramune)
NORVIR – ritonavir oral soln 80 mg/ml
Prior Approval
Drug Name
Specialty
Dispensing Limits
Prior Approval
Drug Name
Specialty
2015
TRIUMEQ – abacavir-dolutegravirlamivudine tab 600-50-300 mg
TRUVADA – emtricitabine-tenofovir
disoproxil fumarate tab 200-300 mg
TYBOST – cobicistat tab 150 mg
VIDEX – didanosine for soln 2 gm
VIDEX – didanosine for soln 4 gm
5
VIRACEPT – nelfinavir mesylate tab 250
mg
atovaquone-proguanil hcl tab
250-100 mg (Malarone)
VIRACEPT – nelfinavir mesylate tab 625
mg
chloroquine phosphate tab 250 mg
VIRAMUNE – nevirapine susp 50 mg/5ml
chloroquine phosphate tab 500 mg
(Aralen)
VIRAMUNE XR – nevirapine tab sr 24hr
100 mg
COARTEM – artemether-lumefantrine tab
20-120 mg
VIREAD – tenofovir disoproxil fumarate oral
powder 40 mg/gm
DARAPRIM – pyrimethamine tab 25 mg
VIREAD – tenofovir disoproxil fumarate tab
150 mg
mefloquine hcl tab 250 mg
PRIMAQUINE PHOSPHATE – primaquine
phosphate tab 26.3 mg (15 mg base)
250 mg
WORM INFECTIONS
300 mg
BILTRICIDE – praziquantel tab 600 mg
ALBENZA – albendazole tab 200 mg
VITEKTA – elvitegravir tab 85 mg
ivermectin tab 3 mg (Stromectol)
VITEKTA – elvitegravir tab 150 mg
SULFONAMIDES
ZIAGEN – abacavir sulfate soln 20 mg/ml
(base equiv)
sulfamethoxazole-trimethoprim susp
200-40 mg/5ml
zidovudine cap 100 mg (Retrovir)
sulfamethoxazole-trimethoprim tab
400-80 mg (Bactrim)
zidovudine tab 300 mg
sulfamethoxazole-trimethoprim tab
800-160 mg (Bactrim ds)
Influenza
OTHER ANTI-INFECTIVES
RELENZA DISKHALER – zanamivir aero
powder breath activated 5 mg/blister
ALINIA – nitazoxanide tab 500 mg
TAMIFLU – oseltamivir phosphate for susp
6 mg/ml (base equiv)
clindamycin hcl cap 75 mg (Cleocin)
ALINIA – nitazoxanide for susp 100 mg/5ml
TAMIFLU – oseltamivir phosphate cap 30
mg (base equiv)
mg (base equiv)
clindamycin palmitate hcl for soln
75 mg/5ml (base equiv) (Cleocin
pediatric gr)
mg (base equiv)
DAPSONE – dapsone tab 25 mg
MALARIA
DAPSONE – dapsone tab 100 mg
atovaquone-proguanil hcl tab 62.5-25 mg
(Malarone)
linezolid tab 600 mg (Zyvox)
6
Dispensing Limits
hydroxychloroquine sulfate tab 200 mg
(Plaquenil)
200 mg
zidovudine syrup 10 mg/ml (Retrovir)
Prior Approval
Drug Name
Specialty
Dispensing Limits
Prior Approval
Drug Name
Specialty
2015
• •
metronidazole tab 250 mg (Flagyl)
metronidazole tab 500 mg (Flagyl)
capecitabine tab 150 mg (Xeloda)
NEBUPENT – pentamidine isethionate for
nebulization soln 300 mg
capecitabine tab 500 mg (Xeloda)
SIVEXTRO – tedizolid phosphate tab 200
mg
CAPRELSA – vandetanib tab 300 mg
CAPRELSA – vandetanib tab 100 mg
Dispensing Limits
Prior Approval
Drug Name
Specialty
Dispensing Limits
Prior Approval
Drug Name
Specialty
2015
•
•
•
•
•
•
•
• •
• •
• •
trimethoprim tab 100 mg
COMETRIQ – cabozantinib s-malate cap 3
x 20 mg (60 mg dose) kit
vancomycin hcl cap 125 mg (Vancocin
hcl)
COMETRIQ – cabozantinib s-mal cap 1 x
80 mg & 1 x 20 mg (100 dose) kit
• • •
vancomycin hcl cap 250 mg (Vancocin
hcl)
COMETRIQ – cabozantinib s-mal cap 1 x
80 mg & 3 x 20 mg (140 dose) kit
• • •
XIFAXAN – rifaximin tab 550 mg
• •
CYCLOPHOSPHAMIDE –
cyclophosphamide cap 25 mg
GRASTEK – timothy grass pollen allergen
ext tab sl 2800 bau
•
CYCLOPHOSPHAMIDE –
cyclophosphamide cap 50 mg
ORALAIR – grass mixed pollen ext tab sl
300 ir (index of reactivity)
•
EMCYT – estramustine phosphate sodium
cap 140 mg
RAGWITEK – short ragweed pollen allergen
extract tab sl 12 amb a 1-u
•
ZYVOX – linezolid for susp 100 mg/5ml
IMMUNIZING AGENTS
ERIVEDGE – vismodegib cap 150 mg
ETOPOSIDE – etoposide cap 50 mg
exemestane tab 25 mg (Aromasin)
CANCER DRUGS
ACTIMMUNE – interferon gamma-1b inj
100 mcg/0.5ml (2000000 unit/0.5ml)
• •
AFINITOR – everolimus tab 2.5 mg
•
•
•
•
•
AFINITOR – everolimus tab 5 mg
AFINITOR – everolimus tab 7.5 mg
AFINITOR – everolimus tab 10 mg
AFINITOR DISPERZ – everolimus tab for
oral susp 2 mg
• • •
•
•
•
•
•
•
FARESTON – toremifene citrate tab 60 mg
(base equivalent)
•
•
•
•
•
FARYDAK – panobinostat lactate cap 10
mg (base equivalent)
• • •
• • •
• • •
flutamide cap 125 mg
oral susp 3 mg
• • •
GILOTRIF – afatinib dimaleate tab 20 mg
(base equivalent)
• • •
oral susp 5 mg
• • •
(base equivalent)
• • •
ALKERAN – melphalan tab 2 mg
•
(base equivalent)
• • •
•
GLEEVEC – imatinib mesylate tab 100 mg
(base equivalent)
• • •
GLEEVEC – imatinib mesylate tab 400 mg
(base equivalent)
• • •
anastrozole tab 1 mg (Arimidex)
bexarotene cap 75 mg (Targretin)
bicalutamide tab 50 mg (Casodex)
BOSULIF – bosutinib tab 100 mg
BOSULIF – bosutinib tab 500 mg
• • •
• • •
GLEOSTINE – lomustine cap 10 mg
7
LENVIMA 24MG DAILY DOSE – lenvatinib
cap therapy pack 10 (2) & 4 mg (24 mg
daily dose)
HEXALEN – altretamine cap 50 mg
HYCAMTIN – topotecan hcl cap 0.25 mg
(base equiv)
HYCAMTIN – topotecan hcl cap 1 mg (base
equiv)
•
• •
IBRANCE – palbociclib cap 100 mg
ICLUSIG – ponatinib hcl tab 15 mg (base
equiv)
•
•
•
•
•
•
•
•
• • •
IMBRUVICA – ibrutinib cap 140 mg
•
•
•
•
•
INLYTA – axitinib tab 1 mg
INLYTA – axitinib tab 5 mg
IRESSA – gefitinib tab 250 mg
JAKAFI – ruxolitinib phosphate tab 5 mg
(base equivalent)
Dispensing Limits
LEUCOVORIN CALCIUM – leucovorin
calcium tab 15 mg
ICLUSIG – ponatinib hcl tab 45 mg (base
equiv)
leucovorin calcium tab 5 mg
leucovorin calcium tab 25 mg
LEUKERAN – chlorambucil tab 2 mg
LOMUSTINE – lomustine cap 10 mg
LYNPARZA – olaparib cap 50 mg
•
•
•
•
•
Prior Approval
LEUCOVORIN CALCIUM – leucovorin
calcium tab 10 mg
• •
•
•
•
•
• • •
letrozole tab 2.5 mg (Femara)
hydroxyurea cap 500 mg (Hydrea)
Drug Name
Specialty
Dispensing Limits
Prior Approval
Drug Name
Specialty
2015
•
•
•
•
•
LYSODREN – mitotane tab 500 mg
MATULANE – procarbazine hcl cap 50 mg
• • •
•
•
megestrol acetate susp 40 mg/ml
(Megace oral)
megestrol acetate tab 20 mg
megestrol acetate tab 40 mg
(base equivalent)
• • •
MEKINIST – trametinib dimethyl sulfoxide
tab 0.5 mg (base equivalent)
• • •
(base equivalent)
• • •
MEKINIST – trametinib dimethyl sulfoxide
tab 2 mg (base equivalent)
• • •
(base equivalent)
• • •
mercaptopurine tab 50 mg (Purinethol)
•
(base equivalent)
• • •
cap therapy pack 10 mg (10 mg daily
dose)
• • •
cap therapy pack 10 & 4 mg (14 mg daily
dose)
• • •
cap therapy pack 10 (2) mg (20 mg daily
dose)
• • •
8
MESNEX – mesna tab 400 mg
methotrexate sodium tab 2.5 mg (base
equiv)
MYLERAN – busulfan tab 2 mg
NEXAVAR – sorafenib tosylate tab 200 mg
(base equivalent)
•
• • •
NILANDRON – nilutamide tab 150 mg
POMALYST – pomalidomide cap 1 mg
•
•
•
•
•
•
•
•
•
•
•
•
PURIXAN – mercaptopurine susp 2000
mg/100ml (20 mg/ml)
•
SOLTAMOX – tamoxifen citrate oral soln 10
mg/5ml (base equivalent)
SPRYCEL – dasatinib tab 20 mg
STIVARGA – regorafenib tab 40 mg
SUTENT – sunitinib malate cap 12.5 mg
(base equivalent)
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Dispensing Limits
Prior Approval
Drug Name
Specialty
Dispensing Limits
Prior Approval
Drug Name
Specialty
2015
TARCEVA – erlotinib hcl tab 150 mg (base
equivalent)
• • •
TARGRETIN – bexarotene cap 75 mg
•
• • •
TASIGNA – nilotinib hcl cap 150 mg (base
equivalent)
TASIGNA – nilotinib hcl cap 200 mg (base
equivalent)
• • •
temozolomide cap 5 mg (Temodar)
•
•
•
•
•
•
•
• • •
SUTENT – sunitinib malate cap 25 mg
(base equivalent)
• • •
tretinoin cap 10 mg
SUTENT – sunitinib malate cap 37.5 mg
(base equivalent)
• • •
TYKERB – lapatinib ditosylate tab 250 mg
(base equiv)
VOTRIENT – pazopanib hcl tab 200 mg
(base equiv)
• • •
SUTENT – sunitinib malate cap 50 mg
(base equivalent)
• • •
SYLATRON – peginterferon alfa-2b for inj
kit 200 mcg
•
XALKORI – crizotinib cap 200 mg
kit 300 mcg
•
XTANDI – enzalutamide cap 40 mg
kit 600 mcg
•
ZOLINZA – vorinostat cap 100 mg
•
•
•
•
•
•
•
•
•
XALKORI – crizotinib cap 250 mg
ZELBORAF – vemurafenib tab 240 mg
ZYDELIG – idelalisib tab 100 mg
TABLOID – thioguanine tab 40 mg
ZYDELIG – idelalisib tab 150 mg
TAFINLAR – dabrafenib mesylate cap 50
• • •
TAFINLAR – dabrafenib mesylate cap 75
• • •
ZYKADIA – ceritinib cap 150 mg
ZYTIGA – abiraterone acetate tab 250 mg
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
HORMONES, DIABETES AND RELATED DRUGS
CORTICOSTEROIDS
tamoxifen citrate tab 10 mg (base
equivalent)
budesonide cap sr 24hr 3 mg (Entocort
ec)
tamoxifen citrate tab 20 mg (base
equivalent)
equivalent)
• • •
equivalent)
• • •
CORTISONE ACETATE – cortisone acetate
tab 25 mg
DEXAMETHASONE – dexamethasone soln
0.5 mg/5ml
DEXAMETHASONE – dexamethasone tab
1 mg
9
Dispensing Limits
Prior Approval
Drug Name
Specialty
Dispensing Limits
Prior Approval
Drug Name
Specialty
2015
DEXAMETHASONE – dexamethasone tab
2 mg
prednisone tab 20 mg
dexamethasone elixir 0.5 mg/5ml
ANDRODERM – testosterone td patch 24hr
2 mg/24hr
•
ANDRODERM – testosterone td patch 24hr
4 mg/24hr
•
ANDROGEL – testosterone td gel 25
mg/2.5gm (1%)
•
ANDROGEL – testosterone td gel 50
mg/5gm (1%)
•
ANDROGEL – testosterone td gel 20.25
mg/1.25gm (1.62%)
•
ANDROGEL – testosterone td gel 40.5
mg/2.5gm (1.62%)
•
ANDROGEL PUMP – testosterone td gel
12.5 mg/act (1%)
•
•
methylprednisolone tab 4 mg (Medrol)
ANDROGEL PUMP – testosterone td gel
20.25 mg/act (1.62%)
ANDROXY – fluoxymesterone tab 10 mg
danazol cap 50 mg
danazol cap 100 mg
prednisolone sod phosph oral soln
6.7 mg/5ml (5 mg/5ml base) (Pediapred)
danazol cap 200 mg
DEXAMETHASONE INTENSOL –
dexamethasone conc 1 mg/ml
dexamethasone tab 0.5 mg
dexamethasone tab 4 mg
dexamethasone tab 6 mg
fludrocortisone acetate tab 0.1 mg
hydrocortisone tab 5 mg (Cortef)
methylprednisolone tab 4 mg dose pack
(Medrol dosepak)
MALE HORMONES
DEPO-TESTOSTERONE – testosterone
cypionate im inj in oil 100 mg/ml
•
DEPO-TESTOSTERONE – testosterone
cypionate im inj in oil 200 mg/ml
•
•
PREDNISONE – prednisone tab 50 mg
testosterone cypionate im inj in oil
100 mg/ml (Depo-testosterone)
PREDNISONE – prednisone oral soln 5
mg/5ml
testosterone cypionate im inj in oil
200 mg/ml (Depo-testosterone)
•
PREDNISONE – prednisone tab 5 mg dose
pack
testosterone enanthate im inj in oil
200 mg/ml
•
PREDNISONE – prednisone tab 10 mg
dose pack
ESTROGENS
prednisolone sod phosphate oral soln
15 mg/5ml (base equiv)
prednisolone syrup 15 mg/5ml (usp
solution equivalent) (Prelone)
prednisone tab 1 mg
prednisone tab 2.5 mg
prednisone tab 5 mg
prednisone tab 10 mg
10
CLIMARA PRO – estradiol-levonorgestrel td
patch weekly 0.045-0.015 mg/day
DIVIGEL – estradiol td gel 0.25 mg/0.25gm
(0.1%)
DIVIGEL – estradiol td gel 0.5 mg/0.5gm
(0.1%)
DIVIGEL – estradiol td gel 1 mg/gm (0.1%)
estradiol & norethindrone acetate tab
0.5-0.1 mg (Activella)
estradiol & norethindrone acetate tab
1-0.5 mg (Activella)
estradiol tab 0.5 mg (Estrace)
estradiol tab 1 mg (Estrace)
estradiol tab 2 mg (Estrace)
estradiol td patch twice weekly
0.025 mg/24hr (Vivelle-dot)
estradiol td patch weekly 0.025 mg/24hr
(Climara)
(37.5 mcg/24hr) (Climara)
(Climara)
(Climara)
(Climara)
(Climara)
ESTROPIPATE – estropipate tab 3 mg
estropipate tab 0.75 mg
estropipate tab 1.5 mg
PREFEST – estradiol tab 1 mg(15)/estradnorgestimate tab 1-0.09mg(15)
PREMARIN – estrogens, conjugated tab 0.3
mg
PREMARIN – estrogens, conjugated tab
0.45 mg
Dispensing Limits
Prior Approval
Drug Name
Specialty
Dispensing Limits
Prior Approval
Drug Name
Specialty
2015
0.625 mg
PREMARIN – estrogens, conjugated tab 0.9
mg
1.25 mg
PREMPHASE – conj est 0.625(14)/conj estmedroxypro ac tab 0.625-5mg(14)
PREMPRO – conjugated estrogenmedroxyprogest acetate tab 0.3-1.5 mg
PREMPRO – conjugated estrogenmedroxyprogest acetate tab 0.625-5 mg
PROGESTINS
medroxyprogesterone acetate tab 2.5 mg
(Provera)
medroxyprogesterone acetate tab 5 mg
(Provera)
medroxyprogesterone acetate tab 10 mg
(Provera)
norethindrone acetate tab 5 mg
(Aygestin)
progesterone micronized cap 100 mg
(Prometrium)
(Prometrium)
BIRTH CONTROL
Most generic oral contraceptives are formulary products.
Selected brands that are not available generically are
also on the formulary and appear as: TRADE NAME
followed by the generic name, e.g., OGESTREL –
norgestrel/ethinyl estradiol.
DEPO-PROVERA CONTRACEPTIV –
medroxyprogesterone acetate im susp
150 mg/ml
desogest-eth estrad & eth estrad tab
0.15-0.02/0.01 mg(21/5) (Mircette)
11
desogest-ethin est tab
0.1-0.025/0.125-0.025/0.15-0.025mg-mg
(Cyclessa)
desogestrel & ethinyl estradiol tab
0.15 mg-30 mcg (Desogen)
drospirenone-ethinyl estradiol tab
3-0.02 mg (Yaz)
drospirenone-ethinyl estradiol tab
3-0.03 mg (Yasmin 28)
norethindrone & ethinyl estradiol tab
0.5 mg-35 mcg (Brevicon-28)
1 mg-35 mcg (Norinyl 1+35)
norethindrone ac-ethinyl estrad-fe tab
1-20/1-30/1-35 mg-mcg (Estrostep fe)
norethindrone ace & ethinyl estradiol tab
1 mg-20 mcg (Loestrin 1/20-21)
ELLA – ulipristal acetate tab 30 mg
norethindrone ace & ethinyl estradiol tab
1.5 mg-30 mcg (Loestrin 1.5/30-21)
ethynodiol diacetate & ethinyl estradiol
tab 1 mg-35 mcg
norethindrone ace & ethinyl estradiol-fe
tab 1 mg-20 mcg (Loestrin fe 1/20)
levonorg-eth est tab 0.1-0.02mg(84) & eth
est tab 0.01mg(7) (Loseasonique)
norethindrone ace & ethinyl estradiol-fe
tab 1.5 mg-30 mcg (Loestrin fe 1.5/30)
levonorg-eth est tab 0.15-0.03mg(84)
& eth est tab 0.01mg(7) (amethia,
camrese, daysee)
norethindrone tab 0.35 mg (Nor-qd)
levonorgestrel & ethinyl estradiol (91day) tab 0.15-0.03 mg
norethindrone-eth estradiol tab
0.5-35/0.75-35/1-35 mg-mcg (Orthonovum 7/7/7)
levonorgestrel & ethinyl estradiol tab
0.1 mg-20 mcg
norethindrone-eth estradiol tab
0.5-35/1-35/0.5-35 mg-mcg (Tri-norinyl
28)
levonorgestrel & ethinyl estradiol tab
0.15 mg-30 mcg
norgestimate & ethinyl estradiol tab
0.25 mg-35 mcg (Ortho-cyclen)
levonorgestrel tab 1.5 mg (Plan b onestep)
norgestimate-eth estrad tab
0.18-35/0.215-35/0.25-35 mg-mcg (Ortho
tri-cyclen)
levonorgestrel-eth estra tab
0.05-30/0.075-40/0.125-30mg-mcg
medroxyprogesterone acetate im susp
150 mg/ml (Depo-provera contrac)
MIRENA – levonorgestrel releasing iud 20
mcg/24hr (52 mg total)
NECON 1/50-28 – norethindrone &
mestranol tab 1 mg-50 mcg
norgestrel & ethinyl estradiol tab
0.3 mg-30 mcg
NUVARING – etonogestrel-ethinyl estradiol
va ring 0.120-0.015 mg/24hr
OGESTREL – norgestrel & ethinyl estradiol
tab 0.5 mg-50 mcg
NECON 10/11-28 – norethindrone-eth
estradiol tab 0.5-35/1-35 mg-mcg (10/11)
ORTHO TRI-CYCLEN LO – norgestimateeth estrad tab 0.18-25/0.215-25/0.25-25
mg-mcg
norelgestromin-ethinyl estradiol td ptwk
150-35 mcg/24hr (Ortho evra)
SKYLA – levonorgestrel releasing iud 13.5
mg
0.4 mg-35 mcg (Ovcon-35)
ZOVIA 1/50E – ethynodiol diacetate &
ethinyl estradiol tab 1 mg-50 mcg
INFERTILITY
12
Dispensing Limits
Prior Approval
Drug Name
Specialty
Dispensing Limits
Prior Approval
Drug Name
Specialty
2015
BRAVELLE – urofollitropin purified for inj 75
unit
•
CETROTIDE – cetrorelix acetate for inj kit
0.25 mg
•
chorionic gonadotropin for inj 10000 unit
•
clomiphene citrate tab 50 mg (Clomid)
Dispensing Limits
Prior Approval
Drug Name
Specialty
Dispensing Limits
Prior Approval
Drug Name
Specialty
2015
acarbose tab 50 mg (Precose)
BYDUREON – exenatide extended release
for susp pen-injector 2 mg
•
BYDUREON – exenatide extended release
for inj susp 2 mg
•
FOLLISTIM AQ – follitropin beta inj 75
unit/0.5ml
•
BYETTA – exenatide soln pen-injector 5
mcg/0.02ml
•
unit/0.36ml
•
BYETTA – exenatide soln pen-injector 10
mcg/0.04ml
•
unit/0.72ml
•
glimepiride tab 1 mg (Amaryl)
unit/1.08ml
•
GANIRELIX ACETATE – ganirelix acetate
inj 250 mcg/0.5ml
•
glipizide tab sr 24hr 2.5 mg (Glucotrol xl)
GONAL-F – follitropin alfa for inj 450 unit
•
•
•
glipizide tab sr 24hr 10 mg (Glucotrol xl)
GONAL-F – follitropin alfa for inj 1050 unit
GONAL-F RFF – follitropin alfa for inj 75
unit
glipizide tab sr 24hr 5 mg (Glucotrol xl)
glipizide tab 5 mg (Glucotrol)
glipizide tab 10 mg (Glucotrol)
glipizide-metformin hcl tab 2.5-250 mg
GONAL-F RFF PEN – follitropin alfa inj 300
unit/0.5ml
•
unit/0.75ml
•
unit/1.5ml
•
GONAL-F RFF REDIJECT – follitropin alfa
inj 300 unit/0.5ml
•
GLYBURIDE – glyburide tab 2.5 mg
inj 450 unit/0.75ml
•
glyburide micronized tab 1.5 mg
(Glynase)
inj 900 unit/1.5ml
•
glyburide micronized tab 3 mg (Glynase)
MENOPUR – menotropins for
subcutaneous inj 75 unit
•
OVIDREL – choriogonadotropin alfa inj 250
mcg/0.5ml
•
REPRONEX – menotropins for inj 75 unit
•
DIABETES
glipizide-metformin hcl tab 2.5-500 mg
glipizide-metformin hcl tab 5-500 mg
GLUCAGON EMERGENCY KIT – glucagon
(rdna) for inj kit 1 mg
GLYBURIDE – glyburide tab 1.25 mg
GLYBURIDE – glyburide tab 5 mg
glyburide micronized tab 6 mg (Glynase)
glyburide tab 1.25 mg
glyburide tab 2.5 mg
glyburide tab 5 mg
glyburide-metformin tab 1.25-250 mg
(Glucovance)
(Glucovance)
13
glyburide-metformin tab 5-500 mg
(Glucovance)
metformin hcl tab 500 mg (Glucophage)
INVOKAMET – canagliflozin-metformin hcl
tab 50-500 mg
tab 50-1000 mg
nateglinide tab 120 mg (Starlix)
nateglinide tab 60 mg (Starlix)
ONGLYZA – saxagliptin hcl tab 2.5 mg
(base equiv)
tab 150-1000 mg
ONGLYZA – saxagliptin hcl tab 5 mg (base
equiv)
INVOKANA – canagliflozin tab 100 mg
pioglitazone hcl tab 15 mg (base equiv)
(Actos)
JANUMET – sitagliptin-metformin hcl tab
50-500 mg
JANUMET – sitagliptin-metformin hcl tab
50-1000 mg
JANUMET XR – sitagliptin-metformin hcl
tab sr 24hr 50-500 mg
tab sr 24hr 50-1000 mg
tab sr 24hr 100-1000 mg
JANUVIA – sitagliptin phosphate tab 25 mg
(base equiv)
JANUVIA – sitagliptin phosphate tab 50 mg
(base equiv)
JANUVIA – sitagliptin phosphate tab 100
mg (base equiv)
(Actos)
(Actos)
pioglitazone hcl-metformin hcl tab
15-500 mg (Actoplus met)
pioglitazone hcl-metformin hcl tab
15-850 mg (Actoplus met)
SYMLINPEN 120 – pramlintide acetate peninj 2700 mcg/2.7ml (1000 mcg/ml)
SYMLINPEN 60 – pramlintide acetate peninj 1500 mcg/1.5ml (1000 mcg/ml)
VICTOZA – liraglutide soln pen-injector 18
mg/3ml (6 mg/ml)
DIABETES - INSULINS
Rapid-Acting Insulins
JARDIANCE – empagliflozin tab 10 mg
NOVOLOG – insulin aspart inj 100 unit/ml
JARDIANCE – empagliflozin tab 25 mg
NOVOLOG FLEXPEN – insulin aspart soln
pen-injector 100 unit/ml
KOMBIGLYZE XR – saxagliptin-metformin
hcl tab sr 24hr 2.5-1000 mg
hcl tab sr 24hr 5-500 mg
hcl tab sr 24hr 5-1000 mg
NOVOLOG PENFILL – insulin aspart soln
cartridge 100 unit/ml
NOVOLOG PENFILL – insulin aspart inj 100
unit/ml
Short-Acting Insulins
metformin hcl tab sr 24hr 500 mg
(Glucophage xr)
NOVOLIN R – insulin regular (human) inj
100 unit/ml
metformin hcl tab sr 24hr 750 mg
(Glucophage xr)
Intermediate-Acting Insulins
14
Dispensing Limits
tab 150-500 mg
INVOKANA – canagliflozin tab 300 mg
Prior Approval
Drug Name
Specialty
Dispensing Limits
Prior Approval
Drug Name
Specialty
2015
•
NOVOLIN N – insulin nph (human)
(isophane) inj 100 unit/ml
levothyroxine sodium tab 175 mcg
(Synthroid)
NOVOLIN 70/30 – insulin nph isophane &
regular human inj 100 unit/ml (70-30)
(Synthroid)
NOVOLOG MIX 70/30 – insulin aspart prot
& aspart (human) inj 100 unit/ml (70-30)
(Synthroid)
NOVOLOG MIX 70/30 PREFILL – insulin
aspart prot & aspart sus pen-inj 100 unit/
ml (70-30)
liothyronine sodium tab 5 mcg (Cytomel)
Basal Insulins
liothyronine sodium tab 50 mcg
(Cytomel)
LANTUS – insulin glargine inj 100 unit/ml
methimazole tab 5 mg (Tapazole)
LEVEMIR – insulin detemir inj 100 unit/ml
propylthiouracil tab 50 mg
LEVEMIR FLEXPEN – insulin detemir soln
GROWTH HORMONE
TOUJEO SOLOSTAR – insulin glargine
soln pen-injector 300 unit/ml
methimazole tab 10 mg (Tapazole)
INCRELEX – mecasermin inj 40 mg/4ml (10
mg/ml)
• •
OMNITROPE – somatropin for inj 5.8 mg
• •
• •
• •
OMNITROPE – somatropin inj 5 mg/1.5ml
THYROID REGULATION
OMNITROPE – somatropin inj 10 mg/1.5ml
(Synthroid)
OTHER HORMONES AND RELATED DRUGS
(Synthroid)
ALENDRONATE SODIUM – alendronate
sodium tab 40 mg
alendronate sodium tab 5 mg
(Synthroid)
(Synthroid)
alendronate sodium tab 70 mg (Fosamax)
(Synthroid)
(Synthroid)
Dispensing Limits
liothyronine sodium tab 25 mcg
(Cytomel)
LANTUS SOLOSTAR – insulin glargine soln
LEVEMIR FLEXTOUCH – insulin detemir
soln pen-injector 100 unit/ml
Prior Approval
Drug Name
Specialty
Dispensing Limits
Prior Approval
Drug Name
Specialty
2015
cabergoline tab 0.5 mg
calcitonin (salmon) nasal soln 200 unit/
act (Miacalcin)
calcitriol cap 0.25 mcg (Rocaltrol)
(Synthroid)
calcitriol cap 0.5 mcg (Rocaltrol)
(Synthroid)
desmopressin acetate inj 4 mcg/ml
(Ddavp)
(Synthroid)
desmopressin acetate nasal soln 0.01%
(refrigerated) (Ddavp)
calcitriol oral soln 1 mcg/ml (Rocaltrol)
15
desmopressin acetate nasal spray soln
0.01% (Ddavp)
SANDOSTATIN – octreotide acetate inj 50
mcg/ml (0.05 mg/ml)
desmopressin acetate nasal spray soln
0.01% (refrigerated)
mcg/ml (0.1 mg/ml)
desmopressin acetate tab 0.1 mg (Ddavp)
desmopressin acetate tab 0.2 mg (Ddavp)
mcg/ml (0.2 mg/ml)
ETIDRONATE DISODIUM – etidronate
disodium tab 200 mg
mcg/ml (0.5 mg/ml)
ETIDRONATE DISODIUM – etidronate
disodium tab 400 mg
SANDOSTATIN – octreotide acetate inj
1000 mcg/ml (1 mg/ml)
FORTEO – teriparatide (recombinant) inj
600 mcg/2.4ml
• • •
SANDOSTATIN LAR DEPOT – octreotide
acetate for im inj kit 10 mg
ibandronate sodium tab 150 mg (base
equivalent) (Boniva)
KUVAN – sapropterin dihydrochloride
soluble tab 100 mg
• •
powder packet 100 mg
• •
SENSIPAR – cinacalcet hcl tab 30 mg
(base equiv)
•
powder packet 500 mg
• •
(base equiv)
•
levocarnitine oral soln 1 gm/10ml (10%)
(Carnitor)
(base equiv)
•
levocarnitine tab 330 mg (Carnitor)
STIMATE – desmopressin acetate nasal
soln 1.5 mg/ml
methylergonovine maleate tab 0.2 mg
octreotide acetate inj 50 mcg/ml
(0.05 mg/ml) (Sandostatin)
octreotide acetate inj 1000 mcg/ml (1 mg/
ml) (Sandostatin)
paricalcitol cap 1 mcg (Zemplar)
raloxifene hcl tab 60 mg (Evista)
16
HEART AND CIRCULATORY DRUGS
ANGIOTENSIN CONVERTING ENZYME (ACE)
INHIBITORS AND COMBINATIONS
benazepril & hydrochlorothiazide tab
5-6.25 mg
10-12.5 mg (Lotensin hct)
20-12.5 mg (Lotensin hct)
20-25 mg (Lotensin hct)
benazepril hcl tab 5 mg
benazepril hcl tab 10 mg (Lotensin)
Dispensing Limits
Prior Approval
Drug Name
Specialty
Dispensing Limits
Prior Approval
Drug Name
Specialty
2015
captopril tab 12.5 mg
lisinopril tab 10 mg (Prinivil)
captopril tab 25 mg
captopril tab 50 mg
lisinopril tab 30 mg (Zestril)
captopril tab 100 mg
lisinopril tab 40 mg (Zestril)
CAPTOPRIL/HYDROCHLOROTHIA –
captopril & hydrochlorothiazide tab 25-15
mg
moexipril hcl tab 7.5 mg (Univasc)
mg
mg
moexipril-hydrochlorothiazide tab
7.5-12.5 mg
15-12.5 mg (Uniretic)
15-25 mg
perindopril erbumine tab 2 mg
enalapril maleate & hydrochlorothiazide
tab 5-12.5 mg
quinapril hcl tab 5 mg (Accupril)
enalapril maleate & hydrochlorothiazide
tab 10-25 mg (Vaseretic)
perindopril erbumine tab 4 mg (Aceon)
perindopril erbumine tab 8 mg (Aceon)
enalapril maleate tab 2.5 mg (Vasotec)
enalapril maleate tab 5 mg (Vasotec)
quinapril-hydrochlorothiazide tab
10-12.5 mg (Accuretic)
20-12.5 mg (Accuretic)
fosinopril sodium & hydrochlorothiazide
tab 10-12.5 mg
20-25 mg (Accuretic)
fosinopril sodium & hydrochlorothiazide
tab 20-12.5 mg
ramipril cap 1.25 mg (Altace)
fosinopril sodium tab 10 mg
lisinopril & hydrochlorothiazide tab
10-12.5 mg (Zestoretic)
20-12.5 mg (Zestoretic)
20-25 mg (Zestoretic)
lisinopril tab 2.5 mg (Zestril)
Dispensing Limits
moexipril hcl tab 15 mg (Univasc)
mg
Prior Approval
Drug Name
Specialty
Dispensing Limits
Prior Approval
Drug Name
Specialty
2015
ramipril cap 2.5 mg (Altace)
ramipril cap 5 mg (Altace)
ramipril cap 10 mg (Altace)
trandolapril tab 1 mg (Mavik)
ANGIOTENSIN II RECEPTOR ANTAGONISTS (ARBS)
AND COMBINATIONS
amlodipine-valsartanhydrochlorothiazide tab 5-160-12.5 mg
(Exforge hct)
•
17
amlodipine-valsartanhydrochlorothiazide tab
10-160-12.5 mg (Exforge hct)
•
amlodipine-valsartanhydrochlorothiazide tab 10-160-25 mg
(Exforge hct)
•
(Exforge hct)
•
candesartan cilexetil tab 4 mg (Atacand)
•
•
•
•
•
candesartan cilexetilhydrochlorothiazide tab 16-12.5 mg
(Atacand hct)
losartan potassium tab 50 mg (Cozaar)
•
candesartan cilexetilhydrochlorothiazide tab 32-25 mg
(Atacand hct)
•
irbesartan tab 75 mg (Avapro)
•
•
•
•
irbesartan-hydrochlorothiazide tab
150-12.5 mg (Avalide)
telmisartan tab 20 mg (Micardis)
candesartan cilexetilhydrochlorothiazide tab 32-12.5 mg
(Atacand hct)
telmisartan-hydrochlorothiazide tab
40-12.5 mg (Micardis hct)
•
•
•
•
•
•
•
80-12.5 mg (Micardis hct)
•
80-25 mg (Micardis hct)
•
valsartan tab 40 mg (Diovan)
•
•
•
•
•
valsartan-hydrochlorothiazide tab
80-12.5 mg (Diovan hct)
•
160-25 mg (Diovan hct)
•
•
320-25 mg (Diovan hct)
•
BETA BLOCKERS AND COMBINATIONS
acebutolol hcl cap 200 mg (Sectral)
irbesartan-hydrochlorothiazide tab
300-12.5 mg (Avalide)
•
acebutolol hcl cap 400 mg (Sectral)
losartan potassium &
hydrochlorothiazide tab 50-12.5 mg
(Hyzaar)
•
atenolol & chlorthalidone tab 50-25 mg
(Tenoretic 50)
hydrochlorothiazide tab 100-12.5 mg
(Hyzaar)
•
hydrochlorothiazide tab 100-25 mg
(Hyzaar)
•
18
Dispensing Limits
Prior Approval
•
Specialty
(Exforge hct)
Prior Approval
Drug Name
Drug Name
Specialty
Dispensing Limits
2015
atenolol & chlorthalidone tab 100-25 mg
(Tenoretic 100)
atenolol tab 25 mg (Tenormin)
bisoprolol & hydrochlorothiazide tab
2.5-6.25 mg (Ziac)
5-6.25 mg (Ziac)
metoprolol tartrate tab 100 mg
(Lopressor)
10-6.25 mg (Ziac)
nadolol & bendroflumethiazide tab
40-5 mg (Corzide)
bisoprolol fumarate tab 5 mg (Zebeta)
bisoprolol fumarate tab 10 mg (Zebeta)
nadolol & bendroflumethiazide tab
80-5 mg (Corzide)
carvedilol tab 3.125 mg (Coreg)
nadolol tab 20 mg (Corgard)
carvedilol tab 25 mg (Coreg)
pindolol tab 5 mg
DUTOPROL – metoprolol &
hydrochlorothiazide tab sr 24hr 25-12.5
mg
pindolol tab 10 mg
mg
PROPRANOLOL HCL – propranolol hcl oral
soln 40 mg/5ml
mg
labetalol hcl tab 100 mg (Trandate)
metoprolol & hydrochlorothiazide tab
50-25 mg (Lopressor hct)
propranolol hcl cap sr 24hr 60 mg
(Inderal la)
(Inderal la)
(Inderal la)
(Inderal la)
propranolol hcl tab 10 mg
100-50 mg
metoprolol succinate tab sr 24hr 50 mg
(Toprol xl)
PROPRANOLOL/HYDROCHLOROTH –
propranolol & hydrochlorothiazide tab
40-25 mg
(Toprol xl)
PROPRANOLOL/HYDROCHLOROTH –
propranolol & hydrochlorothiazide tab
80-25 mg
(Toprol xl)
TIMOLOL MALEATE – timolol maleate tab
5 mg
metoprolol tartrate tab 25 mg
10 mg
metoprolol tartrate tab 50 mg (Lopressor)
Dispensing Limits
PROPRANOLOL HCL – propranolol hcl oral
soln 20 mg/5ml
100-25 mg (Lopressor hct)
(Toprol xl)
Prior Approval
Drug Name
Specialty
Dispensing Limits
Prior Approval
Drug Name
Specialty
2015
19
Dispensing Limits
Prior Approval
Drug Name
Specialty
Dispensing Limits
Prior Approval
Drug Name
Specialty
2015
20 mg
amlodipine besylate-benazepril hcl cap
10-40 mg (Lotrel)
CALCIUM CHANNEL BLOCKERS AND
COMBINATIONS
amlodipine besylate-valsartan tab
5-160 mg (Exforge)
•
amlodipine besylate tab 2.5 mg (Norvasc)
5-320 mg (Exforge)
•
10-160 mg (Exforge)
•
10-320 mg (Exforge)
•
amlodipine besylate tab 5 mg (Norvasc)
amlodipine besylate tab 10 mg (Norvasc)
amlodipine besylate-atorvastatin calcium
tab 2.5-10 mg (Caduet)
diltiazem hcl cap sr 24hr 120 mg
tab 5-10 mg (Caduet)
diltiazem hcl coated beads cap sr 24hr
120 mg (Cardizem cd)
diltiazem hcl extended release beads cap
sr 24hr 120 mg (Tiazac)
2.5-10 mg (Lotrel)
5-10 mg (Lotrel)
5-20 mg (Lotrel)
5-40 mg (Lotrel)
diltiazem hcl tab 30 mg (Cardizem)
10-20 mg (Lotrel)
diltiazem hcl tab 90 mg
20
felodipine tab sr 24hr 2.5 mg
isosorbide dinitrate tab 10 mg
felodipine tab sr 24hr 5 mg
isosorbide dinitrate tab 20 mg
felodipine tab sr 24hr 10 mg
isosorbide mononitrate tab sr 24hr
30 mg (Imdur)
nifedipine tab sr 24hr 30 mg (Adalat cc)
nifedipine tab sr 24hr osmotic 30 mg
(Procardia xl)
(Procardia xl)
120 mg (Imdur)
isosorbide mononitrate tab 10 mg
isosorbide mononitrate tab 20 mg
NITRO-BID – nitroglycerin oint 2%
VERAPAMIL HCL – verapamil hcl tab 40
mg
nitroglycerin cap cr 6.5 mg
verapamil hcl cap sr 24hr 100 mg
(Verelan pm)
nitroglycerin td patch 24hr 0.1 mg/hr
(Nitro-dur)
(Verelan)
(Nitro-dur)
(Verelan)
(Nitro-dur)
(Verelan pm)
(Nitro-dur)
(Verelan)
NITROSTAT – nitroglycerin sl tab 0.3 mg
(Verelan pm)
verapamil hcl tab cr 120 mg (Calan sr)
verapamil hcl tab 80 mg (Calan)
verapamil hcl tab 120 mg (Calan)
Dispensing Limits
60 mg (Imdur)
(Procardia xl)
(Verelan)
Prior Approval
Drug Name
Specialty
Dispensing Limits
Prior Approval
Drug Name
Specialty
2015
nitroglycerin cap cr 2.5 mg
nitroglycerin cap cr 9 mg
CHOLESTEROL LOWERING
atorvastatin calcium tab 10 mg (base
equivalent) (Lipitor)
CHEST PAIN (ANGINA)
ISOSORBIDE DINITRATE – isosorbide
dinitrate tab 30 mg
cholestyramine light powder packets
4 gm
isosorbide dinitrate tab 5 mg (Isordil
titradose)
cholestyramine light powder 4 gm/dose
(Questran light)
21
Dispensing Limits
Prior Approval
Drug Name
Specialty
Dispensing Limits
Prior Approval
Drug Name
Specialty
2015
cholestyramine powder packets 4 gm
(Questran)
JUXTAPID – lomitapide mesylate cap 20
mg (base equiv)
• • •
cholestyramine powder 4 gm/dose
(Questran)
mg (base equiv)
• • •
choline fenofibrate cap dr 45 mg
(fenofibric acid equiv) (Trilipix)
mg (base equiv)
• • •
choline fenofibrate cap dr 135 mg
(fenofibric acid equiv) (Trilipix)
mg (base equiv)
• • •
colestipol hcl granule packets 5 gm
(Colestid flavored)
lovastatin tab 10 mg
colestipol hcl granules 5 gm (Colestid
flavored)
lovastatin tab 40 mg (Mevacor)
lovastatin tab 20 mg (Mevacor)
niacin tab cr 500 mg (antihyperlipidemic)
(Niaspan)
colestipol hcl tab 1 gm (Colestid)
CRESTOR – rosuvastatin calcium tab 5 mg
(Niaspan)
CRESTOR – rosuvastatin calcium tab 10
mg
niacin tab cr 1000 mg
(antihyperlipidemic) (Niaspan)
mg
omega-3-acid ethyl esters cap 1 gm
(Lovaza)
mg
pravastatin sodium tab 10 mg
fenofibrate micronized cap 43 mg
(Antara)
pravastatin sodium tab 20 mg (Pravachol)
(Lofibra)
(Antara)
simvastatin tab 5 mg (Zocor)
(Lofibra)
(Lofibra)
WELCHOL – colesevelam hcl tab 625 mg
fenofibrate tab 48 mg (Tricor)
fenofibrate tab 54 mg (Lofibra)
WELCHOL – colesevelam hcl packet for
susp 3.75 gm
fenofibrate tab 145 mg (Tricor)
FLUID REDUCTION
fenofibrate tab 160 mg (Lofibra)
ACETAZOLAMIDE – acetazolamide tab 125
mg
gemfibrozil tab 600 mg (Lopid)
JUXTAPID – lomitapide mesylate cap 5 mg
(base equiv)
• • •
mg (base equiv)
• • •
22
acetazolamide cap sr 12hr 500 mg
(Diamox)
acetazolamide tab 250 mg
amiloride & hydrochlorothiazide tab
5-50 mg
triamterene & hydrochlorothiazide cap
37.5-25 mg (Dyazide)
amiloride hcl tab 5 mg
triamterene & hydrochlorothiazide tab
37.5-25 mg (Maxzide-25)
bumetanide tab 0.5 mg
bumetanide tab 1 mg
bumetanide tab 2 mg
TRIAMTERENE/HYDROCHLOROTH –
triamterene & hydrochlorothiazide cap
50-25 mg
chlorothiazide tab 500 mg
HEART RHYTHM
CHLORTHALIDONE – chlorthalidone tab 25
mg
amiodarone hcl tab 100 mg
CHLORTHALIDONE – chlorthalidone tab 50
mg
amiodarone hcl tab 400 mg
furosemide tab 20 mg (Lasix)
amiodarone hcl tab 200 mg (Cordarone)
disopyramide phosphate cap 100 mg
(Norpace)
disopyramide phosphate cap 150 mg
(Norpace)
flecainide acetate tab 50 mg
hydrochlorothiazide cap 12.5 mg
(Microzide)
hydrochlorothiazide tab 12.5 mg
hydrochlorothiazide tab 25 mg
hydrochlorothiazide tab 50 mg
indapamide tab 1.25 mg
indapamide tab 2.5 mg
metolazone tab 2.5 mg (Zaroxolyn)
metolazone tab 5 mg (Zaroxolyn)
metolazone tab 10 mg
spironolactone & hydrochlorothiazide
tab 25-25 mg (Aldactazide)
spironolactone tab 25 mg (Aldactone)
torsemide tab 5 mg (Demadex)
Dispensing Limits
triamterene & hydrochlorothiazide tab
75-50 mg (Maxzide)
CHLOROTHIAZIDE – chlorothiazide tab
250 mg
furosemide oral soln 10 mg/ml
Prior Approval
Drug Name
Specialty
Dispensing Limits
Prior Approval
Drug Name
Specialty
2015
mexiletine hcl cap 150 mg
MULTAQ – dronedarone hcl tab 400 mg
(base equivalent)
NORPACE CR – disopyramide phosphate
cap sr 12hr 100 mg
propafenone hcl cap sr 12hr 225 mg
(Rythmol sr)
(Rythmol sr)
(Rythmol sr)
propafenone hcl tab 150 mg (Rythmol)
propafenone hcl tab 225 mg (Rythmol)
propafenone hcl tab 300 mg
quinidine gluconate tab cr 324 mg
23
QUINIDINE SULFATE – quinidine sulfate
tab 200 mg
guanfacine hcl tab 1 mg (Tenex)
QUINIDINE SULFATE ER – quinidine
sulfate tab cr 300 mg
hydralazine hcl tab 10 mg
sotalol hcl (afib/afl) tab 80 mg (Betapace
af)
af)
LETAIRIS – ambrisentan tab 5 mg
af)
methyldopa tab 250 mg
sotalol hcl tab 80 mg (Betapace)
midodrine hcl tab 2.5 mg
midodrine hcl tab 5 mg
midodrine hcl tab 10 mg
sotalol hcl tab 240 mg
minoxidil tab 2.5 mg
LETAIRIS – ambrisentan tab 10 mg
• • •
• • •
methyldopa tab 500 mg
OTHER HEART RELATED DRUGS
clonidine hcl tab 0.1 mg (Catapres)
• • •
minoxidil tab 10 mg
OPSUMIT – macitentan tab 10 mg
• • •
phenoxybenzamine hcl cap 10 mg
(Dibenzyline)
prazosin hcl cap 1 mg (Minipress)
clonidine hcl td patch weekly
0.1 mg/24hr (Catapres-tts-1)
REMODULIN – treprostinil sodium inj 1 mg/
ml (base equiv)
•
REMODULIN – treprostinil sodium inj 2.5
mg/ml (base equiv)
•
DIBENZYLINE – phenoxybenzamine hcl
cap 10 mg
REMODULIN – treprostinil sodium inj 5 mg/
ml (base equiv)
•
DIGOXIN – digoxin oral soln 0.05 mg/ml
REMODULIN – treprostinil sodium inj 10
mg/ml (base equiv)
•
digoxin tab 125 mcg (0.125 mg) (Lanoxin)
digoxin tab 250 mcg (0.25 mg) (Lanoxin)
sildenafil citrate tab 20 mg (Revatio)
doxazosin mesylate tab 1 mg (Cardura)
terazosin hcl cap 1 mg
eplerenone tab 25 mg (Inspra)
TRACLEER – bosentan tab 62.5 mg
eplerenone tab 50 mg (Inspra)
TRACLEER – bosentan tab 125 mg
24
Dispensing Limits
guanfacine hcl tab 2 mg (Tenex)
quinidine sulfate tab 300 mg
ADCIRCA – tadalafil tab 20 mg (pah)
Prior Approval
Drug Name
Specialty
Dispensing Limits
Prior Approval
Drug Name
Specialty
2015
• • •
• • •
• • •
VENTAVIS – iloprost inhalation solution 10
mcg/ml
• • •
triamcinolone acetonide nasal aerosol
suspension 55 mcg/act (Nasacort aq)
VENTAVIS – iloprost inhalation solution 20
mcg/ml
• • •
COUGH/COLD/ALLERGY
Dispensing Limits
Prior Approval
Drug Name
Specialty
Dispensing Limits
Prior Approval
Drug Name
Specialty
2015
•
acetylcysteine inhal soln 10%
BEE STING KITS
acetylcysteine inhal soln 20%
EPIPEN 2-PAK – epinephrine solution autoinjector 0.3 mg/0.3ml (1:1000)
promethazine w/ codeine syrup
6.25-10 mg/5ml
EPIPEN-JR 2-PAK – epinephrine solution
auto-injector 0.15 mg/0.3ml (1:2000)
SSKI – potassium iodide soln 1 gm/ml
ASTHMA/COPD
RESPIRATORY AGENTS
ANTIHISTAMINES
cyproheptadine hcl syrup 2 mg/5ml
cyproheptadine hcl tab 4 mg
promethazine hcl suppos 12.5 mg
promethazine hcl suppos 25 mg
promethazine hcl suppos 50 mg
promethazine hcl syrup 6.25 mg/5ml
promethazine hcl tab 12.5 mg
promethazine hcl tab 25 mg
promethazine hcl tab 50 mg
ADVAIR DISKUS – fluticasone-salmeterol
aer powder ba 100-50 mcg/dose
•
•
•
ADVAIR HFA – fluticasone-salmeterol inhal
aerosol 45-21 mcg/act
•
•
•
ASTEPRO – azelastine hcl nasal spray
0.15% (205.5 mcg/spray)
•
albuterol sulfate soln nebu 0.083%
(2.5 mg/3ml)
azelastine hcl nasal spray 0.1%
(137 mcg/spray)
•
albuterol sulfate soln nebu 0.5% (5 mg/
ml)
azelastine hcl nasal spray 0.15%
(205.5 mcg/spray) (Astepro)
•
albuterol sulfate soln nebu 0.63 mg/3ml
(base equiv)
NASAL PRODUCTS
albuterol sulfate soln nebu 1.25 mg/3ml
(base equiv)
BACTROBAN NASAL – mupirocin calcium
nasal oint 2%
albuterol sulfate syrup 2 mg/5ml
flunisolide nasal soln 25 mcg/act
(0.025%) (Flunisolide)
•
albuterol sulfate tab sr 12hr 4 mg
(Vospire er)
fluticasone propionate nasal susp
50 mcg/act (Flonase)
•
albuterol sulfate tab sr 12hr 8 mg
(Vospire er)
ipratropium bromide nasal soln 0.03%
(21 mcg/spray) (Atrovent)
•
albuterol sulfate tab 2 mg
ipratropium bromide nasal soln 0.06%
(42 mcg/spray) (Atrovent)
•
albuterol sulfate tab 4 mg
ANORO ELLIPTA – umeclidinium-vilanterol
aero powd ba 62.5-25 mcg/inh
•
25
Dispensing Limits
Prior Approval
Drug Name
Specialty
Dispensing Limits
Prior Approval
Drug Name
Specialty
2015
ARNUITY ELLIPTA – fluticasone furoate
aerosol powder breath activ 100 mcg/act
•
DULERA – mometasone furoate-formoterol
fumarate aerosol 100-5 mcg/act
•
ARNUITY ELLIPTA – fluticasone furoate
aerosol powder breath activ 200 mcg/act
•
DULERA – mometasone furoate-formoterol
fumarate aerosol 200-5 mcg/act
•
ASMANEX HFA – mometasone furoate
inhal aerosol suspension 100 mcg/act
•
FLOVENT DISKUS – fluticasone propionate
aer pow ba 50 mcg/blister
•
ASMANEX HFA – mometasone furoate
inhal aerosol suspension 200 mcg/act
•
•
ASMANEX TWISTHALER 120 ME –
mometasone furoate inhal powd 220 mcg/
inh (breath activated)
•
•
FLOVENT HFA – fluticasone propionate hfa
inhal aero 44 mcg/act (50/valve)
•
ASMANEX TWISTHALER 14 MET –
•
•
•
inhal aer 110 mcg/act (125/valve)
inhal aer 220 mcg/act (250/valve)
•
•
FORADIL AEROLIZER – formoterol
fumarate inhal cap 12 mcg
•
•
•
INCRUSE ELLIPTA – umeclidinium br aero
powd breath act 62.5 mcg/inh (base eq)
ATROVENT HFA – ipratropium bromide hfa
inhal aerosol 17 mcg/act
•
ipratropium-albuterol nebu soln
0.5-2.5(3) mg/3ml (Duoneb)
BREO ELLIPTA – fluticasone furoatevilanterol aero powd ba 100-25 mcg/inh
•
levalbuterol hcl soln nebu conc
1.25 mg/0.5ml (base equiv)
BREO ELLIPTA – fluticasone furoatevilanterol aero powd ba 200-25 mcg/inh
•
levalbuterol hcl soln nebu 0.31 mg/3ml
(base equiv) (Xopenex)
budesonide inhalation susp 0.25 mg/2ml
(Pulmicort)
(Pulmicort)
montelukast sodium chew tab 4 mg
(base equiv) (Singulair)
budesonide inhalation susp 1 mg/2ml
(Pulmicort)
COMBIVENT RESPIMAT – ipratropiumalbuterol inhal aerosol soln 20-100 mcg/
act
CROMOLYN SODIUM – cromolyn sodium
soln nebu 20 mg/2ml
26
ipratropium bromide inhal soln 0.02%
•
montelukast sodium chew tab 5 mg
(base equiv) (Singulair)
montelukast sodium oral granules
packet 4 mg (base equiv) (Singulair)
montelukast sodium tab 10 mg (base
equiv) (Singulair)
PROAIR RESPICLICK – albuterol sulfate
aer pow ba 108 mcg/act (90 mcg base
equiv)
•
PULMICORT – budesonide inhalation susp
1 mg/2ml
KALYDECO – ivacaftor packet 75 mg
OFEV – nintedanib esylate cap 100 mg
(base equivalent)
• •
•
•
PULMOZYME – dornase alfa inhal soln 1
mg/ml
QVAR – beclomethasone dipropionate inhal
aero soln 80 mcg/act
•
GASTROINTESTINAL DRUGS
SEREVENT DISKUS – salmeterol xinafoate
aer pow ba 50 mcg/dose (base equiv)
•
lactulose solution 10 gm/15ml
SPIRIVA HANDIHALER – tiotropium
bromide monohydrate inhal cap 18 mcg
(base equiv)
•
peg 3350-kcl-sod bicarb-nacl for soln
420 gm (Nulytely/flavor pack)
SPIRIVA RESPIMAT – tiotropium bromide
monohydrate inhal aerosol 2.5 mcg/act
•
SYMBICORT – budesonide-formoterol
fumarate dihyd aerosol 80-4.5 mcg/act
•
ULCER/GERD
SYMBICORT – budesonide-formoterol
fumarate dihyd aerosol 160-4.5 mcg/act
•
amoxicillin cap-clarithro tab-lansopraz
cap dr therapy pack (Prevpac)
LAXATIVES
peg 3350-kcl-na bicarb-nacl-na sulfate
for soln 236 gm (Golytely)
peg 3350-kcl-na bicarb-nacl-na sulfate
for soln 240 gm (Colyte-flavor packs)
CARAFATE – sucralfate susp 1 gm/10ml
terbutaline sulfate tab 2.5 mg
cimetidine hcl soln 300 mg/5ml
terbutaline sulfate tab 5 mg
cimetidine tab 300 mg
theophylline tab sr 12hr 100 mg
dicyclomine hcl cap 10 mg (Bentyl)
dicyclomine hcl oral soln 10 mg/5ml
dicyclomine hcl tab 20 mg (Bentyl)
•
VENTOLIN HFA – albuterol sulfate inhal
aero 108 mcg/act (90mcg base equiv)
XOLAIR – omalizumab for inj 150 mg
•
esomeprazole magnesium cap delayed
release 20 mg (base eq) (Nexium)
•
esomeprazole magnesium cap delayed
release 40 mg (base eq) (Nexium)
•
zafirlukast tab 10 mg (Accolate)
famotidine tab 40 mg (Pepcid)
zafirlukast tab 20 mg (Accolate)
glycopyrrolate tab 1 mg (Robinul)
OTHER RESPIRATORY DRUGS
ESBRIET – pirfenidone cap 267 mg
KALYDECO – ivacaftor tab 150 mg
• • •
• • •
• •
OFEV – nintedanib esylate cap 150 mg
(base equivalent)
QVAR – beclomethasone dipropionate inhal
aero soln 40 mcg/act
Dispensing Limits
KALYDECO – ivacaftor packet 50 mg
Prior Approval
•
Specialty
PROAIR HFA – albuterol sulfate inhal aero
108 mcg/act (90mcg base equiv)
Prior Approval
Drug Name
Drug Name
Specialty
Dispensing Limits
2015
glycopyrrolate tab 2 mg (Robinul forte)
• •
• • •
hyoscyamine sulfate elixir 0.125 mg/5ml
hyoscyamine sulfate soln 0.125 mg/ml
27
hyoscyamine sulfate tab sl 0.125 mg
(Levsin/sl)
ranitidine hcl syrup 15 mg/ml
(75 mg/5ml)
hyoscyamine sulfate tab sr 12hr
0.375 mg (Levbid)
ranitidine hcl tab 300 mg (Zantac)
hyoscyamine sulfate tab 0.125 mg
(Levsin)
NAUSEA AND VOMITING
•
EMEND – aprepitant capsule therapy pack
80 & 125 mg
lansoprazole cap delayed release 30 mg
(Prevacid)
•
EMEND – aprepitant capsule 40 mg
misoprostol tab 100 mcg (Cytotec)
misoprostol tab 200 mcg (Cytotec)
ondansetron hcl oral soln 4 mg/5ml
(Zofran)
NEXIUM – esomeprazole magnesium for
delayed release susp pack 2.5 mg
•
delayed release susp packet 5 mg
•
•
•
•
NEXIUM – esomeprazole magnesium cap
delayed release 20 mg (base eq)
•
DIGESTIVE ENZYMES
NEXIUM – esomeprazole magnesium cap
delayed release 40 mg (base eq)
•
CREON – pancrelipase (lip-prot-amyl) dr
cap 3000-9500-15000 unit
omeprazole cap delayed release 10 mg
(Prilosec)
•
cap 6000-19000-30000 unit
(Prilosec)
•
cap 12000-38000-60000 unit
(Prilosec)
•
cap 24000-76000-120000 unit
pantoprazole sodium ec tab 20 mg (base
equiv) (Protonix)
•
cap 36000-114000-180000 unit
pantoprazole sodium ec tab 40 mg (base
equiv) (Protonix)
•
ZENPEP – pancrelipase (lip-prot-amyl) dr
cap 3000-10000-16000 unit
rabeprazole sodium ec tab 20 mg
(Aciphex)
•
cap 5000-17000-27000 unit
28
Dispensing Limits
sucralfate tab 1 gm (Carafate)
(Prevacid)
ranitidine hcl cap 300 mg
Prior Approval
Drug Name
Specialty
Dispensing Limits
Prior Approval
Drug Name
Specialty
2015
ondansetron hcl tab 4 mg (Zofran)
ondansetron hcl tab 8 mg (Zofran)
ondansetron hcl tab 24 mg
ondansetron orally disintegrating tab
4 mg (Zofran odt)
ondansetron orally disintegrating tab
8 mg (Zofran odt)
trimethobenzamide hcl cap 300 mg
(Tigan)
cap 10000-34000-55000 unit
•
•
•
•
•
•
•
•
•
cap 15000-51000-82000 unit
RENVELA – sevelamer carbonate packet
2.4 gm
cap 20000-68000-109000 unit
sulfasalazine tab delayed release 500 mg
(Azulfidine en-tabs)
cap 25000-85000-136000 unit
sulfasalazine tab 500 mg (Azulfidine)
cap 40000-136000-218000 unit
ursodiol tab 250 mg (Urso 250)
Dispensing Limits
ursodiol cap 300 mg (Actigall)
ursodiol tab 500 mg (Urso forte)
OTHER GASTROINTESTINAL DRUGS
GENITOURINARY DRUGS
ASACOL HD – mesalamine tab delayed
release 800 mg
URINARY TRACT INFECTIONS
balsalazide disodium cap 750 mg
(Colazal)
nitrofurantoin macrocrystalline cap
50 mg (Macrodantin)
calcium acetate (phosphate binder) cap
667 mg (169 mg ca) (Phoslo)
nitrofurantoin macrocrystalline cap
100 mg (Macrodantin)
calcium acetate (phosphate binder) tab
667 mg (Eliphos)
nitrofurantoin monohydrate
macrocrystalline cap 100 mg (Macrobid)
CANASA – mesalamine suppos 1000 mg
nitrofurantoin susp 25 mg/5ml
(Furadantin)
CHENODAL – chenodiol tab 250 mg
Prior Approval
Drug Name
Specialty
Dispensing Limits
Prior Approval
Drug Name
Specialty
2015
• •
DELZICOL – mesalamine cap dr 400 mg
URINARY TRACT SPASMS
MYRBETRIQ – mirabegron tab sr 24 hr 25
mg
lactulose (encephalopathy) solution
10 gm/15ml
MYRBETRIQ – mirabegron tab sr 24 hr 50
mg
LIALDA – mesalamine tab delayed release
1.2 gm
oxybutynin chloride syrup 5 mg/5ml
mesalamine enema 4 gm
oxybutynin chloride tab sr 24hr 5 mg
(Ditropan xl)
metoclopramide hcl soln 5 mg/5ml
(10 mg/10ml)
(Ditropan xl)
metoclopramide hcl tab 5 mg (Reglan)
metoclopramide hcl tab 10 mg (Reglan)
PENTASA – mesalamine cap cr 250 mg
(Ditropan xl)
PENTASA – mesalamine cap cr 500 mg
oxybutynin chloride tab 5 mg
RELISTOR – methylnaltrexone bromide inj
8 mg/0.4ml (20 mg/ml)
•
tolterodine tartrate cap sr 24hr 2 mg
(Detrol la)
RELISTOR – methylnaltrexone bromide inj
12 mg/0.6ml (20 mg/ml)
•
tolterodine tartrate cap sr 24hr 4 mg
(Detrol la)
RENVELA – sevelamer carbonate tab 800
mg
tolterodine tartrate tab 1 mg (Detrol)
RENVELA – sevelamer carbonate packet
0.8 gm
VESICARE – solifenacin succinate tab 5 mg
tolterodine tartrate tab 2 mg (Detrol)
29
VESICARE – solifenacin succinate tab 10
mg
potassium citrate tab cr 10 meq
(1080 mg) (Urocit-k 10)
VAGINAL PRODUCTS
potassium citrate tab cr 15 meq
(1620 mg) (Urocit-k 15)
CLEOCIN – clindamycin phosphate vaginal
suppos 100 mg
sodium citrate & citric acid soln
500-334 mg/5ml (Shohls solution modi)
clindamycin phosphate vaginal cream
2% (Cleocin)
tamsulosin hcl cap 0.4 mg (Flomax)
metronidazole vaginal gel 0.75%
(Metrogel-vaginal)
CENTRAL NERVOUS SYSTEM DRUGS
PREMARIN – estrogens, conjugated
vaginal cream 0.625 mg/gm
ALPRAZOLAM INTENSOL – alprazolam
conc 1 mg/ml
terconazole vaginal cream 0.4% (Terazol
7)
alprazolam tab sr 24hr 0.5 mg (Xanax xr)
terconazole vaginal cream 0.8% (Terazol
3)
alprazolam tab sr 24hr 2 mg (Xanax xr)
ANXIETY
terconazole vaginal suppos 80 mg
VAGIFEM – estradiol vaginal tab 10 mcg
alprazolam tab 0.25 mg (Xanax)
OTHER GENITOURINARY DRUGS
alprazolam tab 0.5 mg (Xanax)
alfuzosin hcl tab sr 24hr 10 mg (Uroxatral)
alprazolam tab 1 mg (Xanax)
CYSTAGON – cysteamine bitartrate cap 50
mg
•
CYSTAGON – cysteamine bitartrate cap
150 mg
•
alprazolam tab 2 mg (Xanax)
buspirone hcl tab 5 mg
buspirone hcl tab 7.5 mg
CYTRA-3 – pot & sod citrates w/ cit ac
syrup 550-500-334 mg/5ml
ELMIRON – pentosan polysulfate sodium
caps 100 mg
finasteride tab 5 mg (Proscar)
K-PHOS NO 2 – potassium & sodium acid
phosphates tab 305-700 mg
pot & sod citrates w/ cit ac soln
550-500-334 mg/5ml
potassium citrate & citric acid powder
pack 3300-1002 mg
•
clorazepate dipotassium tab 3.75 mg
(Tranxene t)
clorazepate dipotassium tab 7.5 mg
(Tranxene t)
clorazepate dipotassium tab 15 mg
(Tranxene t)
DIAZEPAM – diazepam soln 1 mg/ml
diazepam conc 5 mg/ml
potassium citrate & citric acid soln
1100-334 mg/5ml
diazepam tab 2 mg (Valium)
potassium citrate tab cr 5 meq (540 mg)
(Urocit-k 5)
hydroxyzine hcl syrup 10 mg/5ml
hydroxyzine hcl tab 10 mg
30
Dispensing Limits
Prior Approval
Drug Name
Specialty
Dispensing Limits
Prior Approval
Drug Name
Specialty
2015
clomipramine hcl cap 25 mg (Anafranil)
HYDROXYZINE PAMOATE – hydroxyzine
pamoate cap 100 mg
hydroxyzine pamoate cap 25 mg (Vistaril)
desipramine hcl tab 25 mg (Norpramin)
hydroxyzine pamoate cap 50 mg (Vistaril)
lorazepam conc 2 mg/ml (Lorazepam
intensol)
lorazepam tab 1 mg (Ativan)
DOXEPIN HCL – doxepin hcl cap 75 mg
lorazepam tab 2 mg (Ativan)
doxepin hcl cap 10 mg
DEPRESSION
amitriptyline hcl tab 10 mg
doxepin hcl conc 10 mg/ml
bupropion hcl tab sr 12hr 100 mg
(Wellbutrin sr)
•
(Wellbutrin sr)
•
(Wellbutrin sr)
•
(Wellbutrin xl)
•
(Wellbutrin xl)
•
bupropion hcl tab 75 mg (Wellbutrin)
•
•
•
citalopram hydrobromide oral soln
10 mg/5ml
Dispensing Limits
lorazepam tab 0.5 mg (Ativan)
bupropion hcl tab 100 mg (Wellbutrin)
Prior Approval
Drug Name
Specialty
Dispensing Limits
Prior Approval
Drug Name
Specialty
2015
duloxetine hcl enteric coated pellets cap
20 mg (Cymbalta)
•
30 mg (Cymbalta)
•
60 mg (Cymbalta)
•
escitalopram oxalate soln 5 mg/5ml
(base equiv) (Lexapro)
•
escitalopram oxalate tab 5 mg (base
equiv) (Lexapro)
•
equiv) (Lexapro)
•
equiv) (Lexapro)
•
fluoxetine hcl cap 10 mg (Prozac)
•
•
•
•
•
•
•
citalopram hydrobromide tab 10 mg
(base equiv) (Celexa)
•
•
fluoxetine hcl solution 20 mg/5ml
•
fluoxetine hcl tab 20 mg
fluoxetine hcl tab 10 mg
fluvoxamine maleate tab 25 mg
31
•
•
paroxetine hcl tab 40 mg (Paxil)
Dispensing Limits
Prior Approval
Drug Name
Specialty
Dispensing Limits
Prior Approval
Drug Name
Specialty
2015
•
phenelzine sulfate tab 15 mg (Nardil)
imipramine hcl tab 10 mg (Tofranil)
sertraline hcl oral conc 20 mg/ml (Zoloft)
sertraline hcl tab 25 mg (Zoloft)
imipramine pamoate cap 75 mg (Tofranilpm)
•
•
•
•
tranylcypromine sulfate tab 10 mg
(Parnate)
imipramine pamoate cap 100 mg
(Tofranil-pm)
trazodone hcl tab 50 mg
(Tofranil-pm)
(Tofranil-pm)
mirtazapine orally disintegrating tab
15 mg (Remeron soltab)
•
venlafaxine hcl cap sr 24hr 37.5 mg
(base equivalent) (Effexor xr)
•
•
venlafaxine hcl cap sr 24hr 75 mg (base
equivalent) (Effexor xr)
•
•
venlafaxine hcl cap sr 24hr 150 mg (base
equivalent) (Effexor xr)
•
mirtazapine tab 7.5 mg
•
•
•
•
VENLAFAXINE HCL ER – venlafaxine hcl
tab sr 24hr 225 mg (base equivalent)
•
venlafaxine hcl tab sr 24hr 37.5 mg (base
equivalent) (Venlafaxine hcl er)
•
venlafaxine hcl tab sr 24hr 75 mg (base
•
•
nortriptyline hcl cap 10 mg (Pamelor)
venlafaxine hcl tab sr 24hr 150 mg (base
venlafaxine hcl tab 25 mg
venlafaxine hcl tab 37.5 mg
•
•
•
•
•
mirtazapine tab 15 mg (Remeron)
NORTRIPTYLINE HCL – nortriptyline hcl
soln 10 mg/5ml
paroxetine hcl tab sr 24hr 12.5 mg (Paxil
cr)
•
paroxetine hcl tab sr 24hr 25 mg (Paxil cr)
•
•
paroxetine hcl tab sr 24hr 37.5 mg (Paxil
cr)
32
•
•
•
PSYCHOTIC AND BIPOLAR DISORDERS
chlorpromazine hcl tab 10 mg
clozapine tab 25 mg (Clozaril)
clozapine tab 50 mg
clozapine tab 100 mg (Clozaril)
clozapine tab 200 mg
•
•
•
•
FLUPHENAZINE HCL – fluphenazine hcl
elixir 2.5 mg/5ml
FLUPHENAZINE HCL – fluphenazine hcl
oral conc 5 mg/ml
•
olanzapine orally disintegrating tab
15 mg (Zyprexa zydis)
•
•
olanzapine tab 2.5 mg (Zyprexa)
•
•
•
•
•
•
fluphenazine hcl tab 1 mg
olanzapine tab 7.5 mg (Zyprexa)
fluphenazine hcl tab 2.5 mg
olanzapine tab 10 mg (Zyprexa)
haloperidol lactate oral conc 2 mg/ml
perphenazine tab 2 mg
haloperidol tab 0.5 mg
haloperidol tab 1 mg
prochlorperazine maleate tab 5 mg (base
equivalent) (Compazine)
prochlorperazine maleate tab 10 mg
(base equivalent) (Compazine)
LITHIUM – lithium oral solution 8 meq/5ml
prochlorperazine suppos 25 mg
LITHIUM CARBONATE – lithium carbonate
cap 150 mg
quetiapine fumarate tab 25 mg (Seroquel)
quetiapine fumarate tab 50 mg (Seroquel)
lithium carbonate cap 150 mg (Lithium
carbonate)
quetiapine fumarate tab 100 mg
(Seroquel)
lithium carbonate cap 300 mg
lithium carbonate cap 600 mg (Lithium
carbonate)
lithium carbonate tab cr 300 mg (Lithobid)
lithium carbonate tab cr 450 mg
lithium carbonate tab 300 mg
loxapine succinate cap 5 mg (Loxitane)
loxapine succinate cap 10 mg
olanzapine orally disintegrating tab 5 mg
(Zyprexa zydis)
•
Dispensing Limits
Prior Approval
Drug Name
Specialty
Dispensing Limits
Prior Approval
Drug Name
Specialty
2015
•
•
•
(Seroquel)
•
(Seroquel)
•
(Seroquel)
•
risperidone orally disintegrating tab
0.25 mg
•
0.5 mg (Risperdal m-tab)
•
1 mg (Risperdal m-tab)
•
33
•
•
risperidone soln 1 mg/ml (Risperdal)
•
•
•
•
•
•
•
•
risperidone tab 0.25 mg (Risperdal)
risperidone tab 0.5 mg (Risperdal)
risperidone tab 1 mg (Risperdal)
SEROQUEL XR – quetiapine fumarate tab
sr 24hr 50 mg
eszopiclone tab 1 mg (Lunesta)
PHENOBARBITAL – phenobarbital tab 30
mg
mg
mg
phenobarbital elixir 20 mg/5ml
phenobarbital tab 16.2 mg
•
sr 24hr 200 mg
•
sr 24hr 300 mg
•
temazepam cap 15 mg (Restoril)
sr 24hr 400 mg
•
temazepam cap 30 mg (Restoril)
temazepam cap 7.5 mg (Restoril)
temazepam cap 22.5 mg (Restoril)
zaleplon cap 5 mg (Sonata)
thiothixene cap 1 mg
zaleplon cap 10 mg (Sonata)
zolpidem tartrate tab cr 6.25 mg (Ambien
cr)
trifluoperazine hcl tab 1 mg
ziprasidone hcl cap 80 mg (Geodon)
SLEEP AIDS
•
zolpidem tartrate tab 5 mg (Ambien)
•
•
HYPERACTIVITY/NARCOLEPSY
•
•
•
•
amphetamine-dextroamphetamine cap sr
24hr 5 mg (Adderall xr)
•
•
•
estazolam tab 1 mg
34
•
•
•
zolpidem tartrate tab cr 12.5 mg (Ambien
cr)
zolpidem tartrate tab 10 mg (Ambien)
•
•
•
mg
sr 24hr 150 mg
Dispensing Limits
estazolam tab 2 mg
Prior Approval
•
Specialty
Prior Approval
Drug Name
Drug Name
Specialty
Dispensing Limits
2015
Dispensing Limits
Prior Approval
Drug Name
Specialty
Dispensing Limits
Prior Approval
Drug Name
Specialty
2015
•
methylphenidate hcl cap cr 30 mg
(Metadate cd)
•
•
(Metadate cd)
•
•
(Metadate cd)
•
amphetamine-dextroamphetamine tab
5 mg (Adderall)
•
(Metadate cd)
•
7.5 mg (Adderall)
•
methylphenidate hcl cap sr 24hr 20 mg
(la) (Ritalin la)
•
10 mg (Adderall)
•
(la) (Ritalin la)
•
12.5 mg (Adderall)
•
(la) (Ritalin la)
•
15 mg (Adderall)
•
METHYLPHENIDATE HCL ER –
methylphenidate hcl tab sa osm 18 mg
•
20 mg (Adderall)
•
•
30 mg (Adderall)
•
•
•
•
•
caffeine citrate oral soln 60 mg/3ml
(10 mg/ml base equiv) (Cafcit)
dexmethylphenidate hcl tab 2.5 mg
(Focalin)
•
methylphenidate hcl tab cr 10 mg
dexmethylphenidate hcl tab 5 mg
(Focalin)
•
methylphenidate hcl tab cr 20 mg (Ritalin
sr)
dexmethylphenidate hcl tab 10 mg
(Focalin)
•
dextroamphetamine sulfate cap sr 24hr
5 mg (Dexedrine)
•
methylphenidate hcl tab 20 mg (Ritalin)
10 mg (Dexedrine)
•
modafinil tab 200 mg (Provigil)
15 mg (Dexedrine)
•
STRATTERA – atomoxetine hcl cap 10 mg
(base equiv)
dextroamphetamine sulfate tab 5 mg
•
•
•
dextroamphetamine sulfate tab 10 mg
(Metadate cd)
(Metadate cd)
•
modafinil tab 100 mg (Provigil)
•
•
•
•
•
•
(base equiv)
•
(base equiv)
•
(base equiv)
•
35
Dispensing Limits
Prior Approval
Drug Name
Specialty
Dispensing Limits
Prior Approval
Drug Name
Specialty
2015
(base equiv)
•
REBIF – interferon beta-1a inj 22 mcg/0.5ml
(12mu/ml) (44 mcg/ml)
• • •
(base equiv)
•
REBIF – interferon beta-1a inj 44 mcg/0.5ml
(24mu/ml) (88 mcg/ml)
• • •
(base equiv)
•
REBIF REBIDOSE – interferon beta-1a inj
22 mcg/0.5ml (12mu/ml) (44 mcg/ml)
• • •
VYVANSE – lisdexamfetamine dimesylate
cap 10 mg
•
REBIF REBIDOSE – interferon beta-1a inj
44 mcg/0.5ml (24mu/ml) (88 mcg/ml)
• • •
cap 20 mg
•
• • •
cap 30 mg
•
REBIF REBIDOSE TITRATION – interferon
beta-1a inj 6 x 8.8 mcg/0.2ml & 6 x 22
mcg/0.5ml
• • •
cap 40 mg
•
REBIF TITRATION PACK – interferon
beta-1a inj 6 x 8.8 mcg/0.2ml & 6 x 22
mcg/0.5ml
cap 50 mg
•
TECFIDERA – dimethyl fumarate capsule
delayed release 120 mg
• • •
cap 60 mg
•
TECFIDERA – dimethyl fumarate capsule
delayed release 240 mg
• • •
cap 70 mg
•
TECFIDERA STARTER PACK – dimethyl
fumarate capsule dr starter pack 120 mg
& 240 mg
• • •
MULTIPLE SCLEROSIS
TOBACCO CESSATION
BETASERON – interferon beta-1b for inj kit
0.3 mg
• • •
COPAXONE – glatiramer acetate soln
prefilled syringe 20 mg/ml
• • •
COPAXONE – glatiramer acetate soln
• • •
glatiramer acetate soln prefilled syringe
20 mg/ml (Copaxone)
• • •
PLEGRIDY – peginterferon beta-1a soln
pen-injector 125 mcg/0.5ml
• • •
PLEGRIDY – peginterferon beta-1a soln
prefilled syringe 125 mcg/0.5ml
• • •
CHANTIX STARTING MONTH PA –
varenicline tartrate tab 0.5 mg x 11 & tab
1 mg x 42 pack
PLEGRIDY STARTER PACK –
peginterferon beta-1a soln pen-inj 63 & 94
mcg/0.5ml pack
• • •
NICODERM CQ – nicotine td patch 24hr 7
mg/24hr
PLEGRIDY STARTER PACK –
peginterferon beta-1a soln pref syr 63 &
94 mcg/0.5ml pack
• • •
bupropion hcl (smoking deterrent) tab sr
12hr 150 mg (Zyban)
CHANTIX – varenicline tartrate tab 0.5 mg
(base equiv)
CHANTIX – varenicline tartrate tab 1 mg
(base equiv)
CHANTIX CONTINUING MONTH –
varenicline tartrate tab 1 mg (base equiv)
mg/24hr
mg/24hr
NICORETTE – nicotine polacrilex gum 2 mg
36
NICORETTE – nicotine polacrilex gum 4 mg
NICORETTE – nicotine polacrilex lozenge 2
mg
NICORETTE – nicotine polacrilex lozenge 4
mg
NICORETTE MINI – nicotine polacrilex
lozenge 2 mg
NICORETTE MINI – nicotine polacrilex
lozenge 4 mg
NICORETTE STARTER KIT – nicotine
polacrilex gum 2 mg
NICORETTE STARTER KIT – nicotine
polacrilex gum 4 mg
galantamine hydrobromide cap sr 24hr
8 mg (Razadyne er)
16 mg (Razadyne er)
24 mg (Razadyne er)
galantamine hydrobromide tab 4 mg
(Razadyne)
(Razadyne)
nicotine polacrilex gum 2 mg
nicotine polacrilex gum 4 mg
memantine hcl tab 5 mg (Namenda)
nicotine polacrilex lozenge 2 mg
memantine hcl tab 10 mg (Namenda)
nicotine polacrilex lozenge 4 mg
memantine hcl tab 5 mg (28) & 10 mg
(21) titration pak (Namenda titration pa)
nicotine td patch 24hr 14 mg/24hr
NAMENDA – memantine hcl oral solution 2
mg/ml
NAMENDA – memantine hcl tab 5 mg
NICOTINE TRANSDERMAL SYST –
nicotine td patch 24 hr kit 21-14-7
mg/24hr
NAMENDA – memantine hcl tab 10 mg
NICOTROL INHALER – nicotine inhaler
system 10 mg (4 mg delivered)
NICOTROL NS – nicotine nasal spray 10
mg/ml (0.5 mg/spray)
NAMENDA TITRATION PAK – memantine
hcl tab 5 mg (28) & 10 mg (21) titration
pak
NAMENDA XR – memantine hcl cap sr 24hr
7 mg
OTHER CENTRAL NERVOUS SYSTEM DRUGS
14 mg
acamprosate calcium tab delayed
release 333 mg (Campral)
21 mg
disulfiram tab 250 mg (Antabuse)
28 mg
disulfiram tab 500 mg (Antabuse)
donepezil hydrochloride orally
disintegrating tab 5 mg (Aricept odt)
donepezil hydrochloride orally
disintegrating tab 10 mg (Aricept odt)
donepezil hydrochloride tab 5 mg
(Aricept)
Dispensing Limits
donepezil hydrochloride tab 10 mg
(Aricept)
(Razadyne)
Prior Approval
Drug Name
Specialty
Dispensing Limits
Prior Approval
Drug Name
Specialty
2015
NAMENDA XR TITRATION PACK –
memantine hcl cap sr 24hr 7 mg & 14 mg
& 21 mg & 28 mg pack
olanzapine-fluoxetine hcl cap 3-25 mg
(Symbyax)
(Symbyax)
37
Dispensing Limits
Prior Approval
Drug Name
Specialty
Dispensing Limits
Prior Approval
Drug Name
Specialty
2015
(Symbyax)
buprenorphine hcl sl tab 8 mg (base
equiv)
•
(Symbyax)
butalbital-aspirin-caff w/ codeine cap
50-325-40-30 mg (Fiorinal/codeine #3)
•
(Symbyax)
codeine sulfate tab 15 mg (Codeine
sulfate)
•
ORAP – pimozide tab 1 mg
codeine sulfate tab 30 mg
ORAP – pimozide tab 2 mg
codeine sulfate tab 60 mg
rivastigmine tartrate cap 1.5 mg (Exelon)
fentanyl citrate lozenge on a handle
200 mcg (Actiq)
•
•
•
rivastigmine tartrate cap 3 mg (Exelon)
rivastigmine tartrate cap 4.5 mg (Exelon)
rivastigmine tartrate cap 6 mg (Exelon)
tetrabenazine tab 12.5 mg (Xenazine)
tetrabenazine tab 25 mg (Xenazine)
XENAZINE – tetrabenazine tab 12.5 mg
XENAZINE – tetrabenazine tab 25 mg
•
•
•
•
•
•
•
•
•
•
•
•
PAIN RELIEF DRUGS
NON-NARCOTIC DRUGS
butalbital-acetaminophen-caffeine cap
50-325-40 mg
•
butalbital-acetaminophen-caffeine tab
50-325-40 mg
•
butalbital-aspirin-caffeine cap
50-325-40 mg (Fiorinal)
•
salsalate tab 500 mg
salsalate tab 750 mg
NARCOTIC DRUGS
400 mcg (Actiq)
•
600 mcg (Actiq)
•
800 mcg (Actiq)
•
1200 mcg (Actiq)
•
1600 mcg (Actiq)
•
fentanyl td patch 72hr 12 mcg/hr
(Duragesic)
•
(Duragesic)
•
(Duragesic)
•
(Duragesic)
•
•
acetaminophen w/ codeine soln
120-12 mg/5ml
•
(Duragesic)
•
hydrocodone-acetaminophen soln
7.5-325 mg/15ml (Hycet)
•
acetaminophen w/ codeine tab
300-15 mg (Tylenol/codeine)
•
hydrocodone-acetaminophen tab
10-325 mg (Norco)
•
300-30 mg (Tylenol/codeine #3)
5-300 mg (Xodol)
•
300-60 mg (Tylenol/codeine #4)
•
5-325 mg (Norco)
•
buprenorphine hcl sl tab 2 mg (base
equiv)
•
7.5-325 mg (Norco)
•
38
hydrocodone-ibuprofen tab 7.5-200 mg
(Vicoprofen)
•
hydrocodone-ibuprofen tab 10-200 mg
(Ibudone)
•
HYDROMORPHONE HCL –
hydromorphone hcl suppos 3 mg
hydromorphone hcl liqd 1 mg/ml
(Dilaudid)
•
hydromorphone hcl tab 2 mg (Dilaudid)
•
•
•
•
methadone hcl conc 10 mg/ml
(Methadose)
morphine sulfate tab cr 60 mg (Ms contin)
morphine sulfate tab cr 100 mg (Ms
contin)
•
•
•
morphine sulfate tab cr 200 mg (Ms
contin)
•
OXYCODONE HCL – oxycodone hcl conc
100 mg/5ml (20 mg/ml)
•
oxycodone hcl cap 5 mg
•
•
oxycodone hcl conc 100 mg/5ml (20 mg/
ml) (Oxycodone hcl)
oxycodone hcl soln 5 mg/5ml (Oxycodone
hcl)
•
oxycodone hcl tab 5 mg (Roxicodone)
•
•
•
•
•
•
oxycodone hcl tab 10 mg
methadone hcl soln 5 mg/5ml (Methadone
hcl)
•
methadone hcl soln 10 mg/5ml
(Methadone hcl)
•
oxycodone hcl tab 20 mg
methadone hcl tab for oral susp 40 mg
•
•
•
•
oxycodone w/ acetaminophen tab
5-325 mg (Percocet)
methadone hcl tab 5 mg (Dolophine hcl)
Dispensing Limits
Prior Approval
•
Specialty
hydrocodone-ibuprofen tab 5-200 mg
(Reprexain)
Prior Approval
Drug Name
Drug Name
Specialty
Dispensing Limits
2015
7.5-325 mg (Percocet)
•
10-325 mg (Percocet)
•
oxycodone-aspirin tab 4.8355-325 mg
(Percodan)
•
MORPHINE SULFATE – morphine sulfate
suppos 5 mg
OXYCONTIN – oxycodone hcl tab er 12hr
deter 10 mg
•
suppos 10 mg
deter 15 mg
•
suppos 20 mg
deter 20 mg
•
suppos 30 mg
deter 30 mg
•
deter 40 mg
•
deter 60 mg
•
methadone hcl tab 10 mg (Dolophine)
tab 15 mg
tab 30 mg
•
morphine sulfate (concentrate) oral soln
20 mg/ml
•
morphine sulfate oral soln 10 mg/5ml
•
•
•
morphine sulfate oral soln 20 mg/5ml
39
ROXICET – oxycodone w/ acetaminophen
soln 5-325 mg/5ml
•
tramadol hcl tab sr 24hr 100 mg (Ultram
er)
•
etodolac tab 400 mg
er)
•
flurbiprofen tab 50 mg
er)
•
tramadol hcl tab 50 mg (Ultram)
•
•
Dispensing Limits
etodolac tab sr 24hr 400 mg
Prior Approval
•
Specialty
deter 80 mg
Prior Approval
Drug Name
Drug Name
Specialty
Dispensing Limits
2015
etodolac tab 500 mg
flurbiprofen tab 100 mg
HUMIRA – adalimumab prefilled syringe kit
10 mg/0.2ml
• • •
20 mg/0.4ml
• • •
40 mg/0.8ml
• • •
HUMIRA PEDIATRIC CROHNS D –
adalimumab prefilled syringe kit 40
mg/0.8ml
• • •
HUMIRA PEN – adalimumab pen-injector kit
40 mg/0.8ml
• • •
diclofenac potassium tab 50 mg
(Cataflam)
HUMIRA PEN-CROHNS DISEASE –
adalimumab pen-injector kit 40 mg/0.8ml
• • •
diclofenac sodium tab delayed release
25 mg
HUMIRA PEN-PSORIASIS STAR –
adalimumab pen-injector kit 40 mg/0.8ml
• • •
50 mg
ibuprofen susp 100 mg/5ml
75 mg
ibuprofen tab 600 mg
diclofenac sodium tab sr 24hr 100 mg
(Voltaren-xr)
ILARIS – canakinumab for inj 180 mg
tramadol-acetaminophen tab
37.5-325 mg (Ultracet)
RHEUMATOID AND OSTEOARTHRITIS
celecoxib cap 50 mg (Celebrex)
•
•
•
•
ENBREL – etanercept for subcutaneous inj
kit 25 mg
• • •
ENBREL – etanercept subcutaneous soln
prefilled syringe 25 mg/0.5ml
• • •
ENBREL – etanercept subcutaneous soln
• • •
ENBREL SURECLICK – etanercept
subcutaneous solution auto-injector 50
mg/ml
• • •
indomethacin cap 25 mg
indomethacin cap 50 mg
ketoprofen cap 50 mg
ketoprofen cap 75 mg
ketorolac tromethamine tab 10 mg
leflunomide tab 10 mg (Arava)
leflunomide tab 20 mg (Arava)
meloxicam tab 7.5 mg (Mobic)
etodolac cap 200 mg
meloxicam tab 15 mg (Mobic)
etodolac cap 300 mg
nabumetone tab 500 mg
40
• •
•
nabumetone tab 750 mg
NAPROXEN – naproxen susp 125 mg/5ml
naproxen sodium tab 275 mg (Anaprox)
naproxen sodium tab 550 mg (Anaprox
ds)
naproxen tab ec 375 mg (Ec-naprosyn)
naproxen tab ec 500 mg (Ec-naprosyn)
•
rizatriptan benzoate orally disintegrating
tab 5 mg (Maxalt-mlt)
•
rizatriptan benzoate orally disintegrating
tab 10 mg (Maxalt-mlt)
•
rizatriptan benzoate tab 5 mg (Maxalt)
•
•
•
SUMATRIPTAN – sumatriptan nasal spray
5 mg/act
naproxen tab 375 mg (Naprosyn)
oxaprozin tab 600 mg (Daypro)
piroxicam cap 10 mg (Feldene)
piroxicam cap 20 mg (Feldene)
RIDAURA – auranofin cap 3 mg
Dispensing Limits
naratriptan hcl tab 2.5 mg (base equiv)
(Amerge)
rizatriptan benzoate tab 10 mg (Maxalt)
Prior Approval
Drug Name
Specialty
Dispensing Limits
Prior Approval
Drug Name
Specialty
2015
SUMATRIPTAN – sumatriptan nasal spray
20 mg/act
•
SUMATRIPTAN SUCCINATE – sumatriptan
succinate solution prefilled syringe 6
mg/0.5ml
•
SIMPONI – golimumab subcutaneous soln
auto-injector 50 mg/0.5ml
• • •
SUMATRIPTAN SUCCINATE – sumatriptan
succinate inj 4 mg/0.5ml
•
auto-injector 100 mg/ml
• • •
sumatriptan succinate inj 6 mg/0.5ml
(Imitrex)
•
prefilled syringe 50 mg/0.5ml
• • •
•
• • •
sumatriptan succinate solution autoinjector 4 mg/0.5ml (Imitrex statdose
sys)
sumatriptan succinate solution autoinjector 6 mg/0.5ml (Imitrex statdose
sys)
•
sumatriptan succinate solution cartridge
4 mg/0.5ml (Imitrex statdose ref)
•
sumatriptan succinate solution cartridge
6 mg/0.5ml (Imitrex statdose ref)
•
sumatriptan succinate tab 25 mg (Imitrex)
•
•
•
sulindac tab 150 mg
sulindac tab 200 mg
MIGRAINE HEADACHES
acetaminophen-isometheptene-dichloral
cap 325-65-100 mg
dihydroergotamine mesylate inj 1 mg/ml
(D.h.e. 45)
sumatriptan succinate tab 50 mg (Imitrex)
IMITREX – sumatriptan nasal spray 5 mg/
act
•
sumatriptan succinate tab 100 mg
(Imitrex)
IMITREX – sumatriptan nasal spray 20 mg/
act
•
zolmitriptan orally disintegrating tab
2.5 mg (Zomig zmt)
•
zolmitriptan orally disintegrating tab
5 mg (Zomig zmt)
•
zolmitriptan tab 2.5 mg (Zomig)
•
•
MIGRANAL – dihydroergotamine mesylate
nasal spray 4 mg/ml
naratriptan hcl tab 1 mg (base equiv)
(Amerge)
•
zolmitriptan tab 5 mg (Zomig)
GOUT
41
allopurinol tab 100 mg (Zyloprim)
clonazepam tab 2 mg (Klonopin)
allopurinol tab 300 mg (Zyloprim)
DIASTAT ACUDIAL – diazepam rectal gel
delivery system 10 mg
COLCHICINE – colchicine cap 0.6 mg
DIASTAT ACUDIAL – diazepam rectal gel
delivery system 20 mg
COLCHICINE – colchicine tab 0.6 mg
colchicine w/ probenecid tab 0.5-500 mg
DIASTAT PEDIATRIC – diazepam rectal gel
delivery system 2.5 mg
COLCRYS – colchicine tab 0.6 mg
probenecid tab 500 mg
DILANTIN – phenytoin sodium extended
cap 30 mg
NEUROMUSCULAR DRUGS
SEIZURES
BANZEL – rufinamide susp 40 mg/ml
BANZEL – rufinamide tab 200 mg
BANZEL – rufinamide tab 400 mg
carbamazepine cap sr 12hr 100 mg
(Carbatrol)
(Carbatrol)
(Carbatrol)
•
•
•
DILANTIN – phenytoin sodium extended
cap 100 mg
DILANTIN-125 – phenytoin susp 125
mg/5ml
divalproex sodium cap sprinkle 125 mg
(Depakote sprinkles)
divalproex sodium tab delayed release
125 mg (Depakote)
250 mg (Depakote)
carbamazepine chew tab 100 mg
500 mg (Depakote)
carbamazepine susp 100 mg/5ml
(Tegretol)
divalproex sodium tab sr 24 hr 250 mg
(Depakote er)
carbamazepine tab sr 12hr 200 mg
(Tegretol-xr)
divalproex sodium tab sr 24 hr 500 mg
(Depakote er)
carbamazepine tab sr 12hr 400 mg
(Tegretol-xr)
ethosuximide cap 250 mg (Zarontin)
carbamazepine tab 200 mg (Tegretol)
clonazepam orally disintegrating tab
0.125 mg
ethosuximide soln 250 mg/5ml (Zarontin)
felbamate susp 600 mg/5ml (Felbatol)
felbamate tab 400 mg (Felbatol)
0.25 mg
felbamate tab 600 mg (Felbatol)
0.5 mg
gabapentin cap 300 mg (Neurontin)
1 mg
gabapentin oral soln 250 mg/5ml
(Neurontin)
2 mg
gabapentin tab 600 mg (Neurontin)
clonazepam tab 0.5 mg (Klonopin)
gabapentin tab 800 mg (Neurontin)
clonazepam tab 1 mg (Klonopin)
42
Dispensing Limits
Prior Approval
Drug Name
Specialty
Dispensing Limits
Prior Approval
Drug Name
Specialty
2015
lamotrigine tab chewable dispersible
5 mg (Lamictal chewable di)
topiramate tab 25 mg (Topamax)
lamotrigine tab chewable dispersible
25 mg (Lamictal chewable di)
lamotrigine tab 25 mg (Lamictal)
valproate sodium syrup 250 mg/5ml
(base equiv) (Depakene)
valproic acid cap 250 mg (Depakene)
zonisamide cap 25 mg (Zonegran)
levetiracetam oral soln 100 mg/ml
(Keppra)
zonisamide cap 50 mg
levetiracetam tab sr 24hr 500 mg (Keppra
xr)
PARKINSON'S DISEASE
zonisamide cap 100 mg (Zonegran)
levetiracetam tab sr 24hr 750 mg (Keppra
xr)
benztropine mesylate tab 0.5 mg
levetiracetam tab 250 mg (Keppra)
benztropine mesylate tab 2 mg
bromocriptine mesylate cap 5 mg
(Parlodel)
oxcarbazepine susp 300 mg/5ml (60 mg/
ml) (Trileptal)
oxcarbazepine tab 150 mg (Trileptal)
phenytoin chew tab 50 mg (Dilantin
infatabs)
phenytoin sodium extended cap 100 mg
(Dilantin)
phenytoin susp 125 mg/5ml (Dilantin)
primidone tab 50 mg (Mysoline)
primidone tab 250 mg (Mysoline)
SABRIL – vigabatrin tab 500 mg
SABRIL – vigabatrin powd pack 500 mg
TEGRETOL-XR – carbamazepine tab sr
12hr 100 mg
topiramate sprinkle cap 15 mg (Topamax
sprinkle)
Dispensing Limits
Prior Approval
Drug Name
Specialty
Dispensing Limits
Prior Approval
Drug Name
Specialty
2015
benztropine mesylate tab 1 mg
bromocriptine mesylate tab 2.5 mg
(Parlodel)
carbidopa & levodopa orally
disintegrating tab 10-100 mg
carbidopa & levodopa tab cr 25-100 mg
(Sinemet cr)
carbidopa & levodopa tab cr 50-200 mg
(Sinemet cr)
carbidopa & levodopa tab 10-100 mg
(Sinemet)
(Sinemet)
(Sinemet)
CARBIDOPA/LEVODOPA/ENTACA –
carbidopa-levodopa-entacapone tabs
12.5-50-200 mg
topiramate sprinkle cap 25 mg (Topamax
sprinkle)
43
18.75-75-200 mg
ropinirole hydrochloride tab 5 mg
(Requip)
25-100-200 mg
selegiline hcl tab 5 mg
31.25-125-200 mg
trihexyphenidyl hcl tab 2 mg
37.5-150-200 mg
baclofen tab 10 mg
50-200-200 mg
chlorzoxazone tab 500 mg (Parafon forte
dsc)
entacapone tab 200 mg (Comtan)
cyclobenzaprine hcl tab 10 mg
pramipexole dihydrochloride tab
0.125 mg (Mirapex)
DANTROLENE SODIUM – dantrolene
sodium cap 100 mg
pramipexole dihydrochloride tab 0.25 mg
(Mirapex)
dantrolene sodium cap 25 mg (Dantrium)
selegiline hcl cap 5 mg (Eldepryl)
trihexyphenidyl hcl elixir 0.4 mg/ml
trihexyphenidyl hcl tab 5 mg
MUSCLE RELAXANTS
baclofen tab 20 mg
cyclobenzaprine hcl tab 5 mg
dantrolene sodium cap 50 mg (Dantrium)
(Mirapex)
methocarbamol tab 500 mg (Robaxin)
(Mirapex)
orphenadrine citrate tab sr 12hr 100 mg
methocarbamol tab 750 mg (Robaxin-750)
pramipexole dihydrochloride tab 1 mg
(Mirapex)
orphenadrine w/ aspirin & caffeine tab
25-385-30 mg
(Mirapex)
OTHER NEUROMUSCULAR DRUGS
ropinirole hydrochloride tab 0.25 mg
(Requip)
ropinirole hydrochloride tab 0.5 mg
(Requip)
(Requip)
MESTINON – pyridostigmine bromide syrup
60 mg/5ml
pyridostigmine bromide tab cr 180 mg
(Mestinon timespan)
pyridostigmine bromide tab 60 mg
(Mestinon)
riluzole tab 50 mg (Rilutek)
(Requip)
VITAMINS
(Requip)
MEPHYTON – phytonadione tab 5 mg
(Requip)
ergocalciferol cap 50000 unit (Drisdol)
phytonadione inj 1 mg/0.5ml (2 mg/ml)
VITAMIN K1 – phytonadione inj 10 mg/ml
MULTIVITAMINS
44
Dispensing Limits
Prior Approval
Drug Name
Specialty
Dispensing Limits
Prior Approval
Drug Name
Specialty
2015
ESCAVITE LQ – pediatric multiple vitamins
w/ fl-fe drops 0.25-6 mg/ml
VINATE M – prenatal vit w/ sel-fe fumaratefa tab 27-1 mg
pediatric multivitamins
pediatric vitamins ADC
VINATE ONE – prenatal vit w/ fe fumaratefa tab 60-1 mg
PRENAPLUS – prenatal vit w/ fe fumaratefa tab 27-1 mg
VINATE ULTRA – prenatal vit w/ dss-iron
carbonyl-fa tab 90-1 mg
PRENATABS FA – prenatal vit w/ fe
fumarate-fa tab 29-1 mg
MINERALS AND ELECTROLYTES
PRENATABS RX – prenatal vit w/ iron
PRENATAL AD – prenatal vit w/ dss-iron
PRENATAL PLUS – prenatal vit w/ fe
PRENATAL 19 – prenatal vit w/ fe fumaratefa chew tab 29-1 mg
PRENATAL 19 – prenatal vit w/ dss-fe
PRENATAL-U – prenatal w/o a vit w/ fe
fumarate-fa cap 106.5-1 mg
TRINATE – prenatal vit w/ fe fumarate-fa
tab 28-1 mg
VINACAL B – prenat w/o a w/fecbn-feglu-fa
tab 20-1 mg & vit b6 tab pak
VINATE AZ EXTRA – prenatal vit w/ fe
bisglycinate chelate-fa tab 29-1 mg
VINATE C – prenatal w/o a vit w/ fe
VINATE CALCIUM – prenatal vit w/ iron
carbonyl-fe gluc-fa tab 27-1 mg
VINATE CARE – prenatal w/o a vit w/ fe
fum-fa tab chew 40-1 mg
VINATE DHA RF – prenat w/o a w/fefummethylfol-omegas cap 27-1.13 mg
VINATE GT – prenatal vit w/ dss-iron
VINATE IC – prenatal w/o a w/fe fum-fe
poly-fa cap 162.115.2-1 mg
VINATE II – prenatal vit w/ fe bisglycinate
chelate-fa tab 29-1 mg
Dispensing Limits
Prior Approval
Drug Name
Specialty
Dispensing Limits
Prior Approval
Drug Name
Specialty
2015
FLUOR-A-DAY – sodium fluoride-xylitol
chew tab 0.55 (0.25 mg f)-236.79 mg
chew tab 1.1 (0.5 mg f)-236.79 mg
chew tab 2.2 (1 mg f)-236.79 mg
FLURA-DROPS – sodium fluoride soln 0.25
mg/drop f (from 0.55 mg/drop naf)
K-PHOS – potassium phosphate monobasic
tab 500 mg
pot phos monobasic w/sod phos di &
monobas tab 155-852-130mg (K-phos
neutral)
potassium bicarbonate effer tab 25 meq
potassium chloride cap cr 8 meq (Microk)
potassium chloride cap cr 10 meq (Microk)
POTASSIUM CHLORIDE ER – potassium
chloride tab cr 8 meq (600 mg)
potassium chloride microencapsulated
crys cr tab 10 meq
potassium chloride microencapsulated
crys cr tab 20 meq
potassium chloride oral liq 10% (20
meq/15ml)
potassium chloride oral liq 20% (40
meq/15ml)
potassium chloride powder packet 20
meq
potassium chloride tab cr 8 meq
(600 mg)
potassium chloride tab cr 10 meq (K-tab)
45
SODIUM FLUORIDE – sodium fluoride tab
0.5 mg f (from 1.1 mg naf)
ARANESP ALBUMIN FREE – darbepoetin
alfa-polysorbate 80 soln inj 150 mcg/0.3ml
•
SODIUM FLUORIDE – sodium fluoride tab
1 mg f (from 2.2 mg naf)
alfa-polysorbate 80 soln inj 200 mcg/ml
•
sodium fluoride chew tab 0.25 mg f (from
0.55 mg naf) (Luride)
•
sodium fluoride chew tab 0.5 mg f (from
•
sodium fluoride chew tab 1 mg f (from
•
sodium fluoride soln 0.125 mg/drop f
(0.275 mg/drop naf)
•
sodium fluoride soln 0.5 mg/ml f (from
1.1 mg/ml naf) (Luride)
CERDELGA – eliglustat tartrate cap 84 mg
(base equivalent)
• •
BLOOD MODIFYING DRUGS
cilostazol tab 50 mg (Pletal)
AGGRENOX – aspirin-dipyridamole cap sr
12hr 25-200 mg
cilostazol tab 100 mg (Pletal)
Dispensing Limits
Prior Approval
Drug Name
Specialty
Dispensing Limits
Prior Approval
Drug Name
Specialty
2015
clopidogrel bisulfate tab 75 mg (base
equiv) (Plavix)
AMICAR – aminocaproic acid tab 500 mg
AMICAR – aminocaproic acid syrup 25%
anagrelide hcl cap 0.5 mg (Agrylin)
clopidogrel bisulfate tab 300 mg (base
equiv) (Plavix)
anagrelide hcl cap 1 mg
cyanocobalamin inj 1000 mcg/ml
•
•
dipyridamole tab 75 mg (Persantine)
•
EFFIENT – prasugrel hcl tab 5 mg (base
equiv)
•
EFFIENT – prasugrel hcl tab 10 mg (base
equiv)
•
•
enoxaparin sodium inj 30 mg/0.3ml
(Lovenox)
•
(Lovenox)
•
•
(Lovenox)
•
•
(Lovenox)
•
enoxaparin sodium inj 100 mg/ml
(Lovenox)
•
•
46
enoxaparin sodium inj 150 mg/ml
(Lovenox)
•
enoxaparin sodium inj 300 mg/3ml
(Lovenox)
•
FIRAZYR – icatibant acetate inj 30 mg/3ml
(base equivalent)
• • •
folic acid tab 1 mg
PROCRIT – epoetin alfa inj 20000 unit/ml
PROMACTA – eltrombopag olamine tab
12.5 mg (base equiv)
• •
PROMACTA – eltrombopag olamine tab 50
mg (base equiv)
• •
mg (base equiv)
• •
•
fondaparinux sodium subcutaneous inj
5 mg/0.4ml (Arixtra)
•
7.5 mg/0.6ml (Arixtra)
•
warfarin sodium tab 2 mg (Coumadin)
10 mg/0.8ml (Arixtra)
•
warfarin sodium tab 2.5 mg (Coumadin)
GRANIX – tbo-filgrastim soln prefilled
syringe 300 mcg/0.5ml
GRANIX – tbo-filgrastim soln prefilled
syringe 480 mcg/0.8ml
warfarin sodium tab 7.5 mg (Coumadin)
•
•
•
•
•
XARELTO – rivaroxaban tab 20 mg
NEUPOGEN – filgrastim inj 300 mcg/0.5ml
(600 mcg/ml)
•
EYE
(600 mcg/ml)
•
NPLATE – romiplostim for inj 250 mcg
• •
• •
NEULASTA – pegfilgrastim inj 6 mg/0.6ml
NEULASTA DELIVERY KIT – pegfilgrastim
inj 6 mg/0.6ml
NEUMEGA – oprelvekin for inj 5 mg
NEUPOGEN – filgrastim inj 300 mcg/ml
(300 mcg/ml)
NPLATE – romiplostim for inj 500 mcg
XARELTO STARTER PACK – rivaroxaban
tab starter therapy pack 15 mg & 20 mg
•
•
•
•
TOPICAL PRODUCTS
Anti-infectives
pentoxifylline tab cr 400 mg
•
•
•
• •
mg (base equiv)
2.5 mg/0.5ml (Arixtra)
Dispensing Limits
Prior Approval
•
Specialty
(Lovenox)
Prior Approval
Drug Name
Drug Name
Specialty
Dispensing Limits
2015
•
•
•
BACITRACIN – bacitracin ophth oint 500
unit/gm
bacitracin-polymyxin b ophth oint
CILOXAN – ciprofloxacin hcl ophth oint
0.3%
ciprofloxacin hcl ophth soln 0.3%
(Ciloxan)
erythromycin ophth oint 5 mg/gm
gentamicin sulfate ophth oint 0.3%
47
gentamicin sulfate ophth soln 0.3%
(Garamycin)
neomycin-polymyxin-dexamethasone
ophth susp 0.1% (Maxitrol)
NATACYN – natamycin ophth susp 5%
prednisolone acetate ophth susp 1%
(Pred forte)
neomycin-bacitrac zn-polymyx
5(3.5)mg-400unt-10000unt op oin
neomycin-polymy-gramicid op sol
1.75-10000-0.025mg-unt-mg/ml
(Neosporin)
ofloxacin ophth soln 0.3% (Ocuflox)
polymyxin b-trimethoprim ophth soln
10000 unit/ml-0.1% (Polytrim)
TOBRADEX – tobramycin-dexamethasone
ophth oint 0.3-0.1%
sulfacetamide sodium ophth soln 10%
(Bleph-10)
tobramycin-dexamethasone ophth susp
0.3-0.1% (Tobradex)
tobramycin ophth soln 0.3% (Tobrex)
ZYLET – loteprednol etabonate-tobramycin
ophth susp 0.5-0.3%
VIGAMOX – moxifloxacin hcl ophth soln
0.5% (base equiv)
Steroids and Combination Products
ALREX – loteprednol etabonate ophth susp
0.2%
bacitracin-polymyxin-neomycin-hc ophth
oint 1%
BLEPHAMIDE – sulfacetamide sodiumprednisolone ophth susp 10-0.2%
Glaucoma
ALPHAGAN P – brimonidine tartrate ophth
soln 0.1%
AZOPT – brinzolamide ophth susp 1%
BETOPTIC-S – betaxolol hcl ophth susp
0.25%
brimonidine tartrate ophth soln 0.15%
(Alphagan p)
brimonidine tartrate ophth soln 0.2%
BLEPHAMIDE S.O.P. – sulfacetamide
sodium-prednisolone ophth oint 10-0.2%
carteolol hcl ophth soln 1%
dexamethasone sodium phosphate
ophth soln 0.1%
dorzolamide hcl-timolol maleate ophth
soln 22.3-6.8 mg/ml (Cosopt)
fluorometholone ophth susp 0.1% (Fml
liquifilm)
latanoprost ophth soln 0.005% (Xalatan)
dorzolamide hcl ophth soln 2% (Trusopt)
FML – fluorometholone ophth oint 0.1%
LEVOBUNOLOL HCL – levobunolol hcl
ophth soln 0.25%
LOTEMAX – loteprednol etabonate ophth
gel 0.5%
levobunolol hcl ophth soln 0.5%
(Betagan)
oint 0.5%
LUMIGAN – bimatoprost ophth soln 0.01%
susp 0.5%
neomycin-polymyxin-dexamethasone
ophth oint 0.1% (Maxitrol)
48
Dispensing Limits
PREDNISOLONE SODIUM PHOSP –
prednisolone sodium phosphate ophth
soln 1%
sulfacetamide sodium-prednisolone
ophth soln 10-0.23(0.25)%
trifluridine ophth soln 1% (Viroptic)
Prior Approval
Drug Name
Specialty
Dispensing Limits
Prior Approval
Drug Name
Specialty
2015
METIPRANOLOL – metipranolol ophth soln
0.3%
pilocarpine hcl ophth soln 1% (Isopto
carpine)
•
•
carpine)
CIPRO HC – ciprofloxacin-hydrocortisone
otic susp 0.2-1%
CIPRODEX – ciprofloxacin-dexamethasone
otic susp 0.3-0.1%
timolol maleate ophth gel forming soln
0.25% (Timoptic-xe)
hydrocortisone w/ acetic acid otic soln
1-2%
timolol maleate ophth gel forming soln
0.5% (Timoptic-xe)
neomycin-polymyxin-hc otic soln 1%
(Cortisporin)
timolol maleate ophth soln 0.25%
(Timoptic)
neomycin-polymyxin-hc otic susp
3.5 mg/ml-10000 unit/ml-1%
timolol maleate ophth soln 0.5%
(Timoptic)
•
ofloxacin otic soln 0.3%
MOUTH AND THROAT (LOCAL)
Other Eye Products
chlorhexidine gluconate soln 0.12%
(Peridex)
ATROPINE SULFATE – atropine sulfate
ophth oint 1%
lidocaine hcl viscous soln 2%
atropine sulfate ophth soln 1% (Isopto
atropine)
pilocarpine hcl tab 5 mg (Salagen)
nystatin susp 100000 unit/ml
azelastine hcl ophth soln 0.05% (Optivar)
pilocarpine hcl tab 7.5 mg (Salagen)
cromolyn sodium ophth soln 4%
sodium fluoride cream 1.1% (Prevident
5000 plus)
diclofenac sodium ophth soln 0.1%
flurbiprofen sodium ophth soln 0.03%
(Ocufen)
homatropine hbr ophth soln 5% (Isopto
homatropine)
ketorolac tromethamine ophth soln 0.4%
(Acular ls)
ketorolac tromethamine ophth soln 0.5%
(Acular)
PATADAY – olopatadine hcl ophth soln
0.2%
Dispensing Limits
antipyrine-benzocaine otic soln
54-14 mg/ml (5.4-1.4%)
SIMBRINZA – brinzolamide-brimonidine
tartrate ophth susp 1-0.2%
cyclopentolate hcl ophth soln 1%
(Cyclogyl)
Prior Approval
acetic acid otic soln 2%
carpine)
TRAVATAN Z – travoprost ophth soln
0.004% (benzalkonium free) (bak free)
Drug Name
Specialty
Dispensing Limits
Prior Approval
Drug Name
Specialty
2015
sodium fluoride gel 1.1% (0.5% f)
(Prevident fluoride)
triamcinolone acetonide dental paste
0.1%
ANORECTAL
hydrocortisone acetate suppos 25 mg
(Anusol-hc)
hydrocortisone enema 100 mg/60ml
(Cortenema)
hydrocortisone rectal cream 2.5%
(Anusol-hc)
SKIN CONDITIONS/PRODUCTS
PAZEO – olopatadine hcl ophth soln 0.7%
(base equivalent)
Acne
EAR
adapalene gel 0.1% (Differin)
adapalene cream 0.1% (Differin)
•
•
49
•
•
•
•
•
•
•
•
•
benzoyl peroxide-erythromycin gel 5-3%
(Benzamycin)
TAZORAC – tazarotene cream 0.05%
CLARAVIS – isotretinoin cap 30 mg
TAZORAC – tazarotene gel 0.05%
clindamycin phosph-benzoyl peroxide
(refrig) gel 1.2 (1)-5%, NF = Neuac
(Duac)
TAZORAC – tazarotene gel 0.1%
clindamycin phosphate gel 1% (Cleocin-t)
tretinoin cream 0.05% (Retin-a)
clindamycin phosphate lotion 1%
(Cleocin-t)
clindamycin phosphate soln 1% (Cleocint)
tretinoin gel 0.025%, NF = Avita gel
(Retin-a)
clindamycin phosphate swab 1%
(Cleocin-t)
tretinoin microsphere gel 0.04% (Retin-a
micro)
•
clindamycin phosphate-benzoyl
peroxide gel 1-5% (Benzaclin)
tretinoin microsphere gel 0.1% (Retin-a
micro)
•
erythromycin gel 2% (Erygel)
Anti-infectives
erythromycin pads 2%
ciclopirox gel 0.77% (Loprox)
erythromycin soln 2%
ciclopirox olamine cream 0.77% (base
equiv)
FINACEA – azelaic acid foam 15%
FINACEA – azelaic acid gel 15%
isotretinoin cap 10 mg
metronidazole cream 0.75% (Metrocream)
TAZORAC – tazarotene cream 0.1%
tretinoin gel 0.01% (Retin-a)
ciclopirox olamine susp 0.77% (base
equiv)
ciclopirox shampoo 1% (Loprox shampoo)
clotrimazole w/ betamethasone cream
1-0.05% (Lotrisone)
metronidazole gel 0.75%
clotrimazole w/ betamethasone lotion
1-0.05%
metronidazole gel 1% (Metrogel)
econazole nitrate cream 1%
metronidazole lotion 0.75% (Metrolotion)
GENTAMICIN SULFATE – gentamicin
sulfate cream 0.1%
SODIUM SULFACETAMIDE/SULF –
sulfacetamide sodium w/ sulfur susp
10-5%
GENTAMICIN SULFATE – gentamicin
sulfate oint 0.1%
sulfacetamide sodium lotion 10% (acne)
(Klaron)
ketoconazole cream 2%
sulfacetamide sodium w/ sulfur cream
10-5%
mupirocin calcium cream 2% (Bactroban)
sulfacetamide sodium w/ sulfur emulsion
10-5%
nystatin cream 100000 unit/gm
sulfacetamide sodium w/ sulfur lotion
10-5%
50
ketoconazole shampoo 2% (Nizoral)
mupirocin oint 2% (Bactroban)
nystatin oint 100000 unit/gm
nystatin topical powder
Dispensing Limits
Prior Approval
Drug Name
Specialty
Dispensing Limits
Prior Approval
Drug Name
Specialty
2015
DESOXIMETASONE – desoximetasone
cream 0.05%
VOLTAREN – diclofenac sodium gel 1%
Corticosteroids
desoximetasone cream 0.25% (Topicort)
alclometasone dipropionate cream 0.05%
(Aclovate)
desoximetasone gel 0.05% (Topicort)
alclometasone dipropionate oint 0.05%
AMCINONIDE – amcinonide cream 0.1%
DIFLORASONE DIACETATE – diflorasone
diacetate cream 0.05%
betamethasone dipropionate augmented
cream 0.05% (Diprolene af)
DIFLORASONE DIACETATE – diflorasone
diacetate oint 0.05%
betamethasone dipropionate
augmented gel 0.05%
fluocinolone acetonide cream 0.01%
lotion 0.05% (Diprolene)
oint 0.05% (Diprolene)
betamethasone dipropionate cream
0.05%
desoximetasone oint 0.25% (Topicort)
fluocinolone acetonide cream 0.025%
(Synalar)
fluocinolone acetonide oint 0.025%
(Synalar)
fluocinolone acetonide soln 0.01%
(Synalar)
fluocinonide cream 0.05%
betamethasone dipropionate lotion
0.05%
fluocinonide emulsified base cream
0.05%
betamethasone dipropionate oint 0.05%
fluocinonide gel 0.05%
betamethasone valerate cream 0.1%
fluocinonide oint 0.05%
betamethasone valerate lotion 0.1%
fluocinonide soln 0.05%
betamethasone valerate oint 0.1%
fluticasone propionate cream 0.05%
(Cutivate)
clobetasol propionate cream 0.05%
(Temovate)
clobetasol propionate emollient base
cream 0.05% (Temovate e)
Dispensing Limits
•
silver sulfadiazine cream 1% (Silvadene)
Prior Approval
Drug Name
Specialty
Dispensing Limits
Prior Approval
Drug Name
Specialty
2015
fluticasone propionate oint 0.005%
(Cutivate)
clobetasol propionate foam 0.05% (Olux)
halobetasol propionate cream 0.05%
(Ultravate)
clobetasol propionate gel 0.05%
(Temovate)
halobetasol propionate oint 0.05%
(Ultravate)
clobetasol propionate oint 0.05%
(Temovate)
hydrocortisone cream 2.5%
clobetasol propionate soln 0.05%
(Temovate)
hydrocortisone oint 2.5%
desonide cream 0.05% (Desowen)
desonide lotion 0.05% (Desowen)
hydrocortisone valerate oint 0.2%
(Westcort)
desonide oint 0.05% (Desowen)
mometasone furoate cream 0.1% (Elocon)
hydrocortisone lotion 2.5%
hydrocortisone valerate cream 0.2%
mometasone furoate oint 0.1% (Elocon)
51
mometasone furoate solution 0.1%
(lotion) (Elocon)
lindane shampoo 1%
nystatin-triamcinolone cream 100000-0.1
unit/gm-%
methoxsalen rapid cap 10 mg (Oxsoralen
ultra)
nystatin-triamcinolone oint 100000-0.1
unit/gm-%
permethrin cream 5% (Elimite)
TRIAMCINOLONE ACETONIDE –
triamcinolone acetonide oint 0.5%
PICATO – ingenol mebutate gel 0.05%
Dispensing Limits
Prior Approval
Drug Name
Specialty
Dispensing Limits
Prior Approval
Drug Name
Specialty
2015
malathion lotion 0.5% (Ovide)
•
•
PICATO – ingenol mebutate gel 0.015%
triamcinolone acetonide cream 0.025%
podofilox soln 0.5% (Condylox)
selenium sulfide lotion 2.5%
STELARA – ustekinumab soln prefilled
syringe 45 mg/0.5ml
• • •
STELARA – ustekinumab soln prefilled
syringe 90 mg/ml
• • •
triamcinolone acetonide lotion 0.025%
triamcinolone acetonide lotion 0.1%
SYNERA – lidocaine-tetracaine topical
patch 70-70 mg
Other Products
tacrolimus oint 0.03% (Protopic)
acitretin cap 10 mg (Soriatane)
tacrolimus oint 0.1% (Protopic)
acitretin cap 17.5 mg (Soriatane)
acitretin cap 25 mg (Soriatane)
VALCHLOR – mechlorethamine hcl gel
0.016% (base equivalent)
calcipotriene cream 0.005% (Dovonex)
ZYCLARA – imiquimod cream 3.75%
calcipotriene oint 0.005%
ZYCLARA PUMP – imiquimod cream 2.5%
calcipotriene soln 0.005% (50 mcg/ml)
ZYCLARA PUMP – imiquimod cream 3.75%
CARAC – fluorouracil cream 0.5%
MISCELLANEOUS CATEGORIES
diclofenac sodium (actinic keratoses) gel
3% (Solaraze)
DIABETIC SUPPLIES
DRYSOL – aluminum chloride soln 20%
ELIDEL – pimecrolimus cream 1%
FLUOROPLEX – fluorouracil cream 1%
fluorouracil cream 5% (Efudex)
fluorouracil soln 2%
fluorouracil soln 5%
imiquimod cream 5% (Aldara)
lidocaine-prilocaine cream 2.5-2.5%
(Emla)
lidocaine-prilocaine kit 2.5-2.5%
lindane lotion 1%
52
•
CALIBRATION LIQUID – BAYER
ASCENSIA AUTODISC, BREEZE 2,
CONTOUR, CONTOUR NEXT
CALIBRATION LIQUID – ROCHE ACCUCHEK ACTIVE, AVIVA, COMPACT
BLUE, COMPACT PLUS, INSTANT,
SMARTVIEW
CALIBRATION LIQUID – ROCHE
ACCUTREND
INSULIN PEN NEEDLES – NOVOFINE,
NOVOTWIST; various
INSULIN SYRINGES – various
LANCETS – various
TEST STRIPS – ROCHE ACCU-CHEK
ACTIVE, AVIVA, AVIVA PLUS,
COMPACT, COMPACT PLUS,
SMARTVIEW
•
TEST STRIPS – ROCHE ACCUTREND
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
mycophenolate sodium tab dr 180 mg
(mycophenolic acid equiv) (Myfortic)
mycophenolate sodium tab dr 360 mg
(mycophenolic acid equiv) (Myfortic)
naloxone hcl inj 0.4 mg/ml
naltrexone hcl tab 50 mg (Revia)
RAPAMUNE – sirolimus oral soln 1 mg/ml
MEDICAL DEVICES
REVLIMID – lenalidomide caps 2.5 mg
INHALER ASSIST DEVICES – spacers
REVLIMID – lenalidomide cap 5 mg
MISCELLANEOUS DRUGS
azathioprine tab 50 mg (Imuran)
buprenorphine hcl-naloxone hcl sl tab
2-0.5 mg (base equiv)
•
buprenorphine hcl-naloxone hcl sl tab
8-2 mg (base equiv)
•
sirolimus tab 0.5 mg (Rapamune)
sirolimus tab 1 mg (Rapamune)
CHEMET – succimer cap 100 mg
CUPRIMINE – penicillamine cap 250 mg
Dispensing Limits
•
Prior Approval
TEST STRIPS – BAYER ASCENSIA
AUTODISC, BREEZE 2, CONTOUR,
CONTOUR NEXT
Drug Name
Specialty
Dispensing Limits
Prior Approval
Drug Name
Specialty
2015
•
cyclosporine cap 25 mg (Sandimmune)
cyclosporine cap 100 mg (Sandimmune)
sirolimus tab 2 mg (Rapamune)
sodium polystyrene sulfonate oral susp
15 gm/60ml (Sps)
sodium polystyrene sulfonate powder
(Kayexalate)
cyclosporine modified cap 25 mg
(Neoral)
sodium polystyrene sulfonate rectal
susp 30 gm/120ml
cyclosporine modified cap 100 mg
(Neoral)
cyclosporine modified oral soln 100 mg/
ml (Neoral)
SUBOXONE – buprenorphine hcl-naloxone
hcl sl film 2-0.5 mg (base equiv)
•
•
EXJADE – deferasirox tab for oral susp 125
mg
•
hcl sl film 4-1 mg (base equiv)
•
mg
•
•
mg
•
tacrolimus cap 0.5 mg (Prograf)
mycophenolate mofetil cap 250 mg
(Cellcept)
tacrolimus cap 1 mg (Prograf)
mycophenolate mofetil for oral susp
200 mg/ml (Cellcept)
THALOMID – thalidomide cap 50 mg
mycophenolate mofetil tab 500 mg
(Cellcept)
tacrolimus cap 5 mg (Prograf)
•
•
•
•
•
•
•
•
•
•
•
•
53
Dispensing Limits
Prior Approval
Drug Name
Specialty
2015
ZORTRESS – everolimus tab 0.25 mg
54
2015
INDEX
A
abacavir sulfate-lamivudine-zidovudine tab
300-150-300 mg (Trizivir).................................................4
abacavir sulfate tab 300 mg (base equiv) (Ziagen).........4
acamprosate calcium tab delayed release 333 mg
(Campral)........................................................................ 37
acarbose tab 100 mg (Precose)..................................... 13
acarbose tab 25 mg (Precose)....................................... 13
acarbose tab 50 mg (Precose)....................................... 13
acebutolol hcl cap 200 mg (Sectral).............................. 18
acebutolol hcl cap 400 mg (Sectral)..............................18
acetaminophen-isometheptene-dichloral cap
325-65-100 mg................................................................ 41
acetaminophen w/ codeine soln 120-12 mg/5ml...........38
acetaminophen w/ codeine tab 300-15 mg (Tylenol/
codeine).......................................................................... 38
codeine #3).....................................................................38
codeine #4).....................................................................38
ACETAZOLAMIDE – acetazolamide tab 125 mg.............. 22
acetazolamide cap sr 12hr 500 mg (Diamox)................22
acetazolamide tab 250 mg..............................................22
acetic acid otic soln 2%................................................. 49
acetylcysteine inhal soln 10%........................................25
acetylcysteine inhal soln 20%........................................25
acitretin cap 10 mg (Soriatane)......................................52
acitretin cap 17.5 mg (Soriatane)...................................52
acitretin cap 25 mg (Soriatane)......................................52
ACTIMMUNE – interferon gamma-1b inj 100 mcg/0.5ml
(2000000 unit/0.5ml)..........................................................7
acyclovir cap 200 mg (Zovirax)........................................4
acyclovir susp 200 mg/5ml (Zovirax).............................. 4
acyclovir tab 400 mg (Zovirax)........................................ 4
acyclovir tab 800 mg (Zovirax)........................................ 4
adapalene cream 0.1% (Differin)....................................49
adapalene gel 0.1% (Differin)......................................... 49
ADCIRCA – tadalafil tab 20 mg (pah)............................... 24
adefovir dipivoxil tab 10 mg (Hepsera)........................... 4
ADVAIR DISKUS – fluticasone-salmeterol aer powder ba
100-50 mcg/dose............................................................. 25
250-50 mcg/dose............................................................. 25
500-50 mcg/dose............................................................. 25
ADVAIR HFA – fluticasone-salmeterol inhal aerosol
115-21 mcg/act................................................................ 25
ADVAIR HFA – fluticasone-salmeterol inhal aerosol
230-21 mcg/act................................................................ 25
ADVAIR HFA – fluticasone-salmeterol inhal aerosol 45-21
mcg/act............................................................................ 25
AFINITOR DISPERZ – everolimus tab for oral susp 2
mg...................................................................................... 7
mg...................................................................................... 7
mg...................................................................................... 7
AFINITOR – everolimus tab 10 mg.....................................7
AFINITOR – everolimus tab 2.5 mg....................................7
AFINITOR – everolimus tab 5 mg.......................................7
AFINITOR – everolimus tab 7.5 mg....................................7
AGGRENOX – aspirin-dipyridamole cap sr 12hr 25-200
mg.................................................................................... 46
ALBENZA – albendazole tab 200 mg................................. 6
albuterol sulfate soln nebu 0.083% (2.5 mg/3ml)..........25
albuterol sulfate soln nebu 0.5% (5 mg/ml).................. 25
albuterol sulfate soln nebu 0.63 mg/3ml (base
equiv).............................................................................. 25
albuterol sulfate soln nebu 1.25 mg/3ml (base
equiv).............................................................................. 25
albuterol sulfate syrup 2 mg/5ml................................... 25
albuterol sulfate tab 2 mg.............................................. 25
albuterol sulfate tab 4 mg.............................................. 25
albuterol sulfate tab sr 12hr 4 mg (Vospire er).............25
albuterol sulfate tab sr 12hr 8 mg (Vospire er).............25
alclometasone dipropionate cream 0.05%
(Aclovate)........................................................................51
alclometasone dipropionate oint 0.05%........................ 51
ALENDRONATE SODIUM – alendronate sodium tab 40
mg.................................................................................... 15
alendronate sodium tab 10 mg...................................... 15
alendronate sodium tab 35 mg...................................... 15
alendronate sodium tab 5 mg........................................ 15
alendronate sodium tab 70 mg (Fosamax)................... 15
alfuzosin hcl tab sr 24hr 10 mg (Uroxatral).................. 30
ALINIA – nitazoxanide for susp 100 mg/5ml....................... 6
ALINIA – nitazoxanide tab 500 mg..................................... 6
ALKERAN – melphalan tab 2 mg....................................... 7
allopurinol tab 100 mg (Zyloprim)................................. 42
allopurinol tab 300 mg (Zyloprim)................................. 42
ALPHAGAN P – brimonidine tartrate ophth soln 0.1%...... 48
ALPRAZOLAM INTENSOL – alprazolam conc 1 mg/
ml..................................................................................... 30
alprazolam tab 0.25 mg (Xanax).................................... 30
alprazolam tab 0.5 mg (Xanax)...................................... 30
alprazolam tab 1 mg (Xanax)......................................... 30
alprazolam tab 2 mg (Xanax)......................................... 30
alprazolam tab sr 24hr 0.5 mg (Xanax xr)..................... 30
alprazolam tab sr 24hr 1 mg (Xanax xr)........................ 30
ALREX – loteprednol etabonate ophth susp 0.2%............ 48
AMCINONIDE – amcinonide cream 0.1%.........................51
AMICAR – aminocaproic acid syrup 25%......................... 46
AMICAR – aminocaproic acid tab 500 mg........................ 46
amiloride & hydrochlorothiazide tab 5-50 mg...............23
amiloride hcl tab 5 mg....................................................23
55
2015
amiodarone hcl tab 100 mg........................................... 23
amiodarone hcl tab 200 mg (Cordarone)...................... 23
amiodarone hcl tab 400 mg........................................... 23
amitriptyline hcl tab 100 mg...........................................31
amitriptyline hcl tab 10 mg............................................ 31
amitriptyline hcl tab 150 mg...........................................31
amlodipine besylate-atorvastatin calcium tab 10-10 mg
(Caduet).......................................................................... 20
(Caduet).......................................................................... 20
(Caduet).......................................................................... 20
(Caduet).......................................................................... 20
amlodipine besylate-atorvastatin calcium tab 2.5-10
mg (Caduet)....................................................................20
mg (Caduet)....................................................................20
mg (Caduet)....................................................................20
(Caduet).......................................................................... 20
(Caduet).......................................................................... 20
(Caduet).......................................................................... 20
(Caduet).......................................................................... 20
amlodipine besylate-benazepril hcl cap 10-20 mg
(Lotrel).............................................................................20
(Lotrel).............................................................................20
amlodipine besylate-benazepril hcl cap 2.5-10 mg
(Lotrel).............................................................................20
(Lotrel).............................................................................20
(Lotrel).............................................................................20
(Lotrel).............................................................................20
amlodipine besylate tab 10 mg (Norvasc).....................20
amlodipine besylate tab 2.5 mg (Norvasc)....................20
amlodipine besylate tab 5 mg (Norvasc)...................... 20
amlodipine besylate-valsartan tab 10-160 mg
(Exforge)......................................................................... 20
(Exforge)......................................................................... 20
(Exforge)......................................................................... 20
(Exforge)......................................................................... 20
amlodipine-valsartan-hydrochlorothiazide tab
10-160-12.5 mg (Exforge hct)....................................... 18
56
10-160-25 mg (Exforge hct).......................................... 18
10-320-25 mg (Exforge hct).......................................... 18
5-160-12.5 mg (Exforge hct)......................................... 17
amlodipine-valsartan-hydrochlorothiazide tab 5-160-25
mg (Exforge hct)............................................................18
amoxicillin (trihydrate) cap 250 mg................................. 1
amoxicillin (trihydrate) cap 500 mg................................. 1
amoxicillin (trihydrate) for susp 125 mg/5ml.................. 1
amoxicillin (trihydrate) tab 500 mg..................................1
amoxicillin (trihydrate) tab 875 mg..................................1
amoxicillin & k clavulanate chew tab 200-28.5 mg.........1
amoxicillin & k clavulanate chew tab 400-57 mg............1
amoxicillin & k clavulanate for susp 200-28.5
mg/5ml.............................................................................. 1
amoxicillin & k clavulanate for susp 250-62.5 mg/5ml
(Augmentin)......................................................................1
amoxicillin & k clavulanate for susp 400-57 mg/5ml...... 1
amoxicillin & k clavulanate for susp 600-42.9 mg/5ml
(Augmentin es-600)......................................................... 1
amoxicillin & k clavulanate tab 250-125 mg................... 1
amoxicillin & k clavulanate tab 500-125 mg
(Augmentin)......................................................................1
amoxicillin & k clavulanate tab 875-125 mg
(Augmentin)......................................................................1
amoxicillin & k clavulanate tab sr 12hr 1000-62.5 mg
(Augmentin xr)................................................................. 1
AMOXICILLIN – amoxicillin (trihydrate) chew tab 125
mg...................................................................................... 1
AMOXICILLIN – amoxicillin (trihydrate) chew tab 250
mg...................................................................................... 1
amoxicillin cap-clarithro tab-lansopraz cap dr therapy
pack (Prevpac)............................................................... 27
amphetamine-dextroamphetamine cap sr 24hr 10 mg
(Adderall xr)................................................................... 34
(Adderall xr)................................................................... 34
(Adderall xr)................................................................... 35
(Adderall xr)................................................................... 35
(Adderall xr)................................................................... 35
(Adderall xr)................................................................... 34
amphetamine-dextroamphetamine tab 10 mg
(Adderall)........................................................................ 35
amphetamine-dextroamphetamine tab 12.5 mg
(Adderall)........................................................................ 35
(Adderall)........................................................................ 35
2015
(Adderall)........................................................................ 35
(Adderall)........................................................................ 35
(Adderall)........................................................................ 35
amphetamine-dextroamphetamine tab 7.5 mg
(Adderall)........................................................................ 35
AMPICILLIN – ampicillin for susp 125 mg/5ml.................... 1
AMPICILLIN – ampicillin for susp 250 mg/5ml.................... 1
ampicillin cap 250 mg.......................................................1
ampicillin cap 500 mg.......................................................1
anagrelide hcl cap 0.5 mg (Agrylin).............................. 46
anagrelide hcl cap 1 mg................................................. 46
anastrozole tab 1 mg (Arimidex)..................................... 7
ANDRODERM – testosterone td patch 24hr 2
mg/24hr............................................................................10
ANDRODERM – testosterone td patch 24hr 4
mg/24hr............................................................................10
ANDROGEL PUMP – testosterone td gel 12.5 mg/act
(1%)................................................................................. 10
ANDROGEL PUMP – testosterone td gel 20.25 mg/act
(1.62%)............................................................................ 10
ANDROGEL – testosterone td gel 20.25 mg/1.25gm
(1.62%)............................................................................ 10
ANDROGEL – testosterone td gel 25 mg/2.5gm (1%)...... 10
ANDROGEL – testosterone td gel 40.5 mg/2.5gm
(1.62%)............................................................................ 10
ANDROGEL – testosterone td gel 50 mg/5gm (1%)......... 10
ANDROXY – fluoxymesterone tab 10 mg......................... 10
ANORO ELLIPTA – umeclidinium-vilanterol aero powd ba
62.5-25 mcg/inh............................................................... 25
antipyrine-benzocaine otic soln 54-14 mg/ml
(5.4-1.4%)........................................................................ 49
APTIVUS – tipranavir cap 250 mg......................................4
APTIVUS – tipranavir oral soln 100 mg/ml......................... 4
ARANESP ALBUMIN FREE – darbepoetin alfapolysorbate 80 soln inj 100 mcg/0.5ml............................ 46
ARANESP ALBUMIN FREE – darbepoetin alfapolysorbate 80 soln inj 100 mcg/ml.................................46
ARANESP ALBUMIN FREE – darbepoetin alfapolysorbate 80 soln inj 10 mcg/0.4ml.............................. 46
ARANESP ALBUMIN FREE – darbepoetin alfapolysorbate 80 soln inj 25 mcg/ml...................................46
ARNUITY ELLIPTA – fluticasone furoate aerosol powder
breath activ 100 mcg/act................................................. 26
ARNUITY ELLIPTA – fluticasone furoate aerosol powder
breath activ 200 mcg/act................................................. 26
ASACOL HD – mesalamine tab delayed release 800
mg.................................................................................... 29
ASMANEX HFA – mometasone furoate inhal aerosol
suspension 100 mcg/act..................................................26
ASMANEX HFA – mometasone furoate inhal aerosol
suspension 200 mcg/act..................................................26
ASMANEX TWISTHALER 120 ME – mometasone furoate
inhal powd 220 mcg/inh (breath activated)......................26
ASMANEX TWISTHALER 14 MET – mometasone furoate
ASTEPRO – azelastine hcl nasal spray 0.15% (205.5
mcg/spray)....................................................................... 25
atenolol & chlorthalidone tab 100-25 mg (Tenoretic
100)..................................................................................18
atenolol & chlorthalidone tab 50-25 mg (Tenoretic
50)....................................................................................18
atenolol tab 100 mg (Tenormin).....................................18
atenolol tab 25 mg (Tenormin).......................................18
atenolol tab 50 mg (Tenormin).......................................18
atorvastatin calcium tab 10 mg (base equivalent)
(Lipitor)........................................................................... 21
(Lipitor)........................................................................... 21
(Lipitor)........................................................................... 21
(Lipitor)........................................................................... 21
atovaquone-proguanil hcl tab 250-100 mg
(Malarone).........................................................................6
atovaquone-proguanil hcl tab 62.5-25 mg
(Malarone).........................................................................6
ATRIPLA – efavirenz-emtricitabine-tenofovir df tab
600-200-300 mg................................................................ 4
ATROPINE SULFATE – atropine sulfate ophth oint
1%....................................................................................49
atropine sulfate ophth soln 1% (Isopto atropine)......... 49
57
2015
ATROVENT HFA – ipratropium bromide hfa inhal aerosol
17 mcg/act....................................................................... 26
AUGMENTIN – amoxicillin & k clavulanate for susp
125-31.25 mg/5ml..............................................................1
azathioprine tab 50 mg (Imuran)....................................53
azelastine hcl nasal spray 0.1% (137 mcg/spray).........25
azelastine hcl nasal spray 0.15% (205.5 mcg/spray)
(Astepro)......................................................................... 25
azelastine hcl ophth soln 0.05% (Optivar).................... 49
AZITHROMYCIN – azithromycin powd pack for susp 1
gm...................................................................................... 2
azithromycin for susp 100 mg/5ml (Zithromax)..............2
azithromycin for susp 200 mg/5ml (Zithromax)..............2
azithromycin tab 250 mg (Zithromax)............................. 2
AZOPT – brinzolamide ophth susp 1%............................. 48
B
BACITRACIN – bacitracin ophth oint 500 unit/gm.............47
bacitracin-polymyxin b ophth oint.................................47
bacitracin-polymyxin-neomycin-hc ophth oint 1%.......48
baclofen tab 10 mg......................................................... 44
baclofen tab 20 mg......................................................... 44
BACTROBAN NASAL – mupirocin calcium nasal oint
2%....................................................................................25
balsalazide disodium cap 750 mg (Colazal)..................29
BANZEL – rufinamide susp 40 mg/ml...............................42
BANZEL – rufinamide tab 200 mg.................................... 42
BANZEL – rufinamide tab 400 mg.................................... 42
BARACLUDE – entecavir oral soln 0.05 mg/ml.................. 4
benazepril & hydrochlorothiazide tab 10-12.5 mg
(Lotensin hct)................................................................. 16
benazepril & hydrochlorothiazide tab 20-12.5 mg
(Lotensin hct)................................................................. 16
benazepril & hydrochlorothiazide tab 20-25 mg
(Lotensin hct)................................................................. 16
benazepril & hydrochlorothiazide tab 5-6.25 mg..........16
benazepril hcl tab 10 mg (Lotensin).............................. 16
benazepril hcl tab 5 mg.................................................. 16
benzoyl peroxide-erythromycin gel 5-3%
(Benzamycin)..................................................................50
benztropine mesylate tab 0.5 mg...................................43
benztropine mesylate tab 1 mg..................................... 43
benztropine mesylate tab 2 mg..................................... 43
betamethasone dipropionate augmented cream 0.05%
(Diprolene af)................................................................. 51
betamethasone dipropionate augmented gel
0.05%...............................................................................51
betamethasone dipropionate augmented lotion 0.05%
(Diprolene)...................................................................... 51
betamethasone dipropionate augmented oint 0.05%
(Diprolene)...................................................................... 51
betamethasone dipropionate cream 0.05%...................51
58
betamethasone dipropionate lotion 0.05%................... 51
betamethasone dipropionate oint 0.05%...................... 51
betamethasone valerate cream 0.1%.............................51
betamethasone valerate lotion 0.1%............................. 51
betamethasone valerate oint 0.1%.................................51
BETASERON – interferon beta-1b for inj kit 0.3 mg..........36
BETOPTIC-S – betaxolol hcl ophth susp 0.25%............... 48
bexarotene cap 75 mg (Targretin)................................... 7
bicalutamide tab 50 mg (Casodex).................................. 7
BILTRICIDE – praziquantel tab 600 mg..............................6
bisoprolol & hydrochlorothiazide tab 10-6.25 mg
(Ziac)............................................................................... 19
bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg
(Ziac)............................................................................... 18
bisoprolol & hydrochlorothiazide tab 5-6.25 mg
(Ziac)............................................................................... 19
bisoprolol fumarate tab 10 mg (Zebeta)........................19
bisoprolol fumarate tab 5 mg (Zebeta)..........................19
BLEPHAMIDE S.O.P. – sulfacetamide sodiumprednisolone ophth oint 10-0.2%.....................................48
BLEPHAMIDE – sulfacetamide sodium-prednisolone
ophth susp 10-0.2%........................................................ 48
BOSULIF – bosutinib tab 100 mg....................................... 7
BOSULIF – bosutinib tab 500 mg....................................... 7
BRAVELLE – urofollitropin purified for inj 75 unit..............13
BREO ELLIPTA – fluticasone furoate-vilanterol aero powd
ba 100-25 mcg/inh...........................................................26
BREO ELLIPTA – fluticasone furoate-vilanterol aero powd
ba 200-25 mcg/inh...........................................................26
brimonidine tartrate ophth soln 0.15% (Alphagan
p)......................................................................................48
brimonidine tartrate ophth soln 0.2%............................48
bromocriptine mesylate cap 5 mg (Parlodel)................43
bromocriptine mesylate tab 2.5 mg (Parlodel)..............43
budesonide cap sr 24hr 3 mg (Entocort ec)................... 9
(Pulmicort)...................................................................... 26
(Pulmicort)...................................................................... 26
budesonide inhalation susp 1 mg/2ml (Pulmicort).......26
bumetanide tab 0.5 mg................................................... 23
bumetanide tab 1 mg...................................................... 23
bumetanide tab 2 mg...................................................... 23
buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg (base
equiv).............................................................................. 53
buprenorphine hcl-naloxone hcl sl tab 8-2 mg (base
equiv).............................................................................. 53
buprenorphine hcl sl tab 2 mg (base equiv)................. 38
buprenorphine hcl sl tab 8 mg (base equiv)................. 38
bupropion hcl (smoking deterrent) tab sr 12hr 150 mg
(Zyban)............................................................................ 36
bupropion hcl tab 100 mg (Wellbutrin)......................... 31
bupropion hcl tab 75 mg (Wellbutrin)........................... 31
bupropion hcl tab sr 12hr 100 mg (Wellbutrin sr)........ 31
2015
bupropion hcl tab sr 24hr 150 mg (Wellbutrin xl).........31
bupropion hcl tab sr 24hr 300 mg (Wellbutrin xl).........31
buspirone hcl tab 10 mg................................................ 30
buspirone hcl tab 5 mg.................................................. 30
buspirone hcl tab 7.5 mg............................................... 30
butalbital-acetaminophen-caffeine cap 50-325-40
mg....................................................................................38
butalbital-acetaminophen-caffeine tab 50-325-40
mg....................................................................................38
butalbital-aspirin-caffeine cap 50-325-40 mg
(Fiorinal)..........................................................................38
butalbital-aspirin-caff w/ codeine cap 50-325-40-30 mg
(Fiorinal/codeine #3)......................................................38
BYDUREON – exenatide extended release for inj susp 2
mg.................................................................................... 13
BYDUREON – exenatide extended release for susp peninjector 2 mg....................................................................13
BYETTA – exenatide soln pen-injector 10 mcg/0.04ml..... 13
BYETTA – exenatide soln pen-injector 5 mcg/0.02ml....... 13
C
cabergoline tab 0.5 mg................................................... 15
caffeine citrate oral soln 60 mg/3ml (10 mg/ml base
equiv) (Cafcit).................................................................35
calcipotriene cream 0.005% (Dovonex).........................52
calcipotriene oint 0.005%............................................... 52
calcipotriene soln 0.005% (50 mcg/ml)..........................52
calcitonin (salmon) nasal soln 200 unit/act
(Miacalcin)...................................................................... 15
calcitriol cap 0.25 mcg (Rocaltrol).................................15
calcitriol cap 0.5 mcg (Rocaltrol)...................................15
calcitriol oral soln 1 mcg/ml (Rocaltrol)........................15
calcium acetate (phosphate binder) cap 667 mg (169
mg ca) (Phoslo)............................................................. 29
calcium acetate (phosphate binder) tab 667 mg
(Eliphos)..........................................................................29
CALIBRATION LIQUID – BAYER ASCENSIA AUTODISC,
BREEZE 2, CONTOUR, CONTOUR NEXT.................... 52
CALIBRATION LIQUID – ROCHE ACCU-CHEK ACTIVE,
AVIVA, COMPACT BLUE, COMPACT PLUS, INSTANT,
SMARTVIEW................................................................... 52
CALIBRATION LIQUID – ROCHE ACCUTREND............. 52
CANASA – mesalamine suppos 1000 mg........................ 29
candesartan cilexetil-hydrochlorothiazide tab 16-12.5
mg (Atacand hct)........................................................... 18
candesartan cilexetil-hydrochlorothiazide tab 32-12.5
mg (Atacand hct)........................................................... 18
candesartan cilexetil-hydrochlorothiazide tab 32-25
mg (Atacand hct)........................................................... 18
candesartan cilexetil tab 16 mg (Atacand)....................18
candesartan cilexetil tab 32 mg (Atacand)....................18
candesartan cilexetil tab 4 mg (Atacand)......................18
candesartan cilexetil tab 8 mg (Atacand)......................18
capecitabine tab 150 mg (Xeloda)................................... 7
capecitabine tab 500 mg (Xeloda)................................... 7
CAPRELSA – vandetanib tab 100 mg................................ 7
CAPRELSA – vandetanib tab 300 mg................................ 7
CAPTOPRIL/HYDROCHLOROTHIA – captopril &
hydrochlorothiazide tab 25-15 mg................................... 17
captopril tab 100 mg....................................................... 17
captopril tab 12.5 mg...................................................... 17
captopril tab 25 mg......................................................... 17
captopril tab 50 mg......................................................... 17
CARAC – fluorouracil cream 0.5%....................................52
CARAFATE – sucralfate susp 1 gm/10ml......................... 27
carbamazepine cap sr 12hr 100 mg (Carbatrol)............42
carbamazepine chew tab 100 mg.................................. 42
carbamazepine susp 100 mg/5ml (Tegretol)................. 42
carbamazepine tab 200 mg (Tegretol)........................... 42
carbamazepine tab sr 12hr 200 mg (Tegretol-xr)..........42
carbamazepine tab sr 12hr 400 mg (Tegretol-xr)..........42
CARBIDOPA/LEVODOPA/ENTACA – carbidopalevodopa-entacapone tabs 12.5-50-200 mg.................... 43
CARBIDOPA/LEVODOPA/ENTACA – carbidopalevodopa-entacapone tabs 18.75-75-200 mg.................. 44
CARBIDOPA/LEVODOPA/ENTACA – carbidopalevodopa-entacapone tabs 25-100-200 mg..................... 44
CARBIDOPA/LEVODOPA/ENTACA – carbidopalevodopa-entacapone tabs 31.25-125-200 mg................ 44
CARBIDOPA/LEVODOPA/ENTACA – carbidopalevodopa-entacapone tabs 37.5-150-200 mg.................. 44
CARBIDOPA/LEVODOPA/ENTACA – carbidopalevodopa-entacapone tabs 50-200-200 mg..................... 44
carbidopa & levodopa orally disintegrating tab 10-100
mg....................................................................................43
mg....................................................................................43
mg....................................................................................43
carbidopa & levodopa tab 10-100 mg (Sinemet)...........43
carbidopa & levodopa tab cr 25-100 mg (Sinemet
cr).................................................................................... 43
carbidopa & levodopa tab cr 50-200 mg (Sinemet
cr).................................................................................... 43
carteolol hcl ophth soln 1%........................................... 48
carvedilol tab 12.5 mg (Coreg).......................................19
carvedilol tab 25 mg (Coreg)..........................................19
carvedilol tab 3.125 mg (Coreg).....................................19
carvedilol tab 6.25 mg (Coreg).......................................19
cefaclor cap 250 mg......................................................... 1
59
2015
cefaclor cap 500 mg......................................................... 1
cefadroxil cap 500 mg...................................................... 1
cefadroxil for susp 250 mg/5ml....................................... 1
cefadroxil for susp 500 mg/5ml....................................... 1
cefadroxil tab 1 gm........................................................... 1
cefdinir cap 300 mg.......................................................... 1
cefdinir for susp 125 mg/5ml........................................... 1
cefdinir for susp 250 mg/5ml........................................... 1
cefixime for susp 100 mg/5ml (Suprax).......................... 1
cefixime for susp 200 mg/5ml (Suprax).......................... 1
cefpodoxime proxetil for susp 100 mg/5ml.................... 1
cefpodoxime proxetil for susp 50 mg/5ml...................... 1
cefpodoxime proxetil tab 100 mg.................................... 1
cefpodoxime proxetil tab 200 mg.................................... 1
cefprozil for susp 125 mg/5ml......................................... 1
cefprozil for susp 250 mg/5ml......................................... 1
cefprozil tab 250 mg......................................................... 1
cefprozil tab 500 mg......................................................... 2
CEFTIN – cefuroxime axetil for susp 125 mg/5ml...............2
cefuroxime axetil tab 250 mg (Ceftin)............................. 2
cefuroxime axetil tab 500 mg (Ceftin)............................. 2
celecoxib cap 100 mg (Celebrex).................................. 40
celecoxib cap 50 mg (Celebrex).................................... 40
cephalexin cap 250 mg (Keflex).......................................2
cephalexin cap 500 mg (Keflex).......................................2
cephalexin for susp 125 mg/5ml......................................2
cephalexin for susp 250 mg/5ml......................................2
CERDELGA – eliglustat tartrate cap 84 mg (base
equivalent)....................................................................... 46
CETROTIDE – cetrorelix acetate for inj kit 0.25 mg.......... 13
CHANTIX CONTINUING MONTH – varenicline tartrate tab
1 mg (base equiv)........................................................... 36
CHANTIX STARTING MONTH PA – varenicline tartrate
tab 0.5 mg x 11 & tab 1 mg x 42 pack............................ 36
CHANTIX – varenicline tartrate tab 0.5 mg (base
equiv)............................................................................... 36
CHANTIX – varenicline tartrate tab 1 mg (base equiv)......36
CHEMET – succimer cap 100 mg.................................... 53
CHENODAL – chenodiol tab 250 mg................................29
chlorhexidine gluconate soln 0.12% (Peridex)............. 49
chloroquine phosphate tab 250 mg.................................6
chloroquine phosphate tab 500 mg (Aralen).................. 6
CHLOROTHIAZIDE – chlorothiazide tab 250 mg..............23
chlorothiazide tab 500 mg.............................................. 23
chlorpromazine hcl tab 100 mg..................................... 32
chlorpromazine hcl tab 10 mg....................................... 32
chlorpromazine hcl tab 200 mg..................................... 32
CHLORTHALIDONE – chlorthalidone tab 25 mg.............. 23
CHLORTHALIDONE – chlorthalidone tab 50 mg.............. 23
chlorzoxazone tab 500 mg (Parafon forte dsc).............44
cholestyramine light powder 4 gm/dose (Questran
light)................................................................................ 21
60
cholestyramine light powder packets 4 gm..................21
cholestyramine powder 4 gm/dose (Questran)............ 22
cholestyramine powder packets 4 gm (Questran)........22
choline fenofibrate cap dr 135 mg (fenofibric acid
equiv) (Trilipix)............................................................... 22
choline fenofibrate cap dr 45 mg (fenofibric acid
equiv) (Trilipix)............................................................... 22
chorionic gonadotropin for inj 10000 unit.................... 13
ciclopirox gel 0.77% (Loprox)........................................ 50
ciclopirox olamine cream 0.77% (base equiv).............. 50
ciclopirox olamine susp 0.77% (base equiv)................ 50
ciclopirox shampoo 1% (Loprox shampoo)..................50
cilostazol tab 100 mg (Pletal).........................................46
cilostazol tab 50 mg (Pletal)...........................................46
CILOXAN – ciprofloxacin hcl ophth oint 0.3%................... 47
cimetidine hcl soln 300 mg/5ml..................................... 27
cimetidine tab 300 mg.................................................... 27
CIPRODEX – ciprofloxacin-dexamethasone otic susp
0.3-0.1%...........................................................................49
ciprofloxacin-ciprofloxacin hcl tab sr 24hr 1000
mg(base eq) (Cipro xr)....................................................3
ciprofloxacin-ciprofloxacin hcl tab sr 24hr 500 mg
(base eq) (Cipro xr)......................................................... 3
ciprofloxacin for oral susp 250 mg/5ml (5%) (5
gm/100ml) (Cipro)............................................................ 3
ciprofloxacin for oral susp 500 mg/5ml (10%) (10
gm/100ml) (Cipro)............................................................ 3
CIPROFLOXACIN HCL – ciprofloxacin hcl tab 100 mg
(base equiv).......................................................................3
ciprofloxacin hcl ophth soln 0.3% (Ciloxan).................47
ciprofloxacin hcl tab 250 mg (base equiv) (Cipro)......... 3
ciprofloxacin hcl tab 500 mg (base equiv) (Cipro)......... 3
ciprofloxacin hcl tab 750 mg (base equiv)......................3
CIPRO HC – ciprofloxacin-hydrocortisone otic susp
0.2-1%..............................................................................49
citalopram hydrobromide oral soln 10 mg/5ml.............31
citalopram hydrobromide tab 10 mg (base equiv)
(Celexa)........................................................................... 31
(Celexa)........................................................................... 31
(Celexa)........................................................................... 31
CLARAVIS – isotretinoin cap 30 mg................................. 50
clarithromycin for susp 125 mg/5ml................................2
clarithromycin for susp 250 mg/5ml (Biaxin)..................2
clarithromycin tab 250 mg (Biaxin)................................. 2
clarithromycin tab 500 mg (Biaxin)................................. 2
clarithromycin tab sr 24hr 500 mg (Biaxin xl pac)..........2
CLEOCIN – clindamycin phosphate vaginal suppos 100
mg.................................................................................... 30
CLIMARA PRO – estradiol-levonorgestrel td patch weekly
0.045-0.015 mg/day.........................................................10
clindamycin hcl cap 150 mg (Cleocin)............................ 6
clindamycin hcl cap 300 mg (Cleocin)............................ 6
2015
clindamycin hcl cap 75 mg (Cleocin).............................. 6
clindamycin palmitate hcl for soln 75 mg/5ml (base
equiv) (Cleocin pediatric gr)...........................................6
clindamycin phosphate-benzoyl peroxide gel 1-5%
(Benzaclin)......................................................................50
clindamycin phosphate gel 1% (Cleocin-t)................... 50
clindamycin phosphate lotion 1% (Cleocin-t)...............50
clindamycin phosphate soln 1% (Cleocin-t)................. 50
clindamycin phosphate swab 1% (Cleocin-t)................50
clindamycin phosphate vaginal cream 2%
(Cleocin)..........................................................................30
clindamycin phosph-benzoyl peroxide (refrig) gel 1.2
(1)-5%, NF = Neuac (Duac)........................................... 50
clobetasol propionate cream 0.05% (Temovate).......... 51
clobetasol propionate emollient base cream 0.05%
(Temovate e).................................................................. 51
clobetasol propionate foam 0.05% (Olux).....................51
clobetasol propionate gel 0.05% (Temovate)................51
clobetasol propionate oint 0.05% (Temovate).............. 51
clobetasol propionate soln 0.05% (Temovate)............. 51
clomiphene citrate tab 50 mg (Clomid)......................... 13
clomipramine hcl cap 25 mg (Anafranil)....................... 31
clonazepam orally disintegrating tab 0.125 mg............42
clonazepam orally disintegrating tab 0.25 mg..............42
clonazepam orally disintegrating tab 0.5 mg................42
clonazepam orally disintegrating tab 1 mg...................42
clonazepam orally disintegrating tab 2 mg...................42
clonazepam tab 0.5 mg (Klonopin)................................42
clonazepam tab 1 mg (Klonopin)...................................42
clonazepam tab 2 mg (Klonopin)...................................42
clonidine hcl tab 0.1 mg (Catapres).............................. 24
clonidine hcl td patch weekly 0.1 mg/24hr (Cataprestts-1)................................................................................ 24
clopidogrel bisulfate tab 300 mg (base equiv)
(Plavix)............................................................................ 46
clopidogrel bisulfate tab 75 mg (base equiv)
(Plavix)............................................................................ 46
clorazepate dipotassium tab 15 mg (Tranxene t)......... 30
clorazepate dipotassium tab 3.75 mg (Tranxene t)...... 30
clorazepate dipotassium tab 7.5 mg (Tranxene t)........ 30
clotrimazole w/ betamethasone cream 1-0.05%
(Lotrisone)...................................................................... 50
clotrimazole w/ betamethasone lotion 1-0.05%............ 50
clozapine tab 100 mg (Clozaril)..................................... 33
clozapine tab 200 mg......................................................33
clozapine tab 25 mg (Clozaril)....................................... 33
clozapine tab 50 mg........................................................33
COARTEM – artemether-lumefantrine tab 20-120 mg........ 6
codeine sulfate tab 15 mg (Codeine sulfate)................ 38
codeine sulfate tab 30 mg..............................................38
codeine sulfate tab 60 mg..............................................38
COLCHICINE – colchicine cap 0.6 mg............................. 42
COLCHICINE – colchicine tab 0.6 mg.............................. 42
colchicine w/ probenecid tab 0.5-500 mg......................42
COLCRYS – colchicine tab 0.6 mg...................................42
colestipol hcl granule packets 5 gm (Colestid
flavored)..........................................................................22
colestipol hcl granules 5 gm (Colestid flavored)..........22
colestipol hcl tab 1 gm (Colestid)..................................22
COMBIVENT RESPIMAT – ipratropium-albuterol inhal
aerosol soln 20-100 mcg/act........................................... 26
COMETRIQ – cabozantinib s-malate cap 3 x 20 mg (60
mg dose) kit.......................................................................7
COMETRIQ – cabozantinib s-mal cap 1 x 80 mg & 1 x 20
mg (100 dose) kit.............................................................. 7
COMETRIQ – cabozantinib s-mal cap 1 x 80 mg & 3 x 20
mg (140 dose) kit.............................................................. 7
COMPLERA – emtricitabine-rilpivirine-tenofovir df tab
200-25-300 mg.................................................................. 4
COPAXONE – glatiramer acetate soln prefilled syringe 20
mg/ml............................................................................... 36
COPAXONE – glatiramer acetate soln prefilled syringe 40
mg/ml............................................................................... 36
CORTISONE ACETATE – cortisone acetate tab 25 mg..... 9
CREON – pancrelipase (lip-prot-amyl) dr cap
12000-38000-60000 unit..................................................28
24000-76000-120000 unit................................................28
3000-9500-15000 unit......................................................28
36000-114000-180000 unit..............................................28
6000-19000-30000 unit....................................................28
CRESTOR – rosuvastatin calcium tab 10 mg................... 22
CRESTOR – rosuvastatin calcium tab 5 mg..................... 22
CRIXIVAN – indinavir sulfate cap 200 mg.......................... 4
CRIXIVAN – indinavir sulfate cap 400 mg.......................... 4
CROMOLYN SODIUM – cromolyn sodium soln nebu 20
mg/2ml............................................................................. 26
cromolyn sodium ophth soln 4%...................................49
CUPRIMINE – penicillamine cap 250 mg......................... 53
cyanocobalamin inj 1000 mcg/ml.................................. 46
cyclobenzaprine hcl tab 10 mg......................................44
cyclobenzaprine hcl tab 5 mg........................................44
cyclopentolate hcl ophth soln 1% (Cyclogyl)............... 49
CYCLOPHOSPHAMIDE – cyclophosphamide cap 25
mg...................................................................................... 7
CYCLOPHOSPHAMIDE – cyclophosphamide cap 50
mg...................................................................................... 7
cyclosporine cap 100 mg (Sandimmune)......................53
cyclosporine cap 25 mg (Sandimmune)........................53
61
2015
cyclosporine modified cap 100 mg (Neoral)................. 53
cyclosporine modified cap 25 mg (Neoral)................... 53
cyclosporine modified oral soln 100 mg/ml
(Neoral)........................................................................... 53
cyproheptadine hcl syrup 2 mg/5ml..............................25
cyproheptadine hcl tab 4 mg......................................... 25
CYSTAGON – cysteamine bitartrate cap 150 mg............. 30
CYSTAGON – cysteamine bitartrate cap 50 mg............... 30
CYTRA-3 – pot & sod citrates w/ cit ac syrup 550-500-334
mg/5ml............................................................................. 30
D
danazol cap 100 mg........................................................ 10
danazol cap 200 mg........................................................ 10
danazol cap 50 mg..........................................................10
dantrolene sodium cap 25 mg (Dantrium).................... 44
dantrolene sodium cap 50 mg (Dantrium).................... 44
DANTROLENE SODIUM – dantrolene sodium cap 100
mg.................................................................................... 44
DAPSONE – dapsone tab 100 mg..................................... 6
DAPSONE – dapsone tab 25 mg....................................... 6
DARAPRIM – pyrimethamine tab 25 mg.............................6
DELZICOL – mesalamine cap dr 400 mg......................... 29
demeclocycline hcl tab 150 mg....................................... 2
demeclocycline hcl tab 300 mg....................................... 2
DEPO-PROVERA CONTRACEPTIV –
medroxyprogesterone acetate im susp 150 mg/ml.......... 11
DEPO-TESTOSTERONE – testosterone cypionate im inj
in oil 100 mg/ml...............................................................10
DEPO-TESTOSTERONE – testosterone cypionate im inj
in oil 200 mg/ml...............................................................10
desipramine hcl tab 100 mg (Norpramin)......................31
desipramine hcl tab 10 mg (Norpramin)....................... 31
desipramine hcl tab 150 mg (Norpramin)......................31
desmopressin acetate inj 4 mcg/ml (Ddavp)................ 15
desmopressin acetate nasal soln 0.01% (refrigerated)
(Ddavp)............................................................................15
desmopressin acetate nasal spray soln 0.01%
(Ddavp)............................................................................16
desmopressin acetate nasal spray soln 0.01%
(refrigerated)...................................................................16
desmopressin acetate tab 0.1 mg (Ddavp)................... 16
desmopressin acetate tab 0.2 mg (Ddavp)................... 16
desogest-eth estrad & eth estrad tab 0.15-0.02/0.01
mg(21/5) (Mircette).........................................................11
desogest-ethin est tab
0.1-0.025/0.125-0.025/0.15-0.025mg-mg
(Cyclessa)....................................................................... 12
desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg
(Desogen)....................................................................... 12
desonide cream 0.05% (Desowen).................................51
desonide lotion 0.05% (Desowen)................................. 51
desonide oint 0.05% (Desowen).................................... 51
62
desoximetasone cream 0.25% (Topicort)......................51
DESOXIMETASONE – desoximetasone cream 0.05%.....51
desoximetasone gel 0.05% (Topicort)........................... 51
desoximetasone oint 0.25% (Topicort)..........................51
DEXAMETHASONE – dexamethasone soln 0.5
mg/5ml............................................................................... 9
DEXAMETHASONE – dexamethasone tab 1 mg............... 9
DEXAMETHASONE – dexamethasone tab 2 mg............. 10
dexamethasone elixir 0.5 mg/5ml.................................. 10
DEXAMETHASONE INTENSOL – dexamethasone conc 1
mg/ml............................................................................... 10
dexamethasone sodium phosphate ophth soln
0.1%.................................................................................48
dexamethasone tab 0.5 mg............................................ 10
dexamethasone tab 0.75 mg.......................................... 10
dexamethasone tab 1.5 mg............................................ 10
dexamethasone tab 4 mg............................................... 10
dexamethasone tab 6 mg............................................... 10
dexmethylphenidate hcl tab 10 mg (Focalin)................35
dexmethylphenidate hcl tab 2.5 mg (Focalin)...............35
dexmethylphenidate hcl tab 5 mg (Focalin)..................35
dextroamphetamine sulfate cap sr 24hr 10 mg
(Dexedrine)..................................................................... 35
(Dexedrine)..................................................................... 35
(Dexedrine)..................................................................... 35
dextroamphetamine sulfate tab 10 mg..........................35
dextroamphetamine sulfate tab 5 mg............................35
DIASTAT ACUDIAL – diazepam rectal gel delivery system
10 mg...............................................................................42
DIASTAT ACUDIAL – diazepam rectal gel delivery system
20 mg...............................................................................42
DIASTAT PEDIATRIC – diazepam rectal gel delivery
system 2.5 mg................................................................. 42
diazepam conc 5 mg/ml..................................................30
DIAZEPAM – diazepam soln 1 mg/ml...............................30
diazepam tab 10 mg (Valium).........................................30
diazepam tab 2 mg (Valium)...........................................30
diazepam tab 5 mg (Valium)...........................................30
DIBENZYLINE – phenoxybenzamine hcl cap 10 mg........ 24
diclofenac potassium tab 50 mg (Cataflam)................. 40
diclofenac sodium (actinic keratoses) gel 3%
(Solaraze)........................................................................52
diclofenac sodium ophth soln 0.1%.............................. 49
diclofenac sodium tab delayed release 25 mg............. 40
diclofenac sodium tab sr 24hr 100 mg (Voltarenxr).................................................................................... 40
dicloxacillin sodium cap 250 mg..................................... 1
dicloxacillin sodium cap 500 mg..................................... 1
dicyclomine hcl cap 10 mg (Bentyl).............................. 27
dicyclomine hcl oral soln 10 mg/5ml.............................27
dicyclomine hcl tab 20 mg (Bentyl)...............................27
2015
didanosine delayed release capsule 125 mg (Videx
ec)......................................................................................4
ec)......................................................................................4
ec)......................................................................................4
ec)......................................................................................4
DIFLORASONE DIACETATE – diflorasone diacetate
cream 0.05%................................................................... 51
DIFLORASONE DIACETATE – diflorasone diacetate oint
0.05%...............................................................................51
DIGOXIN – digoxin oral soln 0.05 mg/ml.......................... 24
digoxin tab 125 mcg (0.125 mg) (Lanoxin)....................24
digoxin tab 250 mcg (0.25 mg) (Lanoxin)......................24
dihydroergotamine mesylate inj 1 mg/ml (D.h.e.
45)....................................................................................41
DILANTIN-125 – phenytoin susp 125 mg/5ml...................42
DILANTIN – phenytoin sodium extended cap 100 mg.......42
DILANTIN – phenytoin sodium extended cap 30 mg........ 42
diltiazem hcl cap sr 24hr 120 mg...................................20
diltiazem hcl coated beads cap sr 24hr 120 mg
(Cardizem cd)................................................................. 20
(Cardizem cd)................................................................. 20
(Cardizem cd)................................................................. 20
(Cardizem cd)................................................................. 20
(Cardizem cd)................................................................. 20
diltiazem hcl extended release beads cap sr 24hr 120
mg (Tiazac).....................................................................20
mg (Tiazac).....................................................................20
mg (Tiazac).....................................................................20
mg (Tiazac).....................................................................20
mg (Tiazac).....................................................................20
mg (Tiazac).....................................................................20
diltiazem hcl tab 120 mg (Cardizem)............................. 20
diltiazem hcl tab 30 mg (Cardizem)............................... 20
diltiazem hcl tab 60 mg (Cardizem)............................... 20
diltiazem hcl tab 90 mg.................................................. 20
dipyridamole tab 25 mg (Persantine)............................ 46
disopyramide phosphate cap 100 mg (Norpace)..........23
disopyramide phosphate cap 150 mg (Norpace)..........23
disulfiram tab 250 mg (Antabuse)................................. 37
disulfiram tab 500 mg (Antabuse)................................. 37
divalproex sodium cap sprinkle 125 mg (Depakote
sprinkles)........................................................................ 42
divalproex sodium tab delayed release 125 mg
(Depakote)...................................................................... 42
(Depakote)...................................................................... 42
(Depakote)...................................................................... 42
divalproex sodium tab sr 24 hr 250 mg (Depakote
er).................................................................................... 42
divalproex sodium tab sr 24 hr 500 mg (Depakote
er).................................................................................... 42
DIVIGEL – estradiol td gel 0.25 mg/0.25gm (0.1%).......... 10
DIVIGEL – estradiol td gel 0.5 mg/0.5gm (0.1%).............. 10
DIVIGEL – estradiol td gel 1 mg/gm (0.1%)...................... 11
donepezil hydrochloride orally disintegrating tab 10
mg (Aricept odt).............................................................37
donepezil hydrochloride orally disintegrating tab 5 mg
(Aricept odt)................................................................... 37
donepezil hydrochloride tab 10 mg (Aricept)............... 37
donepezil hydrochloride tab 5 mg (Aricept)................. 37
dorzolamide hcl ophth soln 2% (Trusopt).....................48
dorzolamide hcl-timolol maleate ophth soln 22.3-6.8
mg/ml (Cosopt).............................................................. 48
doxazosin mesylate tab 1 mg (Cardura)....................... 24
doxepin hcl cap 100 mg................................................. 31
doxepin hcl cap 10 mg................................................... 31
doxepin hcl cap 150 mg................................................. 31
doxepin hcl conc 10 mg/ml............................................ 31
DOXEPIN HCL – doxepin hcl cap 75 mg..........................31
doxycycline hyclate cap 100 mg (Vibramycin)............... 2
doxycycline hyclate cap 50 mg....................................... 2
doxycycline hyclate tab 100 mg...................................... 2
doxycycline hyclate tab 20 mg........................................ 2
doxycycline monohydrate cap 100 mg (Monodox)........ 2
doxycycline monohydrate cap 150 mg (Adoxa)............. 2
doxycycline monohydrate cap 50 mg............................. 2
doxycycline monohydrate cap 75 mg (Monodox).......... 2
doxycycline monohydrate tab 100 mg (Adoxa pak
1/100).................................................................................2
doxycycline monohydrate tab 150 mg (Adoxa pak
1/150).................................................................................2
doxycycline monohydrate tab 50 mg (Adoxa)................ 2
doxycycline monohydrate tab 75 mg (Adoxa)................ 2
drospirenone-ethinyl estradiol tab 3-0.02 mg (Yaz)..... 12
drospirenone-ethinyl estradiol tab 3-0.03 mg (Yasmin
28)....................................................................................12
DRYSOL – aluminum chloride soln 20%.......................... 52
DULERA – mometasone furoate-formoterol fumarate
aerosol 100-5 mcg/act..................................................... 26
63
2015
DULERA – mometasone furoate-formoterol fumarate
aerosol 200-5 mcg/act..................................................... 26
duloxetine hcl enteric coated pellets cap 20 mg
(Cymbalta)...................................................................... 31
(Cymbalta)...................................................................... 31
(Cymbalta)...................................................................... 31
DUTOPROL – metoprolol & hydrochlorothiazide tab sr
24hr 100-12.5 mg............................................................ 19
24hr 25-12.5 mg.............................................................. 19
24hr 50-12.5 mg.............................................................. 19
E
E.E.S. 400 – erythromycin ethylsuccinate tab 400 mg........ 2
econazole nitrate cream 1%........................................... 50
EDURANT – rilpivirine hcl tab 25 mg (base equivalent)...... 4
EFFIENT – prasugrel hcl tab 10 mg (base equiv)............. 46
EFFIENT – prasugrel hcl tab 5 mg (base equiv)............... 46
ELIDEL – pimecrolimus cream 1%................................... 52
ELLA – ulipristal acetate tab 30 mg.................................. 12
ELMIRON – pentosan polysulfate sodium caps 100
mg.................................................................................... 30
EMCYT – estramustine phosphate sodium cap 140 mg..... 7
EMEND – aprepitant capsule 125 mg...............................28
EMEND – aprepitant capsule 40 mg.................................28
EMEND – aprepitant capsule 80 mg.................................28
EMEND – aprepitant capsule therapy pack 80 & 125
mg.................................................................................... 28
EMTRIVA – emtricitabine caps 200 mg.............................. 4
EMTRIVA – emtricitabine soln 10 mg/ml............................ 4
enalapril maleate & hydrochlorothiazide tab 10-25 mg
(Vaseretic).......................................................................17
enalapril maleate & hydrochlorothiazide tab 5-12.5
mg....................................................................................17
enalapril maleate tab 10 mg (Vasotec).......................... 17
enalapril maleate tab 2.5 mg (Vasotec)......................... 17
enalapril maleate tab 20 mg (Vasotec).......................... 17
enalapril maleate tab 5 mg (Vasotec)............................ 17
ENBREL – etanercept for subcutaneous inj kit 25 mg...... 40
ENBREL – etanercept subcutaneous soln prefilled syringe
25 mg/0.5ml.....................................................................40
ENBREL – etanercept subcutaneous soln prefilled syringe
50 mg/ml..........................................................................40
ENBREL SURECLICK – etanercept subcutaneous
solution auto-injector 50 mg/ml....................................... 40
enoxaparin sodium inj 100 mg/ml (Lovenox)............... 46
enoxaparin sodium inj 120 mg/0.8ml (Lovenox)...........47
enoxaparin sodium inj 150 mg/ml (Lovenox)............... 47
enoxaparin sodium inj 300 mg/3ml (Lovenox)..............47
enoxaparin sodium inj 30 mg/0.3ml (Lovenox).............46
64
entacapone tab 200 mg (Comtan)..................................44
entecavir tab 0.5 mg (Baraclude).....................................4
entecavir tab 1 mg (Baraclude)........................................4
EPIPEN 2-PAK – epinephrine solution auto-injector 0.3
mg/0.3ml (1:1000)............................................................25
EPIPEN-JR 2-PAK – epinephrine solution auto-injector
0.15 mg/0.3ml (1:2000)................................................... 25
EPIVIR HBV – lamivudine oral soln 5 mg/ml (hbv)............. 4
eplerenone tab 25 mg (Inspra).......................................24
eplerenone tab 50 mg (Inspra).......................................24
EPZICOM – abacavir sulfate-lamivudine tab 600-300
mg...................................................................................... 4
ergocalciferol cap 50000 unit (Drisdol)......................... 44
ERIVEDGE – vismodegib cap 150 mg............................... 7
ERY-TAB – erythromycin tab delayed release 250 mg....... 2
ERYTHROCIN STEARATE – erythromycin stearate tab
250 mg...............................................................................2
ERYTHROMYCIN BASE – erythromycin tab 250 mg......... 2
ERYTHROMYCIN BASE – erythromycin tab 500 mg......... 2
ERYTHROMYCIN ETHYLSUCCINA – erythromycin
ethylsuccinate tab 400 mg................................................ 2
erythromycin gel 2% (Erygel).........................................50
erythromycin ophth oint 5 mg/gm................................. 47
erythromycin pads 2%....................................................50
erythromycin soln 2%.....................................................50
erythromycin w/ delayed release particles cap 250
mg......................................................................................2
ESBRIET – pirfenidone cap 267 mg................................. 27
ESCAVITE LQ – pediatric multiple vitamins w/ fl-fe drops
0.25-6 mg/ml....................................................................45
escitalopram oxalate soln 5 mg/5ml (base equiv)
(Lexapro).........................................................................31
escitalopram oxalate tab 10 mg (base equiv)
(Lexapro).........................................................................31
(Lexapro).........................................................................31
(Lexapro).........................................................................31
esomeprazole magnesium cap delayed release 20 mg
(base eq) (Nexium)........................................................ 27
esomeprazole magnesium cap delayed release 40 mg
(base eq) (Nexium)........................................................ 27
estazolam tab 1 mg.........................................................34
estazolam tab 2 mg.........................................................34
estradiol & norethindrone acetate tab 0.5-0.1 mg
(Activella)........................................................................11
estradiol & norethindrone acetate tab 1-0.5 mg
(Activella)........................................................................11
estradiol tab 0.5 mg (Estrace)........................................11
estradiol tab 1 mg (Estrace)...........................................11
estradiol tab 2 mg (Estrace)...........................................11
estradiol td patch twice weekly 0.025 mg/24hr (Vivelledot).................................................................................. 11
2015
estradiol td patch twice weekly 0.0375 mg/24hr
(Vivelle-dot).................................................................... 11
estradiol td patch weekly 0.025 mg/24hr (Climara)...... 11
estradiol td patch weekly 0.0375 mg/24hr (37.5
mcg/24hr) (Climara)....................................................... 11
estradiol td patch weekly 0.05 mg/24hr (Climara)........ 11
estradiol td patch weekly 0.06 mg/24hr (Climara)........ 11
estradiol td patch weekly 0.075 mg/24hr (Climara)...... 11
estradiol td patch weekly 0.1 mg/24hr (Climara).......... 11
ESTROPIPATE – estropipate tab 3 mg............................ 11
estropipate tab 0.75 mg..................................................11
estropipate tab 1.5 mg....................................................11
eszopiclone tab 1 mg (Lunesta).................................... 34
ethambutol hcl tab 100 mg (Myambutol)........................ 3
ethambutol hcl tab 400 mg (Myambutol)........................ 3
ethosuximide cap 250 mg (Zarontin).............................42
ethosuximide soln 250 mg/5ml (Zarontin).................... 42
ethynodiol diacetate & ethinyl estradiol tab 1 mg-35
mcg..................................................................................12
ETIDRONATE DISODIUM – etidronate disodium tab 200
mg.................................................................................... 16
ETIDRONATE DISODIUM – etidronate disodium tab 400
mg.................................................................................... 16
etodolac cap 200 mg.......................................................40
etodolac cap 300 mg.......................................................40
etodolac tab 400 mg....................................................... 40
etodolac tab 500 mg....................................................... 40
etodolac tab sr 24hr 400 mg.......................................... 40
ETOPOSIDE – etoposide cap 50 mg..................................7
EVOTAZ – atazanavir sulfate-cobicistat tab 300-150 mg
(base equiv).......................................................................4
exemestane tab 25 mg (Aromasin)..................................7
EXJADE – deferasirox tab for oral susp 125 mg...............53
F
famciclovir tab 125 mg (Famvir)...................................... 4
famotidine tab 40 mg (Pepcid).......................................27
FARESTON – toremifene citrate tab 60 mg (base
equivalent)......................................................................... 7
FARYDAK – panobinostat lactate cap 10 mg (base
equivalent)......................................................................... 7
equivalent)......................................................................... 7
equivalent)......................................................................... 7
felbamate susp 600 mg/5ml (Felbatol).......................... 42
felbamate tab 400 mg (Felbatol).................................... 42
felbamate tab 600 mg (Felbatol).................................... 42
felodipine tab sr 24hr 10 mg.......................................... 21
felodipine tab sr 24hr 2.5 mg......................................... 21
felodipine tab sr 24hr 5 mg............................................21
fenofibrate micronized cap 130 mg (Antara)................ 22
fenofibrate micronized cap 134 mg (Lofibra)................22
fenofibrate micronized cap 200 mg (Lofibra)................22
fenofibrate micronized cap 43 mg (Antara).................. 22
fenofibrate micronized cap 67 mg (Lofibra)..................22
fenofibrate tab 145 mg (Tricor)...................................... 22
fenofibrate tab 160 mg (Lofibra).................................... 22
fenofibrate tab 48 mg (Tricor)........................................ 22
fenofibrate tab 54 mg (Lofibra)...................................... 22
fentanyl citrate lozenge on a handle 1200 mcg
(Actiq)..............................................................................38
(Actiq)..............................................................................38
(Actiq)..............................................................................38
(Actiq)..............................................................................38
(Actiq)..............................................................................38
(Actiq)..............................................................................38
fentanyl td patch 72hr 100 mcg/hr (Duragesic)............ 38
fentanyl td patch 72hr 12 mcg/hr (Duragesic).............. 38
FINACEA – azelaic acid foam 15%.................................. 50
FINACEA – azelaic acid gel 15%..................................... 50
finasteride tab 5 mg (Proscar)....................................... 30
FIRAZYR – icatibant acetate inj 30 mg/3ml (base
equivalent)....................................................................... 47
flecainide acetate tab 100 mg........................................ 23
flecainide acetate tab 150 mg........................................ 23
flecainide acetate tab 50 mg.......................................... 23
FLOVENT DISKUS – fluticasone propionate aer pow ba
100 mcg/blister................................................................ 26
250 mcg/blister................................................................ 26
50 mcg/blister.................................................................. 26
FLOVENT HFA – fluticasone propionate hfa inhal aer 110
mcg/act (125/valve)......................................................... 26
FLOVENT HFA – fluticasone propionate hfa inhal aer 220
mcg/act (250/valve)......................................................... 26
FLOVENT HFA – fluticasone propionate hfa inhal aero 44
mcg/act (50/valve)........................................................... 26
65
2015
fluconazole for susp 10 mg/ml (Diflucan)....................... 3
fluconazole for susp 40 mg/ml (Diflucan)....................... 3
fluconazole tab 100 mg (Diflucan)................................... 3
fluconazole tab 50 mg (Diflucan).....................................3
flucytosine cap 250 mg (Ancobon)..................................3
flucytosine cap 500 mg (Ancobon)..................................3
fludrocortisone acetate tab 0.1 mg................................10
flunisolide nasal soln 25 mcg/act (0.025%)
(Flunisolide)....................................................................25
fluocinolone acetonide cream 0.01%............................ 51
fluocinolone acetonide cream 0.025% (Synalar).......... 51
fluocinolone acetonide oint 0.025% (Synalar).............. 51
fluocinolone acetonide soln 0.01% (Synalar)............... 51
fluocinonide cream 0.05%.............................................. 51
fluocinonide emulsified base cream 0.05%.................. 51
fluocinonide gel 0.05%................................................... 51
fluocinonide oint 0.05%.................................................. 51
fluocinonide soln 0.05%................................................. 51
FLUOR-A-DAY – sodium fluoride-xylitol chew tab 0.55
(0.25 mg f)-236.79 mg.....................................................45
FLUOR-A-DAY – sodium fluoride-xylitol chew tab 1.1 (0.5
mg f)-236.79 mg.............................................................. 45
FLUOR-A-DAY – sodium fluoride-xylitol chew tab 2.2 (1
mg f)-236.79 mg.............................................................. 45
fluorometholone ophth susp 0.1% (Fml liquifilm)........ 48
FLUOROPLEX – fluorouracil cream 1%........................... 52
fluorouracil cream 5% (Efudex)..................................... 52
fluorouracil soln 2%........................................................52
fluorouracil soln 5%........................................................52
fluoxetine hcl cap 10 mg (Prozac)................................. 31
fluoxetine hcl solution 20 mg/5ml................................. 31
fluoxetine hcl tab 10 mg.................................................31
fluoxetine hcl tab 20 mg.................................................31
FLUPHENAZINE HCL – fluphenazine hcl elixir 2.5
mg/5ml............................................................................. 33
FLUPHENAZINE HCL – fluphenazine hcl oral conc 5 mg/
ml..................................................................................... 33
fluphenazine hcl tab 10 mg............................................ 33
fluphenazine hcl tab 1 mg..............................................33
fluphenazine hcl tab 2.5 mg........................................... 33
fluphenazine hcl tab 5 mg..............................................33
FLURA-DROPS – sodium fluoride soln 0.25 mg/drop f
(from 0.55 mg/drop naf).................................................. 45
flurbiprofen sodium ophth soln 0.03% (Ocufen).......... 49
flurbiprofen tab 100 mg.................................................. 40
flurbiprofen tab 50 mg.................................................... 40
flutamide cap 125 mg....................................................... 7
fluticasone propionate cream 0.05% (Cutivate)............51
fluticasone propionate nasal susp 50 mcg/act
(Flonase)......................................................................... 25
fluticasone propionate oint 0.005% (Cutivate)..............51
fluvoxamine maleate tab 100 mg................................... 32
66
fluvoxamine maleate tab 25 mg.....................................31
fluvoxamine maleate tab 50 mg.....................................32
FML – fluorometholone ophth oint 0.1%........................... 48
folic acid tab 1 mg.......................................................... 47
FOLLISTIM AQ – follitropin beta inj 300 unit/0.36ml......... 13
FOLLISTIM AQ – follitropin beta inj 75 unit/0.5ml............. 13
fondaparinux sodium subcutaneous inj 10 mg/0.8ml
(Arixtra)........................................................................... 47
fondaparinux sodium subcutaneous inj 2.5 mg/0.5ml
(Arixtra)........................................................................... 47
fondaparinux sodium subcutaneous inj 5 mg/0.4ml
(Arixtra)........................................................................... 47
fondaparinux sodium subcutaneous inj 7.5 mg/0.6ml
(Arixtra)........................................................................... 47
FORADIL AEROLIZER – formoterol fumarate inhal cap 12
mcg.................................................................................. 26
FORTEO – teriparatide (recombinant) inj 600
mcg/2.4ml........................................................................ 16
fosinopril sodium & hydrochlorothiazide tab 10-12.5
mg....................................................................................17
fosinopril sodium & hydrochlorothiazide tab 20-12.5
mg....................................................................................17
fosinopril sodium tab 10 mg.......................................... 17
furosemide oral soln 10 mg/ml...................................... 23
furosemide tab 20 mg (Lasix)........................................ 23
FUZEON – enfuvirtide for inj 90 mg....................................4
G
gabapentin cap 100 mg (Neurontin).............................. 42
gabapentin oral soln 250 mg/5ml (Neurontin).............. 42
gabapentin tab 600 mg (Neurontin)...............................42
gabapentin tab 800 mg (Neurontin)...............................42
galantamine hydrobromide cap sr 24hr 16 mg
(Razadyne er)................................................................. 37
(Razadyne er)................................................................. 37
(Razadyne er)................................................................. 37
galantamine hydrobromide tab 12 mg (Razadyne).......37
galantamine hydrobromide tab 4 mg (Razadyne)........ 37
galantamine hydrobromide tab 8 mg (Razadyne)........ 37
GANIRELIX ACETATE – ganirelix acetate inj 250
mcg/0.5ml........................................................................ 13
gemfibrozil tab 600 mg (Lopid)......................................22
GENTAMICIN SULFATE – gentamicin sulfate cream
0.1%.................................................................................50
GENTAMICIN SULFATE – gentamicin sulfate oint
0.1%.................................................................................50
2015
gentamicin sulfate ophth oint 0.3%...............................47
gentamicin sulfate ophth soln 0.3% (Garamycin)........ 48
GILOTRIF – afatinib dimaleate tab 20 mg (base
equivalent)......................................................................... 7
equivalent)......................................................................... 7
equivalent)......................................................................... 7
glatiramer acetate soln prefilled syringe 20 mg/ml
(Copaxone)..................................................................... 36
GLEEVEC – imatinib mesylate tab 100 mg (base
equivalent)......................................................................... 7
GLEEVEC – imatinib mesylate tab 400 mg (base
equivalent)......................................................................... 7
GLEOSTINE – lomustine cap 100 mg................................ 8
GLEOSTINE – lomustine cap 10 mg.................................. 7
GLEOSTINE – lomustine cap 40 mg.................................. 8
glimepiride tab 1 mg (Amaryl)....................................... 13
glipizide-metformin hcl tab 2.5-250 mg......................... 13
glipizide-metformin hcl tab 2.5-500 mg......................... 13
glipizide-metformin hcl tab 5-500 mg............................ 13
glipizide tab 10 mg (Glucotrol)...................................... 13
glipizide tab 5 mg (Glucotrol)........................................ 13
glipizide tab sr 24hr 10 mg (Glucotrol xl)......................13
glipizide tab sr 24hr 2.5 mg (Glucotrol xl).....................13
glipizide tab sr 24hr 5 mg (Glucotrol xl)....................... 13
GLUCAGON EMERGENCY KIT – glucagon (rdna) for inj
kit 1 mg............................................................................13
GLYBURIDE – glyburide tab 1.25 mg...............................13
GLYBURIDE – glyburide tab 2.5 mg.................................13
GLYBURIDE – glyburide tab 5 mg................................... 13
(Glucovance).................................................................. 13
glyburide-metformin tab 2.5-500 mg (Glucovance)...... 13
glyburide-metformin tab 5-500 mg (Glucovance)......... 14
glyburide micronized tab 1.5 mg (Glynase).................. 13
glyburide micronized tab 3 mg (Glynase)..................... 13
glyburide micronized tab 6 mg (Glynase)..................... 13
glyburide tab 1.25 mg..................................................... 13
glyburide tab 2.5 mg....................................................... 13
glyburide tab 5 mg..........................................................13
glycopyrrolate tab 1 mg (Robinul).................................27
glycopyrrolate tab 2 mg (Robinul forte)........................27
GONAL-F – follitropin alfa for inj 1050 unit....................... 13
GONAL-F – follitropin alfa for inj 450 unit......................... 13
GONAL-F RFF – follitropin alfa for inj 75 unit................... 13
GONAL-F RFF PEN – follitropin alfa inj 300 unit/0.5ml..... 13
unit/0.75ml....................................................................... 13
GONAL-F RFF PEN – follitropin alfa inj 900 unit/1.5ml..... 13
GONAL-F RFF REDIJECT – follitropin alfa inj 300
unit/0.5ml......................................................................... 13
unit/0.75ml....................................................................... 13
unit/1.5ml......................................................................... 13
GRANIX – tbo-filgrastim soln prefilled syringe 300
mcg/0.5ml........................................................................ 47
GRANIX – tbo-filgrastim soln prefilled syringe 480
mcg/0.8ml........................................................................ 47
GRASTEK – timothy grass pollen allergen ext tab sl 2800
bau..................................................................................... 7
griseofulvin microsize susp 125 mg/5ml........................ 3
griseofulvin microsize tab 500 mg (Grifulvin v)............. 3
guanfacine hcl tab 1 mg (Tenex)................................... 24
guanfacine hcl tab 2 mg (Tenex)................................... 24
H
halobetasol propionate cream 0.05% (Ultravate)......... 51
halobetasol propionate oint 0.05% (Ultravate)............. 51
haloperidol lactate oral conc 2 mg/ml...........................33
haloperidol tab 0.5 mg....................................................33
haloperidol tab 10 mg.....................................................33
haloperidol tab 1 mg.......................................................33
haloperidol tab 20 mg.....................................................33
HARVONI – ledipasvir-sofosbuvir tab 90-400 mg............... 4
HEXALEN – altretamine cap 50 mg................................... 8
homatropine hbr ophth soln 5% (Isopto
homatropine).................................................................. 49
HUMIRA – adalimumab prefilled syringe kit 10
mg/0.2ml.......................................................................... 40
mg/0.4ml.......................................................................... 40
mg/0.8ml.......................................................................... 40
HUMIRA PEDIATRIC CROHNS D – adalimumab prefilled
syringe kit 40 mg/0.8ml................................................... 40
HUMIRA PEN – adalimumab pen-injector kit 40
mg/0.8ml.......................................................................... 40
HUMIRA PEN-CROHNS DISEASE – adalimumab peninjector kit 40 mg/0.8ml................................................... 40
HUMIRA PEN-PSORIASIS STAR – adalimumab peninjector kit 40 mg/0.8ml................................................... 40
HYCAMTIN – topotecan hcl cap 0.25 mg (base equiv)....... 8
HYCAMTIN – topotecan hcl cap 1 mg (base equiv)............8
hydralazine hcl tab 100 mg............................................ 24
hydralazine hcl tab 10 mg.............................................. 24
hydrochlorothiazide cap 12.5 mg (Microzide)...............23
hydrochlorothiazide tab 12.5 mg................................... 23
hydrochlorothiazide tab 25 mg...................................... 23
hydrochlorothiazide tab 50 mg...................................... 23
hydrocodone-acetaminophen soln 7.5-325 mg/15ml
(Hycet).............................................................................38
hydrocodone-acetaminophen tab 10-325 mg
(Norco)............................................................................ 38
67
2015
(Xodol).............................................................................38
(Norco)............................................................................ 38
hydrocodone-acetaminophen tab 7.5-325 mg
(Norco)............................................................................ 38
hydrocodone-ibuprofen tab 10-200 mg (Ibudone)........39
hydrocodone-ibuprofen tab 5-200 mg (Reprexain)...... 39
hydrocodone-ibuprofen tab 7.5-200 mg
(Vicoprofen)....................................................................39
hydrocortisone acetate suppos 25 mg (Anusol-hc)..... 49
hydrocortisone cream 2.5%........................................... 51
hydrocortisone enema 100 mg/60ml (Cortenema)....... 49
hydrocortisone lotion 2.5%............................................ 51
hydrocortisone oint 2.5%............................................... 51
hydrocortisone rectal cream 2.5% (Anusol-hc)............ 49
hydrocortisone tab 10 mg (Cortef)................................ 10
hydrocortisone tab 20 mg (Cortef)................................ 10
hydrocortisone tab 5 mg (Cortef).................................. 10
hydrocortisone valerate cream 0.2%.............................51
hydrocortisone valerate oint 0.2% (Westcort).............. 51
hydrocortisone w/ acetic acid otic soln 1-2%...............49
HYDROMORPHONE HCL – hydromorphone hcl suppos 3
mg.................................................................................... 39
hydromorphone hcl liqd 1 mg/ml (Dilaudid)................. 39
hydromorphone hcl tab 2 mg (Dilaudid)....................... 39
hydroxychloroquine sulfate tab 200 mg (Plaquenil)...... 6
hydroxyurea cap 500 mg (Hydrea).................................. 8
hydroxyzine hcl syrup 10 mg/5ml..................................30
hydroxyzine hcl tab 10 mg.............................................30
hydroxyzine pamoate cap 25 mg (Vistaril)....................31
hydroxyzine pamoate cap 50 mg (Vistaril)....................31
HYDROXYZINE PAMOATE – hydroxyzine pamoate cap
100 mg.............................................................................31
hyoscyamine sulfate elixir 0.125 mg/5ml...................... 27
hyoscyamine sulfate soln 0.125 mg/ml......................... 27
hyoscyamine sulfate tab 0.125 mg (Levsin)................. 28
hyoscyamine sulfate tab sl 0.125 mg (Levsin/sl)..........28
hyoscyamine sulfate tab sr 12hr 0.375 mg (Levbid).....28
I
ibandronate sodium tab 150 mg (base equivalent)
(Boniva)...........................................................................16
IBRANCE – palbociclib cap 100 mg................................... 8
IBRANCE – palbociclib cap 125 mg................................... 8
IBRANCE – palbociclib cap 75 mg..................................... 8
ibuprofen susp 100 mg/5ml............................................40
ibuprofen tab 400 mg......................................................40
ibuprofen tab 600 mg......................................................40
ibuprofen tab 800 mg......................................................40
ICLUSIG – ponatinib hcl tab 15 mg (base equiv)................ 8
ICLUSIG – ponatinib hcl tab 45 mg (base equiv)................ 8
68
ILARIS – canakinumab for inj 180 mg.............................. 40
IMBRUVICA – ibrutinib cap 140 mg....................................8
imipramine hcl tab 10 mg (Tofranil).............................. 32
imipramine pamoate cap 100 mg (Tofranil-pm)............32
imipramine pamoate cap 75 mg (Tofranil-pm)..............32
imiquimod cream 5% (Aldara)........................................52
IMITREX – sumatriptan nasal spray 20 mg/act.................41
IMITREX – sumatriptan nasal spray 5 mg/act...................41
INCRELEX – mecasermin inj 40 mg/4ml (10 mg/ml)........ 15
INCRUSE ELLIPTA – umeclidinium br aero powd breath
act 62.5 mcg/inh (base eq)............................................. 26
indapamide tab 1.25 mg................................................. 23
indapamide tab 2.5 mg................................................... 23
indomethacin cap 25 mg................................................ 40
indomethacin cap 50 mg................................................ 40
INHALER ASSIST DEVICES – spacers........................... 53
INLYTA – axitinib tab 1 mg.................................................8
INLYTA – axitinib tab 5 mg.................................................8
INSULIN PEN NEEDLES – NOVOFINE, NOVOTWIST;
various............................................................................. 52
INSULIN SYRINGES – various.........................................52
INTELENCE – etravirine tab 100 mg.................................. 4
INTELENCE – etravirine tab 200 mg.................................. 4
INTELENCE – etravirine tab 25 mg.................................... 4
INVIRASE – saquinavir mesylate cap 200 mg.................... 4
INVIRASE – saquinavir mesylate tab 500 mg.....................5
INVOKAMET – canagliflozin-metformin hcl tab 150-1000
mg.................................................................................... 14
mg.................................................................................... 14
mg.................................................................................... 14
mg.................................................................................... 14
INVOKANA – canagliflozin tab 100 mg.............................14
INVOKANA – canagliflozin tab 300 mg.............................14
ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml
(Duoneb)......................................................................... 26
ipratropium bromide inhal soln 0.02%.......................... 26
ipratropium bromide nasal soln 0.03% (21 mcg/spray)
(Atrovent)........................................................................25
ipratropium bromide nasal soln 0.06% (42 mcg/spray)
(Atrovent)........................................................................25
irbesartan-hydrochlorothiazide tab 150-12.5 mg
(Avalide)..........................................................................18
irbesartan-hydrochlorothiazide tab 300-12.5 mg
(Avalide)..........................................................................18
irbesartan tab 150 mg (Avapro)..................................... 18
irbesartan tab 300 mg (Avapro)..................................... 18
irbesartan tab 75 mg (Avapro)....................................... 18
IRESSA – gefitinib tab 250 mg........................................... 8
2015
ISENTRESS – raltegravir potassium chew tab 100 mg
(base equiv).......................................................................5
ISENTRESS – raltegravir potassium chew tab 25 mg
(base equiv).......................................................................5
ISENTRESS – raltegravir potassium packet for susp 100
mg (base equiv).................................................................5
ISENTRESS – raltegravir potassium tab 400 mg (base
equiv)................................................................................. 5
ISONIAZID – isoniazid syrup 50 mg/5ml.............................3
isoniazid tab 100 mg.........................................................3
isoniazid tab 300 mg.........................................................3
ISOSORBIDE DINITRATE – isosorbide dinitrate tab 30
mg.................................................................................... 21
isosorbide dinitrate tab 10 mg.......................................21
isosorbide dinitrate tab 20 mg.......................................21
isosorbide dinitrate tab 5 mg (Isordil titradose)........... 21
isosorbide mononitrate tab 10 mg................................ 21
isosorbide mononitrate tab 20 mg................................ 21
isosorbide mononitrate tab sr 24hr 120 mg (Imdur).....21
isosorbide mononitrate tab sr 24hr 30 mg (Imdur).......21
isosorbide mononitrate tab sr 24hr 60 mg (Imdur).......21
isotretinoin cap 10 mg....................................................50
itraconazole cap 100 mg (Sporanox)...............................3
ivermectin tab 3 mg (Stromectol).................................... 6
J
JAKAFI – ruxolitinib phosphate tab 10 mg (base
equivalent)......................................................................... 8
equivalent)......................................................................... 8
equivalent)......................................................................... 8
equivalent)......................................................................... 8
equivalent)......................................................................... 8
JANUMET – sitagliptin-metformin hcl tab 50-1000 mg......14
JANUMET – sitagliptin-metformin hcl tab 50-500 mg........14
JANUMET XR – sitagliptin-metformin hcl tab sr 24hr
100-1000 mg................................................................... 14
50-1000 mg..................................................................... 14
50-500 mg....................................................................... 14
JANUVIA – sitagliptin phosphate tab 100 mg (base
equiv)............................................................................... 14
equiv)............................................................................... 14
equiv)............................................................................... 14
JARDIANCE – empagliflozin tab 10 mg............................14
JARDIANCE – empagliflozin tab 25 mg............................14
JUXTAPID – lomitapide mesylate cap 10 mg (base
equiv)............................................................................... 22
equiv)............................................................................... 22
equiv)............................................................................... 22
equiv)............................................................................... 22
equiv)............................................................................... 22
equiv)............................................................................... 22
K
KALETRA – lopinavir-ritonavir soln 400-100 mg/5ml
(80-20 mg/ml).................................................................... 5
KALETRA – lopinavir-ritonavir tab 100-25 mg.................... 5
KALETRA – lopinavir-ritonavir tab 200-50 mg.................... 5
KALYDECO – ivacaftor packet 50 mg.............................. 27
KALYDECO – ivacaftor packet 75 mg.............................. 27
KALYDECO – ivacaftor tab 150 mg..................................27
ketoconazole cream 2%..................................................50
ketoconazole shampoo 2% (Nizoral)............................. 50
ketoprofen cap 50 mg.....................................................40
ketoprofen cap 75 mg.....................................................40
ketorolac tromethamine ophth soln 0.4% (Acular
ls).....................................................................................49
ketorolac tromethamine ophth soln 0.5% (Acular).......49
ketorolac tromethamine tab 10 mg................................40
KOMBIGLYZE XR – saxagliptin-metformin hcl tab sr 24hr
2.5-1000 mg.................................................................... 14
5-1000 mg....................................................................... 14
5-500 mg......................................................................... 14
K-PHOS NO 2 – potassium & sodium acid phosphates tab
305-700 mg..................................................................... 30
K-PHOS – potassium phosphate monobasic tab 500
mg.................................................................................... 45
KUVAN – sapropterin dihydrochloride powder packet 100
mg.................................................................................... 16
KUVAN – sapropterin dihydrochloride powder packet 500
mg.................................................................................... 16
KUVAN – sapropterin dihydrochloride soluble tab 100
mg.................................................................................... 16
L
labetalol hcl tab 100 mg (Trandate)...............................19
lactulose (encephalopathy) solution 10 gm/15ml.........29
lactulose solution 10 gm/15ml....................................... 27
LAMISIL – terbinafine hcl oral granules packet 125 mg...... 3
LAMISIL – terbinafine hcl oral granules packet 187.5
mg...................................................................................... 3
lamivudine oral soln 10 mg/ml (Epivir)........................... 5
lamivudine tab 100 mg (hbv) (Epivir hbv)....................... 4
lamivudine tab 150 mg (Epivir)........................................ 5
69
2015
lamivudine tab 300 mg (Epivir)........................................ 5
lamivudine-zidovudine tab 150-300 mg (Combivir)........ 5
lamotrigine tab 100 mg (Lamictal)................................. 43
lamotrigine tab 25 mg (Lamictal)................................... 43
lamotrigine tab chewable dispersible 25 mg (Lamictal
chewable di)................................................................... 43
lamotrigine tab chewable dispersible 5 mg (Lamictal
chewable di)................................................................... 43
LANCETS – various.......................................................... 52
(Prevacid)........................................................................28
(Prevacid)........................................................................28
LANTUS – insulin glargine inj 100 unit/ml.........................15
LANTUS SOLOSTAR – insulin glargine soln pen-injector
100 unit/ml....................................................................... 15
latanoprost ophth soln 0.005% (Xalatan)...................... 48
leflunomide tab 10 mg (Arava).......................................40
leflunomide tab 20 mg (Arava).......................................40
LENVIMA 10MG DAILY DOSE – lenvatinib cap therapy
pack 10 mg (10 mg daily dose).........................................8
pack 10 & 4 mg (14 mg daily dose).................................. 8
pack 10 (2) mg (20 mg daily dose)................................... 8
pack 10 (2) & 4 mg (24 mg daily dose).............................8
LETAIRIS – ambrisentan tab 10 mg................................. 24
LETAIRIS – ambrisentan tab 5 mg................................... 24
letrozole tab 2.5 mg (Femara).......................................... 8
LEUCOVORIN CALCIUM – leucovorin calcium tab 10
mg...................................................................................... 8
LEUCOVORIN CALCIUM – leucovorin calcium tab 15
mg...................................................................................... 8
leucovorin calcium tab 25 mg..........................................8
leucovorin calcium tab 5 mg........................................... 8
LEUKERAN – chlorambucil tab 2 mg................................. 8
levalbuterol hcl soln nebu 0.31 mg/3ml (base equiv)
(Xopenex)........................................................................26
(Xopenex)........................................................................26
(Xopenex)........................................................................26
levalbuterol hcl soln nebu conc 1.25 mg/0.5ml (base
equiv).............................................................................. 26
LEVEMIR FLEXPEN – insulin detemir soln pen-injector
100 unit/ml....................................................................... 15
LEVEMIR FLEXTOUCH – insulin detemir soln pen-injector
100 unit/ml....................................................................... 15
LEVEMIR – insulin detemir inj 100 unit/ml........................ 15
levetiracetam oral soln 100 mg/ml (Keppra)................. 43
levetiracetam tab 1000 mg (Keppra)..............................43
levetiracetam tab 250 mg (Keppra)................................43
70
levetiracetam tab sr 24hr 500 mg (Keppra xr).............. 43
levetiracetam tab sr 24hr 750 mg (Keppra xr).............. 43
LEVOBUNOLOL HCL – levobunolol hcl ophth soln
0.25%...............................................................................48
levobunolol hcl ophth soln 0.5% (Betagan)..................48
levocarnitine oral soln 1 gm/10ml (10%) (Carnitor)...... 16
levocarnitine tab 330 mg (Carnitor)...............................16
levofloxacin oral soln 25 mg/ml (Levaquin)....................3
levofloxacin tab 250 mg (Levaquin)................................ 3
levonorgestrel & ethinyl estradiol (91-day) tab
0.15-0.03 mg................................................................... 12
levonorgestrel & ethinyl estradiol tab 0.15 mg-30
mcg..................................................................................12
levonorgestrel & ethinyl estradiol tab 0.1 mg-20
mcg..................................................................................12
levonorgestrel-eth estra tab
0.05-30/0.075-40/0.125-30mg-mcg................................ 12
levonorgestrel tab 1.5 mg (Plan b one-step).................12
levonorg-eth est tab 0.1-0.02mg(84) & eth est tab
0.01mg(7) (Loseasonique)............................................ 12
levonorg-eth est tab 0.15-0.03mg(84) & eth est tab
0.01mg(7) (amethia, camrese, daysee)........................ 12
levothyroxine sodium tab 100 mcg (Synthroid)........... 15
levothyroxine sodium tab 25 mcg (Synthroid)............. 15
LEXIVA – fosamprenavir calcium susp 50 mg/ml (base
equiv)................................................................................. 5
LEXIVA – fosamprenavir calcium tab 700 mg (base
equiv)................................................................................. 5
LIALDA – mesalamine tab delayed release 1.2 gm.......... 29
lidocaine hcl viscous soln 2%....................................... 49
lidocaine-prilocaine cream 2.5-2.5% (Emla)..................52
lidocaine-prilocaine kit 2.5-2.5%.................................... 52
lindane lotion 1%.............................................................52
lindane shampoo 1%...................................................... 52
linezolid tab 600 mg (Zyvox)............................................ 6
liothyronine sodium tab 25 mcg (Cytomel)...................15
liothyronine sodium tab 50 mcg (Cytomel)...................15
liothyronine sodium tab 5 mcg (Cytomel).....................15
lisinopril & hydrochlorothiazide tab 10-12.5 mg
(Zestoretic)..................................................................... 17
lisinopril & hydrochlorothiazide tab 20-12.5 mg
(Zestoretic)..................................................................... 17
2015
lisinopril & hydrochlorothiazide tab 20-25 mg
(Zestoretic)..................................................................... 17
lisinopril tab 10 mg (Prinivil)..........................................17
lisinopril tab 2.5 mg (Zestril).......................................... 17
lisinopril tab 20 mg (Prinivil)..........................................17
lisinopril tab 30 mg (Zestril)........................................... 17
lisinopril tab 40 mg (Zestril)........................................... 17
lisinopril tab 5 mg (Prinivil)............................................17
lithium carbonate cap 150 mg (Lithium carbonate)......33
lithium carbonate cap 300 mg....................................... 33
lithium carbonate cap 600 mg (Lithium carbonate)......33
LITHIUM CARBONATE – lithium carbonate cap 150
mg.................................................................................... 33
lithium carbonate tab 300 mg........................................ 33
lithium carbonate tab cr 300 mg (Lithobid)...................33
lithium carbonate tab cr 450 mg....................................33
LITHIUM – lithium oral solution 8 meq/5ml....................... 33
LOMUSTINE – lomustine cap 100 mg................................8
LOMUSTINE – lomustine cap 10 mg..................................8
LOMUSTINE – lomustine cap 40 mg..................................8
lorazepam conc 2 mg/ml (Lorazepam intensol)............31
lorazepam tab 0.5 mg (Ativan)....................................... 31
lorazepam tab 1 mg (Ativan).......................................... 31
lorazepam tab 2 mg (Ativan).......................................... 31
losartan potassium & hydrochlorothiazide tab
100-12.5 mg (Hyzaar).....................................................18
losartan potassium & hydrochlorothiazide tab 100-25
mg (Hyzaar).................................................................... 18
losartan potassium & hydrochlorothiazide tab 50-12.5
mg (Hyzaar).................................................................... 18
losartan potassium tab 100 mg (Cozaar)...................... 18
losartan potassium tab 25 mg (Cozaar)........................ 18
losartan potassium tab 50 mg (Cozaar)........................ 18
LOTEMAX – loteprednol etabonate ophth gel 0.5%..........48
LOTEMAX – loteprednol etabonate ophth oint 0.5%.........48
LOTEMAX – loteprednol etabonate ophth susp 0.5%....... 48
lovastatin tab 10 mg....................................................... 22
lovastatin tab 20 mg (Mevacor)..................................... 22
lovastatin tab 40 mg (Mevacor)..................................... 22
loxapine succinate cap 10 mg....................................... 33
loxapine succinate cap 5 mg (Loxitane)....................... 33
LUMIGAN – bimatoprost ophth soln 0.01%...................... 48
LYNPARZA – olaparib cap 50 mg...................................... 8
LYSODREN – mitotane tab 500 mg................................... 8
M
malathion lotion 0.5% (Ovide)........................................52
MATULANE – procarbazine hcl cap 50 mg........................ 8
medroxyprogesterone acetate im susp 150 mg/ml
(Depo-provera contrac)................................................. 12
medroxyprogesterone acetate tab 10 mg (Provera).....11
medroxyprogesterone acetate tab 2.5 mg
(Provera)......................................................................... 11
medroxyprogesterone acetate tab 5 mg (Provera).......11
mefloquine hcl tab 250 mg...............................................6
megestrol acetate susp 40 mg/ml (Megace oral)............8
megestrol acetate tab 20 mg........................................... 8
megestrol acetate tab 40 mg........................................... 8
MEKINIST – trametinib dimethyl sulfoxide tab 0.5 mg
(base equivalent)............................................................... 8
MEKINIST – trametinib dimethyl sulfoxide tab 2 mg (base
equivalent)......................................................................... 8
meloxicam tab 15 mg (Mobic)........................................40
meloxicam tab 7.5 mg (Mobic).......................................40
memantine hcl tab 10 mg (Namenda)............................37
memantine hcl tab 5 mg (28) & 10 mg (21) titration pak
(Namenda titration pa).................................................. 37
memantine hcl tab 5 mg (Namenda)............................. 37
MENOPUR – menotropins for subcutaneous inj 75
unit................................................................................... 13
MEPHYTON – phytonadione tab 5 mg............................. 44
mercaptopurine tab 50 mg (Purinethol).......................... 8
mesalamine enema 4 gm................................................29
MESNEX – mesna tab 400 mg...........................................8
MESTINON – pyridostigmine bromide syrup 60
mg/5ml............................................................................. 44
metformin hcl tab 1000 mg (Glucophage).....................14
metformin hcl tab 500 mg (Glucophage)...................... 14
metformin hcl tab 850 mg (Glucophage)...................... 14
metformin hcl tab sr 24hr 500 mg (Glucophage xr)......14
metformin hcl tab sr 24hr 750 mg (Glucophage xr)......14
methadone hcl conc 10 mg/ml (Methadose).................39
methadone hcl soln 10 mg/5ml (Methadone hcl)..........39
methadone hcl soln 5 mg/5ml (Methadone hcl)............39
methadone hcl tab 10 mg (Dolophine).......................... 39
methadone hcl tab 5 mg (Dolophine hcl)......................39
methadone hcl tab for oral susp 40 mg........................ 39
methimazole tab 10 mg (Tapazole)................................15
methimazole tab 5 mg (Tapazole)..................................15
methocarbamol tab 500 mg (Robaxin).......................... 44
methocarbamol tab 750 mg (Robaxin-750)................... 44
methotrexate sodium tab 2.5 mg (base equiv)............... 8
methoxsalen rapid cap 10 mg (Oxsoralen ultra).......... 52
methyldopa tab 250 mg.................................................. 24
methyldopa tab 500 mg.................................................. 24
methylergonovine maleate tab 0.2 mg.......................... 16
methylphenidate hcl cap cr 10 mg (Metadate cd).........35
methylphenidate hcl cap sr 24hr 20 mg (la) (Ritalin
la).....................................................................................35
la).....................................................................................35
la).....................................................................................35
METHYLPHENIDATE HCL ER – methylphenidate hcl tab
sa osm 18 mg................................................................. 35
71
2015
sa osm 27 mg................................................................. 35
sa osm 36 mg................................................................. 35
sa osm 54 mg................................................................. 35
methylphenidate hcl tab 10 mg (Ritalin)....................... 35
methylphenidate hcl tab 20 mg (Ritalin)....................... 35
methylphenidate hcl tab 5 mg (Ritalin)......................... 35
methylphenidate hcl tab cr 10 mg................................. 35
methylphenidate hcl tab cr 20 mg (Ritalin sr)...............35
methylprednisolone tab 16 mg (Medrol)....................... 10
methylprednisolone tab 32 mg (Medrol)....................... 10
methylprednisolone tab 4 mg (Medrol)......................... 10
methylprednisolone tab 4 mg dose pack (Medrol
dosepak)......................................................................... 10
methylprednisolone tab 8 mg (Medrol)......................... 10
METIPRANOLOL – metipranolol ophth soln 0.3%............ 48
metoclopramide hcl soln 5 mg/5ml (10 mg/10ml).........29
metoclopramide hcl tab 10 mg (Reglan)....................... 29
metoclopramide hcl tab 5 mg (Reglan)......................... 29
metolazone tab 10 mg.................................................... 23
metolazone tab 2.5 mg (Zaroxolyn)............................... 23
metolazone tab 5 mg (Zaroxolyn).................................. 23
metoprolol & hydrochlorothiazide tab 100-25 mg
(Lopressor hct).............................................................. 19
metoprolol & hydrochlorothiazide tab 100-50 mg........ 19
metoprolol & hydrochlorothiazide tab 50-25 mg
(Lopressor hct).............................................................. 19
metoprolol succinate tab sr 24hr 100 mg (Toprol
xl).....................................................................................19
metoprolol succinate tab sr 24hr 200 mg (Toprol
xl).....................................................................................19
metoprolol succinate tab sr 24hr 25 mg (Toprol xl)..... 19
metoprolol succinate tab sr 24hr 50 mg (Toprol xl)..... 19
metoprolol tartrate tab 100 mg (Lopressor)..................19
metoprolol tartrate tab 25 mg........................................ 19
metoprolol tartrate tab 50 mg (Lopressor)....................19
metronidazole cream 0.75% (Metrocream)....................50
metronidazole gel 0.75%................................................ 50
metronidazole gel 1% (Metrogel)................................... 50
metronidazole lotion 0.75% (Metrolotion)..................... 50
metronidazole tab 250 mg (Flagyl).................................. 6
metronidazole tab 500 mg (Flagyl).................................. 7
metronidazole vaginal gel 0.75% (Metrogelvaginal)........................................................................... 30
mexiletine hcl cap 150 mg............................................. 23
midodrine hcl tab 10 mg................................................ 24
midodrine hcl tab 2.5 mg............................................... 24
midodrine hcl tab 5 mg.................................................. 24
MIGRANAL – dihydroergotamine mesylate nasal spray 4
mg/ml............................................................................... 41
minocycline hcl cap 100 mg (Minocin)............................3
minocycline hcl cap 50 mg (Minocin)............................. 2
72
minocycline hcl cap 75 mg (Minocin)............................. 2
minocycline hcl tab 100 mg............................................. 3
minocycline hcl tab 50 mg............................................... 3
minocycline hcl tab 75 mg............................................... 3
minoxidil tab 10 mg........................................................ 24
minoxidil tab 2.5 mg....................................................... 24
MIRENA – levonorgestrel releasing iud 20 mcg/24hr (52
mg total)...........................................................................12
mirtazapine orally disintegrating tab 15 mg (Remeron
soltab)............................................................................. 32
soltab)............................................................................. 32
soltab)............................................................................. 32
mirtazapine tab 15 mg (Remeron)................................. 32
mirtazapine tab 7.5 mg................................................... 32
misoprostol tab 100 mcg (Cytotec)............................... 28
misoprostol tab 200 mcg (Cytotec)............................... 28
modafinil tab 100 mg (Provigil)......................................35
modafinil tab 200 mg (Provigil)......................................35
moexipril hcl tab 15 mg (Univasc).................................17
moexipril hcl tab 7.5 mg (Univasc)................................17
moexipril-hydrochlorothiazide tab 15-12.5 mg
(Uniretic)......................................................................... 17
moexipril-hydrochlorothiazide tab 15-25 mg................ 17
moexipril-hydrochlorothiazide tab 7.5-12.5 mg............ 17
mometasone furoate cream 0.1% (Elocon)................... 51
mometasone furoate oint 0.1% (Elocon).......................51
mometasone furoate solution 0.1% (lotion)
(Elocon)...........................................................................52
montelukast sodium chew tab 4 mg (base equiv)
(Singulair)....................................................................... 26
montelukast sodium chew tab 5 mg (base equiv)
(Singulair)....................................................................... 26
montelukast sodium oral granules packet 4 mg (base
equiv) (Singulair)........................................................... 26
montelukast sodium tab 10 mg (base equiv)
(Singulair)....................................................................... 26
morphine sulfate (concentrate) oral soln 20 mg/ml..... 39
MORPHINE SULFATE – morphine sulfate suppos 10
mg.................................................................................... 39
mg.................................................................................... 39
mg.................................................................................... 39
mg.................................................................................... 39
MORPHINE SULFATE – morphine sulfate tab 15 mg.......39
MORPHINE SULFATE – morphine sulfate tab 30 mg.......39
morphine sulfate oral soln 10 mg/5ml...........................39
morphine sulfate oral soln 20 mg/5ml...........................39
morphine sulfate tab cr 100 mg (Ms contin)................. 39
morphine sulfate tab cr 15 mg (Ms contin)...................39
morphine sulfate tab cr 200 mg (Ms contin)................. 39
2015
moxifloxacin hcl tab 400 mg (base equiv) (Avelox)....... 3
MULTAQ – dronedarone hcl tab 400 mg (base
equivalent)....................................................................... 23
mupirocin calcium cream 2% (Bactroban)....................50
mupirocin oint 2% (Bactroban)......................................50
mycophenolate mofetil cap 250 mg (Cellcept)............. 53
mycophenolate mofetil for oral susp 200 mg/ml
(Cellcept).........................................................................53
mycophenolate mofetil tab 500 mg (Cellcept).............. 53
mycophenolate sodium tab dr 180 mg (mycophenolic
acid equiv) (Myfortic).................................................... 53
mycophenolate sodium tab dr 360 mg (mycophenolic
acid equiv) (Myfortic).................................................... 53
MYLERAN – busulfan tab 2 mg..........................................8
MYRBETRIQ – mirabegron tab sr 24 hr 25 mg................ 29
MYRBETRIQ – mirabegron tab sr 24 hr 50 mg................ 29
N
nabumetone tab 500 mg.................................................40
nabumetone tab 750 mg.................................................41
nadolol & bendroflumethiazide tab 40-5 mg
(Corzide)......................................................................... 19
nadolol & bendroflumethiazide tab 80-5 mg
(Corzide)......................................................................... 19
nadolol tab 20 mg (Corgard).......................................... 19
naloxone hcl inj 0.4 mg/ml............................................. 53
naltrexone hcl tab 50 mg (Revia)...................................53
NAMENDA – memantine hcl oral solution 2 mg/ml........... 37
NAMENDA – memantine hcl tab 10 mg............................37
NAMENDA – memantine hcl tab 5 mg..............................37
NAMENDA TITRATION PAK – memantine hcl tab 5 mg
(28) & 10 mg (21) titration pak........................................ 37
NAMENDA XR – memantine hcl cap sr 24hr 14 mg......... 37
NAMENDA XR – memantine hcl cap sr 24hr 7 mg........... 37
NAMENDA XR TITRATION PACK – memantine hcl cap sr
24hr 7 mg & 14 mg & 21 mg & 28 mg pack.................... 37
NAPROXEN – naproxen susp 125 mg/5ml.......................41
naproxen sodium tab 275 mg (Anaprox)...................... 41
naproxen sodium tab 550 mg (Anaprox ds)................. 41
naproxen tab 250 mg (Naprosyn).................................. 41
naproxen tab ec 375 mg (Ec-naprosyn)........................ 41
naproxen tab ec 500 mg (Ec-naprosyn)........................ 41
naratriptan hcl tab 1 mg (base equiv) (Amerge)........... 41
naratriptan hcl tab 2.5 mg (base equiv) (Amerge)........ 41
NATACYN – natamycin ophth susp 5%............................48
nateglinide tab 120 mg (Starlix).....................................14
nateglinide tab 60 mg (Starlix).......................................14
NEBUPENT – pentamidine isethionate for nebulization
soln 300 mg.......................................................................7
NECON 1/50-28 – norethindrone & mestranol tab 1 mg-50
mcg.................................................................................. 12
NECON 10/11-28 – norethindrone-eth estradiol tab
0.5-35/1-35 mg-mcg (10/11)............................................12
neomycin-bacitrac zn-polymyx
5(3.5)mg-400unt-10000unt op oin.................................48
neomycin-polymy-gramicid op sol
1.75-10000-0.025mg-unt-mg/ml (Neosporin)............... 48
neomycin-polymyxin-dexamethasone ophth oint 0.1%
(Maxitrol).........................................................................48
neomycin-polymyxin-dexamethasone ophth susp
0.1% (Maxitrol)............................................................... 48
neomycin-polymyxin-hc otic soln 1% (Cortisporin).....49
neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000
unit/ml-1%.......................................................................49
neomycin sulfate tab 500 mg...........................................3
NEULASTA DELIVERY KIT – pegfilgrastim inj 6
mg/0.6ml.......................................................................... 47
NEULASTA – pegfilgrastim inj 6 mg/0.6ml....................... 47
NEUMEGA – oprelvekin for inj 5 mg................................ 47
NEUPOGEN – filgrastim inj 300 mcg/0.5ml (600 mcg/
ml).................................................................................... 47
NEUPOGEN – filgrastim inj 300 mcg/ml........................... 47
ml).................................................................................... 47
ml).................................................................................... 47
nevirapine tab 200 mg (Viramune)...................................5
nevirapine tab sr 24hr 400 mg (Viramune xr)................. 5
NEXAVAR – sorafenib tosylate tab 200 mg (base
equivalent)......................................................................... 8
NEXIUM – esomeprazole magnesium cap delayed release
20 mg (base eq)..............................................................28
NEXIUM – esomeprazole magnesium cap delayed release
40 mg (base eq)..............................................................28
NEXIUM – esomeprazole magnesium for delayed release
susp pack 2.5 mg............................................................28
susp packet 10 mg.......................................................... 28
susp packet 20 mg.......................................................... 28
susp packet 40 mg.......................................................... 28
susp packet 5 mg............................................................28
(Niaspan).........................................................................22
(Niaspan).........................................................................22
(Niaspan).........................................................................22
NICODERM CQ – nicotine td patch 24hr 14 mg/24hr....... 36
NICODERM CQ – nicotine td patch 24hr 21 mg/24hr....... 36
NICODERM CQ – nicotine td patch 24hr 7 mg/24hr......... 36
73
2015
NICORETTE MINI – nicotine polacrilex lozenge 2 mg...... 37
NICORETTE MINI – nicotine polacrilex lozenge 4 mg...... 37
NICORETTE – nicotine polacrilex gum 2 mg.................... 36
NICORETTE – nicotine polacrilex gum 4 mg.................... 37
NICORETTE – nicotine polacrilex lozenge 2 mg.............. 37
NICORETTE – nicotine polacrilex lozenge 4 mg.............. 37
NICORETTE STARTER KIT – nicotine polacrilex gum 2
mg.................................................................................... 37
NICORETTE STARTER KIT – nicotine polacrilex gum 4
mg.................................................................................... 37
nicotine polacrilex gum 2 mg........................................ 37
nicotine polacrilex gum 4 mg........................................ 37
nicotine polacrilex lozenge 2 mg...................................37
nicotine polacrilex lozenge 4 mg...................................37
nicotine td patch 24hr 14 mg/24hr.................................37
nicotine td patch 24hr 21 mg/24hr.................................37
nicotine td patch 24hr 7 mg/24hr...................................37
NICOTINE TRANSDERMAL SYST – nicotine td patch 24
hr kit 21-14-7 mg/24hr.....................................................37
NICOTROL INHALER – nicotine inhaler system 10 mg (4
mg delivered)...................................................................37
NICOTROL NS – nicotine nasal spray 10 mg/ml (0.5 mg/
spray)............................................................................... 37
nifedipine tab sr 24hr 30 mg (Adalat cc).......................21
nifedipine tab sr 24hr osmotic 30 mg (Procardia
xl).....................................................................................21
xl).....................................................................................21
xl).....................................................................................21
NILANDRON – nilutamide tab 150 mg............................... 8
NITRO-BID – nitroglycerin oint 2%................................... 21
nitrofurantoin macrocrystalline cap 100 mg
(Macrodantin)................................................................. 29
nitrofurantoin macrocrystalline cap 50 mg
(Macrodantin)................................................................. 29
nitrofurantoin monohydrate macrocrystalline cap 100
mg (Macrobid)................................................................ 29
nitrofurantoin susp 25 mg/5ml (Furadantin)................. 29
nitroglycerin cap cr 2.5 mg............................................ 21
nitroglycerin cap cr 6.5 mg............................................ 21
nitroglycerin cap cr 9 mg............................................... 21
nitroglycerin td patch 24hr 0.1 mg/hr (Nitro-dur)......... 21
NITROSTAT – nitroglycerin sl tab 0.3 mg.........................21
norelgestromin-ethinyl estradiol td ptwk 150-35
mcg/24hr (Ortho evra)................................................... 12
norethindrone & ethinyl estradiol tab 0.4 mg-35 mcg
(Ovcon-35)...................................................................... 12
74
norethindrone & ethinyl estradiol tab 0.5 mg-35 mcg
(Brevicon-28).................................................................. 12
norethindrone & ethinyl estradiol tab 1 mg-35 mcg
(Norinyl 1+35).................................................................12
norethindrone ace & ethinyl estradiol-fe tab 1.5 mg-30
mcg (Loestrin fe 1.5/30)................................................ 12
norethindrone ace & ethinyl estradiol-fe tab 1 mg-20
mcg (Loestrin fe 1/20)................................................... 12
norethindrone ace & ethinyl estradiol tab 1.5 mg-30
mcg (Loestrin 1.5/30-21)............................................... 12
norethindrone ace & ethinyl estradiol tab 1 mg-20 mcg
(Loestrin 1/20-21)........................................................... 12
norethindrone acetate tab 5 mg (Aygestin).................. 11
norethindrone ac-ethinyl estrad-fe tab 1-20/1-30/1-35
mg-mcg (Estrostep fe).................................................. 12
norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35
mg-mcg (Ortho-novum 7/7/7)....................................... 12
norethindrone-eth estradiol tab 0.5-35/1-35/0.5-35 mgmcg (Tri-norinyl 28).......................................................12
norethindrone tab 0.35 mg (Nor-qd)..............................12
norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg
(Ortho-cyclen)................................................................ 12
norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35
mg-mcg (Ortho tri-cyclen)............................................ 12
norgestrel & ethinyl estradiol tab 0.3 mg-30 mcg........ 12
NORPACE CR – disopyramide phosphate cap sr 12hr 100
mg.................................................................................... 23
nortriptyline hcl cap 10 mg (Pamelor)...........................32
NORTRIPTYLINE HCL – nortriptyline hcl soln 10
mg/5ml............................................................................. 32
NORVIR – ritonavir cap 100 mg......................................... 5
NORVIR – ritonavir oral soln 80 mg/ml...............................5
NORVIR – ritonavir tab 100 mg.......................................... 5
NOVOLIN 70/30 – insulin nph isophane & regular human
inj 100 unit/ml (70-30)..................................................... 15
NOVOLIN N – insulin nph (human) (isophane) inj 100 unit/
ml..................................................................................... 15
NOVOLIN R – insulin regular (human) inj 100 unit/ml....... 14
NOVOLOG FLEXPEN – insulin aspart soln pen-injector
100 unit/ml....................................................................... 14
NOVOLOG – insulin aspart inj 100 unit/ml........................14
NOVOLOG MIX 70/30 – insulin aspart prot & aspart
(human) inj 100 unit/ml (70-30)....................................... 15
NOVOLOG MIX 70/30 PREFILL – insulin aspart prot &
aspart sus pen-inj 100 unit/ml (70-30).............................15
NOVOLOG PENFILL – insulin aspart inj 100 unit/ml........ 14
NOVOLOG PENFILL – insulin aspart soln cartridge 100
unit/ml.............................................................................. 14
NOXAFIL – posaconazole susp 40 mg/ml.......................... 3
NPLATE – romiplostim for inj 250 mcg............................. 47
NPLATE – romiplostim for inj 500 mcg............................. 47
NUVARING – etonogestrel-ethinyl estradiol va ring
0.120-0.015 mg/24hr....................................................... 12
2015
nystatin cream 100000 unit/gm......................................50
nystatin oint 100000 unit/gm..........................................50
nystatin susp 100000 unit/ml......................................... 49
nystatin tab 500000 unit................................................... 3
nystatin topical powder.................................................. 50
nystatin-triamcinolone cream 100000-0.1 unit/gm%......................................................................................52
nystatin-triamcinolone oint 100000-0.1 unit/gm-%....... 52
O
octreotide acetate inj 1000 mcg/ml (1 mg/ml)
(Sandostatin).................................................................. 16
octreotide acetate inj 100 mcg/ml (0.1 mg/ml)
(Sandostatin).................................................................. 16
(Sandostatin).................................................................. 16
(Sandostatin).................................................................. 16
(Sandostatin).................................................................. 16
OFEV – nintedanib esylate cap 100 mg (base
equivalent)....................................................................... 27
OFEV – nintedanib esylate cap 150 mg (base
equivalent)....................................................................... 27
OFLOXACIN – ofloxacin tab 400 mg.................................. 3
ofloxacin ophth soln 0.3% (Ocuflox)............................. 48
ofloxacin otic soln 0.3%................................................. 49
OGESTREL – norgestrel & ethinyl estradiol tab 0.5 mg-50
mcg.................................................................................. 12
olanzapine-fluoxetine hcl cap 12-25 mg (Symbyax).....38
olanzapine-fluoxetine hcl cap 12-50 mg (Symbyax).....38
olanzapine-fluoxetine hcl cap 3-25 mg (Symbyax).......37
olanzapine orally disintegrating tab 10 mg (Zyprexa
zydis)...............................................................................33
zydis)...............................................................................33
zydis)...............................................................................33
zydis)...............................................................................33
olanzapine tab 10 mg (Zyprexa).................................... 33
olanzapine tab 2.5 mg (Zyprexa)................................... 33
olanzapine tab 5 mg (Zyprexa)...................................... 33
olanzapine tab 7.5 mg (Zyprexa)................................... 33
omega-3-acid ethyl esters cap 1 gm (Lovaza).............. 22
omeprazole cap delayed release 10 mg (Prilosec)....... 28
OMNITROPE – somatropin for inj 5.8 mg.........................15
OMNITROPE – somatropin inj 10 mg/1.5ml..................... 15
OMNITROPE – somatropin inj 5 mg/1.5ml....................... 15
ondansetron hcl oral soln 4 mg/5ml (Zofran)............... 28
ondansetron hcl tab 24 mg............................................ 28
ondansetron hcl tab 4 mg (Zofran)................................28
ondansetron hcl tab 8 mg (Zofran)................................28
ondansetron orally disintegrating tab 4 mg (Zofran
odt).................................................................................. 28
ondansetron orally disintegrating tab 8 mg (Zofran
odt).................................................................................. 28
ONGLYZA – saxagliptin hcl tab 2.5 mg (base equiv)........ 14
ONGLYZA – saxagliptin hcl tab 5 mg (base equiv)........... 14
OPSUMIT – macitentan tab 10 mg................................... 24
ORALAIR – grass mixed pollen ext tab sl 300 ir (index of
reactivity)............................................................................7
ORAP – pimozide tab 1 mg.............................................. 38
ORAP – pimozide tab 2 mg.............................................. 38
orphenadrine citrate tab sr 12hr 100 mg.......................44
orphenadrine w/ aspirin & caffeine tab 25-385-30
mg....................................................................................44
ORTHO TRI-CYCLEN LO – norgestimate-eth estrad tab
0.18-25/0.215-25/0.25-25 mg-mcg.................................. 12
OVIDREL – choriogonadotropin alfa inj 250
mcg/0.5ml........................................................................ 13
oxaprozin tab 600 mg (Daypro)..................................... 41
oxcarbazepine susp 300 mg/5ml (60 mg/ml)
(Trileptal).........................................................................43
oxcarbazepine tab 150 mg (Trileptal)............................ 43
oxybutynin chloride syrup 5 mg/5ml.............................29
oxybutynin chloride tab 5 mg........................................ 29
oxybutynin chloride tab sr 24hr 10 mg (Ditropan
xl).....................................................................................29
oxybutynin chloride tab sr 24hr 15 mg (Ditropan
xl).....................................................................................29
oxybutynin chloride tab sr 24hr 5 mg (Ditropan xl)......29
oxycodone-aspirin tab 4.8355-325 mg (Percodan)....... 39
oxycodone hcl cap 5 mg................................................ 39
oxycodone hcl conc 100 mg/5ml (20 mg/ml)
(Oxycodone hcl).............................................................39
OXYCODONE HCL – oxycodone hcl conc 100 mg/5ml (20
mg/ml).............................................................................. 39
oxycodone hcl soln 5 mg/5ml (Oxycodone hcl)........... 39
oxycodone hcl tab 10 mg...............................................39
oxycodone hcl tab 15 mg (Roxicodone)....................... 39
oxycodone hcl tab 20 mg...............................................39
oxycodone hcl tab 30 mg (Roxicodone)....................... 39
oxycodone hcl tab 5 mg (Roxicodone)......................... 39
oxycodone w/ acetaminophen tab 10-325 mg
(Percocet)....................................................................... 39
oxycodone w/ acetaminophen tab 5-325 mg
(Percocet)....................................................................... 39
oxycodone w/ acetaminophen tab 7.5-325 mg
(Percocet)....................................................................... 39
OXYCONTIN – oxycodone hcl tab er 12hr deter 10
mg.................................................................................... 39
mg.................................................................................... 39
75
2015
mg.................................................................................... 39
mg.................................................................................... 39
mg.................................................................................... 39
mg.................................................................................... 39
mg.................................................................................... 40
P
pantoprazole sodium ec tab 20 mg (base equiv)
(Protonix)........................................................................ 28
pantoprazole sodium ec tab 40 mg (base equiv)
(Protonix)........................................................................ 28
paricalcitol cap 1 mcg (Zemplar)................................... 16
paromomycin sulfate cap 250 mg................................... 3
paroxetine hcl tab 10 mg (Paxil).................................... 32
paroxetine hcl tab sr 24hr 12.5 mg (Paxil cr)................ 32
paroxetine hcl tab sr 24hr 25 mg (Paxil cr)...................32
paroxetine hcl tab sr 24hr 37.5 mg (Paxil cr)................ 32
PATADAY – olopatadine hcl ophth soln 0.2%...................49
PAZEO – olopatadine hcl ophth soln 0.7% (base
equivalent)....................................................................... 49
pediatric multivitamins................................................... 45
pediatric vitamins ADC...................................................45
peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm
(Golytely)........................................................................ 27
peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240 gm
(Colyte-flavor packs)..................................................... 27
peg 3350-kcl-sod bicarb-nacl for soln 420 gm
(Nulytely/flavor pack).................................................... 27
PEGASYS – peginterferon alfa-2a inj 180 mcg/0.5ml......... 4
PEGASYS – peginterferon alfa-2a inj 180 mcg/ml.............. 4
PEGASYS PROCLICK – peginterferon alfa-2a inj 135
mcg/0.5ml.......................................................................... 4
PEGASYS PROCLICK – peginterferon alfa-2a inj 180
mcg/0.5ml.......................................................................... 4
penicillin v potassium for soln 125 mg/5ml.................... 1
penicillin v potassium for soln 250 mg/5ml.................... 1
penicillin v potassium tab 250 mg...................................1
penicillin v potassium tab 500 mg...................................1
PENTASA – mesalamine cap cr 250 mg.......................... 29
PENTASA – mesalamine cap cr 500 mg.......................... 29
pentoxifylline tab cr 400 mg...........................................47
perindopril erbumine tab 2 mg...................................... 17
perindopril erbumine tab 4 mg (Aceon)........................ 17
perindopril erbumine tab 8 mg (Aceon)........................ 17
permethrin cream 5% (Elimite)...................................... 52
perphenazine tab 16 mg................................................. 33
76
perphenazine tab 2 mg................................................... 33
phenelzine sulfate tab 15 mg (Nardil)............................32
phenobarbital elixir 20 mg/5ml...................................... 34
PHENOBARBITAL – phenobarbital tab 100 mg............... 34
PHENOBARBITAL – phenobarbital tab 15 mg................. 34
phenobarbital tab 16.2 mg............................................. 34
phenoxybenzamine hcl cap 10 mg (Dibenzyline)......... 24
phenytoin chew tab 50 mg (Dilantin infatabs).............. 43
phenytoin sodium extended cap 100 mg (Dilantin)......43
phenytoin susp 125 mg/5ml (Dilantin).......................... 43
phytonadione inj 1 mg/0.5ml (2 mg/ml).........................44
PICATO – ingenol mebutate gel 0.015%.......................... 52
PICATO – ingenol mebutate gel 0.05%............................ 52
pilocarpine hcl ophth soln 1% (Isopto carpine)............48
pilocarpine hcl tab 5 mg (Salagen)................................49
pilocarpine hcl tab 7.5 mg (Salagen).............................49
pindolol tab 10 mg.......................................................... 19
pindolol tab 5 mg............................................................ 19
pioglitazone hcl-metformin hcl tab 15-500 mg
(Actoplus met)............................................................... 14
pioglitazone hcl-metformin hcl tab 15-850 mg
(Actoplus met)............................................................... 14
pioglitazone hcl tab 15 mg (base equiv) (Actos).......... 14
piroxicam cap 10 mg (Feldene)..................................... 41
piroxicam cap 20 mg (Feldene)..................................... 41
PLEGRIDY – peginterferon beta-1a soln pen-injector 125
mcg/0.5ml........................................................................ 36
PLEGRIDY – peginterferon beta-1a soln prefilled syringe
125 mcg/0.5ml................................................................. 36
PLEGRIDY STARTER PACK – peginterferon beta-1a soln
pen-inj 63 & 94 mcg/0.5ml pack......................................36
PLEGRIDY STARTER PACK – peginterferon beta-1a soln
pref syr 63 & 94 mcg/0.5ml pack.................................... 36
podofilox soln 0.5% (Condylox).....................................52
polymyxin b-trimethoprim ophth soln 10000 unit/
ml-0.1% (Polytrim)......................................................... 48
POMALYST – pomalidomide cap 1 mg.............................. 8
pot & sod citrates w/ cit ac soln 550-500-334
mg/5ml............................................................................ 30
potassium bicarbonate effer tab 25 meq...................... 45
potassium chloride cap cr 10 meq (Micro-k)................ 45
potassium chloride cap cr 8 meq (Micro-k).................. 45
2015
POTASSIUM CHLORIDE ER – potassium chloride tab cr
8 meq (600 mg)...............................................................45
potassium chloride microencapsulated crys cr tab 10
meq..................................................................................45
potassium chloride microencapsulated crys cr tab 20
meq..................................................................................45
potassium chloride oral liq 10% (20 meq/15ml)............45
potassium chloride oral liq 20% (40 meq/15ml)............45
potassium chloride powder packet 20 meq..................45
potassium chloride tab cr 10 meq (K-tab).................... 45
potassium chloride tab cr 8 meq (600 mg)................... 45
potassium citrate & citric acid powder pack 3300-1002
mg....................................................................................30
potassium citrate & citric acid soln 1100-334
mg/5ml............................................................................ 30
potassium citrate tab cr 10 meq (1080 mg) (Urocit-k
10)....................................................................................30
15)....................................................................................30
5)......................................................................................30
pot phos monobasic w/sod phos di & monobas tab
155-852-130mg (K-phos neutral).................................. 45
(Mirapex)......................................................................... 44
(Mirapex)......................................................................... 44
pramipexole dihydrochloride tab 0.5 mg (Mirapex)......44
(Mirapex)......................................................................... 44
pramipexole dihydrochloride tab 1.5 mg (Mirapex)......44
pramipexole dihydrochloride tab 1 mg (Mirapex)........ 44
pravastatin sodium tab 10 mg....................................... 22
pravastatin sodium tab 20 mg (Pravachol)................... 22
prazosin hcl cap 1 mg (Minipress)................................ 24
prednisolone acetate ophth susp 1% (Pred forte)........48
PREDNISOLONE SODIUM PHOSP – prednisolone
sodium phosphate ophth soln 1%................................... 48
prednisolone sod phosphate oral soln 15 mg/5ml
(base equiv)....................................................................10
prednisolone sod phosph oral soln 6.7 mg/5ml (5
mg/5ml base) (Pediapred).............................................10
prednisolone syrup 15 mg/5ml (usp solution
equivalent) (Prelone)..................................................... 10
PREDNISONE – prednisone oral soln 5 mg/5ml.............. 10
PREDNISONE – prednisone tab 10 mg dose pack...........10
PREDNISONE – prednisone tab 50 mg............................10
PREDNISONE – prednisone tab 5 mg dose pack............ 10
prednisone tab 10 mg.....................................................10
prednisone tab 1 mg.......................................................10
prednisone tab 2.5 mg....................................................10
prednisone tab 20 mg.....................................................10
prednisone tab 5 mg.......................................................10
PREFEST – estradiol tab 1 mg(15)/estrad-norgestimate
tab 1-0.09mg(15)............................................................. 11
PREMARIN – estrogens, conjugated tab 0.3 mg.............. 11
PREMARIN – estrogens, conjugated tab 0.45 mg............ 11
PREMARIN – estrogens, conjugated tab 0.625 mg.......... 11
PREMARIN – estrogens, conjugated tab 0.9 mg.............. 11
PREMARIN – estrogens, conjugated tab 1.25 mg............ 11
PREMARIN – estrogens, conjugated vaginal cream 0.625
mg/gm.............................................................................. 30
PREMPHASE – conj est 0.625(14)/conj est-medroxypro
ac tab 0.625-5mg(14)...................................................... 11
PREMPRO – conjugated estrogen-medroxyprogest
acetate tab 0.3-1.5 mg.................................................... 11
acetate tab 0.45-1.5 mg.................................................. 11
acetate tab 0.625-2.5 mg................................................ 11
acetate tab 0.625-5 mg................................................... 11
PRENAPLUS – prenatal vit w/ fe fumarate-fa tab 27-1
mg.................................................................................... 45
PRENATABS FA – prenatal vit w/ fe fumarate-fa tab 29-1
mg.................................................................................... 45
PRENATABS RX – prenatal vit w/ iron carbonyl-fa tab
29-1 mg........................................................................... 45
PRENATAL 19 – prenatal vit w/ dss-fe fumarate-fa tab
29-1 mg........................................................................... 45
PRENATAL 19 – prenatal vit w/ fe fumarate-fa chew tab
29-1 mg........................................................................... 45
PRENATAL AD – prenatal vit w/ dss-iron carbonyl-fa tab
90-1 mg........................................................................... 45
PRENATAL PLUS – prenatal vit w/ fe fumarate-fa tab 27-1
mg.................................................................................... 45
PRENATAL-U – prenatal w/o a vit w/ fe fumarate-fa cap
106.5-1 mg...................................................................... 45
PREZCOBIX – darunavir-cobicistat tab 800-150 mg.......... 5
PREZISTA – darunavir ethanolate susp 100 mg/ml (base
equiv)................................................................................. 5
PREZISTA – darunavir ethanolate tab 150 mg (base
equiv)................................................................................. 5
equiv)................................................................................. 5
equiv)................................................................................. 5
equiv)................................................................................. 5
PRIFTIN – rifapentine tab 150 mg...................................... 3
PRIMAQUINE PHOSPHATE – primaquine phosphate tab
26.3 mg (15 mg base).......................................................6
primidone tab 250 mg (Mysoline).................................. 43
primidone tab 50 mg (Mysoline).................................... 43
PROAIR HFA – albuterol sulfate inhal aero 108 mcg/act
(90mcg base equiv).........................................................27
PROAIR RESPICLICK – albuterol sulfate aer pow ba 108
mcg/act (90 mcg base equiv).......................................... 27
77
2015
probenecid tab 500 mg...................................................42
prochlorperazine maleate tab 10 mg (base equivalent)
(Compazine)................................................................... 33
prochlorperazine maleate tab 5 mg (base equivalent)
(Compazine)................................................................... 33
prochlorperazine suppos 25 mg....................................33
PROCRIT – epoetin alfa inj 10000 unit/ml........................ 47
PROCRIT – epoetin alfa inj 2000 unit/ml.......................... 47
(Prometrium).................................................................. 11
(Prometrium).................................................................. 11
PROMACTA – eltrombopag olamine tab 12.5 mg (base
equiv)............................................................................... 47
PROMACTA – eltrombopag olamine tab 25 mg (base
equiv)............................................................................... 47
equiv)............................................................................... 47
equiv)............................................................................... 47
promethazine hcl suppos 12.5 mg................................ 25
promethazine hcl suppos 25 mg................................... 25
promethazine hcl suppos 50 mg................................... 25
promethazine hcl syrup 6.25 mg/5ml............................ 25
promethazine hcl tab 12.5 mg........................................25
promethazine hcl tab 25 mg...........................................25
promethazine hcl tab 50 mg...........................................25
promethazine w/ codeine syrup 6.25-10 mg/5ml.......... 25
propafenone hcl cap sr 12hr 225 mg (Rythmol sr)....... 23
propafenone hcl tab 150 mg (Rythmol).........................23
propafenone hcl tab 225 mg (Rythmol).........................23
propafenone hcl tab 300 mg.......................................... 23
PROPRANOLOL/HYDROCHLOROTH – propranolol &
PROPRANOLOL/HYDROCHLOROTH – propranolol &
propranolol hcl cap sr 24hr 120 mg (Inderal la)........... 19
propranolol hcl cap sr 24hr 160 mg (Inderal la)........... 19
propranolol hcl cap sr 24hr 60 mg (Inderal la)............. 19
propranolol hcl cap sr 24hr 80 mg (Inderal la)............. 19
PROPRANOLOL HCL – propranolol hcl oral soln 20
mg/5ml............................................................................. 19
PROPRANOLOL HCL – propranolol hcl oral soln 40
mg/5ml............................................................................. 19
propranolol hcl tab 10 mg..............................................19
propylthiouracil tab 50 mg............................................. 15
78
PULMICORT – budesonide inhalation susp 1 mg/2ml...... 27
PULMOZYME – dornase alfa inhal soln 1 mg/ml..............27
PURIXAN – mercaptopurine susp 2000 mg/100ml (20 mg/
ml)...................................................................................... 9
pyrazinamide tab 500 mg................................................. 3
pyridostigmine bromide tab 60 mg (Mestinon).............44
pyridostigmine bromide tab cr 180 mg (Mestinon
timespan)........................................................................ 44
Q
quetiapine fumarate tab 100 mg (Seroquel)..................33
quetiapine fumarate tab 25 mg (Seroquel)....................33
quetiapine fumarate tab 50 mg (Seroquel)....................33
quinapril hcl tab 10 mg (Accupril)................................. 17
quinapril hcl tab 5 mg (Accupril)................................... 17
quinapril-hydrochlorothiazide tab 10-12.5 mg
(Accuretic)...................................................................... 17
quinapril-hydrochlorothiazide tab 20-12.5 mg
(Accuretic)...................................................................... 17
quinapril-hydrochlorothiazide tab 20-25 mg
(Accuretic)...................................................................... 17
quinidine gluconate tab cr 324 mg................................23
QUINIDINE SULFATE ER – quinidine sulfate tab cr 300
mg.................................................................................... 24
QUINIDINE SULFATE – quinidine sulfate tab 200 mg...... 24
quinidine sulfate tab 300 mg..........................................24
QVAR – beclomethasone dipropionate inhal aero soln 40
mcg/act............................................................................ 27
QVAR – beclomethasone dipropionate inhal aero soln 80
mcg/act............................................................................ 27
R
rabeprazole sodium ec tab 20 mg (Aciphex)................ 28
RAGWITEK – short ragweed pollen allergen extract tab sl
12 amb a 1-u.....................................................................7
raloxifene hcl tab 60 mg (Evista)................................... 16
ramipril cap 1.25 mg (Altace)......................................... 17
ramipril cap 10 mg (Altace)............................................ 17
ramipril cap 2.5 mg (Altace)........................................... 17
ramipril cap 5 mg (Altace)..............................................17
ranitidine hcl cap 300 mg...............................................28
ranitidine hcl syrup 15 mg/ml (75 mg/5ml)................... 28
ranitidine hcl tab 300 mg (Zantac).................................28
RAPAMUNE – sirolimus oral soln 1 mg/ml....................... 53
REBIF – interferon beta-1a inj 22 mcg/0.5ml (12mu/ml)
(44 mcg/ml)......................................................................36
REBIF – interferon beta-1a inj 44 mcg/0.5ml (24mu/ml)
(88 mcg/ml)......................................................................36
REBIF REBIDOSE – interferon beta-1a inj 22 mcg/0.5ml
(12mu/ml) (44 mcg/ml).................................................... 36
2015
REBIF REBIDOSE – interferon beta-1a inj 44 mcg/0.5ml
(24mu/ml) (88 mcg/ml).................................................... 36
REBIF REBIDOSE TITRATION – interferon beta-1a inj 6 x
8.8 mcg/0.2ml & 6 x 22 mcg/0.5ml..................................36
REBIF TITRATION PACK – interferon beta-1a inj 6 x 8.8
mcg/0.2ml & 6 x 22 mcg/0.5ml........................................36
RELENZA DISKHALER – zanamivir aero powder breath
activated 5 mg/blister........................................................ 6
RELISTOR – methylnaltrexone bromide inj 12 mg/0.6ml
(20 mg/ml)....................................................................... 29
RELISTOR – methylnaltrexone bromide inj 8 mg/0.4ml (20
mg/ml).............................................................................. 29
REMODULIN – treprostinil sodium inj 10 mg/ml (base
equiv)............................................................................... 24
equiv)............................................................................... 24
REMODULIN – treprostinil sodium inj 2.5 mg/ml (base
equiv)............................................................................... 24
equiv)............................................................................... 24
RENVELA – sevelamer carbonate packet 0.8 gm.............29
RENVELA – sevelamer carbonate packet 2.4 gm.............29
RENVELA – sevelamer carbonate tab 800 mg................. 29
REPRONEX – menotropins for inj 75 unit.........................13
RESCRIPTOR – delavirdine mesylate tab 100 mg............. 5
RESCRIPTOR – delavirdine mesylate tab 200 mg............. 5
REVLIMID – lenalidomide cap 10 mg............................... 53
REVLIMID – lenalidomide cap 5 mg................................. 53
REVLIMID – lenalidomide caps 2.5 mg............................ 53
REYATAZ – atazanavir sulfate cap 150 mg (base
equiv)................................................................................. 5
equiv)................................................................................. 5
equiv)................................................................................. 5
REYATAZ – atazanavir sulfate oral powder packet 50 mg
(base equiv).......................................................................5
ribavirin cap 200 mg (Rebetol).........................................4
ribavirin tab 200 mg (Copegus)....................................... 4
RIDAURA – auranofin cap 3 mg.......................................41
rifabutin cap 150 mg (Mycobutin)....................................3
RIFAMATE – isoniazid & rifampin cap 150-300 mg............ 3
rifampin cap 150 mg (Rifadin)..........................................3
rifampin cap 300 mg (Rifadin)..........................................3
riluzole tab 50 mg (Rilutek)............................................ 44
risperidone orally disintegrating tab 0.25 mg...............33
risperidone orally disintegrating tab 0.5 mg (Risperdal
m-tab).............................................................................. 33
risperidone orally disintegrating tab 1 mg (Risperdal
m-tab).............................................................................. 33
m-tab).............................................................................. 34
m-tab).............................................................................. 34
m-tab).............................................................................. 34
risperidone soln 1 mg/ml (Risperdal)............................34
risperidone tab 0.25 mg (Risperdal).............................. 34
risperidone tab 0.5 mg (Risperdal)................................ 34
risperidone tab 1 mg (Risperdal)................................... 34
rivastigmine tartrate cap 1.5 mg (Exelon)..................... 38
rivastigmine tartrate cap 3 mg (Exelon)........................38
rivastigmine tartrate cap 4.5 mg (Exelon)..................... 38
rivastigmine tartrate cap 6 mg (Exelon)........................38
rizatriptan benzoate orally disintegrating tab 10 mg
(Maxalt-mlt).....................................................................41
rizatriptan benzoate orally disintegrating tab 5 mg
(Maxalt-mlt).....................................................................41
rizatriptan benzoate tab 10 mg (Maxalt)........................41
rizatriptan benzoate tab 5 mg (Maxalt)..........................41
ropinirole hydrochloride tab 0.25 mg (Requip).............44
ropinirole hydrochloride tab 0.5 mg (Requip)...............44
ropinirole hydrochloride tab 1 mg (Requip)................. 44
ROXICET – oxycodone w/ acetaminophen soln 5-325
mg/5ml............................................................................. 40
S
SABRIL – vigabatrin powd pack 500 mg.......................... 43
SABRIL – vigabatrin tab 500 mg...................................... 43
salsalate tab 500 mg....................................................... 38
salsalate tab 750 mg....................................................... 38
SANDOSTATIN LAR DEPOT – octreotide acetate for im
inj kit 10 mg.....................................................................16
inj kit 20 mg.....................................................................16
inj kit 30 mg.....................................................................16
SANDOSTATIN – octreotide acetate inj 1000 mcg/ml (1
mg/ml).............................................................................. 16
SANDOSTATIN – octreotide acetate inj 100 mcg/ml (0.1
mg/ml).............................................................................. 16
mg/ml).............................................................................. 16
mg/ml).............................................................................. 16
mg/ml).............................................................................. 16
selegiline hcl cap 5 mg (Eldepryl)................................. 44
selegiline hcl tab 5 mg................................................... 44
selenium sulfide lotion 2.5%.......................................... 52
SELZENTRY – maraviroc tab 150 mg................................ 5
79
2015
SELZENTRY – maraviroc tab 300 mg................................ 5
SENSIPAR – cinacalcet hcl tab 30 mg (base equiv)......... 16
SEREVENT DISKUS – salmeterol xinafoate aer pow ba
50 mcg/dose (base equiv)............................................... 27
SEROQUEL XR – quetiapine fumarate tab sr 24hr 150
mg.................................................................................... 34
mg.................................................................................... 34
mg.................................................................................... 34
mg.................................................................................... 34
mg.................................................................................... 34
sertraline hcl oral conc 20 mg/ml (Zoloft).....................32
sertraline hcl tab 100 mg (Zoloft).................................. 32
sertraline hcl tab 25 mg (Zoloft).................................... 32
sertraline hcl tab 50 mg (Zoloft).................................... 32
sildenafil citrate tab 20 mg (Revatio).............................24
silver sulfadiazine cream 1% (Silvadene)..................... 51
SIMBRINZA – brinzolamide-brimonidine tartrate ophth
susp 1-0.2%.....................................................................49
SIMPONI – golimumab subcutaneous soln auto-injector
100 mg/ml........................................................................41
SIMPONI – golimumab subcutaneous soln auto-injector
50 mg/0.5ml.....................................................................41
SIMPONI – golimumab subcutaneous soln prefilled
syringe 100 mg/ml........................................................... 41
SIMPONI – golimumab subcutaneous soln prefilled
syringe 50 mg/0.5ml........................................................ 41
simvastatin tab 10 mg (Zocor)....................................... 22
simvastatin tab 5 mg (Zocor)......................................... 22
sirolimus tab 0.5 mg (Rapamune)..................................53
sirolimus tab 1 mg (Rapamune).................................... 53
sirolimus tab 2 mg (Rapamune).................................... 53
SIVEXTRO – tedizolid phosphate tab 200 mg.................... 7
SKYLA – levonorgestrel releasing iud 13.5 mg.................12
sodium citrate & citric acid soln 500-334 mg/5ml
(Shohls solution modi)..................................................30
sodium fluoride chew tab 0.25 mg f (from 0.55 mg naf)
(Luride)............................................................................46
sodium fluoride chew tab 0.5 mg f (from 1.1 mg naf)
(Luride)............................................................................46
sodium fluoride chew tab 1 mg f (from 2.2 mg naf)
(Luride)............................................................................46
sodium fluoride cream 1.1% (Prevident 5000 plus)......49
sodium fluoride gel 1.1% (0.5% f) (Prevident
fluoride)...........................................................................49
SODIUM FLUORIDE – sodium fluoride tab 0.5 mg f (from
1.1 mg naf)...................................................................... 46
80
SODIUM FLUORIDE – sodium fluoride tab 1 mg f (from
2.2 mg naf)...................................................................... 46
sodium fluoride soln 0.125 mg/drop f (0.275 mg/drop
naf).................................................................................. 46
sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml naf)
(Luride)............................................................................46
sodium polystyrene sulfonate oral susp 15 gm/60ml
(Sps)................................................................................ 53
sodium polystyrene sulfonate powder
(Kayexalate)....................................................................53
sodium polystyrene sulfonate rectal susp 30
gm/120ml........................................................................ 53
SODIUM SULFACETAMIDE/SULF – sulfacetamide
sodium w/ sulfur susp 10-5%.......................................... 50
SOLTAMOX – tamoxifen citrate oral soln 10 mg/5ml (base
equivalent)......................................................................... 9
sotalol hcl (afib/afl) tab 120 mg (Betapace af).............. 24
sotalol hcl (afib/afl) tab 160 mg (Betapace af).............. 24
sotalol hcl (afib/afl) tab 80 mg (Betapace af)................ 24
sotalol hcl tab 120 mg (Betapace)................................. 24
sotalol hcl tab 160 mg (Betapace)................................. 24
sotalol hcl tab 240 mg.................................................... 24
sotalol hcl tab 80 mg (Betapace)................................... 24
SOVALDI – sofosbuvir tab 400 mg.....................................4
SPIRIVA HANDIHALER – tiotropium bromide
monohydrate inhal cap 18 mcg (base equiv)...................27
SPIRIVA RESPIMAT – tiotropium bromide monohydrate
inhal aerosol 2.5 mcg/act................................................ 27
spironolactone & hydrochlorothiazide tab 25-25 mg
(Aldactazide)...................................................................23
spironolactone tab 100 mg (Aldactone)........................ 23
spironolactone tab 25 mg (Aldactone).......................... 23
spironolactone tab 50 mg (Aldactone).......................... 23
SPORANOX – itraconazole oral soln 10 mg/ml.................. 3
SPRYCEL – dasatinib tab 100 mg......................................9
SPRYCEL – dasatinib tab 140 mg......................................9
SPRYCEL – dasatinib tab 20 mg........................................9
SSKI – potassium iodide soln 1 gm/ml............................. 25
stavudine cap 15 mg (Zerit)............................................. 5
stavudine for oral soln 1 mg/ml (Zerit)............................5
STELARA – ustekinumab soln prefilled syringe 45
mg/0.5ml.......................................................................... 52
STELARA – ustekinumab soln prefilled syringe 90 mg/
ml..................................................................................... 52
STIMATE – desmopressin acetate nasal soln 1.5 mg/
ml..................................................................................... 16
STIVARGA – regorafenib tab 40 mg...................................9
STRATTERA – atomoxetine hcl cap 100 mg (base
equiv)............................................................................... 36
2015
equiv)............................................................................... 35
equiv)............................................................................... 35
equiv)............................................................................... 35
equiv)............................................................................... 35
equiv)............................................................................... 36
equiv)............................................................................... 36
STRIBILD – elvitegrav-cobicis-emtricitab-tenofov tab
150-150-200-300 mg......................................................... 5
SUBOXONE – buprenorphine hcl-naloxone hcl sl film 12-3
mg (base equiv)...............................................................53
SUBOXONE – buprenorphine hcl-naloxone hcl sl film
2-0.5 mg (base equiv)..................................................... 53
mg (base equiv)...............................................................53
mg (base equiv)...............................................................53
sucralfate tab 1 gm (Carafate)....................................... 28
sulfacetamide sodium lotion 10% (acne) (Klaron)........50
sulfacetamide sodium ophth soln 10% (Bleph-10).......48
sulfacetamide sodium-prednisolone ophth soln
10-0.23(0.25)%................................................................ 48
sulfacetamide sodium w/ sulfur cream 10-5%.............. 50
sulfacetamide sodium w/ sulfur emulsion 10-5%......... 50
sulfacetamide sodium w/ sulfur lotion 10-5%...............50
sulfamethoxazole-trimethoprim susp 200-40
mg/5ml.............................................................................. 6
sulfamethoxazole-trimethoprim tab 400-80 mg
(Bactrim)........................................................................... 6
sulfamethoxazole-trimethoprim tab 800-160 mg
(Bactrim ds)......................................................................6
sulfasalazine tab 500 mg (Azulfidine)........................... 29
sulfasalazine tab delayed release 500 mg (Azulfidine
en-tabs)........................................................................... 29
sulindac tab 150 mg........................................................41
sulindac tab 200 mg........................................................41
sumatriptan succinate inj 6 mg/0.5ml (Imitrex)............ 41
sumatriptan succinate solution auto-injector 4
mg/0.5ml (Imitrex statdose sys)................................... 41
sumatriptan succinate solution auto-injector 6
mg/0.5ml (Imitrex statdose sys)................................... 41
sumatriptan succinate solution cartridge 4 mg/0.5ml
(Imitrex statdose ref)..................................................... 41
sumatriptan succinate solution cartridge 6 mg/0.5ml
(Imitrex statdose ref)..................................................... 41
SUMATRIPTAN SUCCINATE – sumatriptan succinate inj
4 mg/0.5ml.......................................................................41
SUMATRIPTAN SUCCINATE – sumatriptan succinate
solution prefilled syringe 6 mg/0.5ml............................... 41
sumatriptan succinate tab 100 mg (Imitrex)................. 41
sumatriptan succinate tab 25 mg (Imitrex)................... 41
sumatriptan succinate tab 50 mg (Imitrex)................... 41
SUMATRIPTAN – sumatriptan nasal spray 20 mg/act...... 41
SUMATRIPTAN – sumatriptan nasal spray 5 mg/act........ 41
SUPRAX – cefixime cap 400 mg........................................ 2
SUPRAX – cefixime chew tab 100 mg............................... 2
SUPRAX – cefixime chew tab 200 mg............................... 2
SUPRAX – cefixime for susp 100 mg/5ml.......................... 2
SUSTIVA – efavirenz cap 200 mg...................................... 5
SUSTIVA – efavirenz cap 50 mg........................................ 5
SUSTIVA – efavirenz tab 600 mg.......................................5
SUTENT – sunitinib malate cap 12.5 mg (base
equivalent)......................................................................... 9
SUTENT – sunitinib malate cap 25 mg (base
equivalent)......................................................................... 9
SUTENT – sunitinib malate cap 37.5 mg (base
equivalent)......................................................................... 9
SUTENT – sunitinib malate cap 50 mg (base
equivalent)......................................................................... 9
SYLATRON – peginterferon alfa-2b for inj kit 200 mcg....... 9
SYMBICORT – budesonide-formoterol fumarate dihyd
aerosol 160-4.5 mcg/act.................................................. 27
SYMBICORT – budesonide-formoterol fumarate dihyd
aerosol 80-4.5 mcg/act.................................................... 27
SYMLINPEN 120 – pramlintide acetate pen-inj 2700
mcg/2.7ml (1000 mcg/ml)................................................ 14
SYMLINPEN 60 – pramlintide acetate pen-inj 1500
mcg/1.5ml (1000 mcg/ml)................................................ 14
SYNERA – lidocaine-tetracaine topical patch 70-70
mg.................................................................................... 52
T
TABLOID – thioguanine tab 40 mg.....................................9
tacrolimus cap 0.5 mg (Prograf).................................... 53
tacrolimus cap 1 mg (Prograf)....................................... 53
tacrolimus cap 5 mg (Prograf)....................................... 53
tacrolimus oint 0.03% (Protopic)................................... 52
tacrolimus oint 0.1% (Protopic)..................................... 52
TAFINLAR – dabrafenib mesylate cap 50 mg (base
equivalent)......................................................................... 9
TAFINLAR – dabrafenib mesylate cap 75 mg (base
equivalent)......................................................................... 9
TAMIFLU – oseltamivir phosphate cap 30 mg (base
equiv)................................................................................. 6
equiv)................................................................................. 6
equiv)................................................................................. 6
TAMIFLU – oseltamivir phosphate for susp 6 mg/ml (base
equiv)................................................................................. 6
tamoxifen citrate tab 10 mg (base equivalent)............... 9
tamoxifen citrate tab 20 mg (base equivalent)............... 9
tamsulosin hcl cap 0.4 mg (Flomax)............................. 30
81
2015
TARCEVA – erlotinib hcl tab 100 mg (base equivalent)...... 9
TARCEVA – erlotinib hcl tab 150 mg (base equivalent)...... 9
TARCEVA – erlotinib hcl tab 25 mg (base equivalent)........9
TARGRETIN – bexarotene cap 75 mg............................... 9
TASIGNA – nilotinib hcl cap 150 mg (base equivalent).......9
TASIGNA – nilotinib hcl cap 200 mg (base equivalent).......9
TAZORAC – tazarotene cream 0.05%..............................50
TAZORAC – tazarotene cream 0.1%................................50
TAZORAC – tazarotene gel 0.05%................................... 50
TAZORAC – tazarotene gel 0.1%.....................................50
TECFIDERA – dimethyl fumarate capsule delayed release
120 mg.............................................................................36
TECFIDERA – dimethyl fumarate capsule delayed release
240 mg.............................................................................36
TECFIDERA STARTER PACK – dimethyl fumarate
capsule dr starter pack 120 mg & 240 mg...................... 36
TEGRETOL-XR – carbamazepine tab sr 12hr 100 mg..... 43
telmisartan-hydrochlorothiazide tab 40-12.5 mg
(Micardis hct)................................................................. 18
telmisartan-hydrochlorothiazide tab 80-12.5 mg
(Micardis hct)................................................................. 18
telmisartan-hydrochlorothiazide tab 80-25 mg
(Micardis hct)................................................................. 18
telmisartan tab 20 mg (Micardis)................................... 18
temazepam cap 15 mg (Restoril)................................... 34
temazepam cap 22.5 mg (Restoril)................................ 34
temazepam cap 30 mg (Restoril)................................... 34
temazepam cap 7.5 mg (Restoril).................................. 34
temozolomide cap 100 mg (Temodar).............................9
temozolomide cap 20 mg (Temodar)...............................9
temozolomide cap 5 mg (Temodar).................................9
terazosin hcl cap 10 mg................................................. 24
terazosin hcl cap 1 mg................................................... 24
terbinafine hcl tab 250 mg (Lamisil)................................3
terbutaline sulfate tab 2.5 mg........................................ 27
terbutaline sulfate tab 5 mg........................................... 27
terconazole vaginal cream 0.4% (Terazol 7)................. 30
terconazole vaginal cream 0.8% (Terazol 3)................. 30
terconazole vaginal suppos 80 mg................................30
testosterone cypionate im inj in oil 100 mg/ml (Depotestosterone).................................................................. 10
testosterone cypionate im inj in oil 200 mg/ml (Depotestosterone).................................................................. 10
testosterone enanthate im inj in oil 200 mg/ml............ 10
TEST STRIPS – BAYER ASCENSIA AUTODISC,
BREEZE 2, CONTOUR, CONTOUR NEXT.................... 53
TEST STRIPS – ROCHE ACCU-CHEK ACTIVE,
AVIVA, AVIVA PLUS, COMPACT, COMPACT PLUS,
SMARTVIEW................................................................... 53
82
TEST STRIPS – ROCHE ACCUTREND...........................53
tetrabenazine tab 12.5 mg (Xenazine)........................... 38
tetrabenazine tab 25 mg (Xenazine).............................. 38
TETRACYCLINE HCL – tetracycline hcl cap 250 mg......... 3
TETRACYCLINE HCL – tetracycline hcl cap 500 mg......... 3
THALOMID – thalidomide cap 100 mg............................. 53
THALOMID – thalidomide cap 50 mg............................... 53
theophylline tab sr 12hr 100 mg.................................... 27
thiothixene cap 10 mg.................................................... 34
thiothixene cap 1 mg...................................................... 34
timolol maleate ophth gel forming soln 0.25%
(Timoptic-xe).................................................................. 49
timolol maleate ophth gel forming soln 0.5%
(Timoptic-xe).................................................................. 49
timolol maleate ophth soln 0.25% (Timoptic)............... 49
timolol maleate ophth soln 0.5% (Timoptic)................. 49
TIMOLOL MALEATE – timolol maleate tab 10 mg............19
TIMOLOL MALEATE – timolol maleate tab 20 mg............20
TIMOLOL MALEATE – timolol maleate tab 5 mg..............19
TIVICAY – dolutegravir sodium tab 50 mg (base equiv)......5
TOBRADEX – tobramycin-dexamethasone ophth oint
0.3-0.1%...........................................................................48
tobramycin-dexamethasone ophth susp 0.3-0.1%
(Tobradex)...................................................................... 48
tobramycin nebu soln 300 mg/5ml (Tobi)....................... 3
tobramycin ophth soln 0.3% (Tobrex)........................... 48
tolterodine tartrate cap sr 24hr 2 mg (Detrol la)........... 29
tolterodine tartrate cap sr 24hr 4 mg (Detrol la)........... 29
tolterodine tartrate tab 1 mg (Detrol).............................29
tolterodine tartrate tab 2 mg (Detrol).............................29
topiramate sprinkle cap 15 mg (Topamax sprinkle)..... 43
topiramate sprinkle cap 25 mg (Topamax sprinkle)..... 43
topiramate tab 100 mg (Topamax).................................43
topiramate tab 200 mg (Topamax).................................43
topiramate tab 25 mg (Topamax)...................................43
topiramate tab 50 mg (Topamax)...................................43
torsemide tab 100 mg (Demadex)..................................23
torsemide tab 10 mg (Demadex)....................................23
torsemide tab 20 mg (Demadex)....................................23
torsemide tab 5 mg (Demadex)......................................23
TOUJEO SOLOSTAR – insulin glargine soln pen-injector
300 unit/ml....................................................................... 15
TRACLEER – bosentan tab 125 mg................................. 24
TRACLEER – bosentan tab 62.5 mg................................ 24
tramadol-acetaminophen tab 37.5-325 mg
(Ultracet)......................................................................... 40
tramadol hcl tab 50 mg (Ultram).................................... 40
2015
tramadol hcl tab sr 24hr 100 mg (Ultram er).................40
trandolapril tab 1 mg (Mavik)......................................... 17
tranylcypromine sulfate tab 10 mg (Parnate)............... 32
TRAVATAN Z – travoprost ophth soln 0.004%
(benzalkonium free) (bak free)........................................ 49
trazodone hcl tab 100 mg...............................................32
trazodone hcl tab 50 mg.................................................32
tretinoin cap 10 mg...........................................................9
tretinoin cream 0.025% (Retin-a)................................... 50
tretinoin cream 0.05% (Retin-a)..................................... 50
tretinoin cream 0.1% (Retin-a)....................................... 50
tretinoin gel 0.01% (Retin-a)...........................................50
tretinoin gel 0.025%, NF = Avita gel (Retin-a)............... 50
tretinoin microsphere gel 0.04% (Retin-a micro)..........50
tretinoin microsphere gel 0.1% (Retin-a micro)............50
triamcinolone acetonide cream 0.025%........................ 52
triamcinolone acetonide cream 0.1%............................ 52
triamcinolone acetonide cream 0.5%............................ 52
triamcinolone acetonide dental paste 0.1%.................. 49
triamcinolone acetonide lotion 0.025%......................... 52
triamcinolone acetonide lotion 0.1%............................. 52
triamcinolone acetonide nasal aerosol suspension 55
mcg/act (Nasacort aq)................................................... 25
triamcinolone acetonide oint 0.025%............................ 52
triamcinolone acetonide oint 0.1%................................ 52
TRIAMCINOLONE ACETONIDE – triamcinolone
acetonide oint 0.5%.........................................................52
TRIAMTERENE/HYDROCHLOROTH – triamterene &
hydrochlorothiazide cap 50-25 mg.................................. 23
triamterene & hydrochlorothiazide cap 37.5-25 mg
(Dyazide)......................................................................... 23
triamterene & hydrochlorothiazide tab 37.5-25 mg
(Maxzide-25)................................................................... 23
triamterene & hydrochlorothiazide tab 75-50 mg
(Maxzide).........................................................................23
trifluoperazine hcl tab 10 mg......................................... 34
trifluoperazine hcl tab 1 mg........................................... 34
trifluridine ophth soln 1% (Viroptic).............................. 48
trihexyphenidyl hcl elixir 0.4 mg/ml.............................. 44
trihexyphenidyl hcl tab 2 mg......................................... 44
trihexyphenidyl hcl tab 5 mg......................................... 44
trimethobenzamide hcl cap 300 mg (Tigan)..................28
trimethoprim tab 100 mg.................................................. 7
TRINATE – prenatal vit w/ fe fumarate-fa tab 28-1 mg......45
TRIUMEQ – abacavir-dolutegravir-lamivudine tab
600-50-300 mg.................................................................. 5
TRUVADA – emtricitabine-tenofovir disoproxil fumarate
tab 200-300 mg................................................................. 5
TYBOST – cobicistat tab 150 mg....................................... 5
TYKERB – lapatinib ditosylate tab 250 mg (base equiv)..... 9
U
ursodiol cap 300 mg (Actigall).......................................29
ursodiol tab 250 mg (Urso 250)..................................... 29
ursodiol tab 500 mg (Urso forte)................................... 29
V
VAGIFEM – estradiol vaginal tab 10 mcg......................... 30
valacyclovir hcl tab 1 gm (Valtrex).................................. 4
valacyclovir hcl tab 500 mg (Valtrex).............................. 4
VALCHLOR – mechlorethamine hcl gel 0.016% (base
equivalent)....................................................................... 52
VALCYTE – valganciclovir hcl for soln 50 mg/ml (base
equiv)................................................................................. 4
valganciclovir hcl tab 450 mg (base equivalent)
(Valcyte)............................................................................ 4
valproate sodium syrup 250 mg/5ml (base equiv)
(Depakene)......................................................................43
valproic acid cap 250 mg (Depakene)........................... 43
valsartan-hydrochlorothiazide tab 160-12.5 mg
(Diovan hct)....................................................................18
valsartan-hydrochlorothiazide tab 160-25 mg (Diovan
hct).................................................................................. 18
valsartan-hydrochlorothiazide tab 320-12.5 mg
(Diovan hct).................................................................... 18
valsartan-hydrochlorothiazide tab 320-25 mg (Diovan
hct).................................................................................. 18
valsartan-hydrochlorothiazide tab 80-12.5 mg (Diovan
hct).................................................................................. 18
valsartan tab 160 mg (Diovan)....................................... 18
valsartan tab 320 mg (Diovan)....................................... 18
valsartan tab 40 mg (Diovan)......................................... 18
valsartan tab 80 mg (Diovan)......................................... 18
vancomycin hcl cap 125 mg (Vancocin hcl)................... 7
vancomycin hcl cap 250 mg (Vancocin hcl)................... 7
venlafaxine hcl cap sr 24hr 150 mg (base equivalent)
(Effexor xr)..................................................................... 32
venlafaxine hcl cap sr 24hr 37.5 mg (base equivalent)
(Effexor xr)..................................................................... 32
venlafaxine hcl cap sr 24hr 75 mg (base equivalent)
(Effexor xr)..................................................................... 32
VENLAFAXINE HCL ER – venlafaxine hcl tab sr 24hr 225
mg (base equivalent).......................................................32
venlafaxine hcl tab 100 mg............................................ 32
venlafaxine hcl tab 25 mg.............................................. 32
venlafaxine hcl tab 37.5 mg........................................... 32
venlafaxine hcl tab sr 24hr 150 mg (base equivalent)
(Venlafaxine hcl er)....................................................... 32
venlafaxine hcl tab sr 24hr 37.5 mg (base equivalent)
venlafaxine hcl tab sr 24hr 75 mg (base equivalent)
83
2015
VENTAVIS – iloprost inhalation solution 10 mcg/ml..........25
VENTAVIS – iloprost inhalation solution 20 mcg/ml..........25
VENTOLIN HFA – albuterol sulfate inhal aero 108 mcg/act
(90mcg base equiv).........................................................27
verapamil hcl cap sr 24hr 100 mg (Verelan pm)........... 21
verapamil hcl cap sr 24hr 120 mg (Verelan)................. 21
verapamil hcl tab 120 mg (Calan).................................. 21
verapamil hcl tab 80 mg (Calan).................................... 21
verapamil hcl tab cr 120 mg (Calan sr)......................... 21
VERAPAMIL HCL – verapamil hcl tab 40 mg................... 21
VESICARE – solifenacin succinate tab 10 mg.................. 30
VESICARE – solifenacin succinate tab 5 mg....................29
VICTOZA – liraglutide soln pen-injector 18 mg/3ml (6 mg/
ml).................................................................................... 14
VIDEX – didanosine for soln 2 gm......................................5
VIDEX – didanosine for soln 4 gm......................................5
VIEKIRA PAK – ombitas-paritapre-riton & dasab tab pak
12.5-75-50 & 250 mg........................................................ 4
VIGAMOX – moxifloxacin hcl ophth soln 0.5% (base
equiv)............................................................................... 48
VINACAL B – prenat w/o a w/fecbn-feglu-fa tab 20-1 mg &
vit b6 tab pak...................................................................45
VINATE AZ EXTRA – prenatal vit w/ fe bisglycinate
chelate-fa tab 29-1 mg.................................................... 45
VINATE CALCIUM – prenatal vit w/ iron carbonyl-fe glucfa tab 27-1 mg.................................................................45
VINATE CARE – prenatal w/o a vit w/ fe fum-fa tab chew
40-1 mg........................................................................... 45
VINATE C – prenatal w/o a vit w/ fe fumarate-fa tab 30-1
mg.................................................................................... 45
VINATE DHA RF – prenat w/o a w/fefum-methylfolomegas cap 27-1.13 mg................................................. 45
VINATE GT – prenatal vit w/ dss-iron carbonyl-fa tab 90-1
mg.................................................................................... 45
VINATE IC – prenatal w/o a w/fe fum-fe poly-fa cap
162.115.2-1 mg............................................................... 45
VINATE II – prenatal vit w/ fe bisglycinate chelate-fa tab
29-1 mg........................................................................... 45
VINATE M – prenatal vit w/ sel-fe fumarate-fa tab 27-1
mg.................................................................................... 45
VINATE ONE – prenatal vit w/ fe fumarate-fa tab 60-1
mg.................................................................................... 45
VINATE ULTRA – prenatal vit w/ dss-iron carbonyl-fa tab
90-1 mg........................................................................... 45
VIRACEPT – nelfinavir mesylate tab 250 mg..................... 6
VIRACEPT – nelfinavir mesylate tab 625 mg..................... 6
VIRAMUNE – nevirapine susp 50 mg/5ml.......................... 6
VIRAMUNE XR – nevirapine tab sr 24hr 100 mg............... 6
84
VIREAD – tenofovir disoproxil fumarate oral powder 40
mg/gm................................................................................ 6
VIREAD – tenofovir disoproxil fumarate tab 150 mg........... 6
VITAMIN K1 – phytonadione inj 10 mg/ml........................ 44
VITEKTA – elvitegravir tab 150 mg.................................... 6
VITEKTA – elvitegravir tab 85 mg...................................... 6
VOLTAREN – diclofenac sodium gel 1%.......................... 51
voriconazole for susp 40 mg/ml (Vfend)......................... 3
voriconazole tab 200 mg (Vfend).....................................3
voriconazole tab 50 mg (Vfend).......................................3
VOTRIENT – pazopanib hcl tab 200 mg (base equiv)........ 9
VYVANSE – lisdexamfetamine dimesylate cap 10 mg......36
W
warfarin sodium tab 10 mg (Coumadin)........................47
warfarin sodium tab 1 mg (Coumadin)..........................47
warfarin sodium tab 2.5 mg (Coumadin).......................47
warfarin sodium tab 7.5 mg (Coumadin).......................47
WELCHOL – colesevelam hcl packet for susp 3.75
gm.................................................................................... 22
WELCHOL – colesevelam hcl tab 625 mg........................22
X
XALKORI – crizotinib cap 200 mg...................................... 9
XALKORI – crizotinib cap 250 mg...................................... 9
XARELTO – rivaroxaban tab 10 mg................................. 47
XARELTO STARTER PACK – rivaroxaban tab starter
therapy pack 15 mg & 20 mg..........................................47
XENAZINE – tetrabenazine tab 12.5 mg.......................... 38
XENAZINE – tetrabenazine tab 25 mg............................. 38
XIFAXAN – rifaximin tab 550 mg........................................ 7
XOLAIR – omalizumab for inj 150 mg.............................. 27
XTANDI – enzalutamide cap 40 mg................................... 9
Y
Z
zafirlukast tab 10 mg (Accolate).................................... 27
zafirlukast tab 20 mg (Accolate).................................... 27
zaleplon cap 10 mg (Sonata)..........................................34
2015
zaleplon cap 5 mg (Sonata)........................................... 34
ZELBORAF – vemurafenib tab 240 mg.............................. 9
ZENPEP – pancrelipase (lip-prot-amyl) dr cap
10000-34000-55000 unit..................................................28
15000-51000-82000 unit..................................................29
20000-68000-109000 unit................................................29
25000-85000-136000 unit................................................29
3000-10000-16000 unit....................................................28
40000-136000-218000 unit..............................................29
5000-17000-27000 unit....................................................28
ZIAGEN – abacavir sulfate soln 20 mg/ml (base equiv)...... 6
zidovudine cap 100 mg (Retrovir)................................... 6
zidovudine syrup 10 mg/ml (Retrovir).............................6
zidovudine tab 300 mg..................................................... 6
ziprasidone hcl cap 20 mg (Geodon)............................ 34
ZOLINZA – vorinostat cap 100 mg..................................... 9
zolmitriptan orally disintegrating tab 2.5 mg (Zomig
zmt)..................................................................................41
zolmitriptan orally disintegrating tab 5 mg (Zomig
zmt)..................................................................................41
zolmitriptan tab 2.5 mg (Zomig).....................................41
zolmitriptan tab 5 mg (Zomig)........................................41
zolpidem tartrate tab 10 mg (Ambien)...........................34
zolpidem tartrate tab 5 mg (Ambien).............................34
zolpidem tartrate tab cr 12.5 mg (Ambien cr)............... 34
zolpidem tartrate tab cr 6.25 mg (Ambien cr)............... 34
zonisamide cap 100 mg (Zonegran).............................. 43
zonisamide cap 25 mg (Zonegran)................................ 43
zonisamide cap 50 mg....................................................43
ZORTRESS – everolimus tab 0.25 mg............................. 54
ZORTRESS – everolimus tab 0.5 mg............................... 54
ZORTRESS – everolimus tab 0.75 mg............................. 54
ZOVIA 1/50E – ethynodiol diacetate & ethinyl estradiol tab
1 mg-50 mcg................................................................... 12
ZYCLARA – imiquimod cream 3.75%............................... 52
ZYCLARA PUMP – imiquimod cream 2.5%......................52
ZYCLARA PUMP – imiquimod cream 3.75%....................52
ZYDELIG – idelalisib tab 100 mg........................................9
ZYDELIG – idelalisib tab 150 mg........................................9
ZYKADIA – ceritinib cap 150 mg........................................ 9
ZYLET – loteprednol etabonate-tobramycin ophth susp
0.5-0.3%...........................................................................48
ZYTIGA – abiraterone acetate tab 250 mg......................... 9
ZYVOX – linezolid for susp 100 mg/5ml............................. 7
85

BCBSND Formulary - Blue Cross Blue Shield of North Dakota

Transcription

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